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0095-1137/11/$12.00 doi:10.1128/JCM.02130-10
Copyright © 2011, American Society for Microbiology. All Rights Reserved.
The recent international spread of Escherichia coli produc- essary for prediction of clinical outcome. However, it is still of
ing CTX-M extended-spectrum -lactamases (ESBL) is a ma- importance for infection control to limit its spread and to
jor concern because of new microbiological and epidemiolog- measure the evolution of the spread and the impact of control
ical features (2, 29). Indeed, E. coli is a commensal of our programs.
digestive tract and it is the most frequent organism isolated Several phenotypic methods have been developed to detect
from urinary tract infections in the community and in hospitals. or confirm ESBL production by Enterobacteriaceae (8, 10, 15,
Therefore, increases in multiresistance in this species will lead 19, 33–35). The CLSI in the United States issued national
to increased use of the few antibiotics that remain active, such guidelines for laboratory detection of E. coli, Proteus mirabilis,
as carbapenems, and possibly to the emergence of carbap- and Klebsiella spp. with ESBL (6), but not for species with
enem-resistant organisms (22). Finally, ESBL-producing En- inducible AmpC -lactamases, such as Enterobacter spp. The
terobacteriaceae are now found in ambulatory patients without Health Protection Agency in the United Kingdom released
recognized risk factors for multidrug-resistant organisms (28). guidelines for ESBL detection regardless of the tested species
Consequently, recognition of ESBL-producing organisms has (14). Most guidelines recommend screening isolates based on
become a concern for general hospitals and private practice decreased susceptibility to extended-spectrum cephalosporins
laboratories. The recent changes in clinical MIC breakpoints in primary susceptibility testing and to use one of the available
for extended-spectrum cephalosporins and for aztreonam tests to confirm ESBL production. However, it is not clear
against Enterobacteriaceae by EUCAST and CLSI decrease the which confirmatory tests are the most sensitive and which ex-
likelihood of interpreting an ESBL-producing Enterobacteria- tended-spectrum cephalosporins should be tested. In addition,
ceae as susceptible to exended-spectrum cephalosporins (6, the recent emergence of plasmidic AmpC -lactamases in E.
13). Thus, recognition of ESBL production would not be nec-
coli and Klebsiella pneumoniae may lead to changes in recom-
mendations. Guidelines from the Antibiogram Committee of
* Corresponding author. Mailing address: Laboratoire de Bactéri- the French Society for Microbiology (CA-SFM) consider all
ologie-Hygiène, UFR de Médecine Pierre et Marie Curie (UPMC Enterobacteriaceae species and do not recommend use of a
Paris 6), 91 Boulevard de l’hôpital, 75634 Paris Cedex 13, France.
Phone: (33) 1 40 77 97 49. Fax: (33) 1 45 82 75 77. E-mail: jerome
confirmatory test if the screening test provides specific evi-
.robert@psl.aphp.fr. dence of ESBL production (7). Of note, the latter guidelines
䌤
Published ahead of print on 19 January 2011. suggest the use of cloxacillin-containing Mueller-Hinton agar
1048
VOL. 49, 2011 ESBL DETECTION IN ENTEROBACTERIACEAE 1049
Enterobacter spp. isolates, SHV-specific PCR was performed first (4), and in the (LR) of a positive and a negative test for each strategy. The LR of a positive test
case of a negative result, the presence of blaCTX-M or blaTEM was determined. (LR⫹) is the ratio of the true-positive rate to the false-positive rate, and the LR
For other Enterobacteriaceae, or in case of the absence of CTX-M-, TEM-, and of a negative test (LR⫺) is the ratio of the false-negative rate to the true-negative
SHV-encoding genes, isolates were screened for the presence of the following bla rate. LR are not dependent on the pretest probability of the event in the tested
genes: blaPER-1, blaPER-2, blaVEB, blaGES, blaKPC, blaOXA-2, blaOXA-10. population, in contrast with positive and negative predictive values, and are
Detection by two-step strategies. We assessed the performance of two-step therefore preferred for assessment of performances of diagnostic tests. The gain
strategies, based on a first routine method used for global susceptibility testing of adding a second test (II) to a first “screening test” (I) was assessed by using LR
(“triage test”), i.e., routine disk diffusion method or Vitek2, and a second method graphs as previously described (1) and derived from standard receiver operating
specifically designed to detect ESBL production in strains negative or with an characteristics curves analysis. In brief, the false-positive rate (1 ⫺ specificity) of
indeterminate result with the first method. Characteristics of the two-steps strat- the “screening test” (I) is plotted against its true-positive rate (sensitivity). The
egies were computed by using the test which yielded the highest sensitivity for slope of a solid line connecting this defined point to the point (0,0) represents
each of the nine methods described above. the LR of a positive test, and the slope of a dashed line connecting this point to
Statistical analysis. All test results were blindly read by two persons before the point (1,1) represents the LR of a negative test (see Fig. 3, below). Conse-
ESBL-encoding gene detection. They were performed once per strain, except in quently, four regions are defined: region A, where the addition of a second test
cases of the absence of growth on cloxacillin-containing agar or in cases of (II) yields a result superior overall to the single test (LR⫹ II ⬎ LR⫹ I and LR⫺
doubtful interpretation for both readers. II ⬍ LR⫺ I); region B, where the addition of test II is superior to test I for
Statistical analysis was performed by using Stata 10 (StataCorp, College Sta- confirming the absence of ESBL (LR⫹ II ⬍ LR⫹ I and LR⫺ II ⬍ LR⫺ I); region
tion, TX) and SAS (SAS Institute, Cary, NC) software. Sensitivity (Se) and C, where the addition of test II is superior for confirming the presence of ESBL
specificity (Sp) of each phenotypic test were computed by using ESBL-encoding (LR⫹ II ⬎ LR⫹ I and LR⫺ II ⬎ LR⫺ I); region D, where the addition of test II
gene detection by PCR as the gold standard. However, one strain with none of is inferior overall (LR⫹ II ⬍ LR⫹ I and LR⫺ II ⬎ LR⫺ I).
the tested ESBL genes but which yielded a typical ESBL pattern with all methods
was considered ESBL positive. Indeterminate results were grouped with negative
results for sensitivity computations and with positive results for specificity com- RESULTS
putations.
Statistical comparisons of characteristics of the tests (Se and Sp) were per-
Bacterial strains. Among the 416 strains of Enterobacteria-
formed by using McNemar’s test with exact significance probability. In addition, ceae isolated during the study period, a total of 107 strains
to evaluate the interest of each two-step strategy, we computed likelihood ratios (25%) fulfilled the inclusion criteria. The strains were classified
VOL. 49, 2011 ESBL DETECTION IN ENTEROBACTERIACEAE 1051
TABLE 2. Distribution of the 107 Enterobacteriaceae isolates and false-negative results for two strains (one E. coli and one
included in the study and their ESBL genes E. aerogenes strain) producing CTX-M and highly resistant to
No. of No. of isolates with extended-spectrum cephalosporins (MIC ⬎ 128 mg/liter). The
No. of ESBL
Enterobacteriaceae isolates
producersa indicated ESBL type combination of the results of ⬎3 of the 5 -lactams did not
group and species (% of
(% of total) CTX-M SHV TEM improve the Se. As for Vitek2, DDS30 Se was lower for group
total)
3 Enterobacteriaceae than for other groups for a majority of
Group 1 28 (26) 21 (40)
Escherichia coli 27 20 18 2 combinations of -lactams.
Proteus mirabilis 1 1 1 DDS20. Se reached 100% for FEP or ATM alone, whatever
Group 2 25 (23) 18 (35)
the group of Enterobacteriaceae, but was lower for CTX, CAZ,
Klebsiella pneumoniae 21 17 10 2 5 and CPD (Table 3). The combination of two or three disks with
Klebsiella oxytoca 2 0 CTX, CAZ, or CPD allowed Se to reach 100%.
Citrobacter koseri 2 1 1
DDS30 on cloxacillin MH agar. Compared to the routine
Group 3 54 (51) 13 (25) DDS30 test on MH agar, there was no increase in Se or Sp
Vitek2 card
N017 31 64 56 23 77 50 39 23 59
N017 ⫹ extended card 25 79 53 9 95 43 41 31 56
N052 27 65 60 15 80 71 39 23 56
N052 ⫹ extended card 26 73 56 6 92 79 46 15 49
Cica-Beta test
ESBL or multidrug resistance 14 75 80 15 74 57 13 77 88
TABLE 4. Significance levels for sensitivity and specificity comparisons of selected tests for all 107 isolatesa
P value for comparison of Se and Sp for indicated tests
DDS30
DDS30 MH Etest Combined disk
Comparison test Vitek2 with
(CTX ⫹ DDS20 MH Cica-Beta
(N052 ⫹ cloxacillin
FEP ⫹ (FEP) test
EXN5) (CTX ⫹
ATM) MH Cloxacillin MH Cloxacillin
FEP)
Vitek2 N052 ⫹ EXN5 — 0.002 ⬍0.001 0.26 0.01 ⬍0.001 ⬍0.001 ⬍0.001 1.0
DDS30 (CTX ⫹FEP ⫹ ATM) ⬍0.001 — 0.50 0.10 0.45 0.50 1.0 0.50 0.007
DDS20 MH (FEP) ⬍0.001 1.0 — 0.008 0.06 1.0 0.50 1.0 ⬍0.001
DDS30 with cloxacillin 0.003 0.04 0.22 — 0.58 0.008 0.11 0.008 0.33
(CTX⫹FEP)
Etest MH (FEP) 0.001 0.06 0.06 0.77 — 0.06 0.37 0.06 0.08
Etest with cloxacillin 0.11 0.001 ⬍0.001 0.11 0.06 — 0.50 1.0 ⬍0.001
(CTX⫹FEP)
Combined disk MH 0.008 0.008 0.02 1.0 0.55 0.30 — 0.50 0.003
(CTX⫹FEP)
Combined disk with cloxacillin ⬍0.001 0.22 0.22 0.25 1.0 0.04 0.34 — ⬍0.001
(CTX⫹FEP)
Cica-beta test 0.03 0.002 0.002 0.51 0.19 0.58 0.79 0.11 —
a
P values were calculated using using the McNemar test. The upper part of the table (above the dashes) reports the P values for comparisons of sensitivities, and
the lower part reports P values for comparisons of specificities for each pair of the nine selected tests.
1054 GARREC ET AL. J. CLIN. MICROBIOL.
TABLE 5. Summary of results with two-step strategies combining either DDS30 (CTX ⫹ FEP ⫹ ATM) or Vitek2 (N052 ⫹ EXN5) with a
second method specifically designed to detect ESBL
Value for the indicated comparisona
Routine DDS30 alone 0.0 96 98 52.9 0.04 0.0 97 93 9.6 0.04 0.0 92 100 75 0.11
Vitek2 with:
DDS20 on MH (FEP) 0.0 100 89 8.5 0.01 0.0 100 79 4.2 0.02 0.0 100 93 11.6 0.04
DDS30 on MH with 5.6 98 78 9.0 0.01 5.7 97 57 4.6 0.04 5.6 100 85 11.6 0.04
cloxacillin (CTX ⫹ FEP)
Etest strip on MH (FEP) 3.7 92 80 7.3 0.10 1.9 100 64 3.3 0.02 5.6 69 85 9.5 0.38
Etest strip on MH with 11.2 100 67 8.5 0.01 7.5 100 50 4.2 0.03 14.8 100 73 11.6 0.05
cloxacillin (CTX ⫹ FEP)
Combined disk on MH 0.0 96 76 4.1 0.05 0.0 100 71 3.3 0.02 0.0 85 78 3.6 0.23
(CTX ⫹ FEP)
Combined disk on MH with 4.7 100 82 10.1 0.01 5.7 100 75 5.9 0.02 3.7 100 88 11.6 0.04
cloxacillin (CTX ⫹ FEP)
Cica-Beta test 9.3 90 73 7.1 0.13 7.5 92 43 3.2 0.18 11.1 85 83 11.6 0.19
a
Results shown are the percent indeterminate results (In), Se, and Sp, as well as positive and negative likelihood ratios (LR⫹ and LR⫺, respectively).
alone to confirm the absence of ESBL as well as to confirm Numerous studies have tested the ability of phenotypic
the presence of ESBL (Fig. 3, panel 2). When considering methods to detect ESBL production by Enterobacteriaceae (8–
the subset of group 1 and 2 Enterobacteriaceae, the Cica- 10, 15, 17–19, 26, 27, 30, 33–35). Our study is original, because
Beta test fell in the D zone, indicating that addition of the it involved a set of consecutive nonduplicated and nonselected
latter test gave inferior results than the Vitek2 alone. In strains and because 50% of all tested strains were chromo-
contrast, most of the other strategies provided an added somal AmpC producers not covered by some ESBL detection
gain for confirming the absence of ESBL among this subset guidelines (3, 6). In addition, we compared numerous pheno-
(B zone), and DDS20 was superior to confirm the presence typic methods, including some modified methods that have not
and absence of ESBL (A zone) (Fig. 3, panel 4). been systematically evaluated. However, the selection process
of the set of strains relied on the disk diffusion method, and the
DISCUSSION use of another selection method may have led to a somewhat
different set of species and ESBL. Consequently, the global
Detection of ESBL production by Enterobacteriaceae re-
results may have been slightly modified. In addition, some rare
mains a challenge for microbiologists. Although recent
types of ESBL have not been tested (20), and further confir-
changes in the breakpoints of extended-spectrum cephalospo-
rins have decreased the likelihood of reporting ESBL produc- mation of our results with isolates producing these enzymes
ers as susceptible to these compounds, ESBL detection is of may be of interest. Finally, our results may not apply to labo-
interest for prevention of dissemination of ESBL producers by ratories that use other phenotypic methods for routine suscep-
cross-transmission and for epidemiological purposes. We com- tibility testing.
pared nine phenotypic methods, including two methods widely The high sensitivity of the disk diffusion method when using
used for routine antibiotic susceptibility testing and seven three or more extended-spectrum cephalosporins has been re-
methods specifically developed to detect ESBL production ported by others, despite different settings and ESBL being
(32). We showed that the combination of a routine method tested (9, 35). However, all combinations of two or three
followed by a specific test might achieve almost 100% sensi- compounds are not equivalent. To our knowledge, this is the
tivity for ESBL detection in a large panel of Enterobacteriaceae first attempt to evaluate systematically the sensitivities of dif-
species. ferent combinations of extended-spectrum cephalosporins or
VOL. 49, 2011 ESBL DETECTION IN ENTEROBACTERIACEAE 1055
monobactam for detection of ESBL. The Health Protection some authors have reported a high sensitivity, albeit combined
Agency of the United Kingdom recommends testing cefpo- with very low specificity (35).
doxime or both cefotaxime and ceftazidime as a first screening Recommendations of the manufacturer are to test cefo-
test (14). In the present study, the combination of the two taxime and ceftazidime as the first-line method with ESBL
latter drugs achieves 77% sensitivity to adequately detect Etest strips and to complete testing with the cefepime ESBL
ESBL production, meaning that only 33% of the isolates would Etest in cases with an inconclusive result from the first two
need further testing. Including cefepime in the primary routine strips. Our results do not support this strategy. First, the sen-
method will result in 96% sensitivity and therefore reduce the sitivity of the cefotaxime ESBL Etest strip was not significantly
need for further testing to as few as 4% of the isolates. When improved by concomitant testing of the ceftazidime strip (71%
using cefpodoxime alone, the results imply that almost two- versus 73%). Second, the sensitivity and specificity of the
thirds of isolates would need further testing, and all of the cefepime ESBL Etest strip used alone were significantly higher
group 3 Enterobacteriaceae would have to go through a second than those obtained with both cefotaxime and ceftazidime
test. ESBL Etest strips (90% versus 73%). Such a high sensitivity of
The ability of the Vitek2 system as a routine method to the cefepime test has previously been reported for group 1 and
detect ESBL production was rather low, as it remained below 2 Enterobacteriaceae (31, 35).
80% when considering all species. As expected and previously As previously reported, the ability of the combined disk
reported, sensitivity peaked to 92% to 95% for ESBL detection method to detect ESBL is very satisfactory, and sensitivity can
in E. coli and K. pneumoniae (17, 30, 35). Of note, the Vitek2 reach 100% when testing both cefotaxime and cefepime
specificity was low (50% to 79%) because of a rather high against group 1 and 2 Enterobacteriaceae (16). However, in the
frequency of indeterminate results. Microbiologists should present study, sensitivity after testing the two latter drugs was
bear in mind that this method has been validated only for not different from that of cefotaxime alone.
group 1 and 2 Enterobacteriaceae and that it is not reliable to The modified double-disk synergy method has been previ-
detect ESBL among group 3 Enterobacteriaceae, although ously reported to increase the sensitivity of the double-disk
1056 GARREC ET AL. J. CLIN. MICROBIOL.
method (15, 33, 34), but usually the distance between disks is 4. Cambau, E., et al. 2006. Occurrence of qnrA-positive clinical isolates in
French teaching hospitals during 2002–2005. Clin. Microbiol. Infect. 12:
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ommended elsewhere (14, 15). We demonstrated that a stan- Detection of extended-spectrum beta-lactamases in Klebsiellae with the
Oxoid combination disk method. J. Clin. Microbiol. 38:4228–4232.
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The present report is the first to compare the character- 7. Comité de l’Antibiogramme de la Société Française de Microbiologie.
2010. Recommendations 2010. Société Française de Microbiologie, Paris,
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