Multi-drug resistant Klebsiella pneumoniae causing urinary tract infections in children in Pakistan

Multi-drug resistant (MDR) Klebsiella pneumoniae has been associated with different types of infections and the most important aspect is the emergence of MDR strains particularly in hospitalized children. They have the proficiency to cause bacteremia, septicemia and urinary tract infections (UTI). The objective of this study was to determine the susceptibility of MDR K. pneumoniae causing UTI in children. One thousand and fifteen (1015) urine samples were collected aseptically. Specimens were cultured on blood agar, MacConkey agar and cysteine lactose electrolyte deficient (CLED) agar. Antimicrobial susceptibility was determined using Kirby-Bauer disc diffusion method as per CLSI 2011 guidelines. Of the 1015 urine specimens, 230 (22.6%) were positive for bacterial growth. Out of these positive cultures predominantly Gram-negative rods (90%) were isolated and major pathogens were K. pneumoniae (40%) and Escherichia coli (33%). Antimicrobial susceptibility pattern of K. pneumoniae showed that more than 70% of these pathogens were resistant to cephalosporins, 69% to ciprofloxacin and amoxicillin-clavulanic acid and 63% to norfloxacin and nalidixic acid while most effective drugs were pipracillin-tazobactam and meropenem. This study concludes that MDR-K. pneumoniae is a great threat particularly in children in our locality.


Urinary tract infections (UTIs) have become one of the most common disease encounters in clinical practice.
There is an estimation that over 150 million UTIs cases occur worldwide annually (Gobernado et al., 2007).This is associated with a high risk of morbidity, mortality, extra financial budget and even, fatal consequences particularly in children (Hasan et al., 2007).UTIs are mainly caused by Gram negative rods (GNR) which account for 80 to 85% and the leading causative organisms are Escherichia coli (75 to 95%) and Klebsiella pneumoniae (Tanvir et al., 2012).
K. pneumoniae are very often isolated in hospital set up and a significant proportion being multidrug resistant (MDR) that become a formidable challenge nowadays (Rampure et al., 2013).The ability of MDR K. pneumoniae to easily spread makes this bacterium an important nosocomial pathogen (Ramirez et al., 2012).These pathogens are also responsible for an important cause of children infections such as bacteremia, septicemia and urinary tract infections (UTIs) (Manisha and Pratibha, 2012).Treatment of UTI patients infected with K. pneumoniae has become more difficult due to increasing antimicrobial resistance which severely limits the therapeutic options.These strains have typically been resistant to two or more different classes of antibiotics such as β-lactams, β-lactamase inhibitors, aminoglycosides *Corresponding author.E-mail: usman9785@gmail.com.Tel: +92-301-3054705.and quinolones.This is believed that the best empirical therapy to treat mild to moderate infections due to MDR K. pneumoniae would be the ertapenem (Brink, 2008).This is expected that MDR K. pneumoniae will become more and more resistant to antimicrobials with the passage of time because of the generation of their new mutant strains (Khameneh and Afshar, 2009).Therefore, we design this study to determine the frequency and antimicrobial resistant pattern in clinical isolates of K. pneumoniae in a tertiary care hospital, Lahore.

MATERIALS AND METHODS
Prior to start of the study, permission was taken from ethical review committee, School of Allied Health Sciences, tertiary care hospital Lahore, Pakistan.

Study population
A total of 1015 urine specimens suspected for UTIs were collected from children (age: 0 -12 years) in a tertiary care hospital Lahore, Pakistan.Mid stream urine samples were collected aseptically.

Identification of isolates
Urine specimens were cultured on blood agar, MacConkey agar and cysteine lactose electrolyte deficient (CLED) agar and incubated at 35°C for 24 h.The isolates were preliminary identified on the basis of morphology and cultural characteristics.Grampositive isolates were biochemically identified by catalase, slide and tube coagulase and DNAse test whereas, Gram-negative isolates were biochemically identified by cytochrome oxidase and confirmed by API 20E and 20NE (BioMerieux France).

DISCUSSION
Organisms causing UTIs particularly in children are becoming a public health problem.In present study, 22.6% (n=230) urine specimens were positive for significant bacterial growth which is in accordance with previous studies (Ahmad, 2013;Chaudhary et al., 2013).However few data suggested variable results ranging from 9 to 34% of urine positive cultures (Oh et al., 2013;Jahanzeb et al., 2008).This difference could be due to the differrence in samples size, handling and processing of sample techniques.Overall, GNR are the commonest cause of UTIs as compare to GPC.In this study, 91% of GNR were isolated which are comparable with previous studies conducted in Iran (90.3%),Turkey (89%) and Australia (96%) (Ayazi et al., 2010;Mehr et al., 2004;Arslan et al., 2002).This has been identified in earlier studies that Enterobacteriaceae are the predominant pathogens in UTI patients.These organisms are part of gut normal flora and individuals can easily get infected with poor personal hygiene (Afsharpaiman et al., 2012).Overall, E. coli still remains the most frequent isolated pathogens in UTIs but in the present study, the predominant pathogen was K. pneumoniae (40%).These results are in agreement with studies conducted in the Children hospital Lahore, Pakistan and Turkey (Ejaz et al., 2006;Biyikli et al., 2004).Contrary to this study, various other data also documented that E. coli was the predominant pathogen in UTIs patients (Al-Momani, 2006;Qureshi, 2005).In the current study, K. pneumoniae showed high resistance against commonly used antibiotics (cephalosporins, ciprofloxacin, amoxicillin-clavulanic acid and amikacin).These findings are almost in accordance with previous studies conducted in Iran, Pakistan, Mexico and India that reported MDR K. pneumoniae (Rampure et al., 2013;Langarizadeh et al., 2011;Ullah et al., 2009).Contrary few studies from Turkey, Korea and Iran showed low to moderate resistance (Yoon et al., 2011;Jalalpoor, 2011;Senel et al., 2010).Spread of MDR-K.pneumoniae is associated with inappropriate infections control practices.Various other factors includes contaminated intravenous catheters, environment surfaces and colonized hands of health care staff.Substandard and disinfection practices are also common.Another major factor to acquire resistance in our setup is the irrational use of empirical therapy which is not according to WHO criteria (Hannan et al., 2013).
It is concluded that MDR K. pneumoniae play a crucial role in spreading UTIs and these pathogens are also extended from the hospital to community.Now, it is the need of the hour to improve infections control practices, avoid irrational use of antibiotics and empirical regime should be revisited to prevent further resistance.

Figure 1 .
Figure1.Overall percent susceptibility pattern of K. pneumoniae in which high drug resistance was observed against cephalosporins, Amoxicillin+clavulanic acid and ciprofloxacin whereas most effective drug was piperacillin-tazobactam.