There are occasions when clinicians are unsure of a specific drug's activity against anaerobes and may use redundant coverage with metronidazole, such as a carbapenem or a BL-BLIC. More significantly, nim genes are often found on mobilizable plasmids and therefore pose a significant threat to the continuing utility of 5-Ni drugs, including metronidazole, which is the most frequently prescribed drug for anaerobic infections worldwide (50). 17). The combination agents of ampicillin-sulbactam, amoxicillin-clavulanate, ticarcillin-clavulanate, and piperacillin-tazobactam are generally very active against members of the B. fragilis group (27). Their isolation requires appropriate methods of collection, transportation, and cultivation of specimens (2 Acetate like substances, methane, nitrate and sulfide are produced by these bacteria. It has a broad antibacterial spectrum for penicillin-susceptible Streptococcus pneumoniae, Streptococcus pyogenes, methicillin-sensitive Staphylococcus aureus, Haemophilus influenzae, Moraxella catarrhalis, Escherichia coli, Citrobacter spp., Klebsiella spp., Serratia spp., Proteus spp., C. perfringens, Fusobacterium spp., Peptostreptococcus spp., and AGNB (99). The mechanism of metronidazole resistance for non-Bacteroides anaerobes is unknown. – At least 50 to 100 strains should be tested in order to obtain an accurate picture of the pattern of local isolates, and if isolates from different body sites are available, they should be included. Carbapenemases are active against the carbapenems as well as all β-lactam antibiotics. To overcome the problem of renal metabolism of imipenem, it is combined at a 1:1 ratio with an inhibitor of the renal dipeptidase cilastatin. Peripheral neuropathy is associated with prolonged metronidazole use. The indigenous anaerobic microflora are, however, often profoundly affected by pathophysiological states and by exposure to antibiotics and other pharmacological compounds. Obligate anaerobes, together with microaerophils, are characterized by their sensitivity to oxygen. His interests include the diagnosis, pathogenesis, and therapy of anaerobic infections, including intra-abdominal infections, diabetic foot infections, C. difficile, human and animal bites, and the in vitro susceptibility of anaerobic bacteria to new antimicrobial agents. Over 97% of Bacteroides isolates in the United States and 76% in Great Britain produce BLAs (105). The major concerns with expanding the use of fluoroquinolones to treat anaerobic infections have been reports of increasing resistance in strains of the B. fragilis group as well as anaerobic Gram-positive cocci and the impact of these antibiotics on the growing incidence of C. difficile-associated disease (142). Moxifloxacin has been approved by the FDA for the treatment of complicated skin and skin structure infections, including those due to B. fragilis, and for mixed intra-abdominal infections caused by B. fragilis, B. thetaiotaomicron, Peptostreptococcus spp., and C. perfringens. In vitro activity of agents directed at Bacteroides spp. Ampicillin/Sulbactam. If needed, ancillary susceptibility testing can be performed for cefoxitin, tigecycline, and moxifloxacin, which have approved antianaerobe indications. Most B. fragilis group strains produce constitutive BLs that are primarily cephalosporinases (104). Pigmented Prevotella and Porphyromonas spp., Prevotella bivia, Prevotella disiens, and Fusobacterium nucleatum produce primarily penicillinases (107). However, antimicrobial bacterial resistance among anaerobic bacteria is increasing globally, as demonstrated by numerous surveys in Europe, the United States, Canada, and New Zealand [3– 6]. Antimicrobial agents effective against mixed infection Although this type of test is not currently appropriate for clinical settings, there is increasing interest in using this technology for clinical laboratory identification (58), and it is conceivable that it could be potentially developed for testing. Contributed by. Most clinical isolates of the B. fragilis group are resistant to penicillin G, and it should not be used for the treatment of infections caused by these organisms. With some exceptions among some Clostridium spp., strains of Clostridium, Porphyromonas, and Fusobacterium have also been found to express resistance by one or more of the BLAs. (Right) Plate after growth of strains. The most recently published surveys of anaerobic susceptibility testing performed in a clinical laboratory indicated that, as of the time of the survey, only 21% (21/98) of hospital laboratories performed anaerobic susceptibility testing in-house (20). Tigecycline is effective against anaerobic bacteria (137, 140). 1962.-Soils from aerobic and anaerobic sources were investigated for the possible presence of bacteria which produce antibiotics under anaerobic conditions of growth. Thus, a clinical laboratory would have the option of either using Etest (which is FDA approved), using noncommercial panels with CLSI-approved methodology (thus, FDA approval would not be relevant), or sending the isolates to a commercial or reference laboratory for testing. B. fragilis group resistance rates for piperacillin-tazobactam are generally <1% (27). He is an editor, associate editor, and member of the editorial board of several medical journals and the Head and Neck Cancer Alliance. Isolates from patients likely to undergo long-term therapy should be tested so that any development of resistance can be recognized. Also, any bacteria isolated from normally sterile body sites should be tested (as long as they are not likely to be contaminants). b. β-Lactam AntibioticsPenicillin G is the classical drug of choice when the infecting strains are susceptible to this drug in vitro. Compounds with intermediate antianaerobic activity include sparfloxacin and grepafloxacin (141). Table 3 illustrates the resistance of the B. fragilis group and other anaerobes to antimicrobial agents. 4, middle). A prospective study of Bacteroides bacteremia reported adverse clinical outcomes for 128 individuals who received an antibiotic to which the organism was not susceptible (14). Taking antibiotics like penicillin, quinolone, aminoglycosides, tetracyclines, etc. 10:55-59. Imipenem has more activity than meropenem against staphylococci and enterococci, but meropenem provides better coverage of aerobic and facultative Gram-negative bacteria such as Pseudomonas, Enterobacter, Klebsiella, Providencia, Morganella, Aeromonas, Alcaligenes, Moraxella, Kingella, Actinobacillus, Pasteurella, and Haemophilus spp. Anaerobes may be unicellular (e.g. A multiplex PCR test that could detect multiple resistance determinants in B. fragilis isolates was recently described by Pumbwe et al. Despite the emergence of carbapenemase-resistant Enterobacteriaceae, it is also effective against most Enterobacteriaceae, with about 5% to 15% of Pseudomonas species strains being resistant (95). CLSI reference protocol M11-A8 has included extensive discussion on breakpoint interpretation and included several sets of photographs to aid in reading of breakpoints. Anaerobic Bacteria Rebecca L. Penland Michael S. Osato Kirk R. Wilhelmus The eye and ocular adnexa are prone to colonization by anaerobic bacteria that are also part of the flora of periorbital skin, paranasal sinuses, and the oral cavity. B. fragilis group species are generally resistant to penicillins (average, 90%), piperacillin (25%), cefoxitin (25%), cefotetan (30 to 85%), and third-generation cephalosporins (27, 88). However, species-to-species variations in susceptibility occur, and many non-BLA-producing P. distasonis strains have elevated MICs at or approaching the susceptible breakpoint (112). FluoroquinolonesThe earlier fluoroquinolones, such as ciprofloxacin and ofloxacin, are inactive against most anaerobic bacteria. The question of whether these tests are FDA approved for diagnostic purposes is a bit confusing. While aerobes are able to thrive in habitats that have abundant oxygen, anaerobes may die in the presence of oxygen. Because anaerobic bacteria generally are recovered mixed with aerobic organisms, selection of proper therapy becomes more complicated. Most studies conform to CLSI breakpoints, but certain EUCAST breakpoints are different. 17). Moxifloxacin resistance rates varied from 17% for B. fragilis strains isolated from the female genitourinary tract to 52% for all blood culture isolates (moxifloxacin MIC breakpoint, 4 μg/ml). ; Bilophila wadsworthia; and Sutterella wadsworthensis. Details of the procedure are described in the manufacturer's guidelines. The only commercially available ready-made panel is produced by Sensititre (Trek Diagnostic Systems); it is designated for research purposes only and is not FDA approved for diagnostic testing. Surveillance Tests for Particular Hospitals or Geographic RegionsSurveillance tests have been conducted for years by groups worldwide and reflect sweeping general trends (18, 24, 27, 33, 34, 147) However, these results will not necessarily reflect the patterns of specific patients or hospitals. Aerobic Bacteria: Aerobic bacteria live in the soil, water, and on different surfaces. – Linezolid is active against Fusobacterium nucleatum, other Fusobacterium spp., Porphyromonas spp., Prevotella spp., and Peptostreptococcus spp. Furthermore, there are clear differences in the geographic patterns of resistance and even differences in resistance patterns in different hospitals in a single city, perhaps due in part to the variability in prescribing patterns (27). Author information: (1)Istanbul Technical University, Environmental Engineering Department, Maslak, Istanbul, Turkey. These drugs are effective against Enterobacteriaceae and have good activity against most anaerobes in these concentrations. Other common symptoms of anaerobic bacterial infections in dogs incl… (33) observed that 90% of B. fragilis isolates recovered from nosocomial infections and bacteremias in Taiwan were susceptible to moxifloxacin. One must be aware that MICs of chloramphenicol often cluster around the susceptibility breakpoint. Ampicillin, amoxicillin, and penicillin generally are equally active, but the semisynthetic penicillins are less active than the parent compound. (3) Results: In our database of 1719 patients, 365 patients had microbial testing, of which 42 grew anaerobic bacteria. (37 [80.4%] of 46 patients). Some of these strains show MICs of 8 to 32 units/ml of penicillin G. In these instances, administration of very high doses of penicillin G (for non-beta-lactamase producers) may eradicate the infection. 82). However, the rate of resistance of P. distasonis to ampicillin-sulbactam has risen to 20% in 2002 to 2004, but resistance rates continued to be low for the other B. fragilis group species. The Etest is particularly suitable for testing of one or a few isolates against multiple agents (as long as the particular agent is available on an Etest strip). fragilis group species, and resistance to them is generally low, except that more than half of Prevotella species isolates may also produce BLAs. – While anaerobic bacteria can even grow in places wherein oxygen is not available, it is not possible for aerobic species to do that. will help cure infections. This indicated a steep decline from earlier rates; in 1990, 70% of hospital laboratories performed susceptibility testing (36), which declined to 33% in 1993 (37). Agar dilution technique. Studies on the antimicrobial susceptibility profile of anaerobic bacteria are underrepresented in the literature. This increase makes the choice of appropriate empirical therapy even more difficult. Recent large surveillance studies in Europe have also used CLSI methodology and often include both CLSI and EUCAST breakpoints (29, 147). Overall, tigecycline has a low rate (5.5%) of resistance against B. fragilis group species (22). The bacteria that grow in the absence of oxygen are called anaerobic bacteria. An anaerobic organism or anaerobe is any organism that does not require oxygen for growth. In 2007, The Committee on Antimicrobial Susceptibility Testing of the Japanese Society of Chemotherapy recommended the use of the CLSI method (32). Clindamycin does not cross the blood-brain barrier or eye efficiently and should not be administered in CNS infections. For many, there is only a vague familiarity with Prevotella and Porphyromonas spp. The CLSI has standardized many clinical procedures, including anaerobic susceptibility testing, and has published documents for anaerobic susceptibility testing (commonly called M11) (16). A multicenter survey (93) found penicillin resistance for Fusobacterium spp., Porphyromonas spp., and Peptostreptococcus spp. The general principles are limited to questions of whether anaerobes are involved in this type of infection and if the agent chosen has activity against B. fragilis. ChloramphenicolChloramphenicol, a bacteriostatic agent, is active against most anaerobic bacteria but is rarely used in the United States (3, 79). Amoxicillin-clavulanate remains the agent of choice for human and animal bite wound infections (77), especially when anaerobes may be involved. Commercially Available TestingThermoFisher Scientific (Cleveland, OH) now owns Remel, Oxoid, and Sensititre (Trek Diagnostic Systems). (Courtesy of bioMérieux, reproduced with permission.). (4% and 5% resistance to ampicillin-sulbactam, respectively). This implies that these species can also grow in parts of the human body wherein the amount of oxygen supplied is very low. It has low MICs for the B. fragilis group. Aydin S(1), Ince B(2), Ince O(3). The obligate anaerobes that commonly cause infection can tolerate atmospheric oxygen for at least 8 hours and frequently for up to 72 hours. Anaerobic bacteria and antibiotics: what kind of unexpected resistance could I find in my laboratory tomorrow? Chloramphenicol is widely distributed in body fluids and tissue, with a mean volume of distribution of 1.4 liters/kg of body weight (115). (96, 97). The most commonly isolated antibiotic-resistant anaerobes are species within the Bacteroides fragilis group (18). Another important pathogen that belongs to the B. fragilis group is B. thetaiotaomicron, which accounts for 13% to 23% of the isolates. This gene codes for an enzyme that converts 4- or 5-nitroimidazole (4- or 5-Ni, respectively) to 4- or 5-aminoimidazole (thus avoiding the formation of toxic nitroso radicals that are essential for antimicrobial activity). Cefoxitin is therefore the most effective cephalosporin against the B. fragilis group. ; Bilophila wadsworthia; and Sutterella wadsworthensis. Other factors that impact results reported in survey antibiograms include the particular makeup of the groups of strains included. Doripenem has been approved in the United States for use in treatment of complicated intra-abdominal infection and complicated urinary tract infection. Resistance rates differed remarkably between the different countries. will help cure infections. Some studies in mice (129) have shown possible mutagenic activity associated with administration of large doses of this drug. – 15). Should rapid diagnostics (such as MALDI-TOF MS) become available for anaerobes in the future, it is likely that this paradigm would change. Bacterial vaginosis • Bacterial overgrowth, often involving Gardnerella vaginalis, other anaerobes • Helicobacter pylorii •• Peptic ulcers, potentially leading to stomach cancer Combine with proton pump inhibitor (PPI), bismuth, and another antibiotic (e.g. Antibiotics sometimes work even when some of the bacterial species in a mixed infection are resistant to the antibiotic (eg, because of loss of support from other bacterial species or the necrotic anaerobic environment), especially if surgical debridement and drainage are adequate. Liu et al. Antimicrobial resistance among anaerobes has consistently increased in the past decades, and the susceptibility of anaerobic bacteria to antimicrobial agents has become less predictable. Antimicrobial therapy for anaerobic infections usually should be given for prolonged periods because of their tendency to relapse. Other antimicrobial drug classes target bacterial functions that can be affected by the physiological changes that facultative anaerobe bacteria experience in anaerobic conditions [20–22]. This review describes current methods for antimicrobial testing in research or reference laboratories. There are a number of studies showing that inappropriate therapy will directly affect clinical outcome (10 Research laboratories that conduct large surveys, as well as pinpointing the mechanisms of resistance that may be relevant in the antibiograms, can help monitor, understand, and perhaps even control these shifts by making recommendations based on the molecular traits of the pathogen. Resistance to this drug is rare, although it has been reported for some Bacteroides spp. 72). 75). Sometimes, these agents are used for surgical prophylaxis for abdominal surgery and for the treatment of aspiration pneumonia. The enzyme has little or no hydrolytic activity for the second-generation antimicrobial cefoxitin (a cephamycin). Anaerobes were more frequently cultured in patients with hepatic abscesses and gallbladder perforation. (113). Resistance among Gram-positive organisms that are not strict anaerobes is frequent, especially for P. acnes and Actinomyces spp. Infections caused by anaerobic bacteria are common and may be serious and life-threatening. Susceptibility testing should be performed on organisms recovered from sterile body sites, those that are isolated in pure culture, or those that are clinically important and have variable or unique susceptibility patterns. Aydin S(1), Ince B(2), Ince O(3). Furthermore, they are killed by oxygen, they lack enzymes such as catalase [which breaks down hydrogen peroxide (H 2 O 2 ) to water and oxygen], peroxidase [by which 1NADH + H 2 O … Activity of a novel carbapenem, doripenem, against anaerobic pathogens. When testing was performed, blood isolates were always tested. Antibiotics sometimes work even when some of the bacterial species in a mixed infection are resistant to the antibiotic (eg, because of loss of support from other bacterial species or the necrotic anaerobic environment), especially if surgical debridement and drainage are adequate. However, some anaerobic bacteria have become resistant to antimicrobial agents, and many can develop resistance while a patient is receiving therapy (111, 152). In the treatment of mixed infection, the choice of the appropriate antimicrobial agents should provide for adequate coverage of most of the pathogens, aerobic and anaerobic. 2006; 21:161-3. Resistance has also increased among other anaerobes, such as Clostridium spp., that were previously very susceptible. Individuals may improve without antimicrobial or surgical therapy, and others can get better because of adequate drainage. Currently, we are not aware of any commercially available ready-made broth microdilution panels that are “FDA approved” for clinical diagnostic use. Gram-positive anaerobic cocci (GPAC) account for approximately 25–30% of all isolated anaerobic bacteria from clinical specimens . Of the non-B. Therefore, correlation of the results of in vitro susceptibility and clinical and bacteriological responses can be difficult or impossible (1, 3, 6). β-Lactams are generally effective against non-B. Anaerobic bacteria have always been resistant to aminoglycosides and trimethoprim-sulfamethoxazole. (137), who tested 396 unusual anaerobes, found all Gram-positive anaerobes and 228/232 Gram-negative anaerobes to be susceptible to ≤1 μg/ml of tigecycline. The mortality rate among those who received inactive therapy (45%) was higher than that among patients who received active therapy (16%; P = 0.04). At present, approximately 85% of B. fragilis isolates are susceptible to cefoxitin, but the other B. fragilis group species are more resistant (17). This is because clinicians are not aware of their activity against the B. fragilis group locally and are unlikely to have knowledge of the specific antibiotic susceptibility of the isolate recovered from their patients. If you are affected by any of the above infections, it is advisable to seek medical help immediately. Organisms that should be considered for individual isolate testing include highly virulent pathogens for which susceptibility cannot be predicted, such as Bacteroides, Prevotella, Fusobacterium, and Clostridium spp. A recent study (143) reported a pooled analysis of 4 randomized clinical trials (2000 to 2010) that assessed the comparative efficacy of moxifloxacin in complicated intra-abdominal infections of 745 microbiologically evaluable cases and focused on its efficacy against B. fragilis. The CLSI recognized that there are commercially available broth microdilution panels that are FDA approved for testing of all anaerobes and may work satisfactorily for certain non-B. The overall outcomes of all patients were favorable and the resistance rate to commonly used antibiotics remained low. 3). These findings suggested incomplete mobilization of nim gene-associated resistance. In this survey, most hospital laboratories used the Etest (62%; 13/21) for susceptibility testing, while only 17% of reference laboratories used it. ASM journals are the most prominent publications in the field, delivering up-to-date and authoritative coverage of both basic and clinical microbiology. However, up to 30% of strains of the B. fragilis group are resistant to these agents (78). However, EUCAST does not actually specify a testing method for anaerobes. fragilis strains, 65% produce BLs (106, 107). He is the author of 6 medical textbooks, 128 book chapters, and over 700 scientific publications. The CLSI reference standard is not intended for testing of single isolates; rather, it provides a standard against which other methods may be measured. CLSI policy does not permit it to advocate any commercial technique; rather, it describes two reference methods (agar dilution and broth microdilution) and emphasizes that other techniques, such as gradient techniques (generally referring to Etest) or commercial broth microdilution plates, may be used as long as equivalence to the reference methods is established. Aceticlastic methanogen population abundance for Chlortetracycline (CTC) treatments ( Methanosaetaceae and Methanosarcinaceae sp .) fragilis group species. – Low pH, low redox potential – Inoculum effect – Dead bacteria and debris may inactivate drugs After the antimicrobial agents are allowed to diffuse, the isolates are deposited onto the plate with an automated inoculator or manually streaked from the center to the edge of the plate. In cases where other factors that can cause variability are also involved (e.g., differences in techniques or media or different people reading results), it becomes clear that minor changes (e.g., less than 15%) in percent susceptibility may not be significant in reports of large groups of strains; still, survey studies provide useful information on trends and patterns in antimicrobial susceptibility of anaerobes. (40), who evaluated 550 anaerobes recovered from intra-abdominal and diabetic foot infections, reported that 97% were susceptible to moxifloxacin. In the past, he has served as an Associate Editor for Clinical Infectious Diseases and the Journal of Medical Microbiology. It rapidly penetrates into body tissues and fluids, including saliva, sputum, respiratory tissue, pleural fluid, soft tissues, prostate, semen, bones, and joints (124), as well as into fetal blood and tissues. Doripenem, a synthetic 1-beta-methyl carbapenem, is the newest carbapenem to be commercially released. Community-acquired anaerobic bacteremia in adults: one-year experience in a medical center, Antimicrobial resistance and clinical outcome of, Clinical significance and outcome of anaerobic bacteremia, Susceptibility test methods: anaerobic bacteria, Clinical and Laboratory Standards Institute, Methods for antimicrobial susceptibility testing of anaerobic bacteria. Increased activity of efflux pumps or changes in penicillin-binding proteins (PBPs) have been shown to affect MICs of β-lactams for many Bacteroides isolates; systematic surveys of these mechanisms have not been conducted, so the percentage of strains that have or utilize these mechanisms is not known (35, 49). The medium used in the test was Schaedler broth, with incubation in a glove box with an atmosphere of 5% CO (2), 10% H (2), and 85% N (2), or in the GasPak system. Imipenem, a thienamycin, is a beta-lactam antibiotic that is effective against a wide variety of aerobic and anaerobic Gram-positive and Gram-negative organisms, including normally multiresistant species such as Pseudomonas aeruginosa, Serratia spp., Enterobacter spp., Acinetobacter spp., and enterococci (93, 94). The side effect of most concern is C. difficile-associated colitis (125, 126). The antimicrobials potentially effective against anaerobic bacteria include beta-lactams, combinations of beta-lactams and beta-lactamase inhibitors, metronidazole, chloramphenicol, clindamycin, macrolides, tetracyclines, and fluoroquinolones. Is a Rapid Test on the Horizon?It would be very appealing to wish that there could be a simple molecular test, or even a complex test, such as multiplex PCR, that would determine the actual or potential resistance of an organism to multiple antibiotics. A joint ESGAI study. Surveillance studies performed in reference laboratories in the United States and worldwide most commonly use the CLSI method (see below). A variety of studies (19, 22, 144) have reported increases in B. fragilis resistance to moxifloxacin. Each country tested different antibiotics, sometimes depending on the kind of infection and/or the anaerobic species isolated. However, increasing numbers of clinical metronidazole-resistant isolates that do not possess any of the nimA-H genes are being found. Other AgentsBacitracin was active in vitro against pigmented Prevotella and Porphyromonas spp. Studies using different proportions of the various B. fragilis group species may reflect different antibiograms for the B. fragilis group as a whole, when in reality, the only difference is the proportion of the various species used. Dr. Wexler is currently Councilor of Division A (Antimicrobial Agents and Chemotherapy) of the American Society for Microbiology after serving as Chair of the Division. 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