Antimicrobial resistance surveillance of clinical bacterial isolates at Maryamana private hospital, Erbil-Iraq (2023–2025): antibiogram data and multidrug-resistant (MDR)/extensively drug-resistant (XDR)/pandrug-resistant (PDR) classification
Abstract
Background and Objectives: Antimicrobial resistance (AMR) poses a critical global health threat, with multidrug-resistant (MDR), extensively drug-resistant (XDR), and pandrug-resistant (PDR) pathogens increasingly prevalent in healthcare settings. The study aimed to provide a comprehensive analysis of AMR among clinical bacterial isolates, including detailed antibiogram profiling and prevalence of MDR, XDR, and PDR phenotypes, to inform local treatment guidelines and antimicrobial stewardship strategies.
Materials and Methods: A retrospective cross-sectional analysis was conducted on 2,945 clinical specimens (blood, wound, sputum, urine, vaginal swabs, and others). Bacterial identification was performed using VITEK 2 automated system. Antimicrobial susceptibility testing was conducted according to Clinical and Laboratory Standards Institute (CLSI) guidelines. MDR, XDR, and PDR classifications were applied.
Results: Out of 2,851 major clinical specimens, Gram-negative bacteria predominated (53%), with highest isolation rates from wound, sputum, and urine samples. Gram-positive organisms accounted for 30%, while Candida species represented 10%. Among Gram-negative isolates, 55% were classified as MDR, 15% as XDR, and 2% as PDR. Gram-positive bacteria showed lower resistance rates with 30% MDR, 4% XDR, and no PDR detected. Species-specific analysis revealed that Klebsiella pneumoniae and Acinetobacter baumannii exhibited the highest XDR and PDR rates, with A. baumannii showing 45% XDR and 10% PDR prevalence. Among Gram-positive organisms, MRSA demonstrated 100% MDR prevalence. The most effective antimicrobials against resistant isolates were carbapenems, amikacin, and vancomycin (for Gram-positives).
Conclusion: This study demonstrates alarmingly high rates of MDR, XDR, and PDR among clinical bacterial isolates, with Gram-negative bacteria showing significantly greater resistance burden than Gram-positive organisms.
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17. Hamadalneel YB, Eltoum SF, Almustafa ZM, Mustafa WS, Abdelsalam FO, Yousif YM, et al. Prevalence and associated factors of multi-drug resistant bacteria among different clinical specimens at wad Medani, Sudan: a four-year, cross-sectional study. Sci Rep 2025; 15: 15596.
18. Kaye KS, Gupta V, Mulgirigama A, Joshi AV, Scangarella-Oman NE, Yu K, et al. Antimicrobial Resistance Trends in Urine Escherichia coli Isolates From Adult and Adolescent Females in the United States From 2011 to 2019: Rising ESBL Strains and Impact on Patient Management. Clin Infect Dis 2021; 73: 1992-1999.
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22. Tamma PD, Heil EL, Justo JA, Mathers AJ, Satlin MJ, Bonomo RA. Infectious Diseases Society of America 2024 Guidance on the Treatment of Antimicrobial-Resistant Gram-Negative Infections. Clin Infect Dis 2024; ciae403. doi: 10.1093/cid/ciae403.
23. Gutiérrez-Gutiérrez B, Rodríguez-Baño J. Current options for the treatment of infections due to extended-spectrum beta-lactamase-producing Enterobacteriaceae in different groups of patients. Clin Microbiol Infect 2019; 25: 932-942.
24. Dunne MW, Aronin SI, Yu KC, Watts JA, Gupta V. A multicenter analysis of trends in resistance in urinary Enterobacterales isolates from ambulatory patients in the United States: 2011-2020. BMC Infect Dis 2022; 22: 194.
25. Mischnik A, Baumert P, Hamprecht A, Rohde AM, Peter S, Feihl S, et al. In vitro susceptibility to 19 agents other than β-lactams among third-generation cephalosporin-resistant Enterobacteriaceae recovered on hospital admission. J Antimicrob Chemother 2017; 72: 1359-1363.
26. Walker MK, Diao G, Warner S, Babiker A, Neupane M, Strich JR, et al. Carbapenem use in extended-spectrum cephalosporin-resistant Enterobacterales infections in US hospitals and influence of IDSA guidance: a retrospective cohort study. Lancet Infect Dis 2024; 24: 856-867.
27. Riccobene T, Ye G, Lock J, Yu KC, Ai C, Gregory S, et al. Outcomes of inadequate empiric therapy and timing of newer antibacterial therapy in hospitalized adults with culture-positive Enterobacterales and Pseudomonas aeruginosa: a multicenter analysis. BMC Infect Dis 2024; 24: 810.
28. Paterson DL. Impact of antibiotic resistance in gram-negative bacilli on empirical and definitive antibiotic therapy. Clin Infect Dis 2008; 47(Suppl 1): S14-S20.
29. Rodríguez-Baño J, Gutiérrez-Gutiérrez B, Machuca I, Pascual A. Treatment of Infections Caused by Extended-Spectrum-Beta-Lactamase-, AmpC-, and Carbapenemase-Producing Enterobacteriaceae. Clin Microbiol Rev 2018; 31(2): e00079-17.
2. Jernigan JA, Hatfield KM, Wolford H, Nelson RE, Olubajo B, Reddy SC, et al. Multidrug-resistant bacterial infections in U.S. hospitalized patients, 2012-2017. N Engl J Med 2020; 382: 1309-1319.
3. de Oliveira Santos JV, da Costa Júnior SD, de Fátima Ramos Dos Santos Medeiros SM, Cavalcanti IDL, de Souza JB, Coriolano DL, et al. Panorama of bacterial infections caused by epidemic resistant strains. Curr Microbiol 2022; 79: 175.
4. Oliver A, Rojo-Molinero E, Arca-Suarez J, Beşli Y, Bogaerts P, Cantón R, et al. Pseudomonas aeruginosa antimicrobial susceptibility profiles, resistance mechanisms and international clonal lineages: update from ESGARS-ESCMID/ISARPAE Group. Clin Microbiol Infect 2024; 30: 469-480.
5. Macesic N, Uhlemann AC, Peleg AY. Multidrug-resistant Gram-negative bacterial infections. Lancet 2025; 405: 257-272.
6. Diene SM, Rolain JM. Investigation of antibiotic resistance in the genomic era of multidrug-resistant Gram-negative bacilli, especially Enterobacteriaceae, Pseudomonas and Acinetobacter. Expert Rev Anti Infect Ther 2013; 11: 277-296.
7. Karlowsky JA, Lob SH, Raddatz J, DePestel DD, Young K, Motyl MR, et al. In vitro activity of Imipenem/Relebactam and ceftolozane/tazobactam against clinical isolates of Gram-negative Bacilli with difficult-to-treat resistance and multidrug-resistant Phenotypes-study for monitoring antimicrobial resistance trends, United States 2015-2017. Clin Infect Dis 2021; 72: 2112-2120.
8. Terreni M, Taccani M, Pregnolato M. New Antibiotics for Multidrug-Resistant Bacterial Strains: Latest Research Developments and Future Perspectives. Molecules 2021; 26: 2671.
9. Valcek A, Nesporova K, Whiteway C, De Pooter T, De Coster W, Strazisar M, et al. Genomic Analysis of a Strain Collection Containing Multidrug-, Extensively Drug-, Pandrug-, and Carbapenem-Resistant Modern Clinical Isolates of Acinetobacter baumannii. Antimicrob Agents Chemother 2022; 66(9): e0089222.
10. Handa VL, Patel BN, Bhattacharya DA, Kothari RK, Kavathia DG, Vyas BRM. A study of antibiotic resistance pattern of clinical bacterial pathogens isolated from patients in a tertiary care hospital. Front Microbiol 2024; 15: 1383989.
11. CLSI (2024). Performance Standards for Antimicrobial Susceptibility Testing. 34th ed. CLSI supplement M100. Wayne, PA. Clinical and Laboratory Standards Institute.
12. Magiorakos AP, Srinivasan A, Carey RB, Carmeli Y, Falagas ME, Giske CG, et al. Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect 2012; 18: 268-281.
13. Miller JM, Binnicker MJ, Campbell S, Carroll KC, Chapin KC, Gonzalez MD, et al. Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2024 Update by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM). Clin Infect Dis 2024; ciae104. doi: 10.1093/cid/ciae104.
14. Ransom EM, Burnham CD. Routine use of anaerobic blood culture bottles for specimens collected from adults and children enhances microorganism recovery and improves time to positivity. J Clin Microbiol 2022; 60(9): e0050022.
15. Yungyuen T, Chatsuwan T, Plongla R, Kanthawong S, Yordpratum U, Voravuthikunchai SP, et al. Nationwide Surveillance and Molecular Characterization of Critically Drug-Resistant Gram-Negative Bacteria: Results of the Research University Network Thailand Study. Antimicrob Agents Chemother 2021; 65(9): e0067521.
16. Abdeta A, Bitew A, Fentaw S, Tsige E, Assefa D, Lejisa T, et al. Phenotypic characterization of carbapenem non-susceptible gram-negative bacilli isolated from clinical specimens. PLoS One 2021; 16(12): e0256556.
17. Hamadalneel YB, Eltoum SF, Almustafa ZM, Mustafa WS, Abdelsalam FO, Yousif YM, et al. Prevalence and associated factors of multi-drug resistant bacteria among different clinical specimens at wad Medani, Sudan: a four-year, cross-sectional study. Sci Rep 2025; 15: 15596.
18. Kaye KS, Gupta V, Mulgirigama A, Joshi AV, Scangarella-Oman NE, Yu K, et al. Antimicrobial Resistance Trends in Urine Escherichia coli Isolates From Adult and Adolescent Females in the United States From 2011 to 2019: Rising ESBL Strains and Impact on Patient Management. Clin Infect Dis 2021; 73: 1992-1999.
19. Sivarajan V, Ganesh AV, Subramani P, Ganesapandi P, Sivanandan RN, Prakash S, et al. Prevalence and genomic insights of carbapenem resistant and ESBL producing Multidrug resistant Escherichia coli in urinary tract infections. Sci Rep 2025; 15: 2541.
20. Pham TM, Zhang Y, Nevers M, Li H, Khader K, Grad YH, et al. Trends in infection incidence and antimicrobial resistance in the US Veterans Affairs Healthcare System: a nationwide retrospective cohort study (2007-22). Lancet Infect Dis 2024; 24: 1333-1346.
21. Tamma PD, Aitken SL, Bonomo RA, Mathers AJ, van Duin D, Clancy CJ. Infectious Diseases Society of America 2023 Guidance on the Treatment of Antimicrobial Resistant Gram-Negative Infections. Clin Infect Dis 2023; ciad428. doi: 10.1093/cid/ciad428.
22. Tamma PD, Heil EL, Justo JA, Mathers AJ, Satlin MJ, Bonomo RA. Infectious Diseases Society of America 2024 Guidance on the Treatment of Antimicrobial-Resistant Gram-Negative Infections. Clin Infect Dis 2024; ciae403. doi: 10.1093/cid/ciae403.
23. Gutiérrez-Gutiérrez B, Rodríguez-Baño J. Current options for the treatment of infections due to extended-spectrum beta-lactamase-producing Enterobacteriaceae in different groups of patients. Clin Microbiol Infect 2019; 25: 932-942.
24. Dunne MW, Aronin SI, Yu KC, Watts JA, Gupta V. A multicenter analysis of trends in resistance in urinary Enterobacterales isolates from ambulatory patients in the United States: 2011-2020. BMC Infect Dis 2022; 22: 194.
25. Mischnik A, Baumert P, Hamprecht A, Rohde AM, Peter S, Feihl S, et al. In vitro susceptibility to 19 agents other than β-lactams among third-generation cephalosporin-resistant Enterobacteriaceae recovered on hospital admission. J Antimicrob Chemother 2017; 72: 1359-1363.
26. Walker MK, Diao G, Warner S, Babiker A, Neupane M, Strich JR, et al. Carbapenem use in extended-spectrum cephalosporin-resistant Enterobacterales infections in US hospitals and influence of IDSA guidance: a retrospective cohort study. Lancet Infect Dis 2024; 24: 856-867.
27. Riccobene T, Ye G, Lock J, Yu KC, Ai C, Gregory S, et al. Outcomes of inadequate empiric therapy and timing of newer antibacterial therapy in hospitalized adults with culture-positive Enterobacterales and Pseudomonas aeruginosa: a multicenter analysis. BMC Infect Dis 2024; 24: 810.
28. Paterson DL. Impact of antibiotic resistance in gram-negative bacilli on empirical and definitive antibiotic therapy. Clin Infect Dis 2008; 47(Suppl 1): S14-S20.
29. Rodríguez-Baño J, Gutiérrez-Gutiérrez B, Machuca I, Pascual A. Treatment of Infections Caused by Extended-Spectrum-Beta-Lactamase-, AmpC-, and Carbapenemase-Producing Enterobacteriaceae. Clin Microbiol Rev 2018; 31(2): e00079-17.
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| Issue | Vol 18 No 4 (2026) | |
| Section | Original Article(s) | |
| Keywords | ||
| Drug resistance Multiple Bacterial Anti-bacterial agents Microbial sensitivity test Cross infection | ||
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How to Cite
1.
Hanna Aka S. Antimicrobial resistance surveillance of clinical bacterial isolates at Maryamana private hospital, Erbil-Iraq (2023–2025): antibiogram data and multidrug-resistant (MDR)/extensively drug-resistant (XDR)/pandrug-resistant (PDR) classification. Iran J Microbiol. 2026;18(4):490-498.
