Introduction
In spite of the widespread availability of antibacterial drugs, urinary tract infection (UTI) remains one of the major infections in the community and hospital settings.1 Amongst the large number of antibiotic drugs, β-lactams are the diverse and largely used antibiotics contributing above 50% of all systemic antimicrobial agents available.2 The resistance in bacteria towards beta lactam antibiotics is mainly due to the production of beta lactamase enzyme.3 The second and third generation cephalosporin drugs are precisely designed to neutralize the hydrolytic action of beta lactamase enzymes. Nonetheless, the newest in the reserve of these enzymes by the organisms has been the development of extended spectrum beta lactamases. The ESBL enzymes produced largely by the enteric organisms like, E. coli and Klebsiella sps., which hydrolyze oxyimino-cephalosporins leading to the resistance against cephalosporins and monobactams.4
The identification of ESBL producing organisms is difficult for routine diagnostic microbiology laboratories of developing countries without molecular diagnostic facilities. Also screening of ESBL producing organisms by monitoring the decrease in susceptibility to oxyimino-cephalosporin drugs are not a sensitive tool. The recommended methods for screening ESBL producing organisms are based on the decreased susceptibility to cephalosporins in disc diffusion test.5 But, the standard protocol for reliable phenotypic method for detection of ESBL is not available.6 The existing phenotypic methods for ESBL detection are disc diffusion based screening test and double disc synergy test (DDST), Inhibitory potentiated disc diffusion (IPDD) and E-strip confirmatory tests.
According to CLSI guidelines, a screening test for decreased susceptibility to one of the five representative cephalosporin agents, followed by a confirmatory test would increase the chance of identification. Additionally, gene responsible for the production of ESBL enzyme can be detected by molecular methods.7 But these molecular diagnostic facilities will not normally be available in resource constrained routine microbiology laboratories.
The present research work was intended to find out the appropriate method for the identification of ESBL producing urinary Escherichia coli, where the data on the occurrence of ESBL producing E.coli is lacking.
Materials and Methods
This prospective study was conducted in the Department of Microbiology, Shyam Shah Medical College, Rewa, Madhya Pradesh, India. A total of 500 consecutive urine samples were screened from patients with symptomatic UTI. Clean-catch midstream urine samples were collected in sterile disposable container (Uricol, Hi-Media Laboratories Ltd., Mumbai, India) and processed within one hour. Semi quantitative loop (Hi-Media Laboratories Ltd., Mumbai, India) measuring 2.2 mm diameter with a holding capacity of 0.005 ml was employed to culture urine on CLED agar and MacConkey’s agar. The inoculated plates were incubated over night at 37oC. Isolates in significant number (colony count ≥ 105 CFU/ml) were identified by standard procedures.8 Antibiotic susceptibility test was done by Kirby-Bauer disc diffusion method9 using antibiotic discs: ampicillin (10µg), amoxicillin/clavulanic acid (20/10µg), co-trimoxazole (1.25/23.75 µg), amikacin (30µg), imipenem (10µg), gatifloxacin (5µg) and tobramycin (10 µg).
Disc susceptibility test to screen ESBLs
All the isolates were screened for ESBL production by using three indicator cephalosporins, namely ceftazidime (30 µg), cefotaxime (30 µg) and cefpodoxime (30 µg). The isolates were considered to be resistant, if the inhibition zone diameter of ceftazidime, cefotaxime and cefpodoxime were < 22mm, <27mm and <17mm respectively.
The strains which showed resistance to at least one of the three cephalosporins was further included for phenotypic confirmation method.9, 10
Double disc synergy test (DDST)
The Escherichia coli showing decreased susceptibility to any of the three cephalosporins used were further tested for ESBL production by DDST method. Ceftazidime, cefotaxime, cefpodoxime and amoxy-clav (Hi-Media Laboratories Ltd., Mumbai, India) were used in this method.11, 12 Over the lawn cultured Muller-Hinton agar plates, amoxy-clav and third generation cephalosporin discs were placed at a distance of 20mm from the center. The Plates were incubated at 37ºC for 8 hours. The augmentation in the zone of inhibition of cephalosporins towards the amoxy-clav disc was considered to be positive for ESBL. The standard strains of Klebsiella pneumoniae ATCC 700603 and E. coli ATCC 25922 were used as controls.
Inhibitor potentiated disc diffusion test (IPDD)
The turbidity of E.coli in a broth was matched with 0.5 McFarland turbidity standards and inoculated onto two Muller-Hinton agar plates by streak method. Of the two plates, one was supplemented with 0.004 mg/L Potassium clavulanate (Sigma Aldrich Pvt Ltd, Bengaluru) and another without clavulanate. The ceftazidime, cefotaxime and cefpodoxime disks were placed on both of these plates. The inoculated agar plates were then incubated at 37ºC for 8 hours. The inhibition zones of disks were compared between the plates with and without potassium clavulanate. The difference in the zone size of ≥ 10 mm diameter was taken as positive for the production of ESBL.13, 14
ESBL Epsilometer-strip test (E-strip test)
The commercially available ESBL E-strip (make: AB Biomerieux) contains two gradients of antibiotic drugs. At one end, the strip is impregnated with ceftazidime (0.5 to 32 mg/ml) and on the other end is with ceftazidime (0.125 to 8 mg/ml) with clavulanate (4 mg/ml). The overnight growth of E.coli isolate was suspended in saline to match the turbidity with 0.5 McFarland standards and was then inoculated on Muller Hinton agar plate by lawn culture technique. After drying, the E -test strip was placed on the plate and incubated overnight at 37ºC. The MICs on both ends of the E- strip were interpreted as the point of intersection of the inhibition eclipse with the E-test strip edge. The ratio of ceftazidime/ ceftazidime with clavulanate MIC ≥ 8 indicates the presence of ESBL enzymes.7, 15
Result
In our study, 120 symptomatic urinary tract infection cases were diagnosed as significant bacteriuria due to Escherichia coli by calibrated loop culture technique. The isolated E. coli strains were further used for antibiotic susceptibility testing and ESBL detection.
The antibiogram results shown that 110 (91.6%) E.coli isolates were resistant to ampicillin followed by 42 (35.0%) isolates to co-trimoxazole and 41 (34.1%) isolates to gatifloxacin. However, resistance to tobramycin, amoxy-clav and amikacin were recorded as 31.6%, 19.1% and 15.0% respectively. Only one (0.8%) strain has shown resistance to imipenem as depicted in the Table 1.
Table 1
Association between drug resistance pattern and ESBL producing E.coli strains
In the DDST and IPDD screening test for ESBL production, 62 (51.6%) isolates were resistant to at least one of the three representative cephalosporin drugs. The highest resistance was observed with cefpodoxime (n=55; 45.8%) followed by ceftazidime (n=48; 40%) and cefotaxime (n=45; 37.5%). Out of the three cephalosporins tested in the study, ceftazidime was found to be the better antibiotic drug for the identification of ESBL production by both DDST and IPDD (Table 2).
Table 2
Comparisonof different diffusion methods for the detection of extended spectrum of beta lactamases
In the present study, the efficacy of DDST and IPDD disc diffusion tests were compared with ESBL E-strip test. By DDST method, 9 (14.5%) strains were positive for ESBL, one strain was false positive and 18 (29.0%) strains showed false negative result. The IPDD test showed 28 (45.1%) as mentioned in Table 3.
Table 3
Detection of ESBL producing E.coli strains by E-strip test and their respective log2 reduction
The ESBL positives with augmentation zone of inhibition diameter is ≥ 10mm.The mean zone augmentation (95% CI) was 16.2 (12.8, 21.4) mm for ceftazidime, 13.9 (12.2, 18.0) mm for cefotaxime and 18.6 (12.2, 18.6) mm for cefpodoxime as mentioned in Table 4.
Table 4
Confirmation of screening test positive ESBL producers by inhibitory potentiated
disc diffusion (IPDD) test
The ESBL E-strip test results showed, 28 (45.1%) E.coli isolates were identified as ESBL producers with Ceftazidime/ceftazidime-clavulanate (TZ/TZL) ratio between 8 and 256. Of 28 ESBL positives, 26 isolates showed TZ/TZL ratio of between 32 and 256 with MIC log2 dilution reduction ≥ 5. The remaining 34 (54.8%) E.coli isolates were negative for ESBL production with the ratio less than 8 and log2 reduction less than 3 (Table 4).
In 28 ESBL positives E.coli, 27 (96.4%) isolates have shown resistance to cefpodoxime followed by 25 (89.2%) strains to cefotaxime and 23 (82.1%) strains to ceftazidime. Out of 92 Non-ESBL isolates, 28 (30.4%) were resistant to cefpodoxime followed by 25 (27.1%) strains toceftazidime and 20 (21.7%) strains to cefotaxime. The ESBL positive strains exhibited statistically significant (p<0.05) resistance to tobramycin followed by amoxyclav and amikacin compared to non-ESBL isolates. The resistance to multi drugs was noticeable in ESBL producing (96.7%) isolates compared to non- ESBL producing (52.1%) isolates, which was statistically significant (p<0.05).
Discussion
In the our study, 62 (51.6%) Escherichia coli strains from UTI cases showed resistant to one of the three representative cephalosporin drugs. Out of these 62 E.coli isolates, 28 (45.1%) were found ESBL producers by IPDD test and E-strip test. However, only 9 (14.5%) strains were positive by DDST method. A study from Hyderabad (TS) reported that, 19.8% Enterobacteriaceae were potential ESBL producers by double disc synergy test with 63.7% of Escherichia coli and 14% of Klebsiella pneumoniae shown ESBL production.16 In another study from Western part India,48.3% ESBL producing urinary isolates were resistant to cefotaxime drug.17
In comparison to DDST, IPDD test appeared to be better methods for confirming ESBLs shown a sensitivity of 100% and specificity of 95.8%. The DDST method was unsuccessful to detect 30.6% ESBL producing isolates with a low sensitivity of 42.2% and positive predictive value of 91.6%. The sensitivity of the DDST test strongly relies on the accurate location of discs on the culture plate.13 The earlier studies have shown that the ESBL E-strip test was comparatively more sensitive, dependable and appropriate method,15 based on which it was used as the gold standard test for confirming ESBL phenotypically in the present study.
The three representative cephalosporin drugs used in IPDD test showed increased zone of inhibition (≥10mm) to ESBL producers. The cefpodoxime showed superior mean zone augmentation (18.6 mm) compared to mean zone augmentation of ceftazidime (16.2 mm) and cefotaxime (13.9 mm). In our study, the IPDD test was more sensitive with ceftazidime than cefotaxime, which is comparable with the previous work by Ho et al.13 The benefit of IPDD test is that the ESBLs could be easily separated from non-ESBL producing organisms by a break point of ≥ 10 mm zone augmentation and more than one cephalosporin drug can be tested on single test plate.
The Ceftazidime is identified as an exceptional substrate for most ESBL enzymes18, 19 and Bush group 2be enzymes can be differentiated from other beta lactamase enzymes by the decrease in ceftazidime MIC in presence of beta lactamase inhibitors like clavulanate.20 Another study suggested that the automated technique like Vitek and Epsilometer–strip tests are sensitive and reliable compared to the disc diffusion tests.21
The disadvantage of these diffusion methods is that, they may not detect inhibitor-resistant beta lactamases. The ESBL confirmatory test is based on the demonstration of inhibition by clavulanate. But, other mechanisms of beta lactam resistance, like AmpC enzymes, change in the porin channel and variants ESBL enzymes may be present or co-exist with ESBL, which interfere in the results of these diffusion tests.
Due to the presence of a large amount of false positives in the screening procedures, the two steps strategy (screening and confirmatory tests) may be adapted. Even the sensitivity of DDST depends on the accurate placement of the discs on the agar plate and interpretation of DDST results is more subjective compared to recording the results of E-strip test and IPDD test. Therefore, IPDD test may be preferred over E-strip test, as it is equally sensitive, cost effective and more than one cephalosporin drug can be used per test.
The drug resistance of ESBL producing E.coli were significantly higher (p <0.05) than the non-ESBL producing isolates. The ESBL producing isolates showed greater resistance to co-trimoxazole (53.5%) and amikacin (32.1%), which is comparable with the study done by Spanu et al., Baby Padmini et al. and Menon et al.22, 23, 24 The cephalosporin resistant organisms have shown resistance to other antibiotics classes like fluoroquinolones and aminoglycosides which are in concordance with the other study reports.10, 25 It was also noticed that, most of the ESBL producing E.coli (96.7%) were resistant to two or more drugs compared to Non-ESBL producing isolates (52.1%). This finding was in complete agreement with a study conducted by Tankhiwale et al., as they also reported the significantly higher multidrug resistancein ESBL producing isolates than in non ESBL producers.17
In our area, the records pertaining to the incidence of ESBL producing isolates is very limited. In addition, confirmatory molecular methods need to be carried out in the identification of ESBL producing isolates to validate the results of different phenotypic diffusion methods. Probably too much reliance and extensive use of third generation cephalosporin drugs in the treatment of enteric gram negative organisms has been the principal factor responsible for increased drug resistance to cephalosporins and other class of antibiotics. The precise identification of ESBL producing isolates, judicious use of broad spectrum antibiotics, periodic surveillance of antibiotic resistance pattern and efforts to decrease empirical antibiotic therapy would go a long way in addressing some of the issues related with ESBL production in clinical isolates.
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