See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/334670955

A Case Study on Multi Drug Resistant Infection

Article · January 2018

CITATIONS READS

0 163

3 authors, including:

Asha K Rajan s. Vedha Pal Jeyamani

Tamil Nadu Dr. M.G.R. Medical University Tamil Nadu Dr. M.G.R. Medical University
42 PUBLICATIONS   13 CITATIONS    70 PUBLICATIONS   18 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Observational Studies View project

Stress, Anxiety and depression rating among patients of different situ View project

All content following this page was uploaded by Asha K Rajan on 25 July 2019.

The user has requested enhancement of the downloaded file.

 CASE REPORT

A Case Study on Multi Drug Resistant Infection

Asha K Rajan1, Vedha Pal Jeyamani S1*, Senthilnathan B1, Balaji P1
Abstract: The resistance among innumerable microbial species to various antimicrobial drugs has materialized as a cause of
public health hazard all over the world at an alarming rate. Even though the development of multi drug resistant infection is a
natural phenomenon, the incongruous use of antimicrobial drugs, inadequate sanitary conditions, irrational usage of antibiotics
and underprivileged infection prevention and control practices contribute to emergence of multi drug resistant infection. Here
we presented a case on multidrug resistant infection, which seems to be a challenge for antibiotics. So the objective is to create
awareness regarding resistance and rational use of antibiotics to prevent multi drug resistant conditions.

INTRODUCTION Contributing factors are incorrect diagnosis,

Antibiotics are manufactured at an estimated scale of about
100,000 tons annually worldwide and their use had a
profound impact on the life of bacteria on earth. More
strains of pathogens have become antibiotic resistant and
some have become resistant to many antibiotics and
chemotherapeutic agents, the phenomenon of multidrug
resistance. [1] An even more serious threat may be the
emergence of gram-negative pathogens that are resistant to
essentially all of the available agents. [2]
Antibiotic resistance is the ability of a microorganism to
withstand the effects of an antibiotic. The spread of
antibiotic resistance and the appearance of multiple
antibiotic-resistant pathogenic bacteria is an increasingly
prevalent problem that complicates the care of many
patients. It is a specific type of drug resistance which
evolves naturally via natural selection through random
mutation. [3] More surprisingly, there is a paucity of
knowledge of the natural biological functions of antibiotics
and the evolutionary and ecological aspects of their
chemical and biological reactions remain topics of
considerable interest and value. [3]
The pharmacist role in combating and preventing
infectious diseases is essential as antibiotic regimens
become more complex due to continuously evolving
epidemiology of infections. The decrease in drug
development makes the preservation of currently available
antibiotics paramount, highlighting the roles that
pharmacists play in maximizing the utility of available
drugs. [4]
Pharmacists directed antibiotic stewardship programs
(ASP’s) have proliferated considerably in the past decade. It
evolved the pharmacist to educate on pathways for
appropriate empiric use of antibiotics, avoiding chronic or
long term antibiotic prophylaxis, minimizing the use of
broad-spectrum antibiotics. [5, 6]
Pharmacist may counsel patients on viral infections;
futility of anti-bacterial for them and recommends
appropriate OTC (over the counter) products for
supportive cure. Pharmacists are crucial to promoting
currently available vaccines. [7] Vaccines can decrease the
use of antibiotics directly by preventing primary infection
and indirectly by preventing bacterial super-infection after
a primary vaccine-preventable illness. [8]
1Department of Pharmacy Practice, Jaya College of Paramedical Sciences,
College of Pharmacy, Thiruninravur, Chennai-602024, Tamil Nadu, India.
E-mail: swetha21112000@gmail.com
*Corresponding author
unnecessary prescriptions, improper use of antibiotics by
patients and use of antibiotics as livestock food additives
for growth promotion. [9] The following case demonstrates
the perplexity of managing resistance against few
antibiotics on treating an infection due to Klebsiella and
Staphylococcussp in fracture of shaft of both bones of the
left leg.
CASE REPORT
A 48 year old male was admitted to the Orthopedic
Department of General Hospital, Tiruvallur, Chennai, with
fracture of shaft of both bones of the left leg in a Road
Traffic Accident. His General Examination revealed that he
was conscious, oriented and febrile. Pulse rate, Blood
Pressure and other vital signs were seems to be normal.
Systemic Examination revealed normal functioning of all
System, Patient was moderately built. The patient was
smoker and chronic alcoholic for 10 years and on mixed
diet. The patient was an illiterate and lives on low social
status.
The patient past medical history clearly reveals the
irrational use of antibiotics and OTC (over the counter)
medications for all health alignments. The patient was not a
known case of DM (Diabetes mellitus), HTN
(Hypertension), BA (Bronchial asthma) and Epilepsy. The
patient has a normal sleep pattern and bowel - bladder
habits.
He has been admitted for the past 2 months in the
hospital with his wound left open due to its delay in
healing, leading him to be at high-risk for colonization by
resistant organisms which place them at higher risk for
systemic infections. Still the infection shows null
improvement.
Blood cultures of the wound infection reveals presence
of Klebsiella and Staphylococcus sp. His blood culture report
provides impression that the samples are highly sensitive
to amikacin (30 mcg), gentamycin (10 mcg), norfloxacin
and chloramphenicol and was resistant to ampicillin (10
mcg) and amoxicillin.
From his x-ray reports and examination of lower left
limb, it indicated a Grade I compound + fracture of shaft of
both bones of the left leg and was planned for Open
Reduction and Internal Fixation (ORIF) / Close Reduction
and Internal Fixation (CRIF) with Nailing. The ECG reports
were normal.
His lab investigations revealed decreased PCV,
hemoglobin and an increase in monocytes, blood urea

Inventi Rapid: Pharmacy Practice Vol. 2018, Issue 1 1 2018 ppp 24144 © Inventi Journals (P) Ltd
[ISSN 0976-3848] Published on Web 09/10/2017, www.inventi.in
 CASE REPORT

Table 1: Serological and Hematological Investigations

S. No. Parameter Patient Value Inference

1 Hb 11.4 gm/dl ՝
2 PCV 35.5 % ՝
3 Tc 7000 cumm Within limits
4 Neutrophils 52.6% Within limits
5 Lymphocytes 31.6% Within limits
6 Monocytes 15.8% ՛
7 MCV 91.3 fl Within limits
8 MCH 31.9 pg Within limits
9 MCHC 34.9 g/dl Within limits
10 RBC 3.89 X 106 μl Within limits
11 RBS 97 mg/dl Within limits
12 Blood urea nitrogen 26 mg/dl ՛
13 Serum creatinine 0.6 mg/dl Within limits
Hematological reports:
1 Blood group O+ve -
2 Bleeding time 1 min 25 sec Within limits
3 Clotting time 4 min 40 sec Within limits
Serological Investigations:
1 HIV Negative -
2 VDRL Negative -
Culture Susecptibility:
1 Culture Analysis Klebsella and staphylococcus aures
2 Highly sensitive to Amikacin, Gentamycin, Norfloxacin, Chloramphenicol
3 Resistant to Ampicillin, Amoxycillin
ECG Reports:
ECG Normal

Figure 1: Problems associated with multidrug resistant infections

Figure 2: Patients image

nitrogen. The patient was initially treated with antibiotics DISCUSSION

like cefotaxime 1g, IM (12 hrs/ once), Inj. Amoxicillin (500
mg/8hrs) and after multiple culture reports it was
switched over to IV Cepholexin (500 mg/ TID), IV.
Amikacin (15 mg/kg/BD/Day), Norfloxacin (400 mg) in
addition to the old ones.
The emergence and spread of microorganisms with multi-
drug resistance is currently considered as a major public
health concern, given its growing incidence in both
hospitals and communities. In a patient exposed to
antibiotics, resistant organisms may emerge by natural

Inventi Rapid: Pharmacy Practice Vol. 2018, Issue 1 2 2018 ppp 24144 © Inventi Journals (P) Ltd
[ISSN 0976-3848] Published on Web 09/10/2017, www.inventi.in
 CASE REPORT
Figure 3: Remedies of multi drug resistant infections
selection through the expansion of subpopulations
generated spontaneously. [10]
The present case is a classic resistant feature upon
irrational use of OTC drugs and improper therapeutic
regimens for infections without the advice of medical
professionals. The patient was poorly aware about the
antibiotic usage and resistance patterns due to his
educational status and low social economic status which
was the same scenario studied made by Wiedeman and
Lorian et al., [11] and documented under susceptibility to
antibiotics: species incidence and trends.
We have highlighted this case to prevent the threat of
resistance and to promote awareness which is the stepping
stone for rational drug usage. The remedies of multi drug
resistance is explained in Figure 3, as a consequence of
antibiotic overuse and misuse, nosocomial infections
caused by multidrug-resistant bacteria exemplify a
terrifying issue throughout the world.
No newer antimicrobials active against Pseudomonas
aeruginosa, the main multidrug-resistant nosocomial
pathogen, are accessible or under investigation. The only
exceptions are linezolid, some newer glycopeptides
(Dalbavancin, Oritavancin and Telavancin) and Daptomycin
(a lipopeptide), which are active against methicillin-
resistant Staphylococcus aureus (MRSA) and Vancomycin-
resistant Enterococcus (VRE) strains, as well as Tigecycline,
a potent in-vitro glycylcycline against MRSA, VRE,
Acinetobacter baumannii and extended spectrum beta-
lactamase (ESBL)+ Enterobacteriaceae as discussed by
Giamarellou et al., [12] in his study describing treatment
options for multidrug-resistant bacteria.
Table 1 explains the physical and systemic examination
along with his ECG reports which show normal
interference except microbial infection which is multi drug
Inventi Rapid: Pharmacy Practice Vol. 2018, Issue 1
[ISSN 0976-3848]
resistant. The patient was counseled with necessary
information regarding rational drug usage therapy and was
advised to avoid over the counter drugs usage without
medical supervision.
The open wound was under observation for recovery,
so as a pharmacist perspective the infection should be
treated with multi drug regimen with a proper duration of
course to prevent resistance. Blood sugar investigations
(Table 1) states that the patient is not an diabetic and have
normal blood glucose levels, but still the infection is multi-
resistant and challenging which is due to the life style,
improper usage of antibiotics which was discussed by Siby,
Simi et al., [13] in their study on antibiotic resistance. The
infection has to be frequently examined with culture
reports to have a proper check and patient counseling has
to be done on his review visit to improve patient
compliance and to ensure quality of life.
The more often the patient has a course of antibiotics
the more opportunity that patient’s bacteria have to
develop multiple or ongoing resistance. Similar approach
was made by Naomi et al., [14] stating the antibiotic
resistance and emerging need of the pharmacist to control
the antibiotic resistance by proper counseling methods.
Professional medical advice - especially when patients are
delivered with advice on what to anticipate with respect to
the course of the illness, including a realistic recovery time
and self-management strategies - has been shown to
impact on patients’ perceptions and attitude towards their
illness and their perceived need for antibiotics.
CONCLUSION
Pharmacist must be proactive in regard to educate the
public about important infection-control practices such as
general hygiene, hand-hygiene, cough etiquette,
3 2018 ppp 24144 © Inventi Journals (P) Ltd
Published on Web 09/10/2017, www.inventi.in
 CASE REPORT
immunizations. Community pharmacists have a critical role
to play in combating antibiotic resistance as front line
practitioners who can educate and vaccinate patients. This
case report accentuated the need of health care centers and
providers for improvements on microbiological
laboratories in a hospital or medical center. In addition,
intervallic antibiotic resistance surveys could also help all
health care providers as well as the local population on the
best treatment stratagems.
REFERENCES
1. Hiroshi Nikaido, Multidrug resistant bacteria. Annu Rev
Biochem, 78:119–146, 2009.
2. Livermore D M. The need for new antibiotics. Clin Microbiol
Infect, 10(Suppl 4):1–9, 2004.
3. Julian Davies and Dorothy Davies. Orgins and evaluation of
antibiotic resistance, Microbiol Mol Biol Rev, 74(3):417–433,
2010.
4. Dorothy McCoy, Kimberly Toussaint, Jason C Gallagher. The
pharmacist's role in preventing antibiotic resistance. US
Pharm, 36(7):42-49, 2011.
5. Dellit T H, Owens R C, McGowan J E Jr. Infectious diseases
society of America and the society for healthcare
epidemiology of America guidelines for developing an
institutional program to enhance antimicrobial stewardship.
Clin Infect Dis, 44(2):159-177, 2007.
6. Gross R, Morgan A S, Kinky D E. Impact of a hospital-based
antimicrobial management program on clinical and economic
outcomes. Clin Infect Dis, 33(3):289-295, 2001.
7. World health organization, Geneva, The rational use of drugs,
Report of the Conference of Experts, Nairobi, 25-29 November
1985.
8. Diane Ashiru-Oredope, Naomi Fleming, David Ladenheim, The
role of the pharmacist in antimicrobial stewardship. Hospital
Pharmacy Europe. Available from
http://www.hospitalpharmacyeurope.com/patient-
safety/role-pharmacist-antimicrobial-stewardship.
Inventi Rapid: Pharmacy Practice Vol. 2018, Issue 1
[ISSN 0976-3848]
View publication stats
9. Knobler S L, Lemon S M, Najafi M. The resistance phenomenon
in microbes and infectious disease vectors: implications for
human health and strategies for containment: Workshop
Summary. Factors Contributing to the Emergence of
Resistance. National Academies Press (US), Washington (DC),
2003.
10. Martinez J L, Baquero F, Andersson D I. Predicting antibiotic
resistance. Nat Rev Microbiol, 5:958–65, 2007.
11. Wiedeman B G H, Lorian V. Susceptibility to antibiotics:
species incidence and trends, Williams & Wilkins, Baltimore,
1996.
12. Giamarellou H, Treatment options for multidrug-resistant
bacteria. Expert Rev Anti Infect Ther, 4(4):601-18, 2006.
13. Siby Joseph, Simi George, Sonal Shekar M, Meera N K.
Antibiotic resistance – A Global threat to human society.
International Journal of Pharma research, 3(1):01-03, 2012.
14. Naomi Fleming, Sue Barber and Diane Ashiru-Oredope.
Pharmacists have a critical role in the conservation of effective
antibiotics. The Pharmaceutical Journal,
http://www.pharmaceutical-journal.com/news-and-
analysis/pharmacists-have-a-critical-role-in-the-conservation
-of-effective-antibiotics/11086917.article.
Acknowledgment
The authors are thankful to the patient who gave his consent
and cooperation for this study. The authors are grateful to Dr.
K Ajay Karthick. Orthosurgeon, Govt Hospital, Thiruvallur for
his support and encouragement throughout the study.
Cite this article as: Asha K Rajan, Vedha Pal Jeyamani S,
Senthilnathan B et al. A Case Study on Multi Drug
Resistant Infection. Inventi Rapid: Pharmacy Practice,
2018(1):1-4, 2017.
4 2018 ppp 24144 © Inventi Journals (P) Ltd
Published on Web 09/10/2017, www.inventi.in