DOI: http://doi.org/10.54079/jpmi.36.4.

3027 ORIGINAL ARTICLE

ANTIBIOTIC SUSCEPTIBILITY PATTERN OF CARBAPENEM

RESISTANT ENTEROBACTERIACEAE AMONG UROPATHOGENS
ISOLATED IN A REFERRAL LABORATORY OF KARACHI
Department of Pathology Saima Naseem , Ambreen Fatima, Fatima Fasih, Sahar Iqbal, Hareem Gohar, Fouzia Zeeshan
Dow University of Health
Sciences, Karachi - Pakistan ABSTRACT
Address for correspondence: Objective: To determine the antibiotic susceptibility pattern of Carbapenem resistant Enterobacteriaceae among
Saima Naseem uropathogens isolated in a referral laboratory in Karachi.
Department of Pathology
Dow University of Health Methodology: It is a retrospective cross-sectional study, carried out at the Department of Microbiology of Dow
Sciences, Karachi - Pakistan Diagnostic Research and Reference Laboratory. All urine samples collected during the study period of 6 months
from October 2020 to March 2021 were tested for culture and sensitivity patterns by the disc diffusion method.
E-mail:
[email protected].
Data of urine culture and sensitivity test reports were taken from the medical record. and analyzed by using SPSS
pk version 16.

Date Received:
Results: Out of the total 10925 uropathogens isolated, 67% belonged to Enterobacteriaceae family. The most fre-
December, 10th 2021 quent isolate among them was Escherichia coli 84% followed by Klebsiella species at 10%. The overall prevalence
Date Revised: of Carbapenem resistance was 6%. The frequency of Carbapenem resistance was higher in Klebsiella species
August, 3rd 2022 27% than Escherichia coli 8%. Multi-drug resistance was observed in both Escherichia coli and Klebsiella species
Date Accepted: especially against Ampicillin, followed by Cefixime, Cefuroxime, Ceftriaxone, Cotrimoxazole and Ciprofloxacin.
September, 27th 2022
Conclusion: The study showed a significant rate of Carbapenem resistance among Enterobacteriaceae which
emphasizes the need for formulating an antimicrobial policy with its strict implementation and regular surveillance
to control the spread of Carbapenem resistant Enterobacteriaceae at the hospital and community level.
Keywords: Carbapenem; Enterobacteriaceae; Escherichia coli; Resistance

INTRODUCTION meropenem, imipenem, ertapenem, & doripenem.3,4

However, production of carbapenemase hydrolyting
A Urinary Tract Infection (UTI) is considered one of enzymes, coded by blaKPC, blaVIM and blaIMP, has
the most prevailing bacterial infections after the upper further increased resistance among Enterobacteriace-
respiratory tract infection. It is often associated with ae.5 In United Kingdom, a new metallo-ß–lactamase
prolonged hospital stay and increased mortality rate was identified as New Delhi metallo-ß-lactamase
due to septicemia. Every year, 150 million people de- (blaNDM) in clinical isolates of Escherichia coli (E. coli)
velop UTI globally costing health care an approximate and Klebsiella pneumonia in a Swedish patient who
of 6 billion dollars.1 Gram negative bacteria, especially visited India.6 Other studies have also reported similar
the family of Enterobacteriaceae, are the most pre- resistance gene which have posed high level of resis-
dominant cause of both Nosocomial and community tance to the available antimicrobials, making them in-
acquired UTIs. They have developed a multidrug resis- effective in treating infections. It can eventually result
This article may be cited as tance to both the first and second line of antimicrobi- in an increased risk to the public health by spreading
Nassem S, Fatima A, Fasih F, als.2 resistance widely and causing high mortality rates. Lit-
Iqbal S, Gohar H, Zeeshan
erature shows that amongst Enterobacteriaceae, the
F. Antibiotic susceptibility
pattern of Carbapenem re- Earlier, one of the main causes of development of most common isolates with Carbapenem resistance
sistant Enterobacteriaceae resistance in Enterobacteriaceae was the production were E. coli and Klebsiella species (sp.).7 Patients who
among uropathogens iso- of antibiotic degrading enzymes, like pencillinases, are on invasive devices like intravenous catheter, uri-
lated in a referral laboratory cephalosorinases, and extended spectrum ß-lact- nary catheters, nasogastric tubes or ventilators as well
of Karachi. J Postgrad Med
Inst 2022;36(4):230-34.
amase (ESBL). Currently the last antibiotic option avail- as those suffering from recurrent infections and taking
https://doi.org/10.54079/ able to treat ESBL producing Enterobacteriaceae is a antibiotics for a long period of time are key victims of
jpmi.36.4.3027. Carbapenem group of ß-lactam antibiotics including Carbapenem resistant Enterobacteriaceae (CRE).8

230 VOL. 36 NO. 4 | Journal of Postgraduate Medical Institute

 Antibiotic susceptibility pattern of Carbapenem resistant Enterobacteriaceae among uropathogens isolated in a referral laboratory of Karachi

While understanding the magnitude of power of the study was taken for Klebsiella cross tab to compare frequency of uropatho-
the problem, there is a need to have up- sp. with a 10% prevalence. Each report has gens with age groups and also to compare
dated information regarding prevalence and data of patient’s age, gender, isolated organ- sensitivity pattern of uropathogens against
antimicrobial susceptibility pattern of the ism and its antibiotic susceptibility pattern. antibiotics.
Enterobacteriaceae in urinary isolates for Culture reports having complete information
appropriate empirical therapy of urinary tract regarding patient’s age, gender, and iso- RESULTS
infection. Therefore, this study was designed lated organism were included in the study.
to determine prevalence and antibiotic sus- Moreover antibiotic susceptibility pattern of In this study, a total 28,505 urine cul-
ceptibility pattern of Enterobacteriaceae iso- only gram negative bacteria belonging to the tures and sensitivity test report data was
lated from urinary tract infected patients. family of Enterobactericeae were included in taken from medical record of a period of 6
the study. . Culture reports having a lack of months from October 2020 to March 2021.
METHODOLOGY above mentioned in a patient’s information Out of these, 10,925 (38%) showed positive
were excluded from the study. The antibiotic bacterial growth having a female to male ra-
This retrospective, cross-sectional study susceptibility pattern of organisms other than tio of 2.6:1. Amongst these, 7,849 (72%) of
was conducted at the Department of Micro- family of Enterobacteriaceae were excluded specimens belonged to female patients and
biology Dow Diagnostic Research and Refer- as well. In Microbiology lab, urine samples 3,076 (28%) of specimens were of male pa-
ence Laboratory (DDRRL). The data of urine were processed according to standard mi- tients with overall mean age of the patient
and culture sensitivity test report was col- crobiological procedures and antibiotic sus- found to be 42.5 years. Significant bacterial
lected from the medical record of Microbi- ceptibility test was performed as stated in growth was found much higher in the pa-
ology section after getting approval from In- CLSI guidelines 2021.(9) The antibiotic discs tients having age ranging between 21-30
stitutional Review Board (IRB) with Reference used for susceptibility testing of gram neg- years followed by 51-60 years in compari-
No. IRB-1794/DUHS/Approval/2021. The ative bacteria of family Enterobacteriaceae son to other age groups. (Figure-I).
culture reports included samples from both included Ampicillin 10µg, Amoxicillin / Clavu-
inpatient and outpatient department during lanic acid 30µg, Piperacillin / Tazobactam Out of the total 10,925 uropathogens
a period of six months from October 2020 110µg, Amikacin 30µg, Meropenem 10µg, isolated, 67% (7,285) belonged to Entero-
to March 2021. A sample size of 28,505 Gentamicin 10µg, Cefixime 5µg Ceftriaxone bacteriaceae family. The most frequent iso-
subjects was taken, that have achieved 30µg, Cefuroxime 30µg, Ciprofloxacin 5µg, late among them was E. coli 6,135 (84%)
more than 99% power to detect a marginal Cotrimaxazole 25µg, Nitrofurantoin 300µg followed by Klebsiella sp. 704 (10%). (Fig-
error of 5%, a 95% confidence interval, and and Fosfomycin 200µg. The entire data was ure- II)
an 84% prevalence of E. coli using PASS entered in SPSS version 16 and descriptive
version 15 software. A one-sample test statistics was measured in percentages. Fur- Antibiotic sensitivity pattern of only E. coli
was used to calculate proportion. The same ther statistical analysis was done by using and Klebsiella sp. were analyzed as other

Figure 1: Age group wise distribution of isolated uropathogens in %

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 Antibiotic susceptibility pattern of Carbapenem resistant Enterobacteriaceae among uropathogens isolated in a referral laboratory of Karachi

Figure 2: Frequency of isolated Enterobacteriaceae in %

Table 1: Antibiotic resistance pattern of isolated Enterobacteriaceae

Escherichia coli N= 84%
Antibiotics Klebsiella sp. N= 10% (704)
(6,135)
Ampicillin 5276 (86%)* -
Amoxicillin / Clavulanic acid 2024 (33%) 190 (27%)
Piperacillin / Tazobactam 613 (10%) 105 (15%)
Ceftriaxone 4171 (68%)* 282 (40%)
Cefixime 4539 (74%)* 330 (47%)*
Cefuroxime 4539 (74%)* 330 (47%)*
Meropenem 491(8%) 190(27%)
Gentamicin 1533 (25%) 133 (19%)
Amikacin 122 (2%) 77 (11%)
Ciprofloxacin 3865 (63%)* 211(30%)
Cotrimoxazole 4171 (68%)* 295 (42%)*
Fosfomycin 491 (8%) 77 (11%)
Nitrofurantoin 306 (5%) 147 (21%)
*Microorganisms showing increased resistance to antibiotics, - Antibiotics not tested

members of Enterobacteriaceae isolated most sensitive antibiotics to Klebsiella sp. M. et al.10 and in North India by P Datta et
were in very less number. Therefore, a total were Amikacin 89%, Fosfomycin 89% and al.11 However, a high prevalence of CRE was
of 6,839 Enterobacteriaceae isolates (E. coli Tazobactam 85% respectively. (Table-I). reported by Gurung S. et al12 and Wattal C et
6,135 & Klebsiella sp. 704) were analyzed al13 in Nepal and Delhi respectively.
for antibiotic sensitivity pattern. Overall prev- DISCUSSION
alence of Carbapenem resistance among Further in this study, a higher rate of
them was 6% (390/ 6,839). The frequency This study emphasized on the frequency Carbapenem resistance (CR) was noticed
of Carbapenem resistance was higher in of Carbapenem resistant Enterobacteriace- in Klebsiella sp. 27% than in E. coli 8%.
Klebsiella sp. 190 (27%) than E. coli 491 ae (CRE) among urinary isolates which has Similar findings were found in studies con-
(8%). Most sensitive antibiotics to E. coli become an emerging threat to public health. ducted by Shields R.K. et al14 and Matar et
were Amikacin 98 %, Nitrofurantoin 95%, Statistical analysis of the data showed a al.15 In contrast, in Mumbai, Nirangan et al
Meropenem 92%, Fosfomycin 92% and frequency of 6% CRE in this study. Similar reported a higher prevalence of CR in E. coli
Tazobactam 90% respectively. However, the results were observed in Nigeria by Suwaiba 49.8% than in K. pneumonia 37.4%.16 Re-

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 Antibiotic susceptibility pattern of Carbapenem resistant Enterobacteriaceae among uropathogens isolated in a referral laboratory of Karachi

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DOI: 10.1186/s12879-021-06229-x DOI:10.9734/AJRIMPS/2018/41893

Author’s Contribution
SN Performed the data analysis and interpretation of data. AF contributed in the literature search and helped in the analysis of data. FF, SI, and HG
contributed in data collection and drafted the manuscript for final approval. FZ conceived the idea and helped in the write-up of the manuscript.
Authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work
are appropriately investigated and resolved.

Conflict of Interest Grant Support and Financial Disclosure

Authors declared no conflict of interest None

Data Sharing Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

234 VOL. 36 NO. 4 | Journal of Postgraduate Medical Institute