Letters to the Editor / International Journal of Antimicrobial Agents 32 (2008) 459464

461

Table 1
Minimum inhibitory concentrations (MICs) of antimicrobial agents for VIM-1 metallo--lactamase-producing Citrobacter freundii C184/07, its transconjugant strain and
Escherichia coli 26R793
Antibiotic

Imipenem
Meropenem
Ertapenem
Aztreonam
Ampicillin
Amoxicillin/clavulanic acida
Piperacillin/tazobactamb
Ceftazidime
Cefotaxime
Cefuroxime
Ciprooxacin
Netilmicin
a
b

Etest MIC (g/mL)

C. freundii C184/07

Transconjugant strain

E. coli 26R793

4
0.5
1
1
>256
>256
>256
>256
>256
>256
1
12

2
0.25
0.125
0.5
>256
>256
>256
>256
64
>256
0.5
16

0.25
0.016
0.094
0.125
4
4
0.75
0.25
0.094
2
0.047
1.5

Amoxicillin/clavulanic acid 2:1.

Tazobactam at a xed concentration of 4 g/mL.

carditis and intra-abdominal sepsis have also been reported [6].

Citrobacter freundii isolates are usually susceptible to carbapenems
and, at present, only a limited number of carbapenem-resistant
strains have been identied. The mechanism of carbapenem
resistance was mostly due to the acquisition of MBLs and occasionally hyperproduction of class C chromosomal cephalosporinase
combined with reduced porin-mediated permeability [7]. These
ndings are of great concern because C. freundii, although
considered a low virulence organism, is an important reservoir of resistance genes. The prompt and accurate detection
of MBL-producing C. freundii strains is necessary to prevent
the dissemination of resistance determinants to more virulent
pathogens.
Funding: No funding sources.
Competing interests: None declared.
Ethical approval: Not required.

References
[1] Queenan AM, Bush K. Carbapenemases: the versatile beta-lactamases. Clin
Microbiol Rev 2007;20:44058.
[2] Aschbacher R, Doumith M, Livermore DM, Larcher C, Woodford N. Linkage
of acquired quinolone resistance (qnrS1) and metallo--lactamase (blaVIM1 )
genes in multiple species of Enterobacteriaceae from Bolzano Italy. J Antimicrob
Chemother 2008;61:51523.
[3] Weile J, Rahmig H, Gfrer S, Schroeppel K, Knabbe C, Susa M. First detection of
a VIM-1 metallo-beta-lactamase in a carbapenem-resistant Citrobacter freundii
clinical isolate in an acute hospital in Germany. Scand J Infect Dis 2007;39:2646.
[4] Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing. Seventeenth informational supplement. M100-S17.
Wayne, PA: CLSI; 2007.
[5] Yan JJ, Hsueh PR, Ko WC, Luh KT, Tsai SH, Wu HM, et al. Metallo-beta-lactamases
in clinical Pseudomonas isolates in Taiwan and identication of VIM-3, a novel
variant of the VIM-2 enzyme. Antimicrob Agents Chemother 2001;45:22248.
[6] Doran TI. The role of Citrobacter in clinical disease of children: review. Clin Infect
Dis 1999;28:38494.
[7] Mainardi JL, Mugnier P, Coutrot A, Buu-Ho A, Collatz E, Gutmann L. Carbapenem resistance in a clinical isolate of Citrobacter freundii. Antimicrob Agents
Chemother 1997;41:23524.

Efthimia Protonotariou
Maria Tsalidou
Danai Vitti
Department of Clinical Microbiology, Hippokration General Hospital,
Konstantinoupoleos 49, Thessaloniki, Greece
Athanasios Kalogeridis
Department of Hematology, Laboratory of Molecular Biology, Second
Department of Internal Medicine, Hippokration General Hospital,
Thessaloniki, Greece

Danae Soanou
Department of Clinical Microbiology, Hippokration General Hospital,
Konstantinoupoleos 49, Thessaloniki, Greece
Corresponding

author. Tel.: +30 231 089 2050;

fax: +30 231 089 2050.
E-mail addresses: [email protected],
[email protected] (E. Protonotariou)

doi:10.1016/j.ijantimicag.2008.05.008

Fosfomycin for Pseudomonas-related exacerbations of cystic

brosis
Sir,
Patients with cystic brosis (CF) are particularly prone to infection with Pseudomonas aeruginosa and this plays a crucial role in
pulmonary disease progression. Infective pulmonary exacerbations
frequently require treatment with potent intravenous antipseudomonal antibiotics with their attending adverse-effect prole.
Isolates are increasingly multidrug resistant and treatment is difcult [1]. Fosfomycin (()-cis-1,1-epoxy propyl phosphonic acid),
originally termed phosphonomycin, is a broad-spectrum antibiotic
rst isolated in 1969 from Streptomyces spp. [2]. It acts by interfering with an early step of peptidoglycan synthesis and hence
inhibits cell wall formation. Fosfomycin is bactericidal and has a
broad spectrum of action that includes Pseudomonas spp., including multidrug-resistant Pseudomonas (MDRP) [3,4]. Fosfomycin has
been shown to be active against P. aeruginosa growing in biolms,
which would theoretically be of particular benet in the treatment
of patients with CF [5]. Because it acts on a step in cell wall synthesis
that is not affected by other classes of antibiotics, cross-resistance is
unusual. Fosfomycin has a very good safety prole, with serious side
effects being very uncommon. It is also thought to decrease the toxicity of other antibiotics by inhibiting the uptake of concomitantly
administered drugs by renal tubular epithelial cells as well as by its
effect on the stabilisation of lysosomal membranes [6]. Fosfomycin
is also known to have anti-inammatory and immunomodulatory
properties, which again would be of particular benet in CF patients
[7].
In view of the above advantages, fosfomycin should be useful
in the treatment of infective exacerbations in patients with CF,
especially those due to MDRP; however, fosfomycin is not widely
prescribed or recommended in guidelines. We report our experience using fosfomycin in the treatment of Pseudomonas-related
infective exacerbations of CF over a period of 3 years.

462

Letters to the Editor / International Journal of Antimicrobial Agents 32 (2008) 459464

Table 1
Pathogens cultured, sensitivity pattern and treatment
Patient no.

Course no.

Pathogen 1

Sensitive toa

Pathogen 2

Sensitive toa

Fosfomycin combined with

1
2
3
3
3
4
4
4
4
4
4
4
4
4
4
4
5
5
5
6
7
7
7
7
7
7

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

P. aeruginosa (NM)
P. aeruginosa (NM)
P. aeruginosa (NM)
P. aeruginosa (NM)
P. aeruginosa (NM)
P. aeruginosa (NM)
P. aeruginosa (NM)
P. aeruginosa (NM)
P. aeruginosa (NM)
P. aeruginosa (NM)
P. aeruginosa (NM)
P. aeruginosa (NM)
P. aeruginosa (NM)
P. aeruginosa (NM)
P. aeruginosa (NM)
P. aeruginosa (NM)
P. aeruginosa (NM)
P. aeruginosa (NM)
P. aeruginosa (NM)
P. aeruginosa (NM)
P. aeruginosa (NM)
P. aeruginosa (NM)
P. aeruginosa (M)
P. aeruginosa (NM)
P. aeruginosa (NM)
P. aeruginosa (NM)

Ta
Co/To
Co/Ci/Im
Ta/Co/Ge
Co/Ci/Ce
Ta/To/Co
Ta/To/Co
Ta/To/Co
Ta/To/Co
Ta/Co
Ta/Co/Ci
Ta/Co
Ta/To/Co
Ta/To/Co
Ta/To/Co
To/Ge/Im
Ta/Co
Ta/Co
Ta/Co
Ta/To/Ce
Ta
Co
Ta/Co
Ta/Co
Ce/Im/Ci
Ta/To/Co

P. aeruginosa (M)
P. aeruginosa (M)
P. aeruginosa (M)
MRSA

Ta/Ge/Ci
Ta/To/Co
Ta/To/Im
Va/Li

P. aeruginosa (M)
P. aeruginosa (M)
P. aeruginosa (M)

To/Ce/Ci
Ce/Ci/Im

P. aeruginosa (M)
P. aeruginosa (M)
P. aeruginosa (M)

Ce/Ci/Im
Ce/Ci/Im
Ta/To/Co

Ta/To
Co
To
To
To
Ta/To
Ta/To
Ta/To
Ta/To
To
Ta

Ta/To
Ta/To
Ta/To
To
To
Co
Co
To
To
To
To
Ci
To
To

M, mucoid strain; NM, non-mucoid strain; MRSA, meticillin-resistant Staphylococcus aureus; Ce, ceftazidime; Ci, ciprooxacin; Co, colistin; Ge, gentamicin; Im, imipenem;
Li, linezolid; Ta, piperacillin/tazobactam; To, tobramycin; Va, vancomycin.
a
The Pseudomonas strain was resistant to all other antibiotics not documented as being sensitive to.

A diagnosis of an infective exacerbation was made if there

was deterioration in the baseline respiratory symptoms with
worsening cough, breathlessness and/or increased purulence of
sputum. Patients were included in the study if they had previously
grown Pseudomonas in the sputum and not responded to standard
antibacterial treatment, had MDRP isolated or were intolerant to
standard antibiotics. A previous adverse reaction to fosfomycin
was the only exclusion criterion. Fosfomycin was given at a dose
of 5 g intravenously every 8 h. The following were prospectively
recorded: patient demographics; the number and duration of
courses of fosfomycin prescribed; renal and liver function tests pre,
during and post treatment; adverse effects; spirometry studies pre
and post treatment; sputum culture; and sensitivities. The primary
endpoint was symptomatic improvement. Data were analysed
descriptively and statistical analysis was done using t-tests as
appropriate. SPSS version 13.0 was used for statistical analysis,
with a P-value of <0.05 considered signicant.
Fosfomycin was used to treat 26 pulmonary exacerbations in
seven patients. The patient group comprised ve females and
two males with a mean age of 26.7 years (range 1950 years).
Fosfomycin was used as part of a combination of two or three antibiotics, except for one course where it was used as monotherapy.
Eighteen courses were in combination with one other antibiotic
and seven in combination with two.
The organisms cultured, their sensitivity prole and the antibiotic regimen used are given in Table 1. Sixteen cultures grew
non-mucoid strains of Pseudomonas alone. Nine cultures identied both mucoid and non-mucoid strains. One sample grew a
mucoid isolate alone. The antibiotic sensitivity prole was available to antipseudomonal antibiotics, which included ceftazidime,
imipenem, aztreonam, ciprooxacin, piperacillin/tazobactam, gentamicin, amikacin, tobramycin and colistin. We do not perform
routine fosfomycin sensitivity testing and hence these data
are not available. In 22 of the 26 episodes treated, a Pseudomonas isolate was resistant to three or more of the above
antibiotics.

The mean duration of antibiotic therapy was 14.3 days. In

all the episodes treated there was symptomatic improvement.
Mean urea, creatinine and alanine aminotransferase levels were
similar before, during and at the end of treatment, with no signicant changes noted. There were no adverse effects reported
in any of the treated episodes. Mean forced expiratory volume in 1 s (FEV1 ) improved following treatment to 34.4% of
predicted from 30.9% (P = 0.14). Analysing the group given fosfomycin in combination with an antibiotic to which the organism
was resistant, the mean duration of treatment was similar
(14 days) and so was the improvement in FEV1 (2027% of
predicted).
A previous study from the UK has demonstrated good outcomes with fosfomycin in treating pulmonary exacerbations in CF,
with improvement in pulmonary function as well as a good side
effect prole [6]. Our study is an observational, open-label, clinical trial with no control group available for comparison. Our data
lend support to the use of fosfomycin as part of a combination
chemotherapy regimen in the treatment of Pseudomonas-related
infective pulmonary exacerbations of CF. The use of fosfomycin
should be considered especially when treating MDRP as well as
when the use of standard antipseudomonal antibiotics is precluded
due to drug-related reactions.
Funding: No funding sources.
Competing interests: None declared.
Ethical approval: Fosfomycin was used following approval from
the Drugs and Therapeutics committee of Castle Hill Hospital, Cottingham, UK.
References
[1] Gibson RL, Burns JL, Ramsey BW. Pathophysiology and management of pulmonary infections in cystic brosis. Am J Respir Crit Care Med 2003;168:
91851.
[2] Hendlin D, Stapley EO, Jackson M, Wallick H, Miller AK, Wolf FJ, et al. Phosphonomycin, a new antibiotic produced by strains of Streptomyces. Science
1969;166:1223.

Letters to the Editor / International Journal of Antimicrobial Agents 32 (2008) 459464

[3] Schlin T. In vitro activity of the aerosolized agents colistin and tobramycin
and ve intravenous agents against Pseudomonas aeruginosa isolated from
cystic brosis patients in southwestern Germany. J Antimicrob Chemother
2002;49:4036.
[4] Tessier F, Quentin C. In vitro activity of fosfomycin combined with ceftazidime,
imipenem, amikacin, and ciprooxacin against Pseudomonas aeruginosa. Eur J
Clin Microbiol Infect Dis 1997;16:15962.
[5] Rodrguez-Martnez JM, Ballesta S, Pascual A. Activity and penetration of
fosfomycin, ciprooxacin, amoxicillin/clavulanic acid and co-trimoxazole in
Escherichia coli and Pseudomonas aeruginosa biolms. Int J Antimicrob Agents
2007;30:3668.
[6] Mirakhur A, Gallagher MJ, Ledson MJ, Hart CA, Walshaw MJ. Fosfomycin therapy for multiresistant Pseudomonas aeruginosa in cystic brosis. J Cyst Fibros
2003;2:1924.
[7] Zeitlinger M, Marsik C, Steiner I, Sauermann R, Seir K, Jilma B, et al. Immunomodulatory effects of fosfomycin in an endotoxin model in human blood. J Antimicrob
Chemother 2007;59:21923.

S. Faruqi
J. McCreanor
T. Moon
Department of Academic Respiratory Medicine,
Castle Hill Hospital, Cottingham HU16 5JQ, UK
R. Meigh
Department of Microbiology, Castle Hill Hospital,
Cottingham HU16 5JQ, UK
A.H. Morice
Department of Academic Respiratory Medicine,
Castle Hill Hospital, Cottingham HU16 5JQ, UK
Corresponding

author. Tel.: +44 1482 624 967;

fax: +44 1482 624 068.
E-mail addresses: [email protected],
[email protected] (S. Faruqi)

doi:10.1016/j.ijantimicag.2008.05.010

Prevalence of high-level vancomycin-resistant enterococci in

French broilers and pigs
Sir,
National monitoring programmes were implemented in French
slaughterhouses to evaluate the antimicrobial resistance of
zoonotic (Campylobacter) and indicator (Escherichia coli and Enterococcus faecium) bacteria in 1999 in healthy broilers and in 2000 in
pigs [1]. Avoparcin is an analogue of the glycopeptides vancomycin
and teicoplanin used for human enterococci and staphylococci
infections. Avoparcin was used in Europe for years as a growth promoter in animal husbandry but was banned in 1997 because of
cross-resistance with vancomycin and teicoplanin, which are listed
as Critically Important Antimicrobials by the World Health Organization. Data from the French national monitoring programme
indicated that no vancomycin-resistant E. faecium could be detected
from broilers since 2002, and in pigs no vancomycin-resistant E.
faecium was isolated in 2004.
However, in human medicine, an increase in the proportion of
vancomycin-resistant E. faecium was observed in 2004 and several
epidemics due to VanA-type E. faecium were detected in 2005 [2].
To investigate the food origin of this phenomenon, it was decided
to estimate the prevalence of high-level vancomycin-resistant
enterococci, i.e. containing vanA or vanB genes, in broilers and
pigs.
Thus, caeca samples from broilers and faecal samples from
pigs collected during the national monitoring programme in
2005 were obtained. Ten-fold dilutions were prepared and inoculated directly or after enrichment in bile salt broth (AES

463

Laboratories, Combourg, France) on bile aesculin azide agar (BioRad, Marnes-la-Coquette, France) medium supplemented with
6 mg/L vancomycin (Sigma, St. Quentin Fallavier, France). Cultures on medium without vancomycin were also performed to
compare titres of total and resistant Enterococcus populations.
Colonies detected on vancomycin plates and their vancomycin
resistance genes were identied by polymerase chain reaction (PCR) according to Depardieu et al. [3]. The sensitivity
of isolates was analysed by the microbroth dilution method
[4].
In total, 193 chicken samples were obtained; 112 resulted in
colonies on vancomycin media. However, after PCR analysis only
three isolates (1.6%) were shown to contain the vanA gene, two of
which were E. faecium (one isolated from an export broiler and the
other from free-range production). The latter strain was isolated
without enrichment.
Of 113 tested pig samples, 71 resulted in colonies on vancomycin
media. Seven samples (6.2%) contained vanA-positive Enterococcus spp. Four were E. faecium and one was Enterococcus faecalis.
Three were not specied as E. faecalis, E. faecium, Enterococcus
gallinarum or Enterococcus casseliavus by PCR but were identied by biochemical tests as Enterococcus sp. Positive samples
were detected from ve different slaughterhouses from different
geographical origins. For the ve samples in which vancomycinresistant colonies could be detected without enrichment, the
proportion of resistant enterococci/total enterococci was 1/500
to <1/15 000.
The sensitivity of the isolates is shown in Table 1. All strains
were resistant to vancomycin (minimum inhibitory concentration
(MIC) = 32 mg/L for the E. faecalis isolate and MIC > 128 mg/L for
the others) and to tetracycline. Most isolates were resistant to
erythromycin, but none of them were resistant to ampicillin or
gentamicin. It is also noteworthy that none of the isolates were
resistant to avilamycin, in contrast to most of the vancomycinresistant strains isolated in 1999 [4]. Avilamycin is a food additive
that was ofcially banned in 2006, but animal producers may have
opted for a voluntary ban before this date.
In conclusion, this study enabled detection of several vanAcontaining isolates in broiler and pig digestive ora 7 years
after the avoparcin ban. No vanB-containing enterococci were
detected. The prevalence was higher in pig production (P < 0.05).
The antimicrobial resistance proles of the isolates were rather
different from those observed in recently isolated strains from
human cases, as the human strains were usually resistant to ampicillin and frequently high-level resistant to gentamicin [2]. Finally,
these observations regarding the prevalence of animals harbouring
vancomycin-resistant strains are supported by the fact that during
annual monitoring of the sensitivity of E. faecium strains isolated
on non-selective media, no vancomycin-resistant strain was isolated from broilers in 2005 or 2006, but one and four resistant
strains were detected in swine in 2005 and 2006, respectively (A.
Perrin-Guyomard personal observation), gures that are still signicantly much lower than the percentages observed just after the
ban [1] and suggesting a marked decrease in the animal vancomycin
resistance gene reservoir after the ban. In contrast, the prevalence
of vanA-positive enterococci in humans did not change much as
shown by the European Antimicrobial Resistance Surveillance System (EARSS) surveillance network data [5], which suggests that
the avoparcin ban has had little inuence on vancomycin resistance in enterococci of human origin. Actually, it appears that
most hospital vancomycin-resistant enterococci belong to a subpopulation of hospital-adapted, epidemic strain types identied
by multilocus sequence typing (MLST) the so-called clonal complex CC-17 distinct from animal strain types [6]. Although we
did not determine the MLST type of our animal isolates, hypo-