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 Table of Contents  
Year : 2017  |  Volume : 1  |  Issue : 3  |  Page : 80-82

Molecular investigation of carbapenemase-producing enterobacteriaceae isolated from a Tripoli Hospital, Libya

1 Department of Microbiology and Parasitology, Faculty of Veterinary Medicine, University of Tripoli, Tripoli, Libya
2 Burns and Plastic Surgery Centre, Tripoli, Libya
3 Department of Veterinary Medicine, Danish Medicines Agency, Copenhagen, Denmark

Date of Web Publication26-Dec-2017

Correspondence Address:
Dr. Mohamed O Ahmed
Department of Microbiology and Parasitology, Faculty of Veterinary Medicine, P.O. Box 13662, University of Tripoli, Tripoli
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/LJMS.LJMS_24_17

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Background: Carbapenemase producing bacteria are a serious public health concern and further pressure on the last-resort antimicrobials. Objectives: The aim of the study was to investigate the molecular characteristics of 48 multi-resistant Enterobacteriaceae isolates recovered from clinical samples. Materials and Methods: Isolates were investigated by antimicrobial susceptibility testing and polymerase chain reaction protocols for blaOXA-48and metallo-beta-lactamase genes. Results: Klebsiella pneumoniae and Escherichia coli isolates demonstrated high frequencies of multidrug resistance and various phenotypes. Eleven K. pneumoniae carried extended-spectrum β-lactamases genes of which four strains possessed both OXA-48 and New Delhi metallo genes. Conclusion: Carbapenemase-producing bacteria in the Libyan health system warrants further attention and are possibly underestimated. Urgent control and prevention actions are required.

Keywords: Carbapenemase producers, Enterobacteriaceae, Libya, metallo-beta-lactamase genes, OXA-48 gene

How to cite this article:
Ahmed MO, Aghila E, Elamri S, Baptiste KE. Molecular investigation of carbapenemase-producing enterobacteriaceae isolated from a Tripoli Hospital, Libya. Libyan J Med Sci 2017;1:80-2

How to cite this URL:
Ahmed MO, Aghila E, Elamri S, Baptiste KE. Molecular investigation of carbapenemase-producing enterobacteriaceae isolated from a Tripoli Hospital, Libya. Libyan J Med Sci [serial online] 2017 [cited 2023 Mar 28];1:80-2. Available from: https://www.ljmsonline.com/text.asp?2017/1/3/80/221496

  Introduction Top

The emergence of antimicrobial resistance (AMR) has greatly diminished therapeutic drug options and progresses at an alarming rate across the globe. In developing and low-income regions, the AMR threat is further complicated by the underdeveloped infrastructure and economic conditions, which are known to be associated with community-acquired infections and infectious agents.[1] Drug-resistant bacteria have been frequently reported across Africa, from both clinical and nonclinical sources, yet only limited data have been reported, particularly from the underdeveloped regions.[1],[2]

The carbapenemase-producing bacteria have emerged as a serious medical and public health concern, challenging the last-resort antibiotics.[3] Over the last decade, alarming AMR from Libya has been reported, with most originating from healthcare institutions (e.g., Extended-spectrum β-lactamases [ESBLs]).[4],[5] The carbapenemase-producing Gram-negative bacteria have also been documented from Libya, largely by single brief reports involving patients with a history of travel;[6],[7],[8],[9],[10],[11] yet, epidemiological surveillance and molecular investigations of Libyan AMR pathogens are unclear and still very limited. The current investigation involved a collection of 48 multidrug-resistant Enterobacteriaceae isolates that had been collected at a large national hospital in Tripoli during 2014–2015. The burns and plastic surgery centre is one of the largest Libyan hospitals, providing specialized health-care services to the capital as well the north-west region of Libya.

  Materials and Methods Top

The collection included isolates of Klebsiella pneumoniae (n = 28) and  Escherichia More Details coli (n = 20). All isolates were originally isolated from various clinical specimens, identified by routine laboratory protocols and antimicrobial susceptibility tested using the Phoenix™ Automated Microbiology System. The collection was characterized by high multidrug resistance phenotypes (based on the criteria of the expressed resistance to at least three different antimicrobial classes) [Table 1]. The 48 K. pneumoniae and E. coli isolates were screened for OXA-48 producers using temocillin susceptibility test following the recommended criteria by EUCAST (2017).[12] Isolates that showed high-level temocillin resistance (i.e., zone diameter <11 mm with a temocillin 30 μg disk) were further screened by polymerase chain reaction (PCR) for the blaOXA-48 gene following the described protocol as recommended by Poirel et al.[13] and the New Delhi metallo-beta-lactamase (NDM-MBL) “blaNDM” genes following the described protocols as recommended by Ellington et al. and Hansen et al.[14],[15] In addition, temocillin-sensitive isolates but nonsusceptible to any of the carbapenems (i.e., imipenem, meropenem, and ertapenem) were included in the PCR screening. The Carba NP test was performed on selected isolates as recommended by Dortet et al.[16]
Table 1: Proportion of antimicrobial resistance

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  Results and Discussion Top

Fourteen of the isolates showed resistance to temocillin, representing 13 K. pneumoniae and one E. coli. Of these, ten K. pneumoniae were positive for carbapenemase genes; six were positive for blaOXA-48 and four for both blaOXA-48 and blaNDM. Subsequently, the four OXA-48/MBL negative isolates tested negative for carbapenemases using the Carba NP test. These four carbapenem nonsusceptible/temocillin susceptible isolates were further screened by PCR, and one K. pneumoniae was positive for blaNDM.

In general, the prevalence of carbapenemase-producing bacteria is still largely unknown and may substantially differ between countries. In North Africa, carbapenemase-producing bacteria are a growing problem, with reported prevalence in health-care settings ranging from 2.3%–67.7%.[2] ESBL-producing Gram-negative clinical strains have been detected in Libyan hospitals, the first report appearing in the 1980s; the reported ranges of ESBL producers among the clinical Enterobacteriaceae are 8.6%–47% in Tripoli and 1.9%–2.4% in Benghazi.[4] A recent study involving a single Libyan hospital identified ESBLs in 8% of the studied clinical Gram-negative strains and characterized ESBL genes in 3% of the tested strains, which were mostly of the blaOXA type.[17]

Carbapenem-resistant genes have previously been documented in bacterial isolates mainly from Libyan travelers. For instance, K. pneumoniae strains carrying blaOXA-48 and/ or blaNDM-1 genes and Acinetobacter baumannii strains carrying either blaOXA or blaNDM-1 carbapenemase genes were largely documented with high co-colonization rates and in patients with previous hospitalization history in Libyan health-care settings before travelling.[6],[7] Recent reports have also documented other carbapenemase-encoding genes, such as blaVIM and blaOXA-48, and cooccurrences of carbapenemase genes among clinical Gram-negative rods.[8],[9],[10] The cooccurrence of these carbapenem-resistant genes in K. pneumoniae are infrequent although the number of cases reported worldwide seems to be increasing.[18],[19]

Carbapenemase-producing Enterobacteriaceae have been rapidly spreading worldwide and frequently associated with nonclonal and unrelated strains.[2] The OXA-48-carbapenemase producers are widely reported from the Mediterranean and North African countries and rapidly emerging as both nosocomial and community-acquired pathogens.[2],[3] This particular type is mainly plasmid encoded and with weak hydrolysis of carbapenems and broad-spectrum cephalosporins, such as cefotaxime.[20] The OXA-48 carbapenemase producers have been mostly identified in K. pneumoniae and E. coli clones and are difficult to identify in the laboratory; as such, the true prevalence is likely underestimated. In addition, NDM-producing Enterobacteriaceae are also widely described among K. pneumoniae and E. coli clones with variable degrees of resistance to the carbapenems.[3] The blaNDM-1 gene is typically associated with plasmids that can also carry various resistance determinant genes, like other carbapenemase genes (e.g., blaOXA-48 and blaVIM genes) as well as other resistance genes (e.g., aminoglycoside, macrolide, rifampin, and sulfamethoxazole). However, such resistant strains remain largely susceptible to agents such as tigecycline and colistin, nervelessness resistant strain to these “last resort agents” begun to emerge.[21]

  Conclusion Top

This study demonstrates carbapenemase-producing bacteria in higher numbers in the Libyan health-care system and possibly underestimated and neglected. The current study was limited by little epidemiological information and financial resources. Effective control and prevention actions are urgently needed to control and minimize spread and extended epidemiological investigation are required.


The work was done at burns and plastic surgery centre, faculty of veterinary medicine Tripoli, Libya, and Statens Serum Institut, Copenhagen, Denmark.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

World Health Organization (WHO). Antibiotic-resistant priority pathogens list. 2017. Available form: http://www.who.int/mediacentre/news/releases/2017/Antimicrobial_resistance_VPC_27FEB2017.pdf?ua=1.  Back to cited text no. 1
Manenzhe RI, Zar HJ, Nicol MP, Kaba M. The spread of carbapenemase-producing bacteria in Africa: A systematic review. J Antimicrob Chemother 2015;70:23-40.  Back to cited text no. 2
Nordmann P, Naas T, Poirel L. Global spread of carbapenemase-producing enterobacteriaceae. Emerg Infect Dis 2011;17:1791-8.  Back to cited text no. 3
Ghenghesh KS, Rahouma A, Tawil K, Zorgani A, Franka E. Antimicrobial resistance in Libya: 1970-2011. Libyan J Med 2013;8:1-8.  Back to cited text no. 4
Zorgani A, Almagatef A, Sufya N, Bashein A, Tubbal A. Detection of CTX-M-15 among uropathogenic Escherichia coli isolated from five major hospitals in Tripoli, Libya. Oman Med J 2017;32:322-7.  Back to cited text no. 5
Pirš M, Andlovic A, Cerar T, Žohar-Čretnik T, Kobola L, Kolman J, et al. Acase of OXA-48 carbapenemase-producing Klebsiella pneumoniae in a patient transferred to Slovenia from Libya, november 2011. Euro Surveill 2011;16:20042.  Back to cited text no. 6
Ben Nasr A, Decré D, Compain F, Genel N, Barguellil F, Arlet G, et al. Emergence of NDM-1 in association with OXA-48 in Klebsiella pneumoniae from Tunisia. Antimicrob Agents Chemother 2013;57:4089-90.  Back to cited text no. 7
Hammerum AM, Littauer P, Hansen F. Detection of Klebsiella pneumoniae co-producing NDM-7 and OXA-181, Escherichia coli producing NDM-5 and Acinetobacter baumannii producing OXA-23 in a single patient. Int J Antimicrob Agents 2015;46:597-8.  Back to cited text no. 8
Mathlouthi N, Areig Z, Al Bayssari C, Bakour S, Ali El Salabi A, Ben Gwierif S, et al. Emergence of carbapenem-resistant Pseudomonas aeruginosa and Acinetobacter baumannii clinical isolates collected from some Libyan hospitals. Microb Drug Resist 2015;21:335-41.  Back to cited text no. 9
Kraiem AG, Zorgani A, Elahmer O, Hammami A, Chaaben BM, Ghenghesh KS, et al. New Delhi metallo-β-lactamase and OXA-48 carbapenemases in Gram-negative bacilli isolates in Libya. Libyan J Med 2015;10:29206.  Back to cited text no. 10
Ouertani R, Limelette A, Guillard T, Brasme L, Jridi Y, Barguellil F, et al. First report of nosocomial infection caused by Klebsiella pneumoniae ST147 producing OXA-48 and VEB-8 β-lactamases in Tunisia. J Glob Antimicrob Resist 2016;4:53-6.  Back to cited text no. 11
European Committee on Antimicrobial Susceptibility Testing. EUCAST guideline for the detection of resistance mechanisms and specific resistances of clinical and/or epidemiological importance, Version 2.0; 2017. Available from: http://www.eucast.org/fileadmin/src/media/PDFs/EUCAST_files/Resistance_mechanisms/EUCAST_detection_of_resistance_mechanisms_170711.pdf.  Back to cited text no. 12
Poirel L, Héritier C, Tolün V, Nordmann P. Emergence of oxacillinase-mediated resistance to imipenem in Klebsiella pneumoniae. Antimicrob Agents Chemother 2004;48:15-22.  Back to cited text no. 13
Ellington MJ, Kistler J, Livermore DM, Woodford N. Multiplex PCR for rapid detection of genes encoding acquired metallo-beta-lactamases. J Antimicrob Chemother 2007;59:321-2.  Back to cited text no. 14
Hansen F, Johansen HK, Østergaard C, Arpi M, Hansen DS, Littauer P, et al. Characterization of carbapenem nonsusceptible pseudomonas aeruginosa in denmark: A nationwide, prospective study. Microb Drug Resist 2014;20:22-9.  Back to cited text no. 15
Dortet L, Poirel L, Nordmann P. Further proofs of concept for the Carba NP test. Antimicrob Agents Chemother 2014;58:1269.  Back to cited text no. 16
Abujnah AA, Zorgani A, Sabri MA, El-Mohammady H, Khalek RA, Ghenghesh KS, et al. Multidrug resistance and extended-spectrum β-lactamases genes among Escherichia co li from patients with urinary tract infections in Northwestern Libya. Libyan J Med 2015;10:26412.  Back to cited text no. 17
Kilic A, Baysallar M. The first Klebsiella pneumoniae isolate co-producing OXA-48 and NDM-1 in turkey. Ann Lab Med 2015;35:382-3.  Back to cited text no. 18
Doi Y, Hazen TH, Boitano M, Tsai YC, Clark TA, Korlach J, et al. Whole-genome assembly of Klebsiella pneumoniae coproducing NDM-1 and OXA-232 carbapenemases using single-molecule, real-time sequencing. Antimicrob Agents Chemother 2014;58:5947-53.  Back to cited text no. 19
Poirel L, Potron A, Nordmann P. OXA-48-like carbapenemases: The phantom menace. J Antimicrob Chemother 2012;67:1597-606.  Back to cited text no. 20
Delgado-Blas JF, Ovejero CM, Abadia-Patiño L, Gonzalez-Zorn B. Coexistence of mcr-1 and blaNDM-1 in Escherichia coli from Venezuela. Antimicrob Agents Chemother 2016;60:6356-8.  Back to cited text no. 21


  [Table 1]

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