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PubMed1999

Typing and characterization of mechanisms of resistance of Shigella spp. isolated from feces of children under 5 years of age from Ifakara, Tanzania.

Eighty-six strains of Shigella spp. were isolated during the dry season from stool samples of children under 5 years of age in Ifakara, Tanzania. The epidemiological relationship as well as the antimicrobial susceptibility and mechanisms of resistance to ampicillin, chloramphenicol, and co-trimoxazole were investigated. Four different epidemiological tools, pulsed-field gel electrophoresis (PFGE), repetitive extragenic palindromic (REP)-PCR, plasmid analysis, and antibiogram, were compared for typing Shigella strains. Seventy-eight (90%) strains were Shigella flexneri and were distributed into four groups, by either PFGE or REP-PCR, with 51, 17, 7, and 3 strains. The four strains of Shigella dysenteriae belonged to the same group, and the four strains of Shigella sonnei were distributed in two groups with three and one strain each. Plasmid analysis showed a high level of heterogeneity among strains belonging to the same PFGE group, while the antibiogram was less discriminative. REP-PCR provided an alternative, rapid, powerful genotyping method for Shigella spp. Overall, antimicrobial susceptibility testing showed a high level of resistance to ampicillin (81.8%), chloramphenicol (72.7%), tetracycline (96.9%), and co-trimoxazole (87.9%). Ampicillin resistance was related to an integron-borne OXA-1-type beta-lactamase in 85.1% of the cases and to a TEM-1-type beta-lactamase in the remaining 14.8%. Resistance to co-trimoxazole was due to the presence of a dhfr Ia gene in all groups except one of S. flexneri, where a dhfr VII gene was found within an integron. Chloramphenicol resistance was associated in every case with positive chloramphenicol acetyltransferase activity. All strains were susceptible to nalidixic acid, ciprofloxacin, ceftazidime, cefotaxime, and cefoxitin. Therefore, these antimicrobial agents may be good alternatives for the treatment of diarrhea caused by Shigella in Tanzania.

Bacterial Typing Techniques↗
PubMed2003

Antimicrobial resistance and genetic diversity of Shigella sonnei isolates from western Ireland, an area of low incidence of infection.

Shigella sonnei is a significant cause of gastroenteritis in both developing and industrialized countries. Definition of the diversity and antimicrobial susceptibility of S. sonnei isolates may be helpful in the management of individual cases and outbreaks. Antimicrobial susceptibility testing and pulsed-field gel electrophoresis (PFGE) were performed with 67 isolates of S. sonnei predominantly (n = 59) from three counties in the west of Ireland. Phage typing (n = 17), plasmid profiling (n = 28), and integron analysis (n = 24) were performed with subsets of strains. PFGE typing permitted recognition of two major clusters: PFGE type A (n = 53) and PFGE type B (n = 14). PFGE type A was associated with resistance to ampicillin, streptomycin, and sulfonamides (51 of 53 isolates), and those that were phage typed (n = 6) were phage type 3. PFGE type B was associated with resistance to streptomycin, sulfonamides, tetracycline, and trimethoprim (11 of 14 isolates) and phage type 6 (9 of 11 isolates). Fifteen different plasmid profiles were identified among the 28 isolates analyzed. A class 2 integron was present in all 14 PFGE type B isolates. One of these isolates also contained a class 1 integron and showed a unique variant of the PFGE type B pattern. Sequence analysis of the gene cassette structures contained within these integrons identified distinct open reading frames that encoded determinants of resistance to trimethoprim, streptomycin, and streptothricin. Our data demonstrate two predominant PFGE types among S. sonnei isolates circulating in this region. The limited diversity of the S. sonnei isolates in this region means that detection of isolates indistinguishable by PFGE and according to their antibiograms in two or more patients is not persuasive evidence of a common-source food- or waterborne outbreak. Indistinguishable plasmid profiles in addition to indistinguishable PFGE and antibiogram types may be more suggestive of an epidemiologically relevant link between cases.

Bacterial Typing Techniques↗
PubMed2005

[Microbiological diagnosis of urinary tract infections].

Definitive diagnosis of urinary tract infection (UTI) is performed through quantitative urine culture. Traditionally the presence of 100,000 or more bacteria/ml in urine has been considered to represent significant bacteriuria, indicating UTI. However, this criterion is only applicable to certain population groups and cannot currently be considered an absolute criterion. The "real" presence of any number of bacteria in urine can represent a UTI when there are specific symptoms and pyuria. In the last few years various automatic systems have been introduced onto the market which, by adapting classical diagnostic techniques, allow the presence of a UTI to be rapidly ruled out, although their clinical utility is controversial. In addition, the new chromogenic culture media allow direct identification of uropathogens and, in particular, are of enormous help in the detection of polymicrobial cultures. Likewise, automatic systems can provide results on identification and sensitivity to be obtained in a single day. However, because new phenotypes of resistance are continually appearing, the antibiogram model used with classical uropathogens has had to be modified, requiring special techniques for pathogen detection and characterization. Correct interpretation of the antibiogram in these cases is essential to detect these phenotypes and achieve therapeutic success.

Adult↗
PubMedDate not supplied

Use of pulsed-field gel electrophoresis in the analysis of recurrent Staphylococcus aureus infections in patients on continuous ambulatory peritoneal dialysis.

BACKGROUND/AIM: The purpose of this study was to evaluate pulsed-field gel electrophoresis (PFGE) for distinguishing between relapse and reinfection of Staphylococcus aureus infections in patients on continuous ambulatory peritoneal dialysis (CAPD). METHODS: Between July 1993 and May 1997, 4 patients with recurrent CAPD-associated infections caused by S. aureus we enrolled in this study. There were nine episodes of peritonitis, one episode of temporary double lumen catheter infection, and one episode of Hickman catheter infection. A total of eleven S. aureus isolates were collected from peritoneal fluid (n = 9) and blood (n = 2). PFGE typing was applied. RESULTS: In our study, from PFGE typing, the 11 S. aureus isolates were classified into seven patterns. Antibiogram profiling classified only four patterns. Patient A had a reinfection by another strain of S. aureus, and patient B had three episodes of peritonitis caused by the same strain of S. aureus due to exit site infections. Patient C had two episodes of CAPD peritonitis caused by two different strains, respectively. Patient D had four episodes of S. aureus infection (three CAPD peritonitis and one bacteremia); the first two episodes of peritonitis were caused by an identical strain of S. aureus, whereas the subsequent two infections were caused by other organisms. CONCLUSION: PFGE has a high discriminatory power and can be an assistant method to antibiogram profiling for distinguishing relapse from reinfection in CAPD-associated peritonitis.

Anti-Bacterial Agents↗
PubMed1994

Atopic dermatitis of infancy and urinary tract infections.

BACKGROUND: Infants under evaluation for atopic dermatitis (AD) at our clinic undergo a battery of examinations that include urinalysis and urine culture tests with antibiograms. The prevalence of cases with significant bacteriuria and leukocyturia (SBL) appeared to be unexpectedly high. OBJECTIVE: This study attempts to establish whether infants with AD should be suspected of having a higher prevalence of urinary tract infections (UTI). METHODS: A retrospective analysis of urine and urine culture tests was performed in 131 infants (84 males and 47 females) aged 1-24 months with untreated AD and in 1,327 control subjects (621 male, 706 female) aged 1-24 months. RESULTS: SBL was present in 27.5% of cases versus 3% of controls (p < 10(-5)). After routine treatment for AD and antibiotic treatment on the basis of a urine antibiogram, the recurrence rate of SBL, evaluated monthly over a 6-month period, was only 8.3%. CONCLUSION: Infants with AD might be at a greater risk for developing UTI, and when treated for AD this risk might be reduced.

Bacteriuria↗
PubMedDate not supplied

An outbreak of Staphylococcus epidermidis septicemia.

During 45 wk from August 1980 to June 1981, the catheter sepsis rate increased from a prior 2 to 34% (23 of 68 patients on intravenous hyperalimentation). The causative organism was Staphylococcus epidermidis, grown on blood cultures in 21 of the 23 patients and on the catheter-tips of all 23. Routine cultures of the catheter-tips of the 45 patients who received intravenous hyperalimentation during this period with no evidence of catheter sepsis grew S. epidermidis on three catheter-tips (6.7%), possibly contamination during catheter removal. Sepsis resolved within 24 hr after catheter removal, with no antibiotics given for the sepsis. The organism had identical antibiograms on the blood and catheter-tip cultures in each patient, but antibiograms varied between patients. In these complex patients undergoing multiple medical events, the intravenous hyperalimentation nurse recorded that iv tubing in septic patients had leaked solution at the attachment to the catheter hub, and a review of nursing notes on charts of patients who had been on intravenous hyperalimentation revealed that a leak had been noted in the patients who subsequently had catheter sepsis. The leak was due to a manufacturing defect resulting in a decrease in diameter of the plastic connection of the iv tubing, which produced a loose attachment to the hub. The problem was remedied by switching to a Luer-lok attachment. However, in July 1982, two patients had separation of the Luer due to a manufacturing defect in the threads, followed by a catheter sepsis. Sepsis from the local contamination was not manifest until 5.4 +/- 2.7 days later. Quality control by manufacturers is emphasized.

Catheters, Indwelling↗
PubMed2004

External decontamination of wild leeches with hypochloric acid.

BACKGROUND: Medicinal leech, Hirudo medicinalis, has been used in plastic and reconstructive surgery, to relieve venous congestion and to improve the microrevascularization of flaps. In many countries, wild leeches are still provided from local markets and utilised with antibiotic prophylaxies. In this research, results of identification of bacteria in the transport fluid is reported, oral and intestinal floras and the antibiograms of the identified microorganisms are investigated. Also, to avoid possible infections, the ability of hypochloric acid, a disinfectant, to suppress the relevant microorganisms without changing the life style and behavior of leeches in terms of sucking function, is investigated. METHODS: Bacterial identifications and antibiograms of oral and intestinal flora and transport medium were performed for 10 leeches. The optimum concentration of hypochloric acid which eliminated microorganisms without affecting the viability and sucking function of the leeches were determined by dilution of hypochloric acid to 100, 50, 25, 12.5, 6.25 ppm concentrations in different groups of 25 leeches. Finally, 20 leeches were applied atraumatically to the bleeding areas of rats, the duration of suction was determined and compared statistically between the leeches treated and not treated with hypochloric acid solution. RESULTS: Aeromonas hydrophilia was the most commonly identified microorganism and found to be resistant to first generation cephalosporins, frequently used in prophylaxis at surgical wards. In the next stages of the study, the leeches were subjected to a series of diluted hypochloric acid solutions. Although disinfection of the transport material and suppression of the oral flora of hirudo medicinalis were successful in 100, 50, 25, 12.5, 6.25 ppm concentrations; 12.5 ppm solution was the greatest concentration in which hirudo medicinalis could survive and sucking function was not affected significantly. CONCLUSIONS: External decontamination of wild leeches with 12.5 ppm hypochloric acid enables bacterial suppression without causing negative effects on leech sucking function and life.

Aeromonas↗
PubMed1997

Azithromycin and erythromycin resistant Neisseria gonorrhoeae following treatment with azithromycin.

A pre-treatment and a 3-week post-treatment isolate of Neisseria gonorrhoeae from a 13-year-old boy treated with azithromycin in a single 1 g oral dose were characterized microbiologically. Both isolates were of the same serovar/auxotype (1B6/non-requiring) and had similar antibiograms apart from erythromycin and azithromycin: the pre- and post-treatment MICs (minimum inhibitory concentrations) were: 1 mg/L and 32 mg/L to erythromycin and 0.125 mg/L and 3 mg/L to azithromycin. The finding that both isolates were 1B6/NR, had similar antibiograms (other than azithromycin and erythromycin), and no other 1B6/NR isolates were resistant to erythromycin supports the view that macrolide resistance developed following treatment. A high overall level of azithromycin susceptibility was confirmed by testing 67 clinical isolates: MIC90 0.5 mg/L (range 0.023-0.75 mg/L). We conclude that the long half-life of azithromycin which is beneficial in treating chlamydial infection may result in increased selective pressure for resistance in gonococci. This report also highlights the importance of antibiotic susceptibility surveillance of gonococci and stresses the need for appropriate treatment of gonococcal infection, particularly when it is prescribed outwith departments of genitourinary medicine.

Adolescent↗
PubMed2003

Optimizing antibiotic use in hospitals: the role of population-based antibiotic surveillance in limiting antibiotic resistance. Insights from the society of infectious diseases pharmacists.

To minimize antibiotic resistance, pharmacists increasingly are becoming involved in antibiotic surveillance, formulation of antibiotic use policies, and day-to-day control of problematic antibiotic use. Population-based antibiotic surveillance has become common with the proliferation of electronic databases. The most widely applied measure of antibiotic consumption is the defined daily dose/1000 patient days. Most studies correlating antibiotic consumption with resistance have focused on antibiogram-related end points; antibiogram data generally reflect institutional nosocomial infection patterns. Most study designs have been derived from traditional epidemiology such as case-control with regression modeling or simple linear regression; however, these methods have limitations. Several experimental designs show promise. Many historical-control studies, including a multicentered study, suggest that population-based antibiotic surveillance and policy intervention can decrease antibiotic resistance in hospitals. Further research on the relationships among antibiotic surveillance, structured antibiotic policy interventions, and other microbiologic, patient-oriented, and economic end points is needed.

Anti-Infective Agents↗
PubMed2006

Clinical, microbiological, and molecular characterization of methicillin-resistant Staphylococcus aureus infections of cats.

OBJECTIVE: To compare clinical information obtained from medical records of cats with methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-susceptible S aureus (MSSA) infections, evaluate antibiograms of MRSA and MSSA for multiple-drug resistance (MDR), and characterize the strain type and staphylococcal chromosome cassette (SCC)mec type of each MRSA. SAMPLE POPULATION: 70 S aureus isolates obtained from 46 cats. PROCEDURES: Clinical information obtained from medical records, including signalment, clinical signs, histologic examination of affected tissues, and outcomes, was compared between the 2 groups. Composite antibiograms of MRSA and MSSA were compared statistically. The MRSA strains were characterized by use of pulsed-field gel electrophoresis and SCCmec typing. RESULTS: No statistical differences in signalment or subjective differences in clinical signs or outcomes were detected between groups with MRSA or MSSA infection. Significant differences in antimicrobial resistance were detected, with MRSA having complete resistance to fluoroquinolone and macrolide antimicrobials, whereas MSSA maintained a high frequency of susceptibility. Seven pulsed-field patterns were observed in 15 MRSA strains; all but 1 were highly related. All MRSA isolates contained a type II SCCmec element. CONCLUSIONS AND CLINICAL RELEVANCE: Because MDR cannot be predicted in staphylococcal infections in cats on the basis of clinical signalment, culture and susceptibility testing are recommended whenever initial empirical treatment is unsuccessful. Molecular characterization of MRSA strains suggests that there has been reverse-zoonotic transmission from humans. IMPACT FOR HUMAN MEDICINE: The SCCmec type II element is typically associated with nosocomial MRSA infections of people. Cats may serve as reservoirs for MRSA infections in humans.

Animals↗
PubMed1998

Current susceptibility patterns of anaerobic bacteria.

While antibiotic resistance among anaerobes continues to increase, the frequency of antimicrobial susceptibility testing for anaerobes is declining. Because anaerobic infections are often mixed and detailed bacteriology of the organisms involved may take some time, physicians must institute empiric therapy before susceptibility testing results are available. Also, economic realities and prudent use of resources mandate that careful consideration be given to the necessity for routine susceptibility testing of anaerobic bacteria. Determination of appropriate therapy can be based on published antibiograms; however, since patterns may vary within geographic regions and even within hospitals, it is strongly recommended that each hospital center periodically test their isolates to determine local patterns and detect any pockets of resistance. As a general guide, antibiograms from the last several years of susceptibility testing at the Wadsworth Anaerobe Laboratory are reported.

Bacteria, Anaerobic↗
PubMed2004

Treatment of uncomplicated urinary tract infections in an era of increasing antimicrobial resistance.

In the past few years, notable advances have occurred in our understanding of the epidemiology and clinical importance of drug resistance among uropathogens that cause uncomplicated urinary tract infections (UTIs) or cystitis. Guidelines recommend trimethoprim-sulfamethoxazole for empirical treatment of uncomplicated UTI unless trimethoprim-sulfamethoxazole resistance in a community exceeds 10% to 20%. The rationale for this 10% to 20% cutoff appears to be related to clinical and economical considerations and to concerns about the emergence of fluoroquinolone-resistant bacteria. In patients with uncomplicated UTIs caused by uropathogens resistant to trimethoprim-sulfamethoxazole who were treated with this drug combination, clinical outcomes were clarified recently and found to be suboptimal (<60% clinical cure). Following guidelines for empirical treatment of uncomplicated UTIs is problematic. Surveillance of antimicrobial resistance among uropathogens that cause uncomplicated UTIs is performed rarely. Hospital antibiograms provide data on resistance among bacteria that cause community-associated UTIs; however, antibiograms overestimate drug resistance among uropathogens that cause UTIs and may mislead clinicians about the prevalence of local resistance. We review options for management of uncomplicated UTIs in light of these considerations.

Anti-Infective Agents, Urinary↗
PubMed2001

Design of a novel mammalian screening system for the detection of bioavailable, non-cytotoxic streptogramin antibiotics.

Screening and development of new antibiotic activities to counteract the increasing prevalence of multidrug-resistant (MDR) human pathogenic bacteria has once again become a priority in human chemotherapy. Here we describe a novel mammalian cell culture-based screening platform for the detection of streptogramin antibiotics. Quinupristin-dalfopristin (Synercid), a synthetically modified streptogramin, is presently the sole effective agent in the treatment of some MDR nosocomial infections. A Streptomyces coelicolor transcriptional regulator (Pip) has been adapted to modulate reporter gene expression (SEAP, secreted alkaline phosphatase) in Chinese hamster ovary cells (CHO) in response to streptogramin antibiotics. This CHO cell-based technology was more sensitive in detecting the production of the model streptogramin pristinamycin, from Streptomyces pristinaespiralis, than antibiogram tests using a variety of human pathogenic bacteria as indicator strains. The reporter system was able to detect pristinamycin compound produced by a single S. pristinaespiralis colony. The assay was rapid (17 hours) and could be carried out in a high-throughput 96-well plate assay format or a 24-well transwell set-up. This novel mammalian cell-based antibiotic screening concept enables detection of bioavailable and non-cytotoxic representatives of a particular class of antibiotics in a single assay and represents a promising alternative to traditional antibiogram-based screening programs.

Alkaline Phosphatase↗
PubMed1979

[Experiences with the uripret-system in pediatric practice (author's transl)].

The present study reports on the application of the Uripret-System for identification and susceptibility testing of microbial agents causing urinary tract infections carried out in a pediatric outpatient clinic. The findings were compared with those determined with the conventional methods in an institute of medical microbiology. For the detected mono- and mixed-cultures, in 85% of the cases a concurrent result of both methods was found. Only in one case a different microbial agent genus was determined with Uripret from that found in the institute. The quota of concurrence of the antibiograms for the mono-cultures was highest at 100% for gentamicin and lowest at 85.07% for tetracycline. With the mixed-cultures the concurrence ranged between 81.25% for tetracycline and 96.88% for sulphamethoxazole-trimethoprim. With proteus in mono- and mixed-culture the antibiograms showed concurrence to a lesser degree compared to the other microbial agent geni. The application of the Uripret-System in pediatric practice can be recommended on the basis of the present results.

Bacteria↗
PubMedDate not supplied

[The bacterial spectrum in bronchopulmonary infections].

UNLABELLED: This study aimed to establish the bacterial profile of bronchopulmonary infections confirmed by the cytobacteriological examination of sputum, in order to find therapeutical guidelines for empirical treatment. We included in the study 408 patients with clinical signs of bronchopulmonary infection (cough and mucopurulent sputum, fever) among which 294 hospitalised patients (5.5% of the 5280 admitted in 1997) and 114 outpatients. The sputum samples collected respecting the decontamination methods were examined cytobacteriologically (smear, culture and antibiogram). The spectrum of isolated bacteria was the following: H. influenzae--198 cases, anaerobes--54, Kl. pneumoniae--53, Ps. aeruginosa--50, S. pneumoniae--17. Analyzing the diseases for which the bacterial examination was performed, we found the following distribution: COPD--66, bacterial infections in TB patients--61, chronic suppurations--33, bronchiectasis--37, pulmonary abscess--24. We noticed the high frequency of H. influenzae and important numbers of anaerobes, Kl. pneumoniae and Ps. aeruginosa especially in COPD patients and patients with chronic suppurations. We performed antibiograms for establishing the sensitivity of bacterial samples (S. aureus, Kl. pneumoniae, Ps. aeruginosa, beta-lactamase-positive H. influenzae). Most of them were multidrug-resistant. CONCLUSIONS: 1. The cytobacteriological study of sputum may be useful for choosing the right treatment, especially for the patients with multiple antibiotic treatments and infected with multidrug resistant bacteria; 2. Knowing the bacterial spectrum in certain respiratory diseases allows the choice of empirical treatment for bronchopulmonary infections in uncomplicated cases.

Anti-Bacterial Agents↗
PubMed1979

Pseudomonas sternotomy wound infection and sternal osteomyelitis. Complications after open heart surgery.

Pseudomonas aeruginosa sternotomy wound infections occurred in five patients who underwent open heart surgery. The initial isolate in each case was from a mediastinal chest tube routinely cultured on removal. Soft-tissue infection developed in two patients, and sternal osteomyelitis developed in three patients. Pseudomonas-typing studies showed a correlation between five isolates from chest-tube suction pumps used postoperatively and the wound isolates. Analysis of antibiograms of Pseudomonas wound isolates from the cardiac surgery ward from 1975 to 1977 showed eight of 15 with the same antibiogram as the sternotomy pathogens, compared with two of 13 isolates from other wards.

Cardiac Surgical Procedures↗
PubMed1999

["Classic" vs autolubricant catheterization for endovesicular chemotherapy. Preliminary experience].

AIM: The aim of this study was to evaluate the frequency of urinary tract infections (UTI) after catheterisation for instillation comparing two systems: the "classic" method and the catheterisation using a new autolubricant device: EasiCath Coloplast. METHODS: During the period of endovesical chemotherapy (between 4 and 48 weeks), 22 patients (6 females and 18 males) were studied, aged between 53 and 78 years old. We have performed 139 instillations using Nelaton Ch 14 or 12 type catheters lubricated with gel based on lidocaine, neomicyn and fluocinolone ("classic" method). Instead 135 patients have been treated with autolubricant devices according to the manufacturer's instructions. After 48 hours from instillation, a total of 274 catheterisation have been examined using urine tests and urine culture with antibiogram. We administered a 5-point visual analogic score to the patients weighing the post-instillation dysuria. RESULTS: With "classic" method UTI frequency is 7.19% (10/139). The most common pathogen has been E. coli (7/10). With autolubricant catheters UTI frequency is 2.96 (4/135). Klebsiella, Enterobacter, as well as E. coli (2/4) have been identified as pathogen. All patients with infections have been treated with targeted antibiotics based on the antibiogram. CONCLUSIONS: We have observed the people with autolubricant catheters left more comfort then those undergoing to the "classic" catheterisation. The frequency of post-catheterisation, dysuria was also reduced. Our data show that the new method is safer and easier to handle then the "classic" one. Moreover, common anaesthetic/antibiotic lubricant have important bacteriostatic effects that reduce the BCG viability.

Aged↗
PubMed1999

[Acquired antibiotic resistance in Madagascar: first evaluation].

The purpose of this study was to evaluate the incidence of acquired resistance to antibiotics in Madagascar. Testing was carried out on total of 1267 strains of medically significant bacteria isolated from specimens sent to the Pasteur Institute of Madagascar in Antananarivo between October 1997 and October 1998. Antibiograms were performed using the diffusion technique on gel media with antibiotic disks. Results were read according to the criteria of the Antibiogram Committee of the French Society of Microbiology. Preliminary findings documented a high incidence of resistance to widely available, low-price antibiotics including penicillin G and tetracycline for which 84 p. 100 and 65 p. 100 of Staphylococcus aureus respectively demonstrated resistance; tetracyclin to which 80 p. 100 of streptococcus were resistant; and ampicillin, cotrimoxazole, and phenicoles to which 60 p. 100, 60 p. 100 and 28 p. 100 of Escherichia coli respectively and 77 p. 100, 83 p. 100, and 71 p. 100 of Shigella sp. respectively were resistant. Second-line antibiotics including penicillin M, macrolides, nalidixic acid, and nitrofuranes were still relatively active, thus providing an effective alternative. Newly developed antibiotics such as fluoroquinolones and third-generation cephalosporines were highly effective but a few resistant strains were observed. Although not representative of Madagascar as a whole, the findings of this preliminary study indicate that acquired resistance must be taken into account in designing simplified decision charts for front-line laboratories, that appropriate information must be made available to health care workers, and that further testing is needed to monitor the evolution of antibiotic resistance.

Bacterial Infections↗