Hospital Management: Bacterial Infection

Prevalence of bacterial infection on burned patients, in Shafieh hospital, Zanjan, Iran

April 2009

Authors:

Rahim Mosahab, PhD Candidate, School of Management, Universiti Sains Malaysia (USM),
Pulau Pinang, Malaysia (rmosahab@yahoo.com)

Abolfath Shojaie Arani, Assistant Professor, Dep. of Microbiology, University of Iran

Medical Sciences, Tehran, Iran (shojaeiarani@yahoo.com)

Abstract

A retrospective study of bacterial surveillance from wound swab, urine and blood cultures of burned
patients hospitalized in burn ward in Zanjan, Iran was performed on 91 patients over 12 months, and 60
gr. Of negative and positive isolated bacteria were found. Pseudomonas aeruginosa was the most
:frequently isolated organism (41.5%). We were able to isolate 35 other different bacteria as follows
1. E.coli, 10 clinical samples (16.6%)
2. Staphylococcus, 13 clinical samples (21.58%)
3. Enterobacter, 8 clinical samples (13.28%)
4. Citrobacter freundii, 3 clinical samples (4.98%)
5. Klebsiella, one clinical sample (1.66%)
Their antibiogram was determined according to standard Kirby disk diffusion method. The antibiogram
:results indicated that
Most isolated Pseudomonas aeruginosa were sensitive to Amikacin (86%), Cyprofloxacin (75.6%), (1
Gentamicin (54%) and Norfloxacin (21.6%), and were resistant to Ceftazidime tetracycline and
.Ceftizoxime
E.coli was sensitive to Ceftizoxime (100%), Gentamicin (79.2%), Choloramphenicole (85.8%), (2
.Nalidixic acid (100%) and Amikacin (85.8%), and was resistant to Ceftazidime
Staphylococcus was sensitive to Amikacin (100%), Tetracycline (100%), Gentamicin (100%), (3
Erytromicin (100%), Vancomycin (72.5%) and Cefalotin (72.5%), and was resistant to Oxaciline,
.Ampicillin and Penicillin
Enterobacter was sensitive to Tetracycline (100%), Erytromicin (100%), Ceftazidime (75%) and (4
.Vancomycin (50%), and was resistant to Cefalotin, Amikacin and Ampicillin
Citrobacter freundii was sensitive to Nalidixic acid kanamycin (100%), Gentamicin (100%) and (5
Amikacin (66.6%), and was resistant to Cefalixine, Penicillin and Nitrofrantion. The bacterial infection
was more common in male population (66.44%) compared with females (39.56%) and in children under
10 years old, it was the most prevalent cause (30%). The prevalence of wound infection was (74.4%),
(urine infection was (23.5%) and Septicemia was (2.48%

Keywords: bacterial infection, antibiogram, burned patients, hospital

Introduction

The human being is constantly exposed to heat injuries by different sources, and burning is one
of the most common problems of human beings are facing with. One of the most important
problems that may happen in burning is infection of burned area. For controlling this infection,
recognizing of the existing epidemical grows in that area or more limited in burning center, and
their antibiogram are vital for determining microbial sensitivity, because incorrect use of
antibiotics can increase microbial resistance towards antibiotics and create potential resistant
organisms that can reduce reaction to treatment. Pseudomonas is the most common pathogenetic
organism isolated from spread infections which is still considered as an intense infection of
wounds and death of burned patients. Urease staphylococcus is another pathogenetic organism
that causes to destroy skin grafted tissue, and created in septicemia especially due to organism
inside vein congestion.

Considering the importance of affliction to nosocomial infections and patient fates, decision for
accomplishment of these surveys for determining the frequency of bacterial infections and doing
antibiogram test on these bacteria in burn ward of Zanjan Shafieh hospital was made.
Accomplishing this survey will create the ability of using the most sensitive identified antibiotic
when needed. Secondly, we can decrease the imposed costs on patients due to repeatedly
changing of antibiotics or unreasonable use of some antibiotics.

General target: studying the prevalence rate of bacterial infection and its antibiogram in
hospitalized patients in burning ward of Zanjan Shafieh hospital.

Special target:

1. Determining bacteria prevalence rate in burning infections.

2. Determining patients' age distribution in bacterial infections and finding the group exposed to
danger.
3. Determining patients' sex distribution in bacterial infections.

4. Determining education degree of burned patients hospitalized in Shafieh hospital.

5. Determining sensitivity and resistance pattern of isolated bacteria against commonly used
antibiotics.

6. Presenting proper scientific solutions for prevention of bacteria transmission.

Methodology

The present research was written in 2008 by using the following procedure and information:

A) Sampling:

For accomplishing this survey that is an empirical one, I collected 91 clinical samples (wound,
blood, urine…) by sampling method from burn ward of Zanjan Shafieh hospital from October
2002 till the end of September 2003. During these 12 months, permanent and continuous work
has been performed on these samples. To do this, I went every day to the burn ward and took
samples of patients in a correct way, using sterile cotton swab from burned parts. Then for
studying and transferring the swab to this hospital microbiology laboratory, I placed it in
transport environment (Nutrient bruth). This transport environment has been considered standard
in all local and foreign sources, for working with burning samples.

B) Collecting data:

Full information of each patient referring to the burn ward via form No.1 was collected

C) Isolating bacteria from clinical samples:

I transferred samples collected from the burn ward to laboratory immediately for isolating and
determining the type and species.

To do this, I used Blood Agar culture and Maccanky culture environments as the screening test.
Then by using warm coloring for specifying positive or negative warmth, I used special culture
environments as a confirming test. Regarding positive warm cluster bacteria that were of
staphylococcus type, I used Mannitol Salt Agar culture and coagulase test and DNA Agar test as
confirming tests and for diagnosis of species.

For negative warm bacteria that are from Enterobacteriaceae family, I used Maccanky culture
environment as the screening test and special culture environments such as Citrate Cimon, Urea,
Sim, Methyl Redox Proscover, Triple Sugar Iren Agar (TSI) as confirming tests. Then I
identified bacteria, by referring to table 2-1.

Chart (2-1): Distinctive specification of Enterobacteriaceae

Survey method of studying antibiotic resistance spectrum (antibiogram) is as follows:

Determining sensitivity of bacteria to antibiotics is very important in clinical cases. Knowing the
microbe type is the basic part of illness treatment. But it may sometimes happen that determining
the microbe sensitivity to medicine becomes more important, and it is when the treatment should
be started quickly in acute cases.

In laboratory, in order to study microbes' sensitivity to antimicrobial medicines different methods

are used, such as;
1) Rarefaction preparing method

2) Agar diffusion disk preparing method

3) Taking from disk method

Results

In this research, in order to study the title of prevalence of bacterial infections in burned patients
and 91 clinical samples, sampling was done with a sterile swab, where 81 samples were positive
and 10 samples were negative. 36 samples were contaminated by Pseudomonas aeruginosa
(39.25%), 18 samples (19.2%) contaminated by Staphylococcus, and 8 clinical samples (8.72%)
contaminated by Enterobacter, 3 clinical samples (3.27%) contaminated by Citrobacter freundii
and 1 clinical sample (1.09%) contaminated by Klebsiella.

In this survey, 60 clinical samples were culture of wound (74.40%), 19 samples culture of urine
(23.56%) and 2 samples were culture of blood (2.48%).

The existing bacteria in patients' wounds are as follows:

Pseudomonas (41.5%), Escherichia coli (16.6%), Staphylococcus (31.58%), Enterobacter

(13.28%), Citrobacter freundii (4.98%) and Klebsiella (1.66%) (Table3-3). In urine culture too,
Pseudomonas (57.86%), Escherichia coli (26.30%), Staphylococcus (15.78%) were found
(Table3-4). 2 samples of blood culture were positive that one sample was positive

Staphylococcus coagulase and the other one was negative coagulase (Table3-5).

All bacteria isolated from clinical samples were tested by antibiogram test to specify their
sensitivity and resistance to a common antibiotic the results of which have been shown in tables
(3-6, 3-7, 3-8, 3-9 and 3-10). Age distribution of patients has been studied in age groups. The
most prevalent burning age was in the age group under 15 years old (Chart 3-2). Statistic Kaidu
test showed that the difference in this age group is statistically significant (p<0.01). Sex
distribution of under-study patients included 25 men (39.56%) and 46 women (60.44%) and in
view of sex, burning prevalence was more in female group (Chart 3-3) that statistic test did not
show significant correlation between burn infections and sex. Also distribution of education
degree showed that 42 persons (78%) were illiterate, 18 persons (30.52%) had elementary school
degree, 16 persons (17.44%) had high school diploma, and 5 persons (5.45%) had higher degree
(Chart 3-4).

It seems that infection is still the most common cause of death in burned patients. Burning causes
intense suppression of immunity. Generally, the lack of immunity make burned patients
susceptible to infection. On the other hand, these isolated bacteria have become resistant to
antimicrobial factors, and due to sensitivity of natural fluorine bacteria to these antimicrobial
factors, resistant organisms replace these bacteria. Because of unbalance of reaction between
opportunist and host microorganisms, these bacteria enter easily in circulatory system, and create
poison and consequently death in the aged and children, due to the weakness of immune system.

Although confronting with these infections and destroying them completely is very difficult in
burnings, but I can suggest some effective ways in controlling them, as follows:

1) Immediate transfer of burned patient to hospital and hospitalizing him in aseptic quarantine
ward.

2) Quick use of topical antimicrobial materials and dressing of wounds.

3) Microbial surveys of different parts and hospital facilities, and in case of observing this
microorganism, necessary actions should be taken to destroy it.

4) Checking all personnel working in burn ward and in contact with patient, and in case of
finding Urease Staphylococcus in their nose and hand, they should be treated in a suitable way
(Bacitracin ointment and edible Rifampin).

5) Limiting entrance of unknown and unstudied people to the ward and preventing their contact
with the patient.

6) Complete and continuous disinfecting of dressing wound room and following hygienic
principles by personnel of dressing wound room.

Tables and Charts

 Frequency

Type of Number Percent

microorganism

Pseudomonas 36 39.25%
aeruginosa

Escherichia coli 15 16.35%

PositiveStaphylococcus 14 15.26%

Coagulase

Enterobacter 8 8.72%

NegativeStaphylococcus 4 3.36%

Coagulase

Citrobacter Freundii 3 3.27%

Klebsiella 1 1.09%

Negative growth 10 10.9%

Total 91 100%

Table (3-1): Frequency distribution of microorganisms isolated from patients hospitalized in

(burn ward of Zanjan Shafieh hospital (2007
 Sex Female Male Total

Freq. Percent Number Percent

Kind Number Number Percent

of
infection

Wound 36 44.64 24 29.76 60 74.40%

infection % %

Urine 9 11.16% 10 12.4% 19 23.56%

infection

Septicemia 1 1.24% 1 1.24% 2 2.48%

Total 46 57.04 35 43.40 81 100

% %

Table (3-2): Studying frequency of all types of infection in terms of sex in burned patients
(hospitalized in burn ward of Zanjan Shafieh hospital according to sex (2007

Frequency

Kind of Number Percent

bacteria

Pseudomonas 25 41.5%
aeruginosa

Escherichia coli 10 16.6%

 Positive 11 18.26%
Staphylococcus

Coagulase

Enterobacter 8 13.28%

Negative 2 3.32%
Staphylococcus

Coagulase

Citrobacter Freundii 3 4.98%

Klebsiella 1 1.66%

Total 60 100%

Table (3-3): Frequency distribution of bacteria existing in wound of burned patients hospitalized
(in burn ward of Zanjan Shafieh hospital (2007

Frequency

Kind of Number Percent

microorganism

Pseudomonas 11 57.86%
aeruginosa

Escherichia coli 5 26.30%

 Positive 2 10.52%
Staphylococcus

Coagulase

Negative 1 5.26%
Staphylococcus

Coagulase

Total 19 100%

Table (3-4): Frequency distribution of bacteria existing in urine of burned patients hospitalized
(in burn ward of Zanjan Shafieh hospital (2007
 Sensitivity Female Male Total

Freq.

Percent Number Percent

Number Percent

Number
Type

of bacteria

Negative

Staphylococcus 1 50% 0 0 1 50%

Coagulase

Negative
Staphylococcus
0 0 1 50% 1 50%
Coagulase

Total 1 50% 1 50% 2 100

Table (3-5): Frequency distribution of bacteria existing in blood of burned patients hospitalized
(in burn ward of Zanjan Shafieh hospital according to sex (2007
 Sensitivity Sensitive Intermediate Resistant

sensitive

Freq.

Percent Number Percent

Antibiotic Number Percent

Number

Amikacin 31 86% 2 5.4% 3 8.1%

Ciprofloxacin 28 75.6% 4 10.8% 4 10.8%

Gentamicin 20 54% 4 10.8% 12 32.4%

Norfloxacin 8 21.6% 4 10.8% 24 64.8%

Tubramycin 6 16.2% 3 8.1% 27 72.9%

Ceftrioxon 3 8.1% 3 8.1% 30 81%

Ceftazidime 0 0 0 0 36 100%

Tetracycline 0 0 0 0 36 100%

Ceftizoxime 0 0 0 0 36 100%
Table (3-6): Frequency distribution of Pseudomonas aeruginosa sensitivity and resistance to
(common antibiotics in hospitalized patients in burn ward of Zanjan Shafieh hospital (2007

Sensitivity Sensitive Intermediate Resistant

sensitive

Freq. Percent Percent

Number
Antibiotic Number Percent

Number

Ceftizoxime 15 100% 0 0 0 0

12 79.2% 1 6.6% 2 13.2%

Gentamicin

Choloramphenicole 13 85.8% 1 6.6% 1 6.6%

Nalidixic acid 15 100% 0 0 0 0

Ampicillin 2 13.2% 1 % 6.6 12 79.2%

Cefalotin 10 66% 4 26.4% 1 6.6%

Amikacin 13 85.8% 1 6.6% 1 6.6%

Tubracin 3 19.8% 0 0 12 79.2%

Table (3-7): Frequency distribution of Escherichia coli sensitivity and resistance rate to common
(antibiotics in hospitalized patients in burn ward of Zanjan Shafieh hospital (2007

Sensitivity Sensitive Intermediate Resistant

sensitive

Freq. Number Percent Number Percent Number Percent

Antibiotic

Amikacin 18 100% 0 0 0 0

Tetracycline 18 100% 0 0 0 0

Gentamicin 18 100% 0 0 0 0

Erytromicin 18 100% 0 0 0 0

Vancomycin 13 72.5% 0 0 5 27.5%

Cefalotin 13 72.5% 0 0 5 27.5%

Oxaciline 0 0 0 0 18 100%

Ampicillin 0 0 0 0 18 100%

Penicillin 0 0 0 0 18 100%

Table (3-8): Frequency distribution of Staphylococcus sensitivity and resistance rate to common
(antibiotics in hospitalized patients in burn ward of Zanjan Shafieh hospital (2007
 Sensitivity Sensitive Intermediate Resistant

Freq. sensitive

Number Percent Number Percent Number Percent

Antibiotic

Tetracycline 8 100% 0 0 0 0

Erytromicin 8 100% 0 0 0 0

Ceftazidime 8 100% 0 0 0 0

Gentamicin 6 75% 1 125% 1 12.5%

Vancomycin 4 50% 3 27.5% 1 12.5%

Cefalotin 0 0 0 0 8 100%

Amikacin 0 0 0 0 8 100%

Ampicillin 0 0 0 0 8 100%

Table (3-9): Frequency distribution of Enterobacter sensitivity and resistance rate to common
(antibiotics in hospitalized patients in burn ward of Zanjan Shafieh hospital (2007
 Sensitivity Sensitive Intermediate Resistant

sensitive

Freq. Number Percent Number Percent Number Percent

Antibiotic

Nalidixicacid 3 100% 0 0 0 0

Kanamycin 3 100% 0 0 0 0

Gentamicin 3 100% 0 0 0 0

Amikacin 2 66.6% 0 0 1 33.4%

Cefalixine 0 0 0 0 3 100%

Nitrofrantoin 0 0 0 0 3 100%

Penicillin 0 0 0 0 3 100%

Table (3-10): Frequency distribution of Citrobacter freundii sensitivity and resistance rate to
(common antibiotics in patients hospitalized in burn ward of Zanjan Shafieh hospital (2007
Chart (3-1): Frequency of infection in burned patients hospitalized in burn ward of Zanjan
(Shafieh hospital (2007

(Chart (3-2): Age distribution of burned patients in burn ward of Zanjan Shafieh hospital (2007

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