Klebsiella pneumoniae IDENTIFICATION OF PRODUCING EXTENDED SPECTRUM BETA LACTAMASE ( ESBL ) AND RESISTANCE PATTERN OF ANTIBIOTICS IN ULIN GENERAL HOSPITAL BANJARMASIN

Klebsiella pneumoniae(K. pneumoniae) can synthesize beta lactamase enzymes that have the ability to open lactam beta rings and cause resistance to antibiotics such as amoxicillin, third generation cephalosporins namely cefotaxim, ceftazidim, ceftriaxone and monobactam groups such as aztreonam. Extended spectrum beta lactamase (ESBL) is a plasmid enzyme that mediates the occurrence of hydrolysis and inactivation of beta lactam antibiotics. Infections caused by ESBLproducing bacteria become a serious problem for hospitals worldwide. ESBL isolate susceptibility tests against antibiotics are required to provide a sensitivity pattern that can be used as a reference in more rational antibiotic selection. This study was conducted to describe the prevalence of ESBL group K. pneumoniae and antibiotic resistance pattern at Ulin General Hospital Banjarmasin. The method of this research used secondary data material in the form of reporting document of antibiotic sensitivity test result that isolation and identification using VITEK 2, and then be analyzed using Microsoft Excel. The culture examination toward 50 patients in the Dahlia ward, Ulin General Hospital Banjarmasin was taken from January until May 2017, with the results arefrom 24 data Staphylococius aureus (S.aureus) isolate, more than half of it are ESBL group (54.16%). The results of sensitivity test of K.Pneumoniae of ESBLpositive to antibiotic group were found to be antibiotics that still have> 90% sensitive were meropenem (100%), amikacin (100%), tigecycline (92,85%), ertapenem (92,86%). The antibiotics with resistance> 50% was found in ampicillin antibiotics (100%), ceftriaxone (78.5%), ceftazidime (64.28%), cefepime (57.14%) and aztreonam (71.4%). As for ESBL negative results obtained sensitive> 90% for all antibiotics except ampicillin, ampicillin / sulbactam, and nitrofurantoin. Meropenem (100%), amikacin (100%), tigecycline (92.85%), ertapenem (92.86%) are antibiotic choices that are still sensitive to ESBL infection


INTRODUCTION
Antibiotics have been used for a long time to treat infectious diseases, but lately they tend to be excessive and irrational, resulting in an increased prevalence of antibiotic resistance in initially sensitive bacteria.Bacterial resistance to antibiotics has become a worldwide health problem, with many adverse effects that could degrade the quality of health care..2.Various studies have shown that the number of pathogenic bacterial resistance increases sharply, so that morbidity and mortality rates are also increasing.The main cause of resistance in gram-negative bacteria is the extended-spectrum betalactamase (ESBL) in Klebsiella pneumoniae and Escherichia coli..4 Klebsiella pneumoniae belonging to the genus Klebsiella in Enterobactericeae family.These bacteria can be isolated from the gastrointestinal tract, the eye, the respiratory tract and the genitourinary tract of a healthy person.Klebsiella pneumoniae is known to cause several types of infections such as pneumonia, urinary tract infections, bacteremia, an infection in the wound or incision and meningitis.Patients who usually get these bacterial infections are hospitalized patients because of other diseases, who use ventilators, infusions and get old antibiotic therapy. 5,6,7lebsiella pneumoniae can synthesize beta-lactamase enzymes which have the ability to open the beta-lactam ring and cause resistance to antibiotics such as amoxicillin, which is a third generation cephalosporin cefotaxime, ceftazidim, ceftriaxone and groups such as the monobactam aztreonam.Extendedspectrum beta-lactamase (ESBL) is an enzyme plasmid meperantarai the hydrolysis and inactivation of beta-lactam antibiotics.Infection caused by ESBLproducing microorganisms becomes a serious problem for hospitals worldwide. 1,4,8everal studies in the world find K. pneumoniae ESBL producers by 10-40%, which is in Latin America reported a 45.4%, the Western Pacific 24.6%, Europe 22.6%, USA 7.6% and Canada 4.6%. 3Chandra Research has isolated 37 isolates K. pneumoniae in Jakarta and Karawaci and prevalence K. pneumoniae producing ESBL amounted to 33.03%.In addition, research Irawan et al 4 also found that the type of ESBL-producing bacteria that cause sepsis was highest K. pneumoniae (52.08%).The last few years showed that ESBL-producing Klebsiella pneumoniae isolates increased. 1,3,4,9he identification of ESBLproducing Klebsiella pneumoniae is indispensable for improved management and antibiotic therapy for infection control.

RESULTS AND DISCUSSION
Based on the results of the study during the period of January 2017-May 2017 obtained data as in Table 1.The examination's results of the culture cells that were growth in Dahlia Ward from 50 patients had a 24 isolates K.pneumoniae showed more than half of a class of ESBL (54.16%).ESBL isolates from male patients were higher than female patients, ranging in age from 17-80 years and most age groups were young adults 30-60 years old.Gender allegedly influential because of men have activity and mobility higher than women so susceptible to contracting.Age also gives affect because it can be attributed to a person's immune factor.The increasing age then the immunity tends to decrease.The isolates of K.pneumoniae mostly come from sputum specimens are 22 isolates with the amount of ESBL positive equal to 54,54%.The results of bacterial susceptibility tests against some antimicrobials are presented in Table 2.The sensitivity test results of K.pneumoniae ESBL positive groups to antibiotics still has sensitive> 90% meropenem (100%), amikacin (100%), tigecycline (92.85%), and ertapenem (92.86%).Meropenem and ertapenem are antibiotic from beta lactam groups based on their chemical structure.Resistance> 50% is found in antibiotics: ampicillin (100%), ceftriaxone (78.5%), ceftazidime (64.28%), cefepime (57.14%) and aztreonam (71.4%).Meanwhile, for a negative ESBL obtained a sensitivity> 90% for all antibiotics except ampicillin, ampicillin / sulbactam, and nitrofurantoin (Table 2).This is probably caused by antibiotics that are generally widely used as empirical therapy to almost all of patients irrationally.Ampicillin is widely used freely by all patients without supervision and evaluation by the physician so that it is suspected of causing resistance to ESBL.In general, the cause of resistance is also caused by the easy access to get antibiotics, poor adherence to antibiotics, hygiene and sanitation in health care facilities.

CONCLUSIONS
The prevalence of ESBL in Ulin General Hospital is increasing from previous studies.The menopenem (100%), amikacin (100%), tigecycline (92.85%), ertapenem (92.86%) are antibiotic choices that are still sensitive to ESBL infection.Based on the results of the study, it is hoped that the control and prevention of ESBL infection by giving more attention to patients who have ESBL infection risk factors such as patients treated in intensive care, postoperative, long-hospitalized patients and patients using many medical devices; carry out infection prevention and control programs in each room such as washing hands, using personal protective equipment, taking care of the sterility of equipment and room facilities to prevent the transfer of germs from one patient to another or from health-care workers to patients; pay attention to the selection and the use of rational antibiotics to reduce resistance; as well as evaluation and monitoring of antibiotic use should be undertaken to control and prevent increased ESBL incidence.

Table 1 .
Characteristics of ESBL samples in Dahlia Ward, Ulin General Hospital

Table 2 .
ESBL sensitivity test results on antimicrobials