Title: Prevalence of Extended Spectrum Beta Lactamase (ESBLS) Mediated Resistance among E. coli and Kl. Pneumoniae in Clinical Samples Taken from Patients Attending in Tertiary Care Hopital, in DMCH, Laheriasarai, Bihar

Authors: Dr Poonam Kumari, Dr Nandlal Kumar, Dr Satyendu Sagar

 DOI:  https://dx.doi.org/10.18535/jmscr/v6i9.02

Abstract

Objective: The aim of present study was to determine the prevalence of Extended Spectrum Beta Lactamase (ESBLS) mediated resistance among Escherichia coli and klebsiella pneumoniae in clinical sample and their Antimicrobial Resistance (AMR) Pattern, and also to compare chromogenic agar and combined disc diffusion method in identification of these enzymes in routine clinical laboratories.

Materials and Methods: A total of 2640 patient were referred from different OPD and IPD were included in study. From all the patients 2640 clinical specimens like Urine, Pus, CSF, Sputum, Wound swab, discharge from fistula, peritoneal, aspiration, fluid were received in sterilized container by aseptic methods. Any Medical, surgical and drug history were noted. Isolation and Identification of Micro-organism were carried out by Gram’s staining culture character, motility and by standard biochemical procedures according to CLSI guidelines. Antimicrobial susceptibility tests was done by Kirby - baur disc diffusion method. Resistance to at least one of the antibiotics (cephalosporin) was considered as positive in the screening test for possible ESBL production. Isolates of E. Coli and Kl. pneumoniae that were considered to be positive for ESBL production by screening tests were subjected to combined disc diffusion methods and Isolated were also tested for chromogenic ESBL Agar. All the test were performed according to CLSI 2017 guidelines and all the Media, biochemical reagents and Antimicorbial disc are supplied by Hai Media (Mumbai).

Result: Out of 2640 clinical specimens 165 Isolates were isolated. Escherichia coli were obtained predominantly from Urine (94.1%) samples, where as klebsiella pneumoniae, isolates were obtained from sputum (46.2%), the screening test for ESBL production, 78 (42.47%) isolates were found to be resistant to at least one of the cephalosporins disc. Out of 78 isolates that were positive in the screening test, ESBL production was confirmed by combined Disc diffusion method in 62 (79.48%) isolates. ESBL producers were isolated from Urine (33.78%), sputum (80%) and pus (57.14%). ESBL E. coli were predominantly isolated from Urine samples (92%), whereas ESBL-KP were isolated from sputum samples (62.5%), conformation of ESBL positive organism by combined disc diffusion method, E. coli and Klebsiella Spp. Showed Maximum ESBLS production in CTX & CEC combination. Out of 78 isolates that were positive in the screening test, ESBL production was confirmed by chromogenic ESBL Agar in 77 (98.71%) isolates.

Conclusion: Good infection control practices and antibiotic management interventions are instrumental in preventing the emergence of outbreaks due to ESBL producing isolates, especially in high risk areas such as the medical ICU, pediatric wards and surgical wards. Clinical microbiology laboratories need not only use proper phenotypic testing methods but they also need to implement molecular detection protocols. Furthermore, the vigilant surveillance and appropriate infection control programme must be implemented in each hospital setting.

Keywords: Escherichia coli, klebseilla spp, ESBL, Agar, Antimicorbial agent, prevalence.

References

  1. Ena J, Arjona F, Martínez-Peinado C, López-Perezagua Model M, Amador C. Urology. 2006;68(6):1169-74.
  2. Bush K, Jacoby GA. Updated functional classification of beta-lactamases. Anti-microb Agents Chemother 2010;54: 969–76.
  3. Das A, Ray P, Garg R, Kaur B. Extended spectrum beta-lactamase production in Gram negative bacterial isolates from cases of septicemia. Proceedings of the Silver Jubilee Conference. All India Institute of Medical Sciences, New Delhi, 2001.
  4. Livermore DM. Are all beta-lactams created equal? J. Infect. Dis. Suppl. 1996;101:33-43.
  5. Livermore DM. Beta-lactamase-mediated resistance and opportunities for its control. Antimicrob. Chemother. Jun 1998;41 Suppl D:25-41.
  6. Levinson, W, 2010, Review of medical microbiology and immunology. 11th ed. New York: Lange, pp. 85-93
  7. Ghuysen JM. Serine beta-lactamases and penicillin-binding proteins. Annu. Rev. Microbiol. 1991;45:37-67.
  8. Kallman O, Giske CG, Samuelsen O, Wretlind B, Kalin M, Olsson-Liljequist B. Interplay of efflux, impermeability, and AmpC activity contributes to cefuroxime resistance in clinical, non-ESBLproducing isolates of Escherichia coli. Microbial drug resistance (Larchmont, Y.). Jun 2009;15(2):91-95.
  9. Hasdemir UO, Chevalier J, Nordmann P, Pages JM. Detection and prevalence of active drug efflux mechanism in various multidrug-resistant Klebsiella pneumoniae strains from Turkey. Clin. Microbiol. Jun 2004;42(6):2701-2706.
  10. Sumita Y, Fukasawa M. Potent activity of meropenem against Escherichia coli arising from its simultaneous binding to penicillin- binding proteins 2 and 3. Antimicrob. Chemother. Jul 1995;36(1):53-64.
  11. Kallman O, Motakefi A, Wretlind B, Kalin M, Olsson-Liljequist B, Giske CG. Cefuroxime nonsusceptibility in multidrug-resistant Klebsiella pneumoniae overexpressing ramA and acrA and expressing ompK35 at reduced levels. Antimicrob. Chemother. Nov 2008;62 (5):986-990.
  12. Nikaido H, Normark S. Sensitivity of Escherichia coli to various beta-lactams is determined by the interplay of outer membrane permeability and degradation by periplasmic beta-lactamases: a quantitative predictive treatment. Microbiol. Jul 1987;1(1):29-36.
  13. Livermore DM. beta-Lactamases in laboratory and clinical resistance. Microbiol. Rev. Oct 1995;8(4):557-584.
  14. Ambler RP. The structure of beta-lactamases. Trans. R. Soc. Lond. B. Biol. Sci. May 16 1980;289(1036):321-331.
  15. Bush K, Jacoby GA, Medeiros AA. A functional classification scheme for beta-lactamases and its correlation with molecular structure. Agents Chemother. Jun 1995;39(6):1211-1233.
  16. Bush K, Jacoby GA. Updated functional classification of beta-lactamases. Agents Chemother. Mar 2010;54(3):969-976.
  17. Livermore DM. beta-Lactamases in laboratory and clinical resistance. Microbiol. Rev. Oct 1995;8(4):557-584.
  18. Bush K, Jacoby GA, Medeiros AA. A functional classification scheme for beta-lactamases and its correlation with molecular structure. Agents Chemother. Jun 1995;39(6):1211-1233.
  19. Bush K, Jacoby GA. Updated functional classification of beta-lactamases. Agents Chemother. Mar 2010;54(3):969-976.
  20. Sykes RB, Matthew M. The beta-lactamases of gram-negative bacteria and their role in resistance to beta-lactam antibiotics. Antimicrob. Chemother. Jun 1976;2(2):115-157.
  21. Livermore DM. Defining an extended-spectrum beta-lactamase. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases. Jan 2008;14 Suppl 1:3-10
  22. Bush K, Jacoby GA, Medeiros AA (June 1995). "A functional classification scheme for beta-lactamases and its correlation with molecular structure". Agents Chemother. 39 (6): 1211–33 PMC 162717 . PMID 7574506. doi:10.1128/ AAC.39.6.1211
  23. Bush K, Jacoby GA (2010). "Updated functional classification of beta-lactamases". Agents Chemother. 54 (3):     969- 76. PMC 2825993  . PMID 19995920. doi:10.1128/AAC.01009-09
  24. Sanders CC, Sanders WE (June 1979). "Emergence of resistance to cefamandole: possible role of cefoxitin-inducible beta-lactamases". Antimicrob. Agents Chemother. 15 (6): 792–7. PMC 352760 Freely accessible. PMID 314270. doi:10.1128 /AAC.15.6.792.
  25. Spadafino JT, Cohen B, Liu J, Larson E (2014). "Temporal trends and risk factors for extended-spectrum beta-lactamase-producing Escherichia coli in adults with catheter-associated urinary tract infections". Antimicrob Resist Infect Control. 3: 39. PMC 4306238 Freely accessible. PMID 25625011. doi:10.1186/s13756-014-0039-y.
  26. Emery CL, Weymouth LA (August 1997). "Detection and clinical significance of extended-spectrum beta-lactamases in a tertiary-care medical center". J. Clin. Microbiol. 35 (8): 2061–7. PMC 229903 Freely accessible. PMID 9230382.
  27. Bradford PA (October 2001). "Extended-spectrum beta-lactamases in the 21st century: characterization, epidemiology, and detection of this important resistance threat". Clin. Microbiol. Rev. 14 (4): 933–51, table of             contents. PMC 89009 . PMID 11585791. doi:10.1128/CMR.14.4.933-951.2001

Corresponding Author

Dr Satyendu Sagar

Assistant Professor, Department of Microbiology, Nalanda Medical College, Patna, India