Original Article
Incidence of ESBL Producers amongst Gram-negative Bacilli Isolated from Intra-abdominal Infections across India (Based on SMART Study, 2007 Data) BN Chaudhuri1, C Rodrigues2, V Balaji3, R Iyer4, U Sekar5, Chand Wattal6, DS Chitnis7, TN Dhole8, Sangeeta Joshi9 Abstract Objectives: This study was conducted in 9 centers spread over India from January 1 to December 31, 2007 to monitor in vitro susceptibility of Gram-negative bacilli to Group I carbapenem, ertapenem and other antimicrobials in intra-abdominal infections and to identify early changes in susceptibility pattern of community or hospital acquired organisms, with a focus on ESBL producers. Material and Methods: Gram-negative bacilli isolated from intra-abdominal samples of patients with documented intra-abdominal infections were processed for identification by conventional/ automated methods and antimicrobial susceptibility by Micro-Scan (Siemens) MIC panel against 12 antimicrobials (3rd and 4th generation cephalosporins, Groups I and II carbapenems, amikacin, levofloxacin, amoxicillin-clavulanic acid and piperacillin-tazobactam). Results: A total of 588 isolates were identified, of which 351 (60%) were E. coli and 114 (19%) were Klebsiella spp. 79% of E. coli and 70% of Klebsiella spp. were ESBL producers in general. 110 of E. coli and 35 of Klebsiella isolates were from community-acquired intra-abdominal infections. 80% of E. coli and 63% of Klebsiella isolates from community-acquired infections were ESBL producers, against 79% of E. coli and 73% of Klebsiella isolates from hospital-acquired infections. Amongst the ESBL-positive isolates of E. coli, 94% were susceptible in vitro to ertapenem, 96% to imipenem and 76% to piperacillin-tazobactam. For ESBL-positive isolates of Klebsiella spp., the corresponding figures were 80%, 94% and 59% respectively. Conclusion: The study showed a high incidence of ESBL-producers amongst Enterobacteriaceae isolates from intra-abdominal infections in both community-acquired and hospital-acquired settings across India. Ertapenem was comparable with imipenem against ESBL-positive E. coli isolates, while imipenem was more effective than ertapenem against ESBL-positive Klebsiella isolates.
T
Rationale
The purpose of SMART (Study for Monitoring Antimicrobial Resistance Trends) is two-fold:
he emergence of drug-resistant organisms in both hospitals and the community is a major concern. Surveillance studies have provided important information about changes in the spectrum of microbial pathogens and trends in the antimicrobial resistance patterns in nosocomial and community-acquired infections and continued monitoring of antimicrobial resistance patterns in hospitals is essential to guide effective empirical therapy.
1. To monitor the susceptibility of organisms causing intra-abdominal infections).Recent data indicate that the organisms causing these infections exhibit a high degree of susceptibility to drugs as ertapenem but long term surveillance is required to monitor for any important changes in susceptibility of common pathogens;
Aims and Objectives
One of the considerations of hospital formulary committees when considering new antibiotics is the potential for altering the bacterial flora epidemiology, especially resistance rates. Large multi-centre studies are useful for tracking trends over wide geographic areas and over long periods of time. However, most of these studies are not designed to identify early changes in susceptibility patterns or to determine the importance of specific risk factors in promoting resistance. In addition, such studies are not ideally suited to monitor the effect of introduction of new antibiotic because of variable use across the participating centers.
SMART (Study for Monitoring Antimicrobial Resistance Trends), 2007 was conducted worldwide to 1. Monitor, globally and longitudinally, the in vitro susceptibility of Gram-negative bacilli to Group I carbapenem, ertapenem and other antimicrobials in intra-abdominal infections, focusing on isolates causing intra-abdominal infections in patients admitted in all sections of the hospital; 2. Identify early changes in susceptibility patterns based on bacterial population MICs, of community or hospital acquired organisms, with a focus on ESBL producers.
1 AMRI Hospitals, Salt Lake, Kolkata; 2PD Hinduja National Hospital, Mumbai; 3Christian Medical College, Vellore; 4Global Hospitals, Hyderabad; 5Sri Ramchandra Medical College, Chennai; 6Sir Ganga Ram Hospital, Delhi; 7Choithram Hospital, Indore; 8SGPGI, Lucknow; 9 Manipal Hospitals, Bangalore Received: 17.03.2010; Revised: 19.05.2010; Accepted: 22.06.2010
© JAPI • may 2011 • VOL. 59
The present publication focuses on the observations of SMART in India where the study was conducted in 9 centers spread all over the country from January 1 to December 31, 2007.
1
Table 1 : SMART Panel MIC Range for Gram- Negative Aerobic Bacilli Abbreviation AS Ak Cax Caz Caz/CA Cft Cft/CA Cfx Cp Cpe Cpe/CA Etp Imp Lvx P/T
Fig. 1 : Indian centres in the SMART study
Material and Methods Worldwide, around 120 centers participated in the SMART, 2007 study. These centers are spread over USA, Europe, Latin America, Middle East and Africa, and Asia-Pacific. The sample centers include both teaching hospitals and community hospitals. 9 of those centers are in India, spread all over the country (Fig. 1). All the centers in India are basically urban centers and are tertiary care hospitals and teaching institutions. Each centre was required to test up to 100 consecutive nonduplicate isolates of Gram-negative aerobic and facultative anaerobic bacilli from intra-abdominal samples (e.g., appendix, peritoneum, colon, bile, pelvis, stomach, liver, pancreas etc.) of patients with documented intra-abdominal infections. The specimens obtained during surgery or by aseptic paracentesis only were included in the study. The duration of the study was for one year: 01.01.2007. to 31.12.2007. The exclusion criteria for isolate selection were as follows: •
Isolates from in situ drains or drainage bottles.
•
Isolates from stool or peri-rectal abscess.
•
Duplicate isolates (same genus and species) obtained from the same or different specimens from the same patient, irrespective of whether they were obtained from the same or different body sites. If multiple colony types of a particular species are isolated, only one representative colony (i.e. the most prevalent) is tested.
•
Duplicate isolates (same genus and species) obtained at any subsequent time from the same patient regardless of susceptibility or phenotypic profile.
•
Environmental samples (non-patient derived) or surveillance cultures taken for infection control purposes.
The laboratories in the participating centers were responsible for collecting demographic information including age and sex of the patient, site of infection, hospital ward/ unit, and 2
Antibiotic Ampicillin/Sulbactam Amikacin Ceftriaxone Ceftazidime Ceftazidime/Clavulanic acid Cefotaxime Cefotaxime/Clavulanic acid Cefoxitin Ciprofloxacin Cefepime Cefepime/Clavulanic acid Ertapenem Imipenem Levofloxacin Piperacillin/Tazobactam
SMART Panel MIC Range (mg/L) 2 - 16 4 - 32 1 - 32 0.5 - 128 0.12 - 16 0.5 - 128 0.12 - 16 2 - 16 0.25 - 2 0.5 - 32 0.12 - 4 0.03 - 4 0.06 - 8 0.5 - 4 2 - 64
whether the isolate was collected within 48 hrs or after 48 hrs of hospitalization (to differentiate between community-acquired and nosocomial pathogens). The isolates were processed for identification by conventional/automated methods and antimicrobial susceptibility tests using pre-prepared customized microdilution plates (Micro-Scan, Dade, now Siemens) containing 12 antimicrobials (vide Table 1): 3 rd and 4 th generation cephalosporins, Groups I and II carbapenems, amikacin, levofloxacin, amoxicillin-clavulanic acid and piperacillin-tazobactam. These plates were manufactured by Dade Microscan specifically for MRL and were not available commercially. Use of these plates by participating centers for non-study purposes or to guide patient management was not allowed. A standard inoculum as specified in the methods for MIC testing of CLSI (formerly NCCLS), 2007 guidelines, was used. The susceptibility tests were performed following the manufacturers procedure outline. Quality Control: Quality Control (QC) was performed with each batch test. Testing procedures were validated using the following 3 reference strains recommended by CLSI: 1.
Pseudomonas aeruginosa ATCC 27853,
2.
Escherichia coli ATCC 25922,
3.
Klebsiella pneumoniae ATCC 700603 (ESBL + control strain)
QC results were duly recorded on QC worksheets provided with the study materials. If the QC for any antibiotic was out of range, the QC was repeated and documented on another QC worksheet with the date the QC was repeated. If the QC was out of range for one of the ATCC strains, then only that QC was repeated. The results of the QC testing were reviewed by MRL before data were entered into the database; data for antibiotics with QC MICs outside the range cited in the CLSI document were not included in the database. Statistical Analysis: The statistical significance of the data was determined using Fisher’s Exact Test.
© JAPI • may 2011 • VOL. 59
Results
from female patients. The distribution of the isolates according to ward type is shown in Table 2, Fig. 2.
A total of 588 isolates were identified in all the centres put together. 55% of these isolates were from male patients and 45%
Pediatric Ward 2%
Medicine General 23%
The different sample types/ body sites from where the isolates were obtained are shown in Table 3, Fig. 3.
Others 1%
Gall Bladder 3%
Others 17%
Gastro-intestinal 38%
Body Fluids 10% Liver 10%
Surgery General Medical ICU 12% 3%
Surgical ICU 59%
Table 3 : Sample Types
Table 2 : Ward type: Location of Isolates No. of Isolates 344 20 68 138 14 4
Small colon 12%
Fig. 3 : Sample Types
Fig. 2 : Ward Type: Location of isolates
Ward type Surgical ICU Medical ICU Surgery General Medicine General Pediatric Ward Others
Pancreas 10%
Sample type/ Site Gastro-intestinal Small colon Pancreas Liver Body fluids Gall bladder Others
% of Isolates 59 03 12 23 02 01
No. of Isolates 228 68 59 57 57 17 102
% of Isolates 41 11 10 09 09 03 17
Table 4 : Antibiogram of Isolates to the Panel of Drugs Tested Isolates E. coli (non-ESBL) E. coli (ESBL) K. pneumo. (non-ESBL) K. pneumo. (ESBL) K. oxytoca (all ESBL) Klebsiella sp. Enterobacter cloacae Enterobacter aerogenes Enterobacter sp. Citrobacter sp. Edwardsiella sp. Serratia marcescens S. Typhi Salmonella sp. P. mirabilis (ESBL: 33%) P. vulgaris Proteus sp. M. morganii Pseudomonas aeruginosa Pseudomonas fluorescens Pseudo. sp. B. cepacia S. maltophilia A. baumannii A. lwoffi Acineto.sp.
N A/S (%S) P/T (%S) 72 60 97 279 08 76 34 76 97 80 00 59 15 07 87 1 00 100 22 09 93 15 33 64 9 22 78 16 17 64 1 00 100 1 100 100 2 100 100 2 100 100 15 87 100 11 64 100 1 00 100 6 33 83 49 NA 69 (IS) 1 NA 00 3 NA 100 3 NA 67 2 NA 00 27 19 11 3 00 00 5 20 20
Ak (%S) 99 85 97 74 87 100 87 64 89 17 00 100 100 100 100 100 100 100 57 100 (IS) 100 00 00 22 00 20
Cp (%S) 61 05 91 12 13 100 23 40 56 15 00 100 100 100 40 45 00 67 22 00 00 33 00 07 00 20
Lvx (%S) Cfx (%S) 3*CPs (%S) Cpe (%S) Etp (%S) Imp (%S) 63 >90 >90 100 100 100 0 90 >90 100 100 00 48 hrs. of hospitalization (% S)
K. oxytoca (all ESBL) Klebsiella sp.
15 2 (Carbapenems, Amikacin, Pip-taz. 100)
13 (Carbapenems 100, Amikacin, Pip-taz. 85)
1 --Enterobacter spp. 56 21 (Imipenem 100, Ertapenem 95, Amikacin 70, Pip-taz. 75) Citrobacter sp. 16 4 (Carbapenems 100, Amikacin, Pip-taz. 75) Edwardsiella sp. 1 --Serratia marcescens 1 --S. Typhi 2 1 (All sensitive) Salmonella sp. 2 --P. mirabilis (ESBL: 33%) 15 4 (Carbapenems, Amikacin, Pip-taz. 100) P. vulgaris 11 2 (All sensitive)
1 (Carbapenem, Amikacin, Pip-taz. 100) 35 (Imipenem 100, Ertapenem 96, Amikacin 70, Pip-taz 80) 12 (Carbapenems 100, Amikacin, Pip-taz. 80) 1 (Carbapenem, Pip-taz. 100, Amikacin 0)
Proteus sp. M. morganii
1 (Carbapenems, Amikacin, Pip-taz. 100)
Pseudomonas aeruginosa Pseudo. spp. B. cepacia S. maltophilia Acinetobacter spp.
1 ---
1 (All sensitive) 2 (All sensitive) 11 (Carbapenems, Pip-taz. 100, Amikacin 82) 9 (Carbapenems, Amikacin, Pip-taz. 100)
6 1 (Carbapenems, Amikacin, Pip-taz. 100) 49 8 (Imipenem 63, Amikacin 75, Pip-taz 63 IS)
5 (Carbapenems, amikacin 100, Pip-taz. 70) 41 (Imipenem 54, Amikacin 55, Pip-taz. 70 IS)
4 3 2 35
3 (Imipenem, Pip-taz 75, Amikacin 100) 3 (Imipenem, Pip-taz. 67, Amikacin 0) 2 (Only Levofloxacin S) 30 (Imipenem 25, Amikacin 18, Pip-taz. 13)
1 (Imipenem, Amikacin, Pip-taz. 100) ----5 (Imipenem 40, Amikacin 23, Pip-taz 15)
The list of different isolates obtained and the antibiogram of the 588 isolates to the 12 antibiotics tested in the Study are shown in Table 4. Of the 588 isolates identified, 351 (60%) were E. coli; 130 (22%) Klebsiella spp. (K. pneumoniae: 114, K. oxytoca: 15, other sp.:1); 56 (9.5%) Enterobacter spp. (E. cloacae: 22, E. aerogenes: 15, other spp.: 9); 53 (9%) Pseudomonas spp. (P. aeruginosa: 49, other spp.:4); 35 (6%) Acinetobacter spp. (A. baumannii: 27, other spp.: 8); 33 (5.6%) Proteae (P. mirabilis: 15, P. vulgaris: 11, M. morganii: 6, other sp.:1); 16 (2.7%) Citrobacter spp. (C. freundii: 13, other spp.: 3): Vide Table 4. Out of the drugs tested, except for carbapenems, all the others showed a statistically significant drop (p0.05), but more pronounced with ertapenem (80%, p0.05 for all pairs). No difference in ertapenem or imipenem sensitivity was observed between “community-acquired” and hospital-acquired ESBLpositive isolates of Klebsiella oxytoca and Proteus mirabilis (vide Table 5).
and wards housing high-risk patients. •
Disinfection of medical devices and hospital environment.
•
Maintenance of strict asepsis during invasive procedures.
•
‘Standard Precautions’ in wards and laboratories.
No significant differences (p>0.05) were observed in the imipenem sensitivity for “community-acquired” and hospitalacquired isolates of Pseudomonas and Acinetobacter spp.
•
Proper disposal of hospital waste.
•
Patient isolation-/-segregation or barrier nursing to prevent transmission of infection.
Discussion and Conclusion
•
Hand hygiene with chlorhexidine or alcohol - based disinfectants before and between patient contacts: this is the most important measure.
•
Policies for antibiotic stewardship
The study showed an alarming incidence of ESBL-producers amongst Enterobacteriaceae isolates from intra-abdominal infections in both “community-acquired” and hospital-acquired settings across India, especially in case of E. coli and K. pneumoniae isolates.
Note a. The results of this study were presented in a poster session (poster no. GN 103) at the 7th International symposium on Antimicrobial agents and Resistance (ISAAR) held in Bangkok, Thailand on March 18-20,2009
However, the observation of high prevalence of ESBL producers and carbapenem resistant non-fermenters in the “community” could at least partially be attributed to the definition used, i.e., infection within 48 hours and after 48 hours of hospitalization in the centers. Given the nature of the hospitals engaged as centers for the study in India, being predominantly tertiary care set-ups admitting patients already treated in some other institutions, rather than straight from the community. Hence the data may not be representative of the true community scenario.
b. There was a publication in Antimicrobial agents and chemotherapy, Aug 2009,p 3280-3284 titled ‘Emergence of High Levels of Extended-Spectrum-_-Lactamase-Producing Gram-Negative Bacilli in the Asia-Pacific Region: Data from the Study for Monitoring Antimicrobial Resistance Trends (SMART) Program, 2007’
Acknowledgement
Another limitation is that all contributing centers are urban centers located in major cities of India. Hence, the data is not representative of rural settings/ small towns
This study was sponsored by Merck & Co., Inc. USA. We thank Dr. Mahua Ganguly and Dr. Ankur Gupta of MSD, India for their scientific and editorial support.
Ertapenem was comparable with imipenem against ESBLpositive E. coli isolates, while imipenem was more effective than ertapenem against ESBL-positive Klebsiella pneumoniae isolates. No difference in Group I and Group II carbapenem susceptibility was, however, observed in case of ESBL-positive K. oxytoca and P. mirabilis isolates in all settings.
References
A significant observation in the study was that no ESBLproducing Salmonella isolates were identified. In fact, all the Salmonella isolates were susceptible to all the antibiotics included in this study.
The study did not screen isolates for Amp C beta lactamase and MBL production. These tests may be included in the future studies to get a better idea of the incidence of such strains in intra-abdominal infections.
•
Patient contacts and hospital personnel to properly decontaminate their hands with disinfectants (or simply with soap and water) prior to leaving hospital premises.
•
Hospitals to treat and decontaminate its waste, effluents, and sewage before disposal or before releasing those in
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Wexler HM, Molitoris D, Finegold SM. In vitro activities of MK-826 (L-749, 345) against 363 strains of anaerobic bacteria. Antimicrob Agents Chemother 2000;44:2222-4.
8. Pankuch GA, Davies TA, Jacobs MR, Appelbaum PC. Antipneumococcal activity of ertapenem (MK-0826) compared to those of other agents. Antimicrob Agent Chemother 2002;46:42-46.
public sewerage.
9.
Continuous surveillance of hospital, especially ICUs, OT’s
© JAPI • may 2011 • VOL. 59
Sahm, DF, Marsilio, MK & Piazza, G (1999). Antimicrobial resistance in key bloodstream bacterial isolates: electronic surveillance with The Surveillance Network database USA. Clinical Infectious Diseases 1996;29:259-63.
5. Fuchs PC, Barry AL, Brown SD. In-vitro antimicrobial activity of a carbapenem, MK-0826 (L-749,345) and provisional interpretive criteria for disc tests. J Antimicrob Chemother 1999;43:703-6.
The high incidence of nosocomial infection with multi-drug resistant bugs should be prevented and controlled by: •
2.
4.
The high incidence of ESBL producing Enterobacteriaceae as well as carbapenem resistant non-fermenters in the community indicates a grave situation that needs to be tackled urgently by Complete eradication of infectious agents before affected patients are discharged.
Spencer RC, Bauernfeind A, Garcia-Rodriquez J, et al. Surveillance of the current resistance of nosocomial pathogens to antibacterials. Clin. Microbiol Infect 1997;3(Suppl 1):S21-S35.
3. Jones, RN The emergent need for Basic Research, education, and surveillance of antimicrobial resistance. Problems facing the report from the American Society for Microbiology Task Force on Antibiotic Resistance. Diagnostic Microbiology and Infectious Diseases 1996;25:153-61.
The study also identified a high incidence of carbapenem resistance in the case of the non-fermenting Gram-negative isolates, especially, P. aeruginosa and Acinetobacter spp.
•
1.
Kohler J, Dorso KL, Young K, et al. In vitro activities of the potent, broad-spectrum carbapenem MK-0826 (L-749, 345) against broad-spectrum β-lactamase and extended-spectrum β-lactamase producing Klebsiella pneumoniae and Escherichia coli clinical isolates. 5
Antimicrob Agents Chemother 1999;43:1170-6. 10. Jacoby G, Han P, Tran J. Comparative in vitro activities of carbapenem L-749, 345 and other antimicrobials against multiresistant gram-negative clinical pathogens. Antimicrob Agents and Chemother 1997;41:1830-1. 11. Solomkin J, Choe K, Christou N, et al. Results of a prospective, randomized, triple-blind study of ertapenem vs. piperacillin/ tazobactam for complicated intra-abdominal infection [Abstract]. 11th European Congress of Clinical Microbiology and Infectious Diseases 2001 Apr 1-4; Istanbul, Turkey; 2001;1460. 12. Graham D, Lucasti C, Malafaia O, et al. Ertapenem once daily versus piperacillin/tazobactam 4 times per day for treatment of complicated skin and skin-structure infections in adults: results of a prospective, randomized, double-blind study. Clinical Infectious Diseases 2002;11:1460-1468. 13. Roy S, Higareda I, Angel-Muller E, et al. Results of a phase III randomized, double-blind study of ertapenem (ETP) vs piperacillin/
tazobactam (P/T) for acute pelvic infection (Inf) in women [Abstract]. 41st Interscience Conference on Antimicrobial Agents and Chemotherapy; 2001 Sep 23; Chicago, Illinois; 2001: L-888. 14. Tomera, Kevin M, et al. Ertapenem versus ceftriaxone followed by appropriate oral therapy for treatment of complicated urinary tract infections in adults: results of a prospective, randomized, double-blind, multicenter study. Antimicrob Agents Chemother 2002;46:2895-2900. 15. Guillermo O, Caballero-Lopez J, Friedland I, et al. A study evaluating the efficacy, safety, and tolerability of ertapenem versus ceftriaxone for the treatment of community-acquired pneumonia in adults. Clinical Infectious Diseases 2002;34:1076-83. 16. Hawser SP, Bouchillon SK, Hoban DJ, etal. Emergence of High Levels of Extended-Spectrum Beta-Lactamase-Producing GramNegative Bacilli in the Asia-Pacific Region: Data from the Study for Monitoring Antimicrobial Resistance Trends (SMART) Program, 2007. Antimicrob Agents Chemother 2009;53:3280-3284.
The Award of Fellowship of Indian College of Physicians Nominations are invited for the award of Fellowship of Indian College of Physicians Full format is available on API and JAPI websites: www. apiindia.org / www.japi.org Last date to receive nomination for FICP : 31st May 2011
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2.
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