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A Case Study on Multi Drug Resistant Infection

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

1 Department of Pharmacy Practice, Jaya College of Paramedical Sciences, College of Pharmacy, Thiruninravur, Chennai-602024, Tamil Nadu, India.
E-mail: swetha21112000@gmail.com
*Corresponding author

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 Table 1: Serological and Hematological Investigations
CASE REPORT
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
H ematological 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

and Internal Fixation (CRIF) with Nailing. The ECG reports DISCUSSION
were normal. The emergence and spread of microorganisms with
His lab investigations revealed decreased PCV, multidrug resistance is currently considered as a major
hemoglobin and an increase in monocytes, blood urea public health concern, given its growing incidence in both
Figure 2: Patients image hospitals and communities. In a patient exposed to
antibiotics, resistant organisms may emerge by natural
nitrogen. The patient was initially treated with antibiotics
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.

Inventi Rapid: Pharmacy Practice Vol. 2018, Issue 1 2 2018 ppp 24144 © Inventi Journals (P) Ltd
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 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
methicillinresistant Staphylococcus aureus (MRSA) and
Vancomycinresistant Enterococcus (VRE) strains, as well as
Tigecycline, a potent in-vitro glycylcycline against MRSA,
VRE, Acinetobacter baumannii and extended spectrum
betalactamase (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 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 multiresistant
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,

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 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.
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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.
Published on Web 09/10/2017, www.inventi.in