Skip to main content
Download PDF

Prevalence and antimicrobial susceptibility patterns of extended spectrum beta-lactamase producing Entrobacteriaceae in the University of Gondar Referral Hospital environments, northwest Ethiopia

BMC Research Notes volume 11, Article number: 335 (2018) Cite this article

Abstract

Objective

This study aimed at assessing the magnitude, distribution, and the antimicrobial susceptibility of the extended spectrum beta-lactamase producing Entrobacteriaceae in the University of Gondar Referral Hospital environments.

Results

Out of a total of 384 samples, 14.8% were ESBL producing Entrobacteriaceae, where 42.10% Klebsiella pneumoniae, 35.09% Escherchia coli and 7.01% Proteus mirabilis were the predominant isolates. Most ESBL producing isolates, that is, 24.56, 22.8, and 22.8% were found from waste water, sinks and bedside tables respectively. All ESBL producing Entrobacteriaceae were found to be resistant to ceftriaxone, ceftazidime, cefpirome, cefpodoxime, and amoxicillin with Clavulanic acid. Resistance rate was also high for non-beta-lactam antimicrobials, like chloramphenicol (70.18%), cotrimoxazole (64.91%), norfloxacin (42.10%), ciprofloxacin (43.86%), and gentamicin (19.30%).

Introduction

Hospital environment is a potential source of nosocomial infections, since it houses both patients with diverse pathogenic microorganism and a large number of susceptible individuals [1–3].

The ever-increasing bacterial resistance to antibiotics is one of the most thought-provoking tasks of medical issues today [4]. A persistent exposure of bacterial strains to a multitude of beta-lactam antibiotics has induced a dynamic, continuous production and mutation of beta-lactamase in the bacteria leading to the development of extended spectrum beta-lactamases (ESBLs) causing resistance to broad spectrum beta-lactam antibiotics [5–7]. ESBL is a plasmid-mediated enzyme able to hydrolyze all beta-lactams except cephamycin and carbapenems, and constitute a large heterogeneous group of enzymes with different origins [5, 8].

An extended spectrum beta-lactamase production has been observed mostly in Entrobacteriaceae, and their resistance increased mainly due to the spreading of ESBL and the emergence of different genes [9–11]. The frequently ESBL producing Entrobacteriaceae are Escherichia coli, Klebsiella pneumoniae and Proteus species. However, all other clinically relevant Entrobacteriaceae species are also common ESBL producers. The distribution of ESBL depends on geographic locality, hospital wards, groups of patients and the type of infection [12–16].

The resistance patterns of ESBLs were initially considered as a problem related to nosocomial outbreak, mainly in Intensive Care Units, surgical procedures, bladder catheterization, long-term hospitalization, and frequent exposure of broad spectrum antimicrobials. However, the distribution of ESBL producing Entrobacteriaceae becomes common in any other area of the hospital indicating a high possibility of horizontal gene transfer among strains of different genera within the hospital environment [17–21].

Reports about ESBLs producing Entrobacteriaceae at hospital environments in northwest Ethiopia are limited. Thus, this study was carried out to assess and determine the rate of ESBLs producing Entrobacteriaceae and their antimicrobial susceptibility patterns in the hospital environment at the University of Gondar Referral Hospital.

Main text

Methods

Study design and area

A hospital-based cross-sectional study was conducted at the University of Gondar Referral Hospital from January to June 2014. The hospital provides surgical, medical, gynecologic and obstetric, and ophthalmologic services to over 5 million inhabitants. It has different wards with 465 beds and outpatient departments.

Sample size

Seven sample selection sites were identified prior to data collection. The simple random sampling technique was applied. Out of the 2508 total population, 384 were included in the study based on the single population proportion formula.

Sampling techniques

Samples were collected from bed frames, bedside tables, door handlers, floors, sinks, waiting chairs, walls, and the waste water of the hospital which have direct contact with patients, their families, and health care providers. Medical wards, surgical wards, the Gynecology and Obstetrics ward, the Fistula clinic, the Eye clinic, the hospital café, and hospital sewages were the study sites. Sterile cotton tipped swabs moistened with normal saline were rotated against the surfaces of inanimate objects to obtain specimens, and waste water was collected from the hospital sewage by a sterile screw capped bottle and transported to the microbiology laboratory. Each sample was transferred to the selective media, Hicrome ESBL agar base, to assess the ESBL production in 2 h. The species was differentiated by specific colony color and again by a biochemical test [22, 23]. Antimicrobial susceptibility tests were conducted using the disc diffusion method for beta-lactam and non-beta-lactam antimicrobials [24–26].

Data analysis

The descriptive statistical analysis was performed by using SPSS version 20 software program.

Results

Distribution of ESBL producing Entrobacteriaceae in the hospital environment (Table 1)

ESBL producing Entrobacteriaceae, namely Escherchia coli, Klebsiella pneumoniae, Klebsiella ozenae, Proteus mirabilis, Entrobacter cloceae, Entrobacter aerogens, Citrobacter and Providencia stuarti were isolated from the samples. The predominant species were Klebsiella pneumoniae (42.10%), Escherchia coli (35.09%) and Proteus mirabilis (7.01%). Escherchia coli and Klebsiella pneumoniae were found in all the selected types of samples. However, Klebsiella ozenae were found in sinks; Proteus mirabilis in bed frames, floor and sinks; Entrobacter cloace in bed frame; Entrobacter aerogens in bed tables and bed frames; Citrobacter in floor and sinks and Providencia stuarti in bed frames and sinks (Table 2).

Table 1 Profile of ESBL producing Entrobacteriaceae in different hospital environmental samples at the University of Gondar Referral Hospital, January–June 2014
Full size table
Table 2 The distribution of ESBL producing Entrobacteriaceae in different sites of the hospital environment at the University of Gondar Referral Hospital, northwest Ethiopia, January–June 2014
Full size table

The highest number of ESBL producing Entrobacteriaceae isolates were found from sinks (22.80%), bed tables (22.80%), waste water (15.79%) and less than 5% were found in bed frames, door handles, floors, walls, and waiting chairs. However, no isolates were found from hospital cafe chairs.

Antimicrobial susceptibility patterns of ESBL producing Entrobacteriaceae isolates from the hospital environment (Table 3)

All ESBL producing Entrobacteriaceae were found to be 100% resistant to cefpirome, cefpodoxime, ceftazidime, ceftriaxone, and amoxicillin with clavulanic acid. However, 70.18, 64.91, 42.10, 43.86, and 19.30% were resistant to chloramphenicol, cotrimoxazole, norfloxacin, ciprofloxacin, and gentamicin, respectively.

Table 3 Antimicrobial susceptibility pattern of ESBL producing Entrobacteriaceae isolated from the hospital environment at the University of Gondar Referral Hospital, northwest Ethiopia, and January–June 2014
Full size table

Klebsiella pneumoniae were resistant to 91.7% cotrimoxazole, 66.7% chloramphenicol, 45.8% norfloxacin, 45.8% ciprofloxacin, and 25.0% gentamicin. Escherchia coli was also resistant to chloramphenicol (55.0%), cotrimoxazole (35.0%), norfloxacin (25.0%), ciprofloxacin (30.0%), and gentamicin (20.0%).

Of the total ESBL producing Proteus mirabilis, only 25.0% strain was resistant to norfloxacin, ciprofloxacin, and cotrimoxazole. But, all isolates were susceptible to gentamicin.All isolates of Klebsiella ozenae were resistant to chloramphenicol, and cotrimoxazole, whereas all isolates were sensitive to norfloxacin, ciprofloxacin, and gentamicin.

Multiple antibiotics resistance

More than 56% of the ESBL producing Entrobacteriaceae isolates demonstrated multiple non-beta lactam antibiotics resistance against ciprofloxacin, norfloxacin, gentamicin, chloramphenicol, and cotrimoxazole, of which Klebsiella pneumoniae (58%) and Escherchia coli (40%) showed a high level of multiple drug resistance. Despite the fact that the number of isolates was small; Entrobacter cloceae, Entrobacter aerogens, Citrobacter, and Providencia stuart were multidrug resistant.

Discussion

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.

Limitation of the study

Some type of hospital environments were not included in the study. So to get good distribution of ESBLs Entrobacteriaceae in hospital environment, it would be better assessing all types of the hospital environments. It would have a better figurative if the study was conducted in different hospitals that are found in north-west Ethiopia.

Abbreviations

CTX-M:

Cefotaximase Munich

CLSI:

Clinical Laboratory Standard Institute

DDST:

double-disc synergy test

ESBL:

extended spectrum beta lactamase

HAIs:

health care associated infections

MIC:

minimum inhibitory concentration

OXA:

oxacillin

SHV:

sulphydryl variable

SPSS:

statistical package for social sciences

TEM:

temoneira

OPD:

outpatient department

References

  1. Prescott LM, Harley JP, Klein DA. Microbiology. 6th ed. New York: McGraw-Hill; 2005. p. 833–42.

    Google Scholar 

  2. Chikere C, Omoni V, Chikere B. Distribution of potential nosocomial in a hospital environment. Afr J Biotechnol. 2008;7(20):3535–59.

    Google Scholar 

  3. Gelaw A, Gereselassie S, Tiruneh M, Matiwos E, Yifru S. Isolation of bacterial pathogens from patients with postoperative surgical site infection and sources of infections at the University of Gondar Hospital northwest Ethiopia. J Environ Occcup Sci. 2014;3(2):103–8.

    Article  Google Scholar 

  4. Hawkey PM, Jones AM. The changing epidemiology of resistance. J Antimicrob Chemother. 2009;64(1):3–10.

    Article  CAS  Google Scholar 

  5. Pitout JD, Laupland KB. Extended-spectrum beta lactamase-producing Entrobacteriaceae: an emerging public-health concern. Lancet Infect Dis. 2008;8:159–66.

    Article  PubMed  CAS  Google Scholar 

  6. Canton R, Novais A, Valverde A, Machado E, Peixe L, Baquero F, Coque TM. Prevalence and spread of extended-spectrum β-lactamase-producing Entrobacteriaceae in Europe. Clin Microbiol Infect. 2008;14(1):144–53.

    Article  PubMed  CAS  Google Scholar 

  7. Paterson DL, Bonomo RA. Extended spectrum β-lactamases: a clinical update. Clin Microbiol Rev. 2005;18(4):657–86.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  8. Naas T, Poires L, Nordmann P. Minor extended-spectrum β-lactamase. Clin Microbiol Infect. 2008;14(1):42–52.

    Article  PubMed  CAS  Google Scholar 

  9. Pitout JD, Nordmann P, Kevin B, Laupland KB, Poirel L. Emergence of Enterobacteriaceae producing extended-spectrum β-lactamases (ESBLs) in the community. J Antimicrob Chemother. 2005;56:52–9.

    Article  PubMed  CAS  Google Scholar 

  10. Rafay AM, Al-Muharrmi Z, Toki R. Prevalence of extended spectrum β-Lactamases producing isolates over a 1 year period at a University Hospital in Oman. Saud Med J. 2007;28(1):22–7.

    Google Scholar 

  11. Moges F, Endris M, Belyhun Y, Worku W. Isolation and characterization of multiple drug resistance bacterial pathogens from waste water in hospital and non-hospital environments, northwest Ethiopia. BMC. 2014;7:215.

    Google Scholar 

  12. Ben-Ami R, Schwaber MJ, Navon-Venezia S, et al. Influx of extended-spectrum β-lactamase-producing Enterobacteriaceae into the hospital. Clin Infect Dis. 2006;42(1):925–34.

    Article  PubMed  CAS  Google Scholar 

  13. Livermore DM, Canton R, Gniadkwski M, Nordmann P, Rossolini GM, et al. CTX-M: changing the face of ESBLs in Europe. J Antimicrob Chemother. 2007;59(1):165.

    PubMed  CAS  Google Scholar 

  14. Carattoli A. Animal reservoirs for extended-spectrum β-lactamase producers. Clin Microbiol Infect. 2008;14:117–23.

    Article  PubMed  Google Scholar 

  15. Monaghan C, Colleran E. Antibiotic resistance of fecal coli forms in hospital and city sewage in Galway. Iri J Med Sci. 1981;150(10):304–9.

    Article  CAS  Google Scholar 

  16. Korzeniewska E, Harnisz M. Beta-lactamse-producing Entrobacteriaceae in hospital effluents. J Environ Manag. 2013;128:904–11.

    Article  CAS  Google Scholar 

  17. Sturenburg E, Mack D. Extended-spectrum β-lactamases implications for the clinical microbiology laboratory, therapy and infection control. J Infect. 2003;47(4):273–95.

    Article  PubMed  Google Scholar 

  18. Al-Jasser AM. Extended spectrum beta lactamases (ESBLs): a global problem. Kuwait Med J. 2006;38(3):171–85.

    Google Scholar 

  19. Livermore DM, Woodford N. The β-lactamase threat in Entrobacteriaceae, Pseudomonas and Acinetobacter. Trends Microbiol. 2006;14(1):413–4.

    Article  PubMed  CAS  Google Scholar 

  20. Bonnet R. Growing group of extended-spectrum beta-lactamases. The CTX-M enzymes. Antimicrob Agents Chemother. 2004;48(1):1–14.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  21. El-Bialy AA, Abu-Zeid A. Prevalence and risk factors of extended-spectrum B-lactamase producing Klebsiella pneumonia in neonatal intensive care unit. Egypt J Med Microbiol. 2009;18(1):110–5.

    Google Scholar 

  22. Glupczynski Y, Berhin C, Bauraing C, Bogaert P. valuation of a new selective chromogenic agar medium for detection of extended spectrum beta lactamase producing Entrobacteriaceae. J Clin Microbiol. 2007;45(2):501–5.

    Article  PubMed  CAS  Google Scholar 

  23. Arora D. Quality assurance in microbiology. Indian J Med Microbiol. 2013;17(22):81–7.

    Google Scholar 

  24. Cheesbrough M. Manual of medical microbiology. 2nd ed. Britain: Oxford press; 2006. p. 63–143.

    Google Scholar 

  25. Bauer AW, Kirby WM, Sherris JC, Turck M. Antibiotic susceptibility testing by standard single disc method. Am J Clin Pathol. 1996;45(45):493–9.

    Google Scholar 

  26. Clinical and Laboratory Standards Institute (CLSI) performance standards for antibiotic susceptibility testing twenty third informational supplement CLSI document M100-S23. Wayne, Pennsylvania USA: Clinical and Laboratory Standards Institute. 2013.

  27. Amine AEK. Extended spectrum beta lactamase producing bacteria in waste water Alexandria, Egypt. Int J Biosci Biochem Bioinform. 2013;3(6):285–90.

    Google Scholar 

  28. Guet-Revillet H, Le Monnier A, Breton N, et al. Environmental contamination with extended-spectrum beta-lactamses: is there any difference between Escherichia coli and Klebsiella spp. Am J Infect Control. 2012;40(9):845–8.

    Article  PubMed  Google Scholar 

  29. Ahmed ZB, Ayad A, Mesli E, Messai Y, Bakour R, Drissi M. CTX-M-15 extended-spectrum β-lactamases in Entrobacteriaceae in the intensive care unit of Tlemcen Hospital, Algeria. East Medit Health J. 2002;18(4):382–6.

    Article  Google Scholar 

  30. Gbaguidi-Haore H, Talon D, Hocquet D, Bertrand X. Hospital environmental contamination with Enterobacteriaceae producing extended-spectrum β-lactamse. Am J Infect Control. 2013;12(4):56.

    Google Scholar 

  31. Freeman JT, Nimmo J, Gregory E, Tiong A, Almeida MD, Mcauliffe GN, Roberts SA. Predictors of hospital surface contamination with Extended-spectrum beta lactamase producing Eschericha coli and Klebsiella pneumonia: patient and organism factors. Antimicrob Resist Infect Control. 2014;3(1):5.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Affi MM. Detection of extended spectrum beta-lactamase producing Klebsiella pneumonia and Escherichia coli of environmental surfaces at upper Egypt. Int J Biol Chem. 2013;16(2):212–31.

    Google Scholar 

  33. Esiobu N, Armenta L, Lke J. Antibiotic resistance in soil and water environments’. Int J Environ Health Res. 2002;12(2):133–44.

    Article  PubMed  Google Scholar 

Download references

Authors’ contributions

TE: conception of research idea, study design, data collection, analysis and interpretation, manuscript writes up and review. FM: research idea. AG: data analysis. FM: manuscript write up. SE: manuscript write up. All authors read and approved the final manuscript.

Acknowledgements

We would like to thank all respective department of the University of Gondar referral hospital for their support during sample collection.

Competing interests

The Authors declare that they have no competing interests.

Availability of data and materials

All data generated or analyzed during this study were included in this article.

Consent for publication

Not applicable.

Ethical approval and consent to participate

Ethical clearance was obtained from Research and Ethical Review Committee of the School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar.

Funding

No one was responsible for funding of this research.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Author information

Authors and Affiliations

  1. Department of Microbiology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, P. O. Box 196, Gondar, Ethiopia

    Tigist Engda, Feleke Moges, Aschalew Gelaw, Setegn Eshete & Feleke Mekonnen

Authors
  1. Tigist Engda
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Feleke Moges
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Aschalew Gelaw
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Setegn Eshete
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Feleke Mekonnen
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Tigist Engda.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Engda, T., Moges, F., Gelaw, A. et al. Prevalence and antimicrobial susceptibility patterns of extended spectrum beta-lactamase producing Entrobacteriaceae in the University of Gondar Referral Hospital environments, northwest Ethiopia. BMC Res Notes 11, 335 (2018). https://doi.org/10.1186/s13104-018-3443-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s13104-018-3443-1

Keywords

  • ESBL
  • Entrobacteriaceae
  • Hospital environments

BMC Research Notes

ISSN: 1756-0500

Contact us