Chapter 6.

1
The Enterobacteriaceae

The natural resistance

Antibiotics

Why

Penicilin G / M

No penetration of the antibiotics

MLSK

No penetration of the antibiotics

Glycopeptide

No penetration of the antibiotics

Fusidic acid

No penetration of the antibiotics

The Enterobacteriaceae Resistance

Known Mechanisms of
Resistance
β-lactams

•  Impermeability
•  Efflux
•  PBP Modifica8on
•  β-lactamase produc8on
• 
• 
• 
• 
• 
• 
• 

Penicillinase
Broad Spectrum Penicillinase
Extended Spectrum β lactamase (ESβL)
Inhibitor Resistant TEM
Cefuroximase
Low or High Level Cephalosporinase
Carbapenemase

The 7
Enterobacteriaceae
groups

β-lactams Natural
Resistance Group
•  Enterobacteriaceae are divided in 7 groups based on
their Natural resistance or wild-type phenotype
•  Four markers are use to iden8fy the natural resistance
of Enterobacteriaceae
• 
• 
• 
• 

Aminopenicillin (Ampicillin)
Aminopenicillin + Inhibitor (Ampicillin + Clavulanic acid)
Carboxypenicillin (Carbenicillin/Ticarcillin)
Cephalosporin 1st Gen (CefaloJn)

β-lactams Natural
Resistance Group

•  Group 0: No β-lactamase produc8on
•  Salmonella spp, Proteus mirabilis

•  Group 0: No β-lactamase producJon

Antibiotic

Result

•  Group 1: Very Low Level Cephalosporinase

Aminopenicillin

S

Aminopenicillin + Clav. ac

S

•  Group 2: Low Level Penicillinase

Carboxypenicillin

S

Carboxypenicillin + Clav. Ac

S

Ureidopenicillin

S

Ureidopenicillin + Tazobactam

S

Cephalosporin 1st Gen

S

•  Group 5: Cefuroximase

Cephalosporin 2nd Gen

S

Cefoxitine

S

•  Group 6: Low Level Extended Spectrum β-lactamases

Cephalosporin 3rd Gen

•  Group 3: Low level Cephalosporinase
•  Group 4: Low Level Penicillinase + Low level Cephalosporinase

Cephalosporin
Carbapenem

4th

Gen

S
S
S

β-lactams Natural
Resistance Group

•  Group 1: Very Low Level Cephalosporinase
•  E. coli and Shigella spp
Antibiotic

Result

Aminopenicillin

S/I

Aminopenicillin + Clav. ac

S/I

Carboxypenicillin

S

Carboxypenicillin + Clav. Ac

S

Ureidopenicillin

S

Ureidopenicillin + Tazobactam

S

Cephalosporin 1st Gen

S/I

Cephalosporin 2nd Gen

S

Cefoxitine

S

Cephalosporin 3rd Gen

S

Cephalosporin

4th

Gen

S

Carbapenem

S

β-lactams Natural
Resistance Group
•  Group 3: Low level Cephalosporinase
•  E. cloacae, E. aerogenes, Serra=a marcescens, C. freundii, P. stuar=i, P. re?geri,
M. morganii, P. agglomerans
Antibiotic
Result
Aminopenicillin

R

Aminopenicillin + Clav. ac

R

Carboxypenicillin

S

Carboxypenicillin + Clav. Ac

S

Ureidopenicillin

S

Ureidopenicillin + Tazobactam

S

Cephalosporin 1st Gen

R

Cephalosporin 2nd Gen

R/I/S

Cefoxitine

R/I/S

Cephalosporin 3rd Gen

S

Cephalosporin 4th Gen

S

Carbapenem

S

•  Group 5: Cefuroximase

β-lactams Natural
Resistance Group

•  P. vulgaris and P. penneri
Antibiotic

Enterobacteriaceae
β-lactams Natural
Resistance Group
•  Group 2: Low Level Penicillinase
•  K.pneumoniae, K. oxytoca, Citrobacter koseri, C. amalona=cus and E. hermanii
Antibiotic
Aminopenicillin

Result
R

Aminopenicillin + Clav. ac

S

Carboxypenicillin

R

Carboxypenicillin + Clav. Ac
Ureidopenicillin

S
S(-> I)

Ureidopenicillin + Tazobactam

S

Cephalosporin 1st Gen

S

Cephalosporin 2nd Gen

S

Cefoxitine

S

Cephalosporin 3rd Gen

S

Cephalosporin 4th Gen

S

Carbapenem

S

β-lactams Natural
Resistance Group
•  Group 4: Low Level Penicillinase + Low level Cephalosporinase
•  Yersinia enterocoli=ca and S.fon=cola
Antibiotic

Result

Aminopenicillin

R

Aminopenicillin + Clav. ac

R

Carboxypenicillin

R

Carboxypenicillin + Clav. Ac
Ureidopenicillin

S
S(->I)

Ureidopenicillin + Tazobactam

S

Cephalosporin 1st Gen

R

Cephalosporin

2nd

Gen

S

Cefoxitine

S

Cephalosporin 3rd Gen

S

Cephalosporin 4th Gen

S

Carbapenem

S

β-lactams Natural
Resistance Group

•  Group 6: Chromosomic Low level ESβL

•  Kluyvera spp, C. sedlakii and E. persicinia
Result

Antibiotic

Result

Aminopenicillin

R

Aminopenicillin

Aminopenicillin + Clav. ac

S

Aminopenicillin + Clav. ac

R/I
S/I

Carboxypenicillin

S

Carboxypenicillin

R/I

Carboxypenicillin + Clav. Ac

S

Carboxypenicillin + Clav. Ac

S

Ureidopenicillin

S

Ureidopenicillin

S/I

Ureidopenicillin + Tazobactam

S

Ureidopenicillin + Tazobactam

Cephalosporin 1st Gen

R

Cephalosporin 1st Gen

R/I

Cephalosporin 2nd Gen

R

Cephalosporin 2nd Gen

R/I

Cefoxitine

S

Cefoxitine

Cephalosporin 3rd Gen

S

Cephalosporin 3rd Gen

S (->I)

Cephalosporin 4th Gen

S

Cephalosporin 4th Gen

S (->I)

Carbapenem

S

Carbapenem

S

S

S

Resistance via βlactamase Synthesis

β-lactams Natural
Resistance Group
•  Summary
0

1

2

3

4

5

6

Aminopenicillin

Antibiotic

S

S/I

R

R

R

R

R/I

Aminopenicillin + Clav. ac

S

S/I

S

R

R

S

S/I

Carboxypenicillin

S

S

R

S

R

S

R/I

Carboxypenicillin + Clav. Ac

S

S

S

S

S

S

S

Ureidopenicillin

S

S

S(->I)

S

S (->I)

S

S/I

Ureidopenicillin + Tazobactam

S

S

S

S

S

S

S

Cephalosporin 1st Gen

S

S/I

S

R

R

R

R/I

Cephalosporin 2nd Gen

S

S

S

R/I/S

S

R

R/I

Cefoxitine

S

S

S

R/I/S

S

S

S

S

S

S

S

S

S

S (->I)

S

S

S

S

S

S

S (->I)

Cephalosporin 3rd Gen
Cephalosporin

4th

Gen

Carbapenem

S

S

S

S

S

S

S

β-lactams Acquired
Resistance

•  Group 0

•  No Chromosomic resistance => no mutaJon possible
•  Only plasmidic resistance => Pase, IRT, ESβL, HLCase
Antibiotic

•  β-lactamase synthesis is very common for enterobacteriaceae
•  Several hundred different enzymes have been described

Plasmidic

Chromosomic
Cephalosporinase **

Penicillinase*

Broad
Spectrum
Penicillinase

Constitutive
Constitutive

Cephamycinase
Cephalsoporinase

Inducible
Extended
Spectrum
β lactamase

High Level

High level

Inhibitor
Resistant TEM

Natural
Acquired

* : Pase (group 2, 4), ESβL (group 6)
** : Case constitutive (group 1, 4), Inducible (group 3)
Cefuroximase (group 5)

β-lactams Acquired
Resistance

•  Group 1

•  Wild = Case Chromosomic resistance => HLCase (mutaJon)
•  Plasmidic resistance => Pase, IRT, ESβL, HLCase

Wild

Pase

IRT

ESβL

HLCase

Wild

HLCase

Pase

IRT

Aminopenicillin

S

R

R

R

R

Aminopenicillin

S/I

R

R

R

R

Aminopenicillin + Clav. ac

S

S/I/R

R

S/I/R

R

Aminopenicillin + Clav. ac

S/I

R

S/I/R

R

S/I/R

Carboxypenicillin

S

R

R

R

R

Carboxypenicillin

S

R

R

R

R

Carboxypenicillin + Clav. Ac

S

S/I

R

S/I/R

R

Carboxypenicillin + Clav. Ac

S

R

S/I

R

S/I/R

Ureidopenicillin

S

I/R

I/R

R

R

Ureidopenicillin

S

R

I/R

I/R

R

Ureidopenicillin + Tazobactam

S

S/I

I/R

S/I

R

Ureidopenicillin + Tazobactam

S

I/R

S/I

I/R

S/I

Cephalosporin 1st Gen

S

S/I/R

S

R

R

Cephalosporin 1st Gen

S/I

R

S/I/R

S/I

R

Cephalosporin 2nd Gen

S

S

S

R

I/R

Cephalosporin 2nd Gen

S

I/R

S

S

R

Cefoxitine

S

S

S

S

I/R

Cefoxitine

S

I/R

S

S

S

Cephalosporin

3rd

Gen

S

S

S

S ->I/R

I/R

Cephalosporin

4th

Gen

S

S

S

S ->I/R

S

S

S

S

Carbapenem

•  Group 2

Antibiotic

ESβL

Cephalosporin

3rd

Gen

S

I/R

S

S

I/R

S

Cephalosporin

4th

Gen

S

S

S

S

I/R

S

Carbapenem

S

S

S

S

S

β-lactams Acquired
Resistance

•  Wild = Pase Chromosomic resistance => No mutaJon known
•  Plasmidic resistance => HLPase, IRT, ESβL, HLCase

•  Group 3

β-lactams Acquired
Resistance

•  Wild = Case Chromosomic resistance => HLCase (mutaJon)
•  Plasmidic resistance => HLPase, IRT, ESβL

Wild

HLPase

IRT

ESβL

HLCase

Wild

HLCase

HLPase

IRT

ESβL

Aminopenicillin

R

R

R

R

R

Aminopenicillin

R

R

R

R

R

Aminopenicillin + Clav. ac

S

S/I/R

R

S/I/R

R

Aminopenicillin + Clav. ac

R

R

R

R

R

Carboxypenicillin

R

R

R

R

R

Carboxypenicillin

S

R

R

R

R

Carboxypenicillin + Clav. Ac

S

S/I

R

S/I/R

R

Carboxypenicillin + Clav. Ac

S

R

S/I

R

S/I/R

Ureidopenicillin

S

I/R

R

R

R

Ureidopenicillin

S

R

I/R

I/R

R

Ureidopenicillin + Tazobactam

S

S/I

I/R

S/I

R/I

Ureidopenicillin + Tazobactam

S

R/I

S/I

I

S/I

Cephalosporin 1st Gen

S

S/I/R

S

R

R

Cephalosporin 1st Gen

R

R

R

R

R

Cephalosporin 2nd Gen

S

S

S

R

R/I

Cephalosporin 2nd Gen

R/I/S

R/I

R/I/S

R/I/S

R

Cefoxitine

S

S

S

S

R/I

Cefoxitine

R/I/S

R/I

R/I/S

R/I/S

R/I/S

Cephalosporin 3rd Gen

S

S

S

I/R

R/I

Cephalosporin 3rd Gen

S

I/R

S

S

I/R

Cephalosporin 4th Gen

S

S

S

I/R

S

Cephalosporin 4th Gen

S

S

S

S

I/R

Carbapenem

S

S

S

S

S

Carbapenem

S

S

S

S

S

Antibiotic

Antibiotic

β-lactams Acquired
Resistance

•  Group 4

•  Wild = Pase + Case Chromosomic resistance => No mutaJon known
•  Plasmidic resistance => none as of today

β-lactams Acquired
Resistance

•  Group 5

•  Wild = Cefuroximase Chromosomic resistance => HLCase (mutaJon)
•  Plasmidic resistance => HLPase, IRT, ESβL
Wild

HLCase

HLPase

IRT

ESβL

Aminopenicillin

R

Aminopenicillin

R

R

R

R

R

Aminopenicillin + Clav. ac

R

Aminopenicillin + Clav. ac

S

R

R

R

R

Carboxypenicillin

R

Carboxypenicillin

S

R

R

R

R

Carboxypenicillin + Clav. Ac

S

Carboxypenicillin + Clav. Ac

S

R

S/I

R

S/I/R

Ureidopenicillin

S

R

I/R

I/R

R

Ureidopenicillin + Tazobactam

S

R/I

S/I

I

S/I
R

Antibiotic

Antibiotic

Wild

S/I

Ureidopenicillin

S

Ureidopenicillin + Tazobactam
Cephalosporin 1st Gen

R

Cephalosporin

Gen

R

R

R

R

Cephalosporin 2nd Gen

S

Cephalosporin 2nd Gen

R

R

R

R

R

Cefoxitine

S

Cefoxitine

S

R/I

R/I/S

R/I/S

R/I/S

1st

Cephalosporin 3rd Gen

S

Cephalosporin

Gen

S

I/R

S

S

I/R

Cephalosporin 4th Gen

S

Cephalosporin 4th Gen

S

S

S

S

I/R

Carbapenem

S

Carbapenem

S

S

S

S

S

β-lactams Acquired
Resistance
•  Other caracteris8c phenotypes

3rd

β-lactams Acquired Resistance

•  HyperOXY => HyperproducJon of natural penicillinase for K. oxytoca
Wild

HyperOXY

Aminopenicillin

Antibiotic

R

R

Aminopenicillin + Clav. ac

S

R

Carboxypenicillin

R

R

Carboxypenicillin + Clav. Ac

S

R

Ureidopenicillin

S

R

Ureidopenicillin + Tazobactam

S

R

Gen

S

R

Cephalosporin 2nd Gen

S

R

Cefoxitine

S

S

Cephalosporin 3rd Gen

S

S

Cephalosporin 4th Gen

S

S

Carbapenem

S

S

Cephalosporin

1st

• Other caracteris8c phenotypes
•  Resistance to Carbapenem
•  Impermeability
•  Carbapenemase

β-lactams Acquired
Resistance

β-lactams Acquired
Resistance

•  Carbapenemase
Antibiotic

Group 0
Chromosomic
Class A

Plasmidic
Class A

Plasmidic
Class B

Aminopenicillin

R

R

R

Aminopenicillin + Clav. ac

R

S/I/R

R

Carboxypenicillin

I/R

R

R

Carboxypenicillin + Clav. Ac

I/R

S/I/R

R

Ureidopenicillin

S/I

R

I/R

Ureidopenicillin + Tazobactam

S

S/I/R

I/R

Cephalosporin 1st Gen

R

R

R

Cephalosporin 2nd Gen

R

R/I

R/I

Cefoxitine

I/R

R/I

R/I

Cephalosporin 3rd Gen

S

R/I

Aztreonam

S

R/I

S

Cephalosporin 4th Gen

S

R/I

R//I

Carbapenem

S

R/I

R/I

Group 1

Group 2
HyperOXY

HLCase

Pase, IRT,
HLCase, ESβL

Pase, IRT,
HLCase, ESβL

Pase, IRT,
HLCase, ESβL

LLCase

Group 4

Group 3

Pase

Group 5
HLCase

HLCase
Pase, IRT, ESβL

Pase, IRT, ESβL

R/I

Case

Pase + Case

Wild type in green, Acquired resistance in red

Cefuroximasease

Aminoglycoside
• Known Mechanisms of Resistance
•  Enzyme producJon
•  Impermeability
•  Efflux
•  Target ModificaJon

Aminoglycos
idase

Enzym

Phenotype

GEN

TOB

NET

AKN

KAN

APH 3’

K

S

S

S

S

R

AAC 3I

G

R

S

S

S

S

AAC 3II

KGTN

R

R

R

S

R

AAC 6'

KTNA

S

R

R

R

R

AAC 2'

GTN

R

R

R

S

S

ANT 2"

KGT

R

R

S

S

R

Impossible

S

S

S

R

S

Impossible

S

S

R

S

S

Impossible

S

R

S

S

S

If Net=R thus Tob=R

NB:
* AAC 6': Often associated with an ESBL, except for S. marcescens
* P. stuartii has an AAC 2' in the wild state

Quinolones

Tetracyclines

• Known Mechanisms of Resistance

• Known Mechanisms of Resistance

•  Target modificaJon
•  Efflux
•  Impermeability

•  Efflux
•  Target ModificaJon

Chapter 6.1
The Enterobacteriaceae

Other antibiotics
•  Chloramphenicol
•  Enzyme producJon, Efflux, Impermeability (rare)

•  Fosfomycin
•  Natural resistance for M. morganii
•  Target ModificaJon

•  Polymyxines
•  Natural resistance for:
•  Proteeae (Proteus, Providencia, Morganella),
•  S.marscescens,
•  Y. pseudotuberculosis

Susceptibility testing range

AST Enterobacteriaceae: ATB UR 5

Enterobacteriaceae ( manual techniques): bioMerieux solutions

•  For urinary Enterobacteriaceae

Gram (-) ox (-) Bacilli

•  Use of urinary anJbioJcs:

• 
• 
• 
• 

Identification

Quinolones 1st and 2nd gen
Fosfomycin
Furanes
Sulfonamides

•  Excellent detec8on of resistance mechanisms:
•  Use of Markers to iden8fy:

Urine:

•  Penicillinase
•  Cephalosporinase
•  Extended Spectrum Beta Lactamase ...

Other specimens:

Urine set

Regular set

For urinary cocci (Streptococci, Enterococci

and Staphylococci ):

use sets of STAPH or STREP or ENTEROC.

ATB UR 5: characteristics

AST Enterobacteriaceae: ATB G- 5

Code

ANTIBIOTICS mg/l

Code

ANTIBIOTICS

mg/l

AMO

Amoxicillin

8-16

FUR

Nitrofurantoin

32

AMC

Amox. + Clav.

8-16

NAL

Nalidixic acid

16

PIP

Piperacillin

16-64

NOR

Norfloxacin

4-8

CFT

Cefalotin

8-16

CIP

Ciprofloxacin

1-2

CXM

Cefuroxim

4

FOS

Fosfomycin

64

CXT

Cefoxitin

8

TSU

Cotrimoxazol

2

CTX

Cefotaxim

8-32

CAZ

Ceftazidim

8-16

CAZ 1

Ceftazidim 1

1

IMI

Imipenem

4

TOB

Tobramycin

4

AKN

Amikacin

16

GEN

Gentamicin

4

NET

Netilimicin

8

•  For non-urinary Enterobacteriaceae
•  blood culture, stools ...

•  Excellent detec8on of resistance mechanisms:
•  Use of Markers to iden8fy:
•  Penicillinase
•  Cephalosporinase
•  Extended Spectrum Beta Lactamase ...

•  ATB G- 5: 21 an8bio8cs (including 15 b-lactams)

rapid ATB E4: multi drug resistant GNB

ATB G- 5: characteristics
Code

ANTIBIOTICS

mg/l

AMO

Amoxicillin

8-16

TSU

Code

Cotrimoxazol

ANTIBIOTICS mg/l
2

AMC

Amox. + Clav.

8-16

TOB

Tobramycin

4

TIC

Ticarcillin

16

AKN

Amikacin

TCC

Tic + Clav

16

GEN

PIC

Piperacillin

16

TZP

Piper Tazo

16

CFT

Cefalotin

8

CXM

Cefuroxim

CXT
CTX

Code

ANTIBIOTICS

mg/l

Code

ANTIBIOTICS

mg/l

AMP

Ampicillin

8

FEP

Cefepim

8

AMC

Amox. + Clav.

8

GEN

Gentamicin

4

16

TIC

Ticarcillin

16

TOB

Tobramycin

4

Gentamicin

4

TCC

Tic.+ Calv.

16

NET

Netilmicin

8

NET

Netilimicin

8

PIC

Piperacillin

16

AKN

Amikacin

16

CIP

Ciprofloxacin

1-2

TZP

Piper. + Tazo.

16

TET

Tetracyclin

4

IMI

Imipenem

4

CMP

Chloramphenicol

8

CFT

Cefalotin

8

TSU

Cotrimoxazole

Cefoxitin

8

CFZ

Cefazolin

8

NAL

Nalidixic ac

16

Cefotaxim

8-32

CXT

Cefoxitin

8

NOR

Norfloxacin

4

CAZ

Ceftazidim

8-16

CMD

Cefamandol

8

OFL

Ofloxacin

2

CAZ1

Ceftazidim 1

1

CXO

Cefuroxim Axetil

4

CIP

Ciprofloxacin

1

FEP

Cefepim

8-16

CXM

Cefuroxim

8

LVX

Levofloxacin

2

MERO

Meropenem

4

CRO

Ceftriaxon

8

FOS

Fosfomycin

64

IMI

Imipenem

CAZ

Ceftazidime

8

FUR

Nitrofurantoin

32

4-8

8
2/38

Q&A