Introduction: Bloodstream infections (BSIs) are associated with a high mortality rate of 20%-50%. Blood culture is paramount to identify causative agents of BSIs to choose an appropriate antimicrobial therapy. Objectives: The present study was undertaken to analyze the various microorganisms causing BSIs and study their antimicrobial resistance patterns in a tertiary care hospital, Eastern India. Materials and Methods: A total of 239 blood specimens from clinically suspected cases of BSIs were studied for 6 months from July 2015 to December 2015. Blood specimens were incubated in BacT/ALERT ® 3D system (bioMerieux, Durham, NC, USA) a fully automated blood culture system for detection of aerobic growth. Identification and antimicrobial susceptibility testing were conducted on VITEK ® 2 (bioMerieux, Durham, NC, USA) as per Clinical Laboratory Standards Institute guidelines. Results: Out of 239 specimens, 41 (17.2%) yielded growth of different microorganisms. From these isolates, 20 (48.8%) were Gram-negative bacilli, 18 (43.9%) were Gram-positive cocci and rest 3 (7.3%) were yeasts. Among Gram-negative bacilli, Klebsiella pneumoniae sub spp. pneumoniae (70%) was most commonly isolated. Coagulase-negative staphylococci (88.9%) were the most common isolate among Gram-positive cocci. All three Candida spp. isolated were nonalbicans Candida (two Candida tropicalis and one Candida krusei). Gram-negative isolates were least resistant to tigecycline and colistin. All Gram-positive cocci were sensitive to linezolid. Conclusion: Monitoring of data regarding the prevalence of microorganisms and its resistance patterns would help in currently prescribing antimicrobial regimens and improving the infection control practices by formulating policies for empirical antimicrobial therapy.

1. ISSN - 0000-0000
International Journal of
Health & Allied Sciences
www.ijhas.in
Volume 5 / Issue 4 / October-December 2016
Official Publication of JSS University, Mysore
IJHAS
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2. © 2016 International Journal of Health & Allied Sciences | Published by Wolters Kluwer ‑ Medknow210
INTRODUCTION
Bloodstream infections (BSIs) are associated with a high
mortality rate of 20%–50% and one of the most common
health‑care associated infections.[1]
It requires rapid
and aggressive antimicrobial therapy.[2]
The change of
prevalence and antimicrobial resistance pattern among
bloodstream pathogens is a significant problem worldwide
with severe consequences including increased cost of care,
morbidity, and mortality.[1,3]
The increasing resistance to
most commonly used antimicrobials results in a reduction
in therapeutic options.[3]
Thus, the detection of BSIs must be
given priority in all health‑care settings. Clinical laboratory
Bacteriological profile and antimicrobial resistance
patterns of bloodstream infections in a tertiary
care hospital, Eastern India
Muktikesh Dash, Rakesh Kumar Panda, Dharitri Mohapatra, Bimoch Projna Paty, Gitanjali Sarangi,
Nirupama Chayani
Department of Microbiology, Shri Ramachandra Bhanj Medical College and Hospital, Utkal University, Cuttack, Odisha, India
Original Article
ABSTRACT
Introduction: Bloodstream infections (BSIs) are
associated with a high mortality rate of 20%–50%.
Blood culture is paramount to identify causative agents
of BSIs to choose an appropriate antimicrobial therapy.
Objectives: The present study was undertaken to analyze
the various microorganisms causing BSIs and study
their antimicrobial resistance patterns in a tertiary care
hospital, Eastern India. Materials and Methods: A total
of 239 blood specimens from clinically suspected
cases of BSIs were studied for 6 months from July
2015 to December 2015. Blood specimens were
incubated in BacT/ALERT®
3D system (bioMerieux,
Durham, NC, USA) a fully automated blood culture
system for detection of aerobic growth. Identification
and antimicrobial susceptibility testing were conducted
on VITEK®
2 (bioMerieux, Durham, NC, USA) as per
Clinical Laboratory Standards Institute guidelines.
Results: Out of 239 specimens, 41 (17.2%) yielded
growth of different microorganisms. From these isolates,
20 (48.8%) were Gram‑negative bacilli, 18 (43.9%) were
Gram‑positive cocci and rest 3 (7.3%) were yeasts.
Among Gram‑negative bacilli, Klebsiella pneumoniae
sub spp. pneumoniae (70%) was most commonly
isolated. Coagulase‑negative staphylococci (88.9%)
were the most common isolate among Gram‑positive
cocci. All three Candida spp. isolated were nonalbicans
Candida (two Candida tropicalis and one Candida krusei).
Gram‑negative isolates were least resistant to tigecycline
and colistin. All Gram‑positive cocci were sensitive to
linezolid. Conclusion: Monitoring of data regarding
the prevalence of microorganisms and its resistance
patterns would help in currently prescribing antimicrobial
regimens and improving the infection control practices by
formulating policies for empirical antimicrobial therapy.
Key words: Bloodstream infections, coagulase
negative staphylococci, colistin, Klebsiella pneumoniae
sub spp. pneumoniae, linezolid, nonalbicans Candida
Access this article online
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DOI:
10.4103/2278-344X.194083
How to cite this article: Dash M, Panda RK, Mohapatra D,
Paty BP, Sarangi G, Chayani N. Bacteriological profile and antimicrobial
resistance patterns of bloodstream infections in a tertiary care hospital,
Eastern India. Int J Health Allied Sci 2016;5:210-4.
This is an open access article distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as the
author is credited and the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com
Address for correspondence: Dr. Muktikesh Dash,
Department of Microbiology, Shri Ramachandra Bhanj Medical College and
Hospital, Utkal University, Cuttack ‑ 753 007, Odisha, India.
E‑mail: mukti_mic@yahoo.co.in

3. International Journal of Health & Allied Sciences • Vol. 5 • Issue 4 • Oct‑Dec 2016 211
Dash, et al.: Bacteriological profile and antimicrobial resistance patterns of BSIs
diagnosis is crucial to avoiding delay in treatment.[4‑6]
Blood
culture is paramount to identify causative agents of BSIs
to choose an appropriate antimicrobial therapy. In the
Intensive Care Unit, the main causative agents of BSIs
are Staphylococcus sp., Staphylococcus aureus, Pseudomonas
aeruginosa, Escherichia coli, Klebsiella pneumoniae, Proteus
mirabilis, Enterococcus faecalis, Acinetobacter baumannii, and
Candida spp.[7,8]
The use of automated culture system for
monitoring blood cultures increases the speed and improves
efficiency in detection of blood borne pathogens. The
system monitors the consumption of carbon dioxide by
calorimetric method, generally detecting positive growth
after 48 h.
The infections caused by multidrug‑resistant organisms
are more likely to be associated with prolonged hospital
stay, increased mortality and thus requires treatment
with more expensive antimicrobials. In almost all cases,
antimicrobial therapy is initiated empirically before the
results of blood culture are available. Monitoring and
analyzing the antimicrobial resistance pattern of most
frequently isolated microorganisms help the clinicians to
choose effective antimicrobial therapy as well as empirical
antimicrobials. Therefore, the present study was undertaken
to analyze the various microorganisms causing BSIs and
study their antimicrobial resistance patterns in a tertiary
care hospital, Eastern India to guide the clinicians for
formulating antimicrobial policies for empirical therapy.
MATERIALS AND METHODS
A total of 239 blood specimens from clinically suspected
cases of septicemia were studied at a tertiary care hospital
of Eastern India for 6 months from July 2015 to December
2015. Septicemia is defined as a systemic disease caused
by the spread of microorganisms and their toxins via
the circulating blood. Patients presented with sepsis
showed a diversity of clinical signs, i.e. body temperature
higher than 38°C (100.4°F) or lower than 36°C (96.8°F),
heart rate >0 beats/min, respiratory rate >20/min,
hyperventilation (PaCO2
<32 mmHg), and white blood
cell count >12,000/µl or <4000/µl were included as
cases.[9]
The study was conducted after due approval from
Institutional Review Board. Single blood specimen was
collected from inpatients admitted in our hospital during
the study, and the specimens were processed in clinical
microbiology laboratory. The contaminated, duplicate,
and repeat specimens were excluded from the study. Before
the collection of blood samples, verbal informed consent
was sought. Blood sample was collected aseptically from
each patient before the start of antimicrobial therapy.
In case of adults, 5–10 ml (average 7 ml) and pediatrics
1–5 ml (average 3 ml) were inoculated in BacT/ALERT®
FA and PF plus‑aerobic bottles (bioMerieux, Durham,
NC, USA), respectively. The microorganisms were
detected as per manufacturer’s instructions.[10]
In brief, after
inoculation, these bottles were immediately incubated in
BacT/ALERT®
3D system (bioMerieux, Durham, NC,
USA) a fully automated blood culture system for detection
of aerobic growth in blood samples. The blood specimens
were incubated for a maximum period of 7 days, and
if there was no growth, the result was read as negative.
While in case of positive growth, the BacT/ALERT®
system (bioMerieux, Durham, NC, USA) automatically
showed an alert. Then the positive blood culture bottles
were taken out and subcultured on blood agar and
MacConkey agar plates. From the colonies that were grown
on blood agar and MacConkey agar, 0.5% McFarland
suspension was prepared and which was then subjected to
identification and antimicrobial susceptibility testing on
VITEK®
2 (bioMerieux, Durham, NC, USA) as per Clinical
Laboratory Standards Institute (CLSI) guidelines and
manufacturer’s instructions.[11]
The antimicrobial resistance
was determined by VITEK®
2 system (bioMerieux, Durham,
NC, USA) as per CLSI guidelines.
RESULTS
During the study of 6 months, a total of 239 blood culture
specimens were received from various clinical wards.
Out of 239 specimens, 41 (17.2%) yielded growth of
different microorganisms [Table 1]. From these isolates,
20 (48.8%) were Gram‑negative bacilli, 18 (43.9%) were
Gram‑positive cocci and rest 3 (7.3%) were yeasts. Out of 20
Gram-negative and 20 Gram-positive respectively negative
isolates, 14 (70%) were K. pneumoniae sub spp. pneumoniae
and rest 6 were single isolate each of Acinetobacter lwoffii,
Acinetobacter haemolyticus, A. baumannii, Burkholderia
cepacia, Pantoea agglomerans, and P. aeruginosa. From 18 g
positive isolates, 7 (38.9%) were Staphylococcus hominis sub
spp. hominis, 5 (27.8%) were Staphylococcus haemolyticus,
4 (22.2%) were S. epidermidis and rest were single isolates
each of S. aureus and Enterococcus faecium [Table 2]. The
antimicrobial resistances patterns of Gram‑negative bacilli
showed, the majority of isolates were resistant to ß‑lactam
antibiotics, followed by aminoglycosides and quinolones.
These isolates were least resistant to tigecycline and
colistin [Figure 1]. The antimicrobial resistances patterns
of Gram‑positive cocci showed most of the isolates were
resistant to penicillin, oxacillin, and erythromycin followed
by clindamycin, rifampicin, daptomycin, and quinolones.
The Gram‑positive cocci were least resistant to vancomycin,
teicoplanin, and tigecycline and all isolates were sensitive to
linezolid [Figure 2]. Similarly, all three nonalbicans Candida

4. International Journal of Health & Allied Sciences • Vol. 5 • Issue 4 • Oct‑Dec 2016212
Dash, et al.: Bacteriological profile and antimicrobial resistance patterns of BSIs
were sensitive to voriconazole, caspofungin, micafungin,
and amphotericin B [Figure 3].
DISCUSSION
BSI is a major cause of morbidity and mortality worldwide.
Antimicrobial therapy is the mainstay of treatment of BSI
along with management of severe sepsis and septic shock.[12]
During last few years, clinicians have witnessed a growing
incidence of BSIs along with resistance against commonly
used antimicrobials.[13]
Therefore, this present study was
undertaken to detect the prevalence of microorganisms
isolated from blood and study their antimicrobial resistant
patterns in a tertiary care hospital, Eastern India.
From 239 blood specimens (201 pediatric and 38 adults)
cultured in automated blood culture system, our study
detected 41 (17.2%) growth of different microorganisms.
Although the reason for more number of pediatric patients
were tested for BSIs not quite clear, one of the reasons may
be due to fact that in pediatric age group both the innate and
adaptive immune functions are not immunologically mature
thus they are susceptible to infections.[14]
The prevalence rate
of BSIs in our hospital was 17.2%. The similar prevalence
rate of 16% BSIs was observed by Fayyaz et al. in a tertiary
care setting in Rawalpindi, Pakistan.[15]
In contrast, the high
prevalence rate of 28.9% and 42% were reported by Parihar
et al. and Ramana et al. from Western Rajasthan, India,
and South India, respectively.[16,17]
Prevalence rate varies
among different geographical regions as well as the type of
antimicrobials prescribed. The majority of patients reported
to our tertiary care hospital were referred by primary and
secondary care hospitals and private hospitals, and most
of these patients were already received antimicrobials
elsewhere before they reached our hospital. Furthermore,
the patients those were admitted to emergency sometimes
had received antimicrobials before collection of blood for
Table 1: Overall adult and pediatric blood culture results
(n=239)
Result Adults (%) Pediatrics(%) Total (%)
Growth of
microorganisms
5 (2.1) 36 (15.1) 41 (17.2)
No growth (sterile) 33 (13.8) 165 (69) 198 (82.8)
Total 38 (15.9) 201 (84.1) 239 (100)
Table 2: Distribution of microorganisms isolated from
blood cultures (n=41)
Gram reaction Microorganisms n (%)
Gram‑negative
bacilli
Klebsiella pneumoniae sub spp.
pneumoniae
14 (34.2)
Acinetobacter lwoffii 1 (2.4)
Acinetobacter haemolyticus 1 (2.4)
Acinetobacter baumannii 1 (2.4)
Burkholderia cepacia 1 (2.4)
Pantoea agglomerans 1 (2.4)
Pseudomonas aeruginosa 1 (2.4)
Gram‑positive
cocci
Staphylococcus hominis sub spp.
hominis
7 (17.2)
Staphylococcus haemolyticus 5 (12.3)
Staphylococcus epidermidis 4 (9.8)
Staphylococcus aureus 1 (2.4)
Enterococcus faecium 1 (2.4)
Gram‑positive
yeasts
Candida tropicalis 2 (4.9)
Candida krusei 1 (2.4)
Total 41 (100)
Figure 1: Drug-resistant patterns of Gram-negative bacilli (%)
Figure 2: Drug-resistant patterns of Gram-positive cocci (%)
Figure 3: Drug-resistance patterns of yeast isolates (%)

5. International Journal of Health & Allied Sciences • Vol. 5 • Issue 4 • Oct‑Dec 2016 213
Dash, et al.: Bacteriological profile and antimicrobial resistance patterns of BSIs
culture. From 41 microorganisms isolated in our study,
20 (48.8%) were Gram‑negative bacilli, 18 (43.9%) were
Gram‑positive cocci (most commonly isolated were
coagulase negative staphylococci [CONS]) and 3 (7.3%)
were yeasts. Out of 20 g negative bacilli, 14 (70%) isolates
were K. pneumoniae sub spp. pneumoniae. From 18 g
positive cocci, 16 (88.9%) were CONS. All three yeast
isolates were nonalbicans Candida. Similar distributions
of microorganisms were noted by Fayyaz et al. and Parihar
et al. respectively.[15,16]
In comparison, Ramana et al. detected
a higher percentage of Candida spp., i.e., 34% in their
study.[17]
Other studies have reported CONS being the most
commonly isolated species among Gram‑positive cocci.[15,17]
The CONS have been isolated from blood cultures among
patients with increased use of intravascular devices which
could serve as portal of entry to the bloodstream.
The Gram‑negative K. pneumoniae sub spp. pneumoniae
were 100% resistant to ampicillin, ceftazidime, cefixime,
and ceftriaxone followed by cefoperazone + sulbactam,
piperacillin + tazobactam, imipenem, meropenem,
gentamicin, ciprofloxacin, and levofloxacin. They were least
resistant to amikacin, tigecycline, and colistin. One B. cepacia
isolate was resistant to both tigecycline and colistin. Similar
to our study, Fayyaz et al. have reported higher resistance
to third generation cephalosporins and quinolones. On
the other hand, imipenem and amikacin yielded better
activity against Gram‑negative isolates.[15]
Gohel et al.
have demonstrated very poor sensitivity to penicillins,
cephalosporins, and quinolones. Least resistance was
observed with carbapenems, aminoglycosides, tigecycline,
and colistin.[18]
This study revealed that most of the CONS were resistant
to penicillin, oxacillin, and erythromycin, followed by
clindamycin, tetracycline, ciprofloxacin, levofloxacin,
co‑trimoxazole, daptomycin, rifampicin, and gentamicin.
The CONS were least resistant to tigecycline, vancomycin,
and teicoplanin. All isolates were sensitive to linezolid.
Fayyaz et al. in their study have reported all the CONS
isolates were sensitive to linezolid, which is comparable
with our study.[15]
Ramana et al. have revealed 20% of CONS
were resistant to vancomycin, and all CONS were sensitive
to imipenem and linezolid.[17]
In this study, all three Candida spp. isolated were nonalbicans
Candida (two Candida tropicalis and one Candida). C. tropicalis
were sensitive to all antifungal agents tested, whereas
Candida krusei was resistant to fluconazole and flucytosine.
Similarly, Ramana et al. have reported in their study that
all Candida isolates were susceptible to amphotericin B and
nystatin but Candida spp. were resistant to fluconazole and
clotrimazole.[17]
There is the emergence of nonalbicans
Candida and resistant to most commonly used antifungal
agents have been reported in different parts of India.[19,20]
There were few limitations in this present study. The sample
size was less due to short study period. Only single blood
culture specimen could be collected from each patient.
Beside blood specimen other specimens from different sites
were not collected.
CONCLUSION
K. pneumoniae sub spp. pneumoniae and CONS were
the predominant blood borne pathogens isolated in our
region. Most of the Gram‑negative bacilli were sensitive
to tigecycline and colistin. The majority of Gram‑positive
cocci were sensitive to vancomycin, teicoplanin, tigecycline,
and linezolid. There is the emergence of antimicrobial
resistance in almost every corner of the world pointing
toward active microbial surveillance in all clinical settings.
Such monitoring of data regarding the prevalence of
microorganisms and its resistance patterns would definitely
benefit the current prescribed antimicrobial regimens,
especially in resource‑limited countries. This also helps in
improving the infection control practices by formulating
policies for empirical antimicrobial therapy.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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