Mary S.

Farkosh, MT (ASCP), SBB The Organism Extended-spectrum beta-lactamases (ESBLs) are plasmid-mediated beta lactamases of predominantly Bush class A, so far described only in gram negative bacilli. ESBLs are capable of efficiently hydrolyzing penicillins, narrow spectrum cephalosporins, many extended-spectrum cephalosporins, the oxyimino group containing cephalosporins (cefotaxime, ceftazidime), and monobactams (aztreonam). Beta-lactamase inhibitors (clavulanic acid, sulbactam, and tazobactam) generally inhibit ESBL producing strains. Most ESBLs are mutants of TEM-1, TEM-2 and SHV-1; to date none have been described that are able to hydrolyze cephamycin or carbapenems (imipenem, meropenem). Over 25 different TEM and SHV ESBL variants have been claimed to date. ESBL producing isolates are most commonly Klebsiella ssp, predominantly Klebsiella pneumoniae, and Escherichia coli (E. coli). Most ESBL producing organisms are in the family Enterobacteriaeae and have been described in almost all members (1). Bush Class B beta-lactamases include metaloproteases, which are capable of hydrolyzing carbapenems such as imipenim and meropenam. This class of beta-lactamases have recently been reported in Japan among Pseudoomonas aeruginosa and Serratia marcescens. In addition to carbapenams, the isolates were resistant to other Beta-lactams and Betalactamase inhibitors with the exception of aztreonam. Bush Class C enzymes are primarily chromosomal rather that plasmid-mediated. The most prevalent enzyme in this group, which is found among the Enterobacteriaceae and P. aeruginosa, is AmpC. Class C Beta-lactamases are resistant to Betalactamase inhibitors and mutations in the regulatory gene, which occurs at a high frequency among Enterobacter cloacae, can result in high-level constitutive production resulting in resistance to all Beta-lactams except carbapenems. Plasmidencoded AmpC enzymes have been reported and included MIR-1, CMY-2, BIL-1, FOX-1, LAT-1, FEC-1, MOX-1, and CMY-3 from Klebsiella spp. and E. coli isolates. ESBL producing strains have been isolated from abscesses, blood, catheter tips, lung, peritoneal fluid, sputum, and throat culture (3,4). Epidemiology Distribution Worldwide (1,2) Prevalence: SHV variants are important worldwide (2). In the United States in 1990 to 1993 a survey of the intensive care units (ICUs) of 400 hospitals recorded an increase from 3.6% to 14.4% in ESBL producing strains of Klebsiella ssp (5). By 1994 the Center for Disease Control and Prevention National Nosocomial Infections Surveillance System (NNIS) reported that 8% of Klebsiella spp had ESBLs with producers predominately from a few large centers (6,7). A 1995-96 study in Richmond, Virginia reported 1.5% of isolates produced ESBLs. TEM-10, TEM-12 and TEM-26 seem most common in the USA (3). In Europe as of 1995, ESBLs occur in 20%-25% of Klebsiella ssp from patients in ICUs, although they have been found in up to 30%-40% in France. TEM-3 seems to be most common in France (2). Rates vary greatly worldwide and within geographic areas and are rapidly changing over time (2). Acquisition: Resistant strains are generally found post treatment with broad-spectrum cephalosporins or through acquisition of a resistant strain via nosocomial transmission (1,2). Medical use of antibiotics can considerably accelerate the selection pressure for diversification and dissemination of mutant extended-spectrum beta-lactamses (8,9). Diagnosis Diagnosis of the presence of an ESBL producing GNR relies on the microbiology laboratory and in some instances on the observance of increasing rates of treatment failure with extended-spectrum cephalosporins. Detection of ESBL producing GNRs remains a challenge for the microbiology laboratory. The problem is that routine methods for monitoring a decrease in susceptibility to oxyimino-cehalosporins and aztreonam have not been sensitive enough to detect ESBL producing strains, especially those that produce TEM-1, TEM-12 or SHV-2. Minimum inhibitory concentrations (MIC) may be raised only slightly and fail to reach the level of the accepted breakpoint for resistance. A 1994 study by Katsanis found agar dilution, the Etest, and the MicroScan as well as the Vitek automated systems to be insensitive for ESBL detection and recommended new breakpoints and better tests for detection of ESBLs (10). The importance of routinely screening all isolates with extended-spectrum cephalosporins, not just those isolates resistant to

narrower spectrum cehalosporins was recommended by the National Committee for Clinical Laboratory Standards (NCCLS) in 1999 (11). Several screening tests are in current use for ESBL production. Resistance to ceftazidime, regardless of the test method, was shown in one study to have adequate sensitivity to detect ESBL producing strains even when the traditional resistance breakpoints were used. None of 38 laboratories surveyed in Connecticut failed to report ESBL producing strains as resistant or intermediate in this study using this method. Unfortunately, not all laboratories had included ceftazidime resistance (12). Moland et al found the sensitivity of using ceftazidime resistance as marker for ESBL production to be 78% in a broth dilution format (13). The use of cefpodoxime resistance has also been advocated as a screening test for ESBL production (13). The sensitivity of using any particular extended-spectrum cephalosporin as a screening test can be dependent on the geographic variation and the resistance patterns of these organisms. In one study of SHV-3 like ESBLs, 100% were resistant to ceftriaxone but only 50% were resistant to ceftazidime in vitro (14). The current NCCLS recommendations (2000) for detection of ESBL's in Klebsiella spp. and E. Coli includes an initial screening test with any two of the following beta-lactam antibiotics: cefpodoxime, ceftazidime, aztreonam, cefotaxime, or ceftriaxone. Isolates exhibiting a MIC > 1microg/ml should be confirmed phenotypically using ceftazidime plus ceftazidime/clavulanic acid and cefotaxime plus cefotaxime/clavulanic acid. A3 two-fold concentration decrease in a MIC for either antimicrobial agent tested in combination with clavulanic acid versus its MIC when tested alone should be considered an ESBL producer (11). Transmission Known risk factors for colonization and/or infection with organisms harboring ESBLs include admission to an intensive care unit, recent surgery, instrumentation, prolonged hospital stay and antibiotic exposure, especially to extended-spectrum beta-lactam antibiotics (15). Use of extended-spectrum antibiotics exerts a selective pressure for emergence of ESBL producing GNRs. The resistance plasmids can then be transferred to other bacteria, not necessarily of the same species, conferring resistance to them. The lower digestive tract of colonized patients is the main reservoir of these organisms (15). Gastrointestinal carriage can persist for months (16). In some cities in the United States, nursing homes may be an important reservoir of ESBL producing strains. Nursing home patients are more likely to be treated empirically with antibiotics, and thus on admission to a hospital to be more likely to possess an ESBL producing strain (16). Patient to patient transmission of ESBL producing GNRs occurs via the hands of hospital staff (5, 16, 17, 18). It is known that ESBL producing strains can survive in the hospital environment (19). Nosocomial Hospitalized patients: Nosocomial infections in patients occur through the administration of extended spectrum beta-lactam antibiotics or via transmission from other patients via health care workers. Health care workers May become colonized with resistant strains via exposure to patients or other health care workers. Prevention Spread of ESBL producing GNRs can be controlled by good infection control practices (3, 5, 20), especially by good hand washing technique, although Lucet it al showed that stressing good hand washing practice was not sufficient to control transmission of ESBL producing strains. They combined education of staff with careful review of nursing care practices to minimize the risk of transmission (20). Other experts are advocating the role of antibiotic manipulation and restriction to control ESBL outbreaks. Improved laboratory detection and reporting of ESBL producing strains is needed. Laboratories should test for susceptibility of all K. pneumoniae and E. coli isolates to extended-spectrum antibiotics. NCCLS guidelines recommend both screening and confirmatory tests be used (11). Monitoring and control of usage of extended-spectrum cephalosporins and regular surveillance of antibiotic resistance patterns as well as efforts to decrease use as empirical therapy is indicated (3, 4, 5, 21). Reference: http://www.hopkinsmedicine.org/heic/ID/esbl/