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Background  Some strains of  Bacteroides fragilis  species are associated with diarrhea as a result of enterotoxin production (bft or fragilysin). Fragilysin is activated by C11 protease ( fpn ) and together with C10 protease ( bfp ) play a significant role in its invasiveness. The objectives of this study were to investigate the proportion of clinical isolates from extra-intestinal sources that are toxin producers and characterize the genes mediating toxin production. Clinical isolates submitted to our reference laboratory over the last 13 years were screened for toxin production using PCR technique. All stool isolates were excluded. The isolates were tested for their susceptibility to 8 antimicrobial agents by E test. Carbapenem resistance gene  cfiA  was detected by PCR.    Results  A total of 421  B. fragilis  isolates were viable. Out of these,  bft  was detected in 210 (49.9%) isolates. Of the 210  bft -positive isolates, 171 (81.4%), 33 (15.7%) and 6 (2.8%) harbored  bft -1,  bft -2, and  bft -3 genes, respectively. Twenty (9.5%) of the  bft -positive strains originated from bloodstream infections. Twenty-five, 20 and 9 strains harbored  bfp -1,  bfp -2 and  bfp -3 gene, respectively. Two, 3, 4  bfp  isotypes were detected simultaneously in some of strains. The resistance rates against amoxicillin-clavulanic acid was 32%, clindamycin 62%, cefoxitin 26%, imipenem 11%, meropenem 17%, metronidazole 4%, piperacillin 61% and tigecycline 14%. A chromosomally located  cfiA  gene that encode metallo-β-lactamase was identified in only 34 isolates (16.2%).    Conclusions  The prevalence of enterotoxin-producing  B. fragilis  was high among the extra-intestinal isolates. Metronidazole was the most active agent against all isolates. There was no statistically significance difference between resistance rates among  bft -positive and  bft -negative isolates except for clindamycin.

Prevalence and antimicrobial susceptibility of enterotoxigenic extra-intestinal Bacteroides fragilis among 13-year collection of isolates in Kuwait