Journal of Nosocomial Infection

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1 Journal of Nosocomial Infection Original Article The Frequency of Multi Drug Resistance (MDR) Among Klebsiella Pneumoniae Isolates from Kermanshah Medical Centers Parisa Nejat, Alisha Akya *, Azam Elahi, Keyghobad Ghadiri - MSc student of Medical Microbiology, Kermanshah University of Medical Sciences, Kermanshah, Iran - Associate prof. of Medical Microbiology, Nosocomial Infection Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran - Associate Professor of Pediatric infectious diseases, Nosocomial Infection Research Centre, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran *Corresponding author: Alisha Akya akya59@yahoo.com Receive: Jan 0 Revised: Apr 05 Accept: May 05 ABSTRACT Background and Objective: Klebsiella pneumoniae known as one of the most common causes of hospital-acquired infections and multidrugresistant bacterium. The aim of this study was to determine the prevalence of antibiotic resistance among K. pneumoniae isolates from Kermanshah medical centers. Methods: A total of 5 clinical samples were studied and among them, 00 isolates of K. pneumoniae was confirmed by API-0E Kit. Antibiotic susceptibility was performed by disk diffusion method for ampicillin, cefazoline, gentamicin, tobramycin, cefotaxime, ceftriaxone, ceftazidime, cefpodoxime, aztreonam, ertapenem, imipenem, meropenem, piperacillintazobactam, ciprofloxacin and trimethoprim-sulfamethoxazole (Cotrimoxzazole). Multidrug resistance (MDR) was determined based on the resistance to three or more classes of antibiotics. The data were statistically analyzed. Results: The majority of isolates was from urinary tract infection (0). Isolates were resistant to ampicillin (98), cefazoline (59), Cotrimoxazole (58), ceftazidime (5), cefpodoxime (50), ceftriaxone (7), aztreonam, tobramycin (), cefotaxime (), ciprofloxacin (8), gentamicin (5), piperacillin-tazobactam (9), ertapenem, imipenem and meropenem (). Fifty-six of the isolates were MDR. Conclusion: High prevalence of multidrug resistance in the region of Kermanshah represents the spread of resistance genes. Based on the results, one approach to prevent this trend is the treatment of K. pneumoniae infections according to the antimicrobial susceptibility testing. Our results suggest carbapenems are effective against resistant isolates. The rate of antibiotic resistance in K. pneumoniae isolates from hospitalized patients in Kermanshah is alarming. Keywords: Klebsiella pneumoniae, Multidrug resistance, Kermanshah Journal NI, 05, (), -7

2 Nejat et al. The frequency of multidrug resistance (MDR) among Klebsiella pneumoniae Introduction Klebsiella pneumoniae is a gram negative opportunistic bacterium of Enterobacteriaceae family which causes a range of infections, including urinary tract infections, bacteremia, pneumonia and wound infections (). This bacterium is one of the most common causes of hospital-acquired infection and well known for its multidrug-resistant capability (). Microorganisms causing nosocomial infections and are resistant to antibiotics make many problems for patients' treatments (). Nosocomial infections rates in some countries are very high due to the lack of infection control and prevention, as well as improper use of antibiotics and overcrowding hospitals (). The antibiotic resistance in nosocomial infections is a serious problem for the health sector and seriously affects patients' health around the world and imposes high treatment costs on health system sector. The World Health Organization has named 0 as the Year of antibiotic resistance (5, ). Multidrugresistant organisms are classified into three groups: MDR (Multi drug Resistant), XDR (Extreme Drug Resistant) and PDR (Pan Drug Resistant) (7). By definition, MDR strains are resistance to at least one antibiotic of three or more of the antibiotic categories. The XDR strains are resistant at least to one antibiotic in all but two antibiotic categories (bacteria remain sensitive to one or two antibiotics). Thus, a bacterial strain that is considered as XDR, is also MDR (7). The PDR strains are resistant to all antimicrobial agents in all categories. The extensive use of antibiotics increases the spread of resistant strains of bacteria in recent years, particularly MDR K. pneumoniae. Under these conditions, the Journal NI, 05, (), -7 treatment of serious infections caused by K. pneumoniae is associated with problems and increases the risk of mortality among patients (8). Therefore, early detection the MDR isolates of K. pneumoniae and appropriate treatment is essential. The aim of this study was to provide a better view of the prevalence of multidrug-resistant strains of K.pneumoniae in Kermanshah. It can also provide information to effective treatment against MDR strains for better control of resistant strains. Material and Methods In this cross- sectional study, 5 isolates different clinical specimens (eg, wound, blood, urine, stool, and other) primarily identified as Klebsiella were collected. The samples were from Imam Khomeiny, Imam Reza and Taleghani hospitals and the Central Reference laboratory of Kermanshah during 0-0. Samples were transferred in aseptic conditions inside the icebox to the microbiology laboratory of medical school. To diagnose species, isolates were cultured on nutrient agar medium (Merck, Germany). After obtaining a pure culture, the isolates were identified sing the API-0E kit (Biomérieux, France). Antibiotic susceptibility testing Antibiotic susceptibility testing was performed using disk diffusion method. The antibiotic discs were from MAST company (England) and included ampicillin 0 mcg, cefazoline 0 mcg, gentamicin 0 mcg, tobramycin 0 mcg, cefotaxime 0 mg, ceftriaxone 0 mg, ceftazidime0 mg, cefpodoxime 0 mcg, 0 mcg aztreonam, ertapenem 0 mcg, emipenem0 mcg, meropenem0 mcg, piperacillin-tazobactam 00/0 mcg, ciprofloxacin0 mcg, and trimethoprim-

3 Nejat et al. The frequency of multidrug resistance (MDR) among Klebsiella pneumoniae sulfamethoxazole 0 mcg (9). The strain of E.coli ATCC 59 was used for quality control. In this study, as mentioned earlier, a multidrug- resistant strain (MDR) defined as the resistant to at least one antibiotic of three or more antibiotic groups (7). For this definition, isolates with intermediate susceptibility were also considered as resistant. Statistical analysis Data from test results along with samples' data were recorded in an Excel file and then analyzed using SPSS version 8. In this study, the p-value of 0.05 was considered significant. Results (59), 9 (9) and () isolates were from females, males and hospital beds, respectively. A significant difference was detected between the infection rate among men and women with p-value of The average age of patients was 9.5 ±. years. Most isolates (7) were from young women (0 to 9 years old). The 00 isolates were from urine samples (58), burnt tissues ( ), tracheal secretions (), blood (5), wounds (), ascites (), burnt bed dressing () and stretcher bed (). In this study, 5 antibiotics of 9 groups were tested and the most effective antibiotics were carbapenems (Table ). Among isolates, 5 () were multidrug resistant and isolates were resistant to all antibiotics tested (Table ). Of the 5 isolates, 00 isolates were K. pneumoniae (Table ) with 5 (5) and 8(8) isolates were from hospitalized and out-patients, respectively. The 59 Table : The bacterial species diagnosed from 5 isolates primarily identified as Klebsiella in medical centers. Bacteria K. pneumoniae E.coli Acinetobacter baumanii Entrobacter cloacae Pseudomonas aeroginosa Klebsiella oxytoca Klebsiella pneumoniae ssp ozae Entrobacter cloacea or sakazak Entrobacter aerogenes Seratia marcescens Kluyvera spp Raoultella ornithinolytica Aeromonas salmonicida ssp salm Mixed bacteria Sum Number Percent Journal NI, 05, (), -7

4 Nejat et al. The frequency of multidrug resistance (MDR) among Klebsiella pneumoniae Table : Antibiotic susceptibility of K. pneumoniae isolates. Antibiotic Ampicillin Cephazoline Gentamicin Tobramycin Ceftazidime Cephotaxime Ceftriaxone Cefpedoxime Aztereonam Ertapenem Meropenem Imipenem Pipracillintazobactam Ciprofloxacin Co-trimoxazole All isolates Intermediate Resistant Out-patients isolates Intermediate Resistant In-patients isolates Intermediate Resistant Table : The 5 multidrug resistant isolates according to the number of antibiotic groups which they are resistant to them Number of resistant isolates 0 Number of antibiotic groups resistant by isolates Percent Discussion The accurate diagnosis of K. pneumoniae in medical diagnostic laboratories and properly antimicrobial susceptibility testing are critical to better treatment of infections caused by this bacterium (0). Results of our study showed that about 0 of the isolates mistakenly diagnosed as K. pneumoniae, but they were actually other species of enterobacteriaceae and gram-negative bacilli. This misdiagnosis probably results from using a small number of bacteriological tests to Journal NI, 05, (), -7 differentiate isolates, or non-use of standard strains and quality control as well as the lack of accurate diagnostic kits for various bacterial species. In our study, the majority K. pneumoniae isolates was from urine samples which is consistent with the results of a previous research (). As has been noted in other studies K. pneumoniae resistant to penicillin is very high which is consistent with our findings (, ). We observed a high antibiotic resistance among isolates to penicillin group that can be explained by the

5 Nejat et al. The frequency of multidrug resistance (MDR) among Klebsiella pneumoniae intrinsic resistance of K. pneumoniae to penicillins (7). The reported resistance to Co-trimoxazole in other studies was comparable with our results (,, 5). Co-trimoxazole resistance among urinary infections isolates was higher than that of other isolates which is similar to the results of another study on urine samples in Iran (). This may be due to the extensive prescription of Co-trimoxazole for urinary tract infections. As the most effective antibiotics, the majority of our isolates were susceptible to carbapenems, which is consistent with the results of other studies (, 7, 8). The high levels of MDR, in particularly for ciprofloxacin, Co-trimoxazole and aminoglycosides, among isolates in Kermanshah are an alarm for the limited effect of these antibiotics on K. pneumoniae infections. The prevalence of MDR strains in our study was similar to the results of another study in Iran (59.8), as well as with the average prevalence of MDR reported in Iran (8, 5, 9-). Studies in different parts of Iran during 007 to 0 indicated an increase in the prevalence rate of multidrug resistant K. pneumoniae isolates from 0. to 99., which represents a rise of resistance in this opportunistic bacterium (8, 5, 9-). The potential factors for increasing MDR strains could be the extensive prescription of antibiotics, lack of risk factors control in hospitals (e.g. prolonged hospitalization and invasive procedures) and dissemination of resistance genes among bacteria by plasmids, transposons and bacteriophages (). The rate of antibiotic resistance among K. pneumoniae isolates from hospitals was significantly higher than the isolates from out-patient which is similar to other reports in Iran (8,, 0). These results indicate the serious 5 risk of increased antibiotic resistance in nosocomial infections that can cause more mortality and morbidity among patients. Therefore, effective infection control teams are required in hospitals to better control and prevent the spread of MDR strains. Conclusion Our results suggest K. pneumoniae isolates are not correctly diagnosed and thus using accurate and update laboratory tests are essential. High prevalence of MDR isolates in Kermanshah region represents the spread of resistant genes among bacteria. Based on the results, one approach to prevent this trend is the treatment of K. pneumoniae infections according to the antimicrobial susceptibility testing. Our results indicate carbapenems are effective against resistant isolates. The rate of antibiotic resistance among K. pneumoniae isolates from hospitalized patients in Kermanshah is alarming and if it is not appropriately controlled, can cause severe problems in the future. Acknowledgment This article is derived from the MSc Microbiology thesis of Parisa Nejat and financially supported by the Kermanshah University of Medical Sciences. References. Padilla E, Llobet E, Domenech-Sanchez A, Martinez-Martinez L, Bengoechea JA and Alberti S. Klebsiella pneumoniae AcrAB efflux pump contributes to antimicrobial resistance and virulence. Antimicrob Agents Chemother 00:5():77-8. Journal NI, 05, (), -7

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7 Nejat et al. The frequency of multidrug resistance (MDR) among Klebsiella pneumoniae Dar Pezeshki 007: ():-5 [Article in Persian].. Podschun R and Ullmann U. Klebsiella spp. as nosocomial pathogens: epidemiology, taxonomy, typing methods, and pathogenicity factors. Clin Microbiol Rev 998: (): Journal NI, 05, (), -7