Prevalence of ESBL in Surgical Wound Infections and Burns

Prevalence of ESBL in Surgical Wound befoulions and BurnsPREVELANCE OF EXTENDED SPECTRUM BETA LACTAMASES PRODUCERS AMONG SURGICAL appal INFECTIONS AND BURNS PATIENTS AT DR. SHANKARRAO CHAVAN GOVERNMENT MEDICAL COLLEGE, NANDED.*Vivek M Gujar1, Sharmila S Raut2, Sanjaykumar R More31. Assistant Professor, Dept. of Microbiology, Dr. S.C. political sympathies Medical College, Nanded.2. Professor, Dept. of Microbiology, Dr. S.C. Government Medical College, Nanded.3. Associate Professor, Dept. of Microbiology, Dr. S.C. Government Medical College, Nanded.ABSTRACTPurpose- The purpose of this study was to know the preponderance of prolonged Spectrum important lactamases (ESBL) among surgical aggravate infection and burn patients. Methods- A keep down of nose candy patients admitted to the surgical wards with post operative wound infections and destroy from January 2014 to whitethorn 2014 were studied. A total of 137 isolates were obtained from these patients. Of these, 87 existences (63.5% of the total isolates) were ready to be panoptic Spectrum important lactamases (ESBL) producers. The comm geniusst were Escherichia coli and Klebsiella pneumonia . They were studied for ESBL work by screening prove, CLSI phonograph recording diffusion method phenotypic confirmation by bookus potentiation hear. consequent- Out of 100 strains, 87 (63.5%) were confirmed as ESBL producers. Among the ESBL producer all(a) the isolates were tenuous to Imipenem. Resistance against Ampicillin (10ug) is 100%, gentamicin (10ug) is 80.46%, Ciprofloxacin (5ug) is 74.72%, Tetracycline(30ug) is 63.22% and Amikacin (30ug) is 16.10.% oddment- Our study shows presence of ESBL producer among surgical wound infections and burn patients and their prevalence is 63.5%. The numeral antimicrobial esthesia test may fail to light upon ESBL. bring oution of ESBL drudgery should be carried out as a routine in diagnostic laboratories by disc potentiation test as it is a simple and cost effective test. Antibiotics bulwark is significantly more ordinary in ESBL positive isolates as comp ard to ESBL negative.Key words- protracted Spectrum beta Lactamases, ESBL,INTRODUCTIONThe beta lactam antibiotics are amongst the close widely prescribed antibiotics and are an important component of empirical therapy in intensive do by social unit and high risk ward.1,2,3 Resistance to beta lactam antibiotics is an increasing caper worldwide.4 profit in the prevalence of penicillin opposition in Streptococcus pneumoniae, Methicillin resistance in Staphylococcus aureus, Vancomycin resistance in Enterococci, Extended spectrum beta lactamases (ESBL) production in Enteric Gram negative bacilli and Fluroquinolone resistance in Neisseria bam are just a few examples of the rising problem of resistance documented by both national and international surveillance formation in the past few years.5The ESBL are plasmid mediated enzymes that change the oxyimino beta lactam (3rd gener ation cephalosporine) and monobactam (aztreonam), but have no effect on cephamycins (cefoxitin and cefotatan). It is situated in periplasmic space.6 Although TEM type beta lactamases are most ofttimes base in Escherichia coli and Klebsiella pneumoniae, they are too found in Enterobacter spp., Salmonella spp., Morganella morganii, genus Proteus mirabilis, Serratia marcescens, Pseudomanas aeruginosa, Shigella dysenteriae, Capnocytophaga ochracea and Citrobacter 7,8,9,10. However, the frequency of ESBL production in these organisms is low.11 Over 150 diametrical ESBLs have been described as of today.12ESBL pose a major problem for clinical therapeutic. It is necessary to identify the prevalence of these strain in hospitals and to qualify their epidemiology, control spread of these strains and to determine suitable preventive measures and treatment policies.MATERIALS AND METHODSA present study was conducted at Dr. Shankarrao Chavan Government Medical College, Nanded between January 2014 May 2014. A total number of 100 post operative wound infections and burns patients wound swabs were processed during the study. A total of 137 isolates were obtained from these patients.COLLECTION AND naming OF THE ISOLATESUsing aseptic precautions, wound swabs were collected from the patients using barren tip swabs. The organism(s) disjointed were identified based on colony morphology on blood agar, MacConkey agar and by standard biochemical tests.13,14Strains- Escherichia coli ATCC 25922( ESBL negative) and Klebsiella pneumoniae ATCC 700603 (ESBL positive)were intentiond as control organism throughout the study. healthful Susceptibility testing- The antibiotic sensitivity test was performed by Kirby Bauer disc diffusion technique with mercenary available discs (HiMedia, Mumbai, India) on Muller Hinton agar coats. The discs employmentd were Ampicillin (10ug), Amikacin (30ug), Gentamicin (10ug), Ciprofloxacin (5ug), Imipenem (10ug) and Tetracycline (30ug). The diamet er of the zone of inhibition of for each one antibiotic was measured and interpreted as sensitive, intermediate sensitive or resistance according to CLSI criteria.15 spotting of ESBL15- In the present study 137 isolates were tested for ESBL production by the following methods-SCREENING TESTS15- CLSI disc diffusion methodphenotypical CONFIRMATION TEST15- Disc potentiation testCLSI ESBL Screening test- 15 tally to NCCLS 2002 for screening test to be positive or to consider an organism as probable ESBL producer the zone diameter should be-Antibiotic order diameterIn mm or lessCeftazidime(30ug)22cefotaxime (30ug)27Ceftriaxone (30ug)25Cefpodoxime(10ug)17Aztreonam (30ug)27The workout of more than one antimicrobial daysnt suggested for screening will mend the sensitivity of ESBL detection15. Ideally the most sensitive ESBL screening agent is Cefpodoxime for Escherichia coli and Klebsiella pneumoniae.9In the present study, ceftazidime (30ug), cefotaxime (30ug), ceftriaxone(30ug), cefpod oxime (10ug) and aztreonam (30ug) were used. These were stored in refrigerator. Before use they were taken out of refrigerator and brought to room temperature. Then they were applied on Muller Hinton agar for Antibiotic sensitivity testing.DISC POTENTIATION METHOD 15As per CLSI guidelines disc potentiation method was used as phenotypic corroborative test.For confirmation of ESBL production ceftazidime (30ug), ceftazidime + clavulanic venereal disease combination disc (30/10ug) manufactured by HiMedia and cefotaxime (30ug) + cefotaxime clavulanic acid (30/10ug) prepared in laboratory were used.PREPARATION OF CLAVULANIC demigod STOCK SOLUTIONFor preparation of clavulanic acid stock solution Augmentin powder (gsk company) was used-1.2gm vial of (Augmentin) contains 200mg clavulanic acid1200 mg contains 200mg clavulanic acidTherefore, 6 mg Augmentin contains 1 mg clavulanic acid.6 mg Augmentin is dissolved in 1 ml sterile distilled water to make a solutioni.e 1ml solution contain 1 m g clavulanic acid.i.e 1000ul solution contains 1000ug clavulanic acid.PREPARATION OF CEFOTAXIME-CLAVULANIC ACID DISC15,16Cefotaxime (30ug) discs were kept respectively in a sterile petridish. 10ul of stock solution of clavulanic acid was added to each disc with a micropipette. 30 minutes were allowed for clavulanic acid to absorb and also for the disc to dry. The discs were used immediately after preparation.STORAGE OF CEFTAZIDIME+CLAVULANIC ACID DISCClavulanic acid being labile, discs were placed in separate get by capped glass vials and stored at -200C. When antibiotics discs were required for test, they were removed from the freezer and allowed to rise to room temperature before application. 17APPLICATION OF DISCS-After preparing the inoculum, Muller Hinton agar plates were inoculated. With the help of sterile forcep antibiotic discs containing ceftazidime and ceftazidime+clavulanic acid and cefotaxime and cefotaxime+clavulanic acid were placed on inoculated Muller Hinton agar plate at a distance of 24 mm from center to center. Plates were modify and incubated at 370C for 16-18 hours.INTERPRETATIONMore than or equal to 5mm increase in a zone diameter for ceftazidime and cefotaxime tested in combination with clavulanic acid versus its zone when tested alone indicate ESBL production.ESBL convinced(p)- If an isolate is confirmed as ESBL producer, the isolate reported as immune to all Penicillin, Cephalosporins and Monobactam (Aztreonam).ESBL NEGATIVE- If an isolate is not confirmed as ESBL producer, the sensitivity of the isolate was reported as per sensitivity test report.RESULTThe total number of patients screened were 100 of which 64 were males and 36 females (M F = 1.781). The average age was 44.72 years (Range 12-80 years). The types of wounds were post operative wounds (65.7%) and burns (34.3%). Duration of hospital keep ranged from 15 days to 3 months. Out of 137 strains, 87 (63.50%) were confirmed as ESBL producers (Table 1). Susceptibility patt ern of the ESBL producers were studied. All the isolates were sensitive to Imipenem. Resistance against Ampicillin (10ug) is 100%, Gentamicin (10ug) is 80.46%, Ciprofloxacin (5ug) is 74.72%, Tetracycline(30ug) is 63.22% and Amikacin (30ug) is 16.10.% (Table 3).TABLE 1Distribution of ESBL strains among the different organisms isolated senior noOrganismNo. of organismsIsolatedNo. of ESBL strains% ESBL strains1Escherichia coli714563.38%2Klebsiella pneumonia573663.15%3Enterobacter spp.070457.14%4Morganella morganii0101100%5Providentia rettgeri0101100%TOTAL1378763.50%Table 2Distribution of ESBL strains based on clinical diagnosisSr. noClinical diagnosisNo. of organismsIsolatedNo. of ESBL strains% ESBL strains1 spotlight operative woundsInfections905561.11%2Burns473268.08%Table 3Antimicrobial susceptibility pattern of ESBL positive strainsSr. noOrganismSusceptibilityCategoryAAkGCfTI1Escherichia coli(45)S003707101845IS000502010200R4503363425002Klebsiella pneumonia(36)S003005071036IS0002020 20100R3604292725003Other.(06)S040605050406IS000000010100R020001000100A=Ampicillin, Ak = Amikacin, Cf = Ciprofloxacin, G = Gentamicin, T = Tetracycline, I = Imepenem, R= Resistance, S = sensitive, IS = Intermediate sensitiveDISCUSSIONThe prevalence of ESBL among clinical isolates very greatly worldwide, indifferent geographic areas and are rapidly changing overtime.18 In, 1983, Knothe et.al describe for the first time on the table resistance to the broad spectrum cephalosporins in clinical isolates of Klebsiella pneumoniae.19 The routine susceptibility test done by clinical laboratories fail to detect ESBL positive strains. The relative incidence of ESBL producing organisms in various studies has varied from 0-84%. In our study prevalence of ESBL producing strains is found to be 63.5%. All ESBL producers were sensitive to Imipenem. The result is in accordance with observation reported by other investigators.3,12,18,20 The new inhibitor based confirmatory test approach has been rec ommended by the CLSI for detection of ESBL. In the present study we found disc potentiation method to be reproducible, sensitive, easy and cost effective for use in a busy diagnostic laboratory.3,11 The use of both cefotaxime and ceftazidime with and without clavulanic acid increases the sensitivity of detection of ESBL compared to the use of only one of them. Inclusion of Cefpodoxime has been reported to further increase the sensitivity of this tests. 3,11 Among the Enterobacteriaceae, ESBL are most prevalent in Escherichia coli and Klebsiella spp. isolates.CONCLUSIONThe prevalence of ESBL producing strains is 63.5%. Multidrug resistance was found to be significantly higher in ESBL positive isolates as compared to ESBL negative. All the ESBL producers are sensitive to Imipenem. If an isolate is confirmed as ESBL producer, the isolate reported as resistant to all Penicillin, Cephalosporins and Monobactam (Aztreonam). Detection and reporting of beta lactamases producer is responsib leness of every clinical Microbiologist. To prevent the spread of ESBLs producing organisms, infection control precautions handle barrier nursing, cohorting of patients and nurses, attention to hand washing are essential.REFRENCESChambers H F, Neu H C, Other beta lactam antibiotics InMandell G L, Bennetts J E, Daolin R, editors. Principles and drill of infectious diseases 4th ed. Vol.I, New york Churchill Livingstone1995p.264-72.Fatima H M,, Chanawong A, Kevin G K, Birkenhead D and Hawkey P M. 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