Journal of Global Antimicrobial Resistance 25 (2021) 370–376

Contents lists available at ScienceDirect

Journal of Global Antimicrobial Resistance

journal homepage: www.elsevier.com/locate/jgar

Monitoring antibiotic resistance profiles of faecal isolates of

Enterobacteriaceae and the prevalence of carbapenem-resistant
isolates among food handlers in Kuwait
Ola H. Moghnia, Vincent O. Rotimi, Noura A. Al-Sweih∗
Department of Microbiology, Faculty of Medicine, Kuwait University, Kuwait

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: Carbapenem-resistant Enterobacteriaceae (CRE) have become one of the most challenging
Received 1 March 2021 problems in infectious diseases worldwide. Unrecognised personnel such as food handlers (FHs) colonised
Revised 29 March 2021
with CRE serve as a reservoir for transmission. This study assessed the prevalence and susceptibility pat-
Accepted 13 April 2021
terns of CRE isolates from FHs working in commercial eateries in the community (CFHs) and healthcare
Available online 12 May 2021
settings (HCFHs) in Kuwait over the period 2016–2018.
Editor: S. Stefani
Methods: Representative colonies from faecal samples were identified by API 20E and a VITEK®2 ID
Keywords: System. Susceptibility testing against 21 antibiotics was performed by Etest and agar dilution.
Antimicrobial resistance
Carbapenem-resistant Enterobacteriaceae Results: A total of 681 isolates of the family Enterobacteriaceae were isolated from 405 FHs, of which 425
Faecal carriage (62.4%) were Escherichia coli and 126 (18.5%) were Klebsiella pneumoniae. The prevalence of CRE among
Food handlers FHs was 7.7% (31/405), comprising 32% CFHs (10/31) and 68% HCFHs (21/31). Ampicillin, tetracycline and
cefalotin showed very poor activities against most isolates with resistance rates of 63.3%, 41.7% and 40.8%,
respectively. The prevalence of multidrug-resistant (MDR) isolates was 30.5%, including 130 E. coli (30.6%)
and 22 K. pneumoniae (17.5%). An alarming level of colistin resistance (11.3%) was noted. A significant
proportion of FH isolates (13.2%) exhibited extended-spectrum β -lactamases (ESBL) phenotypes, including
80 E. coli (18.8%) and 5 K. pneumoniae (4.0%).
Conclusion: This study revealed that asymptomatic intestinal carriage of CRE, including MDR and ESBL
isolates, was relatively common in our community. It is conceivable that FHs may pose a significant risk
to consumers for the acquisition and spread of resistant strains.
© 2021 The Author(s). Published by Elsevier Ltd on behalf of International Society for Antimicrobial
Chemotherapy.
This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)

1. Introduction out the world. Unfortunately, this scenario is threatened by the

Carbapenems are the last-resort antibiotics for treating severe
bacterial infections caused by multidrug-resistant (MDR) Gram-
negative bacteria belonging to the family Enterobacteriaceae that
are commonly encountered as nosocomial pathogens. They have
been particularly recommended for the treatment of infections
caused by extended-spectrum β -lactamase (ESBL)-producing iso-
lates, which has inevitably led to their increased consumption
in many countries. The consequence of this phenomenal in-
crease in use has been unmitigated resistance problems through-
∗
Corresponding author.
E-mail address: nourah.alsuwaih@ku.edu.kw (N.A. Al-Sweih).
overwhelming spread of carbapenem-resistant Enterobacteriaceae
(CRE), with a significant attendant challenge in clinical and public-
health settings. The wide spread of CRE in the community in de-
veloping countries appears to be related to the ease of spread be-
tween humans owing to several modes of transmission, such as
hand carriage and contaminated food and water, as well as the ac-
quisition of genetic material by bacteria through lateral gene trans-
fer that is mediated predominately by plasmids and transposons
[1,2].
The human gastrointestinal tract (GIT) presents an ideal and
important niche for Enterobacteriaceae and where antibiotic re-
sistance genes can spread through bacterial populations [3]. GIT
colonisation or carriage of CRE is a critical step before develop-
ing nosocomial infections and often precedes infection. It is appar-

https://doi.org/10.1016/j.jgar.2021.04.009
2213-7165/© 2021 The Author(s). Published by Elsevier Ltd on behalf of International Society for Antimicrobial Chemotherapy. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
O.H. Moghnia, V.O. Rotimi and N.A. Al-Sweih
ent that asymptomatic carriers may serve as an important reser-
voir for transmitting resistant bacteria [4]. Few studies in the liter-
ature have addressed the prevalence of community-acquired CRE.
A study carried out in Michigan, USA, showed that 65% of CRE-
infected cases were from the community. This high prevalence
was attributed to interfacility communication, where patients car-
ried resistant bacteria from one healthcare facility to another and
from hospital to community and vice versa [5]. Several other stud-
ies conducted on patients admitted to healthcare settings have
demonstrated correlations between infection and the presence of
GIT colonisation by CRE [6]. Thus, international focus has shifted
to early detection by rectal swab surveillance as well as infection
prevention and control.
Food handlers (FHs) with inadequate personal hygiene can be
potential sources of infection and may serve as a reservoir of an-
timicrobial resistance genes [7,8]. While the prevalence of CRE iso-
lates has been studied extensively among patients in healthcare
facilities, little is known about the prevalence of rectal colonisa-
tion by CRE among healthy populations, particularly FHs. The ob-
jective of this study was to determine the antibiotic susceptibility
patterns of different species of the family Enterobacteriaceae. Also,
to evaluate the prevalence rates of intestinal colonisation by CRE,
including ESBL-producing and MDR isolates, among FHs as well as
prevalence rates between community food handlers (CFHs) versus
healthcare food handlers (HCFHs) in Kuwait, in order to help pre-
vent the spread of CRE.
2. Methods
2.1. Study design
A prospective cohort analytical investigational study was con-
ducted over a 2-year period (September 2016 to June 2018) in-
volving FHs who were working in catering services in healthcare
(HCFHs) and community (CFHs) establishments in six Governorates
of the State of Kuwait, namely Al Ahmadi, Al Asimah, Al Far-
waniyah, Hawalli, Al Jahra and Mubarak Al-Kabeer.
2.2. Ethical approval
This study was approved by the Joint Committee for the Protec-
tion of Human Subjects in Research, Health Sciences Center, Kuwait
University. Additionally, institutional ethical approval was obtained
from the authorising Medical Ethics Committee of the Food and
Nutrition Administration, Ministry of Health, Kuwait. Collection of
specimens was conducted according to the Declaration of Helsinki
and with particular institutional ethical and professional standards.
Written informed consent was obtained from the participants.
2.3. Microbiological studies
One faecal sample was collected from each participant. A ster-
ile swab was dipped into a freshly passed stool and was then in-
oculated directly onto a MacConkey agar plate (Oxoid Ltd., Bas-
ingstoke, UK). Inoculated plates were incubated in an incuba-
tor (Gallenkamp Economy Incubator size 2; Akribis Scientific Ltd.,
Widnes, England) at 37°C for 24 h. A single representative colony
of Enterobacteriaceae isolates was then subcultured onto a fresh
MacConkey agar plate and incubated for another 24 h to obtain a
pure culture. Bacterial isolates were identified to species level us-
ing API 20E and a VITEK®2 ID System (bioMérieux, Marcy-l’Étoile,
France).
2.4. Antimicrobial susceptibility testing
Minimum inhibitory concentrations (MICs) of 21 antibi-
otics were determined by Etest (bioMérieux) and the agar
371
Journal of Global Antimicrobial Resistance 25 (2021) 370–376
Fig. 1. Antimicrobial susceptibility testing of isolates against selected antibiotics by
Etest minimum inhibitory concentration (MIC) determination. CE, cefalotin (MIC 6
μg/mL); XM, cefuroxime (2 μg/mL); FX, cefoxitin (6 μg/mL); TZ, ceftazidime (0.094
μg/mL); CT, cefotaxime (0.047 μg/mL); PM, cefepime (0.064 μg/mL); TX, ceftriax-
one (0.23 μg/mL); CI, ciprofloxacin (0.19 μg/mL). Arrows showed the elliptical zone
of inhibition intersected the Etest strip.
dilution method according to the manufacturer’s instructions.
The following antibiotics were tested: amikacin and gen-
tamicin (aminoglycosides); ampicillin, amoxicillin/clavulanic acid
and piperacillin (β -lactams); piperacillin/tazobactam (β -lactam/β -
lactamase inhibitor); aztreonam (monobactam); cefalotin, ce-
fepime, cefotaxime, cefoxitin, ceftazidime, ceftriaxone and cefurox-
ime (cephalosporins/cephamycin); ciprofloxacin (quinolone); er-
tapenem, imipenem and meropenem (carbapenems); tetracycline
(tetracyclines); tigecycline (glycylcycline); and colistin (polymyxin).
Briefly, a suspension of an overnight culture of the isolate was pre-
pared in sterile phosphate-buffered saline (Invitrogen, Carlsbad, CA,
USA) to a density that matched a 0.5 McFarland turbidity standard,
equivalent to 1.5 × 108 CFU/mL in the test tube. This inoculum
was used to evenly streak the surface of Mueller–Hinton agar (Ox-
oid Ltd.). After drying for ~15 min on the bench, six Etest strips
were radially applied onto the surface of a 140 × 20 mm Petri dish
(Deltalab, Barcelona, Spain) (Fig. 1) and then incubated at 37°C for
24 h in an aerobic incubator. Interpretation of the results was car-
ried out according to Clinical and Laboratory Standards Institute
(CLSI) interpretative criteria [9]. The MIC method for colistin and
resistant breakpoints for colistin and tigecycline were as recom-
mended by the European Committee on Antimicrobial Susceptibil-
ity Testing (EUCAST) [10]. Escherichia coli ATCC 25922 and ATCC
35218 and Klebsiella pneumoniae ATCC BAA-1705 and ATCC BAA-
1706 were used as positive and negative controls, respectively. The
MICs that inhibited 50% (MIC50 ) and 90% (MIC90 ) of the isolates
were calculated to compare susceptibilities of different groups and
isolates. Multidrug resistance was defined as non-susceptibility to
at least one agent in three or more antimicrobial categories.
2.5. Detection of carbapenem-resistant Enterobacteriaceae
Enterobacteriaceae isolates that showed decreased susceptibil-
ity to ertapenem, imipenem or meropenem (MICs of >0.5, >1 and
>1 μg/mL, respectively) were presumptively identified as CRE.
2.6. Detection of extended-spectrum β -lactamases (ESBLs)
Isolates exhibiting resistance to the extended-spectrum
cephalosporin group were tested for the production of ESBLs.
The test was carried out by Etest® ESBL Ceftazidime/ceftazidime
combined with clavulanic acid (TZ/TZL) and Cefotaxime/cefotaxime
combined with clavulanic acid (CT/CTL) (bioMérieux) according to
the manufacturer’s instructions.
O.H. Moghnia, V.O. Rotimi and N.A. Al-Sweih Journal of Global Antimicrobial Resistance 25 (2021) 370–376

Table 1 Table 2
Demographic characteristics of food Resistance patterns of all Enterobacteriaceae iso-
handlers (FHs) included in the study lates (n = 681) from healthcare and community
(n = 405) food handlers

Characteristic No. (%) of FHs Antimicrobial agent No. (%) resistant

Working sector Amikacin 2 (0.3)

HCFHs 223 (55.1) Amoxicillin/clavulanic acid 151 (22.2)
CFHs 182 (44.9) Ampicillin 431 (63.3)
Governorate Aztreonam 85 (12.5)
Hawalli 126 (31.1) Cefepime 68 (10.0)
Al Asimah 88 (21.7) Cefotaxime 94 (13.8)
Al Jahra 17 (4.2) Cefoxitin 103 (15.1)
Mubarak Al-Kabeer 25 (6.2) Ceftazidime 33 (4.8)
Al Ahmadi 64 (15.8) Ceftriaxone 89 (13.1)
Al Farwaniyah 85 (21.0) Cefuroxime 97 (14.2)
Ethnicity Cefalotin 278 (40.8)
Arab 56 (13.8) Ciprofloxacin 73 (10.7)
Non-Arab 349 (86.2) Colistin 77 (11.3)
Nationality Ertapenem 20 (2.9)
Indian 188 (46.4) Gentamicin 26 (3.8)
Filipino 82 (20.2) Imipenem 16 (2.3)
Egyptian 48 (11.9) Meropenem 5 (0.7)
Bangladeshi 37 (9.1) Piperacillin/tazobactam 3 (0.4)
Nepali 23 (5.7) Piperacillin 131 (19.2)
Siri Lankan 11 (2.7) Tetracycline 284 (41.7)
Syrian 4 (1.0) Tigecycline 10 (1.5)
Pakistani 2 (0.5)
Italian 2 (0.5)
Ethiopian 2 (0.5)
Malian 1 (0.2) FHs were male (343; 84.7%), with a male-to-female ratio of 5.5:1.
Iranian 1 (0.2) The majority of participants (178; 44.0%) were in the age group
Afghani 1 (0.2) 29–39 years.
Chinese 1 (0.2)
Tunis 1 (0.2)
3.2. Bacterial isolates and antimicrobial susceptibility
Lebanese 1 (0.2)
Sex
Female 62 (15.3) Microbiological cultures yielded 681 non-duplicate isolates of
Male 343 (84.7) the family Enterobacteriaceae from 405 participants. Escherichia
Age group coli was the most predominant species accounting for 425 (62.4%)
<18 years 0
of all isolates, of which 219 (51.5%) were from HCFHs and 206
18–28 years 135 (33.3)
29–39 years 178 (44.0) (48.5%) were from CFHs. This was followed by K. pneumoniae, rep-
40–49 years 73 (18.0) resenting 126 (18.5%) of all isolates, of which 79 (62.7%) were from
50–59 years 18 (4.4) HCFHs and 47 (37.3%) were from CFHs. The remaining 130 isolates
>60 years 1 (0.2) (19.1%) were other Enterobacteriaceae species.
HCFHs, healthcare food handlers; CFHs, The activities of all antimicrobial agents tested against
community food handlers. Enterobacteriaceae isolates are shown in Table 2. Amikacin,
piperacillin/tazobactam, meropenem and tigecycline demonstrated
excellent activities against all isolates with susceptibility rates
2.7. Statistical analysis of 99.7%, 99.6%, 99.3% and 98.5%, respectively. By contrast, rela-
Data were collected and tabulated using IBM SPSS Statistics tively high percentages of the isolates were resistant to ampicillin
v.25.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics of demo- (63.3%), tetracycline (41.7%) and cefalotin (40.8%). An unacceptably
graphic variables were calculated, including frequencies, percent- high percentage of isolates (77/681; 11.3%) were resistant to col-
ages, means and ranges. The χ 2 or Fisher’s exact test was used istin.
as appropriate to determine the association between variables and
the significance of any observed differences. A two-sided P-value 3.3. Prevalence of carbapenem-resistant Enterobacteriaceae (CRE),
of <0.05 was considered statistically significant. including multidrug-resistant (MDR) and extended-spectrum
β -lactamase (ESBL)-producing isolates, among community and
3. Results healthcare food handlers

3.1. Demographic characteristics
As shown in Table 1, a total of 405 FHs were included in the
study, comprising 182 (44.9%) CFHs working in full-service restau-
rants in the community and 223 (55.1%) HCFHs working in can-
teens and cafeterias within healthcare settings. The 405 FHs were
from the following governorates: Hawalli, 126 (31.1%); Al Asimah,
88 (21.7%); Al Jahra, 17 (4.2%); Mubarak Al-Kabeer, 25 (6.2%); Al
Ahmadi, 64 (15.8%); and Al Farwaniyah, 85 (21.0%). Moreover, 349
FHs (86.2%) were non-Arab. The top four nationalities were Indian,
Filipino, Egyptian and Bangladeshi, accounting for 188 (46.4%), 82
(20.2%), 48 (11.9%) and 37 (9.1%) of the workers, respectively, with
other nationalities accounting for 50 FHs (12.3%). The majority of
Table 3 shows that 405 rectal samples were collected from FHs
and included 681 Enterobacteriaceae isolates. A total of 36/681 iso-
lates (5.3%) were non-susceptible to one or more of the carbapen-
ems obtained from 31/405 FHs (7.7%), with 32% (10/31) and 68%
(21/31) from CFHs and HCFHs, respectively. CRE isolates were as
follows: 15 (41.7%) E. coli; 8 (22.2%) K. pneumoniae; and 13 (36.1%)
other isolates. Of the 425 E. coli isolates, 15 (3.5%) were CRE; of
these, 4 (26.7%) and 11 (73.3%) were from CFHs and HCFHs, re-
spectively. Of the 126 K. pneumoniae isolates, 8 (6.3%) were CRE; of
these, 1 (12.5%) and 7 (87.5%) were from CFHs and HCFHs, respec-
tively.
Of the total 681 isolates, 208 (30.5%) were MDR. The distribu-
tion of MDR isolates was as follows: E. coli, 130 (62.5%); K. pneu-

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O.H. Moghnia, V.O. Rotimi and N.A. Al-Sweih Journal of Global Antimicrobial Resistance 25 (2021) 370–376

Table 3
Comparative distribution of carbapenem-resistant, multidrug-resistant (MDR) and
extended-spectrum β -lactamase (ESBL)-producing isolates among Escherichia coli
and Klebsiella pneumoniae isolates from community food handlers (CFHs) and
healthcare food handlers (HCFHs)

Isolate No. (%) of isolates

Minimum inhibitory concentrations (MICs) of antimicrobial agents against Escherichia coli isolates (n = 425) obtained from healthcare food handlers (HCFHs) and community food handlers (CFHs)

0.001∗
0.011∗
0.006∗
0.001∗

0.001∗
0.001∗

0.044∗

0.008∗
0.485
0.477

0.382

0.064

0.063
0.492
0.677
0.485

0.127
0.613
value
CFHs HCFHs P-value Total FHs

0.58

0.13
P-

1
E. coli 206 (48.5) 219 (51.5) 425 (62.4)
Carbapenem-resistant 4 (26.7) 11 (73.3) 0.114 15 (3.5)

No. (%) resistant

MDR 49 (37.7) 81 (62.3) 0.004∗ 130 (30.6)
ESBL-producer 23 (28.8) 57 (71.3) 0.001∗ 80 (18.8)

27 (13.1)
92 (44.7)
26 (12.6)

24 (11.7)

23 (11.2)
25 (12.1)
74 (35.9)
25 (12.1)

44 (21.4)
79 (38.3)
K. pneumoniae 47 (37.3) 79 (62.7) 126 (18.5)

16 (7.8)

15 (7.3)
20 (9.7)

10 (4.9)

10 (4.9)
1 (0.5)

3 (1.5)
2 (1.0)

1 (0.5)
1 (0.5)

2 (1.0)
Carbapenem-resistant 1 (12.5) 7 (87.5) 0.257 8 (6.3)
MDR 3 (13.6) 19 (86.4) 0.014∗ 22 (17.5)
ESBL-producer 0 5 (100) 0.156 5 (4.0)
∗

MIC90 (μg/mL)
Statistically significant (P < 0.05).

0.094

0.047
>256

>256
>256

>256
>256
0.25

0.75
1.5

1.5
12

16

16
moniae, 22 (10.6%); and others, 56 (26.9%). The rate of MDR E. coli

6
2
8

6
2

3
isolates among FHs was 30.6% (130/425), which showed statistical

MIC50 (μg/mL)
significance between CFHs (49/130; 37.7%) versus HCFHs (81/130;
62.3%) (P = 0.004). The rate of MDR K. pneumoniae isolates among
FHs was 17.5% (22/126), which showed statistical significance be-

0.064
0.032
0.064

0.047

0.023

0.125
0.012

0.023
0.19

0.25

0.25
tween CFHs (3/22; 13.6%) versus HCFHs (19/22; 86.4%) (P = 0.014).

0.5
3
4
4

2
6

2
2
2
For ESBL production, 90 isolates (13.2%) were ESBL-positive. The

MIC50/90 , MIC inhibiting 50% and 90% of the isolates, respectively; AMC, amoxicillin/clavulanic acid; TZP, piperacillin/tazobactam.
distribution of ESBL-positive isolates was as follows: E. coli, 80

MIC range (μg/mL)

(88.9%); K. pneumoniae, 5 (5.6%); and others, 5 (5.6%). The rate

0.0064 to >256
0.064 to >256
0.016 to >256

0.012 to >256
0.016 to >256

0.015 to >256
0.023 to >256
0.064 to >256

0.015 to >256

0.015 to >256
0.032 to >256
0.016 to >256
0.002 to >256
0.38 to >256
of ESBL-producing E. coli among FHs was 18.8% (80/425), which

0.002–1.5
0.016–48

0.016–64

0.064–64
0.002–32

0.002–24
showed statistical significance between CFHs (23/80; 28.8%) and

0.023–6
HCFHs (57/80; 71.3%) (P = 0.001). All ESBL-producing K. pneumo-
niae isolates (5/126; 4.0%) were from HCFHs.
No. (%) resistant

143 (65.3)

100 (45.7)
34 (15.5)

49 (22.4)
42 (19.2)
55 (25.1)

55 (25.1)
54 (24.7)
98 (44.7)
38 (17.4)
29 (13.2)

72 (32.9)
15 (6.8)
14 (6.4)

14 (6.4)
9 (4.1)

2 (0.9)

1 (0.5)

1 (0.5)
3.5. Antibiotic resistance pattern of Escherichia coli and Klebsiella
0

0
pneumoniae isolates between healthcare food handlers (HCFHs) and
community food handler (CFHs)
MIC90 (μg/mL)

The MIC range, MIC50 and MIC90 values, and percentage of re-
sistance of the most prominent species of the family Enterobacte-
>256

>256
>256

>256
>256
CFHs (n = 206 isolates)

0.25

0.38
0.19

0.75
1.5
16

16

32

96

32

riaceae (E. coli and K. pneumoniae) were analysed (Tables 4 and 5).
4

8
4

Table 4 shows that E. coli isolates both from HCFHs and CFHs 3
MIC50 (μg/mL)

exhibited high resistance to antibiotics with MIC90 values of >256

μg/mL for ampicillin, cefalotin, piperacillin, cefuroxime and tetra-
cycline. Comparatively, resistance rates against the following an-
0.125
0.064
0.047
0.064

0.064

0.125

0.032

0.047
0.19

0.25

tibiotics that achieved a statistically significant difference between

0.5

0.5

1.5
96
2
6

3
8

3
3

isolates from HCFHs and CFHs, respectively, were: 65.3% vs. 44.7%
against ampicillin (P = 0.001); 22.4% vs. 12.6% against aztreonam
HCFHs (n = 219 isolates)

(P = 0.011); 19.2% vs. 9.7% against cefepime (P = 0.006); 25.1%

MIC range (μg/mL)

vs. 11.7% against cefotaxime (P = 0.001); 25.1% vs. 11.2% against

Statistically significant (P < 0.05).

ceftriaxone (P = 0.001); 24.7% vs. 12.1% against cefuroxime (P =

0.125 to >256
0.016 to >256

0.015 to >256
0.002 to >256
0.016 to >256

0.002 to >256

0.032 to >256

0.016 to >256
0.032 to >256
0.03 to >256
0.25 to >256

0.001); 13.2% vs. 7.3% against colistin (P = 0.044); and 32.9% vs.
0.008–0.38
0.002–1.5
0.016–96
0.016–64

0.016–96

0.015–64

21.4% against piperacillin (P = 0.008).

0.19–12

0.02–96
0.008–2
1–256

Table 5 shows the resistance pattern of the K. pneumoniae iso-

lates. A total of 126 isolates were obtained from all FHs: 79 (62.7%)
from HCFHs and 47 (37.3%) from CFHs. There were statistically sig-
Antimicrobial

Ciprofloxacin

Meropenem

Tetracycline
Ceftazidime

Gentamicin
Ceftriaxone
Cefuroxime

Piperacillin
Cefotaxime

nificantly differences in the resistance rates amongst isolates from

Tigecycline
Aztreonam

Ertapenem
Ampicillin

Imipenem
Amikacin

Cefepime

Cefoxitin

Cefalotin

HCFHs and CFHs, respectively, against amoxicillin/clavulanic acid

Colistin
Table 4

agent

AMC

(21.5% vs. 4.3% P = 0.009), cefoxitin (11.4% vs. 0%; P = 0.026),

TZP

cefalotin (20.3% vs. 6.4%; P = 0.041) and tetracycline (41.8% vs.

∗

17.0%; P = 0.004). Rates of carbapenem resistance among HCFH K.

pneumoniae isolates were 6.3%, 2.5% and 2.5% against ertapenem,
imipenem and meropenem, respectively (mean, 3.8%), while the
rate for CFH isolates was 2.1% against imipenem. The ampicillin
and cefalotin MIC90 values for HCFH isolates was >256 μg/mL.

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O.H. Moghnia, V.O. Rotimi and N.A. Al-Sweih Journal of Global Antimicrobial Resistance 25 (2021) 370–376

Table 5
Minimum inhibitory concentrations (MICs) of antimicrobial agents against Klebsiella pneumoniae isolates (n = 126) obtained from healthcare food handlers (HCFHs)
and community food handlers (CFHs)

HCFHs (n = 79
Antimicrobial isolates) CFHs (n = 47 isolates)
agent P-value
MIC range MIC50 MIC90 No. (%) MIC range MIC50 MIC90 No. (%)
(μg/mL) (μg/mL) (μg/mL) resistant (μg/mL) (μg/mL) (μg/mL) resistant

Amikacin 0.19–8 2 3 0 1.0–6 2 4 0 –

AMC 0.25 to >256 2 32 17 (21.5) 0.75–128 2 4 2 (4.3) 0.009∗
Ampicillin 0.016 to >256 64 >256 73 (92.4) 2 to >256 24 192 44 (93.6) 1
Aztreonam 0.016–48 0.047 0.38 3 (3.8) 0.0125–0.38 0.047 0.094 0 0.293
Cefepime 0.0125–32 0.047 0.19 3 (3.8) 0.016–0.125 0.047 0.064 0 0.293
Cefotaxime 0.002–96 0.047 0.32 5 (6.3) 0.016–4 0.064 0.125 1 (2.1) 0.41
Cefoxitin 0.016 to >256 4 12 9 (11.4) 0.125–8 3 4 0 0.026∗
0.016 to >256 0.125 1 3 (3.8) 0.016–0.75 0.19 0.38 0 0.293
Ceftazidime
Ceftriaxone 0.016 to >256 0.064 0.125 3 (3.8) 0.023–0.94 0.064 0.125 0 0.293
Cefuroxime 0.032 to >256 2 6 6 (7.6) 0.5–4 2 3 0 0.083
Cefalotin 0.016 to >256 4 >256 16 (20.3) 1.5–12 3 8 3 (6.4) 0.041∗
0.002–1 0.064 0.19 0 0.002–32 0.032 0.064 2 (4.3) 0.137
Ciprofloxacin
Colistin 0.015–8 0.6 4 11 (13.9) 0.03–4 0.25 0.5 3 (6.4) 0.249
Ertapenem 0.003–32 0.047 0.25 5 (6.3) 0.006–0.125 0.016 0.047 0 0.156
Gentamicin 0.064–12 0.5 1 1 (1.3) 0.25–3 0.5 1 0 1
Imipenem 0.004–8 0.25 0.38 2 (2.5) 0.094–1.5 0.19 0.25 1 (2.1) 1
0.002–3 0.094 0.19 2 (2.5) 0.016–0.25 0.047 0.064 0 0.529
Meropenem
TZP 0.023 to >256 3 4 1 (1.3) 1–12 4 6 0 1
Piperacillin 0.19 to >256 6 12 5 (6.3) 0.75 to >256 4 12 2 (4.3) 1
0.75 to >256 3 8 33 (41.8) 0.75–6 3 4 8 (17.0) 0.004∗
Tetracycline
Tigecycline 0.016–3 0.75 1.5 1 (1.3) 0.38–2 1 1.5 0 1

MIC50/90 , MIC inhibiting 50% and 90% of the isolates, respectively; AMC, amoxicillin/clavulanic acid; TZP, piperacillin/tazobactam.
∗
Statistically significant (P < 0.05).

4. Discussion
In the last decade, systematic recourse to carbapenems to treat
ESBL-producing Gram-negative bacterial infections has led to the
emergence of CRE. In this context, attempts to identify a possible
source of MDR and CRE isolates in community settings are practi-
cally relevant. Here we present data on (i) the prevalence of differ-
ent species of the family Enterobacteriaceae isolated from commu-
nity versus healthcare FHs, (ii) the antibiotic resistance profiles of
all isolates and (iii) the prevalence rates of ESBL-producing, MDR
and CRE isolates among all the isolates with statistically significant
differences in the prevalence rates between CFHs versus HCFHs. As
far as we know, this is the first study to comprehensively inves-
tigate rates of faecal shedding of MDR and carbapenem-resistant
isolates of Enterobacteriaceae among apparently healthy popula-
tions in the community, such as FHs in Kuwait and, indeed, the
Gulf Cooperation Council countries.
In this study, the majority of FHs were non-Arab and non-
Kuwaiti, stratified according to sex and age. These workers were
predominantly male (84.7%) in the productive age group (44.0%
were aged 29–39 years old). The explanation for the male pre-
dominance over females may in part be attributed to the influ-
ence of culture, which dictates that females are not to be seen
serving men publicly; additionally, the job is stress-related, requir-
ing a considerable amount of physical ability. The fact that non-
Kuwaitis dominated the workforce in the food industry was a re-
flection of the unattractiveness of the job, often seen by Kuwaitis
as lowly and menial that attracts low salaries. Analysis of the
family Enterobacteriaceae isolates shed from the gut of healthy
FHs revealed that the most predominant species was E. coli. This
finding is in accordance with a previous study conducted among
FHs in Nairobi (Kenya) where E. coli was also the predominant
species [11]. Our data on antimicrobial susceptibility revealed vari-
able findings in resistance patterns. It was notable that the amino-
glycosides and tigecycline were very active against all isolates. This
finding implies that both antimicrobial classes can still be used
effectively for invasive MDR and CRE infections from the com-
munity [12]. Another encouraging finding was the high activities
of piperacillin/tazobactam and meropenem against the isolates. As
shown in this study, 55.3% of E. coli isolates were resistant to
ampicillin. However, in an earlier study in the region from Qatar,
a lower percentage of isolates (32.1%) were resistant to ampi-
cillin [13], making our isolates more resistant to this first-line drug
than in a neighbouring country. The high resistance rates observed
among the community population of FHs reflect the misuse of this
antimicrobial and probably indicates a genetic diversity of circu-
lating strains [14]. In contrast to the experience with clinical iso-
lates of E. coli, the rate of rectal isolates resistant to ciprofloxacin
was relatively low at 14.8%. This finding is essentially in agreement
with the report by Eltai et al. from Qatar [13]. However, a much
lower prevalence of 7% ciprofloxacin-resistant E. coli has been re-
ported among FHs in a study conducted in Nairobi (Kenya) [15].
The two most effective antimicrobials for the treatment of MDR
and CRE infections are colistin and tigecycline. In our study, tigecy-
cline demonstrated excellent activity against all E. coli isolates from
CFHs. However, colistin, a life-saving drug that is frequently used
to treat CRE and MDR infections and is considered the last substi-
tute to carbapenems, demonstrated an unacceptable relatively poor
level of activity against the isolates. Resistance to colistin appears
to be increasing in Kuwait; in our experience with clinical isolates,
a resistance level of 11.3% against faecal isolates is alarming. In a
clinical scenario, this would be a disastrous development for pa-
tients facing untreatable infections by pandrug-resistant isolates. It
is now accepted that colistin resistance is an emerging and poten-
tial problem of clinical significance worldwide, and the spread of
resistance via rectal isolates must be combated by robust infection
control policies [16,17]. A remarkably high percentage of isolates
were MDR (30.5%). Analysis of the top two species (E. coli 30.6%

374
O.H. Moghnia, V.O. Rotimi and N.A. Al-Sweih
and K. pneumoniae 17.6%) showed that a very high proportion of
isolates were MDR, especially from those working in healthcare
settings (62.3% of MDR E. coli and 86.4% of MDR K. pneumoniae
were from HCFHs). Similarly, a high prevalence of MDR isolates
from FHs had also been reported previously [15]. A study con-
ducted in Beijing among healthy hospital FHs showed that >50%
of E. coli isolates were MDR [18], a finding much higher than the
prevalence reported in our study in Kuwait.
Approximately 13% of our isolates were ESBL-producers. This
finding is lower than that reported from Dilla (Ethiopia) among
healthy FHs, with a high faecal carriage rate of 25.3% [19]. How-
ever, this figure is discordant with the 5% reported in a study
conducted in The Gambia [20]. The overall prevalence of ESBL-
producing E. coli isolates from FHs was 18.8%; a higher percentage
was detected among HCFHs (71.3%). However, for K. pneumoniae
isolates, the overall prevalence rate of ESBL-producers was 4.0%
and all were from HCFHs.
The prevalence of carbapenem resistance varies in different
parts of the world. In the present study, the prevalence of rec-
tal colonisation by CRE among FHs was 7.7%. Many reports have
shown that carbapenem resistance rates are escalating with ex-
ponential higher trends per year among each species of the En-
terobacteriaceae, especially in Asia [21]. Limited studies have de-
scribed a strong association between colonisation and subsequent
infection in inpatients [22]. Our finding is consistent with other
published prevalence rates of CRE in the community varying be-
tween 4.9% and 9.9% in Argentina [23] and East Delhi [3], respec-
tively. However, higher figures have been reported of 11.5% in the
USA [24] and 41% in Taiwan [25]. The prevalence of community
rectal colonisation by CRE is generally higher in Asia, mainly Tai-
wan and India, than most other regions of the world, where there
has been evidence of the escalating trends and widespread prop-
agation of CRE [21]. We speculate at this time that risk factors
that could have contributed to the relatively high CRE colonisation
among FHs are poor adherence to hand hygiene and safe food han-
dling, which may enable the easy dissemination of Enterobacteri-
aceae in the environment and enhance human colonisation. This in
turn can lead to the exchange of genetic material between bacte-
ria by horizontal gene transfer mediated mainly by plasmids and
transposons. In a study conducted by Kumarasamy et al. in India,
CRE isolates were found to have originated from the community
[26].
Our results revealed that the overall prevalence rate of
carbapenem-resistant E. coli isolates from FHs was 3.5%. It is inter-
esting to note that a higher percentage was detected among HCFHs
(73.3%). This is also noted for carbapenem-resistant K. pneumoniae
isolates, where the overall prevalence rate was 6.3% and a higher
percentage was detected in HCFHs (87.5%). It is conceivable that
higher percentages of MDR, ESBL-producing and CRE isolates were
detected among HCFHs. This may be due to the fact that these
workers in the hospital cafeteria are often exposed to multiple risk
factors for acquisition of MDR bacteria compared with people in
the general community. Also, the hospital environment can be con-
taminated with various sources of pathogens. Moreover, different
activities have been associated with a greater likelihood of HCFH
exposure to these organisms, including artificial airways and wa-
ter cooling systems of air conditioning equipment that may be-
come contaminated, in addition to environmental contamination.
Furthermore, FHs who directly contact patients by serving food
daily are prone to a high risk of MDR bacterial colonisation. These
data illustrated that faecal bacteria from healthy FHs could serve
as important reservoirs of MDR, ESBL-producing and CRE isolates.
Subsequently, FHs may harbour and shed these bacteria that can
contaminate food consumed by people. It is worth noting that this
may only be the tip of the iceberg in the community. Therefore,
this study is an essential baseline for estimation of the extent of
375
Journal of Global Antimicrobial Resistance 25 (2021) 370–376
the resistance problem in our community and succinctly highlights
the vital role of FHs as they are a potential source of infection in-
volved in catering services. It would be interesting to expand the
scope of this study to include the molecular epidemiology and ge-
netic relatedness of rectal CRE isolates.
5. Conclusion
Finding a relatively sizable prevalence of faecal shedding of CRE
isolates among FHs in our study suggests that this observation may
herald problems of a clinical dimension requiring a major public-
health response for active surveillance and prevention. Our results
also suggest that random monitoring of intestinal levels of coloni-
sation with MDR, ESBL-producing and CRE isolates in a subset of
community workers, especially FHs, may help in guiding empirical
antibiotic treatment of patients from the community with infec-
tions.
Declaration of Competing Interest
None declared.
Acknowledgments
Sincere thanks to the participating food handlers in Kuwait’s
food establishments for their kind co-operation during the study.
The gratitude of the authors goes to Mr Ahmed Mohammed for
his sincere assistance and for sharing his expertise continuously.
The technical assistance of Mrs May Shahin is also appreciated.
Funding
The authors acknowledge the College of Graduate Studies and
Research Sector, Kuwait University, for the funding support through
project no. YM 07/15.
Ethical approval
This study was approved by Joint Committee for the Protec-
tion of Human Subjects in Research, Health Sciences Center, Kuwait
University, and the Food and Nutrition Administration, Ministry of
Health [No. 299/2015]. Collection of specimens was conducted ac-
cording to the Declaration of Helsinki and with particular institu-
tional ethical and professional standards. Written informed consent
was obtained from the participants.
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