scholarly journals In vitro assessment of antimicrobial resistance dissemination dynamics during multidrug resistant bacteria invasion events using a continuous culture device

2020 ◽  
Author(s):  
Ziyun Li ◽  
Lulu Shi ◽  
Bianfang Wang ◽  
Xin Wei ◽  
Jian Zhang ◽  
...  
Keyword(s):  
Public Health ◽  
Gene Transfer ◽  
Antimicrobial Resistance ◽  
Continuous Culture ◽  
Antibiotic Treatment ◽  
Multidrug Resistant ◽  
Resistant Bacteria ◽  
E Coli ◽  
Detrimental Impact ◽  
Vertical Gene Transfer

Antimicrobial resistant pathogens display significant public health threats by causing difficulties in clinical treatment of bacterial infection. Antimicrobial resistance (AMR) is transmissible between bacteria, significantly increasing the appearance of antimicrobial resistant pathogens, aggravating the AMR problem. In this work, the dissemination dynamics of AMR from invading multidrug resistant (MDR) Escherichia coli to a community of pathogenic Salmonella enterica was investigated using a continuous culture device, and the behaviors of dissemination dynamics under different levels of antibiotic stress were investigated. Three MDR E. coli invasion events were analyzed in this work: MDR E. coli-S. enterica co-colonization, MDR E. coli invasion after antibiotic treatment of S. enterica, and MDR E. coli invasion before antibiotic treatment of S. enterica. It was found that both horizontal gene transfer (HGT) and vertical gene transfer (VGT) play significant roles in AMR dissemination, although different processes contribute differently under different circumstances; that environmental levels of antibiotics promote AMR dissemination by enhancing HGT rather than leading to selective advantage for resistant bacteria; and that early invasion of MDR E. coli completely and quickly sabotages the effectiveness of antibiotic treatment. These findings contribute to understanding the drivers of AMR dissemination under different antibiotic stress, the detrimental impact of environmental tetracycline contamination, and the danger of nosocomial presence and dissemination of MDR non-pathogens. IMPORTANCE Antimicrobial resistance poses a grave threat to public health and reduces the effectiveness of antimicrobial drugs in treating bacterial infections. Antimicrobial resistance is transmissible, either by horizontal gene transfer between bacteria, or by vertical gene transfer following inheritance of genetic traits. The dissemination dynamics and behaviors of this threat, however, hasn’t been rigorously investigated. In this work, with a continuous culture device, we studied antimicrobial resistance dissemination processes by simulating antimicrobial resistant Escherichia coli invasion to a pathogenic Salmonella enterica community. Using this novel tool, we provide evidence on the drivers of antimicrobial resistance dissemination, on the detrimental impact of environmental antibiotic contamination, and on the danger of antimicrobial resistance in hospitals, even if what harbors the antimicrobial resistance is not a pathogen. This work furthers our understanding on antimicrobial resistance and its dissemination between bacteria, and on antibiotic therapy, our most powerful tool against bacterial infection.

scholarly journals Retail Chicken Carcasses as a Reservoir of Antimicrobial- Resistant Escherichia coli

2020 ◽  
Author(s):  
Nahla Omer Eltai ◽  
Hadi M. Yassine ◽  
Sara H. Al-Hadidi ◽  
Tahra ElObied ◽  
Asmaa A. Al Thani ◽  
...  
Keyword(s):  
Escherichia Coli ◽  
Antimicrobial Resistance ◽  
Growth Promotion ◽  
Multidrug Resistant ◽  
Chicken Meat ◽  
Resistant Bacteria ◽  
Antibiotic Resistant ◽  
E Coli ◽  
Inappropriate Use ◽  
Esbl Producers

The dissemination of antimicrobial resistance (AMR) bacteria has been associated with the inappropriate use of antibiotics in both humans and animals and with the consumption of food contaminated with resistant bacteria. In particular, the use of antibiotics as prophylactic and growth promotion purposes in food-producing animals has rendered many of the antibiotics ineffective. The increased global prevalence of AMR poses a significant threat to the safety of the world’s food supply. Objectives: This study aims at determining the prevalence of antibiotic-resistant Escherichia coli (E. coli) isolated from local and imported retail chicken meat in Qatar. Methodology: A total of 270 whole chicken carcasses were obtained from three different hypermarket stores in Qatar. A total of 216 E. coli were isolated and subjected to antibiotic susceptibility testing against 18 relevant antibiotics using disc diffusion and micro- dilution methods. Furthermore, extended-spectrum β-lactamase (ESBL) production was determined via a double-disc synergetic test. Isolates harboring colistin resistance were confirmed using multiplex-PCR and DNA sequencing. Results: Nearly 89% (192/216) of the isolates were resistant to at least one antibiotics. In general, isolates showed relatively higher resistance to sulfamethoxazole (62%), tetracycline (59.7%), ampicillin and trimethoprim (52.3%), ciprofloxacin (47.7%), cephalothin, and colistin (31.9%). On the other hand, less resistance was recorded against amoxicillin/clavulanic acid (6%), ceftriaxone (5.1%), nitrofurantoin (4.2%) and piperacillin/tazobactam (4.2%), cefepime (2.3%), meropenem (1.4%), ertapenem (0.9%), and amikacin (0.9%). Nine isolates (4.2%) were ESBL producers. Furthermore, 63.4% were multidrug-resistant (MDR). The percentage of MDR, ESBL producers, and colistin-resistant isolates was significantly higher among local isolates compared to imported chicken samples. Conclusion: We reported a remarkably high percentage of the antibiotic-resistant E. coli in chicken meat sold at retail in Qatar. The high percentage of MDR and colistin isolates is troublesome to the food safety of raw chicken meat and the potential of antibiotic resistance spread to public health. Our findings support the need for the implementation of one health approach to address the spread of antimicrobial resistance and the need for a collaborative solution.

scholarly journals Antimicrobial resistance and R-plasmid in Salmonella spp from swine and abattoir environments

2004 ◽  
Vol 24 (2) ◽  
pp. 57-60 ◽  
Author(s):  
Norma S. Lázaro ◽  
Anita Tibana ◽  
Dália P. Rodrigues ◽  
Eliane M.F. Reis ◽  
Bianca R. Quintaes ◽  
...  
Keyword(s):  
Public Health ◽  
Gene Transfer ◽  
Antimicrobial Resistance ◽  
Animal Species ◽  
Bacterial Conjugation ◽  
Standard Strain ◽  
Salmonella Spp ◽  
Pathogenic Potential ◽  
E Coli ◽  
Transfer Phenomenon

Salmonella serovars isolated from swine are of particular interest not only because of the pathogenic potential for this animal species, but also due to its relevance with regard to public health. On basis of the profile of resistance to antimicrobials, 13 Salmonella strains were selected which belonged to the serovars Muenster (7), Derby (4), Typhimurium (1), and Braenderup (1). They were isolated from healthy swine as well as from the abattoir environment in the state of Rio de Janeiro. All strains of Salmonella were subjected to bacterial conjugation, and the E. coli K12 Nal r Lac+ F standard strain was used as receptor, with the purpose to verify the ability to transfer the resistance marks. Gene transfer phenomenon was detected in seven strains, and except SalmonellaTyphimurium which transconjugated to Sm, Tc and Su, the remaining ones were characterized by transferring mark Su only. By plasmidial analysis of strains used and their respective transconjugants, 63 Kb plasmid was found, which was probably related to S. Typhimurium resistance.

scholarly journals Occurrence and antimicrobial resistance of bacteria in retail market spices

2020 ◽  
Vol 50 (4) ◽  
Author(s):  
Milena da Cruz Costa ◽  
Alexsandra Iarlen Cabral Cruz ◽  
Aline Simões da Rocha Bispo ◽  
Mariza Alves Ferreira ◽  
João Albany Costa ◽  
...  
Keyword(s):  
Antimicrobial Resistance ◽  
Microbiological Quality ◽  
Multidrug Resistant ◽  
Black Pepper ◽  
Resistant Bacteria ◽  
Salmonella Spp ◽  
Food Markets ◽  
E Coli ◽  
Bacillus Spp ◽  
Mar Index

ABSTRACT: This study aimed to evaluate the microbiological quality and the transmission of multidrug-resistant bacteria in different spices sold in town fairs (local food markets) in the municipalities of Recôncavo Baiano. Samples of black pepper, oregano, and cinnamon were collected over a period of six months and investigated for coliforms at 45 °C, Staphylococcus spp., Staphylococcus aureus, Bacillus spp., Bacillus cereus, Escherichia coli and Salmonella spp. The contamination in the black pepper samples (log 4.66 CFU g-1) was higher (P>0.05), than those of cinnamon (log 2.55 CFU g-1) and oregano (log 2.49 CFU g-1), particularly for B. cereus. E. coli (89%) and Salmonella spp. (67%) were isolated only from black pepper. B. cereus and S. aureus showed greater resistance to β-lactams (penicillin, oxacillin, and cefepime), with approximately 40% of the strains with a multiple antimicrobial resistance (MAR) index of 0.33 (i.e., resistant to three antimicrobials). E. coli was more resistant to ampicillin and Salmonella spp. to nalidixic acid, ampicillin, and ceftriaxone. Salmonella spp. had a MAR index ranging from 0.16 to 0.91 (i.e, resistant to up to 11 antimicrobials), and E. coli to up to 0.58 (i.e., resistant to 7 antimicrobials). In conclusion, the spices sold in the town fairs of Recôncavo Baiano are of low microbiological quality, with the presence of pathogens, of which some display high resistance to antimicrobials that are commonly used for treating foodborne illnesses.

scholarly journals Antimicrobial Resistance Pilot Surveillance of Pigs and Chickens in Vietnam, 2017–2019

2021 ◽  
Vol 8 ◽  
Author(s):  
C. V. Tuat ◽  
P. T. Hue ◽  
N. T. P. Loan ◽  
N. T. Thuy ◽  
L. T. Hue ◽  
...  
Keyword(s):  
Public Health ◽  
Antimicrobial Resistance ◽  
Antimicrobial Agents ◽  
Multidrug Resistant ◽  
Surveillance Program ◽  
E Coli ◽  
The North ◽  
Disk Diffusion Assay ◽  
Almost All ◽  
The Impact

Antimicrobial use (AMU) and antimicrobial resistance (AMR) are a growing public health and economic threat in Vietnam. We conducted a pilot surveillance programme in five provinces of Vietnam, two in the south and three in the north, to identify antimicrobial resistance (AMR) in rectal swab samples from pigs and fecal samples from chickens at slaughter points during three different points in time from 2017 to 2019. Escherichia coli (E. coli) and non-typhoidal Salmonella (NTS) isolates were tested for antimicrobial susceptibility using disk diffusion assay for 19 antimicrobial agents belonging to nine antimicrobial classes and Etest for colistin (polymyxin). Almost all E. coli (99%; 1029/1042) and NTS (96%; 208/216) isolates were resistant to at least one antimicrobial agent; 94% (981/1042) of E. coli and 89% (193/216) of NTS isolates were multidrug-resistant (MDR). Higher proportions of E. coli and NTS isolated from chickens were resistant to all antimicrobial classes than those isolates from pigs. There was a significantly higher proportion of MDR NTS isolates from the southern provinces of Ho Chi Minh City and Long An (p = 0.008). Although there were increasing trends of NTS in proportion of resistance to fluoroquinolone over the three surveillance rounds, there was a significant decreasing trend of NTS in proportion of resistance to polymyxin (p = 0.002). It is important to establish an annual AMR surveillance program for livestock in Vietnam to assess the impact of interventions, observe trends and drive decision making that ultimately contributes to reducing AMR public health threat.

scholarly journals Drug Resistance of Pathogens Causing Nosocomial Infection in Orthopedics from 2012 to 2017: A 6-Year Retrospective Study

2020 ◽  
Author(s):  
Xiaowei Yang ◽  
Runsheng Guo ◽  
Banglin Xie ◽  
Qi Lai ◽  
Jiaxiang Xu ◽  
...  
Keyword(s):  
Drug Resistance ◽  
Retrospective Study ◽  
Antimicrobial Resistance ◽  
Bacterial Infections ◽  
Multidrug Resistant ◽  
Dynamic Monitoring ◽  
Resistant Bacteria ◽  
Clinical Microbiology Laboratory ◽  
Valuable Insight ◽  
E Coli

Abstract Background: Hospital-acquired infections (HAIs) are an emerging global problem that increases in-hospital mortality, length of stay, and cost. We performed a 6-year retrospective study to provide valuable insight into appropriate antibiotic use in HAI cases. We also aimed to understand how hospitals could reduce pathogen drug resistance in a population that overuses antibiotics.Methods: All data (2012–2017) were obtained from the Hospital Information Warehouse and Clinical Microbiology Laboratory.Results: We isolated 1392 pathogen strains from patients admitted to the orthopedics department during 2012–2017. Escherichia coli (14.7%, 204/1392), Enterobacter cloacae (13.9%, 193/1392), and Staphylococcus aureus (11.3%, 157/1392) were the most common pathogens causing nosocomial infections. The dominant Gram-negative bacterium was E. coli, with high resistance to ampicillin, levofloxacin, cotrimoxazole, gentamicin, and ciprofloxacin, in that order. E. coli was least resistant to amikacin, cefoperazone-sulbactam. The most dominant Gram-positive bacterium was S. aureus, highly resistant to penicillin and ampicillin, but not resistant to fluoroquinolones and cotrimoxazole. Analysis of risk factors related to multidrug-resistant bacteria showed that patients with open fractures were significantly more susceptible to methicillin-resistant S. aureus infections (p < 0.05). Additionally, extended-spectrum β-lactamase-producing E. coli infections occurred significantly more often in patients with degenerative diseases (p < 0.05). Elderly patients tended to be more susceptible to multidrug-resistant bacterial infections, but this outcome was not statistically significant.Conclusions:Antimicrobial resistance is a serious problem in orthopedics. To effectively control antimicrobial resistance among pathogens, we advocate extensive and dynamic monitoring of MDR bacteria, coupled with careful use of antibiotics.

scholarly journals Multidrug Resistance among Gram Negative E. coli in Chicken Meat (Rafha-Saudi Arabia)

2021 ◽  
pp. 38-48
Author(s):  
Akbar Ali ◽  
Vijay R. Chidrawar
Keyword(s):  
Public Health ◽  
Saudi Arabia ◽  
Antibiotic Resistance ◽  
Multidrug Resistant ◽  
Chicken Meat ◽  
Penicillin G ◽  
Diffusion Method ◽  
Resistant Bacteria ◽  
E Coli ◽  
Northern Border

Aims: Multidrug resistant (MDR) bacteria pose a major public health issuer globally. The genes for antibiotic resistance are transferred vertically in the form of genomic DNA and horizontally in the form of plasmids or transposons. Antibiotic are extensively used in animal farming to treat and prevent animal diseases, and at sub-therapeutic doses, they are used to promote animal growth. This extensive use of antibiotics is causing an increase in resistance among bacteria. More frequent, chicken meat available at retail shops is reported to be contaminated with a variety of drug resistant bacteria including E. Coli. The aim of the present study was to investigate antibiotic resistance in Escherichia coli strains isolated from chicken meat available in the local shops of Rafha, Saudi Arabia. Place and Duration of Study: Department of basic health sciences, College of Pharmacy, Northern Border University, Rafha, Saudi Arabia, between February and October, 2019 Methodology: Eighty-six E. coli strains, isolated from chicken meat, were tested for their antibiotic resistance profile, using the disc diffusion method.    Results: All the isolated E. coli strains were tested against 14 antibiotics. The maximum resistance was found against penicillin G (95%) followed by amoxicillin (85%), Cephalothin (81%), Erythromycin (72%), and Tetracycline (50%). Imipenem was the most effective agent of all with only 1% resistance followed by Cefepime with almost 6% resistance. A high percentage of the isolates (57%,) were multidrug resistant as they were non—susceptible to at least one antimicrobial in ≥3 antimicrobial classes including amoxicillin, erythromycin and tetracycline. Conclusion: The prevalence of MDR E. coli in retail chicken meat is very high and could pose a serious threat to public health.

scholarly journals Drug resistance of pathogens causing nosocomial infection in orthopedics from 2012 to 2017: a 6-year retrospective study

2019 ◽  
Author(s):  
Bin Zhang ◽  
Xiaowei Yang ◽  
Runsheng Guo ◽  
Banglin Xie ◽  
Qi Lai ◽  
...  
Keyword(s):  
Drug Resistance ◽  
Retrospective Study ◽  
Antimicrobial Resistance ◽  
Multidrug Resistant ◽  
Dynamic Monitoring ◽  
Resistant Bacteria ◽  
Clinical Microbiology Laboratory ◽  
E Coli ◽  
Hospital Acquired Infections ◽  
Hospital Acquired

Abstract Abstract Background Hospital-acquired infections (HAIs) are an emerging global problem that increases in-hospital mortality, length of stay, and cost. Orthopedics departments experience a particularly high infection rate, partially due to their heavy reliance on invasive medical devices. We performed a 6-year retrospective study to provide valuable insight into appropriate antibiotic use in HAI cases. We also aimed to understand how hospitals could reduce pathogen drug resistance in a population that overuses antibiotics. Methods All data (2012–2017) were obtained from the Hospital Information Warehouse and Clinical Microbiology Laboratory. Results We isolated 1392 pathogen strains from patients admitted to the orthopedics department during 2012–2017. Escherichia coli (14.7%, 204/1392), Enterobacter cloacae (13.9%, 193/1392), and Staphylococcus aureus (11.3%, 157/1392) were the most common pathogens causing nosocomial infections. The dominant gram-negative bacterium was E. coli, with high resistance to ampicillin, levofloxacin, cotrimoxazole, gentamicin, and ciprofloxacin, in that order. E. coli was least resistant to amikacin, cefoperazone-sulbactam, meropenem, imipenem, and piperacillin-tazobactam. The most dominant gram-positive bacterium was S. aureus, highly resistant to penicillin and ampicillin, but not resistant to fluoroquinolones and cotrimoxazole. We also did not observe isolate resistance to nitrofurantoin, linezolid, and vancomycin. Analysis of risk factors related to multidrug-resistant bacteria showed that patients with open fractures were significantly more susceptible to methicillin-resistant S. aureus infections (p < 0.05). Additionally, extended-spectrum β-lactamase-producing E. coli infections occurred significantly more often in patients with degenerative diseases (p < 0.05). Elderly patients tended to be more susceptible to multidrug-resistant bacterial infections, but this outcome was not statistically significant. Conclusions Antimicrobial resistance is a serious problem in orthopedics. To effectively control antimicrobial resistance among pathogens, we advocate extensive and dynamic monitoring of MDR bacteria, coupled with careful use of antibiotics. Key words: hospital acquired infections; orthopedics; drug resistance; multidrug resistance

scholarly journals Multidrug-Resistant Escherichia coli, Klebsiella pneumoniae and Staphylococcus spp. in Houseflies and Blowflies from Farms and Their Environmental Settings

2019 ◽  
Vol 16 (19) ◽  
pp. 3583 ◽  
Author(s):  
Anil Poudel ◽  
Terri Hathcock ◽  
Patrick Butaye ◽  
Yuan Kang ◽  
Stuart Price ◽  
...  
Keyword(s):  
Escherichia Coli ◽  
Antimicrobial Resistance ◽  
Klebsiella Pneumoniae ◽  
Multidrug Resistant ◽  
Resistant Bacteria ◽  
Coagulase Negative Staphylococcus ◽  
Extended Spectrum Beta Lactamase ◽  
E Coli ◽  
Antimicrobial Resistance Genes ◽  
Staphylococcus Spp

Background: Antimicrobial resistance is rising globally at an alarming rate. While multiple active surveillance programs have been established to monitor the antimicrobial resistance, studies on the environmental link to antimicrobial spread are lacking. Methods: A total of 493 flies were trapped from a dairy unit, a dog kennel, a poultry farm, a beef cattle unit, an urban trash facility and an urban downtown area to isolate Escherichia coli, Klebsiella pneumoniae and Staphylococcus spp. for antimicrobial susceptibility testing and molecular characterization. Results: E. coli, K. pneumoniae and coagulase-negative Staphylococcus were recovered from 43.9%, 15.5% and 66.2% of the houseflies, and 26.0%, 19.2%, 37.0% of the blowflies, respectively. In total, 35.3% of flies were found to harbor antimicrobial-resistant bacteria and 9.0% contained multidrug-resistant isolates. Three Staphylococcus aureus isolates were recovered from blowflies while three extended spectrum beta lactamase (ESBL)-carrying E. coli and one ESBL-carrying K. pneumoniae were isolated from houseflies. Whole genome sequencing identified the antimicrobial resistance genes blaCMY-2 and blaCTXM-1 as ESBLs. Conclusion: Taken together, our data indicate that flies can be used as indicators for environmental contamination of antimicrobial resistance. More extensive studies are warranted to explore the sentinel role of flies for antimicrobial resistance.

Molecular Characterization of Multidrug-Resistant Escherichia coli Isolates from Edible Offal in Korea

2019 ◽  
Vol 82 (7) ◽  
pp. 1183-1190
Author(s):  
SE HYUN SON ◽  
KWANG WON SEO ◽  
YEONG BIN KIM ◽  
HYE YOUNG JEON ◽  
EUN BI NOH ◽  
...  
Keyword(s):  
Escherichia Coli ◽  
Antimicrobial Resistance ◽  
Virulence Genes ◽  
Antimicrobial Agents ◽  
Food Product ◽  
Multidrug Resistant ◽  
Resistant Bacteria ◽  
E Coli ◽  
Antimicrobial Resistance Genes ◽  
Class 1

ABSTRACT Edible offal, which is the nonmuscular part of the livestock, is a popular food product in many countries. However, it can be easily contaminated by bacteria, such as Escherichia coli, during slaughter and processing and regarded as a reservoir for transfer of antimicrobial-resistant bacteria to humans. This study aimed to investigate prevalence and characteristics of antimicrobial-resistant E. coli isolates from edible offal in Korea. A total of 320 chicken offal samples, 540 pig offal samples, and 560 cattle offal samples were collected. Among the 118 E. coli isolates obtained, resistance to at least one antimicrobial agent was revealed in 32 (100%), 46 (95.8%), and 26 (68.4%) isolates of chicken, pig, and cattle offals, respectively, with an overall prevalence of 88.1% (104 of 118). The isolates from chicken offal showed highest resistance to most antimicrobial agents, with the exception of higher ampicillin resistance for isolates from pig offal. In the distribution of antimicrobial resistance genes of 69 (58.5%) multidrug-resistant (MDR) E. coli, blaTEM-1 (97.1%), tetA (76.6%), sul2 (70.6%), and cmlA (57.4%) were most prevalent. Class 1 and class 2 integrons were detected in 82.6 and 2.9% of the MDR isolates, respectively. In total, seven virulence genes (eaeA, escV, astA, fimH, papC, sfa/focDE, and iucC) were also identified in the MDR isolates. The fimH gene was the most frequent (91.3%). Overall, 52 isolates from chicken (24 isolates, 96.0%), pig (16 isolates, 55.2%) and cattle (12 isolates, 80.0%) offals among MDR isolates were found to have some plasmid replicons. Frep (38 isolates) and FIB (27 isolates) replicons were more prevalent than other replicon types. The results suggest that edible offal can become a relevant reservoir of E. coli strains carrying various antimicrobial resistance and virulence genes. HIGHLIGHTS

scholarly journals Profile of antimicrobial resistance in oncologic pediatric patients

2014 ◽  
Vol 2 (4) ◽  
Author(s):  
Mauricio García-Luna ◽  
José Antonio Madrid Gómez-Tagle ◽  
Jessica P. O’Brien
Keyword(s):  
Antimicrobial Resistance ◽  
Lymphoblastic Leukemia ◽  
Multidrug Resistant ◽  
Resistant Bacteria ◽  
Gram Positive ◽  
Gram Negative ◽  
E Coli ◽  
Development Of Resistance ◽  
Drug Resistant Bacteria ◽  
Clinical Records

The development of resistance to antibiotics is due to the widespread use of a wide variety of antimicrobials, coupled with the ability of bacteria to acquire and spread resistance and the ability of humans to disseminate them. The possible consequences of antimicrobial resistance leads to greater chances of hospitalization, prolongation of hospital stay and increased mortality. Furthermore, treatment of drug resistant bacteria requires the use of more toxic drugs and more expense for the patient and hospitals. The main objective of the present study was to determine the frequency and nature of antimicrobial resistance of microorganisms in oncologic and hematologic patients at a Mexican Pediatric Hospital. A retrospective, observational, and analytical study was realized, where we reviewed the clinical records of 20 cases. Blood cultures were obtained from the Laboratory of our institution from 2010 to 2011. The data obtained were organized and analyzed. We observed that the E. coli and S. aureus were the bacteria most resistant, showing the same percentage between gram-positive and gram-negative bacteria. The cancer diagnosis most common in our study was acute lymphoblastic leukemia. It may be concluded that multidrug-resistant bacteria in these patients are of a nosocomial origin, without a specific group of germ (gram positive vs. gram negative).

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