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Evoluzione dellantibiotico-resistenza: miti e realt


Gian Maria Rossolini
Dip. Biologia Molecolare
Sezione di Microbiologia
Universit di Siena
UO Microbiologia e Virologia
Azienda Osp-Univ Senese
MIC values
Inhibition zones
Broth or agar
dilution tests
How do we define resistance?
Interpretation of results
based on clinical breakpoints
Reference MIC/zone values for
interpretation of the results of in vitro
susceptibility testing
The clinical breakpoints
Definition of susceptibility category (S/I/R)
referred to clinical use
Clinical breakpoints are defined by
specific committees
Breakpoint committees in Europe
Committee Country
BSAC United Kingdom
CA-SFM France
CRG The Netherlands
DIN Germany
NWGA Norway
SRGA Sweden
CLSI USA
Enterics / cefotaxime S< / R>
BSAC United Kingdom
1 / 1
CA-SFM France
4 / 32
CRG The Netherlands
4 / 8
DIN Germany
2 / 8
CLSI U.S.A.
8 / 32
NWGA Norway
1 / 2
SRGA Sweden
0.5 / 1
with different opinions...
Kahlmeter et al JAC 2003
December 2004
to harmonise clinical breakpoints in
Europe
to determine breakpoints for new
antimicrobials
to provide standardised methodology
for AST
Setting clinical breakpoints for new
drugs in Europe
Co-ordinated process between the
Company, EMEA and EUCAST

When a Company applies for registration
of a new agent:
EUCAST defines the breakpoints
EMEA decides on all other aspects

EUCAST breakpoints for new drugs are
the only ones included in the SPC
(Summary of Product Characteristics)
EUCAST clinical breakpoints
Freely available on the WEB
Defined by consensus
Institutional decision body
(industry has a consulting role
but does not participate in the
decisional process)
Rationale for decision disclosed
(rationale documents available)
EUCAST vs. CLSI breakpoints:
a remarkable diversity
Courtesy by G. Kahlmeter
EUCAST CLSI
S R> S R>
Cefepime 8 8 8 16
Ceftazidime 8 8 8 16
Imipenem 4 8 4 8
Meropenem 2 8 4 8
Pip/Tazo 16 16 64 64
Aztreonam 1 16 8 16
Ciprofloxacin 0.5 1 1 2
Gentamicin 4 4 4 8
Tobramycin 4 4 4 8
Amikacin 8 16 16 32
Colistin 2 2 2 4
EUCAST vs. CLSI breakpoints:
Pseudomonas aeruginosa
For S: EUCAST 5/11 lower For R: EUCAST 8/11 lower
EUCAST vs. CLSI breakpoints:
Enterobacteriaceae
(beta-lactams & quinolones)
EUCAST CLSI
S R> S R>
Cefepime 1 8 8 16
Ceftriaxone 1 2 8 32
Ceftazidime 1 8 8 16
Ertapenem 0.5 1 2 4
Imipenem 2 8 4 8
Meropenem 2 8 4 8
Pip/Tazo 8 16 16 64
Levofloxacin 1 2 2 4
Ciprofloxacin 0.5 1 1 2
For S: EUCAST 9/9 lower For R: EUCAST 7/9 lower
EUCAST CLSI
S R> S R>
Amikacin 8 16 16 32
Gentamicin 2 4 4 8
Tobramycin 2 4 4 8
Cotrimoxazole 2 4 2 2
Colistin 2 2 NA NA
Tigecycline 1 2 NA NA
For S: EUCAST 3/4 lower
For R: EUCAST 3/4 lower, 1/4 higher
EUCAST vs. CLSI breakpoints:
Enterobacteriaceae
(other agents)
EUCAST vs. CLSI
Will the change from CLSI
to EUCAST breakpoint
system significantly
affect the epidemiology of
antibiotic resistance?
EUCAST vs. CLSI
A comparative analysis of AST
results interpreted according to
CLSI or EUCAST
Data source: historical records
from clinical microbiology
service, Siena University Hospital
(year 2008)
Pseudomonas aeruginosa
Gentamicin (N = 295)
2 4 8 16 32 64
EUCAST
CLSI
MIC (mg/L)
EUCAST: R
CLSI: I
Pseudomonas aeruginosa
Amikacin (N = 296)
2 4 8 16 32 64
EUCAST
CLSI
MIC (mg/L)
EUCAST: R
CLSI: I
EUCAST: I
CLSI: S
Pseudomonas aeruginosa
Ceftazidime (N = 294)
1 2 4 8 16 32
EUCAST
CLSI
MIC (mg/L)
EUCAST: R
CLSI: I
Pseudomonas aeruginosa
Meropenem (N = 216)
2 4 8 16 32 64
EUCAST
CLSI
MIC (mg/L)
EUCAST: I
CLSI: S
Pseudomonas aeruginosa
Pip/Tazo (N = 289)
2 4 8 16 32 64
EUCAST
CLSI
MIC (mg/L)
EUCAST: R
CLSI: S
Pseudomonas aeruginosa
Aztreonam (N = 133)
1 2 4 8 16 32
EUCAST
CLSI
MIC (mg/L)
EUCAST: I
CLSI: S
Pseudomonas aeruginosa
Ciprofloxacin (N = 295)
0.25 0.5 1 2 4 8
EUCAST
CLSI
MIC (mg/L)
EUCAST: R
CLSI: I
EUCAST: I
CLSI: S
Pseudomonas aeruginosa
CLSI vs. EUCAST
%

s
u
s
c
e
p
t
i
b
i
l
i
t
y

Antibiotics
MRSA impact (USA)
Boucher & Corey Clin Infec Dis 2008
a
in hospital deaths
Resistance trends in major pathogens
Europe
EARSS annual report, 2007
MRSA
C
o
u
n
t
r
i
e
s

8/30
8/30
14/30 =
E. coli R to 3GC
23/30
1/30
6/30 =
2008:
2/31
10/31
19/31 =
2008:
21/30
0/30
9/31 =
Resistance trends in major pathogens
Europe
EARSS annual report, 2007
MDR E. coli
(R to 3GC,AG,FQ)
24/30
0/30
6/30 =
C
o
u
n
t
r
i
e
s

E. coli R to 3GC
23/30
1/30
6/30 =
The growing challenge of resistant
Gram-negatives
MRSA and VRE rates have leveled off or
decreasing in several European countries
Resistant Gram-negatives are increasing in
most European countries

Rossolini & Mantengoli, CMI 2008
Major challenges:
Enterobacteriaceae
ESBL/AmpC, MDR, XDR (ESC/FQ/AG/NEM)
Pseudomonas aeruginosa and Acinetobacter
MDR, XDR (COL-S only)
EARSS database
Year
%

r
e
s
i
s
t
a
n
t

t
o

3
G
C

K. pneumoniae
ESBLs: increasing trends
EARSS database
Year
%

r
e
s
i
s
t
a
n
t

t
o

3
G
C

E. coli
ESBLs: increasing trends
%
Spanu et al. - AAC 2002; Luzzaro et al. - JCM 2006; OASIS study, data on file
ESBL-producing Enterobacteriaceae , Italy
Suspect ESBL
2003: Proteus mirabilis (isolates from UTIs and ulcers)
Aztreonam
Ceftazidime
Cefotaxime
Ceftriaxone
Amoxi/Clav
Resistant to 3rd gen. ceph.
but ESBL-negative
Ampicillin >128 R
Amoxi/Clav 32 R
Pip/Tazo 4 S
Cephalotin 32 R
Cefotaxime 64 R
Ceftazidime 32 R
Cefepime 2
Ertapenem 0.12 S
Amikacin 2 S
Gentamicin 4 S
Ciprofloxacin >32 R
Levofloxacin >32 R
MIC (mg/L)
R S
.
P. mirabilis resistant to
3rd gen. cephalosporins
Luzzaro et al IJAA 2009
Same clone detected
in LTCFs
By clonal expansion
Luzzaro et al IJAA 2009
Clinical features of infections caused
by the P. mirabilis CMY-16+
Mean age: 7515 yrs
(7616 for ESBL+; 5728 for susceptible
strains)

Female/male ratio: 1.1
(1.6 for ESBL+; 2.1 for susceptible strains)
Inpatients
LTCFs
HCAss
CA
51% 37%
Patients
UTIs
LRTIs
SSSIs
BSIs
80%
Sources
2007-2008:
P. mirabilis CMY+
spreading in Italy
Clonally related isolates detected in Greece and
Poland: an internationally spreading clone
DAndrea et al unpublished
>30 cases from BSIs
Courtesy of Vincent Jarlier,
Sept 2009 (modified)
ESBLs/AmpC and carbapenem overuse
Increased # ESBL/AmpC
cases
Increased Carb-R strains
Cross
transmission
of Carb-R
strains
Selection of Carb-R
strains

Increased
carbapenem
use
Production of:
- CTX-M-15 ESBL
- SHV-11
- (OXA-9) (TEM-1)
DAndrea et al. 19th ECCMID
2007-2008: emergence of MDR Klebsiella pneumoniae ERT-R
from several hospitals
Ampicillin >16 R
Amoxi/Clav >16 R
Pip/Tazo >64 R
Cefotaxime >16 R
Ceftazidime >32 R
Cefepime >16 R
Aztreonam >16 R
Imipenem 1
Meropenem 2-4
Ertapenem >4 R
Amikacin >32 R
Gentamicin >8 R
Tobramycin >8 R
Ciprofloxacin >32 R
Levofloxacin >32 R
TMP/SXT >2 R
Tigecycline 1 - 2
Colistin <1
MIC (mg/L)
Reduced porin expression
No carbapenemase act.
Nationwide
clonal spread
(ST37)
Ampicillin >16 R
Amoxi/Clav >16 R
Pip/Tazo >64 R
Cefotaxime >16 R
Ceftazidime >32 R
Cefepime >16 R
Aztreonam >16 R
Imipenem 1 R
Meropenem 2-4 R
Ertapenem >4 R
ESBL positive
Amikacin >32 R
Gentamicin >8 R
Tobramycin >8 R
Ciprofloxacin >32 R
Levofloxacin >32 R
TMP/SXT >2 R
Tigecycline 1 - 2 S
Colistin <1
MIC (mg/L)
Klebsiella pneumoniae with reduced carbapenem
susceptibility due to ESBL prod. + porin loss:
detection and reporting issues
Vitek-2 AES:
changes to resistance to all carbapenems
KPC-2
K. oxytoca
Yigit et al. AAC 2003
22% of isolates resistant to:
- Aminoglycosides
- Fluoroquonolones
- 3rd 4th gener. Cephems
- Carbapenems
Klebsiella pneumoniae
Susceptibility only to:
- Colistin
- Tigecycline
Due to spread of KPC
carbapenemases
Brooklyn, New York
Landman et al JAC 2007
KPC-type carbapenemases in Israel: a major problem
Nationwide
outbreak
Carbapenem resistance rates
in K. pneumoniae from Israel:
2006: 11%
2007: 22%
2008: 19%
EARSS database
KPC-type carbapenemases: a new pandemic?
Two cases, one
with Israel
connection
Clonally related
7 cases
4 from Greece
2 from Israel
Clonally related
Nordmann et al. Lancet ID 2009
Villegas et al. AAC 2007
Tsakris et al. JAC 2008
Hawser et al. IJAA 2009
Literacka et al. AAC 2009
Intercontinental spread
of ST258 KPC+ clone
KPC-type carbapenemases: emerging in Italy
Giani et al - JCM 2009
Florence
Oct 2008: KPC-3 positive K. pneumoniae
ST258 isolated from a cIAI (high-level
carbapenem resistance)
No epidemiological link with areas of
endemicity, but patient cared for by a
trainee from Israel
Lecco
May 2009: KPC positive K. pneumoniae
Patient transferred from another hospital
Large outbreak ongoing in that
hospital (26 patients colonized or
infected), variable carbapenem
resistance
Luzzaro et al - unpublished
Santoriello et al - unpublished
Mostly by clonal spread (ST258), but at
least two clones and also in Enterobacter
Additional reports
Carbapenem-resistant K. pneumoniae, Greece
Production of
VIM-1 MBL
Multiple clones
Often
susceptible
only to colistin
and tigecycline
(XDR)
Vatopoulos et al. - Eurosurveillance 2008
Psichogiou et al. JAC 2008
KPC-type (active-site serine, class A)
OXA-type (active-site serine, class D)
Metallo--lactamases (class B)
Carbapenemases of clinical relevance
GM
COL
AK
TOB
FEP
IPM
MEM
CAZ TZP
ATM
CIP
PRL
Lauretti et al. AAC 1999
Cornaglia et al. CID 2000
VERONA
1997
VIM-1 MBL-producing index strain
VR-143/97 (ser. O11; ST227)
Acquired MBLs in Pseudomonas aeruginosa
first Italian nationwide survey
VARESE 2.6%
PAVIA 1.3%
CREMONA 0.6%
PERUGIA 1.1%
SASSARI 0.9%
ROME 0.3%
AVELLINO 1.4%
NEAPLES 9.2%
FOGGIA 1.2%
GENOA
0%
TURIN
0%
LAQUILA
0%
2004:
Overall prevalence
1.3%
Rossolini et al. AAC 2008
2008:
Overall prevalence
7%
Luzzaro et al. - unpublished
CLSI soon replaced by EUCAST: resistance
rates will be affected in some cases
Resistance in Gram-negatives: now a major
problem
XDR phenotypes not only in Pseudomonas and
Acinetobacter but also among enterobacteria
Multiple resistance mechanisms: not easily
deducible from the antibiotype
Open issues in: lab detection, reporting,
infection control and treatment
Conclusions