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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 17
| Issue : 3 | Page : 584-588 |
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Prevalence of Carbapenem-Resistant Escherichia coli and Klebsiella pneumoniae in Rural Uttar Pradesh
Pratiksha Srivastava1, Dakshina Bisht1, Ajay Kumar2, Atosh Tripathi3
1 Department of Microbiology, Santosh Medical College and Hospital, Santosh Deemed to be University, NCR Delhi, Ghaziabad, Uttar Pradesh, India
2 Department of Microbiology, Manipal TATA Medical College, Manipal Academy of Higher Education, Jamshedpur, Jharkhand, India
3 Department of Microbiology, Government Medical College, Azamgarh, Uttar Pradesh, India
| Date of Submission | 24-Feb-2022 |
| Date of Decision | 19-Apr-2022 |
| Date of Acceptance | 26-May-2022 |
| Date of Web Publication | 2-Nov-2022 |
Correspondence Address:
Dr. Dakshina Bisht
Department of Microbiology, Santosh Medical College and Hospital, Santosh Deemed to be University, NCR Delhi, Ghaziabad, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jdmimsu.jdmimsu_76_22
Introduction: In recent years, increased incidences of carbapenem resistance among Escherichia coli and Klebsiella pneumoniae have been reported worldwide. Due to the higher prevalence and wide range of clinical infections, E. coli and K. pneumoniae are considered great risks for public health. Furthermore, carbapenem resistance limits the treatment options in individuals infected with E. coli and K. pneumoniae. Thus, rapid detection of carbapenem resistance is essential to initiate appropriate treatment and effective management and prevent further dissemination. In the present study, we aimed to explore the prevalence of carbapenem-resistant E. coli and K. pneumoniae at a tertiary care hospital in rural Uttar Pradesh. Materials and Methods: A cross-sectional study was performed at Government Medical College, Azamgarh, in collaboration with Santosh Medical College, Ghaziabad. A total of 2736 clinical specimens comprising urine (1939), pus and wound swabs (486), sputum and throat swabs (257), and other samples (54) were collected following the standard guidelines and were processed for culture by standard bacteriological methods. After obtaining the growth, Gram staining and standard biochemical reactions were performed for the identification of E. coli and K. pneumoniae. All these isolates were subjected to antibiotic sensitivity testing for carbapenem by Kirby–Bauer disc diffusion method. Results: Of the 2736 specimens, 48.57% showed the growth of various organisms. Of these, 59.51% of isolates showed the growth of Enterobacteriaceae, of which 60.93% among them were E. coli whereas 26.92% were K. pneumoniae. The overall prevalence of carbapenem resistance in the present study was found to be 29.35%. Among the carbapenem-resistant isolates, 68.13% were E. coli whereas 31.86% were identified as K. pneumoniae. Conclusion: Carbapenem resistance in E. coli and K. pneumoniae isolates in the present study was found to be higher compared to previous studies from India. Our study highlights the urgent need of proper monitoring, judicious use of antibiotics, and implementation of strict infection control practices in this region.
Keywords: Antimicrobial resistance, carbapenem-resistant Enterobacteriaceae, carbapenemase
How to cite this article:
Srivastava P, Bisht D, Kumar A, Tripathi A. Prevalence of Carbapenem-Resistant Escherichia coli and Klebsiella pneumoniae in Rural Uttar Pradesh. J Datta Meghe Inst Med Sci Univ 2022;17:584-8 |
| Introduction | |  |
Antimicrobial resistance has emerged as a major health-related issue in recent decades. Antimicrobial resistance has been observed toward most of the antibiotics which has become the major issue in combating against clinical pathogens. Overuse of antibiotics, inappropriate processing, and lack of regulatory barriers are the major causes for antibiotic resistance.[1] There have been growing epidemics of infections due to Gram-negative bacteria, especially from the Enterobacteriaceae family, which are resistant to many classes of antibiotics.[2] In the past, carbapenems have been reserved for the most difficult infections. They have an exceptionally broad spectrum of activity and are used exclusively in intensive care unit and critically ill patients.[3] Due to extended-spectrum beta-lactamase (ESBL) and AmpC enzyme-producing Enterobacteriaceae, carbapenems are used as the last option against many multidrug-resistant, Gram-negative bacteria.[4] However, there is an alarming increase in carbapenem-resistant Enterobacteriaceae related to high mortality, and the trend is increasing around the world.[5]
Carbapenem-resistant Enterobacteriaceae (CRE) can be defined as Enterobacteriaceae that are resistant to one or all the following carbapenems – ertapenem, meropenem, and imipenem.[6] Klebsiella pneumoniae and Escherichia More Details coli are the most common agents of community- and hospital-acquired infections among the Enterobacteriaceae family. They are also among the most common pathogens reported for CRE infections around the world.[5] The main reason for the resistance to carbapenems is production of carbapenemase that hydrolyzes carbapenem and other beta-lactam drugs.[1] Besides the production of carbapenemase enzyme, the other mechanism of resistance includes overexpression of efflux pumps by the bacteria, lack of porins present in the bacterial cell membrane, and poor binding of carbapenems to penicillin-binding protein.[7] The inter- and intra-species spread of carbapenemase-encoding genes responsible for resistance through horizontal plasmid-mediated transmission is also common among CRE.[8]
Rapid detection of carbapenem resistance is necessary to initiate effective infection control measures to prevent their dissemination and to start appropriate treatment for the patient suffering from carbapenem-resistant strains of E. coli and K. pneumoniae infection as they have limited treatment options. Furthermore, epidemiology and bacteriology of carbapenem-resistant strains of E. coli and K. pneumoniae are essential for formulating guidelines for rational therapy and isolation and contact precautions of such infectious patients preventing further spread in health-care settings.
Data regarding carbapenem resistance among clinical isolates of E. coli and K. pneumoniae prevalent in rural Uttar Pradesh are limited. Thus, in the present study, we aimed to explore the prevalence of carbapenem-resistant E. coli and K. pneumoniae at a tertiary care hospital in rural Uttar Pradesh.
| Materials and Methods | | |
Study design and settings
A cross-sectional study was performed at Government Medical College, Azamgarh, in collaboration with Santosh Medical College, Ghaziabad, after obtaining approval from the Institutional Research and Ethical Committee (SU/2017/187[4]).
Inclusion criteria
E. coli and K. pneumoniae isolated from various clinical samples showing resistance to at least one carbapenem (imipenem, meropenem, and ertapenem) will be included in the study.
Exclusion criteria
E. coli and K. pneumoniae isolated from various clinical samples not showing resistance to any carbapenems will not be included in this study.
Sample collection and processing
A total of 2736 clinical specimens comprising urine (1939), pus and wound swabs (486), sputum and throat swabs (257), and other samples (54) were collected following the standard guidelines and were processed for culture by the standard bacteriological methods in the Department of Microbiology. All the samples were processed and cultured on appropriate culture media depending upon the type of samples and were incubated at 37°C for 24–48 h. After incubation, the culture plates were observed for bacterial growth and colony characteristics, Gram staining of the bacteria was performed, and Gram-negative bacilli were confirmed using standard biochemical tests.
All clinical isolates of E. coli and K. pneumoniae were further processed for antibiotic sensitivity testing for carbapenem using imipenem (10 μg), meropenem (10 μg), and ertapenem (10 μg) by Kirby–Bauer disc diffusion method. After performing the Kirby–Bauer disc diffusion test for carbapenems, the zone of inhibition around the antibiotic disc for the test strains was measured with the help of scale and the result was interpreted following the CLSI guidelines 2019.[6]
Statistical analysis
Data entry was done in Excel format and analyzed using SPSS (Data analysis was done by SPSS trial version 16) in the form of tables, figures, and charts.
| Results | | |
Of the 2736 specimens, 48.57% showed the growth of various organisms. A total of 59.51% of isolates showed the growth of Enterobacteriaceae, of which 60.93% among them were E. coli whereas 26.92% were K. pneumoniae. The overall prevalence of carbapenem resistance in our present study was found to be 29.35%. Among the carbapenem-resistant isolates, 68.13% were E. coli whereas 31.86% (65/204) were K. pneumoniae.
Among 204 carbapenem-resistant isolates of E. coli and K. pneumoniae, 126 (61.76%) isolates were from female patients whereas 79 (38.73%) isolates were from male patients. A maximum number of carbapenem-resistant strains were obtained from urine samples (56.86%), followed by pus/wound swab (25.98%), sputum/throat swab (14.21%), and other samples (2.94%). A detailed description of distribution of carbapenem isolates among different clinical samples in the present study is shown in [Figure 1]. | Figure 1: Distribution of carbapenem-resistant isolates among different clinical samples
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Distribution of carbapenem-resistant isolates among different departments showed that a maximum number of carbapenem-resistant isolates were obtained from the Department of Obstetrics and Gynecology (50.49%), followed by Medicine (25.49%), Surgery (14.21%), Orthopedics (6.37%), and Pediatrics (3.43%). A detailed description of distribution of carbapenem-resistant isolates among different departments is shown in [Figure 2]. | Figure 2: Distribution of carbapenem-resistant isolates among different departments
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Of the 204 resistant strains of E. coli and K. pneumoniae, 180 (88.23%) strains showed resistance to all three carbapenem drugs – imipenem, meropenem, and ertapenem as shown in [Figure 3]. Thirteen (6.37%) strains showed resistance to imipenem and meropenem both whereas seven (3.43%) showed resistance to imipenem alone and three (1.47%) strains showed resistance to imipenem and ertapenem both and one (0.49%) strain showed resistance to meropenem alone. A detailed description of antibiotic susceptibility patterns for carbapenem resistance among E. coli and K. pneumoniae is shown in [Table 1]. | Table 1: A detailed description of antibiotic susceptibility pattern for carbapenem resistance
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| Discussion | | |
Enterobacteriaceae are often associated with a wide range of severe infections including bloodstream infections, ventilator-associated pneumonia, community-acquired pneumonia, hospital-acquired pneumonia, complicated urinary tract infections, and complicated intra-abdominal infections. Therefore, antibiotic resistance in Enterobacteriaceae has significant clinical and socioeconomic impacts. Emergence of ESBL-producing Enterobacteriaceae has led to extensive use of carbapenem as a first-line empirical treatment. The increasing use of carbapenem for possible ESBL infections has led to a more serious problem of the emergence of carbapenemase-producing Enterobacteriaceae.[9] Carbapenemase-producing Enterobacteriaceae pose an exponentially increasing threat for public health worldwide. Carbapenemases are β-lactamases with the ability to hydrolyze penicillins, cephalosporins, monobactams, and carbapenems.[10] Carbapenems are considered last-resort antibiotics for the treatment of infections caused by multidrug-resistant Gram-negative bacteria. In the last decade, the prevalence of CRE has increased rapidly.[11] Early and accurate detection of carbapenem-resistant isolates is important for appropriate treatment of patients and reduces the further escalation of resistance in the community.
Authors from India have reported a high prevalence of carbapenem resistance in their studies. Gupta et al.[12] reported a 17%–22% carbapenem resistance from North India, Nair and Vaz[13] reported 26% of carbapenem-resistant isolates from Mumbai, Pawar et al.[4] from Karda reported a prevalence of 31.77%, Kumarasamy et al.[14] reported a 31.77% prevalence of carbapenem resistance from Haryana, and Wattal et al.[15] reported a 51% carbapenem resistance from Delhi. In 2014, Chauhan et al.[16] reported carbapenem resistance of 20.72%, and in 2015, 25.44% carbapenem resistance was reported by Modi et al.,[17] Rao and Indumati[18] reported a 13.95% resistance in the year 2016, and in the years 2017 and 2018, Modi et al.[17] reported carbapenem resistance of 34.74% and 29.34%, respectively. Thomas and Sarwat[19] reported an 18.54% prevalence in 2019. The overall prevalence of carbapenem resistance in the present study was also found to be as high as 29.35%.
Authors[20],[21] have observed a higher occurrence of Enterobacteriaceae infections, especially E. coli and K. pneumoniae, among females as compared to their male counterparts. Literature suggests that shorter urethra in females allows easy passage to the bladder during sexual contact which later allows the bacteria to colonize and cause urinary tract infections. In support of previous findings, 61.76% of carbapenem-resistant isolates in the present study were also from female patients.
Distribution of carbapenem resistant isolates among different clinical samples showed that majority (56.86%) of isolates were from urine samples which was in concordance with the findings by Nair et al.[13] (42%), Singh et al.[22] (39.4%) and Satyajeet K Pawar et al.[4] (31.76%) who also reported majority of carbapenem resistant isolates from urine in their studies Carbapenemase-producing Enterobacteriaceae spread rapidly because of horizontal transmission of plasmid-encoding genes responsible for carbapenemase production. This occurs mainly by fecal–oral route in community-acquired infections as well as in hospitalized patients.[21] Because of this proximity, urine specimens might show more CRE prevalence.
Department-wise analysis of carbapenem-resistant isolates showed that majority of carbapenem-resistant isolates were obtained from the Department of Obstetrics and Gynecology (50.49%, 103/204) which was in concordance with the findings of Niranjan et al.[21] On contrary to our findings, Pawar et al.[4] and Nagaraj et al.[23] reported maximum carbapenem-resistant isolates from the Department of Surgery which highlights the importance and need of institutional-level data for antimicrobial resistance as the isolates and their resistant patterns vary in different regions of the world. In the current scenario, there are very limited options available for the treatment of multidrug-resistant organisms. Thus, there is an urgent need to implement multidisciplinary approach to limit the spread of these organisms. Strategies for prompt detection, appropriate treatment, antimicrobial stewardship, and adequate infection control measures to stop the spread of carbapenem-resistant organisms are the need of the hour to successfully tackle the global threat imposed by these organisms.
| Conclusion | | |
In this study, the prevalence of carbapenem-resistant E. coli and K. pneumoniae was 29.35%, which is higher than most of the previous studies. Our study further highlights the emphasis of the urgent need of proper monitoring and implementation of strict infection control practices in this region.
Limitations
Molecular study for genes responsible for carbapenem resistance is further required to know the accurate results.
Acknowledgments
We are thankful to the Department of Microbiology, Santosh Medical College, Ghaziabad, and the Department of Microbiology, Government Medical College, Azamgarh, for giving us opportunity to work and providing us full cooperation and support during the study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1]
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