in 2011 , who declared  combat drug resistance : no action today , no cure tomorrow .  . in recent years
presently , antimicrobial resistance ( amr ) poses a major threat to patient 's treatment as it leads to increased morbidity and mortality , increased hospital stay , and severe economic loss to the patient and nation [ 3 , 4 ] .
the clinical isolates such as pseudomonas aeruginosa , methicillin resistant staphylococcus aureus ( mrsa ) , enterococci especially vancomycin resistant enterococci ( vre ) , and members of family enterobacteriaceae , for example , klebsiella pneumoniae , e. coli , and proteus sp .
 in the last two decades , there were so much increase of infectious diseases that the standard of public health in many parts of the world is equivalent to preantibiotic era .
as per standardized international terminology created by european centre for disease control ( ecdc ) and centre for disease control & prevention ( cdc ) , atlanta , the multidrug - resistant ( mdr ) , extensively drug - resistant ( xdr ) , and pandrug - resistant ( pdr ) bacteria have been well defined .
multidrug resistant ( mdr ) was defined as acquired nonsusceptibility to at least one agent in three or more antimicrobial categories . extensively drug
resistant ( xdr ) was defined as nonsusceptibility to at least one agent in all but two or fewer antimicrobial categories ( i.e. , bacterial isolates remain susceptible to only one or two antimicrobial categories ) .
pandrug resistant ( pdr ) was defined as nonsusceptibility to all agents in all antimicrobial categories .
hence , this short term study was undertaken to detect the incidence of mdr , xdr , and pdr bacterial isolates in a tertiary care hospital of central india .
this short term cross - sectional study was conducted in the department of microbiology from 15th of april to 15th of july , 2014 .
the bacterial strains were isolated from different clinical samples and were identified by conventional methods .
the clinical specimens from indoor patient departments ( ipd ) only were included in the study .
antibiotic susceptibility test of bacterial strains was done by kirby bauer disc diffusion method   as per clinical laboratory standard institute ( clsi ) guidelines .
antibiotics used for gram positive cocci ( gpc ) were penicillin , erythromycin , ciprofloxacin , tetracycline , amikacin , vancomycin , and linezolid and for gram negative bacilli ( gnb ) were amikacin , ceftazidime , ceftazidime - clavulanic acid , ciprofloxacin , imipenem , and colistin , respectively .
linezolid and colistin were used as supplemental drugs . for urine sample , instead of ciprofloxacin and tetracycline ,
for routine quality control of antibiotic susceptibility test , s. aureus atcc 25923 , e. coli atcc 25922 , and pseudomonas aeruginosa atcc 27853 were used .
mdr , xdr , and pdr strains were detected as per criteria described by ecdc and cdc .
methicillin resistant staphylococcus aureus ( mrsa ) strains were detected by meca - mediated oxacillin resistance using cefoxitin disk ( 30  g ) on mueller hinton ( mh ) agar plate inoculated with test strains as per standard disk diffusion recommendations and incubated at 3335c for 1618 hours .
inhibition zone 21  mm with cefoxitin disk was interpreted as meca positive according to clsi guidelines .
extended spectrum -lactamases ( esbl ) producing strains were detected by combined disk method using ceftazidime ( 30  g ) and ceftazidime plus clavulanic acid ( 30  g plus 10  g ) .
an increase in diameter of 5  mm with ceftazidime plus clavulanic acid as compared to ceftazidime disk alone was considered positive for esbl detection .
138 clinical samples were received from intensive care unit ( icu ) and 742 clinical samples were received from wards of different clinical specialities .
698 clinical samples had single bacterial growth and 182 had mixed bacterial growth . out of these 182 clinical samples , 172 samples had 2 bacterial isolates , 4 samples had 3 bacterial isolates , and 6 samples had 1 bacterial isolate along with candida albicans .
figure 1 shows that 314 ( 29.6% ) bacterial strains were gram positive cocci ( gpc ) and 746 ( 70.4% ) were gram negative bacilli ( gnb ) .
out of 314 gpc , 252 ( 80.3% ) were coagulase positive staphylococci . amongst 746 gnb , 261 ( 35% ) were e. coli , followed by pseudomonas aeruginosa 212 ( 28.4% ) . during the study period ,
figure 2 shows the incidence of mdr and xdr strains isolated . out of total 1060 bacterial strains
studied , 393 ( 37.1% ) bacterial strains were mdr and 146 ( 13.8% ) strains were xdr .
amongst 314 gpc strains isolated , 143 ( 45.5% ) and 56 ( 17.8% ) were mdr and xdr , respectively .
out of 746 gnb isolates , 250 ( 33.5% ) strains were mdr and 90 ( 12.1% ) were xdr .
out of total 9304 patients admitted , 393 ( 4.2% ) and 146 ( 1.6% ) were positive for mdr and xdr strains , respectively . 

figure 3 shows the incidence of mdr and xdr gram positive cocci isolated . out of total 252 coagulase positive staphylococci
isolated , 125 ( 49.6% ) were mdr and 38 ( 15.1% ) were xdr .
10 coagulase negative staphylococci were isolated and 5 ( 50% ) were mdr , whereas 2 ( 20% ) were xdr .
79 ( 31.3% ) coagulase positive staphylococci strains were mrsa and 2 ( 20% ) coagulase negative staphylococci were mrcons . out of total 45 enterococci isolated , 13 ( 28.9% ) were mdr and 16 ( 35.6% ) were xdr .
no vancomycin intermediate staphylococcus aureus ( visa ) , vancomycin resistant staphylococcus aureus ( vrsa ) , or vancomycin resistant enterococci ( vre ) were isolated .
all streptococcus species including group a , nongroup a , and pneumococcus were sensitive to penicillin .
no mdr or xdr strain was isolated from streptococcus sp . all ( 100% ) gram positive cocci were sensitive to vancomycin and linezolid . 

figure 4 shows incidence of mdr and xdr strains isolated from each species of gram negative bacilli . in the present study ,
e. coli was the commonest isolate 261 ( 35% ) , followed by pseudomonas aeruginosa 212 ( 28.4% ) .
79 ( 30.3% ) and 22 ( 8.4% ) e. coli strains were mdr and xdr , respectively .
out of 200 klebsiella pneumoniae strains isolated , 75 ( 37.5% ) and 25 ( 12.5% ) were detected as mdr and xdr , respectively . out of 42 acinetobacter and other nonfermenter species isolated , 19 ( 45.2% ) and 8 ( 19% ) were mdr and xdr strains , respectively . amongst 250 gnb - mdr strains isolated ,
the commonest mdr strains were detected from e. coli 79/250 ( 31.6% ) , followed by klebsiella pneumoniae 75/250 ( 30% ) .
similarly , out of 90 gnb - xdr strains isolated , the commonest xdr strains were detected from pseudomonas aeruginosa 29/90 ( 32.2% ) , followed by klebsiella pneumoniae 25/90 ( 27.8% ) . in the present study , 137 ( 18.4% )
others include wards like dermatology , pulmonary medicine , orthopedics , and cardiovascular and thoracic surgery ( cvts ) .
the different icus include neonatal icu ( nicu ) , medicine icu ( micu ) , operation theatre icu ( ot icu ) , and paediatric icu ( picu ) .
out of total 393 mdr strains detected , 127 ( 32.3% ) ( the highest number ) mdr strains were isolated from surgery wards followed by 72 ( 18.3% ) mdr strains from different icus .
amongst total 146 xdr strains isolated , 41 ( 28.1% ) ( the highest number ) were isolated from surgery wards also .
out of 72 mdr strains detected from different icus , 29 ( 40.3% ) ( the highest number ) mdr strains were isolated from nicu , followed by 20 ( 27.8% ) and 18 ( 25% ) from ot icu , and only 5 ( 6.9% ) from picu . even in the total 26 xdr strains isolated from different icus , 10 ( 38.5% ) ( the highest number )
the percentage of mdr and xdr strains isolated from different icus was 72/138 ( 52.2% ) and 26/138 ( 18.8% ) , respectively , which were again much more than mdr and xdr strains isolated from wards 321/742 ( 43.3% ) and 120/742 ( 16.2% ) , respectively .
275 patients were admitted to nicu , of whom 29 ( 10.5% ) were positive for mdr strains and 10 ( 3.6% ) were positive for xdr strains . out of total 1907
patients admitted to surgery ward , 127 ( 6.7% ) were positive for mdr strains whereas 41 ( 2.1% ) were positive for xdr strains . in micu ,
545 patients were admitted and 20 ( 3.7% ) were positive for mdr strains and 8 ( 1.5% ) were positive for xdr strains .
the clinical and financial burden to patients and health care providers for mdros is really challenging .
barbara soule , joint commission resources practice leader , infection prevention and control services , has told , 
patients who are infected with mdros often have an increased risk of prolonged illness and mortality .
the cost of care for these patients can be more than double as compared to those without mdro infection  . since the year 2000 , only 4 new classes of antibiotics have been approved by food and drug administration ( fda ) , us , for example , linezolid , streptogramins , daptomycin , and tigecycline .
the problem is that the bacteria are developing resistance at a much faster pace than the new drug development . regarding public health attention , mdros are described as superbugs having very limited treatment options . for some mdros
, only 1 or 2 antibiotics can be effective with toxic side effects . in 2009 , boucher et al .
have reported eskape organisms as  bad bugs ,  where e stands for enterococcus faecium , s for staphylococcus aureus , k for klebsiella pneumoniae , a for acinetobacter baumannii , p for pseudomonas aeruginosa , and e for enterobacter species . in the year 2009 only
, peterson has reported the escape group of organism , which was the same as the above list but k was replaced by c , that is , clostridium difficile , and the last e stands for enterobacteriaceae . in the present study , amongst 250 gnb - mdr strains isolated , the commonest mdr strains were detected from e. coli 79/250 ( 31.6% ) , followed by klebsiella pneumoniae 75/250 ( 30% ) .
similarly , out of 90 gnb - xdr strains isolated , the commonest xdr strains were detected from pseudomonas aeruginosa 29/90 ( 32.2% ) , followed by klebsiella pneumoniae 25/90 ( 27.8% ) .
aly and balkhy reported that most prevalent mdro in their study was e. coli followed by klebsiella pneumoniae . in another study , carried out in a tertiary care hospital in riyadh
, it has been reported that most frequent mdr pathogens were pseudomonas aeruginosa followed by e. coli .
the percentage of mdr e. coli strains was more than klebsiella pneumoniae and even pseudomonas aeruginosa in our study probably because a total number of e. coli strains isolated ( 261 ) were also higher .
the slightly increased incidence of drug resistant strains observed in our study may be because our hospital is a tertiary care center in a rural setup and patients from adjoining districts and even villages are admitted for treatment . before attending the hospital , most of the patients get different antibiotics from general practitioners or due to over - the - counter sell of antibiotics often in improper dose .
the limitation of this study is that this is a single center study for only three - month period in a tertiary care hospital in central india . to reflect the trend of infections caused by mdr and xdr strains of bacteria in the region , a multicenter study involving all types of healthcare setups for a minimum period of one year
there is paucity of data regarding mdros in health care setup not only in india but also worldwide .
unless and until multidrug resistant organisms are detected and their incidence is known , the strategies for their control can not be adopted properly in healthcare setup . hence , detection , prevention of transmission of mdros by following infection control practices , antimicrobial surveillance , and stewardship are need of the hour .
misuse and overuse of antibiotics , over - the - counter selling of antibiotics without prescription to common people , must be stopped by strict implementations of rules and regulations .
we hereby conclude that early detection and close monitoring of mdr , xdr , or even pdr bacterial strains must be started by all clinical microbiology laboratories to reduce the menace of antimicrobial resistance which is now a global problem .
 
 background and objective . 
 antimicrobial resistance is now a major challenge to clinicians for treating patients . 
 hence , this short term study was undertaken to detect the incidence of multidrug - resistant ( mdr ) , extensively drug - resistant ( xdr ) , and pandrug - resistant ( pdr ) bacterial isolates in a tertiary care hospital . 
 material and methods . 
 the clinical samples were cultured and bacterial strains were identified in the department of microbiology . 
 the antibiotic susceptibility profile of different bacterial isolates was studied to detect mdr , xdr , and pdr bacteria . 
 results . the antibiotic susceptibility profile of 1060 bacterial strains was studied . 
 393 ( 37.1% ) bacterial strains were mdr , 146 ( 13.8% ) strains were xdr , and no pdr was isolated . 
 all ( 100% ) gram negative bacterial strains were sensitive to colistin whereas all ( 100% ) gram positive bacterial strains were sensitive to vancomycin . 
 conclusion . 
 close monitoring of mdr , xdr , or even pdr must be done by all clinical microbiology laboratories to implement effective measures to reduce the menace of antimicrobial resistance . 
1. Introduction 
2. Material and Methods
3. Observations and Results
4. Discussion
5. Conclusion