ASA Newsletter, December 2003

Australian Society forAntimicrobials

BackgroundThe use of systemic peri-operative antibioticprophylaxis (PAP) in elective jointreplacement surgery has been demonstratedto significantly lower the rate of prostheticjoint infections.1,2 Surveys have shown thatcompliance with PAP (that is, the percentageadministered in accordance with inter-national standards), though better inorthopaedic surgery compared with othertypes of surgery, varies from 59.3% - 91.3%.3

Due to the diversity of guidelines for PAP injoint replacement surgery, with the majoritysuggesting < 24 - 48 hours of prophylaxis,multiple protocols have been adopted byindividual orthopaedic surgeons at ourinstitution.

We aimed to determine the compliance ofindividual surgeons’ teams with their ownPAP protocols, identify poorly supportedPAP practices based on a review of theliterature and compare PAP in elective jointreplacement surgery at our institution againstthe recently revised Therapeutic AntibioticGuidelines.4

MethodsA retrospective survey of medical records ofpatients who had undergone elective hip orknee joint replacements between June 2001and June 2002 at Concord RepatriationGeneral Hospital (a 550 bed teachinghospital affiliated with the University ofSydney), was undertaken. Each surgeon whoperformed these operations had their owndocumented protocol for antibiotic

prophylaxis in joint replacement surgery(Table 1). A sample of 88 (36%) of 241records of patients who had elective jointreplacement were surveyed using astandardised form. Information collectedincluded patient demographics, methicillinresistant Staphylococcus aureus (MRSA)status, operative details including thesurgeon performing the procedure, thepresence of invasive devices (including in-dwelling urinary catheters (IDCs) and PAPdetails (Table 2). The antibiotic prophylaxis

protocol of the surgeon performing surgeryand compliance with this protocol for eachcase of joint replacement was reviewed. Dataanalysis was performed using the Epi Info 6statistical programme (Centers for DiseaseControl).

ResultsCephalosporinsThe ß-lactam antibiotic, cephalothin, was theonly first generation cephalosporin, providedby pharmacy and hence used in PAP by all ofthe surgeons surveyed, despite theirindividual protocols recommendingcephazolin. Only one of the surgical

protocols (surgeon C’s) specified both therecommended dose and dosing interval forcephalothin; the other protocols specified theinterval appropriate for cephazolin. Howeverdespite this, the actual cephalothin dosinginterval was inappropriate in only 4.5%(4/88) of cases. The duration of cephalothinadministration was generally 48 hours andthe median number of doses was 8 (range 5 -20).

GentamicinOverall, 44.3% (39/88) of patients received asingle dose of gentamicin in theatre as PAPfor operative catheterisation. However 10/39patients given gentamicin did not have anIDC. Only 5 of these patients were operatedon by one of the two surgeons (Table 2)whose protocols called for gentamicinadministration irrespective of IDC status.Figure 1 summarises the initial dose ofgentamicin given as PAP. Appropriateness ofdosing could not be assessed.

Indwelling urinary cathetersThe timing of gentamicin dosing in relationto urinary catheter insertion or removal is notclearly stated in any of the surveyedprotocols. Two surgeons (D & F) recommenda single dose of gentamicin (80mg) as PAP incatheterised patients - 55.5% (5/9) of

Newsletter No.15 December 2003

A Review of Antibiotic Prophylaxis at a Sydney Teaching Hospital

Dept of Microbiology and InfectiousDiseases, Concord Hospital, Sydney

P Valeh, N Gilroy, M Poynten, T Gottlieb

61.50%

>80mg

28.20%

10.20%120 - 180mg

180mg

Figure 1. Gentamicin dose given inelective dose replacement surgery

Also in this issueVanB gene in faecal anaerobes .......................................................................... 4Susceptibility testing of Staphylococcus lugdunensis........................................ 5NHMRC grants for research into antimicrobial agents ..................................... 6 Picture QUIZ...................................................................................................... 7Susceptibility testing of yeasts........................................................................... 8Stability of home intravenous antibiotics .......................................................... 9Antimicrobials 2004, Sydney........................................................................... 11

“The protocols promotedlonger duration ofantibiotic use than

recommended”

2 ASA Newsletter, December 2003

surgeon D and only 10.5% (2/19) of surgeon F’s patientsreceived PAP in accordance with their protocols.

56.8% of patients (50/88) had an indwelling urinarycatheter (IDC) inserted in theatre preoperatively. Of thisnumber, 29 were given IV gentamicin at the time of IDCinsertion; most of these patients (25/29) received 160 mg ofgentamicin, with the remainder being administered 80 mg.A majority (24/29) of these patients were given anadditional, lower dose of gentamicin (80 mg) at the time ofIDC removal.

Most (64.7%) of the 21 catheterised patients who did notreceive gentamicin at the time of IDC insertion laterreceived at least one dose of gentamicin either in relation toIDC removal or subsequent recatheterisation.

Finally, of the 12/50 catheterised patients who received >1dose of gentamicin post-operatively, one was administered2 different doses of gentamicin within the time interval of8 hours and the method of administration of gentamicinwas unclear in 5/40 patients: the same dose was ordered tobe given as either intravenously or intramuscularly withoutclarification as to which method was actually utilised.

Drainage devicesIn the protocols of 4/6 surgeons, PAP duration (IV and oralfollow-on therapy) was guided by drain tube removal. Mostpatients (87/88) had drains inserted intra-operatively. Ofthis number, all had PAP ceased within 24 hours of drainremoval.

Oral antibioticsOral cephalexin was used in 10/88 patients, but whether theintention was to treat or prevent infection could not beascertained.

Tourniquet applicationTourniquet application was used exclusively in patientsundergoing knee arthroplasties. None of these patientsreceived a larger dose of a PAP antibiotic and the timing ofthe administration of the 1st dose of the PAP in relation tothe application of a tourniquet was unable to be accuratelydetermined.

Table 2. Patient characteristics and operative details.

* Tourniquets were used exclusively in knee replacement surgery# All operations except 1 were one-stage revisions## Additional doses of intraoperative antibiotics were not administered in any of

these prolonged operations.

Patient CharacteristicsMedian age (range) 74 (18 - 90)

Cases (%)

Sex Male 53 (60.2%)Female 35 (39.8%)

ß-lactam allergy 10 / 88 (11.3%)rash 5/10 anaphylaxis 2/10not specified 3/10

MRSA Status

No. of preoperative screens 83/88 (94.3%)

MRSA positive 0/83 (0%)

Operative detailsArthroplasty type

Hip Knee* Total (%)

Primary 28 42 70/88 (79.5%)Revision# 11 7 18/88 (20.4%)

50 arthroplasties were cemented and of thisnumber, 31 used antibiotic- impregnated cement.

Operation duration

Median (range) 109.5 mins (47 - 375)

Number of operations > 240 mins## 5/88 (5.6%)

Invasive devices Cases (%)Drain tubes 87/88 (98%)

Median insertion duration (range) 1 day (1 - 3)

Indwelling urinary catheter 50/88 (56.8%)

Median insertion duration (range) 3 days (1 - 11)

DOSE ATINDUCTION

INDWELLING URINARYCATHETER

A cephazolin 1g 1g 8/24 IV Until drain removedcephalexin (if not on IV cephazolin) -

48 hours after IDC removal

Bcephazolincephalexin

1g1g 8/24 IV

500mg 6/24 orally 12 hrs after drain removal If required trimethoprim

Ccephalothin*gentamicin*

1g160mg

1g 6/24 IV160mg daily IV

1 dose after drain removal Total 3 doses

no prophylaxis recorded

cephazolin 1g 8/24 IV One day gentamicin 80mg IV x1

1g 12/24 IVas prescribed by surgeon

Until 1 dose given after drain removal gentamicin (dose not specified)

cephalothin OR cephazolin

no prophylaxis recommended

D 1g

E1g

AustralianGuidelines

Table 1. Individual surgeon’s prophylaxis protocols compared to Antibiotic Guidelines.

* No antibiotics for revision TJR until after intra-op specimens taken

Single dose at induction Repeat dose if operation > 3 hours

2g1g

cephazolingentamicin

or other antibiotic

F cephalothin 1g 8 doses gentamicin 80mg IV x1

DURATIONDOSE POST- OPANTIBIOTIC

3ASA Newsletter, December 2003

AllergiesTwo patients with a history suggestive oftype 1 hypersensitivity reaction to penicillinwere prescribed and administeredcephalothin as PAP.

Discussion The surveyed antibiotic prophylaxisprotocols were directed at junior medicalstaff who often lack the experiencenecessary to make informed judgementsabout antibiotic administration. Outdatedand ambiguous surgical protocols can be thesource of confusion and inconsistentmedical management of patients.

Antibiotic choice and duration1st generation cephalosporins have beenshown to have good serum and boneconcentrations, are active against bacteriaresponsible for up to 80% of prosthetic jointinfections, and have a low toxicity profile.5

The recently updated AustralianAntibiotic Therapeutic Guidelinesrecommend IV cephalothin (2g) orcephazolin (1g) as prophylaxis for electivejoint replacement surgery, with the dosegiven at the time of induction ofanaesthesia.4 Other literature suggests thatdosing of up to 24 hours is appropriate6;prolonged use is not associated with reducedinfection rates but may result in increasedrates of acquisition of MRSA7.

The choice of cephalothin was appropriateamongst all of the surgeons; the dosage usedwas 1g and the post-operative duration ofadministration was mostly 48 hours.Although only two of the six protocolsexamined accommodated the hospitalpharmacy formulary change from cepha-zolin to cephalothin, only one recognisedand recommended the appropriate doseinterval. Despite this, in the majority ofcases where the PAP protocol recommended8-hourly cephazolin, cephalothin was sub-stituted and prescribed at the appropriatedose interval.

The use of gentamicin both in PAP andrelated to IDC manipulation was the area ofgreatest discrepancy from the protocols inthe operations surveyed. The dosage andmethod of administration of gentamicin wasinconsistent in both the surgical protocols(Table 1) and in clinical practice, with nostandardised consideration given to eitherthe patient’s weight or creatinine clearancein determining gentamicin dosage - a factorthat can affect both efficacy and toxicity.The benefit of the routine use of gentamicinin uncomplicated urinary catheterisationremains debatable.8 The Australianguidelines do not recommend the routine

use of gentamicin in PAP4, however singledoses are recommended by others.9

In none of the 5 operations surveyed whichwere more than 4 hours in duration, wereadditional doses of antibiotics given afterthe PAP at induction of anaesthesia. Areview of the literature supports the use ofadditional doses of antibiotics in longoperations.9 For operations more than 3hours in duration, the Australianguidelines recommend the administrationof a second dose of the b-lactam PAP.4

Extending PAP until invasive drainagedevices are removed, a consideration in fourof the six surveyed protocols, is of unprovenbenefit,10 and more likely to promoteMRSA colonisation.7

Tourniquet applicationEvidence exists in the literature to supportthe administration of antibiotics no less than5 minutes prior to the application of atourniquet.11 All patients were given PAPprior to tourniquet application, however thetime from PAP administration to tourniquetinflation was not sufficiently accuratelydocumented to enable this aspect of PAPmanagement to be studied. A review of theliterature identified one study which demon-strated a significant reduction in peak bonelevels of cephazolin in knee replacementsurgery (where tourniquets are routinelyused), compared to hip replacement surgery.The authors of this study recommenddoubling the dose of cephazolin at inductionin order to achieve comparable bone levelsin knee surgery.12 None of the patients towhom an intraoperative tourniquet wasapplied were given more than 1g of cepha-lothin, and the Australian guidelinesrecommend 2g of cephalothin as PAP.4

Drug allergiesCephalosporins were given to patients witha history suggestive of anaphylaxis topenicillins. The Australian guidelinesrecommend the use of IV vancomycin orteicoplanin instead, as ß-lactam anti-biotics are contraindicated in suchpatients.4

MRSA statusNone of the PAP surgical protocols madespecific recommendations for PAP inpatients colonised with MRSA. The recentguidelines recommend the use of IVvancomycin. Interestingly, screening forMRSA colonisation in elective surgery (thatis, in patients without risk factors for MRSAcolonisation) did not yield any positivecultures.

ConclusionsIn short, compliance with the existing PAPprotocols was inconsistent and potentiallyconfusing for resident staff to follow at ourhospital. The PAP protocols promotedlonger duration of antibiotic use thanrecommended; most guidelines wereambiguous with respect to gentamicin useand did not account for several importantpatient and operative factors such as thepatient’s weight and renal function. TheTherapeutic Antibiotic guidelines are anideal frame-work on which to improveexisting PAP protocols. Such best-practiceguidelines, if adopted unit-wide, wouldimprove resident prescribing, and promote amore rational and regimented approach toantibiotic use.

References1. Hill C. et al. Lancet 1981;1:795-796.

2. Espehaug B. et al. J Bone & Joint Surg(British) 1997;79:590-595 .

3. Dettendofer M. et al. Infection2002;30:164-167.

4. Antibiotic Guidelines Writing Group.Therapeutic Guidelines: AntibioticVersion 12. Melbourne: TherapeuticGuidelines Ltd; 2003.

5. McEniery D.W. et al. Drugs1987;34(Suppl 2)216-239

6. Mauerhan D.R. et al. J Bone & Joint Surg1994; 76:39-45

7. Muller A.A. et al. Clin Infect Dis2003;36:971-8

8. Mickelson J.D. et al. NEJM1988;319:321-326

9. Vogley H.C. et al. Reviews in MedicalMicrobiology 2000;11:223-231

10. Gillespie W.J., Clin Infect Dis1997;25:1310-1317

11. Friedman R.J. et al. Clin Ortho & RelatedResearch 1990;260:17-23

12. Cunha B.A. et al. Infection 1984;12:80-84

“Compliance with theexisting protocols was

inconsistent and protocolswere potentially confusing

for resident staff tofollow”

4 ASA Newsletter, December 2003

Correlating the detection of vanB genes in faeces to the presence of vancomycin-resistant enterococci (VRE): interference by vanB-containing anaerobes

IntroductionVRE colonisation and infection isincreasingly common in Australianhospitals. Acquired vancomycin resistancein enterococci encoded by the vanB operonexplains the majority of VRE isolates, andthe vanB2 allele linked to a Tn1549-likeelement appears to dominate.1,2

Recently, the presence of the vanB operonhas been described in organisms other thanenterococci. These organisms includeStreptococcus bovis isolated from a stoolswab and four unrelated anaerobicorganisms isolated from faecal samples.7,9

Three of these organisms were from thegenus Clostridium and the fourth from thegenus Eggerthella. In both reports, thepatients were undergoing routinesurveillance for VRE.

Many multiplex PCR protocols and primersets have been developed for the detectionof van genes in pure isolates of enterococci(reviewed in reference4). Althoughconventional culture methods for thedetection of VRE are sensitive, the timerequired to isolate organisms takes 3-5 days.More recently, PCR protocols have beendescribed for the direct detection of vangenes from clinical samples or enrichmentbroth cultures.5,6,8 However, the presence ofvanB in non-VRE isolates could lead to anunacceptably high false positive rate whenscreening by PCR for VRE carriage.

In this study, we set out to assess thesensitivity (and specificity) of three vanBPCR protocols on three different enrichmentbroth cultures of faeces to identify bothVRE carriage and vanB gene carriage in amixed culture. In a random sample of thosespecimens that were VRE culture negative /vanB PCR positive, attempts were made toisolate the source of the vanB signal toestablish the impact vancomycin resistantorganisms, other than enterococci, mighthave on the performance of a vanB PCR fordetection of VRE.

MethodsThree growth media (anaerobic brain heartinfusion broth, AnO2 BHI; aerobic brainheart infusion broth, BHI; and entero-coccosel broth, EB) were used to culturefaecal specimens from 59 well-characterised

patients (12 vanB VRE culture positive and47 VRE culture negative). Enrichment brothcultures were screened for the presence ofvanB using three different PCR protocols.Carriage of VRE was reconfirmed on allbroth cultures. Specimens positive for vanBby PCR, but VRE culture negative werefurther assessed for the presence of othervanB containing organisms.

ResultsThe sensitivity and specificity of vanB PCRprotocols for the detection of VRE inenrichment broths were as follows:

While primer/PCR protocol “A” and “B”gave the best sensitivity, primer “C” had thebest specificity for VRE. Six Gram-positiveanaerobic bacilli from the order

Clostridiales were isolated from 5specimens that were vanB PCR positive butVRE culture negative. Isolatesdemonstrated the presence of the vanBoperon linked to a Tn1549 - like transposon.

ConclusionsThe sensitivity of PCR detection ofvanB/VRE carriage directly from faecalspecimens is dependent on the primer setand media used. Moreover, as the sensitivityof the vanB PCR protocol increases, so thespecificity of the test for VRE decreaseswith the primer/PCR protocol of Bell et al.,providing the best balance of sensitivity andspecificity. Since carriage of vanB is not theexclusive domain of enterococci, care

should be taken interpreting the results ofPCR-based detection of VRE when usingenrichment broth cultures as the presence ofvanB-containing anaerobes may cause falsepositive results in PCR.

References1. Bell et al. J. Clin. Microbiol. 1998;36;2187-

2190.2. Berry et al. Abstract no. 22, 3rd Annual

Meeting of the Australian Society ofAntimicrobials, Sydney, Australia, 2002

3. Dutka-Malen et al. J. Clin. Microbiol.1995;33: 24-27

4. Facklam et al. In M.S. Gilmore (ed.), TheEnterococci. ASM Press, Washington, D.C,2002.

5. Lu et al. Epidemiol. Infect. 2001;126:357-363.

6. Palladino et al. J. Clin. Microbiol.2003;41:2483-2486

7. Poyart et al. Antimicrob. Agents. Chemother.1997;41:24-29.

8. Satake et al. J. Clin. Microbiol.1997;35:2325-2330

9. Stinear et al. Lancet 2001;357:855-856

S.A. Ballard1, E.A. Grabsch1, S. Xie1, P.D.R. Johnson1,2, M.L. Grayson1,2

1 Depts of Infectious Diseases and Microbiology, Austin and Repatriation Medical Centre, Melbourne.2Dept of Medicine, University of Melbourne, Melbourne.

“vanB-containinganaerobes may cause

false positive results inPCR-based detection of

VRE directly from faecalspecimens”

Primer/PCR

A: Stinear et al9 92% 49% 92% 43% 100% 51%

92% 60% 92% 45% 92% 83%

67% 96% 59% 94% 17% 100%

B: Bell et al1

C: Dutka-Malen et al3

BHI brothSensitivity Specificity

AnO2BHI brothSensitivity Specificity

EB brothSensitivity Specificity

2003 AstraZeneca ASAICAAC Travel AwardCongratulations to Susan Ballard, of theDept of Infectious Diseases at the Austinand Repatriation Medical Centre inVictoria. She was the winner of the 2003AstraZeneca ASA ICAAC Travel Awardfor her ICAAC (Interscience Conferenceon Antimicrobial Agents and Chemo-therapy) abstract. The Award consisted ofa return economy airfare, accommodationand conference registration to attendICAAC, and will be offered again in2004. The next ICAAC is in WashingtonDC in November 2004. ASA memberswho wish to apply for the award areinvited to submit their ICAAC abstracts tothe ASA secretary, Dr Keryn Christiansenat keryn.christiansen@health.wa.gov.auprior to the ICAAC abstract closing date.We thank AstraZeneca for their ongoingsupport.

5

The inability of the NCCLS disc diffusion oxacillin interpretive breakpointfor Staphylococcus aureus to reliably detect oxacillin susceptible

Staphylococcus lugdunensis

IntroductionStaphylococcus lugdunensis was firstdescribed by Freney et al in 1988 and is nowwidely accepted as a significant pathogen,although there continues to be a problem oflow awareness of the organism amongclinicians and laboratory staff. It is acoagulase negative staphylococcus thatmore closely resembles S aureus in itspathogenicity. It has been implicated in avariety of infections including endocarditis,septicaemia, breast abscesses, orthopaedic,skin and soft tissue infections.In 1999, NCCLS introduced an oxacillininterpretive breakpoint for disc diffusiontesting of coagulase negative staphylococci(CNS). However this breakpoint wasestablished primarily for S epidermidis andmay not be suitable for other CNS (eg Slugdunensis)

NCCLS guidelines forstaphylococci

In 2002 - NCCLS added the followingcomment to the guidelines for interpretingoxacillin zone diameters: “Interpretivecriteria for CNS correlate with the mecAgene for S epidermidis. These criteria mayovercall resistance for other CNS eg Slugdunensis or S saprophyticus. For seriousinfections with CNS other than S.epidermidis, testing for mecA or the proteinexpressed by mecA, the penicillin bindingprotein 2a (PBP2a) may be appropriate forstrains with zone diameters in the inter-mediate or resistant range. Isolates that are

not shown to carry mecA or do not producePBP2a should be reported as oxacillinsusceptible.”Most laboratories, however, do not haveaccess to molecular methods for thedetection of the mecA gene, and theaccuracy of phenotypic assays for thedetection of PBP2a in CNS has not beendetermined. As the NCCLS CNS discdiffusion oxacillin breakpoints oftenmisclassify mecA gene negative strains asoxacillin resistant, we investigated if the

NCCLS S aureus disc diffusion breakpointmay be more reliable for detecting oxacillinsusceptible S lugdunensis. Although Slugdunensis is generally consideredoxacillin susceptible, in January 2003 amecA gene positive strain with an oxacillinMIC of >256mg/L was reported (Tee et al,2003).

MethodFrom March 1998 to February 2003, 70clinical isolates of S lugdunensis were

collected at Royal Perth Hospital and theWomen’s and Children’s Hospital in Perth,Western Australia. All isolates wereidentified by a phenotypic disc method or bybioMérieux ID32 STAPH API. A multiplexPCR for the presence of mecA and nuc genewas performed on all isolates. Oxacillinsusceptibility testing was performed byKirby-Bauer disc diffusion using NCCLSinterpretive guidelines (M100-S12 Jan2002) and oxacillin minimum inhibitoryconcentrations (MIC’s) were determinedusing Etest® (AB Biodisk) on MuellerHinton Agar (MHA) with 2% NaCl added.

Results MecA / nuc gene PCR testing (n = 70) · All isolates were mecA and nuc gene

negative.Kirby-Bauer Disc Diffusion testing (n = 70)• Using the CNS oxacillin interpretive

breakpoint (?? 18mm = susceptible), only3 isolates (4%) were classified as oxacillinsusceptible.

• Using the S aureus oxacillin interpretivebreakpoint (?? 13mm = susceptible), 47isolates (67%) were classified as oxacillinsusceptible.

Minimum Inhibitory Concentration (MIC)(n = 67) • Using the CNS oxacillin interpretive

breakpoint (?? 0.25mg/l = susceptible),only 1 isolate (1%) was classified asoxacillin susceptible.

• Using the S aureus oxacillin interpretivebreakpoint (?? 2mg/l = susceptible), all 67isolates (100%) were classified asoxacillin susceptible.

Discussion• The NCCLS CNS disc diffusion and MIC

oxacillin interpretive breakpoints were notsuitable for S lugdunensis.

• Although the NCCLS S aureus discdiffusion oxacillin interpretive breakpointwas not reliable for S lugdunensis, theNCCLS MIC interpretive breakpointcorrectly classified all isolates as oxacillinsusceptible.

ASA Newsletter, December 2003

Cheryll McCullough, Geoffrey Coombs, Sandra Rodgersand Keryn Christiansen

Dept of Microbiology and Infectious Diseases, Royal Perth Hospital, Western Australia

“Oxacillin susceptibilitytesting of S lugdunensis

can be determined by MICtesting on MHA with 2%

NaCl added using NCCLSS aureus interpretive

breakpoints”Table 1. Prior to 1999 - Single NCCLS breakpoint for all staphylococci

Table 2. 1999 - Introduction of CNS breakpoint by NCCLS

Ox Disc(zone diameter)

?? 12mm

?? 13mm

?? 4mg/L

?? 2mg/L

RESISTANT

SUSCEPTIBLE

DETECTED

NOT DETECTED

OX MIC Interpretation mecA gene

Ox Disc(zone diameter)

?? 17mm

?? 18mm

?? 0.5mg/L

?? 0.25mg/L

RESISTANT

SUSCEPTIBLE

DETECTED

NOT DETECTED

OX MIC Interpretation mecA gene

>

>

>

>

>

>

>

>

>

>

>

>

6 ASA Newsletter, December 2003

Conclusions• Clinically significant CNS requiring

susceptibility testing should be fullyidentified.

• NCCLS CNS and S aureus disc diffusioninterpretive breakpoints for oxacillin arenot reliable for S lugdunensis.

• Oxacillin susceptibility testing of Slugdunensis can be determined by mecAgene PCR or by MIC testing on MuellerHinton Agar with 2% NaCl added usingNCCLS S aureus interpretive breakpoints.

AcknowledgementsDr Michelle Porter from the Women’s andChildren’s Hospital and Dr Sue Bensonfrom St John of God Pathology forsupplying clinical isolates.

ReferencesFreney J, Brun Y, Bes M et al. Staphylococcuslugdunensis sp. nov. and Staphylococcusschleiferi sp. nov., two species from humanclinical specimens. Int J Syst Bacteriol.1988;38:168-172

Tee WS, Soh SY, Lin R, Loo LH.Staphylococcus lugdunensis carrying themecA gene causes catheter-associatedbloodstream infection in premature neonateJ Clin Micro 2003;41:519-520

NCCLS. Performance Standards forAntimicrobial Susceptibility Testing; TwelfthInformational Supplement. NCCLS documentM100-S12, Jan 2002. Vol.22 No 1

NCCLS. Performance Standards forAntimicrobial Susceptibility Testing; NinthInformational Supplement. NCCLS documentM100-S9, Jan 1999. Vol.19 No 1

NCCLS. Performance Standards forAntimicrobial Susceptibility Testing; EighthInformational Supplement. NCCLS documentM100-S8, Jan 1998. Vol.18 No 1

Melissa BrownRon Skurray

Multidrug resistance in hospital strainsof Golden Staph

3

3

$490,500

$451,750Control of multidrug resistance genes inhospital strains of Golden Staph

3 $367,725Do long-term antibiotics prevent urinarytract infection?

Lesley RoyJonathan CarapetisGraham ReynoldsJudy SimpsonElisabeth Hodson

3 $425,250Antibiotic resistance in hospital strainsof Golden Staph

Ron SkurrayNeville FirthStephen Kwong

3 $506,625Drug resistance in scabiesShelley WaltonJames McCarthyBart CarrieDeborah Holt

2 $117,000What should be done to preventbloodstream infections in hospitalisedpatients?

Nicholas GravesPeter CollignonMichael WhitbyDiana BattistutaFrances BirrellTony Pettitt

3 $267,750Development of lactobacilli as pathogenkillers

Mark Turner

3 $388,875Acute bronchitis in general practice: canantibiotics help some patients?

Nigel StocksJohn TurnidgeAlan CrockettAnthony Veale

3 $262,125Improving use of an ‘old’ last-lineantibiotic

Roger NationJian LiJohn TurnidgeKingsley CoulthardRobert MilneCraig Rayner

2 $133,513Ways of improving the use of a last-lineantibiotic

Craig Rayner

$3,411,113

Investigators Lay Title Years Totalfunding

Ron SkurrayMelissa Brown

TOTAL FUNDING

2003 NHMRC project grants awarded for researchinto antimicrobial agents

2003 BioMérieux ASA Identifying Resistance awardCongratulations to Cheryll McCullough of the Dept of Microbiology and Infectious Diseases at the RoyalPerth Hospital, the winner of the 2003 BioMérieux ASA Identifying Resistance award. This award isgiven to an individual ASA member for the best proffered paper (oral or poster) at the ASA annualscientific meeting on the identification of bacterial resistance to antimicrobials in a routine clinical setting.It consists of A$1000 cash prize, a commemorative plaque, and a travel award (flights, accommodationand registration) to attend the next ASA annual scientific meeting. This award will be offered again in2004 and all abstracts submitted for the ASA 2004 meeting on the identification of bacterial resistance toantimicrobials in a routine clinical setting will be considered for this award. We thank BioMérieux fortheir ongoing support.

7ASA Newsletter, December 2003

Picture Quiz

In July 2003, an elderly man presented tohospital with a purulent discharge from asuprapubic catheter site. This was

swabbed for culture.

The swab was inoculated onto horse bloodagar and MacConkey plates. After 24 hoursincubation at 35°C, there was a pure growth ofS aureus and Group G Streptococcus. Figure 1shows a disc susceptibility test for S aureus(penicillin 10 ug disc on the left, tetracycline10 ug disc on the right). Figure 2 shows anoxacillin E test for S aureus.

• Comment on the disc sensitivity patterns inFigure 1.

• Comment on the E test result in Figure 2.

• What needs to be done to sort out thisfinding?

Please email your responses to the ASANewsletter Editor Wendy Munckhof atwendy_munckhof@heal th .qld .gov.au.Answers will be published in the next issue,and correct responses will be acknowledged.

Picture quiz provided by Dr Joan L Faoagaliand Jan Bodman, Royal Brisbane Hospital.

Photographs by Cassy Faux.

Figure 2

Figure 1

NEWSLETTER CONTRIBUTIONSSubmission of articles for possible publication or lettersto the editor should be sent to:

Dr Wendy Munckhof,ASA Newsletter Editor,Infection Management Services Southern Queensland,Princess Alexandra Hospital,Ipswich Rd, Woolloongabba,Brisbane, QLD 4102

Telephone: (07) 3240 5920Facsimile: (07) 3240 5540Email: wendy_munckhof@health.qld.gov.au

ASA SUBSCRIPTIONSSubscriptions should be sent to:

Geoffrey CoombsASA TreasurerDept. of Microbiology & Infectious Diseases,Royal Perth HospitalGPO Box X2213Perth WA 6001

Telephone: (08) 9224 2446Facsimile: (08) 9224 1989Email:geoffrey.coombs@health.wa.gov.au

8 ASA Newsletter, December 2003

On the right is a photo of an isolate of Candida albicansfrom a mouth swab of an AIDS patient with oral candidiasis.A RPMI agar plate has been incubated aerobically for 48hours at 35°C. The disc is a Fluconazole 25 mg NeoSensitaband the Etest is for Fluconazole.

• Please read the Etest MIC for Fluconazole. Fluconazole MIC is 0.05 mg/ml or 1.0 mg/ml.

• According to current NCCLS recommendations, whenshould Etests be read for yeasts?The recommended incubation time for yeast Etests is 48hours. However the new revised NCCLS M27-A2document does provide 24 hr QC ranges, so that tests forCandida may be read at 24 hrs.

• Why is trailing seen with the Etest and not the disc?Etests commonly overestimate the yeast MIC forFluconazole due to trailing. Trailing can also occur in discmethods for yeast Fluconazole susceptibility testing but isless common. The reason for trailing MICs is unknown.

• How common is it for Candida albicans to have trailingend points when tested against fluconazole?When read at 48 hrs, 20% of Candida albicans strainsshow trailing end points when tested against Fluconazole.

ReferenceNCCLS Reference method for broth dilution antifungal susceptibilitytesting of yeasts; approved standard - Second edition. NCLLSdocument M27-A2 [Vol 22 No. 15 August 2002]. This replaces M27-A [Vol. 17 No. 9].Picture quiz and answers provided by David Ellis, Women’s &Children’s Hospital, Adelaide.

Answer to Picture Quiz from ASA newsletter No. 14 Sept. 2003

ASA Hospital Antibiotic Usage Survey reminder

ASA is conducting the third AntibioticUsage Survey in major hospitalsaround Australia, following previous

surveys in 1986 and 1992. Survey formswere sent to Chief Pharmacists, InfectiousDisease Physicians and / or ClinicalMicrobiologists in major hospitals around thecountry in January 2002 and havesubsequently been resent.

Thank you to the 32 hospitals that havereturned completed the 2-page survey forms.Unfortunately, 17 hospitals have still notreplied to date. Could any ASA members onstaff at these hospitals please ensure they doso! Data cannot be analysed until most ofthese hospitals return completed surveys.Please contact Dr Mike Whitby (07) 32402595) if you need another survey form.

This is a list of the hospitals that were sentthe survey.

ACT· The Canberra Hospital

NT· Royal Darwin Hospital

NSW· Westmead Hospital· St Vincent’s Hospital· Prince of Wales Hospital· St George Hospital· Nepean Hospital· Royal Prince Alfred Hospital· Concord Repatriation General Hospital· Wollongong & Port Kembla Hospital· Royal North Shore Hospital· John Hunter Hospital· Liverpool Hospital· New Children’s Hospital Westmead

VIC: · Alfred Hospital· Monash Medical Centre· Royal Children’s Hospital· Royal Women’s Hospital· Western Hospital· Box Hill Hospital· Geelong Hospital· Royal Melbourne Hospital· St Vincent’s Hospital· Austin & Repatriation Medical Centre

QLD: · Toowoomba Hospital· Rockhampton Hospital

· Mater Public Hospital· Royal Brisbane Hospital· Princess Alexandra Hospital· Prince Charles Hospital· QE II Hospital· Gold Coast Hospital· Ipswich Hospital· Mackay Base Hospital· Townsville General Hospital· Cairns Base Hospital

SA: · The Queen Elizabeth Hospital· Repatriation General Hospital· Royal Adelaide Hospital· Women’s and Children’s Hospital· Flinders Medical Centre· Modbury Hospital· Lyell McEwin Health Service

WA· Royal Perth Hospital· Princess Margaret Hospital for Children· Sir Charles Gardiner Hospital· Fremantle Hospital

TAS· Royal Hobart Hospital· Launceston Public Hospital

9ASA Newsletter, December 2003

Stability of some commonly used home intravenous antibiotics

Henry K. Lie1, Julia Carroll 2

1 Senior Pharmacist, Centralised Intravenous Additive Services (CIVAS), Dept of Pharmacy, King Edward MemorialHospital for Women and Princess Margaret Hospital for Children, Women’s and Children’s Health Service, Perth

2 Senior Pharmacist, Alternative Site Infusion Service (ASIS), Infection Management Service,Princess Alexandra Hospital, Brisbane

Aciclovir 500mg NaCl 0.9%,Water for injection (WFI)

7 days at room temperature.1,2

Refrigeration causes crystallisation of drug29 days at room temperature.3

Refrigeration causescrystallisation of drug

Amikacin 2.5mg/mL NaCl 0.9% 14 days refrigerated4,5,6

Amoxicillin 10-50mg/mL NaCl 0.9% Unstable (3-8 hours stability only at room temperature, up to 3 daysrefrigerated) 7,8,9

Unstable, similar to amoxicillin at room temperature, up to 2 daysrefrigerated10

10 days refrigerated, 30 days frozen3

Aztreonam 20mg/mL WFINaCl 0.9%

7 days refrigerated11,12 14 days refrigerated, 30 days frozen13

Benzyl Penicillin 3g Sodium citrate 4% 14 days refrigerated14 7 days refrigerated15

Ampicillin 125 mg/ml WFI

DRUG DILUENT STABILITY in syringesa STABILITY inelastomeric devicesb

Cefotaxime 100mg/mL WFI 7 days refrigerated. 3 months at -20°Cplus 7 days refrigerated when thawed.Once thawed, should not be refrozen10,16

10 days refrigerated. 30 days frozen plus 24hourspost thawing.13

Cefepime 100mg/mL WFI 3 months at -20°C plus 7 days refrigeratedwhen thawed. Once thawed, should not berefrozen17,18

14 days refrigerated3

Cefoxitin 2g WFI 7 days refrigerated19

Ceftazidime 100mg/mL WFI 7 days refrigerated. 3 months at -20°Cplus 7 days refrigerated when thawed.Once thawed, should not be refrozen16,20

10 days refrigerated13

7 days refrigerated13

Ceftriaxone 100mg/mL WFI 7 days refrigerated. 3 months at -20°C plus7 days refrigerated when thawed. Oncethawed, should not be refrozen21,22

10 days refrigerated.30 days frozen plus 24 hourspost thawing.13

Cephazolin 1g WFI 7 days refrigerated.19 3 months at -20°Cplus 7 days refrigerated. Once thawed,should not be refrozen.11,16,19,23

10 days refrigerated, 30 days frozen plus 24 hourspost thawing.13

Flucloxacillin 100mg/mL WFI 7 days refrigerated10 Manufacturer states 3 daysrefrigeration.

Gentamicin 10mg/mL NaCl 0.9% 14 days refrigerated24 10 days refrigerated13

Meropenem 50mg/mL WFI 6 months at -60°C25 48 hoursrefrigerated25

4 days refrigerated plus 6hours at room temperature26

Ticarcillin/ClavulanicAcid 100mg/mL

WFI 7 days refrigerated.3 months at -20°Cplus 7 days refrigerated when thawed.Once thawed, should not be refrozen16

7 days refrigerated3

Tobramycin Diluted to 30mL withNaCl 0.9%

14 days refrigerated28 10 days refrigerated13

Vancomycin 5mg/mL NaCl 0.9% 3 months refrigerated29 14 days refrigerated3

Teicoplanin WFI Unstable in plastic due to leaching of silicone particles.Manufacturer recommends storage in glass vial or glass syringe for up to7 days refrigerated27

Dicloxacillin WFI Unsuitable for home IV use due to particle precipitation

Footnote. Refrigeration refers to 2°- 8°C

10 ASA Newsletter, December 2003

a. Information on stability in syringessupplied by Henry K Lie of thePrincess Margaret Hospital forChildren (PMH) CIVAS department,Perth. This department routinelysupply home antibiotics for cysticfibrosis patients, cancer patients, andpatients with cellulitis andosteomyelitis. The antibiotics are firstdiluted using either normal saline or inmost cases water for infusion to 30mL.These are supplied in 30mL Braunsyringes which fit into a springfusorand are infused over 15 minutes (2 to 3times daily). The antibiotics aresupplied in ready to use syringesusually one week at a time, dependingon stability. Most commonly usedhome antibiotics are stable in therefrigerator for at least one week withthe following exceptions: amoxicillin(2-3 days), ampicillin (2-3 days),meropenem (2 days), aciclovir (storedat room temperature) and dicloxacillin(unsuitable for home use due to particleprecipitation).

b. Information on stability in elasto-meric devices supplied by Julia Carrollof the Princess Alexandra HospitalAlternative Site Infusion Service(ASIS). This service suppliesantibiotics in elastomeric devices for inthe home administration, mostly foradult patients with surgical woundinfections, osteomyelitis, synovitis,cellulitis, diabetic foot infections, andoccasionally for cystic fibrosispatients. Antibiotics requiring reconsti-tution are reconstituted with water forinjection (exception being BenzylPenicillin which is reconstituted with aSodium Citrate buffer) and added toelastomeric devices filled with requiredamount of normal saline. Mostantibiotics are infused over 24 hours indisposable elastomeric devices orprogrammable pumps, with theexceptions vancomycin (infused over 2hours) and aminoglycosides (infusedover 30 - 60 minutes). All preparationis carried out in a clean room in avertical laminar flow cabinet. Anadditional concern with stability inelastomeric devices is stability at 31°Cover 24 hours, 31°C being skintemperature under clothing. Thedevices are worn in a waist pouch. Thisdemand for stability at higher thannormal room temperature accounts forsome of the differences in stabilitycompared with syringes.

References

1. Zhang YP, Trissel LA, Martinez JF, etal. Stability of acyclovir sodium 1, 7,and 10mg/mL in 5% dextrose injectionand 0.9% sodium chloride injection. AmJ Health-Syst Pharm 1998;55:574-577.

2. Gupta VD, Pramar Y, and Bethea C.Stability of acyclovir sodium indextrose and sodium chloride injections.J Clin Pharm Ther 1989; 14: 451-456.

3. Guidelines for the administration ofdrugs using the Homepump /Homepump Eclipse disposableelastomeric infusion systems. LakeForest, CA: I-Flow Corporation; 1996.

4. Kaplan MA, Coppola WP, NunningBC, et al. Pharmaceutical properties andstability of amikacin: part 1. Curr TherRes 1976;20:352-358.

5. Nunning BC and Granatek AP. Physicalcompatibility and chemical stability ofamikacin sulfate in large-volumeparenteral solutions, part ii. Curr TherRes Clin Exp 1976;20:359-368.

6. Zbrozek AS, Marble DA, Bosso JA, etal. Compatibility and stability ofclindamycin phosphate-aminoglycosidecombinations within polypropylenesyringes. Drug Intell Clin Pharm1987:21:806-810.

7. Cook B, Hill SA, Lynn B. The stabilityof amoxycillin sodium in intravenousinfusion fluids. J Clin Hosp Pharm1982;7:245-250

8. Lynn B. The stability and administrationof intravenous penicillins. Br J IntravenTher 1981;2:22-39

9. Needle R, Sizer T (Eds). The CIVASHandbook - The CentralisedIntravenous Additive ServicesReference. The Pharmaceutical Press,London, 1998.

10. Ahmed ST, Parkinson R. The stabilityof drugs in pre-filled syringes:flucloxacillin, ampicillin, cefuroxime,cefotaxime, and ceftazidime. HospPharm Pract 1992;2:285-289.

11. Physician’s Desk Reference, 53rdedition. Medical Economics Company.Montvale, New Jersey, 1999.

12. James MJ, Riley CM. Stability ofintravenous admixtures of aztreonamand ampicillin. Am J Hosp Pharm1985;42:1095-1100.

13. Intermate / infusor drug stabilityinformation. Deerfield, IL: BaxterHealthcare Corporation; 1999.

14. Allwood MC, Brown PW. The stabilityof benzylpenicillin injections. Pharm J1991; 247 (Suppl):R12.

15. Drug stability guidelines for use withthe Secure Medical Medflo ElastomericInfusion system. Mudelein, IL: SecureMedical: 1994.

16. McEvoy GK (ed). AHFS DrugInformation 2003. American Society ofHealth-System Pharmacists, Bethesda.

17. Stewart JT, Maddox FC, Warren FW.Stability of cefepime hydrochloride inpolypropylene syringes. Am J Health-Syst Pharm 1999; 56:1134.

18. Stewart JT, Warren FW, Maddox FC.Stability of cefepime hydrochlorideinjection in polypropylene syringes at -20°C, 4°C, and 22-24°C. Am J HealthSyst Pharm 1999; 56:457-459.

19. Borst DL, Sesin GP, Cersosimo RJ.Stability of selected beta-lactamantibiotics stored in plastic syringes.NITA 1987;10:368-372.

20. Stewart JT, et al. Stability ofceftazidime in plastic syringes and glassvials under various storage conditions.Am J Hosp Pharm 1992;49:2765-2768.

21. Plumridge RJ, Rieck AM, Annus TP, etal. Stability of ceftriaxone sodium inpolypropylene syringes at -20, 4 and20°C. Am J Health-Syst Pharm1996;53:2320-2323.

22. O’Connell C, Sabra K, Scott K.Stability of reconstituted ceftriaxonesolution in polypropylene syringes. EurHosp Pharm 1996; 2:47-48.

23. Carone SM, Bornstein M, Coleman DL,et al. Stability of frozen solutions ofcefazolin sodium. Am J Hosp Pharm1976;33:639-641.

24. Parkinson R, et al. The stability ofdrugs in prefilled syringes. Hosp PharmPract 1991;1:243-252

25. Lim CB. Stability of meropenem invarious intravenous fluids. Abstract forthe 24th Federal Conference of theSociety of Hospital Pharmacists ofAustralia, 1999.

26. Kramer I. Stability of meropenem inelastomeric portable infusion devices.Eur Hosp Pharm 1997;3:168-171.

27. Aventis Pharma. Personalcommunication, 2003.

28. Seitz DJ, Archambault JF, Kresel JJ, etal. Stability of tobramycin sulfate inplastic syringes. Am J Hosp Pharm1980; 37:1614-1615

29. Wood MJ, Lund R, Beavan M. Stabilityof vancomycin in plastic syringesmeasured by high-performance liquidchromatography. J Clin Pharm Ther1995;20:760-763.

Plenary Speakers• Steven J ProjanNew Drug Development Director of Antibacterial Research,Wyeth-Ayerst Research, New York, USA

Steve has co-written over 60 originalscientific papers and has several areas ofinterest including antimicrobial chemo-therapy and resistance, genomics, micro-bial pathogenesis, and biotechnology. Inrecent years his research has includedinvestigating antibiotic resistance inbacteria from magpies and rabbits fromwest Wales; identifying compounds thatinhibit the last steps of cell wallbiosynthesis; and using genomics todetect novel antibacterial targets anddrugs. Steve is an enthusiastic oratorwho brings both optimism and a freshapproach to the conquest againstantimicrobial resistance.

In the words of Steve Projan…….

“Steven J Projan, PhD (Columbia 1990,Molecular Genetics) is widely known forhis dilettantish approach to bacterialpathogenicity, antimicrobial drugresistance and anti-infective drugdiscovery. Since 1988 he has directed agroup of dedicated scientists in anti-bacterial drug discovery at WyethResearch in Pearl River, New York, whoclearly deserve better. Dr Projanidentified tigecycline (GAR-936) as apotential clinical candidate in 1994 byblind dumb luck and fortunate timing, hehopes to parlay that success into alucrative career in drug discovery andstandup comedy.”

• John PerfectAntifungal DevelopmentsDirector of the MycologyInterdisciplinary Research Unit,Professor of Medicine and AssociateProfessor of Microbiology,Duke Medical Center, North Carolina,USA

John has over 200 published papers inpeer-reviewed journals to his credit andhas also co-authored a book on

Cryptococcus neoformans. John is amember of numerous professionalsocieties and committees including theAmerican Society of Microbiology andISHAM. He is also an active researcherin the field of medical mycology and alecturer on medical infectious diseases,mycology and tropical medicine.

• Ivan Bastian

Laboratory and clinical aspects ofMDR TB in high- and low-prevalencesettings

Clinical Microbiology Consultant,IMVS, South Australia

Ivan is the laboratory representative forthe Australian National TuberculosisAdvisory Committee which has recentlydrafted guidelines for Australian myco-bacteriology laboratories. His works inthe field of tuberculosis extend inter-nationally including assisting with drugsusceptibility testing in East Timor, EastJava and the Pacific Islands. In 1998,Ivan was awarded a Neil HamiltonFairley Fellowship to investigate im-proved diagnostics for tuberculosis inlow resource countries. Subsequently, hehas reviewed prison TB services inMoldovia for Caritas Luxemburg andworked in a TB prison laboratory inSiberia. In 2000, Ivan was an editor forthe publication “Multidrug-ResistantTuberculosis”.

ESBL Workshop

Extended spectrum beta-lactamases(ESBLs) originally detected inKlebsiella pneumoniae and Escherichiacoli are now being detected in otherspecies of Enterobacteriaceae and Gramnegative glucose nonfermentersthroughout the world. New types areemerging such as CTX-M and plasmid-borne AmpC beta-lactamases. What isthe epidemiology of ESBLs in Australiaand what are the clinical implications?When should laboratories test for theseorganisms and what methods should beused?

The ESBL workshop will discuss theseand other issues including discussion onwhat confirmatory molecular tests areavailable for the diagnostic microbiology

laboratory. The workshop will includeaudience participation.

Registration and abstractsubmission

Via conference website:www.icms.com.au/asa2004

Updated conference and accommodationinformation will also be on the website

Dates to rememberDeadline for abstract submission:19th December 2003Abstract notification:31st December, 2003Close of early bird registration:19th December 2003(persons submitting accepted abstractswill be able to register at early bird rate)Accommodation booking deadline:16th January, 2004

Antimicrobials 2004 TravelAwards

Travel awards are available for ASAmembers presenting a proffered paper(oral or poster) at the conference. Theawards consist of return economy classairfare, accommodation, conferenceregistration and a ticket to the MeetingDinner. Applicants should forward acopy of their abstract to the Secretary(keryn.christiansen@health.wa.gov.au)before 19th December 2003.

2004 BioMérieux ASAIdentifying Resistance TravelAward

This is awarded to an ASA member onthe basis of a proffered paper (oral orposter) presented during Antimicrobials2004 dealing with the identification ofbacterial resistance to antimicrobials in aroutine clinical setting. The awardconsists of a A$1000 cash prize, acommemorative plaque, and flights,accommodation and registration for therecipient to attend Antimicrobials 2005.The award will be announced during theASA Meeting’s Dinner.

ANTIMICROBIALS 2004PROGRAM

Novotel Brighton-Le-Sands, Sydney Thursday 26th - 28th February, 2004

11ASA Newsletter, December 2003

PRELIMINARY PROGRAM

Antimicrobials 2004 SYDNEY 26 - 28 FEBRUARY 2004 Novotel, Brighton Beach, Sydney

THURSDAY FRIDAY SATURDAY

0900 - 1000 Plenary 1 Plenary 2 Plenary 3

New Drug Development Antifungal Developments Laboratory and Clinical Aspects of

Steve Projan John Perfect MDR TB in High-and-Low Prevalence Settings

Ivan Bastian

1000 - 1030 MORNING TEA

1030 - 1200 Symposium 1 Symposium 3 Symposium 5

All Things Fungal Genetics of Resistance 101 Who Benefits from Controlling Resistance

Current Perspectives on Fungal Infections Basic Principles (Ruth Hall) Lessons from the Fields (Steve Powles)(Tania Sorrell) Macrolide Resistance (Julian Rood) Software Solutions (James Black)What we know about Antifungal Therapies

Efflux Pumps (Melissa Brown) The Industry? (Steve Projan)(John Perfect)

Antifungal Prophylaxis - When and with What?

(Ken Bradstock)

1200 - 1400 LUNCH LUNCH LUNCH POSTERS (Authors in Attendance) Pfizer Pharmaceuticals Symposium POSTERS

POSTERS

1400 - 1530 Proffered Papers 1 Proffered Papers 2 ESBL Workshop

(six speakers) (Six speakers) Introduction: The Expanding Spectrum of the

Extended Spectrums (Jan Bell)

Clinical Impact of ESBLs (John Turnidge)

1530 - 1600 AFTERNOON TEA

1600 - 1730 Symposium 2 Symposium 4 ESBL Workshop (cont)

Therapy of Emerging Diseases State of the Art: Management of Phenotypic Tests (Jan Bell)

Anthrax (Richard Lawrence) Staphylococcal Infections - Confirmatory/Molecular Tests (Phil Giffard)

SARS and other Respiratory Viruses The ASA Guidelines Question Time

(John Mills) Introduction (Iain Gosbell)

Four Fatal Fungi - Bacteraemia (David Mitchell)

Scedosporium/Fusarium/Penicillium/ Implant/Skin Soft Tissue (Sally Roberts)

Zygomycetes (John Perfect) Pharmacokinetic/Pharmacodynamic

Considerations (Craig Rayner)

1730 - 1830 AGM

1830 - 1930 Welcome Reception 1900 - 2330

Conference Dinner

12 ASA Newsletter, December 2003