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International Journal
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International Journal of Recent Scientific Research
Research
Vol. 4, Issue, 11, pp.1748-1750, November, 2013
ISSN: 0976-3031
RESEARCH ARTICLE
SUSCEPTIBILITY PATTERN OF ESBL STRAINS OF PSEUDOMONAS AERUGINOSA
IN A TERTIARY CARE HOSPITAL, KANCHIPURAM, TAMILNADU
1Senthamarai*,S., 2Sivasankari,S., and 3Kumudhavathi,M.S
Department of Microbiology, Meenakshi Medical College, Kanchipuram, Tamilnadu, India ARTICLE INFO
ABSTRACT
Article History:
Background: In Pseudomonas aeruginosa, ESBL production has been reported as one of
the mechanisms that contribute to acquired β lactum resistance. Awareness and the detection
Received 16th, October, 2013Received in revised form 25th, October, 2013 of these enzymes are necessary for optimal patient care.
Aim: To detect the ESBL production in P. aeruginosa and to evaluate its susceptibility
pattern in our tertiary care hospital.
Material & Methods: 144 isolates of P. aeruginosa were evaluated for the presence of
Key words:
ESBL enzyme by combined disc diffusion test. Using Kirby – Bauer disc diffusion test, the P. aeruginosa, Extended Spectrum of Beta antibiotic sensitivity pattern of ESBL producing P. aeruginosa against various classes was Lactamase (ESBL), antibiotic susceptibility determined.
Results: Out of 144 P. aeruginosa isolates, 51 (35.4%) were ESBL producers. It was found
maximum in sputum (50.9%) followed by Pus (33.4%). Male (60.8%) were commonly
affected and maximum number of cases (45.1%) has been noted between 21-40 years.100%
sensitivity was observed with imipenem & nitrofurantoin, in our study. Ofloxacin (90.2 %,),
netilmycin (88.2%), amoxyclav (80.4%) and amikacin (70.6%) were also found to be
effective.
Conclusion: This study highlights the prevalence of ESBL production in pseudomonas
aeruginosa in our area. To estimate the real magnitude of the problem a multicentric and
periodic surveillance study should be carried out. Therefore nationwide antibiotic policy
should be instituted to minimize the emergence of resistance. Along with this indiscriminate
and inappropriate use of antibiotics should be curtailed.
Copy Right, IJRSR, 2013, Academic Journals. All rights reserved. INTRODUCTION
worldwide and they create a major problem for clinicaltherapeutics resulting in limitation of options which is a threat to Pseudomonas aeruginosa is the most common opportunistic the community and hospital settings (Iraj Alipourfard et al.,2010).
pathogen and is reported to be amongst the leading cause of Because of the widespread resistance among Pseudomonas nosocomial infections (Ibukun A, et al.,2007). Their widespread aeruginosa isolates, this study was set out to detect the ESBL and distribution in nature, resistance to many antibacterial compounds the susceptibility pattern of these strains to other antibiotic drugs and the number of virulence factors produced by them makes the in our hospital, so as to help in treatment and to formulate infection difficult to eradicate (Greenwood 16th edition).
antibiotic and infection control strategies.
Pseudomonas aeruginosa shows intrinsic resistance to manystructurally unrelated antibiotics because of the low permeability MATERIALS AND METHODS
of its efflux pumps and naturally occurring chromosomal AmpC β Study period and design
lactamase and also through acquired plasmid mediated βlactamase resistance. (Livermore, D M, 2001). The newer β This study was carried out in Microbiology department at lactamases, including Extended Spectrum of Beta Lactamase Meenakshi Medical College Hospital & Research Institute (ESBL), Amp C Beta Lactamase and metallo Beta Lactamase (MMCH&RI), Kanchipuram. Ethical committee clearance was (MBL) have emerged worldwide as a cause of antimicrobial obtained from the Institute. The study period was from February resistance in Gram Negative Bacteria (GNB) (Gupta V, et al.,2007).Indiscriminate use of 3rd generation cephalosporin as Sample collection and processing
broad spectrum empirical therapy and the secretion of ESBLenzymes mediate the resistance by hydrolysis of β-lactam ring of Totally 144 non repetitive clinical isolates of P.aeruginosa were β-lactam antibiotics. (Shahid, M, Malik A and Sheeba et al.,2003) collected. The samples included were Urine, Sputum, Blood, ESBL mediate resistance to extended spectrum of cephalosporins Fluids Pus and wound swab. Medical and demographic data of the such as cefotaxime, ceftriaxone & ceftazidime. The betalactam patients were recorded. The samples were processed for culture and betalactam inhibitor combination and carbapenem are the and biochemical reactions according to standard laboratory drugs active against ESBL producing Pseudomonas aeruginosa.
protocol for P.aeruginosa. The antibiogram was performed by However, resistance to these drugs has also been increasing * Corresponding author: Senthamarai .S
Department of Microbiology, Meenakshi Medical College, Kanchipuram, Tamilnadu, India
International Journal of Recent Scientific Research, Vol. 4, Issue, 11, pp.1748-1750, November, 2013
Kirby Bauer disc diffusion technique with commercially available In the age distribution, more no of cases 23 (45.1%), were seen discs (Hi-Media) on Muller Hinton Agar.
between 21-40yrs which is followed by 14 (27.5%) in the agegroup 41-60yrs. (Table-4) ESBL screening method(CLSI-2012)
Table 4 showing age distribution of ESBL producing
Isolates exhibiting zone size ≤ 25mm with ceftriaxone (30μg), ≤ 22mm for ceftazidime (30μg), and ≤ 27mm with Cefotaxime Age in years
No of isolates(n=51)
Percentage (%)
(30μg), were considered as ESBLs producer.
Phenotypic confirmatory test for ESBL: (combined disc
diffusion method) (CLSI-2012)
They were further confirmed by combined disc diffusion test. 0.5 The antibiotic susceptibility patterns were observed using Kirby McFarland’s turbidity standard suspension was made from the Bauer disc diffusion method for ESBL producing P.aeruginosa colonies of P.aeruginosa isolate. Using this inoculum, lawn culture was made on Muller Hinton Agar plate. Discs ofCeftazidime, Ceftriaxone and Cefotaxime alone and in Table 5 The antibiotic susceptibility patterns ESBL
combination with Clavulanic acid (30 mcg /10 mcg) were placed aseptically on the surface of MHA. The distance of 15mm was ANTIMICROBIAL
Resistance
Resistance
Sensitive
AGENT(mcg)
kept between the disc and overnight incubation was done at 37˚C.
An increase of ≥ 5mm in zone diameter with Clavulanic acid in comparison to the zone diameter of 3GC alone confirmed the Antibiotic susceptibility test for ESBL producing P.aeruginosa
These ESBL strains were tested for the susceptibility pattern for (30mcg),Tobramycin(10),Netilmicin(30mcg),Ciprofloxacin (5mcg), Ofloxacin (5mcg), Piperacillin(100 mcg), Piperacillin Tazobactam (100/10mcg), Amoxyclav( 20/10mcg), Ticarcillin- (75/10mcg), Imipenum(10mcg), Nitrofurantoin(300mcg- for urinary isolates). Results were interpreted according to the nitrofurantoin (urine isolates). Ofloxacin, netilmycin, amoxyclav Clinical and Laboratory Standards Institute (CLSI-2012) and amikacin showed 90.2%, 88.2%, 80.4% & 70.6% sensitivity, respectively. Maximum resistances were observed for gentamycin (94.1%), ciprofloxacin (86.3%) and Piperacillin (84.3%).
Among the total 1148 gram negative bacteria, 144 isolates of DISCUSSION
P.aeruginosa were isolated (12.5%) from various clinical The emergence of ESBL in gram negative bacilli has increased in samples. Among 144 strains of P.aeruginosa, 51 (35.4%) showed recent years, which has led to global concern regarding the ESBL production in the combined disc diffusion test. (Table-1) management of bacterial infections (Refath et al 2013). Though Table 1 showing the prevalence of ESBL producing
the prevalence of ESBL producers varies with geographical areas and times, a relatively high prevalence rate of ESBL producers Isolates
No of isolates
Percentage
were documented by several surveillance studies (Hirakata et al 2005). The prevalence rate of ESBL producing P.aeruginosa in our study is 35.4%. Various prevalence rates reported with the They were identified from various clinical specimens: sputum studies of Varun Goel et al 2012, Prashant et al 2008, and (50.9%) followed by pus (33.4%), urine (11.8%) and blood Aggarwal et al 2008 were 42.3%, 22.2% and 20.3% respectively.
Our study is comparable with these studies. High percentages ofprevalence rate of ESBL mediated resistance in P.aeruginosa Table 2 distribution of ESBL producing P.aeruginosa
reported were, 77.3% by Chaudhari U et al.,2008, and 64% by Mathur et al.,2002. Whereas very low rate has been reported with Clinical samples
No of isolates (n=51)
Percentage
Jacobson et al.,1995, Lim et al.,2009, and Woodford et al.,2008 were, 7.7%, 4.2% and 3.7% respectively. Maximum ESBL production was found in sputum samples (50.9%), followed by pus (33.4%),urine (11.8%), and blood (3.9%).Likewise, in a Males (60.8%) were commonly affected than Females (39.2%) study conducted by Aggarwal et al , sputum , tracheaostomy and pus were the predominant sample of isolation of ESBL. Malewere commonly affected (60.8%) than female (39.2%) with Table 3 showing sex distribution of ESBL producing
ESBL producing strains in our study. Male preponderance (88.9%) was observed with Abiola et al 2012. Males are No of isolates
Percentage
commonly affected because of their outdoor activities which involve them in constant contact with soil, water, and other areaswhich are inhabited by the organism.
International Journal of Recent Scientific Research, Vol. 4, Issue, 11, pp.1748-1750, November, 2013
Clinical and Laboratory Standards Institute. (2012). Performance More number of cases has been noted in the age group between standards for antimicrobial susceptibility testing; twenty 21-40 years (45.1%), followed by 41-60 years (27.5%). In our second informational supplement. Clinical Laboratory study, imipenem and nitrofurantoin (urine isolates), were the drugs found to be 100% sensitive. Similar findings were observed Refath Farzana, SM Shamsuzzaman, KZ Mamun and Paul by Aggarwal et al and Abiola et al.,2012. In this present study, Shears. Antimicrobial susceptibility pattern of extended Ofloxacin, netilmycin, amoxyclav, and amikacin showed the spectrum of β lactamase producing gram negative bacteria susceptibility rates of 90.2%, 88.2%, 80.4% & 70.6% isolated from wound and urine in a tertiary care hospital, respectively. These drugs can be considered as therapeutic options Dhaka city, Bangladesh. Southeast Asian J Trop Med Public for ESBL producers of P.aeruginosa in our environment. They are useful as reserve drugs or as combination therapy. However Hirakata Y, Matsuda J, Miyazaki Y, et al. Regional variation in indiscriminate use of these agents may promote resistance.
the prevalence of extended-spectrum beta-lactamase- pro- Gentamycin, ciprofloxacin and Piperacillin showed resistance rate ducing clinical isolates in the Asia Pacific region (SENTRY of 94.1%, 86.3% and 84.3% respectively in this study. ESBL 1998-2002). Diagn Microbiol Infect Dis 2005; 52: 323-9.
producing bacteria are also frequently resistant to many other Varun Goel, Sumati A. Hogade1, SG Karadesai1Prevalence of classes of antibiotics which include aminoglycosides and extended-spectrum beta-lactamases, AmpC beta‑lactamase, fluoroquinolones. This resistance could be attributable to possiblecoexistence of genes encoding drug resistance to other antibiotics on the plasmids which encode ESBL (Nathisuwan et al., 2001).
aeruginosa and Acinetobacter baumannii in an intensive care In our present study, the combination drugs, β lactam and β unit in a tertiary Care Hospital, Journal of the Scientific lactamase inhibitors showed the resistance ranged from 19.6% to Society, Vol 40 / Issue 1 / January-April 2013 54.9%. Study of Aggarwal et al., 2008, also showed 96.6% resistance to Ticarcillin/Clavulanic Acid and 63.3% to ampicillin/sulbactum. Though combination drugs are alternative to 3rd generation cephalosporin, effects varies with subtypes of therapeutics. Journal of Clinical And Diagnostic Research; ESBL present which makes them unreliable for treatment (Nathisuwan et al.,2001). P.aeruginosa isolates that are resistant to multiple antibiotics are of particular concern and pose a significant clinical challenge in medical world.
aeruginosa. Indian J Pathol Microbiol 2008;51:222‑4.
CONCLUSION
Chaudhari U, Bhaskar H, Sharma M. The Imipenem–EDTA disk method for the rapid identification of metallo β lactamase Our study has demonstrated the presence of ESBL producing producing gram negative bacteria. Indian J Med Res 2008; P.aeruginosa and its susceptibility to various classes of antibiotics in our environment, which is a threat to the public health.
Mathur P,Kapil A,Dhawan B, prevalence of extended-spectrum Therefore nationwide antibiotic policy should be instituted to beta-lactamases, producing gram negative bacteria in a tertiary minimize the emergence of resistance. Along with this care hospital, Indian J MED RES.2002;115:153-7 indiscriminate and inappropriate use of antibiotics should be Jacobson KL,Cohen SH,Inciardi JF, King JH,Lippert WE,Iglesias T,the relationship[ between antecedent antibiotic use andresistance to extended spectrum of cephalosporin in group I References
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