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• W2018530326 abstract "The role of bacterial pathogens in CF pulmonary disease contributes greatly to the morbidity and mortality in patients with CF. CF patients have recurrent and chronic respiratory tract infections and most of their morbidity and mortality is due to such infections throughout their life [1Lyczak J.B. Cannon C.L. Pier G.B. Lung infections associated with cystic fibrosis.Clin Microbiol Rev. 2002; 15: 194-222Crossref PubMed Scopus (1200) Google Scholar, 2Rajan S. Saiman L. Pulmonary infections in patients with cystic fibrosis.Semin Respir Infect. 2002; 17: 47-56Crossref PubMed Scopus (183) Google Scholar]. These infections are usually dominated by non-fermenting Gram-negative organisms (Burkholderia cenocepacia and Stenotrophomonas maltophilia), including Pseudomonas aeruginosa. P. aeruginosa is the single most important pathogen in this patient population. Recent advances in treatment, which include intensive physiotherapy and aggressive antibiotic treatment, have greatly improved the outlook for patients. However, with the improvement in survival rates in CF patients, a new range of pulmonary issues have arisen. These include the emergence of multi-drug resistant strains of P. aeruginosa [[3]Pitt T.L. Sparrow M. Warner M. Stefanidou M. Survey of resistance of Pseudomonas aeruginosa from UK patients with cystic fibrosis to six commonly prescribed antimicrobial agents.Thorax. 2003; 58: 794-796Crossref PubMed Scopus (121) Google Scholar] and the appearance of organisms with increased virulence such as the Burkholderia cepacia complex (BCC). There are approximately 283 adult CF patients in Northern Ireland (NI) with CF, where they receive regional CF centre-based multidisciplinary care at the Regional Adult Cystic Fibrosis Centre, Belfast City Hospital. At present, the UK CF Registry, which is compiled by the CF Trust [[4]Anon UK CF Trust Registry.www.cftrust.org.uk/Date: January 03 2012Google Scholar], includes data on the presence of respiratory pathogens, but does not include any information on antibiotic susceptibility of colonising/infection respiratory pathogens, including P. aeruginosa. A study was therefore undertaken locally to evaluate current levels of antimicrobial susceptibility in adult CF patients who were infected with P. aeruginosa and to compare levels of antibiotic susceptibility, with a comparator non-CF population of invasive P. aeruginosa, isolated from blood culture material. One hundred and twenty seven adult patients (approximately. 61.7% of total adult CF patients in NI) with a confirmed clinical diagnosis of CF were included in the study. There were 72 males and 55 females, with an age range of 19–82 years and 18–61 years, respectively. Of the 127 patients with a documented history of P. aeruginosa infection, P. aeruginosa isolates were selected as part of the routine microbiological workup, which included the selection of isolates which were morphologically different, including those which were mucoid. From these, 99 were non-mucoid, 26 were mucoid and 2 were mixed (mucoid+non-mucoid). Antibiotic susceptibility profiles of the most recent P. aeruginosa isolate were examined and antibiotic susceptibility noted against the following four antibiotic classes [11 agents]: aminoglycosides [amikacin, gentamicin, tobramycin], β-lactams [aztreonam, ceftazidime, imipenem, meropenem, temocillin, tazobactam/piperacillin], fluoroquinolones [ciprofloxacin] and polymyxins [colistin]. Antibiotic susceptibility was recorded as either susceptible (sensitive) or non-susceptible (moderately or totally resistant). For comparative purposes, 173 isolates of P. aeruginosa were examined from a non-CF source, namely from blood culture material from the period 2001–2009, using a similar standard disc diffusion assay to that employing in CF susceptibility testing. - A similar panel of antibiotics with breakpoints was employed to the CF panel with the exception of amikacin, temocillin and imipenem, which were not tested in the non-CF isolates. Comparison of antibiotic susceptibilities for CF and non-CF derived P. aeruginosa isolates is shown in Fig. 1. By employment of the t test, antibiotic susceptibility was statistically significantly lower (p=0.0045) in CF-derived isolates than in non-CF derived P. aeruginosa isolates for all antibiotic classes and agents examined. Antibiotic resistance in CF isolates to amikacin, imipenem and temocillin was 52.8%, 43.3% and 37.0%, respectively. Within the CF population of P. aeruginosa isolates, most antibiotic susceptibility was seen in tazocin/aztreonam >ceftazidime >meropenem >temocillin >imipenem within the β-lactam agents, with tobramycin >amikacin >gentamicin, within the aminoglycoside agents. Multidrug resistance (i.e. antibiotic non-susceptibility in two classes of three from aminoglycosides, β-lactams and fluoroquinolones) was observed in 19 non-mucoid isolates/patients (15.0% CF patient population examined), whilst pan-resistance (i.e. antibiotic non-susceptibility in all three classes, aminoglycosides, β-lactams and fluoroquinolones) was observed in 12 isolates/patients (9.5% CF patient population examined), with all but one isolate being non-mucoid. Tobramycin, meropenem and ciprofloxacin were chosen, as surrogates of the aminoglycosides, the cell wall active agents (β-lactams) and the fluoroquinolones, respectively, as indicated by the Cystic Fibrosis Foundation [[5]Davies G. McShane D. Davies J.C. Bush A. Multiresistant Pseudomonas aeruginosa in a pediatric cystic fibrosis center: natural history and implications for segregation.Pediatr Pulmonol. 2003; 35: 253-256Crossref PubMed Scopus (14) Google Scholar]. The various combinations and frequency of resistance within these classes of antibiotics are shown (Fig. 2). In an attempt to display the clustering relationship of these 127 isolates based on antibiotic susceptibilities, we performed a cluster analysis employing Euclidean distance, i.e.distancex,y={Sixi−yi2}½which is the geometric distance between points in multidimensional space. For each antibiotic susceptibility datapoint with each isolate, the qualitative susceptibility profile of susceptible/non-susceptible was converted to a quantitative score, where 1=susceptible and 2=non-susceptible. The latter category included fully resistant, as well as intermediately/moderately resistant phenotypes. A distance matrix spreadsheet was compiled of all isolates and the similarity displayed on a tree joining dendogram (Fig. 3), employing the multivariate exploratory/cluster analysis function within the Statistica software package (StatsSoft Inc., Tulsa, USA). From this, 31 individual resistotypes (i.e. a specific and unique antibiotic susceptibility phenotype across 11 antibiotic agents) of which resistotype A and resistotype B formed the largest clusters, of 18.1% and 8.7%, respectively, of total isolates examined. In any comparative study, it is important to appreciate the differences between the two sets of isolates being compared. The CF P. aeruginosa isolate examined was the most recent isolate obtained from each CF patient. In most cases, the CF isolates were from January to July 2011, but a minority were from 2010, namely whenever the CF patient last presented to either out-patient clinic or was an in-patient. The isolation methods differed between the way CF and non-CF (blood culture) isolates were obtained, as is normal practise in most clinical microbiology service laboratories. In the case of CF, isolates were cultured directly from CF sputum by selective plating techniques, namely on Pseudomonas Isolation Agar, whereas in the case of P. aeruginosa obtained from blood culture, isolates were obtained via non-selective liquid culture medium (Becton Dickinson BactAlert Aerobic culture medium) followed by plating onto non-selective medium, Columbia Agar Base, supplemented with 5% [v/v] defibrinated horse blood. Once isolated, both P. aeruginosa isolates from CF and non-CF were treated in a similar fashion through identification stages (API 20 NE), as well as through antimicrobial susceptibility testing using standardised disc susceptibility testing using CLSI criteria (www.CLSI.org). The number of antibiotics tested differed between CF and non-CF isolates, where there was a larger number of antibiotics tested for CF isolates, to aid in antibiotic management decision making, due to the inherent higher rates of resistance in the CF isolates, in comparison with the blood culture P. aeruginosa isolates. Breakpoints did not change throughout the periods examined. However, we now wish to report these data as our laboratory is now changing over to EUCAST breakpoint criteria (www.eucast.org/) and such a retrospective examination of susceptibility would be more difficult to perform, hence the timeliness of our manuscript. It is equally important to differentiate P. aeruginosa from CF and non-CF sources, given the major differences in antibiotic susceptibility data between these two cohorts of P. aeruginosa. Previously, in such a study, Bosso et al. [[6]Bosso J.A. Mauldin P.D. Steed L.L. Consequences of combining cystic fibrosis- and non-cystic fibrosis-derived Pseudomonas aeruginosa antibiotic susceptibility results in hospital antibiograms.Ann Pharmacother. 2006; 40: 1946-1949Crossref PubMed Scopus (16) Google Scholar] reported that by combining CF and non-CF isolates, this led to a situation of perceived overestimating antibiotic resistance in non-CF P. aeruginosa isolates, which could potentially lead to alteration in empirical prescribing in such non-CF cases. Given the relatively small numbers of P. aeruginosa examined in this study, as well as the examination of antibiotic susceptibility at a single recent timepoint, it is difficult to reliably attribute increased resistance levels to use of various antibiotics, in a quantitative and statistically robust manner. However, during the period examined and prior to this, most CF patients would have had exposure to the three major classes of antibiotics, namely the β-lactams, the aminoglycosides and the fluoroquinolones. Previously, Manno et al. [[7]Manno G. Cruciani M. Romano L. Scapolan S. Mentasti M. Lorini R. et al.Antimicrobial use and Pseudomonas aeruginosa susceptibility profile in a cystic fibrosis centre.Int J Antimicrob Agents. 2005; 25: 193-197Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar] examined antibiotic susceptibility patterns in 1315 mucoid P. aeruginosa isolates from 224 patients, alongside antibiotic usage data over a five-year period and showed that there was a significant decline in the susceptibility to the aminoglycosides, imipenem and ciprofloxacin, while the susceptibility of P. aeruginosa to piperacillin and ceftazidime was stable. Overall, this study showed that P. aeruginosa isolated from patients with CF is more resistant than P. aeruginosa from non-CF patients. This phenomenon has been shown previously in CF with other organisms, including Staphylococcus aureus, as well as the viridans group streptococci [8Phaff S.J. Tiddens H.A. Verbrugh H.A. Ott A. Macrolide resistance of Staphylococcus aureus and Haemophilus species associated with long-term azithromycin use in cystic fibrosis.J Antimicrob Chemother. 2006; 57: 741-746Crossref PubMed Scopus (82) Google Scholar, 9Tazumi A. Maeda Y. Goldsmith C.E. et al.Molecular characterization of macrolide resistance determinants [erm(B) and mef(A)] in Streptococcus pneumoniae and viridans group streptococci (VGS) isolated from adult patients with cystic fibrosis (CF).J Antimicrob Chemother. 2009; 64: 501-506Crossref PubMed Scopus (29) Google Scholar, 10Maeda Y. Murayama M. Goldsmith C.E. et al.Molecular characterization and phylogenetic analysis of quinolone resistance-determining regions (QRDRs) of gyrA, gyrB, parC and parE gene loci in viridans group streptococci isolated from adult patients with cystic fibrosis.J Antimicrob Chemother. 2011; 66: 476-486Crossref PubMed Scopus (32) Google Scholar] and reflects the chronic burden of antibiotic exposure of pathogens and commensal flora to several classes of antibiotics used in the management of CF airways infection. These data also illustrate the complexity of antibiotic susceptibility within CF P. aeruginosa, with the generation of at least 31 resistotype profiles from 127 patients. Analyses of resistotype information can lead to the arbitrary grouping of P. aeruginosa isolates into sensitive, multidrug resistant (MDR-P. aeruginosa) and pan-resistant (PR-P. aeruginosa) phenotypes, based on previous definitions of these terms [[11]Falagas M.E. Koletsi P.K. Bliziotis I.A. The diversity of definitions of multidrug-resistant (MDR) and pandrug-resistant (PDR) Acinetobacter baumannii and Pseudomonas aeruginosa.J Med Microbiol. 2006; 55: 1619-1629Crossref PubMed Scopus (321) Google Scholar]. In our case, approximately a quarter of the Pseudomonas clinic are either MDR-P. aeruginosa or PR P. aeruginosa (15.0% and 9.5%, respectively). Extended analyses of simple antibiogram information can help elucidate trends in antibiotic susceptibility, as well as patient profiling in terms of the resistotype that individual patients harbour, and help to cohort patients within susceptibility groupings, for infection control purposes, where epidemic strains with a known resistotype pattern are circulating within patients at a CF centre. Author PR was supported by a Nuffield Summer Student Bursary administered through Sentinus. The authors wish to thank Ms. Judith Payne for all her assistance with database queries." @default.
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• W2018530326 title "Comparison of antibiotic susceptibility patterns in Pseudomonas aeruginosa isolated from adult patients with cystic fibrosis (CF) with invasive Pseudomonas aeruginosa from non-CF patients" @default.
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