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Nateghizad H, Sajadi R, Shivaee A, Shirazi O, Sharifian M, Tadi DA, Amini K. Resistance of Vibrio cholera to antibiotics that inhibit cell wall synthesis: A systematic review and meta-analysis. Front Pharmacol 2023; 14:1027277. [PMID: 37021056 PMCID: PMC10069679 DOI: 10.3389/fphar.2023.1027277] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 01/10/2023] [Indexed: 04/07/2023] Open
Abstract
Objective: Cholera is a challenging ancient disease caused by Vibrio cholera (V. cholera). Antibiotics that prevent cell wall synthesis are among the first known antibiotic groups. Due to its high consumption, V. cholera has developed resistance to the majority of antibiotics in this class. Resistance to recommended antibiotics for the treatment of V. cholera has also increased. In light of the decrease in consumption of certain antibiotics in this group that inhibit cell wall synthesis and the implementation of new antibiotics, it is necessary to determine the antibiotic resistance pattern of V. cholera and to employ the most effective treatment antibiotic. Method: An comprehensive systematic search for relevant articles was conducted in PubMed, Web of Science, Scopus, and EMBASE through October 2020. Stata version 17.1 utilized the Metaprop package to execute a Freeman-Tukey double arcsine transformation in order to estimate weighted pooled proportions. Results: A total of 131 articles were included in the meta-analysis. Ampicillin was the most investigated antibiotic. The prevalence of antibiotic resistance was in order aztreonam (0%), cefepime (0%), imipenem (0%), meropenem (3%), fosfomycin (4%), ceftazidime (5%), cephalothin (7%), augmentin (8%), cefalexin (8%), ceftriaxone (9%), cefuroxime (9%), cefotaxime (15%), cefixime (37%), amoxicillin (42%), penicillin (44%), ampicillin (48%), cefoxitin (50%), cefamandole (56%), polymyxin-B (77%), carbenicillin (95%) respectively. Discussion: Aztreonam, cefepime, and imipenem are the most efficient V. cholera cell wall synthesis inhibitors. There has been an increase in resistance to antibiotics such as cephalothin, ceftriaxone, amoxicillin, and meropenem. Over the years, resistance to penicillin, ceftazidime, and cefotaxime, has decreased.
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Affiliation(s)
- Hossein Nateghizad
- Department of Biology, Faculty of Basic Sciences, East of Tehran Branch, Islamic Azad University, Tehran, Iran
| | - Rojina Sajadi
- Department of Biology, Faculty of Basic Sciences, East of Tehran Branch, Islamic Azad University, Tehran, Iran
| | - Ali Shivaee
- Department of Microbiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Omid Shirazi
- Department of Veterinary medicine, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Mohadeseh Sharifian
- Department of Veterinary medicine, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Danyal Abbasi Tadi
- Department Of Veterinary, Azad University Of Shahr-E Kord, Shahrekord, Iran
| | - Kumarss Amini
- Department of Microbiology, Saveh Branch, Islamic Azad University, Saveh, Iran
- *Correspondence: Kumarss Amini,
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Shaw S, Samanta P, Chowdhury G, Ghosh D, Dey TK, Deb AK, Ramamurthy T, Miyoshi SI, Ghosh A, Dutta S, Mukhopadhyay AK. Altered Molecular Attributes and Antimicrobial Resistance Patterns of Vibrio cholerae O1 El Tor Strains Isolated from the Cholera Endemic Regions of India. J Appl Microbiol 2022; 133:3605-3616. [PMID: 36000378 DOI: 10.1111/jam.15794] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/18/2022] [Accepted: 08/20/2022] [Indexed: 11/28/2022]
Abstract
AIMS The present study aimed to document the comparative analysis of differential hyper-virulent features of Vibrio cholerae O1 strains isolated during 2018 from cholera endemic regions in Gujarat and Maharashtra (Western India) and West Bengal (Eastern India). METHODS AND RESULTS A total of 87 V. cholerae O1 clinical strains from Western India and 48 from Eastern India were analyzed for a number of biotypic and genotypic features followed by antimicrobial resistance (AMR) profile. A novel PCR was designed to detect a large fragment deletion in the Vibrio seventh pandemic island II (VSP-II) genomic region, which is a significant genetic feature of the V. cholerae strains that has caused Yemen cholera outbreak. All the strains from Western India were belong to the Ogawa serotype, polymyxin B-sensitive, hemolytic, had a deletion in VSP-II (VSP-IIC) region and carried Haitian genetic alleles of ctxB, tcpA and rtxA. Conversely, 14.6% (7/48) of the strains from Eastern India belonged to the Inaba serotype, polymyxin B-resistant, non-hemolytic, harbored VSP-II other than VSP-IIC type, classical ctxB, Haitian tcpA and El Tor rtxA alleles. Resistance to tetracycline and chloramphenicol has been observed in strains from both the regions. CONCLUSIONS This study showed hyper-virulent, polymyxin B-sensitive epidemic causing strains in India along with the strains with polymyxin B-resistant and non-hemolytic traits that may spread and cause serious disease outcome in future. SIGNIFICANCE AND IMPACT OF THE STUDY The outcomes of this study can help to improve the understanding of the hyper-pathogenic property of recently circulating pandemic V. cholerae strains in India. A special attention is also needed on the monitoring of AMR surveillance because V. cholerae strains are losing susceptibility to many antibiotics used as a second line of defense in the treatment of cholera.
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Affiliation(s)
- Sreeja Shaw
- Division of Bacteriology, ICMR-National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Prosenjit Samanta
- Division of Bacteriology, ICMR-National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Goutam Chowdhury
- Division of Bacteriology, ICMR-National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Debjani Ghosh
- Division of Bacteriology, ICMR-National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Tanmoy Kumar Dey
- Division of Bacteriology, ICMR-National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Alok Kumar Deb
- Division of Epidemiology, ICMR-National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Thandavarayan Ramamurthy
- Division of Bacteriology, ICMR-National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Shin-Ichi Miyoshi
- Collaborative Research Centre of Okayama University for Infectious Diseases at ICMR-NICED, Kolkata, India.,Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Amit Ghosh
- Division of Bacteriology, ICMR-National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Shanta Dutta
- Division of Bacteriology, ICMR-National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Asish Kumar Mukhopadhyay
- Division of Bacteriology, ICMR-National Institute of Cholera and Enteric Diseases, Kolkata, India
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Liu C, Wang Y, Azizian K, Omidi N, Kaviar VH, Kouhsari E, Maleki A. Antimicrobial resistance in Vibrio cholerae O1/O139 clinical isolates: a systematic review and meta-analysis. Expert Rev Anti Infect Ther 2022; 20:1217-1231. [PMID: 35790112 DOI: 10.1080/14787210.2022.2098114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Vibrio cholerae O1/O139 is responsible for cholera epidemics; that remains a huge public health menace across the globe. Furthermore, an increasing resistance rate among V. cholerae strains has been reported around the world. Therefore, the objective of this meta-analysis was to evaluate the weighted pooled resistance (WPR) rates in clinical V. cholerae O1/O139 isolates based on different years, areas, antimicrobial susceptibility testing, and resistance rates. RESEARCH DESIGN AND METHODS : We searched the studies in PubMed, Scopus, Embase, and Web of Science (until January 2020). Statistical analyses were conducted using STATA software (ver. 14.0). RESULTS : A total of 139 studies investigating 24062 V. cholerae O1/O139 isolates were analyzed. The majority of the studies originated in Asia (n=102). The WPR rates were as follows: azithromycin 1%, erythromycin 36%, ciprofloxacin 3%, cotrimoxazole 79%, doxycycline 7%, tetracycline 20%. There was increased resistance to cotrimoxazole, ciprofloxacin, and tetracycline during the 1980 to 2020 years. CONCLUSIONS : Temporal changes in antibiotic resistance rate found in this study demonstrated the critical continuous surveillance of antibiotic resistance. Also, ciprofloxacin, azithromycin, gentamicin, cephalexin, imipenem, ofloxacin, and norfloxacin were found to be the best antibiotics against V. cholera, with the highest and the lowest effectiveness resistance rate.
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Affiliation(s)
- Chaoying Liu
- Zhumadian Academy of Industry Innovation and Development, Huanghuai University, Zhumadian 463000, China
| | - Ye Wang
- School of Biological and Food Processing Engineering, Huanghuai University, Zhumadian 463000, China
| | - Khalil Azizian
- Department of Microbiology, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Nazanin Omidi
- Clinical Microbiology Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Vahab Hassan Kaviar
- Clinical Microbiology Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Ebrahim Kouhsari
- Laboratory Sciences Research Center, Golestan University of Medical Sciences, Gorgan, Iran.,Department of Laboratory Sciences, Faculty of Paramedicine, Golestan University of Medical Sciences, Iran
| | - Abbas Maleki
- Clinical Microbiology Research Center, Ilam University of Medical Sciences, Ilam, Iran
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Globally Vibrio cholera antibiotics resistance to RNA and DNA effective antibiotics: A systematic review and meta-analysis. Microb Pathog 2022; 172:105514. [DOI: 10.1016/j.micpath.2022.105514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/31/2022] [Accepted: 04/01/2022] [Indexed: 11/19/2022]
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Ahmadi MH. Global status of tetracycline resistance among clinical isolates of Vibrio cholerae: a systematic review and meta-analysis. Antimicrob Resist Infect Control 2021; 10:115. [PMID: 34362438 PMCID: PMC8343947 DOI: 10.1186/s13756-021-00985-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 07/19/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There has been an increasing resistance rate to tetracyclines, the first line treatment for cholera disease caused by V. cholera strains, worldwide. The aim of the present study was to determine the global status of resistance to this class of antibiotic among V. cholera isolates. METHODS For the study, electronic databases were searched using the appropriate keywords including: 'Vibrio', 'cholera', 'Vibrio cholerae', 'V. cholerae', 'resistance', 'antibiotic resistance', 'antibiotic susceptibility', 'antimicrobial resistance', 'antimicrobial susceptibility', 'tetracycline', and 'doxycycline'. Finally, after some exclusion, 52 studies from different countries were selected and included in the study and meta-analysis was performed on the collected data. RESULTS The average resistance rate for serogroup O1 to tetracycline and doxycycline was 50% and 28%, respectively (95% CI). A high level of heterogeneity (I2 > 50%, p-value < 0.05) was observed in the studies representing resistance to tetracycline and doxycycline in O1 and non-O1, non-O139 serogroups. The Begg's tests did not indicate the publication bias (p-value > 0.05). However, the Egger's tests showed some evidence of publication bias in the studies conducted on serogroup O1. CONCLUSIONS The results of the present study show that the overall resistance to tetracyclines is relatively high and prevalent among V. cholerae isolates, throughout the world. This highlights the necessity of performing standard antimicrobial susceptibility testing prior to treatment choice along with monitoring and management of antibiotic resistance patterns of V. cholerae strains in order to reduce the emergence and propagation of antibiotic resistant strains as well as the failure of treatment.
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Reethy PS, Lalitha KV. Characterization of V. cholerae O1 biotype El Tor serotype Ogawa possessing the ctxB gene of the classical biotype isolated from well water associated with the cholera outbreak in Kerala, South India. JOURNAL OF WATER AND HEALTH 2021; 19:478-487. [PMID: 34152300 DOI: 10.2166/wh.2021.263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
We investigated 22 water samples (17 well water and five pipe water - both chlorinated) and six soil samples from the surroundings of wells of the households of suspected patients from Palakkad district, Kerala (India), from where a cholera outbreak was reported during June-July 2016. A total of 25 Vibrio cholerae isolates were collected from three well water samples during a recent cholera outbreak. Biochemical and serological studies revealed that all of the isolates belonged to serogroup O1, biotype El Tor, serotype Ogawa. PCR assays confirmed the occurrence of ctxB, ctxA, hlyA, tcpA El Tor,VPI, ace, zot, ompW, rfbO1 and toxR genes in all isolates. The presence of the ctxB gene of the classical biotype in all of the El Tor isolates suggests that it is a new variant of El Tor biotype. Antibiogram profile of all V. cholerae O1 isolates revealed resistance towards five classes of antibiotics island and indicates that they were multidrug resistant. ERIC-PCR and PFGE finger prints showed the clonal relationship among the V. cholerae O1 isolates. The results of this study revealed the emergence of a new variant of El Tor biotype in the water samples from Palakkad district, from where a cholera outbreak was reported.
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Affiliation(s)
- P S Reethy
- Microbiology Fermentation and Biotechnology Division, ICAR-Central Institute of Fisheries Technology, Kochi, India; Cochin University of Science and Technology, Kochi, India E-mail:
| | - K V Lalitha
- Microbiology Fermentation and Biotechnology Division, ICAR-Central Institute of Fisheries Technology, Kochi, India
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Danso EK, Asare P, Otchere ID, Akyeh LM, Asante-Poku A, Aboagye SY, Osei-Wusu S, Opare D, Ntoumi F, Zumla A, Duodu S, Yeboah-Manu D. A molecular and epidemiological study of Vibrio cholerae isolates from cholera outbreaks in southern Ghana. PLoS One 2020; 15:e0236016. [PMID: 32649692 PMCID: PMC7351161 DOI: 10.1371/journal.pone.0236016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 06/27/2020] [Indexed: 11/18/2022] Open
Abstract
Cholera remains a major global public health threat and continuous emergence of new Vibrio cholerae strains is of major concern. We conducted a molecular epidemiological study to detect virulence markers and antimicrobial resistance patterns of V. cholerae isolates obtained from the 2012–2015 cholera outbreaks in Ghana. Archived clinical isolates obtained from the 2012, 2014 and 2015 cholera outbreaks in Ghana were revived by culture and subjected to microscopy, biochemical identification, serotyping, antibiotic susceptibility testing, molecular detection of distinct virulence factors and Multi-Locus Variable-Number of Tandem-Repeat Analysis (MLVA). Of 277 isolates analysed, 168 (60.6%) were confirmed to be V. cholerae and 109 (39.4%) isolates constituted other bacteria (Escherichia coli, Aeromonas sobria, Pseudomonas aeruginosa, Enterobacter cloacae and Enterococci faecalis). Serotyping the V. cholerae isolates identified 151 (89.9%) as Ogawa, 3 (1.8%) as Inaba and 14 (8.3%) as non-O1/O139 serogroup. The O1 serogroup isolates (154/168, 91.7%) carried the cholera toxin ctxB gene as detected by PCR. Additional virulence genes detected include zot, tcpA, ace, rtxC, toxR, rtxA, tcpP, hlyA and tagA. The most common and rare virulence factors detected among the isolates were rtxC (165 isolates) and tcpP (50 isolates) respectively. All isolates from 2014 and 2015 were multidrug resistant against the selected antibiotics. MLVA differentiated the isolates into 2 large unique clones A and B, with each predominating in a particular year. Spatial analysis showed clustering of most isolates at Ablekuma sub-district. Identification of several virulence genes among the two different genotypes of V. cholerae isolates and resistance to first- and second-line antibiotics, calls for scaleup of preventive strategies to reduce transmission, and strengthening of public health laboratories for rapid antimicrobial susceptibility testing to guide accurate treatment. Our findings support the current WHO licensed cholera vaccines which include both O1 Inaba and Ogawa serotypes.
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Affiliation(s)
- Emelia Konadu Danso
- Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
- West African Centre for Cell Biology of Infectious Pathogens, University of Ghana Legon, Legon, Accra, Ghana
- Department of Biochemistry, Cell and Molecular Biology, University of Ghana, Legon, Accra, Ghana
| | - Prince Asare
- Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Isaac Darko Otchere
- Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Lorenzo Moses Akyeh
- Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Adwoa Asante-Poku
- Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Samuel Yaw Aboagye
- Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
- Institute for Environment and Sanitation Studies, University of Ghana, Legon, Accra, Ghana
| | - Stephen Osei-Wusu
- Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - David Opare
- National Public Health and Reference Laboratory, Accra, Ghana
| | - Francine Ntoumi
- Université Marien NGouabi, Fondation Congolaise pour la Recherche Médicale (FCRM), Brazzaville, Congo
- Institute for Tropical Medicine, University of Tübingen, Tübingen, Germany
| | - Alimuddin Zumla
- Division of Infection and Immunity, University College London and NIHR Biomedical Research Centre, UCL Hospitals NHS Foundation Trust, London, England, United Kingdom
| | - Samuel Duodu
- West African Centre for Cell Biology of Infectious Pathogens, University of Ghana Legon, Legon, Accra, Ghana
- Department of Biochemistry, Cell and Molecular Biology, University of Ghana, Legon, Accra, Ghana
| | - Dorothy Yeboah-Manu
- Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
- West African Centre for Cell Biology of Infectious Pathogens, University of Ghana Legon, Legon, Accra, Ghana
- * E-mail:
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Mohanraj RS, Samanta P, Mukhopadhyay AK, Mandal J. Haitian-like genetic traits with creeping MIC of Azithromycin in Vibrio cholerae O1 isolates from Puducherry, India. J Med Microbiol 2020; 69:372-378. [PMID: 31961790 DOI: 10.1099/jmm.0.001131] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction. The emergence of novel strains of Vibrio cholerae O1 El Tor biotype has gained attention due to causing several epidemics around the world. Variant strains have evolved as a result of the acquisition of genes that confer extended virulence and pathogenicity.Aim. This study aimed to determine the presence of the most recently emerging Haitian-like genetic traits among the isolates from Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, Southern India. We also wanted to detect the prevalence of the sulfamethoxazole and trimethoprim (SXT) element, which is an integrating conjugative element (ICE) and the antimicrobial resistance genes present in our isolates.Methodology. Identification of Haitian-specific alleles was done by mismatched amplification mutation assay PCR (MAMA-PCR). The presence of SXT elements was carried out by PCR by detecting int, eex, att-prfC and setR genes. Detection of antibiotic resistance determinant, sul(1,2,3); dfr(A1,18,5) for trimethoprim resistance, tet(A,B,C,D,E,Y,G,M), tet34 for tetracycline resistance and erm(A,B,C), mph(A,B), ere(A,B), msr(A,D) for azithromycin resistance were targeted by PCR. The MIC of tetracycline, ciprofloxacin and azithromycin was determined by the E-test method.Results. Of the 95 isolates, 60 % of the isolates were found to carry Haitian-specific alleles of ctxB, tcpA and rtxA gene, 100 % of the isolates were found to carry SXT elements. All the isolates harboured the four conserved genes of the SXT element, except one which had only eex, att-prfC, setR genes. About 99 % harboured sul2 and dfrA1 genes. No tet and macrolide genes were detected. We observed a progressive increase in the MIC of azithromycin ranging from 0.75 µg ml-1 to 2 µg ml-1.Conclusion. None of the isolates were the prototype El Tor biotype. All the isolates were a Haitian variant. The presence of SXT elements across all our isolates and their creeping MIC of azithromycin is a matter of concern. Further testing for other genetic determinants of resistance will be carried out in our future studies.
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Affiliation(s)
| | | | | | - Jharna Mandal
- Department of Microbiology, JIPMER, Puducherry, India
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Yadav S, Kapley A. Exploration of activated sludge resistome using metagenomics. THE SCIENCE OF THE TOTAL ENVIRONMENT 2019; 692:1155-1164. [PMID: 31539947 DOI: 10.1016/j.scitotenv.2019.07.267] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/17/2019] [Accepted: 07/17/2019] [Indexed: 06/10/2023]
Abstract
Antibiotic resistance is a global problem. In India poor waste management and inadequate sanitary are key factors which encourage the dissemination of antimicrobial resistance. Microbial biodiversity serves as an invaluable source for diverse types of bioactive compounds that encompass most of the pharmaceuticals to date. Therefore, in this study, we used the metagenomic approach for the surveillance of antibiotic resistance genes, drug resistant microbes and mobile-genetic elements in two activated sludge metagenome samples collected from Ankleshwar, Gujarat, India. Proteobacteria were found to be the most abundant bacteria among the metagenome analyzed. Twenty-four genes conferring resistance to antibiotics and heavy metals were found. Multidrug resistant "ESKAPE pathogens" were also abundant in the sludge metagenome. Mobile genetic elements like IncP-1 plasmid pKJK5, IncP-1beta multi resistance plasmid and pB8 were also noticed in the higher abundance. These plasmids play an important role in the spread of antibiotic resistance by the horizontal gene transfer. Statistical analysis of both metagenome using STAMP software confirmed presence of mobile genetic elements such as gene transfer agents, phages, Prophages etc. which also play important role in the dissemination of antibiotic resistant genes.
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Affiliation(s)
- Shailendra Yadav
- Director's Research Cell, National Environmental, Engineering Research Institute (CSIR-NEERI), Nehru Marg, Nagpur 440020, India
| | - Atya Kapley
- Director's Research Cell, National Environmental, Engineering Research Institute (CSIR-NEERI), Nehru Marg, Nagpur 440020, India.
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Sarkar A, Morita D, Ghosh A, Chowdhury G, Mukhopadhyay AK, Okamoto K, Ramamurthy T. Altered Integrative and Conjugative Elements (ICEs) in Recent Vibrio cholerae O1 Isolated From Cholera Cases, Kolkata, India. Front Microbiol 2019; 10:2072. [PMID: 31555253 PMCID: PMC6743048 DOI: 10.3389/fmicb.2019.02072] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 08/22/2019] [Indexed: 12/31/2022] Open
Abstract
The self-transferring integrative and conjugative elements (ICEs) are large genomic segments carrying several bacterial adaptive functions including antimicrobial resistance (AMR). SXT/R391 family is one of the ICEs extensively studied in cholera-causing pathogen Vibrio cholerae. The genetic characteristics of ICE-SXT/R391 in V. cholerae are dynamic and region-specific. These ICEs in V. cholerae are strongly correlated with resistance to several antibiotics such as tetracycline, streptomycin and trimethoprim-sulfamethoxazole. We screened V. cholerae O1 strains isolated from cholera patients in Kolkata, India from 2008 to 2015 for antibiotic susceptibility and the presence of ICEs, and subsequently sequenced their conserved genes. Resistance to tetracycline, streptomycin and trimethoprim-sulfamethoxazole was detected in strains isolated during 2008-2010 and 2014-2015. The genes encoding resistance to tetracycline (tetA), trimethoprim-sulfamethoxazole (dfrA1 and sul2), streptomycin (strAB), and chloramphenicol (floR) were detected in the ICEs of these strains. There was a decrease in overall drug resistance in V. cholerae associated with the ICEs in 2011. DNA sequence analysis also showed that AMR in these strains was conferred mainly by two types of ICEs, i.e., ICETET (comprising tetA, strAB, sul2, and dfrA1) and ICEGEN (floR, strAB, sul2, and dfrA1). Based on the genetic structure, Kolkata strains of V. cholerae O1 had distinct genetic traits different from the ICEs reported in other cholera endemic regions. Transfer of AMR was confirmed by conjugation with sodium azide resistant Escherichia coli J53. In addition to the acquired resistance to streptomycin and trimethoprim-sulfamethoxazole, the conjugally transferred (CT) E. coli J53 with ICE showed higher resistance to chloramphenicol and tetracycline than the donor V. cholerae. Pulsed-field gel electrophoresis (PFGE) based clonal analysis revealed that the V. cholerae strains could be grouped based on their ICEs and AMR patterns. Our findings demonstrate the epidemiological importance of ICEs and their role in the emergence of multidrug resistance (MDR) in El Tor vibrios.
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Affiliation(s)
- Anirban Sarkar
- Division of Bacteriology, National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Daichi Morita
- Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Amit Ghosh
- Division of Bacteriology, National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Goutam Chowdhury
- Division of Bacteriology, National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Asish K. Mukhopadhyay
- Division of Bacteriology, National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Keinosuke Okamoto
- Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
- Collaborative Research Center of Okayama University for Infectious Diseases in India, National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Thandavarayan Ramamurthy
- Center for Human Microbial Ecology, Translational Health Science and Technology Institute, Faridabad, India
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Investigating the virulence genes and antibiotic susceptibility patterns of Vibrio cholerae O1 in environmental and clinical isolates in Accra, Ghana. BMC Infect Dis 2019; 19:76. [PMID: 30665342 PMCID: PMC6341726 DOI: 10.1186/s12879-019-3714-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 01/10/2019] [Indexed: 12/17/2022] Open
Abstract
Background Cholera has been endemic in Ghana since its detection in 1970. It has been shown that long-term survival of the bacteria may be attained in aquatic environments. Consequently, cholera outbreaks may be triggered predominantly in densely populated urban areas. We investigated clinical and environmental isolates of Vibrio cholerae O1 in Accra to determine their virulence genes, antibiotic susceptibility patterns and environmental factors maintaining their persistence in the environment. Methods Water samples from various sources were analyzed for the presence of V. cholerae O1 using culture methods. Forty clinical isolates from a previous cholera outbreak were included in the study for comparison. Antibiotic susceptibility patterns of the bacteria were determined by disc diffusion. Virulence genes were identified by analyzing genes for ctx, tcpA (tcpAEl Tor tcpACl), zot, ompW, rbfO1 and attRS using PCR. Physicochemical characteristics of water were investigated using standard methods. One-way ANOVA and student t - test were employed to analyze the relationship between physicochemical factors and the occurrence of V. cholerae O1. Results Eleven V. cholerae O1 strains were successfully isolated from streams, storage tanks and wells during the study period. All isolates were resistant to one or more of the eight antibiotics used. Multidrug resistance was observed in over 97% of the isolates. All isolates had genes for at least one virulence factor. Vibrio cholerae toxin gene was detected in 82.4% of the isolates. Approximately 81.8% of the isolates were positive for tcpAEl Tor gene, but also harbored the tcpAcl gene. Isolates were grouped into thirteen genotypes based on the genes analyzed. High temperature, salinity, total dissolved solids and conductivity was found to significantly correlate positively with isolation of V. cholerae O1. V. cholerae serotype Ogawa biotype El tor is the main biotype circulating in Ghana with the emergence of a hybrid strain. Conclusions Multidrug resistant V. cholerae O1 with different genotypes and pathogenicity are present in water sources and co-exist with non O1/O139 in the study area. Electronic supplementary material The online version of this article (10.1186/s12879-019-3714-z) contains supplementary material, which is available to authorized users.
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Abstract
PURPOSE OF REVIEW This review describes the basic epidemiologic, clinical, and microbiologic aspects of cholera, highlights new developments within these areas, and presents strategies for applying currently available tools and knowledge more effectively. RECENT FINDINGS From 1990 to 2016, the reported global burden of cholera fluctuated between 74,000 and 595,000 cases per year; however, modeling estimates suggest the real burden is between 1.3 and 4.0 million cases and 95,000 deaths yearly. In 2018, the World Health Assembly endorsed a new initiative to reduce cholera deaths by 90% and eliminate local cholera transmission in 20 countries by 2030. New tools, including localized GIS mapping, climate modeling, whole genome sequencing, oral vaccines, rapid diagnostic tests, and new applications of water, sanitation, and hygiene interventions, could support this goal. Challenges include a high proportion of fragile states among cholera-endemic countries, urbanization, climate change, and the need for cholera treatment guidelines for pregnant women and malnourished children. SUMMARY Reducing cholera morbidity and mortality depends on real-time surveillance, outbreak detection and response; timely access to appropriate case management and cholera vaccines; and provision of safe water, sanitation, and hygiene.
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Affiliation(s)
- William Davis
- Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop H24-9, Atlanta, GA 30329, USA
| | - Rupa Narra
- Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop H24-9, Atlanta, GA 30329, USA
| | - Eric D. Mintz
- Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop H24-9, Atlanta, GA 30329, USA
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Feglo PK, Sewurah M. Characterization of highly virulent multidrug resistant Vibrio cholerae isolated from a large cholera outbreak in Ghana. BMC Res Notes 2018; 11:45. [PMID: 29347965 PMCID: PMC5774149 DOI: 10.1186/s13104-017-2923-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 11/09/2017] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE The purpose of this study was to investigate the virulent factors of Vibrio cholerae which caused an unprecedented large cholera outbreak in Ghana in 2014 and progressed into 2015, affected 28,975 people with 243 deaths. RESULTS The V. cholerae isolates were identified to be the classical V. cholerae 01 biotype El Tor, serotype Ogawa, responsible for the large cholera outbreak in Ghana. These El Tor strains bear CtxAB and Tcp virulent genes, making the strains highly virulent. The strains also bear SXT transmissible element coding their resistance to antibiotics, causing high proportions of the strains to be multidrug resistant, with resistant proportions of 95, 90 and 75% to trimethoprim/sulfamethoxazole, ampicillin and ceftriaxone respectively. PFGE patterns indicated that the isolates clustered together with the same pattern and showed clusters similar to strains circulating in DR Congo, Cameroun, Ivory Coast and Togo. The strains carried virulence genes which facilitated the disease causation and spread. This is the first time these virulent genes were determined on the Ghanaian Vibrio strains.
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Affiliation(s)
- Patrick Kwame Feglo
- Department of Clinical Microbiology, School of Medical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
| | - Miriam Sewurah
- Department of Clinical Microbiology, School of Medical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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Antibiotics resistance in El Tor Vibrio cholerae 01 isolated during cholera outbreaks in Mozambique from 2012 to 2015. PLoS One 2017; 12:e0181496. [PMID: 28792540 PMCID: PMC5549693 DOI: 10.1371/journal.pone.0181496] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 07/03/2017] [Indexed: 11/19/2022] Open
Abstract
RATIONALE Mozambique has recorded cyclically epidemic outbreaks of cholera. Antibiotic therapy is recommended in specific situations for management and control of cholera outbreaks. However, an increase in resistance rates to antibiotics by Vibrio cholerae has been reported in several epidemic outbreaks worldwide. On the other hand, there are few recent records of continuous surveillance of antibiotics susceptibility pattern of V. cholerae in Mozambique. GOALS The purpose of this study was to evaluate antibiotics resistance pattern of Vibrio cholerae O1 Ogawa isolated during Cholera outbreaks in Mozambique to commonly used antibiotics. METHODOLOGY We analyzed data from samples received in the context of surveillance and response to Cholera outbreaks in the National Reference Laboratory of Microbiology from the National Institute of Health of Mozambique, 159 samples suspected of cholera from cholera treatment centers of, Metangula (09), Memba (01), Tete City (08), Moatize (01), Morrumbala (01) districts, City of Quelimane (01), Lichinga (06) and Nampula (86) districts, from 2012 to 2015. Laboratory culture and standard biochemical tests were employed to isolate and identify Vibrio cholerae; serotypes were determined by antisera agglutination reaction in blade. Biotype and presence of important virulence factors analysis was done by PCR. Antibiotics susceptibility pattern was detected by disk diffusion method Kirby Bauer. Antibiotic susceptibility and results were interpreted by following as per recommendations of CLSI (Clinical and Laboratory Standards Institute) 2014. All samples were collected and tested in the context of Africhol Project, approved by the National Bioethics Committee for Health. RESULTS Among isolates from of Vibrio cholerae O1 El Tor Ogawa resistance to Sulphamethoxazole-trimethropim was 100% (53/53) to Trimethoprim-, being 100% (54/54) for Ampicillin, 99% (72/74) for Nalidixic Acid, 97% (64/66) to Chloramphenicol, 95% (42/44) for Nitrofurantoin and (19/20) Cotrimoxazole, 83% (80/97) Tetracycline, 56% (5/13) Doxycycline, 56% (39/70) Azithromycin and 0% (0/101) for Ciprofloxacin. PCR analysis suggested strains of V. cholerae O1 being descendants of the current seventh pandemic V. cholerae O1 CIRS 101 hybrid variant. The V. cholerae O1 currently causing cholera epidemics in north and central Mozambique confirmed a CTXΦ genotype and a molecular arrangement similar to the V. cholerae O1 CIRS 101. CONCLUSION Although V. cholerae infections in Mozambique are generally not treated with antibiotics circulating strains of the bacteria showed high frequency of in vitro resistance to available antibiotics. Continuous monitoring of antibiotic resistance pattern of epidemic strains is therefore crucial since the appearance of antibiotic resistance can influence cholera control strategies.
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Antibiogram and Serotyping of Vibrio cholerae O1 Isolates from a Tertiary Care Centre in South India. JOURNAL OF PURE AND APPLIED MICROBIOLOGY 2017. [DOI: 10.22207/jpam.11.2.46] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Gupta PK, Pant ND, Bhandari R, Shrestha P. Cholera outbreak caused by drug resistant Vibrio cholerae serogroup O1 biotype ElTor serotype Ogawa in Nepal; a cross-sectional study. Antimicrob Resist Infect Control 2016; 5:23. [PMID: 27274815 PMCID: PMC4893239 DOI: 10.1186/s13756-016-0122-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 05/27/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cholera is a major cause of mortality and morbidity in underdeveloped countries including Nepal. Recently drug resistance in Vibrio cholerae has become a serious problem mainly in developing countries. The main objectives of our study were to investigate the occurrence of Vibrio cholerae in stool samples from patients with watery diarrhea and to determine the antimicrobial susceptibility patterns of V. cholerae isolates. METHODS A total of 116 stool samples from patients suffering from watery diarrhea during July to December 2012 were obtained from outbreak areas from all over Nepal. Alkaline peptone water and thiosulphate citrate bile salt sucrose agar (TCBS) were used to isolate the Vibrio cholerae. The isolates were identified with the help of colony morphology, Gram's staining, conventional biochemical testing, serotyping and biotyping. Antimicrobial susceptibility testing was performed by determining the minimum inhibitory concentration (MIC) by agar dilution method. RESULTS Vibrio cholerae was isolated from 26.72 % of total samples. All isolated Vibrio cholerae were confirmed to be Vibrio cholerae serogoup O1 biotype El Tor and serotype Ogawa. All isolates were resistant to ampicillin and cotrimoxazole. Twenty nine isolates were resistant toward two different classes of antibiotics, one strain was resistant to three different classes of antibiotics and one strain was resistant to four different classes of antibiotics. According to the definition of the multidrug resistant bacteria; 6.45 % of the strains of Vibrio cholerae were found to be multidrug resistant. CONCLUSIONS Cholera due to multidrug resistant Vibrio cholerae is also possible in Nepal. According to the antimicrobial susceptibility pattern of Vibrio cholerae in our study we recommend to use any antibiotics among tetracycline, doxycycline, levofloxacin, azithromycin, chloramphenicol and ciprofloxacin for preliminary treatment of cholera in Nepal.
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Affiliation(s)
- Pappu Kumar Gupta
- Department of microbiology, Kathmandu college of science and technology, Kathmandu, Nepal
| | - Narayan Dutt Pant
- Department of microbiology, Grande international hospital, Dhapasi Kathmandu, Nepal
| | | | - Padma Shrestha
- Department of microbiology, Kathmandu college of science and technology, Kathmandu, Nepal
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Joseph HA, Agboatwalla M, Hurd J, Jacobs-Slifka K, Pitz A, Bowen A. What Happens When "Germs Don't Get Killed and They Attack Again and Again": Perceptions of Antimicrobial Resistance in the Context of Diarrheal Disease Treatment Among Laypersons and Health-Care Providers in Karachi, Pakistan. Am J Trop Med Hyg 2016; 95:221-8. [PMID: 27139438 DOI: 10.4269/ajtmh.15-0661] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 03/20/2016] [Indexed: 11/07/2022] Open
Abstract
In south Asia, where diarrhea is common and antibiotics are accessible without prescription, antimicrobial resistance is an emerging and serious problem. However, beliefs and behaviors related to antimicrobial resistance are poorly understood. We explored laypersons' and health-care providers' (HCP) awareness and perceptions of antimicrobial resistance in the context of treatment of adult diarrheal disease in Karachi, Pakistan. In-depth, open-ended interviews were conducted with 40 laypersons and 45 HCPs in a lower-middle-class urban neighborhood. Interviews conducted in Urdu were audiotaped, transcribed, translated, and coded using applied thematic analysis. Slightly over half of laypersons and two-thirds of HCPs were aware that antimicrobial medication could lose effectiveness, but misperceptions were common. Laypersons and HCPs often believed that "the body becomes immune" or "bacteria attack more strongly" if medications are taken "improperly." Another prevalent theme was that causes and effects of antimicrobial resistance are limited to the individual taking the antimicrobial medication and to the specific diarrheal episode. Participants often attributed antimicrobial resistance to patient behaviors; HCP behavior was rarely discussed. Less than half of the HCPs were aware of treatment guidelines. To combat antimicrobial resistance in urban Pakistan, a health systems strategy and community-supported outreach campaigns on appropriate antimicrobial use are needed.
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Affiliation(s)
- Heather A Joseph
- Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, Georgia.
| | | | - Jacqueline Hurd
- Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kara Jacobs-Slifka
- Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia. Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Adam Pitz
- Procter and Gamble, Cincinnati, Ohio
| | - Anna Bowen
- Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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Hajia M, Saboorian R, Rahbar M. Antimicrobial Resistance Patterns of Isolated Vibrio cholerae Strains. INTERNATIONAL JOURNAL OF ENTERIC PATHOGENS 2016. [DOI: 10.17795/ijep31719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Thapa Shrestha U, Adhikari N, Maharjan R, Banjara MR, Rijal KR, Basnyat SR, Agrawal VP. Multidrug resistant Vibrio cholerae O1 from clinical and environmental samples in Kathmandu city. BMC Infect Dis 2015; 15:104. [PMID: 25888391 PMCID: PMC4350293 DOI: 10.1186/s12879-015-0844-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 02/19/2015] [Indexed: 11/21/2022] Open
Abstract
Background Cholera, an infectious disease caused by Vibrio cholerae, is a major public health problem and is a particularly burden in developing countries including Nepal. Although the recent worldwide outbreaks of cholera have been due to V. cholerae El Tor, the classical biotypes are still predominant in Nepal. Serogroup O1 of the V. cholerae classical biotype was the primary cause of a cholera outbreak in Kathmandu in 2012. Thus, this study was designed to know serotypes and biotypes of V. cholerae strains causing recent outbreak with reference to drug resistant patterns. Moreover, we also report the toxigenic strains of V. cholerae from both environmental and clinical specimens by detecting the ctx gene. Methods Twenty four V. cholerae (n = 22 from stool samples and n = 2 from water samples) isolated in this study were subjected to Serotyping and biotyping following the standard protocols as described previously. All of the isolates were tested for antimicrobial susceptibility patterns using the modified Kirby-Bauer disk diffusion method as recommended by CLSI guidelines. The screening of the ctx genes (ctxA2-B gene) were performed by PCR method using a pair of primers; C2F (5′-AGGTGTAAAATTCCTTGACGA-3′) and C2R (5′-TCCTCAGGGTATCCTTCATC-3′) to identify the toxigenic strains of V. cholerae. Results Among twenty four V. cholerae isolates, 91.7% were clinical and 8.3% were from water samples. Higher rate of V. cholerae infection was found among adults of aged group 20–30 years. All isolates were serogroups O1 of the V. cholerae classical biotype and sub serotype, Ogawa. All isolates were resistant to ampicillin, nalidixic acid and cotrimoxazole. 90.9% were resistant to erythromycin however, tetracycline was found to be the most effective drug for the isolates. All isolates were multidrug resistant (MDR) and possessed a ctx gene of approximately 400 base pairs indicating the toxigenic strains. Conclusion Hundred percent strains of V. cholerae were MDR possessing a ctx gene. It suggests that toxigenic strains be identified and proper antibiotic susceptibility testing be conducted. This will allow effective empirical therapy to be used to treat and control cholera.
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Affiliation(s)
- Upendra Thapa Shrestha
- Research Laboratory for Biotechnology and Biochemistry (RLABB), Sanepa, Lalitpur, Nepal. .,Department of Microbiology, Kantipur College of Medical Science (KCMS), Sitapaila, KTM, Nepal.
| | - Nabaraj Adhikari
- Department of Microbiology, Kantipur College of Medical Science (KCMS), Sitapaila, KTM, Nepal.
| | - Rojina Maharjan
- Department of Microbiology, Kantipur College of Medical Science (KCMS), Sitapaila, KTM, Nepal.
| | - Megha R Banjara
- Central Department of Microbiology, Tribhuvan University, Kirtipur, KTM, Nepal.
| | - Komal R Rijal
- Central Department of Microbiology, Tribhuvan University, Kirtipur, KTM, Nepal.
| | - Shital R Basnyat
- Department of Microbiology, Kantipur College of Medical Science (KCMS), Sitapaila, KTM, Nepal.
| | - Vishwanath P Agrawal
- Research Laboratory for Biotechnology and Biochemistry (RLABB), Sanepa, Lalitpur, Nepal.
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Rath S, Padhy RN. Monitoring in vitro antibacterial efficacy of Terminalia alata Heyne ex. Roth, against MDR enteropathogenic bacteria isolated from clinical samples. J Acute Med 2013. [DOI: 10.1016/j.jacme.2013.06.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Surveillance of multidrug resistance of 10 enteropathogens in a teaching hospital and in vitro efficacy of 25 ethnomedicinal plants used by an Indian aborigine. ASIAN PACIFIC JOURNAL OF TROPICAL DISEASE 2012. [DOI: 10.1016/s2222-1808(12)60178-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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