Expression of ESBL, MBL and AmpC B lactamases by extra intestinal Escherichia coli isolates: correlation with treatment and clinical outcome

Abstract

Objective: We investigated the expression of Extended Spectrum β-Lactamases (ESBLs), AmpC β lactamases and Carbapenemases in extraintestinal pathogenic Escherichia coli (ExPEC) isolates and correlated with treatment and outcome of the patients. Methods: Three hundred ExPEC infected patients were included in the study. Demographic data, antibiogram, treatment and outcome were collected. Production of ESBLs was detected by combination disk method; AmpC was detected by AmpC disk test. Carbapenemase production was detected by disk diffusion and confirmed by modified Hodge test. Identification of metallo- β-lactamase (MBL) activity was performed by the carbapenem-EDTA combined disk method and MBL E-test. Results: Out of 300 E. coli isolates, 212 (71%) were ESBL producers. AmpC β lactamase production was seen in 95 (32%) isolates; 16 (17%) isolates were pure AmpC producers whereas 79 (83%) were ESBL co-producers. Twenty nine (9.5%) isolates were carbapenemase producers of which 15 (5%) were MBL producers. For treatment, most widely prescribed antibiotics were β-lactam+β-lactamase inhibitor combinations (39%). Sixty seven percent patients improved; relapse/re-infection was seen in 18% of patients and 11% patients expired. Increased mortality was seen in patients with blood stream infection and more number of relapses was seen in urinary tract infection. Conclusion: ExPEC producing ESBL or AmpC along with carbapenemases are particularly challenging for clinicians and are a major threat worldwide. Early use of appropriate antibiotics like β-lactam+β-lactamase inhibitor combinations will probably reduce complications in these patients.

Keywords

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Expression of ESBL, MBL and AmpC B lactamases by extra intestinal Escherichia coli isolates: correlation with treatment and clinical outcome

Öz

Amaç: Ekstra intestinal patojenik Escherichia coli (EİPEC) izolatlarından salınan GSBL, AmpC β laktamazlar ve Karbapenemazların salınımını ve bu hastaların tedavisi ve klinik gidişle ilişkisini araştırdık.Yöntemler: Çalışmaya 300 EİPEC ile enfekte hasta alındı. Demografik veriler, antibiyogram, tedavisi ve sonuçları toplandı. GSBL üretimi kombine disk metodu ve AmpC üretimi AmpC-disk testi ile tespit edildi. Karbapenemaz salınımına modifiye Hodge testi ile doğrulanmış disk diffüzyonla bakıldı. Metallo-β-laktamaz (MBL) aktivitesi karbapenem-EDTA kombine disk metodu ve MBL E-test ile çalışıldı. Bulgular: Üç yüz E. coli izolatının 212’si (% 71) GSBL pozitif idi. AmpC β laktamaz üretimi 95 (% 32) görüldü; izolatların 16’sı (% 17) saf AmpC üretirken, 79’u (% 83) GSBL ile beraberdi. Karbapenemaz üreten yirmi dokuz (% 9,5) izolatın 15’i (% 5) MBL üretiyordu. Tedavi için, en yaygın olarak reçete edilen antibiyotikler β-laktam + β-laktamaz inhibitör kombinasyonları (% 39) idi. Hastaların % 67’i iyileşti; nüks/yeni enfeksiyon hastaların % 18’inde görülürken % 11 hasta da öldü. Kan dolaşımı enfeksiyonu olan ve sık nüks eden idrar yolu enfeksiyonlarında mortalite daha yüksekti.Sonuç: Karbepenamazlarla birlikte GSBL veya AMPC üreten EİPEC özellikle klinisyenler için dünya çapında büyük bir tehdit oluşturmaktadır β laktam + β laktamaz inhibitör kombinasyonu gibi uygun antibiyotiklerin erken kullanımı muhtemelen bu hastalarda komplikasyonları azaltacaktır

Anahtar Kelimeler

• AmpC, EİPEC, GSBL, MBL

References

1. Russo TA, Johnson JR proposal for a new inclusive designa- tion for extraintestinal pathogenic isolates of Escherichia coli: ExPEC. J Infect Dis 2000; 181:1753-1754.
2. Getzlaff PS, Polsfuss S, Poledica M, et al. Detection of AmpC Beta- Lactamase in Escherichia coli: Comparison of Three Phenotypic Confirmation Assays and Genetic Analysis. J Clin.Microbiol 2011; 49:2924-2932.
3. Naas T, Cuzon G, Bogaerts P, Glupczynski Y, Nordmann P. Evaluation of a DNA Microarray for Rapid Detection of TEM, SHV and CTX-M Extended-Spectrum β- Lactamases and of KPC, OXA-48, VIM, IMP and NDM-1 Carbapenemases. J ClinMicrobiol 2011;49:1608-1613.
4. Lascols C, Hackel M, Marshall HS, et al. Increasing preva- lence and dissemination of NDM-1metallo β lactamase in India: data from the SMART study (2009). J Antimicrob Che- mother 2011; 66:1992-1997.
5. Sharma S, Bhat GK, Shenoy S. Virulence Factors and Drug Resistance in Escherichia coli isolated from extraintestinal infection. Indian J Med Microbiol 2007; 25:369-373.
6. Clinical and laboratory standards institute.2010. Performance standards for antimicrobial susceptibility testing. CLSI M100- S20U. Update June 2010. Clinical and Laboratory Standards Institute, Wayne, PA, USA.
7. Black JA, Moland ES, Thomson KS. AmpC disk test for detec- tion of plasmid - mediated AmpC β lactamases in Enterobac- teriaceae lacking chromosomal AmpC β lactamases. J Clin Microbiol 2005; 43:3110-3113.
8. Yan JJ, Wu JJ, Tsai SH Chuang CL. Comparison of the dou- ble-disk, combined disk and E-test methods for detecting metallo-β-lactamases in gram- negative bacilli. Diagn Micro- biol Infect Dis 2004; 49:5-11.

9. Yong D, Toleman AM, Giske GC, et al. Characterization of a new Metallo- β- lactamase gene, blaNDM-1, and a novel Erythromycin esterase gene carried on a unique genetic structure in Klebsiella pneumoniae sequence type 14 from India. Antimicrob Agents Chemother 2009; 53:5046-5054.
10. Goyal A, Prasad KN, Prasad A, Gupta S, Ghoshal U, Ayya- gari A. Extended spectrum β-lactamases in Escherichia coli & Klebsiella pneumoniae& associated risk factors Indian J Med Res 2009; 129:695-700.
11. Luvsansharav O.U, Hirai I, Niki M, et al. Analysis of risk fac- tors for a high prevalence of extended- spectrum β lacta- mase- producing Enterobacteriaceae in asymptomatic indi- viduals in rural Thailand. J Med Microbiol 2011; 60:619-624.
12. Chandel SD, Johnson AJ, Chaudhry R, et.al. Extended spec- trum β lactamase producing Gram-negative bacteria causing neonatal sepsis in India in rural and urban settings. J Med Microbiol 2011;60.500-507.
13. Khalifa SG, Einass E, Nuri B. Uropathogens from diabetic patients in Libya: virulence factors and phylogenetic groups of Escherichia coli isolates. J Med Microbiol 2009; 58:1006- 1014.
14. Hamalatha V, Padma M, Sekar U, Vinod TM, Arunkumar AS. Detection of AmpC β Lactamases production in Escherichia coli and klebsiella sp by an inhibitor based method. Indian J Med Res 2007; 126:220-223.
15. Sinha P, Sharma R, Rishi S, Sood S, Pathak D. Prevalence of extended spectrum β lactamase and AmpC β- lactamase producers among Escherichia coli isolates in a tertiary care hospital in Jaipur. Ind J Pathol Microbiol 2008; 51:367-369.
16. Mulvey RM, Bryce E, Boyd AD, et al. Molecular characteriza- tion of cefoxitin resistance Escherichia coli from Canadian hospitals. Antimicrob Agents Chemother 2005; 49;358-365.
17. Munier GK, Johnson CL, Snyder JW, Moland ES, Hanson ND, Thomson KS. Positive extended-spectrum-beta-lacta- mase (ESBL) screening results may be due to AmpC be- ta-lactamases more often than to ESBLs. J Clin Microbiol 2010;48:673-677.
18. Bell JM ,Chitsaz M, Turnidge DJ, Barton M, Walters JL, Jones NR. Prevalence and significance of a negative ex- tended-spectrum β-lactamase (ESBL) confirmation test re- sult after a positive ESBL screening test result for isolates of Escherichia coli and Klebsiella pneumoniae: results from the SENTRY Asia-Pacific surveillance program. J Clin Microbiol 2007;45:1478-1482.
19. Getzlaff PS, Polsfuss S, Poledica M, et.al. Detection of AmpC β lactamase in Escherichia coli: Comparison of three pheno- typic confirmation assays and genetic analysis. J Clin Micro- biol 2011; 49: 2924-2932.
20. Mohanty S, Gaind R, Deb M. Prevalence and phenotypic characterization of carbapenem resistance in Enterobacte- riaceae blood stream isolates in a tertiary care hospital in India. Int J Antimicrob Agents 2011;37:270-281.
21. Gupta E, Mohanty S, SoodS, Dhawan B, Das KB, Kapil A. Emerging resistance to carbapenems in a tertiary care hos- pital in north India. Indian J Med Res 2006;124:95-98.
22. Karabinis A, Paramythiotou E, Petropoulou MD, et al. Colistin for Klebsiella pneumoniae associated sepsis. Clin Infect Dis 2004;38: E7-E9.
23. Linden PK, Kusne S, Coley K, Fontes P, Kramer JD, Peter- son D. Use of parenteral colistin for the treatment of serious infection due to antimicrobial resistance Pseudomonas aeru- ginosa. Clin Infect Dis 2003;37:E154-E160.
24. Jaureguy .F, Carbonnelle E, Bonacorsi S, et al. Host and bac- terial determinants of initial severity and outcome of Esch- erichia coli sepsis. Clin MicrobiolInfect 2007;13:854-862.
25. Igra SY, Fourer B, Wasserlauf RO, et al. Reappraisal of com- munity acquired bacteremia: A proposal of a new classifica- tion for the spectrum of acquisition of bacteremia. Clin Infect Dis 2002;34:1431-1440.