Bacterial Etiology of Wound Exudates in Tertiary Care Cancer Patients and Antibiogram of the Isolates

Introduction: Patients with malignancies frequently develop infections as a result of surgical procedures and fungating wounds leading to pus formation. This cross-sectional study was conducted to explore the bacteriological spectra of infections of various cancer sites and their antibiotic sensitivity patterns among the patients visiting minor operation theatre (OT) of B.P. Koirala Memorial Cancer Hospital (BPKMCH), Chitwan, Nepal. Methods: Over a period of 3 months from September to November 2018, a total of 183 wound exudates and pus samples were collected and analyzed by standard microbiological procedures. Isolates were identified based on the colony characters, Gram staining and an array of biochemical tests. Antibiotic susceptibility testing was performed by Kirby-Bauer disc diffusion technique according to criteria set by CLSI, 2016. Methicillin resistance in Staphylococcus aureus was tested with the help of cefoxitin using disc diffusion method. Results: Out of the 183 samples, 149 (81.4%) were culture positive. Among 13 different isolates identified, S. aureus (43.0%) was predominant followed by E. coli (14.0%). Higher incidence of bacteria was seen among the males (52.3%), in the age group 51 to 60 years (26.8%) and among the patients undergoing surgical intervention to deal with cancer (34.2%). The prevalence of wound infection was significantly affected by gender, age, and treatment regimen ( P < .01). Out of the total 68 S. aureus isolates, 38 (44.1%) were deemed as Methicillin-resistant Staphylococcus aureus (MRSA). Among the 158 isolates, 85 (53.8%) were multi-drug resistant (MDR). Cefepime was the most effective antibiotic for Gram positive isolates whereas both imipenem and meropenem were found to be equally more effective for Gram negative isolates. Conclusion: This study suggests that patients with malignancies harbor pathogenic bacteria; therefore, prudent use of antibiotics is essential to prevent the emergence of MDR pathogens.

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A cross sectional study to assess nasal carriage of methicillin resistant Staphylococcus aureus in healthcare professionals in a tertiary care hospital

Journal of the Pakistan Medical Association ◽

10.47391/jpma.062 ◽

2020 ◽

pp. 1-12

Author(s):

Fibhaa Syed ◽

Nasim Akhtar ◽

Mohammad Ali Arif ◽

Adil Ramzan ◽

Rauf Niazi ◽

...

Keyword(s):

Staphylococcus Aureus ◽

Healthcare Workers ◽

Methicillin Resistant Staphylococcus Aureus ◽

Tertiary Care ◽

Nasal Carriage ◽

Cross Sectional Study ◽

Diffusion Method ◽

Cross Sectional ◽

Methicillin Resistant ◽

Nasal Swabs

Abstract Objective: To determine the nasal carriage of staphylococcus aureus and methicillin-resistant staphylococcus aureus among healthcare workers in a tertiary care setting. Methods: The cross-sectional study was conducted at the Pakistan Institute of Medical Sciences, Islamabad, Pakistan, from April to July 2018, and comprised healthcare workers at the institution. Nasal swabs were collected and cultured on Mannitol salt agar. Mannitol fermenting colonies which were gram-positive cocci, catalase-positive and coagulase-positive were identified as staphylococcus aureus. Antibiotic susceptibility test was performed by modified Kirby-Bauer disc diffusion method. Methicillin resistance was detected using cefoxitin disc diffusion method. Data was analysed using SPSS 23. Results: Of the 210 nasal swabs, 52(24.76%) had a staphylococcus aureus growth, and, of them, 15(7.1%) were methicillin-resistant. No association could be established with either any single category of healthcare worker or an inter-department variation (p>0.05). Likewise, there was no association with age, gender, duration of service, smoking, co-morbidities, use of antibiotics in the preceding six months, treating a patient with methicillin-resistant staphylococcus aureus in the preceding six months and hospitalisation in the preceding year (p>0.05). Conclusion: The frequency of nasal carriage of methicillin resistant staphylococcus aureus amongst healthcare workers was regardless of the nature of their professional engagement. Key Words: Methicillin resistant staphylococcus aureus, Nasal carriage, Continuous...

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Prevalence of Methicillin-resistant Staphylococcus Aureus (MRSA) in a Tertiary Care Hospital in Northern India

Journal of Laboratory Physicians ◽

10.4103/0974-2727.72154 ◽

2010 ◽

Vol 2 (02) ◽

pp. 078-081 ◽

Cited By ~ 14

Author(s):

Shilpa Arora ◽

Pushpa Devi ◽

Usha Arora ◽

Bimla Devi

Keyword(s):

Staphylococcus Aureus ◽

Antibiotic Susceptibility ◽

Methicillin Resistant Staphylococcus Aureus ◽

Methicillin Resistance ◽

Tertiary Care ◽

Antibiotic Sensitivity ◽

Diffusion Method ◽

Care Hospital ◽

Methicillin Resistant ◽

Sensitivity Pattern

ABSTRACT Aim: The emergence of Methicillin-resistant Staphylococcus aureus (MRSA) has posed a serious therapeutic challenge. We report the prevalence and antibiotic susceptibility pattern of MRSA in the hospitals attached to GMC, Amritsar, Punjab. Materials and Methods: The study comprised of 250 coagulase-positive staphylococci (COPS) isolated from a total of 6743 clinical specimens (like pus, blood, urine, high vaginal swab, sputum, etc.) of patients admitted in hospitals attached to Government Medical College, Amritsar from January 2008−February 2009. Routine antibiotic susceptibility testing was performed and interpreted as per standard guidelines. Methicillin resistance was detected using oxacillin and cefoxitin disc diffusion method, oxacillin screen agar method, and minimum inhibitory concentration using broth macrodilution method. Results: A total of 115 (46%) strains were found to be methicillin resistant. Multidrug resistance was observed in 73% MRSA strains. However, no strain was resistant to vancomycin. Conclusion: Regular surveillance of hospital-associated infection and monitoring of antibiotic sensitivity pattern is required to reduce MRSA prevalence.

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Antibiogram of Staphylococcus aureus in a Tertiary Care Hospital: Changing Trends

International Journal of Current Microbiology and Applied Sciences ◽

10.20546/ijcmas.2021.1010.040 ◽

2021 ◽

Vol 10 (10) ◽

pp. 319-325

Author(s):

Priyanka Pradhan Sneha Mohan ◽

Tarana Sarwat Dalip Kakru

Keyword(s):

Staphylococcus Aureus ◽

Tertiary Care Hospital ◽

Tertiary Care ◽

Cross Sectional Study ◽

Diffusion Method ◽

Care Hospital ◽

Cross Sectional ◽

Inducible Clindamycin Resistance ◽

Healthcare Facilities ◽

Antimicrobial Susceptibility Pattern

Methicillin resistant Staphylococcus aureus (MRSA) is major cause of nosocomial and community infections. Its prevalence varies with country and with hospitals within a country. Therefore, it is important for continuous surveillance in hospitals and other healthcare facilities in order to limit the spread of infections caused by MRSA. To determine the antibiogram of Staphylococcus aureus in a tertiary care hospital and to determine the change in trends in the antimicrobial susceptibility pattern of Staphylococcus aureus. To determine the prevalence of MRSA in a tertiary care hospital. This cross- sectional study was conducted at the Department of Microbiology, SMSR, Sharda University and Hospital. A total of 100 strains identified by morphological and biochemical characteristics were tested for antibiotic susceptibility using Kirby-Bauer disc diffusion method and the Prevalence of Inducible Clindamycin Resistance among the isolates. 100 out of 13,639 isolates clinical comprising samples were obtained Pus (78.6%), Blood (7%), Swab (4.1%), Sputum (4.1%), Urine (4.1%), Semen (2%). Maximum MRSA were obtained from pus samples (81%). However, out of total 7 isolates of Staphylococcus aureus obtained from blood 4 were MRSA and 3 were MSSA. The prevalence of MRSA that is (40%) infections was a high in our setup and is comparable to studies done earlier. This trend is particularly alarming for Staphylococcus aureus because of the severity and diversity of disease caused by this uniquely versatile pathogen.

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Detection of inducible clindamycin resistance in Staphylococcus aureus from various samples in a tertiary care hospital

International Journal of Research in Medical Sciences ◽

10.18203/2320-6012.ijrms20195541 ◽

2019 ◽

Vol 7 (12) ◽

pp. 4696

Author(s):

Rohit Kumar ◽

Jagarti . ◽

Mrinmoy Sarma ◽

Gautam Shalini

Keyword(s):

Staphylococcus Aureus ◽

Methicillin Resistance ◽

Tertiary Care ◽

Antibiotic Sensitivity ◽

Clinical Isolates ◽

Diffusion Method ◽

Clinical Samples ◽

Care Hospital ◽

Sensitivity Testing ◽

Inducible Clindamycin Resistance

Background: The increasing frequency of MRSA infections and rapidly changing patterns in antimicrobial resistance, led to renewed interest in the usage of Macrolides-Lincosamide-Streptogramin B (MLSB) antibiotics to treat Staphylococcus aureus infection. Clindamycin is an important drug used in the treatment of MRSA and MSSA infection. The aim of this study was to determine inducible and constitutive clindamycin resistance among clinical isolates of Staphylococcus aureus by D-test.Methods: During a period of 6 months from July 2018 to December 2018, a total of 100 Staphylococcus aureus isolated from different clinical samples were subjected to routine antibiotic sensitivity testing by Kirby Bauer’s disc diffusion method. Methicillin-resistance was determined by using the cefoxitin (30 µg) disc. Incidence of MLSBc and MLSBi in Staphylococcus aureus isolates by D-test as per CLSI guidelines.Results: Out of 100 isolates of Staphylococcus aureus obtained from 350 clinical samples, 70(70%) were found to be MRSA and 30(30%) were MSSA. Among 100 Staphylococcus aureus isolates, 40% isolates showed MLSBi resistance, 28% isolates showed MLSBc resistance, 6% isolates showed MS phenotype and 26% isolates showed Sensitive phenotype. MLSBc and MLSBi were found to be higher in MRSA as compared to MSSA (21%, 27% and 7%, 10% respectively). All clinical isolates showed 100% sensitivity to Vancomycin and Linezolid in routine antibiotic susceptibility testing.Conclusions: Continuous surveillance of the MLSB resistance is important and required before the prescription of clindamycin to treat MRSA infections.

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HOSPITALIZED PATIENTS

The Professional Medical Journal ◽

10.29309/tpmj/2016.23.07.1641 ◽

2016 ◽

Vol 23 (07) ◽

pp. 795-801

Author(s):

Muhammad Saeed ◽

Farhan Rasheed ◽

Shahida Hussain ◽

Maqsood Ahmad ◽

Mizna Arif ◽

...

Keyword(s):

Staphylococcus Aureus ◽

Clinical Laboratory ◽

Methicillin Resistance ◽

Nasal Carriage ◽

Cross Sectional Study ◽

Hospitalized Patients ◽

Coagulase Negative Staphylococcus ◽

Biochemical Tests ◽

Carriage Rate ◽

Cross Sectional

Objectives: An alarming rise in Methicillin resistant Staphylococcus aureus(MRSA) associated hospital based infections has been reported in recent decades.Prolongedhospital stay, unhygienic health services are confined to this challenging serious problem.Anterior nares of humans are a natural reservoir for Staphylococcus aureus with asymptomaticcolonization. This study was designed to determine the prevalence of nasal carriage rate ofMRSA among hospitalized patients. Study Design: Cross sectional study. Setting: PunjabInstitute of Cardiology, Lahore, Pakistan. Period: January 2013- 2014. Materials & Methods:Nasal swabs were collected from hospitalized patients. Total 2,440 patients were screened forthe nasal carriage of MRSA. Microbiologically, identification of S. aureus was done on the basisof colony morphology, Gram staining and biochemical tests. Identified isolates of S. aureus werefurther tested for cefoxitin susceptibility testing, following the technique of modified Kirby Bauer discdiffusion using Mueller-Hinton agar as per Clinical Laboratory Standards Institute (CLSI) guidelines2013. Results: Out of total 2,440 nasal swabs, 60.45% (1475/2440) were Staphylococcusspecies. Among Staphylococcus group, 86.10% (1270/1475) were Staphylococcus aureus.The frequency of MRSA and MSSA (Methicillin sensitive Staphylococcus aureus) was 5.20%(66/1270) and 94.8% (1204/1270) respectively. Overall nasal carriage of MRSA is 2.70%(66/2440). The coagulase negative Staphylococcus were found in 205 (13.90%) cases whileMRSE (Methicillin resistance Staphylococcus epidermdis) were found in only 7 (3.41%) cases.Conclusion: Overall nasal carriage rate of MRSA was 2.70%.

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Phenotypic Detection of Inducible Clindamycin Resistance among Clinical Isolates of Staphylococcus aureus in Bharatpur Hospital

Journal of College of Medical Sciences-Nepal ◽

10.3126/jcmsn.v16i3.28490 ◽

2020 ◽

Vol 16 (3) ◽

Author(s):

Ramesh Sharma Regmi ◽

Sujan Khadka ◽

Sanjeep Sapkota ◽

Swekshya Thapa Magar ◽

Sanjib Adhikari ◽

...

Keyword(s):

Staphylococcus Aureus ◽

Treatment Failure ◽

Tertiary Care ◽

Clinical Isolates ◽

Diffusion Method ◽

Clinical Samples ◽

Care Hospital ◽

Disc Diffusion ◽

Cross Sectional ◽

Inducible Clindamycin Resistance

Background: Clindamycin is regarded as a reserve drug in the treatment of staphylococcal infections. Among few therapeutic alternatives available for treatment of erythromycin-resistant Staphylococcus aureus infections, clindamycin has several advantages but major limitation in its use is the development of resistance resulting in treatment failure. Routine clindamycin susceptibility test may fail to detect such inducible resistance which can be detected by Double disc diffusion test (D-test). The present study was undertaken to determine the incidence of inducible clindamycin resistance among clinical isolates of S. aureus in a tertiary care hospital in central Nepal. Methods: A cross-sectional study was carried out among the patients visiting Bharatpur Hospital from September to November 2019. A total of 1279 clinical samples were examined for the identification of S. aureus by standard microbiological procedures. Antibiotic susceptibility testing of the isolates was done by Kirby-Bauer disc diffusion method and all the erythromycin-resistant isolates were subjected to D-test for the phenotypic detection of inducible clindamycin resistance according to CLSI guidelines (2016). Results: S. aureus was recovered from 4.5% (58/1279) samples of which 35 isolates were Methicillin-Resistant Staphylococcus aureus (MRSA) and 23 were multi-drug resistant (MDR). Tetracycline was found to be the most effective antibiotic whereas erythromycin was the least effective. D-test revealed that 39.7% isolates showed iMLSB phenotype, 3.5% showed cMLSB phenotype and 56.8% showed MS phenotype. The percentage of inducible and constitutive resistance was seen higher amongst MRSA isolates compared to Methicillin-Sensitive Staphylococcus aureus (MSSA) isolates. Incidence of S. aureus was found higher among females and in the age group 20-30 years and in pus samples (p<0.01). Conclusions: Routine testing of inducible clindamycin resistance is suggested among the clinical isolates of erythromycin-resistant Staphylococci to avoid treatment failure.

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Methicillin- and Inducible Clindamycin-ResistantStaphylococcus aureusamong Patients with Wound Infection Attending Arba Minch Hospital, South Ethiopia

International Journal of Microbiology ◽

10.1155/2019/2965490 ◽

2019 ◽

Vol 2019 ◽

pp. 1-9 ◽

Cited By ~ 2

Author(s):

Mohammedaman Mama ◽

Addis Aklilu ◽

Kassahun Misgna ◽

Molla Tadesse ◽

Eyerusalem Alemayehu

Keyword(s):

Staphylococcus Aureus ◽

Wound Infection ◽

Methicillin Resistance ◽

Demographic Data ◽

Cross Sectional Study ◽

Diffusion Method ◽

Cross Sectional ◽

Methicillin Resistant ◽

Inducible Clindamycin Resistance ◽

Antimicrobial Susceptibility Pattern

Background. Wound infection is one of the most common hospital-acquired infections. Different bacteria cause infection, of whichStaphylococcus aureusis one of the known bacteria in causing infection with increased drug-resistant isolates.Objective. To assess the prevalence and antimicrobial susceptibility pattern of methicillin and inducible clindamycin-resistantStaphylococcus aureusamong patients with wound infections attending Arba Minch Hospital.Methods. A facility-based cross-sectional study was conducted from April to June 2017. A pretested questionnaire was used to collect demographic data and clinical characteristics. Wound swabs were cultured and identified by standard techniques. Antibiotic susceptibility tests were performed by the Kirby–Bauer disc diffusion method. Methicillin resistance was detected using the cefoxitin (30 μg) antibiotic disc while inducible clindamycin resistance was detected by the D-zone test. The data were analyzed using Statistical Package for Social Science, version 20.pvalue <0.05 was considered statistically significant.Results. A total of 161 patients were enrolled and a majority of them were female (90, 50.9%). Among the collected samples, 79 (49.7%) were positive forS. aureus; of this, methicillin resistance accounted for 65 (82.3%). Out of 22 (27.8%) erythromycin-resistant isolates, 19 (24.1%) showed inducible clindamycin resistance. Methicillin-resistantS. aureusshowed higher resistance against tetracycline (72.3%) followed by cotrimoxazole (43.1%) and 100% sensitivity to vancomycin. The overall prevalence of inducible clindamycin resistance among methicillin-resistant isolates was 16 (24.6%).Conclusion. The increasing prevalence of methicillin-resistantS. aureusand the coresistance against other therapeutic options like clindamycin is becoming an obstacle in the treatment of infections which need attention from concerned bodies.

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Prevalence and Characteristics of Staphylococcus aureus Colonization among Healthcare Professionals in an Urban Teaching Hospital

Infection Control and Hospital Epidemiology ◽

10.1086/652525 ◽

2010 ◽

Vol 31 (6) ◽

pp. 574-580 ◽

Cited By ~ 38

Author(s):

Marie-Carmelle Elie-Turenne ◽

Helen Fernandes ◽

José R. Mediavilla ◽

Marnie Rosenthal ◽

Barun Mathema ◽

...

Keyword(s):

Emergency Department ◽

Staphylococcus Aureus ◽

Intensive Care ◽

Healthcare Professionals ◽

Methicillin Resistance ◽

Tertiary Care ◽

Cross Sectional Study ◽

University Hospital ◽

Cross Sectional ◽

Clerical Workers

Objective.To determine the prevalence of asymptomatic carriage of Staphylococcus aureus and methicillin-resistant S. aureus (MRSA) among healthcare professionals (HCPs) who experience varying degrees of exposure to ambulatory patients and to genetically characterize isolates.Methods.This single-center, cross-sectional study enrolled 256 staff from the intensive care units, emergency department, and prehospital services of an urban tertiary care university hospital in 2008. Occupational histories and nasal samples for S. aureus cultures were obtained. S. aureus isolates were genetically characterized with the use of spa typing and screened for mecA. MRSA isolates underwent further characterization.Results.S. aureus was isolated from 112 of 256 (43.8%) HCPs, including 30 of 52 (57.7%) paramedics, 51 of 124 (41.1%) nurses, 11 of 28 (39.3%) clerical workers, and 20 of 52 (38.5%) physicians. MRSA was isolated from 17 (6.6%) HCPs, including 1 (1.9%) paramedic, 13 (10.5%) nurses, 1 (3.6%) clerical worker, and 2 (3.8%) physicians. Among S. aureus isolates, 15.2% were MRSA. MRSA prevalence was 9.6% (12/125) in emergency department workers, 5.1% (4/79) in intensive care unit workers, and 1.9% (1/52) in emergency medical services workers. Compared with paramedics, who had the lowest prevalence of methicillin resistance among S. aureus isolates (1 of 30 [3.3%] isolates), nurses, who had the highest prevalence (13 of 51 [25.4%] isolates), had an odds ratio of 9.92 (95% confidence interval, 1.32-435.86; P = .02) for methicillin resistance. Analysis of 15 MRSA isolates revealed 7 USA100 strains, 6 USA300 strains, 1 USA800 strain, and 1 EMRSA-15 strain. All USA300 strains were isolated from emergency department personnel.Conclusions.The observed prevalence of S. aureus and MRSA colonization among HCPs exceeds previously reported prevalences in the general population. The proportion of community-associated MRSA among all MRSA in this colonized HCP cohort reflects the distribution of the USA300 community-associated strain observed increasingly among US hospitalized patients.

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Evaluation of antibiotic susceptibility in wound infections: A pilot study from Bangladesh

F1000Research ◽

10.12688/f1000research.12887.1 ◽

2017 ◽

Vol 6 ◽

pp. 2103 ◽

Cited By ~ 4

Author(s):

Sushmita Roy ◽

Mejbah Uddin Ahmed ◽

Bhuiyan Mohammad Mahtab Uddin ◽

Zubair Ahmed Ratan ◽

Monali Rajawat ◽

...

Keyword(s):

Escherichia Coli ◽

Antibiotic Susceptibility ◽

Antibiotic Sensitivity ◽

Cross Sectional Study ◽

Diffusion Method ◽

Resistant Bacteria ◽

Wound Infections ◽

Biochemical Tests ◽

Cross Sectional ◽

Antibiotic Resistant

Introduction: Infections due to antibiotic resistant bacteria have increased alarmingly in both developed and developing countries. Unrestrained and rapidly spreading bacterial growth has turned the management of wound infections into a serious challenge. This study aimed to determine the prevalence of different bacterial pathogens and their antibiotic susceptibility in various types of wound infections. Methods: A cross-sectional study was conducted to collect 105 wound swabs. All isolated bacteria were identified based on colony characteristics, gram stain and standard biochemical tests, and antibiotic susceptibility testing (AST) with the disc diffusion method. Descriptive statistics were used to present the study findings, and all analyses were performed using Stata Version 13. Results: The rate of isolation of bacteria was 92.3%. Staphylococcus aureus was found to be the most frequent isolate (55.7%), followed by Escherichia coli (23.7%), Pseudomonas spp. (8.2%), and Streptococcus pyogenes (7.2%). Gram-positive bacteria were mostly (60%) found sensitive to vancomycin, azithromycin, gentamicin, imipenem, cefixime, and ceftriaxone in this study. Among the Gram-negative bacteria, Escherichia coli (>60%) showed sensitivity to cefixime, azithromycin, cefuroxime, ceftriaxone, cefotaxime, gentamycin, and ceftazidime. Conclusions: The diversity of isolated bacteria and their susceptibility patterns signify a need to implement a proper infection control strategy, which can be achieved by carrying out antibiotic sensitivity tests of the isolates.

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Contamination of the Surfaces of a Health Care Environment by Multidrug-Resistant (MDR) Bacteria

International Journal of Microbiology ◽

10.1155/2019/3236526 ◽

2019 ◽

Vol 2019 ◽

pp. 1-7 ◽

Cited By ~ 2

Author(s):

Laila Chaoui ◽

RajaaAit Mhand ◽

Fouad Mellouki ◽

Naima Rhallabi

Keyword(s):

Staphylococcus Aureus ◽

Pathogenic Bacteria ◽

Multidrug Resistant ◽

Cross Sectional Study ◽

Hospital Environment ◽

Diffusion Method ◽

Health Care Environment ◽

Disk Diffusion Method ◽

Cross Sectional ◽

Gram Negative

Nosocomial infections (NIs) are known worldwide and remain a major problem despite scientific and technical advances in the field of health. The severity of the infection depends on the characteristics of the microorganisms involved and the high frequency of resistant pathogens in the hospital environment. The aim of this study is to determine the distribution of pathogenic bacteria (and their resistance to antibiotics) that spread on hospital surfaces, more specifically, on those of various departments in the Provincial Hospital Center (PHC) of Mohammedia, Morocco. A cross-sectional study was conducted from March 2017 to April 2018. Samples were collected by swabbing the hospital surfaces, and the isolated bacteria were checked for their susceptibility to antibiotics by the Kirby–Bauer disk diffusion method following the standards of the Clinical and Laboratory Standards Institute (CLSI). Among 200 swab samples, 176 (88%) showed bacterial growth. Gram-negative isolates were predominant at 51.5% (101/196), while the Gram-positives were at 48.5% (95/196). The main isolates are Enterobacteria weighted at 31.6% (62/196), Staphylococcus aureus reaching 24% (47/196), Pseudomonas aeruginosa at 9.2% (18/196), and Acinetobacter spp. with 3.3% (6/196). Moreover, the antimicrobial susceptibility profile of the isolates showed that about 31.7% (32/101) of the Gram-negative isolates were found to be MDR. This resistance is also high among isolates of S. aureus of which 44.7% (20/47) were methicillin-resistant Staphylococcus aureus (MRSA). Contamination of hospital surfaces by MDR bacteria is a real danger to public health. The concept of environmental bacterial reservoir is a reality that requires strict compliance with current guidelines and recommendations for hand hygiene, cleaning, and disinfection of surfaces in hospitals.

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