Are GES carbapenemases underdiagnosed? An allelic discrimination assay for their accurate detection and differentiation.

GES (Guiana Extended Spectrum) carbapenemases belong to "minor class A carbapenemases" and its prevalence could be underestimated due to the lack of specific tests. The aim of this study was to develop an easy PCR method to differentiate between GES ß-lactamases with or without carbapenemase activity, based on an allelic discrimination system of SNPs that encode E104K and G170S mutations, without need of sequencing. Two pair of primers and Affinity Plus probes, labeled with different fluorophores; FAM/IBFQ and YAK/IBFQ, were designed for each one of the SNPs. This allelic discrimination assay allows to detect in real time the presence of all type of GES- ß-lactamases, being able to differentiate between carbapenemases and extended-spectrum ß-lactamase (ESBL), through a quick PCR test that avoid costly sequencing approaches and could help to decrease the current underdiagnosis of minor carbapenemases that scape of phenotypic screenings.

Mobile genetic elements related to the diffusion of plasmid-mediated AmpC ß-lactamases or carbapenemases from Enterobacteriaceae: findings from a multicenter study in Spain.

We examined the genetic context of 74 acquired ampC genes and 17 carbapenemase genes from 85 of 640 Enterobacteriaceae isolates collected in 2009. Using S1 pulsed-field gel electrophoresis and Southern hybridization, 37 of 74 bla AmpC genes were located on large plasmids of different sizes belonging to six incompatibility groups. We used sequencing and PCR mapping to investigate the regions flanking the acquired ampC genes. The bla CMY-2-like genes were associated with ISEcp1; the surrounding bla DHA genes were similar to Klebsiella pneumoniae plasmid pTN60013 associated with IS26 and the psp and sap operons; and the bla ACC-1 genes were associated with IS26 elements inserted into ISEcp1. All of the carbapenemase genes (bla VIM-1, bla IMP-22, and bla IMP-28) were located in class 1 integrons. Therefore, although plasmids are the main cause of the rapid dissemination of ampC genes among Enterobacteriaceae, we need to be aware that other mobile genetic elements, such as insertion sequences, transposons, or integrons, can be involved in the mobilization of these genes of chromosomal origin. Additionally, three new integrons (In846 to In848) are described in this study.

Novel mechanisms of resistance to ß-lactam antibiotics in Haemophilus parainfluenzae: ß-lactamase-negative ampicillin resistance and inhibitor-resistant TEM ß-lactamases.

OBJECTIVES: To determine the mechanisms of resistance to ß-lactam antibiotics in clinical isolates of Haemophilus parainfluenzae. METHODS: Twenty clinical isolates of H. parainfluenzae with decreased susceptibility to aminopenicillins were examined and compared with a control group of 20 fully susceptible isolates. In this collection, the presence of amino acid substitutions in the transpeptidase domain of penicillin-binding protein 3 (PBP3), ß-lactamase production and the surrounding genetic regions of blaTEM genes in selected isolates were analysed. RESULTS: Of the 20 non-susceptible isolates, 8 produced TEM ß-lactamase (gBLPAR), 7 had mutations in the transpeptidase domain of the ftsI gene related to decreased susceptibility to ß-lactams (gBLNAR) and 5 had both resistance mechanisms (gBLPACR). No resistance mechanisms were identified in the susceptible control group (gBLNAS). gBLNAR isolates had MIC90 values 4- to 16-fold higher than gBLNAS isolates for ampicillin, amoxicillin/clavulanic acid, cefuroxime, cefotaxime and cefixime, and the most common PBP3 mutation was Asn526Ser. The additional Ser385Thr substitution (III-like group) may confer decreased susceptibility to cefotaxime, cefixime and aztreonam, as in Haemophilus influenzae. In two ß-lactamase-positive isolates without PBP3 mutations, the inhibitor-resistant TEM (IRT) ß-lactamases TEM-34 and the novel TEM-182 were detected and carried by a TnA transposon of the Tn2 type; both isolates had an amoxicillin/clavulanic acid MIC of ≥8 mg/L. The TnA transposons of two ß-lactamase-positive isolates (TEM-1 and TEM-182) were inserted between the tfc20 and tfc21 genes, typically associated with integrative and conjugative elements in Haemophilus spp.; the TEM-34 IRT ß-lactamase was harboured in a ∼5.5 kb plasmid. CONCLUSIONS: Clinical isolates of H. parainfluenzae express a variety of aminopenicillin resistance mechanisms, either alone or in combination, including PBP3 modifications, blaTEM-1 and IRT ß-lactamase production.

Prevalence and molecular epidemiology of acquired AmpC ß-lactamases and carbapenemases in Enterobacteriaceae isolates from 35 hospitals in Spain.

The purpose of this investigation was to determine the prevalence of plasmid-mediated AmpC (pAmpC) and carbapenemases in Enterobacteriaceae collected from 35 hospitals in Spain and to establish their epidemiological relationships. We conducted a prospective multi-centre study on pAmpC- or carbapenemase-producing Enterobacteriaceae isolates from clinical samples collected from February to July 2009. The strains suspected to carry pAmpC were resistant or showed intermediate susceptibility to co-amoxiclav and second- or third-generation cephalosporins. Strains suspected to carry a carbapenemase were selected because they showed a minimum inhibitory concentration (MIC) to imipenem >1 mg/L. Polymerase chain reaction (PCR) and a sequencing strategy were used to characterise the enzymes. The clonal relationships between isolates was analysed by pulsed field gel electrophoresis (PFGE). Among 100,132 Enterobacteriaceae isolates collected, 1,654 were compatible with the production of pAmpC or carbapenemases. We found a prevalence of 0.64 % of pAmpC (n = 635) and 0.04 % of carbapenemases (n = 43). The most prevalent pAmpC enzymes were CMY-type (78.3 %), DHA-type (19.5 %), ACC-type (1.6 %) and FOX-type (0.6 %). The CMY-type was the most frequent in Escherichia coli and Proteus mirabilis species, whereas the DHA-type was mainly found in Klebsiella spp. The enzymes involved in carbapenem resistance were VIM-1, IMP-22 and the new IMP-28. Nine new bla genes were described: bla (CMY-54), bla (CMY-55), bla (CMY-56), bla (CMY-57), bla (CMY-96), bla (DHA-6), bla (DHA-7), bla (FOX-8) and bla (IMP-28). The prevalence of pAmpC or carbapenemases found is not negligible. The CMY-types were the predominant pAmpC, whereas the VIM or IMP enzymes were the predominant carbapenemases. Furthermore, we observed a great genetic diversity among pAmpC-producing strains and a close clonal relationship between carbapenemase-producing strains.

Evaluation of the EUCAST disc diffusion susceptibility testing method for Haemophilus influenzae based on the resistance mechanism to ß-lactam antibiotics.

OBJECTIVES: EUCAST developed an antibiotic susceptibility testing method for Haemophilus influenzae. We assessed the EUCAST testing method and EUCAST clinical breakpoints and newly proposed epidemiological cut-off values against H. influenzae clinical isolates with known molecular mechanisms of resistance to ß-lactam antibiotics. METHODS: In total, 89 clinical isolates were used: 30 were ß-lactamase negative with PBP3 mutations (gBLNAR), 20 were ß-lactamase positive without PBP3 mutations (gBLPAR), 15 were ß-lactamase positive with PBP3 mutations (gBLPACR), and 24 were ß-lactamase negative without resistance mechanism (gBLNAS). Twelve different ß-lactam antibiotics and disc charges were tested. RESULTS: None of the discs tested fully separated between gBLNAS and gBLNAR populations. According to EUCAST clinical zone diameter breakpoints, overall the best values of sensitivity and specificity were obtained with cefuroxime 30 µg and amoxicillin/clavulanic acid 2/1 µg discs for detection of gBLNAR and gBLPACR populations, although a previous ß-lactamase test was needed. Other antibiotic discs could be suitable for epidemiological purposes, such us penicillin 10 U for separating gBLNAR isolates and cefoxitin 30 µg for detection of gBLPACR isolates. By Etest using the EUCAST method, the EUCAST MIC clinical breakpoints for ampicillin and amoxicillin/clavulanic acid showed high specificity, but low sensitivity, for the detection of genotypes with mutations in PBP3. CONCLUSIONS: The main genotypes of ß-lactam-resistant H. influenzae can be separated by using the EUCAST disc diffusion method, although it should be noted that overlapping between populations with and without PBP3 mutations is common.

Susceptibility of 228 non-fermenting gram-negative rods to tigecycline and six other antimicrobial drugs.

The aim of the study was to determine the in vitro activity of tigecycline and 6 other antimicrobial drugs used in clinical practice against 228 clinical isolates of nonfermenting Gram-negative rods (NFGNRs) including Acinetobacter spp., Stenotrophomonas maltophilia, and Pseudomonas aeruginosa. Minimum inhibitory concentrations (MICs) were determined according to the recommendations of the Clinical and laboratory Standards institute. for tigecycline, we used the criteria approved by the fDA. Almost 50% of the clinical isolates of Acinetobacter spp. were resistant to piperacillin/tazobactam, ciprofloxacin, gentamicin, and ceftazidime. Strains of this microorganism were more susceptible to imipenem, and even more susceptible to colistin and tigecycline; no strains were resistant to tigecycline. Stenotrophomonas maltophilia showed even greater resistance to the drugs tested. Thus, all strains were resistant to imipenem and a large percentage (82.6%) were resistant to piperacillin/tazobactam. Resistance to the other agents tested was also high, with the exception of tigecycline, with only 3 resistant strains (MIC >8 microg/ml). Tigecycline, on the other hand, was scarcely active against Pseudomonas aeruginosa, which bears efflux pump systems such as MexXy-OprM. Almost 90% of strains were resistant to ciprofloxacin; only 8% were resistant to gentamicin; over half were colistin-intermediate or -resistant, and finally, approximately half of the strains were susceptible to the 3 beta-lactams studied. In conclusion, NFGNRs present variable susceptibility patterns, although they are generally highly resistant to antimicrobial agents including those considered more specific. Tigecycline, which showed good activity against most of the strains examined, broadens the spectrum of drugs available for the treatment of infections caused by these complex microorganisms.

Limits on the time variation of the electromagnetic fine-structure constant in the low energy limit from absorption lines in the spectra of distant quasars.

We present the results of a detailed many-multiplet analysis performed on a new sample of Mg ii systems observed in high quality quasar spectra obtained using the Very Large Telescope. The weighted mean value of the variation in alpha derived from our analysis over the redshift range 0.4

Significant increase in the prevalence of erythromycin-resistant, clindamycin- and miocamycin-susceptible (M phenotype) Streptococcus pyogenes in Spain.

In 1998 we conducted a multicentre study in Spain on the susceptibility of Streptococcus pyogenes isolates to different 14-, 15- and 16-membered macrolides and clindamycin, in which the number of strains examined was proportional to the number of inhabitants in each geographical area. The aim of the present work was to re-examine the antimicrobial susceptibility of S. pyogenes in 2001, using the same methodology and centres as in 1998, to determine the different susceptibility phenotypes to macrolides-lincosamides, and to compare the results from the 2 years by statistical tests. A total of 529 unique isolates of S. pyogenes, collected in 21 laboratories, were studied. Throat swabs provided 417 isolates (78.8%), and the remaining 112 were from other sources. Four hundred and thirty-five (82.2%) were isolated from children and 94 (17.8%) from adults. One hundred and fifty-seven (29.7%) of the isolates were resistant to erythromycin and azithromycin, whereas resistance to miocamycin, a 16-membered macrolide, was 1.5%. The prevalence of resistance to clindamycin was 1.3%. The majority (98.7%) of the 157 erythromycin-resistant strains presented the M phenotype. When we compared the results obtained in 1998 and 2001, we observed a statistically significant increase in resistance to erythromycin and azithromycin (P = 0.02, chi(2) test), but not to clindamycin or miocamycin (P = 0.47, chi(2) test with Yates' correction). The significant increase in the prevalence of resistance to some macrolides of S. pyogenes in Spain underscores the need for continuous surveillance of antimicrobial resistance in this species.

Susceptibility of strains of Streptococcus agalactiae to macrolides and lincosamides, phenotype patterns and resistance genes.

The Group B streptococcus (Streptococcus agalactiae) is a pathogen of increasing importance in human disease. We therefore studied the susceptibility of clinical isolates of S. agalactiae to penicillin G, erythromycin, azithromycin and clindamycin using National Committee for Clinical Laboratory Standards methodology, and we also determined the phenotypes of macrolide-lincosamide susceptibility and the resistance genes implicated in a group of selected isolates of the different phenotypes. We used 221 isolates collected between 1997 and 1999 in two Health Authority Areas in Móstoles and Granada, Spain. The minimal concentration for 90% inhibition (MIC90) for penicillin G was 0.12 mg/L and all the isolates tested were susceptible. One hundred and eighty-five (83.7%) were susceptible to erythromycin and azithromycin and 191 (86.4%) were susceptible to miocamycin and clindamycin. Twenty-three isolates (10.4%) had a constitutive MLSB phenotype, seven (3.2%) an inducible phenotype, and six (2.7%) an M phenotype. All except one of the MLSB phenotype isolates tested (n = 23) carried erm genes; in two strains with the mef (A) gene, all the M phenotype (n = 6) isolates tested carried mef genes, while erm and mef (A) genes were absent in all the macrolide-lincosamide-susceptible (n = 12) isolates tested. In our environment, resistance to macrolide and lincosamide in S. agalactiae was present in 10-16% of the isolates. The majority of resistant strains had the MLSB phenotype.

[Significant bacteremias by Corynebacterium amycolatum: an emergent pathogen]. / Bacteriemias significativas por Corynebacterium amycolatum: un patógeno emergente.

BACKGROUND: Corynebacterium sp. is an extremely varied genus which includes little known species and of which only Corynebacterium diphteriae, Corynebacterium urealyticum and Corynebacterium jeikeium are considered indisputable pathogens. Other species, such as C. amycolatum are at present being reconsidered as causative agents in infectious pathologies, partly on account of our greater aquaintance and improved identification techniques for these microorganisms and partly on account of the growing number of immunocompromised patients in whom all their pathogenic capacity is usually able to develope. We present 3 cases of significant bacteremia by C. amycolatum. METHODS: Bacterial isoliations from blood culture were obtained using the Vital Systems. Identification was performed by means of Gran stain, colony morphology, the results of numerous biochemical tests (including the Api Coryne systems), the behaviour of the strains against the vibriostatic agent O/129 and the antibiotic susceptibility pattern obtained with the E-test. RESULTS: The three isolates of C. amycolatum were obtained from patients after a lenghtly hospitalization, multi-instrumentation and who had severe underlying disease. All three presented with concomitant isolates of C. amycolatum from other sites: sputum, wound and catheter respectively, which could explain the origin of the bacteremia. Colony morphology, antibiotic susceptibility patterns, resistance to the vibriostatic agent O/129 and the results of the biochemical test carried out were similar to those previously describe in the literature. CONCLUSIONS: C. amycolatum should be born in mind as a agent responsable for significant and severe pathology in this type of patient. In addition, it as certain specific characteristics which assits in its identification in the normal micr

Bacteremia by Dermabacter hominis, a rare pathogen.

Dermabacter hominis is a gram-positive, catalase-positive, glucose-fermenting rod, which, as it grows forms small greyish-white colonies with a characteristic pungent odor. Previously known as coryneform Centers for Disease Control and Prevention groups 3 and 5, it was catalogued as D. hominis in 1994. Various strains isolated in blood cultures, abscesses, or wounds in the 1970s were retrospectively characterized in referral centers as D. hominis. In this report we describe two patients with severe underlying pathology who developed bacteremias by D. hominis within the context of their clinical pictures.

Prevalence of human immunodeficiency virus type 1 (HIV-1) non-B subtypes in foreigners living in Madrid, Spain, and comparison of the performances of the AMPLICOR HIV-1 MONITOR version 1.0 and the new automated version 1.5.

Plasma specimens collected in 1999 from 32 human immunodeficiency virus type 1 (HIV-1)-infected foreigners living in Madrid, Spain, were examined for the presence of non-B subtypes. Furthermore, plasma viremia was quantified using two different AMPLICOR HIV-1 MONITOR tests, version 1.0 and the new upgraded and automated version 1.5 (COBAS). Most patients came from Africa, where they most likely had acquired HIV-1 infection through sexual contact. HIV-1 genetic subtyping was based on the phylogenetic analysis of the protease gene. Twenty-two subtype B, six subtype G, two subtype C, one subtype A, and one D subtype infection were found. Overall, non-B subtypes represented 31.25% of the study population. Irrespective of the HIV-1 variant, viral load values above the detection limit (200 HIV RNA copies/ml) increased from 56.2 to 71.9% for results obtained using MONITOR version 1.0 and COBAS, respectively. Moreover, significant differences in viral load values (>0.5 logs) were recognized in up to 37.5% of samples. In summary, COBAS seemed to be more reliable for testing plasma viral load in HIV-infected immigrants living in Spain, one third of whom carried non-B subtypes.

High prevalence of erythromycin-resistant, clindamycin/miocamycin-susceptible (M phenotype) Streptococcus pyogenes: results of a Spanish multicentre study in 1998. Spanish Group for the Study of Infection in the Primary Health Care Setting.

Using the standard agar dilution method we studied the prevalence of susceptibility to 14-, 15- and 16-membered ring macrolides and clindamycin in Streptococcus pyogenes isolated in 1998 from 21 laboratories in Spain. The number of strains admitted to the study was proportional to the numbers of inhabitants in each geographical area. We also determined the susceptibility phenotypes and the genetic basis for the antibiotic resistance. A total of 486 unduplicated isolates of S. pyogenes were used. Throat swab samples provided 359 (73.9%) isolates, and the remaining 127 isolates were from other sources. One hundred and fourteen (23.5%) isolates were resistant to erythromycin, a 14-membered ring macrolide, and azithromycin, a 15-membered macrolide, whereas only 1% of isolates were resistant to miocamycin, a 16-membered macrolide and 0.8% were resistant to clindamycin. Of the 114 erythromycin-resistant strains, 109 (95.6%) were susceptible to clindamycin and miocamycin. Since induction with erythromycin did not modify susceptibility to the latter antibiotics, these 109 strains were considered to have the M phenotype. Twenty strains with the M phenotype, one per laboratory, were assayed by PCR and showed the presence of the mef gene, which is responsible for antibiotic resistance by an efflux system. Among comparable studies covering entire countries, ours demonstrates one of the highest rates of S. pyogenes erythromycin resistance and clindamycin and miocamycin susceptibility in the world. Strains with the M phenotype account for the great majority of these isolates.

High prevalence of resistance to clindamycin in Bacteroides fragilis group isolates.

Susceptibility to anti-anaerobic agents in the Bacteroides fragilis group varies according to the geographical region studied. In recent years there has been a reduction in the susceptibility of such isolates, particularly to antibiotics such as clindamycin and cefoxitin. The antimicrobial susceptibilities of 100 isolates of the B. fragilis group isolated in 1998 from faecal samples of healthy people to clindamycin and five other anti-anaerobic agents were determined. Meropenem, metronidazole and trovafloxacin showed excellent activity against all isolates. The efficacy of cefoxitin was low, with only 46% of isolates susceptible. A high prevalence of resistance to clindamycin (49% of isolates) was observed.

Drug efflux and parC mutations are involved in fluoroquinolone resistance in viridans group streptococci.

Nine ciprofloxacin-resistant viridans group streptococci isolated from asymptomatic carriers were analyzed. Identification to the species level by using three different commercial systems and a PCR-based approach was inconsistent. The nucleotide sequences of fragments of the parC, parE, gyrA, and gyrB genes showed considerable intra- and interspecies variations, and these variations mainly involved silent mutations. Three isolates had changes in Ser-79 of ParC (to Phe or Tyr). Phenotypic characterization indicated that eight of the nine isolates had a putative efflux mechanism that would confer low-level resistance to ciprofloxacin.

A study of susceptibility of 100 clinical isolates belonging to the Streptococcus milleri group to 16 cephalosporins.

The Streptococcus milleri group are uniformly susceptible to penicillin G, but their susceptibilities to different cephalosporins vary considerably. The antimicrobial susceptibilities of 100 clinically significant strains of the S. milleri group to 16 cephalosporins were determined by the agar dilution method. The majority of first-generation cephalosporins were highly active. Cefamandole, cefuroxime and cefprozil were the most active second-generation agents examined. Third-generation parenteral cephalosporins exhibited excellent activity, with the exception of ceftazidime. The most active of the oral preparations of this group was cefpodoxime, with cefixime and ceftibuten being considerably less active. MICs of cefepime, the only fourth-generation cephalosporin tested, were higher than those of cefotaxime and ceftriaxone.