Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance
Expertos de la ECDC y CDC tuvieron reunión europea para determinar la posible unificación del uso de los términos relacionados con la resistencia bacteriana: multidrogorresistente (MDR), extensamente drogo resistente (XDR) y pandrogorresistente (PDR); pero sugieren mayor investigación para su correcta aplicación.
This document discusses the need for new antibiotics to combat the growing threat of antibiotic resistance in pathogenic bacteria. It notes that while current technologies have improved our ability to identify potential drug targets, significant challenges remain in developing new antimicrobial drugs and bringing them to market. The document outlines factors contributing to the need for new antibiotics, such as emerging infectious diseases, increasing antibiotic resistance, and the impact of bacterial diseases. It argues that without active support of antibiotic research and development, we may face a potential public health crisis as antibiotic-resistant bacteria proliferate and treatment options dwindle.
Dr. Kurt Stevenson - Antimicrobial Resistance Surveillance and Management in ...John Blue
Antimicrobial Resistance Surveillance and Management in Hospital and Community Settings - Issues for Human Population Medicine - Dr. Kurt Stevenson, The Ohio State University Medical Center, from the 2012 NIAA One Health Approach to Antimicrobial Resistance and Use Symposium, October 26-27, 2012, Columbus, OH, USA.
More presentations at:
http://www.trufflemedia.com/agmedia/conference/2012-one-health-to-approach-antimicrobial-resistance-and-use
Preventive and therapeutic strategies in critically ill patients with highly...Sergio Paul Silva Marin
This document discusses preventive and therapeutic strategies for critically ill patients infected with highly resistant bacteria. It notes that antibiotic resistance is a major global problem, with multidrug-resistant and pandrug-resistant organisms increasingly encountered in healthcare settings. The review focuses on strategies for severely ill ICU patients, who are at high risk of nosocomial infections due to medical advances enabling longer stays. Timely diagnosis and optimized antibiotic treatment are important for managing such infections.
Drug-resistant bacteria, known as "super bugs", pose a serious threat to global health. Common types include MRSA, VRE, and ESBL, which have developed resistance to front-line antibiotics. While often acquired in hospitals, some drug-resistant infections are now spread in communities. The overuse and misuse of antibiotics has contributed to this growing problem by placing evolutionary pressure on bacteria to become resistant. An increasing number of infections are caused by "super bugs" like Klebsiella pneumoniae and E. coli that are resistant to powerful antibiotics. If left unaddressed, humanity risks returning to an era where common infections have high mortality rates due to limited drug options. Stronger efforts are needed to prevent the
The document discusses rapid diagnosis of drug resistant tuberculosis. It provides an overview of conventional and newer diagnostic methods. Conventional methods like culture and drug susceptibility testing can take 8-12 weeks to identify resistance. Newer rapid phenotypic tests such as automated liquid cultures, thin layer agar cultures, TK medium and microscopic-observation drug susceptibility assay can reduce the time to 1-2 weeks but require specialized equipment. Molecular methods like real-time PCR and line probe assays that detect gene mutations associated with resistance have been commercialized and can provide results in 1-2 days, aiding early treatment decisions. Effective control of drug resistant tuberculosis will require scaling up rapid testing capacities and expanding use of novel molecular technologies.
Virulence Factor Targeting of the Bacterial Pathogen Staphylococcus aureus fo...Trevor Kane
Staphylococcus aureus is a major bacterial pathogen capable of causing a range of infections from mild to life-threatening. The review discusses several major virulence factors produced by S. aureus including the agr quorum sensing system, α-toxin, phenol soluble modulins, protein A, Panton-Valentine leukocidin, and staphylococcal enterotoxins. Recent research into antivirulence approaches that target these factors are highlighted as a potential alternative to antibiotics for treating S. aureus infections.
(27 10-2021)evaluacióndelconocimientodelosestudiantesbiosanitariossobrelaresi...UDMAFyC SECTOR ZARAGOZA II
Existen múltiples estudios y artículos que abordan el tema de las resistencias antimicrobianas y sus interacciones a nivel humano. Sin embargo, presenta un grado de conciencia social y política muy inferior al necesario. Por ello, es preciso realizar una investigación que analice los conocimientos de aquellas partes implicadas en el proceso de prescripción, administración y consumo de antibióticos.
This document discusses the need for new antibiotics to combat the growing threat of antibiotic resistance in pathogenic bacteria. It notes that while current technologies have improved our ability to identify potential drug targets, significant challenges remain in developing new antimicrobial drugs and bringing them to market. The document outlines factors contributing to the need for new antibiotics, such as emerging infectious diseases, increasing antibiotic resistance, and the impact of bacterial diseases. It argues that without active support of antibiotic research and development, we may face a potential public health crisis as antibiotic-resistant bacteria proliferate and treatment options dwindle.
Dr. Kurt Stevenson - Antimicrobial Resistance Surveillance and Management in ...John Blue
Antimicrobial Resistance Surveillance and Management in Hospital and Community Settings - Issues for Human Population Medicine - Dr. Kurt Stevenson, The Ohio State University Medical Center, from the 2012 NIAA One Health Approach to Antimicrobial Resistance and Use Symposium, October 26-27, 2012, Columbus, OH, USA.
More presentations at:
http://www.trufflemedia.com/agmedia/conference/2012-one-health-to-approach-antimicrobial-resistance-and-use
Preventive and therapeutic strategies in critically ill patients with highly...Sergio Paul Silva Marin
This document discusses preventive and therapeutic strategies for critically ill patients infected with highly resistant bacteria. It notes that antibiotic resistance is a major global problem, with multidrug-resistant and pandrug-resistant organisms increasingly encountered in healthcare settings. The review focuses on strategies for severely ill ICU patients, who are at high risk of nosocomial infections due to medical advances enabling longer stays. Timely diagnosis and optimized antibiotic treatment are important for managing such infections.
Drug-resistant bacteria, known as "super bugs", pose a serious threat to global health. Common types include MRSA, VRE, and ESBL, which have developed resistance to front-line antibiotics. While often acquired in hospitals, some drug-resistant infections are now spread in communities. The overuse and misuse of antibiotics has contributed to this growing problem by placing evolutionary pressure on bacteria to become resistant. An increasing number of infections are caused by "super bugs" like Klebsiella pneumoniae and E. coli that are resistant to powerful antibiotics. If left unaddressed, humanity risks returning to an era where common infections have high mortality rates due to limited drug options. Stronger efforts are needed to prevent the
The document discusses rapid diagnosis of drug resistant tuberculosis. It provides an overview of conventional and newer diagnostic methods. Conventional methods like culture and drug susceptibility testing can take 8-12 weeks to identify resistance. Newer rapid phenotypic tests such as automated liquid cultures, thin layer agar cultures, TK medium and microscopic-observation drug susceptibility assay can reduce the time to 1-2 weeks but require specialized equipment. Molecular methods like real-time PCR and line probe assays that detect gene mutations associated with resistance have been commercialized and can provide results in 1-2 days, aiding early treatment decisions. Effective control of drug resistant tuberculosis will require scaling up rapid testing capacities and expanding use of novel molecular technologies.
Virulence Factor Targeting of the Bacterial Pathogen Staphylococcus aureus fo...Trevor Kane
Staphylococcus aureus is a major bacterial pathogen capable of causing a range of infections from mild to life-threatening. The review discusses several major virulence factors produced by S. aureus including the agr quorum sensing system, α-toxin, phenol soluble modulins, protein A, Panton-Valentine leukocidin, and staphylococcal enterotoxins. Recent research into antivirulence approaches that target these factors are highlighted as a potential alternative to antibiotics for treating S. aureus infections.
(27 10-2021)evaluacióndelconocimientodelosestudiantesbiosanitariossobrelaresi...UDMAFyC SECTOR ZARAGOZA II
Existen múltiples estudios y artículos que abordan el tema de las resistencias antimicrobianas y sus interacciones a nivel humano. Sin embargo, presenta un grado de conciencia social y política muy inferior al necesario. Por ello, es preciso realizar una investigación que analice los conocimientos de aquellas partes implicadas en el proceso de prescripción, administración y consumo de antibióticos.
This document summarizes the history and development of chemical insecticides used for vector control. It describes how DDT, discovered in 1939, revolutionized vector control in the 1940s-1950s by effectively controlling diseases like malaria, typhus, and yellow fever. However, concerns about DDT's toxicity and persistence in the environment led to its ban in many countries starting in the 1970s. Newer classes of insecticides like organophosphates, carbamates, and synthetic pyrethroids were developed with better safety profiles. Today's insect growth regulators have extremely low toxicity and promise for treatment of civilian and military facilities.
The document discusses the relationship between COVID-19 vaccines that target the full-length spike protein versus just the receptor-binding domain (RBD), and their potential relationship to procoagulant effects and rare blood clotting issues. Some key points:
- Vaccines like AstraZeneca use the full-length spike protein in viral vectors, while others just target the RBD region.
- The spike protein plays a role in viral entry and interacts with host cell receptors like ACE2. It also has glycans that help disguise the virus.
- Studies found the AstraZeneca vaccine induces cell spikes similar to SARS-CoV-2, eliciting an immune response.
-
1) The H7N9 avian influenza virus emerged in China in 2013 and caused over 130 human cases with 43 deaths. Researchers propose conducting gain-of-function (GOF) experiments on H7N9 viruses to assess their pandemic risk and inform public health responses.
2) The proposed GOF experiments would study immunogenicity, adaptation, drug resistance, transmission, and pathogenicity of H7N9 viruses. Results could help develop vaccines and treatments, and identify mutations that increase transmissibility or pathogenicity.
3) GOF research on H7N9 viruses would be subject to review and require risk mitigation plans, as was done for H5N1 research previously. Insights from
Methicillin-resistant Staphylococcus aureus (MRSA) infection rates are a growing problem in both developed and developing countries. While traditionally seen as a problem mostly in developing nations, the United States and United Kingdom now have among the highest MRSA prevalence rates globally. The spread of antibiotic resistant strains is facilitated by factors such as international travel and trade, poor sanitation and hygiene, and overuse of antibiotics in healthcare and agriculture. This has contributed to increased healthcare costs and mortality in both developing and developed countries from difficult-to-treat infections. While some areas have seen decreases in certain resistant strains, many developing countries continue to face a high burden without adequate treatment options or infection control.
1) The document discusses the link between air pollution and the spread and severity of COVID-19. It analyzes literature showing that air pollutants like particulate matter can act as carriers for viral particles and other toxins, worsening the inflammatory response in lungs.
2) Areas with high air pollution were hit harder by the first wave of COVID-19 and the emergence of variants may be related to factors in polluted air acting as mutagens.
3) Reducing global air pollution is needed to curb the effects of COVID-19. The rapid spread of the virus, especially variants, suggests it can be airborne, with implications for prevention measures and international responsibility in addressing pollution.
This document discusses the future impacts of antibiotic resistance if it is not addressed. It notes that antibiotic resistance could lead to 10 million deaths per year by 2050 and cost the global economy billions. The world may enter a post-antibiotic era where common infections become difficult to treat again. Many drugs will become ineffective as resistance spreads, and new resistance mechanisms may emerge. Medical procedures could become more dangerous without effective antibiotics to treat associated infections. The costs of antibiotic resistance will be high both in terms of health and economic impacts. Urgent changes are needed in antibiotic use and development to address this growing threat.
This document discusses healthcare-associated infections (HAIs), also known as hospital-acquired infections. It notes that HAIs are a major driver of patient outcomes in healthcare facilities and are associated with increased mortality, costs, and length of stay. The most common types of HAIs are device-associated infections like ventilator-associated pneumonia, central line-associated bloodstream infections, and catheter-associated urinary tract infections. The document reviews the prevalence and impact of HAIs in low and middle-income countries like India, noting estimates of HAI rates between 7-18% in Indian healthcare facilities. It also discusses the major causative organisms of HAIs and high levels of antimicrobial resistance found among pathogens that cause HA
Factors behind emergence of resistancekatefranklyn
Overuse of antibiotics in human medicine, agriculture, and livestock has contributed to the emergence of antibiotic resistance. Inappropriate use stems from over-prescription by doctors, patients not completing treatment courses, and mass administration to farm animals. Lack of public knowledge about antibiotic use and resistance also drives unnecessary consumption. Weak infection control in hospitals and limited diagnostic testing further enable the spread of resistant bacteria. Addressing these interconnected factors through improved prescribing practices, public education, infection prevention, and testing is needed to curb the global rise of antibiotic resistance.
7 efecto de introducción de vacuna conjugada neumocócica sobre el sp resistenteRuth Vargas Gonzales
This document summarizes a study examining the effect of the pneumococcal conjugate vaccine (PCV) on rates of invasive disease caused by drug-resistant Streptococcus pneumoniae. The study found that after the introduction of the PCV in 2000:
1) Rates of invasive disease caused by penicillin-nonsusceptible and multidrug-resistant strains decreased significantly in children under 2 years old and adults over 65.
2) Rates of resistant disease caused by the vaccine serotypes fell sharply.
3) There was an increase in disease caused by non-vaccine serotype 19A.
The research aims to design and develop novel bacteriocin peptides as an alternative therapeutic approach to treat malaria by overcoming drug resistance. The objectives are to screen bacteriocin libraries for toxicity and anti-Plasmodium activity, select bacteriocins that inhibit the asexual blood stage of P. falciparum, and optimize bacteriocins' anti-parasite activity by analyzing structures and motifs. This strategy seeks to discover novel bacteriocin domains that can increase antimalarial effectiveness. The research would help provide safe and affordable treatment options to reduce the global malaria burden and economic costs, especially in developing regions facing emerging drug resistance.
The use of antimicrobial in humans and animals, the consequences of this use, the political and economic barriers to improve prudent use and possible solutions for this problem.
Antimicrobial resistance (AMR) poses a major threat to global healthcare. If left unchecked, more deaths will occur from resistant infections than cancer by 2050. Local actions are needed to tackle AMR through appropriate antimicrobial use. The document discusses various tools and strategies available for local antimicrobial stewardship groups, healthcare professionals, and the public to raise awareness and promote prudent antibiotic use. Public awareness campaigns like the European Antibiotic Awareness Day (EAAD) educate about only taking antibiotics when necessary. Local examples show how engaging stakeholders and monitoring antibiotic prescribing can reduce unnecessary use. Coordinated global and local efforts are required to slow the development of AMR.
Overuse of antibiotics in both human medicine and agriculture has contributed to the emergence of antibiotic resistance. In medicine, antibiotics are often prescribed unnecessarily due to pressure on doctors to treat potential infections and patient demand. Patients also frequently fail to complete antibiotic treatment courses. Agricultural use of antibiotics for growth promotion and disease prevention in healthy animals allows antibiotic resistant bacteria to spread to humans. Poor infection control and lack of rapid diagnostic tests have also facilitated the spread of resistant pathogens in healthcare settings. Addressing these factors through improved prescribing practices, public education, infection control, and testing can help slow the development of antibiotic resistance.
Rational use of face masks in the COVID-19 pandemicValentina Corona
The document discusses recommendations around face mask use during the COVID-19 pandemic. It notes that recommendations vary between countries and health authorities. While masks are recommended for healthcare workers and symptomatic individuals, guidance for general community use differs. Some discourage widespread public use due to supply concerns and lack of evidence of effectiveness, while others suggest vulnerable groups or those in crowded areas use masks. The document calls for rational, evidence-based recommendations on appropriate mask use that consider cultural norms and supply issues.
This document summarizes a book on the epidemiology and diffusion of viruses with a focus on the role of latitude, air pollutants, and humidity. It discusses several viruses including SARS, MERS, influenza, and COVID-19. It reviews literature finding associations between increased air pollutants like PM2.5 and higher risk of influenza-like illness. Some studies found temperature could impact COVID-19 transmission, with an optimal temperature range. Experiments with influenza in guinea pigs found that cold, dry conditions favor airborne transmission. The role of atmospheric conditions in the seasonality and spread of influenza over large geographic areas is discussed.
This study reviewed antibiotic use in the neonatal intensive care unit (NICU) of Misurata Medical Center from January to February 2018. It found that 97.3% of the 37 babies treated received penicillin alone or with gentamicin, for durations mostly between 3-7 days. Most treatment was based on clinical suspicion of infection rather than confirmed diagnosis, as only 2 cases underwent full sepsis workup. The main reasons for admission and initiating antibiotics empirically were preterm birth, caesarean delivery, low birth weight, and prolonged rupture of membranes - highlighting overuse and misuse of antibiotics without microbiological justification in the NICU.
ciclo autonomico-short paper - Witfor 2016 paper_42.. ..
This paper presents an ongoing project to develop a biocomputational platform to analyze genomic data from cancer patients and bacteria in Costa Rica. The platform will integrate genomic data processing, prediction of drug sensitivity, and identification of new therapeutic targets. It will use pattern recognition techniques and mathematical models on genomic and drug response data to predict personalized therapy. Preliminary results include databases to store cancer and bacteria genomic data, and tools for exploring relationships between genomic features and drug responses. The platform aims to help identify optimal personalized treatments to overcome drug resistance in cancer and bacterial infections.
Dr. Kent Schwartz - Disease Interventions: Are We Doing as Good as We Know?John Blue
Disease Interventions: Are We Doing as Good as We Know? - Dr. Kent Schwartz, Veterinary Diagnostic Laboratory, Iowa State University, from the 2016 Ceva Swine U.S. Launch & Scientific Symposium, February 26, New Orleans, LA, USA.
More presentations at http://www.swinecast.com/2016-ceva-symposium-aasv
This document outlines Patient Safety Goal 4 to tackle antimicrobial resistance as part of WHO's 3rd Global Patient Safety Challenge. It describes 3 indicators to monitor the incidence of MRSA, ESBL-Klebsiella Pneumoniae, and ESBL-E.coli infections. Data on newly identified multidrug resistant organism cases will be collected and the infection rates calculated monthly. Strategies like implementing antibiotic guidelines, stewardship programs, and national campaigns aim to optimize antibiotic use and contain the spread of antimicrobial resistance.
This document summarizes the history and development of chemical insecticides used for vector control. It describes how DDT, discovered in 1939, revolutionized vector control in the 1940s-1950s by effectively controlling diseases like malaria, typhus, and yellow fever. However, concerns about DDT's toxicity and persistence in the environment led to its ban in many countries starting in the 1970s. Newer classes of insecticides like organophosphates, carbamates, and synthetic pyrethroids were developed with better safety profiles. Today's insect growth regulators have extremely low toxicity and promise for treatment of civilian and military facilities.
The document discusses the relationship between COVID-19 vaccines that target the full-length spike protein versus just the receptor-binding domain (RBD), and their potential relationship to procoagulant effects and rare blood clotting issues. Some key points:
- Vaccines like AstraZeneca use the full-length spike protein in viral vectors, while others just target the RBD region.
- The spike protein plays a role in viral entry and interacts with host cell receptors like ACE2. It also has glycans that help disguise the virus.
- Studies found the AstraZeneca vaccine induces cell spikes similar to SARS-CoV-2, eliciting an immune response.
-
1) The H7N9 avian influenza virus emerged in China in 2013 and caused over 130 human cases with 43 deaths. Researchers propose conducting gain-of-function (GOF) experiments on H7N9 viruses to assess their pandemic risk and inform public health responses.
2) The proposed GOF experiments would study immunogenicity, adaptation, drug resistance, transmission, and pathogenicity of H7N9 viruses. Results could help develop vaccines and treatments, and identify mutations that increase transmissibility or pathogenicity.
3) GOF research on H7N9 viruses would be subject to review and require risk mitigation plans, as was done for H5N1 research previously. Insights from
Methicillin-resistant Staphylococcus aureus (MRSA) infection rates are a growing problem in both developed and developing countries. While traditionally seen as a problem mostly in developing nations, the United States and United Kingdom now have among the highest MRSA prevalence rates globally. The spread of antibiotic resistant strains is facilitated by factors such as international travel and trade, poor sanitation and hygiene, and overuse of antibiotics in healthcare and agriculture. This has contributed to increased healthcare costs and mortality in both developing and developed countries from difficult-to-treat infections. While some areas have seen decreases in certain resistant strains, many developing countries continue to face a high burden without adequate treatment options or infection control.
1) The document discusses the link between air pollution and the spread and severity of COVID-19. It analyzes literature showing that air pollutants like particulate matter can act as carriers for viral particles and other toxins, worsening the inflammatory response in lungs.
2) Areas with high air pollution were hit harder by the first wave of COVID-19 and the emergence of variants may be related to factors in polluted air acting as mutagens.
3) Reducing global air pollution is needed to curb the effects of COVID-19. The rapid spread of the virus, especially variants, suggests it can be airborne, with implications for prevention measures and international responsibility in addressing pollution.
This document discusses the future impacts of antibiotic resistance if it is not addressed. It notes that antibiotic resistance could lead to 10 million deaths per year by 2050 and cost the global economy billions. The world may enter a post-antibiotic era where common infections become difficult to treat again. Many drugs will become ineffective as resistance spreads, and new resistance mechanisms may emerge. Medical procedures could become more dangerous without effective antibiotics to treat associated infections. The costs of antibiotic resistance will be high both in terms of health and economic impacts. Urgent changes are needed in antibiotic use and development to address this growing threat.
This document discusses healthcare-associated infections (HAIs), also known as hospital-acquired infections. It notes that HAIs are a major driver of patient outcomes in healthcare facilities and are associated with increased mortality, costs, and length of stay. The most common types of HAIs are device-associated infections like ventilator-associated pneumonia, central line-associated bloodstream infections, and catheter-associated urinary tract infections. The document reviews the prevalence and impact of HAIs in low and middle-income countries like India, noting estimates of HAI rates between 7-18% in Indian healthcare facilities. It also discusses the major causative organisms of HAIs and high levels of antimicrobial resistance found among pathogens that cause HA
Factors behind emergence of resistancekatefranklyn
Overuse of antibiotics in human medicine, agriculture, and livestock has contributed to the emergence of antibiotic resistance. Inappropriate use stems from over-prescription by doctors, patients not completing treatment courses, and mass administration to farm animals. Lack of public knowledge about antibiotic use and resistance also drives unnecessary consumption. Weak infection control in hospitals and limited diagnostic testing further enable the spread of resistant bacteria. Addressing these interconnected factors through improved prescribing practices, public education, infection prevention, and testing is needed to curb the global rise of antibiotic resistance.
7 efecto de introducción de vacuna conjugada neumocócica sobre el sp resistenteRuth Vargas Gonzales
This document summarizes a study examining the effect of the pneumococcal conjugate vaccine (PCV) on rates of invasive disease caused by drug-resistant Streptococcus pneumoniae. The study found that after the introduction of the PCV in 2000:
1) Rates of invasive disease caused by penicillin-nonsusceptible and multidrug-resistant strains decreased significantly in children under 2 years old and adults over 65.
2) Rates of resistant disease caused by the vaccine serotypes fell sharply.
3) There was an increase in disease caused by non-vaccine serotype 19A.
The research aims to design and develop novel bacteriocin peptides as an alternative therapeutic approach to treat malaria by overcoming drug resistance. The objectives are to screen bacteriocin libraries for toxicity and anti-Plasmodium activity, select bacteriocins that inhibit the asexual blood stage of P. falciparum, and optimize bacteriocins' anti-parasite activity by analyzing structures and motifs. This strategy seeks to discover novel bacteriocin domains that can increase antimalarial effectiveness. The research would help provide safe and affordable treatment options to reduce the global malaria burden and economic costs, especially in developing regions facing emerging drug resistance.
The use of antimicrobial in humans and animals, the consequences of this use, the political and economic barriers to improve prudent use and possible solutions for this problem.
Antimicrobial resistance (AMR) poses a major threat to global healthcare. If left unchecked, more deaths will occur from resistant infections than cancer by 2050. Local actions are needed to tackle AMR through appropriate antimicrobial use. The document discusses various tools and strategies available for local antimicrobial stewardship groups, healthcare professionals, and the public to raise awareness and promote prudent antibiotic use. Public awareness campaigns like the European Antibiotic Awareness Day (EAAD) educate about only taking antibiotics when necessary. Local examples show how engaging stakeholders and monitoring antibiotic prescribing can reduce unnecessary use. Coordinated global and local efforts are required to slow the development of AMR.
Overuse of antibiotics in both human medicine and agriculture has contributed to the emergence of antibiotic resistance. In medicine, antibiotics are often prescribed unnecessarily due to pressure on doctors to treat potential infections and patient demand. Patients also frequently fail to complete antibiotic treatment courses. Agricultural use of antibiotics for growth promotion and disease prevention in healthy animals allows antibiotic resistant bacteria to spread to humans. Poor infection control and lack of rapid diagnostic tests have also facilitated the spread of resistant pathogens in healthcare settings. Addressing these factors through improved prescribing practices, public education, infection control, and testing can help slow the development of antibiotic resistance.
Rational use of face masks in the COVID-19 pandemicValentina Corona
The document discusses recommendations around face mask use during the COVID-19 pandemic. It notes that recommendations vary between countries and health authorities. While masks are recommended for healthcare workers and symptomatic individuals, guidance for general community use differs. Some discourage widespread public use due to supply concerns and lack of evidence of effectiveness, while others suggest vulnerable groups or those in crowded areas use masks. The document calls for rational, evidence-based recommendations on appropriate mask use that consider cultural norms and supply issues.
This document summarizes a book on the epidemiology and diffusion of viruses with a focus on the role of latitude, air pollutants, and humidity. It discusses several viruses including SARS, MERS, influenza, and COVID-19. It reviews literature finding associations between increased air pollutants like PM2.5 and higher risk of influenza-like illness. Some studies found temperature could impact COVID-19 transmission, with an optimal temperature range. Experiments with influenza in guinea pigs found that cold, dry conditions favor airborne transmission. The role of atmospheric conditions in the seasonality and spread of influenza over large geographic areas is discussed.
This study reviewed antibiotic use in the neonatal intensive care unit (NICU) of Misurata Medical Center from January to February 2018. It found that 97.3% of the 37 babies treated received penicillin alone or with gentamicin, for durations mostly between 3-7 days. Most treatment was based on clinical suspicion of infection rather than confirmed diagnosis, as only 2 cases underwent full sepsis workup. The main reasons for admission and initiating antibiotics empirically were preterm birth, caesarean delivery, low birth weight, and prolonged rupture of membranes - highlighting overuse and misuse of antibiotics without microbiological justification in the NICU.
ciclo autonomico-short paper - Witfor 2016 paper_42.. ..
This paper presents an ongoing project to develop a biocomputational platform to analyze genomic data from cancer patients and bacteria in Costa Rica. The platform will integrate genomic data processing, prediction of drug sensitivity, and identification of new therapeutic targets. It will use pattern recognition techniques and mathematical models on genomic and drug response data to predict personalized therapy. Preliminary results include databases to store cancer and bacteria genomic data, and tools for exploring relationships between genomic features and drug responses. The platform aims to help identify optimal personalized treatments to overcome drug resistance in cancer and bacterial infections.
Dr. Kent Schwartz - Disease Interventions: Are We Doing as Good as We Know?John Blue
Disease Interventions: Are We Doing as Good as We Know? - Dr. Kent Schwartz, Veterinary Diagnostic Laboratory, Iowa State University, from the 2016 Ceva Swine U.S. Launch & Scientific Symposium, February 26, New Orleans, LA, USA.
More presentations at http://www.swinecast.com/2016-ceva-symposium-aasv
Dr. Kent Schwartz - Disease Interventions: Are We Doing as Good as We Know?
Similar to Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance
This document outlines Patient Safety Goal 4 to tackle antimicrobial resistance as part of WHO's 3rd Global Patient Safety Challenge. It describes 3 indicators to monitor the incidence of MRSA, ESBL-Klebsiella Pneumoniae, and ESBL-E.coli infections. Data on newly identified multidrug resistant organism cases will be collected and the infection rates calculated monthly. Strategies like implementing antibiotic guidelines, stewardship programs, and national campaigns aim to optimize antibiotic use and contain the spread of antimicrobial resistance.
The word "vaccine" originates from the Latin word “vacca”, meaning “cow” a virus (cowpox) which manly effect the cow. which Edward Jenner demonstrated in 1798 could prevent smallpox in humans.
Dr. Kurt Stevenson - Antimicrobial Resistance Surveillance and Management in ...John Blue
This document summarizes antimicrobial resistance surveillance in hospitals and communities. It discusses the increasing issues of antibiotic resistance over time, with predictions from 1966 that bacterial diseases would be eliminated by 2000 proving inaccurate. The document outlines various multidrug resistant organisms of concern, including MRSA, and the need to track resistance patterns and transmission. It presents a case study describing the identification of the ST-239 strain of MRSA in a surveillance program, which was previously uncommon in the US. Overall it emphasizes the growing challenges of antimicrobial resistance for treatment of infections.
Antimicrobial Resistance: A Major Cause for Concern and a Collective Responsi...Theresa Lowry-Lehnen
Antimicrobial resistance poses a major global threat as no new class of antibiotics has been introduced in decades and bacteria are developing resistance faster than new drugs can be developed. Antibiotic overuse and misuse in healthcare, agriculture, and the environment contribute to the rise of resistant bacteria. In response, Ireland and many other countries have implemented national action plans to promote appropriate antibiotic use and strengthen surveillance of resistant infections through improved prescribing, infection control, and public education. Coordinated global efforts are needed to address the growing crisis of antimicrobial resistance.
Impact of antimicrobial resistance (AMR) in developing countries.Robin Barmon
This document is a research paper submitted by Parth Protim Barmon to Professor Tahera Ahmed on antimicrobial resistance in developing countries. It provides background information on antimicrobial resistance as resistance of microorganisms to antimicrobial medicines. It discusses how antimicrobial resistance is a growing global problem, but has a greater impact in developing countries due to factors like poverty and limited access to healthcare. The paper aims to study the risk factors for antimicrobial resistance in developing countries, including socio-demographic factors, why developing countries are more vulnerable, the role of poverty, and the disease burden.
This document provides information about malaria vaccines. It discusses the context of malaria globally and the need for a vaccine. Several potential vaccine candidates target different stages of the malaria parasite's lifecycle, including sporozoites, infected hepatocytes, and erythrocytic stages. Developing an effective vaccine is challenging due to the parasite's diversity and complexity. The most promising current candidate is RTS,S, which provides some protection against malaria in clinical trials but is not fully effective.
Anti-microbial resistance has become a world health issue today. Therefore it is imperative to know about the methods of acquiring resistance and ways to deal with the situation and prevent resistance.
Hundred samples viz. urine, blood, wound, pus and sputum collected from different patients were found to harbour Pseudomonas aeruginosa (P. aeruginosa) (27%) with a maximum isolation from wound samples (33.33%) and minimum from blood samples (11.11%). The degree of resistance of P. aeruginosa isolates to different antibiotics like Ceftazidime (30µg), Amikacin (30µg), Imipenem (10µg), Ciprofloxacin (30µg), Tetracycline (30µg), Gentamicin (10µg), Norfloxacin (10µg), Penicillin (30µg), Chloramphenicol (30µg), and Ofloxacin (5µg) varied from 56% to 100%. Antiseptics i.e. Betadine and Dettol were found to be more effective against the MDR strain of P. aeruginosa at the dilutions of 10-1 and 10-2. Duration of the disease and hospitalization duration, evaluated as risk factors for P. aeruginosa colonization were found to be statistically significant while age and gender were found to be statistically non- significant. The incidence of multidrug resistance of P. aeruginosa is increasing fast due to the frequent use of antibiotics and antiseptics, which are used extensively in hospitals and healthcare centers, therefore it is a need to develop alternative antimicrobial agents for the treatment of infectious diseases.
Key-words- Antibiotic, Antiseptic, Betadine and Dettol, Disinfectants, P. aeruginosa
Antibiotic resistance is increasing in Gram Negative organisms. It is important to know the antibiogram of the hospital to start empirical therapy. It can serve as a reference to clinician looking for information on antibiotic resistance. A retrospective analysis of the isolates obtained from January 2016 to December 2016 was performed. Samples were processed as per CLSI guideline. A total of 718 isolates were obtained. These were analysed for the prevalence
of MDR/XDR/PDR. It was found that XDR isolates are prevalent in our teaching hospital. The study showed an emergence in pan drug resistant isolates. The knowledge of local antibiogram
along with strong antibiotic stewardship program can help in guiding antibiotic therapy.This reduces antibiotic pressure among organisms and hence development of resistance.
Emergence of Drug resistant microbes PPT By DR.C.P.PrinceDR.PRINCE C P
Antimicrobial resistance is resistance of a microorganism to an antimicrobial drug that was originally effective for treatment of infections caused by it.
Resistant microorganisms (including bacteria, fungi, viruses and parasites) are able to withstand attack by antimicrobial drugs, such as antibacterial drugs (e.g. antibiotics), antifungals, antivirals, and antimalarials, so that standard treatments become ineffective and infections persist, increasing the risk of spread to others.
The document discusses several key points for effective antibiotic resistance surveillance:
1) Diagnostic microbiology laboratories should standardize reporting of antibiotic resistance data and detect emerging resistance early.
2) Laboratories should generate reliable data by only including the first positive culture from each patient to avoid duplicate results.
3) Rates of antibiotic resistance should be expressed as incidence rates within defined populations, rather than just number of isolates tested, to allow for comparisons over time and between facilities.
4) Proper training of clinical microbiologists and a structured computer system can help effectively monitor changing trends in antibiotic resistance.
This document discusses the global threat of antimicrobial resistance (AMR) and the role that drug and therapeutics committees (DTCs) can play in containing AMR. It outlines the global spread of drug-resistant pathogens and infections. The overuse and misuse of antibiotics in both human and animal settings is a major cause of growing AMR. DTCs can help address this by developing antibiotic policies and formularies, educating on appropriate use, and monitoring antibiotic consumption and resistance patterns. Examples from Kenya and Thailand demonstrate how DTCs have successfully implemented strategies like antibiotic order forms to improve antibiotic use.
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Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance
1. Multidrug-resistant, extensively drug-resistant and pandrug-resistant
bacteria: an international expert proposal for interim standard
definitions for acquired resistance
A.-P. Magiorakos1
, A. Srinivasan2
, R. B. Carey2
, Y. Carmeli3
, M. E. Falagas4,5
, C. G. Giske6
, S. Harbarth7
, J. F. Hindler8
, G.
Kahlmeter9
, B. Olsson-Liljequist10
, D. L. Paterson11
, L. B. Rice12
, J. Stelling13
, M. J. Struelens1
, A. Vatopoulos14
, J. T. Weber2
and D. L. Monnet1
1) European Centre for Disease Prevention and Control, Stockholm, Sweden, 2) Office of Infectious Diseases, Department of Health and Human Services,
Centers for Disease Control and Prevention, Atlanta, GA, USA, 3) Division of Epidemiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, 4) Alfa Institute
of Biomedical Sciences (AIBS), Athens, Greece, 5) Department of Medicine, Tufts University School of Medicine, Boston, MA, USA, 6) Department of Clinical
Microbiology, Karolinska University Hospital, Stockholm, Sweden, 7) Infection Control Programme, University of Geneva Hospitals, Geneva, Switzerland, 8)
Department of Pathology and Laboratory Medicine, University of California Los Angeles Medical Center, Los Angeles, CA, USA, 9) Department of Clinical
Microbiology, Central Hospital, Va¨xjo¨, 10) Department of Bacteriology, Swedish Institute for Infectious Disease Control, Solna, Sweden, 11) The University of
Queensland Centre for Clinical Research, Royal Brisbane and Women’s Hospital, Brisbane, Qld, Australia, 12) Warren Alpert Medical School of Brown
University, Providence, RI, 13) Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA and 14) Department of Microbiology, National
School of Public Health, Athens, Greece
Abstract
Many different definitions for multidrug-resistant (MDR), extensively drug-resistant (XDR) and pandrug-resistant (PDR) bacteria are
being used in the medical literature to characterize the different patterns of resistance found in healthcare-associated, antimicrobial-
resistant bacteria. A group of international experts came together through a joint initiative by the European Centre for Disease Pre-
vention and Control (ECDC) and the Centers for Disease Control and Prevention (CDC), to create a standardized international ter-
minology with which to describe acquired resistance profiles in Staphylococcus aureus, Enterococcus spp., Enterobacteriaceae (other than
Salmonella and Shigella), Pseudomonas aeruginosa and Acinetobacter spp., all bacteria often responsible for healthcare-associated infec-
tions and prone to multidrug resistance. Epidemiologically significant antimicrobial categories were constructed for each bacterium.
Lists of antimicrobial categories proposed for antimicrobial susceptibility testing were created using documents and breakpoints from
the Clinical Laboratory Standards Institute (CLSI), the European Committee on Antimicrobial Susceptibility Testing (EUCAST) and
the United States Food and Drug Administration (FDA). MDR was defined as acquired non-susceptibility to at least one agent in
three or more antimicrobial categories, XDR was defined as non-susceptibility to at least one agent in all but two or fewer antimi-
crobial categories (i.e. bacterial isolates remain susceptible to only one or two categories) and PDR was defined as non-susceptibility
to all agents in all antimicrobial categories. To ensure correct application of these definitions, bacterial isolates should be tested
against all or nearly all of the antimicrobial agents within the antimicrobial categories and selective reporting and suppression of
results should be avoided.
Keywords: Antimicrobial agents, definitions, extensively drug resistant, multidrug resistant, pandrug resistant
Original Submission: 31 January 2011; Revised Submission: 7 April 2011; Accepted: 22 April 2011
Editor: R. Canto´n
Article published online: 7 May 2011
Clin Microbiol Infect 2012; 18: 268–281
10.1111/j.1469-0691.2011.03570.x
Corresponding author: A.-P. Magiorakos, ECDC, Tomtebodava¨gen
11A, SE-171 83, Stockholm, Sweden
E-mail: anna-pelagia.magiorakos@ecdc.europa.eu
Background
Emergence of resistance to multiple antimicrobial agents in
pathogenic bacteria has become a significant public health
ª2011 European Society of Clinical Microbiology and Infectious Diseases
No claim to original US government works
ORIGINAL ARTICLE BACTERIOLOGY
2. threat as there are fewer, or even sometimes no, effective
antimicrobial agents available for infections caused by these
bacteria. Gram-positive and Gram-negative bacteria are both
affected by the emergence and rise of antimicrobial resis-
tance. As this problem continues to grow, harmonized defini-
tions with which to describe and classify bacteria that are
resistant to multiple antimicrobial agents are needed, so that
epidemiological surveillance data can be reliably collected
and compared across healthcare settings and countries. In
the strictest sense, multidrug-resistant organisms (MDROs)
are labelled as such because of their in vitro resistance to
more than one antimicrobial agent. Infections with MDROs
can lead to inadequate or delayed antimicrobial therapy, and
are associated with poorer patient outcomes [1–4]. Of the
MDROs, highly-resistant Gram-negative bacteria (e.g. multi-
drug-resistant carbapenemase-producing Klebsiella pneumoniae
and Acinetobacter spp.) require special mention; these organ-
isms can be resistant to all currently available antimicrobial
agents or remain susceptible only to older, potentially more
toxic agents such as the polymyxins, leaving limited and sub-
optimal options for treatment [5–7]. The problem of increas-
ing antimicrobial resistance is even more threatening when
considering the very limited number of new antimicrobial
agents that are in development [8,9].
No consensus has yet been reached on the definition
and use of terms such as ‘multidrug-resistant’, ‘extreme
drug resistant’, ‘extensive, extensively or extremely drug
resistant’ (all XDR – in this document XDR refers to
‘extensively drug-resistant’) and ‘pandrug-resistant’ (PDR)
[10–15], which characterize resistance in MDROs. This
variability precludes reliable comparison of surveillance data
for MDROs and consequently prevents the medical com-
munity from having a complete comprehension of the
extent of the problem of antimicrobial resistance. More-
over, accurate information cannot be conveyed to the
public and to policy makers about the rising threat of
MDROs to public health [16–18]. Adopting standardized
international terminology to define organisms that are
resistant to a significant number of therapeutically active
drugs would be an important step to improve the compa-
rability of surveillance data for these organisms and to
better assess their global, regional and local epidemiological
importance and public health impact.
Purpose
This document proposes definitions for MDR, XDR and PDR
strains of pathogenic bacteria that are frequently found in
healthcare settings (e.g. Staphylococcus aureus, Enterococcus
spp., Enterobacteriaceae, Pseudomonas aeruginosa and Acineto-
bacter spp.). By applying these definitions, clinical, reference
and public health microbiology laboratories will use a com-
mon terminology for grading various antimicrobial resistance
profiles. This will result in consistent reporting of comparable
data that can reliably track trends of antimicrobial resistance
locally, but also internationally. Moreover, the use of standard
terminology will optimize epidemiological surveillance sys-
tems, facilitating the exchange of information between the
medical community, public health authorities and policy mak-
ers in order to promote the prudent use of antimicrobials
and other public health measures [19–21].
It is important to note that these definitions are meant
for public health use and epidemiological purposes only. They
are not intended to replace clinical judgment, to contribute
to therapeutic decision-making or to offer guidance in infec-
tion control practices. These areas are beyond the scope of
this document and remain the purview of clinical specialists
and local and national health authorities. Similarly, these defi-
nitions do not represent and should not be construed to
represent any agency determination of policy.
Approaches to Creating Definitions for
MDR, XDR and PDR
In a joint initiative by the European Centre for Disease
Prevention and Control (ECDC) and the Centers for Dis-
ease Control and Prevention (CDC), a first meeting of
experts was held in Stockholm in January 2008. The scope
of the initial meeting was to create definitions for highly-
resistant, multidrug-resistant bacteria associated with health-
care-associated infections. This group was later expanded
to include additional experts in the diagnosis, therapy and
surveillance of antimicrobial-resistant bacteria, all of whom
are co-authors of this article. The expert group decided to
concentrate on applying the definitions to S. aureus, Entero-
coccus spp., Enterobacteriaceae (other than Salmonella and
Shigella), P. aeruginosa and Acinetobacter spp., because of the
epidemiological significance, the emerging antimicrobial
resistance and the importance of these bacteria within the
healthcare system. Mycobacteria and other bacteria most
commonly associated with community-acquired infections
such as Streptococcus pneumoniae, Salmonella spp., Shigella
spp. and Neisseria gonorrhoeae were excluded, as their resis-
tance patterns have been previously discussed in the litera-
ture by separate groups of experts [22–25]. These
definitions, however, can also be applied to these organ-
isms in the future, if the respective expert groups wish to
do so.
CMI Magiorakos et al. International standard definitions for acquired resistance 269
ª2011 European Society of Clinical Microbiology and Infectious Diseases, CMI, 18, 268–281
No claim to original US government works
3. A bacterial isolate was considered non-susceptible to an
antimicrobial agent when it tested resistant, intermediate or
non-susceptible when using clinical breakpoints as interpre-
tive criteria, and not epidemiological cut-offs, provided by
the European Committee on Antimicrobial Susceptibility
Testing (EUCAST), the Clinical and Laboratory Standards
Institute (CLSI) [26,27] and/or the US Food and Drug
Administration (FDA). Only acquired antimicrobial resistance
was taken into consideration in creating definitions for MDR,
XDR and PDR; intrinsic resistance was not addressed. Lists
were later created, however, with organisms within specific
organism groups (e.g. the Enterobacteriaceae and Enterococcus
spp.) that are intrinsically resistant to certain antimicrobial
agents. This was done to ensure that these antimicrobial
agents would not be taken into account when applying the
definitions for these organisms.
After comments on the draft manuscript were circulated
among the experts, the proposal for definitions of MDR,
XDR and PDR bacteria was presented to the ECDC Advi-
sory Forum, the official advisory body to the ECDC, in
October and December 2008. Suggestions from the Advisory
Forum were: (i) to post the proposed definitions on the in-
ternet for broad discussion, comments and further consulta-
tions by medical professional societies and other expert
groups; (ii) to pilot-test the proposed definitions by analysing
a database that contained an adequate number of antimicro-
bial resistant organisms; (iii) to convene a second ECDC
Joint Expert Meeting for further review; and (iv) to present
the final proposed definitions to the ECDC Advisory Forum.
In May 2009 and March 2010 the second and third ECDC
Joint Expert Meetings were held in Helsinki, Finland, and
Stockholm, Sweden, respectively, to further refine the defini-
tions. Applying the definitions as a pilot-test on antimicrobial
susceptibility databases was also discussed. Results from the
analyses that were subsequently performed will be available as
supporting information, but are not included in this document.
This draft version was put on the web for public com-
ments from 22 July until 22 August 2010. The final proposed
definitions were presented to the ECDC Advisory Forum on
30 September 2010.
Previous Definitions Applied to Bacteria
Resistant to Multiple Antimicrobial Agents
MDR
In literal terms, MDR means ‘resistant to more than one
antimicrobial agent’, but no standardized definitions for MDR
have been agreed upon yet by the medical community. Many
definitions are being used in order to characterize patterns
of multidrug resistance in Gram-positive and Gram-negative
organisms [10,16,17,28,29]. The absence of specific defini-
tions for MDR in clinical study protocols gives rise to data
that are difficult to compare.
One of the methods used by various authors and authori-
ties to characterize organisms as MDR is based on in vitro
antimicrobial susceptibility test results, when they test ‘resis-
tant to multiple antimicrobial agents, classes or subclasses of
antimicrobial agents’ [10,16,17,30]. The definition most fre-
quently used for Gram-positive [16,31–34] and Gram-nega-
tive [10,18,30,35–37] bacteria is ‘resistant to three or more
antimicrobial classes’. An overview of the variability of these
definitions is provided in a comprehensive review of MDR in
P. aeruginosa and A. baumannii by Falagas et al. [10], where the
authors note that a sizeable number of studies do not pro-
pose any specific definitions for MDR, but the majority define
MDR as ‘resistant to three or more antimicrobial classes’.
Another method used to characterize bacteria as MDR, is
when they are ‘resistant to one key antimicrobial agent’
[17,38]. These bacterial isolates may have public health
importance due to resistance to only one key antimicrobial
agent, but they often demonstrate cross or co-resistance to
multiple classes of antimicrobials, which makes them MDR.
Creating an acronym for a bacterium based on its resistance
to a key antimicrobial agent (e.g. methicillin resistance in
S. aureus, i.e. MRSA) immediately highlights its epidemiologi-
cal significance; the advantage of using this approach for sur-
veillance purposes is that it can be easily applied.
XDR
Bacteria that are classified as XDR are epidemiologically sig-
nificant due not only to their resistance to multiple antimi-
crobial agents, but also to their ominous likelihood of being
resistant to all, or almost all, approved antimicrobial agents.
In the medical literature XDR has been used as an acronym
for several different terms such as ‘extreme drug resistance’,
‘extensive drug resistance’, ‘extremely drug resistant’ and
‘extensively drug resistant’ [12,15,39,40].
Initially, the term XDR was created to describe exten-
sively drug-resistant Mycobacterium tuberculosis (XDR MTB)
and was defined as ‘resistance to the first-line agents isonia-
zid and rifampicin, to a fluoroquinolone and to at least one
of the three-second-line parenteral drugs (i.e. amikacin, kana-
mycin or capreomycin)’ [41,42]. Subsequent to this, defini-
tions for strains of non-mycobacterial bacteria that were
XDR were constructed according to the principle underlying
this definition for XDR MTB (i.e. describing a resistance pro-
file that compromised most standard antimicrobial regimens).
Two sets of criteria have mainly been used to characterize
bacteria as XDR. The first is based on the number of antimi-
270 Clinical Microbiology and Infection, Volume 18 Number 3, March 2012 CMI
ª2011 European Society of Clinical Microbiology and Infectious Diseases, CMI, 18, 268–281
No claim to original US government works
4. crobials or classes or subclasses to which a bacterium is
resistant, and the second on whether they are ‘resistant to
one or more key antimicrobial agents’ [16,17,38].
PDR
From the Greek prefix ‘pan’, meaning ‘all’, pandrug resistant
(PDR) means ‘resistant to all antimicrobial agents’. Defini-
tions in the literature for PDR vary even though this term is
etymologically exact and means that, in order for a particular
species and a bacterial isolate of this species to be character-
ized as PDR, it must be tested and found to be resistant to
all approved and useful agents. Examples of current defini-
tions are: ‘resistant to almost all commercially available anti-
microbials’, ‘resistant to all antimicrobials routinely tested’
TABLE 1. Staphylococcus aureus;
antimicrobial categories and
agents used to define MDR, XDR
and PDR (worksheet for categoriz-
ing isolates)
Antimicrobial category Antimicrobial agent
Results of antimicrobial
susceptibility testing
(S or NS)
Aminoglycosides Gentamicin
Ansamycins Rifampin/rifampicin
Anti-MRSA cephalosporins Ceftaroline
Anti-staphylococcal
b-lactams (or cephamycins)
Oxacillin (or cefoxitin)a
Fluoroquinolones Ciprofloxacin
Moxifloxacin
Folate pathway inhibitors Trimethoprim-
sulphamethoxazole
Fucidanes Fusidic acid
Glycopeptides Vancomycin
Teicoplanin
Telavancin
Glycylcyclines Tigecycline
Lincosamides Clindamycin
Lipopeptides Daptomycin
Macrolides Erythromycin
Oxazolidinones Linezolid
Phenicols Chloramphenicol
Phosphonic acids Fosfomycin
Streptogramins Quinupristin-
dalfopristin
Tetracyclines Tetracycline
Doxycycline
Minocycline
Criteria for defining MDR, XDR and PDR in S. aureus
MDR (one or more of these have to apply): (i) an MRSA is always considered MDR by virtue of being an MRSA, (ii)
non-susceptible to ‡1 agent in ‡3 antimicrobial categories.
XDR: non-susceptible to ‡1 agent in all but £2 categories.
PDR: non-susceptible to all antimicrobial agents listed.
a
Oxacillin or cefoxitin represents all other b-lactams (and cephamycins) and resistance to either of these predicts
non-susceptibility to all categories of b-lactam antimicrobials listed in this document, with the exception of the anti-
MRSA cephalosporins (i.e. all categories of penicillins, cephalosporins, b-lactamase inhibitors and carbapenems cur-
rently approved up until 25 January 2011).
http://www.ecdc.europa.eu/en/activities/diseaseprogrammes/ARHAI/Pages/public_consultation_clinical_microbiology_
infection_article.aspx.
CMI Magiorakos et al. International standard definitions for acquired resistance 271
ª2011 European Society of Clinical Microbiology and Infectious Diseases, CMI, 18, 268–281
No claim to original US government works
5. and ‘resistant to all antibiotic classes available for empirical
treatment’ [10,43,44], making the definition of PDR subject
to inconsistent use and liable to potential misinterpretation
of data.
Considerations in Creating the Definitions
Initially, the expert group agreed that three issues needed to
be addressed to develop the definitions: (i) how to create
antimicrobial ‘categories’ that would be epidemiologically
meaningful; (ii) how to select the antimicrobial categories
and antimicrobial agents to be tested for each relevant bac-
terium; and (iii) how to define resistance within an antimi-
crobial category.
Creating antimicrobial categories
There has been no standard approach for determining the
types, classes or groups of antimicrobial agents that should
be used when defining MDR, XDR and PDR. Frequently,
chemical structures for antimicrobial classes (e.g. cephalospo-
rins) [45–47], antimicrobial subclasses, (e.g. third-generation
cephalosporins) [48] or specific antimicrobial agents (e.g. ce-
ftazidime) [49,50] have been used to define these terms. This
approach is not always conclusive and makes it difficult to
compare results between studies. The expert group, there-
fore, constructed ‘antimicrobial categories’ for each of the
organisms or organism groups with the intent of placing anti-
microbial agents into more therapeutically relevant groups.
These new categories are listed in Tables 1–5 together with
the proposed antimicrobial agents relevant for antimicrobial
susceptibility testing for each organism or organism group.
Defining antimicrobial categories and antimicrobial agents
to be tested for each organism or organism group
Panels of lists of antimicrobial agents were developed for each
organism or organism group, as proposed harmonized tem-
plates that could be used by clinical, reference and pub-
lic health microbiology laboratories that perform in vitro
antimicrobial susceptibility testing, and wish to identify MDR,
TABLE 2. Enterococcus spp.; anti-
microbial categories and agents
used to define MDR, XDR and
PDR (worksheet for categorizing
isolates)
Antimicrobial
category Antimicrobial agent
Results of
antimicrobial
susceptibility
testing (S or NS)
Species with
intrinsic resistance
to antimicrobial
categories (51)a
Aminoglycosides
(except streptomycin)
Gentamicin (high level)
Streptomycin Streptomycin (high level)
Carbapenems Imipenem
Meropenem
Doripenem
Enterococcus faecium
Fluoroquinolones Ciprofloxacin
Levofloxacin
Moxifloxacin
Glycopeptides Vancomycin
Teicoplanin
Glycylcyclines Tigecycline
Lipopeptides Daptomycin
Oxazolidinones Linezolid
Penicillins Ampicillin
Streptogramins Quinupristin-dalfopristin Enterococcus faecalis
Tetracycline Doxycycline
Minocycline
Criteria for defining MDR, XDR and PDR in Enterococcus spp.
MDR: non-susceptible to ‡1 agent in ‡3 antimicrobial categories.
XDR: non-susceptible to ‡1 agent in all but £2 categories.
PDR: non-susceptible to all antimicrobial agents listed.
a
When a species has intrinsic resistance to an antimicrobial category, that category must be removed from the list in
this table prior to applying the criteria for the definitions and should not be counted when calculating the number of
categories to which the bacterial isolate is non-susceptible.
http://www.ecdc.europa.eu/en/activities/diseaseprogrammes/ARHAI/Pages/public_consultation_clinical_microbiology_
infection_article.aspx.
272 Clinical Microbiology and Infection, Volume 18 Number 3, March 2012 CMI
ª2011 European Society of Clinical Microbiology and Infectious Diseases, CMI, 18, 268–281
No claim to original US government works
6. TABLE 3. Enterobacteriaceae; antimicrobial categories and agents used to define MDR, XDR and PDR (worksheet for categor-
izing isolates)
Antimicrobial category Antimicrobial agent
Results of
antimicrobial
susceptibility
testing (S or NS)
Species with intrinsic resistance to
antimicrobial agents or categories (51)a
Aminoglycosides Gentamicin Providencia rettgeri (P. rettgeri), Providencia stuartii (P. stuartii)
Tobramycin P. rettgeri, P. stuartii
Amikacin
Netilmicin P. rettgeri, P. stuartii
Anti-MRSA cephalosporins Ceftaroline (approved only for
Escherichia coli, Klebsiella
pneumoniae, Klebsiella oxytoca)
Antipseudomonal penicillins
+ b-lactamase inhibitors
Ticarcillin-clavulanic acid Escherichia hermannii (E. hermanii)
Piperacillin-tazobactam E. hermanii
Carbapenems Ertapenem
Imipenem
Meropenem
Doripenem
Non-extended spectrum
cephalosporins; 1st and
2nd generation cephalosporins
Cefazolin Citrobacter freundii (C. freundii), Enterobacter aerogenes
(E. aerogenes), Enterobacter cloacae (E. cloacae), Hafnia alvei
(H. alvei), Morganella morganii (M. morganii), Proteus penneri
(P. penneri), Proteus vulgaris (P. vulgaris), P. rettgeri, P. stuartii,
Serratia marcescens (S. marcescens)
Cefuroxime M. morganii, P. penneri, P. vulgaris, S. marcescens
Extended-spectrum
cephalosporins; 3rd and 4th
generation cephalosporins
Cefotaxime or ceftriaxone
Ceftazidime
Cefepime
Cephamycins Cefoxitin C. freundii, E. aerogenes, E. cloacae, H. alvei
Cefotetan C. freundii, E. aerogenes, E. cloacae, H. alvei
Fluoroquinolones Ciprofloxacin
Folate pathway inhibitors Trimethoprim-sulphamethoxazole
Glycylcyclines Tigecycline M. morganii, Proteus mirabilis (P. mirabilis),
P. penneri, P. vulgaris, P. rettgeri, P. stuartii
Monobactams Aztreonam
Penicillins Ampicillin Citrobacter koseri (C. koseri), C. freundii, E. aerogenes, E. cloacae,
E. hermanii, H. alvei, Klebsiellae spp., M. morganii, P. penneri,
P. vulgaris, P. rettgeri, P. stuartii, S. marcescens
Penicillins + b-lactamase inhibitors Amoxicillin-clavulanic acid C. freundii, E. aerogenes, E. cloacae, H. alvei,
M. morganii, P. rettgeri, P. stuartii, S. marcescens
Ampicillin-sulbactam C. freundii, C. koseri, E. aerogenes, E. cloacae,
H. alvei, P. rettgeri, S. marcescens
Phenicols Chloramphenicol
Phosphonic acids Fosfomycin
Polymyxins Colistin M. morganii, P. mirabilis, P. penneri, P. vulgaris,
P. rettgeri, P. stuartii, S. marcescens
CMI Magiorakos et al. International standard definitions for acquired resistance 273
ª2011 European Society of Clinical Microbiology and Infectious Diseases, CMI, 18, 268–281
No claim to original US government works
7. XDR and PDR. These lists were designed to be as compre-
hensive as possible and reflect antimicrobial agents and testing
practices currently used in most countries around the world.
These lists were developed in a stepwise fashion. The first
step was to include the antimicrobial agents listed for each
organism or organism group in the CLSI table of ‘Suggested
TABLE 3. Continued
Antimicrobial category Antimicrobial agent
Results of
antimicrobial
susceptibility
testing (S or NS)
Species with intrinsic resistance to
antimicrobial agents or categories (51)a
Tetracyclines Tetracycline M. morganii, P. mirabilis, P. penneri, P. vulgaris, P. rettgeri, P. stuartii
Doxycycline M. morganii, P. penneri, P. vulgaris, P. rettgeri, P. stuartii
Minocycline M. morganii, P. penneri, P. vulgaris, P. rettgeri, P. stuartii
Criteria for defining MDR, XDR and PDR in Enterobacteriaceae
MDR: non-susceptible to ‡1 agent in ‡3 antimicrobial categories.
XDR: non-susceptible to ‡1 agent in all but £2 categories.
PDR: non-susceptible to all antimicrobial agents listed.
a
When a species has intrinsic resistance to an antimicrobial agent or to the whole category, that agent or category must be removed from the list in this table prior to apply-
ing the criteria for the definitions and should not be counted when calculating the number of agents or categories to which the bacterial isolate is non-susceptible.
http://www.ecdc.europa.eu/en/activities/diseaseprogrammes/ARHAI/Pages/public_consultation_clinical_microbiology_infection_article.aspx.
TABLE 4. Pseudomonas aeruginosa;
antimicrobial categories and
agents used to define MDR, XDR
and PDR (worksheet for categoriz-
ing isolates)
Antimicrobial category Antimicrobial agent
Results of antimicrobial
susceptibility testing
(S or NS)
Aminoglycosides Gentamicin
Tobramycin
Amikacin
Netilmicin
Antipseudomonal carbapenems Imipenem
Meropenem
Doripenem
Antipseudomonal cephalosporins Ceftazidime
Cefepime
Antipseudomonal fluoroquinolones Ciprofloxacin
Levofloxacin
Antipseudomonal penicillins
+ b-lactamase inhibitors
Ticarcillin-clavulanic acid
Piperacillin-tazobactam
Monobactams Aztreonam
Phosphonic acids Fosfomycin
Polymyxins Colistin
Polymyxin B
Criteria for defining MDR, XDR and PDR in Pseudomonas aeruginosa
MDR: non-susceptible to ‡1 agent in ‡3 antimicrobial categories.
XDR: non-susceptible to ‡1 agent in all but £2 categories.
PDR: non-susceptible to all antimicrobial agents listed.
http://www.ecdc.europa.eu/en/activities/diseaseprogrammes/ARHAI/Pages/public_consultation_clinical_microbiology_
infection_article.aspx.
274 Clinical Microbiology and Infection, Volume 18 Number 3, March 2012 CMI
ª2011 European Society of Clinical Microbiology and Infectious Diseases, CMI, 18, 268–281
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8. agents with FDA clinical indications that should be considered
for routine testing and reporting by clinical microbiological lab-
oratories’ [26]. An antimicrobial agent was added or removed,
based on recommendations included in EUCAST’s Expert
Rules [51] and also by applying specific inclusion and exclusion
criteria. The inclusion criteria required that each antimicrobial
agent: (i) was currently approved as an antibacterial agent in
humans by the European Medicines Agency (EMA) or the
FDA; and (ii) had breakpoints for the organism or organism
group established by either EUCAST [51], CLSI [26] or the
FDA. An antimicrobial agent was excluded from an organism/
organism group list if: (i) the organism or the whole organism
group was intrinsically resistant to the agent; (ii) the agent
achieved therapeutic concentrations only in urine (e.g. nitro-
furantoin); or (iii) the organism exhibits widespread acquired
resistance to the agent (e.g. penicillin for S. aureus). A note-
worthy example of an antimicrobial agent that did not meet
the criteria for inclusion is tigecycline, which does not have
species-specific breakpoints for Acinetobacter spp. and was
therefore, not included in Table 5.
Although this document does not address definitions for
individual bacterial species that are intrinsically resistant to
TABLE 5. Acinetobacter spp.; anti-
microbial categories and agents
used to define MDR, XDR and
PDR (worksheet for categorizing
isolates)
Antimicrobial category Antimicrobial agent
Results of antimicrobial
susceptibility testing
(S or NS)
Aminoglycosides Gentamicin
Tobramycin
Amikacin
Netilmicin
Antipseudomonal carbapenems Imipenem
Meropenem
Doripenem
Antipseudomonal fluoroquinolones Ciprofloxacin
Levofloxacin
Antipseudomonal penicillins
+ b-lactamase inhibitors
Piperacillin-tazobactam
Ticarcillin-clavulanic acid
Extended-spectrum cephalosporins Cefotaxime
Ceftriaxone
Ceftazidime
Cefepime
Folate pathway inhibitors Trimethoprim-sulphamethoxazole
Penicillins + b-lactamase inhibitors Ampicillin-sulbactam
Polymyxins Colistin
Polymyxin B
Tetracyclines Tetracycline
Doxycycline
Minocycline
Criteria for defining MDR, XDR and PDR in Acinetobacter spp.
MDR: non-susceptible to ‡1 agent in ‡3 antimicrobial categories.
XDR: non-susceptible to ‡1 agent in all but £2 categories.
PDR: non-susceptible to all antimicrobial agents listed.
http://www.ecdc.europa.eu/en/activities/diseaseprogrammes/ARHAI/Pages/public_consultation_clinical_microbiology_
infection_article.aspx.
CMI Magiorakos et al. International standard definitions for acquired resistance 275
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9. antimicrobial agents or categories, there are bacterial species
within certain organism groups (i.e. the Enterococcus spp. and
the Enterobacteriaceae) that are intrinsically resistant to one
or more antimicrobial agents within a category or to all
agents within a category. When applying the definitions for
MDR, XDR and PDR to these organisms, those agents or
categories will need to be removed and not included in the
analysis. Therefore, a separate column was included in
Tables 2 and 3 listing those organisms that have intrinsic
resistance to the antimicrobial agent or category listed in
that row [51].
Finally, available rules of partial or complete cross-resis-
tance from EUCAST [51] and CLSI [26] were applied to
the lists of antimicrobial agents in order to minimize the
number of agents proposed for testing. An example of a
rule for full cross-resistance is when an E. coli isolate is
tested and found to be non-susceptible to ciprofloxacin, it
is considered non-susceptible to all fluoroquinolones
[51,52]. Similarly, a S. aureus isolate is considered non-sus-
ceptible to all lincosamides when it tests non-susceptible to
clindamycin [51,53]. When rules of full cross-resistance
could be applied to an antimicrobial category in Tables 1–5,
one agent only from that category was proposed for antimi-
crobial susceptibility testing.
Defining antimicrobial resistance within an antimicrobial
category
In the definitions proposed for MDR and XDR in this
document, a bacterial isolate is considered resistant to an
antimicrobial category when it is ‘non-susceptible to at least
one agent in a category’. Thus, resistance of a bacterial iso-
late to only one agent within a category is proposed as
a crude indicator of antimicrobial resistance to the entire
category.
In support of this approach used by the National Health-
care Safety Network (NHSN) a bacterial isolate is consid-
ered resistant to a ‘class’ when it is resistant to one or
more antimicrobial agents within that ‘class’ [17,30]. Thus,
according to this definition, carbapenem resistance in Klebsiel-
la spp. would be defined as ‘resistance to imipenem or me-
ropenem or ertapenem or doripenem’.
Proposed Definitions for MDR, XDR and
PDR
The definitions proposed for the characterization of bacterial
isolates that are MDR, XDR or PDR are given in Table 6.
For all three definitions, non-susceptibility refers to either a
resistant, intermediate or non-susceptible result obtained
from in vitro antimicrobial susceptibility testing.
TABLE 6. Definitions for multidrug-resistant (MDR), extensively drug-resistant (XDR) and pandrug-resistant (PDR) bacteria
Bacterium MDR XDR PDR
Staphylococcus aureus The isolate is non-susceptible to at least 1 agent
in ‡3 antimicrobial categories listed in Table 1a
The isolate is non-susceptible to at least 1 agent in all
but 2 or fewer antimicrobial categories in Table 1.
Non-susceptibility
to all agents in all
antimicrobial categories
for each bacterium in
Tables 1–5
Enterococcus spp. The isolate is non-susceptible to at least 1 agent
in ‡3 antimicrobial categories listed in Table 2
The isolate is non-susceptible to at least 1 agent in all
but 2 or fewer antimicrobial categories in Table 2.
Enterobacteriaceae The isolate is non-susceptible to at least 1 agent
in ‡3 antimicrobial categories listed in Table 3
The isolate is non-susceptible to at least 1 agent in all
but 2 or fewer antimicrobial categories in Table 3.
Pseudomonas aeruginosa The isolate is non-susceptible to at least 1 agent
in ‡3 antimicrobial categories listed in Table 4
The isolate is non-susceptible to at least 1 agent in all
but 2 or fewer antimicrobial categories in Table 4.
Acinetobacter spp. The isolate is non-susceptible to at least 1 agent
in ‡3 antimicrobial categories listed in Table 5
The isolate is non-susceptible to at least 1 agent in all
but 2 or fewer antimicrobial categories in Table 5.
a
All MRSA isolates are defined as MDR because resistance to oxacillin or cefoxitin predicts non-susceptibility to all categories of b-lactam antimicrobials listed in this docu-
ment, with the exception of the anti-MRSA cephalosporins (i.e. all categories of penicillins, cephalosporins, b-lactamase inhibitors and carbapenems currently approved up
until 25 January 2011).
http://www.ecdc.europa.eu/en/activities/diseaseprogrammes/ARHAI/Pages/public_consultation_clinical_microbiology_infection_article.aspx.
FIG. 1. Diagram showing the relationship of MDR, XDR and PDR
to each other.
276 Clinical Microbiology and Infection, Volume 18 Number 3, March 2012 CMI
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10. MDR is defined as non-susceptibility to at least one agent
in three or more antimicrobial categories. XDR is defined as
non-susceptibility to at least one agent in all but two or
fewer antimicrobial categories (i.e. bacterial isolates remain
susceptible to only one or two categories). PDR is defined
as non-susceptibility to all agents in all antimicrobial catego-
ries (i.e. no agents tested as susceptible for that organism).
Thus, a bacterial isolate that is characterized as XDR will
also be characterized as MDR. Similarly, a bacterial isolate
would have to be XDR in order for it to be further defined
as PDR. Fig. 1 illustrates that XDR is a subset of MDR, and
PDR is a subset of XDR. Bacteria that are PDR carry the
most absolute type of antimicrobial resistance possible,
implying that there are no approved antimicrobial agents that
have activity against these strains. One example is presented
in Table 7 for P. aeruginosa. Fig. 2 shows additional examples
of possible antimicrobial susceptibility patterns that can fall
under the definitions for MDR, XDR and PDR.
Within the definition for MDR, a unique rule was applied
when defining antimicrobial resistance for a S. aureus isolate
that is an MRSA. Finding an isolate resistant to oxacillin or
cefoxitin predicts non-susceptibility to all categories of b-lac-
tam antimicrobials listed in this document, with the excep-
tion of the anti-MRSA cephalosporins (i.e. all categories of
penicillins, cephalosporins, b-lactamase inhibitors and carba-
penems, currently approved up until 25 January 2011). An
MRSA isolate thus will always be characterized as MDR
because it meets the definition for MDR, ‘non-susceptible
to at least one antimicrobial agent in three or more catego-
ries’. A very broad spectrum of resistance is also implied
when a bacterial isolate is characterized as XDR, because
the proposed definition of XDR indicates that such strains
TABLE 7. Pseudomonas aeruginosa; examples of antimicrobial susceptibility profiles that fit MDR, XDR and PDR definitions;
isolate no. 1 is PDR; isolate no. 2 is XDR and isolate no. 3 is MDR
Antimicrobial category Antimicrobial agent
Isolate no. 1
(PDR)
Isolate no. 2
(XDR)
Isolate no. 3
(MDR)
Aminoglycosides Gentamicin Xa
X
Tobramycin X b
Amikacin X
Netilmicin X
Antipseudomonal carbapenems Imipenem X X X
Meropenem X X
Doripenem X X
Antipseudomonal cephalosporins Ceftazidime X X
Cefepime X X
Antipseudomonal fluoroquinolones Ciprofloxacin X X X
Levofloxacin X
Antipseudomonal penicillins + b-lactamase inhibitors Piperacillin-tazobactam X
Ticarcillin-clavulanic acid X X
Monobactams Aztreonam X X
Phosphonic acids Fosfomycin X
Polymyxins Colistin X
Polymyxin B X
Criteria for defining MDR, XDR and PDR in Pseudomonas aeruginosa
MDR: non-susceptible to ‡1 agent in ‡3 antimicrobial categories.
XDR: non-susceptible to ‡1 agent in all but £2 categories.
PDR: non-susceptible to all antimicrobial agents listed.
a
X = non-susceptible to the antimicrobial agent.
b
Absence of an ‘X’ means the antimicrobial agent was either ‘susceptible’ or ‘not tested’.
http://www.ecdc.europa.eu/en/activities/diseaseprogrammes/ARHAI/Pages/public_consultation_clinical_microbiology_infection_article.aspx.
CMI Magiorakos et al. International standard definitions for acquired resistance 277
ª2011 European Society of Clinical Microbiology and Infectious Diseases, CMI, 18, 268–281
No claim to original US government works
11. are susceptible to only one or two categories of antimicro-
bial agents. In contrast to MDR and XDR, however, it is
necessary to test every antimicrobial agent listed for the
respective organism or organism group in Tables 1–5 in
order to conclusively characterize a bacterial isolate as
PDR.
Applicability and Limitations of MDR, PDR
and XDR Definitions
The proposed definitions can be applied to results obtained
from antimicrobial susceptibility testing of bacterial isolates
in any clinical, reference or public health microbiology labo-
ratory. However, to apply the definitions correctly and to
ensure their validity, certain conditions should be present.
It is important to note that overall a bacterial isolate will
be considered non-susceptible to an antimicrobial agent or
antimicrobial category, when it is found to be non-suscepti-
ble by using any of the available interpretative criteria estab-
lished by EUCAST, CLSI or the FDA. Furthermore, for
results to be compared between surveillance systems or
facilities, it will be important to report details about the
methods and interpretive criteria used for antimicrobial sus-
ceptibility testing along with the results from applying the
definitions for MDR, XDR and PDR.
For these definitions to be valid and comparable they should
be applied to databases that contain sufficiently large numbers
of bacterial isolates that have been tested against all or nearly all
of the antimicrobial agents within the antimicrobial categories
listed in Tables 1–5. Laboratories that utilize selective reporting
protocols must make sure that results from all the antimicrobial
FIG. 2. Examples of 22 possible antimi-
crobial susceptibility patterns that can
fall under the proposed definitions for
MDR, XDR and PDR. , the isolate is
susceptible to all agents listed in cate-
gory; , the isolate is non-susceptible to
some, but not all agents listed in cate-
gory; , the isolate is non-susceptible to
all agents listed in category; , the iso-
late was not tested for susceptibility to
any agent listed in this category.
278 Clinical Microbiology and Infection, Volume 18 Number 3, March 2012 CMI
ª2011 European Society of Clinical Microbiology and Infectious Diseases, CMI, 18, 268–281
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12. agents tested are available for analysis, including those agents
that might have been suppressed. When too few antimicrobial
agents have been either tested or reported or both, there will
be difficulties in applying the definitions and in particular, in reli-
ably distinguishing XDR from PDR phenotypes [30]. In cases of
incomplete testing, bacterial isolates can only be characterized
as ‘possible XDR’ or ‘possible PDR’ and these results cannot be
compared with other ‘possible XDR’,’possible PDR’ or con-
firmed XDR and PDR obtained from other studies. This prob-
lem cannot be circumvented by defining precise antimicrobial
resistance profiles for the definitions of ‘possible XDR’ and
‘possible PDR’, because their characterization depends on
which antimicrobial agents are tested and reported.
‘Possible XDR’ and ‘possible PDR’, however, should still
be regarded as markers of extensive resistance and their use
should be encouraged despite limitations in their interpreta-
tion.
When performing routine antimicrobial susceptibility test-
ing on bacterial isolates in clinical microbiology laboratories,
the limited number of agents generally tested will result in
many MDR bacteria being categorized as ‘possible XDR’ or
‘possible PDR’. This practical limitation underscores the
necessity of testing an adequate number of antimicrobial
agents, such as those suggested in Tables 1–5 in this docu-
ment, in order to effectively apply the definitions. It also
emphasizes the need to test additional agents beyond those
routinely tested in an individual clinical microbiology labora-
tory when a ‘possible XDR’ or ‘possible PDR’ isolate is
encountered. This additional testing might be carried out in
the clinical microbiology laboratory by using a supplemental
panel or by submitting the isolate to a reference laboratory
to allow definitive classification of these bacteria.
When using ‘MDR’ as a measure of epidemiological or
public health significance, it will be important to understand
one of the limitations in the construction of the definition of
MDR proposed in this document, which also exists for those
definitions currently found in the literature. Bacterial isolates
that are MDR will have many different resistance profiles
because by definition, non-susceptible results for even a sin-
gle agent in only three antimicrobial categories defines an
organism as MDR. For example, two E. coli isolates, one
resistant to trimethoprim-sulphamethoxazole, cefazolin and
ciprofloxacin and the other to ertapenem, gentamicin and
tigecycline, will both be characterized as MDR even though
the agents are different. Further characterizing of resistance
in bacteria that are MDR, based on the agents to which they
are resistant, is beyond the scope of these definitions.
Moreover, it must be emphasized that although MDR is
an important characterization of multidrug resistance, in this
era of extreme resistance and despite differences in the
interpretation of MDR that can depend on geographical area
and endemicity, countries should place high importance on
monitoring resistant bacteria that are XDR and PDR because
of their public health impact.
Conclusions
Applying these definitions for MDR, XDR and PDR world-
wide would allow comparability of data and promote better
comprehension of the problem of highly antimicrobial-resis-
tant bacteria. This has not been possible until now, not only
due to the varied definitions that are being used, but also
because of differences in the antimicrobial agents that are
used for routine antimicrobial susceptibility testing in clinical,
reference and public health microbiology laboratories. The
proposed definitions for MDR, XDR and PDR present an
opportunity for clinical microbiology laboratories to review
and, if necessary, expand the number of antimicrobial agents
routinely tested against various organisms and organism
groups and to consider testing additional agents when a bac-
terial isolate is encountered that could be XDR and PDR.
The list of antimicrobial agents found in Tables 1–5 can be
used as a guide and it is important to note again that these
lists are based on current information available from the CLSI,
the EUCAST and the FDA together with the opinion of the
Expert Group. These lists will need to be regularly reviewed
and updated as new recommendations are made and as new
antimicrobial agents are approved and become available for
therapeutic use. As the title of the document indicates, these
are interim definitions that, we hope, will provide some initial
direction for clinicians, medical laboratory technicians and
researchers alike. As the definitions are applied, we will learn
more about their potential strengths, limitations and applica-
tions in various settings. These lessons learned will not only
advance our understanding of drug-resistant bacteria, but will
also help shape future iterations of these definitions.
Updates of this document will be posted, when per-
formed, on the website of the European Centre for Disease
Prevention and Control. For access to these updates and to
download tables which can be used as worksheets, please go
to: http://www.ecdc.europa.eu/en/activities/diseaseprogrammes/
ARHAI/Pages/public_consultation_clinical_microbiology_infection_
article.aspx.
Transparency Declaration
Y. Carmeli reports being a consultant for various pharma-
ceutical and diagnostic companies. M. E. Falagas reports sit-
CMI Magiorakos et al. International standard definitions for acquired resistance 279
ª2011 European Society of Clinical Microbiology and Infectious Diseases, CMI, 18, 268–281
No claim to original US government works
13. ting on the advisory boards of Pfizer, Astellas, Bayer/Nectar
pharmaceutical companies: Merck, AstraZeneca, Novartis,
Cipla and Grunenthal. C. G. Giske has received consulting
fees and speaker honoraria from Wyeth Pharmaceuticals. S.
Harbarth has received consulting fees and speaker hono-
raria from DaVolterra, BioMerieux and Destiny Pharma. J.
F. Hindler reports being a consultant for the Association of
Public Health Laboratories, and a member of Forest Labo-
ratories Microbiology Advisory Board. She has also received
honoraria from: bioMerieux, Inc., BD Diagnostics and Sie-
mens Healthcare Diagnostics. D. L. Paterson reports receiv-
ing consultancy fees from Leo Pharmaceuticals, Merck,
AstraZeneca, Novartis, Johnson & Johnson and that his
institution has received funds from Novartis. Louis B. Rice
reports consulting agreements with Theradoc and with Tet-
rapase Pharmaceuticals and that he has received speaker
honoraria from Pfizer in the last year. M. J. Struelens
reports consultancies and advisory board participation in
the last 3 years with Wyeth, Novartis and Biome´rieux, and
research and epidemiological survey grants to his previous
institution from Pfizer, Novartis and Biome´rieux. None of
the authors have received any financial support for this
work or has any affiliations associated with any conflicts of
interest with this manuscript.
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