A retrospective study for detection of inducible resistance to clindamycin in staphylococcus aureus isolates using D-Test at RIMS teaching hospital, Raichur, India

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The present study was conducted for detection of inducible resistance to Clindamycin in Staphylococcus aureus isolates using D – test at Raichur Institute of Medical Sciences-teaching hospital, RAICHUR, Karnataka, India.

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Nội dung Text: A retrospective study for detection of inducible resistance to clindamycin in staphylococcus aureus isolates using D-Test at RIMS teaching hospital, Raichur, India

Int.J.Curr.Microbiol.App.Sci (2017) 6(10): 1537-1542 International Journal of Current Microbiology and Applied Sciences ISSN: 2319-7706 Volume 6 Number 10 (2017) pp. 1537-1542 Journal homepage: http://www.ijcmas.com Original Research Article https://doi.org/10.20546/ijcmas.2017.610.184 A Retrospective Study for Detection of Inducible Resistance to Clindamycin in Staphylococcus aureus Isolates Using D-Test at RIMS Teaching Hospital, Raichur, India R. Venkatesh Naik*, Basavaraj V. Peerapur and P. Sandhya Department of Microbiology, RIMS, Raichur, Karnataka, India *Corresponding author ABSTRACT Staphylococcus aureus is recognized as causing nosocomial and community-acquired infections in every region of the world. Clindamycin is considered as useful alternate drug in penicillin-allergic patients in the treatment of skin & soft tissue infections caused by Staphylococcus aureus. Staphylococcus spp. can be resistant to erythromycin through either erm or msr A genes. Strains with erm-mediated erythromycin resistance may Keywords possess inducible Clindamycin resistance but may appear susceptible to Clindamycin by disc diffusion test. The objective of the present study was to know the prevalence of Clindamycin resistance, MRSA, erythromycin-induced Clindamycin resistance among clinical isolates of S. aureus. A total MSSA, D test. of 160 S. aureus isolates from various clinical samples submitted in the Dept. of Microbiology, RIMS teaching hospital, Raichur were studied. Methicillin resistant S. Article Info aureus strains were identified by Cefoxitin disc diffusion method. Inducible Clindamycin resistance was detected by erythromycin and Clindamycin disc approximation test (D-zone Accepted: 14 September 2017 test) as per CLSI guidelines. Among the 160 S. aureus isolates, 75 strains (46.8%) were Available Online: detected as MRSA of which 32(42.6%) strains showed inducible Clindamycin resistance 10 October 2017 (D-test positive) and 12(14.1%) isolates out of 85 strains MSSA were D-test positive. 73(45.6%) isolates of S. aureus were sensitive to both erythromycin and Clindamycin. High prevalence of strains with inducible Clindamycin resistance particularly among MRSA indicates that inducible Clindamycin resistance testing (D-test) should be included as a part of routine antibiotic susceptibility. These isolates may be missed in routine antibiotic testing by disk diffusion method. Introduction Staphylococci are important causative agents Strains with inducible resistance to of nosocomial and community acquired Clindamycin are difficult to detect in the infections in skin and soft tissues. Emergence routine laboratory test, as they appear of methicillin resistance in Staphylococci has erythromycin resistant and Clindamycin left us with very few therapeutic alternatives sensitive in vitro, when not placed adjacent to available to treat. The Macrolide – each other. In such cases, in-vivo therapy with lincosamide Streptogramin B (MLSB) family Clindamycin may select therapeutic failure.[2, 3] of antibiotics serves as one such alternative However widespread use of Macrolides- with Clindamycin being preferred agent due lincosamides-Streptogramin B (MLSB) to its excellent pharmacokinetic properties.[1] antibiotics has led to an increased resistance 1537
Int.J.Curr.Microbiol.App.Sci (2017) 6(10): 1537-1542 to these antibiotics by Staphylococcal resistance missed by using standard strains.[4] susceptibility test methods such as standard broth-based or agar dilution susceptibility The Macrolide-Lincosamide-Streptogramin B tests. The inducible MLSB resistance can be (MLSB) family of antibiotics is commonly detected by a simple test known as Disk used in the treatment of Staphylococcal approximation test or D test. Low level of infections. Clindamycin a protein synthesis Erythromycin is an inducer of MLSBi inhibitor is an attractive option for use in the phenotype and this is the basis of performing scenario of increasing drug resistance among D test.[9] Failure to identify inducible MLSB the Staphylococci especially for skin and soft resistance may lead to clinical failure of tissue infections and as an alternative in Clindamycin therapy. Conversely, labelling Penicillin allergic patients. all erythromycin-resistant staphylococci as Clindamycin resistant prevents the use of This drug has excellent tissue penetration, Clindamycin in infections caused by truly requires no renal dosing adjustments and has Clindamycin-susceptible Staphylococcal a good oral absorption. All these factors make isolates. it convenient for outpatient prescription or as follow-up after intravenous therapy.[5] The present study was conducted for However, one important issue with detection of inducible resistance to Clindamycin treatment is the risk of clinical Clindamycin in Staphylococcus aureus failure during therapy. isolates using D – test at Raichur Institute of Medical Sciences-teaching hospital, The MLS family of antibiotics has three RAICHUR, Karnataka, India. different mechanisms of resistance: target site modification, enzyme antibiotic inactivation Materials and Methods and Macrolide efflux pumps.[6] Macrolide antibiotic resistance in Staphylococcus aureus The study was conducted from September and Coagulase negative Staphylococci 2014 to April 2016 in the Department of (CONS) may be due to an active efflux Microbiology, Raichur Institute of Medical mechanism encoded by msr A (macrolides Sciences-teaching hospital, RAICHUR, Streptogramin resistance) genes, conferring Karnataka, India. A total of 160 S. aureus resistance to macrolides and type B strains were isolated from various clinical Streptogramin only[7] or may be due to specimens like pus, wound swabs, aspirates, ribosomal target modification, affecting blood, sterile fluids etc. Only one isolate per macrolides, lincosamides, and type B patient was included in the study. All the Streptogramin (MLSB resistance). Erm isolates were tested for their susceptibility to (erythromycin resistant methylene) genes are penicillin (10 units), Gentamicin (10 μg), responsible for encoding enzymes that confer tetracycline (30 μg), Cotrimoxazole (25 μg), inducible or constitutive resistance to MLS erythromycin (15 μg), ciprofloxacin (5 μg), agents via methylation of the 23S rRNA and Vancomycin (30 μg) and linezolid (30μg) by reducing binding by MLS agents to the Kirby Bauer disc diffusion method using ribosome.[8] Antimicrobial susceptibility data criteria of standard zone of inhibition. are important for the management of Methicillin resistance was detected by infections, but false susceptibility results may Cefoxitin disk diffusion method using a 30 μg be obtained if isolates are not tested for disk (Hi-media laboratories Pvt. Ltd., inducible Clindamycin resistance. This Mumbai). 1538
Int.J.Curr.Microbiol.App.Sci (2017) 6(10): 1537-1542 D-test detected as MRSA of which 32 (42.6%) strains showed inducible Clindamycin D-test Negative (MS Phenotype): Isolates resistance. Percentage of both inducible and showing resistance to Erythromycin (≤ constitutive resistance was found to be higher 13mm) but susceptible to Clindamycin (≥ amongst MRSA isolates as compared to 21mm) and showing circular zone of MSSA (p
Int.J.Curr.Microbiol.App.Sci (2017) 6(10): 1537-1542 There have been various reports on the pattern resistance were seen in significantly higher of the MLSB resistance among the proportion among MRSA as compared to staphylococci; some reports indicate a high MSSA isolates (p
Int.J.Curr.Microbiol.App.Sci (2017) 6(10): 1537-1542 In this study, 13.3% MRSA belonged to MS References phenotype as compared to 9.4% MSSA. Similar findings were made by Gadepalli et 1. Fiebelkorn KR, Crawford SA, McElmeel al., reported 12.0% strains of the MS ML, Jorgenson JH. Practical disc phenotype among the MRSA and MSSA diffusion method for detection of each. inducible Clindamycin resistance in Staphylococcus aureus and coagulase In present study, 46.8% of the total isolates of negative Staphylococci. J Clin Microbiol, the S. aureus were MRSA. Other studies have 2003; 41:4740-4. also shown such a high prevalence of MRSA 2. Steward CD, Raney PM, Morrell AK, from various parts of the country ranging Williams PP, McDougal LK, Jevitt, et al. from 31% to 44%.[15, 16] Lack of awareness, Testing for induction of Clindamycin the indiscriminate and improper use of resistance in erythromycin resistant antibiotics before coming to the hospital isolates of Staphylococcus aureus. J Clin might be the contributory factors for such a Microbiol, 2005; 43:1716-21. high prevalence of MRSA. Even though there 3. Deotale V, Mendiratta DK, Rant U, are recent reports of the increase in Narang P. Inducible Clindamycin emergence of Vancomycin resistance of resistance in Staphylococcus aureus S.aureus worldwide.[17, 18] isolated from clinical samples. Indian J Med Microbiol, 2010; 28:124-126. As Clindamycin is one of the most commonly 4. Gadepalli R, Dhawan B, Mohanty S, used antibiotics for MRSA isolates, the Kapil A, Das BK, Choudhary R. Inducible increasing Clindamycin resistance in the form Clindamycin resistance in clinical isolates of iMLSB and cMLSB limits the therapeutic of Staphylococcus aureus. Indian J med options for MRSA to the antibiotics like Res, 2006; 123: 571-3. linezolid and Vancomycin. 5. Drinkovic D, Fuller E R, Shore KP, Holland DJ, Ellis –Pegler R. Clindamycin The inducible Clindamycin resistance can be treatment of Staphylococcus aureus easily missed by routine in vitro susceptibility expressing inducible Clindamycin tests, when the erythromycin and the resistance. J Antimicrob Chemother, Clindamycin discs are placed in non-adjacent 2001; 48: 315-316. positions. In view of the therapeutic 6. Yalmaz G, Aydin K, Iskender S, Caylan implications, the D test is a simple, reliable R, Koksal I. Detection and prevalence of and inexpensive test to perform along with inducible Clindamycin resistance in routine susceptibility testing which delineates Staphylococci. J Med Microbiol, 2007; 56 the inducible (iMLSB) and the constitutive (Pt 3): 342-5. (cMLSB) resistance. 7. Ross J I, Eady E A, Cove J H, Cunliffe W J, Baumberg S, Wootton J C. Inducible The incidence of resistance is highly variable erythromycin resistance in staphylococci with regard to geographic locality; hence the is encoded by a member of the ATP- local data regarding inducible Clindamycin binding transport super-gene family. Mol resistance is helpful in guiding anti- Microbiol, 1990; 4: 1207-1214. staphylococcal therapy. Use of D test in a 8. Roberts MC, Sutcliffe J, Courvalin P, routine laboratory will enable us in guiding Jensen LB, Rood J, Seppala H. the clinicians regarding the judicious use of Nomenclature for Macrolide-lincosamide- Clindamycin. Streptogramin resistance determinants. 1541
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