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ISSN: 2155-9597
Journal of Bacteriology & Parasitology
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Extended Spectrum β Lactamase Producing Klebsiella pneumoniae and Escherichia coli in Neonatal Intensive Care Unit

N. Girish*, K. Saileela and S. K. Mohanty

Department of Microbiology, Kamineni Institute of Medical Sciences, Narketpally, Nalgonda District, Andhra Pradesh, India

*Corresponding Author:
Dr. N. Girish
Department of Microbiology
Kamineni Institute of Medical Sciences
Narketpally, Nalgonda District, Andhra Pradesh, India
E-mail: [email protected]

Received Date: March 14, 2012; Accepted Date: May 21, 2012; Published Date: May 27, 2012

Citation: Girish N, Saileela K, Mohanty SK (2012) Extended Spectrum ß Lactamase Producing Klebsiella pneumoniae and Escherichia coli in Neonatal Intensive Care Unit. J Bacteriol Parasitol 3:141. doi: 10.4172/2155-9597.1000141

Copyright: ©2012 Girish N, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Keywords

Neonatal septicaemia; Neonatal intensive care unit; Environment; ESBL

Introduction

Multidrug resistant Gram negative bacilli belonging to the family Enterobacteriaceae have been increasingly responsible for infections among the neonates admitted to the NICU in many countries including India. Klebsiella pneumoniae and Escherichia coli constitutes a majority of these pathogens [1,2,3]. With the emergence of ESBL producing K. pneumoniae and E. coli as the predominant pathogen, the third generation cephalosporins which have been used extensively as a life saving first line antibiotic among septicemic neonates are rendered useless, significantly increasing the morbidity and mortality in the NICUs. Many outbreaks of K. pneumoniae infection in the NICU have frequently been shown to have an environmental reservoir [4,5]. Irrespective of the primary source, the lower digestive tract of the colonised neonates is the main reservoir of these microorganisms and cross contamination is presumably hand carried by the attending staff [6].

In the present study, monitoring of the NICU environment in the KIMS hospital, Narketpally was performed to identify any environmental sources and to know exactly the mode of transmission of the pathogens and initiate corrective measures.

Materials and Methods

The KIMS hospital Narketpally is a tertiary care referral teaching centre. A total of 264 neonates admitted with clinical features suggestive of septicaemia in the NICU were studied by blood culture and CRP estimation. The following environmental samples were collected using sterile swabs from the NICU twice every month from August 2006 to July 2009. Swabs from the incubators, phototherapy units, suction apparatus, trolley, door, floor and work surfaces were taken twice in a month (Table 4). All the samples were transported to the microbiological lab and processed immediately and the isolates identified by standard bacteriological methods [7]. The antimicrobial susceptibility tests were done by Kirby Bauer’s disc diffusion test and ESBL production was detected by double disc synergy test using commercially available ceftazidime (30 μg) and cefotaxime (30 μg) discs around an amoxy clavulanic acid (20 μg) disc (Himedia) at a radius of 30 mm. All clinical isolates of NICU patients were screened for ESBL producing K. pneumoniae and E. coli. Chi-square test was used for analysing the result.

Results

The total no. of sample obtained during the study period was 264, various microorganisms were isolated, 197 in all, of which K. pneumoniae accounts for 64 (32.7%) and E. coli for 55 (28%) (Table 1). Majority of the K. pneumoniae isolates (70.3%) and E. coli isolates (61.2%) were ESBL producers.

Isolate Total No. % ESBL Producers No. %
1. Klebsiella pneumoniae 64 32.7 45 70.3
2. Escherichia coli 55 28 34 61.2
3. Staphylococcus aureus 31 16 - -
4. Pseudomonas aeruginosa 28 14 - -
5. Acinetobacter 13 7 - -
6. Coagulase negative Staphylococci 6 2.8 - -

Table 1: Organism isolated from Neonates of NICU.

The K. pneumoniae and E. coli isolates were grouped based on ESBL production and antibiotic susceptibility patterns into ESBL producers and ESBL non producers (Tables 2 and 3).

Isolate Cu Ce Ci G Ak Nt Cf
ESBL producers 93 87 80 89 14 92 51
ESBL non producers 93 78 80 78 0 78 50

Table 2: Antimicrobial resistance pattern of K. pneumoniae isolates from neonates (%).

Isolate Cu Ce Ci G Ak Nt Cf
ESBL producers 92 92 82 90 20 90 58
ESBL non producers 91 84 77 76 0 75 45

Table 3: Antimicrobial resistance pattern of E. coli isolates from neonates (%).

Discussion

Although various risk factors for colonization of neonates with ESBL producing K. pneumoniae and E. coli in the NICU have been elucidated [1], the wide spread use of cephalosporins form the most important factor in selecting out these strains. These strains are able to survive on skin & watery surfaces and resist dessication making them easily transferable through equipments and the hands of health care workers [6,8]. The Klebsiella and E. coli species, in addition to their virulence and ability to acquire antibiotic resistance determinants [3], are able to survive on skin and watery surfaces and resist dessication [9], making them easily transferable through equipments and the hands of health care workers.

The environmental sampling revealed disturbing details of the extent to which these strains were prevalent in the NICU. Repeated isolation of bacteria also confirmed their persistent presence in the environment and that they are not occasional contaminants. Many of these strains had similar antibiogram as compared to clinical isolates suggesting common source of infection. Though molecular typing of these microorganisms can be very useful in identifying the organisms that have originated from a single strain, it was not done due to lack of facilities at our institution. The other major limitation of this study was inability to perform the Minimum Inhibitory Concentration (MIC) of the various antibiotics and cephalosporins with and without clavulanic acid for ESBL detection. MICs for the former was not performed, as the study was mainly intended to analyze the ESBLs in K. pneumoniae and E. coli and the latter due to the difficulty in procuring clavulanic acid (Table 5 and 6).

Site of sampling Sample collected ESBL producing K. pneumoniae ESBL producing E. coli
No. in each survey Total No. of surveys positive Total isolates % No. of surveys positive Total isolates %
Incubators 2 144 10 11 7.6 4 5 3.5
Phototherapy units 2 144 5 6 4.2 3 4 2.7
Suction apparatus 2 144 5 5 3.5 3 4 2.7
Trolley 1 72 3 4 5.6 1 2 2.8
Door 1 72 2 3 4.2 1 2 2.8
Floor 2 144 4 5 3.5 3 4 2.7
Work surfaces 2 144 5 5 3.5 2 4 2.7
Total = 39 Total = 25

Table 4: Details of the Environmental sampling of the NICU.

ESBL K. pneumoniae Similar antibiogram Dissimilar antibiogram Total No. of isolates
No. % No. %
Neonatal isolates 22 48.9 23 51.1 45
Environmental isolates 30 76.9 9 23.1 39

Table 5: Classification of ESBL producing K. pneumoniae from neonates and environmental samples and their antibiogram pattern.

ESBL E. coli Similar antibiogram Dissimilar antibiogram Total No. of isolates
No. % No. %
Neonatal isolates 15 44.1 19 55.9 34
Environmental isolates 20 80 5 20 25

Table 6: Classification of ESBL producing E. coli from neonates and environmental samples and their antibiogram pattern.

For many years now, third generation cephalosporins, especially cephatoxime along with aminoglycosides are used in the NICU as the pre- emptive antimicrobial therapy for clinically suspected cases of septicaemia. The high prevalence of ESBL producing strains in the NICU could be related to this antibiotic policy.

The interaction between mothers admitted in the maternity wards and their neonates in the NICU, especially for breastfeeding the less unwell babies leads to the possibility of introduction and re-introduction of these bacteria from other areas in the hospital and / or colonization of these infants in the maternity wards and subsequent contamination of the NICU which needs to be evaluated. The good hand hygiene practices among these mothers before handling their babies needs to be monitored. As the NICU caters to both inborn and outborn neonates, there may be a constant replenishment of the NICU environment with these strains from other hospitals through colonised neonates, as has been demonstrated by other studies.

It is likely that the interaction of many factors, like the host, therapeutic, microbial, and environmental all contribute to the colonisation of sick babies [10]. So it is important to take steps to reduce the multidrug resistant pathogens like ESBL producing K. pneumoniae and E. coli in the environment of the NICU. One of the important aspects of these measures is to restrict the widespread use of broad spectrum cephalosporins for empiric therapy.

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