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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
Changing Trends of Antimicrobial Resistance in Neonatal Sepsis: Experience from a Tertiary Care Hospital from West Bengal, India
Correspondence Address :
Abhijit Dutta,
Salboni Complex, 64/98c, Khudiram Bose Sarani, Kolkata-700037, West Bengal, India.
E-mail: dradutta2@gmail.com
Introduction: Sepsis is the second leading cause of neonatal mortality in India. Emergence of highly resistant microorganisms as an aetiology of neonatal sepsis is a matter of serious concern.
Aim: To study the prevailing aetiological agents in neonatal sepsis and their antimicrobial susceptibility pattern.
Materials and Methods: A prospective observational study was performed in a tertiary care teaching hospital in neonatal care units in North Bengal Medical College and Hospital, West Bengal, India, over a period of two years from March 2017 to February 2019. All the neonates having clinical features suggestive of sepsis were subjected to blood culture using BacT/ALERT® PF Plus. Microbial identification and antibiotic susceptibility testing was done by VITEK-2 automated systems. Chi-square test was done using Epi info software version 7.1 and p-value <0.05 was considered significant.
Results: Out of 403 neonates investigated for suspected sepsis, 156 (38.7%) were found to be culture positive. Klebsiella pneumoniae was the most common organism isolated (n=90, 57.7%) followed by Staphylococcus aureus (n=24, 15.4%) and Acinetobacter baumannii (n=10, 6.4%). Klebsiella pneumoniae showed a very high degree of resistance to ampicillin, amoxycillin-clavulenic acid (100% each), cefotaxime (93.4%), ceftazidime (92.3%), gentamycin (94.5%) and tobramycin (94.5%). High resistance of Staphylococcus aureus was seen against ampicillin (100%), cloxacillin (62.5%), amoxicillin-clavulenic acid (70.9%), and cefotaxime (79.2%). Few isolates of Klebsiella pneumonia (6.6%), Acinetobacter baumannii (60%) and Enterobacter cloacae (50%) were sensitive only to colistin and tigecycline.
Conclusion: Most of the isolates showed very high degree of resistance against first line of antibiotics recommended by World Health Organisation (WHO) (ampicillin and gentamycin or amikacin) for empirical treatment of neonatal sepsis. Emergence of highly resistant organisms sensitive only to colistin and tigecycline should be considered as an eye opener. Strict adherence to sepsis prevention along with regular surveillance of organisms and their sensitivity patterns is the need of the hour to improve survival by contributing to antibiotic stewardship.
Acinetobacter baumannii, Antimicrobial resistance, Klebsiella pneumonia, Sepsis
Neonatal sepsis is a clinical syndrome characterised by signs and symptoms of infection with or without accompanying bacteremia in the first 28 days of life (1). The incidence of blood culture proven sepsis in India was reported as 8.5 per 1000 live births in 2002-2003 as per National Neonatal Perinatal Database (NNPD) (2). It is the second leading cause of neonatal mortality in India, accounting for 18.6% neonatal deaths (2). The situation has been compounded by emergence of Multidrug Resistant (MDR) organisms, which is defined as resistance to at least 3 classes of antimicrobial agents, among those that are regarded as potentially effective against the respective pathogen (3). A study from India has showed that 87% of Escherichia coli isolates were Extended Spectrum B Lactamases (ESBL) producers, 13% possessed New Delhi B Lactamases-1 (NDM-1) and 6% were Metallo B Lactamases (MBL) producers (4). Another study from Delhi Neonatal Infection Study (DeNIS) Collaboration has found high rates of multidrug resistance in Acinetobacter baumannii (82%), Klebsiella pneumoniae (54%), and Escherichia coli (38%) isolates (5).
Neonatal units are inherently susceptible to selection and propagation of MDR organisms due to multiple factors like low immunity of sick neonates, multiple opportunities for cross-infection and widespread use of antimicrobials (6). In addition, other factors like poor infection control, lack of knowledge regarding organisms, and unscrupulous use of fixed drug combinations are the tailwinds in the emergence of MDR strains (7),(8),(9),(10). To prevent the emergence and spread of such antimicrobial resistance, knowledge of the common causative agents and their antimicrobial susceptibility remains pivotal. This helps to draft protocol for rational management of neonatal sepsis. The present study was performed to analyse aetiology and antimicrobial susceptibility of neonatal sepsis in a tertiary care teaching hospital in eastern India.
A prospective observational study was carried out in neonatal care units in North Bengal Medical College and Hospital, West Bengal, India over the past two years (from March 2017 to February 2019). Clearance from Institutional Ethical Committee was taken (No: PCM/2014-15/IEC/45 dated 23/12/2014).
Inclusion criteria: All the neonates (postnatal age within 28 days) delivered in our institution or outside who had clinical features suggestive of neonatal sepsis were included in the study.
Exclusion criteria: Neonates with gross congenital malformation and suspected metabolic disorder were excluded from the study.
Written consent for participation in the study was taken from parents of each neonate. All the consecutive cases of suspected neonatal sepsis during the study period were included in the study. Detailed history and clinical examination were done. Sepsis screen was performed in each neonate. For interpretation of sepsis screen, total leukocyte count <5000/mm3, low absolute neutrophil count as per Manroe chart for term neonates and Mouzinho’s chart for very low birth neonates, immature to total neutrophil ratio >0.2, micro-Erythrocyte Sedimentation Rate (ESR) >15 in 1st hour and C-reactive protein >1 mg/dL were considered abnormal. Sepsis screen was considered positive when two or more of the above mentioned parameters were abnormal (11). Diagnosis of sepsis was suspected on the basis of clinical features and results of sepsis screen; and was confirmed by observing growth on blood culture. Early onset sepsis and late onset sepsis were defined as infection within first 72 hour of life and after 72 hour of life respectively. Blood culture was done for all the neonates with suspected sepsis. Blood samples (1-2 mL) were collected by aseptic precautions before starting antibiotics. Blood cultures were performed using BacT/ALERT® PF Plus. Microbial identification and antibiotic susceptibility testing were done by VITEK-2 automated systems.
Statistical Analysis
Chi-square test was done using Epi info software version 7.1 to compare different groups. All the statistical analyses were carried out at 5% level of significance and p-value <0.05 was considered significant.
During the study period, 403 neonates were investigated for suspected sepsis. Sepsis screen was positive in 223 (55.3%) neonates. Total 156 cases (38.7%) showed growth in blood culture and were included in the study. A 126 (80.7%) inborn and 30 (19.2%) outborn neonates showed positive blood culture. Early onset sepsis was documented among 48 (38%) inborn neonates and 7 (23.3%) outborn neonates. Details of demographic data and other baseline characteristics have been given in (Table/Fig 1). Various risk factors associated with sepsis among inborn neonates, and clinical presentations of the study cohort have been detailed in (Table/Fig 2), (Table/Fig 3), respectively.
Out of 156 culture positive cases, 118 (75.6%) were gram-negative (103/126 inborn, 15/30 outborn), 32 (20.5%) were gram-positive (19/126 inborn, 13/30 outborn), and 6 (3.84%) (4/126 inborn, 2/30 outborn) were due to Candida albicans. Klebsiella pneumonia was the most common organism isolated (90, 57.7%), followed by Staphylococcus aureus 24 (15.4%) and Acinetobacter baumannii 10 (6.4%). The details of aetiological agents are given in (Table/Fig 4).
Among 90 Klebsiella isolates, all were sensitive to colistin and tigecycline. 85 (94.4%) isolates were sensitive to cefoperazone-salbactum, 84 (93.3%) were sensitive to meropenem, and 65.6% isolates to ciprofloxacin. Very high resistance to cefotaxime (93.4%), ceftazidime (92.3%), gentamycin (94.5%) and tobramycin (94.5%) was noted. Six (6.6%) Klebsiella isolates were sensitive to only colistin and tigecycline.
All Escherichia coli isolates were highly sensitive to meropenem, cefoperazone-salbactum (100% each), ciprofloxacin, and ofloxacin (87.5% each). Acinetobater baumanii, third most common isolate in our study, was highly resistant to commonly used antimicrobials ranging from 60-100%. However, these isolates were sensitive (100%) to colistin and tigecycline. Similarly, Enterobacter cloacae isolates showed high resistance to common antimicrobials and 50% of them were exclusively sensitive to colistin and tigecycline. All gram-negative isolates are universally resistant to ampicillin (100%) and amoxycillin-clavulenic acid (100%). Staphylococcus aureus was isolated from 24 cultures and they were highly sensitive to meropenem (100%), vancomycin (100%), linezolid (100%), piperacillin-tazobactum (91.7%), gentamycin (70.8%), and amikacin (70.8%). Staphylococcus aureus, Coagulase Negative Staphylococci (CONS) and Enterococcus are universally resistant to ampicillin (100%). Detail of sensitivity pattern is given in (Table/Fig 5).
For effective management of sepsis, study of bacteriological profile along with the antimicrobial sensitivity pattern plays a pivotal role (12),(13). Bacteria are the leading causes of neonatal sepsis; but it can also be caused by viruses (adenovirus, enterovirus, coxsackie virus, rubella virus etc.,), protozoa (e.g., toxoplasma), and fungi (e.g., Candida albicans) (12) resulting in low yield of blood cultures. A negative blood culture does not exclude sepsis as about 26% of all neonatal sepsis might be due to anaerobes, and anaerobic culture is not routinely performed (12). Administration of antimicrobial agents before collecting blood samples for culture also attenuates the proportion of culture positivity. In the present study, bacterial growth could be isolated in 38.7% cases.
In the present study, gram-negative bacilli predominated over gram-positive organisms. Klebsiella pneumoniae was the overall predominant cause of sepsis, which is comparable with studies from India and other developing countries (2),(14). Escherichia coli was the second commonest gram-negative organism and Staphylococcus aureus was commonest gram-positive isolate. Moreover, we found Staphylococcus aureus as the overall second most common aetiology of sepsis, which is similar to findings of NNPD. The predominant causes of sepsis in the developed countries are Group B Streptococcus (GBS) and CONS (13). GBS was not isolated in our cohort. Similarly, GBS is an uncommon isolate of neonatal sepsis in India; mostly attributed to prevalence of less virulent strains, high titers of transplacentally acquired antibodies and also due to non-detection of cases among stillbirths (15). Enterococci was the second most common gram-positive organism isolated and was found to be highly resistant to commonly used antimicrobials. However, it showed 100% sensitivity to rifampicin, linezolid and vancomycin. CONS was the least common gram-positive organism in the present study. A previous study (14) has proposed to consider two positive blood cultures to confirm CONS as aetiological agent, which was followed in the present study.
WHO has recommended the use of penicillin or ampicillin and one aminoglycoside for empirical therapy in neonatal sepsis (16). In the present study, high degree of resistance was found to commonly used antimicrobial agents in neonatal sepsis. High resistance to antimicrobial agents recommended by World Health Organisation (WHO) as empirical therapy (ampicillin and aminoglycosides) is particularly alarming (16). In the present study, sensitivity pattern shows that there is very high resistance against ampicillin (100%) and gentamycin (29.2-100%) which are recommended for empirical use in neonatal sepsis by WHO. Third generation cephalosporins are used as the first line antimicrobials in many units which also face high degree of resistance similar to this study. This high resistance may be related to prolonged exposure to these antibiotics during antenatal period (17). Resistance pattern of organisms towards empirical antimicrobials suggested by WHO, as found in various recent studies (5),(18),(19),(20),(21),(22),(23) is given in (Table/Fig 6). The other striking observation in the present study was emergence of some highly resistant isolates of Klebsiella and Acinetobacter which are sensitive only to colistin and tigecycline. Similar resistance pattern has also been reported from other units in India (22). Considering the sensitivity pattern observed in our study, piperacillin-tazobactum and ciprofloxacin or ofloxacin may be a good combination for empirical therapy which covers most of the organisms. Although ciprofloxacin is not approved for use in neonates, still it is used as empirical treatment in some neonatal units with favorable outcome (23). After receiving the sensitivity report, further treatment should be guided by results of sensitivity pattern of the isolate.
Limitation(s)
The present study has its own share of limitations. It was a single center-based study, so the results cannot be extrapolated to the whole country. Also, larger sample size would have given better results.
Authors noticed a very high degree of resistance to commonly used antimicrobials in the neonatal unit. Most gram-negative organisms are highly resistant to commonly used antimicrobial agents, especially those recommended by WHO. These isolates are sensitive to piperacillin-tazobactum, meropenem, 4th generation cephalosporin or fluoroquinolone to variable extent. Few isolates of Klebsiella, Acinetobacter and Enterobacter are resistant to all antimicrobial agents except colistin and tigecycline which is a matter of great concern. Likewise, gram-positive organisms are only sensitive to piperacillin-tazobactum, meropenem, vancomycin or linezolid. To avoid exponential increase of this problem we should emphasise more on preventive aspects of sepsis. Regular surveillance of organisms and their sensitivity patterns is the need of the hour to improve survival by contributing to antibiotic stewardship.
10.7860/JCDR/2021/49015.15136
Date of Submission: Feb 13, 2021
Date of Peer Review: Apr 26, 2021
Date of Acceptance: May 26, 2021
Date of Publishing: Jul 01, 2021
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
PLAGIARISM CHECKING METHODS:
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