CLINICOPATHOLOGICAL CASE DISCUSSION _ ON ESBL producing bacteria
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ESBL - Extended Spectrum Beta Lactamases - ESBL - Bacteria - HOSPITAL - SECOND MBBS STUDENTS - UNDERGRADUATE STUDENTS - MEDICAL COLLEGE - POWERPOINT
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CLINICOPATHOLOGICAL CASE DISCUSSION _ ON ESBL producing bacteria
- 1. DEPARTMENT OF MICROBIOLOGY KARPAGAM FACULTY OF MEDICAL SCIENCES AND RESEARCH Dr. SHREERAM A. DESHPANDE, MBBS, MD., Dr. R. SOMESHWARAN, MBBS, MD.,
- 2. CLINICAL SCENARION • A clinical isolate of Klebsiella pneumoniae ESBL + Carbapenemase in Urine in a 39 years old female. 12/17/15 2
- 3. ESBLs and Carbapenemases • ESBLs: Extended spectrum Beta lactamases are enzymes produced by certain bacteria especially among Enterobacteriaceae members like Klebsiella pneumoniae, Escherichia coli, Salmonella and Proteus spp., and also observed in Pseudomonas aeruginosa and Acinetobacter baumannii causing Nosocomial infections. ESBLs prevalence: Hospital acquired/ Nosocomial – 80% - Community acquired – 20% 12/17/15 4
- 4. ESBLs and Carbapenemases • Carbapenemases: Carbapenemase producing bacteria are resistant to Carbapenems like Meropenem, Imipenem, Doripenem and or Ertapenem. Ex: Klebsiella pneumoniae Carbapenemase (KPC) 12/17/15 5
- 5. Significance of ESBL and Carbapenemases • ESBLs are resistant to beta lactam antibiotics like Penicillins, Cephalosporins (I, II, II Gen) and Monobactam (Ao) and Carbapenemase resistant to Carbapenems like Imipenem, Meropenem and etc., • Risk of spread - Environment • Morbidity and Mortality - High • Nosocomial infection - Common • Treating physician is left with a only limited choice of antibiotics – poses a threat12/17/15 6
- 7. CLINICAL PROFILE • Patient name: Mrs. XXX XXX XXX • Age: 39 years • Sex: Female • Occupation: Housewife • OP No: O1404026256 • Lab No: 105426 / 2015 • Diagnosis: XXX • Department: OB & GY • Antibiotic details: XXX 12/17/15 8 Patient data could not be retrieved as she was an Out patient (OP) XXX – Not known
- 9. MICROBIOLOGICAL DIAGNOSIS • Sample: Mid stream urine (MSU) • Collected in: wide mouthed sterile plastic container • Date of sample collection: 24-12-2014 / 10.30 am • Transported immediately to lab and processed 12/17/15 10 5µl
- 10. MICROBIOLOGICAL DIAGNOSIS • Test: Culture & Sensitivity • Wet mount performed by Microscopy • Sample INOCULATED ON BAP, MAC for Culture and Incubated overnight @ 37°C. 12/17/15 11
- 11. Urine Wet Mount • Pus cells: 20-40/HPF • Bacteria: Present 12/17/15 12
- 12. DAY 2 • Reading the culture plates and Reporting done 12/17/15 13
- 13. Colony Morphology Reading • BAP: Non hemolytic Mucoid colonies • MAC: Pink Lactose fermenting mucoid colonies 12/17/15 14
- 14. From the colonies • Biochemical reactions – 37°C X 24 hrs • Antibiotic Susceptibility Testing performed on Mueller Hinton Agar with 0.5 Mac Farland standard of bacterial suspension – Incubated at 37°C X 24 hrs. 12/17/15 15
- 16. Bio-chemical reaction Indole Citrate Urease MMM TSI MR VP Negative Positive Positive +/- A+ /A- Negative Positive 12/17/15 17
- 18. Identification discs Antibiotic discs Dose in µg Zone diameter AST report Ceftazidime (Ca) 30 30 mm RESISTANT Ceftazidime Clavulanate (Cac) 30/10 40 mm RESISTANT Cefotaxime (Ce) 30 30 mm RESISTANT Cefotaxime Clavulanate (Cec) 30/10 40 mm RESISTANT Cefoxitin (Cn) 30 21 mm RESISTANT 12/17/15 19
- 19. I & II line discs Antibiotic discs Dose in µg Zone diameter AST report Ampicillin 10 6 mm RESISTANT Amoxy-Clavanate 30 6 mm RESISTANT Piperacillin Tazobactum 100/10 10 mm RESISTANT Ceftriaxone 30 6 mm RESISTANT Cefpodoxime 30 6 mm RESISTANT Cephalothin 30 6 mm RESISTANT Cefaclor 30 6 mm RESISTANT Cefixime 30 10 mm RESISTANT Cefipime 30 10 mm RESISTANT 12/17/15 20
- 20. I & II line discs (Cont.) Antibiotic discs Dose in µg Zone diameter AST report Imipenem (I) 10 15 mm RESISTANT Nitrofurantoin 300 6 mm RESISTANT Co-trimoxazole 1.25/23.75 6 mm RESISTANT Ciprofloxacin 5 6 mm RESISTANT Norfloxacin 5 6 mm RESISTANT Ofloxacin 10 6 mm RESISTANT Amikacin 30 6 mm RESISTANT Gentamicin 10 6 mm RESISTANT 12/17/15 21
- 21. What to do ??? • No sensitive drugs observed in I & II line antibiotic list • Isolate was Klebsiella pneumoniae ESBL positive With ? Carbapenemase. • We subjected the isolate for III line disc antibiotic susceptibility to confirm the diagnosis of Carbapenemase production. 12/17/15 22
- 22. III line discs Antibiotic discs Dose in µg Zone diameter AST report Meropenem (Mr) 10 14 mm RESISTANT Tobramycin (Tb) 10 8 mm RESISTANT Netilmicin 30 6 mm RESISTANT Tigecycline 15 15 mm SENSITIVE Colistin 10 12 mm SENSITIVE Ceforperazone Sulbactum 30 12 mm RESISTANT 12/17/15 23
- 23. Antibiotic Susceptibility Test (AST) 12/17/15 24 • Sensitive to: Tigecycline, Colistin • Resistant to: Ampicillin, Amoxyclav, Ceftazidime, Ceftazidime clavanate, Cefotaxime , Cefotaxime clavanate, Cefpodoxime, Cefoperazone sulbactum, Piperacillin tazobactum, Ceftriaxone, Cefuroxime, Cefpodoxime, Cefaclor, Cefipime, Cefoxitin, Imipenem, Meropenem, Ertapenem, Netilmicin, Gentamicin, Amikacin, Tobramycin, Ciprofloxacin, Ofloxacin, Nitrofurantoin, Co-trimoxazole, Norfloxacin.
- 24. ESBL Detection 1. Screening test 2. Confirmation test 12/17/15 28
- 25. ESBL Screening • Ceftazidime (Ca) and Ceftazidime – Clavulanate (Cac) identification antibiotic discs are used as per Clinical Laboratory Standards Institute (CLSI) guidelines 2014. • A zone difference of ≥ 5mm in Cac and Ca discs is suggestive of ESBLs. 12/17/15 29
- 26. ESBL Screening 12/17/15 30 Ca Cac
- 27. ESBL Screening 12/17/15 31 Ca – 30mm Cac – 40 mm
- 29. ESBL Detection 12/17/15 33 Ce Cec
- 30. ESBL Detection 12/17/15 34 Ce – 30mm Cec – 40 mm
- 31. CLINICAL SIGNIFICANCE • ESBL producing bacteria are resistant to beta lactam antibiotics like Penicillins and 1st , 2nd , 3rd , 4th generation Cephalosporinsm Aztreonam. Note: 5th Generation antibiotics like Ceftabipirole and Ceftaroline are effective against MRSA & VRE but against ESBL. 12/17/15 35
- 35. Carbapenemase detection 12/17/15 39 I – 15mm Mr – 14mm
- 36. Carbapenemase confirmation • Modified Hodge test – will be a confirmatory test for Carbapenemase producer. • Lawn culture of Escherichia coli ATCC 25922, 10µg of Meropenem, isolate to be checked • “Clover-Leaf pattern of indentation at the intersection of the test organism and the ATCC strain within the zone of inhibition” is confirmatory for Carbapenemase production. 12/17/15 40
- 37. MODIFIED HODGE TEST 12/17/15 41
- 38. Treatment of Carbapenemase Limited options left!!!! INJECTABLES (Intravenous) • Inj. Tigecycline • Inj. Colistin 12/17/15 42
- 39. Final identification • Klebsiella pneumoniae ESBL + Carbapenemase producer 105 CFU/mL sensitive to Tigecycline and Colistin only in urine. 12/17/15 43 Klebsiella pneumoniae Carbapenemase (KPC)
- 40. Preventive measures • Hand washing • Disinfection measures • Fumigation of wards • Isolation of patient • Educate nursing staff and other health care providers on Nosocomial infections, Multidrug resistant bugs, their treatment, Prevention. • Rationale use of Antibiotics by physicians 12/17/15 44
- 41. TAKE HOME MESSAGE • If you see a report of ESBL producing Enterobacteriaceae – Don’t prescribe Beta Lactam Antibiotics like Penicillins and Cephalosporins. • Beta lactamase inhibitors like Piperacillin Tazobactum or Aminoglycosides or Fluoroquinolones may be used provided they are sensitive. • Hand washing is an easy, feasible remedy to prevent ESBL producers in the Hospitals. 12/17/15 45
- 42. 12/17/15 46
- 43. TROUBLE SHOOTING • Sample collection – As per SOP • Referral form Filling • Turn Around Time (TAT) • Chief complaints – Patient details • Working diagnosis • Treating physician name and signature • Antibiotic details • Communication – Intercom • Hospital Infection Control Committee (HICC) • Hospital Antibiotic Policy (HAP) • Clinical Audit at regular intervals • OP patients – Track record to be maintained (Publishing papers) 12/17/15 47
- 45. What we expect!!! 12/17/15 49