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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 12  |  Issue : 2  |  Page : 78-81

Audit of infection and antimicrobial drug resistance pattern in bacterial infections in road traffic accident survivors


1 Department of Orthopaedics, Father Muller Medical College Hospital, Mangalore, Karnataka, India
2 Father Muller Medical College Hospital, Mangalore, Karnataka, India
3 Department of Microbiology; Hospital Infection Control, Father Muller Medical College Hospital, Mangalore, Karnataka, India
4 Department of Community Medicine, Father Muller Medical College Hospital, Mangalore, Karnataka, India
5 Father Muller Research Centre, Mangalore, Karnataka, India

Date of Submission12-Dec-2020
Date of Decision30-Dec-2020
Date of Acceptance06-Jan-2021
Date of Web Publication30-Mar-2021

Correspondence Address:
Dr. Manjeshwar Shrinath Baliga
Mangalore Institute of Oncology, Pumpwell, Mangalore, Karnataka
India
Dr. Ramakrishna Jakribettu Pai
MES Medical College, Perinthalmanna - 679 338, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/injms.injms_169_20

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  Abstract 


Background: In countries like India, road traffic accident (RTA) associated morbidity and mortality is rising in alarming rate and is major concern of public health. Around 80% of the late deaths in trauma patients are due to infection. This study was undertaken to study the profile of infection and drug resistance pattern of bacterial infection in RTA survivors. Materials and Methods: This was a retrospective study and was conducted at a tertiary care hospital with documented evidence of infection from the hospital records. The demographic details of the patient, details of injury and the pathogens causing infections with drug resistance patterns were studied. Results: A total of 163 patients were accrued and the majority of the patients were male (140, 85%) and around 66% belonged to the working age group, i e., 20–50 years. Most of the patient's were treated by orthopedics and surgery departments, 72% and 20%, respectively. The majority of the patients had wound infection followed by Urinary tract infection. Among the Gram-negative pathogens, Escherichia coli and Citrobacter species were the common pathogens; and among Gram-positive organisms, Enterococcus species and Staphylococcus aureus. Most of the pathogens were resistant to commonly used presurgical prophylactic antibiotics such as ampicillin, cefuroxime, and ciprofloxacin. Conclusion: The bacterial profile of the pathogens causing infection in RTA survivors may vary among different institutions. Therefore the antibiogram of these pathogens needs to be studied and analyzed by each medical facility attending to RTA survivors to formulate policy for presurgical antibiotic prophylaxis.

Keywords: Antimicrobial resistance, infection, road traffic accident survivors


How to cite this article:
Geevarughese NM, Suresh S, Pai RJ, Mathew JM, Suresh S, Baliga MS. Audit of infection and antimicrobial drug resistance pattern in bacterial infections in road traffic accident survivors. Indian J Med Spec 2021;12:78-81

How to cite this URL:
Geevarughese NM, Suresh S, Pai RJ, Mathew JM, Suresh S, Baliga MS. Audit of infection and antimicrobial drug resistance pattern in bacterial infections in road traffic accident survivors. Indian J Med Spec [serial online] 2021 [cited 2021 Apr 14];12:78-81. Available from: http://www.ijms.in/text.asp?2021/12/2/78/312621




  Introduction Top


According to the World Health Organization in 2016, approximately 1.35 million people die every year from road traffic accidents (RTA). Fast-moving transport systems, unplanned urbanization, and changing social patterns have contributed to the global increase in the incidence of trauma.[1] Reports suggest that 16.7/100,000 deaths in India are primarily due to RTAs, accounting to 13%–18% of all deaths in India, owing to rising population, urbanization, and a tremendous rise in vehicular transport.[2] Trauma care is highly sophisticated and specialized care and is at developmental stage in India and the number of patients requiring this is increasing each day. As most of these patients are young adults belonging to the economically productive age group, with no underlying illness, there is a greater concern to save them.[2]

Infections are one of the most common and fatal complications following trauma, which prolongs the time of recovery in critically injured patients.[3] Immune dysregulation is a much-described consequence of trauma. In addition, treatment modalities frequently circumvent the patient's own defense mechanisms.[3] Early prevention of the development of infection following trauma can reduce the risk of both sepsis and multiple organ dysfunction syndromes (MODS) and can improve the patients' outcome.[4] Primarily, the severity of the injury and its primary management is vital for the immediate outcome. However, in the later course, infection is an important determinant of the outcome. Globally, >80% of late deaths in adult trauma are due to infections.[5] It is of utmost value to study the pattern of pathogens prevalent in Indian trauma care settings, which will be the first step toward prevention and effective treatment. This study was undertaken to determine the pathogens causing infections in traumatized patients.


  Materials and Methods Top


This was a retrospective chart-based study conducted in the Department of Microbiology at Father Muller Medical College Hospital, Mangalore, India and was conducted after obtaining the sanction of the Institutional ethics committee (FMMC/IEC/127/2017) and permission of the administration. All patients who got admitted to the Emergency Unit of a tertiary care trauma center with a history of RTA from January 2015 to December 2017 were included in the study. The details of the patients collected included demographic data, type of injury, site of injury, duration of stay in the hospital, and spectrum of injuries. Information regarding the sample specimens, pathogen isolated and its susceptibility pattern were also recorded. The collected data were entered in Microsoft Excel and then statistical analysis was done.


  Results Top


During the study period, 163 patients were admitted to the emergency department with alleged history of trauma following RTA. Several departments admitted the patients according to their respective injuries and priorities, of which orthopedics and surgery departments took the major share, 72% and 20%, respectively [Table 1]. Majority of the patients were males (140) Majority of the patients (66%) belonged to the working-age group (aged 20–50 years), whereas the dependent population including children below 20 years and senior citizens amounted to 13% and 8%, respectively [Table 1]. The average length of stay was 17 days. The majority of patients, i e., 62 (38%) stayed for 8–15 days [Table 1]. Around 50% of all males were discharged in 15 days, whereas 78% of the ladies got discharged by the same time frame [Table 1]. Majority of the patients were discharged within 1 month (91.4%).
Table 1: Demographic details of patients studied (N=163)

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Various relevant samples were taken from the patients from the suspected site of infection. A total of 376 samples were collected from the patients who were included in the study. The most common infection suspected was skin and soft tissue infection, sepsis and urinary tract infection, thus wound swab, blood, and urine sample accounted for 48%, 15%, and 9.3%, respectively [Table 2]. A total of 169 samples showed significant growth. The wound swab accounted for 64%, followed by urine and blood culture, 12% and 9%, respectively [Table 2].
Table 2: Profile of Samples collected for bacterial culture and their results

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In the study, 79% of the isolates were Gram-negative organisms, of which the majority were Citrobacter species (30.5%) and  Escherichia More Details coli (19%). The nonfermentors, Acinetobacter species, and Pseudomonas aeruginosa isolates accounted for 10% and 3.5%, respectively. Among Gram-positive bacteria, Enterococcus species (9%) and Staphylococcus aureus (7%) were the most common isolated. Streptococcus pyogenes was isolated in four samples [Table 3]. The antimicrobial agents that are used for the presurgical antibiotic prophylaxis were studied. Around 65% and 29% of Citrobacter species isolates were sensitive to amikacin and ciprofloxacin, respectively, whereas 29% of E. coli was sensitive to cefuroxime, amikacin, and ciprofloxacin. Similar, percentages of Acinetobacter species were sensitive to ceftriaxone and amikacin. Enterococcus species were found to be more sensitive toward amikacin 40%. Around 30% of Enterobacterspecies was sensitive to cefuroxime and amikacin. While S. aureus was found to be more sensitive to cefuroxime (44%) and amikacin (22%) [Table 4].
Table 3: Distribution of pathogens isolated

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Table 4: Resistance pattern of the common isolates studied

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  Discussion Top


The rate of nosocomial infection among trauma patients is much higher compared than otherwise.[6] Various invasive procedures such as insertion of devices, which traverse the sterile barriers, as part of diagnostic/therapeutic workup, make trauma patients vulnerable to infections by allowing immediate bacterial access to previously sterile body sites.[7] Wound factors like the degree of tissue trauma, ischemia, foreign material deposition, or hematoma formation impair local host defenses. Systemic factors such as blood transfusion, hypotension, and hypoxia are also among important contributors to the increased risk of infections.[8] Along with these factors, major traumatic injuries also cause alterations in cellular and humoral immunity which is a vital contributor for the increase in the rate of nosocomial infections among such patients.[9]

Both pro- and anti-inflammatory responses are involved in the posttraumatic pathological process, and they increase the risk of acute respiratory distress syndrome, sepsis, and MODS.[10] Wound infection, nosocomial infection, and secondary organ dysfunction are all risk factors that are associated with sepsis following trauma.[11] Early prevention of the development of sepsis following trauma can reduce the risk of both sepsis and MODS and can improve the patients' outcomes.[12] The preliminary line of management for prevention of trauma-related infection mainly includes infection prevention (e.g., surgical management, prophylactic antibiotics, tetanus vaccination, immunomodulatory interventions) and organ dysfunction prevention (e.g., pharmaceuticals, temporary intravascular shunts, lung-protective strategies, enteral immunonutrition, acupuncture).[4]

The overall prognosis depends on the microbiology of the nosocomial infections. In the 1980s, Gram-positive pathogens were the predominant culprit responsible for mortality and morbidity in intensive care unit (ICU).[13] However, more recently pathogens, namely,  Neisseria More Details meningitidis and Streptococcus pneumoniae along with fungal infections (Candida species) have taken over as the leading cause of nosocomial infections among patients admitted to ICU.[12],[14] The spectrum of Gram-negative pathogens which include Acinetobacter species, Pseudomonas aeruginosa, and Klebsiella species in infection in traumatic patients, was similar to other studies.[15] The financial implication of infection and sepsis following trauma are also staggering. Resource utilization is prolonged in traumatized patients with infections, most of which is spent in the ICUs.[16] The cost of caring for these patients will continue to increase with inflation, newer techniques, more sophisticated monitoring, and the advent of newer therapies.[17]

There are a few limitations of our study. First, this was a retrospective study with its inherent limitations and the fact that the data indicate sites of microbial isolation rather than infection. However, retrospective data analysis is useful first step toward further studies. Second, this was an experience from a single center and the results may not be generalized. More studies are required from various centers as this can give a clear picture on the incidence of infection in RTA survivors and also ascertain the impact of it on the well-being of the individual. The outcome of such studies will be extremely important for India which has the highest incidence of RTA-associated injuries, especially in the productive age group individuals.


  Conclusion Top


Infections are common and potentially fatal in traumatized patients due to their vulnerable condition and disruption of tissue integrity. Understanding the epidemiology of infections will aid in its prompt diagnosis and management. Relatively simple antibiotics are effective in trauma patients because the bacteria causing infections are community acquired. Early prevention for trauma patients can improve outcomes and decrease mortality. As the length of hospitalization increases, drug-resistant hospital-acquired bacteria start colonizing wounds, making the patient susceptible for nosocomial infections. Regularly used presurgical prophylactic antimicrobial agents like ampicillin, cefuroxime, ceftriaxone, ciprofloxacin were effective only in a small percentage of isolates. Hence, newer agents like third-generation cephalosporins, amikacin play a major role in the prevention and treatment of infection in RTA survivors.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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World Health Organization. Global Status Report on Road Safety 2018: Summary. Geneva, Switzerland: World Health Organization; 2018.  Back to cited text no. 1
    
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14.
Boeddha NP, Schlapbach LJ, Driessen GJ, Herberg JA, Rivero-Calle I, Cebey-López M, et al. Mortality and morbidity in community-acquired sepsis in European pediatric intensive care units: A prospective cohort study from the European Childhood Life-threatening Infectious Disease Study (EUCLIDS). Crit Care 2018;22:143.  Back to cited text no. 14
    
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Savage-Reid S, Moeng MS, Thomas T. Empirical antibiotic choice alters microbiological outcomes: Findings from comparative antibiograms in a trauma intensive care unit. South Afr J Crit Care 2020;36:96-104.  Back to cited text no. 15
    
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Wakeley ME, Shubin NJ, Monaghan SF, Gray CC, Ayala A, Heffernan DS. Herpes virus entry mediator (HVEM): A novel potential mediator of trauma-induced immunosuppression. J Surg Res 2020;245:610-8.  Back to cited text no. 16
    
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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