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Volume 48, Number 1, February 2015

Relationship between the distribution of cefepime minimum inhibitory concentrations and detection of extended-spectrum β-lactamase production among clinically important Enterobacteriaceae isolates obtained from patients in intensive care units in Taiwan: Results from the Surveillance of Multicenter Antimicrobial Resistance in Taiwan (SMART) in 2007 

Shio-Shin Jean, Wen-Sen Lee, Kuan-Jen Bai, Carlos Lam, Chin-Wang Hsu, Kwok-Woon Yu, Chun-Hsing Liao, Feng-Yi Chang, Wen-Chien Ko, Jiunn-Jong Wu, Yen-Hsu Chen, Yao-Shen Chen, Jien-Wei Liu, Min-Chi Lu, Cheng-Yi Liu, Ray-Jade Chen, Po-Ren Hsueh

Received: March 25, 2013    Revised: May 22, 2013    Accepted: July 2, 2013   


Corresponding author:

* Corresponding author. Department of Laboratory Medicine, National Taiwan University Hospital, Number 7, Chung-Shan South Road,
Taipei 100, Taiwan.
E-mail address: (P.-R. Hsueh). 


Background and purpose: 

The data on susceptibility of important cephalosporins against four Enterobacteriaceae members producing potential extended-spectrum β-lactamase (ESBL) collected from Taiwanese intensive care units are lacking. 



Minimum inhibitory concentrations (MICs) of cefotaxime, ceftazidime, and cefepime were determined using agar dilution method, against Escherichia coli (n = 344), Klebsiella pneumoniae (n = 359), Enterobacter cloacae (n = 103), and Proteus mirabilis (n = 78). Susceptibilities of these isolates to three cephalosporins were assessed according to MIC breakpoints recommended by the Clinical and Laboratory Standards Institute (CLSI) and the European Committee on Antimicrobial Susceptibility Testing (EUCAST) in 2013. The double-disk synergy test using disks containing cefepime (30 μg) with or without clavulanate (10 μg) was applied to confirm production of ESBL for isolates with cephalosporin MIC ≥2 μg/mL. 



A total of 175 isolates were verified as ESBL producers. The rates of cefepime susceptibility among the ESBL-producing isolates, according to CLSI (EUCAST) criteria, were 56.7% (22.4%) for E. coli, 61.3% (12.0%) for K. pneumoniae, 57.9% (31.6%) for E. cloacae, and 71.4% (7.1%) for P. mirabilis. Using different cefepime MIC breakpoints (MICs ≥16 μg/mL recommended by CLSI criteria and ≥2 μg/mL by EUCAST criteria) to define nonsusceptibility, we found that both criteria were poorer at predicting ESBL producers among K. pneumoniae and E. cloacae than among the other two species. In addition, we also found that the cefepime MIC level of 1.0 μg/mL best distinguished non-ESBL- from ESBL-producing K. pneumoniae and E. cloacae. 



To detect ESBLs, CLSI should revise the cefepime MIC breakpoint against Enterobacteriaceae. 


Key words:

Cefepime, Clinical and Laboratory Standards Institute, Enterobacteriaceae, Extended-spectrum β-lactamase, Surveillance for Monitoring Antimicrobial Resistance in Taiwan