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Bacterial Pathogens from Bile and their Antimicrobial Sensitivity Pattern in a Tertiary Care Hospital

The presence of bacteria may be associated with the presence of any foreign body inserted in the biliary system such as a biliary catheter. The bacteria may come through haematogenic path. 2,3,4 Obstruction to the biliary duct due to any reason leads to increase in the pressure in the biliary duct and which will lead to cholangitis. 2,3,4,5 The presence of these bacteria in the gallbladder may lead to malignant epithelial transformation. 6,7,8 Bactibilia is associated with higher postoperative infectious complications due which there is prolonged hospital stay, need for antibiotics based therapy and higher cost. 9,10,11


Introduction
The bile is a lipid rich sterile solution produced in the liver. 1 Infections of biliary tract may occur in many conditions due to break down of human defence mechanism during surgery or endoscopy.
The presence of bacteria may be associated with the presence of any foreign body inserted in the biliary system such as a biliary catheter. The bacteria may come through haematogenic path. 2,3,4 Obstruction to the biliary duct due to any reason leads to increase in the pressure in the biliary duct and which will lead to cholangitis. 2,3,4,5 The presence of these bacteria in the gallbladder may lead to malignant epithelial transformation. 6,7,8 Bactibilia is associated with higher postoperative infectious complications due which there is prolonged hospital stay, need for antibiotics based therapy and higher cost. 9,10,11 Widespread and indiscriminate use of antibiotics over the years has altered the sensitivity pattern of microorganisms which necessitates a change in empiric antibiotic policy. 12,13,14 In our area scanty information is available on bactibilia, hence the present study was undertaken to detect the bacterial pathogen from bile and their AST pattern. The bile is a lipid-rich sterile solution produced in the liver. Infection of biliary tract may occur in many conditions due to breakdown of human defence mechanisms and it is associated with post-operative complication that may prolong hospital stay hence present study was undertaken to detect the bacterial pathogens from bile and their antimicrobial sensitivity pattern. To study antimicrobial susceptibility pattern of organisms isolated from bile specimen and to know common pathogens isolated from bile during study period. To establish empirical therapy for biliary tract infection in our hospital, all the bile specimen received in Microbiology Department for culture and sensitivity were included in study. These specimens were processed as per standard protocol. Relevant patient data was collected. Prospective observational study six months, in this study period total 57 samples were studied Out of which 7 were sterile, in 34 samples single bacterial pathogen was grown and in 16 samples more than one bacterial pathogen was grown. Most common organisms isolated were Escherichia coli and Pseudomonas aeruginosa.
The main aim of this study an antimicrobial susceptibility pattern of organisms isolated from bile specimen. And also to know common pathogens isolated from bile during study period. Also to formulate empirical therapy for biliary tract infection in our hospital.

Design
Prospective observational study.

Materials and Methods
The present study was carried out in a tertiary care hospital. After approval from ethical committee the study was started.
Inclusion criteria: All the bile samples received in the department of Microbiology for culture and sensitivity were included in the study.
Exclusion criteria: Repeat isolate from the same patient were excluded. These samples were from the patients with various biliary diseases. Out of which the most common is choledochocholethiasis. These specimens were processed as per standard protocol. 15 Samples were inoculated on blood agar and MacConkey agar plates and incubated at 37℃ for 24 hrs. Next day the organisms are seen for the colony morphology on blood agar and MacConkey agar plates. Organisms were identified by gram stained smears and biochemical tests. Suitable Vitek card was selected and the growth was processed in the Vitek 2 compact system for identification and AST pattern.
In this study total 57 samples were processed and data was analysed.
If there is growth of single organism, it is called monomicrobial and if there is growth of two or more than two, it is called as poly microbial sample.
For gram negative organisms, the bacteria resistant to two or more classes of antibiotics, including the beta-lactum antibiotics during the microbiological examination and antibiogram were considered to be a multidrug resistant bacteria. 16

Results and Discussion
Out of 57, 38 patients were from more than 50 age group (66.66%) ( Table 1).
Out of these 57 samples, 50 samples showed growth.
Total 67 isolates are identified.
The most common bacterial pathogen isolated were Escherichia coli (n=26, 38.80%) and Pseudomonas aeruginosa (n=25, 37.31%), followed by two pathogen each of Acinetobacter baumanii, Acinetobacter junii and Sphingomonas paucimobilis ( Biliary obstruction causes an increase in ductal pressure, resulting in bacterial proliferation and dissemination. Bacterial infection is the most common type of acute cholangitis, which can range from mild to life threatening with a Gram-negative preponderance. 16 Endoscopic treatment to enable biliary drainage and the use of antibiotics is the main stay of treatment for this condition. 17,18,19 Bactibilia is associated with higher postoperative infectious complications due which prolonged hospital stay, need for antibiotics based therapy and higher cost. 9,10,11 Widespread and indiscriminate use of antibiotics over the years has altered the sensitivity pattern of microorganisms which necessitates a change in empiric antibiotic policy. 12,13,14 In our study the most common organism was E. coli (38.80%) which is in concordance with that of below mentioned studies by Malik 20,21,22,23 Pseudomonas aeruginosa was the 2 nd most common isolate (37.71%) which is higher than the other studies. 20,21,22,23 The sensitivity of E. coli to Amikacin, Gentamicin, Trimethoprim/Sulfametoxazole, imipenem and Ertapenem is 84%, 53.84%, 57.69%, 53.84% and 50% respectively. All E. coli were susceptible to Tigecycline (Table 4).   In an enteric fever endemic country like India, Salmonella enterica serovar typhi and S. paratyphi A are among the major biliary pathogens. Enteric fever persists for many years after convalescence and increases the risk of hepatobiliary malignancy. 24 But in our study there is no such incidence which may be due to lesser sample size.
The high resistance of micro-organisms to susceptible antibiotics of the past may be due to widespread and indiscriminate use of antibiotics. In our institute, empiric therapy for biliary tract infection should be targeted against E. coli and Pseudomonas species. Tigecycline should be reserved for MDR isolates.