Emerging carbapenemase Klebsiella oxytoca with multidrug resistance implicated in urinary tract infection

Falah Hasan Obayes AL-Khikani; Raheem Malalah Abadi; Aalae Salman Ayit

doi:10.4103/bbrj.bbrj_165_19

ORIGINAL ARTICLE

Year : 2020 | Volume : 4 | Issue : 2 | Page : 148-151

Emerging carbapenemase Klebsiella oxytoca with multidrug resistance implicated in urinary tract infection

Falah Hasan Obayes AL-Khikani¹, Raheem Malalah Abadi², Aalae Salman Ayit¹
¹ Department of Microbiology, Al Shomali General Hospital, Babil, Iraq
² Department of Manager, Al Shomali General Hospital, Babil, Iraq

Date of Submission	24-Dec-2019
Date of Acceptance	25-Feb-2020
Date of Web Publication	17-Jun-2020

Correspondence Address:
Dr. Falah Hasan Obayes AL-Khikani
Department of Microbiology, Al Shomali General Hospital, Babil
Iraq

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bbrj.bbrj_165_19

Abstract

Background: At present, Klebsiella oxytoca is emerging as a crucial persisted bacterial pathogen in urinary tract infection (UTI), which causes true public health problems worldwide. This study aimed to detect the incidence of K. oxytoca in patients severe from UTI with antibiotic sensitivity tests that assist urologist doctors for appropriate empirical antimicrobial therapy for this bacterium. Methods: K. oxytoca isolated clinically from urine samples during the period from January 2018 to December 2019 at the Al-Shomally General Hospital, Babil, Iraq, and a private laboratory in Babil city. A total of 430 patients were involved in this study; urine samples were processed at the hospital laboratory during this period; and a diagnosis has been done by the routine bacteriological diagnosis as well as VITEK^® 2 system. Results: Of these 430 urine samples, 122 had bacterial growth; two types of Klebsiella species have been isolated in 18 patients (14.75%) of total specimens; K. pneumonia detected in 16 patients (89%); and K. oxytoca in 2 patients (11%) of the total Klebsiella species. Escherichia coli was the most prevalent bacteria (56; 45.90%). K. oxytoca UTI isolates were sensitive to amikacin, trimethoprim, and ciprofloxacin. However, these isolates showed resistance to amoxicillin, cefotazidime, clindamycin, nitrofurantoin, and cefotaxime. Conclusion: The current study showed an increasing burden of UTI caused by K. oxytoca. Multidrug resistance is associated with K. oxytoca implicated in UTI that causes changeable sensitivity to various antimicrobial agents.

Keywords: Carbapenemase, Klebsiella oxytoca, Klebsiella species, multidrug resistance, urinary tract infection

How to cite this article:
AL-Khikani FH, Abadi RM, Ayit AS. Emerging carbapenemase Klebsiella oxytoca with multidrug resistance implicated in urinary tract infection. Biomed Biotechnol Res J 2020;4:148-51

How to cite this URL:
AL-Khikani FH, Abadi RM, Ayit AS. Emerging carbapenemase Klebsiella oxytoca with multidrug resistance implicated in urinary tract infection. Biomed Biotechnol Res J [serial online] 2020 [cited 2023 Feb 5];4:148-51. Available from: https://www.bmbtrj.org/text.asp?2020/4/2/148/286844

Introduction

Urinary tract infections (UTIs) are considered the most common bacterial infection globally; every year, more than 150 million people suffering from acute or chronic UTI caused by various bacteria.^[1]

Klebsiella oxytoca can cause community-acquired and hospital-acquired infection resembling those caused by Klebsiella pneumonia with less common frequently,^[2] but in recent years, some types of causative agents bacterial UTI became more prevalent clearly with high antibiotic resistance that never seen before, K. oxytoca one of these emerging bacteria.

K. oxytoca is Gram-negative bacilli, nonmotile bacteria, and commensal in the intestinal tract in about 2%–10% of the population.^[3] The main clinically habitats regions in the human body for K. oxytoca are the gastrointestinal and respiratory tract.^[4]K. oxytoca as other enterobacteria can acquire antimicrobial agents resistance by producing lactamases and carbapenemase.^[5]K. oxytoca antibiotic resistance outbreaks have been observed in many hospitals and other places throughout the world and also environment reservoirs play an essential role in infection.^[6] Few studies in Iraq observed K. oxytoca as a causative agent of UTI and emerging of carbapenemase-producing bacteria, and hence, the prevalence of this bacteria with antibiotic sensitivity tests presented in this study highlights the multidrug resistance (MDR) K. oxytoca associated with Iraqi patients severe from UTI.

Materials and Methods

The study protocol has been approved according to the Ethical Committee in the Babil Health Directorate on January 2, 2018. Besides, verbal approval was obtained from the patients before obtaining the sample. Health safety was obtained during the sampling. Furthermore, this work was done according to the Ethics Committee of the Iraqi Ministry of Health and was performed and agreed with all national regulations.

A total number of 430 patients with UTI were evolved in this study from January 2018 to December 2019. These patients have attended the Al-Shomally General Hospital, Babil, Iraq, and a private laboratory in Babil city. Every patient was suffering from the clear symptoms of UTI as a complaint of frequent urge to urinate and painful and also a questionnaire survey has been taken from the patients.

All nonrepetitive midstream urine samples were included in the study. A urine sample for direct examination and basic bacterial-cultured methods have been done. Urine samples were directly inoculated on Blood agar and MacConkey Agar. The bacterial diagnosis of suspected Klebsiella spp was identified by VITEK 2 (Biomerieux). Further identification was done as per the routine laboratory protocols. Mix growth of K. oxytoca and other bacteria were excluded from this study.

Antimicrobial susceptibility investigation was done as to Kirby–Bauer's disc-diffusion method^[7] included ceftriaxone (30 mg), ceftazidime (30 mg), cefotaxime (30 mg), gentamicin (10 mg), amikacin (30 mg) ciprofloxacin (5 mg), imipenem (10 mg), meropenem (10 mg), and clindamycin. Bacteria considered MDR when they resist more than two classes of antibiotics.

Results

K. oxytoca isolated from the urine samples during the period from January 2018 to December 2019 at the Al-Shomally General Hospital, Babil, Iraq. Out of these 430 urine samples, 122 had bacterial growth. The two types of Klebsiella species have been isolated in 18 patients (14.75%) of total specimens; the first was K. pneumonia in 16 patients (89%) and K. oxytoca in 2 patients (11%) of the total Klebsiella species. Escherichia ^{More Details} coli were the most prevalent bacteria in this study (56; 45.90%) [Figure 1] and [Figure 2].

Figure 1: Distribution of bacterial urinary tract infection

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Figure 2: Distribution of Klebsiella oxytoca

to Klebsiella pneumonia

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Biochemical tests of K. oxytoca revealed a positive indole test, whereas K. pneumonia showed a negative indole test; both species have positive results to catalase, urease, and capsule tests [Table 1].

Table 1: Biochemical tests of Klebsiella pneumoniae and Klebsiella oxytoca

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Antibiotic sensitivity pattern was studied, and it was found that all the K. oxytoca isolates were sensitive to trimethoprim, ciprofloxacin, and amikacin. However, these isolates showed resistance to amoxillin, cefotazidime, clindamycin, nitrofurantoin, and cefotaxime. Multidrug-resistant K. oxytoca has been detected in the current study [Table 2].

Table 2: Antibiotic pattern of Klebsiella oxytoca clinically isolated from urinary tract infection

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Discussion

Klebsiella species are becoming a crucial pathogen of all populations and are being implicated in increasing morbidity among the patients. Infections with Klebsiella species regarding cause to prolonged stays in hospitals and compromised immune persons along with exposures to multiple antibiotics are the main factors that increase the risks for infections and MDR.

In the current search, the prevalence of K. oxytoca was 11% of total 18 Klebsiella species isolated in Iraqi UTI patients; some studies detected predominance of K. oxytoca in urine samples as 8% of all patients with UTI.^[8] Another study in elderly adults severing from UTI revealed 32 K. pneumonia and 7 K. oxytoca.^[9] Furthermore, K. oxytoca isolates from four patients (0.7%) in the United Kingdom.^[10] Some studies showed a high prevalence of K. oxytoca reached (34%) in Ghana.^[11]

In the last decades, K. oxytoca showed many reports of the outbreak, one report in Austria when five patients in 2011 infected by K. oxytoca that capable of producing many enzymes as carbapenemase,^[5] in this study, carbapenemase is also detected.

E. coli was the most common prevalent pathogen isolated from UTI patients in the current study. E. coli have been implicated in 56 samples (45.90%), and this finding accords many studies^[12] that mentioned E. coli prevalence was 42.2% in patients with UTI, and also agree with.^{[13],[14],[15]}

Biochemical tests of K. oxytoca revealed a positive indole test, whereas K. pneumonia showed a negative indole test; both species have positive results to catalase, urease, and capsule tests. K. pneumonia and K. oxytoca can be distinguished from each other by indole presentation by K. oxytoca but not produced by K. pneumonia.^[2] This study revealed the sensitivity of K. oxytoca to trimethoprim, ciprofloxacin, and amikacin. Resistance to amoxicillin, cefotazidime, clindamycin, nitrofurantoin, and cefotaxime is observed. Multidrug-resistant K. oxytoca has been detected in the current study.

All K. oxytoca in this search revealed resistance to amoxicillin because most strains of K. oxytoca produce a chromosomally mediated beta-lactamase (K1).^[2]

In this work, K. oxytoca was resistant to cephalosporin as ceftriaxone, cefotazidime, and cefotaxime. Almost all isolates of Klebsiella species were initially considered to be susceptible to cephalosporin; studies over the last two decades have shown variable susceptibility to this antibiotic class; this resistance is mediated by plasmid-mediated extended-spectrum beta-lactamases.^[2]

Conclusion

K. oxytoca with MDR considered serious public health challenges to patients and to clinicians, especially carbapenemase bacteria that emerged in recent years, so this need to direct more attention to antimicrobial resistance monitoring and surveillance. This would be critical for creating and fine-tuning effective antimicrobial resistance control strategies and for informing the accurate antibiotic prescriptions in clinical settings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Stamm WE, Norrby SR. Urinary tract infections: Disease panorama and challenges. J Infect Dis 2001;183 (Suppl 1):S1-4.
2.	Paterson DL, Siu KL, Chang FY. Klebsiella species (K. pneumoniae, K. oxytoca, K. ozaenae and K. rhinoscleromatis). Antimicrobe; 2014. Available from: http://antimicrobe.org/new/b107.asp. [Last assessed on 2015 Mar 15]
3.	Zollner-Schwetz I, Högenauer C, Joainig M, Weberhofer P, Gorkiewicz G, Valentin T, et al. Role of Klebsiella oxytoca in antibiotic-associated diarrhea. Clin Infect Dis 2008;47:e74-8.
4.	Herzog KA, Schneditz G, Leitner E, Feierl G, Hoffmann KM, Zollner-Schwetz I, et al. Genotypes of Klebsiella oxytoca isolates from patients with nosocomial pneumonia are distinct from those of isolates from patients with antibiotic-associated hemorrhagic colitis. J Clin Microbiol 2014;52:1607-16.
5.	Hoenigl M, Valentin T, Zarfel G, Wuerstl B, Leitner E, Salzer HJ, et al. Nosocomial outbreak of Klebsiella pneumoniae carbapenemase-producing Klebsiella oxytoca in Austria. Antimicrob Agents Chemother 2012;56:2158-61.
6.	Leitner E, Zarfel G, Luxner J, Herzog K, Pekard-Amenitsch S, Hoenigl M, et al. Contaminated handwashing sinks as the source of a clonal outbreak of KPC-2-producing Klebsiella oxytoca on a hematology ward. Antimicrob Agents Chemother 2015;59:714-6.
7.	Clinical and Laboratory Standards Institute (CLSI). Performance Standards for Antimicrobial Susceptibility Testing. Wayne, PA: Twenty-Thi. Clinical and Laboratory Standards Institute; 2013.
8.	Mbanga J, Dube S, Munyanduki H. Prevalence and drug resistance in bacteria of the urinary tract infections in Bulawayo province, Zimbabwe. East Afr J Public Health 2010;7:229-32.
9.	Tarkkanen AM, Allen BL, Williams PH, Kauppi M, Haahtela K, Siitonen A, et al. Fimbriation, capsulation, and iron-scavenging systems of Klebsiella strains associated with human urinary tract infection. Infect Immun 1992;60:1187-92.
10.	Hryniewicz K, Szczypa K, Sulikowska A, Jankowski K, Betlejewska K, Hryniewicz W. Antibiotic susceptibility of bacterial strains isolated from urinary tract infections in Poland. J Antimicrob Chemother 2001;47:773-80.
11.	Quansah E, Amoah Barnie P, Omane Acheampong D, Obiri-Yeboah D, Odarkor Mills R, Asmah E, et al. Geographical Distribution of β-Lactam Resistance among Klebsiella spp. from Selected Health Facilities in Ghana. Trop Med Infect Dis 2019;4:117.
12.	AL-Khikani FH, Auda Ga, Ayit AS. Correlation study between urinary tract bacterial infection and some acute inflammatory responses. Biomed Biotechnol Res J 2019;3:236-9. [Full text]
13.	Farhadi Z, Bahador N. Pathotypic and phylogenetic studies of urine Escherichia coli isolates from girls < 5 years of age in Marvdasht hospital. Biomed Biotechnol Res J 2018;2:281.
14.	Alkhudhairy MK, Saki M, Seyed-Mohammadi S, Jomehzadeh N, Khoshnood S, Moradzadeh M, et al. Integron frequency of Escherichia coli strains from patients with urinary tract infection in Southwest of Iran. J Acute Dis 2019;8:113-7. [Full text]
15.	Mehrishi P, Faujdar SS, Kumar S, Solanki S, Sharma A. Antibiotic susceptibility profile of uropathogens in rural population of Himachal Pradesh, India: Where we are heading? Biomed Biotechnol Res J 2019;3:171-5. [Full text]