Detection of Gram Negative Bacilli Producing Extended Spectrum Beta Lactamase on Intensive Care Unit at Tertiary Care Hospital

Antimicrobial resistance is a budding threat worldwide. The every class of antibiotic agents must have resistance mechanisms.The principal mechanism for resistance to the β-lactam antibiotics in gram-negative bacteria is the production of β-lactamase. The creation of extended-spectrum βlactamases (ESBLs) is a vital mechanism which is responsible for the resistance to the cephalosporins. During the last 2 decades, ESBL producing gram-negative bacilli have arose as a major problem in many settings. Resistance to 3 rd generation cephalosporins by attainment and manifestation of extended spectrum beta lactamase (ESBL) enzymes among gram-negative bacilli is on a rise. To isolate the ESBL strains from various clinical samples in ICU. To find out the prevalence of ESBL producing gram negative bacilli during the period of December 2017 December 2018 in the Intensive care unit of Sree Balaji Medical College and Hospital. Totally 27 out of 139 gram negative bacilli (19.42%) were found to be ESBL producers. ESBL triggering gram negative bacilli spiteful the biological sample like blood, urine, wound swab, sputum were 36.36%, 16.00%, 10.00%, 9.09% individually Though Meropenem is 100% sensitive to all ESBL beginning gram negative bacilli, but still sensitivity also witnessed with some cheaper drugs like Cotrimoxazole (33.33%), Amikacin (48.14%), Gentamicin (40.7%), Ciprofloxacin (22.22%). Hence we care and will provide an analysis and treatment for affected patients with Extended Spectrum Beta Lactamase producing organisms. Original Research Article Nishanthy and Saikumar; JPRI, 33(23B): 15-21, 2021; Article no.JPRI.67500 16


INTRODUCTION
WHO predictable the burden of incidence of multiple joint pathologies which present with pain and swelling infection globally around 7 -12%, the statistics from India are distressing, it is very difficult to come to a diagnosis with a frequency of occurrence varying between 11% to 83% for diverse kinds of infections that are acquired in the hospital [1]. Determined the most of diseases can be well-known in the initial stages by adding a few more invasive tests such as synovial fluid analysis and synovial tissue biopsy There is an escalating trend of bacterial infections for serious morbidities that are associated with impaired immunity, increased usage of intrusive diagnostic procedures, delay in sterilization and disinfection, and random usage of antibiotics. ICU from Beta lactam antibiotics are commonly used antibiotic, because of wide spectrum activity and squat toxicity [2].
In 1928, Alexander Fleming exposed the first beta lactam antibiotic Penicillin, which remained antibiotic of choice for many years. But later bacteria learnt new inventive mechanisms by which they can resist the antibiotics acting on them. Production of enzymes called beta lactamases. In young adolescent and adult monoarticular immersion of hip or knee with or without constitutional symptoms often poses analytical problem between tubercular, rheumatoid and non-specific pathology.. But in due course of time these beta lactam antibiotics developed resistance by mutation of enzymes continuously due to pressure that is imposed selectively by the antibiotic usage [3].
To overcome this, novel class of antibiotics belonging to beta-lactam group, third generation cephalosporin was developed which have greater activity against the gram negative bacilli causing infections. Due to inadvertent use of third generation cephalosporins like cefotaxime, ceftazidime, ceftriaxone bacteria soon developed resistance by new beta lactamase. These new beta lactamases are called as (ESBL) extended spectrum beta lactamases because of their extended range of activity against third generation cephalosporins and monobactams. ESBL are enzymes secreted by bacteria and they are efficient in hydrolyzing all beta lactam drugs including third generation cephalosporins and monobactams except cephamycins and carbapenems. This resistance is encoded by transferable conjugative plasmid [4]. Extended spectrum beta lactamases were first identified in 1983 [5]. The first among these is SHV-2 which are efficient in hydrolyzing newer beta lactams, was found in single strain of Klebsiella ozonae isolated in Germany. TEM-1 was the first betalactamase mediated through plasmid in gram negative bacilli that has been elucidated in early 1960s [3].
ESBL producing organisms there is higher chance of infection or colonization due to prolonged antibiotic exposure, increased duration of ICU stay, severe illness, and instrumentation or catheterization [6]. There are diverse varieties of ESBL which vary with geographical locations. ESBL are byproducts of TEM and SHV type enzymes. ESBL are derivatives of Temoniera or Sulfhydryl variety type of enzymes. There are major two type such as >90 TEM type and 25 SHV type enzymes, along with OXA type enzymes and inhibitor tough beta lactamases [3]. ESBL producing organisms has played a major role for causing several outbreaks which has been observed worldwide since 15 yrs [7]. Hence this study was done to find out the prevalence of ESBL producing gram negative bacilli during the period of December 2017 -December 2018 in the Intensive care unit of Sree Balaji Medical College and Hospital.

MATERIALS AND METHODS
The present study was carried out through among patients who were admitted in Intensive Care Unit from December 2017 to December 2018 at Sree Balaji Medical College and Hospital, Chennai. A total of 377 patients from both sexes male and female in age group between 20 to 60 years admitted in Intensive Care Units were incorporated in the study. Separates gained from various clinical samples like pus, blood, tracheobronchial aspirates, urine, sputum, and endotracheal drainage tube tips taken from Intensive medical and intensive surgical care units were incorporated in the study.

Inclusion Criteria
Presence of sustained infections not responding to treatment with routine drugs used in ICU like Ciprofloxacin, Gentamycin, Amikacin and Cefotaxime, Ceftriaxone.
Urine -In non-catheterized patients, Clean-catch midstream urine was collected. In case of catheterized patients, freshly voided urine can be collected by clamping the tube off above the port. The catheter port /Wall of the tubing were cleaned with 70% ethylalcohol, and urine was aspirated via syringe and needle; entry of microorganisms into the bladder was prevented by maintaining the integrity of the closed drainage system. Routine blood inquiries to rule out common joint pathologies were done such as levels of erythrocyte sedimentation rates, serum uric acid levels, total counts and differential counts, rheumatoid factor were done for all the patients. 5 ml of blood was Collected in 50 ml of Brain Heart Infusion broth to give a dilution of one in ten and incubated at 37deg C. Wound Swab -Wound area was wiped with sterile saline or 70% alcohol. Swab was rolled along leading edge of the wound. Endotracheal Aspirate -was collected under strict aseptic precautions in a sterile container. Drainage Tube Tips -were collected in a sterile container.

RESULTS
The present study included patients of both sexes and ages between 20 -80 yrs. Various Samples were obtained from 377 hospitalized patients admitted in Intensive care unit to find the prevalence of Extended Spectrum Beta Lactamase producing gram negative bacilli during the period from December 2017 to December 2018. Samples included Blood, Sputum, catheter tip and endotracheal drainage tube tip and wound swabs.
Out of 377 samples collected, 227 samples showed growth .139 were gram negative isolates, 56 were found to be gram positive isolates. Gram negative separates were known as Klebsiella, Klebsiella oxytoca, Escherichia coli, pneumonia, Proteus vulgaris, Proteus mirabilis, Pseudomonas aeruguinosa, Acinetobacter baumanii by biochemical reactions like IMVIC.   4%. This present study showed that there were16.00% (8/50) ESBL producing organisms in blood which almost correlates with study done by Bithika et al. 73 which is around 11.32% (6/53). Increased percentage of ESBL producing organisms in present study may be due to the increased duration of patient stay in intensive care unit in our study [16]. Although Meropenem is 100% sensitive to all ESBL producing gram negative bacilli, but still sensitivity also observed with some cheaper drugs like Cotrimoxazole (33.33%), Amikacin (48.14%), Gentamicin (40.7%), Ciprofloxacin (22.22%). Hence by vigilant screening we can reduce the cost of treatment for patients infected with Extended Spectrum Beta Lactamase producing organisms.

CONCLUSION
The alarming frequency of beta-lactamase producing infections among patients in the ICU is obtained. These beta-lactamase producing isolates are extremely MDR and revealed a high burden of resistance to antibiotic drugs and antimetabolite classes of antibiotics. Thus, screening for these and taking appropriate measures for control of their spread are of major importance.

CONSENT
As per international standard or university standard, patients' written consent has been collected and preserved by the author(s).

ETHICAL APPROVAL
As per international standard or university standard written ethical approval has been collected and preserved by the author(s).

ACKNOWLEDGMENTS
The encouragement and support from Bharath University, Chennai is gratefully acknowledged. For provided the laboratory facilities to carry out the research work.