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Fecal carriage of extended-spectrum β-lactamase- and carbapenemase-producing Enterobacteriaceae in Egyptian patients with community-onset gastrointestinal complaints: a hospital -based cross-sectional study
Antimicrobial Resistance & Infection Controlvolume 6, Article number: 62 (2017)
The aim of this study was to determine the prevalence of extended-spectrum β-lactamase (ESBL) and carbapenemase production among Enterobacteriaceae isolated from ambulatory patients with gastrointestinal complaints admitted to El-Ahrar General Hospital, Zagazig, Egypt in the period between January 2013 and May 2013.
One hundred and thirteen Enterobacteriaceae isolates were recovered from 100 consecutive Egyptian patients with community–onset gastrointestinal complaints. The fecal samples were plated directly on selective EbSA-ESBL Screening Agar and on MacConkey agar. Isolate identification was performed with matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF-MS). Screening for ESBLs and carbapenemases production was done by both the automated VITEK®2 system with AST N198 and by disk diffusion method. Real-time PCR and sequencing were used to characterize the resistance genes. Phylogroups of the E. coli isolates were determined by a triplex PCR-based method.
Of 100 patients screened for fecal colonization with extended-spectrum β-lactamase -producing Enterobacteriaceae (ESBL-E) and carbapenemase- producing Enterobacteriaceae (CPE), 68 were colonized with ESBL-E whereas five patients were positive for CPE. One hundred and thirteen Enterobacterceae isolates were recovered from 100 fecal samples, they belonged to E. coli (n = 72), Klebsiella pneumoniae (n = 23), Enterobacter cloacae(n = 3), Salmonella spp. (n = 1) and other Enterobacterceae isolates (n = 14). The bla CTX-M gene was detected in 89.04% (65/73) of the ESBL-producing Enterobacteriaceae, whereas bla SHV and bla TEM were detected in 30.14% (22/73) and 19.18% (14/73) respectively. Three out of 5 carbapenem-resistant isolates harbored New Delhi metallo-beta-lactamase (NDM) and 2 produced Verona integron-encoded metallo- beta -lactamase (VIM). Twenty-two (47.83%) of the ESBL positive isolates were multidrug resistant (MDR). Phylogenetic analysis showed that, of the 51 ESBL-EC isolates, 17 belonged to group B2, 13 to group D, 11 to group A and 10 to group B1.
Nearly two-thirds of the Enterobacteriaceae isolates recovered from feces of ambulatory patients with community–onset gastrointestinal complaints admitted to El-Ahrar General Hospital, Zagazig, Egypt were ESBL producers and one in every 20 patients included in our study was colonized by carbapenemase-producing Enterobacteriaceae. These high colonization rates are worrying, therefore prudent antimicrobial use should be adopted in Egyptian community settings.
Infections due to extended-spectrum beta-lactamase–and carbapenemase-producing Enterobacteriaceae represent a major global health threat  since such bacteria are usually resistant to multiple antimicrobial agents and carbapenems are expensive and not always available, especially in less wealthy countries. Infections with these resistant strains are associated with treatment failure, high mortality, and increased healthcare costs [2,3,4].
ESBL-producing Enterobacteriaceae (ESBL-E) and carbapenemase-producing Enterobacteriaceae (CPE) are incriminated in both nosocomial and community-acquired infection [5, 6]. The fecal carriage rate of ESBL-E has mainly been investigated during nosocomial outbreaks, whilst few studies were conducted in community settings [5, 7]. High community carriage rates were reported in Thailand (69.3%) and China (50.5%) [8, 9]. Lower rates were demonstrated in most European countries (not more than 12%) and North America (less than 2%) [10,11,12,13]. In Egypt, data on the prevalence of ESBL-E in the community remain scarce. A study performed in Cairo (urban population) reported high fecal carriage rate (63.3%) of ESBL-E among healthy individuals . To the best of our knowledge, no previous research has been carried out to determine the fecal carriage rate of CPE in the community. In this study, we aimed to assess the prevalence of ESBL-E and CPE among ambulatory patients with community–onset gastrointestinal complaints admitted to El-Ahrar General Hospital, Zagazig (semi-urban population, 65 km from Cairo), Egypt.
This study was performed in the period between January 2013 and May 2013, at El-Ahrar General Hospital, Zagazig, Egypt, a 608-bed hospital affiliated to the Egyptian health ministry. Approximately 1.5 g of feces was collected aseptically from 100 consecutive patients admitted to the hospital with community–onset gastrointestinal complaints (one sample per patient). Fecal samples were obtained for routine diagnosis of the gastrointestinal complaints and in addition to routine testing for gastrointestinal pathogens. The patients had no past history of travel to the Indian subcontinent or to South-Eastern Asia, nor relatives that had recently traveled to those regions. Fecal samples were suspended in 5 mL of saline (0.9%) and 100 ul of each sample was plated directly on selective EbSA-ESBL Screening Agar  for the isolation of bacteria resistant to broad-spectrum cephalosporins and on MacConkey agar for the characterization of the dominant isolates. At least one and up to five colonies per agar plate were investigated. Bacteria were identified by the automated Vitek® MS system (BioMérieux, Marcy l’Étoile, France).
Phenotypic screening and confirmation of ESBL-E and CPE
Antibiotic susceptibility testing was performed by both the automated VITEK®2 system with AST card N198 (BioMérieux, Marcy l’Étoile, France) and by disk diffusion on Mueller-Hinton agar using ceftazidime (30 μg), cefotaxime (30 μg), meropenem (10 μg), and imipenem (10 μg) disks. The AST card antimicrobial agents panel were ampicillin, amoxicillin-clavulanic acid, piperacillin, piperacillin-tazobactam, cefuroxime, cefoxitin, cefepime, ceftazidime, cefotaxime, meropenem, imipenem, ciprofloxacin, norfloxacin, gentamicin, tobramycin, nitrofurantoin, and trimethoprim-sulfamethoxazole. The results of antibiotic susceptibility tests were interpreted according to the clinical breakpoints recommended by Clinical and Laboratory Standards Institute (CLSI) and the Dutch Society of Medical Microbiology [16, 17]. ESBL production was confirmed with the ESBL combination disks (Rosco, Taastrup, Denmark) according to the guidelines of the Dutch Society of Medical Microbiology .
Carbapenemases production was confirmed by carbapenemases double disk synergy test . Enhancement of the inhibition zone in the area between the inhibitor-containing disk (boronic acid and/or dipicolinic acid) and any one of the two carbapenems discs used (meropenem and /or imipenem) was regarded as a positive result [17, 19].
Characterization of β-lactamase-encoding genes
ESBL phenotypes were analyzed for the presence of genes encoding bla TEM, bla SHV and bla CTX-M by real-time PCR using primers described before [20,21,22]. Carbapenem-resistant isolates were tested for the presence of genes encoding bla KPC, bla NDM, bla OXA-48, bla IMP, and bla VIM by multiplex PCRs as previously described . DNA extraction was done by a boiling lysis method as described . The PCR Amplification conditions were described elsewhere [25, 26].
DNA sequencing analysis
The Purified PCR products of ESBL producers were sequenced with the Sanger ABI 3730 XL automated DNA sequencer by a commercial company (BaseClear, Leiden, The Netherlands). Nucleotide sequences were aligned by the Codon Code Aligner software (Version 5.0.2) and compared to sequences available at the National Center for Biotechnology Information website ( www.ncbi.nlm.nih.gov ).
E. coli isolates were segregated into phylogroups (A, B1, B2 or D) by a triplex PCR targeting chuA, yjaA and the TspE4.C2 DNA fragment, as developed by Clermont et al. .
All statistical analyses were performed according to Newcombe, Robert G .
Sixty-eight out of 100 feces samples yielded ESBL-E while CPE was identified in 5% of theses samples. Some samples demonstrated the growth of more than one species of Enterobacteriaceae, resulting in 113 isolates available for analysis. ESBLs were identified in 64.61% (73/113) (with 95% confidence interval (CI): 55.44–72.80) of the isolates and five (4.42%) (95% CI: 1.9–9.94) isolates showed carbapenemase activity. The prevalence of different ESBL types among the different Enterobacteriaceae species is shown in Table 1. It was highest in Klebsiella pneumoniae. Because only one Salmonella strain isolated, which produced CTX-M, we could not estimate the prevalence of ESBL-production in this species. All five carbapenem-resistant Enterobacteriaceae isolates were K. pneumoniae.CTX-M enzymes were detected in 89.04% (65/73) of the ESBL-producing Enterobacteriaceae, whereas SHV and TEM were detected in 30.14% (22/73) and 19.18% (14/73) respectively. The simultaneous presence of CTX-M, SHV, and TEM was identified in 9 isolates, 12 isolates coproduced CTX-M and SHV, 4 harbored CTX-M and TEM genes, one expressed SHV and TEM genes and 40 produced CTX-M genes only. Seven E.coli isolate expressed ESBL phenotype but no TEM, SHV or CTX-M were detected by PCR.
A summary of the distribution of different ß-lactamase-encoding genes among different Enterobacteriaceae is shown in Table 1.
Three out of 5 carbapenem-resistant K. pneumoniae harbored blaNDM and 2 produced blaVIM. No isolate expressed a combination of carbapenemase resistance genes.Of the 65 CTX-M – producing Enterobacteriaceae isolates, 52 (80%) produced CTX-M-15, five (7.7%) produced CTX-M-3, four (6.2%) produced CTX-M-14, one produced CTX-M-27, one produced CTX-M-32, and two, which belonged to CTX-M group 9, remained unidentified.
Antimicrobial susceptibility testing revealed that of the 73 ESBL-positive isolates, 58 (79.45%) expressed co-resistance to trimethoprim/sulfamethoxazole, 48 (65.75%) to quinolones (ciprofloxacin and /or norfloxacin), 33 (45.21%) to aminoglycosides (gentamicin and/or tobramycin) and only one to nitrofurantoin. Twenty-two (30.14%) of the ESBL-positive isolates were multidrug resistant (MDR) (i.e. resistant to at least one agent in three or more classes of antimicrobials (aminoglycosides, quinolones and cotrimoxazole) .The antimicrobial resistance pattern of CPE is provided in Table 2
Phylogenetic analysis of E.coli isolate revealed that, ESBL-positive isolates were evenly distributed over the different phylogroups, while phylogroup A was underrepresented among ESBL-negative E. coli (Table 3).
This study was conducted to determine the prevalence of extended-spectrum β-lactamase and carbapenemase production among Enterobacteriaceae isolates recovered from the feces of ambulatory patients with community–onset gastrointestinal complaints admitted to El-Ahrar General Hospital, Zagazig, Egypt.
Our findings showed that almost two in every three Egyptian patients with community–onset gastrointestinal complaints are carriers of ESBL-E. Furthermore, nearly 5% of these patients were colonized with CPE. This high rate of colonization with ESBL-E and CPE is most likely due to imprudent antimicrobial use, as in Egypt and other developing countries, antimicrobial agents are readily available and can be purchased as a commodity. What is more, many Egyptian patients receive antimicrobial treatment without the advice or prescription of a physician or other trained health care provider. Also, even when the antimicrobial treatment is officially prescribed, it is almost entirely empirical and not based on individual susceptibility data nor on surveillance data .
Overall, the rate of fecal ESBL-E demonstrated in our study is higher than reported from many other countries in Africa, Asia, Europe and North America, but lower than what has been described for Thailand [9,10,11,12,13, 31,32,33,34].
The prevalence of fecal ESBL-E found in a study conducted in Cairo by Abdul Rahman and El-Sherif in 2011, was similar to what we observed . In that study, ESBL-E were detected phenotypically, without genotypic confirmation and the prevalence of CPE was not determined.
CTX-M enzymes were the most common ß-lactamases among the Enterobacteriaceae isolates, followed by SHV and TEM. These results are consistent with those of previous studies from other countries around the world [11,12,13, 35, 36] that reported the dominance of CTX-M over other types of ESBLs. Which CTX-M alleles are dominant may differ by geographical region; we found that CTX-M-15 was the most frequently identified genotype among CTX-M–producing Enterobacteriaceae isolates. These findings confirm the reports of the worldwide spread and predominance of CTX-M-15 [37, 38].
Approximately one in every 20 patients included in our study, was colonized with CPE. This high frequency of carriage of CPE has not been described before in any African country and is quite alarming. It raises public health concern about the efficacy of carbapenems, which are the last resort for treatment of multidrug-resistant enterobacterial infections .
The bla NDM gene was identified in three of the five Klebsiella pneumoniae isolates which showed a carbapenem–resistant phenotype while the other two isolates expressed a bla VIM gene.
Our findings of NDM–producing isolates among patients who had no identified epidemiological link with the Indian subcontinent, the main reservoir of these isolates, along with the recent reports of NDM-producing Enterobacteriaceae derived from Egyptian septicemic patients and from retail chicken meat in Zagazig, Egypt [40, 41], support the hypothesis of the presence of autochthonous NDM-producing strains in the Middle East region .
The presence of Enterobacteriaceae producing NDM or VIM has been documented recently in several countries in the Middle East and North Africa [41, 43,44,45]. All reports, however, are case reports, describing the molecular characteristics of a few strains isolated from clinical specimens in hospitalized patients. Our study is the first that documents the prevalence, hence the size of the problem, in community-dwelling persons.
The antibiotic susceptibility testing revealed that four-fifths of ESBL-positive isolates were also resistant to trimethoprim/sulfamethoxazole, nearly two-thirds also to quinolones, and one-third also to aminoglycosides. Approximately half of the isolates were multidrug resistant, which stresses the public health threat by these isolates, which leave few options for treatment. Nitrofurantoin still had good activity against ESBL-E and CPE.
ESBL- E. coli isolates mainly belonged to the virulent groups B2/D, whereas ESBL- negative E. coli isolates were nearly equally distributed over the commensal groups A/B1 and the virulent groups B2/D. This finding suggests that there may be a relationship between virulence and resistance determinants, in contrast to the previously suggested trade-off between virulence and resistance .
In conclusion, nearly two third of the Enterobacteriaceae isolates recovered from feces of Egyptian patients in Zagazig region with community–onset gastrointestinal complaints were ESBL producers and one in every 20 patients included in our study was colonized with CPE. These high rates call for better surveillance of resistance in Egypt, and for a more prudent antimicrobial use. Regulation of sales of antimicrobial agents, as recently introduced in India would be a large step forward .
Clinical and laboratory standards institute
Carbapenemase- producing Enterobacteriaceae.
Extended-spectrum β-lactamase -producing Enterobacteriaceae.
Matrix-assisted laser desorption ionization time-of-flight mass spectrometry.
New Delhi metallo-beta-lactamase.
Verona integron-encoded metallo- beta -lactamase.
Shaikh S, Fatima J, Shakil S, Rizvi SMD, Kamal MA. Antibiotic resistance and extended-spectrum beta-lactamases: types, epidemiology and treatment. Saudi J Biol Sci. 2015;22:90–101. [cited 2016 Mar 31]. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4281622&tool=pmcentrez&rendertype=abstract
Bradford PA. Extended-spectrum beta-lactamases in the 21st century: characterization, epidemiology, and detection of this important resistance threat. Clin Microbiol Rev. 2001;14:933–51. [cited 2014 Dec 27], table of contents. Available from: http://cmr.asm.org/content/14/4/933.abstract?ijkey=ee4d374e9991270b273bab1b470247e510edb106&keytype2=tf_ipsecsha
de Kraker MEA, Jarlier V, Monen JCM, Heuer OE, van de Sande N, Grundmann H. The changing epidemiology of bacteraemias in Europe: trends from the European antimicrobial resistance surveillance system. Clin Microbiol Infect. 2013;19:860–8. [cited 2015 Jan 26]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23039210
Schwaber MJ, Navon-Venezia S, Kaye KS, Ben-Ami R, Schwartz D, Carmeli Y. Clinical and economic impact of bacteremia with extended- spectrum-beta-lactamase-producing obacteriaceae. Antimicrob Agents Chemother. 2006;50:1257–62. [cited 2015 Feb 11]. Available from: http://aac.asm.org/content/50/4/1257.abstract?ijkey=89ea06a2b38fe1368a38aae72d8b752510514325&keytype2=tf_ipsecsha
Lukac PJ, Bonomo RA, Logan LK. Extended-spectrum β-lactamase-producing Enterobacteriaceae in children: Old Foe, Emerging Threat. Clin. Infect. Dis. 2015 [cited 2015 Feb 5];civ020-. Available from: http://cid.oxfordjournals.org/content/early/2015/01/15/cid.civ020.short
Girlich D, Bouihat N, Poirel L, Benouda A, Nordmann P. High rate of faecal carriage of extended-spectrum β-lactamase and OXA-48 carbapenemase-producing Enterobacteriaceae at a university hospital in Morocco. Clin Microbiol Infect. 2014;20:350–4. [cited 2015 Feb 10]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23927757
Mirelis B, Navarro F, Miró E, Mesa RJ, Coll P, Prats G. Community transmission of extended-spectrum beta-lactamase. Emerg Infect Dis. 2003;9:1024–5. [cited 2015 Mar 2]. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3020612&tool=pmcentrez&rendertype=abstract
Luvsansharav U-O, Hirai I, Nakata A, Imura K, Yamauchi K, Niki M, et al. Prevalence of and risk factors associated with faecal carriage of CTX-M β-lactamase-producing Enterobacteriaceae in rural Thai communities. J Antimicrob Chemother. 2012;67:1769–74. [cited 2015 Mar 2]. Available from: http://jac.oxfordjournals.org/content/67/7/1769.abstract?ijkey=4534e73fe311b5ddc7a4110a60de8e0f71f35b83&keytype2=tf_ipsecsha
Li B, Sun J-Y, Liu Q-Z, Han L-Z, Huang X-H, Ni Y-X. High prevalence of CTX-M β-lactamases in faecal Escherichia Coli strains from healthy humans in Fuzhou, China. Scand J Infect Dis. 2011;43:170–4. [cited 2015 Mar 23]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21128708
Valverde A, Coque TM, Sánchez-Moreno MP, Rollán A, Baquero F, Cantón R. Dramatic increase in prevalence of fecal carriage of extended-spectrum beta-lactamase-producing Enterobacteriaceae during nonoutbreak situations in Spain. J Clin Microbiol. 2004;42:4769–75. [cited 2015 Mar 2]. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=522353&tool=pmcentrez&rendertype=abstract
Valenza G, Nickel S, Pfeifer Y, Eller C, Krupa E, Lehner-Reindl V, et al. Extended-spectrum-β-lactamase-producing Escherichia Coli as intestinal colonizers in the German community. Antimicrob Agents Chemother. 2014;58:1228–30. [cited 2015 Mar 2]. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3910888&tool=pmcentrez&rendertype=abstract
Reuland EA, Overdevest ITMA, Al Naiemi N, Kalpoe JS, Rijnsburger MC, Raadsen SA, et al. High prevalence of ESBL-producing Enterobacteriaceae carriage in Dutch community patients with gastrointestinal complaints. Clin Microbiol Infect. 2013;19:542–9. [cited 2014 Jun 25]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22757622
Weisenberg SA, Mediavilla JR, Chen L, Alexander EL, Rhee KY, Kreiswirth BN, et al. Extended spectrum beta-lactamase-producing Enterobacteriaceae in international travelers and non-travelers in New York City. PLoS One. 2012;7:e45141. [cited 2015 Mar 2]. Available from: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0045141
Abdul Rahman EM, El-Sherif RH. High rates of intestinal colonization with extended-spectrum lactamase-producing Enterobacteriaceae among healthy individuals. J Investig Med. 2011;59:1284–6. [cited 2015 Mar 19]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22068018
Al Naiemi N, Murk JL, Savelkoul PHM, Vandenbroucke-Grauls CMJ, Debets-Ossenkopp YJ. Extended-spectrum beta-lactamases screening agar with AmpC inhibition. Eur J Clin Microbiol Infect Dis. 2009;28:989–90. [cited 2014 Aug 11]. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2723665&tool=pmcentrez&rendertype=abstract
CLSI. Performance standards for antimicrobial 2014.
al Naiemi N, Cohen Stuart J, Leverstein van Hall M. NVMM guideline laboratory detection of highly resistant microorganisms (HRMO) ,version 2.0. 2012; Available from: http://www.nvmm.nl/richtlijnen/hrmo-laboratory-detection-highly-resistant-microorganisms.
Pasteran F, Mendez T, Guerriero L, Rapoport M, Corso A. Sensitive screening tests for suspected class a carbapenemase production in species of Enterobacteriaceae. J Clin Microbiol. 2009;47:1631–9. [cited 2014 Nov 19]. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2691115&tool=pmcentrez&rendertype=abstract
Tsakris A, Kristo I, Poulou A, Themeli-Digalaki K, Ikonomidis A, Petropoulou D, et al. Evaluation of boronic acid disk tests for differentiating KPC-possessing Klebsiella Pneumoniae isolates in the clinical laboratory. J Clin Microbiol. 2009;47:362–7. [cited 2014 Dec 24]. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2643660&tool=pmcentrez&rendertype=abstract
Olesen I, Hasman H, Aarestrup FM. Prevalence of beta-lactamases among ampicillin-resistant Escherichia Coli and salmonella isolated from food animals in Denmark. Microb Drug Resist. 2004;10:334–40. [cited 2014 Sep 8]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15650379
Weill F-X, Demartin M, Tandé D, Espié E, Rakotoarivony I. Grimont PAD. SHV-12-like extended-spectrum-beta-lactamase-producing strains of salmonella enterica serotypes Babelsberg and Enteritidis isolated in France among infants adopted from Mali. J Clin Microbiol. 2004;42:2432–7. [cited 2014 Sep 8]. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=427894&tool=pmcentrez&rendertype=abstract
Mulvey MR, Soule G, Boyd D, Demczuk W, Ahmed R. Characterization of the first extended-spectrum beta-lactamase-producing salmonella isolate identified in Canada. J Clin Microbiol. 2003;41:460–2. [cited 2014 Sep 11]. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=149628&tool=pmcentrez&rendertype=abstract
Poirel L, Walsh TR, Cuvillier V, Nordmann P. Multiplex PCR for detection of acquired carbapenemase genes. Diagn Microbiol Infect Dis. 2011;70:119–23. [cited 2014 Aug 5]. Available from: http://www.sciencedirect.com/science/article/pii/S0732889310005559
De Medici D, Croci L, Delibato E, Di Pasquale S, Filetici E, Toti L. Evaluation of DNA extraction methods for use in combination with SYBR green I real-time PCR to detect salmonella enterica serotype Enteritidis in poultry. Appl Environ Microbiol. 2003;69:3456–61. [cited 2014 Sep 24]. Available from: http://aem.asm.org/content/69/6/3456.full
Naas T, Oxacelay C, Nordmann P. Identification of CTX-M-type extended-spectrum-beta-lactamase genes using real-time PCR and pyrosequencing. Antimicrob Agents Chemother. 2007;51:223–30. [cited 2014 Nov 28]. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1797662&tool=pmcentrez&rendertype=abstract
Wang L, Gu H, Lu X. A rapid low-cost real-time PCR for the detection of Klebsiella pneumonia carbapenemase genes. Ann Clin Microbiol Antimicrob. 2012;11:9. [cited 2014 Nov 28]. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3377543&tool=pmcentrez&rendertype=abstract
Clermont O, Bonacorsi S, Bingen E. Rapid and simple determination of the Escherichia Coli phylogenetic group. Appl Environ Microbiol. 2000;66:4555–8. [cited 2014 Nov 27] Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=92342&tool=pmcentrez&rendertype=abstract
Newcombe RG. Two-sided confidence intervals for the single proportion: comparison of seven methods. Stat Med. 1998;17:857–72. [cited 2016 May 18]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9595616
Epstein S. Small Animal Critical Care Medicine. Small Anim. Crit. Care Med. Elsevier; 2015 [cited 2014 Oct 13]. Available from: http://www.sciencedirect.com/science/article/pii/B9781455703067001033
Knobler SL, Lemon SM, Najafi M, Burroughs T. Factors Contributing to the Emergence of Resistance [Internet]. National Academies Press (US); 2003 [cited 2015 Mar 23]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK97126/
Ahmed SF, MMM A, Mohamed ZK, Moussa TA, Klena JD. Fecal carriage of extended-spectrum β-lactamases and AmpC-producing Escherichia Coli in a Libyan community. Ann Clin Microbiol Antimicrob. 2014;13:22. [cited 2015 Feb 9]. Available from: http://www.ann-clinmicrob.com/content/13/1/22
Ben Sallem R, Ben Slama K, Estepa V, Jouini A, Gharsa H, Klibi N, et al. Prevalence and characterisation of extended-spectrum beta-lactamase (ESBL)-producing Escherichia Coli isolates in healthy volunteers in Tunisia. Eur J Clin Microbiol Infect Dis. 2012;31:1511–6. [cited 2015 Feb 20]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22065280
Luvsansharav U-O, Hirai I, Niki M, Nakata A, Yoshinaga A, Moriyama T, et al. Prevalence of fecal carriage of extended-spectrum β-lactamase-producing Enterobacteriaceae among healthy adult people in Japan. J Infect Chemother. 2011;17:722–5. [cited 2015 Apr 1]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21359543
Kader AA, Kumar A, Kamath KA. Fecal carriage of extended-spectrum beta-lactamase-producing Escherichia Coli and Klebsiella Pneumoniae in patients and asymptomatic healthy individuals. Infect Control Hosp Epidemiol. 2007;28:1114–6. [cited 2015 Mar 23]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17932839
Zhang J, Zheng B, Zhao L, Wei Z, Ji J, Li L, et al. Nationwide high prevalence of CTX-M and an increase of CTX-M-55 in Escherichia Coli isolated from patients with community-onset infections in Chinese county hospitals. BMC Infect Dis. 2014;14:659. [cited 2015 Apr 9]. Available from: http://www.biomedcentral.com/1471-2334/14/659
Pournaras S, Ikonomidis A, Kristo I, Tsakris A, Maniatis AN. CTX-M enzymes are the most common extended-spectrum beta-lactamases among Escherichia Coli in a tertiary Greek hospital. J Antimicrob Chemother. 2004;54:574–5. [cited 2015 Apr 9]. Available from: http://jac.oxfordjournals.org/content/54/2/574.full
Rossolini GM, D’Andrea MM, Mugnaioli C. The spread of CTX-M-type extended-spectrum beta-lactamases. Clin Microbiol. 2008;14(Suppl 1):33–41. [cited 2014 Jun 10]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18154526
Cantón R, Coque TM. The CTX-M beta-lactamase pandemic. Curr Opin Microbiol. 2006;9:466–75. [cited 2015 Apr 10]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16942899
Vardakas KZ, Tansarli GS, Rafailidis PI, Falagas ME. Carbapenems versus alternative antibiotics for the treatment of bacteraemia due to Enterobacteriaceae producing extended-spectrum β-lactamases: a systematic review and meta-analysis. J Antimicrob Chemother. 2012;67:2793–803. [cited 2015 Apr 9]. Available from: http://jac.oxfordjournals.org/content/67/12/2793.abstract?ijkey=d56e6b71d2644189b8663c79402a480aa6b02f3d&keytype2=tf_ipsecsha
Abdallah HM, Reuland EA, Wintermans BB, Al Naiemi N, Koek A, Abdelwahab AM, et al. Extended-Spectrum β-Lactamases and/or Carbapenemases-Producing Enterobacteriaceae Isolated from Retail Chicken Meat in Zagazig, Egypt. PLoS One. Public Library of Science; 2015 [cited 2015 Nov 12];10:e0136052. Available from: http://www.plosone.org/article/Metrics/info:doi/10.1371/journal.pone.0136052
Abdallah HM, Wintermans BB, Reuland EA, Koek A, al Naiemi N, Ammar AM, et al. Extended-Spectrum β-Lactamase- and Carbapenemase-Producing Enterobacteriaceae Isolated from Egyptian Patients with Suspected Blood Stream Infection. PLoS One [Internet]. Public Library of Science; 2015 [cited 2015 Nov 12];10:e0128120. Available from: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0128120
Nordmann P, Poirel L, Walsh TR, Livermore DM. The emerging NDM carbapenemases. Trends Microbiol. [Internet]. 2011;19:588–595 [cited 2015 Mar 24]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22078325.
Sonnevend A, Al Baloushi A, Ghazawi A, Hashmey R, Girgis S, Hamadeh MB, et al. Emergence and spread of NDM-1 producer Enterobacteriaceae with contribution of IncX3 plasmids in the United Arab Emirates. J Med Microbiol. 2013;62:1044–50. [cited 2014 Oct 14]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23579399
Shahcheraghi F, Nobari S, Rahmati Ghezelgeh F, Nasiri S, Owlia P, Nikbin VS, et al. First report of New Delhi metallo-beta-lactamase-1-producing Klebsiella Pneumoniae in Iran. Microb Drug Resist. 2013;19:30–6. [cited 2014 Oct 14]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22984942
Nordmann P, Naas T, Poirel L, Carbapenemases CA. Global spread of Carbapenemase- producing Enterobacteriaceae. Emerg Infect Dis. 2011;17:1791–8.
Clermont O, Lavollay M, Vimont S, Deschamps C, Forestier C, Branger C, et al. The CTX-M-15-producing Escherichia Coli diffusing clone belongs to a highly virulent B2 phylogenetic subgroup. J Antimicrob Chemother. 2008;61:1024–8. [cited 2015 Apr 13]. Available from: http://jac.oxfordjournals.org/content/61/5/1024.abstract?ijkey=bbb28712027050a89bd7bd8255b3666af11a677e&keytype2=tf_ipsecsha
Ghafur A. Perseverance, persistence, and the Chennai declaration. Lancet. Infect. Dis. [Internet]. Elsevier; 2013 [cited 2015 Nov 17];13:1007–8. Available from: http://www.thelancet.com/article/S1473309913703141/fulltext
We would like to express our gratitude to the staff of the microbiology department, El-Ahrar General Hospital, Zagazig, Egypt, for collecting the feces samples.
The research is funded by the joint supervision mission between Egyptian high education ministry and VU medical center, the Netherlands.
Availability of data and materials
All data generated or analyzed during this study are included in this published article.
CV, NA, HA, AK Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; and HA, NA, CV, BW, KA, ER: Drafting the work or revising it critically for important intellectual content; and HA, NA, CV, AM, AS Final approval of the version to be published; and HA, CV. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Ethics approval and consent to participate
This study was approved by the review boards of the Research Ethics Committee, Faculty of Medicine, Zagazig University. Informed written consent was obtained from all participants in this study.