Plasmid-mediated quinolone resistance among extended-spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae isolated from hospitalized patients, hospital environment and wastewaters in Cameroon

Plasmid-mediated quinolone resistance among extended-spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae isolated from hospitalized patients, hospital environment and wastewaters in Cameroon | 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 Article Plasmid-mediated quinolone resistance among extended-spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae isolated from hospitalized patients, hospital environment and wastewaters in Cameroon Patrice Landry Koudoum, Raspail Carrel Founou, Luria Leslie Founou, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5856415/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Oct, 2025 Read the published version in Scientific Reports → Version 1 posted 19 You are reading this latest preprint version Abstract Introduction Extended-spectrum β-lactamase-producing Escherichia coli (ESBL- Ec ) and Klebsiella pneumoniae (ESBL- Kp ) are among the leading cause of hospital-acquired infections globally. Fluoroquinolone-resistant ESBL- Ec and ESBL- Kp infections have limited therapeutic options. This study investigated the phenotypic and genotypic characteristics of plasmid-mediated quinolone resistance (PMQR) genes in ESBL- Ec and ESBL- Kp circulating among hospitalized patients, the hospital environment, and wastewaters in Cameroon. Method A cross-sectional study was conducted, from February to June 2024 in two healthcare facilities in Yaoundé, Cameroon. Clinical, inanimate surfaces and wastewater samples were collected. Bacteria identification was done using the API20E kit. The ESBL phenotype was detected using the double-disk synergy test and on CHROMagar™ ESBL. Antimicrobial susceptibility testing was performed using the disc diffusion method. Genes conferring resistance to β-lactams and fluoroquinolones were detected using polymerase chain reaction (PCR). Clonal relatedness was assessed using enterobacterial repetitive intergenic consensus (ERIC)-PCR. Results The overall ESBL prevalence across all sources was 16% (103/652). This ESBL prevalence was 10% (49/495) in hospitalized patients, 27% (38/141) in the hospital environment and 100% (16/16) in hospital wastewaters. Nearly all (99.5%) ESBL- Ec and ESBL- Kp were multidrug-resistant. The bla CTX−M was the most prevalent β-lactamase gene with prevalence ranging from 74 to 85%. The main plasmid-mediated quinolone resistance gene was aac-(6’)-Ib with prevalence varying from 57 to 70%. The circulation of ESBL- Kp between both three interfaces as well as within and across the two healthcare facilities was evidenced. Conclusion Our results underscore the crucial need to implement real-time surveillance and monitoring antimicrobial resistance and implement antimicrobial stewardship programs to curb the circulating ESBL- Kp and ESBL- Ec responsible to neonatal sepsis in neonatology unit in healthcare facilities in Cameroon. Finally, genomic surveillance through the One Health approach is needed to fully understand the transmission dynamics of resistant bacteria in healthcare facilities in Cameroon. Biological sciences/Microbiology Biological sciences/Molecular biology Health sciences/Health care Health sciences/Risk factors Hospital-acquired infection Hospital environment Extended-Spectrum β-Lactamase Enterobacterales Plasmid-Mediated Quinolone Resistance One Health Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Antimicrobial Resistance (AMR) remains a global public health threat associated with significant socioeconomic and clinical implications [ 1 , 2 ]. According to a recent systematic analysis, bacterial AMR was associated with 4.71 million deaths of which 1.14 million were directly attributable to AMR [ 3 ]. It has been forecasted that, if no immediate actions are taken, bacterial AMR will be associated with 8.22 million deaths and $ US100 trillion economic loss yearly globally by 2050 [ 3 , 4 ]. The clinical and economic burden of AMR is expected to be disproportionately felt by developing countries, especially those in sub-Saharan Africa where the misuse and overuse of antibiotics coupled with sub-optimal hygiene measures in healthcare settings prevail [ 4 ]. The World Health Organization (WHO) has listed ESBL- Enterobacterales including Escherichia coli and Klebsiella pneumoniae as critical priority bacteria needing research, discovery, and development of new antibiotics [ 1 ]. These pathogens commonly colonize the human intestinal flora where they can become multi-drug resistant (MDR, resistance to one antibiotic of three or more antibiotic families) [ 5 ]. In hospital settings, patients are frequently exposed to antibiotics for prophylactic and therapeutic purposes [ 6 ]. As such, hospital settings are hotspots for AMR, especially ESBL- Enterobacterales (ESBL-E). Antimicrobial resistance is recognized as a “quintessential One Health issue” because it exemplifies the interconnectedness of human, animal, and environmental health [ 7 ]. While the implication of humans and animals in the dissemination of AMR has been well-established, the role played by the environmental interface is yet to be duly understood especially in developing countries [ 8 ]. Correspondingly, it seems to be the most neglected component of the One Health triad, while its contribution to the emergence and spread of AMR remains tremendous [ 8 ]. Wastewaters have been reported as reservoirs for ESBL-E exhibiting numerous β-lactam resistance genes including Cefotaximase-München (CTX-M), Temoniera (TEM) and Sulfhydryl Variable (SHV) from which the most common ESBL variants evolved [ 9 – 13 ]. These ESBL enzymes are threatening as they can hydrolyze almost all β-lactams used in the management of a variety of hospital-acquired infections caused by Escherichia coli and Klebsiella pneumoniae [ 14 , 15 ]. ESBL-encoding genes are usually found on highly mobile genetic elements such as plasmids and as such, they are readily transferable within and across bacterial species. Moreover, ESBL plasmids usually harbor genes that confer co-resistance to several other families of antibiotics including fluoroquinolones [ 16 ]. The mobilization of resistance via plasmids is particularly concerning especially in the context of hospital-acquired infections, where fluoroquinolones are used in the case of ESBL resistance (including carbapenem resistance) [ 17 ]. The emergence and escalation of fluoroquinolone resistance among ESBL- E. coli (ESBL- Ec ) and ESBL- K. pneumoniae (ESBL- Kp ) has further restricted the therapeutic options, exacerbating the challenges of managing these infections [ 18 ]. One mechanism of fluoroquinolone resistance involves chromosomal mutations within the quinolone resistance-determining regions, specifically in the target genes gyr A and par C, which encode for DNA gyrase and topoisomerase IV, respectively [ 19 ]. However, because mutations are genetically rare, the genetic mechanisms for decreasing susceptibility to fluoroquinolone are commonly conferred by Plasmid-Mediated Quinolone Resistance (PMQR) including (i) the modification of fluoroquinolones by aminoglycoside acetylation enzymes encoded by aac(6’)-Ib-cr , (ii) the active efflux of fluoroquinolones using efflux pump systems (encoded by qep A, oqx A and oqx B) and (iii) the protection of DNA gyrase from fluoroquinolone activity by quinolone resistance ( qnr ) proteins frequently encoded by qnr A, qnr B and qnr S [ 17 , 19 – 21 ]. Plasmid-mediated quinolone resistance genes generally confer a low level of fluoroquinolone resistance [ 21 ]. However, their clinical significance stems from the fact that they facilitate the selection of highly resistant mutants [ 19 ]. Studies conducted in Northern [ 22 ], Southern [ 23 ], Western [ 24 ] and Eastern [ 25 ] Africa have also reported the co-existence of ESBL and PMQR genes in E. coli and/or K. pneumoniae . However, there is still a knowledge gap regarding Central Africa. A systematic review revealed that aac(6’)-Ib-cr and qnr S were the most prevalent PMQR genes in clinical Enterobacterales in Africa [ 26 ]. A previous study in Cameroon reported aac(6’)-Ib- cr (62%) and qnr B (20%) as the predominant PMQR genes in clinical E. coli and K. pneumoniae [ 27 ]. The present study, therefore, performed the phenotypic and genotypic characterization of plasmid-mediated quinolone resistance in ESBL- Ec and ESBL- Kp with a view to evidence their circulation among hospitalized patients, hospital environment, and hospital wastewater (HWWs) in two main healthcare facilities in Yaoundé, Cameroon. Results Population characteristics Hospitalized patients Out of 501 eligible clinical samples processed in the laboratory from hospitalized patients, 495 were included in the study. The mean age of the participants was 34.92 ± 28.01 years old (median: 35 years; min:1 day; max:95 years). Infants less than one year (25.05%, 124/495) and patients aged over 60 years (26.06%, 129/495) were the most represented. Fifty-three percent (264/495) of participants were female ( Table 1) . Blood (46.06%, 228/495) and urine (25.86%, 128/495) were the most represented samples. Most patients were hospitalized at the emergency (23.43%, 116) and neonatology (17.37%, 86/495) wards. A higher proportion of clinical samples originated from the Yaoundé University Teaching Hospital (YUTH) (57.98%, 287/495 vs 42.02%, 208/495). Hospital environment and wastewater. Of the 141 environmental samples collected, most samples originated from the beds (39.00%, 55/141), door handles (21.99%, 32/141) and nurse’s table (12.06%, 17/141). A slightly higher number of these samples originated from the YCH (55.32%, 78/141). Regarding wastewater, a total of 16 wastewater samples were collected: 10 from the YCH and 6 from the YUTH. Population characteristics in relation to ESBL- Ec/Kp and PMQR-ESBL- Ec/Kp status Hospitalized patients Overall, 9.90% (49/495) of clinical samples were positive for ESBL- Ec / Kp while 7.88% (39/495) were positive for PMQR-ESBL- Ec/Kp ( Table 1 and Fig. 1 ). ESBL positivity was similar in females (9.85%, 26/264) than in males (9.96%, 23/231). The highest prevalence was in patients over 60 years for ESBL- Ec / Kp (20.16%, 26/129) and PMQR-ESBL- Ec / Kp (15.50%, 20/129). The prevalence of ESBL- Ec / Kp in clinical samples was significantly higher at the YCH compared to the YUTH (13.94% vs 6.97%, p < 0.001 ). Regarding the type of samples, urinary catheters were the most positive for ESBL- Ec / Kp (57.14%, 12/21) and PMQR-ESBL- Ec / Kp (42.86%, 9/21). Hospital environment Overall, 26.95% (38/141) of hospital environment samples were positive for ESBL- Ec / Kp while 15.60% (22/141) were positive for PMQR-ESBL- Ec / Kp . Environmental samples from the YCH were significantly more positive than those from the YUTH for both ESBL- Ec / Kp (39.74% vs 11.11%, p < 0.001 ) and PMQR-ESBL- Ec / Kp (25.64% vs 3.17%, p < 0.001 ( Table 2 ). Samples collected during the second time point were significantly more positive than those of the first time point only for ESBL- Ec / Kp (37.66% vs 27.27%, p = 0.036 ). Hospital wastewaters All the 16 (100%) collected wastewater samples were positive for ESBL- Ec / Kp and PMQR-ESBL- Ec / Kp . The mean ESBL-E (including ESBL- Ec , Klebsiella spp. , Enterobacter spp. , Serratia spp. , and Citrobacter spp. ) bacteria load was higher at the YCH than at the YUTH (5.80x10 5 CFU/mL vs 4.70x10 5 CFU/mL). The final effluent of the YUTH had a mean ESBL bacteria load of 1.90×10 4 CFU/mL. The load of ESBL-E (in log10CFU/mL) was highest in the maternity and neonatology wards of YCH and lowest in the effluents of YUTH as shown in ( supplementary figure S1 ) . Overall prevalence of ESBL- Ec/Kp isolates A total of 182 ESBL-E were isolated from 103 samples in all the three study populations. Among these, 58.79% were ESBL- Kp (107/182) and 41.21% were ESBL- Ec (75/182). Thirty-one percent of the isolates were detected from hospitalized patients (31.31%, 57/182), with a higher proportion of ESBL- Kp (54.39%, 31/57) compared to ESBL- Ec (45.61%, 26/57). In the hospital environment, 45 (24.72%) isolates were identified including 34 ESBL- Kp (75.56%) and 11 ESBL- Ec (24.44%). Eighty isolates (43.95%), including 38 (47.50%) ESBL- Ec and 42 (52.50%) ESBL- Kp were recovered from hospital wastewater. Antibiotic resistance profiles of ESBL- Ec and ESBL- Kp Of the 182 ESBL- Ec and ESBL- Kp isolated from all three interfaces, all except one were concomitantly MDR (99.5%, 181/182). These isolates displayed a high level of resistance (ranging from 98–100%) to all β-lactams tested except for meropenem (31.31%, 57/182) ( Table 3) . Furthermore, most isolates were resistant to tetracycline (97.25%, 177/182), cotrimoxazole (93.95%, 171/182) and ciprofloxacin (87.91%, 160/182). Resistance rates of ESBL- Ec and ESBL- Kp were similar for most antibiotics and across all interfaces. However, a significant disparity in Fosfomycin resistance was observed between clinical (63.15%, 36/57) and hospital environment isolates (8.89%, 4/45). Meropenem resistance was higher in ESBL- Kp (38.31%, 41/107) compared to ESBL- Ec (21.33%, 16/75) across all sources. A strikingly high meropenem resistance was observed in ESBL- Kp isolated from HWWs (47.61%, 20/42). The most prevalent resistance pattern across all sources in ESBL- Ec was AMC-ATM-CIP-CTX-FEP-LEV-SXT/TMP-TET ( supplementary Table S1 online). In ESBL- Kp , the most prevalent resistance pattern was AMC-ATM-CHL-CIP-CN-CTX-FEP-FOX-MEM-LEV-SXT/TMP-TET across all sources ( supplementary Table S2 online) . One clinical ESBL- Ec and four clinical ESBL- Kp were resistant to all antibiotics tested. Similarly, three ESBL- Kp from HWWs resisted to all tested antibiotics. Prevalence of resistance genes Of the 182 ESBL- Ec and ESBL- Kp , 154 (84.61%) harbored at least one of the three β-lactam encoding genes tested ( Table 4 and Fig. 2 ) . Globally, the bla CTX−M (n = 146; 80.22%) was the most prevalent bla gene followed by bla TEM (n = 107; 58.79%) and bla SHV (n = 52; 28.57%). The bla CTX−M prevalence ranged from 74% (n = 42/57; 73.7%) in clinical samples to 85% in wastewater (n = 68; 85.0%). The most prevalent bla gene combination in ESBL- Ec and ESBL- Kp was bla CTX−M + bla TEM (n = 66; 36.26%) ( supplementary Table S3 online). Overall, the aac-(6’)-Ib-cr gene (61.88%, 99/160) was the most detected PMQR gene followed by oqx A (37.50%, 60/160) and qnr B (30.00%, 48/160). The most prevalent PMQR genes in ESBL- Ec were the aac-(6’)-Ib-cr (67.16%, 45/67), qnr B (19.40%, 13/67) and qnr S (17.91%, 12/67). On the other hand, the most prevalent PMQR genes in ESBL- Kp were aac-(6’)-Ib-cr (58.06%, 54/93), oqx A (58.06%, 54/93) and qnr B (37.6%, 35/93). The qnr A was only detected in two clinical ESBL- Ec isolates. The most prevalent PMQR gene combinations were aac-(6’)-Ib-cr + qnr S (10.45%, 7/67) in ESBL- Ec ( Supplementary table S4 ) and aac(6')-Ib-cr + qnr B + oqx A (9.68%, 9/93) in ESBL- Kp ( supplementary Table S5 online) . Co-occurrence of ESBL and PMQR genes Overall, 80.00% (128/160) of ciprofloxacin-resistant ESBL- Ec and ESBL- Kp harbored at least one ESBL and PMQR gene. The bla CTX−M + bla TEM + aac(6’)-Ib-cr + oqxB was the most detected bla and PMQR gene combination in ESBL- Ec (14.93%, 10/67) across all interfaces ( supplementary Table S6 online) . In ESBL- Kp , the bla CTX−M + bla TEM + bla SHV + aac(6')-Ib-cr + qnrB + oqxA was the most detected combination in hospitalized patients (11.54%, 3/26), while bla CTX−M + bla TEM + bla SHV + aac(6’)-Ib-cr + qnrS + oqxA + oqxB (15.38%, 4/26) and bla CTX−M + bla TEM + bla SHV + qnrB + oqxA (7.31%, 3/41) were the most detected combination in hospital environment and wastewaters, respectively ( supplementary Table S7 online) . Clonal relatedness of ESBL- Ec and ESBL- Kp ERIC genotyping grouped ESBL- Ec (Fig. 3 ) into 12 clusters (E1-E12) and ESBL- Kp (Fig. 4 ) in 11 clusters (K1-K11). ESBL- E. coli recovered from hospitalized patients of both hospitals fell principally within clusters E5 and E6 while they were distantly related to those originating from wastewater that clustered together from E9 to E12. In contrast, four ESBL- Kp isolates causing neonatal sepsis (HP121 and HP123 in cluster K7 and HP126 and HP127 in cluster K11) collected on the same day and with a two-day interval at the same hospital (YCH), had 100% similarity and harbored similar bla and PMQR genes. Moreover, in cluster K7, the ERIC profile of an ESBL- Kp isolated from a catheter-associated UTI of a patient (HP105) hospitalized in the ICU of the YUTH was 100% similar to that of an isolate collected from an ICU bed (HE38) of YCH. Interestingly, these two isolates had similar genes conferring resistance to β-lactams and fluoroquinolones ( bla CTX−M , bla TEM , bla SHV , aac(6')-Ib-cr , qnr S, and oqx A) and additionally shared a common ancestor with two isolates from ICU wastewaters of YCH (HWW5 and HWW6). In cluster K3, two ESBL- Kp (HE21 and HE22) isolated the same day from a door handle and a bed of the Surgery ward of the YUTH were closely related and harbored identical resistance genes ( bla CTX−M , bla TEM, and bla SHV) (Fig. 4 ). Discussion To the best of our knowledge, this is the first report of plasmid-mediated quinolone resistance in ESBL- Ec and ESBL- Kp circulating between hospitalized patients and hospital environments during the same period in neonatology unit in Cameroon. The WHO emphasized the critical threat posed by ESBL- Ec and ESBL- Kp to human health, due to their increasing AMR trends, limited therapeutic choices and high transmission across the human-animal-environment interfaces [ 1 ]. The co-occurrence of PMQR in ESBL- Ec and ESBL- KP further exacerbates the threat and jeopardizes the management of infections caused by these bacteria [ 17 ]. The results revealed that 71% (57/80) of Ec and Kp recovered from hospitalized patients were ESBL producers. Previous studies in Cameroon have reported much lower rates of ESBL-E isolated from clinical and urine samples in the West (29.61%) [ 28 ], and North (23%) [ 29 ] regions of Cameroon respectively. The observed higher prevalence in our study is likely because we focused only on hospitalized patients while the aforementioned studies included both community and hospitalized patients and it is well-established that hospitalization increases the likelihood of being infected by MDR bacteria [ 30 ]. A 27% (38/141) ESBL prevalence was detected in hospital environment samples with a predominance of ESBL- Kp (76%, 34/45) compared to ESBL- Ec (24%, 11/45). The predominance of ESBL- Kp can be explained by the biological structure of K. pneumoniae with the capsule and biofilm-forming ability, which enables it to thrive even under detrimental environmental conditions and resist biocides [ 31 ]. The overall ESBL prevalence in environmental samples is elevated compared to that observed in a labor ward in Cameroon (10%) [ 32 ]. Similarly, our results are higher than that observed by the BARNARDS study, which reported a 13.3% ESBL-Gram-negative bacteria prevalence in the environment of neonatal wards of six developing countries [ 33 ]. The discordance in ESBL prevalence might be due to the variance in study settings and study design. All HWW samples were positive for ESBL- Ec and ESBL- Kp , and the mean ESBL-E bacteria load was high (6.16 x10 5 CFU/mL). These results corroborate with those obtained by Garba et al (2023) who detected ESBL-Gram-negative bacteria in nearly all HWW samples (97.5%) in Burkina Faso with a load varying between 1.10 × 10 5 to 5.23 × 10 6 CFU/mL [ 34 ]. The high ESBL-E load observed in hospital wastewaters might be explained by the fact that they act as a melting pot in which there are sub-therapeutic concentrations of antibiotics and there is high transmission of genetic elements harboring resistance determinants between bacteria [ 6 ]. Moreover, the presence of some compounds such as heavy metals in wastewater is known to drive antibiotic resistance [ 35 ]. Intriguingly, the mean ESBL-E load in the final effluent of YUTH (19000 CFU/mL) was 19 times higher than the upper limit of global safety standards which recommend a coliform count ranging from 100–1000 CFU/mL in treated hospital effluents [ 36 ]. This suggests an inefficient wastewater treatment system and the high risk of spread of ESBL- Ec and ESBL- Kp to the community through these contaminated hospital effluents. Antibiotic susceptibility testing revealed that nearly all (99.45%) ESBL- Ec and ESBL- Kp recovered from the three sources were MDR. This high MDR level could probably be explained by the fact that ESBL-encoding genetic determinants are usually located on mobile genetic elements such as plasmids harboring resistance determinants to several antibiotic families of antibiotics other than β-lactam [ 16 ]. In four previous studies carried out in Cameroon from 2022 to 2024 all ESBL- Ec and ESBL- Kp isolated from human samples including clinical and carriage samples (fecal and vaginal) were multidrug-resistant [ 28 , 32 , 37 , 38 ]. Similar MDR levels have been reported amongst ESBL-E isolated from the hospital environment in Ghana (100%) [ 39 ], and HWWs in Burkina Faso (100%) [ 34 ]. The bla CTX−M predominated in ESBL- Ec and ESBL- Kp isolated from hospitalized patients (74%), the hospital environment (80%), and wastewater (85%). This aligns with global trends as bla CTX−M has emerged to be the most prevalent ESBL gene in Enterobacterales worldwide [ 40 ]. A high bla CTX−M prevalence was also reported in ESBL-E among clinical isolates from the Western (84.4%), and Centre regions (100%) of Cameroon [ 41 – 43 ]. However, a Ghanaian study reported a lower prevalence of bla CTX−M (62.5%) among ESBL- Ec isolated from hospitalized patients [ 39 ]. Regarding the hospital environment, Yeboah et al (2024) reported bla TEM (57%) as the most prevalent bla gene among ESBL- Ec in Ghana [ 39 ]. The observed disparity may be due to the difference in the use of third-generation cephalosporin in both countries. Numerous studies have also reported a towering prevalence of bla CTX−M among ESBL-E isolated from hospital wastewater in Nigeria (100%) and Brazil (93%) [ 44 , 45 ]. The prevalence of ESBL encoding genes in ESBL- Ec and ESBL- Kp isolated from wastewaters mirrored to some extent that of clinical and hospital environments. This suggests that wastewater could act as a reservoir of clinically resistant K. pneumoniae and E. coli and their resistance genes. This finding gives ground for the use of wastewater-based epidemiology as a tool for AMR surveillance and monitoring [ 6 ]. Overall, 84.40% of all ciprofloxacin-resistant ESBL- Ec and ESBL- Kp , harbored at least one of the PMQR genes tested. All genes (except qnr A) were detected in all interfaces. Two studies in Cameroon have previously reported PMQR genes among Enterobacterales isolated from clinical samples [ 27 ], and broiler chicken [ 46 ]. To the best of our knowledge, this is the first report of PMQR genes among ESBL- Ec and ESBL- Kp in the hospital environment and wastewaters of Cameroon. The most prevalent PMQR gene across all sources was aac-(6’)-Ib-cr detected with prevalence ranging from 57–70%. Mbamyah et al (2020) reported overlapping aac-(6’)-Ib-cr (62%) prevalence among clinical fluoroquinolone-resistant E. coli and Klebsiella spp from clinical samples in Yaoundé. [ 27 ]. Yeboah et al (2024) reported a similar prevalence of aac-(6’)-Ib -cr among ESBL- Ec isolated from hospitalized patients (62.50%) but lower in the hospital environment (50.00%) in Ghana [ 39 ]. A lower prevalence (41%) has been detected among fluoroquinolone-resistant Ec isolated from hospital wastewaters in Iran [ 47 ]. The varied aac-(6’)-Ib-cr prevalence may reflect the varied fluoroquinolone and aminoside use in each setting [ 19 ]. The qnr genes ( qnr A, qnr B and qnr S) were the second most prevalent PMQR genes identified in hospitalized patients (56%), hospital environment (63%), and wastewaters (43%). The prevalence of qnr genes among patients was higher than that previously reported in clinical samples in Cameroon (31%) [ 27 ]. Similarly, the prevalence in the hospital environment is higher than that detected in the hospital environment of a tertiary hospital in Ghana [ 39 ]. Conversely, the qnr prevalence in this study is lower than that reported in HWWs of Iran [ 47 ]. The observed difference could be attributed to the difference in fluoroquinolone prescription, infection prevention control measures, wastewater management and geographical location. The multidrug efflux pump encoding genes oqx AB were the third most prevalent PMQR genes with a higher prevalence in the hospital environment (76%) compared to hospitalized patients (46%) and wastewaters (40%). The high prevalence of oqx AB in the environmental interface could be explained by the fact that, these genes also confer resistance to biocides, detergents and disinfectants commonly used on hospital surfaces and equipment to control the spread of resistant microorganisms [ 48 ]. The oqx AB prevalence in HWW is significantly lower than that reported in HWWs of Iran (65%) [ 47 ]. Conversely, oqx AB prevalence from hospitalized patients is higher than that reported from hospitalized patients in Iran (21%) [ 47 ] suggesting a difference in the use of different antibiotics which promote the selection of oqx AB-positive E. coli and K. pneumoniae including quinolones, chloramphenicol, nitrofurantoin and tigecycline [ 48 ]. The most recently identified and rare PMQR gene member qep A was detected at rates ranging from 3 to 8% across all sources. The qep A prevalence from hospitalized patients is higher than that reported (2%) in clinical samples in Cameroon [ 27 ]. Other than the changes in fluoroquinolone use in different settings, the observed discrepancies regarding PMQR gene prevalence, may likely be due to the difference in the proportion of Enterobacterales species included in each study as PMQR gene epidemiology is known to vary at the specie-level [ 19 ]. Also, the presence/dominance of additional resistance mechanisms such as topoisomerase IV and gyrase gene mutations may explain the discrepancies between fluoroquinolone-resistant ESBL- Ec and ESBL- Kp with no PMQR genes detected [ 19 ]. The high PMQR gene prevalence is particularly worrying even though they usually grant a low level of resistance because of their ability to favor the selection of highly resistant mutants [ 19 ]. The co-existence of ESBL and PMQR genes evidenced in 80% of the fluoroquinolone-resistant ESBL- Ec and ESBL- Kp isolates in our study is further concerning. This high co-carriage rate is likely because ESBL and PMQR genes are usually located on the same plasmids, increasing the likelihood of co-transmission by horizontal gene transfer between various members of the Enterobacteriaceae family [ 20 ]. The co-occurring of ESBL and PMQR genes contributes to a rise in MDR infections which are more difficult to treat due to the restricted choice of antibiotics [ 49 ]. Genomic fingerprinting revealed the circulation of two neonatal sepsis ESBL- Kp isolates collected on the same day at the Neonatal ward of YCH who had 100% similarity and harbored similar resistance genes. Twenty days later, a similar scenario was observed with two other isolates in the same ward. These results could suggest that there may be neonatal sepsis outbreaks occurring in this neonatal ward. This finding is in line with a systematic review that reported 860 ESBL-E infections in 75 outbreak conditions of neonatal intensive care units worldwide with 15% of included studies from Africa [ 50 ]. The detected putative outbreaks are particularly worrying as ESBL-E neonatal infection outbreaks result in a 31% (95% CI; 20–40%) mortality rate worldwide [ 50 ]. Another interesting finding was that an ESBL- Kp isolated from a catheter-associated UTI from a hospitalized patient at the ICU of the YUTH exhibited 100% similarity to an environmental ICU isolate from the YCH and harbored similar resistance genes. This suggests the dissemination of particular ESBL- Kp strains between ICU patients and the environmental interface. Outbreaks due to ESBL- Kp in ICUs with hospital environment have been reported worldwide [ 51 ]. These two similar ESBL- Kp clustered with two other isolates from the HWWs of the ICU of YCH suggesting that HWWs could serve as potential reservoirs of clinically relevant ESBL- Kp that could lead to community-acquired infections among people living close to these hospitals. However, this study had some limitations. First, monthly sampling of the hospital environment likely reduced the real-time monitoring of clinically relevant ESBL- Ec and ESBL- Kp . Second, topoisomerase and gyrase gene mutations were not investigated to fully elucidate the underlying mechanisms of fluoroquinolone resistance. Finally, PCR-based genotyping was used to assess genetic relatedness while robust methods such as pulse-field gel electrophoresis and whole genome sequencing could have increased phylogenetic resolution. Notwithstanding these limitations, the study helps to address important data gaps on the genetic characteristics and dissemination of fluoroquinolone-resistant and ESBL- Ec and ESBL- Kp in healthcare settings in Cameroon. Conclusion The high prevalence of PMQR genes in ESBL- Ec and ESBL- Kp detected in hospitalized patients, hospital environment, and HWWs underscores the need to implement strong infection prevention and control measures coupled with reinforced antimicrobial stewardship programs to curb the dissemination and growing antibiotic resistance rates among neonatal sepsis in healthcare facilities in Cameroon. Furthermore, efficient HWW treatment systems are needed to prevent the dissemination of these highly resistant bacteria to community settings. The observed widespread resistance to multiple antibiotic families necessitates a revision of the current empirical therapy commonly used within these facilities. Finally, the circulation of ESBL- Kp among hospital environments and hospitalized patients emphasizes the need to implement longitudinal genomic surveillance through the One Health approach to fully understand the transmission dynamics of resistant bacteria in healthcare facilities in Cameroon. Method Study design and site A cross-sectional study was conducted during five months, from February to June 2024 at the Yaoundé Central Hospital (YCH) and the Yaoundé University Teaching Hospital (YUTH), which are second-category and reference hospitals respectively. Study population The primary population was composed of clinical samples collected from hospitalized patients at the two hospitals. The secondary population was the hospital environment of the emergency, intensive care unit (ICU), medicine, neonatology, surgery, cardiology, and maternity wards. The sampling sites included beds, door handles, neonatal incubators, pulse oximeters, sinks, tables and trolleys. The tertiary study population consisted of hospital wastewaters (HWWs) of the emergency, neonatology, maternity, neurosurgery, ICU and surgery wards. The influent and effluents of the wastewater treatment plant (WWTP) of the YUTH was also collected. Sample collection Clinical samples for microbiology analysis including urine, blood, genital and wound swabs were collected following laboratory standard operating procedures of the two healthcare facilities throughout the study period were included. The hospital environment was swabbed at two time points (in March and April). During these time points, 500mL of HWWs from each sampling point was also collected in sterile 1000mL glass containers. HWWs were collected at three sites at the YUTH (emergency, influent, and effluent) while five sites collecting HWWs from seven services were collected at the YCH (emergency, neonatology and maternity, urology and neurosurgery, ICU, and surgery). Samples were transported within four hours to the Research Institute of the Centre of Expertise and Biological Diagnostic of Cameroon ( https://cedbcam.com/ ) for analysis. Ethical considerations All methods were conducted by ethical principles of the Declaration of Helsinki and its later amendments. This study was approved by the Centre Region Ethics Committee for Human Research (N°00098/CRERSHC/2024). Research authorizations from the YCH (N°025/AR/MINSANTE/SG/DHCY/CUAF), YUTH (N°36/AR/CHUY/DG/CAPRC/CEAA) and the CEDBCAM Research Institute (N°2024/03/005/L/CEDBCAM-RI/DG/DRD) were granted. Informed consent was provided by participants, parents or the child’s legal guardian. A unique anonymous code was attributed to each clinical sample for confidentiality purposes. Laboratory analysis Bacteria isolation, identification and ESBL screening All clinical samples were cultured on Eosin-Methylene Blue agar at 37°C for 24 hours. Growing colonies were identified using API20E (BioMérieux, Marcy l’Etoile, France) following the manufacturer’s instructions. ESBL production was screened using CHROMagar ESBL (CHROMagar™ Orientation, Paris, France) and confirmation was done using the double-disk synergy testing. Hospital environment and HWW samples were directly cultured on CHROMagar ESBL. For HWWs, ESBL bacteria culture and enumeration were done following the WHO Global Tricycle Surveillance Project [ 52 ]. Briefly, each water sample was serially diluted at 1/10, 1/100, 1/1000, 1/10000 and 1/100000 and 100uL of each diluent was inoculated on ESBL CHROMagar and incubated for 18-24hrs at 37°C. The next day, bacterial colonies were visually counted and bacterial load expressed as UFC/mL. Each ESBL bacterial colonies were purified and stored at -40°C in cryovials containing trypticase soya broth (Oxoid LTD, Bagingstoke, Hamsphire, England) supplemented with 20% (v/v) glycerol for future analysis. Antimicrobial Susceptibility testing The disk diffusion method was used to assess the susceptibility of all ESBL- Ec and ESBL- Kp against a panel of 13 antibiotics including: ciprofloxacin (5 µg), levofloxacin (5 µg), amoxicillin-clavulanic acid (20–10 µg), cefoxitin (30 µg) cefotaxime (30 µg), cefepime (30 µg), aztreonam (30 µg), meropenem (10 µg), fosfomycin (10 µg), gentamicin (5 µg), trimethoprim-sulfamethoxazole (23.75–1.25 µg), chloramphenicol (10 µg) and tetracycline (30 µg). Interpretation of the inhibition diameters was done following EUCAST 2023 guidelines. An isolate was considered multi-drug resistant (MDR) if it displayed resistance to at least one antibiotic of three or more different families [ 53 ]. Detection of β-lactamase and PMQR resistance genes DNA extraction of all ESBL- Ec and ESBL- Kp was performed using a modified boiling method [ 54 ]. All ESBL- Ec and ESBL- Kp were screened for β-lactamase encoding genes ( bla TEM , bla CTX−M, and bla SHV ) while only ciprofloxacin non-susceptible isolates were screened for the PMQR genes: ( qnr B, qnr S, qnr A, aac(6′)-Ib-cr, oqx A, oqx B, and qep A) using polymerase chain reaction (PCR) with specific primers ( Supplementary Table S7 online). Each amplification occurred in a 10-µL reaction mixture consisting of 5 µL BenTaq polymerase (Beneficial bio, UK), 0.1 µL of each forward and reverse primer (100 µM) set(s), 1.5 µL of template DNA and 3.3 µL (for singleplex reactions: bla SHV, aac(6′)-Ib-cr , oqx A, oqx B and qep A) or 3.1 µL (for bla TEM , and bla CTX−M ) or 2.9 µL (for qnr B, qnr S and qnr A multiplex) of nuclease-free sterile distilled water. Amplification steps included: initial denaturation at 95°C for 3 min, followed by 32 cycles of denaturation at 95°C for 30 seconds, annealing (gene-specific temperature in Supplementary Table S7 online ) for 45 seconds, elongation at 72°C for 45 seconds, and final elongation at 72°C for 6 min in a thermal cycler (Bio-Rad Laboratories, Lasec, South Africa). Generated amplicons were resolved by agarose gel electrophoresis on a 1.5% (w/v) together with a 50bp ladder (Biolabs, New England) and ran in an electric field of 90 V for 45 minutes. Genetic relatedness Clonal relatedness of all ESBL- Ec and ESBL- Kp isolated from hospitalized patients, hospital environment and HWWs was assessed using enterobacterial repetitive intergenic consensus (ERIC)-PCR as previously described [ 55 ]. Generated amplicons were resolved on a 1.5% (w/v) agarose gel run at 110V for 2 hours and visualized under a UV transilluminator. For cluster analysis, gel images and metadata were exported to GelJ software (version 2.1) [ 56 ]. Quality control Quality control of antibiotic discs was performed using E. coli ATCC 25922. PCR amplification was done along with K. pneumoniae ATCC 700603 (for bla SHV ), E. coli ATCC 35218 (for bla TEM ) and previously whole-genome sequenced Enterobacterales harboring all β-lactam and quinolone resistance genes found (unpublished data) were used as positive controls. Statistical analysis Data were entered into a Microsoft Office Excel 2016 spreadsheet and exported to SPSS software (version 27) for data analysis. A sample was considered ESBL-positive when at least an ESBL- EC or KP colony was detected. Proportions of qualitative variables were compared using the Chi-square test and a p-value < 5% was considered statistically significant. Declarations Author’s contributions PLK co-conceptualized the study, performed sample collection, microbiological, genetic and statistical analyses and drafted the article. RCF co-conceptualized the study, vetted study results and revised the article. LLF vetted the results, provided partial funding for the study, and critically revised the article. MDF assisted in sample collection, microbiological, genetic and statistical analyses. GWG & RD assisted in genetic analysis. GAN & HG took part in the design of the study, facilitated the implementation of the study and reviewed the article. SPC co-conceptualized the study and undertook a critical revision of the article. All authors read and approved the final article. Data availability All the data generated during this study are included in this article. Consent for publication Not applicable Competing of interest The authors declare no conflict of interest. Acknowledgements We thank all staff members and participants of these healthcare facilities who agreed to participate to this study. Fundings Raspail Carrel Founou received funding from the Mérieux Institute, Lyon France for the CAREFOOD project. CAREFOOD project has supported all the molecular aspects of this study. This work was also supported by the Research Institute of Centre of Expertise and Biological Diagnostic of Cameroon (CEDBCAM-RI). The funders had no role in the study design, nor the decision to submit the work for publication. Any opinions, findings and conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project. References WHO. 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Tables Table 1: Positivity to ESBL-Ec and Kp and PMQR- ESBL-Ec and Kp according to patient socio-demographic characteristics Variables Modalities Overall ESBL- Ec/Kp PMQR-ESBL- Ec/Kp n(%) n(%) p-value n(%) p-value Overall 495(100) 49 (9.90) 39 (7.88) Sex Female 264 (53.33) 26 (9.85) 0.955 21 (7.96) 0.947 Male 231 (46.67) 23 (9.96) 18 (7.79) Age* Mean (SD) 34.92 (28.01) 51.00 (27.21) 48.68 (28.64) Median 35 62 58 (Min, Max) (1 # , 95) (1 # , 90) (1 # ,90) Age* groups < 1 124 (25.05) 6 (4.84) < 0.001 6 (4.84) 0.029 1-10 17 (3.43) 0 0 11-20 30 (6.06) 2 (6.67) 2 (6.67) 21-30 63 (12.73) 5 (7.94) 4 (6.35) 31-40 60 (12.12) 2 (3.33) 1 (1.67) 41-50 31 (6.26) 5 (16.13) 4 (12.90) 51-60 41 (8.28) 3 (7.32) 2 (6.45) > 60 129 (26.06) 26 (20.16) 20 (15.50) Sample types Urinary catheters 21 (4.24) 12 (57.14) < 0.001 9 (42.86) 0.001 faecal 18 (3.64) 0 0 Urine 128 (25.86) 13 (10.16) 8 (12.50) Throat swab 2 (0.40) 0 0 Blood 228 (46.06) 15 (6.58) 14 (6.14) Ascites fluid 5 (1.01) 0 0 CSF 25 (5.05) 0 0 Pleural fluid 5 (1.01) 0 0 Genital swab 33 (6.67) 1 (3.03) 1 (3.03) Wound 29 (5.86) 7 (24.14) 7 (24.13) Semen 1 (0.20) 1 (100.00) 0 Hospitals YCH 208 (42.02) 29 (13.94) < 0.001 22 (10.58) 0.058 YUTH 287 (57.98) 20 (6.97) 17 (5.92) Wards Cardiology 14 (2.83) 4 (28.57) 0.003 4 (28.57) 0.002 Surgery 24 (4.85) 6 (25.00) 5 (20.83) Gynecology 20 (4.04) 1 (5.00) 1 (5.00) ICU 36 (7.27) 6 (16.67) 6 (16.67) Maternity 46 (9.29) 0 0 Medicine 31 (6.26) 3 (9.68) 1 (3.22) Neonatalogy 86 (17.37) 6 (6.98) 6 (6.77) Others 36 (7.27) 5 (13.89) 2 (5.56) Pediatric 50 (10.10) 0 0 Emergency 116 (23.43) 13 (11.21) 11 (9.48) Urology 36 (7.27) 5 (13.89) 3 (9.09) ICU= Intensive Care Unit, YCH= Yaoundé Central Hospital, YUTH= Yaoundé University Teaching Hospital, CSF= Cerebro-Spinal Fluid, SD= Standard Deviation, Min= Minimum, Max= Maximum, *=Age in years, #=Age in days. Table 2: Positivity to ESBL-Ec/Kp and PMQR-ESBL-Ec/Kp according to patient socio-demographic characteristics to environmental sample characteristics Variables Modalities Overall ESBL- Ec/Kp PMQR-ESBL- Ec/Kp n(%) n(%) p-value n(%) p-value Overall 141 (100) 38 (26.95) 22 (15.60) Hospital YCH 78 (55.32) 31 (39.74) <0.001 20 (25.64) <0.001 YUTH 63 (44.68) 7 (11.11) 2 (3.17) Time point T1 64 (45.39) 9 (14.06) 0.002 6 (9.34) 0.063 T2 77 (54.61) 29 (37.66) 16 (37.66) Sampling sites Bed 55 (39.00) 15 (27.27) 0.036 6 (10.91) 0.014 Door handle 31 (21.99) 9 (29.03) 7 (7.78) Drip stand 13 (9.22) 0 0 Incubator 2 (1.42) 2 (100.00) 2 (100.00) Nurse’s table 17 (12.06) 5 (29.41) 3 (17.65) Saturometer 2 (1.42) 0 0 Sink 4 (2.84) 2 (50.00) 2 (50.00) Table 4 (2.84) 4 (100.00) 1 (25.00) Trolley 9 (6.38) 1 (11.11) 1 (11.11) Ward Cardiology 14 (9.93) 6 (42.86) 0.053 3 (21.43) 0.338 Emergency 26 (18.44) 7 (26.92) 3 (11.54) Medicine 19 (13.48) 0 0 ICU 33 (23.40) 9 (27.27) 6 (18.18) Maternity 8 (5.67) 4 (50.00) 1 (12.50) Neonatalogy 9 (6.38) 4 (44.44) 3 (33.33) Surgery 32 (22.69) 8 (25.00) 6 (18.75) YCH= Yaoundé Central Hospital, YUTH= Yaoundé University Teaching Hospital, ICU= Intensive Care Unit, T1= first time point, T2= second time point. Table 3: Antibiotic resistance rates of ESBL- E. coli and K. pneumoniae isolated from hospitalized patients, hospital environment and wastewaters. Source β-Lactams n (%) Fluoroquinolones n (%) Other antibiotics n (%) AMC CTX FEP ATM MEM CIP LEV CHL CN FF FOX SXT TET ESBL- E. coli Hospitalized patients n=26 26 (100.00) 25 (96.15) 26 (100.00) 25 (96.15) 2 (7.69) 26 (100.00) 22 (84.62) 12 (46.15) 14 (53.85) 17 (65.38) 19 (73.08) 23 (88.46) 25 (96.15) Environment n=11 11 (100.00) 11 (100.00) 11 (100.00) 11 (100.00) 2 (18.18) 7 (63.63) 5 (45.45) 3 (27.27) 2 (18.18) 0 6 (54.54) 11 (100.00) 11 (100.00) Wastewaters n=38 38 (100.00) 38 (100.00) 38 (100.00) 38 (100.00) 12 (31.58) 34 (89.47) 31 (81.58) 11 (28.95) 14 (36.84) 6 (15.79) 24 (63.16) 34 (89.47) 37 (97.36) Total N=75 75 (100.00) 74 (98.67) 75 (100.00) 74 (98.67) 16 (21.33) 67 (89.33) 58 (77.33) 26 (34.67) 30 (40.00) 23 (30.67) 49 (65.33) 68 (90.67) 73 (97.33) Hospitalized patients n=31 31 (100.00) 31 (100.00) 31 (100.00) 29 (93.55) 12 (38.71) 26 (83.87) 28 (90.32) 21 (67.74) 26 (83.87) 19 (61.29) 26 (83.87) 29 (93.55) 31 (100.00) ESBL- K. pneumoniae Environment n=34 34 (100.00) 34 (100.00) 34 (100.00) 34 (100.00) 9 (26.47) 26 (76.47) 23 (67.64) 9 (26.47) 7 (20.59) 4 (11.76) 22 (64.71) 32 (94.11) 33 (97.06) Wastewaters n=42 42 (100.00) 42 (100.00) 42 (100.00) 42 (100.00) 20 (47.62) 41 (97.62) 33 (78.57) 16 (38.10) 19 (45.24) 13 (30.95) 28 (66.67) 42 (100.00) 40 (95.23) Total N=107 107 (100.00) 107 (100.00) 107 (100.00) 105 (98.13) 41 (38.32) 92 (85.98) 84 (78.50) 46 (42.99) 52 (48.60) 36 (33.65) 76 (71.03) 103 (96.26) 104 (97.20) Table 4: Prevalence of β-lactamase and Plasmid-Mediated Quinolone Resistance genes detected among ESBL- and ciprofloxacin-resistant ESBL-Ec and ESBL-Kp respectively β -lactamase genes n (%) Plasmid-Mediated Quinolone Resistance genes n (%) Source bla CTX-M bla TEM bla SHV Source aac-(6’)-Ib-cr qnr A qnr B qnr S oqx A oqx B qep A ESBL- E. coli N=75 Ciprofloxacin-resistant ESBL- E. coli N= 67 Hospitalized patients n=26 19 (73.08) 15 (57.69) 4 (15.39) Hospitalized patients n=26 15 (57.69) 2 (7.69) 8 (30.77) 4 (15.39) 5 (19.23) 2 (7.69) 3 (11.54) Hospital Environment n=11 10 (90.90) 4 (36.36) 1 (9.09) Hospital Environment n=11 4 (57.14) 0 0 1 (14.29) 1 (14.28) 0 0 Wastewaters n=38 36 (94.73) 21 (55.26) 2 (5.56) Wastewaters n=38 26 (76.47) 0 5 (14.71) 7 (19.44) 0 2 (5.88) 6 (17.65) Total N=75 65(86.67) 40 (53.33) 7 (9.33) Total N=75 45 (67.16) 2 (2.99) 13 (19.40) 12 (17.91) 6 (8.96) 4 (5.97) 9 (13.43) Ciprofloxacin-resistant ESBL- K. pneumoniae N= 107 Ciprofloxacin-resistant ESBL- K. pneumoniae N=93 Hospitalized patients n=31 23 (71.30) 22 (70.96) 17 (54.84) Hospitalized patients n=31 18 (69.23) 0 10 (40.00) 7 (26.92) 15 (57.69) 9 (34.62) 0 Hospital Environment n=34 26 (76.47) 20 (58.82) 17 (50.00) Hospital Environment n=34 19 (73.08) 0 9 (34.62) 11 (42.30) 15 (57.69 16 (61.54) 1 (3.85) Wastewaters n=42 32 (76.19) 25 (62.50) 11 (26.19) Wastewaters n=42 17 (41.46) 0 16 (39.02) 7 (17.07) 24 (58.53) 9 (21.95) 0 Total N=107 81 (75.70) 67 (62.62) 45 (42.06) Total N=107 54 (58.06) 0 35 (37.63) 25 (26.88) 54 (58.06) 34 (36.56) 1 (1.08) Overall N= 182 146 (80.22) 107 (58.79) 52 28.57) Overall N= 182 99 (61.88) 2 (1.25) 48 (30.00) 37 (23.13) 60 (37.50) 38 (23.75) 10 (6.25) Additional Declarations No competing interests reported. Supplementary Files KoudoumetalSupplementaryTableandFigures17012025.docx Cite Share Download PDF Status: Published Journal Publication published 21 Oct, 2025 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 15 Apr, 2025 Reviews received at journal 13 Apr, 2025 Reviews received at journal 13 Apr, 2025 Reviews received at journal 11 Apr, 2025 Reviews received at journal 09 Apr, 2025 Reviews received at journal 08 Apr, 2025 Reviewers agreed at journal 25 Mar, 2025 Reviewers agreed at journal 25 Mar, 2025 Reviewers agreed at journal 22 Mar, 2025 Reviewers agreed at journal 22 Mar, 2025 Reviewers agreed at journal 22 Mar, 2025 Reviewers agreed at journal 22 Mar, 2025 Reviewers agreed at journal 21 Mar, 2025 Reviewers agreed at journal 19 Mar, 2025 Reviewers invited by journal 19 Mar, 2025 Editor assigned by journal 19 Mar, 2025 Editor invited by journal 19 Mar, 2025 Submission checks completed at journal 18 Mar, 2025 First submitted to journal 18 Mar, 2025 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. 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Cameroon","correspondingAuthor":false,"prefix":"","firstName":"Patrice","middleName":"Landry","lastName":"Koudoum","suffix":""},{"id":431788242,"identity":"02e77ce3-3367-49a9-b97d-b69a818fe4ed","order_by":1,"name":"Raspail Carrel Founou","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxUlEQVRIiWNgGAWjYBADOQYGHihNLDCGajEmXktiA9Fa+PsPP3v4tc0mfcPxswcffGAwyCeoReLAMXNj2ba03A1n8pINZzAYWDYQ0mLA2GAmLdl2OHfDgRwzaR6GPwYEbTFgZv8G1PI/3eD8G5AWAyK0sPGYSX5sO5BgcCOHSC0SZ3jKpBnOJRvOvPHG2HCGARFa+PuPb5P8UWYnz3c+x/DBhwoitIAAMyhGFA6A3UmUBgYGxh9AQr6BSNWjYBSMglEw8gAALAM3PcXD5WUAAAAASUVORK5CYII=","orcid":"","institution":"Department of Microbiology- Haematology and Immunology, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon","correspondingAuthor":true,"prefix":"","firstName":"Raspail","middleName":"Carrel","lastName":"Founou","suffix":""},{"id":431788244,"identity":"f064f5ad-ebce-4e3b-ab41-7a184391d942","order_by":2,"name":"Luria Leslie Founou","email":"","orcid":"","institution":"Antimicrobial Research Unit, School of Health Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban 4000, South Africa","correspondingAuthor":false,"prefix":"","firstName":"Luria","middleName":"Leslie","lastName":"Founou","suffix":""},{"id":431788246,"identity":"cee5ed68-19e1-45e7-94ce-1bbfd4c70686","order_by":3,"name":"Megane Daina Foueyem","email":"","orcid":"","institution":"Department of Microbiology- Haematology and Immunology, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon","correspondingAuthor":false,"prefix":"","firstName":"Megane","middleName":"Daina","lastName":"Foueyem","suffix":""},{"id":431788248,"identity":"161d493b-d1ea-4b3c-ba97-a4b1a649b0aa","order_by":4,"name":"Giresse Wilfried Guemkam","email":"","orcid":"","institution":"Department of Microbiology- Haematology and Immunology, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon","correspondingAuthor":false,"prefix":"","firstName":"Giresse","middleName":"Wilfried","lastName":"Guemkam","suffix":""},{"id":431788250,"identity":"9e04c32a-ad7d-451a-afbf-53a46823eb7c","order_by":5,"name":"Richard Deuguen","email":"","orcid":"","institution":"Department of Microbiology- Haematology and Immunology, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon","correspondingAuthor":false,"prefix":"","firstName":"Richard","middleName":"","lastName":"Deuguen","suffix":""},{"id":431788254,"identity":"52bd6226-4402-4794-97f4-b66f7630f1f5","order_by":6,"name":"Gisele Ateba Nke","email":"","orcid":"","institution":"Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon","correspondingAuthor":false,"prefix":"","firstName":"Gisele","middleName":"Ateba","lastName":"Nke","suffix":""},{"id":431788255,"identity":"9b453052-647f-4b6c-b4fa-899400c2d950","order_by":7,"name":"Hortense Kamga Gonsu","email":"","orcid":"","institution":"Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon","correspondingAuthor":false,"prefix":"","firstName":"Hortense","middleName":"Kamga","lastName":"Gonsu","suffix":""},{"id":431788257,"identity":"533f5c8a-2fee-4e02-9edb-05948cd3e033","order_by":8,"name":"Simeon Pierre Choukem","email":"","orcid":"","institution":"Department of Internal Medicine and Specialties, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon","correspondingAuthor":false,"prefix":"","firstName":"Simeon","middleName":"Pierre","lastName":"Choukem","suffix":""}],"badges":[],"createdAt":"2025-01-18 17:53:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5856415/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5856415/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-025-15465-z","type":"published","date":"2025-10-21T16:16:52+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":79094931,"identity":"99550f2d-5055-46d2-9d5d-3b766a5885af","added_by":"auto","created_at":"2025-03-24 10:43:41","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":997386,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of study results.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5856415/v1/b5f2500cd133aa841399e9ed.jpg"},{"id":79093658,"identity":"f06f734b-f13b-4189-984c-ecf45f137a05","added_by":"auto","created_at":"2025-03-24 10:35:41","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":371125,"visible":true,"origin":"","legend":"\u003cp\u003eAgarose gel electrophoresis of amplified β-lactamase (\u003cem\u003ebla\u003c/em\u003e\u003csub\u003eCTX-M\u003c/sub\u003e, \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eTEM\u003c/sub\u003e \u0026amp; \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eSHV) \u003c/sub\u003eand PMQR genes (\u003cem\u003eaac(6')-Ib-cr\u003c/em\u003e, \u003cem\u003eqnr\u003c/em\u003eB, \u003cem\u003eqnr\u003c/em\u003eS, \u003cem\u003eoqx\u003c/em\u003eA, \u003cem\u003eoqx\u003c/em\u003eB \u0026amp; \u003cem\u003eqep\u003c/em\u003eA) detected among ESBL- and ciprofloxacin-resistant ESBL-\u003cem\u003eEC/Kp\u003c/em\u003e isolated from hospitalized patients, hospital environment and wastewaters.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5856415/v1/b0d00506257bdb7a4c973ae9.jpg"},{"id":79094930,"identity":"28506a76-a8db-4b90-a803-8c2150bbfb5b","added_by":"auto","created_at":"2025-03-24 10:43:41","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":834143,"visible":true,"origin":"","legend":"\u003cp\u003eGenetic relatedness of ESBL-\u003cem\u003eE. coli\u003c/em\u003e(N=66) isolated from hospitalized patients (n=20), the hospital environment (n=10) and wastewater (n=36) of two healthcare centers in Yaoundé, Cameroon. Genetic relatedness assessed using ERIC PCR and dendogram generated using GelJ software.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5856415/v1/448b8de3a064be475f36a29f.jpg"},{"id":79093663,"identity":"9bec1f00-5d6a-4c27-96c6-717f75bd1ffe","added_by":"auto","created_at":"2025-03-24 10:35:41","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":785564,"visible":true,"origin":"","legend":"\u003cp\u003eGenetic relatedness of ESBL-\u003cem\u003eK. pneumoniae\u003c/em\u003e (N=62) isolated from hospitalized patients (n=25), the hospital environment (n=18) and wastewater (n=19) of two healthcare centers of Yaoundé, Cameroon. Genetic relatedness assessed using ERIC PCR and dendogram generated using GelJ software.\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5856415/v1/a76fa18ab23872de7bfc8410.jpg"},{"id":94490495,"identity":"b8905416-f1e8-4fbd-a6fa-feffb16bc353","added_by":"auto","created_at":"2025-10-27 17:11:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5095782,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5856415/v1/9be1ee97-a762-4299-b975-d48406eb5c9a.pdf"},{"id":79093659,"identity":"e6180309-eb6e-4812-8fdb-92a56b713008","added_by":"auto","created_at":"2025-03-24 10:35:41","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":1334863,"visible":true,"origin":"","legend":"","description":"","filename":"KoudoumetalSupplementaryTableandFigures17012025.docx","url":"https://assets-eu.researchsquare.com/files/rs-5856415/v1/6f7b007bde46cec63759050e.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Plasmid-mediated quinolone resistance among extended-spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae isolated from hospitalized patients, hospital environment and wastewaters in Cameroon","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAntimicrobial Resistance (AMR) remains a global public health threat associated with significant socioeconomic and clinical implications [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. According to a recent systematic analysis, bacterial AMR was associated with 4.71\u0026nbsp;million deaths of which 1.14\u0026nbsp;million were directly attributable to AMR [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. It has been forecasted that, if no immediate actions are taken, bacterial AMR will be associated with 8.22\u0026nbsp;million deaths and \u003cspan\u003e$\u003c/span\u003eUS100 trillion economic loss yearly globally by 2050 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The clinical and economic burden of AMR is expected to be disproportionately felt by developing countries, especially those in sub-Saharan Africa where the misuse and overuse of antibiotics coupled with sub-optimal hygiene measures in healthcare settings prevail [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The World Health Organization (WHO) has listed ESBL-\u003cem\u003eEnterobacterales\u003c/em\u003e including \u003cem\u003eEscherichia coli\u003c/em\u003e and \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e as critical priority bacteria needing research, discovery, and development of new antibiotics [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. These pathogens commonly colonize the human intestinal flora where they can become multi-drug resistant (MDR, resistance to one antibiotic of three or more antibiotic families) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In hospital settings, patients are frequently exposed to antibiotics for prophylactic and therapeutic purposes [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. As such, hospital settings are hotspots for AMR, especially ESBL-\u003cem\u003eEnterobacterales\u003c/em\u003e (ESBL-E).\u003c/p\u003e \u003cp\u003eAntimicrobial resistance is recognized as a \u0026ldquo;quintessential One Health issue\u0026rdquo; because it exemplifies the interconnectedness of human, animal, and environmental health [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. While the implication of humans and animals in the dissemination of AMR has been well-established, the role played by the environmental interface is yet to be duly understood especially in developing countries [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Correspondingly, it seems to be the most neglected component of the One Health triad, while its contribution to the emergence and spread of AMR remains tremendous [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWastewaters have been reported as reservoirs for ESBL-E exhibiting numerous β-lactam resistance genes including Cefotaximase-M\u0026uuml;nchen (CTX-M), Temoniera (TEM) and Sulfhydryl Variable (SHV) from which the most common ESBL variants evolved [\u003cspan additionalcitationids=\"CR10 CR11 CR12\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. These ESBL enzymes are threatening as they can hydrolyze almost all β-lactams used in the management of a variety of hospital-acquired infections caused by \u003cem\u003eEscherichia coli\u003c/em\u003e and \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. ESBL-encoding genes are usually found on highly mobile genetic elements such as plasmids and as such, they are readily transferable within and across bacterial species. Moreover, ESBL plasmids usually harbor genes that confer co-resistance to several other families of antibiotics including fluoroquinolones [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe mobilization of resistance via plasmids is particularly concerning especially in the context of hospital-acquired infections, where fluoroquinolones are used in the case of ESBL resistance (including carbapenem resistance) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The emergence and escalation of fluoroquinolone resistance among ESBL-\u003cem\u003eE. coli\u003c/em\u003e (ESBL-\u003cem\u003eEc\u003c/em\u003e) and ESBL-\u003cem\u003eK. pneumoniae\u003c/em\u003e (ESBL-\u003cem\u003eKp\u003c/em\u003e) has further restricted the therapeutic options, exacerbating the challenges of managing these infections [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. One mechanism of fluoroquinolone resistance involves chromosomal mutations within the quinolone resistance-determining regions, specifically in the target genes \u003cem\u003egyr\u003c/em\u003eA and \u003cem\u003epar\u003c/em\u003eC, which encode for DNA gyrase and topoisomerase IV, respectively [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. However, because mutations are genetically rare, the genetic mechanisms for decreasing susceptibility to fluoroquinolone are commonly conferred by Plasmid-Mediated Quinolone Resistance (PMQR) including (i) the modification of fluoroquinolones by aminoglycoside acetylation enzymes encoded by \u003cem\u003eaac(6\u0026rsquo;)-Ib-cr\u003c/em\u003e, (ii) the active efflux of fluoroquinolones using efflux pump systems (encoded by \u003cem\u003eqep\u003c/em\u003eA, \u003cem\u003eoqx\u003c/em\u003eA and \u003cem\u003eoqx\u003c/em\u003eB) and (iii) the protection of DNA gyrase from fluoroquinolone activity by quinolone resistance (\u003cem\u003eqnr\u003c/em\u003e) proteins frequently encoded by \u003cem\u003eqnr\u003c/em\u003eA, \u003cem\u003eqnr\u003c/em\u003eB and \u003cem\u003eqnr\u003c/em\u003eS [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Plasmid-mediated quinolone resistance genes generally confer a low level of fluoroquinolone resistance [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, their clinical significance stems from the fact that they facilitate the selection of highly resistant mutants [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStudies conducted in Northern [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], Southern [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], Western [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] and Eastern [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] Africa have also reported the co-existence of ESBL and PMQR genes in \u003cem\u003eE. coli\u003c/em\u003e and/or \u003cem\u003eK. pneumoniae\u003c/em\u003e. However, there is still a knowledge gap regarding Central Africa. A systematic review revealed that \u003cem\u003eaac(6\u0026rsquo;)-Ib-cr\u003c/em\u003e and \u003cem\u003eqnr\u003c/em\u003eS were the most prevalent PMQR genes in clinical \u003cem\u003eEnterobacterales\u003c/em\u003e in Africa [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. A previous study in Cameroon reported \u003cem\u003eaac(6\u0026rsquo;)-Ib-\u003c/em\u003ecr (62%) and \u003cem\u003eqnr\u003c/em\u003eB (20%) as the predominant PMQR genes in clinical \u003cem\u003eE. coli\u003c/em\u003e and \u003cem\u003eK. pneumoniae\u003c/em\u003e [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The present study, therefore, performed the phenotypic and genotypic characterization of plasmid-mediated quinolone resistance in ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e with a view to evidence their circulation among hospitalized patients, hospital environment, and hospital wastewater (HWWs) in two main healthcare facilities in Yaound\u0026eacute;, Cameroon.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePopulation characteristics\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eHospitalized patients\u003c/h2\u003e \u003cp\u003eOut of 501 eligible clinical samples processed in the laboratory from hospitalized patients, 495 were included in the study. The mean age of the participants was 34.92\u0026thinsp;\u0026plusmn;\u0026thinsp;28.01 years old (median: 35 years; min:1 day; max:95 years). Infants less than one year (25.05%, 124/495) and patients aged over 60 years (26.06%, 129/495) were the most represented. Fifty-three percent (264/495) of participants were female (\u003cb\u003eTable\u0026nbsp;1)\u003c/b\u003e. Blood (46.06%, 228/495) and urine (25.86%, 128/495) were the most represented samples. Most patients were hospitalized at the emergency (23.43%, 116) and neonatology (17.37%, 86/495) wards. A higher proportion of clinical samples originated from the Yaound\u0026eacute; University Teaching Hospital (YUTH) (57.98%, 287/495 vs 42.02%, 208/495).\u003c/p\u003e \u003cp\u003e \u003cb\u003eHospital environment and wastewater.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eOf the 141 environmental samples collected, most samples originated from the beds (39.00%, 55/141), door handles (21.99%, 32/141) and nurse\u0026rsquo;s table (12.06%, 17/141). A slightly higher number of these samples originated from the YCH (55.32%, 78/141). Regarding wastewater, a total of 16 wastewater samples were collected: 10 from the YCH and 6 from the YUTH.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePopulation characteristics in relation to ESBL-\u003c/b\u003e \u003cb\u003eEc/Kp\u003c/b\u003e \u003cb\u003eand PMQR-ESBL-\u003c/b\u003e\u003cb\u003eEc/Kp\u003c/b\u003e \u003cb\u003estatus\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eHospitalized patients\u003c/h3\u003e\n\u003cp\u003eOverall, 9.90% (49/495) of clinical samples were positive for ESBL-\u003cem\u003eEc\u003c/em\u003e/\u003cem\u003eKp\u003c/em\u003e while 7.88% (39/495) were positive for PMQR-ESBL-\u003cem\u003eEc/Kp\u003c/em\u003e (\u003cb\u003eTable\u0026nbsp;1\u003c/b\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e ESBL positivity was similar in females (9.85%, 26/264) than in males (9.96%, 23/231). The highest prevalence was in patients over 60 years for ESBL-\u003cem\u003eEc\u003c/em\u003e/\u003cem\u003eKp\u003c/em\u003e (20.16%, 26/129) and PMQR-ESBL-\u003cem\u003eEc\u003c/em\u003e/\u003cem\u003eKp\u003c/em\u003e (15.50%, 20/129). The prevalence of ESBL-\u003cem\u003eEc\u003c/em\u003e/\u003cem\u003eKp\u003c/em\u003e in clinical samples was significantly higher at the YCH compared to the YUTH (13.94% vs 6.97%, \u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e). Regarding the type of samples, urinary catheters were the most positive for ESBL-\u003cem\u003eEc\u003c/em\u003e/\u003cem\u003eKp\u003c/em\u003e (57.14%, 12/21) and PMQR-ESBL-\u003cem\u003eEc\u003c/em\u003e/\u003cem\u003eKp\u003c/em\u003e (42.86%, 9/21).\u003c/p\u003e\n\u003ch3\u003eHospital environment\u003c/h3\u003e\n\u003cp\u003eOverall, 26.95% (38/141) of hospital environment samples were positive for ESBL-\u003cem\u003eEc\u003c/em\u003e/\u003cem\u003eKp\u003c/em\u003e while 15.60% (22/141) were positive for PMQR-ESBL-\u003cem\u003eEc\u003c/em\u003e/\u003cem\u003eKp\u003c/em\u003e. Environmental samples from the YCH were significantly more positive than those from the YUTH for both ESBL-\u003cem\u003eEc\u003c/em\u003e/\u003cem\u003eKp\u003c/em\u003e (39.74% vs 11.11%, \u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e) and PMQR-ESBL-\u003cem\u003eEc\u003c/em\u003e/\u003cem\u003eKp\u003c/em\u003e (25.64% vs 3.17%, \u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e (\u003cb\u003eTable\u0026nbsp;2\u003c/b\u003e). Samples collected during the second time point were significantly more positive than those of the first time point only for ESBL-\u003cem\u003eEc\u003c/em\u003e/\u003cem\u003eKp\u003c/em\u003e (37.66% vs 27.27%, \u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.036\u003c/em\u003e).\u003c/p\u003e\n\u003ch3\u003eHospital wastewaters\u003c/h3\u003e\n\u003cp\u003eAll the 16 (100%) collected wastewater samples were positive for ESBL-\u003cem\u003eEc\u003c/em\u003e/\u003cem\u003eKp\u003c/em\u003e and PMQR-ESBL-\u003cem\u003eEc\u003c/em\u003e/\u003cem\u003eKp\u003c/em\u003e. The mean ESBL-E (including ESBL-\u003cem\u003eEc\u003c/em\u003e, \u003cem\u003eKlebsiella spp.\u003c/em\u003e, \u003cem\u003eEnterobacter spp.\u003c/em\u003e, \u003cem\u003eSerratia spp.\u003c/em\u003e, and \u003cem\u003eCitrobacter spp.\u003c/em\u003e) bacteria load was higher at the YCH than at the YUTH (5.80x10\u003csup\u003e5\u003c/sup\u003e CFU/mL vs 4.70x10\u003csup\u003e5\u003c/sup\u003e CFU/mL). The final effluent of the YUTH had a mean ESBL bacteria load of 1.90\u0026times;10\u003csup\u003e4\u003c/sup\u003e CFU/mL. The load of ESBL-E (in log10CFU/mL) was highest in the maternity and neonatology wards of YCH and lowest in the effluents of YUTH as shown in (\u003cb\u003esupplementary figure \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003eOverall prevalence of ESBL-\u003c/b\u003e \u003cb\u003eEc/Kp\u003c/b\u003e \u003cb\u003eisolates\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA total of 182 ESBL-E were isolated from 103 samples in all the three study populations. Among these, 58.79% were ESBL-\u003cem\u003eKp\u003c/em\u003e (107/182) and 41.21% were ESBL-\u003cem\u003eEc\u003c/em\u003e (75/182). Thirty-one percent of the isolates were detected from hospitalized patients (31.31%, 57/182), with a higher proportion of ESBL-\u003cem\u003eKp\u003c/em\u003e (54.39%, 31/57) compared to ESBL-\u003cem\u003eEc\u003c/em\u003e (45.61%, 26/57). In the hospital environment, 45 (24.72%) isolates were identified including 34 ESBL-\u003cem\u003eKp\u003c/em\u003e (75.56%) and 11 ESBL-\u003cem\u003eEc\u003c/em\u003e (24.44%). Eighty isolates (43.95%), including 38 (47.50%) ESBL-\u003cem\u003eEc\u003c/em\u003e and 42 (52.50%) ESBL-\u003cem\u003eKp\u003c/em\u003e were recovered from hospital wastewater.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAntibiotic resistance profiles of ESBL-\u003c/b\u003e \u003cb\u003eEc\u003c/b\u003e \u003cb\u003eand ESBL-\u003c/b\u003e\u003cb\u003eKp\u003c/b\u003e\u003c/p\u003e \u003cp\u003eOf the 182 ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e isolated from all three interfaces, all except one were concomitantly MDR (99.5%, 181/182). These isolates displayed a high level of resistance (ranging from 98\u0026ndash;100%) to all β-lactams tested except for meropenem (31.31%, 57/182) (\u003cb\u003eTable\u0026nbsp;3)\u003c/b\u003e. Furthermore, most isolates were resistant to tetracycline (97.25%, 177/182), cotrimoxazole (93.95%, 171/182) and ciprofloxacin (87.91%, 160/182). Resistance rates of ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e were similar for most antibiotics and across all interfaces. However, a significant disparity in Fosfomycin resistance was observed between clinical (63.15%, 36/57) and hospital environment isolates (8.89%, 4/45). Meropenem resistance was higher in ESBL-\u003cem\u003eKp\u003c/em\u003e (38.31%, 41/107) compared to ESBL-\u003cem\u003eEc\u003c/em\u003e (21.33%, 16/75) across all sources. A strikingly high meropenem resistance was observed in ESBL-\u003cem\u003eKp\u003c/em\u003e isolated from HWWs (47.61%, 20/42).\u003c/p\u003e \u003cp\u003eThe most prevalent resistance pattern across all sources in ESBL-\u003cem\u003eEc\u003c/em\u003e was \u003cb\u003eAMC-ATM-CIP-CTX-FEP-LEV-SXT/TMP-TET\u003c/b\u003e (\u003cb\u003esupplementary Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e online).\u003c/b\u003e In ESBL-\u003cem\u003eKp\u003c/em\u003e, the most prevalent resistance pattern was \u003cb\u003eAMC-ATM-CHL-CIP-CN-CTX-FEP-FOX-MEM-LEV-SXT/TMP-TET\u003c/b\u003e across all sources (\u003cb\u003esupplementary Table S2 online)\u003c/b\u003e. One clinical ESBL-\u003cem\u003eEc\u003c/em\u003e and four clinical ESBL-\u003cem\u003eKp\u003c/em\u003e were resistant to all antibiotics tested. Similarly, three ESBL-\u003cem\u003eKp\u003c/em\u003e from HWWs resisted to all tested antibiotics.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePrevalence of resistance genes\u003c/h2\u003e \u003cp\u003eOf the 182 ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e, 154 (84.61%) harbored at least one of the three β-lactam encoding genes tested (\u003cb\u003eTable\u0026nbsp;4 and\u003c/b\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. Globally, the \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eCTX\u0026minus;M\u003c/sub\u003e (n\u0026thinsp;=\u0026thinsp;146; 80.22%) was the most prevalent \u003cem\u003ebla\u003c/em\u003e gene followed by \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eTEM\u003c/sub\u003e (n\u0026thinsp;=\u0026thinsp;107; 58.79%) and \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eSHV\u003c/sub\u003e (n\u0026thinsp;=\u0026thinsp;52; 28.57%). The \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eCTX\u0026minus;M\u003c/sub\u003e prevalence ranged from 74% (n\u0026thinsp;=\u0026thinsp;42/57; 73.7%) in clinical samples to 85% in wastewater (n\u0026thinsp;=\u0026thinsp;68; 85.0%). The most prevalent \u003cem\u003ebla\u003c/em\u003e gene combination in ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e was \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eCTX\u0026minus;M\u003c/sub\u003e + \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eTEM\u003c/sub\u003e (n\u0026thinsp;=\u0026thinsp;66; 36.26%) (\u003cb\u003esupplementary Table S3 online).\u003c/b\u003e\u003c/p\u003e \u003cp\u003eOverall, the \u003cem\u003eaac-(6\u0026rsquo;)-Ib-cr\u003c/em\u003e gene (61.88%, 99/160) was the most detected PMQR gene followed by \u003cem\u003eoqx\u003c/em\u003eA (37.50%, 60/160) and \u003cem\u003eqnr\u003c/em\u003eB (30.00%, 48/160). The most prevalent PMQR genes in ESBL-\u003cem\u003eEc\u003c/em\u003e were the \u003cem\u003eaac-(6\u0026rsquo;)-Ib-cr\u003c/em\u003e (67.16%, 45/67), \u003cem\u003eqnr\u003c/em\u003eB (19.40%, 13/67) and \u003cem\u003eqnr\u003c/em\u003eS (17.91%, 12/67). On the other hand, the most prevalent PMQR genes in ESBL-\u003cem\u003eKp\u003c/em\u003e were \u003cem\u003eaac-(6\u0026rsquo;)-Ib-cr\u003c/em\u003e (58.06%, 54/93), \u003cem\u003eoqx\u003c/em\u003eA (58.06%, 54/93) and \u003cem\u003eqnr\u003c/em\u003eB (37.6%, 35/93). The \u003cem\u003eqnr\u003c/em\u003eA was only detected in two clinical ESBL-\u003cem\u003eEc\u003c/em\u003e isolates. The most prevalent PMQR gene combinations were \u003cem\u003eaac-(6\u0026rsquo;)-Ib-cr\u0026thinsp;+\u0026thinsp;qnr\u003c/em\u003eS (10.45%, 7/67) in ESBL-\u003cem\u003eEc\u003c/em\u003e (\u003cb\u003eSupplementary table S4\u003c/b\u003e) and \u003cem\u003eaac(6')-Ib-cr\u0026thinsp;+\u0026thinsp;qnr\u003c/em\u003eB\u0026thinsp;\u003cem\u003e+\u0026thinsp;oqx\u003c/em\u003eA (9.68%, 9/93) in ESBL-\u003cem\u003eKp\u003c/em\u003e (\u003cb\u003esupplementary Table S5 online)\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCo-occurrence of ESBL and PMQR genes\u003c/h3\u003e\n\u003cp\u003eOverall, 80.00% (128/160) of ciprofloxacin-resistant ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e harbored at least one ESBL and PMQR gene. The \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eCTX\u0026minus;M\u003c/sub\u003e + \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eTEM\u003c/sub\u003e + \u003cem\u003eaac(6\u0026rsquo;)-Ib-cr\u0026thinsp;+\u0026thinsp;oqxB\u003c/em\u003e was the most detected \u003cem\u003ebla\u003c/em\u003e and PMQR gene combination in ESBL-\u003cem\u003eEc\u003c/em\u003e (14.93%, 10/67) across all interfaces (\u003cb\u003esupplementary Table S6 online)\u003c/b\u003e. In ESBL-\u003cem\u003eKp\u003c/em\u003e, the \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eCTX\u0026minus;M\u003c/sub\u003e + \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eTEM\u003c/sub\u003e + \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eSHV\u003c/sub\u003e + \u003cem\u003eaac(6')-Ib-cr\u0026thinsp;+\u0026thinsp;qnrB\u0026thinsp;+\u0026thinsp;oqxA\u003c/em\u003e was the most detected combination in hospitalized patients (11.54%, 3/26), while \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eCTX\u0026minus;M\u003c/sub\u003e + \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eTEM\u003c/sub\u003e + \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eSHV\u003c/sub\u003e + \u003cem\u003eaac(6\u0026rsquo;)-Ib-cr\u0026thinsp;+\u0026thinsp;qnrS\u0026thinsp;+\u0026thinsp;oqxA\u0026thinsp;+\u0026thinsp;oqxB\u003c/em\u003e (15.38%, 4/26) and \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eCTX\u0026minus;M\u003c/sub\u003e + \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eTEM\u003c/sub\u003e + \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eSHV\u003c/sub\u003e + \u003cem\u003eqnrB\u0026thinsp;+\u0026thinsp;oqxA\u003c/em\u003e (7.31%, 3/41) were the most detected combination in hospital environment and wastewaters, respectively (\u003cb\u003esupplementary Table S7 online)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003eClonal relatedness of ESBL-\u003c/b\u003e \u003cb\u003eEc\u003c/b\u003e \u003cb\u003eand ESBL-\u003c/b\u003e\u003cb\u003eKp\u003c/b\u003e\u003c/p\u003e \u003cp\u003eERIC genotyping grouped ESBL-\u003cem\u003eEc\u003c/em\u003e (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e3\u003c/span\u003e) into 12 clusters (E1-E12) and ESBL-\u003cem\u003eKp\u003c/em\u003e (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e4\u003c/span\u003e) in 11 clusters (K1-K11). ESBL-\u003cem\u003eE. coli\u003c/em\u003e recovered from hospitalized patients of both hospitals fell principally within clusters E5 and E6 while they were distantly related to those originating from wastewater that clustered together from E9 to E12.\u003c/p\u003e \u003cp\u003eIn contrast, four ESBL-\u003cem\u003eKp\u003c/em\u003e isolates causing neonatal sepsis (HP121 and HP123 in cluster K7 and HP126 and HP127 in cluster K11) collected on the same day and with a two-day interval at the same hospital (YCH), had 100% similarity and harbored similar \u003cem\u003ebla\u003c/em\u003e and PMQR genes. Moreover, in cluster K7, the ERIC profile of an ESBL-\u003cem\u003eKp\u003c/em\u003e isolated from a catheter-associated UTI of a patient (HP105) hospitalized in the ICU of the YUTH was 100% similar to that of an isolate collected from an ICU bed (HE38) of YCH. Interestingly, these two isolates had similar genes conferring resistance to β-lactams and fluoroquinolones (\u003cem\u003ebla\u003c/em\u003e\u003csub\u003eCTX\u0026minus;M\u003c/sub\u003e, \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eTEM\u003c/sub\u003e, \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eSHV\u003c/sub\u003e, \u003cem\u003eaac(6')-Ib-cr\u003c/em\u003e, \u003cem\u003eqnr\u003c/em\u003eS, and \u003cem\u003eoqx\u003c/em\u003eA) and additionally shared a common ancestor with two isolates from ICU wastewaters of YCH (HWW5 and HWW6). In cluster K3, two ESBL-\u003cem\u003eKp\u003c/em\u003e (HE21 and HE22) isolated the same day from a door handle and a bed of the Surgery ward of the YUTH were closely related and harbored identical resistance genes (\u003cem\u003ebla\u003c/em\u003e\u003csub\u003eCTX\u0026minus;M\u003c/sub\u003e, \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eTEM,\u003c/sub\u003e and \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eSHV)\u003c/sub\u003e (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo the best of our knowledge, this is the first report of plasmid-mediated quinolone resistance in ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e circulating between hospitalized patients and hospital environments during the same period in neonatology unit in Cameroon. The WHO emphasized the critical threat posed by ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e to human health, due to their increasing AMR trends, limited therapeutic choices and high transmission across the human-animal-environment interfaces [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The co-occurrence of PMQR in ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKP\u003c/em\u003e further exacerbates the threat and jeopardizes the management of infections caused by these bacteria [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe results revealed that 71% (57/80) of \u003cem\u003eEc\u003c/em\u003e and \u003cem\u003eKp\u003c/em\u003e recovered from hospitalized patients were ESBL producers. Previous studies in Cameroon have reported much lower rates of ESBL-E isolated from clinical and urine samples in the West (29.61%) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], and North (23%) [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] regions of Cameroon respectively. The observed higher prevalence in our study is likely because we focused only on hospitalized patients while the aforementioned studies included both community and hospitalized patients and it is well-established that hospitalization increases the likelihood of being infected by MDR bacteria [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA 27% (38/141) ESBL prevalence was detected in hospital environment samples with a predominance of ESBL-\u003cem\u003eKp\u003c/em\u003e (76%, 34/45) compared to ESBL-\u003cem\u003eEc\u003c/em\u003e (24%, 11/45). The predominance of ESBL-\u003cem\u003eKp\u003c/em\u003e can be explained by the biological structure of \u003cem\u003eK. pneumoniae\u003c/em\u003e with the capsule and biofilm-forming ability, which enables it to thrive even under detrimental environmental conditions and resist biocides [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The overall ESBL prevalence in environmental samples is elevated compared to that observed in a labor ward in Cameroon (10%) [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Similarly, our results are higher than that observed by the BARNARDS study, which reported a 13.3% ESBL-Gram-negative bacteria prevalence in the environment of neonatal wards of six developing countries [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The discordance in ESBL prevalence might be due to the variance in study settings and study design.\u003c/p\u003e \u003cp\u003eAll HWW samples were positive for ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e, and the mean ESBL-E bacteria load was high (6.16 x10\u003csup\u003e5\u003c/sup\u003e CFU/mL). These results corroborate with those obtained by Garba et \u003cem\u003eal\u003c/em\u003e (2023) who detected ESBL-Gram-negative bacteria in nearly all HWW samples (97.5%) in Burkina Faso with a load varying between 1.10 \u0026times; 10\u003csup\u003e5\u003c/sup\u003e to 5.23 \u0026times; 10\u003csup\u003e6\u003c/sup\u003e CFU/mL [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The high ESBL-E load observed in hospital wastewaters might be explained by the fact that they act as a melting pot in which there are sub-therapeutic concentrations of antibiotics and there is high transmission of genetic elements harboring resistance determinants between bacteria [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Moreover, the presence of some compounds such as heavy metals in wastewater is known to drive antibiotic resistance [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Intriguingly, the mean ESBL-E load in the final effluent of YUTH (19000 CFU/mL) was 19 times higher than the upper limit of global safety standards which recommend a coliform count ranging from 100\u0026ndash;1000 CFU/mL in treated hospital effluents [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. This suggests an inefficient wastewater treatment system and the high risk of spread of ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e to the community through these contaminated hospital effluents.\u003c/p\u003e \u003cp\u003eAntibiotic susceptibility testing revealed that nearly all (99.45%) ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e recovered from the three sources were MDR. This high MDR level could probably be explained by the fact that ESBL-encoding genetic determinants are usually located on mobile genetic elements such as plasmids harboring resistance determinants to several antibiotic families of antibiotics other than β-lactam [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In four previous studies carried out in Cameroon from 2022 to 2024 all ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e isolated from human samples including clinical and carriage samples (fecal and vaginal) were multidrug-resistant [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Similar MDR levels have been reported amongst ESBL-E isolated from the hospital environment in Ghana (100%) [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], and HWWs in Burkina Faso (100%) [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eCTX\u0026minus;M\u003c/sub\u003e predominated in ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e isolated from hospitalized patients (74%), the hospital environment (80%), and wastewater (85%). This aligns with global trends as \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eCTX\u0026minus;M\u003c/sub\u003e has emerged to be the most prevalent ESBL gene in \u003cem\u003eEnterobacterales\u003c/em\u003e worldwide [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. A high \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eCTX\u0026minus;M\u003c/sub\u003e prevalence was also reported in ESBL-E among clinical isolates from the Western (84.4%), and Centre regions (100%) of Cameroon [\u003cspan additionalcitationids=\"CR42\" citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. However, a Ghanaian study reported a lower prevalence of \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eCTX\u0026minus;M\u003c/sub\u003e (62.5%) among ESBL-\u003cem\u003eEc\u003c/em\u003e isolated from hospitalized patients [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Regarding the hospital environment, Yeboah et \u003cem\u003eal\u003c/em\u003e (2024) reported \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eTEM\u003c/sub\u003e (57%) as the most prevalent \u003cem\u003ebla\u003c/em\u003e gene among ESBL-\u003cem\u003eEc\u003c/em\u003e in Ghana [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. The observed disparity may be due to the difference in the use of third-generation cephalosporin in both countries. Numerous studies have also reported a towering prevalence of \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eCTX\u0026minus;M\u003c/sub\u003e among ESBL-E isolated from hospital wastewater in Nigeria (100%) and Brazil (93%) [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. The prevalence of ESBL encoding genes in ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e isolated from wastewaters mirrored to some extent that of clinical and hospital environments. This suggests that wastewater could act as a reservoir of clinically resistant \u003cem\u003eK. pneumoniae\u003c/em\u003e and \u003cem\u003eE. coli\u003c/em\u003e and their resistance genes. This finding gives ground for the use of wastewater-based epidemiology as a tool for AMR surveillance and monitoring [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOverall, 84.40% of all ciprofloxacin-resistant ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e, harbored at least one of the PMQR genes tested. All genes (except \u003cem\u003eqnr\u003c/em\u003eA) were detected in all interfaces. Two studies in Cameroon have previously reported PMQR genes among \u003cem\u003eEnterobacterales\u003c/em\u003e isolated from clinical samples [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], and broiler chicken [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. To the best of our knowledge, this is the first report of PMQR genes among ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e in the hospital environment and wastewaters of Cameroon.\u003c/p\u003e \u003cp\u003eThe most prevalent PMQR gene across all sources was \u003cem\u003eaac-(6\u0026rsquo;)-Ib-cr\u003c/em\u003e detected with prevalence ranging from 57\u0026ndash;70%. Mbamyah et \u003cem\u003eal\u003c/em\u003e (2020) reported overlapping \u003cem\u003eaac-(6\u0026rsquo;)-Ib-cr\u003c/em\u003e (62%) prevalence among clinical fluoroquinolone-resistant \u003cem\u003eE. coli\u003c/em\u003e and \u003cem\u003eKlebsiella\u003c/em\u003e spp from clinical samples in Yaound\u0026eacute;. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Yeboah et \u003cem\u003eal\u003c/em\u003e (2024) reported a similar prevalence of \u003cem\u003eaac-(6\u0026rsquo;)-Ib\u003c/em\u003e-cr among ESBL-\u003cem\u003eEc\u003c/em\u003e isolated from hospitalized patients (62.50%) but lower in the hospital environment (50.00%) in Ghana [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. A lower prevalence (41%) has been detected among fluoroquinolone-resistant \u003cem\u003eEc\u003c/em\u003e isolated from hospital wastewaters in Iran [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. The varied \u003cem\u003eaac-(6\u0026rsquo;)-Ib-cr\u003c/em\u003e prevalence may reflect the varied fluoroquinolone and aminoside use in each setting [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe \u003cem\u003eqnr\u003c/em\u003e genes (\u003cem\u003eqnr\u003c/em\u003eA, \u003cem\u003eqnr\u003c/em\u003eB and \u003cem\u003eqnr\u003c/em\u003eS) were the second most prevalent PMQR genes identified in hospitalized patients (56%), hospital environment (63%), and wastewaters (43%). The prevalence of \u003cem\u003eqnr\u003c/em\u003e genes among patients was higher than that previously reported in clinical samples in Cameroon (31%) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Similarly, the prevalence in the hospital environment is higher than that detected in the hospital environment of a tertiary hospital in Ghana [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Conversely, the \u003cem\u003eqnr\u003c/em\u003e prevalence in this study is lower than that reported in HWWs of Iran [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. The observed difference could be attributed to the difference in fluoroquinolone prescription, infection prevention control measures, wastewater management and geographical location.\u003c/p\u003e \u003cp\u003eThe multidrug efflux pump encoding genes \u003cem\u003eoqx\u003c/em\u003eAB were the third most prevalent PMQR genes with a higher prevalence in the hospital environment (76%) compared to hospitalized patients (46%) and wastewaters (40%). The high prevalence of \u003cem\u003eoqx\u003c/em\u003eAB in the environmental interface could be explained by the fact that, these genes also confer resistance to biocides, detergents and disinfectants commonly used on hospital surfaces and equipment to control the spread of resistant microorganisms [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. The \u003cem\u003eoqx\u003c/em\u003eAB prevalence in HWW is significantly lower than that reported in HWWs of Iran (65%) [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Conversely, \u003cem\u003eoqx\u003c/em\u003eAB prevalence from hospitalized patients is higher than that reported from hospitalized patients in Iran (21%) [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] suggesting a difference in the use of different antibiotics which promote the selection of \u003cem\u003eoqx\u003c/em\u003eAB-positive \u003cem\u003eE. coli\u003c/em\u003e and \u003cem\u003eK. pneumoniae\u003c/em\u003e including quinolones, chloramphenicol, nitrofurantoin and tigecycline [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe most recently identified and rare PMQR gene member \u003cem\u003eqep\u003c/em\u003eA was detected at rates ranging from 3 to 8% across all sources. The \u003cem\u003eqep\u003c/em\u003eA prevalence from hospitalized patients is higher than that reported (2%) in clinical samples in Cameroon [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Other than the changes in fluoroquinolone use in different settings, the observed discrepancies regarding PMQR gene prevalence, may likely be due to the difference in the proportion of \u003cem\u003eEnterobacterales\u003c/em\u003e species included in each study as PMQR gene epidemiology is known to vary at the specie-level [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Also, the presence/dominance of additional resistance mechanisms such as topoisomerase IV and gyrase gene mutations may explain the discrepancies between fluoroquinolone-resistant ESBL-\u003cem\u003eEc and\u003c/em\u003e ESBL-\u003cem\u003eKp\u003c/em\u003e with no PMQR genes detected [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The high PMQR gene prevalence is particularly worrying even though they usually grant a low level of resistance because of their ability to favor the selection of highly resistant mutants [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe co-existence of ESBL and PMQR genes evidenced in 80% of the fluoroquinolone-resistant ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e isolates in our study is further concerning. This high co-carriage rate is likely because ESBL and PMQR genes are usually located on the same plasmids, increasing the likelihood of co-transmission by horizontal gene transfer between various members of the \u003cem\u003eEnterobacteriaceae\u003c/em\u003e family [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The co-occurring of ESBL and PMQR genes contributes to a rise in MDR infections which are more difficult to treat due to the restricted choice of antibiotics [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGenomic fingerprinting revealed the circulation of two neonatal sepsis ESBL-\u003cem\u003eKp\u003c/em\u003e isolates collected on the same day at the Neonatal ward of YCH who had 100% similarity and harbored similar resistance genes. Twenty days later, a similar scenario was observed with two other isolates in the same ward. These results could suggest that there may be neonatal sepsis outbreaks occurring in this neonatal ward. This finding is in line with a systematic review that reported 860 ESBL-E infections in 75 outbreak conditions of neonatal intensive care units worldwide with 15% of included studies from Africa [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. The detected putative outbreaks are particularly worrying as ESBL-E neonatal infection outbreaks result in a 31% (95% CI; 20\u0026ndash;40%) mortality rate worldwide [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Another interesting finding was that an ESBL-\u003cem\u003eKp\u003c/em\u003e isolated from a catheter-associated UTI from a hospitalized patient at the ICU of the YUTH exhibited 100% similarity to an environmental ICU isolate from the YCH and harbored similar resistance genes. This suggests the dissemination of particular ESBL-\u003cem\u003eKp\u003c/em\u003e strains between ICU patients and the environmental interface. Outbreaks due to ESBL-\u003cem\u003eKp\u003c/em\u003e in ICUs with hospital environment have been reported worldwide [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. These two similar ESBL-\u003cem\u003eKp\u003c/em\u003e clustered with two other isolates from the HWWs of the ICU of YCH suggesting that HWWs could serve as potential reservoirs of clinically relevant ESBL-\u003cem\u003eKp\u003c/em\u003e that could lead to community-acquired infections among people living close to these hospitals.\u003c/p\u003e \u003cp\u003eHowever, this study had some limitations. First, monthly sampling of the hospital environment likely reduced the real-time monitoring of clinically relevant ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e. Second, topoisomerase and gyrase gene mutations were not investigated to fully elucidate the underlying mechanisms of fluoroquinolone resistance. Finally, PCR-based genotyping was used to assess genetic relatedness while robust methods such as pulse-field gel electrophoresis and whole genome sequencing could have increased phylogenetic resolution. Notwithstanding these limitations, the study helps to address important data gaps on the genetic characteristics and dissemination of fluoroquinolone-resistant and ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e in healthcare settings in Cameroon.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe high prevalence of PMQR genes in ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e detected in hospitalized patients, hospital environment, and HWWs underscores the need to implement strong infection prevention and control measures coupled with reinforced antimicrobial stewardship programs to curb the dissemination and growing antibiotic resistance rates among neonatal sepsis in healthcare facilities in Cameroon. Furthermore, efficient HWW treatment systems are needed to prevent the dissemination of these highly resistant bacteria to community settings. The observed widespread resistance to multiple antibiotic families necessitates a revision of the current empirical therapy commonly used within these facilities. Finally, the circulation of ESBL-\u003cem\u003eKp\u003c/em\u003e among hospital environments and hospitalized patients emphasizes the need to implement longitudinal genomic surveillance through the One Health approach to fully understand the transmission dynamics of resistant bacteria in healthcare facilities in Cameroon.\u003c/p\u003e "},{"header":"Method","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003eStudy design and site\u003c/h2\u003e \u003cp\u003eA cross-sectional study was conducted during five months, from February to June 2024 at the Yaound\u0026eacute; Central Hospital (YCH) and the Yaound\u0026eacute; University Teaching Hospital (YUTH), which are second-category and reference hospitals respectively.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eThe primary population was composed of clinical samples collected from hospitalized patients at the two hospitals. The secondary population was the hospital environment of the emergency, intensive care unit (ICU), medicine, neonatology, surgery, cardiology, and maternity wards. The sampling sites included beds, door handles, neonatal incubators, pulse oximeters, sinks, tables and trolleys. The tertiary study population consisted of hospital wastewaters (HWWs) of the emergency, neonatology, maternity, neurosurgery, ICU and surgery wards. The influent and effluents of the wastewater treatment plant (WWTP) of the YUTH was also collected.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eSample collection\u003c/h2\u003e \u003cp\u003eClinical samples for microbiology analysis including urine, blood, genital and wound swabs were collected following laboratory standard operating procedures of the two healthcare facilities throughout the study period were included. The hospital environment was swabbed at two time points (in March and April). During these time points, 500mL of HWWs from each sampling point was also collected in sterile 1000mL glass containers. HWWs were collected at three sites at the YUTH (emergency, influent, and effluent) while five sites collecting HWWs from seven services were collected at the YCH (emergency, neonatology and maternity, urology and neurosurgery, ICU, and surgery). Samples were transported within four hours to the Research Institute of the Centre of Expertise and Biological Diagnostic of Cameroon (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://cedbcam.com/\u003c/span\u003e\u003cspan address=\"https://cedbcam.com/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) for analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e All methods were conducted by ethical principles of the Declaration of Helsinki and its later amendments. This study was approved by the Centre Region Ethics Committee for Human Research (N\u0026deg;00098/CRERSHC/2024). Research authorizations from the YCH (N\u0026deg;025/AR/MINSANTE/SG/DHCY/CUAF), YUTH (N\u0026deg;36/AR/CHUY/DG/CAPRC/CEAA) and the CEDBCAM Research Institute (N\u0026deg;2024/03/005/L/CEDBCAM-RI/DG/DRD) were granted. Informed consent was provided by participants, parents or the child\u0026rsquo;s legal guardian. A unique anonymous code was attributed to each clinical sample for confidentiality purposes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eLaboratory analysis\u003c/h2\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003eBacteria isolation, identification and ESBL screening\u003c/h2\u003e \u003cp\u003eAll clinical samples were cultured on Eosin-Methylene Blue agar at 37\u0026deg;C for 24 hours. Growing colonies were identified using API20E (BioM\u0026eacute;rieux, Marcy l\u0026rsquo;Etoile, France) following the manufacturer\u0026rsquo;s instructions. ESBL production was screened using CHROMagar ESBL (CHROMagar\u0026trade; Orientation, Paris, France) and confirmation was done using the double-disk synergy testing. Hospital environment and HWW samples were directly cultured on CHROMagar ESBL. For HWWs, ESBL bacteria culture and enumeration were done following the WHO Global Tricycle Surveillance Project [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Briefly, each water sample was serially diluted at 1/10, 1/100, 1/1000, 1/10000 and 1/100000 and 100uL of each diluent was inoculated on ESBL CHROMagar and incubated for 18-24hrs at 37\u0026deg;C. The next day, bacterial colonies were visually counted and bacterial load expressed as UFC/mL. Each ESBL bacterial colonies were purified and stored at -40\u0026deg;C in cryovials containing trypticase soya broth (Oxoid LTD, Bagingstoke, Hamsphire, England) supplemented with 20% (v/v) glycerol for future analysis.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eAntimicrobial Susceptibility testing\u003c/h2\u003e \u003cp\u003eThe disk diffusion method was used to assess the susceptibility of all ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e against a panel of 13 antibiotics including: ciprofloxacin (5 \u0026micro;g), levofloxacin (5 \u0026micro;g), amoxicillin-clavulanic acid (20\u0026ndash;10 \u0026micro;g), cefoxitin (30 \u0026micro;g) cefotaxime (30 \u0026micro;g), cefepime (30 \u0026micro;g), aztreonam (30 \u0026micro;g), meropenem (10 \u0026micro;g), fosfomycin (10 \u0026micro;g), gentamicin (5 \u0026micro;g), trimethoprim-sulfamethoxazole (23.75\u0026ndash;1.25 \u0026micro;g), chloramphenicol (10 \u0026micro;g) and tetracycline (30 \u0026micro;g). Interpretation of the inhibition diameters was done following EUCAST 2023 guidelines. An isolate was considered multi-drug resistant (MDR) if it displayed resistance to at least one antibiotic of three or more different families [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eDetection of β-lactamase and PMQR resistance genes\u003c/h2\u003e \u003cp\u003eDNA extraction of all ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e was performed using a modified boiling method [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. All ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e were screened for β-lactamase encoding genes \u003cb\u003e(\u003c/b\u003e\u003cem\u003ebla\u003c/em\u003e\u003csub\u003eTEM\u003c/sub\u003e, \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eCTX\u0026minus;M,\u003c/sub\u003e and \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eSHV\u003c/sub\u003e) while only ciprofloxacin non-susceptible isolates were screened for the PMQR genes: (\u003cem\u003eqnr\u003c/em\u003eB, \u003cem\u003eqnr\u003c/em\u003eS, \u003cem\u003eqnr\u003c/em\u003eA, \u003cem\u003eaac(6\u0026prime;)-Ib-cr, oqx\u003c/em\u003eA, \u003cem\u003eoqx\u003c/em\u003eB, and \u003cem\u003eqep\u003c/em\u003eA) using polymerase chain reaction (PCR) with specific primers (\u003cb\u003eSupplementary Table S7 online).\u003c/b\u003e Each amplification occurred in a 10-\u0026micro;L reaction mixture consisting of 5 \u0026micro;L BenTaq polymerase (Beneficial bio, UK), 0.1 \u0026micro;L of each forward and reverse primer (100 \u0026micro;M) set(s), 1.5 \u0026micro;L of template DNA and 3.3 \u0026micro;L (for singleplex reactions: \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eSHV,\u003c/sub\u003e \u003cem\u003eaac(6\u0026prime;)-Ib-cr\u003c/em\u003e, \u003cem\u003eoqx\u003c/em\u003eA, \u003cem\u003eoqx\u003c/em\u003eB and \u003cem\u003eqep\u003c/em\u003eA) or 3.1 \u0026micro;L (for \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eTEM\u003c/sub\u003e, and \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eCTX\u0026minus;M\u003c/sub\u003e) or 2.9 \u0026micro;L (for \u003cem\u003eqnr\u003c/em\u003eB, \u003cem\u003eqnr\u003c/em\u003eS and \u003cem\u003eqnr\u003c/em\u003eA multiplex) of nuclease-free sterile distilled water. Amplification steps included: initial denaturation at 95\u0026deg;C for 3 min, followed by 32 cycles of denaturation at 95\u0026deg;C for 30 seconds, annealing (gene-specific temperature in \u003cb\u003eSupplementary Table S7 online\u003c/b\u003e) for 45 seconds, elongation at 72\u0026deg;C for 45 seconds, and final elongation at 72\u0026deg;C for 6 min in a thermal cycler (Bio-Rad Laboratories, Lasec, South Africa). Generated amplicons were resolved by agarose gel electrophoresis on a 1.5% (w/v) together with a 50bp ladder (Biolabs, New England) and ran in an electric field of 90 V for 45 minutes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eGenetic relatedness\u003c/h2\u003e \u003cp\u003eClonal relatedness of all ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e isolated from hospitalized patients, hospital environment and HWWs was assessed using enterobacterial repetitive intergenic consensus (ERIC)-PCR as previously described [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Generated amplicons were resolved on a 1.5% (w/v) agarose gel run at 110V for 2 hours and visualized under a UV transilluminator. For cluster analysis, gel images and metadata were exported to GelJ software (version 2.1) [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eQuality control\u003c/h2\u003e \u003cp\u003eQuality control of antibiotic discs was performed using \u003cem\u003eE. coli\u003c/em\u003e ATCC 25922. PCR amplification was done along with \u003cem\u003eK. pneumoniae\u003c/em\u003e ATCC 700603 (for \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eSHV\u003c/sub\u003e), \u003cem\u003eE. coli\u003c/em\u003e ATCC 35218 (for \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eTEM\u003c/sub\u003e) and previously whole-genome sequenced \u003cem\u003eEnterobacterales\u003c/em\u003e harboring all β-lactam and quinolone resistance genes found (unpublished data) were used as positive controls.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData were entered into a Microsoft Office Excel 2016 spreadsheet and exported to SPSS software (version 27) for data analysis. A sample was considered ESBL-positive when at least an ESBL-\u003cem\u003eEC\u003c/em\u003e or \u003cem\u003eKP\u003c/em\u003e colony was detected. Proportions of qualitative variables were compared using the Chi-square test and a p-value\u0026thinsp;\u0026lt;\u0026thinsp;5% was considered statistically significant.\u003c/p\u003e \u003c/div\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePLK\u003c/strong\u003e co-conceptualized the study, performed sample collection, microbiological, genetic and statistical analyses and drafted the article. \u003cstrong\u003eRCF\u003c/strong\u003e co-conceptualized the study, vetted study results and revised the article. \u003cstrong\u003eLLF\u003c/strong\u003e vetted the results, provided partial funding for the study, and critically revised the article. \u003cstrong\u003eMDF\u003c/strong\u003e assisted in sample collection, microbiological, genetic and statistical analyses. \u003cstrong\u003eGWG \u0026amp; RD\u003c/strong\u003e assisted in genetic analysis. \u003cstrong\u003eGAN \u0026amp; HG\u003c/strong\u003e took part in the design of the study, facilitated the implementation of the study and reviewed the article. \u003cstrong\u003eSPC\u003c/strong\u003e co-conceptualized the study and undertook a critical revision of the article. All authors read and approved the final article. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the data generated during this study are included in this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank all staff members and participants of these healthcare facilities who agreed to participate to this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFundings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRaspail Carrel Founou received funding from the M\u0026eacute;rieux Institute, Lyon France for the CAREFOOD project. CAREFOOD project has supported all the molecular aspects of this study. This work was also supported by the Research Institute of Centre of Expertise and Biological Diagnostic of Cameroon (CEDBCAM-RI). The funders had no role in the study design, nor the decision to submit the work for publication. Any opinions, findings and conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWHO. Bacterial Priority Pathogens List: bacterial pathogens of public health importance to guide research, development and strategies to prevent and control antimicrobial resistance. Geneva: World Health Organization; 2024. Licence: CC BY-NC-SA 3.0 IGO.; 2024.\u003c/li\u003e\n\u003cli\u003eFounou RC, Founou LL, Essack SY. 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Multidrug-Resistant and Extended-Spectrum \u0026beta;-Lactamase (ESBL) - Producing Enterobacterales Isolated from Carriage Samples among HIV Infected Women in Yaound\u0026eacute;, Cameroon. Pathogens. 2022;11(5).\u003c/li\u003e\n\u003cli\u003eYeboah EEA, Agyepong N, Mbanga J, Amoako DG, Abia ALK, Owusu-Ofori A, et al. Genomic characterization of multi drug resistant ESBL-producing Escherichia coli isolates from patients and patient environments in a teaching hospital in Ghana. 2024.\u003c/li\u003e\n\u003cli\u003eCastanheira M, Simner PJ, Bradford PA. Extended-spectrum \u0026beta;-lactamases: an update on their characteristics, epidemiology and detection. JAC Antimicrob Resist. 2021;3(3):dlab092.\u003c/li\u003e\n\u003cli\u003eBayaba S, Founou RC, Tchouangueu FT, Dimani BD, Mafo LD, Nkengkana OA, et al. High prevalence of multidrug resistant and extended-spectrum \u0026beta;-lactamase-producing Escherichia coli and Klebsiella pneumoniae isolated from urinary tract infections in West region, Cameroon. 2024.\u003c/li\u003e\n\u003cli\u003eDjuikoue IC, Njajou O, Gonsu K, Fokunang C, Bongoe A, Ela Ondo B, et al. Prevalence of CTX-M beta-Lactamases in Escherichia coli from community-acquired urinary tract infections and associated risk factors among women in Cameroon. J Epidemiol Res. 2017;3(1):10.5430.\u003c/li\u003e\n\u003cli\u003eNkengkana OA, Founou RC, Founou LL, Dimani BD, Koudoum PL, Zemtsa JR, et al. Phenotypic and genotypic characterization of multidrug resistant (MDR) and extended-spectrum \u0026beta;-lactamase (ESBL)-producing Enterobacterales isolated from clinical samples in the Western region in Cameroon. 2023.\u003c/li\u003e\n\u003cli\u003eAdekanmbi AO, Akinpelu MO, Olaposi AV, Oyelade AA. Extended spectrum beta-lactamase encoding gene-fingerprints in multidrug resistant Escherichia coli isolated from wastewater and sludge of a hospital treatment plant in Nigeria. International Journal of Environmental Studies. 2021;78(1):140-50.\u003c/li\u003e\n\u003cli\u003eConte D, Palmeiro JK, da Silva Nogueira K, de Lima TMR, Cardoso MA, Pontarolo R, et al. Characterization of CTX-M enzymes, quinolone resistance determinants, and antimicrobial residues from hospital sewage, wastewater treatment plant, and river water. Ecotoxicology and environmental safety. 2017;136:62-9.\u003c/li\u003e\n\u003cli\u003eLeinyuy JF, Ali IM, Karimo O, Tume CB. Patterns of Antibiotic Resistance in Enterobacteriaceae Isolates from Broiler Chicken in the West Region of Cameroon: A Cross‐Sectional Study. Canadian Journal of Infectious Diseases and Medical Microbiology. 2022;2022(1):4180336.\u003c/li\u003e\n\u003cli\u003eNeyestani Z, Khademi F, Teimourpour R, Amani M, Arzanlou M. Prevalence and mechanisms of ciprofloxacin resistance in Escherichia coli isolated from hospitalized patients, healthy carriers, and wastewaters in Iran. BMC Microbiol. 2023;23(1):191.\u003c/li\u003e\n\u003cli\u003eLi J, Zhang H, Ning J, Sajid A, Cheng G, Yuan Z, et al. The nature and epidemiology of OqxAB, a multidrug efflux pump. Antimicrob Resist Infect Control. 2019;8:44.\u003c/li\u003e\n\u003cli\u003eAbdelrahim SS, Hassuna NA, Waly N, Kotb DN, Abdelhamid H, Zaki S. Coexistence of plasmid-mediated quinolone resistance (PMQR) and extended-spectrum beta-lactamase (ESBL) genes among clinical Pseudomonas aeruginosa isolates in Egypt. BMC Microbiol. 2024;24(1):175.\u003c/li\u003e\n\u003cli\u003eStapleton PJ, Murphy M, McCallion N, Brennan M, Cunney R, Drew RJ. Outbreaks of extended spectrum beta-lactamase-producing Enterobacteriaceae in neonatal intensive care units: a systematic review. Arch Dis Child Fetal Neonatal Ed. 2016;101(1):F72-8.\u003c/li\u003e\n\u003cli\u003eCalbo E, Garau J. The changing epidemiology of hospital outbreaks due to ESBL-producing Klebsiella pneumoniae: the CTX-M-15 type consolidation. Future Microbiol. 2015;10(6):1063-75.\u003c/li\u003e\n\u003cli\u003eWHO. Global Tricycle Surveillance \u0026ndash; ESBL E.coli - Integrated Global Surveillance on ESBL-producing E. coli Using a \u0026ldquo;One Health\u0026rdquo; Approach: Implementation and Opportunities [Internet]. World Health Organization, Global Antimicrobial Resistance Surveillance System (GLASS), Surveillance Prevention and Control. 2021. 76 p. Available from: http://apps.who.int/bookorders. 2021.\u003c/li\u003e\n\u003cli\u003eMagiorakos AP, Srinivasan A, Carey RB, Carmeli Y, Falagas ME, Giske CG, et al. Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect. 2012;18(3):268-81.\u003c/li\u003e\n\u003cli\u003eZemtsa RJ, Noubom M, Founou LL, Dimani BD, Koudoum PL, Mbossi AD, et al. Multidrug-Resistant and Extended-Spectrum \u0026beta;-Lactamase (ESBL)-Producing Enterobacterales Isolated from Carriage Samples among HIV Infected Women in Yaound\u0026eacute;, Cameroon. Pathogens. 2022;11(5):504.\u003c/li\u003e\n\u003cli\u003eDimani BD, Founou RC, Zemtsa JR, Mbossi A, Koudoum PL, Founou LL, et al. Faecal carriage of multidrug-resistant and extended-spectrum \u0026beta;-lactamase-producing Enterobacterales in people living with HIV in Yaound\u0026eacute;, Cameroon. Journal of Global Antimicrobial Resistance. 2023;35:26-34.\u003c/li\u003e\n\u003cli\u003eHeras J, Dom\u0026iacute;nguez C, Mata E, Pascual V, Lozano C, Torres C, et al. GelJ\u0026ndash;a tool for analyzing DNA fingerprint gel images. BMC bioinformatics. 2015;16(1):1-8.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1:\u0026nbsp;\u003c/strong\u003ePositivity to ESBL-Ec and Kp and PMQR- ESBL-Ec and Kp according to patient socio-demographic characteristics\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"593\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eModalities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eESBL-\u003cem\u003eEc/Kp\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePMQR-ESBL-\u003cem\u003eEc/Kp\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\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\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eOverall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e495(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e49 (9.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e39 (7.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e264 (53.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e26 (9.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.955\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e21 (7.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.947\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e231 (46.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e23 (9.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e18 (7.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eAge*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e34.92\u003c/p\u003e\n \u003cp\u003e(28.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 51.00\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; (27.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003e48.68 (28.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e(Min, Max)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e(1\u003csup\u003e#\u003c/sup\u003e, 95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e(1\u003csup\u003e#\u003c/sup\u003e, 90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e(1\u003csup\u003e#\u003c/sup\u003e,90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"8\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eAge* groups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026lt;\u0026nbsp;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e124 (25.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e6 (4.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"8\" valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e6 (4.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"8\" valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.029\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\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\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1-10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e17 (3.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e11-20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e30 (6.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e2 (6.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e2 (6.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e21-30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e63 (12.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e5 (7.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e4 (6.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e31-40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e60 (12.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e2 (3.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e1 (1.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e41-50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e31 (6.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e5 (16.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e4 (12.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e51-60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e41 (8.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e3 (7.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e2 (6.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026gt;\u0026nbsp;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e129 (26.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e26 (20.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e20 (15.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"11\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eSample types\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eUrinary catheters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e21 (4.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e12 (57.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"11\" valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e9 (42.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"11\" valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\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\" style=\"width: 90px;\"\u003e\n \u003cp\u003efaecal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e18 (3.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eUrine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e128 (25.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e13 (10.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e8 (12.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eThroat swab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e2 (0.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eBlood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e228 (46.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e15 (6.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e14 (6.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eAscites fluid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e5 (1.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eCSF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e25 (5.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003ePleural fluid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e5 (1.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eGenital swab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e33 (6.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e1 (3.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e1 (3.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eWound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e29 (5.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e7 (24.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e7 (24.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eSemen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e1 (0.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e1 (100.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eHospitals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eYCH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e208 (42.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e29 (13.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e22 (10.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.058\u003c/p\u003e\n \u003cp\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\" style=\"width: 90px;\"\u003e\n \u003cp\u003eYUTH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e287 (57.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e20 (6.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e17 (5.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"11\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eWards\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eCardiology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e14 (2.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e4 (28.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"11\" valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.003\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e4 (28.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"11\" valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\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\" style=\"width: 90px;\"\u003e\n \u003cp\u003eSurgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e24 (4.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e6 (25.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e5 (20.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eGynecology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e20 (4.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e1 (5.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e1 (5.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eICU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e36 (7.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e6 (16.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e6 (16.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMaternity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e46 (9.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMedicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e31 (6.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e3 (9.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e1 (3.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eNeonatalogy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e86 (17.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e6 (6.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e6 (6.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e36 (7.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e5 (13.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e2 (5.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003ePediatric\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e50 (10.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eEmergency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e116 (23.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e13 (11.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e11 (9.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eUrology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e36 (7.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e5 (13.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e3 (9.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eICU= Intensive Care Unit, YCH= Yaound\u0026eacute; Central Hospital, YUTH= Yaound\u0026eacute; University Teaching Hospital, CSF= Cerebro-Spinal Fluid, SD= Standard Deviation, Min= Minimum, Max= Maximum, *=Age in years, #=Age in days.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2:\u0026nbsp;\u003c/strong\u003ePositivity to ESBL-Ec/Kp and PMQR-ESBL-Ec/Kp according to patient socio-demographic characteristics to environmental sample characteristics\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"528\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eModalities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eESBL-\u003cem\u003eEc/Kp\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePMQR-ESBL-\u003cem\u003eEc/Kp\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003eOverall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e141 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e38 (26.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e22 (15.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003eHospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eYCH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e78 (55.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e31 (39.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e20 (25.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eYUTH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e63 (44.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e7 (11.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2 (3.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003eTime point\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eT1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e64 (45.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e9 (14.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e6 (9.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.063\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eT2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e77 (54.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e29 (37.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e16 (37.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"9\" valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003eSampling sites\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eBed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e55 (39.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e15 (27.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"9\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.036\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e6 (10.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"9\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.014\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\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\" style=\"width: 94px;\"\u003e\n \u003cp\u003eDoor handle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e31 (21.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e9 (29.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e7 (7.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eDrip stand\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e13 (9.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eIncubator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2 (1.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2 (100.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2 (100.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eNurse\u0026rsquo;s table\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e17 (12.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e5 (29.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e3 (17.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eSaturometer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2 (1.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eSink\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e4 (2.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2 (50.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2 (50.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eTable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e4 (2.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e4 (100.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1 (25.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eTrolley\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e9 (6.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1 (11.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1 (11.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\" valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003eWard\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eCardiology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e14 (9.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e6 (42.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"7\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.053\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e3 (21.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"7\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.338\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\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\" style=\"width: 94px;\"\u003e\n \u003cp\u003eEmergency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e26 (18.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e7 (26.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e3 (11.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eMedicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e19 (13.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eICU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e33 (23.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e9 (27.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e6 (18.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eMaternity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e8 (5.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e4 (50.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1 (12.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eNeonatalogy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e9 (6.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e4 (44.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e3 (33.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eSurgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e32 (22.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e8 (25.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e6 (18.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eYCH= Yaound\u0026eacute; Central Hospital, YUTH= Yaound\u0026eacute; University Teaching Hospital, ICU= Intensive Care Unit, T1= first time point, T2= second time point.\u003c/p\u003e\n\u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:12px;font-family:\"Times New Roman\",serif;color:#0E2841;font-style:italic;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:16px;color:black;font-style:normal;\"\u003eTable \u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cspan style=\"font-size:16px;color:black;font-style:normal;\"\u003e3: \u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size:16px;color:black;font-style:normal;\"\u003eAntibiotic resistance rates of\u0026nbsp;\u003c/span\u003e\u003cspan style=\"font-size:15px;color:black;font-style:normal;\"\u003eESBL-\u003c/span\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003eE. coli\u003c/span\u003e\u003cspan style=\"font-size:15px;color:black;font-style:normal;\"\u003e\u0026nbsp;and\u0026nbsp;\u003c/span\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003eK. pneumoniae\u003c/span\u003e\u003cspan style=\"font-size:15px;color:black;font-style:normal;\"\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style=\"font-size:16px;color:black;font-style:normal;\"\u003eisolated from hospitalized patients, hospital environment and wastewaters.\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"border-collapse: collapse;border: none;width: 994px;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 78.85pt;border-top: 1.5pt solid windowtext;border-left: none;border-bottom: 2.25pt solid windowtext;border-right: none;padding: 0in 5.4pt;height: 2.1pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:justify;line-height: normal;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:justify;line-height: normal;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eSource\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48.75pt;border-top: 1.5pt solid windowtext;border-left: none;border-bottom: 1.5pt solid windowtext;border-right: none;background: rgb(193, 228, 245);padding: 0in 5.4pt;height: 2.1pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-family: \"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 205.55pt;border-top: 1.5pt solid windowtext;border-left: none;border-bottom: 1.5pt solid windowtext;border-right: none;background: rgb(193, 228, 245);padding: 0in 5.4pt;height: 2.1pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026beta;-Lactams n (%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 127.55pt;border-top: 1.5pt solid windowtext;border-left: none;border-bottom: 1.5pt solid windowtext;border-right: none;background: rgb(149, 220, 247);padding: 0in 5.4pt;height: 2.1pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003eFluoroquinolones n (%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"7\" style=\"width: 284.75pt;border-top: 1.5pt solid windowtext;border-left: none;border-bottom: 1.5pt solid windowtext;border-right: none;background: rgb(179, 229, 161);padding: 0in 5.4pt;height: 2.1pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003eOther antibiotics n (%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 48.75pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 2.25pt solid windowtext;background: rgb(193, 228, 245);padding: 0in 5.4pt;height: 1.2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-family: \"Times New Roman\",serif;color:black;'\u003eAMC\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53.35pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 2.25pt solid windowtext;background: rgb(193, 228, 245);padding: 0in 5.4pt;height: 1.2pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003eCTX\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53.35pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 2.25pt solid windowtext;background: rgb(193, 228, 245);padding: 0in 5.4pt;height: 1.2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003eFEP\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53.4pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 2.25pt solid windowtext;background: rgb(193, 228, 245);padding: 0in 5.4pt;height: 1.2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003eATM\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45.45pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 2.25pt solid windowtext;background: rgb(193, 228, 245);padding: 0in 5.4pt;height: 1.2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003eMEM\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61.7pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 2.25pt solid windowtext;background: rgb(149, 220, 247);padding: 0in 5.4pt;height: 1.2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003eCIP\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65.85pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 2.25pt solid windowtext;background: rgb(149, 220, 247);padding: 0in 5.4pt;height: 1.2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003eLEV\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35.65pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 2.25pt solid windowtext;background: rgb(179, 229, 161);padding: 0in 5.4pt;height: 1.2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003eCHL\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 2.25pt solid windowtext;background: rgb(179, 229, 161);padding: 0in 5.4pt;height: 1.2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003eCN\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 2.25pt solid windowtext;background: rgb(179, 229, 161);padding: 0in 5.4pt;height: 1.2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New 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style=\"width:48.0pt;background:#B3E5A1;padding:0in 5.4pt 0in 5.4pt;height:12.9pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e14 (53.85)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.0pt;background:#B3E5A1;padding:0in 5.4pt 0in 5.4pt;height:12.9pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e17 (65.38)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.0pt;background:#B3E5A1;padding:0in 5.4pt 0in 5.4pt;height:12.9pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e19 (73.08)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:49.5pt;background:#B3E5A1;padding:0in 5.4pt 0in 5.4pt;height:12.9pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e23 (88.46)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.9pt;background:#B3E5A1;padding:0in 5.4pt 0in 5.4pt;height:12.9pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e25 (96.15)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;padding:0in 0in 0in 0in;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;'\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 78.85pt;padding: 0in 5.4pt;height: 9.45pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eEnvironment n=11\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.75pt;background:#C1E4F5;padding:0in 5.4pt 0in 5.4pt;height:9.45pt;\"\u003e\n \u003cp 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style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e11 (100.00)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.4pt;background:#C1E4F5;padding:0in 5.4pt 0in 5.4pt;height:9.45pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e11 (100.00)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.45pt;background:#C1E4F5;padding:0in 5.4pt 0in 5.4pt;height:9.45pt;\"\u003e\n \u003cp 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style=\"width:54.9pt;background:#B3E5A1;padding:0in 5.4pt 0in 5.4pt;height:9.65pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e37 (97.36)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;padding:0in 0in 0in 0in;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;'\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 78.85pt;padding: 0in 5.4pt;height: 9.65pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eTotal N=75\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.75pt;background:#C1E4F5;padding:0in 5.4pt 0in 5.4pt;height:9.65pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e75 (100.00)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.35pt;background:#C1E4F5;padding:0in 5.4pt 0in 5.4pt;height:9.65pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e74 (98.67)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.35pt;background:#C1E4F5;padding:0in 5.4pt 0in 5.4pt;height:9.65pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e75 (100.00)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.4pt;background:#C1E4F5;padding:0in 5.4pt 0in 5.4pt;height:9.65pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e74 (98.67)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.45pt;background:#C1E4F5;padding:0in 5.4pt 0in 5.4pt;height:9.65pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e16 (21.33)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:61.7pt;background:#95DCF7;padding:0in 5.4pt 0in 5.4pt;height:9.65pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e67 (89.33)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:65.85pt;background:#95DCF7;padding:0in 5.4pt 0in 5.4pt;height:9.65pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan 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style=\"width:48.0pt;background:#B3E5A1;padding:0in 5.4pt 0in 5.4pt;height:9.65pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e23 (30.67)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.0pt;background:#B3E5A1;padding:0in 5.4pt 0in 5.4pt;height:9.65pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e49 (65.33)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:49.5pt;background:#B3E5A1;padding:0in 5.4pt 0in 5.4pt;height:9.65pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e68 (90.67)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.9pt;background:#B3E5A1;padding:0in 5.4pt 0in 5.4pt;height:9.65pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e73 (97.33)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;padding:0in 0in 0in 0in;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;'\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 78.85pt;padding: 0in 5.4pt;height: 12.9pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eHospitalized patients n=31\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.75pt;background:#C1E4F5;padding:0in 5.4pt 0in 5.4pt;height:12.9pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e31 (100.00)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.35pt;background:#C1E4F5;padding:0in 5.4pt 0in 5.4pt;height:12.9pt;\"\u003e\n \u003cp 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style='font-family:\"Times New Roman\",serif;color:black;'\u003e33 (78.57)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:35.65pt;background:#B3E5A1;padding:0in 5.4pt 0in 5.4pt;height:9.65pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e16 (38.10)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.0pt;background:#B3E5A1;padding:0in 5.4pt 0in 5.4pt;height:9.65pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e19 (45.24)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.0pt;background:#B3E5A1;padding:0in 5.4pt 0in 5.4pt;height:9.65pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e13 (30.95)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.0pt;background:#B3E5A1;padding:0in 5.4pt 0in 5.4pt;height:9.65pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e28 (66.67)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:49.5pt;background:#B3E5A1;padding:0in 5.4pt 0in 5.4pt;height:9.65pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e42 (100.00)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.9pt;background:#B3E5A1;padding:0in 5.4pt 0in 5.4pt;height:9.65pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e40 (95.23)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;padding:0in 0in 0in 0in;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;'\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 78.85pt;padding: 0in 5.4pt;height: 9.45pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eTotal N=107\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.75pt;background:#C1E4F5;padding:0in 5.4pt 0in 5.4pt;height:9.45pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e107 (100.00)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.35pt;background:#C1E4F5;padding:0in 5.4pt 0in 5.4pt;height:9.45pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e107 (100.00)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.35pt;background:#C1E4F5;padding:0in 5.4pt 0in 5.4pt;height:9.45pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e107 (100.00)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.4pt;background:#C1E4F5;padding:0in 5.4pt 0in 5.4pt;height:9.45pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e105 (98.13)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.45pt;background:#C1E4F5;padding:0in 5.4pt 0in 5.4pt;height:9.45pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e41 (38.32)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:61.7pt;background:#95DCF7;padding:0in 5.4pt 0in 5.4pt;height:9.45pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e92 (85.98)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:65.85pt;background:#95DCF7;padding:0in 5.4pt 0in 5.4pt;height:9.45pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e84 (78.50)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:35.65pt;background:#B3E5A1;padding:0in 5.4pt 0in 5.4pt;height:9.45pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e46 (42.99)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.0pt;background:#B3E5A1;padding:0in 5.4pt 0in 5.4pt;height:9.45pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e52 (48.60)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.0pt;background:#B3E5A1;padding:0in 5.4pt 0in 5.4pt;height:9.45pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e36 (33.65)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.0pt;background:#B3E5A1;padding:0in 5.4pt 0in 5.4pt;height:9.45pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e76 (71.03)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:49.5pt;background:#B3E5A1;padding:0in 5.4pt 0in 5.4pt;height:9.45pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e103 (96.26)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.9pt;background:#B3E5A1;padding:0in 5.4pt 0in 5.4pt;height:9.45pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:left;line-height:normal;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:black;'\u003e104 (97.20)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;padding:0in 0in 0in 0in;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;'\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4:\u003c/strong\u003e Prevalence of \u0026beta;-lactamase and Plasmid-Mediated Quinolone Resistance genes detected among ESBL- and ciprofloxacin-resistant ESBL-Ec and ESBL-Kp respectively\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"1004\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 15.7997%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026beta;\u003c/strong\u003e\u003cstrong\u003e-lactamase genes n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 22.6007%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlasmid-Mediated Quinolone Resistance genes n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 5.4238%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSource\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.7731%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ebla\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003csub\u003eCTX-M\u003c/sub\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0656%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ebla\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003csub\u003eTEM\u003c/sub\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.5373%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp; \u0026nbsp;bla\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003csub\u003eSHV\u0026nbsp;\u003c/sub\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.4238%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSource\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eaac-(6\u0026rsquo;)-Ib-cr\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2.3582%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eqnr\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003eA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eqnr\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eqnr\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003eS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eoqx\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003eA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eoqx\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eqep\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003eA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 15.7997%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eESBL-\u003cem\u003eE. coli\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;N=75\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 25.0556%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCiprofloxacin-resistant ESBL-\u003cem\u003eE. coli\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;N= 67\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 5.4238%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospitalized patients n=26\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.7731%;\"\u003e\n \u003cp\u003e19 (73.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.0656%;\"\u003e\n \u003cp\u003e15 (57.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.5373%;\"\u003e\n \u003cp\u003e4 (15.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.4238%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospitalized patients n=26\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e15 (57.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.3582%;\"\u003e\n \u003cp\u003e2 (7.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e8 (30.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e4 (15.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e5 (19.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e2 (7.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e3 (11.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 5.4238%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospital Environment n=11\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.7731%;\"\u003e\n \u003cp\u003e10 (90.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.0656%;\"\u003e\n \u003cp\u003e4 (36.36)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.5373%;\"\u003e\n \u003cp\u003e1 (9.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.4238%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospital Environment n=11\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e4 (57.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.3582%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e1 (14.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e1 (14.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 5.4238%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWastewaters n=38\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.7731%;\"\u003e\n \u003cp\u003e36 (94.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.0656%;\"\u003e\n \u003cp\u003e21 (55.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.5373%;\"\u003e\n \u003cp\u003e2 (5.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.4238%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWastewaters n=38\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e26 (76.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.3582%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e5 (14.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e7 (19.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e2 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e6 (17.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 5.4238%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal N=75\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.7731%;\"\u003e\n \u003cp\u003e65(86.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.0656%;\"\u003e\n \u003cp\u003e40 (53.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.5373%;\"\u003e\n \u003cp\u003e7 (9.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.4238%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal N=75\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e45 (67.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.3582%;\"\u003e\n \u003cp\u003e2 (2.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e13 (19.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e12 (17.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e6 (8.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e4 (5.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e9 (13.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 15.7997%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCiprofloxacin-resistant ESBL-\u003cem\u003eK. pneumoniae\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;N= 107\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 25.0556%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCiprofloxacin-resistant ESBL-\u003cem\u003eK. pneumoniae\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;N=93\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 5.4238%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospitalized patients n=31\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.7731%;\"\u003e\n \u003cp\u003e23 (71.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.0656%;\"\u003e\n \u003cp\u003e22 (70.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.5373%;\"\u003e\n \u003cp\u003e17 (54.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.4238%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospitalized patients n=31\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e18 (69.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.3582%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e10 (40.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e7 (26.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e15 (57.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e9 (34.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 5.4238%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospital Environment n=34\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.7731%;\"\u003e\n \u003cp\u003e26 (76.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.0656%;\"\u003e\n \u003cp\u003e20 (58.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.5373%;\"\u003e\n \u003cp\u003e17 (50.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.4238%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospital Environment n=34\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e19 (73.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.3582%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e9 (34.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e11 (42.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e15 (57.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e16 (61.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e1 (3.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 5.4238%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWastewaters n=42\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.7731%;\"\u003e\n \u003cp\u003e32 (76.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.0656%;\"\u003e\n \u003cp\u003e25 (62.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.5373%;\"\u003e\n \u003cp\u003e11 (26.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.4238%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWastewaters n=42\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e17 (41.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.3582%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e16 (39.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e7 (17.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e24 (58.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e9 (21.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 5.4238%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal N=107\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.7731%;\"\u003e\n \u003cp\u003e81 (75.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.0656%;\"\u003e\n \u003cp\u003e67 (62.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.5373%;\"\u003e\n \u003cp\u003e45 (42.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.4238%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal N=107\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e54 (58.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.3582%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e35 (37.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e25 (26.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e54 (58.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e34 (36.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e1 (1.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 5.4238%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall N= 182\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.7731%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e146 (80.22)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.0656%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e107 (58.79)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.5373%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e52 28.57)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.4238%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall N= 182\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e99 (61.88)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.3582%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2 (1.25)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e48 (30.00)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e37 (23.13)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e60 (37.50)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e38 (23.75)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 2.8298%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e10 (6.25)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\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":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Hospital-acquired infection, Hospital environment, Extended-Spectrum β-Lactamase, Enterobacterales, Plasmid-Mediated Quinolone Resistance, One Health","lastPublishedDoi":"10.21203/rs.3.rs-5856415/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5856415/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eExtended-spectrum β-lactamase-producing \u003cem\u003eEscherichia coli\u003c/em\u003e (ESBL-\u003cem\u003eEc\u003c/em\u003e) and \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e (ESBL-\u003cem\u003eKp\u003c/em\u003e) are among the leading cause of hospital-acquired infections globally. Fluoroquinolone-resistant ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e infections have limited therapeutic options. This study investigated the phenotypic and genotypic characteristics of plasmid-mediated quinolone resistance (PMQR) genes in ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e circulating among hospitalized patients, the hospital environment, and wastewaters in Cameroon.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA cross-sectional study was conducted, from February to June 2024 in two healthcare facilities in Yaoundé, Cameroon. Clinical, inanimate surfaces and wastewater samples were collected. Bacteria identification was done using the API20E kit. The ESBL phenotype was detected using the double-disk synergy test and on CHROMagar™ ESBL. Antimicrobial susceptibility testing was performed using the disc diffusion method. Genes conferring resistance to β-lactams and fluoroquinolones were detected using polymerase chain reaction (PCR). Clonal relatedness was assessed using enterobacterial repetitive intergenic consensus (ERIC)-PCR.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe overall ESBL prevalence across all sources was 16% (103/652). This ESBL prevalence was 10% (49/495) in hospitalized patients, 27% (38/141) in the hospital environment and 100% (16/16) in hospital wastewaters. Nearly all (99.5%) ESBL-\u003cem\u003eEc\u003c/em\u003e and ESBL-\u003cem\u003eKp\u003c/em\u003e were multidrug-resistant. The \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eCTX−M\u003c/sub\u003e was the most prevalent β-lactamase gene with prevalence ranging from 74 to 85%. The main plasmid-mediated quinolone resistance gene was \u003cem\u003eaac-(6’)-Ib\u003c/em\u003e with prevalence varying from 57 to 70%. The circulation of ESBL-\u003cem\u003eKp\u003c/em\u003e between both three interfaces as well as within and across the two healthcare facilities was evidenced.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur results underscore the crucial need to implement real-time surveillance and monitoring antimicrobial resistance and implement antimicrobial stewardship programs to curb the circulating ESBL-\u003cem\u003eKp\u003c/em\u003e and ESBL-\u003cem\u003eEc\u003c/em\u003e responsible to neonatal sepsis in neonatology unit in healthcare facilities in Cameroon. Finally, genomic surveillance through the One Health approach is needed to fully understand the transmission dynamics of resistant bacteria in healthcare facilities in Cameroon.\u003c/p\u003e","manuscriptTitle":"Plasmid-mediated quinolone resistance among extended-spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae isolated from hospitalized patients, hospital environment and wastewaters in Cameroon","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-24 10:35:36","doi":"10.21203/rs.3.rs-5856415/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-16T03:26:40+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-13T13:32:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-13T04:34:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-11T18:52:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-09T17:56:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-08T06:32:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"159006704618735292963909245827295587207","date":"2025-03-25T07:30:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"324325850298331089141369031336379004127","date":"2025-03-25T07:14:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"15614683549410479976107357440564283464","date":"2025-03-22T18:51:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"265128090084461179648716041052135117519","date":"2025-03-22T07:38:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"89543519687794626983724670334913244000","date":"2025-03-22T05:24:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"10523874923323204491702366079110994864","date":"2025-03-22T04:13:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"197812052683711624241983316648730427790","date":"2025-03-21T17:12:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"253445485533596357847536823423120347908","date":"2025-03-20T03:58:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-19T17:01:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-19T16:51:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-03-19T05:11:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-18T13:16:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-03-18T13:15:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"857788ed-2254-4a73-9976-c2a2279a008d","owner":[],"postedDate":"March 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":45993071,"name":"Biological sciences/Microbiology"},{"id":45993072,"name":"Biological sciences/Molecular biology"},{"id":45993073,"name":"Health sciences/Health care"},{"id":45993074,"name":"Health sciences/Risk factors"}],"tags":[],"updatedAt":"2025-10-27T16:30:06+00:00","versionOfRecord":{"articleIdentity":"rs-5856415","link":"https://doi.org/10.1038/s41598-025-15465-z","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2025-10-21 16:16:52","publishedOnDateReadable":"October 21st, 2025"},"versionCreatedAt":"2025-03-24 10:35:36","video":"","vorDoi":"10.1038/s41598-025-15465-z","vorDoiUrl":"https://doi.org/10.1038/s41598-025-15465-z","workflowStages":[]},"version":"v1","identity":"rs-5856415","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5856415","identity":"rs-5856415","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}