Antibiotic susceptibility patterns of some clinical isolates from Al-Rass ...

Int. J. Biosci.

2015 International Journal of Biosciences | IJB | ISSN: 2220-6655 (Print), 2222-5234 (Online) http://www.innspub.net Vol. 6, No. 9, p. 47-54, 2015

RESEARCH PAPER

OPEN ACCESS

Antibiotic susceptibility patterns of some clinical isolates from Al-Rass general hospital Emad M. Abdallah1*, Fiaz Ahamed2, Abdulmalik S. Al-Omari2 1

Department of Laboratory Sciences, College of Sciences and Arts at Al-Rass, Qassim University,

Saudi Arabia 2

Department of Pathology and Laboratory medicine, Al-Rass General Hospital, Saudi Arabia

Key words: Antibiotics resistance, Susceptibility, MDR, Clinical isolates, Saudi Arabia.

http://dx.doi.org/10.12692/ijb/6.9.47-54

Article published on May 08, 2015

Abstract In this investigation, 98 clinical isolates of 10 different bacterial pathogens were tested for antibiotic susceptibility. The sources of these isolates were urine, blood, sputum and wound swaps collected from patients from Al-Rass General Hospital, Saudi Arabia. Bacterial isolates were identified and tested for susceptibility by disk diffusion method as recommended by the Clinical and Laboratory Standards Institute (CLSI). The results have shown that, of the 98 bacterial isolates representing 9 different bacterial pathogens, 71 (72.4 %) were Gram negatives and 27 (27.6 %) were Gram positives. 21 different antibiotic disks were used. The majority of these isolates were resistant to most antibiotics tested. Accordingly, almost all the isolates were defined as multidrug resistant (MDR). Acinetobacter baumanii and Enterococcus faecalis are among the most resistant MDR which poses a serious concern. There is a need for continuous monitoring of the susceptibility of pathogens to antibiotics prescribed in hospitals. * Corresponding

Author: Emad M. Abdallah  [email protected]

47 Abdallah et al.

Int. J. Biosci.

2015

Introduction

The targets of most antibiotics are present in the cell

In recent years, there is a decreasing phenomenon of

wall, cytoplasmic membrane or in the cytoplasm.

antibiotics

common

Although gram-positive and gram-negative bacteria

infections, in both of high-income and low-income

have different structural characteristics, such as the

countries (Laxminarayan et al., 2013). Although,

outer membrane of gram-negatives that may provide

resistance of microorganisms to antibiotics may result

an additional barrier and prevents the antibiotic to

from natural selection or mutation (Hsu et al., 2007).

reach its target (Kaye et al., 2004). The aim of the

However, human behavior in dealing with antibiotics

present study was to evaluate the antibiotic resistant

encourages and accelerate this phenomenon, the

patterns of the pathogenic bacteria.

effectiveness

in

treating

overdosing, self-medication and prescription of antibiotics by some physicians without proper

Materials and methods

susceptibility

Sample collection

test,

besides

long

duration

of

hospitalization are the main reasons for emerging of

A total of 98 Samples received to the Department of

multi-drug –resistant microorganisms worldwide

Pathology and Laboratory medicine from consecutive

(Godebo et al., 2013). It is estimated that in low-

patients from Al-Rass General Hospital, between the

income countries the antibiotics are prescribed for

periods from December 2014 to March 2015 were

44–97%

mostly

investigated. Many clinical specimens come to the

unnecessarily or inappropriately (Baktygul et al.,

laboratory from numerous sources. We choose the

2011). Accordingly, Resistance to antibiotics is highly

most five frequent sources which were wound swab,

prevalent, numerous studies reported some outbreaks

blood, urine, pus and sputum.

of

hospitalized

patients,

of multi-drug resistant strains (MDR) and nosocomial infections. MDR is defined as acquired non-

Use of antibiotics

susceptibility to at least one agent in three or more

21 standard commercial antibiotic discs were tested

antimicrobial categories (Magiorakos et al., 2012). As

against gram positive and gram negative isolates.

examples,

of

Discs used against gram positive bacteria were as

Acinetobacter baumannii was recorded in Taiwan

an

outbreak

of

MDR

strain

follows: Gentamicin (10 mcg), Augmentin (30 mcg),

due to the transmission among medical staff and their

Ceftriaxone

administration equipment (Chang et al., 2009).

Cotrimoxazole

An

(30

mcg),

(25

Ciprofloxacin

mcg),

Tetracycline

(10mcg),

Azithromycin (15

reported in the intensive care unit in a hospital

Oxacillin (1 mcg), Penicillin G (10 units), Rifampicin

southern Italy (Pagani et al., 2005). Many African

(5mcg), Vancomycin (30mcg), Norfloxacin (10 mcg)

countries had recorded an outbreak of MDR

and Nitrofurntoin (300 mcg). Discs used against

microorganisms which were isolated from patients

gram negative bacteria were as follows: Ampicillin (10

and from environment (Godebo et al., 2013) and now

mcg), Gentamicin (10 mcg), Amikacin (30 mcg),

MDR bacteria are becoming global clinical problem

Augmentin

(30

mcg),

Cephalothin

not in human only, but also in veterinary medicine,

Ceftriaxone

(30

mcg),

Ciprofloxacin

contributing significant economic losses in poultry

Piperacillin

(100

and its related industries (Mamza et al., 2010). In

Ceftizoxime

(30

general,

Cotrimoxazole (25 mcg), Tetracycline (10 mcg) and

phenomena

of

MDR

strains

are

responsible of a considerable number of mortality

mcg), mcg),

Clindamycin

mcg),

outbreak of MDR strains of Pseudomonas aeruginosa

the

mcg),

(5

(2 mcg),

(30

mcg),

(5

mcg),

Imipenem

(10

mcg),

Meropenem

(10

mcg),

Azithromycin (15 mcg).

and morbidity worldwide, this is beside the economic impact and financial expenses since patients need

Isolation and identification

more expensive second-line drugs and may stay

The experiments was carried out at the Department of

longer in hospitals until treated (Hulscher et al.,

Pathology and Laboratory medicine Al-Rass General

2010).

Hospital, it is located in Qassim province, Saudi

48 Abdallah et al.

Int. J. Biosci.

2015

Arabia. Samples were collected from patients and

Results and discussion

transferred directly to the laboratory, cultured and

As shown in Table 1, the incidence of bacterial isolates

incubated overnight. Bacterial strains were identified

among 98 specimens examined were 62.2% urine,

by different microbiological and biochemical tests

14.3% wound swab, 11.2% Blood, 7.1% sputum and

following

techniques,

5.1% pus. Urine specimens were the most frequent.

including Gram stain, Motility, Catalase, Coagulase,

Urinary tract infections are considered among the

Indole, Growth in EMB Agar, MA, MR, VP, Glucose,

most

Sucrose, Lactase, Maltase, Galactase, and API 20 E

particularly women where about 25% of women

(Bio Merie ux, France).

treated from urinary tract infections had re-infected

standard

microbiological

common

infectious

disease

in

human,

again within six months (Johnson and Stamn, 1989; Antibiotic susceptibility testing

Ehinmidu, 2003). The results of the hospital

The antibiotic susceptibility test was performed by

specimens revealed Gram negative bacteria are much

Kirby–Bauer disk diffusion method as set by Clinical

resistant to antibiotics than gram positives (Table 2

and Laboratory Standards Institute (CLSI, 2012).

and 3). It is known that Gram negative bacteria are

Briefly, overnight culture from each isolate adjusted

more resistant to antibiotics than gram positive.

to be equivalent to 0.5 McFarland seeded in sterile

Currently, Gram negatives particularly Pseudomonas

plates containing Mueller Hinton agar (Oxoid). Then,

aeruginosa, Acinetobacter baumannii and Klebsiella

standard antibiotic disks were aseptically loaded in to

pneumonia present a critical problem since they

seeded plates. Plates were then incubated for 18h at

develop resistance to most known antibiotics (Li et

37

C. The diameter of inhibition zones around the

al., 2006). The most frequent isolates from urine was

antibiotic discs were measured and interpreted as

E. coli (Table 1), this is in harmony with the findings

sensitive/resistant according to CLSI guidelines

of Khalili et al., 2012. Similar study in another general

(CLSI, 2012).The data obtained were tabulated and

hospital in Saudi Arabia showed that the most

analyzed

frequent

o

using

SPSS

software,

version

17.0.

isolates

were

from

urine

specimens,

Multidrug resistance (MDR) was defined as resistant

representing 57.5% (Kader and Kumar, 2005). This

to at least three tested antibiotics (Oteo et al., 2005)

could be related to urosepsis which is a major cause of nosocomial infections (Khalili et al., 2012.).

Table 1. Incidence of bacterial isolates from the hospital (From December 2014 to March 2015)*. Clinical

No. of isolates

specimens

(Percent)

Urine

Gram positive bacteria

Gram negative bacteria

Staphylococcus

Staphylococcus

Staphylococcus

Enterococcus

Escherichia

Proteus

Klebsiella

Pseudomonas

Acinetobacter

aureus

epidermidis

Saprophyticus

faecalis

coli

mirabilis

pneumoniae

aeruginosa

baumanii

61 (62.2%)

2

1

7

9

13

6

12

8

3

Wound swab 14 (14.3%)

5

–

–

–

1

1

–

4

3

Blood

11(11.2%)

–

–

–

1

3

4

1

2

–

Sputum

7 (7.1%)

–

–

–

–

–

–

–

3

4

Pus

5 (5.1%)

2

–

–

–

1

–

–

1

1

Total

98 (100%)

9

1

7

10

18

11

13

18

11

*From these five specimen sources only. The resistance rates of Gram positive isolates are

Tetracycline

shown in Table 2. Interestingly, these were as follows,

Ciprofloxacin

the

Ceftriaxone

highest

Enterococcus

resistant faecalis

bacterial which

isolates resistant

was

(60%), (50%),

Cotrimoxazole

(66.6%),

Azithromycin

(55,5%),

and

Rifampicin

(50%),

to

respectively. Although enterococci are rarely causes

Penicillin G (100%), Augmentin (100%), Clindamycin

serious infections, but recently they have emerged as

(100%), Norfloxacin (88.8%),

MDR and reported highly resistant to ampicillin,

49 Abdallah et al.

was

(70%),

Gentamicin (80%),

Int. J. Biosci.

2015

gentamicin and glycopeptides in many countries in

Rifampicin

Europe and North America (Hällgern et al., 2001).

respectively.

Staphylococcus saprophyticus isolates were resistant

common uropathogens, it is an important cause of

to

(83.3%),

urinary tract infections particularly in young women.

Clindamycin

(80%),

It was found resistant ampicillin, nalidixic acid and

Norfloxacin

(42.8%),

Azithromycin

(28.5%),

Penicillin

G

Gentamicin

(100%),

(80%),

Cotrimoxazole Tetracycline

Augmentin

(57.1%), (28.5%),

(28.5%)

and

Nitrofurntoin

Staphylococcus

cotrimoxazole

(14.2%),

saprophyticus

(Jhora

and

Paul,

is

a

2011).

Table 2. Resistance of Gram positive bacteria to antibiotics *. Bacteria

Antibiotic classes resistant to No. ( %)

Staphylococcus aureus

GM

AUG

CRO

CIP

TS

0

3 (37.5)

0

0

6 (66.6) 0

(0)

(0)

0 (0)

0 (0)

(0) Staphylococcus epidermidis

0 (0)

0 (0)

T

0 (0)

AZI

CD

OX

PG

RIF

VA

NOR

NI

0 (0)

8

0 (0)

0 (0)

1

1

(50)

(50)

1

8

(0)

(12)

(100)

0 (0)

0 (0)

0 (0)

(100) 0 (0)

1

0 (0)

0 (0)

0 (0)

0 (0)

6

2

0 (0)

3

1

(100)

(28.5)

(42.8)

(14.2)

2

2

8

0 (0)

(100)

(50)

(100) Staphylococcus Saprophyticus 2 Enterococcus faecalis

5

0 (0)

(28.5)

(83.3)

8

8

5

(80)

(100)

(50)

0 (0)

4

2

(57.1)

(28.5) (28.5) (80)

2

4

6

6

7

5

(60)

(66.6)

(70)

(55.5) (100)

4

0 (0) 0 (0)

* isolated from urine, wound swab, blood, sputum and pus specimens.

0 (0)

(88.8)

GM=Gentamicin (10 mcg),

AUG=Augmentin (30 mcg), CRO=Ceftriaxone (30 mcg), CIP=Ciprofloxacin (5 mcg), TS=Cotrimoxazole (25 mcg), T=Tetracycline (10mcg), AZI=Azithromycin (15 mcg),CD= Clindamycin (2 mcg), OX=Oxacillin (1 mcg), PG=Penicillin G (10 units), RIF=Rifampicin (5mcg), VA=Vancomycin (30mcg), NOR=Norfloxacin (10 mcg) and NI=Nitrofurntoin (300 mcg). Staphylococcus aureus isolates were resistant to

able to develop antibiotic resistance quickly. Similar

Clindamycin

(100%),

Cotrimoxazole Nitrofurntoin

Penicillin

(66.6%), (50%),

G

(100%),

study revealed that Staphylococcus aureus was highly

Norfloxacin

(50%),

resistant to ampicillin, cotrimoxazole, tetracycline,

Augmentin

(37.5%)

and

Azithromycin (12%), respectively. Staphylococcus

chloramphenicol

and

erythromycin,

respectively

(Kitara et al., 2011).

aureus is a highly prevalent nosocomial infection, it is Table 3. Resistance of Gram negative bacteria to antibiotics*. Bacteria

Antibiotic classes resistant to No. ( %) AMP

GM

AK

AUG

CEP

CRO

CIP

PIP

IMP

CAZ

MER

TS

T

AZI

Escherichia coli

3 (100)

4 (30)

0 (0)

13 (76)

0 (0)

4 (22.2)

4 (22.2)

1 (33.3)

0 (0)

1 (33.3)

0 (0)

8 (44.4)

8 (53.3)

5 (35.7)

Proteus mirabilis

5 (100)

4 (36.3)

0 (0)

10 (90.9)

2 (40)

5 (45.4)

3 (27.2)

2 (40)

0 (0)

1 (20)

0 (0)

10 (90.9)

7 (70)

4 (66.6)

Klebsiellapneumoniae

1 (100)

3 (23)

0 (0)

10 (76.9)

1 (100)

2 (15.3)

0 (0)

1 (100)

0 (0)

0 (0)

0 (0)

7 (53.8)

9 (69.2)

1 (8.3)

Pseudomonas aeruginosa

2 (100)

7 (41.1)

1 (7.6)

8 (88.8)

10 (76.9)

12 (66.6)

4 (22.2)

1 (8.3)

0 (0)

4 (30.7)

0 (0)

5 (41.6)

5 (71.4)

5 (100)

Acinetobacter baumanii

Nill

10 (90.9)

8 (80)

4 (100)

10 (100)

11 (100)

11 (100)

10 (100)

0 (0)

10 (100)

0 (0)

11 (100)

1 (100)

1 (100)

*isolated from urine, wound swab, blood, sputum and pus specimens. AMP=Ampicillin (10 mcg), GM=Gentamicin (10 mcg), AK=Amikacin (30 mcg), AUG=Augmentin (30 mcg), CEP=Cephalothin (30 mcg), CRO=Ceftriaxone (30 mcg), CIP=Ciprofloxacin (5 mcg), PIP=Piperacillin (100 mcg), IMP=Imipenem (10 mcg), CAZ=Ceftizoxime (30 mcg), MER=Meropenem (10 mcg), TS=Cotrimoxazole (25 mcg), T=Tetracycline (10 mcg) and AZI=Azithromycin (15 mcg).

50 Abdallah et al.

Int. J. Biosci.

2015

Staphylococcus epidermidis isolates were resistant to

bacteria. Generally, Staphylococcus epidermidis is a

Penicillin G (100%), only and sensitive to other tested

common ethiologic agents of nosocomial infections

antibiotics.

of

which is basically associated with infections in

Staphylococcus epidermidis cannot be relied up on

patients implanted with medical devices (Cabrera-

due to the sample size of this bacteria which was very

contreras et al., 2013).

Here,

the

susceptibility

test

small (only one sample), it was the least frequent Table 4.The most resistant bacterial isolates to some antibiotics (Resistance incidence ≥ 50%). Gram stain

Bacterial isolates

Antibiotic to which the isolate was resistant (≥ 50%)

Definition

Gram

Enterococcus faecalis

GM, AUG, CRO, CIP, TS, T, AZI, CD, PG, RIF, NOR

MDR

Staphylococcus Saprophyticus

AUG, TS, CD, PG

MDR

Staphylococcus aureus

CD, PG, NOR, NI

MDR

Staphylococcus epidermidis

PG

Non-MDR

Acinetobacter baumanii

GM, AK, AUG, CEP, CRO, CIP, PIP, CAZ, TS, T, AZI

MDR

Pseudomonas aeruginosa

AMP, AUG, CEP, CRO, T, AZI

MDR

Klebsiella pneumonia

AMP, AUG, CEP, PIP, TS, T

MDR

Proteus mirabilis

AMP, AUG, TS, T, AZI

MDR

Escherichia coli

AMP, AUG, T

MDR

positive

bacteria

Gram

negative

bacteria

MDR= Multi Drug resistant bacteria. AMP=Ampicillin (10 mcg), GM=Gentamicin (10 mcg), AK=Amikacin (30 mcg), AUG=Augmentin (30 mcg), CEP=Cephalothin (30 mcg), CRO=Ceftriaxone (30 mcg), CIP=Ciprofloxacin (5 mcg), PIP=Piperacillin (100 mcg), IMP=Imipenem (10 mcg), CAZ=Ceftizoxime (30 mcg), MER=Meropenem (10 mcg), TS=Cotrimoxazole (25 mcg), T=Tetracycline (10 mcg), AZI=Azithromycin (15 mcg), CD= Clindamycin (2 mcg), OX=Oxacillin (1 mcg), PG=Penicillin G (10 units), RIF=Rifampicin (5mcg), VA=Vancomycin (30mcg), NOR=Norfloxacin (10 mcg) and NI=Nitrofurntoin (300 mcg). The resistance rates of Gram negative isolates are

Cotrimoxazole

shown in Table 3. Interestingly, they were as follows,

Ceftizoxime

Acinetobacter

Piperacillin (8.3) and Amikacin (7.6%), respectively.

resistant,

baumanii

recorded

isolates

considerable

were

highly

Ampicillin

(41.1%),

Ciprofloxacin

(22.2%),

to

Infections caused by Pseudomonas aeruginosa are

Augmentin (100%), Cephalothin (100%), Ceftriaxone

difficult to treat due to its high resistance to large

(100%), Ciprofloxacin (100%), Piperacillin (100%),

numbers of antibiotics which make it serious life

Ceftizoxime

Cotrimoxazole

(100%),

threatening

Azithromycin

(100%)

investigation

(80%),

Pseudomonas aeruginosa isolates are frequently

respectively. Acinetobacter baumanii is one of the

isolated from Saudi hospitals which are highly

most opportunistic pathogens, responsible for serious

resistant and classified as MDR (Yezli et al., 2014).

Tetracycline Gentamicin

(100%),

resistance

(41.6%), (30.7%),

(100%), (90.9%)

and

Amikacin

pathogens in

(Poole,

Saudi

Arabia

2011).

Another

showed

that

infections. The current results are in agreement with previous study stated that almost all strains of

Klebsiella pneumoniae isolates were resistant to

Acinetobacter baumanii were highly resistant to the

Ampicillin (100%), Piperacillin (100%), Cephalothin

majority of antibiotics tested which ranging between

(100%), Augmentin (76.9%), Tetracycline (69.2%),

69%-100% (Goudarzi et al., 2013).

Cotrimoxazole Ceftriaxone

(53.8%),

(15.3%)

and

Gentamicin

(23%),

Azithromycin

(8.3%),

Pseudomonas aeruginosa isolates were resistant to

respectively. Klebsilla pneumonia is an enteric gram-

Azithromycin Augmentin Tetracycline

Gentamicin

(90.9%),

negative bacillus, it is one of the most deadly

(88.8%),

(100%),

Cephalothin

(76.9%),

pathogens of Enterobacteriaceae which are mostly

(71.4%),

Ceftriaxone

(66.6%),

resistant to β-lactam antibiotics and have become an

51 Abdallah et al.

Int. J. Biosci.

2015

international threat (Amin et al., 2009). In a similar

evaluate the susceptibility of different pathogens, in

study in India, up to 50% of Klebsiella pneumonia

order to prescribe the suitable antibiotics to patients.

isolated from pus and urine was found to be

The

multidrug resistant pathogens (Sikarwar and Batra,

surveillance program is a must.

antibiotics

are

losing

their

efficacy

and

2011). Acknowledgement Proteus mirabilis isolates were resistant to Ampicillin

This research was supported by the Deanship of

(100%), Augmentin (90.9%), Cotrimoxazole (90.9%),

Scientific Research, Qassim University, Saudi Arabia,

Tetracycline

(66.6%),

under grant number 2419. The authors thanks Al-

Ceftriaxone (45.4%), Cephalothin (40%), Piperacillin

Rass General Hospital, Saudi Arabia for cooperation

(40%), Gentamicin (36.3%), Ciprofloxacin (27.2%)

and facilitate the practical work. Special thanks to the

and Ceftizoxime (20%), respectively. Proteus species

staff of the Department of Pathology and Laboratory

are one of the major causative bacteria in wound

medicine.

(70%),

Azithromycin

infection. Mordi and Momoh (2009) stated that Proteus mirabilis was the most frequent isolates from

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