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Advances in Environmental Biology, 7(11) Oct 2013, Pages: 3544-3548
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Advances in Environmental Biology
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Multidrug Resistant Organisms; Hospitalized and non Hospitalized Iranian Patients:
Review Article
Shila Jalalpour
Molecular Medicine Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran.
ARTICLE INFO
Article history:
Received 23August 2013
Received in revised form 24
September 2013
Accepted 29 September 2013
Available online 17 November 2013
Key words:
Multidrug Resistant Organisms,
Extended Spectrum Beta Lactamase,
Escherichia
coli,
Klebsiella
pneumoniae
ABSTRACT
Multidrug resistant organisms that, have important infection control implications
have received limited consideration in many countries including Iran previous
isolation guidelines. Extended spectrum beta lactamase are a group of active-site
serine enzymes that are able to hydrolyse a wide range of beta-lactams, including
the most recently developed cephalosporins and monobactam. In this present study
the prevalence of extended spectrum beta-lactamases (ESBL) producing Escherichia
coli and Klebsiella pneumoniae in hospitalized and non hospitalized Iranian patients
during the period of 2008 to 2011 was determined. Related papers on prevalence of
extended spectrum beta lactamase in isolated E. coli and K. pneumoniae from
hospitalized and non hospitalized patients were extracted from original and review
articles published in Pubmed, Elsivier Science, and Yahoo during the period of 1995
to 2013. For this study “key words” which were search include “multidrug resistant
organisms, extended spectrum beta lactamase, Escherichia coli and Klebsiella
pneumonia”. Comparing of ESBLs percentage showed that frequency of occurrence
of ESBLs in E.coli and K. pneumonia were highly in hospitalized patients
comparated to non hospitalized patients. Present results showed very higher ESBLs
producing E.coli and K. pneumonia prevalence in Iran province that alarm an
emerging public-health concern and emphasize on emergence need for developing a
treatment guideline for antibiotic consumption.
© 2013 AENSI Publisher All rights reserved.
INTRODUCTION
Antimicrobial resistance is one of the significant problems worldwide leads to curative failure of therapy
and it has been a threat to the patient’s safety not only in developing countries but also indeveloped countries
[3,14,16,35,21-23]. Therefore, awareness of the local prevalence of pathogens and their antimicrobial sensitivity
patterns is essential for clinicians. Establishing surveillance systems integrate clinical and laboratory data and by
it the necessary data can be captured and strengths of both data setscan be combined. There is evidence that the
wiser use of antimicrobials may reduce the rate of resistance emerges [4,5,19,20,42,45]. Thus information from
surveillance of antimicrobial resistance and data on the use of antimicrobials provides a powerful tool for the
control of resistance. The aim of antimicrobial resistance surveillance is to provide information necessary to
obtain an approach to the management of communicable diseases that diminishes morbidity and
mortality[24,25]. The main applications of surveillance information are to optimize the use of antimicrobials
and assist in the prevention and control of antimicrobial resistance at the local, regional and national levels
[42,45,46].
Multidrug-resistant organisms (MDROs), including methicillin-resistant Staphylococcus aureus (MRSA),
vancomycin-resistant enterococci (VRE) and certain Gram-negative bacilli (GNB) have important infection
control implications that either have not been addressed or received only limited consideration in previous
isolation guidelines. Increasing experience with these organisms is improving understanding of the routes of
transmission and effective preventive measures. For epidemiologic purposes, MDROs are defined as
microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents .
Although the names of certain MDROs describe resistance to only one agent (e.g., MRSA, VRE), these
pathogens are frequently resistant to most available antimicrobial agents . These highly resistant organisms
deserve special attention in healthcare facilities [41]. In addition to MRSA and VRE, certain GNB, including
those producing extended spectrum beta-lactamases (ESBLs) and others that are resistant to multiple classes of
antimicrobial agents, are of particular concern. In addition to Escherichia coli and Klebsiella pneumoniae, these
include strains of Acinetobacter baumannii resistant to all antimicrobial agents, or all except imipenem and
Corresponding Author: Shila Jalalpour, Molecular Medicine Research Center, Rafsanjan University of Medical Sciences,
Rafsanjan, Iran.
E-mail:[email protected]
3545
Shila Jalalpour
Advances in Environmental Biology, 7(11) Oct 2013, Pages: 3544-3548
organisms such as Stenotrophomonas maltophilia, Burkholderia and Ralstonia pickettii that are intrinsically
resistant to the broadest-spectrum antimicrobial agents. In some residential settings (e.g., LTCFs), it is important
to control multidrug-resistant [17-19,41].
Members of the family Enterobacteriaceae commonly express plasmid-encoded β-lactamases (e.g., TEM-1,
TEM-2, and SHV-1), which confer resistance to penicillins but not to expanded-spectrum cephalosporins.
ESBLs are beta-lactamases that hydrolyze extended-spectrum cephalosporins with an oxyimino side chain.
These cephalosporins include cefotaxime, ceftriaxone, and ceftazidime, as well as the oxyimino-monobactam
aztreonam. Thus ESBLs confer resistance to these antibiotics and related oxyimino-beta lactams [28,34,36].
Typically, they derive from genes for TEM-1, TEM-2, or SHV-1 by mutations that alter the amino acid
configuration around the active site of these beta-lactamases. This extends the spectrum of beta-lactam
antibiotics susceptible to hydrolysis by these enzymes [28,34,36]. An increasing number of ESBLs not of TEM
or SHV lineage have recently been described [7]. The ESBLs are frequently plasmid encoded. Plasmids
responsible for ESBL production frequently carry genes encoding resistance to other drug classes (for example,
aminoglycosides). Therefore, antibiotic options in the treatment of ESBL-producing organisms are extremely
limited. Carbapenems are the treatment of choice for serious infections due to ESBL-producing organisms, yet
carbapenem-resistant isolates have recently been reported. ESBL-producing organisms may appear susceptible
to some extended-spectrum cephalosporins. However, treatment with such antibiotics has been associated with
high failure rates. While ESBL-producing organisms were previously associated with hospitals and institutional
care, these organisms are now increasingly found in the community [26,27]. CTX-M-15-positive E. coli are a
cause of community-acquired urinary infections in the UK and tend to be resistant to all oral beta-lactam
antibiotics, as well as quinolones and sulfonamides. Treatment options may include nitrofurantoin, fosfomycin,
mecillinam and chloramphenicol. In desperation, once-daily ertapenem or gentamicin injections may also be
used. Although the inhibitor-resistant beta-lactamases are not ESBLs, they are often discussed with ESBLs
because they are also derivatives of the classical TEM- or SHV-type enzymes. These enzymes were at first
given the designation IRT for inhibitor-resistant TEM beta lactamase; however, all have subsequently been
renamed with numerical TEM designations. There are at least 19 distinct inhibitor-resistant TEM β-lactamases.
Inhibitor-resistant TEM beta lactamases have been found mainly in clinical isolates of E. coli, but also some
strains of K. pneumoniae, Klebsiella oxytoca, Proterious mirabilis, and Citrobacter freundii .Although the
inhibitor-resistant TEM variants are resistant to inhibition by clavulanic acid and sulbactam, thereby showing
clinical resistance to the beta-lactam lactamase inhibitor combinations of amoxicillin-clavulanate (Coamoxiclav), ticarcillin-clavulanate, and ampicillin/sulbactam, they normally remain susceptible to inhibition by
tazobactam and subsequently the combination of piperacillin/tazobactam, although resistance has been
described. To date, these beta-lactamases have primarily been detected in France and a few other locations
within Europe [4,30,38].
Extended spectrum beta lactamase (ESBL) production is one of the different mechanisms of drug resistance
in Gram-negative bacilli predominantly present in E. coli and K. pneumoniae [2,6-8,31,32]. Infectious Diseases
Society of America listed ESBL-producing Klebsiella spp and E coli as one of the six drug-resistant microbes to
which new therapies are urgently needed [28,29,44]. Author aimed to determine the prevalence of ESBLproducing E.coli and K. pneumoniae isolated from acquired urinary trace infection hospitalized and non
hospitalized Iranian patients in from 2008 to 2011.Relater papers to prevalence of extended spectrum beta
lactamase in isolated E.coli, K. pneumoniae from hospitalized and non hospitalized patients were extracted of
original and review articles (Available freely to download) in Pubmed, Elsivier Science, and Yahoo from 1995
to 2013 years. For this study key words which were search include multidrug resistant organisms, extended
spectrum beta lactamase, E. coli and K.pneumoni and IRAN.
Discussion:
Study and comparing of ESBLs percentage showed that frequency of occurrence of ESBLs in E. coli and K.
pneumonia were higher in hospitalized patients in comparison to non hospitalized patients, for example in some
study in Iran prevalence of ESBL in isolated E.coli and K. pneumoniae from hospitalized and non hospitalized
patients was 72.22%, 23.73% and 83.33% and 0%, respectively [11-16].
The rapid spread of ESBL-producing bacteria worldwide indicated needing of a continuous monitoring
systems and effective infection control measures [4,35,42]. Comprehensive epidemiologic data and
characterization of ESBL-producing isolates among hospitalized and non hospitalized in Iran are still rarely
documented and previous studies failed in extend number of patients, long-term study and comprehensive
epidemiologic data despite of their useful content leading to a global view on ESBL producing bacteria in Iran.
For example, [1] determine the prevalence of extended spectrum beta-lactamase (ESBL) producing E.coli in one
900-bed general teaching hospital showed 56% (n=140) of E. coli isolates produced ESBLs from 3 university
hospitals in Tehran during six months. Therefore, for first time we (Mobasherizaded and et al) launched a
prospective surveillance study of laboratory based antimicrobial resistance (Antimicrobial Resistance
Surveillance System) in Isfahan province, Iran. In this surveillance study, the prevalence of ESBL producing E.
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Shila Jalalpour
Advances in Environmental Biology, 7(11) Oct 2013, Pages: 3544-3548
coli in hospitalized and non hospitalized infections has been studied during three years (2008 to 2011) and
WHONET software as an analysis program helping in forming hospital drug policy was used. (This WHONET
is free Windows-based database software developed for the management and analysis of microbiology
laboratory data with a special focus on the analysis of antimicrobial susceptibility test results). The prevalence
of ESBL-producing E. coli under antimicrobial resistance surveillance system has been studied in several
countries [5,32,37,39,40,43,45,46].
Establish systems for monitoring antimicrobial resistance in hospitals and the community and link these
findings to resistance and disease surveillance data are fundamental to developing treatment guidelines
accurately and to assessing the effectiveness of interventions appropriately. For first time launched
(Mobasherizaded and et al) a prospective Antimicrobial Resistance Surveillance System in Iran. Present result
showed very high prevalence of ESBL producing E.coli and K. pneumoniae in Iran province that alarm an
emerging public-health concern, showed emergence need for developing a treatment guideline for antibiotic
consumption. Continued surveillance will provide an important function for succeed in the efforts of infection
control programs in future and it is a critical step for controlling of the growing worldwide threat of
antimicrobial drug resistance [9,10].
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