NEWS

• WORKSHOPS

• SITE VISITS

• FORTHCOMING EVENTS

ESBL: SOME INFORMATION FROM THE INTERNET

• Extended Spectrum Beta Lactamase (ESBL

• Frequency of Extended Spectrum Beta Lacrimase...

GABROVO PSBHI 2004 PROJECTS - COMPLETED OR IN ACTION

NEWS

WORKSHOPS

 A Problem Solving for Better Health Workshop on Nosocomial Infections took place in Pleven on April 1-3, 2005. The workshop was organized by Dreyfus Health Foundation, the Association for Better Health – Pleven, Medical University – Pleven and the University Hospital. The fifty-one participants were addressed by Assoc. Prof. Tashko Deliiski, MD, PhD, Dean of Faculty of Medicine and Director of the University Oncology Center Assoc. Prof. Dimitar Stoikov, MD, PhD, Executive Director of the University Hospital and Mrs. Yanka Tzvetanova, President of Association for Better Health and country coordinator. Participants were selected with the assistance of the hospital director, the chief nurses Mrs. Anelia Dimitrova and consulted prior the workshop by the hospital epidemiologist – Dr. Emilia Kanyovska, MD. General problems that were identified included hospital hygiene, control and registration of nosocomial infections, cost effectiveness of hospital care including antibiotic treatment, problems related to sterilization and availability of disposable protective gear, training of staff and patient education.

Dr. Assen Pachedjiev, coordinator of the Swiss-Bulgarian project on Hospital Hygiene, made a comprehensive introduction to the problems and issues of hospital hygiene and nosocomial infections, presenting information on the current status of the program, its achievements and perspectives. His organization – Hygia, also provided each participant with specialized literature on the problems.

With the assistance of facilitators – Dr. Daniel Levine, PhD (USA), and the local facilitators – Assoc. Prof. Maria Alexandrova, MD, PhD, Assoc. Prof. Angelika Velkova, MD, PhD, Mrs. Yanka Tzvetanova, Mrs. Polya Zhivkova, Mrs. Makretta Draganova and Mrs. Evgenia Dimitrova, they prepared the following plans of action:

·        Reduction of rate of complications due to nosocomial infections by introducing individual protective gear for health personnel working in a risk pregnancy clinic - Dr. Antoaneta Lyubomirova, Risk Pregnancy Clinic

·        Introducing of disposable sterile catheters for re-catheterization of patients undergone hysterectomy - Dr. Chavdar Tzvetkov, Clinic of Oncogynecological Surgery

·        A training program to improve compliance with proper hand disinfection protocol - Dr. Ghinka Ivanova, Clinic of Obstetrics

·        Introduction of routine antiseptic treatment of delivery pathways for women admitted to the clinic to prevent perinatal and postnatal infections n babies - Dr. Michail Tzvetkov, Clinic of Obstetrics

·        A health educational program for nursing staff to reduce the rates of superficial nosocomial phlebitis in patients with intravenous cannula - Dr. Milen Predovski, Cardiology clinic

·        A training program for link-doctors on definition and registration of nosocomial infections - Dr. Emilia Kanyovska, Hospital Epidemiologist

·        A training program for general practitioners on proper techniques of urinary cathetherization - Dr. Orlin Michailov, Urosurgery Clinic

·        Health education on the risks of promiscuous sex for 100 girls and 50 young women - Dr. Roumyana Koleva, Cytology Lab

·        Introduction of protocols for safe tonometry of non-infected eye surgery patients - Dr. Snezhana Mourgova, Eye Surgery Clinic

·        An information program to reduce non-compliance with disinfection of bronchoscopy equipment - Dr. Stefan Stanimirov, Pulmology Clinic

·        Health education for pregnant women to reduce rates of conjunctivitis, pyodermia and dermatitis in new-born babies - Dr. Yonka Marcheva, Neonatology Clinic

·        A training program on proper disposal of hazardous hospital waste - Mr. Ivailo Stefanov, Hospital Hygiene Inspector

·        Training medical students proper techniques of hand washing and disinfection during clinical practice - Mr. Tzvetko Andreev, Medical Student

·        Providing enough sterile cannulas for patients undergoing surgery at the eye clinic - Mrs. Boyanka Groshevska, Eye Disease Department

·        A health education program for on the hygiene and prevention of recurrent allergy attacks for newly diagnosed patients - Mrs. Christina Batolska, Allergology Consulting Room

·        A training program for improving compliance of staff with protocols for carrying out intravenous procedures on risk patients - Mrs. Daniela Georgieva, Clinic of Narcology

·        Health education program for new hemodialysis patients on proper hygiene of peritoneal catheter - Mrs. Dechka Nikolova, Nephrology Clinic

·        Introducing water proof sterile fixing pads for permanent infusion pathways for surgical patients - Mrs. Diana Koukova, Anesthesiology Department

·        Regulating the admission of visitors to surgical patients - Mrs. Emilia Minkova, Surgery Clinic

·        A program to introduce standardized system for control of hospital hygiene at Pleven University Hospital - Mrs. Erka Andreeva, Hospital Hygiene Nurse

·        Raising compliance of staff with standardized protocols for delivery of sterilized gear from sterilization unit to clinics - Mrs. Iliana Vitanova, Cental Sterilization Unit

·        Training patients and families for proper postoperative hygiene and daily regimen after discharge from hospital - Mrs. Izabella Georgieva, Eye Disease Department

·        A training program for nurses on proper cleaning, disinfection and handling of intubation equipment in the operating room - Mrs. Kamelia Ivanova, Anesthesiology Department

·        Health education for low-educated parents to reduce the rates of reinfections in children with pneumonia- Mrs. Katya Angelova, Pediatric Clinic II

·        Improving control on nosocomial infections in Pleven University Hospital         Mrs. Lilyana Slavkova -Hospital Hygiene Nurse

·        Prevention of decubital ulcers in ICU patients - Mrs. Margarita Yakova, Intensive Care Unit

·        A health education program on proper hygiene and diet for mothers accompanying infants during the hospital stay - Mrs. Maria Milanova – Zlatanova, Paediatric Clinic I

·        An educational program to increase compliance of staff for proper hand disinfection - Mrs. Maria Sankova, Neurology Clinic

·        Health education on proper hygiene for postoperative ENT clinic patients to prevent complications - Mrs. Mariana Dimitrova, ENT Clinic

·        Providing timely disinfection of bronchoscopy equipment -Mrs. Mariana Nedkova, Lung Disease Clinic

·        A health educational program on prevention of post operative infections for patients operated on in the surgery clinic -Mrs. Mariyana Dimitrova, Surgery Clinic II

·        A program to reduce the number of cases of contamination with blood among operating room staff - Mrs. Maya Tzvetkova, Surgery Department

·        A health education program for pregnant women to reduce the rates of infections of the newborn - Mrs. Miglena Petrova, Neonatology Clinic

·        A training program for nurses to improve management of permanent peripheral intravenous infusion pathway - Mrs. Minka Geteva, Cardiology Clinic

·        A health education for couples expecting babies to prevent birth-related infections due to low level of knowledge of hygiene of pregnancy - Mrs. Natasha Andreeva, Neonatology Clinic

·        Regulation of admission of diabetic patients with acute virus respiratory infections to reduce the number of infected staff and patients - Mrs. Nedyalka Andreeva, Endocrinology Clinic

·        Providing proper disinfection and handling of sterile dressing materials - Mrs. Nezabravka Lazarova, Urology Clinic

·        Introduction of updated standardized protocols for use of sterile gear for intracavitary brachytherapy - Mrs. Pepa Ivanova, Radiology Clinic

·        Providing proper fixing and transportation of biopsy materials to reduce the rate of infections among lab staff - Mrs. Raina Marinova, Department of Pathological Anatomy

·        A health education program on the hygiene of breast feeding roma mothers accompanying their babies in hospital - Mrs. Stefka Kancheva, Pediatric Clinic I

·        Improving on the skills of nursing and hygiene support staff to prevent pediculosis of frequently admitted psychiatric patients- Mrs. Stela Dyulgerova, Psychiatry Department Increasing the skills of department staff to observe high levels of hygiene during diagnostic procedures - Mrs. Temenouzhka Yatanska, X- ray Department

·        Introduction of check-list for disinfection control - Mrs. Tyulai Moustafova, Gynaecology Clinic

·        Introduction of transparent fixing pads for children with permanent infusion peripheral venous pathways - Mrs. Vanya Dobreva, Pediatric Clinic II

·        A training program to introduce standard protocols for proper hand washing and disinfection for health personnel of the risk pregnancy clinic - Mrs. Vanya Zacharieva, Risk Pregnancy Clinic

·        Reduction of permanent urinary catheter-related infections by introducing standardized protocol for cathetirization of stroke patients - Mrs. Vesselka Ivanova, Neurology Clinic

·        A training program on proper disinfection procedures for nurses and hygiene support workers at the clinic - Mrs. Yordanka Stoyanova, Gastroenterology Clinic

SITE VISITS:

On March 31, Dr. Daniel Levine, President of Children’s Help Net Foundation, USA, Mrs. Yanka Tzvetanova, country coordinator and Assoc. Prof. Angelika Velkova – country co-coordinator of PSBH in Bulgaria visited “Ivan Vasov” Comprehensive School in Pleven. There, a project started in 1999 for computer training of underprivileged children.  

After 10 laptops were donated by CHNF in 2001, other underprivileged children were included aged 7-11.  Since then, every year children are selected by the school psychologist Mrs. Malina Petzova, and she works together with class teachers and three teachers of informatics.

Alongside with computer training, children are individually assessed and followed up.  Results of the program are: better integration into the group of peers; self-confidence being able to work on the computer. As the children said themselves, they enjoyed the classes. Those who have no computers at home have a chance to learn.

As discussed during the meeting with the team and the school director, benefits from the donation of computers extended to the whole school:

·        the computer classroom gave a chance to all children aged 7-11 to have computer classes. Software designed for teaching maths and languages through computer games makes computer classes children’s favorite ones. Basic computer skills - Paint,  Excel, Word, Power Point, Internet are taught;

·        the computer room is still used 10 hours a day, and higher grades students have lessons in computer programming there;

·        the school managed to attract another donor for desktop computers;

·        a videoconference room is being installed, funding provided by the school and sponsors (appr. $18,000), and children will be able to communicate with other children around the world via the Internet..

On April 4^th, Dr. Daniel Levine, Mrs. Yanka Tzvetanova, and Assoc. Prof. Angelika Velkova visited Shtastlivo Detsvo crèche is Pleven.  Mrs. Emilia Taskova, a participant in the June 2004 PSBHN workshop, and her team have implemented a program aiming at prevention of flat foot deformities in 101 children aged 1.5 –3 years.

The project was started in September 2004, with assessment of the children by a specialist. Regular check ups are made by a pediatrician and a kinesitherapist, and records for each child are kept according to the requirements for crèches. Evaluation of results is to be made using the data concerning general health, physical fitness, presence/absence of deformities and motor capacity of the children from a final check up at the end of May 2005. Parents are kept informed about the activities, and provided with information what physical activities are recommendable for the time outside the crèche. Sports activities for parents and children are also organized.

The crèche staff, said Mrs. Tzenka Ivanova, Director, and Mrs. Raina Kouleva, trainer in kinesitherapy at the Nursing College in Pleven, plan to compile a manual with set of remedial gymnastics exercises adapted to the age of the children and presented in the form of games. The exercises are to cover prevention of spinal deformities, flat foot and incorrect posture in children up to 3 years, and are an integrated part of physical education to improve physical fitness and activities.

With the support of the municipality in Pleven, said Dr. Pacheva of Children’s Health Department, the manual will be printed and distributed to all 29 crèches, and the program for prevention of flat foot and spinal deformities is to become mandatory.

The team was provided with laptop computer by Children’s Help Net Foundation, USA, and with a printer by the municipality. The computer will also be used for preparing educational materials for the parents.

The scope of the project activities is even wider, in view of the fact that it is a training center for Nursing College students. After graduation, they carry out the program for prevention and rehabilitation in the places they later work: e.g.  the program is run in all 6 crèches in Svistov. 

Mrs. Antoaneta Zlatkova, a participant in the September 2004 PSBHN workshop started a project on dental hygiene, and timely detection/ treatment of dental caries for 140 children aged 3-6 attending Snezhanka kindergarten in Pleven.  Glaxo-Smith Kline company provided tooth pastes and brushes, Orbit provided leaflets, and a local software company helped with designing and printing of educational materials prepared by the project team. A dental center organized dental check up for all children, and a dentist gave consultations to parents of children with problems. The funds raised by the team exceeded $1,500.

Reports on project activities were published in the local papers, and the party to celebrate the completion of the first stage of the project was attended by Dr. Keremedchiev, Dr. Pacheva of the Municipality Health Department, by representatives of the sponsors and the Association for Better Health and parents.

The project was presented at the National Conference on pre-School Education in Sandanski. The results obtained and methods applied brought due recognition and provoked the interest of specialists. Mrs. Zlatkova’s participation expenses were covered by the municipality..

The plans of the team are to continue the program and organize further prevention of caries with fluoride tablets.

The project leader expressed her satisfaction with working on the project: “I have worked as a kindergarten nurse for 25 years, yet this is the first time I feel I have learned many new things myself. What pleased me most was that the results were better than I expected, and the response from sponsors and parents.”

In the afternoon, another PSBHN September 2005 project was visited. Mrs. Margarita Nikolova, a nurse started a project aiming to train parents of handicapped children to carry out rehabilitation at home. Skills and knowledge of parents are essential in the rehabilitation process.

The team of the project – the kindergarten staff, a rehabilitation specialist and a part-time paediatrician work in close collaboration with the general practitioners and specialists at the University Hospital in Pleven.

At present, the team works with parents of seven children with cerebral palsy and nine children with mild forms of locomotor deficiencies. Five children with hearing problems are on an early rehabilitation program, and a speech therapist works with 20 other children. Eight children with asthma also attend the kindergarten. All children are continuously assessed by specialists, and referred for hospital treatment when necessary.

Results:

·        the children with special needs have better chances for integration since the kindergarten is also attended by healthy children;

·        parents often spend hours with the kids and participate in the activities, which has proved useful to building confidence in the children

·        parents are instructed how to continue rehabilitation at home when the children do not attend, and on weekends;

·        parents readily collaborate with the team. 

The “School for parents of low birth weight children” was started in July 2004 by Mrs. Gorcheva and the team - Dr. Simov - pediatrician, Dr. Rosmanova – a pediatrician, consultant in neonatology and head of intensive neonatology unit at the University Hospital in Pleven, Dr. Yonov – pediatrician, Mrs. Bondjeva – a pedagogue, nurses and physical rehabilitation specialists.

The project was funded by Children’s Health Net Foundation, and was implemented on the premises of the home for medico-social care with an intensive care neonatology section. A room was renovated where parents come for training and individual talks and instructions as needed. The target group are biological and adoptive parents of low-birth weight and premature babies. The aim of the team is to prepare parents to give proper care to their children after discharge from intensive care. Individual approach to parents is applied, depending on the problem of children. Brochures were prepared by the team, and individual talks and training sessions for parents are organized. The team has organized continuous follow-up for medical and psychological assessment of children until they catch up with normal birth weight children.

Parents are given a chance to spend time with their babies, and the management of the home has also provided rooms so that mothers from outside Pleven can breast feed.

Results as of April 2005: parents of 70 children were included in the program, and recruitment for the program is an on-going process. The benefits of training are not need proofs further than meeting parents of babies not different from their peers. Unfortunately, proving benefits sometimes needs negative experiences: two of the ten children whose parents refused to be included in the program died after discharge.

The project was selected for presentation in the medico-social section of the National Congress in Neonatology in early June 2005.  The program providing organized training for parents of low birth-weight children starting while the children are still in intensive care is new for the country, and is expected to have a big impact in view of the increasing number of low birth-weight children.

FORTHCOMING EVENTS: 

·        A PSBHN workshop will be held on June 3-5, 2005 in Stara Zagora, with nurses taking a bachelor’s degree program at the Faculty of Medicine of Thracian University. Nurses from several other hospitals in South Bulgaria will participate. The workshop is organized by Dreyfus Health Foundation, Association for Better Heath, Pleven Medical University and Medical Faculty in Stara Zagora;

·         A follow-up workshop will be held in Gabrovo in June 6th 2005, for participants in the PSBHI June 2004 workshop, organized by Dreyfus Health Foundation, Association for Better Heath, Gabrovo Regional Hospital and Gabrovo NGOs;

·         A follow-up workshop will be held in Pleven on June 7th 2005, with participants from the June and September 2004 PSBHN workshops.  The workshop is organized by Dreyfus Health Foundation, Association for Better Heath and the Health Department of Pleven Municipality.

Note! You can visit www.livebg.net/psbh-digest, where you can see some pictures from both workshops and site visits.

Please send your suggestions and materials to abh-psbh-bg@el-soft.com

ESBL: Some Information from the Internet

Extended Spectrum Beta Lactamase (ESBL)

How is it spread?

How is it detected?

What do I look for?

How is it treated?

How can I protect myself?

What is it?

Extended spectrum beta lactamase (ESBL) microbes are specific bacteria that produce enzymes (extended spectrum beta lactamases) that can break down many common antibiotics, making the antibiotics ineffective.

ESBL microbes have been present in Europe and the USA for almost 20 years. Only recently have these bacteria been detected in Canada in significant numbers. The types of bacteria that are most commonly associated with ESBL are E. coli and Klebsiella.

E. coli is a bacteria found in the normal human bowel flora and is necessary for digestion. Sometimes E. coli will get into tissues or organs where it does not belong, such as the urinary tract, and can lead to infection. E. coli is the most common cause of bladder infection and is usually treated with antibiotics. Symptomatic infections that are caused by ESBL E. coli may not be effectively cured by some commonly used antibiotics.

NOTE: This is not the same E. coli that causes “hamburger disease” or caused the waterborne outbreak in Walkerton, Ontario.

How is it spread?

Poor personal hygiene, especially after using the washroom, can spread the bacteria from the bowel of one carrier or infected person to the mouth of another person. The spread of ESBL E. coli in a facility occurs most commonly through direct contact with someone with ESBL, a contaminated environment or on the hands of some care providers. Careful cleaning of areas that might be touched by hands is important to reduce the spread of this organism in a facility. Faucets, door handles, bedrails, bathrooms, and other surfaces that people touch must be cleaned regularly to prevent the spread of ESBL Ecoli..

How is it detected?

Currently, testing for ESBL E. coli is only done at specific hospitals. Testing can be arranged through the Health Department. For screening, a swab of the rectum is taken. For people with symptoms, urine, blood, wound area or phlegm samples may be required.

What do I look for

For most people, ESBL E.coli does not cause harm and does not cause any symptoms. People who are carriers of ESBL do not require antibiotic treatment since this could lead to increased resistance. For the few people who develop symptoms including symptoms of urinary tract, wound, pneumonia or blood infections, antibiotics should be used. These infections can be serious so knowing whether a person has ESBL E. coli is important to ensure the most appropriate treatments are prescribed.

Risk factors for ESBL infection for people in hospital include previous antibiotic use, catheters, length of stay, frail health, and admission to an intensive care unit. The risk of ESBL microbes to the general public is low. Appropriate use of all antibiotics is important to ensure effective treatments are available should the need arise.

How is it treated?

For people who carry ESBL E. coli but are not ill (i.e. carriers), no treatment is needed. Antibiotics to clear ESBL E.coli should only be taken if someone has symptoms of an infection. Not treating carriers of ESBL E.coli helps prevent further resistance and allows optimum treatment should the need arise. Carriers can frequently clear this organism without any treatment. Treatment should rely on culture and sensitivity of the test. Consultation with an infectious disease specialist should be considered for those with symptoms of infection from ESBL E. coli.

How can I protect myself?

·         Wash hands after going to the washroom and before eating or preparing food

·         Everyone working or visiting health care facilities must wash their hands prior to entering and upon leaving the resident’s room, and prior to assisting a resident with feeding. Wash hands using an antibacterial soap and/or alcohol hand sanitizer. Note: alcohol hand sanitizers should not be rinsed off.

·         All staff in health care facilities must wash their hands before and after every contact with residents.

·         Gloves should be worn when providing direct personal care or cleaning the environment. Gloves must be changed and hands washed between procedures and between resident contacts.

·         No masks are required. Gowns are only required if the environment is grossly contaminated and giving care may result in soiling the clothing of staff and family.

·         Good environmental cleaning and infection control procedures must be carried out in all facilities.

Adapted from FACTS About ESBL E.coli Durham Region Health Department

FREQUENCY OF EXTENDED SPECTRUM BETA LACTAMASE PRODUCING GRAM NEGATIVE BACILLI AMONG CLINICAL ISOLATES AT CLINICAL LABORATORIES OF ARMY MEDICAL COLLEGE, RAWALPINDI

Ali AM, Rafi S, Qureshi AH

Microbiology Department, Army Medical College Rawalpindi, Pakistan

Background: This study was carried out in Microbiology department of Army Medical College, Rawalpindi to find out the frequency of extended spectrum beta lactamase producing gram negative bacilli among clinical isolates recovered from clinical specimens received  from Military Hospital, Rawalpindi. Methods: This study was carried out from 1st Jan 2002 to 30th Dec 2002. A total of 812 consecutive Gram-negative bacilli were recovered during the study period from various samples including urine, blood, pus, sputum, high vaginal swab (HVS), aspirates, i/v canula/ Central venous lines (CVP), chest tubes and catheter tips. Extended spectrum beta lactamase detection in these isolates was carried out by Kirby Bauer disc diffusion method on Mueller Hinton agar. A susceptibility disk containing amoxicillin-clavulanate was placed as the inhibitor of beta lactamase in the center of the plate, and cefotaxime, ceftazidime, ceftriaxone and aztreonam disks were placed 30 mm (center to center) from the amoxicillin-clavulanate disk. Enhancement of the zone of inhibition of the oxyimino--lactam caused by the synergy of the clavulanate in the amoxicillin-clavulanate disk was considered as evidence of ESBL production. Escherichia coli ATCC 25922 and K. pneumoniae ATCC 700603 were used as control strains. Results: The frequency of ESBL producing gram negative bacilli among the clinical isolates was 45%.

Keywords: ESBL. Antibiotic. Nosocomial. Enterobacteriaceae

INTRODUCTION
ß-Lactam antibiotics are among the most frequently prescribed antimicrobial agents worldwide. The emergence of resistance to these agents in the past two decades has resulted in a major clinical crisis.^1,2 Gram negative bacteria resistant to agents such as extended-spectrum cephalosporins, monobactams, carbapenems and ß-lactam–ß-lactamase inhibitor combinations have emerged through the production of a variety of ß-lactamases, alterations in the penicillin-binding proteins, outer membrane permeability and combinations of multiple mechanisms of resistance. This increase has paralleled the introduction, administration and overuse of ß-lactam drugs.³

Resistance to ß-lactam antimicrobial agents, especially extended-spectrum cephalo-sporins and other antimicrobial agents among clinical isolates of gram negative bacteria is on the rise worldwide.^4,5 These antimicrobial resistant pathogens include extended-spectrum cephalosporin resistant Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Serratia marcescens and Citrobacter freundii, Pseudomonas aeruginosa and Acinetobacter baumannii. Recent studies in Taiwan have demonstrated a high prevalence of these antimicrobial-resistant bacteria and a trend of increasing resistance under continued antibiotic selective pressure.⁶

The objective of this study was to determine the frequency of extended-spectrum ß-lactamase (ESBL) producing gram-negative bacilli recovered from clinical specimens in our set up.

MATERIAL AND METHODS

A total of 812 consecutive non duplicate gram-negative bacilli recovered from clinical specimens during the study period from 1^st Jan 2002 to 30^th Dec 2002 were included in the study. These were isolated from various samples including urine, blood, pus aspirate, sputum, chest tube, HVS, i/v canula/ CVP lines and catheter tips received from patients admitted in Military Hospital, Rawalpindi. The samples received were initially inoculated on Blood agar and MacConkey`s agar besides Chocolate agar (in case of sputum) where appropriate. Urine samples were cultured on Cystiene lactose electrolyte deficient agar (CLED). The samples were incubated at 37^oC under aerobic conditions for 24 hours. The organisms were primarily identified by standard techniques. Confirmation to the species level was done by API 20 E & API 20 NE where required. ESBL production was detected by placing a susceptibility disk containing amoxicillin-clavulanate (20/10 ug) as the inhibitor of beta lactamase in the center of the plate and cefotaxime (30ug), ceftazidime (30ug), ceftriaxone (30ug) and aztreonam (30ug) disks at 30 mm (center to center) from the amoxicillin-clavulanate disk. Enhancement of the zone of inhibition of the oxyimino--lactam caused by the synergy with clavulanate in the amoxicillin-clavulanate disk was considered as evidence of ESBL production.⁷ Escherichia coli ATCC 25922 and Klebsiella pneumoniae ATCC 700603 were used as control strains. The results were tabulated as frequencies.

RESULTS

Three hundred and sixty six isolates were ESBL producers making a frequency of 45 %. Enterobacter cloacae was the most frequent ESBL producer. Escherichia coli (45%) was the most frequent organism isolated followed by Klebsiella pneumoniae (21%), Pseudomonas aeruginosa (19.2%), Enterobacter cloacae (4.6%) and Acinetobacter baumannii (4.4%) (Table-1).

DISCUSSION

 Extended spectrum beta lactamase (ESBL) refers to beta lactamase enzymes produced by gram negative organisms that confer resistance against broad-spectrum beta-lactam antibiotics, normally having activity against gram-negative bacilli. Examples of such antibiotics are cefotaxime, ceftriaxone, ceftazidime and aztreonam.³

The first hospital outbreak of an ESBL producing gram-negative organism was reported in Germany in 1983.⁸ Within one year, nosocomial outbreaks caused by a multidrug resistant Klebsiella clone carrying a TEM-3 gene were described in France.⁹ Over the past decade, ESBL-producing Enterobacteriaceae have emerged as serious nosocomial pathogens throughout Europe.¹⁰ Outbreaks have occurred among the most critically ill patients in intensive care units (ICUs).¹¹

The prevalence of ESBL-producing bacteria in most hospitals remains unknown inspite of numerous reports of nosocomial outbreaks of infection due to these organisms. Important ESBL producing gram-negative bacilli include Klebsiella pneumoniae, Escherichia coli, and Proteus mirabilis, enterobacter species, Citrobacter freundii, Pseudomonas aeruginosa, Acinetobacter and Stenotrophomonas maltophilia.¹²

The percentage of isolates expressing ESBL production is variable although a recent study from the United States reported 83 ESBL-producing isolates from 906 consecutive isolates of Enterobacteriaceae over a 20 week period. Klebsiella pneumoniae and Escherichia coli were the most frequently associated with ESBL production in this study.¹²

 During a five-year surveillance study in northern France, the overall proportion of ESBL producers was 11.4% in the 6121 strains of Klebsiella species and 47.7% in the 2353 strains of Enterobacter aerogenes.¹³

In a national surveillance program conducted in 1996 in Argentina, resistance to extended-spectrum cephalosporins was shown in 48%, 26%, and 8% of K. pneumoniae, Proteus mirabilis, and Escherichia coli isolates respectively.¹⁴

In a study carried out in All India Institute of Medical Sciences, New Delhi during March to June 2001 out of the 678 isolates tested 68% were ESBL producers, which are  more than that found in our study. ESBL production was most common in Klebsiella spp. (80%).¹⁵

In our study Enterobacter cloacae (79%) was the most frequent ESBL producer followed by Acinetobacter baumannii (72%) and Klebsiella oxytoca (66.66%).

Table-1: Frequency of gram negative bacilli and ESBLS among the recovered isolates (n=812)

However these bacteria were infrequently recovered. The relative frequency of ESBL producing Gram negative bacilli in our study is similar to frequency reported from Islamabad, Pakistan¹⁶ with Escherichia coli (48%) being the most prevalent organism reported as was found in our study. 

The frequency of ESBL producing Gram negative bacilli (35 %) in nosocomial isolates reported from Armed Forces Institute of Pathology, Rawalpindi is lower than our study. Klebsiella spp. was the commonest ESBL producing organism reported followed by Enterobacter cloacae and Escherichia coli whereas Enterobacter cloacae was the most frequent ESBL producer in our study.¹⁷

The frequency of ESBL producing gram negative bacilli clinical isolates in our study was 45 %. Enterobacter cloacae (79%) was the most frequent ESBL producing organism detected followed by Acinetobacter  baumanii (72%) and Proteus mirabilis (61%) though Escherichia coli (45%) was commonest organism identified  followed by Klebsiella pneumoniae (21%) and Pseudomonas aerugenosa beside other gram negative rods

CONCLUSION

The resistance to beta lactam antimicrobial agents among gram-negative bacilli is on the increase in our setup. Laboratories can detect ESBL production by simple technique of Jarlier et al. Bacterial strains resistant to most classes of antibiotics will continue to emerge unless the inappropriate use of these drugs is curtailed. Clinicians should consider ESBL production as a possibility in case of treatment failure with -lactam antimicrobials.

REFERENCES

1. Wood AJ. Antimicrobial-drug resistance. N  Eng J Med 1996; 335: 1445–53. 

2. D'Agata FEMC. Antibiotic resistance and exposure to different generation cephalosporins. N Eng J Med 2000;28:2678-81.

3. Fridkin SK, Steward CD, Edwards JR, Pryor ER, McGowan JE Jr, Archibald LK, et al. Surveillance of antimicrobial use and antimicrobial resistance in United States hospitals: project ICARE phase 2. Clin Infect Dis 1999; 29 (2):245–52.

4. Pfaller MA, Jones RN. MYSTIC (Meropenem Yearly Susceptibility Test Information Collection) results from the Americas: resistance implications in the treatment of serious infections. J Antimicrob Chemother 2000; 46(Suppl ):25–37.

5. Goossens H. MYSTIC (Meropenem Yearly Susceptibility Test Information Collection) results from Europe: comparison of antibiotic susceptibilities between countries and centre types. J Antimicrob Chemother 2000;46 (suppl):39–52. 

6. Hsueh PR, Chen ML, Sun CC, Pan HJ, Yang LS, Ho SW  et al. Emergence of antimicrobial drug resistance of major pathogens causing nosocomial infections at a university hospital in Taiwan 1981–1999. Emerg Infect Dis 2002; 8(1):63-8

7. Jarlier V, Nicolas M, Fournier G, Philippon A. Extended broad-spectrum -lactamases conferring transferable resistance to newer -lactam agents in Enterobacteriaceae: hospital prevalence and susceptibility patterns. Rev Infect Dis 1988;10 (4):867-78.

8. Knothe H, Shah P, Krcmery V, Antal M, Mitsuhashi S. Transferable resistance to cefotaxime, cefoxitin, cefamandole and cefuroxime in clinical isolates of Klebsiella pneumoniae and Serratia marcescens. Infection 1983;11(6):315-7.

9. Brun-Buisson C, Legrand P, Philippon A, Montravers F, Ansquer M, Duval J et al. Transferable enzymatic resistance to third-generation cephalosporins during a nosocomial outbreak of multiresistant Klebsiella pneumoniae. Lancet 1987; 8(2): 302-6.

10. Livermore DM, Yuan M. Antibiotic resistance and production of extended spectrum b-lactamases amongst Klebsiella spp. from intensive care units in Europe. J Antimicrob Chemother 1996; 38(3):409-24.

11. Jacoby GA. Extended-spectrum b-lactamases and other enzymes providing resistance to oxyimino--lactams. Infect Dis Clin North Am 1997; 11(4):875-87.

12. Coudron PE, Moland ES, Sanders CC. Occurrence and Detection of Extended-Spectrum ß-lactamases in members of the family Enterobacteriaceae at a Veterans Medical Center: Seek and You May Find. J Clin Microbiol 1997; 35(10):2593-7.

13. Albertini MT. Surveillance of methicillin-resistant Staphylococcus aureus (MRSA) and Enterobacteriaceae producing extended-spectrum beta-lactamase (ESBLE) in Northern France: a five-year multicentre incidence study. J Hosp Infect 2002; 52(2): 107-13.

14. Bantar C, Famiglietti A, Goldberg M. Three-year surveillance study of nosocomial bacterial resistance in Argentina. The Antimicrobial Committee; and the National Surveillance Program (SIR) Participants Group. Int J Infect Dis 2000; 4(2):85-90.

15. Mathur P, Kapil A, Das B, Dhawan B. Prevalence of extended spectrum beta lactamase producing gram negative bacteria in a tertiary care hospital. Indian J Med Res 2002; 115:153-7

16. Shah AA, Hasan F, Ahmed S, Hameed A. Extended-spectrum beta-lactamases in enterobact-eriaceae: related to age and gender. New Microbiol 2002; 25(3): 363-6.

17. Zaman G, Karamat KA, Abbasi S, Rafi S, Ikram A. Prevalence of Extended-spectrum beta-lactamase (ESBL) producing enterobacteriaceae in nosocomial isolates. PAFMJ 1999: 49 (2): 91-6

Address for Correspondence:

Dr. Arif Maqsood Ali, House No. B- 889, Satellite Town, Rawalpindi, Ph :+92-51-4413383,4429514,4842055