1

CHAPTER ONE INTRODUCTION

1.1

Background and literature review

Klebsiella species are common causes of nosocomial infections such as urinary tract
infections, pneumonia, wound infections and septicaemia. Klebsiella species have
emerged as important pathogens capable of exhibiting resistance to many antibiotics
including Penicillins and Aminoglycosides. Although Klebsiella species have
generally been susceptible to third generation Cephalosporins there have been reports
of resistance to these agents (1). Klebsiella pneumoniae is naturally resistant to
Ampicillin and amoxicillin usually by the production of SHV-1 lactamase encoded
on the chromosome or a transferable plasmid (2, 3). Because of this natural resistance,
Klebsiella pneumoniae often colonizes the skin and mucosa of hospitalized patients
treated with Ampicillin or similar drugs; it may go on to produce invasive infections
and septicaemia. Most colonized patients are asymptomatic, but may act as sources of
cross infection for others, with the outbreak strain usually being transferred on staff
hands (4). Resistance to broad spectrum Cephalosporins has emerged in strains of
members of the enterobacteriaceae family following frequent use of these drugs in
hospital settings (5, 6).Endemic and epidemic nosocomial infections caused by
extended spectrum lactamase (ESBL) producing Klebsiella pneumoniae cells
represent a persistent problem in many parts of the world, especially in intensive care
units (6, 7, 8, 9-12).Epidemic strains of cephalosporin-resistant Klebsiella
pneumoniae have been associated with increased morbidity and mortality in
hospitalized patients(6, 9).
A study carried out on urinary pathogens isolated at Parirenyatwa hospital Harare (13)
showed that 76.2% of Klebsiella isolates were susceptible to Nalidixic acid and 98%

to ciprofloxacin and most isolates were resistant to Gentamicin (87.2 %) and

Ampicillin (97.2%). Some studies have shown high resistance of Klebsiella species to
Cephalosporins such as Cefaroxime and Ceftraixone (14). Emergence of Klebsiella
strains resistant to Flouroquinolones has been reported in some countries (15).
1.1.1

Epidemiology
The genus Klebsiella is a member of the Enterobacteriaceae family. Klebsiella species
are ubiquitous in nature and can be found in the natural environment (e.g., water and
soil) and on mucosal surfaces of mammals (16). Common sites of colonization in
healthy humans are the gastrointestinal tract, eyes, respiratory tract, and genitourinary
tract (16).
Klebsiella pneumoniae has emerged as an important cause of hospital-acquired
infections, especially among patients in the neonatal intensive-care unit (NICU) and
mortality rates can be as high as 70% (17). Over the last two decades, the incidence of
infections caused by multidrug-resistant Klebsiella strains has increased.
Extended spectrum -lactamase enzymes were first described in Klebsiella
pneumoniae and Serratia marcescens isolates in 1983 in Europe and in Klebsiella
pneumoniae and Escherichia coli isolates in 1989 in the United States (18). Since
then, there has been a marked increase in the incidence of bacteria that produce ESBL
enzymes. In the United States, the proportion of Klebsiella pneumoniae strains
resistant to Ceftazidime increased from 1.5% in 1987 to 3.6% in 1991, and by 1993 as
many as 20% of strains were resistant to Ceftazidime in some teaching hospitals
(19,20 ). Of 824 Klebsiella pneumoniae strains isolated from 15 hospitals in New
York City during 1999, 34% expressed ESBL enzymes (21).

1.1.2

Virulence factors and pathogenesis

A number of virulence factors have been suggested in K. pneumoniae, including the
prominent polysaccharide capsule expressed by the vast majority of clinical isolates as
well as different adhesins, lipo polysaccharide (LPS) and iron-scavenging proteins
(16).Knowledge of the exact role of individual K. pneumoniae virulence factors in
different types of infection is, however, sparse and even less is known of the factors
involved in the ability of the bacteria to colonize and reside in the GI tract of the host.
Such knowledge is important in the search for new strategies to treat and prevent K.
pneumoniae infections.
The vast majority of clinical K. pneumoniae isolates express a prominent
polysaccharide capsule that covers the bacterial cells. The capsule is generally
considered to be a major virulence factor in K. pneumoniae, especially in systemic
infections, whereas its role in serum-poor host environments is less clear (16).
Extracellular capsules are essential to virulence; the capsular material forms thick
bundles of fibrillous structures that cover the bacterial surface in massive layers (16).
This protects the bacterium from phagocytosis by polymorphonuclear granulocytes
and prevents killing by bactericidal serum factors via the complement-mediated
cascade. Currently, about 80 different capsular (K) antigens are known.
Although Klebsiella capsular polysaccharide (CPS) has generally been thought to
mediate virulence, it has been shown more recently that the mannose content of the
CPS confers the degree of virulence.
For example, strains that contain repetitive sequences of mannose-alpha-2 or alpha 3mannose, L-rhamnose-alpha-2 or 3-L-rhamnose are of lower virulence. These

mannose sequences are recognized by the surface lectin of macrophages and the
organism is more efficiently ingested and killed by opsonin-independent
phagocytosis. (22)
In addition to the capsule, there are about five somatic or O antigens, fimbrial and
nonfimbrial adhesins, which serve as virulence factors. The fimbriae or pili are
nonflagellar, filamentous projections on the bacterial surface that mediate attachment
of the organism to respiratory, gastrointestinal, and urinary tract mucosal cells. Most
clinical K. pneumoniae isolates are able to produce the two fimbrial adhesins, type 1
fimbriae and type 3 fimbriae. Type 1 fimbriae mediate adhesion to mannosecontaining structures on host cells and extracellular matrix and are present in many
species of Enterobacteriaceae.
Additional virulence determinants for Klebsiella species include the ability of the
organism to scavenge iron from the surrounding medium using secreted siderophores,
that is, enterochelin and aerobactin. These are high-affinity, low molecular weight iron
chelators that competitively take up iron bound to host proteins (23).

1.1.3

Molecular mechanisms of resistance

ESBL are plasmid-mediated enzymes that hydrolyze oxyimino- lactam agents such
as third-generation Cephalosporins and Aztreonam (24). These plasmids also carry
resistance genes to other antibiotics including aminoglycosides, Chloramphenicol,
sulphonamides, Trimethoprim, and tetracycline.

Thus, Gram negative bacilli containing these plasmids are multidrug-resistant (25).
Furthermore, these plasmids are mobile genetic elements and can be transmitted
between Gram negative bacilli of different species in vivo (26).
During a 30-month outbreak of ESBL-producing K. oxytoca in an NICU, the plasmid
from K. oxytoca spread to K. pneumoniae, E. coli, Enterobacter cloacae, and
Citrobacter freundii (27).
Over 100 different ESBL enzymes have been identified, each with a preferential
substrate. Thus, an ESBL-producing isolate may be resistant to Ceftazidime, but
susceptible to Cefotaxime. As a result, ESBL-producing isolates may not be detected
if susceptibility testing is limited to a single third-generation cephalosporin. The
National Committee for Clinical Laboratory Standards (NCCLS) recommends routine
screening for ESBL activity in E. coli, K. pneumoniae, and K. oxytoca isolates by
determining susceptibility to several Cephalosporins including Cefpodoxime,
Cefotaxime, Ceftriaxone, and Ceftazidime (28,29 ).

If an isolate is resistant to any one of these agents, that is, minimum inhibitory
concentration (MIC) 2 g/ml, confirmatory tests for an ESBL enzyme are
performed by demonstrating increased susceptibility to Cefotaxime or Ceftazidime in
the presence of Clavulanic acid, as Clavulanic acid inhibits ESBL enzymes and
lowers the MIC of the Cephalosporins. However bacteria with ESBL-containing
plasmids remain susceptible to the Carbapenems, that is, Meropenem and Imipenem,
and Cephamycins such as Cefoxitin and Cefotetan.

1.1.4

Risk Factors for Acquisition of ESBL-producing Pathogens

Epidemiological studies suggest that the increasingly widespread use of thirdgeneration Cephalosporins is a major risk factor that has contributed to the emergence
of ESBL-producing K. Pneumoniae (6, 12, and 30). Several additional risk factors for
colonization and infection with ESBL-producing organisms have been reported and
include: arterial and central venous catheterization, gastrointestinal tract colonization
with ESBL-producing organisms, prolonged length of stay in an intensive-care unit,
low birth weight in preterm infants, prior antibiotic use, and mechanical ventilation
(31, 32, and 33). Carriage of this organism increases dramatically among hospitalized
patients, as colonization rates increase in direct proportion to the length of stay (27).
Outbreaks of ESBL-producing organisms have been described. Asymptomatic
patients colonized with ESBL-producing K. pneumoniae can serve as reservoirs for
this pathogen with subsequent patient-to-patient spread via the hands of health-care
workers.
In addition, contaminated patient-care items and artificial fingernails worn by healthcare workers have been implicated in transmission (34, 35, 36, and 37). Most studies
have demonstrated a poor adherence to infection control policies as an important
factor. Outbreaks of ESBL-producing K. pneumoniae in NICUs have been notable for
high attack rates and large numbers of colonized infants (37).The neonates at greatest
risk for colonization are those with a longer length of stay, a lower estimated
gestational age and or a lower birth weight (27).

1.1.5

Clinical presentations
The importance of Gram negative bacilli as major causes of hospital-acquired
infections in NICU patients has been well documented. K. pneumoniae can cause
early-onset and, more commonly, late-onset sepsis, conjunctivitis, hospital-acquired
pneumonia, urinary tract infections (UTIs), and surgical site infections (16, 38).
Approximately 4% of episodes of late-onset sepsis in very low birth infants and 6% of
overall infections in the neonatal ICU population are caused by K. Pneumoniae (39,
40). According to the most recent National Nosocomial Infection Surveillance System
data, K. pneumoniae has been noted to cause 2.9% of bloodstream infections, 2.9% of
eye, ear, nose and throat infections, 9.8% of GI tract infections, 5.7% of pneumonia,
and 6.3% of surgical site infections in the NICU (41). As demonstrated by the
CDC/National Association of Children's Hospitals and Related Institutions
(NACHRI) point-prevalence survey conducted in 1999, K. pneumoniae caused 1.7%
of bloodstream infections, 20% of respiratory tract infections, 8.3% of UTIs, and
5.6% of other infections in patients in NICUs (40).
The present study is designed to determine the prevalence of Klebsiella species in
clinical specimens at Parirenyatwa hospital and to determine the antimicrobial
susceptibility patterns of the isolates.

1.2

Statement of the problem

Considering the ubiquitous nature of Klebsiella species and their intrinsic resistance
to a wide variety of antimicrobial agents the organisms are able to survive within a
hospital setting. Endemic and epidemic nosocomial infections caused by extended
spectrum lactamase (ESBL) producing Klebsiella pneumoniae cells represent a

persistent problem in many parts of the world, especially in intensive care units (6, 7,
8, 9-12). Klebsiella species are successful opportunistic pathogens thus their
prevalence and antimicrobial susceptibility patterns need constant evaluation so as to
reduce further health risks, recurrence and continual spread of infection within
hospital settings.
1.3

Hypothesis
Null Hypothesis (Ho)
The prevalence of Klebsiella species in clinical specimens at Parirenyatwa is 10%
Alternative Hypothesis (Ha)
The prevalence of Klebsiella species in clinical specimens at Parirenyatwa is greater
than 10%

1.3

Specific objectives

2.1

To determine the prevalence of Klebsiella species in clinical specimens at

Parirenyatwa
To determine the antimicrobial susceptibility patterns of the isolates.
CHAPTER TWO MATERIALS AND METHODS

Materials
Latex examination gloves
Bunsen burner
Light microscope
Lens tissue
Diamond marker
Immersion oil
76 26mm glass slides
Slide rack
Crystal violet
Lugols iodine
Acetone
Carbol fuschin
Incubator
Gram negative antibiotic discs: Tetracycline (25g), Kanamycin (30g),
Chloramphenicol (25 g), Ampicillin (25 g), Streptomycin (10g), Cotrimoxazole
(25g), Amikacin (10g), Gentamicin (30g) and Ceftazidime (30g).
Distilled water

Sulphuric acid
Barium chloride
Inoculating wire loop
MacConkey agar
Muller Hinton agar
Lysine iron agar
M.RVP (Methyl red Voges- Proskauer) broth
Simmons citrate agar
Kovacs reagent
Peptone water
Petri dishes
Mighty marker
Bijou bottles
Long test tubes
Khan tubes
Cotton wool
Meter rule
Tongs
Physiological saline

2.2
2.2.1

Methods
Study site
The study was conducted at Parirenyatwa Central Hospital which is one of the
countrys largest referral hospitals where patients are received from local clinics,
district and provincial hospitals.

2.2.2

Study design
A cross sectional study was carried out on clinical specimens (urines and pus swabs)
of patients at Parirenyatwa Central Hospital. Isolates identified as Klebsiella species
were tested for antimicrobial susceptibility patterns

2.2.3

Study subjects

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The study was carried out on urine and pus swab specimens sent to Parirenyatwa
Hospital Public Health Microbiology laboratory for microscopy, culture and
sensitivity. The study was performed during the periods April 2010 to June 2010.
2.2.4

Sample size
A total of 150 specimens were analysed during the study. Statistically this was
sufficient enough to determine the prevalence and antimicrobial susceptibility patterns
of Klebsiella species. (Appendix I).

2.2.5

Inclusion criteria
Inclusion into the study required specimens sent to Parirenyatwa Hospital Public
Health Microbiology laboratory accompanied by laboratory request form with patient
demographic data. Only specimens that reached the laboratory within twenty four
hours of their collection were included

2.2.6

Exclusion criteria
Specimens delivered to the laboratory after 24 hours of their collection were
excluded. Specimens which were not accompanied by patient details and clinical data
were not enrolled into the study.

2.2.7

Procedure
Permission to carry out the study was sought from the Clinical Director of
Parirenyatwa Group of Hospitals and from the Chairman of the Joint Research Ethics
Committee. After being granted, the study commenced in mid April 2010 and
concluded in mid June 2010.Samples which were included in the study were allocated
study numbers. The age, sex and clinical data for each specimen were also recorded.

11

All identifying details were removed from specimens after allocation of a study
number and results were correlated after completion of all assays.

2.2.7.1 Culturing of specimens

Pus swab specimens were inoculated on MacConkey agar plates using the isolation
technique. The inoculated plates were incubated aerobically at 37C overnight, after
which characteristic colonies were observed.
Using a standard graduated inoculating wire loop, urine specimens were cultured on
MacConkey agar plates using the isolation technique. The inoculated plates were
incubated aerobically at 37C overnight, after which characteristic colonies were
observed.
2.2.7.2 Identification of isolates
After observing visible growth on the culture plates the following procedures were
performed:

Isolates were checked for lactose fermentation on MacConkey agar plates, typical

lactose fermenting colonies were observed as pink colonies.

Colonies were checked for mucoid appearance which is a typical feature of

Klebsiella species.
Colonies were emulsified with saline on a glass slide to make a smear.

12

Smears were stained using the Gram stain technique (Appendix II) and were
observed under the light microscope at the 100x objective lens under immersion

oil to identify the respective gram reactions.

Isolates identified as lactose fermenting, gram negative rods and suspected to be
Klebsiella were then sub cultured on fresh MacConkey agar plates to obtain pure
cultures for further identification based on biochemical reactions (Appendix III) of

the pure isolates.

Table 1.Biochemical tests used to differentiate Klebsiella pneumoniae subspecies
Species

VogesProskauer
K.p pneumoniae
-

Lactose
fermentation
+

Urease Citrate
+

Malonate
utilization
+

Lysine
decarboxylase
+

K.p aerogenes

K.p ozaenae

K.p
rhinoscleromatis

Key: K.p = Klebsiella pneumoniae

2.2.7.3 Antimicrobial Susceptibility Testing
The Kirby-Bauer disk diffusion test, which conforms to the recommended standard of
the National Committee for Clinical Laboratory Standards (NCCLS), was used in the
study. Briefly, a small inoculum of each pure bacterial isolate was emulsified in 3ml
sterile normal saline in Bijou bottles and the density of the solution was compared to a
barium chloride standard (0.5 McFarland). The standardised solution of bacterial
cultures was poured onto Muller Hinton agar plates to evenly inoculate the culture
media. The excess bacterial suspension was discarded from the agar and the
inoculated plates were left to dry. Thereafter, antibiotic disks with the following drug
contentsAmpicillin

(25g),

Amikacin

(10g),

Chloramphenicol

(25g),

Cotrimoxazole (25g), Gentamicin (30g), Kanamycin (30g), Streptomycin (10g)

13

and Tetracycline (25g) were placed on the plates, spacing them well to prevent
overlapping of inhibition zones. The plates were incubated aerobically at 37C
overnight and the inhibition zone diameters were then compared with recorded
diameters of the control organism, E. coli ATCC 25922 to determine susceptibility or
resistance.
2.2.7.4 Data analysis
Data was captured using Microsoft excel and all statistical analysis performed by Epi
info. The hypothesis was tested using the standard Z test at 5% level of significance
whether it is true. The prevalence of Klebsiella species in clinical specimens was
calculated at 5% level of significance and the antimicrobial susceptibility patterns
were determined through comparison with standard patterns of control organisms.

14

CHAPTER THREE RESULTS AND ANALYSIS

During the study, 150 specimens were processed for Klebsiella positivity; of the 150
specimens only 18 specimens were positive for Klebsiella pneumoniae. Of the
positive specimens 11(61%) were females and 7(39%) were males (Fig 1). The
patients age ranged from 4 years to 85 years with a mean of 36 years and a median of
30 years. The calculated prevalence of the isolates was 12% (Table 2).The discrete
variables were analysed using the standard normal Z test (Appendix IV). At 5% level
of significance, statistically there was no sufficient evidence to reject the null
hypothesis.
Figure 1. Pie chart for patients sex distribution in positive specimens.

Table 2.Distribution of isolates in clinical specimens

TYPE OF SPECIMEN

NUMBER OF SAMPLES

NUMBER
ISOLATED

%
PREVALENCE

15

Urine

90

11

18.33

Swab

60

7.78

Total

150

18

12

Table 3 shows the antimicrobial susceptibility results exhibited by Klebsiella

pneumoniae isolates. Of the 18 isolates tested, most strains showed varied
susceptibilities to the Aminoglycosides (Gentamicin and Streptomycin).
Over 85% of the isolates were resistant to the sulphonamide Cotrimoxazole and 22%
of the isolates were sensitive to Kanamycin, Chloramphenicol, Amikacin and
Gentamicin. Over 80% of the isolates were resistant to two antibiotics or more.
However, all isolates showed total resistance (100%) to Ampicillin.
Table 3 Antimicrobial susceptibility patterns of Klebsiella pneumoniae strains
isolated from various clinical specimens.
Antibiotic

Sensitive

Intermediate

Resistant

Frequency Percentage Frequency Percentage frequency Percentage

Chloramphenicol 4

22.22

11.11

12

66.67

Ampicillin

18

100

Tetracycline

11.11

11.11

14

77.78

Streptomycin

16.67

15

83.3

Cotrimoxazole

11.11

16

88.89

Kanamycin

22.22

22.22

10

55.56

Amikacin

22.22

27.78

50.00

Gentamicin

22.22

11.11

12

66.67

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All isolates demonstrated total resistance to Ampicillin. Based on the susceptibility to

other aminoglycosides (Gentamicin, Amikacin and Streptomycin), Tetracycline,
Cotrimoxazole, Kanamycin and Chloramphenicol, 7 Antibiotypes (A1A7) were
defined for the 18 Klebsiella pneumoniae isolates (Table 4).
Most of the isolates sixteen were resistant to three or more antibiotics. The
predominant antibiotype (A1) constituted sixteen (88.89%) of the isolates while the
least patterns (A6 and A7) were exhibited by six (33.33%) isolates respectively.
Table 4. Antibiotypes of Klebsiella Pneumoniae isolates from various specimens.
Antibiotypes

Frequency

Percentage

A1

16

88.89

A2

13

72.22

A3

10

55.56

A4

12

66.67

A5

10

55.56

A6

33.33

A7

33.33

A1= Resistance to Ampicillin and Cotrimoxazole. A2= Resistance to Ampicillin,

Cotrimoxazole and Streptomycin. A3= Resistance to Ampicillin, Tetracycline and
Chloramphenicol. A4= Resistance to Ampicillin, Cotrimoxazole, Tetracycline and
Streptomycin.

A5=

Resistance

to

Streptomycin and Chloramphenicol.

Amikacin

and

Kanamycin.A7=

Ampicillin,

Cotrimoxazole,

Tetracycline,

A6= Resistance to Ampicillin, Gentamicin,

Resistance

to

Ampicillin,

Cotrimoxazole, Tetracycline, Chloramphenicol and Kanamycin.

Streptomycin,

17

Klebsiella pneumoniae strains isolated from pus swab specimens demonstrated total
resistance to Ampicillin and Cotrimoxazole, whilst only 28.57% of the isolates were
sensitive to Amikacin (Figure 2). All the isolates showed zero sensitivity to all the
antibiotics except Amikacin.
Fig 2.Antimicrobial susceptibility patterns of Klebsiella pneumoniae strains
isolated from pus swab specimens.

PERC
E
N
T
A
G
E

ANTIBIOTIC
Fig 3. Antimicrobial susceptibility patterns of Klebsiella pneumoniae strains
isolated from urine specimens.

18

PERC
E
N
T
A
G
E

ANTIBIOTIC
CHAPTER FOUR DISCUSSION AND CONCLUSION
4.0

Discussion
Klebsiella pneumoniae accounts for a substantial degree of nosocomial infections (1,
2) and the increasing tendency for nosocomial pathogens to acquire new antibiotic
resistance traits poses a problem in the control of infections. This feature reveals the
need for an updated antibiotic susceptibility pattern for the effective management of
infections caused by Klebsiella pneumoniae. The present study reports on the
antimicrobial susceptibility patterns of Klebsiella pneumoniae isolates and the
prevalence of the isolates at the study site. The findings revealed that Klebsiella
pneumoniae isolates showed marked resistance to Ampicillin, Cotrimoxazole
Tetracycline, Gentamicin and Chloramphenicol. Total resistance was exhibited on
Ampicillin (100%), (88.89%) resistance to the sulfonamide Cotrimoxazole followed
by (77.78%) resistance to Tetracycline. Gentamicin and Chloramphenicol both
exhibited (66.67%) resistance from the isolates. However a few isolates were
sensitive to Aminoglycosides and most of the isolates were resistant. The isolates
showed extremely low levels of susceptibility (22.22%) to Gentamicin,
Chloramphenicol, Amikacin and Kanamycin which was recorded as the highest

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degree of susceptibility indicating increased resistance of the isolates. In the same

vain of analysis Cotrimoxazole and Tetracycline exhibited (11.11%) susceptibility
whereas none of the isolates showed susceptibility to Ampicillin and Streptomycin.
The overwhelming increased resistance of Klebsiella pneumoniae isolates may be
attributed to the production of ESBL. On the other hand speculations could be raised
in that the non determination of ESBL production could be a contributing factor to
this unusual susceptibility since the production of ESBL has been reported to cause
hidden resistance to broad spectrum Cephalosporins (14).
The extreme resistance to Gentamicin and Ampicillin were also observed
corroborating a previous study carried on urinary pathogens at Parirenyatwa Hospital
(13), with a slight increase in resistance to Ampicillin from (92.7%) to total resistance
(100%). In addition Cotrimoxazole and Tetracycline also exhibited increased
resistance from the isolates, this outcome could be linked to the fact that
Cotrimoxazole, Tetracycline, Gentamicin and Ampicillin are commonly used in the
environment under study to treat other infections, and are highly abused thus putting
selective pressure on the antibiotics, hence the emergence of resistance to the
antimicrobial drugs. Results of this study revealed seven distinct resistance patterns
(Antibiotypes), of which the most prevalent exhibited resistance to Ampicillin and
Cotrimoxazole accounting for 88.89% of the isolates (Table 4). The least patterns A6
and A7 were exhibited by six (33.33%) isolates respectively. All the Antibiotypes
shared resistance to Ampicillin and this suggests that the drug may not be useful in
treatment of Klebsiella pneumoniae infections in the area studded. An interesting
feature of the study was that all Klebsiella pneumoniae isolates were resistant to three
or more antibiotics. In addition five (27.78%) of the isolates exhibited total resistance
to all the antibiotics used in the study. The multiple resistances to these drugs could be
attributed to the fact that these antibiotics are highly abused due to constant and

20

indiscriminate usage (13). Also Klebsiella pneumoniae strains are known to be an

important source of transferable antibiotic resistance among gram negative bacilli. (58, 30). Consequently, the occurrence of multiple resistant Klebsiella pneumoniae
strains might pose a potential problem in the treatment and management of infections
in the study area.
4.1 Limitations
Only 150 samples were obtained for the study which was not sufficient enough to
draw feasible conclusions. Due to shortage of time the samples lacked randomization
hence all samples available were used for the study. The amount of resources was
limited and some procedures could not be undertaken, for example: the unavailability
of third generation Cephalosporins (Ceftazidime, Clavulanate and Cefuroxime) which
were required for demonstration of ESBL production by the isolates. Blood culture
specimens and sputum specimens suspected of pneumoniae which were crucial for the
study were unavailable, thus were left out.
4.2 Recommendations
If the study could be performed with adequate amounts of resources and over a long
period of time fruitful results can be obtained. The isolates obtained should be Serotyped and demonstration of ESBL production should be done so as determine the
prevalence and antimicrobial susceptibility patterns of species specific isolates.
4.3 Conclusion
Results from the study revealed that Klebsiella pneumoniae isolates were resistant to
three or more antibiotics, with some exhibiting total resistance to all antibiotics and a
few isolates exhibited sensitivity. Klebsiella pneumoniae was identified to be an
important cause of urinary tract infections especially amongst females. This outcome
reveals the need for an updated antibiotic susceptibility pattern for the effective
treatment and management of infections caused by Klebsiella pneumoniae.

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