Clinico-Pathological Conference (CPC) Meet Karpagam Medical College Hospital 27-02-2015

Dr. SHREERAM A. DESHPANDE, MBBS, MD., Dr. R. SOMESHWARAN, MBBS, MD., DEPARTMENT OF MICROBIOLOGY KARPAGAM FACULTY OF MEDICAL SCIENCES AND RESEARCH Dr. SHREERAM A. DESHPANDE, MBBS, MD., Dr. R. SOMESHWARAN, MBBS, MD.,

Clinical Scenario A clinical isolate of Klebsiella pneumoniae Extended Spectrum Beta Lactamase (ESBL) and Carbapenemase producer in Urine in a 39 years old female. 9/16/2018

Clinical Profile Patient name: Mrs. XXXXXXXXX Age: 39 years Sex: Female Occupation: Housewife OP No: O1404026256 Lab No: 105426 / 2015 Sample: Mid Stream Urine (MSU) Test: Culture & Sensitivity Diagnosis: XXX Department: OB & GY Antibiotic details: XXX Co-morbid conditions: XXX Patient data could not be retrieved as she was an Out patient (OP) XXX – Not known 9/16/2018

DAY 0 Sample: Mid stream urine (MSU) in a wide mouthed sterile plastic container Date of sample collection: 24-12-2014 / 10.30 am Transported immediately to lab and processed 5µl 9/16/2018

Culture & Sensitivity Wet mount performed by Microscopy Sample inoculated on: BAP, MAC for Culture and Incubated overnight @ 37C. 9/16/2018

Urine Wet Mount Pus cells: 20-40/HPF Bacteria: Present 9/16/2018

DAY 1 Culture plates read for Colony Morphology BAP: Blood Agar Non hemolytic Mucoid colonies MAC: Mac Conkey’s Agar Pink Lactose fermenting mucoid colonies 9/16/2018

Day 1 Biochemical reaction - Incubated @ 37°C X 24 hrs Antibiotic Susceptibility Testing (AST) performed on Mueller Hinton Agar with 0.5 Mac Farland’s standard of bacterial suspension – Incubated at 37°C X 24 hrs. 9/16/2018

Isolate: Klebsiella pneumoniae DAY 2 Bio-chemical reaction Indole Citrate Urease MMM TSI MR VP Negative Positive +/- A+/A- Isolate: Klebsiella pneumoniae 9/16/2018

Antibiotic Susceptibility Test 9/16/2018

Identification discs Antibiotic discs Dose in µg Zone diameter AST report Ceftazidime (Ca) 30 30 mm RESISTANT Ceftazidime Clavulanate (Cac) 30/10 40 mm Cefotaxime (Ce) Cefotaxime Clavulanate (Cec) Cefoxitin (Cn) 21 mm 9/16/2018

I & II line discs Antibiotic discs Dose in µg Zone diameter AST report Ampicillin 10 6 mm RESISTANT Amoxy-Clavanate 30 Piperacillin Tazobactum 100/10 10 mm Ceftriaxone Cefpodoxime Cephalothin Cefaclor Cefixime Cefipime 9/16/2018

I & II line discs (Cont.) Antibiotic discs Dose in µg Zone diameter AST report Imipenem (I) 10 15 mm RESISTANT Nitrofurantoin 300 6 mm Co-trimoxazole 1.25/23.75 Ciprofloxacin 5 Norfloxacin Ofloxacin Amikacin 30 Gentamicin 9/16/2018

What to do ??? No sensitive drugs observed in I & II line antibiotic list Isolate was Klebsiella pneumoniae ESBL producer with ? Carbapenemase. We subjected the isolate for III line antibiotic susceptibility to confirm the diagnosis of Carbapenemase production. 9/16/2018

III line discs Antibiotic discs Dose in µg Zone diameter AST report Meropenem (Mr) 10 14 mm RESISTANT Tobramycin (Tb) 8 mm Netilmicin 30 6 mm Tigecycline 15 15 mm SENSITIVE Colistin 12 mm Ceforperazone Sulbactum 9/16/2018

Antibiotic Susceptibility Test (AST) 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. 9/16/2018

ESBL Detection 1. Screening test 2. Confirmation test 9/16/2018

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. 9/16/2018

ESBL Screening Ca Cac 9/16/2018

ESBL Screening Ca – 30mm Cac – 40 mm 9/16/2018

ESBL Confirmation Cefotaxime (Ce) and Cefotaxime – Clavulanate (Cac) identification antibiotic discs are used as per Clinical Laboratory Standards Institute (CLSI) guidelines 2014. A zone difference of ≥ 5mm in Cec and Ce discs is diagnostic of ESBLs. 9/16/2018

ESBL Detection Ce Cec 9/16/2018

ESBL Detection Ce – 30mm Cec – 40 mm 9/16/2018

CLINICAL SIGNIFICANCE ESBL producing bacteria are resistant to beta lactam antibiotics like Penicillins and 1st, 2nd, 3rd, 4th generation Cephalosporins and Monobactams like Aztreonam. Note: 5th Generation antibiotics like Ceftabipirole and Ceftaroline are effective against MRSA & VRE but against ESBL. 9/16/2018

CEPHALOSPORINS 9/16/2018

CARBAPENEMASE DETECTION Carbapenems like Imipenem, Meropenem, Ertapenem, Doripenem can be used for screening for Carbapenemase production by bacteria. Disk diffusion - Zone size for Urine samples: Carbapenem Resistant (mm) Intermediate (mm) Sensitive (mm) Imipenem 17 19-20 21 Meropenem 19 20-22 23 9/16/2018

Carbapenemase detection Mr 9/16/2018

Carbapenemase detection I – 15mm Mr – 14mm 9/16/2018

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. 9/16/2018

MODIFIED HODGE TEST 9/16/2018

Treatment of Carbapenemase Limited options left!!! INJECTABLES (Intravenous) Inj. Tigecycline Inj. Colistin 9/16/2018

Final identification Klebsiella pneumoniae ESBL + Carbapenemase producer 105 CFU/mL sensitive to Tigecycline and Colistin only in urine. Klebsiella pneumoniae Carbapenemase (KPC) 9/16/2018

ESBLs and Carbapenemases 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% 9/16/2018

ESBLs and Carbapenemases Carbapenemase producing bacteria are resistant to Carbapenems like Meropenem, Imipenem, Doripenem and or Ertapenem. Ex: Klebsiella pneumoniae Carbapenemase (KPC) 9/16/2018

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 threat 9/16/2018

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 9/16/2018

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. 9/16/2018