ISSN No.

2456-4400
Int J Med Lab Res 2017, 2(3): 19-25

RESEARCH ARTICLE INTERNATIONAL JOURNAL OF MEDICAL LABORATORY RESEARCH (IJMLR)

OUTCOME OF IMPLEMENTATION OF HOSPITAL INFECTION CONTROL

GUIDELINES ON THE ANTIBIOTIC RESISTANCE PATTERN IN
STAPHYLOCOCCUS AUREUS ISOLATED FROM SKIN AND SOFT TISSUE
INFECTIONS: A RETROSPECTIVE TWO TIME POINT STUDY

Ramakrishna Pai Jakribettu1, 2, SurluVidya Rao2, 3, Ovine Loyster D’souza2,Valerian Sudeep Pinto2,
BrincyLoyalaD’souza2,LaveenaAgnisTellis2,Manjeshwar Shrinath Baliga4

1
Departments of Microbiology,
2
Hospital Infection Control,
3
Hospital Administration, Father Muller Medical College Hospital, Kankanady, Mangalore 575002,
Karnataka, India
4
Father Muller Research Centre, Kankanady, Mangalore 575002, Karnataka, India

Received:16 August, 2017/Accepted:18 Sep, 2017

ABSTRACT:BACKGROUND: Skin and soft tissue infections (SSTIs), by Staphylococcus aureus is a

commonly observed phenomena. However, when the organism is methicillin-resistant S. aureus (MRSA)
the morbidity is high and the organism can also lead to death of the individual if immunocompromised.
Treatment of MRSA involves use of high end drugs that are extremely expensive and accompanied by
side effects. METHODS: This is a retrospective study and the medical records for the year 2010 and 2015
for S aureus in SSTIs were accessed. The two time points were selected because in the beginning of the
decade Hospital Infection control was upgraded and emphasized through rigorous sensitization and
implementation audits. The incidence and drug resistance pattern for various clinically used antibiotics
against S aureus at two time points were analyzed.RESULTS:The results indicated that there was a
23.24% decrease in the incidence of MRSA and was significant (p< 0.019). However there was an
increase in resistance of S aureus to fluoroquinolones and macrolides (p< 0.0001).CONCLUSIONS: The
safety measures adopted has immense use in reducing hospital infection and be of use to public health.
This study indicates that adoption of hospital infection control measures by regular practice of the
stipulated guidelines is an important way in reducing the incidence of MRSA infection.

KEY WORDS: Staphylococcus aureus; MRSA; Hospital Infection Control; Skin and soft tissue
infections.

Corresponding Author:
Dr Ramakrishna PaiJakribettu,
Infection Control Officer,Hospital Infection Control Division, Father Muller
Medical College Hospital, Mangalore, Karnataka, India, 575002

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associated with untoward side effects and is

INTRODUCTION:
expensive for the patient and the hospital.
Skin and soft tissue infections (SSTIs), also termed
In lieu of these observations, the Centre for Disease
as skin structure infections is an important common
Control and Prevention (CDC) has recommended
medical condition, and needs immediate medical
that a close monitoring of the resistance pattern of
attention and care.1,2From a classification
the S. aureus is the need of the hour to map and
perspective, SSTIs are grouped as purulent
combat the emergence of the resistant pathogen.20,21
infections (e.g., furuncles, carbuncles, and
In accordance to the tenets of the recommendation,
abscesses) and non purulent infections (e.g.,
the present study was conducted to observe if there
erysipelas, cellulitis, necrotizing fasciitis) and on
is any change in the sensitivity pattern of S aureus
the degree of severity further as mild, moderate,
isolated from the SSTI patients in the year 2010 and
and severe. 2 The mild infections normally manifest
2015 at a tertiary care hospital.
as local symptoms, while the moderate to severe
infections also involves systemic effects that
MATERIAL AND METHODS:
manifest as sepsis with fever, spurt in the number
of WBC cells, increased heart rate and or higher This was a retrospective study and was
respiratory rate.1,2 carried out in the department of Hospital Infection
Control Unit of the Clinical Microbiology of Father
In most cases, bacteria are responsible for
Muller Medical College Hospital. The data on the
the SSTIs and report indicates that the very
antibiotic sensitive pattern of the Staphylococcus
prevalent gram-positive cocci StaphylococcuS
aureus isolated from the skin and soft tissue
aureus (SA)is the causative agent.3 Historically, S
infections were studied for 2010 and 2015. The data
aureus were very well controlled by administration
was collected from Hospital database after
of penicillin.1 However, the rampant injudicious
obtaining the necessary permission from the
use of antibiotics had lead to evolution of S aureus
Institutional ethics Committee.
that are today resistant not only to pencillin but also
for subsequent antibiotics like methicillin a The sensitive pattern for the following antibiotic
semisynthetic penicillinase-resistant antibiotic was collected from the database: Ampicillin (10μg)
introduced and found to be effective against S Amoxyclav (20/10 μg), Cephalexin (30 μg),
aureus in the early 1960s 2,4. The S aureus that are Cefoxitin (30 μg), Cotrimoxazole (1.25/23.75 μg),
resistant to the drug methicillin are now termed as Gentamicin (10 μg), Amikacin (30 μg),
methicillin-resistant S. aureus (MRSA).2,4,5 Ciprofloxacin (5 g), Levofloxacin (5 μg),
From a clinical perspective, the spread of Azithromycin (15 μg), Clindamycin (2 μg),
MRSA is alarming as the therapeutic outcome of Vancomycin (30 μg), Linezolid (30 μg),
infections resulting from MRSA is worse when Teicoplanin (30 μg) according to the Clinical and
compared to that of the methicillin-sensitive Laboratory Standards Institute (CLSI) guidelines.22
strains.2,6 Global data affirms that Infections due to The drug resistance pattern for each of the isolate
MRSA causes significant morbidity and mortality was entered in the Microsoft Excel, coded and then
especially among the immunocompromised and the subjected to statistical analysis for the incidence of
weak.5 MRSA is increasing worldwide, and in resistance for every antibiotic tested. Additionally
various parts of India.7-19 Under these data was also sorted taking in to consideration the
circumstances the development of antibiotics like pharmacological class/type they belonged to. The
vancomycin, teicoplanin and linezolid has been data were analyzed by x2 for each antibiotic tested.
observed to be beneficial. However their use is In addition to this the mean was calculating

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considering the number of resistance possessed by to the antibiotics increased from 3.47±1.19 (in
each against each drug, as well as for the class the 2010) to 3.71±2.39 (in 2015) and was significant (p
antibiotic belonged to by using unpaired students t < 0.04) (Table 2).
test. A statistical value of p < 0.05 was considered
significant. DISCUSSION:
Innumerable data published from around the
RESULTS: world have equivocally shown that S. aureus,
The study indicates that a total of 735 and 776 especially the MRSA, is a major pathogen
S aureus organisms were isolated from the SSTIs especially amongst vulnerable at risk patients and
were isolated and tested against a panel of also that their characteristics are changing rapidly.23
antibiotics in accordance to the CLSI guidelines. The SSTIs are one of the most common infections
The most important observation was all the by S aureus and the emergence of MRSA has
organisms tested in both the years were sensitive to compelled the use of fusidic acid, cotrimoxazole,
vancomycin, linezolid and teicoplanin. The results clindamycin, tetracycline, rifampicin, quinolones,
of resistance to the various antibiotics and grouped chloramphenicol, vancomycin, teicoplanin and
in accordance to the chemical class are depicted in linezolid.24
Table 1 and 2. In this study it was observed that all the organisms
With respect to the data when analyzed from the tested in both the years were sensitive to
perspective of individual antibiotics, the results vancomycin, linezolid and teicoplanin. However
indicated that when compared to the year 2010 the drug resistant pattern changed significantly over
there was decrease in the percentage of S aureus a 5 year time period for most other antibiotics. The
resistant to A (87.21 vs 83.39), CP (45.85 vs incidence of S. aureus resistant to the antibiotics
14.93), CN (19.45 vs 14.93), CO (47.89 vs 30.75), like A, CP, CN, CO and G reduced while that for
G (32.78 vs 26.38) (P < 0.02 to 0.0001). On the AK, OF, LF, E and CD increased. Additionally
contrary, during the study time points there was from the chemical classification perspective, a
increase in the number of organisms resistant to AK decrease in the percentage of S aureus resistant was
(2.31 vs 7.07), OF (41.49 vs 62.16), LF (22.44 vs seen for beta lactams, folic acid inhibitors,
32.43), E (20.40 vs 42.59) and CD (3.67 vs 17.11) aminoglycoside, while on the contrary there was an
(P < 0.0001). The data are all represented in Table increase in resistance to fluoroquinolones and
1. macrolides (Table 1 and 2).
When the data was analyzed from the In our study it was observed that the pattern of drug
perspective of the class the antibiotics belonged to, resistance for S aureus was different in the two time
the results indicated that when compared to the year points (Table 1 and 2). The most important aspect
2010 there was decrease in the percentage of S to be observed is that there was a 23.24% decrease
aureus resistant to the beta lactams (p < 0.0001), in the incidence of MRSA and 35.79% reduction in
folic acid inhibitors (p < 0.0001), aminoglycoside resistance to the Folic acid inhibitor CO (Table 1,
(p < 0.6), while on the contrary there was a increase 2). With respect to aminoglycoside antibiotics there
in resistance to fluoroquinolones (p < 0.0001) and was a 19.53% reduction in resistance to G while for
macrolides (p < 0.0001). It was also observed that AK a 3.06 fold increase in the resistance was seen
there was a 23.24% reduction in the incidence of (Table 1). The reason for this change is that the
MRSA. However a cumulative analysis for all the Infection Control practices were implemented and
11 antibiotics tested indicated that when compared monitored by the committee through regular
to the year 2010, the number of organism resistant sensitization, teaching and evaluation programs.

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Table 1: Drug Sensitivity pattern of various antibiotics for S aureus tested in the year 2010 and

Folic
Amino Fluro
acid
Beta lactams Macrolides
inhibi
glycosides quninolones
tor
A AC CP CN CO G AK OF LF E CD
Resistant 641 191 337 143 352 241 17 305 165 150 27
2010

Sensitive 94 544 398 592 383 494 718 430 570 585 708
% Resistant 87.21 25.98 45.85 19.45 47.89 32.78 2.312 41.49 22.44 20.4 3.67
Resistant 648 294 116 116 239 205 55 483 252 331 133
2015

Sensitive 129 483 661 661 538 572 722 294 525 446 644
% Resistant 83.39 37.84 14.93 14.93 30.75 26.38 7.078 62.16 32.43 42.59 17.11
2 172.0
X value 4.36 172.09 5.45 46.56 7.45 18.91 64.65 19.12 85.75 72.16
9
0.000 0.000 0.000 0.000
P value 0.036 0.0001 0.019 0.0001 0.006 0.0001 0.0001
1 1 1 1

These observations are in agreement to the previous

Table 2: Drug Sensitivity pattern of various types of
reports of Tinelli and associates (2009) who have
antibiotics on S aureus tested in the year 2010 and 2015
also observed that implementation of hospital
infection control lead to a decline in the incidence
2010 2015 p t of MRSA.25On the contrary, the resistance to
aminoglycoside AK, the Fluroquninolones OF and
(4)
Beta lactams

LF and Macrolides E and CD increased by 2.08 and

1.78±0.49 1.52±1.20 <0.0001 4.25
4.66 folds respectively (Table 1). These
observations are in congruence to reports published
from around the world for these classes of
inhibitor (1)
Folic acid

0.47±0.51 0.31±0.46 <0.0001 6.89

antibiotics for S aureus.26-29 S. aureus is reported
for its remarkable propensity to resist the effects of
various antibiotics. In fact, the resistant strains of S
aureus colonize, at times to spurt in to epidemic
ides (2)
Aminoglycos

0.35±0.51 0.33±0.59 0.6 0.51 proportions. The unnerving ability of S aureus to

asymptomatically colonized in normal individuals
to become nasal carriers and the direct skin to skin
nes (2)
Fluroquinolo

contact mode of transmission increases

0.62±0.81 0.90±0.78 <0.0001 -6.57 susceptibility to infections. S aureus shows hyper
virulence behavior due to selective pressure of
antibiotics and horizontal/vertical gene
(2)
Macrolides

transmission making it a formidable adversary in

0.23±0.48 1.18±0.74 <0.0001 -9.82 clinical management.24With respect to
themechanisms of drug resistance seen in S aureus
reports indicate that for the antibiotic
Total (11)

aminoglycoside, the resistant organisms have been

3.47±1.19 3.71±2.39 0.044 -2.01 shown to produce microbial enzymes the
aminoglycosidase that inactivate the drug and
reduce the affinity of the drug to the bacterial

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ribosomes by inducing conformational changes of LF); and the macrolides (E and CD) increased. The
the bacterial binding site.30 For the macrolides like possible explanation for this is that in the recent
ketolides and azalides, resistant strains of S aureus past these drugs have been the cornerstone in
are reported to up regulate genes that mediate the treating infections and their rampant prescription
active efflux of antibiotics by the pumps on without having an antibiogram results by the
bacterial cell membrane.30 Additionally reports professionals and non-adherence to the dose and
also indicate that in some S aureus strains schedule, and over the counter prescription must
resistance is also conferred to macrolides by have led to the resistant strains. Efforts have
genetically coded inducible constitutive enzymes to already been initiated towards remedial measures
protect the ribosome from the macrolide attacks or and on adherence to the good practice guidelines
by 50s ribosome.30 With respect quinolones reports and antibiotic policy to minimize the evolution of
exists that S aureus develop drug resistance by drug resistant strains.
causing chromosomal mutations to the DNA gyrase
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Cite of article: Jakribettu R P, Rao S V, D’souza O L, Pinto V S, D’souza B L, Tellis L A, Baliga M S;
Outcome of implementation of hospital infection control guidelines on the antibiotic resistance pattern in
staphylococcus aureus isolated from skin and soft tissue infections: a retrospective two time point study; Int. J.
Med. Lab. Res. 2017, 2(3): 19-25

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