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Carbapenem-Resistant Klebsiella pneumoniae: Virulence Factors, Molecular Epidemiology and Latest Updates in Treatment Options. Antibiotics (Basel) 2023; 12:antibiotics12020234. [PMID: 36830145 PMCID: PMC9952820 DOI: 10.3390/antibiotics12020234] [Citation(s) in RCA: 54] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 01/26/2023] Open
Abstract
Klebsiella pneumoniae is a Gram-negative opportunistic pathogen responsible for a variety of community and hospital infections. Infections caused by carbapenem-resistant K. pneumoniae (CRKP) constitute a major threat for public health and are strongly associated with high rates of mortality, especially in immunocompromised and critically ill patients. Adhesive fimbriae, capsule, lipopolysaccharide (LPS), and siderophores or iron carriers constitute the main virulence factors which contribute to the pathogenicity of K. pneumoniae. Colistin and tigecycline constitute some of the last resorts for the treatment of CRKP infections. Carbapenemase production, especially K. pneumoniae carbapenemase (KPC) and metallo-β-lactamase (MBL), constitutes the basic molecular mechanism of CRKP emergence. Knowledge of the mechanism of CRKP appearance is crucial, as it can determine the selection of the most suitable antimicrobial agent among those most recently launched. Plazomicin, eravacycline, cefiderocol, temocillin, ceftolozane-tazobactam, imipenem-cilastatin/relebactam, meropenem-vaborbactam, ceftazidime-avibactam and aztreonam-avibactam constitute potent alternatives for treating CRKP infections. The aim of the current review is to highlight the virulence factors and molecular pathogenesis of CRKP and provide recent updates on the molecular epidemiology and antimicrobial treatment options.
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Amoudizaj FF, Aghayi E, Matin MG, Soltani N, Mala P. Antibiotic Resistance Pattern and Frequency of PER-1, SHV-1 and AMPC Type B-Lactamase Genes in Pseudomonas aeruginosa Isolated from Clinical Samples. Open Microbiol J 2019. [DOI: 10.2174/1874285801913010308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background:
The existence of Extended Spectrum B-lactamase (ESBL) genes plays an important role in spreading B-lactam antibiotic resistance in the producing strains of these enzymes. The resistance of gram-negative bacteria, such as Pseudomonas aeruginosa, to different antimicrobial agents, especially B-lactams, has increasingly been reported.
Objective:
This study was conducted to determine the prevalence of TEM-1and VEB-1 beta-lactamases gene in P. aeruginosa isolates through Polymerase Chain Reaction (PCR) method.
Methods:
100 clinical isolates of P. aeruginosa were collected from different clinical samples. The antibiotic susceptibility was examined by the disc diffusion method. The presence of PER-1, SHV-1 and AMPC genes was detected by PCR method.
Results:
Out of the studied P. aeruginosa isolates, 7, 9 and 37 isolates were positive for PER-1, SHV-1 and AMPC B-lactamases resistance genes, respectively. Patients with urinary infection had the most resistant isolates. All isolates (100%) were sensitive to polymyxin B.
Conclusion:
Antibiotic resistance in isolates of Pseudomonas can be caused by B-lactamases resistance genes. Noticing the increasing rate of the ESBLs producing strains, using the appropriate treatment protocol based on the antibiogram pattern of the strains is highly recommended.
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Infections Caused by Extended-Spectrum β-Lactamase Producing Escherichia Coli in Systemic Lupus Erythematosus Patients: Prevalence, Risk Factors, and Predictive Model. BIOMED RESEARCH INTERNATIONAL 2018; 2018:8296720. [PMID: 30581868 PMCID: PMC6276506 DOI: 10.1155/2018/8296720] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 09/10/2018] [Accepted: 10/18/2018] [Indexed: 02/05/2023]
Abstract
Objective To investigate the prevalence and risk factors of infections caused by Extended-Spectrum β-Lactamase (ESBL) producing Escherichia coli (E. coli) in systemic lupus erythematosus (SLE) patients and develop a predictive model. Methods Three hundred and eighty-four consecutive SLE patients with E. coli infection were enrolled in this retrospective case control study from January 2012 to December 2017. Prevalence and antimicrobial susceptibility pattern of ESBL producing E. coli were analyzed. Multivariate analysis was performed to determine the risk factors. Sensitivity and specificity were obtained at various point cutoffs and area under the receiver operator characteristic curve (AuROC) was determined to confirm the prediction power of the model. Results Of the total 384 E. coli strains tested, 212 (55.2%) produced ESBL. The majority of these isolates were from urine (44.3%). Carbapenems (>80%) and amikacin (89.6%) had good activity against ESBL producing E. coli. Eleven variables were identified as independent risk factors for ESBL producing E. coli infection including Enterobacteriaceae colonization or infection in preceding year (OR=8.15, 95%CI 5.12-21.71), daily prednisone dose > 30mg (OR=5.48, 95%CI 3.12-13.72), low C3 levels (OR=2.17, 95%CI 1.62-6.71), nosocomial acquired infection (OR=4.12, 95%CI 1.98-8.85), etc. The model developed to predict ESBL producing E. coli infection was effective, with the AuROC of 0.840 (95% CI 0.799-0.876). Conclusions The prevalence of ESBL producing E. coli was increasing with high antibiotics resistance in patients with SLE. The model revealed excellent predictive performance and exhibited a good discrimination.
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van den Bijllaardt W, Janssens MM, Buiting AG, Muller AE, Mouton JW, Verweij JJ. Extended-spectrum β-lactamase (ESBL) polymerase chain reaction assay on rectal swabs and enrichment broth for detection of ESBL carriage. J Hosp Infect 2017; 98:264-269. [PMID: 29080706 DOI: 10.1016/j.jhin.2017.10.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 10/19/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Extended-spectrum β-lactamase (ESBL) screening and contact precautions on patients at high risk for ESBL carriage are considered important infection control measures. Since contact precautions are costly and may negatively impact patient care, rapid exclusion of ESBL carriage and therefore earlier discontinuation of contact precautions are desired. AIM In the present study, the performance of an ESBL polymerase chain reaction (PCR) targeting blaCTX-M genes was evaluated as a screening assay for ESBL carriage. METHODS Two methods were assessed: PCR performed directly on rectal swabs and PCR on enrichment broth after incubation overnight. The reference standard was culture of ESBL-producing Enterobacteriaceae on selective agar after overnight enrichment and confirmation by the combination disc diffusion method. Microarray was used for discrepancy analysis. A secondary analysis was performed to evaluate the added value of including a blaSHV target in the PCR. FINDINGS A total of 551 rectal swabs from 385 patients were included, of which 28 (5%) were ESBL positive in culture. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 86%, 98%, 67%, and 99%, respectively, for PCR directly on swabs, and 96%, 98%, 75%, and 100%, respectively, for PCR on enrichment broth. Adding a blaSHV target to the assay resulted in a lower PPV without increasing the sensitivity and NPV. CONCLUSION Screening for ESBL by PCR directly on rectal swabs has a high negative predictive value, is up to 48h faster than traditional culture and therefore facilitates earlier discontinuation of contact precautions, thereby improving patient care and saving valuable resources in the hospital.
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Affiliation(s)
- W van den Bijllaardt
- Laboratory for Medical Microbiology and Immunology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands; Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands.
| | - M M Janssens
- Laboratory for Medical Microbiology and Immunology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - A G Buiting
- Laboratory for Medical Microbiology and Immunology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - A E Muller
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands; Department of Medical Microbiology, Haaglanden Medical Centre, The Hague, The Netherlands
| | - J W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | - J J Verweij
- Laboratory for Medical Microbiology and Immunology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
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Espinal P, Miró E, Ramoneda L, Flores M, Rivera A, Coll P, Navarro F. Characterization of the Genetic Environment of theblaVEB-4Gene, Associated with a Transposable Region in aProteus mirabilisClinical Isolate. Microb Drug Resist 2017; 23:833-837. [DOI: 10.1089/mdr.2016.0262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Paula Espinal
- Servei de Microbiologia, Hospital de la Santa Creu i Sant Pau and Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Elisenda Miró
- Servei de Microbiologia, Hospital de la Santa Creu i Sant Pau and Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Laia Ramoneda
- Servei de Microbiologia, Hospital de la Santa Creu i Sant Pau and Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Barcelona, Spain
- Departament de Genètica i de Microbiologia, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Manel Flores
- Servei de Microbiologia, Hospital de la Santa Creu i Sant Pau and Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Alba Rivera
- Servei de Microbiologia, Hospital de la Santa Creu i Sant Pau and Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Pere Coll
- Servei de Microbiologia, Hospital de la Santa Creu i Sant Pau and Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Barcelona, Spain
- Departament de Genètica i de Microbiologia, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ferran Navarro
- Servei de Microbiologia, Hospital de la Santa Creu i Sant Pau and Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Barcelona, Spain
- Departament de Genètica i de Microbiologia, Universitat Autònoma de Barcelona, Barcelona, Spain
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Han ST, Fei Y, Huang JY, Xu M, Chen LC, Liao DJ, Tan YJ. Establishment of a Simple and Quick Method for Detecting Extended-Spectrum β-Lactamase (ESBL) Genes in Bacteria. J Biomol Tech 2016; 27:132-137. [PMID: 27672351 DOI: 10.7171/jbt.16-2704-001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Extended-spectrum β-lactamase (ESBL) genes that render bacteria resistant to antibiotics are commonly detected using phenotype testing, which is time consuming and not sufficiently accurate. To establish a better method, we used phenotype testing to identify ESBL-positive bacterial strains and conducted PCR to screen for TEM (named after the patient Temoneira who provided the first sample), sulfhydryl reagent variable (SHV), cefotaxime (CTX)-M-1, and CTX-M-9, the 4 most common ESBL types and subtypes. We then performed multiplex PCR with 1 primer containing a biotin and hybridized the PCR products with gene-specific probes that were coupled with microbeads and coated with a specific fluorescence. The hybrids were linked to streptavidin-R-phycoerythrins (SA-PEs) and run through a flow cytometer, which sorted the fluorescently dyed microbeads and quantified the PEs. The results from single PCR, multiplex PCR, and cytometry were consistent with each other. We used this method to test 169 clinical specimens that had been determined for phenotypes and found 154 positive for genotypes, including 30 of the 45 samples that were negative for phenotypes. The CTX-M genotype tests alone, counting both positive and negative cases, showed 99.41% (168/169) consistency with the ESBL phenotype test. Thus, we have established a multiplex-PCR system as a simple and quick method that is high throughput and accurate for detecting 4 common ESBL types and subtypes.
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Affiliation(s)
- Song-Tao Han
- Clinical Laboratory, Baiyun Hospital affiliated to Guizhou Medical University Hospital, Guiyang 550058, P.R. China;; Central Laboratory, Guizhou Medical University Hospital, Guiyang 550004, P.R. China
| | - Ying Fei
- Department of Microbiology and Immunology, Guizhou Medical University Hospital, Guiyang 550004, P.R. China
| | - Jin-You Huang
- Clinical Laboratory, Baiyun Hospital affiliated to Guizhou Medical University Hospital, Guiyang 550058, P.R. China
| | - Mei Xu
- Clinical Laboratory, Baiyun Hospital affiliated to Guizhou Medical University Hospital, Guiyang 550058, P.R. China
| | - Li-Chan Chen
- The Hormel Institute, University of Minnesota, Austin, Minnesota 55912, USA; and
| | - D Joshua Liao
- Department of Pathology, Guizhou Medical University Hospital, Guiyang 550004, P.R. China
| | - Yu-Jie Tan
- Clinical Laboratory, Baiyun Hospital affiliated to Guizhou Medical University Hospital, Guiyang 550058, P.R. China;; Central Laboratory, Guizhou Medical University Hospital, Guiyang 550004, P.R. China
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Ceyssens PJ, Garcia-Graells C, Fux F, Botteldoorn N, Mattheus W, Wuyts V, De Keersmaecker S, Dierick K, Bertrand S. Development of a Luminex xTAG®assay for cost-effective multiplex detection of β-lactamases in Gram-negative bacteria. J Antimicrob Chemother 2016; 71:2479-83. [DOI: 10.1093/jac/dkw201] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 04/29/2016] [Indexed: 01/23/2023] Open
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Karampatakis T, Antachopoulos C, Iosifidis E, Tsakris A, Roilides E. Molecular epidemiology of carbapenem-resistant Klebsiella pneumoniae in Greece. Future Microbiol 2016; 11:809-23. [PMID: 27206024 DOI: 10.2217/fmb-2016-0042] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Hospital infections caused by carbapenem-resistant Klebsiella pneumoniae (CRKP) constitute a worldwide problem associated with high rates of treatment failure and mortality. In Greece, CRKP have emerged in 2002 due to VIM carbapenemase production and later due to KPC, NDM and OXA-48-like carbapenemases that have become endemic. The molecular epidemiology of CRKP strains is dynamic, as antibiotic consumption and worldwide traveling are strongly associated with global spread of CRKP isolates. Lately, porin defects, such as disruption of OmpK35 and production of OmpK36 variant, have also contributed to carbapenem resistance. In the coming years, the high prevalence of CRKP will require intense infection control measures, while novel molecular patterns may appear. To our knowledge, this is the first review analyzing the molecular epidemiology of CRKP strains in Greece.
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Affiliation(s)
- Theodoros Karampatakis
- Infectious Diseases Unit, 3rd Department of Pediatrics, Medical Faculty, School of Health Sciences, Aristotle University, Hippokration General Hospital, Thessaloniki, Greece
| | - Charalampos Antachopoulos
- Infectious Diseases Unit, 3rd Department of Pediatrics, Medical Faculty, School of Health Sciences, Aristotle University, Hippokration General Hospital, Thessaloniki, Greece
| | - Elias Iosifidis
- Infectious Diseases Unit, 3rd Department of Pediatrics, Medical Faculty, School of Health Sciences, Aristotle University, Hippokration General Hospital, Thessaloniki, Greece
| | - Athanassios Tsakris
- Microbiology Department, Athens University School of Medicine, Athens, Greece
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, Medical Faculty, School of Health Sciences, Aristotle University, Hippokration General Hospital, Thessaloniki, Greece
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Identification of Novel VEB β-Lactamase Enzymes and Their Impact on Avibactam Inhibition. Antimicrob Agents Chemother 2016; 60:3183-6. [PMID: 26926646 DOI: 10.1128/aac.00047-16] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 02/21/2016] [Indexed: 11/20/2022] Open
Abstract
Ceftazidime-avibactam has activity against Pseudomonas aeruginosa and Enterobacteriaceae expressing numerous class A and class C β-lactamases, although the ability to inhibit many minor enzyme variants has not been established. Novel VEB class A β-lactamases were identified during characterization of surveillance isolates. The cloned novel VEB β-lactamases possessed an extended-spectrum β-lactamase phenotype and were inhibited by avibactam in a concentration-dependent manner. The residues that comprised the avibactam binding pocket were either identical or functionally conserved. These data demonstrate that avibactam can inhibit VEB β-lactamases.
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Drug resistance and virulence of uropathogenic Escherichia coli from Shanghai, China. J Antibiot (Tokyo) 2014; 67:799-805. [PMID: 24984795 DOI: 10.1038/ja.2014.72] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Revised: 04/22/2014] [Accepted: 04/28/2014] [Indexed: 11/08/2022]
Abstract
Uropathogenic Escherichia coli (UPEC) is the major cause of urinary tract infections (UTIs). In the present study, 198 E. coli isolates from patients with UTIs in Shanghai in 2008 were examined by susceptibility testing, with an extremely high number (153/198) showing multidrug resistance (MDR). And, the expression of extended-spectrum β-lactamases (ESBLs) reached 48.5% (96/198). The resistance rates to penicillins, fluoroquinolone, folate pathway inhibitors and first- and second-generation cephalosporins were high. Molecular analyses showed that the CTX-M-9 group (70/96) was the most common CTX-M group among UPEC, followed by the CTX-M-1 group (27/96). Phylogenetic group D accounted for 42.4% (84/198) of the isolates, exhibiting the highest ESBLs (50/84) and MDR (75/84) rates. Virulence genes were present in a significantly high proportion in the phylogenetic group B2 isolates, except for the afaBC gene. The ESBL-producing strains analyzed by pulsed-field gel electrophoresis (PFGE) were clustered into six groups at a cutoff of 67%. Notably, the findings that afaBC was specific to phylogenetic group D and PFGE group I and was correlated with the CTX-M-9 group were different from a previous report. In conclusion, knowledge of antimicrobial resistance data and virulence factors may enable clinicians to tailor empirical antibiotic treatments for UTIs.
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Outbreak of PER-1 and diversity of β-lactamases among ceftazidime-resistant Pseudomonas aeruginosa clinical isolates. J Med Microbiol 2014; 63:386-392. [DOI: 10.1099/jmm.0.069427-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
A growing number of β-lactamases have been reported in Pseudomonas aeruginosa clinical isolates. The aim of this study was to investigate the diversity of β-lactamases in the collection of 51 ceftazidime-resistant P. aeruginosa clinical isolates in four hospitals of southern China. Among these isolates, variable degrees of resistance to other β-lactam and non-β-lactam agents were observed. Pulsed-field gel electrophoresis (PFGE) revealed a high degree of clonality with five main genotypes. Of the 51 isolates tested, 35 (68.6 %) were identified as extended-spectrum β-lactamase (ESBL) producers, with 35 producing PER-1, 1 CTX-M-3, 7 CTX-M-15 and 1 CTX-M-14. Most (82.9 %, 29/35) PER-1-producing isolates were collected from two hospitals between January and April in 2008 and belonged to the same PFGE pattern (pattern B) with similar antibiogram and β-lactamase profiles, which suggested an outbreak of this clone at the time. The prevalence of CTX-M-type ESBL (17.6 %, 9/51) was unexpectedly high. One isolate was identified as producing VIM-2. Furthermore, we also reported an occurrence of a novel OXA-10 variant, OXA-246, in 14 P. aeruginosa isolates. In addition, AmpC overproduction was found to be the β-lactamase-mediated mechanism responsible for ceftazidime resistance in 6 isolates (11.8 %). Our results revealed an overall diversity of β-lactamases and outbreak of a PER-1-producing clone among ceftazidime-resistant P. aeruginosa in southern China.
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Lupo A, Papp-Wallace KM, Sendi P, Bonomo RA, Endimiani A. Non-phenotypic tests to detect and characterize antibiotic resistance mechanisms in Enterobacteriaceae. Diagn Microbiol Infect Dis 2013; 77:179-94. [PMID: 24091103 DOI: 10.1016/j.diagmicrobio.2013.06.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Accepted: 06/12/2013] [Indexed: 02/07/2023]
Abstract
In the past 2 decades, we have observed a rapid increase of infections due to multidrug-resistant Enterobacteriaceae. Regrettably, these isolates possess genes encoding for extended-spectrum β-lactamases (e.g., blaCTX-M, blaTEM, blaSHV) or plasmid-mediated AmpCs (e.g., blaCMY) that confer resistance to last-generation cephalosporins. Furthermore, other resistance traits against quinolones (e.g., mutations in gyrA and parC, qnr elements) and aminoglycosides (e.g., aminoglycosides modifying enzymes and 16S rRNA methylases) are also frequently co-associated. Even more concerning is the rapid increase of Enterobacteriaceae carrying genes conferring resistance to carbapenems (e.g., blaKPC, blaNDM). Therefore, the spread of these pathogens puts in peril our antibiotic options. Unfortunately, standard microbiological procedures require several days to isolate the responsible pathogen and to provide correct antimicrobial susceptibility test results. This delay impacts the rapid implementation of adequate antimicrobial treatment and infection control countermeasures. Thus, there is emerging interest in the early and more sensitive detection of resistance mechanisms. Modern non-phenotypic tests are promising in this respect, and hence, can influence both clinical outcome and healthcare costs. In this review, we present a summary of the most advanced methods (e.g., next-generation DNA sequencing, multiplex PCRs, real-time PCRs, microarrays, MALDI-TOF MS, and PCR/ESI MS) presently available for the rapid detection of antibiotic resistance genes in Enterobacteriaceae. Taking into account speed, manageability, accuracy, versatility, and costs, the possible settings of application (research, clinic, and epidemiology) of these methods and their superiority against standard phenotypic methods are discussed.
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Affiliation(s)
- Agnese Lupo
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
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Bush K. Proliferation and significance of clinically relevant β-lactamases. Ann N Y Acad Sci 2013; 1277:84-90. [DOI: 10.1111/nyas.12023] [Citation(s) in RCA: 231] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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