RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE

ANNEXURE II

SYNOPSIS FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 / NAME OF THE CANDIDATE AND ADDRESS: / Dr. MALATHI .N
POST GRADUATE STUDENT ,
DEPT. OF MICROBIOLOGY,
VICTORIA HOSPITAL CAMPUS,
BANGALORE MEDICAL COLLEGE AND RESEARCH INSTITUTE
BANGALORE -560002.
2 / NAME OF THE INSTITUTION / BANGALORE MEDICAL COLLEGE AND RESEARCH INSTITUTE, BANGALORE.
3 / COURSE OF STUDY AND SUBJECT / M.D IN MICROBIOLOGY
4 / DATE OF ADMISSION TO COURSE / 25th July, 2012.
5 / TITLE OF THE STUDY / “BACTERIOLOGICAL PROFILE OF SURGICAL SITE INFECTIONS AND THEIR ANTIBIOGRAMS IN A TERTIARY CARE HOSPITAL”.
6 / BRIEF RESUME OF INTENDED WORK:
6.1. NEED FOR THE STUDY:
Surgical site infection is a type of healthcare-associated infection in which a wound infection occurs after an invasive (surgical) procedure. Surgical site infections have been shown to compose up to 20% of all of healthcare-associated infections. At least 5% of patients undergoing a surgical procedure develop a surgical site infection [1].
Many of infections are nosocomial, contracted after invasive procedures, surgical manipulations or placement of prosthesis [2].
Surgical site infections are the second most common cause of nosocomial infections. Surgical site infections are still a threat to surgeons, in spite of the newer antibiotics available today. Although properly administered antibiotics can reduce postoperative surgical site infections secondary to bacterial contamination, widespread use of prophylactic antibiotics can lead to emergence of multi drug resistant bacteria The higher rates of surgical site infections are associated with higher morbidity, mortality and increased medical expenses [3].
The organism that would invade the tissue depends on the location of the wound, Superficial incisions are mostly colonized by endogenous bacterial flora (Commensals) or pathogen, of which S.aureus is frequently observed. Surgical site infection rate has varied from a low of 2.5% to high of 41.9% [4].
The aim of the present study is to identify bacterial etiology of surgical site infections and their antibiogram.
REVIEW OF LITERATURE
·  SP Lilani, et al, (2005) reported the overall infection rate was 8.95% with 3.03% in clean surgeries, 22.41% in clean contaminated surgeries, and significant increase with an increase in preoperative stay. The Staphylococcus aureus was found to be the commonest isolate in the study, followed by Pseudomonas aeruginosa. Mixed infections were reported from two cases, both of which had Staphylococcus aureus as one of the isolates. The other organisim were E.coli, Acinetobacter spp.
Pseudomonas aeruginosa exhibited 100% resistant to gentamicin. Other Gram negative bacilli were found to be 100% resistant to tetracycline followed by ampicillin and cephalothin 83.33% each[4].
·  Jyoti sonawane, et al, (2010) in their study of one and a half year included 440 pus samples from surgical site infections from which 540 bacteria were isolated. Of these, 63.5% of the isolates were Gram negative bacteria and 36.5% were Gram positive bacteria. The commonest pathogen was Staphylococcus aureus (29.26%), of which 27.85% were MRSA, followed by E.coli (18.70%), Pseudomonas spp (15.37%), Acinetobacter spp. (8.33%) and Enterococcus spp. (7.22%), while other Gram negative bacilli were 7.04%. Gram positive bacteria were predominantly sensitive to Vancomycin. . Extended spectrum beta lactamase (ESBL) production was seen in 71.72% of Gram negative bacteria and they were predominantly sensitive to Piperacillin-Tazobactum and Imipenem[5].
·  In a study by A Ramesh, et al, (2010), a total of 50 samples of which 66% had growth and 34% had no growth, Among the clean surgical cases (n=30), the predominant isolates were Staphylococcus aureus (9), followed by Klebsiella pneumoniae (5). In case of clean contaminated surgeries (n=20), Staphylococcus aureus (10) and Klebsiella pneumoniae (6) were the leading pathogens. Among the 19 isolates of Staphylococcus aureus recorded in the study, 16 were methicillin resistant Staphylococcus aureus, susceptible to amikacin, gentamycin, vancomycin, ciprofloxacin, and ofloxacin,. All the sixteen Gram negative bacterial isolates noted in the study were susceptible to imipenam and amikacin [6].
·  Adegoke, Anthony A, et al, (2010) studied a total of 64 samples of which forty eight (75%) of the samples yielded monomicrobial growth while 16 (25%) yielded polymicrobial growth. Staphylococcus aureus was the predominant bacteria (25%) followed by Pseudomonas aeruginosa (20%), Escherichia coli (15%), Klebsiella oxytoca (10%), Proteus mirabilis (10%), Klebsiella aerogenes (5%), Coagulase-negative Staphylococcus (5%), Streptococcus pyogenes (5%) and Proteus vulgaris (5%). The antibiogram revealed Gram positive organisms being highly susceptible to gentamicin, erythromycin, streptomycin and tetracycline with a percentage varying between 70-95%. Gram negative organisms were noted,which are highly susceptible to gentamicin, the percentage ranging between 70-90%[7].
·  In a study of 110 cases from surgical site infections by Nutanbala N. Goswami et al. (2011), Staphylococcus aureus (26.23%) was the predominant organism followed by Gram negative bacteria. 68.85% of the total isolates were Gram negative. S. aureus was sensitive to levofloxacin (60.42%) and vancomycin (54.17%). Pseudomonas aeruginosa was sensitive to ciprofloxacin (83.78%), gatifloxacin (51.35%), and meropenem (51.35%). 72.41% of the Escherichia coli isolates were sensitive to levofloxacin, followed by 62.07% being sensitive to ciprofloxacin. Among Klebsiella pneumoniae isolates, 63.6% were sensitive to ciprofloxacin, followed by 63.16% of the isolates showing susceptibility to levofloxacin and gatifloxacin. 75% of the Proteus mirabilis isolates were sensitive to ciprofloxacin. Proteus vulgaris was most susceptible to ampicillin+sulbactam (57.14%) followed by levofloxacin(50%)[8]
AIMS AND OBJECTIVES OF STUDY:
1)  To isolate and identify bacteria associated with surgical site infections.
2)  To study the antibiogram pattern of the organism causing surgical site infection.
7 / MATERIALS AND METHODS:
7.1.  SOURCE OF DATA:
The study will be carried out in the department of Microbiology, Bangalore Medical College and Research Institute B’lore. It is a prospective study of bacteriology of surgical site infection which includes 100 consecutive pus samples from surgical site infections from various surgical specialties of Victoria Hospital, Vani Vilas Hospital, Bowring and Lady Curzon Hospital attached to Bangalore Medical College and Research Institute during the period Nov 2012 to Oct 2014.
7.2 A. STUDY DESIGN:
It is a prospective study of Bacteriology of Sugical site infection
B.STUDY PERIOD:
November2012-October2014
C. PLACE OF STUDY:
Victoria Hospital, Vani Vilas Hospital, Bowring and Lady Curzon Hospital attached to Bangalore Medical College and Research Institute.
D. SAMPLE SIZE
100 consecutive pus samples
E. INCLUSION CRITERIA:
Post Operative Cases of clean and clean contaminated surgeries satisfying the definition of surgical site infections.
F. EXCLUSION CRITERIA:
1)  Post Operative Cases of contaminated and dirty wound surgeries.
2)  Procedures in which healthy skin was not incised, such as opening of an abscess.
3)  Burn injuries and donor sites of split skin grafts
4)  Wounds due to road traffic accidents.
G.METHOD OF COLLECTION OF DATA:
Surgical site infections are classified into: Superficial, Deep and Organ-Space Infections
according to CDC guidelines [9]
The wound classification used is based on that developed by the National Research Council in the USA [10].
The surgical sites are examined for suggestive signs/symptoms of infection in the post-operative period, during wound dressing or when the dressings were soaked, until the patient was discharged from the hospital and also in the out-patient department up to 30 days after discharge (optional).
When infection was clinically suspected, the area around the surgical wound was cleaned with 70% ethyl alcohol .The exudate was collected from the depth of the wound using four sterile cotton swabs and for anaerobic culture and the tissue bit or material aspirated in a sterile syringe.
one of them was put in Brain Heart Infusion(BHI) broth and the other into a RCMB (Robertson Cooked Meat Broth) at the bed side.
All the specimens collected were transported immediately to the laboratory for further processing. The BHI broth and Robertson Cooked Meat Broth were incubated at 37°C.
Ø  One swab will be used for Gram staining.
Ø  Aerobic Culture; The second swab will immediately be inoculated onto Blood Agar, Mac Conkey Agar. These plates will be kept at 37°C for 24-48 hours. The isolates were identified by colony morphology and standard biochemical tests [11].
Ø  Subcultures will be done from BHI broth onto blood agar and Mac Conkey Agar after overnight incubation, correlated with growth on the primary plates.
Ø  Antibiotics susceptibility study will be performed using Kirby-Bauer disc diffusion methods following CLSI guidelines [12].
Ø  Anaerobic culture; The aspirate in the syringe or tissue bit after homogenisation is Inoculated into a plate of freshly poured 5% Blood Agar and RCMB The plated media is incubated in gas pak jars the anaerobic plates are incubated at 37°C for 48 -72 hrs, subcultures will be done similarly from the Robertson Cooked Meat Broth correlated with growth on the primary plates. The growth obtained is further identified upto the genus level.[11]
H. STASTICAL ANALISIS:
By descriptive analysis and correlation
7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMAN OR ANIMALS? IF SO, PLEASE DESCRIBE BRIEFLY.
No.
7.4 HAS THE ETHICAL CLEARANCE OBTAINED FROM YOUR INSTITUTION?
8 / LIST OF REFERENCES:
1.  Surgical Site Infection, NICE Guideline 2008. National Institute for Health and Clinical Excellence Clinical Guideline 74. Available from.
http//www.nice.org.uk/nicemedia/pdf/CG&$NICEGuideline.pdf. [Cited in October, 2008].
2.  Koneman EW, Allen SD, Janda WM, Schrekenberger PC, Procop G, Baker Woods. Konmen’s Color atlas and text book of Diagnostic Microbiology; 2006, p.95-96.
3.  Sohil Ahmed Khan, Padma .G M.Rao, Anand Rao Gabril Rodrigues. Survey and evaluations of antibiotic prophylaxis usage in surgery Wards of tertiary level institution before and after the implementation of clinical guidelines Indian Journal of Surgery 2006; vol. 68.
4.  SP Lilani, Jangle N, Chowdhary A and Daver GB surgical site infection in clean and clean- contaminated cases. Indian journal of medical Microbiogy,(2005)23 (4):249-52.
5.  Jyoti Sonawane, Narayan Kamath, Rita Swamynathan, Kaushal Dosani. Bacterial Profile of Surgical Site Infections and Their Antibiograms in a Tertiary Care Hospital in Navi Mumbai.Bombay Hospital Journal, vol.52, no, 3, 2010.
6.  A Ramesh and Ms. R. Dharini/Int J Biol Med Res. 3(3):2050-2053.
7.  Adegoke, Anthony A. Tom Mvuyo, Okoh, Anthony I and Jacob Steve. Studies on multiple antibiotic resistant bacteria isolated from surgical site infection.
8.  Nutanbala N Goswami, Hiren Trivedi , Alipesh Puri P Goswamy, Tejas K Patil , C B Tripathi. Antibiotic sensitivity profile of bacterial pathogens in postoperative wound infections at a tertiary care hospital in Gujarat, India.
9.  VICNISS SURVEILLANCE CDC/NHSN Surveillence HAI Criteria Version: October 2011 page 7 of 31.
10.  National Institute of Clinical Excellence. Surgical Site infection; Prevention and treatment of Surgical site infection October 2008.
11.  Collee JG, Miles RS, Van B, Test for the identification of Bacteria. Mackie and McCartney practical medical microbiology 14th edition, Edinborough; Churchill Living Stone; 1996; 131-152.
12.  Clinical Laboratory Standard Information. Performance Standards for Anti-Microbial Susceptibility testing, Twenty first information Supplement Wayne PA; CLSI. M100-SS21. Vol .31 No.1.
9 / SIGNATURE OF CANDIDATE:
(Dr. MALATHI N)
10 / REMARKS OF THE GUIDE:
The study of SSI helps the clinician in selection of appropriate treatment and control of infection. .Recommended for registration.
11 / NAME AND DESIGNATION OF:
11.1. GUIDE:
DR.T NAGARATHNAMMA MD
PROFESSOR AND HOD
DEPARTMENT OF MICROBIOLOGY
BANGALORE MEDICAL COLLEGE AND RESEARCH INSTITUTE
BANGALORE:560002
11.2.  SIGNATURE:
11.3 HEAD OF THE DEPARTMENT:
DR.T NAGARATHNAMMA MD
PROFESSOR AND HOD
DEPARTMENT OF MICROBIOLOGY
BANGALORE MEDICAL COLLEGE AND RESEARCH INSTITUTE
. BANGALORE:560002
11.4 SIGNATURE:
12 / 12.1. REMARKS OF THE CHAIRMAN AND DEAN:
12.2. SIGNATURE OF THE DEAN: