Multi-drug resistant Pseudomonas aeruginosa and Klebsiella pneumoniae circulation in a burn hospital, Tehran, Iran

dgkh000317 10.3205/dgkh000317 urn:nbn:de:0183-dgkh0003173 Research Article Multi-drug resistant Pseudomonas aeruginosa and Klebsiella pneumoniae circulation in a burn hospital, Tehran, Iran Zirkulation multiresistenter Pseudomonas aeruginosa und Klebsiella pneumoniae in einem Krankenhaus für Verbrennungspatienten in Teheran, Iran Azimi Azimi Leila L

Pediatric Infectious Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran

author Alaghehbandan Alaghehbandan Reza R

Department of Pathology, University of British Columbia, Royal Columbian Hospital, Vancouver, BC, Canada

author Asadian Asadian Mahla M

Division of Microbiology, Department of Pathobiology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran

author Alinejad Alinejad Faranak F

Burn Research Center, Iran University of Medical Sciences, Tehran, Iran

author Lari Lari Abdolaziz Rastegar AR Prof.

Department of Microbiology, Iran University of Medical Sciences, P.O. Box 14515-717, Tehran, Iran, Phone: +98 21 1005448Department of Microbiology, Iran University of Medical Sciences, Tehran, Iran

azizlari@gmail.com author German Medical Science GMS Publishing House

Düsseldorf

610 health care-associated infection P. aeruginosa K. pneumoniae antibiotic resistance genetic relationship pulsed-field gel electrophoresis nosokomiale Infektion P. aeruginosa K. pneumoniae Antibiotikaresistenz genetische Verwandtschaft Pulsfeld-Gel-Elektrophorese 20190122 engl This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. Dieser Artikel ist ein Open-Access-Artikel und steht unter den Lizenzbedingungen der Creative Commons Attribution 4.0 License (Namensnennung). 2196-5226 14 GMS Hygiene and Infection Control GMS Hyg Infect Control 01 Iran University of Medical Sciences, Tehran, Iran Pseudomonas (P.) aeruginosa und Klebsiella (K.) pneumoniae gehören zu den wichtigsten Gram-negativen Erregern nosokomialer Infektionen speziell bei Verbrennungspatienten. Zur Identifizierung der Infektionsquelle ist es wichtig, die genetische Verwandtschaft zwischen Proben des Patienten und aus der patientennahen Umgebung zu bestimmen. Zielsetzung der Studie war die Analyse der Ausbreitung multiresistenter Pseudomonas aeruginosa und Klebsiella pneumoniae Stämme in einem Krankenhaus für Verbrennungspatienten in Teheran. Nach der mikrobiologischen Differenzierung wurde das Antibiogramm gemäß Richtlinie des Clinical Laboratory Standards Institute bestimmt. Die molekulare Typisierung erfolgt mit der Pulsfeld-Gel-Elektrophorese (PFGE). Es wurden 97 Stämme von Patienten und 33 aus der Umgebung analysiert. 40 (55%) Patientenstämme von P. aeruginosa und K. pneumoniae Patientenstämme erwiesen sich als multiresistent bzw. extensiv resistent. Die PFGE zeigte ähnliche genetische Merkmale bei multiresistenten und extensiv resistenten Stämmen beider Species aus klinischen und Umgebungsisolaten. Die Unterbrechung der Erregerausbreitung im Krankenhaus ist eine wichtige Maßnahme zur Prävention nosokomialer Infektionen speziell bei Verbrennungspatienten mit eingeschränkter Immunantwort. Pseudomonas aeruginosa and Klebsiella pneumoniae are among the most important Gram-negative bacteria that can cause nosocomial infections, especially in burn patients. It is important to determine genetic relationships in different clinical specimens as well as between clinical and environmental specimens, which can aid in detecting the source of infection. The aim of this study was to investigate multi-drug resistant Pseudomonas aeruginosa and Klebsiella pneumoniae spread in a burn hospital, Tehran, Iran. After identification, antibiotic susceptibility testing of all isolates was conducted according to the CLSI guidelines. Further, pulsed-field gel electrophoresis (PFGE) was performed for molecular typing. 97 clinical and 33 environmental specimens were collected. 40 (55%) clinical strains of P. aeruginosa and K. pneumoniae were highly drug resistant. PFGE findings showed similar genetic features to those seen in multi-drug resistant and/or extensively drug resistant P. aeruginosa and K. pneumoniae in clinical and environmental isolates. Inhibition of bacterial spread in the hospital can help to control health care-associated infection and subsequently decrease the morbidity and mortality in hospitalized patients, particularly immunocompromised populations such as burn patients. IntroductionPseudomonas aeruginosa and Klebsiella pneumoniae are the most common causes of nosocomial infections in burn patients , , . P. aeruginosa is able to survive in the hospital environment and survive chemical cleaners consistently used in the hospital , , , . Since P. aeruginosa has the potential to develop resistance to many effective antibiotics, treatment of infections with these Gram-negative organisms can be very challenging , , , . Similarly, the resistance of K. pneumoniae to antibiotics is an increasing problem in burn units in Iran , . Multi-drug resistant (MDR) and/or extensively drug resistant (XDR) Gram-negative bacteria have proven to cause significant problems in burn care settings in Iran , , , . On the other hand, because they are immune-suppressed, burn patients are at high risk of nosocomial infections by environmental bacteria , , , . In the case of burns and skin damage, the skin is one of the most susceptible areas for bacterial colonization, which can lead to infections , , , . This is where proper control of environmental factors such as patients’ surroundings in hospitals could play a critical role in reducing and preventing opportunistic infections , , ultimately decreasing associated morbidity and mortality . Molecular epidemiological studies are necessary to detect the source of infections and develop preventative strategies in order to control the transmission of bacteria among patients and even between wards , . Molecular typing methods such as restriction fragment length polymorphism (RFLP), random amplified polymorphic DNA (RAPD), multilocus enzyme electrophoresis and pulsed-field gel electrophoresis (PFGE) are utilized for molecular typing , . PFGE of restricted genomic DNA fragments is commonly considered the most appropriate technique available, due to its high discriminatory power to type closely related isolates of Gram-negative bacteria . The aim of this study was to investigate the genetic relationships between clinical and environmental MDR isolates of the most important and common Gram-negative bacteria among burn patients. Further, we molecularly typed P. aeruginosa and K. pneumoniae isolated from different clinical and environmental samples. Materials and methodsSampling and bacterial analysis130 bacterial isolates (n=97 clinical, n=33 environmental) were collected from the laboratory of a teaching hospital in Tehran during a six-month period in 2013. The environmental specimens were collected simultaneously from areas such as the patient’s file, water from the washbasin, chair, shower, soap dispenser and refrigerator’s handle (Table 1 ) from different wards pertinent to hospitalized patients. All samples were cultured in nutrient agar and MacConkey agar. P. aeruginosa and K. pneumoniae were identified by specific biochemical and microbiological tests . P. aeruginosa ATCC® 27853 and K. pneumoniae ATCC® BAA-1705 were used as standard strains. Antibiotic susceptibility testingAntibiotic susceptibility testing was performed according to the CLSI 2013 by disk-diffusion agar methods against imipenem (10 µg), meropenem (10 µg), cefepime (30 µg), cefotaxime (30 µg), ceftazidime (30 µg), ticarcillin (75 µg), ticarcillin-clavulanic acid (75/10 µg), piperacillin (100 µg</PlainText></TextGroup>), piperacillin-tazobactam (100/10 µg), ciprofloxacin (<TextGroup><PlainText>5 µg</PlainText></TextGroup>), gentamicin (10 µg), tobramycin (10 µg), amikacin (<TextGroup><PlainText>30 µg</PlainText></TextGroup>), tetracycline (30 µg), trimethoprim (5 µg) and trimethoprim-sulfamethoxazole (1.25/23.75). Susceptibility to colistin was examined using the Epsilometer test (E. test). Each isolated bacterial strain that was resistant to three or more antibiotic families was considered as MDR. <Mark2>P. aeruginosa</Mark2> ATCC<Superscript>®</Superscript> 27853 was used as control strain in the antibiotic susceptibility testing. All strains resistant to all tested antibiotics were considered extensively drug resistant (XDR) strains. </Pgraph><SubHeadline>Molecular typing of strains using PFGE</SubHeadline><Pgraph><Mark2>P. aeruginosa</Mark2> and <Mark2>K. pneumoniae</Mark2> specimens that showed similar antibiotic resistant patterns in clinical and environmental specimens were selected for PFGE. <Mark2>Xba</Mark2>I-digested genomic DNA was prepared from <Mark2>P. aeruginosa</Mark2>. DNA fragments were separated into two blocks program included; block 1: 13 h at 6 V/cm at induced angle 120° with initial and final pulse times of 2 s and 10 s, respectively; block 2: 6 h at 6 V/cm at induced angle 120° with initial and final pulse times of 20 s and 25 s, respectively. <Mark2>Xba</Mark2>I digested DNA was prepared for <Mark2>K. pneumoniae</Mark2>. DNA fragments were separated with program included; <TextGroup><PlainText>block 1:</PlainText></TextGroup> 20 h at 6 V/cm at induced angle 120° with initial and final pulse times of 2.2 s and 63.8 s, respectively by using a CHEF-DR II System (Bio-Rad, Hercules, CA, USA).</Pgraph><Pgraph><Mark2>Salmonella braenderup</Mark2> was used as a DNA size marker. Banding patterns were analyzed with special gene-comparing software to generate a dendrogram based on the unweighted pair group method using arithmetic averages from the Dice coefficient.</Pgraph></TextBlock> <TextBlock linked="yes" name="Results"> <MainHeadline>Results</MainHeadline><Pgraph>In this study, 97 clinical MDR strains include 64 <Mark2>P. </Mark2><TextGroup><Mark2>aeruginosa</Mark2></TextGroup> and 33 <Mark2>K. pneumoniae</Mark2> were collected from 79 patients (62 men, 17 women) with bacterially colonized burn wounds. Eighteen patients had more than one specimen with different antibiotic resistance patterns. The age range of patients was between one to 73 years old. </Pgraph><Pgraph>33 environmental specimens were collected from different areas of the hospital, such as water, shower etc. (Table 1 <ImgLink imgNo="1" imgType="table"/>). <Mark2>P. aeruginosa</Mark2> was the most prevalent environmental bacterium, followed by <Mark2>K. pneumoniae</Mark2>. The desired bacteria were isolated from the following environmental sources: washing liquid, ventilator, serum antibiotic cover, tap water, refrigerator handles, chlorhexidine solution, patient’s file and patient’s mobile phone.</Pgraph><Pgraph>The antibiotic resistance patterns of both clinical and environmental specimens are presented in Table 2 <ImgLink imgNo="2" imgType="table"/>. 43% and 10% of <Mark2>P. aeruginosa</Mark2> isolated from clinical and environmental samples, respectively, were resistant to all tested antibiotics except for colistin and tetracycline. 40% and 50% of <Mark2>P. aeruginosa</Mark2> isolated from clinical and environmental samples, respectively, were resistant to all tested antibiotics except for colistin and were considered XDR. On the other hand, 55% and 44% of clinical and environmental isolates of <Mark2>K. pneumoniae</Mark2>, respectively, were resistant to all tested antibiotics except for colistin, were deemed as XDR (<TextGroup><PlainText>Table 2 </PlainText></TextGroup><ImgLink imgNo="2" imgType="table"/>). Colistin, followed by tetracycline, was the most effective antibiotics. </Pgraph><Pgraph>The results of PFGE showed that all clinical and environmental <Mark2>P. aeruginosa</Mark2> as well as <Mark2>K. pneumoniae</Mark2> have similar clonal groups in PFGE (Figure 1 <ImgLink imgNo="1" imgType="figure"/>).</Pgraph></TextBlock> <TextBlock linked="yes" name="Discussion"> <MainHeadline>Discussion</MainHeadline><Pgraph>Burn patients are at high risk for nosocomial infections with opportunistic environmental bacteria <TextLink reference="1"></TextLink>, <TextLink reference="2"></TextLink>, <TextLink reference="10"></TextLink>, <TextLink reference="11"></TextLink>. As such, prevention of bacterial transmission from hospital environments to patients or directly from one patient to another, especially MDR strains, can decrease morbidity and mortality in burns <TextLink reference="13"></TextLink>, <TextLink reference="14"></TextLink>. Genotyping is an important technique to determine infection routes and to aid in developing preventative strategies <TextLink reference="3"></TextLink>, <TextLink reference="14"></TextLink>.</Pgraph><Pgraph>This study showed that there is a strong association between genetic relationships of <Mark2>P. aeruginosa</Mark2> and <TextGroup><Mark2>K. p</Mark2></TextGroup><Mark2>neumoniae</Mark2> isolated from different patients and in different wards. Further, it should be noted that genetic relationships between clinical and environmental specimens is of paramount importance clinically. This is because MDR bacteria can be transferred from one patient to another via hospital staff <TextLink reference="10"></TextLink>, <TextLink reference="11"></TextLink>. The transfer can also occur from hospital environment to patients <TextLink reference="10"></TextLink>, <TextLink reference="11"></TextLink>. Such bacterial cycling in a hospital system is a crucial factor to recognize, especially in burn care units with opportunistic bacterial colonizations and infections <TextLink reference="1"></TextLink>, <TextLink reference="2"></TextLink>, <TextLink reference="10"></TextLink>, <TextLink reference="11"></TextLink>. Furthermore, such bacterial transfer can complicate patient management and increase mortality and morbidity. Salimi et al. <TextLink reference="14"></TextLink> also reported the genetic relationship in <Mark2>P. aeruginosa</Mark2> isolated from different burn patients in a burn hospital and even between clinical and environmental specimens in Iran. In France, Petit et al. <TextLink reference="18"></TextLink> investigated that <Mark2>P. aeruginosa</Mark2> isolated from waste-water treatment lagoons was related to similar lineages of major clinical clones. Finnan et al. <TextLink reference="12"></TextLink> showed similarity between clusters of <Mark2>P. aeruginosa</Mark2> isolate from cystic fibrosis patients and the hospital environment. Tofteland et al. <TextLink reference="19"></TextLink> reported an outbreak of KPC-producing <Mark2>K. pneumoniae</Mark2> in a general hospital chain located in three different cities in southern Norway in 2015. Voulgari et al. <TextLink reference="20"></TextLink> also showed an outbreak of OXA-48-producing <Mark2>K. pneumoniae</Mark2> in Greece. </Pgraph><Pgraph>Overall, the findings of our study as well as those mentioned above highlight the importance of outbreak and bacterial circulation in hospitals. The existence of the antibiotic-resistant bacteria in hospitals can easily lead to therapeutic complications, longer hospital stays, high mortality and morbidity, and increased treatment costs. Molecular typing is one of the first and most important steps in determining the source of bacteria isolated from hospitals. The hospital infection control authorities would not be able to effectively stop bacterial circulation in the hospital without applying the basic rules of sanitation and efficient use of disinfectants.</Pgraph></TextBlock> <TextBlock linked="yes" name="Notes"> <MainHeadline>Notes</MainHeadline><SubHeadline>Funding</SubHeadline><Pgraph>This study was supported by a grant (M/T 91-04-134-20187) from Iran University of Medical Sciences, Tehran, Iran.</Pgraph><SubHeadline>Competing interests</SubHeadline><Pgraph>The authors declare that they have no competing interests.</Pgraph></TextBlock> <References linked="yes"> <Reference refNo="1"> <RefAuthor>Azimi L</RefAuthor> <RefAuthor>Motevallian A</RefAuthor> <RefAuthor>Ebrahimzadeh Namvar A</RefAuthor> <RefAuthor>Asghari B</RefAuthor> <RefAuthor>Lari AR</RefAuthor> <RefTitle>Nosocomial infections in burned patients in motahari hospital, tehran, iran</RefTitle> <RefYear>2011</RefYear> <RefJournal>Dermatol Res Pract</RefJournal> <RefPage>436952</RefPage> <RefTotal>Azimi L, Motevallian A, Ebrahimzadeh Namvar A, Asghari B, Lari AR. Nosocomial infections in burned patients in motahari hospital, tehran, iran. Dermatol Res Pract. 2011;2011:436952. DOI: 10.1155/2011/436952 </RefTotal> <RefLink>http://dx.doi.org/10.1155/2011/436952</RefLink> </Reference> <Reference refNo="2"> <RefAuthor>Alaghehbandan R</RefAuthor> <RefAuthor>Azimi L</RefAuthor> <RefAuthor>Rastegar Lari A</RefAuthor> <RefTitle>Nosocomial infections among burn patients in Teheran, Iran: a decade later</RefTitle> <RefYear>2012</RefYear> <RefJournal>Ann Burns Fire Disasters</RefJournal> <RefPage>3-7</RefPage> <RefTotal>Alaghehbandan R, Azimi L, Rastegar Lari A. Nosocomial infections among burn patients in Teheran, Iran: a decade later. Ann Burns Fire Disasters. 2012 Mar 31;25(1):3-7.</RefTotal> </Reference> <Reference refNo="3"> <RefAuthor>Lari AR</RefAuthor> <RefAuthor>Alaghehbandan R</RefAuthor> <RefTitle>Nosocomial infections in an Iranian burn care center</RefTitle> <RefYear>2000</RefYear> <RefJournal>Burns</RefJournal> <RefPage>737-40</RefPage> <RefTotal>Lari AR, Alaghehbandan R. Nosocomial infections in an Iranian burn care center. Burns. 2000 Dec;26(8):737-40. DOI: 10.1016/S0305-4179(00)00048-6</RefTotal> <RefLink>http://dx.doi.org/10.1016/S0305-4179(00)00048-6</RefLink> </Reference> <Reference refNo="4"> <RefAuthor>Zanetti G</RefAuthor> <RefAuthor>Blanc DS</RefAuthor> <RefAuthor>Federli I</RefAuthor> <RefAuthor>Raffoul W</RefAuthor> <RefAuthor>Petignat C</RefAuthor> <RefAuthor>Maravic P</RefAuthor> <RefAuthor>Francioli P</RefAuthor> <RefAuthor>Berger MM</RefAuthor> <RefTitle>Importation of Acinetobacter baumannii into a burn unit: a recurrent outbreak of infection associated with widespread environmental contamination</RefTitle> <RefYear>2007</RefYear> <RefJournal>Infect Control Hosp Epidemiol</RefJournal> <RefPage>723-5</RefPage> <RefTotal>Zanetti G, Blanc DS, Federli I, Raffoul W, Petignat C, Maravic P, Francioli P, Berger MM. Importation of Acinetobacter baumannii into a burn unit: a recurrent outbreak of infection associated with widespread environmental contamination. Infect Control Hosp Epidemiol. 2007 Jun;28(6):723-5. DOI: 10.1086/517956</RefTotal> <RefLink>http://dx.doi.org/10.1086/517956</RefLink> </Reference> <Reference refNo="5"> <RefAuthor>Naze F</RefAuthor> <RefAuthor>Jouen E</RefAuthor> <RefAuthor>Randriamahazo RT</RefAuthor> <RefAuthor>Simac C</RefAuthor> <RefAuthor>Laurent P</RefAuthor> <RefAuthor>Blériot A</RefAuthor> <RefAuthor>Chiroleu F</RefAuthor> <RefAuthor>Gagnevin L</RefAuthor> <RefAuthor>Pruvost O</RefAuthor> <RefAuthor>Michault A</RefAuthor> <RefTitle>Pseudomonas aeruginosa outbreak linked to mineral water bottles in a neonatal intensive care unit: fast typing by use of high-resolution melting analysis of a variable-number tandem-repeat locus</RefTitle> <RefYear>2010</RefYear> <RefJournal>J Clin Microbiol</RefJournal> <RefPage>3146-52</RefPage> <RefTotal>Naze F, Jouen E, Randriamahazo RT, Simac C, Laurent P, Blériot A, Chiroleu F, Gagnevin L, Pruvost O, Michault A. Pseudomonas aeruginosa outbreak linked to mineral water bottles in a neonatal intensive care unit: fast typing by use of high-resolution melting analysis of a variable-number tandem-repeat locus. J Clin Microbiol. 2010 Sep;48(9):3146-52. DOI: 10.1128/JCM.00402-10</RefTotal> <RefLink>http://dx.doi.org/10.1128/JCM.00402-10</RefLink> </Reference> <Reference refNo="6"> <RefAuthor>Azimi L</RefAuthor> <RefAuthor>Talebi M</RefAuthor> <RefAuthor>Pourshafie MR</RefAuthor> <RefAuthor>Owlia P</RefAuthor> <RefAuthor>Rastegar Lari A</RefAuthor> <RefTitle>Characterization of Carbapenemases in Extensively Drug Resistance Acinetobacter baumannii in a Burn Care Center in Iran</RefTitle> <RefYear>2015</RefYear> <RefJournal>Int J Mol Cell Med</RefJournal> <RefPage>46-53</RefPage> <RefTotal>Azimi L, Talebi M, Pourshafie MR, Owlia P, Rastegar Lari A. Characterization of Carbapenemases in Extensively Drug Resistance Acinetobacter baumannii in a Burn Care Center in Iran. Int J Mol Cell Med. 2015;4(1):46-53.</RefTotal> </Reference> <Reference refNo="7"> <RefAuthor>Lari AR</RefAuthor> <RefAuthor>Azimi L</RefAuthor> <RefAuthor>Soroush S</RefAuthor> <RefAuthor>Taherikalani M</RefAuthor> <RefTitle>Low prevalence of metallo-beta-lactamase in Pseudomonas aeruginosa isolated from a tertiary burn care center in Tehran</RefTitle> <RefYear>2015</RefYear> <RefJournal>Int J Immunopathol Pharmacol</RefJournal> <RefPage>384-9</RefPage> <RefTotal>Lari AR, Azimi L, Soroush S, Taherikalani M. Low prevalence of metallo-beta-lactamase in Pseudomonas aeruginosa isolated from a tertiary burn care center in Tehran. Int J Immunopathol Pharmacol. 2015 Sep;28(3):384-9. DOI: 10.1177/0394632015578343</RefTotal> <RefLink>http://dx.doi.org/10.1177/0394632015578343</RefLink> </Reference> <Reference refNo="8"> <RefAuthor>Rastegar Lari A</RefAuthor> <RefAuthor>Azimi L</RefAuthor> <RefAuthor>Rahbar M</RefAuthor> <RefAuthor>Fallah F</RefAuthor> <RefAuthor>Alaghehbandan R</RefAuthor> <RefTitle>Phenotypic detection of Klebsiella pneumoniae carbapenemase among burns patients: first report from Iran</RefTitle> <RefYear>2013</RefYear> <RefJournal>Burns</RefJournal> <RefPage>174-6</RefPage> <RefTotal>Rastegar Lari A, Azimi L, Rahbar M, Fallah F, Alaghehbandan R. Phenotypic detection of Klebsiella pneumoniae carbapenemase among burns patients: first report from Iran. Burns. 2013 Feb;39(1):174-6. DOI: 10.1016/j.burns.2012.02.025</RefTotal> <RefLink>http://dx.doi.org/10.1016/j.burns.2012.02.025</RefLink> </Reference> <Reference refNo="9"> <RefAuthor>Azimi L</RefAuthor> <RefAuthor>Nordmann P</RefAuthor> <RefAuthor>Lari AR</RefAuthor> <RefAuthor>Bonnin RA</RefAuthor> <RefTitle>First report of OXA-48-producing Klebsiella pneumoniae strains in Iran</RefTitle> <RefYear>2014</RefYear> <RefJournal>GMS Hyg Infect Control</RefJournal> <RefPage>Doc07</RefPage> <RefTotal>Azimi L, Nordmann P, Lari AR, Bonnin RA. First report of OXA-48-producing Klebsiella pneumoniae strains in Iran. GMS Hyg Infect Control. 2014 Mar 7;9(1):Doc07. DOI: 10.3205/dgkh000227</RefTotal> <RefLink>http://dx.doi.org/10.3205/dgkh000227</RefLink> </Reference> <Reference refNo="10"> <RefAuthor>Fazeli H</RefAuthor> <RefAuthor>Akbari R</RefAuthor> <RefAuthor>Moghim S</RefAuthor> <RefAuthor>Narimani T</RefAuthor> <RefAuthor>Arabestani MR</RefAuthor> <RefAuthor>Ghoddousi AR</RefAuthor> <RefTitle>Pseudomonas aeruginosa infections in patients, hospital means, and personnel’s specimens</RefTitle> <RefYear>2012</RefYear> <RefJournal>J Res Med Sci</RefJournal> <RefPage>332-7</RefPage> <RefTotal>Fazeli H, Akbari R, Moghim S, Narimani T, Arabestani MR, Ghoddousi AR. Pseudomonas aeruginosa infections in patients, hospital means, and personnel’s specimens. J Res Med Sci. 2012 Apr;17(4):332-7.</RefTotal> </Reference> <Reference refNo="11"> <RefAuthor>Beheshti S</RefAuthor> <RefAuthor>Zia M</RefAuthor> <RefTitle>Bacteriology of burns and antibiogram in an Iranian burn care center</RefTitle> <RefYear>2011</RefYear> <RefJournal>Afr J Pharm Pharmacol</RefJournal> <RefPage>538-41</RefPage> <RefTotal>Beheshti S, Zia M. Bacteriology of burns and antibiogram in an Iranian burn care center. Afr J Pharm Pharmacol. 2011;5(4):538-41. DOI: 10.5897/AJPP10.375</RefTotal> <RefLink>http://dx.doi.org/10.5897/AJPP10.375</RefLink> </Reference> <Reference refNo="12"> <RefAuthor>Finnan S</RefAuthor> <RefAuthor>Morrissey JP</RefAuthor> <RefAuthor>O’Gara F</RefAuthor> <RefAuthor>Boyd EF</RefAuthor> <RefTitle>Genome diversity of Pseudomonas aeruginosa isolates from cystic fibrosis patients and the hospital environment</RefTitle> <RefYear>2004</RefYear> <RefJournal>J Clin Microbiol</RefJournal> <RefPage>5783-92</RefPage> <RefTotal>Finnan S, Morrissey JP, O’Gara F, Boyd EF. Genome diversity of Pseudomonas aeruginosa isolates from cystic fibrosis patients and the hospital environment. J Clin Microbiol. 2004 Dec;42(12):5783-92. DOI: 10.1128/JCM.42.12.5783-5792.2004</RefTotal> <RefLink>http://dx.doi.org/10.1128/JCM.42.12.5783-5792.2004</RefLink> </Reference> <Reference refNo="13"> <RefAuthor>Lanini S</RefAuthor> <RefAuthor>D’Arezzo S</RefAuthor> <RefAuthor>Puro V</RefAuthor> <RefAuthor>Martini L</RefAuthor> <RefAuthor>Imperi F</RefAuthor> <RefAuthor>Piselli P</RefAuthor> <RefAuthor>Montanaro M</RefAuthor> <RefAuthor>Paoletti S</RefAuthor> <RefAuthor>Visca P</RefAuthor> <RefAuthor>Ippolito G</RefAuthor> <RefTitle>Molecular epidemiology of a Pseudomonas aeruginosa hospital outbreak driven by a contaminated disinfectant-soapdispenser</RefTitle> <RefYear>2011</RefYear> <RefJournal>PLoS One</RefJournal> <RefPage>e17064</RefPage> <RefTotal>Lanini S, D’Arezzo S, Puro V, Martini L, Imperi F, Piselli P, Montanaro M, Paoletti S, Visca P, Ippolito G. Molecular epidemiology of a Pseudomonas aeruginosa hospital outbreak driven by a contaminated disinfectant-soapdispenser. PLoS One. 2011 Feb 16;6(2):e17064. DOI: 10.1371/journal.pone.0017064</RefTotal> <RefLink>http://dx.doi.org/10.1371/journal.pone.0017064</RefLink> </Reference> <Reference refNo="14"> <RefAuthor>Salimi H</RefAuthor> <RefAuthor>Owlia P</RefAuthor> <RefAuthor>Yakhchali B</RefAuthor> <RefAuthor>Martini L</RefAuthor> <RefTitle>Characterization of Pseudomonas aeruginosain burn patients using PCR- restriction fragment length polymorphism and random amplified polymorphic DNA analysis</RefTitle> <RefYear>2010</RefYear> <RefJournal>Iran J Med Sci</RefJournal> <RefPage>236-41</RefPage> <RefTotal>Salimi H, Owlia P, Yakhchali B, Martini L. Characterization of Pseudomonas aeruginosain burn patients using PCR- restriction fragment length polymorphism and random amplified polymorphic DNA analysis. Iran J Med Sci. 2010;35(3):236-41. </RefTotal> </Reference> <Reference refNo="15"> <RefAuthor>Salimi H</RefAuthor> <RefAuthor>Yakhchali B</RefAuthor> <RefAuthor>Owlia P</RefAuthor> <RefTitle>Molecular epidemiology and drug susceptibility of Pseudomonas aeruginosa strains isolated from burn patients</RefTitle> <RefYear>2010</RefYear> <RefJournal>Lab Med</RefJournal> <RefPage>540-4</RefPage> <RefTotal>Salimi H, Yakhchali B, Owlia P. Molecular epidemiology and drug susceptibility of Pseudomonas aeruginosa strains isolated from burn patients. Lab Med. 2010;41(9):540-4. DOI: 10.1309/LMNIJE31EDC1WAMP</RefTotal> <RefLink>http://dx.doi.org/10.1309/LMNIJE31EDC1WAMP</RefLink> </Reference> <Reference refNo="16"> <RefAuthor>Azimi L</RefAuthor> <RefAuthor>Talebi M</RefAuthor> <RefAuthor>Owlia P</RefAuthor> <RefAuthor>Rastegar-Lari A</RefAuthor> <RefTitle>Investigated of ampC in Carbapenem Resistant Gram-Negative Bacteria Isolated from Burned Patients</RefTitle> <RefYear>2014</RefYear> <RefJournal>J Med Bacteriol</RefJournal> <RefPage>20-5</RefPage> <RefTotal>Azimi L, Talebi M, Owlia P, Rastegar-Lari A. Investigated of ampC in Carbapenem Resistant Gram-Negative Bacteria Isolated from Burned Patients. J Med Bacteriol. 2014;3(3-4):20-5.</RefTotal> </Reference> <Reference refNo="17"> <RefAuthor>Clinical Laboratory Standards Institute</RefAuthor> <RefTitle></RefTitle> <RefYear>2013</RefYear> <RefBookTitle>Performance standards for antimicrobial susceptibility testing: nineteenth informational supplement M100–S21</RefBookTitle> <RefPage></RefPage> <RefTotal>Clinical Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing: nineteenth informational supplement M100–S21. Wayne, PA: CLSI; 2013.</RefTotal> </Reference> <Reference refNo="18"> <RefAuthor>Petit SM</RefAuthor> <RefAuthor>Lavenir R</RefAuthor> <RefAuthor>Colinon-Dupuich C</RefAuthor> <RefAuthor>Boukerb AM</RefAuthor> <RefAuthor>Cholley P</RefAuthor> <RefAuthor>Bertrand X</RefAuthor> <RefAuthor>Freney J</RefAuthor> <RefAuthor>Doléans-Jordheim A</RefAuthor> <RefAuthor>Nazaret S</RefAuthor> <RefAuthor>Laurent F</RefAuthor> <RefAuthor>Cournoyer B</RefAuthor> <RefTitle>Lagooning of wastewaters favors dissemination of clinically relevant Pseudomonas aeruginosa</RefTitle> <RefYear>2013</RefYear> <RefJournal>Res Microbiol</RefJournal> <RefPage>856-66</RefPage> <RefTotal>Petit SM, Lavenir R, Colinon-Dupuich C, Boukerb AM, Cholley P, Bertrand X, Freney J, Doléans-Jordheim A, Nazaret S, Laurent F, Cournoyer B. Lagooning of wastewaters favors dissemination of clinically relevant Pseudomonas aeruginosa. Res Microbiol. 2013 Oct;164(8):856-66. DOI: 10.1016/j.resmic.2013.06.007</RefTotal> <RefLink>http://dx.doi.org/10.1016/j.resmic.2013.06.007</RefLink> </Reference> <Reference refNo="19"> <RefAuthor>Tofteland S</RefAuthor> <RefAuthor>Naseer U</RefAuthor> <RefAuthor>Lislevand JH</RefAuthor> <RefAuthor>Sundsfjord A</RefAuthor> <RefAuthor>Samuelsen O</RefAuthor> <RefTitle>A long-term low-frequency hospital outbreak of KPC-producing Klebsiella pneumoniae involving Intergenus plasmid diffusion and a persisting environmental reservoir</RefTitle> <RefYear>2013</RefYear> <RefJournal>PLoS ONE</RefJournal> <RefPage>e59015</RefPage> <RefTotal>Tofteland S, Naseer U, Lislevand JH, Sundsfjord A, Samuelsen O. A long-term low-frequency hospital outbreak of KPC-producing Klebsiella pneumoniae involving Intergenus plasmid diffusion and a persisting environmental reservoir. PLoS ONE. 2013;8(3):e59015. DOI: 10.1371/journal.pone.0059015</RefTotal> <RefLink>http://dx.doi.org/10.1371/journal.pone.0059015</RefLink> </Reference> <Reference refNo="20"> <RefAuthor>Voulgari E</RefAuthor> <RefAuthor>Zarkotou O</RefAuthor> <RefAuthor>Ranellou K</RefAuthor> <RefAuthor>Karageorgopoulos DE</RefAuthor> <RefAuthor>Vrioni G</RefAuthor> <RefAuthor>Mamali V</RefAuthor> <RefAuthor>Themeli-Digalaki K</RefAuthor> <RefAuthor>Tsakris A</RefAuthor> <RefTitle>Outbreak of OXA-48 carbapenemase-producing Klebsiella pneumoniae in Greece involving an ST11 clone</RefTitle> <RefYear>2013</RefYear> <RefJournal>J Antimicrob Chemother</RefJournal> <RefPage>84-8</RefPage> <RefTotal>Voulgari E, Zarkotou O, Ranellou K, Karageorgopoulos DE, Vrioni G, Mamali V, Themeli-Digalaki K, Tsakris A. Outbreak of OXA-48 carbapenemase-producing Klebsiella pneumoniae in Greece involving an ST11 clone. J Antimicrob Chemother. 2013 Jan;68(1):84-8. DOI: 10.1093/jac/dks356</RefTotal> <RefLink>http://dx.doi.org/10.1093/jac/dks356</RefLink> </Reference> </References> <Media> <Tables> <Table format="png"> <MediaNo>1</MediaNo> <MediaID>1</MediaID> <Caption><Pgraph><Mark1>Table 1: Genus, frequency and location of environmental isolates</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>2</MediaNo> <MediaID>2</MediaID> <Caption><Pgraph><Mark1>Table 2: Antibiotic resistance patterns of both clinical and environmental specimens</Mark1></Pgraph></Caption> </Table> <NoOfTables>2</NoOfTables> </Tables> <Figures> <Figure format="png" height="211" width="465"> <MediaNo>1</MediaNo> <MediaID>1</MediaID> <Caption><Pgraph><Mark1>Figure 1: PFGE pulsotypes algorithm</Mark1><LineBreak></LineBreak>A: 1-8; different clinical and environmental isolates of <Mark2>P. aeruginosa</Mark2><LineBreak></LineBreak>B: 1-4; different clinical and environmental isolates of <Mark2>K. pneumoniae</Mark2></Pgraph></Caption> </Figure> <NoOfPictures>1</NoOfPictures> </Figures> <InlineFigures> <NoOfPictures>0</NoOfPictures> </InlineFigures> <Attachments> <NoOfAttachments>0</NoOfAttachments> </Attachments> </Media> </OrigData> </GmsArticle>