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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 journals–No manuscripts–No 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 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
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Retrospective Analysis Of The Incidence Of Nosocomial Infections In The ICU - Associated Risk Factors And Microbiological Profile
Correspondence Address :
*M.D.,(Micro), Department of Microbiology, Vinayaka Missions Medical College, Salem, Email id: mohanapalani@gmail.com, Mobile number-94431-32290, No,14, 3rd street, Malligai nagar, Kandaiyan thottam, Soolai, Erode,638004
Background
Nosocomial infections, also known as health care associated infections, have become an important public health issue worldwide. Nosocomial infections pose a critical threat to patients, especially in high-risk departments such as intensive care units.
Aim
A retrospective review of the incidence of nosocomial infections in the ICU of a tertiary care hospital in Salem from January 2009 to December 2009 was performed.
Results
Among the 5680 patients who were admitted, the incidence of the nosocomial infection rate was 16%. Urinary tract infections (29.5%) were the most common ones, followed by lower respiratory tract infections occurring in 28.1% of the patients and blood stream infections in 22.8% of the patients.
Klebsiella pneumoniae was the most commonly isolated pathogen (23.1%), followed by Pseudomonas aeruginosa (12.7%) and Escherichia coli (10.4%).
Conclusion
An increased duration of the time spent in the ICU and interventional procedures increase the risk of nosocomial infections.
nosocomial infections, ICU
INTRODUCTION:
The rising incidence of antibiotic resistance among bacterial organisms is alarming worldwide, especially in developing countries like ours, where the indiscriminate use of antibiotics is common. Antimicrobial resistance has emerged as an important determinant of the outcome for patients in the intensive care units (ICUs). Nosocomial infections can lead to complications in 25-33% of the patients who are admitted in the ICU(1). The recurrent problems with these nosocomially-acquired infections are the changes in the microbiological profile and the antibiotic sensitivity pattern of the pathogens which are isolated(2). The documented phenomena include the emergence of extended betalactamase producing organisms, the tendency of fluroquinolones, both to select the resistant strains of major pathogens and to induce cross resistance among the different classes like beta lactam and vancomycin resistance in Enterococci and Coagulase negative Staphylococci(3). In industrialized countries, nosocomial infections occur in 2-12% of the hospitalized patients, with the rates being upto 21% in ICUs (4).Nosocomial infections may result in an excess length of stay in the hospital for upto 10 days and increase in the costs of hospitalization .(1),(5),(6)
Nosocomial pneumonia remains to be a major medical problem in critically ill patients. It occurs at a rate of 5 –10 cases per 1000 hospital admissions and increases by as much as 6 to 20 fold in patients requiring mechanical ventilation(6). Mechanically ventilated patients have a higher incidence of pneumonia and mortality than non-ventilated patients, with aspiration as the major route of entry of the bacteria into the lower respiratory tract.
Urinary tract infection is the second most common infection which is encountered in clinical practice, accounting for 40% of all such infections 3. Most patients with nosocomial UTI have had genitourinary manipulation and 80% develop after urethral catheterization (3),(7). Studies on nosocomial infections in the ICU are only limited in India. Recently, we carried out a retrospective study to determine the current status of nosocomial infections at a tertiary hospital in Salem. All data on nosocomial infections from January 2009 to December 2009 were retrieved and reviewed. The incidence of nosocomial infections in the ICU, most frequently, isolated pathogens and their antimicrobial profiles, were investigated.
The study population consisted of all patients admitted to the intensive care unit (Medical, Surgical, Cardiac and Neurosurgical) from January 1 2009 to December 31 2009.
INCLUSION CRITERIA:
1. Hospital stay for more than 48 hours.
2. The recovery of clinically significant isolates after 48 hours of hospital stay from any of the following specimens submitted. -Sputum, endotracheal /tracheal swabs, urine, blood, CSF, pus, exudates/discharges from surgical sites and wound swabs.
EXCLUSION CRITERIA:
1. The initial isolates that are taken during the first 48 hours of hospitalization, that are known to be community acquired.
2. Succeeding isolates, similar to the initial organisms that were labeled as community acquired.
PROCEDURE:
All patients admitted in the different ICUs from January 2009 to December 2009 were recorded. Data on the date and site of infection, patient demographic information and the devices used were collected for each patient. Moreover, the date on the isolated pathogens and their antimicrobial susceptibility pattern were also collected. The laboratory isolates of ICU patients from any clinical specimen were monitored for the presence of organisms. Patients with positive isolates and those who were in the ICU for more than 48 hours were evaluated.
The CDC (Center for Disease Control and Prevention) definitions and guidelines were used to identify the nosocomial infections.(8) The major nosocomial infections including lower respiratory tract infections (LRTIs), urinary tract infections (UTIs), and blood stream infections (BSIs) were defined as follows:
1. LRTIs refer to lower respiratory tract infections other than pneumonia, i.e. bronchitis, tracheobronchitis, bronchiolitis and tracheitis without the evidence of pneumonia.
2. 2.UTIs refer to symptomatic urinary tract infections and
3. BSIs refer to laboratory confirmed blood stream infections. The detailed criteria to diagnose these nosocomial infections were followed as per the CDC guidelines on nosocomial definitions.
Statistical analysis was performed by using SPSS software. Chi square test and Spearman’s rank correlation coefficients were applied wherever applicable. For all analyses, a p value of less than 0.05 was considered to be significant.
OPERATIONAL DEFINITIONS OF TERMS:
Nosocomial infections- Infections that develop 48 hours after confinement. The clinical basis for NI can be any one of the following: new onset fever, new chest x-ray findings, leucocytosis/leucopaenia, purulent surgical wound discharge, new onset UTI and the deterioration of the vital signs. By using the CDC guidelines, patients with possible nosocomial infections were evaluated.
Clinically significant isolates-isolates which are responsible for the ongoing infection as supported by the history, clinical findings and other laboratory results.
Baseline isolates-Organisms isolated from any specimen which was submitted from the patients who were diagnosed to have nosocomial infections.
Co-infection-Presence of a second organism in the patients with baseline isolates.
(Table/Fig 1): Diagnostic criteria for nosocomial infection
A total of 5680 patients were admitted in different ICUs from January 1 2009 to December 31 2009.Among these patients, 355 developed nosocomial infections with an incidence of 16%. The mean age was 47 and 77% of the patients were males. The mean length of hospital stay was 20.30+/- 13.14 days.
A majority of patients were admitted with neurological disorders (29.9%), followed by respiratory conditions (16.1%) and renal disorders (13.8%). Urinary tract infections and lower respiratory tract infections were the most common types of infections, occurring in 29.5% and 8.7% of the catheterized patients, followed by lower respiratory tract infections including bronchitis and bronchiolitis, occurring in 28.1% and17.7% of the patients who had mechanical ventilation or tracheostomy. 22.8% of the patients had blood stream infections and 4.5% of them were catheter associated. The nosocomial infections of surgical sites, skin and soft tissue were 8.2%. A majority of the patients with nosocomial infections had co-infection (24) or super infection (42) or both (31).
Klebsiella pneumoniae was the most commonly isolated pathogen (23.1%), followed by Pseudomonas aeruginosa (12.7%) and E.coli (10.4%). The other organisms which were isolated were Acinetobacter baumanni (9.9%), Candida spp (8.2%), S.aureus (3.9%), S.epidermidis (1.7%) and Enterococci (3.1%). In patients with urinary tract infections, E.coli was the most commonly isolated pathogen, followed by Candida species. In patients with lower respiratory tract infections, Klebsiella pneumoniae and Pseudomonas aeruginosa were the most commonly isolated pathogens, followed by Acinetobacter baumannii. Acinetobacter baumannii, S.aureus and S.epidermidis were the most commonly isolated pathogens in blood stream infections.
Very high resistance rates were seen with Gram-negative bacteria against third generation cephalosporins (77.2%), fourth generation cephalosporins (82.4%) and a combination of cephalosporins and beta lactamase inhibitors (37.9%). A fairly low level of resistance was seen with Ciprofloxacin (25%), Amikacin (16.7) and Augmentin (35%). All S.aureus isolates were susceptible to Vancomycin. A high rate of resistance was noted for Oxacillin (90%) and Co-trimaxazole (68.4%).(Table/Fig 2)
All patients with nosocomial infections were treated with empirical antimicrobial therapies or according to the susceptibility testing reports.
46 patients with nosocomial infections died in the ICU.
(Table/Fig 2): Susceptibility pattern of S.aureus
Nosocomial infections have become an important public health issue worldwide. The epidemiology of nosocomial infections, mainly in the ICUs, is less studied and is given less emphasis in the developing countries.(9) The relatively high incidence of nosocomial infections may be due to the excess length of hospital stay following high severity of illness, more intervention, no antibiotic policy and possibly poor adherence to aseptic techniques.(10)
In the present study, the overall incidence of nosocomial infections in the ICU was 16%, which was lower than that observed in the ICUs of developing countries. However, the rate was comparable with those reported from many industrialized countries, where it ranged from 7.7% to 16.5%.(9)
The general distribution pattern of the nosocomial infections that emerged in our study showed UTIs (29.5%) to be the most common, followed by LRTIs (28.1%), BSIs (22.8%) and skin and soft tissue infections (11.26%). This is in concordance with the study performed by Mukherjee et al(11), which showed UTIs (45%) as the commonest nosocomial infections, followed by LRTIs (30%)and BSIs (16%). A study performed by Zoleta(1) et al showed LRTIs (66%) as the predominant infections, followed by UTIs (31%).
Our study population included 355 patients and a majority (n=272) were males. The higher rate of UTIs in the present study could be due to the male preponderance BPH in association with restricted mobility in the ICU and many of these patients had diabetes as a co morbid illness.
The study showed that 28.1% of the patients with nosocomial lower respiratory tract infections received mechanical ventilation (23.9%) or tracheostomy (10.1%). 8.7% of nosocomial urinary tract infections and 4.5% of blood stream infections were catheter associated.(Table/Fig 1) These findings indicate that the nosocomial infections are often associated with the use of invasive devices. Therefore, to effectively reduce nosocomial infections, the use of invasive devices should be minimized and specific disinfection precautions should be taken during the application of the device.(8)
The most frequently encountered microorganisms were Klebsiella (23.1%), Pseudomonas aeruginosa (12.1%), Escherichia coli (10.4%) and Acinetobacter (9.9%). (Table/Fig 3)
(Table/Fig 3): Percentage of organisms isolated
The pathogen distribution of nosocomial infections in our study differs slightly from the findings of Mukherjee et al. We found Klebsiella spp to be the predominant pathogen which caused UTIs, but Mukherjee et al reported Pseudomonas aeruginosa to be the predominant cause of nosocomial UTIs. This difference could be explained by the difference in geographical locations, nutritional status and health care systems.
The rates of Gram negative isolates which were resistant to commonly used antibiotics ranged from 29.2% (imipenem) to 86.63% (II generation cephalosporins). (Table/Fig 4)
(Table/Fig 4): Susceptibility pattern of gram negative isolates
(Table/Fig 4): Susceptibility pattern of gram negative isolates
90% of the S.aureus species were Methicillin resistant and 15% were resistant to Linezolid. All isolates showed an in vitro susceptibility to Vancomycin
Since resistant organisms cause a high percentage of nosocomial infections, the antimicrobials used for the treatment of nosocomial infections must have a balanced and reliable spectrum of activity against these pathogens. Careful drug selection, coupled with surveillance and effective infection control procedures, may help in controlling pathogen resistance.
The present study has some limitations due to its retrospective nature. The data on the clinical consequences were not available for most cases, thus making it impossible to compare the clinical outcome of the patients with and without nosocomial infections. However, the present study showed that the length of stay in the hospital was significantly increased in patients with nosocomial infections, as compared to those without the infections.
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