Current challenges and emergence of carbapenemase-producing bacteria: a brief report from a libyan hospital

Current challenges and emergence of carbapenemase-producing bacteria: a brief report from a libyan hospital

Asma Elramalli¹, Nariman Almshawt², Mohamed Omar Ahmed^2,&

 

¹Tripoli Medical Centre, Tripoli, Libya, ²Department of Microbiology and Parasitology, Faculty of Veterinary Medicine, University of Tripoli, Libya

 

 

^&Corresponding author
Mohamed Omar Ahmed, Department of Microbiology and Parasitology, Faculty of Veterinary Medicine, University of Tripoli, Libya

 

 

 

 

The emergence of antimicrobial resistance (AMR) is a major threat to human health and is occurring at an alarming rate throughout the globe, diminishing the already limited therapeutic options [1]. Low-income regions, such as Africa, are at high and particular risk. Such threats are complicated by the underdeveloped regional conditions and socioeconomic factors that are associated with health and community-acquired pathogens [2]. AMR in Africa is a rising problem and frequently reported from clinical, non-clinical and environmental sources [2,3]. Carbapenems are potent 46;-lactam antibiotics that are considered as the last resort option for treating serious nosocomial infections caused by a broad spectrum of Gram-negative bacteria [4]. Prior to 2000, only few clinical isolates showed resistance to carbapenems, mostly represented by Acinetobacter baumannii and Pseudomonas aeruginosa. Thereafter, carbapenem resistance has emerged as a major, global health concern and a major clinical problem [5]. Carbapenemase-producing bacteria has come to the forefront as a global concern representing a serious medical and public health issue due to multidrug resistances (MDRs) that involve valuable therapeutic choices, including the so-called drugs of last resort [6-9].

 

Over the past decade, studies and investigations have reported the problem of AMR in Libya among different nosocomial bacterial, with a particular focus on methicillin-resistant Staphylococcus aureus (MRSA) [10,11]. Recent and increasing reports have also documented the carbapenamase-producing bacteria, and the majority of cases have involved Libyan traveller patients [6, 12-16]. These recent and limited studies have reported different carbapenemase-encoding genes in Gram-negative bacteria, including the blaVIM-2, blaNDM and OXA-genes [17,18]. Nevertheless, surveillance and epidemiological investigations on AMR bacterial pathogens in this particular region remain inadequate, limited and incomplete. In this short report, we investigate and provide data of the species spectrum and antibiotic susceptibility patterns of 94 Gram-negative bacteria that were collected in 2015 from clinical cases at a single Libyan hospital located in Tripoli. These strains were isolated and collected on the basis of expressed resistance to the carbapenem classes only. This brief work aimed to report and discuss the current status and potential concern of carbapenemase-producing Gram-negative bacteria in Libyan hospitals.

 

 

The 94 Gram-negative bacterial strains were initially isolated and identified based on culture and biochemical characteristics (i.e. Gram stain, catalase reactivity, and API 20E system). Isolates were further defined and characterized at species level and the antibiotic susceptibility profile was determined using the VITEK automated system (VITEK-Compact 2). The strains were selected and collected based on the expressed resistance to at least one carbapenem class (i.e. meropenem or/and ertapenem) and stored at -20°C. The VITEK system tested A. baumannii only against meropenem, while the E. coli and K. pneumoniae were tested against both of the carbapenem classes. The antibiotic susceptibility profile, including MDR phenotypes (based on the resistance to ≤5 different antimicrobial classes) were investigated.

 

 

Among the collection of tested isolates, 45/94 (48%) were A. baumannii, 47/94 (50%) were K. pneumoniae and only 2/94 (2%) were E. coli. Among the A. baumannii strains, 43/45 (96%) showed resistance to meropenem. Among the K. pneumonia strains, 33/47 (70%) showed resistance to meropenem and 44/47 (94%) showed resistance to ertapenem (Table 1). Both E. coli isolates show resistance to ertapenem and only one strain show resistance to meropenem. A total of 73/94 (78%) of the strains showed different MDR phenotypes, with 67% of A. baumannii and 91% of K. pneumoniae strains accounting for this.

 

 

S. aureus, Pseudomonas spp. and Klebsiella spp. were previously reported as the most frequent causes of nosocomial infections, highlighting the reported emerging challenge of antimicrobial resistance in Libyan hospitals [10]. A recent investigation involving a single Libyan hospital found P. aeruginosa, A. baumannii and S. aureus as the most identified nosocomial bacterial strains expressing high rates of MDR phenotypes, including to the cephalosporins and carbapenems (personal unpublished 2015 data). In the current brief report, A. baumannii and K. pneumonia were identified as the dominant bacteria among the collection and showed a high level of resistance to different antimicrobial classes of the carbapenems. The Klebsiella strains, in particular, showed a remarkable rate of MDRs and different antimicrobial resistance patterns (Table 1). Previously, Extended spectrum beta-lactamases (ESBLs)- in the Gram-negative isolates from Libya hospitals was reported at a range of 9-15% [10]. Generally, MDR and ESBLs are frequent among the clinical strains of Gram-negative rods of P. aeruginosa, A. baumannii and K. pneumonia, and show the concomitant resistance phenotypes [3, 13, 19].

 

The documented cases of carbapenemase-producing bacteria from/within Libya have exclusively involved Libyan travellers and described MDR phenotypes in patients with high co-colonization rates and a pre-hospitalization history in Libyan healthcare settings [12-16]. Moreover, this reported MDR in K. pneumonia and A. baumannii strains were shown to harbour either or a combination of OXA-48, OXA-23 or NDM-1. Yet another report demonstrated the presence of blaVIM-2 gene in P. aeruginosa and of OXA-carbapenemase-encoding genes (the blaOXA-23 type, followed by blaOXA-24- and blaOXA-48- genes) in A. baumannii isolates from hospitalized patients in a Libyan hospital [17].

 

The carbapenemase-producing bacteria, are generally recognized as difficult to identify and estimate [9]. The current estimates of carbapenemase-producing bacteria for Africa range from 2.3% to 67.7% [8]. The North African and Mediterranean regions have recently been designated as an endemic/reservoir area of the carbapenemase-producing bacteria (i.e. OXA-48 type) [6, 7, 9, 14]. Globally KPC VIM IMP NDM and OXA-48 are the most prevalent β-lactamase classes produced by the carbapenemase-producing bacteria [9]. The carbapenem-resistant bacteria in Gram negative strains, in particular, are a global emergent problem and surveillance and follow-up studies focused on these pathogens are urgently needed in Libya. Due to our limited resources at the present time, investigation of ESBL genes within the current collection was not carried out, but future investigations are needed since they will allow for estimation of the presence and extent of carbapenemase-producers in the Gram-negative bacteria in Libyan hospitals.

 

 

The antimicrobial resistance (AMR) pose a serious medical and public health concern. The recent published reports and the current information indicate a current and prospective concern of AMR pathogens. The report and rise of AMR in Libya has been mainly attributed to the consumption of antibiotic drugs (i.e. β-lactam drugs) and to the improved identification methods and applied laboratory skills. However, epidemiological data and molecular investigations remain lacking for from healthcare settings (nosocomial isolates) and are even more rare from community-acquired sources. Certainly, the lack of epidemiological and molecular investigations (particularly from the community), the lack of surveying and monitoring studies, as well as the socioeconomic factors and underdeveloped healthcare infrastructure play important roles in the development and spread of AMR. Professional upgrading of healthcare personnel, along with educational campaigns to increase public awareness of AMR and of the importance of controlled use of antibiotics are too important steps that need to be taken towards gaining control over the spread of AMR.

 

 

The author declare no competing interest.

 

 

MOA, analyzed and interpreted the data, and drafted the manuscript. AKE and NFA performed the laboratory work and interpretation of the data. Manuscript was approved by all authors.

 

 

Table 1: antimicrobial resistance of the collection-strains

 

 

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