Annals of R.S.C.B., ISSN:1583-6258, Vol. 25, Issue 6, 2021, Pages. 12561 - 12575 Received 25 April 2021; Accepted 08 May 2021.
Uncommon Bacteria Causing Inflammation of the Surgical Site of a Caesarean Section
*Nedaa Yaseen Taha *Laith Mosleh Najeeb * University of Anbar/college of science/department of biology, Anbar, Iraq.
Abstract Lower segment caesarean section is a common mode of delivery now and surgical site infection is the second most common infectious complication in these patients. Surgical site infection plays an important role in the development of chronicity, delaying wound healing. This study aimed to identify the bacterial pathogens present in infected wounds and characterize their resistance profile to the most common antibiotics used in therapy. Definessurgical site infection as an infection occurring within 30 days from the operative procedure in the part of the body where the surgery took place. Incisional SSI is further divided into superficial, and deep Surgical site infection,(61) isolates were obtained from the study, and the common isolates occupied the largest number in our study by (54.1%). As for the uncommon isolates, 28 bacterial isolates were shown at a rate (45.9%), as it was found that Morganella morganaii, Streptococcus agalatica bacteria accounted for 7 isolates, at a rate of (25%), It was followed by Acinetobacter baumannii with 5 isolates (17.9%), Staphylococcus lugdunensis with 2 isolates (7.1%), Sphingomonas paucimobilis, Methylobacterium spp., Staphylococcus lentus, Staphylococcus homini, Staphylococcus haemolyticus, Bacillus cereus ,Burkholderia cepacia One at a rate of (3.6%).The results showed the sensitivity of most of the uncommon isolates to ciprofloxacin, Colistin , Levofloxacin, Amikacin, while most of them showed high resistance to Ampicillin / cloxacillin, Amoxicillin / clavulanic acid, cefixime, and the bacteria differed from their sensitivity to the antibioticsAzithromycin, Ceftriaxone,Piperacillin, Cefoxitin ,Trimethoprime/Sulfamethoxazole , The uncommon positive Gram stain is more resistant than the uncommon Gram-negative bacteria, especiallyStreptococcus agalatica, whose isolates showed high resistance to antibiotics. Introduction Cesarean section It is a procedure performed by obstetricians to remove the infant through the incision of the abdomen and the mother's womb instead of the vagina, and
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it is one of the mostcommon operations in the world (Martin, 2017) . The rise in caesarean section rates has agreat effect on infection. Surgical sites (Osterman et al., 2015), are considered major surgeries as they come with the same risks,including inflammation of the surgical site asOther types of surgery, one-third to two-thirds of patients who undergo cesarean sections in low-income countries are infected with a surgical site infection, which is nine times higher than in high-resource countries(Lijaemiro et al., 2020) . Bacteria are one of the main and important causes of inflammation, and the bacteria vary between bacteria The common and uncommon bacteria (T Fernández & Hancock, 2012), and there is a low presence bacteria (which is not common), where bacteria have been found in some genera of uncommon aerobic bacteria that cause inflammation at the surgical site of caesarean section. -Morganella morganii, a Gram-negative bacillus(Al-Douri & Maaroof, 2018). It is an anaerobic facultative bacterium. It grows as flat and colorless colonies from 2 to 3 mm on MacoConkey agar and blood agar and Morganella morganii is considered an opportunistic pathogen. Due to the optional pressure of widely used antibiotics significantly accelerating bacterial development(Liu et al., 2016) (Fernández & Hancock, 2012), it causes postoperative wound infection and is a cause of hospital infection in adults. -Sphingomonas paucimobilis:- is a motile aerobic bacterium with polar flagella at 22 ° C and not moving at 37 ° C, non-fermented, Gram-negative bacillus, growing on blood agar and chocolate agar, and not growing on MacConkey agar or selective bacteria media Intestinal. With Oxidase positive and Catalase positive, Urease negative, Indole negative, DNAase negative(Mahon et al., 2018), they are found in the natural environment, they were isolated from water, soil and hospital equipment and cases of infection are due to contaminated solutions suchas distilled water and dialysis means(Maragakis et al., 2009). - Methylobacterium spp.:- It isaerobic bacteria a slow-growing compulsive aerial bacterium that takes 5-7 days. It grows best on medium dextrose agar sabouraud, buffered charcoal yeast extract agar, and it is a gram-negative bacterium, moving in the form of a rod and having a single polar flagellum, not fermented, CatalasePositive, oxidase positive weak, negative for the nitrate reductase test, positive for urease(Kovaleva et al., 2014). Itgrows in small colonies with a pinkish pigment and mucus on solid media such as solid blood medium and solid nutrient agar and does not grow onMacConkey agar. It is an opportunistic pathogen for humans and is a
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cause of health care-related infections, especially in immunocompromised patients(Pathogens, 2020). - Acinetobacter baumanii:- is one of the opportunistic pathogens as one of the most dangerous pathogens in health care facilities,facultative anaerobic bacteria, the most common species that causes infection due to its possession of virulent factors results in hospital-acquired infections (Drummond, 2010), growing on solid blood and MacConkey agar In the form of mucous white-gray colonies with a diameter of 1.5 to 3 mm, it is a gram-negative bacillus bacteria in the form of nearly round rods, facultative non-fermented anaerobes of lactose sugar, oxidase negative , catalase positive, citrate positive, non-motile(Ahmad et al., 2020). - Burkholderia cepacia:- Gram-negative bacillus, aerobic, non-fermented lactose, Catalase positive, Oxidase positive weak, transported through a polar flagellum(Pollini et al., 2018), growing on the medium of MacConkey agar and the medium of, Burkholderia cepacia is an opportunistic pathogen in hospital patients(Tavares et al., 2020).. - Coagulase-negative staphylococci: - Its cells are arranged in clusters and can be seen single or double, and are positive for a chromium pigment, and the spores do not form, do not move, and do not form flagella growing in Optional anaerobic conditions (Baker et al. 2011). It consists of S. lugdunensis,S. epidermidis, S. lentus, S. hominis, S. haemolyticus and others called coagulase-negative staphylococci, which affect human diseases, especially in hospitals, they do not produce a free coagulase, where there is a bound factor. Coagulase is an extracellular fibrinogen binding protein and extracellular adhesion protein that binds fibrinogen or fibrin and does not cause coagulation (Argemi et al., 2017). . - Streptococcus agalactiae :- It is a harmless,facultative anaerobic bacteria symbiotic bacteria that colonizes the gastrointestinal and genitourinary systems of up to 30% of healthy adults in colonial women. S. agalactiae is important because it precedes invasive diseases and spontaneous abortions(Cumley, 2012). And they appear under the microscope after staining Gram stain in the form of non-motile, spherical, gram- positive chains or pairs surrounded by a capsule that is not spores, Catalase test negative, positive CAMP test which is important for determining the synergy of each S. agalactiae with S. aureus(Carrillo-Ávila et al., 2018)as for GBS colonies in women who are at risk of miscarriage and premature labor during pregnancy(Esleem, 2017).
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- Bacillus cereus:- is a facultative anaerobic bacteria that grow on solid blood medium, a beta-type hemolytic, and grow on an optional medium such as mannitol- egg yolk-polymyxin (MYP) (Griffiths & Schraft, 2017), are Gram-positive bacteria , bacilli, motile, Formed for citrate, positive for vogse-proskauer, positive for nitrate reduction, positive for citrate, causing skin infections(Wu et al., 2019). Antibiotics are known as organic compounds produced by certain types of microorganisms, naturally or synthesized and these materials, in small concentrations, can kill or inhibit other microorganisms, through the first two mechanisms, which impede the structural integration as it prevents the building of the plasma membrane and the cell wall, and the second metabolic structure such as the building of acids The nuclear industry and the various proteins that play a major role in the life of the bacterial cell(BALAT & HILL, 1999). In the study, antibiotics from different families were used to demonstrate the effect of antibiotics on bacterial growth, and large groups of antibiotics were used, including Beta-lactum. These groups share a Beta-lactum ring, including the family of cephalosporins and penicillin(Sader & Jones, 2005).. Materials and methods of work Sample collection:-And 140 patients were followed up for an extended period from August 2020 to January 2021, and it was found that 26 patients suffered from inflammation of the surgical site during the follow-up of the patients for 30 days after the cesarean delivery, and the sample was taken by a swab and distributed to the culture media under air conditions in the microbiology laboratory, and it was recorded. Information related to age, number of births and the status of caesarean section, emergency or elective and infected with covid 19 during the operation, taking pre-operative antibiotics for each patient separately. Isolation of aerobic bacteriaSterile cotton swabs were used to take samples, and they were implanted on a medium, blood agar, chocolate agar, MaCconkey agar. The dishes were incubated at a temperature of 37 ° C for a period of 24 hours, after which the bacteria were diagnosed on the basis of biochemical tests and finally we confirm the diagnosis with a VITEC device. Vitek 2. These colonies were transferred to the center of the nutritious tilts, then incubated at (37 ° C) for a period of (24) hours, and then preserved at (4 ° C) until the tests were carried out, taking into
account their renewal every period in the same way(Hawkeye and Lewis, 1989).
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Culture characteristics and Microscopically examination The bacteria are initially diagnosed based on the phenotypic characteristics of the colonies growing on different cultural media, and the colony color, size, texture, convexity, edges, shape, height, odor, type of decomposition, and its ability to ferment sugars and produce hemolysin enzymes on a blood agar, then take a part of modern bacterial culture spread on a slide. They were stained with Gram stain, and then examined under a microscope using an oily lens to observe the shape and arrangement of the cells(Collee et al., 1996). Biochemical tests:- Perform biochemical tests to diagnose the isolated bacteria ,Indol production test, Urease test, Citrate utilization test , Kligleres test, Methyl red test, Voges-Proskauer test, Motility test, Gelatinase production test, Coagulase production test, Detection of lactose fermentation , Manitol fermentation test, Catalase test, Oxidase test, Haemolysin production test , Nitrate Reduction test,, Lipase production test, (CAMP) Christie-Atkinson-Munch-Peterson test (Brooks et al.,2013) Identification of bacteria by Vitek-2 compact system (S Awayid & Khamas, 2013( This device was used to confirm the diagnosis of isolates after diagnosing them in the usual ways, as it is used to diagnose most types of bacteria through a diagnostic kit for the device. Antibiotic sensitivity test The sensitivity test was performed by using 16 types of antibiotics on Gram positive and negative bacteria isolates under study by the method of spreading by tablets on Muller-Hunton medium according to the modified Kirby-bauer method described by the World Health Organization(Vandepitte et al., 2003). Result A total of 1934 patients underwent a Caesarean section in the Women's and Children's Hospital in Ramadi, 140 patients were followed up for an extended period from August 2020 to January 2021, and it was found that (26) patients suffered from inflammation of the surgical site, and their ages were extended from (14-40>). Obtaining (61) bacterial isolates from this study, and the number of uncommon isolates was (28) 45.9%. The results of the diagnosis showed differences in the types
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of isolated bacteria, their numbers, percentages, and staining them with a gram stain, as shown in Table (1) Gram stain Percentage The number of isohation Races of bacteria
_ %25 7 Morganella morganaii -1
_ %3.6 1 Sphingomonas paucimobilis -2
_ %3.6 1 Methylobacterium spp. -3
_ % 17.7 5 Acinetobacter baumannii -4
+ %7.1 2 Staphylococcus lugdunensis -5
+ %3.6 1 Staphylococcus lentus -6
+ %3.6 1 -7 Staphylococcus haemolyticus
+ %3.6 1 Staphylococcus homini-8
_ %3.6 1 Burkholderia cepacia-9
+ %25 7 Streptococcus agalatica -10
+ %3.6 1 Bacillus cereus-11
100 28(%45.9) Total
The results of the sensitivity test showed that all the uncommon isolates studied, negative and positive for Gram stain, were sensitive to ciprofloxacin and Levofloxacin with a percentage of (100%). Demonstrated high resistance to cefixime, Ampicillin / cloxacillin, Amoxicillin / clavulanic acid. Gram-positive bacteria, such as isolates of Staphylococcus lugdunensis, Staphylococcus lentus, Staphylococcus haemolyticus, and Staphylococcus homini, were sensitive (100%) to Clindamycin,And it showed different resistance to the antibiotics used, as it was (100%) resistance to cefixime, Ampicillin/cloxacillin, while it showed high resistance (85.7%) to ceftriaxone, Amoxicillin/clavulanic acid, and the isolates resisted Piperacillin ratio (71.4%), and the percentage of resistance was equal For cefoxitin, Trimethoprime/ Sulfamethoxazole it was (42.9%), and it was resistant by (28.6%) to ciprofloxacin, Levofloxacin, Azithromycin, Cefepime, Methicillin, and it showed less resistance to Amikacin by (14.3%).As for Streptococcus agalatica, its isolates were 100% sensitive to ciprofloxacin, Levofloxacin, and showed high resistance (100%) to cefixime, Azithromycin, ceftriaxone, Ampicillin / cloxacillin, Amoxicillinclavulanicacid. These bacteria were resistant to Clindamycin and Piperacillin, at a rate of (85.7%) and
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(57.1%) respectively. Bacillus cereus isolate showed sensitivity (100%) to all antibiotics except Cefixime, Azithromycin, Ceftriaxone, Ampicillin/cloxacillin, Amoxicillin/clavulanic acid, Piperacillin, Cefoxitin, Cefepime. Discussion The results showed that Morganella morganaii bacteria was the largest percentage of isolates, and by (7) isolates and a percentage (25%), the bacteria grew on MacConkey agar medium without lactose fermentation, and upon microscopic examination, they found in the form of Gram-negative bacilli as shown in Figure (1) that The results of this study doubled the bacteria obtained in relation to the results of the periodic researcher(Al-Douri & Maaroof, 2018), where the percentage of Morganella morganaii bacteria was (12.5%) in Tikrit and Samarra. This bacterium is an opportunistic pathogen and it shared with other bacteria to cause infection as a result of damage. Tissue due to surgery and the etiology of surgical site inflammation is likely to include Gram-negative bacilli, including the intestinal tract)Lachiewicz et al., 2015(.Among the uncommon bacteria Sphingomonas paucimobilis, was isolatedfromInflammation of the cesarean section site on the fourth day of surgery for a 42-year-old patient who suffers from obesity. It was also consistent with the global study in India who obtained a single isolate of Sphingomonas paucimobilis.
AB
Figure (1) = A colonies of Morganella morganaii bacteria growingMacConkey agar , = B Morganella morganaii under the microscope A single isolate was obtained from Methylobacterium spp. With a percentage of (3.6%) of a patient who suffered inflammation of the surgical site and the result of the sample transplantation was a multi-bacterial infection that includes aerobic, facultative anaerobic and compulsive anaerobic bacteria that took an incubation period of 7 days, these bacteria are considered to be types acquired from the
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environment or may be acquired from the hospital environment because It is not from the patient's internal natural flora bacteria, and it is one of the pathogens of opportunistic human diseases found in soil and water, especially since the patient had previously used multiple antibiotics, and this agreed with Akhi and others (2015) who clarified that infections acquired from the hospital or the external environment include aerobic bacteria or facultative anaerobic bacteria(Akhi et al., 2015)(Kovaleva et al.,2014) . .
Methylobacterium sppSphingomonas paucimobilisFigure (2): Five isolates of Acinetobacter baumannii were obtained. This bacterium is responsible for a large proportion of nosocomial infections, and is characterized by its intrinsic and acquired resistance to a wide range of antibiotics. Acinetobacter baumannii is an opportunistic pathogen associated with infections acquired from the external environment. This study agreed with the study ofSadeghi et al. 2016 which was shown to be commonly found in hospital settings and responsible for a large proportion of hospital infections(Sadeghi et al. 2016) . The results showed that two isolates of Staphylococcus lugdunensis were obtained (7.1%), and their colonies were characterized by similarity to Staphylococcus aureus by yellow pigmentation on the medium of Nutrient agar. And the distinctive feature is that it appears positive for the coagulase test on a slide, but this bacteria appears negative for the coagulase tube test ,The similarity of the characteristics between the two types is difficult for the researcher to accurately diagnose, but it can be diagnosed by the Vitek2 device. Our study agreed with the study ofYazgi and Uyanik (2010) which isolated Staphylococcus lugdunensis from a wound sample with similar characteristics of isolation obtained with the isolation of our study(Yazgi & Uyanik, 2010). shown in figure (2)
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B A
Figure (3) A - S. aureus, S. lugdunensis is positive for the coagulaes test on the slide, B- but negative for the coagulase test for the tube
As for the two isolates Staphylococcus homini and Staphylococcus lentus, they were obtained from the same patient and upon follow-up of the patient, the development of her infection was observed late and a swab was taken on the eighth day of the cesarean section and the results of the transplant showed the growth of Staphylococcus lentus bacteria. As an infection acquired from the environment, which is a negative bacterium to test for coagulase of animal origin 9, Staphylococcus is considered positive for Gram stain, and here our study agreed with the study ofShareef and others (2019) by studying that Staphylococcus lentus is one of the known animal pathogens and was isolated from Rodents, chickens and mammals(Shareef et al., 2019)(Table (1) of the uncommon bacteria also showed the emergence of Staphylococcus haemolyticus from the incision of the wound after the cesarean section.it is a negative bacterium for the test coagulase , Researcher Lingaraj and others(2015) who demonstrated that the skin is dominated by Gram-positive bacteria(Lingaraj et al.,2015). Burkholderia cepacia isolation was obtained with a percentage (3.6%), which is a colonized and not often pathological organism, and this result agreed with Leitão et al. (2017) (Leitão et al., 2017). Streptococcus agalatica, this bacteria was obtained through our study, and upon microscopic examination it was found that it is Gram-positive cocci, arranged in pairs and chains. The number was seven isolates (25%) and it was accompanied by five isolates of the patients who suffered miscarriage before this birth, and it may be believed that there is a connection between Of course, before this birth, these opportunistic bacteria can sabotage the host's defenses below the optimal level, causing tissue damage and causing inflammation of the skin and soft tissues., And
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these results agreed with Rajagopal and others (2009) who noted that it is a bacterium that colonizes healthy people without symptoms, but it is transmitted from pregnant women to children during childbirth when it contaminates it colonizes healthy people without symptoms, but it is transmitted from pregnant women to children during childbirth when the amniotic fluid surrounding the surgery is contaminated, causing Infection of the skin, soft tissuesetc (Rajagopal et al.,2009). The results of the study showed that one isolate of the surgical site infection of Bacillus cereus with a percentage of (3.6%) causing wound infection, which is an infection acquired from the environment. and our study also agreed with Dryden (1987) who isolated Bacillus cereus from wounds(Dryden, 1987) .
Figure(4) Bacillus cereus bacteria growing in the middle of a MYP agar
Antibiotic sensitivity test Gram-negative bacteria test for antibiotic sensitivity The results of the sensitivity test showed that all isolates are uncommon, studied negative bacteria gram stain, and this resistance may be caused by changing the cell membrane of bacteria by losing the openings of the outer membrane, which performs the function of transporting the antigen into the cell and is known as the efflux pump, which leads to a decrease in the concentration of antigens at the target sites and thus the bacteria resist cephalosporine.The stream pumps act by co-expressing the enzyme Beta-lactamases, as well as the presence of multiple antibiotic resistance genes, or the resistance of the antibiotic carried on a plasmid encodes resistance to more than one antibiotic. Our study agreed with Glasset et al. (2018) whose data were revealed. The efficacy of the aminoglycosides and fluoroquinolones and bacterial resistance to most Beta-lactams, so it is recommended not to use the penicillin and cephalosporine family (Glasset et al., 2018).
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Table (2) the resistance of Gram-negative bacteria to antibiotics Methylobacteriu Sphingomonas Acinetobacter Morganella Burkholderia m spp. paucimobilis baumannii morganaii cepacia Antibodies used N=1 N=1 N=5 N=7 N=1
0(0%) 0(0%) 1(20%) 0(0%) 0(0%) Ciprofloxacin
1(100%) 1(100%) 5(100%) 7(100%) 1(100%) Cefixime
1(100%) 0(0%) 2(40%) 3(42.9%) 0(0%) Azithromycin
0(0%) 1(100%) 2(40%) 0(0%0 0(0%) Ceftriaxone
1(100%) 1(100%) 5(100%) 7(100%) 1(100%) Ampicillin/cloxacillin
0(0%) 0(0%) 0(0%) 0(0%) 0(0%) Levofloxacin
0(0%) 0(0%) 1(20%) 5(71.4%) 0(0%) Colistin
1(100%) 1(100%) 5(100%) 7(100%) 1(100%) Amoxicillin/clavulanic acid
1(100%) 1(100%) 1(20%) 0(0%) 0(0%) Piperacillin
0(0%) 1(100%) 1(20%) 5(71.4%) 0(0%) Cefoxitin
0(0%) 1(100%) 1(20%) 0(0%) 0(0%) Cefepime
0(0%) 0(0%) 1(20%) 0(0%) 0(0%) Amikacin
Trimethoprime/ 1(100%) 0(0%) 1(20%) 7(100%) 0(0%) Sulfamethoxazole Gram-positive bacteria test for antibiotic sensitivity Staphylococcus lugdunensis, Staphylococcus lentus, Staphylococcus haemolyticus, Staphylococcus homini isolates had increased levels of resistance to Beta-lactam resulting from the hydrolysis of the Beta-lactam ring by the penicillinase-mediated enzyme. The types of staphylococci produce a protein that binds penicillin and inactivates the Beta-lactam loop, and even fluoroquinolones, Aminogiycosides and Azithromycin prove the ability to rapidly acquire and modify resistance genes. It is believed that resistance genes lead to the acquisition of binding sites and the transfer of antibiotics out of the cell through the pumps of drug flow, that Coagulase-negative staphylococcus represents a problem for the human host when the resistance strains resulting from contact between humans and poultry are transmitted because they are often antibiotic-resistant strains. Infection becomes more difficult to treat França et al. (2021) noted that Coagulase-negative staphylococci showed more than (90%) resistance to penicillin-derived antibiotics and resistance to newer antibiotics, which hinders treatment options(França et al., 2021). The results were also in agreement with the study by Michels and others (2021) He noted the rise in antibiotic resistance
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and considered the coagulase negative staphylococcus bacteria to be difficult to treat(Michels et al., 2021).As for Streptococcus agalatica, there is more than one antibiotic resistance mechanism that could produce broad-spectrum Beta-lactamases that are resistant to the penicillin family and the cephalosporine family, or to have flow systems that send the antagonists from inside the cell to the outside, and the sensitivity of S. agalatica indicates. The fluoroquinolones family has shown that these antibiotics are effective against isolates and this is due to their novelty, as these antigens inhibit DNA synthesis by binding to the DNA gyase, leading to their rapid death (Brooks et al., 2013). Bacillus cereus isolate showed resistance that may be caused by changing the cell membrane of bacteria by losing the openings of the outer membrane, which carries the function of transporting the antigen into the cell and known as the efflux pump, which leads to a decrease in the concentration of antigens at the target sites and thus the bacteria resist the cephalosporine family. The stream pumps act by co-expressing the enzyme Beta-lactamases, as well as the presence of multiple antibiotic resistance genes, or the resistance of the antibiotic carried by a plasmid encodes resistance to more than one antibiotic. Our study agreed Glasset et al., 2018 with whose data revealed The efficacy of the family of aminoglycosides and fluoroquinolones and the resistance of bacteria to most Beta-lactam therefore recommended against the use of penicillin and the cephalosporine family(Glasset et al., 2018) . . Table (3) the resistance of Gram-positive bacteria to antibiotics Number of isolated and percentage of isolated resistant to antibiotics
Bacillus Streptococcus Staphylococcus S.aureus Antibodies used cereus agalatica spp 8 1 7 7.
0(0%) 0(0%) 2(28.6%) 0(0%) Ciprofloxacin
1(100%) 7(100%) 7(100%) 8(100%) Cefixime
1(100%) 7(100%) 2(28.6%) 3(37.5%) Azithromycin
1(100%) 7(100%) 6(85.7%0) 8(100%) Ceftriaxone
1(100%) 7(100%) 7(100%) 8(100%) Ampicillin/cloxacillin
0(0%) 0(0%) 2(28.6%) 0(0%) Levofloxacin
1(100%) 7(100%) 6(85.7%) 7(87.5%) Amoxicillin/clavulanic acid
1(100%) 4(57.1%) 5(71.4%) 8(100%) Piperacillin
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1(100%) 7(100%) 3(42.9%) 3)37.5%) Cefoxitin
1(100%) 7(100%) 2(28.6% 0(0%) Cefepime
0(0%) 7(100%0 1(14.3%) 0(0%) Amikacin
0(0%) 7(100%) 2(28.6) 5(62.5%) Methicillin
0(0%) 6(85.7%) 0(0%)0 0(0%) Clindamycin
0(0%) 1(14.6%) 3(42.9%) 1(12.5%) Trimethoprime/
Sulfamethoxazole Conclusions The presence of a wide bacterial diversity in the cesarean section wound, as it increased in turn, the Gram-negative bacteria increased over the Gram-positive bacteria in isolates obtained from inflammation of the surgical site and showed that most types of normal human bacteria are able to form infection at sites Where they are found where they are considered to be the cause of microbial infections, uncommon bacteria causing inflammation of the surgical site were obtained, including natural flora bacteria from the human body that became opportunistic pathogens such as Morganella morganii and Staphylococcus lugdunensis and some of them acquired from the external environment such as the genus Methylobacterium spp. Sphingomonas paucimobilis,. The result of the antibiotic susceptibility test showed that Gram positive strains are more resistant to the antibiotics used than Gram negative strains. References 1. Ahmad, I., Nygren, E., Khalid, F., Myint, S. L., & Uhlin, B. E. (2020). A Cyclic-di- GMP signalling network regulates biofilm formation and surface associated motility of Acinetobacter baumannii 17978. Scientific reports, 10(1), 1-11. 2. Argemi, X., Hansmann, Y., Riegel, P., & Prévost, G. (2017). Is Staphylococcus lugdunensis significant in clinical samples?. Journal of clinical microbiology, 55(11), 3167-317. A. França, V. Gaio, N. Lopes, and L. D. R. Melo, ―Virulence factors in coagulase-negative staphylococci,‖ Pathogens, vol. 10, no. 2, p. 170, 2021. 3. Różańska et al., ―Does surgical site infection after Caesarean section in Polish hospitals reflect high-quality patient care or poor postdischarge surveillance? Results from a 3-year multicenter study,‖ Am. J. Infect. Control, vol. 46, no. 1, pp. 20–25, 2018. 4. BALAT, A., & HILL, L. L. (1999). Genitourinary abnormalities in children with urinary tract infections. Turkish Journal of Medical Sciences, 29(1), 59-64. 5. A. Forbes, D. F. Sahm, and A. S. Weissfeld, Study Guide for Bailey and Scott’s Diagnostic Microbiology-E-Book. Elsevier Health Sciences, 2016 6. Glasset et al., ―Bacillus cereus, a serious cause of nosocomial infections: epidemiologic and genetic survey,‖ PLoS One, vol. 13, no. 5, p. e0194346, 2018. 7. Carrillo-Ávila, J. A., Gutiérrez-Fernández, J., González-Espín, A. I., García-Triviño, E., & Giménez-Lirola, L. G. (2018). Comparison of qPCR and culture methods for
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