Multidrug-resistant Bacterial Profile and Patterns for Wound Infections in Nongovernmental Hospitals of Jordan

Globally, multidrug-resistant bacteria affects wound infections, both hospital-acquired infections and community-acquired infections. The main isolates cultured from 607 subjects with wound infections were methicillin-resistant Staphylococcus aureus (MRsA), Escherichia coli, Pseudomonas aeruginosa, and Acinetobacter spp. [multidrug resistant (MDR)]. Gram-negative bacteria caused most of the infections (67%) compared with gram-positive bacteria. Diabetic patients tend to have wound infections with mixed causative agents compared with non-diabetic patients.

in intensive care or burns units worldwide 6 . This has resulted in a great threat to efforts against bacterial pathogens 7 . The aim of this study is to determine the rate of antibiotic-resistant bacterial isolates from wound patients at Islamic hospitals, Amman, Jordan.

MATERIAls AND METHoDs study design
This study was conducted at Islamic hospitals in Amman, Jordan from January 1 to November 11, 2018. In and outpatients from surgery and admitted wards were involved in this study. All the patients who fulfilled the criteria above were consecutively enrolled into the study.

sampling and processing
Clinical samples from 607 wound infected patients, including wound swabs 331 (54.4%), pus 128 (21.1%), and diabetic foot swabs 148 (24.4%) were aseptically collected using the appropriate sterile containers. The collected samples were transported to the lab with the appropriate transport media and bacterial identification to species level was performed using standard procedures including culture and colony characteristics, Gram reaction, and different biochemical analysis.

Data analysis
Data analysis was performed using Statistical Package for the Social Sciences (SPSS) version 23 (IBM Corp, 2015). Qualitative data were described as proportions or percentages; cross tabulation was used where necessary. Test of significance for differences for quantitative and categorical variables were performed using the t-test and Chi square test, respectively. A p-value of < 0.05 was considered significant.

General characteristics
The total number of patients enrolled in this study was 607; 331 of them were wound infected patients, which forms 54.4% of the total population. Of these, females were 124 (63%) and males were 207 (37%). The patients with diabetic foot ulceration (DFU) were 148, which forms 24.4% of the total population. Among them, 83 (56%) were female patients and 65 (44%) were   (Table 3-A, Table 3-B, Table 3-C, Table 3-D) and Fig. 3.
A total of 30 pathogenic organisms were isolated from the cultivated wound samples, one yeast and 29 types of bacteria. MRSA was the most frequent pathogen followed by E. coli, S. aureus, Acinetobacter spp (MDR), K. pneumoniae,     Table 4-A.2) and Fig. 5.
The result shows 27.5% of the infections were MDR infections. MRSA was the most aggressive pathogen among the multidrugresistant isolates (MDR) for wound cultures, which formed more than 51% of MDR agents, followed by Acinetobacter spp. (MDR), and then by Enterobacter spp MDR (Table4-A.3) and Fig. 6.
In diabetic foot ulcer swabs, 17 pathogens were isolated. One yeast and 16 types of bacteria.
S. aureus was the most frequent pathogen followed by E. coli, Acinetobacter spp. (MDR), K. pneumoniae, P. aeruginosa, and P. mirabilis. Enterobacter spp. ESBL, CoNS, and Streptococcus viridans were the less frequent pathogens. Candida spp. were recorded as one of the causes of infection in two cases. Nineteen patients had no pathogenic microbes (Table 4-B.1) and Fig. 7.
The result showed that 3.3% of the wounds were mixed infections caused by more than one bacterium; all of the mixed infections were in diabetic patients (Table 5).
Acinetobacter spp. (MDR) and MRSA were the most frequent combination in mixed infections by percent of 27.3% of the total infections of wounds, followed by E. coli and MRSA, E. coli ESBL and P. vulgaris, Enterobacter spp. MDR and P. aeruginosa and S. aureus, P. aeruginosa and Acinetobacter spp. (MDR), S. aureus and nonhemolytic streptococci, Acinetobacter spp. (MDR) and P. mirabilis, K. oxytoca ESBL and MRSA, and MRSA and K. pneumoniae (Table 6) and Fig. 12.

DIscussIoN
Wound infections are becoming an actual burden of lesions globally. Recently, the World Health Organization reported a catalog of antibiotic-resistant "priority pathogens." In this catalog was a list of 12 families of bacteria that are the greatest threat to human health. At the top of the list was the most important causative pathogen in wound infection MRSA, which is spreading globally and constitutes the cause of approximately 20% of wound infections. The prevalence of antibiotic-resistant strains of S. aureus is increasing at an alarming rate. The highest resistance was recorded against ampicillin and erythromycin (88% each), while resistances against oxacillin, fosfomycin, cefoxitin, and ciprofloxacin were also worrisome 8 .
In this study, the results showed that MRSA accounted for 16 Fig. 4. 4,9 .
Infection with MDR gram-negative organisms in most cases leads to poorer outcomes in burns, especially in critical cases. These bacteria and the future horror of multidrug-resistance (MDR), the challenge among Jordanian healthcare providers, and the patients suffering from complications demonstrate the actual burden of infections and the progression of the infections cause the causative bacteria to be highly resistant to wound infections. This study showed that approximately 67% of the infections are caused by gram-negative bacteria while approximately 32% are caused by gram-positive bacteria, which is within the global ratios 9,10 . The highly significant (p<0.001) MDR results are drawing attention to focusing more on handling and taking care of the management and treatment of wounds in Jordan. The risk of developing high drug-resistant isolates of wound was high, approximately 32% of the total infections. The new types of bacteria, especially E. coli ESBL, K. pneumoniae ESBL, K. pneumoniae carbenem resistant, P. mirabilis ESBL, K. oxytoca ESBL, Enterobacter ESBL spp., and VRE, constituted 8.8% while the actual MDR constituted 23.2% (see Table 4-A.2) and Fig. 5 10 .
The high cost and lack of well-trained multidisciplinary medical personnel, facilities, and standardized management protocols are possible contributory factors. Physicians also have an important role in the prevention, early diagnosis, and management of infections of wounds with multidrug resistant or high resistant microbes for chemotherapies. MDR isolates of foot ulcers were reported though the patients reported that the ulcers resulted from spontaneous blisters or physicians reported the ulcers as wounds. There is a small percentage of overlap between diabetic foot ulcers and diabetic wounds, therefore, there is a possibility that some of the ulcers may have resulted from unnoticed micro-trauma. Inappropriate footwear might lead to spontaneous blisters; this was found to be the second commonest predisposing event for DFU. In addition, fitting of footwears in patients with peripheral neuropathy may result in foot ulcerations in patients with insensate feet. The use of disordered machines or tools and abnormal weight-bearing in peripheral areas of the foot in patients with peripheral neuropathy could make the foot susceptible to ulceration while wearing shoes.
Self-inflicted burns due to thermal injury resulting from the application of hot compresses to numb feet precipitated two cases of DFU. This might cause ulcerations and wounds or burns and should be taken care of in foot ulceration studies 11 . Thus, there is a need to ensure that better-focused education and the determination of the best way to handle and take care of ulcer foot cases on appropriate footwear, foot care, and other harmful practices be intensified among these patients.

The bacteriological pattern of diabetic foot ulcers
In the present study, a total of 17 different microorganisms were isolated from the participants, with mixed gram-positive and gramnegative species and the yeast Candida albicans; an average of 1:4 gram-positive aerobic bacteria, 4:1 gram-negative aerobic bacteria, and 1:16 yeast gave an overall average of 0.13% (6.7) organisms per case. This is similar to the findings of a study in the USA, which had a larger sample size 12 .
The predominance of gram-negative aerobes has also been reported by field workers and previous studies 13 . These differences could be partly due to changes in the causative organisms occurring over time, and the capability of microbes to develop more resistance to antibiotics. It might also be affected by geographical variations or the types and severity of the infection. The differences in results might be due to the use of a "relatively small number of specimens", and limited specimen collection techniques, which would fail to exclude superficial or colonizing organisms, poor handling techniques, and poor preservation methods, which might affect the cultivation of anaerobic organisms 14,15 .

The bacteriological pattern of pus sample isolates
In the present study, a total of 18  Table  4-C.1) and Fig. 9. 16 . The multidrug resistant bacteria in pus isolates represented 14.3% of all the infections and the main causative agents were Acinetobacter spp. (MDR), which is prevalent in Jordan as the cause of nosocomial infections. This explains its predominance in pus and chronic infections than MRSA, which is one of the main causes of wound infection worldwide (Table 4-C.3) and Fig. 11. 1,2,12,17 .
Most (27.3%) of the cases of mixed infections were caused by Acinetobacter spp. (MDR) and MRSA, which may be due to hospitalacquired infections and/or the aggressiveness of these bacteria. Mixed infections by more than two microbes were very rare; only one such case was reported in the present study with three mixed causative agents; Enterobacter spp. MDR, P. aeruginosa, and S. aureus. This is an indication of the low chance of multibacterial infections by more than two organisms ( Table 6) and Fig. 12.

coNclusIoN
The global burden from multidrug resistant bacteria affects wound infections, either in hospital-acquired infections or communityacquired infections. The main causative agents of wound infections are MRSA, E. coli, P. aeruginosa, and Acinetobacter spp. (MDR). Gram-negative bacteria caused more than 67% of the infections compared with gram-positive bacteria. Diabetic patients have more predisposition to mixed infections than the non-diabetic patients.

suPPlEMENTARy INFoRMATIoN
Supplementary information accompanies this article at https://doi.org/10.22207/JPAM. 15.3.25 Additional file: Additional Table. AcKNoWlEDGMENTs We would like to thank the entire microbiology department and medical directory in Islamic hospital, Jordan for the collaboration during the recruitment process and provided surveillance data.