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 ~ Results
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  Table of Contents  
Year : 2011  |  Volume : 29  |  Issue : 3  |  Page : 269-274

OXA beta-lactamase-mediated carbapenem resistance in Acinetobacter baumannii

1 Department of Microbiology, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra University, Porur, Chennai, India
2 Department of Molecular Biology, Department of Microbiology, Central Leprosy Teaching and Research Institute, Chengalpattu, India
3 Pasteur Institute of India, Coonoor, Nilgiris, Tamil Nadu, India

Date of Submission21-Apr-2011
Date of Acceptance01-Jul-2011
Date of Web Publication17-Aug-2011

Correspondence Address:
U Sekar
Department of Microbiology, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra University, Porur, Chennai
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0255-0857.83911

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 ~ Abstract 

Objectives: Acinetobacter baumannii is a significant pathogen in health care settings. In recent years, an increase in carbapenem resistance among A. baumannii due to Ambler class B metallo-beta-lactamases or class D OXA carbapenamases has been reported. In this study we detected the presence of OXA carbapenamases and coproduction of metallo-beta-lactamases (blaVIM and blaIMP ) by phenotypic and genotypic methods in carbapenem resistant clinical isolates of Acinetobacter baumannii. Materials and Methods: A total of 116 consecutive, non-duplicate carbapenem resistant A. baumannii isolated from various clinical specimens were included in the study. The modified Hodge test and inhibitor potentiated disk diffusion tests were done for the screening of carbapenamase and metallo-beta-lactamase production, respectively. Polymerase chain reaction (PCR) was performed for the detection of OXA (blaOXA 23 like, blaOXA 24 like, blaOXA-51 like and blaOXA-58 like genes) and metallo-beta-lactamases (blaVIM and blaIMP ) genes. Gene sequencing was performed for representative isolates. Results: Among 116 A. baumannii, OXA genes were detected in 106 isolates. BlaOXA 51 like (n = 99) and blaOXA -23 like (n = 95) were the most common and they coexisted in 89 isolates. blaOXA-24 like gene was detected in two isolates of which one also carried blaOXA-51 like and blaOXA-58 like genes. The modified Hodge test was positive in 113 isolates. The metallo-beta-lactamase screening test was positive in 92 isolates. blavim was detected in 54 isolates of which 1 also carried the blaIMP gene. Conclusions: blaOXA-23 like and bla OXA 51 like genes are the most common types of OXA carbapenamases while the blaVIM type is the most common type of metallo-beta-lactamase contributing to carbapenem resistance in clinical isolates of A. baumannii. The coproduction of OXA and metallo-beta-lactamases is not an uncommon phenomenon in A. baumannii.

Keywords: Acinetobacter baumannii, bla OXA , carbapenamases, modified Hodge test, minimum inhibitory concentration

How to cite this article:
Amudhan S M, Sekar U, Arunagiri K, Sekar B. OXA beta-lactamase-mediated carbapenem resistance in Acinetobacter baumannii. Indian J Med Microbiol 2011;29:269-74

How to cite this URL:
Amudhan S M, Sekar U, Arunagiri K, Sekar B. OXA beta-lactamase-mediated carbapenem resistance in Acinetobacter baumannii. Indian J Med Microbiol [serial online] 2011 [cited 2021 Feb 25];29:269-74. Available from:

 ~ Introduction Top

Multidrug resistant Acinetobacter baumannii is a significant pathogen in health care settings, where it causes a multitude of infections that include bacteremia, pneumonia, meningitis and urinary tract and wound infections. Its ability to survive under a wide range of environmental conditions makes it a frequent cause of outbreaks of infection and an endemic health care-associated pathogen. [1] A. baumannii is often resistant to a wide variety of antimicrobial agents, including carbapenems. Carbapenem resistance in A. baumannii is due to a variety of combined mechanisms such as hydrolysis by beta-lactamases, alterations in the outer membrane protein and penicillin-binding proteins and increased activity of efflux pumps. Acquired resistance to carbapenems, mediated by the Ambler class D beta-lactamases or OXA-type carbapenamases and Ambler class B metallo-beta-lactamases are of greatest concern as they are encoded by genes which are transmissible and account for most of the resistance to carbapenems. [2],[3] Carbapenem-hydrolyzing blaOXA-23 was first reported in A. baumannii in 1985. Since then several of them have been reported worldwide. Four families of OXA genes have been identified in A. baumannii: blaOXA-23 like (blaOXA-23 , blaOXA-27 and bla OXA-49 ); bla OXA-24 like (blaOXA-24 , blaOXA-25 , blaOXA-26 and blaOXA-40 ); blaOXA-58 and blaOXA-51 like. The last group constitutes a family of chromosomal enzymes typically present in A. baumannii.[2],[4],[5] Though the presence of bla OXA genes in A. baumannii is widely known, there is a paucity of information on the distribution of different types of OXA carbapenamases in isolates from the Indian subcontinent. [6],[7],[8] This study was undertaken to detect the prevalence of different blaOXA -type carbapenamases among nosocomial isolates of A. baumannii. The simultaneous presence of metallo-beta-lactamases (blaVIM and blaIMP ) type of carbapenamases was also determined in the study isolates.

 ~ Materials and Methods Top

Bacterial strains

The study was conducted in a 1600-bedded university teaching hospital from April 2010 to October 2010. It included 116 clinically significant, non-duplicate, carbapenem resistant Acinetobacter baumannii recovered from clinical specimens of patients hospitalized for >48 h. The isolates were obtained from clinical specimens such as blood, cerebrospinal fluid, pus, wound swabs, and urine and lower respiratory secretions (bronchoalveolar lavage, bronchial wash and endotracheal secretions). The organisms were identified up to the species level using Microscan Walk Away 96, Gram-negative panels. Care was taken to differentiate commensals from pathogens for isolates obtained from nonsterile sites (respiratory tract, urinary tract, and wound swabs). The significance of the isolates was based on clinical history, presence of the organism in the Gram stain, presence of intracellular forms of the organism, and pure growth in culture with a significant colony count.

Antimicrobial susceptibility testing

Susceptibility to various classes of antibiotics was determined by the disc diffusion method in accordance with Clinical Laboratory Standard Institute (CLSI) guidelines. [6] The antibiotics tested were amikacin (30 μg), ciprofloxacin (5 μg), ceftazidime (30 μg), piperacillin-tazobactam (100/10 μg), imipenem (10 μg), meropenem (10 μg) and polymyxin B (300 units), [9] from Himedia Laboratories (Mumbai, Maharashtra, India). Disc diffusion susceptibility testing was also performed for all the isolates using tigecycline disks (15 μg; BBL TM BD, USA). The interpretation of zone diameters was done using the United States Food and Administration's tigecycline susceptibility breakpoint criteria listed for Enterobacteriaceae (susceptible ΃19 mm, intermediate 15--18 mm, resistance ≤14 mm). [10] MIC to imipenem and meropenem was done by the agar dilution method (range: 0.008-256 μg/ml) in accordance with CLSI guidelines. [9]

Detection of carbapenamases

The detection of carbapenamases was done by the modified Hodge Test.  Escherichia More Details coli ATCC 25922 was cultured overnight and suspended to achieve a 0.5 McFarland standard turbidity and was lawn cultured onto a Mueller-Hinton agar plate using a sterile cotton swab. After drying, a disk containing imipenem (10 μg) was placed at the center of the plate, and an overnight cultured test strain was heavily streaked from the center to the periphery of the plate. The presence of a distorted zone after overnight incubation was interpreted as a positive result. [11] Though CLSI [9] does not advocate the use of the modified Hodge test for the detection of carbapenamase production in nonfermenting Gram-negative bacilli, several authors have found the modified Hodge test using imipenem as a useful screening test for carbapenamase production. [12],[13],[14]

Detection of metallo-beta-lactamases

Zone enhancement with ethylenediaminetetraacetic acid (EDTA)-impregnated imipenem and ceftazidime discs

Test organisms were inoculated on the plates with Mueller-Hinton agar. A 0.5 M EDTA solution was prepared by dissolving 186.1 g of disodium EDTA in 1000 ml of distilled water and adjusting its pH to 8.0. The EDTA solution was sterilized by autoclaving. Two 10-μg imipenem discs and two 30-μg ceftazidime discs were placed on the surface of the agar plate and EDTA solution (5 μl) was added to one of them to obtain a desired concentration of 750 μg. The inhibition zones of the imipenem and ceftazidime and their EDTA-impregnated discs were compared after incubation in air at 37°C. A zone size difference of ΃7 mm was taken as indicative of metallo-beta-lactamase production. [15]

Detection of carbapenem resistance genes

DNA template

A 1:10 dilution of an overnight culture was boiled for 10 mins. Amplification was then performed with 10 μl of this dilution as the DNA template.

Multiplex PCR for the detection of OXA genes [5]

Multiplex PCR was done for the detection of the four families of OXA-type carbapenamases found in A baumannii. Sequences of primers used for multiplex PCR for the detection of genes encoding blaOXA-23 like, blaOXA-24 like, blaOXA-51 like and blaOXA-58 like genes are given in [Table 1].
Table 1: PCR primers for the detection of genes encoding OXA carbapenemase and metallo-beta-actamases
(blaVIM and blaIMP) (MWG Denmark)

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The PCR conditions were as follows: Initial denaturation at 94°C for 5 min, 33 cycles of 94°C for 25 s, 53°C for 40 s and 72°C for 50 s, followed by an elongation step at 72°C for 6 min.

The PCR products of 501 bp (blaOXA-23 like), 353 bp (blaOXA-51 like), 246 bp (blaOXA-24 like) and 599 bp (blaOXA-58 like) were visualized by agarose gel electrophoresis.

PCR for metallo-beta-lactamase genes: blaVIM and blaIMP [16] Primers used are given in [Table 1].

PCR conditions included 30 cycles of amplification under the following conditions: Denaturation at 95°C for 30 s, annealing for 1 min at specific temperatures (blaVIM , 66°C, and blaIMP , 45°C), and extension at 72°C for 1 min/kb product. Cycling was followed by a final extension at 72°C for 10 min. The PCR product of 500 bp (blaVIM ) and 432 bp (blaIMP ) was visualized by agarose gel electrophoresis.

DNA sequencing

The PCR products of representative isolates were then purified by using the PCR DNA purification kit (QIA Quick Gel Extraction Kit; Qiagen, Valencia, CA, USA) and subjected to automated DNA sequencing (ABI 3100, Genetic Analyser; Applied Biosystems, Foster City, CA, USA). The aligned sequences were then analysed with the Bioedit sequence program and similarity searches for the nucleotide sequences were performed with the BLAST program (

 ~ Results Top

A. baumannii were isolated from clinical specimens such as blood (n = 25), respiratory secretions (n = 62), pus and wound swab (n = 18), cerebrospinal fluid (n = 4), body fluids (n = 3) and urine (n = 4). Most isolates were from patients in the intensive care units (ICU) of the health care facility (n = 111) and only 5 were from patients in the wards.

All of them were resistant to amikacin, ciprofloxacin, ceftazidime, piperacillin-tazobactam, imipenem and meropenem. The MIC to imipenem and meropenem ranged from 8 to 128 μg/ml. The MIC 50 and MIC 90 values for imipenem were 16 and 32 μg/ml, respectively. For meropenem, MIC 50 and MIC 90 values were 32 and 64 μg/ml, respectively.

Among the 116 isolates, 97.4% (n = 113) were susceptible to polymyxin and 93.1% (n = 108) to tigecycline.

Phenotypic tests

Of 116 A. baumannii, the modified Hodge test was positive for 113 (97.4%) of isolates [Figure 1] while in 3, the test was negative. The metallo-beta-lactamase screening test with EDTA was positive in 92 (79.3%) isolates.
Figure 1: Modified Hodge test

Click here to view


OXA-23 like, blaOXA-24 like, blaOXA-51 like and blaOXA-58 like were detected in the majority (n = 106) of isolates [Figure 2]. Most of them carried the blaOXA-51 like (n = 99) and blaOXA-23 like (n = 95) genes. Both coexisted in 89 isolates. Of the other OXA types, blaOXA-24 like was found only in two isolates, of which one also harboured blaOXA-51 like and bla OXA-58 like genes. The distribution of different types of OXA genes in the test organisms is given in [Table 2].
Table 2: Distribution of different types of blaOXA genes in the test organisms

Click here to view
Figure 2: Detection of genes encoding OXA carbapenamases by multiplex PCR. Lanes 1 and 2 blaOXA -23 like gene; lane 3 blaOXA -58 like gene; molecular mass marker (100 bp DNA ladder); lane 4 and 5 bla OXA -51like gene

Click here to view

Among the modified Hodge test-positive A. baumannii (n = 113), OXA genes were not detected in seven isolates. Of them (n = 7), blaVIM was detected in four and the remaining three did not have blaOXA /blaVIM or blaIMP.

Regarding metallo-beta-lactamase, PCR detected blaVIM in 54 isolates, of which 1 carried both blaVIM and blaIMP [Figure 3] and [Figure 4]. Of the above, 50 also harboured the OXA gene, particularly the blaOXA-23 like and blaOXA-51 like.
Figure 3: Detection of bla VIM. Molecular mass marker (100 bp DNA ladder). Lanes 2, 3 and 5 blaVIM positive; lanes 1 and 4 bla VIM negative

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Figure 4: Detection of blaIMP. Molecular mass marker (100 bp DNA ladder). Lane 8 blaIMP positive

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On review of the patient care areas from where the blaOXA -positive (n = 106) isolates were obtained, it was found that the multidisciplinary open ICU had the highest number of isolates carrying the blaOXA gene (69/74), followed by neurosurgery ICU (25/28), cardiothoracic ICU (6/7) and general wards (4/5). From the paediatric ICU, though the isolates obtained were only two, both carried the blaOXAgene.

 ~ Discussion Top

A. baumannii accounts for a substantial proportion of endemic nosocomial infections. Multidrug resistance increasingly reported in these pathogens is posing a threat to hospitalized patients due to the limitation of therapeutic options. The acquisition of multidrug resistance is related to environmental contamination and contact with transiently colonized health care providers. Carbapenems have been the drug of choice for treatment of infections caused by A. baumannii. However, in recent years, the number of isolates showing resistance to carbapenems has increased worldwide. [2],[12],[17] This is mediated by the lack of drug penetration (i.e. porin mutations and efflux pumps) and/or carbapenem-hydrolyzing beta-lactamase enzymes such as OXA carbapenamases and metallo-beta-lactamases. [2]

The first identified OXA-type enzyme with carbapenem-hydrolyzing activity was from an A. baumannii strain isolated in 1985 from Scotland and was originally named ARI-1, but was renamed as blaOXA-23 . The blaOXA-23 cluster (blaOXA-23,27,49 ) now contributes to carbapenem resistance in A. baumannii globally. Two other plasmid-encoded acquired OXA-type clusters with a carbapenamase activity have been described, which are blaOXA-24 -like (blaOXA-24,25,26,40 ) and blaOXA-58 -like genes. The blaOXA-23 , blaOXA-24 and blaOXA-58 like enzymes are plasmid/chromosomally encoded which explains their widespread distribution. The blaOXA-51 like gene cluster is unique in that it naturally occurs in  A.baumannii Scientific Name Search . Therefore it is chromosomally located and is widely prevalent. Similar to other class D enzymes, they have a greater affinity for imipenem than meropenem. Their role in carbapenem resistance is related to the presence of an insertion sequence ISAba1, situated upstream, possibly providing a promoter for the hyperproduction of beta-lactamase genes. [2],[18],[19] Strains that harbour multiple OXA encoding genes have been reported from several geographical areas. [12],[17],[20]

In this study, overall OXA carbapenamases were detected in 91.3% (n = 106) of carbapenem resistant A. baumannii. blaOXA-51 (n = 99) and blaOXA-23 (n = 95) were the most common OXA carbapenamases and they coexisted in 89 isolates. blaOXA-51 was found alone in nine isolates and blaOXA-23 alone in six isolates. blaOXA-24 was detected only in two isolates, of which one also carried blaOXA-51 and blaOXA-58 .

Numerous studies have reported that blaOXA-23 is the most frequent type of carbapenamases identified among the carbapenem resistant A. baumannii.[5],[13],[19] The coexistence of blaOXA-23 like, blaOXA-24 like, blaOXA-51 like and blaOXA-58 like genes has been reported, especially that of blaOXA-23 and blaOXA-51. [14],[20] Bla OXA-24 has been reported from Spain, Belgium, France and United States while blaOXA-58 has been identified in many countries. [2] There is a paucity of information on the frequency of occurrence, prevalence and distribution of OXA carbapenamases from India. [6],[7],[8] In one study on 62 isolates of the Acinetobacter species, blaOXA 23 was the most common. [6] In another study on four carbapenem resistant A. baumannii blood stream isolates, blaOXA-23 was found to be the most prevalent. [7]

Among the 54 blaVIM -positive isolates, 1 also carried blaIMP . The metallo-beta-lactamase screen test was positive in 92 isolates, thereby suggesting the presence of other metallo-beta-lactamases such as GIM, SPM and NDM-1. [1],[8] Despite metallo-beta-lactamases being less commonly identified in A. baumannii compared to the OXA carbapenamases, their hydrolytic activity towards carbapenems are significantly more potent. These enzymes hydrolyze all beta-lactams except the monobactams (aztreonam). [1],[4] In this study, blaVIM coexisted with blaOXA-23 and blaOXA-51 in 49 isolates and in 1 isolate blaVIM , blaIMP , blaOXA-23 and blaOXA-51 were found. The simultaneous existence of blaOXA and metallo-beta-lactamases has been reported from several geographic regions. [2],[8],[14],[19]

In four carbapenem resistant A. baumannii, blaVIM was detected without the OXA genes. Among the modified Hodge test-positive isolates (n = 113), PCR for OXA, blaVIM and blaIMP was negative in three isolates suggesting the presence of other carbapenamases.

For the carbapenem resistant isolates which were modified Hodge test-negative (n = 3), it may be assumed to be due to the presence of porin mutations and upregulation of efflux pumps.

Among the 116 study isolates, 97.4% (n = 113) were susceptible to polymyxin and 93.1% (n = 108) to tigecycline. The lack of universal susceptibility to these two drugs is a cause for concern. All the study isolates were uniformly resistant to aminoglycosides and fluoroquinolones.

Though carbapenems are the drug of choice to treat A. baumannii infections, such resistance profiles limit therapeutic options to polymyxins and tigecycline. These drugs also have their own limitations and are not indicated as the drug of choice under a variety of clinical conditions. Easy and simple phenotypic tests are required for the early identification of carbapenamases in the clinical laboratories to notify the treating physicians and also devise methods to contain their spread.

Since the acquisition of multidrug resistant A. baumannii is related to environmental contamination and colonization in health care providers, control measures should address the source of infection. Continued careful attention to hand hygiene, contact isolation, barrier precautions, adequate environmental cleaning, and careful disinfection of patient care equipments along with surveillance are essential to prevent the outbreak of infections caused by these multidrug resistant strains. [21]

To conclude, blaOXA-23 and blaOXA-51 are the most common types of OXA carbapenamases in A. baumannii. This type of resistance is a factor with a significant threat in hospitals. It should be addressed with alternative and newer therapeutic strategies, strict infection control measures and continuous surveillance. A simultaneous existence of different classes of carbapenamases is a problem to reckon with and hence detection methods are required for each of these. In outbreak settings, an initial screening of the putative carbapenamase producers will help to organize intervention and early directed therapy.

 ~ References Top

1.Maragakis LL, Perl TM. Acinetobacter baumannii: Epidemiology, antimicrobial resistance, and treatment options. Clin Infect Dis 2008;46:1254-63.  Back to cited text no. 1
2.Peleg AY, Seifert H, Paterson DL. Acinetobacter baumannii: Emergence of a successful pathogen. Clin Microbiol Rev 2008;21:538-82.  Back to cited text no. 2
3.Rasmussen JW, Høiby N. OXA-type carbapenemases. J Antimicrob Chemother 2006;57:373-83.  Back to cited text no. 3
4.Poirel L, Nordmann P. Carbapenem resistance in Acinetobacter baumannii: Mechanism and epidemiology. Clin Microbiol Infect 2006;9:826-36.  Back to cited text no. 4
5.Mostachio AK, Heidjen IV, Rossi F, Levin AS, Costa SF. Multiplex PCR for rapid detection of genes encoding OXA and metallo-beta-lactamases in carbapenem resistant Acinetobacter spp. J Med Microbiol 2009;58:1552-4.  Back to cited text no. 5
6.Karunasagar A, Maiti B, Shekar M, Shenoy MS, Karunasagar I. Prevalence of OXA - type carbapenamase genes and heterogeneity in clinical isolates of Acinetobacter spp. from Mangalore, India. Microbiol Immunol 2011;55:239-46.  Back to cited text no. 6
7.Roy S, Basu S, Dasgupta S, Singh AK, Viswanathan R. Carbapenem resistance in Acinetobacter baumannii isolated from blood of neonates with sepsis. Indian J Med Microbiol 2011;28:416-7.  Back to cited text no. 7
8.Karthikeyan K, Thirunarayan MA, Krishnan P. Coexistence of bla OXA-23 with bla NDM-1 and armA in clinical isolates of Acinetobacter baumannii from India. J Antimicrob Chemother 2010;65:2253-4.  Back to cited text no. 8
9.CLSI. Performance standards for Antimicrobial Susceptibility Testing: Twentieth Informational Supplement. CLSI document M100-S20. Wayne, PA: Clinical and Laboratory Standards Institute; 2010.  Back to cited text no. 9
10.Dehera B, Das A, Mathur P, Kapil A, Gadepalli R, Dhawan B. Tigecycline susceptibility report from an Indian tertiary care hospital. Indian J Med Res 2009;129:446-50.  Back to cited text no. 10
11.Lee K, Chong Y, Shin HB, Kim A, Yong D, Yum JH. Modified Hodge and EDTA - disk synergy tests to screen metallo beta lactamases-producing strains of Pseudomonas and Acinetobacter species. Clin Microbiol Infect 2001;7:88-102.  Back to cited text no. 11
12.Yang HY, Lee HJ, Suh JT, Lee KM. Outbreaks of Imipenem resistant Acinetobacter baumannii 0producing OXA-23 â-Lactamase in a tertiary care hospital in Korea. Yonsei Med J 2009;50:764-70.  Back to cited text no. 12
13.Andriamanantena TS, Ratsima E, Rakotonirina HC, Randrianirina F, Ramparany L, Carod JF, et al. Dissemination of multidrug resistant Acinetobacter baumannii in various hospitals of Antananarivo Madagascar. Ann Clin Microbiol Antimicrob 2010;9:17.  Back to cited text no. 13
14.Sung JY, Kwon KC, Park JW, Kim YS, Kim JM, Shin KS, et al. Dissemination of IMP-1 and OXA Type -Lactamase in Carbapenem-resistant Acinetobacter baumannii. Korean J Lab Med 2008;28:16-23.  Back to cited text no. 14
15.Hemalatha V, Sekar U, Kamat V. Detection of metallo beta lactamases producing Pseudomonas aeruginosa in hospitalised patients. Indian J Med Res 2005;122:148-52.  Back to cited text no. 15
16.Hujer KM, Hujer AM, Hulten EA, Bajaksouzian S, Adams JM, Donskey CJ, et al. Analysis of antibiotic resistance genes in multidrug-resistant Acinetobacter sp. isolates from military and civilian patients treated at the Walter Reed Army medical center. Antimicrob Agents Chemother 2006;50:4114-23.  Back to cited text no. 16
17.Feizabadi MM, Fatholllahzadeh B, Taherikalani M, Rasoolinejad M, Sadeghifard N, Aligholi M, et al. Antimicrobial susceptibility patterns and distribution of blaOXA g enes among Acinetobacter spp. isolated from patients at Tehran hospital. Jpn J Infect Dis 2008;61:274-8.  Back to cited text no. 17
18.Susan B, Amyes S. OXA â - lactamases in Acinetobacter: The story so far. J Antimicrob Chemother 2006;57:1-3.  Back to cited text no. 18
19.Koh TS, Sng LH, Wang GC, Hsu LY, Zhao Y. IMP-4 and OXA â - lactamases in Acinetobacter baumannii from Singapore. J Antimicrob Chemother 2007;59:627-32.  Back to cited text no. 19
20.Mendes RE, Bell JM, Turnidge JD, Castanheira M, Jones RN. Emergence and widespread dissemination of OXA-23, -24/40 and -58 carbapenemases among Acinetobacter spp. in Asia-Pacific nations: Report from the SENTRY Surveillance Program. J Antimicrob Chemother 2009;63:55-9.  Back to cited text no. 20
21.Shanthi M, Sekar U. Multi-drug resistant Pseudomonas aeruginosa and Acinetobacter baumannii infections among hospitalized patients; risk factors and outcome. J Assoc Physicians India 2009;57:635-45.  Back to cited text no. 21


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]

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