Prevalence and Antibiotic Resistance Profile of Secondary Bacterial Pneumonia and Bloodstream Infections Among Hospitalized COVID-19 Patients and Their Relation to Procalcitonin
DOI:
https://doi.org/10.25156/ptj.v13i1.953Keywords:
Covid-19, Secondary bacterial infections, Antimicrobial resistance, ProcalcitoninAbstract
Background: Secondary bacterial infections (SBIs) are known complication of viral respiratory infections, and are significantly associated with poorer outcomes in COVID-19 patients.
Objective: We aimed to determine the prevalence, clinical profile, antimicrobial resistance profiles and patient’s outcomes of secondary bacterial pneumonias and bloodstream infections in COVID-19 hospitalized patients and its correlation with PCT levels.
Method: One hundred thirty COVID-19 hospitalized patients were obtained which 90 from ICU and 40 were from Non-ICU Dept. Clinical samples (Blood and respiratory specimens) were taken from the patients. The necessary inflammatory biomarkers (Procalcitonin PCT, C-reactive protein CRP, WBC count) were evaluated. All samples were applied for bacterial identification via routine microbiological tests, Vitek-2 and molecular (PCR) detection. Finally, the antibiotic resistant profile was obtained via Vitek-2 and Standard international Kirby - Bauer disc diffusion method.
Results: Among 130 patients, 64.16% were positive for SBI, in which 86.9% were from ICU and 13.1% were from Non-ICU Dept. The most prevalent SBIs were Gram-negative (77.7%) versus (22.3%) of Gram-positive bacteria. Klebsiella pneumoniae, Acinetobacter baumannii and Coagulase-negative staphylococci were the top predominant species in both blood and respiratory specimen samples. There were obvious relation between mortality rate and SBI in studied patients reached up to (81%). Most of the isolated bacteria, especially the ICU isolated ones were multidrug resistant. Procalcitonin (PCT) level was significantly higher (9.9 ng/ml) in patients with SBI, especially Klebsiella pneumoniae infection. The highest PCT level was found in patients with Gram negative infection in blood stream samples.
Conclusion: There is a high prevalence of bacterial superinfections in patients with COVID-19 who require hospitalization. Gram negative bacteria, especially Klebsiella pneumoniae and Acinetobacter baumannii were the main bacteria, and the resistance rates against the major isolated bacteria were generally high. While the PCT level was positively associated with secondary bacterial infection and patient outcome.
Downloads
References
AHMED, S. S., MOHAMMED, D. A. & MOHAMMED, A. A. 2021. Hematological parameters in adult patients with COVID-19; A case-control study. International Journal of Infection, 8.
ALI, A. M., ROSTAM, H. M., FATAH, M. H., NOORI, C. M., ALI, K. M. & TAWFEEQ, H. M. 2022. Serum troponin, D‐dimer, and CRP level in severe coronavirus (COVID‐19) patients. Immunity, Inflammation and Disease, 10, e582.
BAKALETZ, L. O. 2017. Viral–bacterial co-infections in the respiratory tract. Current opinion in microbiology, 35, 30-35.
BALKHAIR, A., AL-MUHARRMI, Z., AL’ADAWI, B., AL BUSAIDI, I., TAHER, H., AL-SIYABI, T., AL AMIN, M. & HASSAN, K. 2019. Prevalence and 30-day all-cause mortality of carbapenem-and colistin-resistant bacteraemia caused by Acinetobacter baumannii, Pseudomonas aeruginosa, and Klebsiella pneumoniae: description of a decade-long trend. International Journal of Infectious Diseases, 85, 10-15.
BOORGULA, S. Y., YELAMANCHILI, S., KOTTAPALLI, P. & NAGA, M. D. 2022a. An Update on Secondary Bacterial and Fungal Infections and Their Antimicrobial Resistance Pattern (AMR) in COVID-19 Confirmed Patients. Journal of Laboratory Physicians, 14, 260-264.
BOORGULA, S. Y., YELAMANCHILI, S., KOTTAPALLI, P. & NAGA, M. D. 2022b. An Update on Secondary Bacterial and Fungal Infections and Their Antimicrobial Resistance Pattern (AMR) in COVID-19 Confirmed Patients. Journal of Laboratory Physicians, 14, 260.
BREWSTER, J. D. & PAOLI, G. C. 2013. DNA extraction protocol for rapid PCR detection of pathogenic bacteria. Analytical Biochemistry, 442, 107-109.
CATAÑO-CORREA, J. C., CARDONA-ARIAS, J. A., PORRAS MANCILLA, J. P. & GARCÍA, M. T. 2021. Bacterial superinfection in adults with COVID-19 hospitalized in two clinics in Medellín-Colombia, 2020. PloS one, 16, e0254671.
CHEN, J. & GRIFFITHS, M. 1998. PCR differentiation of Escherichia coli from other Gram‐negative bacteria using primers derived from the nucleotide sequences flanking the gene encoding the universal stress protein. Letters in applied microbiology, 27, 369-371.
CHEN, N., ZHOU, M., DONG, X., QU, J., GONG, F., HAN, Y., QIU, Y., WANG, J., LIU, Y. & WEI, Y. 2020a. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. The lancet, 395, 507-513.
CHEN, T., WU, D., CHEN, H., YAN, W., YANG, D., CHEN, G., MA, K., XU, D., YU, H. & WANG, H. 2020b. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. bmj, 368.
CHENG, K., HE, M., SHU, Q., WU, M., CHEN, C. & XUE, Y. 2020. Analysis of the risk factors for nosocomial bacterial infection in patients with COVID-19 in a tertiary hospital. Risk Management and Healthcare Policy, 13, 2593.
CHRIST-CRAIN, M., STOLZ, D., BINGISSER, R., MULLER, C., MIEDINGER, D., HUBER, P. R., ZIMMERLI, W., HARBARTH, S., TAMM, M. & MULLER, B. 2006. Procalcitonin guidance of antibiotic therapy in community-acquired pneumonia: a randomized trial. American journal of respiratory and critical care medicine, 174, 84-93.
CONTOU, D., CLAUDINON, A., PAJOT, O., MICAËLO, M., FLANDRE, P. L., DUBERT, M., CALLY, R., LOGRE, E., FRAISSÉ, M. & MENTEC, H. 2020. Bacterial and viral co-infections in patients with severe SARS-CoV-2 pneumonia admitted to a French ICU. Annals of Intensive Care, 10, 1-9.
COSTELLO, R. E., YIMER, B. B., ROADS, P., JANI, M. & DIXON, W. G. 2021. Glucocorticoid use is associated with an increased risk of hypertension. Rheumatology (Oxford), 60, 132-139.
COVINGTON, E. W., ROBERTS, M. Z. & DONG, J. 2018. Procalcitonin Monitoring as a Guide for Antimicrobial Therapy: A Review of Current Literature. Pharmacotherapy, 38, 569-581.
DE BRUYN, A., VERELLEN, S., BRUCKERS, L., GEEBELEN, L., CALLEBAUT, I., DE PAUW, I., STESSEL, B. & DUBOIS, J. 2022. Secondary infection in COVID-19 critically ill patients: a retrospective single-center evaluation. BMC Infect Dis, 22, 207.
DENG, F., GAO, D., MA, X., GUO, Y., WANG, R., JIANG, W. & GONG, S. 2021. Corticosteroids in diabetes patients infected with COVID-19. Ir J Med Sci, 190, 29-31.
ELABBADI, A., TURPIN, M., GEROTZIAFAS, G. T., TEULIER, M., VOIRIOT, G. & FARTOUKH, M. 2021. Bacterial coinfection in critically ill COVID-19 patients with severe pneumonia. Infection, 49, 559-562.
FALCONE, M., TISEO, G., GIORDANO, C., LEONILDI, A., MENICHINI, M., VECCHIONE, A., PISTELLO, M., GUARRACINO, F., GHIADONI, L. & FORFORI, F. 2021. Predictors of hospital-acquired bacterial and fungal superinfections in COVID-19: a prospective observational study. Journal of Antimicrobial Chemotherapy, 76, 1078-1084.
FENG, X., LI, S., SUN, Q., ZHU, J., CHEN, B., XIONG, M. & CAO, G. 2020. Immune-inflammatory parameters in COVID-19 cases: a systematic review and meta-analysis. Frontiers in medicine, 7, 301.
GARCIA-VIDAL, C., SANJUAN, G., MORENO-GARCÍA, E., PUERTA-ALCALDE, P., GARCIA-POUTON, N., CHUMBITA, M., FERNANDEZ-PITTOL, M., PITART, C., INCIARTE, A. & BODRO, M. 2021. Incidence of co-infections and superinfections in hospitalized patients with COVID-19: a retrospective cohort study. Clinical Microbiology and Infection, 27, 83-88.
GREEN, A. D. & LIDDY, M. A. 2020. Specimen Collection: Sputum by Suction (Respiratory Therapy). Elsevier.
GUAN, W. J., NI, Z. Y., HU, Y., LIANG, W. H., OU, C. Q., HE, J. X., LIU, L., SHAN, H., LEI, C. L., HUI, D. S. C., DU, B., LI, L. J., ZENG, G., YUEN, K. Y., CHEN, R. C., TANG, C. L., WANG, T., CHEN, P. Y., XIANG, J., LI, S. Y., WANG, J. L., LIANG, Z. J., PENG, Y. X., WEI, L., LIU, Y., HU, Y. H., PENG, P., WANG, J. M., LIU, J. Y., CHEN, Z., LI, G., ZHENG, Z. J., QIU, S. Q., LUO, J., YE, C. J., ZHU, S. Y. & ZHONG, N. S. 2020. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med, 382, 1708-1720.
HALL, G. S. 2013. Bailey & Scott’s Diagnostic microbiology, 13th edn. American Society for Clinical Pathology.
HANADA, S., PIRZADEH, M., CARVER, K. Y. & DENG, J. C. 2018. Respiratory viral infection-induced microbiome alterations and secondary bacterial pneumonia. Frontiers in immunology, 2640.
HASAN, N. S. & HOSHYAR, D. F. 2019. Detection of Enterotoxigenic Staphylococcus aureus Strains in Raw Milk of Cows Reared in Erbil Province/Iraq. ZANCO JOURNAL OF PURE AND APPLIED SCIENCES.
HE, S., LIU, W., JIANG, M., HUANG, P., XIANG, Z., DENG, D., CHEN, P. & XIE, L. 2021. Clinical characteristics of COVID-19 patients with clinically diagnosed bacterial co-infection: A multi-center study. PLoS One, 16, e0249668.
HUANG, C., WANG, Y., LI, X., REN, L., ZHAO, J., HU, Y., ZHANG, L., FAN, G., XU, J. & GU, X. 2020. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The lancet, 395, 497-506.
HUGHES, S., TROISE, O., DONALDSON, H., MUGHAL, N. & MOORE, L. S. P. 2020. Bacterial and fungal coinfection among hospitalized patients with COVID-19: a retrospective cohort study in a UK secondary-care setting. Clin Microbiol Infect, 26, 1395-1399.
HUI, D. S., AZHAR, E. I., MADANI, T. A., NTOUMI, F., KOCK, R., DAR, O., IPPOLITO, G., MCHUGH, T. D., MEMISH, Z. A. & DROSTEN, C. 2020. The continuing 2019-nCoV epidemic threat of novel coronaviruses to global health—The latest 2019 novel coronavirus outbreak in Wuhan, China. International journal of infectious diseases, 91, 264-266.
JIN, J.-M., BAI, P., HE, W., WU, F., LIU, X.-F., HAN, D.-M., LIU, S. & YANG, J.-K. 2020. Gender differences in patients with COVID-19: focus on severity and mortality. Frontiers in public health, 152.
KALOREY, D. R., SHANMUGAM, Y., KURKURE, N. V., CHOUSALKAR, K. K. & BARBUDDHE, S. B. 2007. PCR-based detection of genes encoding virulence determinants in Staphylococcus aureus from bovine subclinical mastitis cases. Journal of Veterinary Science, 8, 151-154.
KARATAŞ, M., YAŞAR-DUMAN, M., TÜNGER, A., ÇILLI, F., AYDEMIR, Ş. & ÖZENCI, V. 2021a. Secondary bacterial infections and antimicrobial resistance in COVID-19: comparative evaluation of pre-pandemic and pandemic-era, a retrospective single center study. Ann Clin Microbiol Antimicrob, 20, 51.
KARATAŞ, M., YAŞAR-DUMAN, M., TÜNGER, A., ÇILLI, F., AYDEMIR, Ş. & ÖZENCI, V. 2021b. Secondary bacterial infections and antimicrobial resistance in COVID-19: comparative evaluation of pre-pandemic and pandemic-era, a retrospective single center study. Annals of clinical microbiology and antimicrobials, 20, 1-8.
KHURANA, S., SINGH, P., SHARAD, N., KIRO, V. V., RASTOGI, N., LATHWAL, A., MALHOTRA, R., TRIKHA, A. & MATHUR, P. 2021. Profile of co-infections & secondary infections in COVID-19 patients at a dedicated COVID-19 facility of a tertiary care Indian hospital: Implication on antimicrobial resistance. Indian journal of medical microbiology, 39, 147-153.
LAI, C.-C., SHIH, T.-P., KO, W.-C., TANG, H.-J. & HSUEH, P.-R. 2020. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): The epidemic and the challenges. International journal of antimicrobial agents, 55, 105924.
LANGFORD, B. J., SO, M., RAYBARDHAN, S., LEUNG, V., WESTWOOD, D., MACFADDEN, D. R., SOUCY, J.-P. R. & DANEMAN, N. 2020. Bacterial co-infection and secondary infection in patients with COVID-19: a living rapid review and meta-analysis. Clinical microbiology and infection, 26, 1622-1629.
LANSBURY, L., LIM, B., BASKARAN, V. & LIM, W. S. 2020a. Co-infections in people with COVID-19: a systematic review and meta-analysis. J Infect, 81, 266-275.
LANSBURY, L., LIM, B., BASKARAN, V. & LIM, W. S. 2020b. Co-infections in people with COVID-19: a systematic review and meta-analysis. Journal of Infection, 81, 266-275.
LI, J., WANG, J., YANG, Y., CAI, P., CAO, J., CAI, X. & ZHANG, Y. 2020. Etiology and antimicrobial resistance of secondary bacterial infections in patients hospitalized with COVID-19 in Wuhan, China: a retrospective analysis. Antimicrobial Resistance & Infection Control, 9, 1-7.
LI, S., RONG, H., GUO, Q., CHEN, Y., ZHANG, G. & YANG, J. 2016. Serum procalcitonin levels distinguish Gram-negative bacterial sepsis from Gram-positive bacterial and fungal sepsis. J Res Med Sci, 21, 39.
MAHON, C. R., LEHMAN, D. C. & MANUSELIS, G. 2018. Textbook of diagnostic microbiology-e-book, Elsevier Health Sciences.
MANOHAR, P., LOH, B., NACHIMUTHU, R., HUA, X., WELBURN, S. C. & LEPTIHN, S. 2020. Secondary bacterial infections in patients with viral pneumonia. Frontiers in medicine, 7, 420.
MEGAHED, A. A., NASR, S. S. & MOHAMMED, G. 2015. Bacteriological and molecular detection of Pseudomonas species from raw milk sold in Port-Said Citymarkets. Egypt. J. Chem. Environ. Health, 1, 986-1002.
MEWES, J. C., PULIA, M. S., MANSOUR, M. K., BROYLES, M. R., NGUYEN, H. B. & STEUTEN, L. M. 2019. The cost impact of PCT-guided antibiotic stewardship versus usual care for hospitalised patients with suspected sepsis or lower respiratory tract infections in the US: A health economic model analysis. PLoS One, 14, e0214222.
MICROBIOLOGY, N. 2020. Antimicrobial resistance in the age of COVID-19. Nat Microbiol, 5, 779.
MIRZAEI, R., GOODARZI, P., ASADI, M., SOLTANI, A., ALJANABI, H. A. A., JEDA, A. S., DASHTBIN, S., JALALIFAR, S., MOHAMMADZADEH, R. & TEIMOORI, A. 2020. Bacterial co‐infections with SARS‐CoV‐2. IUBMB life, 72, 2097-2111.
MONDAL, U. K., HAQUE, T., BISWAS, M. A. A. J., SATTER, S. M., ISLAM, M. S., ALAM, Z., SHOJON, M., DEBNATH, S., ISLAM, M., MURSHID, H. B., HASSAN, M. Z. & HOMAIRA, N. 2022. Antibiotic Prescribing Practices for Treating COVID-19 Patients in Bangladesh. Antibiotics, 11, 1350.
MORENS, D. M., TAUBENBERGER, J. K. & FAUCI, A. S. 2008. Predominant role of bacterial pneumonia as a cause of death in pandemic influenza: implications for pandemic influenza preparedness. The Journal of infectious diseases, 198, 962-970.
MORRIS, D. E., CLEARY, D. W. & CLARKE, S. C. 2017. Secondary bacterial infections associated with influenza pandemics. Frontiers in microbiology, 8, 1041.
NORI, P., COWMAN, K., CHEN, V., BARTASH, R., SZYMCZAK, W., MADALINE, T., PUNJABI KATIYAR, C., JAIN, R., ALDRICH, M., WESTON, G., GIALANELLA, P., CORPUZ, M., GENDLINA, I. & GUO, Y. 2021. Bacterial and fungal coinfections in COVID-19 patients hospitalized during the New York City pandemic surge. Infect Control Hosp Epidemiol, 42, 84-88.
OPAL, S. M., GIRARD, T. D. & ELY, E. W. 2005. The immunopathogenesis of sepsis in elderly patients. Clinical infectious diseases, 41, S504-S512.
ORGANIZATION, W. H. 2020a. Community-based health care, including outreach and campaigns, in the context of the COVID-19 pandemic: interim guidance, May 2020. World Health Organization.
ORGANIZATION, W. H. 2020b. WHO Director-General’s opening remarks at the media briefing on COVID-19-11 March 2020. Geneva, Switzerland.
PINCUS, D. H. 2006. Microbial identification using the bioMérieux Vitek® 2 system. Encyclopedia of Rapid Microbiological Methods. Bethesda, MD: Parenteral Drug Association, 1-32.
QIN, C., ZHOU, L., HU, Z., ZHANG, S., YANG, S., TAO, Y., XIE, C., MA, K., SHANG, K. & WANG, W. 2020. Dysregulation of immune response in patients with coronavirus 2019 (COVID-19) in Wuhan, China. Clinical infectious diseases, 71, 762-768.
RAWSON, T. M., MOORE, L. S. P., ZHU, N., RANGANATHAN, N., SKOLIMOWSKA, K., GILCHRIST, M., SATTA, G., COOKE, G. & HOLMES, A. 2020. Bacterial and Fungal Coinfection in Individuals With Coronavirus: A Rapid Review To Support COVID-19 Antimicrobial Prescribing. Clin Infect Dis, 71, 2459-2468.
RIPA, M., GALLI, L., POLI, A., OLTOLINI, C., SPAGNUOLO, V., MASTRANGELO, A., MUCCINI, C., MONTI, G., DE LUCA, G., LANDONI, G., DAGNA, L., CLEMENTI, M., ROVERE QUERINI, P., CICERI, F., TRESOLDI, M., LAZZARIN, A., ZANGRILLO, A., SCARPELLINI, P., CASTAGNA, A. & GROUP, C. O.-B. S. 2021. Secondary infections in patients hospitalized with COVID-19: incidence and predictive factors. Clin Microbiol Infect, 27, 451-457.
RUSSELL, C. D., FAIRFIELD, C. J., DRAKE, T. M., TURTLE, L., SEATON, R. A., WOOTTON, D. G., SIGFRID, L., HARRISON, E. M., DOCHERTY, A. B. & DE SILVA, T. I. 2021. Co-infections, secondary infections, and antimicrobial use in patients hospitalised with COVID-19 during the first pandemic wave from the ISARIC WHO CCP-UK study: a multicentre, prospective cohort study. The Lancet Microbe, 2, e354-e365.
SHARIFIPOUR, E., SHAMS, S., ESMKHANI, M., KHODADADI, J., FOTOUHI-ARDAKANI, R., KOOHPAEI, A., DOOSTI, Z. & EJ GOLZARI, S. 2020a. Evaluation of bacterial co-infections of the respiratory tract in COVID-19 patients admitted to ICU. BMC infectious diseases, 20, 1-7.
SHARIFIPOUR, E., SHAMS, S., ESMKHANI, M., KHODADADI, J., FOTOUHI-ARDAKANI, R., KOOHPAEI, A., DOOSTI, Z. & EJ GOLZARI, S. 2020b. Evaluation of bacterial co-infections of the respiratory tract in COVID-19 patients admitted to ICU. BMC Infect Dis, 20, 646.
SHIMPOH, T., HIRATA, Y., IHARA, S., SUZUKI, N., KINOSHITA, H., HAYAKAWA, Y., OTA, Y., NARITA, A., YOSHIDA, S. & YAMADA, A. 2017. Prevalence of pks-positive Escherichia coli in Japanese patients with or without colorectal cancer. Gut pathogens, 9, 1-8.
TAHA, S. I., SHATA, A. K., BAIOUMY, S. A., FOUAD, S. H., MOUSSA, A. H., EL-SEHSAH, E. M., SALLAM, D. & YOUSSEF, M. K. 2022. The Clinical Utility of Serial Procalcitonin and Procalcitonin Clearance in Predicting the Outcome of COVID-19 Egyptian Patients. Afro-Egyptian Journal of Infectious and Endemic Diseases, 12, 115-123.
TURTON, J. F., WOODFORD, N., GLOVER, J., YARDE, S., KAUFMANN, M. E. & PITT, T. L. 2006. Identification of Acinetobacter baumannii by detection of the blaOXA-51-like carbapenemase gene intrinsic to this species. J Clin Microbiol, 44, 2974-6.
USMAN, M., FAROOQ, M. & HANNA, K. 2020. Environmental side effects of the injudicious use of antimicrobials in the era of COVID-19. Science of the Total Environment, 745, 141053.
VIJAY, S., BANSAL, N., RAO, B. K., VEERARAGHAVAN, B., RODRIGUES, C., WATTAL, C., GOYAL, J. P., TADEPALLI, K., MATHUR, P., VENKATESWARAN, R., VENKATASUBRAMANIAN, R., KHADANGA, S., BHATTACHARYA, S., MUKHERJEE, S., BAVEJA, S., SISTLA, S., PANDA, S. & WALIA, K. 2021. Secondary Infections in Hospitalized COVID-19 Patients: Indian Experience. Infect Drug Resist, 14, 1893-1903.
WANG, D., HU, B., HU, C., ZHU, F., LIU, X., ZHANG, J., WANG, B., XIANG, H., CHENG, Z. & XIONG, Y. 2020. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. Jama, 323, 1061-1069.
WAYNE, P. 2007. Principles and procedures for blood cultures; approved guideline, CLSI document M47-A. Clinical and Laboratory Standards Institute (CLSI).
WAYNE, P. 2019. Clinical and Laboratory Standard Institute: Performance standards for antimicrobial susceptiblity testing: 29th information supplement. CLSI document M100-S29.
WORLD HEALTH ORGANIZATION. 2022. WHO Coronavirus disease( COVID-19) dashboard [Online]. Available: https://covid19.who.int/ [Accessed].
WORLDOMETER. 2022. COVID-19 pandemic in Iraq [Online]. Available: https://www.worldometers.info/coronavirus/country/iraq/ [Accessed].
YANEZ, N. D., WEISS, N. S., ROMAND, J.-A. & TREGGIARI, M. M. 2020. COVID-19 mortality risk for older men and women. BMC public health, 20, 1-7.
ZHOU, F., YU, T., DU, R., FAN, G., LIU, Y., LIU, Z., XIANG, J., WANG, Y., SONG, B. & GU, X. 2020. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The lancet, 395, 1054-1062.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2023 Azhinn Dilshad, Adel Khider
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Authors who publish with this journal agree to the following terms:
1. Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License [CC BY-NC-ND 4.0] that allows others to share the work with an acknowledgment of the work's authorship and initial publication in this journal.
2. Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgment of its initial publication in this journal.
3. Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See The Effect of Open Access).
Polytechnic Journal ; A Periodical Open Access Scientific Journal