division of medical microbiology - alberta health services · division of medical microbiology ......

Division of Medical Microbiology

Department of Laboratory Medicine and Pathology

University of Alberta Hospital and Stollery Children's Hospital

Antibiogram 2006

This material is supported in part by unrestricted educational grants from: Abbott, Bayer HealthCare, Merck Frosst, Roche Diagnostics, and Wyeth Inc.

University of Alberta Hospitals Antibiogram 2006

Table of Contents

Page Introduction ……………………………………………………………………... 2 Highlights: University of Alberta Antibiogram ………………………………... 3 Organism Characteristics ………………………………………………………. 5

Gram-positive Cocci ………………………………………………………. 5 Gram-negative Bacilli ……………………………………………………. 5

Antibiotics/Antifungals and the Abbreviations Used In the Tables …………….... 7 Aerobic Glucose Fermenting Gram-Negative Bacilli

Citrobacter koseri ………………………………………………………….. 8 Citrobacter freundii comples ……………………………………………… 8 Enterobacter aerogenes ……………………………………………………. 9 Enterobacter cloacae ……………………………………………………… 9 Escherichia coli …………………………………………………………… 10 Klebsiella species ………………………………………………………….. 11 Morganella morganii ……………………………………………………… 12 Proteus mirabilis ………………………………………………………….. 12 Serratia marcescens ……………………………………………………….. 12

Aerobic Glucose Non-fermenting Gram-Negative Bacilli Pseudomonas aeruginosa …………………………………………………. 13 Burkholderia cepacia ……………………………………………………… 14 Stenotrophomonas maltophilia …………………………………………… 14 Acinetobacter baumanii complex ………………………………………… 15

Fastidious Aerobic Gram-Negative Bacilli Haemophilus influenzae ………………………………….……………….. 15

Aerobic Gram-positive Cocci Enterococcus species ……………………………………………………… 16 Staphylococcus aureus ……………………………………………………. 17 Staphylococcus aureus, MRSA only ……………………………………… 17 Staphylococcus lugdunensis ………………………………………………... 18 Staphylococcus species, coagulase-negative, All Specimen Sources ……. 18 Streptococcus pneumoniae ………………………………………………... 19

Anaerobic Organisms Actinomyces species ……………………………………………………….. 20 Bacteroides species fragilis group ………………………………………… 20 Clostridium perfringens …………………………………………………... 20

Candida species ……………………………………………………………………. 21

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Introduction The antibiotic susceptibility material presented here includes primary data for the year 2006 for the University of Alberta Hospital, the Stollery Children's Hospital (UAH site) and their clinics and the WWC Cancer Institute. Susceptibility results represent clinical isolates of medically relevant pathogens. Identical organisms isolated from the same patient within a two-week period are excluded from analysis. Antibiogram tables include:

- University of Alberta and Stollery Children's Hospitals and WWC patients (inpatient and outpatient) presented as total numbers, and according to age (adults > 17 years)

- UAH 3C3/3C4 (General Systems Intensive Care units) - UAH 3C2 (Burn Unit) - WWC patients - For Pseudomonas aeruginosa, Burkholderia cepacia and Stenotrophomonas maltophilia cystic fibrosis (CF) patients and non-cystic

fibrosis patients are listed separately. - For individual tables, data is not presented for hospital locations when <10 organisms are isolated.

Highlights and trends for specific organism – antimicrobial combinations are presented following the Introduction. This antibiogram is published on an annual basis to provide physicians, pharmacists, and other health care professionals with antimicrobial susceptibility and resistance information for the patients of the University of Alberta Hospital, Stollery Children’s Centre, and other referral centres to the hospital. The production of this information is made possible in part by unrestricted education grants from Abbott, Bayer HealthCare, Roche Diagnostics, Merck Frosst, and Wyeth Inc. The efforts of Linda Rosmus (Technologist II) and the staff in Medical Microbiology in compiling the data are gratefully acknowledged. Feedback on the presentation of this information and on requests for additional information in subsequent years should be made to Dr. J. Fuller at 407-2767. The antibiogram may also be accessed via the Department of Laboratory Medicine and Pathology website (www.capitalhealth.ca/laboratorymedicine). Jeff Fuller, PhD, FCCM, ABMM Medical Microbiologist Division of Medical Microbiology University of Alberta Hospital Edmonton, Alberta.

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http://www.capitalhealth.ca/laboratorymedicine

Highlights: University of Alberta Hospitals Antibiogram 2006 Acinetobacter baumannii complex:

Strains resistant to multiple antibiotics, including carbapenems, were isolated from seriously infected patients in 2006. Colistin susceptibility testing is now available for these strains.

Candida:

Susceptibility results for Candida species are represented by sterile site isolates from UAH patients and Dynacare Kasper Medical Laboratories (DKML). C. albicans and C. glabrata comprise 80% of all candidal isolates (183) tested in 2006 (no change from 2005). Fluconazole resistance to C. glabrata (11%) remains comparable to global resistance rates using North American standards. However, European susceptibility standards would indicate that C. glabrata resistance is >70%. As such, it is recommended that fluconazole therapy for serious C. glabrata infections be directed cautiously and in consultation with Medical Microbiology and Infectious Disease services.

Enterobacteriaceae:

AmpC beta-lactamase resistance was indicated for 20 – 30% of Citrobacter and Enterobacter species (unchanged from 2005), which confers resistance to all beta-lactam antibiotics except for imipenem and meropenem.

ESBL-positive Escherichia coli and Klebsiella species increased to ~2.5% (<1% in 2005). The ESBL phenotype confers resistance to all third-generation cephalosporins, and in many cases, beta-lactam/beta-lactamase inhibitor compounds (ie. piperacillin-tazobactam). A significant proportion of ESBL-positive isolates are also resistant to quinolones, aminoglycosides, and TMP-SMX.

Enterococci: 20 clinical isolates of vancomycin-resistant enterococci (VRE) were identified in 2006. Both VanA and VanB phenotypes were identified during a nosocomial outbreak that was ultimately controlled. Pseudomonas aeruginosa:

Quinolones: 29% of strains are resistant to ciprofloxacin. Carbapenems: 19% of total strains are resistant to imipenem. In CF patients imipenem and meropenem resistance is 22% and 14%, respectively. These rates reflect all CF patient isolates, which is a change from 2005 reporting, and is more representative of resistance in this patient population. Ureidopenicillins: 14% and 9% of strains are resistant to piperacillin and piperacillin-tazobactam, respectively. 19% of non-CF and 52% of CF patients are resistant to ticarcillin-clavulanate. Ceftazidime: 15% of total isolates are resistant. In CF patients ceftazidime resistance dropped from 30% in 2003 to 14% in 2004 and has

not changed significantly since then. Aminoglycosides: In non-CF patients gentamicin resistance is 12%, while tobramycin and amikacin resistance is ~5%. Gentamicin,

tobramycin, and amikacin resistance in CF patients is 57%, 28%, and 51%, respectively.

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S. aureus: The overall beta-lactam resistance of nosocomial S. aureus continues to increase due to the dramatic increase of methicillin-resistant S. aureus (MRSA); 4%, 7%, and 18% for 2004, 2005, and 2006, respectively. A total of 307 clinical MRSA isolates are included in the S. aureus antibiogram. MRSA is also largely resistant to quinolones, macrolides, clindamycin, and TMP/SMX. Stenotrophomonas maltophilia:

Trimethoprim-sulfamethoxazole: Overall resistance is 31%, which is relatively unchanged from 2005 (27%). Resistance in CF patients (31%) has increased from 2005 (19%) but these values are based on a small number of isolates (36% in 2004). Doxycycline: Overall resistance is 26%.

Streptococcus pneumoniae: Macrolides: 14% of strains are erythromycin-resistant (unchanged from 2005). In 1999 the percentage of erythromycin-resistant strains was 4%. This is consistent with National surveillance data, which indicates dramatically increasing macrolide resistance. Penicillin: <1% of strains were fully resistant to penicillin. Intermediate resistance has steadily decreased from 15% in 2003 to 5% in 2006. This most likely reflects an improvement in the appropriate use of beta-lactams for pneumococcal infections. Third-generation cephalosporins: No resistance has been observed to ceftriaxone and cefotaxime (unchanged since 2003). Quinolones: 1% of strains are resistant to levofloxacin. 5-year analysis of all invasive S. pneumoniae in Alberta indicates a significant increase (>10%) in isolates with reduced levofloxacin susceptibility. This trend may be attributed, in part, to the development of bacterial mutations that can increase the likelihood of clinical failure for patients on levofloxacin therapy, and the 7-valent vaccine

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Organism Characteristics: In the Microbiology Laboratory it may take a number of days before an isolated organism’s identification is known. In order to prevent a delay in reporting results, a presumptive identification may be provided based on initial assay results. In some cases isolates are not fully identified either because they are unlikely to be clinically significant or because of organism/testing limitations. A comprehensive, but not entire, list of medically relevant pathogens is listed below and categorized based on initial Gram morphology and metabolic characteristics:

Gram-positive Cocci (in order of decreasing prevalence)

Gram-positive Cocci in Chains Gram-positive Cocci in Clumps

Enterococcus species Staphylococcus species, coagulase-negative

Streptococcus species, including: Staphylococcus aureus

Streptococcus pyogenes (Group A) Micrococcus species

Streptococcus agalactiae (Group B) Aerococcus species

Streptococcus pneumoniae Rothia (Stomatococcus) mucilaginosus

Viridans group streptococci

Beta-hemolytic streptococci, Groups G and C

Streptococcus anginosus group

Abiotrophia/Granulicatellaa species (formerly nutritionally variant streptococci)

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Gram-negative Bacilli (in order of decreasing prevalence)

Lactose Fermenting Gram-negative Bacilli [LFGNB]

Non-lactose Fermenting Gram-negative Bacilli [NLFGNB]

Glucose Non-fermenting Gram-negative Bacilli [GNFGNB]

Escherichia coli Serratia marcescens Pseudomonas aeruginosa

Klebsiella pneumoniae Proteus mirabilis Pseudomonas species

Klebsiella oxytoca Morganella morganii Stenotrophomonas maltophilia *

Enterobacter cloacae Aeromonas species Acinetobacter baumanii complex *

Citrobacter freundii complex Providencia rettgeri Acinetobacter lwoffii *

Enterobacter aerogenes Providencia stuartii Achromobacter species

Pantoeae agglomerans Salmonella species Burkholderia cepacia

Citrobacter koseri Chryseobacterium species

Comomonas species

Alcaligenes species

N.B. This table illustrates a general classification scheme used by microbiology laboratories for the preliminary reporting of gram-negative organisms, listed in order of decreasing prevalence at the UAH. This table should be used as a guide only and health-care providers need to recognize that metabolic variability within a species does occur. It is not uncommon for pathogens marked with an asterix (*) to be initially identified as NLFGNB.

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ANTIBIOTICS/ANTIFUNGALS AND THE ABBREVIATIONS USED IN THE ANTIBIOGRAM TABLES

ANTIBIOTIC ABBREVIATION ANTIBIOTIC ABBREVIATION ANTIFUNGAL ABBREVIATION

Amikacin AMIK Gentamicin GENT

Amoxicillin-clavulanic acid A/C Gentamicin Synergy GSYN 5-Fluorocytosine 5FC

Ampicillin AMP Imipenem IMP

Aztreonam AZT Levofloxacin LEVO Amphotericin B AMB

Cefazolin CZ Linezolid LINEZ

Cefepime CFP Meropenem MERO Caspofungin CASP

Cefotaxime CTX Metronidazole METR

Cefoxitin CFOX Minocycline MINO Fluconazole FLUC

Ceftazidime CAZ Nitrofurantoin NITRO

Cefuroxime CXM Norfloxacin NOR Itraconazole ITRA

Ceftriaxone CRO Penicillin PEN

Cephalothin CEPH Pipercillin PIP Ketoconazole KETO

Chloramphenicol CHLO Piperacillin-tazobactam TAZO

Clindamycin CLIN Rifampin RIF Voriconazole VORI

Cloxacillin CLOX Ticarcillin-clavulanic acid TIM

Ciprofloxacin CIP Tobramycin TOB

Doxycycline DOXY Trimethoprim-sulfamethoxazole T/S

Erythromycin ERY Vancomycin VANC

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ANTIBIOGRAM REPORT UNIVERSITY OF ALBERTA HOSPITALS (CHA) JAN 1/06 - DEC 31/06

Citrobacter freundii complexAll Specimen Sources AMIK A/C AMP CZ CEPH CXM CTX CRO CIP GENT IMP NITRO TAZO TOB T/SAll Patients % US S 99 5 0 0 0 0 84 76 85 91 100 92 86 91 84

ALL Ages # US S 115 6 0 0 0 0 98 26 99 106 116 107 100 105 97# TESTED 116 116 116 116 116 116 116 34 116 116 116 116 116 116 116

% US S 100 0 0 0 0 0 92 86 92 96 100 88 84 92 68Children < 17 years old # US S 25 0 0 0 0 0 23 6 23 24 25 22 21 23 17

# TESTED 25 25 25 25 25 25 25 7 25 25 25 25 25 25 25% US S 99 7 0 0 0 0 82 74 84 90 100 93 87 90 88

Adults >= 17 years old # US S 90 6 0 0 0 0 75 20 76 82 91 85 79 82 80# TESTED 91 91 91 91 91 91 91 27 91 91 91 91 91 91 91

% US S 100 20 0 0 0 0 70 88 80 90 100 90 80 100 90UAH 3C3/3C4 # US S 10 2 0 0 0 0 7 7 8 9 10 9 8 10 9

# TESTED 10 10 10 10 10 10 10 8 10 10 10 10 10 10 10

Citrobacter koseriAll Specimen Sources AMIK A/C AMP CZ CEPH CXM CTX CRO CIP GENT IMP NITRO TAZO TOB T/SAll Patients % SUS 100 75 0 90 85 85 100 100 100 100 100 85 100 100 100

ALL Ages # SUS 20 15 0 18 17 17 20 2 20 20 20 17 20 20 20# TESTED 20 20 20 20 20 20 20 2 20 20 20 20 20 20 20

% SUSChildren < 17 years old # SUS Insufficient numbers tested

# TESTED% SUS 100 78 0 89 83 83 100 100 100 100 100 83 100 100 100

Adults >= 17 years old # SUS 18 14 0 16 15 15 18 2 18 18 18 15 18 18 18# TESTED 18 18 18 18 18 18 18 2 18 18 18 18 18 18 18


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Enterobacter aerogenesAll Specimen Sources AMIK A/C AMP CZ CEPH CXM CTX CRO CIP GENT IMP NITRO TAZO TOB T/SAll Patients % US S 100 3 0 0 0 0 68 72 85 98 94 29 67 98 98


% SUSChildren < 17 years old # SUS Insufficient numbers tested

# TESTED% US S 100 3 0 0 0 0 67 71 84 98 94 30 65 98 98


Enterobacter cloacaeAll Specimen Sources AMIK A/C AMP CZ CEPH CXM CTX CRO CIP GENT IMP NITRO TAZO TOB T/SAll Patients % US S 100 5 0 0 0 0 79 77 88 94 >99 32 82 94 89


% US S 100 5 0 0 0 0 83 82 97 95 100 37 88 95 85Children < 17 years old # US S 60 3 0 0 0 0 50 23 58 57 60 22 53 57 51

# TESTED 60 60 60 60 60 60 60 28 60 60 60 60 60 60 60% US S 100 4 0 0 0 0 77 76 85 93 >99 30 80 93 90


% US S 100 3 0 0 0 0 73 78 73 97 97 42 73 97 91UAH 3C3/3C4 # US S 33 1 0 0 0 0 24 18 24 32 32 14 24 32 30

# TESTED 33 33 33 33 33 33 33 23 33 33 33 33 33 33 33


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Escherichia coli - Includes ESBL ProducersAll Specimen Sources AMIK A/C AMP CZ CEPH CXM CTX CRO CIP GENT IMP NITRO TAZO TOB T/S

UAH Site In/Out Patients % SUS >99 80 56 87 17 90 96 81 81 92 100 99 97 92 75 & WWC patients # SUS 1906 1527 1075 1672 334 1727 1837 86 1542 1765 1910 1889 1845 1756 1425

ALL Ages # TESTED 1911 1910 1911 1911 1911 1910 1911 106 1911 1910 1910 1911 1910 1911 1911UAH Site In/Out Patients % SUS 100 79 52 89 16 93 96 71 94 94 100 100 97 94 74

Children < 17 years old # SUS 394 312 206 349 62 365 379 10 371 369 394 394 381 370 292# TESTED 394 394 394 394 394 394 394 14 394 394 394 394 394 394 394

UAH Site In/Out Patients % SUS >99 80 57 87 18 90 96 83 77 92 100 99 97 91 75 & WWC pts; # SUS 1512 1215 869 1323 272 1362 1458 76 1171 1396 1516 1495 1464 1386 1133

Adults >= 17 years old # TESTED 1517 1516 1517 1517 1517 1516 1517 92 1517 1516 1516 1517 1516 1517 1517% SUS 100 72 52 76 13 79 91 81 72 87 100 98 91 85 77

UAH 3C3/3C4 # SUS 115 83 60 87 15 91 105 22 83 100 115 113 105 98 89# TESTED 115 115 115 115 115 115 115 27 115 115 115 115 115 115 115

% SUS 91 73 55 82 27 91 91 50 82 73 100 100 100 73 91UAH 3C2 # US S 10 8 6 9 3 10 10 1 9 8 11 11 11 8 10

# TESTED 11 11 11 11 11 11 11 2 11 11 11 11 11 11 11% SUS 99 76 54 84 22 87 97 100 79 97 100 100 97 94 78

WWC # SUS 66 51 36 56 15 58 65 5 53 65 67 67 65 63 52# TESTED 67 67 67 67 67 67 67 5 67 67 67 67 67 67 67

Escherichia coli - ESBL Producing Isolates onlyAll Specimen Sources AMIK A/C AMP CZ CEPH CXM CTX CRO CIP GENT IMP NITRO TAZO TOB T/S

UAH Site In/Out Patients % US S 94 29 0 0 0 0 0 0 42 63 100 94 81 48 31 & WWC patients # US S 45 14 0 0 0 0 0 0 20 30 48 45 39 23 15

ALL Ages # TESTED 48 48 48 48 48 48 48 48 48 48 48 48 48 48 48UAH Site In/Out Patients % US S 100 38 0 0 0 0 0 0 100 50 100 100 100 63 50

Children < 17 years old # US S 8 3 0 0 0 0 0 0 8 4 8 8 8 5 4# TESTED 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8

UAH Site In/Out Patients % US S 93 28 0 0 0 0 0 0 30 65 100 93 78 45 28 & WWC pts; # US S 37 11 0 0 0 0 0 0 12 26 40 37 31 18 11

Adults >= 17 years old # TESTED 40 40 40 40 40 40 40 40 40 40 40 40 40 40 40Antibiogram for Escherichia coli includes 41 patients with an ESBL (Extended-spectrum Beta-lacatamase producer) - 6 patients were children <17 years old. - 35 patients were adults >=17 years old.


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Klebsiella species - Includes ESBL ProducersAll Specimen Sources AMIK A/C AMP CZ CEPH CXM CTX CRO CIP GENT IMP NITRO TAZO TOB T/SUAH Site In/Out Patients % SUS 99 93 0 80 72 86 97 82 93 97 100 56 96 96 90

& WWC patients # SUS 642 603 0 519 467 557 629 62 602 629 647 365 624 624 580ALL Ages # TESTED 648 646 648 648 648 647 647 76 648 648 647 648 647 648 648

UAH Site In/Out Patients % SUS 99 94 0 80 69 91 97 86 99 94 100 76 96 94 88Children < 17 years old # SUS 117 110 0 94 81 107 114 12 117 111 118 90 113 111 104

# TESTED 118 117 118 118 118 118 118 14 118 118 118 118 118 118 118UAH Site In/Out Patients % SUS 99 93 0 80 73 85 97 81 92 98 100 52 97 97 90

& WWC pts; # SUS 525 493 0 425 386 450 515 50 485 518 529 275 511 513 476Adults >= 17 years old # TESTED 530 529 530 530 530 529 529 62 530 530 529 530 529 530 530

% SUS 97 93 0 72 66 76 94 75 90 99 100 63 94 96 90UAH 3C3/3C4 # US S 65 62 0 48 44 51 63 15 60 66 67 42 63 64 60

# TESTED 67 67 67 67 67 67 67 20 67 67 67 67 67 67 67% SUS 100 91 0 55 36 64 91 100 100 100 100 64 91 100 91

UAH 3C2 # US S 11 10 0 6 4 7 10 3 11 11 11 7 10 11 10# TESTED 11 11 11 11 11 11 11 3 11 11 11 11 11 11 11

% SUS 100 94 0 83 74 89 100 100 100 100 100 60 94 100 100WWC # SUS 35 33 0 29 26 31 35 2 35 35 35 21 33 35 35

# TESTED 35 35 35 35 35 35 35 2 35 35 35 35 35 35 35

Klebsiella species - ESBL Producing Isolates onlyAll Specimen Sources AMIK A/C AMP CZ CEPH CXM CTX CRO CIP GENT IMP NITRO TAZO TOB T/SUAH Site In/Out Patients % US S 60 33 0 0 0 0 0 0 47 33 100 53 53 20 27

& WWC patients # US S 9 5 0 0 0 0 0 0 7 5 15 8 8 3 4ALL Ages # TESTED 15 15 15 15 15 15 15 11 15 15 15 15 15 15 15

UAH Site In/Out Patients % US S 75 50 0 0 0 0 0 0 75 25 100 75 50 25 25Children < 17 years old # US S 3 2 0 0 0 0 0 0 3 1 4 3 2 1 1

# TESTED 4 4 4 4 4 4 4 2 4 4 4 4 4 4 4UAH Site In/Out Patients % US S 55 27 0 0 0 0 0 0 36 36 100 45 55 18 27

& WWC pts; # US S 6 3 0 0 0 0 0 0 4 4 11 5 6 2 3Adults >= 17 years old # TESTED 11 11 11 11 11 11 11 9 11 11 11 11 11 11 11

Antibiogram for Klebsiella species includes 14 patients with an ESBL (Extended-spectrum Beta-lacatamase producer) - 4 patients were children <17 years old. - 10 patients were adults >=17 years old.



Morganella morganiiAll Specimen Sources AMIK A/C AMP CZ CEPH CXM CTX CRO CIP GENT IMP NITRO TAZO TOB T/SUAH Site In/Out Patients % SUS 98 2 0 0 0 0 87 91 89 89 98 0 92 96 77





Proteus mirabilisAll Specimen Sources AMIK A/C AMP CZ CEPH CXM CTX CRO CIP GENT IMP NITRO TAZO TOB T/SUAH Site In/Out Patients % SUS 98 73 80 97 93 99 100 100 84 94 100 0 96 95 80





Serratia marcescensAll Specimen Sources AMIK A/C AMP CZ CEPH CXM CTX CRO CIP GENT IMP NITRO TAZO TOB T/SAll Patients % SUS 100 0 0 0 0 0 98 99 90 100 99 0 98 76 95

ALL Ages # SUS 99 0 0 0 0 0 97 66 89 99 98 0 97 75 94# TESTED 99 99 99 99 99 99 99 67 99 99 99 99 99 99 99

% SUS 100 0 0 0 0 0 100 100 89 100 100 0 100 79 100Children < 17 years old # SUS 19 0 0 0 0 0 19 14 17 19 19 0 19 15 19

# TESTED 19 19 19 19 19 19 19 14 19 19 19 19 19 19 19% SUS 100 0 0 0 0 0 98 98 90 100 99 0 98 75 94

Adults >= 17 years old # SUS 80 0 0 0 0 0 78 52 72 80 79 0 78 60 75# TESTED 80 80 80 80 80 80 80 53 80 80 80 80 80 80 80

% SUS 100 0 0 0 0 0 87 91 73 100 100 0 87 93 93UAH 3C3/3C4 # SUS 15 0 0 0 0 0 13 10 11 15 15 0 13 14 14

# TESTED 15 15 15 15 15 15 15 11 15 15 15 15 15 15 15

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Pseudomonas aeruginosaAll Specimen Sources AMIK AZT CAZ CFP CIP GENT IMP MERO PIP TAZO TIM TOBAll Patients % SUS 76 70 85 60 71 69 81 89 86 91 80 85

ALL Ages # SUS 790 710 895 294 742 724 844 889 902 918 449 890# TESTED 1039 1011 1047 493 1045 1047 1045 1001 1045 1012 560 1047

% SUS 78 77 86 64 93 71 87 94 89 92 87 86Children < 17 years old # SUS 174 168 193 80 209 160 195 208 200 203 88 192

#TESTED 224 219 224 125 224 224 224 221 224 221 101 224% SUS 76 68 85 58 65 69 79 87 86 90 79 85

Adults >= 17 years old # SUS 616 542 702 214 533 564 649 681 702 715 361 698#TESTED 815 792 823 368 821 823 821 780 821 791 459 823

Non-CF Patients % SUS 96 64 87 55 70 88 83 91 89 93 81 94 ALL Ages # SUS 577 374 533 41 427 537 504 517 540 544 439 575

#TESTED 603 586 611 75 610 611 609 568 609 587 539 611% SUS 98 73 90 67 95 93 91 96 93 96 88 99

Children < 17 years old # US S 95 69 87 4 92 90 88 90 90 93 83 96#TESTED 97 95 97 6 97 97 97 94 97 97 94 97

% SUS 95 62 87 54 65 87 81 90 88 92 80 93Adults >= 17 years old # SUS 482 305 446 37 335 447 416 427 450 451 356 479

# TESTED 506 491 514 69 513 514 512 474 512 490 445 514CF Patients % SUS 49 79 83 61 72 43 78 86 83 88 48 72

ALL Ages # SUS 213 336 362 253 315 187 340 372 362 374 10 315#TESTED 436 425 436 418 435 436 436 433 436 425 21 436

% SUS 62 80 83 64 92 55 84 93 87 89 71 76Children < 17 years old # SUS 79 99 106 76 117 70 107 118 110 110 5 96

#TESTED 127 124 127 119 127 127 127 127 127 124 7 127% SUS 43 79 83 59 64 38 75 83 82 88 36 71

Adults >= 17 years old # SUS 134 237 256 177 198 117 233 254 252 264 5 219#TESTED 309 301 309 299 308 309 309 306 309 301 14 309

% SUS 83 51 73 46 56 77 73 75 73 90 66 86UAH 3C3/3C4 # US S 52 31 47 6 36 49 47 45 47 54 33 55

#TESTED 63 61 64 13 64 64 64 60 64 60 50 64

Quinolones: 29% of strains are resistant to ciprofloxacin. Carbapenems: 19% of total strains are resistant to imipenem. In CF patients imipenem and meropenem resistance is 22% and 14%, respectively. These rates reflect all CF patient isolates, which is a change from 2005 reporting, and is more representative of resistance in this patient population. Ureidopenicillins: 14% and 9% of strains are resistant to piperacillin and piperacillin-tazobactam, respectively. 19% of non-CF and 52% of CF patients are resistant to ticarcillin-clavulanate. Ceftazidime: 15% of total isolates are resistant. In CF patients ceftazidime resistance dropped from 30% in 2003 to 14% in 2004 and has not changed significantly since then. Aminoglycosides: In non-CF patients gentamicin resistance is 12%, while tobramycin and amikacin resistance is ~5%. Gentamicin, tobramycin, and amikacin resistance in CF patients is 57%, 28%, and 51%, respectively.

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Burkholderia cepacia complexAll Specimen Sources CAZ CIP GENT IMP MERO TAZO T/SAll isolates were CF Patients % SUS 89 22 0 33 100 67 67

ALL Ages # US S 8 2 0 3 9 6 6# TESTED 9 9 9 9 9 9 9

Stenotrophomonas maltophiliaAll Specimen Sources DOXY TIM T/SAll Patients % SUS 74 51 69

ALL Ages # SUS 190 131 178# TESTED 257 257 257

% SUS 73 50 73Children < 17 years old # SUS 51 35 51

# TESTED 70 70 70% SUS 74 51 68

Adults >= 17 years old # SUS 139 96 127# TESTED 187 187 187

NON-CF Patients % SUS 75 53 69ALL Ages # SUS 149 105 138

# TESTED 199 199 199% SUS 79 47 76

Children < 17 years old # SUS 27 16 26# TESTED 34 34 34

% SUS 74 54 68Adults >= 17 years old # SUS 122 89 112

# TESTED 165 165 165CF Patients % SUS 71 45 69

ALL Ages # SUS 41 26 40# TESTED 58 58 58

% SUS 67 53 69Children < 17 years old # SUS 24 19 25

# TESTED 36 36 36% SUS 77 32 68

Adults >= 17 years old # SUS 17 7 15# TESTED 22 22 22

% SUS 74 56 74UAH 3C3/3C4 # SUS 25 19 25

# TESTED 34 34 34

Trimethoprim-sulfamethoxazole: Overall resistance is 31%, which is relatively unchanged from 2005 (27%). Resistance in CF patients (31%) has increased from 2005 (19%) but these values are based on a small number of isolates (36% in 2004). Doxycycline: Overall resistance is 26%.


Acinetobacter baumanni complexAll Specimen Sources A/C CAZ CIP GENT IMP TOB T/S

% US S 0 74 72 69 91 80 70ALL Ages # SUS 0 34 33 31 41 37 32

# TESTED 5 46 46 45 45 46 46% SUS N/A 89 100 78 100 100 78

Children < 17 years old # SUS 0 8 9 7 9 9 7# TESTED 0 9 9 9 9 9 9

% US S 0 70 65 67 89 76 68Adults >= 17 years old # SUS 0 26 24 24 32 28 25

# TESTED 5 37 37 36 36 37 37

Strains resistant to multiple antibiotics, including carbapenems, were isolated from seriously infected patients in 2006. Colistin susceptibility testing is now available for these strains.

Haemophilus influenzaeAll Specimen Sources AMP A/C CTX CXM CRO CIP RIF SXT

UAH Site In/Out Patients % SUS 61 100 100 100 100 100 100 80 & WWC patients # SUS 59 11 45 46 8 10 8 45

ALL Ages # TESTED 96 11 45 46 8 10 8 56UAH Site In/Out Patients % SUS 65 100 100 100 100 100 100 88

Children < 17 years old # SUS 20 5 19 17 6 2 6 15# TESTED 31 5 19 17 6 2 6 17

UAH Site In/Out Patients % SUS 60 100 100 100 100 100 100 77 & WWC pts; # SUS 39 6 26 29 2 8 2 30

Adults >= 17 years old # TESTED 65 6 26 29 2 8 2 39% SUS 67 N/A 100 100 100 N/A 100 80

UAH 3C3/3C4 # US S 8 0 5 5 1 0 1 4# TESTED 12 0 5 5 1 0 1 5

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Enterococcus species - Includes VRE isolatesAll Specimen Sources AMP CIP NITRO VANC GSYN

UAH Site In/Out Patients % SUS 85 27 81 98 66 & WWC patients # SUS 1217 389 1147 1403 950

ALL Ages # TESTED 1430 1423 1422 1427 1430UAH Site In/Out Patients % SUS 95 49 92 >99 91Children < 17 years old # SUS 215 110 207 224 205

# TESTED 226 225 225 225 226UAH Site In/Out Patients % SUS 83 23 79 98 62

& WWC pts; # SUS 1002 279 940 1179 745Adults >= 17 years old # TESTED 1204 1198 1197 1202 1204

% SUS 65 15 57 94 68UAH 3C3/3C4 # SUS 63 14 55 91 66

# TESTED 97 96 96 97 97% SUS 92 50 92 96 48

UAH 3C2 # SUS 23 12 22 24 12# TESTED 25 24 24 25 25

% SUS 94 33 92 100 65WWC Patients # SUS 51 18 49 54 35

# TESTED 54 54 53 54 54

Enterococcus species (VRE)All Specimen Sources AMP CIP LINEZ NITRO VANC GSYN

UAH Site In/Out Patients % SUS 5 0 90 0 0 80 & WWC patients # SUS 1 0 18 0 0 16

Patients were all >= 17 years old # TESTED 20 20 20 20 20 20

20 clinical isolates of vancomycin-resistant enterococci (VRE) were identified in 2006. Both VanA and VanB phenotypes were identified during a nosocomial outbreak that was ultimately controlled.

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Staphylococcus aureus - Includes MRSA IsolatesAll Specimen Sources CZ CIP CLIN CLOX ERY GENT LEVO LINEZ NITRO PEN T/S VANC

UAH Site In/Out Patients % SUS 82 79 68 82 63 88 78 100 100 11 89 100 & WWC patients # SUS 1429 1364 1186 1432 1103 1524 1358 1735 1737 200 1538 1738

ALL Ages # TESTED 1737 1737 1740 1740 1740 1737 1736 1735 1737 1740 1736 1740UAH Site In/Out Patients % SUS 93 96 80 93 74 98 95 100 100 6 94 100Children < 17 years old # SUS 287 297 247 287 229 301 294 308 308 17 288 308

# TESTED 308 308 308 308 308 308 308 308 308 308 308 308UAH Site In/Out Patients % SUS 80 75 66 80 61 86 75 100 100 13 88 100

& WWC pts; # SUS 1142 1067 939 1145 874 1223 1064 1427 1429 183 1250 1430Adults >= 17 years old # TESTED 1429 1429 1432 1432 1432 1429 1428 1427 1429 1432 1428 1432

% SUS 66 65 56 66 50 75 65 100 100 13 76 100UAH 3C3/3C4 # SUS 111 108 93 111 84 125 108 166 167 21 127 167

# TESTED 167 167 167 167 167 167 166 166 167 167 167 167% SUS 65 67 54 65 50 77 67 100 100 2 75 100

UAH 3C2 # SUS 31 32 26 31 24 37 32 48 48 1 36 48# TESTED 48 48 48 48 48 48 48 48 48 48 48 48

% SUS 95 89 83 95 81 97 91 100 100 14 98 100WWC # SUS 60 57 53 61 52 62 58 64 64 9 63 64

# TESTED 63 64 64 64 64 64 64 64 64 64 64 64

Staphylococcus aureus, MRSA Isolates onlyAll Specimen Sources CZ CIP CLIN CLOX ERY GENT LEVO LINEZ NITRO PEN T/S VANC

UAH Site In/Out Patients % SUS 0 10 19 0 4 48 11 100 100 0 50 100 & WWC patients # SUS 0 30 57 0 12 147 33 307 307 0 153 307

ALL Ages # TESTED 307 307 307 307 307 304 306 307 307 307 306 307UAH Site In/Out Patients % SUS 0 55 80 0 35 89 55 100 100 0 90 100Children < 17 years old # SUS 0 11 16 0 7 17 11 20 20 0 18 20

# TESTED 20 20 20 20 20 19 20 20 20 20 20 20UAH Site In/Out Patients % SUS 0 7 14 0 2 46 8 100 100 0 47 100

& WWC pts; # SUS 0 19 41 0 5 130 22 287 287 0 135 287Adults >= 17 years old # TESTED 287 287 287 287 287 285 286 287 287 287 286 287

% SUS 0 7 13 0 0 32 7 100 100 0 34 100UAH 3C3/3C4 # SUS 0 4 7 0 0 18 4 56 56 0 19 56

# TESTED 56 56 56 56 56 56 55 56 56 56 56 56

The overall beta-lactam resistance of nosocomial S. aureus continues to increase due to the dramatic increase of methicillin-resistant S. aureus (MRSA); 4%, 7%, and 18% for 2004, 2005, and 2006, respectively. A total of 307 clinical MRSA isolates are included in the S. aureus antibiogram. MRSA is also largely resistant to quinolones, macrolides, clindamycin, and TMP/SMX.

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Staphylococcus lugdunensisAll Specimen Sources CZ CIP CLIN CLOX ERY GENT NITRO PEN T/S VANCUAH Site In/Out Patients % SUS 100 100 82 100 82 100 100 73 100 100

& WWC patients # SUS 11 11 9 11 9 11 11 8 11 11ALL Ages # TESTED 11 11 11 11 11 11 11 11 11 11

UAH Site In/Out Patients % SUSChildren < 17 years old # SUS Insufficient numbers tested

# TESTEDUAH Site In/Out Patients % SUS 100 100 80 100 80 100 100 80 100 100

& WWC pts; # SUS 10 10 8 10 8 10 10 8 10 10Adults >= 17 years old # TESTED 10 10 10 10 10 10 10 10 10 10

Staphylococcus species, coagulase-negativeAll Specimen Sources CZ CIP CLIN CLOX ERY GENT NITRO PEN T/S VANCUAH Site In/Out Patients % SUS 35 47 46 36 34 65 100 10 56 100

& WWC patients # SUS 114 140 152 117 111 192 296 32 179 325ALL Ages # TESTED 322 296 328 327 328 295 296 328 322 326

UAH Site In/Out Patients % SUS 30 66 42 30 30 49 100 4 56 100Children < 17 years old # SUS 15 31 21 15 15 23 47 2 28 50

# TESTED 50 47 50 50 50 47 47 50 50 50UAH Site In/Out Patients % SUS 36 44 47 37 35 68 100 11 56 100


% SUS 16 24 29 16 26 62 100 3 32 100UAH 3C3/3C4 # SUS 5 7 9 5 8 18 29 1 10 31

# TESTED 31 29 31 31 31 29 29 31 31 31

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Streptococcus pneumoniaeAll Specimen Sources CXM CTX CRO CLIN ERY LEVO MERO PEN T/S VANC

UAH Site In/Out Patients % SUS 86 100 100 97 86 100 100 94 80 100 & WWC patients # SUS 43 134 89 194 177 198 36 237 162 232

ALL Ages # TESTED 50 134 89 200 205 198 36 251 202 232UAH Site In/Out Patients % SUS 86 100 100 98 82 100 100 95 76 100Children < 17 years old # SUS 19 44 29 60 54 59 11 71 50 67

# TESTED 22 44 29 61 66 59 11 75 66 67UAH Site In/Out Patients % SUS 86 100 100 96 88 100 100 94 82 100


% SUS 83 100 100 100 92 100 100 94 86 100UAH 3C3/3C4 # SUS 10 24 19 39 36 38 3 46 32 45

# TESTED 12 24 19 39 39 38 3 49 37 45

Macrolides: 14% of strains are erythromycin-resistant (unchanged from 2005). In 1999 the percentage of erythromycin-resistant strains was 4%. This is consistent with National surveillance data, which indicates dramatically increasing macrolide resistance.

Penicillin: <1% of strains were fully resistant to penicillin. Intermediate resistance has steadily decreased from 15% in 2003 to 5% in 2006. This most likely reflects an improvement in the appropriate use of beta-lactams for pneumococcal infections.

Third-generation cephalosporins: No resistance has been observed to ceftriaxone and cefotaxime (unchanged since 2003).

Quinolones: 1% of strains are resistant to levofloxacin. 5-year analysis of all invasive S. pneumoniae in Alberta indicates a significant increase (>10%) in isolates with reduced levofloxacin susceptibility. This trend may be attributed, in part, to the development of bacterial mutations that can increase the likelihood of clinical failure for patients on levofloxacin therapy, and the 7-valent vaccine.

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Actinomyces speciesAll Specimen Sources A/C CLIN IMP METR PEN


ALL Ages # TESTED 8 25 25 25 25UAH Site In/Out Patients % SUS N/A 50 100 0 100

Children < 17 years old # US S 0 2 4 0 4# TESTED 0 4 4 4 4

UAH Site In/Out Patients % SUS 100 86 100 0 100 & WWC pts; # SUS 8 18 21 0 21

Adults >= 17 years old # TESTED 8 21 21 21 21

Bacteroides species, fragilis groupAll Specimen Sources A/C CLIN IMP METR PEN


ALL Ages # TESTED 27 27 27 27 27UAH Site In/Out Patients % SUS

Children < 17 years old # SUS Insufficient Numbers Tested (1)# TESTED

UAH Site In/Out Patients % SUS 96 50 100 100 0 & WWC pts; # SUS 25 13 26 26 0


Clostridium perfringensAll Specimen Sources A/C CLIN IMP METR PEN

UAH Site In/Out Patients % SUS 100 100 100 100 91 & WWC patients # US S 1 11 11 11 10

ALL Ages # TESTED 1 11 11 11 11UAH Site In/Out Patients % SUS

Children < 17 years old # SUS Insufficient Numbers Tested# TESTED

UAH Site In/Out Patients % SUS 100 100 100 100 91 & WWC pts; # US S 1 11 11 11 10


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Candida albicansSterile Site Sources AMB 5FC ITRA KETO FLUC VORI CASPUAH In/Out % Susc * 100 68 * 100 99 *and WWC and DKML MIC90** 1 1 0.25 0.12 1 0.12 0.5ALL Ages # Tested 82 82 82 82 82 82 82

Candida glabrataSterile Site Sources AMB 5FC ITRA KETO FLUC VORI CASPUAH In/Out % Susc * 100 5 * 62 86 *and WWC MIC90** 1 0.06 2 2 64 2 1ALL Ages # Tested 63 63 63 63 63 63 63

Candida tropicalisSterile Site Sources AMB 5FC ITRA KETO FLUC VORI CASPUAH In/Out % Susc * 100 14 * 93 93 *and WWC MIC90** 2 0.5 0.5 0.5 4 1 1ALL Ages # Tested 14 14 14 14 14 14 14

Candida parapsilosisSterile Site Sources AMB 5FC ITRA KETO FLUC VORI CASPUAH In/Out % Susc * 100 100 * 100 100 *and WWC MIC90** 2 0.12 0.25 0.12 1 0.06 1ALL Ages # Tested 13 13 13 13 13 13 13

* Susceptible and resistant interpretations for Candida exist only for 5FC, ITRA, FLUC, and VORI

** MIC90 - minimum inhibitory concentration of 90% of isolates for each species

Susceptibility results for Candida species are represented by sterile site isolates from UAH patients and Dynacare Kasper Medical Laboratories (DKML). C. albicans and C. glabrata comprise 80% of all candidal isolates (183) tested in 2006 (no change from 2005). Fluconazole resistance to C. glabrata (11%) remains comparable to global resistance rates using North American standards. However, European susceptibility standards would indicate that C. glabrata resistance is >70%. As such, it is recommended that fluconazole therapy for serious C. glabrata infections be directed cautiously and in consultation with Medical Microbiology and Infectious Disease services.

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