INTRODUCTION:

With over 800,000 new cases occurring every year, cancer has become an important public health problem, and is one of the main causes of death in India^1,2. Cancer patients are susceptible to infections as a result of their disease and the immunosuppressive medication they undergo.

Surgical site infections (SSIs) are one of the most prevalent healthcare–associated infections (HAIs) in low- and middle-income countries, affecting up to a third of patients who have had surgery. In contrast to hematologic malignant patients, patients with solid tumours routinely undergo numerous diagnostic and therapeutic surgical procedures, and SSIs are more common in these patients^3-5. Much of the SSIs are caused by bacteria or fungal pathogens, isolated dependency on surgical procedure, susceptible host and etiology agents⁶.

SSI is the third most frequent nosocomial infection in hospitals around the world, trailing only urinary tract infections and pneumonia^7-9. The Centers for Disease Control and Prevention (CDC) and National Nosocomial Infections Surveillance System (NNIS) distinguishes between three forms of SSIs: superficial infections, deep incisional infections, and infections affecting organs or bodily compartments. Clean, clean contaminated wounds, contaminated wounds, and dirty or infected wounds impact the risk of SSI, so does the degree of surgical site contamination at the time of surgery^10,11.

Wound Type	Definition/Major Characteristics of Respective Classes
Clean	No inflammation stumbles upon and the gastrointestinal (GI), respiratory, genital and urinary tract is not involved. Discretionary (elective), not emergency, principally closed and without rupture/break techniques involved
Clean – contaminated	Operative method involved a colonized viscera or cavity (opening) of the body, although with controlled and elective situations with nominal spillage. Furthermore, emergency and urgent cases are cleanotherwise, inconsequential break in technique

Exogenous and/or endogenous bacteria that enter the operative site either during surgery (primary infection) or after surgery (secondary infection) are the most common causes of SSI^12,13. SSIs continue to be a problem for postoperative patients despite the use of prophylactic antibiotics both before and after surgery, as well as other preventive measures such as enhanced operating room ventilation, sanitation processes, the use of barriers, and surgical skill, SSI continue to be an issue for postoperative patients. This has mostly been linked to the rise of antimicrobial resistance as a result of irrational antibiotic use. Inappropriate antibiotic use increases selection pressure, allowing harmful drug- resistant microorganisms to evolve^14-17.

Uncontrolled and rapidly spreading anti-microbial resistance among bacterial populations has posed the management and treatment of post-operative wound infections a serious challenge in clinical and surgical practice. Multidrug-resistant (MDR) organisms such as methicillin-resistant Staphylococcus aureus (MRSA), MR-coagulase-negative staphylococci (MR-CoNS), and MDR Gram-negative bacteria (GNB) are complicating HAIs even more^5,18. The hospital infection control (HIC) team monitors SSI rates on a regular basis, which allows them to evaluate antibiotic management tactics and their effectiveness in lowering nosocomial infections. Microbial antibiotic resistance patterns have also changed in recent decades, probably due to the selective pressure imposed by frequently used antibiotics¹⁹. SSI-associated bacteria have different resistance patterns around the world, depending on the area, local epidemiology data, and susceptibility testing methodology^12,20,21. Bacterial resistance is a problem that makes SSI treatment more difficult.

Pathogens that cause SSI in cancer patients have a wide variety of microbiological spectrums and antimicrobial susceptibilities. However, there is paucity of data on the isolation rate by demographic and clinical characteristics of patient’s prevalence and incidence of resistant bacteria that cause SSI, particularly in Southern India, and epidemiological data on pathogens that cause SSI in cancer patients is scarce.As a result, the current study was conducted to examine the microorganisms and its antibiotic resistance isolated from SSIs in cancer patients at North Kerala.

MATERIALS AND METHODS:

The study was carried out in a tertiary cancer centre in North Kerala, India, from May to September 2021. The study did not include patients who had contaminated or unclean operations. This study was approved by the Institutional Review Board (IRB) [1616/IRB-SRC/13/MCC/14-12-2019/1].

Operational definition:

If either of the following circumstances were met, SSI was defined: (1) the surgical procedural registry or medical chart was consistent with a diagnosis of SSI, or (2) the hospital surveillance system reported an SSI according to the CDC's defining criteria¹⁰. Duplicate cultures of a previously identified SSI were excluded from the analysis.

Age, sex, surgery type (clean, clean-contaminated), and SSI type were all taken into account. SSI cases that occurred within 30 days of surgery, or within a year if prosthesis was placed, were included.

Between January 2018 and December 2020, clinical samples such as pus, pus aspirates, wound swabs, deep incisional and organ space SSI aspirates were analysed in this study. Patients with a community-acquired abscess, furuncle, or carbuncle, patients with infection after an episiotomy, and patients with open fractures were also excluded. Using sterile cotton swabs, two pus /wound swabs were obtained aseptically from each patient suspected of having SSI.

One of the swab was used to make Gram-stained preparations for provisional diagnosis. The other swab was inoculated on 5% sheep blood agar and Mac Conkey agar (HiMedia, India) culture plates and incubated at 37°C for 48 hours before being reported as no growth.

A combination of colony features and Gram staining characteristics were used to identify the isolates. The bacterial colony features were manually observed on the culture plate. Before inoculating into the identification panel kits, these colonies were picked from the culture plate, suspended, and compared to the MacFarland standard. For bacterial identification and antibiotic susceptibility testing, the bacterial suspensions were added to the appropriate Gram-positive and Gram-negative panel kits and placed into the automated bacterial identification system (VITEK 2 compact Biomerieux, France).

Since 2020, isolates have been identified by using matrix-assisted laser desorption/ionization–time of flight (MALDI-TOF) mass spectrometry (VITEK - MS, Biomerieux) since 2020.

Quality control:

The developed proforma was checked for completeness and validity prior to data collection. All standard operating procedures (SOPs) were strictly followed throughout the microbiological analysis process. The Clinical Laboratory Standards Institute (CLSI) recommendations were used to determine antibiotic susceptibility²².

For antimicrobial susceptibility testing quality control, standard reference strains from the American Type Culture Collection (ATCC) (S. aureus ATCC 25923, E. coli ATCC 25922, and P. aeruginosa ATCC 27853) were used.

Statistical Analysis:

The microorganisms isolated and its antibiotic sensitivity patterns were analysed using MYLA software (Biomerieux). Categorical variables were represented as frequency and percentages. Data was analyzed using SPSS version 20.0 software, A statistically relevant p value was <0.05.

RESULT:

During the study period, 2949 patients underwent clean and clean contaminated surgical procedures. The study population's median age was years (18–80 years), and females made up the majority of the cases (63%). Head and neck surgery was the most prevalent, followed by breast surgery (Table 1 and 2).

A total of 215 individuals (7.2%) developed SSI (figure 1). There were 1933(65.5%) clean procedures and 1016 (34.5%) clean contaminated surgeries. Overall, 57% of infections were superficial incisional, 26% were deep incisional and 17% were infections in the organ space. S. aureus (39%) had the greatest isolation rate among the 224 bacterial isolates, followed by Pseudomonas aeruginosa. A total of 215 individuals with SSI were investigated, and 224 microorganisms were identified from 190 patients (164 patients yielded growth of single organism and 26 patients had polymicrobial growth causing SSI). There was no growth in 25(11.6%) of the cases. Figure 2 shows the microbiological etiology of SSI; Gram-positive bacteria were more common than GNB. In the superficial, deep, and organ/space SSI, both Gram positive and Gram negative bacterial isolates were found. In Superficial (n = 53) and Deep SSI (n = 30), S. aureus was the most common organism, while in organ space SSI, P. aeruginosa (n = 13) and E. coli (n = 11) were the most common (figure 2).

Table 1. Surgical procedures performed on SSI patients (n = 215).

Type of surgery	Number of clean and contaminated cases	Total SSI	SSI Prevalence Rate (%)
Head and neck	878	46	5.2
Breast	784	69	8.8
Stomach	563	30	5.3
Colon	286	22	7.6
Recto-sigmoid	162	12	7.4
Ovary	106	6	5.7
Bone and soft tissue tumors	82	16	19.5
Skin	52	7	13.5
Bladder	12	2	17
Others	24	5	21
Total	2949	215	7.2

Table 2.Isolation rate of patients based on demographic and clinical variables

Characteristic		Number analyzed	Growth	P - value
Age	1 - 10	32 (1.08)	0 (0)	0.74
	11-20	120 (4.06)	0 (0)
	21-30	278 (9.4%)	5 (2.6%)
	31-40	575 (19.5%)	32 (17%)
	41-50	922 (31.2%)`	71 (37%)
	51-60	654 (22%)	57 (30)
	61-70	228 (8%)	17 (9)
	71-80	140 (5%)	8 (4.2)
	Total	2949	190
Sex	Male	1286 (43.7%)	76 (40)	0.33
	Female	1663 (56.3)	114 (60)	0.33
	Total	2949	190
Type of SSIs	Superficial (%)	122 (57%)	121 (63.6)	0.202
	Deep (%)	57 (26.5%)	48 (25.4%)
	Organ (%)	36 (16.5)	21 (11)
	Total	215	190
Class of Surgical Wound	Clean (%)	1933	62 (32.6%)	0.0001*
Class of Surgical Wound	Clean contaminated (%)	1016	128 (67.3%)	0.0001*
	Total	2949	190

Figure 1.Year wise segregation of type of surgical site infections.

Figure 2: Surgical site infections (n = 224): microbial aetiology

Table 3 b: Distribution of Antibiotic resistance of isolated Gram-positive bacteria.

	Gram-positive bacteria causing SSI, N (%)
Antibiotics	*S. aureus* (n = 87)	*Enterococcus* (n = 10 )
Cefoxitin	54 (62)	----
Ciprofloxacin	64 (73.5)	4 (40)
Clindamycin	18 (20.6)	3 (30)
Erythromycin	48 (55)	5 (50)
Tetracycline	14 (16)	3 (30)
Trimethoprim - Sulfamethoxazole	26 (30)	----

Antibiotic resistance profiles for microbes isolated from SSI patients were described. Tables 3a and 3b show the antibiotic resistance rates of bacterial isolates

MRSA was observed in 57 of the S. aureus isolates, while MRSA and MR-CoNS were found in 57 (65.5%) and 6 (67%) of the S. aureus (n = 87) and CoNS (n = 9) isolates, respectively. Inducible clindamycin resistance (ICR) was found in ten of the S. aureus isolates. S. aureus showed 73.5% resistance to ciprofloxacin, 55 % resistance to erythromycin, 30% resistance to cotrimoxazole, and 21% resistance to clindamycin. In organisms carrying MRSA, the level of resistance to ciprofloxacin, erythromycin, and co-trimoxazole was exceedingly high.

Except for ampicillin, all the tested Enterococcus species showed low to moderate resistance to all of the antibiotics tested. Vancomycin and linezolid was sensitive to all the gram-positive isolates.

Tables illustrate the susceptibility of GNB isolates. Among the Enterobacteriaceae, K. pneumoniae showed higher resistant to ciprofloxacin (87%), cefepime (77.4%), and amikacin (45%). When compared to E.coli (34.5%), the beta-lactam-beta-lactamase inhibitor (BL-BLI) showed much resistance to K. pneumoniae (48%).

Among the Non-fermenting GNB, A. baumannii showed high-level resistance when compared to P. aeruginosa. A. baumannii showed high level resistance to ciprofloxacin (71.4%), BL-BLI (57%) and meropenem (57%), whereas P. aeruginosa showed resistance to ciprofloxacin (26.8%), gentamicin (22%), BL-BLI (14.6) and carbapenems (9.7%).

DISCUSSION:

In surgically treated patients, postoperative SSI is still one of the leading causes of morbidity. Longer hospitalizations, more nursing care, further wound care, potential hospital admissions, and additional surgical procedures all result in increased costs for these individuals^3-5. The proper treatment of SSI relies on early identification of infecting microorganism and its antibiotic sensitivity. Thus immediate treatment can be precious to save the life of the patient from the life threatening nature of SSI. Postoperative SSI is still one of the primary causes of morbidity in surgically treated patients. In the history of evolution, widespread use of antibiotics not only in human beings but also in animals and in environmental setting such as agriculture has induced a selection pressure²³. Early identification of the infectious microorganisms and its antibiotic sensitivity is critical for effective SSI treatment. As a result, prompt treatment may be necessary to save the patient's life from the life-threatening nature of SSI. In this current study, 2949 patients were treated with both clean and contaminated procedures. The median age of the study participants in this study were 18–80 years, and females made up the majority of the cases (63%). The most common procedure performed was head and neck surgery, followed by breast surgery. A total of 215 cancer patients (7.2%) acquired SSI during the study period.

The frequency of SSI during the study period was 7.2%. The SSI rate in our study was lower than the previous report which was reported 7.9%⁴. The rate of SSI varies according to surgery type, post discharge surveillance, hospital type and others. There were 1933 clean procedures (65.5%) and 1016 clean contaminated surgeries (34.5%). In total, 57% of infections were caused by superficial incisions, 26% by deep incisions, and 17% by infections in the organ space. Also in this study, 65% of patients with SSIs were between the ages of 40 and 75, which are consistent with previous study, who found that SSIs were more common in the older age group²⁴. Malinzak et al., on the other hand, revealed that SSI predominates in a younger age range²⁵. This can be explained by differences in the kind of surgeries performed in each study, as well as the existence of various comorbid illnesses that predispose to infection in older people. In the current study, SSI infections were more in female (60%) than male patients.There is much significant difference observed among the male and female patients.In contrast, Dale et al., reported a higher incidence of SSI infection in male compared to female patients²⁶. Breast cancer may be a significant risk factor for SSI. When compared to non-cancer patients who undergo equivalent extensive surgeries, such as breast enlargement surgery, infection rates are higher in breast cancer patients. Recent research has also indicated that the microbiome of breast tumours differs significantly from that of normal breast tissue, with a more diverse and rich bacterial load²⁷.

Among HAIs, SSI is ranked second. Their incidence rate may vary in several nations due to the various system integrated in the epidemiological control of hospital acquired infections. Knowing the local epidemiology and antibiotic resistance trend, for example, can assist lower the chances of treatment failure. A total of 224 aerobic bacteria were identified, with more pure isolates (73%) recovered than polymicrobial isolates (11.6%), which is consistent with previous studies^7,17. In contrast, a study in Italy found that polymicrobial isolates were collected in more numbers than pure isolates²⁸. The purity of the isolates is affected by the surgical wound class, with clean procedures being related with monomicrobial isolates and contaminated and filthy wounds being associated with polymicrobial isolates¹⁷. Majority of the surgeries in this study were clean.

S. aureus was the predominant organism isolated in the present study followed by P. aeruginosa. Our data from this study correlates well with the previous SSI studies from India and other developing nations^12,29,30. Gram-negative bacteria, on the other hand, have been identified as the leading cause of SSI in other studies^4,7,17,31.

One explanation for its high prevalence could be S. aureus usual flora nature in the skin and anterior nares, which can enter a deep site during surgery to remove the skin's natural barrier. Gram-positive organisms, such as S. aureus, are the most common infections in resource-rich environments, according to several studies^8,32,33. Most published series on SSI include general, cardiovascular, gynecologic, orthopedic, and thoracic surgery; however, cancer surgery is frequently excluded or underrepresented. To our knowledge, this is the first initiation at Northern Kerala to study a larger group of SSI patients with cancer and one of the longest duration series reporting the microbiology of SSI.

The diversity of the research population and local antimicrobial usage patterns could explain the heterogeneity in bacterial isolate distribution patterns in different setups, which could contribute to the formation of diseases resistant to currently used antibiotics. The majority of the infected patients had undergone abdominal surgery, and Gram negatives are typically associated with intra-abdominal surgeries⁸. The causative agents are retrieved in clean operations, when internal organs are removed through the abdomen include the gut's typical Gram negative flora, as well as foreign bacteria or skin colonisers^8,34.

When compared to previous investigations in India, MRSA was found in 62% of S. aureus isolates, which was a considerable amount. In contrast, a prior Ugandan study found a high prevalence of MRSA¹⁷. Antibiotic resistance among GNB is of great concern, with very high levels of resistance (ESBL – 75%, piperacillin-tazobactum – 41.5%, gentamicin – 50%, and carbapenems – 20%) to most commonly used antibiotics such as piperacillin-tazobactam, gentamicin, cefepime, and ciprofloxacin^8,35. When compared to E. coli, K. pneumoniae had a higher rate of antibiotic resistance. However, rates of antimicrobial resistance noted in this study are significantly lower than those reported by our previous study in bloodstream infections as well as other studies from India and other countries^8,36.

In Enterobacteriaceae, ciprofloxacin resistance ranged from 70 to 87%, with A. baumannii exhibiting a rise in resistance. Because fluoroquinolones are effective medications for treating Gram-negative bacterial infections, resistance to ciprofloxacin is an early warning indicator. The high resistance rate of GNB to fluoroquinolones is another source of concern around the world (ciprofloxacin and levofloxacin). This high fluoroquinolone resistance was also seen in a large community-based WHO surveillance project in India³⁷. Increased length of hospital stay along with the antibiotics prescribed for post-surgical infections greatly influence the economic outcomes of the patients. It is also observed from previous report that 5.4% infection rate was reported in those patients who received prophylaxis antibiotic while 16.8% infection reported in those who do not receive prophylaxis antibiotic³⁸.

This clear-cut proves that prophylactic antibiotic should be administered prior to surgery in order to reduce the rate of SSI. Clinician, Nurses, Pharmacist and other allied health personnel’s can minimize the risk of SSIs by giving proper guidance to the patients who have undergone surgery. This will help them to select the appropriate post-surgical wound care products, the array of accessible resources, and provide knowledge about wound care. Additional control measures include the maintaining/keeping the elevated inspired oxygen levels, deterrence of hypothermic condition before, during and after the surgical process, and limiting the shaving of the specific operated area^39,40. Thus surgical procedural factors, patient factors and potential morbidity of infection determines the potential benefits of antimicrobial prophylaxis^41.

CONCLUSION:

In the present study, SSI remains a significant concern in postoperative cancer patients. The bacterial isolates had an alarming MRSA incidence followed by Gram-negative bacteria. Antibiotic therapy should be directed based on antimicrobial susceptibility patterns reported from the Microbiology lab. The incidence, aetiology, antibiotic susceptibility profile, and source of infection should all be monitored on a regular basis in a hospital setup. To segregate afflicted patients and reduce unnecessary antibiotic use, we recommend a preoperative rectal swab to detect microbial colonisation. Finally, to prevent the transmission of pathogenic organisms, we encourage rigorous adherence to appropriate sanitation practises such as thorough hand washing, disinfection of inanimate objects, and other infection control measures.

CONFLICT OF INTEREST:

None to declare.

REFERENCES:

1. Krishnaveni K, Jose R, Sumitha SK, Johny T, Shanmuga Sundaram R, Sambathkumar R. A Study on Socio Demographic and Associated Risk Factors for Cancer Patients in Private Cancer Hospital, Bangalore, India. Education. Research Journal of Pharmacy and Technology. 2018; 11(2): 677-680. doi: 10.5958/0974-360X.2018.00127.0

2. Patel SK, Sinha M, Mitra M. Epidemiological and Socio-demographic Profile of Oral Cancer Patients of Chhattisgarh: A Retrospective Study. Research Journal of Science and Technology. 2012; 4(4):145-147. doi: Not available

3. Sutton SH. Sutton SH. Infections Associated with Solid Malignancies. Infectious Complications in Cancer Patients. 2014; 161: 371.doi: 10.1007/978-3-319-04220-6_13

4. Hernaiz-Leonardo JC, Golzarri MF, Cornejo-Juárez P, Volkow P, Velázquez C, Ostrosky-Frid M, Vilar-Compte D. Microbiology of surgical site infections in patients with cancer: A 7-year review. American Journal of Infection Control. 2017; 45(7):761-766. doi: Not available

5. Haque M, Sartelli M, McKimm J, Bakar MA. Health care-associated infections–an overview. Infection and Drug Resistance. 2018; 12:2321-34. doi: 10.2147/IDR.S177247

6. Ahmad R. Evaluation of the Gram-Negative Bacilli Causing Surgical-Site Infections and their Sensitivity to Antibiotics in Al-Mowasat Hospital, Damascus, Syria. Research Journal of Pharmacy and Technology. 2018; 11(5): 2070-3. doi: 10.5958/0974-360X.2018.00384.0

7. Manyahi J, Matee MI, Majigo M, Moyo S, Mshana SE, Lyamuya EF. Predominance of multi-drug resistant bacterial pathogens causing surgical site infections in Muhimbili National Hospital, Tanzania. BMC Res Notes. 2014;7:500. doi: 10.1186/1756-0500-7-500.

8. Shah S, Singhal T, Naik R, Thakkar P. Predominance of multidrug-resistant Gram-negative organisms as cause of surgical site infections at a private tertiary care hospital in Mumbai, India. Indian Journal of Medical Microbiology. 2020; 38(3-4):344-50. doi: org/10.4103/ijmm.IJMM_20_284.

9. Rajagopalan R, Shivamurthy MC. A Retrospective Evaluation of Compliance in Various Surgical Departments with Respect to Surgical Antibiotic Prophylaxis in a Tertiary Care Hospital. Research Journal of Pharmacy and Technology. 2013; 6(7): 749 – 752. doi: Not available

10. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR, Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Infection Control and Hospital Epidemiology. 1999; 20(4): 247-80.doi: https://doi.org/10.1086/501620

11. Centers for Disease Control and Prevention. Procedure Associated Module: Surgical Site Infection (SSI) Event. Atlanta, GA: Centers for Disease Control and Prevention. 2017.

12. Negi V, Pal S, Juyal D, Sharma MK, Sharma N. Bacteriological profile of surgical site infections and their antibiogram: A study from resource constrained rural setting of Uttarakhand State, India. Journal of Clinical and Diagnostic Research. 2015; 9(10): DC17.doi: 10.7860/JCDR/2015/15342.6698

13. Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, Reinke CE, et al. Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017; 152(8): 784-91. doi:10.1001/jamasurg.2017.0904

14. Global Guidelines for the Prevention of Surgical Site Infection. Geneva: World Health Organization; 2018.

15. Anderson DJ, Sexton DJ, Kanafani ZA, Auten G, Kaye KS. Severe surgical site infection in community hospitals: epidemiology, key procedures, and the changing prevalence of methicillin-resistant Staphylococcus aureus. Infection Control and Hospital Epidemiology. 2007;28(9):1047-53.doi: 10.1086/520731

16. Seni J, Najjuka CF, Kateete DP, Makobore P, Joloba ML, Kajumbula H, et al. Antimicrobial resistance in hospitalized surgical patients: a silently emerging public health concern in Uganda. BMC Research Notes. 2013; 6(1):1-7. doi: 10.1186/1756-0500-6-298

17. Hope D, Ampaire L, Oyet C, Muwanguzi E, Twizerimana H, Apecu RO. Antimicrobial resistance in pathogenic aerobic bacteria causing surgical site infections in Mbarara regional referral hospital, Southwestern Uganda. Scientific Reports. 2019; 9(1): 1-10. doi: org/10.1038/s41598-019-53712-2

18. Prestinaci F, Pezzotti P, Pantosti A. Antimicrobial resistance: a global multifaceted phenomenon. Pathogens and Global Health. 2015; 109(7): 309-18. doi: 10.1179/2047773215Y.0000000030

19. Chandanashree KS, Jacob J, Srivatsa S. Utilization Study of Antibiotics in Febrile Neutropenic Cancer patients with Bacteraemia. Research Journal of Pharmacy and Technology. 2020;13(8):3765-70. doi : 10.5958/0974-360X.2020.00666.6

20. Monegro AF, Muppidi V, Regunath H. Hospital acquired infections. InStatPearls [Internet] 2020. StatPearls Publishing.

21. Thomson WM, Sudha M, Venkateswaramurthy N, Kumar RS. A Review on the Irrational Antibiotics usage in Pediatrics for Respiratory Tract Infections. Research Journal of Pharmacy and Technology. 2019; 12(10): 5126-30.doi: 10.5958/0974 360X.2019.00888.6

22. Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing; Twenty-seventh Informational Supplement. CLSI Document M100-S27. Wayne, PA: Clinical and Laboratory Standards Institute; January, 2017.

23. Ramalingam AJ. History of Antibiotics and Evolution of Resistance. Research Journal of Pharmacy and Technology. 2015; 8(12): 1719-24. doi : 10.5958/0974-360X.2015.00309.1

24. Zahran WA, Zein-Eldeen AA, Hamam SS, Sabal MS. Surgical site infections: Problem of multidrug-resistant bacteria. Menoufia Medical Journal. 2017; 30(4): 1005. doi: 10.4103/mmj.mmj_119_17

25. Malinzak RA, Ritter MA, Berend ME, Meding JB, Olberding EM, Davis KE. Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates. The Journal of Arthroplasty. 2009; 24(6):84-8. doi: org/10.1016/j.arth.2009.05.016

26. Dale H, Fenstad AM, Hallan G, Havelin LI, Furnes O, Overgaard S, Pedersen AB, et al. Increasing risk of prosthetic joint infection after total hip arthroplasty. Acta Orthop. 2012; 83(5):449-58. doi: 10.3109/17453674.2012.733918

27. O'Connor RÍ, Kiely PA, Dunne CP. The relationship between post-surgery infection and breast cancer recurrence. Journal of Hospital Infection. 2020; 106(3): 522-535. doi: 10.1016/j.jhin.2020.08.004

28. Giacometti A, Cirioni O, Schimizzi AM, Del Prete MS, Barchiesi F, D'errico MM, Petrelli E, et al. Epidemiology and microbiology of surgical wound infections. Journal of Clinical Microbiology. 2000; 38(2): 918-22. doi:org/10.1128/JCM.38.2.918-922.2000

29. Rolston KV, Nesher L, Tarrand JT. Current microbiology of surgical site infections in patients with cancer: a retrospective review. Infectious Diseases and Therapy. 2014; 3(2):245-56.doi: 10.1007/s40121-014-0048-4

30. Golia S, Kamath BA, Nirmala AR. A study of superficial surgical site infections in a tertiary care hospital at Bangalore.2014.

31. Sumathi BG. Bacterial pathogens of surgical site infections in cancer patients at a tertiary regional cancer centre, South India. International Journal of Current Microbiology and Applied Sciences. 2016; 5: 605-16.doi: org/10.20546/ijcmas.2016.510.068

32. Mawalla B, Mshana SE, Chalya PL, Imirzalioglu C, Mahalu W. Predictors of surgical site infections among patients undergoing major surgery at Bugando Medical Centre in Northwestern Tanzania. BMC Surgery. 2011; 11(1): 1-7.doi: 10.1186/1471-2482-11-21

33. Abdelghafar A, Yousef N, Askoura M. Combating Staphylococcus aureus biofilm with Antibiofilm agents as an efficient strategy to control bacterial infection. Research Journal of Pharmacy and Technology. 2020; 13(11): 5601-6. doi: 10.5958/0974-360X.2020.00977.4

34. Nazneen Siddiqui, SomnathNandkar, MuktaKhaparkuntikar and Arvind Gaikwad. Surveillance of post-operative wound infections along with their bacteriological profile and antibiotic sensitivity pattern at government cancer hospital, Aurangabad, India. Int J Curr Microbiol Appl Sci. 2017; 6: 595-600.doi: org/10.20546/ijcmas.2017.603.069

35. Aljanaby AA, Aljanaby IA. Profile of Antimicrobial Resistance of Aerobic Pathogenic Bacteria isolated from Different Clinical Infections in Al-Kufa Central Hospital–Iraq During period from 2015 to 2017. Research Journal of Pharmacy and Technology. 2017;10(10):3264-70.doi: 10.5958/0974-360X.2017.00579.0

36. Parthiban R, Sajani S, Saravanan M. Microbiological Profile and Antibiotic Resistance of Bloodstream Infections among Cancer Patients at a Tertiary Care Cancer Centre in North Kerala, India. National Journal of Laboratory Medicine. 2022; 11(1): MO16-MO21. doi: 10.7860/NJLM/2022/50713.2576

37. World Health Organization. Community-based surveillance of antimicrobial use and resistance in resource-constrained settings: report on five pilot projects. Geneva: World Health Organization; 2009.

38. Tariq A, Ali H, Zafar F, Sial A, Hameed K, Naveed S. A systemic review on surgical site infections: classification, risk factors, treatment complexities, economical and clinical scenarios. Journal of Bioequivalence and Bioavailability. 2017;9(1):336-40.doi: 10.4172/jbb.1000321.

39. Centers for Disease Control and Prevention (2015) surgical site infection (SSI) event.

40. Ponto JA.ASHP statement on the pharmacist's role in antimicrobial stewardship and infection prevention and control. American Journal of Health-System Pharmacy. 2010;67(7):575-7. doi: 10.2146/sp100001

41. Satishchandra A, Anusha R, Krishna EV, Eshwaraiah C. Prophylactic Antibiotics and Prevention of Surgical Site Infections. Research Journal of Pharmacy and Technology. 2021; 14(2):1091-3. doi: 10.5958/0974-360X.2021.00196.7

Received on 25.05.2022 Modified on 07.11.2022

Research J. Pharm. and Tech 2023; 16(10):4635-4641.

DOI: 10.52711/0974-360X.2023.00754

	Gram-negative bacteria causing SSI, N (%)
Antibiotics	*E. coli* (n = 26)	**K. pneumoniae(n = 31 )**	*P. aeruginosa* (n = 41)	*A. baumannii* (n = 7 )
Amikacin	2 (7.7)	14 (45)	5 (12)	1 (14.2)
Gentamicin	12 (46)	19 (61)	9 (22)	3 (42.8)
Cefotaxime	18 (69)	25 (80.6)	NT	NT
Cefepime	16 (61.5)	24 (77.4)	NT	NT
Ceftazidime	13 (50)	21 (67.7)	6 (14.6)	4 (57)
Imipenem	4 (15.4)	8 (26)	4 (9.7)	4 (57)
Meropenem	3 (11.5)	6 (19)	4 (9.7)	3 (42.8)
Ciprofloxacin	20 (77)	27 (87)	11 (26.8)	5 (71.4)
Piperacillin-Tazobactam	9 (34.5)	15 (48.3)	6 (14.6)	4 (57)