Antibiotic Susceptibility Profile of Clinical Isolate of Carbapenem-Resistant Pseudomonas aeruginosa
South Asian Journal of Research in Microbiology,
Page 14-23
DOI:
10.9734/sajrm/2022/v14i2267
Abstract
Background and Objectives: Carbapenem-resistant Pseudomonas aeruginosa, are among the top tier of the list of antibiotic-resistant priority pathogens that pose the greatest threat to human health. In recent years, the rate of carbapenem resistance in Pseudomonas aeruginosa has increased worldwide and has become of great concern since it significantly restricts the therapeutic options for patients. Therefore this study was undertaken to determine the antibiotic susceptibility profile of the clinical isolate of Carbapenem-resistant Pseudomonas aeruginosa.
Methodology: A total of five hundred (500) clinical samples were collected from patient’s attending Alex Ekwueme Federal University Teaching Hospital Abakaliki, Ebonyi State (AFEUTHA). The collected samples were analyzed for the presence of Pseudomonas aeruginosa using standard microbiological techniques for isolation and characterization of bacteria. Further strain confirmation was performed using VITEK 2 System. Phenotypic detection of Carbapenem-resistant Pseudomonas aeruginosa was performed using Modified Hodge testing. Antibiotic susceptibility was performed by employing Kirby-Bauer disk diffusion method and the results were interpreted using the Clinical Laboratory Standard Institute (CLSI) zone diameter breakpoints.
Results: The occurrence rate of Pseudomonas aeruginosa in clinical samples accounted for 119(23.8%) consisting of a high proportion from urine sample 81(27.4%) followed by wound swabs 13(25.5%), high vaginal swabs 17(20.7) while the least occurrence rate was observed against catheter tips 5(12.8%) and sputum 3(9.4%). Modified Hodge testing revealed 31(6.2%) carbapenem-resistant Pseudomonas aeruginosa comprising of high proportion of 24(8.1%) from urine samples followed by wound swab 5(9.8%) while Carbapenem-resistant Pseudomonas aeruginosa was absent in High Vaginal Swab recording 0(0.0%). Carbapenem-resistant Pseudomonas aeruginosa isolates were highly resistant to amoxicillin-clavulanic 100%, colistin 100%, tetracycline 100%, nitrofurantoin 70.8%, aztreonam 87.5% but were susceptible to nalixidic acid 50.0 %, ofloxacin 75.0%, and ciprofloxacin 100%.
Conclusion: As in-vitro susceptibility of carbapenem-resistant Pseudomonas aeruginosa isolates to ofloxacin and ciprofloxacin is known, their judicious utilization will accelerate a significant improvement in the patient's condition. As such, there is a substantial need for the evaluation of a wide spectrum and new therapies in different classes to counteract this imminent crisis of resistance among Carbapenem-resistant Pseudomonas aeruginosa.
Keywords:
- Carbapenem-resistant
- Pseudomonas aeruginosa
- susceptibility
How to Cite
Ogba, R. C., Akpu, P. O., Nwuzo, A. C., Peter, I. U., Nomeh, O. L., & Iroha, I. R. (2022). Antibiotic Susceptibility Profile of Clinical Isolate of Carbapenem-Resistant Pseudomonas aeruginosa. South Asian Journal of Research in Microbiology, 14(2), 14-23. https://doi.org/10.9734/sajrm/2022/v14i2267
References
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Yoon EJ, Jeong SH. Mobile carbapenemase genes in Pseudomonas aeruginosa. Front Microbiol. 2021;12:614-058
Qu J, Cai Z, Liu Y, Duan X, Han S, Liu J, Zhu Y, Jiang Z, Zhang Y, Zhuo C. Persistent bacterial coinfection of a COVID-19 patient caused by a genetically adapted Pseudomonas aeruginosa chronic colonizer. Front Cell Infect Microbiol. 2021;11:641920.
Loyola-Cruz MÁ, Durán-Manuel EM, Cruz-Cruz C, Marquez-Valdelamar LM, Bravata-Alcantara, JC, Cortés-Ortíz IA, Cureño-Díaz MA, Ibáñez-Cervantes G, Fernández-Sánchez V, Castro-Escarpulli G. ESKAPE bacteria characterization reveals the presence of Acinetobacter baumannii and Pseudomonas aeruginosa outbreaks in COVID-19/VAP patients. Am J Infect Cont. 2022;20:22-67.
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Zilberberg M, Shorr AF. Prevalence of multidrug-resistant Pseudomonas aeruginosa and carbapenem-resistant enterobacteriaceae among specimens from hospitalized patients with pneumonia and bloodstream infections in the united states from 2000 to 2009. J Hospital Med. 2013;8:559–563.
Moradali MF, Ghods S, Rehm BH. Pseudomonas aeruginosa lifestyle: A paradigm for adaptation, survival, and persistence. Front Cell Infect Microbiol. 2017;7:39-78.
Jean SS, Ko WC, Lu MC, Lee WS, Hsueh PR. Multicenter surveillance of In vitro activities of cefepime-zidebactam, cefepime-enmetazobactam, omadacycline, eravacycline, and comparator antibiotics against enterobacterales, pseudomonas aeruginosa, and acinetobacter baumannii complex causing bloodstream infection in Taiwan 2020. Exp Rev Anti Infect Ther. 2022;1:13-45.
El Solh AA, Alhajhusain A. Update on the treatment of Pseudomonas aeruginosa pneumonia. J Antimicrob Agent Chemother. 2009;64:229–238.
Willyard C. The drug resistant bacteria that pose the greatest health threats. Nature. 2017;543:15-78.
Sheu CC, Chang YT, Lin SY, Chen YH, Hsueh PR. Infections caused by carbapenem-resistant enterobacteriaceae: An update on therapeutic options. Frontier in Microbiol. 2019;10:80-89.
Verma N, Prahraj AK, Mishra B, Behera B, Gupta K. Detection of carbapenemase-producing pseudomonas aeruginosa by phenotypic and genotypic methods in a tertiary care hospital of East India. J Laboratory Physiol. 2019;11:287–291.
Rahman M, Prasad KN, Gupta S, Singh S, Singh A, Pathak A. Prevalence and molecular characterization of new delhi metallo-betalactamases in multidrug-resistant pseudomonas aeruginosa and acinetobacter baumannii from India. Microb Drug Resist. 2018;24:792–798.
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Edemekong CI, Iroha IR, Thompson MD, Okolo IO, Uzoeto HO, Ngwu JN, Mohammed ID, Chukwu EB, Nwuzo AC, Okike BM, Okolie SO, Peter IU. Phenotypic characterization and antibiogram of non-oral bacteria isolates from patients attending dental clinic at federal college of dental technology and therapy medical center enugu. Int J Pathog Res. 2022;11(2):7-19.
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Peter IU, Okolo IO, Uzoeto HO, Edemekong CI, Thompson MD, Chukwu EB, Mohammed ID, Ubom IJ, Joseph OV, Nwuzo AC, Akpu PO, Iroha IR (2022a). Identification and antibiotic resistance profile of biofilm-forming methicillin resistant Staphylococcus aureus (MRSA) Causing Infection among Orthopedic Wound Patients. Asian J Res Med Pharm Sci. 2022b; 11(4):45-55.
Olayinka AT, Onile BA, Olayinka BO. Prevalence of multi-drug resistant (MDR) Pseudomonas aeruginosa isolates in surgical units in Ahmadu Bello University Teaching Hospital, Zaria, Nigeria: An indication for effective control measures. Annals of Afri Med. 2004;3(1):13-16.
Okon KO, Agukwe PC, Oladosu W, Balogun ST, Uba A. Antibiotic resistance pattern of Pseudomonas aeruginosa isolated from clinical specimens in a tertiary care hospital in North-eastren Nigeria. Internet J Microbiol. 2010;2(9)8:1-6.
Rajat RM, Ninama GL, Mistry K, Parmar R, Patel K, Vegad MM. Antibiotic resistance pattern in Pseudomonas aeruginosa species isolated at a tertiary care Hospital, Ahmadabad. National J Med Res. 2012;2(11):156-9.
Javiya VA, Ghatak SB, Patel KR, Patel JA. Antibiotic susceptibility patterns of Pseudomonas aeruginosa at a tertiary care hospital in Gujarat, India. Indian J Pharmacol. 2008;40:230-4.
Sewunet T, Asrat D, Woldeamanuel Y, Aseffa A, Giske CG. Molecular epidemiology and antimicrobial susceptibility of Pseudomonas species and Acinetobacter species from clinical samples at jimma medical center, Ethiopia. Front Microbiol. 2022;13:5-9.
Schäfer E, Malecki M, Tellez-Castillo CJ, Pfennigwerth N, Marlinghaus L, Higgins PG, Mattner F, Wendel AF. Molecular surveillance of carbapenemase producing Pseudomonasaeruginosa at three medical centres in Cologne, Germany. Antimicrob Resist Infect Cont. 2019;8:208-209.
Aruhomukama D, Najjuka CF, Kajumbula H, Okee M, Mboowa G, Sserwadda I. BlaVIM- and blaOXA-mediated carbapenem resistance among Acinetobacter baumannii and Pseudomonas aeruginosa isolates from the mulago hospital intensive care unit in Kampala, Uganda. BMC Infect Dis. 2019;19:853.
Gill CM, Aktaþ E, Alfouzan W, Bourassa L, Brink A, Burnham CD, Canton R, Carmeli Y, Falcone M, Kiffer C, Marchese A, Martinez O, Pournaras S, Satlin M, Seifert H, Thabit AK, Thomson KS, Villegas MV, Nicolau DP. ERACE-PA global study group. The ERACE-PA global surveillance program: Ceftolozane/tazobactam and Ceftazidime/avibactam In vitro activity against a global collection of carbapenem-resistant Pseudomonas aeruginosa. European J Clin Microbiol Infect Dis. 2021; 40(12):2533–2541.
Tenover FC, Nicolau DP, Gill CM. Carbapenemase producing Pseudomonas aeruginosa –an emerging challenge. Emerg Microbes Infect. 2022;11:1811-814
Osei Sekyere J, Reta MA. Genomic and resistance epidemiology of gram-negative bacteria in africa: a systematic review and phylogenomic analyses from a one health perspective. mSystems. 2020;5: 897-20
Rizk SS, Elwakil WH, Attia AS. Antibiotic-resistant Acinetobacter baumannii in low-income countries (2000–2020): Twenty-one years and still below the radar, is it not there or can they not afford to look for it? Antibiotics. 2021;10:764-768.
Gaballah A, Elbaradei A, Elbaradei A. Emergence of blaVEB and blaGES among VIM-producing Pseudomonas aeruginosa clinical isolates in Alexandria, Egypt. Acta Microbiol Immunol. 2018;66:131– 142.
Kunz Coyne AJ, Amer E, Dana H, Nicholas R, Michael J R. Therapeutic strategies for emerging multidrug- resistant Pseudomonas aeruginosa. Infect Dis Ther. 2022;11:661–682.
Abdelrahman DN, Taha AA, Dafaallah MM. Extended Spectrum β-lactamases and class C β-lactamases gene frequency in Pseudomonas aeruginosa isolated from various clinical specimens in Khartoum State, Sudan: A cross sectional study. F1000Research. 2020;9:7-74.
Ahmad M, Hassan M, Khalid A. Prevalence of extended spectrum βlactamase and antimicrobial susceptibility pattern of clinical isolates of Pseudomonas from Patients of Khyber Pakhtunkhwa, Pakistan. Biomed Res Int. 2016;10(2):143–148.
Amadi ES, Uzoaru PN, Orji I, Nwaziri AA. Antibiotic resistance in clinical isolates of P. aeruginosa in Enugu and Abakalilki, Nigeria. Internet J Infect Dis. 2009;7(1):23-100.
Jombo GA, Jonah P, Ayeni JA. Multidrug resistant Pseudomonas aeruginosa in contemporary medical practice: Findings from urinary isolates at a nigerian university teaching hospital. Niger J Physiol Sci. 2008;23(1-2):105-109.
Li H, Luo YF, Williams BJ, Blackwell TS, Xie CM. Structure and function of OprD protein in Pseudomonas aeruginosa: From antibiotic resistance to novel therapies. Int J Med Microbiol. 2012;302(24):63–68.
Pungcharoenkijkul S, Traipattanakul J, Thunyaharn S, Santimaleeworagun W. Antimicrobials as single and combination therapy for colistin-resistant Pseudomonas aeruginosa at a university hospital in thailand. Antibiotics. 2020;9:475-489.
Miller MB, Bassler BL. Quorum sensing in bacteria. Annual Rev Microbiol. 2001; 55(2):165–199.
Moskowitz SM, Ernst RK, Miller SI. PmrAB, a two-component regulatory system of Pseudomonas aeruginosa that modulates resistance to cationic antimicrobial peptides and addition of aminoarabinose to lipid A. J Bacteriol. 2004;186(43)5:75–579.
Owusu-Anim D, Kwon DH. Differential role of two-component regulatory systems (phoPQ and pmrAB) in polymyxin B susceptibility of Pseudomonas aeruginosa. J Adv Microbiol. 2012;2(55)90-201.
Berrazeg M, Jeannot K, Ntsogo Enguene VY, Broutin I, Loeffert S. Mutations in beta-Lactamase AmpC increase resistance of Pseudomonas aeruginosa isolates to antipseudomonal cephalosporins. J Antimicrob Agents Chemother. 2015;59 (234):6248–6255.
Juan C, Macia MD, Gutierrez O, Vidal C, Perez JL, Oliver A. Molecular mechanisms of beta-lactam resistance mediated by AmpC hyperproduction in Pseudomonas aeruginosa clinical strains. J Antimicrob Agents Chemother. 2005;49(345):4733–4738.
Li XZ, Nikaido H. Efflux-mediated drug resistance in bacteria: an update. Drugs Resist Update. 2009; 69(55):1555–1623.
Ferguson D, Cahill OJ, Quilty B. Phenotypic, molecular and antibiotic resistance profiling of nosocomial Pseudomonas aeruginosa strains isolated from two Irish Hospitals. J Medicine. 2007;1(1):201-210.
Al-Khafaji J. Isolation of Pseudomonas aeruginosa from clinical cases and environmental samples, and analysis of its antibiotic resistant spectrum at hilla teaching hospital. Med J Babylon. 2011;12:82-11.
Abd El-Baky RM, Masoud SM, Mohamed DS, Waly NGFM, Shafik EA, Mohareb DA, Elkady A, Elbadr MM, Hetta HF. Prevalence and some possible mechanisms of colistin resistance among multidrug-resistant and extensively drug-resistant Pseudomonas aeruginosa. J Infect Drug Resist. 2020;13:323-333.
Tamma PD, Aitken SL, Bonomo RA, Mathers AJ, van Duin D, Clancy CJ. Infectious diseases society of america guidance on the treatment of extendedspectrum b-lactamase producing enterobacterales (ESBL-E), carbapenem-resistant enterobacterales (CRE), and Pseudomonas aeruginosa with difficult-totreat resistance (DTR-P. aeruginosa). Clin Infect Dis J. 2021;72(7): 169–83.
Kadri SS, Adjemian J, Lai YL. Difficult- to-treat resistance in Gram- negative bacteremia at 173 US hospitals: Retrospective cohort analysis of prevalence, predictors, and outcome of resistance to all first-line agents. Clin Infect Dis J. 2018;67(12):1803–14.
Yoon EJ, Jeong SH. Mobile carbapenemase genes in Pseudomonas aeruginosa. Front Microbiol. 2021;12:614-058
Qu J, Cai Z, Liu Y, Duan X, Han S, Liu J, Zhu Y, Jiang Z, Zhang Y, Zhuo C. Persistent bacterial coinfection of a COVID-19 patient caused by a genetically adapted Pseudomonas aeruginosa chronic colonizer. Front Cell Infect Microbiol. 2021;11:641920.
Loyola-Cruz MÁ, Durán-Manuel EM, Cruz-Cruz C, Marquez-Valdelamar LM, Bravata-Alcantara, JC, Cortés-Ortíz IA, Cureño-Díaz MA, Ibáñez-Cervantes G, Fernández-Sánchez V, Castro-Escarpulli G. ESKAPE bacteria characterization reveals the presence of Acinetobacter baumannii and Pseudomonas aeruginosa outbreaks in COVID-19/VAP patients. Am J Infect Cont. 2022;20:22-67.
European centre for disease prevention and control (ECDC). European Antimicrobial Resistance Surveillance Network; 2019
Accessed on 18 November 2020.
Available:https://www.ecdc.europa.eu/en/publications-data/surveillance-antimicrobial-resistance europe-2019
Herrera-Espejo S, Del Barrio-Tofiño E, Cebrero-Cangueiro T, López-Causapé C, Álvarez-Marín R, Cisneros JM, Pachón J, Oliver A, Pachón-Ibáñez ME. Carbapenem combinations for infections caused by carbapenemase-producing Pseudomonas aeruginosa: Experimental in vitro and in vivo analysis. Antibiotics. 2022;11:12-12.
Zilberberg M, Shorr AF. Prevalence of multidrug-resistant Pseudomonas aeruginosa and carbapenem-resistant enterobacteriaceae among specimens from hospitalized patients with pneumonia and bloodstream infections in the united states from 2000 to 2009. J Hospital Med. 2013;8:559–563.
Moradali MF, Ghods S, Rehm BH. Pseudomonas aeruginosa lifestyle: A paradigm for adaptation, survival, and persistence. Front Cell Infect Microbiol. 2017;7:39-78.
Jean SS, Ko WC, Lu MC, Lee WS, Hsueh PR. Multicenter surveillance of In vitro activities of cefepime-zidebactam, cefepime-enmetazobactam, omadacycline, eravacycline, and comparator antibiotics against enterobacterales, pseudomonas aeruginosa, and acinetobacter baumannii complex causing bloodstream infection in Taiwan 2020. Exp Rev Anti Infect Ther. 2022;1:13-45.
El Solh AA, Alhajhusain A. Update on the treatment of Pseudomonas aeruginosa pneumonia. J Antimicrob Agent Chemother. 2009;64:229–238.
Willyard C. The drug resistant bacteria that pose the greatest health threats. Nature. 2017;543:15-78.
Sheu CC, Chang YT, Lin SY, Chen YH, Hsueh PR. Infections caused by carbapenem-resistant enterobacteriaceae: An update on therapeutic options. Frontier in Microbiol. 2019;10:80-89.
Verma N, Prahraj AK, Mishra B, Behera B, Gupta K. Detection of carbapenemase-producing pseudomonas aeruginosa by phenotypic and genotypic methods in a tertiary care hospital of East India. J Laboratory Physiol. 2019;11:287–291.
Rahman M, Prasad KN, Gupta S, Singh S, Singh A, Pathak A. Prevalence and molecular characterization of new delhi metallo-betalactamases in multidrug-resistant pseudomonas aeruginosa and acinetobacter baumannii from India. Microb Drug Resist. 2018;24:792–798.
Iroha IR, Orji JO, Onwa NC, Nwuzo AC, Okonkwo EC, Ibiam EO, Nwachi AC, Afuikwa FN, Agah VM, Ejikeugwu EPC, Agumah NB, Moses IB, Ugbo E, Ukpai EG, Nwakaeze E A, Oke B, Ogbu L, Nwunna E. Microbiology practical handbook. (Editor; Ogbu. O), 1st Edition. Charlieteximage Africa (CiAfrica Press). 2019;344.
Edemekong CI, Iroha IR, Thompson MD, Okolo IO, Uzoeto HO, Ngwu JN, Mohammed ID, Chukwu EB, Nwuzo AC, Okike BM, Okolie SO, Peter IU. Phenotypic characterization and antibiogram of non-oral bacteria isolates from patients attending dental clinic at federal college of dental technology and therapy medical center enugu. Int J Pathog Res. 2022;11(2):7-19.
Clinical and laboratory standards institute (CLSI). Performance standards for antimicrobial susceptibility testing; twenty-eighth edition (M100). Wayne, PA: Clinical and Laboratory Standards Institute; 2019.
Peter IU, Ngwu JN, Edemekong CI, Ugwueke IV, Uzoeto HO, Joseph OV, Mohammed ID, Mbong EO, Nomeh OL, Ikusika BA, Ubom IJ, Inyogu JC, Ntekpe ME, Obodoechi IF, NseAbasi PL, Ogbonna IP, Didiugwu CM, Akpu PO, Alagba EE, Ogba RC, Iroha IR. first report prevalence of livestock acquired methicillin resistant Staphylococcus aureus (LA-MRSA) Strain in South Eastern, Nigeria . IOSR J Nurs Health Sci. 2022a;11(1):50-56.
Peter IU, Okolo IO, Uzoeto HO, Edemekong CI, Thompson MD, Chukwu EB, Mohammed ID, Ubom IJ, Joseph OV, Nwuzo AC, Akpu PO, Iroha IR (2022a). Identification and antibiotic resistance profile of biofilm-forming methicillin resistant Staphylococcus aureus (MRSA) Causing Infection among Orthopedic Wound Patients. Asian J Res Med Pharm Sci. 2022b; 11(4):45-55.
Olayinka AT, Onile BA, Olayinka BO. Prevalence of multi-drug resistant (MDR) Pseudomonas aeruginosa isolates in surgical units in Ahmadu Bello University Teaching Hospital, Zaria, Nigeria: An indication for effective control measures. Annals of Afri Med. 2004;3(1):13-16.
Okon KO, Agukwe PC, Oladosu W, Balogun ST, Uba A. Antibiotic resistance pattern of Pseudomonas aeruginosa isolated from clinical specimens in a tertiary care hospital in North-eastren Nigeria. Internet J Microbiol. 2010;2(9)8:1-6.
Rajat RM, Ninama GL, Mistry K, Parmar R, Patel K, Vegad MM. Antibiotic resistance pattern in Pseudomonas aeruginosa species isolated at a tertiary care Hospital, Ahmadabad. National J Med Res. 2012;2(11):156-9.
Javiya VA, Ghatak SB, Patel KR, Patel JA. Antibiotic susceptibility patterns of Pseudomonas aeruginosa at a tertiary care hospital in Gujarat, India. Indian J Pharmacol. 2008;40:230-4.
Sewunet T, Asrat D, Woldeamanuel Y, Aseffa A, Giske CG. Molecular epidemiology and antimicrobial susceptibility of Pseudomonas species and Acinetobacter species from clinical samples at jimma medical center, Ethiopia. Front Microbiol. 2022;13:5-9.
Schäfer E, Malecki M, Tellez-Castillo CJ, Pfennigwerth N, Marlinghaus L, Higgins PG, Mattner F, Wendel AF. Molecular surveillance of carbapenemase producing Pseudomonasaeruginosa at three medical centres in Cologne, Germany. Antimicrob Resist Infect Cont. 2019;8:208-209.
Aruhomukama D, Najjuka CF, Kajumbula H, Okee M, Mboowa G, Sserwadda I. BlaVIM- and blaOXA-mediated carbapenem resistance among Acinetobacter baumannii and Pseudomonas aeruginosa isolates from the mulago hospital intensive care unit in Kampala, Uganda. BMC Infect Dis. 2019;19:853.
Gill CM, Aktaþ E, Alfouzan W, Bourassa L, Brink A, Burnham CD, Canton R, Carmeli Y, Falcone M, Kiffer C, Marchese A, Martinez O, Pournaras S, Satlin M, Seifert H, Thabit AK, Thomson KS, Villegas MV, Nicolau DP. ERACE-PA global study group. The ERACE-PA global surveillance program: Ceftolozane/tazobactam and Ceftazidime/avibactam In vitro activity against a global collection of carbapenem-resistant Pseudomonas aeruginosa. European J Clin Microbiol Infect Dis. 2021; 40(12):2533–2541.
Tenover FC, Nicolau DP, Gill CM. Carbapenemase producing Pseudomonas aeruginosa –an emerging challenge. Emerg Microbes Infect. 2022;11:1811-814
Osei Sekyere J, Reta MA. Genomic and resistance epidemiology of gram-negative bacteria in africa: a systematic review and phylogenomic analyses from a one health perspective. mSystems. 2020;5: 897-20
Rizk SS, Elwakil WH, Attia AS. Antibiotic-resistant Acinetobacter baumannii in low-income countries (2000–2020): Twenty-one years and still below the radar, is it not there or can they not afford to look for it? Antibiotics. 2021;10:764-768.
Gaballah A, Elbaradei A, Elbaradei A. Emergence of blaVEB and blaGES among VIM-producing Pseudomonas aeruginosa clinical isolates in Alexandria, Egypt. Acta Microbiol Immunol. 2018;66:131– 142.
Kunz Coyne AJ, Amer E, Dana H, Nicholas R, Michael J R. Therapeutic strategies for emerging multidrug- resistant Pseudomonas aeruginosa. Infect Dis Ther. 2022;11:661–682.
Abdelrahman DN, Taha AA, Dafaallah MM. Extended Spectrum β-lactamases and class C β-lactamases gene frequency in Pseudomonas aeruginosa isolated from various clinical specimens in Khartoum State, Sudan: A cross sectional study. F1000Research. 2020;9:7-74.
Ahmad M, Hassan M, Khalid A. Prevalence of extended spectrum βlactamase and antimicrobial susceptibility pattern of clinical isolates of Pseudomonas from Patients of Khyber Pakhtunkhwa, Pakistan. Biomed Res Int. 2016;10(2):143–148.
Amadi ES, Uzoaru PN, Orji I, Nwaziri AA. Antibiotic resistance in clinical isolates of P. aeruginosa in Enugu and Abakalilki, Nigeria. Internet J Infect Dis. 2009;7(1):23-100.
Jombo GA, Jonah P, Ayeni JA. Multidrug resistant Pseudomonas aeruginosa in contemporary medical practice: Findings from urinary isolates at a nigerian university teaching hospital. Niger J Physiol Sci. 2008;23(1-2):105-109.
Li H, Luo YF, Williams BJ, Blackwell TS, Xie CM. Structure and function of OprD protein in Pseudomonas aeruginosa: From antibiotic resistance to novel therapies. Int J Med Microbiol. 2012;302(24):63–68.
Pungcharoenkijkul S, Traipattanakul J, Thunyaharn S, Santimaleeworagun W. Antimicrobials as single and combination therapy for colistin-resistant Pseudomonas aeruginosa at a university hospital in thailand. Antibiotics. 2020;9:475-489.
Miller MB, Bassler BL. Quorum sensing in bacteria. Annual Rev Microbiol. 2001; 55(2):165–199.
Moskowitz SM, Ernst RK, Miller SI. PmrAB, a two-component regulatory system of Pseudomonas aeruginosa that modulates resistance to cationic antimicrobial peptides and addition of aminoarabinose to lipid A. J Bacteriol. 2004;186(43)5:75–579.
Owusu-Anim D, Kwon DH. Differential role of two-component regulatory systems (phoPQ and pmrAB) in polymyxin B susceptibility of Pseudomonas aeruginosa. J Adv Microbiol. 2012;2(55)90-201.
Berrazeg M, Jeannot K, Ntsogo Enguene VY, Broutin I, Loeffert S. Mutations in beta-Lactamase AmpC increase resistance of Pseudomonas aeruginosa isolates to antipseudomonal cephalosporins. J Antimicrob Agents Chemother. 2015;59 (234):6248–6255.
Juan C, Macia MD, Gutierrez O, Vidal C, Perez JL, Oliver A. Molecular mechanisms of beta-lactam resistance mediated by AmpC hyperproduction in Pseudomonas aeruginosa clinical strains. J Antimicrob Agents Chemother. 2005;49(345):4733–4738.
Li XZ, Nikaido H. Efflux-mediated drug resistance in bacteria: an update. Drugs Resist Update. 2009; 69(55):1555–1623.
Ferguson D, Cahill OJ, Quilty B. Phenotypic, molecular and antibiotic resistance profiling of nosocomial Pseudomonas aeruginosa strains isolated from two Irish Hospitals. J Medicine. 2007;1(1):201-210.
Al-Khafaji J. Isolation of Pseudomonas aeruginosa from clinical cases and environmental samples, and analysis of its antibiotic resistant spectrum at hilla teaching hospital. Med J Babylon. 2011;12:82-11.
Abd El-Baky RM, Masoud SM, Mohamed DS, Waly NGFM, Shafik EA, Mohareb DA, Elkady A, Elbadr MM, Hetta HF. Prevalence and some possible mechanisms of colistin resistance among multidrug-resistant and extensively drug-resistant Pseudomonas aeruginosa. J Infect Drug Resist. 2020;13:323-333.
Tamma PD, Aitken SL, Bonomo RA, Mathers AJ, van Duin D, Clancy CJ. Infectious diseases society of america guidance on the treatment of extendedspectrum b-lactamase producing enterobacterales (ESBL-E), carbapenem-resistant enterobacterales (CRE), and Pseudomonas aeruginosa with difficult-totreat resistance (DTR-P. aeruginosa). Clin Infect Dis J. 2021;72(7): 169–83.
Kadri SS, Adjemian J, Lai YL. Difficult- to-treat resistance in Gram- negative bacteremia at 173 US hospitals: Retrospective cohort analysis of prevalence, predictors, and outcome of resistance to all first-line agents. Clin Infect Dis J. 2018;67(12):1803–14.
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