When working on an anaerobic culture from an abdominal source (especially ruptured appy), how far should someone go in working

up the anaerobes? There are likely to be many relatively insignificant anaerobes present and identification can take a long time. At one time we had a policy of looking for and identifying B. fragilis group and C. perfringens and all other flora went into “mixed anaerobic flora”. We have not had complaints from physicians but want to do right for the patient. RRR

Dealing Anaerobes from Abdomen
The most common anaerobic

This is a good question, and there would probably be a few different answers,

depending on whom you ask. However, the extent of your work-up should be guided in part by local resistance patterns.

gram-negative rods isolated from the abdomen or intestine, including inflamed appendices, include Bacteroides, Bilophila, Fusobacterium, Parabacteroides, Porphyromonas and Sutterella. Bacteroides fragilis is the main anaerobic organism
recovered from intra-abdominal infections and nearly all acute appendicitis cases. Many places are seeing increasing resistance in certain organisms, such as Parabacteroides distasonis and Bacteroides thetaiotamicron of the B. fragilis group. Other organisms which may warrant identification include Clostridium

septicum (associated with gastrointestinal malignancy ); C. ramosum, C.

innocuum, and C. clostridioforme (frequently resistant to antimicrobials); and C. perfringens. Other organisms to consider identifying fully include Finegoldia

magna due to its pathogenicity and Peptostreptococcus anaerobius, but these organisms wouldn’t be expect ed to be isolated very often from the intestinal
tract. It is stated in the Anaerobic Gram-negative Rods chapter of the current 10 th edition Manual of Clinical Microbiology that a definitive identification of anaerobic isolates should be performed for all isolates from normally sterile body sites, isolates obtained from severely ill patients who are not responding to therapy, and isolates for which prolonged treatment may be necessary. Audrey N. Schuetz, MD, MPH, D(ABMM). Associate Director, Clinical Microbiology Laboratory. Assistant Professor, Pathology and Laboratory Medicine. Weill Cornell Medical Center/NewYork-Presbyterian Hospital, New York, NY

2/10 Are bile stents an acceptable specimen for anaerobic culture? If not, why not? RRR

Culture of Bile Stent

Bacteria colonize biliary stents, due to positioning of the stent near the duodenum and propensity for duodenal biliary reflux into the stent. Stents frequently are plugged up by biofilms which result from microbes which produce bacterial slime. Cultures of biliary stents are not typically performed , since a positive culture likely reflects colonization of the stent. If performed, such cultures have
not typically been used to guide individual patient therapy but have been used for sci entific studies of biofilms. If performed, the technique of culturing the stent is meticulous. Various methods include scraping the endoscopy suite or in the operating room) and then stent. Yet another method used was flushing

the intraluminal material immediately after removal (in placing into saline and agitating vigorously in a vortex before directly plating. Another

method involved freezing the stent at negative 20 degree Celsius, then longitudinally sectioning the stent under sterile conditions and scraping the ends of the

the biliary stent during surgery and culturing the saline flush material. References (Molinari, Eur J Clin

Microbiol 1996;15:88 and Dowidar N, Scand J Gastroenterol, 1991;26:1137). Most culture studies of biliary stents have grown aerobic

organisms, such as those normally found in bile.

A recent paper using molecular methods to

assess the biofilms of biliary stents has shown that a variety of organisms are present, including Fusobacterium spp., clostridia, Veillonella spp., Streptococcus angionosus, and bifidobacteria (Scheithauer, ISME Journal, 2009;3:797). However, these results were not used for guiding patient therapy.

4/10 XXX About the bactec machine, i would like to know if i can place a vial adaptor (such as those who Equshields produces and if it could get to inside otherwise .second, can i get empty vials for my study and fill them up with any kind of media i want? On the BACTEC website, there is some information on needle adapters, such as the Luer adapter, which is available for use with certain bottles. I don’t know how similar it is to the adapter by Equashields Medical. As far as obtaining empty vials for your study, this would require discussion with BACTEC. It depends on the purpose of your study. If you are validating different anaerobic organisms and wish to use the BACTEC bottles for clinical purposes (according to FDA guidelines), you would need to use the broth provided in the bottles. If your study has another purpose, the company may work with you in another capacity. However, when you are validating the bottles for use, you are validating the bottles and the broth within the bottles. Another issue I see with adding your own broth after obtaining empty vials is guaranteeing the sterility of the process. It is very important that the broth be added into the bottles in a sterile manner. Does anybody use a Flagyl disk on the primary plates of an anerobic culture? I understand this practice is widespread in Europe, but I have yet to see it used anywhere I worked in the US. A zone of inhibition is definitive for presence of anarobes, although due to increasing incidence of resistance among Bacteroides spp, absence of a zone cannot definitevley rule them out. RRR

Hecht DW. Hsueh PR. Snydman DR. Jacobus NV.) If a gram positive branching bacillus does not grow on GC selective media can it be assumed that the isolate is not a Nocardia sp. Since the two are identical. Actinobacillus actinomycetemcomitans and Haemophilus actinomycetemcomitans are the same organism. Antimicrob Agents Chemother. Liao CH. fragilis group. Reference: Dubreuil and Odou. The spot indole test may be accomplished with the spot indole reagent. coli ATCC 35218 (for amoxicillin-clavulanic acid). acnes & Actino The majority of clinical isolates of Propionibacterium are P. Propionibacterium acnes and Actinomyces spp. aeruginosa ATCC 27853 and E. farcinica and a N.actinomycetemcomitans and H. Barth Reller. Microaerophilic streptococci. In several longitudinal studies of antimicrobial susceptibility of Bacteroides spp. Lin HY. against Amoxicillin clavulanic acid and piperacillin tazobactam. Pierson. Leona W. and metronidazole in the United States . Golan Y. Charles V. there are other important anaerobes which may not test susceptible to metronidazole. Rihs J. Antimicrob Agents Chemother. penicillins. Gorbach SL. Finegold SM. 7th Ed. 12/9 How do you distinguish Actinomyces from Propionibacterium? D/D Prop. if one antibiotic is sensitive and other is resistant? We usually report both resistant. include S. The acceptable ranges can be found in CLSI M100. Although metronidazole resistance remains rare for the B. For the B. Venezia R. Fritz Schoenknecht. resistance to one does not indicate resistance to the other. National survey on the susceptibility of Bacteroides fragilis group: report and analysis of trends in the United States from 1997 to 2004. resistance to metronidazole is increasing. inclusive of Nocardia.)? 12/2/1 . Fermentation of carbohydrates. Richard C. Same organism? Pathogenicity? Yes. Sanders Increasing trends in antimicrobial resistance among clinically important anaerobes and Bacteroides fragilis isolates causing nosocomial infections: emerging resistance to carbapenems. Yu V. Goldstein EJ. Jeanette Wilkins. asteroides but have no zone size limits.g bacteroides. (ASM Press) and the Wadsworth Anaerobic Bacteriology Manual. Aileen Janney. Issue 4. fragilis group carbapenems and piperacillin-tazobactam are still the most active agents. Carl L. Amy Henderberg. coli? 12/8 QC for Sensi of Actino/Nocardia The QC organisms for susceptibility testing of the aerobic actinomycetes. are almost uniformly resistant. P. Harrell LJ. In addition. paradimethylaminocinnamaldehyde. It might be a good idea for your laboratory to run an antibiogram of your anaerobes and examine resistance patterns. (P 353 Oxford) What QC organisms are used to QC the antibiotics for the ID scheme for Nocardia? We currently use a N. cephamins. Jenkins SG. e. Ruthazer R. Epub 2007 Feb 5. McDermott LA.actinomycetemcomitans. Anaerobic bacteria and antibiotics: What kind of unexpected resistance could I find in my laboratory tomorrow? Anaerobe 2010. the biochemical profile and pathogenicity remain the same. The organism is of uncertain taxonomic status as since 16S rRNA gene sequencing placed it more closely with the the genus Haemophilus. avidum is catalase-positive and also produces a large zone of beta-hemolysis on blood agar. Denise D.16:555-9. piperacillin-tazobactam has better activity than amoxicillin-clavulanate.MZ Disk on Anaerobic plate As you point out. Yen LC. A five-year multicenter study of the susceptibility of the Bacteroides fragilis group isolates to cephalosporins. 2007 May. it has been detected worldwide and has also been observed spreading to other species. amoxicillin-clavulanate. Should we be using KB Staph aureus and E. 6/11 How should one report sensitivity results of bacteria. the proposed name change to Haemophilus was not approved by the International Committee on Systematic Bacteriology. Michael Gelfand. All other species of Propis and all Actinos are indole-negative. Epub 2008 Jul 14. the orgnization that officially approves such changes. presence of preformed enzymes and other biochemical tests are used for species identification. 1992 (Star Publishing Co.52(9):3161-8. Is it the right way to report? RRR Sensi for Anaerobes Aug Vs Tzp For anaerobic suceptibility reporting. Diagnostic Microbiology and Infectious Disease. Liu CY. Additionally. aureus ATCC 29213. Volume 18. Pierson C. Marlene Johnson. While these rapid tests will suffice in most instances. Tilton. Aldridge. most clinical isolates of Propis are catalase-positive while most Actinos are catalase-negative.515 MCM 8th. April 1994. Schiro. Tables of these reactions are published in the Manual of Clinical Microbiology 9th Ed. P. (this question in reference to p. 7/11 A. as well as other anaerobic gram negative organisms. clindamycin. Pages 235-241 Kenneth E. acnes and about 90% of these are catalase and indole-positive. definitive identification of the genera requires identification of end products of glucose metabolism: Propionibacteria produce major amounts of propionic acid while actinomyces produce major amounts of succinic with lactic acid present in some species. L. 2008 Sep.Ed. piperacillintazobactam and any of the beta-lactam/beta-lactamase inhibitor combinations should be reported as tested. The appropriate strains should be tested weekly or each day of use if testing performed more frequently then weekly. Huang YT. including some Prevotella and many gram-positive anaerobic rods. Ayers.51(5):1649-55. However.

some strains may fail to grow and thus selective media should never be used alone. 12/2/Finish Antimicrobial Testing What is the definition of CRE Carbapenem-Resistant Enterobacteriaceae organism if your lab has not implemented the new rd breakpoints? We use (vitek ii) the following 3 generation cephalosporins: cefotaxime. the test cannot be reported and must be repeated. ceftriaxone. ertapenem. Proteus. or doripenem). AND Resistant to all tested third generation cephalosporins.e. even QC organisms.g. You already confirmed pigment production and the hippurate. meropenem. or are purity plates only set when the technologist feels there could me a mixed isolate? Purity Plate significance on Vitek………Yes. Serratia. consideration should be given to modifying the definition to include ertapenem in order to increase sensitivity. and the following carbapenems: doripenem. In your case. E. However. Can an Enterococcus gallinarum be Vancomycin susceptible? I got from a blood culture a PYR+ preliminary identified as Enterococcus spp. lack of growth on such media should not be used to rule out the nocardia. It is essential to have proof that the inoculum used for testing was pure.. could the Vancomycin interpretation be chang ed to Resistant? RRR Isolates of Enterococcus gallinarum and E. motility and pigment test s can be done to distinguish among species phenotypically. imipenem. Joan-Miquel Balada-Llasat. it is also a CAP requirement: ”MIC.21820 Pure Culture. no mixed susceptibilities)”. Clinical Microbiology Assistant Professor. and ceftazidime). casseliflavus and E. If older CLSI breakpoints (pre-dating M100-S20) are being used to determine carbapenem susceptibility. gallinarum and E. whereas E. cefotaxime. gallinarum but the Vitek 2 also showed susceptible to Vancomycin with a MIC =4. gallinarum. Without continuing to perform purity checks on every isolate every time.The use of selective media (such as Thayer-Martin. or Yersinia may have different resistance mechanisms that result in elevated imipenem MICs. AND Resistant to all tested third generation cephalosporins (e. not only is it a “best practice” to set up a purity check for every isolate that is being tested for identification …. isolates are considered CRE ONLY if they meet the following criteria:   Intermediate or resistant to at least two carbapenem antibiotics (imipenem. ceftriaxone. 1991 October.html).Susceptibility Testing Phase II. the vancomycin MIC is in range with what has been published. casseliflavus/E. Only single isolates or pure cultures are only used for final performance of antimicrobial susceptibility (i. They carry vanC genes that typically confer vancomycin MICs of 2 to 16 µg/ml. including the use of purity plate verification”.D. Providencia. flavescens generally are motile. RRR ___________________________________________________________________________________________________________ . Legionella Selective media and others) is very effective for isolation of Nocardia species from specimens with mixed flora and may provide some evidence that the isolate may be a nocardia species. meropenem. but did not didactically evaluate the growth capability of all strains. faecalis are non-motile. Some isolates of Morganella. if you have doubts about the MIC you can always confirm by an E-test. The Vitek 2 showed a Low Discrimination between E. It is always recommended to confirm the results. Is this still considered a “best lab practice”. 29(10): 2335 –2337. PharmD. casseliflavus/E. low-level resistance to vancomycin (J Clin Microbiol. RRR CRE   The CRE surveillance definition developed by the CDC as part of their CRE Toolkit is based on the 2012 CLSI breakpoints (M100 S22): Enterobacteriaceae meet the CRE definition is they test:: Intermediate or resistant to imipenem. flavescens have an inherent. For species differentiation.balada-llasat@osumc. you simply wouldn’t be able to ensure that the test result is accurate….and susceptibility testing. faecium and E. The final ID using pigment production and hippurate reaction was E. D(ABMM) Associate Director. Clinical Pathology The Ohio State University Wexner Medical Center joan-miquel. casseliflavus/E. or doripenem. as if it were mixed. Furthermore. or meropenem.Would this Vancomycin susceptibility discard the E.http://www. The evidence of compliance includes “written procedure describing the use of pure isolates for susceptibility testing.cdc. Therefore.edu We have a Vitek 2XL we use for identification and susceptibility testing. ceftazidime. Conceivably. Original trials asked the question will the selective media help in ioslation. Is there any reference that addresses when to set a purity plate for isolates that are set up on the Vitek? I was trained to always set a purity check for every isolate. gallinarum as final ID? If it wouldn’t. flavescens have a distinct yellow pigment. Most isolates of E. Hafnia.gov/HAI/settings/lab/VREClinical-Laboratory. Ph.

what you are seeing seems outside the norm. Of the 36 PCR positive isolates. 99 –137 and Scheld WM. some reports have shown that The quinolones. intermediate or resistant) to one of doripenem. Of the strains enrolled in the study 56% were susceptible to ampicillin. Let me share a bit of background for my concerns. did you validate the new breakpoints before you started using them? And if so.html#definition). p. if ertapenem is 2 mcg/ml and meropenem is <= 1 mcg/ml should we report them as R and S respectively or both as R? We are using the new CLSI breakpoints RRR 4/290 Carbapenem reporting If you are using the new CLSI breakpoints. While. A couple of questions about the use of the new breakpoints. and efflux mechanisms. J Antimicrob Chemother. So. Bulik and colleagues documented 0% susceptibility to meropenem by broth microdilution among 46 clinical K. 3rd ed. aeruginosa because of their equivalent AUC24h /MIC ratios (MacGowan AP. if ertapenem is 2 mcg/ml and meropenem is 1 mcg/ml. Therefore. King A. but unlike Klebsiella do not possess a chromosomal class A beta-lactamase making them resistant to ampicillin. Hope this helps. San Diego: Academic Press. porin proteins. I would try to confirm the meropenem-susceptible phenotype by sending the isolates out to a reference laboratory. did you see any such errors? Some have documented 24-27% very major errors (eg. or imipenem AND resistant to all of the following third-generation cephalosporins that were tested: ceftriaxone. First. should be the organism be called CRE if it is a Enterobacteriaceae or that denomination is not necessary with the new CLSI? How to define CRE is a somewhat complicated matter. as this will differ across the United States. Maintaining fluoroquinolone class efficacy: review of influencing factors. an organism with one or more mutations may show different MICs for different levofloxacin can be less potent than ciprofloxacin against Pseudomonas aeruginosa based on MIC (Phillips I. Immunology. the percent susceptibility is considered to be a better measure.gov/hai/organisms/cre/cre-toolkit/background. J Clin Microbiol 49:3931033). Emerg Infect Dis.” Two points about this definition: 1) Morganella morganii. the two fluoroquinolones have equivalent activity against P. Wootton M. agglomerans to be 8 and the MIC 90 to be 128. meropenem. For this reason. you would see a strong positive result from KPC expressing organisms. However. you may expect to see some isolates that test resistant to ertapenem but susceptible to the other carbapenems. false susceptibility) by Vitek2 for meropenem (see Lat et al J Clin Microbiol 2011 49:1795-1798. 1999. for your example. Similarly. aeruginosa isolates have lower ciprofloxacin than levofloxacin MICs. cefotaxime. While certain P. 5/290 X Are Pantoea sp.43:345 –9). editor. In particular.9:1–9). In a study by Cheng et al(Journal of Microbiology. as we now know that there are multiple mechanisms of carbapanem resistanc e expressed among the Enterobacteriaceae. We do not Thanks Dr. I wonder if you might be seeing a strain that is not expressing KPC or is expressing KPC at low levels (see for example Kitchel et al Antimicrob Agents Chemother 2010 54:4201)? Are all the errors in the same species of Enterobacteriaceae? Any indication that there is clonal dissemination going on among the isolates that are testing? This is more of a long shot. considered intrinsically resistant to Ampicillin? RRR Pantoea are former members of the genus Enterobacter. and I would guess the problem stems from errors in your automated system. 15 have had meropenem MICs of <=1 as reported by our automated method. 2000. you should be reporting all carbapenems as tested. We still have a low incidence of feel that we can stop doing Hodge screening due to the large number of KPC isolates that would have been reported as Meropenem susceptible even with the new breakpoints. Proteus spp and Providencia spp have intrinsic imipenem nonsusceptibility – and so for these organisms. In: Andriole VT. Shannon K Comparative in-vitro properties of the quinolones. and ceftazidime. If it is not a problem. In the case that Susan just mentioned and reporting each Carbapenem how it tested. I would like to add another question to it. The CDC definitions are as follows: CRE = “Enterobacteriaceae that are nonsusceptible (eg. and somewhat concerning. 2012) the authors found the MIC 50 of P. are your MHT strong positives? Typically. First. and Infection. KPC and currently have sent all of our positive Hodge tests for PCR confirmation. fluoroquinolones. pre-dating M100-S20 U) then you may consider including ertapenem non-susceptibility as part of the definition for CRE. Holt HA. meropenem resistance was noted in 97. you should report them as R and S respectively. pneumoniae (Landman et al. Also. as this might help increase sensitivity. While the new breakpoints aren’t intended to catch all isolates that express a mechanism for carbapenem resistance. If not. 2003. I would suggest contacting your institution’s infection control practitioners and local public health authorities for guidance on what they would like included in reporting. in this validation. which are available on the CDC website (http://www. Is it unusual for a Pseudomonas aeruginosa to be susceptible to ciprofloxacin and intermediate to levofloxacin? Should these results be verified before reporting? 6/290 Cipro Vs Levo against Pseudomonas The fluoroquinolone susceptibility profile is determined by the number and location of mutational changes in enzyme target sites. which will result in different phenotypes in vitro tests.8% of 721 KPC genotype K. The antibacterial efficacy of levofloxacin and ciprofloxacin against Pseudomonas aeruginosa assessed by combining antibiotic exposure and bacterial susceptibility. I would suggest to test some of the isolates that you got . The CDC has provided interim surveillance definitions for CRE (carbapenem resistant Enterobacteriaceae). we would expect the opposite result. and perhaps you are seeing a similar issue? I have a couple of suggestions on what can be done.If any one of the carbapenems is resistant should all the carbapenems be reported as resistant. a CRE definition should require nonsusceptibility to carbapenems other than imipenem (eg doripenem and/or meropenem) 2) If a lab is still using the OLD CLSI breakpoints (eg. Humphries. I am concerned that I am missing an essential piece of this puzzle! This is an interesting finding. without editing any of the results.cdc. For example. pneumoniae isolates that with KPC genotypes. This will help you get a handle on if the issue is with the automated system you are using. Bulik et al J Clin Microbiol 48:2402-6). or by trying Etest or disk diffusion on them.

is it necessary still to report Cefazolin? If yes. Martinez. Eliopoulos. FOX-5. CMY-2. 3. A. J. without worrying about ESBL presence. As well as suppressing penicillins. there is not enough clinical evidence to avoid P/T use for susceptible SPICE organisms. A. e -test) to confirm the results. I would discuss this with your infectious diseases physicians. Vol54. S. 2. Inurrieta. Increase of P/T MICs when bacterial inocula reach 107 cfu/mL. Some of the reasons are: 1. Clin Microbiol Rev 2005.A. Carmeli. should ampicillin/sulbactam or piperacillin/tazobactam be suppressed also? If your laboratory has not yet adopted the current (2010) breakpoints for cephalosporin and aztreonam for the Enterobacteriaceae. and piperacillin/tazobactam. as you may report all beta-lactams as they test. If the GNR strain is susceptible to 3rd and 4th generation Cephalosporins. mirabilis as resistant to penicillins. may provide reduce the activity of P/T.e. In another study analyzing 377 episodes of Enterobacter bacteremia in adults. cephalosporins and aztreonam for ESBL positive organisms. issue 2). Inf. Presence of other mechanisms of β-lactam resistance (SPICEM organisms) such as AmpC enzymes (eg. This rule does not however apply to the beta-lactam/ beta-lactamase inhibitor combinations. 4. and there are some who fee that beta-lactam / beta-lactamase inhibitor combinations should not be used to treat ESBL infections. you cannot predict that it will also be susceptible to Cefazolin. Marcos. However. the only factor independently associated with a reduction in 30-day mortality was the early use of P/Z (M. 62 (2008). pp. M. Marco et al. however why do we avoid the use of P/T to treat infections caused by ESBL-producing organisms even when the MICs indicate susceptibility? (Can We Really Use ß-Lactam/ß-Lactam Inhibitor Combinations for the Treatment of Infections Caused by Extended-Spectrum ß-Lactamase? Producing Bacteria? Clin. 2628–2630). So. hyperproduction and specific mutations of non-ESBL enzymes (eg.M. Soriano. in fact it could be resistant. SHV or TEM). Harris. Kaye. because the beta lactamases are inhibited by tazobactam and clavulanate (manifested in the double disc diffusion test where the third generation zone of inhibition is increased by clavulanate). Generally. Note that if you are able to verify the current breakpoints for the cephalosporins and aztreonam. which may be reported as they test. coli. aztreonam. pneumoniae and P. Pharmacokinetic/pharmacodynamic studies indicate that normal doses of P/T do not achieve therapeutic concentrations and this is associated with unsatisfactory outcomes. especially to treat life threatening infections. Cosgrove. What am I missing? Piperacillin/tazobactam (P/T) and amoxicillin/clavulanate are “stable” against ESBLs. the questions revolve around isolates that are resistant to the cephs and aztreonam but susceptible to pip/taz or vice versa. COMMENT 1 I just reread my question and realized I left out a crucial part of it! The isolates we are questioned on are not ESBL producers. P/T is often Susceptible and we report it as such but it seems to cause concern. Comment 2 Regarding your question. pharmacy and other key players before making a decision on how to report. regardless of how they test to the individual agents. Almela.S. can you recommend a good reference for determining which are and which aren’t? . if it is resistant to 3rd and 4th generation Cephalosporins. we can conclude that it will also be resistant to Cefazolin. The risk of clinical failure due to emergent resistance is in general small * If you report 3rd and 4th generation Cephalosporins rutinary for Gram negative rods. Antimicrob Agents Chemother. pp. More clinical relevant data is needed. ACT-1).. G. Dis. you can avoid this situation. or additional ESBLs. F. then you should report all ESBL-confirmed E. Y. J Antimicrob Chemother. 45 (200 1).(Ciprofloxacin “S” and Levofloxacin “I”) by the method used in the lab and by an alternative method (i. why is the reason of this 8/209 Reporting Cefazolin You should always include the report for Cefazolin (First Generation Cephalo). A. The use of P/T TzP for the treatment of infections caused by ESBL-producing organisms is limited and controversial (Extended-spectrum beta-lactamases: a clinical update. just to be sure that is not assay dependent. K.18:657-86). while organisms that produce inducible AmpC enzymes may be ineffectively treated by P/T. Often they are the SPACE bugs so AmpC is likely the issue. Kaye et al. cephalosporins and aztreonam. I realize this is confusing to many people. found that P/Z use was not associated with the emergence of cephalosporin resistance in the treatment of Enterobacter bacteremia (K. In summary. 397–403). Based on the MIC it should be OK to used them on ESBL-producing organisms. 290 / 2/1 Are all resistance mechanism inducible? If not. They believe that pip/taz should agree with these other drugs. there is little clinical data to verify this if isolates test susceptible in vitro. 7/290 We get frequent questions from our physicians and pharmDs regarding the relationship between cephalosporins.

balada-llasat@osumc. Based on the CLSI M100-S22 for Enterobacteriacea and Staphylococcus spp. I would be most concerned about a cfr mechanism. but has also subsequently mobilized to human Staphylococci (including S. The acetoxyethyl ester prodrug of cefuroxime (effective orally). if they test susceptible to ampicillin we confirm the result by checking the purity plate and then we repeat the susceptibility test.Inducible Resistance Some mechanisms of resistance are inducible. I would use these MIC interpretations for oral and parenter al dosage. However. there are a number of mechanisms that could account for an Erythromycin-S. I am most concerned with the first resistance (LR) in Coagulase-negative Staphylococci is 28-times that of S. cefuroxime breakpoints interpretations are as follows: Joan-Miquel Balada-Llasat. but not to Erythromycin (although some plasmids harboring cfr also habor erm and other resistance genes). Streptogramin (Quinupristin-Dalfopristin) – sensitive. its activity depends on in vivo hydrolysis and release of cefuroxime to the bloodstream. CID.or R? MICs are based on PK-PD properties. while others are constitutive. However. This gene was originally detected on a multi-resistance plasmid from a bovine strain of S. sciuri. D(ABMM) Associate Director. The presence of cfr in Staphylococcus species is associated with a low fitness cost and outbreaks due to clonal spread of cfr-containing strains have been described (Bonilla H et al. has a modification to allow absorption. CID 2012). The Manual of Clinical Microbiology is a good resource for reviewing mechanisms of resistance. aureus). the product of which adds a methyl group at the C-8 position of the 23S rRNA nucleotide A2503. Resistance to Linezolid can result from mutations occurring in the 23S rRNA binding sites. Some of these mutations can also confer resistance to Clindamycin. However.. faecium strains are often resistant to ampicillin or vancomycin or both.I.sensitive. Clindamycin. 2012}.5 g every 8 H MIC of Cefuroxime S Parental Oral ≤8 ≤4 I 16 8-16 and resistance may change. however there is a high correlation with vancomycin and ampicillin resistance in Enterococcus faecium strains.coli with an MIC of 8 susceptible to parenteral cefuroxime and intermediate to oral cefuroxime regardless of whether we tested cefuroxime axetil or cefuroxime sodium? Comment 2/answer Cefuroxime sodium is the drug tested in vitro. E. An example of inducible resistance is inducible clindamycin resistance conferred by the erm gene. Depending on the route of administration the MIC used for susceptible/intermediate R (µg/ml) ≥32 ≥32 Based on a dosage regimen of 1.D. PharmD. I know the resistance mechanisms are different between these drugs. cotrimaxazole. this is what you are looking for when you do the D-test. Given the multidrug resistant pattern you described for this isolate. most concerning is resistance d ue to acquisition of a plasmid-borne ribosomal methyltransferase known ascfr (chloramphenicol florfenicol resistance). faecium strains are ampicillin resistant. faecium and E.edu Comment 1 So. This is based on the fact that these strains are nosocomialy transmitted. In terms of the susceptibility results that you described. The incidence of Linezolid A difficult question As you point out. gentamycin etc. Clinical Microbiology Assistant Professor. Could this be due to drug inactivation by lnu A / lnu B? Can we rule out the possibility of rRNA methylase / efflux pumps for this rare pattern? Can there be any other mechanisms for this pattern? Linezolid Resistance in CONS result that you listed: Linezolid resistance. aureus (LRSA) {Gu B et al. Morales G et al. faecalis in the Vitek 2 with Vancomycin resistent pattern and Ampicillin susceptible confirmed by KB. lsa genes). but is it a normal or common pattern in those organisms? must be necessary confirm those results from the Vitek 2 with a KB? 290/2/4 Amp/Vanc Resistance in Enteroc As you mentioned the mechanisms are different. Ph. The isolate is resistant to chloramphenicol. I have found in E. Clindamycin-R Staphylococcus including both inactivation (lnu genes) and efflux (vga. . as well as in the peptide translocation center of the ribosome. Clinical Pathology The Ohio State University Wexner Medical Center Phone: (614) 257-2785 joan-miquel. rifampicin. 290 /2/2 Can MICs for parenteral cefuroxime be used to interpret oral cefuroxime as S. cfr also confers resistance to Clindamycin. A linezolid resistant and mecA positive coagulase negative staphylococcus was isolated from a cellulitis patient who underwent linezolid therapy. Moreover this is showing an unusual susceptibility pattern:Erythromycin. J Antimicrob Chemother. I could call an E. confirming the presence of this gene would require PCR that most likely would have to be performed in a specialty laboratory. In our institution most of the E. 2012.resistant.

However. arguing that the breakpoints should be reviewed. cephalosporins. However. We use the Vitek 2 for AST and often get results for E. and . What is the basis for that? startt 291/2/7 Tzp . etc) can be reported as ESBL? 291/2/8 Cephalosporins and ESBL The “new” CLSI guidelines focus on the minimum inhibitory concentration for various bug-drug combinations rather than detection of mechanisms of resistance. Gavin et al (Antimicrob Agents Chemother. Is this an acceptable result? At the moment we check the cefazolin by KB disk diffusion and it often is S. although laboratories are not required to confirm the presence of ESBLs. when they test as such in the laboratory. for all confirmed ESBL-producing strains. using those new breakpoints. this antimicrobial should only be reported on organisms isolated from Nitrofurantoin is not a beta-lactam antibiotic and ESBL enzymes have no activity against nitrofurantoin. while urinary tract infections caused by piperacillin-tazobactam-susceptible ESBL producers may be successfully treated. The ESBL status of an organism is irrelevant to reporting of nitrofurantoin. aztreonam. Clin. The mechanism of action of nitrofurantoin has not been fully described. If current cephalosporin and aztreonam interpretative criteria are used. Nitrofurantoin is a synthetic antibacterial agent that is indicated for use for treatment of uncomplicated cystitis. Serratia. they should be reported as tested. like piperacillin-tazobactam. Therefore.for ESBL producers Based on the M100-S22 CLSI document. it recommends reporting ESBL-producing isolates as susceptible to β -lactam/β-lactamase inhibitor combination antimicrobials. However. In this case we are not reporting the cefixime as the first generation is S. and aztreonam. If I am using the new 2012 CLSI breakpoints for Cephalosporins and I don´t have to confirm the ESBL tested strains with KB. they may still do so if they wish. Strains of bacteria that are resistant to nitrofurantoin have been shown to possess reduced nitroreductase activity. Pseudomonas spp. Furthermore. Drugs 63:353-365). 50(6): 2244 –2247) assessed infections caused by extended-spectrum-β-lactamase-producing Escherichia coli or Klebsiella spp. such as Staphylococci and E. do I have to report the MIC or area disk tested without to change the interpretation for Cephalosporins in ESBL isolates? also. Morganella. I suggest to test Cefixime by a different susceptibility method and also check the susceptibilities to other third generation cephalosporins such as Ceftriaxone or Ceftazidime. any Enterobacteriaceae tested as Resistent or Intermediate to 3rd generation of Cephalosporins (Enterobacter. it has been some failure for other more serious infections. In conclusion. I would question the Vitek result. and Proteus spp. How are others handling this? 291/2/6 CZ Sensitive but CFM Resistant The fact that you are observing higher MICs for Cefixime (third generation cephalosporin) than for Cefazolin (first generation cephalosporin) is unusual. urine specimens. coli where cefazolin is S and Cefixime is I/R. Microbiol. 2006 June. Would you report snesi results of Coamoxiclav (augmentin) and ticra/tazobactam (tazocin) for an ESBL producer? In certain practices only tazocin is reported but not augmentin . Treatment was successful in 10 of 11 nonurinary infections from susceptible strains and in 2 of 6 infections with MICs of >16/4 μg/ ml. 39 :2206-2212.Is there any reason not to report Nitrofurantoin on ESBL organisms? Nitrofurantoin has a broad spectrum of activity against a variety of Gram positive and Gram negative bacteria. The new guidelines state: If the current cephalosporin. All six urinary infections responded to treatment regardless of susceptibility. are resistant to this antimicrobial. reports of clinical failures have led to recommend a carbapenem antimicrobial for all ESBL infections (J. The new breakpoints are more sensitive for detection of cephalosporin resistance in Enterobacteriaceae. treated with piperacillin-tazobactam to determine if the susceptibility breakpoint predicts outcome. regardless of an organism’s ESBL status. for the labs that do not use current cephalosporin and aztreonam interpretative criteria. the test interpretation should be reported as resistant for all penicillins. coli.

3 generation cephalosporin resistance in these organisms does not rule in or rule out the presence of an ESBL. carbapenem breakpoints are used. Using the revised breakpoints. In your email. should an E. you would not be able to detect the presence of an ESBL using the CLSI procedure even if this isolate were an ESBL producer. It is important to take into consideration that In a simplistic way I would define ESBL organisms as those organisms that are resistant to all betalactams antibiotics but carbapemems. it is well known that these organisms harbor other mechanisms of β-lactam resistance such as porin mutations and encode other β-lactamases including ESBLs and AmpCs. 2009. if using the disc diffusion assay for ESBL detection the carbapenemase producers organisms may be positive . So the answer to your question depends on whether or not you are using the revised breakpoints. I’m not sure I understand the second part of your question. Citrobacter and other SPICE group organisms. if you are using the breakpoints from 2009 or before. you would just report the antibiotic results as is with no further need for ESBL testing. ESBL. Carbapenamese producing organisms to be resistant to all betalactams (including penicillins. 292/3/2 Should a P. monobactam and carbapemens). But in the E. the CLSI published revised interpretive guidelines in 2010 . coli case you describe. etc. Pseudo as MDR There are many different definitions for multi-drug resistant organism (MDRO). Indeed. on the minimum inhibitory concentration (MIC) of the organism to a given agent. However. I assume that the MDRO label was applied to this organism by the Vitek2 software? Regardless. aztreonam or penicillins to resistant when an ESBL is detected. Cephalosporin resistance in these isolates may be due to a variety of mechanisms. bacteria are labeled MDR based on susceptibility to one key antimicrobial agent often . Serratia.ESBL and/or Modified Hodge testing are not required. in some cases. depending on the rest of the rd resistance profile. However. KPC β-lactamases are inhibited by clavulanic acid.) has no specific correlation to ESBL. inducible AmpC. coli strain shown an AmpC pattern and a negative confirmatory KB double-disk diffusion test (less than 5mm and all of them resistant) be called ESBL 291/2/9 ESBL & 3rd Gen Cephalo In order to detect the presence of either or both of the AmpC and ESBL enzymes. How is it that Enterobacter. However. but since the CLSI does not have protocols or procedures to confirm ESBL or AmpC phenotypes on these genera. And therein lies one of the advantages of the revised breakpoints… Is is possible for an enteric gram negative rod to have an ESBL AND a carbapenemase? How can I easily define ESBL and carbapenemase for non-microbiology staff? 292/2/10 Difference between ESBL & β-lactamases It is possible for Enterobacteriaceae organisms to have an ESBL and a carbapenemase. how should they be reported? In the same way. coli with a pattern of resistance suggestive of the presence of an AmpC betalactamase (and not surprisingly. but rather. including AmpC. the literal interpretation for MDRO is for an organism to be resistant to more than one antimicrobial agent. a negative ESBL test). these tests may be used to confirm the presence of a resistance mechanism of epidemiologic significance. These organisms have chromosomal. ESBL testing should continue to be performed with the appropriate editing of the results for cephalosporins. pAmpC or both and ESBL & pAmpC had MIC’s to 3rd generation cephalosporins that were in the non-susceptible range using the revised break-points (but in the susceptible range with the older breakpoints). cephalosporins. but generally this term is applied to bacteria that are resistant to three or more antimicrobial classes. It is these very issues that speak to the rationale behind the revision of the breakpoints which are focused not on the detection of specific resistance mechanisms themselves. or even carbapenemase. you raise the example of SPACE-MP organisms having de-repressed AmpC’s and an E. being resistant to 3rd generation of Cephalosporins. Serratia. 47(8): 2419–2425) demonstrated that the majority of strains tested harboring an ESBL. but I or R to cepahlosporins in the Genera you list ( Enterobacter. should be called ESBL? I have found few strains of Enterobacter with a suggestive pattern of AmpC producer. aeruginosa only non-susceptible to Carbapenems and susceptible to all others antimicrobial classes (including Ceftazidime and Cefepime) be called MDRO? I have gotten few strains being only Intermediate or Resistante to Imipenem or Meropenem in Vitek II and confirmed by KB using the CLSI 2012 and still they are called MDRO. Kohner et al (J Clin Microbiol.

should they be called CRE and change the susceptibility pattern of all the Carbapenems and Cephalosporins? SME Vs CRE (It is a difficult question). Although a number of inhibitors (e. Plasmid-borne ampCgenes are constitutively expressed. 292/3/5 (It is a difficult question) We have been followed and documenting few Serratia marcescens strains with a discrepant pattern on Carbapenems and Cehalosporins. Amp/Sulb. and the al. marcescens and we are looking for how deal with these strains about if to call it CRE and to change all the Cephalosporins to resistant in these cases.. coli ATCC 35218 is the QC strain recommended and sufficient when testing β-lactam/ β-lactamase inhibitors against P. Aztreonam & Pipericillin-Tazobactam. amikacin). levofloxacin). this isolate would certainly be considered multi-drug resistant and contact precautions for the patient may be warranted depending on your institution’s infection control policies. there was a proposal for international definitions of MDR among various bacteria. piperacillin-tazobactam). with carbapenem resistance in Pseudomonas aeruginosa. aeruginosa.for Pseudo Sensi The E. Aztreonam and TZP and only the Cefepime disk was susceptible.associated with co-resistance to other agents. Because Klebsiella pneumoniae does not harbor a chromosomal ampC gene (Bergstrom S et al. and thus no induction of expression would be observed with the Fox-Tzp or Imi-Caz disks. leads to imipenem resistance. approximately 50% of E. it is not required as routine user QC testing. loss of the OprD outer membrane porin. the CLSI currently recommends that ESBL testing only be performed for infection control purposes where necessary when the current Enterobacteriaceae breakpoints are used. coli 35218. One thing to consider is which carbapenems you are testing in this case — is the isolate in question resistant to imipenem AND meropenem? Or are you only testing imipenem? In P. in that the phenotype you are observing (eg. in combination with this organism’s chromasomal AmpC.g. fosfomycin. this might be a loss/downregulation of OprD. the antipseudomonal carbapenems (imipenem. etc. If we are testing a Pseudomonas aeruginosa against Pip/Tazo Etest. coli 25922 or is 35218 sufficient? 292/3/3 QC Strain . Citrobacter species. Buchan mentioned before. The gold standart to determine the presence of SME is a KPC PCR but we don´t count with possibility to make a KPC PCR to each S. It is possible that the isolate could also harbor an ESBL despite the Cefepime result obtained: In a study by Kohner et al (J Clin Micro. Could it be an AmpC producer strain because its resistance to TZP? Is it possible to use the IMP-CAZ or FOX-TZP disk method to induce the production of AmpC when it is suspect even without CLSI guidelines about it? 292/3/4 AmpC beta-lactamase The resistance pattern you describe certainly is suspicious for an AmpC betalactamase (resistant to 3rd generation cephalosporins. if the MIC to imipenem is elevated (you say ‘non -susceptible’. antipseudomonal fluoroquinolones (ciprofloxacin. tobramycin.Nasrullah U have this article……. I setup a new KB using Cefepime. when I confirmed it by diffusion disk KB using Ceftazidime and Ceftriaxone with Clavulanic Acid.: Magiorakos et MDR in P. 47(8): 2419–2425). I assume this is R?) but meropenem is susceptible. Based on this definition. your isolate would not qualify as “MDR”. antipseudomonal penicillins + betalactamase inhibitors (ticarcillin-clavulanate. 2009. 155:1297-1305). cefepime). the areas were less than 5mm and all the disks tested resistant. J Bacteriol. aeruginosa. coli andKlebsiella isolates harboring both an ESBL and pAmpC had Cefepime MICs in the susceptible range (MIC≤8). where a blunting of the Tzp and Caz zones would be expected if an inducible ampC were present. The categories included are: aminoglycosides (gentamicin. We are looking for to test some of these strains to determine the presence of SME and documenting their pattern through Vitek II and KB. monobactams (aztreonam). etc. but How could this case be directed? is it possible to use the phenotypical pattern of the SME positive strains to create a protocol for upcoming report of these strains? if those strains are SME positive. such as here. This is in fact a very complicated issue (as I am sure you are well aware!) I would like to re-iterate what Dr. boronic acid. 1993.) have been published to enable detection of ESBL’s in the presence of an expressed AmpC beta -lactamase. Should we also be doing QC on Pseudo 27853 and ATCC E. whereas meropenem (and cefepime and ceftazidime) are less dependent on OprD for cell entry. antipseudomonal cephalosporins (ceftazidime. pneumoniae ESBL alert. This is in contrast to organisms like Enterobacter species. So. doripenem). cloxacillin. I got in the Vitek II a possible K. I refer you to this article…. but susceptible to Cefepime). polymyxins. meropenem. a plasmid-ampC (pAmpC) is more likely. Furthermore. no CLSI-approved methods have been published. 2012 Clin Microb Infect 18:268. I have asked this before about the possible explanation about having Imipenem I or R and Meropenem and the rest of 3rd and 4th generation of Cephalosporins S. Recently. Per this group’s definition. aeruginosa is non-susceptible to >=1 agent in >=3 antimicrobial categories. We generally use QC E. I read that one of the difference between AmpC and inhibitor-resistant beta-lactamase was the resistance to Tazobactam. Regardless of whether an ESBL is present in this particular isolate or whether the presence of a pAmpC were confirmed. I or R to carbapenems .

Is it antibiotics antagonism? Does it have any clinical significance? Inducible expression of AmpC beta-lactamase most likely due to inducible expression of the P. but did not see a blunting of the Imipenem zone itself. The result that you observed with this isolate was Many isolates of certain enteric (Serratia marcescens. such as Infection Control. Enterobacter spp. Antimicrob. and current consensus recommendations for firstchoice and alternative drugs. Agents Chemother. 2011 Diagnostic Microbol and Infecti Dis 71:3: 325-6). 292/3/6 Why are there no CLSI breakpoints for viridans strep and trimeth/sulfa? Why cot NOT used for Strep viridians The clinical laboratory in consultation with infectious disease. TMP-SMX) breakpoints and FDA approval use agaisnt Streptococcus pneumoniae . the only real way to determine this would be to perform a SME-specific PCR. J Clin Microbiol. CLSI use voluntary consensus standards and include antibiotic interpretations that have proven efficacy by acceptable in vitro test performance against the pathogen. or a combination of these. A.M. but rather tell you only if the isolates in question harbor a KPC gene: SME is a different carbapenemase altogether. When investigated. cephalosporin-S phenotype between 2010-2011. You might consider sending some of the isolates to a reference lab to additional testing (such as SME PCR). aeruginosa AmpC beta-lactamase. M. and non-enteric organisms (P. at UCLA we encountered a number of S. including carbapenemase such as SME. and call the isolates with carbapenem resistance CRE. Finally from an infection control perspective. AmpC/porin loss or other mechanisms. So the question remains on how to deal with these isolates. 37(6): 1876 –1880). Based on the fact that B-lactams are a great first choice for treatment. marcescens isolates that produced SME-2 were isolated at UCLA in 1992. This shape looks like gram positive ICR strains. Castanheira. it is not a good substrate for the enzyme and is therefore relatively resistant to hydrolysis. I can tell you that SME is relatively rare (see for example. 44:3035-3039). Infectious Diseases specialists and Infectious Diseases Pharmacists. Antimicrob. there is no evidence that these drugs will work in vivo. Performing a PCR for blaKPC will not help you resolve the question as to whether these isolates harbor SME. aeruginosa. Providencia spp. However. 52:570-573) and so I would be surprised if you have multiple isolates that harbor the gene coming through your lab. _____________________________________________________________________________________________________________________________ ____ Recently I have performed manual sensitivity for Pseudomonas aeroginosa isolated form Blood and when it comes to reading I have noticed that piperacillin tazobactam has D shape from Imipenem side (distance between Imipenem and TZP is 30 mm) . pharmacy as well as the pharmacy and therapeutics and infection control committees should select the most appropriate antimicrobial to test and to report and are ultimely responsible for the selection of antibiotics to be used in different infections. prevalence of resistance. FDA clinical indications for use. Regardless.but S to 3rd and 4th generation cephalosporins) may be caused by multiple mechanisms. While these isolates test susceptible to the cephalosporins in vitro. as you suggested. 2007 Genetics 176:4: 2381-92). 2000. As an example. I would suggest this is a discussion to be had with key stakeholders at your institution. Our experience from the past indicates that when multiple isoaltes with SME are encountered. porin mutations. et al. however increasing resistance is well documented with resistance rates of 18 to 26% (J Clin Microbiol. marcescens with the unusual carbapenem-R. et al. pneumoniae breakpoints and E-test have shown very high rates of Viridans Streptococcus resistance to TMP-SMX (68%. There are only trimethoprim-sulfamethoxazole (cotrimoxazole. and the high level of resistance. 37(1): 215–217). the pharmacokinetics. 2008. and pulsed-field gel electrophoresis analysis revealed that all of the isolates were the same strain ( Queenan. Aeromonas) can up-regulate expression of their chromosomally-encoded ampC genes in response to sub-inhbitory concentrations of certain beta-lactam antibiotics. Citrobacter freundii. chromosomally encoded AmpC enzymes. there is no good phenotypic test to confirm SME vs. Morganella morganii). 1999 June. from my perspective the most conservative thing to do would be to edit the cephalosporins to resistant in these cases. Unfortunatly. the use of TMP-SMX is not recommended to treat Viridans Streptococcus infections. Five S. Some suggest looking at the relative in vitro MICs to imipenem (usually high) versus ertapenem (usually low) as an indication SME might be at play (Carrer et al. This is why you saw a blunting of the TZP zone. this may be related to nosocomial spread. The relative infrequency of SME may relate to a significant fitness cost associated with acquiring the SME-1 signal sequence (Marciano et al. although case reports suggest cefepime may be an option (Fairfax et al. No studies have addressed this issue (probably because such isolate are so uncommon). Although Imipenem is a strong inducer of AmpC expression. I would suggest using the current CLSI breakpoints to define carbapenem resistance. 1999 January. clinical efficacy. 2008 International J Antimicrobial Agenets 31:181-2). Agents Chemother. none of 18 strains harbored SME genes as determined by a SME-PCR specific PCR. Research susceptibility studies using the S. KPC vs. .

Cefazolin R/I or S. However. the organisms carrying them. Inducing agents for these enzymes include . ceftriaxone) for serious infections with the aforementioned organisms. After verify these results using a KB diffusion disk and the CLSI 2012. 22:161-182. and Beta lactam-beta lactamase combinations. For the purpose of determining MDRO status. but are likely the result of different resistance mechanisms. There are some excellent reviews available on AmpC beta-lactamases (e. However. in our laboratory we divide the Beta lactams in these 5 classes. porin mutations. different labs use different criteria. are all beta-lactam drugs considered one class are they broken up into multiple classes? For example.Interestingly. and cefepime be one class or three? Classes in MDROs This is a great question and unfortunately there is a lack of consensus. this pattern in S. when this result is gotten do those organism have to be called CRE? calling them CRE all the Carbapenems and Cephalosporins tested as Susceptible have to be changed to Resistant? How those organisms could be interpreted and reported? SME Difficult Question . areogenes isolates is also typical of some of the Ambler class A beta-lactamases. extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance 2012 294/4/1 I have found 4 strains of Serratia marcescens and 5 of Enterobacter aerogenes with a commond susceptibility pattern. Such enzymed are typically not inducible and are chromosomally encoded. 2005. cetriaxone. For the purpose of MDRO definition. Cefazolin R/I or S. there is no CLSI-approved method for the detection of inducible AmpC expression and no consensus about how to report antibiotics when an isolate is found to have inducible AmpC expression. 48(4):1019-25).Read it…………. and interpretation of susceptibility results continues to expand and evolve with the discovery of new beta-lactamase enzymes and increased understanding of PK/PD properties associated with the different beta-lactams. conferring high-level expression of this enzyme to organisms that acquire the plasmid. E. Ceftazidime S. J Clin Micro. but the Carbapenems has a discrepancy between Meropenem S and Imipenem R in all of them. Thomson KS. Ultimely. the susceptibility pattern has been the same. Carbapenems. It is also important to keep in mind that the AmpC beta-lactamase has also been mobilized onto a plasmid. Ceftazidime S and Cefepime S. and aztreonam considered to be one class or three? What about the varying cephalosporin generations? Would cefazolin. SME-3) have been described that differ from SME-1 by single amino acid substitutions. Hi Nasrullah You have this article…. These enzymes are chromosomally located and are expressed at a low basal level in the absence of an inducing agent. not only on the definition of MDRO but also in how to divide the Beta lactams. S. SME-1 was the first SME reported and demonstrates a broad spectrum of activity against beta-lactams including penicillins.g. although in most cases Carbapenems are always considered a different class. Multidrug-resistant. In Enterobacter species the enzymes NMC-A and IMI-1 would be the most likely candidates. other mechanisms of resistance may produce a similar susceptibility profile in the family Enterobacteriacae including chromosomally encoded (inducible) AmpC enzymes. This susceptibility pattern is consistent with the pattern you report and may indicate the presence of SME-2 or SME-3 in your strains. 43(12):5945-5949). Monobactams. marcescens strains containing SME-2 or SME-3 suggest that these strains remain susceptible to third and fourth generation cephalosporins including ceftazidime and cefepime despite demonstrated resistance to imipenem. I would suggest getting a clear understanding from your Infection Control Group in how to interpret the definition of MDRO and which classes of antibiotics should be included. Resistance by this mechanism can occur in some patients receiving certain broad-spectrum cephalosporins (e. The AmpC betalactamase can become stably over-expressed when mutations are acquired in the regulators of ampC expression (so-called derepressed AmpC strains). I have read about the SME in those organisms as the possible cause of Imipenem R. are cefepime. These substitutions result in up to a 100-fold lower affinity (and thus reduced hydrolysis) for a number of substrates including the extended spectrum cephalosporins. the combination of TZP with Imipenem was shown to be the most sensitive antibiotic combination for the detection of inducible AmpC expression in a previously published study (Dunne & Hardin. The strains you report (4 Serratia marcescens and 5 Enterobacter aerogenes) share a common susceptibility pattern. Several case reports of S. thus do not present a risk for spread of these resistance determinants to other bacteria. Ceftriaxone S. marcescens As you allude to in your question. Ceftriaxone S. The study of beta-lactamase enzymes. Cephems. two additional SME enzymes (SME-2. Cefepime S. and meropenem while retaining high level activity against first and second generation cephalospoirins and imipenem. Beta lactams can be divided in 5 different classes: Penicillins. 2009. Subsequently. carbapenems and aztreonam. However.g. cephalosporins. Based on CLSI. or a combination of mechanisms. Imipenem R. 2010. marcescens is likely the result of an SME enzyme. aerogenes The susceptibility pattern you describe for four E. These are Ambler class A serine beta-lactamases. Meropenem S. Clin Micro Rev. Jacoby GA. the reporting of MDRO should be used for Epidemiology and infection control purposes. J Clin Micro. Therefore without molecular or nucleic acid sequence confirmation of SME type it is most appropriate to treat as a CRE and rely on alternative (non-beta-lactam) antibiotics if available/appropriate. zosyn.

false susceptibility rates of 0. The CLSI is fairly stringent on this rule..org/question2answer/?p=3460 https://clinmicro. but I would suggest you contact your local company representative if you have questions on this.9. and if an amikacin results is needed.SME carbapenemase & KPC Serratia marcescens have intrinsic resistance to Ampicillin/Amoxicillin ± Clavulanic/Sulbactam. but all the 3rd and 4th gen Cephalosporins were susceptible (<=1).org/question2answer/?p=2515 https://clinmicro. agents are listed in a single box when interpretive results and clinical efficacy are similar. IMI) these strains should be regarded as CRE and alternative (non-beta-lactam) antibiotic therapies should be pursued. Assistant Professor of Pathology & Immunology and Pediatrics. Meropenem “S”. Washington University School of Medicine. these strains can demonstrate in vitro resistance to imipenem while appearing phenotypically susceptible to ertapenem. this would explain the phenotype observed for these drugs. Barnes Jewish Hospital In different opportunities. These colonies are not observed when tested in the presence of clavulanic acid. I do not know the basis for this suppression.asm. Cephamycins.org/question2answer/?p=2487 Carey-Ann Burnham. marcescens with a particular susceptibility profile on Vitek II: Imipenem “I” or “R”. Do we still have to confirm Amikacin if both Gentamicin and Tobramycin are resistant? 294/4/2 Amika. CLSI M100-S22). and has a different breakpoint (eg. As far as the Vitek suppressing the amikacin result. 1 st and 2nd generation Cephalosporins (Appendix B. Enterobacter spp. Therefore. agents must be in the same box AND seperated by an “or” before they can be sued to predict results for the other agent. and 54% susceptibility to tobramycin. just because the tobramycin or gentamicin is resistant it does not necessarily mean the amikacin will also be resistant. one is resistant). A couple of points about this: If you refer to the CLSI M100 S22 document. Intrinsic resistance. Furthermore.4%. 2010 Aminoglycoside Resistance and Susceptibility Testing Errors in Acinetobacter baumannii-calcoaceticus complex J. and also varies depending on geography and patient population. It varies depending on the species of GNB you are talking about. I can tell y ou some have reported poor performance on the automated systems as compared to reference methods at detecting amikacin resistance (eg. should all the 3rd and 4th gen of Cephalosporins and the Carbapenems be interpreted as “resistant”? Difference . can also inducible AmpC enzymes or other beta-lactamases that make correlation of a specific resistance mechanism to a specific susceptibility pattern difficult. Amikacin is in a box seperate from gentamicin and tobramycin.D. Such strains should also demonstrate inducible resistance as a flattening of the meropenem or ertapenem zone of inhibition proximal to an imipenem or cefoxitin disk in a standard double disk diffusion assay (D-zone test). Clinical Microbiology 48:1132-8) and it is possible the instrument is suppressing the result based on the fact the tobramycin and gentamicin are resistant. This means that less than 3% of the time the results can be discrepant (one drug is susceptible. you must test amikacin.asm.imipenem and cefoxitin. the same profile was gotten. should they be called CRE because the Imipenem? And if it is the case. Medical Director of Microbiology. Enterobacteriaceae.. D(ABMM). Characteristics that further support the presence of NMC or IMI include the growth of isolated colonies inside the zone of inhibition upon disk diffusion or Etest for carbapenems. Ph.asm. <=16 ug/mL for susceptible. F(CCM). we have found strains of S. That is to say. resistant to Penicillins and 1st gen of Cephalosporins. we see ~60% susceptibility of Acinetobacter baumannii to amikacin. Tobra for Acineto Amikacin results for Acinetobacter cannot be extrapolated from tobramycin or gentamicin results . 294/4 3 XXXX What percentage of gentamicin resistant GNB are sensitive to tobramycin? There is not one answer to your question. meropenem.36. Been these strains susceptible to 3rd and 4th gen of Cephalosprins. Table 1A. to be safe. tobramycin or amikacin may be more active… here at UCLA. Because of the inducible nature of these carbapenemease enzymes (NMC. As with Serratia spp. whereby a combined major + very major error are fewer than 3%. we have noticed that Amikacin result is suppresed from VITEK II . Dependant on your local collection of Acinetobacter.Using the CLSI 2012 criteria and setting up a Kirby Bauer agar. Some other Q&As relating to aminoglycoside discrepancies can be found here: https://clinmicro. refer to Akers et al. versus <=4 ug/mL for susceptible for gentamicin and tobramycin). Genta. and other extended spectrum cephalosporins. . For Multidrug resistant Acinetobacter.

joan-miquel. OH 43205 University Hospital East. this is not consistent with your observations. Clinical Pathology 1492 East Broad Street. These rd th carbapenemases are not KPC (KPC confer resistance to most Beta lactams including 3 and 4 generation rd th Cephalosporins). 2006 October. it does not look that the S.edu . and carbapenems . Phone: (614) 257-2785. D(ABMM) The Ohio State University Wexner Medical Center. ————————————————————————————— Joan-Miquel Balada-Llasat. marcescens strains described are KPC. aztreonam. Clinical Microbiology Assistant Professor.balada-llasat@osumc.D. but they still confer lower resistance to Meropenem and Doripenem (Antimicrob Agents Chemother. Ph. 50(10): 3485–3487). Based on the information provided. Class A carbapenemases (SME) have been identified in Serratia marcescens strains (Antimicrob Agents Chemother. Columbus. PharmD. it is less common to find resistance to Carbapenems. 1990 May. 34(5):755-8).However. the presence of SME should be confirmed by molecular methods. SME carbapenemases have a broad hydrolysis spectrum that includes penicillins. Ideally. Associate Director. however it would suggest to perform the KPC PCR (feel free to send the strains to my attention and I can test them for you if you do not offer the test). and they do not confer resistance to 3 and 4 generation Cephalosporins. Previous publications have shown that SME hydrolyze preferably Imipenem. 1st and 2ndgeneration cephalosporins.

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