Abstract
The emergence and spread of resistance in Enterobacteriaceae are complicating the
treatment of serious nosocomial infections and threatening to create species resistant
to all currently available agents. Approximately 20% of Klebsiella pneumoniae infections and 31% of Enterobacter spp infections in intensive care units in the United States now involve strains not
susceptible to third-generation cephalosporins. Such resistance in K pneumoniae to third-generation cephalosporins is typically caused by the acquisition of plasmids
containing genes that encode for extended-spectrum β-lactamases (ESBLs), and these
plasmids often carry other resistance genes as well. ESBL-producing K pneumoniae and Escherichia coli are now relatively common in healthcare settings and often exhibit multidrug resistance.
ESBL-producing Enterobacteriaceae have now emerged in the community as well. Salmonella and other Enterobacteriaceae that cause gastroenteritis may also be ESBL producers,
which is of relevance when children require treatment for invasive infections. Resistance
of Enterobacter spp to third-generation cephalosporins is most typically caused by overproduction
of AmpC β-lactamases, and treatment with third-generation cephalosporins may select
for AmpC-overproducing mutants. Some Enterobacter cloacae strains are now ESBL and AmpC producers, conferring resistance to both third- and
fourth-generation cephalosporins. Quinolone resistance in Enterobacteriaceae is usually
the result of chromosomal mutations leading to alterations in target enzymes or drug
accumulation. More recently, however, plasmid-mediated quinolone resistance has been
reported in K pneumoniae and E coli, associated with acquisition of the qnr gene. The vast majority of Enterobacteriaceae, including ESBL producers, remain susceptible
to carbapenems, and these agents are considered preferred empiric therapy for serious
Enterobacteriaceae infections. Carbapenem resistance, although rare, appears to be
increasing. Particularly troublesome is the emergence of KPC-type carbapenemases in
New York City. Better antibiotic stewardship and infection control are needed to prevent
further spread of ESBLs and other forms of resistance in Enterobacteriaceae throughout
the world.
Keywords
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