Occurrence of extended-spectrum beta-lactamases in members of the family Enterobacteriaceae in Italy: implications for resistance to beta-lactams and other antimicrobial drugs

Abstract

An Italian nationwide survey was carried out to assess the prevalences and the antimicrobial susceptibilities of members of the family Enterobacteriaceae producing extended-spectrum beta-lactamases (ESBLs). Over a 6-month period, 8,015 isolates were obtained from hospitalized patients and screened for resistance to extended-spectrum cephalosporins and monobactams. On the basis of a synergistic effect between clavulanate and selected beta-lactams (ceftazidime, aztreonam, cefotaxime, cefepime, and ceftriaxone), 509 isolates were found to be ESBL positive (6.3%). Colony blot hybridization with bla(TEM) and bla(SHV) DNA probes allowed one to distinguish four different genotypes: TEM-positive, SHV-positive, TEM- and SHV-positive, and non-TEM, non-SHV ESBL types. MICs for each isolate (E-test) were obtained for widely used beta-lactams, combinations of beta-lactams with beta-lactamase inhibitors, aminoglycosides, and fluoroquinolones. Among ESBL-positive strains, Klebsiella pneumoniae, Proteus mirabilis, and Escherichia coli accounted for 73.6% of isolates. Overall, TEM-type ESBLs were more prevalent than SHV-type enzymes (234 versus 173), whereas the prevalence of strains producing both TEM- and SHV-type ESBLs was similar to that of isolates producing non-TEM, non-SHV enzymes (55 and 38, respectively). In vitro, all but one of the ESBL-producing isolates remained susceptible to imipenem. Susceptibility to other drugs varied: piperacillin-tazobactam, 91%; amoxicillin-clavulanic acid, 85%; cefoxitin, 78%; amikacin, 76%; ampicillin-sulbactam, 61%; ciprofloxacin, 58%; and gentamicin, 56%. Associated resistance to aminoglycosides and ciprofloxacin was observed most frequently among TEM-positive strains. Since therapeutic options for multiresistant Enterobacteriaceae are limited, combinations of beta-lactams and beta-lactamase inhibitors appear to represent an important alternative for treating infections caused by ESBL-producing ENTEROBACTERIACEAE:

FIG. 1.

ESBL-positive Enterobacteriaceae: frequency distribution of MICs of cefotaxime (□) and ceftazidime (▪). Results obtained from isolates carrying different ESBL gene types are shown in separate panels. Numbers of isolates were as follows: TEM type, n = 234; SHV type, n = 173; TEM and SHV type, n = 55; non-TEM-non-SHV, n = 38.

FIG. 2.

ESBL-positive Enterobacteriaceae: frequency distribution of MICs of amoxicillin-clavulanate (gray bars), ampicillin-sulbactam (white bars), and piperacillin-tazobactam (black bars). Results obtained from isolates carrying different ESBL gene types are shown in separate panels. See Fig. 1 for numbers of isolates.