Prevalence of Resistance Genes to Biocides in Antibiotic-Resistant Pseudomonas Aeruginosa Clinical Isolates

Prevalence of Resistance Genes to Biocides in Antibiotic-Resistant Pseudomonas Aeruginosa Clinical Isolates | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prevalence of Resistance Genes to Biocides in Antibiotic-Resistant Pseudomonas Aeruginosa Clinical Isolates Farzad Khademi, Shahram Habibzadeh, Hamid Vaez, Mohsen Arzanlou, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-886208/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 3 You are reading this latest preprint version Abstract Background: Biocides are frequently used as preservative, disinfectant and sterilizer against many microorganisms in hospitals, industry and home. However, the resistance rate of Pseudomonas aeruginosa ( P. aeruginosa ) strains to biocides is increasing. The aim of this study was to evaluate the antimicrobial activity of four frequently used biocides against P. aeruginosa and to determine the prevalence of genes involved in biocide resistance. Methods: A total of 76 clinical isolates of P. aeruginosa strains were used in the present study. The minimum inhibitory concentrations (MICs) of four biocides, i.e. chlorhexidine digluconate, benzalkonium chloride, triclosan and formaldehyde, against P. aeruginosa strains were determined using agar dilution method. In addition, the prevalence of biocide resistance genes was determined using the polymerase chain reaction (PCR) method. Results: In the present study, the highest MIC 90 value was observed for benzalkonium chloride (MIC 90 =1024 μg/mL), followed by formaldehyde (MIC 90 =512 μg/mL), triclosan (MIC 90 =512 μg/mL) and chlorhexidine digluconate (MIC 90 =64 μg/mL). Furthermore, the prevalence of qacEΔ1 , qacE , qacG , fabV , cepA and fabI genes were 73.7% (n=56), 26.3% (n=20), 11.8% (n=9), 84.2% (n=64), 81.5% (n=62) and 0% (n=0), respectively. A significant association was observed between the presence of biocide resistance genes and MICs ( p 0.05), except for levofloxacin and norfloxacin antibiotics and qacE and qacG genes ( p <0.05). Conclusion: Our results revealed that chlorhexidine digluconate is the most effective biocide against P. aeruginosa isolates in Ardabil hospitals. However, we recommend continuous monitoring of the antimicrobial activity of biocides and the prevalence of biocide-associated resistance genes for a better prevention of microorganism dissemination and infection control in hospitals. Molecular Biology Pseudomonas aeruginosa resistance triclosan benzalkonium chloride chlorhexidine digluconate formaldehyde 1. Introduction Pseudomonas aeruginosa ( P. aeruginosa ) is a Gram-negative bacillus, which is frequently isolated from hospital environments, especially from medical equipments used in intensive care units (ICUs) [1-3]. P. aeruginosa is an opportunistic human pathogen that is associated with various community-acquired and nosocomial infections such as ventilator-associated pulmonary infections, skin and soft-tissue infections, catheter-related urinary tract infections, eye and ear infections, bloodstream infections, endocarditis and surgical site/transplantation infections [1-3]. Therefore, it seems that hygiene control of surfaces and medical equipments in the hospital settings in terms of P. aeruginosa contamination is important because nosocomial infections are considered as a growing global threat in terms of economical and public health [3]. The most common antiseptic and disinfectant biocides used in clinical settings are chlorhexidine digluconate (a biguanide), benzalkonium chloride (a quaternary ammonium compound), triclosan (a bisphenol) and formaldehyde (an aldehyde) [4, 5]. However, several studies have reported bacterial resistance to various biocides due to the presence of resistance genes. On the other hand, the risk of P. aeruginosa infections in ICU-hospitalized patients is high (up to 30%) despite applying hygiene programs [5]. Such a high prevalence can be attributed to the resistance of P. aeruginosa strains against a variety of antiseptics and disinfectants over time [6]. Another problem is the emergence of multi-drug resistant (MDR) P. aeruginosa strains, which can lead to treatment failure [3]. Interestingly, P. aeruginosa strains have shown cross-resistance to biocides and antibiotics with probably similar mechanisms, thereby making bacterial elimination from hospital environments difficult [5, 7]. Therefore, obtaining information on the prevalence and mechanisms of bacterial resistance to antimicrobial agents and the selection of suitable biocides and antibiotics can be helpful for controlling hospital-acquired infections caused by P. aeruginosa . Several mechanisms of resistance to antibiotics and tolerance to biocides have been identified in P. aeruginosa strains including: 1) simple growth requirements and ability of biofilm formation, 2) enzymatic degradation, 3) target site modification, 4) outer membrane impermeability, and 5) presence of efflux pumps. These properties are involved in bacterial persistence in medical environments and development of nosocomial infections [2, 8-13]. Various compounds are used in hospitals and non-hospital environments in Ardabil city but there is no exact data on the rate of biocide effectiveness against local isolates of P. aeruginosa . Moreover, the mechanisms of biocide resistance in P. aeruginosa clinical isolates of Ardabil are still unclear. Therefore, the aim of the current study was to assess the distribution of biocide resistance genes, namely qacEΔ1 , qacE , qacG , fabV , cepA and fabI , and to determine the minimum inhibitory concentrations (MICs) of various biocides against antibiotic-resistant P. aeruginosa strains isolated from clinical samples in Ardabil. 2. Methods 2.1 Data on P. aeruginosa isolates A total of 76 confirmed clinical P. aeruginosa isolates were obtained from various specimens in Ardabil hospitals and then used to assess the distribution of biocide resistance genes as well as determination of the MICs of four biocides. Drug resistance characteristics of P. aeruginosa isolates was evaluated using the disk diffusion method based on the Clinical and Laboratory Standards Institute (CLSI, 2018) guideline [14]. Data on the prevalence of class I integron, harboring resistance genes to biocides and antibiotics, was used in this study in order to evaluate the association with resistance to biocides. It is noteworthy, the prevalence of antibiotic resistance along with class I integrin rate were previously determined by authors [15, unpublished data]. 2.2 Preparation of biocide solutions Biocides used in this study were chlorhexidine digluconate (20%) (Sigma-Aldrich, USA), benzalkonium chloride (>95%) (Sigma-Aldrich, USA), triclosan (98%) (Bio Basic, Canada) and formaldehyde (37%) (Thermo Fisher Scientific, USA). Stock solutions of antimicrobial agents were prepared in distilled water or water-alcohol for water-insoluble antimicrobial agents. All antibacterial solutions were sterilized using sterile syringe filters (0.22 µm) before use. 2.3 Determination of the MICs of biocides The MICs of antiseptics and disinfectants including chlorhexidine digluconate, benzalkonium chloride, triclosan and formaldehyde were determined by agar dilution technique and according to the CLSI guideline [14]. For this purpose, at first a range of biocide concentrations (0.125-1024 μg/mL) was prepared in Mueller-Hinton agar medium and then a 0.5 McFarland standard concentration of P. aeruginosa isolates (1.5 × 10 8 cfu/mL) was prepared in normal saline. Finally, diluted bacterial inoculum (1:10) (1.5 × 10 7 cfu/mL) was poured onto medium containing different biocides as a spot (10 4 cfu per spot). The plates were incubated at 37 ˚C overnight and then checked in terms of bacterial growth. In the current study, epidemiological cut-off value (ECOFF) for antibacterial susceptibility testing against four biocides was determined equal to MIC 95 (95% rule). Therefore, P. aeruginosa strains with higher MIC value compared with ECOFF value were considered as resistant organisms. 2.4 Detection of biocide resistance genes Extraction of total genomic DNA was done using a simple boiling method. Extracted DNA was stored at -20 ˚C until use for detection of biocide resistance genes. The presence of qacEΔ1 , qacE , qacG , fabV , cepA and fabI genes was detected by specific primers in polymerase chain reaction (PCR). According to the thermal cycling condition for amplification and the oligonucleotide primer sequences presented in Table 1, PCR was performed in a volume of 25 μL containing 20 μL of master mix (Ampliqon, Denmark), 1 μL of each primers (10 μmol/L) and 3 μL of extracted DNA. PCR products were detected by electrophoresis on 1% agarose gel in a TBE 0.5x buffer and then confirmed by sequencing technique. Table 1. Used primers and PCR programs in the present study Gene Primer sequence Thermal cycling condition Amplicon size (bp) Reference 1 2 3 4 Cycle qacEΔ1 F: AATCCATCCCTGTCGGTGTT 94 94 53 72 30 190 16 R: CGCAGCGACTTCCACGATGGGGAT 4 min , 1 min 50 sec 1 min qacE F: TTAGGATGGAGACGAAATTTTCA 94 94 59 72 30 240 This study R: CGCTTAACACCTAGTATTATTACCGT 4 min 1 min 1 min 1 min fabI F: ATGCTGAAAATTGTTTTGAGTGAGA 94 94 59 72 30 830 This study R: TTCATCATCCTTCATAGATTGGCTC 4 min 1 min 1 min 1 min qacG F: TTGAATAATTGGTTATTTCTGGCT 94 94 59 72 30 333 This study R: TTAGTGAACACTTGCCTTAGATAG 4 min 1 min 1 min 1 min cepA F: GCTCGCTGATGTCGGTAGG 94 94 59 72 30 481 This study R: CTGCTGGCAGTGCACTATTC 4 min 1 min 1 min 1 min fabV F: TCGACCTGGTGGTCTACAGC 94 94 59 72 30 530 This study R: GACCTGCTCGATGCAACC 4 min 1 min 1 min 1 min Abbreviations: 1-Initial denaturation, 2-Denaturation, 3-Annealing, 4-Extension. 2.5 Data analysis All data on the MICs of biocides against P. aeruginosa strains , the presence of resistance genes to biocides and P. aeruginosa resistance to various antibiotics were collected and their correlation analyzed by the SPSS software version 16. The Chi-square test was used to analyses and a p value of <0.05 was considered statistically significant. 3. Results In the present study, among 76 P. aeruginosa clinical isolates, the prevalence of qacEΔ1 , qacE , qacG , fabV , cepA and fabI genes were 73.7% (n=56), 26.3% (n=20), 11.8% (n=9), 84.2% (n=64), 81.5% (n=62) and 0%, respectively. As shown in Table 2, the MIC range for various biocides was as follows: benzalkonium chloride 256-1024 μg/mL, formaldehyde 32-512 μg/mL, triclosan 32-512 μg/mL and chlorhexidine digluconate 4-64 μg/mL. In total, the highest MIC 90 was observed for benzalkonium chloride (MIC 90 =1024 μg/mL), followed by formaldehyde (MIC 90 =512 μg/mL), triclosan (MIC 90 =512 μg/mL) and chlorhexidine digluconate (MIC 90 =64 μg/mL), Therefore, it seems that chlorhexidine digluconate and benzalkonium chloride had the highest and the lowest effects, respectively, in terms of growth inhibition of P. aeruginosa isolates in this study. As shown in Table 3, a significant association was observed between the presence of biocide resistance genes and MICs ( p <0.05). Additionally, biocide resistance gene profiles revealed that isolates simultaneously harboring qacEΔ1, cepA and fabV genes are more prevalent (n=35, 46%), while 8 isolates (10.5%) did not harbor any biocide resistance genes (Table 4). Moreover, strains containing biocide resistance genes had higher MIC 50 and MIC 90 values compared with isolates without these genes. In this study, ECOFF for resistance to benzalkonium chloride, triclosan, formaldehyde and chlorhexidine digluconate were determined as 1024, 512, 512 and 64 μg/mL, respectively. Isolates with and without biocide resistance genes were compared in terms of resistance rate to the following antibiotics: piperacillin, piperacillin-tazobactam, ticarcillin-clavulanate, ceftazidime, cefepime, aztreonam, doripenem, imipenem, meropenem, gentamicin, tobramycin, amikacin, netilmicin, ciprofloxacin, levofloxacin, norfloxacin, lomefloxacin and ofloxacin. There was no significant association between the presence of biocide resistance genes and antibiotic resistance ( p >0.05), except for levofloxacin and norfloxacin antibiotics and qacE and qacG genes ( p <0.05). The prevalence of integron I positive P. aeruginosa strains harboring qacEΔ1 gene was 32 out of 76 (42.1%). No significant association was observed between the presence of class I integron and biocide resistance genes ( qacEΔ1, qacE, cepA and fabV) , except for qacG gene ( p = 0.00). Table 2. Minimal inhibitory concentration of biocides against clinical isolates of P. aeruginosa Biocides MIC (μg/mL) ECOFF * (μg/mL) 4 16 32 64 128 256 512 1024 MIC 50 MIC 90 Formaldehyde - - 2 (2.6%) 47 (61.9%) 15 (19.7%) - 12 (15.8%) - 64 512 512 Benzalkonium chloride - - - - - 12 (15.8%) 53 (69.7%) 11 (14.5%) 512 1024 1024 Triclosan - - 11 (14.5%) 3 (3.9%) 5 (6.6%) - 57 (75%) - 512 512 512 Chlorhexidine digluconate 4 (5.3%) 10 (13.2%) 22 (28.9%) 40 (52.6%) - - - - 64 64 64 * ECOFF-epidemiological cut-off value Table 3. Association between biocide resistance genes and MIC Biocide (MIC) Gene Formaldehyde ≤128 256≤ Benzalkonium chloride ≤256 512≤ Triclosan ≤128 256≤ Chlorhexidine ≤16 32≤ qacEΔ1+ 46 10 3 53 5 51 6 50 qacEΔ1- 18 2 9 11 13 7 8 12 p value 0.019 0.00 0.00 0.02 qacE+ 15 6 2 19 2 19 2 19 qacE- 49 6 10 45 16 39 12 43 p value 0.24 0.00 0.426 0.491 qacG+ 7 2 0 9 0 9 0 9 qacG- 57 10 12 55 18 49 14 53 p value 0.88 0.00 0.53 0.32 cepA+ 50 12 7 55 8 54 9 53 cepA- 14 0 5 9 10 4 5 9 p value 0.00 0.03 0.00 0.00 fabV+ 52 12 7 57 8 56 10 54 fabV- 12 0 5 7 10 2 4 8 p value 0.00 0.01 0.00 0.00 Table 4. Gene profile and minimal inhibitory concentration of biocides Formaldehyde Benzalkonium chloride Triclosan Chlorhexidine digluconate Isolate (n) Gene MIC 90 MIC 50 MIC 90 MIC 50 MIC 90 MIC 50 MIC 90 MIC 50 128 64 512 256 64 0.5 32 32 2 qacEΔ1 64 64 512 512 512 512 32 32 1 qacE 64 64 512 512 512 512 64 64 1 qacEΔ1+cepA 128 128 512 512 512 512 64 32 2 qacEΔ1+fabV 64 64 512 256 512 128 64 32 5 cepA+fabV 512 128 1024 512 512 512 64 32 6 qacE+cepA+fabV 512 64 512 512 512 512 64 64 35 qacEΔ1+cepA+fabV 512 64 1024 512 512 512 64 64 7 qacEΔ1+qacE+cepA+fabV 64 64 1024 512 512 512 64 64 2 qacEΔ1+qacG+cepA+fabV 512 128 1024 1024 512 512 64 64 7 qacEΔ1+qacE+qacG+cepA+fabV 64 64 512 256 64 0.5 64 4 8 No gene 4. Discussion Biocides are basic compounds to control microorganism dissemination and ensuing infections and are frequently used as preservative, disinfectant and sterilizer against various microorganisms, in particular P. aeruginosa [17]. One of the most useful biocides against microbes, especially Gram-positive bacteria, is triclosan, which is widely used in toothpastes, soaps and other daily products [17]. Triclosan is an anionic and lipophilic compound, which its anti-bacterial function stems from inhibition of enoyl-acyl-carrier protein reductase (ENR), an enzyme involved in fatty acid synthesis [19, 21]. However, P. aeruginosa strains are inherently resistant to this biocide (MIC>2,000 μg/mL) [21]. ENR enzymes show diversity among different bacteria in terms of sequence and structure, and contain four isozymes including FabI (triclosan- sensitive ENR), FabL, FabV and FabK (triclosan-resistant ENRs) [19, 21]. The FabV isozyme is involved in swimming motility, energy metabolism, protein secretion and adherence, and is responsible for P. aeruginosa resistance to triclosan biocide [21]. Genes encoding FabI and FabV enzymes are found in most bacterial chromosomes such as P. aeruginosa [19, 21]. Bacterial resistance to triclosan is associated with mutation in the active site of fabI gene and the presence of fabV gene [17, 21]. In the current study, the prevalence fabI resistance gene among P. aeruginosa isolates was 0%. Unlike fabI gene, the frequency of fabV gene was high in the present study (84.2%). Zhu et al . showed that deletion of fabV gene confers extremely high susceptibility to triclosan (>2,000 folds) in P. aeruginosa isolates [19]. Similar result was reported by Huang et al . [21]. In this study, the MIC 50 and MIC 90 values of triclosan for fabV resistance gene- harboring P. aeruginosa strains was higher than fabV gene-negative strains (Table 4). Chlorhexidine digluconate, an antiseptic, disinfectant and preservative, is a bactericidal biocide, which has higher antibacterial activity against Gram-positive compared with Gram-negative bacteria [22]. This biocide is used in oral health antiseptics, hand washes and other hygienic solutions. The antibacterial mechanism of chlorhexidine digluconate is via the bacterial cell membrane [17]. However, P. aeruginosa is intrinsically resistant to this biocide due to the presence of an outer membrane [22]. Adaptive resistance to chlorhexidine biocide is mediated by a membrane protein encoded by Acinetobacter chlorhexidine efflux gene ( aceI ). The AceI protein identified in Acinetobacter baumannii is involved in chlorhexidine efflux via an energy-dependent mechanism [23]. However, genes encoding this protein were not identified in P. aeruginosa strains in the current study (data not shown). The antiseptic resistance gene cepA , an efflux pump gene, is associated with chlorhexidine resistance in Gram-negative bacteria causing high chlorhexidine MICs [24, 25]. In our study, 62 (81.5%) cepA -positive strains were found, which is higher than those reported by Mendes et al . (44.5%) and Vijayakumar et al . (63.6%) [24, 25]. According to MIC results, chlorhexidine digluconate is more effective than other biocides against P. aeruginosa isolates (MIC range=4-64 μg/mL) (Table 2). In this study, the presence of cepA gene had variable effects on the MIC 50 and MIC 90 values of chlorhexidine (Table 4). A major biocide resistance mechanism in Gram-negative bacteria including P. aeruginosa is the action of efflux pumps such as the small multidrug resistance family (SMR) [13, 18]. Biocide resistance genes qacEΔ1 , qacE and qacG encode multidrug efflux pumps, which confer resistance to quaternary ammonium compounds like benzalkonium chloride [13, 18]. In our study, the qacEΔ1 gene was observed in 73.7% of clinical isolates of P. aeruginosa , while in studies conducted by Subedi et al ., Roma˜o et al ., Kücken et al ., Helal et al . and Mahzounieh et al . the qacEΔ1 gene was detected in 46.1%, 48%, 10%, 48% and 91.5% of the isolates, respectively [13, 18, 26-28]. According to the reports of Subedi et al ., Kücken et al ., Helal et al . and Mahzounieh et al ., 100%, 2.7%, 13.5% and 50% of P. aeruginosa strains, respectively, had the qacE gene [13, 26-28], while we detected this gene in 26.3% of isolates. The frequency of qacG gene in the present study was 11.8%, which is higher compared to the frequency reported by Subedi et al . (0%) [13]. The MIC 50 and MIC 90 values of benzalkonium chloride were significantly high for qacEΔ1 -, qacE - and qacG -positive P. aeruginosa strains compared with the negative strains (Table 4). Class I integron carries qacEΔ1 and antibiotic resistance genes in clinical isolates of P. aeruginosa [13]. Therefore, P. aeruginosa strains harboring class I integron are resistant to benzalkonium chloride and various antibiotics [26]. Comparison of our current and previous study (unpublished data) showed that the frequency of integron I-positive P. aeruginosa strains harboring qacEΔ1 gene was 32 out of 76 (42.1%). No significant association was observed between the presence of class I integron and biocide resistance genes ( qacEΔ1, qacE, cepA and fabV ), except for qacG gene ( p = 0.00). Formaldehyde is an organic electrophilic biocide, which its mechanism of action involves cross-linking of macromolecules (proteins, RNA and DNA) [17, 29]. Our results indicated that the MIC 50 and MIC 90 values of formaldehyde were high for biocide resistance genes-positive P. aeruginosa strains compared with the negative strains (Table 4). A study by Chuanchuen et al . showed a cross-resistance between biocide and antibiotic resistance. They demonstrated a link between P. aeruginosa exposure to triclosan biocide and efflux-mediated resistance to ciprofloxacin [12]. In the present study, there was no significant association between biocide resistance genes and antibiotic resistance, except for levofloxacin and norfloxacin antibiotics and qacE and qacG genes. However, more studies are needed to substantiate the existence of biocide-antibiotic cross-resistance. 5. Conclusion Our results revealed that the frequency of resistance genes to benzalkonium chloride, chlorhexidine digluconate, triclosan and formaldehyde was high in clinical isolates of P. aeruginosa . Furthermore, P. aeruginosa isolates harboring resistance genes had higher MIC values compared with those lacking these genes. On the other hand, chlorhexidine digluconate was the most effective biocide against P. aeruginosa isolates in Ardabil hospitals. We recommend continuous monitoring of the antimicrobial activity of biocides and biocide-associated resistance genes in order to prevent microorganism dissemination and infection control in hospitals. Abbreviations MIC: Minimum inhibitory concentration; PCR: Polymerase chain reaction; Pseudomonas aeruginosa : P. aeruginosa ; ICU: Intensive care unit; MDR: Multi-drug resistant; CLSI: Clinical and Laboratory Standards Institute; ECOFF: Epidemiological cut-off value; ENR: Enoyl-acyl-carrier protein reductase. Declarations Ethics approval and consent to participate This research was approved by the Research Ethics Committee of Ardabil University of Medical Sciences (approval ID: IR.ARUMS.REC.1398.591). Informed written consent was given to subjects from whom the samples were obtained for this study. Consent for publication Not applicable. Availability of data and materials The data that support the findings of this study are available from the corresponding author on reasonable request. Competing interests The authors declare that there is no conflict of interest. Authors’ contributions MN, SS and SAB collected the data. 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Clin Microbiol Rev 12(1):147–179 Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 15 Sep, 2021 Editor assigned by journal 07 Sep, 2021 First submitted to journal 06 Sep, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-886208","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":52535698,"identity":"95d8dd86-cd8d-4c25-8c23-6c93a3e189b6","order_by":0,"name":"Farzad Khademi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0UlEQVRIiWNgGAWjYBACCQbGByCasZ+BgY1YLcwGYC0zG0jWsuEAsVokG5gZP1f8sZPdfCP52YMPFQzy/GIH8GuRZmBmljzDk2y87UaaueGMMwyGM2cn4Ncix8B/QLJBgjlx240EM2neNoYEg9sEtTAz/2wwqE/cPCP9G3FagA5jk2xIOJy4QSKHSFuA3mezbDhw3HjGmTdlkjPOSBD2i8QBZuabDX+qZfvb07dJfKiwkeeXJqCFQf4BlCEAVilBQDkK4D9AiupRMApGwSgYSQAAB5o96KpjWbEAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0001-6181-4903","institution":"Ardabil University of Medical Sciences: Ardebil University of Medical Sciences","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Farzad","middleName":"","lastName":"Khademi","suffix":""},{"id":52535699,"identity":"5352a828-151b-43c2-a828-17a0079d97cb","order_by":1,"name":"Shahram Habibzadeh","email":"","orcid":"","institution":"Ardabil University of Medical Sciences: Ardebil University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shahram","middleName":"","lastName":"Habibzadeh","suffix":""},{"id":52535700,"identity":"36231eea-b11e-4762-828d-5ee78c3fb6fc","order_by":2,"name":"Hamid Vaez","email":"","orcid":"","institution":"Zabol University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hamid","middleName":"","lastName":"Vaez","suffix":""},{"id":52535701,"identity":"0b5c4670-d866-4f93-9e5e-ad366bb77a02","order_by":3,"name":"Mohsen Arzanlou","email":"","orcid":"","institution":"Ardabil University of Medical Sciences: Ardebil University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mohsen","middleName":"","lastName":"Arzanlou","suffix":""},{"id":52535702,"identity":"fcaab2db-bb34-4924-a87a-707a616f8352","order_by":4,"name":"Somayeh Safarirad","email":"","orcid":"","institution":"Ardabil University of Medical Sciences: Ardebil University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Somayeh","middleName":"","lastName":"Safarirad","suffix":""},{"id":52535703,"identity":"c114cf83-4f38-47ff-91c0-9c07c61f1f7c","order_by":5,"name":"Seyed Ali Bazghandi","email":"","orcid":"","institution":"Ardabil University of Medical Sciences: Ardebil University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Seyed","middleName":"Ali","lastName":"Bazghandi","suffix":""},{"id":52535704,"identity":"0ed0758d-de5e-4cdc-b313-bfdafad4f316","order_by":6,"name":"Amirhossein Sahebkar","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Amirhossein","middleName":"","lastName":"Sahebkar","suffix":""}],"badges":[],"createdAt":"2021-09-08 13:28:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-886208/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-886208/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":13788213,"identity":"0285e32e-423b-48ca-9da6-1bfcbc29df11","added_by":"auto","created_at":"2021-09-20 17:53:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":325528,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-886208/v1/c7029cf0-a955-4d98-9d8e-fc54f93e602f.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003ePrevalence of Resistance Genes to Biocides in Antibiotic-Resistant Pseudomonas Aeruginosa Clinical Isolates\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003e\u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e (\u003cem\u003eP. aeruginosa\u003c/em\u003e) is a Gram-negative bacillus, which is frequently isolated from hospital environments, especially from medical equipments used in intensive care units (ICUs) [1-3]. \u003cem\u003eP. aeruginosa\u003c/em\u003e is an opportunistic human pathogen that is associated with various community-acquired and nosocomial infections such as ventilator-associated pulmonary infections, skin and soft-tissue infections, catheter-related urinary tract infections, eye and ear infections, bloodstream infections, endocarditis and surgical site/transplantation infections [1-3]. Therefore, it seems that hygiene control of surfaces and medical equipments in the hospital settings in terms of\u003cem\u003e\u0026nbsp;P. aeruginosa\u003c/em\u003e contamination is important because nosocomial infections are considered as a growing global threat in terms of economical and public health [3]. The most common antiseptic and disinfectant biocides used in clinical settings are chlorhexidine digluconate (a biguanide), benzalkonium chloride (a quaternary ammonium compound), triclosan (a bisphenol) and formaldehyde (an aldehyde) [4, 5]. However, several studies have reported bacterial resistance to various biocides due to the presence of resistance genes. On the other hand, the risk of \u003cem\u003eP. aeruginosa\u003c/em\u003e infections in ICU-hospitalized patients is high (up to 30%) despite applying hygiene programs [5]. Such a high prevalence can be attributed to the resistance of \u003cem\u003eP. aeruginosa\u003c/em\u003e strains against a variety of antiseptics and disinfectants over time [6].\u0026nbsp;Another problem is the emergence of multi-drug resistant (MDR) \u003cem\u003eP. aeruginosa\u003c/em\u003e strains, which can lead to treatment failure [3]. Interestingly, \u003cem\u003eP. aeruginosa\u003c/em\u003e strains have shown cross-resistance to biocides and antibiotics with probably similar mechanisms, thereby making bacterial elimination from hospital environments difficult [5, 7].\u0026nbsp;Therefore, obtaining information on the prevalence and mechanisms of bacterial resistance to antimicrobial agents and the selection of suitable biocides and antibiotics can be helpful for controlling hospital-acquired infections caused by \u003cem\u003eP. aeruginosa\u003c/em\u003e. Several\u003cem\u003e\u0026nbsp;\u003c/em\u003emechanisms of\u0026nbsp;resistance to antibiotics and tolerance to biocides have been identified in \u003cem\u003eP. aeruginosa\u003c/em\u003e strains including: 1) simple growth requirements and ability of biofilm formation, 2)\u0026nbsp;enzymatic degradation, 3) target site modification, 4) outer membrane impermeability, and 5) presence of efflux pumps. These properties are involved in bacterial persistence in medical environments and development of\u0026nbsp;nosocomial infections [2, 8-13].\u003c/p\u003e\n\u003cp\u003eVarious compounds are used in hospitals and non-hospital environments in Ardabil city but there is no exact data on the rate of biocide effectiveness against local isolates of \u003cem\u003eP. aeruginosa\u003c/em\u003e. Moreover,\u003cem\u003e\u0026nbsp;\u003c/em\u003ethe mechanisms of biocide resistance in \u003cem\u003eP. aeruginosa\u003c/em\u003e clinical isolates of Ardabil are still unclear. Therefore, the aim of the current study was to assess the distribution of biocide resistance genes, namely\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eqacE\u0026Delta;1\u003c/em\u003e,\u0026nbsp;\u003cem\u003eqacE\u003c/em\u003e,\u0026nbsp;\u003cem\u003eqacG\u003c/em\u003e,\u0026nbsp;\u003cem\u003efabV\u003c/em\u003e,\u0026nbsp;\u003cem\u003ecepA\u003c/em\u003e and\u0026nbsp;\u003cem\u003efabI\u003c/em\u003e,\u0026nbsp;and to determine\u0026nbsp;the minimum inhibitory concentrations (MICs) of various biocides against\u0026nbsp;antibiotic-resistant \u003cem\u003eP. aeruginosa\u003c/em\u003e strains isolated from clinical samples\u003cem\u003e\u0026nbsp;\u003c/em\u003ein Ardabil.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e\u003cstrong\u003e2.1 Data on \u003cem\u003eP. aeruginosa\u003c/em\u003e isolates\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 76 confirmed clinical \u003cem\u003eP. aeruginosa\u003c/em\u003e isolates were obtained from various specimens in Ardabil hospitals and then used to assess the distribution of biocide resistance genes as well as determination of the MICs of four biocides. Drug resistance characteristics of \u003cem\u003eP. aeruginosa\u003c/em\u003e isolates was evaluated using the disk diffusion method based on the Clinical and Laboratory Standards Institute (CLSI, 2018) guideline [14]. Data on the prevalence of class I integron, harboring resistance genes to biocides and antibiotics, was used in this study in order to evaluate the association with resistance to biocides. It is noteworthy, the prevalence of antibiotic resistance along with class I integrin rate were previously determined by authors [15, unpublished data].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 Preparation of biocide solutions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBiocides used in this study were\u0026nbsp;chlorhexidine digluconate (20%) (Sigma-Aldrich, USA), benzalkonium chloride (\u0026gt;95%) (Sigma-Aldrich, USA), triclosan (98%) (Bio Basic, Canada) and formaldehyde (37%) (Thermo Fisher Scientific, USA). Stock solutions of antimicrobial agents were prepared in distilled water or water-alcohol for water-insoluble antimicrobial agents. All antibacterial\u0026nbsp;solutions were sterilized using sterile syringe filters (0.22 \u0026micro;m) before use.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3 Determination of the MICs of biocides\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe MICs of antiseptics and disinfectants including chlorhexidine digluconate, benzalkonium chloride, triclosan and formaldehyde were determined by agar dilution technique and according to the CLSI guideline [14]. For this purpose, at first a range of biocide concentrations (0.125-1024 \u0026mu;g/mL) was prepared in Mueller-Hinton agar medium and then a 0.5 McFarland standard concentration of \u003cem\u003eP. aeruginosa\u003c/em\u003e isolates (1.5 \u0026times; 10\u003csup\u003e8\u003c/sup\u003e cfu/mL) was prepared in normal saline. Finally, diluted bacterial inoculum (1:10) (1.5 \u0026times; 10\u003csup\u003e7\u003c/sup\u003e cfu/mL) was poured onto medium containing different biocides as a spot (10\u003csup\u003e4\u003c/sup\u003e cfu per spot). The plates were incubated at 37 ˚C overnight and then checked in terms of bacterial growth. In the current study, epidemiological cut-off value (ECOFF) for antibacterial susceptibility testing against four biocides was determined equal to MIC\u003csub\u003e95\u003c/sub\u003e (95% rule). Therefore, \u003cem\u003eP. aeruginosa\u003c/em\u003e strains with higher MIC value compared with ECOFF value were considered as resistant organisms.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4 Detection of\u003c/strong\u003e \u003cstrong\u003ebiocide resistance genes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eExtraction of total genomic\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eDNA was done using a simple boiling method. Extracted DNA was stored at -20 ˚C until use for detection of biocide resistance genes. The presence of \u003cem\u003eqacE\u0026Delta;1\u003c/em\u003e, \u003cem\u003eqacE\u003c/em\u003e, \u003cem\u003eqacG\u003c/em\u003e, \u003cem\u003efabV\u003c/em\u003e, \u003cem\u003ecepA\u003c/em\u003e and \u003cem\u003efabI\u003c/em\u003e genes was detected by specific primers in polymerase chain reaction (PCR). According to the thermal cycling condition for amplification and the oligonucleotide primer sequences presented in Table 1, PCR was performed in a volume of 25 \u0026mu;L containing 20 \u0026mu;L of master mix (Ampliqon, Denmark), 1 \u0026mu;L of each primers (10 \u0026mu;mol/L) and 3 \u0026mu;L of extracted DNA. PCR products were detected by electrophoresis on 1% agarose gel in a TBE 0.5x buffer and then confirmed by sequencing technique.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Used primers and PCR programs in the present study\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"8.180535966149506%\"\u003e\n \u003cp\u003eGene\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"36.530324400564176%\"\u003e\n \u003cp\u003ePrimer sequence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" valign=\"top\" width=\"30.04231311706629%\"\u003e\n \u003cp\u003eThermal cycling condition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"13.681241184767277%\"\u003e\n \u003cp\u003eAmplicon size (bp)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"11.56558533145275%\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.093457943925234%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.1588785046729%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.093457943925234%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.1588785046729%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.49532710280374%\"\u003e\n \u003cp\u003eCycle\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"8.169014084507042%\"\u003e\n \u003cp\u003e\u003cem\u003eqacE\u0026Delta;1\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"36.478873239436616%\"\u003e\n \u003cp\u003eF: AATCCATCCCTGTCGGTGTT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.056338028169014%\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.774647887323944%\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.056338028169014%\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.774647887323944%\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"6.47887323943662%\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"13.661971830985916%\"\u003e\n \u003cp\u003e190\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"11.549295774647888%\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"60.65573770491803%\"\u003e\n \u003cp\u003eR: CGCAGCGACTTCCACGATGGGGAT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.070257611241217%\"\u003e\n \u003cp\u003e4 min\u003csup\u003e,\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.601873536299765%\"\u003e\n \u003cp\u003e1 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.070257611241217%\"\u003e\n \u003cp\u003e50 sec\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.601873536299765%\"\u003e\n \u003cp\u003e1 min\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"8.169014084507042%\"\u003e\n \u003cp\u003e\u003cem\u003eqacE\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"36.478873239436616%\"\u003e\n \u003cp\u003eF: TTAGGATGGAGACGAAATTTTCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.056338028169014%\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.774647887323944%\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.056338028169014%\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.774647887323944%\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"6.47887323943662%\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"13.661971830985916%\"\u003e\n \u003cp\u003e240\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"11.549295774647888%\"\u003e\n \u003cp\u003eThis study\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"60.65573770491803%\"\u003e\n \u003cp\u003eR: CGCTTAACACCTAGTATTATTACCGT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.070257611241217%\"\u003e\n \u003cp\u003e4 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.601873536299765%\"\u003e\n \u003cp\u003e1 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.070257611241217%\"\u003e\n \u003cp\u003e1 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.601873536299765%\"\u003e\n \u003cp\u003e1 min\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"8.169014084507042%\"\u003e\n \u003cp\u003e\u003cem\u003efabI\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"36.478873239436616%\"\u003e\n \u003cp\u003eF: ATGCTGAAAATTGTTTTGAGTGAGA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.056338028169014%\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.774647887323944%\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.056338028169014%\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.774647887323944%\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"6.47887323943662%\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"13.661971830985916%\"\u003e\n \u003cp\u003e830\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"11.549295774647888%\"\u003e\n \u003cp\u003eThis study\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"60.65573770491803%\"\u003e\n \u003cp\u003eR: TTCATCATCCTTCATAGATTGGCTC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.070257611241217%\"\u003e\n \u003cp\u003e4 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.601873536299765%\"\u003e\n \u003cp\u003e1 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.070257611241217%\"\u003e\n \u003cp\u003e1 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.601873536299765%\"\u003e\n \u003cp\u003e1 min\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"8.169014084507042%\"\u003e\n \u003cp\u003e\u003cem\u003eqacG\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"36.478873239436616%\"\u003e\n \u003cp\u003eF: TTGAATAATTGGTTATTTCTGGCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.056338028169014%\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.774647887323944%\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.056338028169014%\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.774647887323944%\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"6.47887323943662%\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"13.661971830985916%\"\u003e\n \u003cp\u003e333\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"11.549295774647888%\"\u003e\n \u003cp\u003eThis study\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"60.65573770491803%\"\u003e\n \u003cp\u003eR: TTAGTGAACACTTGCCTTAGATAG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.070257611241217%\"\u003e\n \u003cp\u003e4 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.601873536299765%\"\u003e\n \u003cp\u003e1 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.070257611241217%\"\u003e\n \u003cp\u003e1 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.601873536299765%\"\u003e\n \u003cp\u003e1 min\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"8.169014084507042%\"\u003e\n \u003cp\u003e\u003cem\u003ecepA\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"36.478873239436616%\"\u003e\n \u003cp\u003eF: GCTCGCTGATGTCGGTAGG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.056338028169014%\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.774647887323944%\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.056338028169014%\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.774647887323944%\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"6.47887323943662%\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"13.661971830985916%\"\u003e\n \u003cp\u003e481\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"11.549295774647888%\"\u003e\n \u003cp\u003eThis study\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"60.65573770491803%\"\u003e\n \u003cp\u003eR: CTGCTGGCAGTGCACTATTC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.070257611241217%\"\u003e\n \u003cp\u003e4 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.601873536299765%\"\u003e\n \u003cp\u003e1 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.070257611241217%\"\u003e\n \u003cp\u003e1 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.601873536299765%\"\u003e\n \u003cp\u003e1 min\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"8.169014084507042%\"\u003e\n \u003cp\u003e\u003cem\u003efabV\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"36.478873239436616%\"\u003e\n \u003cp\u003eF: TCGACCTGGTGGTCTACAGC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.056338028169014%\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.774647887323944%\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.056338028169014%\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.774647887323944%\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"6.47887323943662%\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"13.661971830985916%\"\u003e\n \u003cp\u003e530\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"11.549295774647888%\"\u003e\n \u003cp\u003eThis study\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"60.65573770491803%\"\u003e\n \u003cp\u003eR: GACCTGCTCGATGCAACC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.070257611241217%\"\u003e\n \u003cp\u003e4 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.601873536299765%\"\u003e\n \u003cp\u003e1 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.070257611241217%\"\u003e\n \u003cp\u003e1 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.601873536299765%\"\u003e\n \u003cp\u003e1 min\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e 1-Initial denaturation, 2-Denaturation, 3-Annealing, 4-Extension.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.5 Data analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data on the MICs of biocides against\u003cem\u003e\u0026nbsp;P. aeruginosa\u003c/em\u003e strains\u003cem\u003e,\u0026nbsp;\u003c/em\u003ethe presence of resistance genes to biocides and\u003cem\u003e\u0026nbsp;P. aeruginosa\u003c/em\u003e resistance to various antibiotics were collected and their correlation analyzed by the SPSS software version 16. The Chi-square test was used to analyses and a \u003cem\u003ep\u003c/em\u003e value of \u0026lt;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eIn the present study, among 76 \u003cem\u003eP. aeruginosa\u003c/em\u003e clinical isolates, the prevalence of \u003cem\u003eqacE\u0026Delta;1\u003c/em\u003e, \u003cem\u003eqacE\u003c/em\u003e, \u003cem\u003eqacG\u003c/em\u003e, \u003cem\u003efabV\u003c/em\u003e, \u003cem\u003ecepA\u003c/em\u003e and \u003cem\u003efabI\u003c/em\u003e genes were 73.7% (n=56), 26.3% (n=20), 11.8% (n=9), 84.2% (n=64), 81.5% (n=62) and 0%, respectively. As shown in Table 2, the MIC range for various biocides was as follows: benzalkonium chloride 256-1024 \u0026mu;g/mL, formaldehyde 32-512 \u0026mu;g/mL, triclosan 32-512 \u0026mu;g/mL and chlorhexidine digluconate 4-64 \u0026mu;g/mL. In total, the highest MIC\u003csub\u003e90\u003c/sub\u003e was observed for benzalkonium chloride (MIC\u003csub\u003e90\u003c/sub\u003e=1024 \u0026mu;g/mL), followed by\u0026nbsp;formaldehyde (MIC\u003csub\u003e90\u003c/sub\u003e=512 \u0026mu;g/mL), triclosan (MIC\u003csub\u003e90\u003c/sub\u003e=512 \u0026mu;g/mL) and\u0026nbsp;chlorhexidine digluconate (MIC\u003csub\u003e90\u003c/sub\u003e=64 \u0026mu;g/mL), Therefore, it seems that chlorhexidine digluconate and benzalkonium chloride had the highest and the lowest effects, respectively, in terms of growth inhibition of \u003cem\u003eP. aeruginosa\u003c/em\u003e isolates in this study. As shown in Table 3, a significant association was observed between the presence of biocide resistance genes and MICs (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05). Additionally, biocide resistance gene profiles revealed that isolates simultaneously harboring \u003cem\u003eqacE\u0026Delta;1, cepA\u0026nbsp;\u003c/em\u003eand\u003cem\u003e\u0026nbsp;fabV\u003c/em\u003e genes are more prevalent (n=35, 46%), while 8 isolates (10.5%) did not harbor any biocide resistance genes (Table 4). Moreover, strains containing biocide resistance genes had higher MIC\u003csub\u003e50\u003c/sub\u003e and MIC\u003csub\u003e90\u003c/sub\u003e values compared with isolates without these genes. In this study, ECOFF for resistance to benzalkonium chloride, triclosan, formaldehyde and chlorhexidine digluconate were determined as 1024, 512, 512 and 64 \u0026mu;g/mL, respectively.\u003c/p\u003e\n\u003cp\u003eIsolates with and without biocide resistance genes were compared in terms of resistance rate to the following antibiotics: piperacillin, piperacillin-tazobactam, ticarcillin-clavulanate, ceftazidime, cefepime, aztreonam, doripenem, imipenem, meropenem, gentamicin, tobramycin, amikacin, netilmicin, ciprofloxacin, levofloxacin, norfloxacin, lomefloxacin and ofloxacin. There was no significant association between\u0026nbsp;the presence of\u0026nbsp;biocide resistance genes and antibiotic resistance (\u003cem\u003ep\u003c/em\u003e\u0026gt;0.05), except for levofloxacin and norfloxacin antibiotics and \u003cem\u003eqacE\u003c/em\u003e and \u003cem\u003eqacG\u003c/em\u003e genes (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05). The prevalence\u0026nbsp;of integron I positive\u003cem\u003e\u0026nbsp;P. aeruginosa\u003c/em\u003e strains harboring \u003cem\u003eqacE\u0026Delta;1\u003c/em\u003e gene was 32 out of 76 (42.1%). No significant association was observed between the presence of class I integron and biocide resistance genes (\u003cem\u003eqacE\u0026Delta;1, qacE, cepA\u0026nbsp;\u003c/em\u003eand\u003cem\u003e\u0026nbsp;fabV)\u003c/em\u003e, except for \u003cem\u003eqacG\u003c/em\u003e gene (\u003cem\u003ep\u003c/em\u003e = 0.00).\u003c/p\u003e\n\u003cp\u003eTable 2. Minimal inhibitory concentration of biocides against clinical isolates of\u003cem\u003e\u0026nbsp;P. aeruginosa\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"121%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003eBiocides\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"10\" valign=\"top\" width=\"77.55102040816327%\"\u003e\n \u003cp\u003eMIC (\u0026mu;g/mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"8.16326530612245%\"\u003e\n \u003cp\u003eECOFF\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e(\u0026mu;g/mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"10%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10%\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10%\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10%\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10%\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10%\"\u003e\n \u003cp\u003e256\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10%\"\u003e\n \u003cp\u003e512\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10%\"\u003e\n \u003cp\u003e1024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10%\"\u003e\n \u003cp\u003eMIC\u003csub\u003e50\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10%\"\u003e\n \u003cp\u003eMIC\u003csub\u003e90\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.217391304347826%\"\u003e\n \u003cp\u003eFormaldehyde\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e(2.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003cp\u003e(61.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003cp\u003e(19.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e(15.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e512\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.695652173913043%\"\u003e\n \u003cp\u003e512\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.217391304347826%\"\u003e\n \u003cp\u003eBenzalkonium chloride\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e(15.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003cp\u003e(69.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003cp\u003e(14.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e512\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e1024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.695652173913043%\"\u003e\n \u003cp\u003e1024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.217391304347826%\"\u003e\n \u003cp\u003eTriclosan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003cp\u003e(14.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e(3.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e(6.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e-\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003cp\u003e(75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e512\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e512\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.695652173913043%\"\u003e\n \u003cp\u003e512\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.217391304347826%\"\u003e\n \u003cp\u003eChlorhexidine digluconate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e(5.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e(13.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003cp\u003e(28.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003cp\u003e(52.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e-\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e-\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.608695652173913%\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.695652173913043%\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e*\u003c/sup\u003eECOFF-epidemiological cut-off value\u003c/p\u003e\n\u003cp\u003eTable 3. Association between biocide resistance genes and MIC\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"23.841059602649008%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Biocide (MIC) \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eGene\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"18.211920529801326%\"\u003e\n \u003cp\u003eFormaldehyde\u003c/p\u003e\n \u003cp\u003e\u0026le;128 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;256\u0026le;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.509933774834437%\"\u003e\n \u003cp\u003eBenzalkonium chloride\u003c/p\u003e\n \u003cp\u003e\u0026le;256 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;512\u0026le;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"17.218543046357617%\"\u003e\n \u003cp\u003eTriclosan\u003c/p\u003e\n \u003cp\u003e\u0026le;128 \u0026nbsp; \u0026nbsp; \u0026nbsp;256\u0026le;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"17.218543046357617%\"\u003e\n \u003cp\u003eChlorhexidine\u003c/p\u003e\n \u003cp\u003e\u0026le;16 \u0026nbsp; \u0026nbsp; \u0026nbsp;32\u0026le;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"23.841059602649008%\"\u003e\n \u003cp\u003e\u003cem\u003eqacE\u0026Delta;1+\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.947019867549669%\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.264900662251655%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.589403973509933%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.920529801324504%\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.437086092715232%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.781456953642384%\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.582781456953642%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"4.635761589403973%\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"23.841059602649008%\"\u003e\n \u003cp\u003e\u003cem\u003eqacE\u0026Delta;1-\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.947019867549669%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.264900662251655%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.589403973509933%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.920529801324504%\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.437086092715232%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.781456953642384%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.582781456953642%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"4.635761589403973%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"23.841059602649008%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"18.211920529801326%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.019\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.509933774834437%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.00\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"17.218543046357617%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.00\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"17.218543046357617%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.02\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"23.841059602649008%\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.947019867549669%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.264900662251655%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.589403973509933%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.920529801324504%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.437086092715232%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.781456953642384%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.582781456953642%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"4.635761589403973%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"23.841059602649008%\"\u003e\n \u003cp\u003e\u003cem\u003eqacE+\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.947019867549669%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.264900662251655%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.589403973509933%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.920529801324504%\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.437086092715232%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.781456953642384%\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.582781456953642%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"4.635761589403973%\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"23.841059602649008%\"\u003e\n \u003cp\u003e\u003cem\u003eqacE-\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.947019867549669%\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.264900662251655%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.589403973509933%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.920529801324504%\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.437086092715232%\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.781456953642384%\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.582781456953642%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"4.635761589403973%\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"23.841059602649008%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"18.211920529801326%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.24\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.509933774834437%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.00\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"17.218543046357617%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.426\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"17.218543046357617%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.491\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"23.841059602649008%\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.947019867549669%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.264900662251655%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.589403973509933%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.920529801324504%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"17.218543046357617%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.582781456953642%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"4.635761589403973%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"23.841059602649008%\"\u003e\n \u003cp\u003e\u003cem\u003eqacG+\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.947019867549669%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.264900662251655%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.589403973509933%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.920529801324504%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.437086092715232%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.781456953642384%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.582781456953642%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"4.635761589403973%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"23.841059602649008%\"\u003e\n \u003cp\u003e\u003cem\u003eqacG-\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.947019867549669%\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.264900662251655%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.589403973509933%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.920529801324504%\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.437086092715232%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.781456953642384%\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.582781456953642%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"4.635761589403973%\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"23.841059602649008%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"18.211920529801326%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.88\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.509933774834437%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.00\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"17.218543046357617%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.53\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"17.218543046357617%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.32\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"23.841059602649008%\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.947019867549669%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.264900662251655%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.589403973509933%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.920529801324504%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.437086092715232%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.781456953642384%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.582781456953642%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"4.635761589403973%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"23.841059602649008%\"\u003e\n \u003cp\u003e\u003cem\u003ecepA+\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.947019867549669%\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.264900662251655%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.589403973509933%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.920529801324504%\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.437086092715232%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.781456953642384%\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.582781456953642%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"4.635761589403973%\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"23.841059602649008%\"\u003e\n \u003cp\u003e\u003cem\u003ecepA-\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.947019867549669%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.264900662251655%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.589403973509933%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.920529801324504%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.437086092715232%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.781456953642384%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.582781456953642%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"4.635761589403973%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"23.841059602649008%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"18.211920529801326%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.00\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.509933774834437%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.03\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"17.218543046357617%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.00\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"17.218543046357617%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.00\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"23.841059602649008%\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.947019867549669%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.264900662251655%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.589403973509933%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.920529801324504%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.437086092715232%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.781456953642384%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.582781456953642%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"4.635761589403973%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"23.841059602649008%\"\u003e\n \u003cp\u003e\u003cem\u003efabV+\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.947019867549669%\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.264900662251655%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.589403973509933%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.920529801324504%\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.437086092715232%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.781456953642384%\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.582781456953642%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"4.635761589403973%\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"23.841059602649008%\"\u003e\n \u003cp\u003e\u003cem\u003efabV-\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.947019867549669%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.264900662251655%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.589403973509933%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.920529801324504%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.437086092715232%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.781456953642384%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.582781456953642%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"4.635761589403973%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"23.841059602649008%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"18.211920529801326%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.00\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.509933774834437%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"17.218543046357617%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.00\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"17.218543046357617%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.00\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 4. Gene profile and minimal inhibitory concentration of biocides\u003c/p\u003e\n\u003cdiv align=\"right\"\u003e\n \u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" dir=\"rtl\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eFormaldehyde\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eBenzalkonium chloride\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eTriclosan\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eChlorhexidine digluconate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003eIsolate\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003eGene\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eMIC\u003csub\u003e90\u003c/sub\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eMIC\u003csub\u003e50\u003c/sub\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eMIC\u003csub\u003e90\u003c/sub\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eMIC\u003csub\u003e50\u003c/sub\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eMIC\u003csub\u003e90\u003c/sub\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eMIC\u003csub\u003e50\u003c/sub\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eMIC\u003csub\u003e90\u003c/sub\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eMIC\u003csub\u003e50\u003c/sub\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e128\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e256\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.5\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e32\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e32\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eqacE\u0026Delta;1\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e32\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e32\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eqacE\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eqacE\u0026Delta;1+cepA\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e128\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e128\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e32\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eqacE\u0026Delta;1+fabV\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e256\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e128\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e32\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003ecepA+fabV\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e128\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e1024\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e32\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eqacE+cepA+fabV\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eqacE\u0026Delta;1+cepA+fabV\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e1024\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eqacE\u0026Delta;1+qacE+cepA+fabV\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e1024\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eqacE\u0026Delta;1+qacG+cepA+fabV\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e128\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e1024\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e1024\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eqacE\u0026Delta;1+qacE+qacG+cepA+fabV\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e512\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e256\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.5\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003eNo gene\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eBiocides are basic compounds to control microorganism dissemination and ensuing infections and are frequently used as preservative, disinfectant and sterilizer against various microorganisms, in particular \u003cem\u003eP. aeruginosa\u0026nbsp;\u003c/em\u003e[17]. One of the most useful biocides against microbes, especially Gram-positive bacteria, is triclosan, which is widely used in toothpastes, soaps\u0026nbsp;and\u0026nbsp;other daily products\u0026nbsp;[17]. Triclosan is\u0026nbsp;an\u0026nbsp;anionic and lipophilic compound, which its anti-bacterial function stems from inhibition of enoyl-acyl-carrier protein reductase (ENR), an enzyme involved in fatty acid synthesis [19, 21]. However, \u003cem\u003eP. aeruginosa\u003c/em\u003e strains are inherently resistant to this biocide (MIC\u0026gt;2,000 \u0026mu;g/mL) [21]. ENR enzymes show diversity among different bacteria in terms of sequence and structure, and contain four isozymes including FabI (triclosan- sensitive ENR), FabL, FabV and FabK (triclosan-resistant ENRs) [19, 21]. The FabV isozyme is involved in swimming motility, energy metabolism, protein secretion and adherence, and is responsible for \u003cem\u003eP. aeruginosa\u003c/em\u003e resistance to triclosan biocide [21]. Genes encoding FabI and FabV enzymes are found in most bacterial chromosomes such as \u003cem\u003eP. aeruginosa\u003c/em\u003e [19, 21]. Bacterial resistance to triclosan is associated with mutation in the active site of \u003cem\u003efabI\u003c/em\u003e gene and the presence of \u003cem\u003efabV\u003c/em\u003e gene [17, 21].\u0026nbsp;In the current study, the prevalence\u003cem\u003e\u0026nbsp;fabI\u003c/em\u003e resistance gene among \u003cem\u003eP. aeruginosa\u003c/em\u003e isolates was 0%. Unlike \u003cem\u003efabI\u003c/em\u003e gene, the frequency of\u003cem\u003e\u0026nbsp;fabV\u0026nbsp;\u003c/em\u003egene was high in the present study (84.2%).\u0026nbsp;Zhu \u003cem\u003eet al\u003c/em\u003e. showed that deletion of \u003cem\u003efabV\u0026nbsp;\u003c/em\u003egene confers extremely high susceptibility to triclosan (\u0026gt;2,000 folds) in \u003cem\u003eP. aeruginosa\u003c/em\u003e isolates [19]. Similar result was\u0026nbsp;reported by Huang\u003cem\u003e\u0026nbsp;et al\u003c/em\u003e. [21]. In this study,\u0026nbsp;the\u0026nbsp;MIC\u003csub\u003e50\u003c/sub\u003e and MIC\u003csub\u003e90\u003c/sub\u003e values of\u0026nbsp;triclosan for\u003cem\u003e\u0026nbsp;fabV\u003c/em\u003e resistance gene-\u0026nbsp;harboring\u003cem\u003e\u0026nbsp;P. aeruginosa\u003c/em\u003e strains was higher than\u0026nbsp;\u003cem\u003efabV\u003c/em\u003e gene-negative strains (Table 4).\u003c/p\u003e\n\u003cp\u003eChlorhexidine\u0026nbsp;digluconate, an antiseptic, disinfectant and preservative, is a bactericidal biocide, which has higher antibacterial activity against Gram-positive compared with Gram-negative bacteria [22]. This biocide is used in oral health antiseptics, hand washes and other hygienic solutions.\u0026nbsp;The antibacterial mechanism of chlorhexidine\u0026nbsp;digluconate is \u003cem\u003evia\u003c/em\u003e the bacterial cell membrane [17]. However,\u003cem\u003e\u0026nbsp;P. aeruginosa\u003c/em\u003e is intrinsically resistant\u0026nbsp;to this biocide\u0026nbsp;due to\u0026nbsp;the presence of an outer membrane [22].\u0026nbsp;Adaptive resistance to chlorhexidine biocide is mediated by a membrane protein encoded by\u003cem\u003e\u0026nbsp;Acinetobacter\u003c/em\u003e chlorhexidine efflux gene (\u003cem\u003eaceI\u003c/em\u003e). The AceI protein identified in \u003cem\u003eAcinetobacter baumannii\u003c/em\u003e is involved in chlorhexidine efflux \u003cem\u003evia\u003c/em\u003e an energy-dependent mechanism [23]. However, genes encoding this protein were not identified in\u003cem\u003e\u0026nbsp;P. aeruginosa\u003c/em\u003e strains in\u0026nbsp;the current study (data not shown). The antiseptic resistance gene\u003cem\u003e\u0026nbsp;cepA\u003c/em\u003e, an efflux pump gene, is associated with\u0026nbsp;chlorhexidine resistance in\u0026nbsp;Gram-negative bacteria causing high chlorhexidine MICs [24, 25].\u0026nbsp;In our study, 62 (81.5%) \u003cem\u003ecepA\u003c/em\u003e-positive strains were found, which is higher than those reported by\u0026nbsp;Mendes \u003cem\u003eet al\u003c/em\u003e. (44.5%) and\u0026nbsp;Vijayakumar \u003cem\u003eet al\u003c/em\u003e. (63.6%) [24, 25]. According to MIC results, chlorhexidine\u0026nbsp;digluconate is more effective than other biocides against \u003cem\u003eP. aeruginosa\u003c/em\u003e isolates\u0026nbsp;(MIC range=4-64 \u0026mu;g/mL) (Table 2). In this study, the presence of \u003cem\u003ecepA\u003c/em\u003e gene had variable effects on the MIC\u003csub\u003e50\u003c/sub\u003e and MIC\u003csub\u003e90\u003c/sub\u003e values of chlorhexidine (Table 4).\u003c/p\u003e\n\u003cp\u003eA major biocide resistance mechanism in Gram-negative bacteria including\u003cem\u003e\u0026nbsp;P. aeruginosa\u003c/em\u003e is\u0026nbsp;the action of efflux pumps such as\u0026nbsp;the small multidrug resistance family (SMR)\u0026nbsp;[13, 18].\u0026nbsp;Biocide resistance genes\u0026nbsp;\u003cem\u003eqacE\u0026Delta;1\u003c/em\u003e, \u003cem\u003eqacE\u003c/em\u003e and \u003cem\u003eqacG\u003c/em\u003e encode multidrug efflux pumps,\u0026nbsp;which\u0026nbsp;confer resistance to\u0026nbsp;quaternary ammonium compounds like benzalkonium chloride [13, 18]. In our study, the\u0026nbsp;\u003cem\u003eqacE\u0026Delta;1\u0026nbsp;\u003c/em\u003egene was observed in\u0026nbsp;73.7%\u0026nbsp;of\u003cem\u003e\u0026nbsp;\u003c/em\u003eclinical isolates of \u003cem\u003eP. aeruginosa\u003c/em\u003e, while in studies conducted by\u0026nbsp;Subedi\u0026nbsp;\u003cem\u003eet al\u003c/em\u003e., Roma\u0026tilde;o \u003cem\u003eet al\u003c/em\u003e., K\u0026uuml;cken \u003cem\u003eet al\u003c/em\u003e., Helal \u003cem\u003eet al\u003c/em\u003e. and Mahzounieh \u003cem\u003eet al\u003c/em\u003e. the\u0026nbsp;\u003cem\u003eqacE\u0026Delta;1\u0026nbsp;\u003c/em\u003egene was detected in 46.1%, 48%, 10%, 48% and 91.5% of the isolates, respectively\u0026nbsp;[13, 18, 26-28]. According to the reports of Subedi\u0026nbsp;\u003cem\u003eet al\u003c/em\u003e., K\u0026uuml;cken\u003cem\u003e\u0026nbsp;et al\u003c/em\u003e., Helal \u003cem\u003eet al\u003c/em\u003e. and Mahzounieh \u003cem\u003eet al\u003c/em\u003e., 100%, 2.7%, 13.5% and 50% of\u0026nbsp;\u003cem\u003eP. aeruginosa\u003c/em\u003e strains, respectively, had the \u003cem\u003eqacE\u003c/em\u003e gene [13,\u0026nbsp;26-28], while we detected this gene\u0026nbsp;in 26.3% of isolates. The frequency of \u003cem\u003eqacG\u003c/em\u003e gene in the present study was 11.8%, which is higher compared to the frequency reported by\u0026nbsp;Subedi\u0026nbsp;\u003cem\u003eet al\u003c/em\u003e. (0%) [13].\u0026nbsp;The\u0026nbsp;MIC\u003csub\u003e50\u003c/sub\u003e and MIC\u003csub\u003e90\u003c/sub\u003e values of benzalkonium chloride were significantly high for\u0026nbsp;\u003cem\u003eqacE\u0026Delta;1\u003c/em\u003e-, \u003cem\u003eqacE\u003c/em\u003e- and \u003cem\u003eqacG\u003c/em\u003e-positive \u003cem\u003eP. aeruginosa\u003c/em\u003e strains compared with the negative strains (Table 4).\u003c/p\u003e\n\u003cp\u003eClass I integron\u0026nbsp;carries\u0026nbsp;\u003cem\u003eqacE\u0026Delta;1\u003c/em\u003e and antibiotic resistance genes in clinical isolates of\u0026nbsp;\u003cem\u003eP. aeruginosa\u003c/em\u003e [13]. Therefore,\u0026nbsp;\u003cem\u003eP. aeruginosa\u003c/em\u003e strains harboring\u0026nbsp;class I integron are resistant to\u0026nbsp;benzalkonium chloride and various antibiotics [26]. Comparison of our current and previous study (unpublished data) showed that the frequency\u0026nbsp;of integron I-positive\u003cem\u003e\u0026nbsp;P. aeruginosa\u003c/em\u003e strains harboring\u0026nbsp;\u003cem\u003eqacE\u0026Delta;1\u003c/em\u003e gene was 32 out of 76 (42.1%).\u0026nbsp;No significant association was observed between the presence of class I integron and biocide resistance genes (\u003cem\u003eqacE\u0026Delta;1, qacE, cepA\u0026nbsp;\u003c/em\u003eand\u003cem\u003e\u0026nbsp;fabV\u003c/em\u003e), except for \u003cem\u003eqacG\u003c/em\u003e gene (\u003cem\u003ep\u003c/em\u003e = 0.00).\u003c/p\u003e\n\u003cp\u003eFormaldehyde is an organic electrophilic biocide, which its mechanism of action involves\u0026nbsp;cross-linking of macromolecules (proteins, RNA and DNA) [17, 29].\u0026nbsp;Our results indicated that\u0026nbsp;the\u0026nbsp;MIC\u003csub\u003e50\u003c/sub\u003e and MIC\u003csub\u003e90\u003c/sub\u003e values of formaldehyde were high for\u0026nbsp;biocide resistance genes-positive \u003cem\u003eP. aeruginosa\u003c/em\u003e strains compared with the negative strains (Table 4).\u003c/p\u003e\n\u003cp\u003eA study by Chuanchuen \u003cem\u003eet al\u003c/em\u003e. showed a cross-resistance between biocide and antibiotic resistance. They demonstrated a link between \u003cem\u003eP. aeruginosa\u003c/em\u003e exposure to\u0026nbsp;triclosan\u0026nbsp;biocide and\u0026nbsp;efflux-mediated resistance to ciprofloxacin [12]. In the present study, there was no significant association between biocide resistance genes and antibiotic resistance, except for levofloxacin and norfloxacin antibiotics and \u003cem\u003eqacE\u003c/em\u003e and \u003cem\u003eqacG\u003c/em\u003e genes. However, more studies are needed to substantiate the existence of biocide-antibiotic cross-resistance.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eOur results revealed that the frequency of resistance genes to benzalkonium chloride, chlorhexidine digluconate, triclosan\u0026nbsp;and\u0026nbsp;formaldehyde was high in clinical isolates of \u003cem\u003eP. aeruginosa\u003c/em\u003e. Furthermore, \u003cem\u003eP. aeruginosa\u003c/em\u003e isolates harboring resistance genes had higher MIC values compared with those lacking these genes. On the other hand, chlorhexidine digluconate was the most effective biocide against \u003cem\u003eP. aeruginosa\u003c/em\u003e isolates in Ardabil hospitals. We recommend continuous monitoring of the antimicrobial activity of biocides and biocide-associated resistance genes in order to prevent microorganism dissemination and infection control in hospitals.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMIC: Minimum inhibitory concentration; PCR: Polymerase chain reaction; \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e: \u003cem\u003eP. aeruginosa\u003c/em\u003e; ICU: Intensive care unit; MDR: Multi-drug resistant; CLSI: Clinical and Laboratory Standards Institute; ECOFF: Epidemiological cut-off value; ENR: Enoyl-acyl-carrier protein reductase.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was approved by the Research Ethics Committee of Ardabil University of Medical Sciences (approval ID: IR.ARUMS.REC.1398.591). Informed written consent was given to subjects from whom the samples were obtained for this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there is no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMN, SS and SAB collected the data. FK and HV analyzed the data and led the writing of the manuscript. SH and MA revised the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by Ardabil University of Medical Sciences, Iran (grant number: 1005761).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to acknowledge the Vice Chancellor for Research and Technology, Ardabil University of Medical Sciences, Ardabil, Iran, due to financial support.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDriscoll JA, Brody SL, Kollef MH (2007) The epidemiology, pathogenesis and treatment of \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e infections. 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J Infect Public Health 11(6):812\u0026ndash;816\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eK\u0026uuml;cken D, Feucht HH, Kaulfers PM (2000) Association of \u003cem\u003eqacE\u003c/em\u003e and \u003cem\u003eqacE∆1\u003c/em\u003e with multiple resistance to antibiotics and antiseptics in clinical isolates of Gram-negative bacteria. FEMS Microbiol Lett 183(1):95\u0026ndash;98\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHelal ZH, Khan MI (2015) \u003cem\u003eQacE\u003c/em\u003e and \u003cem\u003eQacE∆1\u003c/em\u003e Genes and Their Correlation to Antibiotics and Biocides Resistance \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e. Am J Biomed Sci 7(2): 52\u0026ndash;62\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMahzounieh M, Khoshnood S, Ebrahimi A, Habibian S, Yaghoubian M (2014) Detection of antiseptic-resistance genes in \u003cem\u003ePseudomonas\u003c/em\u003e and \u003cem\u003eAcinetobacter\u003c/em\u003e spp. isolated from burn patients. Jundishapur J Nat Pharm Prod 9(2):e15402\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcDonnell G, Russell AD (1999) Antiseptics and disinfectants: activity, action, and resistance. Clin Microbiol Rev 12(1):147\u0026ndash;179\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"molecular-biology-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mole","sideBox":"Learn more about [Molecular Biology Reports](https://www.springer.com/journal/11033)","snPcode":"11033","submissionUrl":"https://submission.nature.com/new-submission/11033/3","title":"Molecular Biology Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Pseudomonas aeruginosa, resistance, triclosan, benzalkonium chloride, chlorhexidine digluconate, formaldehyde","lastPublishedDoi":"10.21203/rs.3.rs-886208/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-886208/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Biocides are frequently used as preservative, disinfectant and sterilizer against many microorganisms in hospitals, industry and home. However, the resistance rate of \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e (\u003cem\u003eP. aeruginosa\u003c/em\u003e) strains to biocides is increasing. The aim of this study was to evaluate the antimicrobial activity of four frequently used biocides against \u003cem\u003eP. aeruginosa\u003c/em\u003e and to determine the prevalence of genes involved in biocide resistance. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA total of 76 clinical isolates of \u003cem\u003eP. aeruginosa\u003c/em\u003e strains were used in the present study.\u003cstrong\u003e \u003c/strong\u003eThe minimum inhibitory concentrations (MICs) of four biocides, \u003cem\u003ei.e.\u003c/em\u003e chlorhexidine digluconate, benzalkonium chloride, triclosan and formaldehyde, against \u003cem\u003eP. aeruginosa\u003c/em\u003e strains were determined using agar dilution method. In addition, the prevalence of biocide resistance genes was determined using the polymerase chain reaction (PCR) method.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eIn the present study, the highest MIC\u003csub\u003e90\u003c/sub\u003e value was observed for benzalkonium chloride (MIC\u003csub\u003e90\u003c/sub\u003e=1024 μg/mL), followed by formaldehyde (MIC\u003csub\u003e90\u003c/sub\u003e=512 μg/mL), triclosan (MIC\u003csub\u003e90\u003c/sub\u003e=512 μg/mL) and chlorhexidine digluconate (MIC\u003csub\u003e90\u003c/sub\u003e=64 μg/mL).\u003cstrong\u003e \u003c/strong\u003eFurthermore, the prevalence of \u003cem\u003eqacEΔ1\u003c/em\u003e, \u003cem\u003eqacE\u003c/em\u003e, \u003cem\u003eqacG\u003c/em\u003e, \u003cem\u003efabV\u003c/em\u003e, \u003cem\u003ecepA\u003c/em\u003e and \u003cem\u003efabI\u003c/em\u003e genes were 73.7% (n=56), 26.3% (n=20), 11.8% (n=9), 84.2% (n=64), 81.5% (n=62) and 0% (n=0), respectively. A significant association was observed between the presence of biocide resistance genes and MICs (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05). Furthermore, there was no significant association between the presence of biocide resistance genes and antibiotic resistance (\u003cem\u003ep\u003c/em\u003e\u0026gt;0.05), except for levofloxacin and norfloxacin antibiotics and \u003cem\u003eqacE\u003c/em\u003e and \u003cem\u003eqacG\u003c/em\u003e genes (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05). \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Our results revealed that chlorhexidine digluconate is the most effective biocide against \u003cem\u003eP. aeruginosa\u003c/em\u003e isolates in Ardabil hospitals. However, we recommend continuous monitoring of the antimicrobial activity of biocides and the prevalence of biocide-associated resistance genes for a better prevention of microorganism dissemination and infection control in hospitals.\u003c/p\u003e","manuscriptTitle":"Prevalence of Resistance Genes to Biocides in Antibiotic-Resistant Pseudomonas Aeruginosa Clinical Isolates","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-09-20 17:53:40","doi":"10.21203/rs.3.rs-886208/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2021-09-15T17:42:15+00:00","index":0,"fulltext":""},{"type":"editorAssigned","content":"","date":"2021-09-07T10:24:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"Molecular Biology Reports","date":"2021-09-07T03:05:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"molecular-biology-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mole","sideBox":"Learn more about [Molecular Biology Reports](https://www.springer.com/journal/11033)","snPcode":"11033","submissionUrl":"https://submission.nature.com/new-submission/11033/3","title":"Molecular Biology Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"214e72e3-5898-4e1f-ad2a-eee98efb6790","owner":[],"postedDate":"September 20th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":7314416,"name":"Molecular Biology"}],"tags":[],"updatedAt":"2021-11-27T08:47:28+00:00","versionOfRecord":[],"versionCreatedAt":"2021-09-20 17:53:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-886208","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-886208","identity":"rs-886208","version":["v1"]},"buildId":"-HB7Z8yhvgn0wM9Nzuekk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}