June 13, 2019

EXTENDED SPECTRUM
BETA-LACTAMASE
(ESBL)

Siti Lestari
 OUT LINE
History and Prevalence of ESBL

Clinical Manifestation and Pathophysiology of ESBL

Nursing Process of Client with ESBL

Evaluation of ESBL Treatment

Discharge Planning of Client with ESBL

 1. HISTORY OF ESBL
DEFINITION

Extended spectrum beta-lactamases (ESBLs)

are one of a group of enzymes produced by
certain bacteria, most commonly Escherichia
coli and Klebsiella species
- These enzymes break down antibiotics
belonging to the beta-lactam group, making
them ineffective.
- Bacteria that produce ESBLs are resistant to
all ‘beta-lactam’ antibiotics e.g. Penicillins,
Co-amoxiclav and Cephalosporins.
- These bacteria are also commonly resistant to
other non beta-lactam antibiotics e.g.
Trimethoprim, Ciprofloxacin and Gentamicin
(HPA, 2014).
- ESBL dilaporkan tahun 1986 di
Perancis, 54 pasien di 3 ruang ICU
terinfeksi ESBL
- Swedia tahun 2006, 1,1 % E. Coli dan
0,8 K. Pneumonia menghasilkan ESBL
- Eropa, 2007 , ESBL 5,6 %
- USA , ESBL 6,1 ( tahun 2012)
 Prevalence of ESBL-organisms
in some Asian countries

Country Klebsiella spp. E. coli

Japan 5.0% 8.1%
Taiwan 21.7% 16.7%
Philipines 31.3% 13.3%
Malaysia / 38.0% 5.6%
Singapore
Indonesia 33.3% 23.0%
Evolution of β-Laktamase
 Epidemiology of ESBL producing organisms.
ESBL producing
organism Country References
E. coli, K. pneumoniae Sweden Alsterlund et al. (2009)
Salmonella spp. Spain Fernandez et al. (2006)
E. coli, K. pneumoniae Italy Perilli et al. (2011)
K. pneumoniae Turkey Aktas et al. (2008)
Enterobacteriaceae, P. aeruginosa Nigeria Ruth et al. (2011)
E. coli Nepal Thakur et al. (2013)
E. coli, K. pneumoniae Tanzania Mshana et al. (2009)
E. coli, K. pneumoniae Iran Fatemeh et al. (2012)
E. coli Middle East Al-Agamy et al. (2006)
E. coli Saudi Arabia Tawfik et al. (2011)
K. pneumoniae Saudi Arabia Khanfar et al. (2009)
E. coli, K. pneumoniae Lebanon Moubareck et al. (2005)
E. coli, K. pneumoniae Kuwait Moubareck et al. (2005)
E. coli, K. pneumoniae China Hawkey (2008) and Hirakata et al. (2005)
E. coli, K. pneumoniae India Ensor et al. (2006) and Nasa et al. (2012)
E. coli, K. pneumoniae Punjab Rupinder et al. (2013)
E. coli Odisha Shakti et al., 2014
Enterobacteriaceae Pakistan Perry et al. (2011)
E. coli, K. pneumoniae Lahore Majda et al. (2013)
E. coli, K. pneumoniae Latin America Rossi et al. (2008)
2. Clinical Manifestation and
Mekanisme of ESBL
 INFECTIONS ASSOCIATED WITH
ESBL-PRODUCING BACTERIA
1. Urinary tract infection
2. Bactaeremia -primary or secondary
3. Respiratory tract infection
- nosocomial pneumonia
- ventilator associated pneumonia
4. Gastrointestinal tract infection
- intra-abdominal abscess
- peritonitis
- cholangitis
INFECTIONS ASSOCIATED WITH
ESBL-PRODUCING BACTERIA

5. Skin and soft tissue infection

6. Catheter or device related infection
7. Sinusitis
8. Neurosurgical meningitis
-related to ventricular drainage
catheters
When it occurs in the intestine
Blood stools
Diarrhea
No appetite
Abdominal cramps
Bloated
Fever
 ESBL in the bloodstream
Fever
Shivering
Nausea
Vomitus
Having respiratory problems
 How do Antibiotics work?

1. Interference with cell wall synthesis

Beta-lactam
2. Inhibition of protein synthesis
3. Interference with nucleic acid synthesis
4. Inhibition of a metabolic pathway
5. Disorganizing of the cell membrane
 Mekanisme Kerja Antibiotika
No Mekanisme Kerja Golongan Antibiotika
1 Menghambat sintesa atau Beta laktam ( Penisilin,
merusak dinding Sel BakteriSefalosporin, Monobaktam,
karbapenem, inhibitor Beta
laktamase ), Basitrasin,
vankomisin
2 Memodifikasi atau Aminoglikosida , kloramfenikol,
menghambat sintesa protein tetrasiklin, makrolida dan
klindamisin
3 Menghambat enzim enzim Trimetoprim , Sulfonamida
esensial dalam metabolisme
folat
4 Mempengaruhi sintesis atau Kuinolon, nitrofurantoin
metabolisme asam nukleat
Different antibiotic resistance
mechanisms
 Perawat
1.Menerapkan kewaspadaan standar dalam
upaya mencegah penyebaran mikroba
resisten.
2. Terlibat dalam cara pemberian antibiotik
yang benar.
3. Terlibat dalam pengambilan spesimen
mikrobiologi secara teknik aseptik.

( Permenkes Nomor 8 / 2015: Program pengendalian

resistensi antimikroba di rumah sakit )
3. Nursing Process
1. Assessment
 Risk factors for infection with
ESBL
1. Previous history of ESBL colonization
or infection.
2. Repeated courses of antibiotics
particularly for urinary tract infections.
3. Recent broad spectrum antibiotics such
as Cephalosporins or Quinolones.
4. Previous hospitalisation particularly
involving specialist or intensive care.
5. Contact with areas of the world where
there is a higher prevalence of ESBL
organisms (e.g. Indian sub-continent,
Southern Europe)
6. Presence of a device that breaches the
skins normal line of defense i.e.
urinary catheters and intravenous
cannulae. (Health Protection Agency
, HPA, 2014)
 Diagnosis Infeksi Bakteri
Penghasil ESBL
- Pemeriksaan laboratorium
- Sampel diambil dari urin, darah, tinja,
atau cairan luka
 Nursing Diagnosis
- Risk for infection
- Risk for surgical site infection
- Impaired skin integrity
- Delayed surgical recovery
- Risk for contamination
- Hypertermia
- Chronic pain
- Readiness for health enhanced health
management
- Ineffective health maintenance
- Ineffective health management
IMPLEMENTATION
 Manajemen non farmakologi
- Eliminasi sumber infeksi
- Penggantian jalur intravaskuler
- Kateter urine
- Drainage dari abses intraabdomen atau
intra visceral
Manajemen farmakologi
 1. Karbapenem
1. imepenem, meropenem, erapenem,
dan doripenem
2. Dosis standar pada dewasa :
meropenem 1 gram IV setiap 8 jam
imipenem 500 mg 4 kali sehari IV
ertapenem 1 gr setiap 24 jam IV
2. β-laktam / β- lactamase inhibitor

- Untuk ESBL yang tidak berat

- Amoxicillin /Klavunalat utk ISK
- Tazobaktam utk ESBL CTX-M
- Sulbaktam utk SHV dan TEM
 3. Aminoglikosida
1. Gentamisin ,
- bakterisida cepat
- memiliki kerentanan bervariasi
- penggunaan monoterapi dihindari.
- dosis 5 mg / Kg BB/ hari IV
2. Kamikasin
dosis dewasa 15 mg / Kg BB perhari
terbagi dalam 2 dosis intravena
 Infection Prevention and
Controll
1. Isolation (Inpatient areas and
Intermediate Care) Optimum
2. Screening Routine
3. Hand Hygiene
4. Use of Personal Protective Equipment
Gloves
 Infection Prevention and
Control ( Cont’d)
5. Equipment
6. Linen (Inpatient areas and Intermediate
Care)
7. Outbreaks
8. Documentation
 Precautions required for ESBL
1. Single room accommodation
2. Gloves and gown must be worn
3. Equipment used in daily care will remain
in the room
4. Hand wash.
 Procedures for patients infected by
ESBL Producing Organisms
1. Tagging records/patients' cards
- Attach ESBL identification label to
medical records/ x-ray envelopes
2. Education
Develop a system to ensure that hospital
patients, personnel, and visitors are
educated about the use of precautions
 Additional Nursing Procedures
1. Clothes
Change all night clothes daily after body
wash. Other disposable garments should be
changed preferably daily
2. Linen
Change all bed linen daily. Send to
laundry in appropriate bags for "infected" linen
3. Bedpan and urinals
Provide a dedicated bedpan (if
possible) for ESBL stool carriers.
Heat-treat bedpans and urinals at
80°C by using bedpan disinfector
Do not soak bedpans or urinals in
disinfectant.
Ensure that bedpans, urinals and
bowls are stored clean, inverted and dry
4.Urinary catheters
Ensure that an aseptic procedure is used
for insertion of catheters.
Do not catheterize patients repeatedly.
Empty the urinary drainage bag by the
tap and wear disposable gloves while doing
so. Do not break the circuit and reconnect.
Use a separate jug or container for each
patient when empty urinary drainage bags
4. EVALUATION of
TREATMENT
Complication

Diarhea
Pneumonia
Skin Infection
Renal Failure
Meningitis
Hemoragic
Seizure
 5. Discharge Planning of Client with
ESBL

- Make sure to applied

special precaution
at home and in the
community
- Wash hands after go
to the bathroom, before
preparing food or eating
food
- Carry a hand sanitizer
- If ESBL skin infection, wash hands befo
re and after touching the wound.
- Keep skin infections and wounds covere
d with clean, dry bandages
- Place used bandages into a plastic bag
and directly into the garbage
- Maintain excellent personal hygiene
- Do not share personal items
- Always tell the physicians, nurses or ot
her care providers that you have ESBL
TERIMA KASIH !!!!