|Year : 2020 | Volume
| Issue : 2 | Page : 189-193
Ceftriaxone-sulbactam-EDTA susceptibility profile of multi-drug resistant gram-negative bacterial isolates: Experience from a tertiary care teaching hospital in Rishikesh, Uttarakhand
Manisha Paul, Mohit Bhatia, Anusha Krishna Raj, Amit Mangla, Balram Ji Omar, Pratima Gupta
Department of Microbiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
|Date of Submission||20-Mar-2020|
|Date of Decision||18-Apr-2020|
|Date of Acceptance||25-May-2020|
|Date of Web Publication||22-Jul-2020|
Department of Microbiology, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Studies have shown that ceftriaxone-sulbactam-EDTA combination is a promising therapeutic option as carbapenem sparer in cases of infections caused by ESBL and MBL producing pathogens, respectively. This study is aimed to generate preliminary data on in-vitro susceptibility profile of clinical multi-drug resistant (MDR) Gram-negative bacterial isolates to ceftriaxone-sulbactam-EDTA combination. Materials and Methods: A cross-sectional study was conducted from January 1st, 2019 to October 31st, 2019. Antibiotic susceptibility data (including that of ceftriaxone-sulbactam-EDTA combination) of 200 multi-drug-resistant Gram-negative bacterial isolates obtained from various nonrepetitive clinical samples of patients of all age groups and sexes, was retrospectively analyzed. All clinical samples were processed aerobically as per standard guidelines, and the bacterial isolates obtained in culture were identified by conventional biochemical methods. Antibiotic susceptibility testing of bacterial isolates was performed using the modified Kirby Bauer disk diffusion method, the results of which were interpreted as per the Clinical and Laboratory Standards Institute (CLSI) guidelines 2019. In vitro susceptibility test results of ceftriaxone-sulbactam-EDTA combination, disks were interpreted as per the manufacturer's instructions. Results: Acinetobacter spp. was the most common isolate (53%), followed by Escherichia coli (20.5%), Klebsiella spp. (17.5%), Pseudomonas aeruginosa (16.5%), Citrobacter spp. (2%), and Proteus spp. (1%), respectively. 99.1%, 92.7%, 88.6%, and 69.3% of Acinetobacter spp., E. coli, Klebsiella spp. and P. aeruginosa, respectively, were susceptible to ceftriaxone-sulbactam-EDTA combination disks. Conclusions: The preliminary data generated by our study could be an eye-opener for clinicians practicing in this part of the country and should prompt further investigation in the form of clinical trials.
Keywords: Antibiotic adjuvant entity, ceftriaxone-sulbactam-edetate, Gram-negative bacilli, multi-drug resistant, Uttarakhand
|How to cite this article:|
Paul M, Bhatia M, Raj AK, Mangla A, Omar BJ, Gupta P. Ceftriaxone-sulbactam-EDTA susceptibility profile of multi-drug resistant gram-negative bacterial isolates: Experience from a tertiary care teaching hospital in Rishikesh, Uttarakhand. J Nat Sc Biol Med 2020;11:189-93
|How to cite this URL:|
Paul M, Bhatia M, Raj AK, Mangla A, Omar BJ, Gupta P. Ceftriaxone-sulbactam-EDTA susceptibility profile of multi-drug resistant gram-negative bacterial isolates: Experience from a tertiary care teaching hospital in Rishikesh, Uttarakhand. J Nat Sc Biol Med [serial online] 2020 [cited 2021 Mar 4];11:189-93. Available from: http://www.jnsbm.org/text.asp?2020/11/2/189/290497
| Introduction|| |
A vast majority of healthcare-associated infections in India are caused by multi-drug resistant (MDR) Gram-negative bacteria, thereby posing a therapeutic challenge to treating physicians. Apart from being associated with increased morbidity and mortality among hospitalized patients, these infections are associated with increased health care costs and an overall negative impact on the economy., With limited treatment options in hand, optimizing antibiotic utilization and exploring alternate options can be a potential way to control this menace.
Resistance to beta lactam-beta lactamase inhibitor (BL-BLI) combinations and carbapenems, which are used to treat MDR Gram-negative bacterial infections, is rampant. Therefore, the inclusion of an antibiotic adjuvant entity (AAE) in the form of Ceftriaxone + Sulbactam + Disodium Edetate (EDTA), in routine in-vitro antibiotic susceptibility testing panel for clinical Gram-negative bacterial isolates may be considered. The mechanism of action of this fixed-dose combination is based on the synergism between ceftriaxone (base beta-lactam antibiotic which inhibits bacterial cell wall synthesis), sulbactam (beta-lactamase inhibitor, providing protection against ESBLs) and EDTA (nonantibiotic adjuvant which extends anti-bacterial effect against MBLs and catalyzes resistance breaking mechanisms) respectively., Studies have shown that ceftriaxone-sulbactam-EDTA combination is a promising therapeutic option as carbapenem sparer in cases of infections caused by ESBL and MBL producing pathogens, respectively.,,,
To the best of our knowledge, there is no data available from the state of Uttarakhand on in-vitro susceptibility profile of clinical MDR Gram-negative bacterial isolates to this AAE. Keeping this lacuna in mind, we conducted a study with the aim of generating preliminary laboratory data on this subject.
| Materials and Methods|| |
A cross-sectional study was conducted at a tertiary care teaching hospital located in Rishikesh, Uttarakhand, for a period of 10 months from January 1st, to October 31st, 2019. This study was approved by Institutional Ethics Committee vide letter number AIIMS/IEC/19/1319 dated December 31, 2019. Antibiotic susceptibility data (including that of ceftriaxone-sulbactam-EDTA combination) of 200 multi-drug resistant Gram-negative bacterial isolates obtained from various nonrepetitive clinical samples like cerebrospinal fluid, blood, sputum, endotracheal aspirates, Bronchoalveolar lavage, pleural, pericardial, ascitic, synovial and drain fluids respectively, bile, urine, pus, tissue, etc., of patients of all age groups and sexes, was retrospectively analyzed. All clinical samples were processed aerobically as per standard guidelines. The bacterial isolates obtained in culture were subjected to preliminary conventional biochemical tests like catalase and oxidase, respectively, followed by final identification using a panel of other manually performed biochemical reactions as per standard guidelines. While colonies of Acinetobacter spp. and Enterobacteriaceae spp. were catalase-positive and oxidase negative, those of Pseudomonas spp. gave positive catalase and oxidase test results, respectively.
Antibiotic susceptibility testing of bacterial isolates was performed using Kirby Bauer disk diffusion method. Briefly, a standardized inoculum was swabbed onto the surface of the Mueller Hinton agar (MHA) plate (150-mm plate diameter). Filter paper disks impregnated with standardized concentrations of antimicrobial agents were placed on the surface of MHA. The size of the zone of inhibition around each antibiotic disk was measured after overnight incubation. The antibiotic susceptibility test results were interpreted as sensitive, intermediate, and resistant, respectively, as per the Clinical and Laboratory Standards Institute (CLSI) guidelines 2019.In-vitro susceptibility test results of ceftriaxone-sulbactam-EDTA combination disks (Venus Remedies Limited, India) were interpreted as per manufacturer's instructions, which were based on 1000 clinical isolates surveillance data. Appropriate ATCC control strains were used to ensure the quality of each procedure.
| Results|| |
During the study period, 71.5% (143/200) and 28.5% (57/200) of multi-drug resistant Gram-negative bacterial isolates were obtained from clinical samples of male and female patients, respectively, with a male to female ratio of 2.5:1. Mean age ± standard deviation of these patients was 45.19 ± 19.81 years. 97% (194/200) of the bacterial isolates were obtained clinical samples of inpatients.
Among the MDR Gram-negative bacterial isolates obtained in culture, Acinetobacter spp. was the most common (106/200; 53%) followed by Escherichia coli (41/200; 20.5%), Klebsiella spp. (35/200; 17.5%), Pseudomonas aeruginosa (13/200; 6.5%), Citrobacter spp. (4/200; 2%), and Proteus spp. (1/200; 1%), respectively, as depicted in [Figure 1].
|Figure 1: Frequency distribution of bacterial isolates obtained in culture|
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In-vitro antibiotic susceptibility profile
The percentage antibiotic resistance pattern of the predominant Gram-negative bacterial isolates, namely Acinetobacter spp., E. coli, Klebsiella spp. and P. aeruginosa, respectively, has been depicted in [Table 1]. It was observed that 99.1%, 92.7%, 88.6%, and 69.3% of Acinetobacter spp., E. coli, Klebsiella spp. and P. aeruginosa, respectively, were susceptible to ceftriaxone-sulbactam-EDTA combination disks. While all four isolates of Citrobacter spp. were susceptible to this AAE, the only Proteus spp. isolate obtained in culture was found to be resistant.
|Table 1: Percentage antibiotic resistance pattern of Gram-negative bacterial isolates|
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| Discussion|| |
Infections caused by MDR bacteria (especially those producing ESBL/MBL) are usually treated with carbapenems. However, the emergence of carbapenem-resistant superbugs in recent times has become a serious threat to public health due to high mortality, potential dissemination, and limited availability of effective treatment options. To address this issue, effects of nonantibiotic adjuvants and beta-lactamase inhibitors have been studied from time to time.
In the present study, in-vitro susceptibity to ceftriaxone-sulbactam-EDTA combination disks ranged from 69.3% to 99.1% depending on the bacterial isolates obtained in culture. Several in-vitro studies have been carried out in the last couple of years in India and have revealed similar findings, which are summarized in [Table 2].
|Table 2: Recently published Indian studies depicting in-vitro susceptibility of multi-drug resistant Gram-negative bacterial isolates to ceftriaxone-sulbactam- ethylenediaminetetraacetic acid combination|
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Some of the limitations of this study were: (1) Although, in-vitro antibiotic susceptibility profile of MDR Gram-negative bacterial isolates was studied, evaluation of treatment outcomes in patients was not done. (2) Species-level identification of many bacterial isolates could not be performed as conventional methods of identification were used.
| Conclusion|| |
We would like to conclude by stating that the preliminary data generated by our study could be an eye-opener for clinicians practicing in this part of the country. Ceftriaxone-sulbactam-EDTA fixed-dose combination seems to be a promising carbapenem sparing therapeutic option in the management of MDR bacterial infections. The findings of this study should prompt further investigation in the form of clinical trials, from the state of Uttarakhand.
We are thankful to Venus Remedies Limited, for providing us ceftriaxone-sulbactam-EDTA combination disks free of cost, for the purpose of this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chaudhry D, Prajapat B. Intensive care unit bugs in India: How do they differ from the western world? J Assoc Chest Phys 2017;5:10-7.
Gandra S, Barter DM, Laxminarayan R. Economic burden of antibiotic resistance: How much do we really know? Clin Microbiol Infect 2014;20:973-80.
Zimlichman E, Henderson D, Tamir O, Franz C, Song P, Yamin CK, et al
. Health care-associated infections: A meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med 2013;173:2039-46.
Chaudhary M, Payasi A. A randomized, open-label, prospective, multicenter phase-III clinical trial of Elores in lower respiratory tract and urinary tract infections. J Pharm Res 2013;6:409-41.
Gupta R. Antibiotic adjuvant therapy for multi-drug resistant carbapenemases producing Klebsiella pneumoniae
associated sepsis: A case study. J Clin Diagn Res 2016;10:DD08-9.
Shameem M, Mir MA. Management of pneumonia and blood stream infections with new antibiotic adjuvant entity (Ceftriaxone + Sulbactam + Disodium Edetate)-A novel way to spare carbapenems. J Clin Diagn Res 2016;10:LC23-7.
Attili VS, Chaudhary M. Pharmacokinetics and pharmacodynamics of Elores in complicated urinary tract infections caused by extended spectrum beta-lacatamase strains. Int J Pharm Sci Res 2014;6:2569-78.
Patil UN, Jambulingappa KL. A combination strategy of ceftriaxone, sulbactam and disodium edetate for the treatment of multi-drug resistant (MDR) septicaemia: A retrospective, observational study in Indian tertiary care hospital. J Clin Diagn Res 2015;9:FC29-32.
Bhatia P. Alternative empiric therapy to carbapenems in management of drug resistant gram negative pathogens: A new way to spare carbapenems. Res J Infect Dis 2015;3:2.
Collee JG, Duguid JP, Fraser AG, Marmion BP, Simmons A. Laboratory strategy in the diagnosis of infective syndromes. In: Collee JG, Fraser AG, Marimon BP, Simmons A, editors. Mackie & Mc Cartney Practical Medical Microbiology. 14th
ed. New Delhi: Elsevier; 2007. p. 53-94.
Collee JG, Miles RS, Watt B. Tests for the identification of bacteria. In: Collee JG, Fraser AG, Marimon BP, Simmons A, editors. Mackie & McCartney Practical Medical Microbiology. 14th
ed. New Delhi: Elsevier; 2007. p. 131-49.
Miles RS, Amyes SG. Laboratory control of antimicrobial therapy. In: Collee JG, Fraser AG, Marimon BP, Simmons A. editors. Mackie & McCartney Practical Medical Microbiology. 14th
ed. New Delhi: Elsevier: 2007. p. 151-78.
Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing; 29th
Informational Supplement. CLSI Document M100. Wayne, PA: Clinical and Laboratory Standards Institute; 2019.
Sahu M, Sanjith S, Bhalekar P, Keny D. Waging war against extended spectrum Beta lactamase and metallobetalactamase producing pathogens- novel adjuvant antimicrobial agent cse1034- an extended hope. J Clin Diagn Res 2014;8:DC20-3.
Bagga R. Retrospective analysis of antibiotic susceptibility and resistant patterns against nosocomial Gram-negative pathogens in Fortis Memorial Research Institute, Gurgaon. Int J Curr Adv Res 2015;4:347-51.
Arora S, Munshi N. Comparative assessment of antibiotic susceptibility pattern of Gram-negative pathogens isolated from Intensive Care Unit patients in Pune. Brit Microbiol Res J 2015;10:1-9.
Prasanthi K, Nagamani K, Anuradha PR, Murray DS. Trends in susceptibility pattern to commonly used antibacterial agents and role of ceftriaxone + sulbactam and EDTA combination against ESBL and carbapenemase producing Gram negative isolates. Int J Rec Sci Res 2015;6:4486-90.
Sachdeva N. Antibiotic sensitivity pattern of bacterial pathogens in Rajeev Gandhi Cancer Hospital, Delhi. Int J Rec Sci Res 2016;7:8480-85.
Chakravorty S, Arun P. Antibiotic/adjuvant combinationns (ceftriaxone + sulbactam + adjuvant disodium edetate) as an alternative empiric therapy for the treatment of nosocomial infections: Results of a retrospective study. Indian J Cancer 2017;54:685-90.
] [Full text]
Chaudhary M, Mir MA, Ayub SG. Protocol 06 Group Safety and efficacy of a novel drug Elores (ceftriaxone + sulbactam + disodium edetate) in the management of multi-drug resistant bacterial infections in tertiary care centers: A post-marketing surveillance study. Braz J Infect Dis 2017;21:408-17.
Sriram A, Tulara NK. Prevalence and susceptibility analysis of carbapenem resistant gram negative pathogens in tertiary care hospital, Mumbai. J Basic Clin Pharma 2018;9:26-30.
Patil NB, Sharma S, Aggarwal M, Vora M, Virani Z, Gupte P, Shah B. Prevalence and susceptibility analysis of gram negative pathogens in tertiary care transplant hospital, Mumbai. AJRIMPS 2018;4:1-8.
Bade J, Rohilla K, Chande C, Shirpurkar R, Chopdekar K, Lilani S, et al
. Evaluation of a combination of third generation cephalosporin, ESBL inhibitor and MBL inhibitor: An in vitro
study to assess the efficacy for treatment of carbapenemase producing Gram negativebacilli. Int J Sci Res 2018;7:70-2.
[Table 1], [Table 2]