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IJCRR - 8(19), October, 2016

Pages: 12-16

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IN-VITRO SUSCEPTIBILITY TO TIGECYCLINE IN MULTIDRUG RESISTANT BACTERIAL ISOLATES FROM A TERTIARY CARE HOSPITAL

Author: Kusuma G.R., Tejashree A., Vijay Kumar G.S.

Category: Healthcare

Abstract:Objective: The present study was conducted to evaluate the in vitro activity of tigecycline against a contemporary collection of multidrug resistant (MDR) bacterial isolates by disc diffusion and MIC by E-Test method.
Methods: A total of 100 non repetitive clinically significant MDR bacterial isolates from urine, pus, sputum endotracheal aspirates, Skin and soft tissue and surgical site infection of patients in a tertiary care teaching hospital in Karnataka, south India from March 2013 to December 2013 were included in the study. MDR bacteria tested for Tigecycline susceptibility were: Methicillin resistant S.aureus (MRSA) (15), ESBL producing Escherichia coli (E.col) (15), Klebsiella pneumoniae (35) and MDR Acinetobacter species (35).
Result: Tigecycline was found to be effective against all MRSA, MDR E.coli and Acinetobacter isolates by disc diffusion and E-test method. Among the selected K. pneumoniae isolates all were sensitive by disc diffusion and 34 (97.1%) were found sensitive with the MIC range 0.25- 1.5\?g/ml, One (2.9%) isolate was found intermediate resistant with the MIC of 3\?g/ml by E-test.
Conclusion: To conclude, the present study showed that, tigecycline is a potent antimicrobial agent against MRSA, ESBL producing Enterobacteriaceae Acinetobacter species and disc diffusion is simple to perform, highly reproducible and inexpensive method to predict tigecycline resistance. It is also prudent to reserve tigecycline for life threatening infections.

Keywords: Tigecycline, MDR, E-Test, India

Full Text:

INTRODUCTION

Antimicrobial resistance has been identified as one of the major challenges facing public health, as it has increased rates of morbidity, mortality and socioeconomic costs1.

The rates of multiple drug resistance are increasing among Enterobacteriaceae, metallo beta lactamase [MBL] producing non fermenting  gram negative bacilli and Gram-positive pathogens such as methicillin resistant Staphylococcus aureus [MRSA] vancomycin resistant enterococci [VRE]  that commonly cause serious life-threatening diseases and present a  challenge for clinicians by limiting the  potentially active antimicrobial agents to treat. Thus, the development and evaluation of new antimicrobial agents that overcome existing mechanisms of resistance is urgently needed.

In this scenario, research has led to development of a new group of drugs called glycylcyclines, a broad spectrum tetracycline analogues that overcome the resistance mechanisms and the most promising compound being the tigecycline, a glycyclamido derivative of minocycline3

Tigecycline [TGC] is the first of a new class of modified tetracycline antimicrobials known as glycylcyclines. It exerts its bacterostatic effect by binding to the bacterial 30S ribosome and inhibits protein biosynthesis, but its unique feature is its ability to evade the major determinants of tetracycline resistance, that provide ribosomal protection. Its structural modification is the addition of a 9-t-butyl-glycylamido side chain to the central skeleton of minocycline . This provides the drug with an expanded spectrum of activities, including those against susceptible and multidrug-resistant Gram-positive and Gram-negative organisms, anaerobes, and atypical Mycobacteria but tigecycline has poor activities against certain organisms, most importantly Pseudomonas spp. and Proteus spp. as they carry inherently encoded resistance-nodulation-division (RND) efflux pumps that confer decreased sensitivity.4&5

Tigecycline was approved in 2005 by the U.S. Food and Drug Administration (FDA) and in 2006 by the European Medicines Agency for the treatment of complicated skin and skin structure infections and complicated intra abdominal infections 6

Thus the present study was conducted to evaluate the in vitro activity of tigecycline against a contemporary collection of multidrug resistant bacteria isolated from clinical specimens, by disc diffusion and MIC by E-Test method.

Materials and Methods:

This prospective study was conducted in the microbiology department, at JSS Hospital, Mysore a Tertiary Care Teaching Hospital in Karnataka, South India from March 2013 to December 2013. 

A total of 100 non repetitive clinically significant MDR bacterial isolates were included in the study. Susceptible bacteria, Pseudomonas spp. and Proteae were excluded from the study as tigecycline has decreased activity against Pseudomonas and Proteae.

The specimens such as  urine, pus, sputum and endotracheal aspirates ,swabs from skin and soft tissue and surgical site infection   received for culture and sensitivity testing from various departments in our hospital were immediately processed and initial isolation , identification and antibiotic susceptibility testing  was done according to standard recommended procedure  in the clinical laboratory.7

All Gram negative pathogens were tested for extended spectrum beta lactamase [ESB production by CLSI phenotypic confirmatory method using ceftazidime (CAZ) and ceftazidime +clavulinic acid (CAZ+clav) disc according to CLSI guidelines Acinetobacter species were tested for MBL production by imipenem-EDTA combined disk test11. Screening of MRSA was done by using cefoxitin (30μg) disc. Interpretation was done according to clinical laboratory standards institute [CLSI] guidelines8.

MDR  Gram negative bacterial isolates  and MRSA randomly selected for tigecycline susceptibility testing  by disc diffusion & E –test were  MRSA (15), ESBL producing Escherichia coli [E.coli] (15), Klebsiella pneumonia (35) and MDR Acinetobacter species (35), both MBL and non MBL producers were included. 

Selected isolates were tested for tigecycline susceptibility by Kirby Bauer disc diffusion method using commercially available tigecycline (15μg) disc. [Hi media]. S.aureus strain 25923 and ATCC E.coli strain 25922 were used as control.7&8.

The minimum inhibitory concentration of tigecycline for all the selected MDR bacteria was done by E- Test method .The E-test strips were procured from Biomeriux SA, France, and the test was performed according to manufacturers instructions. Since there were no CLSI recommended interpretative criteria for MIC of tigecycline, the US FDA breakpoints were used.For Enterobacteriaceae sensitive isolates were those with MIC ≤ 2μg/ml, and ≥ 19 mm zone size and resistance was defined as MIC ≥ 8 μg/ml and zone size ≤ 14 mm. For S. aureus MIC ≤ 0.5μg/ml and ≥ 19mm zone size was considered sensitive 9

RESULTS

 All randomly selected MRSA [15] isolates for tigecycline susceptibility testing by disc diffusion & E –test were found susceptible to tigecycline by both methods. The MIC range by E-test was 0.125 – 0.032μg/ml .The range of diameter of the zone of inhibition around tigecycline disc was 19mm -25mm.There was a gradual reduction of  tigecycline zone diameter as the MICs for the isolates increased.

All selected E.coli [15] and K.pneumoniae [35] isolates were ESBL producers and resistant to Amikacin , Gentamycin, Cephalosporins, Ciprofloxacin, Cotrimoxozole.   Among K.pneumoniae isolates 30 were resistant to Piperacillin/tazobactam  and  06 isolates  were resistant to Imipenem.

Susceptibility to tigecycline among E.coli isolates was found 100% by both methods. MIC range by E-test was 0.064 – 0.25μg/ml. The diameter of the zone of inhibition around tigecycline disc was in the range of 21mm – 25mm and there was correlation between MIC and disc diffusion.

Among the selected K.pneumoniae isolates, 34(97.1%) were found sensitive by E-test with the MIC range 0.25- 1.5μg/ml. One isolate was found intermediate resistant with the MIC of 3μg/ml.  All isolates were in the sensitive  range 19mm – 21mm by disc diffusion .

Acinetobacter species [35] were resistant to Amikacin, Gentamycin, Tobramycin, Cefipime, Piperacillin/ tazobactam and Ciprofloxacin .11 isolates were resistant to Imipenem.

By disc diffusion method all Acinetobacter species were in the sensitive range. The zone of inhibition remains between 19mm-24mm. All isolates were found to be sensitive with the MIC range between 1.5 – 0.032 μg/ml by E-test.

Discussion

Tigecycline shows high potency against Gram-negative bacilli belonging to family Enterobacteriaceae in whom multi-drug resistant strains have emerged as important nosocomial pathogens. Tigecycline is also very active against non-fermentative GNB, such as  Acinetobacter species. and tigecycline has promising microbiological,  pharmacodynamics & pharmacokinetic profile .Therefore it is considered as a good alternative to treat infections due to multidrug resistant organisms.10

In our study tigecycline showed 100% activity against all, MRSA by a concentration of  ≤0.25 μg/ml of tigecycline  with a zone of inhibition of  ≥ 19mm. The results of our study were in concordance with study conducted by Bijayani Behra et al11, Rouchelle Tellis et al6, Manisha Mane et al13, Maria Souli et al12

ESBLs are one of the most evolving mechanism of antibiotic resistance among the family Enterobacteriaceae   and therapeutic options  are limited.  Although Carbapenems are the drug of choice in the treatment of infections due to ESBL producing strains of Enterobacteriaceae, the emergence and proliferation of bacteria resistant to this important group of drug is jeopardizing the use of carbapenems and   options are limited to tigecycline, colistin and polymyxin 13&14 .

In our study tigecycline remains an important option against the management of  E.coli infections by retaining 100% in vitro activity against  E.coli isolates with the MIC90≤0.25. µg/ml by  E-test. All isolates showed zone of inhibition ≥ 19mm. the zone diameter remains within a range of 21mm- 25mm.and shows the correlation between E-test and disc diffusion. Similar results were found in studies conducted by Soham Gupta et al, Shanti. M et al15 , Anand Manoharan et al16,  Rouchelle Tellis et al, Te-Din Huang et al17 ,Goran Kronvall et al18 .

Among our selected   K. pneumoniae isolates 34/35 (97.1%) were found sensitive with the MIC range 0.25- 1.5μg/ml. One isolate was found intermediate with the MIC of 3μg/ml  by E-test. None were found resistant /intermediate by disc diffusion. All the isolates showed zone of inhibition ≥ 19mm. the zone diameter remains within a narrow range of 19mm- 21mm.Other studies by Shanthi.M et al 100%, Anand Manoharan et al,100% Simit Kumar et al19 100% Bijayini Behera et al 97% Soham Gupta  et al20 85.7%  also showed  high in vitro activity of tigecycline against K.pneumoniae. In the study conducted by Subhash C. Arya2166% were found sensitive. It was also noted that in our study, increased MIC of 1-3µg/ml in K.pneumoniae compared  to E.coli with MIC90≤ 0.25µg/ml. Similar results with increased MIC were found by Soham Gupta et al, and Maria Souli et al.

Break points for Tigecycline  MIC and disc diffusion for Acinetobacter were not included  in the CLSI guidelines. Therefore cut off values given for Enterobacteriaceae were used and all selected Acinetobacter species isolates were in the sensitive range. The zone of inhibition between 19 mm-24 mm.  The MIC remains between 0.75 – 0.032 μg/ml with MIC90 ≤0.75 by  E-test. It was observed that there was gradual reduction in the size of zone of inhibition as MIC increases .This was also observed by Bijayini Behera et al   In our study, the E test correlated 100 percent with the inhibition zone diameters, which was in contrast to the findings of a study which was done by Behera et al.  But, it was similar to the findings of a study which was done by Venezia et al22,Surapee Tiengrim A et al23.

 In our study Tigecycline remains as a good option for the management of MRSA, multidrug resistant  E.coli , Klebsiella species and Acinetobacter infections  by retaining 100% activity against these pathogens 

We carried out the in-vitro activity of tigecycline by disc diffusion and E test. By both methods all isolates were found to be sensitive except one Klebsiella isolate which was found to be intermediate by E-test and sensitive by disc diffusion. Thus we found no significant difference between these two methods. Disc diffusion method is simple to perform, highly reproducible and inexpensive while E test is though costly for routine use, it can be used to determine MIC.

Tigecycline does not require dose adjustment in patients with impaired renal function and is conveniently administered every 12 h. It has a long terminal half-life and a large volume of distribution and has low potential for organ toxicity and drug-drug interactions. These properties make the use of this antibiotic relatively uncomplicated, but patients may develop moderate-to-severe nausea and vomiting during tigecycline therapy. It can be used as a life saving antimicrobial in polymicrobial infections due to Gram-positive and enteric Gram-negative bacteria.

Conclusion

 The present study shows that, tigecycline is a potent antimicrobial agent against MRSA, ESBL producing Enterobacteriaceae  and multi-drug resistant Acinetobacter baumannii and  disc diffusion  is simple to perform, highly reproducible and inexpensive method to predict tigecycline resistance. However, use of tigecycline needs to be strictly monitored to prevent development and dissemination of resistance against this one of the last available antimicrobial molecule and it is prudent to reserve tigecycline for life threatening infections.

Acknowledgement

Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles,  journals and books from where the literature for this article has been reviewed and discussed.

References:

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A Study by Anu et al. entitled "Effectiveness of Cytological Scoring Systems for Evaluation of Breast Lesion Cytology with its Histopathological Correlation" is awarded Best Article of Vol 13 issue 04
A Study by Sharipov R. Kh. et al. entitled "Interaction of Correction of Lipid Peroxidation Disorders with Oxibral" is awarded Best Article of Vol 13 issue 03
A Study by Tarek Elwakil et al. entitled "Led Light Photobiomodulation Effect on Wound Healing Combined with Phenytoin in Mice Model" is awarded Best Article of Vol 13 issue 02
A Study by Mohita Ray et al. entitled "Accuracy of Intra-Operative Frozen Section Consultation of Gastrointestinal Biopsy Samples in Correlation with the Final Histopathological Diagnosis" is awarded Best Article for Vol 13 issue 01
A Study by Badritdinova MN et al. entitled "Peculiarities of a Pain in Patients with Ischemic Heart Disease in the Presence of Individual Combines of the Metabolic Syndrome" is awarded Best Article for Vol 12 issue 24
A Study by Sindhu Priya E S et al. entitled "Neuroprotective activity of Pyrazolone Derivatives Against Paraquat-induced Oxidative Stress and Locomotor Impairment in Drosophila melanogaster" is awarded Best Article for Vol 12 issue 23
A Study by Habiba Suhail et al. entitled "Effect of Majoon Murmakki in Dysmenorrhoea (Usre Tams): A Standard Controlled Clinical Study" is awarded Best Article for Vol 12 issue 22
A Study by Ghaffar UB et al. entitled "Correlation between Height and Foot Length in Saudi Population in Majmaah, Saudi Arabia" is awarded Best Article for Vol 12 issue 21
A Study by Siti Sarah Binti Maidin entitled "Sleep Well: Mobile Application to Address Sleeping Problems" is awarded Best Article for Vol 12 issue 20
A Study by Avijit Singh"Comparison of Post Operative Clinical Outcomes Between “Made in India” TTK Chitra Mechanical Heart Valve Versus St Jude Mechanical Heart Valve in Valve Replacement Surgery" is awarded Best Article for Vol 12 issue 19
A Study by Sonali Banerjee and Mary Mathews N. entitled "Exploring Quality of Life and Perceived Experiences Among Couples Undergoing Fertility Treatment in Western India: A Mixed Methodology" is awarded Best Article for Vol 12 issue 18
A Study by Jabbar Desai et al. entitled "Prevalence of Obstructive Airway Disease in Patients with Ischemic Heart Disease and Hypertension" is awarded Best Article for Vol 12 issue 17
A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for  Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for  Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09

List of Awardees

A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award


A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award


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International Journal of Current Research and Review (IJCRR) provides platform for researchers to publish and discuss their original research and review work. IJCRR can not be held responsible for views, opinions and written statements of researchers published in this journal

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