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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 2  |  Page : 96-101

Bacteriological profile and antimicrobial susceptibility pattern in sterile body fluid specimens from a tertiary care hospital, South India


1 Department of Microbiology, JIPMER, Puducherry, India
2 Department of Microbiology, JSS Medical College, Mysore, Karnataka, India

Date of Submission21-Feb-2020
Date of Decision06-Apr-2020
Date of Acceptance09-May-2020
Date of Web Publication21-Dec-2020

Correspondence Address:
Apurba Sankar Sastry
Department of Microbiology, JIPMER, Puducherry - 605 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrsm.jcrsm_10_20

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  Abstract 


Introduction: Sterile body fluids are biological fluids that do not normally contain any microorganisms. Examples include cerebrospinal fluid (CSF), pleural, peritoneal, synovial, drain, and pericardial fluids along with bile. If these are infected with microorganisms, then this could be life-threatening and may result in severe morbidity and mortality. Therefore, early identification of these organisms with antimicrobial susceptibility is decisive for the proper management of these infections.
Materials and Methods: This was a retrospective study conducted between December 2017 and August 2019, in the Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research. During this period, a total of 4358 sterile fluid samples from patients with suspected body fluid infections were received. Then, the specimen processing, identification, and antimicrobial susceptibility testing were performed.
Results: During the study period, a total of 4358 sterile fluid specimens were received which included 313 CSF, 224 pleural, 391 peritoneal, 30 synovial, 66 drain fluid, and 281 bile. Of the samples received, 1305 were culture positive, with an isolation rate of 29.9%. Among the culture positives, the frequency of Gram-negative bacteria was 83.2% (1086/1305) and Gram-positive bacteria: 16.3% (213/1305) and yeast: 0.4% (6/1305).
Conclusion: Sterile body fluid infections are usually life-threatening and have a high chance of morbidity and mortality. Therefore, early identification of the organism and performing the antimicrobial susceptibility testing are very important. This not only helps to reduce longer hospital stay and start the patient on targeted therapy but also decreases the risk of acquiring infections in the hospital and develop resistance to antibiotics.

Keywords: Antimicrobial susceptibility pattern, bacteriological profile, sterile body fluids


How to cite this article:
Madigubba H, Deepashree R, Monika, Gopichand P, Sastry AS. Bacteriological profile and antimicrobial susceptibility pattern in sterile body fluid specimens from a tertiary care hospital, South India. J Curr Res Sci Med 2020;6:96-101

How to cite this URL:
Madigubba H, Deepashree R, Monika, Gopichand P, Sastry AS. Bacteriological profile and antimicrobial susceptibility pattern in sterile body fluid specimens from a tertiary care hospital, South India. J Curr Res Sci Med [serial online] 2020 [cited 2021 Apr 21];6:96-101. Available from: https://www.jcrsmed.org/text.asp?2020/6/2/96/304195




  Introduction Top


Sterile body fluids are biological fluids that do not normally contain any microorganisms. The sterile fluids that are frequently sent for bacteriological culture include cerebrospinal fluid (CSF), pleural, peritoneal, synovial, drain, and pericardial fluids along with bile. If these sterile fluids are infected with microorganisms, then this could be life-threatening and may result in severe morbidity and mortality.[1],[2],[3] There are certain pathogenic bacteria of concern like Escherichia coli, Acinetobacter spp., Klebsiella spp., Pseudomonas spp., Staphylococcus aureus, and Enterococcus spp. Early identification of these organisms with antimicrobial susceptibility is decisive for the proper management of these infections. This helps the clinician to initiate early and targeted antimicrobial therapy, which, in turn, will reduce the length of stay of the patients in the hospital with less adverse effects.[3]

Data on antimicrobial susceptibility tests of the organisms isolated from sterile body fluid over a period of time can be used to create a local antibiogram. Knowledge on common causative organisms in various sterile body sites and their antimicrobial susceptibility pattern can help in starting appropriate empirical antibiotics.[4] Therefore, the present study was undertaken to evaluate aerobic bacteriological profile and their antimicrobial susceptibility pattern from various sterile fluids in a tertiary care hospital in South India.


  Materials and Methods Top


This was a retrospective study conducted between December 2017 and August 2019 in the Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research. During this period, a total of 4358 sterile fluid samples from patients with suspected body fluid infections were received. Samples included were CSF (including CSF drawn from shunts), pleural, peritoneal, synovial, drain fluid, and bile. Sterile body fluids excluded from the study were blood culture specimens (as the processing is different than other sterile body fluids) and pericardial fluid specimens (due to their low samples size, 10).

Sample processing

Initially, after receiving the sterile fluid specimens, they were subjected to direct Gram stain, following which the culture was carried out on enriched media such as blood agar and chocolate agar and differential media such as MacConkey agar. Then, the plates were incubated for 24 h aerobically and checked for growth of bacteria. The blood agar and chocolate agar were additionally incubated in the capnophilic environment. The colonies grew on these media were subjected to identification by conventional biochemical tests and MALDI-TOF MS. If there were no growth after 24 h of incubation, then the plates were further incubated for another 24 h (i.e., 48 h total) and then checked for growth. If there was no growth even after 48 h, then the sample would be reported as sterile.

The advantage of MALDI-TOF MS over the conventional biochemical tests for the identification of the organisms was that MALDI-TOF identified the organism with the genus and species level identification within 15–20 min, whereas for the conventional method, it took 24 h for the results of the biochemical tests to report with the genus level identification only.

Simultaneously, all the specimens were also inoculated into brain heart infusion (BHI) broth and incubated aerobically for 7 days. The BHI broth was inspected everyday for the presence of turbidity. If turbidity developed, they were plated on the agar media and identification of the organisms was carried out as described before.

The antimicrobial susceptibility test was done by Kirby–Bauer disc-diffusion method, according to the clinical and laboratory standard institute guidelines. For Gram-positive organisms, cefoxitin (30 μg), tetracycline (30 μg), high-level gentamycin (120 μg), ampicillin (10 μg), trimethoprim-sulfamethoxazole (1.25/23.75 μg), linezolid (30 μg), and vancomycin (30 μg) were tested. For Gram-negative organisms, pipracillin/tazobactam (100/10 μg), ceftazidime (30 μg), ceftriaxone (30 μg), amikacin (30 μg), gentamicin (10 μg), ciprofloxacin (5 μg), meropenem (10 μg), cefoperazone-sulbactam (75 μg/30 μg) were tested.


  Results Top


During the study period, a total of 4358 sterile fluid specimens were received which included 313 CSF, 224 pleural, 391 peritoneal, 30 synovial, 66 drain fluid, and 281 bile [Table 1]. Of the samples received, 1305 were culture positive, with an isolation rate of 29.9%. Among the culture positives, the frequency of Gram-negative bacteria was 83.2% (1086/1305) and Gram-positive bacteria: 16.3% (213/1305) and yeast: 0.4% (6/1305) [Table 2].
Table 1: Growth pattern of various body fluids

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Table 2: Division of Gram-positive and Gram-negative organisms

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Others include Elizabethkingia, Stenotrophomonas maltophilia, Serratia marcescens, Proteus spp., Pantoea spp., unidentified non-fermenting Gram-negative bacteria, Citrobacter spp., Burkholderia pseudomallei, Burkholderia cepacia, Aeromonas spp., Achromobacter, Candida spp., and Chryseobacterium.

[Table 3] depicts the frequency distribution of organisms in various sterile fluid specimens. E. coli (29.8%) was the most common pathogen isolated among the Gram-negative bacteria, followed by Klebsiella pneumoniae (14.7%), Acinetobacter baumannii (13.7%), and Pseudomonas aeruginosa (13.1%). Among the Gram-positives, Enterococcus spp.(9.1%) was the most commonly isolated pathogen followed by S. aureus (4.5%). The six yeast isolates were identified as Candida species, of which C. tropicalis was the most frequent. Other less frequently isolated organisms (9.8%) were Elizabethkingia spp., S. maltophilia, S. marcescens, Proteus spp., Pantoea spp., Citrobacter spp., B. pseudomallei, B. cepacia, Aeromonas spp., Achromobacter, Candida spp., and Chryseobacterium spp.
Table 3: Frequently isolated organisms from different samples (%[n/N])

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Among the CSF isolates, A. baumannii (22.6%) was the most frequently isolated organism. Similarly, E. coli was the most commonly isolated organism among the peritoneal fluid (40.1%), drain fluid (31.8%), and bile (49.4%) isolates. P. aeruginosa was the most common organism isolated from pleural fluid and synovial fluid at a rate of 23.6% and 36.6%, respectively. Among the samples received, ten were pericardial fluid samples, of which all of them were culture positive (four grew Enterococcus species, two E. coli, two S. aureus, and two A. baumannii). However, since the sample size was very less, we did not include these samples for our analysis [Table 3].

The antimicrobial susceptibility pattern of Gram-negative and Gram-positive isolates is shown in [Table 4] and [Table 5].
Table 4: Antibiotic susceptibility pattern of Gram-Negative Bacteria (% susceptible, [n/N])

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Table 5: Antibiotic sensitivity pattern of Gram-Positive bacteria

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Members of Enterobacteriaceae such as E. coli, Klebsiella pneumoniae, and Enterobacter spp., were mostly susceptible to amikacin (60%–83%), followed by meropenem (60%–81%) and moderately susceptible to cefoperazone-sulbactam (50%–60%).

Among nonfermenters, P. aeruginosa was moderately susceptible to cefoperazone-sulbactam (67.2%), followed by piperacillin-tazobactam (64.3%), ceftazidime (63.1%), and meropenem (63.1%). A. baumannii was moderately sensitive to cefoperazone-sulbactam (44.4%), followed by amikacin and piperacillin-tazobactam, both 31.1%.

Among the Gram-positive organisms, all the S. aureus isolates were highly susceptible to linezolid (100%) as well as vancomycin (100%). About 72.8% were methicillin sensitive S. aureus and 27.1% were methicillin resistant S. aureus (MRSA). Enterococcus spp. was highly susceptible to linezolid (99.1%) followed by vancomycin (89.9%). About 7.5% of the isolates were vancomycin resistant (VRE).


  Discussion Top


Normally, sterile body fluids are those sites in which no microorganisms will usually grow, in a healthy or immunocompetent individual. However, if any of the organisms such as bacteria, fungi, parasites, or viruses are isolated from these sterile fluids, then they are considered as significant and would be of life-threatening to the patient, either immunocompetent or immunocompromised.[4],[5] Moreover, these microorganisms as well as their antimicrobial susceptibility patterns may change every now and then. Therefore, it is important to know the correct identification of the organisms as early as possible and the susceptibility pattern of these organisms to start the patient on targeted antimicrobial therapy immediately.

The identification of the organisms was done by both MALDI-TOF MS and by conventional biochemical testing. The advantage of MALDI-TOF MS over the conventional biochemical tests for the identification of the organisms was that MALDI-TOF identified the organism with the genus and species level identification within 15–20 min, whereas for the conventional method, it took 24 h for the results of the biochemical tests to report with the genus level identification only. If the organism was identified by the genus level, then further biochemicals were put up for the accurate species identification. Therefore, MALDI-TOF was more helpful in early identification of the organisms and to start definitive therapy than conventional biochemical tests.

Of the 1305 culture positive, 313 (23.9%) were CSF, 391 (29.9%) were peritoneal fluid, 224 (17.1%) were pleural fluid, 30 (2.2%) were synovial fluid, 66 (5%) were drain fluid, and 281 (21.5%) were bile. Pathogens were mostly isolated from peritoneal fluid, followed by CSF and bile.

In the present study, the distribution rate of Gram-negative organisms was 83.2% and for Gram-positive organisms, it was 16.3%. However, in various other studies done by Rouf and Nazir and Mandira et al., the isolation rate of Gram-negative organisms was 70% and for Gram-positives, it was 30%.[2],[3]

Among all the culture-positive specimens, the predominant organism isolated was E. coli(29.8%), followed by K. pneumoniae (14.7%), A. baumannii (13.7%) and P. aeruginosa (13.1%). Among the Gram-negatives, E. coli was the most commonly isolated pathogen, and among Gram-positives, Enterococcus spp. was most common. This finding was similar to studies done by Rouf and Nazir Deb et al., and Harshika et al.'s study.[2],[4],[6] In contrary to this, Acinetobacter spp. was the most commonly isolated pathogen in a study done by Sharma and Anuradha.[1]

In the CSF specimens, A. baumannii (22.6%) was commonly isolated followed by P. aeruginosa (18.2%). This was similar to the study done by Rouf and Nazir.[2] Among the peritoneal fluid specimens, the most commonly isolated was E. (40.1%) followed by K. pneumoniae (14.8%). Furthermore, this goes in conjunction with several other studies done by rajesh prasad et al., Sujatha et al., Arroyo et al., and Mandira et al., who also found E. coli to be the most common organism isolated.[3],[7],[8],[9] Among the pleural and synovial fluid isolates, P. aeruginosa was the most common organism isolated at a rate of 23.6% and 36.6%, respectively, in our study. This was similar to few other studies done by Rouf and Nazir and Mandira et al.,[2],[3] which was in contrary to studies done by Kasana et al., Deb et al. and Vijayalakshmi et al.[6],[10],[11] where Gram-positive organisms were isolated most commonly from the pleural fluid isolates, and among the synovial fluid specimens, S. aureus was most commonly isolated in many studies.[12],[13] In drain fluid and bile, E. coli was the most commonly isolated organism, 31.8% and 49.4%, respectively. This was similar to other studies done by Suna et al., Rouf and Nazir and Mandira et al.[2],[3],[14]

Antimicrobial susceptibility pattern among the Gram-negative organisms showed that E. coli was highly sensitive to amikacin (83%) followed by meropenem (81%) and moderately resistant to cefoperazone-sulbactam (62.7%) and piperacillin-tazobactam (57.3%). In Sharma and Anuradha study also, E. coli was moderately sensitive to beta-lactam-beta-lactamase inhibitors and highly sensitive to carbapenems.[1] In a study done by Barai et al., E. coli was found to be highly resistant (>80) to cephalosporins and fluoroquinolones.[15] Similar finding was seen in our study where ceftriaxone, ceftazidime, and ciprofloxacin were sensitive only in 16.1%, 20.8% and 18.2% of the isolates. K. pneumoniae and Enterobacter spp. were moderately resistant to amikacin (59.8%) and meropenem (58.3%). In Sharma and Anuradha study, Klebsiella was least resistant to carbapenems and moderately resistant to aminoglycosides and beta-lactam beta-lactamase inhibitor combination.[1] P. aeruginosa was moderately sensitive to cefoperazone-sulbactam (67.2%) and piperacillin-tazobactam (64.3%), followed by meropenem (63.1%) and ceftazidime (63.1%). This was different from Sharma and Anuradha and Durga Anuradha studies where 95% of Pseudomonas isolates were sensitive to Piperacillin-tazobactam and >80% were sensitive to carbapenems.[1],[16] A. baumannii was least sensitive to all the antibiotics. This was similar to many other studies.[1],[2],[3],[4],[5],[6],[7],[9],[10],[11] A. baumannii is the most common hospital-acquired multidrug resistant organism, mainly in patients of prolonged hospital stay and on broad-spectrum antibiotics.

Among the Gram-positive organisms, all the S. aureus isolates were sensitive to linezolid and vancomycin (100%). This finding was in agreement to several other studies done by Deb et al., Kasana et al., Sharma and Anuradha, etc.[1],[6],[10] MRSA rate was 27.1% in our study. It was almost similar to other studies done in India.[17],[18] Enterococcus spp. were highly susceptible to linezolid in 99.1% of the isolates followed by vancomycin in 89.9%. In Kasana et al.'s study, all the isolates were sensitive to linezolid and vancomycin.[10] VRE cases were 7.5% in our study. High-level gentamycin (HLG) susceptibility was seen in 30.2% of the isolates. In a study done by Mandira et al., HLGR was seen in 44.8% and no VRE was detected.[3]


  Conclusion Top


Sterile body fluid infections are usually life-threatening and have a high chance of morbidity and mortality. Therefore, early identification of the organism and performing the antimicrobial susceptibility testing are very important. This not only helps to reduce the duration of hospital stay and start the patient on targeted therapy but also decreases the risk of acquiring infections in the hospital and develops resistance to antibiotics. Therefore to combat antimicrobial resistance, judicious use of antibiotics should be considered.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Sharma R, Anuradha ND. Bacteriological profile and antimicrobial sensitivity pattern in sterile body fluids from a tertiary care hospital. J Appl Microbiol Biochem 2017;1:1.  Back to cited text no. 1
    
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Rouf M, Nazir A. Aerobic bacteriological profile and antimicrobial sensitivity pattern of bacteria isolated from sterile body fluids: A study from a Tertiary Care Hospital in North India. Microbiology Research Journal International. 2019:1.  Back to cited text no. 2
    
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Ramudamu, Khyriem M, Durairaj A, Elantamilan. A study on aerobic bacteriological profile and antibiogram in sterile body fluids from a tertiary care hospital in Northeast India. Int J Sci Res 2018;7:1-4.  Back to cited text no. 3
    
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Harshika YK, Shobha MK, Patil AB, Smita NR. A study on bacteriological profile and antimicrobial resistance pattern from various body fluids of patients attending the tertiary care Hospital, KIMS, Hubli. Indian J Microbiol Res 2018;5:530-4.  Back to cited text no. 4
    
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Alfageme I, Muñoz F, Peña N, Umbría S. Empyema of the thorax in adults. Etiology, microbiologic findings, and management. Chest 1993;103:839-43.  Back to cited text no. 5
    
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Sujatha R, Pal N, Arunagiri D, Narendran D. Bacteriological profile and antibiotic sensitivity pattern from various body fluids of patients attending Rama medical college hospital Kanpur. Int J Adv Case Rep 2015;2:119-24.  Back to cited text no. 7
    
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Prasad R, Renu K, Anand AK, Kumar A. Study on Ascitic Fluid Culture and Antimicrobial Sensitivity Profile in Cirrhotic Patients admitted in a Medical College Hospital. IAIM, 2019;6:53-7.  Back to cited text no. 9
    
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Nutt L, Orth H, Goodway J, Wasserman E. Superior detection of pathogens in synovial fluid by the Bactec 9240 Peds Plus/F system compared to the conventional agar-based culture method. Southern African J Epidemiol Infect 2010;25:11-4.  Back to cited text no. 12
    
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Lafi SA, Al-Mashhadani O, Al-Obaidi WI. Bacteriological and serological study on synovial Fluid in septic arthritis patients. Egyp Acad J Biol Sci G Microbiol 2010;2:27-35.  Back to cited text no. 13
    
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Suna N, Yıldız H, Yüksel M, Parlak E, Dişibeyaz S, Odemiş B, et al. The change in microorganisms reproducing in bile and blood culture and antibiotic susceptibility over the years. Turk J Gastroenterol 2014;25:284-90.  Back to cited text no. 14
    
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Barai L, Fatema K, Haq JA, Faruq MO, Ahsan AA, Morshed MA, et al. Bacterial profile and their antimicrobial resistance pattern in an intensive care unit of a tertiary care hospital of Dhaka. Ibrahim Med Coll J 2010;4:66-9.  Back to cited text no. 15
    
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Ray P, Manchanda V, Bajaj J, Chitnis DS, Gautam V, Goswami P, Gupta V, Harish BN, Kagal A, Kapil A, Rao R. Methicillin resistant Staphylococcus aureus (MRSA) in India: prevalence & susceptibility pattern. The Indian journal of medical research. 2013;13:363.  Back to cited text no. 17
    
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Gopalakrishnan R, Sureshkumar D. Changing trends in antimicrobial susceptibility and hospital acquired infections over an 8 year period in a tertiary care hospital in relation to introduction of an infection control programme. J Assoc Physicians India 2010;58 Suppl: 25-31.  Back to cited text no. 18
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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