Oral Science International 12 (2015) 59–66

View metadata, citation and similar papers at core.ac.uk brought to you by CORE

Contents lists available at ScienceDirect provided by Elsevier - Publisher Connector

Oral Science International

j ournal homepage: www.elsevier.com/locate/osi

Original Article

Baseline burden and antimicrobial susceptibility of pathogenic

bacteria recovered from oral lesions of patients with HIV/AIDS in

South-Western Uganda

a,b,∗ c d e

Ezera Agwu , John C. Ihongbe , Joseph O. Ezeonwumelu , Moazzam M. Lodhi

a

The Special Pathogens Research Network Limited, Bushenyi, Kampala, Uganda

b

Department of Microbiology, Kampala International University, Western Campus, Ishaka, Bushenyi, Kampala, Uganda

c

Department of Medical Laboratory Sciences, Babcock University, Illisan Remo, Ogun State, Nigeria

d

Department of Clinical and Biopharmacy, School of Pharmacy, Kampala International University, Western Campus, Ishaka, Bushenyi, Kampala, Uganda

e

Department of Public Health, School of Allied Health Sciences, Kampala International University, Western Campus, Ishaka, Bushenyi, Kampala, Uganda

a r t i c l e i n f o a b s t r a c t

Article history: Background: The need to map pathogenic bacteria from oral lesions of patients with human immuno-

Received 19 May 2014

deficiency virus and acquired immunodeficiency syndrome (HIV/AIDS) remains crucial to estimate the

Received in revised form 5 March 2015

potential risk of localized and systemic diseases.

Accepted 13 March 2015

Objective: The aim of this study was to determine the baseline burden and antibiotic susceptibility of

pathogenic bacteria recovered from oral lesions of patients with HIV/AIDS in South-Western Uganda.

Keywords:

Methods: World Health Organization’s aseptic criteria were adopted in oral examination, sample (605)

Oral pathogenic bacteria

collection, pathogenic bacteria isolation, and sensitivity testing. The included patients with HIV/AIDS had

Persistent oral lesions

persistent oral lesions, and they received antibiotic treatment. The study was ethically approved by the

Susceptibility status

institutional and national boards.

South-Western Uganda

Results: Pathogenic bacteria (31% Streptococcus mutans, 16.4% Proteus mirabilis, 11.8% nonhemolytic Strep-

tococcus species, 11.3% Staphylococcus aureus, 9.5% Branhamella catarrhalis, 8.6% Pseudomonas aeruginosa,

8.1% Klebsiella pneumoniae, 6.8% Escherichia coli, and 5.5% Streptococcus pyogenes) prevalence varied sig-

nificantly (p < 0.05) with participating districts, and this may indicate that patients are at an increased

risk of systemic infection and antibiotic resistance. Females were more in number than males, and 31–50

years were the most predominant age groups. The variation of oral pathogenic bacteria represents the

distribution of two ethnics made of five tribes. Gentamycin was the most effective antibiotic against

all isolates. Relative resistance to oral antibiotics and sensitivity to ciprofloxacin/cefaclor were bacteria-

dependent. An effective treatment plan for persistent oral lesions should be against pathogenic bacteria

and fungi.

Conclusions: An observed wide array of potentially pathogenic bacteria in the oral cavity of patients with

HIV/AIDS poses a real problem in the world of antimicrobial resistance, and this clearly provides a higher

risk of systemic infectious diseases in these population with HIV/AIDS.

© 2015 Japanese Stomatological Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction [1,2]. Pathogenic bacteria frequently detected from different

oral conditions may include Fusobacterium necrophorum, Pre-

The oral microbial population predominated by pathogenic votella intermedia, cloxacillin-sensitive and erythromycin-sensitive

bacteria may relatively be stable in health, but any adverse Staphylococcus aureus, Treponema palladium and other species,

changes by surgery and underlying defects in the innate or Mycobacterium tuberculosis, alpha-hemolytic Streptococci, Strepto-

specific immune systems predispose the mouth to infections cocci aureus, and Gram-negative anaerobic organisms [3–5].

Defining the burden of oral pathogenic bacterial infections is dif-

ficult because apart from taking part in primary oral mucosal

∗ infections, they are frequently associated with secondary systemic

Corresponding author at: The Special Pathogens Research Network Limited,

disease, induced by bacteremia, injury due to oral microorganisms,

Bushenyi, Kampala, Uganda. Tel.: +256 782101486; fax: +256 703129679.

E-mail addresses: [email protected], [email protected] (E. Agwu). and pathogenic bacterial toxins [6–8].

http://dx.doi.org/10.1016/S1348-8643(15)00018-X

1348-8643/© 2015 Japanese Stomatological Society. Published by Elsevier Ltd. All rights reserved.

60 E. Agwu et al. / Oral Science International 12 (2015) 59–66

The prevalence of oral microbial (including pathogenic bacte- bacteria even in classical cases of treatment failure of oral lesions

ria) lesions among patients with human immunodeficiency virus among patients with HIV/AIDS.

and acquired immunodeficiency syndrome (HIV/AIDS) shows a

regional and geographical variation. The global report of oral 1.3. Objectives

microbial (including pathogenic bacteria) disease prevalence in

HIV/AIDS disease was 40–50% [9], and other reports from dif- The objectives of this study were to determine the baseline bur-

ferent regions of the world include 13–45% from India [10], den of pathogenic bacteria recovered from oral lesions of patients

43–79% from Nigeria [11], 34–74.9% from USA [12], and an aver- with HIV/AIDS in South-Western Uganda, and to outline the suscep-

age of 73% from Uganda [12]. The condition was slightly similar tibility pattern of isolates to commonly used antibacterial agents

(5.5–57%) in a Brazilian report on patients with non-HIV having with the ultimate goal of providing a database for the future man-

other infectious diseases [13]. Persistent oral microbial (includ- agement of pathogenic oral and systemic bacterial diseases.

ing pathogenic bacteria) lesions in patients who are HIV-positive

may be explained by the concept of idiosyncratic reactions or 2. Methods

illnesses [14], and they are defined as adverse reactions of the

body to foreign substances including food and drugs, which occur A total of 605 known patients with HIV/AIDS, recruited for this

through unknown mechanisms and with a poorly understood cause study, were clinically diagnosed with oral lesions by trained and

and effect relationship of the variables. Such variables may be calibrated oral clinicians, while attending clinics at three TASO

due to host-related (malnutrition, age, gender, pregnancy, or obe- (The AIDS Support Organization) Centers in Masaka, Rukunguri,

sity), environmental-related (smoking, alcohol consumption, and and Mbarara districts of Uganda. Mbarara district TASO centers

infection), and drug-related (daily dose, metabolic profile, drug included Mbarara Metropolitan Center and Mbarara-controlled

interaction, and cross-sensitization) variables [14–16]. outreach centers located in Mitooma, Katungu, and Kigarama vil- lages.

1.1. Justification

2.1. Inclusion criteria

Despite the high prevalence of recurrent oral conditions,

Known patients with HIV/AIDS who were clinically diagnosed

etiopathogenesis remains elusive, incompletely understood, and

with oral lesions by trained and calibrated oral clinicians using

warrants research attention. There are many reports about oral

the World Health Organization’s established clinical criteria for

lesion prevalence, but little is known about reoccurring lesions

HIV-associated oral lesions used in our former report [1] and who

among patients with HIV/AIDS under routine drugs. United States

complained of oral lesions’ persistence despite receiving routine

of America and Nigeria reported 15.2% and 26% rebound of

oral co-trimoxazole, clotrimazole, nystatin, and fluconazole were

oral lesions, respectively, in HIV/AIDS disease [12,17]. A previ-

included.

ous report [18] suggesting that S. aureus, hemolytic Streptococci,

Enterococci, Escherichia coli, Klebsiella, Pseudomonas, and other

2.2. Ethical issues

pathogenic bacteria play a role in the pathogenesis and persis-

tence of complicated oral fungal lesions needs to be confirmed

Informed consent was sought and obtained from the Uganda

and/or duplicated in HIV/AIDS endemic in South-Western Uganda.

National Council for Science and Technology, the Kampala Interna-

Worthy of note and replication is the report that pathogenic

tional University Western Campus Research and Ethics Committee,

bacteria are involved in the microbial, immunological, and

and TASO at both local and national levels, and from TASO clients

nonmicrobial factors (trauma, drugs, hematinic deficiency, sodium-

(patients) through their informed consent. Letters were written

lauryl-sulfate-containing toothpaste, tobacco, and stress) leading

in English, translated, and interpreted into local languages spo-

to the persistence of oral lesion among patients on routine drugs in

ken at the various TASO centers. TASO clients signed or printed

resource-limited settings [19].

their thumb to show the approval for sample collection. Where the

Understanding the microbial details of recurrent oral disease

clients could not read or write in English or local languages, the

conditions, especially in the immunocompromised patients, may

letter containing the benefits of the research study was read and

strengthen the capacity to mount a more focused and coor-

interpreted to the clients before thumb-printing after understand-

dinated surveillance for an effective intervention. Furthermore,

ing the read text.

the association of oral pathogenic bacteria with secondary sys-

temic disease and the confirmation that the oral cavity may

2.3. Sample size

be a potential source or reservoir of pathogenic species justify

the need to characterize as well as determine the susceptibil-

The number of oral samples (n = 605) obtained from oral lesions

ity status of the pathogenic bacterial isolates of persistent oral

of patients with HIV/AIDS was guided by the upper limit required

lesions of patients with HIV infection and AIDS [6,20]. A clear

to give a 95% level of confidence at an expected prevalence of

outline of the susceptibility pattern of pathogenic bacterial iso-

about 55% [24], using the precise prevalence formula: sample size

lates to antibiotics is paramount to the design and implementation 2 2

(N) = Z P(100 − P)/D (Epi-info version 3.2 database, 1995), where

of an effective intervention during the rebound of oral lesions

Z is a constant given as (1.96), P is the expected prevalence (55%),

[21,22].

and D is the acceptable error (5%).

1.2. Significance 2.4. Sample collection and analysis

A survey of oral pathogenic bacteria carriage and an outline of A disposable wooden tongue depressor was used to retract

®

its susceptibility status would have a profound epidemiological the cheeks, while sterile swab sticks (Evepon , Anambra, Nigeria)

and public health significance in relation to the plan for effec- were used to aseptically collect samples from the oral lesions

tive interventions. The management of oral mucosal disease in of the patients. After collection, the samples were immediately

resource-poor settings currently focuses on oral mycosis [1,23], taken to the Laboratory Unit of the Microbiology Department, Kam-

with little attention paid to the possible involvement of pathogenic pala International University, Western Campus (KIU-WC), Ishaka,

E. Agwu et al. / Oral Science International 12 (2015) 59–66 61

Table 1

Demographic characteristics of 605 participants from Mbarara, Rukungiri, and Masaka.

Age (years) Mbarara Rukungiri Masaka

F = 253 M = 58 F = 109 M = 43 F = 107 M = 35

1–10 3 (1.2) 0 (0.0) 1 (0.9) 0 (0.0) 1 (1.0) 0 (0.0)

11–20 4 (1.6) 1 (1.7) 1 (0.9) 0 (0.0) 4 (3.7) 1 (2.9)

21–30 29 (11.5) 7 (12.1) 15 (13.8) 7 (16.3) 18 (16.8) (14.3)

31–40 109 (43.0) 32 (55.2) 42 (38.5) 16 (37.2) 47 (44.0) 5 (42.8)

41–50 78 (30.8) 14 (24.1) 37 (34.0) 12 (27.9) 24 (22.4) 0 (28.5)

51–60 28 (11.1) 4 (6.9) 8 (7.3) 5 (11.6) 10 (9.3) 3 (8.6)

>60 2 (0.8) 0 (0.0) 5 (4.6) 3 (7.0) 3 (2.8) 1 (2.9)

F, females; M, males.

Bushenyi, Uganda, for analysis. In cases where there were delays measured and interpreted as “sensitive”, “intermediate”, and

in getting the samples to the laboratory, the samples were trans- “resistant” using CLSI guidelines [32].

ported in a phosphate-buffered physiological saline in a vaccine

carrier [25], and all media used were prepared under aseptic con- 2.6. Statistical analysis

ditions and with stringent adherence to media performance control

criteria in line with manufacturer’s instructions (Mast Diagnos- The randomized block design (RBD) (˛ = 0.05 or 99.95% level of

tics, Mumbai, India). Briefly, an overnight broth culture of samples confidence), summarized as (the total sum of squares (SST) = sum

inoculated on a brain–heart infusion (BHI) broth was incubated for of squares due to different effects (SSD) + error sum of effects

◦

18–24 h (overnight) at 37 C, under reduced oxygen tension in an (SSE)) [34], for one observation per treatment was used to test for

enclosed jar with a glowing candle. The candle glows till extinction the relationship between oral pathogenic bacteria population and

to create an atmosphere containing reduced oxygen and increased oral lesions among TASO clients with HIV infection. Susceptibility

carbon dioxide to support the growth of fastidious aero-tolerant results were also tested with RBD or completely randomized design

oral pathogenic bacteria species. Overnight broth suspensions were (CRD).

plated out on a BHI agar supplemented with 5% sheep blood to get a

blood agar, which was then incubated overnight on reduced oxygen

3. Results

tension as mentioned above [26–28].

Inoculation of samples onto prepared media was done asepti-

3.1. Demographic characteristics of participants

cally, and after an 18–48-h incubation, suspect pathogenic bacteria

species of clinical significance (>25 discrete colonies per cul-

Table 1 shows the demographic characteristics of participants in

ture plate) were picked for further identification. Thus, discrete

three (Mbarara, Rukungiri, and Masaka) districts of Uganda. Overall,

pathogenic bacteria colonies appearing on the pool of inoculum

there were more females than males in the entire three districts

and in the lines of striking were picked for further identification,

studied. Majority of the participants fall within the age groups of

while mixed growth was first purified to get discrete colonies

31–50 years, while participants at extremes of ages (<10 years and

before being taken for further identification. Standard guidelines

>60 years of age) were least in the number of recruited participants.

were adopted during the identification of pathogenic bacte-

The total number of participants was highest in Mbarara followed

rial isolates [29,30]. Briefly, some tests performed that assisted

by those from Rukungiri and Masaka districts, respectively.

in pathogenic bacterial identification using standard guidelines

included pathogenic bacterial assimilation of selected sugars such

3.2. Recurrent oral conditions of participants

as glucose, lactose, raffinose, sucrose, mannitol, dextrose, and malt-

ose; pathogenic bacterial production of enzymes such as catalase,

Table 2 shows the recurrent oral conditions of patients with

coagulase, lipase, DNAse, and esterase enzymes; and pathogenic

HIV infection and AIDS receiving routine co-trimoxazole, nystatin,

bacterial hemolytic characteristics tested on blood agar. Other tests

and highly active antiretroviral therapy (HAART) from the three

conducted included optochin and bacitracin susceptibility, oxidase,

districts sampled. Patients whose oral lesions were swabbed for

methyl red, Voges–Proskauer, citrate utilization, urease hydroly-

pathogenic bacterial isolation were those who complained of treat-

sis, hydrogen sulfide production, indole and motility tests, starch

ment failure, and have oral lesions despite being placed on routine

hydrolysis, nitrate reduction, and bile esculin test.

Table 2

A summary of the recurrent oral conditions among patients with HIV infection and

2.5. Antibacterial susceptibility testing

AIDs receiving routine cotrimoxazole, nystatine, and HAART.

Number (%) positive recurrent oral conditions n = 605

This was done in line with the modified Clinical Laboratory Stan-

dards Institute (CLSI) guidelines for conducting the Kirby–Bauer Pseudomembranous candidiasis 166 (27.4)

Erythematous candidiasis 27 (4.5)

disk diffusion susceptibility testing of antibiotics [31]. Antibiotic

Angular chelitis 12 (2.0)

selection was done in line with previously reported standard

Linear gingival erythematous banding 6 (1.0)

methods [32,33]. Briefly, standard suspensions (0.5 McFarland)

Pseudomembranous and erythematous candidiasis 171 (28.2)

of identified pathogenic bacteria colonies were inoculated onto Pseudomembranous candidiasis and angular chelitis 78 (12.9)

prepared plates of Mueller–Hinton agar using sterile swab sticks. Erythematous candidiasis and angular chelitis 9 (1.5)

Kaposi sarcoma 19 (3.1)

Commercially available disks (Mast Group, India; Oxoid, UK) with

Recurrent aphthous ulceration 12 (2.0)

disk content as shown in Tables 4–6 were aseptically placed at

Xerostomia 50 (8.3)

the top of the inoculated media. To ensure noninterference of

Unclassified oral conditions 55 (9.1)

zones of clearance and ease of interpretation, five disks were used

◦

n, number sampled.

per plate. After incubation at 35 C for 18–24 h, zone sizes were

62 E. Agwu et al. / Oral Science International 12 (2015) 59–66

Table 3

Percentage prevalence of pathogenic bacteria isolated from patients with HIV infection and AIDS in the three districts (Masaka, Rukungiri, and Mbarara) surveyed.

Organisms n = 605

Number (%) prevalence

Masaka Rukungiri Mbarara

n = 142 n = 152 n = 311

Streptococcus mutans 45 (31.7) 34 (22.4) 96 (30.9)

Streptococcus pyogenes 7 (4.9) 0 (0.0) 17 (5.5)

Staphylococcus aureus 16 (11.3) 11 (7.2) 35 (11.3)

Non-hemolytic Streptococcus 0 (0.0) 18 (11.8) 14 (4.5)

Pseudomonas aeruginosa 2 (1.4) 13 (8.6) 0 (0.0)

Klebsiella pneumoniae 12 (8.5) 8 (5.3) 13 (4.2)

Proteus mirabilis 4 (2.8) 25 (16.4) 0 (0.0)

Escherichia coli 10 (7.0) 5 (3.3) 19 (6.1)

Bacillus subtilis 4 (2.8) 2 (1.3) 0 (0.0)

Bacillus cereus 2 (1.4) 1 (0.7) 0 (0.0)

Brahmella catarrhalis 14 (9.9) 9 (5.9) 14 (4.5)

Diphtheroids 7 (4.9) 0 (0.0) 0 (0.0)

Total number of pathogenic bacterial isolates 123 (86.6) 126 (82.9) 208 (66.9)

No pathogenic bacterial growth 19 (13.4) 26 (17.1) 103 (33.1)

n, total number sampled. Using RBD and FLSD, there were significant differences when the prevalence of different pathogenic bacterial strains in the oral mucosa was

compared within districts (a) and between districts (b).

antiviral, antifungal, and antipathogenic bacterial drugs (HAART, from Mbarara, seven (4.9%) diphtheroids from Masaka district, and

nystatine, and co-trimoxazole, respectively) during their previous four (2.8%) Bacillus subtilis from Masaka district. The prevalence

visits to the hospital. Xerostomia was included because it was of pathogenic bacteria strains in the oral mucosa was significantly

among the oral conditions seen among patients who came for dependent on the district where pathogenic bacteria were isolated.

the second time. Unclassified oral conditions are those lesions in

which the attending clinicians could not make definite decisions

about their clinical diagnosis but they wrote oral lesions diagnosed. 3.4. Susceptibility status of pathogenic bacteria isolates from

Pseudomembranous and erythematous oral lesions were the most Masaka patients

common lesions seen among the patients.

Table 4 shows 30 (66.7%) out of 45 strains of S. mutans; 30 (66.7%)

were susceptible to gentamycin and 22 (48.9%) were susceptible to

3.3. Pathogenic bacteria distribution by districts surveyed

ciprofloxacin. All seven (100%) strains of S. pyogenes were suscep-

tible to ciprofloxacin and six (85.7%) strains were susceptible to

The result in Table 3 shows that out of 605 samples collected

gentamycin. Twelve (80%) strains of S. aureus were susceptible to

and analyzed, 142 were from Masaka, 152 from Rukungiri, and 311

ciprofloxacin, 11 (68.8%) strains were susceptible to gentamycin,

from Mbarara region. Pathogenic bacteria prevalence was highest

and eight (50.0%) to penicillin G. All two (100%) strains of P.

at 123 (86.6%) in Masaka followed by 126 (82.9%) in Rukungiri and

aeruginosa were uniformly susceptible to ciprofloxacin and gen-

208 (66.9%) in Mbarara region. The most predominant bacterium

tamycin, respectively. Eleven (91.7%) out of 12 strains of Klebsiella

in the districts surveyed was 96 (30.9%) Streptococcus mutans from

pneumoniae were susceptible to gentamycin, and six (50%) were

Mbarara, followed by 25 (16.4%) Proteus mirabilis from Rukungiri,

susceptible to amoxicillin and penicillin G. All four (100%) strains

35 (11.3%) S. aureus and 18 (11.8%) nonhemolytic Streptococcus

of P. mirabilis were susceptible to both ciprofloxacin and gen-

species each from Mbarara and Rukungiri districts, respectively,

tamycin. Generally, it can be seen from the narrative above that the

and 14 (9.5%) Branhamella catarrhalis isolated from Masaka.

quinolones and aminoglycosides appear to be very effective against

Other pathogenic bacteria isolated in the descending order

predominant pathogenic bacterial isolates. Antibacterial suscep-

of their percentage distribution include 13 (8.6%) Pseudomonas

tibilities were significantly dependent on the type of pathogenic

aeruginosa from Rukungiri district, 12 (8.5%) from Masaka dis-

bacteria isolated and the type of antibiotics used.

trict, 10 (7.0%) E. coli from Masaka district, 17 (5.5%) S. pyogenes

Table 4

Susceptibility pattern of pathogenic bacterial isolates from Masaka district.

Organisms Antibiotics and number (%) positive

Met (10 ␮g) Cip (5 ␮g) Clox (5 ␮g) Ox (1 ␮g) Tet (10 ␮g) Gen (10 ␮g) Amx (25 ␮g) PenG (10 units)

S. mutans (n = 45) 8 (17.8) 22 (48.9) 0 (0.0) 5 (11.1) 7 (15.6) 30 (66.7) 7 (15.6) 14 (31.1)

S. pyogenes (n = 7) 3 (42.9) 7 (100.0) 2 (28.2) 3 (42.9) 0 (0.0) 6 (85.7) 2 (28.2) 2 (28.2)

S. aureus (n = 16) 3 (18.8) 12 (80.0) 5 (31.3) 3 (18.8) 4 (25.0) 11 (68.8) 7 (43.8) 8 (50.0)

P. aeruginosa (n = 2) 0 (0.0) 2 (100.0) 0 (0.0) 0 (0.0) 0 (0.0) 2 (100.0) 0 (0.0) 0 (0.0)

K pneumo (n = 12) 5 (41.7) 4 (33.3) 4 (33.3) 2 (16.7) 4 (33.3) 11 (91.7) 6 (50.0) 6 (50.0)

P. mirab (n = 4) 0 (0.0) 4 (100.0) 0 (0.0) 0 (0.0) 0 (0.0) 4 (100.0) 2 (50.0) 2 (50.0)

E. coli (n = 10) 3 (30.0) 7 (70.0) 0 (0.0) 0 (0.0) 3 (30.0) 10 (100.0) 3 (30.0) 6 (60.0)

B. subtilis (n = 4) 2 (50.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 4 (100.0) 4 (100.0) 2 (50.0)

B. cereus (n = 2) 0 (0.0) 0 (0.0) 2 (100.0) 2 (100.0) 2 (100.0) 0 (0.0) 2 (100.0) 0 (0.0)

B. catars (n = 14) 6 (42.9) 8 (57.1) 3 (21.4) 6 (42.9) 6 (42.9) 7 (50.0) 5 (35.4) 4 (28.6)

Diphth (n = 7) 2 (28.6) 4 (57.1) 0 (0.0) 3 (42.9) 0 (0.0) 6 (85.7) 0 (0.0) 2 (28.6)

Key: Met, Methicillin; Cip, Ciprofloxacin; Clox, Cloxacillin; Ox, Oxacillin; Tet, Tetracycline; Gent, Gentamycin; Amx, Amoxycillin; Pen G, Penicillin G; S. mut, Streptococcus

mutans; S. pyogenes, Streptococcus pyogenes; S. aureus, Staphylococcus aureus; P. aerug, Pseudomonas aeruginosa; K. pneumo, Klebsiella pneumoniae; P. mirab, Proteus mirabilis;

E. coli, Escherichia coli; B. subtilis, Bacillus subtilis; B. cereus, Bacillus cereus; B. catars, Brahmalella catarrhalis; Diphth, Diphtheroids. n = 123 and p < 0.05.

E. Agwu et al. / Oral Science International 12 (2015) 59–66 63

Table 5

Susceptibility pattern of isolates from Mbarara districts.

Organisms n = 208

Antibiotics and number (%) positive

Met (100 ␮g) Cip (5 ␮g) Clx (300 ␮g) Ox (1 ␮g) Ccl (30 ␮g) Gent (100 ␮g) Ery (5 ␮g) Amx (25 ␮g)

K. pneumo (n = 13) 0 (0.0) 9 (69.2) 6 (46.2) 0 (0.0) 6 (46.2) 12 (92.3) 0 (0.0) 5 (38.5)

S. mutans (n = 96) 26 (27.1) 80 (83.3) 60 (62.5) 25 (26.0) 30 (31.3) 96 (100.0) 11 (11.5) 5 (5.2)

NH strept (n = 14) 0 (0.0) 9 (64.3) 14 (100.0) 0 (0.0) 7 (50.0) 13 (92.8) 13 (92.8) 0 (0.0)

S. pyogenes (n = 17) 3 (17.6) 10 (58.8) 6 (35.5) 0 (0.0) 10 (58.8) 17 (100.0) 6 (35.2) 0 (0.0)

E. coli (n = 19) 0 (0.0) 12 (63.2) 10 (52.6) 0 (0.0) 13 (69.4) 18 (94.7) 0 (0.0) 9 (47.5)

S. aureus (n = 35) 0 (0.0) 15 (42.9) 0 (0.0) 0 (0.0) 20 (57.1) 33 (94.3) 16 (45.7) 0 (0.0)

B. catars (n = 14) 0 (0.0) 7 (50.0) 0 (0.0) 0 (0.0) 10 (71.4) 13 (92.9) 13 (92.9) 2 (14.3)

Key: Met, Methicillin; Cip, Ciprofloxacin; Clx, Cephalexin; Ox, Oxacillin; CCL, Cefaclor; Gent, Gentamycin; Amx, Amoxycillin; Ery, Erythromycin; S. mutans, Streptococcus

mutans; S. pyogenes, Streptococcus pyogenes; S. aureus, Staphylococcus aureus; K. pneumo, Klebsiella pneumoniae; E. coli, Escherichia coli; B. catars, Brahmalella catarrhalis. Using

RBD and FLSD, there was a significant difference in the effect of the antibiotics when compared between different pathogenic bacteria (a) and within each bacterium (b). (%)

Percentage-sensitive.

3.5. Susceptibility status of pathogenic bacteria from Mbarara the 83 K. pneumoniae isolated, 73 (86.7%) were susceptible to gen-

patients tamycin whereas other antibiotics used were poorly active against

K. pneumoniae. Out of the 34 strains of S. mutans isolated, 30

Table 5 shows the summary of susceptibility results of isolates (88.2%) were susceptible to gentamycin and 20 (58.9%) were sus-

obtained from Mbarara district against selected representative ceptible to erythromycin. All other antibiotics used were poorly

antimicrobial agents. Out of the 13 strains of K. pneumoniae iso- active against B. cereus. Out of the 18 nonhemolytic Streptococ-

lated, 12 (92.3%) were susceptible to gentamycin, nine (69.2%) cus isolates, 17 (94.4%) strains were susceptible to gentamycin.

were susceptible to ciprofloxacin, and all 13 (100%) were resis- Out of the 13 strains of P. aeruginosa isolates, 12 (92.3%) were

tant to methicillin, oxacillin, and erythromycin, respectively. All susceptible to gentamycin and eight (61.5%) were susceptible to

the 96 (100%) strains of S. mutans were susceptible to gen- ciprofloxacin. Gentamycin, ciprofloxacin, and erythromycin were

tamycin, 80 (83.3%) strains were susceptible to ciprofloxacin, and among the most effective drugs used against the pathogenic bacte-

60 (62.5%) were susceptible to cloxacillin. All the 14 (100%) strains rial isolates. The pattern of observed antibacterial susceptibilities is

of nonhemolytic Streptococcus were susceptible to cloxacillin, 13 significantly dependent on the type of pathogenic bacteria isolated

(92.8%) strains were susceptible to gentamycin and erythromycin, and the type of antibiotics used.

nine (64.3%) strains were susceptible to ciprofloxacin, and seven

(50.0%) were susceptible to cefaclor. It can be seen that the 4. Discussion

quinolones and the aminoglycosides appear to be very effec-

tive against predominant pathogenic bacterial isolates, while Although studies on the pattern of microbial colonization of

the emergence of resistance was recorded by K. pneumoniae the oral mucosa and antimicrobial susceptibility are abundant,

against each of methicillin, oxacillin, and erythromycin, respec- persistent oral lesions continue to intensify among patients with

tively. Antibacterial susceptibilities were significantly dependent HIV/AIDS receiving routine antimicrobial treatment in resource-

on the type of pathogenic bacteria isolated and the type of antibi- limited settings, emphasizing the need for an in-depth laboratory

otics used. investigation for microbial etiology. It appears that broadening the

treatment regimen for oral lesions to include pathogenic bacteria

3.6. Susceptibility status of pathogenic bacteria from Rukungiri etiology could help in the reduction of persistent oral lesions among

patients recipients of antimicrobial agents. Mapping the oral pathogenic

bacterial disease is important because the oral cavity is a known

As shown in Table 6, which depicts the summary of susceptibil- potential source of systemic disease especially in the immuno-

ity results of pathogenic bacteria obtained from Rukungiri district, compromised individuals [6,20]. The observation in this study, in

all five (100%) strains of E. coli were susceptible to gentamycin, which females were simply more in number than males, is the

and four (80.0%) strains were susceptible to ciprofloxacin. Out of fact that gender poses a high risk in HIV distribution because

Table 6

Susceptibility pattern of 126 pathogenic bacterial isolates from Rukungiri district.

Organisms Antibiotics and number (%) positive

Met (10 ␮g) Cip (5 ␮g) Clox (5 ␮g) Ox (1 ␮g) CCL (30 ␮g) Gent (10 ␮g) Amx (25 ␮g) Min (5 ␮g) Ery (5 ␮g)

E. coli (n = 5) 2 (20.0) 4 (80.0) 0 (0.0) 0 (0.0) 0 (0.0) 5 (100.0) 0 (0.0) 0 (0.0) 0 (0.0)

K. pneum (n = 83) 0 (0.0) 0 (0.0) 2 (2.4) 10 (12.0) 0 (0.0) 73 (86.7) 21 (25.3) 31 (37.3) 31 (37.3)

S. mutans (n = 34) 0 (0.0) 0 (0.0) 0 (0.0) 3 (8.8) 0 (0.0) 30 (88.2) 0 (0.0) 0 (0.0) 20 (58.9)

B. cereus (n = 18) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 7 (38.9) 0 (0.0) 0 (0.0)

NH strept (n = 18) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 17 (94.4) 2 (11.1) 0 (0.0) 4 (22.2)

B. subtilis (n = 2) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)

P aerugin (n = 13) 0 (0.0) 8 (61.5) 0 (0.0) 2 (15.4) 8 (61.5) 12 (92.3) 0 (0.0) 3 (23.1) 8 (61.5)

P. mirab (n = 25) 0 (0.0) 18 (72.0) 0 (0.0) 3 (12.0) 14 (56.0) 23 (92.3) 0 (0.0) 17 (68.0) 7 (28.0)

S. aureus (n = 11) 4 (36.4) 7 (63.6) 0 (0.0) 5 (45.5) 7 (63.6) 9 (81.8) 0 (0.0) 4 (36.4) 6 (54.5)

B. catarrs (n = 9) 6 (66.7) 0 (0.0) 2 (22.2) 0 (0.0) 0 (0.0) 7 (77.8) 0 (0.0) 0 (0.0) 2 (22.2)

Key: Met, Methicillin; Cip, Ciprofloxacin; Clox, Cloxacillin; Ox, Oxacillin; CCL, Cefaclor; Gent, Gentamycin; Amx, Amoxycillin; Min, Minocycline; Ery, Erythromycin; S. mutans,

Streptococcus mutans; S. aureus, Staphylococcus aureus; P. aerugin, Pseudomonas aeruginosa; K. pneum, Klebsiella pneumoniae; P. mirabilis, Proteus mirabilis; E. coli, Escherichia coli;

B. subtilis, Bacillus subtilis; NH strept, non-hemolytic Streptococcus; B. catars, Brahmalella catarrhalis. Using RBD and FLSD, there was a significant difference in the effect of the

antibiotics when compared between different pathogenic bacteria (a) and within each bacterium (b). (%) Percentage-sensitive.

64 E. Agwu et al. / Oral Science International 12 (2015) 59–66

in sub-Saharan Africa males easily engage in risky multiple sex may have contributed to our observed 31% S. mutans prevalence in

practice while females are denied the chance to negotiate for oral lesions of patients with HIV/AIDS in this region [36–39].

sex [35]. However, we did not test for the statistical significance TASO record made available to us clearly indicated that a

between the observed higher females than males and the pattern monthly visit to >60% of participants in Mbarara region constituted

of bacteria distribution/sensitivity, among our randomly selected poor oral care because 4 weeks was too long to ensure adherence.

population with HIV/AIDS in Uganda. This may warrant further Those who missed medical attention due to an increasing number

study. of new cases had to wait until the next 4 weeks because they could

Oral pathogenic bacteria recovered from the mouth of patients not afford to come to the regional clinics. Recommended supple-

with HIV/AIDS varied significantly among participating districts, mentation of the nystatin and co-trimoxazole routine drugs with

with the highest prevalence being 86.6% pathogenic bacterial iso- azoles, quinolones, and newer generation cephalosporins was sim-

lates from Masaka patients followed by 82.9% from Rukungiri ply impossible and not adhered to, due to the low socioeconomic

patients and 66.9% from Mbarara patients. The observed pattern status of the patients already devastated by the HIV pandemic.

of variation is interestingly unique because Mbarara patients were Although limited resources hindered us from getting more

expected to show a higher pathogenic bacterial prevalence com- details of microbial characteristics, standard and calibrated phe-

pared to patients from Masaka and Rukungiri districts in particular, notypic microbiological methods were used to aseptically collect

because most participants from Mbarara district came from remote and analyze clinical specimens for pathogenic bacterial identity.

areas to reach villages where TASO provides monthly clinic-style It is therefore not clear if the method of microbial retrieval from

services to participants, while Rukungiri and Masaka provide daily oral lesions played any role in the observed variations in the dis-

routine oral care at the clinic. tribution of nonoral pathogenic bacteria as shown in Table 1. The

Oral care alone may therefore not explain completely oral observed pattern of nonoral pathogenic bacteria colonizing the oral

pathogenic bacterial prevalence because a higher oral care at lesions (Proteus species, S. aureus, P. aeruginosa, E. coli, diphtheroids,

Masaka and Rukungiri districts leads to a higher pathogenic bac- and nonhemolytic Streptococcus species) is in line with the Brazil-

terial prevalence compared to Mbarara, which had a lower rate ian report [40]. The observed pattern of oral pathogenic bacterial

of oral care and a lower pathogenic bacterial prevalence. There- distribution may also be due to the underlying diabetic condition

fore, other underlying factors [19] such as microbial (pathogenic reported among the participating HIV-infected patients [41].

bacteria), immunological, and nonmicrobial factors (trauma, drugs, S. aureus isolates are now more frequently isolated from the oral

hematinic deficiency, sodium-lauryl-sulfate-containing tooth- cavity than anticipated, and they are the known potential sources

paste, tobacco, and stress), not measured by this study, may have of systemic (including prosthetic joint and hip) infections [42,43].

played a role in this conflicting but interesting observation. The Oral cavity Staphylococci are a potential source of prosthetic joint

microbial population of the oral cavity remains relatively constant infection. The mean 10.2% isolates in all the districts surveyed

in health; however, a variation in pathogenic bacterial popula- are lower than the previous reports of 20% [42] and 2830% [43].

tion seen in the studied districts may suggest an emergence or a Although there were no data to confirm if S. aureus was colonizing

progress of oral disease [23]. or infecting the oral cavity, the role of S. aureus in several diseases

The roles of pathogenic bacteria in oral infections are still highly of the oral mucosa merits further investigation. The health risk of

debated compared to oral Candida. The observed significant influ- enteric pathogenic bacteria recovered from the oral cavity may

ence of the study districts on the pattern of pathogenic bacteria be explained by the fact that nonpathogenic bacteria may show

recovered from the oral lesions of patients with HIV/AIDS may be some pathogenicity through the trans-species transfer of genetic

explained by the known idiosyncratic response of diverse popula- material, a phenomenon already published elsewhere [44].

tion to different diseases and drugs, thus depicting the distribution The oro-facial soft and hard tissues of participants <20 years of

of the two major ethnics (Bantus and Nile Hermites) made of five age were not destroyed to have suggested Noma or cancrum oris,

tribes (Banyankole, Baganda, Bahororo, Bakiga, and Banyarwanda), and there was no osteomyelitis of the jaws to have explained the

which inhabit the study area [14–16,23]. The observed prevalence isolation of up to 11% S. aureus from among the isolates [45,46].

of 31% S. mutans is strange because S. mutans is rarely associated We excluded Mycopathogenic bacteria screening due to poor facil-

with oral mucosal infections, and it may be regarded as baseline ities and the complications involved in the clinical definition of skin

data, as mainstream search does not seem to have a previous study. and oral infections of Mycopathogenic bacterial species [3,47]. There

We could not clarify whether the presence of S. mutans in the oral was no classical chronic, nonhealing, deep, solitary oral ulceration

mucosal lesions indicates an emergence of alliance between fungal to have suggested oral syphilis [4]. There were no data to con-

and pathogenic bacterial agents in causing persistent oral lesions firm salivary gland pathogenic bacterial infection (sialadenitis) of

of HIV/AIDS. 8.3% of the patients with Xerostomia. Susceptibility, intermediate,

TASO offers relief and health package to its clients with HIV/AIDS and resistance of isolates to used antibiotics were defined using

in both the clinics and the outreach centers. The available health standard guidelines [31,32].

package at the time of this study excluded dental care but cov- Susceptibility in this study implied that isolates are inhibited by

ered health talks, routine clinical examination, administration the usually achievable concentration of antimicrobial agents when

of co-trimoxazole, nystatin, and combined antiretroviral ther- the recommended dosage is used for the site of infection. An inter-

apy (zidovudine, nevirapine, and stavudine), given in selection to mediate included isolates with antimicrobial agent’s minimum

patients whose CD4 cells are <200. On the other hand, relief pack- inhibitory concentrations (MICs) that approach usually attainable

ages included food supplements and TV shows aimed at reducing blood and tissue levels and for which response rates may be lower

stigma and encouraging infected people to learn how to live with than for susceptible isolates. It implies clinical efficacy in body sites

HIV virus. where drugs are physiologically concentrated or when a higher

All the patients who received TASO health and relief package had than normal dosage of drugs can be used. Resistance implies that

relatively poor oral hygiene, had no oral parasites, had low socioe- isolates are not inhibited by the usually achievable concentrations

conomy, used sucrose-rich antiretroviral therapy such as zidovu- of agents with normal dosage schedules, and/or that demonstrates

dine, used sugared milk contained in the TASO’s daily morning tea, a zone diameter that falls in the range where specific microbial

and frequently took carbohydrates as staple food (locally called resistance mechanisms are likely, and clinical efficacy of the agents

“matooke”). These factors are in line with oral conditions reported to against the isolates has not been reliably shown in treatment stud-

encourage a high prevalence of S. mutans in oral infections, and they ies. In this study, both susceptible and intermediately susceptible

E. Agwu et al. / Oral Science International 12 (2015) 59–66 65

were recorded as susceptible so that we showed susceptibility pro- HIV whose cooperation made this study possible, and we also thank

file of isolates in Tables 4–6. the dentistry team who assisted in the oral examination of the

The result of penicillin resistance in oral pathogenic bacterial clients with HIV.

infections demonstrated using oxacillin, methicillin, cloxacillin,

penicillin G, and amoxicillin, as shown in Tables 2–4, was in line References

with previous reports [48,33]. The addition of oxacillin in the

Kirby–Bauer modified disk diffusion experiment validates the use- [1] Agwu E, Ihongbe JC, Tirwomwe JF, et al. Appraisal of oral lesions status of

HIV/AIDS patients in South Western Uganda. Braz J Oral Sci 2008;7:1591–5.

fulness of disk diffusion as a screening method for the detection

[2] Holbrook WP. Pathogenic bacterial infections of the oral soft tissues. Curr Opin

of pathogenic bacterial resistance to penicillin. Although penicillin

Dent 1991;1:404–10.

resistance by pathogenic bacteria is usually a consequence of ␤- [3] Adalla SA, Garmole B. Tuberculous parotitis: two cases in Libyan patients. Br J

Clin Pract 1996;50:62–3.

lactamase production, the mechanism of Streptococcal resistance

[4] Gwanzura L, Latif A, Bassett M. Syphilis serology in HIV infection in Harare,

to penicillin centers on the alteration of the penicillin-binding pro-

Zimbabwe. Sex Transm Infect 1999;75:426–30.

teins found on the resistant Streptococci [48]. In all the districts, [5] Fox PC. Pathogenic bacterial infection of the salivary gland. Curr Opin Dent

1991;1:411–4.

as shown in Tables 4–6, gentamycin was the most effective drug

[6] Xiaojing L, Kristin MK, Leif T, et al. Systemic diseases

against all the oral pathogenic bacteria isolated, and this is in line

caused by oral infection. Clin Microbiol Rev 2000;4:547–58,

with most of our earlier reports [48,49]. The observed suscepti- http://dx.doi.org/10.1128/CMR.13.4.547-558.2000.

bility of different pathogenic bacteria to different antibiotics was [7] Wu T, Trevisan M, Genco RJ, et al. Periodontal disease and risk of cerebrovas-

cular disease: the first national health and nutrition examination survey and

significantly influenced by pathogenic bacterial strains and district

its follow-up study. Arch Intern Med 2000;160:2749–55.

of isolation.

[8] Buduneli N, Baylas H, Buduneli E, et al. Periodontal infections and pre-term low

An additional and interesting observation in this study is birth weight: a case–control study. J Clin Periodontol 2005;32:174–81.

[9] Petersen PE, Bourgeois D, Ogawa H, et al. The global burden of oral diseases and

that some pathogenic bacterial isolates were relatively more

risks to oral health. Bull World Health Org 2005;83:661–9.

resistant to oral antibiotics and more sensitive to intravenous

[10] Smith T, Mohan CV. HPV associated oral lesions among HIV/AIDS

drugs (Tables 4–6). In selection, some pathogenic bacteria also patients – a cross sectional study. BMC Infect Dis 2014;14(Suppl. 3):E31,

http://dx.doi.org/10.1186/1471-2334-14-S3-E31.

showed relative resistance to amoxicillin and tetracyclines while

[11] Adebola AR, Adeleke SI, Mukhtar M, et al. Oral manifestation of HIV/AIDS infec-

being more sensitive to ciprofloxacin and cefaclor, respectively. In

tions in paediatric Nigerian patients. Niger Med J 2012;53:150–4.

Uganda, there is no antibiotic prescription policy; thus, all antibi-

[12] Tamí-Maury IM, Willig JH, Jolly PE, et al. Prevalence, incidence, and

otics may be purchased across the counter of local drug vendors or recurrence of oral lesions among HIV-infected patients on HAART in

Alabama: a two-year longitudinal study. South Med J 2011;104(8):561–6,

pharmacy shops by anyone. It is clear that allowing the locals to

http://dx.doi.org/10.1097/SMJ.0b013e318224a15f.

purchase antibiotics without prescription may expose them to the

[13] Gemaque K, Nascimento GG, Junqueira JLC, et al. Prevalence of oral lesions in

risk of using sub-lethal dose to treat infections. This observation hospitalized patients with infectious diseases in Northern Brazil. Sci World J

may have impacted on the pattern of sensitivity reported in this 2014:5, http://dx.doi.org/10.1155/2014/586075 [article ID 586075].

study. [14] Roth RA, Luyendyk JP, Maddox JF, et al. Inflammation and drug idiosyncrasy. Is

there a connection? J Pharmacol Exp Ther 2003;307(1):1–8.

[15] Chalasani NP, Hayashi PH, Bonkovsky HL, et al. Diagnosis and management of

idiosyncratic drug-induced liver injury. Am J Gastroenterol 2014;109:950–66.

5. Conclusion

[16] Salkeld DJ, Padgett KA, Jones HJ. A meta-analysis suggesting that the rela-

tionship between biodiversity and risk of zoonotic pathogen transmission is

This study has revealed a wide array of potentially pathogenic

idiosyncratic. Ecol Lett 2013;16:679–86.

bacteria in the oral cavity of patients with HIV/AIDS, all of which [17] Eweka OM, Agbelusi GA, Odukoya O. Prevalence of oral lesions and the effects

of HAART in adult HIV patients attending a tertiary hospital in Lagos, Nigeria.

pose a real problem in the world of antimicrobial resistance, and

OJST 2012;2(3):200–5.

they also clearly provide a higher risk of systemic infectious dis-

[18] Jenkinson HF, Douglas LJ. Interactions between Candida Species and Pathogenic

eases in these populations with HIV/AIDS. Oral pathogenic bacteria bacteria. In: Brogden KA, Guthmiller JM, editors. Mixed infections. Polymicrobial

population varied significantly with participating districts depict- diseases. Washington, DC: ASM Press; 2002.

[19] Preeti L, Magesh KT, Rajkumar K, et al. Recurrent apht-

ing the distribution of the two major ethnics (Bantus and Nile

hous stomatitis. J Oral Maxillofac Pathol 2011;15(3):252–6,

Hermites) made of five tribes (Banyankole, Baganda, Bahororo, http://dx.doi.org/10.4103/0973-029X.86669.

Bakiga, and Banyarwanda). TASO health and relief package encour- [20] Renata S, Arnaldo FBA, Milton U, et al. Prevalence of “non-oral” pathogenic

bacteria in subgingival biofilm of subjects with chronic periodontitis. Braz J

aged a high prevalence of S. mutans in oral infections. Oral lesions

Microbiol 2006;37:208–15.

yielded a large proportion of nonoral pathogenic bacteria such

[21] Canedo-Guzmán˜ CB, Espinosa-Gutiérrez A, Guzmán-Murillo MA. Bacteriolog-

as P. mirabilis, nonhemolytic Streptococcus species, S. aureus, B. ical study of oral cavity of people of Mexican origin to determine aetiology

catarrhalis, P. aeruginosa, K. pneumoniae, E. coli, S. pyogenes, Diph- agents of human infections in hand bite. Cir Cir 2013;81:41–7.

[22] Tagg JR. Prevention of Streptococcal pharyngitis by anti-Streptococcus pyogenes

theroids, B. subtilis, and B. cereus. Some pathogenic bacterial isolates

bacteriocin-like inhibitory substances (BLIS) produced by Streptococcus saliva-

were relatively more resistant to oral antibiotics and more sensi-

rius. Indian J Med Res 2004;119(Suppl.):13–6.

tive to intravenous drugs. In selection, some pathogenic bacteria [23] Agwu E, Ihongbe JC, McManus BA, et al. Distribution of yeast species associated

with oro-pharyngeal candidiasis in HIV-infected patients in Southwest Uganda.

showed relative resistance to penicillins and tetracyclines while

Med Mycol 2011:1–5, http://dx.doi.org/10.3109/13693786.2011.604862.

being more sensitive to quinolones and cephalosporines, respec-

[24] Tirwomwe JF, Rwenyonyi CM, Muwazi LM, et al. Oral manifestation of HIV/AIDS

tively. Data on oral mucosal infections by other bacteria are in clients attending TASO clinics in Uganda. Clin Oral Invest 2007;11:3.

incomplete in developed countries, and they are virtually nonex- [25] Doméjean S, Zhan L, DenBesten PK, et al. Horizontal transmis-

sion of mutans streptococci in children. J Dent Res 2010;89(1):51–5,

istent in low- and middle-income countries, indicating the need for

http://dx.doi.org/10.1177/0022034509353400.

further epidemiological studies.

[26] Liu G, Saxena D, Deng H, et al. Effect of protease inhibitors on the quantita-

tive and qualitative assessment of oral microorganisms. FEMS Microbiol Lett

Conflict of interest 2010;312:63–70.

[27] Hasslöf P, Hedberg M, Twetman S, et al. Growth inhibition of

oral mutans Streptococci and Candida by commercial probio-

None declared.

tic lactobacilli – an in vitro study. BMC Oral Health 2010;10:18,

http://dx.doi.org/10.1186/1472-6831-10-18.

Acknowledgments [28] Ahn S-J, Ahn S-J, Browngardt CM, et al. Changes in biochemical and phenotypic

properties of Streptococcus mutans during growth with aeration. Appl Environ

Microbiol 2009;75(8):2517–27.

This research was supported in part by the Kampala Interna- [29] Krieg NR, Brenner DJ, Staley JR. Bergey’s manual of systematic bacteriology. New

York: Springer-Verlag; 2005.

tional University, Western Campus. We thank all TASO clients with

66 E. Agwu et al. / Oral Science International 12 (2015) 59–66

[30] Barrow HI, Feltham RKI. Cowan and Steels manual for identification of medical [40] Souto R, Andrade AFB, Uzeda M, et al. Prevalence of “non-oral” pathogenic

pathogenic bacteria. 3rd ed. Cambridge University Press; 1993. bacteria in subgingival biofilm of subjects with chronic periodontitis. Braz J

[31] Clinical Laboratory Standards Institute. Manual of antimicrobial susceptibility Microbiol 2000;37:208–15.

testing QW 25.5 M6 M2945 2005] Cavalieri, Stephen J. II. American Society for [41] Sharma M, Tiwari SC, Singh K, et al. Occurrence of pathogenic bacterial flora

Microbiology; 2005, ISBN 1-55581-349-6 [CLSI document/book]. in oral infections of diabetic and non-diabetic patients. Life Sci Med Res 2011.

[32] Clinical Laboratory Standards Institute. Performance Standard for antimi- LSMR-32.1.

crobial susceptibility testing: eleventh informational supplement. Wayne [42] Smith AJ, Robertson D, Tang MK, et al. Staphylococcus aureus in the oral cav-

Pennsylvania Clinical Laboratory Standards Institute; 2007 [CLSI documents ity: a three-year retrospective analysis of clinical laboratory data. Br Dent J

M100-S17]. 2003;195:701–3, http://dx.doi.org/10.1038/sj.bdj.4810832.

[33] Agwu E, Ihongbe JC, Okogun GRA, et al. Chromobacterium violacium associated

[43] Berbari EF, Osmon DR, Carr A, et al. Dental procedures as risk factors for pros-

with recurrent vaginal discharge among apparently healthy females in Ekpoma

thetic hip or knee infection: a hospital-based prospective case–control study.

Nigeria. Online J Health Allied Sci 2007;1:2.

Clin Infect Dis 2010;50:8–16.

[34] Randomized Block Designs. 5.3.3.2. NIST/SEMATECH e-handbook of statistical

[44] Inomata K, Nishikawa M, Yoshida K. The yeast Saccharomyces kluyveri as a recip-

methods; 2006. http://www.itl.nist.gov/div898/handbook [cited 2006].

ient eukaryote in transkingdom conjugation: behavior of transmitted plasmids

[35] Agwu E, Pazos V, Ihongbe JC, et al. Appraisal of the inherent socio-demographic

in transconjugants. J Bacteriol 1994;176:4770–3.

dynamics of HIV/AIDS epidemic in four districts of South-Western Uganda.

[45] Falkler Jr WA, Enwonwu CO, Idigbe EO. Microbiological understandings and

SAHARA J 2011;8:3:150–5.

mysteries of Noma (cancrum oris). Oral Dis 1999;5:150–5.

[36] Agwu E, Ihongbe JC, Pazos V, et al. Zero prevalence of parasites associated with

[46] Asseri L, Nguvumali HI, Matee MIN. Chronic osteomyelitis of the mandible

oral lesions of HIV infected and AIDS patients in South Western Uganda. Afr

following tooth extraction in HIV infection. Oral Dis 1997;3:193–5.

Health Sci 2009;9:239–44.

[47] Okodua MA, Nwobu GO, Tatfeng YM, et al. Incidence of HIV-related pulmonary

[37] Hernández Juyol M. Manifestaciones orales de la infección por el VIH en Odon-

tuberculosis in Edo State Nigeria. Shiraz Electr Med J 2004;51:1–8.

topediatría. RCOE 1999:4157–67.

[48] Agwu E, Agba MI, Nwobu GO, et al. Antimicrobial resistant profile of Streptococ-

[38] Costa LR, Villena RS, Sucasas PS, et al. Oral findings in paediatric AIDS:

cus pneumoniae isolated from suspected tuberculosis patients in Ekpoma and

a case control study in Brazilian children. ASDC J Dent Child 1998;65:

its environs. Shiraz Electr Med J 2004;5:3.

186–90.

[49] Agwu E, Agba MI, Esumeh FI, et al. Susceptibility status of Streptococcus pneu-

[39] Hicks MJ, Flaitz CM, Carter AB, et al. Dental caries in HIV-infected children: a

moniae against streptomycin and rifampicin commonly used for pulmonary

longitudinal study. Pediatr Dent 2000;22:359–64. PMID:11048301.

tuberculosis. J Appl Basic Sci 2005;3:33–6.