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smoking. Both smokers and non smokers were aware of the health hazards of smoking but facts like risk of heart attack and GI malignancy, effect on pregnancy and hazard of passive smoking were less known. Unlike other studies which show a higher proportion of smokers with a family member smoking,3,5 in our study no difference was noted. Tobacco use in children of age 10 to 15 years has been reported.5 In our study onset was noted in 16 to 20 year age group. Knowledge score on smoking was higher in males in this study. This could be due to the larger number of males in the study and that the exposure to smoking may be more in males. Among those who preferred the company of smokers more males preferred it. Supari and pan use were significantly higher among the smokers than non smokers. More males felt that antismoking campaigns are not useful to control smoking than the females. The study emphasizes that knowledge on health hazard on certain aspects has to be filled in, but knowledge imparting may not be the only component in effective control of smoking. SUMMARY 176 Arts students out of 450 students doing their under-graduation in an age range of 17 to 24 years returned a questionnaire designed to test their level of knowledge about smoking, attitude towards smoking and practice of smoking. 96.6% of the respondents were aware of the injurious

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nature of smoking. Potential to induce lung cancer was known by 93.2% of them, but only 34.1% knew it was a factor for GI malignancy. A higher proportion of males had good knowledge whereas females had moderate knowledge (p = 0.04). The incidence of smoking was 33.1%. A higher proportion of smokers chewed pan and consumed supari. 68.2% of smokers wished to quit smoking. Easy availability (47.7%) and influence of friends (34.1%) were the predominant reasons to smoke. Interestingly, 48% of males felt that smoking women had appeal. Anti smoking campaigns in addition to provision of information has to focus to towards a change in attitude to smoking. REFERENCES 1. Kapoor SK, Anand K, Kumar G. Prevalence of tobacco use among school and college going adolescents of Harayana. Indian J Pediatr 1995;62:461-6. 2. Gavarasana S, Dodd VP, Prasad GV, Allam A, Murthy BS. Smoking survey of college students in India: Implications for designing an anti smoking policy. Jpn J Cancer Res 1991;82:1425. 3. Singh SK, Narang RK, Chandra S, Chaturvedi K, Dubey AL. Smoking habits of medical students. Indian J Chest Dis Allied Sci 1989;31:99-103. 4. Venkataraman S, Mukhopadhya A, Muliyil J. Trends of smoking among medical students, Indian J Med J Res 1996;104:316-20. 5. Jayant K, Notani PN, Gulati SS, Gadre VV. Tobacco usage in school children in Bombay, India. A study of knowledge attitude and practice. Indian J Cancer 1991;28:139-47.

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IMIPENEM RESISTANCE IN NONFERMENTERS CAUSING NOSOCOMIAL URINARY TRACT INFECTIONS N TANEJA, S MAHARWAL,* M SHARMA,**

INTRODUCTION Nonfermentative gram-negative bacilli (nonfermenters) are generally saprophytic in nature but can cause a significant number of infections, particularly in the hospitalised patients and compromised hosts. Pseudomonas aeruginosa and Acinetobacter baumanii are most common nonfermenters pathogenic for humans. Infections caused by other species are relatively infrequent. 1 Antimicrobial treatment of the nosocomial infections caused by these agents may be compromised by multiple drug resistance to β-lactams, aminoglycosides and 2,3 fluoroquinolones. Imipenem, a broad spectrum β-lactam antibiotic and the first carbapenem to be used for clinical use, is an impor tant drug for treatment of such infections. Imipenem offers the advantage of being more stable to most β-lactamases than the third generation cephalosporins. 4 Unfortunately paralleling its increasing use in the west, resistance to imipenem has Assistant Professor; *Ph.D student; **Professor & Head, Depar tment of Medical Microbiology, PGIMER, Chandigarh 160012.

Correspondence: Dr. Meera Sharma, Professor & Head, Department of Medical Microbiology, PGIMER, Chandigarh 160012. Email:[email protected]

Accepted on 13-3-2003. Ind J Med Sci Vol. 57 No. 7, July 2003

Ind J Med Sci Vol. 57 No. 7, July 2003

increased mainly among gram negative bacilli and particularly P. aeruginosa. 4,5 In the SENTRY Antimicrobial Surveillance program (SASP), 10 to 30% of P. aeruginosa strains from various countries have been found to be resistant to imipenem. The nosocomial strains of nonfermenters exhibited a higher level of resistance. Though imipenem is not yet licensed in India, it is being used in the treatment of complicated infections not responding to other antimicrobial agents. To the best of our knowledge, no published data is available as far as resistance to this drug in nonfermenters is concerned. Therefore, the present study was undertaken to find out the minimum inhibitory concentration (MIC) of imipenem for nonfermenters causing nosocomial UTI, to study the antibiotic resistance to other antimicrobial agents and to compare the difference in antibiotic susceptibility among imipenem sensitive and resistant strains. MATERIAL AND METHODS Test organisms : A total of 85 strains of nonfermenters isolated in pure culture and significant numbers from same number of patients suffering from nosocomial urinary tract infections were taken up for the study. The strains were identified and characterized

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by the following tests: gram strain, oxidase test, catalase test, motility both by hanging drop as well as semisolid agar method, citrate utilization, urease production, hemolysis on 5% sheep blood agar, growth in 6.5% NaCl, ability to grow on MacConkey’s agar, nitrate reduction, pigment production, indole production, lysine and ornithine decarboxylation, arginine dehydrolase test, growth at 40C and 420C, oxidation of 1 % glucose, xylose, lactose, maltose, sucrose and mannitol in Hugh Leifson’s medium, susceptibility to penicillin (10U) and polymyxin (3000). The identification was done as per the manual for identification of nonfermenters.7 The media were obtained from HiMedia laboratories, Bombay (India). Antibiotic Sensitivity : Antibiotic sensitivity was done by the disk diffusion method of modified Stokes.8 The Strains were tested against gentamicin (10µg), amikacin (100µg), ceftazidime (30µg), piperacillin (100µg) and ciprofloxacin (5µg). P. aeruginosa NCTC 10662 and E. coli NCTC 10418 were used as the control organisms. Antibiotic discs were obtained from HiMedia laboratories, Bombay (India). Minimum inhibitory concentration of Imipenem : (Merck, Sharp and Dohme Co) was done by the agar dilution method. Briefly Mueller - Hinton agar plates with the following concentrations of the antibiotic were prepared 1,2,4,8,16,32,64 & 128 µg/ml. The strains were incubated overnight into the Mueller -

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Hinton broth. Next day the turbidity was adjusted to 0.5 McFarland and the broths were diluted 1:100 to give an inoculum of 10 4 colonies/10µ spot. The plates were incubated overnight at 370C. P. aeruginosa NCTC 10662 and E. coli NCTC 10418 were used as control strains. Isolates were classified as either resistant (R) (MIC > 16µg/ ml) or susceptible (S) (MIC < 4 µg/ml) or intermediately sensitive (IS) if MIC was 8 µg/ ml.

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Table 1:Susceptibility of nonfermenters to imipenem

Species

No.

Sensitive

Intermediate Sensitive

Resistant

Statistical analysis : Statistical analysis was done by applying Chi-square test.

Pseudomonas aeruginosa Acinetobacter baumanii Pseudomonas putida Acinetobacter calcoaceticus Acinetobacter Iwoffii Alcaligenes xylosooxidans sub sp. Xylooxidans Alcaligenes piechaudii Weeksella virosa Pseudomonas putrifaciens Pseudomonas vesicularis Pseudomonas maltophilia Acinetobacter junnii Alcaligenes fecalis Flavobacter odoratum Flavobacter inologenes CDC 11g Pseudomonas pickettii Acinetobacter hemolyticus Total

31 27 03 03 03 03 02 02 01 01 01 01 01 01 01 01 02 01 85

13(42%) 19(70%) 01 02 02 00 00 02 01 00 01 00 01 00 00 00 01 00 43(50.5%)

5(16%) 03(11%) 02 00 00 01 00 00 00 00 00 00 00 00 00 00 00 00 11(12.9%)

13(42%) 5(18.5%) 00 01 01 02 02 00 00 01 00 01 00 01 01 01 01 01 31(36.4%)

RESULTS

Table 2:Percentage resistance of nonfermenters to other antimicrobial agents

Organism

The 85 strains included Pseudomonas spp. (39); Acinetobacter spp (35); Alcaligenes spp (6), Flavobacter spp (2), Weeksella virosa (2) and one strain of CDC IIg. Overall 36.4% of the strains were resistant (R) and 12 % were intermediately sensitive (I S) to imipenem. Forty-two percent of P. aeruginosa and 18.5% of Acinetobacter baumanii were imipenem resistant. Other strains which were resistant to imipenem included Alcaligenes spp (4/6), Acinetobactercalcoaceticus (1/3), Acinetobacterlwoffi (1/3), Acinetobacterhemolyticus (1/1), Acinetobacterjunii (1/1), Burkholderia (Pseudomonas) pickettii (1/2), Burkholderia vesicularis (1/1), CDC IIg (1/1) and Flavobacter odoratum (1/1) and Flavobacter indologenes (1/1) (Table 1). The table 2 depicts the percentage resistance Ind J Med Sci Vol. 57 No. 7, July 2003

P. aeruginosa N=31 Acinetobacter Spp N=35 Flavobacter Spp N=5 Alcaligenes Spp N=6 Overall resistance N=85

G

Ak

Cef

Nt

Pp

Cip

19 (61.2%) 29 (82.8%) 4 (80%) 5 (83.3%) 63 (74.1%)

14 (45.1%) 17 (48.5%) 4 (80%) 2 (33.3%) 39 (45.8%)

21 (67.6%) 26 (74.2%) 4 (80%) 5 (83.3%) 60 (70.5%)

19 (61.2%) 22 (62.8%) 4 (80%) 4 (66.6%) 52 (61.1%)

15 (48.3%) 14 (40%) 4 (80%) 4 (66.6%) 38 (44.7%)

26 (83.8%) 24 (68.5%) 4 (80%) 3 (50%) 60 (70.5%)

G-gentamicin, Ak-amikacin, Cef-ceftazidime, Nt-netilmicin, Pp-piperacilin, Cip- ciprofloxacin.

to other antimicrobial agents. A high level of drug resistance was observed (>70% for ceftazidime, gentamicin and ciprofloxacin). Least resistance was observed for piperacillin and amikacin (approximately 45% each). Seven out of 31 strains were multi drug resistant. P. aeruginosa (MDR PSA- defined3 as P. aeruginosa resistant to gentamicin, piperacillin, ceftazidime and imipenem). The difference in the antibiotic susceptibility Ind J Med Sci Vol. 57 No. 7, July 2003

to other agents among the imipenem susceptible (n=54) and imipenem resistant (n=31) is depicted in table 3. The difference was not statistically significant even for piperacillin. DISCUSSION Nonfermenters are ubiquitous in the environment. Usually considered as

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Antibiotics

Imipenem resistant n=31

Imipenem susceptible and moderately susceptible (n=54)

Gentamicin Amikacin Caftazidime Netilimicin Piperacillin Ciprfloxacin

23 (74.1%) 14 (45.1%) 22 (70.9%) 19 (61.2%) 16 (51.6%) 22 (70.9%)

40 (74.0%) 25 (46.2%) 38 (70.3%) 33 (61.1%) 22 (40.7%) 38 (70.3%)

contaminants they have emerged as important nosocomial pathogens especially in immunocompromised hosts. These organisms cause a variety of infections including UTI,9,10 ( Antibiotic resistance is a major clinical problem in treating infections caused by these microorganisms. A combination of a b-lactam agent and an aminoglycoside has most commonly been used for treatment especially the ones caused by P. aeruginosa;9,11 Other antibiotics which have been used are 7,8 fluoroquinolones. The resistance to the antimicrobials has increased over the years. Resistance rates vary from country to country. 3,6 Overall, isolates from Latin American countries show the lowest susceptibility rates to all antimicrobial agents followed by Asian-Pacific isolates and European strains. Strains from Canada exhibit the best global susceptibility testing results. (SENTRY Antimicrobial Surveillance Program, SASP).3,6 The reported resistance (R) rates for P. aeruginosa in this program were as follows : ciprofloxacin (16 to 40%); piperacillin and ceftazidime (15 to 35%) and amikacin (3 to 31 %). Similarly, the resistance

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rates for Acinetobacter spp were ciprofloxacin (27 to 65.5%); piperacillin (23 to 72.9%); ceftazidime (19.8 to 65.6%) and amikacin (8 to 62.6%). The nosocomial strains from Latin American countries exhibited the maximum resistance. 6 The results of our study are comparable to the situation in Latin America. Overall, approximately seventy percent of the strains were resistant to ciprofloxacin, ceftazidime, gentamicin and netimicin. Piperacillin and amikacin showed the best in vitro susceptibility pattern (approximately 45% R). These results are also comparable to those found in the SASP where amikacin had the best antimicrobial susceptibility profile. Apar t from P. aeruginosa & Acinetobacter spp, Alcaligenes and Flavobacter also exhibited a high level of drug resistance to all the antibiotics. Least resistance was shown by other Pseudomonas spp. Imipenem is a carbapenem antibiotic, which is highly active against P. aeruginosa and Acinetobacter spp.1 This drug is highly blactamase stable and has an unusual property of causing a post antibiotic effect on gram negative bacteria.12 It is a small molecule, which can over come the poor outer membrane permeability of b-lactams for Pseudomonas by penetrating through the porin omp D2. Unfortunately paralleling its increasing use, resistance to this agent has also increased.5,9 The reported resistance varies from 10 to 30% in P. aeruginosa and 3 to 10.3% in Acinetobacter spp. In the present Ind J Med Sci Vol. 57 No. 7, July 2003

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study overall imipenem resistance was 36.4%; the rates for P. aeruginosa and Acinetobacter baumanii being 42% and 18.5% respectively. Other nonfermenters showed variable resistances. Some like Alcaligenes exhibited high level of resistance (4 out of 6) and other Pseudomonas spp showed relatively less resistance (2 out of 8). In the present study, seven out of 31 strains of P. aeruginosa were MDR PSA resistant to piperacillin, ceftazidime, imipenem and gentamicin. Maximum numbers (8.2%) of these are reported from Latin America, followed by Europe (4.7%), Asia Pacific (1.6%), USA (1.2%) and Canada (0.9%).3 Apart from piperacillin, all other antibiotic exhibited the same resistance profile among the imipenem S and R isolates. However, this difference was not statistically significant. In the present study, the high level of drug resistance was most probably due to inclusion of strains causing complicated nosocomial infections. In fact, some of the patients failed treatment with 3 to 4 antibiotics. Piperacillin and imipenem either alone or in combination with amikacin were used for treating the patients not responding to treatment with fluoroquinolones, aminoglycosides and ceftazidime. More studies are required to know the exact magnitude of the problem in India. SUMMARY Nonfermenting

gram-negative

Ind J Med Sci Vol. 57 No. 7, July 2003

bacilli

(nonfermenters) have emerged as important nosocomial pathogens causing opportunistic infections in immunocompromised hosts. These organisms show high level of resistance to b-lactam agents, fluoroquinolones and aminoglycosides. Imipenem is a carbapenem antibiotic, which can be very useful for treatment of infections caused by nonfermenters. Eighty-five nonfermenters causing nosocomial UTI were tesed for MIC to imipenem by agar dilution method. Resistance to other antimicrobial agents was compared between imipenem sensitive (S) and resistance (R) groups. Overall 36.4% of nonfer menters were resistant to imipenem. Forty two percent of

P. aeruginosa and 18.5% of Acinetobacter baumanii were imipenem resistant. Other nonfermenters showed variable resistance, resistance in Alcaligenes spp. being very high. More than 70% of the nonfermenters were resistant to ceftazidime, gentamicin and ciprofloxacin. Piperacillin and amikacin had the best invitro susceptibility. No significant difference was found in the antibiotic susceptibility profile among imipenem sensitive (S) or resistant (R) strains. REFERENCES 1. Fass RJ, Barnishan J, Solomon MC, Ayers LW. In vitro activities of quinolones, β-lactams, tobramycin and trimethoprim sulfamethoxzol

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2.

3.

4.

5.

6.

against nonfermentative gram-negative bacilli. Antimicrob Agents Chemother 1996;40X:14128. Bergogne-Berezin E. Resistance of Acinetobacter spp to antimicrobials overview of clinical resistance patterns and therapeutic problems, In: Bergogne-Berezin E, ML Joly Guillous, KJ Towner, eds. Acinetobacter : microbiology, epidemiolo infections, management. New York: CRC Press; 1996. pp. 133-83. Gales AC, Jones RN, Turnidge J, Rennie T, Ramphal R. Characterization of Pseudomonas aeruginosa isolates: occurrence rates, antimicrobial susceptibility patter ns and molecular typing in the global SENTRY antimicrobial surveillance program 1997-1999. Clin Infect Dis 2001;32(Suppl2):S146-55. Troillet N, Samore HM, Carmeli Y. Imipenem resistant Pseudomonas aeruginosa: risk factors and antibiotic susceptibility patterns. Clin Infect Dis 1997;25:1094-8. Gaynes RP, Culver DH. The National Nosocomial infections surveillance system. Resistance to imipenem among selected gram-negative bacilli in the United States. Infect Control Hosp Epidemiol 1992;13:10-4. Gales AC, Jones RN, Forward KR, Linares J, Sader HS, Verhoef J. Emerging importance of multi drug-resistant Acinetobacter

sp and Stenotrophomonas maltophilia as pathogens in ser iously ill patients: Geographic patterns, epidemiological features and trends in the SENTRY antimicrobial surveillance program 1997-1999. Clin Infect Dis 2001;32(Suppl2):S104-12. 7. Weyant SR, Moss CW, Weaver RE, Hollis DG, Jordan JG, Cook EC, et al. Identification of unusual pathogenic gram negative aerobic and facultative anaerobic bacteria, 2nd edn. Baltimore, Maryland, USA: The William & Wilkins Co; 1996. 8. Agarwal KC. Antibiotic sensitivity test by disc diffusion method. Ind J Pathol Microbiol 1974;17:149-59. 9. Ouinn PJ. Clinical problems posed by multiresistant nonfermenting gram- negative pathogens. Clin Infect Dis 1998;27(Suppl I):S11724. 10. Meharwal SK, Taneja N, Sharma SK, Sharma M. Complicated nosocomial UTI caused by nonfermenters. Indian J Urol 2002;18:123-8. 11. Nicoletti G, Stefans S. Survey of antibiotic resistance in gram negative nonfermentative bacteria other than pseudomonas in Italy. J Chemother 1994;6:20-4. 12. Neu HC. Resistance of Pseudomonas aeruginosa to imipenem. Infect Control Hosp Epidemiol 1992;13:7-9.

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KNOWLEDGE AND PRACTICES REGARDING INJURY CARE AMONG STONE QUARTZ WORKERS R R TIWARI,* R NARAYAN,* H N SAIYED**

Injuries are common occurrences in today’s world. However, certain occupation exposes the workers employed in it to unusual excess risk of injuries. Stone quartz industry, which provides livelihood to a large proportion of population, is one such occupation.1,2 This industry mostly being an unorganized one exposes the worker through dual risk. Firstly, being unorganized sector these are small industry devoid of mechanized processes. Processes such as screening, loading and unloading, etc. are all carried out manually. This exposes the workers to increased risk of getting minor and severe injuries. Secondly, the workers are not covered under any social security scheme and thus most of the times they do not get timely care for injuries. Additionally widespread prevalence of illiteracy among workers also prevents the workers from proper care of injuries. If the initial management of wounds and injuries is improper and inadequate, even minor injuries may be complicated by wound sepsis.3-5 Thus, the awareness about proper injury care among stone quar tz worker gains *Research Officer, Occupational Medicine Division; **Director, National Institute of Occupational Health, Ahmedabad.

Correspondence: Dr. Rajnarayan R. Tiwari, Research Officer, (Occupational Medicine Division, National Institute of Occupational Health, Meghani Nagar, Ahmedabad 380016, Gujarat. Ind J Med Sci Vol. 57 No. 7, July 2003

importance. Moreover, no such studies among this group of workers had been carried out, particularly in India. Fortified by this fact the present study was carried out to study the level of knowledge and practices about injury care among stone quartz workers. MATERIAL AND METHODS The present cross sectional study was carried out among the stone quartz workers of Chhotaudepur taluka of Gujarat state. A total of 137 stone quartz workers were included in the present study. Using inter view technique as a tool for data collection the details of demographic characteristics were recorded on predesigned proforma. The questions eliciting knowledge, attitude and practices of stone quartz workers were included in the second part of questionnaire. Statistical analysis included calculation of proportions and percentages. RESULTS The distribution of study subjects according to demographic characteristics is depicted in Table 1. Of the total 137 subjects, 75(54.7%) were males while 62 (45.3%) were females. Majority of the workers belongs to the age group of