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 Table of Contents  
Year : 2023  |  Volume : 6  |  Issue : 1  |  Page : 58-61

Type of microbial flora in patients with bone and joint infections: Our experience at a tertiary care center of Eastern India

1 Department of Microbiology, Netaji Subhash Chandra Bose Medical College, Patna, Bihar, India
2 Department of Orthopaedics, NMCH, Patna, Bihar, India
3 Department of Orthopaedics, IGIMS, Patna, Bihar, India

Date of Submission19-May-2022
Date of Decision31-May-2022
Date of Acceptance01-Jun-2022
Date of Web Publication27-Dec-2022

Correspondence Address:
Ritesh Runu
Room No. 325, Ward Block, 3rd Floor, IGIMS, Sheikhpura, Patna - 800 014, Bihar
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jodp.jodp_46_22

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Introduction: Bone and joint infections are very common in eastern India. Due to the lack of authentic data on the type of bacteriology in our region, this study was planned. Materials and Methods: After ethical clearance, retrospective data of 2 years from 2019 to 2021 were collected. Out of 115 patients, 77 patients were included in the study whereas 38 were excluded due to nonbacterial infections and incomplete data. Results: The average age of patients was 21.14 years. Pediatric patients were 58.66%. The common clinical condition was chronic osteomyelitis, followed by septic arthritis. The most common bone affected was femur, followed by tibia. The most common organism noted was methicillin-resistant Staphylococcus aureus (MRSA) and coagulase-negative Staphylococcus aureus (CNSA). Gram-negative infections were also noted. Conclusions: Eastern India has a high incidence of bone and joint infection. MRSA followed by CNSA is the most common isolate affecting large bones such as femur and tibia.

Keywords: Bones and joints, eastern India, infections, microbial flora

How to cite this article:
Singh A, Singh RK, Bimal BK, Runu R. Type of microbial flora in patients with bone and joint infections: Our experience at a tertiary care center of Eastern India. J Orthop Dis Traumatol 2023;6:58-61

How to cite this URL:
Singh A, Singh RK, Bimal BK, Runu R. Type of microbial flora in patients with bone and joint infections: Our experience at a tertiary care center of Eastern India. J Orthop Dis Traumatol [serial online] 2023 [cited 2023 Jan 30];6:58-61. Available from: https://jodt.org/text.asp?2023/6/1/58/365282

  Introduction Top

Infections in orthopedic patients are high in India and abroad.[1],[2] We can classify orthopedic infections into osteomyelitis, septic arthritis, implant-related infections, and soft-tissue infections. Fracture-related infections are also an entity.[3]

Several studies in India and abroad have been done on the type of bacterial flora in orthopedic cases.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11] With variation in time and place, the bacterial flora changes, hence, we need a dynamic study. The aim of the present study is to know the type of bacterial infections in orthopedic cases in eastern India.

  Materials and Methods Top

After ethical clearance, vide letter no. 13/IEC/IGIMS/2021, this study was conducted. From January 2019 to December 2020 (2 years), the records of patients presenting with suspected orthopedic infections were procured from the medical record department. A total of 115 patients record were procured. The clinical presentation and radiological findings were considered for the clinical diagnosis. Clinically septic arthritis was defined as warm tender swollen joint with fever and loss of limb function. It was confirmed by radiological and microbiological tests. Chronic osteomyelitis was defined as painful swollen limb with or without fever, discharging sinus, pathological fractures, limb deformity, joint function affection, or severe recurrent pain. Implant infection was defined as patients with features of osteomyelitis or septic arthritis and implant in situ. Infected nonunion was defined as ununited fractures with or without discharging sinus and loss of function. Patients with a history of compound fractures, nonbacterial growth, and incomplete data were excluded from the study. Finally, 77 patients were included in the study. The details of patients, their diagnosis, and bacteriological growth were recorded.

  Observations and Results Top

The total number of patients for the study was 77. Males were 53 and females were 24. The average age of patients was 21.14 years. Pediatric patients with age < 16 years were 57.14% (44/77) and adults more than 16 years were 42.85% (33/77). The youngest were two infants of 1 month age with femoral osteomyelitis, and the eldest patient was 73 years male with infected hip prosthesis. The region of the body affected was as mentioned in [Table 1] and [Table 2].
Table 1: Clinical condition in each region

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Table 2: Regions affected by each clinical condition

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Associated illness such as diabetes was seen in four patients, hypertension in two, and rheumatic heart disease in two patients. No comorbidity was seen in 69 patients.

Fever was present in 67 patients, swelling of limb and joints in 68 patients, discharging sinus in 49 patients, pathological fracture in 21 patients, and healed fracture in 1 patient. Previous surgery was done in 39 patients.

Type of microbial flora

Growth was seen in 59 samples (76.62%).

No growth was seen in 18 patients. On Gram stain, three broths showed Gram-positive bacteria [Table 3].
Table 3: Gram-specific Bacterial growth

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  Discussions Top

The type of bacterial flora in osteomyelitis is largely decided by the type of population, their disease pattern, antibiotic usage, and environmental factors.[2] To the best of our knowledge, this is the first study done in our region.

Total number of patients

The sample size in other studies was 760 patients (Kremer et al.), 725 patients (Latha et al.), 209 patients (Agrawal et al.), 204 patients (Shenoy et al.), 100 samples (Pandey et al.), and in our study, it was 77. Tumalla et al. conducted their study on 75 patients during a 2-year period.[4] Compared to other studies, the number of patients is less but it seems adequate to show the trend of microbial infection.


The affection in males was 58% to 79% as noted in various studies (Kremers et al. 58%, Latha et al. 83.7%, Tummala et al. 76%, Bonhoeffer et al. 61%, Shenoy et al. 78.8%, and Pandey et al. 79%). We noticed male affection in 68.83% similar to other studies. In the pediatric age group 0–16 years also, the male dominance (59.09%) was noted in our study. Do males get more infection due to trauma, poor immunity, poor healing process, poor adherence to treatment process, or something else needs investigation.


Tummala et al. found 38.66% of patients in 20–39 years of age group, 29.33% of patients in 40–59 years of age group, 17.33% of patients in 0–19 years of age group, and 14.66% of patients in more than 60 years of age group.[4] In our study, the pediatric population was 57.14%. Kremer et al.[2] noted average age of 52 years and Latha et al.[1] noted 40.3 years. In our study, the average age was 21.14 years ± standard deviation. Compared to other studies, the average age of patients was less in our series as more pediatric patients were reported here.

Region affected

In our study, the most commonly affected bone was femur in 38.96%, followed by tibia 12.98%, humerus and hip joint 10.38% each, knee joint 7.79%, calcaneus 5.19%, elbow joint 3.89%, spine 3.89%, ankle joint 2.59%, finger 1.29%, and wrist joint 1.29%.

In other studies, the most common bone affected was tibia[4],[7],[10] and foot.[2] Pandey et al. noticed femur involvement in 38% and tibia in 36% of cases.[11] Similar to other studies, we noticed femur and tibia as the most commonly affected bones. It may be due to large metaphysis and rich blood supply in the bones. In foot, the most commonly affected bone was calcaneum. Our study had similar results as previous studies.

Association with medical conditions

Although patients with co-morbidities were less, diabetics were 50% (4/8). This shows its relation with infections.[8]

Type of microbial flora

Broth showing bacterial growth is known as culture-positive samples and those not showing any growth are culture-negative samples. Culture positivity seen in various studies was 42% to 85%. (Shenoy et al. 50%, Agrawal et al. 53.11%, Neethu et al. 59.5%, Devi et al. 68%, Vasundhara et al. 68%, Pandey et al. 85%). Shenoy et al.[10] showed that bacterial yield from the bones was 40%, from pus aspirates 44.2%, and from soft tissues 52.7%. In our study, the culture positivity rate was 76.62%. It may be due to pus or tissue fluid collected for culture. Therefore, the type of tissue sent for culture should be considered to read the report.

In various studies, the Gram-positive growth varied from 21% to 60.8%.[1],[2],[5],[6],[10],[11] In our study, the Gram-positive bacterias were 64.40%. Gram-negative growth was 20.33%. The Gram-negative bacteria were Providentia, Pseudomonas, Acinetobacter,  Escherichia More Details coli, Enterobacter, Enterococcus, and Klebsiella. Tuberculosis was found in 14.51% of patients. Gram-positive growth was highest among all types.

In our study, among Gram-positive bacteria, methicillin-resistant Staphylococcus aureus (MRSA) was the most common (81.57%), followed by coagulase-negative Staphylococcus aureus (CNSA) (18.42%). In other studies, MRSA was the most common growth with 15% to 44%.[1],[2],[4],[6],[7],[11] However, its presence in various specialties was studied by Tyagi et al.[9] He noted the incidence of MRSA in neurosurgery was 26%, in orthopedics 24%, in pediatrics 17.8%, in cardiothoracic surgery 14%, and in gen surgery 7.1%.[9] CNSA is also an important growth seen in various studies. Its incidence in our study was 18.42% compared to 22% in other studies.[1],[6] MSSA is also a common bacterial isolate in aerobic cultures. Its presence has been seen in 15% to 29%.[1],[4],[10] We did not get any isolate of MSSA in our study.

Gram-negative bacteria as major growth was found in some studies.[5],[10] Among Gram-negatives, pseudomonas being the most common along with E coli. High incidence of pseudomonas, 20%–26% was seen in few studies.[1],[5],[6] Agrawal et al.[5] noted very high incidence of E coli 34.4% in their study. In our study, the most common Gram-negative isolate was E coli and pseudomonas 6% each. We found low incidence of Gram-negative bacterial growth as reported by Kremer et al.[2] [Table 4].
Table 4: Studies showing bacterial isolate incidence

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Limitations in our study were low number of subjects. Due to the COVID pandemic, the number of patients enrolled in the study was less. However, this study gave us an idea on the type of microbiological flora seen in our hospital and the region. The result of the effect of antibiotics on microbial flora is beyond the scope of this article.

  Conclusions Top

Eastern India still reports a high incidence of bones and joints infection where MRSA followed by CNSA is the most common isolate affecting the large bones such as femur and tibia.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Latha T, Anil B, Manjunatha H, Chiranjay M, Elsa D, Baby N, et al. MRSA: The leading pathogen of orthopedic infection in a tertiary care hospital, South India. Afr Health Sci 2019;19:1393-401.  Back to cited text no. 1
Kremers HM, Nwojo ME, Ransom JE, Wood-Wentz CM, Melton LJ 3rd, Huddleston PM 3rd. Trends in the epidemiology of osteomyelitis: A population-based study, 1969 to 2009. J Bone Joint Surg Am 2015;97:837-45.  Back to cited text no. 2
Cook GE, Markel DC, Ren W, Webb LX, McKee MD, Schemitsch EH. Infection in orthopaedics. J Orthop Trauma 2015;29 Suppl 12:S19-23.  Back to cited text no. 3
Tummala VS, Surapaneni SB, Pigilam S. Bacteriological study of orthopaedic infections. Int J Orthop Sci 2017;3:90-2.  Back to cited text no. 4
Agrawal AC, Jain S, Jain RK, Raza HK. Pathogenic bacteria in an orthopaedic hospital in India. J Infect Dev Ctries 2008;2:120-3.  Back to cited text no. 5
Devi PV, Reddy PS, Shabnum M. Microbial profile and antibiotic susceptibility pattern of orthopedic infections in a tertiary care hospital: A study from South India. Int J Med Sci Public Health 2017;6:838-41.  Back to cited text no. 6
Philip NS, Jakribettu RP, Boloor R, Adiga R. Characterisation of aerobic bacteria isolate from orthopaedic implant associated infections. J Acad Clin Microbiol 2018;20:33-6.  Back to cited text no. 7
  [Full text]  
Irie S, Anno T, Kawasaki F, Shigemoto R, Kaneto H, Kaku K, et al. Acute exacerbation of chronic osteomyelitis triggered by aggravation of type 2 diabetes mellitus: A case report. J Med Case Rep 2019;13:7.  Back to cited text no. 8
Tyagi A, Kapil A, Singh P. Incidence of Methicillin resistance Staphylococcus aureus (MRSA) in pus samples at a tertiary care hospital, AIIMS, New Delhi. J Indian Acad Clin Med 2008;9:33-5.  Back to cited text no. 9
Shenoy PA, Vishwanath S, Bhat SN, Mukhopadhyay C, Chawla K. Microbiological profile of chronic osteomyelitis with special reference to anaerobic osteomyelitis in a tertiary care hospital of coastal Karnataka. Trop Doct 2020;50:198-202.  Back to cited text no. 10
Pandey A, Shaw P, Johar A. Bactriological profile of chronic osteomyelitis with special reference to antibiotic resistance Mechanisms/patterns – A cross sectional prospective study from tertiary care hospital in central India. J Adv Med Med Res 2020;32:43-52.  Back to cited text no. 11


  [Table 1], [Table 2], [Table 3], [Table 4]


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