ISSN 2320-5407 International Journal of Advanced Research (2016), Volume 4, Issue 3, 855-861

Journal homepage: http://www.journalijar.com INTERNATIONAL JOURNAL

OF ADVANCED RESEARCH

RESEARCH ARTICLE

IDENTIFICATION OF NON FERMENTING GRAM NEGATIVE BACILLI FROM PATEINS IN AL-

DIWANIYA CITY AND DETECTION OF THEIR VIRULENCE FACTORS.

Aamal Ghazi Mahdi Al-Saadi , Alaa Fahim Abbas , Tha’ir Abid D’asheesh.
College of science, Al-Qadisiyah University, Iraq.

Manuscript Info Abstract

Manuscript History: Non fermenting gram negative bacilli (NFGNB) have emerged as multidrug
resistant pathogens associated with life threating nosocomial infections. To
Received: 14 January 2016
Final Accepted: 26 February 2016 assess the frequency of these pathogens, (873) different clinical specimens
Published Online: March 2016 were collected from patients admitted to Al- Diwaniya teaching hospital
during a period extended from January to December 2015. Bacterial isolates
Key words: recovered from the collected sampled have identified based on biochemical
NFGNB, prevalence, virulence tests and confirmed using Vitek2 Compact system. The predominant isolate
factors, antibiotic resistance. was Pseudomonas aeruginosa (60%) followed by Burkholdaria cepacia
(26%), Acintobacter spp.(6%). Pseudomonas putida , Pseudomonas leutella,
Sphingomonas paucimobilis, and Achromobacter spp. (2%). The highest
*Corresponding Author number of the NFGNB was obtained from ear swabs (36%) followed by
sputum (24%), vaginal swabs and urine (12%), throat swabs (10%), and
Aamal Ghazi Mahdi Al- blood (6%). The NFGNB were isolated from both males and females and
Saadi. most of them detected in the age group 15-30 years followed by the age
group 47-62 year then 31-46 year. Virulence factors, including colonization
factors antigens I and III, proteases, siderophores, and capsule have
identified in the isolated NFGNB. Results also showed that isolates of the
predominant species, P. aeruginosa, were resistant to multiple antibiotics
including, Ampicillin (93.98%), Ceftriaxone (82.13%), Chloramphenicol
(72.09%), Piperacillin (64.31%), Ciprofloxacin (46.97%), Gentamycin
(32.4%), Tetracycline (30.75%), Levofloxacin (15.17%), Amikacin
(12.12%), Trimethoprim–Sulfamethoxazole (10.67%). P. aeruginosa isolates
showed low resistance to Colistin (2.34%) and Imipenem (6.89%). The
outcome of this study may be helpful to understand the epidemiology of
these organisms, which is crucial for appropriate management of infections
caused by NFGNB.

Copy Right, IJAR, 2016,. All rights reserved

Introduction:-
Non fermenting gram negative bacilli (NFGNB) is a diverse group of aerobic, non spore forming, gram negative
bacteria that either do not use carbohydrates as energy source or utilize them by means of metabolic pathways other
than fermentation (Vijaya, Bavani et al. 2000, Benachinmardi, Padmavathy et al. 2014). This group comprises of
organisms from various genera such as Pseudomonas, Acinetobacter, Alcaligenes, Burkholderia cepacia,
Sphingobacterium, Agrobacter, and Weeksiella. These organisms exist commonly in soil and water, and they are
also present as harmless parasites on the mucus membranes of humans and animals (Baron, Peterson et al. 1994).
Although the members of NFGNB are normally considered to be commensals or contaminants, the pathogenic
potential of this group has been established undeniably because of their regular isolation from clinical specimens
and their involvement with many diseases(Sujatha Karjigi 2013). Recent studies revealed that these organisms are
now associated with serious infections, such as meningitis, ventilator associated pneumonia (VAP), surgical site
infection, osteomyelitis, and wound infections (Juyal, Prakash et al. 2013). The NFGNB reported to form about
(15%) of all bacterial isolates from clinical samples(Gokale and Metgud 2012). Infections caused by these

855
ISSN 2320-5407 International Journal of Advanced Research (2016), Volume 4, Issue 3, 855-861

organisms are endogenous or exogenous origin, depending on numerous factors like abusive use of wide spectrum
antimicrobial agents, the use of immunosuppressant substance, prolong surgical procedure, and inadequate
instrumentation (Frota and Moreira 1998, Kaur, Gupte et al. 2015). Most of the NFGNB are resistant to many
antibiotics because of the extensive use of the antimicrobial agents used to treat infections caused by these
organisms, making them important health care associate pathogens (Gokale and Metgud 2012). They have diverse
mechanisms for resistance, including: enzymes production, enzymatic deactivation of antibiotics, precise targeted
enzyme which is inhibited by antimicrobial agents, modification in target locations, creation of efflux pumps, defeat
of outer membrane proteins or porins, and decrease of the antimicrobial agent uptake; therefore , the therapeutic
choices are strictly restricted to treat the NFGNB infections (Zahid, Akbar et al. 2014). This is the first study to
investigate the clinical significance of NFGNB in Iraq. The objectives of this study are to: (1) Isolate and
identificate NFGNB from different clinical specimens, including sputum, throat swabs, ear swabs, urine, blood, and
vaginal swabs (2) Investigate the prevalence of NFGNB in Iraq, particularly in Al-Diwaniyah city (3) Identificate
the various virulence factors related to infections caused by NFGNB, and (4) Test the susceptibility of the isolated
and identified predominant species, P. aeruginosa, to the commonly used antimicrobial agents.

Methods and materials:-

Specimens collection:-
A total of 873 different clinical specimens, including sputum, throat swabs, ear swabs, urine, blood, stool, wound
and vaginal swabs were collected from patients admitted to Al- Diwaniya teaching hospital during a period extended
from January to December 2015. The following data were recorded for each patient: age, sex, hospitalization. The
specimens were collected by standard methods as mentioned in (Forbes 2007).

Isolation and Identification:-

The specimens were cultured on MacConkey's agar and nutrient agar then incubated aerobically at 37ºC for 24-
72hrs for primary isolation. Non lactose fermenting colonies on MacConkey's agar were selected and sub cultured to
obtain pure culture. Bacterial isolates were identified by routine diagnostic tests including cultural, morphological
and biochemical characteristics (Baron 1994, Forbes 2007). Confirmative diagnosis was done by using Gram-
negative GN identification card automated Vitek2 Compact system (Biomeriux).

Virulence factors tests:-

Virulence factors were detected as described in (Cruckshank 1975, Piret 1983, Nassif 1989, Baron 1994).
Haemagglutination test was carried out to detect the ability of bacterial isolates to produce colonization factors
antigens. Negative staining method was performed to determine if bacterial isolates posse’s polysaccharide capsule.
M9 medium was used to investigate siderophore and extracellular proteases production.

Antibiotic susceptibility test:-

Antibiotic susceptibility pattern were determined by Bauer Kirby's disc diffusion method according to the Clinical
and Laboratory Standard Institute (CLSI) guidelines(CLSI 2007). Mueller-Hinton plates were inoculated with a 0.5
McFarland standard suspension of bacteria, and disks were placed. Zones of growth inhibition were recorded in
millimeters after overnight incubation.

Results:-
Out of 873 different clinical specimens collected during the study period, the NFGNB were isolated from 50
samples (5.72%), while other bacterial species were isolated from 563 samples to form (64.49%) of the total
specimens number. No growth was detected in 260 samples with a percentage of (29.78%).Table (1).

Table(2) shows the specimens profile and frequency of NFGN bacilli isolated from sputum, throat swabs, ear swabs,
urine, blood, vaginal swabs, stool, and wounds. The NFGNB were predominant in ear swabs (36%) followed by
sputum (24%), vaginal swabs and urine (12%). The NFGNB were also isolated from throat swabs (10%) and blood
(6%).Table (3) illustrates the specimens profile and distribution of NFGN bacilli isolates. The most common
NFGNB isolated during the current study was Pseudomonas aeruginosa (60%) followed by Burkholdaria cepacia
(26%), Acintobacter spp.(6%). Pseudomonas putida , Pseudomonas leutella, Sphingomonas paucimobilis, and
Achromobacter spp.were also isolated with a percentage of (2%). Most of Pseudomonas aeruginosa (16 isolates)
were recovered from ear swabs followed by urine (6 isolates), vaginal swabs (5 isolates), sputum (2 isolates), and
throat swab (1 isolate). Burkholdaria cepacia was predominant in sputum samples (7 isolates) followed by throat

856
ISSN 2320-5407 International Journal of Advanced Research (2016), Volume 4, Issue 3, 855-861

swabs (4 isolates) and blood (2 isolates). Two Acintobacter spp. isolates were recovered from sputum and one
isolate from ear swab. Pseudomonas putida was isolated only from one blood sample, while Pseudomonas leutella
was obtained only from a vaginal swab. A single isolate of Sphingomonas paucimobilis was recovered from an ear
swab, and one isolate of Achromobacter spp. was isolated from a sputum sample.

The distribution of NFGN bacilli in relation to age and sex is demonstrated in table (4). The age range in our study
was 15-63 years. The NFGNB were isolated from 26 (52%) male and 24 (48 %) female. The highest number of
isolates (22 isolate) (44%) was detected in the age group 15-30 years followed by the age group 47-62 year(17
isolates)(34%) then 31-46 year (9 isolates)(18%).

Table (5) summarizes the type and percentages of virulence factors identified in the present study. Colonization
factors antigenI were detectable in (50%) of Pseudomonas aeruginosa isolates, (33.3%) of Acintobacter spp., and
(15.4%) of Burkholdaria cepacia isolates. Colonization factors antigen III were detected in (100%) of Pseudomonas
putida , Pseudomonas leutella, and Acintobacter spp. isolates, (86.7%) of Pseudomonas aeruginosa isolates, and
(76.9%) of Burkholdaria cepacia isolates. Sidrophores were identified in (83.3%) of Pseudomonas aeruginosa
isolates and (84.6%) of Burkholdaria cepacia isolates. Extracellular proteases were detected in (100%) of
Pseudomonas leutella and Sphingomonas paucimobilis isolates, (36.7%) of Pseudomonas aeruginosa isolates, and
(23%) of Burkholdaria cepacia. Moreover, capsule was found in (100%) of Pseudomonas putida, Pseudomonas
leutella, Sphingomonas paucimobilis, and Achromobacter spp. isolates, (84.6%%) of Burkholdaria cepacia isolates,
(73.3%) of Pseudomonas aeruginosa isolates, and (66.6%) of Acintobacter spp .isolates. Our results showed that P.
aeruginosa isolates were resistant to multiple antibiotics including, Ampicillin (93.98%), Ceftriaxone (82.13%),
Chloramphenicol (72.09%), Piperacillin (64.31%), Ciprofloxacin (46.97%), Gentamycin (32.4%), Tetracycline
(30.75%), Levofloxacin (15.17%), Amikacin (12.12%), Trimethoprim–Sulfamethoxazole (10.67%). The most
effective antibiotics are Colistin(2.34%) and Imipenem (6.89%) (Figure1).

Table 1: Numbers and percentages of NFGN bacilli and other bacteria isolated during the current study.
Cultural result specimens Number of specimens %
NFGN bacilli isolates 50 5.72
Other bacteria 563 64.49
No growth 260 29.78
Total 873 100

Table 2: Specimens profile and frequency of NFGN bacilli isolates.

Types of specimens Number of Number of NFGN %
Specimens bacilli isolates
Sputum 117 12 24
Throat swabs 86 5 10
Ear swabs 98 18 36
Urine 381 6 12
Blood 93 3 6
Vaginal swabs 41 6 12
Stool 45 0 0
Wounds 12 0 0
Total 873 50 100
Table 3: Specimens profile and distribution of NFGN bacilli isolates.
Specimens profile Sputum Throat Ear Urine Blood Vaginal Total %
Bacterial species swabs swabs swabs
Pseudomonas aeruginosa 2 1 16 6 0 5 30 60
Pseudomonas putida 0 0 0 0 1 0 1 2
Pseudomonas leutella 0 0 0 0 0 1 1 2
Burkholdaria cepacia 7 4 0 0 2 0 13 26
Acintobacter spp. 2 0 1 0 0 0 3 6
Sphingomonas paucimobilis 0 0 1 0 0 0 1 2
Achromobacter spp. 1 0 0 0 0 0 1 2
Total 12 5 18 6 3 6 50 100

857
ISSN 2320-5407 International Journal of Advanced Research (2016), Volume 4, Issue 3, 855-861

Table 4: Occurrence of NFGN bacilli in relation to age and sex.

Age-group Male Female Total
(years)
No. isolates % No. isolates % No. isolates %

15-30 10 20 12 24 22 44
31-46 7 14 2 4 9 18
47-62 8 16 9 18 17 34
≥63 1 2 1 2 2 4
total 26 52 24 48 50 100

Table 5: Virulence factors detected in NFGN bacilli isolates

Virulence factors colonization colonization Sidrophores Extracellular Capsule
factors factors proteases
Bacterial species antigen I antigen III
Pseudomonas aeruginosa 50 % 86.7% 83.3% 36.7% 73.3%
Pseudomonas putida 0% 100% 0 0 100%
Pseudomonas leutella 0% 100% 0 100% 100%
Burkholdaria cepacia 15.4% 76.9% 84.6% 23% 84.6%
Acintobacter spp. 33.3% 100% 0 0 66.6%
Sphingomonas paucimobilis 0 0 0 100% 100%
Achromobacter spp. 0 0 0 0 100%

Figure 1: Antibiotic resistant profile of P. aeruginosa

Discussion:-
Non-Fermenting Gram negative bacilli have emerged as significant opportunistic pathogens that are responsible to
cause many infections especially in the growing inhabitants of patients who are immunocompromised by their
disease or medical treatment(Baron 1994, Enoch, Birkett et al. 2007). The NFGNB epidemiological complexity,
tendency to cause outbreaks of infection, and antimicrobial resistance make these organisms worth mentioning and
investigating (Rahbar and Hajia 2006, Taherikalani, Etemadi et al. 2008). Studies performed by different researchers

858
ISSN 2320-5407 International Journal of Advanced Research (2016), Volume 4, Issue 3, 855-861

have illustrated that the range of isolation rate of NFGNBs vary from (9.32%) to (45.9%) (Sidhu, Arora et al. 2010,
Juyal, Prakash et al. 2013). The most common non fermenting pathogens for humans are Pseudomonas aeruginosa
and Acinetobacterbaum-aniiare, and infections by other bacterial species are quite uncommon (Taneja, Maharwal et
al. 2003, Thipperudraswamy, Nadigar et al. 2014). In the present study, the predominant bacteria was Pseudomonas
aeruginosa (60%) followed by Burkholdaria cepacia (26%). In other studies, the most frequent NFGNB isolated
were Pseudomonas aeruginosa (70.43%) (50.24%) then Acinetobacter calcoaciticus-baumaniicomplex (25.44%)
( 24.78%) respectively (Thipperudraswamy, Nadigar et al. 2014, Bhargava, Kar et al. 2015). Among the diverse
clinical specimens that we collected and processed for the isolation of pathogens capable of causing diseases, the
NFGNB were predominant in ear swabs (36%) followed by sputum (24%) in comparison to other studies where the
highest numbers of NFGNB were isolated from the pus exudates and body fluid samples (Bhargava, Kar et al.
2015) (Malini, Deepa et al. 2009).

Pseudomonas aeruginosa isolates were recovered from ear swabs, urine , and vaginal swabs where they can
colonize and cause chronic otitis (Rowlands, Devalia et al. 2001) and urinary tract infection(Ferroni, Nguyen et al.
1998) respectively. It was also isolated from sputum and a throat swab where consider the most significant cause of
morbidity and mortality of chronic airway infections, such as cystic fibrosis (Moffett 2010). We have identified two
colonization factors antigens I and III, proteases, siderophores, and capsule in our P. aeruginosa isolates. To
establish an infection, a bacterium must adhere to the epithelium and multiply; to accomplish this, P. aeruginosa
have evolved colonization factors, such as pili or fimbria that recognize and attach the bacteria to host cells.
P. aeruginosa produces several surface-associated adherence factors which promote attachment and contribute to
the virulence of this pathogen(Hahn 1997). Proteases can cause bleeding and tissue necrosis. Siderophores are
implicated in the chronic infection caused by P. aeruginosa by allowing the bacteria to multiply even if there is
ferrous ions deficiency (Ben Haj Khalifa, Moissenet et al. 2011). Mucoid exopolysaccharide capsule can protect
P. aeruginosa from host phagocytic activity and from antibiotics (Vasil 1986). P. aeruginosa in the present study
showed high sensitivity to Colistin and Imipenem, and the results are similar to (Meghna, Bhat et al. 2014,
Bhargava, Kar et al. 2015) and different from (Taneja, Maharwal et al. 2003) when they found high resistance to
Imipenem by P. aeruginosa. This difference is likely because of the diversity in antibiotic susceptibility in different
environmental conditions and regions. On the other hand, P. aeruginosa isolates were highly resistant to multiple
antibiotics including, Ampicillin, Ceftriaxone, Chloramphenicol, Piperacillin; the results are consistent with(Kalidas
Rit 2013).

Burkholdaria cepacia isolates were recovered from sputum, throat swabs, and blood. This bacterium has emerged as
an opportunistic pathogen of pulmonary infections in patients suffering from cystic fibrosis and
immunocompromised patients without cystic fibrosis (Govan, Hughes et al. 1996), and it is progressively more
reported as a cause of healthcare associated infections, including bloodstream infections (De Smet, Veng et al.
2013). We also identified colonization factors antigens I and III, proteases, siderophores, and capsule in our B.
cepacia isolates. Acintobacter spp. isolates were isolated from sputum and ear swab. Acinetobacter has appeared as
a significant nosocomial bacterium causing infectious outbreaks in patients leading to high mortality and morbidity.
It is associated with blood stream infections (Kaur, Gupte et al. 2015), acute or chronic otitis media, and otitis
externa (Dadswell 1976).

Pseudomonas putida was isolated only from one blood sample, and it is reported to cause lethal case of bacteremia
because of skin and soft tissue infections (Thomas, Okamoto et al. 2013). Pseudomonas leutella was obtained only
from a vaginal swab; it is an uncommon opportunistic pathogen that documented as an unusual cause of infections
in underlying medical disorders (Yousefi, Shoja et al. 2014). A single isolate of Sphingomonas paucimobilis was
recovered from an ear swab; it is infrequently isolated from clinical specimens and it is related to a vast variety of
infections. The majority S. paucimobilis infections reported in either hospital acquired or associated to nosocomial
outbreaks (Toh, Tay et al. 2011). One isolate of Achromobacter spp. was isolated from a sputum sample. This
bacterium is increasingly found in sputum of cystic fibrosis people (De Baets, Schelstraete et al. 2007)

Our study also revealed that the NFGNB were isolated from both males and females, and the highest number of
NFGNB isolates was detected in the age group 15-30 years followed by the age group 47-62 year then 31-46 year.
People at the age of 15 - 30 years are more energetic, have more public contacts, more movement from one place to
another so the chances of getting infection at this age is high. The possibility of getting infections depends on
number of experiences to the injurious bacteria, viruses and toxins. In contrast, at older ages, the people are limited
from social contact, so the chances of developing infections is less(Akbar, Zahid et al. 2014).

859
ISSN 2320-5407 International Journal of Advanced Research (2016), Volume 4, Issue 3, 855-861

Accurate identification and revealing of antibiotic sensitivity profile is vital for a proper management of infections
caused by NFGNB (Benachinmardi, Padmavathy et al. 2014). It is also important to start the clinical relevance of
the NFGNB members before considering as pathogens to keep people away from unnecessary use and appearance of
drug resistance strains(Kalidas Rit 2013).

Conclusion:-
To the best of our knowledge, this is the first report to explore the prevalence of NFGNB in Iraq, particularly in Al-
Diwaniya city. Results of this study may be useful to understand the epidemiology and the pathogenic functions of
these organisms, and they are also vital for appropriate management of infections caused by NFGNB.

Acknowledgement:-
Thanks for Al-Diwaniya teaching hospital to provide us with samples for our study.

References:-
1. Akbar, M., M. Zahid, P. A. Ali, A. A. Sthanadar, M. Shah, I. A. Sthanadar, M. Kaleem, M. Aslam, K. Z. S.
M. U. Hassan and N. Jehan (2014). "Isolation and Identification of Multi-Drug Resistant Strains of Non-
Lactose Fermenting Bacteria from Clinical Isolates." Open Journal of Medical Microbiology.
2. Baron, E., L. Peterson and S. Finegold (1994). "Nonfermentative gram-negative bacilli and coccobacilli."
Bailey & Scott’s diagnostic microbiology, 9th ed. Mosby-Year Book, Inc. St. Louis, MO: 386-405.
3. Baron ,E. J. P., L. R. and Finegold, S. M. (1994). "Bailey and Scott’s Diagnostic Microbiology." 9th ed.,
The C.V. Mosby Company, U.S.A
4. Ben Haj Khalifa, A., D. Moissenet, H. Vu Thien and M. Khedher (2011). "[Virulence factors in
Pseudomonas aeruginosa: mechanisms and modes of regulation]." Ann Biol Clin (Paris) 69(4): 393-403.
5. Benachinmardi, K. K., M. Padmavathy, J. Malini and B. Naveneeth (2014). "Prevalence of non-fermenting
Gram-negative bacilli and their in vitro susceptibility pattern at a tertiary care teaching hospital." Journal of
the Scientific Society 41(3): 162.
6. Bhargava, D., S. Kar and M. Saha (2015). "Prevalence of Non-Fermentative Gram Negative Bacilli
Infection in Tertiary Care Hospital in Birgunj, Nepal." Int. J. Curr. Microbiol. App. Sci.307-301 :)7(4
7. CLSI (2007). "Performance Standards for Antimicrobial Susceptibility Testing; Seventeenth
Informational Supplement." 27(1).
8. Cruckshank, R. D., J.P.; Marmion, B.P. and Swain, R.H.A (1975). "Medical microbiology The English
language bock society London." ( 12 th ed) 2: 459.
9. Dadswell, J. V. (1976). "Acinetobacter and similar organisms in ear infections." J Med Microbiol 9(3):
345-353.
10. De Baets, F., P. Schelstraete, S. Van Daele, F. Haerynck and M. Vaneechoutte (2007). "Achromobacter
xylosoxidans in cystic fibrosis: prevalence and clinical relevance." Journal of Cystic Fibrosis 6(1): 75-78.
11. De Smet, B., C. Veng, L. Kruy, C. Kham, J. van Griensven, C. Peeters, S. Ieng, T. Phe, E. Vlieghe, P.
Vandamme and J. Jacobs (2013). "Outbreak of Burkholderia cepacia bloodstream infections traced to the
use of Ringer lactate solution as multiple-dose vial for catheter flushing, Phnom Penh, Cambodia." Clin
Microbiol Infect 19(9): 832-837.
12. Enoch, D., C. Birkett and H. Ludlam (2007). "Non-fermentative Gram-negative bacteria." International
journal of antimicrobial agents 29: S33-S41.
13. Ferroni, A., L. Nguyen, B. Pron, G. Quesne, M. C. Brusset and P. Berche (1998). "Outbreak of nosocomial
urinary tract infections due to Pseudomonas aeruginosa in a paediatric surgical unit associated with tap-
water contamination." Journal of Hospital Infection 39(4): 301-307.
14. Forbes, B. A. D., F. S. and Alice, S. W (2007). "Baily and Scotťs Diagnostic microbiology." 12thed.
Mosby. Elsevier Company, USA.
15. Frota, C. C. and J. L. B .Moreira (1998). "Frequency of Nonfermentative Gram-Negative Bacilli Isolated
from Clinical Materials of Pacients at Universidade Federal do Ceará Hospital Complex-Brazil." Revista de
Microbiologia 29(3).
16. Gokale, S. K. and S. Metgud (2012). "characterization and antibiotic sensitivity pattern of nonfermenting
gram negative bacilli from various clinical samples in a tertiary care hospital, belgaum." Journal of
Pharmaceutical and Biomedical Sciences©(JPBMS) 17(17).

860
ISSN 2320-5407 International Journal of Advanced Research (2016), Volume 4, Issue 3, 855-861

17. Govan, J. R., J. E. Hughes and P. Vandamme " .)1996 ( Burkholderia cepacia: medical, taxonomic and
ecological issues." J Med Microbiol 45(6): 395-407.
18. Hahn, H. P. (1997). "The type-4 pilus is the major virulence-associated adhesin of Pseudomonas
aeruginosa." Gene 192(1): 99-108.
19. Juyal, D., R. Prakash, S. A. Shanakarnarayan, M. Sharma, V. Negi and N. Sharma (2013). "Prevalence of
non-fermenting gram negative bacilli and their in vitro susceptibility pattern in a tertiary care hospital of
Uttarakhand: A study from foothills of Himalayas." Prevalence 2.112-108 :)2(
20. Kalidas Rit, F. N., Hirak Jyoti Raj†, PK Maity (2013). "Prevalence and Susceptibility Profiles of
Nonfermentative Gram-negative Bacilli Infection in a Tertiary Care Hospital of Eastern India." Indian
Journal of Clinical Practice 24(5).
21. Kaur ,M., S. Gupte, M. Kaur, P. Aggarwal, A. Manhas, M. Bala and T. Kaur (2015). "Non-fermenters–
Emerging Health Care Pathogens." SMU medical jornal 2(2): 266-277.
22. Malini, A., E. Deepa, B. Gokul and S. Prasad (2009). "Nonfermenting gram-negative bacilli infections in a
tertiary care hospital in Kolar, Karnataka." Journal of laboratory physicians 1(2): 62.
23. Meghna, C., S. Bhat and K. Vidyalakshmi (2014). "Risk Factors And Antibiotic Susceptibility Pattern
Among Non-Fermenting Gram Negative Bacilli In A Teaching Hospital." Journal of Pharmaceutical and
Biomedical Sciences 4(08): 715-718.
24. Moffett, K. S. (2010). "Pseudomonas aeruginosa in patients with cystic fibrosis." Antimicrob. Ther 1(1)
25. Nassif, X. F., J.;Arnodel, J.and Sansonetti, P. (1989). "Mucoid phenotype of Klebsiella pneumoniae is a
plasmid encoded virulence factor." Infect. Immun 2(57): 546 – 552.
26. Piret, J. M., J. and Demain, A (1983). "Production of protease during sporulation of Bacillus brevis." Eur.
J.Appl.Microbiol. Biotechnol(17): 227-230.
27. Rahbar, M. and M. Hajia (2006). "Detection and quantitation of the etiologic agents of ventilator-associated
pneumonia in endotracheal tube aspirates from patients in Iran." Infection Control 27(08): 884-885.
28. Rowlands, S., H. Devalia, C. Smith, R. Hubbard and A. Dean (2001). "Otitis externa in UK general
practice: a survey using the UK General Practice Research Database." Br J Gen Pract 51(468): 533-538.
29. Sidhu, S., U. Arora and P. Devi (2010). "Prevalence of nonfermentative gram negative bacilli in seriously
ill patients with bacteraemia." JK Science 12(4): 168-171.
30. Sujatha Karjigi, S. a. G. a. M. R. K., S. (2013). "PHENOTYPIC CHARACTERIZATION AND
ANTIBIOTIC SUSCEPTIBILITY PATTERN OF NON -FERMENTATIVE GRAM NEGATIVE
BACILLI FROM CLINICAL SAMPLES." nternational Journal of Basic and Applied Medical Sciences
3(2): 248 - 255.
31. Taherikalani, M., G. Etemadi, K. N. Geliani, B. Fatollahzadeh, S. Soroush and M. M. Feizabadi (2008).
"Emergence of multi and pan-drug resistance Acinetobacter baumannii carrying blaOXA-type-
carbapenemase genes among burn patients in Tehran, Iran." Saudi medical journal 29(4): 623-624.
32. Taneja, N., S. Maharwal and M. Sharma (2003). "Imipenem resistance in nonfermenters causing
nosocomial urinary tract infections." Indian journal of medical sciences 57(7): 294.
33. Thipperudraswamy, T., S. Nadigar and M. Kumar (2014). "Prevalence of Non-Fermenting Gram Negative
Bacilli from Clinical Isolates and Their Antibiogram Profile." Journal of Biomedical and Pharmaceutical
Research 3(2): 55-61.
34. Thomas, B. S ,.K. Okamoto, M. J. Bankowski and T. B. Seto (2013). "A Lethal Case of Pseudomonas
putida Bacteremia Due to Soft Tissue Infection." Infectious diseases in clinical practice (Baltimore, Md.)
21(3): 147.
35. Toh, H.-S., H.-T. Tay, W.-K. Kuar, T.-C. Weng, H.-J .Tang and C.-K. Tan (2011). "Risk factors associated
with Sphingomonas paucimobilis infection." Journal of Microbiology, Immunology and Infection 44(4):
289-295.
36. Vasil, M. L. (1986). "Pseudomonas aeruginosa: biology, mechanisms of virulence, epidemiology ".The
Journal of pediatrics 108(5): 800-805.
37. Vijaya, D., S. Bavani and M. Veena (2000). "Prevalence of nonfermenters in clinical specimens." Indian
journal of medical sciences 54(3): 87.
38. Yousefi, F., S. Shoja and N. Honarvar (2014). "Empyema Caused by Pseudomonas luteola: A Case
Report." Jundishapur J Microbiol 7(7).
39. Zahid, M., M. Akbar, A. A. Sthanadar, P. A. Ali, M. Shah, I. A. Sthanadar, M. Kaleem, M. Aslam, K. N.
M. I. Khan and S. M. U. Hassan (2014). "Isolation and Identification of Multi-Drug Resistant Strains of
Non-Lactose Fermenting Bacteria from Clinical Refuses in Major Hospitals of Khyber Pakhtunkhwa,
Pakistan." Open Journal of Medical Microbiology.

861