Extended-spectrum β-lactamase (ESBL) microorganisms have been shown to increase multidrug resistance worldwide, which is a great concern. The prevalence of ESBL-producing clinical pathogens and their antimicrobial resistance patterns were identified in 66 isolates from patients in Khwaja Yunus Ali Hospital with several clinical infections cultured on blood agar and MacConkey agar media. The most prevalent bacteria were Escherichia coli (80.3%), which were identified by the BD-Phonex automated identifier machine, followed by Pseudomonas spp. (6%), Klebsiella spp. (12.1%), and others (4.4%). This research was conducted from January 2023 to June 2023. Generally, a large number of antibiotic resistance patterns and ESBL-producing common bacterial isolates were found in this study, where most of the resistant percentage was found in third-generation cephalosporin antibiotics, which increases the public health problem. In this study, the most prevalent bacteria E. coli isolates were mostly resistant to penicillin (100%), ceftazidime, cefotaxime, and cefuroxime (98.4%). Besides, 95.4% resistance was shown against ceftriaxone. The double-disc synergy test was done to determine the presence of ESBL-producing bacterial strains. The most widely ESBL-positive isolate was Escherichia coli (83%). Among the 66 sample strains produced, the ESBL maximum (53.03%) belonged to female patients, while 46.97% belonged to male patients. This study focuses on the prevalence and patterns of clinical pathogens and the antimicrobial susceptibility profiles of ESBL-producing bacterial infections in a tertiary-level health service center in Bangladesh. Generally, a large number of antibiotic resistance patterns and ESBL-producing common bacterial isolates were found in this study, which increases the public health risk. Therefore, to save human lives, we ought to be taking appropriate action against the threat.
Extended-spectrum beta-lactamase (ESBL)-produ-cing bacteria have expanded dramatically globally, and they are one of the leading causes of morbidity and mortality in hospital-acquired infections (Kumar et al., 2014). This could be explained by the pre-sence of the multidrug resistance in ESBL-producing isolates. Resistant bacteria are growing around the world as a challenge to the successful treatment of common diseases in both hospitals and the com-munity (Prestinaci et al., 2015). The most frequent infections contracted in hospitals caused by Enterobacteriaceae include urinary tract, gastro-intestinal, and pyogenic infections (Atici et al., 2016). Escherichia coli is the most commonly isolated species among the Enterobacteriaceae (Karlowsky et al., 2003; Shahen et al., 2019).
Multidrug resistance in the E. coli is extensively documented (Karlowsky et al., 2003). Prolonged antibiotic exposure, hospitalization, severe sickness, unprecedented usage of third-generation cephalos-porin (Kumar et al., 2014; Tewari et al., 2018) and increased use of intravenous devices or catheters are all risk factors for multidrug-resistant E.coli infec-tion. Lactamase synthesis is possibly the single most important mechanism of penicillin and cephalos-porin resistance (Tang et al., 2014). E. coli naturally produces chromosomally-mediated or the plasmid-mediated lactamases (Poirel et al., 2002). Penicillin-binding proteins are considered to have evolved into these enzymes (Hakenbeck, 1998). This evolution was most likely caused by the selection pressure applied by lactamase-producing soil organisms in the environment (Allen et al., 2009). Extended-spec-trum beta-lactamases (ESBLs), enzymes that acce-lerate the hydrolysis of oxyimino-lactams such as cefotaxime, ceftriaxone, ceftazidime, and aztreo-nam, have recently been described (Jacoby, 1997).
They are members of the Ambler molecular class A and the Bush-Jacoby functional group 2be (Sawa et al., 2020). These enzymes have been identified in considerable quantities in diverse places and have been found to be abundant in several E. coli strains (Sawa, Kooguchi et al., 2020). They have also been discovered in other Enterobacteriaceae members, including Klebsiella spp, Citrobacter spp, Entero-bacter spp, Proteus spp, and non-lactose fermenters such as Pseudomonas aeruginosa (Abbott, 2011). Over 200 distinct ESBLs have been described to date (Kumari, 2017). Major epidemics of these resistant organisms in the several members of the Enterobacteriaceae and Pseudomonas spp. have been documented all over the world, resulting in a lack of therapeutic choices (Chaudhary, 2004).
ESBL-producing bacteria are likely more common than is currently known because they frequently go unnoticed by standard susceptibility testing methods (MP et al., 2010). Resistance to other non-lactam antibiotics, such as aminoglycosides and chloram-phenicol, has been linked to ESBL strains (Pitout et al., 1997). Another characteristic of these ESBL strains is that they may exhibit a falsely sensitive zone of inhibition when tested using the Kirby-Bauer disk diffusion method (Kumar et al., 2014). To comprehend the disease burden and take the appropriate precautions to avoid its spread, current knowledge of the prevalence of ESBL generation by commonly isolated pathogens such as E. coli is required (Kumar et al., 2014). As a result, the current investigation was carried out with the goal of determining the prevalence of ESBL-producing Enterobacteriaceae and their antimicrobial resis-tance profile in order to develop an effective antibiotic strategy and plan.
Sample collection
Bacterial isolates from clinical samples such as pus, urine, blood, wound swab, throat, sputum, ear swab, and other bodily fluids were obtained in the depart-ment of microbiology at Khwaja Yunus Ali Medical College and Hospital (KYAMCH). The research was conducted from January 2023 to June 2023. Khwaja Yunus Ali Universitys Ethics Committee granted ethical permission.
Isolation and identification
20 ml of urine samples collected in a universal container and one loopful (0.002 ml) were inocula-ted into the chromogenic UTI agar, MacConkey agar, and blood agar plates. For the blood sample, we used a BactecTM BD-M15 (USA) automated mac- hine along with a positive signal, which was then sub-cultured on MacConkey and Blood Agar media. Other specimens, such as sputum, body fluids, and swabs, were collected in sufficient amounts and then inoculated on the blood agar and MacConkey agar plates using an inoculating loop. All inoculated media were incubated aerobically overnight at 37°C. On the basis of colony morphology, the organisms were identified, and biochemical analyses were per-formed using oxidase test, Kligler Iron Agar stain, motility indole urea, and Simon citrate reaction, etc.
Antimicrobial Susceptibility Test
Antimicrobial susceptibility testing (AST) for all isolates was conducted on commercially available common antibiotics disc. All ESBL and non-ESBL producing clinical pathogen were studied for anti-microbial sensitivity using disc diffusion technique by "Kirby-Bauer method" on the culture medium of Mueller-Hinton agar (Himedia, India) and inter-pretations were recorded according to the guide-lines of clinical and laboratory standard institute.
Testing for the ESBL Production
The identification of ESBLs production by 66 positive clinical bacterial pathogens was conducted by a modified double-disc synergism test (Ahmed et al., 2017). Bacterial suspension of 0.5 McFarland standards was plated in Muller-Hinton agar with the Amoxycillin+clavulanic acid (30 µg) disc in bet-ween and 20 mm apart from Ceftazidime (30 µg) and Ceftriaxone (30 µg) discs. Expansion of the zone of inhibition around Ceftriaxone and/or ceftazi-dime disc towards the amoxicillin-clavulanic acid disc was considered ESBL production.
Statistical analysis
Chi-square test is used for statistical analysis of the data. A ‘P value less than 0.05 were considered statistically significant.
During the research period, 66 clinical pathogens were detected in various clinical samples of inpati-ents. In 66 sample isolates, phenotypic identification of ESBL production revealed that E. coli was the most common (80.3%), followed by Klebsiella spp. (12.1%), P. aeruginosa (3%), and others (4.5%). The bulk (45%) of the 66 sample strains developed belonged to female patients, while the other 55% belonged to male patients. In terms of patient age groups, females over the age of 49 had the highest prevalence (47%), followed by those aged 13-24 years (3%), and those aged 37-48 years (19%). In men, the age group was 37-48 years (33%), the age group was 25-36 years (17%), and the remaining 13% were in the age group of 13-24 years (Table 1).
ESBL Prevalence and the Antimicrobial Susceptibility Profiles
Number and frequency of ESBL producing bacteria, E.coli, Klebsiella spp as well as Pseudomonas spp found highest percentage in urine sample presented in Table 2. Overall antibiotic resistant pattern for ESBL-producing bacteria among all the 15 tested antibiotics. Where Amikacin (22.7%), Amoxicillin (42.4%), Imipenem (46.9%), Meropenem (33.3%), and Nitrofurantoin (40.9%) showed less resistance than the other tested antibiotics. The rest of the anti-biotics were mostly above 90% resistant as well as.
In this study, the most prevalent bacteria, namely E. coli isolate, showed mostly resistance to penicillin (100%), ceftazidime, cefotaxime, and the cefuroxime (98.4%). Besides, the 95.4% resistance was shown against ceftriaxone presented in the Table 3. The resistance rates for the aminoglycoside and carba-penem groups of antibiotics were quite less than those for the third generation of antibiotics, where amikacin, gentamicin, imipenem, meropenem, and nitrofurantoin were 16.7%, 57.5%, 39.4%, 33.3%, and 31.8%, respectively.
Table 1: Demographic data of study population.
Table 2: Number and Frequency (%) of ESBL producing bacteria.
Table 3: Results of Antibiotic Susceptibility pattern of bacteria.
For physicians around the world, extended-spectrum β-lactamase-expressing multidrug-resistant clinical pathogens provide major obstacles to the therapeutic management of clinical cases of urinary tract infec-tion. The goal of the current investigation was to show that an ESBL-producing bacterium could be isolated from clinical samples of patients in a major hospital in Bangladesh. It was found that 66% of pathogens produced ESBLs. E. coli (80.3%) pro-duced ESBLs more frequently than Psedomonas spp. (3%), or Klebsiella spp. (12%). This figure was reported in a study completed in Khartoum State hospitals by Mekki et al. (2010) who recorded ESBL production among E. coli and Klebsiella species isolates as 66%. Similarly, a few numbers of ESBL-producing E. coli (36%), Egypt, occurred during 2013-14 (ElSayed et al., 2023). The high ranges of 41.0 to 63.6 percent in E. coli were repor-ted for the prevalence of ESBL production in other studies in India (Grover et al., 2006). The most well-known pathogens, E. coli, are thought to be part of the normal flora in the genitourinary and digestive tracts. However, they can ascend the urethra and enter the urinary tract. E. coli has explicit virulence characteristics that allow it to adhere to and attack host cells, create toxins, consume supplements, and evade the hosts immune system (Abedin et al., 2020).
ESBLs pose a significant risk to β-lactam treatment. Many of these bacterial isolates have been incor-rectly reported to be susceptible to the widely used broad-spectrum beta-lactams because they are diffi-cult to detect using existing clinical procedures (MacKenzie et al., 2002). We found such an asso-ciated resistance with gentamicin (36%) and the flouroquinolones (67%). Gupta et al. (2007) repor-ted 91.17% and 94.91% resistance, respectively, to gentamicin and ciprofloxacin in the ESBL produ-cers. Compared with our previous studies done at Khwaja Yunus Ali Medical College & Hospital, the current investigation found lower resistance rates for the majority of the isolated E. coli, which were resistant to Meropenem (50%) and Amikacin (66%), followed by gentamicin (34%), amoxiclav (40%), and Ciprofloxacin (57.8%) (Ahmed et al., 2016). This decreased drug resistance indicates successful coordinated monitoring of drug activity and usage. Overall, these results show that ESBL production in bacterial species varies significantly over the world and changes quickly over time and space.
Study limitations
This study carries several basic limitations. This study analyzed only a few ESBL producing bacteria and the use limited b-lactam antibiotics. The small sample size was also a limiting factor in performing fully powered statistical analyses. However, our results were generated from a Resource - limited setting and maintained internal validity by repeating independent experiments where necessary.
In this investigation, the incidence and trends of ESBL and the non-ESBL-producing uropathogens against routinely prescribed antibiotics in clinical isolates from tertiary institutions in Bangladesh were examined. This discovery emphasizes how crucial it is to continuously monitor and program antibiotic resistance in our hospitals. It also demonstrated the necessity of creating strategies to lessen the occur-rence of clinical infections that produce ESBLs. Patients infected with ESBL-producing bacteria must be treated with the proper antibiotics since ESBLs are clinically significant. Finally, the results of numerous studies differed depending on location and time, raising concerns about their validity and making it challenging to draw comparisons between them. In order to reduce the overall rate of resis-tance, it is necessary for observation methods and routine surveillance to be normalized throughout the nation. These results call for immediate surveillance and action to prevent the introduction of ESBL-producing bacteria on a national and international scale.
We are grateful to the Chairman of the Trusty Board and the Director of Khwaja Yunus Ali Medical College Hospital for carrying out this study. We express gratitude toward Md. Abdul Karim and Mazharul Haque for assisting in laboratory work at the Department of Laboratory Services of Khwaja Yunus Ali Medical College & Hospital, Sirajganj, Bangladesh.
There is no conflict of interest among the authors.
Academic Editor
Md. Ekhlas Uddin Dipu, Department of Biochemistry and Molecular Biology Gono Bishwabidalay, Dhaka, Bangladesh.
Assistant Professor & Head, Department of Microbiology, Khwaja Yunus Ali University, Sirajganj, Bangladesh.
Prity SS, Akter K, Aktar MB, Mehzabin K, Jarin L, Shilpi RY, Ashrafi MFF, Ahmed AA, Islam J, and Abedin MZ. (2024). Multidrug-resistant ESBL-producing Enterobacteriaceae associated with clinical samples in a tertiary care hospital, Sirajganj, Eur. J. Med. Health Sci., 6(1), 44-49. https://doi.org/10.34104/ejmhs.024.044049