High Gastrointestinal Colonization Rate with Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae in Hospitalized Patients: Emergence of Carbapenemase-Producing K. pneumoniae in Ethiopia

Abstract

We investigated the gastrointestinal colonization rate and antibiotic resistance patterns of Extended-Spectrum Beta-Lactamase (ESBL)- producing Escherichia coli and Klebsiella pneumoniae in hospitalized patients admitted at Ethiopia's largest tertiary hospital. Fecal samples/swabs from 267 patients were cultured on chrome agar. ESBL. Bacterial species identification, verification of ESBL production and antibiotic susceptibility testing were done using Vitek 2 system (bioMérieux, France). Phenotype characterization of ESBL-E.coli and ESBL- K.pneumoniae was done using Neo-Sensitabs™. ESBL positivity rate was much higher in K. pneumoniae (76%) than E. coli (45%). The overall gastrointestinal colonization rate of ESBL producing Enterobacteriaceae (ESBL-E) in hospitalized patients was 52% (95%CI; 46%-58%) of which, ESBL-E. coli and K.pneumoniae accounted for 68% and 32% respectively. Fecal ESBL-E carriage rate in neonates, children and adults was 74%, 59% and 46% respectively. Gastrointestinal colonization rate of ESBL-E.coli in neonates, children and adults was 11%, 42% and 42% respectively. Of all E. coli strains isolated from adults, children and neonates, 44%, 49% and 22% were ESBL positive (p = 0.28). The prevalence of ESBL-K.pneumoniae carriage in neonates, children and adults was 68%, 22% and 7% respectively. All K. pneumoniae isolated from neonates (100%) and 88% of K. pneumoniae isolated from children were ESBL positive, but only 50% of K.pneumoniae isolated from adults were ESBL positive (p = 0.001). Thirteen patients (5%) were carriers of both ESBL-E.coli and ESBL-KP. The overall carrier rate of ESBL producing isolates resistant to carbapenem was 2% (5/267), all detected in children; three with E.coli HL cephalosporinase (AmpC), resistant to ertapenem and two with K. pneumoniae Carbapenemase (KPC) resistant to meropenem, ertapenem and impenem. We report a high gastrointestinal colonization rate with ESBL-E and the emergence of carbapenems-resistant K. pneumoniae in Ethiopia. Urgent implementation of infection control measures, and surveillance are urgently needed to limit the spread within healthcare facilities and further to the community.

Fig 1

Colonization rate of ESBL producing Enterobacteriaceae (Top) and distribution of ESBL positive E. coli and K. pneumonia (bottom) in fecal samples collected from 267 hospitalized patients (154 adults, 94 children and 19 neonates). Thirteen out of 267 patients (5%) were carriers of both ESBL producing K.pneumoniae and E. coli (7 adults, 5 children and 1 neonates).

Fig 2. Distribution of gastrointestinal colonization rates of E. coli and K.pneumoniae stratified by presence (+ve) and or absence (-ve) of ESBL producing isolates in all hospitalized patients (n = 267).

Fig 3. Antimicrobial resistance pattern of ESBL producing (n = 106) E.coli strains isolated from hospitalized patients fecal samples/swab.

The over all prevalence of ESBL positivity among the 235 E.coli isolates was 45.1% (106/235).

Fig 4. Antimicrobial resistance pattern of ESBL positive (n = 44) K.pneumoniae strains isolated from hospitalized patients fecal samples/swab.

The prevalence of ESBL positivity among the 58 K.pneumoniae isolates was 76% (44/58).