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PubMed1991

Carbapenem resistance in Enterobacter aerogenes is due to lipopolysaccharide alterations.

The extensive characterization of 2 clinical Enterobacter aerogenes isolates resistant to all beta-lactam antibiotics including imipenem revealed that imipenem resistance could not be attributed to overproduction of the chromosomal beta-lactamase; moreover, it was lost after subcultivation and can be thus considered as unstable. The comparison of sensitive and resistant clones revealed that the beta-lactamase in the resistant clones was less inducible in the resistant clones and moreover, there was an altered 2-keto-3-deoxyoctonate/carbohydrate ratio in the resistant clones as compared to the imipenem-sensitive clones, thus suggesting alterations in the lipopolysaccharide (LPS). Neither enzymatic degradation of both imipenem and meropenem nor alterations of the outer membrane proteins could be observed. These findings make it apparent that this type of resistance is likely due to an impaired uptake of the agents due to LPS alterations.

Bacterial Outer Membrane Proteins↗

PubMedDate not supplied

Susceptibility of Moraxella catarrhalis to 21 antimicrobial drugs: validity of current NCCLS criteria for the interpretation of agar disk diffusion antibiograms.

Ninety-four clinical isolates of Moraxella catarrhalis were examined for susceptibility to 21 antimicrobial drugs; 67 isolates (= 71.3%) produced beta-lactamase(s). In terms of antibiotic resistance, the number of isolates resistant to penicillin G, ampicillin, and cotrimoxazole were 56, 32, and 1, respectively. The number of isolates with intermediate susceptibility to penicillin G, ampicillin, ciprofloxacin, ofloxacin, cotrimoxazole, and fosfomycin were 11, 34, 1, 2, 2, and 47, respectively. All 94 isolates proved susceptible to ampicillin + 10 micrograms/ml of sulbactam, amoxicillin + 4 micrograms/ml of clavulanic acid, cefuroxime, cefotaxime, cefepime, cefepime, cefixime, imipenem, meropenem, chloramphenicol, doxycycline, tetracycline, fusidic acid, erythromycin, clarithromycin, and rifampin, as based on currently valid NCCLS criteria, where applicable. There were no very major or major discrepancies between agar dilution and agar disk diffusion test results. There were only a few minor discrepancies between test results, specifically: penicillin G (category IV = 4, category VI = 1); ampicillin (category IV = 4, category V = 1, category VI = 7), amoxicillin + clavulanic acid (category III = 11), cotrimoxazole (category IV = 1, category V = 1, category VI = 1), ciprofloxacin (category V = 1), and ofloxacin (category VI = 2). The sole exception was fosfomycin, with a total of 25 minor discrepancies encountered (category III = 14, category V = 9, category VI = 2). Wilkins-Chalgren agar compared favorably with Mueller-Hinton agar following examination with 11 selected antimicrobial drugs against 31 representative isolates of M. catarrhalis.

Anti-Bacterial Agents↗

PubMedDate not supplied

Antibiotic susceptibility and serotype distribution of 240 Streptococcus pneumoniae causing meningitis in Belgium 1997-2000.

Cerebrospinal fluid isolates of Streptococcus pneumoniae, collected during the years 1997-2000 at more than 100 Belgian laboratories were studied. The 10 most common serotypes-serogroups representing 76% of the isolates were 14, 6, 9, 19, 23, 18, 4, 10, 8 and 12 (in order of frequency). Thirty-six percent of strains were isolated in children < 5 years old. In this age group the number of serogroups was more limited and 81.4% are included in the 7-valent conjugate vaccine. Decreased susceptibility to penicillin was observed in 13.9% of 237 strains (MIC > 0.06 mg/L), with only 2.1% resistant strains (MIC > 1 mg/L). Twelve strains showed reduced susceptibility to cefotaxime (MIC > 0.5 mg/L). Only three of the 237 strains were intermediately susceptible to meropenem. All strains were susceptible to vancomycin and moxifloxacin. In Belgium, high doses of third generation cephalosporins remain effective for the treatment of pneumococcal meningitis. The new fluoroquinolones seem the most promising agents for the treatment of pneumococcal meningitis in the future.

Adolescent↗

PubMedDate not supplied

Susceptibility testing of Pseudomonas aeruginosa by the Vitek 2 system: a comparison with Etest results.

P. aeruginona infections need accurate antimicrobial susceptibility data, as treatment mainly relies on antibiotic efficiency in debilitated patients. Vitek 2, a popular automated susceptibility testing method, was compared with Etest to assess its reliability on 150 Belgian P. aeruginonas isolates. Vitek 2 and Etest exhibited a high degree of concordance, but some discrepancies in clinical category were evident for cefepime (high minor and borderline very major error rate) and for piperacillin/tazobactam (high very major error rate). Vitek 2 appears to yield valuable information to the clinician concerning the antimicrobials amikacin, ceftazidime, ciprofloxacin and meropenem, in the setting of pseudomonas infection. For cefepime and piperacillin/tazobactam, a confirmatory testing by means of disk diffusion is worth considering.

Bacteriological Techniques↗

PubMed1996

Transferable resistance to specific antibiotics in nosocomial strains of Pseudomonas aeruginosa from two teaching hospitals.

We describe the transfer of resistance to kanamycin, carbenicillin and cephaloridine to a recipient strain of Escherichia coli K-12 No. 3110 from three strains of Pseudomonas aeruginosa out of 146 strains tested in 1995. The P.aeruginosa No. 201, 203, 208 donor strains were isolated from patients in the University Clinics in Frankfurt, Germany. They were resistant to most beta-lactam antibiotics including cephalosporins of the 1st, 2nd and 3rd generation, imipenem, meropenem and aztreonam. They transferred kanamycin, carbenicillin and cephaloridine resistance determinants to recipient strain E.coli K-12 3110. These determinants were accompanied in strain P. aeruginosa No. 203, with a transfer of ceftazidime resistance determinants and in P.aeruginosa No. 208 with transfer of cefotaxime, ceftazidime and aztreonam resistance determinants. Transfer of antibiotic resistance was also studied in 13 nosocomial strains of P.aeruginosa collected for their ceftazidime and/or imipenem resistance in a large Teaching Hospital in Ostrava, Czech Republic. Six of these strains transferred carbenicillin and/or cephaloridine resistance to the E.coli K-12 3110 recipient strain. Resistance to kanamycin and cefotaxime was also co-transferred with carbenicillin and cephaloridine determinants. Ceftazidime, imipenem or ofloxacin resistance was not transferred and is thus, most probably, of chromosomal origin.

Carbenicillin↗

PubMed1998

Two nosocomial strains of Stenotrophomonas maltophilia transferring antibiotic resistance to Proteus mirabilis P-38 recipient strain.

In this report we describe a specific transfer of carbenicillin and cephaloridine resistance determinants from two different strains of Stenotrophomonas maltophilia: No. 215 and 221 isolated from two critically ill patients treated in different Intensive Care Units of a large University Hospital in Ostrava, Czech Republic. These strains were resistant to flouroquinolones and the following beta-lactam drugs: carbenicillin, cephaloridine, cefotaxime, ceftazidime, cefepime, imipenem, meropenem and aztreonam. Both strains transferred carbenicillin and cephaloridine resistance determinants, with rather different frequency, to Proteus mirabilis P-38. All carbenicillin-selected transconjugants were found by an indirect selection method to be co-resistant to cephaloridine only. In a second cycle of transfers Proteus mirabilis R+ strains directly transferred carbenicillin and cephalothin determinants to Escherichia coli K-12 No. 185 nal+ lac+ recipient strain.

Anti-Bacterial Agents↗

PubMed1999

The increase in carbapenem use and emergence of Stenotrophomonas maltophilia as an important nosocomial pathogen.

Carbapenems, being the broadest spectrum antibiotics, may allow those organisms intrinsically resistant to these drugs to be involved more frequently in nosocomial infections. Imipenem was introduced to the specialized hospital units in Kuwait in October, 1992 and meropenem in late 1996. The main objective of this study was to observe prospectively whether, under similar laboratory conditions for microbial isolation/identification while these drugs are in use in the hospital, there is any proportional increase over time in the recovery of Stenotrophomonas maltophilia in relation to the number of yearly admissions and drug use. In addition, we also looked for categories of patients infected by S. maltophilia, type of infection and antibiotic susceptibility. There was an increase in the number of S. maltophilia isolates from 1993 to 1997 significantly correlated with the increase in year-wise consumption of carbapenems (p<0.004). No correlation was observed between yearly number of admissions and both the consumption of carbapenems (p>0.51) and isolation of the organism (p>0.59). Most isolates were from cancer, burns and cardiac patients. The commonest types of infection were wound and septicemia. The organisms were susceptible mostly to ciprofloxacin and co-trimoxazole. The study thus indicates that carbapenem use in a hospital environment may result in emergence of nosocomial infections due to multiresistant S. maltophilia in high risk patients with very limited choice of antibiotics for therapy.

Bacteremia↗

PubMed1999

Extended-spectrum beta-lactamase producing strains of Enterobacter cloacae transferring resistance to cefotaxime and ceftazidime.

Transferability of ceftazidime resistance and of extended-spectrum beta-lactamase (ESBL) production was recorded in three strains of Enterobacter cloacae from Frankfurt University Clinics. All three strains were resistant to rifampicin, carbenicillin, cephaloridine, cefotaxime, ceftazidime, aztreonam, imipenem and meropenem. They transferred directly determinants of resistance to carbenicillin and cephaloridine to Escherichia coli K-12 No. 185 nal+ recipient strain. All transconjugant colonies also contained determinants of resistance to cefotaxime, ceftazidime and aztreonam. In the second cycle of transfers, determinants of resistance to carbenicillin, cephaloridine, cefotaxime, ceftazidime and aztreonam were transferred en bloc to the recipient Escherichia coli K-12 No. 3110 rif+ indicating that the "transfer factor" (tra+) mediating the process of conjugational transfer had also been co-transferred. Double-disk diffusion test showed the same pattern of production of ESBLs both in original strains and in transconjugants. Transfer of cefotaxime, ceftazidime and aztreonam was accompanied by the transfer of ESBL production.

Cefotaxime↗

PubMed1999

Antimicrobial chemotherapy in the control of surgical infectious complications.

In spite of the progress in surgical technique and antibiotic prophylaxis, postoperative infection still accounts for both the commonest surgical complication and one of the most frequent nosocomial infections, also causing an increase in duration and costs of hospital stay. The choice of treatment for post-surgical infections requires an understanding of the usual infecting flora, available antimicrobial agents, and susceptibility patterns. The most common organisms in simple wound infection are gram-positive cocci and mainly Staphylococcus aureus. Staphylococcus epidermidis and S. aureus (quite often methicillin-resistant strains) are the organisms which predominate in the infectious complications following clean surgical procedures with implantation of vascular grafts or prosthetic devices. Mixed aerobic and anaerobic flora are mainly responsible for cases of intra-abdominal and intra-pelvic postoperative infections: the most common aerobes are Enterobacteriaceae (Escherichia coli, Proteus spp., and others) and enterococci, and among anaerobes Bacteroides fragilis group prevails. Adequate drainage and surgical control of the source of infection, when needed, and adjunctive effective antimicrobial therapy are important factors in successful treatment of postoperative infections. Semisynthetic penicillinase-resistant penicillins and glycopeptides (vancomycin and teicoplanin) are the drugs of choice for the treatment of infections caused by penicillin-resistant methicillin-sensitive, and methicillin-resistant, respectively, S. aureus and S. epidermidis. For the treatment of intra-abdominal and intra-pelvic infections, animal and human studies support the recommendation that treatment should be directed against both gram-negative enteric and anaerobic bacteria. Combinations of aminoglycosides with clindamycin or metronidazole have been widely used with great success; however adverse reactions such as nephrotoxicity and ototoxicity have been a problem in some patients. In recent years monotherapy with either a carbapenem (imipenem/cilastatin or meropenem) or a penicillin/beta-lactamase inhibitor combination has been proposed. Among these combination antimicrobials, piperacillin combined with tazobactam is a very well designed formulation. Indeed, piperacillin is active against a broad range of gram-negative and gram-positive pathogens, and tazobactam is a potent beta-lactamase inhibitor which acts on a variety of clinically important plasmid and chromosomal beta-lactamases. This combination seems particularly attractive for the treatment of mixed polymicrobial anaerobic-aerobic infections such as intra-abdominal and intra-pelvic postoperative infections.

Anti-Bacterial Agents↗

PubMed2000

Influence of five antianaerobic antibiotics on endotoxin liberation by gram-negative anaerobes.

Endotoxin, a lipopolysaccharide (LPS), has for many years been recognized as a key effector molecule in the pathogenesis of gram-negative sepsis and septic shock. Seven strains of the Bacteroides fragilis group were studied for their ability to liberate endotoxin upon exposure to five anti-anaerobic antibiotics, trovafloxacin, cefoxitin, imipenem, meropenem and piperacillin/tazobactam, in an in-vitro experiment. The minimum inhibitory concentrations (MICs) of the antibiotics were determined by using the broth macrodilution technique. Thereafter, endotoxin liberation was detected in the filtered broth cultures of the anaerobic bacteria by the limulus amebocyte lysate (LAL) assay after exposing the organisms to four different concentrations of the antibiotics in supplemented Brucella broth. Aliquots of the broth cultures were also taken at intervals of 0, 6, 24 and 48 h for viable counts. All seven gram-negative anaerobic bacteria investigated liberated induced cell-free endotoxin in filtered broth culture many times higher than the control. There was noticeable variation in the propensity of some antibiotics to induce endotoxin liberation. At four times the MICs, cefoxitin and piperacillin/tazobactam induced negligible quantities of endotoxin after 48 h exposure, whereas the others induced high levels of endotoxin release. After exposure to all concentrations for 48 h, endotoxin activity in the test system was many times higher with the Bacteroides fragilis sensu stricto than with the rest of the species in the Bacteroides group. To varying degrees, all five antibiotics had the capacity to induce endotoxin liberation by gram-negative anaerobic bacteria. This differential endotoxin release by the B. fragilis group may, in part, explain why B. fragilis sensu stricto, more than the other Bacteroides spp., is usually associated with clinical infections and higher morbidity.

Anti-Bacterial Agents↗

PubMed2000

Low-Frequency transduction of imipenem resistance and high-frequency transduction of ceftazidime and aztreonam resistance by the bacteriophage AP-151 isolated from a Pseudomonas aeruginosa strain.

Bacteriophage AP-151, isolated from a multidrug resistant Pseudomonas aeruginosa strain, was found to transduce antibiotic resistance determinants to recipient strains of P. aeruginosa. Resistance to cefotaxime, ceftazidime, aztreonam, imipenem and meropenem was transduced as a block, at different frequencies, to two P. aeruginosa strains. Resistance was two logarithms higher (in the range 10(-5)) for cefotaxime, ceftazidime or aztreonam than for imipenem in recipient strain PAO-1670. The frequency of transduced imipenem resistance was also lower in recipient strain ML-1008. This phenomenon reflects the difference in the lytic activity of AP-151 in both strains, as the titer of the AP-151 phage in the PAO strain was found to be restricted to 10(-4)-10(-5) in contrast to the titer of the same phage in the ML strain which was 10(-10). The limited lytic activity in the PAO recipient strain was correlated with higher transducing activity. It can be concluded that some wild-type bacteriophages of P. aeruginosa might have highly individual relations between lytic and transducing activity in various potential recipient nosocomial strains of P. aeruginosa. The nature of resistance to ceftazidime and imipenem was studied using clavulanate and EDTA as inhibitors of individual class of beta-lactamases, indicating the presence of extended-spectrum beta-lactamase and a metallo-beta-lactamase in this isolate.

Anti-Bacterial Agents↗

PubMed2003

In vitro interaction of colistin and rifampin on multidrug-resistant Pseudomonas aeruginosa.

The administration of colistin is considered as the last alternative for infections by multidrug-resistant isolates of Pseudomonas aeruginosa; however its use is limited due to its considerable toxicity and poor pharmacokinetics. In order to define the in vitro activity of colistin combined with rifampin, 28 isolates resistant to piperacillin, ceftazidime, imipenem, meropenem, ciprofloxacin, amikacin, rifampin and colistin were tested. Seventeen of them that were found by PFGE to be genetically distinct were over time exposed to 2 microg/ml of colistin, to 2 microg/ml of rifampin and to their combination. Applied concentrations were selected to correspond to the mean serum level of the tested antimicrobials. Synergy between colistin and rifampin was found in four (23.5%), six (35.3%), seven (41.7%) and two (11.8%) isolates after 2, 4, 6 and 24 hours of growth, respectively. Bacterial re-growth was detected after 24 hours of exposure to the tested interaction. It is concluded that colistin and rifampin express a considerable in vitro synergistic effect on multidrug-resistant P. aeruginosa. The reported interaction should be tested in animal studies before introduction in clinical practice.

Colistin↗

PubMed2004

Susceptibility patterns in Pseudomonas aeruginosa causing nosocomial infections.

Nosocomial infection caused by Pseudomonas aeruginosa has not been reported previously in the Gaza Strip. This study aims to determine the distribution of antimicrobial drug resistance in P. aeruginosa causing nosocomial infections. One hundred thirty-one P. aeruginosa isolates were collected from various nosocomial infection clinical samples. The study was conducted between April and October 2003. The results of this study reveal that the most common resistance was to ampicillin, followed by cephalexin. The most effective antimicrobial agents were meropenem and amikacin, respectively. The highest resistance to ciprofloxacin was found among ICU and surgery sections. The data analysis shows that no remarkable difference was reported with respect to previous admission and prior antimicrobial treatment for most antibiotics. The results of this study emphasize the need for constant monitoring of antimicrobial effectiveness to correctly guide empiric therapy and local intervention programs in an attempt to reduce antimicrobial resistance.

Anti-Bacterial Agents↗

PubMed2004

Monitoring of antibiotic resistance in bacterial isolates from bacteremic patients.

The aim of the study was to monitor the prevalence of pathogens and development of resistance in bacteria isolated from bacteremic patients. Five University Clinics and/or Regional Hospitals in the Slovak Republic participated in the study and a total of 421 isolates were collected in the second half of the year 2002. The most prevalent organisms were coagulase-negative staphylococci (CONS) (19%), Staphylococcus aureus (18.3%), among Gram-negative bacteria Escherichia coli (13.3%), Klebsiella pneumoniae (11.4%) and Pseudomonas aeruginosa (7.8%) followed by enterococci, Acinetobacter baumannii and Enterobacter sp. All CONS and S. aureus were susceptible to vancomycin; resistance to oxacillin was observed for 55% of the CONS and only for 4% of S. aureus isolates. A higher prevalence of resistance to erythromycin, clindamycin, gentamicin and ofloxacin was found in CONS in comparison to S. aureus. Enterococcus sp. isolates were fully susceptible to vancomycin and teicoplanin. Gentamicin, amoxicillin/clavulanate, third generation cephalosporins and ciprofloxacin showed good activity against E. coli. Although 17% of K. pneumoniae isolates were resistant to ciprofloxacin, it was the most effective drug against K. pneumoniae; the prevalence of resistance to other antibiotics was rather higher. Gentamicin and ciprofloxacin were the most active against Enterobacter sp. isolates and ceftazidime and meropenem against P. aeruginosa.

Anti-Bacterial Agents↗

PubMed2005

Bacteremia due to Pseudomonas aeruginosa: results from a 3-year national study in the Slovak Republic.

Risk factors, mortality and antimicrobial susceptibility of Pseudomonas aeruginosa bacteremias isolated from 148 patients from all University Hospitals in Slovakia were analyzed. Only 1.2% of 169 strains of P. aeruginosa were resistant to meropenem, 4.1% to piperacillin/tazobactam, 7.7% to ceftazidime as well as cefepime and 12% to amikacin. More than 30% of P. aeruginosa were resistant to ciprofloxacin. Our analysis of risk factors for antimicrobial resistance to the particular antimicrobials, indicated no difference in risk factors and outcome in cases infected with P. aeruginosa bacteremias resistant to amikacin, piperacillin/tazobactam or ceftazidime in comparison to episodes caused by P. aeruginosa due to susceptible isolates. When comparing risk factors for P. aeruginosa bacteremia in children vs. adults, cancer vs. non-cancer patients, several differences in risk factors were observed. Neither antimicrobial resistance to amikacin, ceftazidime or piperacillin/tazobactam, nor appropriateness of therapy according to two separate analyses were associated with better outcome.

Adult↗

PubMed2005

In vitro activity of beta-lactam antimicrobial agents in combination with aztreonam tested against metallo-beta-lactamase-producing Pseudomonas aeruginosa and Acinetobacter baumannii.

We evaluate the antimicrobial interactions between aztreonam and selected beta-lactams when tested against metallo-beta-lactamase (MbetaL)-producing clinical strains. Ten Pseudomonsa aeruginosa strains, including nine MbetaL-producers (IMP-1, -2, -13, -16, VIM-1, -2, -7, SPM-1 and GIM-1) and five Acinetobacter baumannii strains, including three MbetaL-producers (IMP-1 and -2) were tested using time kill/bactericidal activity methods. Aztreonam at 4, 8 and 16 mg/L was combined with four other beta-lactam antimicrobials (cefepime, ceftazidime, meropenem and piperacillin/tazobactam or ampicillin/sulbactam), each tested at the recognized susceptible breakpoint concentration. Enhanced activity (synergism or additive effect) was observed with four P. aeruginosa strains (IMP-16, VIM-2, SPM-1 and GIM-1 containing strains) and four A. baumannii strains, while antagonism was observed with two P. aeruginosa (IMP-16 and SPM-1-producing strains) and one A. baumannii (non-MbetaL) strain. All other strains showed indifferent interaction (variation of +/- 1 log10 CFU/ml) with any combination evaluated.

Acinetobacter baumannii↗

PubMed2006

Appropriateness of empiric gentamicin and vancomycin therapy for bacteremias in chronic dialysis outpatient units in the era of antibiotic resistance.

Bacteremias in inpatient chronic HD units have been described, but there is little information on bacteremias in ambulatory HD units. To determine the frequency of bacteremia and pathogen distribution in ambulatory chronic HD units, we retrospectively reviewed our experience with 107 bacteremias in 5 chronic ambulatory HD units over a 3 year period. The object of the study was twofold. The first objective was to determine if bacteremias in ambulatory HD setting were substantially different in frequency or type than in the inpatient HD setting. Secondly, febrile patients suspected of having bacteremia in chronic HD patients are often empirically treated with vancomycin and gentamicin. Chronic HD patients require repeated and frequent venous access for HD. Bacteremias are common in chronic HD patients and may be primary or secondary and are often related to venous access site infections. The distributions of bacteremia pathogens in chronic HD patients are predominantly reflective of skin flora, i.e., staphylococci and to lesser extent aerobic Gram-negative bacilli. After S. aureus (MSRA/MSSA) and coagulase-negative staphylococcus (CoNS), enterococci are the next most important Gram-positive pathogens in bacteremic HD patients. Most strains of E. faecalis are sensitive to vancomycin and for practical purposes should be considered as vancomycin sensitive enterococci (VSE). In contrast, most strains of E. faecium are resistant to vancomycin and should be considered as vancomycin resistant enterococci (VRE). We retrospectively reviewed 107 patients on chronic ambulatory HD to determine the adequacy of empiric vancomycin and gentamicin prophylaxis. We found amikacin is preferred to gentamicin and that meropenem is an effective alternate substitution for gentamicin and vancomycin combination therapy.

Antibiotic Prophylaxis↗

PubMed2003

Melioidosis: an important cause of pneumonia in residents of and travellers returned from endemic regions.

Melioidosis is endemic in South East Asia, Asia and northern Australia. Infection usually follows percutaneous inoculation or inhalation of the causative bacterium, Burkholderia pseudomallei, which is present in soil and surface water in the endemic region. While 20-36% of melioidosis cases have no evident predisposing risk factor, the vast majority of fatal cases have an identified risk factor, the most important of which are diabetes, alcoholism and chronic renal disease. Half of all cases present with pneumonia, but there is great clinical diversity, from localised skin ulcers or abscesses without systemic illness to fulminant septic shock with multiple abscesses in the lungs, liver, spleen and kidneys. At least 10% of cases present with a chronic respiratory illness (sick > 2 months) mimicking tuberculosis and often with upper lobe infiltrates and/or cavities on chest radiography. As with tuberculosis, latency with reactivation decades after infection can also occur, although this is rare. Confirmation of diagnosis is by culture of B. pseudomallei from blood, sputum, throat swab or other samples. Microbiology laboratories need to be informed of the possibility of melioidosis, as those not familiar with it can misidentify the organism. Antibiotic therapy is initial intensive therapy with i.v. ceftazidime or meropenem or imipenem +/- cotrimoxazole for > or = 10 days, followed by eradication therapy with cotrimoxazole +/- doxycycline +/- chloramphenicol (first 4 weeks only) for > or = 3 months. Melioidosis has been increasingly recognised in returning travellers in Europe and recently melioidosis and colonisation with B. pseudomallei have been documented in cystic fibrosis patients visiting or resident in endemic areas.

Alcoholism↗