Clonal Dissemination of Extended-Spectrum Beta-Lactamase (ESBL)- producing Klebsiella pneumoniae isolated from Medical devices and Hospital environments in the West region, Cameroon

doi:10.21203/rs.3.rs-5006261/v1

Background

Hospital-acquired infections (HAIs) caused by antibiotic resistant Klebsiella pneumoniae are serious public health concern globally. Extended-spectrum β-lactamase-producing Klebsiella pneumoniae (ESBL-K. pneumoniae) are major contributors to life-threatening HAIs especially in surgery and intensive care unit wards. Suboptimal hygiene measures and the non-existence of infection prevention control programs and policies contribute to the dissemination of ESBL-K. pneumoniae from the inanimate surfaces, medical devices, healthcare workers to hospitalized patients. This study aimed at determining the prevalence, genotypic characteristics and clonal relatedness of ESBL- K. pneumoniae isolated from surgical patients, medical devices and hospital environments at the Annex Regional Hospital of Dschang in the West region in Cameroon.

Methods

A cross-sectional study was conducted over a four-month period from February to May 2022. A total of 91 samples were collected from hospitalized patients (n = 46), medical equipments (n = 20) and hospital environments (n = 25). Samples were cultured on Eosin Methylene Blue agar. After culture and biochemical identification with API 20E, antibiotic susceptibility testing was carried out using disc diffusion method on Müller Hinton agar. ESBL phenotype was screening using ChromAgar™ ESBL (CHROMagar, Paris, France) coupled with double discs synergy test. In addition, the detection of resistance genes was done with Polymerase Chain Reaction (PCR) methods, while the clonal relatedness of isolates was performed using the Enterobacterial Repetitive Intergenic Consensus (ERIC) PCR method.

Results

The prevalences of ESBL-K. pneumoniae isolated from surgical patients was 23.9% (11/46). Only two Klebsiella pneumoniae were isolated from medical equipment of which one isolate was ESBL producer with 5% (n = 01/20). The result of the hospital environment revealed 28% (07/25) were positive for ESBL-K. pneumoniae. High level of resistance (100%) to cefuroxime, amoxicillin-clavulanic acid, cefuroxime, ceftriaxone and cefotaxime were observed. In addition, the resistance rates to gentamicin and meropenem were (89.4%) and (42.1%) respectively. The leading β-lactam resistance gene detected was bla_CTX−M (65.6%) followed by bla_TEM (43.7%) and bla_SHV (25%). The clonal relatedness revealed the likely circulation of ESBL-Klebsiella pneumoniae between wards and the hospital environment respectively.

Conclusion

Hospital environment remains a reservoir of ESBL-K. pneumoniae in this hospital setting and could be transmitted to the hospitalized patients. It is therefore imperative, even very urgent, to implement stringent infection prevention and control measures to curb the dissemination of ESBL-Klebsiella pneumoniae in hospital setting in West region.

Klebsiella pneumoniae

Medical devices

Hospital environments

Surgical patients

Cameroon

Hospital-acquired infections (HAIs) are a worldwide health concern with a disproportionately high burden in resource-limited countries [1, 2]. They posed a significant public health problem by increasing hospital length of stay and healthcare-associated costs, higher morbidity and mortality rates, especially in Low- and Low-Middle-Income Countries (LLMICs) [2, 3, 4]. The global dissemination of antimicrobial resistance exacerbates the problem of HAIs. The major drivers of antimicrobial resistance in these settings remain inappropriate antimicrobial prescription practices and poor infection prevention and control measures in healthcare facilities [5]. The hospital environment (HE) remains an important reservoir for numerous pathogens that could lead to HAIs [6]. Klebsiella pneumoniae is a leading cause of opportunistic healthcare-associated infections, which are increasingly complicated by the presence of extended-spectrum beta-lactamases (ESBLs) [7]. It is thus clear that the heavy antibiotic usage among hospitalized and surgical patients in sub-Saharan Africa remain a major public health threat. The majority of these antibiotics are prescribed for prophylaxis purposes, thus increasing antimicrobial resistance, length of hospitalization and deaths. In 2019 a systematic review and meta-analysis shown that 51.0% of K. pneumonia was multi-drug resistant (MDR) in Cameroon, and that commonly prescribed antibiotics were highly resistant [8]. In 2022, a study of antibiotic susceptibility profile of germs responsible for nosocomial infections in the surgical and intensive care units at Military Hospital Region N° 1, Yaoundé, Cameroon reported a 60% prevalence of surgical site infections and a low sensitivity rate for the different antibiotics tested due to the systematic administration of antibiotics to patients [2]. More recently, a descriptive study investigating bacteriological profiles of surgical site infection at Deido District Hospital in Douala, Cameroon reported that the prevalence of post-surgical site infection was 32, 3%, the clinical spectrum and bacterial sensitivity was diverse in 2023[9]. Yet, data about K. pneumoniae in the Western region of the country remains scarce.

Extended-spectrum β-lactamase-producing Klebsiella pneumoniae (ESBL-Kp) were listed as critical priority bacteria for research and development of new antibiotics by the World Health Organisation (WHO) [10]. Extended-spectrum β-lactamase-producing K. pneumoniae is among the leading pathogens implicated in HAIs especially those with surgical operations [11]. A report in Algeria has shown a high prevalence of ESBL-Kp isolated from inanimate objects, hospital environment and revealed that bla_{CTX−M−1−group} was the most prevalent genes detected [6]. To the best of our knowledge, no study has focused on the genetic diversity of ESBL-Kp in surgical patients, medical devices and hospital environment in the Western region of Cameroon. This study therefore aimed at determining the prevalence and genotypic characteristics of ESBL-Kp circulating among surgical patients, medical equipment, and hospital environment in the West region of Cameroon with view to invigorate infection prevention and control policies and serves as a proof of concept to implement the One Health Approach in hospital settings.

1. Study design, population and settings

A cross-sectional study was conducted for four months, from February to May 2022. Samples were collected at Annex Regional Hospital of Dschang (ARHD) in the West region of Cameroon. The study population included patients older than 18 years old, hospitalized and scheduled to undergo a surgery at the different surgical wards of ARHD. In addition, medical equipment was composed of inanimate surfaces by tweezers, vacuum cleaners, oxygen masks and Farabeuf retractors. The hospital environments were composed of inanimate surfaces including bed-side tables and door handles of operating theatres, treatment room and gynaecology ward.

2. Sampling procedure and sample collection

All hospitalized patients who met the inclusion criteria including: be at least 18 years old, have had or planned to have a surgery and consenting to participate in the study. Moreover, the participants were selected based on the length of stay post-operative. All participants were followed up to get samples and clinical information before and after surgery. All wound samples were collected using sterile swabs from included patients during or within five days after surgery. Hospital environment (tables, door handles, care cart and cyalidic) and medical equipment (Tweezers, vacuum cleaners, oxygen masks and Farabeuf retractors) were also sampled using sterile swabs moistened with sterile normal saline water (0.9% w/v NaCl) any time an operation was scheduled.

3. Ethical considerations

Ethical clearance was granted by the West Regional Ethics Committee for Research in Human Health, Bafoussam, Cameroon under the number (638/26/07/2023/CE/CRERSH-OU/VP) and the authorization of the Director of the Hospital under the number (159/AR/MSP/DRSPO/DSD/HDD). Oral and written informed consent was obtained either from the participants directly or from the closest relative for patients of legal age who were critically ill and could not provide informed consent. All samples and information from patients were codified to ensure confidentiality.

4. Laboratory analysis

4.1. Phenotypical characterization and ESBL screening

After sampling, samples collected were cultured onto Eosin Methylene Blue (EMB) agar and incubated overnight at 37°C for 18 to 24 hours in presence of oxygen. All growing colonies were subjected to biochemical tests using Enterosystem 18R kit (LIOFILCHEM, Scozia, Italia) according to the manufacturer’s instructions. Pure K. pneumoniae colonies were stored in 1.5ml Tryptone Soy Broth (TSB) supplemented with 20% glycerol (v/v) and stored at -20°C for further experiments. Klebsiella pneumoniae isolates were double screened for the production of ESBL enzyme using CHROMAgar ESBL™ (CHROMagar, Paris, France) and synergy test using the ceftazidime, cefotaxime- and clavulanic acid (30/10 µg) .

4.2. Antimicrobial Susceptibility Testing (AST)

The Kirby-Bauer disc diffusion method was used to assess the susceptibility profiles of K. pneumoniae. Briefly, Mueller-Hinton agar was swabbed with a standardized 0.5 McFarland bacterial inoculum. Subsequently, a panel of nine antibiotics discs of four different families were tested including amoxicillin-clavulanic acid (20–10 µg), cefuroxime (30 µg), cefotaxime (30 µg), ceftriaxone (30 µg), meropenem (10µg), ofloxacin (5 mcg), gentamicin (30 µg), levofloxacin (5 µg), and chloramphenicol (10 µg). The plates were then incubated overnight at 37◦C for 18–24 h. The different diameters of inhibition zones were measured and interpreted as susceptible (S) or resistant (R) according to the Antibiogram Committee of the French Society of Microbiology’s recommendations (CA-SFM 2022). When reading the antibiogram, Klebsiella pneumoniae isolates that were resistant to at least 3 different antibiotic families were considered multi-drug resistant.

4.3. Genomic Extraction

The genomic DNA of all ESBL-K. pneumoniae isolates was obtained using a modified boiling method as previously described [12]. Briefly, one or two pure ESBL-K. pneumoniae colonies were suspended into 400 µL of Tris-EDTA (10 mM Tris, 0.1 mM EDTA) and then vortexed for five seconds. The bacterial suspension was then incubated for 25 min at 95◦C in a dry bath digital (MIULab DKT200-1, Lasec International Ltd., Johannesburg, South Africa). After incubation, the suspension was centrifuged for 5 min at 9500 rpm and then, 300 µL of the supernatant containing genomic DNA was subsequently transferred to a new Eppendorf tube and then stored at − 40◦C for future experiments.

4.4. Conventional and multiplex polymerase chain reaction methods (PCRs)

Polymerase chain reaction (PCR) methods were used to detect the genes conferring resistance to β-lactams family. The detection of bla_SHV gene was done using conventional PCR method, the reaction took place in a 10 µl reaction mix consisting of 5 µl of Dream Green Taq polymerase 2X (Thermo Fisher Scientific, Lithuania), 2.8 µl of nuclease-free water, 0.1 µl of each forward and reverse primers [10 µM] and 2 µl of template DNA. The detection of the bla_CTX−M and bla_TEM genes was done using a multiplex PCR method. The reaction took place in a 10 µl reaction mixture made up of 5 µl of Dream Green Taq polymerase 2X (Thermo Fisher Scientific, Lithuania), 2.6 µl of nuclease-free water, 0.1 µl of each forward (CTX-MU1 and TEM-F) and reverse (CTX-MU2 and TEM-R) primers [50 µM] and 2 µL of template DNA. Each amplification was done in 30 cycles with PCR conditions of both conventional and multiplex PCR are presented as follows: Initial denaturation (95°C for 3min), cyclic denaturation at 95°C for 4s, annealing at 46.9°C for 1min, elongation at 72°C for 1min and final elongation at 72°C for 5min. The characteristics of selected primers are described in supplementary table.

4.5 Clonal relatedness of ESBL-K. pneumoniae

Enterobacterial Repetitive Intergenic Consensus Polymerase Chain Reaction (ERIC-PCR) was used to establish the clonal relatedness between ESBL-K. pneumoniae isolates. It was carried out using the primers ERIC1 5’ATGTAAGCTC CTGGGGATTCAC3’ and ERIC2R 5’AAGTAAGTGAC TGGGGTGAGCG3’ [13]. Each reaction mixture consisted of 10 µl PCR mix made up of 5µl of DreamTaq Green Polymerase Master Mix 2X (Thermo Fisher Scientific, Johannesburg, South Africa), 2.8 µl of nuclease free water, 0.1 µl of each primer [100 Μm], and 2 µl of template DNA. Amplification conditions was done as previously described (R. C. Founou et al., 2018). The generated amplicons were resolved by agarose gel electrophoresis on a 1.5% (w/v) Tris-EDTA 1X (Thermofisher) agarose gels, together with 1-kb ladder (Biolabs, New England) and run in an electric field of 110 V for 2 h 30 min [14]. Electrophoresis gels were visualized by a UV light trans-illuminator, images were captured using a gel documentation system G-BOX chemi XL (Syngene, Cambridge, UK). The gel pictures were exported to GelJ software (version 2.0) where strains were allocated to different clusters by calculating the similarity coefficient from the homology matrix using the Dice method. Dendrograms were constructed based on the average linkages of the matrix and using the Unweighted Pair-Group Method (UPGMA).

4.6. DNA Electrophoresis and Visualization

Electrophoresis was performed on 1.5% (v/v) agarose gel at 90V for 45 min along with a 100bp ladder (New England Biolabs, MA, USA). The gel was then stained in ethidium bromide solution (0.5 µg/mL) and rinsed with distilled water. PCR products were visualized under UV light using a gel documentation system G-BOX chemi XL (Syngene, Cambridge, UK).

4.7. Quality control

The K. pneumoniae ATCC 700603 and E. coli ATCC 35218 were used as a positive control strains for quality assessment of antibiotics, chromogenic culture media, as well as for bla_TEM and bla_SHV genes detection. An internal control strain of ESBL-E. coli was used as positive control for bla_CTX−M gene.

4.8. Data analysis

Before recording for analysis all data were carefully checked. The data was reported and analyzed using the software Microsoft® Office Excel 2016 and SPSS® version 26. A participant was considered positive for ESBL-K. pneumoniae when at least one K. pneumoniae detected from the sample displayed ESBL phenotype. Categorical variables were compared using either the χ² test or Fischer's exact test where appropriate. A result was considered statistically significant at a p-value < 0.05. The results obtained were analyzed, interpreted and presented in the form of figures and tables.

1. Socio-demographic and the clinical characteristics of patients

A total of 58 hospitalized patients were contacted among surgical and gynaecology wards. Out of these, 57 were enrolled and 46 were sampled during the study period. The Table 1 illustrates the distribution of these participants according to socio-demographic and the clinical characteristics. The majority of the participants were women aged between [21-31] years old with a sex-ratio (0.43). The majority of participants were married (n= 33/46; 71.7%); most of them (n=26/46; 56.5%) lived in urban areas and had a secondary educational level (n=18/46; 39.1%). The factors associated with ESBL-K. pneumoniae among with significant p-value patients were the wards (p-value=0.042), antibiotic consumption (p-value=0.019), length of hospitalization (p-value=0.001) and history of previous infection (Table 1).

2. Description of medical equipment and hospital environment samples

In addition, 20 samples were collected from medical equipment mainly the oxygen mask (n=3), tweezers (n= 14), vacuum cleaners (n= 2) and Farabeuf retractors (n=1). A total of 25 samples were collected in hospital environment including bedsides table (n= 4), care cart (n=6) door handles (n=13) and cyalidic (n=2).

3. Distribution of ESBL-Klebsiella pneumoniae isolated from surgical patients, medical equipment and hospital environment

The overall prevalence of ESBL-K. pneumoniae in the study was 20.87% (19/91). More specifically, of the 46 hospitalized patients who provided samples, 23.9% (11/46) were positive for ESBL-K. pneumoniae. Out of the 20 samples collected from medical equipment including oxygen mask and tweezers, 5% (n=01/20) being positive for ESBL-K. pneumoniae. The frequency of ESBL-K. pneumoniae in hospital environment was 28% (n=07/25).

4. Antimicrobial resistance profiles of ESBL-K. pneumoniae isolates

Antimicrobial resistance profiles of ESBL-K. pneumoniae revealed an overall 100% resistance to amoxicillin-clavulanic acid, cefuroxime, ceftriaxone and cefotaxime. It also shown a high resistance rates to gentamicin (89.4%) and meropenem (42.1%) (Figure 1). However, ciprofloxacin and chloramphenicol were the more susceptible antibiotics with 26.3% of resistance rates. The most common resistant patterns between three sources of samples was AMC-CRO-CTX-CTR-MER-OF-LEV-CN-CHL (5/32; 15.6%) with resistance to nine antibiotics tested during our study of different families: β-lactamines, phenicols, aminoglycosides and fluoroquinolone. More specifically, resistance to AMC-CRX-CTX-CTR-MER-LEV-CN-CHL predominated in patients while in medical equipment and environment, AMC-CRO-CTX-CTR-MER-OF-LEV-CN-CHL was the most resistant antibiotic.

5. Occurrence of β-lactamase genes

Among three β-lactamase resistance genes screened, the leading β-lactam resistance gene detected in patients, medical devices and environment was bla_CTX-M(65.6%) followed by bla_TEM(43.7%)and bla_SHV (25%). The distribution of these resistant genes is illustrated in Table 2 and Figure 2.

6. Genotypic relatedness

Enterobacterial Repetitive Intergenic Consensus fingerprints revealed the association between ESBL-K. pneumoniae isolated from surgical patients, hospital environment and medical equipment as illustrated in figure 3. The phylogenetic tree constructed revealed that ESBL-K. pneumoniae were grouped into one cluster. Two ESBL-K. pneumoniae isolates (EV10A and EV10B) collected on bedside table from the surgery department shared 100% of similarity with another strain isolated after 21 days from a medical equipment (EQ3) within an operating theater. In addition, these batch of three isolates were MDR and harbored the same β-lactamase genes (bla_CTX-M and bla_TEM). Similar findings were observed where two isolates collected the same day from wound shared 100% of similarity with two MDR isolates (P4 and P7A) and harbored the same β-lactamase genes. However, an ESBL-Klebsiella pneumoniae isolate from an hospitalized patient was not typable.

The aim of this study was to perform the genotypic characterization and evidence the clonal dissemination of ESBL-Kp isolated from medical equipment, surgical patients and hospital environment at the Annex Regional Hospital of Dschang in the West region in Cameroon. The high incidence observed among the post-operative patients attending treatment room for dressing suggest to re-evaluate the antibiotic prophylaxis used in these services to reduce antimicrobial resistance level.

Our results revealed that prevalence of ESBL and MDR-Kp circulating among hospitalized patients 5 days after surgery with 23.9% (n = 11/46) and 28.6% (13/46) respectively. Furthermore, these findings are similar to previous studies investigating ESBL-Kp which reported a high ESBL-Kp prevalence from the hospitalized patients in KwaZulu-Natal, South Africa (29%) in 2019 and Tertiary Care Hospital in Kurnool, India (17%) [13,15 ].

The prevalence of ESBL-Kp among medical equipment (5%, n = 1/20) and the hospital environment (20%, n = 05/25) are higher than that reported in the hospital environment in two referral hospitals in Yaoundé, Cameroon in 2015 where 2.02% (n = 3/148) of Klebsiella pneumoniae were detected in the hospital environment [16]. This discrepancy could be explained by the fact that the hospitals level’s following the health care level involved in this study was different and the biosecurity implemented in these hospitals were also different.

The antimicrobial susceptibility profiles revealed that all ESBL-Kp isolates were resistant to amoxicillin-clavulanic acid, cefuroxime, ceftriaxone and cefotaxime. These results are higher than those obtained in Ghana in 2020 where the resistance rates of theses antibiotic families have increased over the years ranging from 80%, 74%, 69% and 65–100% respectively [17]. The high resistance rates to gentamicin (89.4%) was also observed in our study. This is an agreement with several previous studies investigating on high prevalence of Multidrug Resistant Klebsiella Species and Evolution of antibiotic resistance of Enterobacteriaceae, where 75.7% and 72% of resistance rates to gentamicin were detected in the Yaoundé university teaching hospital and Douala general hospital in Cameroon from 2005 to 2012 in 2015 and 2021, respectively [18, 19]. The high resistance rate to meropenem (42.1%) observed, is high compared to a study carried out in the Yaoundé university teaching hospital where the resistance to meropenem among patients was 2.7% in February 2019 to July 2019 [18].

The bla_CTX−M was the leading β-lactamase resistance genes detected among our isolates. This result is agreement with previous studies which demonstrated that bla_CTX−M is widely circulating in Africa [20, 21, 22, 23, 24]. These results can also be explained by the fact that, ESBLs are likely disseminating in hospital environment through horizontal transfer mechanisms involving mobile genetic elements such as plasmids, transposons, and insertion sequences, carrying frequently these β-lactam resistance genes [25].

The clonal relatedness showed that ESBL-Kp are likely circulating in this hospital setting reinforcing the need to strengthen infection prevention and control policy, instigate monitoring of HAI and antibiotic-resistant bacteria in healthcare settings, and heighten awareness on simple measures that can save lives [26].

Our study has several limitations. First, the population studied was delicate so we were not able to obtain all the information sought from patients such as the antibiotics consumed before the operation. This prevented us from providing an exact prevalence of nosocomial infections due to ESBL-K. pneumoniae linked to the previous ß-lactams usage. Second, in our geographical context, many people do not understand the importance of the “One Health” Approach in healthcare facilities and have not yet become aware of the impact of the emergence of ESBL on environmental interface. It was therefore became difficult to convince participants and healthcare workers of the importance of this study reducing thus our patient sample size which prevented us to determe meaningfully the risk factors for nosocomial infections.

This study reveals the high prevalence of ESBL-Kp among three interfaces. High clonal dissemination of ESBL-Kp has been demonstrated at the ARHD in the Western region, Cameroon. The principal risk factors were length of hospitalization, antibiotic consumption and history of previous infection as well as previous antibiotic treatment. The high incidence observed among the post-operative patients attending treatment room for dressing suggest to re-evaluate the antibiotic prophylaxis used in these services to reduce incidence of antimicrobial resistance. It is thus imperative to implement antimicrobial stewardship program and reinforce infection prevention and control coupled with strict hygiene measures in these wards in order to curb the dissemination of ESBL-K. pneumoniae.

ARHD

Annex Regional Hospital of Dschang

AST

Antibiotic Susceptibility Test

ERIC

Enterobacterial Repetitive Intergenic Consensus

ESBL

Extended Spectrum β-lactamase

ESBL-Kp

Extended Spectrum β-lactamase Klebsiella pneumoniae

HAI

Hospital Acquired Infections

HE

Hospital Environment

MDR

Multidrug Resistance

MDR-Kp

Multidrug Resistant Klebsiella pneumoniae

LMICs

Low Middle-Income Countries

3GC

Third Generation Cephalosporin

PCR

Polymerase Chain Reaction

SSIs

Surgical Site Infections

Ethics approval and consent to participate

This research has been approved by the Regional Ethics Committee for Health Research for the Western region (N°638/26/07/2023/CE/CRERSH-OU/VP) and the authorization of the Director of the Hospital under the number (159/AR/MSP/DRSPO/DSD/HDD). The study was approved by the Centre of Expertise and Biological Diagnostic of Cameroon (CEDBCAM-RI) under the number (N° 004/06/22/LA/CEDBCAM-RI/DG). The study was conducted in accordance with the declaration of Helsinki. In addition, the research authorizations of the various healthcare structures have been granted. All methods and protocols used were approved by the CEDBCAM-RI in accordance with the relevant international guidelines and regulations for research laboratory ethics.

Data availability

The data are available upon request in accordance with confidentiality and privacy regulations from the corresponding author.

Consent for publication

Not applicable

Competing of interest

The authors declare no conflict of interest.

Funding

Raspail Carrel Founou received funding from the Mérieux Foundation, Lyon France for the CAREFOOD project. CAREFOOD project had supported all the molecular aspect of this study. This work was also supported by the Research Institute of the Centre of Expertise and Biological Diagnostic of Cameroon (CEDBCAM-RI). Dr Luria Founou received funding from the Thrasher Research Fund through the Thrasher Early Career Award (Award number 01364). The funders had no role in the study design, nor the decision to submit the work for publication. Any opinions, findings and conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project.

Author information

Authors and affiliations

Department of Microbiology-Haematology and Immunology, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon;

Antimicrobial Research Unit, School of Health Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban 4000, South Africa;

Antimicrobial Resistance and Infectious Disease (ARID) Research Unit, Research Institute of Centre of Expertise and Biological Diagnostic of Cameroon (CEDBCAM-RI), Yaoundé, Cameroon;

Reproductive, Maternal, Newborn and Child Health (ReMARCH) Research Unit, Research

Institute of the Centre of Expertise and Biological Diagnostic of Cameroon (CEDBCAM-RI); Yaoundé, Cameroon;

Bioinformatics & Applied Machine Learning Research Unit, EDEN Biosciences Research Institute (EBRI), EDEN Foundation, Yaoundé Cameroon;

Infection & Global Health Division, School of Medicine, University of St Andrews, St Andrews, United Kingdom;

Annex Regional Hospital of Dschang (ARHD), Dschang, Cameroon

Author contributions

Conceptualization: TEN, RCF and BK; Methodology: RCF, LLF; Software: TEN, PLK; Validation: RCF, LLF and BK; Formal analysis: TEN, LLF, RCF; Investigation: TEN, BDD, PLK, ADM, JRZ; Resources: RCF, LLF and BK; Writing original draft: TEN and RCF; Review and editing: RCF, LLF, NM and BK; Visualization: TEN, PLK, RCF; Supervision: RCF, LLF, MN, BK; Project administration: RCF and LLF. All authors have read and agreed to the published version of the manuscript.

Acknowledgements

We thank all staff members and participants of this healthcare facility who agreed to participate to this study.

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Table 1: Distribution of ESBL-Klebsiella pneumoniae according to socio-demographic characteristics and the clinical characteristic of the participants

			ESBL-KP n (%)
Variable	Terms	Frequency n (%) N=46	Negative N=35	Positive N=11	p-value
Sex	Female	32 (69.5)	26(74.3)	6(54.5)	0.493
Sex	Male	14 (30.4)	9(25.7)	5(45.5)	0.493
Age group	≤20	03 (06.5)	3(8.6)	0(0.0)	0.911
	[21-31]	20 (43.4)	14(40.0)	6(54.5)
	[31-41]	12 (26.0)	9(25.7)	3(27.3)
	[41-51]	3 (06.5)	2(5.7)	1(9.1)
	>51	8 (17.3)	7(20.0)	1(9.1)
Marital status	Single	11 (23.9)	8(22.9)	3(27.3)	0.850
	Married	33 (71.7)	26(74.3)	7(63.6)
	Widow	2 (04.3)	1(2.9)	1(9.1)
Residence	Rural	20 (43.4)	15(42.9)	5(45.5)	1
Residence	Urban	26 (56.5)	20(57.1)	6(54.5)	1
Education	Illiterate	2 (04.3)	0(0.0)	2(18.2)	0.093
	Primary school	5 (10.8)	4(11.4)	1(9.1)
	Secondary school	18 (39.1)	15(42.9)	3(27.3)
	University	8 (17.3)	4(11.4)	4(36.4)
	Unknown	13 (28.2)	12(34.3)	1(9.1)
Length of hospitalization	<3 days	25 (54.3)	24(68.6)	1(9.1)	0.001
	[3-5] days	9 (19.5)	5(14.3)	4(36.4)
	1 week	4 (08.6)	1(2.9)	3(27.3)
	2 weeks	6 (13.0)	3(8.6)	3(27.3)
	3 weeks	2 (04.3)	2(5.7)	0(0.0)
Hospital wards	Bloc 1	9 (19.5)	8(22.9)	1(9.1)	0.042
	Bloc 2	5 (10.8)	5(14.3)	0(0.0)
	Gynecology bloc	10 (21.7)	9(25.7)	1(9.1)
	Hospitalization ward	2 (04.3)	0(0.0)	2(18.2)
	Treatment room	20 (43.4)	13(37.1)	7(63.6)
Surgery types	Minor surgery	16 (34.7)	13(37.1)	3(27.3)	0.454
	Major surgery	10 (21.7)	6(17.1)	4(36.4)
	Gynecological surgery	20 (43.4)	16(45.7)	4(36.4)
Behaviors with Antibiotic consumption	None	20 (43.4)	18(51.4)	2(18.2)	0.019
	Self-medication	4 (8.6)	2(5.7)	2(18.2)
	Self-medication and medical prescription	2 (04.3)	0(0.0)	2(18.2)
	Medical prescription	20 (43.4)	15 (42.9)	5 (45.5)
β-lactam intake before surgery	Yes	44 (95.6)	33 (94.6)	11 (100)	0.501
β-lactam intake before surgery	No	2 (4.3)	2 (5.7)	0(0.0)	0.501
β-lactam intake after surgery	Yes	36 (78.2)	26 (74.6)	10 (91)	0.547
β-lactam intake after surgery	No	10 (21.7)	9 (25.7)	1 (9)	0.547
History of previous infection	Yes	24 (52.1)	15 (42.9)	9(81.8)	0.009
	No	6 (13.0)	4 (11.4)	2(18.2)
	Unknown	16 (34.7)	16(45.7)	0(0.0)

Table 2: Distribution of resistance genes among ESBL-K. pneumoniae

Variable	Environment	Medical devices	Patients
Variable	Frequency n (%)	Frequency n (%)	Frequency n (%)
CTX-M	8(25.0)	1(3.1)	12(37.5)
TEM	5(15.6)	1(3.1)	8(25.0)
SHV	1(3.1)	0(0.0)%	7(21.8)
Total (N=32)	14 (43.7)	2(6.2)	20(62.5)

No competing interests reported.

EspoiretalAdditionalfile.docx

Clonal Dissemination of Extended-Spectrum Beta-Lactamase (ESBL)- producing Klebsiella pneumoniae isolated from Medical devices and Hospital environments in the West region, Cameroon

Status:

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Abstract

Background

Methods

Results

Conclusion

Figures

BACKGROUND

MATERIALS AND METHODS

1. Study design, population and settings

2. Sampling procedure and sample collection

3. Ethical considerations

4. Laboratory analysis

4.1. Phenotypical characterization and ESBL screening

4.2. Antimicrobial Susceptibility Testing (AST)

4.3. Genomic Extraction

4.4. Conventional and multiplex polymerase chain reaction methods (PCRs)

4.6. DNA Electrophoresis and Visualization

4.7. Quality control

4.8. Data analysis

RESULTS

DISCUSSION

CONCLUSION

Abbreviations

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1