Latent Chronic Osteomyelitis Presenting Decades After Initial Trauma: A Case Report and Literature Review.

Osteomyelitis is an inflammatory bone process secondary to infection, and often presents as a chronic, recurrent illness, posing diagnostic and treatment challenges. It is frequently the result of previous inadequate treatment or undiagnosed acute infection. Clinical suspicion, thorough evaluation, laboratory studies, and advanced imaging modalities such as magnetic resonance imaging (MRI) and computed tomography (CT) play crucial roles in diagnosis. Treatment typically entails a combination of antibiotics and surgical debridement to eliminate infection and facilitate bone healing. In this report, we present a rare case involving a 64-year-old male who presented with new-onset pain in the right femur decades after experiencing a complicated femur fracture and forearm crush injury. Imaging studies revealed evidence of chronic osteomyelitis, leading to a diagnosis of latent infection. The patient underwent a comprehensive evaluation, including clinical examination, imaging studies, laboratory tests, and bone biopsy, confirming the diagnosis. This case of latent osteomyelitis highlights the clinical presentation, diagnostic modalities, and treatment strategies employed in managing this challenging condition.

Unsolved Controversies in Management of Infective Endocarditis.

Infective endocarditis (IE) is defined as an infection in the cardiac endothelium. It is triggered by both bacteremia and endothelial dysfunction and poses many risks to the health of the patient. Many organisms can cause IE with Staphylococcus aureus being the major cause. Signs and symptoms may vary according to age and agent but almost all cases are presented with fever, fatigue, and a maculopapular rash. Although pediatric IE is very rare, risk factors such as congenital heart defects have been identified, with some of the cases remaining a mystery. We present a case of a 19-year-old patient, previously healthy and developing subacute IE with sepsis and septic embolic showers in multiple organs. IE cannot be taken for granted as mortality is high, hence a multidisciplinary approach is prompt and necessary for the survival of the patient.

The emergence of carbapenemase-producing Enterobacterales in hospitals: a major challenge for a debilitated healthcare system in Lebanon.

Background: Carbapenem- and extended-spectrum cephalosporin-resistant Enterobacterales (CR-E and ESCR-E, respectively) are increasingly isolated worldwide. Information about these bacteria is sporadic in Lebanon and generally relies on conventional diagnostic methods, which is detrimental for a country that is struggling with an unprecedented economic crisis and a collapsing public health system. Here, CR-E isolates from different Lebanese hospitals were characterized. Materials and methods: Non-duplicate clinical ESCR-E or CR-E isolates (N = 188) were collected from three hospitals from June 2019 to December 2020. Isolates were identified by MALDI-TOF, and their antibiotic susceptibility by Kirby-Bauer disk diffusion assay. CR-E isolates (n = 33/188) were further analyzed using Illumina-based WGS to identify resistome, MLST, and plasmid types. Additionally, the genetic relatedness of the CR-E isolates was evaluated using an Infrared Biotyper system and compared to WGS. Results: Using the Kirby-Bauer disk diffusion assay, only 90 isolates out of the 188 isolates that were collected based on their initial routine susceptibility profile by the three participating hospitals could be confirmed as ESCR-E or CR-E isolates and were included in this study. This collection comprised E. coli (n = 70; 77.8%), K. pneumoniae (n = 13; 14.4%), Enterobacter spp. (n = 6; 6.7%), and Proteus mirabilis (n = 1; 1.1%). While 57 were only ESBL producers the remaining 33 isolates (i.e., 26 E. coli, five K. pneumoniae, one E. cloacae, and one Enterobacter hormaechei) were resistant to at least one carbapenem, of which 20 were also ESBL-producers. Among the 33 CR-E, five different carbapenemase determinants were identified: blaNDM-5 (14/33), blaOXA-244 (10/33), blaOXA-48 (5/33), blaNDM-1 (3/33), and blaOXA-181 (1/33) genes. Notably, 20 CR-E isolates were also ESBL-producers. The analysis of the genetic relatedness revealed a substantial genetic diversity among CR-E isolates, suggesting evolution and transmission from various sources. Conclusion: This study highlighted the emergence and broad dissemination of blaNDM-5 and blaOXA-244 genes in Lebanese clinical settings. The weak AMR awareness in the Lebanese community and the ongoing economic and healthcare challenges have spurred self-medication practices. Our findings highlight an urgent need for transformative approaches to combat antimicrobial resistance in both community and hospital settings.

The First Documented Ibuprofen-Induced Toxic Epidermal Necrolysis in the Middle East and North Africa Region: A Case Report, Complications, and Management.

INTRODUCTION: Stevens-Johnson syndrome (SJS), Stevens-Johnson/toxic epidermal necrolysis overlap syndrome (SJS/TEN) and toxic epidermal necrolysis (TEN) are rare, acute, potentially lethal conditions, considered to be part of the severe cutaneous adverse reactions (SCARs) spectrum, with TEN being the most life-threatening. The distinction between these three entities is based on the extent of total skin surface involvement, with SJS involving < 10%, SJS/TEN involving 10-30% and TEN involving > 30% of total body surface area. These mucocutaneous reactions are most commonly caused by a hypersensitivity reaction to a drug, with infections and vaccines being possible, less common etiologies. CASE PRESENTATION: In the following case report, we summarize a rare case of a 43-year-old, previously healthy male patient who presented with TEN after taking ibuprofen, a non-steroidal anti-inflammatory drug. According to PubMed literature, this is the first documented case of ibuprofen-induced TEN in the Middle East and North Africa (MENA) region. DISCUSSION: TEN is an autoimmune bullous disorder that results in the death of keratinocytes, leading to complete dermo-epidermal separation. In the case of our patient, the desquamation was extensive, involving 70% of the total body surface area, and was complicated by a triple bacterial infection with Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas aeruginosa. The patient was treated with colistin and meropenem, in addition to supportive management, hydration and nutritional support. CONCLUSION: In the case of TEN, early diagnosis and hospitalization in a burn centre are crucial to allow rapid healing, and improve the quality of life of the affected patients. Immediate cessation of the causative mediation is critical. Supportive management, hydration, nutritional support, and maintenance of aseptic conditions are highly encouraged to reduce the mortality and morbidity associated with TEN.

Prevalence and Molecular Mechanisms of Carbapenem Resistance among Gram-Negative Bacilli in Three Hospitals of Northern Lebanon.

Carbapenem resistance (CR) is an emerging health issue. Epidemiological surveys on carbapenem-resistant Gram-negative bacilli (CR-GNB) in Lebanon remain scarce. In this study, we determined the prevalence of CR-GNB isolated between 2015 to 2019 in three hospitals in northern Lebanon: 311 CR-Enterobacterales (out of 11210; 2.8%), 155 CR-Pseudomonas (out of 1034; 15%) and 106 CR- Acinetobacter (out of 184; 57.6%) were identified. CR mechanisms were determined for 146 randomly chosen isolates: the Carba NP test revealed an enzymatic resistance to carbapenems in 109 isolates (out of 146, 74.7%). Produced carbapenemases were evaluated by the NG-Test Carba5, NG-Test OXA-23 immunochromatographic assays and PCR. Carbapenemase-producing (CP) Enterobacterales expressed blaOXA-48-like, blaNDM-like and blaVIM-like genes and CP-Pseudomonas expressed blaIMP-like and blaVIM-like genes, whereas CP-Acinetobacter expressed blaOXA-23-like genes. The NG-Test Carba5 results were confirmed by PCR sequencing and revealed several variants, such as NDM-19, VIM-62 and OXA-162, never described so far in Lebanon. Isolates with discordant results were sequenced by WGS and highlighted novel variants of the natural oxacillinases of Pseudomonas aeruginosa: blaOXA-50-like genes. Their role in carbapenem resistance should be further studied. Overall, our findings highlight an alarming situation and encourage health care centers to establish performant registration systems that could help in limiting resistance spread.

The Role of Lebanon in the COVID-19 Butterfly Effect: The B.1.398 Example.

In the present study, we provide a retrospective genomic surveillance of the SARS-CoV-2 pandemic in Lebanon; we newly sequence the viral genomes of 200 nasopharyngeal samples collected between July 2020 and February 2021 from patients in different regions of Lebanon and from travelers crossing the Lebanese-Syrian border, and we also analyze the Lebanese genomic dataset available at GISAID. Our results show that SARS-CoV-2 infections in Lebanon during this period were shaped by the turnovers of four dominant SARS-CoV-2 lineages, with B.1.398 being the first to thoroughly dominate. Lebanon acted as a dispersal center of B.1.398 to other countries, with intercontinental transmissions being more common than within-continent. Within the country, the district of Tripoli, which was the source of 43% of the total B.1.398 sequences in our study, was identified as being an important source of dispersal in the country. In conclusion, our findings exemplify the butterfly effect, by which a lineage that emerges in a small area can be spread around the world, and highlight the potential role of developing countries in the emergence of new variants.

Antimicrobial resistance in the protracted Syrian conflict: halting a war in the war.

The Syrian conflict has damaged key infrastructure and indirectly affected almost all parts of the Middle East and Europe, with no end in sight. Exhausting conditions created by the Syrian crisis and related massive displacement promote the emergence of numerous public health problems that fuel antimicrobial resistance (AMR) development. Here, we explore the current situation of the Syrian displaced population, and AMR inside Syria and among refugees in host countries. We then suggest a roadmap of selected key interventions and strategies to address the threat of AMR in the context of the Syrian crisis. These recommendations are intended to urge health policy-makers in governments and international health organizations to optimize and push for implementing an effective policy taking into consideration the current obstacles.

Species distribution and antifungal susceptibility of Aspergillus clinical isolates in Lebanon.

Aim: We sought to provide first insights into the epidemiology and antifungal susceptibility patterns of the aspergilli in Lebanon. Materials & methods: After species identification, antifungal susceptibility was investigated according to EUCAST recommendations. CYP51A gene was sequenced in resistant isolates and its expression level was evaluated by Reverse transcription-quantitative PCR. Results: Among the 73 Aspergillus isolates studied (mostly from ears), the predominant species was Aspergillus niger (54.8%). The overall drug resistance was highest for amphotericin B (38.4%), followed by itraconazole (31.5%), posaconazole (30.1%) and voriconazole (23.3%). In addition, CYP51A gene mutations were not the major cause of azole resistance among these isolates. Conclusion: Our findings indicate the paramount need for an integral One Health strategy and a national reference center for invasive mycoses and antifungals.

Investigation of an XDR-Acinetobacter baumannii ST2 outbreak in an intensive care unit of a Lebanese tertiary care hospital.

Aim: We sought to investigate the genetic epidemiological relatedness of carbapenem-resistant Acinetobacter baumannii (CRAB) strains of a suspected outbreak in a Lebanese tertiary care hospital to implement necessary infection prevention and control measures. Methods: Twenty-eight nonduplicate CRAB isolates detected among hospitalized patients between January 2016 and July 2017 were studied by real-time polymerase chain reaction (PCR), pulsed-field gel electrophoresis and multilocus sequence typing analyses. Results: Twenty-seven isolates harbored blaOXA-23, of which one also carried blaNDM-1. The isolates distributed temporally in two presumably episodes were stratified by pulsed-field gel electrophoresis into many clusters. Although several clones have become endemic in the hospital, we have rapidly implemented appropriate infection prevention and control measures, achieving full eradication from August 2017 to November 2019. Conclusion: We have successfully investigated and controlled a polyclonal outbreak of OXA-23 producing ST2 CRAB.

Update on invasive fungal infections in the Middle Eastern and North African region.

In the recent years, the epidemiology of invasive fungal infections (IFIs) has changed worldwide. This is remarkably noticed with the significant increase in high-risk populations. Although surveillance of such infections is essential, data in the Middle Eastern and North African (MENA) region remain scarce. In this paper, we reviewed the existing data on the epidemiology of different IFIs in the MENA region. Epidemiological surveillance is crucial to guide optimal healthcare practices. This study can help to guide appropriate interventions and to implement antimicrobial stewardship and infection prevention and control programs in countries.

Seroprevalence of hepatitis E virus in pregnant women in northern Lebanon.

BACKGROUND: Hepatitis E virus is the main cause of acute hepatitis globally. Infection is especially serious in pregnant women in whom the death rate can reach 25%. The prevalence of hepatitis E virus in pregnant women in Lebanon is not known. AIMS: This study aimed to investigate the seroprevalence of hepatitis E virus infection in a sample of pregnant women in northern Lebanon. METHODS: A total of 450 pregnant women from Tripoli, North Lebanon were enrolled in the study. Sera were tested for the presence of anti-hepatitis E virus IgG antibodies using an ELISA technique. Information was collected on the sociodemographic characteristics of the women and their risk factors for hepatitis E virus infection (drinking-water source, blood transfusion and contact with animals). RESULTS: Only one woman was positive for hepatitis E virus giving a prevalence of 0.22%. She had good living conditions, socioeconomic status and educational level and reported no exposure to any risk factors associated with hepatitis E virus infection. Most of the women (87.3%) had a medium or high income level, 47.1% had a university education and 64.9% drank bottled water. Only a small proportion were exposed to risk factors for hepatitis E virus infection: 14.7% had direct contact with animals and 3.8% had had a blood transfusion. CONCLUSION: The prevalence of hepatitis E virus infection in the sample was low (0.22%). However, further epidemiological studies among other population groups are required to determine the national prevalence of hepatitis E virus in Lebanon.

Prevalence of anti-hepatitis E virus IgG antibodies in sera from hemodialysis patients in Tripoli, Lebanon.

Hepatitis E virus (HEV) is an important global public health concern. Several studies reported a higher HEV prevalence in patients undergoing regular hemodialysis (HD). In Lebanon, the epidemiology of HEV among HD patients has never been investigated previously. In this study, we examine the seroprevalence of HEV infection among 171 HD patients recruited from three hospital dialysis units in Tripoli, North Lebanon. Prevalence of anti-HEV IgG antibodies was evaluated in participant's sera using a commercial enzyme-linked immunosorbent assay (ELISA). The association of socio-demographic and clinical parameters with HEV infection in patients was also evaluated. Overall, 96 women and 75 men were enrolled in this study. Anti-HEV IgG antibodies were found positive in 37/171 HD patients showing a positivity rate of 21.63%. Among all examined variables, only the age of patients was significantly associated with seropositivity (P = 0.001). This first epidemiological study reveals a high seroprevalence of HEV infection among Lebanese HD patients. However, further evaluations that enroll larger samples and include control groups are required to identify exact causative factors of the important seropositivity rate in this population.

Challenges in identification of enteroinvasive Escherichia coli and Shigella spp. in Lebanon.

This study aimed to evaluate the routine identification tools available in Lebanon for differentiation of Escherichia coli and Shigella spp. The identification of 43 isolates defined as Shigella spp. by Api 20E was accessed using MALDI-TOF, serological testing, duplex PCR targeting ipaH (present in Shigella spp. and enteroinvasive E. coli "EIEC") and lacY (found in E. coli including EIEC but not Shigella spp.) as well as gyrB gene sequencing. Antibiotic susceptibility was investigated as well as Shiga-toxin production. All isolates were identified as E. coli by MALDI-TOF while the PCR showed a disparate group of 26 EIEC, 11 Shigella spp., 5 E. coli and 1 inactive E. coli. However, the sequencing of gyrB gene, which was recently described as a suitable marker for distinguishing E. coli and Shigella spp., identified all isolates as E. coli. Antibiotic resistance was noticeable against ß-lactams, rifampicin, trimethoprim-sulfamethoxazole, gentamicin, and ciprofloxacin. The most common variants of beta-lactamase genes were blaTEM-1, blaCTX-M-15, and blaCTX-M-3. A great discordance between the used methods in identification was revealed herein. An accurate identification technique able to distinguish E. coli from Shigella spp. in routine laboratories is a pressing need in order to select the appropriate treatment and assess the epidemiology of these bacteria.

Recent trends in the epidemiology, diagnosis, treatment, and mechanisms of resistance in clinical Aspergillus species: A general review with a special focus on the Middle Eastern and North African region.

Globally, more than billion people suffer from fungal infections each year. The early diagnosis of aspergillosis is mandatory for successful treatment outcome. As careful testing takes time, epidemiological surveillance is crucial to guide individual patient therapy and to promote a high standard of health care. In this paper, we first present current trends in the epidemiology and antifungal susceptibility patterns of Aspergillus spp. in Middle Eastern and North African (MENA) countries in order to support infectious disease specialists and health workforces in this geographic area to treat adequately patients with aspergillosis. Then we discuss the existing literature data regarding the available diagnostic tools and antifungal resistance mechanisms of Aspergillus spp. Although a limited number of studies were reviewed here, the currently available data show that Aspergillus infections are not negligible in the MENA region, and that the emergence of antifungal resistance is a growing health issue, especially among immunocompromised patients.

Plasmid-mediated quinolone resistance: Mechanisms, detection, and epidemiology in the Arab countries.

Quinolones are an important antimicrobial class used widely in the treatment of enterobacterial infections. Although there are multiple mechanisms of quinolone resistance, attention should be paid to plasmid-mediated genes due to their ability to facilitate the spread of quinolone resistance, the selection of mutants with a higher-level of quinolone resistance, and the promotion of treatment failure. Since their discovery in 1998, plasmid-mediated quinolone resistance (PMQR) mechanisms have been reported more frequently worldwide especially with the extensive use of quinolones in humans and animals. Nevertheless, data from the Arab countries are rare and often scattered. Understanding the prevalence and distribution of PMQR is essential to stop the irrational use of quinolone in these countries. This manuscript describes the quinolone resistance mechanisms and particularly PMQR among Enterobacteriaceae as well as their methods of detection. Then the available data on the epidemiology of PMQR in clinical and environmental isolates from the Arab countries are extensively reviewed along with the other associated resistance genes. These data shows a wide dissemination of PMQR genes among Enterobacteriaceae isolates from humans, animals, and environments in these countries with increasing rates over the years and a common association with other antibiotic resistance genes as blaCTX-M-15. The incontrovertible emergence of PMQR in the Arab countries highlights the pressing need for effective stewardship efforts to prevent the selection of a higher rate of quinolone resistance and to preserve these crucial antibiotics.

Evaluation of different testing tools for the identification of non-gonococcal Neisseria spp. isolated from Lebanese male semen: a strong and significant association with infertility.

PURPOSE: The aim was to evaluate several microbiological tools for the identification of non-gonococcal Neisseria spp. isolated from semen samples from Lebanese men and to determine the putative link between the presence of Neisseria commensal species and infertility. METHODOLOGY: Within a cross-sectional retrospective study design, the whole population included in this investigation was divided in 2 categories: 173 patients with symptoms of infertility and 139 patients with normal seminograms. Epidemiological and microbiological investigations were performed for 59 strains of Neisseria through several phenotypic and genotypic tools, including seminograms, an analytical profile index of Neisseria and Haemophilus (API-NH), matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS), porA PCR, 16S rRNA and rplF gene sequencing, and antimicrobial susceptibility testing. RESULTS: The risk of Neisseria infection was twice as high in infertile patients compared to the control group [odds ratio (OR): 1.95, confidence interval (CI): 1.05-3.65, P =0.03]. Unreliable diagnosis of Neisseria urogenital infection has serious health and social consequences. Our findings showed that API-NH and 16S rRNA sequencing are poor tools to identify Neisseria at the species level. Therefore, reliable diagnosis of cases using MALDI-TOF MS and/or rplF sequencing is needed to provide critical treatment decisions and prevent antimicrobial resistance spreading in the community. CONCLUSION: This work predicted a strong and significant association between the presence of Neisseria spp. in semen and male infertility among the Lebanese population. For a better understanding of this association, it is recommended that more genomic and large-scale epidemiological investigations are undertaken to reach definitive conclusions.

Cutaneous leishmaniasis in north Lebanon: re-emergence of an important neglected tropical disease.

BACKGROUND: Cutaneous leishmaniasis (CL) is the most prevalent neglected tropical disease among externally displaced people in the Middle East. In recent years, the Lebanese population has increased >30%, mainly due to a mass influx of Syrian migrants, thousands of them carrying CL, among other infectious diseases. Here we revisit the current CL prevalence among refugees in northern Lebanon. METHODS: This cohort study was conducted at the Al Bashaer Medical Center in north Lebanon between January and June 2017. A total of 48 randomly selected suspected CL patients were clinically diagnosed by dermatologists and samples were obtained for microscopic examination and molecular identification by polymerase chain reaction restriction fragment length polymorphism. The treatment response to antimonials was assessed each week and was followed for up 6 months. RESULTS: Leishmania tropica was the predominant species (91.7%) followed by Leishmania major (8.3%). Confirmed cases were treated with one to two courses of antimonials and healing was usually achieved after receiving a second course of treatment. Importantly, we show evidence of possible local CL transmission by indigenous sandflies in three separate patients who had no history of recent travel to Syria. CONCLUSIONS: This highlights the urgent necessity to implement preventive disease strategies to avoid further dispersion of L. tropica CL in north Lebanon.

Molecular epidemiology of Cryptosporidium spp. in North Lebanon.

Cryptosporidium spp. are enteroparasites with worldwide distribution that infect the gastrointestinal tract of several vertebrates including humans. Human to human, zoonotic, foodborne and waterborne are reported as the main transmission routes of this parasite. Cryptosporidium spp. have been recognized as the predominant cause of waterborne and foodborne outbreaks. However, the epidemiological situation of cryptosporidiosis is not well known in Lebanon, a developing country with a population often affected by intestinal parasitic infections. This study was devoted to determine the prevalence and the genetic diversity of Cryptosporidium spp. in symptomatic hospitalized patients and in two children populations with different socio-economic level in North-Lebanon, as well as the risk factors associated with cryptosporidiosis. Fecal samples obtained from these populations were examined microscopically by modified Ziehl-Neelsen staining as well as nested PCR were done for the detection of Cryptosporidium oocysts. Out of 163 symptomatic hospitalized patients and 249 children, Cryptosporidium was present in 11% and 10.4% respectively according to microscopy examination and/or molecular tests. The genotyping showed the predominance of Cryptosporidium hominis in both populations. Subgenotype analysis of the isolates at the gp60 locus identified three subtypes IdA19, IbA10G2 and IaA18R3 for C. hominis and two subtypes IIaA15G1R1 and IIaA15G2R1 for C. parvum. Moreover, cryptosporidiosis was correlated with having meals outside home and presence of gastrointestinal symptoms especially diarrhea (p <0.05). This work constitutes the first molecular epidemiology study outlining risk factors associated with cryptosporidiosis in Lebanon. These findings support a need of a control program to prevent the circulation of this parasite.

Molecular detection of genes responsible for macrolide resistance among Streptococcus pneumoniae isolated in North Lebanon.

In recent years, the increased use of macrolides was linked with the emergence of resistance Streptococcus pneumoniae worldwide. The main aim of this study was to determine the prevalence of S. pneumoniae resistant to macrolides and to identify the macrolide resistance genotypes among clinical isolates collected in North Lebanon. Disk diffusion susceptibility method was performed for 132 strains of S. pneumoniae isolated over a period of 5 years in North Lebanon. Polymerase Chain Reaction followed by pyrosequencing was carried out for confirmation of phenotypic diagnosis. The macrolide resistance genotypes were also identified by using PCR amplification of genes implicated in this resistance: erm(A), erm(B), erm(C), msr(A), lin(A) and mef(A/E). Macrolide resistance was found in 34.1% of S. pneumoniae isolates. We observed that the cMLSB phenotype (31/45, 68.9%) was the most common in these pneumococci and erm(B) was the most common resistance gene (32/45, 71.1%). This study shows that macrolide resistance in S. pneumoniae in North Lebanon is mainly related to target site modification with predominance of cMLSb phenotype but is also mediated by efflux pumps. lin(A) gene was reported for the first time in one S. pneumoniae strain in combination with erm(B) and mef(A/E) genes.

Prevalence, antibiotic susceptibility and characterization of antibiotic resistant genes among carbapenem-resistant Gram-negative bacilli and yeast in intestinal flora of cancer patients in North Lebanon.

The emergence and spread of carbapenem-resistant bacteria are a significant clinical and public health concern. The aim of the study is to determine the prevalence of intestinal carriage of carbapenem-resistant bacteria and yeasts in cancer patients under chemotherapy. 41 stool samples collected from cancer patients in Nini hospital in Tripoli, North Lebanon have been analyzed. After isolating yeasts and carbapenem-resistant bacteria, a biochemical identification and antimicrobial susceptibility profile were determined. The mechanism of enzymatic carbapenem-resistance was detected by searching for carbapenemases by both Hodge test and PCR assays. The association of several mechanisms of resistance was also searched. 46.3% (19/41) of patients were colonized by yeast. Candida glabrata (6/19) was the major species. The prevalence of carbapenem-resistant bacteria was 24.4% (10/41) including Escherichia coli (5/10), Enterobacter cloacae (1/10), Enterobacter aerogenes (1/10) Edwardsiella hoshinae (1/10) Pantoea agglomerans (1/10) and Pseudomonas stutzeri (1/10). PCR and sequencing of the amplified fragments revealed that Pseudomonas stutzeri (1/1) carried VIM gene and Enterobacter aerogenes (1/1) and E. coli (1/5) carried OXA-48 gene. The other Enterobacteriaceae were resistant to carbapenems by mechanisms other than a carbapenemase including hyperproduction of cephalosporinase (4/10), extended spectrum beta-lactamases (1/10) and both cephalosporinase and extended spectrum beta-lactamases (2/10). High prevalence of intestinal carriage of carbapenem-resistant bacteria and yeasts were detected in cancer patients under chemotherapy. In order to prevent the development of endogenous infection and the dissemination of antimicrobial resistance, an implementation of antibiotic stewardship programs and infection control measures is required in hospitals particularly in the department of chemotherapy.