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  • 1. Gram- . ,

2. & Gram- ;H ) 3. Klebsiella pneumoniae : combined resistance to cephalosporins, aminoglycosides and fluoroquinolones in the EU, 2011 (Source: EARS-Net) 4. ENTE - SBLs ( , 3 4 , ). . Class A mbler - + : 1983 , -CTX-M - SHV scherichia coli lebsiella 5. ESBLs - - ( - , , ) (2000 : 1 K. pneumoniae: SHV-5 E. coli: CTX-M ( 130 ESBLs) )1. S, Miyakis et al. The chalenges of Antimicrobial Drug Resistance in Greece. Clinical Infectious Diseases, 2011, Vol 53, Issue 2, p: 177-184. 6. AmpCs :Enterobacter, Citrobacter, Morganella, Providencia , Serratia , Hafnia alvei Y , 4 . - +Class C Ambler 3 ,, . 7. : X mpC (Ent, Citr, Ser, Morg, Prov) - mpCs:E. coli, K. pneumoniae, Klebsiella oxytoca, Salmonella enterica P. mirabilis , - 1980K , , de novoCMY-2-like 8. (ESBLs & mpCs) SBLs, AmpCs) Expert rules ( , , , report as found) 9. V4, 2014-01-01: 10. 1. 20 ESBLs (CLSI) 2. 3. 4. (PK/PD, Monte Carlo) SBL-test .coli, K. pneumoniae P. mirabilis, ESBLs. ESs 5. 11. , H 1-g/ml MIC -50% . M onte Carlo) SBLs, MIC. 12. EUCAST CLSI E EUCAST CLSIEUCASTmm)CLSIC (g/ml)SRSRCefpodoxime212121171128Cefepime2421181414 4832Cefotaxime201726221214Ceftazidime2219211714 4416Ceftriaxone232023191214Cefuroxime**1818181488832Cefuroxime Ax.*1818231488432* **E. coli, Klebsiella spp, P. mirabilis (3x1,5gr) 13. Outcome of cephalosporin therapy for bacteraemias caused by K. pneumoniae with ESBL IC Sex/age (years)/underlying disease M/72/intracerebral haematoma M/76/hypertension M/58/cirrhosis M/39/abdominal surgery F/35/caesarean M/48/abdominal surgery M/49/cirrhosis F/73/neurosurgery M/25/multiple trauma F/25/bone marrow transplantSource ventilator-acquired pneumonia central line hospital-acquired pneumoniaCephalosporin as therapy ESBLsMIC (mg/L)Outcomeceftazidime16failceftriaxone16failceftriaxone1(1)died within 48 hcentral lineceftriaxone8died within 48 hsurgical woundcefotaxime4failunknowncefepime2failperitonitis ventilator-acquired pneumonia ventilator-acquired pneumoniaceftriaxone1()curecefepime1()curecefepime0.5fail, died septiccentral lineceftazidime0.5curePaterson DL, et al. Outcome of cephalosporin treatment for serious infections due to apparently susceptible organisms producing extended-spectrum -lactamases: implications for the clinical microbiology laboratory. J Clin Microbiol 2001;39:2206-12 14. ENTE : - 15. 1. 10 (SME, NMC, IMI, GES, KPC, IMP, VIM, NDM, KHM, KPC(2001) , NDM(2009) - + (KPC OXA-48 (K. pneumoniae, E.coli) 2. AmpCs + , 2010 PM R pneumoniae ME: 69,8% K: 27,2% S, Miyakis et al. 16. ( ) : MIC wild type MICs PC L Pk/Pd Expert rules ( , , , report as found) 17. EUCAST CLSI E EUCAST CLSIEUCAST (mm)CLSIMIC (g/ml)SRSRDoripenem2421--12--Imipenem*221623192 28 814Meropenem221623192 28 814R CLSI R> EUCAST *Proteus, Providencia spp. Morganella morganii MIC . MIC 18. EUCASTCLSIT . (report as tested).M C H . ( 3- . . , Cs Morganella, Proteus, Morganella, Proteus, Providencia o Providencia 19. ( ) : MIC Daikos et al. Prospective observational study of the impact of VIM-1 metallo-beta-lactamase on the outcome of patients with Klebsiella pneumoniae bloodstream infections. Antimicrob Agents Chemother. 2009 May;53(5):1868-73 Pneumoniae VIM+, bacteraemias 18,9% mortality Ig/ml K. Pneumoniae , bacteraemias 15,8% mortality Pneumoniae VIM+, bacteraemias 42,9% mortality Ig/ml 20. ENTEOBAKTHIAKA DNA- IV gyrA, gyrB, parC, parE ) ) . qnr DNA- 21. EUCAST CLSI E EUCAST CLSIEUCAST (mm)CLSIMIC (g/ml)SRSRCiprofloxacin221921150.5114Ciprofloxacin Salmonella****0.060.06--Moxifloxacin2017--0.51--Nalidixic Acid Nalidixic acid***19*13***16*32*Norfloxacin221917120.51416Pefloxacin(screen) Salmonella***2424--NANA-- screening test ** Cip 5g Salmonella 22. ENTEOBAKTHIAKA , , ) :- - - , MIC 23. EUCAST CLSI E UCAST CLSIEUCAST (mm)CLSIMIC (g/ml)SRSR161317148161664Gentamcin*1714151224416Tobramycin**1714151224416Netilmcin***1512151224832mikacin* evidence grade C** , evidence grade C*** , evidence grade C 24. V4, 2014-01-01: Fosfomycin iv & oral: MICs in preparation (IP). 25. Gram- E cinetobacter Pseudomonas aeruginosa Stenotrophomonas maltophilia Burkholderia cepacia 26. Acinetobacter - mpC ) , , , UCAST K : K )CLSI : 27. cinetobacter -- (P, VIM) -23, -24/40, 58 ... , ) ANT deABC (80% ) , CarO 28. EUCAST CLSI Acinetobacter EUCAST CLSIEUCAST (mm)CLSIMIC (g/ml)SRSRDoripenem*2320--12--Imipenem2317161328416Meropenem2115161328416* EUCAST: 29. EUCAST CLSI Acinetobacter EUCAST CLSIEUCAST (mm)CLSIMIC (g/ml)SRSRCiprofloxacin212121151114Levofloxacin211817131228Moxifloxacin--------Nalidixic Acid screenNANANANANorfloxacin--------Ofloxacin-------- 30. EUCAST CLSI Acinetobacter UCAST CLSIEUCAST (mm)CLSIMIC (g/ml)SRSRmikacin181517148161664Gentamcin1717151244416Tobramycin1717151244416Netilmcin1616--44832 31. Pseudomonas P. aeruginosa: prD HprD(-) . OprD:5-1. 2. - % 32. Pseudomonas P. aeruginosa: MexAB-OprM P. aeruginosa MIC - C 2-32 g/ml - : MIC: 0.12-0.5 - prD MexAB-OprM MIC: 2-4 - prD MexAB-OprM C: 8-32 33. Maniati M., Ikonomidis A., Mantzana P., Daponte A., Maniatis A., Pournaras S. A highly carbapenem-resistant Pseudomonas aeruginosa isolate with a novel blaVIM-4/blaP1b integron overexpresses two efflux pumps and lacks OprD. J Antimicrob Chemother. 2007 Jul;60(1):132-5. :A prD Y 2 (MexAB-OprM exXY-OprM) -- VIM MIC 34. Stenotrophomonas maltophilia A - , - ) : - & ( ) : SmQnr: : A biofilms 35. O EUCAST 23 / 12 / 12 36. O EUCAST ( 37. C ; ; ; ; MIC 38. 1 ; MICs ( MIC 40% E.coli 5-10%, 1. D.M. Livermore et al. Are susceptibility tests enough, or should laboratories still seek ESBLs and carbapenemases directly? J Antimicrob Chemother 2012, 67 (7) 1569-1577. 39. E ( SBLs & ) , 40. think we are blind. Blind people who can see but do not see. Jose Saramago