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ORIGINAL ARTICLE
Year : 2014  |  Volume : 51  |  Issue : 4  |  Page : 450-452
 

Susceptibility profile of Gram-negative bacteremic isolates to beta lactam-beta lactamase inhibitor agents in comparison to other antibiotics


1 Department of Infectious Diseases, Apollo Specilaity Hospitals, Chennai, Tamil Nadu, India
2 Department of Microbiology, Apollo Specilaity Hospitals, Chennai, Tamil Nadu, India

Date of Web Publication1-Feb-2016

Correspondence Address:
K Ghafur Abdul
Department of Infectious Diseases, Apollo Specilaity Hospitals, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.175361

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 » Abstract 

Background: Comprehensive understanding about the local antibiogram is an essential requirement for preparation of hospital or unit based antibiotic policy. Bacteremic isolates are the most useful ones for this purpose, representing invasive disease. Objective: To analyze susceptibility pattern of bacteremic Gram-negative isolates in our center, to various antibiotics, including beta lactam-beta lactamase inhibitor (BL-BLI) agents and carbapenem. Materials And Methods: This is a retrospective study done in Apollo Specialty Hospital, a tertiary care oncology center in South India. The susceptibility of Escherichia coli, Klebsiella, Acinetobacter and Pseudomonas blood culture isolates, identified between January 2013 and June 2014 to various antibiotics were analyzed. Results: A total of 231-Gram-negative bacteremic isolates were analyzed. ESBL rate among E. coli isolates was 82.7% (67 out of 81) and 74.3% (58 out of 78) in Klebsiella. Carbapenem (imipenem) susceptibility rate in E. coli was 76.5%, Klebsiella 58.9%, Acinetobacter 32% and Pseudomonas 77.2%. Colistin susceptibility in E. coli was 96.2%, Klebsiella 93.5%, Acinetobacter 92.8% and Pseudomonas 97.7%. Difference in the susceptibility of Enterobacteriaceae to BL-BLI agents (especially cefepime-tazobactam) and carbapenem were minimal. In nonfermenters, BL-BLI susceptibility was better than that of carbapenem. Conclusion: Findings of the study make a strong argument for using BL-BLI agents and sparing carbapenem to curtail the spiraling scenario of carbapenem resistance.


Keywords: Bacteremia, beta lactam-beta lactamase inhibitor, carbapenem spareres, India, oncology center


How to cite this article:
Abdul K G, Vidyalakshmi P R, Jayalakshmi V A, Poojary I. Susceptibility profile of Gram-negative bacteremic isolates to beta lactam-beta lactamase inhibitor agents in comparison to other antibiotics. Indian J Cancer 2014;51:450-2

How to cite this URL:
Abdul K G, Vidyalakshmi P R, Jayalakshmi V A, Poojary I. Susceptibility profile of Gram-negative bacteremic isolates to beta lactam-beta lactamase inhibitor agents in comparison to other antibiotics. Indian J Cancer [serial online] 2014 [cited 2019 Dec 8];51:450-2. Available from: http://www.indianjcancer.com/text.asp?2014/51/4/450/175361



 » Introduction Top


Increasing antimicrobial resistance is a serious regional and global threat. [1] Immunocompromised patients, especially cancer and transplant patients are the most vulnerable targets to this dangerous scenario. [2] Carbapenem, the most potent group of antibiotics available in the armamentarium has started losing its sharpness and accuracy due to increasing resistance amongst Enterobacteriaceae and nonfermenter isolates. This scenario has serious implications in oncology patients, especially in the ones with neutropenia. [3],[4] In nononcology practice, restricted usage of carbapenem, to those patients with severe sepsis is recommended as a strategy to curtail the escalating trend of carbapenem resistance. This strategy may not always be feasible in oncology patients, where there can be a low threshold in initiating administration of this molecule. In the era of increasing carbapenem resistance, reducing their usage by exploring alternative options could be an intelligent approach. [5],[6] Beta lactam-beta lactamase inhibitors (BL-BLI) have withstood the test of time by retaining sensitivity against most Gram-negative bacteria. BL-BLI agents have been found useful in managing neutropenic sepsis even in India, a country with high Gram-negative resistance rate. [7],[8],[9] We analyzed susceptibility of bacteremic Gram-negative isolates in our center to various antibiotics, including BL-BLI agents and carbapenem.


 » Materials and Methods Top


This is a retrospective study done in Apollo Specialty Hospital, a tertiary care oncology center in South India. The susceptibility of E. coli, Klebsiella, Acinetobacter and Pseudomonas blood culture isolates, identified between January 2013 and June 2014 to various antibiotics including ceftriaxone, cefoperazone-sulbactam (CS), piperacillin-tazobactam (PTZ), cefepime-tazobactam (CT), ciprofloxacin, colistin, tigecyline, aminoglycosides, cotrimoxazole and chloramphenicol were analyzed. Identification of the isolates and susceptibility testing were done using Vitek 2 compact autoanalyzer. Colistin susceptibility was done using Vitek 2 compact for all isolates and if found resistant, rechecked using E test. Pseudomonas isolates were considered to be resistant to colistin if the MIC is >8 and Acinetobacter if MIC >4. There is no available colistin breakpoint for Enterobacteriaceae as per CLSI guideline, so EUCAST breakpoints were followed (S ≤2; R >2). [10],[11] Breakpoints for CS and cefepime/tazobactam are not elucidated in CLSI guideline. Hence, the breakpoints of cefoperazone and cefepime were applied for cefoperazone/sulbactam and cefepime/tazobactam, respectively.


 » Results Top


A total of 231 gram negative bacteremic isolates were analyzed [Table 1]. ESBL rate among Escherichia coli isolates was 82.7% (67 out of 81) and 74.3% (58 out of 78) in Klebsiella. Carbapenem (imipenem) susceptibility rate in E. coli was 76.5%, Klebsiella 58.9%, Acinetobacter 32% and Pseudomonas 77.2%. CT and carbapenam sensitivities were similar amongst ESBL E. coli isolates (both 76.5%), with good sensitivity to aminoglycosides (74%) and chloramphenicol (88.8%). Klebsiella isolates also had comparable susceptibility to carbapenem and CT (58.9 and 55% respectively). CT had a better sensitivity than CS and PTZ in E. coli and Klebsiella isolates. Out of the 44 Pseudomonas isolates 90% showed susceptibility to PTZ. Susceptibility to CT (88.6%) was better than imipenem (77.2%). Of 28 Acinetobacter isolates, there was a higher sensitivity to CT (39.2%) than imipenem (32%). Though ciprofloxacin susceptibility was very low in E. coli (25.9%), Klebsiella (39.7%) and Acinetobacter (32%), Pseudomonas retained excellent sensitivity (81.8%). Colistin susceptibility in E. coli was 96.2%, Klebsiella 93.5%, Acinetobacter 92.8% and Pseudomonas 97.7%.
Table 1: Susceptibility of Gram-negativeblood culture isolates (%)

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 » Discussion Top


As reported from most centers in the region and across the globe, high rates of antimicrobial resistance amongst Gram-negative bacteria, is a serious problem in our center as well. [12],[13],[14] Our hospital has a well-established department of Infectious diseases and Infection control with published evidence of the success of antibiotic stewardship. We have a strict policy on the use of high-end antibiotics including carbapenem and on antibiotic usage for perioperative surgical prophylaxis. [15],[16],[17],[18] Our published data reveals relatively stable, but high rate of carbapenem resistance in Acinetobacter and a very encouraging trend of increasing susceptibility among Pseudomonas isolates. [17] At the same time, carbapenem resistance among the Enterobacteriaceae has been steadily increasing over the last few years, in tune with the trend in most centers in the country. [19]

The current data reveals an interesting picture of a very comparable susceptibility of Enterobacteriaceae to BL-BLI agents and carbapenem. In nonfermenters, BL-BLI susceptibility is, in fact, better than that of carbapenem. Of all BL-BLI agents tested, CT was the most susceptible agent in E. coli, Klebsiella and Acinetobacter though all BL-BLI agents performed well against Pseudomonas.

The concern on the impact of "inoculum effect" in patients with severe sepsis with possible high bacteria load has been an important factor hindering clinicians from using BL-BLI agents in these patients. Emerging evidence on the effectiveness of these agents in bacteremic and even in neutropenic patients could be a very encouraging trend, helping clinicians to choose BL-BLI agents rather than being overtly dependent on carbapenem antibiotics. [20],[21],[22],[23] A clinical study from our own center had shown similar mortality and outcomes among the carbapenem and BL-BLI treated groups, in neutropenics and nonneutropenic population. [24],[25],[26] Published data from our center had also highlighted high CT in-vitro susceptibility and good in-vivo performance. [7],[8]

Emerging problem of colistin resistance is a serious cause for anxiety, similar to reports from many other centers. [27],[28],[29],[30],[31],[32],[33] Fosfomycin sensitivity was not done, and so these colistin resistant isolates are better referred to as "possible Pan drug-resistant" isolates. [34] We have recently published clinical profile of a series of patients with possible pan drug-resistant bacterial infections. [35]


 » Conclusion Top


The high rate of Enterobacteriaceae resistance to carbapenem is a serious concern. At the same time reducing carbapenem resistance in Pseudomonas is encouraging. The study reveals similar susceptibility of BL-BLI agents and carbapenem in Enterobacteriaceae and better susceptibility in nonfermenters. Compelling laboratory data on the superior susceptibility and available clinical data in literature on equivalence make a strong argument for using BL-BLI agents and sparing carbapenem to curtail the spiraling and catastrophic scenario of carbapenem resistance.

 
 » References Top

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