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 ~  Introduction
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 ~  Results
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  Table of Contents  
Year : 2011  |  Volume : 29  |  Issue : 2  |  Page : 130-135

An outbreak of CTX-M-15-producing Klebsiella pneumoniae isolates in an intensive care unit of a teaching hospital in Kuwait

1 Department of Microbiology, Faculty of Medicine, Kuwait University, P. O. Box 24923, Safat 13110, Kuwait
2 Infection Control Unit, Mubarak Al Kabir Hospital, P. O. Box 43787, Hawally 32052, Kuwait

Date of Submission11-Dec-2010
Date of Acceptance01-Feb-2011
Date of Web Publication2-Jun-2011

Correspondence Address:
N Al Sweih
Department of Microbiology, Faculty of Medicine, Kuwait University, P. O. Box 24923, Safat 13110
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0255-0857.81791

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 ~ Abstract 

Objective: This study reports an outbreak of Klebsiella pneumoniae infections in 14 patients during a 2-month period (August-September, 2008) in the intensive care unit (ICU) of a teaching hospital in Kuwait. Materials and Methods: The clinical sources were blood (9), urine (3) and respiratory secretions (2) identified by the automated VITEK-2 ID System. Susceptibility testing was performed by the E-test method. Extended-spectrum β-lactamase (ESBL) production was assessed using the ESBL E-test and confirmed by PCR. Carriage of bla genes was determined by PCR and sequence analysis. The transferability of resistance phenotypes was demonstrated by conjugation experiments and clonal relatedness was determined by PFGE. Results: The isolates were susceptible to imipenem, meropenem, and tigecycline and produced ESBL. All isolates yielded an amplicon of 499 bp with universal consensus primers (MA primers). DNA sequence analysis showed that they all harboured blaCTX-M-15 and blaTEM-1 genes. The environmental isolate obtained from a suction machine was also CTX-M-15/TEM-1 producer. The resistance phenotypes were transferrable to the Escherichia coli J53 r strain. PFGE, revealed two clones, A and B, related with a Dice coefficient of >94.1%. A mortality rate of 21.4% was recorded. Conclusion: The outbreak was contained by robust and aggressive infection control measures. This study highlights the first outbreak of CTX-M-15-producing K. pneumoniae associated with high mortality in an adult medical ICU in Kuwait.

Keywords: CTX-M-15, ICU, Kuwait, Klebsiella pneumoniae, outbreak

How to cite this article:
Al Sweih N, Salama M F, Jamal W, Al Hashem G, Rotimi V O. An outbreak of CTX-M-15-producing Klebsiella pneumoniae isolates in an intensive care unit of a teaching hospital in Kuwait. Indian J Med Microbiol 2011;29:130-5

How to cite this URL:
Al Sweih N, Salama M F, Jamal W, Al Hashem G, Rotimi V O. An outbreak of CTX-M-15-producing Klebsiella pneumoniae isolates in an intensive care unit of a teaching hospital in Kuwait. Indian J Med Microbiol [serial online] 2011 [cited 2021 Jan 22];29:130-5. Available from:

 ~ Introduction Top

The increasing prevalence of extended-spectrum β-lactamase (ESBL)-producing Klebsiella pneumoniae (ESBL-KP) isolates is of particular concern as these isolates often express resistance to multiple antibiotics and, as a result, complicate antibiotic therapy and interfere with empirical therapy. [1] Hospital outbreaks due to multidrug resistant K. pneumoniae isolates producing different ESBL types have been described throughout the world. [2],[3] A prevalence as high as 50% of nosocomial bloodstream infections caused by ESBL-KP has been reported in some countries in Europe and South America. [4] Derivatives of TEM and SHV enzymes constituted the majority of ESBLs in the 1980s and 1990s but have now been replaced by the CTX-M enzymes which have rapidly disseminated throughout the world. [5],[6],[7] CTX-M-15, the most expansive of these enzymes, was first found in isolates of Enterobacteriaceae from India but is now prevalent almost everywhere in the world. It appears to be associated with epidemic plasmids flanked with insertion sequences that facilitate easy spread and hyperproduction of β-lactamase which may, in part, explain the rapid spread of the enzyme.[8]

In a previous report that studied the burden of CTX-M-15-producing  Salmonella More Details spp. in Kuwait and United Arab Emirates, Rotimi et al.[9] found that 12.1% of their isolates were producers of this enzyme. Other recent experiences in Kuwait lent credence to the dramatic worldwide increase in the prevalence of CTX-M-15-type β-lactamase among the family of Enterobacteriaceae, in particular clinical isolates of  Escherichia More Details coli and K. pneumoniae. This assertion is supported by finding CTX-M-15 as the most common CTX-M-type enzyme in E. coli in Kuwait, [10] a finding which confirmed the earlier report by Ensor et al. [7] In our experience, CTX-M-15-producing K. pneumoniae causing outbreaks of infections is rare in Kuwait and, rarer still, are those associated with high mortality.

In the present study, we investigated a nosocomial outbreak of multi-resistant ESBL-producing isolates of K. pneumoniae in the adult intensive care unit (ICU) of our hospital.

 ~ Materials and Methods Top


Our hospital is a 531-bed tertiary university-affiliated hospital with a catchment population of over 1 million people. It has a compliment of general medical, urology, paediatrics, surgical, and dialysis wards, paediatric and adult ICUs, and outpatient departments. The adult ICU comprises 2 wings of 12 beds each in addition to 3 separate isolation rooms.


K. pneumoniae
-positive cases were defined as those patients admitted to the ICUs from whom at least one clinical sample recovered during the ICU stay contained an ESBL producer together with clinical evidence of infection. Episodes of clinical infection were considered acquired in the ICU if they appeared 48 h after ICU admission. Standard Centers for Disease Control and Prevention (CDC) criteria were used to carefully define healthcare-associated infections. [11]

Bacterial identification and antibiotic susceptibility testing

All the isolates were identified as K. pneumoniae by the API 20E system (bioMérieux Marcy-řÉtoile, France) and VITEK 2 ID System (bioMérieux). Antibiotic susceptibility testing against amikacin, amoxicillin-clavulanic acid, ampicillin, cefepime, cefotaxime, cefoxitin, ceftazidime, ceftriaxone, cefuroxime, ciprofloxacin, imipenem, meropenem, piperacillin, piperacillin-tazobactam, and tigecycline was performed using the E-test (AB Biodisk, Solna, Sweden) method according to the manufacturer's protocol. E. coli ATCC 25922 was included in each run for quality control. Results were interpreted according to the recommendations of the Clinical Laboratory Standard Institute (CLSI) [12] and US FDA tigecycline breakpoint of ≤2 μg/ml [Tygacil package insert (June 2005), Wyeth Pharmaceuticals Inc., Philadelphia, PA, USA].

Detection of extended-spectrum ß-lactamases and DNA extraction

The ESBL strips (AB Biodisk) consisting of cefotaxime (CT)/cefotaxime combined with clavulanic acid (CTL) and ceftazidime (TZ)/ceftazidime combined with clavulanic acid (TZL; AB Biodisk) were used to identify the ESBL-producing strains according to the manufacturer's protocol. Quality assurance was performed for the isolates using ATCC strains: E. coli ATCC 25922 (ESBL-negative), K. pneumoniae ATCC 700603 (ESBL-positive), and Pseudomonas aeruginosa ATCC 27853 control for ceftazidime.

All the isolates were cultured on blood agar and incubated at 37°C for 24 h. A QIAmp DNA Minikit (QIAGEN GmbH, Hidden, Germany) was used for the extraction of DNA according to manufacturer's manual protocol C for the isolation of genomic DNA from bacterial culture.

Identification of β-lactamase genes and insertion sequences

Genes encoding the ESBLs and other β-lactamases were detected by PCR using published specific primer pairs for blaCTX-M , blaSHV , and blaTEM genes as follows: universal consensus primers, MA-1 5′-SCS ATG TGC AGY ACC AGT AA-3′ and MA-2 5′-CCG CRA TAT GRT TGG TGG TG-3′ (for blaCTX-M ), [13] OS-5 5′-TTA TCT CCC TGT TAG CCA CC-3 and OS-6 5′-GAT TTG CTG ATT TCG CTC GG-3′ (for blaSHV ), and C 5′- TCG GGG AAA TGT GCG CG-3 and D 5′-TGC TTA ATC AGT GAG GCA CC-3′ (blaTEM ). [14] OXA-1 and insertion sequence ISEcp1 were detected using primers specific for blaOXA-1 A, 5′-GGA TAA AAC CCC CAA AGG AA-3; blaOXA-1 B, 5′-TGC ACC AGT TTT CCC ATA CA-3′; [15] and insertion sequence ISEcp1A, 5′-GCAGGTCTTTTTCTGCTCC-3′; ISEcp1B, 5′-ATTTCCGCAGCACCGTTTGC-3′. [16] Cycling conditions were as follows: Initial denaturation at 94°C for 3 min; 35 cycles of 94°C for 30 s, 55°C for 30 s, and 72°C for 45 s followed by a final elongation at 72°C for 5 min. [17] Both strands of the PCR products were sequenced with an automated sequencer (ABI 300; Applied Biosystems, Foster, CA, USA). Analysis of sequences was carried out with software available at the internet web page .

Transfer of resistance phenotypes

Transfer experiments were carried out between the CTX-M-producing K. pneumoniae donors and recipient E. coli J53 rif r as previously described. [18] The conjugative transfer of CTX-M to E. coli J53 was performed on nutrient agar (NA) plates with culture grown into the logarithmic phase. Transconjugants were selected on NA supplemented with 100 μg/ml rifampicin (Sigma-Aldrich) and 2 μg/ml cefotaxime.

Genomic fingerprinting by PFGE

The isolates were fingerprinted by pulsed-field gel electrophoresis (PFGE) typing of the extracted whole-cell genomic DNA embedded in 1% agarose plugs and digested with Xba1. The Xba1-digested genomic DNA was electrophoresed in a 1% certified agarose gel with a voltage gradient of 6 V/h at 14°C at an angle of 120° using the CHEF-MAPPER XI System (Bio-Rad Laboratories, Hercules, CA, USA). Banding patterns were analyzed using FPQuest TM software (Bio-Rad Laboratories) and strains defined as having PFGE profiles of >94% similarity. A lambda ladder (New England Biolabs, Beverly, MA, USA) was included in each gel run. DNA relatedness was estimated using the criteria of Tenover et al .[19]

 ~ Results Top

Outbreak and intervention

An outbreak of ESBL-KP in 14 patients within 2 months was encountered in the medical ICU of our teaching hospital. Nine patients had bloodstream infections (BSI; isolates 1-3, 5-9 and 14), three urinary tract infections (UTI; 10, 11 and 13) and two pulmonary infections (PI; 4 and 12). The profiles of the patients including source of the isolate, date of isolation, underlying disease and treatment are shown in [Table 1]. The ages of the patients ranged from 24 to 89 years (mean 59.5 ± 12.6 years). The time of admission to isolation of the ESBL-KP ranged from 3 to 43 days with an average of 15.8 days. A mortality rate of 21.4% was recorded in patients whose cause of death was overwhelming septicaemia and septic shock.
Table 1: Biodata, underlying diseases, and outcomes of patients involved in the outbreak of CTX-M-15-
producing K. pneumoniae

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The index case was a 53-year-old male patient admitted on 28 June 2008 as a result of myocardial infarction (MI) complicating cardiovascular accident (CVA). He presented on 3 August with fever, septicaemia and subsequent septic shock. His blood culture yielded ESBL-KP susceptible only to carbapenems and tigecycline. He was treated with meropenem and tigecycline but died 12 days later. The second case was a patient with obstructive jaundice and pancreatitis admitted on 29 June and initially nursed on a bed next to the index case. He presented with high fever 8 days after the isolation of ESBL-KP from the index case. His blood culture taken on 10 August yielded a phenotypically similar organism. He was promptly moved to an isolation room and treated with meropenem but died 2 days later. Within the next 3 weeks, phenotypically identical ESBL-KP were isolated from six patients, three of whom were positive on the same day, 17 August. They presented with septicaemia (five patients) and pneumonia complicated by pancytopaenia and anaemia (one patient). Despite reinforcing infection control measures, the epidemic strain reappeared 3 weeks later with a spate of infections in another set of 6 patients within 6 days of each other during 20-25 September [Table 1]. The total number of K. pneumoniae strains isolated in the ICU in 2008, including the 14 outbreak strains, was 19; the 5 non-outbreak isolates were susceptible strains.

Patients, staff members and ICU environment were screened. Control measures instituted included isolation of some patients in isolation rooms as well cohort nursing the others in a localized area in the ICU under the supervision of dedicated nurse. Multi-component intervention included extensive decontamination of the ICU environment three times daily, with initial cleaning with warm water followed by disinfection with a hypochlorite solution (1000 ppm), continued ICU personnel educational programmes, rigorous open surveillance of adequate compliance with barrier precautions, the use of disposable gloves and aprons, and careful disinfection of hands with soap and water and hydro-alcohol solution before and after patient care. Cleaning protocols and housekeeping procedures were revised. Compliance with the antibiotic policy was monitored by the clinical microbiologists. Adequate compliance with the control programme was supervised by two specially designated members of the infection control team (one physician and one nurse) who attended the ICU daily after the implementation of the interventional programme in August 2008.

Results of patients, personnel (fingers, rectal and throat swabs) and environmental screening were negative but a swab specimen obtained from suction equipment in a room of one of the infected patients yielded an identical ESBL-KP.

Antibiotic susceptibility and resistance transfer

The 14 clinical isolates were resistant to all the β-lactam antibiotics (MICs, >256 μg/ml) tested, except for carbapenems (MICs, 0.002-1 μg/ml), ciprofloxacin (MIC, >32 μg/ml) and amoxicillin-clavulanic acid (MICs, 6-12 μg/ml). Tigecycline (MICs, 0.032-2 μg/ml) had excellent activities against all isolates. Strains isolated from the suction pump (isolate 15) had the same resistance pattern as the others.

Transconjugants created in E. coli J53 from all the donors were shown by PCR to contain blaCTX-M-15 and blaTEM-1 . MICs of cefotaxime and ciprofloxacin for the transconjugants and recipient strains were >256 and >32 μg/ml and 0.064 and 0.012 μg/ml, respectively.

Sequencing analysis and clonality of isolates

All isolates were positive for CTX-M β-lactamase [Figure 1]. The DNA sequencing revealed identical sequences belonging to CTX-M-15. They also expressed blaTEM ; sequencing on positive PCR products of the same isolates showed that they carried the blaTEM-1 gene. None of the 15 isolates was positive for blaSHV , blaOXA-1 , or bla ISEcp1 frequently identified upstream of the blaCTX-M genes.
Figure 1: Ethidium bromide-stained gel electrophoresis indicating the presence of blaCTX-M amplicon with a molecular size 499 bp. Lane M, 100 bp ladder marker; lane – ve, negative control; lane 1, positive control; lanes 2– 15, CTX-M-producing isolates from patients; lane 16, multiresistant isolate from the suction pump

Click here to view

The digestion of genomic DNA with Xba1 produced 10-13 fragments. The 15 isolates gave a related PFGE pattern. DNA restriction analysis shown in the dendogram [Figure 2] distinguished two patterns (clones A and B) and corresponding bands of the same apparent size all showing close relatedness with a Dice coefficient of >94.1% similarity.
Figure 2: Dendogram based on similarity by the Dice coeffi cient using FP Quest (version 4.5) software. The scale at the top left hand represents similarity. Pulsed-fi eld gel electrophoresis revealed two clones A (1, 2, 3, 6, 10, 11, 13, 14, and 15) and B (4, 5, 7, 8, 9, and 12) closely related with a Dice coeffi cient of >94.1 %

Click here to view

 ~ Discussion Top

Our report highlights the spread of clonally related CTX-M-15-producing K. pneumoniae in the adult ICU of a teaching hospital in Kuwait. Both the clinical and microbiological data show that the infections were acquired in the ICU. There was an overlapping ICU stay which was probably involved in the spread of the epidemic strain from one patient to the other as a result of contamination of the hands of healthcare providers, or medical equipment, corroborated by the isolation of ESBL-producing K. pneumoniae from the suction pump located in the room of an infected patient.

The DNA amplification of the ESBL genes revealed that the K. pneumoniae isolates produced only CTX-M-15 and non-ESBL β-lactamase (TEM-1). CTX-M-15 β-lactamase, first detected in India in 2001, [18] is one of the most frequently reported ESBLs produced by various species of Enterobacteriaceae worldwide, including Kuwait. [5],[7],[20] Several reports have confirmed the emergence of scattered CTX-M-15-producing K. pneumoniae isolates causing outbreaks in adult and neonatal ICUs in Sweden, [20] Saudi Arabia, [21] France, [22] Madagascar, [23] and Croatia. [24]

Experience with this epidemic strain appears to have been limited to the 2-month period in 2008. However, our concern regarding the possibility of future outbreaks is predicated on the fact that K. pneumoniae is a very efficient hospital pathogen and, in addition, can readily acquire plasmid-mediated CTX-M-15 genes from E. coli.

A PFGE study is an excellent method of determining clonality of ESBL-producing K. pneumoniae isolates and it was used to confirm that the outbreak was caused by two closely related clones. We can speculate at this time that these isolates are essentially the same clone which had mutated to produce a related subclone. Outbreaks of MDR K. pneumoniae are usually monoclonal although a few studies have reported multiclonalilty of epidemic strains causing outbreaks. [21] It is conceivable that the epidemic strain had undergone spontaneous mutation in the gut of some of these long-stay patients resulting in polyclonality and antibiotic resistance in the critically ill. [25] Although no K. pneumoniae was isolated from the stool or throat of these patients, a prolonged stay in the ICU particularly of the index case and some others and the severity of the underlying illnesses might have played a role in the evolution of the second clone.

Dedicated and robust infection control measures used during the period no doubt helped in stemming the outbreak resulting in complete eradication of the MDR strain.

In conclusion, we have documented an outbreak caused by CTX-M-15-producing K. pneumoniae in an adult ICU which is the first detailed report of such outbreak in an adult ICU in Kuwait. Our report also showed that stringent infection control practices when meticulously followed can stop and prevent a repeat of similar outbreaks.

 ~ References Top

1.Podschun R, Ullmann U. Klebsiella spp. as nosocomial pathogens: Epidemiology, taxonomy, typing methods, and pathogenicity factors. Clin Microbiol Rev 1998;11:589-603.  Back to cited text no. 1
2.Johnson AP, Weinbren MJ, Ayling-Smith B, Du Bois SK, Amyes SG, George RC. Outbreak of infection in two UK hospitals caused by a strain of Klebsiella pneumoniae resistant to cefotaxime and ceftazidime. J Hosp Infect 1992;20: 97-103.  Back to cited text no. 2
3.Mena A, Plasencia V, Garcia L, Hidalgo O, Ayestaran JI, Alberti S, et al. Characterization of a large outbreak by CTX-M-1-producing Klebsiella pneumoniae and mechanisms leading to in vivo carbapenem resistance development. J Clin Microbiol 2006;44:2831-7.  Back to cited text no. 3
4.Goossens H, Grabein B. Prevalence and antimicrobial susceptibility data for extended-spectrum beta-lactamase- and AmpC-producing Enterobacteriaceae from the MYSTIC Program in Europe and the United States (1997-2004). Diagn Microbiol Infect Dis 2005;53:257-64.  Back to cited text no. 4
5.Eckert C, Gautier V, Saladin-Allard M, Hidri N, Verdet C, Ould-Hocine Z, et al. Dissemination of CTX-M-type beta-lactamases among clinical isolates of Enterobacteriaceae in Paris, France. Antimicrob Agents Chemother 2004;48:1249-55.   Back to cited text no. 5
6.Livermore DM, Hawkey PM. CTX-M: Changing the face of ESBLs in the UK. J Antimicrob Chemother 2005:56:451-4.  Back to cited text no. 6
7.Ensor VM, Jamal W, Rotimi VO, Evans JT, Hawkey PM. Predominance of CTX-M-15 extended-spectrum beta-lactamases in diverse Escherichia coli and Klebsiella pneumoniae form hospital and community patients in Kuwait. Int J Antimicrob Agents 2009;33:487-9.  Back to cited text no. 7
8.Poirel L, Decousser JW, Nordmann P. Insertion sequence ISEcp1B in involved in expression and mobilization of a bla(CTX-M) beta-lactamase gene. Antimicrob Agents Chemother 2003;47:2938-45.  Back to cited text no. 8
9.Rotimi VO, Jamal W, Pal T, Sovenned A, Albert MJ. Emergence of CTX-M-15 type extended-spectrum â-lactamase-producing Salmonella spp. in Kuwait and the United Arab Emirates. J Med Microbiol 2008;57:881-6.  Back to cited text no. 9
10.Al Hashem G, Al Sweih N, Jamal W, Rotimi VO. Sequence analysis of bla CTX-M genes carried by clinically significant Escherichia coli isolates in Kuwait hospitals. Med Princ Pract 2011;20: 213-9.  Back to cited text no. 10
11.Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections. Am J Infect Control 1988;16:128-40.  Back to cited text no. 11
12.Clinical Laboratory Standards Institute (CLSI). Performance standards for antimicrobial susceptibility testing. 19th Informational Supplement. Vol. 29. Document M100-S19. Wayne (PA): CLSI; 2009.   Back to cited text no. 12
13.Saladin M, Cao VT, Lambert T, Donay J-L, Herrmann J-L, Ould-Hocine Z, et al0. Diversity of CTX-M â-lactamases and their promoter regions from Enterobacteriaceae isolated in three Parisian hospitals. FEMS Microbiol Lett 2009;209:161-8.  Back to cited text no. 13
14.Karisik E, Ellington MJ, Pike R, Warren RE, Livermore DM, Woodford N. Molecular characterization of plasmids encoding CTX-M-15 â-lactamases from Escherichia coli strains in the United Kingdom. J Antimicrob Chemother 2006;58:665-8.  Back to cited text no. 14
15.Eckert C, Gautier V, Arlet G. DNA sequence analysis of the genetic environment of various blaCTX-M genes. J Antimicrob Chemother 2006;57:14-23.  Back to cited text no. 15
16.Lartigue M-F, Poirel L, Nordmann P. Diversity of genetic environment of blaCTX-M genes. FEMS Microbiol Lett 2004;234:201-7.   Back to cited text no. 16
17.Woodford N, Ward ME, Kaufmann ME, Turton J, Fagan EJ, James D, et al. Community and hospital spread of Escherichia coli producing CTX-M extended-spectrum â-lactamases in the UK. J Antimicrob Chemother 2004;54:735-43.  Back to cited text no. 17
18.Karim A, Poirel L, Nagarajan S, Nordmann P. Plasmid-mediated extended-spectrum â-lactamase (CTX-M-3 like) from India and gene association with insertion sequence ISEcp1. FEMS Microbiol Lett 2001;201:237-41.  Back to cited text no. 18
19.Tenover FC, Arbeit RD, Goering RV, Mickelsen PA, Murray BE, Persing DH, et al. Interpreting chromosomal DNA restriction patterns produced by pulsed-field gel electrophoresis: Criteria for bacterial strain typing. J Clin Microbiol 1995;33:2233-9.  Back to cited text no. 19
20.Lytsy B, Sandegren L, Tano E, Torell E, Andersson DI, Melhus A. The first major extended-spectrum â-lactamase outbreak in Scandinavia was caused by clonal spread of a multiresistant Klebsiella pneumoniae producing CTX-M-15. APMIS 2008;116:302-8.  Back to cited text no. 20
21.Al-Agamy MH, Shibl AM, Tawfik AF. Prevalence and molecular characterization of extended- spectrum beta-lactamase-producing Klebsiella pneumoniae in Riyadh, Saudi Arabia. Ann Saudi Med 2009;29:253-7.  Back to cited text no. 21
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22.Carrer A, Lassel L, Fortineau N, Mansouri M, Anguel N, Richard C, et al. Outbreak of CTX-M-15-producing Klebsiella pneumoniae in the intensive care unit of a French Hospital. Microbial Drug Resist 2009;15:47-54.  Back to cited text no. 22
23.Randrianirina F, Vedy S, Rakotovao D, Ramarokoto CE, rasitohaina H, Carod JF, et al. Role of contaminated aspiration tubes in nosocomial outbreak of Klebsiella pneumoniae producing SHV-2 and CTX-M-15 extended-spectrum â-lactamases. J Hosp Infect 2009;72:23-9.  Back to cited text no. 23
24.Vranic-Ladavac M, Bosnjak Z, Beader N, Barisic N, Kalenic S, Bedenic B. Clonal spread of CTX-M-15 producing Klebsiella pneumoniae in Croatian hospital. J Med Microbiol 2010;59:1069-78.  Back to cited text no. 24
25.van Saene HK, Taylor N, Damjanovic V, Sarginson RE. Microbial overgrowth guarantees increased spontaneous mutation leading to polyclonality and antibiotic resistance in the critically ill. Curr Drug Targets 2008;9:419-21.  Back to cited text no. 25


  [Figure 1], [Figure 2]

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