ABSTRACT
This study evaluated the bacterial isolates associated with post operative wound of women that underwent caeserean section and their susceptibility pattern to some antibiotics. Streak method of inoculation was adopted to isolate the associated bacteria and the disc diffusion method was used to test for the susceptibility pattern. Six bacteria isolates namely Escherichia coli, Staphylococcus aureus, Pseudomonas aeruginosa, Streptococcus specie, Klebsiella specie and Proteus specie were isolated. Amongst the six isolates, pseudomonas aeruginosa had the highest frequently of occurrence (29%), followed by Staphylococcus aureus (24.4%), Klebsiella specie (19.5%) Escherichia coli (12%)in that order while the least was recorded against Proteus specie (49%).Among the gram positive bacteria, the high level of resistance was recorded with Streptococcus (80%) against penicillin followed by Staphylococcus aureus (70%) whiles the level of resistance was observed with Ampicillin (25%) against Streptococcus specie. The high isolation rate of aerobic bacteria and their increased resistance to the commonly used antibiotics warrant s the need to practice aseptic procedures and rational use of antimicrobial agents leading to minimize infection rate and emergence of drug resistance.
TABLE OF CONTENTS
Title Page i
Certification ii
Dedication iii
Acknowledgement iv
Table of Contents v
Lists of Tables vii
Abstract viii
CHAPTER ONE
1.0 Introduction 1
1.1 Frequency of Infection 3
1.2 Impact of Nosocomial Infections 3
1.3 Factors Influencing the Development of
Nosocomial Infections 4
1.3.1 The microbial agent 4
1.3.2 Patient susceptibility 5
1.3.3 Environmental factors 6
1.3.4 Bacterial resistance 6
1.4 Aims and Objectives 7
1.5 Objectives 8
CHAPTER TWO
2.0 Literature Review 10
CHAPTER THREE
3.0 Materials and Methods 17
3.1 Collection
of Sample 17
3.2 Media Used and Its Preparation 17
3.3 Sterilization 17
3.4
Isolation and Identification of Bacteria 18
3.5 Identification of Bacterial Isolates 18
3.6 Gram Staining 18
3.7 Biochemical Cultural
Characteristics 19
3.7.1 Catalase Test 19
3.7.2 Coagulase test 19
3.7.3 Citrate test 19
3.7.4 Motility, indole, urease
test (MIU). 19
3.7.5 Triple sugar iron test 20
3.7.6 Oxidase test 20
3.8 Antibiotic Sensitivity Testing 21
CHAPTER FOUR
4.0 Results
22
CHAPTER FIVE
5.0
Discussion, Conclusion and Recommendation
27
5.1 Discussion
27
5.2 Conclusion
30
5.3 Recommendation 30
References 31
LIST OF TABLES
Table Title page
1: Biochemical
and Cultural Characteristics of Bacteria Isolates
from Post Operative Wounds of Cesarean section 23
2: Frequency of occurrence of
Bacteria Isolates from
Post Operative
Wound of Cesarean section 24
3:
Percentage of Resistance in Gram
Positive Isolates from
Post-Operative
Wounds of Cesarean section 25
4: Percentage Resistance in Gram Negative
Isolates from
Post-Operative
Wounds of Cesarean section 26
CHAPTER ONE
1.0 INTRODUCTION
Nosocomial infection is defined according to
the National Nosocomial Infections Surveillance (NNIS) as “a localized or
systemic condition that results from adverse reaction to the presence of an infectious
agents or its toxins and that was not
present or incubating at the time of admission to the hospital” (Abdel
Rahman et al.,2010).
The
common definition of nosocomial infection is, an infection which occurs within
48 hours after hospitalization, or after 3 days from discharging, or 30 days
from an operation. According to studies, the nosocomial infections are found
mainly in intensive care units (ICU) compared other units of the hospital (Adegoke
and Komolafe, 2008).
These
infections affect healthcare quality and cause many problems and they were
identified more than a century ago. They account for about 5 – 10% of the cases
admitted to hospitals for emergency care in the developed countries. It is the
result of a chain of events influenced by the microbe involved, the
transmission method, and patient’s adherence to physician’s instructions. The
rate of nosocomial infection increases with administration of many treatment
methods such as hemodialysis, respirators, urinary catheters and intravenous
catheters (Agnihotri et al.,2004). In
industrialized counties such as USA, comprehensive studies were carried out on
nosocomial infections because of their devastating effect of patient mortality
rate and money consuming treatments yearly. On the other hand, there are only
few reports from developing countries, and rare premature studies from the
Middle East. As reported by the WHO in 2001, nosocomial infection has the
highest percentage in South-East Asia, and the Eastern Mediterranean and one of
the main reasons for this has been the inadvertent misuse of antibiotics
leading to widespread resistance (Bahar et al.,2010).
Nosocomial infections have become a
very important public health issue and Staphylococcus aureus (SA) is one
of several pathogens that have emerged as a major culprit. Carriage of Staphylococcus
aureus appears to play a significant role in the epidemiology and pathogenesis
of infections (Agwung-Fobellah,2007; Bahar, et al.,2010). Several studies have recognized
hospital personnel as an important reservoir or healthy carriers (Armour et al.,2007).
Prevalence rates of 16.8% to 56.1%
have been documented amongst this group . More so, that, hospital personnel
often harbor more resistant strains of Staphylococcus
aureus. Retrospective studies have shown that over 20% of nasal isolates
from hospital personnel exhibit multiple drug resistant and may be a
significant reservoir for onward transmission to patients, who are more likely
to be infected due to their weakened immune status (Alfred,
2007).
If the patient is immuno-compromised,
microorganism that are not normally pathogenic, are capable of causing disease.
Transmission of strains from hospital personnel to patients is usually by
exogenous spread and occurs mostly during routine patient care (Anguzu, and Olila, 2007).
These resistant strains when transmitted to
patients, may complicate the latter’s treatment options particularly in
resource-limited areas where antimicrobial susceptibility assessment is not
systematic. Investigations of hospital-acquired outbreaks involving neonates
and patients colonized with multi-drug resistance Staphylococcus aureus strain
using typing demonstrated epidemiologically related strains between health
personnel and the latter. Other studies have reported clear molecular and
epidemiological evidence of Methicillin Resistance Staphylococcus aureus (MRSA)
transmission from health care workers to patients (Angyoet al.,2001). Hospitalized patients with Staphylococcus
aureus infection have been shown to have five times the risk of in-hospital
mortality compared with inpatients without this infection (Bach et al., 2002).
Considering the relevance of Staphylococcus
aureus as an important pathogen associated with nosocomial infections, the
role played by hospital personnel in transmission, and the dearth in data on
susceptibility patterns (CDC, 2009).
1.1 FREQUENCY OF INFECTION
Nosocomial infections occur worldwide and
affect both developed and resource-poor countries. Infections acquired in
health care settings are among the major causes of death and increased
morbidity among hospitalized patients (Culver et al.,1991).
They
are a significant burden both for the patient and for public health. A
prevalence survey conducted under the auspices of WHO in 55 hospitals of 14
countries representing 4 WHO Regions (Europe, Eastern Mediterranean, South-East
Asia and Western Pacific) showed an average of 8.7% of hospital patients had
nosocomial infections (Culver et al.,1991).
At any time, over 1.4 million people
worldwide suffer from infectious complications acquired in hospital. The
highest frequencies of nosocomial infections were reported from hospitals in
the Eastern Mediterranean and South-East Asia Regions (11.8 and 10.0% respectively),
with a prevalence of 7.7 and 9.0% respectively in the European and Western
Pacific Regions (Thomas et al.,1998).
1.2 IMPACT OF NOSOCOMIAL INFECTIONS
Hospital-acquired infections add to
functional disability and emotional stress of the patient and may, in some
cases, lead to disabling conditions that reduce the quality of life. Nosocomial
infections are also one of the leading causes of death (Thomas et al.,1998). The economic costs are
considerable (Katz,2004). The
increased length of stay for infected patients is the greatest contributor to
cost.
One study (Katz,2004) showed that the overall increase in the duration of
hospitalization for patients with surgical wound infections was 8.2 days,
ranging from 3 days for gynaecology to 9.9 for general surgery and 19.8 for orthopedic
surgery. Prolonged stay not only increases direct costs to patients or payers
but also indirect costs due to lost work. The increased use of drugs, the need
for isolation, and the use of additional laboratory and other diagnostic
studies also contribute to costs (Giacometti et al.,2000).
Hospital-acquired infections add to the
imbalance between resource allocation for primary and secondary health care by
diverting scarce funds to the management of potentially preventable conditions.
The advancing age of patients admitted to health care settings, the greater
prevalence of chronic diseases among admitted patients, and the increased use
of diagnostic and therapeutic procedures which affect the host defences will
provide continuing pressure on nosocomial infections in the future (Holzheimeet al.,1990).
Organisms causing nosocomial infections can be
transmitted to the community through discharged patients, staff, and visitors.
If organisms are multi resistant, they may cause significant disease in the
community (Kleven, 2007).
1.3 FACTORS
INFLUENCING THE DEVELOPMENT OF NOSOCOMIAL INFECTIONS
1.3.1 The Microbial Agent
The patient is exposed to a variety of
microorganisms during hospitalization. Contact between the patient and a
microorganism does not by itself necessarily result in the development of clinical
disease other factors influence the
nature and frequency of nosocomial infections (Kleven,2007).
The likelihood of exposure leading to
infection depends partly on the characteristics of the microorganisms,
including resistance to antimicrobial agents, intrinsic virulence, and amount
(inoculum) of infective material. Many different bacteria, viruses, fungi and
parasites may cause nosocomial infections. Infections may be caused by a
microorganism acquired from another person in the hospital (cross-infection) or
may be caused by the patient’s own flora
(endogenous infection) (Ibrahim,2002).
Some organisms may be acquired from an
inanimate object or substances recently contaminated from another human source
(environmental infection). Before the introduction of basic hygienic practices
and antibiotics into medical practice, most hospital infections were due to
pathogens of external origin (food borne and airborne diseases, gas gangrene,
tetanus, etc.) or were caused by microorganisms not present in the normal flora
of the patients (e.g. diphtheria, tuberculosis) (Kirkland et al.,1999).
Progress in the antibiotic treatment of
bacterial infections has considerably reduced mortality from many infectious
diseases. Most infections acquired in hospital today are caused by microorganisms
which are common in the general population, in whom they cause no or milder
disease than among hospital patients (Staphylococcus aureus,
coagulase-negative staphylococci,
enterococci, Enterobacteriaceae) (Ibrahim,2002).
1.3.2 Patient Susceptibility
Important patient factors influencing
acquisition of infection include age, immune status, underlying disease, and
diagnostic and therapeutic interventions. The extremes of life infancy and old
age are associated with a decreased
resistance to infection (Cowan and Steel,2000).
Patients with chronic disease such as
malignant tumours, leukaemia, diabetes mellitus, renal failure, or the acquired
immunodeficiency syndrome (AIDS) have an increased susceptibility to infections
with opportunistic pathogens (Cowan and Steel,2000).
The latter are infections with organisms that
are normally innocuous, e.g. part of the normal bacterial flora in the human,
but may become pathogenic when the body’s immunological defences are
compromised. Immunosuppressive drugs or irradiation may lower resistance to
infection (Kardes,2007).
Injuries to skin or mucous membranes bypass
natural defence mechanisms. Malnutrition is also a risk. Many modern diagnostic
and therapeutic procedures, such as biopsies, endoscopic examinations,
catheterization, intubation/ventilation and suction and surgical procedures
increase the risk of infection (Giacometti et
al.,2000).
Contaminated objects or substances maybe
introduced directly into tissues or normally sterile sites such as the urinary
tract and the lower respiratory tract (Ibrahim,2002)
1.3.4 Environmental Factors
Health care settings are an environment where
both infected persons and persons at increased risk of infection congregate.
Patients with infections or carriers of pathogenic microorganisms admitted to
hospital are potential sources of infection for patients and staff. Patients
who become infected in the hospital are a further source of infection (Bachet al., 2002).
Crowded conditions within the hospital,
frequent transfers of patients from one unit to another, and concentration of
patients highly susceptible to infection in one area (e.g. newborn infants,
burn patients, and intensive care) all contribute to the development of
nosocomial infections. Microbial flora may contaminate objects, devices, and
materials which subsequently contact susceptible body sites of patients. In
addition, new infections associated with bacteria such as waterborne bacteria
(atypical mycobacteria) and viruses and parasites continue to be identified (Bach et al., 2002)
1.3.5 Bacterial Resistance
Many patients receive antimicrobial drugs.
Through selection and exchange of genetic resistance elements, antibiotics
promote the emergence of multi drug resistant strains of bacteria;
microorganisms in the normal human flora sensitive to the given drug are
suppressed, while resistant strains persist and may become endemic in the
hospital. The widespread use of antimicrobials for therapy or prophylaxis
(including topical) is the major determinant of resistance (Bach et al., 2002).
Antimicrobial agents are, in some cases, becoming less effective because of
resistance. As an antimicrobial agent becomes widely used, bacteria resistant
to this drug eventually emerge and may spread in the health care setting. Many
strains of pneumococci, staphylococci,
enterococci, and tuberculosis are currently resistant to most or all
antimicrobials which were once effective. Multi resistant Klebsiella and
Pseudomonas aeruginosa are prevalent in many hospitals. This problem is
particularly critical in developing countries where more expensive second-line
antibiotics may not be available or affordable (Thomas et al.,1998).
1.4
AIMS AND OBJECTIVES
The aim of this
study is to assess the susceptibility pattern of pathogenic bacteria isolated
from post operative wounds of women who underwent caesarean section.
1.5 OBJECTIVES
1. To isolate,
identify, and characterize microorganisms isolated from post operative wounds
of women who underwent caesarean section.
2. To determine
pathogenic organisms that causes nosocomial infections.
3. To determine the
susceptible pattern of organisms isolated from post operative wounds
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