Prevalence of mupirocin resistance in clinical isolates of Staphylococcus aureus and Staphylococcus epidermidis: results of the Antimicrobial Resistance Surveillance Study of the Paul-Ehrlich-Society for Chemotherapy, 2001

A multicentre surveillance study comprising 26 laboratories located in Austria, Germany, and Switzerland was carried out in November 2001. A total of 787 isolates of Staphylococcus aureus and 456 isolates of Staphylococcus epidermidis mainly recovered from hospitalised patients, were tested. MICs for mupirocin were determined using the broth microdilution procedure. Breakpoints were < or = 4 mg/l (susceptible), 8-256 mg/l (low-level resistance) and > or = 512 mg/l (high-level resistance). Rates of low- and high-level resistances were 2.9 and 0.9% in S. aureus, and 9.4 and 3.3% in S. epidermidis, respectively. Mupirocin resistance was almost exclusively observed in oxacillin-resistant isolates of S. aureus (MRSA) and S. epidermidis (MRSE). High-level mupirocin resistance was detected in 3.1 and 4.5% of MRSA and MRSE, respectively.

[beta-lactam-antibiotics in the treatment of community-acquired respiratory tract infections with penicillin-resistant pneumococci]

Streptococcus pneumoniae is still the most important pathogen of community-acquired respiratory tract infections. During the last decades in many countries an increase in the spread of antibiotic resistant strains (e. g. against beta-lactams, macrolides, tetracyclin) was observed. Resistance against penicillin is often associated with resistance against macrolides and other antibiotic classes. In Germany surveillance studies including isolates from patients with community-acquired respiratory tract infections have shown that about 14 % of strains show a reduced susceptibility against penicillin (MIC-values 0.12 - 1 mg/L) and up to 4 % are highly resistant against penicillin (MIC >/= 2 mg/L). Resistance against tetracycline or macrolides was detected in up to 12 and 15 % of strains, respectively. According to the treatment guidelines of the Paul-Ehrlich-Gesellschaft für Chemotherapie and the Deutschen Atemwegsliga penicillins and cephalosporins are recommended as first line antibiotics for the treatment of community-acquired respiratory tract infections. As pneumococcal strains with reduced susceptibility against penicillin show often also a reduced susceptibility against cephalosporins the questions arises which beta-lactam antibiotics should still be used in empirical treatment of such strains. beta-Lactam-antibiotics highly differ in their in-vitro-activity against S. pneumoniae and their pharmacokinetic properties. In different models is has been demonstrated for beta-lactams that an adequate clinical and bacteriological efficacy is achievable when the serum levels of the free, i. e. not protein bound fraction of drug exceeds the MIC of the pathogen for at least 40 to 50 % of the dosing interval (T > MIC). In a clinical situation where pneumococci with reduced susceptibility against penicillin cannot be ruled out, only beta-lactam antibiotics with favourable pharmacological properties (good in-vitro activity, high and long lasting serum levels) should be used for treatment.

Changing pattern of antibiotic resistance in methicillin-resistant Staphylococcus aureus from German hospitals

OBJECTIVE

To investigate the background of changes of resistance phenotypes in methicillin-resistant Staphylococcus aureus (MRSA) from nosocomial infections in German hospitals by molecular typing and identification of particular resistance genes.

METHODS

Isolates from the network for monitoring the spread of MRSA in Germany were subjected to quantitative susceptibility testing, to molecular typing, and to polymerase chain reaction identification of resistance genes.

PARTICIPANTS

The network consists of 175 German clinical microbiological laboratories collaborating with the German Reference Center for Staphylococci, which performs typing of staphylococcal isolates from nosocomial infections and data analysis.

RESULTS

During the past 5 years, MRSA susceptible to other antibiotics such as oxytetracycline, erythromycin, and gentamicin became more frequent. The proportion of epidemic MRSA clones that had been disseminated in the past and that exhibited broad resistance phenotypes decreased, whereas the proportion of recently emerging MRSA carrying only a few other resistance determinants has increased (1994, 11.5%; 1998, 39%).

CONCLUSIONS

The changing pattern of resistance phenotypes of MRSA from nosocomial infections in Germany is mainly due to the spread of recently emerging epidemic strains that are less frequently resistant to antibacterials other than oxacillin. The observed changes cannot simply be attributed to overall antibiotic consumption.

Nationwide German multicenter study on the prevalence of antibiotic resistance in streptococcal blood isolates from neutropenic patients and comparative in vitro activities of quinupristin-dalfopristin and eight other antimicrobials

In a prospective multicenter study (1996 to 1999), 156 episodes of bacteremic streptococcal infections of neutropenic patients were evaluated. Streptococcus oralis (26.3%), S. pneumoniae (26.3%), S. agalactiae (11.5%), S. mitis (9%), and S. pyogenes (5.8%) were the predominant species. Four strains (2.6%) were found to be intermediately resistant to penicillin. One strain (0.6%) was found to be highly resistant to penicillin (MIC, 8 mg/liter). Reduced susceptibility to penicillin was detected among S. oralis (14.6%), S. mitis (7.1%), and S. pneumoniae (4.9%) isolates but was not recorded among S. agalactiae and S. pyogenes. Resistance rates and intermediate resistance rates for other antimicrobials were as follows (all species): amoxicillin, 1.3 and 3.2%; erythromycin, 16 and 2.6%; clindamycin, 5.8 and 0%; ciprofloxacin, 1.9 and 7.7%. Quinupristin-dalfopristin showed good in vitro activity against most streptococcal isolates (MIC at which 50% of the isolates were inhibited [MIC(50)], 0.5 mg/liter; MIC(90), 1 mg/liter, MIC range, 0.25 to 4 mg/liter).

Nationwide German multicenter study on prevalence of antibiotic resistance in staphylococcal bloodstream isolates and comparative in vitro activities of quinupristin-dalfopristin

Antibiotic-resistant gram-positive bacteria have become an increasing problem in the last two decades. In order to evaluate the prevalence of antibiotic resistance in staphylococcal bloodstream isolates in Germany, 2,042 staphylococci collected in 21 tertiary-care hospitals were investigated during a 3-year period (March 1996 to March 1999). Altogether, 1,448 S. aureus isolates and 594 coagulase-negative staphylococci (CoNS) that comprised 13 different species were included. Furthermore, the antistaphylococcal activities of quinupristin-dalfopristin were compared with those of eight other compounds by the broth microdilution method. The rates of oxacillin resistance in Staphylococcus aureus, S. epidermidis, S. haemolyticus, and other CoNS were 13.5, 69, 90, and 34%, respectively. In oxacillin-resistant strains high rates of resistance (up to 100%) to erythromycin, clindamycin, ciprofloxacin, and gentamicin were also observed. However, no strain appeared to be resistant to vancomycin or quinupristin-dalfopristin. The streptogramin combination exhibited excellent in vitro activity against all staphylococcal species tested, regardless of the patterns of resistance to other drug classes. In terms of MICs at which 90% of the isolates are inhibited, quinupristin-dalfopristin was 2 times more active against S. aureus isolates, 4 to 16 times more active against S. haemolyticus, and 8 to 32 times more active against S. epidermidis than vancomycin or teicoplanin.

Drug resistance among clinical isolates of frequently encountered bacterial species in central Europe during 1975-1995. Study Group Bacterial Resistance of the Paul-Ehrlich-Society for Chemotherapy

A multicenter study for monitoring antimicrobial drug resistance in clinical isolates of the family Enterobacteriaceae, Pseudomonas aeruginosa, Staphylococcus and Enterococcus species in central Europa conducted by the Study Group Bacterial Resistance of the Paul-Ehrlich-Society for Chemotherapy has been ongoing since 1975. Between 1975 and 1995 susceptibility data on almost 60,000 bacteria, which were isolated and sampled under a common protocol by laboratories from Austria, Germany and Switzerland, were collected. These bacterial isolates were known by the respective investigators to have caused infections. From 1975 to the mid-80s none of the bacterial species examined showed an increase in resistance. The frequency of resistance in klebsiellae and Staphylococcus aureus to some antibiotics even declined. In 1990 and particularly in 1995, a clear increase in resistance for a number of antibiotic-organism pairs was observed. Resistance rates to fluoroquinolones increased in all species under investigation. In Escherichia coli the increase of resistance to ampicillin, co-trimoxazole and gentamicin was remarkable. Resistance to imipenem increased in P. aeruginosa. Resistance to cephalosporins, on the other hand, remained largely unchanged in gram-negative bacilli. Between 1990 and 1995, the prevalence of oxacillin resistance increased from 1.7 to 12.9% in S. aureus and from 15.8 to 55.8% in coagulase-negative staphylococci, whereas staphylococcal and enterococcal resistance to glycopeptides was still rare.

In vitro activity of quinupristin/dalfopristin against erythromycin-susceptible and erythromycin-resistant Streptococcus pneumoniae

Minimal inhibitory concentrations (MICs) of quinupristin/dalfopristin, penicillin, erythromycin, and clindamycin were determined by a standard agar dilution method for 93 Streptococcus pneumoniae strains isolated from patients with invasive disease in Germany. Quinupristin/dalfopristin showed good activity against 32 penicillin-susceptible/erythromycin-susceptible strains (MIC90 0.5 mg/l; range 0.25-0.5 mg/l) and 31 penicillin-intermediate/erythromycin-susceptible strains (MIC90 0.5 mg/l; range 0.25-1 mg/l). Erythromycin-resistant strains (n=30) were slightly less susceptible (MIC90 1 mg/l; range 0.125-2 mg/l). Quinupristin/dalfopristin was bactericidal (99.9% killing) for all six strains investigated after 2 h at a concentration of 4 mg/l.

Increasing incidence and widespread dissemination of methicillin-resistant Staphylococcus aureus (MRSA) in hospitals in central Europe, with special reference to German hospitals

OBJECTIVE: to present data on prevalence and interregional spread of methicillin-resistant Staphylococcus aureus (MRSA) in Germany. METHODS: A nationwide collection of MRSA isolates from nosocomial infections in 143 hospitals was established from isolates (n=4368) sent to a microbiological reference center during 1993--95. As chosen by distinguishable resistance phenotypes at each time of occurrence during the study period, 1830 isolates were subjected to molecular typing by means of Smal macrorestriction patterns, PCR for RNA gene spacer patterns, and PCR for patterns of DNA stretches flanked by the ERIC-2 sequence and flanked by Tn916 and ribosomal binding site. In addition, data from a multicenter study on the incidence of antibiotic resistance have been analyzed (32 centers, 637 S. aureus isolates). RESULTS: In 1995 the prevalence of MRSA among S. aureus isolates was 8.7% overall in central Europe (including Germany), in comparison to 1.7% in 1990. From 1993 until now, a continuous interregional dissemination of six epidemic strains, which were identified by molecular typing, was recorded. Besides these epidemic strains, 15 MRSA strains were identified which could not be allocated to the epidemic MRSA or to the known clonal groups of the species S. aureus. MRSA from three cases of sporadic nosocomial infections exhibited characteristics of the clonal group of S. aureus with the capacity for toxic shock syndrome formation. The pattern of one MRSA corresponded to those of the S. aureus group exhibiting phage pattern 94,96. CONCLUSIONS: The prevalence of MRSA has increased in central Europe (and Germany) during the last 5 years, to 8.7%. The main source of infection with MRSA is obviously interregional dissemination of epidemic strains. At the same time, the mecA gene has been acquired by strains previously sensitive to methicillin.

Urine bactericidal activity of pefloxacin versus norfloxacin in healthy female volunteers after a single 800-mg oral dose

In an open randomised crossover study the antibacterial activity of pefloxacin and norfloxacin was assessed in the urine after a single 800-mg oral dose in 14 healthy female volunteers. Pefloxacin demonstrated lower peak concentrations in the urine than norfloxacin (mean, 217.2 mg/l versus 492.9 mg/l as determined by the microbiological assay) but pefloxacin was present over a longer period of time in sufficient concentrations than norfloxacin. Mean urine levels of at least 2 mg/l were present for 7 days after pefloxacin administration and 2 days after norfloxacin administration as determined by the microbiological assay. Overall, the urinary recovery of pefloxacin and norfloxacin amounted to 49.3% and 25.1%, respectively, of the total administered dose. The average urine bactericidal activity against the five test organisms was as follows: against reference strain Escherichia coli ATCC 25922 susceptible to nalidixic acid (Nal-S) for 5 days with pefloxacin and 2 days with norfloxacin; against three clinical isolates, one strain each of E. coli resistant to nalidixic acid (Nal-R), Klebsiella pneumoniae Nal-R, and Staphylococcus saprophyticus, for 3 days with pefloxacin and 24 h with norfloxacin; and against a clinical isolate of Enterococcus faecalis for 2 days with pefloxacin and 12 h with norfloxacin. In conclusion, pefloxacin as a single dose proved to have sufficiently high and long-lasting urine bactericidal activity against urinary pathogens. These findings support the results of a meta-analysis of seven clinical trials in patients with uncomplicated lower UTI, demonstrating a single oral dose of 800 mg pefloxacin to be as effective as a conventional treatment with comparative drugs.

Antimicrobial resistance and type distribution of Streptococcus pneumoniae isolates causing systemic infections in Germany, 1992-1994

A prospective study of pneumococcal infections was performed in cooperation with 40 clinical microbiology laboratories in Germany. Minimal inhibitory concentration (MIC) values for 844 strains of Streptococcus pneumoniae, isolated from patients with systemic infections, were determined in tests with penicillin, tetracycline, erythromycin, chloramphenicol, cefotaxime, and clindamycin by a standard broth microdilution method; 1.8% of pneumococcal isolates exhibited reduced susceptibility to penicillin (MIC, > or = 0.1 micrograms/mL). The Etest, which was used to confirm the level of resistance to penicillin, proved to be a reliable and easily performed method for determination of MICs. The rates of resistance to clindamycin, erythromycin, tetracycline, and chloramphenicol were 1.4%, 3.2%, 11.0%, and 1.9%, respectively. Resistance to cefotaxime was not observed. Typing of a randomly selected subgroup of all strains (n = 115) showed types 1 (9.6%), 14 (8.7%), 3 (7.8%), and 23F (7.8%) to be the most prevalent types in Germany. At least 86.1% of these pneumococcal strains belonged to capsular types included in the 23-valent vaccine.

Prevalence of fluoroquinolone resistance in Europe. Study Group 'Bacterial Resistance' of the Paul-Ehrlich-Society for Chemotherapy e. V

Since 1984, when the first fluoroquinolone, norfloxacin, was marketed in Europe, there has been a marked increase in the usage of this class of drugs. In order to evaluate the influence of this drug usage on the prevalence of resistance to fluoroquinolones in clinical isolates of the family Enterobacteriaceae, Pseudomonas aeruginosa, Staphylococcus aureus, coagulase-negative staphylococci and Enterococcus faecalis we reviewed the susceptibility data from four collaborative surveys conducted between 1983 and 1990 by the Study Group 'Bacterial Resistance' of the Paul-Ehrlich-Society for Chemotherapy. All participating laboratories used the same standardized methods. Minimal inhibitory concentrations were determined by the broth microdilution method. More than 20,000 bacterial strains were tested. The results are presented for ciprofloxacin, which is regarded as the representative of the fluoroquinolones. Using > or = 4 mg/l as a breakpoint for resistance to ciprofloxacin, the prevalence of resistant strains of the family Enterobacteriaceae in Central Europe between 1983 and 1990 remained below 1%. In contrast, the resistance rates in P. aeruginosa were 0.7%, 1.0%, 3.8% and 7.0%, in S. aureus 0%, 0.5%, 6.6% and 6.8%, and in E. faecalis 2.2%, 0.7%, 4.9% and 7.7% in 1983, 1986, 1989 and 1990, respectively. The latest study carried out in cooperation with 78 laboratories from 12 European countries revealed great differences in the prevalence of resistance to fluoroquinolones from one species to another ranging from 0% with Proteus vulgaris and Salmonella spp. to 26.7% with Providencia stuartii.(ABSTRACT TRUNCATED AT 250 WORDS)

German multicentre study on the in vitro susceptibility of Bacteroides species. The German Bacteroides Study Group

In 1990 the first German multicentre study on the in vitro susceptibility of Bacteroides species was completed. Employing a commercially prepared microbroth dilution assay, nine participating institutions evaluated approximately 100 consecutive isolates of Bacteroides species from relevant clinical specimens. A total of 911 strains (449 Bacteroides fragilis, 201 Bacteroides thetaiotaomicron, 79 Bacteroides ovatus, 78 Bacteroides vulgatus, 77 Bacteroides distasonis, 25 Bacteroides uniformis, 2 others) were tested. Most of the isolates came from surgical patients (72%); other sources included gynaecological patients (9%) and medical patients (5%). Seventy-eight percent of the anaerobes were found in mixed culture together with at least one aerobic organism (Escherichia coli 36%, streptococci 15%, or enterococci 13%), while in 22% of the cases, the anaerobes were the only bacteria grown from the specimens. The results showed that many of the strains were potent beta-lactamase producers (as judged by resistance to amoxicillin). However, all but one of the isolates demonstrated susceptibility in vitro when clavulanic acid was added to amoxicillin or ticarcillin. At the same time, 13% of the organisms were resistant to mezlocillin, 5% to cefoxitin and 4% to clindamycin. Three strains were reported resistant to imipenem and one strain to metronidazole.

The epidemiology of beta-lactamases

Chromosomally mediated species-specific beta-lactamases, as well as plasmid-mediated beta-lactamases, contribute to bacterial resistance to beta-lactam antibiotics. Chromosomally mediated enzymes confer primary resistance to some drugs and secondary resistance, by mutation to over-production of the enzyme. By far the most prevalent and most important of the, more than thirty, described plasmid-mediated beta-lactamases are those of the TEM group. They can be found in nearly all Gram-negative bacterial species of clinical importance. Furthermore these enzymes have changed their specificity by mutation so that recently described TEM enzymes hydrolyse even third generation cephalosporins. Although there is no change in the quantity of these enzymes, as far as the percentage of producer strains in any species is concerned, there has been a change in quality. The enzymes are further distributed to new species and hydrolyse more so-called 'stable' beta-lactam compounds.

The pharmacokinetics of ticarcillin/clavulanate acid in neonates

The pharmacokinetics of a 25:1 combination of ticarcillin and clavulanate were studied in nine pre-term and seven full-term neonates. Pre-term neonates with a gestational age ranging from 30 to 36 weeks received 83.3 mg of ticarcillin and 3.3 mg of clavulanate per kg bw and full-term neonates with a gestational age from 39 to 43 weeks received 100 mg of ticarcillin and 4 mg of clavulanate per kg bw 8-hourly, each by a slow infusion over 10 min. Serum was sampled 15, 30, 60, 120, 240 and 480 min after the first dose and trough samples were additionally obtained on the fourth day of treatment. The patients were allocated to Groups 1-3 on the basis of the pharmacokinetic characteristics obtained. Group 1 comprised seven full-term babies. Group 2 contained seven pre-term neonates with a birth weight between 1915 and 2650 g and Group 3 consisted of two pre-term neonates of low birth weight (1400 g and 1640 g). Mean (+/- S.E.) pharmacokinetic characteristics of Group 1 patients for ticarcillin were: Cmax = 404.9 mg/l (36.0); T = 2.68 h (0.23); AUC = 1287 h.mg/l (69); Vd = 266 ml/kg (28) and for clavulanate: Cmax = 15.0 mg/l (1.2); T = 1.39 h (0.12); AUC = 30.1 h.mg/l (1.7); Vd = 263 ml/kg (22). Corresponding parameters for Group 2 patients for ticarcillin were: Cmax 278.7 mg/l (30.4); T = 4.20 h (0.49); AUC = 1107 h.mg/l (57); Vd = 338 ml/kg (35) and for clavulanate: Cmax = 8.4 mg/l (0.56); T = 2.56 h (0.18); AUC = 27.1 h.mg/l (2.0); Vd = 414 ml/kg (29). Drug accumulation was not observed in patients of Groups 1 and 2. Each of the two patients of Group 3 presented a pharmacokinetic profile which was considerably different from those observed in Groups 1 and 2. While in patients of the latter group the peak serum concentrations were achieved at 15-30 min after the end of infusion, these concentrations occurred between 120 and 240 min in one of the Group 3 patients. In the other Group 3 patient a remarkable drug accumulation was noted but was not associated with clinical or laboratory evidence of toxicity. These data show that ticarcillin and clavulanic acid in these dose ranges achieved adequate peak and trough concentrations in pre-term and full-term neonates.