RESUMEN
The global rise in infections caused by multidrug resistant (MDR) Enterobacterales poses a public health problem. We have performed a molecular epidemiological characterisation of representative plasmid-mediated AmpC (pAmpC) and ESBL-positive clinical isolates of Escherichia coli (n = 38) and Klebsiella pneumoniae (n = 17) from a tertiary hospital in Malawi collected in 2017. BlaCTX-M-15 was the most prevalent ESBL-determinant in E. coli (n = 30/38) and K. pneumoniae (n = 17/17), whereas blaCMY-2 was detected in nearly all AmpC-phenotype E. coli (n = 15/17). Whole genome sequencing revealed dominant globally disseminated E. coli sequence types (STs); ST410 (n = 16), ST131 (n = 7), and ST617 (n = 6). The ST distribution in K. pneumoniae was more diverse but included ST101 (n = 2), ST14 (n = 2), and ST340 (n = 2), all considered high-risk MDR clones. The isolates expressed an MDR profile, including resistance against commonly used antibiotics, such as fluoroquinolones, aminoglycosides, and/or trimethoprim-sulfamethoxazole, and harboured corresponding resistance determinants. Clonal analyses of the major STs of E. coli revealed closely related genetic clusters within ST410, ST131, and ST617 supporting within-hospital transmission between patients and/or via a common reservoir. The overall findings add to the limited knowledge on the molecular epidemiology of MDR E. coli and K. pneumoniae in Malawi and may help health policy makers to identify areas to target when addressing this major threat of antibiotic resistance.
RESUMEN
Background: The aim of this prospective study was to ascertain antimicrobial resistance (AMR) in clinical bacterial pathogens from in-hospital adult patients at a tertiary hospital in Lilongwe, Malawi. Methods: Clinical specimens (blood culture, pus, urine and cerebrospinal fluid) collected during June to December 2017 were examined for bacterial growth in standard aerobic conditions. One specimen per patient was included. Antimicrobial susceptibility testing (AST) was performed using the disk diffusion method and interpreted according to EUCAST guidelines. Results: A total of 694 specimens were collected during the study period, of which 336 (48%) specimen yielded visible bacterial growth. Of the 336 specimens, a total of 411 phenotypically different isolates were recovered. Of the 411 isolates, 84 isolates (20%) were excluded and the remaining 327 (80%) were further characterised. The characterised isolates were identified as ESKAPE pathogens (n=195/327; 60%), Escherichia coli (n=92/327; 28%), Proteus mirabilis (n=33/327; 10) or Salmonella spp. (n=7/327; 2%) and were included for further analysis. The excluded isolates (n=84) comprised of coagulase-negative staphylococci (n=25), streptococci (n=33), and low-prevalence Gram-negative bacilli (n=26). E. coli (n=92; 28%) and S. aureus (n=86; 26%) were the most dominant species. A multidrug resistant (MDR) extended spectrum ß- lactamase (ESBL)-positive phenotype was detected in Klebsiella pneumoniae (n=20/29; 69%) and E. coli (n=49/92; 53%). One third of the Pseudomonas aeruginosa isolates were resistant to meropenem (MEM), but did not appear to be carbapenemase-producers. Methicillin resistant Staphylococcus aureus (MRSA) was molecularly confirmed in 10.5% of S. aureus (n=9/86). Conclusion: The high proportion of the MDR ESBL-phenotype in clinical isolates of Enterobacterales, strongly limits antimicrobial treatment options and has consequences for empirical and targeted antimicrobial treatment as well as clinical microbiology services and hospital infection control. There is need for a continuous surveillance and an antimicrobial stewardship (AMS) program to contain and prevent the spread of AMR.
