Resistencia inducible a clindamicina en Staphylococcus aureus resistentes a meticilina aislados de pacientes pediátricos en Paraguay / Inducible resistance to clindamycin in methicillin-resistant Staphylococcus aureus isolated from Paraguayan children

Resumen Introducción: El método de difusión de doble disco se presenta como una alternativa diagnóstica que permite identificar aislados de Staphylococcus aureus susceptibles a clindamicina, ante el aumento de resistencia a meticilina, reduciendo así la posibilidad de fallo en el tratamiento. Objetivo: Determinar la frecuencia de resistencia a clindamicina inducida por eritromicina en S. aureus resistentes a meticilina (SARM) aislados de niños paraguayos. Materiales y Métodos: Estudio observacional, descriptivo, de corte transversal. Se colectaron 145 aislados S. aureus que causaron infecciones de piel y tejidos blandos y osteo-articulares en pacientes pediátricos del Hospital Central del Instituto de Previsión Social en el período de diciembre-2012 a noviembre-2013. La resistencia a clindamicina se determinó por métodos automatizados y de difusión de doble disco. Se realizó reacción de polimerasa en cadena para genes ermA, ermB, ermC y msrA de aislados representativos. Resultados: La resistencia global a meticilina y clindamicina fue de 67 y 13%, respectivamente (11% atribuible al mecanismo de resistencia a clindamicina inducible). Los genes ermC y msrA fueron detectados individualmente en 25 y 17% de los aislados, respectivamente, mientras que un aislado presentó ambos genes en simultáneo. Discusión: La frecuencia de mecanismo de resistencia inducible a clindamicina señala la importancia de los métodos de difusión de doble disco en la práctica microbiológica, así como se encuentran en los límites de puntos de cortes considerados como aceptables para el uso de este antimicrobiano para infecciones cutáneas y osteo-articulares causadas por SARM.

Background: The double disc diffusion method is an alternative diagnostic that allows the identification of Staphylococcus aureus isolates apparently susceptible to clindamycin but that may develop resistance due to an induction phenomena, mainly asociated to the increase in resistance to methicillin, thus increasing the possibility of failure in the treatment. Aim: To determine the frequency of induced clindamycin resistance in methicillin-resistant S. aureus (MRSA) isolated from Paraguayan children. Materials and Methods: In this cross sectional study, we collected 145 S. aureus isolates that caused skin and soft tissue and osteoarticular infections in pediatric patients of the Central Hospital I.P.S. in the period from December-2012 to November-2013. Resistance to clindamycin was determined by automated methods and double disc diffusion. PCR was performed for ermA, ermB, ermC and msrA genes from representative isolates. Results: The global resistance to methicillin and clindamycin was 67 and 13%, respectively (11% attributable to the inducible mechanism). The ermC and msrA genes were detected individually in 25 and 17% of the isolates respectively while an isolate presented both genes simultaneously. Discussion: The frequency of inducible resistance to clindamycin indicates the importance of double disc diffusion methods in microbiological practice, as well as being within the cut off points considered acceptable for the use of this antibiotic for skin infections. and osteoarticular caused by MRSA.

Susceptibility of Streptococcus agalactiae to erythromycin and clindamycin in pregnant women in the prenatal screening

Introduction: Group B streptococcus (GBS), or Streptococcus agalactiae, is a bacterium found in normal human microbiota. However, it may cause neonatal pneumonia, sepsis, and meningitis. Genital colonization in pregnant women is associated with a higher risk of preterm birth. The treatment of choice is antibiotic therapy with beta-lactams, but in the case of multidrug-resistance, erythromycin and clindamycin can be used. Methods: This study evaluated bacterial cultures in the period from 2014 to 2015 from a group of 29,875 pregnant women. GBS colonization and resistance to erythromycin and clindamycin were investigated. Results: Positive cultures were found in 26.8% and 26.1% of the samples in 2014 and 2015, respectively. Levels of resistance to erythromycin and clindamycin were, respectively, 2.4% and 5.5% in 2014 and 3.2% and 6.5% in 2015. Conclusion: The investigation of GBS colonization and the evaluation of GBS resistance to erythromycin and clindamycin are of extreme relevance, given the increasing incidence of bacterial resistance, risks of preterm birth. (AU)

Impacto de la clindamicina in vitro en la combinación clindamicina - ketoconazol sobre el exopolímero de biopelículas de candida spp de origen urogenital / Impact of in vitro clIndamycIn on the combInatIon of clIndamycIn and ketoconazole on exopolymer of candida spp bIofIlms of urogenItal orIgIn

La mucosa vaginal ha sido utilizada largamente para la administración de antimicrobianos destinados al tratamiento de infecciones endógenas del tracto genital inferior (IETGI) en mujeres embarazadas y no embarazadas. Candida spp elabora biopelículas (BP) y su formación es un proceso complejo que requiere que las células fúngicas establezcan múltiples interacciones con el medio. Las BP están rodeadas por un exopolímero (EPM) que puede restringir la actividad de anticuerpos, la difusión de sustancias y unirse a los antimicrobianos (AM), limitando su acción. Los antimicrobianos (AM) en general y los antimicóticos en particular (AMC) pueden tener dificultades para llegar a las células dentro del EPS. Muchas de las fórmulas que se emplean para el tratamiento empírico usan combinaciones inapropiadas con limitada o nula actividad sobre las biopelículas (BP). La presencia de moléculas que provoquen su inhibición anulando los inductores del EPM o por otro mecanismo, permitirá la actividad del AM específico. Objetivo: demostrar que la actividad de la clindamicina (CLI) en fórmula dual con ketoconazol (KET) actúa sobre BP Candida albicans (CA) y especies no albicans de Candida . (NAC). Métodos: estudiamos la actividad de clindamicina-ketoconazol (CK) sobre la adherencia y dispersión de BP de 8 aislamientos vaginales de CA y 7 de CNA. Se inocularon en 3 tubos con caldo Sabouraud y un dispositivo de vidrio para la formación de la BP según técnica ya descrita. Adherencia: Se incubaron durante 6 horas y se agregó una combinación de CK proveniente del material de óvulos, diluido convenientemente (62,5/260,4 ug/ml), a uno de los tubos de cada aislamiento tomándose como hora 0. Dispersión: esa misma dilución se agregó a otro tubo a las 16 horas. El tercer tubo quedó como testigo sin antimicrobianos. La lectura se efectuó con microscopio óptico a las 24 horas de agregada la combinación CK previa tinción con cristal violeta y se evaluaron con programas fotográficos. Por separado analizamos la actividad de CLI (62,5 ug/ml) y KET (260,4 ug/ml) con técnica similar. Seleccionamos las muestras de 7 pacientes que demostraron candidiasis vulvovaginal (CVV) y las estudiamos con la técnica de capas celulares. Se empleó la combinacion CK para el estudio de la adherencia y dispersión. Resultados: Adherencia se demostró poca influencia de CK en la adherencia con respecto a cada testigo. Dispersión: la influencia de CK se demostró en la mayoría de los aislamientos particularmente en los de CNA que mostraron una mayor presencia de EPM. Las hifas solo se observaron en 1/15 de los aislamientos de Candida spp cuando se agregó CK a las 16 horas. En las BP de las muestras clínicas no aparecieron hifas ni otro elemento micótico en 5/7 con respecto a los testigos. Conclusión: Según estos resultados el uso de una combinación de CK en BP de Candida spp, resulta en una adecuada penetración del AMC demostrada por la dispersión de la BP al cabo de 24 horas. Clindamicina no interfiere con la acción del ketoconazol sino que promovería su actividad anti-candida modificando posiblemente estructuras de superficie y la del EP por inhibición de las moléculas que facilitan la expresión del mismo. In vivo promueve la actividad inmunomoduladora que no se puede demostrar con este modelo in vitro. Su uso combinado en fórmulas duales facilitaría la actividad del AMC sobre Candida spp actuando como inhibidora o modificadora de las BP mediante la dispersión del EPM

The vaginal mucosa has been widely used for administering antimicrobial agents to treat endogenous infections of the lower genital tract in pregnant and non-pregnant women. Candida spp. elaborates biofilms, and its formation is a complex process requiring that fungal cells establish multiple interactions with the medium. Biofilms are surrounded by an exopolymer matrix that can restrict the activity of antibodies, the diffusion of substances, and be associated with antimicrobials, therefore limiting its actions. General antimicrobials and particular anti-mycotic agents can face difficulties to access the cells within the exopolymer matrix. Many formulas used for empirical treatment have improper combinations with limited or null activity on the biofilms. The presence of molecules that cause its inhibition, thus eliminating the exopolymer matrix inducers, or by other mechanism, will allow the specific antimicrobial activity. Objective: To show that the activity of clindamycin used in dual formula with ketoconazole works on Candida albicans biofilm and on non- albicans species of Candida . Methods: We studied the activity of clindamycin and ketoconazole regarding the adherence and dispersion of biofilms from eight vaginal isolates of C. albicans and 7 of non- albicans Candida . The isolates were inoculated in three tubes with Sabouraud agar and a glass device to form the biofilm according to a known technique. Adherence : Each isolate was incubated for a six-hour period and a combination of clindamycin and ketoconazole from the material of ovules was added and conveniently diluted to one of the tubes of each isolate (62.5/260.4 ug/mL), considering 0 hour. Dispersion: The same dilution was added to another tube after 16 hours. The third tube was used as a control without antimicrobials. The reading was carried out with an optical microscope after 24 hours that the clindamycin and ketoconazole combination had been added and colored with crystal violet. They were then evaluated using photographic programs. The activity of clindamycin (62.5 ug/mL) and ketoconazole (260.4 ug/mL) was analyzed alone with a similar technique. We chose vaginal samples from seven patients with vulvovaginal candidiasis and studied them through the cell layer technique. The clindamycin and ketoconazole combination was used for studying the adherence and dispersion. Results: Adherence: Little influence of clindamycin and ketoconazole was seen in adherence regarding each control. Dispersion: The clindamycin and ketoconazole influence was seen in most of the isolates, especially in those of non- albicans Candida that showed higher presence of exopolymer matrix . The hyphae were only seen in 1 of 15 isolates of Candida spp after the clindamycin and ketoconazole were added at the 16th hour. In biofilms of clinical samples, neither hyphae nor mycotic elements were seen in 5 of 7 compared with the controls. Conclusion: According to these results, the use of a clindamycin and ketoconazole combination in biofilms of Candida spp results in proper penetration of the antimicrobial agent, which is seen by the biofilm dispersion during 24 hours. Clindamycin does not interfere with the action of ketoconazole, but it would promote its anti- Candida activity and would possibly modify surface and EP structures through inhibition of the molecules that facilitate its expression. The in vivo model promotes the immunomodulatory activity that in vitro models do not. Its combined use in dual formulas would facilitate the antimicrobial activity on Candida spp, therefore working as an inhibitor or modifier of the biofilms after dispersion of the exopolymer matrix

The prevalence of genotypes that determine resistance to macrolides, lincosamides, and streptogramins B compared with spiramycin susceptibility among erythromycin-resistant Staphylococcus epidermidis

Coagulase-negative staphylococci, particularly Staphylococcus epidermidis, can be regarded as potential reservoirs of resistance genes for pathogenic strains, e.g., Staphylococcus aureus. The aim of this study was to assess the prevalence of different resistance phenotypes to macrolide, lincosamide, and streptogramins B (MLSB) antibiotics among erythromycin-resistant S. epidermidis, together with the evaluation of genes promoting the following different types of MLSB resistance:ermA, ermB, ermC,msrA, mphC, and linA/A’. Susceptibility to spiramycin was also examined. Among 75 erythromycin-resistantS. epidermidis isolates, the most frequent phenotypes were macrolides and streptogramins B (MSB) and constitutive MLSB (cMLSB). Moreover, all strains with the cMLSB phenotype and the majority of inducible MLSB (iMLSB) isolates were resistant to spiramycin, whereas strains with the MSB phenotype were sensitive to this antibiotic. The D-shape zone of inhibition around the clindamycin disc near the spiramycin disc was found for some spiramycin-resistant strains with the iMLSB phenotype, suggesting an induction of resistance to clindamycin by this 16-membered macrolide. The most frequently isolated gene was ermC, irrespective of the MLSB resistance phenotype, whereas the most often noted gene combination wasermC, mphC, linA/A’. The results obtained showed that the genes responsible for different mechanisms of MLSB resistance in S. epidermidis generally coexist, often without the phenotypic expression of each of them.

Inducible clindamycin resistance in Staphylococcus aureus: Reason for treatment failure.

Emergence of methicillin resistance in Staphylococcus aureus (S.aureus) has left us with very few therapeutic alternatives available to treat staphylococcal infection. The widespread use of macrolide-lincosamide-streptogramin B (MLSB) antibiotics has led to an increase in number of staphylococcal strains acquiring resistance to MLSB antibiotics. This study was done to investigate the infections by hospital and community acquired “erythromycin- induced clindamycin resistant” strains or D-test positives of clinical isolates of Staphylococcus aureus (S.aureus) in a hospital. Three hundred isolates of S.aureus were subjected to routine antibiotic susceptibility testing including Cefoxitin (30µg) by modified disc diffusion method. Inducible resistance to clindamycin in S.aureus was tested by D-test as per CLSI guidelines. Among 300 S.aureus isolates, 114 (38%) were methicillin resistant Staphylococcus aureus (MRSA) and 186 (62%) methicillin susceptible Staphylococcus aureus (MSSA). Forty one (13.67%) isolates showed induced clindamycin resistance, 49(16.33%) showed constitutive resistance and 94 (31.33%) showed the MS phenotype. Inducible resistance and constitutive resistance were found to be higher in MRSA compared to MSSA (22.81%, 23.68% and 8.1%, 11.8% respectively). D-test should be included as a part of routine antibiotic susceptibility testing to detect induced clindamycin resistance to prevent treatment failure.

Evaluation of constitutive and inducible resistance to clindamycin in clinical samples of Staphylococcus aureus from a tertiary hospital

Introduction Infections caused by methicillin-resistant Staphylococcus aureus (MRSA) have become common in hospitals and the community environment, and this wide resistance has limited patient treatment. Clindamycin (CL) represents an important alternative therapy for infections caused by S. aureus. Antimicrobial susceptibility testing using standard methods may not detect inducible CL resistance. This study was performed to detect the phenotypes of resistance to macrolides-lincosamides-streptogramin B (MLSB) antibiotics, including CL, in clinical samples of S. aureus from patients at a tertiary hospital in Santa Maria, State of Rio Grande do Sul, Brazil. Methods One hundred and forty clinical isolates were submitted to the disk diffusion induction test (D-test) with an erythromycin (ER) disk positioned at a distance of 20mm from a CL disk. The results were interpreted according to the recommendations of the Clinical and Laboratory Standards Institute (CLSI). Results In this study, 29 (20.7%) of the 140 S. aureus samples were resistant to methicillin (MRSA), and 111 (79.3%) were susceptible to methicillin (MSSA). The constitutive resistance phenotype (cMLSB) was observed in 20 (14.3%) MRSA samples and in 5 (3.6%) MSSA samples, whereas the inducible resistance phenotype (iMLSB) was observed in 3 (2.1%) MRSA samples and in 8 (5.8%) MSSA samples. Conclusions The D-test is essential for detecting the iMLSB phenotype because the early identification of this phenotype allows clinicians to choose an appropriate treatment for patients. Furthermore, this test is simple, easy to perform and inexpensive. .

Tratamiento de las infecciones invasivas por Staphylococcus aureus meticilino resistente adquirido en la comunidad / Treatment of invasive infections due to community acquired methicillin resistant Staphylococcus aureus

Las infecciones por Staphylococcus aureus meticilino resistente adquirido en la comunidad (SAMR-AC) constituyen un problema emergente debido a su elevada virulencia y gran capacidad de diseminación. Para las infecciones invasivas, las recomendaciones publicadas sugieren vancomicina como droga de elección. Sin embargo, no está claro si otras alternativas pudieran ser mejores en determinadas situaciones, o si el uso de combinaciones de antibióticos sería beneficioso. No se han realizado trabajos que sugieran que alguna alternativa terapéutica sea preferible a otra para el tratamiento de pacientes con infecciones invasivas por SAMR-AC, por lo que las decisiones a tomar se basan en la extrapolación de datos de estudios realizados en otros contextos o en la opinión de expertos. Por tal motivo, se presenta esta revisión, con el objeto de poner en manos de los infectólogos y otros especialistas la evidencia disponible, a fin de intentar encontrar las mejores alternativas de tratamiento para estas infecciones...

Infections caused to community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is an emerging problem due to its high virulence and large capacity of spread. For invasive infections, published recommendations suggest vancomycin as the drug of choice. However, it is unclear whether other alternatives might be better in certain situations, or if the use of combinations of antibiotics would be beneficial. No studies has been done to suggest that any therapeutic alternative is better than another for the treatment of patients with invasive CA-MRSA infections, so the decisions you make are based on extrapolation of data from studies in other contexts or expert opinion. Therefore, this review is presented, in order to put in the hands of infectologist and others specialists the available evidence, in order to find the best treatmente options for these infections...

Prevalencia de portación vaginal-anal de Streptococcus agalactiae en el tercer trimestre de gestación y susceptibilidad a macrólidos y lincosamidas, en mujeres embarazadas de Clínica Alemana Temuco, Chile / Prevalence of anal-vaginal colonization of Streptococcus agalactiae in third trimester of pregnancy and susceptibility to macrolides and lincosamides, in pregnant women controlled at Clínica Alemana Temuco, Southern Chile

Introduction: Streptococcus agalactiae (GBS) is the most common agent in early neonatal sepsis. Strategies incorporating universal screening for maternal colonization show the lowest rates of perinatal infection. A significant increase in resistance to erythromycin and clindamycin by GBS has been reported around the world. There are no published data regarding prevalence and antimicrobial resistance in southern regions of Chile. Surveillance of antimicrobial resistance is essential to define the drugs of choice and alternatives, in an institution that applies prevention protocols, as Clinica Alemana Temuco (CAT) does. Objectives: to determine the prevalence of carriage of GBS in vaginal-anal areas at end of pregnancy, in CAT, Araucanía Region, Chile. To determine the susceptibility to erythromycin and clindamycin of GBS strains isolated. Results: 1,181 pregnant women were included; 167 were positive for GBS (14.4% of colonization). Sixteen were resistant to erythromycin (9.5%); 15 of these strains were also clindamycin resistant. Twenty-three of 167 were resistant to clindamycin (13.7%). Conclusions: The prevalence rate of GBS colonization was lower than previously reported in other regions of Chile. Due to the high rates of resistance to clindamycin and erythromycin it is necessary to widen the study of susceptibility to other antimicrobials to have alternatives in allergy to penicillin (primarily cefazolin and vancomycin).

Introducción: Streptococcus agalactiae es el más frecuente causal de sepsis neonatal precoz. Las estrategias con pesquisa universal de colonización materna muestran las tasas más bajas de infección perinatal. Se ha reportado un significativo aumento de resistencia de S. agalactiae a eritromicina y clindamicina en el mundo. No existen datos publicados de prevalencia y susceptibilidad antimicrobiana en las regiones del sur de Chile. La vigilancia de resistencia es fundamental para definir los antimicrobianos de elección y alternativas para prevención del cuadro en instituciones que apliquen estrategias de prevención, como Clínica Alemana Temuco (CAT). Objetivos: Determinar la prevalencia de portación de S. agalactiae en la región vaginal-anal de mujeres embarazadas de tercer trimestre en CAT. Determinar la susceptibilidad a eritromicina y clindamicina de las cepas aisladas. Resultados: 1.181 embarazadas fueron incluidas. 167 resultaron S. agalactiae (+) (14,4% de colonización). Diez y seis eran resistentes a eritromicina (9,5%). Quince de ellas también lo eran a clindamicina. Veintitrés de 167, eran resistentes a clindamicina (13,7%). Conclusiones: La tasa de prevalencia de colonización (14%) fue más baja que lo reportado anteriormente en el centro del país. Debido a la alta tasa de resistencia a clindamicina y eritromicina se hace necesario aumentar el estudio de susceptibilidad a otros antimicrobianos alternativos en pacientes alérgicas a penicilina (principalmente cefazolina y vancomicina).

Detection of various types of resistance patterns and their correlation with minimal inhibitory concentrations against clindamycin among methicillin-resistant Staphylococcus aureus isolates.

Purpose: The macrolide lincosamide streptogramin B (MLS B ) family of antibiotics serves as an alternative for the treatment of skin and soft tissue infections caused by methicillin-resistant Staphylococcus aureus (MRSA). However, resistance to clindamycin too has emerged, which is of two types, inducible and constitutive. Therapeutic failure is common with inducible type of clindamycin resistance. This study was done to determine the various clindamycin resistance patterns in MRSA isolates and to compare them with minimal inhibitory concentration (MIC) of clindamycin. Materials and Methods: Fifty MRSA isolates were studied by disc approximation test (D test) to detect inducible iMLS B resistance and MIC by agar dilution technique. Results: Of the 50 isolates, 34 were sensitive to both clindamycin and erythromycin. 16 isolates showed different sensitivity patterns; nine of these were positive for D zone indicating inducible iMLS B resistance, five were positive for constitutive MLS B resistance and two showed possible efflux mechanism for macrolide resistance. Out of the 34 sensitive isolates, 5 showed isolated colonies (subpopulation) inside the clindamycin-sensitive zone. When these sub-populations were tested further, two were constitutive MLS B phenotypes, two were inducible iMLS B and one was HD (hazy D zone), which is D + with growth up to clindamycin disc (which is also considered as constitutive MLS B phenotype). Seven isolates showed an MIC of ≥4 μg/ml to clindamycin in spite of being susceptible to both erythromycin and clindamycin by Kirby Bauer disc diffusion technique. Out of these seven isolates, five were those which grew as subpopulation inside the clindamycin-sensitive zone. Conclusion: Detection of iMLS B resistance among MRSA helps to avoid treatment failure with clindamycin. Studying the subpopulation inside the clindamycin-sensitive zone raises the question of existence of hetero-resistance or some other mechanism, which needs further study.

Análisis de los fenotipos y genotipos de resistencia a eritromicina y clindamicina en cepas de Streptococcus pyogenes aisladas en Chile en un período de 10 años / Resistance phenotypes and genotypes of Streptococcus pyogenes clinical isolates in Chile over a 10-year period

Background: Macrolide and lincosamide resistance in Streptococcus pyogenes is due to the acquisition of mef, ermB and ermA genes, which confer different resistance phenotypes, namely M, MLSBconstitutive and MLSBinducible respectively. The last report of resistance in Chile was done in the period 1990-1998, in which resistance to macrolides was 5.4 percent, with M phenotype as the predominant one. Aim: To characterize the evolution of erythromycin and clindamycin resistance and their associated genes in S. pyogenes strains isolated from patients with invasive and non-invasive infections in the period 1996 to 2005. Material and Methods: Resistance to erythromycin and clindamycin was determined in 1,282 clinical isolates using the disk diffusion test. Resistant isolates were analyzed by polymerase chain reaction (PCR) for the presence of the above mentioned resistance genes. Results: Global resistance to erythromycin and clindamycin was 3.5 and 0.7 percent respectively. Eighty percent of the resistant strains possessed the M. phenotype. Conclusions: Resistance levels of S. pyogenes have decreased in Chile in the last years. Most resistant strains have M phenotype in contrast to many countries in which the MLSB constitutive phenotype is the predominant one.

Aumento de resistencia de Streptococcus agalactiae vaginal-anal en el tercer trimestre de gestación a eritromicina y clindamicina al cabo de una década de tamizaje universal / Streptococcus agalactiae increase in resistance to erythromycin and clindamycin in vaginal-anal colonization in third quarter of pregnancy in one decade of universal screening

Introduction: Streptococcus agalactiae (GBS) is the main causative agent of early perinatal sepsis. The acquisition of prevention policies has led to frequent use of intrapartum antibiotics. Surveillance of antimicrobial resistance is indispensable for defining drugs of choice and alternatives for such prophylaxis. Objectives: To determine the evolution of antimicrobial resistance of GBS from maternal colonization to drugs used in the prevention of neonatal sepsis, between 2002 and 2008. Methods: We studied 100 GBS positive vaginal and anal samples from pregnant women. Disc diffussion susceptibility method was performed for penicillin, ampicillin, cefazolin, erythromycin and clindamycin according to the Clinical and Laboratory Standards Institute (CLSI). Results: We analyzed the susceptibility of 99 strains. Seventeen were resistant to erythromycin (17.1 percent) and 13 were resistant to clindamycin (13.1 percent). Thirteen of the 17 strains resistant to erythromycin had the MLS phenotype (resistance to erythromycin and clindamycin) and 4 had the M phenotype (resistance to erythromycin only). Within the MLS phenotype, resistance was constitutive in 9 strains, and induced in 4 strains (positive D test). Compared with 2002 there was a significant increase in resistance to clindamycin (from 3.27 percent to 13.1 percent p < 0.002) and erythromycin (1.09 percent to 17 percent p < 0.001). 100 percent GSB remained sensitive to penicillin and ampicillin. Conclusions: GBS remains highly susceptible to drugs of choice for prevention of perinatal sepsis. There is a significant increase in antimicrobial resistance to clindamycin and erythromycin. Therefore, it is necessary to request susceptibility testing in GBS from third trimester of pregnancy screening in patients allergic to penicillin.

Introducción: Streptococcus agalactiae es el principal agente causal de sepsis perinatal precoz. La adquisición de políticas de prevención ha traído consigo la utilización frecuente de antimicrobianos intra-parto. La vigilancia de resistencia antimicrobiana se hace indispensable para definir el fármaco de elección y alternativas en dicha profilaxis. Nuestro centro realiza tamizaje universal desde hace 10 años. Objetivos: Determinar la evolución de la resistencia antimicrobiana de S. agalactiae de colonización materna, a los antimicrobianos utilizados en la prevención de sepsis neonatal, entre 2002 y 2008. Métodos: Se estudiaron 100 muestras vaginales-anales positivas para S. agalactiae de mujeres embarazadas, con edad gestacional de 35 a 37 semanas. Se realizó estudio de susceptibilidad in vitro por discos a penicilina, ampicilina, cefazolina, eritromicina y clindamicina, según método estandarizado por Clinical and Laboratory Standards Institute (CLSI). Resultados: Se analiza la susceptibilidad de 99 cepas. Diecisiete fueron resistentes a eritromicina (17,1 por ciento) y 13 eran resistentes a clindamicina (13,1 por ciento). De las 17 cepas resistentes a eritromicina, 13 eran fenotipo MLS y 4 del fenotipo M. Dentro del fenotipo MLS, la resistencia fue constitutiva en nueve cepas e inducible en cuatro cepas (test D positivo). En comparación con el año 2002, hubo un aumento significativo de resistencia a clindamicina (de 3,2 a 13,1 por ciento p < 0,002) y a eritromicina (de 1,09 a 17 por ciento p < 0,001). Streptococcus agalactiae se mantuvo 100 por ciento sensible a penicilina y ampicilina. Conclusiones: S. agalactiae mantiene alta sensibilidad a los antimicrobianos de elección para la prevención de sepsis neonatal y a un antimicrobiano alternativo: cefazolina. Se observó un aumento significativo de resistencia antimicrobiana a clindamicina y eritromicina. Se hace necesario, entonces, solicitar antibiograma en el tamizaje del tercer trimestre del embarazo, en pacientes alérgicas a penicilina.

Evaluation of MicroScan Synergies plus Positive Combo 3 Panels for Identification and Antimicrobial Susceptibility Testing of Staphylococcus aureus and Enterococcus Species / 대한진단검사의학회지

BACKGROUND: Few studies have evaluated the performance of the recently introduced MicroScan Synergies plus Positive Combo 3 Panels (SIPC3) (Dade Behring Inc., USA). We evaluated the clinical efficacy of the panels in identification (ID) and antimicrobial susceptibility testing (AST) of Staphylococcusaureus and enterococci. METHODS: To evaluate the panels' accuracy of identification, the results obtained using the test panels were compared with those obtained by using conventional biochemical tests in conjunction with VITEK 2 system (bio-Merieux, USA). In addition, the AST results obtained using the panels were compared with those obtained by performing CLSI broth microdilution. RESULTS: The overall agreement between the approaches for the ID of S. aureus and enterococci was 100% and 96%, respectively. The categorical and essential agreements (CA and EA) for S. aureus were 98%, each. Very major errors (VME), major errors (ME), and minor error (mE) for S. aureus were 0.45%, 0.3%, and 4.2%, respectively. The majority of VMEs were for oxacillin (8.6%), penicillin (2.0%), erythromycin (7.9%), clindamycin (3.8%), and tetracycline (4.1%). For enterococci, the CA, EA, VME, ME, and mE were 88.8%, 93.7%, 4.4%, 0%, and 2.8%, respectively. The 80.5% (29/36) of Enterococcus faecium had concordant ID with the reference. Most of the categorical errors (3 VMEs and 14 mEs) were observed for quinupristin/dalfopristin (Synercid; Catalytica Pharmaceuticals Inc., USA). CONCLUSIONS: The panels compared favorably with conventional methods for the ID and AST of S. aureus. However, we expected a better performance for ID of E. faecium and AST using Synercid.

Evaluation of the Performance of the MicroScan Pos Breakpoint Combo Panel Type 28 for Susceptibility Testing of Staphylococcus aureus: Low-range Minimum Inhibitory Concentration of Vancomycin, Cefoxitin Screening, and Inducible Clindamycin Resistance Dete / 대한진단검사의학회지

BACKGROUND: Susceptibility testing of Staphylococcus aureus often requires cumbersome supplementary tests. MicroScan Pos Breakpoint Combo Panel Type 28 (PBC28) (Siemens, USA) includes cefoxitin screening to detect methicillin-resistant Staphylococcus aureus (MRSA), inducible clindamycin resistance detection (ICD), and determination of low-range minimum inhibitory concentration of vancomycin (0.5-16 microgram/mL). The purpose of this study was to evaluate the performance of PBC28 in comparison with that of Pos Combo Type 1A (PC1A) (Siemens). METHODS: From December 2009 to March 2010, 500 non-duplicate clinical isolates of S. aureus were tested with PC1A and PBC28. Categorical agreements (CA) between the interpretations of the 2 panels were estimated. The presence of the mecA gene was determined by PCR, and double-disk diffusion test (D-test) was performed on the isolates resistant to erythromycin but susceptible or intermediately resistant to clindamycin. Ninety-six isolates representing various vancomycin minimum inhibitory concentrations (MICs) were tested in parallel with repeat PBC28, broth macrodilution, and epsilometer test (E test). RESULTS: The CA was 99.3% with a very major error (VME) of 0.2%, major error (ME) of 0.1%, and minor error (mE) of 0.4% in total. PBC28 showed 100% CA for 1 isolate with vancomycin MIC of 4 microgram/mL and 35 isolates (7.0%) with MIC of 2 microgram/mL. However, only 15, 27, and 35 isolates with vancomycin MIC of 2 microgram/mL showed 100% CA in repeat PBC28, broth macrodilution, and E test, respectively. PC1A and PBC28 detected all 314 mecA-positive isolates. Among the 63 isolates tested with the D-test, 58 (92.1%) were positive, and the results were 100% concordant with those of ICD. CONCLUSIONS: PBC28 can be appropriate susceptibility testing of S. aureus, including MRSA detection and ICD. However, the lower-range vancomycin MIC test was not reproducible enough to reliably differentiate MIC of 2 microgram/mL from MIC< or =1 microgram/mL.

Antimicrobial Susceptibility Patterns of Legionella isolates in the Environment and in Patients / 대한진단검사의학회지

BACKGROUND: Antimicrobial susceptibility of Legionella spp. has rarely been studied in Korea. Therefore, we aimed to determine the susceptibility of Legionella spp. to various antibiotics. METHODS: We assessed the antimicrobial susceptibility of 66 environmental and clinical Legionella isolates collected between January 2001 and December 2008 from Korea and Japan. The minimum inhibitory concentrations (MICs) of 6 antibiotics, namely, azithromycin, ciprofloxacin, clarithromycin, clindamycin, gatifloxacin, and gemifloxacin were determined by the broth microdilution method using buffered starch yeast extract broth. RESULTS: The MIC ranges of the 6 antibiotics used against the Legionella isolates were as follows: 0.004-0.062 microgram/mL (azithromycin), 0.002-0.5 microgram/mL (ciprofloxacin), 0.004-0.5 microgram/mL (clarithromycin), 0.12-4 microgram/mL (clindamycin), 0.002-0.12 microgram/mL (gatifloxacin), and 0.008-1 microgram/mL (gemifloxacin). CONCLUSIONS: Legionella spp. isolates from Korea and Japan were most susceptible to gatifloxacin. Azithromycin, clarithromycin, ciprofloxacin, and gemifloxacin were also effective for treating legionellosis.

Resistencia inducible a clindamicina en Staphylococcus aureus meticilino resistente / Clindamycin inducible resistance in methicillin-resistant Staphylococcus aureus

The increase in methicillin-resistant Staphylococcus aureus (MRSA) infections has limited the use of efective available antibiotics. Clindamycin, an alternative against MRSA, might have inducible resistance that is not detected by common antibiograms. The disk diffusion method (D-test) detects the inducible resistance. Objetive: To establish the frecuency of inducible resistance in MRSA from blood and secretion samples obtained from hospitalyzed patients. Methods: Prospective and descriptive research, including MRSA positive blood and secretion samples from patients of Hospital Luis Calvo Mackenna, between July 2005-July 2006. A D-test was performed to the samples. Results: 220 MRSA samples were obtained and D-test was performed on 155 of them. 80 percent of the samples carne from tracheobronquial secretion and 90 percent> had used antibiotics. From all analyzed MRSA isolates, 32 (20.6 percento) were Clindamycin susceptible and 14 (43.8 percent) had Clindamycin inducible resistance (D-test+). Conclusions: A high percentage of MRSA Clindamycin resistant was found. From MRSA Clindamycin susceptible, 43.8 percent> had Clindamycin inducible resistance (D test+). D-test was implemented in the Microbiology Laboratory at Hospital Luis Calvo Mackenna, allowing the identification of MRSA isolates suceptible to Clindamicyn treatment.

El aumento de infecciones por Staphylococcus aureus meticilino resistente (SAMR) ha disminuido las alternativas de antimicrobianos efectivos. Clindamicina, una alternativa contra SAMR, puede presentar resistencia inducible no detectable con antibiogramas habituales. El test de difusión en disco (D test) detecta esta resistencia inducible. Objetivo: Determinar la frecuencia de resistencia inducible a clindamicina en muestras de sangre y/o secreciones positivas para SAMR de pacientes del hospital. Materiales y Métodos: Estudio prospectivo descriptivo, incluyó muestras de sangre y secreciones positivas para SAMR de pacientes del Hospital Luis Calvo Mackenna, recolectadas entre Julio 2005 y Julio 2006. A cada muestra se le realizó el D-test estandarizado según pautas CLSI. Resultados: Se recolectaron 220 cepas de SAMR, se realizó D test a 155. El 80 por ciento de las muestras era secreción tráqueo-bronquial. El 90 por ciento tenía antecedente de uso de antimicrobianos. Del total de cepas estudiadas, 32 (20,6 por ciento) resultó sensible a clindamicina y 14 (43,8 por ciento) presentaron resistencia inducible a clindamicina (D-test +). Discusión: Se encontró alto porcentaje de SAMR resistentes a clindamicina en nuestro medio hospitalario. Aquellos SAMR informados como sensibles a clindamicina, 43,8 por ciento presenta resistencia inducible a clindamicina (D-Test +). Se implemento en el Laboratorio de Microbiología la técnica de D test, permitiendo identificar cepas de SAMR susceptibles de tratar con clindamicina.

Inducible clindamycin resistance among clinical isolates of Staphylococci.

INTRODUCTION: Clinical failure of clindamycin therapy has been reported due to multiple mechanisms that confer resistance to macrolide, lincosamide and streptogramin antibiotics. This study was undertaken to detect the presence of inducible clindamycin resistance among clinical isolates of staphylococci. MATERIALS AND METHODS: The detection of inducible clindamycin resistance was performed by D-test using erythromycin and clindamycin discs as per CDC guidelines. RESULTS: Among the 244 clinical isolates of staphylococci studied, 32 (13.1%) showed inducible clindamycin resistance and belonged to the MLSBi phenotype. Among the MLS B i phenotypes, 10 isolates were methicillin-resistant Staphylococcus aureus (38.4% of the total MRSA), 16 were methicillin-sensitive Staphylococcus aureus (12.9% of the total MSSA) and 6 were coagulase-negative staphylococci (6.3% of the total CONS). CONCLUSION: The test for inducible resistance to clindamycin should be included in the routine antibiotic susceptibility testing, as it will help in guiding therapy.

Inducible clindamycin resistance among staphylococci isolated from burn patients

Clindamycin has been used successfully to treat pneumonia and soft-tissue infections caused by methicillin-resistant Staphylococcus aureus. However, inducible clindamycin resistance has been described as a cause of treatment failure of such infections. A total of 159 staphylococcal isolates from different clinical specimens from burn patients in Tripoli Burn Center were tested for inducible clindamycin resistance by the disk-diffusion induction test. Inducible clindamycin resistance was detected in 66.2% of 65 methicillin-resistant S. aureus isolates and in none of 55 methicillin-sensitive S. aureus, 10 methicillin-resistant coagulase negative staphylococci and 29 methicllin-sensitive coagulase negative staphylococci isolates. In our setting, clindamycin can be used for the treatment of infections due to staphylococci, but we recommend that staphylococci isolates, particularly methicillin-resistant S. aureus, are tested by the D-test before treatment

Phenotypic detection of inducible clindamycin resistance among Staphylococcus aureus isolates by using the lower limit of recommended inter-disk distance.

CONTEXT: Clindamycin is one of the important alternative antibiotics in the therapy of Staphylococcus aureus, particularly in methicillin-resistant S. aureus (MRSA) infections. Inducible clindamycin resistance (iMLS B--inducible Macrolide-Lincosamide-Streptogramin B resistance) is a critical factor in antimicrobial susceptibility testing. AIMS: To know the rate of inducible clindamycin resistance among clinical isolates of Staphylococcus aureus in our hospital by Disk approximation test (D-test) using the average recommended inter-disk distance and comparing the results with that of D-test using the lower limit of recommended inter-disk distance. MATERIALS AND METHODS: A total of 51 erythromycin-resistant and clindamycin-susceptible S. aureus isolates were subjected to disk approximation testing with 21 +/- 1 mm and 15 mm edge-to-edge distance between the clindamycin and erythromycin disks. STATISTICAL METHODS: Z-test levels. RESULTS: Among 51 erythromycin-resistant and clindamycin-susceptible S. aureus isolates, 25 (49%) were recorded as inducible clindamycin resistant by D-test with 21 +/- 1 mm edge-to-edge distance between the clindamycin and erythromycin disks. When we re-tested all the 51 strains by D-test with 15 mm inter-disk distance, we identified 14% more iMLS B strains previously reported as D-test negative. Z-test for MRSA indicates that 15 mm edge-to-edge distance has significant advantage. CONCLUSIONS: Since the incidence of inducible clindamycin resistance is high (63% in our study), accurate identification of inducible clindamycin resistance is important to prevent therapeutic failure in infections caused by these strains. We suggest the use of D-test with 15 mm edge-to-edge inter-disk distance for detecting iMLS B .

Prevalence of inducible clindamycin resistance in gram positive organisms in a tertiary care centre.

Gram positive organisms are one of the leading pathogens causing skin and soft tissue infections. For these infections, clindamycin is a useful alternate drug in penicillin-allergic patients. This study was conducted to investigate the prevalence of erythromycin-induced clindamycin resistance in gram positive organisms in the southern part of the country. A total of 522 consecutive clinical isolates from blood, CSF, sputum, throat, pus, and urine were collected between November 2006 and April 2007 and tested for erythromycin resistance and inducible clindamycin resistance. There was a relatively higher incidence of inducible clindamycin resistance among the MRSA isolates. We conclude, therefore, that clindamycin is not a suitable alternative antibiotic for use in staphylococcal skin and soft tissue infections.

Antibiotic resistance of Gardnerella vaginalis in recurrent bacterial vaginosis.

Fifty strains of Gardnerella vaginalis isolated from 321 high vaginal swabs over a period of five months were tested for their antibiotic sensitivity. Sixty eight per cent of all isolates were resistant to metronidazole while 76% were sensitive to clindamycin. All the strains isolated from cases with recurrence of infection were resistant to metronidazole. Clindamycin therapy has a better clinical efficacy than metronidazole in cases of recurrent bacterial vaginosis.