Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411110EnglishN2019May30HealthcareHost Bacterial Interactions in Periodontal Disease - An Overview English0106M. SujeethaEnglish Anitha LogaranjaniEnglish Vijayalakshmi R.English RajapriyaEnglish Jaideep MahendraEnglishThere are several microbiological and immunological aspects involved in the interactions between bacteria and the host during the initiation and progression of periodontal disease. Periodontal therapy lacks the diagnostic capability to tailor predictable therapy for the individual. An understanding of the various mechanisms involved will enable us to plan better therapeutic approach that aims in the eradication of the disease process. In future, we can improve the host’s ability and thereby prevent the colonization of harmful periodontal pathogens. This review article provides the current state of the art in regard to bacterial host cell interactions that take place during periodontal disease pathogenesis EnglishAdhesins, Evasion, Immunity, Invasion, P. gingivalisIntroduction Periodontitis is a complex multifactorial infectious disease of the supporting structures of the teeth characterized by destruction of alveolar bone and connective tissue. The primary etiologic agents for causing peritonitis are the specific periodontopathic bacteria and their virulence factors. The collective interaction of these etiologic agents and the host defence mechanism responses along with the environmental factors play an important role in the onset and progression of the disease. This review article provides the current state of the art in regard to bacterial host cell interactions that take place during periodontal disease pathogenesis. Microbiological aspects of the microbial host interactions Dental plaque forms an integral part of the microbiological aspect of periodontal disease1. The process of plaque formation can be divided into three major phases The formation of the pellicle on the tooth surface Initial adhesion and attachment of the bacteria Colonization and plaque maturation These processes have been extensively described in the microbiological aspects of the host microbial interactions as: Bacterial colonization and survival in the periodontal region Microbial mechanisms of host tissue damage Bacterial colonization and survival in the periodontal region Periodontal disease progression is dependent on the simultaneous recurrence of a number of factors. The bacterial species which enhance infection must be present in the local environment or it should not inhibit the pathogen’s activity. The host must be susceptible both locally and systemically. The environment also must be promotive to the expression of virulence factors by the pathogen. The virulence factors are the properties of the microorganism that enable it to cause disease. They enhance the microbial activity on periodontal tissues. They can be broadly categorised into two groups1: Factors that enable a bacterial species to colonize and invade host tissues and Factors that enable a bacterial species to cause tissue damage directly or indirectly. Adherence Adherence represents a virulence factor for periodontal pathogens. Infections are generally initiated by bacteria to a wide variety of biotic and abiotic host surfaces2. Many pathogenic bacteria have developed incredibly large and diverse array of adhesive molecules, called adhesins, on their surfaces. The adhesins interact with a variety of host components and are responsible for recognizing and binding to specific host cell receptor moieties. Adhesins can be subdivided into two major classes3: Fimbrialadhesins Non-fimbrialadhesins Fimbrialadhesins In the bacterial pathogenesis or infection, adherence is an essential step required for colonizing a new host. Fimbrial adhesins are appendages or cell surface components of bacteria which facilitates bacterial adhesion to other cells or to inanimate surfaces.They are a type of virulence factor. In gram-negative bacteria, the fimbriae function as adhesins. In many cases, the actual adhesin is a minor subunit protein at the tip of the fimbriae. Ingram-positive bacteria, the specific adhesion is a protein or polysaccharide surface layer. Fimbrial adhesins in gram negative bacteria are classified into five major classes based on their biosynthetic pathway: Chaperone – usher pili (CU pili) Curli Type IV pili Type III secretion pili Type IV secretion pili Chaperone-usher pili (CU pili) Pili and fimbriae are thin, filamentous, proteinaceous surface appendages that protrude from the surface of many different bacterial species and are prominent on gram negative bacteria where they are anchored within the outer membrane. In CU pili, a periplasmic chaperone and outer membrane assembly platform known as “usher” are strictly required for the pilus assembly. Curli Curli are thin aggregative fimbriae that were identified as a new type of fimbrialadhesin expressed on the outer surfaces of some Enterobacteriae. Type IV pili Type IV pili are extruded across the outer membrane and form long and flexible surface appendages. Type III secretion system It is a complex assembly that spans the inner membrane, periplasmic space, outer membrane and cellular membrane of the host. Several species of gram negative bacteria like the Salmonella, Shigella, Yersenia, Escherichia and Pseudomonas use this to inject bacterial proteins as a way to translocate substrates directly into the cytoplasm of the host cell where they exert a broad range of virulence functions. Type IV secretion system pili This not only translocates effectors into eukaryotic cells, but also mediates the transfer of a single stranded DNA molecule, resulting in genetic colonization of the host. Gene acquisition is an important adaptive mechanism that enables pathogens to respond to a changing environment during invasion of the host and T4SS pili are thought to be able to establish stable and specific contacts between cells before substrate transfer. Non fimbrial adhesins:  These adhesins recognise many different elements on host cell surfaces, including components of the extracellular matrix such as collagen, laminin, elastin, proteoglycans, hyaluronan, vitronectin, fibrinogen and fibronectin. Types of non fimbrial adhesins: Auto transporter adhesins Outer membrane adhesins Secreted adhesins Those associated with biofilm formation Autotransporter adhesins They constitute a family of outer membrane/secreted proteins used for translocation to the surface of the bacterium. Outer membrane adhesins These outer membrane proteins contain a beta-barrel structure and function as a membrane anchor for adhesins. Type 1 secretion system adhesin It is a translocator contained in gram negative bacteria which allows secretion of proteins of various sizes and functions from the cytoplasm to the extracellular medium in a single step. Adhesins associated with biofilm formation Although exopolysaccharides are important matrices to develop biofilm, a large family of adhesins, termed biofilm associated proteins, also play a leading role in the formation of microbial biofilms. Adhesins of periodontal bacteria Adherence of bacteria to mucosal and tooth surfaces, as well as bacterial coaggregation, are essential steps for colonization with various oral bacterial species4. Fimbrial adhesins Porphyromonas gingivalis expresses two distinct fimbriae-molecules on its cell surfaces: one is composed of a subunit protein encoded by the fimA gene and it is called the long, or major fimbriae, while the other consists of subunit minor fimbrial protein encoded by the mfa1 gene and it is called the short, minor, or mfa fimbriae. Aggregatibacter actinomycetemcomitans has both fimbrial and non-fimbrial adhesins on its surface. The bacterium possesses long bundles of pili. Prevotella intermedia has four morphologically distinct types of fimbriae and are designated as types A, B, C and D based on their size. Fusobacterium nucleatum has Fusobacterium adhesion A, which is a novel fimbrial adhesion protein. It exists in two forms, namely the non-secreted form and the secreted mature form. In oral actinomyces species, A. viscosus expresses two distinct types of fimbriae (Type 1 and 2) which are involved in adherence to host tissues and inter bacterial coaggregation. Other actinomyces species lack fimbriae and their related genes. Non fimbrial adhesins P. gingivalis has gingipain complex. The gingipains or extracellular cysteine proteinases are the product of three genes: two that code for arginine-specific genes (RgpA and RgpB) and one that code for lysine-specific proteinase gene (Kgp). Gingipains are involved in the virulence potential of P. gingivalis. It influences the binding of the bacterium to the host tissues5. Hemin-binding protein (HBP) 35, may also be an essential protein for bacterial survival in evasion from environmental stress in Porphyromonas gingivalis. It binds hemin and expresses haemagglutination activity. HBP 35 is involved in multiple P. gingivalis binding to erythrocytes and host epithelial gingival cells. The virulence of P. gingivalis may either directly or indirectly be affected by this protein. HBP35 is also involved with other bacteria6. The adherence of Treponemadenticola includes the number of components in the outer membrane which are the chymotrypsin-like protease, (also named dentilisin), major outer sheath protein, oligopeptide-binding protein ortholog, and a leucine-rich repeat protein. The non fimbrial adhesins of  Tannerella forsythia is BspA, surface associated protein, encoded by the bspA gene and S-layer proteins, outside the outer membrane of the organism. Non-fimbrial adhesins of Aggregatibacter actinomycetemcomitans has been identified on the surface of A. a, including three auto-transporter adhesins, Aae, ApiA, extracellular matrix protein adhesion A and various polysaccharides. In Fusobacterium nucleatum, two distinct types of adherence have been found and they are classified based on their inhibition mode using either D-galactose or L-arginine. Adherence to gram positive early colonizing species is associated with arginine inhibiting interactions whereas adherence to predominantly gram-negative late colonizing bacteria is associated with galactose-inhibiting interactions. Bacterial evasion of host defense mechanism To survive in the periodontal environment, bacteria must neutralize or evade the host defence mechanisms involved in bacterial clearance and killing. The host tissue invasion occurs by The initial interaction with epithelial cells and Through various bacterial entry mechanisms. Initial interaction with epithelial cells Interactions between bacteria and their surrounding epithelium are critical factors in bacterial infections. Adherence to epithelial cells is important for colonization. Besides serving as a physical barrier, the epithelium also functions as a sensor for the presence of bacteria. The direct physical contact between bacteria and the mucosal surface triggers the expression of a variety of immune response mediators from the epithelial cells. Bacterial entry mechanism Traverse of the plasma membrane by small molecules, such as ions and sugars, is easily mediated through various transmembrane channels and pumps in the bilayer but the transport of macromolecules through the plasma membrane requires endocytosis7. In endocytosis, membrane domain invaginate and are then pinched off from the inner side of the plasma membrane and transported within the cell. Most invasive bacteria utilise endocytosis to become engulfed by the host cells. Entry mechanism of various periodontal bacteria P. gingivalis Entry mechanism of P. gingivalis exploits cellular endocytosis to enter a cell in a trigger mechanism like manner. It is considered to be mediated by the interaction between bacterial fimbriae and α5β1 integrin. P. gingivalis releases outer membrane vesicles in an extracellular manner, after which the bacteria retain the full range of outer membrane constituents. Intracellular P. gingivalis is localised in various cellular compartments which is specific to the type of the host cell. P. gingivalis is engulfed by endocytic vacuoles for entry, it must exit from endocytic vacuoles to localise in the cytoplasm. Following internalization, P. gingivalis may be able to replicate inside the cell. Some intracellular P. gingivalis are able to exit from the primarily infected host cell into the intercellular space and can enter new host cells, which enables futher penetration into host cells in a trans-cellular manner. Aggregatibacter actinomycetemcomitans This bacterium can exploit cellular endocytosis to enter cells in a trigger mechanism like manner similar to P. gingivalis. The entry process is initiated by direct interactions between bacterial adhesins and cellular receptors. The bacteria are captured by ruffled pseudopodia and they are probably internalized via an endocytic pathway by an actin dependent mechanism. Those that are captured by endocytic compartments are suggested to destroy the compartment membranes, based on the secretion of phospholipase C and exit to the cytoplasm. Then it reportedly undergoes rapid multiplication and subsequently propagates in an intercellular manner. The bacteria residing in the cytoplasm can spread intracellularly to adjacent epithelial cells via intercellular protrusions. The direct cell-to-cell spreading allows bacteria to disseminate in infected tissues. Some strains were found to be internalized through actin-independent, receptor-mediated endocytosis. Other bacteria The “S- layer” isolated from Tannerella forsythia is shown to mediate haemagglutination, adhesion or invasion of epithelial cells. This layer is composed of two glycoproteins of molecular mass 200 and 210 kDa. The entry mechanism of P. intermedia is because of its fimbriae. The type C fimbriae, present in P. intermedia enables it to bind to human buccal epithelial cells more avidly than the other strains. Entry of Fusobacterium nucleatum into human gingival epithelial cells in-vitro was accompanied by an increased secretion of interleukin-8 from the epithelial cells. Microbial mechanisms of host tissue damage Tissue damage is mainly caused by microbial virulence factors. Virulence factors are specific to each pathogenic bacteria and include sustenins, endotoxins, adhesins, invasins, bacteriocins, leukotoxin, Fc-binding proteins, immunosuppressive proteins, cytotoxins, collagenase, extracellular membranous vesicles, inhibitors of polymorphonuclear leukocytes function, proteases, fibronectin, laminin, fibrinogen, dentilisin and various fimbriae. Immunologic aspects of the microbial host interaction Innate immunity and adaptive immunity are two fundamental aspects of the immune system response to invading microbes8. When there is a bacterial infection, in periodontal pathogenesis the role of immune system involves the following: firstly the innate factors such as a compliment, resident leukocytes and especially the mast cells play an important role in signalling endothelium thus initiating the inflammation; then the acute inflammatory cells protect the local tissues by controlling the periodontal microbiota within the gingival crevice and junctional epithelium; finally the chronic inflammatory cells, macrophages and lymphocytes protect the entire host from within the subjacent connective tissues and do all that is necessary to prevent a local infection from becoming systemic and life threatening, including the sacrifice of local tissues. The innate defence system Gingival crevice is the first region of the periodontium that comes into contact with microorganism that attempts to attach and colonize the area. Gingival epithelium provides a physical barrier to infection and has an active role in the innate host defence. The innate mechanisms which serve to prevent such microbial colonisation include, the mechanical washing effect of saliva and GCF and the detrimental effect of these fluid constituents on the bacterial growth. The cells of the epithelium can respond to the bacteria by producing antimicrobial peptides including beta defensin and the release of interleukin-8 and interleukin-13. The polymorphonuclear leukocytes appear to play a key role in the maintenance of periodontal health, as molecular defects in PMN’s, with a variety of functional consequences can result in accelerated periodontitis. Important component of innate immune response is the toll like receptors. When microorganisms enter the tissue after penetrating the epithelial barrier, they are encountered by tissue macrophages, mast cells and immature dendritic cells. Apoptotic particles generated by normal tissue turnover and particles that are indicative of infection must be distinguished by these cells. The molecules mainly responsible for making this pivotal distinction are those of the family of Toll-like receptors9. Members of the toll-like receptor family are responsible for the recognition of pathogen associated molecular patterns expressed by a wide spectrum of infectious agents. The signalling pathway of toll-like receptor consists of the MyD88-dependent pathway and the MyD88-independent pathway. The adaptive defence system The adaptive response utilizes strategies of recognition, memory and binding to support the effector systems in the elimination of challenging elements. Parts of the adaptive response in periodontitis are: the nature of the lymphocyte type; antigen recognition by the toll-like receptor; cytokine profiles of  T helper cells and autoimmune reactions that may influence the adaptive response in periodontitis. The neutrophils reach the site of host bacterial interaction because of increased vascular permeability and engorgement of blood vessels produced by the inflammatory changes that occur due to the induction of cytokines by host cells as a result of the endotoxins produced by bacteria10. The antigen presentation is one of the major component of acquired immune response where the recognition of the pathogen is done by the molecules called as the major histocompatibility complex. They are the central molecules that participate in the interaction during antigen presentation by antigen presenting cells to T cells. Role of complement system in periodontal disease progression is important. The complement system can be activated by immune complexes and immunologic molecules like endotoxins. It occurs by three mechanisms, including the classical pathway, alternate pathway and the lectin pathway. Cell mediated immune response in periodontal diseases T-lymphocyte response to antigenic challenges is called the cell mediated immune response. T-lymphocytes can be functionally divided into CD4+ cells and CD8+ cells by the type of the antigen receptors. Helper T cells can be differentiated into T helper 1 and T helper 2 cells. They are distinguished by the cytokines they produce and respond to and are involved in different immune responses. Role of regulatory T cells in periodontal diseases These cells are different from Th1 or Th2 cells and play an important role in the cell mediated immune response. Three distinct regulatory T cells have been described including the naturally occurring Treg cells, CD4+ and CD 25+ T cells. Role of Th17 cells in periodontal disease A distinct type of helper T-cell lineage is Th17. It produces several proinflammatory cytokines including the cytokine interleukin-17 and hence the name. It is thought to play an important role in the pathogenesis of cell mediated tissue damage caused by autoimmunity or immune responses against microbial infection. Role of B cells They may be T-cell dependent or independent B-cell response, but B-cell response is actually regulated by T-cells. T-cell independent response occurs by cross-linking of the IgM by antigen receptor on the B-cell, responding with IgM synthesis in the absence of T-cell help. T-cell dependent activation of B-cells occurs when a pathogen is ingested by an antigen presenting cell such as a macrophage or dendritic cell. The pathogens proteins are then digested to peptides and attached to a class II MHC protein. This complex is then moved to the outside of the cell membrane. The antigen presenting cell then interacts with helper T cell. This activation leads to the secretion of cytokines by helper T-cells which causes B-cell proliferation and maturation. Activated B-cells subsequently produce antibodies which assist in division of the pathogen11. Discussion Precision medicine, as viewed by the National Institute of health, is disease treatment and prevention that accounts for individual variability. In general, periodontal therapy lacks diagnostic capability to tailor predictable therapy for the individual. Initial non-surgical therapy for chronic periodontitis consists of broad base reduction of ecological factors through scaling and root planning to control inflammation. The initial periodontal therapy is generally successful in improving clinical measures of disease but assumes that all patients will respond in the same way. Furthermore, the clinical measures of periodontal disease status, including probing pocket depth, bleeding on probing and calculated measures of loss of attachment reflect the macroscopic history of disease progression rather than a more precise measure of real time changes of inflammation or advancing periodontitis12. Substantial work has been undertaken to identify risk factors or markers for disease progression. Strategies to improve the host’s ability by preventing bacterial colonization or eliminating the important microbial species can be employed in the future. For example, attention has been focused on eliciting immune responses to adhesins and proteases of Porphyromonas gingivalis. Alternatively preformed antigen and antibodies could be produced and applied to dental surfaces to prevent attachment and bacterial colonization. In-vitro and in-vivo preclinical studies using NSAID’s has shown the extensive ability of the drug to reduce prostanoid production by inhibiting the cyclooxygenases. The use of bone sparing drugs that inhibit alveolar bone resorption is another field in host modulation therapy13. Inhibition of signal transduction pathways would be expected to abolish both cell activation by cytokines or other stimuli and the production of pro-inflammatory cytokines. Therapeutic strategies have been directed towards many of these major signalling pathways. The efficacy of anti-cytokine therapy in patients with inflammatory bone diseases is proof that blocking the effects of a cytokine can slow a disease process. The main advantages of pharmacological inhibitors are ease of administration and low cost compared with biotherapies or gene therapy. Osteoprotegerin is expressed by the osteoblastic cells and it acts as a decoy receptor. It binds to RANKL and inhibits osteoclast development. Reduction of the bacteria and their metabolic by products through periodontal therapy also results in a decrease in both interleukin-1 and tumor necrosis factor-alpha which is significantly elevated in diseased periodontal sites when compared with healthy or inactive sites and can result in bone resorption. A variety of treatment strategies have been developed to target the host response to periodontal infection. Matrix metalloproteinase inhibitors, such as low dose formulations of doxycycline have been used in combination with scaling and root planning or surgical therapy. Other therapeutic strategies being explored are aimed at inhibiting signal transduction pathways involved in inflammation. Using these novel strategies, inflammatory mediators, including proinflammatory cytokines, matrix metalloproteinases and others would be inhibited at the level of cell signalling pathways required for transcription factor activation which is necessary for inflammatory gene expression or mRNA stability. These therapies may provide the next wave of disease specific chemotherapeutics to manage chronic periodontitis. Conclusion Recent investigations have revealed that not all strains of a specific microbial species are equal in their capacity to cause disease and not all hosts are equal in their susceptibility to disease. The challenge for the future is to be able to better identify the more virulent bacterial strains and the more susceptible host. In this manner it may be possible to predict accurately the individuals at risk for future disease and to develop more effective strategies to prevent the onset and progression of periodontitis. A new perspective has been emphasized about the influence of periodontal health on the overall health of the individual. In addition this new data automatically move bacteria mediated periodontal diseases more into the mainstream of medicine, a fact which is likely to have profound implication on our profession. ACKNOWLEDGEMENT: Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Source of Funding: Nil Conflict of interest: There was no conflict of interestEnglishhttp://ijcrr.com/abstract.php?article_id=2603http://ijcrr.com/article_html.php?did=2603 Socransky SS and Haffajee AD. The bacterial etiology of destructive periodontal disease: current concepts. J Periodontol 1992;63(4):322-331. Pizarro-Cerda J and Cossart P. Bacterial adhesion and entry into host cells. Cell 2006;124(4):715-727. Soto GE, Hultgren SJ. Bacterial adhesins: common themes and variations in architecture and assembly. J Bacteriol 1999;181(4):1059-1071. Darveau RP, Tanner A, Page RC. The microbial challenge in periodontitis. Periodontol 2000 1997;14:12–32. Chen T, Nakayama K, Belliveau LL, Duncan MJ. Porphyromonas gingivalis gingipains and adhesion to epithelial cells. Infect Immun 2001;69(5):3048–3056. Hiratsuka K, Hayakawa M, Kiyama-Kishikawa M, Sasaki Y, Hirai T, Abiko Y. Role of the hemin-binding protein 35 (HBP35) of Porphyromonas gingivalis in coaggregation. Microb Pathog 2008;44(4):320–328. Conner SD, Schmid SL. Regulated portals of entry into the cell. Nature 2003;422(6927):37-44. Azuma M. Fundamental mechanisms of host immune responses to infection. J Periodontal Res 2006;41(5):361–373. Botos I, Segal DM, Davies DR. The structural biology of Toll-like receptors. Structure 2011;19(4):447-459. Nathan C. Neutrophils and immunity: challenges and opportunities. Nat Rev Immunol 2006;6(3):173–182. Carpenter AB, Sully EC, Ranney RR, Bick PH. T-cell regulation of polyclonal B cell activation induced by extracts of oral bacteria associated with periodontal diseases. Infect Immun 1984;43(1):326–336.  Hung HC, Douglass CW. Meta-analysis of the effect of scaling and root planning, surgical treatment and antibiotic therapies on periodontal probing depth and attachment loss. J Clin Periodontol 2002;29(11):975–986. Shimizu N, Ozawa Y, Yamaguchi M, Goseki T, Ohzeki K, Abiko Y. Induction of COX-2 expression by mechanical tension force in human periodontal ligament cells. J Periodontol 1998;69(6):670–677.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411110EnglishN2019May30HealthcareA Tertiary Care Hospital Based Study on Antimicrobial Sensitivity Pattern Among Septic Patients English0711Spenta Rachel ThomasEnglish Sajeena Jose C.English Deepthi DamodaranEnglish Eldhose BennyEnglish Ateendra JhaEnglish Viresh K. ChandurEnglish Ramakrishna Shabaraya A.EnglishIntroduction: Sepsis is a common and highly fatal clinical syndrome that is characterized by systemic inflammatory response syndrome due to infection. It is a final common pathway of many infectious processes, e.g. bacterial, viral, fungal and parasitic infection in critically ill patients. There is a need of study regarding the sensitivity and resistivity pattern of antimicrobials for the proposal or implementation of rational therapy guidelines. This study will also provide the best microbiological information to clinicians to pick the most effective treatment options, positively influencing patient outcomes. Methodology: A retrospective observational study was conducted among 202 patients at tertiary care teaching hospital during the period from March to November 2018. Patients with sepsis of either gender who are 18 years old or above are included in the study. Non-sepsis adult patient and special populations (pregnant women, psychiatry, HIV) or patients younger than 18 years of age are excluded from the study. Data were collected using validated data collection form. Data were analysed using SPSS 20.0 and Microsoft Excel 2013. Results: From a total of 202 patients involved in the study, the highest incidence rate was found in the age group >68 years. Gram negative organisms isolated were 81.86%, of these Klebsiella species being the most frequent. This isolates showed high rates of sensitivity towards Colistin (96%) Tigecycline (93. 3%). Conclusion: The sensitivity of antibiotics towards species are going down and it is an unpleasant warning of emergence of resistance. From our study it can be anticipated that routine culturing and sensitivity testing should be performed to detect the appearance of resistance EnglishAntibiotic, Organisms, Sepsis, SensitivityINTRODUCTION  Sepsis is a common and highly fatal clinical syndrome that is characterized by systemic inflammatory response syndrome due to infection [1]. Sepsis is commonly defined as the presence of infection in association with the systemic inflammatory response to microbial infection which can cause organ damage, shock, and eventual death [2]. There are typically four progressive stages of sepsis specifically Systemic inflammatory response syndrome, sepsis, septic shock and multi organ dysfunction. Systemic inflammatory response syndrome is stated as the presence of 2 or more of the following: (1) temperature greater than 38°C (100.4°F) or less than 36°C (96.8°F); (2) pulse rate greater than 90 beats/min; (3) respiratory rate greater than 20 breaths/min (or partial pressure of carbon dioxide less than 32); and (4) WBC count greater than 12,000/mm3 or less than 4,000/mm3, or greater than 10% immature band forms [3]  Age, male gender, black race, and increased burden of chronic health conditions are important risk factors for severe sepsis.  It is also more likely to occur in individuals with chronic obstructive pulmonary disease, cancer, chronic renal and liver disease, and diabetes. [4,5] Other risk factors include residence in long-term care facilities, malnutrition, and use of immunosuppressive medications and prosthetic devices. Severe sepsis is more common in colder months, both in the UK (35% higher in winter than in summer) 44 and US (17.7% higher in fall than in summer). [4] The elderly patient also presents with many symptoms, thus affecting the diagnosis and making it more difficult to make an early diagnosis and to provide therapeutic management [6]. Although SIRS (Systemic inflammatory response syndrome) often occurs in the setting of infection, non-infectious conditions, such as burns, acute pancreatitis, and trauma, can lead to SIRS. Sepsis was defined as the presence of the SIRS criteria and presumed or proven infection. Severe sepsis was defined as sepsis accompanied by acute organ dysfunction.[4] The high incidence of sepsis in elderly patients is affected by aging factors that cause the decline in body systems such as metabolism, cardiovascular, visual, genitourinary, immune, nervous system, and drug response. Worldwide, 31.5 million cases of sepsis occur annually and 5.3 million people have died annually. [1,7]  In 1996, there were 4774 patients admitted to a teaching hospital in Surabaya, Indonesia and 504 patients were diagnosed with sepsis, with a mortality rate of 70.2%. In another study at a teaching hospital in Yogyakarta, Indonesia, there were 631 cases of sepsis in 2007, with a 48.96% mortality rate [6]. Gram-positive organisms as a cause of sepsis have increased in frequency over time and are now almost as common as gram-negative infections, likely due to greater use of invasive procedures and the increasing proportion of hospital-acquired infection. More frequent use of broad-spectrum antibiotics in increasingly sick patients who remain in the ICU for longer periods of time has likely resulted in an increased bacterial resistance over time. Antibiotic resistance is problematic, prolonging length of stay and duration of mechanical ventilation, although the effect on mortality is uncertain. International variations in the implementation of the two main strategies to control resistance (the more rational use of antibiotics and the prevention of cross-infection between patients) may explain different rates in different countries.[4] The discrimination of infection from non-infectious causes of inflammation could also be tough. Biomarkers are prompt to help physicians during this call. There is presently no biochemical technique obtainable that alone permits a speedy and reliable discrimination between infection and non-infectious inflammation. Procalcitonin (PCT) is presently the foremost investigated biomarker for this purpose. C-reactive protein and interleukin 6 perform inferior to PCT in most studies and their value in identification infection is not outlined. All biomarkers together with PCT also are released after various non-infectious inflammatory impacts. Sepsis is often diagnosed based on simple measurements such as temperature, heart rate and breathing rate. Other tests can help to determine the type of infection and where it is located in body and which body functions have been affected. These include urine or stool samples, wound culture, vaginal secretion, pus or fluid is taken from the affected area for testing, respiratory secretion testing taking a sample of saliva, phlegm or mucous secretion, blood pressure tests, imaging studies such as an X-ray, ultrasound scan or computerised tomography (CT) scan. A wide spectrum of organisms has been represented that cause blood stream infections and this spectrum is subject to geographical alteration. Increasing antimicrobial resistance is a worldwide concern. The prevalence of resistance of blood borne isolates is increasing and it also varies in accordance with geographical and regional location. The infection caused by MDR organisms is more likely to prolong the hospital stay, increase the risk of death, and require treatment with more expensive antibiotics. In the majority cases, antimicrobial medical care is initiated through empirical observation before the results of blood culture are available. Keeping in mind the high mortality and morbidity associated with septicaemia, right choice of empiric therapy is of importance. Therapeutic management of sepsis, severe sepsis, and septic shock requires a systematical approach which combines an accurate diagnosis, rationality of antibiotic use, as well as a rapid and right treatment. Appropriateness in antibiotic use is very important to decrease the mortality and morbidity rate in patients with sepsis. The selection of antibiotics requires information about the location of source infection, the common pathogen that develops into an infection, and the local sensitivity pattern of antibiotics Aggressive, early antimicrobial therapy is critical in the management of sepsis patients. The regimen selected should be based on the suspected site of infection, likely pathogens, and the local antibiotic susceptibility patterns, whether the organism was acquired from the community or a hospital, and the patient’s immune status. Although antibiotic therapy is the cornerstone in the treatment of infections, several studies have questioned that inadequate initial antibiotic treatment of sepsis and bacteraemia is associated with increased mortality. [8] One out of four patients in Indian intensive care unit suffer sepsis, a life threatening condition due to bacteria and germs and nearly half of those patients die as a result. An average age of incidence of sepsis in western countries is 57 years and in India 55 years. Economic burden on the patient due to sepsis is very high so the selection of antibiotics should be rational and more appropriate to avoid the burden. METHODOLOGY A retrospective observational study was carried out at a multispecialty tertiary care teaching hospital in Mangaluru from November 2017 to March 2018. The study protocol was approved by Institutional Ethics Committee (IEC). Medical records of (male & female) admitted in hospital between November 2016 and November 2018 were obtained from the Medical Records Department of the hospital. A total of 202 cases were collected. Patients with sepsis of either sex who are 18 years old or above were included in the study. Non-septic adult patient and special populations (pregnant women, psychiatry, HIV) and Patients younger than 18 years of age were excluded in the study. The collected data were analysed by using Microsoft Excel 2013 and SPSS 20. The resistivity and sensitivity pattern of antimicrobial agents and prescription pattern were noted and the same were observed and concluded on the basis of prescription to the hospitalized patients in tertiary care hospital RESULT Data from 202 patients were collected from the medical record department of tertiary care hospital, out of which 124 (61.4%) were males and 78 (38.6%) were females(Table 1). Out of total population 95 patients had been hospitalized for a duration < 1 week, 68 patients for 1-2 weeks, 28 patients for 2-3 weeks, 8 subjects for 3-4 weeks, 3 patients for > 4 weeks. Most of the patients stayed in hospital for less than one week. Mortality rate  of males were  57.25% (N=124)  and  females, 51.28% (N=78). 77 people were cured during the course of treatment. On analysis we founf that out of 78 femles and 124 males the percetage of cured population were 41.02% and 36.29% respectively. While 6.93% (14) patients discontinued therapy under LAMA (Leaving Against Medical Advice ).             In the present study diabetes mellitus 74(36.6%) is the most common risk factor among patients followed by acute kidney injury 68 (33.6%), bronchopneumonia 47 (23.2%) , chronic kidney disease 36 (17.8%) , urinary tract infection 18 (8.9%)  chronic obstructive pulmonary disorder  15(7.4%) , urosepsis  14(6.9%) , chronic liver disease 11(5.4%) and acute pulmonary edema 4 (1.9%). We found that 182 culture sensitivity test were conducted out of 202 patients. Out of 182 culture sensitivity tests, gram negative organisms were 149(81.86%) and gram positive organisms were 33(18.14%) (Table 2). During the study period, 182 culture sensitivity tests were done for 21 organisms out of which klebsiella spp. (39, 21.40%) (Figure 1), Acinetobacter spp.(33, 18.10%) (Figure 2), Escherichia coli (30, 16.40%) (Figure 3) and Pseudomonas aeruginosa (18, 09.80%) (Figure 4) were analysed to prescribe antimicrobials. DISCUSSION Globally burden of sepsis in healthcare is of considerable importance. Patients with sepsis and no ongoing sign of organ failure at the time of diagnosis have increased chance of death. Patients with severe sepsis or septic shock have the highest mortality rate. A total of 202 patients, 124 males (61.4%) and 78 females (38.6%) were diagnosed with sepsis. The present study shows that incidence rate of sepsis remains high in males which was also supported by study done by Angus-DC and Schroder et al[9,10] Our study found that mortality rate was higher in men than women which was 63.96% and 36.03% respectively, same result was found in study by Schroder, et al[9] Also according to the study conducted by Adrie et al, in a group of severe sepsis patients of 50 years of age, women have a lower mortality risk than men. [11] The differences of incidence and mortality rate between male and female is due to hormonal and non-hormonal factors that influence the immune system. Women have more estrogens production than men, which influences greater activity of the immune system. [12] In the present study the highest percentage 32.18% incidence of sepsis is seen in age group above 68 followed by 25.74% fall into age group 59-68 and 31% in age group of 49-58. The highest mortality rate was found in the age group ≥68 years. The similar result was found in a study conducted by Ivan pradiptha et al. At Bandung private hospital in Indonesia, which showed that highest mortality rate was found in the age group ≥ 65 years. In critically ill sepsis patients, lacking the quality of antimicrobial therapy at admission to the ICU is associated with a significant attributable mortality. Major among those survivors who did not receive adequate antimicrobial therapy, there is a remarkable increase in ICU and hospital length of stay with the consequences that this implies. Our study showed that highest risk factor was diabetes mellitus 36.6% which was similar to the result found in the study done by G.C.K.W. Kho et.al [13]. The same results were also reported in another study done by Florian B Mayr [4] that severe sepsis is more likely to occur in individuals with diabetes mellitus, Chronic kidney disease and liver disease. Among the blood isolated organisms, current study reported that gram positive organisms and gram negative were found as causing sepsis. Organisms isolated were categorized according to their species. Among the blood isolates Klebsiella spp. (21.4%) was the predominant cause of sepsis in adults. The second isolated gram negative organism was Acinetobacter spp. (18.1%) followed by other organism E.coli (16.4%) Pseudomonas aeruginosa (9.6%). This finding was similar to other studies reported where Gram negative organism were the common isolated organism than Gram positive such as in Jalandhar (India) (58.46 % and 38.46 %) done by Kumar et al. [14] In our study imipenem was found to resistant to Klebsiella spp.  (51.40%). This similar result was found in the study done by Nidhi Pal and Ramamurthy Sujatha that resistance to imipenem seen approximately in 60% with the same organism. [15] CONCLUSION Our study found that gram negative and gram positive bacteria were responsible for adult sepsis while gram negative found to be predominant. Among that, Klebsiella species and Acinetobacter species were found to be common. It was found that the antibiotic Piperacillin/tazobactam was prescribed the most and the same is lacking sensitive to the Acinetobacter species and Klebsiella species. Which gives an alarming conclusion that sensitivity of antibiotics towards the species are going down.  From our study it can be anticipated that routine culturing and sensitivity testing should be performed to detect the appearance of resistance. Acknowledgement Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Englishhttp://ijcrr.com/abstract.php?article_id=2604http://ijcrr.com/article_html.php?did=2604 Kumalo A, Kassa T, Mariam ZS, Daka D, and Tadesse AH. Bacterial Profile of Adult Sepsis and their Antimicrobial Susceptibility Pattern at Jimma University Specialized Hospital, South West Ethiopia. Health Science Journal. 2016; 10(2):3. Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003; 31:1250-6 Malmir J, Bolvardi E, Afzal Aghaee M. Serum lactate is a useful predictor of death in severe sepsis and septic shock. Reviews in clinical medicine. 2014;1(3):97-104. Mayr FB, Yende S, Angus DC. Epidemiology of severe sepsis. Virulence.2014;5(1):4–11 Mendu ML, Zager S, Gibbons FK, Christopher KB. Relationship between neighbourhood poverty rate and bloodstream infections in the critically ill. Crit Care Med. 2012 May 1;40(5):1427-36. Pradipta IS, Sandiana AT, Halimah E, Diantini A, Lestari K, et al. Microbial and Resistance Profile in Isolate from Adult Sepsis Patients: An Observational Study at an Indonesian Private Hospital during 2009-2012. Int Jour of Pharm Sci Rev and Res 19: 24 -9. Fleischmann C, Scherag A, Adhikari NK, Hartog CS, Tsaganos T, Schlattmann P, Angus DC, Reinhart K. Assessment of global incidence and mortality of hospital-treated sepsis. Current estimates and limitations. Am J Respir Crit Care Med. 2016 Feb 1;193(3):259-72. Garnacho-Montero J, Ortiz-Leyba C, Herrera-Melero I, Aldabo-Pallas T, Cayuela-Dominguez A, Marquez-Vacaro JA, Carbajal-Guerrero J, Garcia-Garmendia JL. Mortality and morbidity attributable to inadequate empirical antimicrobial therapy in patients admitted to the ICU with sepsis: a matched cohort study. Journal of Antimicrobial Chemotherapy. 2007 Dec 3;61(2):436-41. Schröder J, Kahlke V, Staubach KH, Zabel P, Stüber F. Gender differences in human sepsis. Arcz1998 1; 133(11):1200-5. Berkowitz DM, Martin GS. Sepsis and sex: can we look beyond our hormones? Chest. 2007 1; 132(6):1725-7. Bodmann KF. Current guidelines for the treatment of severe pneumonia and sepsis. Chemotherapy. 2005; 51(5):227-33. Bone RC. Sepsis and its complications: the clinical problem. Crit care med.1994;22(7):S8-11. C.K.W.K. Koh, S.J.P Peacock, T.Van Der Poll. The Impact of diabetes on the pathogenesis of sepsis, Eur J Clin Microbiol Infect Dis. 2012, (4):379-88. Kumar A, Zarychanski R, Light B et al (2010) Early combination antibiotic therapy yields improved survival compared with monotherapy: a propensity- matched analysis. Crit Care Med 38:1773–85. Pal N, Sujatha R. Antimicrobial Resistant Pattern of  Blood Culture Isolates, Among Septicaemia Suspected Patients. National Journal of Laboratory Medicine.2016;5(1):17-21.V