Submit manuscript...
Journal of
eISSN: 2373-437X

Microbiology & Experimentation

Research Article Volume 4 Issue 5

Bacteriological Profile of Wound Infection and Antibiotic Susceptibility Pattern of the Isolates

Mahat P,1 Manandhar S,1 Baidya Baidya2

1Department of Microbiology, National College, Nepal
2B and B Hospital, Nepal

Correspondence: Pushpa Mahat, Department of Microbiology, National College, Khusibu, Kathmandu

Received: June 29, 2016 | Published: April 17, 2017

Citation: Mahat P, Manandhar S, Baidya R (2017) Bacteriological Profile of Wound Infection and Antibiotic Susceptibility Pattern of the Isolates. J Microbiol Exp 4(5): 00126. DOI: 10.15406/jmen.2017.04.00126

Download PDF

Abstract

Introduction: Wound infection is the one of the most important causes of morbidity and mortality worldwide and antibiotics resistant bacteria are the great part of complications on treatment of the infection.

Objectives: The present study was conducted to isolate and identify the etiological agents of wound infection and assess the antimicrobial susceptibility pattern of the isolates.

Methods: The study was carried out on wound infection suspected patients visiting B and B Hospital for six months duration. The collected pus specimen were first observed macroscopically then streaked on MacConkey agar and blood agar, incubated at 370C for 24 hours. The isolated bacteria were identified by macroscopic and microscopic observations and biochemical reactions. Antibiotic susceptibility pattern of the isolates was assessed by Modified Kirby Baur disc diffusion technique.

Results: A total of 503 pus samples were collected; of which 43.7% showed bacterial growth. Out of a total 220 bacterial isolates; 158 (71.82%) were Gram negative and 62 (28.18%) were Gram positive bacteria. Pseudomonas spp. (34.55%) was most common followed by Staphylococcus aureus (21.36%), Escherichia coli (11.82%), Acinetobacter baumannii (11.36%), Enterobacter aerogens (8.18%), Coagulase negative Staphylococci (CoNS) (5.45%), Klebsiella pneumoniae (4.55%), Citrobacter freundii (1.36%), Streptococcus spp. (0.91%) and Enterococcus spp. (0.46%). Most of Gram negative bacteria (63.9%) and Gram positive bacteria (93.5%) were susceptible to amikacin and chloramphenicol respectively. Among 220 isolates, 138 (62.73%) were found to be multi drug resistant (MDR). All the isolates of A. baumannii were isolated from in-patients and almost 96.4% (24/25) were MDR.

Conclusion: In this study, significant number of MDR strains was found as the causative agent of wound infection. So, routine microbiological analysis of the wound specimen and their antibiotic susceptibility testing are recommended that will guide medical practitioners for empirical treatment of wound infection, so as to reduce the spread of resistant bacteria.

Keywords: wound infection, antibiotic susceptibility, MDR

Introduction

The exposure of subcutaneous tissue following a loss of skin integrity (i.e. a wound) provides a moist warm and nutritive environment that is conducive to microbial colonization and proliferation. The progression of a wound to an infected state is likely to involve a multitude of microbial and host factors.1 Wound can be infected by a variety of microorganisms ranging from bacteria to fungi and parasites as well as virus.2 The most common organisms are S. aureusP. aeruginosaE. coliKlebsiella spp. and Acinetobacter spp.3,4

Antibiotics, although, have been of great value in treatment and in prophylaxis to prevent infections, the timing of administration, choice of antimicrobial agent, durations of administration have clearly defined the value of antibiotics in reducing wound infections.5 Advance in control of infection have not completely eradicated the problem of the wound infection because of development of drug resistance.6

Wound infection results in sepsis, limb loss, long hospital stays, higher costs and is responsible for significant human mortality and morbidity worldwide.7 It is one of the most common hospital acquired infections.8 It remains an ongoing problem which although, cannot be completely eradicated however, by taking prompt control measures against the most commonly isolated organism and proper care of wound may lead to the minimum of wound infection.1 Hence, the present study was carried out to identify the causative agent of wound infection and antibiotic susceptibility pattern of the isolates, which will be beneficial as guidance for medical practitioners to select empirical antimicrobial therapy and on the implementation of infection control measures that plays an important role in minimizing the emergence rate of antimicrobial resistance (MDR).

Methods

A cross-sectional study was carried out in a total of 503 aseptically collected pus samples from wound infection suspected patients visiting B and B hospital, Lalitpur from October 2013 to April 2014. The pus specimen were macroscopically analyzed for their color and odor then were streaked on MacConkey agar and Blood agar plates and incubated at 370C for 24 to 48 hours. All the isolates were identified by colony morphology, staining reaction and the biochemical properties.9 The antimicrobial susceptibility test of isolates was performed by Modified Kirby Bauer disc diffusion method using the standard guidelines of the10 and MDR strain was identified as resistant to ≥3 antimicrobial classes.11 The computer data were studied using the statistical software SPSS version 17. Chi-square test was used to calculate probabilities and determine significance. A p-value of less than or equal to 0.05 was considered to be statistically significant p<0.05).

Results

Out of 503 pus samples from wound infection suspected patients, 220 (43.7%) showed bacterial growth whereas 283 (56.3%) were growth negative (Table 1). Out of 302 samples from in-patients, 160 (53.0%) samples and among 201 samples from out patients, 60 (29.9%) samples showed bacterial growth. The higher percentage of culture positivity seen among in-patients was found to be statistically significant (P<0.001) (Table 2).

S. No.

Growth

No. of samples

% of samples

1

Culture positive

220

43.7

2

Growth negative

283

56.3

 

Total

503

100

Table 1 Growth pattern of Bacteria

Patient type

Growth

No growth

Total

P-Value

No.

%

No.

%

In-patient

160

53

142

47

302

0.001

Out-patient

60

29.9

141

70.1

201

Total

220

43.7

283

56.3

503

 

Table 2 Distribution of growth positive cases in in-patient and out-patient

Among 370 (73.56%) male patients and 133 (26.44%) female patients, 172 (46.50%) and 48 (36.1%) were found growth positive respectively. The result was statistically significant (P=0.038) (Table 3). Among 220 positive cases the highest positive cases 67 (30.45%) was found in the patients of age group 21-30 years (Table 4).

Patient type

Growth

No Growth

Total

P-Value

No.

%

No.

%

Male

172

46.5

198

53.5

370

0.038

Female

48

36.1

85

63.9

133

Total

220

43.7

283

56.3

503

 

Table 3 Gender-wise distribution of growth positive cases

Age group(Yrs)   

Male total   

Positive   

Female total   

Positive   

Total cases   

Total positive cases

1≤10

21

7

13

4

34

11 (5%)

20-Nov

74

43

7

1

81

44(20%)

21-30

82

50

36

17

118

67(30.45%)

31-40

61

25

30

14

91

39(17.73%)

41-50

56

18

16

3

72

21(9.55%)

51-60

41

21

12

2

53

23(10.45%)

61-70

16

2

11

4

27

6(2.73%)

≥71

19

6

8

3

27

9(4.09%)

Total

370

172

133

48

503

220

Table 4 Age and Gender-wise distribution of growth positive cases

Among 220 bacterial isolates, Gram negative bacteria were predominant with 158 (71.82%) isolates, while Gram positive bacteria contributed 62 (28.18%) of total isolates. Altogether 10 different bacterial species were isolated, among which Pseudomonas spp. (34.55%) were predominant followed by S. aureus (21.36%) (Table 5). Out of 220 isolates, most of the isolates were isolated from in-patient (72.73%) than out-patient (27.27%). All the A. baumannii were from in-patients (Table 6).

Organism

No of isolates (%)

% of Total isolates

Gram Positive Bacteria

S. aureus

47 (75.81)

21.36

CoNS

12 (19.35)

5.45

Streptococcus spp.

2 (3.23)

0.91

Enterococcus spp.

1 (1.61)

0.46

Total

62 (100)

28.18

Gram Negative Bacteria

Pseudomonas spp.

76 (48.10)

34.55

E. coli

26 (16.46)

11.82

Acinetobacter baumannii

25 (15.82)

11.36

E. aerogens

18 (11.39)

8.18

K. pneumoniae

10 (6.33)

4.55

C. freundii

3 (1.90)

1.36

Total

158 (100)

71.82

Table 5 Distribution of bacterial isolates

Organisms

In patient

Out patient

Total

Frequency

%

Frequency

%

S. aureus

23

48.9

24

51.1

47

CoNS

8

66.7

4

33.3

12

Streptococcus spp.

2

100

0

0

2

Enterobacter spp.

1

100

0

0

1

Pseudomonas spp.

58

76.3

18

23.7

76

E. coli

20

76.9

6

23.1

26

Acinetobacter baumannii

25

100

0

0

25

E. aerogens

14

77.8

4

22.2

18

K. pneumoniae

7

66.7

3

30.3

10

C. freundii

2

66.7

1

33.3

3

Total

160

72.73

60

27.27

220

Table 6 Distribution of isolates among in-patient and out-patient

Vancomycin was used only for the isolates resistant to cloxacillin. Most of the Gram positive bacterial isolates (more than 90%) were found to be sensitive to chloramphenicol. Penicillin G was ineffective (100%) to all the Gram positive isolates followed by amoxycillin (Table 7). Most of the Gram negative bacterial isolates (more than 48%) were found to be sensitive to amikacin, gentamicin and cefoperazone/ sulbactum whereas 73.4% of them were resistant to ciprofloxacin (Table 8).

Antibiotics

Sensitive

Intermediate

Resistant

Total

No.

%

No.

%

No.

%

Ciprofloxacin

27

43.5

7

11.3

28

45.2

62

Ofloxacin

27

43.5

7

11.3

28

45.2

62

Ceftiraxone

46

74.2

6

9.7

10

16.1

62

Gentamicin

41

66.1

1

1.6

20

32.3

62

Chloramphenicol

58

93.5

1

1.6

3

4.8

62

Cefoperazone/ Sulbactam

31

86.11

1

2.78

4

11.11

36

Penicillin G

0

0

0

0

62

100

62

Amoxycillin

11

17.7

0

0

51

82.3

62

Erythromycin

29

46.8

5

8.1

28

45.2

62

Clindamycin

54

91.53

0

0

5

8.47

59

Cloxacillin

56

94.92

0

0

3

5.08

59

Vancomycin

5

100

0

0

0

0

5

Table 7 Antibiotic susceptibility pattern of Gram positive isolates

Antibiotics

Sensitive

Intermediate

Resistant

Total

No.

%

No.

%

No.

%

Ciprofloxacin

40

25.3

2

1.3

116

73.4

158

Ofloxacin

41

25.9

3

1.9

114

72.2

158

Ceftriaxone

5

6.1

1

1.22

76

92.68

82

Ceftazidime

4

5.26

0

0

72

94.74

76

Gentamicin

78

49.4

2

1.3

78

49.4

158

Amikacin

101

63.9

14

8.9

43

27.2

158

Chloramphenicol

52

32.9

8

5.1

98

62.6

158

Cefoperazone/ Sulbactum

77

48.7

31

19.6

50

31.6

158

Meropenem

47

37.9

10

8.07

67

54.03

124

Imipenem

97

78.22

12

9.68

15

12.1

124

Piperacillin/ Tazobactam

42

33.87

23

18.55

59

47.58

124

Colistin

50

100

0

0

0

0

50

Table 8 Antibiotic susceptibility pattern of Gram negative isolates

Out of 47 isolates of S. aureus, 95.7% showed sensitivity towards chloramphenical, clindamycin, and cloxacillin. Penicillin G was ineffective (100%), followed by amoxycillin (89.4%). Among the S. aureus isolates, two isolates were found to be methicillin resistant S. aureus (MRSA), sensitive to vancomycin (Table 9).

Antibiotic

Sensitive

Intermediate

Resistant

Total

No

%

No

%

No

%

Ciprofloxacin

16

34

6

12.8

25

53.2

47

Ofloxacin

16

34

6

12.8

25

53.2

47

Ceftriaxone

37

78.7

6

12.8

4

8.5

47

Gentamicin

29

61.7

1

2.1

17

36.2

47

Chloramphenicol

45

95.7

0

0

2

4.3

47

Cefoperazone/ Sulbactum

23

92

1

4

1

4

25

Amox Ycillin

5

10.6

0

0

42

89.4

47

Erythromycin

27

57.4

4

8.5

16

34

47

Clindamycin

45

95.7

0

0

2

4.3

47

Cloxacillin

45

95.7

0

0

2

4.3

47

Vancomycin

2

100

0

0

0

0

2

Table 9 Antibiotic susceptibility of S. aureus

The effective antibiotics against Pseudomonas spp. were amikacin with (68.4%) sensitivity and gentamicin with (63.2%) respectively. The most ineffective antibiotic was ceftazidime (94.7%) (Table 10).

Antibiotics

Sensitive

Intermediate

Resistant

Total

No.

%

No.

%

No.

%

Ciprofloxacin

24

31.6

0

0

52

68.4

76

Ofloxacin

25

32.9

0

0

51

67.1

76

Ceftazidime

4

5.3

0

0

72

94.7

76

Gentamicin

48

63.2

1

1.3

27

35.5

76

Amikacin

52

68.4

10

13.2

14

18.4

76

Chloramphenicol

14

18.4

3

3.9

59

77.6

76

Cefoperazone/ Sulbactum

37

48.7

22

28.9

17

22.4

76

Meropenem

19

31.67

2

3.33

39

65

60

Imipenem

55

91.67

2

3.33

3

5

60

Piperacillin/ Tazobactam

21

35

15

25

24

40

60

Colistin

24

100

0

0

0

0

24

Table 10 Sensitivity pattern of Pseudomonas spp. to different antibiotics

The most effective antibiotics against A. baumannii isolates was colistin with 100% sensitivity, the opposite was ceftriaxone with 100% respectively. Out of the isolates, more than 92% were resistant to ciprofloxacin, ofloxacin, gentamicin, cefoperazone/ sulbactum and piperacillin/ tazobactam (Table 11).

Antibiotics

Sensitive   

Intermediate

Resistant

Total

No

%

No

%

No

%

Ciprofloxacin

1

4

0

0

24

96

25

Ofloxacin

1

4

0

0

24

96

25

Ceftriaxone

0

0

0

0

25

100

25

Gentamicin

2

8

0

0

23

92

25

Amikacin

3

12

3

12

19

76

25

Chloramphenicol

1

4

3

12

21

84

25

Cefoperazone/ Sulbactum

2

8

0

0

23

92

25

Meropenem

3

12

5

20

17

68

25

Imipenem

6

24

8

32

11

44

25

Piperacillin/

1

4

1

4

23

92

25

Tazobactam

Colistin

23

100

0

0

0

0

25

Table 11 Antibiotic susceptibility pattern of A. baumannii

Out of 220 bacterial isolates, 138 were found to be the MDR isolates. The higher MDR pattern was found in Gram negative isolates 106 (48.18%) than in Gram positive isolates 32 (14.55%). The highest percentage (96%) of MDR pattern was shown by A. baumannii followed by K. pneumoniae and the least (21.92%) by E. coli (Table 12).

Organisms

No. of Isolates

MDR Isolates

Frequency

%

S. aureus

47

24

50

CoNS

12

6

51.06

Streptococcus spp.

2

1

50

Enterococcus spp.

1

1

100

Pseudomonas spp.

76

52

68.42

E. coli

26

7

26.92

Acinetobacter Baumannii

25

24

96

E. aerogens

18

13

72.22

K. pneumoniae

10

9

90

C. freundii

3

1

33.33

Total

220

138

62.73

Table 12 Distribution of MDR pathogens among total isolates

Among the 160 isolates from in-patients, 96 (60%) were MDR strains and out of 60 out-patient, 42 (70%) were found to be MDR strains, were statistically insignificant (P=0.172) (Table 13). Out of 172 isolates from male 103 (59.88%) were MDR strains and among 48 isolates from female patients, 35 (72.92%) were MDR strains, were statistically insignificant (P=0.99) (Table 14).

Types of patient

Total isolates

MDR isolates

P-Value

Frequency

%

In-patient

160

96

60

0.172

Out-patient

60

42

70

Total

220

138

62.73

 

Table 13 Distribution of MDR pathogens among in-patient and out-patient

Gender

Total isolates

MDR isolates

P-Value

Frequency

%

Male

172

103

59.88

0.99

Female

48

35

72.92

Total

220

138

62.73

 

Table 14 Gender-wise distribution of MDR pathogens

Discussion

Out of 503 samples, 220 (43.7%) showed bacterial growth. In similar studies by Maharjan.12 showed similar result 50.95% growth but by Puyal.13 showed 71.84% growth. The lesser percentage of growth positive cases may be due to the collection of samples from patients taking antibiotics.

The occurrence of higher number of male patients 370 (73.56%) than female patients for the collection of pus samples may be due to the higher involvement of males in physical outdoor works for earning livelihood as compared to females and more chances of accidents during the activities. The higher growth positive cases in male patients (78.18%) than in female (21.82%) was observed in this study and was supported by the similar studies carried out by KC et al.7 & Shrestha.14

The higher number of bacterial growth was observed in in-patients 160 (72.73%) than in out-patients 60 (27.27%). Similarly, Acharya15 & Bhattrai16 also reported the higher number of growth positive cases in in-patients. This may be due to the factors associated with acquisition of nosocomial pathogens in in-patients and immunologically weak health status facilitates the wound infection in them.

The highest positive cases 30.45% (67/226) were observed in the age group of 21-30 years might be due to the active participation of this age group of people in different physical and mechanical works and during they may get injured.

Among the total 220 bacterial isolates, 71.82% were Gram negative and 28.18% were Gram positive bacteria. In similar study conducted by Yakha et al.17 & Acharya15 Gram negative bacteria were found predominant. Isolation of Gram negative bacteria, during this study was higher, as they are more prevalent aerobes and facultative anaerobes in abscesses and skin wound, these bacteria have well recognized property for abscess formation in open as well as in visceral infection, which increases their incidence in both open and closed types of wound. Isolation of Gram negative bacteria also increases in the cases of Hospital acquired infections (HAIs). A study conducted by Banjara18 at TUTH showed the high rate of Gram negative bacteria in HAI.

Altogether, 10 different bacterial species were isolated with Pseudomonas spp. being the predominant one (34.55%) followed by S. aureus (21.36%), E. coli (11.82%), A. baumannii (11.36%), E. aerogens (8.18%) Coagulase negative Staphylococci (CoNS) (5.45%), K. pneumoniae (4.55%), C. freundii (1.36%), Streptococcus spp (0.91%) and Enterococcus spp (0.46%). Similar studies carried out by Hani and Adnan19 & Ranjan et al.20 also showed Pseudomonas spp. was the most prevalent bacteria among the total cases with 27.8% and 29.6% respectively. But, the study conducted by Zafar et al.21 showed Pseudomonas spp. the second commonest bacteria with 18.35% and S. aureus as the most predominant isolates with 41.28% of the total cases. Pseudomonas spp was predominant (36.25%) among in-patients followed by A. baumannii (15.63%) but S. aureus was the most prevalent (40%) among out-patients. All the isolates of A. baumannii isolated from in-patients.

Regarding antibiotic susceptibility testing, chloramphenicol (93.5%) and amikacin (63.9%) were the most effective antibiotics, in general to the Gram positive and Gram negative bacteria respectively. Among 47 S. aureus, two were found to be methicillin resistant (MRSA). 89.4% of S. aureus were resistant to amoxycillin. The resistance of S. aureus to β- lactam antibiotics is due to the production of penicillinas that hydrolyzed the β-lactam ring. MRSA resistance to β-lactam antibiotics is conferred primarily by the production of a bacterial cell wall penicillin binding protein, PBP2a. This has low binding to β-lactams which allows the organism to survive and multiply. PBP2a production is mecA gene encode.9 51.06% (24/47) S. aureus isolates were MDR. The studies by Puyal,13 Acharya15 and Bhattarai16 support this result.

In present study, out of 76 Pseudomonas spp. isolates, 52 (68.42%) were found to be MDR isolates. Colistin was absolutely effective antibiotic against Pseudomonas spp. followed by imipenem (91.67%), amikacin (68.4%) and gentamicin (63.2%) respectively. ceftazidime was found to be the most ineffective (94.7%) antibiotics. Similar study by Acharya15 found 62.16% MDR among Pseudomonas spp. isolates and amikacin was found to be 84.61% effective antibiotics. The study by Hani and Adnan19 showed amikacin and gentamicin effectiveness, 78% and 72% respectively against Pseudomonas spp. But the study carried out by Falagas et al.22 isolated the organism from ICU patients which was almost resistant to amikacin, gentamicin and other anti-pseudomonal antibiotics. The study conducted by Li et al.23 showed that active efflux played role in the resistance to various non-β-lactam agents by Pseudomonas spp. strains and de-energization by the addition of a proton conductor increased the accumulation level to that expected for equilibration across the cytoplasmic membrane.

 In this study, A. baumannii constituted 25 (15.82%) of the Gram negative isolates and 11.82% among the total bacterial isolates. Among the isolated A. baumannii 24 (96%) were found to be MDR strains. In the study conducted by Kelper et al.,24 out of 237 samples 38 (16.03%) were found to be Acinetobacter spp. out of which 29 (76.31%) isolates were found to be MDR. Almost all the antibiotics used in this study were found to be resistant to the organism. However, the imipenem and meropenem were effective 24% and 12% respectively against the A. baumannii. MDR A. baumannii is an important nosocomial pathogen. It has the capacity to survive in dry environments, which increases the risk for nosocomial transmission. A. baumannii can cause infection in any organ system, including bacteremia, pneumonia, endocarditis, meningitis, urinary tract infection, intra-abdominal abscess, osteomyelitis, soft tissue infection, surgical site infections.25

The prevalence of MDR isolates was found independent of gender and types of patients. Imipenem was found to be the most effective antibiotic for Gram negative bacteria from in-patients. P. aeruginosa and S. aureus were found as the most frequent etiological agents from pus samples. The prevalence of MDR was found to be 62.7% (138/220) among the total bacterial isolates. All the A. baumannii were isolated from in-patients and almost 96% (24/25) were found to be MDR. The result obtained from this study will be helpful for policy makers in evaluating the infection control measures in hospitals. The routine antimicrobial susceptibility testing before antibiotic administration is highly recommended since it can play key role to limit the wound infections to minimum as the emergence of drug resistant bacteria is less likely when there is empirical drug therapy, fasten the process of wound healing hence the appropriate use of drug decreases the cost of wound infection treatment.

Conflicts of interest

There is no conflict of interest.

Acknowledgment

None.

Funding

None.

References

  1. Bowler P, Durden B, Armstrong D. Wound Microbiology and Associated Approaches to Wound Management. Clin Microbiol Rev. 2001;14(2):244–269.
  2. Church D, Elsayed S, Reid O, et al. Burn wound infection. Clin Microbiol Rev. 2006;19:403–434.
  3. Gupta N, Gautam V, Saini S, et al. Prevalence of multi drug resistant organism in wound infection. J Infect Dis Antimicrobial Agent. 2002;19:111–117.
  4. Esebelahie NO, Esebelahie FO, Omoregie R. Aerobic bacterial isolates from wound infection. Afr J Cln Exper Microbial. 2013;14(3):155–159.
  5. Nichole RE. Preventing surgical site infection: a surgeon’s perspective. Emerg Infect Dis. 2001;7(2):220–224.
  6. Thomas KH. Surgical Wound Infection, an overview. Am J Med. 1981;70(3):712–718.
  7. KC R, Shrestha A, Sharma VK. Bacteriology Study of Wound Infection and Antibiotic susceptibility Oattern of Isolates. Nepal Journal of Science and Technology. 2013;14(2):143–150.
  8. Gottrup F, Melling A, Hollander D. An overview of surgical site infections: aetiology, incidence and risk factors. EWMA Journal. 2005;5(2):11–15.
  9. Cheesbrough M. District Laboratory Practice in Tropical Countries. Part 2, Cambridge University Press, India. 2000:124–132.
  10. CLSI. Performance standards foe antimicrobial susceptibility testing twenty–first informational supplement. 2011;31(1):M100–S21.
  11. Magiorakos AP, Srinivasan A, Carey RB, et al. Multidrug–resistant, extensively drug–resistant and pandrug–resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect. 2012;18(3):268–281.
  12. Maharjan S. Bacteriology of Wound Infection Among patients Visiting B &B Hospital and Antibiotic Sensitivity Profile of the Isolates. M.Sc. dissertation submitted to the department of Microbiology, Nepal. 2009.
  13. Phuyal K. Bacteriology of Wound Infection with Reference to Multi Drug Resistant Isolates. M.Sc. dissertation submitted to the Department of Microbiology, Nepal. 2008.
  14. Shrestha P. Bacteriology of Wound Infection and their Antibiotic Susceptibility Pattern. M.Sc. dissertation submitted to the Department of Microbiology, Nepal. 2013.
  15. Acharya S. Multi Drug Resistant of bacterial Isolates from wound Infection. M.Sc. dissertation submitted to the Department of Microbiology, Nepal. 2012.
  16. Bhattarai S. Microbiological Profile of Wound Infection and their Antibiotic Susceptibility pattern. M.Sc. dissertation submitted to the Department of Microbiology, National College, Kathmandu Nepal. 2013.
  17. Yakha JK, Sharma AR, Dohal N, et al. Antibiotic Susceptibility Pattern of Bacterial Isolates Causing Wound Infection Amongthe Patients Visiting B & B Hospital. Nepal Journal of Science and Technology. 2014;15(2):91–96.
  18. Banjara MR. Study of Air, Water and Wound Infection in Different Wards of TUTH. M.Sc. dissertation submitted to the Central Department of Microbiology, Nepal. 2002.
  19. Hani AM, Adnan SJ. Incident of Pseudomonas aeruginosa in Post–perative Wound Infection. Am J Infect Dis. 2009;5(1):1–6.
  20. Ranjan KP, Ranjan N, Bansal SK, et al. Prevalence of Pseudomonas aeruginosa in Post–operative Wound Infection in a Referral Hospital in Haryana, India. J Lab Physicians. 2011;2(2):74–77.
  21. Zafar A, Anwar N, Ejaz H. Bacteriology of Infected Wounds– A Study Conducted at Children Hospital Lahore. Biomedicavol. 2011;23:1.
  22. Flagas ME, loannis AB, Sofia KK, et al. Outcome of Infection Due to Pandrug–resistant (PDR) Gram Negative Bacteria. BMC infect Dis. 2005;5:24.
  23. Li XZ, Ma D, Livermore DM, et al. Role of Efflux Pump(s) in Intrinsic Resistance of Pseudomonas aeruginosa: Active Efflux as a Contributing Factor to β–Lactam Resistance. Antimicrob Agents Chemother. 1994;8(8):1742–1752.
  24. Davis KA, Moran KA, McAllister CK, et al. Multidrug Resistant Acinetobacter Extremity Infections in Soldiers. Emerg Infect Dis. 22005;11(8):1218–1224.
  25. Brooks GF, Carroll KC, Butel JS, et al. Jawez, Melnick and Adelberg’s Medical Microbiology. (24th edn), MC Graw Hill Companies, New York, USA. 2007;263–270.
Creative Commons Attribution License

©2017 Mahat, et al. This is an open access article distributed under the terms of the, which permits unrestricted use, distribution, and build upon your work non-commercially.