Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 27912

AbstractMaterial and MethodsResultsDiscussionKey MessageAcknowledgementReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2011 | Month : June | Volume : 5 | Issue : 3 | Page : 470 - 475 Full Version

The Prevalence of ESBL among Enterobacteriaceae in a Tertiary Care Hospital of North Karnataka, India


Published: June 1, 2011 | DOI: https://doi.org/10.7860/JCDR/2011/.1304
METRI BASAVARAJ C,JYOTHI P PEERAPUR, BASAVARAJ V

Microbiology Dept, BLDEA’s Shri B M Patil Medical college Bijapur, Karnataka.

Correspondence Address :
Basavaraj C Metri M.D. # 7,Old Staff Quarters, Near Lingad
Gudi BLDEA’s Shri B M Patil Medical college campus,
Bijapur, Karnataka-586103
E-mail: basucm@rediffmail.com, Phone: 09964106980

Abstract

Background and Objectives: Extended-spectrum β-lactamase (ESBL) production in the members of the family Enterobacteriaceae can confer resistance to expanded–spectrum cephalosporins such as aztreonam and the penicillins. In the recent years, there has been an increased incidence and prevalence of ESBLs all over the world and also in various parts of India. As there was no data which was available on the prevalence of ESBL in this region and as multi-drug resistance was rampant, the current study was undertaken to know the prevalence of ESBL producing Enterobacteriaceae at our tertiary health care centre.

Aim: To know the prevalence of ESBL producing Enterobacteriaceae at our tertiary health care centre.

Materials and Methods: This study was carried out on 218 clinical isolates of Enterobacteriaceae. The screening for ESBL production was done by the disc diffusion test which was recommended by the Clinical and Laboratory Standards Institute(CLSI)and the screen positive isolates were confirmed by the the double disc synergy test (DDST) and phenotypic disc confirmatory test (PDCT).

Results: E.coli (57.8%) was most common isolate, followed by K. pneumoniae (25.6%). ESBL production was confirmed in 70(32.1%) isolates. The isolates of K. pneumoniae (46.4%) were the most common ESBL producers, followed by the isolates of E coli (31.7%) and others. ESBL production was most commonly seen in the Enterobacteriaceae which were isolated from the intensive care unit patients.

Conclusion: There is a high prevalence of ESBL production in our hospital. Specific tests to detect ESBL production should be done routinely and an empirical therapy policy should be applied to the high risk units, based on the prevalence of the ESBL producing Enterobacteriaceae.

Keywords

Extended-Spectrum β-lactamases, Enterobacteriaceae, Double disc synergy test, Phenotypic disc confirmatory test

Microbes are remarkably adaptable and amazingly versatile. Through the course of evolution, they have developed sophisticated mechanisms for preserving genetic information and disseminating it efficiently in the interests of their survival. They recognize no boundaries. The resistance developing in one part of the country, or indeed in the world, can be disseminated readily (1).

The problem of microbial drug resistance is a major public health concern due to its global dimension and alarming magnitude, although the epidemiology of resistance can exhibit a remarkable geographical variability and a rapid temporal evolution. The major resistance issues overall, are those which are related to the methicillin- resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), extended-spectrum β-lactamase producing Enterobacteriaceae, and the multidrug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii (2).

The extended- spectrum β-lactamases (ESBLs) are mutant, plasmid mediated β-lactamases which are derived from the older, broad spectrum β-lactamases and they confer resistance to all the extended spectrum cephalosporins and aztreonam, except to the cephamycins and the carbapenems (3), (4). ESBLs have spread threateningly in many regions of the world and they presently compriseover 300 variants (5).

These enzymes are the result of the mutations of the TEM-1 and TEM-2 and the SHV-1 enzymes. All of the β-lactamase enzymes are commonly found in the Enterobacteriaceae family. Normally the TEM-1, TEM-2 and the SHV-1 enzymes confer a high level resistance to the early penicillins and a low level resistance to the first generation cephalosporins. The widespread use of the third generation cephalosporins and aztreonam is believed to be the major cause of the mutations in these enzymes, that has led to the emergence of the ESBLs. Because of their greatly extended substrate range, these enzymes were called as the extended-spectrum β- lactamases (6).

The first ESBL isolates were discovered in Western Europe in the mid 1980s and subsequently in the US in the late 1980s (7). ESBLs can be found in a variety of Entrerobacteriaceae species, but however, the majority of ESBL producing strains are K. pneumoniae, K. oxytoca and E.coli. Other organisms which are reported to harbour ESBLs include Enterobacter spp., Salmonella spp., Morganella morganii, Proteus mirabilis, Serratia marcescens and Pseudomonas aeruginosa. However, the frequency of ESBL production in these organisms is low (6).

The resistant organisms are now a world wide problem. They are found in variety of Enterobacteriaceae species. Over the last 15 years, numerous outbreaks of infections which were caused by ESBL producing organisms have been observed world wide (8).

The overall prevalence of ESBL-positive Enterobacteriaceae varies greatly among different geographical areas. According to published reports from Europe, ESBLs appeared to be increasing among Enterobacteriaceae in the periods 1997 through 1999 to 2001 and 2002. In Enterobacteriaceae, classical ESBLs evolved from the TEM and the SHV families. In the recent years, several new ESBLs of the non-TEM and the non-SHV types emerged, such as the enzymes of the CTX-M, PER, VEB, and the GES lineages (9).

In India, the ESBL producing strains of Enterobacteriaceae have emerged as a challenge in the hospitalized as well as the community based patients. These have been studied at New Delhi (10), Varnasi (11), Chennai (12), Coimbatore (13), Pondicherry (14), Mumbai (15), Aligarh (16) and also in various parts of the country. In Karnataka, they have been studied at Gulbarga (17), Bangalore (18), Hubli (19) and Davangere (20).

The advent of the ESBL producers has posed a great threat to the use of many classes of antibiotics, particularly the cephalosporins. The detection of ESBL expression has proved to be difficult for many laboratories because the resistant ESBL producing organisms appear to be susceptible in the in vitro routine testing and result in treatment failure (21), (22).

Hence, ESBL detection should be routinely undertaken by using specific detection methods for the proper management of infections. As there was no data which was available on the prevalence of ESBL production in this region and as multi-drug resistance was rampant, the current study was undertaken to know the prevalence of ESBL producing Enterobacteriaceae at our tertiary health care centre.

Material and Methods

The present study was conducted in the Department of Microbiology at the Shri B M Patil Medical College, Bijapur, from June 2009 to May 2010.

Sample size
All the clinical samples that came to the Microbiology laboratory during the study period constituted the material for the study.

A total of 218 random, non repetitive, clinical isolates of Enterobacteriaceae, which were recovered in the microbiology laboratory over a period of one year, were identified, based on the colony morphology and the biochemical reactions from a variety of clinical specimens like urine, stool, sputum, blood, exudates, pus and other body fluids.

Inclusion criterion:
The samples which yielded Enterobacteriaceae were included in the study.

Exclusion criterion:
The samples which did not yield Enterobacteriaceae were excluded from the study.

Antimicrobial susceptibility tests were performed by using the Kirby Bauer disc diffusion method as per the CLSI guidelines (23). The antimicrobials which were tested were ampicillin (10μg), amikacin (30μg), cefuroxime (30μg), ciprofloxacin(5μg), gentamicin (10μg), co-trimoxazole (25μg), nalidixic acid (30μg), gatifloxacin(5 μg), nitrofurantoin(300μg), ceftazidime and imipenem (10μg). All the discs were obtained from Hi - Media, Mumbai, India.

Screening for ESBL producers by the disk diffusion methods:
The screening for ESBL producers was done by the disc diffusiontest as was recommended by the CLSI (23), (24). Ceftazidime (30 μg) was used as indicator drug. Those with a zone diameter of ≤22mm were suspected of possible ESBL production and these were confirmed by the double disc synergy test and the phenotypic disc confirmatory test.

The detection of ESBLs by the confirmatory tests
1. The double disc synergy test (DDST) (25)
The test inoculum (0.5 McFarland’s turbidity) was spread onto Mueller-Hinton agar(MHA) by using a sterile cotton swab. A disc of augmentin (20 μg amoxycillin + 10 μg clavulanate) was placed on the surface of the MHA; then, discs of cefotaxime (30 μg) and ceftazidime (30 μg) were kept 16 to 20 mm apart from the augmentin disc (centre to centre). The plate was incubated at 37 °C overnight. The enhancement of the zone of inhibition of the cephalosporin disc towards the clavulanic acid disc was inferred as synergy and the strain was considered as an ESBL producer. (Table/Fig 1)

2. The phenotypic disc confirmatory test (PDCT) (24)
This test was performed as a disc diffusion test, as recommended by the CLSI. The test inoculum (0.5 McFarland’s turbidity) was spread onto the MHA by using a sterile cotton swab; then, a) a ceftazidime(CA) disc containing 30 μg of the antibiotic and a ceftazidime- clavulanic acid (CAC) disc containing 20+10 μg of the antibiotics were placed at a distance of 30 mm from each other b) a cefotaxime(CE) disc containing 30 μg of the antibiotic and a cefotaxime-clavulanic acid (CEC) disc containing 20+10 μg of the antibiotics were placed at a distance of 30 mm from each other. (Table/Fig 2)

The plates were incubated overnight at 37oC and the results were read. A ≥ 5 mm increase in the zone diameter for CAC, versus its zone diameter when it was tested alone by CA and/or a ≥ 5 mm increase in the zone diameter for CEC, versus its zone diameterwhen it was tested alone by CE, confirmed an ESBL-producing organism. All the discs were obtained from Hi- Media, Mumbai, India.

Quality control when performing the screening and the phenotypic
confirmatory tests (24).

Simultaneous tests with a non-ESBL-producing organism (Escherichia coli ATCC 25922) and an ESBL-producing organism (Klebsiella pneumoniae ATCC 700603) were performed.

Results

The present study was conducted in the Department of Microbiology at the Shri B M Patil Medical College, Bijapur, from June 2009 to May 2010, to know the prevalence of ESBL producing Enterobacteriaceae at our tertiary health care centre.

The antibiotic sensitivity pattern of the isolates revealed that 92.6% of the isolates were sensitive to imipenem, 67.6% were sensitive to amikacin, 28.5% were sensitive to gatifloxacin and 23.2% were sensitive to gentamicin. High resistance was seen for cefuroxime (99.1%), ampicillin (94.5%), ceftazidime (91.8%), co-trimoxazole (91.7%), ciprofloxacin (84.4%), nitrofurantoin (83%) and nalidixic acid (81%) .

Out of 218 enterobacteriaceae isolates, 200 were suspected to be ESBL producers, based on the screening method which was suggested by the CLSI. Out of the 200 suspected isolates, 70 (32.1) were confirmed as ESBL producers. DDST detected only 61 ESBL producers and all the 70 were detected by the PDCT. (Table/Fig 3)

(Table/Fig 3) shows different members of family Enterobacteriaceae isolated from clinical samples. E.coli was the most common (57.8%) isolate followed by K. pneumoniae (25.6%) and others.

K. pneumoniae was the most common ESBL producing Enterobacteriaceae, followed by E. coli and others, as shown in (Table/Fig 4), by both the PDCT and the DDST.

Specimen wise distribution of ESBL producers is shown in (Table/Fig 5). Maximum ESBL producers were seen in urine samples.

(Table/Fig 6) shows that maximum ESBL producing isolates were from ICCU, surgical ICU and medical ICU.

The age and sex wise distribution of the ESBL producers which is shown (Table/Fig 7), revealed that the maximum number of ESBL producers were seen in the 41-60 years age group and that the prevalence was more among the females than among the males.

Discussion

The spread of ESBL-producing bacteria has been strikingly rapid worldwide, indicating that continuous monitoring systems and effective infection control measures are absolutely required. Therapeutic options for the infections which are caused by the ESBL producers have also become increasingly limited (5).

Antibiotic resistance has been noted as a serious problem, even at our medical college hospital. The third generation cephalosporins have been used in a majority of patients and resistance even to these antibiotics has been reported. As there was no data whichwas available on the prevalence of ESBL production in this region, the current study was undertaken to know the prevalence of ESBL producing Enterobacteriaceae at our tertiary health care centre.

Out of the 218 Enterobacteriaceae isolates, a majority were E. coli (57.8%), followed by Klebsiella pneumoniae (25,6%), Citrobacter spp (6.5%), Proteus spp (6.5%), Salmonella spp (1.8%) and Enterobacter spp(1.8%). This finding was on par with those of many studies from this region. Mathur et al. (26) from New Delhi, have also reported E. coli and Klebsiella pneumoniae as the most common Enterobacteriaceae which were prevalent in their clinical samples and this was well comparable to the reports from our study. Babypadmini et al. (13) from Chennai too reported the prevalence of 49% E. coli and 8% Klebsiella spp.

As of now, no countrywide study has been conducted for the detection of the prevalence of ESBL production in India. Individual studies which were done in different parts of the country showed a varying prevalence, based on various risk factors and local reasons.

The prevalence of ESBL producing organisms in this study was found to be 32.1%, which was slightly higher than that which was reported by other studies which were done in the same region- Gulbarga (17) and Bangalore (18) and it was lower than that which was reported by studies which were done in Hubli (19) and Davangere (20).

Previous studies from India have reported the prevalence of ESBL producers to be 6.6 to 91% (Table/Fig 8). The wide variation in the prevalence is probably due to the variation in the risk factors and in the extent of antibiotic use. The prevalence of ESBL production is high in the referral centers and the intensive care units where the patients are referred from the peripheral centers and where the antibiotic use is profuse. Studies which were undertaken in Hubli by Krishna et al. (19) and in New Delhi by Wattal et al. (27) revealed a markedly higher incidence of ESBL production, which can be attributed to the subjects from the intensive care units, where the prevalence and the risk factors which are responsible for the emergence of the ESBL producers is high. Other reasons for the high prevalence of the ESBL producers were indwelling catheters, endotracheal or nasogastric tubes, gastrostomies or tracheostomies, severity of the illness, the excessive use of cephalosporins and a high rate of patient transfer from the peripheral centers (28), (29).

The present study reveals K. pneumoniae and E. coli as the major ESBL producers. Babypadmini et al. (13) have shown 40% and41% ESBL positivity among K. pneumoniae and E. coli respectively and Vinod Kumar et al. (17) from Gulbarga reported 16.8% and 48.6% of E.coli and K. pneumoniae respectively as the ESBL producers. In Citrobacter and Proteus, ESBL production was 14.3 %, which was consistent with the findings of the study which was carried out by Gangone et al. (30).

ESBL producing K. pneumoniae evolved due to a mutation in the class A TEM and SHV β-lactamases. TEM 1, SHV 2 and SHV 5 are the common types of beta lactamases which are produced by these strains. Cross-resistance to other unrelated antibiotics may occur and this resistance is transferable in association with plasmids (14).

Salmonella and Enterobacter (31), (32) species are also known to produce ESBLs, but in our study, none of the Salmonella spp. and the Enterobacter spp. showed ESBL production. This could be due to the few (4 each) isolates which were obtained in these genera.

Of the 218 isolates, 200 were suspected to be ESBL producers based on the screening test. When these 200 isolates were subjected to the confirmatory test, 70 (32.1%) isolates were identified as ESBL producers by using the DDST and the PDCT. Of the two tests which were used in the study, PDCT was a more sensitive procedure for the detection of ESBL production than the DDST. 61 (87%%) of the 70 ESBL producing strains were detected by the DDST by using two drugs, cefotaxime and ceftazidime. The PDCT test was compared with the DDST and it was found to be an inexpensive alternative to the DDST for the detection of ESBL. The DDST lacks sensitivity because of the problem of optimal disc space and the correct storage of the clavulanate containing discs. Assuming that a laboratory is currently testing the sensitivity for ceftazidime and cefotaxime with the disc diffusion test and for the phenotypic confirmatory disc diffusion test only two discs are required to be added to the sensitivity plate and would screen all gram negative bacteria in the diagnostic laboratory for ESBL production. This method is technically simple and inexpensive (16).

A study which was conducted by Khan et al. (10) found that the DDST was less sensitive than the PDCT, since it could detect ESBLs in 25 of the 39 isolates that were confirmed as ESBL positive by the latter technique. Shukla et al. (16) also reported similar findings.

Among the 218 isolates of the Enterobacteriaceae family which were analyzed, their sensitivity was found to be 92.6% with imipenem and 67.6% with amikacin. Their resistance was 99.1% against cefuroxime, followed by ampicillin (94.5%), ceftazidime (91.8%) co-trimoxazole(91.7%) and ciprofloxacin (84.4%). Sahm et al. (33) reported 97.8% resistance to ampicillin and 92.8% resistance to cotrimoxazole, which was similar to the resistant pattern which was observed in the present study. The resistance to gentamicin (91%) co-trimoxazole(82.6%) and ciprofloxacin (82.6%) which was reported by Babypadmini et al. (13) was also similar to that which was found in our study.

As indicated in many previous studies, the 92 % imipenem sensitivity in the present study advocates the usage of carbapenem antibiotics as a therapeutic alternative in the wake of the increasing resistance rates which were observed with the the conventional β-lactam and non β-lactam antibiotics. However, we need to keep in mind that the carbapenems are antimicrobials that are usually kept in reserve (15) In the case of non-life-threatening infections and in non outbreak situations, it is not necessary to administer carbapenems. This approach intends to preserve the therapeutic value of these precious drugs. The heavy use of carbapenems, in fact, may favour the selection of Stenotrophomonas maltophilia (a species which is naturally resistant to these drugs) (9).

In the present study, the highest number of ESBL producers wereobtained in the isolates from the ICCU, the surgical ICU and the medical ICU, followed by other wards and this was comparable with a study which was carried out at AIIMS, New Delhi, India (26). This could be due to the prolonged hospital stay, inappropriate therapy, total antibiotic use, indwelling catheters, endotracheal or nasogastric tubes, gastrostomies or tracheostomies and the severity of the illness.

The present study revealed a slight female preponderance for ESBL production among the study subjects. This was similar to the findings of an earlier study which were reported by Kiratisin et al. (5) which revealed a female preponderance. The age wise distribution of the ESBL producers showed the highest prevalence among the 41-60 years age group (38.9%). This was not statistically significant (p>0.005). This was closely followed by the >60 years age group (30%). This may be because of the increased hospitalization of the patients with ages around 60 years in the medical and surgical units. Kiratisin et al. (5) have also reported similar findings.

The knowledge of the resistance pattern of the bacterial strains in this geographical area will help in guiding an appropriate and judicious antibiotic use. There is a possibility that a restricted use can lead to the withdrawal of the selective pressure and that the resistant bacteria will no longer have a survival advantage in such settings.

There is a high prevalence of ESBL producers among Enterobacteriaceae and the routine susceptibility tests which are done, fail to detect the ESBL positive strains. With the spread of ESBL producing strains in hospitals all over the world, it was necessary to know the prevalence of ESBL positive strains in our hospital. The reporting of ESBL producing Enterobacteriaceae from the clinical samples will be useful for the clinicians to select the appropriate antibiotics for the treatment of these strains and to take proper precautions to prevent the spread of these resistant organisms. The failure to detect these enzymes results in an uncontrolled spread of these organisms and finally, therapeutic failures. This study underscores the need for the routine detection of ESBL producers by specific tests.



Key Message

1. There is high prevalence of ESBL producing Enterobacteriaceae. 2. Specific tests to detect ESBL production among the Enterobacteriaceae should be done on a routine basis in all the clinical laboratories. 3. Based on the prevalence of ESBL producing Enterobacteriaceae, each hospital should formulate a policy of empirical therapy in the high risk units.

Acknowledgement

Dr .Mahesh C Baragundi, Asso Professor, Microbiology Department, SN Medical college, Bagalkot.

References

1.
Greenwood D. Resistance to antimicrobial agents: a personal view. J Med Microbiol 1998; 47: 751-5.
2.
Rossolini GM ,Mantengoli E. Antimicrobial resistance in Europe and its potential impact on empirical therapy. Clin Microbiol Infect 2008; 14 (6): 2–8.
3.
Thomson KS. Controversies about extended-spectrum and AmpC β- lactamases. Emerg Infect Dis 2001;7:333-6.
4.
Bush K, Jacoby GA, Medeiros AA. A functional classification scheme for β-lactamases and its correlation with molecular structure. Antimicrob Agents Chemother 1995;39:1211-33.
5.
Kiratisin P, Apisarnthanarak A, Laesripa C, and Saifon P. Molecular characterization and epidemiology of extended-spectrum β-lactamase- producing Escherichia coli and Klebsiella pneumoniae isolates causing health care-associated infection in Thailand, where the CTXM family is endemic. Antimicrob Agents Chemother 2008;52(8):2818- 24.
6.
Chaudhary U, Aggarwal R. Extended spectrum β-lactamases (ESBL) - An emerging threat to clinical therapeutics. Indian J Med Microbiol 2004;22(2): 75-80.
7.
Nathisuwan S, Burgess DS, Lewis JS. Extended-spectrum β-lactamases: epidemiology, detection, and treatment. Pharmacotherapy 2001 ;21:920-8.
8.
Palucha A, Mikiewiez B, Hryniewiez W, Griadkowski M. Concurrent outbreaks of extended-spectrum β-lactamase producing organisms of the family Enterobacteriaceae in a Warsaw Hospital. J Antimicrob Chemother 1999;44:489-499.
9.
Luzzaro F, Mezzatesta M, Mugnaioli C, Perilli M, Stefani S,Amicosante G,Rossolini GM, Toniolo A. Extended-Spectrum Ăź-lactamases among enterobacteria of Medical Interest: Report of the Second Italian Nationwide Survey. J Clin Microbiol 2006; 44(5) :1659-1664.
10.
Khan MKR, Thukral SS, Gaind R. Evaluation of a modified doubledisc synergy test for detection of extended- spectrum β-lactamasesin AMPC β-lactamase-producing Proteus mirabilis, Indian J Med Microbiol 2008;26(1): 58-61.
11.
Bhattacharjee A, Sen MR, Prakash P, Gaur A, Anupurba S. Increased prevalence of extended-spectrum β lactamase producers in neonatal septicaemic cases at a tertiary referral hospital. Indian J Med Microbiol 2008;26(4): 356-60.
12.
Menon T, Bindu D, Kumar CPG, Nalini S, Thirunarayan MA. Comparison of double disc and three dimensional methods to screen for ESBL producers in a tertiary care hospital. Indian J Pathol Microbiol 2006;24(2): 117-120.
13.
Babypadmini S, Appalaraju B. Extended -spectrum β-lactamases in urinary isolates of Escherichia coli and Klebsiella pneumoniae - Prevalence and susceptibility pattern in a tertiary care hospital. Indian J Med Microbiol 2004;22(3):172-174.
14.
Shanmuganathan C, Ananthakrishnan A, Jayakeerthi SR, Kanungo R, Kumar A, Bhattacharya S,Badrinath S. Learning from an outbreak: ESBL- the essential points. Indian J Med Microbiol 2004;22(4): 255- 257.
15.
Rodrigues C, Joshi P, Jani SH, Alphonse M, Radhakrishnan R, Mehta A. Detection of -β -Lactamases in nosocomial Gram negative clinical isolates. Indian J Med Microbiol 2004;22(4): 247-250.
16.
Shukla I, Tiwari R, Agarwal M. Prevalence of Extended spectrum β- lactamase producing Klebsiella pneumoniae in a tertiary care hospital. Indian J Med Microbiol.(2004) ;22 (2): 87-91.
17.
Vinodkumar CS, Neelagund YF. Extended-spectrum β-lactamase mediated resistance to third generation cephalosporins among Klebsiella pneumoniae in neonatal septicemia. J Indian Paediatr; 2004: 41: 97-99
18.
Krishnan PU and Macaden R. Spread of multidrug resistant Klebsiella pneumoniae in a tertiary care hospital. Abstracted in the proceedings of the 4th International conference of the hospital infection society, Edinburgh, Sept 1998;676.
19.
Krishna BVS, Patil AB, Chandrasekhar MR. Extended-spectrum β-lactamase Producing Klebsiella pneumoniae in Neonatal Intensive Care Unit. Indian J Pediatr 2007; 74 (7): 627-630.
20.
Sridhar Rao PN, Basavarajappa KG, Krishna GL. Detection of extended- spectrum β-lactamase from clinical isolates in Davangere .Indian J Pathol Microbiol 2008;51(4):497-9.
21.
Paterson DL, Ko WC, Gottberg AV, Casellas JM, Mulazimoglu L, Klugman KP, Bonomo RA, Rice LB, McCormack JG, Yu VL. Outcome of cephalosporin treatment for serious infections due to apparently susceptible organisms producing extended-spectrum β-lactamases: Implications for the clinical microbiology laboratory. J Clin Microbiol 2001; 39(6): 2206-2212;
22.
Sanders CC, Sanders WE, Molandes ES. Characterization of β-lactamases in situ on polyacrylamide gels. Antimicrob Agents Chemother 1986;30(6):951-52.
23.
National Committee for
24.
Clinical Laboratory Standards: Performance standards for antimicrobial susceptibility testing; Eighth informational supplement. M100-S8. NCCLS, Wayne, PA;1998;7767 Clinical and Laboratory Standards Institute. 2005 guidelines by CLSI/ NCCLS - CLSI informational supplement. Approved standard M100- S15 Wayne, PA; 2000;565
25.
Jarlier V, Nicolas M, Fournier G, Philippon A. Extended spectrum β-lactamases conferring transferable resistance to newer β-lactam agents in Enterobacteriaceae: Hospital prevalence and susceptibility patterns. Rev Infect Dis 1988;10:867-78.
26.
Mathur P, Kapil A, Das B, Dhawan B. Prevalence of extended-spectrum β- lactamase producing Gram negative bacteria in tertiary care hosptital. Indian J Med Res 2002;115:153-157.
27.
Wattal C , Sharma A, Oberoi JK, Datta S, Prasad KJ, Raveendr R. ESBL- An emerging threat to antimicrobial therapy. Microbiology Newsletter 2005. Sir Ganga Ram Hospital, Vol 10, No 1. 1-8.
28.
Subha A, Ananthan S. Extended-Spectrum β-lactamase (ESBL) mediated resistance to third generation cephalosporins among Klebsiella pneumoniae in Chennai. Indian J Med Microbiol 2002;20:92-5.
29.
Jain A, Roy I, Gupta MK, Kumar M, Agarwal SK. Prevalence of extended- spectrum β-lactamase-producing Gram-negative bacteria in septicemic neonates in a tertiary care hospital. J Med Microbiol 2003;52:421-5.
30.
Gangone PJ, Bedenic B, Koulla SS, Randegger C, Adiogod D, Petal N. Extended-spectrum β-lactamase-producing Enterobacteriaceae in Yaounde,Cameroon. J Clin Microbiol 2005;43(7):3273-7.
31.
Gotale M, Manthalkar P, Kandle S, Yamul V, Jahagirdhar V. Co-relation of extended-spectrum β-lactamase-production with cephalosporins resistance in Gram negative bacilli. Indian J Pathol Microbiol 2004;47(1): 82-84.
32.
Bell JM, Turnidge JD, Jones RN. Prevalence of extended-spectrum β- lactamase-producing Enterobactor cloacae in the Asia –pacific region; Results for the SENTRY antimicrobial surveillance program , 1998 to2001. Antimicrob Agents Chemother 2003;47(12): 3989-93.
33.
Sahm F D, Thornsberry C, Mayfield DC, Jones ME, Karlowsky JA. Multidrug-resistant urinary tract isolates of Escherichia coli: prevalence and patient demographics in the United States in 2000. Antimicrob Agents Chemother 2001;Vol 45(5): 1402-06.

DOI and Others

JCDR/2011/1304

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com