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10.1128/CMR.18.4.657-686.2005.

2005, 18(4):657. DOI:Clin. Microbiol. Rev.David L. Paterson and Robert A. BonomoClinical Update

-Lactamases: aExtended-Spectrum

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CLINICAL MICROBIOLOGY REVIEWS, Oct. 2005, p. 657686 Vol. 18, No. 40893-8512/05/$08.000 doi:10.1128/CMR.18.4.657686.2005Copyright 2005, American Society for Microbiology. All Rights Reserved.

Extended-Spectrum -Lactamases: a Clinical UpdateDavid L. Paterson1* and Robert A. Bonomo2

Infectious Disease Division, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania,1 and Infectious Disease Division,

Louis Stokes VA Medical Center, Cleveland, Ohio2

INTRODUCTION ................. ................. .................. ................. ................. .................. ................. .................. ............658DEFINITION OF EXTENDED-SPECTRUM -LACTAMASES.........................................................................658DIVERSITY OF ESBL TYPES .................. ................. ................. .................. ................. ................. .................. .......659

SHV...........................................................................................................................................................................659TEM..........................................................................................................................................................................660CTX-M and Toho -Lactamases ................ .................. ................. ................. .................. ................. .................. .660OXA ................ ................. .................. ................. ................. .................. ................. .................. ................. ...............661PER...........................................................................................................................................................................661

VEB-1, BES-1, and Other ESBLs............... .................. ................. ................. .................. ................. .................. .661EPIDEMIOLOGY OF ESBL-PRODUCING ORGANISMS.................................................................................661

Global Epidemiology ..............................................................................................................................................661Europe ................. ................. ................. .................. ................. ................. .................. ................. .................. ......661

North America.....................................................................................................................................................662South and Central America...............................................................................................................................662Africa and the Middle East ................ ................. ................. .................. ................. ................. .................. .......662Australia........... ................. ................. .................. ................. ................. .................. ................. ................. ..........662Asia ................ ................. ................. .................. ................. ................. .................. ................. .................. ............662

Molecular Epidemiology of Nosocomial Infections with ESBL-Producing Organisms ................................663Risk Factors for Colonization and Infection with ESBL Producers ...............................................................663Nursing Homes and ESBL Producers .................................................................................................................664Community-Acquired Infections ................. .................. ................. ................. .................. ................. .................. .664

INFECTION CONTROL IMPLICATIONS OF ESBL-PRODUCING ORGANISMS ......................................664Use of Typing Methods ............... .................. ................. ................. .................. ................. .................. ................. .664Modes of Spread of ESBL-Producing Organisms within Hospitals................................................................666Infection Control When ESBL-Producing Organisms Have Not Been Endemic...........................................666Infection Control When ESBL-Producing Organisms Are Already Endemic................................................667

DETECTION OF ESBLs IN THE CLINICAL MICROBIOLOGY LABORATORY.........................................667

Need for Clinical Microbiology Laboratories To Detect ESBL Production by Members of theEnterobacteriaceae ................................................................................................................................................667

CLSI Recommended Methods for ESBL Detection ...........................................................................................669Screening for ESBL producers .........................................................................................................................669

(i) Disk diffusion methods ................. ................. ................. .................. ................. ................. .................. ....676(ii) Screening by dilution antimicrobial susceptibility tests.....................................................................669

Phenotypic Confirmatory Tests for ESBL Production ......................................................................................669Cephalosporin/clavulanate combination disks................................................................................................669Broth microdilution ................. .................. ................. ................. .................. ................. .................. ................. .669Quality control when performing screening and phenotypic confirmatory tests.......................................670Implications of positive phenotypic confirmatory tests.................................................................................670

False positives and false negatives obtained with phenotypic confirmatory tests.................................670Commercially Available Methods for ESBL Detection .....................................................................................670

Etest for ESBLs ..................................................................................................................................................670Vitek ESBL cards............. ................. ................. .................. ................. ................. .................. ................. ..........671MicroScan panels ...............................................................................................................................................671BD Phoenix Automated Microbiology System ................ .................. ................. ................. .................. ..........671

Other Methods for ESBL Detection.....................................................................................................................671Cephalosporin/clavulanate combination disks on Iso-Sensitest agar .........................................................671Double-disk diffusion test ................ ................. .................. ................. ................. .................. ................. ..........671

Agar supplemented with clavulanate .................... ................. ................. .................. ................. .................. ....672Disk replacement method ................ ................. .................. ................. ................. .................. ................. ..........672Three-dimensional test.......................................................................................................................................672

Difficult Organisms.................................................................................................................................................672

* Corresponding author. Mailing address: Suite 3A, Falk MedicalBuilding, 3601 5th Avenue, Pittsburgh, PA 15213. Phone: (412) 648-6401. Fax: (412) 648-6401. E-mail: patersond@dom.pitt.ed