AUTHOR=Daaboul Dina , Oueslati Saoussen , Rima Mariam , Kassem Issmat I. , Mallat Hassan , Birer Aurélien , Girlich Delphine , Hamze Monzer , Dabboussi Fouad , Osman Marwan , Naas Thierry 

TITLE=The emergence of carbapenemase-producing Enterobacterales in hospitals: a major challenge for a debilitated healthcare system in Lebanon

JOURNAL=Frontiers in Public Health

VOLUME=11

YEAR=2023

URL=https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2023.1290912

DOI=10.3389/fpubh.2023.1290912

ISSN=2296-2565

ABSTRACT=<sec id="sec1"><title>Background</title><p>Carbapenem- and extended-spectrum cephalosporin-resistant <italic>Enterobacterales</italic> (CR-E and ESCR-E, respectively) are increasingly isolated worldwide. Information about these bacteria is sporadic in Lebanon and generally relies on conventional diagnostic methods, which is detrimental for a country that is struggling with an unprecedented economic crisis and a collapsing public health system. Here, CR-E isolates from different Lebanese hospitals were characterized.</p></sec><sec id="sec2"><title>Materials and methods</title><p>Non-duplicate clinical ESCR-E or CR-E isolates (<italic>N</italic> = 188) were collected from three hospitals from June 2019 to December 2020. Isolates were identified by MALDI-TOF, and their antibiotic susceptibility by Kirby-Bauer disk diffusion assay. CR-E isolates (<italic>n</italic> = 33/188) were further analyzed using Illumina-based WGS to identify resistome, MLST, and plasmid types. Additionally, the genetic relatedness of the CR-E isolates was evaluated using an Infrared Biotyper system and compared to WGS.</p></sec><sec id="sec3"><title>Results</title><p>Using the Kirby-Bauer disk diffusion assay, only 90 isolates out of the 188 isolates that were collected based on their initial routine susceptibility profile by the three participating hospitals could be confirmed as ESCR-E or CR-E isolates and were included in this study. This collection comprised <italic>E. coli</italic> (<italic>n</italic> = 70; 77.8%), <italic>K. pneumoniae</italic> (<italic>n</italic> = 13; 14.4%), <italic>Enterobacter</italic> spp. (<italic>n</italic> = 6; 6.7%), and <italic>Proteus mirabilis</italic> (<italic>n</italic> = 1; 1.1%). While 57 were only ESBL producers the remaining 33 isolates (i.e., 26 <italic>E. coli</italic>, five <italic>K. pneumoniae</italic>, one <italic>E. cloacae</italic>, and one <italic>Enterobacter hormaechei</italic>) were resistant to at least one carbapenem, of which 20 were also ESBL-producers. Among the 33 CR-E, five different carbapenemase determinants were identified: <italic>bla</italic><sub>NDM-5</sub> (14/33), <italic>bla</italic><sub>OXA-244</sub> (10/33), <italic>bla</italic><sub>OXA-48</sub> (5/33), <italic>bla</italic><sub>NDM-1</sub> (3/33), and <italic>bla</italic><sub>OXA-181</sub> (1/33) genes. Notably, 20 CR-E isolates were also ESBL-producers. The analysis of the genetic relatedness revealed a substantial genetic diversity among CR-E isolates, suggesting evolution and transmission from various sources.</p></sec><sec id="sec4"><title>Conclusion</title><p>This study highlighted the emergence and broad dissemination of <italic>bla</italic><sub>NDM-5</sub> and <italic>bla</italic><sub>OXA-244</sub> genes in Lebanese clinical settings. The weak AMR awareness in the Lebanese community and the ongoing economic and healthcare challenges have spurred self-medication practices. Our findings highlight an urgent need for transformative approaches to combat antimicrobial resistance in both community and hospital settings.</p></sec>