Prevalence and Antibiogram of Multidrug Resistant Klebsiella Species

Aim: To find out the prevalence and susceptibility of MDR klebsiella isolates in Karachi. Study Design: Pre-clinical in-vitro study. Place and Duration of Study: Study was conducted at the microbiology lab of the tertiary care hospital of Karachi, Pakistan during May to October 2021. Methodology: About 550 samples of blood, urine and wound swab were inoculated on blood agar and MacConkey agar and incubated at 37° Celsius for 24 hours. The antibiotic susceptibility was identified by Kirby Bauer’s disc diffusion method. Antibiotic disc of amoxicillin-clavulanate 20 μg, Fosfomycin 200 μg, Ciprofloxacin 5 μg, Moxifloxacin μg, Gentamicin 10 μg and Ceftolozane/tazobactam (30/10 μg) were placed on agar plate and then incubated at 35°C for 1624 hours. Data was analyzed by using Statistical Package for Social Sciences (SPSS) version 20. Results: Out of total 550 strains of Klebsiella 35% were multidrug resistant while 64% were not. Sensitivity and resistance pattern of multiple antibiotics against Klebsiella showed that majority of antibiotics were resistant to Klebsiella. The highest resistance was noted with amoxicillin that was 90%, followed by amoxiclave, nitrofurantoin, doxycycline, ceftazidime and ciprofloxacin with Original Research Article Sultana et al.; JPRI, 33(64B): 187-191, 2021; Article no.JPRI.78831 188 frequency of 86%, 75%, 64% 56% and 54% respectively. On the other hand, combination of Ceftolozane and tazobactam were highly sensitive against klebsiella followed by fosfomycin, Imipenem and combination of piperacillin and tazobactam with frequency of 95%, 89%, 88% and 68% respectively. Conclusion: It can be concluded that klebsiella species have developed high resistance against a number of antibiotics resulting in high morbidity and mortality. Currently combination of Ceftolozane and tazobactam is highly sensitive so it should be preserved as a future lifesaving drug. Beside this, fosfomycin, Imipenem and combination of piperacillin and tazobactam also reported high sensitivity.

frequency of 86%, 75%, 64% 56% and 54% respectively. On the other hand, combination of Ceftolozane and tazobactam were highly sensitive against klebsiella followed by fosfomycin, Imipenem and combination of piperacillin and tazobactam with frequency of 95%, 89%, 88% and 68% respectively. Conclusion: It can be concluded that klebsiella species have developed high resistance against a number of antibiotics resulting in high morbidity and mortality. Currently combination of Ceftolozane and tazobactam is highly sensitive so it should be preserved as a future lifesaving drug. Beside this, fosfomycin, Imipenem and combination of piperacillin and tazobactam also reported high sensitivity.

INTRODUCTION
Bacterial infection caused by any type of bacteria is primarily treated with antibiotics [1]. In medical science, the identification and formation of new antibiotics are the need of current era as these are the lifesaving drugs which fight against multiple infections [2]. On the other hand, resistance against these antibiotics is also increasing day by day, which is developing a global threat. There are multiple reasons behind this rise in resistance these include excessive misuse, frequent intake in infections, delayed use and use in those infections where already antibiotics fails to respond [3]. Current era is the challenging one for the medical physician to cure the infections because of development of antibiotic resistance.
Multi-drug resistance (MDR) is labelled when there is resistance to at least three classes of antimicrobials simultaneously. There are few underlying mechanisms including antimicrobial enzymatic reactions, mutated bacterial protein which bind with penicillin, disrupted efflux pump, or mutated genes [4]. MDR organisms are increasing rapidly in developing countries which is a troublesome condition, producing difficulty in treating infection and creating risk of patient's life [5].
The most common cause of hospital and community acquired infection is Klebsiella pneumonia, which is an encapsulated, facultative anaerobic bacterium. Most commonly it is involved in urinary tract infections, intraabdominal infections, wound infection, pneumonia, septicemia and many other pyogenic infections [6]. Klebsiella specie is resistant to majority of antibiotics like ampicillin, quinolones and aminoglycosides. The mechanism of resistance by klebsiella is mediated by plasmids, transposons and gene mutation [7,8]. Carbapenems are used for treating MDR klebsiella but recently resistance against carbapenems are also reported leading to increase in morbidity and mortality rates [9]. So the aim of current study is to find out the prevalence and susceptibility of MDR klebsiella isolates in Karachi.

MATERIAL AND METHODS
A pre-clinical in-vitro study was conducted at the microbiology lab of the tertiary care hospital of Karachi during May to October 2021. About 550 samples of blood, urine and wound swab was collected and culture and sensitivity was performed as per guidelines.
The samples were inoculated on blood agar and MacConkey agar and incubated at 37° Celsius for 24 hours. On the basis of their dome-shaped colonies on blood agar and lactose fermenting mucoid colonies on MacConkey agar, the Klebsiella species were identified. The antibiotic susceptibility was identified by Kirby Bauer's disc diffusion method. A bacterial inoculum lawn was created on a 150 mm Mueller Hinton Agar plate. Antibiotic disc of Amoxicillin-clavulanate 20 µg, Fosfomycin 200 µg, Ciprofloxacin 5 μg, Moxifloxacin µg, Gentamicin 10 μg and Ceftolozane/tazobactam (30/10 μg) were placed on agar plate and then incubated at 35°C for 16-24 hours. According to CLSI recommendations (2018), the zones of growth inhibition around each antibiotic disc were quantified and designated as either sensitive or resistant.
Data was analyzed by using Statistical Package for Social Sciences (SPSS) version 20. Categorical variables were presented as frequencies and percentages.

RESULTS
About 550 strains of Klebsiella were isolated out of which 35% (195) were MDR Klebsiella while 64% (355) were non-MDR. Gender wise distribution revealed that majority of strains were of female and mostly were having MDR Klebsiella as mentioned in Table 1.
Blood, mucous and urine sample was used to isolate the Klebsiella species, majority were found in urine sample, out of which 80% were MDR. All the samples of blood, mucous and urine were predominantly having MDR strains with frequency of 65%, 56% and 80% respectively as reported in Table 2.
Sensitivity and resistance pattern of multiple antibiotics against Klebsiella have been shown in Fig. 1, among them majority of antibiotics were resistant to Klebsiella. The highest resistance against Klebsiella, was noted with amoxicillin that was 90%, followed by amoxiclave, nitrofurantoin, doxycycline, ceftazidime and ciprofloxacin with frequency of 86%, 75%, 64% 56% and 54% respectively. On the other hand, combination of Ceftolozane and tazobactam (C/T) were highly sensitive against klebsiella followed by fosfomycin, Imipenem and combination of piperacillin and tazobactam with frequency of 95%, 89%, 88% and 68% respectively.  Current study reported Imipenem as a highly sensitive drugs, with 89% sensitivity against klebsiella species as majority of specimen responded well but in some regions of the world the resistance for carbapenem and Imipenem have been developed with rate of 81% and 89% respectively [13,18,19]. The combination of Ceftolozane and tazobactam showed highest sensitivity against klebsiella specie in the current study with a rate of 95%. Randomized controlled trials revealed that this combination is 2 times more potent than any other antibiotic and having high clinical cure rates that is 97.4% [20].

CONCLUSION
It can be concluded that klebsiella species have developed high resistance against a number of antibiotics resulting in high morbidity and mortality. Currently combination of Ceftolozane and tazobactam is highly sensitive so it should be preserved as a future lifesaving drug. Beside this, fosfomycin, Imipenem and combination of piperacillin and tazobactam also reported high sensitivity.

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

ETHICAL APPROVAL
Study got approval from the ethical review committee of concerned hospital.