G Model JIPH-693; No of Pages ARTICLE IN PRESS Journal of Infection and Public Health xxx (2017) xxx–xxx Contents lists available at ScienceDirect Journal of Infection and Public Health journal homepage: http://www.elsevier.com/locate/jiph Prevalence, antibiotic susceptibility and characterization of antibiotic resistant genes among carbapenem-resistant Gram-negative bacilli and yeast in intestinal flora of cancer patients in North Lebanon Rima Christophy a , Marwan Osman a , Hassan Mallat a , Marcel Achkar b , Azzam Ziedeh c , Walid Moukaddem c , Fouad Dabboussi a , Monzer Hamze a,∗ a Laboratoire Microbiologie Santé et Environnement (LMSE), Ecole Doctorale des Sciences et de Technologie, Faculté de Santé Publique, Université Libanaise, Tripoli, Lebanon b Clinical Laboratory, Nini Hospital, Tripoli, Lebanon c Cancerology Department, Nini Hospital, Tripoli, Lebanon a r t i c l e i n f o Article history: Received January 2016 Received in revised form August 2016 Accepted October 2016 Keywords: Cancer Yeasts Carbapenemases Multidrug resistant bacteria Colonization a b s t r a c t The emergence and spread of carbapenem-resistant bacteria are a significant clinical and public health concern The aim of the study is to determine the prevalence of intestinal carriage of carbapenemresistant bacteria and yeasts in cancer patients under chemotherapy 41 stool samples collected from cancer patients in Nini hospital in Tripoli, North Lebanon have been analyzed After isolating yeasts and carbapenem-resistant bacteria, a biochemical identification and antimicrobial susceptibility profile were determined The mechanism of enzymatic carbapenem-resistance was detected by searching for carbapenemases by both Hodge test and PCR assays The association of several mechanisms of resistance was also searched 46.3% (19/41) of patients were colonized by yeast Candida glabrata (6/19) was the major species The prevalence of carbapenem-resistant bacteria was 24.4% (10/41) including Escherichia coli (5/10), Enterobacter cloacae (1/10), Enterobacter aerogenes (1/10) Edwardsiella hoshinae (1/10) Pantoea agglomerans (1/10) and Pseudomonas stutzeri (1/10) PCR and sequencing of the amplified fragments revealed that Pseudomonas stutzeri (1/1) carried VIM gene and Enterobacter aerogenes (1/1) and E coli (1/5) carried OXA-48 gene The other Enterobacteriaceae were resistant to carbapenems by mechanisms other than a carbapenemase including hyperproduction of cephalosporinase (4/10), extended spectrum beta-lactamases (1/10) and both cephalosporinase and extended spectrum beta-lactamases (2/10) High prevalence of intestinal carriage of carbapenem-resistant bacteria and yeasts were detected in cancer patients under chemotherapy In order to prevent the development of endogenous infection and the dissemination of antimicrobial resistance, an implementation of antibiotic stewardship programs and infection control measures is required in hospitals particularly in the department of chemotherapy © 2017 The Authors Published by Elsevier Limited This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) Introduction Cancer patients are at increased risk of infection either because they have a deficiency of the immune function [1] either because of chemotherapy or radiotherapy which induce neutropenia [2] The prophylactic antibiotic use is a standard practice in patients with neutropenia after chemotherapy [3] Disruption of the flora of the gastrointestinal tract is then created In addition, treatment with broad-spectrum antibiotics increases the risk of candidiasis by increasing the concentration of Candida spp in the gastroin- ∗ Corresponding author E-mail address: mhamze@monzerhamze.com (M Hamze) testinal tract [4] The integrity of the mucous membranes that can be damaged by the use of cytotoxic chemotherapy agents also represent a risk factor for the development of fungal infections in these patients [5] Potentially pathogenic bacteria are able to colonize the intestine which leads to a vicious circle of treatments and the emergence of new bacteria resistant to antibiotics including carbapenem-resistant species [6] Carbapenems are often used to treat infections caused by enterobacteria producing extended-spectrum -lactamases (ESBL) or cephalosporinase [7] They differ from other -lactams by their post-antibiotic effect against Gram-negative bacteria [8] Unfortunately, the prevalence of Enterobacteriaceae producing carbapenemases increased over the last ten years which seriously leads to a treatment impasse and a challenge in the treatment of nosocomial infections [7] Two http://dx.doi.org/10.1016/j.jiph.2016.10.009 1876-0341/© 2017 The Authors Published by Elsevier Limited This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-ncnd/4.0/) Please cite this article in press as: Christophy R, et al Prevalence, antibiotic susceptibility and characterization of antibiotic resistant genes among carbapenem-resistant Gram-negative bacilli and yeast in intestinal flora of cancer patients in North Lebanon J Infect Public Health (2017), http://dx.doi.org/10.1016/j.jiph.2016.10.009 G Model ARTICLE IN PRESS JIPH-693; No of Pages R Christophy et al / Journal of Infection and Public Health xxx (2017) xxx–xxx mechanisms of resistance are described, the acquisition of carbapenemases genes that encode enzymes capable of degrading carbapenems or overexpression of ß-lactamases that have a very low affinity for the carbapenems such as cephalosporinase and ESBL trait along with outer membrane porin loss or hyper-expression of efflux pumps [9,10] On the other hand, the adequate antibiotic therapy is a key issue in multidrug resistant bacteria management Several studies have shown that cancer patients infected with resistant bacteria more often receive inadequate initial empirical antibiotic therapy, which may impair outcomes, increase mortality and prolong hospitalization [11] Therefore, the aim of this study was to determine the prevalence of carriage of carbapenem-resistant bacteria and yeasts in the intestinal flora of cancer patients under chemotherapy Table List of primers used for the detection of ESBL and carbapenemase genes Genes Sequences (5 –3 ) Size (bp) Refs KPC ATGTCACTGTATCGCCGTCT TTACTGCCCGTTGACGCCC 882 [14] OXA-48 GGGGACGTTATGCGTGTATT GAGCACTTCTTTTGTGATGGC 900 [15] NDM-1 GGTGCATGCCCGGTGAAATC ATGCTGGCCTTGGGGAACG 660 [16] VIM GATGGTGTTTGGTCGCATA CGAATGCGCAGCACCAG 170 [17] GES CTATTACTGGCAGGGATCG CCTCTCAATGGTGTGGGT 594 [18] SME ACTTTGATGGGAGGATTGGC ACGAATTCGAGCATCACCAG 551 [19] IMP GAGTGGCTTAATTCTCRATC AACTAYCCAATAYRTAAC 120 [18] IMI NMC-A TGCGGTCGATTGGAGATAAA CGATTCTTGAAGCTTCTGCG 399 [19] TEM ATGAGTATTCAACATTTCCG CTGACAGTTACCAATGCTTA 867 [20] CTX-M ATGTGCAGYACCAGTAARGT TGGGTRAARTARGTSACCAGA 593 [20] SHV GGTTATGCGTTATATTCGCC TTAGCGTTGCCAGTGCTC 867 [20] OXA ACACAATACATATCAACTTCGC AGTGTGTTTAGAATGGTGATC 885 [20] GES CTTCATTCACGCACTATTAC TAACTTGACCGACAGAGG 827 [20] PER GGGACARTCSKATGAATGTCA GGGYSGCTTAGATAGTGCTGAT 827 [20] Materials and methods Samples and data collection 41 cancer patients were included in this study, 28 were suffering from solid tumors and 13 with malignant blood disorders These patients are treated at Nini hospital in Tripoli, North Lebanon A standard questionnaire was completed in order to obtain information including the age, gender, type of cancer, date of disease diagnosis, surgical operations in relation to cancer and microbiological history 41 stool samples were collected between February and July 2014 and transported quickly to the laboratory in a thermostatically controlled container Yeast isolation and antifungal susceptibility Isolation of yeasts was made by culture of stool on Sabouraud ® agar (Pronadisa —Spain) supplemented with chloramphenicol (0.5 g/l) followed by incubation for 24 h at 37◦ C The identifica® tion was conducted by the use of AuxacolorTM (BioRad —France) The determination of the sensitivity of different isolates to antifun® gals was made using FungitestTM (BioRad —France) according to the manufacturer’s recommended procedures Isolation of carbapenem-resistant bacteria Isolation after enrichment method An amount of stool in the volume of a pea is introduced in a volume of ml of enrichment Tryptic Soy Broth ® (Scharlau —Spain) supplemented by an antifungal Nystatin ® (2500 IU/l) (Medistan —Lebanon) and a disc of ertapenem of 10 g ® (BioRad —France) and then incubated for 24 h at 37◦ C 10 l of this ® suspension is then spread on MacConkey agar (Liofilchem —Italy) ◦ followed by incubation for 24 h at 37 C [12] Direct isolation method An amount of stool in the volume of a pea is introduced in a volume of ml of sterile distilled water 10 l of this suspension is inoculated onto MacConkey agar supplemented by ertapenem ® (Invanz —Canada) with a concentration of mg/l and with Nystatin (2500 IU/L) and then incubated for 24 h at 37◦ C Microbiologie—European Committee on Antimicrobial Susceptibility (CASFM—EUCAST) recommendations For the detection of a cephalosporinase, Müller–Hinton agar with cloxacillin (0.25 g/l) was used Discs of ertapenem, imipenem, meropenem, amoxicillin/clavulanic acid, cefoxitin, ceftazidime, cefotaxime, cefepime and aztreonam were used This test was repeated on Müller–Hinton agar without cloxacillin After incubation for 24 h at 37 ◦ C, the diameter of inhibition zones were compared between both Müller–Hinton agar, with and without cloxacillin For the detection of a carbapenemase, the Hodge test was performed [13] The same procedure was repeated for Pseudomonas strains by using imipenem (10 g) instead of ertapenem Detection of carbapenemases and ESBL genes Bacterial DNA was extracted by GenEluteTM Bacterial Genomic ® DNA Kit (Sigma–Aldrich —USA) The Protocol followed is the one proposed by the manufacturer The gene amplification was carried out by the thermal cycler (MycyclerTM Thermal cycler, Biorad—France) using the primers described in Table Results Biochemical identification and resistance pattern The identification of Enterobacteriaceae and oxidase-positive Gram-negative bacilli was carried out through the use of RapID ® ® ONE (Remel —USA) and RapID NF (Remel —USA), respectively The susceptibility to antibiotics of strains resistant to at least one carbapenem was performed by the disk diffusion according to “Comité de l’Antibiogramme de la Société Franc¸aise de 46.3% (19/41) of patients were infected with yeast Candida glabrata (C glabrata) (6/19) was the major species followed by Candida albicans (2/19), Candida inconspicua (2/19), Candida tropicalis (1/19), Candida parapsilosis (1/19) and strains were non identifiable Table expresses the various antifungal susceptibility profile The prevalence of colonization of bacteria resistant to carbapenems in cancer patients under chemotherapy in North Lebanon was Please cite this article in press as: Christophy R, et al Prevalence, antibiotic susceptibility and characterization of antibiotic resistant genes among carbapenem-resistant Gram-negative bacilli and yeast in intestinal flora of cancer patients in North Lebanon J Infect Public Health (2017), http://dx.doi.org/10.1016/j.jiph.2016.10.009 G Model JIPH-693; No of Pages ARTICLE IN PRESS S I I S I S nd, not determined S S I S S S S S S S S S I S I I I I I R I I I I S S S I I S S S I I I S S I I I I I I S I I I I S S S S S S S S S I I S S S I I I S I S I I I S nd nd nd nd nd nd C parapsilosis C tropicalis C albicans C inconspicua C inconspicua C inconspicua C glabrata C glabrata C glabrata Non-identifiable Non-identifiable Non-identifiable Non-identifiable Non-identifiable Carbapenem-resistant bacteria are associated with increased morbidity and mortality and are capable of silently colonizing the digestive tract The present study shows a high prevalence of carbapenem-resistant bacteria intestinal carriage (24.4%) in cancer patients under chemotherapy in Nini hospital, North Lebanon Recent study showed a high incidence and prevalence of carbapenem-resistant Enterobacteriaceae (CRE) intestinal carriage in a Mexican tertiary care hospital, particularly in hematologic malignancy patients [21] In addition, Tischendorf et al [22] suggested an overall 16.5% risk of infection with CRE amongst patients colonized with CRE Regarding the detection of Gram negative bacilli resistant to carbapenems, results have shown that the isolation method proposed by the Centers for Disease Control (CDC) failed to detect strains detected by the method of direct isolation on MacConkey agar supplemented by ertapenem Several authors found differences in the detection of the colonization of carbapenemases producing strains between the methods used [23–25] The major mechanism of resistance detected in our study was overexpression of ß-lactamase (cephalosporinase or ESBL) with a problem of impermeability Our recent study, also performed in Nini hospital, including 2767 Enterobacteriaceae isolates during the period 2008–2012 showed that among enterobacterial resistant species to carbapenem, 88% produced OXA-48 carbapenemase with the predominance of E coli (73%) [26] In addition, this study showed an increase in the rate of CRE colonization which was 0.4% between 2008 and 2010 and 1.6% in 2012 [26] Another study in the same hospital from 2006 to 2013 showed that 46% of P aeruginosa strains with decreased sensitivity to imipenem were harboring blaVIM-2 gene [27] On the other hand, a study conducted in the United States in 2013 on the colonization of carbapenems resistant strains of 18 patients with malignant blood diseases has shown that the majority of isolated strains were Klebsiella pneumoniae (14 strains) and E cloacae (3 strains) The mechanism of resistance was related to the production of KPC and CTX-M-15 enzymes in combination with outer-membrane porin loss [28] Furthermore, a third study performed in 2014 in Colombia on 45 cancer patients showed that KPC gene was more frequent in infections (82.3%) comparing to colonization (17.7%) [29] With regard to the screening for yeast, our study showed that C glabrata was the major species which is in agreement with a study conducted in Germany in 1999 on 116 patients with acute leukemia [30] C glabrata was reported as predominant species (51%), followed by C albicans (18%) and C krusei (4%) [30] A review of 37 reports including 1591 cases of systemic Candida infection among oncology patients showed the importance of non-albicans Candida 46% of cases were due to non-albicans Candida such as C tropicalis (25%), C glabrata (8%), C parapsilosis (7%), and C krusei (4%) [31] Moreover, several studies were conducted in Lebanon Table Susceptibility profiles of yeast Discussion Nb of strains 5-Fluorocytosine Amphotericin B Miconazole Ketoconazole Itraconazole Fluconazole 24.4% (10/41 patients) One patient was carrying resistant strains Isolated strains were Escherichia coli (5/10), Enterobacter cloacae (1/10), Enterobacter aerogenes (1/10), Edwardsiella hoshinae (1/10), Pantoea agglomerans (1/10) and Pseudomonas stutzeri (1/10) Note that only strains of carbapenem-resistant bacteria were detected by both methods used Table expresses the percentage of sensitivity to antibiotics for 10 carbapenem-resistant strains Moreover, out of 10 strains resistant to carbapenems, were positive for Hodge test (E aerogenes and E coli) of them harbored OXA-48 gene and the third one (P stutzeri) harbored VIM gene In addition to OXA-48, E coli also contain CTX-M gene The other carbapenem-resistant strains had an overproduced cephalosporinase and/or ESBL (Table 4) Strains R Christophy et al / Journal of Infection and Public Health xxx (2017) xxx–xxx Please cite this article in press as: Christophy R, et al Prevalence, antibiotic susceptibility and characterization of antibiotic resistant genes among carbapenem-resistant Gram-negative bacilli and yeast in intestinal flora of cancer patients in North Lebanon J Infect Public Health (2017), http://dx.doi.org/10.1016/j.jiph.2016.10.009 G Model ARTICLE IN PRESS JIPH-693; No of Pages R Christophy et al / Journal of Infection and Public Health xxx (2017) xxx–xxx Table Susceptibility profiles of resistant strains to carbapenems AMP AMC TIC TCC PIP PPT ATM IMI MEM ERT CEF CXM FOX CFM CTX FEP CAZ GMN TMN AKN NET PI OFX CIP SXT CS TGC FSF E coli E coli E coli E coli E coli E aerogenes E cloacae E hoshinae P agglomerans Pseudomonas stutzeri R R R R R S R S S R R R R R R R R S S S S S S S R S S – R R R R R R S S S R R R S I I I R S S S S R S S R S S – R R R R R R R S S R R R R R R I R R R S S R R R R S S – R R R R R R R S I R R R R R R R R S R S S R R R R S S – R S R R R R R S S R R R R R R R R S S S S S S S S S S – R R R R R R S I I R R S S S S S I S S S S S S S S S S – R R R I S S S S S R R I R R S S S S S S S S S S S S S – R R S S S I S S S R R I R S S S S S S S S S S S S S S – R R R R R I R S S R R R R R R S R S S S S S S S R S R – – – R R I I S R R – – – – R – – S R R S R – – S – R – R S, sensitive; I, intermediate; R, resistant; nd, not determined AMP, ampicillin (10 g); AMC, amoxicillin/clavulanic acid (20/10 g); TIC, ticarcillin (75 g); TCC, ticarcillin/clavulanic acid (75/10 g); PIP, piperacillin (30 g); PPT, piperacillin/tazobactam (30/4 g); ATM, aztreonam (30 g); IMP, imipenem (10 g); MEM, meroprnem (10 g); ERT, ertapenem (10 g); CEF, cefalotin (30 g); CXM, cefuroxim (30 g); FOX, cefoxitin (30 g); CFM, cefixim (5 g); CTX, cefotaxime (5 g); FEP, cefepime (30 g); CAZ, ceftazidime (30 g); GMN, gentamicin (10 g); TMN, tobramycin (10 g); AKN, amikacin (30 g); NET, netilmicin (10 g); PI, pipemidic acid (20 g); OFX, ofloxacin (5 g); CIP, ciprofloxacin (5 g); SXT, trimethoprim/sulfamethoxazole (1,25/23,75 g); CS, colistin (50 g); TGC, tigecyclin (15 g); FSF, fosfomycin (200 g) Table Phenotypic and genotypic test for carbapenems resistant Gram negative bacilli Strains Hodge test Cephalosporinase inhibition Carbapenemases genes ESBL genes Classe A Classe B Classe D CTX-M TEM OXA SHV GES VEB KPC IMI NMC-A SME GES IMP VIM NDM-1 OXA-48 Pseudomonas stutzeri E coli E coli E coli E coli E coli E hoshinae E aerogenes E cloacae P agglomerans + − + − − − − + − − nd + − + − + + − + + − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − + − − − − − − − − − − − − − − − − − − − − − + − − − − + − − nd + + − + − − − − − nd − − + − − − − − − nd − − − + − − − − − nd − − − − − − − − − nd − − − − − − − − − nd − − − − − − − − − nd, not determined aiming the determination of antifungal susceptibility profiles of Candida isolates Basma et al [32] showed that among 116 C albicans strains, 12% were resistant to itraconazole, 6% to ketoconazole, 7.7% to voriconazole, 1.7% to amphotericin B, and 5% to fluconazole Another investigation conducted by Bitar et al [33] has shown a significant and rapid level of increased resistance to amphotericin B (37.6%), even though its use is limited in Lebanon due to its toxicity Conclusion In conclusion, our study has allowed us to report a high prevalence of intestinal carriage of carbapenem-resistant bacteria and yeasts in cancer patients under chemotherapy Otherwise, cancer patients are at high risk for developing endogenous infections related to the compromised host defenses and the sequelae of treatment This draws attention to the urgent need to improve antibiotic use and to support implementation of antibiotic stewardship programs and infection control measures in hospitals particularly in the department of chemotherapy These results also argue the importance need to carry out screening tests for carbapenemresistant bacteria before each admission of a cancer patient Competing interests None declared Author contributions Conceived and designed the experiments: Monzer Hamze, Fouad Dabboussi and Hassan Mallat Performed the experiments and wrote the paper: Rima Christophy and Marwan Osman Please cite this article in press as: Christophy R, et al Prevalence, antibiotic susceptibility and characterization of antibiotic resistant genes among carbapenem-resistant Gram-negative bacilli and yeast in intestinal flora of cancer patients in North Lebanon J Infect Public Health (2017), http://dx.doi.org/10.1016/j.jiph.2016.10.009 G Model JIPH-693; No of Pages ARTICLE IN PRESS R Christophy et al / Journal of Infection and Public Health xxx (2017) xxx–xxx Analyzed the data: Azzam Ziedeh, Marcel Achkar and Walid Mokaddem Acknowledgements We would like to thank Taha Abdou, Husam Khaled, Mariam Yehya, Imane Darwich and Farah Charrouf for their excellent technical assistance This study was financed by Doctoral School of Science and Technology, Lebanese University, Tripoli, Lebanon References [1] Vento S, Cainelli F Infections in patients with cancer undergoing chemotherapy: aetiology, prevention, and treatment Lancet Oncol 2003;4:595–604 [2] Zinner S Antimicrobial therapy in cancer patients: studies from the EORTC International Antimicrobial Therapy Cooperative Group Eur J Cancer 1997;33(Suppl 4):44–9 [3] Mishra R, Oviedo-Orta E, Prachi P, Rappuoli R, Bagnoli F Vaccines and antibiotic resistance Curr Opin Microbiol 2012;15:596–602 [4] Samonis G, Anaissie E, Bodey G Effects of broad-spectrum antimicrobial agents on yeast colonization of the gastrointestinal tracts of mice Antimicrob Agent Chemother 1990;34:2420–2 [5] Carle S Les antifongiques dans le traitement des infections invasives Pharmactuel 2003;36:25–41 [6] Schjørring S, Krogfelt KA Assessment of bacterial antibiotic resistance transfer in the gut Int J Microbiol 2011:312956 [7] Levey G, Gould I, Endimiani A, Pilar R, Daikos G, Po-Ren H Detection, treatment and prevention of carbapenemase-producing Enterobacteriaceae: recommendations from an International Working Group J Chemother 2013;25:129–40 [8] Katherine M, Knapp MD, Keith B Carbapenems Semin Pediatr Infect Dis 2001;12:175–85 [9] Nordmann P, Dortet L, Poirel L Carbapenem resistance in Enterobacteriaceae: here is the storm! Trends Mol Med 2012;18:263–72 [10] Grall N, Andremont A, Armand-Lefèvre L Résistance aux carbapénèmes: vers une nouvelle impasse? J Anti-Infect 2011;13:87–102 [11] Gudiol C, Carratala J Antibiotic resistance in cancer patients Expert Rev Anti Infect Ther 2014;12:1003–16 [12] Laboratory Protocol for Detection of Carbapenem-Resistant or CarbapenemaseProducing, Klebsiella spp and E coli from Rectal Swabs Laboratory Testing and Practices Department of health and human services Centers for disease control and prevention (CDC); 2008 December http://www.cdc.gov/HAI/pdfs/ labSettings/Klebsiella or Ecoli.pdf [13] Girlich D, Poirel L, Nordmann P Value of the modified hodge test for detection of emerging carbapenemases in Enterobacteriaceae J Clin Microbiol 2012;50:477–9 [14] Pillai DR, Melano R, Rawte P, Lo S, Tijet N, Fuksa M Klebsiella pneumoniae carbapenemase, Canada Emerg Infect Dis 2009;15:827–9 [15] Beyrouthy R, Robin F, Cougnoux A, Dalmasso G, Darfeuille-Michaud A, Mallat H, et al Chromosome-mediated OXA-48 carbapenemase in highly virulent Escherichia coli J Antimicrob Chemother 2013;68:1558–61 [16] Bonnin RA, Naas T, Poirel L, Nordmann P Phenotypic, biochemical, and molecular techniques for detection of metallo--lactamase NDM in Acinetobacter baumannii J Clin Microbiol 2012;50:1419–21 [17] Nagaraj S, Chandran SP, Shamanna P, Macaden R Carbapenem resistance among Escherichia coli and Klebsiella pneumoniae in a tertiary care hospital in south India Indian J Med Microbiol 2012;30:93–5 [18] Monteiro J, Widen RH, Pignatari AC, Kubasek C, Silbert S Rapid detection of carbapenemase genes by multiplex real-time PCR J Antimicrob Chemother 2012;67:906–9 [19] Hong SS, Kim K, Huh JY, Jung B, Kang MS, Hong SG Multiplex PCR for rapid detection of genes encoding class A carbapenemases Ann Lab Med 2012;32:359–61 [20] Lim KT, Yasin R, Yeo CC, Puthucheary S Characterization of multidrug resistant ESBL-producing Escherichia coli isolates from hospitals in Malaysia J Biomed Biotechnol 2009:165637 [21] Torres-Gonzalez P, Cervera-Hernandez ME, Niembro-Ortega MD, Leal-Vega F, Cruz-Hervert LP, Garcia-Garcia L Factors associated to prevalence and incidence of carbapenem-resistant Enterobacteriaceae fecal carriage: a cohort study in a Mexican tertiary care hospital PLoS One 2015;10(10):e0139883 [22] Tischendorf J, de Avila RA, Safdar N Risk of infection following colonization with carbapenem-resistant Enterobactericeae: a systematic review Am J Infect Control 2016;44(5):539–43 [23] Landman D, Salvani JK, Bratu S, Quale J Evaluation of techniques for detection of carbapenem-resistant Klebsiella pneumoniae in stool surveillance cultures Clin Microbiol 2005;43:5639–41 [24] Lolans K, Calvert K, Won S, Clark J, Hayden MK Direct ertapenem disk screening method for identification of KPC-producing Klebsiella pneumoniae and Escherichia coli in surveillance swab specimens J Clin Microbiol 2010;48:836–41 [25] Perc¸in D, Colako˘glu S, Durmaz S, Ekincio˘glu P Comparison of ertapenem-EMB agar with traditional methods for screening carbapenem-resistant Klebsiella pneumoniae from rectal swabs Mikrobiyol Bul 2012;46:546–52 [26] Beyrouthy R, Robin F, Dabboussi F, Mallat H, Hamzé M, Bonnet R Carbapenemase and virulence factors of Enterobacteriaceae in North Lebanon between 2008 and 2012: evolution via endemic spread of OXA-48 J Antimicrob Chemother 2014;69:2699–705 [27] Al Bayssari C, Diene S, Loucif L, Gupta S, Dabboussi F, Mallat H Emergence of VIM-2 and IMP-15 carbapenemases and inactivation of oprD gene in carbapenem-resistant Pseudomonas aeruginosa clinical isolates from Lebanon Antimicrob Agents Chemother 2014;58:4966–70 [28] Satlin MJ, Calfee DP, Chen L, Fauntleroy KA, Wilson SJ, Jenkins SG Emergence of carbapenem-resistant Enterobacteriaceae as causes of bloodstream infections in patients with hematologic malignancies Leuk Lymphoma 2013;54:799–806 [29] Cuervo SI, Sánchez R, Gómez-Rincón JC, Almenares C, Osorio JP, Vargas MJ Behavior of carbapenemase-producing Klebsiella pneumoniae cases in cancer patients at a third level hospital in Bogotá, D.C Biomedica 2014;34(Suppl 1):170–80 [30] Glasmacher A, Hahn C, Molitor E, Sauerbruch T, Schmidt-Wolf IG, Marklein G Fungal surveillance cultures during antifungal prophylaxis with itraconazole in neutropenic patients with acute leukaemia Mycoses 1999;42:395–402 [31] Wingard J Importance of Candida species other than C albicans as pathogens in oncology patients Clin Infect Dis 1995;20:115–25 [32] Basma R, Barada G, Ojaimi N, Khalaf RA Susceptibility of Candida albicans to common and novel antifungal drugs, and relationship between the mating type locus and resistance, in Lebanese hospital isolates Mycoses 2009;52:141–8 [33] Bitar I, Khalaf RA, Harastani H, Tokajian S Identification, typing, antifungal resistance profile and biofilm formation of Candida albicans isolates from Lebanese hospital patients Biomed Res Int 2014;2014:931372 Please cite this article in press as: Christophy R, et al Prevalence, antibiotic susceptibility and characterization of antibiotic resistant genes among carbapenem-resistant Gram-negative bacilli and yeast in intestinal flora of cancer patients in North Lebanon J Infect Public Health (2017), http://dx.doi.org/10.1016/j.jiph.2016.10.009 ... antibiotic susceptibility and characterization of antibiotic resistant genes among carbapenem -resistant Gram- negative bacilli and yeast in intestinal flora of cancer patients in North Lebanon J Infect... susceptibility and characterization of antibiotic resistant genes among carbapenem -resistant Gram- negative bacilli and yeast in intestinal flora of cancer patients in North Lebanon J Infect Public... susceptibility and characterization of antibiotic resistant genes among carbapenem -resistant Gram- negative bacilli and yeast in intestinal flora of cancer patients in North Lebanon J Infect Public