Distribution of Class I Integron and Sulfamethoxazole Trimethoprim Constin inVibrio choleraeIsolated from Patients in Iran

Spotlight on the epidemiology and antimicrobial susceptibility profiles of Vibrio species in the MENA region, 2000-2023

Recent cholera outbreaks in many countries in the Middle East and North Africa (MENA) region have raised public health concerns and focused attention on the genus Vibrio. However, the epidemiology of Vibrio species in humans, water, and seafood is often anecdotal in this region. In this review, we screened the literature and provided a comprehensive assessment of the distribution and antibiotic resistance properties of Vibrio species in different clinical and environmental samples in the region. This review will contribute to understanding closely the real burden of Vibrio species and the spread of antibiotic-resistant strains in the MENA region. The overall objective is to engage epidemiologists, sanitarians and public health stakeholders to address this problem under the One-health ethos.

Antimicrobial resistance in Vibrio cholerae O1/O139 clinical isolates: a systematic review and meta-analysis

OBJECTIVES

Vibrio cholerae O1/O139 is responsible for cholera epidemics; that remains a huge public health menace across the globe. Furthermore, an increasing resistance rate among V. cholerae strains has been reported around the world. Therefore, the objective of this meta-analysis was to evaluate the weighted pooled resistance (WPR) rates in clinical V. cholerae O1/O139 isolates based on different years, areas, antimicrobial susceptibility testing, and resistance rates.

RESEARCH DESIGN AND METHODS

: We searched the studies in PubMed, Scopus, Embase, and Web of Science (until January 2020). Statistical analyses were conducted using STATA software (ver. 14.0).

RESULTS

: A total of 139 studies investigating 24062 V. cholerae O1/O139 isolates were analyzed. The majority of the studies originated in Asia (n=102). The WPR rates were as follows: azithromycin 1%, erythromycin 36%, ciprofloxacin 3%, cotrimoxazole 79%, doxycycline 7%, tetracycline 20%. There was increased resistance to cotrimoxazole, ciprofloxacin, and tetracycline during the 1980 to 2020 years.

CONCLUSIONS

: Temporal changes in antibiotic resistance rate found in this study demonstrated the critical continuous surveillance of antibiotic resistance. Also, ciprofloxacin, azithromycin, gentamicin, cephalexin, imipenem, ofloxacin, and norfloxacin were found to be the best antibiotics against V. cholera, with the highest and the lowest effectiveness resistance rate.

Global status of antimicrobial resistance among environmental isolates of Vibrio cholerae O1/O139: a systematic review and meta-analysis

BACKGROUND

Vibrio cholerae O1/O139 were the predominant circulating serogroups exhibiting multi-drug resistance (MDR) during the cholera outbreak which led to cholera treatment failures.

OBJECTIVE

This meta-analysis aimed to evaluate the weighted pooled resistance (WPR) rates in V. cholerae O1/O139 isolates obtained from environmental samples.

METHODS

We systematically searched the articles in PubMed, Scopus, and Embase (until January 2020). Subgroup analyses were then employed by publication year, geographic areas, and the quality of studies. Statistical analyses were conducted using STATA software (ver. 14.0).

RESULTS

A total of 20 studies investigating 648 environmental V. cholerae O1/O139 isolates were analysed. The majority of the studies were originated from Asia (n = 9). In addition, a large number of studies (n = 15 i.e. 71.4%) included in the meta-analysis revealed the resistance to cotrimoxazole and ciprofloxacin. The WPR rates were as follows: cotrimoxazole 59%, erythromycin 28%, tetracycline 14%, doxycycline 5%, and ciprofloxacin 0%. There was increased resistance to nalidixic acid, cotrimoxazole, furazolidone, and tetracycline while a decreased resistance to amoxicillin, ciprofloxacin, erythromycin, chloramphenicol, ampicillin, streptomycin, and ceftriaxone was observed during the years 2000-2020. A significant decrease in the doxycycline and ciprofloxacin-resistance rates in V. cholerae O1/O139 isolates was reported over the years 2011-2020 which represents a decrease in 2001-2010 (p < 0.05).

CONCLUSIONS

Fluoroquinolones, gentamicin, ceftriaxone, doxycycline, kanamycin, and cefotaxime showed the highest effectiveness and the lowest resistance rate. However, the main interest is the rise of antimicrobial resistance in V. cholerae strains especially in low-income countries or endemic areas, and therefore, continuous surveillance, careful appropriate AST, and limitation on improper antibiotic usage are crucial.

Antimicrobial resistance not related to 1,2,3 integrons and Superintegron in Vibrio spp. isolated from seawater sample of Lima (Peru)

Antimicrobial resistance (AMR) in microorganisms has been attributed to integrons, which have the ability to capture antimicrobial resistance gene cassettes and express them in their hosts. 170 strains of Vibrio spp. were isolated from Lima (Peru) seawater samples and identified by biochemical tests and PCR. AMR profiles were generated using 15 standard antibiotics. The presence of class 1, 2 and 3 integrons and Superintegron in these strains were also investigated by PCR. Ten species of Vibrio were identified with V. alginolyticus the most frequent. All strains were resistant to antibiotics, especially to penicillin group. No resistance to norfloxacin or tetracycline was observed. Class 1, 2 and 3 integrons were not found, only one Superintegron containing the mutT gene was identified in V. cholerae L22 strain. This indicated that AMR is not related to integrons as mentioned previously and that these strains can be reservoirs of resistance genes in marine environments.

Heterogeneity of Multidrug-Resistant Salmonella enterica Isolates with Increasing Frequency of Resistance to Ciprofloxacin During a 4-Year Period in Iran

BACKGROUND

The study was conducted to assess the trend of antimicrobial resistance among Salmonella enterica strains during a period of 4 years and to compare the effectiveness of three genotyping methods, including flagellin polymerase chain reaction (PCR)-restriction fragment length polymorphism (RFLP), enterobacterial repetitive intergenic consensus (ERIC)-PCR, and pulsed-field gel electrophoresis (PFGE), and to determine the most efficient method for S. enterica genotyping.

METHODS AND RESULTS

About 50 S. enterica isolates were isolated from 5,064 stool samples. All of the isolates harbored fliC gene, 29 of which (58%) showed diphasic characteristic with a fliC⁺/fljB⁺ genotype. Simpson diversity index (Di) for RFLP analysis of fliC and fljB genes was calculated as 0.71 and 0.82, respectively. Strains were differentiated into 40 ERIC genotypes and 27 pulsotypes. All isolates with identical pulsotypes belonged to common serogroups which depict their correlation in a good manner. The Di calculated for ERIC-PCR and PFGE analysis was 0.99 and 0.94, respectively. The frequency of multidrug resistance (MDR) was dramatically increased from 25% in 2009-2010 to 63% in 2011-2012 with the emergence of 10% ciprofloxacin resistance in the latter period.

CONCLUSION

About 44% increase in MDR phenotype among S. enterica isolates during a 4-year period and concomitant appearance of ciprofloxacin resistance is a traumatic situation for health professionals in Iran. PFGE profiles offered a satisfactory discriminatory power, which was positively correlated with S. enterica serogrouping. The current study marks the superiority of PFGE method over other conventional molecular techniques in epidemiological investigations; however, their limitations need to be addressed for further refinement.

Identification of Atypical El TorV. cholerae O1 Ogawa Hosting SXT Element in Senegal, Africa

Vibrio cholerae O1 is the causative agent of cholera with classical and El Tor, two well-established biotypes. In last 20 years, hybrid strains of classical and El Tor and variant El Tor which carry classical ctxB have emerged worldwide. In 2004-2005, Senegal experienced major cholera epidemic with a number of cases totalling more than 31719 with approximately 458 fatal outcomes (CFR, 1.44%). In this retrospective study, fifty isolates out of a total of 403 V. cholerae biotype El Tor serovar Ogawa isolates from all areas in Senegal during the 2004-2005 cholera outbreak were randomly selected. Isolates were characterized using phenotypic and genotypic methods. The analysis of antibiotic resistance patterns revealed the predominance of the S-Su-TCY-Tsu phenotype (90% of isolates). The molecular characterization of antibiotic resistance revealed the presence of the SXT element, a self-transmissible chromosomally integrating element in all isolates. Most of V. cholerae isolates had an intact virulence cassette (86%) (ctx, zot, ace genes). All isolates tested gave amplification with primers for classical CT, and 10/50 (20%) of isolates carried classical and El Tor ctxB. The study reveals the presence of atypical V. cholerae O1 El Tor during cholera outbreak in Senegal in 2004-2005.

Distribution of resistance genetic determinants among Vibrio cholerae isolates of 2012 and 2013 outbreaks in IR Iran

The objective of this study was to characterize antimicrobial resistance determinants in relation to antimicrobial susceptibility and genotyping profile in 20 clinical isolates of Vibrio cholerae. All of the isolates were resistant to streptomycin. The second most prevalent resistance was observed to trimethoprim (75%), co-trimoxazole (60%), tetracycline (50%), and minocycline (45%). About 50% of the isolates fulfilled the criteria of Multi Drug Resistance (MDR) phenotype. None of the isolates carried tet A, B, C, and, D determinants. This finding shows that tetracycline resistance determinants recognized so far, does not satisfactorily describe the 50% tetracycline resistance phenotype in this study, suggesting the possible contribution of other not yet characterized resistance mechanisms involved. Class 1 integron, widely distributed among enteric bacteria, was not detected among V. cholerae strains under study. Conversely, 100% of the isolates harbored SXT constin_(int), among which 70% were positive for dfrA1, strA, and strB genes. The sul1gene was present in 60% of the isolates while none of them contained floR gene. All the isolates uniformly appeared to be identical in fingerprinting profiles expected from outbreak strains. In conclusion, SXT element with its mosaic structure was the exclusive antimicrobial resistance determinant of clonal V. cholerae isolates taken from outbreaks of 2012 and 2013 in Iran.

Multi-locus variable number tandem repeat analysis of Vibrio cholerae isolates from 2012 to 2013 cholera outbreaks in Iran

Cholera remains to be an international threat, with high rates of illness and death. In 2012 and 2013, two cholera outbreak happened in Iran, affecting lots of people. Vibrio cholerae O1 was confirmed as the etiological agent. Source identification and controlling the spread of the cholera disease are two critical approaches in cholera outbreaks. In this study, thirty V. cholerae O1 isolates were selected and has been evaluated for antimicrobial resistant as well as molecular typing by multilocus variable-number tandem-repeat analysis (MLVA) method. Twenty-nine (97%) isolates were sero-grouped as El Tor (one isolate was classical) and 100% were related to Inaba serotype. All of the isolates were susceptible to ciprofloxacin, chloramphenicol, ampicillin and gentamicin. On the other hand, 60% of the isolates were MDR (resistant to 3 or more classes). There were three resistance patterns. The most prevalent pattern was resistance to streptomycin, erythromycin, trimethoprim-sulfamethoxazole, and tetracycline (ST-SXT-E-T) which was seen in 50% of isolates. Using MLVA method 14 MLVA types were identified. MLVA type 2 (5-7-7-16-15) accounted for 43% of isolates. Isolates with the same genotype often did not have the same antibiogram. Overall, the data indicate that the Iranian V. cholerae were MDR and clonaly related. Furthermore, the results of this study shows that MLVA can be used as useful method for V. cholerae genotyping in epidemiological investigations.

The trend of enteropathogenic Escherichia coli towards atypical multidrug resistant genotypes

The aim of this study was to investigate the prevalence of multidrug resistance (MDR) in atypical enteropathogenic Escherichia coli (EPEC) genotypes among 547 diarrheal children. All E. coli isolates with eae⁺stx1^-stx2^- genotypes included in this study and atypical property of EPEC was characterized by the absence of Bundle-forming pili (bfpA gene). Bacterial pathogens were detected in 70 patients (12.8%) among which atypical EPEC (5.3%) were the most common. The higher resistance rate was seen to tetracycline (70%), cotrimoxazole (60%) and nalidixic acid (53.3%) related to MDR phenotype in 63.3% of isolates. The presence of class 1 and 2 integrons was 30% and 6.6% with the dominance of dfrA, aadA gene cassettes among the isolates. Eleven out of 21 phenotypically tetracycline-resistant isolates (52.38%) harboured one or two tetracycline resistance genes (A-D) which shows the incapability of known data to reasonable tetracycline resistance phenotypes among EPEC isolates. A high level of genotypic diversity was seen among the isolates by Pulsed-field gel electrophoresis method which ranged from 89.7 to 29% and no clear correlation was obtained between tetracycline resistance or integron carriage and specific pulsotypes. In conclusion, the data presented here add to knowledge about the heterogeneous nature of MDR EPEC population in Iran which has a growing tendency towards atypical genotypes. The distribution of integrons among EPEC isolates in Iran is decreasing; although, the resistance gene content is almost stable through years.

Molecular Detection of Genomic Islands Associated With Class 1 and 2 Integron in Haemophilus influenzae Isolated in Iran

Background:

High levels of multidrug resistance are usually associated with mobile genetic elements that encode specific resistance genes. Integrons are important genetic elements involved in spreading antibiotic multi-resistance. In special cases, large exogenous segments in bacterial genomes form genomic islands, and one of the functions of these genomic islands is antibiotic resistance. Due to geographical heterogeneity in antibiotic resistance pattern, it is mandatory to determine resistance patterns that are region-specific rather than generalized.

Objectives:

The objective of this study was to detect class 1 and 2 integrons in clinical isolates of Haemophilus influenzae.

Patients and Methods:

Antibiogram tests were carried out for twenty clinical isolates collected from different patients admitted to the Milad hospital. The PCR reactions were performed using universal primers specified for Int1 and Int2 genes attributed to class 1 and 2 integrons. Also amplification of integrase genes related to genomic islands was investigated by designing specific primers.

Results:

Of the twenty isolates, all (100%) were resistant to clindamycin, chloramphenicol and tetracycline, 95% to amoxicillin, 50% to ceftriaxone, 45% to ciprofloxacin and 5% to azithromycin. Also, all isolates (100%) were sensitive to trimethoprim/sulfamethoxazole. Class 1 and 2 integrons were not detected in any of the isolates; however the integrase gene attributed to genomic islands was identified in twelve isolates.

Conclusions:

Antibiotic resistance gene cassettes may be carried on integron or other genetic elements. The purpose of this study was to detect integron or genomic islands involved in antibiotic resistance profile of the isolates of H. influenzae collected in this study.

Resistance-Gene Cassettes Associated With Salmonella enterica Genotypes

BACKGROUND

The epidemiology of salmonellosis is complex because of the diversity and different serotypes of Salmonella enterica (S. enterica) that occur in different reservoirs and geographic incidences.

OBJECTIVES

To determine the genotype distribution and resistance-gene content of 2 classes of integron among S. enterica isolates.

METHODS

Thirty-six S. enterica species were isolated and tested for their serological distribution and the resistance-gene contents of 2 classes of integron, as well as for their genetic diversity, using the pulsed-field gel electrophoresis (PFGE) genotyping method.

RESULTS

Serogroups E (36.1%) and D (30.5%) were dominant among the isolates. All of the isolates in serogroup D belonged to the serovar enteritidis. The aadA1 gene was found within all resistance-gene cassettes. We observed 4 common and 26 single pulsotypes among the isolates, which indicated a high degree of genetic diversity among the isolates. Using the PulseNet International standard protocol, it was found that these isolates were different from those reported previously in Iran.

CONCLUSIONS

The presence of a few common and new pulsotypes among the isolates suggests the emergence and spread of new clones of S. enterica in Iran.

Clonal Dissemination of a Single Vibrio cholerae O1 Biotype El Tor Strain in Sistan-Baluchestan Province of Iran During 2013

Although much is known about the mechanisms affecting cholera spread, cholera outbreaks occur annually in Iran. The aim of this study was to characterize and assess the clonal correlation of strains obtained from an outbreak in 2013 in Iran. Thirty-three strains of Vibrio cholerae were isolated from stool sample of patients majority of them belonged to Afghan nationality. PCR and sequencing analysis was performed to characterize virulence and resistance associates genes and cassettes. Clonality of isolates was assessed by Pulsed-field gel electrophoresis (PFGE) method. The ctx, zot, and tcp genes were present in 100 % of isolates. The wbeT gene was absent in all V. cholerae outbreak isolates, integrity of which is essential for Ogawa phenotype. This correlates with Inaba phenotype of all isolates under study. Sequencing of the ctxB (+) strains revealed that all isolates (El Tor strains) possessed the ctxB sequence of classical biotype allele known as El Tor variant strains. No class 1 or 2 integrons were detected among the isolates which indicate that in spite of high rate of resistance, integrons do not play an important role in V. cholerae resistance. All isolates were chloramphenicol sensitive all of which showed resistance to tetracycline and harbored the tetB resistance gene. PFGE analysis showed identical pulsotypes indicative of clonal dissemination of a single V. cholerae strain among the patients under study. Clonal cholera outbreak in boarder cities is alarming due to fear of import and spread of V. cholerae strains from out of the country which may lead to more spreading epidemics.

Assessing clonal correlation of epidemic Vibrio cholerae isolates during 2011 in 16 provinces of Iran

A total of 1,187 Vibrio cholerae isolates were received during 2011 cholera outbreaks from 16 provinces in different geographical location to Iranian reference Health laboratory. A random selection was performed, and 61 isolates were subjected to further investigations. Cholera cases were come up from May with nine cases and reached to its maximum rate at August (57 cases) and continued to October after which a fall occurred in September. All of the isolates were susceptible to three antimicrobial agents including ciprofloxacin, cefixime, and ampicillin. The highest rate of resistance was seen to nalidixic acid (96.7 %) and co-trimoxazole (91.8 %). Clonality of isolates was investigated through genotyping by PFGE method. A total of seven pulsotypes were obtained from 61 isolates under study. The pulsotypes were highly related with only 1-3 bands differences. Three pulsotypes (PT5, PT6, and PT7) constituted 93.4 % of total isolates. One environmentally isolated strain showed distinct pattern from clinical specimens. This strain although had no any evidence in identified cholera infections, highlighted selecting more environmental specimens in any future outbreaks as long as human samples. In conclusion, emergence and dominance of Ogawa serotypes after about 7 years in Iran are alarming due to fear of import of new V. cholerae clones from out of the country. Approximately, one third of patients in 2011 cholera outbreak in Iran were of Afghan or Pakistani nationality which makes the hypothesis of import of Ogawa serotype strains from neighboring countries more documented and signifies the need to monitor and protect the boundaries.

Molecular characterization of enterohemorrhagic Escherichia coli isolates from cattle

A total of 21 (4.3%) enterohemorrhagic E. coli strains were isolated by biochemical tests and identification of the eae⁺stx1⁺stx2⁺ genotype from 490 stool samples obtained from calves with diarrhea during 1-year period from a major farm in Tehran, Iran. All of the strains showed resistance to ampicillin, ciprofloxacin, trimethoprim, streptomycin, chloramphenicol and tetracycline, while 19% showed resistance to gentamicin. Out of 21 EHEC strains, 11 (53%) harbored class 1 integron. Two different amplification products, which were approximately 750 and 1,700 bp in size, were obtained from amplified variable regions (in-F/in-R primers) in 3 (14.3%) and 4 (19%) of the EHEC isolates, which corresponded to dfrA7(dihydrofolate reductase type I) and dfrA1/aadA1(dihydrofolate reductase/aminoglycoside adenyltransferase) resistance gene cassettes, respectively, and this was confirmed by sequencing. Genotyping analysis revealed a total of 16 pulsotypes that corresponded to 16 isolates with the similarity indices of 62% and 30% for the most and least similar isolates, respectively, 9 of which harbored class 1 integron. Analysis of pulsotypes showed an extensive diversity among the isolates harboring integron, which is indicative of a lack of any significant genetic relatedness among the isolates. No obvious relation could be deduced between integron content and special pulsotypes. The little data available on the genotyping patterns of EHEC isolates from cattle and their resistance gene contents emphasize the need to establish genotyping databases in order to monitor and source track the source of emergence and spread of new resistant and integron-carrying genotypes.

Genetic elements associated with antimicrobial resistance among intestinal bacteria

Background:

Integrons are the major reasons of multidrug resistance (MDR) among enteropathogenic bacteria. Occurrence of horizontal gene transfer between integron-carrying microorganisms and other enteric bacteria may increase the rate of emergence of integron-associated antibiotic resistance.

Objectives:

The objective of this study was to investigate class 1 integrons among members of enteropathogenic bacteria isolated from patients in Iran.

Materials and Methods:

A total of 120 enteropathogenic bacterial isolates from diarrhoeal patients were included in this study. Identities of the isolates were investigated by biochemical tests and confirmed by genus or species specific PCRs. Antimicrobial susceptibility testing was performed according to the Clinical and Laboratory Standards Institute (CLSI) guidelines. Presence of class 1 integron among the isolates was investigated using primers specific for the integrase gene conserved region.

Results:

The result of this study showed the highest resistance to trimethoprim and cotrimoxazole, especially in enteropathogenic Escherichia coli (EPEC) (100%), Shigella sonnei (93.7%) and Vibrio cholerae (95%). The results showed that 16 (57.1%) of the 28 EPEC, 9 (25%) of the 36 Salmonella enterica, 32 of the 13 (40.6%) Sh. sonnei, and only 1 (4.2%) of the 24 V. cholerae isolate harbored class 1 integron.

Conclusions:

The data obtained in the present study suggested that class 1 integrons are widely distributed among members of Enterobacteriaceae. The resistance patterns of our E. coli, S. sonnei, and S. enterica isolates were nearly identical, suggesting the same genetic elements involved in attainment of multi-drug resistance.

Genetic diversity of Shigella spp. and their integron content

OBJECTIVES

The aim of this study was to investigate the occurrence and resistance gene content of class 1 and 2 integrons among Shigella spp. and to study the genetic diversity of isolates using the pulsed-field gel electrophoresis (PFGE) method.

METHODS AND RESULTS

A total of 32 Shigella spp. were identified from 700 stool samples of patients with diarrhea from two provinces in Iran. S. sonnei (70.8%) and S. flexneri (62.5%) were the most frequent serogroups in Tehran and Razavi Khorasan provinces, respectively. Class 2 integrons were more frequent among Shigella spp. in comparison with class 1 integrons. Three different resistance gene arrays were identified among class 1 integrons. Dihydrofolate reductase (dfrA) gene cassette was detected in 78.9% of total integrons (class 1 and 2). PFGE analysis revealed clonal dissemination (62.5%) of a single clone with identical class 2 resistance gene content in Tehran province. Comparison of our Shigella pulsotypes with those published from other countries showed similar pulsotypes in India and Korea, with identical resistance profiles, which suggests dissemination of this (these) clone(s) in Asian countries.

CONCLUSIONS

Class 2 integrons were found to be predominant among our Shigella spp. This reflects the need to monitor the acquisition and dissemination of different resistant gene cassettes among integrons. Comparison of PFGE pattern through standard procedures promoted the molecular epidemiological surveys and identification of clonal isolates in Iran and other Asian countries.

Distribution of class 1 integrons among enteropathogenic Escherichia coli

The aim of this study was to investigate the incidence of and resistance gene content of class 1 integrons among enteropathogenic Escherichia coli (EPEC) and non-EPEC and to investigate intraspecies genetic diversity of EPEC strains isolated from children with diarrhea in Iran. Twenty-eight EPEC and 16 non-EPEC strains isolated from children with diarrhea were tested for the presence of a class 1 integron associated integrase gene (int1). Sequence analysis was performed to identify the resistance gene content of integrons. Genetic diversity and cluster analysis of EPEC isolates were also investigated using enterobacterial repetitive intergenic concensus-polymerase chain reaction (ERIC-PCR) fingerprinting. Twenty-three (82%) EPEC isolates and 11 (68.7%) non-EPEC isolates harbored the int1 gene specific to the conserved integrase region of class 1 integrons. Sequence analysis revealed the dominance of dfrA and aadA gene cassettes among the isolates of both groups. ERIC-PCR fingerprinting of EPEC isolates revealed a high diversity among these isolates. The widespread distribution of 2 resistance gene families (dfrA and aadA) among both groups of EPEC and non-EPEC isolates indicates the significance of integrons in antibiotic resistance transfer among these bacteria. Furthermore, clonal diversity of EPEC isolates harbouring a class 1 integron also suggests the circulation of these mobile elements among a diverse population of EPEC in this country.

Antibiotic resistance mechanisms of Vibrio cholerae

As the causative agent of cholera, the bacterium Vibrio cholerae represents an enormous public health burden, especially in developing countries around the world. Cholera is a self-limiting illness; however, antibiotics are commonly administered as part of the treatment regimen. Here we review the initial identification and subsequent evolution of antibiotic-resistant strains of V. cholerae. Antibiotic resistance mechanisms, including efflux pumps, spontaneous chromosomal mutation, conjugative plasmids, SXT elements and integrons, are also discussed. Numerous multidrug-resistant strains of V. cholerae have been isolated from both clinical and environmental settings, indicating that antibiotic use has to be restricted and alternative methods for treating cholera have to be implemented.