aerobic bacteria isolates, drug susceptibility

I

AEROBIC BACTERIA ISOLATES, DRUG SUSCEPTIBILITY

PATTERN AND ASSOCIATED FACTORS AMONG CLINICALLY

SUSPECTED PATIENTS ADMITTED FOR WOUND INFECTION AT

DIL-CHORA REFERRAL HOSPITAL, DIRE DAWA, EASTERN

ETHIOPIA

M.Sc. Thesis

Adil Ibrahim

November 2016

Haramaya University

II

AEROBIC BACTERIA ISOLATES, DRUG SUSCEPTIBILITY

PATTERN AND ASSOCIATED FACTORS AMONG CLINICALLY

SUSPECTED PATIENTS ADMITTED FOR WOUND INFECTION AT

DIL-CHORA REFERRAL HOSPITAL, DIRE DAWA, EASTERN

ETHIOPIA

A Thesis Submitted to the Department of Medical Laboratory Science,

Postgraduate Programs Directorate

HARAMAYA UNIVERSITY

In Partial Fulfillment of the Requirements for the Degree of Masters of

Science in Medical Microbiology

Adil Ibrahim (BSc)

Major Advisor: Zelalem Teklemariam (MSc, Assistant Professor)

Co-Advisor: GudinaEgata (MPH. PhD.)

November 2016

Haramaya University

III

HARAMAYA UNIVERSITY

SCHOOL OF GRADUATE STUDIES

APPROVAL SHEET

I hereby certify that I have read and evaluated this Thesis entitled “Bacterial Isolates, Drug

Susceptibility Pattern and Associated Factors Among Patients Admitted for Wound Infection

at Dil-Chora Referral Hospital, Dire Dawa, Eastern Ethiopia” prepared under my guidance by

Adil Ibrahim. I recommend that it be submitted as fulfilling the thesis requirements.

Mrs. Zelalem Teklemariam _________ _________

Major Advisor Signature Date

Dr. Gudina Egata ______________ __________

Co-Advisor Advisor Signature Date

As a member of the Board of Examiners of the MSc Thesis Open Defense Examination, I

certify that I have read and evaluated the Thesis prepared by Adil Ibrahim and examined the

candidate. I recommend that the thesis be accepted as fulfilling the Thesis requirements for

the degree of Masters of Science in Medical Microbiology.

______________________ ___________________ ___________

Chairperson Signature Date

______________________ ___________________ ___________

Internal Examiner Signature Date

______________________ ___________________ ___________

External Examiner Signature Date

Final approval and acceptance of the Thesis is contingent upon the submission of its final

copy to the Council of Graduate Studies through the candidate’s department or postgraduate

programdirectorate.

IV

STATEMENT OF THE AUTHOR

By my signature below, I declare and affirm that this thesis is my own work. I have followed

all ethical and technical principles of scholarship in the preparation, data collection, data

analysis and compilation of this thesis. Any scholarly matter that is included in the thesis has

been given recognition through citation.

This thesis is submitted in the partial fulfillment of the requirements for the degree of masters

of Sciences in Medical Microbiology at Haramaya University. The thesis is deposited in the

Haramaya University Library and is made available to borrowers under the rules of the

Library. I solemnly declare that this thesis has not been submitted to any other institution

anywhere for the award of any academic degree, diploma or certificate.

Brief questions from thesis may be made without special permission provided that accurate

and complete acknowledgement of the source is made. Requests for permission for extended

quotations from or reproduction of this thesis in whole or part may be granted by the head of

the school or department when in his or judgment the proposed use of the material is in the

interest of scholarship. In all other instances, however, permission must be obtained from the

author of the thesis.

Name: Adil Ibrahim Mussa

Signature: ________________

Date: ___________________

School/Department: ______________________

V

BIOGRAPHICAL SKETCH

I was born in 1990 GC in Dire Dawa Town. I completed my Elementary and junior education

in Laghare primary and secondary School, Grade 9 and 10 in Meahdel-nur Al-Islamic

Primary and Secondary School and Grade 11 and 12 in Jigjig Senior Secondary School. Then

I have graduated from Wollega University with Bachelors of Science in Medical Laboratory

Sciences in 2012 GC. After graduation, I have been working at Dire Dawa Dil-Chora

Referral Hospital as Junior Laboratory Technologist.

VI

ACKNOWLEDGEMENTS

First I would like to thank Haramaya University, College of Health and Medical Sciences

department of Medical Laboratory Sciences

My acknowledgement also extends to Haramaya University, Postgraduate Programs Directorate

For most I would like to express my deepest gratitude and appreciation to my advisor Mr.

Zelalem Teklemariam and Co–Advisor Dr. Gudina Egata for their valuable scientific advice,

continuous encouragement and overall for their contribution for the preparation of this Research

thesis. I am grateful to my friend Mr. Hamdi Ibrahim and Mrs. Seada Abdurehman for their

continuous support in my academic journey and financial support.

My heartfelt gratitude also extends to all the Institutional Health Research Ethics Review

Committee for their constructive comments given to finalize the development of this thesis.

My great thanks goes to my study participants for their full of participation, Mr. Adugna senior

clinical nurses who collected specimens from study participant and Ms. Iman who collected the

questionnaire from study participants.

My deep gratitude also goes to Mr. Behailu Derese and Mrs. Elisabeth Tadesse for their useful

comments and ideas.

I would like to thank all staff members of Dil-Chora Hospital Laboratory for their precious

support in every circumstance.

VII

ABBREVIATOINS

AOR Adjusted Odds Ratio

ATCC American Type Culture Collection

CLSI Clinical and Laboratory Standard Institute

CONS Coagulase Negative Staphylococcus

CSA Central Statistical Agency

DDARHB Dire Dawa Administration Regional Health Bureau

EPHI Ethiopian Public Health Institute

FMHACA Food, Medicine, Healthcare Authority and Control Agency

GNB Gram Negative Bacilli

GPB Gram Positive Bacilli

HMIS Health Management and Information System

MDR Multi- Drug Resistance

MHA Muller Hinton agar

MRSA Methicillin Resistance Staphylococcus Aureus

NHS Non Hemolytic Streptococcus

PFSA Pharmceutical Fuand and Supply Agency

SPSS Statistical packaging for social science

SSI Surgical Site Infection

WHO World Health Organization

VIII

TABLE OF CONTENTS Page No

STATEMENT OF THE AUTHOR IV

BIOGRAPHICAL SKETCH V

ACKNOWLEDGEMENTS VI

ABBREVIATOINS VII

TABLE OF CONTENTS VIII

LIST OF TABLES XI

LIST OF FIGURES XII

ABSTRACT XIII

1. INTRODUCTION 1

1.1 Background 1

1.2 Statement of the Problem 3

1.3 Significance of the Study 5

1.4 Objectives 6

1.4.1 General Objective 6

1.4.2 Specific Objectives 6

2. LITERATURE REVIEW 7

2.1. Magnitude of bacteria isolates from wound infection 7

2.2. Drug susceptibility patterns of bacteria isolates from wound 10

2.3. Factors associated with bacteria isolates from wound infection 13

3. MATERIALS AND METHODS 18

3.1. Study Area and Period 18

3.2. Study Design 18

3.3 Source Population 19

3.4 Study Population 19

IX

3.5. Inclusion and Exclusion Criteria 19

3.5.1. Inclusion Criteria 19

3.5.2. Exclusion Criteria 19

3.6. Sample Size Determination 19

3.7. Sampling techniques 21

3.8. Data Collection method 21

3.9. Study Variables 26

3.9.1. Dependent/ Outcome Variable 26

3.9.2. Independent/ Explanatory Variables 26

3.10. Operational Definition of Terms 26

3.11. Data Quality Control 27

3.12. Data processing and Analysis 28

3.13. Ethical Considerations 28

4. RESULTS 30

4.1 Socio-demographic characteristics of the study participants 30

4.2 Bacteria isolates among clinically suspected patients admitted for wound infection 31

4.3. Drug susceptibility pattern of bacteria isolates among patients admitted for wound

infection 33

4.4. Factors associated with bacteria isolates among patients admitted for wound infection 37

5. DISCUSSION 42

6. CONCLUSION AND RECOMMENDATIONS 47

6.1 CONCLUSION 47

6.2 RECOMMENDATIONS 48

7. REFERENCES 49

8. APPENDIX 57

X

Appendix A: Participant Information Sheet and Informed Voluntary Consent Form for Study

Participant 57

Appendix B: Participant Information Sheet and Informed Voluntary Consent Form for Parents

or Guardians of Under 18 Years Study Participant 65

Appendix C: Information Sheet and Informed Voluntary Consent Form for Head of the

Hospital 73

Appendix D: Data Collection Format 75

Appendix E: Laboratory Data 87

Appendix F: Sample collection procedure \Sample examination procedure 91

Appendix G: Curriculum Vitae 97

XI

LIST OF TABLES Page No

Table 1. Socio-demographic characteristics of patients admitted for wound infection at Dil-Chora

Referral Hospital, Dire Dawa, Ethiopia, 2016 (N=188) 30

Table 2. Bacteria isolates among patients admitted for wound infection at Dil-Chora Referral

Hospital, Dire Dawa, Ethiopia, 2016 32

Table 3. Drug susceptibility pattern of gram positive bacteria isolates among patients admitted

for wound infection at Dil-Chora Referral Hospital, Dire Dawa, Ethiopia, 2016 35

Table 4. Drug susceptibility pattern of gram negative bacteria isolates among patients admitted

for wound infection at Dil-Chora Referral Hospital, Dire Dawa, Ethiopia, 2016 35

Table 5. Antibiogram of gram positive bacteria isolates among patients admitted for wound

infection at Dil-Chora Referral Hospital, Dire Dawa, Ethiopia, 2016 36

Table 6. Antibiogram of gram negative bacteria isolates among patients admitted for wound

infection at Dil-Chora Referral Hospital, Dire Dawa, Ethiopia, 2016 36

Table 7. Bi-variable analysis of Socio-demographic characteristics of bacteria isolates among

patients admitted for wound infection at Dil-Chora Referral Hospital, Dire Dawa, Ethiopia,

2016 37

Table 8. Bi-variable analysis of Clinical and other factors of bacteria isolates among patients

admitted for wound infection at Dil-Chora Referral Hospital, Dire Dawa, Ethiopia, 2016 38

Table 9. Bivariate and Multivariate analysis of socio-demographic and Clinical and other factors

of bacteria isolated among patients admitted for wound infection at Dil-Chora Referral Hospital,

Dire Dawa, Ethiopia, 2016 41

XII

LIST OF FIGURES Page No

Figure 1 Conceptual framework of bacteria isolates from wound infection, drug susceptibility

pattern and associated factors 17

Figure 2. Blood and Macckonkey agar 22

Figure 3. Gram posative and Gram negative bacteria 23

Figure 4. Biochemical test for gram positive and gram negative 23

Figure 5. Drug susceptibility pattern 24

Figure 6. Flow chart of the laboratory work for this study 25

Figure 7. Number of bacterial isolated from culture of wound infection specimens at Dil-Chora

Referral Hospital, Dire Dawa, Ethiopia, 2016 32

XIII

ABSTRACT

A wound is a breach in the skin and the exposure of subcutaneous tissue following loss of skin

integrity providing moist, warm and nutritive environment that is conducive to microbial

colonization and proliferation. Wound can be infected by a variety of microorganisms ranging

from bacteria to fungi and parasites as well as virus. The aim of this study is to identify bacteria

isolate, their drug susceptibility pattern and associated factors among clinically suspected

patients admitted for wound infection at Dil-Chora Referral Hospital from March 15/2016 to

June 14/2016. A hospital based cross-sectional study was used among a total of 188 patients

using purposive sampling techniques. Data on socio-demographic and clinical information and

other factors were collected using a pretested structured questionnaire. Wound swab/pus

discharge were collected and inoculated on Blood and Macckonckey agar. Biochemical tests and

Antimicrobial susceptibility test was performed following standard disk diffusion technique of

modified Kirby-Bauer method. Data were analysed using Statistical package for social science

(SPSS) version 16 software. The overall magnitude of bacteria isolated from wound infection in

this study was 89.4%. Staphylococcus aureus was the predominant organisms (32.9%) followed

by Proteus species (28.6), CONS (13.1%), P. aeruginosa (8.5%), Klebsiella species (6.1%), E.

coli (4.2%), Citrobacter (3.8%) and Providencia (2.8%). Gram positive bacteria showed high

frequency of resistance to ampicillin, penicillin and erythromycin. Gram negative bacteria

showed high frequency of resistance to ampicillin, chloramphenicol, cotrimoxazole, ceftriaxone

and doxycycline. The overall Multi drug resistance rate was 85%. Of the following risk factors:

Sex, Type of specimens and Type of ward was identified as a risk factor for wound infection.

The magnitude of bacteria isolated from wound infection in Dil-Chora Referral Hospital was

found to be high. Drug resistance was seen in 207/213(97.2%) of the isolated bacteria. Such

widespread resistance to antimicrobial agents is something serious because a few treatment

options remain for patients with wound infection. Amikacin, Gentamicin and Vancomycin are

best antibiotics for treatment of bacterial wound infection at Dil-Chora Referral Hospital and

other nearby health institutions at Dire Dawa.

Keywords: Bacterial isolates, Drug susceptibility pattern, Wound infection

1

1. INTRODUCTION

1.1 Background

Wound is a breach in the skin and the exposure of subcutaneous tissue following loss of skin

integrity caused by trauma, surgeries, burns and diabetic ulcers that could result in open or

closed wound infections. The wound infection can progress from acute to chronic state

depending on the interplay of different factors such as the age/ sex of the patients, immune

status, associated clinical condition, and virulence factors of infecting bacterial pathogens.

Trauma may be accidental or intentionally induced. Wound provides a moist, warm and nutritive

environment that is conductive to microbial colonization and proliferation that leads to serious

bacterial wound infections and death (Bowler et al., 2001; Dai et al., 2010).

Wound can be infected by a variety of microorganisms ranging from bacteria to fungi and

parasites as well as virus (Church et al., 2006). The most common bacterial organisms are

Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli, Klebsiella species and

Acinetobacter species (Gupta et al., 2002; Esebelahie et al., 2013).

In Ethiopia, different studies reported that the prevalence of bacteria isolates from wound

infection ranges from 70.2%-96.3%. Staphylococcus. aureus, Kelbsiella species, Eschiarcia.

coli, Proteus species, Pseudomonas species and Coagulase Negative Staphylococci were

reported as the most common pathogens (Dagnachew et al., 2014; Mohammedaman et al., 2014;

Girma et al., 2013).

The progression of a wound to an infected state is likely to involve a multitude of microbial or

host or operation related risk factors. Microbial factors like microbial load, and virulence

expressed by the types of microorganisms involved; host factors like the general health and

immune status of the host, diabetes, cigarate smoking, obesity, and coincident remote site

infections or colonization and operation related risk factors like prolonged hospital stay before

surgery, duration of the operation, tissue trauma, poor homeostasis and foreign material in the

wound (Olsen et al., 2008; Reichman & Greenberg, 2009).

2

The majority of wounds are characterized by a polymicrobial aerobic and anaerobic micro flora.

Therefore, careful use of broad spectrum antibiotics ’agents is likely to be the most successful

treatment in the management of infected wound. However, various antibiotics are frequently and

sometimes inappropriately prescribed or administered in wound treatments, which often leads to

the selection of antibiotic resistant bacteria strains (Adenike et al., 2012). There is a report of

high antibiotic resistance among pathogens of wound infections from different studies (Sani et

al., 2012; Girma et al., 2013; Reiye et al., 2014).

The study conducted on Multi drug resistance (MDR) bacterial isolates in infected wounds in

Jimma indicated that, the overall rate of MDR among gram positive isolates was 77%. About,

86.2% of Staphylococcus. aureus and 28.6% of Coagulase Negative Staphylococci (CONS) were

becoming MDR. Moreover, 30.1% of Staphylococcus. aureus showed resistance to six

antimicrobial classes (Oxacillin/Methicillin, Penicillin, Ampicillin and Vancomycin). About

21.4% of CONS was resistant to three classes (penicillin, tetracycline and phenicoles). The

overall MDR rate of gram negative bacteria was 59.3%. Relatively higher rate of MDR was seen

among Proteus, Klebsiella and Providencia species accounting average resistance of 74.8%,

69.6% and 75% respectively (Girma et al., 2013).

3

1.2 Statement of the Problem

Wound infections have been a problem in the field of medicine for a long time. The presence of

foreign materials increases the risk of serious infection even with relatively small bacterial

inoculums (Rubin, 2006). Infected wounds are likely to be more painful, hypersensitive and

odors, resulting in increased discomfort and inconvenience for the patient (Kotz et al., 2009).

Wound infections are the most expensive complications following surgery and moreover, it is

thought to be second most common type of nosocomial infections (Praveen and Neelima, 2013).

Nosocomial infections (Nis) are the infections acquired during the hospital stay and are

widespread. They are important contributors to morbidity and mortality. These infections

concern 2 million cases annually worldwide i.e., 5-15 per cent of hospitalized patients and up to

10 per cent of patients acquire more than one of this infection (Anusha et al., 2010).

Surgical site infection wounds (SSIs) are a worldwide problem that has far reaching implications

on patient morbidity and mortality as well as significant financial implications. Worldwide it has

an incidence of between 2-5%, with an incidence as high as 20% in colorectal surgery (Berrios,

2008). It is the third most common nosocomial infection, and the most common nosocomial

infection amongst surgical patients with up to 38% of nosocomial infections being due to

surgical site infections (Leigh, 2007). Patients whose surgery was complicated by a SSI had a 2-

11% higher risk of death. In those patients who died, 75% was directly attributable to the SSI

(Berrios, 2008). On average, it increases length of hospital stay and in America in 2002, it was

estimated to cost between $3000 up to $30,000 per incident of a SSI. This cost estimate excluded

cost to the patient after discharge from hospital (Berrios, 2008).

As of 2004, 11 million burns required medical care worldwide and resulted in 300,000 deaths.

This makes it the 4th leading cause of injuries after motor vehicle collisions, falls and violence.

About 90% of burns occur in the developing world (MD, 2011). An estimated 500,000 burn

injuries receive medical treatment yearly in the United States and about 3,300 deaths in 2008

(Marx, 2010). In developing countries 60% of fatal burns occur in Southeast Asia with a rate of

11.6 per 100, 000. The number of fatal burns has increased from 280,000 in 1990 to 338,000 in

2010 (Lozano, 2012). In India, about 700,000 to 800,000 people per year sustain significant

burns, though very few are looked after in specialist burn units (Lozano, 2012).

4

Up to 25% of individuals with diabetes will develop a foot ulcer during their lifetime (Singh et

al., 2005). In 2004 about 71,000 non-traumatic lower-limb amputations were performed in

people with diabetes in United States (CDC, 2008). Ulcers and other foot complications are

responsible for 20% of the nearly 3 million hospitalizations every year related to diabetes

(Anonymous, 2006). Adjusting for health-care inflation in 2007, foot ulcers cost between $7,439

and $20,622 per episode in United States (Rogers et al., 2008).

In Africa the rate of SSIs varied from 2.5% to 30.9% following various types of surgical

procedures (Sepideh et al., 2011). Studies have shown that the average hospital stays doubled

and that the cost of hospitalization was correspondingly increased when postoperative surgical

wound infection developed (Suchitra and Lakshmidevi, 2009). A study from Ethiopia reported

that the mean postoperative stay and mortality were significantly higher in patients with surgical

site infection compared with in uninfected patients (Taye, 2005).

The rapid emergence of antimicrobial among bacteria is a public health crisis. Wound infections

with antimicrobial-resistant bacteria increase patient morbidity, mortality and greatly increase

the cost of medical care (Theoklis, 2009). The control of wound infections has become more

challenging due to widespread bacterial resistance to antibiotics and a greater incidence of

infection caused by methicillin resistant S. aureus (MRSA) and polymicrobialflora (Sani et al.,

2012).

In most developing countries like Ethiopia, it is a common practice that antibiotics can be

purchased without prescription. This leads to misuse of antibiotics by the public thus

contributing to the emergence and spread of antimicrobial resistance (Mulugeta and Bayeh,

2011). The current spread of MDR bacteria pathogens has added a new dimension to the problem

of wound infections. A regular bacteriological review of infected wounds is therefore a necessity

if affected patients must receive quality care, particularly when blind treatment is a necessity, as

in underdeveloped and developing nations (Mohammad et al., 2013).

In Ethiopia, few studies reported that the associated risk factors of bacteria isolate from wound

were age, sex type of specimens and laparotomy type of surgery (Dagnachew et al., 2014;

Shewatatek et al., 2014; Amlsha et al at., 2014).

5

In Dire Dawa routine culture and sensitivity testing are not done and mostly treatment is on

empirical basis and the diagnostic dilemma of wound infection may lead to overuse of antibiotics

and development of resistant microbial species. There is no data on the current prevalence, its

association factor and drug susceptibility pattern of bacteria isolates from wound infection at the

study area. Therefore, this study was to assess aerobic bacteria isolates, drug susceptibility

pattern and associated factors among clinically suspected patients admitted for wound infection

at Dil-Chora Referral Hospital, Dire Dawa, Eastern Ethiopia.

1.3 Significance of the Study

Identification of pathogens and associated risk factors of wound infections will help health

facilities or health bureau to reduce morbidity, mortality, cost and long period of Hospital

admission due to wound infection in the study area.

Assessment of drug susceptibility pattern will benefit those patients, who have bacteria isolated

from their wound infection, by getting appropriate treatment based on their drug susceptibility

results. It will help health care workers to select the appropriate antibiotics for treatment of

bacteria isolates from wound which will minimize to them from inappropriate use of antibiotics.

Thus, the emergence of multi-drug resistant strain of bacteria will be reduced. In addition, it will

also guide PFSA (Pharmceutical Fuand and Supply Agency) in the distribution of essential

antibiotics among the health facilities.

The finding of this study will be also use as important information regarding wound infection for

Dil-Chora Referral Hospital to treat wound infection and Dire Dawa Health Bureau (DDHB) to

assess further study on this area. This research with other similar studies done in Ethiopia will

provide reliable data about the distribution of bacterial pathogen among wound infection patients

in different parts of the country which will help the Ministry of Health and other concerned

bodies working on wound infections to take appropriate measures or set guideline about wound

infection management.

6

1.4 Objectives

1.4.1 General Objective

To assess aerobic bacteria isolates, drug susceptibility pattern and associated factor among

clinically suspected patients admitted for wound infection at Dil-Chora Referral Hospital, Dire

Dawa, Eastern Ethiopia from March 15/2016 to June 14/2016.

1.4.2 Specific Objectives

To determine the magnitude of bacteria isolates among clinically suspected patients

admitted for wound infection at Dil-Chora Referral Hospital.

To describe the drug susceptibility pattern of bacteria isolates among clinically

suspected patients admitted for wound infection at Dil-Chora Referral Hospital.

To identify factors associated with bacteria isolates among clinically suspected

patients admitted for wound infection at Dil-Chora Referral Hospital.

Research Hypothesis: Is a statistical test that is used to determine whether is enough evidence

in a sample of data to infer that a certain condition is true for the entire population.

7

2. LITERATURE REVIEW

2.1. Magnitude of bacteria isolates from wound infection

A research to find the incidence and screening of wound infection causing microorganisms was

done by Valarmathi et al in Namakkal, India from March-April 2011. A total of 19 patients with

different types of wounds samples were collected during study period. Totally 78.9% of sample

exhibited 24 isolates. Among them, Staphylococcus aureus (54.1%) was the predominant isolate,

second most was Klebsiella pneumonia (20.8%) followed by Pseudomonas aeruginosa (16.6%)

and the lowest percentage was recorded by Escherichia coli (8.3%) (Valarmathi et al., 2013).

Another study on the Antibiotic susceptibility of bacterial strains isolated from wound infection

patients was done by Manikandan and Amsath in Pattukkottai, Tamilnadu, India. A total of

seventy wound swab specimens were collected and cultured, of which all samples showed

bacterial growth. Six different species of bacteria were isolated. Pseudomonas aeruginosa was

the predominant (30 isolates; 42.9%) followed by Staphylococcus aureus (17 isolates; 24.3%),

Staphylococcus epidermidis (11 isolates; 15.7%). Proteus species, (6 isolates; 8.6%),

Escherichia coli (4 isolates; 5.7%) and Klebsiella species (2 isolates; 2.8%) (Manikandan

andAmsath, 2014).

According to a research done to determine the Antimicrobial susceptibility pattern among

Aerobic bacteriological isolates in infected wounds of patients done by Vikas et al at tertiary care

Hospital in Central India from July to September 2013, Out of 234 pus samples received for

culture and sensitivity 137 (58.52%) cases yielded positive culture while 97 (41.48%) cases had

no growth. Among the 137 culture positive pus samples, 79 (57.66%) sample yielded Gram

negative bacilli (GNB) and 58 (42.34%) samples yielded Gram positive bacilli (GPB). Out of

GNB isolates Escherichia coli 37 (27.01%) was the commonest organism followed by

Pseudomonas aeruginosa 28 (20.44%), Klebsiella species 9 (6.57%) and Acinetobacter 5

(3.65%). Amongst GPBStaphylococcus aureus 46 (33.6%) was the common organism followed

by Enterococci 7 (5.11%) and Coagulase Negative Staphylococcus (CoNS) 5 (3.65%) (Vikas et

al., 2015).

Study done on the Antimicrobial susceptibility pattern of bacterial isolates from wound infection

and their sensitivity to antibiotic agents which was done by Hrishikesh et al at super specialty

8

hospital, Amravati city, India from January 2012 to December 2013. Seventy-eight bacterial

isolates were recovered from 258 specimens showing an isolation rate of 31.2%. The

predominant bacteria isolated from wounds were gram positive Staphylococcispecies 36

(46.2%), followed by gram negative Streptococci species 18 (23.1%) gram negative

Pseudomonasspecies 12 (15.4 %) and gram negative Proteusspecies 8 (10.4%). The gram

positive and gram negative bacteria constituted 68 (87.2%) and 10 (12.8%) of bacterial isolates;

respectively (Hrishikesh et al., 2015).

Another study on the Antimicrobial Susceptibility Patterns of the Bacterial Isolates in Post-

Operative Wound Infections was done by Mohammad et alin a Tertiary Care Hospital,

Kathmandu, Nepal from January to September 2012. Pus swabs from 120 post-operative wound

infections were analyzed in this study and processed for culture. Bacterial isolates were obtained

from 96 pus swabs. The predominant isolates were gram positive bacteria 40 (41.67%). The most

frequently isolated organisms were Staphylococcus aureus 36 (37.5%) followed by Escherichia

coli 24 (25%), Klebsiella pneumonia 10 (10.4%) and Citrobacter species 9 (9.38%) (Mohammad

et al., 2013).

According to a research done to determine the Antibiotic Susceptibility Pattern of bacterial

isolates causing wound infection was done by Jaya et al amongthe Patients Visiting B & B

Hospital, Lalitpur, Nepal, of 870 sample processed, 390 (44.1%) showed their growth, Gram

negative bacteria were found 70.6%, while Gram positive bacteria in 29.4%. Among the gram

negative isolates Pseudomonas. aeruginosa 106(31.5%) was the most predominant followed by

Escherichia coli 82(24.4%), Acinetobacter species 49(14.6%), Enterobacter species 47(14.0%)

and Klebsiella species 45(13.4%). Other bacteria like Proteus species 6(1.8%) and Citrobacter

species 1 (0.3%) were lower in a number. Similarly, among Gram positive bacteria, S. aureus

104 (74.2%) was the most common isolates followed by CONS 12 (8.6%), NHS 12 (8.6%)

Enterococcus species and β Hemolytic Streptococci (Jaya et al., 2014).

A research to find the Bacteria colonization and Antibiotic susceptibility pattern of wound

infections was done by Motayo et al in a Hospital, Abeokuta, Nigeria from April 2009 to March

2010. A total of 209 samples from patients with various wound infections were processed for

culture from wound swabs. Gram negative organisms accounted for 80.2% of all isolates while

gram positive organisms accounted for 19.8%. Among gram negative organisms, Pseudomonas

9

aureginosa accounted for 45(25.4%), Escherichia coli 42(23.8%), Klebseilla species 36(20.3%)

and Proteus species 28(15.8%). For gram positive organisms only Staphylococcus aureus was

isolated with a frequency of 26(14.7%). Polymicrobial infections accounted for 2.8% of all

isolates recovered. (Motayo et al., 2013).

Other study done on the Aerobic bacteria isolates of septic wound infections and Their

Antibiogram was done by James et al in North Central Nigeria. A total of 345 wound swabs were

collected and examined in medical microbiology laboratory in which 243 (70.4%) aerobic

bacteria were isolated. Aerobic bacteria isolated from this study were Staphylococcus aureus

(45.2%), Klebsiella species (19.4%), Escherichia coli (12.9%), Proteus species (12.9%) and

Pseudomonas aeruginosa (9.7%) (James et al., 2015).

Another study on the Predominance of multi-drug resistant bacterial pathogens causing surgical

site infections was done by Joel et al in Muhimbili national Hospital, Tanzania from September

2011 to February 2012. Of the 100 wound swabs collected, 90% had bacterial growth. More than

half (52.2%, 47/90) had pure bacterial growth (mono isolate). Gram negative organisms were

more prevalent than gram positive bacteria accounting for 77.5% (114/147) of all isolates. The

most predominant gram negative organism was Pseudomonas aeruginosa comprising 16.3%

(24/147) of all bacteria isolates. Klebsiella pneumonia 10.8% (16/147) and Proteus mirabilis

10.8% (16/147) were the next two common gram negative organisms. Of the gram positive

isolates, Staphylococcus aureus was the leading cause of SSIs accounting 12.2% (18/147) of all

isolates, followed by CONS (6.8%) and Enterococcus faecalis (3.4%) (Joel, 2012).

A research to find the Antimicrobial susceptibility pattern of bacterial isolates from wound

infection and their sensitivity to alternative topical agents was done by Mohammedaman et al at

Jimma University Specialized Hospital, Ethiopia from May-September, 2013. Of the 150 swabs

131 (87.4%) were culture positive for bacterial pathogens, while 19 (12.6%) were

bacteriologically sterile. The presence of only one species isolated from each sample was the

most frequent (91.6%) while, more than one species isolated from the total swabs were (8. 4%).

A total of 145 bacterial isolates were obtained, 77 (53%) were gram negative while 68 (47%)

were gram positive. Staphylococcus aureus was the predominant organism isolated 47 (32.4%),

followed by Escherichia coli 29 (20%), Proteus species 23 (16%), coagulase negative

10

Staphylococci 21 (14.5%), Klebsiella pneumonia 14 (10%) andPseudomonas aeruginosa

11(8%). (Mohammedaman et al., 2014).

Another study on the Bacterial isolates and their antibiotic susceptibility patterns among patients

with pus and/or wound discharge was done by Dagnachew et al at Gondar university hospital

from September, 2009 to August, 2012. A total of 628 study subjects were included in the study

with bacterial isolation rate of 441 (70.2%). Two hundred eighty-two (63.9%) of the isolates

were gram positive and 159 (36.1%) were gram negative. About 331/ 441 (75.0%) of the total

isolates were Staphylococcus. aureus, (32.9%) Coagulase Negative staphylococci, (14.7%)

Streptococcus species, (11.6%) Escherichia coli, (9.5%) Klebsiella species and (6.3%)

Streptococcus pyogenes (Dagnachew et al., 2014).

2.2. Drug susceptibility patterns of bacteria isolates from wound

According to a research Antibiotic susceptibility pattern of bacterial isolates from wound

infection which was done by Rajendra et al in Chitwan Medical College Teaching Hospital,

Chitwan, Nepal from December 2011 to June 2012, Staphylococcus aureus species were highly

sensitive to amikacin (83.6%) followed by ceftriaxone (67.3%), ciprofloxacin (65.3%),

cephotaxime (55%), gentamicin (53.06%) and highly resistance to ampicillin (67.3%) and

cotrimoxazole (65.3%). Coagulase negative staphylococci showed 100% sensitivity to

vancomycin followed by amikacin (66.6%). Ofloxacin, ciprofloxacin and gentamicin all were

equally effective (55.5% sensitivity). However, high rate of resistance was observed for

cefotaxime (88.8%), ceftriaxone (77.7%) and cotrimoxazole (77.7%). Pseudomonas aeruginosa

exhibited 100% sensitivity to gentamicin & amikacin, (75%) sensitivity to ceftriaxone &

ofloxacin, (50%) sensitivity to ampicillin and cotrimoxazole whereas only 25% sensitivity to

cephotaxime (Rajendra et al., 2013).

According to a research on Antibiotic Sensitivity Pattern of Aerobic Bacterial Isolates in Wound

Infections which was done by Nitin et al in Navi Mumbai, India. Antibiotic sensitivity test

showed that the most effective antibiotics for Gram positive bacteria were Linezolid (87.2%) and

Ampicillin + Sulbactam (82.3%) whereas Cefotaxime (48%) was the least effective antibiotic.

The most effective antibiotic for Gram negative isolates was Amikacin (72.3%) followed by

11

Netilline (67.3%). Cefuroxime (21.9%) was the least effective antibiotic for Gram negative

bacteria (Nitin et al., 2015).

According to a research Culture and Sensitivity Pattern of Organisms in Infected Wounds which

was done by Ammar et al in Bahawal Victoria Hospital Bahawalpur, Pakistan from January 2014

to March 2014, Klebsiella was sensitive to combination of cefoparazone and sulbactam (91.6%),

moxifloxacin (83%), gentamycin (83%), tazobactam (70.8%), ceftriaxone (70.8%),

Ciprofloxacin (62.5%) and linezolid (12.5%). Pseudomonas was sensitive to tazobactam (80%),

ciprofloxacin (80%), combination of cefoperazone and sulbactam (53.3%), gentamycin (53.3%),

moxifloxacin (53.3%), ceftriaxone (33.3%) and linezolid (13.3%). Staphylococcus aureus was

sensitivity to linezolid (87.5%) (Ammar et al., 2015).

A research conducted on Analysis of Bacterial Pathogens Isolated from Wound Infections was

done by Bularafa et al in Nguru, Yobe State Nigeria from January to December 2013. The

bacterial pathogens demonstrated high resistance to ampicillin (78%), amoxicillin (66%), and

cotrimoxazole (78%), in contrast to high sensitivity pattern observed with fluoroquinolone

(ofloxacin 83%, norfloxacin 71%, and ciprofloxacin 78%), erythromycin 72%, chloramphenicol

62%, gentamycin 58% and ceftazidime 60% (Bularafa et al., 2015).

According to a research Risk factors for wound infection of aerobic bacterial pathogens and

Antibiogram of isolates which was done by Akoachere et al in health care facilities in Buea,

Cameroon from October 2010 to March 2011, all isolates (100%) were susceptible to ofloxacin

and pefloxacin but resistant to oxacillin. Other active drugs were ceftriaxone (94.3%),

gentamicin (97.2%), ceftazidime (89.7%), norfloxacin (76.7%) and Augmentin (76.4%). Low

susceptibility was recorded for chloramphenicol (6.5%), erythromycin (7.1%), co-trimoxazole

(22.6%), aztreonam (27.4%), doxycycline (34.2%) and ampicillin (39.6%) (Akoachere et al.,

2014).

According to a research on Multidrug-resistant bacterial isolates in infected wounds which was

done by Girma et al in at Jimma University Specialized Hospital, Ethiopia from May to

December 2011, The drug resistance profile of gram positive bacterial isolates tested for 16

antimicrobials showed that 94.5% of Staphylococcus. aureus was resistant to penicillin, 91.8% to

ampicillin and 76.7% to oxacillin. About 16.4% of Staphylococcus. aureus became vancomycin

12

resistant. Similarly, 68.3% of coagulase negativeStaphylococcus (CONS) was resistance to both

penicillin and ampicillin. Fortunately, CONS was 100% sensitive to many of the antimicrobial

drugs tested. On the other hand, the resistance patterns of gram negative bacteria isolates (n =

297) tested against nine antimicrobial drugs showed that P. aeruginosa was 97.3%, 87.8%, and

83.8% resistance to ampicillin, cotrimoxazole, and doxycycline respectively. Similarly,

Citrobacter species showed 100% resistance to ampicillin, cotrimoxazole and chloramphenicol

and 88.9% to doxycycline. Furthermore, Proteus species, showed 85% resistance to

chloramphenicol and 75.7% to cotrimoxazole. With the exception of Citrobacter and Proteus

species, all other gram negative isolates in this study showed relatively low resistance to

ceftriaxone, cefotaxime, norfloxacin, ciprofloxacin and chloramphenicol (Girma et al., 2013).

Similar study on Antimicrobial susceptibility pattern of bacterial isolates from wound infection

and their sensitivity to alternative topical agents was done by Mohammedaman et al at Jimma

University Specialized Hospital, South-West Ethiopia from May to September 2013. Gram

positive bacteria were tested against selected 14 antibiotics. The results obtained showed that the

organisms varied in their susceptibility to all the antimicrobials used. Majority of them showed

multi-resistances (resistance to two or more classes of antimicrobials). Rate of isolates resistant

to ampicillin was 94%, followed by penicillin G, 86.8%. All isolates were 100% susceptible to

vancomycin and amikacin, and showed low resistance to norfloxacin (10%), ciprofloxacin

(10%), sulphamethoxazole trimethoprim (8.8%) and gentamicin (8.8%). The susceptibility

patterns of gram negative bacteria (n = 77) isolated from wound infections and tested against

selected 11 antimicrobial agents. Rate of isolates resistant to ampicillin was 96%, followed by

cephalothin, 92.4% (Mohammedaman et al., 2014).

Another study on Aerobic bacteria in post-surgical wound infections and pattern of their

antimicrobial susceptibility was done by Reiye et al in Ayder Teaching and Referral Hospital,

Mekelle, Ethiopia from January to June 2012. Drug resistance of isolated Gram negative

bacteria, irrespective of species/genus, was 92.3% to Ampicillin, 92.3% to Tetracycline and

92.3% to Amoxicillin, 81.5% to Ceftriaxone, 69.2% to Amoxicillin Clavunilic-acid, 46.2% for

Ciprofloxacin, 26.2% to Erythromycin and 16.9% for Gentamicin. Klebseilla species, showed

100%, 93.1%, 89.7% and 86.2% resistance for Amoxicillin, Tetracycline and ceftriaxone,

respectively. P. aeruginosa isolates were 100% resistant for ceftriaxone, Amoxicillin,

13

Amoxicillin clavunilic-acid and Tetracycline. All P. aeruginosa isolates were; however, 100%

sensitive to Gentamicin. All the 15 (100%) Proteus species were resistant for Amoxicillin and

Tetracycline whereas, Gentamicin was 12/15 (80%) sensitive. Isolated E. coli showed 100%

resistance to Amoxicillin-clavulunic acid, Tetracycline and Ampicillin, whereas, all of them 6

(100%) were sensitive for Gentamicin. Isolated Citrobacter species were 100% sensitive to

Gentamicin, while all 4(100%) of them were resistant to Ampicillin. Resistance by S. aureus was

36/40 (90%) to Tetracycline, ceftriaxone and Ampicillin, and 34/40 (85%) to Cloxacillin. All of

the isolates S. aureus 40(100%) were sensitive for Vancomycin. High resistance rate of CONS

was observed for Amoxicillin, Amoxicillin-clavunilic acid, Ampicillin and Tetracycline, 88.9%,

77.8%, 77.8% and 77.8%, respectively. All isolates of CONS 18 (100%) were however, sensitive

for Vancomycin (Reiye et al., 2014).

2.3. Factors associated with bacteria isolates from wound infection

A research conducted on Factors associated with deep sternal wound infection and hemorrhage

following cardiac surgery was done by Penelope et al in Victoria from July 2001 to June

2005.When thediabetes patients compared with non-diabetes patients, diabetes patients were

2.50 times more at risk to get wound infection than non-diabetes patients (OR = 2.50, 95%CI:

1.79-3.74, P<0.000) (Penelope et al., 2006).

According to a research done on Prevalence and factors associated with wound colonization by

Staphylococcus species and Staphylococcus aureus was done by Gilmara et al in hospitalized

patients in inland northeastern Brazil, there were no significant associations between wound

colonization by Staphylococcus species and comorbidities, except for pneumonia and other

respiratory disease (p = 0.03). There were also no significant associations between wound

colonization by S. aureus and comorbidities. However, there was significant associations with

wound colonization by Staphylococcus species (p = 0.003). Multivariable analysis found that

wound colonization by S. aureus was independently associated with nasal colonization by S.

aureus, fewer days of prior antibiotic use, and admission to the medical ward. Age was close to

the threshold for independent association with wound colonization by S. aureus (Gilmara et al.,

2014).

14

According to a research done to determine the Antibiotic Susceptibility Pattern of bacterial

isolates causing wound infection was done by Jaya et al among the Patients Visiting B & B

Hospital, Lalitpur, Nepal. Of 870 sample processed, 390 (44.1%) showed growth. Among

growth positive cases, 304(77.9%) were mono isolates while 86(22.1%) had poly microbial

growth (56%).High rate of growth positive rate in infection was found in case of male gender

than female gender, i.e. 46.9% in male and 37.4% in female, which was found to be statistically

significant (p-value < 0.05). Among total growth, the highest growth rate was found in age group

21-30 (25.4%), followed by 31-40 (16.2%) and 11-20 (16.2%). Least growth was found in an age

group of 0-10 and above 60 years. A regard to the location of patients, high growth was found in

indoor patients (54.9%) than outdoor (OPD) patients (38.8%) and emergency patients (20.3%)

(Jaya et al., 2014).

Another study on Antibiogram of Bacteria Isolated from Wound Exudates was done by Arjun et

al in KIST Medical College and Teaching Hospital, Lalitpur, Nepal form November 2012 to

June 2013. Out of 83 S. aureus isolates, 42(50.6%) were isolated from inpatients and the

remaining 41(49.4%) were isolated from outpatients. Such a distribution of S. aureus among in-

patients and out-patients is statistically insignificant (p value 0.531 > 0.05). Among 83 S. aureus,

gender wise distribution of the isolates showed that 41(49.4%) were from female patients and

42(50.6%) were from male patients. However, there was no statistical significance of such

distribution pattern (p value; 0.118 > 0.05). Similarly, on the basis of age of the patient, the rate

of S. aureus infection was found to be higher in the adults (61.4%) than in the pediatric patients

(38.6%). Such distribution pattern of S. aureus on the basis of age-group was statistically

significant (p value; 0.027 < 0.05) (Arjun et al., 2015).

A research conducted on Microbiology of Wound Infections and its Associated Risk Factors was

done by Christopher et al among Patients of a Tertiary Hospital in Benin City, Nigeria from

January 2008 to December 2010. The overall prevalence of wound infections was 64.8%. The

prevalence of wound infections was 64.9% (796/1227) in males and 64.8% (540/834) in females

(P=0.332). In addition, the prevalence of mixed infection was 33.3% (265/1227) in males and

33.1% (179/834) in females (P=0.647). The prevalence of wound infections was significantly

affected by age (P=0.000. The minimum (20%) and maximum (77.5%) prevalence rates of

15

wound infections were seen among the age group of 1-5 and 36-40 years old (Christopher et al.,

2011).

Other study on Aerobic Bacteria Isolates of Septic Wound Infections and Their Antibiogram was

done by James et al in North Central Nigeria. Males had the highest prevalence of 82.1%

compared with the females who had 55.0%. The difference was statistically significant (p =

0.001) (James et al., 2015).

Another similar study on Current Microbial Isolates from Wound Swabs, their culture and

sensitivity pattern was done by Kemebradikumo et al at the Delta University Teaching Hospital,

Okolobiri, Nigeria from October 2010 to January 2011. There was no association between the

types of wound and the type of micro-organism isolated (p = 0.34). All swabs obtained from

patients with traumatic wounds yielded bacterial growth, and the majority of these patients were

male (95.45%). There was greater incidence of wound infection in the 21 to 30-year age group,

but there was no significant association between age and the incidence of wound infection (p =

0.23). There was no significant association between the types of organism isolated and the sex of

the subject (p = 0.66) or between the wound type and the sex of the subject (p = 0.7)

(Kemebradikumo et al., 2013).

According to a research risk factors for wound infection of aerobic bacterial pathogens and

Antibiogram of isolates was done by Akoachere et al in health care facilities in Buea, Cameroon

from October 2010 to March 2011. The highest rate of isolation was from the age group > 60

(84.2%) followed by 0-15 years (84.0%) and least (63.6%) in individuals 46-60 years. However,

the difference was not significant (p = 0.376). With respect to gender, bacteria were isolated

more from females (82%, 73/89) compared to males (78%, 96/123). The difference however,

was not significant (p = 0.478). There was no significant difference in the distribution of bacteria

in the various types of wounds (p = 0.972) (Akoachere et al., 2014).

A research conducted on Bacterial isolates and their antibiotic susceptibility patterns among

patients with pus and/or wound discharge was done by Dagnachew et al at Gondar university

hospital from September, 2009 to August, 2012. When we compared the culture positivity of the

samples, pus /discharge samples were 2.38 times positive for bacterial isolates than wound swab

samples Adjusted Odds Ratio (AOR = 2.38, 95%CI: 1.64-3.45, P < 0.0001). Among 441

16

isolates, 194/334 (58.1%) were from male and 247/284 (86.9%) were from female patients.

Females were found to be 5.16 times more at risk to get infection than males Adjusted Odds

Ratio (AOR = 5.16, 95% CI: 3.38-7.91, P < 0.0001). The majority of the patients who were

positive for wound culture were in the age range of 21 to 30 years, which was 113 (25.6%),

followed by in the age range of 1-10 years, which was 95 (21.5%); age range of 11-20 which was

70 (15.9%). Age was also found to have significant association with a p-value of 0.003

(Dagnachew et al., 2014).

Another study on Drug sensitivity of Pseudomonas aeruginosa from wound infections was done

by Shewatatek et al in Jimma University Specialized Hospital, Ethiopia from July 2009 to Feb

2010. Among the total 112 wound swab samples, 36 (32.1%) were shown growth of P.

aeruginosa and the overall prevalence of P. aeruginosa isolates were 28 (25%) for inpatient and

8 (7.1%) for outpatient isolates. It was found that there was a significant variation in the

prevalence between inpatient and outpatient (P<0.05). Among the total study subjects 33

(29.5%) were males and 79 (70.5%) were females. It was found that male was a significant

association with a p-value of 0.001. Among the total study subjects 83 (16%) were in the age

range of 19-45, followed by 20 (8.9%) were in the age range of ≥46, 9 (7.1%) were in the age

range of 12-18. There was a significant association in the age range of 12-18 with p-value of

0.023 (Shewatatek et al., 2014).

Other study conducted on Isolation and antimicrobial susceptibility pattern of Staphylococcus

aureus in patients with surgical site infection was done by Amlsha et al at Debre Markos Referral

Hospital, Amhara Region, Ethiopia from December 1, 2011 to March 30, 2012. In bivariate

analysis statistically significant association were found laparotomy type of surgery (OR = 3.92,

95% CI = 1.82-8.43, p -value = 0.0001), Clinical symptom of induration (OR = 0.53, 95% CI =

0.28-0.99, p -value = 0.049) and Duration of operation ≥61 minutes (OR = 2.93, 95% CI = 1.46-

5.91, p -value = 0.003). However, in multivariable logistic regression analysis, laparotomy type

of surgery showed a significant association with S. aureus infection. Patients who had

undergone laparotomy type of surgery were 2.03 times more likely to develop infection with S.

aureus (OR = 2.03, 95% CI = 1.91-7.01) than other types of surgery (Amlsha et al at., 2014).

17

Conceptual Framework

Source of conceptual frame work: (Dagnachew et al., 2014; Mohammedaman et al., 2014;

Amlsha et al at., 2014).

Figure 1 Conceptual framework of bacteria isolates from wound infection, drug susceptibility

pattern and associated factors

Socio-demographics

and Socio-economic

Age

Sex

Residence

Marital Status

Educational

Background

Monthly Income

Family Size

Personal Habit

Cleaning of wound

Cleaning of room

Clinical Information

Previous history of wound

Previous history of DM

Type of wound

Site of wound

Type of surgery

Duration of surgery

Duration of hospital stay

Type of ward

Type of specimens

Drug

Susceptibility

Pattern

Previous history of

Antibiotic

Bacteria

Wound

Infection

18

3. MATERIALS AND METHODS

3.1. Study Area and Period

Dire Dawa administration council is one of the two chartered cities in Ethiopia. It is located in

the Eastern part of Ethiopia which is 550 Km away from Addis Ababa, and it lies with a latitude

and longitude of 9o36’N 41o52’E. Based on the 2014-2017 Census conducted by the Central

Statistical Agency of Ethiopia (CSA), the town has a total population of 440,000, of whom

221,000 were men and women 219,000. The urban accounts 277,000 and the rural accounts 163,

000 in habitants (CSA, 2014-2017). It has 85 health facilities consisting of 34 health post, 33

private clinics, 16 health centers, and 6 hospitals (three private hospitals one belong to Ethio-

Djibouti railway and only two belongs to the DDARHB) serving the population with promote,

preventive and basic curative services as a result the primary health coverage of the town is

100% according to DDARHB. This study was conducted in Dil-Chora Referral Hospital from

March 15/2016 to June 14/2016.

Dil-Chora Referral Hospital was established by Majesty Emperor Haile Silase in 1959 to serve

for 30,000 Population. Currently it serves as referral hospital for more than two million people

Dire Dawa and neighboring regions Eastern Oromia, Harer and Somali according 2014 Hospital

annual bulletin.

According to the information obtained from Dil-Chora Hospital, human source management

Bureau and Health management information system (HMIS) the hospitalhas the capacity of 220

beds and has a total of 423 workers among this 230 are health professional of different

disciplines, of this 11 midwifery nurses, 113 clinical nurses, 16 are laboratory technician and the

rest of them are other professional and 194 are supportive workers. Annually there are 120,000

outpatients, 11,000 in patient and averagely 545 patients getting service from the hospital per

day. The Hospital are not only providing service to the People in the region but also serving as

referral centers to neighboring regions. Besides, the Hospital are serving as a teaching facility for

different Governmental and Private Colleges.

3.2. Study Design

A hospital based cross-sectional study was conducted.

19

3.3 Source Population

All patients with wound infection who were admitted at Dil-Chora Referral Hospital from March

15/2016 to June 14/2016

3.4 Study Population

All selected ward patients with wound infection who were admitted at Dil-Chora Referral

Hospital from March 15/2016 to June 14/2016

3.5. Inclusion and Exclusion Criteria

3.5.1. Inclusion Criteria

All age patients with wound infection except neonates. Presence of wound infection (An infected

wound may be characterized by pain, redness or swelling, exuding pus or fluid, bad odors or

non-healing of the wound).

3.5.2. Exclusion Criteria

a) Neonates

b) Mental ill patients

c) Patients who undergoing antibiotic therapy two weeks’ prior of the study

(Kemebradikumo et al., 2013).

3.6. Sample Size Determination

For first specific objective: The prevalence of bacteria isolates from wound infection from

similar study was used to determine the sample size which is 87.3% (Mohammedaman et al.,

2014). The expected margin of error (d) was taken 0.05 with the confidence interval level of

95%. The number of samples of wound patients to be included in the study was calculated based

on the following single population proportion formula.

n= z2 x p (1-p)/ d2

Z=1.96 for 95% confidence interval

d= 0.05 which is margin of error

20

p=0.873 which is prevalence of bacteria isolates from wound infection from previous study.

n= sample size study population

Thus n= (1.96)2x 0.873(1-0.873)/ (0.05)2

n= (3.8416) x (0.110871)/ (0.0025)

n= (0.42592203)/ (0.0025)

n= 170.36≈ 171

Including 10% contingency (non-response rate) which is 17.1, the sample size was 171+17.

Therefore, the required sample size for the 1st specific objective was 188.

For second specifi objective: Sample size of factors associated with bacterial wound infection

from different studies were use.

S.no Factors Exposed Unexposed AOR Sample Size Autors

1. Sex 44% 13% 5.16 80 (Dagnachew et al., 2014)

Gonder

2. Type of Surgery 5% 21.1% 2.03 160 (Amlsha et al at., 2014) Debra

Merkos

3. Type of

specimens

55% 33.3% 2.4 170 (Dagnachew et al., 2014)

Gonder

Including 10% contingency (non-response rate) which is 17, the sample size was 170+17.

Therefore, the required sample size for the second specific objective was 187.

The study was take the sample size with the highest number of study participants that is 188.

21

3.7. Sampling techniques

A purposive sampling technique was used to select patients with infected wound who is admitted

to Dil-Chora Referral Hospital until the sample size is full fill.

3.8. Data Collection method

The following data were collected from patients with clinically suspected wound infection.

a) Face to face interview

A face to face interview using pre tested structured questionnaires was used to collect data by

data collector (one clinical nurse). The questionnaire was adopted from previous study conducted

(Dagnachew et al., 2014; Mohammedaman et al., 2014; Amlsha et al at., 2014). This

questionnaire contained socio-demographic and socio-economic, clinical data like previous

history of wound infection and laboratory specimen’s type and other factors useful for the study.

The questionnaires were translated by language experts to Amharic, Afan Oromo and Somale

language then back to English by another person (third party) to ensure consistency of

translation. One clinical nurse was assigned as interviewer and one senior clinical nurse was

assigned as wound swab/pus discharge sample collector. Two days training were given to data

collectors about the questionnaires, data collection techniques and wound swab/pus discharge

sample collecting procedures. Then the questionnaire was pre-tested by principal investigator at

Dil-Chora Referral Hospital on 5% of the total sample size, which did not include the study

group, before the start of data collection. After obtaining signed consent, from the patients,

background information useful for the study was asked and collected in a form of questionnaire.

b) Wound sample collection, inoculation and incubation, isolation and identification

and anti bacterial susceptibility test

Wound Swab/Pus Discharge Sample collection.

Open wound swabs were aseptically obtained after the wound immediate surface exudates and

contaminants were cleansed off with moistened sterile gauze and sterile normal saline solution.

Dressed wounds were cleansed with sterile normal saline after removing the dressing. The

specimen was collected on sterile, cotton swab by rotating with sufficient pressure. Double

wound swabs were taken from each wound at a point in time to reduce the chance of

22

contamination. Then, wound specimens were transported to Dil-Chora Referral Hospital

microbiology laboratory within 20 minutes by placing the swabs in to the sterile test tubes

having 0.5 ml of sterile normal saline solution (Cheesbrough, 2006).

Inoculation and Incubation

The wound swab/pus discharge sample was inoculate on blood agar (OXOID, England) and

MaCconkey agar (OXOID, England) by sterile inoculation loop using streak plate method

following the Standard Microbiological techniques and procedures (Cheesbrough, 2006). All

culture plates were incubated at 37°c for 24–48 hours. Bacterial colonies differing in size, shape

and color were select from the different plates and further subculture on nutrient agar by the

streak plate technique and incubated at 37°c for 24 hours.

Figure 2. Blood and Macckonkey agar

Isolation and Identification

All positive wound cultures were identified by their physical and colony characteristics such as

hemolysis on blood agar, changes in physical appearance in differential media, enzyme activities

of the organisms and Gram stain. Then it was further confirmed by the pattern of biochemical

reactions using the standard procedures (Cheesbrough, 2006). Thus Gram-negative rods were

identified with the help of a series of biochemical tests such asTriple Sugar Iron Agar

(DIFCOMT, England), Indole (OXOID, England), Urea (OXOID, France), Citrate Utilization

(OXOID, England), and Oxidase test (PARK, Northampton). Gram-positive cocci were

identified based on their gram reaction, catalase and coagulase test results (Cheesbrough, 2006).

To obtain the true picture of biochemical tests, pure colonies obtained by sub-culturing on

Nutrient broth were used to maximize the process of identification, that is, morphologically

23

identical colonies of the suspected strains were taken from the agar plates and suspended in

nutrient broth. Then the suspensions were inoculated to the butt and slant of the biochemical

testing media. The inoculated media was incubated at 37°c and after overnight incubation

bacteria was identified following the standard flow chart (Cheesbrough, 2006).

Figure 3. Gram posative and Gram negative bacteria

Figure 4. Biochemical test for gram positive and gram negative

Drug susceptibility testing (DST)

The antibiotic susceptibility tests of the pathogens isolated from the clinical specimen against

different antibiotics was done on Mueller Hinton agar (MHA). The standard disk diffusion

technique of modified Kirby-Bauer method was used as recommended by Clinical and

Laboratory Standard Institute (CLSI, 2014). For disk diffusion testing, antibiotics such as

ampicillin (10 μg), ciprofloxacin (5 μg), gentamicin (10 μg), cotrimoxazole (25 μg),

chloramphenicol (30 μg), doxycycline (30 μg), amikacin (10μg) and ceftriaxone (30 μg).

Penicillin G (10 IU), erythromycin (15 μg) and vancomycin (30 μg) were used only for gram

24

positive bacteria isolates. The criteria used to select the antimicrobial agents to be tested were

based on the national list of medicines (FMHACA Ethiopia, 2010) to treat wound infections,

their availability and frequent prescriptions for the management of different wound infections in

the hospital. Three to five colonies of bacteria from pure culture were picked with an inoculating

loop and transferred into a tube containing 5ml nutrient broth and mixed gently until a

homogenous suspension formed and incubated at 37oc for 3-5 hrs until the turbidity of the

suspension adjusted to a density of 0.5 McFarland standards, which yield a uniform suspension

containing 105-106 cells/ml. Using a sterile non-toxic dry cotton swab, the standardized

inoculums were streaked on the entire surface of Mueller-Hinton agar plate three times, turning

the plate at 60º angle between each streaking to ensure even distribution. The inoculums were

allowed to dry for 5-15 min. and the selected antibiotic disk were applied onto the plates at a

distance of 15 mm away from the edge and 24 mm apart from each other. After incubating the

plates at 37oC for overnight. Interpretation of the strains as sensitive, intermediate or resistance

were based on the measure of zone of complete inhibition including the diameter of the disk by

ruler in millimeters according to current CLSI standards in accordance with WHO requirements

(WHO, 2003).

Figure 5. Drug susceptibility pattern

25

Laboratory Work Flow

Figure 6. Flow chart of the laboratory work for this study

Cleaning the infected wound sampling labeling

Wound swab/ Pus discharge

Transport sample to the laboratory and inoculate on MacConkey and BAP

Bacterial

growth

No bacterial growth

(Other microorganisms

like virus, fungi etc)

Subculture by inoculate on

nutrient agar at 37°c for 24hrs Gram stain

Biochemical test was performed from pure culture

Drug susceptibility test

Report the result to the physician

Interpretation of results

Interpretation of results

Registration of results

26

3.9. Study Variables

3.9.1. Dependent/ Outcome Variable

Bacteria isolates from wound

Drugs susceptibility pattern

3.9.2. Independent/ Explanatory Variables

Socio-demographic variables like age, sex, place of residence, marital status

educational background, monthly income and family size

Clinical information like previous history of any wound, type of wound, type of

specimens, previous history of antibiotic, site of wound, previous history of DM,

duration of wound. Type of surgery and duration of surgery

Personal habit like cleaning of wound and cleaning of room

3.10. Operational Definition of Terms

Wound: is a breakdown in the protective function of the skin; the loss of continuity of

epithelium, with or without loss of underlying connective tissue (i.e. muscle, bone,

nerves) following injury to the skin or underlying tissues or organs caused by surgery, a

blow, a cut, chemicals, heat or cold, friction or shear force, pressure or as a result of

disease, such as leg ulcers or carcinomas.

Wound infection: the invasion or replication of microorganisms with in the wound area, leading

to cell injury and tissue damage.

Prevalence: the proportion of wound infection patient having laboratory confirmed bacteria

isolates from wound to those all wound infection suspected patients during the study

period.

Drugs Susceptibility Pattern: the test is used to measure the ability of the drug to inhibit

or kill bacteria in vitro. i.e. it is used to select effective antimicrobial drugs.

Bacteria isolates from wound: the presence of replicating bacteria with in a wound that

were inoculated and isolated from culture media for their growth.

27

Susceptible (S): The “susceptible” category implies that isolates are inhibited by the

usually achievable concentrations of antimicrobial agent when the dosage

recommended to treat the site of infection is used.

Intermediate (I): The “intermediate” category includes isolates with antimicrobial agent

MICs that approach usually attainable blood and tissue levels, and for which

response rates may be lower than for susceptible isolates. The intermediate

category implies clinical efficacy in body sites where the drugs are

physiologically concentrated (eg, quinolones and β-lactams in urine) or when a

higher than normal dosage of a drug can be used (eg, β-lactams).

Resistant (R): The “resistant” category implies that isolates are not inhibited by the

usually achievable concentrations of the agent with normal dosage schedules,

and/or that demonstrate MICs or zone diameters that fall in the range where

specific microbial resistance mechanisms (e.g., β-lactamases) are likely, and

clinical efficacy of the agent against the isolate has not been reliably shown in

treatment studies.

3.11. Data Quality Control

The principal investigator provided two days training to data collectors about the

questionnaire and data collection techniques. Then the questionnaire was pre-tested on

sample populations which are not included in the study. The interviewer was submitted the

collected data to the supervisors on daily basis. The principal investigator was the

supervision of data collection procedures on daily basis. Then the collected data was

checked for completeness at the end of each day. During laboratory analysis of different

sample culture, standard operating procedures were followed. Culture media was prepared

and sterilized based on the manufactures instruction. Then the sterility of culture media

was checked by incubating 3–5% of the batch at 37°C overnight and observed for bacterial

growth. Finally, those media which showed any growth will be discarded. The American

Type Culture Collection (ATCC) S. aureus (ATCC-25923), E. coli (ATCC -25922) and P.

aeruginosa (ATCC-27853) obtained from Ethiopian Public Health Institute (EPHI) were

28

used as a quality control during different sample culture, biochemical test and drugs

susceptibility testing.

3.12. Data processing and Analysis

The collected data was checked for completeness, coded, entered and cleaned using Epi-

Data version 3.02. Analysis of data was done using SPSS version 16. Descriptive statistics

such as frequency, percentage and cross tabulation was used to present the findings. The

prevalence of bacteria isolates from wound was calculated by dividing the frequency of

positive samples by the total number of sample examined. Multivariate analysis was

performed using stepwise logistic regression techniques to evaluate whether individual

associated factors of interest was independently significantly with the outcomes of interest.

To ascertain the association; variables found to be significant (p<0.3) in the bivariate

analysis were used to construct a multivariate model. Finally, logistic regression analysis

was done to control possible confounders and to determine factors that may be

significantly associated with wound infection. For multivariate analysis statistical

significance were considered with p -value of < 0.05.

3.13. Ethical Considerations

Data collection were carried out after approval of the research proposal by Institutional Health

Research Ethics Review Committee of Haramaya University, College of Medical and Health

Sciences, permission letter obtained from post graduate programme directorate was submitted to

Dire Dawa Administer Regional Health Bureau, Dil-Chora Referral Hospital. Then written

permission was obtained from head health bureau and Dil-Chora Referral Hospital. After getting

all permission letters from the responsible body, the data collector wasinformed to the patients

by reading or giving to read the information sheet which is translated to patients’ language about

the objectives of the study (which means the data collection was made in both oral and written

approach). Confidentiality was maintained by using of identification numbers instead of

individual names. No other investigations were done from the wound samples collected except

the indicated test. Discussion were made with study participants on their rights and benefits of

participating. Patients were informed that they have full right to refuse participating in the

research. This could not affect services rendered to the patient from the hospital in any way and

have the right to declare not to participate before and after the start of data collection. There was

29

no risk associated with the collection of open wound swabs if the participants with close wound.

However, if syringe aspirating sample is required to obtain the pus discharge, there is minor pain

during insertion of syringe into wound. After understanding all the information patients were

signed on the consent form and voluntarily participate on the study. The study participants were

benefited from the study by confirming whether they are positive for bacteria isolates from

wound infection or not. For each confirmed infection case, the responsible clinician of the

participant was informed and treatment started as per the culture result and drug susceptibility

pattern. Cost of treatment required was covered by investigator.

30

4. RESULTS

4.1 Socio-demographic characteristics of the study participants

A total of 188 patients with clinical evidence of wound infection who admitted at Dil-Chora

Referral Hospital were included in this study. The response rate was 100%. The age range of the

study participants were from 3 to 95 years with a mean of 35± SD16.Seventeen (37.2%) of the

study participants were found in the 21-30 years of age group and 112 (59.6%) of them were

female. Ninety-nine (52.7%) of respondents were urban. The majority or one hundred twenty-

nine (68.6%) of the study participants were married. Seventeen (37.2%) of the study participants

were can’t read and write. Interms of monthly income 73 (38.8%) of the study participant’s

family had monthly income of 501-1000 and 94 (50%) of them had 5-8 family size (Table 1).

Table 1. Socio-demographic characteristics of patients admitted for wound infection at Dil-

Chora Referral Hospital, Dire Dawa, Ethiopia, 2016 (N=188)

Variables Frequency Percentage (%)

Age

1-10 5 (2.7%)

11-20 21 (11.2%)

21-30 70 (37.2%)

31-40 44 (23.4%)

41-50 16 (8.4%)

51-60 11 (5.9%)

>60 21 (11.2%)

Sex

Female 112 (59.6%)

Male 76 (40.4%)

Residence

Urban 99 (52.7%)

Rural 89 (47.3%)

31

Educational status

Can’t read and write 70 (37.2%)

Write and read only 20 (10.6%)

Primary 1-8 51 (27.1%)

Secondary 9-12 28 (14.9%)

College and Above 19 (10.2%)

Marital status

Single 31 (16.5%)

Married 129 (68.6%)

Widowed 25 (13.3%)

Divorce 3 (1.6%)

Monthly income

<=500 60 (31.9%)

501-1000 73 (38.8%)

1001-1500 18 (9.6%)

1501-2000 18 (9.6%)

>2000 19 (10.1%)

Family size

1-4 79 (42%)

5-8 94 (50%)

>8 15 (8%)

4.2 Bacteria isolates among clinically suspected patients admitted for wound infection

Out of 188 pus discharge or wound swabs samples collected for culture and drug susceptibility;

168 (89.4%) of them had growth of bacterial pathogens in their culture. Among growth positive

cases, 125 (74.4%) of the sample had single bacterial pathogens (Figure 3).

32

Figure 7. Number of bacterial isolated from culture of wound infection specimens at Dil-Chora

Referral Hospital, Dire Dawa, Ethiopia, 2016

A total of 213 bacteria were isolated from 168 cases. Gram negative [115(54%)] were more

prevalent than gram positive [98(46%)] bacteria isolates. Staphylococcus aureus was the

predominant organisms [70 (32.9%)] and the least was Providencia spp [6 (2.8%)] (Table 2).

Table 2. Bacteria isolates among patients admitted for wound infection at Dil-Chora

Referral Hospital, Dire Dawa, Ethiopia, 2016

Bacteria Isolates from wound Frequency Percentage (%)

Staphylococcus aureus 70 32.9

Proteus species 61 28.6

Coagulase negative Staphylococcus species 28 13.1

Pseudomonas aeruginosa 18 8.5

Klebsiella species 13 6.1

Escherichia coli 9 4.2

Citrobacter species 8 3.8

Providencia species 6 2.8

Total 213 100

74.40%

24.40%

1.20%0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

Mono Isolates Two Isolates Three Isolates

% O

F C

UL

TU

RE

WIT

H

GR

OW

TH

33

4.3. Drug susceptibility pattern of bacteria isolates among patients admitted for wound

infection

Gram positive bacteria

The susceptibility patterns of gram positive bacteria isolates (n=98) tested against eleven

antimicrobial showed that S. aureus was 100% sensitive to Amikacin and Vancomycin but

85.7%, 80% and 64.3% sensitive to Chloramphenicol, Gentamycin and Cotrimoxazole

respectively. On the other hand, S. aureus was resistance 100% to Ampicillin and Penicillin,

91.4% to Erythromycin and 74.3% to Doxycycline. Similarly, 100% Coagulase negative

Staphylococcus species (CONS) was sensitive to Vancomycin, Gentamycin (85.7%), Ceftriaxone

(82.1%). and Chloramphenicol (64.3%). Coagulase negative Staphylococcus species (CONS)

was 71.4% resistance to Ampicillin and Penicillin respectively (Table 3).

Gram negative bacteria

The susceptibility patterns of gram negative bacteria isolates (n=115) tested against eight

antimicrobial showed that Protues spp the highest sensitivity to Amikacin (100%) and

Gentamycin (75.4%) but Protues spp was resistance to Ampicillin, Chloramphenicol,

Cotrimoxazole and Ciprofloxacin 100%, 88.5%, 78.7% and 72% respectively. Similarly,

Peudomonas. aeruginosa isolates had resistance rate of 100%, to Cotrimoxazole, Doxycycline

and Ampicillin respectively. Klebsiella spp had resistance rate of 92.3% to Ampicillin, 69.2% to

Chloramphenicol. However, Klebsiella isolates had resisitance rate of 15% to Gentamycin.

Isolated Citrobacter showed 100% resistance to Ampicillin and 87.5 to Doxycycline, whereas,

all of them 100% sensitive to Gentamycin and Amikacin respectively. Providencia showed

83.3% resistance to Ampicillin and Cotrimoxazole but they had 100% sensitive to amikacin. E.

coli showed 100% sensitive to Amikacin and 77.8% to Ceftriaxone, whereas, 66.7 resistance to

Doxycycline (Table 4).

Multidrug-resistance pattern of bacteria isolates

In this study, only 2.8% of the total isolates were sensitive. From this 4(4.1%) of gram postive to

11 antibotics test and 2(1.7%) of gram negative were sentitive to 8 classes of antibotics tested.

The overall Multi Drug Resistance (MDR) rate was 181(85%). The overall MDR rate for gram

positive bacteria was 82(83.7%). About 100% of S. aureus and 42.9% of Coagulase Negative

Staphylococcus spp (CONS) were becoming MDR. From those with MDR isoltes; 25.7% of S.

aureus and 7.1% of Coagulase Negative Staphylococcus spp (CONS) isolates were resistance to

34

three antimicrobial classes (Table 5). While, the overall MDR rate for gram negative bacteria

was 99(86.1%). Higher rate of MDR was seen among Pseudomonas aeruginosa, Proteus spp

and Citrobacter spp. From those with MDR isoltes, 37.5% of Citrobacter spp, 33.3% of

Pseudomonas aeruginosa and 27.9% of protues spp were showed resistant to three antimicrobial

classes (Table 6).

35

Table 3. Drug susceptibility pattern of gram positive bacteria isolates among patients admitted for wound infection at Dil-Chora

Referral Hospital, Dire Dawa, Ethiopia, 2016

Isolates Results Antimicrobial agents /No. of bacterial isolates (%)

C CRO CN AK TS CIP E AP P V DO

S.aureus S 60(85.7) 35(50) 56(80) 70(100) 45(64.3) 35(50) - - - 70(100) 18(25.7)

(n=70) I 3(4.3) 15(21.4) - - - 5(7.1) 6(8.6) - - - -

R 7(10) 20(28.6) 14(20) - 25(35.7) 30(42.9) 64(91.4) 70(100) 70(100) - 52(74.3)

CONS S 18(64.3) 23(82.1) 24(85.7) 15(53.6) 12(42.9) 15(53.6) 9(32.1) 6(21.4) 5(17.9) 28(100) 13(46.4)

(n=28) I 3(10.8) 2(7.1) - 6(21.4) 3(10.7) 4(14.3) 5(17.9) 2(7.1) 3(10.7) - 6(21.4)

R 7(25) 3(10.8) 4(14.3) 7(25) 13(46.4) 9(32.1) 14(50) 20(71.4) 20(71.4) - 9(32.1)

KEY: S = Sensitive I = Intermediate R = Resistant; −: zero; CN: Gentamicin; C: Chloramphenicol; TS: Cotrimoxazole; CRO: Ceftriaxone;

CIP: Ciprofloxacin; AP: Ampicillin; P: Penicillin; DO: Doxycycline; A: Amikacin; E: Erythromycin; V: Vancomycin.

Table 4. Drug susceptibility pattern of gram negative bacteria isolates among patients admitted for wound infection at Dil-Chora

Referral Hospital, Dire Dawa, Ethiopia, 2016

Isolates Results Antimicrobial agents /No. of bacterial isolates (%)

C CRO CN AK TS AP DO CIP

Proteus spp S 7(11.5) 19(31.1) 46(75.4) 61(100) 10(16.4) - 34(55.7) 11(18)

(n=61) I - 5(8.2) 5(8.2) - 3(4.9) - 7(11.5) 6(10)

R 54(88.5) 37(60.7) 10(16.4) - 48(78.7) 61(100) 20(32.8) 44(72)

P.aeuruginosa S 10(55.6) 6(33.3) 4(22.2) 14(77.8) - - - 8(44.4)

(n=18) I 2(11.1) - 2(11.1) - - - - 3(16.7)

R 6(33.3) 12(66.7) 12(66.7) 4(22.2) 18(100) 18(100) 18(100) 7(38.9)

Klebseilla spp S 4(30.8) 5(38.5) 11(84.6) 10(76.9) 7(53.8) - 6(46.2) 8(61.5)

(n=13) I - 1(7.7) - 3(23.1) - 1(7.7) 2(15.4) 1(7.7)

R 9(69.2) 7(53.8) 2(15.4) - 6(46.2) 12(92.3) 5(38.4) 4(30.8)

E. coli S 4(44.5) 7(77.8) 5(55.6) 9(100) 5(55.6) 5(55.6) 3(33.3) 4(44.5)

(n=9) I 3(33.3) - 1(11.1) - 3(33.3) 2(22.2) - 2(22.2)

R 2(22.2) 2(22.2) 3(33.3) - 1(11.1) 2(22.2) 6(66.7) 3(33.3)

Citrobacter spp S 3(37.5) 2(25) 8(100) 8(100) 4(50) - 1(12.5) 4(50)

(n=8) I 2(25) 2(25) - - 1(12.5) - - -

36

R 3(37.5) 4(50) - - 3(37.5) 8(100) 7(87.5) 4(50)

Providencia spp S 4(66.7) 3(50) 4(66.7) 6(100) - 1(16.7) 3(50) 4(66.6)

(n=6) I - - 2(33.3) - 1(16.7) - 1(16.7) 1(16.7)

R 2(33.3) 3(50) - 5(83.3) 5(83.3) 2(33.3) 1(16.7)

KEY: S = Sensitive I = Intermediate R = Resistant; −: zero; CN: Gentamicin; C: Chloramphenicol; TS: Cotrimoxazole; CRO: ceftriaxone;

CIP: Ciprofloxacin; AP: Ampicillin; DO: Doxycycline; A: Amikacin.

Table 5. Antibiogram of gram positive bacteria isolates among patients admitted for wound infection at Dil-Chora Referral Hospital,

Dire Dawa, Ethiopia, 2016

Bacteria isolates Antimicrobial classes resisted to No (%) Total MDR

R0 R1 R2 R3 R4 R5 R6 R7 (%)

S. aureus (n=70) 0 0 6(8.6) 18(25.7) 30(42.9) 9(12.9) 5(7) 2(2.9) 70(100)

CONS (n=28) 4(14.3) 12(42.9) 6(21.4) 2(7.1) 1(3.6) 2(7.1) - 1(3.6) 12(42.9)

Total (n=98) 4(4.1) 12(12.2) 12(12.2) 20(20.4) 31(31.6) 11(11.2) 5(5.1) 3(3.1) 82(83.7)

Key: R0= Sensitive to all antimicrobials tested; R1, R2, R3, R4, R5, R6, R7 -Resistant to one, two, three, four, five, six, seven antimicrobials,

respectively.

Table 6. Antibiogram of gram negative bacteria isolates among patients admitted for wound infection at Dil-Chora Referral Hospital,

Dire Dawa, Ethiopia, 2016

Bacteria isolates Antimicrobial classes resisted to No (%) TotalMDR

R0 R1 R2 R3 R4 R5 R6 R7 (%)

Proteus spp (61) 0 7(11.5) 13(21.3) 17(27.9) 10(16.4) 6(9.8) 7(11.5) 1(1.6) 54(88.5)

P. aeruginosa (n=18) 0 0 0 6(33.3) 5(27.8) 4(22.2) 2(11.1) 1(5.6) 18(100)

Klebseilla spp (n=13) 0 3(23) 4(30.8) 2(15.4) 3(23) 1(7.7) 0 0 10(76.9)

E. coli (n=9) 2(22.2) 2(22.2) 1(11.1) 3(33.4) 1(11.1) 0 0 0 5(55.6)

Citrobacter spp (n=8) 0 1(12.5) 2(25) 3(37.5) 2(25) 0 0 0 7(87.5)

Providencia spp (n=6) 0 1(16.7) 2(33.3) 2(33.3) 0 1(16.7) 0 0 5(83.3)

Total (n=115) 2(1.7) 14(12.2) 22(19.2) 33(28.7) 21(18.3) 12(10.4) 9(7.8) 2(1.7) 99(86.1)

Key: R0= Sensitive to all antimicrobials tested; R1, R2, R3, R4, R5, R6, R7 -Resistant to one, two, three, four, five, six, seven antimicrobials,

respectively.

37

4.4. Factors associated with bacteria isolates among patients admitted for wound infection

In bivariate logistic regression analysis, the age group 1-10 and female in sex were realted to

high prevalence of wound infection among socio demographic variables (Table 7).

Table 7. Bi-variable analysis of Socio-demographic characteristics of bacteria isolates

among patients admitted for wound infection at Dil-Chora Referral Hospital, Dire Dawa,

Ethiopia, 2016

Variables Positive (%) Negative (%) COR 95%CI P-value

Age

1-10 3 (60%) 2 (40%) 4 (2.46-4.9) 0.21*

11-20 18 (85.71%) 3 (14.29%) 1.5 (0.178-5.632) 0.65

21-30 65 (93%) 5 (7%) 0.4 (0.101-2.118) 0.3203

31-40 41 (93%) 3 (7%) 0.4 (0.081-2.388) 0.341

41-50 13 (81.25%) 3 (18.75%) 1.3 (0.24-7.985) 0.716

51-60 10 (90.91%) 1 (9.09%) 0.6 (0.055-6.558) 0.675

>60 18 (85.71%) 3 (14.29%) 1 - -

Sex

Female 107 (95.54%) 5 (4.46%) 5.3 (1.8-5.2) 0.002*

Male 61 (80.26%) 15 (19.74%) 1 - -

Residence

Urban 90 (90.91%) 9 (9.09%) 0.709 (0.279-1.8) 0.47

Rural 78 (87.64%) 11 (12.36%) 1 - -

Educational status

Can’t read & write 58 (82.86%) 12 (17.14%) 1.759 (0.358-8.6) 0.48

Read & write 18 (90%) 2 (10%) 0.944 (0.119-7.4) 0.95

Primary 1-8 48 (94.12%) 3 (5.88%) 0.531 (0.082-3.5) 0.51

Secondary 9-12 27 (96.43%) 1 (3.57%) 0.315 (0.026-3.74) 0.36

Collage and above 17 (89.47%) 2 (10.53%) 1 - -

Monthly income

<=500 54 (90%) 6 (10%) 0.944 (0.174-5.12) 0.94

501-1000 65 (89.04%) 8 (10.96%) 1.046 (0.203-5.38) 0.95

1001-1500 15 (83.33%) 3 (16.67%) 1.7 (0.249-11.5) 0.58

1501-2000 17 (94.44%) 1 (5.56%) 0.5 (0.41-6.04) 0.58

>2000 17 (89.47%) 2 (10.53%) 1 - -

Family size

1-4 74 (93.67%) 5 (6.33%) 0.946 (0.103-8.73) 0.96

5-8 80 (85.11%) 14 (14.89%) 2.45 (0.298-20.1) 0.4

>8 14 (93.33%) 1 (6.67%) 1 - -

38

While Previous history of wound infection, Trauma type of wound, Pus discharge type of

specimens; and types of wards (Orthopedic, Gynecology and Obstetrics and Surgical type of

ward) were related to high prevalence of wound infection among clinical and other factors

variable (Table 8).

Table 8. Bi-variable analysis of Clinical and other factors of bacteria isolates among

patients admitted for wound infection at Dil-Chora Referral Hospital, Dire Dawa, Ethiopia,

2016

Variables Positive (%) Negative(%) COR 95%CI P-value

Previous history of wound infection

Yes 5 (83.3%) 1 (16.7%) 8.78 (3.53-12) 0.13*

No 163 (89.6%) 19 (10.4%) 1 -

Previous history of antibiotics

Yes 11 (50%) 11 (50%) 0.62 (0.25-1.6) 0.33

No 157 (86.36%) 9 (13.64%) 1 -

Site of wound infection

Leg 32 (86.49%) 5 (13.51%) 0.5 (0.16-1.8) 0.32

Abdomen 83 (92.22%) 7 (7.78%) 1.3 (0.37-4.9) 0.63

Hand 28 (82.35%) 6 (17.65%) 0.85 (0.14-4.91) 0.85

Foot 15 (88.24%) 2 (11.76%) 1.5 (0.32-3.84) 0.56

Genital 10 (100%) 0 (0%) 1 1 -

Type of wound infection

Trauma 41 (83.67%) 8 (16.33%) 0.43 (0.14-0.72) 0.33

Postoperative 83 (92.22%) 7 (7.78%) 1.46 (0.38-5.61) 0.57

Abscess 14 (77.78%) 4 (22.22%) 0.73 (0.07-6.79) 0.78

Burn 7 (87.5%) 1 (12.5%) 2.3 (0.04-0.6) 0.32

Diabetic foot ulcer 14 (100%) 0 (0%) 4.8 (2.37-5.2) 0.61

Other 9 (100%) 0 (0%) 1 1 -

Type of surgery

Casern section 64 (98.46%) 1 (1.54%) 3.5 (0.21-5.6) 0.37

Laparotomy 18 (94.74%) 1 (5.26%) 1.8 2.31-6.8) 0.46

Appendectomy 1 (16.67%) 5 (83.33%) 1 1 -

39

Time of operation

<=30 minutes 36 (100%) 0 (0%) 0.36 0.027-3.6) 0.81

31-60 minutes 41 (87.23%) 6 (12.77%) 0.87 (0.089-8.6) 0.9

>60 minutes 6 (85.71%) 1 (14.29%) 1 1 -

Duration of hospital admission

<=7 days 123 (87.86%) 17 (12.14%) 0.46 (0.1-2.1) 0.32

8-15 days 31 (93.94%) 2 (6.06%) 1.03 (0.12-8.9) 0.97

16-30 days 7 (87.5%) 1 (12.5%) 1.62 (0.25-6.7) 0.36

>30 days 7 (100%) 0 (0%) 1 1 -

History of diabetics

Yes 19 (100%) 0 (0%) 4.65 (3.6-9.7) 0.68

No 149 (88.17%) 20 (11.83%) 1 1 -

Type of specimens

Pus discharge 120 (97.56%) 3 (2.44%) 14.2 (7.97-15.03) 0.0001*

Wound swab 48 (73.85%) 17 (26.15%) 1 1 -

Type of ward

Gyn & Obs 73 (97.33%) 2 (2.67%) 0.02 (0.02-0.19) 0.001*

Orthopedic 51 (94.44%) 3 (5.56%) 0.05 (0.01-0.35) 0.002*

Surgical 26 (86.67%) 4 (13.33%) 0.15 (0.027-0.87) 0.035*

Medical 14 (66.67%) 7 (33.33%) 0.5 (0.09-2.62) 0.41

Pediatrics 4 (50%) 4 (50%) 1 1 -

Wound cleaning

1 per day 65 (89.04%) 8 (10.96%) 1.04 (0.203-5.38) 0.95

3 per weeks 54 (90%) 6 (10%) 0.94 (0.17-5.12) 0.94

1 per weeks 15 (83.33%) 3 (16.67%) 1.7 (0.249-11.5) 0.58

1 per 2 weeks 17 (94.44%) 1 (5.56%) 0.5 (0.41-6.04) 0.58

No 17 (89.47%) 2 (10.53%) 1 1 -

Ward daily room cleaning

1 per day 90 (90.91%) 9 (9.09%) 0.7 (0.279-1.8) 0.47

2 per day 78 (87.64%) 11 (12.36%) 1 1 -

40

In Multivariate logistic regression analysis , female in sex was found to be 7.5 times more likely

to develop bacterial wound infection than male [(AOR=7.5; 95% CI=5.6-13.2)], pus discharge

samples were 16.8 times more likely to develop bacterial wound infection than wound swabs

samples [(AOR=16.8; 95% CI=12.7-18.3)] and patients who admitted to orthopedic ward were

12.3 time more likely to develop bacterial wound infection than patients who admitted to other

ward [(AOR=12.3, 95% CI=8.3-16.5)] (Table 9).

41

Table 9. Bivariate and Multivariate analysis of socio-demographic and Clinical and other factors of bacteria isolated among

patients admitted for wound infection at Dil-Chora Referral Hospital, Dire Dawa, Ethiopia, 2016

*Statically significance (p<0.05), ** Statically significance (p=0.004). *** Statically significance (p=0.001), 1=Reference group,

COR= Crude odd ratio, AOR=Adjusted odd ratio, 95%CI=95% Confidence interva

Variables Culture Bivariate analysis Multivariate analysis

Positive (%) Negative (%) COR (95% CI) P-value AOR (95% CI)

Age

1-10 3 (60%) 2 (40%) 4 (2.46-14.9) 0.21 0.14 (0.004-5.78)

11-20 18 (85.71%) 3 (14.29%) 1.5 (0.178-5.632) 0.65 0.94 (0.28-31.6)

21-30 65 (93%) 5 (7%) 0.4 (0.101-2.118) 0.3203 0.2 (0.15-2.6)

31-40 41 (93%) 3 (7%) 0.4 (0.081-2.388) 0.341 0.64 (0.68-5.9)

41-50 13 (81.25%) 3 (18.75%) 1.3 (0.24-7.985) 0.716 0.29 (0.025-3.36)

51-60 10 (90.91%) 1 (9.09%) 0.6 (0.055-6.558) 0.675 1.1 (0.06-19.5)

>60 18 (85.71%) 3 (14.29%) 1 1

Sex

Female 107 (95.54%) 5 (4.46%) 5.3 (1.823-15.2) 0.002 7.5 (5.6-13.2)*

Male 61 (80.26%) 15 (19.74%) 1 1

Previous history of wound infection

Yes 5 (83.3%) 1 (16.7%) 8.78 (3.53-12) 0.1 5.3 (3.53-12)

No 163 (89.6%) 19 (10.4%) 1 1

Type of specimens

Pus discharge 120 (97.56%) 3 (2.44%) 14.2 (3.97-16.03) 0.0001 16.8 (12.7-18.3)***

Wound swab 48 (73.85%) 17 (26.15%) 1 1

Type of ward

Gyn & Obs 73 (97.33%) 2 (2.67%) 0.02 (0.02-0.19) 0.001 2.4 (0.16-3.6)

Orthopedic 51 (94.44%) 3 (5.56%) 0.05 (0.01-0.35) 0.002 12.3 (8.3-16.5)**

Surgical 26 (86.67%) 4 (13.33%) 0.15 (0.027-0.87) 0.035 3.49 (0.4-3.5)

Medical 14 (66.67%) 7 (33.33%) 0.5 (0.09-2.62) 0.41 3.78 (0.46-3.8)

Pediatrics 4 (50%) 4 (50%) 1 1

42

5. DISCUSSION

In this study bacterial pathogens were isolated 89.4% of study participants admitted for wound

infection. This is comparable with a similar studies conducted in Jimma (87.4%)

(Mohammedaman et al., 2014), Nigeria (89.4%) (Esebelahie et al., 2013), Pakistan (86.1%)

(Ammar et al., 2015) and India (89.4%) (Raghav et al., 2014), but it was lower than study

conducted in Jimma (96.3%) (Girma et al., 2013), Nigeria (92.8%) (Motayo et al., 2013) and

India (93.3%) (Swati et al., 2013). However, it was higher than report from Gonder (72%)

(Dagnachew et al., 2014), Mekelle (75%) (Reiye et al., 2014), Cameroon (79.7%) (Akoachere et

al., 2014) and Nepal (65.1%) (Arjun et al., 2015). The possible reason for such difference could

be different geographical location, study period, study design, sample size and types of wound

sample collected. The other reason might be the types bacteria isolated for instance

Acinetobacter spp, M. morganii, gram positive bacilli and Yeast were identified in study

conucted from Jimma (Girma et al., 2013) and Nigeria (Motayo et al., 2013).

In this study, 74.4% of culture positive wounds showed mono-microbial growth and 25.6%

showed poly-microbial growth which is consistence with study conducted in Mekelle mono-

microbial growth (76.05%) and poly-microbial growth (23.95%) (Reiye et al., 2014) and Nepal

mono-microbial growth (77.9%) and poly-microbial growth (22.1%) (Jaya et al., 2014) but it

disagree with study done in Jimma mono-microbial growth (91.6%) and poly-microbial growth

(8.4%) (Mohammedaman et al., 2014), Nigeria mono-microbial growth (100%)

(Kemebradikumo et al., 2013) and India mono-microbial growth (95.1%) and poly-microbial

growth (4.9%) (Raghav et al., 2014). The possible reason for such difference migh be due

difference infection prevention applications and wound managament.

Among the total isolates, gram negative bacteria were more predominate. But, when it was

analyzed individual isolates S. aureus (32.9%) was the most prevalent. This was in line with

previous study conducted in Gonder (32.9%) (Dagnachew et al., 2014) and India (30.1%) (Malik

et al., 2011). But it was higher than study conducted in Jimma (19%) (Girma et al., 2013),

Nigeria (14.7%) (Motayo et al., 2013), Bangladesh (15.3%) (Mehedi et al., 2013) and Iran

(12.4%) (Mohammad et al., 2015). The high prevalence of S. aureus infection may be due to the

normal flora nature of S. aureus in the skin and endogenous source of infection due to

43

contamination from the environment (Mohammedaman et al., 2014). The present finding was

lower than study done in Debra Merkos (39.7%) (Amlsha et al at., 2014), Nigeria (62%) (Sani et

al., 2012) and Nepal (74.2%) (Jaya et al., 2014).

The second prevalent bacterial isolate identified was Proteus spp (28.6%). This was similar to a

study conducted in Jimma (27.9%) (Girma et al., 2013). But it, was higher than reported in

Mekelle (12.8%) (Reiye et al., 2014), Gonder (4.5%) (Dagnachew et al., 2014), Nigeria (12.9%)

(James et al., 2015), Nepal (1.8%) (Jaya et al., 2014), Pakistan (8.3%) (Ammar et al., 2015) and

India (7.47%) (Raghav et al., 2014), The possible reason for such difference might be proteus

spp its a nosocomial infection so my study was conducted among patients admitted for wound

infection at hospital (inpatients) but the other studies like (Dagnachew et al., 2014), (James et al.,

2015) and (Raghav et al., 2014) were conducted among both patients (inpatients and outpatients).

The overall prevalence of Coagulase Negative Staphylococcus spp (CONS) in this study was

13.1%. This was comparable with previous study conducted in Jimma (14.5%)

(Mohammedaman et al., 2014), Mekelle (14.6%) (Reiye et al., 2014), Gonder (Dagnachew et al.,

2014) (14.7%) and India (12.61%) (Swati et al., 2013).

The present in vitro antimicrobial susceptibility test showed that isolated bacteria showed

differently to susceptibly to various antibiotics. among gram positive isolates all the isolated S.

aureus 70 (100%) were susceptible to Amikacin and Vancomycin in our finding exactly the

same with that of report from Jimma (Mohammedaman et al., 2014), Nepal (Mohammad et al.,

2013) and India (Manikandan and Amsath, 2014). On the other hand, S. aureus isolated showed

high resistance against commonly prescribed drugs like Ampicillin and Penicillin (100%),

Erythromycin (91.4%) and Doxycycline (74.3%). This is consistence with study drug resistance

report from Nepal [ 99.1% for Ampicillin (Jaya et al., 2014) and 100% for Penicillin (Arjun et

al., 2015)]; in Jimma [ 79.4 % for Erythromycin (Girma et al., 2013) and in Bangladesh 72% for

Doxycycline (Mehedi et al., 2013)]. This may be due to the antibiotics having been in use for

much longer time, their easily availability on open market, low cost, indiscriminate use of the

drugs without proper prescription and misuse of this drug by health professional. In this studies

Coagulase Negative Staphylococcus spp (CONS) was resistance to Ampicillin (78.6%),

Penicillin (71.4%) and Erythromycin (50%). This was agreement with study done in Mekelle

44

(Reiye et al., 2014) and Tanzania (Joel, 2012). The same isolate highly sensitive to Vancomycin

and Amikacin (100%), Gentamycin (85.7%) and Ceftriaxone (82.1%). This finding was

comparable with report from Addis Ababa (Yishak et al., 2009), Jimma (Girma et al., 2013) and

Nepal (Rajendra et al., 2013). In general, Gram positive bacteria were sensitive to Vancomycin,

Amikacin and Gentamycin in this study may be due to lesser use of these antibiotic as a result of

their less availability, brand, cost and toxic effect respectively. This is consistence with study

done in Jimma (Mohammedaman et al., 2014). But, Gram positive bacteria were highly

resistance to Ampicillin, Penicillin and Erythromycin. This is in line with report from Jimma

(Girma et al., 2013). This may be due to the antibiotics having been in use for much longer time,

their easily availability on open market, low cost, indiscriminate use of the drugs without proper

prescription and misuse of this drug by health professional.

Among the Gram negatives, the predominant isolate was Protues spp, which is resistant to

Ampicillin (100%), Chloramphenicol (88.5%), Cotrimoxazole (78.7%) and Ciprofloxacin (72%)

which is consistent with report from Jimma (Girma et al., 2013) and India (Hrishikesh et al.,

2015). This isolate was sensitive to Amikacin (100%) and Gentamycin (75.4%) which is similar

with study conducted in Mekelle (Reiye et al., 2014) and India (Manikandan and Amsath, 2014).

However, P. aeruginosa was resistance to Ampicillin, Cotrimoxazole and Doxycycline (100%),

Gentamycin and Ceftriaxone (66.7%). This is agreement with study conducted in Jimma

(Mohammedaman et al., 2014; Shewatatek et al., 2014), Nepal (Mohammed et al., 2013), Iran

(Mohammad et al., 2015) and India (Vikas et al., 2015). Klebseilla spp was 92.3% resistance to

Ampicillin and 69.2% to Chloramphenicol. The isolate was sensitive to Amikacin (76.9%) and

Gentamycin (84.6%). This is comparable with report from India (Manikandan and Amsath,

2014) and (Mathangi and Prabhakaran, 2013). Most of the gram negative bacteria isolated in this

study were resistance to Ampicillin, Chloramphenicol and Cotrimoxazole. This may be due to

the antibiotics having been in use for much longer time, their easily availability on open market,

low cost, indiscriminate use of the drugs without proper prescription and misuse of this drug by

health professional. But, Gram negative bacteria isolated were sensitive to Gentamycin and

Amikacin. This is consistence with report from India (Manikandan andAmsath, 2014). This is

may be due to lesser use of these antibiotic as a result of their less availability, brand, cost and

toxic effect respectively in my study area.

45

In this study, the overall MDR rate were 85%. This is in line with report from Jimma

(Mohammedaman et al., 2014). The overall rate of MDR among gram positive isolates was

83.7%. This is in line with study conducted in Mekelle (Reiye et al., 2014). About 100% of S.

aureus also became MDR of which 12.9% were resistance to six antimicrobial classes

(Ampicillin and Penicillin, Erythromycin, Doxycycline, Cotrimoxazole, Ceftraixone and

Ciprofloxacin), Similarly 42.9% of Coagulase Negative Staphylococcus spp (CONS) showed

MDR of which 7.1% were resistance to three classes (Ampicillin and Penicillin, Erythromycin

and Cotrimoxazole).

On the other hand, the overall MDR rate of gram negative bacteria was 86.1%. This is

consistence with report from Mekelle (Reiye et al., 2014). Whereas 100% of Pseudomonas.

aeruginosa became MDR of which 22.2% were resistance to five antimicrobial classes

(Ampicillin, Doxycycline, Cotrimoxazole, Gentamycin and Ceftraixone), 88.5% of Proteus spp

became MDR of which 9.8% was resistance to five antimicrobial classes (Ampicillin,

Doxycycline, Cotrimoxazole, Chloramphenicol and Ciprofloxacin) and 87.5% of Citrobacter spp

became MDR of which 25% was resistance to four antimicrobial classes (Ampicillin,

Doxycycline, Ceftraixone and Ciprofloxacin). It is known that antimicrobial resistance is a

growing global and national problem. However, the increased proportion of MDR seen in this

study was considered as alarming.

In this study, overall bacterial wound infection rate was higher among age groups of 21-30 years

but it was not statistically significant with bacterial wound infection. This is consistence with

similar study conducted in Mekelle (Reiye et al., 2014), Cameroon (Akoachere et al., 2014),

Nigeria (James et al., 2015) and Nepal (Jaya et al., 2014) and inconsistence with study done in

Gonder (Dagnachew et al., 2014), Jimma (Shewatatek et al., 2014), Nigeria (Christopher et al.,

2011) and Nepal (Arjun et al., 2015). The prevalence of bacterial infection isolated in this age

group in this and other study might be this group being active age group or working age group,

hence they might have the chances of occurring accidents leading to hospital admission.

In this study sex, being female was found 7.5 times more likely to develop bacterial wound

infection than male patients. This is in line with similar study conducted in Gonder (Dagnachew

et al., 2014) and disagree with study conducted in Debre Markos (Amlsha et al at., 2014),

Mekelle (Reiye et al., 2014), Jimma (Shewatatek et al., 2014), Cameroon (Akoachere et al.,

46

2014), Nigeria (Kemebradikumo et al., 2013), Pakistan (Safia et al., 2011) and Nepal (Jaya et al.,

2014). The possible explanation for difference might be due to high number of bacteria islated

were female and from Gynecology and Obstetrics wards in this study.

Patients who had pus discharge type of specimen was found to be 16.8 times more likely to

develop wound infection than patients with wound swab specimens. This is similar with study

conducted in Gonder (Dagnachew et al., 2014). The possible reason for high bacterial iosation

among pus discharge might be, presence of the pus in the wound it indicates bacterial and fungal

wound infection and also pus is a dead white blood cells that fovourable condition for bacterial

growth.

Patients who were admitted to Orthopedics ward was 12.3 times more likely to develop bacterial

wound infection than patients who admitted to pediatrics. This study is consistence with study

conducted in Mekelle (Reiye et al., 2014) but it is inconsistence with study done in Jimma

(Shewatatek et al., 2014) and Brazil (Gilmara et al., 2014). The possible reason for high

prevalence bacterial isolation in patients admitted to Orthopedic wards, might be patients

admitted to it require longer hospitalization time to recover from their bone cases. So, they might

become prone for bacterial wound infection.

This study had some limitation since the sample size used for this study was somehow small,

some of the confidence intervals were wide and the study did not isolate strict anaerobes

bacteria, fungi, viruses, mycoplasma, and chlamydia which could have increased the number of

bacterial isolates reported as negative cultures.

47

6. CONCLUSION AND RECOMMENDATIONS

6.1 CONCLUSION

The overall magnitude of bacteria isolates from wound infection in my study area was found to

be high. Staphylococcus aureus was the predominant organisms followed by Proteus species,

CONS, Pseudomonas. aeruginosa, Klebsiella species, Escherichia coli, Citrobacter and

Providencia.

Among Gram positive bacteria isolates resistant to antibotices; S. aureus were highly resistant

against Ampicillin, Penicillin, Erythromycin and Doxycycline. While among gram negative

isolated Pseudomonas aeurognosa were highly resistance to Ampicillin, Doxycycline,

Cotrimoxazole, Chloramphenicol and Gentamycin in the study area.

Among gram positive bacteria isolates sentive to antibotice; Coagulase Negative Staphylococcus

spp highly sensitive to Vancomycin, Gentamycin, Ceftriaxone, Chloramphenicol, Amikacin and

Ciprofloxacin. While among gram negative bacteria isolated E. coli highly sensitive to

Amikacin, Ceftriaxone, Gentamycin and Cotrimoxazole. Thus, these drugs appear to be effective

against bacterial wound infection in the study area. These antibiotics should however be used

with caution because of the emerging low level of resistanc which might have great danger in the

future.

The overall MDR in study area are more than 80%. However, Gram positive bacteria isolated

showed MDR to Ampicillin, Penicillin, Erythromycin and Cotrimoxazole combination of drugs

but gram negative bacteria showed MDR to Ampicillin, Doxycycline, Cotrimoxazole and

Ciprofloxacin combination of drugs. This may be an alarming issue because majority of drugs

commonly prescribed in Ethiopia might becoming less effective.

Female in sex, pus discharge type of specimens and Orthopedic ward had a strong significant

association with bacterial wound infection.

48

6.2 RECOMMENDATIONS

The following recommendations are forwarded based on the findings of the present study

Health professional:

Amikacin, Gentamicin and Vancomycin, are best anibiotics for treatment of

bacterial wound infections in study area. But drug such as Ampicillin, Penicillin,

Erythromycin, Cotrimoxazole, Ceftriaxone might not be used for empirical

therapy of bacterial wound infection.

Dil-Chora Referral Hospital and Dire Dawa regional Health beruoe:

Establish and implement strict guidelines for antibiotics prescriptions in

treatment of bacterial wound infection.

Further studies by including large sample size, study area, aethlogical cuases wounds

infections, possible factors and drug susceptiblty to find out the magnitude, risk factosr

and overall drug resistance patterns isolates.

49

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Shewatatek, G., Gizachew, T., Molalegne, B. and Terefe, G. 2014. Drug sensitivity of

Pseudomonas aeruginosa from wound infections in Jimma University Specialized

Hospital, Ethiopia. ISSN 2277-0879; 3(2); 13-18.

Singh, N., Armstrong, D.G. and Lipsky, B.A. 2005. Preventing foot ulcers in patients with

diabetes. JAMA, 293:217–28.

Suchitra, J.B. and Lakshmidevi, N. 2009. Surgical site infections: Assessing risk factors,

outcomes and antimicrobial sensitivity patterns. Afr J Microbiol Res, 3(4): 175-179.

Swati, D., Khatri, P. K., Parihar, R. S. and Rajat, A. 2013. Antibiogram of various bacterial

isolates from pus samples in a tertiary care center in Rajasthan. International Journal of

Science and Research, 4(5):2319-7064.

Taye., M. 2005. Wound infection in Tikur Anbessa Hospital, surgical department. Ethiop Med J,

43(3):167-174.

Theoklis, E.Z. 2009. Antibiotic resistance: Who will pay the biis? Clinical Infectious Diseases,

49: 1185-6.

56

Uwaezuoke, J.C. and Nnodim, J.K. 2015. Bacteriology of Different Wound Infections and Their

Antimicrobial Susceptibility Patterns in Owerri, Nigeria. JPRB, 1(1); 2454-1672.

www.scitecresearch.com

Valarmathi, S., Rajasekara, P.M. and Senthilkumar, B. 2013. Incidence and screening of

woundinfection causing microorganisms. J Acad Indus Rev, 1(8).

Vikas, J., Ramnani, V.K. and Navinchandra, K. 2015. Antimicrobial susceptibility pattern among

Aerobic bacteriological isolates in infected wounds of patients at tertiary care Hospital in

Central India. Int J Microbiol App Sci, 4(5); 711-719.

WHO. 2003. Manual for the Laboratory Identification and Antimicrobial Susceptibility Testing

of Bacterial Pathogens of Public Health Importance in the Developing World. P.103-118.

Yishak, A., Daniel, A., Yimtubezinash, W., Tezera, C., Dereje, N. and Biruk, L. M. 2009.

Bacteriology of compound (open) fracture wounds at tikur anbessa specialized hospital,

Addis Ababa University, Ethiopia. Afr J Microbial Res, 3:939-951.

57

8. APPENDIX

Appendix A: Participant Information Sheet and Informed Voluntary Consent Form for

Study Participant

Good morning/ afternoon?

My name is……………………………………. I am working as a data collector for the study

being conducted in this community by ADIL IBRAHIM who is studying for his master’s degree

at Haramaya University, college of Health and Medical science. I kindly request you to lend me

your attention to explain you about the study and being selected as the study participants.

The Study Title:

Bacteria isolates, Drug susceptibility pattern and associated factors among patients

admitted for wound infection at Dil-Chora Referral Hospital, Dire Dawa, Eastern

Ethiopia

Purpose/aim of the study:

The finding of this study can be of a paramount importance for the Regional Health Bureau to

plan intervention programs to prevent bacteria isolates from wound in your community and

others; thereby improving public health in general. Moreover, the aim of this study is to write a

thesis as a partial requirement for the fulfillment of a Master’s Program in Medical Microbiology

for the principal investigator.

Procedure and duration:

I will be interviewing you using a questionnaire to provide me with pertinent data that is helpful

for the study. There are 21 questions to answer where I will fill the questionnaire by interviewing

you. Then you will give laboratory sample for laboratory investigation. The interview will take

about 25 minute, so I kindly request you to spare me this time for the interview.

Risk and benefits:

The risk of being participating in this study is very minimal, but only taking few minutes from

your time and minor pain for close wound during insertion of syringe into the wound to collect

the sample. There would not be any direct payment for participating in this study and for each

bacterial wound infection confirmed test, the responsible clinician of the participant informed

58

and treatment started as per the culture result and drug susceptibility pattern. But the findings

from this research may reveal important information for the local health planners.

Confidentiality:

The information you will provide us will be confidential. There will be no information that will

identify you in particular. The findings of the study will be general for the study community and

will not reflect any thing particular of individual persons or housing. The questionnaire will be

coded to exclude showing names. No reference will be made in oral or written reports that could

link participants to the research.

Rights:

Participation for this study is fully voluntary. You have the right to declare participate or not in

this study. If you decide to participate, you have the right to withdraw from the study at any time

and this will not label you for any loss of benefits which you otherwise are entitled you do not

have answer any questions that you do not want to answer.

Contact Address:

If there are any questions or enquiries any time about the study or the procedure, please contact:

Mobile Phone: 0915010522 or Email Address: [email protected]

Contact address of the Institutional Health Research Ethics Review Committee (IHRERC) Office

phone: 0254660708or P.O. Box 235, Harar.

Declaration of informed voluntary consent:

I have read/ was read to me the participant information sheet. I have clearly understood the

propose of the research, the procedures, the risk and benefits issues of confidentiality, the rights

of participating and the contact address of any queries. I have been given the opportunity to ask

questions for the things that may have been unclear. I was informed that I have the right to

withdraw from the study at any time or not to answer any questions that I do not want. Therefore,

I declare my voluntary consent to participate in this study with my initials (signature) as

indicated below.

Name and Signatures of participants………………………………….

Name and Signature of data collector………………………………...

59

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½Õናx T©Y

ባክቴሪያ ከቁስል መለየት, በተደጋጋሚ የመድኃኒት ዝንባሌ እና ተጓዳኝ ጉዳዮች በድልጮራ ሆስፒታል ከሚታከሙ

ህሙማን መሀከል፡

የጥናቱ ዓላማ

H«H ›«ኳ« Á; Õና| ½wÃOάú ½Æ;O-HOc :ûÃx« >Gሟ?| oü<«H ŒÎT Ы ½Õናx

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F«Y¨þ°… ¬Á«H H¡«¿}…« >G¬e ÁI¡R@$ Á;H ÃÐI ባክቴሪያ ከቁስል o]z« >F»?»@

›ና>FfÔÓT ½Gû¿Y…@ /úŒýz ›«ÃGûëÕT ÁzFና@$

½Õናቱ eÃH w»w@ና የሚፈጁዉ ጊዜ

_ናቱጠቃሚየሆኑመረጃዎችንበሚጠየቁትጥያቄመሰረትይመልሱልኛል፡፡ባጠቃላይ 21 ጥያቄዎችንመልስይሰጣሉ፡፡ከዚያም

እርስዎ/ልጅዎት የቁስሉ ናሙና ይሰጡኛልÝÝ መጠይቁምየሚፈጀዉጊዜ25ደቂቃይሆናል፤

በመሆኑምየህንንጊዜከኔጋርእንዲያሳልፉበትህትናእየጠየኩኝ ምስጋናዬም አቀርባለሁኝ።

™ÃÏና ጥቅም

በዚህ ጥናት በመሳተፍዎ ያለዉ አደጋ በጣም ጥቂት ነዉ፤ነገር ግን ትንሽ ጊዜ ከርስዎ የወስዳል እና የቁስሉ አይነት ዝግ ከሆነ

ናሙና በመርፌ ስለሚወሰድ ትንሽ ህመም ይኖረዋል፡፡ በዚህ ጥናት ሲሳተፉ ሚከፈልዎት ክፍያ በቀጥታ ባይኖርም

በተገኘው ውጤት መሠረት ለሃኪም ሙሉ መረጃ በመስጠት ትክክልኛ መድኃኒት እንዲያገኙ ይጠቅማል ፡፡ በተጨማሪም

ይህ ጥናት የጤና እቅድ ለማቀድ ጥሩ መረጃን የሰጣል፡፡

መተማመኛ

Y¸s-#N mr© ¸S_‰êE YçÂLÝÝ XRSãN ¥NnT y¸Gl} mr© xYñRMÝÝ

k_ናቱምየሚገኘዉዉጤትአጠቃላይየህብረተሰቡእንጂየአንድንግለሰብወይምቤትአያመላክትም፡፡

60

መጠይቁምላይስምወደሌላይተረጎማል፡፡

ምንምዓይነትማጣቀሻተሳታፊዉንከጥናቱጋርየሚያያይዝበቃላትምይሁንበፅሁፍአይኖርም፡፡

Fq}…

o±ü; Õና| FXwð oFú>ú ðcÖŒ?Á½wFWOw Œ¬ú$ o±ü; Õና| >FXwð ¬ÁH ?>FXwð

Fq| ™>°|$ >FXwð ¬YŒ¬ú »<«! oë>Îú| Îû±þ »Õናቱ ማቋረጥ ይችላሉ፡ ይህም የማይፈልጉትን ጥያቄ

ባለመመለስዎ የሚያስቀርብዎት ጥቅም የለም፡፡

አድራሻ

ስለ ጥናቱ ወይም ሂደት በማንኛዉም ጊዜ ጥያቄ ካለዎት፤ በዚህ አድራሻ ያግኙን፡ ሞባይል ቁጥር፡ 0915010522 ወይም

ኢሜይል አድራሻ፡ [email protected]

IHRERC አድራሻ፡ የቢሮ ስልክ ቁጥር፡ 0254660708 ወይም ፖ.ሳ.ቁ. 235 ሀረር

የፍቃደኝነት ማረጋገጫ

የተሳታፊዎች መረጃ አንብቤዋለሁ/ተነቦልኛል፡፡ የጥናቱንም ዓላማ፤ሂደቱን፤አደጋና ጥቅሙን፤መተማመኛዉን፤ የመሳተፍ

መብት እና አድራሻ በግልፅ ተረድቼዋለሁ፡፡የልተረዳሁትንም ነገር እንድጠይቅ ምቹ ሁኔታ ተመቻችቶልኛል፡፡

ከጥናቱምበፈለኩት ሰዓት ለማቃረጥ ወይም የማልፈልገዉን ጥያቄ ላለመመለስ መብት እንዳለኝ ተነግሮኛል / ከጥናቱም

ራሴን በፈለኩበት ሰዓት ለማቃረጥ ወይም የማልፈልገዉን ጥያቄ ላለመመለስ መብት እንዳለኝ ተነግሮኛል፡፡ስለዚህም በዚህ

ጥናት በፈቃደኝነት መሳተፌን ክዚህ በታች ባለዉ ፊርማዬ እገልፃለሁ፡፡

½wXzí¬ú ስም እና íTG------------------------------ ½FOÉ WqXoü¬ú ስም እና íTG------------------------------------

61

(Afan Oromo Version)

Maqaan kiyya ------------------------- jedhama. Yeroo ammaa kana yunivarsitii Haroomayaatti

digrii lammataabarachaa kanjiru ADIL IBRAHIM wajjiiin odeeffannoo funaanaatiin jira.

Qo’annoo kanaaf waan filatamtaniif waa’ee qo’annichaa yeroon isinii himu akka na

dhageeffattan kabajaaniin isiin gaafadha.

Mata Duree Qo’annoo

Qo’annoo waa’ee bakteeriyaa infeeshiinaa maaddaa irraa fuunanamnii, qorichaa waliin walbaruu

isaaniifi waantotaa infeeshiinaa maaddaatiif nama saaxilaan waarreen hospitaala Dilchoratii

yaalamaniif.

Kaayyoo Qo’annoo

Qorannoon kun digrii lammataa ittiin ebbifamuuf tahullee fayidaan isaa kana qofaa miti. Kuniis

infeeshiinaa maaddaatiif bakteeriyaa sababa tahan beekuuf fi qorichaa wajjiin walbaruu isaanii ni

qo’ata. Akkasumaas sababa rakkoo beekuuf ni yaala. Kuniis infeeshiinaa maaddaaa ittisuufi

ta’achuuf ni gargaara.

Akkataa qo’nnnoofi yeroo fudhatu

Adeeffanno qo’annoof barbaachisu gaafille 21 qo’annoof dhibaate gaafachuun deebisaanaaf

kennan walumaagalatii gaafilee deebisaa kennitu. Yeroo hanga daqiiqaa 25 fudhata. Kanaafuu

yeroo kana na wajjiin akka dabarsitan kabajaan isiin gaafanna.

Midhaafi fayidaa qoranno

Qorannoo kanarrati hirmaachuuf midhaan isin irra gahu baay’ee xiqqaadha. Haaata’uu malee,

yeroo keessan xiqqo fudhachuu ni danda’a. qorannoo kanarrattii yeroo hirmaattan kafalttin isiniif

kafalamu hin jiru. Qorannoon kun karoora fayyaarratti karroorsuuf odeeffannoo ni kenna.

Amantummaa

Odeeffannoon kennitan icitiin isaa kan eeggameedha. Waa’ee kee odeeffannon ibsu hin jiru.

Bu’aan qorannoorraa argamu ummata waligalaatiifi malee kan nama tokko hin ilaallatu. Gaafilee

yeroo gaafatamtan maqaan keessan lakkoofsa iciti ni kennamaaf.

62

Mirga

Qo’annoo kanarratti hirmaachuun fedhii keessan qofaan ta’a. hirmachuufiis hirmachuu

dhiisuufiis mirga qabdan. Hirmachuuf kan murteessitan taanaan, yeroo barbaaddanitti adda

muruuf mirga qabdan. Gaafilee hin barbaanne deebissu dhabuuf bu’aan sirraa hafu hin jiru.

Teessoo

Waa’ee qorannoorratti gaafii qabaannan yeroo barbaaddanitti teessoon kanaan nu argachu

dandeessu. Lekkoysa bilbilaa: 0915010522; email: [email protected]

IHRERC teesso፡ lakkoysa bilbilaa: 0254660708 ykn lekkoysaa postaa 235 Harar

Ibsa hayyamammaa

Odeefannon hirmattotaa dubbiseera/ naaf dubbifameera. Kaayyoo, adeemsa, midhaafi bu’aa,

amantummaa, mirga hirmachuufi teesso qo’annoo ifatti hubadheera. Waaniin hin hubatin akkaan

gaafadhuuf haalli mijjaawaan naaf uumameera. Qo’annoorraa yeroo berbaadetti hafuufi

akkasumaas gaafileen hin barbaanne deebisuu dhiisuuf mirga akkaan qabu naaf himameera /

Qo’annoorraa yeroo berbaadetti Ilmoo tiiyaa baasuufi akkasumaas gaafileen hin barbaanne

deebisuu dhiisuuf mirga akkaan qabu naaf himameera. Kanaafuu qo’annoo kanarratti hirmachuu

kiyya mallattoo gaditti ibsa meeniin mirkaneessa.

Maqaa fi Mallatto hirmaataa………….

Maqaa fi Mallatto walitti qabaa odeeffannoo…………..

63

(Somali Version)

Magacaygu waa______________waxaan ahay xog ururriye ururrinaya daraasaad kusaabsan

bulshda, dhigtana barasha heerka labaad(master degree) ee jaamacada haramaya qaybta

caafimadka iyo sayniska magacayguna yahay ADIL IBRAHIM waxaan si naxariisle kaaga

codsanyaa in aad isiiso dareenkaaka aad ku sharaxaso daraasadan isla markana aad kaga qayb

qaadato.

Cinwaanka daraasadka

Si bacteriyaad looga saaro amalooga illaaliyo dhaawacain infection soogaadho sidookale

unuglaanta daawooyinka iyo waxyaabaha kale ee laxidhiidha ee kadhax jira xanuusadayaasha

lagudaa waynayo Cusbitaalka diljora, Dire Dhawa, bariye Itoobiya.

Ujeedada daraasada

Natiijada daraasadani waxay muhiiim u noqonaysaa xafiiska caafimaadka ee gobolka si ay u

qorsheeyaan waxqabadka iyo barnaamijyada lagaga hor tagayo shubanka caruurta ka yar sano

ee bulshada. Ujeedada daraasadani waa in la qoro cilm I baadhis kaaso qayb ka ah barnaamijka

wax barashada heerka labaad (master) eek u saabsan dawaynta cayayaanka yaryar si baadhitaan

dheeraada loogu sameeyo.

Habka iyo mudada

Waxaan kula yeelan doonaa waraysi anoo isticmaalaya qaab su aaleed qoraal ah si aad iisiiso

xog ku saabsan daraasadayda. Waxa jira suaalo aad ka jawaabaysid kaasi oon kaaga qaadi doono

hab waraysi 21 waraysigu. Ilmuhu Saxarahagu waa isee. wuxuu qaadan dooona 25 daqiiqo sidaa

daraaded waxaan kaa codsanayaaa inaad ii hurto wakhtigaaaga muhiiimka ah.

Khatarta iyo faa,idada daraasadan:

Khatarta kaqayb qaadashada daraasadani waa mid aad u kooban laakiin waxay qaadan doontaa

daqiiqado yar oo kamida wakhtigaaga.. Majiri doonto kharash toosa oo lagaga qayb qaadanayo

daraasadan. laakiin natiijada cilmibaadhistani waxay war bixin muhiima siinaysaa

gadhwadeenada dajiya qorshayaasha caafimadka ee deegaanka..

64

Sirta daraasada

War bixinta aad nasiisaa waxay noqondoontaa mid qarsoon. Majiri doonto war bixin si gaara u

muujinasa ka qaybgalkaaga.natiijada daraasadani waxay u noqon doontaa bulshada mid guud oo

aan cid gaara khusayn. Hadaba qaab su aaleedkan waxaa lagu calaamadin doonaa inaan la

muujin wax magaca mana jiri doonto wax tixraacaoo ku saabsan warbixinta qoraalka ama

waraysiga ka qayb galaha

Xuquuqda Ka Qayb Galaha

Ka qaybgalka daraasadani waa mid muta dawac nimo ah. Waxaad xaq uu leedahy in aad

cadayso kaqayb galkaaga daraasadan iyo in kale. Hadii aad go aansato in aad ka qayb qaadato

waxaad xaq uleedahay inaad isaga tagto daraadan wakhtiga aad doonto taasina calaamad u ma

aha inay kaa luminayso faa idooyinka kuu gaarka ah.

Ciwaanka La Igala Soo Xidhiidhayo

Hadii ay jirto wax su aala ah oo ku saabsan habka daraasadan fadlan igala soo xidhiidh

Taleefanka gacanta: 0915010522ama email address: [email protected]

Waxa kale oo la iga helaa numberka xafiiska cilmi baadhista iyo anshaxa

Lanbarka xafiisaka: 0254660708 ama Po,Box 235, Harar

Cadaynta Mutadawacnimadayda.

Waxaan akhriyey warqada warbixinta ka qayb qaataha.waxaan si cad u fahmay u jeedada

daraasada,habka,khatarta iyo faaidada ,cadaymaha kalsoonaanta,xaqa ka qayb qaataha iyo halka

la igala soo xidhiidhayo wixii loo baahdo. waxaan ku siiyey fursad aad igu weydiiso su,aalaha

aan kuu cadayn.waxaan kuu sheegay inaan xaq u leeyahay inaan iska daayo daraasadan wakhtiga

aan doono ama aanad ka jawaabin su,aalaha aanan doonaynin. Sidaa Ilmuhu daraadeed waxaan

ku cadaynayaa mutadawacnimadayda khusaysa daraasadan sexeexayga gaarka ah sida hoos ku

qoran.

Sexeexa ka qaybqaataha_________________taarikhda____________________

Xog ururiyah: magaca____________________sexeexa________taarikhda________

65

Appendix B: Participant Information Sheet and Informed Voluntary Consent Form for

Parents or Guardians of Under 18 Years Study Participant

My name is …………………….. I am working as a data collector for the study conducted in this

community by ADIL IBRAHIM who is studying for his master’s degree at Haramaya

University, the College of Health and Medical Science. I kindly request you to lend me your

attention to explain you about the study and your child being selected as the study participants.

The Study Title:

Bacteria isolates, Drug susceptibility pattern and associated factors among patients

admitted for wound infection at Dil-Chora Referral Hospital, Dire Dawa, Eastern

Ethiopia

Purpose/aim of the study:

The finding of this study can be of a paramount importance for the Regional Health Bureau to

plan intervention programs to prevent bacteria isolates from wound in your community and

others; thereby improving public health in general. Moreover, the aim of this study is to write a

thesis as a partial requirement for the fulfillment of a Master’s Program in Medical Microbiology

for the principal investigator.

Procedure and duration:

I will be interviewing you using a questionnaire to provide me with pertinent data that is helpful

for the study. There are 21 questions to answer where I will fill the questionnaire by interviewing

you. Then your child will give laboratory sample for laboratory investigation. The interview will

take about 25 minute, so I kindly request you to spare me this time for the interview.

Risk and benefits:

The risk of being participating in this study is very minimal, but only taking few minutes from

your time and minor pain for close wound during insertion of syringe into the wound to collect

the sample. There would not be any direct payment for participating in this study and for each

bacterial wound infection confirmed test, the responsible clinician of the participant informed

and treatment started as per the culture result and drug susceptibility pattern. But the findings

from this research may reveal important information for the local health planners.

66

Confidentiality:

The information you will provide us will be confidential. There will be no information that will

identify your child in particular. The findings of the study will be general for the

studycommunity and will not reflect any thing particular of individual persons or housing. The

questionnaire will be coded to exclude showing names. No reference will be made in oral or

written reports that could link participants to the research.

Rights:

Participation for this study is fully voluntary. You have the right to declare your child participate

or not in this study. If you decide to participate, you have the right to withdraw from the study at

any time and this will not label you for any loss of benefits which you otherwise are entitled you

do not have answer any questions that you do not want to answer.

Contact Address:

If there are any questions or enquiries any time about the study or the procedure, please contact:

Mobile Phone: 0915010522 or Email Address: [email protected]

Contact address of the Institutional Health Research Ethics Review Committee (IHRERC) Office

phone: 0254660708 or P.O. Box 235, Harar.

Declaration of informed voluntary consent:

I have read/ was read to me the participant information sheet. I have clearly understood the

propose of the research, the procedures, the risk and benefits issues of confidentiality, the rights

of participating and the contact address of any queries. I have been given the opportunity to ask

questions for the things that may have been unclear. I, as child’s parent/guardian, was informed

that I have the right to withdraw my child from the study at any time or not to answer any

questions that I do not want. Therefore, I declare my voluntary consent to participate in this

study with my initials (signature) as indicated below.

Name and Signatures of parents or guardian participants……………………..

Name and Signature of data collector………………………………………..

67

(Amharic Version)

YGý-------------------------------------------------------Áp?@$ o™/úŒú K¨| o/UG¿ ¾ŒûsTWüy ½Óþናና ;¡Hና

LÁ«Y ¢>þË ½/ú>w” ÆÐQ wGQአዲል ኢብራሂም ሙሳ ½<Œ¬ú >Õናt$ FOÉ WqXoü <•

›½WR/ú ›Î”>/ú$ o±ü;H Õና| ›TY° wXzí ›«Äü<Œú Y>wFOÓú Y>Õናx Î>ä

›«ÄüÃOÐ@°| |«] Îû±þ°|« ›«ÄüWÓú– o|;|ና ›ÓÁc>/ú$

½Õናx T©Y

ባክቴሪያ ከቁስል መለየት, በተደጋጋሚ የመድኃኒት ዝንባሌ እና ተጓዳኝ ጉዳዮች በድልጮራ ሆስፒታል ከሚታከሙ

ህሙማን መሀከል፡

የጥናቱ ዓላማ

H«H ›«ኳ« Á; Õና| ½wÃOάú ½Æ;O-HOc :ûÃx« >Gሟ?| oü<«H ŒÎT Ы ½Õናx

ÕeH »±ü;H o?Á ›«Ã<Œ ÁzFና@$Á;H ®Œ” ከቁስል ™HÙባክቴሪያ»G¬eH o?Á o™/úŒú W™|

o;¡Hና ±úQ¿ |@e …ÐT ½<Œ¬ú« FÆ/Œû| FቋቋH ÁF>»z@$ ow×GQH ½…ÐP«

F«Y¨þ°… ¬Á«H H¡«¿}…« >G¬e ÁI¡R@$ Á;H ÃÐI ባክቴሪያ ከቁስል o]z« >F»?»@

›ና>FfÔÓT ½Gû¿Y…@ /úŒýz ›«ÃGûëÕT ÁzFና@$

½Õናቱ eÃH w»w@ና የሚፈጁዉ ጊዜ

_ናቱጠቃሚየሆኑመረጃዎችንበሚጠየቁትጥያቄመሰረትይመልሱልኛል፡፡ባጠቃላይ 21 ጥያቄዎችንመልስይሰጣሉ፡፡ከዚያም

እርስዎ/ልጅዎት የቁስሉ ናሙና ይሰጡኛልÝÝ መጠይቁምየሚፈጀዉጊዜ25ደቂቃይሆናል፤

በመሆኑምየህንንጊዜከኔጋርእንዲያሳልፉበትህትናእየጠየኩኝ ምስጋናዬም አቀርባለሁኝ።

™ÃÏና ጥቅም

በዚህ ጥናት በመሳተፍዎ ያለዉ አደጋ በጣም ጥቂት ነዉ፤ነገር ግን ትንሽ ጊዜ ከርስዎ የወስዳል እና የቁስሉ አይነት ዝግ ከሆነ

ናሙና በመርፌ ስለሚወሰድ ትንሽ ህመም ይኖረዋል፡፡ በዚህ ጥናት ሲሳተፉ ሚከፈልዎት ክፍያ በቀጥታ ባይኖርም

በተገኘው ውጤት መሠረት ለሃኪም ሙሉ መረጃ በመስጠት ትክክልኛ መድኃኒት እንዲያገኙ ይጠቅማል ፡፡ በተጨማሪም

ይህ ጥናት የጤና እቅድ ለማቀድ ጥሩ መረጃን የሰጣል፡፡

መተማመኛ

Y¸s-#N mr© ¸S_‰êE YçÂLÝÝ XRSãN ¥NnT y¸Gl} mr© xYñRMÝÝ

k_ናቱምየሚገኘዉዉጤትአጠቃላይየህብረተሰቡእንጂየአንድንግለሰብወይምቤትአያመላክትም፡፡

68

መጠይቁምላይስምወደሌላይተረጎማል፡፡

ምንምዓይነትማጣቀሻተሳታፊዉንከጥናቱጋርየሚያያይዝበቃላትምይሁንበፅሁፍአይኖርም፡፡

Fq}…

o±ü; Õና| FXwð oFú>ú ðcÖŒ|?Á ½wFWOw Œ¬ú$ o±ü; Õና| >FXwð ¬ÁH ?>FXwð

Fq| ™>°|$ >FXwð ¬YŒ¬ú »<«! oë>Îú| Îû±þ »Õናቱ ማቋረጥ ይችላሉ፡ ይህም የማይፈልጉትን ጥያቄ

ባለመመለስዎ የሚያስቀርብዎት ጥቅም የለም፡፡

አድራሻ

ስለ ጥናቱ ወይም ሂደት በማንኛዉም ጊዜ ጥያቄ ካለዎት፤ በዚህ አድራሻ ያግኙን፡ ሞባይል ቁጥር፡ 0915010522 ወይም

ኢሜይል አድራሻ፡ [email protected]

IHRERC አድራሻ፡ የቢሮ ስልክ ቁጥር፡ 0254660708 ወይም ፖ.ሳ.ቁ. 235 ሀረር

የፍቃደኝነት ማረጋገጫ

የተሳታፊዎች መረጃ አንብቤዋለሁ/ተነቦልኛል፡፡ የጥናቱንም ዓላማ፤ሂደቱን፤አደጋና ጥቅሙን፤መተማመኛዉን፤ የመሳተፍ

መብት እና አድራሻ በግልፅ ተረድቼዋለሁ፡፡የልተረዳሁትንም ነገር እንድጠይቅ ምቹ ሁኔታ ተመቻችቶልኛል፡፡

ከጥናቱምበፈለኩት ሰዓት ለማቃረጥ ወይም የማልፈልገዉን ጥያቄ ላለመመለስ መብት እንዳለኝ ተነግሮኛል ከጥናቱም ልጄን

በፈለኩበት ሰዓት ለማቃረጥ ወይም የማልፈልገዉን ጥያቄ ላለመመለስ መብት እንዳለኝ ተነግሮኛል፡፡ስለዚህም በዚህ ጥናት

በፈቃደኝነት መሳተፌን ክዚህ በታች ባለዉ ፊርማዬ እገልፃለሁ፡፡

የተሳታፊው ቤተሰብ ወይም አሳዳጊ ስምና ፊርማ ------------------------------ ½FOÉ WqXoü¬ú ስም እና íTG-----------------

69

(Afan Oromo Version)

Maqaan kiyya ------------------------- jedhama. Yeroo ammaa kana yunivarsitii Haroomayaatti

digrii lammataabarachaa kanjiru ADIL IBRAHIM wajjiiin odeeffannoo funaanaatiin jira.

Qo’annoo kanaaf waan filatamtaniif waa’ee qo’annichaa yeroon isinii himu akka na

dhageeffattan kabajaaniin isiin gaafadha.

Mata Duree Qo’annoo

Qo’annoo waa’ee bakteeriyaa infeeshiinaa maaddaa irraa fuunanamnii, qorichaa waliin walbaruu

isaaniifi waantotaa infeeshiinaa maaddaatiif nama saaxilaan waarreen hospitaala Dilchoratii

yaalamaniif.

Kaayyoo Qo’annoo

Qorannoon kun digrii lammataa ittiin ebbifamuuf tahullee fayidaan isaa kana qofaa miti. Kuniis

infeeshiinaa maaddaatiif bakteeriyaa sababa tahan beekuuf fi qorichaa wajjiin walbaruu isaanii ni

qo’ata. Akkasumaas sababa rakkoo beekuuf ni yaala. Kuniis infeeshiinaa maaddaaa ittisuufi

ta’achuuf ni gargaara.

Akkataa qo’nnnoofi yeroo fudhatu

Adeeffanno qo’annoof barbaachisu gaafille 21 qo’annoof dhibaate gaafachuun deebisaanaaf

kennan walumaagalatii gaafilee deebisaa kennitu. Yeroo hanga daqiiqaa 25 fudhata. Kanaafuu

yeroo kana na wajjiin akka dabarsitan kabajaan isiin gaafanna.

Midhaafi fayidaa qoranno

Qorannoo kanarrati hirmaachuuf midhaan isin irra gahu baay’ee xiqqaadha. Haaata’uu malee,

yeroo keessan xiqqo fudhachuu ni danda’a. qorannoo kanarrattii yeroo hirmaattan kafalttin isiniif

kafalamu hin jiru. Qorannoon kun karoora fayyaarratti karroorsuuf odeeffannoo ni kenna.

Amantummaa

Odeeffannoon kennitan icitiin isaakan eeggameedha. Waa’ee kee odeeffannon ibsu hin jiru.

Bu’aan qorannoorraa argamu ummata waligalaatiifi malee kan nama tokko hin ilaallatu. Gaafilee

yeroo gaafatamtan maqaan keessan lakkoofsa iciti ni kennamaaf.

70

Mirga

Qo’annoo kanarratti hirmaachuun fedhii keessan qofaan ta’a. hirmachuufiis hirmachuu

dhiisuufiis mirga qabdan. Hirmachuuf kan murteessitan taanaan, yeroo barbaaddanitti adda

muruuf mirga qabdan. Gaafilee hin barbaanne deebissu dhabuuf bu’aan sirraa hafu hin jiru.

Teessoo

Waa’ee qorannoorratti gaafii qabaannan yeroo barbaaddanitti teessoon kanaan nu argachu

dandeessu. Lekkoysa bilbilaa: 0915010522; email:[email protected]

IHRERC teesso፡ lakkoysa bilbilaa: 0254660708 ykn lekkoysaa postaa 235 Harar

Ibsa hayyamammaa

Odeefannon hirmattotaa dubbiseera/ naaf dubbifameera. Kaayyoo, adeemsa, midhaafi bu’aa,

amantummaa, mirga hirmachuufi teesso qo’annoo ifatti hubadheera. Waaniin hin hubatin akkaan

gaafadhuuf haalli mijjaawaan naaf uumameera. Qo’annoorraa yeroo berbaadetti Ilmoo tiiyaa

baasuufi akkasumaas gaafileen hin barbaanne deebisuu dhiisuuf mirga akkaan qabu naaf

himameera.Kanaafuu qo’annoo kanarratti hirmachuu kiyya mallattoo gaditti ibsa meeniin

mirkaneessa.

Maqaa fi Mallatto warra / egduu da’imaa hirmaataa………………………….

Maqaa fi Mallatto walitti qabaa odeeffannoo……………………….

71

(Somali Version)

Magacaygu waa______________waxaan ahay xog ururriye ururrinaya daraasaad kusaabsan

bulshda, dhigtana barasha heerka labaad(master degree) ee jaamacada haramaya qaybta

caafimadka iyo sayniska magacayguna yahay ADIL IBRAHIM waxaan si naxariisle kaaga

codsanyaa in aad isiiso dareenkaaka aad ku sharaxaso daraasadan isla markana aad kaga qayb

qaadato.

Cinwaanka daraasadka

Si bacteriyaad looga saaro amalooga illaaliyo dhaawacain infection soogaadho sidookale

unuglaanta daawooyinka iyo waxyaabaha kale ee laxidhiidha ee kadhax jira xanuusadayaasha

lagudaa waynayo Cusbitaalka diljora, Dire Dhawa, bariye Itoobiya.

Ujeedada daraasada

Natiijada daraasadani waxay muhiiim u noqonaysaa xafiiska caafimaadka ee gobolka si ay u

qorsheeyaan waxqabadka iyo barnaamijyada lagaga hor tagayo shubanka caruurta ka yar sano

ee bulshada. Ujeedada daraasadani waa in la qoro cilm I baadhis kaaso qayb ka ah barnaamijka

wax barashada heerka labaad (master) eek u saabsan dawaynta cayayaanka yaryar si baadhitaan

dheeraada loogu sameeyo.

Habka iyo mudada

Waxaan kula yeelan doonaa waraysi anoo isticmaalaya qaab su aaleed qoraal ah si aad iisiiso

xog ku saabsan daraasadayda. Waxa jira suaalo aad ka jawaabaysid kaasi oon kaaga qaadi doono

hab waraysi 21 waraysigu. Ilmuhu Saxarahagu waa isee. wuxuu qaadan dooona 25 daqiiqo sidaa

daraaded waxaan kaa codsanayaaa inaad ii hurto wakhtigaaaga muhiiimka ah.

Khatarta iyo faa,idada daraasadan:

Khatarta kaqayb qaadashada daraasadani waa mid aad u kooban laakiin waxay qaadan doontaa

daqiiqado yar oo kamida wakhtigaaga.. Majiri doonto kharash toosa oo lagaga qayb qaadanayo

daraasadan. laakiin natiijada cilmibaadhistani waxay war bixin muhiima siinaysaa

gadhwadeenada dajiya qorshayaasha caafimadka ee deegaanka..

Sirta daraasada

War bixinta aad nasiisaa waxay noqondoontaa mid qarsoon. Majiri doonto war bixin si gaara u

muujinasa ka qaybgalkaaga.natiijada daraasadani waxay u noqon doontaa bulshada mid guud oo

aan cid gaara khusayn. Hadaba qaab su aaleedkan waxaa lagu calaamadin doonaa inaan la

muujin wax magaca mana jiri doonto wax tixraacaoo ku saabsan warbixinta qoraalka ama

waraysiga ka qayb galaha

72

Xuquuqda Ka Qayb Galaha

Ka qaybgalka daraasadani waa mid muta dawac nimo ah. Waxaad xaq uu leedahy in aad

cadayso kaqayb galkaaga daraasadan iyo in kale. Hadii aad go aansato in aad ka qayb qaadato

waxaad xaq uleedahay inaad isaga tagto daraadan wakhtiga aad doonto taasina calaamad u ma

aha inay kaa luminayso faa idooyinka kuu gaarka ah.

Ciwaanka La Igala Soo Xidhiidhayo

Hadii ay jirto wax su aala ah oo ku saabsan habka daraasadan fadlan igala soo xidhiidh

Taleefanka gacanta: 0915010522ama email address: [email protected]

Waxa kale oo la iga helaa numberka xafiiska cilmi baadhista iyo anshaxa

Lanbarka xafiisaka: 0254660708 ama Po,Box 235, Harar

Cadaynta Mutadawacnimadayda.

Waxaan akhriyey warqada warbixinta ka qayb qaataha.waxaan si cad u fahmay u jeedada

daraasada,habka,khatarta iyo faaidada ,cadaymaha kalsoonaanta,xaqa ka qayb qaataha iyo halka

la igala soo xidhiidhayo wixii loo baahdo. waxaan ku siiyey fursad aad igu weydiiso su,aalaha

aan kuu cadayn.waxaan kuu sheegay inaan xaq u leeyahay inaan iska daayo daraasadan wakhtiga

aan doono ama aanad ka jawaabin su,aalaha aanan doonaynin. Sidaa waalidka iyo qofka

masuulika kaah caruurta dadeedu ka yaryihiin waxaan ku cadaynayaa mutadawacnimadayda

khusaysa daraasadan sexeexayga gaarka ah sida hoos ku qoran.

Sexeexa waalidka iyo qofka masuulka…………………… taarikhda____________________

Xog ururiyah: magaca____________________sexeexa________taarikhda________

73

Appendix C: Information Sheet and Informed Voluntary Consent Form for Head of the

Hospital

My name is …………………….. I am working as a data collector for the study conducted in this

community by ADIL IBRAHIM who is studying for his master’s degree at Haramaya

University, the College of Health and Medical Science. I kindly request you to lend me your

attention to explain you about the study being conducted in this Hospital.

The Study Title:

Bacteria isolates, Drug susceptibility pattern and associated factors among patients

admitted for wound infection at Dil-Chora Referral Hospital, Dire Dawa, Eastern

Ethiopia

Purpose/aim of the study:

The finding of this study can be of a paramount importance for the Regional Health Bureau to

plan intervention programs to prevent bacteria isolates from wound in your community and

others; thereby improving public health in general. Moreover, the aim of this study is to write a

thesis as a partial requirement for the fulfillment of a Master’s Program in Medical Microbiology

for the principal investigator.

Procedure and duration:

I will be interviewing you using a questionnaire to provide me with pertinent data that is helpful

for the study. There are 21 questions to answer where I will fill the questionnaire by interviewing

you. Then you will give laboratory sample for laboratory investigation. The interview will take

about 25 minute, so I kindly request you to spare me this time for the interview.

Risk and benefits:

The risk of being participating in this study is very minimal, but only taking few minutes from

your time and minor pain for close wound during insertion of syringe into the wound to collect

the sample. There would not be any direct payment for participating in this study and for each

bacterial wound infection confirmed test, the responsible clinician of the participant informed

and treatment started as per the culture result and drug susceptibility pattern. But the findings

from this research may reveal important information for the local health planners.

74

Confidentiality:

The information you will provide us will be confidential. There will be no information that will

identify you in particular. The findings of the study will be general for the studycommunity and

will not reflect any thing particular of individual persons or housing. The questionnaire will be

coded to exclude showing names. No reference will be made in oral or written reports that could

link participants to the research.

Rights:

Participation for this study is fully voluntary. You have the right to declare participate or not in

this study. If you decide to participate, you have the right to withdraw from the study at any time

and this will not label you for any loss of benefits which you otherwise are entitled you do not

have answer any questions that you do not want to answer.

Contact Address:

If there are any questions or enquiries any time about the study or the procedure, please contact:

Mobile Phone: 0915010522 or Email Address: [email protected]

Contact address of the Institutional Health Research Ethics Review Committee (IHRERC) Office

phone: 0254660708 or P.O. Box 235, Harar.

Declaration of informed voluntary consent:

I have read the participant information sheet. I have clearly understood the purpose of the

research, the procedures, the risks and benefits, issues of confidentiality, the rights of

participating and the contact address for any queries. I have been given the opportunity to ask

questions for things that may have been unclear. I was informed that participants have the right

to withdraw from the study at any time or not to answer any question that they do not want. I am

also informed that the Hospital has the right to stop this study from being conducted in the

Hospital if any misdeeds and unethical procedures are observed during the data collection

process in the Hospital’s premises. Therefore, I declare my voluntary consent on behalf of the

Hospital management to allow this study to be conducted in the Hospital with my initials

(signature). Name and Signatures of Head of the Hospital ……………………….

Name and Signature of data collector……………………………

75

Appendix D: Data Collection Format

Questionnaire for investigation of Bacteria isolates, drug susceptibility pattern and associated

factors among patients treatedfor wound infection at Dil-Chora Referral Hospital, Dire Dawa,

Eastern Ethiopia.

Eligibility questionnaire

101. Are you taking antibiotic drug? Yes………..1

No………..2

I don’t know…3

102. If yes for the above question When...................

Date ____/_____/__________

Label number_______

Socio demographic characteristics

201. Age ……………………

202. Sex Female..............1

Male..................2

203. Residence Urban............. 1

Rural............... 2

204. Educational background

Illiterate……………….1

Write and read only…...2

Primary 1-8……………...3

Secondary 9-12…………….4

76

Collage and Above 12……………..5

205. Marital status Single…………1

Married………..2

Woudewoun………3

Divorce……………4

206. Monthly income ………………………….

207. Family size …………………………

Clinical information

301. Previous history of wound infection Yes…………………...1

No…………………....2

302. Previous history of antibiotic use Yes…………………..1

No……………………2

I don’t know…………3

303. Site of wound Leg…………………...1

Abdomen…………….2

Hand………………....3

Foot………………….4

Head and neck……….5

Back………………….6

Breast and chest...........7

Genitals………………8

Armpit………………..9

77

304. Type of wound Trauma……………….1

Postoperative wound…2

Abscess………………3

Ulcers………………..4

Burn wound………….5

Diabetic foot ulcers….6

Other ………………...7

305. If for Q no 304 Postoperative wound

Types of Surgery

Caesarean section……...1

Laparotomy……………2

Appendectomy………...3

Hysterectomy………….4

Prostectomy……………5

Other specify…………….6

306. If for Q no 304 Postoperative wound

Duration of Operation

……………………..

307. Duration of wound ………………………

308. History of Diabetics Yes…………………..1

No…………………...2

309. Type of Specimens Wound Swab………...1

Pus Discharge………..2

310. Type of Ward …………………………

Personal habit

401. Frequency of wound cleaning …………………………….

402. Frequency of dail ward room cleaning ……………………………..

78

(Amharic Version)

101. የባክቴሪያመድኃኒትይወስዳሉ? አዎ!

አይደለም!

አላውቅም!

102. መልሶአዎከሆነ መቼ........................

ቀን፡____/_____/__________

Label number_______

የማህበራዊባህሪያት

201. ዕድሜ ……………………

202. ፆታ ሴት

ወንድ

203. የመኖሪያስፍራ ከተማ

ገጠር

204. የትምህርትደረጃ ያልተማረ

መፃፍናማንበብብቻ

ከ1-8ኛክፍልየተማረ

ከ9-12ኛክፍልየተማረ

ዩኒቨርሲቲደረጃ

205. የጋብቻሁኔታ ያላገባ/ች

ያገባ/ች

በሞትየተለያዩ

79

የተፈታ/ች

206. ወርሃዊገቢ ………………………….

207. የቤተሰብብዛት …………………………

ክሊኒካልመረጃ

301. ከአሁንበፊትቆስለዋል/infected/ አዎ

አይደለም

302. ከአሁንበፊትየባክቴሪያመድኃኒትወስደዋል አዎ

አይደለም

አላውቅም

303. የቁስልስፍራ እግርከቁርጭምጪሚትበላይ

ሆድ

እጅ

እግርከቁርጭምጪሚትበታች

ራስእናአንገት

ወገብ

ጡትእናደረት

የግብረስጋአካል

ብብት

304. የቁስሉአይነት ፍንካቴ

ቀዶጥገና

ምግልየቋጠረዕብጠት

የጣትቁስል

የቃጠሎቁስል

የሱኳርበሽተኛየጣትቁስል

ሌላ................................

80

305. ለጥያቄቁ. 304 መልሶየቀሶጥገናከሆነ፡

የቀዶጥገናውአይነት

ሴዜሪያንሴክሽን (Caesarean section)

ላፕራቶሚ (Laparotomy)

አፔንድክቶሚ (Appendectomy)

ሂስተረክቶሚ (Hysterectomy)

ፕሮስቴክቶሚ (Prostectomy)

ሌላከሆነያብራሩ ..........................

306. ለጥያቄ ቁ. 304 መልሶ የቀሶ ጥገና ከሆነ፡የስራውፍጆታ

(ጊዜ)

……………………..

307. የቁስሉፍጆታ (ግዜ) ………………………

308. በስኳርበሽታተይዘውያውቃሉ? አዎ

አይደለም

309. Type of Specimens

የናሙናውአይነት

ውንድስዋብ (Wound Swab)

ፑስድስቻርጅ (Pus Discharge)

310. የክፍሉአይነት …………………………

የግልባህሪይ

401. የቁስልማፅዳትሁኔታ (ብዛት) …………………………….

402. የክፍልማፅዳትሁኔታ (ብዛት) ……………………………..

81

(Afan Oromo version)

101. Kana dura qoricha bakteeriyaa fudhattee jirta? Eyyen………..1

Lakki………..2

Ani hin beeku…3

102. Yoo deebiin kee eyyen tahe Yoom...................

Guyaa ____/_____/__________

lakka_______

Oddefanoo wa’ee keessanii

201. Umrii ……………………

202. Saala Dhalaa..............1

Dhiira..................2

203. Iddoo jireenyaa Magaala............. 1

Baadiyaa............... 2

204. Sadarkaa barnootaa

Hin baranee……………….1

Dubbisuufi barreessu qofa…...2

Daree 1-8……………...3

Daree 9-12…………….4

Yuniversiitii……………..5

82

205. Haala bultii Qeerroo(Hin fuune/heerumne)………1

Kan gaayela qabu (Fuudhe/Heerumte

………..2

Du’aan adda kan bahan………3

Kan wal hiikan……………4

206. Galii ji’a ………………………….

207. Heeddumina maatii keessanii …………………………

Oddeefannoo wa’ee fayaa keessanii

301. Kana dura madoftaanii turtanii? Eyyen…………………...1

Lakki…………………....2

302. Kana dura qoricha/daawaa bakteeriyaa

fudhattee jirta?

Eyyen…………………..1

Lakki……………………2

Ani hin beeku …………3

303. Amma eessara madooftan? Mila…………………...1

Garaa…………….2

Harkaa………………....3

Faanta………………….4

Matafi morma……….5

Dugda guba………………….6

Harmafi laphee......................7

Qama wal quunamti saalaa………8

Bobaa jala………………..9

83

304. Gosa mada keessanii Fotaqii………………..1

Baqaqsaamee…………2

Bisholee(dhiitoo bishaan kuufate)

………………3

Madaa quba …………...4

Gubadhee……………...5

Madaa dhukkubaa sukarara quba mila

irra nama qabdu ………6

Kan bira ………………...7

305. Yoo gaafi 304 baqaqsaadha jattee gosa

baqaqsaa kamii

Caesarean section……...1

Laparotomy……………2

Appendectomy………...3

Hysterectomy………….4

Prostectomy……………5

Other specify…………….6

306. Yoo gaafi 304 baqaqsaadha jattee Yeroon

baqaqsaa hamam takka fudhatee

……………………..

307. Yeroon dhukkubii hamam takka ………………………

308. Kan dura dhukkubaa sukara nii qabda Eyyan…………………..1

Lakki…………………...2

Ani hin beeku

309. Gosa saampila(eddattoo) Wound Swab………...1

Pus Discharge………..2

310. Kutaa itti yaalamtan essa ……….....................

Haala amala keessanii

401. Bayiina yeroo madaan dhiiqame …………………………….

402. Bayiina yeroo kutaan keessa jirtan

dhiiqame

……………………………..

84

(Somali Version)

Xaqinta su’aalaynta

101. Wax daawooyin ahoo qalajiye ah maqaadata Haa………..1

Maya………..2

Ma,agi………3

102. Hadii ay haatahay su’aasha kore Markee...................

Date ____/_____/__________

Label number_______

Astaamaha Sinjiyaynta

201. Da’ad ……………………

202. Sinji Dhadig..............1

Lab..................2

203. Daganaanshaha Magaalo............. 1

Miyi............... 2

204. Aqoontisa

Waxaan qorin Aana

akhrinayn……………….1

Wax qorikara akhrinakara…...2

Fasalka 1-8……………...3

Fasalka 9-12…………….4

University……………..5

85

205. Waguursaday Maguursadin…………1

Guursaday………..2

Garoob………3

Lafuray……………4

206. Dakhliga bilaha ah ………………………….

207. Baaxada qoyska …………………………

Xogta daawooyinka

301. In uujiro dhaawae hore infection kiisa Haa…………………...1

Maya…………………....2

302. Majiraa antibiotic Aad hory uqaatay Haa…………………..1

Maya……………………2

Ma,agi…………………3

303. Meesha dhaawaea

Lugta…………………...1

Dhaxda…………….2

Gaean………………....3

Lugan………………….4

Cad aha madaxa……….5

Qoorta………………….6

Haasaha aha xabadka...........7

Xubnaha cawrada………………8

Boba ah………………..9

86

304. Nooca dhaawaca Jug……………….1

Dhqqwaca qaliinka kadib…2

Malax………………3

Xanfaf………………..4

Olalka dhaawaca………….5

Kabuubyo lugta ah….6

Iwm ………………...7

305. Hdii su’aasha 304 aytahay qaliinka ka

danbeeya dhaawaca qaliin noolma ah

Qaliin jeexitaan ah .……...1

Qaliin baadhitaan ah……………2

Qaliin qabsin laga galay………...3

Qaliin kaadihaysta ah………….4

Waykale……………5

Iwm…………….6

306. Hdii su’aasha 304 aytahay qaliinka

Mudade qaliin ke uu qaasay

……………………..

307. Mudade dhaawaca ke uu qaasay ………………………

308. Sonkor/ macaan maleedahoy Haa…………………..1

Maya…………………...2

309. Nooca/qaabkaloobaadhay Wound Swab………...1

Pus Discharge………..2

310. Qaybta wardaad joogto …………………………

Waan xasssiyoo

401. Inta jeeree dhaawaca lanadiifiyo …………………………….

402. Inta jeeree golka lanadiifiyo ……………………………..

87

Appendix E: Laboratory Data

Laboratory Data (culture request form)

Haramaya University College Of Health And Medical Sciences, Department Of Medical

laboratory sciences

bacteria isolates, Drug susceptibility pattern and associated factors among patients

admittedfor wound infection at Dil-Chora Referral Hospital, Dire Dawa, Easter Ethiopia

LABORATORY REQUEST FORM

Label number: ________ Time of sample collection Type of specimens

____:_____ ________

Age ________

Sex Male……………1

Female………...2

Date of sample collection ____/_____/_____

Laboratory Results For Culture

Laboratory Results For Biochemical Test

88

Laboratory Results For DST

Name of lab personnel …………………… signature ……………….

1. Type of wound specimens: Wound swab or Pus discharge

2. Wound swab or Pus discharge culture results: ……………………………

3. If significant growth: Colony morphology and name of bacteria isolated: …....................

4. Gram reaction and Biochemical Tests:

Recommended for general bacteriology use

Basic Gram Stain Method

Gram staining technique

Required

Crystal violet

Lugol’s iodine

Acetone- alcohol decolizer

Natural red1g/l(0.1%W/V)

Procedures

1. Fix the dried smear with methanol for 2 minute

89

2. Cover the fixed smear with crystal violate for 30-60 minute

3. Rapidly wash off the stain with clean water

4. Tip of all the water and cover the smear with logos iodine for 30-60 min

5. wash off the iodine with clean water

6. Decolorize rapidly (few seconds) with acetone-alcohol. Wash immediately with clean

water

7. Cover the smear with natural red stain for 2 minute

8. wash of the stain with clean water

9. Wipe the pack of the slide clean and place it in a draining rack for the smear to air dry.

10. Examine the smear microscopically, first with the 40x objective to check the staining

and the oil immersion to report the bacteria and the cells.

Result

Gram positive bacteria dark purple

Yeast cells dark purple

Gram negative bacteria pale or dark red

Epithelial cells pale red

BIOCHEMICAL FLOW-CHARTS FOR IDENTIFICATION OF GRAM NEGATIVE

BACTERIA

Bacterial spp

LF

NLF

I

C

U

M

OX

TSIA

E.coli + - + - - + - A/AG

Klebsiella spp + - - + + - - A/A

Entrobacter spp + - - + - + - A/AG

Citrobacter spp + - V + - + - K/AG,H

2S

Salmonella spp - + - + - + - K/AG,H

2S

Morganella - + + - + V - K/A

90

Proteus vulgaries - + + V + + - K/A,H2S

Proteus mirables - + - + + + - K/A,H2S

Serratia - + - + - + - K or

A/A

Pseudomonas - + - + - + + K/K

Providencia - + + + V + - K/A

LF-lactose fermenters; I-indole; TSIA-triple sugar iron agar; M-motility; V-variable; NLF-non-

lactose fermenters; C-citrate; U-urea; A/A-acid over acid (yellow slope & yellow butt); K/A-

alkaline over acid (red slope &yellow butt); K/K-alkaline over alkaline (red slope & red butt);

H2S=hydrogen sulfide; G=gas

5. Drug Susceptibility Pattern (DST)

Interpretation for Drug Susceptibility Pattern (CLSI, 2010; CLSI, 2014

Antibiotics tested Interpretation of the result

Sensitive Intermediate Resistant

Ampicillin ≥ 17 14-16 ≤ 13

Ceftriaxone ≥ 23 20-22 ≤ 19

Chloramphenicol ≥ 18 13-17 ≤ 12

Vancomycin ≥ 12 10-11 ≤ 9

Erythromycin ≥23 14-22 ≤13

Gentamicin ≥ 15 13-14 ≤ 12

Penicillin G ≥ 29 28-29 ≤ 28

Cotrimoxazole ≥ 16 11-15 ≤ 10

Amikacin ≥ 16 15-16 ≤ 15

Ciprofloxacilline ≥ 31 21-30 ≤ 20

Doxycycline ≥ 16 13-15 ≤ 12

91

Appendix F: Sample collection procedure \Sample examination procedure

I. Wound Sample Collection

1. Prepare all the necessary equipment like clean glove, sterile culture tube, dressing, guaz ,

bacteriology requisition, Sterile saline and red bag.

2. Identify patient according to Patient Identifier.

3. Inform and prepare the patient.

4. Screen-off the area as appropriate. To maintain the patient's privacy.

5. Arrange the necessary equipment at the bedside.

6. Wash your hands and put on clean gloves.

7. Remove the dressing from the area to be cultured.

8. Avoid touching the infected site. Clean around the wound by 70% alcohol.

9. The wound should be cleansed with sterile saline to irrigate any purulent debris

10. Moisten the swab with sterile saline before taking sample.

11. Use a “zig-zag” motion whilst simultaneously rotating between the fingers.

12. Insert the swab into the sterile culture tube and transport to the labotatory

II. Wound Culture

1. The collected swabs streaked on blood agar and MaCconkey agar by sterile inoculation

loop.

2. The plates incubated at 35–37°C for 24–48 hours.

3. Preliminary identification of bacteria based on colony characteristics of the organisms.

Such as hemolysis on blood agar, changes in physical appearance in differential media,

enzyme activities of the organisms, Gram stain and Lactose fermenter or Non-lactose

fermenter.

III. Biochemical Test

1. Performed on colonies from pure cultures by using an inoculating loop for each test for

identification of the isolates.

2. Gram-negative rods identified by performing a series of biochemical tests such as Triple

sugar iron agar (TSI), Indole, Citrate Utilization, Urea and Oxidase and Motility.

I. Oxidase test

The oxidase test is used to detect bacteria that produce the enzyme cytochrome oxidase which

catalyze oxidation of reduced cytochrome by oxygen molecule.

92

Material Required

Fresh Oxidase reagent (Tetramethyle-p-phenylenediamine dihydrochloride, 1%)

Filter paper

Method

Place a piece of filter paper in a clean petri dish

Add 2 or 3 drops of freshly prepared oxidase reagent,

Using a piece of stick or glass rod (not an oxidized wire loop), remove a colony of the

test organism and smear it on the filter paper.

Look for the development of a blue-purple color within a few seconds

II. Urease test

This test is used to detect the enzyme urease, which breaks down urea into ammonia. Testing for

urease enzyme activity is important in differentiating enterobacteria.

Method

Inoculate heavily the test organism in a bijou bottle containing 3 ml sterile Christensen’s

modified urea broth

Incubate at 35-370C for 3-12 h (preferably in a water bath for a quicker result).

Look for a pink color in the medium.

Results

Pink color…………………..Positive urease test

No pink color……………… Negative urease test

III. Indole test

The test detects the ability of an organism to produce indole from Tryptophan. Testing for indole

production is important in the identification of enterobacteria.

Material required

Kovac’s or Ehrlich’s reagent

Bijou bottle/test tube

93

Method

Inoculate the test organism in a bijou bottle containing 3 ml of sterile tryptone water.

Incubate at 35 – 37oC for up to 48 hr

Test for indole by adding 0.5ml of Kovac’s reagent and shake gently.

Examine for a red color in the surface layer within 10 minutes.

Results

Red surface layer…………………Positive indole test

No red surface layer………………. Negative indole test

IV. Citrate utilization test

The test detects the ability of an organism to use citrate as its only source of carbon. This test is

one of several techniques used occasionally to assist in the identification of enteric bacteria.

Material required

Simmon’s citrate medium/agar

Inoculating loop

Method

Prepare slopes of the medium in bijou bottles as recommended by the manufacturer (store

at 2-8 C)

Using a sterile straight wire, first streak the slope with a saline suspension of the test

organism and then stab the butt.

Incubate at 35 0C for 48 hours

Look for a bright blue color in the medium

Results

Bright blue-----------------------------------------Positive citrate test

No change in color of medium------------Negative citrate test

94

V. Motility test

The motility test is not a biochemical test since we are not looking at metabolic properties of the

bacteria. Rather, this test can be used to check for the ability of bacteria to migrate away from a

line of inoculation.

Method

The bacterial sample will be inoculated into motility media using inoculating straight

wire.

Simply stab the media in as straight line as possible and withdraw the needle very

carefully to avoid destroying the straight line.

After incubating the sample for 24-48 hours, observations can be made.

Check to see if the bacteria have migrated away from the original line of inoculation.

Results

If migration away from the line of inoculation is evident then you can conclude that the test

organism is motile………………….. Positive motility test

Lack of migration away from the line of inoculation indicates a lack of motility………. Negative

motility test

VI. Triple sugar Iron (TSI) and Hydrogen sulfide production (H2S)

Method

All tubes containing media will be labeled.

Purified colonies will be inoculated in to the motility test medium by inserting a straight

inoculating needle to 2mm above the bottom of the tube. Withdraw the needle along the

same line.

Inoculation in to the TSI was by stabbing the agar butt with a straight inoculating needle

and streaking the slant in a zigzag.

Incubate overnight at 37oc.

Examination of the TSI medium. All Enterobacteriaceae ferment glucose, producing acid

and gas or acid only, which gives a yellow slant. If gas is produced, bubbles or cracks are

seen throughout the medium; the medium may even be pushed up in the tube if a large

amount of gas is produced. If lactose is simultaneously fermented, both the agar butt and

95

the slant become acid, i.e. yellow (e.g. in the case of E. coli),i.e. red. Blackening along

the stab line or throughout the medium indicates the production of hydrogen sulfide.

3. Gram-positive cocci identified based on their gram reaction, catalase and coagulase test

results.

I. Catalase test

This test is used to differentiate those bacteria that produce the enzyme catalase such as

Staphylococci from non catalase producing bacteria such as Streptococci.

Material Required

Hydrogen peroxide (3% H2O2)

Test tubes

Swab

Method

Pour 2-3 ml of the hydrogen peroxide solution into a test tube.

Using a sterile wooden stick or a glass rod, remove several colonies of the test organism

and immerse in the hydrogen peroxide solution.

Look for immediate bubbling.

Results

Active bubbling----- Positive test- Catalase produced

No release of bubbles ----- Negative test - No catalase produced

II. Coagulase Test

This test is used to differentiate Staphylococcus aureus which produces the enzyme coagulase,

from S. epidermidis and S. saprophyticus which do not produce coagulase.

Material Required

EDTA anticogulated human plasma.

Method

Place a drop of distilled water on each end of a slide or on two separate slides

Emulsify a colony of the test organism (previously checked by Gram staining) in each of

the drops to make two thick suspensions.

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Add a loopful (not more) of plasma to one of the suspensions, and mix gently.

Look for clumping of the organisms within 10 seconds.

No plasma is added to the second suspension. This is used to differentiate any granular

appearance of the organism from true coagulase clumping

Results

Clumping within 10 seconds…...S. aureus

No clumping within 10 seconds …No bound coagulase (Cheesbrough, 2006).

IV. Technique of Drug Susceptibility Test

1. Pick four to six morphologically identical colonies of bacteria frompure culture with an

inoculating loop

2. Transferred into a tube containing 5ml nutrient broth and mix gently until a homogenous

suspension form

3. Incubated at 37oC for 3-5 hours

4. Streak the standardized inoculums using a sterile non-toxic dry cotton swab on the entire

surface of the dried Mueller-Hinton agar plate three times, turning the plate at 60º angle

between each streaking to ensure even distribution.

5. Allows the inoculums to dry for 5-15 minutes with lid in place

6. Using mechanical dispensing apparatus or a sterile

7. forceps dispense the selected antibiotics discs onto the plates at a distance of 15 mm

away from the edge and 24 mm apart from each other.

8. After incubating the plates at37oC for 24 hours, diameters of the zone of bacterial growth

inhibition around the discs measured to the nearest millimeter

9. Determine the agent as sensitive, intermediate or resistant according to the standardized

table provided by the manufacturer (CLSI, 2010; CLSI, 2014).

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Appendix G: Curriculum Vitae

Contact information

Name: Adil Ibrahim

Address: Dire Dawa

Cell phone: 0915010522

Email: [email protected]

Personal data

Date of birth: October 15, 1990

Place of birth: Dire Dawa, Ethiopia

Sex: Male

Nationality: Ethiopian

Marital status: Single

Employment history

1. Dil-Chora Referral Hospital: From 2013 onwards as a Laboratory technologist.

Education Grade SchoolYear

1-8 Legahare primary and secondary school 1997-2004 G.C

9-10 Meahdel-Nur Al-Islam No. 1 School 2005-2006 G.C

11-12 Jijiga Senior Secondary School 2007-2008 G.C

1st – 4th year Wollega University 2009-2012 G.C

University/higher institution

Wollega University from 2009-2012, Ethiopia

Professional qualifications

BSc degree in medical laboratory technology, Wollega University, Ethiopia

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Languages

Written Skills Oral Skills

English Excellent Excellent

Amharic Excellent Excellent

Somali ………… Excellent

Afan Oromo Excellent Excellent

References

Eyasu Ejeta (BSc, MSc), Lecturer in Wollega University, Medical Laboratory Technology

Department

Mob: - (251)-917817012

Abdurrahman Said (BSc, MSc), Lecturer in Wollega University, Medical Laboratory

Technology Department

Mob: - (251)-923390981