الفهرس 
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Abstract
Antibiotics are life saving agents with limited resources. They are used for treating serious infections to prevent morbidity and mortality. Today, the irrational use of antibiotics has led to development of multidrug resistant organisms which are commonly associated with human infections.
Bacteria are developing newer mechanisms for inactivating the antimicrobials with production of various enzymes capable of inactivating almost all groups of antimicrobials. This is more apparent in β-lactam antimicrobial groups, making bacteria resistant to penicillin, all generations of cephalosporins, monobactams and β-lactam- β-lactamase inhibitor combinations. Mechanisms for this resistance are productions of β lactamases, extended spectrum β-lactamase, AmpC and other enzymes.
Carbapenem antimicrobials include imipenem, meropenem, ertapenem and doripenem, which are helpful treatment of multidrug resistant bacterial infections. But since last few years, these antimicrobials have also been overcome by production of carbapenemase enzymes.
E.coli and Klebsiella pneumoniae are the leading species producing these enzymes. These carbapenemase enzymes belong to Class A, B and Class D of Ambler classification system. Besides carbapenemase enzyme production, over expression of efflux pump and outer membrane porin loss are the other mechanism of development of carbapenem resistance.
Molecular methods are the gold standard for detection of carbapenemase production. But because of its cost, expertise requirement, and time consumption, phenotypic tests have been developed. MHT is one of various phenotypic tests used to detect CRE.
These tests are growth dependent, turn around time is 18-24 hours, and interpretations are also subjective. The MHT is useful for detection of carbapenemases but has disadvantage due to its variable sensitivity and specificity.
Possible causes of the high prevalence of CREs in many hospitals in Egypt may be attributed to the limited implementation of stewardship programs and IPC measures. IPC activities are a vital component of preventing healthcare-related CRE transmission and include practices as hand hygiene, limiting device use, environmental cleaning, and isolation through contact precautions and promoting patients or staff cohort.
In order to investigate the prevalence of carbapenem resistant Klebsiella pneumoniae, estimate the antibiotic resistance patterns and molecular study of resistant isolates, this study was conducted in Beni- Sueif University Hospital during the period of December 2016 through January 2018. During this period, 100 samples (55 urine and 45 sputum) were collected.
The study was conducted on 100 patients, 31 (31%) were identified as Klebsiella by conventional methods, while 69 (69%) were other organisms.The collected samples were 54 (54%) urine and 45 (45%) sputum samples.
Clinical isolates from male patients were 55(55%) 20 of them were identified as Klebsiella pneumoniae while female patients were 45(45%) and 11 samples were identified as Klebsiella pneumoniae.
Klebsiella pneumoniae was isolated from 16 (51.6%) urine and 15 (48.4%) sputum samples.
In this study, 19 (61.8%) were resistant to ertapenem with (MICs ≥2 μg/ml) while 12 isolates (38.2%) were sensitive (MIC>0.5μg/ml).
All isolates resistant to ertapenem were subjected to Modified Hodge Test. 17 isolates were found to be positive for carbapenemase production by Hodge test while 2 isolates were negative.
PCR was performed to assess presence of KPC gene in isolates. 13 (68.4%) were found to be KPC positive by PCR, while 6 (31.5%) were negative.
The relation of PCR to Hodge test, 13 isolates were positive for both PCR and Hodge test, 4 isolates were positive Hodge but negative PCR. Considering PCR as a gold standard, the sensitivity of MHT was 100% and specificity was 33%. Whereas, two isolates were negative for both Hodge and PCR.
Seven isolates were selected for sequencing for the gene KPC. The result obtained was analyzed through NCBI purposing for identifying similarities between strains. Sequencing confirmed the presence of the carbapenemase gene blaKPC-2 in all 7 isolates.