The magnitude of extended-spectrum beta-lactamase- producing Enterobacteriaceae from clinical samples in Ethiopia: a systematic review and meta-analysis

Antimicrobial resistance profile and associated factors of hospital-acquired gram-negative bacterial pathogens among hospitalized patients in northeast Ethiopia

BACKGROUND

Antimicrobial resistance is a major global public health issue. Infections caused by resistant species are associated with higher mortality rates, longer hospital stays, medication failure, and rising medical costs. The World Health Organisation has declared multidrug resistance-associated infections as an epidemic of public health concern.

OBJECTIVE

This study aimed to evaluate the antimicrobial resistance profile and associated factors of hospital-acquired Gram-negative bacterial pathogens among hospitalized patients in Northeast Ethiopia.

MATERIALS AND METHODS

A health facility-based cross-sectional study was conducted among hospitalized patients from March 2021 to February 2022. About 810 clinical specimens were collected, transported, and processed from admitted patients following the standard bacteriological procedures. The clinical samples were inoculated onto blood agar, MacConkey agar, and chocolate agar. Furthermore, the species identification was done using gram reactions, colony morphology, and color and biochemical tests. Antimicrobial susceptibility tests, extended-spectrum beta-lactamase, and carbapenemase production were performed as per the clinical laboratory standard institute guidelines. For analysis, the information was entered into Epi-data and exported to SPSS. A P value of < 0.05 with a 95% confidence interval was considered as a statistically significant association.

RESULTS

Out of 810 clinical specimens, 285/810 (35.2%) developed bacterial infections. From the isolated bacteria, E. coli was the predominant bacteria accounting for 78/285 (27.4%) followed by K. pneumoniae, 69/285(24.42%), whereas P. vulgaris accounted for the least, 7/285 (2.5%). Overall, 132/285 (46.3%) and 99/285 (34.7%) of culture-positive patients were infected by extended-spectrum beta-lactamase and carbapenemase-producing bacteria. The overall multidrug resistance rate of the isolated bacteria was 89.4%. The highest antibiotic resistance rates were detected for doxycycline (92.9%), amoxicillin-clavulanic acid (83.9%), and ampicillin (93%). The least antibiotic resistance rate was observed for meropenem at 41.1% and amikacin at 1.7%, respectively.

CONCLUSIONS AND RECOMMENDATIONS

In the study area, significant health concerns include a range of hospital-acquired bacterial infections associated with elevated rates of multidrug resistance, Extended-spectrum beta-lactamase (ESBL), and carbapenemase-producing bacterial pathogens. Consequently, it is recommended to conduct drug-susceptibility testing of isolates and molecular detection at a national level to optimize antibiotic usage for treating prevalent bacterial infections in this area.

Incidence of catheter-associated urinary tract infections by Gram-negative bacilli and their ESBL and carbapenemase production in specialized hospitals of Bahir Dar, northwest Ethiopia

BACKGROUND

Catheter-associated urinary tract infections (CAUTIs) due to multidrug-resistant Gram-negative bacilli (GNB) is a common concern globally. Investigating the incidence of CAUTI and associated antibiotic resistance has paramount importance from the health care associated infections perspective. This study therefore assessed the incidence of CAUTIs due to GNB and the production of extended-spectrum beta-lactamase (ESBL) and carbapenemase among inpatients in specialized hospitals of Northwest, Ethiopia.

METHODS

A total of 363 patients with indwelling urinary catheters who were admitted in the hospital for > 48 h were consecutively enrolled and followed from 3 to 18 days. Data were collected through interviewing and review of medical records. Patients who developed at least one of the following: fever (> 38 OC), suprapubic tenderness, or costovertebral angle pain, coupled with a GNB positive urine culture of ≥ 103 CFU/mL with no more than two bacterial species were defined as CAUTI. The ESBL and carbapenemase production were detected and identified by chromogenic medium. Logistic regression analysis was done to identify associated factors.

RESULTS

From 363 patients followed, the incidence rate of CAUTI was 27.8 per 1000 catheter days. Catheterization for ≥ 8 days (AOR = 10.6, 95%CI:1.8-62.1) and hospitalization for > 10 days (AOR = 8.1, 95%CI: 2.4-27.2) were the factors significantly associated with CAUTIs. E. coli (n = 18, 34.6%), Proteus species (n = 7, 13.5%), and P. aeruginosa (n = 6, 11.5%) were the most frequent GNB. Isolates revealed high rates of resistance to amoxicillin-clavulanic acid (100%), cefazolin (n = 51, 98%), ceftazidime (n = 47, 90%) and cefotaxime (n = 46, 88%). Most of the GNB isolates (86.5%) were multidrug-resistant. Overall, 19.2% and 5.8% of GNB isolates were ESBL and carbapenemase producers, respectively.

CONCLUSIONS

Incidence of CAUTI with Gram-negative bacilli is high. As most of the GNB isolates are MDR and showed a super high rate of resistance to amoxicillin-clavulanic and third-generation cephalosporins, empirical treatment with these substances is virtually ineffective in patients with suspected GNB infection in Ethiopia. The expression of ESBL and carbapenemase among GNB isolates is also a concern. Therefore, improved infection prevention and control measures, careful use of catheters and third generation of cephalosporins are needed to improve patient outcomes and reduce the burden of CAUTIs and the spreading of antimicrobial resistance.

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.

Extended-spectrum β-lactamase- producing gram-negative bacterial infections in severely ill COVID-19 patients admitted in a national referral hospital, Kenya

BACKGROUND

Bacterial infections in COVID-19 patients, especially those caused by multidrug-resistant gram-negative strains, are associated with increased morbidity, hospital stay and mortality. However, there is limited data on the epidemiology of extended-spectrum β-lactamase (ESBL)-producing bacteria in COVID-19 patients. Here, we assessed the prevalence and the factors associated with ESBL-producing gram-negative bacterial (GNB) infections among severely ill COVID-19 patients admitted in Kenyatta National Hospital (KNH), Kenya.

METHODS

We adopted a descriptive cross-sectional study design for patients admitted between October 2021 and February 2022, purposively recruiting 120 SARS-CoV- 2 infected participants based on clinical presentation. Demographics and clinical characteristics data were collected using structured questionnaires and case report forms. Clinical samples were collected and analyzed by standard microbiological methods in the KNH Microbiology laboratory and the Centre for Microbiology Research, Kenya Medical Research Institute.

RESULTS

GNB infections prevalence was 40.8%, majorly caused by ESBL-producers (67.3%) predominated by Klebsiella pneumoniae (45.5%). Generally, 73% of the ESBL producers harboured our target ESBL genes, mainly CTX-M-type (59%, 17/29) in K. pneumoniae (76.9%, 20/26). GNB harbouring TEM-type (83%, 10/12) and SHV-type (100%, 7/7) genes showed ESBLs phenotypes and inhibitor resistance, mainly involving clavulanate, but most of them remained susceptible to tazobactam (60%, 6/10). SHV-type genes carrying ESBL producers showed resistance to both cefotaxime (CTX) and ceftazidime (CAZ) (K. pneumoniae), CAZ (E. coli) or CTX (E. cloacae complex and K. pneumoniae). About 87% (20/23) of isolates encoding CTX-M-type β-lactamases displayed CTX/ceftriaxone (CRO) resistance phenotype. About 42% of isolates with CTX-M-type β-lactamases only hydrolyzed ceftazidime (CAZ). Isolates with OXA-type β-lactamases were resistant to CTX, CAZ, CRO, cefepime and aztreonam. Patients with comorbidities were 10 times more likely to have an ESBL-producing GNB infection (aOR = 9.86, 95%CI 1.30 - 74.63, p = 0.003).

CONCLUSION

We report a high prevalence of ESBL-GNB infections in severely ill COVID-19 patients, predominantly due to Klebsiella pneumoniae harbouring CTX-M type ESBL genes. The patient's underlying comorbidities increased the risk of ESBL-producing GNB infection. In COVID-19 pandemic, enhanced systematic and continuous surveillance of ESBL-producing GNB, strict adherence to infection control measures and antimicrobial stewardship policies are warranted in the current study setting.

Colonization of extended-spectrum β-lactamase-producing Enterobacteriaceae does not affect subsequent infection and liver transplant outcomes: a retrospective observational cohort study

Objective

To investigate the colonization rate of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E), subsequent infections by ESBL-E and ESBL-producing gram-negative bacilli (ESBL-GNB), and the effect of ESBL-E colonization on clinical outcomes in liver transplantation (LT) recipients.

Methods

This is a retrospective cohort study that included patients who underwent LT at Shanghai Renji Hospital between July 2016 and December 2017. Rectal swabs from LT patients at the postoperative ICU enrollment were screened anonymously for ESBL-E carriage. Demographics data, laboratory indexes, operative complications, and clinical course information were also obtained. The extent of ESBL-E colonization, the subsequent infection rates of ESBL-E and ESBL-GNB, and the clinical outcomes were compared between ESBL-E colonized and non-colonized patients.

Results

In total, 496 liver transplant recipients (387 males) were included in this study. ESBL-E colonization was detected in 240 patients (48.4%). There was no significant difference between the rates of ESBL-E infection (5.8 vs. 3.1%, p = 0.143), Ischemia-reperfusion ≥ 3 (27.9 vs. 24.6%, p = 0.403), acute kidney injury (39.6 vs. 38.7%, p = 0.835), acute rejection (2.1 vs. 1.6%, p = 0.664), graft versus host reaction (1.3 vs. 1.2%, p = 0.937), duration of hospitalization (22 vs. 23 days, p = 0.568), 90-day mortality (7.1 vs. 4.7%, p = 0.262) and 1-year mortality (12.9 vs. 9.3%, p = 0.265) in patients with and without ESBL-E colonization. Though the ESBL-GNB infection rate was higher in ESBL-E colonized patients (12.1 vs. 6.6%, p = 0.037), multivariate analysis showed that ESBL-E colonization did not increase the risk of ESBL-GNB infection (Model 1: aOR 1.755, 95% CI: 0.911-3.380, p = 0.093; Model 2: aOR 1.556, 95% CI: 0.761-3.181, p = 0.226). The ESBL-producing bacteria spectrum of colonization was significantly different from that of infections occurring after LT, with only three colonization events leading to infection by the same pathogen identified.

Conclusion

ESBL-E colonization in liver transplant patients is not associated with ESBL-E infection, nor is it a risk factor for post-transplant ESBL-GNB infection. Additionally, ESBL-E colonization does not lead to worse prognoses when compared with non-colonized patients.

Clinical trial registration

Chinese Clinical Trial Registry, Identifier [ChiCTR2100043034].

Efficacy of Zidovudine-Amikacin Combination Therapy In Vitro and in a Rat Tissue Cage Infection Model against Amikacin-Resistant, Multidrug-Resistant Enterobacteriales

Multidrug-resistant (MDR) Enterobacteriales infections have become an urgent global threat to public health. The aim of this study was to evaluate the efficacy of zidovudine-amikacin combination therapy in vitro and in vivo. Molecular characteristics and antibiotic resistance profiles of 53 amikacin-resistant MDR, extensively drug-resistant (XDR), or pan-drug-resistant (PDR) clinical isolates were examined via PCR and susceptibility testing. Checkerboard assays were performed for these 53 isolates to assess in vitro synergistic effects of the zidovudine-amikacin combination, and static time-kill experiments were performed for four XDR or PDR Enterobacteriales isolates. A Galleria mellonella model and a rat tissue cage infection model were established to assess in vivo synergistic effects. The aac(6')-Ib gene was detected in 25 (47.2%) isolates, followed by armA in 5 (9.4%) isolates, rmtB in 27 (50.9%) isolates, and rmtC in 3 (5.8%) isolates. Checkerboard assays showed the synergy of this combination against 38 (71.7%) isolates. The time-kill assays further confirmed that zidovudine strongly synergized with amikacin against four XDR or PDR Enterobacteriales isolates. The Galleria mellonella model study showed that the survival benefit of zidovudine-amikacin combination therapy was significantly better than that of monotherapy for those four Enterobacteriales isolates. Furthermore, the rat tissue cage infection model study showed that zidovudine-amikacin combination therapy displayed more potent bactericidal activity than monotherapy after 3 and 7 days of treatment for the above four isolates. Our data support the idea that the zidovudine-amikacin combination could be a plausible alternative therapy against infections with amikacin-resistant MDR Enterobacteriales, especially with XDR and PDR Enterobacteriales. IMPORTANCE Our study revealed for the first time that the zidovudine-amikacin combination shows a significant bactericidal effect against amikacin-resistant MDR, XDR, and PDR Enterobacteriales. Second, using in vitro and in vivo approaches, our study showed that zidovudine strongly synergized with amikacin against amikacin-resistant MDR Enterobacteriales isolates. Most importantly, with regard to survival benefit, pharmacokinetics, and bactericidal effects, our in vivo experiment demonstrated the effectiveness of zidovudine-amikacin.

Emergence of High Prevalence of Extended-Spectrum Beta-Lactamase and Carbapenemase Producing Acinetobacter Species and Pseudomonas aeruginosa Among Hospitalized Patients at Dessie Comprehensive Specialized Hospital, North-East Ethiopia

Background

The emergence of extended spectrum beta lactamase and carbapenemase production of Acinetobacter and Pseudomonas aeruginosa is a great concern and major cause of nosocomial infections due to its ability to production of extended spectrum beta lactamase and carbapenemase enzymes.

Objective

To assess Emergence of high prevalence of extended-spectrum beta-lactamase and Carbapenemase producing Acinetobacter species and Pseudomonas aeruginosa among hospitalized patients at Dessie Comprehensive Specialized Hospital, North-East Ethiopia.

Materials and Methods

A hospital-based cross-sectional study was conducted from February–August 2021 at Dessie Referral Hospital in the North eastern Ethiopia. A total of 423 clinical samples taken from admitted patients. Clinical specimens were collected aseptically and inoculated on blood agar and MacConkey agar media. Antimicrobial susceptibility test, ESBL and carbapenemase production were performed as CLSI guideline. The data were entered into the Epi-data and imported to Statistical Package for Social Science version 25. P value of <0.05 with odds ratio and 95% confidence interval was considered as statistically significant.

Results

Out of 423 clinical specimens 17.7% (75/423) were culture positive nosocomial infection. The proportions of nosocomial infection were higher in blood stream followed by wound infection which accounted 24.6%, 20.8%, respectively. Overall, 32/75 (42.7%) and 19/75 (25.3%) patients had infection with ESBL and CP producing bacterial infection. P. aeruginosa was the most predominant isolated bacteria 46/75 (52.9%). The overall multidrug resistance rate of the isolated bacteria was 88% (66/75). The majority of highest resistance rate was Piperacillin tazobactam 50 (66.7%) and Aztreonam 26 (56.5%), respectively, while least resistance rate was Amikacin 27 (36%).

Conclusion

The incidence rates of ESBL, carbapenemase production and antimicrobial resistant Acinetobacter species and P. aeruginosa infections are high. Therefore, treatment should be based on culture and antimicrobial test result and minimize the use of antibiotics empirically.

Antimicrobial Resistance and Molecular Epidemiology of Escherichia coli From Bloodstream Infection in Shanghai, China, 2016-2019

Background: Bloodstream infections are recognized as important nosocomial infections. Escherichia coli (E. coli) is the most prevalent Gram-negative bacillary pathogen causing bloodstream infections (BSIs). This retrospective study investigated drug susceptibility and molecular epidemiology of E. coli isolated from patients with BSI in Shanghai, China.

Methods: We collected E. coli isolated from the blood cultures of patients with BSI between January 2016 and December 2019. We randomly selected 20 strains each year to investigate antimicrobial resistance, resistance genes, and molecular epidemiological characteristics. Antimicrobial susceptibility testing was performed by the disk diffusion method. PCR was performed to detect extended-spectrum β-lactamases (ESBLs), carbapenemase genes, and housekeeping genes, and phyloviz was applied to analyze multilocus sequence typing (MLST).

Results: Penicillins, first- and second-generation cephalosporins and fluoroquinolones have high resistance rates (>60%). Among the 80 randomly selected strains, 47 (58.8%) produced ESBLs, and one produced carbapenemase. Sequencing of resistance genes identified bla_CTX−M−14 (34%, 16/47), bla_CTX−M−15 (23.4%, 11/47) and bla_CTX−M−27 (14.8%, 7/47) as the most prevalent genotypes of ESBLs. ST131 (14/80) was the most prevalent sequence type (ST), followed by ST1193 (10/80), ST648 (7/80).

Conclusions: Our findings suggest that amikacin, carbapenems, and piperacillin-tazobactam have relatively low resistance rates and may be the preferred antibiotic regimens for empiric therapy. ST131 and bla_CTX−M−14 are still the main prevalent in Shanghai with a rapid increase in the occurrence of ST1193 is rapidly increasing and more diverse bla_CTX genes.