Research Article | Open Access

Sulakshana Sony Cheemala1 , Aarthi Vara2, M. Swarajya Lakshmi2Shilpa Pradhan2 and K. Kalyani2

1Department of Microbiology, Government Medical College, Ongole, Andhra Pradesh, India.
2Department of Microbiology, Mamata Academy of Medical Sciences, Bachupally, Hyderabad, Telangana, India.
Article Number: 8736 | © The Author(s). 2023
J Pure Appl Microbiol. 2023;17(4):2111-2118. https://doi.org/10.22207/JPAM.17.4.07
Received: 29 May 2023 | Accepted: 07 September 2023 | Published online: 13 October 2023
Issue online: December 2023
Abstract

Antimicrobial resistance (AMR) in Gram negative bacteria (GNB) has become a critical health concern across the globe. Unveiling of β-lactamase, extended spectrum β-lactamase (ESBL) and AmpC β-lactamase producing bacteria has led to the development of multidrug-resistant organisms (MDRO’s). Carbapenems are considered to be very effective in morbid infections caused by MDRO’s. Now, the upsurge of carbapenem resistance among GNB is an issue of concern as these infections are very difficult to treat. Rapid and reliable methods to detect these CPO’s in all Microbiology laboratories is essential to streamline the antimicrobial therapy. Accordingly, this study is conducted to determine the enormity of CPO’s among clinical isolates by various phenotypic tests along with differentiation of serine β-lactamases from metallo-β-lactamases. This is a Prospective Cross-sectional study meticulously planned & conducted for a period of one year. Among the 76 suspected Carbapenemase Producing Organisms (CPO’s), 42% were Klebsiella spp. followed by Escherichia coli (25%), Pseudomonas aeruginosa (24%), Citrobacter spp. (5%) and Proteus spp. (4%). Out of the total isolates 82% of the isolates were confirmed as CPO’s by Carba NP test, whereas 93% by mCIM test. 53% of the total isolates tested were Serine-β-lactamase producers and 41% were Metallo-β-lactamase producers. In conclusion, Carba NP test and mCIM in conjunction with eCIM test could be considered as reliable phenotypic diagnostic methods for carbapenemase detection to guide the clinicians for initiating antibiotic therapy.

Keywords

mCIM, eCIM, Carba NP, Serine-β-lactamase Producers, Metallo-β-lactamase Producers , Carbapenemase Producing Organisms

Introduction

Antimicrobial resistance among Gram negative bacteria (GNB) has become a major global health concern. Previously, antimicrobial agents such as penicillin’s, 1st & 2nd generation cephalosporins have been used effectively as first line drugs for the effective management of infections with GNB. However, organisms had acquired resistance to these 1st line antibiotics, thereby enforcing the utilization of second-line drugs like the 3rd & 4th generation cephalosporins for treatment of life-threatening infections. Evolution of β-lactamase, extended spectrum β-lactamase (ESBL) and AmpC β-lactamase producing bacteria has led to the development of multidrug-resistant organisms (MDRO’s).

Carbapenems (Imipenem, Meropenem, Ertapenem) are considered to be very effective in morbid infections caused by these MDRO’s. So, they are considered as antibiotics of last resort by clinicians for critically ill patients due to their broad-spectrum activity. Now, the emergence of carbapenem resistance among GNB is becoming a significant community health issue due to their complexity for treatment. Also, Carbapenemase-Producing Organisms (CPO’s) can cause outbreaks as Carbapenemase genes are transferable to the susceptible bacteria.1-4 Infections due to CPO’s are associated with disquieting rates of mortality.5 It is essential to distinguish between CPO’s from non-producers to prioritize the usage of antimicrobials which might hamper the emergence of resistance to untouched newly developed antimicrobials.

Expeditious methods to detect these CPO’s in all Microbiology laboratories including those in resource-limited settings, is essential not only to streamline the antimicrobial therapy but also to minimize their spread in health-care facilities and the community, for epidemiologic and infection prevention & control purposes.

It is also important to differentiate between Carbapenemase classes because newly available β-lactam (BL) and β-lactamase inhibitor (BLI) combinations like ceftazidime-avibactam as well as others under research & development are mostly active against serine carbapenemases, but not against metallo-β-lactamases (MBLs).

In the past few years many phenotypic and genotypic assays were developed for their detection. The advantage of phenotypic assay compared to genotypic assay is that they are less expensive and also they will detect the Carbepenemase activity but not specific genes which will help in detection of emergence of a new or a previously uncommon Carbapenemases.6

In this context, this study is intended to determine the enormity of CPO’s among clinical isolates by various phenotypic tests along with differentiation of serine β-lactamases from metallo-β-lactamases.

Materials and Methods

It is a prospective cross-sectional study meticulously planned & conducted in the Department of Microbiology in a tertiary care teaching hospital in Telangana, South India from February 2022 to 2023 for a period of 1 year after approval from Institutional Ethical Committee.

Varied clinical samples which include pus, urine, blood, body fluids, sputum from wards, intensive care units and OPD’s were processed for identification of organisms as per standard operating procedures. Gram positive organisms were excluded from the study. All the GNB were screened for carbapenem resistance by Kirby Bauer disc diffusion method (KBDD) following CLSI M100 – Ed 32, 2022 guidelines using Ertapenem 10 µg disk.7 Isolates with zone diameter of ≤18 mm were considered as strains with suspected carbapenemase production.

These carbapenem resistant isolates were further evaluated for carbapenemase production by Carba NP and modified carbapenem Inactivation method (mCIM) in conjunction with EDTA modified carbapenem Inactivation method (eCIM). Carba NP and mCIM tests were used for detecting carbapenemase among Enterobacterales and Pseudomonas aeruginosa and eCIM is used along with mCIM to differentiate serine β-lactamases from metallo-β-lactamases in Enterobacterales.

Carba NP test
Carba NP test is a calorimetric microtube assay to detect Imipenem hydrolysis by CPO’s. The pH indicator present in the medium depicts a colour change as the medium gets acidified due to hydrolysis. 1µl loopful of bacterial growth from Muller Hinton Agar plate (MHA) is taken and emulsified in microcentrifuge tube containing 100µl of 20mM Tris Hcl lysis buffer and vortexed for 5 seconds. It is then emulsified using 100µl solution containing phenol red indicator along with 0.1mmol/litre ZnSO4, which is preadjusted to pH 7.8. Then 3mg/0.5ml of imipenem powder is taken and mixed in reaction tube and control tube contains indicator solution but will not have antibiotic. Tubes are then vortexed for about 10 seconds. Before reaction, both the tubes will be red to orange in colour. The tubes are then incubated at 37°C and observed for 2 hours for colour change from red orange to light orange/dark yellow/yellow [Figure 1]. Change in colour indicates that the organism is a carbapenemase producer.7

Figure 1. Carba NP test to differentiate between Carbapenamse Producers and non-producers

Modified Carbapenem Inactivation method (mCIM) in conjunction with EDTA Modified Carbapenem Inactivation method (eCIM)
Emulsify, 1µL loopful of test isolate for Enterobacterales and 10µL loopful for Pseudomonas aeruginosa from culture on Blood agar plate in 2ml Tryptic soy broth (TSB). Two test tubes containing 2mL of TSB with test isolate needs to be taken. One tube is without EDTA for mCIM and the other tube is with EDTA for eCIM. A meropenem (MRP) disk is immersed in each tube and incubated for 4 hours. Then the disks are then picked out of the test tubes and placed on MHA plates with a fresh lawn culture of carbapenem-susceptible E. coli ATCC 25922 and incubated overnight. Zone dimensions are to be recorded for interpretation of test results [Figure 2,3].7

Figure 2. Isolate 1&2 in the figure shows Metallo-β-lactamase production Isolate 3 shows Serine-β-lactamase production with mCIM + eCIM test

Figure 3. Metallo-β-lactamase production detected by mCIM + eCIM test

Quality Control (QC)
Data quality is validated using standardized data collection tools. For laboratory investigations all the three phases of quality assurance as per standard guidelines of the lab were strictly followed. Escherichia coli ATCC 25922, Pseudomonas aeruginosa ATCC 27853 and Klebsiella pneumoniae ATCC 700603, Klebsiella pneumoniae ATCC BAA-1705  were used as QC strains.

RESULTS

Among the 76 suspected carbapenemase producing organisms (CPO’s), 42% were Klebsiella spp. followed by Escherichia coli (25%), Pseudomonas aeruginosa (24%), Citrobacter spp.(5%) and Proteus spp.(4%) (Table 1 and 2).

Table (1):
Frequency distribution of suspected Carbapenemase producing Organisms

No
Isolate (n= 76)
 Number
Percentage
1.
Klebsiella spp.
32
42%
2.
E. coli
19
25%
3.
Pseudomonas aeruginosa
18
24%
4.
Citrobacter spp.
04
05%
5.
Proteus spp.
03
04%
Total (n)
76

Table (2):
Phenotypic detection of CPO’s by Carba NP and mCIM test

No. Isolate (n= 76) Carba NP test Positive mCIM test positive
Number Percentage Number Percentage
1. Klebsiella spp. 26 81% 30 93%
2. Escherichia coli 17 89% 18 94%
3. Citrobacter spp. 04 100% 04 100%
4. Proteus spp. 02 66% 03 100%
5. Pseudomonas aeruginosa 12 66% 16 88%
Total 62 82% 71 93%

7% of Klebsiella spp., 11% of Pseudomonas aeruginosa and 6% of Escherichia coli gave indeterminate results by mCIM in conjunction with eCIM test (Table 3).

Table (3):
Frequency distribution of isolates tested with mCIM in conjunction with eCIM test

No
Isolate (n= 76)
mCIM
mCIM + eCIM
Indeterminate
1.
Klebsiella spp.
30 (93%)
14 (43%)
02 (7%)
2.
Escherichia coli
18 (94%)
07 (36%)
01 (6%)
3.
Citrobacter spp.
04 (100%)
0
0
4.
Proteus spp.
03 (100%)
01 (33%)
0
5.
Pseudomonas aeruginosa
16 (88%)
09 (50%)
02(11%)

53% of the total isolates tested were Serine-β-lactamase producers and 41% were Metallo-β-lactamase producers whereas 6% of the isolates gave indeterminate test results (Table 4).

Table (4):
Differentiation of CPO’s into different classes based on mCIM in conjunction with eCIM test

No
Organism n= 76
Serine-β-lactamases
Metallo-β-lactamases
1.
Klebsiella spp.
16 (50%)
14 (43%)
2.
Escherichia coli
11 (57%)
07 (36%)
3.
Citrobacter spp.
04 (100%)
0
4.
Proteus spp.
02 (66%)
01(33%)
5.
Pseudomonas aeruginosa
07 (39%)
09 (50%)
Total
40 (53%)
31(41%)
DISCUSSION

Infections due to CPO’s entail challenges in their detection in resource limited settings, thus emphasizing the need of optimization of diagnostics which are cost-effective and easy to use on a daily basis. Though genotypic tests are very precise in the identification of genes coding for resistance, it also has a disadvantage that if a new or uncommon enzyme coding gene which is not included in the testing panel cannot be detected and the mere presence of gene will not always confer resistance as the organism may not express the gene phenotypically. Genotypic tests are also very expensive. On the other side, Phenotypic tests detect the expression and probably will not miss the carbapenemase production and is also cost effective. Diagnostic perfection comes for a test which is cost-effective with a lower turnaround time and is highly sensitive and specific.

CarbaNP & mCIM tests are two phenotypic detection methods with good diagnostic perfection as recommended by CLSI M100 guidelines.7

In the present study, a total of 76 isolates with suspected carbapenemase production were tested with Carba NP and mCIM test. Carba NP test is positive for 82% of the total isolates which correlated with a study by Patidar et al.,8 where 88% of the isolates were positive in contrast to Sinha D. et al.9 showing only 71% positivity. 93% of the total isolates were confirmed to be carbapenemase producers by mCIM test which is similar to studies by Tsai et al.10 100%, Li et al.11 97.5% , Sinha et al. 87% and Aboulela et al. 83% whereas Koul et al. reported only 53.5% Positivity.

In this study, mCIM detected carbapenemase production in 93% of Klebsiella spp which correlated with Li et al.11 96% whereas Tsai et al., Koul et al. and Alemayehu et al.12 reported 65%, 48.48% and 30% respectively. Similarly, 94% of E. coli were positive by mCIM test in correlation with Li et al. & Tsai et al. 100% and Alemayehu et al.12 reported only 20% positivity. Citrobacter spp. and Protues spp. were 100% positive to mCIM test as with Li et al. & Tsai et al. 83% of Pseudomonas aeruginosa strains were positive as compared to 30% by Alemayehu et al.

Carbapenemase production by Carba NP test in this study was confirmed in 100% of Citrobacter spp., 89% Escherichia coli, 81% Klebsiella spp. and 66% of P.aeruginosa & Proteus whereas a study by Pragasam et al.13 detected 97% and 89% of E.coli & Klebsiella respectively.

Current study reveals, 53% of total isolates tested were Serine-β-lactamase producers and 41% were Metallo-β-lactamase producers which is comparable to Aboulela et al.14 & Koul et al.15 who reported 52.8% MBL, 30.2% Serine carbapenemase producers & 58.3% MBL, 41.6% Serine carbapenemase producers respectively.

50% of Pseudomonas aeruginosa, 43% of Klebsiella spp., 36% of E.coli, 33% of Proteus spp. were MBL producers in the study. A study by Koul et al.15 reported 75% Klebsiella spp., 25% of E.coli were MBL producers.

By analysing the findings of the present study mCIM test detected more number of carbapenem producing strains compared to Carba NP test. The strength of Carba NP test is that it can be considered as rapid biochemical test with a turnaround time of less than 2 hours for detection of CRO’s. Nordmann et al.16 had reported this test to be 100% sensitive for detection of carbapenemase production but subsequent studies revealed a lower sensitivity of <90%.17-19 Limitations of Carba NP test is that it cannot differentiate between different classes of carbapenemases, low sensitivity for detection of class D carbapenemases and false negative results were obtained with some mucoid strains of Enterobacteriaceae. Tamma et al. reported a lower detection rate of 40% OXA-48 like enzyme producing Enterobacterales.20 Tijet et al. reported that false negative results were probably due to partial lysis of the cell wall in mucoid MBL producing Enterobacterales.21

Modified CIM has shown good results in this study which corroborated with foregoing studies who have revealed excellent precision to detect KPC, VIM, NDM, OXA-48 like carbapenemases.22,24-28 It is preferable for resource limited laboratories as it is easy to do and inexpensive test. As eCIM is also performed along with mCIM for the detection of MBL’s it will be helpful for differentiation between serine & metallo beta-lactamases.23,29,30 The disadvantage with this method is a turnaround time of 18-24 hours and also when class B and class A/D carbapenemases are co-expressed, eCIM test cannot detect class B enzymes but the prevalence of isolates encoding both classes is very low.22 Also, it has lower sensitivity for IMP type of MBL detection 79.6% but is 100% sensitive for NDM enzyme detection.23

CONCLUSION

The Health implications caused by CPO’s were increasing day by day as reported in several studies globally, accentuating the expeditious demand for optimization of diagnostics and therapeutics and also for establishment of definitive and effective infection prevention and control practices. Thus, understanding the mechanisms causing carbapenem resistance has gained significance. The study results showed that mCIM combined with eCIM test was superior to CarbaNP test. Newer classes of β-lactam & β-lactamase inhibitors, like ceftazidime-avibactam have a significant therapeutic effect on serine carbapenemase producers whereas concomitant therapy with ceftazidime-avibactam along with aztreonam and colistin were highly active on MBL producers. As mCIM with eCIM can differentiate between both, it could be utilised as simple, reliable, cost-effective phenotypic method for carbapenemase detection which will contribute in the formulation of better treatment plan to curtail therapeutic failures. Into the bargain, it will help the resource limited laboratories to consider restricting the genotypic testing for carbapenamase production.

Limitations of the study
With this study’s results, one cannot extrapolate the carbapenemase resistance in this particular region, as a multitude of people suffering from various infections visit the tertiary care hospitals after taking many antibiotics over the counter.

Declarations

ACKNOWLEDGMENTS
The authors would sincerely thank the Management of Mamata Academy of Medical sciences, Hyderabad, Telangana, India, for providing an excellent platform for the research work and also thank the technical staff of Microbiology laboratory for their constant support throughout the study.

CONFLICT OF INTEREST
The authors declare that there is no conflict of interest.

AUTHORS’ CONTRIBUTION
All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.

FUNDING
None.

DATA AVAILABILITY
The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.

ETHICS STATEMENT
This study was approved by the Institutional Ethics Committee,  Mamata Academy of Medical Sciences, Hyderabad, India, with review letter number IEC/MAMS/2023/019.

References
  1. Goodman KE, Simner PJ, Tamma PD, Milstone AM. Infection control implications of heterogeneous resistance mechanisms in carbapenem-resistant Enterobacteriaceae (CRE). Expert Rev Anti Infect Ther. 2016;14(1):95-108.
    Crossref
  2. Beyrouthy R, Barets M, Marion E, et al. Novel Enterobacter Lineage as Leading Cause of Nosocomial Outbreak Involving Carbapenemase-Producing Strains. Emerg Infect Dis. 2018;24(8):1505-1515.
    Crossref
  3. Jimenez A, Castro JG, Munoz-Price LS, et al. Outbreak of Klebsiella pneumoniae Carbapenemase-Producing Citrobacter freundii at a Tertiary Acute Care Facility in Miami, Florida. Infect Control Hosp Epidemiol. 2017;38(3):320-326.
    Crossref
  4. Ahn K, Hwang GY, Kim YK, et al. Nosocomial Outbreak Caused by NDM5 and OXA-181 Carbapenemase Co-producing Escherichia coli. Infect Chemother. 2019;51(2):177-182.
    Crossref
  5. Logan LK, Weinstein RA. The epidemiology of carbapenem resistant Enterobacteriaceae: the impact and evolution of a global menace. J Infect Dis. 2017;215(Suppl 1):S28-S36.
    Crossref
  6. Sfeir MM, Hayden JA, Fauntleroy KA, et l. EDTA-Modified Carbapenem Inactivation Method: a Phenotypic Method for Detecting Metallo-beta-Lactamase-Producing Enterobacteriaceae. J Clin Microbiol. 2019;57(5):e01757-18.
    Crossref
  7. CLSI. [Performance Standards for Antimicrobial Susceptibility Testing]. [32nd Edition]. CLSI guideline [M100]. Wayne, PA: Clinical and Laboratory Standards Institute. 2022.
  8. Patidar N, Vyas N, Sharma S, Sharma B. Phenotypic Detection of Carbapenemase Production in Carbapenem-Resistant Enterobacteriaceae by Modified Hodge Test and Modified Strip Carba NP Test. J Lab Physicians. 2021;13(1):14-21.
    Crossref
  9. Sinha D, Shantala GB, Ambica R, Kusuma CR. In vitro methods of CLSI to detect Carbapenemases in Carbapenem-resistant Enterobacteriaceae. Trop J Pathol Microbiol. 2020;6(4):324-328.
  10. Tsai Y-M, W S, Chiu H-C, Kao C-Y, Wen L-L. Combination of modified carbapenem inactivation method (mCIM) and EDTA-CIM (eCIM) for phenotypic detection of carbapenemase-producing Enterobacteriaceae. BMC Microbiol. 2020;20(1):315.
    Crossref
  11. Li J, Li C, Cai X, et al. Performance of modified carbapenem inactivation method and inhibitor-based combined disk test in the detection and distinguishing of carbapenemase producing Enterobacteriaceae. Ann Transl Med. 2019;7(20):566.
    Crossref
  12. Alemayehu T, Asnake S, Tadesse B, et al. Phenotypic Detection of Carbapenem-Resistant Gram-Negative Bacilli from a Clinical Specimen in Sidama, Ethiopia: A Cross-Sectional Study. Infect Drug Resist. 2021;14:369-380.
    Crossref
  13. Pragasam AK, Veeraraghavan B, Bakthavatchalam YD, Gopi R, Aslam RF. Strengths and limitations of various screening methods for carbapenem-resistant Enterobacteriaceae including new method recommended by clinical and laboratory standards institute, 2017: A tertiary care experience. Indian J Med Microbiol. 2017;35(1):116-119.
    Crossref
  14. Aboulela A, Jabbar M, Hammouda A, Ashour M. Assessment of Phenotypic Testing by mCIM with eCIM for Determination of the type of Carbapenemase Produced by Carbapenem-resistant Enterobacterales. Egypt J Med Microbiol. 2023;32(1):37-46.
    Crossref
  15. Koul N, Kakati B, Agarwal S. Use of the Combined Modified Carbapenem Inactivation Method and EDTA-modified Carbapenem Inactivation Method for Detection of Carbapenemase-Producing Enterobacteriaceae Causing Ventilator-associated Respiratory Infections. J Pure Appl Microbiol. 2022;16(2):1239-1244.
    Crossref
  16. Nordmann P, Poirel L, Dortet L. Rapid detection of carbapenemase-producing Enterobacteriaceae. Emerg Infect Dis. 2012;18(9):1503-1507.
    Crossref
  17. Tijet N, Boyd D, Patel SN, Mulvey MR, Melano RG. Evaluation of the Carba NP test for rapid detection of carbapenemase-producing Enterobacteriaceae and Pseudomonas aeruginosa. Antimicrob Agents Chemother. 2013;57(9):4578-4580.
    Crossref
  18. Girlich D, Poirel L, Nordmann P. Value of the modified Hodge test for detection of emerging carbapenemases in Enterobacteriaceae. J Clin Microbiol. 2012;50(2):477-479.
    Crossref
  19. Cunningham SA, Limbago B, Traczewski M, et al. Multicenter Performance Assessment of Carba NP Test. J Clin Microbiol. 2017;55(6):1954-1960.
    Crossref
  20. Tamma PD, Opene BN, Gluck A, Chambers KK, Carroll KC, Simner PJ. Comparison of 11 Phenotypic Assays for Accurate Detection of Carbapenemase-Producing Enterobacteriaceae. J Clin Microbiol. 2017;55(4):1046-1055.
    Crossref
  21. Tijet N, Boyd D, Patel SN, Mulvey MR, Melano RG. Reply to “further proofs of concept for the Carba NP test”. Antimicrob Agents Chemother. 2014;58(2):1270.
    Crossref
  22. Castanheira M, Huband MD, Mendes RE, Flamm RK. Meropenem-vaborbactam tested against contemporary Gram-negative isolates collected worldwide during 2014, including carbapenem-resistant, KPC producing, multidrug-resistant, and extensively drug-resistant Enterobacteriaceae. Antimicrob Agents Chemother. 2017;61(9):e00567-17.
    Crossref
  23. Yamada K, Sasaki M, Imai W, et al. Evaluation of inhibitor-combination mCIM for detecting MBL-producing Enterobacterales using three MBL inhibitors. J Med Microbiol. 2019;68(11):1604-1606.
    Crossref
  24. Liao Q, Yuan Y, Zhang W, Deng J, Wu S, Liu Y, Xiao Y, Kang M. Detection and Characterization of Carbapenemases in Enterobacterales With a New Rapid and Simplified Carbapenemase Detection Method Called rsCDM. Front Microbiol. 2022;13:860288.
    Crossref
  25. Liao Q, Yuan Y, Li Q, et al. Comparing three different phenotypic methods for accurate detection of carbapenemase-producing Enterobacterales. J Infect Chemother. 2021;27(6):794-799.
    Crossref
  26. Petit M, Camelena F, Cointe A, et al. Rapid Detection and Characterization of Carbapenemases in Enterobacterales with a New Modified Carbapenem Inactivation Method, mCIMplus. J Clin Microbiol. 2020;58(11):e01370-20.
    Crossref
  27. Zhang Z, Wang D, Li Y, Liu Y, Qin X. Comparison of the Performance of Phenotypic Methods for the Detection of Carbapenem-Resistant Enterobacteriaceae (CRE) in Clinical Practice. Front Cell Infect Microbiol. 2022;12:849564.
    Crossref
  28. Zhong H, Wu ML, Feng WJ, Huang SF, Yang P. Accuracy and applicability of different phenotypic methods for carbapenemase detection in Enterobacteriaceae: A systematic review and meta-analysis. J Glob Antimicrob Resist. 2020;21:138-147.
    Crossref
  29. Gill CM, Lasko MJ, Asempa TE, Nicolau DP. Evaluation of the EDTA-Modified Carbapenem Inactivation Method for Detecting Metallo-b-Lactamase-Producing Pseudomonas aeruginosa. J Clin Microbiol. 2020;58(6):e02015-19.
    Crossref
  30. Vamsi SK, Moorthy RS, Hemiliamma MN, Chandra Reddy RB, Chanderakant DJ, Sirikonda S. Phenotypic and genotypic detection of carbapenemase production among gram negative bacteria isolated from hospital acquired infections. Saudi Med J. 2022;43(3):236-243.
    Crossref

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