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Daaboul D, Kassem II, El Omari K, Eltai NO, Hassan J, Al Jamal H, Fayad S, Salma R, Ghorbani Tajani A, Bisha B, Hamze M, Oueslati S, Cummings KJ, Dabboussi F, Naas T, Osman M. Genomic characterization of plasmid-borne colistin resistance variants, mcr-1.1 and mcr-1.26, in multidrug-resistant Escherichia coli isolated from backyard farm animals. J Glob Antimicrob Resist 2024; 38:194-197. [PMID: 38969269 DOI: 10.1016/j.jgar.2024.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 05/26/2024] [Accepted: 06/23/2024] [Indexed: 07/07/2024] Open
Affiliation(s)
- Dina Daaboul
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli 1300, Lebanon; Team 'ReSIST' UMR1184, Immunology of Viral, Auto-Immune, Hematological and Bacterial diseases (IMVA-HB), INSERM, Université Paris-Saclay, CEA, LabEx LERMIT, Faculty of Medicine, 94270 Le Kremlin-Bicêtre, France
| | - Issmat I Kassem
- Center for Food Safety, Department of Food Science and Technology, University of Georgia, 1109 Experiment Street, Griffin, GA 30223-1797, USA
| | - Khaled El Omari
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli 1300, Lebanon; Quality Control Center Laboratories at the Chamber of Commerce, Industry & Agriculture of Tripoli & North Lebanon, Tripoli 1300, Lebanon
| | - Nahla O Eltai
- Biomedical Research Centre, Microbiology Department, Qatar University, Doha 2713, Qatar
| | - Jouman Hassan
- Center for Food Safety, Department of Food Science and Technology, University of Georgia, 1109 Experiment Street, Griffin, GA 30223-1797, USA
| | - Hadi Al Jamal
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli 1300, Lebanon
| | - Souad Fayad
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli 1300, Lebanon
| | - Rayane Salma
- Quality Control Center Laboratories at the Chamber of Commerce, Industry & Agriculture of Tripoli & North Lebanon, Tripoli 1300, Lebanon
| | | | - Bledar Bisha
- Department of Animal Science, University of Wyoming, Laramie, WY 82071, USA
| | - Monzer Hamze
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli 1300, Lebanon
| | - Saoussen Oueslati
- Team 'ReSIST' UMR1184, Immunology of Viral, Auto-Immune, Hematological and Bacterial diseases (IMVA-HB), INSERM, Université Paris-Saclay, CEA, LabEx LERMIT, Faculty of Medicine, 94270 Le Kremlin-Bicêtre, France
| | - Kevin J Cummings
- Department of Public and Ecosystem Health, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA
| | - Fouad Dabboussi
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli 1300, Lebanon
| | - Thierry Naas
- Team 'ReSIST' UMR1184, Immunology of Viral, Auto-Immune, Hematological and Bacterial diseases (IMVA-HB), INSERM, Université Paris-Saclay, CEA, LabEx LERMIT, Faculty of Medicine, 94270 Le Kremlin-Bicêtre, France; Bacteriology-Hygiene unit, Bicêtre Hospital, APHP Paris-Saclay, 94270 Le Kremlin-Bicêtre, France; French National Reference Center for Antibiotic Resistance: Carbapenemase-producing Enterobacterales, 94270 Le Kremlin-Bicêtre, France
| | - Marwan Osman
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06510, USA.
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Osman M, Yassine I, Hamze M, Al Mir H, Ghorbani Tajani A, Bisha B, Cummings KJ, Madec JY, Haenni M, Kassem II. Emergence of Extended-Spectrum Cephalosporin- and Colistin-Resistant Enterobacterales in Otherwise Healthy University Students. Microb Drug Resist 2024; 30:101-107. [PMID: 38011748 DOI: 10.1089/mdr.2023.0213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Abstract
Resistance to last resort antibiotics has been increasing, particularly in low- and middle-income countries such as Lebanon, which has well established challenges in antimicrobial stewardship and other public health and environmental issues. However, data on the emergence of antibiotic resistance in the community in Lebanon are limited. In this study, we assessed resistance to last resort antibiotics in the fecal samples of 111 otherwise healthy university students in north Lebanon. The results showed that 47.7% of the samples harbored extended-spectrum cephalosporin-resistant isolates, while 2.7% of the samples yielded colistin-resistant isolates. Furthermore, molecular analyses showed that the β-lactamase gene group, blaCTX-M-1 group, was detected in the majority (93%) of screened extended-spectrum β-lactamase isolates. In addition, the colistin-resistant Escherichia coli isolates carried mcr-1, including the novel mcr-1.26 variant, which was previously reported in clinical samples as well as in domesticated animals and the environment in Lebanon. Taken together, these findings highlight the occurrence of resistance to important antibiotics in the community, perhaps suggesting diffuse sources, including clinical and environmental settings, and multiple factors driving the spread of multidrug-resistant bacteria and resistance determinants. There is a pressing need for comprehensive antimicrobial stewardship programs and the implementation of evidence-based practices in clinical and community settings to mitigate the increasing spread of antimicrobial resistance.
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Affiliation(s)
- Marwan Osman
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
- Cornell Atkinson Center for Sustainability, Cornell University, Ithaca, New York, USA
- Department of Public and Ecosystem Health, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Iman Yassine
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon
| | - Monzer Hamze
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon
| | - Hiba Al Mir
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon
- ANSES, Université de Lyon, Unité Antibiorésistance et Virulence Bactériennes, Lyon, France
| | | | - Bledar Bisha
- Department of Animal Science, University of Wyoming, Laramie, Wyoming, USA
| | - Kevin J Cummings
- Department of Public and Ecosystem Health, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Jean-Yves Madec
- ANSES, Université de Lyon, Unité Antibiorésistance et Virulence Bactériennes, Lyon, France
| | - Marisa Haenni
- ANSES, Université de Lyon, Unité Antibiorésistance et Virulence Bactériennes, Lyon, France
| | - Issmat I Kassem
- Department of Food Science and Technology, Center for Food Safety, University of Georgia, Athens, Georgia, USA
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Serhan M, Hourieh H, El Deghel M, Serhan C. Hygienic sanitary risk and microbiological quality of meat and meat-contact surfaces in traditional butcher shops and retail establishments- lessons from a developing country. INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 2024; 34:600-610. [PMID: 36576123 DOI: 10.1080/09603123.2022.2161487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/19/2022] [Indexed: 06/17/2023]
Abstract
In this study, we determined both hygienic sanitary risk and microbiological quality of raw meat and meat-contact surfaces in butcher shops and retails from the North Governorate in Lebanon. A total of 55 samples were analyzed (36 raw meat and 19 environmental swabs). The overall counts of pathogenic bacteria indicate high levels of contamination of both minced meat and contact surfaces. Presumptive Salmonella and Listeria were found in the samples. Salmonella spp. was observed in 63.8% of all cuts, of whom 41.6% is detected from butcher shops' meat. L. monocytogenes was present in 47.2% of meat from butcher shops and 30.5% of retails. Total aerobic count followed by S. aureus and fecal coliforms were the most detected pathogens in environmental swabs. Most visited facilities presented moderate hygienic sanitary risk, with average scores of 55.25 in butchers' shops and 65.25 in retail. Findings highlight the necessity for governmental surveillance and implementation of food safety laws.
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Affiliation(s)
- Mireille Serhan
- Department of Nutritional Sciences, Faculty of Health Sciences, University of Balamand, Tripoli, Lebanon
| | - Hiba Hourieh
- Department of Nutritional Sciences, Faculty of Health Sciences, University of Balamand, Tripoli, Lebanon
| | - Maria El Deghel
- Department of Nutritional Sciences, Faculty of Health Sciences, University of Balamand, Tripoli, Lebanon
| | - Carole Serhan
- Department of Business Management and Administration, Issam Fares Faculty of Technology, University of Balamand, Tripoli, Lebanon
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Daaboul D, Oueslati S, Rima M, Kassem II, Mallat H, Birer A, Girlich D, Hamze M, Dabboussi F, Osman M, Naas T. The emergence of carbapenemase-producing Enterobacterales in hospitals: a major challenge for a debilitated healthcare system in Lebanon. Front Public Health 2023; 11:1290912. [PMID: 38074718 PMCID: PMC10699444 DOI: 10.3389/fpubh.2023.1290912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/26/2023] [Indexed: 12/18/2023] Open
Abstract
Background Carbapenem- and extended-spectrum cephalosporin-resistant Enterobacterales (CR-E and ESCR-E, respectively) are increasingly isolated worldwide. Information about these bacteria is sporadic in Lebanon and generally relies on conventional diagnostic methods, which is detrimental for a country that is struggling with an unprecedented economic crisis and a collapsing public health system. Here, CR-E isolates from different Lebanese hospitals were characterized. Materials and methods Non-duplicate clinical ESCR-E or CR-E isolates (N = 188) were collected from three hospitals from June 2019 to December 2020. Isolates were identified by MALDI-TOF, and their antibiotic susceptibility by Kirby-Bauer disk diffusion assay. CR-E isolates (n = 33/188) were further analyzed using Illumina-based WGS to identify resistome, MLST, and plasmid types. Additionally, the genetic relatedness of the CR-E isolates was evaluated using an Infrared Biotyper system and compared to WGS. Results Using the Kirby-Bauer disk diffusion assay, only 90 isolates out of the 188 isolates that were collected based on their initial routine susceptibility profile by the three participating hospitals could be confirmed as ESCR-E or CR-E isolates and were included in this study. This collection comprised E. coli (n = 70; 77.8%), K. pneumoniae (n = 13; 14.4%), Enterobacter spp. (n = 6; 6.7%), and Proteus mirabilis (n = 1; 1.1%). While 57 were only ESBL producers the remaining 33 isolates (i.e., 26 E. coli, five K. pneumoniae, one E. cloacae, and one Enterobacter hormaechei) were resistant to at least one carbapenem, of which 20 were also ESBL-producers. Among the 33 CR-E, five different carbapenemase determinants were identified: blaNDM-5 (14/33), blaOXA-244 (10/33), blaOXA-48 (5/33), blaNDM-1 (3/33), and blaOXA-181 (1/33) genes. Notably, 20 CR-E isolates were also ESBL-producers. The analysis of the genetic relatedness revealed a substantial genetic diversity among CR-E isolates, suggesting evolution and transmission from various sources. Conclusion This study highlighted the emergence and broad dissemination of blaNDM-5 and blaOXA-244 genes in Lebanese clinical settings. The weak AMR awareness in the Lebanese community and the ongoing economic and healthcare challenges have spurred self-medication practices. Our findings highlight an urgent need for transformative approaches to combat antimicrobial resistance in both community and hospital settings.
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Affiliation(s)
- Dina Daaboul
- Faculty of Medicine, Team "Resist" UMR1184, "Immunology of Viral, Auto-Immune, Hematological and Bacterial Diseases (IMVA-HB)," INSERM, Université Paris-Saclay, CEA, Health and Therapeutic Innovation (HEALTHI), Le Kremlin-Bicêtre, France
- Laboratoire Microbiologie Santé et Environment (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon
| | - Saoussen Oueslati
- Faculty of Medicine, Team "Resist" UMR1184, "Immunology of Viral, Auto-Immune, Hematological and Bacterial Diseases (IMVA-HB)," INSERM, Université Paris-Saclay, CEA, Health and Therapeutic Innovation (HEALTHI), Le Kremlin-Bicêtre, France
- Bacteriology-Hygiene Unit, Assistance Publique-Hôpitaux de Paris, AP-HP Paris-Saclay, Bicêtre Hospital Le Kremlin-Bicêtre, Paris, France
| | - Mariam Rima
- Faculty of Medicine, Team "Resist" UMR1184, "Immunology of Viral, Auto-Immune, Hematological and Bacterial Diseases (IMVA-HB)," INSERM, Université Paris-Saclay, CEA, Health and Therapeutic Innovation (HEALTHI), Le Kremlin-Bicêtre, France
| | - Issmat I. Kassem
- Center for Food Safety and Department of Food Science and Technology, University of Georgia, Griffin, GA, United States
| | - Hassan Mallat
- Laboratoire Microbiologie Santé et Environment (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon
| | - Aurélien Birer
- French National Reference Center for Antibiotic Resistance, Clermont-Ferrand, France
| | - Delphine Girlich
- Faculty of Medicine, Team "Resist" UMR1184, "Immunology of Viral, Auto-Immune, Hematological and Bacterial Diseases (IMVA-HB)," INSERM, Université Paris-Saclay, CEA, Health and Therapeutic Innovation (HEALTHI), Le Kremlin-Bicêtre, France
| | - Monzer Hamze
- Laboratoire Microbiologie Santé et Environment (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon
| | - Fouad Dabboussi
- Laboratoire Microbiologie Santé et Environment (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon
| | - Marwan Osman
- Cornell Atkinson Center for Sustainability, Cornell University, Ithaca, NY, United States
- Department of Public and Ecosystem Health, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Thierry Naas
- Faculty of Medicine, Team "Resist" UMR1184, "Immunology of Viral, Auto-Immune, Hematological and Bacterial Diseases (IMVA-HB)," INSERM, Université Paris-Saclay, CEA, Health and Therapeutic Innovation (HEALTHI), Le Kremlin-Bicêtre, France
- Bacteriology-Hygiene Unit, Assistance Publique-Hôpitaux de Paris, AP-HP Paris-Saclay, Bicêtre Hospital Le Kremlin-Bicêtre, Paris, France
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Kassem II, Osman M, Hassan J, Sulaiman AA, Mann D, Esseili MA, Naas T, Deng X. First report of the mobile colistin resistance gene, mcr-1.26, in multidrug-resistant Escherichia coli isolated from retail chicken meat. J Glob Antimicrob Resist 2023; 34:176-178. [PMID: 37429544 DOI: 10.1016/j.jgar.2023.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 05/25/2023] [Accepted: 07/06/2023] [Indexed: 07/12/2023] Open
Abstract
OBJECTIVES We isolated a highly colistin-resistant Escherichia coli, strain 58, from fresh chicken wings in Lebanon. Here, we performed in-depth phenotypic and genomic analyses to identify the resistome of the isolate, focusing on the determinants that encoded colistin resistance. METHODS The minimum inhibitory concentration (MIC) of colistin and resistance to other antibiotics were determined using the broth microdilution method and the Kirby-Bauer disk diffusion assay, respectively. Whole-genome sequencing (WGS) and different software available at the Center of Genomic Epidemiology were used to predict the resistome, the sequence type (ST), and the presence of virulence genes and plasmid replicon types. RESULTS Susceptibility testing revealed that E. coli 58 exhibited multidrug resistance, including against colistin (MIC = 32 µg/mL). Whole-genome sequencing analyses showed that E. coli 58 carried 26 antimicrobial resistance genes associated with resistance to polymyxins (mcr-1.26), β-lactams (blaTEM-1b and blaCMY-2), fosfomycin (fosA4), aminoglycosides (aac(3)-IId, aadA2b, aadA5, partial aadA1, aph(3'')-Ia, aph(3')-Ia, and aph(6)-Id), tetracyclines (tetA and tetM), quinolones (qnrS1), sulphonamides (sul2 and sul3), trimethoprim (dfrA14, dfrA17, and dfrA5), phenicols (floR and cmlA1), macrolides (mphA), lincosamides (lnu(F)), quaternary ammonium compounds (partial qacL and qacE), and peroxides (sitABCD). mcr-1.26 was located on an IncX4 plasmid and induced colistin resistance in otherwise naïve E. coli and Salmonella Enteritidis. Escherichia coli 58 was predicted to be a human pathogen and belonged to ST3107. CONCLUSION To our knowledge, this is the first report of mcr-1.26 in poultry meat worldwide. We previously reported mcr-1.26 in an MDR E. coli (ST2207) isolated from a pigeon in Lebanon, which suggests that it might be spreading in different animal hosts and genetic backgrounds.
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Affiliation(s)
- Issmat I Kassem
- Center for Food Safety, Department of Food Science and Technology, University of Georgia, Griffin, Georgia.
| | - Marwan Osman
- Department of Public and Ecosystem Health, College of Veterinary Medicine, Cornell University, Ithaca, New York
| | - Jouman Hassan
- Center for Food Safety, Department of Food Science and Technology, University of Georgia, Griffin, Georgia
| | - Abdallah Alhaj Sulaiman
- Division of Biological and Biomedical Sciences, College of Health and Life Sciences, Hamad Bin Khalifa University, Doha, Qatar
| | - David Mann
- Center for Food Safety, Department of Food Science and Technology, University of Georgia, Griffin, Georgia
| | - Malak A Esseili
- Center for Food Safety, Department of Food Science and Technology, University of Georgia, Griffin, Georgia
| | - Thierry Naas
- Team ReSIST, UMR1184, INSERM, Université Paris-Saclay, CEA, School of Medicine, LabEx LERMIT, Le krem-lin-Bicêtre, France; Bacteriology-Hygiene unit, Bicêtre Hospital, APHP Paris-Saclay, Le Kremlin-Bicêtre, France; French National Reference Center for Antibiotic Resistance: Carbapenemase-producing Enterobacterales, Le Kremlin-Bicêtre, France
| | - Xiangyu Deng
- Center for Food Safety, Department of Food Science and Technology, University of Georgia, Griffin, Georgia
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Shaib H, Aoun P, Ghaddar A, Al Labadi H, Obeid Y. Multidrug Resistance and Plasmid Profiles of Escherichia coli Isolated from Lebanese Broiler Farms. Int J Microbiol 2023; 2023:8811675. [PMID: 37303775 PMCID: PMC10250091 DOI: 10.1155/2023/8811675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 05/13/2023] [Accepted: 05/19/2023] [Indexed: 06/13/2023] Open
Abstract
The present study was undertaken to determine the antimicrobial resistance patterns and plasmid fingerprints of commensal Escherichia coli isolated from Lebanese broiler chickens. To that end, a total of 30 E. coli isolates were collected from 15 semi-open broiler farms from North Lebanon and Bekaa Valley. Results showed that all the isolates were resistant to at least nine out of 18 evaluated antimicrobial agents. The best-performing antibiotic families were Carbapenems (Imipenem) and Quinolones (Ciprofloxacin and Norfloxacin) to which only 0.0 and 8.3% of the isolates were resistant, respectively. Fifteen various plasmid profiles were depicted, and all the isolates were found to possess one or multiple plasmids. The plasmid sizes varied from 1.2 to 21.0 kbp, and the most commonly detected plasmid had a size of 5.7 kbp (23.3% of the isolates). There was no significant association between the number of plasmids per isolate and resistance to a particular drug. Nevertheless, the presence of specific plasmids, namely, the 2.2 or 7.7 kbp sized ones, was strongly correlated to Quinolones or Trimethoprim resistance, respectively. Both the 7.7 and 6.8 kbp plasmids showed mild correlation to Amikacin resistance, and the 5.7 kbp plasmid was mildly correlated to Piperacillin-Tazobactam resistance. Our findings highlight the need to revise the list of antimicrobials currently used in Lebanese poultry and associate the presence of specific plasmids to antimicrobial resistance patterns in E. coli isolates. The revealed plasmid profiles could also serve any future epidemiological investigation of poultry disease outbreaks in the country.
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Affiliation(s)
- Houssam Shaib
- Department of Agriculture, Faculty of Agricultural and Food Sciences, American University of Beirut, Beirut, Lebanon
| | - Paul Aoun
- Department of Agriculture, Faculty of Agricultural and Food Sciences, American University of Beirut, Beirut, Lebanon
| | - Ahmad Ghaddar
- Department of Agriculture, Faculty of Agricultural and Food Sciences, American University of Beirut, Beirut, Lebanon
| | - Hamza Al Labadi
- Department of Agriculture, Faculty of Agricultural and Food Sciences, American University of Beirut, Beirut, Lebanon
| | - Youssef Obeid
- Department of Agriculture, Faculty of Agricultural and Food Sciences, American University of Beirut, Beirut, Lebanon
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Hussein ND, Hassan JW, Osman M, El-Omari K, Kharroubi SA, Toufeili I, Kassem II. Assessment of the Microbiological Acceptability of White Cheese (Akkawi) in Lebanon and the Antimicrobial Resistance Profiles of Associated Escherichia coli. Antibiotics (Basel) 2023; 12:antibiotics12030610. [PMID: 36978477 PMCID: PMC10044863 DOI: 10.3390/antibiotics12030610] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/10/2023] [Accepted: 03/16/2023] [Indexed: 03/22/2023] Open
Abstract
Dairy foods are a staple in Lebanon, a low- and middle-income country that has been experiencing serious challenges to food safety and antimicrobial stewardship among other issues. The microbiological acceptability of dairy products has been of increasing concern. This is partially due to the failing economy and prolonged power outages that affect the quality of raw material and disrupt the dairy cold chain, respectively. Therefore, we assessed the microbiological acceptability of Akkawi, a popular white-brined cheese in Lebanon. For this purpose, we quantified the densities of Escherichia coli (a fecal indicator) and Staphylococcus aureus in cheeses collected from Lebanese retail stores. Additionally, we evaluated the antibiotic resistance profiles of the E. coli isolated from the cheese. E. coli and S. aureus were detected in 40 (80%) and 16 (32%) of the 50 cheese samples, respectively. Notably, 40 (80%) and 16 (32%) of the samples exceeded the maximum permissible limit of E. coli and S. aureus, respectively. A high percentage of the 118 E. coli isolated from the cheeses showed resistance to clinically and agriculturally important antibiotics, while 89 (75%) isolates were classified as multidrug-resistant (MDR). Given that Akkawi can be consumed without cooking, our findings highlight serious food safety and antimicrobial resistance problems that require immediate interventions.
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Affiliation(s)
- Nasri Daher Hussein
- Department of Nutrition and Food Sciences, Faculty of Agricultural and Food Sciences, American University of Beirut (AUB), Beirut 1107 2020, Lebanon
| | - Jouman W. Hassan
- Center for Food Safety, Department of Food Science and Technology, University of Georgia, 1109 Experiment Street, Griffin, GA 30223, USA
| | - Marwan Osman
- Cornell Atkinson Center for Sustainability, Cornell University, Ithaca, NY 14853, USA
- Department of Public and Ecosystem Health, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA
| | - Khaled El-Omari
- Quality Control Center Laboratories at the Chamber of Commerce, Industry & Agriculture of Tripoli & North Lebanon, Tripoli 1300, Lebanon
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli 1300, Lebanon
| | - Samer A. Kharroubi
- Department of Nutrition and Food Sciences, Faculty of Agricultural and Food Sciences, American University of Beirut (AUB), Beirut 1107 2020, Lebanon
| | - Imad Toufeili
- Department of Nutrition and Food Sciences, Faculty of Agricultural and Food Sciences, American University of Beirut (AUB), Beirut 1107 2020, Lebanon
| | - Issmat I. Kassem
- Center for Food Safety, Department of Food Science and Technology, University of Georgia, 1109 Experiment Street, Griffin, GA 30223, USA
- Correspondence:
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Osman M, Albarracin B, Altier C, Gröhn YT, Cazer C. Antimicrobial resistance trends among canine Escherichia coli isolated at a New York veterinary diagnostic laboratory between 2007 and 2020. Prev Vet Med 2022; 208:105767. [PMID: 36181749 PMCID: PMC9703301 DOI: 10.1016/j.prevetmed.2022.105767] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 08/21/2022] [Accepted: 09/21/2022] [Indexed: 11/30/2022]
Abstract
Dogs are a potential source of drug-resistant Escherichia coli, but very few large-scale antimicrobial resistance surveillance studies have been conducted in the canine population. Here, we assess the antimicrobial susceptibility patterns, identify temporal resistance and minimum inhibitory concentration (MIC) trends, and describe associations between resistance phenotypes among canine clinical E. coli isolates in the northeastern United States. Through a retrospective study design, we collected MICs from 7709 E. coli isolates from canine infections at the Cornell University Animal Health Diagnostic Center between 2007 and 2020. The available clinical data were limited to body site. Isolates were classified as resistant or susceptible to six (urinary) and 22 (non-urinary) antimicrobials based on Clinical and Laboratory Standards Institute breakpoints. We used the Mann-Kendall test (MKT) and Sen's slope to identify the presence of a significant trend in the percent of resistant isolates over the study period. Multivariable logistic regression (MLR) models were built with ceftiofur, enrofloxacin, or trimethoprim-sulfamethoxazole resistance as the outcome and either body site and isolation date, or resistance to other antimicrobials as predictors. MIC trends were characterized with survival analysis models, controlling for body site and year of isolation. Overall, 16.4% of isolates were resistant to enrofloxacin, 14.3% to ceftiofur, and 14% to trimethoprim-sulfamethoxazole. The MKT and Sen's slope revealed a significant decreasing temporal trend for gentamicin and trimethoprim-sulfamethoxazole resistance among non-urinary isolates. No significant temporal resistance trends were detected by MKT for other antimicrobials. However, controlling for body-site in MLR models identified a decrease in resistance rates to enrofloxacin and trimethoprim-sulfamethoxazole after 2010. Similarly, survival analysis data confirmed these findings and showed a decrease in MIC values after 2010 for gentamicin and trimethoprim-sulfamethoxazole, but an increase in cephalosporin MICs. MLR showed that non-urinary isolates were significantly more likely than urinary isolates to demonstrate in vitro resistance to ceftiofur, enrofloxacin, and trimethoprim-sulfamethoxazole after controlling for year of isolation. We identified a higher level of ceftiofur resistance among enrofloxacin resistant isolates from urinary and non-urinary origins. Our findings confirmed that dogs are still a non-negligeable reservoir of drug-resistant E. coli in the northeastern United States. The increase in extended-spectrum cephalosporin MIC values in 2018-2020 compared to 2007-2010 constitutes a particularly worrying issue; the relationship between ceftiofur and enrofloxacin resistance suggests that the use of fluoroquinolones could contribute to this trend. Trimethoprim-sulfamethoxazole may be a good first-line choice for empiric treatment of E. coli infections; it is already recommended for canine urinary tract infections.
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Affiliation(s)
- Marwan Osman
- Cornell Atkinson Center for Sustainability, Cornell University, Ithaca, NY 14853, USA; Department of Public and Ecosystem Health, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA.
| | - Belen Albarracin
- Department of Public and Ecosystem Health, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA
| | - Craig Altier
- Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA
| | - Yrjö T Gröhn
- Department of Public and Ecosystem Health, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA; Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA
| | - Casey Cazer
- Department of Public and Ecosystem Health, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA; Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA
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9
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Kojok HE, Khalil M, Hage R, Jammoul R, Jammoul A, Darra NE. Microbiological and chemical evaluation of dairy products commercialized in the Lebanese market. Vet World 2022; 15:2575-2586. [PMID: 36590110 PMCID: PMC9798062 DOI: 10.14202/vetworld.2022.2575-2586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 09/30/2022] [Indexed: 11/16/2022] Open
Abstract
Background and Aim Cheese is considered an essential component of the Lebanese table, however, several foodborne illnesses have been reported due to cheese consumption. This study aimed to assess the microbiological quality and the occurrence of antibiotic and pesticide residues in two traditional Lebanese cheeses, Akkawi and Baladiyeh. In addition, drug resistance of isolated pathogens from the cheese samples was evaluated. Materials and Methods Fifty Akkawi and Baladiyeh cheese samples were obtained in duplicate from 37 different commercial brands in supermarkets and shops from various regions of Lebanon. Samples of different weights were either individually vacuum packed or soaked in brine unpacked where it was placed in plastic bag after being purchased. Samples were homogenized to determine antibiotic and pesticide residues using liquid and gas chromatography coupled to mass spectrometry, and microbiological evaluation was performed according to the International Organization for Standardization reference analytical methods. The disk diffusion method was used to determine the susceptibility of these isolates to antibiotics. Results Microbiologically, 17% of Akkawi and 14% of Baladiyeh samples were found to be non-conforming. The bacterial isolates (n = 29) were tested for their susceptibility to 11 different antibiotics commonly prescribed in the Lebanese community or used for treating infections caused by Gram-negative bacteria and listeriosis. Each isolate was found to be resistant to at least three antibiotics. Liquid and gas chromatography coupled to mass spectroscopy analysis showed the absence of pesticide residues in all samples. However, sulfamethazine antibiotic residue was found in 14% of the samples. Conclusion The results suggest that the cheese samples tested could cause foodborne illnesses due to the detection of pathogenic bacteria and are a public health concern due to the presence of antibiotic residues and the transmission of multidrug-resistant organisms.
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Affiliation(s)
- Hiyam El Kojok
- Department of Biological Sciences, Beirut Arab University, Faculty of Sciences, Tarik El Jedidah - Beirut, P.O. Box: 115020 Riad EL Solh 1107 2809, Lebanon
| | - Mahmoud Khalil
- Department of Biological Sciences, Beirut Arab University, Faculty of Sciences, Tarik El Jedidah - Beirut, P.O. Box: 115020 Riad EL Solh 1107 2809, Lebanon
| | - Rima Hage
- Department of Food, Lebanese Agricultural Research Institute, Fanar, Lebanon P.O. Box 2611, Beirut 1107 2809, Lebanon
| | - Rola Jammoul
- Department of Food, Lebanese Agricultural Research Institute, Fanar, Lebanon P.O. Box 2611, Beirut 1107 2809, Lebanon
| | - Adla Jammoul
- Department of Food, Lebanese Agricultural Research Institute, Fanar, Lebanon P.O. Box 2611, Beirut 1107 2809, Lebanon,Phytopharmacy Laboratory, Ministry of Agriculture of Lebanon, Kfarchima, Lebanon
| | - Nada El Darra
- Beirut Arab University, Faculty of Health Sciences, Tarik El Jedidah - Beirut, P.O. Box: 115020 Riad EL Solh 1107 2809, Lebanon,Corresponding author: Nada El Darra, e-mail: Co-authors: HE: , MK: , RH: , RJ: , AJ:
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10
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Dabbousi AA, Dabboussi F, Hamze M, Osman M, Kassem II. The Emergence and Dissemination of Multidrug Resistant Pseudomonas aeruginosa in Lebanon: Current Status and Challenges during the Economic Crisis. Antibiotics (Basel) 2022; 11:687. [PMID: 35625331 PMCID: PMC9137902 DOI: 10.3390/antibiotics11050687] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/11/2022] [Accepted: 05/17/2022] [Indexed: 12/30/2022] Open
Abstract
Pseudomonas aeruginosa is a common cause of healthcare-associated infections and chronic airway diseases in non-clinical settings. P. aeruginosa is intrinsically resistant to a variety of antimicrobials and has the ability to acquire resistance to others, causing increasingly recalcitrant infections and elevating public health concerns. We reviewed the literature on multidrug-resistant (MDR) P. aeruginosa isolated from humans (nosocomial and community-associated), animals, and the environment in Lebanon, a country that has been suffering from a surge in antimicrobial resistance (AMR). We identified 24 studies that described the epidemiology and antimicrobial susceptibility profiles of P. aeruginosa. Our analysis showed that the bacterium was predominant in lesions of patients on mechanical ventilation and in burn patients and those with diabetic foot infections and hematological malignancies. We also found that carbapenem resistance in P. aeruginosa isolates in Lebanon involved both enzymatic and non-enzymatic mechanisms but depended predominantly on VIM-2 production (40.7%). Additionally, MDR P. aeruginosa was detected in animals, where a recent study reported the emergence of carbapenemase-producing P. aeruginosa in livestock in Lebanon. Notably, no studies evaluated the contribution of MDR P. aeruginosa in the environment to human infections. Taken together, our findings highlight the need for AMR surveillance programs and a national action plan to combat resistance in Lebanon.
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Affiliation(s)
| | - Fouad Dabboussi
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli 1300, Lebanon; (F.D.); (M.H.)
| | - Monzer Hamze
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli 1300, Lebanon; (F.D.); (M.H.)
| | - Marwan Osman
- Department of Public and Ecosystem Health, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA
| | - Issmat I. Kassem
- Center for Food Safety, Department of Food Science and Technology, University of Georgia, 1109 Experiment Street, Griffin, GA 30223-1797, USA
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11
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A brewing storm: The impact of economic collapse on the access to antimicrobials in Lebanon. J Glob Antimicrob Resist 2022; 29:313-315. [DOI: 10.1016/j.jgar.2022.04.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 11/19/2022] Open
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12
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Zhang S, Abbas M, Rehman MU, Wang M, Jia R, Chen S, Liu M, Zhu D, Zhao X, Gao Q, Tian B, Cheng A. Updates on the global dissemination of colistin-resistant Escherichia coli: An emerging threat to public health. THE SCIENCE OF THE TOTAL ENVIRONMENT 2021; 799:149280. [PMID: 34364270 DOI: 10.1016/j.scitotenv.2021.149280] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/22/2021] [Accepted: 07/22/2021] [Indexed: 06/13/2023]
Abstract
Colistin drug resistance is an emerging public health threat worldwide. The adaptability, existence and spread of colistin drug resistance in multiple reservoirs and ecological environmental settings is significantly increasing the rate of occurrence of multidrug resistant (MDR) bacteria such as Escherichia coli (E. coli). Here, we summarized the reports regarding molecular and biological characterization of mobile colistin resistance gene (mcr)-positive E. coli (MCRPEC), originating from diverse reservoirs, including but not limited to humans, environment, waste water treatment plants, wild, pets, and food producing animals. The MCRPEC revealed the abundance of clinically important resistance genes, which are responsible for MDR profile. A number of plasmid replicon types such as IncI2, IncX4, IncP, IncX, and IncFII with a predominance of IncI2 were facilitating the spread of colistin resistance. This study concludes the distribution of multiple sequence types of E. coli carrying mcr gene variants, which are possible threat to "One Health" perspective. In addition, we have briefly explained the newly known mechanisms of colistin resistance i.e. plasmid-encoded resistance determinant as well as presented the chromosomally-encoded resistance mechanisms. The transposition of ISApl1 into the chromosome and existence of intact Tn6330 are important for transmission and stability for mcr gene. Further, genetic environment of co-localized mcr gene with carbapenem-resistance or extended-spectrum β-lactamases genes has also been elaborated, which is limiting human beings to choose last resort antibiotics. Finally, environmental health and safety control measures along with spread mechanisms of mcr genes are discussed to avoid further propagation and environmental hazards of colistin resistance.
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Affiliation(s)
- Shaqiu Zhang
- Avian Disease Research Center, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, PR China; Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, PR China; Key Laboratory of Animal Disease and Human Health of Sichuan Province, Sichuan Agricultural University, Chengdu 611130, PR China
| | - Muhammad Abbas
- Avian Disease Research Center, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, PR China; Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, PR China; Key Laboratory of Animal Disease and Human Health of Sichuan Province, Sichuan Agricultural University, Chengdu 611130, PR China; Livestock and Dairy Development Department Lahore, Punjab 54000, Pakistan
| | - Mujeeb Ur Rehman
- Avian Disease Research Center, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, PR China; Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, PR China; Key Laboratory of Animal Disease and Human Health of Sichuan Province, Sichuan Agricultural University, Chengdu 611130, PR China; Disease Investigation Laboratory, Livestock & Dairy Development Department, Zhob 85200, Balochistan, Pakistan
| | - Mingshu Wang
- Avian Disease Research Center, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, PR China; Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, PR China; Key Laboratory of Animal Disease and Human Health of Sichuan Province, Sichuan Agricultural University, Chengdu 611130, PR China
| | - Renyong Jia
- Avian Disease Research Center, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, PR China; Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, PR China; Key Laboratory of Animal Disease and Human Health of Sichuan Province, Sichuan Agricultural University, Chengdu 611130, PR China
| | - Shun Chen
- Avian Disease Research Center, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, PR China; Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, PR China; Key Laboratory of Animal Disease and Human Health of Sichuan Province, Sichuan Agricultural University, Chengdu 611130, PR China
| | - Mafeng Liu
- Avian Disease Research Center, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, PR China; Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, PR China; Key Laboratory of Animal Disease and Human Health of Sichuan Province, Sichuan Agricultural University, Chengdu 611130, PR China
| | - Dekang Zhu
- Avian Disease Research Center, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, PR China; Key Laboratory of Animal Disease and Human Health of Sichuan Province, Sichuan Agricultural University, Chengdu 611130, PR China
| | - Xinxin Zhao
- Avian Disease Research Center, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, PR China; Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, PR China; Key Laboratory of Animal Disease and Human Health of Sichuan Province, Sichuan Agricultural University, Chengdu 611130, PR China
| | - Qun Gao
- Avian Disease Research Center, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, PR China; Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, PR China; Key Laboratory of Animal Disease and Human Health of Sichuan Province, Sichuan Agricultural University, Chengdu 611130, PR China
| | - Bin Tian
- Avian Disease Research Center, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, PR China; Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, PR China; Key Laboratory of Animal Disease and Human Health of Sichuan Province, Sichuan Agricultural University, Chengdu 611130, PR China
| | - Anchun Cheng
- Avian Disease Research Center, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, PR China; Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, PR China; Key Laboratory of Animal Disease and Human Health of Sichuan Province, Sichuan Agricultural University, Chengdu 611130, PR China.
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13
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Occurrence of the Colistin Resistance Gene mcr-1 and Additional Antibiotic Resistance Genes in ESBL/AmpC-Producing Escherichia coli from Poultry in Lebanon: A Nationwide Survey. Microbiol Spectr 2021; 9:e0002521. [PMID: 34494875 PMCID: PMC8557922 DOI: 10.1128/spectrum.00025-21] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The objective of the present study was to determine genomic characteristics of expanded-spectrum cephalosporin (ESC)-resistant Escherichia coli spreading in healthy broilers in Lebanon in 2018. Rectal swabs (n = 280) from 56 farms were screened for the presence of ESC-resistant E. coli isolates. Antimicrobial susceptibility and extended-spectrum β-lactamase (ESBL)/AmpC production were determined by the disk diffusion method. Whole-genome sequencing (WGS) of 102 representative isolates of E. coli was performed to determine their phylogenetic diversity, serotypes, sequence types (ST), acquired resistance genes, and virulence-associated genes. Fifty-two out of 56 farms housed broilers carrying ESC-resistant E. coli isolates. These farms had large and recurrent antimicrobial practices, using, for some of them, critically important antibiotics for prophylactic and therapeutic purposes. Among the 102 sequenced multidrug-resistant (MDR) E. coli isolates, the proportion of ESBL, plasmid-mediated AmpC β-lactamase (pAmpC) producers, and ESBL/pAmpC coproducers was 60%, 27.6%, and 12.4%, respectively. The most prevalent ESBL/pAmpC genes were blaCMY-2, blaCTX-M-3, blaCTX-M-15, blaCTX-M-27, and blaCTX-M-14b (n = 42, n = 31, n =15, n = 9, and n = 7, respectively). These ESBL/pAmpC producers were distributed in different STs, most being well-known avian-associated and sometimes pathogenic STs (ST-10, ST-48, ST-93, ST-115, ST-117, and ST-457). Phylogenetic single nucleotide polymorphism (SNP) analysis confirmed their genetic diversity and wide dispersion across the Lebanese territory. Most isolates were also resistant to ciprofloxacin (101/102 with 3 QRDR mutations), and 19/102 isolates from 11 unrelated STs also carried the mobile resistance gene mcr-1. This survey illustrates the alarming prevalence of MDR E. coli resistant to medically important antibiotics in broilers in Lebanon. This advocates the need for surveillance programs of antimicrobial resistance in Lebanon and the reduction of excessive use of antibiotics to limit the spread of MDR E. coli in food-producing animals. IMPORTANCE Poultry production is a main contributor of the global trend of antimicrobial resistance arising from food-producing animals worldwide. In Lebanon, inappropriate use of antibiotics is frequent in chickens for prophylactic reasons and to improve productivity, resulting in an alarming prevalence of extended-spectrum β-lactamase (ESBL)/AmpC-producing Escherichia coli, also resistant to other medically important antibiotics (i.e., colistin and ciprofloxacin). Their complex genomic epidemiology highlighted by an important genetic diversity suggests that these resistance determinants are largely spreading in enteric bacteria in Lebanese poultry. Further molecular surveillance is needed to understand the country-specific epidemiology of ESBL/AmpC and mcr-1 genes in Lebanese poultry production. In addition, decisive interventions are urgently needed in order to ban the use of critically important antibiotics for human medicine in food-producing animals and limit the spread of antibiotic resistance in Lebanon.
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14
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Majavie L, Johnston D, Messina A. A retrospective review of colistin utilisation at a tertiary care academic hospital in South Africa. S Afr J Infect Dis 2021; 36:205. [PMID: 34485491 PMCID: PMC8378127 DOI: 10.4102/sajid.v36i1.205] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/15/2021] [Indexed: 11/12/2022] Open
Abstract
Background The use of the antibiotic colistin was increasing as a treatment option for multidrug-resistant (MDR) infections. Standardisation of colistin dosing and more appropriate record-keeping practices were required to fully assess the optimal usage of colistin. The aim of this study was to determine how and why colistin was used in the treatment of MDR infections in a tertiary care public hospital in South Africa (SA). Methods This cross-sectional retrospective record review described adult and paediatric patients who received colistin intravenously from 01 May 2016 to 31 April 2017. Information from patient records were captured on a data collection tool and analysed using descriptive statistics. Ethical approval was obtained from the Human Research Ethics Committee of the University of the Witwatersrand. Results A total of 43 patient records were reviewed. Acinetobacter baumannii was the most common organism isolated (85.2% adults and 62.5% paediatrics). Colistin was mostly prescribed for sepsis (18 adults and 15 paediatrics). Most adults (66.7%) received loading doses as recommended; however, there was a great variation in maintenance doses. Paediatric patients reviewed also showed varying dosing according to weight. The mean duration of colistin therapy was 10 days. Carbapenems were most commonly co-administered with colistin (58%). Conclusion The findings suggested that although colistin usage was restricted in the hospital, it was not adequately monitored or controlled. Doses prescribed were made at the discretion of prescribing doctors and differed to currently accepted guidelines. Improved record-keeping practices related to the monitoring of colistin use were required.
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Affiliation(s)
- Liezl Majavie
- Department of Pharmacy and Pharmacology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Deanne Johnston
- Department of Pharmacy and Pharmacology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Angeliki Messina
- Antimicrobial Stewardship unit, Netcare hospitals, Johannesburg, South Africa
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15
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Dagher LA, Hassan J, Kharroubi S, Jaafar H, Kassem II. Nationwide Assessment of Water Quality in Rivers across Lebanon by Quantifying Fecal Indicators Densities and Profiling Antibiotic Resistance of Escherichia coli. Antibiotics (Basel) 2021; 10:antibiotics10070883. [PMID: 34356804 PMCID: PMC8300662 DOI: 10.3390/antibiotics10070883] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/02/2021] [Accepted: 07/16/2021] [Indexed: 11/23/2022] Open
Abstract
The use of contaminated water has been associated with severe disease outbreaks. Due to widespread pollution with untreated sewage, concerns have been raised over water quality in Lebanon, a country with well-documented challenges in infrastructure. Here, we evaluated the water quality of major rivers in Lebanon by quantifying the densities of fecal indicator bacteria (fecal coliforms and Escherichia coli). Additionally, we assessed the dissemination of antibiotic-resistant E. coli in river water. Composite water samples (n = 132) were collected from fourteen rivers, and 378 E. coli were isolated and analyzed. Fecal coliforms and E. coli were detected in 96.29% and 95.5% of the samples, respectively. Additionally, 73.48–61.3% and 31.81% of the samples exceeded the microbiological acceptability standards for irrigation and the fecal coliform limit for recreational activities, respectively. The E. coli exhibited resistance to ampicillin (40% of isolates), amoxicillin + clavulanic acid (42%), cefepime (4%), cefotaxime (14%), cefalexin (46%), cefixime (17%), doripenem (0.3%), imipenem (0.5%), gentamicin (6%), kanamycin (9%), streptomycin (35%), tetracycline (35%), ciprofloxacin (10%), norfloxacin (7%), trimethoprim-sulfamethoxazole (32%), and chloramphenicol (13%). Notably, 45.8% of the isolates were classified as multidrug resistant (MDR). Our results highlight the need to urgently address fecal pollution and the dissemination of antibiotic resistance in Lebanese rivers.
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Affiliation(s)
- Lea A. Dagher
- Department of Nutrition and Food Sciences, Faculty of Agricultural and Food Sciences, American University of Beirut (AUB), Beirut 1107 2020, Lebanon; (L.A.D.); (S.K.)
| | - Jouman Hassan
- Center for Food Safety, Department of Food Science and Technology, University of Georgia, 1109 Experiment Street, Griffin, GA 30223, USA;
| | - Samer Kharroubi
- Department of Nutrition and Food Sciences, Faculty of Agricultural and Food Sciences, American University of Beirut (AUB), Beirut 1107 2020, Lebanon; (L.A.D.); (S.K.)
| | - Hadi Jaafar
- Department of Agriculture, Faculty of Agricultural and Food Sciences, American University of Beirut (AUB), Beirut 1107 2020, Lebanon;
| | - Issmat I. Kassem
- Department of Nutrition and Food Sciences, Faculty of Agricultural and Food Sciences, American University of Beirut (AUB), Beirut 1107 2020, Lebanon; (L.A.D.); (S.K.)
- Center for Food Safety, Department of Food Science and Technology, University of Georgia, 1109 Experiment Street, Griffin, GA 30223, USA;
- Correspondence:
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16
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Abboud Z, Galuppo L, Tolone M, Vitale M, Puleio R, Osman M, Loria GR, Hamze M. Molecular Characterization of Antimicrobial Resistance and Virulence Genes of Bacterial Pathogens from Bovine and Caprine Mastitis in Northern Lebanon. Microorganisms 2021; 9:1148. [PMID: 34071800 PMCID: PMC8228836 DOI: 10.3390/microorganisms9061148] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/08/2021] [Accepted: 05/18/2021] [Indexed: 12/26/2022] Open
Abstract
Mastitis is an infectious disease encountered in dairy animals worldwide that is currently a growing concern in Lebanon. This study aimed at investigating the etiology of the main mastitis-causing pathogens in Northern Lebanon, determining their antimicrobial susceptibility profiles, and identifying their antimicrobial resistance (AMR) genes. A total of 101 quarter milk samples were collected from 77 cows and 11 goats presenting symptoms of mastitis on 45 dairy farms. Bacterial identification was carried out through matrix-assisted laser desorption/ionization-time of flight mass spectrometry. Antimicrobial susceptibility was tested by disc diffusion and broth microdilution methods. Molecular characterization included polymerase chain reaction (PCR) screening for genes encoding extended-spectrum beta-lactamases (ESBLs) and plasmid-mediated AmpC among Enterobacterales isolates, and virulence factors among Staphylococcus isolates. Escherichia coli isolates were subjected to phylogenetic typing by a quadruplex PCR method. The most frequently identified species were Streptococcus uberis (19.2%), Streptococcus agalactiae (15.1%), E. coli (12.3%), and Staphylococcus aureus (10.96%). Gram-positive bacteria were resistant to macrolides and tetracycline, whereas gram-negative bacteria displayed resistance to ampicillin and tetracycline. Two ESBL genes, blaTEM (83.3%) and blaOXA (16.7%), and one AmpC beta-lactamase gene, blaCMY-II (16.7%), were detected among six E. coli isolates, which mainly belonged to phylogenetic group B1. Among Staphylococcus spp., the mecA gene was present in three isolates. Furthermore, four isolates contained at least one toxin gene, and all S. aureus isolates carried the ica operon. These findings revealed the alarming risk of AMR in the Lebanese dairy chain and the importance of monitoring antimicrobial usage.
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Affiliation(s)
- Zahie Abboud
- Laboratoire Microbiologie Santé et Environnement, Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli P.O. Box 146404, Lebanon;
| | - Lucia Galuppo
- Istituto Zooprofilattico Sperimentale della Sicilia, Via G. Marinuzzi 3, 90129 Palermo, Italy; (L.G.); (M.V.); (R.P.)
| | - Marco Tolone
- Dipartimento di Scienze Agrarie, Alimentari e Forestali, University of Palermo, Viale delle Scienze, 90128 Palermo, Italy;
| | - Maria Vitale
- Istituto Zooprofilattico Sperimentale della Sicilia, Via G. Marinuzzi 3, 90129 Palermo, Italy; (L.G.); (M.V.); (R.P.)
| | - Roberto Puleio
- Istituto Zooprofilattico Sperimentale della Sicilia, Via G. Marinuzzi 3, 90129 Palermo, Italy; (L.G.); (M.V.); (R.P.)
| | - Marwan Osman
- Laboratoire Microbiologie Santé et Environnement, Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli P.O. Box 146404, Lebanon;
- Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY 14850, USA
| | - Guido Ruggero Loria
- Istituto Zooprofilattico Sperimentale della Sicilia, Via G. Marinuzzi 3, 90129 Palermo, Italy; (L.G.); (M.V.); (R.P.)
| | - Monzer Hamze
- Laboratoire Microbiologie Santé et Environnement, Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli P.O. Box 146404, Lebanon;
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17
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Emergence of the Mobile Colistin Resistance Gene, mcr-1, in Multidrug-Resistant E. coli Isolated from the Fecal Matter of Toddlers in a Community. Antimicrob Agents Chemother 2021; 65:AAC.00243-21. [PMID: 33593846 PMCID: PMC8092863 DOI: 10.1128/aac.00243-21] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Colistin is one of the few first-line options for treating complicated infections with certain multidrug-resistant bacteria (1).….
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18
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Draft Genome Sequences of Colistin-Resistant and mcr-1.1-Carrying Escherichia coli Strains Isolated from Irrigation Water. Microbiol Resour Announc 2021; 10:10/14/e00120-21. [PMID: 33833024 PMCID: PMC8032466 DOI: 10.1128/mra.00120-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Colistin has been classified as a highest priority clinically important antibiotic. However, the emergence of mobile colistin resistance (mcr) genes has threatened the therapeutic uses of colistin. Here, we report the draft genome sequences, antibiotic resistance genes, and sequence types (STs) of two multidrug-resistant and mcr-1.1-positive Escherichia coli strains isolated from irrigation water. Colistin has been classified as a highest priority critically important antibiotic. However, the emergence of mobile colistin resistance (mcr) genes has threatened the therapeutic uses of colistin. Here, we report the draft genome sequences, antibiotic resistance genes, and sequence types (STs) of two multidrug-resistant and mcr-1.1-positive Escherichia coli strains isolated from irrigation water.
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19
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Al-Mir H, Osman M, Drapeau A, Hamze M, Madec JY, Haenni M. WGS Analysis of Clonal and Plasmidic Epidemiology of Colistin-Resistance Mediated by mcr Genes in the Poultry Sector in Lebanon. Front Microbiol 2021; 12:624194. [PMID: 33763043 PMCID: PMC7982416 DOI: 10.3389/fmicb.2021.624194] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 02/11/2021] [Indexed: 12/19/2022] Open
Abstract
Poultry and poultry meat are important contributors to the global antimicrobial burden. Unregulated and illegal use of extended-spectrum cephalosporins (ESC) in this sector has long been identified as a major cause of massive spread of ESC-resistant Escherichia coli, and colistin usage is considered a main driver of plasmid-mediated mcr genes dissemination. In Lebanon, the first mcr-1-positive E. coli found in poultry dates back to 2015, followed by a few reports of mcr-1-positive E. coli in poultry, swine, humans, and the environment. On the contrary, a comprehensive picture of the population structure of mcr-1-positive E. coli and mcr-1-bearing plasmids carrying the mcr-1 gene using whole-genome analysis is largely lacking. This study reports the prevalence of mcr-1-positive E. coli in poultry originating from 32 farms across three Lebanese governorates and slaughtered in the same place. We report 27/32 (84.4%) mcr-1 positive farms, leading to a total of 84 non-duplicate E. coli collected, of which 62 presented the mcr-1 gene. Numerous associated resistances were identified, including to ESC through the presence of bla CTX-M or bla CMY genes. The mcr-1 gene was mostly carried by IncX4 (n = 36) and IncI2 (n = 24) plasmids, which are both known for their efficient transfer capacities. A high genetic diversity was detected, arguing for the lack of contamination during the slaughter process. ST744 and ST1011 were the most widely identified clones, which have been both regularly associated to mcr-1-carrying E. coli and to the poultry sector. The wide dissemination of colistin-resistance, coupled to resistances to ESC and numerous other molecules, should urge authorities to implement efficient guidelines for the use of antibiotics in the poultry sector in Lebanon.
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Affiliation(s)
- Hiba Al-Mir
- Laboratoire Microbiologie Santé et Environnement, Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon
- Université de Lyon – ANSES Laboratoire de Lyon, Unité Antibiorésistance et Virulence Bactériennes, Lyon, France
| | - Marwan Osman
- Laboratoire Microbiologie Santé et Environnement, Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon
| | - Antoine Drapeau
- Université de Lyon – ANSES Laboratoire de Lyon, Unité Antibiorésistance et Virulence Bactériennes, Lyon, France
| | - Monzer Hamze
- Laboratoire Microbiologie Santé et Environnement, Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon
| | - Jean-Yves Madec
- Université de Lyon – ANSES Laboratoire de Lyon, Unité Antibiorésistance et Virulence Bactériennes, Lyon, France
| | - Marisa Haenni
- Université de Lyon – ANSES Laboratoire de Lyon, Unité Antibiorésistance et Virulence Bactériennes, Lyon, France
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Kharroubi S, Nasser NA, El-Harakeh MD, Sulaiman AA, Kassem II. First Nation-Wide Analysis of Food Safety and Acceptability Data in Lebanon. Foods 2020; 9:foods9111717. [PMID: 33266478 PMCID: PMC7700422 DOI: 10.3390/foods9111717] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/16/2020] [Accepted: 11/19/2020] [Indexed: 11/16/2022] Open
Abstract
The challenges to food safety in Lebanon are numerous and have coalesced to pose a serious public health concern. This is evident in well-documented food poisoning outbreaks and adulteration cases. In response, the Lebanese government initiated an unprecedented food safety campaign (2015–2017) that aimed to test food samples that were randomly collected from foodservices and industries across the country. The data were made available publicly, but they were never analyzed to prioritize and determine high risk foods and most prevalent contaminants nationally or across governorates. To answer these questions, we performed an in-depth statistical analysis of the data, which included 11,625 individual food samples. Our analysis showed that water (55% of tested water samples), spices (49.3%), red meat (34.4%), poultry (30.9%) and dairy (28.3%) were the main foods associated with the highest rejection rates. The most common biological contaminants detected in rejected foods were sulfate-reducing bacteria (34.7%), Escherichia coli (32.1%), coliforms (19.6%), Staphylococcus aureus (12.8%), and Salmonella (11.6%). We conclude that Lebanon needs rigorous and sustainable programs to monitor the quality and safety of foods. Given the lack of resources, we recommend putting emphasis on extensive outreach programs that aim at enhancing food safety knowledge from farm to fork.
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Affiliation(s)
- Samer Kharroubi
- Department of Nutrition and Food Sciences, Faculty of Agricultural and Food Sciences, American University of Beirut (AUB), Beirut 1107 2020, Lebanon; (S.K.); (M.D.E.-H.); (A.A.S.)
| | - Nivin A. Nasser
- Center for Food Safety, Department of Food Science and Technology, University of Georgia, 1109 Experiment Street, Griffin, GA 30223-1797, USA;
| | - Marwa Diab El-Harakeh
- Department of Nutrition and Food Sciences, Faculty of Agricultural and Food Sciences, American University of Beirut (AUB), Beirut 1107 2020, Lebanon; (S.K.); (M.D.E.-H.); (A.A.S.)
| | - Abdallah Alhaj Sulaiman
- Department of Nutrition and Food Sciences, Faculty of Agricultural and Food Sciences, American University of Beirut (AUB), Beirut 1107 2020, Lebanon; (S.K.); (M.D.E.-H.); (A.A.S.)
| | - Issmat I. Kassem
- Department of Nutrition and Food Sciences, Faculty of Agricultural and Food Sciences, American University of Beirut (AUB), Beirut 1107 2020, Lebanon; (S.K.); (M.D.E.-H.); (A.A.S.)
- Center for Food Safety, Department of Food Science and Technology, University of Georgia, 1109 Experiment Street, Griffin, GA 30223-1797, USA;
- Correspondence: or
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21
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Prevalence and Loads of Fecal Pollution Indicators and the Antibiotic Resistance Phenotypes of Escherichia coli in Raw Minced Beef in Lebanon. Foods 2020; 9:foods9111543. [PMID: 33114538 PMCID: PMC7692955 DOI: 10.3390/foods9111543] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/19/2020] [Accepted: 10/23/2020] [Indexed: 11/30/2022] Open
Abstract
Meat is an important source of high biological value proteins as well as many vitamins and minerals. In Lebanon, beef meats, including raw minced beef, are among the most consumed of the meat products. However, minced beef meat can also be an important source of foodborne illnesses. This is of a major concern, because food safety in Lebanon suffers from well-documented challenges. Consequently, the prevalence and loads of fecal coliforms and Escherichia coli were quantified to assess the microbiological acceptability of minced beef meat in Lebanon. Additionally, antibiotic resistance phenotypes of the E. coli were determined in response to concerns about the emergence of resistance in food matrices in Lebanon. A total of 50 meat samples and 120 E. coli isolates were analyzed. Results showed that 98% and 76% of meat samples harbored fecal coliforms and E. coli above the microbial acceptance level, respectively. All E. coli were resistant to at least one antibiotic, while 35% of the isolates were multidrug-resistant (MDR). The results suggest that Lebanon needs to (1) update food safety systems to track and reduce the levels of potential contamination in important foods and (2) implement programs to control the proliferation of antimicrobial resistance in food systems.
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The Mobile Colistin Resistance Gene, mcr-1.1, Is Carried on IncX4 Plasmids in Multidrug Resistant E. coli Isolated from Rainbow Trout Aquaculture. Microorganisms 2020; 8:microorganisms8111636. [PMID: 33113918 PMCID: PMC7690709 DOI: 10.3390/microorganisms8111636] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 10/13/2020] [Accepted: 10/21/2020] [Indexed: 12/22/2022] Open
Abstract
Colistin, a last resort antibiotic, is important for controlling infections with carbapenem-resistant Enterobacteriaceae. The recent emergence of mobile-colistin-resistance (mcr) genes has threatened the effectiveness of colistin. Aquaculture is hypothesized to be a major contributor to the evolution and dissemination of mcr. However, data on mcr in aquaculture are limited. Here, the occurrence of mcr-1 was assessed in Rainbow Trout in Lebanon, a country with developing antimicrobial stewardship and an established use of colistin for medical and farming purposes. mcr-1 was detected in 5 Escherichia coli isolated from fish guts. The isolates were classified as multidrug-resistant and their colistin minimum inhibitory concentration ranged between 16 and 32 μg/mL. Whole genome sequencing analysis showed that mcr-1 was carried on transmissible IncX4 plasmids and that the isolates harbored more than 14 antibiotic resistance genes. The isolates belonged to ST48 and ST101, which have been associated with mcr and can occur in humans and fish. The mcr-1-positive E. coli persisted in 6-day biofilms, but there was a potential fitness cost. Given the status of infrastructure in Lebanon, there is a high potential for the dissemination of mcr via aquatic environments. Urgent actions are needed to control mcr and to enhance antimicrobial stewardship in Lebanon.
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Alhaj Sulaiman AA, Kassem II. First report of the plasmid-borne colistin resistance gene (mcr-1) in Proteus mirabilis isolated from domestic and sewer waters in Syrian refugee camps. Travel Med Infect Dis 2020; 33:101482. [DOI: 10.1016/j.tmaid.2019.101482] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 09/12/2019] [Indexed: 11/27/2022]
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Hmede Z, Kassem II. First report of the plasmid-borne colistin resistance gene ( mcr- 1) in Proteus mirabilis isolated from a toddler in non-clinical settings. IDCases 2019; 18:e00651. [PMID: 31700801 PMCID: PMC6831782 DOI: 10.1016/j.idcr.2019.e00651] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 09/27/2019] [Accepted: 09/28/2019] [Indexed: 11/30/2022] Open
Abstract
We report the detection of a plasmid-borne mobile colistin-resistance-gene, mcr-1, in Proteus mirabilis, a known community and hospital pathogen, that was isolated from a toddler (2 years old) in the community in Lebanon. To our knowledge, this is the first report of the occurrence of mcr-1 in human-associated P. mirabilis as well as mcr-1 in humans in the Lebanese community.
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Affiliation(s)
- Zaynab Hmede
- Department of Nutrition and Food Sciences, Faculty of Agricultural and Food Sciences, American University of Beirut (AUB), Lebanon
| | - Issmat I Kassem
- Department of Nutrition and Food Sciences, Faculty of Agricultural and Food Sciences, American University of Beirut (AUB), Lebanon.,Center for Food Safety, Department of Food Science and Technology, University of Georgia, 1109 Experiment Street, Griffin, GA 30223-1797, USA
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Sulaiman AAA, Kassem II. First report on the detection of the plasmid-borne colistin resistance gene mcr-1 in multi-drug resistant E. coli isolated from domestic and sewer waters in Syrian refugee camps in Lebanon. Travel Med Infect Dis 2019; 30:117-120. [DOI: 10.1016/j.tmaid.2019.06.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/24/2019] [Accepted: 06/27/2019] [Indexed: 10/26/2022]
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Hmede Z, Sulaiman AAA, Jaafar H, Kassem II. Emergence of plasmid-borne colistin resistance gene mcr-1 in multidrug-resistant Escherichia coli isolated from irrigation water in Lebanon. Int J Antimicrob Agents 2019; 54:102-104. [DOI: 10.1016/j.ijantimicag.2019.05.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 04/24/2019] [Accepted: 05/01/2019] [Indexed: 11/26/2022]
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