Prevenção e controle de resistência aos antimicrobianos na Atenção Primária à Saúde: evidências para políticas / Prevention and control of antimicrobial resistance in Primary Health Care: evidence for policies

Resumo A resistência aos antimicrobianos é um problema mundial que põe em risco a segurança da saúde da população. O objetivo deste artigo é identificar e avaliar estratégias para prevenção e controle de resistência microbiana, bem como barreiras para sua implementação em serviços de Atenção Primária à Saúde (APS). Realizou-se uma síntese de evidências para políticas. As buscas de evidências foram realizadas entre novembro/dezembro de 2018, em 13 bases de dados. Um diálogo deliberativo foi realizado para validação dos resultados e levantamento de barreiras e facilitadores para implementação das estratégias. As 13 revisões sistemáticas incluídas mostraram que intervenções com foco em educação, uso de sistemas eletrônicos e biomarcadores reduziram o consumo e prescrição de antimicrobianos. É um obstáculo à implementação a expectativa de usuários/cuidadores em receber prescrição de antibióticos, e são facilitadores as ações educativas que envolvem profissionais de saúde. O uso racional de medicamentos se impõe na APS com vistas à prevenção da resistência dos microrganismos aos antibióticos. As intervenções identificadas neste estudo podem ser implementadas isoladamente ou em conjunto, conforme o contexto local.

Abstract Antimicrobial resistance is a global problem that puts the population's health at risk. This paper aims to identify and evaluate strategies for the prevention and control of antimicrobial resistance, and barriers to their implementation in Primary Health Care (PHC) services. We developed an evidence brief for policies. The search for evidence occurred in 13 databases from November to December 2018. A deliberative dialogue was performed to validate the results and we identified barriers and facilitators to implementing the strategies. The 13 systematic reviews included evidenced that the interventions focused on education, use of electronic systems and biomarkers reduced antimicrobial consumption and prescription. User/caregiver's expectation to receive antibiotic prescriptions was the main obstacle to implementing strategies, while education actions involving health professionals were facilitators. The rational use of medications in the PHC services is crucial to prevent antimicrobial resistance to antibiotics. The interventions identified in this study can be implemented alone or combined, according to local context.

Escherichia coli productora de BLEE de origen comunitario e intrahospitalario / BLEE-producing Escherichia coli of community and hospital-acquired origin / Escherichia coli produtora de BLEE de origem comunitária e hospitalar

Escherichia coli (E. coli) constituye una de las principales enterobacterias patógenas causantes de infecciones asociadas a la asistencia en salud, con alto impacto a nivel hospitalario y comunitario por su elevada tasa de morbilidad y mortalidad. El mecanismo de defensa de estas bacterias es mediante la generación de enzimas de resistencia, como la producción de Beta-lactamasas de espectro extendido. OBJETIVO: caracterizar la resistencia a betalactámicos de espectro extendido a partir de su prevalencia en aislados de Escherichia coli de origen comunitario e intrahospitalario de la ciudad de Azogues. MATERIALES Y MÉTODOS: estudio de tipo descriptivo, documental. La población estuvo conformada por 877 registros de la base de datos WHONET de aislados de E. coli procedentes de muestras de origen comunitario e intrahospitalario del laboratorio del Hospital Homero Castanier Crespo. RESULTADOS: el 75,5% de los aislados fueron de mujeres y el 24,5 % de varones. La media de edad fue 43,5 años. La frecuencia de E. coli productora de BLEE fue del 17,7 % con mayor frecuencia en varones (23,7%), en el área de clínica (25,2%), cirugía (16,8%) y en muestras de herida quirúrgica (11,6%). Predominó la resistencia a betalactámicos (84,5%) y cefalosporinas de primera y segunda generación mayor al 48%. Los carbapenemes (imipenen 97,3% y meropenem 96,7%), aminoglucósidos (amikacina 94,9 y gentamicina 80,5), fosfomicina (90,3) y nitrofurantoina (96,7%) mostraron mayor sensibilidad. CONCLUSIONES: la monitorización constante de enzimas BLEE, permite la detección temprana de patrones de sensibilidad y a la vez orienta a un tratamiento terapéutico adecuado, evitando generación de nuevas resistencias y altas tasas de morbilidad y mortalidad.

Escherichia coli (E. coli) is one of the main pathogenic enterobacteria causing infections associated with health care, with high impact at hospital and community level due to its high morbidity and mortality rate. The defense mechanism of these bacteria is through the generation of resistance enzymes, such as the production of extended spectrum beta-lactamases. OBJECTIVE: to characterize extended-spectrum beta-lactam resistance based on its prevalence in Escherichia coli isolates of community and intrahospital origin in the city of Azogues. MATERIALS AND METHODS: descriptive, documentary study. The population consisted of 877 records from the WHONET database of E. coli isolates from community and in-hospital samples from the Homero Castanier Crespo Hospital laboratory. RESULTS: 75.5% of the isolates were from females and 24.5% from males. The mean age was 43.5 years. The frequency of BLEE-producing E. coli was 17.7%, with a higher frequency in males (23.7%), in the clinical area (25.2%), surgery (16.8%) and in surgical wound samples (11.6%). Resistance to beta-lactams predominated (84.5%) and first and second generation cephalosporins was greater than 48%. Carbapenems (imipenem 97.3% and meropenem 96.7%), aminoglycosides (amikacin 94.9 and gentamicin 80.5), fosfomycin (90.3) and nitrofurantoin (96.7%) showed higher sensitivity. CONCLUSIONS: the constant monitoring of BLEE enzymes allows the early detection of sensitivity patterns and at the same time guides to an adequate therapeutic treatment, avoiding the generation of new resistances and high morbidity and mortality rates.

A Escherichia coli (E.coli) é uma das principais enterobactérias patogênicas que causam infecções associadas aos cuidados de saúde, com alto impacto em nível hospitalar e comunitário devido a sua alta taxa de morbidade e mortalidade. O mecanismo de defesa dessas bactérias é através da geração de enzimas de resistência, tais como a produção de beta-lactamases de espectro estendido. OBJETIVO: caracterizar a resistência beta-lactam de amplo espectro com base em sua prevalência em Escherichia coli isolados de origem comunitária e intra-hospitalar na cidade de Azogues. MATERIAIS E MÉTODOS: estudo descritivo, documental. A população consistia de 877 registros do banco de dados WHONET de E. coli isolados de amostras comunitárias e hospitalares do laboratório do Hospital Homero Castanier Crespo. RESULTADOS: 75,5% dos isolados eram de fêmeas e 24,5% de machos. A idade média era de 43,5 anos. A freqüência da E. coli produtora de BLEE foi de 17,7%, com maior freqüência em homens (23,7%), na área clínica (25,2%), na cirurgia (16,8%) e em amostras de feridas cirúrgicas (11,6%). A resistência aos beta-lactâmicos (84,5%) e às cefalosporinas de primeira e segunda geração predominou (mais de 48%). Carbapenems (imipenem 97,3% e meropenem 96,7%), aminoglicosídeos (amikacin 94,9 e gentamicina 80,5), fosfomicina (90,3) e nitrofurantoína (96,7%) mostraram maior sensibilidade. CONCLUSÕES: o monitoramento constante das enzimas BLEE permite a detecção precoce de padrões de sensibilidade e, ao mesmo tempo, orienta para um tratamento terapêutico adequado, evitando a geração de novas resistências e altas taxas de morbidade e mortalidade.

Identification Des Nouveaux Progrès Sur Les Molécules Dérivées Du Pyrazole Comme AgentsAntimicrobiens Et Antifongiques

Microbial infections remain a worldwide leading cause of death,despite the evolution of a large number of new antibiotics everyyear. Currently, several bacteria have developed resistanceagainst antibiotics drugs which remain a major issue inantibiotics drug discovery. This review provides detailedinformation about antimicrobial and antifungal agent synthesisbelonging to the pyrazoles scaffold. We reassemble the resultsobtained from several studies to characterize the importance ofheteroatom nuclei in many synthetic products. Additionally,several compounds based on pyrazole derivatives such asbenzimidazole, benzothiazole, indole, acridine, oxadiazole,imidazole, isoxazole, pyrazole, triazole, quinoline and quinazolineincluding other pyrazole containing drugs such as pyridazine,pyridine and pyrimidine are highlighted. Furthermore, you willfind in this review 134 best promise structures collected fromrecent studies, relating the pyrazoles structures to the relevantbiological activities, in particular, antimicrobial and antifungalone.

Antimicrobial resistance of Escherichia coli isolates from spray‑chilled sheep carcasses during cooling / Resistencia antimicrobiana en aislados de Escherichia coli de canales de ovejas asperjadas durante la refrigeración / Resistência antimicrobiana de isolados de Escherichia coli de carcaças ovinas aspergidas durante o resfriamento

Abstract Background: Multidrug-resistant bacteria present in food of animal origin raise human and animal health concerns. Objective: To assess antimicrobial resistance of Escherichia coli isolates from sheep carcasses subjected to spray-chilling with water (4 and 10 hours) during cooling. Methods: Thirty surface swabs were collected from carcasses before and after the last water spray in two slaughter periods. In a first assessment (1st sampling), three spray-chilled carcasses (4 hours), three non-sprayed and one control carcass were sampled. In a second assessment (2nd sampling), the same number of carcasses and treatments were maintained, but spray-chilling was extended to 10 hours. All samples collected were isolated and submitted to susceptibility test using 16 (1st sampling) and 17 (2nd sampling) antimicrobials, respectively. Results: Overall, E. coli isolates were resistant most antimicrobials. Spray-chilled and control carcasses (10 hours) showed resistance to meropenem. Conclusion: E. coli isolates from carcasses subjected to spray-chilling with water for 10 hours had higher antimicrobial resistance to one, two, and four antimicrobial classes, characterizing a multidrug resistance profile. These results highlight the need to monitor health status throughout the meat production processes.

Resumen Antecedentes: las bacterias multirresistentes presentes en alimentos de origen animal son motivo de alerta para la salud humana y animal. Objetivo: verificar la resistencia a antimicrobianos de aislados de Escherichia coli en canales ovinas sometidas a aspersión (4 y 10 h) durante la refrigeración. Métodos: Luego de dos faenas de sacrificio, treinta hisopos fueron colectados en la superficie de las canales antes y después de la última aspersión. En un primer sacrificio (1era colecta) se recolectaron muestras de tres canales sometidas a aspersión (4 horas), tres sin aspersión y una canal como control. En un segundo sacrificio (2da colecta), el mismo número de canales y tratamientos se mantuvo, y el período de aspersión se extendió a 10 horas. Las muestras recogidas fueron aisladas y sometidas a la prueba de susceptibilidad utilizándo 16 (1.ª colecta) y 17 (2.ª colecta) antimicrobianos, respectivamente. Resultados: los aislamientos de E. coli fueron, en general, resistentes a las principales clases de antimicrobianos. Las canales con aspersión y el control (10 h) presentaron resistencia al meropenem. Conclusión: cuando la asperción duró 10 h, los aislados de E. coli presentaron mayor resistencia para una, dos y cuatro clases de antimicrobianos, es decir, fueron multirresistentes a los fármacos utilizados. Esto resalta la necesidad de monitorear el estado de salud durante todos los procesos de producción de carne.

Resumo Antecedentes: bactérias multirresistentes presentes em alimentos de origem animal são motivo de preocupação e alerta na saúde humana e animal. Objetivo: verificar a resistência antimicrobiana em isolados de Escherichia coli de carcaças de ovinos pulverizadas ou não (4 e 10 horas) durante a refrigeração. Métodos: foram coletados trinta swabs de superfície em carcaças antes e após a última aspersão em dois abates. Em outubro do 2015, três carcaças aspergidas foram amostradas, três sem aspersão e uma carcaça para controle, por um período de 4 horas. Em julho de 2016 (2ª coleta), o mesmo número de carcaças e tratamentos foram mantidos e o período de aspersão foi prolongado em 10 horas. As amostras coletadas foram isoladas e submetidas ao teste de susceptibilidade em 16 (1ª coleta) e 17 (2ª coleta) antimicrobianos, respectivamente. Resultados: isolados de E. coli foram, em geral, resistentes às principais classes de antimicrobianos. As carcaças e o controle aspergidos (10 h) apresentaram resistência ao meropenem. Conclusão: quando a aspersão de água durou 10 horas, os isolados de E. coli apresentaram maior resistência antimicrobiana a uma, duas e quatro classes de antimicrobianos, o que é uma multirresistência aos fármacos testados. Isso alerta para a necessidade de monitorar os aspectos de saúde durante todos os processos de produção de carne.

Subinhibitory concentrations of silver nanoparticles and silver nitrate on the adaptative and cross-resistance to antibiotics on bovine mastitis pathogens / Concentrações subinibitórias de nanopartículas de prata e nitrato de prata na resistência adaptativa e cruzada com antibióticos em patógenos de mastite bovina

ABSTRACT: Biocides and/or antibiotics used in subinhibitory concentrations can promote the development of adaptive resistance or even cross-resistance in microorganisms. However, studies on these responses following silver treatments are scarce in the literature. Silver-based compounds, including silver nanoparticles (Ag-NPs), can be an alternative in the prevention and treatment of bovine mastitis. Thus, this research evaluated the effect of subinhibitory dosages of Ag-NPs and Ag+ ions from silver nitrate (AgNO3) on Staphylococcus aureus and Escherichia coli isolated from milk of cows with mastitis. Ag-NPs were synthesized by chemical reduction using AgNO3 and sodium citrate and the minimum inhibitory concentration (MIC) of Ag-NPs and Ag+ ions on the mastitis pathogens were determined. Isolates were exposed to subinhibitory concentrations of Ag-NPs or AgNO3 for 10 consecutive days to verify the development of adaptive resistance evaluated by changes in the MIC values. The development of cross-resistance with antibiotics was also studied, being verified by comparing the sensitivity profile of treated cells with non-treated cells. AgNO3 was more effective against all isolates. There was no change in the MIC values or in the antibiotic sensitivity profile for both bacteria following consecutive exposure to subinhibitory dosages of Ag-NPs or AgNO3, indicating that silver was not able to select adaptive resistance or cross resistance to the tested antibiotics. The potential of silver presented by these results is favorable to the continuity of studies aiming to elaborate silver-based therapies for the treatment of bovine mastitis.

RESUMO: Biocidas e/ou antibióticos em concentrações sub-inibitórias podem promover o desenvolvimento de resistência adaptativa ou mesmo resistência cruzada nos micro-organismos. Entretanto, estudos destas respostas após o tratamento com a prata são escassos na literatura. Compostos a base de prata, incluindo as nanopartículas de prata (Ag-NPs), podem ser uma alternativa na prevenção e/ou tratamento de mastite bovina. Assim, este trabalho objetivou determinar o efeito de doses sub-inibitórias de Ag-NPs e dos íons Ag+ provenientes do nitrato de prata (AgNO3) sobre isolados de Staphylococcus aureus e de Escherichia coli, provenientes de leite de vacas com mastite. As Ag-NPs foram sintetizadas por redução química utilizando AgNO3 e citrato de sódio e a Concentração Mínima Inibitória (CMI) das Ag-NPs e íons Ag+ nos patógenos da mastite foi determinada. Os isolados foram expostos a concentrações sub-inibitórias de Ag-NPs ou de AgNO3 por 10 dias consecutivos para verificar o desenvolvimento de resistência adaptativa à prata pela mudança no valor da CMI, e de resistência cruzada com antibióticos pela mudança no perfil de sensibilidade em relação ao controle. AgNO3 apresentou-se mais efetivo contra todos os isolados. Não foi verificada alteração no valor da CMI nem do perfil de sensibilidade aos antibióticos, indicando que não houve seleção de resistência adaptativa à prata e de resistência cruzada aos antibióticos pelos micro-organismos estudados. O uso potencial da prata apresentado nos resultados é favorável à continuidade dos estudos objetivando a elaboração de terapias à base de prata para o tratamento da mastite bovina.

Bactérias resistentes isoladas de superfícies inanimadas em um hospital público / Bacterias resistentes aisladas de superficies inanimadas en un hospital público / Isolated resistant bacteria from inanimate surfaces in a public hospital

RESUMO Objetivo: descrever o perfil de resistência a antimicrobianos de microrganismos presentes em superfícies inanimadas. Método: estudo descritivo, realizado entre fevereiro e junho de 2018. Coletou-se 40 amostras microbiológicas de superfícies da Clínica Médica e Unidade de Terapia Intensiva Adulto em um hospital de Mato Grosso, Brasil. A identificação e sensibilidade microbiana foram realizadas através do VITEK-2. A análise dos resultados de resistência foi avaliada conforme as diretrizes do Clinical Laboratory Standards Institute. Resultados: foram isolados 32 microrganismos das 22 amostras contaminadas, dentre eles 14 (43,8%) Staphylococcus coagulase negativa, sete (21,9%) Acinetobacter baumanni complex, três (9,4%) Enterobacter aerogenes. Dentre os Staphylococcus coagulase negativa, 11 (78,6%) apresentaram multirresistência a antimicrobianos e três (42,9%) dos isolados de Acinetobacter baumanni complex foram extremamente resistentes. Conclusão: evidenciou-se a necessidade de educação com ênfase na desinfecção correta e frequente de superfícies e na higienização das mãos após tocar o paciente e as superfícies próximas a ele.

RESUMEN Objetivo: describir el perfil de resistencia de microrganismos presentes en superficies inanimadas a agentes antimicrobianos. Método: estudio descriptivo realizado entre febrero y junio de 2018. Se recolectaron 40 muestras microbiológicas de superficies de la Clínica Médica y de la Unidad de Cuidados Intensivos para Adultos de un hospital de Mato Grosso, Brasil. Los procesos de identificación y sensibilidad microbiana se realizaron a través del dispositivo VITEK 2. El análisis de los resultados de resistencia se evaluó conforme a las directrices del Clinical Laboratory Standards Institute. Resultados: se aislaron 32 microrganismos de las 22 muestras contaminadas; entre ellos, hubo 14 (43,8%) Staphylococcus coagulasa negativa, siete (21,9%) Acinetobacter baumanni complex y tres (9,4%) Enterobacter aerogenes. Entre los Staphylococcus coagulasa negativa, 11 (78,6%) presentaron multi-resistencia a agentes antimicrobianos y tres (42,9%) de los aislados bacterianos de Acinetobacter baumanni complex fueron extremamente resistentes. Conclusión: se hizo evidente la necesidad de instrucción con énfasis en la correcta y frecuente desinfección de superficies y en el lavado de manos después de entrar en contacto con el paciente y con las superficies próximas al paciente.

ABSTRACT Objective: to describe the antimicrobial resistance profile of microorganisms present on inanimate surfaces. Method: a descriptive study, conducted between February and June 2018. Forty microbiological samples were collected from surfaces of the Medical Clinic and Intensive Care Unit for Adults in a hospital located in Mato Grosso, Brazil. Microbial identification and sensitivity were performed by means of VITEK 2. The analysis of the resistance results was assessed according to the Clinical Laboratory Standards Institute guidelines. Results: a total of 32 microorganisms were isolated from the 22 contaminated samples, the following among them: 14 (43.8%) Coagulase-Negative Staphylococcus, seven (21.9%) Acinetobacter baumanni complex, and three (9.4%) Enterobacter aerogenes. Of the Coagulase-Negative Staphylococcus, 11 (78.6%) presented multi-drug resistance to antimicrobial agents, and three (42.9%) of the Acinetobacter baumanni complex isolates were extremely resistant. Conclusion: this study evidenced the need for education with emphasis on proper and frequent disinfection of surfaces and on hand hygiene after touching patients and surfaces close to them.

Innovaciones en la terapia antimicrobiana / Innovations in antimicrobial therapy

Resumen La resistencia microbiana ha llevado a la búsqueda de innovadoras alternativas para su contención y dentro de las más promisorias están el uso de péptidos sintéticos, no sólo por sus características intrínsecas antimicrobianas, sino por las interacciones sinérgicas y antagónicas que presenta con otros mediadores inmunológicos. Estas propiedades han permitido crear péptidos sintéticos reguladores de defensa innata que representan un nuevo enfoque inmunomodulador para el tratamiento de infecciones; sin embargo, sólo los diseñados con alto score antimicrobiano, han demostrado eficacia en estudios clínicos de Fase 3. Debido a su amplio espectro de actividad, un único péptido puede actuar contra bacterias Gram negativas, Gram positivas, hongos, e incluso virus y parásitos, aumentando el interés por investigar estas dinámicas moléculas. Por otra parte, se encuentra el sistema CRISPR, para la edición de genomas bacterianos, permitirá reducir su actividad virulenta y diseñar antimicrobianos basados en nucleasas CRISPR-Cas 9 programables contra dianas específicas, las que representan un promisorio camino en el estudio de nuevas alternativas con alto potencial para eliminar la resistencia a antibióticos de bacterias altamente patógenas. Asimismo, se aborda la terapia con fagos, referida a la acción de virus que infectan bacterias, usados solos o en cocteles para aumentar el espectro de acción de estos, aprovechando su abundancia en la naturaleza, ya que se ha considerado que cada bacteria tiene un virus específico que podría emplearse como potente agente antibacteriano. Finalmente, mientras se usen como principal medio de contención solo tratamientos convencionales antimicrobianos, incluso de manera oportuna y acertada, la microevolución en las bacterias se asegurará de seguir su curso.

Abstract Microbial resistance has led to the search for innovative alternatives to contain it. One of the most promising ones is the use of peptides, not only due to their intrinsically antimicrobial characteristics, but also due to the synergistic and antagonistic interactions they present with other immunological mediators. These properties have enabled the creation of innate immune regulatory peptides, which represent a new immunomodulatory approach to treat infections. However, despite multiple attempts tested, only the designed with a high antimicrobial score have demonstrated effectiveness in phase three clinical trials. Yet, given their exceptionally wide spectrum of activity, a single peptide can have activity against Gram-negative bacterial, Gram-positive bacterial, fungi and even viruses and parasites, increasing the interest in researching these dynamic molecules. Furthermore, the CRISPR system enables the editing of bacterial genomes, which would make it possible to reduce their virulent activity and design antimicrobials based on programmable CRISPR-Cas 9 nucleases against specific targets. This system represent a promising path in the study of new alternatives with high potential to eliminate antibiotic resistance of highly pathogenic bacteria. Likewise, phage therapy, that is, the action of viruses that infect bacteria, used alone or in cocktails to increase their spectrum of action, taking advantage of their abundance in nature, given that it has been considered that each bacterium has a specific virus that it could be used as a potent antibacterial agent. Finally, as long as conventional antimicrobial treatments continue to be used as the main means of containment, even when they are used correctly, the microevolution of bacteria will be itself sure to continue its own path.

Multiresistant microorganism infection in newborns at an intermediate neonatal care unit and intensive care unit of reference: cross-sectional study / Infecção por microrganismo multirresistente em recém-nascidos na unidade de cuidados intermediários neonatais e unidade de cuidados intensivos de referência: estudo transversal

The objective was to describe the infection profile of multidrug-resistant organisms of newborns (NB), admitted to the neonatal intermediate care unit and the intensive care unit. It was a descriptive cross-sectional study of epidemiological nature, composed of 931 medical records and/or Hospital Infection Control Committee notification records, during the period of June to September 2012. Eight hundred and seventy newborns (NB) were admitted to the neonatal intensive care units and to intermediate care, with a final sample of 45 NB presenting bloodstream infections (BSI) caused by multiresistant microorganisms. From the analyses, the following results were highlighted: gestational age < 37 weeks in 42 (93.3%); low weight at birth between < 750g to 1.499g. The profile for resistance to enterobacteriaceae was 100% for cefepime and ceftazidime concerning non-fermenting gram-negative bacteria, it was found that (100%) of P.aeruginosa was resistant to aztreonam, (100%) of S. maltophilia resistant to ceftazidime and to gentamycin, however, (1.1%) of S. aureus isolates were resistant to oxacillin and (12.5%) of S. haemolyticus demonstrated a confirmed resistance to vancomycin. These results are worrying and express the importance of correct monitoring, and the need for producing a propaedeutic protocol in consensus with the multiprofessional team through the Hospital Infection Control Committee and managers, which is then implemented and regularly assessed by the service.

Objetivou-se descrever a infecção por microorganismo multirresistente em recém-nascidos na unidade de cuidados intermediários neonatais e unidade de cuidados intensivos de referência. Tratou-se de estudo transversal de natureza epidemiológica, composto por 931 fichas e/ou prontuários de notificação da Comissão de Controle de Infecção Hospitalar (CCIH), no período junho a setembro de 2012. Foram 870 recém-nascidos (RN), admitidos nas unidades de terapia intensiva neonatal e de cuidados intermediários, como amostra final 45 RN apresentaram infecção de corrente sanguínea por microorganismo multirresistente. Dessas análises destacam-se os resultados: idade gestacional < 37 semanas em 42 (93,3%); baixo peso ao nascer entre < 750g a 1.499g. O perfil de resistência à enterobactérias foi de 100% para o cefepime e ceftazidime, e para as bactérias gram-negativas não fermentadoras, verificou-se que (100%) da P.aeruginosa era resistente ao aztreonam, (100%) de S.maltophilia resistente à ceftazidima e à gentamicina; Entretanto, (1,1%) dos isolados de S. aureus eram resistentes à oxacilina e (12,5%) de S. haemolyticus conferiu resistência à vancomicina. Esses resultados são preocupantes e demonstram a relevância do monitoramento, propondo a elaboração de protocolo propedêutico em consenso com a equipe multiprofissional, com a CCIH e gestores a ser implementado e avaliado, regularmente pelo serviço.

Emerging Threat of Salmonella typhimurium in Extraintestinal Infections: Cases from a Tertiary Care Hospital in North India

Purpose:Infections due to invasive non-typhoid salmonella can be dangerous and fatal. The mode of infection and the severity varies from the typhoidal fevers. It is important to find the association between clinical features and the infecting serovar to understand the pathophysiology and course of treatment Methods:In the present study, extra-intestinal specimens (blood, cerebrospinal fluid and pus) from three patients suffering from septicaemia, meningitis and osteomyelitis were received. Micro-biological and biochemical test for species identification and antibiotic susceptibility was done as per standard protocol.Further, PCR based amplification and sequencing of a portion of the flagellin gene (FliC) was done to confirm the serovar.Results: Salmonellaentericawas identified from all the threeby microbiological and biochemical examination.The sequence of the Flic gene confirmed the serovar to be S.typhimurium. All the patients were treated successfully for the infectionby appropriate antibiotic therapy. Conclusion:The study highlights that serovarTyphimurium is common in invasive non-typhoidal salmonellosis and its pathophysiology and virulence factors expression should be understood in various organ types for better treatment options and outcomes

Clinico-microbiological Profile of Diabetic Foot Ulcers at a Tertiary Care Hospital of Odisha

Introduction: Child abuse is a global phenomenonoccurring either in a child’s home or in institution, school orcommunities. Though it bears an impact on the individual,families and community at large, the exact extent of the issuestill remain unclear. This study was taken up with the aimof reporting awareness regarding child neglect and abuse asliterature evidence in this part of the country is scant.Material and methods: A cross sectional study was employedto assess the awareness regarding child abuse and neglectamong 331 dental professionals of Telangana using a pre –designed structured questionnaire of 12 parameters.Results: The study participants were practitioners of bothpublic and private sector and students, both undergraduateand post graduates.80.6% of the respondents were awareregarding child abuse and neglect.Conclusion: Though majority of the dentists were awareabout CAN, sensitization regarding identification, reportingand treating of abuse is called for by continuing educationprogrammes and seminars.

Empirical Antibiotic Prescription Pattern among Patients in a Nigerian Tertiary Hospital, is There Evidence of Irrationality?

Background:Resistance to antibiotics is spreading rapidly around the world with its associated morbidity and mortality. Infections are becoming increasingly difficult to treat resulting in increasedcost of medical care. In low income countries with high infectious disease burden, antibiotic resistance is reported to be accelerated by irrational prescriptions in health facilities. In the absence of adequate resources, many clinicians engage in empirical antibiotic prescriptions some of which their appropriateness is questionable. There is need for laboratory evidence to justify empirical antibiotic use in the light of increasing resistance to commonly prescribed antibiotics.Aims:This study aims to determine empirical antibiotic prescription pattern and to determine rationality using resistance profile of common bacterial isolates inhospitals.Methods:Antibiotic prescriptions in the NHIS department and antibiogram records were obtained from pharmacy and laboratory records respectively. Analysis was carried out using descriptive statistics and comparison between antibiotics prescribed and their respective resistance pattern were compared to determine rationality.Resultsand Discussion:The Penicillins and Quinolones were the most prescribed class of antibiotics and resistance range between 30 –90% and 3 –23% respectively. Resistance to other antibiotics was high thus making empirical prescriptions irrational in most of the cases. These findings have been consistently reported in several studies so widespread empirical antibiotic prescriptions are not in tandem with principles of rational drug use.Conclusion:Antibiotic resistance is common among hospital isolates, so there is need to emphasize that prescriptions be based on laboratory evidence of microbial sensitivity

Resistencia de Staphylococcus aureus frente a cefalosporinas en la sepsis neonatal y puerperal / Staphylococcus Aureus Resistance against Cephalosporins in Neonatal and Puerperal Sepsis

Introducción: El mecanismo más común de actividad antibiótica es la interferencia en la síntesis de la pared celular bacteriana. Las cefalosporinas tienen el mismo mecanismo de acción que las penicilinas; sin embargo, tienen un espectro antibacteriano más amplio, son resistentes a muchas b-lactamasas y tienen propiedades farmacocinéticas mejoradas. Objetivos: Identificar por servicios los gérmenes aislados y determinar la resistencia del Staphylococcus aureus a las cefalosporinas. Método: Se realizó un estudio retrospectivo, transversal y descriptivo en hospital Ginecobstétrico de Guanabacoa desde enero de 2014 hasta diciembre de 2016. Se seleccionaron como variables los gérmenes aislados y el patrón de resistencia del germen que predominó frente a todas las generaciones de cefalosporinas. Resultados: En el servicio de neonatología el mayor aislamiento fue en el hemocultivo seguido del catéter venoso (19 pacientes) y tubo endotraqueal. En el servicio de Obstetricia, los loquios y el sitio quirúrgico fue donde se aisló mayor número (69 y 31 pacientes, respectivamente). Conclusiones: El germen más frecuente aislado en ambos servicios fue el Staphylococcus aureus y la resistencia a las cefalosporinas fue muy elevado(AU)

Introduction: The synthesis interference of bacterial cell wall is the most common antibiotic mechanism. Cephalosporins have the same mechanism of action as penicillin. However, they have wider antibacterial spectrum, they are more resistant to B-lactamases and better pharmacokinetics properties. Additionally, cephalosporins have higher activity in front of gram-negative bacteria than penicillin. Objective: To identify isolated germs in these services and to determine the Staphylococcus aureus resistance to cephalosporins. Method: A retrospective, transversal and descriptive study was conducted in Guanabacoa Gynecobstetric hospital from January 2014 to December 2016. selected variables as isolated microorganism, and resistance pattern in front of cephalosporin generations. The isolated germs and the resistance pattern of the germ that prevailed against all generations of cephalosporins were selected as variables. In the Obstetrics Service, the largest number of germs was isolated in the lochia and surgical sites. (69 and 31, respectively). Results: In neonatology service, the most frequent isolation occurred in blood culture (35), venous catheter (19) and endotracheal tube (10). In Obstetric service, the most frequent isolation occurred in liquors (69) and the surgical site isolated (31). Conclusions: Staphylococcus Aureus was the main microorganism isolated in hospital and its cephalosporin resistance was very high(AU)

Los enzibióticos como alternativa terapéutica contra las enfermedades bacterianas / The enzybiotics as therapeutic alternative against bacterial diseases

El constante desarrollo de las enfermedades infecciosas, conjuntamente con la aparición de la resistencia microbiana a los antibióticos, ha originado que nuevamente se piense en los fagos como opción terapéutica. De hecho, existe una importante aportación bibliográfica sobre los bacteriófagos y su utilidad para eliminar los procesos infecciosos, lo que ha justificado el continuar investigando acerca del posible uso de estos y de sus productos génicos, como esperanzadora alternativa a los tratamientos con antimicrobianos disponibles en la actualidad. Por ello, en este artículo se ofrece información sobre estos microorganismos, en específico sobre los enzibióticos, y se propone que sean considerados en el combate contra las infecciones bacterianas.

The constant development of the infectious diseases, together with the emergence of the microbial resistance to the antibiotics, has originated that again it is thought on the phages as therapeutic option. In fact, an important literature contribution exists about the bacteriophages and their use to eliminate infectious processes, what has justified the continuity in investigating about the possible use of them and of their genic products, as a promising alternative for treatments with antimicrobials currently available. That is why, information on these microorganisms is offered in this work, specifically on the enzibiotics, and is it intended them to be considered in the bacterial infections control.

Política antimicrobiana. Necesidad imperiosa ante la creciente resistencia microbiana actual / Antimicrobial policy. Imperative need in view of the current increasing microbial resistance

Introducción: Los antimicrobianos constituyen uno de los grupos farmacológicos más utilizados en la práctica clínica y está demostrada su relación con la resistencia microbiana. El uso racional de antibióticos puede producir beneficios desde el punto de vista médico y social, pero su uso en ocasiones no es el más adecuado y debe ser objeto de una vigilancia especial y sistemática. Es necesaria una política antimicrobiana coherente en las unidades de salud. Objetivo: Revisar consensos y criterios nacionales e internacionales sobre política antimicrobiana para tratar de unificar criterios aplicables lo más uniforme posible en las instituciones de salud. Material y Método: Se realizó una búsqueda bibliográfica en diferentes bases de datos: Clinical Evidence, The Cochrane Library, PUBMED, Google Académico, MEDLINE, LIS, Scielo, Medscape, LILACS, Latindex, HINARI, MEDIGRAPHIC-NEWS, NIH Reporter y en la web de la OPS/OMS sobre política antimicrobiana, comisión de antibióticos, política de antibióticos. Desarrollo: Se consideraron conceptos de diferentes publicaciones cubanas y consensos internacionales, componentes humanos, objetivos, funciones, recursos, métodos, estrategias y control. Conclusiones: Introducir cualquier modificación terapéutica en la atención médica tiene que ser correctamente valorado en todas sus dimensiones: científica, tecnológica y social. La selección del antibiótico cuando no es posible el estudio microbiológico y/o se carece de antibiograma debe ser hecha sobre las bases clínicas y epidemiológicas locales. La creación de una Política Antimicrobiana con todos sus componentes, recursos y metodología es necesaria más que nunca en estos tiempos. Puede estar sujeta a modificaciones con nuevas evidencias; pero tiene que ser cumplida para disminuir la resistencia microbiana, los costos y obtener mejores resultados(AU)

Introduction: Antimicrobials are one of the most pharmacological groups used in the clinical practice, and its relation to microbial resistance is demonstrated. The rational use of antibiotics can be beneficial from the social and medical point of view, but occasionally, their use is not the most correct one and there should be a systematic and special surveillance. A rational antimicrobial policy is necessary in the health care centers. Objective: To review national and international consensuses and criteria on antimicrobial policy to try to unify criteria and apply them the most uniform way possible in health care centers. Material and method: A bibliographic review on antimicrobial policy, antibiotics commission, and antibiotics policy was made in different databases; some of them were: Clinical Evidence, The Cochrane Library, PUBMED, Academic Google, MEDLINE, LIS, Scielo, Medscape, LILACS, Latindex, HINARI, MEDIGRAPHIC-NEWS, NIH Reporter, and the Web sites of the PAHO/ WHO. Development: Concepts on different Cuban publications, international consensuses, human components, objectives, functions, resources, methods, strategies, and controls were considered. Conclusions: The implementation of any therapeutic modification in the medical attention has to be analyzed correctly in all its dimensions: scientific, technological, and social ones. When the microbiological study is not possible or there is no antibiogram, the selection of the antibiotic should be made on the local epidemiological and clinical basis. The creation of an Antimicrobial Policy with all its components, resources, and methodology is needed now more than ever. It can be submitted to modifications with new evidences, but it has to be fulfilled to reduce both microbial resistance and the costs, and obtain better results(AU)

La resistencia microbiana en el contexto actual y la importancia del conocimiento y aplicación en la política antimicrobiana / Microbial resistance in the current context and the importance of knowledge and application in antimicrobial policy

La resistencia actual de los gérmenes a los antimicrobianos constituye un grave problema actual de salud en todo el orbe. Los mecanismos pueden ser intrínsecos o adaptativos. El uso indiscriminado e irracional de estos fármacos constituye la principal causa de la gravedad de la situación que hoy se presenta. Objetivo: Realizar una revisión actualizada sobre la resistencia a los antimicrobianos, sus causas y mecanismos y la importancia del conocimiento y aplicación de la política antimicrobiana. Material y Métodos: Se realizó una búsqueda bibliográfica en diferentes bases de datos: Clinical Evidence, The Cochrane Library, PUBMED, Google Académico, MEDLINE, LIS, Scielo, Medscape, LILACS, Latindex, HINARI, MEDIGRAPHIC-NEWS, NIH Reporter, en Scholar google y en la web de la OPS/OMS sobre los temas resistencia microbiana, política de uso de antimicrobianos e infecciones hospitalarias o asociadas a la asistencia sanitaria. Desarrollo: Se consideraron conceptos de resistencia microbiana, los mecanismos por los cuales se establecen, la resistencia y multirresistencia de gérmenes actuales, la importancia de la política antimicrobiana y sus derivados y la forma de prevenir, combatir y disminuir los efectos de este problema de salud que afecta a escala mundial. Conclusiones: Es muy importante la actualización y concientización del problema, así como la superación profesional, institucional, de organismos y organizaciones, del Estado y gobierno. La importancia de la vigilancia epidemiológica, del Comité de Infección Hospitalaria, la información de las resistencias y el análisis de la calidad de la atención médica con el uso adecuado de antimicrobianos son importantes en el enfrentamiento a esta problemática de salud(AU)

Introduction: The current resistance of germs to antimicrobials constitutes a serious health problem throughout the world. Mechanisms may be intrinsic or adaptive. The indiscriminate and irrational use of these drugs is the main cause of the gravity of the situation that is presented today. Objective: to carry out an updated review about of antibiotics, resistance, its causes and mechanisms and the importance of the knowledge and application of the antimicrobial policy. Material and Methods: A bibliographic research in different databases was carried out: Clinical Evidence, The Cochrane Library, PUBMED, Academic, MEDLINE, LIS, SciELO, Medscape, LILACS, Latindex, HINARI, MEDIGRAPHIC-NEWS, NIH Reporter, Google Scholar and in the PAHO / WHO website about the topics, microbial resistance, antimicrobial policy and hospital or associated health care infections. Development: The concepts of microbial resistance, its established mechanisms, the resistance and multiresistance of current germs, the importance of the antimicrobial policy and its derivatives and how to prevent, combat and diminish the effects of this health problem are considered. Conclusions: It is very important to update and raise awareness of the problem, as well as professional, institutional, oversight of agencies and organizations, state and government. The importance of epidemiological surveillance, Hospital Infection Committee, resistance information and the analysis of the quality of medical care with the appropriate use of antimicrobials drugs are important in confronting this health problem(AU)

Efeito modulador do extrato de plantas medicinais do gênero Spondias sobre a resistência de cepas de Staphylococcus aureus à Eritromicina / Modulatory effect of the extract of medicinal plants of Spondias genus on resistance of Staphylococcus aureus to Erythromycin

A acentuada resistência bacteriana gera uma necessidade de desenvolver novos fármacos e a pesquisa com plantas medicinais, como fontes de substâncias bioativas vêm sendo um indicativo para descoberta de eficientes agentes terapêuticos. Microrganismos do gênero Staphylococcus são cocos Gram positivos, que podem causar supurações, abscessos e diversas infecções piogênicas em humanos e animais. Assim, o objetivo deste trabalho foi analisar a atividade moduladora de extratos de plantas medicinais do gênero Spondias frente à Staphylococcus aureus resistentes a eritromicina. A concentração inibitória mínima e a capacidade de modular a resistência das cepas de S. aureus à Eritromicina foram avaliadas pelo método de microduluição. Os resultados mostraram que a associação de eritromicina com Spondias purpurea apresentou efeito sinérgico sobre as cepas SA04 e SA05. Enquanto que a Spondias mombin apresentou sinergismos sobre a ATCC, SA01, SA03 e SA05. O bioensaio com A. salina demonstrou que S. purpurea e S. mombin, apresentaram em CL 50 1000 e 482,5 ?g/ mL, respectivamente. Os resultados são promissores e sugerem que os extratos de espécies do gênero Spondias possuem potencial como agentes moduladores de resistência bacteriana.(AU)

The marked bacterial resistance generates a need to develop new drugs and research on medicinal plants as sources of bioactive substances has been an indication for efficient discovery of therapeutic agents. Microorganisms of the genus Staphylococcus are Gram positive coccus, which can cause suppuration, abscesses and various pyogenic infections in humans and animals. Thus, the objective of this study was to evaluate the modulatory activity of extracts of medicinal plants of genus Spondias against Staphylococcus aureus resistant to erythromycin. The minimum inhibitory concentration and modulating activity of the plant extracts studied and erythromycin were evaluated by the microdilution method. The results showed that the association of erythromycin with Spondias purpurea showed synergistic effect on the strains SA04 and SA05. While Spondias mombin showed synergism on the ATCC, SA01, SA03 and SA05 strain. The bioassay with A. saline showed that S. purpurea and S. mombin presented a LC50 1000 and 482.5 mg/ mL, respectively. The results are promising and suggest that that the extracts species of the genus Spondias agents have potential as modulator agents of bacterial resistance.(AU)

Susceptibility and resistance to antimicrobial Staphylococcus aureus under biofilm / Susceptibilidade e resistência a antimicrobianos de Staphylococcus aureus em condições de biofilme

Staphylococcus is an important agent of mastitis, especially when biofilm producers are related to a number of mechanisms of resistance to different types of infections. The objective of this research was to evaluate the susceptibility and resistance of Staphylococcus aureus strains isolates from cases of bovine mastitis and milking environment under conditions of biofilm, compared to three different concentrations in different antimicrobials. Thirty-two strains used were S. aureus that, due to the inhibition tests, minimal biofilm eradication concentration were tested using cephalexin, amoxicillin and rifampin at concentrations of 30 mg/mL, and 50 mg/mL 100 mg/mL for 12 hours, and efficiency of tests evaluated by counting the colony forming units and the microplate test. The results revealed that among the tested antibiotics cephalexin showed the best efficiency at the three concentrations tested, and rifampin and amoxicillin were more efficient at concentrations of 50 and 100 mg/mL. These data demonstrate the importance of targeted antibiotic therapy associated with the correct cleaning of milking equipment, thus, preventing the formation of biofilm, avoiding persistent microbial adhesion in equipment, and the spread of microorganisms by ascending channel teats among herd animals.

Os Staphylococcus, principais agentes causadores da mastite, quando em biofilmes, estão relacionados a uma série de mecanismos de resistência em diferentes tipos de infecções. O presente trabalho avaliou a susceptibilidade e resistência dos Staphylococcus aureus, isolados de casos de mastite bovina e do ambiente de ordenha, em condições de biofilme, frente a três antimicrobianos distintos em diferentes concentrações. Foram utilizadas trinta e duas estirpes de S. aureus testadas frente aos testes de inibição da concentração mínima de erradicação de biofilmes, utilizando cefalexina, amoxicilina e rifampicina, nas concentrações de 30 mg/mL, 50 mg/mL e 100 mg/mL, por doze horas de contato, e a eficiência dos testes avaliada pela contagem das unidades formadoras de colônias e pelo teste de microplacas. Os resultados revelaram que, entre os antimicrobianos testados, a cefalexina foi o que apresentou melhor eficiência nas três concentrações testadas, e a rifampicina e amoxacilina tiveram maior eficiência nas concentrações de 50 e 100 mg/ mL. Esses dados demonstram a importância sobre antibioticoterapia orientada associada com a correta higienização dos equipamentos de ordenha, evitando-se, assim, a formação de biofilmes, a adesão microbiana persistente em equipamentos, e a difusão dos microrganismos pelo canal ascendente dos tetos entre os animais do rebanho.

Final thoughts on antibiotic use：wake up call for the oral health care professionals

Antibiotic treatment is a form of pharmacotherapy with the specialty of rendering both etiological and curative action. Dentists traditionally administer antibiotics, to restrain contagions and to handle the prevailing dental ailments. Penicillins have been the drug of choice to be opted by the dental practitioners in their routine dental practice. Prudent application of antibiotics in concoction with surgical therapy is the most pertinent mode to cure odontogenic contagions. Considerable prescriptions of antibiotics are ascribed especially in cases which induce bleeding in the oral cavity. Regardless of the obvious indications, perplexity prevails between the oral health care professional’s pertaining to the administration of antibiotics in coalition with dental maneuvers. Dreadful ailments have been cured after the incipience of antibiotics in 1929. Besides it also leads to cumbersome consequences by virtue of its misuse. Irrational usage of antibiotic therapy leads to false positive effects on both health and financial grounds and poses a threat to the microbial resistance. The present communication aims to delineate the absolute indications, consequences of abuse and imperative factors to be considered while prescribing antibiotics in routine dental practice.

In Vitro Alkaline pH Resistance of Enterococcus faecalis

Enterococcus faecalis is a bacterial species often found in root canals with failed endodontic treatment. Alkaline pastes are widely used in Endodontics because of their biocompatibility and antimicrobial activity, but this microorganism can resist alkalinity. The purpose of this study was to evaluate in vitro the alkaline pH resistance of E. faecalis for different periods up to 14 days. Samples were obtained from the oral cavity of 150 patients from the Endodontic clinic. The pH of the experimental tubes (n=84) was first adjusted with 6M NaOH to pH values of 9.5, 10.5, 11.5 and 12.5 (21 tubes per pH). Twenty clinical isolates and the ATCC 29212 strain were tested. The 5 positive controls and experimental tubes of each pH were inoculated with 10 µL of bacterial suspension and incubated at 36 °C for 24, 48 and 72 h, 7 and 14 days. For each period, the turbidity of the medium was visually compared with a 0.5 McFarland standard. The presence of the microorganism was confirmed by seeding on M-Enterococcus agar. Four tubes containing BHI broth adjusted to the tested pHs were incubated for 14 days to verify if pH changes occurred. The pH of inoculated BHI broth was also measured on day 14 to determine if the microorganism acidified the medium. The growth of all E. faecalis strains occurred at pH 9.5 to 11.5 in all periods. Although turbidity was not observed at pH 12.5, there was growth of 13 and 2 strains at 24 and 48 h, respectively, on M-Enterococcus agar. No tube showed growth at pH 12.5 after 72 h. It was concluded that E. faecalis can survive in highly alkaline pH, and some clinical isolates require 72 h at pH 12.5 to be killed.

Enterococcus faecalis é uma espécie bacteriana frequentemente encontrada em canais radiculares com insucesso do tratamento endodôntico. Pastes alcalinas são amplamente utilizada em Endodontia por causa de sua biocompatibilidade e atividade antimicrobiana, porém esse microrganismo pode ser resistente a alcalinidade. Este estudo avaliou in vitro a resistência do E. faecalis ao pH alcalino por diferentes períodos até 14 dias. Amostras foram obtidas da cavidade oral de 150 pacientes da Clínica de Endodontia. O pH dos tubes experimentais (n=84) foram inicialmente ajustados com NaOH 6M a valores de pH 9.5, 10.5, 11.5 e 12.5 (21 tubes per pH). Vinte isolados clínicos e a cepa ATCC 29212 foram testados. Os 5 controles positivos e os tubos experimentais de cada pH foram inoculados com 10 µL de suspensão bacteriana e incubados a 36 °C por 24, 48 e 72 h, 7 e 14 dias. Para cada período, turvação do meio foi compara visualmente com padrão 0.5 da escala de McFarland. A presença de microorganism foi confirmada por semeadura no meio ágar M-Enterococcus. Quatro tubos contendo caldo BHI ajustado aos pHs testados foram incubados por 14 dias para verificar a ocorrência de alterações de pH. O pH do caldo BHI inoculado também foi medido no 14° dia para determinar se o microrganismo acidificou o meio. O crescimento de todas as cepas de E. faecalis ocorreu com pH entre 9.5 e 11.5 em todos os períodos. Embora não tenha sido observada turvação do meio no pH 12.5, houve crescimento de 13 e 2 cepas às 24 e 48 h, respectivamente, no meio ágar M-Enterococcus. Nenhum tube apresentou crescimento bacteriano no pH 12.5 após 72 h. Concluiu-se que o E. faecalis pode sobreviver em pH altamente alcalino, que alguns isolados clínicos requerem 72 h em pH 12.5 para serem eliminados.

Anti-microbial resistance profile of Citrobacter species in a tertiary care hospital of southern India.

Background: Recently, the isolation of this pathogen in hospital settings is increasing and multidrug-resistant strains are emerging; these strains present a challenge for clinician and the clinical microbiologist because of their increased occurrence in nosocomial infection. The current study was done to find out the antibiotic sensitivity pattern of Citrobacter species from various clinical specimens. Materials and Methods: Samples were collected from patients in accordance with standard protocols. Citrobacter species were identified by conventional biochemical tests. Antibiotic susceptibility of the isolates was done by disc diffusion method according to National Committee for Clinical Laboratory Standards (NCCLS) recommendations. Results: Out of 563 isolates of Citrobacter, majority were from pus (48.1%), followed by urine (24.3%), sputum (20.3%), body fluids (05.2%), blood (02.1%). C. koseri was the predominant species [391 (70%)] isolated. Infection was nosocomialy acquired in 493 (87.4%) patients. The mean age was 39.5 years. Anti-biograms of Citrobacter isolates revealed that effective agent against Citrobacter isolates was imipenem (91.8% sensitive), followed by piperacillin/tazobactam (58.3%) and amikacin (53.4%). Conclusion: Citrobacter isolates resistant to multiple anti-microbial agents have emerged, including strains resistant to imipenem, making it an emerging nosocomial pathogen. Therefore, the results of this study suggest that surveillance of anti-microbial resistance in Citrobacter is necessary. Antibiotic policy should be formulated in the hospital. Depending on the antibiotic sensitivity pattern of the Citrobacter isolates, antibiotics should be used, and proper infection control measures should be strictly followed to prevent spread of this pathogen.