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




Dr. Rajendra Kumar Ghritlaharey

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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.


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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.
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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
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2012 | Month : September | Volume : 6 | Issue : 7 | Page : 1200 - 1202 Full Version

The Prevalence of Metallo β-Lactamases in the Clinical Isolates of Pseudomonas aeruginosa in a Tertiary Care Hospital: An Alarming Threat


Published: September 1, 2012 | DOI: https://doi.org/10.7860/JCDR/2012/.2434
Nutan Narayan Bhongle, Neena Vinay Nagdeo, Vilas R. Thombare

1. Assistant Professor, PCMS and RC Bhopal, India. 2. Associate Professor, NKPSIMS and LMH Nagpur, India. 3. Professor and HOD, NKPSIMS and LMH Nagpur, India.

Correspondence Address :
Dr. Nutan Narayan Bhongle
140, Jaidurga Colony 1, Narendra Nagar (South),
Nagpur, India.
Phone: 9921024500
E-mail: Nutan.bobade@yahoo.co.in

Abstract

Introduction:
Pseudomonas aeruginosa is most frequently responsible for nosocomial infection. Current isolates of P. aeruginosa are often multi-drug resistant.
Objective:
Thus present study was done to find out prevalence of metallo-β-lactamases (MBL) in clinical isolates of P. aeruginosa.
Methods:
A total 310 clinical isolates of Pseudomonas were identified and 200 clinical isolates were selected for the study based on their resistance to atleast - 2 third generation cephalosporins.
Results:
29(9.35%) isolates of P. aeruginosa were having zone size <28mm for imipenem , 27 were positive for MBL by EDTA double -disc synergy test (EDTA DDST) and all 29 were positive by modified Hodge test. Minimum inhibitory concentration (MIC’s) were determined by the agar dilution method and 26 isolates out of 29 were resistant, 2 were intermediate isolates & 1 was susceptible as per Clinical and Laboratory Standards Institute (CLSI ) breakpoints. Out of 29 MBL producing isolates, 25 were sensitive to both polymyxin B and colistin, 3 isolates were resistant to polymyxin B but sensitive to colistin, 1 was resistant to polymyxin B and colistin both by disc diffusion method. Sensitivity of MBL producing strains to polymyxin B was found to be 86% and that of colistin was 96.55% in our study.
Conclusion:
The early detection of MBL carrying organisms together with judicious use of antibiotics help in extending the longevity of carbapenems, the last resort antibiotic. MBLs are the major threats for the 21st century which pertain to bacterial drug resistance.

Keywords

P. aeruginosa, MDR, MBL, DDST

Introduction
Pseudomonas aeruginosa is a troublesome opportunistic pathogen which is most frequently responsible for nosocomial infections. The spectrum of the infections ranges from superficial skin infections to fulminant sepsis. It possesses an intrinsic resistance to many antibiotics and it has an ability to develop resistance through mutations in different chromosomal loci or through the horizontal acquisition of resistant genes which are carried on plasmids, transposons or integrons (1). Carbapenems are resistant to hydrolysis by most of the β-lactamases (ESBLs and AmpC beta lactamases) and they are often used as antibiotics of the last resort in infections which are caused by multidrug resistant gram negative bacilli (2). Carbapenem resistance has been observed frequently in P. aeruginosa (3). The carbapenem hydrolyzing β-lactamases are called as metallo β-lactamases (MBL) and they belong to the Bush and Jacoby group 3 classification of β-lactamases. They require the divalent cations of zinc as cofactors for their enzyme activity and they are inhibited by chelating agents like CuCl3, FeCl3, EDTA, sodium mercaptoacetic acid (SMA), 2 mercapto-propionic acid (2MPA), 2 mercaptoethanol (2ME) in vitro (4). P. aeruginosa which produces MBL was first reported from Japan in 1991 (5) and since then, its incidence has been reported from various parts of the world, which include Asia (2), Europe (6),(7),(8) Australia (9),(10) south America (11) and north America (10),(12). The current isolates of P. aeruginosa are often multi-drug resistant (MDR) (2). The infections which are caused by such bacteria are believed to result in high mortality as well as high healthcare costs and a prolonged hospitalization and so, a regular monitoring of the incidence of the β-lactamase producing organisms has become the need of the time (13).

Material and Methods

This study was carried out in the Department of Microbiology in a tertiary care hospital from December 2008 to November 2010. Some criteria were applied for the isolation of the clinically significant P. aeruginosa isolates as per the CDC/NHSN surveillance definition of the health care–associated infections and the criteria for specific types of infections in the acute care setting (14). The identification of P.aeruginosa was done as per the standard of biochemical tests (15). The third generation cephalosporin resistant P. aeruginosa which displayed a reduced susceptibility or resistance to imipenem by the disc diffusion method were selected for further studies (the zone size for imipenem was <28mm), since MBL was responsible for the carbapenem resistance. These strains were further screened for the MBL production by the double disc synergy test (DDST) which used EDTA and by the modified Hodge test. The minimum inhibitory concentration of imipenem was obtained by the agar dilution method as was recommended by clinical laboratory standard institute (CLSI) guidelines (16).
The Double Disc Synergy Test with EDTA (17)
The test strains were adjusted to McFarland’s 0.5 standard and a lawn culture was put up onto Mueller Hinton agar plates. 2 discs of 10 μg imipenem were placed on plate at 15mm distance. To one of the imipenem discs, 10μl of 0.5 M EDTA was added. This disc contained 1900 μg of EDTA. After an overnight incubation at 37ÂşC, the MBL-positive isolates could be well demarcated from the MBL-negative isolates on the basis of the criterion of more than 7 mm of increase of the inhibition zone with the disks to which EDTA was added .
The Modified Hodge Test (18)
The indicator organism, Escherichia coli ATCC 25922, at a turbidity of 0.5 McFarland’s standard, was swab inoculated onto the surface of a Mueller Hinton agar plate. The test strain was heavily streaked from the centre of the plate to its periphery and a 10μg imipenem disc was placed at the centre. The plate was incubated overnight. The presence of a distorted inhibition zone was interpreted as a positive result for the carbapenem hydrolysis screening. All these MBL producing strains were tested for their MICs against imipenem by the agar dilution method and they were then tested for their susceptibility to polymyxin B (300 units) and colistin (10 μg) by using commercially available disks (Hi Media), by the Kirby Bauer disc diffusion method (19).

Results

A total of 310 isolates of P. aeruginosa were isolated, of which 200 isolates were resistant to th 3rd generation cephalosporins (ceftazidime 30μg/ cefotaxime 30μg). Of these isolates, 29 had a zone size of <28mm for imipenem , out of which 27 were positive for MBL by the DDST with EDTA test and all 29 were positive by the modified Hodge test, as has been shown in (Table/Fig 2) One isolate was found to be susceptible to imipenem on the basis of its MIC, but it was also found to be positive for MBL by both the methods, thus indicating that MBL producers could show susceptibility to imipenem. All these MBL producing isolates were tested for their susceptibility to polymyxin B and colistin by the disc diffusion method.

Discussion

The prevalence of MBLs in P. aeruginosa was reported to be 10-30% among various clinical samples which were tested across the country (20). In our study, the frequency of the MBL producing P. aeruginosa was highest in urine i.e., 3.8%, followed by 2.2% in pus, 1.9% in respiratory specimens, 0.6% in blood and 0.3% in other samples as shown in (Table/Fig 1). Similarly, K Lee et al. (2009) (2), Ami Varaiya et al. (2008) (20), I. Aibinu et al. (2007) (21) had mentioned similar incidences of the MBL producing P. aeruginosa in various samples. Various studies had reported varying results regarding the comparative outcome of the DDST and the modified Hodge tests, but there no clear reason was found for such a variation amongst the 2 tests. In our experience, out of the 29 imipenem resistant isolates, all the 29 were found to be positive for metallo beta lactamases by the modified Hodge test and 27 were found to be positive by the double disc synergy test. As per our study, the modified Hodge test had detected 2 additional MBL producers as compared to the DDST test. Although (comparative statistical analysis) the pvalues of these two tests were not significant (<0.05), any of these 2 tests could be used for screening MBLS. However, the modified Hodge test is easy to perform, it doesn’t require any inhibitors and it is a cheaper test in comparison to DDST. In this study, 26 of the 29 MBL producing P. aeruginosa was resistant to imipenem, 2 were intermediately resistant and 1 isolate was sensitive as per breakpoints as shown in (Table/Fig 3).

One isolate was found to be sensitive to imipenem on the basis of its MIC, but it was found to be positive for MBL by both the tests, thus indicating that MBL producers could show susceptibility to imipenem. The organisms can appear to be susceptible to carbapenems though they carry carbapenemases. Such organisms thus carry hidden MBL genes, whereby the microbiologist may remain unaware of their presence (22). As per (Table/Fig 4), out of 29 MBL producing isolates, 25 were sensitive to both polymyxin B and colistin, 3 isolates were resistant to polymyxin B and sensitive to colistin and 1 isolate was resistant to both by the disc diffusion method. The sensitivity of the MBL producing strains to polymyxin B was found to be 86% and that of colistin was found to be 96.55% in our study; which correlated with the findings of A C Gales et al (2003) (11) and I M Heijden et al. (2007) (23) and it differed from the findings of G Agrawal et al. (2008) (24).

The development of simple screening tests which are designed to detect the β-lactamases will be a crucial step towards a large scale monitoring of these emerging resistant strains. Such institutional studies will help in the formulation of an antibiotic policy for a particular geographical area. A good infection control practice and a careful introspection during the prescription of beta-lactam drugs are necessary for the formulation of a good antimicrobial policy in a hospital. The combination of piperacillin and tazobactum and that of polymyxin B and colistin should be kept as reserve drugs and they should be used only in patients who have infections which are caused by MDR organisms, especially the strains which produce MBLs.

The current data suggests that the MBLs are a heterogeneous group of enzymes which may prove it difficult in the designing agents that would be efficient against all MBLs. Combating the MBLs may prove to be a therapeutic challenge (25). The mobile MBLs genes are capable of a horizontal spread among the nosocomial strains of Enterobacteriaceae. P. aeruginosa and other gram-negative nonfermenters may have considerably increased the attention which has been given to these enzymes, thus including them among the major threats for the 21st century in the field of microbial drug resistance (26). As the phenotypic methods are easier to perform, they are able to discriminate among the various beta lactamases, which the automated systems fail to do. Hence, the phenotypic methods should be regularly performed where the molecular methods are not available. Strict infection control practices, the judicious use of antibiotics, an early detection of the MBL carriage, all will together help in extending the longevity of the carbapenems, which are the last resort antibiotics.

References

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Lee K, Park AJ, Kim MY, Lee HJ, Cho J-H, Kang JO, et al. Metallo-β- lactamase producing Pseudomonas spp. in Korea: a high prevalence of the isolates with the VIM-2 type and the emergence of the isolates with the IMP-1 type. Yonsei Med J 2009;50(3):335-39.
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Arakawa Y, Shibata N, Shibayama K, Urokawa HK, Yagi T, Fujiwara H, et al. A convenient test which was done for screening the metallo- β-lactamase producing gram negative bacteria by using thiol compounds. J Clin Microbiol 2000;38(1):40-43.
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Lagatolla C, Tonin EA., Monti-Bragadin C, Dolzani L, Gombac F, Bearzi C, et al. Endemic carbapenem resistant Pseudomonas aeruginosa with acquired metallo-β-lactamase .determinants in a European hospital. Emerg Infect Dis 2004; 10(3):535-39.
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Libisch B, Gacs M, Csiszar K, Muzslay M, Rokusz L, Fuzi M. The isolation of an integron-borne blaVIM-4 type metallo-β-lactamase gene from a carbapenem-resistant Pseudomonas aeruginosa clinical isolate in Hungary. Antimicrob Agents Chemother 2004; 48(9): 3576-78.
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Patzer J, Toleman MA, Deshpande LM, Kaminska W, Dzierzanowska D, Bennett PM, et al. The Pseudomonas aeruginosa strains which harbour an unusual blaVIM-4 gene cassette, which were isolated from hospitalized children in Poland (1998-2001). J Antimicrob Chemother. 2004; 53(3):451-56.
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Peleg AY, Franklin C, Bell JM, Spelman DW. The dissemination of the metallo-β-Lactamase gene, blaIMP-4 among gram-negative pathogens in a clinical setting in Australia. Clin Infect Dis 2005; 41:1549-56.
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Saderi H, Karimi Z, Owlia P, Bahar MA, Rad SMBA. The phenotypic detection of metallo-beta-lactamase producing Pseudomonas aeruginosa strains which were isolated from burn patients. Iranian Journal of Pathology 2008;3 (1): 20-24.
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Gales AC, Menezes LC, Silbert S, Sader HS. The dissemination in distinct Brazilian regions of an epidemic carbapenem-resistant Pseudomonas aeruginosa which produces an SPM metallo-β- lactamase. Journal of Antimicrobial Chemotherapy 2003;( 52): 699- 702.
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Toleman MA, Rolston K, Jones RN, Walsh TR. The molecular and the biochemical characterization of OXA-45, an extended-spectrum class 2d β-Lactamase in Pseudomonas aeruginosa. Antimicrobial Agents and Chemotherapy 2003; 47(9) : 2859-63.
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Carmeli Y, Troillet N, Karchmer AW, Samore MH. Health and the economic outcomes of antibiotic resistance in Pseudomonas aeruginosa. Arch Intern Med. 1999;159:1127-32.
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Horan TC, Andrus M, Dudeck MA. The CDC/NHSN surveillance definition of the health care–associated infections and the criteria for specific infections in the acute care setting. Am J Infect Control 2008;36(5):309-32.
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ID: JCDR/2012/4562:2434

Financial OR OTHER COMPETING INTERESTS:
None.
Date of Submission: May 19, 2012
Date of Peer Review: Jul 17, 2012
Date of Acceptance: Aug 03, 2012
Date of Publishing: Sep 30, 2012

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