Transcript DEPARTMENT OF MICROBIOLOGY KARPAGAM FACULTY OF MEDICAL

Clinico-Pathological Conference
(CPC) Meet
Karpagam Medical College Hospital
27-02-2015
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.
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Clinical Profile
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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
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Patient data could not be retrieved
as she was an Out patient (OP)
XXX – Not known
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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
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Culture & Sensitivity
• Wet mount performed by Microscopy
• Sample inoculated on: BAP, MAC for Culture
and Incubated overnight @ 37C.
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Urine Wet Mount
• Pus cells: 20-40/HPF
• Bacteria: Present
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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
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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.
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DAY 2
Bio-chemical reaction
Indole
Citrate
Urease
MMM
TSI
MR
VP
Negative
Positive
Positive
+/-
A+/A-
Negative
Positive
Isolate: Klebsiella pneumoniae
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Antibiotic Susceptibility Test
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Identification discs
Antibiotic discs
Dose in µg
Zone diameter
AST report
Ceftazidime (Ca)
30
30 mm
RESISTANT
30/10
40 mm
RESISTANT
30
30 mm
RESISTANT
30/10
40 mm
RESISTANT
30
21 mm
RESISTANT
Ceftazidime Clavulanate (Cac)
Cefotaxime (Ce)
Cefotaxime Clavulanate (Cec)
Cefoxitin (Cn)
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I & II line discs
Antibiotic discs
Dose in µg
Zone diameter
AST report
Ampicillin
10
6 mm
RESISTANT
Amoxy-Clavanate
30
6 mm
RESISTANT
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
Piperacillin Tazobactum
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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
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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.
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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
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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.
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ESBL Detection
1. Screening test
2. Confirmation test
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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.
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ESBL Screening
Ca
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Cac
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ESBL Screening
Ca – 30mm
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Cac – 40 mm
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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.
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ESBL Detection
Ce
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Cec
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ESBL Detection
Ce – 30mm
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Cec – 40 mm
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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.
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CEPHALOSPORINS
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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
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Resistant
(mm)
Intermediate
(mm)
Sensitive
(mm)
Imipenem
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19-20
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Meropenem
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20-22
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Carbapenemase detection
I
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Mr
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Carbapenemase detection
I – 15mm
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Mr – 14mm
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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.
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MODIFIED HODGE TEST
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Treatment of Carbapenemase
Limited options left!!!
INJECTABLES (Intravenous)
• Inj. Tigecycline
• Inj. Colistin
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Final identification
• Klebsiella pneumoniae ESBL + Carbapenemase
producer 105 CFU/mL sensitive to Tigecycline
and Colistin only in urine.
Klebsiella pneumoniae Carbapenemase (KPC)
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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%
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- Community acquired – 20%
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ESBLs and Carbapenemases
• Carbapenemases:
Carbapenemase producing bacteria are resistant to
Carbapenems like Meropenem, Imipenem,
Doripenem and or Ertapenem.
Ex: Klebsiella pneumoniae Carbapenemase (KPC)
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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
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Preventive measures
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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
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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.
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