1. No category

Title:
EXTENDED SPECTRUM BETA-LACTAMASE (ESBL)
RODUCING OLIFORMS
Directorate:
Infection Control
Responsible
for review:
S Hoque, Consultant Microbiologist
Infection Control Support Team
Ratified by:
Dr J Lowes, Medical Director
Ms E Childs, Director of Nursing and Quality
Paul Foster, Clinical Director of Pharmacy
Ref: 0916 Version 2
Classification: Protocol
Due for Review: 18/10/14
Document Control
Applicability: All staff
Torbay and Southern Devon Health and Care NHS Trust
The Community Infection Control Team are available 09:00 – 17.00 Monday to Friday, excluding Bank
Holidays. The Consultant Medical Microbiologist is available at all other times via Torbay Hospital
switchboard or Derriford Hospital switchboard (Southams/Tavistock Community hospitals).
South Devon Healthcare NHS Foundation Trust
The Infection Control Team are available 08:30-17:00 Monday-Friday.
Microbiologist is available at all other times via switchboard.
The Consultant Medical
CONTENTS
1
2
3
4
5
6
7
8
9
INTRODUCTION
SPREAD
PREVENTION AND CONTROL
ISOLATION
HAND HYGIENE AND ENVIROMENTAL MEASURES
ESBL CARRIAGE/ SCREENING
TREATMENT OF ESBL PRODUCING COLIFORM INFECTIONS
DECOLONISATION
OUTBREAKS
REFERENCES
AMENDMENTS
Amendments: Proposals for amendment should be sent to Infection Control
Appendix A – ESBL Patient information leaflet
Appendix B – ESBL prescribing guidelines
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Extended Spectrum Beta-Lactamase (ESBL) Producing Coliforms
Page 1 of 11
1.0
INTRODUCTION
Extended spectrum beta-lactamase producing coliforms are identified in the laboratory by their resistance to
the beta-lactam antibiotic cefpodoxime. The gene for this resistance is carried on a plasmid which can be
readily transmitted between similar strains. This resistance is partially inhibited by beta lactamase inhibitors
(e.g. clavulinic acid), which distinguishes it from other mechanisms of resistance such as chromosomal
(AmpC) resistance.
Most ESBLs detected in the UK are of the CTX-M type and typically occur in Klebsiella pneumoniae and
E.coli. The number of coliforms producing ESBLs is increasing at an alarming rate, particularly in South East
England and the West Midlands.
The clinical significance of these finding clinically is that ESBLs are resistant to penicillin’s and
cefalosporins. In addition, they are frequently multiply resistant to other antibiotics such as trimethoprim,
ciprofloxacin and even aminoglycosides. This situation is analogous to that of MRSA.
ESBL producing coliforms are usually susceptible to Nitrofurantoin PO (suitable for uncomplicated UTI
only), fosfomycin PO (available from pharmacy at SDHFT & Derriford) and carbapenems such as
meropenem and ertapenem.
There is a new type transferable antibiotic resistance in gram-negative organisms (including E.coli). NDM1(New Delhi Metallo-beta-lactamase 1) is named after the city that was visited by the patient in whom the
first organism carrying this enzyme was isolated but this resistance has spread worldwide. NDM-1 is a new
type of pasmid-mediated resistance that is active against all beta-lactamase, carbapenems and can also carry
other resistance mechanisms and is readily transferable to other strains.
Most ESBL & Metallo-beta-lactamase infections will be urinary tract or gut associated, although they may
cause other infections e.g. Klebsiella pneumoniae can cause pneumonia.
Infections with ESBLs are a concern for the following reasons:
 They are difficult to treat because they carry plasmids that confer resistance to many antibiotics.
 Patients may experience a delay in appropriate treatment because the microbe is resistant to first-line
antibiotics.
 Patients may experience significantly longer hospital stays with increased costs.
 Patients with infections have an increased risk of death. The colonisation rate for K. pneumoniae is
low in healthy individuals in the general population; however it is increased in hospitalised patients,
especially during prolonged hospitalisation or antibiotic therapy. ESBLs are primarily identified in
long-term care facilities and hospitals.
 The length of stay in an intensive care unit (with exposure to endemic strains) and health care
manipulations, e.g. use of catheters, are associated with acquisition of ESBLs.
 The most successful pathogens causing healthcare-associated infections (HCAl) develop antibiotic
resistance, have the ability to spread (transmissibility), and cause disease (virulence). HCAl caused by
ESBLs are most often associated with intensive care units, oncology, burn and neonatal units, as well
as receiving previous antibiotic therapy.
 Most colonised patients are asymptomatic and may be a source of transmission to others.
2.0
SPREAD
Selective antibiotic pressure leads to colonisation of patient’s bowel and skin with a risk of subsequent
infection. Faecal colonisation may play a critical role in facilitating spread. Outbreaks associated with
procedures, e.g., catheterisation, and contamination of medical devices has also been reported.
Secondary spread in health care settings can readily occur through healthcare personnel hands. Endemic
strains may persist in health care settings for years because of patient colonisation, environmental
Extended Spectrum Beta-Lactamase (ESBL) Producing Coliforms
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contamination, and hand transmission.
Infection prevention and control practices are essential to prevent spread and outbreaks of ESBL-producing
coliforms. There are few expert recommendations to direct management of these microbes in healthcare
settings and this policy will be re-evaluated on a regular basis to incorporate developing best practice.
3.0
PREVENTION AND CONTROL
Health care workers (both hospital and community based) should be encouraged to promote practices known
to reduce the spread of ESBLs. These fall into two broad groups, the first being good hand hygiene and
cleanliness and the second being a restrictive approach to antibiotic prescribing, especially in the limitation of
third generation cephalosporin use. These simple interventions can have a major influence on the impact of
ESBLs in the health care setting.
Appropriate use of antibiotics will greatly reduce the selection pressure for colonisation and infection with
ESBLs. Those prescribing antibiotics in SDHFT should adhere to the Trust Antibiotic Guidelines (CG 0040 &
CG1118). For those prescribing within the TSDHCT please adhere to your respective joint formulary: South
Devon Joint Formulary – www.torbaycaretrust.nhs.uk/jointformulary or Plymouth Joint Formulary –
http://plymouthformulary.nhs.uk/ . There should be a daily review of the need for continuation of antibiotics
for all patients on antibiotics. In the situation where there is more than one case on a ward, the prescriber
should consider avoiding cephalosporin use altogether in patients on the ward. In an outbreak situation, the
Infection Control Support Team/Community Infection Control Team, Consultant Medical Microbiologist
and/or Antimicrobial Pharmacist (Antimicrobial Pharmacist not available in TSDHCT) will suggest interim
alternative antibiotic prescribing guidelines on a ward / unit.
4.0
ISOLATION
4.1
Use of Barrier Precautions
Contact precautions in addition to other infection prevention measures, e.g., hand hygiene, environmental
cleaning, and restriction of antibiotics, have been shown to be effective in preventing transmission in outbreak
situations.
Contact precautions are recommended for colonised/infected patients in facility-based health care settings.
This includes the use of gloves and aprons/gowns. No additional precautions are required in outpatient or
home care settings.
Patients known to be colonised or infected with an ESBL producing coliforms must be managed in a single
room. If this is not possible, then appropriate additional precautions will need to be discussed with the
Infection Control Support Team/ Community Infection Control Team.
4.2
Type of isolation
Single room, ideally with a hand wash basin and toilet. If a toilet is not available a commode must be used and
be designated for the sole use of that patient. It must be thoroughly cleaned after each use. An isolation notice
must be placed on the outer door of the single room.
4.3
Duration of isolation
Isolation should be continued throughout the inpatient stay to reduce the risk of secondary spread.
4.4
Main infection source
Faeces, urine, skin (moist sites).
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4.5
Pathology specimens
Normal procedures apply. Clinical details, recent and current antibiotic history must be written on the request
form.
4.6
Protective clothing
Always use plastic apron and gloves for direct patient contact or contact with the immediate environment and
when handling body excretions/secretions.
4.7
Disposal of faeces/urine
Use a side room toilet if possible, otherwise use a designated commode.
4.8
Disposal of clinical waste
Yellow/Orange clinical waste bags
4.9
Cutlery/crockery
Normal ward issue – machine dishwasher on ward or in central kitchen.
4.10
Medical equipment
Patients must use designated equipment, which must be cleaned and disinfected on discharge. If unable to
designate for the sole use of the patient, then equipment must be cleaned and disinfected prior to removal.
Always ensure that the manufactures instructions are followed.
4.11
Linen
Use a water-soluble red bag then put into the laundry’s red bag.
4.12
Room cleaning
Rooms must be cleaned daily, paying special attention to dust-collecting areas and horizontal surfaces.
4.13
Visitors
Visitors with only social contact need not wear protective clothing but should wash their hands on leaving the
room. Alcohol based hand rubs are also effective against ESBL producing coliforms.
5.0
HAND HYGIENE AND ENVIRONMENTAL MEASURES
5.1
Patient to patient transfer of microorganisms via the hands of healthcare workers is thought to be the
main mode of transmission for ESBLs, although some ESBL outbreaks have been attributed to contaminated
medical devices (e.g. ultrasound gel).
Hand hygiene is a simple and effective infection prevention and control intervention. Hand washing with soap
and water is effective; however alcohol hand rubs are a quick and accessible alternative when hands are not
visibly soiled and are very effective at killing ESBLs when used correctly. Improving hand hygiene
compliance will significantly reduce the risk of healthcare associated infection.
5.2
Commodes, toilets, wheelchairs, floors, sinks, linen and medical devices may all become
contaminated. ESBL producing coliforms survive best in moist environments. Following discharge or transfer,
thorough terminal cleaning of furniture and the room is required. The curtains must also be changed.
6.0
ESBL CARRIAGE/ SCREENING
Patients with known ESBL carriage should have their records flagged consistent with established policies.
This will include an alert on the inside cover of their notes as well as on the IHCS screen. As with other alert
organisms/conditions, this needs to be routinely checked for all inpatient admissions or outpatient
assessments/procedures.
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Upon readmission consider screening for ESBL. Sites most often sampled for carriage are those where
coliforms are typically found - perianal/rectal and urine.
Patients with persistent carriage (e.g. 3 consecutive positive samples taken at least a week apart and the
continuation of ESBL-associated risk factors) do not require continued screening during an admission.
Precautionary measures are required and should be maintained. It is reasonable to re-screen during the
admission if there are changes in ESBL-associated risk factors.
Re-screening should be determined on an individual patient basis. Factors to consider include:
 continuing use of antibiotics
 predicted invasive interventions
 proposed removal of precautions
 On patient transfer, the receiving healthcare facility should be informed about a patient’s ESBL
carriage as with any antimicrobial-resistant microorganism.
Screening of health care workers is not recommended. The only exception would be if there is
epidemiological evidence of transmission from a suspected common source, where screening of personnel
may be warranted as part of the investigation. This would only be undertaken following consultation between
the Infection Control Support Team/Community Infection Control Team, Occupational Health and the
Clinical Director/ Matron covering the area concerned.
7.0
TREATMENT OF ESBL PRODUCING COLIFORM INFECTIONS
Medical staff should review the requirement for antibiotic(s). Inappropriate use of antibiotics may encourage
colonisation and secondary infection.
Asymptomatic patients do not require treatment nor those with resolving and very mild symptoms.
If treatment is required, please discuss treatment with a Consultant Microbiologist or Antimicrobial
Pharmacist ( not in the Community). Treatment guidelines are currently being produced but any serious
infection that may be due to ESBLs should include antibiotics to which the organism is known to be
susceptible. Most ESBLs are susceptible to meropenem IV.
8.0
OUTBREAKS
If there is an outbreak (two or more acquired cases), patient screening will be used for control purposes.
Identified cases should be placed in single rooms and full contact precautions followed (see section 3).
Patients in close proximity to colonised/infected patients should be screened for asymptomatic carriage.
Continue to screen exposed patients weekly until the outbreak ends (e.g. 2-4 weeks with no further cases or
colonisations).
The Devon Health Protection Unit will be notified should such a course of action be taken. Outbreaks of
infection caused by ESBL producing coliforms will be reported as serious untoward incidents associated with
infection.
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Extended Spectrum Beta-Lactamase (ESBL) Producing Coliforms
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Appendix A
Patient Information about
ESBLs
What are ESBLs?
This stands for Extended Spectrum Beta-Lactamases - which is a name used for a group of bacteria1 that are
resistant to many commonly used antibiotics. These bacteria are usually found in the bowel, where they live
quite happily without causing any problem. They are no more likely to cause infection than other bacteria
found within everyone’s bowel. However, occasionally they end up in a place where they shouldn’t be and
then it does cause an infection, for example, a urinary tract infection. This can still be treated with antibiotics,
but it does mean a different choice of antibiotics from the ones that would normally be used.
How are ESBLs spread?
It isn’t quite clear why ESBLs are suddenly starting to become a problem now and where most people get
them from. The most important route is likely to be through poor hand hygiene, but poorly maintained or
cleaned clinical and living areas may be significant in some cases. People with urinary catheters and those
who are taking antibiotics are more likely to pick them up.
How are they treated?
If you have ESBLs in your bowel, you are likely to carry them for a long time and there is no ‘treatment’ for
this. You will only be treated if you are showing signs of infection, for example, a high temperature with
burning pain when passing urine. If antibiotic tablets / syrups can be used, this would obviously be the first
choice. However, antibiotics in tablet or syrup form will not work against all ESBLs and it may then require
treatment with injectable antibiotics even if you are not seriously ill. If this is the case, we would hope that a
nurse could come out from the hospital and give you the antibiotic once a day in your own home.
Are ESBLs a big problem?
In South Devon we
 Screen patients regularly for these bacteria
 Take steps to ensure patient get the right antibiotics wherever they are
 Make sure all local doctors know about ESBLs
We do all this because we know there have been problems elsewhere in Britain when this has not been done.
Some of the correct antibiotics are very expensive and this is also an issue for the NHS.
What if I do have to come into hospital?
You will be nursed in a side room to reduce the risk of environmental contamination and so reduce the risk of
spreading it to others. Please remind staff as soon as you come into hospital that you have had an ESBL in the
past.
1
The most common bacteria in this group are species of Klebsiella or Escherichia coli (E. coli) – although the
strains involved are quite different from the E. coli O157 found in food poisoning.
Extended Spectrum Beta-Lactamase (ESBL) Producing Coliforms
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Will my hospital treatment be affected?
No. You will be allowed to attend other departments for investigations as normal. You will have any
operation or procedure that you need, as normal. The only difference is that, if you do get an infection whilst
you are in hospital, the doctors are likely to choose a different antibiotic to treat you.
How can I prevent the spread of ESBL?



Good hand hygiene, especially after using the toilet and when looking after people with urinary
catheters.
Maintaining a clean home.
Taking antibiotics only when they are really necessary.
Should I change my lifestyle?
No. You should live your life as normal. With good basic hygiene, as described above, you should put
absolutely no restrictions on your family or social life, secure in the knowledge that you are not placing your
friends or family at risk. There is no need to avoid young children, or sick or elderly relatives and friends. And
remember, you are no more likely to get an infection than anyone else - but if you do get an infection, remind
the doctor that you have had ESBLs before so that they can choose the right antibiotic for you.
These bacteria have been around for years, the only difference
is that they have learnt to stand up for themselves against
some antibiotics!
If you require further advice after reading this leaflet, please contact;
In hospital:
Lynn Kelly
Infection Control Nurse
Torbay Hospital
01803 655757
In the community:
Consultants in Communicable Disease Control
(01803) 861849
Community Infection Control Team: (01803) 210547/210548
References:
International Infection Control Council – Best Infection Control Practices for Patients with Extended Spectrum BetaLactamase Enterobacteriacae – C Friedman, S Callery, A Jeanes, P Piaskowski, L Scott (representing the International
Infection Control Council) and members of the Best Practices Expert Panel and Reviewer
It is very hard to find good information about ESBLs on the internet, but here are two places to start;
http://www.phls.co.uk/infections/topics_az/esbl/q_and_a.htm
http://www.cbc.ca/news/background/hospital-infections/esbl_bacteria.html
ESBLs/Infection Control/SDHC/06.06
Collated by Clinical Effectiveness
Extended Spectrum Beta-Lactamase (ESBL) Producing Coliforms
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Appendix B
A guide to the management of ESBLs
Dr Tony Maggs
V1.0 Jan 2006
What are ESBLs?
ESBL stands for “Extended Spectrum Beta-Lactamase producer”, and the bacteria included in this category
are usually coliform bacteria. For a long time now, many coliforms have been resistant to antibiotics such as
amoxicillin because they posess a ß-lactamase enzyme which breaks down the antibiotic and renders it
useless. However, ESBLs have a new form of this ß-lactamase enzyme which now allows them to destroy a
much greater range of ß-lactam antibiotics, including most cephalosporins and penicillins. In addition, and not
directly related to their ß-lactamase enzyme, these tend to be more antibiotic resistant strains generally and
they are often resistant to other non-ß-lactam antibiotics as well, such as ciprofloxacin and gentamicin.
Does it matter clinically?
These bacteria are probably no more likely to cause infections than any other coliform, but when infections do
occur they can be more difficult to treat with antibiotics. As coliforms cause over 90% of community acquired
urinary tract infections, not surprisingly ESBLs are seen most commonly in this area and they raise the
prospect of a simple urinary tract infection which can only be treated by intravenous antibiotics.
How big a problem is it?
ESBLs can be identified in the laboratory. In 2012 about 4% of coliforms causing UTIs have been ESBLs.
However, as UTIs are so common, this represents a significant number of infections.
Who is at risk of ESBL infection?
The risk factors for urinary tract infection with ESBLs are the same as for UTIs generally. As with other
antibiotic-resistant organisms, those who receive antibiotics frequently are most likely to acquire ESBLs,
although we are seeing small numbers of ESBL infections in younger patients without a history of repeated or
recent antibiotic usage. There does not seem to be any association with previous hospital stays, but patients in
nursing homes are over-represented in the figures.
How should the infection control issues be addressed?
The infection control precautions are broadly similar to those used for MRSA, with a particular emphasis on
hand cleansing before and after clinical contact, but with no restrictions in terms of social contact. Given
their importance in UTI, scrupulous attention should be paid to urinary catheter care including the use of a
new pair of gloves for each patient for catheter bag emptying or other manipulation, and hand cleansing
following the removal of all gloves. Any patient with an ESBL UTI is likely to have the organism within
their gut but, unlike MRSA, there is no decolonisation programme; therefore good infection control
practices are important all the time and not just when someone is known to have a current ESBLrelated infection. Patients who have had an ESBL infection will have their notes marked / a PAS computer
flag set to help future empirical antibiotic choice / nursing. Within hospitals, it would be sensible to place
known ESBL patients in side-rooms; within nursing homes, it would be best not to allow known colonised or
infected clients to share rooms with catheterised clients who have not had problems with ESBLs. As ever, all
antibiotics should carry a health warning and they should only be used where the benefits outweigh the
risks.
Treatment of ESBL infections
The great majority of infections are simple urinary tract infections in patients being managed in the
community.

If the symptoms are not severe, repeat the urine sample; a significant number of these infections may
clear spontaneously without the need for any antibiotics.

If the bacteriuria is persistent with relatively mild but significant symptoms, if the organism is
sensitive to it, then use nitrofurantoin (50 mg qds O: enteric coated formulations are preferable to
avoid GI disturbance) or fosfomycin PO (available from SDHFT and Derriford pharmacies).

In moderate / severe infection AND if a patient is <65 years of age, use ciprofloxacin (500 md bd O)
if the organism is sensitive to ciprofloxacin. Ertapenem (1g od IV) can be used and administered by
the MAT team (SDHFT) or other hospital services (TSDHCT) if ciprofloxacin-resistant (or if .65
years or a history of C.difficile) but ertapenem sensitive.
Extended Spectrum Beta-Lactamase (ESBL) Producing Coliforms
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




In the community, for patients who have previously had ESBL problems themselves or are from a
nursing home where a number of residents have had such problems, empirical choice of antibiotics
for a new UTI should be as above, and there should be lower threshold for sending urine samples to
the lab.
If you refer a patient to hospital from a nursing home where you know there have been a number of
ESBL problems, please mention this on your referral letter.
In hospitals, for patients who have previously had ESBL problems themselves or are from a nursing
home where a number of residents have had such problems, if there are severe symptoms consistent
with a Gram negative infection meropenem (1g tds IV) should be part of their empirical therapy.
Please discuss with consultant microbiologist if you are considering ertapenem or meropenem
treatment in patients with previous penicillin hypersensitivity / renal failure.
For patients with known previous ESBL problems, if you would normally give antibiotic prophylaxis
for a given procedure using a drug such as co-amoxiclav or cefuroxime, a single dose of gentamicin
or imipenem should be used in its place. Contact consultant microbiologist for further discussion.
Ertapenem and the MAT team
If needed, the MAT team is available to give ertapenem intravenously in the community to patients whose
symptoms are not sufficiently severe to warrant hospital admission. Patients should be asked about penicillinhypersensitivity and severe renal dysfunction noted, and so their suitability for ertapenem treatment before
referral. The drug will then be prescribed at South Devon Healthcare Trust, and the treatment given and
monitored by the MAT team, before handing care back to the relevant general practitioner. The MAT team
can be reached on (01803) 655776 or via long distance pager (07699 664766).
For the areas not covered by the MAT team this service would need to be arranged with the prescriber and the
appropriate Community Hospital team.
Who to contact for further advice?
For advice about treatment;
Dr Paul Turner / Dr Tony Maggs
Dr S Hoque
Consultant Microbiologists
Torbay Hospital
(01803) 654990
Dr James Greig
Consultant Microbiologist
Derriford Hospital Plymouth
0845 1558155
Dr Peter Jenks
Consultant Microbiologist
Derriford Hospital Plymouth
0845 1558155
Collated by Clinical Effectiveness
For Acute advice on infection control issues;
Lynn Kelly
Infection Control Nurse
Torbay Hospital,
(01803) 655757
Surgery, nursing and patients’ homes:
Local Consultants in Communicable Disease Control
(CCDC)
(01803) 861849
For Community infection control advice contact:
Community Infection Control Team:
Bay House
Nicholson Road
Torquay
(01803 210547/210548)
Extended Spectrum Beta-Lactamase (ESBL) Producing Coliforms
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Protocols & Guidelines – Document Control
This is a controlled document. It should not be altered in any way without the express permission of the
author or their representative. On receipt of a new version, please destroy all previous versions.
Ref: 0916
Title: Extended Spectrum Beta-Lactamase (ESBL) Producing Coliforms
Date of Issue:
Version:
18 October 2012
Next Review Date: 16 September 2014
1
Dr S Hoque, Consultant Microbiologist
Infection Control Support Team
Infection Control
Protocol
All staff
The guidance contained in this document is intended to be inclusive for all
patients within the clinical group specified, regardless of age, disability, gender,
gender identity, sexual orientation, race and ethnicity & religion or belief.
Yes
Author:
Index:
Classification:
Applicability:
Equality Impact:
Evidence based:
International Infection Control Council Best Infection Control Practices for
Patients with Extended Spectrum Beta Lactamase Enterobacteriacae. Available
via http://www.chica.org
References:
D M Livermore, N Woodford. Guidance to diagnostic laboratories: Laboratory
Detection and Reporting of Bacteria with Extended-spectrum R-lactamases.
Health Protection Agency, London, 2004. Available via http://www.hpa.org.uk
Investigations into multi-drug resistant ESBL producing Escherichia coli
strains causing infections in England. Available via http://www.hpa.org.uk
Produced following audit:
Audited:
Approval Route:
No
No
See ratification
Date Approved:
11October 2012
Ms E Childs, Director of Nursing & Quality
Approved By:
Dr S Smith, Medical Director
Paul Foster, Clinical Director of Pharmacy
Links or overlaps with other policies: 0040 –Adult Emperical Antimicrobial Guidelines: 1118 Paediatric
Empirical Antimicrobial Guidelines
All SDHCF Trust strategies, policies and procedure documents.
RATIFICATION:
Extended Spectrum Beta-Lactamase (ESBL) Producing Coliforms
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PUBLICATION HISTORY:
Issue
1
Date
29 June 2006
Status
New
1
16 October 2008
Date Change
1
25 September 2009
1
16 September 2010
Document
Info Added
Date Change
18 October 2012
Revised
22 January 2013
TSDHCT
Community
Aspects
Included.
2
2
Collated by Clinical Effectiveness
Authorised
Paul Turner, Consultant Microbiologist
Ms E Childs, Director of Nursing & Quality
Dr S Smith, Medical Director
Medicines Governance Group
Paul Turner, Consultant Microbiologist
Infection Control Support Team
Ms E Childs, Director of Nursing and Quality,
Dr S Smith, Medical Director,
Medicines Governance Group
Dr J Lowes, Medical Director
MS E Childs, Director of Nursing & Governance
Paul Foster, Clinical Director of Pharmacy
Anne Harding Community Infection Control Nurse.
Extended Spectrum Beta-Lactamase (ESBL) Producing Coliforms
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