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

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



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Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
Knowledge is treasure of a wise man. The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help ones reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journalsNo manuscriptsNo authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



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.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2008 | Month : August | Volume : 2 | Issue : 4 | Page : 979 - 984

Prevalence of Methicillin Resistant Staphylococcus aureus among Diabetes Patients with Foot Ulcers and their Antimicrobial Susceptibility Pattern

MURUGAN S *, MANI KR**, UMA DEVI P***

**Central Research Institute, Himachal Pradesh,Kasauli 173204,(India).***School of Biotechnology, Karunya University, Coimbatore- 641 114.

Correspondence Address :
S.Murugan Senior Lecturer in Biotechnology,School of Biotechnology Karunya University,Karunya Nagar,Coimbatore-641 114.E:mail:micro_murugs@inbox.com

Abstract

Background and Objectives: MRSA infection is common in diabetes patients with foot ulcers, and is associated with previous antibiotic treatment and prolonged healing. As only a few studies with a small number of samples were done in this regard in India, the present study was undertaken to report the prevalence and antibiotic susceptibility pattern of MRSA screened from diabetes patients with foot ulcers, attending tertiary care hospitals.
Settings and Design: It was a retrospective study carried out at Department of Microbiology, Dr.N.G.P Arts and Science College, Coimbatore, Tamil Nadu, India during the period from November 2002 to October 2006.
Methods: The present study comprised of 7354 pus specimens of diabetic foot ulcer patients collected from various tertiary care hospitals in and around Coimbatore. All the samples were subjected to gram staining and bacterial culture, and the S. aureus isolates were screened for MRSA prevalence using conventional microbiological methods. Subsequently, the antibiotic sensitivity test was performed for the confirmed MRSA isolates.
Results: Out of 2314 (37.82 %) strains of S. aureus isolated form diabetic foot ulcers, 992 (42.86 %) were found to be methicillin resistant. More precisely, all MRSA strains (100 %) were resistant to penicillin, 90.92 % to ampicillin, 82.76 % to clotrimoxazole, 64.11 % to gentamicin, 60.08 % to erythromycin, 51.91 % to omnatax and 50.10 % to cephalexin. Multi drug resistance for about 7 to 10 antibiotics was observed among 55.0 % of the isolates. However, all the strains were sensitive to vancomycin (100 %).
Conclusions: The determination of prevalence and antibiotic sensitivity pattern of MRSA screened from diabetic foot ulcer patients will help the clinician for first line treatment in tertiary care hospitals.

Keywords

Diabetes patients, foot ulcers, MRSA, prevalence, multi drug resistant, S. aureus.

Introduction
Diabetes currently affects more than 194 million people worldwide, and the figure is expected to reach 333 million by 2025, with the maximum burden falling upon developing countries. India, considered as the “diabetic capital of the world”, alone, currently accounts for over 35 million people harbouring diabetes(1). This number is estimated to touch 73.5 million by 2025, as a consequence of longer life expectancy, sedentary life style and changing dietary patterns(2). Diabetes is a chronic disorder and affects a large segment of the population. Diabetes and foot problems are almost synchronous(3). As many as 25 % of diabetic individuals are expected to develop severe foot problems at some point in their lifetime, which often leads to amputation (4). Diabetic foot infections are more severe and more difficult to treat than infections in non-diabetics. Staphylococci and β-haemolytic Streptococci are the most commonly isolated pathogens in moderate and severe diabetic foot infections. Aerobic gram-positive cocci are the predominant microorganisms that colonize and acutely infect breaks in the skin.(5) The genus Staphylococcus includes pathogenic organisms in which S. aureus is the most important one that has become resistant to most of the therapeutic agents that have been developed in the recent years, and hence the antimicrobial chemotherapy for this species has always been empirical(6). S. aureus is the most important pathogen in diabetic foot infections, even when it is not the only isolate; it is usually a component of a mixed infection(5). The most notable example of this phenomenon was the emergence of methicillin resistant Staphylococcus aureus (MRSA), which was reported just one year after the launch of methicillin(7). Overuse of antibiotics and the selection of broad, rather than narrow spectrum agents, have contributed to the high prevalence of methicillin- resistant S. aureus (MRSA) colonization in diabetic foot wounds. Many of these MRSA isolates are becoming multidrug resistant, and are susceptible only to glycopeptide antibiotics such as vancomycin(8). Low-level resistance to vancomycin is emerging at present(9).

Methicillin-resistant S. aureus (MRSA) has become a considerable public health issue during the past decade, due to a significant increase in the incidence of MRSA isolated from patients with complicated infections, including diabetic foot infections of varying severity. Additionally, empiric coverage against MRSA should be considered in institutions with a high MRSA infection rate, or in patients who are at increased risk for MRSA by way of previous MRSA infection, exposure to previous courses of antibiotics, recent hospitalization or nursing home stay, or by close contact with an MRSA patient. Therefore, the knowledge of prevalence of MRSA and their current antimicrobial profile becomes necessary in the selection of appropriate empirical treatment of diabetic foot infections. We determined the prevalence of MRSA from pus samples of diabetes patients with foot ulcers and their in vitro susceptibility pattern to various antmicrobial agents, to record their current status of MRSA response to commonly used anti Staphylococcus antibiotics in tertiary care hospitals in and around Coimbatore, South India.

Material and Methods

A total of 7354 pus specimens from diabetic foot ulcer patients were collected for S. aureus screening. The samples were obtained from various tertiary care hospitals in Coimbatore and Erode, from Nov 2002 to Oct 2006. All the samples were aseptically handled and processed. Morphotypes were done for all the samples based on the Gram staining method, to determine the organism which was likely to be present. Subsequently, the specimens were inoculated on to Blood agar (BA) plates (aerobic with 5% Co2), MacConkey’s agar (MA) and RCM (Robertson Cooked Meat medium) for further subculturing, and these plates were incubated at 370C for 24 hrs. The colonies of Gram-positive cocci in clusters were further confirmed using API-Staph biochemical Strip (bioMeriux, France). All the strains were further tested for the production of free coagulase enzyme using the tube coagulase test, based on standard methods(10). Staphylococcus aureus ATCC 25923, a known coagulase producer, was included as a control strain.
All the confirmed S. aureus strains were subsequently tested for methicillin resistance based on the Kirby-Bauer disk diffusion method, using oxacillin discs (10μg) obtained from Hi-Media Laboratories Pvt Ltd. The isolates were considered methicillin resistant, if the zone of inhibition was 10 mm or less. Further, the antibiotic susceptibility pattern of methicillin resistant S. aureus was determined on the day of their isolation by the modified Kirby-Bauer disc diffusion method on Mueller Hinton (MHA) Agar, using the criteria of standard zone sizes of inhibition to define sensitivity or resistance to different antimicrobials. The antibiotics used were penicillin-G (10 Unit); ampicillin (10µg); cloxacillin (30µg); cephalexin (30µg); erythromycin (15µg); gentamicin (10µg); amikacin (30µg); ciprofloxacin (5µg); ofloxacin (5µg); norfloxacin (10µg); cotrimoxazole (25µg); vancomycin (30µg); linezolid (30µg); netromycin (10 µg) and omnatax (5 µg). Finally the data were recorded and analyzed at the completion of the study as per recommendations of the Clinical Laboratory Standards Institute(11). S. aureus ATCC 29213 was used as a reference strain for the standardization of antibiotic susceptibility testing.

Results

Methicillin Resistant Staphylococcus aureus (MRSA)
The Mueller-Hinton agar based antibiogram-resistogram pattern study confirmed the presence of 992 MRSA out of 2314 isolates of S. aureus obtained from pus samples of diabetes patients with foot ulcers. The remaining strains (1322) were considered as methicillin sensitive S. aureus (MSSA). The present study has shown that 42.86 % of S. aureus isolates were MRSA. However all the isolates were sensitive to vancomycin, which determined the importance of vancomycin resistant S. aureus (VRSA), as it was being increasingly reported (12). Among the 19 isolates of S. aureus, 8 (10.3 %) were methicillin resistant, in a study conducted in a private hospital in Chennai(13). It is interesting to note that the prevalence of MRSA was found to be 20.83 % in Chennai among diabetic patients(14). Similarly, in a study of 55 patients in Chennai, 66.6 % of S. aureus were found to be methicillin-resistant. Infection of foot ulcers with MRSA was associated with delayed wound healing, compared to ulcers infected with methicillin sensitive S. aureus (15).
Previous studies have found that infections caused by MRSA were more common among patients who were previously treated with antibiotics, than in those who were antibiotic naive. Overall, MRSA infections have been associated with increased morbidity, extended hospital stay and increased costs. However, literature on the effect on mortality has been mixed. When it comes to diabetic foot infections, the presence of MRSA may lead to poorer outcomes, an increased risk of amputations, higher treatment costs and increased mortality(16).

In this study, out of 7354 pus samples, 37.82 % was found to be of S. aureus isolates, out of which MRSA and MSSA were found to be in the order of 42.86 % and 57.13 %, respectively. The prevalence rate of S. aureus and MRSA isolated from pus specimens was compared, as shown in (Table/Fig 1). Similarly, the comparative analysis of MRSA and MSSA isolates obtained from pus samples of diabetic foot ulcers is shown in (Table/Fig 2).

Antibiogram Pattern for Methicillin Resistant S. Aureus
All the 992 MRSA strains screened from 2314 isolates of S. aureus, earlier isolated from pus specimens exhibited different resistant patterns against 16 antibiotics. The diverse drug resistance patterns of MRSA obtained from diabetic foot ulcers is shown in (Table/Fig 3).The percentage of resistance to antibiotics such as penicillin, ampicillin, cotrimoxazole, gentamicin, erythromycin, cloxacillin, omnatax, cephalexin, ciprofloxacin, norfloxacin, amikacin, ofloxacin, netromycin, linezolid and vancomycin was found to be in the order of 100 %, 90.92 %, 82.76 %, 64.11 %, 60.08 %, 52.11 %, 51.91 %, 50.10 %, 48.08 %, 43.75 %, 43.24 %, 39.99 %, 35.88 %, 12.90 % and 0.00 %, respectively. Mehta et al. had reported the percentage of resistance to antibiotics such as penicillin, tetracycline, kanamycin, streptomycin, chloramphenicol and erythromycin to be in the descending order of 88.8 %, 54.4 %, 37.5 %, 28.6 %, 26.3 % and 25 %, respectively. However, no strains were resistant to gentamicin and vancomycin. About 29.0 % of MRSA strains isolated during 1992-1996 from both patients and health care workers and these isolates showed 100 % sensitivity to vancomycin(8). The antibiogram results in this study suggest that pathogens remain sensitive to a number of agents. Vancomycin was found to be the most effective drug overall against S. aureus. These findings are consistent with previous studies. No single antimicrobial agent can cover all of the possible organisms isolated from diabetic foot infections. Our findings illustrate that antimicrobial therapy needs to be selected, based on actual culture findings and antimicrobial sensitivity patterns of isolates.

In one study on spectrum of antimicrobial resistance among MRSA, ciprofloxacin resistance was as high as 90 %, and Qureshi had reported the same as 98.9 %(7). In contrast, we observed that 48.08 % of the strains were resistant to ciprofloxacin and 39.91 % were resistant to ofloxacin. However, Pulimood has observed only 8 % resistance of MRSA to gentamicin (5) as against 64.11 % in our study. Gentamicin resistance is on the rise since 1996, and an increase of gentamicin resistance from 0 % before 1996 to 80 % after 1996, has been reported (17). Qureshi et al. had reported a gentamicin resistance of 97.8 %, which is comparatively higher to the current study.

Multiple Drug Resistant Pattern of MRSA
The multi drug resistant pattern for all MRSA isolates is shown in (Table/Fig 4), and it is found that about 55.0 % of the isolates were found to be resistant from 7 to 10 antibiotics, which implies that an alternative antibiotic is the need of the hour to combat MRSA infection associated with diabetic foot ulcers. Although MRSA from diabetic foot ulcers showed higher susceptibility to individual antibiotics when compared with others, we obtained a high percentage of multi drug resistant MRSA from diabetic foot ulcer patients. Majmuder from Assam had reported 23.2 % of the MRSA isolated from clinical specimens to be multidrug resistant (18). In India, the significance of MRSA has been recognized relatively late, and it emerged as a problem in the 80s and 90s. During the past 15 years, the world wide spread of many such clones have caused major therapeutic problems in many hospitals, as well as the diversion of considerable resources to attempts at controlling their spread(19). In this study, all the strains showed susceptibility to vancomycin, and most of them were susceptible to linezolid. As expected, all the strains were resistant to penicillin, and most of them were resistant to ampicillin. But the significant and clinical relevant observation of this study is the moderate resistance shown by MRSA to other conventional antibiotics. The other contemporary reports state higher resistance rates for aminoglycosides and fluoroquinolones.

In conclusion, the degree of resistance or sensitivity of MRSA towards commonly used antibiotics is recognized to be diverse from region to region, and vancomycin was the only antibiotic found to give uniform sensitivity (100%). When antimicrobials including vancomycin are considered for treatment, choice inevitably requires the need for in vitro susceptibility testing of every isolate of MRSA in the clinical laboratories. Our study is a preface to enable the epidemiologist to understand the nature of MRSA isolates from diabetic foot ulcers in this part of South India.

References

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. International Diabetes Federation. Diabetes Atlas, 2nd edn.2003.
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. Frykberg RG. 1998. Diabetic foot ulcers: current concepts.J Foot Ankle Surg 1998; 37(5): 440-46.
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. Jun IS, Tomoko F, Katsutoshi S, Hisami K, Haruo N, Akihiko K. Prevalence of erythromycin, tetracycline and aminoglycoside resistance genes in methicillin resistant Staphylococcus aureus in hospitals in Tokyo and Kumamoto. Jpn J Infect Dis 2004; 20:361-64.
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. Qureshi AH, Rafi S, Qureshi SM, Ali AM. 2004. The current susceptibility patterns of methicillin-resistant Staphylococcus aureus to conventional anti Staphylococcus antimicrobials in Rawalpindi. Pak J Med 2004; 20: 361-64.
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. Mehta AP, Rodrigues C, Sheth K, Jani S, Hakimiyan A, Fazalbhoy N.Control of Methicillin Resistant Staphylococcus aureus in a tertiary care center-Afive year study. J Med Microbiol 1998; 16: 31-34.
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. Assadullah S, Kakru DK, Thoker MA, Bhat FA, Hussain N, Shah A.
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. Emergence of low level vancomycin resistance in MRSA. Indian J Med Microbiol 2003; 21:1-3.
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. Betty AF, Daniel FS, Alice SW. (Editors) Staphylococcus, Micrococcus and similar organisms, Chapter 19.In: Baily and Scott’s Diagnostic Microbiology, 11th edn. (Mosby Inc: St. Louis); 2002 page 284.
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