Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
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Dr. P. Ravi Shankar
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E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
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On Jan 2020

Important Notice

Original article / research
Year : 2007 | Month : October | Volume : 1 | Issue : 5 | Page : 385 - 389 Full Version

Speciation and Antimicrobial Susceptibility pattern of Enterococci from a Tertiary Health Care Center in North India.


Published: October 1, 2007 | DOI: https://doi.org/10.7860/JCDR/2007/.111
GUPTA V, SINGLA N

Deptt. Of Microbiology, Govt. Medical College & Hospital. Sector 32 B, CHANDIGARH, India.

Correspondence Address :
Dr Varsha Gupta, Professor, Deptt. Of Microbiology, Govt. Medical College & Hospital. Email: varshagupta_99@yahoo.com

Abstract

Introduction: In recent years, Enterococci have become important nosocomial pathogens. Therefore, it is important for a hospital setting to continuously monitor such infections, and to determine their species and antimicrobial susceptibility pattern from time to time. Keeping these objectives in mind, the present study was conducted in our tertiary health care center in North India.
Methods: A total of 100 enterococcal strains isolated from urine and blood samples were speciated as per the scheme of Facklam and Collins. Antibiotic susceptibility was determined for Amoxycillin, Penicillin, Cephalexin, Erythromycin, Cotrimoxazole, Gentamicin, Vancomycin, Teicoplanin, Linezolid, Imipenem, Piperacillin, Ampicillin- sulbactam, and Nitrofurantoin by the Kirby Bauer disc diffusion method. MIC detection was done by the agar dilution method for penicillin and vancomycin. HLAR detection was done by the agar dilution method for gentamicin and streptomycin, by supplementing the Mueller Hinton agar with 500μg/ml and 2000 μg/ml of the antibiotics, respectively.
Results: 96 of the strains were of Enterococcus faecalis, and 4 were of Enterococcus faecium. Antibiotic susceptibility tests showed a high level of resistance to cephalexin (100%), gentamicin(96.42%), cotrimoxazole (87.03%), erythromycin (77.19%), and penicillin (61.17%). However, only two strains were found to be resistant to vancomycin and teicoplanin. All the strains were sensitive to linezolid. HLAR was seen in 75% of the strains for gentamicin, and in 69% strains for streptomycin. In case of penicillin, MIC values were found to be >16 μg/ml for 14 strains (14%). 6 strains had MIC values of upto 4μg/ml for vancomycin. Out of these, one E. faecalis strain turned out to be Vancomycin resistant enterococci (VRE) showing an MIC value as high as 512 μg/ml.
Conclusion: We conclude that enterococcal strains with high rate of resistance to penicillin and aminoglycosides are prevalent in our nosocomial setting, and emergence of the VRE strain has further worsened this situation. There is an urgent need for more rational and restricted use of antimicrobials in order to minimize the selection and spread of such strains.

Introduction:
Since the advent of Vancomycin resistant Enterococci (VRE) by Uttley et al (1) in 1988, Enterococcal infections have been a cause of great concern among the clinicians, especially in nosocomial settings. In western countries, especially in USA, they have been reported as the third most common pathogen associated with blood stream infections, and the second most common isolated pathogen over all (2).

Though primarily, they are opportunistic pathogens, their inherently low virulence is well compensated for, by their intrinsic resistance to antibiotics, and their ability to acquire resistance to several broad spectrum antibiotics (3). Vancomycin resistance in Enterococci not only leaves fewer options for disease management, but also is important due to the potential risk of vancomycin resistant gene transfer from Enterococci to Staphylococcus aureus (4). VRE has been frequently reported from USA and Europe, but there have not been many reports on their isolation from many Asian countries, including India (5). In addition to it, Enterococci also show an acquired high level resistance to Aminoglycosides (HLAR). Traditionally, a combination of penicillin/ampicillin with an aminoglycoside was the treatment of choice for Enterococci, with vancomycin as the last resort. Therefore, VRE along with HLAR has made the treatment of these infections extremely difficult, and they pose a great challenge to health professionals.

Although 12 species in the Genus Enterococcus have been recognized, the most common species implicated in human infection is E. faecalis (causing 90% of the infections), followed by E. faecium. E. faecium predominantly is the more resistant species than E. faecalis, and emergence of vancomycin resistance in it has caused an increase in the frequency of its isolation (6). Considering all these facts, the present study was conducted in the tertiary health care centre of North India, to speciate as well as to study the antibiogram of enterococcal strains isolated from clinical samples –urine and blood. Minimum inhibitory concentration (MIC) values were also determined for penicillin and vancomycin, along with HLAR detection in these isolates.

Material and Methods

The present study was conducted in the Department of Microbiology, Government Medical College Hospital, and Chandigarh. A total of 100 strains of Enterococci were isolated from clinical samples namely- urine (49) and blood (51). The strains isolated were identified and speciated according to standard laboratory procedures as per the scheme of Facklam and Collins (7).

Antimicrobial susceptibility testing was done by the Kirby- Bauer disc diffusion method as per the recommendations of CLSI (8). Various antibiotics tested were: Amoxycillin (10 μg), Penicillin (10units/disc), Cephalexin (30 μg), Erythromycin (15 μg), Cotrimoxazole (25 μg),Gentamicin (30 μg), Vancomycin (30 μg), Teicoplanin (30 μg), Linezolid (30 μg), Imipenem (10μg), Piperacillin (100 μg), Ampicillin- sulbactam (10/10 μg), and Nitrofurantoin (300 μg).

MIC detection was done by the agar dilution method (9) for penicillin and vancomycin for the MIC values of 2 – 512g/ml. HLAR detection was done by the agar dilution method for gentamicin and streptomycin by supplementing the Mueller Hinton agar with 500 μg/ml and 2000 μg/ml of the antibiotics, respectively.

The source of media and antibiotic discs was Hi - Media Ltd. (Mumbai), India. The standard strain E. faecalis ATCC 29212 was used as control.

Results

Of the total enterococcal strains isolated, 96 of the strains turned out to be those of E. faecalis, and 4 were E. faecium on the final species level identification. We could not isolate any other species of Enterococci from our settings. Antibiotic susceptibility tests showed high level resistance to various antibiotics tested. Only two strains were found to be vancomycin and teicoplanin resistant. All the strains were sensitive to linezolid (Table/Fig 1)HLAR was seen in 75% of the strains for gentamicin and 69% strains for streptomycin(Table/Fig 2). In case of penicillin, MIC values were found to be >16 μg/ml for 14 strains. Out of these 14 strains, 6 had raised MIC values of upto 256 μg/ml. For vancomycin, 6 strains had MIC values upto 4 μg/ml. Out of these, one E. faecalis strain turned out to be Vancomycin resistant Enterococci (VRE) showing an MIC value as high as 512 μg/ml.

Discussion

Enterococci have turned into significant human pathogens because of a combination of colonizing abilities and drug resistance, both inherent and acquired. In the present study, E. faecalis (96%) was the predominant species isolated, followed by E. faecium (4%). Most of the studies done on Enterococci, support the same finding. The reason could be the predominance of E. faecalis in the endogenous flora of the body (10).

Penicillin, along with aminoglycosides, is the mainstay of therapy for infections with Enterococci. Therefore, resistance of Enterococci against these antibiotics has important clinical implications. In the present study, about 61% of the strains were resistant to penicillin by the disc diffusion method, and 14 (14%) of the strains had raised MIC values (>16μg/ml). 6 of them had MIC values of more than 200 μg/ml, which is considered as cut off for high level resistance to penicillin.2 The mechanism of this resistance could be due to the low affinity penicillin binding proteins, or production of beta lactamases.

Among aminoglycosides, 96% of the isolates exhibited resistance to gentamicin by the disc diffusion method. HLAR was seen in 75% of the strains for gentamicin, and in 69% for streptomycin. HLAR was more in E. faecium than in E. faecalis (Table/Fig 2), as has been reported previously also (11), (12). . Both HLGR and HLSR were seen in 55 isolates. HLAR in these strains can well nullify the efficacy of combination therapy. Therefore, distinguishing HLAR from simple intrinsic resistance is important, and should be adopted as a part of any routine microbiology laboratory.

Only 2 strains were found to be resistant to vancomycin and teicoplanin by the disc diffusion method. Out of these, one strain did not show any rise in the MIC value, but the other strain turned out to be VRE, with a highly raised MIC value with a range of upto 512μg/ml. This strain (VRE) was isolated from the blood sample of a female patient with left Guillain Barre’ Syndrome, with polyneuritis cranialis. Blood samples taken from the patient on days 1 and 3 of admission revealed the growth of Enterococcus species organisms, which on further confirmation, was reported as E. faecalis. On checking by antibiogram, the organism was found resistant to ampicillin, penicillin, erythromycin, gentamicin, cotrimoxazole, imipenem, piperacillin, teicoplanin, and vancomycin, but sensitive to nitrofurantoin and linezolid. MIC detection for vancomycin showed a value of upto 512 μg/ml. The strain also showed positive HLAR for streptomycin, but was negative for HLAR for gentamicin.

The patient was managed conservatively, and was administered a combination drug, piperacillin-tazobactam along with clarithromycin, to which she responded well. In the present case, the organism isolated, probably belongs to the Van A phenotype, as it showed resistance to vancomycin upto an MIC of 512 μg/ml, and was resistant to teicoplanin by the disc diffusion test. The various risk factors associated in this case were, history of previous hospitalization, admisssion to ICU, catheterization, and prolonged antibiotic treatment. Previously from India, there are few reports of emergence of vancomycin resistance in enterococcal strains with increased MIC values (Table/Fig 3) (13), (14), (15), (16). The strain isolated in our case had an MIC value as high as 512 μg/ml. Previously also, only a single case of vancomycin resistant E. faecalis strain with MIC value as high as 512 μg/ml has been reported from the blood sample of an ICU patient from Delhi, India.

We concl

References

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Uttley A, Collins C, Naidoo J, George R. Vancomycin resistant Enterococci. Lancet 1988; (i):57-8.
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Jesudason MV, Pratima VL, Pandian R, Abigail S. Characterisation of penicillin resistant Enterococci. Indian J Med Microbiol 1998; 16(1):16-8.
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Cetinkaya Y, Falk P, Mayhall CG. Vancomycin resistant Enterococci. Clinical Microbiology Reviews 2000; 13(4): 686-707.
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Noble W, Virani Z, Crec R. Co-transfer of vancomycin and other resistant genes from E. faecalis NCTC 12201 to Staphylococcus aureus. FEMS Microbiol Lett 1992; 93:195-8.
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Mathur P, Kapil A, Chandra R, Sharma P, Das B. Antimicrobial resistance in Enterococcus faecalis at a tertiary care centre of northern India. Indian J Med Res 2003; 118:25-8.
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Rice LB. Emergence of vancomycin-resistant Enterococci. Emerg Infect Dis 2001; 7: 83–187.
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Facklam RR, Collins MD. Identification of Enterococcus species isolated from human infections by a conventional test scheme. J Clin Microbiol 1989; 27:731-4.
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Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial susceptibility testing; 15th informational supplement. CLSI/NCCLS M100- S15. Wayne (PA).The Institute; 2005.
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Colles JG, Miles RS, Wan B. Tests for the identification of bacteria. In: Colles JG, Fraser AG, Marmion BP, Simmons A Eds. Mackie and McCartney Practical Medical Microbiology. 14th ed. Edinburg Churchill Livingstone 1996:131-50.
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Hall LMC. Recent advances in understanding of the epidemiology of Enterococci. Rev Med Microbiol 1993; 4:192-7.
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Bhat KG, Paul C, Bhat MG. Neonatal bacteremia due to high level aminoglycoside resistant (HLAR) Enterococci. Indian J Pediatr 1997; 64:537-9.
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Miskeen PA, Deodhar L. Antimicrobial susceptibility pattern of Enterococcus species from Urinary Tract Infections. J Assoc Physicians India 2002; 50:378-81.
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Taneja N, Rani P, Emmanuel R, Sharma M. Signi

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