Antibiogram of Bacteria Isolated from Wounds of Diabetic Patients on Admission at Federal Medical Centre, Owerri, Imo State, Nigeria

Antibiogram of Bacteria Isolated from Wounds of Diabetic Patients on Admission at Federal Medical Centre, Owerri, Imo State, Nigeria
Antibiogram of Bacteria Isolated from Wounds of Diabetic
Patients on Admission at Federal Medical Centre, Owerri,
Imo State, Nigeria
*1
Anyadoh-Nwadike Sylvia O., 2
Okali Linda Onyekachi, 3
Offor Jovita Chioma, 4
Onu Onyinyechi S.
1,2,3
Department of Biotechnology, Federal University of Technology, Owerri, Imo State, Nigeria
4
Department of Science Laboratory Technology, Federal University of Technology, Owerri, Imo State, Nigeria
A major challenge faced by diabetic patients is infected diabetic ulcers usually associated with
substantial morbidity and mortality. Worse issues arise from antibiotic resistant microorganisms.
This study was conducted to determine the antibiogram of bacteria isolated from wounds of
diabetic patients on hospital admission. Nine wound swab samples were collected from nine
diabetic in-patients with ulcers. These were processed using standard protocols. Multi antibiotic
sensitivity discs (Gram negative and Gram positive) containing ten antibiotics respectively were
used. Total of 91 bacterial isolates were obtained belonging to five species. Staphylococcus
aureus was most predominant (34.07%) and Proteus mirabilis was the least isolated (7.69%).
Pseudomonas aeruginosa showed highest (100%) resistance to the antibiotics used, followed by
Proteus mirabilis (90%), Staphylococcus aureus (80%) and Escherichia coli (30%). Klebsiella
pneumoniae was 100% susceptible. Streptomycin was the most efficacious antibiotic while
Ciprofloxacin and Augmentin were the least. The level of resistance exhibited by these clinical
isolates is worrisome and likely to impede treatment outcomes. Streptomycin showed broad
spectrum activity and may be the best drug of choice for treating wounds in diabetic patients
however, there is need for antibiotic susceptibility testing and consideration of patient’s
physiologic disposition before introducing antibiotic regimen.
Keywords: Antibiogram, Diabetes, Pseudomonas aeruginosa, Staphylococcus aureus, Wounds, antibiotic resistance,
ulcers, in-patients
INTRODUCTION
Every wound provides a very conducive environment for
microorganisms to colonize, proliferate and subsequently
cause infection (Bowler et al., 2001; Aynalem et al., 2017).
When wounds are not properly taken care of, they become
vulnerable to infections.
Diabetic patients have a higher risk of developing infection
of wounds, Bhatia et al. (2003) and Restrepo et al., (2011)
reported that the reason for this vulnerability amongst
diabetic patients maybe as a result of altered host
response, poor glucose control and impaired leukocytes
function associated with vascular diseases. The white
blood cells of diabetic patients may even fail to destroy
pathogenic microbes because of fluctuating and elevated
blood sugar as well as hypoxia from poor circulation; this
can seriously increase risk of infection (Ihsan 2010).
One common infection associated with diabetes is diabetic
foot ulcer; ulceration of tissues of the foot associated with
neuropathy and/or peripheral artery disease in the lower
extremity of people with diabetes (Fahrum, 2017). The
mechanisms involved in the pathogenesis of this diabetic
foot disease are neuropathy, infection, microvascular
dysfunction and ischemia (Ankur et al., 2017). The
infection often starts superficially, but delayed treatment
*Corresponding Author: Anyadoh-Nwadike Sylvia
Onyinyechi, Department of Biotechnology, Federal
University of Technology, Owerri, Imo State, Nigeria.
E-mail: sylvia.anyadohnwadike@futo.edu.ng
Co-Author 2
E-mail: linnysprings@gmail.com
3
E-mail: jovitachiomaoffor@gmail.com
4
E-mail: Onyinyechi.onu@futo.edu.ng
Research Article
Vol. 6(1), pp. 172-178, March, 2021. © www.premierpublishers.org. ISSN: 0379-9160
World Journal of Microbiology

Anyadoh-Nwadike et al. 173
and impaired body defense mechanisms can make it
spread to other subcutaneous tissues and deeper
structures leading to dangerous complications such as
amputations (Hefni et al., 2013).
Diabetic foot infections are mostly polymicrobial. Many
microorganisms singly or in association with others are
frequently encountered in such wounds but the most
common seems to be the Gram positive cocci;
Staphylococci sp. (Vasanthan et al., 2018). Other common
microorganisms found in such wounds according to
Gadepalli et al., (2006) are: Escherichia coli, Proteus sp.,
Enterococcus sp. and Pseudomonas sp.
Microbial infections pose great risks to diabetic patients
but worse still with antibiotic resistant strains (Anyadoh et
al., 2011). Long ago, antibiotics were successfully used to
treat bacterial infections and diseases until, gradually the
issue of antibiotic resistance started becoming a very
alarming clinical crisis. With antibiotic resistance, an
antibiotic that was once used to treat a disease is no longer
effective against such disease, making it very difficult to
treat. This places a heavy burden on treatment/
management of the infected wounds. Production of a
variety of beta-lactamases, alterations in the antibiotic-
binding proteins/modification of target sites (Anyadoh-
Nwadike et al., 2018; Todar, 2020) and even increased
outer membrane permeability (Todar, 2020) are some of
the mechanisms by which microorganisms become
antibiotic resistant.
The aim of this study was to determine the antibiogram of
bacteria associated with diabetic wounds/ulcers of in-
patients at Federal Medical Center, Owerri, Imo State,
Nigeria during the study period. This aim was with a view
of providing baseline data for effective treatment/
management of the ulcers.
MATERIALS AND METHOD
Ethical Approval and Informed consent
Prior to sample collection, ethical approval was sought and
obtained from the institutional ethical review committee of
Federal Medical Center Owerri, Imo State with Reference
number; FMC/OW/AD.535/VOL.XII/Pg.234. The patients
were properly informed about the research and their
consent obtained before being recruited for the study.
Study subjects and sample collection
This study was done using nine (9) diabetic patients with
wounds who were on admission at the Federal Medical
Center, Owerri during the time of study. Pus
samples/specimen from wounds of the diabetic patients
were aseptically collected for this study and appropriately
labelled A to I (A, B, C, D, E, F, G, H, I) according to the
nine subjects. Surroundings of the wounds were first
disinfected with alcohol pads. Then the wound was
thoroughly cleaned with 100 ml sterile normal saline prior
to sample collection to avoid contamination of the swab
with normal skin flora after which the pus was collected
with sterile cotton swabs. The samples were labelled
appropriately and taken to the laboratory for analysis
within 30 minutes of collection.
Isolation and identification of bacteria
The pus swabs were streaked on Blood Agar, Nutrient
Agar and MacConkey Agar plates and incubated
aerobically for 24 h at 37oC. The observed bacterial
colonies were isolated in pure cultures and identified
morphologically, microscopically, and biochemically using
the methods of Sharma (2008). Gram staining was done
to differentiate between Gram positive and Gram negative
bacteria. The biochemical tests carried out to identify the
isolated bacteria include: catalase test, oxidase test,
citrate test, coagulase test, indole test and motility test.
Antibiotic Susceptibility testing / Antibiogram
Antibiotic susceptibility test was carried out using Kirby-
Bauer disc diffusion method on Muller Hinton Agar plates
using the modified method of Cheesbrough (2010). For
the Gram negative isolates, Gram-negative multi antibiotic
sensitive disc was used which contained the following
antibiotics: Ampicillin, Septrin, Peflacin, Ciprofloxacin,
Augmentin, Gentamycin, Tarivid, Ceporex, Nalidixic acid
and Streptomycin. For the Gram positive isolates,
commercial Gram positive multi antibiotic sensitivity disc
was used which contained the following antibiotics:
Norfloxacin, Chloramphenicol, Erythromycin, Ampiclox,
Ciprofloxacin, Gentamycin, Levofloxacin, Streptomycin
and Amoxicillin. The antibiotic discs were placed at equal
distance from the center of the plates and pressed gently
with forceps. The diameter of zones of inhibition were read
and recorded after incubation of 24 hours at 37oC with ruler
in mm and matched correctly with standard zone of
inhibition charts according to Clinical and Laboratory
Standards Institute (CLSI) (2017).
RESULTS
The results of the study are shown in Tables 1 to 5 below.
Isolation and identification of bacteria
A total of 91 bacterial isolates were obtained from the
wound swabs of the 9 patients. All specimen showed
polybacterial growth except specimen H (Table 1).
Characterization differentiated the isolates into 5 species
with one species being Gram positive and others Gram
negative (Tables 1 & 2).

World J. Microbiol. 174
Table 1: Characterization / Identification of pure cultures isolated from wound swabs from diabetic patients
Sample
Isolate
ID
(No)
Morphology
Gram
reaction
Catalase
Motility
Citrate
Oxidase
Indole
Coagulase
Probable
Organism
A
A1
(3)
Large, mucuoid, colourless and stringy
colonies
-ve rod in
capsule
+ - + - - - Klebsiella sp
A2
(5)
Smooth, mucoid colonies with blue-green
pigmentation
-ve rod + + + + + - Pseudomonas
aeruginosa
A3
(7)
Small, round, smooth, raised, and glistening
deep golden yellow colonies with beta
haemolysis on blood agar
+ve cocci + - + - - + Staphylococcus
aureus
B
B1
(5)
Smooth, raised, mucoid, pink coloured
colonies on MacConkey agar
-ve rod + + - - + - Escherichia coli
B2
(2)
Flat, swarming, colourless colonies with
rough edges on blood agar
-ve large
rod
+ + + - - - Proteus mirabilis
B3
(5)
pigmentation
aeruginosa
C
C1
(2)
Large , mucuoid, colourless and stringy
colonies
-ve rod in
capsule
C2
(6)
pigmentation
aeruginosa
C3
(6)
aureus
D
D1
(3)
D2
(7)
pigmentation
aeruginosa
E E1
(6)
E2
(8)
aureus
F
F1 (1) Large, mucuoid, colourless and stringy
colonies
-ve rod in
capsule
F2 (2) Smooth, mucoid colonies with blue-green
pigmentation
aeruginosa
F3 (4) Small, round, smooth, raised, and glistening
aureus
G G1
(2)
Flat, swarming, colourless colonies with
rough edges on blood agar
-ve large
rod
+ + + - - - Proteus mirabilis
G2
(6)
cream colonies with beta haemolysis on
blood agar
aureus
H H (2) Large , mucuoid, colourless and stringy
colonies
-ve rod in
capsule
I I (3) Large, swarming colonies -ve rod + + + - - - Proteus mirabilis
I2 (6) Smooth, raised, mucoid, pink coloured

Table 2: Summary of the number of bacteria isolated from diabetic foot infection
Bacterial Isolates Number of isolates Percentage (%)
Gram Positive Staphylococcus aureus 31 34.07
Gram Negative
Pseudomonas aeruginosa 25 27.47
Escherichia coli 20 21.98
Klebsiella sp. 8 8.79
Proteus mirabilis 7 7.69
Total 91 100
TABLE 3a: Antibiotic Susceptibility of Gram negative bacterial isolates from the wounds of diabetic patients
ZONES OF INHIBITION (mm)
Isolates ID AMP S SXT CIP AU CN PEF NA OFX CEP
Proteus mirabilis
B2
G1
I
0
17
0
15
0
15
0
20
0
15
13
14
0
0
0
0
11
19
0
21
11
0
0
0
0
11
0
0
0
0
Klebsiella sp.
A1
C1
F
H
0
14
15
17
19
17
20
20
18
17
17
25
20
21
16
25
16
18
17
21
15
16
20
20
17
15
19
15
0
20
25
19
20
19
23
18
0
18
16
16
Escherichia coli B1
D1
E1
I2
0
15
13
11
20
20
18
19
17
19
15
17
11
15
17
19
0
10
13
10
15
13
14
15
17
20
23
20
0
19
14
15
16
19
20
17
0
16
17
14
Pseudomonas
aeruginosa
A2
B3
C2
D2
F2
0
5
0
3
0
8
4
7
5
0
0
0
7
4
0
0
2
2
3
5
0
0
0
2
0
7
9
10
4
3
6
0
3
0
0
4
0
0
2
3
4
0
0
2
4
0
5
3
0
0
Key: AMP – Ampicillin; S – Streptomycin; SXT – Septrin; CIP – Ciprofloxacin; AU – Augumentin; PEF – Peflacin; NA –
Nalidixic acid; OFX – Tarivid; CEP – Ceporex
TABLE 3b: Antibiotic Susceptibility of Gram positive bacterial isolates from the wounds of diabetic patients
Isolate ID Zone of inhibition
S LEV E CIP CN NOR AML RD APX CHL
S. aureus
A3 17 11 13 0 0 0 0 0 0 0
C3 20 13 19 20 9 22 0 0 0 0
E2 17 0 18 0 0 0 0 0 0 0
F3 20 9 20 8 3 0 0 0 0 3
G2 18 15 12 14 0 0 0 0 0 0
Key: S – Streptomycin; LEV – Levofloxacin; E – Erythromycin; CIP – Ciprofloxacin; CN – Gentamycin; NOR – Norfloxacin;
AML – Amoxicillin; RD – Rifampin; APX – Ampiclox; CHL – Chloramphenicol
Table 4: Interpretation of the Antibiotic susceptibility pattern in percentage of the Gram negative bacterial isolates
S/
NO
Antibiotics Pseudomonas E. coli Klebsiella Proteus
S (%) I (%) R (%) S (%) I (%) R (%) S (%) I (%) R (%) S (%) I (%) R (%)
1 Ampicillin - - 100 - 25 75 25 50 25 33.33 - 66.67
2 Streptomycin - - 100 100 - - 100 - - 66.67 - 33.33
3 Septrin - - 100 100 - - 100 - - 33.33 - 66.67
4 Ciprofloxacin - - 100 - - 100 - 75 25 - - 100
5 Augmentin - - 100 - - 100 50 50 - - - 100
6 Gentamycin - - 100 50 50 - 100 - - 33.33 - 66.67
7 Peflacin - - 100 75 25 - 25 75 - 33.33 - 66.67
8 Nalixidic Acid - - 100 25 50 25 75 - 25 - - 100
9 Tarivid - - 100 100 - - 100 - - - - 100
10 Ceporex - - 100 - 75 25 - 75 25 - - 100
KEY: S – Sensitive, I – Intermediate, R- Resistant

Antibiotic susceptibility test results /Antibiogram
Most of the organisms were multidrug resistant with
Pseudomonas aeruginosa showing the highest (100%)
resistance. The least resistance was shown by Klebsiella
Sp. Streptomycin showed the best broad-spectrum
activities against both Gram positive (Tables 3b & 5) and
Gram negative bacteria (Tables 3a & 4).
Table 5: Antibiotic susceptibility pattern of the isolated
Gram-positive bacteria
S/No Antibiotics Staphylococcus aureus
S (%) I (%) R (%)
1 Streptomycin 100 - -
2 Levofloxacin - - 100
3 Erythromycin - 60 40
4 Ciprofloxacin - 20 80
5 Gentamycin - - 100
6 Norfloxacin 20 - 80
7 Amoxicillin - - 100
8 Rifampin - - 100
9 Ampiclox - - 100
10 Chloramphenicol - - 100
KEY: S – Sensitive, I – Intermediate, R- Resistant
DISCUSSION
Pus samples from nine (9) diabetic patients who had foot
ulcers (wounds) were examined microbiologically. A total
of 91 bacterial isolates were obtained from the nine
patients. The isolates fell into five (5) species; four (4)
Gram negative and one Gram positive (Tables 1 and 2).
More Gram negative bacterial species were isolated than
Gram positive bacteria; Staphylococcus aureus was the
only Gram-positive bacterium isolated (Tables 1 and 2).
This corroborated the works of Pappau et al., (2011),
Benwan et al., (2012) and even Reham et al., (2015) but
contradicted the works of Abdulrazak et al., (2005) and
Citron et al., (2007). This may imply a changing trend in
microorganisms associated with diabetic foot ulcers
having Gram-negative bacteria gradually replacing Gram-
positive bacteria.
Of the 91 bacterial isolates obtained, Staphylococcus
aureus was the most abundant isolate while Proteus was
the least (Table 2). This observation is similar to a study
carried out in Ranchi, India (Ankur et al., 2017) and in
concordance with the report of Kassam et al., (2017).
Anyadoh-Nwadike et al., (2011) explains that the
abundance of this organism especially in hospitals could
be attributed to its versatility and possibly because it is also
a normal flora of the skin, it can be deposited easily in the
hospital environment by patients, relatives of the patients,
visitors and even the health workers. Of the samples, eight
(8) had more than one infecting bacterial species implying
polybacterial /mixed infections while one sample (H) had
just one bacterial infection (Table 1); Lipsky et al., (2012)
and Zubair et al., (2010) in their findings observed mixed
infections in diabetic foot infections but in the study by
Joseph et al., (2013), none of the samples resulted in more
than one or two bacterial pathogens. According to Todar
(2020), most of the bacterial species isolated in this study
(Pseudomonas aeruginosa, Proteus mirabilis,
Staphylococcus aureus and Klebsiella sp.) are
opportunistic pathogen and mostly cause nosocomial
infections. This is not surprising as the subjects were on
hospital admission. The fact that the patients showed
diminished resistance may possibly be due to the already
underlying ailment (diabetes) was also a risk factor (Todar,
2020; Zubair et al., 2010).
The antibiotic susceptibility pattern of the Gram positive
bacteria (Staphylococcus aureus) showed that all S.
aureus isolates were very susceptible to Streptomycin
while showing 100% resistance to Levofloxacin,
Gentamycin, Amoxicillin, Ampiclox and Chloramphenicol
(Tables 3b and 5). Anyadoh-Nwadike et al., (2015)
however noted 28.9% and 48.3% susceptibility to
Gentamycin by S. aureus isolated from urine and high
vaginal swabs respectively. They also reported 47.1%
susceptibility of S. aureus to Amoxicillin. These reveal that
the antibiogram of the organism keeps changing and may
be linked to the environment from which it is isolated. It
also had high (80%) resistance to Ciprofloxacin (Tables 3b
and 5). A similar result was recorded in the work of
Aynalem et al., (2017) but a slight difference was observed
in a study carried out in Kano, Northwestern Nigeria
(Emmanuel and Magaji, 2011) where Staphylococcus
aureus was highly susceptible to Levofloxacin and showed
an intermediate result for Streptomycin. The reason for
the high resistance of Staphylococcus aureus to most of
the antibiotics may be because of their overuse as empiric
treatment option for any suspected Staphylococcal
infection. Secondly, Staphylococcus aureus can grow and
survive under harsh environmental conditions unlike many
organisms (Anyadoh-Nwadike et al., 2011).
Pseudomonas aeruginosa showed the highest resistance
(100%) to all the antibiotics (Tables 3a and 4). High
resistance was also observed in the work of Manikandan
and Prabhakaran (2015). Chikwendu et al., (2010),
Paranjothi and Dheepa (2010) and even Sujeet et al.,
(2016) have all recorded consistent resistance of
Pseudomonas aeruginosa to most of these antibiotics,
especially Ciprofloxacin. Pseudomonas aeruginosa has
been acclaimed a recalcitrant organism (Todar, 2020;
Zheng et al., 2019). E. coli showed a 100% resistance to
Ciprofloxacin and Augmentin but had a high resistance
(75%) to Ampicillin (Tables 3a and 4). Treating the
infections with these commonly used first line antibiotics
will therefore not affect these bacteria and the wound will
remain infected. Klebsiella showed no resistance to all the
antibiotics but this contrasts with the report of Ibiene et al.,
(2011) where Klebsiella showed the highest percentage of
resistance of all isolates. The quinolones including
ciprofloxacin are newer antibiotics known to be broad

spectrum in action, however, this study corroborates
reports from recent studies that these antibiotics are fast
losing the fight. Anyadoh-Nwadike et al., (2018) noted that
the molecular mechanism of such resistance to quinolones
involves modification of the quinolone on the DNA of the
bacteria which is the target sites of the quinolones.
Pseudomonas aeruginosa and Staphylococcus aureus
have been reported to be the most common organisms to
cause wound infection (Taiwo et al., 2002; Orji et al., 2009;
Shriyan et al., 2010) and the fact that they exhibit such rate
of antibiotic resistance calls for serious concern. It implies
a great demand on management of diabetic ulcers.
Several epidemiological studies indicate that antibiotic
resistance is increasing in clinical isolates (Todar, 2020;
Anyadoh-Nwadike et al., 2015). With increasing cases of
antibiotic resistance, diabetic patients who have wound
ulcers may have worsened conditions such as amputation
of lower extremity, systemic formation and even gangrene
formation. The use of combined antibiotics may be a
successful remedy for this problem. It is also crucial that
antibiotic susceptibility pattern of the specific infecting
bacterium be properly ascertained before a drug regimen
is proposed for the patient. The physiologic disposition of
the patient also must be considered.
CONCLUSION
This study has revealed a polymicrobial infection of
diabetic ulcers. It also revealed multidrug resistance by
pathogens especially opportunistic pathogens capable of
surviving with minimal nutritional requirements (Todar
2020; Ryan and Ray, 2004). Streptomycin and Septrin
and Tarivid were efficacious against the Gram negative
bacteria (Tables 3a and 4). while Streptomycin was very
effective against the Gram positive species (Tables 3b and
5). Streptomycin may therefore be said to be broad
spectrum in action against bacteria associated with
diabetic ulcers/wounds. The presence of multiple antibiotic
resistance was high especially among the most common
bacterial species associated with diabetic wounds;
Staphylococcus aureus and Pseudomonas aeruginosa
(Tables 4 and 5). This observation is very important in the
management of diabetic patients’ ulcers. It will also help
in developing an appropriate antibiotic treatment regimen
and thus, prevent the cases from getting worse. However,
there is need for antibiotic susceptibility testing and
consideration of patient’s physiologic disposition before
introducing antibiotic regimen.
CONFLICT OF INTEREST
Authors hereby declare that there is no known conflict of
interests.
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Accepted 2 September 2020
Citation: Anyadoh-Nwadike SO, Okali LO, Offor JC, Onu
OS (2021). Antibiogram of Bacteria Isolated from Wounds
of Diabetic Patients on Admission at Federal Medical
Centre, Owerri, Imo State, Nigeria. World Journal of
Microbiology, 6(1): 172-178.
Copyright: © 2021 Anyadoh-Nwadike et al. This is an
open-access article distributed under the terms of the
Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are cited.

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