JCBPS; Section B; August 2015–October 2015, Vol. 5, No. 4; 4040-4052.

E- ISSN: 2249 –1929

Journal of Chemical, Biological and Physical Sciences

An International Peer Review E-3 Journal of Sciences
Available online atwww.jcbsc.org
Section B: Biological Sciences

CODEN (USA): JCBPAT Research Article

Growing Challenge against Extended Spectrum Beta-

Lactamase Producing Klebsiella Pneumoniae with
Evaluation of Effective Antimicrobial Treatment Option
Maria Ayub1*, Hina Liaquat2 & Dr. Munawerah Fahad3
1
Lecturer, Faculty of Pharmacy, Jinnah University for Women, Karachi 74600, Pakistan
2
Jinnah University for Women, Karachi 74600, Pakistan
3
Ministry of Health, Alqasim, KSA.

Received: 6 August 2015; Revised: 7 September2015; Accepted: 14 September 2015

Abstract: On the back of the, increasing multidrug resistance, synthetic polymeric

antimicrobial has received extensive attention. In every aspect of life pathogen virtually
present everywhere and reached. Antimicrobial resistance has been increased against
K.pneumoniae. A wide variety of diseases in humans have shown by the result of strains
of klebsiella. In nosocomial infection, these bacteria have become important pathogen.
The objective of the study is to determine and evaluate the possible and effective
treatment against K.pneumoniae and ESBL because there is a diminish in sensitivity
patterns of antimicrobials against this bacterium, reflects the inappropriate use of
antibiotics. More than 100 isolates were obtained from antibiograms of hospitals in order
to study the susceptibility and resistance pattern to the most harmful pathogen klebsiella
pneumonia. Gradual decline in sensitivity pattern has been observed by polymixin B
[51%], sulzone [73%], imipenem [79%] and [80%] natidixic acid and meropenem. After
careful considerations, it has been concluded that there is a limited treatment option to
treat this pathogen due to gradually decreased in the sensitivity pattern of antimicrobials
and furthermore investigations are required to evaluate and for the development of
irrational as well as cost effective therapy.
Keywords: ESBL, antimicrobial resistance, sensitivity, k. pneumonia, treatment.

4040 J. Chem. Bio. Phy. Sci. Sec. B, August 2015 – October 2015; Vol.5, No.4; 4040-4052
Growing Challenge… Ayub et al.

INTRODUCTION

On the back of the, increasing multidrug resistance, synthetic polymeric antimicrobials have received
extensive attention. Destroying the cell membrane of the organism considering them ineffective performs
macromolecular antibiotics while inhibiting microbes activity by acting on pinpoint targets are a function
of small conventional molecular antibiotics1. In therapeutics, between the drugs the most successful class
has been antibiotics and many overhaul medicine’s greatest advances enabled by them. With recent
accounts of bacterial strains resistant to all approved antibiotics, especially at intensive care unit in
immune compromised patients. Antibiotic-resistant bacteria are emerging as a grave health, public health
hazard. With the potential to serve as the footing for a new class of anti-infective this targeting these
difficult to treat bacteria2. The most frequent pathogen to the human is the food borne disease and
accounts for many laborious problems, especially anti-microbial resistance have been increased3. In each
aspect of life pathogens virtually near everywhere and reached. Resulting in unwarranted deaths and
illness due to the potential risk of bacteria in foods, soils, and water has historically outrun by any
detection efforts4. In 1983, ESBL’s were 1st narrated from the Germany5. From the lungs of patients who
died of pneumonia, Friedlander isolated a capsulated bacillus in 1883. Friedlander bacillus was named of
this pathogen after him. Ubiquitously present and described worldwide, this organism was given the
generic name of Klebsiella later on. A wide variety of diseases in humans have shown by the account of
strains of klebsiella. During nosocomial infection, these bacteria have turned to important pathogen6.
Isolates of ESBL producing organisms from nosocomial infection were at first, but isolation from
community of this organism now also being described7. In hospitalized patients, especially with long care
facilities, health care, manipulations, use of catheters, the colonization rate for K. pneumonia is enlarged8.
CTX-M-1, CTX-M-3, CTX-M-14 was isolated in 2002 from Enterobacteriaceae in France9. TEM and
CTX-M were predominantly found in E.coli [39.2%] while among the klebsiella species TEM, SHV,
CTX-M occurred together in 42.6% of the isolates found very recently in 2011 in India Monoharam10.
Contingency of extended spectrum Beta lactams ESBL producing bacteria, Asia has a long history
probably11.
In mild 1980’s in western ESBL’s are first isolated which are plasmid mediated TEM [temoniera gene]
and SHV [sulfhydril variable gene] derived enzymes in Klebsiella species followed by Escherichia coli
are most frequently observed. Broad spectrum cephalosporin’s, penicillin’s and monobactams such as
aztreonam are hydrolyzed by this ESBL enzymes, but inhibited by beta-lactams antibiotics inhibitors such
as cluvalunic acid and are usually inactive against cephamycins and imipenum. There is a great quantity
of plasmids [80kb or more in size] responsible for the ESBL’s production and thus diverse agents show
resistance followed by this pattern. Resulting in limitation of therapeutics, amino glycosides,
fluroquinolones, chloramphenicol and sulphamethaxazole+trimethoprim are most often co-resistance
established in ESBL producing organisms12. In humans and animal infections caused by Escherichia coli
and Klebsiella species13 In the recent years resistance to these antimicrobials especially in ESBL’s has
enlarged14,15. An increase in resistance in gram negative bacilli has important witnessed by east region.
The significant emergence of ESBL is produced by E. coli and K. pneumonia, also reported by many
reports in Lebanon16,17. An opportunistic pathogen, k.pneumonia in immuncompromise patients causes
life threatening infections. The vital reservoirs of the K. pneumonia are the gastrointestinal tract and
hands of health care staff. The ability to extend rapidly within the hospital environment is the most
important problem of K.pneumoniae18,19. In most Enterobacteriaceae species extended spectrum beta
lactamases diffused during the past 30 years, especially in Klebsiella pneumonia. CTX-M enzymes are a
4041 J. Chem. Bio. Phy. Sci. Sec. B, August 2015 – October 2015; Vol.5, No.4; 4040-4052
Growing Challenge… Ayub et al.

great problem among ESBL because in many nosocomial outbreaks and are associated with expanded
mortality, they have been involved20-22. Subsequently led to the establishment of ESBL producing
bacteria with the emergence of beta lactamases mediated bacterial resistance has been associated with the
enlarged use of antibiotics particularly with third generation cephalosporins23. With the ability to
hydrolyze and root of resistance to the monobactams [i.e. aztreonam] and oxyimino cephalosporin’s
[cefotaxime, ceftriaxone, ceftazidime, ceforuxime and cefepime], but not the carbapenems [imipenum,
meropenem, ertapenem] or cephamycins [cefotetan, cefoxitin], rapidly involving the group of lactamases
enzymes, produced by the gram negative bacteria more commonly in E.coli and K.pneumoniae are the
ESBL’s24-26. When tested invitro some ESBL-producing organism are not resistant to all cephalosporin’s,
although cephalosporin’s antibiotics hydrolyzed by ESBL’s, the majority of the American clinical
microbiology laboratories did not make efforts to detect ESBL, while screening klebsiella and Escherichia
coli is not clinically necessary have suggested by some authors27. Being the fourth and fifth most common
cause of pneumonia and bacteremia, respectively, in intensive care patients, K.pneumoniae is the most
familiar nosocomial pathogen28. Recovered from intensive care areas cephalosporin’s resistance has been
established in 14% of all Isolates of K.pneumoniae, although this percentage is much higher in some
regions, according to the National nosocomial Surveillance data29,30. In isolates of K.pneumoniae,
carbapenems resistance has been unusual. To treat serious infections originated by ESBL’s, carbapenems
antibiotics are used31-34. In New York City isolates of carbapenems-resistant K.pneumoniae are rapidly
emerging. In regional hospitals the spread of strains that possess a carbapenem-hydrolyzing beta
lactamase has occurred. Control of their extended is crucial, because these isolates are resistant to
virtually all frequently used antibiotics27.
The objective of this study is to evaluate extended spectrum beta-lactamase producing klebsiella
pneumonia to determine sensitivity of antimicrobials which is a major growing concern especially at
intensive care unit of the healthcare sector.

METHODOLOGY

The study plotted primarily comprised of re-evaluation data of the past two years from intensive care
units of public and private health care centre of paths cancer patients. In-vitro sensitivity laboratory test
from different hospitals were collected above 100 isolates in order to study the susceptibility and
resistance ornamentation to the very ruinous pathogen klebsiella pneumonia. The basic criteria of this
study based on, disk diffusion method of Mullier-Hinton agar [MHA], and Broth micro dilution of cation
adjusted Mullier-Hinton agar [CAMHB]. The data collected admitting to the information supplement of
performance standards for anti-microbial susceptibility test, CLSI [NCCLS], documents explained on
information were established35. Versus standard micro dilution system, relatively more than 30
antimicrobial was tested with both the standard disk diffusion technique and standard broth diffusion
technique having incubation situations 35+2 C, ambient air with the incubation period of 16-18 hours on
concluded result, antimicrobials susceptible to the K.pneumoniae isolates were understood only. For an
explanation of susceptibility resistance ornament were based on the standard disk content of zone size
inhibition amassment of parenteral cephalosporins 30 µg [cefotaxime, ceftriaxone, ceftazidime]and 10 µg
[cefpodaxime], Aztreonam 30 µg, ceftazidime-clavulanate 30 µg/10 µg subsequently, admitting to the
CLSI of a zone of sensitivity and resistance measurement with standard reference. Sequels of results with
American type culture collection [ATCC] standard strain 700603 K.pneumoniae were correlated.

4042 J. Chem. Bio. Phy. Sci. Sec. B, August 2015 – October 2015; Vol.5, No.4; 4040-4052
Growing Challenge… Ayub et al.

RESULT

About more than 100 isolates of klebsiella pneumonia were included in this study and detailed study
based on retrospective data of the past two years of this opportunistic pathogen, for the determination of
the antimicrobials susceptible and resistance pattern. BLD centraline, Blood C/S, ear swab C/S, HVS C/S,
Pleural fluid C/S, Pus C/S, Sputum C/S, Urine C/S included samples collection for the isolation of this
pathogen. Shown with percentage in Figure 1, most common source of isolation of this bacterium in
urinary tract infections is found to be Blood C/S, Urine C/S and Pus C/S.

NO OF ISOLATES OBTAINED FROM SAMPLE SOURCE

BLD centraline
2%

Urine C/S
27%

Blood C/S
53%
Pus C/S
9%
Sputum C/S
2%

Pleural fluid C/S

2%

HVS C/S Ear swab C/S

2% 3%
BLD centraline Blood C/S Ear swab C/S

Fig. 1: Sample collection source percentage Frequency

Table 1: Antimicrobials highest sensitivity pattern against K.Pneumoniae

4043 J. Chem. Bio. Phy. Sci. Sec. B, August 2015 – October 2015; Vol.5, No.4; 4040-4052
Growing Challenge… Ayub et al.

From intensive care units of different hospitals participated in this study after the collection of data,
according to their highest frequency of utilization in past two years, antimicrobials susceptibility and
resistance pattern were analysed and emergence of multi-drug resistance as well as improper utilization of
detailed study. There is a frequent rise in antimicrobial agents resistance and susceptibility fashion for
Klebsiella pneumoniae clearly illustrate the antimicrobials resistance and susceptibility pattern shown in
Table 2 &Table 1, incredibly higher sensitivity percentage against klebsiella pneumoniae with imipenum
and natidixic acid 80%, meropenem 79%, sulzone 73%, polymixin B 51% and piperacillin 33%. Shown
in Table 2, percentage frequency of resistance against Klebsiella pneumoniae to Penicillins [amoxicillin
99.90%], Aminoglycosides [tobramycin 90%, gentamycin 82%] and Quinolones [ciprofloxacin 90%,
norlloxacin80%, pipimedic acid and co-trimaxazole 75%] was higher compared to cephalosporins
[ceftazidime and sulzone 27%] except ceftriaxone sodium 90%, cefotaxime sodium 85%
cefixime 90%, cefepime and aztreonam 80% highly resistant against K.pneumoniae shown in Table 1.
With significant association among Cephalosporins, Penicillins, ciprofloxacin and Aminoglycosides
decreasing sensitivity create an emergence of multi-drug resistance of antibiotics against K.pneumoniae
shown in Figure 2 and 3 which represents susceptibility and resistance pattern of antimicrobials.

Antimicrobial resistance pattern against K.pneuminiae

RESISTANCE

120%
100%
Resistance

80%
60%
40%
20%
0%

Fig. 2: Antimicrobial resistance pattern against K.Pneumeniae

4044 J. Chem. Bio. Phy. Sci. Sec. B, August 2015 – October 2015; Vol.5, No.4; 4040-4052
Growing Challenge… Ayub et al.

Antimicrobial sensitivity pattern against K.pneumeniae

SENSITIVITY

90%
80%
70%
60%
RESISTANCE

50%
40%
30%
20%
10%
0%

Fig. 3: Antimicrobial sensitivity pattern against K.Pneumoniae

Association between resistance and sensitivity of

antimicrobial agents against K.pneumeniae
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%

Fig. 4: Antimicrobials against K.Pneumeniae sensitivity and resistance pattern, a comparative analysis

4045 J. Chem. Bio. Phy. Sci. Sec. B, August 2015 – October 2015; Vol.5, No.4; 4040-4052
Growing Challenge… Ayub et al.

Table 2: Percentage of antimicrobials sensitivity and resistance Pattern

Where N.M.T represents No More Tested

DISCUSSION

Infectious disease create an emergence against lifesaving antimicrobial in patient with immunodeficient &
klebsiella pneumoniae accounts for major community-acquired pyogenic infections 36,37 also with urinary
tract abnormalities such as urolithiases, hydronephrosis or congenital deformities in pregnant women also
commonly involved in acute pyelonephritis38. bacteremia community-acquired pneumonia39 complicated
skin and soft tissue infections, liver abscess, brain abscess, lung abscess, , prostatic abscess, deep neck
infection and thoracic emphysema40. Mortality rate was 80% in patients with K. pneumoniae infections41-
44
found in South Africa from January 1982 through July 1985 in a of ICU cases with bacteremic
community-acquired pneumonia (CAP).45 Severe hospital-acquired respiratory tract infections and
death43, Klebsiella pneumoniae is a leading consequence43, infections in premature infant in intensive care
unit.46-51 as well as in nosocomial infections considered as important pathogen in respiratory tract
infections52-55. Interviewed the second most familiar septic organism in patients56,44. Increasingly relevant
medical problem worldwide with limited clinical treatment options in multidrug resistance strains of kleb
siella pneumoniae57-63. As though, this multidrug resistance is majorly caused by Bacteria
producing Klebsiella pneumoniae carbapenemases (KPCs) with ESBL’s are rapidly emerging worldwide.

4046 J. Chem. Bio. Phy. Sci. Sec. B, August 2015 – October 2015; Vol.5, No.4; 4040-4052
Growing Challenge… Ayub et al.

These enzymes are capable of hydrolyzing a broad spectrum of β-lactams including the penicillins,
cephalosporins, carbapenems and monobactam by the bacterial isolates which give them shelter.
Carbapenems are often an agent of the last resort for resistant Gram-negative infections due to the
treatment of infection caused by this type of enzymes is particularly worrisome64. Able to withstand
hydrolysis by ESBLs and class A carbapenemases are currently in development that are several new β-
lactamase inhibitors. NXL104, LK-157 and BLI-489 are included to restore the activity of several β-
lactam antibiotics were shown65. Avoided by provider and rational use of the existing and newer
antimicrobial agents from certain infections, with the increasing health care costs as well as severity and
death rates is antimicrobial resistance. By forming local, national and global wide Antibiograms, cost
effective and rational use of antimicrobial is possible66. Besides, increased carriage of K. pneumoniae and
the development of multidrug resistant strains that produce extended–spectrum beta lactamase [ESBL] as
an outcome of extensive use of broad-spectrum antibiotics in hospitalized patients62. Most frequently used
and misused of all drugs is the antibiotics. Emergence of antibiotic resistant pathogens as an unavoidable
consequence of the widespread use of antimicrobial agents servicing and leads to the development of new
drugs. In a country like Pakistan, microbiological diagnosis is not available to the 80% of the population,
but to prescribe multiple antibiotics, leaving doctors with no option could be a possible reason behind this
multi-drug resistance67. The best way to control the resistance is to reducing the inappropriate use of
antibiotic68. Familiar and significant problem in the hospital environment is a bacterial resistance69.
Personify an important public health problem that is in extension, coherent laboratory techniques
additionally, for prevention and control multidisciplinary forces70,71. Four resistant strategies are
associated with this multi-drug resistant bacteria that decline the effects of antibiotics. Antibiotics
inactivation and modification of enzymes is first, drug targeted restriction is second, drug targeting
alteration72 and phenotypic resistance is last The production of beta-lactamases is the primary form of
bacterial resistance to betalactamic antimicrobials, among the Gram-negative bacteria. Inactivating the
antimicrobial and impeding its activity against the enzymes responsible for the synthesis of the bacterial
cell wall, promote degradation of the betalactamic ring are the beta lactamases enzymes. Beta lactamases
and carbapenemases currently the most concerning groups as an amplified aspect among the beta
lactamases73.
It has been observed in a précised way from the above discussion of the past two years of Pakistan
healthcare sector in intensive care units, the huge utilization of antibiotics with irrational practice are a
fundamental aspect pledged for diminishing in the sensitivity of antibiotics and a leading consequence of
resistance mechanism. Further analysis is required and should be needed to treat this gracious organism.

CONCLUSION

Whatever has been studying the above data is the challenging data for the peoples which relate to the
healthcare professionals, because there is only limited treatment among the antibiotics to treat dangerous
infections caused by this K.pneumoniae. Increased resistance against K.pneumoniae from the major
classes of antibiotics like Quinolones, aminoglycosides, monobactams, carbapenems is the only treatment
option. It is concluded after careful considerations, as it is well known that it has a major role in
propagating different infections in community, especially nosocomial infection, with the emergence of the
increasing multidrug resistance blistering worldwide, including Pakistan, there is need to be further
investigations and evaluation of the elaboration of new and irrational therapy against K.pneumoniae and
to battle as well as to eradicate from the community.

4047 J. Chem. Bio. Phy. Sci. Sec. B, August 2015 – October 2015; Vol.5, No.4; 4040-4052
Growing Challenge… Ayub et al.

REFRENCES

1. V. W. Lin Ng, J. Leong, Z. X. Voo, J. Hedrick and Y. Y. Yang, Antimicrobial Polycarbonates:

Investigating the Impact of Nitrogen-Containing Heterocycles as Quaternizing Agents,
Macromolecules, 2014, 47 (4), 1285–1291.
2. S. Gul and M. Ayub, Gradual Decline in the Potency of Antipseudomonas Drugs: Evaluated by
Retrospective Comparative studies of Susceptibility and Resistance Pattern of Antimicrobials
against Pseudomonas Aeruginosa Isolates Obtained from Intensive Care Unit, World Journal of
Pharmaceutical Sciences, 2015, 3(7).
3. A. Abdaslam, Mohamed. A. Hassan, Hazem. H. Kaheel, Talib M. Abobaker , Tassneem. H.
Alnourain, Hamid. A. Hamdan, S. Gokul Shankar and John J. Thambirajah, Research Article Open
Access ISSN: 2320-2246 Isolation of Escherichia coli O157 and other food borne pathogens from
meat products and their susceptibility to different antimicrobial agents Sami, 2014.
4. A. M. younes, Molecular diversity and genetic organization antibiotic resistence in Klebsiella
species. University of Edinbuergh. Research, Current Research in Microbiology and
Biotechnology, 2010, 2(3), 391-397
5. D. Girlich, T. Naas and P. Nordmann, Biochemical Characterization of the Naturally Occuring
Oxacillinase OXA-50 of Pseudomonas aeruginosa, Antiicrobial, Agents and Chemotherapy, 2004,
48(6), 2043-2048.
6. V. T. Arlet, G. Ericsson, B. M. Tammelin, A. Courvalin, P. Lambert, Emergence of imipenem
resistance in Klebsiella pneumoniae owing to combination of plasmid-mediated CMY-4 and
permeability alteration, J Antimicrob Chemother., 2000, 46895- 900
7. J. D. D. Pitout and K. B. Laupland, Extended Spectrum Lactamase producing Enterobacteriaceae:
an emerging public health concern, Lancet infect Dis, 2008, 8, 159-66.
8. L. Poirel, J. D. Pitout, P. Nordmann, Carbapenemases: molecular diversity and clinical
consequences, Future Microbiol, 2007, 2(5), 501-512.
9. M. M. Yushau, A. S. Kumurya and L. Suleiman, Prevalence of Extended spectrum lactamases
among Enterobacteriaceae in Murtala Mohammed specialist hospital, Kano, N, Journal of Pure and
Applied Sciences, 2010, 3(1), 169- 172.
10. C. Dutour, R. Bonnet, H. Marchandin, M. Boyer, C. Chanal, D. Sirot and J. Sirot, CTXM-1,CTX-
M-3 and CTX-M-14 - lactamases from Enterobacteriaceae Isolated in France, Antimicrobial Agents
and Chemotherapy, 2002, 46(2), 534 - 537.
11. A. Manoharan, K. Premalatha, S. Chatterjee and D. Mathai, Correlation of TEM, SHV and CTX-M
extended-spectrum beta lactamases among Enterobacteriaceae with their in vitro antimicrobial
susceptibility, Indian Journal of Medical Microbiology, 2011, 29(2), 161-164
12. U. Chaudhary and R. Aggarwal, Extended spectrum -lactamases (ESBL) - An emerging threat to
clinical therapeutics, Indian J Med Microbiol, 2004, 22, 75-80.
13. M. Webber, L. J. Piddock, Quinolone resistance in Escherichia coli, Vet. Res., 2001, 32, 275-284.
14. A. Sorlózano, J. Gutiérrez, J. de Dios Luna, J. Oteo, J. Liébana, M. J. Soto, G. Piédrola, High
presence of extendedspectrum beta-lactamases and resistance to quinolones in clinical isolates of
Escherichia coli, Microbiol. Res., 2007, 162, 347- 354.
15. J. D. D. Pitout, P. Nordmann, K. B. Laupland, L. Poirel, Emergence of Enterobacteriaceae
producing Extended Spectrum Beta Lactamases (ESBLs) in the community, J Antimicrob.
Chemoth., 2005, 56, 52–59.

4048 J. Chem. Bio. Phy. Sci. Sec. B, August 2015 – October 2015; Vol.5, No.4; 4040-4052
Growing Challenge… Ayub et al.

16. S. S. Kanj, J. E. Corkill, Z. A. Kanafani, G. F. Araj, C. A. Hart, R. Jaafar and G. M. Matar,

Molecular characterisation of Extended Spectrum Beta Lactamase-producing Escherichia coli and
Klebsiella spp. isolates at a tertiary-care center in Lebanon, Clin. Microbiol. Infect., 2008, 14, 501-
504.
17. Z. Daoud and N. Hakime, Prevalence and susceptibility patterns of Extended Spectrum Beta
Lactamase-producing Escherichia coli and Klebsiella pneumoniae in a general university hospital in
Beirut, Lebanon, Rev. Esp. Quimioter., 2003, 16, 233-238.
18. S. Fukigai, J. Alba and S. Kimura et al., Nosocomial outbreak of genetically related IMP-1 β-
lactamase-producing Klebsiella pneumoniae in a general hospital in Japan, Int. J Antimicrob.
Agents, 2007, 29, 3306-10.
19. P. Giakkoupi, A. Xanthaki and M. Kanelopoulou et al., VIM-1 Metallo- β -Lactamase-Producing
Klebsiella pneumoniae Strains in Greek Hospitals, J Clin. Microbiol., 2003, 41, 3893–6.
20. Extended spectrum - Lactamases in Escherichia coli and Klebsiella pneumoniae and the prevalence
of qnr in Extended spectrum Lctamase Isolates in a tertiatiary Care Hospital in Korea, Yonesei
Medical Journal, vol. 51, no. 5, pp. 768-774.
21. M. Edelstein, M. Pimkin, I. Palagin, I. Edelstein and L. Stratchounski, Prevalence and molecular
epidemiology of CTX-M extendedspectrum beta-lactamase-producing Escherichia coli and
Klebsiella pneumoniae in Russian hospitals, Antimicrob. Agents Chemother., 2003, 47, 3724-3732.
22. E. Lebessi, H. Dellagrammaticas and P. T. Tassios et al., Extended spectrum β-lactamase-producing
Klebsiella pneumoniae in a neonatal intensif care unit in the high prevalence area of Athens Greece,
J. Clin. Microbiol., 2002, 40, 799-804.
23. R. Podschun and U. Ullmann, Klebsiella spp. as nosocomial pathogens: epidemiology, taxonomy,
typing methods, and pathogenicity factors, Clin. Microbiol. Rev., 1998, 11, 589-603.
24. CLSI. Performance Standards for Antimicrobial Susceptibility Testing, Twentieth Informational
Supplement, CLSI Document M100-S20, Wayne, PA: Clinical and Laboratory Standards Institute,
2010.
25. P. Lal, A. Kapil, B. K. Das and S. Sood, Occurence of TEM and SHV gene in extended spectrum
beta lactamases (ESBLs) producing Klebsiella spp. isolated from a tertiary care hospital, Indian
Journal Medical, 2007, 125, 173-178.
26. M. E. Rupp and D. Paul, Extended Spectrum -Lactamase (ESBL) Producing Enterobacteriaceae,
Drugs, 2003, 63(4), 353-356.
27. J. D. Pitout, Infections with extended-spectrum beta-lactamase-producing enterobacteriaceae:
changing epidemiology and drug treatment choices, Drugs, 2010, 70(3), 313-33.
28. Rapid Spread of Carbapenem-Resistant Klebsiella pneumoniae in New York City: A New Threat to
Our Antibiotic Armamentarium, 2005.
29. S. Bratu, D. Landman, R. N. Haag, R. Recco, R. N. A. Eramo, M. Alam, J. Quale, Rapid spread of
carbapenem-resistant Klebsiella pneumoniae in New York City: a new threat to our antibiotic
armamentarium. Arch Intern Med., 2005, 165(12).
30. Centers for Disease Control and Prevention, National Nosocomial Infections Surveillance (NNIS)
System Report, data summary from January 1992 through June 2003, issued August 2003, Am. J
Infect. Control., 2003, 31481- 498
31. D. L. Paterson, W. C. Ko, A. V. Gottberg, J. M. Casellas, M. Keith, P. Klugman, A. Robert,
B. Louis, B. Rice, J. G. Mc Cormack and L. Victor, YuOutcome of Cephalosporin Treatment for

4049 J. Chem. Bio. Phy. Sci. Sec. B, August 2015 – October 2015; Vol.5, No.4; 4040-4052
Growing Challenge… Ayub et al.

Serious Infections Due to Apparently Susceptible Organisms Producing Extended-Spectrum β-

Lactamases: Implications for the Clinical Microbiology Laboratory, March 2001
32. P. L. Winokur, R. Canton, J. M. Casellas and N. Legakis, Variations in the prevalence of strains
expressing an extended-spectrum β-lactamase phenotype and characterization of isolates from
Europe, the Americas, and the Western Pacific region, Clin. Infect. Dis., 2001, 32(2), S94- S103.
33. P. A. Bradford, C. Urban, N. Mariano, S. J. Projan, J. J. Rahal and K. Bush, Imipenem resistance
in Klebsiella pneumoniae is associated with the combination of ACT-1, a plasmid-mediated AmpC
β-lactamase, and the loss of an outer membrane protein, Antimicrob. Agents Chemother., 1997,
41563- 569
34. H. S. Gold and R. C. Mollering, Jr Antimicrobial drug resistance, N Engl. J Med., 1996,335, 1445-
1453
35. Clinical and laboratory standard institute, M-100-S 24 performance standard for antimicrobial
susceptibility testing; twenty-fourth informational supplement, 2014, 34 # 1
36. Somia Gul and Maria Ayub.Gradual Decline in the Potency of Antipseudomonas Drugs: Evaluated
by Retrospective Comparative studies of Susceptibility and Resistance Pattern of Antimicrobials
against Pseudomonas Aeruginosa Isolates Obtained from Intensive Care Unit.2015,Volume
: 3 Issue :7.
37. T. L. Lauderdale, F. Y. Chang, R. J. Ben, H. C. Yin, Y. H. Ni, J. W. Tsai, S. H. Cheng, J. T. Wang,
Y. C. Liu and Y. W. Cheng et al., Etiology of community acquired pneumonia among adult patients
requiring hospitalization in Taiwan, Respiratory Medicine, 2005, 99, 1079-1086.
38. P. Nordamann, G. Cuzon and T. Naas, The real threat of Klebsiella pneumonia carbapenemase-
producing bacteria, Lancet Infec. Dis., 2009, 9(4), 228-236.
39. C. M. Chang, H. C. Lee, N. Y. Lee, I. W. Lee, C. J. Wu, P. L. Chen, C. C. Lee, N. Y. Ko,
Community-acquired Klebsiella pneumoniae complicated skin and soft-tissue infections of
extremities: emphasis on cirrhotic patients and gas formation, Infection, 2008, 36, 328-334.
40. C. Feldman, J. M. Kallenbach, H. Levy, J. R. Thorburn, M. D. Hurwitz and H. J. Koornhof,
Comparison of bacteraemic community-acquired lobar pneumonia due to Streptococcus
pneumoniae and Klebsiella pneumoniae in an intensive care unit, Respiration, 1991, 58, 265-270.
41. F. Paganin, F. Lilienthal, A. Bourdin, N. Lugagne, F. Tixier, R. Genin, J. L. Yvin, Severe
community-acquired pneumonia: assessment of microbial aetiology as mortality factor, Eur. Respir.
J., 2004, 24, 779-785.
42. H. Hackstein, S. Kranz , A. Lippitsch, A. Wachtendorf, O. Kershaw, A. D. Gruber, G. Michel, J.
Lohmeyer, G. Bein, N. Baal and S. H. Hackstein et al., Modulation of respiratory dendritic cells
during Klebsiella pneumonia infection, Respiratory Research, 2013, 14, 91.
43. A. D. Dean, A. J. Dean, A. H. Burton and R. C. Dicker, EpiInfoversion 5: a word processing
database and statistics 2013, 1(6), 928 -933. programme for epidemiology on
microcomputers.VSD. Inc Stone Mountain Ga, 1990.
44. K. Bush, Bench-to-bedside review: The role of beta-lactamases in antibiotic-resistant Gram-
negative infections, Crit. Care, 2010, 14, 224
45. T. A. Ahmad, L. H. El-Sayed, M. Haroun, A. A. Hussein, E. S. H. El Ashry, Development of
immunization trials against Klebsiella pneumoniae, Vaccine, 2012, 30, 2411–2420.
46. D. M. Livermore, Current epidemiology and growing resistance of gram negative pathogens,
Korean J Intern Med., 2012, 27, 128–142.

4050 J. Chem. Bio. Phy. Sci. Sec. B, August 2015 – October 2015; Vol.5, No.4; 4040-4052
Growing Challenge… Ayub et al.

47. A. Gupta, Hospital-acquired infections in the neonatal intensive care unit–Klebsiella pneumoniae,
Semin. Perinatol., 2002, 26, 340–345.
48. J. M. Matsen, The sources of hospital infection, Medicine (Baltimore), 1973, 52, 271–277.
49. W. R. Jarvis, V. P. Munn, A. K. Highsmith, D. H. Culver, J. M. Hughes, The epidemiology of
nosocomial infections caused by Klebsiella pneumoniae, Infect. Control., 1985, 6, 68–74.
50. I. V. Yankov, T. I. Shmilev, Ventilator-associated pneumonias in children (I)–diagnostic criteria,
etiology and pathogenesis, Folia Med (Plovdiv), 2012, 54, 5–11.
51. R. S. Arnold, K. A. Thom, S. Sharma, M. Phillips, J. K. Johnson and D. J. Morgan, Emergence of
Klebsiella pneumoniae carbapenemase-producing bacteria, South Med. J., 2011, 104, 40–45.
52. P. Nordamann, G. Cuzon and T. Naas, The real threat of Klebsiella pneumoniae carbapenemase
producing bacteria, Lancet Infec. Dis., 2009, 9(4), 228-236.
53. S. J. Cryz, R. Furer and R. Germanier, Protection against fatal Klebsiella pneumoniae burn wound
sepsis by passive transfer of anticapsular polysaccharide, Infect. Immun., 1985, 45, 139-142.
54. M. T. Johnson, R. Reichley, J. Hoppe-Bauer, W. M. Dunne, S. Micek and M. Kollef, Impact of
previous antibiotic therapy on outcome of Gram-negative severe sepsis, Crit. Care Med., 2011, 39,
1859-1865.
55. A. Mushtaq, M. Abid and M. A. Qureshi, Is prophylactic antibiotic treatment justified in neonates?
J. Pak. Med. Assoc., 2012, 62, 856-57.
56. B. A. Khan, S. Saeed, A. Akram, F. B. Khan and A. Nasim, Nosocomial uropathogens and their
antibiotic sensitivity patterns in a tertiary referral teaching hospital in Rawalpindi, Pakistan, J. Ayub
Med. Coll. Abbottabad, 2010, 22, 11-12.
57. R. P. Rapp, C. Urban, Klebsiella pneumoniae carbapenemases in Enterobacteriaceae: history,
evolution, and microbiology concerns, Pharmacotherapy, 2012, 32, 399–407.
58. R. M. da Silva, J. Traebert and D. Galato, Klebsiella pneumoniae carbapenemase (KPC)-producing
Klebsiella pneumoniae: a review of epidemiological and clinical aspects, Expert Opin. Biol. Ther.,
2012, 12, 663–671.
59. Y. Chong, Y. Ito and T. Kamimura. Genetic evolution and clinical impact in extended-spectrum
beta-lactamase-producing Escherichia coli and Klebsiella pneumoniae, Infect. Genet. Evol., 2011,
11, 1499–1504.
60. P. Nordmann, G. Cuzon and T. Naas, The real threat of Klebsiella pneumoniae carbapenemase-
producing bacteria, Lancet Infect. Dis., 2009, 9, 228–236.
61. Detection and treatment options for Klebsiella pneumoniae carbapenemases (KPCs): an emerging
cause of multidrug-resistant infection, J. Antimicrob. Chemother., 2010, 65(6), 1119-1125. First
published online: April 8, 2010
62. F. H. Chambers, General principles of antimicrobial therapy; Goodman & Gillman’s, The
Pharmacological basis of Therapeutics, 11th edition, New York: McGraw-Hill, 2006, 1095.
63. J. E. Yoon, W. K. Kim, J. S. Lee, K. S. Shin and T. S. Ha, Antibiotic susceptibility and imaging
findings of the causative microorganisms responsible for acute urinary tract infection in children: A
five-year single center study, Korean J. Pediatr., 2011, 54, 79-85.
64. T. Stachyra, P. Levasseur, M. C. Pechereau et al., In vitro activity of the β-lactamase inhibitor
NXL104 against KPC-2 carbapenemase and Enterobacteriaceae expressing KPC carbapenemases, J
Antimicrob. Chemother., 2009, 64, 326-9.
65. Antimicrobial Sensitivity Pattern of Klebsiella Pneumoniae isolated from Sputum from Tertiary
Care Hospital, Surendranagar, Gujarat and Issues Related to the Rational Selection of

4051 J. Chem. Bio. Phy. Sci. Sec. B, August 2015 – October 2015; Vol.5, No.4; 4040-4052
Growing Challenge… Ayub et al.

Antimicrobials Asati Rakesh Kumar, Scholars Journal of Applied Medical Sciences (SJAMS) ISSN
2320-6691 (Online) Sch, J. App. Med. Sci., 2013, 1(6), 928-933
66. P. Nordamann, G. Cuzon and T. Naas, The real threat of Klebsiella pneumonia ecarbapenemase
producing bacteria, Lancet Infec. Dis., 2009; 9 (4), 228-236.
67. S. Henry, M. D. Fraimow, T.Constantine, Antimicrobial resistance in the Intensive Care Unit:
Mechanism, Epidemiology and Management of specific Resistant Pathogens, Crit. Care Clin.,
2011, 27(1), 163-205.
68. Nosocomial infections by Klebsiella pneumoniae carbapenemase producing enterobacteria 283
einstein., 2014, 12(3), 282-6.
69. J. B. Patel, J. K. Rasheed, M. S. B. Kitchel, Carbapenemases in Enterobacteriaceae: activity,
epidemiology and laboratory detection, Clin. Microb. News, 2009, 31(8), 55-62.
70. C. G. Giske, L. Gezelius, Q. Samuelsen, M. Warner, A. Sundsfjord, N. Woodford, A sensitive and
specific phenotypic assay for detection of metallo-β- lactamases and KPC in Klebsiella pneumoniae
with the use of meropenem disks supplemented with aminophenylboronic acid, dipicolinic acid and
cloxacillin, Clin. Microbiol. Infect., 2011, 17(4), 552-6.
71. A. P. Alves and P. R. Behar, Infecções hospitalares por enterobactérias produtoras de KPC em um
hospital terciário do sul do Brasil, Rev AMRIGS, 2013, 57(3), 213-8.
72. D. R. Burwen, S. N. Banerjee and R. P. Gaynes, The national nosocomial infections surveillance
system. Ceftazidime resistance among selected nosocomial gram negative bacilli in the United
States, I. Infect. Dis., 1994, 170, 1622–1625.
73. A. Amin, P. B. Ghumro, S. Hussain and A. Hameed, Prevalence of antibiotic resistance among
clinical isolates of Klebsiella pneumonia isolated from a Tertiary Care Hospital in Pakistan, Mal. J.
Microbiol., 2009, 5, 81-86.

Corresponding author: Maria Ayub;

Lecturer, Faculty of Pharmacy, Jinnah University for Women, Karachi 74600, Pakistan

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