Journal of IMAB - Annual Proceeding (Scientific Papers) Oct-Dec;23(4) Original article

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1 Journal of IMAB ISSN: X Journal of IMAB - Annual Proceeding (Scientific Papers) Oct-Dec;23(4) Original article ANTIMICROBIAL SUSCEPTIBILITY OF CLINICALLY SIGNIFICANT ISOLATES OF ENTEROBACTER SPP., OBTAINED FROM PATIENTS, HOSPITALISED IN VARNA UNIVERSITY HOSPITAL DURING THE PERIOD Dobromira Dimitrova 1, Temenuga Stoeva 1, Rumyana Markovska 2, Petya Stankova 2, Milena Bozhkova 1, Gergana Nedelcheva 1, Ivan Mitov 2 1) Department of Microbiology and Virology, Medical University, Varna 2) Department of Medical Microbiology, Medical University, Sofia, Bulgaria. ABSTRACT Purpose: Rapidly increasing antimicrobial resistance in medically important bacterial species from family Enterobacteriaceae is one of the most significant microbiological, clinical and epidemiological issues of modern medicine. The aim of this study is to investigate the antibiotic susceptibility of clinically significant isolates of Enterobacter spp., obtained from patients, hospitalized in University Hospital Saint Marina Varna during the period Material and methods: a total of 433 clinical isolates of Enterobacter spp. from blood cultures, urine and wound secretions were studied. The species identification was made by conventional, semi-automated (Crystal, BD) and automated systems (Phoenix, BD). The susceptibility to piperacillin/tazobactam (TZP), ceftazidime (CAZ), meropenem (MEM), gentamicin (Gm), amikacin (Ak), ciprofloxacin (CIP), levofloxacin (LVX), trimethoprime/ sulfamethoxazole (SXT) and tetracycline (Tet) was tested by disc-diffusion method and / or automated system Phoenix 100, BD. The results were interpreted according to EUCAST 2016 guidelines. Results: The resistance in the studied collection of isolates, shown in increasing order is as follows: Ak, 4.2% < LVF, 25.4% < TZP, 37.4% < Tet, 38.7% < SXT, 40% < CIP, 44.1% < Gm, 49.7% < CAZ, 57%. Meropenem demonstrated fully preserved activity. In the group of CAZ resistant isolates, the levels of antimicrobial resistance are: Ak, 5.7% < LVF, 42.9% < Tet, 52.4% < SXT, 60.3% < TZP, 64.4% < CIP, 84.6% < Gm, 86.2%. The rate of CAZ resistant Enterobacter spp. was 66.9% among the urine isolates, 61.9% - among those from blood culture and 46.3% - in the group of isolates from wound secretions. In the three mentioned groups of isolates, the lowest level of resistance was detected to Ak (1.6%; 4%; 6.9%). The isolates from wound and blood cultures demonstrated the highest level of resistance to Gm (60.3%, 42.9%) and the urine isolates to Tet (60%) and CIP (56.9%). Conclusions: CAZ resistant Enterobacter spp. demonstrated significantly higher levels of resistance in comparison to the whole studied group especially to quinolones and aminoglycosides. The highest level of CAZ resistant Enterobacter spp. was detected in the group of urine isolates. Keywords: Enterobacter spp., antimicrobial susceptibility, resistance. INTRODUCTION Species from genus Enterobacter are ubiquitous bacteria, widely distributed in nature. They are part of the normal enteric flora of humans and animals but also can cause nosocomial infections predominantly in immunocompromized patients and patients from the ICUs [1, 2]. Recently, a selected group of bacteria has been described by the acronym of ESKAPE, and they cause most of the healthcare-associated infections: Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species. These bacteria are clinically important not only because are causative agents of nosocomial infections but also because are a paradigm for pathogenesis, transmission and resistance [3]. Bacteria from genus Enterobacter are associated predominantly with bacteremia, pneumonia, urinary tract and intra-abdominal infections, endocarditis, skin and soft tissue infections [1]. Enterobacter species are with intrinsic resistance to aminopenicillins, amoxicillin/clavulanic acid, cefoxitin and first-generation cephalosporins because of the production of chromosomally encoded, inducible Amp C â- lactamase [1, 4, 5]. This enzyme does not hydrolyse carboxy- and ureidopenicillins, II, III and IV generation cephalosporins and carbapenems [4, 5]. During the last decades Enterobacter isolates, resistant to extended spectrum cephalosporins have been reported more frequently [1, 4]. Usually, these isolates are associated with the production of plasmid encoded Extended Spectrum Beta Lactamases (ESBLs) and/or derepressed production of Amp C enzymes J of IMAB Oct-Dec;23(4)

2 [1, 4]. The ESBLs are most widely dessiminated, and cause hydrolyses to penicillins and all generations cephalospoirins [6, 7]. Such isolates of Enterobacter spp. demonstrate very often cross-resistance to other antimicrobial agents - aminoglycosides, quinolones, trimethoprim/sulphamothoxazole, etc. [8]. The resistance to β-lactams, quinolones, aminoglycosides, trimethoprim/sulphamothoxazole is higher in the European, Asian and some countries in South America than in the USA and Canada [9, 10]. Very worrisome is the fact that worldwide carbapenem-resistant isolates of Enterobacter have been reported with increasing frequency [1, 4]. The study aimed to investigate the antimicrobial susceptibility of a collection of clinically significant isolates of Enterobacter spp., obtained from patients, hospitalized in the University Hospital Saint Marina Varna, Bulgaria during the period MATERIALS AND METHODS Between January 2014 and December 2016, a total of 433 clinically significant Enterobacter spp. isolates were collected from patients, hospitalized in different wards of the University Hospital Saint Marina in Varna, Bulgaria. The isolates were recovered from various clinical specimens: urine samples - 130; blood - 126; wound secretions Species identification was made by the semi-automated and automated systems Crystal (BD) and Phoenix 100 (BD). Antimicrobial susceptibility to set of antimicrobial agents (ceftazidime, meropenem, tetracycline, gentamicin, amikacin, trimethoprime/sulphometoxazole, ciprofloxacin, levofloxacin) was determined by disk - diffusion method and/or by the automated system Phoenix 100 (BD). The results were interpreted according to EUCAST 2016 guidelines [11]. RESULTS The results from the antimicrobial susceptibilty testing are presented on Figures 1, 2 and 3. The antimicrobial resistance in the whole collection of isolates (n=433), shown in increasing order, is as follows: amikacin, 4.2% < levofloxacin, 25.4% < piperacillin/ tazobactam, 37.4% < tetracycline, 38.7% < trimethoprime/ sulphometoxazole, 40% < ciprofloxacin, 44.1% < gentamicin, 49.7% < ceftazidime, 57%. Meropenem demonstrated fully preserved activity (no resistance detected) (Figure 1). Fig. 1. Antimicrobial resistance in the whole collection of Enterobacter spp. isolates (n=433) CAZ - ceftazidime, TZP piperacillin/tazobactam, Gm - gentamicin, Ak - amikacin, T - tetracycline, SXT - trimethoprime/sulphometoxazole, CIP - ciprofloxacin, LVX levofloxacin. In the group of ceftazidime resistant isolates (n=247), the levels of antimicrobial resistance, presented in increasing order, are as follows: amikacin, 5.7% < levofoxacin, 42.9% < tetracycline, 52.4% < trimethoprime/sulphometoxazole, 60.3% < piperacillin/tazobactam, 64.4% < ciprofloxacin, 84.6% < gentamicin, 86.2% (Figure 2). J of IMAB Oct-Dec;23(4)

3 Fig. 2. Antimicrobial resistance of 247 clinical isolates of Enterobacter spp., resistant to ceftazidime (%). CAZ - ceftazidime, TZP piperacillin/tazobactam, Gm - gentamicin, Ak - amikacin, T - tetracycline, SXT - trimethoprime/sulphometoxazole, CIP - ciprofloxacin, LVX - levofloxacin. Antimicrobial resistance of the tested isolates according to their site of isolation is presented on Figure 3. (%). Fig. 3. Antimicrobial resistance of 433 clinical isolates of Enterobacter spp. according to their site of isolation CAZ - ceftazidime, TZP piperacillin/tazobactam, Gm - gentamicin, Ak - amikacin, T - tetracycline, SXT - trimethoprime/sulphometoxazole, CIP - ciprofloxacin, LVX - levofloxacin. A total of 126 isolates of Enterobacter spp. were obtained from blood cultures. The resistance rate to III generation cephalosporins was 61.9%. The resistance to piperacillin/tazobactam was 50% and above 40% for ciprofloxacin (49.2%), tetracycline (50.9%), trimethoprime/sulphometoxazole (52.4%) and gentamicin (60%) (figure 3). The most active antimicrobial agents were meropenem (100% susceptibility), amikacin (98.4%) and levofloxacin (86.1%). In the group of ceftazidime resistant isolates from blood cultures, the levels of antimicrobial resistance, presented in increasing order, were as follows: levofoxacin, 25.4% < trimethoprime/sulphometoxazole, 60.7% < tetracycline, 75% < piperacillin/tazobactam, 81.5% < ciprofloxacin, 85.0% < gentamicin, 90.0%. A total of 130 isolates of Enterobacter spp. were obtained from urine samples. The resistance rate to III generation cephalosporins was 66.9%. The resistance to piperacillin/tazobactam was 39.2% and above 40% for trimethoprime/sulphometoxazole (48.5%), levofloxacin (48.5%), gentamicin (52.3%), ciprofloxacin (56.9%) and tetracycline (60%). Lowest resistance rate was detected for meropenem (0%) and amikacin (6.9%) (Figure 3). A total of 177 isolates of Enterobacter spp. were obtained from wound secretions. The resistance rate to III generation cephalosporins was 46.3%. The resistance to piperacillin/tazobactam was 27.1% and above 30% for trimethoprime/sulphometoxazole (31.6%), ciprofloxacin (31.1%), tetracycline (37.5%) and gentamicin (42.9%) (Figure 3). The most active antimicrobial agents were meropenem (100% susceptibility), amikacin (96%) and levofloxacin (83.1%) J of IMAB Oct-Dec;23(4)

4 DISCUSSION During the last decade, the species from genus Enterobacter are among the fifth most commonly isolated bacterial species from clinical materials worldwide [2, 4]. In Varna University Hospital Saint Marina, Enterobacter cloacae takes the second place as a causitive agent of bacteremia for 2015 and the fourth place for 2016 (not published data). Our results demonstrate a worrisome increase of resistance to beta-lactam antibiotics: 57% of the isolates were resistant to III generation cephalosporins (ceftazidime) and 37.4% to piperacillin/tazobactam. High resistance levels (above 25%) were detected for quinolones, gentamicin, tetracycline and trimethoprime/sulphometoxazole. The most active antimicrobial agents were meropenem (no resistant isolates found) and amikacin (4.2%). For a collection of 177 isolates of Enterobacter spp. Xie et al. reported similar to our results regarding ceftazidime and amikacin resistance levels: 40% and 3.6% respectively [12]. These authors reported lower levels of resistance to other groups of antimicrobial agents: ciprofloxacin, 16.7%; levofloxacin, 10.5%; gentamicin, 15%; piperacillin/tazobactam, 6.8%; cefepime, 17.3% and trimethoprime/sulphometoxazole, 29.4%. The resistance to imipenem and meropenem was 14.5% and 13.2% respectively [12]. In a recent study, Maraki et al. investigated the susceptibility and the resistance phenotype of 939 isolates of Enterobacter spp., collected during a 6-year period ( ) [13]. The most active antimicrobial agents in this study were colistin (97.9% susceptibilty), followed by imipenem (96.1%) and gentamicin (95.7%). Resistance to beta-lactams was lower than our results with the exception of carbapenems: piperacillin/tazobactam, 26.0%; ceftazidime, 25.7%; cefepime, 10.2%; imipenem, 3.4%; meropenem, 6.3%. The authors reported low resistance levels to amikacin, 4.2%; gentamicin, 2.8%; ciprofloxacin, 6.4%; levofloxacin, 6.1% and trimethoprime/sulphometoxazole, 11.1% [13]. In these reports, the resistance to III and IV generation cephalosporins is found to be associated predominantly with Amp C, and all isolates are determined as multi-drug resistant (MDR) [13, 14]. In a recent study performed in our hospital in 2014, the ESBLs production in clinical isolates of Enterobacter spp., collected during the period from hospitalized patients was investigated. An increasing level of ESBL - producing Enterobacter spp. was detected: from 28% in 2007 ã. to 36% and 39% in 2010 and 2011 [15]. This was followed by the current study where we detected 57% ceftazidime resistant isolates. This result shows the need for urgent infection control measures. In the present study higher levels of resistance to all tested antimicrobials were detected in the group of ceftazidime resistant isolates. This result probably is associated with the possible production of plasmid mediated ESBLs or/and Amp C production. Different types of plasmids, identified in family Enterobacteriaceae, play an important role in the dissemination of ESBL genes [16, 17]. Some of these plasmids (IncFI, IncFII, Inc A/C, Inc M/L and IncHI2) carry not only ESBLs genes, but also genes, that encode plasmid-mediated quinolone resistance (qnr, aac (6')-Ib-cr, qepa, oqxab) and genes, associated with resistance to other antimicrobial agents (aminoglycosides, trimethoprime/sulfametoxazole) [6, 9, 18, 19, 20, 21, 22, 23, 24]. This fact explains the common association of ceftazidime resistance (an indicator for ESBLs or/and AmpC production) with the resistance to other antimicrobial groups and the MDR phenotype, usually exhibited by these isolates. The antimicrobial resistance of the studied isolates varied according to their site of isolation (blood, urine and wound secretions). The urine isolates were more resistant to most of the tested antimicrobial agents: ceftazidime (66.9%), amikacin (6.9%), ciprofloxacin (56.9%), levofloxacin (48.5%) and tetracycline (60%). As part of SMART Program , Karlowsky et al. report the following rates of resistance among 165 isolates of Enterobacter spp. isolated from hospitalized patients with urinary tract infections in Latin American countries: ceftazidime %, cefepime %, amikacin - 4.9%, imipenem - 7.3%, levofloxacin %, piperacillin/ tazobactam % [25]. A similar study on 154 isolates of Enterobacter spp., isolated from hospitalized patients with urinary tract infections in Asia - Pacific countries during the period , demonstrates similar levels of resistance: ceftazidime %, cefepime %, amikacin - 8.4%, imipenem - 6.5%, levofloxacin %, piperacillin/tazobactam % [26]. In contrast to these studies, we detected higher rates of resistance to extended spectrum cephalosporins (66.9%) and the quinolones ciprofloxacin (56.9%) and levofloxacin (48.5%). Similar to the urine isolates, high levels of resistance to all tested antimicrobials were also detected in the group of blood culture isolates. Most of the ceftazidime resistant isolates from blood samples demonstrated multi-drug resistance. The high rate of resistance to extended spectrum beta-lactams, quinolones and aminoglycosides is a serious therapeutic challenge, as well as a significant factor for the outcome of blood stream infections caused by Enterobacter spp. In this study carbapenems and amikacin exhibit, the highest in vitro activity against Enterobacter spp., isolated from blood cultures with no resistance detected for carbapenems and 1.6% resistance for amikacin. Many authors report results that clearly demonstrate the advantage of carbapenem therapy for blood stream infections caused by ESBL - producing E. cloacae [27, 28]. In contrast to the urine and blood culture isolates, the isolates from wound secretions exhibit lower levels of resistance to most of the tested antimicrobials: ceftazidime 46.9%, gentamicin 42.9%, ciprofloxacin 31.1%, tetracycline 37.5%, trimethoprime/sulphometoxazole 31.6%, piperacillin/tazobactam 27.1%. In all three groups of isolates (blood, urine and wound secretions) the most active antimicrobial agents were carbapenems with fully preserved activity and amikacin with resistance levels varying between 1.6%, 4% and 6.9%. In conclusion, the studied collection of 433 isolates of Enterobacter spp. is associated with high levels of resistance to commonly used antimicrobial agents in the J of IMAB Oct-Dec;23(4)

5 clinical practice: piperacillin/tazobactam, ceftazidime, quinolones and gentamicin. In comparison to the whole studied group, ceftazidime resistant Enterobacter spp. demonstrated significantly higher levels of resistance to most of the tested antimicrobials as well as MDR phenotype. The highest level of ceftazidime resistant Enterobacter spp. was detected in the group of urine isolates. In the studied collection of isolates, the resistance to amikacin is the lowest, and the susceptibility to carbapenems is fully preserved. These antimicrobials are agents of the first choice in cases of severe infections caused by Enterobacter spp. or in cases of infections associated with MDR Enterobacter spp. Abbreviations: CAZ ceftazidime; TZP piperacillin/tazobactam; Gm gentamicin; Ak amikacin; T tetracycline; SXT - trimethoprime/sulphometoxazole; CIP ciprofloxacin; LVX levofloxacin; Acknowledgments: The study was funded by grant No.8383/ and contract No.D-59/ from Medical University - Sofia, Bulgaria. REFERENCES: 1. Mezzatesta ML, Gona F, Stefani S. Enterobacter cloacae complex: clinical impact and emerging antibiotical resistance. Future Microbiol Jul;7(7): [PubMed] 2. Sanders WE Jr, Sanders CC. Enterobacter spp.: pathogens poised to flourish at the turn of the century. Clin Microbiol Rev Apr;10(2): [PubMed] 3. Rice LB. Federal funding for the study of antimicrobial resistance in nosocomial pathogens: no ESKAPE. J Infect Dis Apr;197(8): [PubMed] 4. Davin-Regli A, Pagès JM. Enterobacter aerogenes and Enterobacter cloacae; versatile bacterial pathogens confronting antibiotic treatment. Front Microbiol May 18;6:392. [PubMed] 5. Jacoby GA. AmpC β-lactamases. Clin Microbiol Rev Jan; 22 (1): [PubMed] 6. Paterson DL, Bonomo RA. Extended-spectrum β-lactamases: a Clinical Update. Clin Microbiol Rev Oct;18(4): [PubMed] 7. Rawat D, Nair D. Extended-spectrum β-lactamases in Gram Negative Bacteria. J Glob Infect Dis Sep; 2(3): [PubMed] 8. Strahilevitz J, Jacoby GA, Hooper DC, Robicsek A. Plasmid-Mediated Quinolone Resistance: a Multifaceted Threat. Clin Microbiol Rev Oct;22(4): [PubMed] 9. Jacoby GA, Strahilevitz J, Hooper DC. Plasmid-mediated quinolone resistance. Microbiol Spectr. 2014; 2(2). [PubMed] 10. Rosii F, Baquero F, Hsueh PR, Paterson DL, Bochicchio GV, Snyder TA, et al. In vitro susceptibilities of aerobic and facultatively anaerobic Gram-negative bacilli isolated from patients with intra-abdominal infections worldwide: 2004 results from SMART (Study for Monitoring Antimicrobial Resistance Trends). J Antimicrob Chemother Jul;58(1): [PubMed] 11. The European Committee on Antimicrobial Susceptibility Testing. Breakpoint tables for interpretation of MICs and zone diameters. Version 6.0, [Internet] 12. Xie J, Peters BM, Li B, Li L, Yu G, Xu Z, et al. Clinical features and antimicrobial resistance profiles of important Enterobacteriaceae pathogens in Guangzhou representative of Southern China, Microb Pathog Jun;107: [PubMed] 13. Maraki S, Vardakas KZ, Samonis G, Perdikis D, Mavromanolaki VE, Kofteridis DP, et al. In vitro susceptibility and resistance phenotypes in contemporary Enterobacter isolates in a university hospital in Crete, Greece. Future Microbiol Jun;12: [PubMed] 14. Magiorakos 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 Mar; 18(3): [PubMed] 15. Markovska RD, Stoeva TJ, Bojkova KD, Mitov IG. Epidemiology and Molecular Characterization of Extended-Spectrum Beta-Lactamase-Producing Enterobacter spp., Pantoea agglomerans, and Serratia marcescens Isolates from a Bulgarian Hospital. Microbial Drug Resist Apr; 20(2): [PubMed] 16. Carattoli A. Resistance Plasmid Families in Enterobacteriaceae. Antimicrob Agents Chemoth Jun; 53(6): [PubMed] 17. Carattoli A. Plasmids in Gram negatives: Molecular typing of resistance plasmids. Int J Med Microbiol Dec; 301 (8): [PubMed] 18. Chmelnitsky I, Navon-Venezia S, Strahilevitz J, Carmeli Y. Plasmidmediated qnrb2 and carbapenemase gene bla(kpc-2) carried on the same plasmid in carbapenem-resistant ciprofloxacin-susceptible Enterobacter cloacae isolates. Antimicrob Agents Chemother Aug;52(8): [PubMed] 19. Fernández J, Montero I, Martínez Ó, Fleites A, Poirel L, Nordmann P, et al. Dissemination of multiresistant Enterobacter cloacae isolates producing OXA-48 and CTX- M-15 in a Spanish hospital. Int J Antimicrob Agents Oct;46(4): [PubMed] 20. Miro E, Segura C, Navarro F, Sorli L, Coll P, Horcajada JP, et al. Spread of plasmids containing the blavim-1 and blactx-m genes and the qnr determinant in Enterobacter cloacae, Klebsiella pneumoniae and J of IMAB Oct-Dec;23(4)

6 Klebsiella oxytoca isolates. J Antimicrob Chemother Apr; 65(4): [PubMed] 21. Nilsen E, Haldorsen BC, Sundsfjord A, Simonsen GS, Ingebretsen A, Naseer U, et al. Large IncHI2-plasmids encode extendedspectrum b-lactamases (ESBLs) in Enterobacter spp. bloodstream isolates, and support ESBL-transfer to Escherichia coli. Clin Microbiol Infect Nov;19(11):E [PubMed] 22. Potron A, Poirel L, Bernabeu S, Monnet X, Richard C, Nordmann P. Nosocomial spread of ESBL-positive Enterobacter cloacae co-expressing plasmid-mediated quinolone resistance Qnr determinants in one hospital in France. J Antimicrob Chemother Sep; 64(3): [PubMed] 23. Shibl AM, Al-Agamy MH, Khubnani H, Senok AC, Tawfik AF, Livermoree DM. High prevalence of acquired quinolone-resistance genes among Enterobacteriaceae from Saudi Arabia with CTX-M-15 β-lactamase. Diagn Microbiol Infect Dis Aug; 73(4): [PubMed] 24. Wu JJ, Ko WC, Tsai SH, Yan JJ. Prevalence of plasmid-mediated quinolone resistance determinants QnrA, QnrB, and QnrS among clinical isolates of Enterobacter cloacae in a Taiwanese hospital. Antimicrob Agents Chemother Apr;51(4): [PubMed] 25. Karlowsky JA, Hoban DJ, Hackel MA, Lob SH, Sahm DF. Resistance among Gram-negative ESKAPE pathogens isolated from hospitalized patients with intra-abdominal and urinary tract infections in Latin American countries: SMART Braz J Infect Dis May-Jun;21(3): [PubMed] 26. Karlowsky JA, Hoban DJ, Hackel MA, Lob SH, Sahm DF. Antimicrobial susceptibility of Gram-negative ESKAPE pathogens isolated from hospitalized patients with intra-abdominal and urinary tract infections in Asia-Pacific countries: SMART J Med Microbiol Jan; 66(1):61-9. [PubMed] 27. Lee CC, Lee NY, Yan JJ, Lee HC, Chen PL, Chang CM, et al. Bacteremia due to extended-spectrumβ-lactamase-produsing Enterobacter cloacae : role of carbapenem therapy. Antimicrob Agents Chemother Sep;54(9): [PubMed] 28. Qureshi ZA, Paterson DL, Pakstis DL, Adams-Haduch JM, Sandkovsky G, Sordillo E, et al. Risk factors and outcome of extended-spectrum-β-lactamase-produsing Enterobacter cloacae bloodstream infections. Int J Antimicrob Agents Jan; 37(1): [PubMed] Please cite this article as: Dimitrova D, Stoeva T, Markovska R, Stankova P, Bozhkova M, Nedelcheva G, Mitov I. Antimicrobial susceptibility of clinically significant isolates of Enterobacter spp., obtained from patients, hospitalised in Varna University Hospital during the period J of IMAB Oct-Dec;23(4): DOI: Received: 29/08/2017; Published online: 18/12/2017 Address for correspondence Assoc. Prof. Temenuga Stoeva, MD, PhD Department of Microbiology and Virology, Medical University, Varna, 55, Marin Drinov Str., Varna, Bulgaria. temenuga.stoeva@abv.bg J of IMAB Oct-Dec;23(4)