Extended spectrum β-lactamase producing Enterobacteriaceae in Lebanese ICU patients: Epidemiology and patterns of resistance

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Abstract
Our study aims to investigate and describe the epidemiology of the intestinal carriage of ESBL-PS in intensive care units of five Lebanese hospitals and to analyze the potential risk factors for the acquisition of these strains. At the same time, we intend to determine the patterns of susceptibility of these strains, exploring therefore the availability of alternative treatment. One thousand, four hundred forty-two fecal samples were collected between January 1, 2003 and March 31, 2003 from 378 patients admitted to the ICUs of five Lebanese tertiary care general hospitals located in different areas of Lebanon. ESBL production was detected by the double disk synergy test and antibiotic susceptibility of ESBL-producing strains as well as minimum inhibitory concentrations were determined. A paired case-control study was undertaken to identify risk factors for carriage of ESBL-PS. One hundred eighteen strains isolated from 72 subjects were identified as ESBL producers, including 95 (80.5%) E. coli, 16 (13.6%) Klebsiella pneumoniae, and 7 (5.6%) Enterobacter cloacae. A higher rate of multiple ESBL-PS carriage was described among these acquisition cases (21 double carriages and 3 triple carriages of ESBL-PS compared to only 1 double carriage of ESBL-PS at admission). In general, similar trends of susceptibility were observed in the different hospitals. As expected, the lowest MIC was observed with imipenem for all E. coli, Klebsiella, and Enterobacter isolates. Ciprofloxacin, followed by trimethoprim-sulfamethoxazole seem to be associated with the lowest susceptibility. In vitro susceptibility to cefoxitin for all isolates was 74.6%; more resistance was associated to ceftazidime (90.7%) than to cefotaxime (69.7%). Our data agree with other national and international reports showing the increase in ESBL-PS carriage in ICU patients. They demonstrate the endemic character of this carriage in Lebanese hospitals and the important risk factors including immunosuppression and evidence of ESBL infection. The highly resistant profile of ESBL-PS to antimicrobial agents available for treatment reflects the severity of this issue. The significance of this study resides in the direct correlation between our results and the nationwide increase in multi-drug resistant bacteria and the continuous change in bacterial resistance epidemiology. Our data may have an important impact on infection control policies in hospitals and on treatment of infectious diseases.

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