Prevalence and Antimicrobial Resistance of Klebsiella Strains Isolated from a County Hospital in Romania

Abstract

The study evaluated the evolution of the incidence of infections with Klebsiella in the County Clinical Emergency Hospital of Craiova (SCJUC), Romania. Also, we monitored antibiotic resistance over more than two years and detected changes in resistance to various antimicrobial agents. Our study included 2062 patients (823 women and 1239 men) hospitalised in SCJUC during the period 1st of September 2017 to 30 June 2019. In 458 patients (22.21%) from the 2062 total patients, the collected samples (1116) were positive and from those, we isolated 251 strains of Klebsiella spp. We conducted a longitudinal analysis of the prevalence of Klebsiella spp. over calendar months, which showed a prevalence in surgical wards that ranged between 5.25% and 19.49% in June 2018, while in medical wards the variation was much wider, between 5.15% and 17.36% in April 2018. Klebsiella spp. strains showed significant resistance to Amoxicillin/Clavulanate, Aztreonam and Cephalosporins such as Ceftriaxone, Ceftazidime and Cefepime. We examined the possible link with the consumption of antibiotics in the same month by performing a multiple linear regression analysis. The evolution of antibiotic resistance in Klebsiella was correlated with the variation of resistance in other bacteria, which suggests common resistance mechanisms in the hospital environment. By performing the regression for dependency between antibiotic resistance and antibiotic consumption, we observed some correlations between antibiotic consumption and the development of antibiotic resistance after 1, 2 and even 3 months (e.g., resistance to meropenem was influenced by the consumption in the hospital ward of imipenem 1 month and two months before, but only 1 month before by the consumption of meropenem). The clustering of strains showed filiation between multiresistant Klebsiella spp. strains isolated from specific patients from the ICU. The evolution of prevalence and antibiotic resistance in Klebsiella correlated with the resistance in other bacteria, which suggest common resistance mechanisms in the hospital environment, and also with the consumption of antibiotics.

Keywords: Klebsiella; antibiotic resistance; multidrug-resistant bacteria.

Figure 1

Prevalence of Klebsiella strains by hospital ward. The bars heights are the percentages of prevalence in different wards.

Figure 2

Evolution of the incidence of Klebsiella strains: (a) in the surgical wards; (b) in medical wards.

Figure 3

Histogram of the distribution of MAR index in various wards from SCJUC. The columns heights are the number of strains for which MAR falls in a specific interval (bin). The green line is a smoothing line of the heights of the bars.

Figure 4

Resistance to antimicrobial substances of the isolated Klebsiella strains.

Figure 5

Evolution of antibiotic resistance in Klebsiella strains. MAR = Multiple Antibiotic Resistance index. Note: here were presented the resistance for typical antibiotics from each chemical class, however, because multiple cephalosporins were used we calculated MAR index specific for cephalosporins. TGC: Tigecyclin; TPZ: Piperacillin/Tazobactam; MEM: Meropenem; CIP: Ciprofloxacin; Rez_Cef: Resistance index to cephalosporins.

Figure 6

Monthly evolution of Meropenem resistance in E. coli, Klebsiella, and Gram-negative non-fermenter rods (NFR).

Figure 7

Clustering analys1is of the isolated Klebsiella strain using hospital ward as a label. ICU: Intensive Care Unit; NS: Neurosurgery; PS: Plastic Surgery; ORT: Orthopaedics; TS: Thoracic Surgery; MED: Medical wards; NEP: Nephrology; ONC: Oncology; URO: Urology; GS: General Surgery. Blue lines: low resistance cluster, red lines: high resistance cluster.

Figure 8

Evolution of the Klebsiella phenotype ATM-CAZ-FEP-AMC-TZP-ETP-CIP. Aztreonam (ATM) Ceftazidime (CAZ), Cefepime (FEP), Amoxicillin/Clavulanate (AMC) TPZ: Piperacillin/Tazobactam, Ertapenem (ETP) and Ciprofloxacin (CIP).