Bacteremia Associated with Pressure Ulcers at Alyarmuk Teaching Hospital in Baghdad

Fifty patients(24 female and 26 male)with pressure ulcersassociated with different diseasesand attending AL-yarmouk Teaching Hospital in Baghdad were selected in this study. The duration of sample collection was from March to December 2018. All blood samples collected from patients were submitted to a blood culturing technique to examine bacteremia. The results showed that12 blood bacterial isolates were obtained. The isolated bacteria were subjected to Vitek-2, which is an accurate identification technique. The results of the blood culturing technique revealed that 33.3% were Gram negative bacteria, while 66.6% were Gram positive. Diagnosis by Vitek-2 showed that 33.3% wereStaphylococcus spp. , 33.3% were Enterococcus spp. , 25.1% wereSerratiamarcescens and 8.3% comprised Acinetobacterbaumannii. The results of minimum inhibitory concentration (MIC)by Vitek-2showed that Trimethoprime –Sulfamethazole concentration at 320 μg\ml was the MIC for Acinetobacterbaumanni, while piperacilin, Ticarcillin, and Ticarcillin-Clavulanic acidat 128 μg\ml were the MIC for Serratia marcescens . Acinetobacterbaumanniishowed 100% resistance to all antimicrobial agents, while for the Serratiamarescenceresistancevalues were 54.55%, 54.55%, and 45.45% for isolate numbers 1, 2, and 3, respectively. Gram positive bacteria recorded NitrofurantionMIC of 256 μg\ml against Staphylococcus epidermidisand Enterococcus spp., withboth species showinghigh resistance compared with the others which had a value of87.50%.


Introduction
Pressure ulcers (PUs) are an injury to the skin or underlying tissue due to unrelieved pressure [1]. It is a serious health problem for the world, specifically toweakened geriatric or bed-bound patients in hospital [2].The symptomstypically range from skin redness to serious injuries to thebones or attached tissues,raisinga significant threat to patients with restricted mobility [3]. The prevalence of developed pressure sore is high in elderly people, appearing within those between the 70s and 80s decades. These ulcers appear in community setting, nursing homes and hospitals, with an incidence varying from 1.2% to 11.2% [4]. Pressure ulcers are generally followed by an inflammatory response andmostly bylocal bacterial colonization or systemic disease [5].
Risksof pressureulcers are correlated with remarkable morbidity and mortality with bacteria, which are the most prevalent complicating factors related with pressure ulcers [6]. PUs can serve as foci for blood infection asthe mostprevalent considerable Infected PUs complication. Patientsare often more probable to develop bacteremia [7]. The association between PUand bacteremia was related with 50 percent mortality rate in hospitalize d patients [8].Septicaemiaor secondary bacteremia can represent complications of the pressure ulcer where both of these situations are correlated with increased death [9]. Precise identification of bacterial isolates from blood at species level as well as accurate identification of portal of entry and/or thesource of infection are essential for the ideal management of such infections [10]. From 1995 to 2002, a database of a hospital in the United Statesrecognizedcoagulase negative staphylococcus (CoNS) as the most prevalent cause, responsible for 31 percent of cases [11].In recent years, the prevalence of Acinetobacterbaumanniibacteremia has increased significantly, particularly in immunocompromised populations and intensive care units [12]. Enterococci have recently become one of the most prevalent nosocomial pathogens, with an elevated mortality rate of up to 61% [13].Serratiamarcescens is considered as an opportunistic bacterium that causes a variety of human infections, including keratitis ,bacteremia, as well as urinary tract and wound infections [14].
The aim of this study is to detect bacteremia associated with pressure ulcers,along withtesting MIC values of several antibacterial agents.

Materials and methods Patients
Fifty patients (24 female and 26 male). 40% of patients between 70 and 80 years were included in this study suffering from pressure ulcer and another disease (30% heart disease, 18% lung disease, 16% kidney disease, 16% diabetic patients and the remaining percent for another disease) all these disease with a pressure ulcer were made the patients bed redden at department of medicine\ ALyarmouk teaching hospital and the patients diagnosed clinically by a physician for pressure ulcer and bacteremia.The duration of study from the march 2018 to December 2018.

Blood sample collection and bacteremia
The following guidelines were implemented rigidly when samples of blood were obtained for blood culture [15]: Whenever possible, blood sampleswere taken for culture before antimicrobial therapy was administered.ninemillilitres of blood was injected into a sterile bottle containing brain heart infusion broth culture.The same method was repeated to another blood sampletaken from separate sites over a duration of 10 min.Then, the bottles were incubated for 18-24 hours at 37 ° C.The presence of macroscopic alterations such as haemolysis, turbidity, cotton ball like colonies,and gas bubbles were screened during the next days.Gram staining was performedirrespective to the macroscopic indications of growth,whileblind subcultures ofblood and Macconkyagar were performed after 1,3,and 7 days.

Identification of bacterial isolates
Morphological identification was performed by examiningthe colonieson different mediaand by gram staining. The precise identificationwas achieved throughdiagnosis by vitek-2 system.

Antimicrobial screening of bacterial isolates
Antimicrobial screening test wasperformed by using vitek-2 system, with the susceptibility card for Gram positive bacteria was AST-P580 and that for Gram negative bacteria was AST-222. Interpretation of the results wascarried out using the criteria of the Clinical Laboratory Standards Institute (CLSI, 2018) [16].

Statistical Analysis:
The Statistical Analysis System-SAS (2012) program was used to detect the effects of differentfactors onstudy parameters [17]. Least significant difference -LSDtest was used to compare significant differences between means and Chi-square test was used to compare significant differences between percentages.

Resultsand Discussion
From 50 patients with pressure ulcer, 12 samples (24%) were blood culture positive and different types of bacterial isolates were isolated and stained (33.3%Gram negative bacteria and Gram positive 66.6%), as shown in Table-   Acinetobacterbaumanniishowed 100% resistance to all antimicrobial agents used in this study, while the resistance values for the Serratiamarescencewere54.55%, 54.55%, and 45.45% for isolates number 1,2, and 3, respectively, as shown in Table-3.     The bacterial isolate that had the highestbacterial resistance was S.epidermidis87.50%,withthe same percentage being recorded forEnterococcus spp. , as shown in Table-5.   Thomas (2006) on 21 sepsis syndrome with a attributable to pressure ulcers revealed that 76% had bacteremia resulted from pressure ulcer [18]. Another study by Bragaet al.(2017) revealed that,amongsixteen patients with infected pressure ulcer, 62.5% developed bacteremia [19]. These results demonstratedhigher proportions of bacteriemic patients than that recorded in our study, which was24%. The Gram negative bacteria associated with bacteremia: (Acinetobacterbaumannii andS. marescence)

Types of antibiotics
In our study,A. baumannii showed resistance to all antimicrobial agents.Thisresultis corresponding with other studies. A study by Yang et al.,(2018)showed that77.8% of the patients were multidrugresistant [20].In addition, China's antimicrobial resistance monitoring program has wide ly identified extensive drug resistance to A. baumannii (XDRAB) [21].
In the same study of Xuet al., (2016) Acinetobacterbaumanniiisolated from blood was resistant to Cefepime, Ceftazidime ,Ciprofloxacin, Gentamicin and Tobramycin this results correspond the current study results only the different in the isolatewas intermediately resistant to Meropenem, while in a present study was resistant to it [22]. The abilityofA. baumanniifor the acquisition of genetic resistance determinants is responsible for the development of MDR strains. Other resistance mechanisms include Beta-lactamases, changes in porin canals, efflux pump (responsible for resistance to beta lactam antibiotics), mutations in deoxyribonucleic acid topoisomerase (mediated resistance to quinolone), and genes coding aminoglycoside-modifying enzymes .In addition, oxacillinases and metallo-blactamases (e.g., blaOXA58andblaOXA24\40, blaOXA23, ) contribute to the resistance of carbapenem [23].
A retrospective cohort study was also previously performed,were 10 patients with one or more positive blood cultures for S. marcescenswere recordedin a tertiary care hospital in Seoul, South Korea, from January 2006 to December 2012 [24]. While in the present study, 3 patients with positive blood cultures of S. marcescens were recorded for the period from March 2018 to December 2018.
The majority of the isolates in a study by Kim et al., (2015) were susceptible tomeropenem, cefepime, and ceftazidime [24].While in this study, only 2 isolates weresensitive to meropenemsensitive and one isolate was sensitive to cefepime,whereasall isolates were resistant to ceftazidime.
Recent epidemiological analysisdemonstrated an increase in the rate of antimicrobial resistance among isolates of S.Marcescens. In contrast, the multidrug-resistant (MDR) strains of S. Marcescenswere linked with severe outcomes [25].

The Gram positive bacteria associated with bacteraemia
The most common bacteria associated with pressure ulcers were reported to be Enterococcus faecalis and Staphylococcus aureus [26]. The incidence of MRSA infections, particularly bacteremia, varies worldwide. In 2014, the proportio n of MRSA isolates in Europe ranged from 0.9% in the Netherlands to 56% in Romania [27].In a study on patients with coagulase-negative staphylococci(CoNS), three cases out of 56 (5.4%) of bacteremia were associated with pressure ulcers [28], whereas the proportion of those withCoNS was 10.09% [29] Enterococcus spp.was shown to be responsible for 3.6% of bacteremia associated with pressure ulcers [30].Enterococci have recently become one of the most prevalent nosocomial pathogens, with an elevated death rate of up to 61%.Enterococci are reported as the second most cause of urinary tract and wound infections and the third common cause of bacteraemia [31].In the UK,there were 7066 cases reported of bacteremia by Enterococcus species in 2005, reflecting an increase of 8% from 2004. E. Faecaliswas responsible for 63% of these cases,whereas28% were caused byE. Faecium. In addition, 80% of all cases were resistant to antibiotics. Also, it was reported that approximately 12 percent of nosocomial infections in the USA are caused by Enterococcus species [32].

Conclusions
Pressure ulcer is a serious health problem andbacteremiacould certainly be one of its dangerous complications. Appropriate antibiotic treatment should be selected in order to eradicate the infection associated with pressure ulcer and avoid bacteremia.