The rise of bacterial pathogens in hospital environment is associated with an increasing in nosocomial infections. Entrobacteriaceae is one of the most important causes of nosocomial and community acquired infections where Beta-lactam antibiotics are the first choice for treatment of infections caused by Entrobacteriaceae. However, they produce extended spectrum beta-lactamases (ESBLs) that cause high resistance to the beta-lactam antibiotics. Of the different genera of Entrobacteriaceae, Escherichia coli is the leading urinary tract pathogens with septicemic potential, Klebsiella pneumonia causes lobar pneumonia and often outbreaks in hospital settings, Proteus mirabilis cause urinary tract infections, chronic ear infection and septicaemia, Klebsiella ozane cause atrophic rhinitis, Enterobacter causes urinary tract infection & sepsis and Citrobacter Causes urinary tract infection, sepsis, wound infection, osteomyelitis in elderly hospitalized patients and neonatal meningitis [1].
Routine ESBLs detection is not common in many developing countries including Ethiopia. Hence, assessing the prevalence and the drug susceptibility of ESBL producing bacteria is very important to develop guideline for the management of infections associated with such organisms. This study was carried out to examine the prevalence and rate of antimicrobial drug resistance of ESBL producing Entrobacteriaceae at the University of Gondar Referral Hospital environments. The data presented in this study will provide information of immediate public health importance to clinicians on the selection of antimicrobial agents for patients suffering from infections caused by ESBL Entrobacteriaceae in northwest Ethiopia.
According to this study, the total ESBL producing Entrobacteriaceae were 14.8% of which the predominant isolate was Klebsiella pneumoniae (14.7%) which is in line with a study finding in Alexandria, Egypt (14.9%) [27] but lower than those of studies conducted in France (37%), Algeria (44.5%) [28, 29] and Upper Egypt (56.25%) [30]. these variations might be due to the number of patients that attended each hospital, disease exposure, and geographic differences among the study areas. The second predominant ESBL producing organism was Escherchia coli (12.3%) which is higher than those of studies conducted in France (5%) and Algeria (4%) [28, 29]. However, it is lower than the report of studies in Alexandria, Egypt (85%) and Upper Egypt (43.75%) [27, 30]. These differences may be due to differences in the type of health care activities and infection control practices in the hospitals. The result of Entrobacter cloceae (1.2%) was lower than those of a research carried out in Algeria’s Intensive Care Unit of the hospital (11%) [29].
In our findings, inanimate objects in the hospital OPD, wards, surgical room, delivery room, waiting area, and the waste water from different sewage systems were variously contaminated by multiple drug resistant ESBL producing bacteria. Moreover, medical wards, sewage, and the surgical ward had 52.6, 24.6, and 10.5% of ESBL producing Entrobacteriaceae respectively, the overall distribution of ESBL producing Entrobacteriaceae in different sections was higher than the report in France [28]. This may be due to differences in the number of patients attending each section of the hospitals, and because the value of ESBL producing organisms in different sites is directly related to the type of samples taken.
Different studies also showed that the proportion of organisms which cause environmental contamination is directly associated to the number of patients who visit the hospitals. According to this and a previous study more hospital environment contamination was caused by ESBL producing Klebsiella pneumoniae than ESBL producing Escherchia coli in an Entrobacteriaceae family [28, 31, 32].
In an antimicrobial susceptibility test, all isolates of ESBL producing Entrobacteriaceae were 100% resistant to cefpirome, cefpodoxime, ceftazidime, ceftriaxone and amoxicillin with clavulanic acid which is much higher than reports from Poland, cefpodoxime(73.5%) and ceftazidime(81.6%) [33], and Upper Egypt, Klebsiella pneumonia (95.5%) for ceftazidime and Escherchia coli (91.4%) for ceftazidime [32].
Even though the rate of resistance was low for non-beta lactam antibiotics compared to beta-lactam antibiotics, ESBL producing Entrobacteriaceae demonstrated an alarming rate of resistance. In this finding, the rate of resistance to Klebsiella pneumoniae was 25.0% gentamicin and 45.8% ciprofloxacin which is lower than that of a study done in Upper Egypt where gentamicin was 84.4% and ciprofloxacin 77.7% [32]. Moreover, Escherchia coli isolates showed 20% resistance to gentamicin and 30% to ciprofloxacin. This result shows a lower resistance rate compared to the study done in Upper Egypt (42.8%) to gentamicin and (68.5%) to ciprofloxacin [32].
The most challenging condition in the management of infectious diseases associated with ESBL producing Entrobacteriaceae are the development of multiple drug resistance (Resistant to two or more drugs). There is a report on co-resistance of ESBL producing Entrobacteriaceae, but not to more than three antibiotics [30]. However, the current study showed that a high frequency of multiple antibiotics resistance to commonly used antibiotics. This might be due to inappropriate use of antimicrobials, lack of laboratory diagnostic tests, failure of patient adherence to their medication, and unavailability of guidelines for the selection of antibiotics.
Based on our findings, the hospital should install a proper hygiene and rational use of antimicrobial activities in order to control and prevent the possibility of spreading of infectious diseases in the compound. Moreover; the sewage system of the hospital should be managed to decrease environmental contaminations.