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Shaaban MT, Abdel-Raouf M, Zayed M, Emara MA. Microbiological and molecular studies on a multidrug-resistant Pseudomonas aeruginosa from a liver transplant patient with urinary tract infection in Egypt. BMC Microbiol 2024; 24:184. [PMID: 38802754 PMCID: PMC11129433 DOI: 10.1186/s12866-024-03318-0] [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: 07/21/2023] [Accepted: 05/03/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND Pseudomonas aeruginosa is an opportunistic pathogen responsible for complicated UTIs and exhibits high antibiotic resistance, leading to increased mortality rates, especially in cases of multidrug-resistant strains. This study aimed to investigate the antibiotic susceptibility patterns and genomic characterization of XDR strains identified in end-stage liver disease patients who underwent liver transplants. METHODS In this study, a number of 30 individuals who underwent liver transplants were registered. Ninety urine and 60 wound site swab samples were collected and processed for culturing, identification, and antimicrobial sensitivity. Extensively drug-resistant strain EMARA01 was confirmed through Sanger sequencing and was then processed for whole genome sequencing to characterize the genomic pattern. Sequencing data were processed for de novo assembly using various tools and databases, including genome annotation, serotype identification, virulence factor genes, and antimicrobial resistance gene. Pangenome analysis of randomly selected 147 reference strains and EMAR01 sequenced strain was performed using the Bacterial Pan Genome Analysis (BPGA) software. RESULTS Of these total examined samples, nosocomial infection due to P. aeruginosa was detected in twelve patients' samples. AST analysis showed that P. aeruginosa strains exhibit resistance to tobramycin, erythromycin, and gentamicin, followed by piperacillin and ofloxacin, and no strains exhibit resistance to meropenem and imipenem. The CARD database identified 59 AMR genes similar to the EMAR01 strain genome and mostly belong to the family involved in the resistance-nodulation-cell division (RND) antibiotic efflux pump. Five genes; nalC, nalD, MexR, MexA, and MexB, exhibit resistance to 14 classes of antibiotics, while two AMR; CpxR, and OprM, exhibit resistance to 15 classes of drugs. Pangenome analysis revealed that the pan-genome remained open, suggesting the potential for acquiring accessory and unique genes. Notably, the genes predominantly involved in amino acid transport metabolism were identified using the KEGG database. CONCLUSIONS This study provides valuable insights into the antimicrobial resistance profile, genetic features, and genomic evolution of P. aeruginosa strains causing UTIs in liver transplant patients. The findings emphasize the significance of comprehending AMR mechanisms and genetic diversity in P. aeruginosa for developing effective treatment strategies and infection control measures.
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Affiliation(s)
- Mohamed T Shaaban
- Department of Botany and Microbiology, Faculty of Science, Menoufia University, Shebin El- Kom, Egypt
| | | | - Muhammad Zayed
- Department of Botany and Microbiology, Faculty of Science, Menoufia University, Shebin El- Kom, Egypt.
| | - Mahmoud A Emara
- Department of Botany and Microbiology, Faculty of Science, Menoufia University, Shebin El- Kom, Egypt
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Denissen J, Havenga B, Reyneke B, Khan S, Khan W. Comparing antibiotic resistance and virulence profiles of Enterococcus faecium, Klebsiella pneumoniae, and Pseudomonas aeruginosa from environmental and clinical settings. Heliyon 2024; 10:e30215. [PMID: 38720709 PMCID: PMC11076977 DOI: 10.1016/j.heliyon.2024.e30215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 04/19/2024] [Accepted: 04/22/2024] [Indexed: 05/12/2024] Open
Abstract
Antibiotic resistance and virulence profiles of Enterococcus faecium, Klebsiella pneumoniae, and Pseudomonas aeruginosa, isolated from water sources collected in informal settlements, were compared to clinical counterparts. Cluster analysis using repetitive extragenic palindromic sequence-based polymerase chain reaction (REP-PCR) indicated that, for each respective species, low genetic relatedness was observed between most of the clinical and environmental isolates, with only one clinical P. aeruginosa (PAO1) and one clinical K. pneumoniae (P2) exhibiting high genetic similarity to the environmental strains. Based on the antibiograms, the clinical E. faecium Ef CD1 was extensively drug resistant (XDR); all K. pneumoniae isolates (n = 12) (except K. pneumoniae ATCC 13883) were multidrug resistant (MDR), while the P. aeruginosa (n = 16) isolates exhibited higher susceptibility profiles. The tetM gene (tetracycline resistance) was identified in 47.4 % (n = 6 environmental; n = 3 clinical) of the E. faecium isolates, while the blaKPC gene (carbapenem resistance) was detected in 52.6 % (n = 7 environmental; n = 3 clinical) and 15.4 % (n = 2 environmental) of the E. faecium and K. pneumoniae isolates, respectively. The E. faecium isolates were predominantly poor biofilm formers, the K. pneumoniae isolates were moderate biofilm formers, while the P. aeruginosa isolates were strong biofilm formers. All E. faecium and K. pneumoniae isolates were gamma (γ)-haemolytic, non-gelatinase producing (E. faecium only), and non-hypermucoviscous (K. pneumoniae only), while the P. aeruginosa isolates exhibited beta (β)-haemolysis and produced gelatinase. The fimH (type 1 fimbriae adhesion) and ugE (uridine diphosphate galacturonate 4-epimerase synthesis) virulence genes were detected in the K. pneumoniae isolates, while the P. aeruginosa isolates possessed the phzM (phenazine production) and algD (alginate biosynthesis) genes. Similarities in antibiotic resistance and virulence profiles of environmental and clinical E. faecium, K. pneumoniae, and P. aeruginosa, thus highlights the potential health risks posed by using environmental water sources for daily water needs in low-and-middle-income countries.
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Affiliation(s)
- Julia Denissen
- Department of Microbiology, Faculty of Science, Stellenbosch University, Private Bag X1, Stellenbosch, 7602, South Africa
| | - Benjamin Havenga
- Department of Microbiology, Faculty of Science, Stellenbosch University, Private Bag X1, Stellenbosch, 7602, South Africa
| | - Brandon Reyneke
- Faculty of Health Sciences, University of Johannesburg, PO Box 17011, Doornfontein, 2028, South Africa
| | - Sehaam Khan
- Faculty of Health Sciences, University of Johannesburg, PO Box 17011, Doornfontein, 2028, South Africa
| | - Wesaal Khan
- Department of Microbiology, Faculty of Science, Stellenbosch University, Private Bag X1, Stellenbosch, 7602, South Africa
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Kamel NA, Tohamy ST, Alshahrani MY, Aboshanab KM. Evaluation of fortimicin antibiotic combinations against MDR Pseudomonas aeruginosa and resistome analysis of a whole genome sequenced pan-drug resistant isolate. BMC Microbiol 2024; 24:164. [PMID: 38745145 PMCID: PMC11092080 DOI: 10.1186/s12866-024-03316-2] [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] [Received: 12/18/2023] [Accepted: 04/29/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Multidrug-resistant (MDR) P. aeruginosa is a rising public health concern, challenging the treatment of such a ubiquitous pathogen with monotherapeutic anti-pseudomonal agents. Worryingly, its genome plasticity contributes to the emergence of P. aeruginosa expressing different resistant phenotypes and is now responsible for notable epidemics within hospital settings. Considering this, we aimed to evaluate the synergistic combination of fortimicin with other traditional anti-pseudomonal agents and to analyze the resistome of pan-drug resistant (PDR) isolate. METHODS Standard methods were used for analyzing the antimicrobial susceptibility tests. The checkerboard technique was used for the in vitro assessment of fortimicin antibiotic combinations against 51 MDR P. aeruginosa and whole genome sequencing was used to determine the resistome of PDR isolate. RESULTS Out of 51 MDR P. aeruginosa, the highest synergistic effect was recorded for a combination of fortimicin with β-lactam group as meropenem, ceftazidime, and aztreonam at 71%, 59% and 43%, respectively. Of note, 56.8%, 39.2%, and 37.2% of the tested MDR isolates that had synergistic effects were also resistant to meropenem, ceftazidime, and aztreonam, respectively. The highest additive effects were recorded for combining fortimicin with amikacin (69%) and cefepime (44%) against MDR P. aeruginosa. Resistome analysis of the PDR isolate reflected its association with the antibiotic resistance phenotype. It ensured the presence of a wide variety of antibiotic-resistant genes (β-lactamases, aminoglycosides modifying enzymes, and efflux pump), rendering the isolate resistant to all clinically relevant anti-pseudomonal agents. CONCLUSION Fortimicin in combination with classical anti-pseudomonal agents had shown promising synergistic activity against MDR P. aeruginosa. Resistome profiling of PDR P. aeruginosa enhanced the rapid identification of antibiotic resistance genes that are likely linked to the appearance of this resistant phenotype and may pave the way to tackle antimicrobial resistance issues shortly.
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Affiliation(s)
- Noha A Kamel
- Department of Microbiology, Faculty of Pharmacy, Misr International University (MIU), Cairo, 19648, Egypt
| | - Sally T Tohamy
- Department of Microbiology & Immunology, Faculty of Pharmacy-girls, Al-Azhar University, Cairo, 11651, Egypt
| | - Mohammad Y Alshahrani
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Khalid University, P.O. Box 61413, Abha, 9088, Saudi Arabia
| | - Khaled M Aboshanab
- Microbiology and Immunology Department, Faculty of Pharmacy, Ain Shams University, African Union Organization Street, Abbassia, Cairo, 11566, Egypt.
- Department Pharmaceutical Life Sciences, Faculty of Pharmacy, University Technology MARA (UiTM), Campus Puncak Alam, Bandar Puncak Alam, Selangor, 42300, Malaysia.
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Elfadadny A, Ragab RF, AlHarbi M, Badshah F, Ibáñez-Arancibia E, Farag A, Hendawy AO, De los Ríos-Escalante PR, Aboubakr M, Zakai SA, Nageeb WM. Antimicrobial resistance of Pseudomonas aeruginosa: navigating clinical impacts, current resistance trends, and innovations in breaking therapies. Front Microbiol 2024; 15:1374466. [PMID: 38646632 PMCID: PMC11026690 DOI: 10.3389/fmicb.2024.1374466] [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: 01/23/2024] [Accepted: 03/05/2024] [Indexed: 04/23/2024] Open
Abstract
Pseudomonas aeruginosa, a Gram-negative bacterium, is recognized for its adaptability and opportunistic nature. It poses a substantial challenge in clinical settings due to its complicated antibiotic resistance mechanisms, biofilm formation, and capacity for persistent infections in both animal and human hosts. Recent studies revealed a potential zoonotic transmission of P. aeruginosa between animals, the environment, and human populations which highlights awareness of this microbe. Implementation of the One Health approach, which underscores the connection between human, animal, and environmental health, we aim to offer a comprehensive perspective on the current landscape of P. aeruginosa management. This review presents innovative strategies designed to counteract P. aeruginosa infections. Traditional antibiotics, while effective in many cases, are increasingly compromised by the development of multidrug-resistant strains. Non-antibiotic avenues, such as quorum sensing inhibition, phage therapy, and nanoparticle-based treatments, are emerging as promising alternatives. However, their clinical application encounters obstacles like cost, side effects, and safety concerns. Effectively addressing P. aeruginosa infections necessitates persistent research efforts, advancements in clinical development, and a comprehension of host-pathogen interactions to deal with this resilient pathogen.
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Affiliation(s)
- Ahmed Elfadadny
- Laboratory of Internal Medicine, Cooperative Division of Veterinary Sciences, Tokyo University of Agriculture and Technology, Fuchu, Japan
- Department of Internal Medicine, Faculty of Veterinary Medicine, Damanhour University, Damanhour, Egypt
| | - Rokaia F. Ragab
- Laboratory of Internal Medicine, Cooperative Division of Veterinary Sciences, Tokyo University of Agriculture and Technology, Fuchu, Japan
- Department of Biochemistry, Faculty of Veterinary Medicine, Damanhour University, Damanhour, Egypt
| | - Maha AlHarbi
- Department of Biology, College of Science, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Farhad Badshah
- State Key Laboratory of Animal Biotech Breeding, Institute of Animal Science, Chinese Academy of Agricultural Science, Beijing, China
| | - Eliana Ibáñez-Arancibia
- PhD Program in Sciences Mentioning Applied Molecular and Cell Biology, La Frontera University, Temuco, Chile
- Laboratory of Engineering, Biotechnology and Applied Biochemistry – LIBBA, Department of Chemical Engineering, Faculty of Engineering and Science, La Frontera University, Temuco, Chile
- Department of Biological and Chemical Sciences, Faculty of Natural Resources, Catholic University of Temuco, Temuco, Chile
| | - Ahmed Farag
- Department of Surgery, Anesthesiology, and Radiology, Faculty of Veterinary Medicine, Zagazig University, Zagazig, Egypt
| | - Amin Omar Hendawy
- Department of Animal and Poultry Production, Faculty of Agriculture, Damanhour University, Damanhour, Egypt
| | - Patricio R. De los Ríos-Escalante
- Department of Biological and Chemical Sciences, Faculty of Natural Resources, Catholic University of Temuco, Temuco, Chile
- Nucleus of Environmental Sciences, Faculty of Natural Resources, Catholic University of Temuco, Temuco, Chile
| | - Mohamed Aboubakr
- Department of Pharmacology, Faculty of Veterinary Medicine, Benha University, Moshtohor, Toukh, Qaliobiya, Egypt
| | - Shadi A. Zakai
- Department of Clinical Microbiology and Immunology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Wedad M. Nageeb
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
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Shbaita S, Abatli S, Sweileh MW, Aiesh BM, Sabateen A, Salameh HT, AbuTaha A, Zyoud SH. Antibiotic resistance profiles and associated factors of Pseudomonas Infections among patients admitted to large tertiary care hospital from a developing country. Antimicrob Resist Infect Control 2023; 12:149. [PMID: 38124074 PMCID: PMC10734127 DOI: 10.1186/s13756-023-01355-4] [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] [Received: 09/12/2023] [Accepted: 12/11/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Pseudomonas infections are among the most common infections encountered in hospitalized patients, especially those with chronic illnesses or an immunocompromised state. Management of these infections has become challenging due to increased antibiotic resistance. Therefore, this study examines the antibiotic resistance profiles of Pseudomonas spp. and the associated factors among patients admitted to a large tertiary hospital in a developing country. METHODS This retrospective observational chart review study assessed patients admitted to a large tertiary hospital in a developing country with a positive culture growth of Pseudomonas from anybody site. Antibiotic susceptibility of the isolated Pseudomonas and patient characteristics were studied from the start of 2021 to the end of 2022. The study ground consisted of 185 patients. RESULTS The study included 185 patients with positive Pseudomonas isolates. Males constituted 54.6% of the sample, while 45.4% were females. The median age of the patients was 53 years. Patient comorbidities and risk factors for Pseudomonas infection and multidrug resistance were assessed. Antibiotic resistance to the Pseudomonas regimens showed the highest resistance to meropenem and ciprofloxacin (23.4%, similarly) among isolates of Pseudomonas aeruginosa. Multidrug resistance (MDR) was found in 108 (58.4%) isolates. The most commonly used antibiotic for treatment was piperacillin-tazobactam, accounting for 33.3% of cases, followed by aminoglycosides at 26.6%. CONCLUSIONS Pseudomonas aeruginosa isolates were resistant to meropenem and ciprofloxacin. Over half of the isolates were multidrug-resistant, which was worrying. Piperacillin-tazobactam and aminoglycosides were the most often utilized antibiotics, highlighting the significance of susceptibility testing. Implementing antimicrobial stewardship programs and infection control measures can help reduce drug resistance and improve outcomes in Pseudomonas infections.
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Affiliation(s)
- Sara Shbaita
- Department of Medicine, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839, Palestine
| | - Safaa Abatli
- Department of Medicine, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839, Palestine
| | - Mamoun W Sweileh
- Department of Internal Medicine, An-Najah National University Hospital, Nablus, 44839, Palestine
| | - Banan M Aiesh
- Infection Control Department, An-Najah National University Hospital, Nablus, 44839, Palestine.
| | - Ali Sabateen
- Infection Control Department, An-Najah National University Hospital, Nablus, 44839, Palestine
| | - Husam T Salameh
- Department of Medicine, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839, Palestine
- Department of Hematology and Oncology, An-Najah National University Hospital, Nablus, 44839, Palestine
| | - Adham AbuTaha
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, 44839, Palestine
- Department of Pathology, An-Najah National University Hospital, Nablus, 44839, Palestine
| | - Sa'ed H Zyoud
- Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839, Palestine
- Poison Control and Drug Information Center (PCDIC), College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839, Palestine
- Clinical Research Center, An-Najah National University Hospital, Nablus, 44839, Palestine
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Thomsen J, Menezes GA, Abdulrazzaq NM, Moubareck CA, Senok A, Everett DB. Evolving trends among Pseudomonas aeruginosa: a 12-year retrospective study from the United Arab Emirates. Front Public Health 2023; 11:1243973. [PMID: 38106909 PMCID: PMC10721971 DOI: 10.3389/fpubh.2023.1243973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 10/30/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction Pseudomonas is a group of ubiquitous non-fermenting Gram-negative bacteria (NFGNB). Of the several species associated with humans, Pseudomonas aeruginosa (PA) can acclimate to diverse environments. The global frequency of PA infections is rising and is complicated by this organism's high intrinsic and acquired resistance to several clinically relevant antibiotics. Data on the epidemiology, levels, and trends of antimicrobial resistance of PA in clinical settings in the MENA/GCC region is scarce. Methods A retrospective 12-year analysis of 56,618 non-duplicate diagnostic Pseudomonas spp. from the United Arab Emirates (UAE) was conducted. Data was generated at 317 surveillance sites by routine patient care during 2010-2021, collected by trained personnel and reported by participating surveillance sites to the UAE National antimicrobial resistance (AMR) Surveillance program. Data analysis was conducted with WHONET (https://whonet.org/). Results Among the total isolates (N = 56,618), the majority were PA (95.6%). Data on nationality revealed 44.1% were UAE nationals. Most isolates were from soft tissue (55.7%), followed by respiratory tract (26.7%). PA was more commonly found among inpatients than among outpatients, followed by ICUs. PA showed a horizontal trend for resistance to fluoroquinolones, 3rd- and 4th-generation cephalosporins, and decreasing trends of resistance for aminoglycosides and meropenem. The highest percentage of multidrug resistant (MDR) isolates was reported in 2011 at 35.6%. As an overall trend, the percentage of MDR, extensively drug-resistant (XDR), and possible pandrug-resistant (PDR) isolates generally declined over the study period. Carbapenem-resistant PA (CRPA) were associated with a higher mortality (RR: 2.7), increased admission to ICU (RR: 2.3), and increased length of stay (LOS) (12 excess inpatient days per case), as compared to carbapenem-susceptible PA (CSPA). Conclusion The resistance trends in Pseudomonas species in the UAE indicated a decline in AMR and in percentages of Pseudomonas isolates with MDR and XDR profiles. The sustained Pseudomonas spp. circulation particularly in the hospital settings highlights the importance of surveillance techniques, infection control strategies, and stewardship to limit the continued dissemination. This data also shows that CRPA are associated with higher mortality, increased ICU admission rates, and a longer hospitalization, thus higher costs due to increased number of in-hospital and ICU days.
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Affiliation(s)
- Jens Thomsen
- Department of Occupational and Environmental Health and Safety, Abu Dhabi Public Health Center, Abu Dhabi, United Arab Emirates
- Department of Pathology and Infectious Diseases, Khalifa University, Abu Dhabi, United Arab Emirates
| | - Godfred A. Menezes
- Department of Medical Microbiology and Immunology, RAK Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
| | - Najiba M. Abdulrazzaq
- Al Kuwait Hospital Dubai, Emirates Health Services Establishment, Dubai, United Arab Emirates
| | | | | | - Abiola Senok
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
- School of Dentistry, Cardiff University, Cardiff, United Kingdom
| | - Dean B. Everett
- Department of Pathology and Infectious Diseases, Khalifa University, Abu Dhabi, United Arab Emirates
- Biotechnology Research Center, Khalifa University, Abu Dhabi, United Arab Emirates
- Infection Research Unit, Khalifa University, Abu Dhabi, United Arab Emirates
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Thabit AK, Alabbasi AY, Alnezary FS, Almasoudi IA. An Overview of Antimicrobial Resistance in Saudi Arabia (2013-2023) and the Need for National Surveillance. Microorganisms 2023; 11:2086. [PMID: 37630646 PMCID: PMC10460018 DOI: 10.3390/microorganisms11082086] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/08/2023] [Accepted: 08/10/2023] [Indexed: 08/27/2023] Open
Abstract
Antimicrobial resistance (AMR) is a well-recognized global threat. The World Health Organization (WHO) issued a report ranking the critical types of bacterial resistance that need to be monitored. Several studies from individual institutions in Saudi Arabia have reported rates of antimicrobial resistance using automated methods. However, no national surveillance study has been conducted to date using gold standard methods for antimicrobial susceptibility testing. This review summarizes AMR rates for major bacterial pathogens in Saudi Arabia and provides a justification for the need for a national surveillance project. In Saudi Arabia, AMR rates for both Gram-positive and Gram-negative bacteria are on the rise. Surveillance studies help identify AMR trends and emergence of outbreaks. The WHO has started a program, the Global Antimicrobial Resistance Surveillance System (GLASS), encouraging its member states, including Saudi Arabia, to conduct antimicrobial surveillance studies to estimate AMR rates worldwide. Of the microbiological methods used to test antimicrobial susceptibility, only broth microdilution (BMD) is considered the "gold standard." As AMR studies in Saudi Arabia are sparse, mostly limited to single centers and were conducted using automated methods, a national AMR surveillance project is needed to evaluate the current status and to inform stewardship decisions.
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Affiliation(s)
- Abrar K. Thabit
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, 7027 Abdullah Al-Sulaiman Rd, Jeddah 22254-2265, Saudi Arabia
| | - Afaq Y. Alabbasi
- Eastern Health Cluster, Ministry of Health, Dammam 32253, Saudi Arabia
| | - Faris S. Alnezary
- Department of Clinical and Hospital Pharmacy, College of Pharmacy, Taibah University, Madinah 41477, Saudi Arabia
| | - Imtinan A. Almasoudi
- Clinical Pharmacy Department, King Saud Medical City, Ministry of Health, Riyadh 12746, Saudi Arabia
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