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ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 3  |  Page : 182-187

A study of aerobic and anaerobic bacterial profile along with In vitro antibiotic susceptibility pattern in cases of puerperal, postabortion sepsis in a Tertiary Care Hospital


Department of Microbiology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India

Date of Submission07-Nov-2018
Date of Acceptance20-Jan-2019
Date of Web Publication25-Jan-2021

Correspondence Address:
Kalidas Rit
70B T. C. Mukherjee Street, PO: Rishra, Dist-Hooghly - 712 248, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_152_18

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  Abstract 


Background: Puerperal pyrexia and sepsis are still among the leading causes of preventable maternal morbidity and mortality both in developing and developed countries. The study was aimed to determine the causative organisms, risk factors, and antibiotic susceptibility of the isolates of puerperal sepsis. Materials and Methods: A total of 52 clinically suspected cases of puerperal sepsis were included in this study. Collected blood and endocervical samples were inoculated in appropriate culture media and incubated both aerobic and anaerobically. The isolated organisms were identified by standard biochemical tests. Antimicrobial sensitivity testing was performed by as per the CLSI guidelines. Results and Observation: In the present study, among 52 patients, majority of women (61.53%) were between 20 and 25 years and uniparous (55.76%). The present study showed predominance of Gram-negative bacilli (82.69%) with 17.30% isolates being Gram-positive cocci. Klebsiella pneumoniae (28.84%) was the most frequent isolate pathogen followed by Escherichia coli (19.23%). Bacteremia was present in 27.03% of cases. Most of the organisms were resistant to commonly used antibiotics such as amoxicillin, ciprofloxacin, levofloxacin, and amikacin. Conclusion: In the prospect of changing the spectrum of pathogens of puerperal sepsis and their antibiotic susceptibility patterns from time to time, positive blood culture and the antibiotic susceptibility testing of the isolates are the best guides in choosing the appropriate antimicrobial therapy in the treatment of puerperal sepsis.

Keywords: Antimicrobial susceptibility test, blood culture, puerperal sepsis


How to cite this article:
Haldar T, Rit K, Pal N. A study of aerobic and anaerobic bacterial profile along with In vitro antibiotic susceptibility pattern in cases of puerperal, postabortion sepsis in a Tertiary Care Hospital. CHRISMED J Health Res 2020;7:182-7

How to cite this URL:
Haldar T, Rit K, Pal N. A study of aerobic and anaerobic bacterial profile along with In vitro antibiotic susceptibility pattern in cases of puerperal, postabortion sepsis in a Tertiary Care Hospital. CHRISMED J Health Res [serial online] 2020 [cited 2021 Feb 26];7:182-7. Available from: https://www.cjhr.org/text.asp?2020/7/3/182/307819




  Introduction Top


Puerperal pyrexia and sepsis are still among the leading causes of preventable maternal morbidity and mortality both in developing and developed countries.[1],[2] The WHO has defined puerperal sepsis as “a genital tract infection occurring between rupture of membranes and 42nd day postpartum, coinciding with fever and one of the following such as pelvic pain, abnormal vaginal discharge, abnormal odor or discharge, or a delay in reduction of uterine size must also be present.”[3] Puerperal sepsis occurs in 1%–8% of all deliveries. It can occur following normal vaginal deliveries and of cesarean section. Fifteen percentage of maternal death is attributed to puerperal sepsis in India. Maternal mortality ratio is a sensitive indicator of the health status of women in a country.[2] A variety of microorganisms have been isolated from the cases of puerperal sepsis, for example, Escherichia coli, Enterococci, Klebsiella (Selluer, 1968), Staphylococcus aureus, Streptococcus faecalis, Streptococcus pyogenes, other hemolytic and nonhemolytic Streptococci, Aerobacter aerogenes (Stevenson, 1969), and Clostridia (Sweet, 1975).[4],[5] There are very few studies on bacterial etiology of puerperal sepsis, particularly in this region of the country. The study of common organisms causing puerperal sepsis and its antibiotic sensitivity pattern will help to start prompt antibiotics treatment until the culture report comes. Thereby, the study was aimed to determine the causative organisms, risk factors, and antibiotic susceptibility of the isolates of puerperal sepsis.


  Materials and Methods Top


This prospective observational study was carried out at our tertiary care set up for a period of 1½ year (January 2016 to June 2017). Necessary Institutional Ethical Committee clearance and informed consent of every patient was obtained. In this study, all patients of puerperal and postabortal sepsis having the criteria defined by the WHO were included. Patients with similar sign and symptoms but diagnosed with having other diseases, for example, UTI, malaria, typhoid, carcinoma of the cervix, cervical polyp, ulcerated uterine prolapsed, and vaginosis and also the patients with a history of taking prior antibiotic treatment within 7 days were excluded from the study. A total of 52 clinically suspected cases of puerperal sepsis were included in this study. All relevant history, clinical findings, and laboratory records of every case were systematically recorded in a predesigned data sheet for subsequent analysis. Informed consent was obtained from every patient before sample collection, and the purpose of the procedure was explained clearly. Necessary ethical clearance was also obtained. Endocervical swab or secretion and blood from each case were collected following standard procedure Specimens were collected carefully to avoid normal resident flora. The media used are-MacConkey agar, 5% of sheep blood agar, Müller-Hinton agar, nutrient agar, peptone water, and nutrient broth as required. For isolation of anaerobic organisms, the modified candle-jar procedure was used.[6],[7],[8],[9] For anaerobic culture thioglycollate broth, Robertson's cooked meat media, Brucella agar (supplemented with menadione, hemin, and 5% of sheep blood). One aliquot of collected specimen was immediately inoculated in blood agar media at bed side for anaerobic culture. The rest of the specimen was transferred to the Department of Microbiology for further investigations. Wet film and smear were prepared from each of the cervical sample. Prepared smear was stained by Gram-staining. Wet film and the stained smears were searched for observing the morphology of relevant organisms and number of pus cell.[10] Cervical swab\secretion was further inoculated into two plates of blood agar, one MacConKey agar, one nutrient agar, and one mannitol salt agar medium. One blood agar, MacCon Key agar, nutrient agar, and mannitol salt agar medium were incubated at 37°C for 24 h aerobically. Another blood agar plate was incubated anaerobically at 37°C for 48 h. The isolates were further identified as per standard biochemical testing, and antibiotic sensitivity testing was done as per CLSI guidelines.[11] Detection of extended-spectrum β-lactamase (ESBL) enzymes among Gram-negative isolates was performed using the double-disc synergy test. For detection of mettalo β-lactamase (MBL), we used a minimum inhibitory concentration assay using microboth dilution method.

For aerobic bacteria, the following quality control strains were used namely Escherichia coli ATCC 25922, Pseudomonas spp ATCC27853, S. aureus ATCC25923.

The following quality control strains (Microbiologics USA) were included in the study for observing growth characteristics in conventional and anaerobic system.

Bacteroides fragillis ATCC 25285, Clostridium perfringens ATCC 13124, and Clostridium sporogenes ATCC11437 were supplied in KWIK-STIK device in the form of lyophilized pellets.

Data were collected and analyzed using the standard statistical tests. Chi-square test and t-test were used and evaluations were carried out at 95% confidence level. A value of P < 0.05 was considered statistically significant.


  Results and Analysis Top


In the present study, among 52 patients, 9.61% were <19 years of age, the majority of women (76.22%) were between 20 and 34 years. In the present study, 55.76% of patients were uniparous, 34.61% belonged to gravida two. Among the admitted patients, 51.92% were from rural areas whereas 48.07% of patients were urban residents. It has been found in the study that among the affected women, 48.07% gave birth vaginally, 26.92% undergone cesarean section, and 13.46% got admission with postabortion sepsis [Table 1]. We found that 3.84% of patients developed puerperal sepsis after intrauterine fetal death. It became clear from this study that premature rupture of membrane (PROM) was a definite risk factor for the development of puerperal sepsis and accounts for 42.30% of cases followed by prolonged labor (26.92) and 13.54% of cases due to obstructed labor (P < 0.05) [Table 2].
Table 1: Obstetric factors assessment of the study cases

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Table 2: Risk factors assessment of puerperal sepsis

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The present study showed predominance of Gram-negative bacilli (82.69%) with 17.30% isolates being Gram-positive cocci among the total bacterial isolates [Graph 1]. Among the total 52 patients, no growth of organisms was found in only two patients. Among the 50 patients, 47 patients were found to be infected with aerobic organisms. We got three patients who were found to be infected with Peptostreptococcus anaerobius, an anaerobic organism isolated in our laboratory by the modified candle jar method. Klebsiella pneumoniae (28.84%) and E. coli (19.23%) were the major isolates in this study followed by Acinetobacter spp (15.38%) and Pseudomonas aeruginosa (9.61%). S. aureus and Enterococcus both contributed 7.69% of all culture-positive cases. Among the 47 patients of puerperal sepsis infected by aerobic bacteria, five of them were identified as infected with polymicrobial flora. Hence, it has been finally calculated that total 52 aerobic organisms were isolated. Hence, in this study, we found that three isolates of P. anaerobius were found to be 100% sensitive to clindamycin, chloramphenicol, and imipenem. Most of the organisms were resistant to commonly used antibiotics such as amoxicillin, ciprofloxacin, levofloxacin, and amikacin [Table 3]. It has been found that K. pneumoniae was 100% sensitive to polymixin B and colistin followed by imipenem and meropenem (80% sensitive) and was least sensitive to fluoroquinolones and amoxicillin [Graph 2]. Out of total persons studied 23.07% were blood culture positive. During antibiotic sensitivity testing, we have also performed tests to detect metallo-beta-lactamase and ESBL, and the results were as followed metallo-beta-lactamase-16.07%, ESBL-23.25%.

Table 3: Susceptibility profile of isolated organisms

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  Discussion Top


Puerperal sepsis is one of the most common causes of maternal mortality and morbidity in developing countries.[2] It is being believed that in developing countries, 65% of all women have some forms of antenatal care, and 53% intranatal care, only 30% receive postpartum care. A big proportion of Indian women still deliver at home with or without any prenatal and intranatal care. They are malnourished, anemic, and remain prone to postpartum complications. Thereby, this study was done to find out the risk factors and microbiological profile of puerperal sepsis which include both aerobic and anaerobic flora. We have also studied the antibiotic sensitivity pattern of aerobic bacteria along with the production of MBLs and ESBLs by them.

Out of all, the women included in the present study, 76.22% belonged to the age group between 20 and 34 years. These age groups are definitely the common child bearing age group in our country. In the present study, we found 55.76% of women were primipara followed by 34.61% of patients with parity two and 9.61% with parity three or four. Similar findings were found in the study of Ingole and Shendre[12] in which it was revealed that 80.59% of patients affected with puerperal sepsis were between the age group of 20 and 29 years. The study by Tamboli et al.[13] also found 80.59% of patients belonging to a similar age group. Majority of affected patients in his study were primipara (50.74%), 29.85% belonged to parity two, and 19.40% belonged to parity three or four.

In the present study, out of 52 patients admitted with puerperal sepsis, 51.92% of women were from rural areas, and 48.07% of women were residents of urban areas. Hence, we have got no significant difference in rural and urban prevalence of puerperal sepsis in this study which indicates improvement in antenatal, intranatal, and postnatal care in West Bengal.

From this study, it became evident that PROM is the predominant risk factor (42.30%) followed by prolonged labor (26.92%) and obstructed labor (13.54%). In the study by Ezra et al.,[14] it has clearly been documented that PROM very often leads to increased vaginal examination (>5 in number) resulting in increased risk of puerperal sepsis.

Prolonged labor and obstructed labor also result in increased number of vaginal examinations and often needs a referral to higher centers. In this study, we have found that 85.71% of patients with obstructed labor required referral from other hospital to our institution. This probably increased the interval between onset of labor and delivery resulting in increased access of microorganism entry to uterus and adenexa leading to puerperal sepsis.

In this present study, out of 52 admitted women, 48.07% delivered vaginally, 26.92% delivered by cesarean section, and seven patients (13.46%) admitted with sepsis developed after induced or spontaneous abortion with retained product of conception. The study by Ingole and Shendre[12] revealed that 65.67% of women delivered vaginally, and remaining patients delivered by cesarean section. Furthermore, in the study by Quadri et al.,[15] only 13% of admitted patients delivered by cesarean section and remaining patients delivered vaginally. In this study, only two patients reported to be delivered at home. In the contrary, a study by Quadri et al.[15] found 47% home delivery, and in the study by Tamboli et al., 31.34% had delivered at home[13] which is much higher than the present study result. It signifies better antenatal care and transport of expectant mothers even in remote rural areas, and hence that they could get a chance for institutional deliveries.

It is important to understand the bacteriology of puerperal sepsis. Enhanced detection of blood stream infections needs to be a national priority. In the present study, among the total 52 patients, we found the growth of microorganisms from 50 patients in their high vaginal and endocervical swabs. In two cases, no bacterial growth was obtained. Among the fifty patients, 47 were found to be infected with aerobic organisms, and we got P. anaerobius as anaerobic organism isolated in our laboratory by the modified candle jar method in three patients. Among the 47 patients with puerperal sepsis, five of them were identified as infected with polymicrobial flora. It has been finally calculated that total 52 aerobic organisms were responsible for infections. In the present study, out of 67 cases studied, bacteremia was present in 46 (68.65%) cases. The ratio of Gram-negative to Gram-positive organism was (4.78:1).

Klebsiela pneumoniae (28.84%) and E. coli (19.23%) were the major isolates in this study followed by Acinetobacter spp (15.38%) and Pseudomonas aeruginosa (9.61%). S. aureus and Enterococcus both contributed 7.69% of all culture-positive cases, and coagulase-negative Staphylococcus (CONS) were found in 1.92% of cases. In the study by Tamboli et al.[13] also, K. pneumoniae was the predominant organisms followed by Staphylococcus, Pseudomonas and E. coli, S. pyogenes and coagulase-negative Staphylococci in their decreasing order of frequency. Furthermore in the study by Ingole and Shendre[12] revealed that Klebsiella was found as the most frequent isolates followed by S. aureus and Proteus and E. coli. Venugopal, Vaskaran, and Omu reported E. coli as the predominant pathogen in puerperal sepsis.[16],[17] Another study by Gerstner et al. showed that in cases of puerperal sepsis, the most common bacteria are Staphylococcus epidermidis, E coli, Enterococci, and Streptococci.[18]

Another study observed that in cases of puerperal sepsis, the most common bacteria were S. epidermidis, E. coli, Enterococci, and streptococci.[10] The frequency of puerperal infection due to Group A beta-hemolytic Streptococci has decreased greatly in the 21st century and now rarely caused maternal death.

According to the study by Tamboli et al.,[13] aerobic blood culture is the essential investigation for the management of sepsis, and in his study, bacteremia was present in 68.65% cases, we also have found bacteremia in 57.69% of cases.

We have studied the antimicrobial sensitivity profile of different bacteria and it becomes evident from the study that a change in the sensitivity profile of microorganisms to different antimicrobial agents has taken place. K. pneumoniae is found to be the most predominant organism in this study, and it shows sensitivity to polymixin B and colistin (100%), carbapenems (80%), and ceftazidime (73.3%). Majority of E. coli were sensitive to polymixin B and colistin (100%) followed by carbapenem group of drug (80%). Acinetobacter spp. shows sentivity only to polymixin B and colistin (100%), ceftazidime (37.5%), and carbapenem group of drugs (37.5%). S. aureus shows 100% sensitivity to vancomycin, linezolid, and teicoplanin. From the sensitivity pattern of Gram-negative organisms, it is evident that among the cephalosporin groups, 40%–50% of organisms are sensitive to ceftazidime and piperazine-tazobactam, but sensitivity of organisms toward fluoroquinolones is not very promising, and sensitivity to amoxicillin is also very poor though sensitivity to amikacin is moderate (46.51%). This study differs from the result by Ingole and Shendre[12] where Klebsiella and Pseudomonas show better sensitivity to ciprofloxacin (82%) though sensitivity to amikacin was almost similar to our findings (50%). The study by Quadri et al.[15] revealed that amikacin and gentamicin are the most effective antibiotic in both Gram-negative bacteria and Gram-positive bacteria. In a study by Quadri et al.[15] fluoroquinolones were sensitive only against 15% of Gram-negative isolates. Among the Gram-positive cocci, we have found that vancomycin is the most effective drug because both S. aureus, CONS and Enterococcus are 100% sensitive to this drug. Among the four isolated Staphylococcus strain, three are MRSA, and the only detected CONS is also found to be methicillin resistant. The study by Quadri et al.[15] also revealed that among the Gram-positive bacteria, vancomycin was most effective with 100% sensitive, and among Staphylococcus isolates, 36% were MRSA positive.

The three isolated P. anaerobius showed 100% sensitivity to clindamycin, chloramphenicol, and imipenem. According to Ananthnarayan and Panikar, P. anaerobius is a commensal of vagina and introitus, and one of the common organism responsible for puerperal sepsis.[19]

In this study, we have found metallo beta-lactamase production in 16.07% isolates and 23.25% isolates detected to be ESBL producers. In the study by Livermore and Hawky, they found that the percentage of patients infected with ESBL--producing organisms is steadily increasing since 2000.[20] On the other hand, in a study by Wilson P, it has been reported that in the United States, Klebsiella accounts for 3%–7% of all nosocomial infections, placing them among the eight most important infectious pathogen in hospitals. According to Nordmann et al.,[21] K. pneumoniae that produce carbapenemase (KPC) have rapidly spread across worldwide in the past decade. These isolates are typically resistant to carbapenems (ertapenem, doripenem, and imipenem) as well as penicillins, cephalosporins, fluoroquinolones, and frequently among aminoglycosides. The most alarming thing is that members of the Enterobacteriaceae family such as E. coli, Klebsiella spp., and Enterobacter spp are among the common organisms responsible for puerperal sepsis and resistance to the carbapenem class of drug, mediated primarily by plasmid-mediated carbapenemases, is becoming widespread in many areas.

There is no doubt that the incidence of puerperal sepsis worldwide is estimated with difficulty, epidemiology of sepsis is extremely variable due to local conditions prevailing in a particular community. Hence, we have to keep these words in mind, that of all the components of health care, delivery, postnatal, and early newborn care are the fields demanding heightened vigilance.


  Conclusion Top


Blood culture is still the method for the diagnosis of puerperal sepsis and should be done in all cases of suspected septicemia with supplementary proper endocervical sample collection. Proper antenatal, intranatal, and postnatal care is the cornerstone for the prevention of puerperal sepsis. In view of the changing spectrum of the causative microbial agents of puerperal sepsis and their antibiotic susceptibility patterns from time to time and from one hospital to another, positive blood culture and the antibiotic susceptibility testing of the isolates are the best guides in choosing the appropriate antimicrobial therapy in treating puerperal sepsis.

Acknowledgments

The authors would like to thank Professor Prasanta Kumar Maiti, Professor and Head, Department of Microbiology, Institute of Postgraduate Medical Education and Research, 244 AJC Bose Road, Kolkata - 700 020. Department of Dermatology, Institute of Postgraduate Medical Education and Research.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Maharaj D. Puerperal pyrexia: A review. Part II. Obstet Gynecol Surv 2007;62:400-6.  Back to cited text no. 1
    
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Kaur T, Mor S, Puri M, Sood R, Nath J. A study of predisposing factors and microbial flora in puerperal sepsis. Int J Reprod Contracep Obstet Gynecol 2017;5:3133-6.  Back to cited text no. 2
    
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Jousimies-Somar HR, Summanen P, Citron DM, Baron EJ, Wexler HM, Finegold SM. Wadsworth-KTL anaerobic bacteriology manual. 6th ed. Bedmont Belmont, California: Star Publishing Company; 2003.  Back to cited text no. 6
    
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Tamboli SS, Tamboli SB, Shrikhande S. Puerperal sepsis: predominant organisms and their antibiotic sensitivity pattern. Int J Reprod Contracept Obstet Gynecol 2016;5:762-5.  Back to cited text no. 13
    
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Ezra Y, Michaelson-Cohen R, Abramov Y, Rojansky N. Prelabor rupture of the membranes at term: When to induce labor? Eur J Obstet Gynecol Reprod Biol 2004;115:23-7.  Back to cited text no. 14
    
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Quadri S, Sharma K, Siddiqui B, Ehsan A, Sherwani R K, Sultan A, et al. Microbial profile in females with puerperal sepsis- a major threat to wemen's health: Study at a tertiary health care centre. Int J Curr Microbiol Appl Sci 2015;1:248-55.  Back to cited text no. 15
    
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Gerstner G, Leodolter S, Rotter M. Endometrial bacteriology in puerperal infections (author's transl). Z Geburtshilfe Perinatol 1981;185:276-9.  Back to cited text no. 18
    
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