f3S"{l )-07/ -ottt

Jor-rrnal Q Dhaka International Univclsity, 4, No. I

A Survey on Antimicrobial Susceptibility ofStrepto co cct,rs pnet;l1.Loniae from Different Diagnostic

,Centers in Dhaka CitY, Banglaclesh

Mol'ramnrad Shahriar and Sanj ida Shahicil

Abstract: Strcptococctts pttt:rrntoninc (irneumococcal) rert-rairrs an impot'tirnL c;'tttsc ol

pneumgnia, nreningitis, Lracteremias, arrd ncLrtc otitis mctlia rvorldr'r'ic1c.

Antirnic;obial resistance among pnelrmocc.rcci has ntt.;r-renLcd clt'rn-raticalltr ove r tl'rc

past Lhree clecac-les, and is inflr-rcnccd by patterns ol anlibiotic .,t". aun.i.1gral'rlc

1;cogr.piric variation ip slsceprtibiliLl, nccessiiates regional resistatrce tracl<inq. The

oL.,.,.ti,r" of the str-rdy is to assr-.ss antil-iotic sr-rsccptibility ol S, pttr'rrnrotlinc to p lrctat'r-l

a^C Macrolide antimicrobial agcnts. The data u'as collected lctrclspeclivclv fr:ollr

antibiotic susceptibility re;rorts from clif{c'r'ent laLrctlatories atrcl assesscc'i Sirt?iococctt:;

srsceplibility to nrr,rltiple igcnts. Aggrcgating data is a fc'asible and tirr.rely tncthod of

moniioring regional susceptibilitl/ paLterns and mav also ptovc bcnefici;rl irr

measgring- t1-r,: effects of ilterventions [o c'lecrease antimicrolriirl rtsis[atrcc lrncl gr.riclt:

in ernprili6 ;rnl imiclobial trea tment'

Key worcls: Strt,ptococctrs y;ttt'tnttottioc, SLrsceptibility, Antimiclobial re'sistarrcc, p

lactam, Nfacrolides.

Introduction

Strt:ptococctrs pnertmoninc is onc of the leading catlscs oI ptrettrnoni;r, b:'tc[cmctnir,

meningilis, url.l .rpp". respiraiory tract infections worlcl'"vide.r-r Chiltlhood lltretttnorri:tand meningitis, acconnt for 20 to 40'/o annttal child mort;rlitl' 6t-' ihe estirrrated 'ltlntt:rlgtobal burdin of 2.7 million childhood deatl-r frorn pncumouia in developing colrtrtrics.5'6-lob"lly, pnc,rnococcal diseases accorlnt for I to 2 million dcaths arnl-rttallv irr lrotl-r

extrernes of age.7 S.Ttnantonil7d often colonizes the nasopharvnx of heaithv chilc'lrcn ar.rcl

can then, in specific situations, spread to thc lungs, paranasal tissues and caltse t.t-tt-tcosai

infectiols, r.,ah, or pncumonia, or invade the bloodstreat.u aud caltse lrrcuit-rgitis.s Anli-

microbial resistanci: of S. pntttrtttorrinr, lo p-laclant, r-nacroliclcs, arrcl othcr antilriotic clrls:rcs

has ipcrease dranratically throughorrt the lvorld in the past ihrcc clccacie.''-ll Thc

ipfections c;rusetf try Lhis pathogen arc anong thosc least iil<elv to bc lt'solvecl urilhoul

effectirre antibioiic treatment. I-'[o,wc..'er, sirrcc ]980s, a clramalic incrt:ase ir-r.rntiLriotir:

rcsistance ait1ol1g S, pnt:ttntitttinc lras bccu clbscrved in l.uarrv parls ol llls 1r.'1'lf ii'.l .rr-Lt'

Treatment failure associatecl I'r,ith antibiolic-rc-'sisl.ruI ptleLllnococci has bccn rcpor'i.ecl lor

patients rn,iih pnertrnonia.r6,lT i-ligh level oI antibiotic tlsc is plobably tl're r-najrr ilctordrivir-rg thc emergencc of resistance.ls Additionaily, t'csistance to nraclolidcs and oihr:r

antibiotic classcs escalated in t:rnclem rt,ith pcnicilliu resistance. Crrrrctrtlv, l5 to 30'l' of S.

pnetnnonine rvr:rldwide are ptrlticlrrrg-rcsistar-rl (MDR) (i.c., rcsisiant to 2 3 clrsses of

antibiotics). Despite the dramatic escalalion in [ltc ratc of antimiclobial rcsis',ancc anlorrg

streptococciworliwide, the clirticnl itn1tnct of antir.nicrobial resistancc is diffictrlt lo defirrc'.

r Department of Phamracy, Univer:sity oI Asia Pacilic, Dhantnontli, Dhalca- i209, Ban'.il;rclcslr

Corrcspondence to: Mohammad shahriar, Il-nlail: shahriar-l 2(uryahoo.corn

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88 A Strrt,ctl ot1 /\tltinticrobinl StrscL'ptiltilil.tl ol'SLrcplococL-t!s In(uurotrint.f lltt DiJJ't,rt:ttll )l/7r / ros/ l. (lr,l ir,r--s i t t D I r n lin C i 1 .t1. E n t t 14 I n rl rcl t

l'rclttl-rlcrrt iailrrrcs clLre lo arliibioIic-rcsistirrrI sIrc;-rIococci havc Lrt-.crr rcportccl \viLhlllcrlillsiLis, oIi lis i.ncdi;'r, ancl lower rcspirator\r iract inl'ccLiolls, bqt l6e rel;rtior.r bctr,r,ecrrclrr-tr; r'csistatrcc atrcl Ircitlr.ncnt 1'.rilurcs ]-ras noI bccr.r convincingllr csL;rLrlisirecl.re,zo Thcse"nrLrlIicll'trg rcsist.rnl" Pncultloc()cci havc notv Lrcc:r-r rc;trtrtccl all orrcr: t5c,,rrt>t.]cl.:tlniccIicllrs cltt'tsctl lt1, r'csisLanI rnicrobcs f;ril Lo rcspond to Ir.catr.ncr.rL, rcsrrlliug ir.rprolorlq'-11 illrless llld grcitcr risk of dcirth. TrcriInrcrrt [aiitLrcs a]so lead lo longcr pr.rio.l.ol ink.clir''it1', which ittcrcas:L thc nuri.rbers of inl'ccLcd pcopJc rnovirlg in thc ionrirLrpitl;al-icl LhLrs cxposc Lhc genclal population lo thc risk ol contracting a r.esisLant straip ofinfcctior-r. N4trch cviclcncc strpporls ll-rc vicu, ih;il thc lotlticotrsut.nptiop of arrtjmicr-olria.lsis tl'ic critical factor in selccLirrg rcsis[ancr'. Tl-re objcctive of thc s1r.rc-ly is lo asscss airl.ibioticstrsceplibility of S. Ttttttttrtt'ttrine to 11 l.rclam and macrolicie aniinricrobial agents. T6e datawas collcctccl r^r:trosprcctirrcly fronr ,antibiotic sr.rsccptibility rcports fror-n ciiflercrrllaLroratorics and asscsscd stt'tyttococcris susccptiLrility to mr,rltiplc agents.

Methodology

The data of antin-riclobial sr-rsceptibilitv was rctrospectively colleclecl from differ:errtdiagnostic centets in Dhaka city. The data covcrs the iast 3 years period (August 2O0g toAugusi 2011) ior which cot'nplcte sLrsceptibility data were availible at the-ti11e of tireir-rqtrirv. We compiied total trnmbcrs of S. pnannonlcc isolates identified fror-n the lab.salong lvith thc pcrcent of ir.rtcn-nediate arld rcsistant isolates, focr,rsilg on 11ol1sttsccptibilitY to pcnicillin, uracrolidcs, arrd extcr-rdcd-sp.rcctrtrm cephalospo'rirr,s (e.g.,cefotaxin-re, ceftriaxone). Wc clefirred ncn susceptible iiolates nu il"ror.' ihat were ofintermediate alnd irig)r-levcl resistance or those were siurply described as noL sLrsceplibleto tire arrtibiotic tcsled. If only a subset of isolates rvcr-e tesied a$rinst eryLhrorr)/ciii andcxtcnded-speclrttm cephaiosporins, wc exch-rclcd thcse rcsults frorn the iggregatecl totalittr crv th ronr),ci r-r,

Rcsults and Discussion

Five diffcrerrt di.rgnos[ic centcrs in Dhaka city compleLet] thc srlr'cvs. All the data from 5laboratorrcs w'1rost: pneumococcal ar-rtibiotic ir-rsceptibilitv t-esting resr-rlls \,vcresummarizcd. ln lhc pleggnt sttrdy, rve folurd the pcrccnt;rge of norr-si,rscJptible isoiates ir-rcase oI peniciliin is 59.85"i', cephaiosporin \1 .27o/r, and 47.56"/" forl }lrythro1nyci1.Ptrricillin rcsislatlcc alllollg S. Ttnctnitoniac is a global ploblem. Laboratoly nurtar-ris olpllcLlrttococci rcsistant to penicillin wcre selccled as ear.l1, as t|e l9{0s.22.2r lr wrs 20 1,earsbeforc th'c first clinical isolate, with rcduced susccptibility to p"ni.ittir.r, *"r',..i-,i.,"aflotn IJosLon, il'lassachusetts;21 Literaturc revealed that, a +% totat resislance to pcrlic;llinand 10'll, irrtelmecliate resjstat-Lcc, as observed irr the present str.rdy, shor.t,s i.he incr.easirrgemergence of resistancc str.ains oi S. prtLtutrrcrtinc in Irrdia.-Earlici, tirree,year sr.rniCillar-rcifor pcr-ricilliu resistancc frotn Vellole revealed 1.6nL of interr-nediatc resista.ce topenicillin,?s whereas, a Nolth hrdiarr str-rdy rcported 15.2% (26/lZ0) ipterprediateresistance arrd 2.3'lo (4/170) penicillin t"rirlor-,i".2r,'ihe differer-rce in thc resistance pattcmof S. pnettrttottiue as observed irr South and North lndian sttrdies has been

"*ptuin"j iy or.'thc basis of the high genctic divcrsity that exisLs among strairrs isolated froqr diffe1eltgeograplrical areas within ]rrdia.z7 Ptttrtntococcal resistance rates tend to ipcrease pror,,ilgalong the spc'ctrLtnl of isolatcs obtained from bloodstrealn to lower lespiratory tract toupper respiratorv-tract.28 This fact potentially corlfor,urds point comparisorrs of rlesistalcerates siuce a marked increase itr resistance can result frbm testing a preporrderancc of

[otrrrnl ol D

upPer reslresistant I

pt-LclttltoCOCr

resis tanceresistaltcemodificatir l

efflux nrec$both p lacriresistancelevel resisoLltcomes ,

likely med ,

stable over rr

azithromyc .

erythromyrprescribed '

Iow-level n I

l

Table 1: Pe ,.

**Table 2: P,.

generation ,

No. of Dj r,Cenl

Table 3: pe

generation I:

iv

itl

.(

i

No. of Di;Centr

1

2

3

4

5

Fi

tI

Irlu*l o{ Dhakn Intarnntional LJrtioersity ' Vol' 4' No' 89

..p8":r'i1::yi::'3:::;;^ffiii'",lii*:'J':"i*1i];'ii,r;:'*ffi1:':?i:l'l"tJ."1resisbant sLrarns m

;;;;;.;'t'115lJj{iTgg$*ilt;\,'.:Jf#$Ui9.1"."'l':,:i'il::li'l?:reslstance may incl ;;".-,; lo..&t'r"t of t'e trvo nrechat'risms -

m:nruJii""; jd,r#il';#,+r11;i jiJ::.Trf}*,:,a jE:? jl':ac'[i'e

effrux mechanism, it.,,:h i;;tg"trt* o"i't''"iill g"'* " iro"9pt"1'"0 o'9qt:::1"" ot

-' both p lacram ma_r".je#iiai reEisrune" iJ orrf nrii*i., .o',..r.. T^e inc'ease in per.ric'ri.

resistance appears i. ."*"r^r" *itt-, ur',.1,r'..:;;il'itlilllevel rathel than intermediate-

le'el resistar.,.u u'd nign-terret,p.r,lcliiri ,""tjtt^'t* 'itas beet-t associated wit6' w.rse

outcomes ro, pr-r".rl,'o.Zlcal i*fectio^r:i;'ih;";tt"ased tnacrolide resista.ce is 'rost

likely mediut"a rry'^'io*-r"""r effl'x prrmf since clir-rdalnycin susceptibilily remai.ed

stabie over the strriy -purioa.,* E.ytniffi'"'^t''"*f tn'ility gunt"lly predicts tlrrI of

;*"y:,1 ;"r :11,,{'}*,il*,i'uji: ;lt*y*:;':i';.;' i';ii'::1H,,i;iliervdrromYcrfi' azr

prescribed ^^,,o,"iilr'i"i;.,ip",;;,.'a,..^i;;;i oi tont"'tu'''ity-acqr-rirccl pncutnonirt rntl

Iorv-level ,nn.ro,,d"-r-"rir,nn."'t-,n, t "".r

orri.i.,J witir clinicil [ailrrre'3('-]d

tococcrrs prtctrnronineisolates "o^ tttt."p"Ot" to n"^i:]l'lin

fSrhle 'l: Percentage IlNon strscepti['le

ilo. of Diagnostic(-enters

-F6tt *tc"Ptible isolates Total nunrlrer otisol a tes

30.57

I 1{\7

n57n

520 45 19

2 940 81.91

J 60.33

443)85

lcX){f ,Jr)

5 2727 59.85

. Total

of S trep to co cclts p1teu117o1t1 flc isolates non susceptible to thirdTable 2:

"l' NonsusccPtibleNon suscePtible

isolates

Total nulnber ofisolatesNo. of Diagnostic

Centers 2.7872I z

?9n 4.3s

2t+

G10.98l/:l

3 450 7.56

4 Jr! 2tl104 520

5 1535 -+1./

Total

StrePtoco ccrts Pttcttttlontne isolatcs non suscePtible to third

Percentage

% Nor.t susce PtiblcffiLn.ttt',b"t ofisolntes

Non suscePtibleN-o.-of Diagnostic

d,t?$W]ffi &d'4$ffi lisi!r;$^.'i

90 t\ srrr|ty on AtttittttcroLtinl sttsccltttLtiliLll ol strcyttocctcctls pt1(tttlnttina t'ront Di'il'trntt

1j;6'l,rosti,:t Cr'rrisrs in Dltnkn Citq' Bnttl;lnLlult

1gg3. Aetiology and trcatmeut oI col.ulrttttrity-acquired lllletlmollla l11

lristoricalpcr:specl-ivc.Iotu.nn!o.fAtltiltticrollinlC]rcntotllcrapv./Str1rplA,32'

S.J. and Phillips, I' 1935' Puettmococcal Lracieraerr-ria: 3?5

it-ro*or', l-tospital' I3ritislt Madi}l lotn'nnl Clinicnl R(?s(rfl r'trit

L,ltt.90, pP. 505-6.

l(ragsbjerg, P., Kallman, J. and olcerr, P" 1994. Prrcltmococcal meningilis in adr'rlts'

Srn,i,li,rn ,i'n,r lotu'rnl of Inft:ctiotts Di-strnsds' 26' 1tp' 659-66' ^

TJlock, S.L., I larris.t",, a i , Flcd'ick, 1 a'' ryicit' R'D'' S.rit6' R'A' and l(ecga^' E' 1995'

Pcr-ricillin-rcsistant strcptococctLs 90pttt:ttmttninc iu aclttc otitis nredia: risk iactclrs'

si_rsceptibilitv pattcr.ns 'ancL antir-r-ricrobial r-nanagen-rent. i','tlintric Inft'ctiorts I)iscnsr

loLtrnnl. 14. PP' 751-9'N{ullrolland ,I<. 191)9.MagniLucle of the problem of child}rood pneumoni;r' Lafcrrf' 354'

t-l;.111;]?., IJac1, F., sack, D', Br-Ltlcr, T', trzad' A'' Alar'' A' ar-rd Nahar' N' 1e90'

Acute Jowcr respiratory tract ir-riccLiong in hospitalized patients witl-' diarrhea in

Dlraka. Ilnttg!ndeitt' Iu.fect Dis 12, pp' 5899-5906'

\4trlho1land, . fCCC. Strategies fli t1-'.'corrl"rol of pnetrmoco.ccal discascs' Vnccittt'-I7'

pp' 79-S-l' ^n^- ^

n .): .^r Atti.,'nhinlnotr st T orris: ElscrricrMtrrray,P'11.,ilosent]ral,K.S.,Pfallel'2005'McdicnIMicrobiology.St.L,or-ris:Elser'ier

lou'nnl of ,

I

11. Appove{

12. SongSuh.clini,a.gat:,

13. AdarCher

14. Jacoi'Ale>

i

acqr:Antil.

15. Ried.M.,arrtir:26(7

S

16. FeikiMcCpner-iHealt

17. Tlerrr'J )r

impapneLr.

42(6)'

18.-frosiLTSC :'

Lanct19. Ghel

Pneui20. Farrc

Eme;resis ir

21. Blocl,PenirSUSCE

lottrn22. Eriks

tYPe '23. McKr

stapl24. Kislar

pneu25. Laliti

multiInvasEpide

Co.rclusion """''";n"r'rrrlitrrt.s lo g.ificarrt morbicliiy ar-rd

l)rug-r'csistaut S. Prir:ttrriottinc coulitltlcs to ilrcrcasc' caus1l1g sl I

r-'ortriity. Tlie 3 *.t;;:';..;.;., it-,,',t ^a'e

lt:el I'^c cl'r-rg-rcsistirucc irrcitrde: irrarppropriatc

r-lscoIar-r|.iLliotrcs,pro}olrgccidosagcregtl.llclls;rrrdr.rtrdcrdosirrg.Iitrrcl:gerrceofrcsislantstrairrs.ind also thc lvlDlislr:airrs of s. lttrruitottitlrr nccrf continr'rous local as well irs global

'-rouilori.g of tirc serrsili'il), pattc.l, rn ".'io fr"n [6e linc of treat're't' Edtlcatio^ of

hcaltir c.ri.c pror,iclc.rs arrci' rhc p,'.rblic is csscrrlial fot' errsltring the rational usc of

anliuricrolriais. l)harrrracists cau play a significalrt role. in. edttcating botir grollps'

assunirrg 'oies

as edltcators to assist i^ dissemirrati'g vital iuformatio. that etlcottl'alges

the rationi'rl nsc o1' atrlinricrobi.-rls. Thc judicious 1'se of a^tibiotics b-v lhe hcalth

profcssiorral irrrd cfforl.s to coirtrol p,o.'''l.,1.I.,-.'t atrd r.rse of arrtibiotics olficially irr tlre

locality will probabrf i''"rp to li'rit []ie irrcreasirrq rate of clrr'rg resistarrce in t5e patSogens'

I^ Ba^glacierr..,, "*pi.i.nt ,t.I"rnpy is the *rle .at6er tha. the exceptio^3') and in this

cor-rtcxtofchangingtl'redyuatnicsofrcsistar-rccloantibiotics'itisimperatil'eforoptirnalpaticr-rt car:c that.ot",rio,-ti evalltatiolr of antibiotic sensitivity pral-tertr of patl-rogerrs for

comuronly uscd antimicrobial agents in a partictrlar euvirontrtelrt shor-rld be carried out'

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-. " '':..i'

:i l '1r .. irrj :t" r-l: .I*:

..,:-r,., :tl,.t,rr.til:

4 :-,iil: ':.{'

l

.; i." i::,r1,'

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