Prevalence of Drug‑resistant Pseudomonas aeruginosa in Iranian Burned Patients: A Meta‑analysis

Document Type: Original Article


1 Microbiology Research Center, Pasteur Institute of Iran

2 Department of Microbiology, School of Medicine, Iran University of Medical Sciences

3 Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran


The increasing prevalence of drug‑resistant Pseudomonas aeruginosa in burned patients is one of the main public health problems worldwide.
Although drug‑resistant P. aeruginosa in burn units is frequent in some countries and unusual in others, the level of this conditions is not
precisely known in Iran. Imipenem is one of the most potent agents against P. aeruginosa. Imipenem resistance is a major obstacle to treatment
of P. aeruginosa infections. We aimed to determine the true prevalence of imipenem‑resistant P. aeruginosa in Iranian burned patients according
to the Preferred Reporting Items for Meta‑Analyses statement. Moreover, resistance to several potent anti‑P. aeruginosa drugs were indicated
according to the Clinical and Laboratory Standards Institute guidelines for the disc diffusion method. Several databases including Web of
Science, Scopus, PubMed, Scientific Information Database, Magiran, Iranmedex, and science direct were searched to get studies addressing
drug‑resistant P. aeruginosa in Iranian burned patients from March 2006 to May 2015. A total of 34 reports available from different areas
of Iran were included in the current study. The meta‑analyses showed that 54.9% of P. aeruginosa were resistant to imipenem. The most
common resistance was seen against ceftazidime (66.9%), followed by ciprofloxacin (52.9%) and cefepime (52.3%). It is necessary to know
the epidemiology of drug‑resistant P. aeruginosa because it can promote control strategies for decreasing their prevalence. The high incidence
of drug‑resistant P. aeruginosa in Iran emphasizes the need for precise drug susceptibility testing, continuous monitoring of drug resistance,
especially in burn units, use of sensitive methods for the laboratory diagnosis, and close relation between physician and laboratories.


1. Khoshnood S, Eslami G, Hashemi A, Bahramian A, Heidary M,
Yousefi N, et al. Distribution of aminoglycoside resistance genes among
Acinetobacter baumannii strains isolated from burn patients in Tehran,
Iran. Arch Pediatr Infect Dis 2017;5:1-5. [DOI: 10.5812/pedinfect.
2. Lari AR, Alaghehbandan R. Nosocomial infections in an Iranian burn
care center. Burns 2000;26:737‑40.
3. Control CFD, Prevention. Antibiotic Resistance Threats in the United
States, 2013. Centres for Disease Control and Prevention (CDC): US
Department of Health and Human Services; 2013.
4. Bahar MA, Jamali S, Samadikuchaksaraei A. Imipenem-resistant
Pseudomonas aeruginosa strains carry metallo-β-lactamase gene bla
VIM in a level I Iranian burn hospital. Burns 2010;36:826-30. [DOI:
5. Heidary M, Hashemi A, Goudarzi H, Khoshnood S, Roshani M,
Azimi H, et al. The antibacterial activity of Iranian plants extracts
against metallo beta‑lactamase producing Pseudomonas aeruginosa
strains. J Paramed Sci 2016;7: 13-19.
6. Rafla K, Tredget EE. Infection control in the burn unit. Burns
7. Japoni A, Alborzi A, Kalani M, Nasiri J, Hayati M, Farshad S, et al.
Susceptibility patterns and cross‑resistance of antibiotics against
Pseudomonas aeruginosa isolated from burn patients in the South of
Iran. Burns 2006;32:343‑7.
8. Kohanteb J, Dayaghi M, Motazedian M, Ghayumi MA. Comparison
of biotyping and antibiotyping of Pseudomonas aeruginosa isolated
from patients with burn wound infection and nosocomial pneumonia in
Shiraz, Iran. Pak J Biol Sci 2007;10:1817‑22.
9. Mahini F, Khosravi A. MBL‑producing P. aeruginosa strains isolated
from patients with burns, infections and identify genes of blaIMP and
blaVIM by PCR technique. Iran J Microbiol 2007;1:23‑31.
10. Owlia P, Bahar MA, Saderi H, Amini H. Antibiotic susceptibility pattern
of Pseudomonas aeruginosa infections in burn patients. J Med Counc
Iran 2007;25:26‑33.
11. Khorasani G, Salehifar E, Eslami G. Profile of microorganisms and
antimicrobial resistance at a tertiary care referral burn centre in Iran:
Emergence of citrobacter freundii as a common microorganism. Burns
12. Mashouf RY, Zamani A, Farahani HS. Diagnostic multiplex polymerase
chain reaction assay for the identification of Pseudomonas aeruginosa
from the skin biopsy specimens in burn wound infections and detection
of antibiotic susceptibility. Saudi Med J 2008;29:1109‑14.
13. Saderi H, Karimi Z, Owlia P, Bahar MA, Rad SM. Phenotypic detection
of metallo‑beta‑lactamase producing Pseudomonas aeruginosa strains
isolated from burned patients. Iran J Pathol 2008;3:20‑4.
14. Mirsalhian A, Faizabadi MM, Akbari Nakhjavani F, Jabalameli F,
Goli HR. Frequency broad spectrum beta‑lactamases in Pseudomonas
aeruginosa in burn patients isolated. Tehran Univ Med J 2008;66:333‑7.
15. Khosravi AD, Mihani F. Detection of metallo‑beta‑lactamase‑producing
Pseudomonas aeruginosa strains isolated from burn patients in Ahwaz,
Iran. Diagn Microbiol Infect Dis 2008;60:125‑8.
16. Afrasiabian SH, Heidari M. Burn wound infections and antibiotic
resistance patterns in patients admitted to burn unit of Tohid hospital in
Sanandaj. J Infect Trop Dis 2008;42:61‑5.
17. Zolfaghari MR, Khodadad Motlagh M, Aghaee S, Heidarpour A. Factors
affecting bacterial infections after burns in burn unit of Nekoii‑Hedayati
hospital in Qom, 2009‑2010. J Qom Univ Med Sci 2011;5:23‑9.
18. Mirsalehian A, Feizabadi M, Nakhjavani FA, Jabalameli F, Goli H,
Kalantari N, et al. Detection of VEB‑1, OXA‑10 and PER‑1 genotypes in
extended‑spectrum beta‑lactamase‑producing Pseudomonas aeruginosa
strains isolated from burn patients. Burns 2010;36:70‑4.
19. Alipour T, Sadeghifard N, Amirmozafari N, Ghafurian S, Abdulamir AS,
Mohebi R, et al. Incidence of extended spectrum beta‑lactamase
producing Pseudomonas aeruginosa and frequency of oxa‑2 and oxa‑10
genes. Aust J Basic Appl Sci 2010;4:3202‑7.
20. Saderi H, Lotfalipour H, Owlia P, Salimi H. Detection of
metallo‑β‑lactamase producing Pseudomonas aeruginosa isolated from
burn patients in Tehran, Iran. Lab Med 2010;41:609‑12.
21. Jazani N, Babazadeh H, Sabah Z, Zartoshti M. The evaluation of
antibiotic resistance to cefepime in hospital isolates of Pseudomonas
aeruginosa. J Med Biomed Sci 2010;9:17.
22. Jabalameli F, Mirsalehian A, Sotoudeh N, Jabalameli L, Aligholi M,
Khoramian B, et al. Multiple‑locus variable number of tandem
repeats (VNTR) fingerprinting (MLVF) and antibacterial resistance
profiles of extended spectrum beta lactamase (ESBL) producing
Pseudomonas aeruginosa among burnt patients in Tehran. Burns
23. Bayat M, Zia M, Haghi M, Hemmatyar G, Toghyani M. Antibiotic
resistance pattern of Escherichia coli, Staphylococcus aureus and
Pseudomonas aeruginosa isolated from burnt patients in Urmia, Iran.
Afr J Microbiol Res 2011;5:996‑1000.
24. Ranjbar R, Owlia P, Saderi H, Mansouri S, Jonaidi‑Jafari N, Izadi M,
et al. Characterization of Pseudomonas aeruginosa strains isolated from
burned patients hospitalized in a major burn center in Tehran, Iran. Acta
Med Iran 2011;49:675‑9.
25. Rezaei E, Safari H, Naderinasab M, Aliakbarian H. Common
pathogens in burn wound and changes in their drug sensitivity. Burns
26. Vahdani M, Azimi L, Asghari B, Bazmi F, Rastegar Lari A. Phenotypic
screening of extended‑spectrum ß‑lactamase and metallo‑ß‑lactamase in
multidrug‑resistant Pseudomonas aeruginosa from infected burns. Ann
Burns Fire Disasters 2012;25:78‑81.
27. Sepehriseresht S, Boroumand MA, Pourgholi L, Sotoudeh Anvari M,
Habibi E, Sattarzadeh Tabrizi M, et al. Detection of vim‑ and ipm‑type
metallo‑beta‑lactamases in Pseudomonas aeruginosa clinical isolates.
Arch Iran Med 2012;15:670‑3.
28. Nikokar I, Tishayar A, Flakiyan Z, Alijani K, Rehana‑Banisaeed S,
Hossinpour M, et al. Antibiotic resistance and frequency of class 1
integrons among Pseudomonas aeruginosa, isolated from burn patients
in Guilan, Iran. Iran J Microbiol 2013;5:36‑41.
29. Jafari M, Fallah F, Borhan RS, Navidinia M, Karimi A, Tabatabaei SR,
et al. The first report of CMY, aac (6′)‑Ib and 16S rRNA methylase
genes among Pseudomonas aeruginosa isolates from Iran. Arch Pediatr
Infect Dis 2013;1:109‑12.
30. Fallah F, Borhan RS, Hashemi A. Brief communication detection
of bla (IMP) and bla (VIM) metallo‑β‑lactamases genes among
Pseudomonas aeruginosa strains. Int J Burns Trauma 2013;3:122‑4.
31. Moazami‑Goudarzi S, Eftekhar F. Assessment of carbapenem
susceptibility and multidrug‑resistance in Pseudomonas aeruginosa
burn isolates in Tehran. Jundishapur J Microbiol 2013;6:162‑5.
32. Vala M, Hallajzadeh M, Fallah F, Hashemi A, Goudarzi H.
Characterization of the extended‑spectrum beta‑lactamase producers
among non‑fermenting gram‑negative bacteria isolated from burnt
patients. Arch Hyg Sci 2013;2:1-6.
33. Goudarzi M, Azad M, Seyedjavadi SS, Goudarzi G, Rashidan M.
Study of flagellin profiling in multidrug resistant Pseudomonas
aeruginosa (MDRPA) isolated from burn wound infections, Tehran,
Iran. J Paramed Sci 2014;5:40-5.
34. Akhavan‑Tafti F, Eslami G, Zandi H, Mousavi SM, Zarei M. Prevalence
of blaVIM blaNDM and blaIPM lactamases in isolates of Pseudomonas
aeruginosa infection from burn wounds in Shahid Sadughi hospital in
Yazd. J Isfahan Univ Med Sci 2013;31:1955‑64.
35. Farshadzadeh Z, Khosravi AD, Alavi SM, Parhizgari N, Hoveizavi H.
Spread of extended‑spectrum β‑lactamase genes of blaOXA‑10,
blaPER‑1 and blaCTX‑M in Pseudomonas aeruginosa strains isolated
from burn patients. Burns 2014;40:1575‑80.
36. Neyestanaki DK, Mirsalehian A, Rezagholizadeh F, Jabalameli F,
Taherikalani M, Emaneini M, et al. Determination of extended spectrum
beta‑lactamases, metallo‑beta‑lactamases and ampC‑beta‑lactamases
among carbapenem resistant Pseudomonas aeruginosa isolated from
burn patients. Burns 2014;40:1556‑61.
37. Japoni A, Anvarinejad M, Farshad S, Giammanco GM, Rafaatpour N,
Alipour E, et al. Antibiotic susceptibility patterns and molecular
epidemiology of metallo‑β‑lactamase producing Pseudomonas
aeruginosa strains isolated from burn patients. Iran Red Crescent Med J
38. Hakemi Vala M, Hallajzadeh M, Hashemi A, Goudarzi H, Tarhani M,
Sattarzadeh Tabrizi M, et al. Detection of ambler class A, B and D
ß‑lactamases among Pseudomonas aeruginosa and Acinetobacter
baumannii clinical isolates from burn patients. Ann Burns Fire Disasters
39. Roshani M, Heidary M, Goudarzi H, Hashemi A, Eslami G, Yousefi N.
Investigating the antibacterial effect of methanol and acetone extracts
of Urtica dioica and Zataria Multiflora against metallo beta‑lactamase
producing Pseudomonas aeruginosa. SJIMU 2016;24:70‑8.
40. Soltani J, Poorabbas B, Miri N, Mardaneh J. Health care associated
infections, antibiotic resistance and clinical outcome: A surveillance
study from Sanandaj, Iran. World J Clin Cases 2016;4:63‑70.
41. Poorabbas B, Mardaneh J, Rezaei Z, Kalani M, Pouladfar G, Alami MH,
et al. Nosocomial infections: Multicenter surveillance of antimicrobial
resistance profile of Staphylococcus aureus and Gram negative rods
isolated from blood and other sterile body fluids in Iran. Iran J Microbiol
42. Bhatt P, Rathi KR, Hazra S, Sharma A, Shete V. Prevalence of multidrug
resistant Pseudomonas aeruginosa infection in burn patients at a tertiary
care centre. Indian J Burns 2015;23:56.
43. Ozkurt Z, Ertek M, Erol S, Altoparlak U, Akcay MN. The risk factors
for acquisition of imipenem‑resistant Pseudomonas aeruginosa in the
burn unit. Burns 2005;31:870‑3.
44. Nathwani D, Raman G, Sulham K, Gavaghan M, Menon V. Clinical
and economic consequences of hospital‑acquired resistant and
multidrug‑resistant Pseudomonas aeruginosa infections: A systematic
review and meta‑analysis. Antimicrob Resist Infect Control 2014;3:32.
45. Morita Y, Tomida J, Kawamura Y. Responses of Pseudomonas
aeruginosa to antimicrobials. Front Microbiol 2014;4:422.
46. Hamouda A, Findlay J, Amyes SG. Imipenem resistance in Pseudomonas
aeruginosa of animal origin. J Chemother 2012;24:59‑60.
47. Tarashi S, Goudarzi H, Erfanimanesh S, Pormohammad A, Hashemi A.
Phenotypic and molecular detection of metallo‑beta‑lactamase genes
among imipenem resistant Pseudomonas aeruginosa and Acinetobacter
baumannii strains isolated from patients with burn injuries. Arch Clin
Infect Dis 2016;11:1-6. [DOI: 10.5812/archcid. 39036].
48. Heidary M, Bahramian A, Hashemi A, Goudarzi M, Omrani VF,
Eslami G, et al. Detection of acrA, acrB, aac(6’)‑ib‑cr, and qepA genes
among clinical isolates of Escherichia coli and Klebsiella pneumoniae.
Acta Microbiol Immunol Hung 2017;64:63‑9.
49. Heidary M, Salimi Chirani A, Khoshnood S, Eslami G, Atyabi SM,
Nazem H, et al. Molecular detection of aminoglycoside‑modifying
enzyme genes in Acinetobacter baumannii clinical isolates. Acta
Microbiol Immunol Hung 2017;64:143‑50.
50. Patel H, Garala R. Antibiotic susceptibility pattern of Pseudomonas
aeruginosa isolated at SSG hospital Baroda. J Res Med Dent Sci
51. Hakemi‑Vala M, Eslamzadeh A, Bejestany FB, Asgarpanah J,
Heidary M, Khoshnood S. Preliminary evaluation of the antimicrobial
activity of total extract and fractions of chloroform, methanol, and
aqueous from the aerial parts of Salvia aegyptiaca. Avicenna J Clin
Microbiol Infect 2017. [In Press]. [DOI: 10.5812/ajcmi. 43457].
52. Anvarinejad M, Japoni A, Rafaatpour N, Mardaneh J,
Abbasi P, Amin Shahidi M, et al. Burn patients infected with
metallo‑beta‑lactamase‑producing Pseudomonas aeruginosa:
Multidrug‑resistant strains. Arch Trauma Res 2014;3:e18182.
53. Sadredinamin M, Hashemi A, Goudarzi H, Tarashi S,
Yousefi Nojookambari N, Taki E. Detection of blaIMP, blaVIM and
OprD genes among Pseudomonas aeruginosa isolated from burn
patients. J Mazandaran Univ Med Sci 2016;26:181‑6.
54. World Health Organization. A WHO Plan for Burn Prevention and Care.
Geneva: World Health Organization; 2008.
55. Sadredinamin M, Hashemi A, Goudarzi H, Tarashi S, Nojookambari NY,
Erfanimanesh S. Detection of ISPa1328 and ISPpu21, two novel
insertion sequences in the OprD porin and bla IMP‑1 gene among
metallo‑beta‑lactamase‑producing Pseudomonas aeruginosa isolated
from burn patients. Arch Trauma Res 2016;6:1-7. [DOI: 10.5812/atr.
56. Weber J, McManus A, Nursing Committee of the International
Society for Burn Injuries. Infection control in burn patients. Burns
57. Ducel G, Fabry J, Nicolle L. Prevention of Hospital Acquired Infections:
A Practical Guide. 2nd ed. 2002.
58. Arslan E, Dalay C, Yavuz M, Göcenler L, Acartürk S. Gram‑negative
bacterial surveillance in burn patients. Proteus 1999;95:53.