Fluoroquinolone-resistance mechanisms and molecular epidemiology of ciprofloxacin-resistant Klebsiella pneumoniae isolates in Iran.

Humans Ciprofloxacin / pharmacology Fluoroquinolones / pharmacology Klebsiella pneumoniae / genetics Anti-Bacterial Agents / pharmacology Molecular Epidemiology Multilocus Sequence Typing Iran / epidemiology DNA Gyrase / genetics Plasmids Microbial Sensitivity Tests Drug Resistance, Bacterial / genetics
GyrA Klebsiella pneumoniae MLST ParC Plasmid mediated quinolone resistance genes

Journal

Folia microbiologica
ISSN: 1874-9356
Titre abrégé: Folia Microbiol (Praha)
Pays: United States
ID NLM: 0376757

Informations de publication

Date de publication:
Aug 2023
Historique:
received: 15 08 2022
accepted: 15 02 2023
medline: 7 7 2023
pubmed: 5 3 2023
entrez: 4 3 2023
Statut: ppublish

Résumé

Klebsiella pneumoniae is an important cause of nosocomial infections and displays increasing resistance to fluoroquinolones (FQ). This study surveyed the mechanisms of FQ resistance and molecular typing of K. pneumoniae isolates from intensive care units patients in Tehran, Iran. A total of 48 ciprofloxacin (CIP) resistant K. pneumoniae isolates from urine samples were included in this study. Broth microdilution assays revealed high-level CIP resistance (MIC > 32 μg/mL) in 31.25% of the isolates. Plasmid-mediated quinolone resistance genes were detected in 41 (85.4%) isolates. Among which, qnrS (41.67%) was the most prevalent followed by qnrD (35.42%), qnrB (27.1%), qnrA (25%), qepA (22.9%), aac(6')-Ib-cr (20.83%), and qnrC (6.25%). Target site mutations (gyrA and parC) were assessed using PCR and sequencing on all isolates. A single mutation in gyrA (S83I) was found in 13 (27.1%) isolates and two isolates harbored six simultaneous mutations. Fourteen isolates (29.2%) had mutations in parC and S129A and A141V mutations were the most prevalent. Real time PCR showed an increase in the expression level of acrB and oqxB efflux genes in 68.75 and 29.16% isolates, respectively. Enterobacterial repetitive intergenic consensus (ERIC)-PCR revealed 14 genotypes and 11 of them were classified by multilocus sequence typing (MLST) into 11 different sequence types belonging to seven clonal complexes and two singletons, most of them have not been reported in Iran yet. We are concerned about the spread of these clones throughout our country. Most FQ resistance mechanisms were detected among our isolates. However, target site mutation had the greatest effect on CIP resistance among our isolates.

Identifiants

DOI: 10.1007/s12223-023-01042-2 PMID: 36870040
pubmed: 36870040
doi: 10.1007/s12223-023-01042-2
pii: 10.1007/s12223-023-01042-2
doi:

Substances chimiques

Ciprofloxacin 5E8K9I0O4U
Fluoroquinolones 0
Anti-Bacterial Agents 0
DNA Gyrase EC 5.99.1.3

Types de publication

Journal Article

Langues

eng

Sous-ensembles de citation

IM

Pagination

633-644

Informations de copyright

© 2023. Institute of Microbiology, Academy of Sciences of the Czech Republic, v.v.i.

Références

Abossedgh R, Ghane M, Babaeekhou L (2020) High Frequency of qnr Genes in Urinary Isolates of Extended-Spectrum β-Lactamase (ESBL)-producing Klebsiella pneumoniae in Tehran. Iran Shiraz E-Medical Journal 21:1–7
Ahmadkhan Beygi L, Ghane M, Babaeekhou L (2019) High prevalence of CTXM-15 type extended-spectrum beta-lactamase among clinical isolates of Klebsiella pneumoniae. J Kerman Univ Med Sci 26:339–348
Aldred KJ, Kerns RJ, Osheroff N (2014) Mechanism of quinolone action and resistance. Biochemistry 53(10):1565–1574
pubmed: 24576155 doi: 10.1021/bi5000564
Alheib O, Al Kayali R, Abajy MY (2015) Prevalence of plasmid-mediated quinolone resistance (PMQR) determinants among extended spectrum beta-lactamases (ESBL)-producing isolates of Escherichia coli and Klebsiella pneumoniae in Aleppo, Syria. Archives of Clinical Infectious Diseases 10:1–5
doi: 10.5812/archcid.20631
Araújo BF, de Campos PA, Royer S, Ferreira ML, Gonçalves IR, da Fonseca Batistão DW, Ribas RM (2017) High frequency of the combined presence of QRDR mutations and PMQR determinants in multidrug-resistant Klebsiella pneumoniae and Escherichia coli isolates from nosocomial and community-acquired infections. J Med Microbiol 66:1144–1150
pubmed: 28771139 doi: 10.1099/jmm.0.000551
Azargun R, Barhaghi MHS, Kafil HS, Oskouee MA, Sadeghi V, Memar MY, Ghotaslou R (2019) Frequency of DNA gyrase and topoisomerase IV mutations and plasmid-mediated quinolone resistance genes among Escherichia coli and Klebsiella pneumoniae isolated from urinary tract infections in Azerbaijan. Iran J Glob Antimicrob Resist 17:39–43
pubmed: 30445211 doi: 10.1016/j.jgar.2018.11.003
Blondeau JM (2004) Fluoroquinolones: mechanism of action, classification, and development of resistance. Surv Ophthalmol 49:S73–S78
pubmed: 15028482 doi: 10.1016/j.survophthal.2004.01.005
Brisse S, Verhoef J (2001) Phylogenetic diversity of Klebsiella pneumoniae and Klebsiella oxytoca clinical isolates revealed by randomly amplified polymorphic DNA, gyrA and parC genes sequencing and automated ribotyping. Int J Syst Evol Microbiol 51:915–924
pubmed: 11411715 doi: 10.1099/00207713-51-3-915
Cattoir V, Poirel L, Rotimi V, Soussy C-J, Nordmann P (2007) Multiplex PCR for detection of plasmid-mediated quinolone resistance qnr genes in ESBL-producing enterobacterial isolates. J Antimicrob Chemother 60:394–397
pubmed: 17561500 doi: 10.1093/jac/dkm204
Cavaco LM, Hasman H, Xia S, Aarestrup FM (2009) qnrD, a novel gene conferring transferable quinolone resistance in Salmonella enterica serovar Kentucky and Bovismorbificans strains of human origin. Antimicrob Agents Chemother 53:603–608
pubmed: 19029321 doi: 10.1128/AAC.00997-08
Chanbari M, Mirnejad R, Babapour E (2020) Evaluation of Resistance to Fluoroquinolones and its Relationship whit parC Gene mutation in Klebsiella pneumoniae Clinical Isolates. Iranian Journal of Medical Microbiology 14:270–289
doi: 10.30699/ijmm.14.3.270
Ciesielczuk H, Hornsey M, Choi V, Woodford N, Wareham D (2013) Development and evaluation of a multiplex PCR for eight plasmid-mediated quinolone-resistance determinants. J Med Microbiol 62:1823–1827
pubmed: 24000223 doi: 10.1099/jmm.0.064428-0
Clinical Institute (2020) Performance standards for antimicrobial susceptibility testing: Clinical and Laboratory Standards Institute Wayne, PA
Correia S, Poeta P, Hébraud M, Capelo JL, Igrejas G (2017) Mechanisms of quinolone action and resistance: where do we stand? J Med Microbiol 66:551–559
pubmed: 28504927 doi: 10.1099/jmm.0.000475
David S, Reuter S, Harris SR, Glasner C, Feltwell T, Argimon S, Errico G (2019) Epidemic of carbapenem-resistant Klebsiella pneumoniae in Europe is driven by nosocomial spread. Nat Microbiol 4:1919–1929
pubmed: 31358985 pmcid: 7244338 doi: 10.1038/s41564-019-0492-8
Diancourt L, Passet V, Verhoef J, Grimont PA, Brisse S (2005) Multilocus sequence typing of Klebsiella pneumoniae nosocomial isolates. J Clin Microbiol 43:4178–4182
pubmed: 16081970 pmcid: 1233940 doi: 10.1128/JCM.43.8.4178-4182.2005
Drago L, Nicola L, Mattina R, De Vecchi E (2010) In vitro selection of resistance in Escherichia coli and Klebsiella spp. at in vivo fluoroquinolone concentrations. BMC Microbiol 10:1–7
doi: 10.1186/1471-2180-10-119
Duan H, Chai T, Liu J, Zhang X, Qi C, Gao J, Yao M (2009) Source identification of airborne Escherichia coli of swine house surroundings using ERIC-PCR and REP-PCR. Environ Res 109:511–517
pubmed: 19349045 pmcid: 7126843 doi: 10.1016/j.envres.2009.02.014
El-Badawy MF, Eed EM, Sleem AS, El-Sheikh AA, Maghrabi IA, Abdelwahab SF (2022) The First Saudi Report of Novel and Common Mutations in the gyrA and parC Genes Among Pseudomonas spp. Clinical Isolates Recovered from Taif Area. Infection and Drug Resistance 15:3801–3814
pubmed: 35875614 pmcid: 9300750 doi: 10.2147/IDR.S372027
El-Badawy MF, Tawakol WM, El-Far SW, Maghrabi IA, Al-Ghamdi SA, Mansy MS, Shohayeb MM (2017) Molecular identification of aminoglycoside-modifying enzymes and plasmid-mediated quinolone resistance genes among Klebsiella pneumoniae clinical isolates recovered from Egyptian patients. Int J Microbiol 2017:1–12
doi: 10.1155/2017/8050432
Galehdar M, Ghane M, Babaeekhou L (2021) Co-occurrence of Carbapenemase-encoding Genes Among Klebsiella pneumoniae Clinical Isolates: Positive Relationship of bla
doi: 10.5812/jjm.112486
Geetha PV, Aishwarya KVL, Mariappan S, Sekar U (2020) Fluoroquinolone Resistance in Clinical Isolates of Klebsiella Pneumoniae. Journal of Laboratory Physicians 12:121–125
pubmed: 32905353 pmcid: 7467831 doi: 10.1055/s-0040-1716478
Ghane M, Babaeekhou L, Asgharifard M (2022) Prevalence of Plasmid-Mediated Quinolone Resistance Genes and Molecular Typing of Klebsiella pneumoniae Isolates from Blood Cultures in Milad Hospital, Tehran, Iran, Within 2018–2019. Jundishapur J Microbiol 15:1–9
doi: 10.5812/jjm-124054
Giske CG, Fröding I, Hasan CM, Turlej-Rogacka A, Toleman M, Livermore D, Walsh TR (2012) Diverse sequence types of Klebsiella pneumoniae contribute to the dissemination of blaNDM-1 in India, Sweden, and the United Kingdom. Antimicrob Agents and Chemother 56:2735–2738
doi: 10.1128/AAC.06142-11
Haeili M, Salehzeinali H, Mirzaei S, Pishnian Z, Ahmadi A (2021) Molecular characterization of quinolone resistance and antimicrobial resistance profiles of Klebsiella pneumoniae and Escherichia coli isolated from human and broiler chickens. Int J Environ Health Res 32:1382–1392
pubmed: 33615919 doi: 10.1080/09603123.2021.1885632
Hamed SM, Elkhatib WF, El-Mahallawy HA, Helmy MM, Ashour MS, Aboshanab KM (2018) Multiple mechanisms contributing to ciprofloxacin resistance among Gram negative bacteria causing infections to cancer patients. Sci Rep 8:1–10
doi: 10.1038/s41598-018-30756-4
Hooper DC, Jacoby GA (2015) Mechanisms of drug resistance: quinolone resistance. Ann N Y Acad Sci 1354:12–31
pubmed: 26190223 pmcid: 4626314 doi: 10.1111/nyas.12830
Hopkins KL, Davies RH, Threlfall EJ (2005) Mechanisms of quinolone resistance in Escherichia coli and Salmonella: recent developments. Int J Antimicrob Agents 25:358–373
pubmed: 15848289 doi: 10.1016/j.ijantimicag.2005.02.006
Huang Y, Ogutu JO, Gu J, Ding F, You Y, Huo Y, Zhang W (2015) Comparative analysis of quinolone resistance in clinical isolates of Klebsiella pneumoniae and Escherichia coli from Chinese children and adults. Biomed Res Int 2015:1–6
Jacoby GA, Strahilevitz J, Hooper DC (2015) Plasmid‐mediated quinolone resistance. Plasmids: Biol Impact Biotechnol Dis 475–503
Jafari Z, Harati AA, Haeili M, Kardan-Yamchi J, Jafari S, Jabalameli F, Feizabadi MM (2019) Molecular epidemiology and drug resistance pattern of carbapenem-resistant Klebsiella pneumoniae isolates from Iran. Microb Drug Resist 25:336–343
pubmed: 30351186 doi: 10.1089/mdr.2017.0404
Jamshidi MRM, Zandi H, Eftekhar F (2019) Correlation of quinolone-resistance, qnr genes and integron carriage in multidrug-resistant community isolates of Klebsiella spp. Iran J Basic Med Sci 22:1387–1391
Jlili NE-H, Rejiba S, Smaoui H, Guillard T, Chau F, Kechrid A, Cambau E (2014) Trend of plasmid-mediated quinolone resistance genes at the Children’s Hospital in Tunisia. J Med Microbiol 63:195–202
pubmed: 24194556 doi: 10.1099/jmm.0.062216-0
Kareem SM, Al-Kadmy IM, Kazaal SS, Ali ANM, Aziz SN, Makharita RR, Batiha GE-S (2021) Detection of gyrA and parC mutations and prevalence of plasmid-mediated quinolone resistance genes in Klebsiella pneumoniae. Infection and Drug Resistance 14:555–563
pubmed: 33603418 pmcid: 7886241 doi: 10.2147/IDR.S275852
Kim HB, Wang M, Park CH, Kim E-C, Jacoby GA, Hooper DC (2009) oqxAB encoding a multidrug efflux pump in human clinical isolates of Enterobacteriaceae. Antimicrob Agents Chemother 53:3582–3584
pubmed: 19528276 pmcid: 2715617 doi: 10.1128/AAC.01574-08
Kotb DN, Mahdy WK, Mahmoud MS, Khairy RM (2019) Impact of co-existence of PMQR genes and QRDR mutations on fluoroquinolones resistance in Enterobacteriaceae strains isolated from community and hospital acquired UTIs. BMC Infect Dis 19:1–8
doi: 10.1186/s12879-019-4606-y
Magiorakos A-P, Srinivasan A, Carey RB, Carmeli Y, Falagas M, Giske C, Olsson-Liljequist B (2012) Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect 18:268–281
pubmed: 21793988 doi: 10.1111/j.1469-0691.2011.03570.x
Moghadasi M, Mirzaee M, Mehrabi MR (2016) Frequency of quinolone resistance and qnrB and qnrC genes in clinical isolates of Klebsiella pneumoniae. Journal of Medical Bacteriology 5:39–45
Nabilou M, Babaeekhou L, Ghane M (2021) Fluoroquinolone resistance contributing mechanisms and genotypes of ciprofloxacin-unsusceptible Pseudomonas aeruginosa strains in Iran: emergence of isolates carrying qnr/aac (6)-Ib genes. Int Microbiol 25:1–11
Navon-Venezia S, Kondratyeva K, Carattoli A (2017) Klebsiella pneumoniae: a major worldwide source and shuttle for antibiotic resistance. FEMS Microbiol Rev 41:252–275
pubmed: 28521338 doi: 10.1093/femsre/fux013
Ni RT, Onishi M, Mizusawa M, Kitagawa R, Kishino T, Matsubara F, Ogawa W (2020) The role of RND-type efflux pumps in multidrug-resistant mutants of Klebsiella pneumoniae. Sci Rep 10(1):1–10
doi: 10.1038/s41598-020-67820-x
Nikaido H, Pagès J-M (2012) Broad-specificity efflux pumps and their role in multidrug resistance of Gram-negative bacteria. FEMS Microbiol Rev 36(2):340–363
pubmed: 21707670 doi: 10.1111/j.1574-6976.2011.00290.x
Norouzi A, Azizi O, Hosseini H, Shakibaie S (2014) Amino acid substitution mutations analysis of gyrA and parC genes in clonal lineage of Klebsiella pneumoniae conferring high-level quinolone resistance. Journal of Medical Microbiology and Infectious Diseases 2:109–117
Pajand O, Darabi N, Arab M, Ghorbani R, Bameri Z, Ebrahimi A, Hojabri Z (2020) The emergence of the hypervirulent Klebsiella pneumoniae (hvKp) strains among circulating clonal complex 147 (CC147) harbouring bla NDM/OXA-48 carbapenemases in a tertiary care center of Iran. Ann Clin Microbiol Antimicrob 19:1–9
doi: 10.1186/s12941-020-00349-z
Pan Y-J, Lin T-L, Lin Y-T, Su P-A, Chen C-T, Hsieh P-F, Wang J-T (2015) Identification of capsular types in carbapenem-resistant Klebsiella pneumoniae strains by wzc sequencing and implications for capsule depolymerase treatment. Antimicrob Agents Chemother 59:1038–1047
pubmed: 25451047 pmcid: 4335867 doi: 10.1128/AAC.03560-14
Papagiannitsis CC, Dolejska M, Izdebski R, Dobiasova H, Studentova V, Esteves FJ, Gniadkowski M (2015) Characterization of pKP-M1144, a novel ColE1-like plasmid encoding IMP-8, GES-5, and BEL-1 β-lactamases, from a Klebsiella pneumoniae sequence type 252 isolate. Antimicrob Agents Chemother 59:5065–5068
pubmed: 26033721 pmcid: 4505226 doi: 10.1128/AAC.00937-15
Park KS, Yang H-S, Nam YS, Lee HJ (2017) Mutations in DNA Gyrase and Topoisomerase IV in Ciprofloxacin-Nonsusceptible Extended-Spectrum β-Lactamase-Producing Escherichia coli and Klebsiella pneumoniae. Clin Lab 63:535–541
pubmed: 28271673 doi: 10.7754/Clin.Lab.2016.160924
Paul M, Narendrakumar L, Vasanthakumary AR, Joseph I, Thomas S (2019) Genome sequence of a multidrug-resistant Klebsiella pneumoniae ST78 with high colistin resistance isolated from a patient in India. J Glob Antimicrob Resist 17:187–188
pubmed: 31005731 doi: 10.1016/j.jgar.2019.04.008
Piekarska K, Wołkowicz T, Zacharczuk K, Rzeczkowska M, Chróst A, Bareja E, Gierczyński R (2015) Co-existence of plasmid-mediated quinolone resistance determinants and mutations in gyrA and parC among fluoroquinolone-resistant clinical Enterobacteriaceae isolated in a tertiary hospital in Warsaw, Poland. Int J Antimicrob Agents 45:238–243
pubmed: 25468717 doi: 10.1016/j.ijantimicag.2014.09.019
Robicsek A, Jacoby GA, Hooper DC (2006) The worldwide emergence of plasmid-mediated quinolone resistance. Lancet Infect Dis 6:629–640
pubmed: 17008172 doi: 10.1016/S1473-3099(06)70599-0
Roshani M, Goodarzi A, Hashemi A, Afrasiabi F, Goudarzi H, Arabestani M (2022) Detection of qnrA, qnrB, and qnrS genes in Klebsiella pneumoniae and Escherichia coli isolates from leukemia patients. Rev Med Microbiol 33:14–19
doi: 10.1097/MRM.0000000000000250
Samuelsen Ø, Toleman M, Hasseltvedt V, Fuursted K, Leegaard T, Walsh TR, Giske C (2011) Molecular characterization of VIM-producing Klebsiella pneumoniae from Scandinavia reveals genetic relatedness with international clonal complexes encoding transferable multidrug resistance. Clin Microbiol Infect 17:1811–1816
pubmed: 21595797 doi: 10.1111/j.1469-0691.2011.03532.x
Shokoohizadeh L, Saniee M, Mirzaee M, Taheri M (2019) Mutations in gyrA and parC genes in quinolone-resistant Klebsiella pneumoniae isolates from borujerd hospitals. Journal of Advances in Medical and Biomedical Research 27:1–7
doi: 10.30699/jambs.27.120.1
Solgi H, Badmasti F, Giske CG, Aghamohammad S, Shahcheraghi F (2018) Molecular epidemiology of NDM-1-and OXA-48-producing Klebsiella pneumoniae in an Iranian hospital: clonal dissemination of ST11 and ST893. J Antimicrob Chemother 73:1517–1524
pubmed: 29518198 doi: 10.1093/jac/dky081
Vaez H, Sahebkar A, Khademi F (2019) Carbapenem-resistant Klebsiella pneumoniae in Iran: a systematic review and meta-analysis. J Chemother 31:1–8
pubmed: 30595129 doi: 10.1080/1120009X.2018.1533266
Wang Q, Li B, Tsang AK, Yi Y, Woo PC, Liu CH (2013) Genotypic analysis of Klebsiella pneumoniae isolates in a Beijing Hospital reveals high genetic diversity and clonal population structure of drug-resistant isolates. PLoS ONE 8:1–12
Wareham D, Umoren I, Khanna P, Gordon N (2010) Allele-specific polymerase chain reaction (PCR) for rapid detection of the aac (6′)-Ib-cr quinolone resistance gene. Int J Antimicrob Agents 36:476–477
pubmed: 20843664 doi: 10.1016/j.ijantimicag.2010.07.012
Wasfi R, Elkhatib WF, Ashour HM (2016) Molecular typing and virulence analysis of multidrug resistant Klebsiella pneumoniae clinical isolates recovered from Egyptian hospitals. Sci Rep 6:1–11
doi: 10.1038/srep38929
Wong MHY, Chan EWC, Chen S (2015) Evolution and dissemination of OqxAB-like efflux pumps, an emerging quinolone resistance determinant among members of Enterobacteriaceae. Antimicrob Agents Chemother 59:3290–3297
pubmed: 25801572 pmcid: 4432112 doi: 10.1128/AAC.00310-15
Yamane K, Wachino J-i, Suzuki S, Arakawa Y (2008) Plasmid-mediated qepA gene among Escherichia coli clinical isolates from Japan. Antimicrob Agents Chemother 52:1564–1566
pubmed: 18285488 pmcid: 2292543 doi: 10.1128/AAC.01137-07
Yang HY, Nam YS, Lee HJ (2014) Prevalence of plasmid-mediated quinolone resistance genes among ciprofloxacin-nonsusceptible Escherichia coli and Klebsiella pneumoniae isolated from blood cultures in Korea. Canadian Journal of Infectious Diseases and Medical Microbiology 25:163–169
pubmed: 25285114 pmcid: 4173980 doi: 10.1155/2014/329541
Yasufuku T, Shigemura K, Shirakawa T, Matsumoto M, Nakano Y, Tanaka K, Fujisawa M (2011) Correlation of overexpression of efflux pump genes with antibiotic resistance in Escherichia coli strains clinically isolated from urinary tract infection patients. J Clin Microbiol 49:189–194
pubmed: 21048014 doi: 10.1128/JCM.00827-10
Yin L, He L, Miao J, Yang W, Wang X, Ma J, Lu G (2020) Active surveillance and appropriate patient placement in contact isolation dramatically decreased carbapenem-resistant Enterobacterales infection and colonization in paediatric patients in China. J Hosp Infect 105:486–494
doi: 10.1016/j.jhin.2020.03.031
Zhong X, Xu H, Chen D, Zhou H, Hu X, Cheng G (2014) First emergence of acrAB and oqxAB mediated tigecycline resistance in clinical isolates of Klebsiella pneumoniae pre-dating the use of tigecycline in a Chinese hospital. PLoS ONE 9:1–11
doi: 10.1371/journal.pone.0115185

Auteurs

Ghazaleh Shahabi Sani (GS)

Department of Biology, Islamshahr Branch, Islamic Azad University, Islamshahr, Iran.
ORCID: 0000-0002-4992-068X

Maryam Ghane (M)

Department of Biology, Islamshahr Branch, Islamic Azad University, Islamshahr, Iran. ghane@iiau.ac.ir.
ORCID: 0000-0003-0305-0241

Laleh Babaeekhou (L)

Department of Biology, Islamshahr Branch, Islamic Azad University, Islamshahr, Iran.
ORCID: 0000-0002-5127-3813

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Classifications MeSH

questionsmedicales.fr › Eucaryotes › Animaux › Chordés › Vertébrés › Mammifères › Eutheria › Primates › Haplorhini › Catarrhini › Hominidae › Humains › Fluoroquinolone-resistance mechanisms and...
questionsmedicales.fr › Composés hétérocycliques › Composés hétérocycliques à cycles fusionnés › Composés hétérobicycliques › Quinoléines › Quinolinone › Fluoroquinolones › Ciprofloxacine › Fluoroquinolone-resistance mechanisms and...
questionsmedicales.fr › Composés hétérocycliques › Composés hétérocycliques à cycles fusionnés › Composés hétérobicycliques › Quinoléines › Quinolinone › Fluoroquinolones › Fluoroquinolone-resistance mechanisms and...
questionsmedicales.fr › Bactéries › Proteobacteria › Gammaproteobacteria › Enterobacteriaceae › Klebsiella › Klebsiella pneumoniae › Fluoroquinolone-resistance mechanisms and...
questionsmedicales.fr › Actions chimiques et utilisations › Actions pharmacologiques › Utilisations thérapeutiques › Anti-infectieux › Antibactériens › Fluoroquinolone-resistance mechanisms and...
questionsmedicales.fr › Environnement et santé publique › Santé publique › Méthodes épidémiologiques › Épidémiologie moléculaire › Fluoroquinolone-resistance mechanisms and...
questionsmedicales.fr › Techniques d'investigation › Techniques génétiques › Analyse de séquence › Analyse de séquence d'ADN › Typage par séquençage multilocus › Fluoroquinolone-resistance mechanisms and...
questionsmedicales.fr › Régions géographiques › Asie › Asie de l'Ouest › Moyen Orient › Iran › Fluoroquinolone-resistance mechanisms and...
questionsmedicales.fr › Acides aminés, peptides et protéines › Protéines › Protéines bactériennes › DNA gyrase › Fluoroquinolone-resistance mechanisms and...
questionsmedicales.fr › Phénomènes génétiques › Structures génétiques › Plasmides › Fluoroquinolone-resistance mechanisms and...
questionsmedicales.fr › Techniques d'investigation › Évaluation préclinique de médicament › Tests de sensibilité microbienne › Fluoroquinolone-resistance mechanisms and...
questionsmedicales.fr › Phénomènes physiologiques › Phénomènes pharmacologiques et toxicologiques › Phénomènes pharmacologiques › Résistance aux substances › Résistance microbienne aux médicaments › Résistance bactérienne aux médicaments › Fluoroquinolone-resistance mechanisms and...