Prevalence of Extended-Spectrum Beta-Lactamases-Producing Microorganisms in Patients Admitted at KRRH, Southwestern Uganda

Monitoring Multi-Drug Resistant Klebsiella pneumoniae in Kitagata Hot Spring, Southwestern Uganda: A Public Health Implication

Background

The concerning frequency of K. pneumoniae in various recreational settings, is noteworthy, especially regarding multi-drug resistant (MDR) strains. This superbug is linked to the rapid spread of plasmids carrying these resistance genes. The objective of this study was to evaluate the spatiotemporal prevalence of MDR-K. pneumoniae in the Kitagata hot spring, Southwestern Uganda.

Methods

A laboratory-based descriptive longitudinal study was conducted between May and July 2023. During rainy and dry seasons, we collected eighty water samples in the morning and evening from the hot spring. The temperature at each point was measured prior to sample collection, and two samples were obtained at varying depths. 5 mL of each homogenized sample were pre-enriched in brain heart infusion broth, and subsequently in both blood and violet red bile agar. The Kirby-Bauer disk diffusion method was performed, followed by the detection of carbapenemase (CR) and extended-spectrum β-lactamase (ESBL) production. Polymerase chain reaction showed resistance genes viz. bla TEM, bla CTX-M and bla KPC. Data were analyzed using SPSS-20 to obtain chi-square tests and regression analysis.

Results

K. pneumoniae accounted for 30.0% of isolates obtained from Kitagata hot springs, with all isolates classified as multi-drug resistant. All isolates were resistant to ampicillin, rifampicin, ceftazidime, and azithromycin (79.2%). Additionally, 95.8% of isolates harbored bla TEM gene alone and both bla TEM and bla CTX genes, followed by bla KPC alone (33.3%), with 25% harboring all three resistance genes. During the dry season, K. pneumoniae had a higher prevalence (35.0%) compared to the wet season (25.0%). The prevalence of MDR-K. pneumoniae significantly increased over the course of the study. The presence of the three studied resistance genes in the isolates showed a positive correlation with the second phase of sample collection and the dry season but exhibited a negative correlation with temperature, except for isolates harboring either bla TEM alone or bla TEM+KPC+CTX genes.

Conclusion

Kitagata hot spring serves as a hotspot for continuous dissemination and acquisition of MDR-K. pneumoniae harboring resistance genes that encode for ESBL and CR production. The healthcare sector ought to implement an ongoing monitoring and surveillance system as well as robust antimicrobial resistance stewardship programs aimed at delivering health education to the community.

Phenotypic and Genotypic Characterization of Extended Spectrum Beta-Lactamase-Producing Clinical Isolates of Escherichia coli and Klebsiella pneumoniae in Two Kenyan Facilities: A National Referral and a Level Five Hospital

Background

The emergence of antimicrobial resistance (AMR) and multidrug resistance (MDR) among Escherichia coli and Klebsiella pneumoniae, especially through the production of extended spectrum β-lactamases (ESBLs), limits therapeutic options and poses a significant public health threat.

Objective

The aim of this study was to assess the phenotypic and genetic determinants of antimicrobial resistance of ESBL-producing Escherichia coli and Klebsiella pneumoniae isolates from patient samples in two Kenyan Hospitals.

Methods

We collected 138 E. coli and 127 K. pneumoniae isolates from various clinical specimens at the two health facilities from January 2020 to February 2021. The isolates' ESBL production and antibiotic susceptibility were phenotypically confirmed using a standard procedure. Molecular analysis was done through conventional polymerase chain reaction (PCR) with appropriate primers for gadA, rpoB, blaTEM, blaSHV, blaOXA, blaCTX-M-group-1, blaCTX-M-group-2, blaCTX-M-group-9, and blaCTX-M-group-8/25 genes, sequencing and BLASTn analysis.

Results

Most E. coli (82.6%) and K. pneumoniae (92.9%) isolates were ESBL producers, with the highest resistance was against ceftriaxone (69.6% among E. coli and 91.3% among K. pneumoniae) and amoxicillin/clavulanic acid (70.9% among K. pneumoniae). The frequency of MDR was 39.9% among E. coli and 13.4% among K. pneumoniae isolates. The commonest MDR phenotypes among the E. coli isolates were CRO-FEP-AZM-LVX and CRO-AZM-LVX, while the FOX-CRO-AMC-MI-TGC-FM, FOX-CRO-FEP-AMC-TZP-AZM-LVX-MI and CRO-AMC-TZP-AZM-MI were the most frequent among K. pneumoniae isolates. Notably, the FOX-CRO-FEP-AMC-TZP-AZM-LVX-MI phenotype was observed in ESBL-positive and ESBL-negative K. pneumoniae isolates. The most frequent ESBL genes were blaTEM (42%), blaSHV (40.6%), and blaOXA (36.2%) among E. coli, and blaTEM (89%), blaSHV (82.7%), blaOXA (76.4%), and blaCTX-M-group-1 (72.5%) were most frequent ESBL genes among K. pneumoniae isolates. The blaSHV and blaOXA and blaTEM genotypes were predominantly associated with FOX-CRO-FEP-MEM and CRO-FEP multidrug resistance (MDR) and CRO antimicrobial resistance (AMR) phenotypes, among E. coli isolates from Embu Level V (16.7%) and Kenyatta National Hospital (7.0%), respectively.

Conclusions

The high proportion of ESBL-producing E. coli and K. pneumoniae isolates increases the utilization of last-resort antibiotics, jeopardizing antimicrobial chemotherapy. Furthermore, the antimicrobial resistance patterns exhibited towards extended-spectrum cephalosporins, beta-lactam/beta-lactamase inhibitor combinations, fluoroquinolones, and macrolides show the risk of co-resistance associated with ESBL-producing isolates responsible for MDR. Hence, there is a need for regular surveillance and implementation of infection prevention and control strategies and antimicrobial stewardship programs.

Addressing gaps in AMR awareness in the public: an evidence-based policy brief to guide school curriculum review in Uganda

The government of Uganda, through its Ministry of Health, previously adopted curriculum review as a mechanism to respond to public health threats such as HIV/AIDS and include content in primary and secondary schools. This approach contributes to raising public awareness, a key strategy recommended by the World Health Organization to support the global response to the threat of antimicrobial resistance (AMR). This policy brief, developed for policymakers related to school curricula, aims to advocate for and support integration of AMR content in Uganda's primary and secondary level school curricula. The policy brief supports efforts by the multisectoral National AMR Subcommittee to create awareness on this issue as part of its role in facilitating the operationalization of Uganda's National Action Plan on AMR.

Risk Factors for Community Colonization With Extended-Spectrum Cephalosporin-Resistant Enterobacterales (ESCrE) in Botswana: An Antibiotic Resistance in Communities and Hospitals (ARCH) Study

BACKGROUND

The epidemiology of extended-spectrum cephalosporin-resistant Enterobacterales (ESCrE) in low- and middle-income countries (LMICs) is poorly described. Identifying risk factors for ESCrE colonization is critical to inform antibiotic resistance reduction strategies because colonization is typically a precursor to infection.

METHODS

From 15 January 2020 to 4 September 2020, we surveyed a random sample of clinic patients at 6 sites in Botswana. We also invited each enrolled participant to refer up to 3 adults and children. All participants had rectal swabs collected that were inoculated onto chromogenic media followed by confirmatory testing. Data were collected on demographics, comorbidities, antibiotic use, healthcare exposures, travel, and farm and animal contact. Participants with ESCrE colonization (cases) were compared with noncolonized participants (controls) to identify risk factors for ESCrE colonization using bivariable, stratified, and multivariable analyses.

RESULTS

A total of 2000 participants were enrolled. There were 959 (48.0%) clinic participants, 477 (23.9%) adult community participants, and 564 (28.2%) child community participants. The median (interquartile range) age was 30 (12-41) and 1463 (73%) were women. There were 555 cases and 1445 controls (ie, 27.8% of participants were ESCrE colonized). Independent risk factors (adjusted odds ratio [95% confidence interval]) for ESCrE included healthcare exposure (1.37 [1.08-1.73]), foreign travel [1.98 (1.04-3.77]), tending livestock (1.34 [1.03-1.73]), and presence of an ESCrE-colonized household member (1.57 [1.08-2.27]).

CONCLUSIONS

Our results suggest healthcare exposure may be important in driving ESCrE. The strong links to livestock exposure and household member ESCrE colonization highlight the potential role of common exposure or household transmission. These findings are critical to inform strategies to curb further emergence of ESCrE in LMICs.

Whole strains vs MGEs in short and longterm transmission of ESBL genes between healthcare and community settings in Uganda

Multidrug-resistant ESBL-producing Escherichia coli are a leading cause of infections in hospital and community settings. Based on samples from two hospitals in Uganda and households of inpatients we tested the hypothesis that ESBL E. coli and/or their resistance determinants could spread within the healthcare and community settings through discharged patients that were still colonized. We used bacterial culture, susceptibility testing whole genome sequencing and detailed bioinformatics analysis to test the above hypothesis. Genome analysis revealed presence of predominantly blaCTX-M-15 and blaOXA-1 genes with a total resistome with genes belonging to 14 different classes of antimicrobials. Short-term cases of strain sharing were reported within each setting and strains from the two settings were found to cluster together based on their overall resistome. Long-term horizontal transfer of ESBL genes by various IncF and IncY types of plasmids shared between healthcare and community settings was demonstrated. Based on hybrid assembly, plasmid reconstruction and phylogenetic analyses, our study suggests that while the dissemination of AMR between healthcare and community settings in the short-term is possible at whole strain level, the long-term transmission between healthcare and communities is sustained by the transfer of plasmids circulating across niches and disseminating related resistomes.

Epidemiology and prevention of hospital-acquired carbapenem-resistant Enterobacterales infection in hospitalized patients, Northeast Ethiopia

OBJECTIVE

Carbapenemase-producing carbapenem-resistant Enterobacterales (CP-CRE) are usually healthcare associated. The aim of this study was to investigate the epidemiology of hospital-acquired CRE and multi-drug-resistant infections, and identify associated risk factors in hospitalized patients in Northeast Ethiopia.

METHODS

This cross-sectional study was conducted in patients admitted with sepsis between January and June 2021. Demographic and clinical data were collected using questionnaires. In total, 384 samples were collected and cultured based on source of infection. Bacterial species identification was performed using biochemical tests, and drug susceptibility testing was done using the Kirby-Bauer disk diffusion method. The modified carbapenem inactivation method was employed for carbapenemase detection. Data were analysed using Statistical Package for the Social Sciences.

RESULTS

The overall rate of CP-CRE infection was 14.6%. Bloodstream infections and urinary tract infections were the predominant hospital-acquired infections (HAIs). The majority of CP-CRE were Escherichia coli and Klebsiella pneumoniae, and accounted for 4.9%. Chronic underlying disease (adjusted odds ratio (AOR): 7.9, 95% confidence interval (CI): 1.9-31.5), number of beds per room (AOR: 11, 95% CI: 1.7-75) and eating raw vegetables (AOR: 11, 95% CI: 3.4-40) were significantly associated with hospital-acquired CRE infection.

CONCLUSIONS

The rate of CP-CRE infection found in this study is concerning. There is a need for further evaluation of risk factors and measures to decrease HAI. Hand hygiene, increased laboratory capacity, improved infection prevention measures, and antimicrobial stewardship programmes are needed in healthcare settings to halt the transmission of CP-CRE.

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.

Colonization with extended-spectrum cephalosporin-resistant Enterobacterales (ESCrE) and carbapenem-resistant Enterobacterales (CRE) in healthcare and community settings in Botswana: an antibiotic resistance in communities and hospitals (ARCH) study

OBJECTIVES

Although extended-spectrum cephalosporin-resistant Enterobacterales (ESCrE) and carbapenem-resistant Enterobacterales (CRE) are a global challenge, data on these organisms in low- and middle-income countries are limited. In this study, we sought to characterize colonization data critical for greater antibiotic resistance surveillance efforts.

METHODS

This study was conducted in three hospitals and six clinics in Botswana. We conducted ongoing surveillance of adult patients in hospitals and clinics and adults and children in the community. All participants underwent rectal swab sampling to identify ESCrE and CRE.

RESULTS

Enrollment occurred from January 15, 2020, to September 4, 2020, but paused from April 2, 2020, to May 21, 2020, because of a countrywide COVID-19 lockdown. Of 5088 individuals approached, 2469 (49%) participated. ESCrE colonization prevalence was 30.7% overall (43% for hospital participants, 31% for clinic participants, 24% for adult community participants, and 26% for child community participants) (P <0.001). A total of 42 (1.7%) participants were colonized with CRE. CRE colonization prevalence was 1.7% overall (6.8% for hospital participants, 0.7% for clinic participants, 0.2% for adult community participants, and 0.5% for child community participants) (P <0.001). ESCrE and CRE prevalence varied substantially across regions and was significantly higher prelockdown versus postlockdown.

CONCLUSIONS

ESCrE colonization was high in all settings in Botswana. CRE prevalence in hospitals was also considerable. Colonization prevalence varied by region and clinical setting and decreased after a countrywide lockdown.

High Prevalence of Multi-Drug Resistance and Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae Among Hospitalized Patients Presumptive for Bacterial Infection at Debre Berhan Comprehensive Specialized Hospital, Ethiopia

Background

Multi-drug resistant Enterobacteriaceae (MDR-E), primarily extended-spectrum beta-lactamase producers (ESBLs), have emerged as a major public health concern. This study aimed to determine the prevalence of multi-drug resistance and extended-spectrum beta-lactamase-producing Enterobacteriaceae among hospitalized patients presumptive for bacterial infections at Debre Berhan Comprehensive Specialized Hospital, Ethiopia.

Methods

A hospital-based cross-sectional study was conducted from January to May 2021. A total of 384 hospitalized patients presumptive for bacterial infections were included in the study. Urine, wound, blood, stool, and sputum samples were collected and cultured on MacConkey agar, Cysteine Lactose Electrolyte Deficient medium, and Blood agar. Identification was done using a panel of biochemical tests. The antimicrobial susceptibility test was done by disc diffusion. Screening of ESBL production was done by using cefotaxime and ceftazidime and confirmed by the combination disk method per clinical laboratory standard institute guidelines. Data analysis was performed by Statistical Package for Social Sciences software version 25, and a P-value ≤0.05 was considered as statistically significant.

Results

Out of 384 study participants, a total of 164 Enterobacteriaceae were isolated. The overall multi-drug resistance rate (MDR) was 92.1%. The overall prevalence of ESBL-PE was 104 (63.4%). E. coli 50 (30.5%) and K. pneumoniae 24 (14.6%) were the predominant ESBL producers. The highest ESBL producers E. coli (13.4%) and K. pneumoniae (6.1%) were isolated from urine sample. History of antibiotic use for the last three months (P-value=0.01), admission in neonatal intensive care unit (P-value=0.02), history of hospital stays (P-value=0.01), and chronic disease (P-value=0.04) showed statistically significant association with ESBL-PE infection.

Conclusion

The prevalence of MDR-E and ESBL-PE was high. Therefore, strong infection prevention and control measures and careful selection of antibiotics are needed in the study area to block the transmission and infection in the healthcare setting.

High Magnitude of Fecal Carriage of Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae at Debre Berhan Comprehensive Specialized Hospital, Ethiopia

Background

Gastrointestinal colonization rate of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) is the major risk factor for infection and dissemination of resistance clones in healthcare facilities. This study aimed to investigate the magnitude of the fecal carriage of ESBL-PE and associated factors among hospitalized patients at Debre Berhan Comprehensive Specialized Hospital, North Shoa, Amhara Regional State, Ethiopia.

Methods

A hospital-based cross-sectional study was conducted among 383 hospitalized patients from November 2020 to March 2021. Stool sample or rectal swab was aseptically collected and cultured on different culture media for isolation of Enterobacteriaceae. Identification was done by conventional biochemical tests. Screening of extended-spectrum beta-lactamase (ESBL) production was done by using cefotaxime and ceftazidime and confirmed by the combination disk method. Data analysis was performed by Statistical Package for Social Sciences software version 25 and a P-value ≤0.05 was considered as statistically significant.

Results

From the total of 383 hospitalized patients, a total of 347 Enterobacteriaceae were isolated. The overall gastrointestinal colonization rate of ESBL-PE was 47.3% (164/347). The predominant ESBL-PE were E. coli 54.9% (90/164) and K. pneumoniae 33.5% (55/164). The overall multi-drug resistance rate (MDR) was 87.8% (305/347). The highest resistance was observed to ampicillin (98.3%), followed by gentamicin (80.7%), and tetracycline (73.3%), respectively. ESBL-PE were highly susceptible to meropenem (90.2%) and imipenem (89.0%). History of antibiotic use in the past 3 months (p<0.001), admission in the neonatal intensive care unit (p=0.023), and presence of chronic disease (p<0.001) were independently associated with fecal carriage of ESBL-PE.

Conclusion

The magnitude of ESBL-PE and MDR was high in the study area. Meropenem and imipenem were active against ESBL-PE. Therefore, strict infection control measure is needed in the study area to limit the infection and dissemination of ESBL-PE.

Extended-spectrum Beta-lactamase and AmpC beta-lactamases producing gram negative bacilli isolated from clinical specimens at International Clinical Laboratories, Addis Ababa, Ethiopia

BACKGROUND

Extended spectrum Beta-lactamases (ESBLs) and AmpC beta-lactamases (AmpC) are the common enzymes produced by gram negative bacilli, which are their main mechanisms of resistance to all generations of cephalosporins. Hence, this study aimed to determine the magnitude of ESBLs and AmpC producing gram negative bacilli (GNB) isolated from clinical specimens at International clinical Laboratories in Addis Ababa, Ethiopia.

METHODS

A cross sectional study was conducted from January to May 2018. From different clinical specimens, 338 GNB were isolated and characterized. Bacterial species identification, antimicrobial susceptibility testing and screening for ESBLs and AmpC production were performed using Phoenix automated system (BD phoenix100). ESBLs production was confirmed using a combination disc method. All Cefoxitin resistant and confirmed ESBLs producing GNB were confirmed for AmpC beta-lactamases production by AmpC confirmatory Neo-Sensitabs discs (ROSCO tablet). Data were analyzed using SPSS version 20 software.

RESULTS

E. coli 66.0% (224/338) followed by K. pneumoniae 12.1% (41/338) were GNB most frequently isolated. The overall magnitude of ESBLs producing GNB was 38.8% (131/338) and the extent of AmpC beta-lactamase producing GNB was 2.4% (8/338). Majority of ESBLs and AmpC beta-lactamases producing GNB were isolated from urine specimens 47.5% (116/338). Ampicillin (75.4%), amoxicillin with clavulanic acid (64.0%) and sulfamethoxazole-trimethoprim (55.6%) were most the antibiotics to which resistance was most commonly found. The multidrug resistance (MDR) level of GNB was 74.0% (250/338). Of ESBLs and AmpC beta-lactamases producing GNB, 99.3% were MDR (p < 0.05).

CONCLUSION

The high magnitude of ESBLs and AmpC beta-lactamases producing GNB calls the needs of strong intervention to minimize further occurrence and spread of such GNB. More importantly, the MDR level was high which suggests continuous monitoring & reviewing of antimicrobial policy in hospitals and the country at large.

ESBL Producers in Gram Negative Isolates from Clinical Samples

Resistance to beta lactam antibiotics is the most common cause for beta-lactamase production. Increasing number of extended spectrum beta-lactamase (ESBL) producers has reduced the treatment options which resulted in emergence of multidrug resistant strains, treatment failure and hence increased mortality. To detect phenotypically, ESBL producers in Gram negative isolates from different samples and to know their susceptibility pattern. A retrospective study of Gram negative isolates was conducted. Total of 521 isolates were isolated from various samples. They were processed and identified by standard procedures. The antibiotic susceptibility testing was performed by Kirby- Bauer disc diffusion method using CLSI guidelines. ESBL was detected by combination disk test. A total of 521 Gram negative isolates were isolated which included E. coli, Klebsiella pneumoniae, Citrobacter spp., Enterobacter spp., Proteus spp. and Acinetobacter spp. Pseudomonas aeruginosa. Of 521 isolates tested, ESBL was detected in 329 (63.1%) isolates. These isolates showed maximum susceptibility to piperacillin- tazobactam (86%) followed by imipenem (78.4%), amikacin (63.5%), cotrimoxazole (54.4%), ciprofloxacin (51%), amoxi-clav (44.9%), cefepime (44.1%), gentamicin (38.9%), cefoxitin (34.9%) and ampicillin (19.1%). ESBL producers which are resistant to beta lactam antibiotics have become a major problem. Detection of these beta-lactamase enzymes by simple disk method and its reporting will help clinicians in prescribing proper antibiotics.

High rate of extended-spectrum beta-lactamase-producing gram-negative infections and associated mortality in Ethiopia: a systematic review and meta-analysis

Background

Extended-spectrum beta-lactamase (ESBL)-producing Gram-negative bacteria have become a serious threat to global health. Their rapid spread is associated with high mortality due to ineffective antibiotic treatment. To date a regular surveillance of multidrug-resistant (MDR) pathogens in Ethiopia is not established. For this report, published data regarding ESBL-producing bacteria in different health facilities of Ethiopia were reviewed.

Methods

This study collates data from published information on the rates and clinical implications of infection with ESBL-producing Gram-negative bacteria in Ethiopia. A systematic literature search was conducted using PubMed, PubMed Central, Medline, Science Direct and Google scholar from October 2018 to March 2019. Eligible studies were identified by applying quality criteria. The pooled proportion of ESBL-producing Gram-negative bacteria was estimated based on a random effect model. The publication bias and the variation in proportion estimates attributed to heterogeneity were assessed.

Results

Fourteen studies with relevant data were included in the review. In total, 1649 Gram-negative bacteria isolated from 5191 clinical samples were included. The pooled proportion estimate of ESBL-producing Gram-negative bacteria was 50% (95% CI: 47.7–52.5%. Data showed a high level of heterogeneity (I² = 95%, P <  0.01). ESBL rates varied by species; 65.7% (263/400) in Klebsiella spp., 48.4% (90/186) in Salmonella spp., and 47.0% (383/815) in E. coli. ESBL-encoding genes were reported in 81 isolates: 67 isolates harbored the CTX-M-1 group and 14 isolates TEM. The mortality associated with infections by bacteria resistant to third generation cephalosporins has rarely been investigated. However, two studies reported a mortality of 33.3% (1/3) and 100% (11/11).

Conclusions

In this meta-analysis, the pooled prevalence of ESBL-producing pathogens is alarmingly high. Data on mortality rates is scarce. This highlights the need for establishing and upgrading clinical microbiology laboratories in Ethiopia for routine antibiotic susceptibility testing and extended surveillance of multidrug resistance.

Pathogenic spectrum of blood stream infections and resistance pattern in Gram-negative bacteria from Aljouf region of Saudi Arabia

Background

The pathogenic spectrum of bloodstream infections (BSIs) varies across regions. Monitoring the pathogenic profile and antimicrobial resistance is a prerequisite for effective therapy, infection control and for strategies aimed to counter antimicrobial resistance. The pathogenic spectrum of BSIs in blood cultures was analysed, focusing on the resistance patterns of Acinetobacter baumannii, Escherichia coli, and Klebsiella pneumoniae, in Aljouf region.

Methods

This descriptive cross-sectional study analysed the culture reports of all non-duplicate blood samples collected from January 1 to December 31, 2019. Antibiograms of A. baumannii, E. coli, and K. pneumoniae were analysed for antibiotic resistance. The frequency and percentages of multi-drug, extensively-drug, pan-drug and carbapenem resistance were calculated.

Results

Of the 222 bloodstream infections, 62.2% and 36.4% were caused by gram-negative and gram-positive bacteria, respectively. Most BSIs occurred in patients aged ≥60 years (59.5%). Among the 103 isolates of the studied Gram-negative bacteria (GNB), 47.6%, 38.8%, and 2.9% were multi-drug, extensively drug and pan-drug resistant respectively. 46% of K. pneumoniae isolates were carbapenemase producers. Resistance to gentamycin, 1^st–4^th generation cephalosporins, and carbapenems was observed for A. baumannii. More than 70% of E. coli isolates were resistant to 3^rd- and 4^th-generation cephalosporins. Klebsiella pneumoniae presented a resistance rate of >60% to imipenems.

Conclusions

Gram-negative bacteria dominate BSIs, with carbapenem-resistant K. pneumoniae most frequently detected in this region. Resistant GNB infections make it challenging to treat geriatric patients. Regional variations in antimicrobial resistance should be continually monitored.

Resistance Patterns and Phenotypic Detection of β-lactamase Enzymes among Enterobacteriaceae Isolates from Referral Hospitals in Khartoum State, Sudan

Background Beta-lactamase enzymes-producing Enterobacteriaceae have emerged in many hospital settings resulting in poor treatment outcomes. We aimed to determine resistant patterns of Beta-lactamase enzymes among Enterobacteriaceae collected from referral hospitals in Khartoum state, Sudan. Methods A total of 168 Enterobacteriaceae recovered from clinical samples of patients during May 2014 to February 2015. Identification and susceptibility testing of the isolates were performed as per standard methods. Double-disk synergy test was applied to determine the presence of extended-spectrum β-lactamase (ESBL) production. AmpC beta-lactamases and carbapenemase were screened using AmpC disk test and the modified Hodge test, respectively. Results ESBL-producing Enterobacteriaceae represented 45.2%, with a higher rate among K. pneumoniae. AmpC beta-lactamase detected as 49.3%, with peak levels among Acinetobacter baumannii (A. baumannii) (83.3%) and Enterobacter cloacae (75%). Carbapenemase production was found among 74.5% of isolates, with high rates among A. baumannii (89%) and K. pneumoniae (78%). Overall Enterobacteriaceae, highest resistance rates were found in penicillins and cephalosporins agents. Amikacin and imipenem revealed good activities against most of the isolates, except for A. baumannii (66.7% and 75%, respectively). E. coli yielded high resistance rates for amoxicillin (98.8%), amoxicillin-clavulanic acid (93.8%), cefotaxime (93.8%), and ciprofloxacin (76.5%). Moderate resistance rates were observed among K. pneumoniae for ciprofloxacin (61.5%), nitrofurantoin (57.7%) and cefoxitin (40.4%). Conclusions ESBL, AmpC beta-lactamase and carbapenemase-producing Enterobacteriaceae are emerging and may contribute to increasing antimicrobial resistance in Sudan. Phenotypic screening of such enzymes is rapid and straightforward and should be simultaneously done and carried out routinely in our hospitals.

High Prevalence of Antimicrobial Resistance Among Gram-Negative Isolated Bacilli in Intensive Care Units at a Tertiary-Care Hospital in Yucatán Mexico

Background and Objectives: Antimicrobial resistance (AMR) is increasing worldwide and imposes significant life-threatening risks to several different populations, especially to those in intensive care units (ICU). The most commonly isolated organisms in ICU comprise gram-negative bacilli (GNB), and these represent a leading cause of serious infections. This study was conducted to describe the prevalence of resistance in GNB isolated from patients in adults, pediatric, and neonatal ICU in a tertiary-care hospital in Mérida, Mexico. Materials and Methods: A retrospective study was done on samples collected in Neonatal (NICU), Pediatric (PICU) and Adult (AICU) ICU of Unidad Médica de Alta Especialidad, Instituto Mexicano del Seguro Social in Mérida, México. The identification of isolates and antimicrobial susceptibility testing were performed using an automated system. Results: A total of 517 GNB strains were isolated. The most common positive culture was bronchial secretions. Pseudomonas aeruginosa was the prevalent pathogen in NICU and PICU, whereas Escherichia coli was common in the AICU. Overall, GNB exhibited a high resistance rates for Ampicillin (95.85%), Cefuroxime (84.17%), Piperacillin (82.93%), Cefotaxime (78.07%), Ceftriaxone (77.41%), Aztreonam (75.23%), Cefazolin (75.00%), and Ceftazidime (73.19%). There are significant differences in the resistance rates of GNB from different ICUs for penicillins, cephalosporins, carbapenems and fluoroquinolones drugs. Escherichia coli (multidrug-resistant [MDR] = 91.57%, highly resistant microorganisms [HRMO] = 90.36%) and Acinetobacter baumannii (MDR = 86.79%, HRMO = 83.02%) exhibited the highest percentage of MDR and HRMO profiles. The prevalence of the extended-spectrum beta-lactamases (ESBL)-producing isolates was 83.13% in E. coli, 78.84% in Klebsiella pneumoniae, and 66.67% in Proteus mirabilis, respectively. Conclusions: The high resistance rates to drugs were exhibited by our GNB isolates. Continuous surveillance and control of the use of antimicrobials are urgently needed to reduce the emergence and spreading of MDR, HRMO, and/or ESBL-producing bacilli.

Phenotypic Characterization and Antibiotic Resistance Patterns of Extended-Spectrum β-Lactamase- and AmpC β-Lactamase-Producing Gram-Negative Bacteria in a Referral Hospital, Saudi Arabia

Background

Emergence of pathogenic bacteria carrying β-lactamase-resistant determinants has become a major health problem in the hospital setting. The study aimed to determine antibiotic-resistant patterns and frequency of extended-spectrum β-lactamase- (ESBL-) producing Gram-negative bacteria (GNB) and AmpC β-lactamase-producing GNB.

Methodology

A prospective cross-sectional study was conducted during a period from September 2017 to August 2018 at King Abdullah Hospital, Bisha Province, Saudi Arabia. GNB (n = 311) were recovered from patients' clinical specimens including sputum, urine, wound pus, blood, tracheal aspirates and high vaginal swabs, umbilical discharge, eye discharge, and cerebrospinal fluids. Isolates were identified by the Phoenix identification system. Antimicrobial susceptibility was tested by the Kirby–Bauer disk procedure. Phenotypic characterization of ESBLs and AmpC β-lactamases was performed utilizing the double-disk synergy test and inhibitor-based method, respectively. Associations with outcome measures were determined by simple descriptive statistics and a chi-square test.

Results

Out of 311 GNB isolates, the frequency of ESBL and AmpC β-lactamase producers was 84 (27%) and 101 (32.5%), respectively. Klebsiella pneumoniae and Escherichia coli were common ESBL producers. AmpC β-lactamases predominate among Acinetobacter spp. and Pseudomonas aeruginosa. Coproduction of ESBLs and AmpC β-lactamases was found in 36 (11.6%) isolates, with very close relative frequencies among K. pneumoniae, Acinetobacter spp., and P. aeruginosa. β-Lactamase producers were predominantly found in the surgical department (56.5%) and ICUs (44.2%). ESBL producers revealed high resistance for cefuroxime (96.4%), cefotaxime (92.9%), and trimethoprim/sulfamethoxazole (90.5%). The resistance rates were significantly higher among ESBL producers than nonproducers for cephalosporins (p < 0.001), amoxicillin/clavulanate (p < 0.001), piperacillin/tazobactam (p = 0.010), nitrofurantoin (p = 0.027), aztreonam (p < 0.001), ciprofloxacin (p = 0.002), and trimethoprim/sulfamethoxazole (p < 0.001). Significantly higher (p < 0.05) resistance rates were observed among AmpC β-lactamase producers than nonproducers for all tested antibiotics.

Conclusions

This finding showed a high prevalence of ESBL- and AmpC β-lactamase-producing GNB in our hospital. Quality control practice and routine detection of β-lactamase producers before deciding on antibiotic therapy are advocated.

Prevalence of Bacterial Urinary Tract Infections and Associated Factors among Patients Attending Hospitals in Bushenyi District, Uganda

Urinary tract infections (UTIs) are one of the major causes of morbidity and comorbidities in patients with underlying conditions, and it accounts for the majority of the reasons for hospital visit globally. Sound knowledge of factors associated with UTI may allow timely intervention that can easily bring the disease under control. This study was designed to determine the prevalence of UTI by isolating and characterizing the different bacterial etiological agents and to evaluate the factors associated with UTI. In this cross-sectional study, a total of 267, clean catch midstream urine (MSU) samples were collected aseptically and analyzed using standard microbiology methods. Data for the factors associated with UTI were obtained by use of questionnaires and standard laboratory tests for selected underlying conditions. The study revealed 86/267 (32.2%) UTI prevalence among patients attending hospitals in Bushenyi District, Uganda. Escherichia coli was the most prevalent bacterial uropathogen with 36/86 (41.9%) followed by Staphylococcus aureus 27/86 (31.4%), Klebsiella pneumoniae 10/86 (11.6%), Klebsiella oxytoca 6/86 (7.0%), Proteus mirabilis 3/86 (3.5%), Enterococcus faecalis 3/86 (3.5%), and Proteus vulgaris 1/86 (1.2%). This study has demonstrated that age ≤19 years, female gender, married individuals, genitourinary tract abnormalities, diabetes, hospitalization, indwelling catheter <6 days, and indwelling catheter >6 days had statistically significant relationships (p < 0.05) with UTI. Screening for UTI in hospitalized patients, female gender, married individuals, genitourinary tract abnormalities, indwelling catheter, and diabetics should be adopted.

Phenotypic prevalence of extended spectrum beta-lactamases among enterobacteriaceae isolated at Mulago National Referral Hospital: Uganda

Objective

Enterobacteriaceae, common causes of health care associated and community acquired infections are mainly treated with beta-lactam agents. Our study objective was to determine the prevalence and common enterobacteriaceae pathogen producing extended spectrum beta lactamases (ESBLs). The isolates were recovered from various clinical specimens. This was cross sectional study conducted between July 2016 and September 2016 at Mulago National Referral Hospital, Uganda. We used ChromID™ ESBL agar (Biomerieux SA, Lyon, France) and Vitek2 compact system GN83 card (BioMerieux Inc, Hazelwood, Missouri, USA) to detect and confirm presence of phenotypic extended spectrum beta lactamases producing pathogens respectively.

Results

Of the 261 tested clinical isolates, 35 (13.4%) were identified as ESBLs producing bacteria. Escherichia coli predominated in the samples [18 (51.4%)], presenting the highest frequency of ESBLs producing, followed by Klebsiella pneumonia [10 (28.5%)], Proteus mirabilis [4 (11.4%)], Enterobacter sp. [2 (5.7%)] and least among Acinetobacter baumanii [1 (2.8%)].