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

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Dr Mohan Z Mani

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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.
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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 one’s 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 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

Important Notice

Original article / research
Year : 2022 | Month : June | Volume : 16 | Issue : 6 | Page : DC01 - DC05 Full Version

Secondary Infections among COVID-19 Hospitalised Patients and their Antimicrobial Susceptibility Pattern: A Cross-sectional Study in a Tertiary Care Hospital


Published: June 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/55549.16527
Gouri Sankar Sabat, Susmita Kumari Sahu, Monalisa Panigrahi, Nihar Ranjan Sahoo, Ganeswar Sethi

1. Junior Resident, Department of Microbiology, MKCG Medical College, Berhampur, Odisha, India. 2. Associate Professor, Department of Microbiology, MKCG Medical College, Berhampur, Odisha, India. 3. Assistant Professor, Department of Microbiology, SJMCH, Puri, Odisha, India. 4. Assistant Professor, Department of Medicine, MKCG Medical College, Berhampur, Odisha, India. 5. Associate Professor, Department of Medicine, MKCG Medical College, Berhampur, Odisha, India.

Correspondence Address :
Dr. Gouri Sankar Sabat,
Lanjipo, Llychaka, Khala Street, Berhampur, Odisha, India.
E-mail: gourisankarsabat19292@gmail.com

Abstract

Introduction: The novel coronavirus (2019-nCoV) is a contagious virus that causes respiratory infection and has shown evidence of human-to-human transmission. In this infection the immunity of the patient is decreased; making them susceptible to various secondary infections. This leads to increased morbidity and mortality in these patients.

Aim: To estimate the profile of secondary infections in hospitalised Coronavirus Disease-2019 (COVID-19) patients and analyse their antimicrobial susceptibility pattern.

Materials and Methods: A cross-sectional study was conducted for a period of five months from June to October 2021, which included COVID-19 positive patients with secondary infection admitted in the dedicated COVID hospital, Maharaja Krishna Chandra Gajapati Medical College and Hospital (MKCG MCH), Berhampur, Odisha, India. Clinical samples like blood, urine, sputum, tissue biopsy and Bronchoalveolar Lavage (BAL) were collected aseptically from patients with COVID-19 and were processed in microbiology laboratory as per standard operating procedures. All the necessary information like demographic features (age, gender), associated co-morbidities and oxygen saturation levels of COVID-19 positive patients at the time of admission were collected and entered in a Microsoft Excel sheet for further analysis. Results of continuous variables were described by mean and range while categorical variables were described by frequency. All the generated data was analysed by Statistical Package for the Social Sciences (SPSS) 16.0.

Results: A total of 438 patients suspected of COVID-19 were admitted during the study period, out of which 138 patients were positive for COVID-19 by Reverse Transcriptase Polymerase Chain Reaction (RT-PCR). Out of 138 COVID-19 positive patients, 105 patients were willing to give samples and their samples were processed for bacterial and fungal culture and sensitivity. Total 18/105 (17.1%) samples were positive for bacterial and fungal growth. Blood Stream Infection (BSI) were seen in 14/18 (77.8%) and was predominantly associated with Staphylococcus aureus 5/14 (35.7%), followed by Enterococcus spp. 3/14 (21.4%). Out of total culture positive cases, 2/18 (11.1%) showed Urinary Tract Infection (UTI). Of the UTI cases Escherichia coli was isolated from 1/2 (50%) of cases. Out of total culture positive cases, 2/18 (11.1%) were identified having mucormycosis. All gram positive bacteria had shown maximum resistant to ampicillin and gram negative bacteria were resistant to ampicillin-sulbactam, levofloxacin, cotrimoxazole.

Conclusion: In COVID-19 positive patients with secondary infection, early diagnosis and prompt treatment will lead to improved patient care and better outcome.

Keywords

Co-infection, Community acquired infection, Drug resistance, Hospital acquired infection, Superinfection

Secondary infections are commonly identified in viral respiratory tract infections e.g. Influenza and are important cause of mortality and morbidity which require prompt diagnosis and antimicrobial therapy (1),(2),(3). These infections can have worse outcomes if not treated on time. Secondary infection in patients with severe influenza has been published as high as 20-30% (3),(4). It has been shown that most of the deaths reported in 1918-19 during influenza pandemic were due to secondary bacterial infections (5).

Corona viruses have been known to the human kind as important pathogens causing respiratory tract infections in both children and adults. Severe pneumonia has been reported due to Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) and more recently the novel coronavirus (2019-nCoV) or SARS-CoV-2. Compared to the SARS and MERS the virulence of SARS-CoV-2 is relatively low, only few infected people developed severe manifestation (6). It is a highly infectious virus that causes respiratory infection and human-to-human transmission. It spreads through inhalation or ingestion of viral droplets.

Its target receptor Angiotensin Converting Enzyme 2 (ACE2) is mainly expressed in the cells of cardiopulmonary system and the final outcome can be lung injury, myocarditis, inflamed and leaking vessels, rise or fall in blood pressure and organ damage (7),(8),(9),(10). India has reported 3.71cr cases of COVID-19 till 15th Jan 2022.

In COVID-19, secondary infection have been detected, including bacterial and fungal infections, especially in severe or critical cases (11),(12),(13). The overall secondary infection rate in patients infected with COVID-19 is about 5-30% (14),(15),(16),(17),(18),(19),(20). Early diagnosis, prompt identification and judicious use of antibiotics and antifungals will lead to improved patient care and better outcome. This would also justify the need for initial empiric antibiotic treatment and will decrease routine use and (overuse) of antibiotics and antimicrobial resistance. Present study aimed to estimate the profile of secondary infections in hospitalised COVID-19 patients and to determine the antimicrobial susceptibility pattern.

Material and Methods

A cross-sectional study was conducted for a period of five months in Department of Microbiology (June to October 2021) in MKCG medical college, Berhampur, a tertiary care 1190 bedded, teaching, and referral hospital in Odisha, India. With the onset of the COVID-19 pandemic, a Dedicated COVID Hospital (DCH) with 150 beds capacity was established. The study was approved by the Institutional Ethical Committee (IEC), MKCG medical college (IEC-870) and informed consent was taken from the participants. All the COVID-19 positive patients admitted in the DCH of MKCG Medical College during the above study period were included.

According to Centers for Disease Control and Prevention (CDC), infections that are identified after 48 hours of hospital admission should be referred as hospital-acquired infection and infections that are identified within 48 hours of admission as community-acquired infection (21),(22). According to CDC, co-infection is one occurring concurrently with the initial infection and super infection/secondary infection is an infection following a previous infection especially when caused by microorganisms that are resistant to the earlier used antibiotics, the difference being purely temporal (23),(24).

Inclusion criteria: COVID-19 patients of all age group, with or without symptoms of Severe Acute Respiratory Infection (SARI), who were admitted for the above study period, within 48 hours of hospitalisation were included in the study.

Exclusion criteria: Unwilling patients were excluded from the study.

Sample collection: Relevant clinical samples like blood, urine, sputum, tissue biopsy and BAL were collected aseptically (25) from the COVID-19 positive patients admitted in the DCH for the above study period were received in the microbiology laboratory and processed for the same as below (Table/Fig 1).

Blood, sputum and BAL samples were inoculated on MacConkey agar, Blood agar, Nutrient agar and Sabouraud’s Dextrose Agar (SDA). Urine was inoculated on Cystine Lactose Electrolyte Deficient agar (CLED) and processed as (1) in above flow chart and Antimicrobial Susceptibility Test (AST) was done according to the Clinical and Laboratory Standards Institute (CLSI)-2021 guidelines (26). Growth on SDA (2) was identified as yeast or mould and processed under (2a) and (2b) respectively as in the above flowchart. Antifungal Susceptibility Test (AFST) was done according to CLSI-2021 guidelines (26). BAL fluid and tissue biopsy samples were subjected to gram stain and 40% KOH test to see for fungal elements and processed as (3) in the above flowchart. All the clinical samples were processed in the biosafety cabinet (BSL-2) (Table/Fig 2), (Table/Fig 3), (Table/Fig 4), (Table/Fig 5), (Table/Fig 6). Personal protective equipments were used while processing the samples. All the clinical samples were disposed as per the biomedical waste management guidelines in India (27).

Statistical Analysis

All the necessary information like demographic features (age, gender), associated co-morbidities and oxygen saturation levels of COVID-19 positive patients at the time of admission were collected and entered in a Microsoft Excel sheet for further analysis. Results of continuous variables were described by mean and range while categorical variables were described by n (%). Here (n) is total number of COVID-19 positive patients, total samples collected for microbiological culture, microbiological culture positive for bacterial and fungal growth and organisms isolated from culture positive samples All the generated data was analysed by SPSS 16.0.

Results

A total of 438 patients suspected of COVID-19 were admitted during the study period, out of which 138 (31.5%) patients were positive for COVID-19 by RT-PCR. Out of 138 COVID-19 positive patients 71 (51.5%) were females and 19/138 (13.8%) had pregnancy. The mean age of the COVID-19 positive patients was 43 years with a range of 6 to 84 years. Mean saturation level of the COVID-19 positive patient’s was 90%, with a range of 54%-94%. Out of 138 COVID-19 positive cases 58/138 (42%) had co-morbidities. Diabetes with hypertension was seen in 23/138 (16.7%), hypertension alone in 8/138 (5.8%), asthma in 2/138 (1.4%).

Demographic features of COVID-19 positive patients and COVID-19 positive patients with secondary infection were compared in (Table/Fig 7). Out of 138 COVID-19 positive patients, 105 patients were willing to give samples and were processed for bacterial and fungal culture and sensitivity. Out of total samples tested, 58/105 (55.2%) were blood, 36/105 (34.3%) were urine, 6/105 (5.7%) were sputum, 1/105 (1.0%) was BAL fluid and 4/105 (3.8%) were tissue. Out of 105 samples collected for microbiological culture, 18/105 (17.1%) samples were positive for bacterial and fungal growth. Out of total culture positive cases, BSI was seen in 14/18 (77.8%) samples and was predominantly associated with Staphylococcus aureus 5/14 (35.7%). Out of 18 samples, 2/18 (11.1%) showed UTI in which Escherichia coli was isolated from 1/2 (50%) of cases, (Table/Fig 8). Out of total culture positive cases, 2/18 (11.1%) were identified as having mucormycosis based on the growth on SDA.

The antibiotic susceptibility pattern of the isolated organisms is tabulated in (Table/Fig 9) and (Table/Fig 10). All gram positive bacteria had shown maximum resistant to ampicillin and gram negative bacteria were resistant to ampicillin-sulbactam, levofloxacin, cotrimoxazole. Staphylococcus aureus was isolated in five cases, of which 3/5 (60%) were Methicillin resistant Staphylococcus aureus (MRSA). Of the pathogens isolated gram negative bacteria isolated were 7, of which 7/7 (100%) were Extended spectrum beta-lactamases (ESBL) producers and Carbapenem resistantance was seen in 2/7 (28.6%). Among gram positive isolates 8/8 (100%) were sensitive to linezolid. Among the gram negative pathogens 4/7 (57.1%) were sensitive to Piperacillin/Tazobactam, and 5/7 (72%) were sensitive to meropenem. Antifungal susceptibility pattern of Candida albicans tabulated in (Table/Fig 11). Out of 138 patients 28/138 (20.3%) patients succumbed to death and rest were discharged.

Discussion

The present study identified the profile and incidence of secondary infections in COVID-19 infected hospitalised patients over a period of five months. Among 138 COVID-19 positive patients, 105 patients were willing to give samples and 105 samples were sent to the microbiology department for the processing. Out of these, culture positive were seen in 18 (17.1%) samples. This results were similar with reports from other studies where the secondary infection rate ranged from 5-30% (14),(15),(16),(17),(18),(19),(20),(28),(29). Majority of patients were females constitute around 51.5%. In contrast to this, other studies showed male predominance (7),(28),(30). The mean age of the COVID-19 positive patients was 43 year with a range of 6-84 years. Other study showed almost similar results with age range of 1 to 97 years with a mean of 53.3 year (29). When co-morbidity was compared, diabetes with hypertension was seen in 16.7% patients, hypertension in 5.8%, and 13.8% positive cases were seen in pregnant women. Report from other study showed associated co-morbidities were diabetes mellitus 18%, hypertension 46.8%, asthma 6.5%, heart disease 24% (28). BSI constitute majority of secondary infections with 14/18 culture positive samples. Staphylococcus aureus was the most common bacteria isolated followed by Enterococcus spp. which were gram positive organisms. Few previously documented studies were in line with this result, showed BSI was predominantly due to gram positive pathogens (28),(31). In contrast to this other previously reported studies showed BSI was predominantly due to gram negative pathogens (29),(32),(33). Present study showed gram negative septicaemia was predominantly associated with Klebsiella spp. and Acinetobacter spp. This result was similar to the previously reported studies which showed among gram negative organisms Klebsiella spp. was the commonest organism followed by acinetobacter spp. or vice versa (29),(32).

After BSI, UTI constitute 2/18 (11.1%) culture positive samples. Previous study showed total urine culture positive cases in the first wave of COVID-19 pandemic were 9.3% and 18.8% in the second wave (33). UTI was mainly due to Escherichia coli and Candida tropicalis. This result were in line with the previously reported studies, which showed among COVID-19 positives predominant urinary pathogens were Escherichia coli, Klebsiella spp. Candida spp. (29),(34).

All gram positive bacteria have shown maximum resistant to ampicillin and gram negative bacteria were resistant to ampicillin-sulbactam, levofloxacin, cotrimoxazole. This was in contrast with previously documented studies, which showed gram negative pathogens pathogens isolated from blood and urine of COVID-19 positive patients showed highly resistant to ampicillin, levofloxacin, piperacillin/tazobactam (29),(34). MRSA strain was seen in 60% of the Staphylococcus isolates. In contrast to this result, previously reported study showed Methicillin resistance was observed in 100% of Staphylococcus aureus isolates (32). Among the gram negative isolates in the study, 100% were ESBL strains and 28.6% were carbapenem resistance strains. Most of the previously documented studies showed high level of meropenem resistance (carbapenem resistance) among Klebsiella spp. and Acinetobacter spp., which was about 60-90% (29),(34),(35) in contrast to the present study. Present study showed the incidence of secondary infection in COVID-19 positive patients was maximum due to gram positive organisms followed by multiple drug resistance gram negative bacilli. BSI was predominant among COVID-19 positive patients followed by UTI and mucormycosis. As most of secondary infections in the present study were community origin as they occurred within 48 hours of admission.

Limitation(s)

Present study was done as a single centre study done in a tertiary care hospital so the results cannot be generalised. Our hospital is a referral centre from PHCs (Primary Health Centre) and CHCs (Community Health Centers), they might acquire these pathogens at the previous hospital where they admitted.

Conclusion

Secondary infections are more commonly seen in COVID-19 patients with co-morbidities and BSI are more commonly reported due to gram positive bacteria and multi drug resistant gram negative bacteria. It may be difficult to differentiate which patient have co-infection/hospital acquired infection and which do not; however, proper history taking and examination should be made to determine if a bacterial co-infection is present on admission of a patient with COVID-19. Strict hospital infection control programs should be followed at all healthcare set-ups without non compliance. Antimicrobial stewardship programmes should be administered to treat patients and to decrease multiple drug resistant infections. Although secondary infections appear to be prevalent among COVID-19 patients, it is still an understudied phenomenon.

Acknowledgement

Authors are deeply grateful to their teachers, seniors of the microbiology department and hospital administration for their guidance and cooperation in the present study.

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DOI and Others

DOI: 10.7860/JCDR/2022/55549.16527

Date of Submission: Feb 08, 2022
Date of Peer Review: Mar 08, 2022
Date of Acceptance: May 07, 2022
Date of Publishing: Jun 01, 2022

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:
• Plagiarism X-checker: Feb 11, 2022
• Manual Googling: May 02, 2022
• iThenticate Software: May 06, 2022 (10%)

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