Recently, ESBL-producing P. aeruginosa has become a significant source of infections in healthcare settings, particularly in immunocompromised individuals and burn victims [18]. Because the surface of moist wounds provides a habitat that is suited for their existence, it thrives in the clinical setting, proving that this environment is perfect for their colonization. Because of the high levels of resistance to the most often given antibiotics in hospital settings, the treatment of infections brought on by these multidrug-resistant organisms is becoming more difficult [19].
Our study revealed the prevalence of P. aeruginosa isolates among burn patients at the Duhok Burn Hospital, at a rate of 64.55% (71/110), a similar finding was made in an Algerian study, where the rate was recorded at 62% [20]. On the other hand, another study conducted in Iraq recorded a high prevalence of P. aeruginosa isolates at 97.6% [21]. however, results from other studies from other nations showed lower prevalence rates, including Morocco (15.1%) [22], and Egypt (19.8%) [23]. This difference might be attributed to antibiotics abuse, different hospital strategies for the management of infections, hygiene, and geographic climatic.
The current study showed the highest rate of 38.18% from flame burn followed by scald burn (15.45%). Regarding gender and age, females showed the highest rate of burn wounds than males (38.18% vs 26.36%), with the ages of 21–30 showing the highest rate (13.64%). These results are somewhat similar to the study conducted in Basra/Iraq [24] they showed that females had a higher proportion of burns than males (57.5% vs. 19.16%), with flame burns accounting for 76.6%, followed by scald burns (19.1%). Additionally, studies from Iraq and Iran have reported somewhat lower rates; 57% in the Iraqi city of Suleimani [25], 54.84%, and 56% in Iran [1, 26] respectively. Due to the fact that most flame injuries occur at home and that most women in our society perform daily household tasks like heating and cooking in areas of the kitchen where there is a greater danger of flame burns, females were significantly more likely than males to sustain flame burns.
While a study conducted in Suleimani/Iraq showed the highest infection in males (56.2%) with scald (Hot water) being the highest (72.5%) group involved, followed by flame (22.8%) [27]. According to this research's findings, the highest rate 45.45% were second-degree burn, followed by 12.73% of mixed burn infections and only 6.36% had third-degree burns. Similarly, Al-Aali et al. [3] revealed that 72.1% of burn patients had second-degree burns. According to the present study observations, patients who had TBSA burns were 20–40% more likely to contract an infection (48.18%), this finding is consistent with the research conducted by Rashid et al. [27] in Suleimani/Iraq found infection rates were higher in patients with TBSA burns of 20–40% compared to those with burns of 40%. The higher the total body surface area damaged by the thermal assault the higher the potential for the bacteria to colonize and proliferate increasing the wound thickness and depth making way to the bloodstream involvement [28].
Regardless to the etiology of the burns, female patients over the age of ten years were the most prevalent patient demographics linked to a higher prevalence of P. aeruginosa infection. In the present investigation, 76.06% of the patients had MDR P. aeruginosa infection which is higher than that reported by other studies in Iran (16.5–41%), Iraq (12.4%) (29, 30, 31), Brazil (71.4%) and Egypt (70%) (32, 33). On the other hand, another study in Iran found a much higher rate (89.24%) of patients infected with MDR P. aeruginosa [26]. Worldwide increasing of MDR P. aeruginosa could be attributed to improper use of antibiotics in hospitals and communities in addition to the accumulation of a variety of resistance mechanisms [34].
In the current investigation, 100% of the isolates demonstrated sensitivity to Colistin. In contrast, a substantially lower percentage of Colistin-sensitive individuals (53.1%) were reported by Jalil et al. [24] in their investigation in Iraq. Another study in Iraq also reported resistance to colistin at a rate of 7.4% [21]. However, susceptibility to Colistin remains vastly high against P. aeruginosa approaching 100% in most countries in the area of the Middle East and North Africa (35).
In this study, 60.56% of P. aeruginosa isolates were resistant to Imipenem, which is higher than that reported by a study conducted in Iran at a rate of 41.3% [17] and Iraq at a rate of 47% [36], and lower than that reported by studies conducted in Iran at a rate (83.9%) [26], in Iraq 68.40% [21]. Multifactorial agents, such as increased carbapenemase production, oprD mutation, AmpC, and efflux pumps overexpression, a shift in drug target sites, and other mechanisms, are contributing to P. aeruginosa increasing resistance to carbapenems [37].
The current study reported the highest resistance of P. aeruginosa to Piperacillin (98.59%). This finding is higher than previous studies conducted in Iran 74.8% [38] and in South Africa, 94% [39]. These findings raise a major concern that requires Health Authorities to urgently work on finding rapid and accurate diagnostic procedures and regulating the dispensing of antibiotics, in addition to tightening microbiological control systems in hospitals.
ESBLs are one of the most common sources of ß-lactam antibiotic resistance in Gram-negative bacteria. These enzymes are plasmid-encoded ß -lactamases that have been discovered in Klebsiella pneumoniae and Escherichia coli, as well as clinical isolates of Enterobacteriaceae and Pseudomonas [40]. In the current study, the genes linked to blaOXA−10, blaPER−1, and blaSHV were found in 59.26% (32), 44.44% (24), and 11.11% (6) of the ESBL-producing P. aeruginosa isolates. The level of resistance was even higher in isolates carrying the OXA-10 gene. The results were consistent with a study conducted in Iran by Farshadzadeh [41], which used the same primers for the OXA-10 and PER-1 genes and produced a band of the same molecular weight. Another study conducted in Shiraz, Iran reported a rate of 76.2% blaOXA−10, and 40% of resistant isolates contain blaPER−1-related genes [13]. The prevalence of the blaSHV gene in the current study is consistent with the rate of 10.7% reported by Peymani et al. [17] in Iran.
Different environments may have a different distribution of ESBL-resistant bacteria, as evidenced by the varying prevalence of ESBL-encoding genes. In addition, the prevalence of blaPER−1 in Ahvaz, Iran, was 62.75%, which was higher than the prevalence of blaPER−1 in Italy (34.61%) [42], Hungary (1.3%), and Belgium (2%), respectively [43], but less than the incidence of blaPER−1 in Turkey (86.75%) [44]. The results of our study showed a high prevalence of the ESBL-producing P. aeruginosa isolates in burn patients, which is an alarming sign and should be taken into consideration because increasing of the antimicrobial-resistant bacteria isolated from burn patients is an important issue.