Background: The widespread use of antibiotics has resulted in emergence of community-acquired antibiotic resistance among uropathogens in outpatient’s population. This constitutes an impediment in the management of urinary tract infection (UTI) in both community and hospital settings. Objective: The aim of this study was to determine the current antibiotic resistance trends, extended spectrum beta-lactamase (ESBL) production and plasmid profile of uropathogens from outpatients. Methods: A total of 370 mid-stream urine samples were collected and cultured by standard methods. Isolated uropathogens were identified using appropriate biochemical methods. The modified Kirby Bauer disk method was used for antibiotic susceptibility test. The ESBL-producing uropathogens were identified and their plasmid DNA extraction and curing were carried out by standard methods. Results: About 35.7% and 32.7% of uropathogens were multi-drug resistant and ESBL-producing respectively. There was higher prevalence of ESBL-production among isolates from female patients (62.5%) when compared to that from male patients (37.5%). The isolated uropathogens were most resistant to Cefotaxime, and most sensitive to Imipenem. Resistance to antibiotics by ESBL-producing uropathogens was found to be plasmid-mediated. Conclusion: Community acquired Uropathogens from outpatients were multidrug resistant due to ESBL production localized on plasmids, a probable cause of treatment failures experienced in Uyo.
Prevalence and Characterisation of Beta Lactamases in Multi Drug Resistant Gr...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Incidence rate of multidrug-resistant organisms in a tertiary care hospital, ...Apollo Hospitals
Antimicrobial resistance to microorganisms is a growing public health concern globally, especially in developing countries. This study was conducted to study the incidence rate of multidrug-resistant organisms with their antibiotic sensitivity pattern.
Introduction: Bloodstream infections (BSIs) are associated with a high mortality rate of 20%-50%. Blood culture is paramount to identify causative agents of BSIs to choose an appropriate antimicrobial therapy. Objectives: The present study was undertaken to analyze the various microorganisms causing BSIs and study their antimicrobial resistance patterns in a tertiary care hospital, Eastern India. Materials and Methods: A total of 239 blood specimens from clinically suspected cases of BSIs were studied for 6 months from July 2015 to December 2015. Blood specimens were incubated in BacT/ALERT ® 3D system (bioMerieux, Durham, NC, USA) a fully automated blood culture system for detection of aerobic growth. Identification and antimicrobial susceptibility testing were conducted on VITEK ® 2 (bioMerieux, Durham, NC, USA) as per Clinical Laboratory Standards Institute guidelines. Results: Out of 239 specimens, 41 (17.2%) yielded growth of different microorganisms. From these isolates, 20 (48.8%) were Gram-negative bacilli, 18 (43.9%) were Gram-positive cocci and rest 3 (7.3%) were yeasts. Among Gram-negative bacilli, Klebsiella pneumoniae sub spp. pneumoniae (70%) was most commonly isolated. Coagulase-negative staphylococci (88.9%) were the most common isolate among Gram-positive cocci. All three Candida spp. isolated were nonalbicans Candida (two Candida tropicalis and one Candida krusei). Gram-negative isolates were least resistant to tigecycline and colistin. All Gram-positive cocci were sensitive to linezolid. Conclusion: Monitoring of data regarding the prevalence of microorganisms and its resistance patterns would help in currently prescribing antimicrobial regimens and improving the infection control practices by formulating policies for empirical antimicrobial therapy.
Background: The widespread use of antibiotics has resulted in emergence of community-acquired antibiotic resistance among uropathogens in outpatient’s population. This constitutes an impediment in the management of urinary tract infection (UTI) in both community and hospital settings. Objective: The aim of this study was to determine the current antibiotic resistance trends, extended spectrum beta-lactamase (ESBL) production and plasmid profile of uropathogens from outpatients. Methods: A total of 370 mid-stream urine samples were collected and cultured by standard methods. Isolated uropathogens were identified using appropriate biochemical methods. The modified Kirby Bauer disk method was used for antibiotic susceptibility test. The ESBL-producing uropathogens were identified and their plasmid DNA extraction and curing were carried out by standard methods. Results: About 35.7% and 32.7% of uropathogens were multi-drug resistant and ESBL-producing respectively. There was higher prevalence of ESBL-production among isolates from female patients (62.5%) when compared to that from male patients (37.5%). The isolated uropathogens were most resistant to Cefotaxime, and most sensitive to Imipenem. Resistance to antibiotics by ESBL-producing uropathogens was found to be plasmid-mediated. Conclusion: Community acquired Uropathogens from outpatients were multidrug resistant due to ESBL production localized on plasmids, a probable cause of treatment failures experienced in Uyo.
Prevalence and Characterisation of Beta Lactamases in Multi Drug Resistant Gr...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Incidence rate of multidrug-resistant organisms in a tertiary care hospital, ...Apollo Hospitals
Antimicrobial resistance to microorganisms is a growing public health concern globally, especially in developing countries. This study was conducted to study the incidence rate of multidrug-resistant organisms with their antibiotic sensitivity pattern.
Introduction: Bloodstream infections (BSIs) are associated with a high mortality rate of 20%-50%. Blood culture is paramount to identify causative agents of BSIs to choose an appropriate antimicrobial therapy. Objectives: The present study was undertaken to analyze the various microorganisms causing BSIs and study their antimicrobial resistance patterns in a tertiary care hospital, Eastern India. Materials and Methods: A total of 239 blood specimens from clinically suspected cases of BSIs were studied for 6 months from July 2015 to December 2015. Blood specimens were incubated in BacT/ALERT ® 3D system (bioMerieux, Durham, NC, USA) a fully automated blood culture system for detection of aerobic growth. Identification and antimicrobial susceptibility testing were conducted on VITEK ® 2 (bioMerieux, Durham, NC, USA) as per Clinical Laboratory Standards Institute guidelines. Results: Out of 239 specimens, 41 (17.2%) yielded growth of different microorganisms. From these isolates, 20 (48.8%) were Gram-negative bacilli, 18 (43.9%) were Gram-positive cocci and rest 3 (7.3%) were yeasts. Among Gram-negative bacilli, Klebsiella pneumoniae sub spp. pneumoniae (70%) was most commonly isolated. Coagulase-negative staphylococci (88.9%) were the most common isolate among Gram-positive cocci. All three Candida spp. isolated were nonalbicans Candida (two Candida tropicalis and one Candida krusei). Gram-negative isolates were least resistant to tigecycline and colistin. All Gram-positive cocci were sensitive to linezolid. Conclusion: Monitoring of data regarding the prevalence of microorganisms and its resistance patterns would help in currently prescribing antimicrobial regimens and improving the infection control practices by formulating policies for empirical antimicrobial therapy.
Antimicrobial resistance as an emerging food-borne infectious diseaseJean Jacques Bernatas
Food safety is also about acquired antimicrobial resistance in big farms, and its spread in the environment. Be a smart consumer, a smart producer, and a smart patient to contributing to get antimicrobial resistance under control.
CONTACT: sayantand691@gmail.com
Superbugs are strains of bacteria, viruses, parasites and fungi that are resistant to most of the antibiotics and other medications commonly used to treat the infections they cause. A few examples of superbugs include resistant bacteria that can cause pneumonia, urinary tract infections and skin infections.
Drug resistance (antimicrobial resistance) is a naturally occurring phenomenon that can be slowed, but not stopped. Over time, germs such as bacteria, viruses, parasites and fungi adapt to the drugs that are designed to kill them and change to ensure their survival. This makes previously standard treatments for some infections less effective, and sometimes ineffective. Researchers continue to evaluate how these germs develop resistance. They also study how to diagnose, treat and prevent antimicrobial resistance.
Certain actions may step up the appearance and spread of antimicrobial-resistant germs, such as:
Using or misusing antibiotics
Having poor infection prevention and control practices
Living or working in unclean conditions
Mishandling food
To protect yourself from harmful germs and lower the risk of illnesses:
Wash your hands often with soap and water, or use an alcohol-based hand sanitizer
Handle food properly, such as separating raw and cooked food, cooking food thoroughly, and using clean water
Avoid close contact with people who are ill
Make sure your vaccinations are up to date
You can also help tackle antibiotic resistance by:
Using antibiotics as directed and only when needed
Completing the full treatment course, even if you feel better
Not sharing antibiotics with others
Not using leftover prescriptions.
Multidrug Resistance Pattern of Staphylococcus Aureus Isolates in Maiduguri M...Scientific Review
Multi drug-resistant (MDR) isolates of Staphylococcus aureus are on rise and are becoming a challenge for timely and appropriate treatment. The present study was carried out with an objective to isolate Staphylococcus aureus from clinical samples and determine their sensitivity. Out of 110 samples collected, 44 were shown to contained S. aureus. The isolates were subjected to antibiotic sensitivity tests using 10 different and commonly used antibiotics by modified Kirby- Bauer disc diffusion technique. Out of the total isolates (42) tested, only 7.1% were susceptible to all the antibiotics. Multiple resistance was eminent in over 92% with highest occurrence in 4.8% where the entire antibiotics were resisted. Multiple antibiotic resistance indixes (MAR index) indicated that 0.6 index occurred most (23.8%) followed by 0.5 (19.0%). On the other hand, 0.1 and 0.8 indexes were the lowest with 0.0% and 1.0% occurrence respectively. Ciprofloxacin was resisted by most of the organisms (64.3%) while amoxicillin (64.3%) and streptomycin (61.9%) were most efficacious. With over 90% isolate having MAR index ≥ 0.2, the multiple drug resistance by the S. aureus is quite alarming and might suggest inappropriate antibiotic usage by the sampled population. Therefore, the need to strategize the nature of antibiotic treatment against S. aureus and massive campaign on indiscriminate antibiotic use is urgent.
Antibiotics for surgical prophylaxis.
Surgical site infections(SSIs) are a significant cause of morbidity and mortality.
Approximately 2% to 5% of patients undergoing clean extra-abdominal operations and 20%undergoing intra-abdominal operations will develop an SSI.
SSIs have become the second most common cause of nosocomial infection and these data are likely underestimated.
Fighting the growing threat of antimicrobial resistance webinar4 All of Us
Lord Jim O’Neill, the UK Commercial Secretary to the Treasury and Chair of the Review on Antimicrobial Resistance, recently released a report laying out recommendations to fight the global threat of antimicrobial resistance (AMR).
Overuse of antibiotics, especially of broad spectrum antibiotics rather than targeted narrow spectrum therapies, has led to an increase in drug-resistant bacterial infections. This emerging health issue is poised to have devastating global consequences, making it impossible to treat previously curable diseases. AMR already contributes to 700,000 deaths a year, and the report warns that it could cause 10 million deaths a year and $100 trillion in lost global productivity by 2050 if nothing is done to stop its spread.
In recent years, advances in diagnostic technology have made rapid point-of-care testing possible for many diseases – enabling providers to immediately prescribe the most appropriate therapy during the course of a patient’s visit.
This webinar will focused on the importance of understanding the need for diagnostics, what is being done in development and the solutions that are available now.
Antimicrobial resistance (AMR) in N. gonorrhoeae (GC) - global problem but v...Игорь Шадеркин
Antimicrobial resistance (AMR) in N. gonorrhoeae (GC) - global problem but valid data are lacking in many geographic areas
Magnus Unemo, PhD, Assoc. Professor
Reference Laboratory for Pathogenic Neisseria
Department of Clinical Microbiology
Örebro University Hospital
Sweden
This is part of our project that aims to assess current state of anti-microbial resistance in Egypt with a specific focus on development of anti-parasitic drugs resistance in addition.
A study of antibiotic resistance of Extended-Spectrum Beta-Lactamases produci...Premier Publishers
Background: Extended-Spectrum Beta-Lactamases - producing Enterobacteriaceae are common in hospitals. This study aims to describe the antibiotic resistance of these bacteria and their associated demographic and clinical factors. Methods: It was a prospective study of 73 isolates of Extended-Spectrum Beta-Lactamases - producing Enterobacteriaceae for a period of six months from July to December 2019 in the laboratory of Befelatanana. Results: This study showed 73 (6.3%) isolates of Extended-Spectrum Beta-Lactamases- producing Enterobacteriaceae, represented by 25 (34.2%) isolates of Klebsiella spp, 24 (32.9%) isolates of Escherichia coli, 22 (30.1%) isolates of Enterobacter spp and 2 (2.7%) isolates of Proteus spp. The antibiotic resistance of these bacteria varied from 0% to 100% for all of the antibiotics tested. Resistance to aminoglycosides ranged from 0% (amikacin) to 69.9% (gentamycin). Resistance to quinolones ranged from 43.8% (levofloxacin) to 76.7% (nalidixic acid). Similarly, 60 (82.2%) isolates were resistant to cotrimoxazole and 25 (34.2%) isolates to chloramphenicol. Patients under 20 years (57.1%) (p=0.03), men (52.2%)(p=0.11; NS), patients with respiratory samples (83.3%)(p=0.004), with pus (61.9%)(p=0.02) and hospitalized in surgery and intensive care units (68.4%)(p=0.0009) were the most affected by these enterobacteria. Conclusion: Extended-Spectrum Beta-Lactamases - producing Enterobacteriaceae are responsible for severe infections and the majorities are multi-resistant bacteria.
Keywords: Beta-lactamase, Enterobacteriaceae, antibiotic resistance, amikacin, imipenem.
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
Antimicrobial stewardship to prevent antimicrobial resistanceGovindRankawat1
India is among the nations with the highest burden of bacterial infections.
India is one of the largest consumers of antibiotics worldwide.
India carries one of the largest burdens of drug‑resistant pathogens worldwide.
Highest burden of multidrug‑resistant tuberculosis,
Alarmingly high resistance among Gram‑negative and Gram‑positive bacteria even to newer antimicrobials such as carbapenems.
NDM‑1 ( New Delhi Metallo Beta lactamase 1, an enzyme which inactivates majority of Beta lactam antibiotics including carbapenems) was reported in 2008
Antibiotics are most common therapeutic agents used in hospitals across world, however, microbial world is becoming resistant day by day, posing special challenges to clinicians specially working in ICU set ups. There are multiple ways to curb this menace, if approached together in antibiotic stewardship way, can bring about wonders and retain therapeutic potentials of these drugs.
Antimicrobial resistance as an emerging food-borne infectious diseaseJean Jacques Bernatas
Food safety is also about acquired antimicrobial resistance in big farms, and its spread in the environment. Be a smart consumer, a smart producer, and a smart patient to contributing to get antimicrobial resistance under control.
CONTACT: sayantand691@gmail.com
Superbugs are strains of bacteria, viruses, parasites and fungi that are resistant to most of the antibiotics and other medications commonly used to treat the infections they cause. A few examples of superbugs include resistant bacteria that can cause pneumonia, urinary tract infections and skin infections.
Drug resistance (antimicrobial resistance) is a naturally occurring phenomenon that can be slowed, but not stopped. Over time, germs such as bacteria, viruses, parasites and fungi adapt to the drugs that are designed to kill them and change to ensure their survival. This makes previously standard treatments for some infections less effective, and sometimes ineffective. Researchers continue to evaluate how these germs develop resistance. They also study how to diagnose, treat and prevent antimicrobial resistance.
Certain actions may step up the appearance and spread of antimicrobial-resistant germs, such as:
Using or misusing antibiotics
Having poor infection prevention and control practices
Living or working in unclean conditions
Mishandling food
To protect yourself from harmful germs and lower the risk of illnesses:
Wash your hands often with soap and water, or use an alcohol-based hand sanitizer
Handle food properly, such as separating raw and cooked food, cooking food thoroughly, and using clean water
Avoid close contact with people who are ill
Make sure your vaccinations are up to date
You can also help tackle antibiotic resistance by:
Using antibiotics as directed and only when needed
Completing the full treatment course, even if you feel better
Not sharing antibiotics with others
Not using leftover prescriptions.
Multidrug Resistance Pattern of Staphylococcus Aureus Isolates in Maiduguri M...Scientific Review
Multi drug-resistant (MDR) isolates of Staphylococcus aureus are on rise and are becoming a challenge for timely and appropriate treatment. The present study was carried out with an objective to isolate Staphylococcus aureus from clinical samples and determine their sensitivity. Out of 110 samples collected, 44 were shown to contained S. aureus. The isolates were subjected to antibiotic sensitivity tests using 10 different and commonly used antibiotics by modified Kirby- Bauer disc diffusion technique. Out of the total isolates (42) tested, only 7.1% were susceptible to all the antibiotics. Multiple resistance was eminent in over 92% with highest occurrence in 4.8% where the entire antibiotics were resisted. Multiple antibiotic resistance indixes (MAR index) indicated that 0.6 index occurred most (23.8%) followed by 0.5 (19.0%). On the other hand, 0.1 and 0.8 indexes were the lowest with 0.0% and 1.0% occurrence respectively. Ciprofloxacin was resisted by most of the organisms (64.3%) while amoxicillin (64.3%) and streptomycin (61.9%) were most efficacious. With over 90% isolate having MAR index ≥ 0.2, the multiple drug resistance by the S. aureus is quite alarming and might suggest inappropriate antibiotic usage by the sampled population. Therefore, the need to strategize the nature of antibiotic treatment against S. aureus and massive campaign on indiscriminate antibiotic use is urgent.
Antibiotics for surgical prophylaxis.
Surgical site infections(SSIs) are a significant cause of morbidity and mortality.
Approximately 2% to 5% of patients undergoing clean extra-abdominal operations and 20%undergoing intra-abdominal operations will develop an SSI.
SSIs have become the second most common cause of nosocomial infection and these data are likely underestimated.
Fighting the growing threat of antimicrobial resistance webinar4 All of Us
Lord Jim O’Neill, the UK Commercial Secretary to the Treasury and Chair of the Review on Antimicrobial Resistance, recently released a report laying out recommendations to fight the global threat of antimicrobial resistance (AMR).
Overuse of antibiotics, especially of broad spectrum antibiotics rather than targeted narrow spectrum therapies, has led to an increase in drug-resistant bacterial infections. This emerging health issue is poised to have devastating global consequences, making it impossible to treat previously curable diseases. AMR already contributes to 700,000 deaths a year, and the report warns that it could cause 10 million deaths a year and $100 trillion in lost global productivity by 2050 if nothing is done to stop its spread.
In recent years, advances in diagnostic technology have made rapid point-of-care testing possible for many diseases – enabling providers to immediately prescribe the most appropriate therapy during the course of a patient’s visit.
This webinar will focused on the importance of understanding the need for diagnostics, what is being done in development and the solutions that are available now.
Antimicrobial resistance (AMR) in N. gonorrhoeae (GC) - global problem but v...Игорь Шадеркин
Antimicrobial resistance (AMR) in N. gonorrhoeae (GC) - global problem but valid data are lacking in many geographic areas
Magnus Unemo, PhD, Assoc. Professor
Reference Laboratory for Pathogenic Neisseria
Department of Clinical Microbiology
Örebro University Hospital
Sweden
This is part of our project that aims to assess current state of anti-microbial resistance in Egypt with a specific focus on development of anti-parasitic drugs resistance in addition.
A study of antibiotic resistance of Extended-Spectrum Beta-Lactamases produci...Premier Publishers
Background: Extended-Spectrum Beta-Lactamases - producing Enterobacteriaceae are common in hospitals. This study aims to describe the antibiotic resistance of these bacteria and their associated demographic and clinical factors. Methods: It was a prospective study of 73 isolates of Extended-Spectrum Beta-Lactamases - producing Enterobacteriaceae for a period of six months from July to December 2019 in the laboratory of Befelatanana. Results: This study showed 73 (6.3%) isolates of Extended-Spectrum Beta-Lactamases- producing Enterobacteriaceae, represented by 25 (34.2%) isolates of Klebsiella spp, 24 (32.9%) isolates of Escherichia coli, 22 (30.1%) isolates of Enterobacter spp and 2 (2.7%) isolates of Proteus spp. The antibiotic resistance of these bacteria varied from 0% to 100% for all of the antibiotics tested. Resistance to aminoglycosides ranged from 0% (amikacin) to 69.9% (gentamycin). Resistance to quinolones ranged from 43.8% (levofloxacin) to 76.7% (nalidixic acid). Similarly, 60 (82.2%) isolates were resistant to cotrimoxazole and 25 (34.2%) isolates to chloramphenicol. Patients under 20 years (57.1%) (p=0.03), men (52.2%)(p=0.11; NS), patients with respiratory samples (83.3%)(p=0.004), with pus (61.9%)(p=0.02) and hospitalized in surgery and intensive care units (68.4%)(p=0.0009) were the most affected by these enterobacteria. Conclusion: Extended-Spectrum Beta-Lactamases - producing Enterobacteriaceae are responsible for severe infections and the majorities are multi-resistant bacteria.
Keywords: Beta-lactamase, Enterobacteriaceae, antibiotic resistance, amikacin, imipenem.
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
Antimicrobial stewardship to prevent antimicrobial resistanceGovindRankawat1
India is among the nations with the highest burden of bacterial infections.
India is one of the largest consumers of antibiotics worldwide.
India carries one of the largest burdens of drug‑resistant pathogens worldwide.
Highest burden of multidrug‑resistant tuberculosis,
Alarmingly high resistance among Gram‑negative and Gram‑positive bacteria even to newer antimicrobials such as carbapenems.
NDM‑1 ( New Delhi Metallo Beta lactamase 1, an enzyme which inactivates majority of Beta lactam antibiotics including carbapenems) was reported in 2008
Antibiotics are most common therapeutic agents used in hospitals across world, however, microbial world is becoming resistant day by day, posing special challenges to clinicians specially working in ICU set ups. There are multiple ways to curb this menace, if approached together in antibiotic stewardship way, can bring about wonders and retain therapeutic potentials of these drugs.
AMR & Alternative Stratergies - MicrobiologySijo A
Antibiotic resistance poses one of the most important health challenges of the 21st century.
The rise of multidrug-resistant bacteria has already led to a significant increase in human disease and death.
The U.S. Centers for Disease Control and Prevention estimates that approximately 2.8 million people worldwide are infected with antibiotic-resistant bacteria, accounting for 35,000 deaths each year in the U.S. and 700,000 deaths around the globe.
Multidrug Resistance Pattern of Staphylococcus Aureus Isolates in Maiduguri ...Scientific Review SR
Multi drug-resistant (MDR) isolates of Staphylococcus aureus are on rise and are becoming a
challenge for timely and appropriate treatment. The present study was carried out with an objective to isolate
Staphylococcus aureus from clinical samples and determine their sensitivity. Out of 110 samples collected, 44
were shown to contained S. aureus. The isolates were subjected to antibiotic sensitivity tests using 10 different
and commonly used antibiotics by modified Kirby- Bauer disc diffusion technique. Out of the total isolates (42)
tested, only 7.1% were susceptible to all the antibiotics. Multiple resistance was eminent in over 92% with
highest occurrence in 4.8% where the entire antibiotics were resisted. Multiple antibiotic resistance indixes
(MAR index) indicated that 0.6 index occurred most (23.8%) followed by 0.5 (19.0%). On the other hand, 0.1
and 0.8 indexes were the lowest with 0.0% and 1.0% occurrence respectively. Ciprofloxacin was resisted by
most of the organisms (64.3%) while amoxicillin (64.3%) and streptomycin (61.9%) were most efficacious. With
over 90% isolate having MAR index ≥ 0.2, the multiple drug resistance by the S. aureus is quite alarming and
might suggest inappropriate antibiotic usage by the sampled population. Therefore, the need to strategize the
nature of antibiotic treatment against S. aureus and massive campaign on indiscriminate antibiotic use is urgent.
Antibiotics and similar drugs, together called antimicrobial agents, have been used for the last many years to treat patients who have infectious diseases. The treatment of bacterial infections is increasingly complicated because microorganisms can develop resistance to antimicrobial agents, since the first usage of antimicrobials, the resistance among bacteria has progressively increased and has accelerated within the last 10 years. This is largely due to the increasing presence of pathogenic microorganisms with resistance to previous antibiotic agents, resulting in the administration of improper treatment, not only in humans but also in companion and food animals and the environment which has caused the rise in antibiotic resistance. Although efforts are being made in all the areas, there is an urgent need to increase the effectiveness of these interventions or some bacterial infections will become difficult if not impossible to treat reliably.
1. Indian Journal of Basic and Applied Medical Research; December 2015: Vol.-5, Issue- 1, P. 379-387
379
www.ijbamr.com P ISSN: 2250-284X , E ISSN : 2250-2858
Original article:
Antibiotic susceptibility pattern of gram negative bacilli isolated in a super-specialty
hospital-Are we gradually losing the battle against superbugs?
1Mohit Bhatia, 2Bibhabati Mishra, 3Archana Thakur , 4Vinita Dogra , 5Poonam Sood Loomba
1Senior Resident, Department of Microbiology, Govind Ballabh Pant Institute of Post Graduate Medical Education and
Research, New Delhi, India.
2Director Professor & Head, Department of Microbiology, Govind Ballabh Pant Institute of Post Graduate Medical
Education and Research, New Delhi, India.
3Director Professor, Department of Microbiology, Govind Ballabh Pant Institute of Post Graduate Medical Education and
Research, New Delhi, India.
4Director Professor, Department of Microbiology, Govind Ballabh Pant Institute of Post Graduate Medical Education and
Research, New Delhi, India.
5Professor, Department of Microbiology, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research,
New Delhi, India.
Corresponding author: Dr. Mohit Bhatia, Senior Resident, Department of Microbiology, Govind Ballabh Pant Institute of
Post Graduate Medical Education and Research, New Delhi, India.
Abstract:
Introduction: Multi-drug resistant Gram negative bacilli are increasingly being isolated from hospitals throughout the world.
The aim of this study was to determine the antimicrobial susceptibility profile of Gram negative bacterial isolates obtained from
various clinical samples of patients admitted in different ICUs and wards of a super-specialty hospital during 2014.
Materials and Methods: A cross-sectional study was conducted in a super-specialty hospital from January to December 2014.
Various clinical specimens obtained from patients admitted in different wards and Intensive Care Units (ICUs) of this hospital
were subjected to culture and sensitivity as per the requisition received from clinicians. Bacterial isolates (both Gram negative
and positive respectively) obtained from these samples were identified as per standard guidelines. The antibiotic susceptibility
profile of Gram negative bacterial isolates was recorded as per standard guidelines.
Results and Discussion: 81% of the bacterial isolates were Gram negative bacilli and only 19% were Gram positive cocci.
Members of the family Enterobacteriaceae (Escherichia coli, Klebsiella spp. and Proteus spp. taken together) were the major
Gram negative bacteria isolated during the study period followed by Acinetobacter spp. and Pseudomonas aeruginosa. The in-
vitro susceptibility of isolates belonging to the family Enterobacteriaceae to β-lactam/β-lactamase inhibitor combinations,
cephalosporins, carbapenems, fluoroquinolones, aminoglycosides, trimethoprim-sulfamethoxazole, tigecycline and nitrofurantoin
was 18-47%, 32-48%, 23-51%, 35-56%, 33-46%, 31-40%, 61-71% and 56-71% respectively. While 70% of Escherichia coli and
75% of Klebsiells spp. isolates were susceptible to colistin, only 2% of Proteus spp. The susceptibility of Acinetobacter
baumannii isolates to aminoglycosides, β-lactam/β-lactamase inhibitor combinations, carbapenems, cephalosporins,
fluoroquinolones, trimethoprim-sulfamethoxazole, tigecycline and colistin was in the range of 27-30%, 12-15%, 31-39%, 15-
21%, 23-38%, 10%, 68% and 39% respectively. The susceptibility of P. aeruginosa isolates to aminoglycosides, β-lactam/β-
lactamase inhibitor combinations, carbapenems, cefepime, fluoroquinolones, colistin was in the range of 31-35%, 15-59%, 31-
42%, 56%, 39-49% and 89% respectively.
2. Indian Journal of Basic and Applied Medical Research; December 2015: Vol.-5, Issue- 1, P. 379-387
380
www.ijbamr.com P ISSN: 2250-284X , E ISSN : 2250-2858
Conclusion: Since the discovery of new antimicrobial agents has slowed down substantially over the last decade, we are left with
limited therapeutic options. Antibiotic susceptibility pattern like the one presented in this study further adds to our woes and
forces the entire medical community to think seriously about rational usage of these drugs.
Key words: Enterobacteriaceae, Acinetobacter baumannii, Pseudomonas aeruginosa, antibiotic susceptibility profile
Introduction:
The emergence of antimicrobial resistance has posed
a major challenge for health care professionals
worldwide. Continuous monitoring of antimicrobial
resistance pattern in health care set-ups is the key to
determine appropriate therapeutic options especially
among critically ill patients. A considerable number
of critically ill patients, in particular those staying in
Intensive Care Units (ICUs), acquire different
infections following hospitalization.[1-4]
Several
factors such as severity of underlying illness resulting
in impaired defense mechanisms, length of hospital
stay, usage of invasive devices and monitoring
procedures and exposure to broad-spectrum
antibiotics are associated with an increased risk of
acquiring nosocomial infections. The frequent usage
of broad-spectrum antibiotics results in selection of
so-called ‘super-bugs’ which are mostly multi-drug
resistant Gram negative bacilli. Colonization and
subsequent serious infections with these
microorganisms results in increased morbidity and
mortality among hospitalized patients.[5-8]
The aim of
this study was to determine the antimicrobial
susceptibility profile of Gram negative bacterial
isolates obtained from various clinical samples of
patients admitted in different ICUs and wards of a
super-specialty hospital during 2014.
Materials & Methods:
A cross-sectional study was conducted in a super-
specialty hospital from January to December 2014.
Various clinical specimens which included urine,
cerebrospinal, peritoneal, pleural, pericardial and
drain fluids, pus, bile, blood, arterial and central
venous catheters, sputum and mucus traps
respectively obtained from patients admitted in
different wards and Intensive Care Units (ICUs) of
this hospital were subjected to culture and sensitivity
as per the requisition received from clinicians.
Bacterial isolates (both Gram negative and positive
respectively) obtained from these samples were
identified as per standard guidelines.[9]
The antibiotic
susceptibility profile of Gram negative bacterial
isolates in the form of Minimum Inhibitory
Concentration (MIC) was recorded using VITEK-2
(Bio Meriux Pvt. Ltd.) automated system as per
Clinical & Laboratory Standards Institute (CLSI)
guidelines 2014 and European Committee on
Antimicrobial Susceptibility testing (EUCAST)
guidelines 2014 (as applicable- see footnotes of Table
1). Susceptibility to additional antibiotics namely
levofloxacin, norfloxacin, ofloxacin, netimicin,
tobramycin & ticarcillin-clavulanate (as applicable
for different Gram negative bacterial isolates as per
CLSI guidelines 2014) was determined using
modified Kirby-Bauer disk diffusion method.[10]
Results and Discussion:
A total of 12,223 clinical samples were received
during the study period. Majority of the bacterial
isolates (81%) obtained from these samples were
Gram negative bacilli and only 19% were Gram
positive cocci. Members of the family
Enterobacteriaceae (Escherichia coli, Klebsiella spp.
and Proteus spp. taken together) were the major
Gram negative bacteria isolated during the study
period followed by Acinetobacter spp. and
Pseudomonas aeruginosa. Figure 1 shows the
3. Indian Journal of Basic and Applied Medical Research; December 2015: Vol.-5, Issue- 1, P. 379-387
380
www.ijbamr.com P ISSN: 2250-284X , E ISSN : 2250-2858
percentage distribution of various bacterial isolates
obtained during 2014. The percentage antibiotic
susceptibility profile of Gram negative bacterial
isolates obtained from different clinical samples
during 2014 has been depicted in Table 1 and Figure
2 respectively.
Resistance rates are steeply rising among several
Gram negative pathogens that are often responsible
for serious nosocomial infections, including
Acinetobacter spp., Pseudomonas aeruginosa, and
members of the family Enterobacteriaceae.[11]
The
presence of multi-drug resistant strains of these
organisms has been associated with prolonged
hospital stays, higher health care costs and increased
morbidity and mortality.[11]
Recognizing the growing
problem of antibiotic resistance, as well as the
decreasing investment being made in antimicrobial
research and development, the Infectious Diseases
Society of America created the Antimicrobial
Availability Task Force in March 2003.[12]
This task
force identified six particularly problematic
pathogens, including three Gram negative organisms:
Acinetobacter baumannii, extended spectrum β-
lactamase (ESBL)-producing members of the family
Enterobacteriaceae and Pseudomonas aeruginosa.
The other problematic organisms were the Gram-
positive pathogens pariculartly, methicillin resistant
Staphylococcus aureus (MRSA) and vancomycin
resistant Enterococcus faecium and the filamentuous
fungi Aspergillus spp.[12]
The first-line antibiotics traditionally used for
treating serious infections caused by members of the
family Enterobacteriaceae include penicillins,
cephalosporins, monobactams, carbapenems,
fluorquinolones and aminoglycosides. The frequency
of resistance to these first-line agents is increasing
and now reach high proportions in many areas of the
world.[13-16]
In the present study, the in-vitro
susceptibility of isolates belonging to the family
Enterobacteriaceae (namely E.coli, Klebsiella spp.,
Proteus spp.) to β-lactam/β-lactamase inhibitor
combinations, cephalosporins, carbapenems,
fluoroquinolones, aminoglycosides, trimethoprim-
sulfamethoxazole, tigecycline and nitrofurantoin was
18-47%, 32-48%, 23-51%, 35-56%, 33-46%, 31-
40%, 61-71% and 56-71% respectively. While 70%
of Escherichia coli and 75% of Klebsiells spp.
isolates were susceptible to colistin, only 2% of
Proteus spp. were susceptible to this antibiotic in-
vitro. There are several underlying mechanisms of
resistance to different antibiotic groups, which,
although not looked into in the present study, may
possibly explain our findings.
The most common mechanism of resistance to β-
lactam antibiotics among members of the family
Enterobacteriaceae is the production of the enzymes
β-lactamases (both intrinsic or chromosomal
mediated and acquired or plasmid mediated).[17]
Plasmid-mediated AmpCs are increasingly found as a
cause of cephalosporin resistance among members of
this family in many areas of the world, although their
frequency is heterogeneous according to the
geographical area. Other mechanisms of resistance to
β-lactams include porin loss, efflux pumps, and
modified targets (penicillin-binding proteins [PBPs]).
When combined with β-lactamases, some of these
mechanisms may also confer resistance to
carbapenems.[18]
Also, it is worth noting that many
non-β-lactam agents such as quinolones,
aminoglycosides and trimethoprim sulfamethoxazole
are often found to be useless against ESBL producing
organisms because the plasmids carrying the ESBL
gene also harbour genes encoding resistance to these
drugs.[18]
Resistance to quinolones most commonly
results from the accumulation of chromosomal
mutations in DNA gyrase (GyrA) then in
381
4. Indian Journal of Basic and Applied Medical Research; December 2015: Vol.-5, Issue- 1, P. 379-387
381
www.ijbamr.com P ISSN: 2250-284X , E ISSN : 2250-2858
topoisomerase IV (ParC). Also, decreased membrane
permeability or an over expression of efflux pump
systems cause lower intracellular concentration of the
drug, which is associated with decreased
susceptibility. Several plasmid-mediated mechanisms
have also been enumerated, which include the Qnr
proteins (which act by protecting the antibiotic
target), the modified aminoglycoside
acetyltransferase AAC(6’)-Ib-cr and the efflux pump
QepA. The association of different mechanisms of
quinolone resistance (both plasmid and chromosomal
mediated) at the same isolate is common.[18]
Resistance to aminoglycosides may be due to several
mechanisms like enzymatic modification (which is
the most prevalent mechanism), inactivation,
alteration of diffusion through the outer membrane
due to porin loss, mutations in the target of the
antimicrobial by methylation of ribosomal RNA.
There are three main types of aminoglycoside
modifying enzymes (AMEs) namely,
acetyltransferases (AAC), phosphortransferases
(APH) and nucleotidyltransferases (ANT) which
modify this class of antibiotics thereby, preventing
it’s attachment to bacterial ribosomes. Recently, a
novel mechanism causing high-level resistance to all
aminoglycosides mediated by a 16S rRNA
methylase, which causes methylation of the
aminoglycoside binding site has been described.[18]
Development of resistance to carbapenems during
therapy due to porin loss has been repeatedly
described in depressed chromosomal and plasmid-
mediated AmpC producers.[18]
Colistin is a
bactericidal antibiotic with concentration-dependent
activity. It has been mainly used in the treatment of
invasive infections caused by multidrug-resistant
(particularly carbapenem-resistant) Gram-negative
bacteria. Colistin is active only against Gram-
negative aerobic bacilli, including most
Enterobacteriaceae, nonfermentative bacilli (e.g.
Acinetobacter spp., P. aeruginosa, and
Stenotrophomonas maltophilia) and other Gram
negative bacilli like Haemophilus influenzae. Among
the Enterobacteriaceae, Proteus spp., Providencia
spp., Serratia spp. and Edwardsiella spp. are all
resistant to colistin.[18]
Tigecycline has also shown
good in vitro activity against AmpC-hyperproducing
Enterobacteriaceae, but clinical experience is
limited.[18]
Nitrofurantoin is an agent approved for
use in uncomplicated urinary infections, and is active
against many ESBL producers.[18]
Most of the Acinetobacter baumannii isolates
obtained during the study period were resistant to all
major groups of antibiotics with in-vitro
susceptibility to aminoglycosides, β-lactam/β-
lactamase inhibitor combinations, carbapenems,
cephalosporins, fluoroquinolones, trimethoprim-
sulfamethoxazole, tigecycline and colistin lying in
the range of 27-30%, 12-15%, 31-39%, 15-21%, 23-
38%, 10%, 68% and 39% respectively. Acinetobacter
calcoaceticus-baumannii complex is emerging as a
multiresistant nosocomial and community-acquired
pathogen.[12]
Multi-drug resistant strains of
Acinetobacter spp. are being isolated with increasing
frequency in many nosocomial infections. These
pathogens have rapidly developed resistance to
currently available antimicrobials via a wide range of
mechanisms, including production of
aminoglycoside-modifying enzymes, ESBLs and
carbapenemases, as well as through changes in outer
membrane proteins, penicillin binding proteins and
topoisomerases.[19,20]
Strains of Acinetobacter spp.
that are resistant to all aminoglycosides,
cephalosporins and fluoroquinolones are commonly
seen in many areas.[21]
In the present study, while the in-vitro susceptibility
of P. aeruginosa isolates to aminoglycosides was in
382
5. Indian Journal of Basic and Applied Medical Research; December 2015: Vol.-5, Issue- 1, P. 379-387
382
www.ijbamr.com P ISSN: 2250-284X , E ISSN : 2250-2858
the range of 31-35%, it was 15-59% for β-lactam/β-
lactamase inhibitor combinations, 31-42% for
carbapenems, 56% for cefepime, 39-49% for
fluoroquinolones and 89% for colistin respectively.
Pseudomonas aeruginosa is an invasive Gram-
negative bacterial pathogen which causes a wide
range of severe nosocomial infections, including
pneumonia, urinary tract infections and
bacteremia.[12]
This organism is intrinsically
susceptible to only a limited number of antibacterial
agents because of the low permeability of its cell
wall.[22]
In addition to its intrinsic resistance, P.
aeruginosa has also acquired resistance via multiple
mechanisms, including production of β-lactamases
and carbapenemases, up regulation of multidrug
efflux pumps and finally cell wall mutations leading
to a reduction in porin channels. Many small
antibiotics, including β-lactams and quinolones,
require these aqueous porin channels in order to enter
P. aeruginosa. In addition, mutation of genes
encoding antibacterial targets such as DNA gyrase
for fluoroquinolones contributes to resistance in P.
aeruginosa.[22]
Conclusion:
Considering the results obtained in our study, it
appears that multi-drug resistant Gram negative
bacterial isolates are ubiquitously distributed in our
hospital. This calls for formulation of a policy for
rational drug administration. Most nosocomial
infections with multi-drug resistant bacteria can be
prevented and controlled by following some basic
procedures like hand-washing, timely use of
appropriate antibiotics, cessation of antibiotic therapy
as indicated, timely change or removal of indwelling
‘lines’ etc. The clinical specimens should be
subjected to bacterial culture and antibiotic
susceptibility testing prior to initiating antibiotic
therapy to determine the appropriate drug. Since the
discovery of new antimicrobial agents has slowed
down substantially over the last couple of years, we
are left with limited therapeutic options. Antibiotic
susceptibility pattern like the one presented in this
study further adds to our woes and forces the entire
medical community to ponder over one raging
question time and again: Are we gradually losing the
battle against the so called ‘superbugs’?
Figure 1: Percentage distribution of bacterial isolates obtained from clinical samples from January to
December 2014
383
6. Indian Journal of Basic and Applied Medical Research; December 2015: Vol.-5, Issue- 1, P. 379-387
380
www.ijbamr.com P ISSN: 2250-284X , E ISSN : 2250-2858
Figure 2: Percentage antibiotic susceptibility profile of Gram negative bacterial isolates obtained from
different clinical samples during 2014
*Tazact: Piperacillin-tazobactam
Table 1: Table showing percentage antibiotic susceptibility profile of different Gram negative bacterial
isolates obtained from different clinical samples during 2014
*Susceptibility of Acinetobacter baumanni to netilmicin could not be recorded as only MIC and not zone diameter of netilmicin
has been defined for Acinetobacter baumannii as per CLSI guidelines 2014. VITEK-2 automated system does not calculate MIC
of netilmicin for Acinetobacter baumannii. ** Amoxicillin-clavulanate is not recommended for use against Pseudomonas
aeruginosa and Acinetoacter spp. respectively as per CLSI guidelines 2014. *** Ertapenem is not recommended for use against
Pseudomonas aeruginosa and Acinetobacter baumannii respectively as per CLSI guidelines 2014. # Cefotaxime, ceftriaxone,
cefuroxime axetil and cefuroxime are not recommended for use against Pseudomonas aeruginosa as per CLSI guidelines 2014.
## Norfloxacin is not recommended for use against Acinetobacter baumannii as per CLSI guidelines 2014; Ofloxacin was used
instead of norfloxacin in case of urinary Pseudomonas aeruginosa isolates as per CLSI guidelines 2014. ### Ofloxacin is not
recommended for use against Acinetobacter baumannii as per CLSI guidelines 2014. @ Trimethoprim-sulfamethoxazole is not
recommended for use against Pseudomonas aeruginosa as per CLSI guidelines 2014. @@ MIC for tigecycline was recorded as
per European Committee on Antimicrobial Susceptibility testing (EUCAST) guidelines 2014. As per both CLSI and EUCAST
guidelines 2014, tigecycline is not recommended for use against Pseudomonas aeruginosa. @@@ MIC for colistin was recorded
for Pseudomonas aeruginosa and Acinetobacter baumannii as per CLSI guidelines 2014. However, for members of the family
Enterobacteriaceae, MIC for this antibiotic was recorded as per EUCAST guidelines 2014. $ As per CLSI guidelines 2014,
nitrofurantoin is not recommended for use against Pseudomonas aeruginosa and Acinetobacter baumannii respectively.
384
7. Indian Journal of Basic and Applied Medical Research; December 2015: Vol.-5, Issue- 1, P. 379-387
381
www.ijbamr.com P ISSN: 2250-284X , E ISSN : 2250-2858
References:
1. Alberti C, Brun-Buisson C, Burchardi H, Martin C, Goodman S, Artigas A, et al. Epidemiology of sepsis and
infection in ICU patients from an international multicenter cohort study. Intensive Care Med 2002; 28:108-121.
2. Trilla A. Epidemiology of nosocomial infections in adult intensive care units. Care Med 1994; 20:1-4.
3. Fournier PE, Richet H. The epidemiology and control of Acinetobacter baumannii in health care facilities. Clin
Infect Dis 2006; 42: 692–699.
4. Fagon JY, Novara A, Stephan F, Girou E, Safar M. Mortality attributable to nosocomial infections in the ICU.
Infect Control Hosp Epidemiol 1994; 15: 428-434.
5. Gunseren F, Mamikoglu L, Ozturk S, Yucesoy M, Biberoglu K, Yulug N, et al. A surveillance study of
antimicrobial resistance of gram-negative bacteria isolated from intensive care units in eight hospitals in
Turkey. J Antimicrob Chemother 1999; 43: 373-378.
Antibiotic Group E. coli Klebsiella spp Proteus spp P. aeruginosa A. baumannii
Aminoglycosides
Amikacin 46% 45% 43% 35% 29%
Gentamicin 41% 39% 40% 31% 27%
Netilmicin
*
33% 43% 31% 33% Not Applicable
Tobramycin 33% 43% 33% 33% 30%
β-Lactam/β-Lactamase Inhibitor Combinations
Amoxicillin-cavulanate**
47% 46% 38% Not Applicable Not Applicable
Piperacillin-tazobactam 34% 32% 38% 59% 15%
Ticarcillin-clavulanate 19% 18% 18% 15% 12%
Carbapenems
Ertapenem***
42% 40% 47% Not Applicable Not Applicable
Imipenem 55% 51% 54% 42% 29%
Meropenem 24% 23% 31% 31% 21%
Cephalosporins
Cefepime 48% 43% 38% 56% 21%
Cefotaxime
#
32% 32% 34% Not Applicable 15%
Ceftriaxone#
39% 39% 35% Not Applicable 17%
Cefuroxime axetil
#
37% 39% 32% Not Applicable Not Applicable
Cefuroxime
#
37% 39% 32% Not Applicable Not Applicable
Fluoroquinolones
Ciprofloxacin 48% 44% 41% 39% 23%
Levofloxin 35% 45% 45% 41% 38%
Norfloxacin
##
48% 55% 48% Not Applicable Not Applicable
Ofloxin
###
56% 53% 45% 49% Not Applicable
Folate Pathway Inhibitors
Trimethoprim-
sulfamethoxazole
@
31% 33% 40% Not Applicable 10%
Glycylcyclines
Tigecycline
@@
71% 75% 61% Not Applicable 68%
Lipopeptides
Colistin@@@
70% 75% 2% 85% 69%
Nitrofurans
Nitrofurantoin$
69% 71% 56% Not Applicable Not Applicable
385
8. Indian Journal of Basic and Applied Medical Research; December 2015: Vol.-5, Issue- 1, P. 379-387
382
www.ijbamr.com P ISSN: 2250-284X , E ISSN : 2250-2858
6. Kucukates E. Antimicrobial resistance among Gram negative bacteria isolated from intensive care units in a
Cardiology Institute in Istanbul Turkey. Jpn J Infect Dis.2005: 58: 228-231.
7. Kollef MH, Sharpless L, Vlasnik J, Pasque C, Murphy D, Fraser VJ. The impact of nosocomial infections on
patient outcomes following cardiac surgery. Chest 1997;112: 666-675.
8. Trouillet JL, Chastre J, Vuagnat A, Joly Guillou ML, Combaux D, Dombret MC, et al. Ventilator-associated
pneumonia caused by potentially drug-resistant bacteria. Am J Respir Crit Care Med 1998; 157: 531-539.
9. Collee JG, Miles RS, Watt B. Tests for the identification of bacteria. In:Collee JG, Fraser AG, Marimon BP,
Simmons A, (eds). Mackie & Mc Cartney Pracatical Medical Microbiology, 14th
edition, New Delhi,Elsevier,
2007(reprint), pp.131-49
10. Miles RS, Amyes SGB. Laboratory control of antimicrobial therapy. In:Collee JG, Fraser AG, Marimon BP,
Simmons A, (eds). Mackie & Mc Cartney Pracatical Medical Microbiology, 14th
edition, New Delhi,Elsevier,
2007(reprint), pp.151-78
11. Thomas GS. Gram-negative antibiotic resistance: there is a price to pay. Critical Care 2008;12(Suppl 4):S4
12. Talbot GH, Bradley J, Edwards JE Jr, Gilbert D, Scheld M, Barlett JG; Antimicrobial Availability Task Force of
the Infectious Diseases Society of America: Bad bugs need drugs: an update on the development pipeline from the
Antimicrobial Availability Task Force of the Infectious Diseases Society of America. Clin Infect Dis 2006, 42:657-
668.
13. Paterson, D. Resistance in gram-negative bacteria: Enterobacteriaceae. Am J Infect Control, 2006; 34: S20-S28,
discussion S64-S73.
14. Rhomberg, P. and Jones, R. Summary trends for the Meropenem Yearly Susceptibility Test Information
Collection Program: a 10-year experience in the United States (1999_2008). Diagn Microbiol
Infect Dis, 2009; 65: 414_426.
15. Houghton, J., Green, K., Chen, W., Garneau TS.The future of aminoglycosides: the end or renaissance?
Chembiochem, 2010; 11: 880-902.
16. Nordmann, P., Naas, T., Poirel, L. Global spread of Carbapenemase-producing Enterobacteriaceae. Emerg Infect
Dis, 2011; 17: 1791-98.
17. Jacoby GA, Munoz-Price LS. The new β-lactamases. N Engl J Med 2005, 352:380-391.
18. Mercedes DV, Jesus SD, Alvaro P, Jesus RB. Clinical management of infections caused by multidrug-resistant
Enterobacteriaceae. Ther Adv Infect Dis, 2013; 0(0): 1-21.
19. Gales AC, Jones RN, Forward KR, Linares J, Sader HS, Verhoef J. Emerging importance of multidrug-resistant
Acinetobacter species and Stenotrophomonas maltophilia as pathogens in seriously ill patients: geographic patterns,
epidemiological features, and trends in the SENTRY Antimicrobial Surveillance Program (1997-1999). Clin Infect
Dis 2001, 32(suppl 2): S104-S113.
20. Bonomo RA, Szabo D: Mechanisms of multidrug resistance in Acinetobacter species and Pseudomonas
aeruginosa. Clin Infect Dis 2006, 43(suppl 2):S49-S56.
21. Landman D, Quale JM, Mayorga D, Adedeji A, Vangala K, Ravishankar J et al. Citywide clonal outbreak of
multiresistant Acinetobacter baumannii and Pseudomonas aeruginosa in Brooklyn, NY: the preantibiotic era has
returned. Arch Intern Med 2002, 162:1515-20.
386
9. Indian Journal of Basic and Applied Medical Research; December 2015: Vol.-5, Issue- 1, P. 379-387
383
www.ijbamr.com P ISSN: 2250-284X , E ISSN : 2250-2858
22. Lambert PA: Mechanisms of antibiotic resistance in Pseudomonas aeruginosa. J Roy Soc Med, 2002; 95(suppl
41): 22-26.
387