Microbial Profile and Antibiotic Susceptibility of the Bacterial contaminants of infected Wounds… Hameed-ud Din et al

Original Article

Hameed-ud-Din*
Microbial Profile and Antibiotic Muhammad Saaiq**
Muhammad ibrahim Khan***
Susceptibility of the Bacterial
contaminants of infected Wounds- *Assistant Professor
**Postgraduate Resident
*** Senior Registrar
Experience at a Plastic and Department of Plastic Surgery,
Reconstructive Unit PIMS, Islamabad

Objective: To study the microbial profile of the infected wounds and to detect the
antibiotic susceptibility pattern of the microbes in our setup.
Study design: Single centre non-interventional descriptive study.
Place and duration of the study: Department of plastic and Reconstructive Surgery,
Pakistan Institute of Medical Sciences (PIMS), Islamabad from Jan 2004 to Dec. 2005.
Subjects and Methods: A total of 193 adult patients of either gender having clinical
features of infected wound were included in the study. Patients with healthy wounds, those
who had been taking antibiotic therapy within the preceding 72 hours and those not
consenting to participate in the study were excluded. Specimens for culture and sensitivity
were collected by employing standard collection techniques and analyzed at a single
microbiological laboratory. All the samples were incubated for 24 hours at 37 C for
obtaining aerobic and anaerobic growths. Microbes were identified by their colonial
morphology and characteristic biochemical tests.
Results: There was male predominance with a male : female of 2.11 : 1 . The mean age
was 33 + 16.21 years with a range of 15-68 years. Bacterial growths were obtained in 127
(65.8 % ) specimens while the remaining 66 (34.2 %) specimens yielded no growth. 119
(93.7 % ) isolates were monobacterial whereas 8 (6.29 %) were polybacterial . Pseudomonas
aeruginosa 49 ( 36.02%) was the most frequent isolate followed by Escherichia coli 31
(22.79 %), Staphylococcus aureaus 17 ( 12.5 %), Klebsiella pneumoniae 12 (8.82%) ,
Methicillin resistant Staphylococcus aureaus (MRSA) 10 ( 7.35 %), Acinetobacter 8 (5.88%),
Proteus and Enterobacter each 4 (2.94%) and Serratia 1 (0.73%). Sensitivity tests showed
variable response to different antibiotics.
Conclusion: In this era of evidence based medicine and evidence based surgery the
importance of objectivity can’t be overemphasized. For evidence based antibiotic
prescribing practices it is mandatory to have periodic audits of the infected wounds to
know about the invading microbes and their antibiotic susceptibility. This will also help not
only to prevent the emergence of antibiotic resistance owing to the irrational and
indiscriminate use of antibiotics but also reduce the financial sufferings of our
patients.
Key words: Wound infection, Culture and sensitivity, Antibiotic resistance.
management with the application of various potions and
Introduction grease to assist wound healing. 1,2 For centuries the
process of wound healing remained a mystery as
Surgeon has no greater enemy than wound infection. highlighted by the famous saying by French military
The history of wound infection is probably as old as that surgeon Ambroise Pare’ “I dressed the wound , God
of surgery itself. The ancient Egyptians were the first healed it . 3 German microbiologist Koch laid down the
civilization to have a definite protocol for wound first scientific definition of infection through his famous

Ann. Pak. Inst. Med. Sci. 2006; 2(2): 93-98 93

Microbial Profile and Antibiotic Susceptibility of the Bacterial contaminants of infected Wounds… Hameed-ud Din et al

Koch’s postulates.4 The discovery of Penicillins by
Alexander Fleming (1881-1955) heralded a new era in
wound management that led to the proliferation of many
other antibiotics especially Cephalosporins in 1950s
.4,5 Despite of significant advances in antimicrobial and
surgical therapy wound infection continues to pose a
major challenge in the context of surgery and trauma.
The wound may become infected either by the patient’s
own endogenous flora present on the skin, mucosa or
in hollow viscera or by exogenous microbes. The
chance of developing an established wound infection
depends on a variety of factors most notably the count
and virulence of the microbes and the host defense
mechanisms. Generally infection is associated with a
bacterial count of over 10,000 per gram tissue or per
square cm in case of burns.6
In Plastic and Reconstructive surgery, wound infection
in an elective procedure rather happens to be a
catastrophe. As the bacterial spectrum of wounds and
their antibiotic susceptibility vary from unit to unit and
center to center, the present study was conducted to
establish our own database regarding the microbial
profile of infected wounds as well as their antibiotic
sensitivity profile. Such studies would ensure more
appropriate and rational use of antibiotics thereby not
only reducing the financial sufferings of the ailing
humanity but also help to prevent the emerging
antibiotic resistance which poses a major threat to
the existing antimicrobial therapies
Materials and Methods
This non-interventional descriptive study was
undertaken at the department of Plastic and
Reconstructive Surgery, Pakistan Institute of Medical
Sciences (PIMS), Islamabad from Jan 2004 to Dec.
2005. It prospectively included 193 adult patients of
either sex by convenience sampling technique. All
patients with local or systemic clinical features of wound
infection were included in the study. Patients with
healthy wounds, those who had been taking antibiotic
therapy within the preceding 72 hours and those not
consenting to participate in the study were excluded
from the study Specimens for culture and sensitivity
were collected by employing standard
collection techniques 7 and analyzed at a single
microbiological laboratory for culture and sensitivity.
After inoculation on appropriate culture media, the
specimens were incubated for 24 hours at 37 C for
obtaining aerobic and anaerobic growths. The microbes
were identified by their colonial morphology and
characteristic biochemical tests. Antibiotic susceptibility
was tested by employing disc diffusion method
according to NCCLS (National Committee for Clinical
Laboratory Standards) guidelines using standard
antibiotic discs. 8
STASTICAL ANALYSIS:
The data were analyzed through SPSS for
Windows version 10. The nominal variables were
reported as frequency and percentages. The numerical
data was reported as mean + standard deviation.
Results
Their was male predominance with a male: female of
2.11: 1. The mean age was 33 + 16.21 years with a
range of 15-68 years. Fig. I show the various types of
wounds from which the bacterial growths were obtained.
Bacterial growths were obtained in 127 (65.8%)
specimens while the remaining 66(34.2 %) specimens
yielded no growth. 119 (93.7 %) isolates were
monobacterial whereas 8 (6.29 %) were polybacterial.
Pseudomonas aeruginosa 49 (36.02 %) was the most
frequent isolate followed by Escherichia coli 31 (22.79
%), Staphylococcus aureaus 17 (12.5 %), Klebsiella
pneumoniae 12 (8.82%), Methicillin resistant
Staphylococcus aureaus (MRSA) 10 (7.35 %),
Acinetobacter 8 (5.88%), Proteus and Enterobacter 4
(2.94%) each and Serratia 1 (0.73%).
TYPES OF WOUNDS
Burns Miscellan
19% eous
1%
Postoper Truamatic
ative wounds
wounds 75%
5%
Fig. I The various types of wounds from which
bacterial cultures were obtained.
Sensitivity tests showed variable response to different
antibiotics. Table I shows the antibiotic susceptibility
profile of the various isolates of Aerobic gram negative
bacilli (AGNB). The antibiotic sensitivity of the Methicillin
sensitive staphylococcus aureaus (MSSA) and
Methicillin resistant staphylococcus aureaus is
depicted in table II.
Discussion
Aerobic gram negative bacilli have always been
problematic nosocomial pathogens encountered by
surgeons as well as physicians, often acquiring
antibiotic resistance that limits our therapeutic choices in
their management.

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Microbial Profile and Antibiotic Susceptibility of the Bacterial contaminants of infected Wounds… Hameed-ud Din et al

Ann. Pak. Inst. Med. Sci. 2006; 2(2): 93-98 95

Microbial Profile and Antibiotic Susceptibility of the Bacterial contaminants of infected Wounds… Hameed-ud Din et al
TABLE I : THE SENSITIVITY PROFILE OF THE CULTURED AEROBIC GRAM NEGATIVE BACILLI (AGNB). (n=109)
ANTIBIOTICS Pseudomonas E.Coli Klebsiella Acinetobacte Enterobacte Proteus Serratia
TESTED Aeruginosa Pneumoni r r Marcescen
(n=49) (n=31) ae (n=12) (n=8) (n=4) (n=4) s (n=1)
CEPHALOSPORINS
Cefoclor Sensitive 4(8.1%) 3(9.67%) - 12(100%) 1(12.7%) 1(25%) 1(25%) -
Resistant 45(91.8%) 28(90.32%) 7(87.5%)_ 3(75%) 3(75%) 1(100%)
Cefotaxime Sensitive 8(16.32%) 8(25.80%) 5(41.66%) 1(12.7%) 2(50%) - 4(100%) -
Resistant 41(83.67%) 23(74.19%) 7(58.33%) 7(87.5%)_ 2(50%) 1(100%)
Ceftriaxone Sensitive 5(10.20%) 8(25.80%) 6(50%) 1(12.7%) 2(50%) - 4(100%) -
Resistant 44(89.79%) 23(74.19%) 6(50%) 7(87.5%) 2(50%) 1(100%)

Cefoperazon Sensitive 26(53.06%) 9(29.03%) 2(16.66%) - 3(75%) 1(25%) -

e Resistant 23(46.93%) 22(70.96%) 10(83.33%) 8(100%) 1(25%) 3(75%) 1(100%)

Cefoperazon Sensitive 49(100%) 28(90.32%) 12(100%) - 6(75%) 3(75%) 4(100%) - -

e+Sulbactum Resistant - 3(9.67%) 2(25%) 1(25%) 1(100%)

Ceftazidime Sensitive 12(24.48%) 15(48.38%) 11(91.66%) - 3(75%) 3(75%) -

Resistant 37(75.51%) 16(51.61%) 1(8.33%) 8(100%) 1(25%) 1(25%) 1(100%)

Cefpodoxime Sensitive - - 31(100%) - - 1(25%) 1(25%) -

Resistant 49(100%) 12(100%) 8(100%) 3(75%) 3(75%) 1(100%)

QUINOLONES
Ofloxacin Sensitive 19(38.77%) 2(6.45%) 2(16.66%) 2(25%) 4(100%) - 4(100%) - 1(100%)
Resistant 30(61.22%) 29(93.54%) 10(83.33%) 6(75%) -

Ciprofloxacin Sensitive 22(44.89%) 4(12.90%) 2(16.66%) 5(62.5%) 4(100%) - 4(100%) - 1(100%)

Resistant 27(55.10%) 27(87.04%) 10(83.33%) 3(37.5%) -

Enoxacin Sensitive 17(34.69%) 2(6.45%) 6(50%) 6(75%) 2(50%) - 4(100%) - 1(100%)

Resistant 32(65.30%) 29(93.54%) 6(50%) 2(25%) 2(50%)
Sparfloxacin Sensitive 18(36.73%) 15(48.38%) 6(50%) 6(75%) 4(100%) 3(75%) - 1(100%)
Resistant 31(63.26%) 16(51.61%) 6(50%) 2(25%) - 1(25%)

PENICILLINS & ALIKE AGENTS

Carbenicillin Sensitive - 26(83.87%) 10(83.33%) 7(87.5%) 4(100%) 1(25%)

Resistant 49(100%) 5(16.12%) 2(16.66%) 1(12.7%) - 3(75%) - 1(100%)

Co-amoxilav Sensitive - 15(48.38%) 6(50%) 2(25%) 2(50%) - 4(100%) - 1(100%)

Resistant 49(100%) 16(51.61%) 6(50%) 6(75%) 2(50%)
Ampicil+Sulb Sensitive - 9(29.03%) 1(8.33%) 7(87.5%) 1(25%) - -
actm Resistant 49(100%) 22(70.96%) 11(91.66%) 1(12.7%) 3(75%) 4(100%) 1(100%)

Piperacillin+T Sensitive 35(71.42%) 26(83.82%) 8(66.66%) 4(50%) 4(100%) 3(75%) 1(100%)

azobactum Resistant 14(28.57%) 5(16.12%) 4(33.33%) 4(50%) - 1(25%) -

Imipenem Sensitive 47(95.91%) 26(83.82%) 10(83.88%) 7(87.5%) 4(100%) 1(25%) 1(100%)

Resistant 2(4.08%) 5(16.12%) 2(16.66%) 1(12.7%) - 3(75%) -

Aztreonam Sensitive 12(24.48%) 2(6.45%) 3(25%) - 2(50%) 2(50%) - 1(100%)

Resistant 37(75.51%) 29(93.54%) 9(75%) 8(100%) 2(50%) 2(50%)

AMINOGLYCOSIDES
Gentamicin Sensitive 24(48.97%) 21(67.74%) 10(83.88%) 6(75%) - - - 1(100%)
Resistant 25(51.02%) 10(32.25%) 2(16.66%) 2(25%) 4(100%) 4(100%)

Tobramycin Sensitive 26(53.06%) - 6(50%) - 1(25%) 1(25%) - 1(100%)

Resistant 23(46.93%) 31(100%) 6(50%) 8(100%) 3(75%) 3(75%)

Amikicin Sensitive 30(61.22%) 26(83.87%) 12(100%) - 6(75%) 1(25%) 2(50%) - 1(100%)

Resistant 19(38.77%) 5(16.12%) 2(25%) 3(75%) 2(50%)

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Microbial Profile and Antibiotic Susceptibility of the Bacterial contaminants of infected Wounds… Hameed-ud Din et al

In our study Pseudomonas aeruginosa (36.02%) was

TABLE II : Antibiotic Susceptibility profile of the isolated Gram positive organisms . (n=27
ANTIBIOTICS TESTED MSSA MRSA
( n=17) (n=10)
Sensitive Resistant Sensitive Resistant
PENICILLINS

Oxacillins 16(94.11%) 1 (5.89%) - 10(100%)

Amoxycillin 15(88.23%) 2(11.76%) - 10(100%)

Co-amoxiclav 17(100%) - - 10(100%)

Penicillin G 2(11.78%) 15(88.23%) - 10(100%)

Ampicillin + Salbactum 8(47.05%) 9(52.94%) - 10(100%)

Piperacillin + Tazobactum 17(100%) -

Impipenem 17(100%) - 2(20%) 8(80%)

CEPHALOSPORINS

Cefazolin 9(52.94%) 8(47.05%) - 10(100%)

Cefaclor 8(47.05%) 9(52.94%) - 10(100%)

Cefotaxime 11(64.70%) 6(35.29%) - 10(100%)

Ceftriaxone 11(64.70%) 6(35.29%) - 10(100%)

Cefoperazone 10(58.82%) 7(41.17%) - 10(100%)

Cefoperazone + Salbactum 17(100%) - - 10(100%)

Ceftazidime 16(94.11%) 1(5.89%) - 10(100%)

QUINOLONES
Ofloxacin 16(94.11%) 1(5.89%) - 10(100%)

Ciprofloxacin 14(82.35%) 3(17.64%) - 10(100%)

Sparfloxacin 15(88.23%) 2(11.76%) - 10(100%)

Enoxacin 16(94.11%) 1(5.89%) - 10(100%)

MISCELLANEOUS
Erythrocin 6(35.29%) 11(64.70%) 2(20%) 8(80%)

Vancomycin 17 (100%) - 10(100%) -

Fusidic acid 17(100%) - 7(70%) 3(30%)

Teicoplanin 17(100%) - 7(70% 3(30%)

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Microbial Profile and Antibiotic Susceptibility of the Bacterial contaminants of infected Wounds…
the most frequently cultured microbe followed by
Escherichia coli 22.79% and Staphylococcus aureus
19.85%. Khan JS et al 9 reported Staphylococcus
aureus (45%), E.Coli (14%) and Pseudomonas
aeruginosa ( 6 % ) as the three most frequent isolates
from skin and soft tissue infections. In an other study
on the microbial profile of patients in intensive care unit
Mahmood A 10 reported Staphylococcus aureus (39.53
%), Pseudomonas aeruginosa (15.11 %) and
Escherichia Coli (10.4%) as the commonest bacterial
isolates. Batool T et al 11 recorded Pseudomonas
aeruginosa, Staphylococcus aureus and Klebsiella
pneumoniae as the most common microbial isolates
from burn wounds. Unlike the other studies ,
Pseudomonas aeruginosa and Escherichia Coli were
the two most frequent microbial isolates in our study.
This reflects our local microbial flora and negates the
common perception that gram positive cocci are the
dominant pathogens causing wound infection. With this
evidence based new scenario , if our initial empiric
antibiotic cover is still merely directed against gram
positive organisms it would simply be irrational and
counterproductive leading to wasteful use of our limited
resources.
In our study MRSA isolates were 37 % of the
Staphylococcal contaminants. Other local studies have
reported variable incidence ranging from 5 % 12 to
38.5% 13 Internationally the reported incidence of
MRSA among Staphylococcal isolates range from less
than 10 % to over 65 % . 14,15 The emergence of MRSA
was first reported in Europe in the early 1960s and even
today it continues to be a major threat to antimicrobial
therapy as Methicillin resistance means resistance to
all beta lactam antibiotics .16 ,17 It has rather proven to
be one of the most widespread and durable nosocomial
pathogens of the late 20th century. 18 MRSA is spread
by direct contact and healthcare workers are the most
frequent culprits responsible for their transmission from
one patient to another by their transiently colonized
hands. This cross infection can be effectively prevented
by adoption of standard aseptic measures by all hospital
workers.
Emergence of antibiotic resistance is a major concern
as it limits our therapeutic choices for infection control.
Pseudomonas aeruginosa is one of the difficult to treat
microbes. Ceftazidime has historically been perceived
as an effective antibiotic against it, however in our study
only 24.48 % of its isolates were sensitive to it. Rather
there was 100% sensitivity to Cefoperazone +
Sulbactum, 95.91 % to Imipenem and 53 % to
Cefoperazone. The antibiotic susceptibility of various
other AGNB showed remarkable variability as shown
in table I .
The MRSA isolates in our study were generally multi
drug resistant. Except for Vancomycin to which 100 %
sensitivity of MRSA was found, there was variable
Ann. Pak. Inst. Med. Sci. 2006; 2(2): 93-98
Hameed-ud Din et al
antibiotic susceptibility pattern. Sensitivity to Fuscidin
and Teicoplanin was 70 % each while there was only
20 % sensitivity to both imipenem and Erythromycin.
Table II shows the in vitro activity of the various tested
antimicrobial agents against MRSA in our study. Bukhari
MH et al 13 reported 96 % , 94 % and 86 %
susceptibility of MRSA to Vancomycin, Teicoplanin and
Fuscidic acid respectively. Qureshi AH 19 and Latif S
20
also reported 100 % sensitivity of MRSA to
Vancomycin which is in conformity with our study. Our
study proves that Vancomycin is the only agent that can
be confidently employed on empirical basis to combat
life threatening infection caused by multi drug resistant
strains of MRSA, however the worldwide reports of
intermediate resistance to Vancomycin warrants regular
periodic monitoring of the prevalence and antibiotic
sensitivity of this challenging microbe . 21-23
Conclusion
In this era of evidence based medicine and evidence
based surgery the importance of objectivity can’t be
overemphasized. For evidence based antibiotic
prescribing practices it is mandatory to have periodic
audits of the infected wounds to know about the
invading microbes and their antibiotic susceptibility. This
will also help to prevent the emergence of antibiotic
resistance owing to the irrational and indiscriminate use
of antibiotics but also reduce the financial sufferings of
our patients.
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