Article in PDF
How to Cite
Citation Manager
Readers' Comments (0)
Audio Visual Article Statistics
Link
to PUBMED
Print this Article
Send to a Friend
Advertisers
Access Statistics Resources
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
Pattern of Bacterial Infections among Children with Sickle Cell Disease in a Tertiary Care Hospital of Nagpur, Maharashtra, India
Correspondence Address :
Dr. Swagnik Roy,
Associate Professor, Department of Microbiology, Zoram Medical College,
Falkawn Pin-796005, Aizawl, Mizoram, India.
E-mail: swagnik.roy1442@gmail.com
Introduction: In India Sickle Cell Disease (SCD) is associated with significant morbidity and represents a major health problem in central India. Patients with SCD are susceptible to a variety of bacterial infections, which are major cause of morbidity and mortality. The burden of disease caused by bacterial infections in patients with SCD is less studied and have long been neglected. Therefore there is scarcity of data for the association between SCD and invasive bacterial diseases. So it becomes necessary to have knowledge of distribution of these pathogens and their susceptibility to antibiotics.
Aim: To identify the most common bacterial infections among children with SCD and to check antibiotic susceptibility patterns of all the clinical isolates.
Materials and Methods: Present study was a descriptive observational study which was conducted in Department of Microbiology, Govt Medical College and Hospital Nagpur, Maharashtra, India, for two years from October 2013 to October 2015. Paediatric patients of age ≤12 years diagnosed as SCD and admitted in paediatric wards of tertiary care hospital, having body temperature ≥38.5°C were enrolled in the study. Clinical specimen i.e. blood, urine, pus, and body fluids such as Cerebrospinal Fluid (CSF), pleural fluids were collected aseptically and the bacteria causing infections were isolated and identified conventionally in accordance with the standard operative procedures. Antimicrobial susceptibility testing was performed as per the Clinical and Laboratory Standards Institute (CLSI) guidelines 2013 by modified Kirby-Bauer method. Data was presented as numbers and percentages.
Results: A total of 824 samples including blood, urine, CSF, pus and pleural fluid were collected from 412 SCD patients. Prevalence of bacterial infections among patients with SCD was 17.35%. Bacteraemia was the most common infection among febrile children with SCD 84 (20.38%) followed by Urinary Tract Infection (UTI) 55 (15.02%), Osteomyelitis 2 (13.34%), and Meningitis 1 (5.56%). Total 143 organisms were isolated from different samples and gram negative bacilli 106 (74.12%) were found to be the commonest cause of bacterial infections among children with SCD. Imipenem was the best antibiotic for infections with multidrug resistant gram negative bacilli.
Conclusion: To identify children with SCD and prevent bacterial infections in them should be a priority target for health research as these infections make a large contribution to the morbidity and mortality among children with SCD.
Bacteraemia, Meningitis, Osteomyelitis, Paediatric, Urinary tract infections
The SCD is the name for a group of related disorders caused by sickle haemoglobin (HbS). HbS is a qualitatively abnormal Hb caused by a point mutation of the β-globin gene. This change decreases the solubility of HbS in the deoxygenated state. Thus, as sickle Red Blood Cells (RBC’s) traverse the circulation, cycling through oxygenated and deoxygenated states, HbS repeatedly forms rigid polymers that damage the RBC membrane, causing a haemolytic anaemia and, ultimately, the manifestations of SCD (1). In India SCD is common in Vidharba, Chattisgarh, Madhya Pradesh, Orissa, Gujarat, Tamil Nadu and Andhra Pradesh. It is associated with significant morbidity and represents a major health problem in central India (2).
Patients with SCD are susceptible to a variety of bacterial infections, which are major cause of morbidity and mortality (3). This increased susceptibility to infections is related to abnormalities in the defence mechanisms of these patients, including functional hyposplenism, an abnormality in the alternative pathway of complement activities, and defective neutrophil function (4). The burden of disease caused by bacterial infections in patients with SCD is less studied and long been neglected. Therefore there is scarcity of data for the association between SCD and invasive bacterial diseases (5). So it becomes necessary to have knowledge of distribution of these pathogens and their susceptibility to antibiotics. Therefore this study was designed to identify the common bacterial infections in SCD patients and to study antibiotic susceptibility patterns of all the clinical isolates.
Descriptive observational study was conducted in the Department of Microbiology, Government Medical College and Hospital, GMCH Nagpur, Maharashta, India, for two years from October 2013 to October 2015. Ethical clearance was obtained from Institutional Ethical Committee (IEC) with approval number ECR/43/Inst/MH/2013. A written informed consent was obtained from parents or guardians of each enrolled subject who were willing to get enrolled in the study after explaining to them the nature of the study.
Sample size calculation: Sample size calculation formula for descriptive research studies is given by
Sample size n =
where
n = desired sample size
z1- α/2 = Critical value and a standard value for the corresponding level of confidence.
p = Expected prevalence or based on previous research
q = 1-p
d = Margin of error or precision
A descriptive study was employed to understand the prevalence bacterial infection among children with SCD. A previous study stated that bacterial infection among children with SCD was 16% (5). At 95% CI and 5% margin of error, the estimated sample size was 207. However 412 patients were enrolled in the study.
Inclusion criteria: Paediatric patients of age ≤12 years diagnosed as SCD and admitted in paediatric wards of tertiary care hospital, having body temperature ≥38.5oC.
Exclusion criteria: Patients with SCD who were admitted in paediatric wards for blood transfusion and patients who attended and managed at Outpatient Department (OPD).
Conventional Blood culture was done for SCD patients having fever i.e. body temperature ≥38.5oC. Urine culture was done for those SCD patients admitted in paediatric ward, with or without sign and symptoms of Urinary tract Infections (Table/Fig 1). CSF samples were collected for suspected cases of meningitis that is any person with sudden onset of fever and one of the following signs: neck stiffness, altered consciousness or other meningeal sign (6). Aspirated pus samples were collected for suspected cases of osteomyelitis which is defined as the presence of any two of these findings.
a. Presence of fever, pain, tenderness over involved bone and decreased range of motion in adjacent joints to move the limb.
b. Presence of pus on aspiration.
c. Radiological changes typical of osteomyelitis (7).
Processing of Specimens
Clinical specimen i.e. blood, urine, pus, and body fluids such as CSF, pleural fluids received in Department of Microbiology Laboratory were included in the study. The samples were transported to the lab and streaked on Blood agar, MacConkey agar and Chocolate agar medium. After the incubation period at 37oC, the culture plates were examined and bacterial isolates were observed by gram staining, motility test. Isolates were identified by standard biochemical tests (8). Antimicrobial susceptibility testing was performed and interpretation as sensitive, intermediate or resistant was done as per the CLSI guidelines 2013 by modified Kirby-Bauer method (9).
Quality control:
• Escherichia coli ATCC® 25922.
• Escherichia coli ATCC® 35218 (for β-lactam/β-lactamase inhibitor combination).
• Pseudomonas aeruginosa ATCC® 27853.
• Staphylococcus aureus ATCC® 25923 (disc diffusion).
MRSA Detection (9)
All the S. aureus isolates were subjected to cefoxitin disc diffusion test using a 30 μg disc. If the zone of inhibition around cefoxitin disc is ≥22 mm, it is said to be Methicillin Sensitive S. aureus (MSSA) where as if the zone of inhibition is ≤21 mm, organism is said to be Methicillin Resistant S. aureus (MRSA).
Testing for Extended Spectrum ß Lactamase (ESBL) among SCD paediatric patients (9).
ESBL was tested by applying the discs of ceftazidime (30 μg) and ceftazidime + clavulanic acid (30 μg + 10 μg) to the lawn culture of the test organism. If the zone of inhibition around ceftazidime clavulanic acid is ≥5 mm than the zone of inhibition around ceftazidime disc, then the test organism is said to be ESBL producer.
Testing for Metallo ß –Lactamase by Double Disc Synergy Test with EDTA (10)
MBL activity is inhibited by chelating agents. Double disc synergy tests using ceftazidime disc and a 2-mercaptopropionic acid disc (11), or an imipenem disc and Ethylenediaminetetra Acetic Acid (EDTA) disc (12) are the two simplest method to detect MBL producing bacterial isolates. Test strains were adjusted to McFarland 0.5 standard and used to inoculate Mueller Hinton agar plates. Two discs of 10 μg imipenem were placed on plate at 15 mm distance. To one of imipenem disc add 10 μL of 0.5 M EDTA .This disc contains 1900 μg of EDTA. After overnight incubation, zone of imipenem with EDTA should be >7 mm than plain imipenem disc to consider test to be positive. All isolates of Pseudomonas spp. which are imipenem resistant are tested for MBL production.
Statistical Analysis
The data has been collected in Microsoft Excel sheets and results were presented as count and percentage.
Out of the total 412 patients, 252 (61.17%) were males and 160 (38.83%) were females. The most common age group were 5-9 years 213 (51.70%) and ≤4 years 162 (39.32%). Fever was present in all the cases 412 (100%). Paleness of body 360 (87.38%) and jaundice 310 (75.24%) were the common symptoms whereas there was history of convulsion in 25 cases (6.06%). About 143 organisms were isolated from different samples including blood, urine, pus, CSF and pleural fluid. Among 143 organisms isolated, positive blood culture was detected in 84 (20.38%) cases which implies bacteraemia as the most common type of infection among children with SCD in present study, followed by UTI 55 (15.02%), Osteomyelitis 2 (13.34%), Pleural infection 1 (7.69%) and Meningitis 1 (5.56%) (Table/Fig 1).
Out of 824 samples, the total culture positive was 143 (17.35%). Out of 143 culture positive samples, maximum number were obtained from blood followed by Urine, Pus, Pleural fluid and CSF (Table/Fig 2).
Out of 143 organisms isolated from different samples, gram negative bacilli 106 (74.13%) were found to be the commonest cause of bacterial infections among children with SCD, followed by gram positive cocci in 37 (25.87%). Escherichia coli 47 (32.86%) was found to be the single most common organism isolated from different samples followed by Staphylococcus aureus 21 (14.68%) (Table/Fig 3).
Total 84 samples were positive for blood culture. Out of 84 organisms isolated from blood culture, gram negative bacilli, 56 (66.67%) were found to be the commonest cause of bacteraemia among children with sickle cell disease while Gram positive cocci were found in 28 (33.33%) cases (Table/Fig 4).
All the gram positive cocci in present study were 100% sensitive to vancomycin and linezolid. They showed good sensitivity towards Aminoglycosides; amikacin, gentamicin, tobramycin. There was low percentage, 12% of MRSA in bacterial isolates from children with SCD was observed (Table/Fig 5).
Gram negative bacilli showed low sensitivity to ampicillin, aztreonam, cefazolin, cefoperazone, ceftazidime. Most of them had a good sensitivity to piperacillin-tazobactum, imipenem, amikacin, gentamicin, tobramycin and ciprofloxacin (Table/Fig 6).
Out of 46 Enterobactericeae isolated from urine, we obtained 11 (23.91%) as ESBL producer. In these maximum ESBL production was shown by K. pneumoniae 2 (50%) followed by E.coli 9 (30%). Out of 45 Enterobactericeae isolated from blood, we obtained 11 (24.45%) as ESBL producer. In these maximum ESBL production was shown by K. pneumoniae 6 (46.15%) followed by E.coli 5 (31.25%) (Table/Fig 7).
A total of 14 non-fermenters (Pseudomonas aeruginosa (n=11) and Acinetobacter (n=3)) were isolated from different samples including blood, urine and pus. Pseudomonas aeruginosa and Acinetobacter baumannii showed a good sensitivity to amikacin, piperacillin-tazobactam and imipenem (Table/Fig 8).
In present study, prevalence of bacterial infections among patients with SCD was 17.35%. A study conducted in 2013 by Bansil NH et al., showed an incidence rate of 16.0% (5). A recent studies conducted by Alsaif MA et al., reported 6% of prevalence of bacterial infections among children with SCD (13), and in a study conducted in Cameron of children with SCD, the rate of bacterial infections was 9.7% (14). According to Alzahrani F et al., the rate of bacterial infection among febrile children with SCD was 8.6% (15).
Bacteraemia was the most common infection among febrile children with SCD. Present study detected 84 (20.38%) organisms in suspected cases of bacteraemia. Studies from Africa reported 47(28%) (16) and 14% cases of bacteraemia (17). According to study conducted by Williams TN et al., organisms such as Streptococcus pneumoniae and Haemophilus influenzae were the most common causes of bacteraemia (18).
Children with SCD have increased susceptibility to develop UTI because of altered blood flow in the renal vasculature which causes papillary necrosis and loss of urinary concentrating and acidifying ability of the nephrons with the consequent formation of abnormally dilute and alkaline urine which favours bacterial proliferation (19). Development of compromised renal function may occur due to recurrent UTI and repeated vaso-occlusive episodes (20). In present study, UTI were the second most common infection and 15.02% organisms were detected among febrile children with SCD. Iwalokun BA et al., from Nigeria, analysed 103 urine sample. Out of these, 15 grew bacteria significantly to yield a prevalence rate of 14.6% (21).
In present study, Osteomyelitis was found in 13.34% of cases. As in previous reports, osteomyelitis was uncommon and accounted for less than 5% of bacterial infections with SCD (14),(19),(22). Present study detected 5.56% organisms in suspected cases of meningitis. A low prevalence of meningitis was also reported in recent studies from Cameroon and Brazil (14),(23).
Gram negative bacilli 56 (66.67%) were found to be the commonest cause of bacteraemia among children with SCD while gram positive cocci were found in 28 (33.33%) isolates. Wierenga KJJ et al., also reported gram negative organisms as the predominant pathogen (24). Whereas Yee ME et al., reported S. pneumoniae as the most prevalent pathogen causing blood stream infection among children with SCD followed by E. coli (25).
The antimicrobial sensitivity of gram positive cocci isolated from blood culture in suspected cases of septicemia showed 100% sensitive to vancomycin and linezolid. MRSA was seen only in 12%. Jain et al., however reported very high percentage (50%) of MRSA from positive blood culture (26).
Total number of ESBL producers in urine and blood was 11 (23.91%) and 11 (24.45%) respectively. Elbashier AM et al., from Saudi Arabia, reported one case of ESBL shown by Salmonella typhi (3).
Gram negative bacilli (K. pneumoniae, K. aerogenes, C. freundii) isolated from blood in present study were 100% sensitive to imipenem and (K. aerogenes, C. freundii) were 100% sensitive to piperacillin-tazobactam. Similarly, Jain et al., also reported high sensitivity to piperacillin + tazobactam and imipenem (26).
This study can be useful in understanding the common bacterial infections among children with SCD and also helps in framing the empirical antibiotic policy for effective management of bacterial infections with SCD. Moreover, the use of appropriate antibiotics will minimise the risk of severe morbidity and mortality besides reducing the emergence of multidrug resistant organisms.
Limitation(s)
The present study evaluates only bacterial infection as a cause of febrile episode in SCD. Various infections (viral, fungal and parasitic) known to cause significant illnesses among the patients could not be evaluated because of limited resources.
Escherichia coli was found to be the single most common organism isolated from different samples followed by Staphylococcus aureus. The spectrum of pathogens isolated in the current study appears to be different from earlier studies where capsulated organisms like Streptococcus pneumoniae and Haemophilus influenzae were the most common organisms isolated. Present study observed that imipenem was the best antibiotic for infections with multidrug resistant gram negative bacilli. Bacterial infection remains a risk for SCD. Therefore screening of SCD patients from childhood for various infections and an understanding of the antibiotic susceptibility profile of such pathogens is crucial to the implementation of appropriate therapeutic and prophylactic measures and prevention of antibiotic resistance in future.
DOI: 10.7860/JCDR/2022/56049.16767
Date of Submission: Mar 02, 2022
Date of Peer Review: Apr 20, 2022
Date of Acceptance: May 28, 2022
Date of Publishing: Aug 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: Mar 09, 2022
• Manual Googling: May 20, 2022
• iThenticate Software: May 24, 2022 (18%)
ETYMOLOGY: Author Origin
- Emerging Sources Citation Index (Web of Science, thomsonreuters)
- Index Copernicus ICV 2017: 134.54
- Academic Search Complete Database
- Directory of Open Access Journals (DOAJ)
- Embase
- EBSCOhost
- Google Scholar
- HINARI Access to Research in Health Programme
- Indian Science Abstracts (ISA)
- Journal seek Database
- Popline (reproductive health literature)
- www.omnimedicalsearch.com