Prevalence of extended spectrum beta lactamase producing Escherichia coli and Klebsiella pneumoniae urinary isolates in a tertiary care hospital in Kathmandu, Nepal

Effectiveness of selective antibiotics use in ESBL-related UTIs

BACKGROUND

Urinary tract infections (UTIs) are the second most common infection, affecting 150 million people each year worldwide. Enterobacteriaceae species expressing extended-spectrum β-lactamases (ESBLs) are on the rise across the globe and are becoming a severe problem in the therapeutic management of clinical cases of urinary tract infection. Knowledge of the prevalence and antibiogram profile of such isolates is essential to develop an appropriate treatment methodology. This study aimed to investigate the prevalence of Enterobacteriaceae isolates exhibiting ESBL and their selective oral antibiogram profile at the district general hospital, Polonnaruwa.

RESULTS

A total of 4386 urine specimens received to the Microbiology Laboratory during the study period. Among them, 1081 (24.6%) showed positive results for urine culture while 200/1081 specimens showed ESBL isolates. Out of the selected 200 specimen's majority (67.5%) of samples received from the In-Patient Department. There were 200 patients and reported that 115 (57.5%) were females and 85 (42.5%) were males. The majority (51%) of the patients belong to the age group of 55-74 years. Among the ESBLs positive specimens, the majority 74.5% (n = 149) identified organisms were E. coli followed by Klebsiella spp.17.5% (n = 35), Enterobacteriaceae 7% (n = 14) and only1% (n = 2) isolate of Proteus spp. Mecillinam (87.92%) and Nitrofurantoin (83.2%) showed higher effectiveness against E. coli. Nitrofurantoin showed the highest effectiveness against Klebsiella spp. (40%), other Enterobacteriaceae spp. (100%). Proteus spp. showed 100% effectiveness and resistance respectively against Ciprofloxacin, Cotrimoxazole and Nitrofurantoin.

CONCLUSION

The most predominant ESBLs producing uro-pathogen was the E. coli in the study setting and E. coli had higher sensitivity rate against Mecillinam. Among currently used oral antibiotics Nitrofurantoin was the best choice for UTIs caused by ESBL producers.

Resistance and Co-Resistance of Metallo-Beta-Lactamase Genes in Diarrheal and Urinary-Tract Pathogens in Bangladesh

Carbapenems are the antibiotics of choice for treating multidrug-resistant bacterial infections. Metallo-β-lactamases (MBLs) are carbapenemases capable of hydrolyzing nearly all therapeutically available beta-lactam antibiotics. Consequently, this research assessed the distribution of two MBL genes and three β-lactamases and their associated phenotypic resistance in diarrheal and urinary-tract infections (UTIs) to guide future policies. Samples were collected through a cross-sectional study, and β-lactamase genes were detected via PCR. A total of 228 diarrheal bacteria were isolated from 240 samples. The most predominant pathogens were Escherichia coli (32%) and Klebsiella spp. (7%). Phenotypic resistance to amoxicillin-clavulanic acid, aztreonam, cefuroxime, cefixime, cefepime, imipenem, meropenem, gentamicin, netilmicin, and amikacin was 50.4%, 65.6%, 66.8%, 80.5%, 54.4%, 41.6%, 25.7%, 41.2%, 37.2%, and 42.9%, respectively. A total of 142 UTI pathogens were identified from 150 urine samples. Klebsiella spp. (39%) and Escherichia coli (24%) were the major pathogens isolated. Phenotypic resistance to amoxicillin-clavulanic acid, aztreonam, cefuroxime, cefixime, cefepime, imipenem, meropenem, gentamicin, netilmicin, and amikacin was 93.7%, 75.0%, 91.5%, 93.7%, 88.0%, 72.5%, 13.6%, 44.4%, 71.1%, and 43%, respectively. Twenty-four diarrheal isolates carried blaNDM-1 or blaVIM genes. The overall MBL gene prevalence was 10.5%. Thirty-six UTI pathogens carried either blaNDM-1 or blaVIM genes (25.4%). Seven isolates carried both blaNDM-1 and blaVIM genes. MBL genes were strongly associated with phenotypic carbapenem and other β-lactam antibiotic resistance. blaOXA imparted significantly higher phenotypic resistance to β-lactam antibiotics. Active surveillance and stewardship programs are urgently needed to reduce carbapenem resistance in Bangladesh.

Prevalence of drug resistant Enterobacteriaceae in a Nepalese tertiary care hospital

Antimicrobial resistance in Enterobacteriaceae is an emerging global public health problem. Numerous studies have reported community-acquired AmpC beta-lactamase and extended spectrum beta-lactamase (ESBL) producing Enterobacteriaceae in Nepal. However, there are limited data on community-acquired Metallo-beta-lactamase (MBL) producing Enterobacteriaceae. A hospital-based descriptive cross-sectional study was conducted using 294 Enterobacteriaceae isolates from a total of 2,345 different clinical specimens collected from patients attending a tertiary care hospital in Nepal. Bacteria were isolated using standard microbiological growth media and identified using biochemical tests. For antimicrobial susceptibility testing, Kirby-Bauer disc diffusion technique was used. AmpC, ESBL, and MBL productions were detected by using combined disc method. AmpC, ESBL, and MBL productions were detected in 19.4%, 29.6%, and 8.5% of total Enterobacteriaceae isolates respectively. Higher rates of beta-lactamases production were seen among the isolates from in-patients in comparison with those from out-patients. However, 11.6%, 25%, and 3.7% of the total isolates from out-patients were AmpC, ESBL, and MBL producers respectively. The co-production of the beta-lactamases was also detected, with two Klebsiella pneumoniae isolates producing all three beta-lactamases. One MBL producing Proteus vulgaris isolate that was pan-resistant with no remaining treatment options was also isolated. Prevalence of drug resistant Enterobacteriaceae in our study was very high. Detection of AmpC, ESBL, and MBL positive isolates from out-patients, who did not have recent history of hospital visit, indicated the community dissemination of the drug resistant bacteria. This is a matter of great concern and an immediate attention to formulate strategies to prevent further development and spread of antibiotic resistance is required.

Extended-spectrum β-lactamases producing Enterobacteriaceae (ESBL-PE) prevalence in Nepal: A systematic review and meta-analysis

An alarming increase in the occurrence of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) has threatened the treatment and management of bacterial infections. This systematic review and meta-analysis aimed to provide a quantitative estimate of the prevalence of ESBL among the members of the Enterobacteriaceae family by analyzing the community-based and clinical studies published between 2011 and 2021 from Nepal and determine if ESBL-PE correlates with multidrug resistance (MDR). The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed for systematic review and meta-analysis and the articles' quality was assessed using the Newcastle-Ottawa scale. Of the 2529 articles screened, 65 articles were systematically reviewed, data extracted, and included in in-depth meta-analysis. The overall pooled prevalence of ESBL-producers in Enterobacteriaceae was 29 % (95 % CI: 26-32 %) with high heterogeneity (I2 = 96 %, p < 0.001). Escherichia coli was the predominant ESBL-producing member of the Enterobacteriaceae family, followed by Citrobacter spp. and Klebsiella spp. The prevalence of ESBL-PE increased from 18.7 % in 2011 to 29.5 % in 2021. A strong positive correlation (r = 0.98) was observed between ESBL production and MDR in Enterobacteriaceae. ESBL-PE isolates showed high resistance to ampicillin, cephalosporins, and amoxicillin-clavulanic acid, and blaCTX-M type was the most reported gene variant among ESBL-PE. In conclusion, this study demonstrated an increased prevalence of ESBL-PE in Nepal over the last decade, and such isolates showed a high level of MDR against the β-lactams and non-β-lactam antibiotics. Tackling the rising antibiotic resistance (AR) and MDR in ESBL-PE would require concerted efforts from all stakeholders to institute effective infection control programs in the community and clinical settings.

Systematic Review and Meta-analysis on Extended-Spectrum β-lactamases Producing Klebsiella pneumoniae in Nepal

Objective

This systematic review and meta-analysis aimed to assess the pool estimates of extended-spectrum β-lactamases producing K. pneumoniae (ESBL-KP) and study their drug resistance profile by evaluating the studies from Nepal.

Methods

A literature search was carried out in PubMed, Google Scholar, and NepJOL to screen all articles on ESBL-KP published between 2011 and 2021 from Nepal. This review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Relevant data were extracted, and R language 4.2.0 software was used for statistical analysis.

Results

The pooled prevalence of K. pneumoniae was 5%, while the pooled prevalence of ESBL and multidrug resistance (MDR) in K. pneumoniae were 23% and 55%, respectively. Imipenem was the drug of choice (in vitro) against ESBL-KP infection.

Conclusion

Our analyses showed a high prevalence of ESBL-KP and their high resistance toward commonly used drugs. This study highlights the need for the development of new antibiotics for the management of ESBL-KP infections.

Carbapenem-Resistant Klebsiella pneumoniae: Diversity, Virulence, and Antimicrobial Resistance

Background

Klebsiella pneumoniae (K. pneumoniae) is one of the most important pathogens in nosocomial infections. It has resistance to most antibiotics, even carbapenem, resulting in restricted therapeutic options.

Purpose

We tried to assess the antimicrobial resistance and virulence fitness of carbapenem-resistant K. pneumoniae (CRKP) in addition to their phenotypic and genotypic diversity.

Materials and Methods

The conventional methods, automated Vitek-32 system, and antimicrobial susceptibility pattern were used to detect CRKP isolates. Virulence and resistance genes profiles were created by using PCR technique. The correlation analysis was done by using R-program.

Results

The antimicrobial resistance profile for all our K. pneumoniae isolates was shocking as the MDR and CRKP were the most prominent phenotypes. Unfortunately, high degrees of heterogeneity among our CRKP isolates were recorded, as 97.5% of them were differentiated into different clusters. We found a negative correlation between the existence of virulence and antimicrobial resistance genes. In contrast to sputum and urine CRPK isolates, the blood isolates showed high antimicrobial resistance and low virulence fitness. Finally, K. pneumoniae creates several outbreaks and crises in Egypt owing to the highly heterogeneity and the wide spread of multidrug-resistant (MDR) and multi-virulent CRKP phenotypes.

Conclusion

Our results are significant and alarming to health organizations throughout the world for the severity and heterogeneity of K. pneumoniae infections. Therefore, the traditional method for treatment of CRKP infections must be renewed. Additionally, the treatment protocols must be well correlated with the site of infections, phenotypes, and genotypes of CRKP strains.

Detection of NDM Variants (bla NDM-1, bla NDM-2, bla NDM-3) from Carbapenem-Resistant Escherichia coli and Klebsiella pneumoniae: First Report from Nepal

Background

Increasing burden of carbapenem resistance among Enterobacterales is attributable to their ability to produce carbapenemase enzymes like metallo-beta-lactamase (MBL), Klebsiella pneumoniae carbapenemase (KPC), and OXA-type. This study aimed to determine the prevalence of carbapenemases and MBL genes ((bla_NDM-1,bla_NDM-1 and bla_NDM-3) among E. coli and K. pneumoniae isolates.

Methods

A total of 2474 urine samples collected during the study period (July–December 2017) were processed at the microbiology laboratory of Kathmandu Model Hospital, Kathmandu. Isolates of E. coli and K. pneumoniae were processed for antimicrobial susceptibility testing (AST) by disc diffusion method. Carbapenem-resistant isolates were subjected to Modified Hodge Test (MHT) for phenotypic confirmation, and inhibitor-based combined disc tests for the differentiation of carbapenemase (MBL and KPC). MBL-producing isolates were screened for NDM genes by polymerase chain reaction (PCR).

Results

Of the total urine samples processed, 19.5% (483/2474) showed the bacterial growth. E. coli (72.6%; 351/483) was the predominant isolate followed by K. pneumoniae (12.6%; 61/483). In AST, 4.4% (18/412) isolates of E. coli (15/351) and K. pneumonia (3/61) showed resistance towards carbapenems, while 1.7% (7/412) of the isolates was confirmed as carbapenem-resistant in MHT. In this study, all (3/3) the isolates of K. pneumoniae were KPC-producers, whereas 66.7% (10/15), 20% (3/15) and 13.3% (2/15) of the E. coli isolates were MBL, KPC and MBL/KPC (both)-producers, respectively. In PCR assay, 80% (8/10), 90% (9/10) and 100% (10/10) of the isolates were positive for bla_NDM-1, bla_NDM-2 and bla_NDM-3, respectively.

Conclusion

Presence of NDM genes among carbapenemase-producing isolates is indicative of potential spread of drug-resistant variants. This study recommends the implementation of molecular diagnostic facilities in clinical settings for proper infection control, which can optimize the treatment therapies, and curb the emergence and spread of drug-resistant pathogens.

High prevalence of extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella pneumoniae isolates: A 5-year retrospective study at a Tertiary Hospital in Northern Thailand

Background

The global emergence and spread of extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales, especially Escherichia coli and Klebsiella pneumoniae, have been recognized as a public health concern as severe infections caused by these microorganisms increase morbidity and mortality. This study aimed to assess the prevalence of ESBL-positive E. coli and K. pneumoniae strains isolated from hospitalized patients in Chiangrai Prachanukroh hospital, Chiangrai province, Thailand.

Methods

This retrospective analysis was conducted from January 2016 to December 2020. A total of 384,001 clinical specimens were collected aseptically and further cultivated on an appropriate medium. All clinical isolates (one isolate per patient) were identified based on standard laboratory methods. Antibiotic susceptibility testing was performed by the Kirby Bauer disc diffusion technique following CLSI guidelines. ESBL production was screened with ceftazidime and cefotaxime discs based on the CLSI recommendations. Phenotypic confirmation of ESBL production was carried out using a double-disc synergy technique following the CLSI standard.

Results

Of a total of 384,001 clinical samples analyzed for bacterial species identification, 11,065 (2.9%) tested positive for E. coli and 5,617 (1.5%) for K. pneumoniae. Approximately 42.5% (4,706/11,065) of E. coli and 30.2% (1,697/5,617) of K. pneumoniae isolates were classified as ESBL producers. A higher proportion of ESBL producers was found in patients older than 60 years and male groups. The highest infection rates of ESBL-positive pathogens were observed among patients in a medical unit. ESBL-producing E. coli and K. pneumoniae isolates were predominantly found in urine and sputum, respectively. ESBL producers exhibited a high resistance rate to ampicillin (99.8–100%), cefazolin (100%), cefotaxime (100%), fluoroquinolones, and trimethoprim/sulfamethoxazole.

Conclusions

This study demonstrated the high prevalence and emerging antibiotic resistance of ESBL-positive E. coli and K. pneumoniae isolates from patients admitted to a provincial hospital in northern Thailand. Most ESBL-producing strains were highly resistant to several antimicrobial agents apart from carbapenems and aminoglycosides. These findings indicated that carbapenems and aminoglycosides should be advised as the first-line drugs of choice for serious infections with ESBL-producing Enterobacterales.

Association between Virulence Factors and Antimicrobial Resistance of Klebsiella pneumoniae Clinical Isolates from North Kerala

Klebsiella pneumoniae is a common bacterial pathogen causes wide range of infections all over the world. The antimicrobial resistance of K. pneumoniae is a global concern and expresses several virulence factors contributing to the pathogenesis. The incidences of bacterial co-infection in viral pneumonia are common. Increased risk of K. pneumoniae co-infection in viral respiratory tract infection should be alerted in COVID-19 pandemic period. The study aims to detect the association between antimicrobial resistance and factors causing pathogenicity of K. pneumoniae. For the current study, 108 K. pneumoniae clinical isolates were included. Antimicrobial susceptibility test was done by Kirby-Bauer disc diffusion method according to CLSI guidelines. Virulence factors such as biofilm formation, haemagglutination, haemolysins, hypermucoviscocity, siderophore, amylase, and gelatinase production were determined by phenotypic method. In this study K. pneumoniae showed high level of antimicrobial resistance towards ampicillin (92.59%) followed by amoxicillin-clavulanic acid (67.59%) and cotrimoxazole (47,22%). An important association between biofilm formation and antimicrobial resistance was found to be statistically significant for cotrimoxazole (P-value 0.036) and amoxicillin-clavulanic acid (P-value 0.037). Other virulence factors like hypermucoviscocity, haemagglutination, amylase, and siderophore production were also showed a statistically significant relation (P-value <0.05) with antimicrobial resistance. Further molecular studies are necessary for the identification of virulence and antimicrobial resistance genes, for the effective control of drug-resistant bacteria.

Antimicrobial Resistance Patterns, Extended-Spectrum Beta-Lactamase Production, and Associated Risk Factors of Klebsiella Species among UTI-Suspected Patients at Bahir Dar City, Northwest Ethiopia

Introduction

Klebsiella species cause pneumonia, UTI, and septicemia in human beings. Beta-lactam drugs are used extensively to treat patients infected with Klebsiella, but most of the Klebsiella species are resistant to third- and fourth-generation cephalosporins and monobactams to which data are scarce in the study area.

Objective

To determine the prevalence, antimicrobial resistance, ESBL production, and associated risk factors of Klebsiella species among UTI-suspected patients in Bahir Dar City, Northwest Ethiopia.

Methods

A multi-institution-based prospective cross-sectional study was conducted from January to May 2019. Midstream urines were collected from 385 patients and inoculated onto CLED and MacConkey agars. Identification of growth was done by a battery of biochemical tests. Antimicrobial resistance and ESBL production patterns were determined by using the disc-diffusion method on Mueller–Hinton agar. Quality of data was maintained by following SOPs and using Klebsiella pneumoniae (ACTT700603). Logistic regression statistical analysis was done using the SPSS, version 25, statistical package. A pvalue ≤ 0.05 was considered statistically significant.

Results

The median age of the study participants was 32 years. Majority of them were female, urban residents, and unable to read and/or write. The total Klebsiella species detected were 38 (9.9%). Of which, 25 (65.8%) were Klebsiella pneumoniae, followed by 6 (15.8%) Klebsiella ozaenae. 20 (80%), 19 (76%), and 19 (76%) Klebsiella pneumoniae showed resistance to amoxicillin/clavulanic acid, ampicillin, and cotrimoxazole, respectively. All K. oxytoca were resistant to ampicillin, and all K. rhinoscleromatis were resistant to cefoxitin and cefotaxime. Klebsiella species that showed resistance to ≥3 antimicrobials were 26 (68%). ESBL-producing Klebsiella species were 10 (26.3%). Patients who had history of antibiotic use, hospitalization, and tight dressing habit had more risk of getting UTI (p < 0.05) than their counterparts.

Conclusions

Overall UTI prevalence in our study was lower than that of previous Ethiopian studies. High MDR and ESBL-producing Klebsiella species were detected. Patients' history of antibiotic use, hospitalization, and tight dressing habit were risk factors for UTI. It calls up for improving prevention/control systems of Klebsiella species.

The Magnitude of Carbapenemase and ESBL Producing Enterobacteriaceae Isolates from Patients with Urinary Tract Infections at Tikur Anbessa Specialized Teaching Hospital, Addis Ababa, Ethiopia

BACKGROUND

The emergence of multidrug-resistant organisms, such as extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE), and carbapenemase-producing Enterobacteriaceae (CPE) is a public health concern. Therefore, this study aimed to determine the magnitude of carbapenemase and ESBL producing bacteria isolated from patients affected by Urinary Tract Infection (UTI).

METHODS

A cross-sectional study was conducted from December 2018 to March 2019 at Tikur Anbessa Specialized Hospital. A total of 120 Enterobacteriaceae isolates from UTI patients were collected and identified on species level using standard microbiological methods. Antimicrobial susceptibility test was determined according to the guidelines of the Clinical and Laboratory Standards Institute. Detection of ESBL production was carried out by using ESBL ChromoSelect Agar medium and the combined disk diffusion. Production of carbapenemase was determined by using Hodge-test and modified carbapenem inactivation method as described in CLSI guidelines.

RESULTS

Out of the total 120 Enterobacteriaceae isolates, 74 (61.7%) were ESBL-producers, and 8 (6.7%) were carbapenemase producers. The most common ESBL producing isolate was E.coli 38 (51.4%) and the most common carbapenemase-producing isolate was K.pneumoniae five (62.5%). Most of the ESBL and carbapenemase-producing isolates were recovered from hospitalized patients 46 (62.2%) and 7 (87.5%) respectively. The rate of ESBL and CPE production was observed high among patients taking antibiotics 64.8% (59/91) and 7.7% (7/91) respectively, but no significant association was observed p > 0.05. Furthermore, about 1.7% (2/120) isolates were found both ESBL and carbapenemase producers. Significant resistances rates were observed in ESBL and CPE isolates.

CONCLUSION

Enterobacteriaceae isolates showed a significantly higher rate of ESBL production. A significant figure of carbapenemase production was observed among Enterobacteriaceae isolates causing UTI. The production of ESBL and CPE enhanced for an increased rate of MDR patterns. Efforts need to be made to introduce a system for tracking and detecting ESBL-PE and CPE-producing bacteria in hospitals, and monitoring dissemination of ESBL and CPE-producing Enterobacteriaceae is strongly recommended.

Pediatric Febrile Urinary Tract Infection Caused by ESBL Producing Enterobacteriaceae Species

BACKGROUND

Over the past decade, drug resistance pattern has worsened for many of the uropathogens due to overuse of antibiotics for empiric treatment. The burden of extended spectrum beta-lactamase (ESBL) producing Enterobacteriaceae associated urinary tract infections (UTI) has become increasingly more common, limiting treatment options among children presenting with febrile UTI. We investigated the burden and correlates of ESBL producing Enterobacteriaceae associated UTI among children and antibacterial resistance pattern.

METHODS

284 midstream urine specimens were collected using standard aseptic techniques from 284 children who were diagnosed with suspected UTI. Urine culture and bacteria isolation were performed following standard bacteriological techniques. The Kirby-Bauer disk diffusion technique and the double-disc synergy test were used to investigate antibiotic susceptibility and presence of ESBL production.

RESULTS

UTI was confirmed using a positive urine culture for a relevant pathogen in 96/284 (33.8%) of the cases. Enterobacteriaceae accounted for 75% (72/96) of etiologies of UTI in children. The most frequent Enterobacteriaceae spp. were E. coli, 44.4% (32/72) and K. pneumonia, 27.8% (20/72). The overall multidrug resistance rate was 86.1% (62/72). ESBL-producers accounted for 41.7% (30/72) of the isolated Enterobacteriaceae. ESBL producing K. pneumonia and E. coli isolates accounted for 70% (14/20) and 37.5% (12/32), respectively. History of UTI in the past 1 year (adjusted odds ratio (AoR) = 0.08, 95%CI (0.01 - 0.57)) and medium family wealth index (AoR = 0.03, 95%CI (0.00 - 0.27)) protected from infection with ESBL-producing Enterobacteriaceae. Conclusion. ESBL production was more common in K. pneumonia and appeared to be a major factor contributing drug resistance UTI in children. The findings call for the need to incorporate ESBL testing in the routine clinical practice. The resistance level to commonly prescribed first-line antibiotics observed within Enterobacteriaceae was alarming calling for strengthened antimicrobial stewardship.

High prevalence of extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella pneumoniae fecal carriage among children under five years in Addis Ababa, Ethiopia

Background

Extended-spectrum beta-lactamase (ESBL) producing bacteria present an ever-growing burden in the hospital and community settings. Data on the prevalence of ESBL fecal carriage remain scarce in Ethiopia. Therefore, this study aimed to determine the prevalence of ESBL producing Escherichia coli and Klebsiella pneumoniae fecal carriage among children under five years in Addis Ababa, Ethiopia.

Methods

A facility-based cross-sectional study was conducted from April to May 2017. A total of 269 fecal/rectal swab samples were cultured on MacConkey agar. All positive cultures were characterized by colony morphology, Gram stain, and standard biochemical tests. Further, bacteria identification, antimicrobial susceptibility testing, and phenotypic detection of ESBL production were performed using VITEK 2 Compact as per the instruction of the manufacturer. Socio-demographic and risk factors data were collected using questionnaires. Data were entered by EPI INFO version 7.2.1.0 and analyzed by SPSS version 20.

Results

The overall prevalence of ESBL-producing E. coli and K. pneumoniae was 17.1% (46/269; 95% CI: 12.9%–22.7%). A total of 47 isolates were ESBL-positive, of which, 83.0% were E. coli and 17.0% were K. pneumoniae. ESBL producing E. coli and K. pneumoniae isolates were also showed high levels of MDR (93.6%) and high rates of co-resistance to aminoglycosides, fluoroquinolones, and trimethoprim-sulfamethoxazole. However, all isolates were carbapenem susceptible. In the risk factors analysis, Children’s mothers who had lower educational level (primary school) (OR: 2.472, 95% CI: 1.323–4.618, P = 0.0062) and children who used tap water for drinking (OR: 1.714, 95% CI: 1.001–3.659, P = 0.048) were found to be significantly associated with higher ESBL fecal carriage.

Conclusions

In this study, the high prevalence rate of ESBL producing E. coli and K. pneumoniae fecal carriage and high level of multidrug resistance among ESBL producing E. coli and K. pneumoniae were demonstrated. This suggested that the necessity of routine screening of ESBL is crucial for the early detection and appropriate antibiotics selection for infection caused by ESBL producing pathogens.

Evolution of the Antimicrobial resistance of Bacteria causing Urinary Tract Infections

BACKGROUND

The bacteria, Escherichia coli (E. coli) and Klebsiella pneumoniae (K. pneumoniae), are the main reasons for urinary tract infections (UTIs). This research aimed to investigate the isolation of etiologic agents from patients with UTI; it also investigates the antibiotic resistance activities and incidence of ESBL genes between different clinical separates of uropathogenic E. coli, determining their association with ESBL genes.

METHODS

The study enrolled 1000 positive growth isolates. The predominant pathogen associated with urinary tract infection, Gram-negative, were the main isolates from UTI patients, including E. coli, K. pneumoniae, Pseudomonas aeruginosa, Proteus mirabilis, Staphylococcus aureus and Enterococcus faecalis.

RESULTS

Among suspicious cases of urinary tract infection, we showed that 15.2% of the patients had UTI, and female patients in the childbearing age group were more affected. 644 E. coli (64.4%) and 322 (32.2%) K. pneumoniae were more isolated. Among 936 (93.6%) ESBL producing bacteria, 614 (61.4 %) E. coli showedhigh resistance to the antibiotics, Cefotaxime (85.7 %), Cefepime (85.7 %), Ciprofloxacin (83.1 %) and Kanamycin (77.9 %). Most ESBL-producing K. pneumoniae were multidrug-resistant (MDR). Nitrofurantoin, gentamycin, and imipenem were the most effective antibiotics for ESBL-producing E. coli isolates.

CONCLUSION

This study shows that the high rates of MDR Escherichia coli infection in our hospital were frequentative reasons for UTI. Nitrofurantoin and aminoglycosides were the most beneficial first-line drugs to be applied in the cases of UTI. It is recommended to conduct regular investigations on the drug resistance of all isolates and formulate helpful antibiotic treatment policies in China. It is important to determine the prevalence of ESBL in urine E. coli and K. pneumoniae isolates because it has a great influence on the selection of suitable antibacterial agents. In short, more than half of ESBL producers have multiple drug resistance (MDR).

Prevalence of multidrug-resistant and extended-spectrum beta-lactamase producing Gram-negative isolates from clinical samples in a tertiary care hospital of Nepal

BACKGROUND

The existence of multidrug-resistant organisms, including extended-spectrum beta-lactamases (ESBLs), is on rise across the globe and is becoming a severe problem. Knowledge of the prevalence and antibiogram profile of such isolates is essential to develop an appropriate treatment methodology. This study aimed to study the prevalence of Gram-negative isolates exhibiting ESBL at a tertiary care hospital and study their antibiogram profile.

METHODS

A cross-sectional study was conducted at Shahid Gangalal National Heart Centre, Kathmandu, Nepal, from June 2018 to November 2018. A total of 770 clinical samples were collected and identified using the conventional biochemical tests following the Clinical and Laboratory Standard Institute (CLSI) guidelines. Antimicrobial susceptibility testing (AST) was performed using the standardized Kirby-Bauer disk diffusion method. The screening test for ESBL producers was performed as recommended by the CLSI and the confirmatory test was performed phenotypically using the E-test.

RESULTS

Out of the 92 isolates, 84 (91.3%) were multidrug-resistant, and 47 (51.1%) were found to be potential ESBL producers. Of these, 16 isolates were confirmed ESBL producers by the E-test. Escherichia coli and Klebsiella pneumoniae were the predominant isolates and were also the major ESBL producers. Besides polymyxin B (100% sensitive), meropenem and imipenem showed high efficacy against the ESBL producers.

CONCLUSION

Multidrug resistance was very high; however, ESBL production was low. Polymyxin B and carbapenems are the choice of drugs against ESBL producers but should be used only as the last line drugs.

Detection of TEM and CTX-M Genes in Escherichia coli Isolated from Clinical Specimens at Tertiary Care Heart Hospital, Kathmandu, Nepal

Background: Antimicrobial resistance (AMR) among Gram-negative pathogens, predominantly ESBL-producing clinical isolates, are increasing worldwide. The main aim of this study was to determine the prevalence of ESBL-producing clinical isolates, their antibiogram, and the frequency of ESBL genes (bla_TEM and bla_CTX-M) in the clinical samples from patients. Methods: A total of 1065 clinical specimens from patients suspected of heart infections were collected between February and August 2019. Bacterial isolates were identified on colony morphology and biochemical properties. Thus, obtained clinical isolates were screened for antimicrobial susceptibility testing (AST) using modified Kirby–Bauer disk diffusion method, while ESBL producers were identified by using a combination disk diffusion method. ESBL positive isolates were further assessed using conventional polymerase chain reaction (PCR) to detect the ESBL genes bla_TEM and bla_CTX-M. Results: Out of 1065 clinical specimens, 17.8% (190/1065) showed bacterial growth. Among 190 bacterial isolates, 57.4% (109/190) were Gram-negative bacteria. Among 109 Gram-negative bacteria, 40.3% (44/109) were E. coli, and 30.2% (33/109) were K. pneumoniae. In AST, 57.7% (n = 63) Gram-negative bacterial isolates were resistant to ampicillin and 47.7% (n = 52) were resistant to nalidixic acid. Over half of the isolates (51.3%; 56/109) were multidrug resistant (MDR). Of 44 E. coli, 27.3% (12/44) were ESBL producers. Among ESBL producer E. coli isolates, 58.4% (7/12) tested positive for the bla_CTX-M gene and 41.6% (5/12) tested positive for the bla_TEM gene. Conclusion: Half of the Gram-negative bacteria in our study were MDR. Routine identification of an infectious agent followed by AST is critical to optimize the treatment and prevent antimicrobial resistance.

Multidrug-resistant and extended-spectrum beta-lactamase-producing uropathogens in children in Bhaktapur, Nepal

Background

The emergence of multidrug-resistant (MDR) and extended-spectrum beta-lactamase (ESBL)-producing uropathogens has complicated the treatment of urinary tract infections (UTI). Paediatric UTI is a common illness, which if not treated properly, may lead to acute and long-term complications, such as renal abscess, septicaemia, and renal scarring. This study aimed to determine the prevalence of MDR and ESBL-producing uropathogens among children.

Methods

During the study period (April 2017–April 2018), midstream urine samples were collected following aseptic procedures from children < 16 years in Siddhi Memorial Hospital. Standard culture and biochemical tests were performed to identify uropathogens and antimicrobial susceptibility test was done by modified Kirby-Bauer disc diffusion method following Clinical and Laboratory Standard Institute (CLSI) guidelines. ESBL-producing uropathogens were screened by ceftazidime (30 μg) and cefotaxime (30 μg) discs, and confirmed by the combination disc tests: ceftazidime + clavulanic acid (30/10 μg) or cefotaxime + clavulanic acid (30/10 μg) as recommended by CLSI.

Results

We processed 5545 non-repeated urine samples from the children with symptoms of UTI. A significant growth of uropathogens was observed in 203 samples (3.7%). The median age of the children was 24 months (interquartile range (IQR), 12–53 months). Escherichia coli (n = 158, 77.8%) and Klebsiella pneumoniae (n = 30, 14.8%) were common among the uropathogens. Among them, 80.3% were resistant to amoxycillin and 51.2% were resistant to cotrimoxazole. Most of them were susceptible to amikacin, nitrofurantoin, and ofloxacin. MDR was detected in 34.5% (n = 70/203) and ESBL producers in 24.6% (n = 50/203) of them. The proportion of MDR isolates was higher in children < 5 years (n = 59/153, 38.6%) than children ≥ 5 years (n = 11/50, 22%) (P = 0.03).

Conclusions

Nitrofurantoin, ofloxacin, and amikacin can be used for the empirical treatment for UTI in children in Bhaktapur, Nepal. MDR and ESBL-producing uropathogens are prevalent; this warrants a continuous surveillance of antimicrobial resistance.

The spectrum of bacteria and mechanisms of resistance identified from the casualties treated in the Israeli field hospital after the earthquake in Nepal, 2015: A retrospective analysis

BACKGROUND

On the April 25, 2015, a 7.8 magnitude earthquake struck Nepal. Soon-after, the Israel Defense Force (IDF) dispatched a tertiary field-hospital to Kathmandu. The field-hospital was equipped with a clinical laboratory with microbiology capabilities. Limited data exists regarding the spectrum of bacteria isolated from earthquake casualties. We aimed to identify the spectrum of bacteria and their mechanisms of resistance in-order to allow preparedness of antibiotic treatment protocols for future disaster scenarios.

METHODS

- The field-laboratory phenotypically processed cultures from sterile and non-sterile sites as needed clinically. Later-on, the isolates were brought to Israel for quality control, definite identification and molecular characterization including mechanisms of resistance.

RESULTS

A total of 82 clinical pathogens were isolated from 56 patients; 68% of them were Gram negative bacilli. The most common isolates were Enterobacteriaceae (55%) -36% carried bla-_NDM and 33% produced Extended-spectrum beta-lactamase (ESBL), mostly bla_CTX-M-15. Enterococcus spp were the main Gram positive bacteria isolated (22 isolates), yet, none were vancomycin resistant. The overall level of resistance was 27% MDR and 23% extensively drug resistant (XDR) bacteria.

CONCLUSIONS

- Gram negative bacteria were the predominant organism cultured from the casualties, of them 77% were MDR or XDR. NDM was the most common resistance mechanism. The Antibiotic inventory of a field-hospital should be set to cover a wide and unexpected spectrum of bacteria, including resistant organisms. This report adds important information to the scarce reports of bacterial resistance in Nepal.

Extended-Spectrum β-Lactamase (ESBL) Genotypes among Multidrug-Resistant Uropathogenic Escherichia coli Clinical Isolates from a Teaching Hospital of Nepal

Urinary tract infections (UTI) represent the most common bacterial infections among patients visiting outpatient clinics of healthcare centers in Nepal. However, treatment of such infections is compounded by emergence and spread of multidrug-resistant uropathogens associated with extended-spectrum β-lactamases (ESBLs). In this study, we aimed to investigate the burden of antimicrobial resistance and occurrence of ESBL genes among clinical isolates of uropathogenic Escherichia coli at a tertiary care teaching hospital of Nepal. During the study period, we processed a total of 1,626 urinary tract specimens, isolated significant bacterial pathogens, and investigated their antimicrobial susceptibilities. Escherichia coli (n = 154), the predominant pathogen associated with UTI, was further investigated for the existence of ESBL enzymes by using conventional phenotypic as well as molecular approaches. Among suspected cases of UTI, we found that 15.2% were having UTI and female patients of the reproductive age group were more affected (p < 0.05). Escherichia coli (154, 62.1%) was the key uropathogen, and majority (∼64.9%) of them were multidrug resistant (MDR). Among MDR E. coli isolates, 40.3% were producing extended-spectrum β-lactamases (ESBLs). bla-TEM (83.8%), bla-CTX-M (66.1%), and bla-SHV (4.8%) were common ESBL genotypes. Nitrofurantoin, gentamycin, and imipenem were the most effective antibiotics for ESBL-producing Escherichia coli isolates. It indicates that the high rates of multidrug-resistant Escherichia coli are frequent causes of UTI in our hospital. Nitrofurantoin and aminoglycosides are the most useful first-line drugs to be used in the cases of UTI. We recommend the regular investigation of drug resistance among all isolates and develop a useful antibiotic prescription policy in our country.

Extended-Spectrum β-Lactamase-Producing Escherichia coli and Klebsiella Species in Pediatric Patients Visiting International Friendship Children's Hospital, Kathmandu, Nepal

INTRODUCTION

Emergence and spread of antimicrobial resistance (AMR) is a global threat and significantly affects the treatment options for common infectious diseases. Inappropriate use of antibiotics, particularly third-generation cephalosporins, has contributed to the development of AMR. This study aims to determine the prevalence of extended-spectrum β-lactamase (ESBL) production in Escherichia coli and Klebsiella species isolated from various clinical samples.

METHODS

This cross-sectional study was conducted at International Friendship Children's Hospital, Kathmandu, Nepal, from August 2017 to January 2018. A total of 1443 samples that included urine, pus, wound swab, endotracheal tip, catheter tip, and blood were collected from pediatric patients below 15 years and processed by standard microbiological methods. Following sufficient incubation, isolates were identified by colony morphology, gram staining, and necessary biochemical tests. Identified bacterial isolates were then tested for antibiotic susceptibility test by modified Kirby-Bauer disk diffusion method and were subjected to ESBL screening by using 30 µg cefotaxime and ceftazidime. The ESBL production was confirmed by combination disk method.

RESULTS

From a total of 103 nonduplicated clinical isolates, E. coli (n = 79), Klebsiella pneumoniae (n = 18), and Klebsiella oxytoca (n = 6) were isolated from different clinical specimens. Of which, 64 (62.1%) exhibited multidrug resistance, and 29 (28.2%) were ESBL producers. All ESBL-producing isolates were resistant toward ampicillin, cefotaxime, ceftriaxone, and ceftazidime. Most ESBL producers were susceptible toward imipenem (89.7%; 26/29), nitrofurantoin (82.8%; 24/29), piperacillin/tazobactam (79.3%; 23/29), and amikacin (72.4%; 21/29).

CONCLUSIONS

A high prevalence of multidrug-resistant ESBL organisms was found in this study among pediatric patients. Treatment based on their routine identification and susceptibility to specific antibiotics is critical to halt the spread of AMR and ESBL.

Coexistence of β-Lactamases in Community-Acquired Infections in a Tertiary Care Hospital in India

Introduction

The trends of β-lactamases producing Enterobacteriaceae is ever increasing, and limited studies have reported investigating coexistence of β lactamases in Enterobacteriaceae. A cross-sectional study after approval from the Institutional Ethical committee was conducted between June 2014 and May 2016 in community-acquired infections due to multidrug-resistant organisms in our tertiary care. Nonrepetitive clinical samples from the out-patient department (OPD) were processed for bacteriological culture and identification of Enterobacteriaceae. An antibiotic susceptibility test, screening, and phenotypic confirmation for ESBLs and carbapenemases and AmpC producers were performed to check for coexistence of these enzymes.

Results

Nonrepetitive clinical specimens processed for culture and identification in our hospital revealed 417 positive isolates in community acquired infections which were multidrug-resistant organisms, and on screening for β-lactamases, 293 isolates were positive for one of the three beta lactamases, ESBL, AmpC, or carbapnemases. Coproduction of ESBL and MBL was seen in 5 isolates, 35 isolates showed coproduction of ESBL and AmpC enzymes, and AmpC and MBL coproduction was exhibited in only in 5 isolates.

Conclusions

Coexistence of ESBLs, AmpC producers, and carbapenemases has been described. Continuous monitoring and surveillance and proper infection control and prevention practices will limit the further spread of these superbugs within the hospital and beyond.

Antibiotic resistance, virulence and genetic diversity of Klebsiella pneumoniae in community- and hospital-acquired urinary tract infections in Iran

Klebsiella pneumoniae is among the most important causes of urinary tract infection (UTI). The aim of this study was to investigate the prevalence and correlation of antibiotic resistance with virulence characteristics and genetic diversity in K. pneumoniae isolated from UTIs in Iran. Phenotypic tests and antibiotic susceptibility were carried out on the isolates. Detection of the virulence and extended-spectrum β-lactamase (ESBL) genes was performed by polymerase chain reaction. Pulsed-field gel electrophoresis (PFGE) was used for exploring the genomic relatedness. Hemolysin, biofilm, and hypermucoviscosity formation were observed in 87.1%, 86.4%, and 12.1% of isolates, respectively. The antibiotic resistance rate of K. pneumoniae isolates ranged from 12.1% for meropenem to 100% for amoxicillin. The prevalence of virulence genes ranged from 1.4% for cnf-1 to 100% for mrkD, fimH, kpn, and entB genes. In this study, 91.7%, 33.3%, and 4.2% of phenotypically ESBL-producers were positive for bla_CTX-M, bla_TEM, and bla_SHV genes, respectively. An association was observed between the presence of traT, fyuA, or cnf-1 genes with antibiotic resistance. Two clone types were obtained by PFGE that indicate different K. pneumoniae clones in community- and hospital-acquired UTIs. The findings of this study are valuable in development of treatment strategies against UTIs in Iran.

Distribution of bla CTX - M , bla TEM , bla SHV and bla OXA genes in Extended-spectrum-β-lactamase-producing Clinical isolates: A three-year multi-center study from Lahore, Pakistan

Background

Frequency of extended-spectrum-β-lactamase-producing clinical isolates is increasing worldwide. This is a multi-center study which was aimed to check the frequency of third-generation cephalosporin resistance and distribution of the key genetic determinants of Extended-spectrum-β-lactamase-producing Clinical isolates in Pakistan.

Methods

A total of 2372 samples were processed in three tertiary care hospitals and one diagnostic research center of Lahore, Pakistan during Aug-2014 to Sep-2017. Analytical profile index (API 20-E) was used for biochemical characterization of isolates. Antibiotic susceptibility testing (AST) and third generation cephalosporin resistant (3GC-R) isolates were subjected to: double disc synergism test (DDST), combination disc test (CDST) and epsilometric test (E-test) for confirmation of ESBL-production. PCR amplification of isolates with plasmid and genomic DNA was performed. Amplicon sequences were checked for gene-variants and statistical analyses were performed to check the significance of data.

Results

A total of 497/995 (50%) isolates including Escherichia coli 65% (n = 321), Klebsiella spp. 25% (n = 124) and Pseudomonas. 5% (n = 24), Enterobacter spp. 4% (n = 20) and Acinetobacter spp. 2% (n = 8) were screened as third generation cephalosporin resistant (3GC-R). Urine 56% (n = 278) followed by pus 20% (n = 99) and wound swab 6% (n = 29) were frequent sources. Incidence of ESBL-producers detected by combination disc test was 79% (n = 392). PCR revealed bla_{CTX − M} (76%) gene followed by bla_OXA (52%), bla_TEM (28%) and bla_SHV (21%) were most prevalent among ESBL-producers detected by CDST. bla_{CTX − M − 1}(65%), bla_OXA (78%) and bla_TEM (57%) genes were carried on plasmids. Amplicon sequencing revealed bla_{CTX − M − 15} (75%), bla_OXA − 1 (49%) and bla_{TEM − 1B} (34%) and 21 (n = 28) isolates carried three genes in them.

Conclusion

Prevalence of ESBL-producing isolates has increased 1.13 folds during study years. Isolates had high prevalence of ESBL-encoding bla_{CTXM − 15} gene and narrow spectrum bla_OXA − 1 and bla_{TEM − 1B} were also prevalent.

Molecular characterization, serotypes and phenotypic and genotypic evaluation of antibiotic resistance of the Klebsiella pneumoniae strains isolated from different types of hospital-acquired infections

Purpose: Virulent and resistant Klebsiella pneumoniae strains are considered as one of the most significant causes of hospital-acquired infections. The present investigation was done to study the distribution of virulence factors, capsule serotypes and phenotypic and genotypic evaluation of antibiotic resistance of the K. pneumoniae strains isolated from hospital-acquired infections.

Patients Materials and methods: Two hundred and sixty different types of hospital-acquired infections were collected and cultured. Antibiotic resistance pattern of K. pneumoniae isolates and their molecular characterization were studied using disk diffusion and PCR, respectively.

Results: One hundred and fifty out of 260 (44.22%) hospital-acquired infections harbored K. pneumoniae. Urine samples (63.75%) had the highest prevalence of K. pneumoniae, while wound (33.33%) had the lowest. K. pneumoniae strains harbored the highest prevalence of resistance against ampicillin (100%), cefuroxime (100%), amoxicillin/clavulanic acid (95.65%) and ceftazidime (95.52%). FimH-1 (93.04%), traT (92.17%), mrkD (84.34%), and entB (80.86%) were the most commonly detected virulence genes. AcrAB (96.52%) and tolC (85.21%) were the most commonly detected antibiotic resistance genes. Prevalence of ompK35 and ompK36 virulence genes were 75.65% and 79.13%, respectively. Prevalence of K1 and K2-positive serotypes were 27.82% and 6.96%, respectively.

Conclusions: High prevalence of resistance against several types of antibiotics and simultaneous presence of some virulence factors and multi-drug resistance genes pose an important public health issue.

Low rate of gut colonization by extended-spectrum β-lactamase producing Enterobacteriaceae in HIV infected persons as compared to healthy individuals in Nepal

A worldwide increase in the gastrointestinal colonization by extended-spectrum β-lactamase (ESBL)-producing bacteria has been observed. Their prevalence amongst Healthy People Living with HIV (HPLWH) has not been investigated adequately. The aim of this study was to determine and compare the rates of and risk factors for intestinal carriage and acquisition of extended-spectrum β-lactamase producing Enterobacteriaceae (ESBL-E) and carbapenemase-producing Enterobacteriaceae (CPE) among healthy people living with HIV (HPLWH) and healthy HIV negative population in the community. A cross-sectional study was conducted. Rectal swabs from HPLWH (n = 119) and HIV negative individuals (n = 357) from the community were screened for ESBL and CPE. Phenotypically confirmed ESBL-E strains were genotyped by multiplex PCR. The risk factors associated with ESBL-E colonization were analyzed by a multivariable conditional logistic regression analysis. Specimen from 357 healthy volunteers (213 female and 144 male) and 119 HPLWH (82 female and 37 male) with a median age of 30 [IQR 11–50] years were included in the study. ESBL colonization were found in 45 (37.82% [CI 29.09, 47.16]) and 246 (68.91% [CI 63.93, 73.49]), HPLWH and healthy HIV negative participants respectively. HPLWH had lower ESBL carriage rate (odds ratio 0.274 [CI 0.178, 0.423]) compared to healthy HIV negative subject’s (p<0.01). In this study, no carbapenemase-producing bacteria were isolated.CTX-M-15 type was the most predominant genotype in both groups. Livestock contact and over-the-counter medications were significantly associated with a higher ESBL-E carriage rate among healthy subjects. This is the first study in Nepal that has demonstrated a high rate of gut colonization by ESBL-E in the community, predominantly of blaCTX-M-15 genotype. This study divulges the low fecal carriage rate of ESBL producing bacteria in HPLWH group compared to healthy individuals in western Nepal. The factors responsible for this inverse relationship of HIV status and gut colonization by ESBL-E are unidentified and require further large-scale study.

Predominance of CTX-M Type Extended Spectrum β-lactamase (ESBL) Producers Among Clinical Isolates of Enterobacteriaceae in a Tertiary Care Hospital, Kathmandu, Nepal

Background:

ESBL problem is increasing worldwide and only limited studies on genes of ESBL are performed in Nepal.

Objectives:

We aimed to focus on the molecular detection of plasmid-mediatedblaTEM,blaSHVandblaCTX-Mgenes among the ESBL producing Enterobacteriaceae from different clinical samples.

Methods:

A total of 550 clinical samples were processed and organisms of Enterobacteriaceae were identified using standard microbiological process. ESBL producers were screened and confirmed using modified Kirby Bauer disc diffusion method by CLSI guidelines. Plasmids extracted from the confirmed ESBL positives were the template for PCR.blaSHV,blaTEMandblaCTX-Mgenes were amplified using specific primers of respective genes by uniplex PCR. The presence of these genes was confirmed by gel electrophoresis.

Results:

Among 550 different clinical samples 343 (62.36%) were culture positive. Of which, 157 (45.57%) belonged to Enterobacteriaceae.Escherichia coli(45.9%) was predominant. Of these 33.2% (52/157) isolates ESBL positive. ESBL-E. coli(52.8%) were prevalent. All ESBL positive organisms were sensitive to imipenem. Of confirmed ESBL positives, 34.6% harboringblaTEMgene, 30.8% harboringblaSHVgene andblaCTX-Mgenes were present in all ESBL producers. Twenty-eightout of 52 (53.9%) isolates harbored multipleblagenes, the most common combination beingblaCTX-M+blaTEM(21.2%).

Conclusion:

We report 100% plasmid mediated CTX-M genotype among ESBL producers which might indicate rapid dissemination ofblaCTX-Mgenes from the community to the patients. Besides, there is a need for regular monitoring of antibiotic resistance in the country and de-escalate the use of antibiotics so as to preserve the antibiotics for future generation.

Antimicrobial Resistance Profile of Different Clinical Isolates against Third-Generation Cephalosporins

BACKGROUND

Drug resistant microorganisms lead to an increase in morbidity and mortality as they boost the risk of inappropriate therapy. Hence, data on antimicrobial resistance help define the best possible treatment for individual patients. Therefore, this study aimed to screen the antimicrobial resistant profile of 3rd generation cephalosporin drugs in Jimma University Specialized Teaching Hospital.

METHODS

A hospital based prospective cross-sectional study was conducted in Jimma University Specialized Hospital (JUSH) from April to August 2016. The clinical samples such as wound swab, urine, sputum, and stool were collected from hospitalized patients. Then, bacterial species were isolated and identified as per the standard microbiological methods. Antimicrobial susceptibility tests were carried out using various antimicrobial discs by Kirby-Bauer disc diffusion method.

RESULTS

Totally, 248 bacterial isolates were obtained from 154 (62.1%) male and 94 (37.9%) female patients. Escherichia coli (25.4%) and Staphylococcus aureus (19.0 %) were the predominant organisms isolated from specimens. About 140 (56.5%) and 149 (60.1%) of the total bacterial isolates were found to be resistant to ceftriaxone and ceftazidime, respectively. The majority of Escherichia coli isolates 46 (73%) were resistant to ceftriaxone and 41 (65%) of them were resistant to ceftazidime. Staphylococcus aureus, which accounted 19% of the total bacterial isolates, showed 23.4% and 34% resistance to ceftriaxone and ceftazidime, respectively. Among the bacterial strains revealing resistant to ceftriazone and ceftazidime, about 109 (44%) and 108 (43.5%) of them were resistant to two, three, or four other drugs, respectively.

CONCLUSION

Bacterial resistance towards third-generation cephalosporin (ceftriaxone and ceftazidime) is escalating as more than half of the isolated strains demonstrated resistance to these drugs. Moreover, these strains also revealed multidrug resistance mainly against clinically used drugs which could render therapy unsuccessful. Therefore, in clinical use appropriate medications should be selected based on the data obtained from antimicrobial susceptibility tests.

Antimicrobial misuse in pediatric urinary tract infections: recurrences and renal scarring

Background

In children, urinary tract infection (UTI) is one of a common bacterial infection. This study was conducted to detect the uropathogen, antimicrobial susceptibility, pathogen associated with recurrences and renal scarring in children initially taken care from general practitioners and later presented to tertiary care.

Methods

Every inward UTI episode, culture and antimicrobial susceptibility was done while on past 6-month, history of infections and use of antimicrobials was collected using clinical records and demonstration of antimicrobials. Children with recurrent pyelonephritis was followed and in vitro bio film formation was assessed.

Results

Frequency of UTI was significantly high among infants (p = 0.03). Last 6-month, all (220) were exposed to antimicrobials. Cefixime was the commonly prescribed antimicrobial (p = 0.02). In current UTI episode, 64.5% (142/220) of children with UTI were consulted GPs’ prior to seek treatment from tertiary care pediatric unit (p = 0.02). While on follow up child who developed UTI, found urine culture isolates were significantly shifted from E. coli and K. pneumoniae to extended spectrum of beta-lactamase (ESBL) E. coli and K. pneumoniae. Out of 208 participants, 36 of them had re-current pyelonephritis (R-PN). Renal scarring (RS) was detected in 22 out of 70 patients with pyelonephritis following dimercaptosuccinic acid scan. Following each episodes of recurrent pyelonephritis 11% of new scar formation was detected (p = 0.02). Bio film forming E. coli and K. pneumoniae was significantly associated in patients with R-PN (p = 0.04).

Discussion

Medical care providers often prescribe antimicrobials without having an etiological diagnosis. While continuing exposure of third generation cephalosporin and carbapenem leads to development of ESBL and CRE microbes in great. The empiric uses of antimicrobials need to be stream lined with local epidemiology and antimicrobial susceptibility pattern. R-PN in childhood leads to RS. In great, bio film formation act as the focus for such recurrences.

AmpC and extended spectrum beta-lactamases production among urinary isolates from a tertiary care hospital in Lalitpur, Nepal

Background

Production of AmpC and extended spectrum beta-lactamases among urinary isolates has created a serious problem to the successful management of the urinary tract infection. The main purpose of this study was to determine the rates of the extended spectrum beta-lactamase (ESBL) production and AmpC beta-lactamase (ABL) production among urinary isolates.

Results

Among total 564 urinary isolates, 514 (91.1%) were gram negative bacilli and 50 (8.9%) were gram positive cocci. E. coli (76.1%) was the most common bacteria isolated. Staphylococcus aureus (6.7%) was the predominant gram positive bacteria isolated. 35 (6.8%) of the 514 gram negative bacilli were ESBL producers. Similarly, 14 (2.7%) of the gram negative bacilli were ABL producers. Only one isolate was ESBL and ABL co-producer. Highest rate of susceptibility of gram negative bacteria was seen toward amikacin (97.3%) followed by imipenem (94.4%). Similarly, highest rate of susceptibility among gram positive cocci was seen toward vancomycin (100%) followed by amikacin (93.5%).

Conclusions

Low rates of AmpC and extended spectrum beta-lactamases production in comparison to other previous studies were reported. On the basis of the antimicrobial susceptibility patterns of the bacteria we reported in our study, amikacin, imipenem and nitrofurantoin can be used for the preliminary treatment of urinary tract infections caused by gram negative bacteria and vancomycin and amikacin for treatment of urinary tract infections caused by gram positive bacteria.

Antimicrobial susceptibility pattern of Shigella spp. isolated from children under 5 years of age attending tertiary care hospitals, Nepal along with first finding of ESBL-production

Background

Shigella is an important cause of bacterial gastroenteritis in resource-poor countries. The treatment of shigellosis mostly requires antibiotics. However, the increase of multidrug resistance along with emergence of extended-spectrum β-lactamase and ciprofloxacin resistance among Shigella spp. has challenged the situation. This study was conducted to determine the distribution of species and antibiotic susceptibility pattern of Shigella species isolated from stool specimen among children less than 5 years of age in Nepal.

Results

Out of total 717 stool samples collected, 15 cases of Shigella spp. was isolated which includes 12 S. flexneri and 3 S. sonnei. Multidrug resistance was found among 13(86%) of the isolates. One of the isolates of S. flexneri was found to be ESBL-producer with MIC >256 mg/L for cefixime.

Conclusion

The high occurrence of multidrug resistance among Shigella spp. along with a case of ESBL-production for the first time in Nepal alarms the concerns about dissemination of the resistant isolates. So, systemic monitoring of the antimicrobial susceptibility pattern of Shigella spp. is becoming crucial to guide therapy.

ESBL Production Among E. coli and Klebsiella spp. Causing Urinary Tract Infection: A Hospital Based Study

Introduction:

Increase in extended-spectrum β-lactamases (ESBL) producing microbes in recent years has led to limitations of treatment options. This study aimed to assess the prevalence of ESBL producing E. coli and Klebsiella spp. at a tertiary hospital in Nepal.

Methods:

A total of 2209 non-repetitive mid-stream urine (MSU) samples were collected during the study period (March to September 2014). Identification of the isolates was done by Gram's staining followed by biochemical tests. Antibiotic susceptibility testing was done by modified Kirby-Bauer disc diffusion method and interpretation was done following Clinical and Laboratory Standard Institute (CLSI) guidelines, 2013. ESBL screening among E. coli and Klebsiella spp. isolates were done using ceftriaxone, cefotaxime, ceftazidime and cefpodoxime. The confirmation was done by phenotypic disc diffusion test (combined disc method) using ceftazidime (30µg) and ceftazidime plus clavulanic acid (30/10µg), and cefotaxime (30µg) and cefotaxime plus clavulanic acid (30/10µg) disc as per CLSI guidelines.

Results:

A total of 451 samples showed significant bacteriuria with 365 (80.9%) E. coli, 17 (3.8%) Klebsiella pneumoniae and 3 (0.7%) Klebsiella oxytoca. Of 451 isolates, 236 (52.3%) were found MDR strains. By combined disk test, 33 (91.7%) E. coli and 3 (8.3%) Klebsiella spp. were found ESBL producers.

Conclusion:

Higher prevalence of ESBL producing E. coli and Klebsiella spp. was observed warranting prompt need of surveillance for effective management of such MDR strains.

Emerging Perils of Extended Spectrum β-Lactamase Producing Enterobacteriaceae Clinical Isolates in a Teaching Hospital of Nepal

Introduction. Infections due to extended spectrum β-lactamase producing Enterobacteriaceae are on the rise. They pose serious public health problems due to their resistance to large number of antibiotics. However, little is known about the genotypes of ESBL from Nepal. Therefore, the study presents results of phenotypic and molecular characterization of ESBL producing Escherichia coli and Klebsiella spp. isolated from various clinical specimens in a tertiary care teaching hospital of Nepal. Methods. A total of 172 Enterobacteriaceae clinical isolates recovered from various clinical specimens were analyzed for their antibiotic susceptibility test. Detection of ESBLs was carried out using combination disk test and multiplex PCR for their genotypes (CTX-M, SHV, and TEM). Results. Out of 172 clinical isolates, 70 (40.6%) of them were found ESBL producers. The major source of ESBL producers was urinary tract samples and the highest ESBL production was observed in Escherichia coli (46.5%). Among ESBL genotypes, CTX-M (91.4%) was most predominant, followed by TEM (65.7%) and SHV (11.4%) in both of the isolates. Conclusions. High level of drug resistance and ESBL production was observed among the clinical isolates. There is a need for longitudinal and nationwide surveillance for drug resistance in clinical isolates and antimicrobial stewardship is necessary to guide the appropriate and judicious antibiotic use.

Extended-spectrum ß-Lactamase-producing Enterobacteriaceae as a Common Cause of Urinary Tract Infections in Sri Lanka

Background

Extended-spectrum ß-lactamase-producing Enterobacteriaceae (ESBL-PE) are increasingly reported as pathogens in urinary tract infections (UTIs). However, in Sri Lanka, the clinical and molecular epidemiology of ESBL-PE implicated in UTIs has not been well described.

Materials and Methods

We conducted prospective, laboratory-based surveillance from October to December 2013 at a tertiary care hospital in southern Sri Lanka and enrolled patients ≥1 year of age with clinically relevant UTIs due to ESBL-PE. Isolate identity, antimicrobial drug susceptibility, and ESBL production were determined. Presence of ß-lactamase genes, bla_SHV, bla_TEM, and bla_CTX-M, was identified by polymerase chain reaction.

Results

During the study period, Enterobacteriaceae were detected in 184 urine samples, with 74 (40.2%) being ESBL producers. Among 47 patients with ESBL-PE who had medical records available, 38 (80.9%) had clinically significant UTIs. Most UTIs (63.2%) were community acquired and 34.2% were in patients with diabetes. Among 36 cultured ESBL-PE isolates, significant susceptibility (>80%) was only retained to amikacin and the carbapenems. The group 1 bla_CTX-M gene was present in 90.0% of Escherichia coli isolates and all Klebsiella pneumoniae and Enterobacter cloacae isolates. The bla_SHV and bla_TEM genes were more common in K. pneumoniae (75% and 50%) and E. cloacae (50% and 50%) isolates than in E. coli (10% and 20%) isolates, respectively.

Conclusion

The majority of UTIs caused by ESBL-PE were acquired in the community and due to organisms carrying the group 1 CTX-M ß-lactamase. Further epidemiologic studies of infections due to ESBL-PE are urgently needed to better prevent and treat these infections in South Asia.

Multidrug resistant Enterobacteriaceae and extended spectrum β-lactamase producing Escherichia coli: a cross-sectional study in National Kidney Center, Nepal

Background

Emergence of antibacterial resistance and production of Extended spectrum β-lactamases (ESBLs) are responsible for the frequently observed empirical therapy failures. Most countries have experienced rapid dissemination of ESBLs producing Enterobacteriaceae isolates, particularly E. coli and Klebsiella pneumoniae. ESBLs are clinically significant and when detected, indicate the need for the use of appropriate antibacterial agents. But antibacterial choice is often complicated by multi-resistance.

Methods

This study was carried from June to November 2014 to study the multidrug resistant (MDR) Enterobacteriaceae and ESBL producing E. coli among urine isolates in hospital setting. Isolates from urine samples were primarily screened for possible ESBL production followed by phenotypic confirmation. Antibiotic susceptibility testing (AST) was done by Kirby Bauer disk diffusion method following Clinical and Laboratory Standard Institute (CLSI) guidelines.

Results

Out of 450 urine samples processed, 141 significant growths were obtained including 95 Enterobacteriaceae isolates with 67 E. coli. Among Enterobacteriaceae, 92 (96.84 %) were recorded as MDR and 18 (26.87 %) E. coli were confirmed as ESBLs producers.

Conclusions

Using the phenotypic confirmatory test forwarded by the CLSI, relatively significant E. coli isolates tested were ESBL producers. Also high numbers of MDR organisms were isolated among Enterobacteriaceae. Isolates showed significant resistance to the commonly prescribed drugs. These findings suggest for further study in this field including the consequences of colonization with MDR and ESBL-producing bacteria both in the community and in the hospital setting.

The role of point-of-care tests in antibiotic stewardship for urinary tract infections in a resource-limited setting on the Thailand-Myanmar border

Objective

Published literature from resource‐limited settings is infrequent, although urinary tract infections (UTI) are a common cause of outpatient presentation and antibiotic use. Point‐of‐care test (POCT) interpretation relates to antibiotic use and antibiotic resistance. We aimed to assess the diagnostic accuracy of POCT and their role in UTI antibiotic stewardship.

Methods

One‐year retrospective analysis in three clinics on the Thailand–Myanmar border of non‐pregnant adults presenting with urinary symptoms. POCT (urine dipstick and microscopy) were compared to culture with significant growth classified as pure growth of a single organism >10⁵ CFU/ml.

Results

In 247 patients, 82.6% female, the most common symptoms were dysuria (81.2%), suprapubic pain (67.8%) and urinary frequency (53.7%). After excluding contaminated samples, UTI was diagnosed in 52.4% (97/185); 71.1% (69/97) had a significant growth on culture, and >80% of these were Escherichia coli (20.9% produced extended‐spectrum β‐lactamase (ESBL)). Positive urine dipstick (leucocyte esterase ≥1 and/or nitrate positive) compared against positive microscopy (white blood cell >10/HPF, bacteria ≥1/HPF, epithelial cells <5/HPF) had a higher sensitivity (99% vs. 57%) but a lower specificity (47% vs. 89%), respectively. Combined POCT resulted in the best sensitivity (98%) and specificity (81%). Nearly one in ten patients received an antimicrobial to which the organism was not fully sensitive.

Conclusion

One rapid, cost‐effective POCT was too inaccurate to be used alone by healthcare workers, impeding antibiotic stewardship in a high ESBL setting. Appropriate prescribing is improved with concurrent use and concordant results of urine dipstick and microscopy.

Community acquired multi-drug resistant clinical isolates of Escherichia coli in a tertiary care center of Nepal

BACKGROUND

Multi-drug resistance (MDR) in Gram-negative organisms is an alarming problem in the world. MDR and extensively-drug resistance (XDR) is in increasing trend due to the production of different types of beta (β)-lactamases. Thus the aim of this study was to document the incidence of MDR and XDR in clinical isolates of Escherichia coli and also to find out the enzymatic mechanisms of β-lactam antibiotics resistance.

METHODS

Two hundred clinical isolates of Escherichia coli (E. coli) identified by standard laboratory methods were studied. Antibiotic susceptibility profile was performed for all the isolates and the suspected isolates were phenotypically tested for the production of extended spectrum β-lactamase (ESBL), metallo β-lactamase (MBL) and AmpC β-lactamase (AmpC) by recommended methods.

RESULTS

Around three-fourth (78%) of the total isolates were multi-drug resistant. ESBL, MBL and AmpC production was found in 24%, 15% and 9% of isolates respectively. Amikacin, chloramphenicol and colistin were found to be the most effective antibiotics.

CONCLUSIONS

High percentage of MDR was observed. β-lactamase mediated resistance was also high. Thus, regular surveillance of drug resistance due to β-lactamases production and infection control policy are of utmost importance to minimize the spread of resistant strains.

Co-existence of beta-lactamases in clinical isolates of Escherichia coli from Kathmandu, Nepal

BACKGROUND

The trend of extended-spectrum beta-lactamases producing Escherichia coli (ESBL-EC) is increasing in Nepal. Limited studies have been reported investigating ESBL types and carbapenemases in E. coli.

METHODS

A cross sectional study was conducted between June 2012 to January 2013 in Kathmandu Medical College and Teaching Hospital, Nepal. Non-repetitive clinical samples from out-patient department (OPD) and Intensive Care Units (ICU) were processed for bacteriological culture and identification of E. coli. Antibiotic susceptibility test, screening and phenotypic confirmation for ESBLs and carbapenemases and PCR (blaCTX-M, blaSHV and blaTEM-type ESBLs, blaVIM, blaIMP and blaNDM-1-type carbapenemases, and class 1 integron element integrase gene) were performed. Clones were resolved by PCR-Randomly Amplified Polymorphic DNA.

RESULTS

Out of 332 non-repetitive clinical specimens processed for culture and identification 160 (48.2%) were culture positive. Of which, 93 (58.1%) were E. coli. Of these, 24 (25.8%) were phenotypically confirmed as ESBL-EC and 3 (12.50%) of 24 ESBL-EC were carbapenemase producers. blaCTX-M-type ESBL was most common (23, 95.8%) followed by blaTEM (7, 29.2%) and blaSHV (3, 12.5%). blaVIM, blaIMP and blaNDM-1 were present in 3, 2 and 2 ESBL-EC, respectively. Class 1 integron element was present in 18 (75.0%) ESBL-EC. Nine isolates possessed more than one type of beta-lactamases. Interestingly, all carbapenemase producers were isolated form ICU and co-existence of blaCTX-M, blaSHV, blaTEM, blaIMP, blaVIM and blaNDM-1 beta-lactamases was documented in one ESBL-EC (EC104). All most all isolates had different RAPD patterns.

CONCLUSIONS

For the first time in Nepal, high prevalence of blaCTX-M-type ESBL and co-existence of ESBLs and carbapenemases has been described. Continuous monitoring and surveillance and proper infection control and prevention practices will limit the further spread of these super-bugs within this hospital and beyond.

High colonization rates of extended-spectrum β-lactamase (ESBL)-producing Escherichia coli in Swiss travellers to South Asia- a prospective observational multicentre cohort study looking at epidemiology, microbiology and risk factors

BACKGROUND

International travel contributes to the worldwide spread of multidrug resistant Gram-negative bacteria. Rates of travel-related faecal colonization with extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae vary for different destinations. Especially travellers returning from the Indian subcontinent show high colonization rates. So far, nothing is known about region-specific risk factors for becoming colonized.

METHODS

An observational prospective multicentre cohort study investigated travellers to South Asia. Before and after travelling, rectal swabs were screened for third-generation cephalosporin- and carbapenem-resistant Enterobacteriaceae. Participants completed questionnaires to identify risk factors for becoming colonized. Covariates were assessed univariately, followed by a multivariate regression.

RESULTS

Hundred and seventy persons were enrolled, the largest data set on travellers to the Indian subcontinent so far. The acquired colonization rate with ESBL-producing Escherichia coli overall was 69.4% (95% CI 62.1-75.9%), being highest in travellers returning from India (86.8%; 95% CI 78.5-95.0%) and lowest in travellers returning from Sri Lanka (34.7%; 95% CI 22.9-48.7%). Associated risk factors were travel destination, length of stay, visiting friends and relatives, and eating ice cream and pastry.

CONCLUSIONS

High colonization rates with ESBL-producing Enterobacteriaceae were found in travellers returning from South Asia. Though risk factors were identified, a more common source, i.e. environmental, appears to better explain the high colonization rates.