Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
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Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




Dr Mohan Z Mani

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Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2012 | Month : May | Volume : 6 | Issue : 4 | Page : 645 - 651

Antibiotic Resistance Pattern in Uropathogens at a Tertiary Care Hospital at Jhalawar with Special Reference To Esbl, AmpC b-Lactamase and Mrsa Production

Gaurav Dalela, Sweta Gupta, Dinesh Kumar Jain, Pushpa Mehta

1. Assistant Professor, Department of Microbiology, Jhalawar Medical College and Hospital, Jhalawar, Rajasthan, India - 326001. 2. Professor And Head, Department of Microbiology, Mahatma Gandhi Medical College and Hospital, Sitapura, Jaipur, Rajasthan, India. 3. Resident, Department of Microbiology, Mahatma Gandhi Medical College and Hospital, Sitapura, Jaipur, Rajasthan, India. 4. Professor And Head, Department Of Microbiology, Jhalawar Medical CoLlege And Hospital, Jhalawar, Rajasthan, India - 326001.

Correspondence Address :
Gaurav Dalela
Assistant Professor, Department of Microbiology,
Jhalawar Medical College and Hospital, Jhalawar,
Rajasthan, India - 326001.
Phone: 09314607245
E-mail: drgauravdalela@yahoo.in

Abstract

Background: Urinary tract infections (UTIs) are one of the most common bacterial infections in humans, both in the community as well as in the hospital settings. Worldwide, the data show that there is an increasing resistance among the organisms which cause UTI, to the conventional drugs. A study on the changing antibiotic resistance pattern is pertinent for an appropriate treatment and for the prevention and control of the different mechanisms of resistance.

Aim: To find out the drug option for the treatment of UTI due to the presence of various clinical isolates in our geographical area, in the current scenario of increasing antimicrobial resistance, with special reference to ESBL, AmpC β-lactamase and MRSA production.

Materials and Methods: A total of 184 clinical isolates from the urine of various patients who presented to the outpatient and inpatient departments of Jhalawar Medical College and Hospital, Jhalawar, Rajasthan, India, were studied from January 2011 to September 2011. The antimicrobial susceptibility to various drugs was studied by the disc diffusion method, by following the CLSI guidelines. Confirmation of the extended spectrum β-lactamase (ESBL), ampC β-lactamase and methicillin resistant Staphylococcus aureus (MRSA) production was done by the phenotypic confirmatory disc diffusion test (PCDDT), the ampC disk test (ADT) and the oxacillin E test respectively.

Results: The antibiotic sensitivity pattern of the gram negative bacilli (GNB) revealed that the maximum sensitivity was seen for imipenem (95.1%), followed by cefoxitin (79.6%), piperacillin/ tazobactum (71.8%), cefepime (71.8%), and amikacin (66.9%), and that of the gram positive cocci (GPC) showed that the maximum sensitivity was seen for vancomycin and linezolid (100%), followed by amikacin (95.2%), gentamicin (69.1%) and nitrofurantoin (61.9%). High resistance was seen against amoxycillin/clavulanate, cotrimoxazole, cefotaxime, doxycycline and norfloxacin. Overall, the prevalence of ESBL and ampC β-lactamase and the coexistence of the phenotype (ESBL + ampC β-lactamase) and MRSA in the urinary isolates was found to be 66.9%, 21.1%, 3.5% and 42.4% respectively.

Conclusion: Among the oral drugs, amoxycillin/clavulanic acid, norfloxacin, doxycycline and co-trimoxazole should no longer be considered as the first line drugs for the empirical treatment of clinically evident UTI, because of the very high resistance rates. Nitrofurantoin can be used as an alternative drug only after the sensitivity testing. Parentral drugs such as aminoglycosides, carbapenams and piperacillin/tazobactum can be the alternative choice for complicated UTI. Also, control measures which include the judicious use of antibiotics, antibiotic cycling, the implementation of appropriate infection control measures and the formulation of an antibiotic policy must be done, to prevent the spread of these strains.

Keywords

UTI, Antibiotic resistance, ESBL, AmpC β-lactamase, MRSA

INTRODUCTION
Urinary tract infections (UTIs) are one of the most common bacterial infections in humans, both in the community as well as in the hospital settings (1),(2),(3). In almost all the cases, there is a need to start the treatment before the final microbiological results are available. Area specific monitoring studies which are aimed to gain knowledge about the type of pathogens which are responsible for UTIs and their resistance patterns may help the clinicians to choose the right empirical treatment. Knowledge on the antibiotic resistance patterns of the pathogens is important not only to provide an appropriate therapy, but also for the prevention of resistance amongst the microbes, as the treatment is given without considering the prevalent microbe and its antibiotic resistance pattern results in the selection of more resistant strain (4) and also increase in the prevalence of resistance mechanisms. The aim of the study was to obtain data on the resistance patterns of the major pathogens from patients with UTIs, to the antimicrobial Original Article agents which are currently used in the treatment of UTIs, along with the production of resistance mechanisms such as ESBL, AmpC β-lactamase and MRSA.

Material and Methods

Bacterial isolates: A total of 184 consecutive, non-repetitive, clinical isolates which were obtained from the patients of UTI in the clinical bacteriology laboratory, Jhalawar Medical College, Jhalawar, Rajasthan, India from January 2011 to September 2011, were included in the study.

Antimicrobial susceptibility testing: The isolates were tested by disc diffusion method (modified Kirby-Bauer method) on Muller Hinton agar (Hi-Media), by following the zone size criteria which was recommended by the CLSI (5). The antibiotics (μg) which were included for the gram negative isolates were amikacin (30), piperacillin (100), piperacillin/tazobactum (100/10), cefepime (30),cefotaxime (30), ceftriaxone (30), ceftazidime (30), amoxyclav (20/10), cotrimoxazole (25), norfloxacin (10), imipenam (10), doxycycline (30), azithromycin (15), nitrofurantoin (300) and cefoxitin (30). The gram positive clinical isolates were tested with amoxyclav (20/10), cephalexin (30), linezolid (30), azithromycin (15), doxycycline (30), cefotaxime (30), norfloxacin (10), amikacin (30), gentamicin (10), vancomycin (30), cotrimoxazole (25) and nitrofurantoin (300).

Criteria for the selection of the ESBL producing strains: The isolates were tested for their susceptibility to the third generation cephalosporins (3GCs) e.g. ceftazidime (30 μg), cefotaxime (30 μg) and ceftriaxone (30 μg) by using the standard disc diffusion method, as was recommended by the CLSI (5). If a zone diameter of < 22 mm for ceftazidime, < 27 mm for cefotaxime and < 25 mm for ceftriaxone were recorded, the strain was considered to be “suspicious for ESBL production” (5). Only those isolates which were resistant to one of the 3 GCs were selected for the study and they were processed for the ESBL production.

The phenotypic confirmatory disc diffusion test (PCDDT): All the strains which were screened out for the ESBL production were subjected to confirmation by using the PCDDT, as was recommended by the CLSI (5). In this test, ceftazidime (30 μg) discs alone and in combination with clavulanic acid (ceftazidime +clavulanic Acid, 30/10 μg) discs, were applied onto a plate of Mueller Hinton Agar (MHA) which was inoculated with the test strain. An increase of ≥ 5mm in the zone of inhibition of the combination discs in comparison to that of the ceftazidime disc alone was considered to be a marker for ESBL production (5) (Table/Fig 1).

The AmpC Disc Test (ADT): All the screened isolates were tested for the confirmation of AmpC β-lactamase production by using ADT. A lawn culture of Escherichia coli ATCC 25922 was prepared on an MHA plate. A sterile disc (6 mm) was moistened with sterile saline, it was inoculated with several colonies of the test organism and it was placed besides a cefoxitin disc (almost touching) on the inoculated plate. The plate was incubated overnight at 350C aerobically for 16-18 hours. A positive test was indicated as a flattening or indentation of the cefoxitin inhibition zone in the vicinity of the test disc. An undistorted zone showed a negative test (6) (Table/Fig 2).

The Oxacillin E test: The MICs of oxacillin were determined by the E-test (AB Biodisk, Solna, Sweden), according to the instructions of the manufacturer (7). The plates were inoculated by swabbing the surfaces with a 0.5 McFarland’s standard bacterial suspension on the MHA medium which was supplemented with 2% NaCl. The E-test strips were placed on the medium, and the plates were then incubated at 35°C for 24 hrs. The results were analyzed on the basis of the CLSI guidelines (5) (Table/Fig 3).

Quality control: Escherichia coli ATCC 25922 (β-lactamase negative), Klebsiella pneumoniae ATCC 700603 (ESBL-producing), Staphylococcus aureus ATCC 25923 (Oxacillin susceptible) and Staphylococcus aureus ATCC 43300 (Oxacillin resistant) were used as the control strains (5).

Statistical analysis: The statistical analysis was performed by using the Chi-square test and a p value of less than 0.05 was considered as statistically significant.

Results

The present study was conducted in the Clinical Bacteriology Laboratory, Department of Microbiology, Jhalawar Medical College,Jhalawar, Rajasthan, from January 2011 to September 2011, to know the antibiotic resistance patterns of the uropathogens in our geographical area, in the current scenario of increasing antimicrobial resistance, with special reference to the various mechanisms of drug resistance which were observed at our tertiary health care centre.

The antibiotic sensitivity pattern of the gram negative bacilli revealed that the maximum sensitivity was seen for imipenem (95.1%), followed by cefoxitin (79.6%), piperacillin/tazobactum (71.8%), cefepime (71.8%), amikacin (66.9%) and nitrofurantoin (54.2%). The maximum resistance was seen against ceftazidime and amoxycillin/clavulanate (82.4%), piperacillin (80.3%), cotrimoxazole (78.9%), ceftriaxone (78.2%), cefotaxime and doxycycline (77.5%) and norfloxacin (67.6%) (Table/Fig 4). The antibiotic sensitivity pattern for gram positive cocci revealed that 100% sensitivity was seen for vancomycin and linezolid, followed by amikacin (95.2%), gentamicin (69.1%), nitrofurantoin (61.9%) and norfloxacin (52.4%). The maximum resistance was seen against cotrimoxazole (83.3%), cefotaxime (59.5%), azithromycin and cephalexin (57.1%), amoxycillin/clavulanate and doxycycline (50%) (Table/Fig 5).

Overall, the prevalence of ESBL and ampC β-lactamase and the coexistence of the phenotype (ESBL + ampC β-lactamase) and MRSA in the urinary isolates was found to be 66.9%, 21.1%, 3.5% and 42.4% respectively (Table/Fig 6) and (Table/Fig 7). Only 2 ESBL producer strains, one of which was Citrobacter freundii, was sensitive to ceftazidime and the second, Proteus mirabilis, was intermediately sensitive to ceftazidime. All the other isolates showed resistance to ceftazidime, thus indicating that ceftazidime was a good drug for the detection of the ESBL activity. This showed a significant correlation (p value <0.01). One isolate of Klebsiella pneumoniae and 4 isolates of Escherichia coli showed coexistence of their phenotypes. Only one cefoxitin sensitive isolate of K. pneumoniae showed the production of ampC β-lactamase. It showed a significant correlation (p value <0.01) along with the production of ESBL. All the cefoxitin resistant GNB and GPC were ampC β-lactamase and MRSA producers respectively, thusindicating that cefoxitin was a good drug for the detection of ampC β-lactamase as well as MRSA production. This showed a highly significant correlation (p value <0.001) The maximum ESBL activity was seen in Escherichia coli (73.5%), followed by Acinetobacter spp. (66.1%), Proteus vulgaris (66.7%) and Klebsiella pneumoniae (59.1%). The maximum ampC β-lactamase production was found in Providencia spp. (100%), Citrobacter freundii (50%), Proteus vulgaris (33.3%), Klebsiella pneumoniae (31.8%) and Escherichia coli (18.4%). The ΜRSΑ production was maximally seen in Staphlococcus saprophyticus (50%) and Staphylococcus aureus (41.4%). Out of 23 oxacillin resistant strains, only 14 isolates were resistant to cefoxitin, which were further confirmed as MRSA strains by the oxacillin e-test, which showed a highly significant correlation (p value <0.001) [Table/Fig-6] and (Table/Fig 7).

The prevalence of ESBL and ampC β-lactamase and the coexistence of the phenotype and the MRSA production in the outdoor patients was 66.9%, 17.9%, 2.7% and 31.8% respectively, while in the indoor patients, it was 66.7%, 33.3%, 6.7% and 63.6% respectively, thus indicating that the prevalence of the resistance mechanisms were more common in the indoor patients as compared to that in the outdoor patients, thus indicating a highly significant correlation (p value <0.001) (Table/Fig 8).

ESBL producers have less resistant isolates for piperacillin/tazobactum (24.2%), amikacin (26.3%), cefepime (16.8%) and cefoxitin (4.2%) as compared to their counterpart non ESBL producers (p value >0.05), because the non ESBL producers can have different mechanisms for their resistance patterns, such as the production of ampC β-lactamase, metallo-betalactamase, etc. in having more drug resistant isolates. For other antibiotics, the resistance pattern was quiet more in the ESBL, ampC β-lactamase and the MRSA isolates as compared to their counterparts, thus showing a highly significant correlation (p value <0.001). In the ampC β-lactamase producers, amoxycillin/clavulanate and ceftriaxone showed 100% resistance (Table/Fig 9),(Table/Fig 10) and (Table/Fig 11).

Discussion

Most of the nosocomial UTIs are caused by gram-negative bacteria, particularly Escherichia coli, Klebsiella spp., Pseudomonas spp., and organisms from the Enterobacteriaceae group. Collectively, they account for more than 80% of the culture positive cases of UTIs and the rest are caused by gram positive cocci such as Staphylococcus aureus and fungi, e.g. candida species. Fungal infections have gained increased prevalence with the advent of HIV/ AIDS and with the widespread use of broad spectrum antibiotics.

This also causes an increase in the prevalence of multidrug resistant organisms.

Continuous monitoring systems and effective infection control measures are absolutely required to prevent the rapid and worldwide spread of ESBL, ampC β-lactamase and MRSA producing organisms. The therapeutic options for the infections which are caused by these organisms have also become increasingly limited. Although most of the outbreaks were limited to the high risk patient care areas such as ICUs, oncology units, etc., the first report of an outbreak in nursing homes appeared in the literature in the year 1999 (8). Therefore, now- a- days the threat of the ESBL, ampC β-lactamase and the MRSA producing isolates is not limited to the ICUs or the tertiary care hospitals only, but they are also found in OPD patients. The Clinical and Laboratory Standards Institute (CLSI) have issued recommendations for ESBL and MRSA screening and for their confirmation. No CLSI recommendations exist for ESBL detection, for the reporting for organisms other than Escherichia coli and Klebsiella spp. (9) and also for the detection of ampC β-lactamase, which were included in our study.

The prevalence of the ESBL producers as in previous studies from India was reported to be 6.6 to 68%. Subha et al (10) reported 6.6% ESBL producers among Klebsiella pneumoniae from children, whereas Babypadmini et al (11) showed 40.3% ESBL producers in their study cohort. The occurrence of ESBL producers among the gram negative bacilli in the current study was 95/142 (66.9%), while 73.5% Escherichia coli, 66.7% Acinetobacter lowffi and Proteus vulgaris, 59.1% Klebsiella pneumoniae, 50% Proteus mirabilis, Citrobacter koserii and Citrobacter freundii and 28.6% Pseudomonas aeruginosa were found to elaborate ESBLs. The ESBL production which was reported among gram negative bacteria by Mathur et al (12), Singhal et al (13) and C. Rodrigues et al (14) correlated well with that which was found in our study. We observed that 73.5% Escherichia coli and 59.1% Klebsiella pneumoniae isolates were ESBL producers. Although K. pneumoniae was more often reported as an ESBL producer in other studies, in our study, the ESBL production was more common in the Escherichia coli isolates as compared to that in the K. pneumoniae isolates. (11), (15), (16).

The ESBL production in Pseudomonas aeruginosa is less (28.6%) as compared to that in other gram negative bacilli, because their resistance mechanism is mediated by the production of metallobetalactamase, lack of drug penetration due to mutations in the porins or loss of certain outer membrane proteins and an efflux pump. (13), (17), (18) Recently, the co-existance of both ampC β-lactamase and ESBL in some gram negative bacilli has also been reported. This could be because plasmid mediated ampC β-lactamase has been disseminated among the Enterobacteriaceae, sometimes in combination with ESBL (13). Such strains may give false negative tests in the detection of ESBL. 3.5% (5/142) of the isolates in the present study probably represented co-existance of the phenotypes of both the ampC β-lactamase and the ESBL producers, as was mentioned by Singhal et al (13). 1.25% (1/80) of such a co-existence among the Escherichia coli isolates was demonstrated. With Klebsiella spp. and Escherichia coli, clavulanic acid may induce the expression of high-level AmpC production, and it may then antagonize rather than protect the antibacterial activity of the partner β-lactam, thus masking any synergy which might have arisen from the inhibition of an ESBL. A much better inhibition was achieved with the sulfones such as tazobactam and sulbactam (19). Another reasonable approach is to rely on cefepime as an ‘indicator drug’. High-level AmpC production has a minimal effect on the activity of cefepime, thus making this drug a more reliable detection agent for ESBLs in the presence of an AmpC β-lactamase (19).

There were 21.1% AmpC β-lactamase producers in our study. 37.5% and 47.8% have been reported from Chennai and Kolkata, respectively (20), (21). Cefoxitin resistance can be used to screen the isolates for detecting any possible ampC β-lactamase production. But the lack of permeation in the porins has also been reported as one of the resistance mechanisms of cefoxitin in the ampC nonproducers (22). AmpC β-lactamase production in the cefoxitin susceptible isolates may have a mechanism which is similar to that of the ESBL producing organisms. Only one cefoxitin sensitive isolate of K. pneumoniae showed the production of ampC β-lactamase along with the production of ESBL. Thus, although studies have indicated that the screening methods which use cefoxitin in the standardized methods to detect the ampC harbouring isolates are useful, they are not still perfect (23) as compared to genotyping.

The identification of the mecA gene is the most reliable method for detecting the MRSA isolates. However, not all laboratories can include molecular biology techniques in their routine clinical practice. So, it is essential that phenotypic techniques which are able to detect the MRSA isolates in a rapid and accurate manner are made available, in order to ensure the correct antibiotic treatment and to avoid the spread of the MRSA isolates in the hospital environment. This study confirms that those antibiotics which are able to induce the expression of methicillin resistance, e.g. cefoxitin, are the most appropriate drugs for detecting the MRSA isolates, as was found in our study also. In our study, the confirmation of the MRSA isolates was done by the oxacillin E-test which gave a correlative study with cefoxitin, but the oxacillin disc showed false positivity. The mecA-positive isolates were detected with the cefoxitin disc (30 μg) in predicting oxacillin resistance has been reported (24),(25),(26). It has been suggested that no special medium or incubation temperature is required for cefoxitin (25), so that it can be used as better indicator for the detection of MRSA.

The prevalence of MRSA was 42.4% in our study, while Sanjana RK et al (27) in Nepal, detected the prevalence of MRSA as 39.6%, Rajaduraipandi K et al (28) in Coimbatore found 31.1% strains of MRSA and Anupurba S et al (29) in eastern Uttar Pradesh found a 54.85% prevalence of MRSA, which correlated well with the findings of our study. Onanuga A et al (30) in Nigeria have reported a high prevalence of 69%, while Coombs GW et al (31) in Australia found it to be very low as 16%. A majority of the urinary isolates were susceptible to imipenem (95.1%) and piperacillin/tazobactum and cefepime (71.8%). Similarly, in a study from Coimbatore, all the members of Enterobacteriaceae were found to be susceptible to imipenem and piperacillin/tazobactum (32). In both the studies, amikacin also showed good activity against the gram negative bacteria. Therefore, imipenem is the most active drug for the treatment of infections which are caused by the ESBL producers, followed by piperacillin/ tazobactum and amikacin. Carbapenem must be kept in reserve for non-life-threatening infections, where other susceptible antibiotics can be used (14). The heavy use of carbapenem, in fact, may favour the selection of Stenotrophomonas maltophilia (a species which is naturally resistant to these drugs) (33).

Only 2 ESBL producer strains, one of which was Citrobacter freundii was sensitive to ceftazidime and the second, Proteus mirabilis was intermediately sensitive to ceftazidime. All the other isolates showed resistance to ceftazidime, thus indicating that ceftazidime was a good drug for the detection of ESBL production in our study. Therefore, cefpodoxime and ceftazidime have been proposed as the indicators of ESBL production as compared to cefotaxime and ceftriaxone (34). The use of a three day course of co-trimoxazole, as recommended by the Infectious Disease Society of America (IDSA), is a first line treatment, except in communities with a high rate of resistance (>10-20%) among uropathogens (35). A very high resistance rate (78.9% in case of GNB and 83.3% in case of GPC) was found against this drug and so this drug couldn’t be used in our geographical area.

Norfloxacin, as it is an oral drug which is cost effective and which has an easy dosing schedule, is commonly prescribed for the treatment of UTI, not only in India, but also in other countries (36). It showed a high resistance rate (67.6% in GNB and 47.6% in GPC) in our study, which reflects that an increased quinolone resistance was seen in our area, which was showed by other studies also (37),(38),(39).

Among other oral antibiotics, nitrofurantoin was found to be more effective in the treatment of UTI, only after the culture and sensitivity testing studies were done. This finding has been corroborated by other studies also (4), (40), (41). Akram M et al, in Aligarh, found a very high resistance rate (80%) to nitrofurantoin in patients with community acquired UTI (38). The inappropriate and empirical usage of wide spectrum antibiotics, insufficient hygiene, immunosuppression and a prolonged stay in the hospital are some of the major aetiological factors that elevate the chances of infection (39). Continuous analysis of the antibiotic resistance pattern acts as a guide in initiating the empirical treatment of UTI and the therapy must be started only after the urine culture and the sensitivity testing have been done. This acts as a gold standard test and it helps in avoiding the treatment failure. So, the rapid dissemination of the antibiotic resistance and its mechanism can be prevented.

Conclusion

It is essential to report ESBL, AmpC β-lactamase and MRSA production along with the routine susceptibility testing, which will help the clinicians in prescribing proper antibiotics. The addition of ceftazidime + clavulanic acid for the detection of ESBL and the addition of cefoxitin for the detection of AmpC β-lactamase and MRSA must be done for the reporting of resistant organisms, because the restricted use of antibiotics can lead to the withdrawal of selective pressure and the resistant bacteria will no longer have a survival advantage against these antibiotics. In the end, it is felt that there is a need to formulate strategies to detect and prevent the emergence of resistance for an effective treatment of the infections which are caused by them.

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