Multiresistant Clinical Isolates Research Articles

Release of Gentamicin and Vancomycin from Preformed Spacers in Infected Total Hip Arthroplasties: Measurement of Concentrations and Inhibitory Activity in Patients’ Drainage Fluids and Serum

Gentamicin (G) and vancomycin (V) concentrations in drainage fluids obtained from patients during the first 24 hours after implantation of antibiotic-loaded polymethylmethacrylate (PMMA) spacers in two-stage revision of infected total hip arthroplasty were studied. The inhibitory activity of drainage fluids against different multiresistant clinical isolates was investigated as well. Seven hips were treated by implantation of industrial G-loaded spacers. Vancomycin was added by manually mixing with PMMA bone cement. Serum and drainage fluid samples were collected 1, 4, and 24 hours after spacer implantation. Antibiotics concentrations and drains bactericidal titer of combination were determined against multiresistant staphylococcal strains. The release of G and V from PMMA cement at the site of infection was prompt and effective. Serum levels were below the limit of detection. The local release kinetics of G and V from PMMA cement was similar, exerting a pronounced, combined inhibitory effect in the implant site. The inhibitory activity of drainage fluids showed substantial intersubject variability related to antibiotic concentrations and differed according to the pathogens tested. Gentamicin and vancomycin were released from temporary hip spacers at bactericidal concentrations, and their use in combination exerted strong inhibition against methicillin-resistant S. aureus and Coagulase Negative Staphylococci strains.

Avaliação biológica de Foeniculum vulgare (Mill.) (Umbelliferae/Apiaceae)

Foeniculum vulgare Mill. é espécie herbácea da família Umbelliferae, nativa da região do Mediterrâneo e da Ásia Menor, amplamente distribuída em todo o território brasileiro. É conhecida popularmente como funcho ou erva-doce e usada na medicina como analgésico, digestivo, carminativo, diurético, expectorante, lactígeno, anti-inflamatório, e antiespasmódico. O extrato bruto etanólico para a verificação das atividades biológicas foi preparado a partir de sementes compradas no comércio. Para a realização do perfil fitoquímico foi utilizada a cromatografia em camada delgada analítica; a atividade antimicrobiana foi determinada pelo teste de difusão em disco de papel e da concentração inibitória mínima (CIM); a atividade antinociceptiva foi realizada pelo método de contorções abdominais em cobaias. Os micro-organismos testados foram isolados clínicos multirresistentes obtidos do Setor de Bacteriologia do Hospital das Clínicas de Pernambuco. O estudo fitoquímico identificou a maioria dos compostos secundários presentes na fração metanólica das sementes, sendo eles: triterpenos, glicosídeos de flavanóides, terpenos menores (monoterpenóides, sesquiterpenóide e diterpenóides), e açúcares redutores. Os resultados obtidos mostraram que o extrato etanólico apresentou maior atividade frente à Micrococcus spp. (CIM=250µg/mL). Os resultados da avaliação da atividade antinociceptiva demonstraram que apenas a dosagem de 298 mg/Kg quando comparado com o padrão indometacina conseguiu uma redução significativa no número de contorções abdominais dos animais. Estudos posteriores deverão ser realizados para a identificação e isolamento de alguns compostos secundários, bem como a realização de outros protocolos de analgesia.

New integron gene arrays from multiresistant clinical isolates of members of the Enterobacteriaceae and Pseudomonas aeruginosa from hospitals in Malaysia

This study investigated 147 multidrug-resistant Enterobacteriaceae and Pseudomonas aeruginosa isolates from hospitalized patients in Malaysia. Class 1 integrons were the most dominant class identified (45.6%). Three isolates were shown to contain class 2 integrons (2.0%), whilst one isolate harboured both class 1 and 2 integrons. No class 3 integrons were detected in this study. In addition, the sul1 gene was amplified in 35% of isolates and was significantly associated with the presence of integrase genes in an integron structure. RFLP and DNA sequencing analyses revealed the presence of 19 different cassette arrays among the detected integrons. The most common gene cassettes were those encoding resistance towards aminoglycosides (aad) and trimethoprim (dfr). As far as is known, this study is the first to identify integron-carrying cassette arrays such as aadA2-linF, aacC3-cmlA5 and aacA4-catB8-aadA1 in the Malaysian population. Patients' age was demonstrated as a significant risk factor for the acquisition of integrons (P=0.028). Epidemiological typing using PFGE also demonstrated a clonal relationship among isolates carrying identical gene cassettes in Klebsiella pneumoniae and P. aeruginosa but not in Escherichia coli isolates.

Effect of subinihibitory and inhibitory concentrations of Plectranthus amboinicus (Lour.) Spreng essential oil on Klebsiella pneumoniae

We evaluated the antimicrobial activity and some mechanisms used by subinhibitory and inhibitory concentrations of the essential oil, obtained from leaves of Plectranthus amboinicus, against a standard strain of Klebsiella pneumoniae and 5 multiresistant clinical isolates of the bacteria. The minimal inhibitory concentration (MIC) and minimal bactericidal concentration (MBC), the rate of kill and the pH sensitivity of the essential oil were determined by microdilution tests performed in 96-well plates. Subinhibitory and inhibitory concentrations of the essential oil were tested in order to check its action on K. pneumoniae membrane permeability, capsule expression, urease activity and cell morphology. The MIC and MBC of the essential oil were 0.09±0.01%. A complete inhibition of the bacterial growth was observed after 2h of incubation with twice the MIC of the essential oil. A better MIC was found when neutral or alkaline pH broth was used. Alteration in membrane permeability was found by the increase of crystal violet uptake when the bacteria were incubated with twice the MIC levels of the essential oil. The urease activity could be prevented when all the subinhibitory concentrations were tested in comparison to the untreated group (p<0.001). Alteration of the bacterial morphology besides inhibition of the capsule expression was verified by atomic force microscopy, and Anthony's stain method, respectively. Our data allow us to conclude that the essential oil of P. amboinicus can be a good candidate for future research.

Alginate Films Containing Viable Lactobacillus Plantarum: Preparation and In Vitro Evaluation

The objective of the study was to develop calcium alginate films, containing Lactobacillus plantarum ATCC 8040 with preserved and stable viability and antibacterial activity. L. plantarum-loaded films containing different calcium concentrations were physically characterized for mechanical and bioadhesive properties and lactobacilli release. The viability and antibacterial activity of L. plantarum was studied before and after processing, and during 6 months of storage. A multiresistant clinical isolate, VIM-2-metalo-β-lactamase producing Pseudomonas aeruginosa, was used as an indicator strain. Interference between L. plantarum and films enhanced films elasticity, water absorption ability, release of lactobacilli, and decreased films adherence. A decrease of L. plantarum viability in alginate films (≤1 log unit) was observed after freeze drying. L. plantarum, at cell concentrations of 108 cfu/ml, was inhibitory active. The viability and antibacterial activity of the immobilized lactobacilli remained stable during 6 months of storage. The study has proved the potential of alginate films to deliver L. plantarum in high numbers to individuals.

Phototoxic and modulatory effects of natural products from the skin of Rhinella jimi (Stevaux, 2002)

The skin of amphibians possesses a large diversity of biologically active compounds that are associated with the natural defenses of these animals against pathogens. Five different extracts and fractions were obtained from the skin of Rhinella jimi: methanol extract (ME), methanol fractions (MF), chloroform extract of methanol extract (CF), aqueous alkaloid fraction (AAF) and aqueous non-alkaloid fraction (ANAF). All fractions were evaluated with respect to their antibiotic modifying activity in standard bacterial strains and multiresistant clinical isolates. Antagonism was detected with kanamycin and gentamicin when combined with substances obtained from the skin of R. jimi. Phototoxic activity was observed in the methanol and chlorophorm fractions, as well as the aqueous non-alkaloid fraction. The antagonistic action was apparently associated with the protection afforded by the bacterial populations that inhabit the skin of this amphibian, preventing colonization by pathogenic fungi. The phototoxic activity demonstrated by natural products from the skin of R. jimi showed an interruption of the bacterial growth after UV exposure. This could indicate an antibacterial effect activated by the UV light, opening a path for carrying the attack by pathogenic fungi, causing the disease related with the amphibian decline.

Identification and diversity of multiresistant Corynebacterium striatum clinical isolates by MALDI-TOF mass spectrometry and by a multigene sequencing approach

BackgroundThe genus Corynebacterium is composed of Gram-positive bacteria that are widely distributed throughout the environment; these bacteria are also part of the normal microbiota of human skin and mucous membranes. Multiple studies have shown that species of this genus, including C. striatum, become pathogenic to humans under special conditions. Our aim was to determine the characteristics of clinical multiresistant strains of C. striatum that were isolated in our geographical region, to determine their diversity, and to compare them with the type strain and with related species. We studied fifty-two strains of C. striatum isolated from different hospitals from Mallorca, Spain, mainly from the Hospital Joan March in Bunyola, Mallorca. Most of the strains were isolated from sputum cultures of respiratory samples from patients with chronic obstructive pulmonary disease. To gain further insight into the genetic diversity of the strains, we analysed several housekeeping genes and other genes associated with antibiotic resistance. Strains were also characterised phenotypically by their antibiotic resistance profiles and by MALDI-TOF mass spectrometry analysis.ResultsThe ITS1 region, gyrA and rpoB were chosen as the appropriate genes in the C. striatum genome to study the genetic diversity of C. striatum species and to discriminate between strains. After analysing these three genes, four sequence types (ST2, ST4, ST1 and ST11) were found to be the most abundant. Splits tree analysis of the strains demonstrated that these clinical isolates did not share any alleles with the type strain of the species. Recombination was detected within all of the C. striatum isolates, and different clonal populations were detected within the samples.ConclusionsOur results demonstrate that the isolates were best identified using gene-based molecular methods; using these methods, the isolated strains were determined to be different from the type strain of C. striatum. The ITS1 region and the gyrA and rpoB genes were selected because of their variability and were the most useful tools for discriminating between strains. The phenotype and antibiotype characteristics of the strains did not seem suitable for typing purposes. MALDI-TOF mass spectrometry can be a useful method for identifying and discriminating between C. striatum strains.

Alginate films containing Lactobacillus plantarum as wound dressing for prevention of burn infection

The topical application of lactobacilli is receiving attention for the prevention of superficial skin and burn wound infections. We studied the properties of Lactobacillus plantarum immobilized in calcium alginate films and investigated the antibacterial activity of these films in a model burn wound in rats. A multiresistant clinical isolate, VIM-2-metallo-β-lactamase-producing Pseudomonas aeruginosa, was used as the indicator strain. Films incorporating L. plantarum at cell concentrations of 10(8)cfu/mL caused a reduction of 5-6 log(10) in P. aeruginosa in the model burn wounds. L. plantarum immobilized in freeze-dried calcium alginate films remained viable during six months of storage at 4 °C.

In vitro antibacterial activity of some antihistaminics belonging to different groups against multi-drug resistant clinical isolates

Antihistaminics are widely used for various indications during microbial infection. Hence, this paper investigates the antimicrobial activities of 10 antihistaminics belonging to both old and new generations using multiresistant Gram-positive and Gram-negative clinical isolates. The bacteriostatic activity of antihistaminics was investigated by determining their MIC both by broth and agar dilution techniques against 29 bacterial strains. Azelastine, cyproheptadine, mequitazine and promethazine were the most active among the tested drugs. Diphenhydramine and cetirizine possessed weaker activity whereas doxylamine, fexofenadine and loratadine were inactive even at the highest tested concentration (1 mg/ml). The MIC of meclozine could not be determined as it precipitated with the used culture media. The MBC values of antihistaminics were almost identical to the corresponding MIC values. The bactericidal activity of antihistaminics was also studied by the viable count technique in sterile saline solution. Evident killing effects were exerted by mequitazine, meclozine, azelastine and cyproheptadine. Moreover, the dynamics of bactericidal activity of azelastine were studied by the viable count technique in nutrient broth. This activity was found to be concentration-dependant. This effect was reduced on increasing the inoculum size while it was increased on raising the pH. The post-antimicrobial effect of 100 fg/ml azelastine was also determined and reached up to 3.36 h.

Complete Genome Sequence of Staphylococcus aureus T0131, an ST239-MRSA-SCC mec Type III Clone Isolated in China

We report here the complete genome sequence of Staphylococcus aureus T0131, which is a multiresistant clinical isolate recovered in China and the first sequenced epidemic ST239-MRSA-SCCmec type III strain obtained in Asia. Comparison with two published genomes of ST239 reveals the polymorphism among strains of this type from different continents.

First report of the blaOXA-58 gene in a clinical isolate of Acinetobacter baumannii in Rio de Janeiro, Brazil

Carbapenemase production is an important mechanism of carbapenem resistance among nonfermentative Gram-negative isolates. This study aimed to report the detection of bla(OXA-58) gene in multiresistant clinical isolates of Acinetobacter baumannii recovered from inpatients in a public hospital. Polymerase chain reaction tests were performed to detect the bla(OXA-23-like), bla(OXA-24-like), bla(OXA-58-like) and bla(OXA-51-like) genes. The bla(OXA-58) and bla(OXA-23) genes were detected in one and three isolates, respectively. Sequencing of the bla(OXA-58-like) amplicon revealed 100% identity with the A. baumannii bla(OXA-58) gene listed in the GenBank database. This is the first report of an OXA-58-producing A. baumannii isolate in Rio de Janeiro, Brazil.

Different microbial biofilm formation on polymethylmethacrylate (PMMA) bone cement loaded with gentamicin and vancomycin

We studied the in vitro effects of gentamicin and vancomycin alone and in combination added to polymethylmethacrylate (PMMA) cement specimens on the bacterial adhesion of multiresistant clinical isolates. The PMMA specimens (discs) loaded with gentamicin (1.9%) or vancomycin (1.9%) or with a combination of the two were placed in Mueller-Hinton Broth inoculated with bacterial strains. After incubation, bacterial growth was determined by optical density (OD 540) and sub-cultures. The biofilm PMMA-associated dye (crystal violet) was measured. Antibiotic concentrations in broth were determined by fluorescence polarisation immunoassay. All antibiotic-loaded PMMA cement specimens released high, inhibitory concentrations of gentamicin and vancomycin. However, differences in strain growth and adhesion were recorded. The clinical isolates Met-R/Gent-R CoNS showed no adhesion to gentamicin-loaded specimens for 24 h; strains with Gent-Intermediate susceptibility exhibited growth after 48 h but reduced adhesion. Some Gent-R strains exhibited growth and adhesion to antibiotic-loaded specimens similar to controls (plain discs). Only the VRSA strain ( Staphylococcus aureus 5/7) and Escherichia coli were able to grow and adhere to vancomycin-loaded specimens after 24 h of incubation. The specimens loaded with the gentamicin + vancomycin combination showed a synergistic inhibitory effect against all tested strains (no bacterial growth). The degree of bacterial adhesion to PMMA cement loaded with gentamicin or vancomycin may be reduced in spite of a normal growth rate and is different for the tested strains. The effect of gentamicin and vancomycin on bacterial growth and adhesion to PMMA bone cement depends on the antibiotic concentrations, on the characteristics of each specific strain and on its ability to produce biofilm and adhere to antibiotic-loaded PMMA bone cement.

In vitro antibacterial activity of some antihistaminics belonging to different groups against multi-drug resistant clinical isolates.

Antihistaminics are widely used for various indications during microbial infection. Hence, this paper investigates the antimicrobial activities of 10 antihistaminics belonging to both old and new generations using multiresistant Gram-positive and Gram-negative clinical isolates. The bacteriostatic activity of antihistaminics was investigated by determining their MIC both by broth and agar dilution techniques against 29 bacterial strains. Azelastine, cyproheptadine, mequitazine and promethazine were the most active among the tested drugs. Diphenhydramine and cetirizine possessed weaker activity whereas doxylamine, fexofenadine and loratadine were inactive even at the highest tested concentration (1 mg/ml). The MIC of meclozine could not be determined as it precipitated with the used culture media. The MBC values of antihistaminics were almost identical to the corresponding MIC values. The bactericidal activity of antihistaminics was also studied by the viable count technique in sterile saline solution. Evident killing effects were exerted by mequitazine, meclozine, azelastine and cyproheptadine. Moreover, the dynamics of bactericidal activity of azelastine were studied by the viable count technique in nutrient broth. This activity was found to be concentration-dependant. This effect was reduced on increasing the inoculum size while it was increased on raising the pH. The post-antimicrobial effect of 100 μg/ml azelastine was also determined and reached up to 3.36 h.

Membrane permeability alteration of some bacterial clinical isolates by selected antihistaminics.

Several antihistaminics possess antibacterial activity against a broad spectrum of bacteria. However, the exact mechanism of such activity was unclear. Hence, the aim of this study is to investigate their mechanism of antibacterial activity especially their effect upon the permeability of the bacterial cytoplasmic membrane. The effects of azelastine, cetirizine, cyproheptadine and diphenhydramine were studied using Gram-positive and Gram-negative multiresistant clinical isolates. Leakage of 260 and 280 nm UV-absorbing materials was detected upon treatment with the tested antihistaminics; indicative of membrane alteration. Using an artificial membrane model, cholesterol-free negatively-charged unilamellar liposomes, confirmed the effect of antihistaminics upon the membrane permeability both by showing an apparent membrane damage as observed microscopically and by detection of leakage of preloaded dye from the liposomes colorimatrically. Moreover, examination of the ultrastructure of cells treated with azelastine and cetirizine under the transmission electron microscope substantiated the detected abnormalities in the cell wall and membrane. Furthermore, the effect of pretreating certain isolates for both short and long periods with selected antihistaminics was followed by the viable count technique. Increased vulnerability towards further exposure to azelastine was observed in cells pretreated with azelastine for 2 days and those pretreated with azelastine or cetrizine for 30 days.

Preservation of viability and antibacterial activity of Lactobacillus spp. in calcium alginate beads

The objective of the study was to produce calcium alginate beads able to deliver Lactobacillus spp. ( Lactobacillus plantarum, Lactobacillus rhamnosus GG, Lactobacillus bulgaricus and Lactobacillus lactis) with preserved viability and antibacterial activity. Four types of beads, containing entrapped (E), surface and entrapped (ES), surface (S) and concentrated surface and entrapped lactobacilli (C ES) were prepared and physically characterized. The antibacterial activity of lactobacilli cultures before and after immobilization, freeze-drying and throughout storage was studied in relationship to the viable number of lactobacilli. Multi-resistant clinical isolates (methicillin-resistant Staphylococcus aureus, vancomycine-resistant Enterococcus faecalis, VIM-2-metalo-β-lactamase producing Pseudomonas aeruginosa and CTX-M-15-β-lactamase producing strains: Escherichia coli and Klebsiella pneumoniae) were used as indicator strains. Alginate beads in which lactobacilli proliferated to the beads surface (ES and C ES) differed significantly from the other types of beads in their physicochemical properties, showing smoother surface morphology, more spherical shape, bigger weight, lower calcium content, density and crushing force. Lactobacilli cultures, at high cell concentrations (10 8 cfu/ml) were active against both Gram-positive and negative multi-resistant bacteria. Beads containing both entrapped and surface lactobacilli (ES) resulted in viability and antibacterial activity most similar to non-processed lactobacilli cultures. The viability and antibacterial activity of the immobilized lactobacilli remained stable after 6 months storage.

In vitro antimicrobial activity of extracts from Abarema cochliacarpos (Gomes) Barneby and J. W. Grimes

The usage of Abarema cochliacarpos (Mimosaceae) in traditional medicine by many communities in Brazil for diseases such as leucorrhea and dermatitis and as an antiseptic might indicate its antimicrobial activities. In order to assay in vitroantimicrobial activity, three extracts (hot aqueous extract, cold aqueous extract andmethanol extract) from stem bark of A. cochliacarpos were tested against a panel of standard microorganisms (Staphylococcus aureus ATTC 6835, Micrococcus luteusATCC 9341, Escherichia coli ATCC 10536, Pseudomonas aeruginosa ATCC 15442,Salmonella choleraesuis ATCC 10708, Candida albicans ATCC 10231,Trichophyton mentagrophytes ATCC 9533 and Aspergillus niger ATCC 16404) and multiresistant clinical isolates (S. aureus MR 01, MR02 and MR03). The antimicrobial activity was evaluated through the disk diffusion method, and the minimum inhibitory concentration (MIC) was determined using the micro dilution method. The results indicated that both aqueous extracts are active against gram-positive bacteria (M. luteus ATCC 9341, S. aureus ATCC 6835, and all clinical multiresistant samples) and against gram-negative bacteria (S. choleraesuis ATCC 10708). MIC values ranged between 5.0 and 15.62 µg/ml for gram-positive bacteria. The methanol extract gave a positive result only for gram-positive bacteria (ATTC standards M. luteus and S. aureus and all clinical multiresistant samples). Key words: Abarema cochliacarpos, antimicrobial activity, gram-negative bacteria, gram-positive bacteria, medicinal plant, traditional use.

Acquisition of multidrug resistance transposon Tn6061 and IS6100-mediated large chromosomal inversions in Pseudomonas aeruginosa clinical isolates

Pseudomonas aeruginosa is a major human opportunistic pathogen, especially for patients in intensive care units or with cystic fibrosis. Multidrug resistance is a common feature of this species. In a previous study we detected the ant(4')-IIb gene in six multiresistant clinical isolates of P. aeruginosa, and determination of the environment of the gene led to characterization of Tn6061. This 26 586 bp element, a member of the Tn3 family of transposons, carried 10 genes conferring resistance to six drug classes. The ant(4')-IIb sequence was flanked by directly repeated copies of ISCR6 in all but one of the strains studied, consistent with ISCR6-mediated gene acquisition. Tn6061 was chromosomally located in six strains and plasmid-borne in the remaining isolate, suggesting horizontal acquisition. Duplication-insertion of IS6100, that ended Tn6061, was responsible for large chromosomal inversions. Acquisition of Tn6061 and chromosomal inversions are further examples of intricate mechanisms that contribute to the genome plasticity of P. aeruginosa.

Activity of the siderophore monobactam BAL30072 against multiresistant non-fermenters

We tested the activity of BAL30072, a novel siderophore monobactam, against multiresistant clinical isolates of Pseudomonas aeruginosa, Burkholderia cepacia group and Acinetobacter spp. and against laboratory P. aeruginosa strains with defined resistance mechanisms. MICs were determined on Mueller-Hinton agar supplemented with 2,2' bipyridyl to induce iron transport; comparators were aztreonam, imipenem, meropenem and piperacillin/tazobactam. BAL30072 was strikingly active against Acinetobacter baumannii, with 73% of 200 carbapenemase-producing isolates, most of them belonging to the UK-dominant OXA-23 clone 1 and SE clone lineages, susceptible at 1 mg/L and 89% at 8 mg/L. Resistance nevertheless was seen in a few representatives of these clones and appeared commoner among isolates representing other A. baumannii clones. Sixty-eight per cent of 50 B. cepacia complex isolates from cystic fibrosis (CF) were susceptible to BAL30072 at 1 mg/L and 78% at 8 mg/L, compared with only 22% susceptible to aztreonam at 8 mg/L. Activity against P. aeruginosa was good, though less dramatic, with 36% of 50 (mostly multiresistant) CF isolates susceptible at 8 mg/L, compared with 12% susceptible to aztreonam at 8 mg/L. BAL30072 was active against 11/19 metallo-beta-lactamase-producing P. aeruginosa at 8 mg/L compared with 3/19 for aztreonam (12/19 versus 8/19 at 16 mg/L). Studies on P. aeruginosa mutants, isolates and transconjugants showed that BAL30072 was affected by efflux, AmpC and by a few uncommon acquired beta-lactamases, including some extended-spectrum OXA types and PER-1. BAL30072 displayed impressive activity against many carbapenemase-producing A. baumannii, particularly against the two clones most prevalent in the UK, and also against B. cepacia complex isolates from CF; it was more active than aztreonam against P. aeruginosa.

Chemical composition and antimicrobial activity of Satureja hortensis L. essential oil

AbstractEssential oil of Satureja hortensis L. was analyzed by GC and GC/MS and tested by a broth micro-well dilution method for activity against multiresistant clinical isolates of pathogenic bacteria from 10 different genera: Klebsiella, Escherichia, Proteus, Staphylococcus, Streptococcus, Pseudomonas, Enterococcus, Enterobacter, Citrobacter and Acinetobacter. The main compounds in the oil were carvacrol (67%), γ-terpinene (15.3%) and p-cymene (6.73%). The oil showed activity against all tested strains. MIC/MBC values were in the range of 0.78-25 μl/ml, with the exception of the strain P. aeruginosa. Microbicidal concentration for this particular strain (50 μl/ml) was the highest tested concentration. The oil showed inhibitory and bactericidal effect at the same concentration (MIC=MBC) for all but three strains.

Emerging Klebsiella pneumoniae Isolates Coproducing KPC-2 and VIM-1 Carbapenemases

VIM-1-producing Klebsiella pneumoniae strains, increasingly isolated in Greece since 2002, constitute the majority of multiresistant clinical isolates of this species found in most Greek hospitals ([9][1]). Moreover, following reports on Klebsiella pneumoniae carbapenemase (KPC)-producing isolates