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Cite this article: Louzi L, Doblali T, Sbiti M, L’ Kassmi H (2016) Microbiological and Resistance Patterns of Blood Cultures Clinical Isolates at Moulay Ismail Military Hospital of Meknes, Morocco. A Four-Year Period Retrospective Study: 2011-2014. JSM Microbiology 4(1): 1030.

*Corresponding authorLhoussain Louzi, Service de microbiologie médicale de l’Hôpital Militaire Moulay Ismail, 50000, Meknès-aviation, Maroc, Morocco, Email:

Submitted: 30 April 2016

Accepted: 20 October 2016

Published: 21 October 2016

Copyright© 2016 Louzi et al.

OPEN ACCESS

Keywords•Septicemia•Bloodstream infections•Blood cultures•Antimicrobial resistance•Meknes

Research Article

Microbiological and Resistance Patterns of Blood Cultures Clinical Isolates at Moulay Ismail Military Hospital of Meknes, Morocco. A Four-Year Period Retrospective Study: 2011-2014Lhoussain Louzi*, Taoufik Doblali, Mohamed Sbiti and Hachemi L’ KassmiDepartment of Medical Microbiology, MIMH, Morocco

Abstract

Introduction: Septicemia poses a problem of diagnosis and treatment in hospitals. There is lack of data on the epidemiological patterns of this topic in Morocco. Indeed, the goal here is to describe microbiological patterns and antimicrobial resistance of clinical microorganisms isolated from blood cultures of patients hospitalized in different departments of the Moulay Ismail Military Hospital in Meknes, Morocco, throughout a four-year period (2011-2014).

Material and Methods: In this study, aerobic and anaerobic blood cultures are analyzed retrospectively. Samples are processed in the BD Bactec™ 9050. All grown microorganisms were identified by Api system (BioMérieux™) or rapid specific kits (BioRad™). The antibiotics susceptibility testing was conducted by disk diffusion method on appropriate Mueller-Hinton agar media according to CA-SFM or EUCAST recommendations (guidelines of French committee and/or European committee on antimicrobial susceptibility). Resistance against carbapenems is confirmed by modified Hodge test.

Results: A total of 712 blood cultures performed for 371 patients gave a positivity rate of 31.3%. Main of inpatients were hospitalized in the intensive care unit (n=116) versus 41 in surgical departments. The mean of age was 55.6 years-old (13 to 87) with a sex ratio m/f of 2.74. The involved microorganisms (n=120) were Staphylococcus sp (50/120 or 41.67%), Staphylococcus aureus (20/50 or 40%), Enterobacteriaceae (43/120 or 35.83%) among which Escherichia coli is the most encountered (21/43). Streptococci/Enterococci were noted in 8.33% (10/120) containing a case of Lactococcus lactis cremoris endocarditis. Non-fermenter Gram-negative bacilli represented 6.67% (8/120). Lowest frequencies are observed with other kinds of aerobic, anaerobic flora; and Candida albicans.

Resistance to methicillin reached 25% (n=5) with Saureus (MRSA) versus 36.67% when CoNS are considered (n=11). The amount of extended spectrum beta lactamase-producing Enterobacteriaceae (ESBLE) was 37.21% (16/43), mainly observed with Escherichia coli (n=11) and Klebsiella pneumoniae (n=8) while carbapenemase-producing Enterobacteriaceae (CPE) were seen in three cases of extremely drug-resistantstrains: K pneumoniae, Enterobacter cloacae and E coli. Non-fermenter Gram-negative rods isolates were four wild strains of Pseudomonas aeruginosa and Ppaucimobilis and three imipenem resistant Acinetobacter baumannii. Resistance patterns against other antibiotics (fluoroquinolones,aminoglycosides, …)is reported.

Conclusion: Staphylococcus sp and Enterobacteriaceae are the predominant cause of septicemia in our settings. Empirical antimicrobial therapy might repose on the fact that ESBLE and MR-Staphylococci have to be expected in first for more efficiency of septicemia management. In the other hand, the reinforcement of hand washing and screening for patients carrying resistant strains is recommended in our settings, as well as culture free diagnostic methods (TAANs and MALDI-TOF) for more efficient diagnosis and accurate antimicrobial therapy.

INTRODUCTIONSepticemia is a severe condition in healthcare settings,

inducting significant morbidity and mortality worldwide, and is part of healthcare associated infections [1].The detection of living microorganisms in the blood of a patient is of major diagnostic and prognostic importance. Blood cultures are the

gold standard in the diagnosis of BSIs (bloodstream infections) [2]. Over the past two decades, changes in epidemiological and clinical features of bacteremia are associated with the emergence of new pathogens, the frequency of increasingly serious diseases or therapeutic promoting occurrence of infections and increased bacterial antibiotic resistance [3]. The treatment and prognosis

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of sepsis depend on rapidity and effectiveness of antimicrobial therapy, usually probabilistic in the first 48 hours and then based on the microbiological data [4]. In Morocco, there is lack of specific studies on bacteremia and absence of consensus on antibiotic therapy. In this way, the main objective of this study is to determine the epidemiological profile of microorganisms isolated from blood cultures and their antibiotic sensitivity throughout a four-year-period analyze of data collected from registers of the laboratory of medical microbiology at Moulay Ismail Military Hospital (MIMH) Meknes Morocco.

MATERIAL AND METHODSThis study is carried out from 2011to 2014 retrospectively

on blood cultures of inpatients hospitalized in different facilities of MIMH, and on isolated bacteria or fungi from these samples. Micro organisms belonging to the soil or commensally flora (as well as Bacillus sp and Corynebacterium sp, Propionibacterium sp,…), are excluded, except when they are isolated twice or higher with the same sensitivity profile and in the absence of known pathogens.

Patients with fever spikes to 39-40oC, chills, hypotension or evident vascular or parietal portal of entry, are indicated as clinical situations for performing blood cultures by introducing 8 to 10 milliliters of venous blood into aerobic and anaerobic vials (BD Bactec TM 9050 system, Becton Dickinson Microbiology Systems, Sparks, Maryland USA) (Figure 1a).

When positive vials are detected, we achieve both of Gram stained smears to observe the morphology of grown microorganisms and subcultures on enriched media to obtain separated colonies. The result of the microscopic examination helps physicians in starting or adjusting probabilistic antibiotic therapy. The isolated strains are identified by combining Gram stain data, cultural characters and biochemical profile of involved microorganisms (API system, bio Mérieux SA, Marcy-L’étoile / France) (Figure 1b).

The study of antibiotic susceptibility was conducted by disk diffusion method on the Mueller-Hinton agar (MHA) (Oxoid™), supplemented when fastidious organisms are concerned as recommended by the CA-SFM and EUCAST [5]. An incubation of18 to 24 hours at 36+/-1°C, in appropriate atmosphere, is necessary (Figures 1c,d).

The MICs are evaluated for some antibiotics by E-test strip when this determination is indicated as well as in the case of glycopeptides molecules often used against methicillin-resistant Staphylococci (Figure 1e).

Besides, MHT is performed against ertapenem-resistant Enterobacteriaceae in order to assess the presence or absence of carbapenemase (Figure 1f).

RESULTSA number of 712 aerobic and anaerobic blood cultures pairs

have been numbered during the studied period, and 371 patients were involved. Positivity rate was 31.27% (116/371). Positive cases were hospitalized in the intensive care unit (43/116 so 37.1%), medical services (34/116 so 29.31%) then emergencies department (23/116 so 19.83%) which can be considered as

Figure 1a Bactec 9050 BD (open) with some vials inside is the automated incubator used in the microbiological department of MIMH, Meknes, Morocco for the diagnosis of septicemia. Image of MIMH Laboratory.

Figure 1b Example of identified bacteria by Api20 E. Here, the biochemical profile corresponds to Salmonella enteric Typhi, (confirmed by serotyping). Image of MIMH Laboratory.

Figure 1c Upper: Api Staph after incubation and revelation showing a biochemical profile of Staphylococcus aureus. Lower: The diameter of inhibition zone of Cefoxitin disk on MHA plate means that the tested strain is sensitive to Methicillin (MSSA). Image of MIMH Laboratory.

community acquired BSIs; and surgical departments (16/116 so 13.79%). These latest facilities gave highest values of positivity rates: 42% (16/38). The mean of age was 55.6 years-old (13 to 87) with a sex ratio 86m/30w equal to 2.87 (Table 1).

In all, 120 microorganisms were isolated and studied. The rate of mono-microbial positive cultures was 93.3% (112/120). Involved microorganisms were mainly Staphylococci (50/120 or 41.67%), Enterobacteriaceae (43/120 or 35.83%), Streptococci group and Enterococci (10/120 or 8.33%) where

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Figure 1d An ESBLE disc diffusion synergy test. Image from MIMH.

Figure 1e E-test using a strip impregnated with a gradient of concentrations of Vancomycin performed on MHA plate against a strain of MRSA. The meeting point between culture and the strip (arrow) determines the MIC. Here, we can read 3 mg/L, which seems a VISA or Vancomycin-Intermediate Staphylococcus aureus. Image of MIMH Laboratory.

Figure 1f Positive MHT of a carbapenemase-producing Enterobacteriaceae strains (streak). Here are given two tested strains on MHA plate: a patient isolated quasi-pandrug resistant Enterobacter cloacae and a positive control Klebsiella Pneumoniae strain. Image of MIMH Laboratory.

Figure 1g Quasi-pandrug-resistant Enterobacter cloacae. The identification of species is based on biochemical profile on Api 20 E (Upper). Susceptibility testing on MHA shown a multi-drug-resistance including betalactams, fluoroquinolones, aminoglycosides (Except amikacine) and cotrimoxazole. This strain is demonstrated as carbapenemase-producing strain on MHA using the modified Hodge test (Figure f). Image of MIMH Laboratory.

the first Moroccan diagnosed case of Lactococcus lactis cremoris endocarditis. Non-fermenter Gram-negative bacilli represented 6.67% (8/120). Some positive blood cultures shown fastidious bacteria belonging to endogenous anaerobe flora like Bacteroides fragilis, Clostridium perfringens (2.5%) and HACEK group (1.67%). During the whole period of study, a single episode of invasive candidiasis due to Candida albicans was diagnosed (0.83%) (Table 2,3).

Staphylococcus aureus related positivity rate was 16.67% (20/120) versus 25% (30/120) for coagulase negative Staphylococci (CoNS) mainly encountered in patients who had vascular surgery or hospitalized in nephrology. Resistance to methicillin, tested by cefoxitin disk (OxoidTM), has reached 25% (n=5) in the case of Sa (MRSA) versus 36.67% when CoNS are considered (n=11). Only one Sa strain showed lack of susceptibility to glycopeptides (VISA), detected by E-Test, MIC=3mg/L) (Figure 1e, Table 4). No acquired resistances were noted with streptococci and enter ococci strains.

In the other hand, Enterobacteriaceae strains showed several susceptibility patterns against betalactams as well as acquired penicilli carbapenemase nase (low level, high level and TRI (Tem-Resistant to Inhibitors)), cephalosporinase and extended spectrum betalactamase (ESBL) (Table 5).

The amount of extended spectrum betalactamase-producing Enterobacteriaceae (ESBLE) was 37.21% (16/43), mainly observed with Escherichia coli strains (11/24) and K pneumoniae strains (8/12). However, the finding means that K pneumoniae is more able to produce ESBL than E coli (67% vs 46%)while carbapenemase-producing Enterobacteriaceae (CPE) were seen in three solitary cases: K pneumoniae, E cloacae and E coli, confirmed by modified Hodge test, single available approach in our Laboratory (Figure 1f, 1g).

Table (6), Figure (1h) report antibiotic resistance profile against main of antibiotics tested in our laboratory.

The isolated strains of Pseudomonas aeruginosa (n=4 or 3.33%) were wild types in their profile of susceptibility to

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Table 1: Positivity rates of septicemia in different departments of MIMH.ICU Medical services Emergencies Surgical services Total

Whole patients 120 112 101 38 371Positive cases 43 34 23 16 116

Positivity rates 35.83% 30.6% 22.77% 42% 31.27%Abbreviations: ICU: Intensive Care Unit, Medical services (Nephrology, Oncology, Hematology…); Surgical services (Urology, Gynecology, Visceral surgery, Traumatology, Chest Surgery …)

Table 2: Groups of microorganisms isolated from blood cultures in the MIMH from 2011 to 2014.Bacteria groups Number Rate (%)

Staphylococci (S aureus and CoNS) 50 41.67Enterobacteriaceae 43 35.83

Streptococci and Enterococci *10 8.33Non-fermenter Gram negative bacilli **8 6.67

Anaerobes (Bacteroidesfragilis, Clostridium perfringens) 3 2.50Gram positive bacilli 2 1.67

HACEK Group (Cardiobacteriumhominis, Kingellakingae) 2 1.67Fungus (Candida albicans) 1 0.83

Aeromonas hydrophila 1 0.83Total 120 100

(*)Streptococcus pneumoniae, Streptococcus sp, Gemellasp, Lactococcussp, Enterococcus sp(**)Pseudomonas aeruginosa, Pseudomonas paucimobilis, Acinetobacter baumannii

Table 3: Complete inventory of isolated microorganisms from blood cultures.Designation Number Rate (%)

Staphylococcus sp (CoNS) 30Staphylococcus aureus 19

Escherichia coli 21Klebsiella pneumoniae 12Enterobacter cloacae 5

Salmonella entericaTyphi 2Enterococcus faecalis 2Gemellahaemolysans 1

Lactococcuslactissubspcremoris 1Streptococcus pneumoniae 2

Streptococcus sp 3Escherichia coli + Aeromonas hydrophila 1+1

Escherichia coli + Pseudomonas aeruginosa 1+1Escherichia coli + Enterococcus faecalis 1+1

Staphylococcus aureus + Pseudomonas aeruginosa 1+1Acinetobacter baumannii 3Pseudomonas aeruginosa 2

Pseudomonas paucimobilis 1Kingellakingae and Cardiobacteriumhominis 2

Clostridium perfringens 1Bacteroidesfragilis group 2

Corynebacterium sp 2Candida albicans 1

Total 120

Table 4: Numbers and rates of resistant strains of S aureus to selected antibiotics.

P FOX K CN PEF VA SYN LZD

Number 20 5 6 4 5 1(*) 1 0

Rate (%) 100 25 30 20 25 5 5 0Abbreviations: P: Penicillin; FOX: Cefoxitin; K: Kanamycine; CN: Gentamycin; PEF: Pefloxacine; VA: Vancomycin; SYN: Quinupristine+Dalfopristine; LZD: Linezolid. (*): VISA (MIC: 3 µg/mL)

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Table 5: Resistance profiles of isolated Enterobacteriaceae strains against betalactams.Absence LL-Pase Pase TRI HL-Pase LL-Case H-Case ESBL Carbase

No 7 4 2 7 2 2 16 3Rate 16.28% 9.3% 4.65% 16.28% 4.65% 4.65% 37.21% 6.98%

Abbreviations: Absence: No Acquired Resistance; LL-Pase Low Level Penicillinase; HL-: High Level; H-: Hyper Produced; Case: Cephalosporinase; ESBL: Extended Spectrum Betalactamase; Carbase: Carbapenemase.

Table 6: resistance of Enterobacteriaceae strains to foremost antibiotics.AM AMC CL CXM CTX CAZ ATM FEP ETP CIP CN AK CT FOS

R 38 29 34 32 24 23 33 26 3 26 24 0 0 5I 0 5 0 0 2 3 3 0 0 0 1 0 0 0S 5 9 9 11 17 17 17 17 40 17 18 43 43 38

Abbreviations: R: Resistant; I: Intermediate; S : Sensitive (according to CA-SFM and/or EUCAST annual recommendations and guidelines) ; AM: Ampicillin; AMC: Coamoxiclav; CL: Cephalothin; CXM: Cefuroxim; CTX: Cefotaxim; CAZ: Ceftazidim; ATM: Aztreonam; FAP: Cefepim; ETP: Ertapenem; CIP: Ciprofloxacin; CN: Gentamicin; AK: Amikacin; FSO: Fosfomycin.

0%10%20%30%40%50%60%70%80%90%

100%

AM AMC CL CXM CTX CAZ ATM FEP ETP CIP CN AK CT FOS

Resistance patterns of Enterobcteriaceae strains

R I S

Figure 1h Resistance patterns of isolated Enterobacteriaceae strains against antibiotics (according to table 6). See comments below Figure g for abbreviations.

antibiotics (LL-Case) while isolated strains of Acinetobacter baumannii (n=3) were XDR (extremely drug-resistant), including a resistance to imipenem.

DISCUSSIONBloodstream infections (BSIs) are a significant source of

morbidity and mortality. Patient outcomes are now improved in developed countries by rapid identification of the causative pathogen and prompt administration of appropriate antimicrobial therapy [6]. The detection of living microorganisms in the blood of a patient is of major diagnostic and prognostic importance. Blood cultures are the gold standard in the diagnosis of BSIs since bacteremia represents a real diagnostic and therapeutic challenge where first antimicrobial therapy is necessarily presumptive awaiting bacteriological data. The obligatory time before providing blood culture and antibiotics sensitivity testing results is often a prognostic factor for bacteremia. In the other hand, the establishment of appropriate presumptive antibiotic therapy requires adequate and updated knowledge of the local bacterial ecology and antibiotic susceptibility of isolates responsible of bacteremia [7]. In this way, the current study aims to determine both of, causative microorganisms and the sensitivity profiles to

antibiotics of predominant involved strains in bacteremia at the city and the region of Meknes, Morocco.

In blood cultures, positivity rates reported are ranging from 9.02 to 45.5% [8-12]. The slightly high rate, as ours, found in some studies is probably due to the dissimilarities in patients recruitment criteria. A second reason may be the severity of underlying disease and invasive procedures achieved in ICUs and in surgical departments. Furthermore, inclusion criteria considered in our study were limited to microbiological characteristics for excluding or accepting potential contaminant isolates like Gram-positive bacilli and CoNS, which can be responsible of real sepsis process and bacteremia in several situations. However, the subjectivity in the interpretation of a positive blood culture contributes certainly to variances in study’s conclusions.

The bacterial septicemia profile in the present study is largely dominated by two bacterial groups: Staphylococci and Enterobacteriaceae as well as reported in either national data including a study at a tertiary hospital in Marrakech [8], a national study at Mohammed the 5th military hospital of Rabat [9], or globally [10-13]. Indeed, sepsis data from Mali [10], given

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data from C.CLIN-OUEST in France [11] and an Australian study [12] join this finding. The most frequently isolated species in our study are also in accordance with those reported by Gohel K and al. [13], about resistance patterns of blood culture isolates in a tertiary care Nephrourology teaching institute in 2014 showing respective rates of34% for CoNS, 20% in the case of S aureus, and 19% with E coli.

The predominance of Staphylococci strains is reported in the majority of studies on bacteremia [14]. In Belgium, monitoring of sepsis in hospital in 2013 reported a rate of11% of S aureus (with 21% of MRSA) versus 13% of CoNS [15]. In the USA, a study found a rate close to ours corresponding to 20.8% isolates of S aureus with 40% of MRSA; and a rate of 38.8% of CoNS among which 75% were resistant to methicillin [16]. The main found portals of entry was often cutaneous where Staphylococcus sp is the most predominant commensal flora. Invasive procedures or infections related to intravascular catheters are known to be involved.

Enterobacteriaceae arrive in the second range of more frequent involved bacteria in BSIs in our hospital with an isolation rate of 22%. This proportion remains too low when compared to those found in literature, including Moroccan data, which indicates rates varying from 28.7% to 44.24% [7] while a study in Belgium shown a rate of 42% [15]. In a Tunisian study, Ben Haj Khalifa et al., reported a very high rate isolation of Enterobacteriaceae (83.2%) [16].

The ESBLE phenotype rate was 31.81% in our study. In France, during the celebrating day of awareness andrational use of antibiotics on 2013, scientists noted that ESBLE infections have become more common than MRSA related infections; and density of incidence was 0.53 per 1000 patient day. In these infections, 10% were invasive with bacteremia [17]. A study conducted in Cameroon reported that 27% of Enterobacteriaceae were ESBL-producing strains [4] versus29.5% in Tunisia [16].

Bacteremia of urinary origin remained the most common in this study with Escherichia coli as the main causative microorganism, confirming its predominance in hospital-acquired urinary tract infections (UTIs). The isolation rate of E coli was 16%. This rate is similar to that reported in a study performed in India, which reports a proportion of 15.2% [13] and slightly lower compared to other studies. A rate of 25.8% in a Tunisian study was noted [16] and 22% in Belgium [15]. However, E cloacae and K pneumoniae were involved only in 2% of cases. A recent study showed that E coli was the most common cause of bacteremia in England, with an incidence of 507 cases per million inhabitants and a mortality rate of 18.2%. Three-quarters of the deaths (75%) occurred within 14 days of collection for blood for culture [18]. A previous study showed that ESBL production by strains of Escherichia coli increased from zero in 2001 to 9% in 2007 [19]. ESBL production in our study was 23.52% in isolated strains of Escherichia coli. In Spain, Garcia et al. [20], reported that 10% of E coli bacteremia was responsible for producing ESBL. In a French prospective study of 2011, E coli seems to be resistant to 3rd generation cephalo sporins (3GCS) in 3.8% when isolated from bloodstream and only 1.7% were producing ESBL [21]. However, the ESBLE rates reported in the literature are highly variable worldwide. Studies show that this difference is due to the geographic origin of the patients. In France, a study reported

that patients who come from Paris region were more likely to be infected with a strain of ESBLE (14%) than patients from the West of France (3.6%) [21].The variability in resistance levels or rates could even be seen between units in the same hospital as reported by Binkley et al. [22].

Our study reported three CPE where a single strain of producing carbapenemase K pneumoniae. An American study reported that the majority of carbapenemases producing strains are K pneumonia [23]. It is reported worldwide that carbapenemase production has spread to other Enterobacteriaceae species like E coli and E cloacae. The threat with CPE is the antibiotic therapy impasse and mortality. In this way, Girometti N et al. [24], have retrospectively analyzed the impact of resistance on the appropriateness of empirical therapy and treatment outcomes of K pneumoniae bloodstream infections (BSIs) during a 2-year period at a 1420-bed tertiary-care teaching hospital in northern Italy where they identified 217 unique patient BSIs, including 92 (42%) KPC-positive, 49 (23%) ESBL-positive and 1 (0.5%) metallo-beta-lactamase-positive isolates. Multidrug-resistant K pneumoniae accounted for two-thirds of all K pneumoniae BSIs, high rates of inappropriate empirical therapy, and twofold higher rates of patient death irrespective of underlying illness.

Streptococci isolation rate was lower than the previous two groups (8%), but their incrimination in endocarditis identified in our study remains remarkable. Indeed, Streptococci are the most common type of non-associated healthcare isolates, which are bloodstream infections with continuous bacteremia, usually from heart valve vegetation and whose detection and/or isolation of the pathogen in blood and the visualization of vegetation, are of fundamental importance [25]. Among the positive cases of septicemia recorded in our study, 7%arevery likely infective endocarditis (IE). As sepsis, laboratory diagnosis of endocarditis is based on positive blood cultures. However, other criteria, as the Duke criteria, are suitable for decision [26].

The NF-GNB isolation rate was 6.67% where Pseudomonas aeruginosa represented the half (3.33%). In Marrakesh, a study found an isolation rate of 8.9% for P aeruginosa [7], a rate that is a higher than that found in our study because of a service for burnt patients is investigated. However, data from ONERBA (France, 2011-2012) reported a rate close to that of our study (3.8%) [27].

The only case of fungemia due to Candida albicans was observed in this study (1.1% rate) joins a previous study in Rabat [28] and seams a stable rate of this entity when all patients are considered. A study in the USA over a 20 year-period (1979 to 2000) illustrated that the incidence of fungemia is significantly higher(4.6%) [29] and Candida albicans was the most frequently isolated species, either in the USA [30] European union [31] or on other continents [32]. Nevertheless, diagnosis of candidemia is difficult to establish because of the non-specific clinical signs and laboratory uneasiness methods despite of the fact that blood culture is the gold standard method for the diagnosis of systemic candidiasis. This test has low sensitivity and takes several days to be positive, thus delaying diagnosis and initiation of appropriate treatment. De Almeida et al. [33], precise that invasive candidiasis is a major invasive fungal infection. It has high lethality, and even higher if not treated early. We need methods that are more efficient, such as the detection of specific antigens

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and metabolites of Candida sp and detection of specific DNA by PCR method or by mass spectrometry (MALDI-TOF-MS).This technique is associated with substantial time saving in pathogen identification and instigation of appropriate therapy, which may also reduce hospital stay. Nevertheless, more and better proof, including impact on patient health and cost-effectiveness, is required [6].

Hence, bloodstream infection is a major cause of morbidity and mortality worldwide. Despite positive blood-culture allows concluding for septicemia; there are many determinants to take in account for establishing this entity [34].

CONCLUSIONSepticemia is significant in the spectrum of infections

diagnosed at the Moulay Ismail Military Hospital in Meknes, Morocco. Its diagnosis is critical and has to be as fast and accurate as possible. Blood culture is the suitable tool because it permits the growth of microorganisms prior to their subculture, identification and antibiotics sensitivity testing. However, interpretation can be difficult, especially against usual contaminant flora. The time required before results rendering remains incompatible with the concept of emergency. The findings emphasize that rapid and accurate culture free techniques being widely used are necessary.

ACKNOWLEDGEMENTSThe authors thank all the team workers and broadcast

of Clinical Laboratory of MIMH, Meknes, Morocco, for their contribution to this article.

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Louzi L, Doblali T, Sbiti M, L’ Kassmi H (2016) Microbiological and Resistance Patterns of Blood Cultures Clinical Isolates at Moulay Ismail Military Hospital of Meknes, Morocco. A Four-Year Period Retrospective Study: 2011-2014. JSM Microbiology 4(1): 1030.

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