Multidrug Resistance Among Enterococci at a Tertiary Care Hospital in Northern Bulgaria

Summary Multidrug-resistant (MDR) enterococci are a growing threat. The aim of this study was to determine the species distribution and prevalence of multidrug resistance among 100 enterococcal strains, isolated from patients treated in the University Hospital in Pleven, Bulgaria. Susceptibility to 11 antimicrobial agents was determined, using the disc diffusion method according to the performance standards of Clinical Laboratory Standards Institute (CLS1), 2012. All isolates were screened for high-level aminoglycoside resistance and resistance to vancomycin according to the recommendations of CLS1, 2012. For strains with reduced susceptibility to vancomycin, minimal inhibitory concentrations (MIC) of glycopeptides were determined by Etest (Liofilchem, Italy) and by Vitek 2 automated system. Our results demonstrated decreased susceptibility of enterococci to almost all intensively used anti-enterococcal drugs. Resistance to both penicillins (ampicillin and penicillin) among E.faecium strains was significantly higher (83-87%) than among E.faecalis isolates (4-27%). HLGR was detected in 70% of E.faecium and 38% of E.faecalis isolates. All HLGR strains were foundtobemultiple-drug resistant. Of particular note was the emergence of concomitant resistance to 6 antimicrobials in almost 50% of E.faecium isolates. Despite the wide dissemination of MDR E.faecium strains penicillins in our hospital, acquired resistance to vancomycin was not found.

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Distribution of MR-CoNS in the clinical staffs of tertiary care hospital

IP International Journal of Medical Microbiology and Tropical Diseases ◽

10.18231/j.ijmmtd.2021.022 ◽

2021 ◽

Vol 7 (2) ◽

pp. 100-102

Author(s):

Sonu S. Ahirwar ◽

Prabhat Jatav ◽

Kirti Kushwaha

Keyword(s):

Low Income ◽

Nasal Swab ◽

Tertiary Care Hospital ◽

Methicillin Resistance ◽

Tertiary Care ◽

Automated System ◽

Diffusion Method ◽

Care Hospital ◽

Methicillin Resistant ◽

Vitek 2

Methicillin-resistant coagulase-negative staphylococci (MR-CoNS) associated infection is a growing concern in healthcare settings now a day. MR-CoNS are the main infectious agents of the hospital acquired infection. Clinical staffs to patients transmission of resistant strains have caused a rapid increase in the prevalence of antimicrobial resistance in recent years. Growing rate of antimicrobial resistant against available antibiotics of MR-CoNS is a developing problem in low income or lower middle income counties. This study was conducted to determine the occurrence MR-CoNS isolated from different clinical staffs of tertiary care hospital. This prospective study conducted in clinical staffs, nasal swab were collected from all the participants. Screening of CoNS were done on the basis of cultural, morphological and biochemical tests, identification and AST analysis done by VITEK-2 automated system. Methicillin resistance pattern was checked by VITEK-2 and Kirby-Bauer disc diffusion method according to CLSI guideline. A total of 129 nasal swab samples were collected from clinical staffs, of which n=81 isolates (85.6%) were CoNS. Among n=81 CoNS, (48.12%) , (41.97%) , (7.4%) and (2.4%) were reported. Out of n=81 CoNS isolates, n=26 were conformed as MR-CoNS. Maximum methicillin resistance were reported in 53.48% (14/26), 42.30% (11/26), 3.84% (1/26) and 0% (0/26). Theoccurrence rate of MR-CoNS are higher (20.6%) in the healthcare workers and most of the methicillin resistant-CoNS isolates shows high level of resistance against widely used antibiotics but all the isolates susceptible against vancomycin.

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PREVALENCE OF HIGH LEVEL AMINOGLYCOSIDE RESISTANCE AND VANCOMYCIN RESISTANT ENTEROCOCCI IN ENTEROCOCCAL ISOLATES IN A TERTIARY CARE HOSPITAL

10.36106/gjra/5900236 ◽

2021 ◽

pp. 3-5

Author(s):

Sunita Agarwal ◽

Nazneen Pathan ◽

Shivra Batra ◽

Rajni Sharma

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Tertiary Care ◽

Automated System ◽

Care Hospital ◽

Enterococcus Species ◽

Aminoglycoside Resistance ◽

Vancomycin Resistant Enterococci ◽

Vancomycin Resistant ◽

High Level

Introduction: The emergence of High Level Aminoglycoside Resistance (Resistant to Gentamycin and Streptomycin) and Vancomycin Resistant Enterococci among Indoor and Intensive Care Unit admitted patient presents a serious challenge for clinicians. Objective: To determine Enterococcal burden in blood and urine specimens and to detect the prevalence of High Level Aminoglycoside Resistance and Vancomycin Resistant Enterococci. Material & Methods: One hundred ten Enterococci were isolated from blood and urine samples and processed according to standard laboratory protocol. Species identication and sensitivity was done using the VITEK 2 automated system (Biomerieux France) with the cards GPID and AST 67 respectively. Results: Out of 110 Enterococci isolates, 36 were from blood and 74 from urine were detected. Different Species isolated were Enterococcal faecium (59%), Enterococcal faecalis (34%), Enterococcal rafnosus (2.7%), Enterococcal gallinarum (1.8%), Enterococcal casseliavus (0.9%) and Enterococcal duran (0.9%).Out of 36 blood isolates, 14 (38%) were found to be both High Level Gentamycin Resistant (HLGR) & High Level Streptomycin Resistant (HLSR), 10 (27%) were only HLGR and 8 (22%) were only HLSR. 20 strain (55%) of Enterococcus species isolated in blood were VRE. All VRE strains were found to be resistant to both aminoglycosides ( HLAR).Among the 74 urinary isolates, 24 (34%) were found to be both HLGR & HLSR, only HLGR was observed in 20 (27%) and HLSR was observed in 11 (14%) isolates. 24 strains (34%) of Enterococcus species were found to be vancomycin resistant in urine. 23 strains out of 24 were resistant to high level of aminoglycosides. Conclusion: The prevalence of HLAR and VRE is very high among Enterococcus specimens from indoor/ intensive care unit patients. Early species identication and antibiotic sensitivity result can help in better clinical outcome.

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Bacteriological Profile of Chronic Osteomyelitis with Special Reference to Antibiotic Resistance Mechanisms/Patterns – A Cross-sectional Prospective Study from Tertiary Care Hospital in Central India

Journal of Advances in Medicine and Medical Research ◽

10.9734/jammr/2020/v32i330381 ◽

2020 ◽

pp. 43-52

Author(s):

Aparna Pandey ◽

Prachi Shaw ◽

Aamir Johar

Keyword(s):

Multidrug Resistance ◽

Antimicrobial Susceptibility ◽

Chronic Osteomyelitis ◽

Tertiary Care Hospital ◽

Tertiary Care ◽

Central India ◽

Diffusion Method ◽

Care Hospital ◽

Age Group ◽

Gram Negative

Objective: Chronic osteomyelitis is the infection and inflammation of the bone. Inappropriate use of antibiotics and multidrug resistance has raised the morbidity and mortality rate in chronic osteomyelitis. This study aims to determine the bacterial profile and antimicrobial susceptibility patterns of chronic osteomyelitis with special mention to various resistant mechanisms. Methods: The study is a prospective design. Hundred (100) clinically diagnosed cases of chronic osteomyelitis of all age group and both sex admitted in a tertiary care hospital at central India, in one year were included. Samples like pus, sinus discharge or exudates were collected aseptically and sent for microbiological investigation. Antimicrobial susceptibility of bacterial isolates to the commonly used antibiotics was done by using modified Kirby Bauer disc diffusion method. Results: The aerobic bacteriological study of chronic osteomyelitis showed Staphylococcus aureus is being continued to be major etiological agent followed by Pseudomonas aeruginosa and Staphylococcus epidermidis. Gram-positive isolates were sensitive to linezolid, teicoplanin while gram-negative isolates were sensitive to colistin, ciprofloxacin in the majority. The disease occurs mostly due to traumatic injuries commonly affecting the middle age group. In present study prevalence of methicillin-resistant Staphylococci aureus and β Lactamase producing (ESBL, Amp-C and MBL) gram-negative bacilli is found to be on the higher side. Conclusion: It has been the major cause of morbidity for a long time. The emerging multidrug-resistant strain is a major concern for the treatment. Identification of causative isolates and using a judicious selection of antibiotics will help the clinician in starting the empirical treatment accordingly would limit the multidrug resistance strains in the hospital as well as the community.

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Retrospective study on susceptibility and resistance pattern of urinary pathogens in a tertiary care hospital

International Journal of Basic & Clinical Pharmacology ◽

10.18203/2319-2003.ijbcp20194257 ◽

2019 ◽

Vol 8 (10) ◽

pp. 2211

Author(s):

Sudha Ramu

Keyword(s):

Antimicrobial Resistance ◽

Antimicrobial Agents ◽

Tertiary Care Hospital ◽

Tertiary Care ◽

Empirical Therapy ◽

Diffusion Method ◽

Resistance Pattern ◽

Surveillance Program ◽

Care Hospital ◽

Susceptibility And Resistance

Background: Indiscriminate and inappropriate use of antimicrobial agents (AMA) resulted in rapid emergence of antimicrobial resistance. Institutional level surveillance program to be carried out to track AMA use. The study was conducted to evaluate the prevalence of uropathogens and their susceptibility and resistance pattern in a tertiary care hospital to revise empirical therapy.Methods: Urine samples received from the inpatients and outpatients Departments of Mahatma Gandhi memorial hospital for culture sensitivity between January 2018 to December 2018 were included in this study. Data collected from the Department of Microbiology register by using WHONET software. After identification, isolates were tested for antimicrobial susceptibility by the standard Kirby Bauers diffusion method. Descriptive analysis done and results were expressed as percentage.Results: Out of 3425 samples 68.5% showed no growth, 15.5% normal flora and only 15.9% reported as culture positive. In this study the highest isolate was Escherichia coli (59%) followed by Klebsiella pneumoniae (10.6%), Enterococcus sp. (7%), Staphylococcus aureus (5%), Candid (3.6%), Acinetobactor (3%) and Pseudomonas (2.9%). Uropathogens developed resistance against penicillins, cephalosporins, macrolides and cotrimaxazole.Conclusions: This study confirms, the frequently prescribed empirical therapy drugs were less susceptible and developed resistance than less frequently prescribed and costly drugs. The current antimicrobial resistance pattern alarms the irrational and excessive use of antimicrobial agents. Hence the treating physicians should revise empirical therapy periodically based on the institutional antibiogram and resistance pattern reported from the laboratory to preserve antimicrobial source for the future generation.

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Salmonella isolates’ serotypes and susceptibility to commonly used drugs at a tertiary care hospital in Riyadh, Saudi Arabia

The Journal of Infection in Developing Countries ◽

10.3855/jidc.1805 ◽

2011 ◽

Vol 6 (06) ◽

pp. 478-482 ◽

Cited By ~ 9

Author(s):

Ali Mohammed Somily ◽

Samina Bashir Sayyed ◽

Hanan Ahmed Habib ◽

Abdulaziz Saleh Al-Khattaf ◽

Fawzia Eida Al Otabi ◽

...

Keyword(s):

Saudi Arabia ◽

Nalidixic Acid ◽

Tertiary Care ◽

University Hospital ◽

Diffusion Method ◽

Care Hospital ◽

Disk Diffusion Method ◽

Salmonella Infections ◽

Overall Resistance ◽

Resistance Rates

Introduction: Resistance of Salmonella to therapeutic agents currently being used for treatment of Salmonella infections is emerging as a global problem. This study aimed to assess the prevalence of Salmonella serotypes and their susceptibility patterns to commonly used drugs for treatment of Salmonella infections including quinolones. Correlation between nalidixic acid susceptibility of these isolates and their ciprofloxacin minimum inhibitory concentrations was also sought. Methodology; Salmonella isolates (n=213) were collected between January 2007 and May 2009 at King Khalid University Hospital in Riyadh, Saudi Arabia. The isolates were serotyped and their susceptibilities to commonly used first-line anti-Salmonella drugs (ampicillin, ceftriaxone, trimethoprim/sulfamethoxazole, nalidixic acid and ciprofloxacin) were determined using the automated Microscan system, the Kirby-Bauer disk diffusion method, and E-test. Results: The most frequently detected serotype was D1 (37%) followed by the serotypes, B (24%) and C1 (11%). Non-typable Salmonella isolates detected using available conventional Salmonella anti-sera were (11%). Overall resistance rates to nalidixic acid, ampicillin, trimethoprim/sulfamethoxazole and ceftriaxone were 99/213 (46%), 43/213 (20%), 34/213 (16%) and 7/213 (3%), respectively. Of the total isolates, 117 (55%) had a ciprofloxacin MIC of < 0.125 µg/ml and among these 105 (90%) were susceptible to nalidixic acid. The remaining 96 (45%) isolates had a ciprofloxacin MIC of ≥ 0.125 µg/ml and among them, 83 (86.5%) were resistant to nalidixic acid. Conclusions: The majority of Salmonella isolates in this study were non-typhi serotypes. Significantly higher proportions of Salmonellae were resistant to nalidixic acid and ciprofloxacin and a vast majority of nalidixic acid resistant organisms exhibited decreased susceptibility to ciprofloxacin.

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β-lactamase genes in carbapenem resistance Acinetobacter baumannii isolates from a Turkish university hospital

The Journal of Infection in Developing Countries ◽

10.3855/jidc.10556 ◽

2019 ◽

Vol 13 (01) ◽

pp. 50-55

Author(s):

Umut Safiye Say Coskun ◽

Emel Caliskan ◽

Asegul Copur Cicek ◽

Halbay Turumtay ◽

Cemal Sandalli

Keyword(s):

Acinetobacter Baumannii ◽

Resistance Genes ◽

Antimicrobial Agents ◽

Low Frequency ◽

Carbapenem Resistance ◽

University Hospital ◽

High Rate ◽

Automated System ◽

Diffusion Method ◽

Disk Diffusion Method

Introduction: The spread of Acinetobacter baumannii, resistant to most of the available antimicrobial agents, is a serious health problem. The high rate of carbapenem resistance among Acinetobacter baumannii isolates is considered as a threat to public health. In this study, we aimed to determine the antibiotic resistance and related genes in carbapenem-resistant Acinetobacter baumannii isolates. Methodology: Ninety six isolates of A. baumannii were included. Antimicrobial susceptibility was performed by Phoenix Automated System and disk diffusion method. Carbapenem resistane was characterized by scrneeing of resistance genes such as blaTEM, blaSHV, blaCTX-M1-2, blaPER, blaVEB, blaKPC, blaGES, blaNDM, blaVIM, blaIMP and blaOXA23-24-51-58 using multiplex polymerase chain reaction. Results: Resistance for the levofloxacin, gentamicin, amikacin, and tigecycline were determined as 96.9%, 93.7%, 72.9% and 45.8% respectively. Colistin was the only susceptible antibiotic against all clinical isolates. All isolates were defined as multidrug resistance and of these, 31.2% were extensively drug-resistant (sensitive only to colistin). BlaOXA-51 and blaOXA-23 genes were detected in 100% strains while blaTEM was found in only 2% strains. There was no amplification for the blaSHV, blaCTX-M1-2, blaPER, blaVEB, blaKPC, blaGES blaNDM, blaVIM, blaIMP and blaOXA24-58 genes. Conclusions: The high frequency of blaOXA-23 and low frequency of blaTEM gene was observed that indicate prevalence of a variety of A. baumannii strains. The rates of resistance genes vary from region to region. Studies are required for the prevention and control of A. baumannii infection and to formulate the strategies of antibiotic usage.

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Bacteriological profile and antimicrobial resistance pattern of ventilator associated pneumonia in tertiary care hospital

Indian Journal of Microbiology Research ◽

10.18231/j.ijmr.2021.039 ◽

2021 ◽

Vol 8 (3) ◽

pp. 191-195

Author(s):

Eshwar Rajesh ◽

Radhika Katragadda ◽

C P Ramani

Keyword(s):

Mechanical Ventilation ◽

Antimicrobial Agents ◽

Tertiary Care ◽

Diffusion Method ◽

Resistance Pattern ◽

Ventilator Associated Pneumonia ◽

Care Hospital ◽

Mortality And Morbidity ◽

Endotracheal Aspiration ◽

Life Threatening

With an occurrence ranging from 6-52%, ventilator-associated pneumonia (VAP) is the most common ICU acquired infection, accounting for a significant portion of hospital-acquired infections (HAIs). VAP is pneumonia that develops after a period of more than 48 hours of mechanical ventilation or endotracheal intubation. To isolate and identify the potential pathogens causing VAP and to study their antimicrobial susceptibility patterns. Endotracheal aspiration (ETA) or bronchoalveolar lavage (BAL) were collected from patients on mechanical ventilation >48 hours. Bacterial isolates were identified based on culture colony characteristics and biochemical parameters. Antibiotic susceptibility profile was determined for these isolates by Kirby-Bauer disc diffusion method as per Clinical and laboratory Standards Institute (CLSI) 2020 guidelines and studied. The collected data was entered in Excel, and analyzed by using SPSS version 16. Among the isolates, the most common were (31.31%) and (31.31%). These were followed by (22.22%), (7.07%), (3.03%) and (3.03%) and (2.02%).Multi Drug Resistant (MDR) microbes causing VAP are on the increase. The patient population at risk will benefit by the application of the results of this study. The antibiotic resistance pattern of these isolates will aid clinicians in selecting the appropriate antimicrobial agents. Hence, it can lead to decreased mortality and morbidity due to life-threatening VAP.

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Epidemiology of Chronic Hepatitis C Infections at a Tertiary Care Centre in Oman

Sultan Qaboos University Medical Journal [SQUMJ] ◽

10.18295/squmj.2017.17.04.005 ◽

2018 ◽

Vol 17 (4) ◽

pp. 404 ◽

Cited By ~ 1

Author(s):

Said A. Al-Busafi ◽

Halima Al-Shuaili ◽

Heba Omar ◽

Haifa Al-Zuhaibi ◽

L. Jeyaseelan ◽

...

Keyword(s):

Liver Cirrhosis ◽

Chronic Hepatitis ◽

Hepatitis C ◽

Chronic Hepatitis C ◽

Clinical Laboratory ◽

Tertiary Care ◽

University Hospital ◽

Decompensated Cirrhosis ◽

Care Hospital ◽

Early Screening

Objectives: Chronic hepatitis C (CHC) is a leading cause of liver cirrhosis and hepatocellular carcinoma (HCC) worldwide. However, there is a lack of data regarding the epidemiology of CHC in Oman. This study aimed to describe the clinicopathological characteristics and outcomes of CHC-infected patients at a tertiary care hospital in Oman. Methods: This retrospective descriptive hospital-based study included all CHC-infected patients who presented to the Sultan Qaboos University Hospital (SQUH) in Muscat, Oman, between January 2010 and December 2015. The baseline demographic, clinical, laboratory and radiological data of the patients were analysed. Results: A total of 603 CHC-infected patients were identified during the study period; of these, 65.8% were male and the mean age was 44.8 ± 16.5 years. The main risk factors associated with CHC infection were intravenous drug abuse (23.9%) and a history of blood transfusions (20.7%). The most prevalent virus genotypes were 1 and 3 (44.0% and 35.1%, respectively). Upon initial presentation, 33.0% of the cohort had liver cirrhosis; of these, 48.7% had decompensated cirrhosis and 23.1% had HCCs. Liver transplantation was only performed for 7.5% of the cirrhosis patients, mostly as a curative treatment for HCC. Conclusion: The implementation of national policies to prevent hepatitis C transmission and encourage the early screening of at-risk patients is recommended to reduce the burden and consequences of this disease in Oman.

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Clinical relevance, Speciation, and Antibiogram of Non -Diphtherial Corynebacteria isolated from various clinical samples in a tertiary care hospital in Zagazig, Egypt

10.51429/ejmm30207 ◽

2021 ◽

Vol 30 (2) ◽

pp. 43-49

Author(s):

Shymaa Yahia ◽

May M. Sami

Keyword(s):

Tertiary Care ◽

Resistance Rate ◽

University Hospital ◽

British Society ◽

Diffusion Method ◽

Clinical Samples ◽

Care Hospital ◽

Beta Lactam ◽

Beta Lactam Antibiotics ◽

Isolated Species

Background: The non-diphtherial Corynebacteria, also called “Coryneforms” bacteria are a diversified group of gram positive non sporing bacilli belonging to the genus Corynebacteria. Such bacteria are considered members of human microbiota (skin, respiratory and genital mucus membranes). Coryneform bacteria's pathogenic capacity has been undervalued until recently. Despite of frequently deemed as contaminants, these bacteria have been correlated to diverse clinical infections recently. Objectives: To isolate, speciate, and determine antimicrobial susceptibility pattern of clinically relevant non-diphtherial Corynebacteria from various clinical samples. Methodology: Different clinical samples (blood, urine, sputum, wound swabs, pus) collected from hospitalized patients attending at Zagazig University Hospital. The samples were processed and cultured as per conventional bacteriological methods. A total of 75 clinically relevant corynebacterial isolates exhibited speciation utilizing matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) analysis and their antibiogram was done by disc diffusion method by means of combined guidelines of Clinical and Laboratory Standards Institute (CLSI) as well as British Society for Antimicrobial Chemotherapy (BSAC) because of lack of definite CLSI guidelines. Results: The mean age of the studied patients was 64.6 ± 14.9 years, 60% were male and 40% female. A total 75 clinically relevant Corynebacteria species were obtained from different clinical samples, including wound swabs and pus (53%), sputum (20%), and blood (17%). Forty two percent were isolated from ICUs. The most prevalent isolated species was C.amycolatum (27%), C. striatum (20%), and C.jeikieum (16%). Beta lactam antibiotics showed least activity against Corynebacteria species with resistance rate against penicillin 76% and ceftriaxone 72%, while all isolates exhibited uniform sensitivity (100%) against vancomycin as well as linezolid. Conclusion: This study showed isolation of different clinically relevant non-diaphterial Corynebacteria from different clinical samples with pus and wound swabs as the most common samples from which Corynebacteria were isolated. In particular, C.amycolatum was the most common isolated species. Beta lactam antibiotics (penicillin, ceftriaxone) showed the least activity while vancomycin and linezolid were the most active agents against nondiapdhterial Corynebacteria isolates. Herein, we confirm diphtheroids’ clinical importance among different infections that necessitate evaluating their susceptibility patterns to some common antibacterial agents for guide the best antibiotic to treat infections caused by these species.

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Antimicrobial Susceptibility, Serotyping, and Molecular Characterization of Antibiotic Resistance Genes in Listeria monocytogenes Isolated from Pregnant Women with a History of Abortion

Iranian Journal of Public Health ◽

10.18502/ijph.v50i1.5084 ◽

2021 ◽

Author(s):

Siamak HEIDARZADEH ◽

Mohammad Reza POURMAND ◽

Saeedeh HASANVAND ◽

Reyhaneh PIRJANI ◽

Davoud AFSHAR ◽

...

Keyword(s):

Listeria Monocytogenes ◽

Pregnant Women ◽

Resistance Genes ◽

Antimicrobial Agents ◽

Tertiary Care ◽

Antibiotic Resistance Genes ◽

Diffusion Method ◽

Care Hospital ◽

Disk Diffusion Method ◽

History Of

Background: Listeria monocytogenes show high mortality among pregnant women and newborns. This study aimed to detect L. monocytogenes in pregnant women with a history of abortion and assess the serotypes, antibiotic susceptibility patterns, and its resistance genes. Methods: Overall, 400 vaginal swabs were taken from pregnant women with a history of abortion in the past few years in a tertiary care hospital in Tehran, Iran, during 2015-2018. Antibiotics susceptibility to a panel of 10 antibiotics was determined using the standard disk diffusion method and the isolates serotyped by the agglutination method. The antimicrobial-resistant isolates were also screened for the presence of tetM, ermB and dfrD genes by PCR. Results: Overall, 22 L. monocytogenes isolates were identified. High rates of resistance were observed for trimethoprim (50%; n=11), sulphamethoxazole (50%; n=11), tetracycline (45.45%; n=10) and gentamicin (36.36%; n=8). From 22 L. monocytogenes isolates, 13 (59.10 %), 5 (22.73%), 3 (13.63%) and 1 (4.54%) belonged to serotypes 4b, 1/2a, 1/2b, and 3c, respectively. The genetic determinant tetM was detected in 70% of the tetracycline-resistant isolates. Out of 11 trimethoprim-resistant isolates, 27.27% isolates contained dfrD. Moreover, the ermB gene was found in 83.33% of the erythromycin-resistant isolates. Conclusion: Ampicillin and partly penicillin consider to be suitable antimicrobial agents to treat human listeriosis. Moreover, due to resistance against many antibiotics, it is necessary to continue monitoring and managing antimicrobial resistance.

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