Felipe Fernández-Cuenca

Hospital Universitario Virgen Macarena, Hispalis, Andalusia, Spain

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Publications (63)222.43 Total impact

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    ABSTRACT: Introduction: The main aim of this study was to assess changes in the epidemiology and clinical presentation of Acinetobacter baumannii over a 10-year period, as well as risk factors of mortality in infected patients. Method: Prospective, multicentre, hospital-based cohort studies including critically ill patients with A. baumannii isolated from any clinical sample were included. These were divided into a first period ("2000 study") (one month), and a second period ("2010 study") (two months). Molecular typing was performed by REP-PCR, PFGE and MSLT. The primary endpoint was 30-day mortality. Results: In 2000 and 2010, 103 and 108 patients were included, and the incidence of A. baumannii colonization/infection in the ICU decreased in 2010 (1.23 vs. 4.35 cases/1000 patient-days; p<0.0001). No differences were found in the colonization rates (44.3 vs. 38.6%) or infected patients (55.7 vs. 61.4%) in both periods. Overall, 30-day mortality was similar in both periods (29.1 vs. 27.8%). The rate of pneumonia increased from 46.2 in 2000 to 64.8% in 2010 (p<0.001). Performing MSLT, 18 different sequence types (ST) were identified (18 in 2000, 8 in 2010), but ST2 and ST79 were the predominant clones. ST2 isolates in the ICU increased from 53.4% in the year 2000 to 73.8% in 2010 (p=0.002). In patients with A. baumannii infection, the multivariate analysis identified appropriate antimicrobial therapy and ST79 clonal group as protective factors for mortality. Conclusions: At 10 years of the first analysis, some variations have been observed in the epidemiology of A. baumannii in the ICU, with no changes in mortality. Epidemic ST79 clone seems to be associated with a better prognosis and adequate treatment is crucial in terms of survival.
    Full-text · Article · Jan 2016 · Enfermedades Infecciosas y Microbiología Clínica
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    ABSTRACT: Objectives The objective of this study was to analyse whether there is an association between reduced susceptibility to biocides in Acinetobacter baumannii and (i) antimicrobial resistance (co-resistance), (ii) prevalent (epidemic) clones, (iii) changes in the fitness or (iv) expression of genes related to efflux pumps and porins. Methods Susceptibility to biocides and antimicrobials was determined in 49 clonally unrelated isolates of A. baumannii. Biological cost, in terms of mean generation time, was determined by spectrophotometry. Quantitative real-time RT–PCR was used to determine the relative expression of genes encoding several efflux pumps and porins. Results Reduced susceptibility to chlorhexidine digluconate, benzalkonium chloride and Irgasan® was associated with resistance to aminoglycosides, tetracycline and ciprofloxacin (P < 0.05). The MICs of carbapenems, aminoglycosides, doxycycline and ciprofloxacin for isolate Ab70 (epidemic clone) exposed to these biocides increased by ≥2 dilutions. Reduced susceptibility to Orsan® was more frequent among prevalent clones than non-prevalent clones (P < 0.05). Mean generation times for Ab70 before and after exposure to benzalkonium chloride were 57.8 and 78.1 min, respectively (P = 0.02). Relative expression of abeS and adeB was increased in Ab46 and Ab70 after exposure to chlorhexidine digluconate, but was decreased for ompA and carO after exposure to Irgasan®. Conclusions Reduced susceptibility to biocides is associated with co-resistance to carbapenems, aminoglycosides, tetracycline and ciprofloxacin. Reduced susceptibility to Orsan® may be a marker of prevalent clones. Acquisition of reduced susceptibility to benzalkonium chloride has a biological cost. Exposure to biocides affects the relative expression of genes related to some efflux pump genes (increased expression) or porins (reduced expression).
    No preview · Article · Sep 2015 · Journal of Antimicrobial Chemotherapy
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    ABSTRACT: A carbapenem-resistant Acinetobacter baumannii expressing blaOXA-23 was recovered from an intensive care unit patient in a third-level hospital from Spain. Genetic analysis showed the association of this carbapenemase with the transposon Tn2007 located in a plasmid of 10 kb. The isolate was classified as ST-1. This strain has shown a potential ability to displace other endemic strains in the hospital and is the first reported identification of A. baumannii carrying blaOXA-23 related to Tn2007 in Spain.
    No preview · Article · Nov 2014 · Microbial drug resistance (Larchmont, N.Y.)
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    ABSTRACT: Background Treatment of multidrug-resistant Acinetobacter baumannii (MDRAB) infection presents a challenge because of the scarcity of available options. Even though combination therapy (CT) is frequently used in clinical practice, data are needed to support its use instead of monotherapy (MT).
    No preview · Article · Nov 2014 · Journal of Antimicrobial Chemotherapy
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    ABSTRACT: Acinetobacter baumannii is one of the most important antibiotic-resistant nosocomial bacteria. We investigated changes in the clinical and molecular epidemiology of A. baumannii over a 10-year period. We compared the data from 2 prospective multicenter cohort studies in Spain, one performed in 2000 (183 patients) and one in 2010 (246 patients), which included consecutive patients infected or colonized by A. baumannii. Molecular typing was performed by repetitive extragenic palindromic polymerase chain reaction (REP-PCR), pulsed-field gel electrophoresis (PFGE), and multilocus sequence typing (MLST). The incidence density of A. baumannii colonization or infection increased significantly from 0.14 in 2000 to 0.52 in 2010 in medical services (p < 0.001). The number of non-nosocomial health care-associated cases increased from 1.2% to 14.2%, respectively (p < 0.001). Previous exposure to carbapenems increased in 2010 (16.9% in 2000 vs 27.3% in 2010, p = 0.03). The drugs most frequently used for definitive treatment of patients with infections were carbapenems in 2000 (45%) and colistin in 2010 (50.3%). There was molecular-typing evidence of an increase in the frequency of A. baumannii acquisition in non-intensive care unit wards in 2010 (7.6% in 2000 vs 19.2% in 2010, p = 0.01). By MSLT, the ST2 clonal group predominated and increased in 2010. This epidemic clonal group was more frequently resistant to imipenem and was associated with an increased risk of sepsis, although not with severe sepsis or mortality. Some significant changes were noted in the epidemiology of A. baumannii, which is increasingly affecting patients admitted to conventional wards and is also the cause of non-nosocomial health care-associated infections. Epidemic clones seem to combine antimicrobial resistance and the ability to spread, while maintaining their clinical virulence.
    Full-text · Article · Jul 2014 · Medicine
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    ABSTRACT: Introduction. Acinetobacter baumannii is one of the most important antibiotic-resistant, nosocomial bacteria. We investigated changes in the clinical and molecular epidemiology of A. baumannii over a 10 year period. Methods. We compared the data from two prospective multicenter cohort studies performed in 2000 (183 patients) and 2010 (246 patients) in Spain, which included consecutive patients infected or colonized by A. baumannii. Molecular typing was performed by REP-PCR, PFGE and MSLT. Results. The incidence density of A. baumannii colonization or infection increased significantly from 0.14 to 0.52 in medical services (p<0.001). The number of non-nosocomial healthcare-associated cases increased from 1.2% to 14.2% (p<0.001). Previous exposure to carbapenems increased in 2010 (16.9 vs 27.3%, p=0.03). The drugs most frequently used for definitive treatment of patients with infections were carbapenems in 2000 (45%) and colistin in 2010 (50.3%). There was molecular-typing evidence of an increase in the frequency of A. baumannii acquisition in non-intensive care unit (ICU) wards in 2010 (7.6% vs 19.2%, p=0.01). By MSLT, the ST2 clonal group predominated and increased in 2010. This epidemic clonal group was more frequently resistant to imipenem and was associated with an increased risk of sepsis, although not with severe sepsis or mortality. Conclusions. Some significant changes were noted in the epidemiology of A. baumannii, which is increasingly affecting patients admitted to conventional wards and is also the cause of non-nosocomial healthcare-associated infections. Epidemic clones seem to combine antimicrobial resistance and the ability to spread, while maintaining their clinical virulence.
    No preview · Article · Feb 2014 · Medicine
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    ABSTRACT: We investigated the mechanisms of resistance to carbapenems, aminoglycosides, glycylcyclines, tetracyclines, and quinolones in 90 multiresistant clinical strains of Acinetobacter baumannii isolated from two genetically unrelated A. baumannii clones: clone PFGE-ROC-1 (53 strains producing the OXA-58 β-lactamase enzyme and 18 strains with the OXA-24 β-lactamase) and clone PFGE-HUI-1 (19 strains susceptible to carbapenems). We used real-time reverse transcriptase PCR to correlate antimicrobial resistance (MICs) with expression of genes encoding chromosomal β-lactamases (AmpC and OXA-51), porins (OmpA, CarO, Omp33, Dcap-like, OprB, Omp25, OprC, OprD, and OmpW), and proteins integral to six efflux systems (AdeABC, AdeIJK, AdeFGH, CraA, AbeM, and AmvA). Overexpression of the AdeABC system (level of expression relative to that by A. baumannii ATCC 17978, 30- to 45-fold) was significantly associated with resistance to tigecycline, minocycline, and gentamicin and other biological functions. However, hyperexpression of the AdeIJK efflux pump (level of expression relative to that by A. baumannii ATCC 17978, 8- to 10-fold) was significantly associated only with resistance to tigecycline and minocycline (to which the TetB efflux system also contributed). TetB and TetA(39) efflux pumps were detected in clinical strains and were associated with resistance to tetracyclines and doxycycline. The absence of the AdeABC system and the lack of expression of other mechanisms suggest that tigecycline-resistant strains of the PFGE-HUI-1 clone may be associated with a novel resistance-nodulation-cell efflux pump (decreased MICs in the presence of the inhibitor Phe-Arg β-naphthylamide dihydrochloride) and the TetA(39) system.
    Full-text · Article · Aug 2013 · Antimicrobial Agents and Chemotherapy
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    ABSTRACT: The fitness and virulence costs associated with the clinical acquisition of colistin resistance by Acinetobacter baumannii were evaluated. The growth of strain CR17 (colistin resistant) was less than that of strain CS01 (colistin susceptible) when the strains were grown in competition (72-h competition index, 0.008). In a murine sepsis model, CS01 and CR17 reached spleen concentrations when coinfecting of 9.31 and 6.97 log10 CFU/g, respectively, with an in vivo competition index of 0.016. Moreover, CS01 was more virulent than CR17 with respect to mortality and time to death.
    Full-text · Article · Jul 2013 · Antimicrobial Agents and Chemotherapy
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    Full-text · Article · May 2013 · Enfermedades Infecciosas y Microbiología Clínica
  • Lorena López-Cerero · Felipe Fernández-Cuenca · Alvaro Pascual
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    ABSTRACT: The most relevant activities of clinical microbiologist and the laboratory in the surveillance and the control of nosocomial infections (NI) are mainly focused on the collection, analysis and management of the information obtained in the Microbiology Laboratory; the design, development and validation of microbiological techniques, particularly rapid tests for the early detection of nosocomial pathogens, especially those multi-drug resistant ones, and the study of the genetic relationship between them. It also assists in the design of specific programs for the prevention of the NI, and the evaluation of their impact, as well as taking part in educational and training programs on topics related to NI. The management of laboratory resources, and communications with hospital information systems is also important.The most suitable tools for the control of NI include the correct identification at the species level of relevant nosocomial pathogens, analysis of the evolution of resistance to antimicrobials, monitoring sentinel organisms, active surveillance of carriers, and molecular epidemiology studies (genotyping). Prospectively typing of these pathogens, which has been achieved through advances in technology, and dissemination of molecular techniques, have a direct impact on the design of prevention and control interventions. To achieve the maximum performance with all these tools, it is essential to have a good communication strategy and an effective alert system.
    No preview · Article · Jan 2013 · Enfermedades Infecciosas y Microbiología Clínica
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    ABSTRACT: Objectives To determine the prevalence of resistance to antimicrobials in Acinetobacter baumannii (A. baumannii) from Spain and to compare it with those obtained in the first national study (GEIH-Ab project 2000).MethodsA total of 446 isolates of A. baumannii obtained from 43 Spanish hospitals during February-March 2010 were studied. Identification of A. baumannii was confirmed by ARDRA and MALDI-TOF. Susceptibility to 18 antimicrobial agents was determined by microdilution (Clinical and Laboratory Standards Institute, CLSI). The CLSI break-points were used, except for doripenem, rifampin, sulbactam (Societé Française de Microbiologie [SFM] break-points) and tigecycline (European Committee on Antimicrobial Susceptibility Testing [EUCAST] break-points for Enterobacteriaceae).ResultsThe percentage of resistant isolates (intermediate susceptible plus resistant) was: > 94% (ceftazidime, piperacillin and ciprofloxacin), 82-86% (carbapenems, tetracycline), 60-70% (tobramycin, sulbactam, gentamicin, doxycycline), 49% (amikacin), 30% (minocycline, rifampin), 24% (tigecycline), and 3% (colistin). These isolates were, in comparison with those of the first study, more resistant (P < .01) to ceftazidime (99% vs 83%), carbapenems (82-86% vs 43-48%), sulbactam (65% vs 53%) and colistin (3% vs 0%), but more susceptible to aminoglycosides (particularly gentamicin: 70% vs 96% of resistant isolates), tetracycline (83% vs 91%) and rifampicin (30% vs 51%).Conclusion There is a high prevalence of A. baumannii resistant to antimicrobials, particularly to carbapenems. The resistance to carbapenems, ceftazidime and sulbactam was significantly higher than that observed for isolates from the GEIH-Ab project 2000. The resistance to aminoglycosides, tetracycline and rifampin, however, was significantly decreased.
    No preview · Article · Jan 2013 · Enfermedades Infecciosas y Microbiología Clínica
  • Lorena López-Cerero · Felipe Fernández-Cuenca · Alvaro Pascual
    [Show abstract] [Hide abstract]
    ABSTRACT: The most relevant activities of clinical microbiologist and the laboratory in the surveillance and the control of nosocomial infections (NI) are mainly focused on the collection, analysis and management of the information obtained in the Microbiology Laboratory; the design, development and validation of microbiological techniques, particularly rapid tests for the early detection of nosocomial pathogens, especially those multi-drug resistant ones, and the study of the genetic relationship between them. It also assists in the design of specific programs for the prevention of the NI, and the evaluation of their impact, as well as taking part in educational and training programs on topics related to NI. The management of laboratory resources, and communications with hospital information systems is also important. The most suitable tools for the control of NI include the correct identification at the species level of relevant nosocomial pathogens, analysis of the evolution of resistance to antimicrobials, monitoring sentinel organisms, active surveillance of carriers, and molecular epidemiology studies (genotyping). Prospectively typing of these pathogens, which has been achieved through advances in technology, and dissemination of molecular techniques, have a direct impact on the design of prevention and control interventions. To achieve the maximum performance with all these tools, it is essential to have a good communication strategy and an effective alert system.
    No preview · Article · Dec 2012 · Enfermedades Infecciosas y Microbiología Clínica
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    ABSTRACT: Background To describe the long term outcome of patients who interrupted highly active antiretroviral therapy (HAART) once, identify the variables associated with earlier need to re-start HAART, and the response when therapy was resumed. A retrospective observational cohort of 66 adult patients with HIV-1 infection who interrupted HAART with a CD4+cell count ≥350 cells/μL and undetectable viral load (VL) was performed. The pre-established CD4+ cell count for restarting therapy was 300cells/μL. Cox regression was used to analyse the variables associated with earlier HAART reinitiation. Results The median follow-up was 209 weeks (range, 64–395). Rates of HIV-related or possible HIV-related events were 0.37 (one case of acute retroviral syndrome) and 1.49 per 100 patient-years, respectively. Two patients died after re-starting therapy and having reached undetectable VL. Three patients suffered a sexually transmitted disease while off therapy. Fifty patients (76%) resumed therapy after a median of 97 weeks (range, 17–267). Age, a nadir of CD4+ <250 cells/μL, and a mean VL during interruption of >10,000 copies/ml were independent predictors for earlier re-start. The intention-to-treat success rate of the first HAART resumed regimen was 85.4%. There were no differences by regimen used, nor between regimens that were the same as or different from the one that had been interrupted. Conclusions Our data suggest highly active antiretroviral therapy may be interrupted in selected patients because in these patients, when the HAART is restarted, the viral and clinical response may be achieved.
    Full-text · Article · Oct 2012 · BMC Research Notes
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    P Espinal · M D Macià · I Roca · E Gato · E Ruíz · F Fernández-Cuenca · A Oliver · J Rodríguez-Baño · G Bou · M Tomás · J Vila
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    ABSTRACT: A carbapenem-resistant Acinetobacter baumannii clinical isolate belonging to European clone II and sequence type 2 was recovered from a patient in the Son Espases hospital in Mallorca, Spain. Genetic analysis showed the presence of the blaOXA-23 gene in association with the widely disseminated transposon Tn2006. This is the first reported identification of A. baumannii carrying blaOXA-23 in Spain.
    Full-text · Article · Oct 2012 · Antimicrobial Agents and Chemotherapy
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    ABSTRACT: Objectives: The aims of this study were to analyse the presence of oqxA and oqxB genes in a collection of extended-spectrum β-lactamase (ESBL)-producing Klebsiella pneumoniae strains, to determine their chromosomal and/or plasmidic locations and to analyse expression levels in relation to susceptibility or resistance to quinolones. Methods: A collection of 114 non-repetitive isolates of ESBL-producing K. pneumoniae was used. K. pneumoniae ATCC 27799 and K. pneumoniae ATCC 700603 were also included. Detection of oqxA and oqxB genes was performed by PCR. Testing for chromosomal and/or plasmidic location was carried out using plasmid DNA and subsequent hybridization. oqxA gene expression was analysed using real-time RT-PCR. Transfer of the plasmid-encoded OqxAB was evaluated. Results: The prevalence of both oqxA and oqxB detected in K. pneumoniae was high: 76% and 75%, respectively. Hybridization assays showed that oqxA (16%) and oqxB (13%) were simultaneously present in locations on the chromosome and on large plasmids. The plasmids were transferable by transformation into K. pneumoniae. RT-PCR assays showed higher expression (4-fold) in strains with reduced susceptibility to quinolones than in susceptible strains. Interestingly, K. pneumoniae ATCC 700603 showed an 18-fold higher expression than K. pneumoniae ATCC 27799. These differences were in accordance with quinolone susceptibility. Conclusions: The prevalence of the OqxAB efflux pump (both chromosomal and plasmid encoded) in ESBL-producing K. pneumoniae is high in Spain and represents a potential reservoir for the spread of these genes. High expression of this pump contributes to reduced susceptibility to quinolones in clinical isolates of ESBL-producing K. pneumoniae.
    No preview · Article · Sep 2012 · Journal of Antimicrobial Chemotherapy
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    ABSTRACT: OBJECTIVES: To determine the prevalence of resistance to antimicrobials in Acinetobacter baumannii (A. baumannii) from Spain and to compare it with those obtained in the first national study (GEIH-Ab project 2000). METHODS: A total of 446 isolates of A. baumannii obtained from 43 Spanish hospitals during February-March 2010 were studied. Identification of A. baumannii was confirmed by ARDRA and MALDI-TOF. Susceptibility to 18 antimicrobial agents was determined by microdilution (Clinical and Laboratory Standards Institute, CLSI). The CLSI break-points were used, except for doripenem, rifampin, sulbactam (Societé Française de Microbiologie [SFM] break-points) and tigecycline (European Committee on Antimicrobial Susceptibility Testing [EUCAST] break-points for Enterobacteriaceae). RESULTS: The percentage of resistant isolates (intermediate susceptible plus resistant) was: > 94% (ceftazidime, piperacillin and ciprofloxacin), 82-86% (carbapenems, tetracycline), 60-70% (tobramycin, sulbactam, gentamicin, doxycycline), 49% (amikacin), 30% (minocycline, rifampin), 24% (tigecycline), and 3% (colistin). These isolates were, in comparison with those of the first study, more resistant (P < .01) to ceftazidime (99% vs 83%), carbapenems (82-86% vs 43-48%), sulbactam (65% vs 53%) and colistin (3% vs 0%), but more susceptible to aminoglycosides (particularly gentamicin: 70% vs 96% of resistant isolates), tetracycline (83% vs 91%) and rifampicin (30% vs 51%). CONCLUSION: There is a high prevalence of A. baumannii resistant to antimicrobials, particularly to carbapenems. The resistance to carbapenems, ceftazidime and sulbactam was significantly higher than that observed for isolates from the GEIH-Ab project 2000. The resistance to aminoglycosides, tetracycline and rifampin, however, was significantly decreased.
    No preview · Article · Aug 2012 · Enfermedades Infecciosas y Microbiología Clínica
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    ABSTRACT: The objective of this study was to identify risk factors for the acquisition of Acinetobacter baumannii with phenotypic heterogeneous resistance (PHR) to carbapenems and to determine whether these factors are similar to those associated with A. baumannii not showing this phenotype. Microbiological and clinical data from 211 patients included in the GEIH-Ab 2000 project were used. Isolates of A. baumannii were studied for their susceptibility to imipenem (IPM) by microdilution and for PHR to IPM as determined by the presence of colonies growing within the inhibition zone of IPM disks. Isolates were divided into three groups: (i) IPM-PHR isolates, i.e. susceptible and non-susceptible A. baumannii displaying PHR to IPM; (ii) non-IPM-PHR isolates, i.e. susceptible A. baumannii showing an inhibition halo but no colonies growing within it; and (iii) IPM-FR isolates, i.e. fully resistant A. baumannii displaying no halo of inhibition. IPM-PHR isolates of A. baumannii were more commonly isolated from respiratory tract samples and less commonly from urine, and were more frequently causes of infection than were IPM-FR isolates. Independent risk factors identified in patients with IPM-PHR isolates were Intensive Care Unit admission, surgery, and previous use of piperacillin/tazobactam or carbapenems, whilst risk factors for IPM-FR and IPM-PHR were previous use of cephalosporins and isolation from a urine sample. In conclusion, risk factors associated with colonisation/infection by isolates of A. baumannii with PHR to carbapenems are similar to those previously described for isolates resistant to carbapenems.
    No preview · Article · Jul 2012 · International journal of antimicrobial agents

  • No preview · Article · Jan 2012 · International journal of antimicrobial agents
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    ABSTRACT: Extended-spectrum AmpC cephalosporinases (ESACs) have been reported in Enterobacteriaceae, Pseudomonas aeruginosa and Acinetobacter baumannii. Here, we characterize a new AmpC variant presenting a broadened substrate activity towards fourth-generation cephalosporins, selected in vivo following cefepime treatment for Enterobacter aerogenes. Two consecutive clonally related isolates of E. aerogenes were evaluated. Screening for ESAC production was performed using plates containing 200 mg/L cloxacillin. MICs were determined by microdilution (CLSI guidelines). bla(AmpC) genes were cloned into a pCR-Blunt II-TOPO vector and expressed in Escherichia coli. The ampC genes were cloned into vector pGEX-6P-1 for protein purification. Isolate Ea595 was resistant to two fourth-generation cephalosporins, cefepime and cefpirome; using plates containing cloxacillin, susceptibility to ceftazidime and cefepime was restored, suggesting overproduction of the ESAC β-lactamase. Sequencing identified a new AmpC β-lactamase variant presenting one amino acid substitution, Val291Gly, inside the H-10 helix. Recombinant plasmids harbouring this ESAC β-lactamase conferred a broadened resistance profile to cefepime and cefpirome, with resistance levels increasing from 16- to 32-fold in E. coli. AmpC-Ea595 hydrolysed ceftazidime, cefepime and cefpirome at high levels, presenting a lower K(m) and enabling us to classify the enzyme as an ESAC. Homology modelling suggested that the size of the active site could have increased. We characterized an ESAC β-lactamase selected in vivo and conferring a high level of resistance to fourth-generation cephalosporins in E. aerogenes. The broadened spectrum was caused by a new modification to the H-10 helix, which modified the active site.
    No preview · Article · Jan 2012 · Journal of Antimicrobial Chemotherapy
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    ABSTRACT: Optimizing treatment for patients with persistent low-level viremia is complicated because most genotyping tests are validated for viral loads >1000 copies per milliliter. In this study, genotypes of 92 treatment-experienced patients with persistent low-level viremia were determined using an in-house assay. Based on the resistance profiles obtained from genotyping and patient pharmacologic history, patients were either maintained on their antiviral regimen (n = 51) or received an optimized regimen (n = 41). In the group receiving optimized treatment, undetectable viral loads were achieved in 73.2% at 6 months and at 90.2% at 1 year, indicating that treatment guided by genotyping of patients with low-level viremia is effective in achieving viral suppression.
    No preview · Article · Sep 2011 · JAIDS Journal of Acquired Immune Deficiency Syndromes

Publication Stats

1k Citations
222.43 Total Impact Points

Institutions

  • 2004-2014
    • Hospital Universitario Virgen Macarena
      Hispalis, Andalusia, Spain
  • 2013
    • Instituto de Salud Carlos III
      Madrid, Madrid, Spain
  • 2006-2013
    • Universidad de Sevilla
      • • Departamento de Microbiología
      • • Medicine
      Hispalis, Andalusia, Spain
  • 2004-2008
    • Hospital Clínic de Barcelona
      • Servicio de Microbiología
      Barcino, Catalonia, Spain