This material is supported in part by unrestricted educational grants from: Abbott, Bayer HealthCare, Merck Frosst, Roche Diagnostics, and Wyeth Inc.

Transcription

1 Division of Medical Microbiology Department of Laboratory Medicine and Pathology University of Alberta Hospital and Stollery Children's Hospital Antibiogram 2006 This material is supported in part by unrestricted educational grants from: Abbott, Bayer HealthCare, Merck Frosst, Roche Diagnostics, and Wyeth Inc.

2 University of Alberta Hospitals Antibiogram 2006 Table of Contents Page Introduction... 2 Highlights: University of Alberta Antibiogram... 3 Organism Characteristics. 5 Gram-positive Cocci. 5 Gram-negative Bacilli. 5 Antibiotics/Antifungals and the Abbreviations Used In the Tables... 7 Aerobic Glucose Fermenting Gram-Negative Bacilli Citrobacter koseri.. 8 Citrobacter freundii comples 8 Enterobacter aerogenes. 9 Enterobacter cloacae 9 Escherichia coli 10 Klebsiella species.. 11 Morganella morganii 12 Proteus mirabilis.. 12 Serratia marcescens.. 12 Aerobic Glucose Non-fermenting Gram-Negative Bacilli Pseudomonas aeruginosa. 13 Burkholderia cepacia 14 Stenotrophomonas maltophilia 14 Acinetobacter baumanii complex 15 Fastidious Aerobic Gram-Negative Bacilli Haemophilus influenzae Aerobic Gram-positive Cocci Enterococcus species 16 Staphylococcus aureus. 17 Staphylococcus aureus, MRSA only 17 Staphylococcus lugdunensis Staphylococcus species, coagulase-negative, All Specimen Sources. 18 Streptococcus pneumoniae Anaerobic Organisms Actinomyces species.. 20 Bacteroides species fragilis group 20 Clostridium perfringens Candida species. 21 Page 1 of 21

3 Introduction The antibiotic susceptibility material presented here includes primary data for the year 2006 for the University of Alberta Hospital, the Stollery Children's Hospital (UAH site) and their clinics and the WWC Cancer Institute. Susceptibility results represent clinical isolates of medically relevant pathogens. Identical organisms isolated from the same patient within a twoweek period are excluded from analysis. Antibiogram tables include: - University of Alberta and Stollery Children's Hospitals and WWC patients (inpatient and outpatient) presented as total numbers, and according to age (adults > 17 years) - UAH 3C3/3C4 (General Systems Intensive Care units) - UAH 3C2 (Burn Unit) - WWC patients - For Pseudomonas aeruginosa, Burkholderia cepacia and Stenotrophomonas maltophilia cystic fibrosis (CF) patients and non-cystic fibrosis patients are listed separately. - For individual tables, data is not presented for hospital locations when <10 organisms are isolated. Highlights and trends for specific organism antimicrobial combinations are presented following the Introduction. This antibiogram is published on an annual basis to provide physicians, pharmacists, and other health care professionals with antimicrobial susceptibility and resistance information for the patients of the University of Alberta Hospital, Stollery Children s Centre, and other referral centres to the hospital. The production of this information is made possible in part by unrestricted education grants from Abbott, Bayer HealthCare, Roche Diagnostics, Merck Frosst, and Wyeth Inc. The efforts of Linda Rosmus (Technologist II) and the staff in Medical Microbiology in compiling the data are gratefully acknowledged. Feedback on the presentation of this information and on requests for additional information in subsequent years should be made to Dr. J. Fuller at The antibiogram may also be accessed via the Department of Laboratory Medicine and Pathology website ( Jeff Fuller, PhD, FCCM, ABMM Medical Microbiologist Division of Medical Microbiology University of Alberta Hospital Edmonton, Alberta. Page 2 of 21

4 Highlights: University of Alberta Hospitals Antibiogram 2006 Acinetobacter baumannii complex: Strains resistant to multiple antibiotics, including carbapenems, were isolated from seriously infected patients in Colistin susceptibility testing is now available for these strains. Candida: Susceptibility results for Candida species are represented by sterile site isolates from UAH patients and Dynacare Kasper Medical Laboratories (DKML). C. albicans and C. glabrata comprise 80% of all candidal isolates (183) tested in 2006 (no change from 2005). Fluconazole resistance to C. glabrata (11%) remains comparable to global resistance rates using North American standards. However, European susceptibility standards would indicate that C. glabrata resistance is >70%. As such, it is recommended that fluconazole therapy for serious C. glabrata infections be directed cautiously and in consultation with Medical Microbiology and Infectious Disease services. Enterobacteriaceae: AmpC beta-lactamase resistance was indicated for 20 30% of Citrobacter and Enterobacter species (unchanged from 2005), which confers resistance to all beta-lactam antibiotics except for imipenem and meropenem. ESBL-positive Escherichia coli and Klebsiella species increased to ~2.5% (<1% in 2005). The ESBL phenotype confers resistance to all third-generation cephalosporins, and in many cases, beta-lactam/beta-lactamase inhibitor compounds (ie. piperacillin-tazobactam). A significant proportion of ESBL-positive isolates are also resistant to quinolones, aminoglycosides, and TMP-SMX. Enterococci: 20 clinical isolates of vancomycin-resistant enterococci (VRE) were identified in Both VanA and VanB phenotypes were identified during a nosocomial outbreak that was ultimately controlled. Pseudomonas aeruginosa: Quinolones: 29% of strains are resistant to ciprofloxacin. Carbapenems: 19% of total strains are resistant to imipenem. In CF patients imipenem and meropenem resistance is 22% and 14%, respectively. These rates reflect all CF patient isolates, which is a change from 2005 reporting, and is more representative of resistance in this patient population. Ureidopenicillins: 14% and 9% of strains are resistant to piperacillin and piperacillin-tazobactam, respectively. 19% of non-cf and 52% of CF patients are resistant to ticarcillin-clavulanate. Ceftazidime: 15% of total isolates are resistant. In CF patients ceftazidime resistance dropped from 30% in 2003 to 14% in 2004 and has not changed significantly since then. Aminoglycosides: In non-cf patients gentamicin resistance is 12%, while tobramycin and amikacin resistance is ~5%. Gentamicin, tobramycin, and amikacin resistance in CF patients is 57%, 28%, and 51%, respectively. Page 3 of 21

5 S. aureus: The overall beta-lactam resistance of nosocomial S. aureus continues to increase due to the dramatic increase of methicillin-resistant S. aureus (MRSA); 4%, 7%, and 18% for 2004, 2005, and 2006, respectively. A total of 307 clinical MRSA isolates are included in the S. aureus antibiogram. MRSA is also largely resistant to quinolones, macrolides, clindamycin, and TMP/SMX. Stenotrophomonas maltophilia: Trimethoprim-sulfamethoxazole: Overall resistance is 31%, which is relatively unchanged from 2005 (27%). Resistance in CF patients (31%) has increased from 2005 (19%) but these values are based on a small number of isolates (36% in 2004). Doxycycline: Overall resistance is 26%. Streptococcus pneumoniae: Macrolides: 14% of strains are erythromycin-resistant (unchanged from 2005). In 1999 the percentage of erythromycin-resistant strains was 4%. This is consistent with National surveillance data, which indicates dramatically increasing macrolide resistance. Penicillin: <1% of strains were fully resistant to penicillin. Intermediate resistance has steadily decreased from 15% in 2003 to 5% in This most likely reflects an improvement in the appropriate use of beta-lactams for pneumococcal infections. Third-generation cephalosporins: No resistance has been observed to ceftriaxone and cefotaxime (unchanged since 2003). Quinolones: 1% of strains are resistant to levofloxacin. 5-year analysis of all invasive S. pneumoniae in Alberta indicates a significant increase (>10%) in isolates with reduced levofloxacin susceptibility. This trend may be attributed, in part, to the development of bacterial mutations that can increase the likelihood of clinical failure for patients on levofloxacin therapy, and the 7-valent vaccine Page 4 of 21

6 Organism Characteristics: In the Microbiology Laboratory it may take a number of days before an isolated organism s identification is known. In order to prevent a delay in reporting results, a presumptive identification may be provided based on initial assay results. In some cases isolates are not fully identified either because they are unlikely to be clinically significant or because of organism/testing limitations. A comprehensive, but not entire, list of medically relevant pathogens is listed below and categorized based on initial Gram morphology and metabolic characteristics: Gram-positive Cocci (in order of decreasing prevalence) Gram-positive Cocci in Chains Gram-positive Cocci in Clumps Enterococcus species Staphylococcus species, coagulase-negative Streptococcus species, including: Staphylococcus aureus Streptococcus pyogenes (Group A) Micrococcus species Streptococcus agalactiae (Group B) Aerococcus species Streptococcus pneumoniae Rothia (Stomatococcus) mucilaginosus Viridans group streptococci Beta-hemolytic streptococci, Groups G and C Streptococcus anginosus group Abiotrophia/Granulicatellaa species (formerly nutritionally variant streptococci) Page 5 of 21

7 Lactose Fermenting Gram-negative Bacilli [LFGNB] Gram-negative Bacilli (in order of decreasing prevalence) Non-lactose Fermenting Gram-negative Bacilli [NLFGNB] Glucose Non-fermenting Gram-negative Bacilli [GNFGNB] Escherichia coli Serratia marcescens Pseudomonas aeruginosa Klebsiella pneumoniae Proteus mirabilis Pseudomonas species Klebsiella oxytoca Morganella morganii Stenotrophomonas maltophilia * Enterobacter cloacae Aeromonas species Acinetobacter baumanii complex * Citrobacter freundii complex Providencia rettgeri Acinetobacter lwoffii * Enterobacter aerogenes Providencia stuartii Achromobacter species Pantoeae agglomerans Salmonella species Burkholderia cepacia Citrobacter koseri Chryseobacterium species Comomonas species Alcaligenes species N.B. This table illustrates a general classification scheme used by microbiology laboratories for the preliminary reporting of gram-negative organisms, listed in order of decreasing prevalence at the UAH. This table should be used as a guide only and health-care providers need to recognize that metabolic variability within a species does occur. It is not uncommon for pathogens marked with an asterix (*) to be initially identified as NLFGNB. Page 6 of 21

8 ANTIBIOTICS/ANTIFUNGALS AND THE ABBREVIATIONS USED IN THE ANTIBIOGRAM TABLES ANTIBIOTIC ABBREVIATION ANTIBIOTIC ABBREVIATION ANTIFUNGAL ABBREVIATION Amikacin AMIK Gentamicin GENT Amoxicillin-clavulanic acid A/C Gentamicin Synergy GSYN Ampicillin AMP Imipenem IMP Aztreonam AZT Levofloxacin LEVO Cefazolin CZ Linezolid LINEZ Cefepime CFP Meropenem MERO Cefotaxime CTX Metronidazole METR Cefoxitin CFOX Minocycline MINO Ceftazidime CAZ Nitrofurantoin NITRO Cefuroxime CXM Norfloxacin NOR Ceftriaxone CRO Penicillin PEN Cephalothin CEPH Pipercillin PIP Chloramphenicol CHLO Piperacillin-tazobactam TAZO Clindamycin CLIN Rifampin RIF Cloxacillin CLOX Ticarcillin-clavulanic acid TIM Ciprofloxacin CIP Tobramycin TOB Doxycycline DOXY Trimethoprim-sulfamethoxazole T/S Erythromycin ERY Vancomycin VANC 5-Fluorocytosine Amphotericin B Caspofungin Fluconazole Itraconazole Ketoconazole Voriconazole 5FC AMB CASP FLUC ITRA KETO VORI Page 7 of 21

9 Citrobacter freundii complex All Specimen Sources AMIK A/C AMP CZ CEPH CXM CTX CRO CIP GENT IMP NITRO TAZO TOB T/S All Patients % SUS ALL Ages # SUS # TESTED % SUS Children < 17 years old # SUS # TESTED % SUS Adults >= 17 years old # SUS # TESTED % SUS UAH 3C3/3C4 # SUS # TESTED Citrobacter koseri All Specimen Sources AMIK A/C AMP CZ CEPH CXM CTX CRO CIP GENT IMP NITRO TAZO TOB T/S All Patients % SUS ALL Ages # SUS # TESTED % SUS Children < 17 years old # SUS Insufficient numbers tested # TESTED % SUS Adults >= 17 years old # SUS # TESTED AmpC beta-lactamase resistance was indicated for 20 30% of Citrobacter and Enterobacter species (unchanged from 2005), which confers resistance to all beta-lactam antibiotics except for imipenem and meropenem. Page 8 of 21

10 Enterobacter aerogenes All Specimen Sources AMIK A/C AMP CZ CEPH CXM CTX CRO CIP GENT IMP NITRO TAZO TOB T/S All Patients % SUS ALL Ages # SUS # TESTED % SUS Children < 17 years old # SUS Insufficient numbers tested # TESTED % SUS Adults >= 17 years old # SUS # TESTED Enterobacter cloacae All Specimen Sources AMIK A/C AMP CZ CEPH CXM CTX CRO CIP GENT IMP NITRO TAZO TOB T/S All Patients % SUS > ALL Ages # SUS # TESTED % SUS Children < 17 years old # SUS # TESTED % SUS > Adults >= 17 years old # SUS # TESTED % SUS UAH 3C3/3C4 # SUS # TESTED AmpC beta-lactamase resistance was indicated for 20 30% of Citrobacter and Enterobacter species (unchanged from 2005), which confers resistance to all beta-lactam antibiotics except for imipenem and meropenem. Page 9 of 21

11 Escherichia coli - Includes ESBL Producers All Specimen Sources AMIK A/C AMP CZ CEPH CXM CTX CRO CIP GENT IMP NITRO TAZO TOB T/S UAH Site In/Out Patients % SUS > & WWC patients # SUS ALL Ages # TESTED UAH Site In/Out Patients % SUS Children < 17 years old # SUS # TESTED UAH Site In/Out Patients % SUS > & WWC pts; # SUS Adults >= 17 years old # TESTED % SUS UAH 3C3/3C4 # SUS # TESTED % SUS UAH 3C2 # SUS # TESTED % SUS WWC # SUS # TESTED Escherichia coli - ESBL Producing Isolates only All Specimen Sources AMIK A/C AMP CZ CEPH CXM CTX CRO CIP GENT IMP NITRO TAZO TOB T/S UAH Site In/Out Patients % SUS & WWC patients # SUS ALL Ages # TESTED UAH Site In/Out Patients % SUS Children < 17 years old # SUS # TESTED UAH Site In/Out Patients % SUS & WWC pts; # SUS Adults >= 17 years old # TESTED Antibiogram for Escherichia coli includes 41 patients with an ESBL (Extended-spectrum Beta-lacatamase producer) - 6 patients were children <17 years old patients were adults >=17 years old. ESBL-positive Escherichia coli and Klebsiella species increased to ~2.5% (<1% in 2005). The ESBL phenotype confers resistance to all third-generation cephalosporins, and in many cases, beta-lactam/beta-lactamase inhibitor compounds (ie. piperacillin-tazobactam). A significant proportion of ESBL-positive isolates are also resistant to quinolones, aminoglycosides, and TMP-SMX. Page 10 of 21

12 Klebsiella species - Includes ESBL Producers All Specimen Sources AMIK A/C AMP CZ CEPH CXM CTX CRO CIP GENT IMP NITRO TAZO TOB T/S UAH Site In/Out Patients % SUS & WWC patients # SUS ALL Ages # TESTED UAH Site In/Out Patients % SUS Children < 17 years old # SUS # TESTED UAH Site In/Out Patients % SUS & WWC pts; # SUS Adults >= 17 years old # TESTED % SUS UAH 3C3/3C4 # SUS # TESTED % SUS UAH 3C2 # SUS # TESTED % SUS WWC # SUS # TESTED Klebsiella species - ESBL Producing Isolates only All Specimen Sources AMIK A/C AMP CZ CEPH CXM CTX CRO CIP GENT IMP NITRO TAZO TOB T/S UAH Site In/Out Patients % SUS & WWC patients # SUS ALL Ages # TESTED UAH Site In/Out Patients % SUS Children < 17 years old # SUS # TESTED UAH Site In/Out Patients % SUS & WWC pts; # SUS Adults >= 17 years old # TESTED Antibiogram for Klebsiella species includes 14 patients with an ESBL (Extended-spectrum Beta-lacatamase producer) - 4 patients were children <17 years old patients were adults >=17 years old. ESBL-positive Escherichia coli and Klebsiella species increased to ~2.5% (<1% in 2005). The ESBL phenotype confers resistance to all third-generation cephalosporins, and in many cases, beta-lactam/beta-lactamase inhibitor compounds (ie. piperacillin-tazobactam). A significant proportion of ESBL-positive isolates are also resistant to quinolones, aminoglycosides, and TMP-SMX.

13 Morganella morganii All Specimen Sources AMIK A/C AMP CZ CEPH CXM CTX CRO CIP GENT IMP NITRO TAZO TOB T/S UAH Site In/Out Patients % SUS & WWC patients # SUS ALL Ages # TESTED UAH Site In/Out Patients % SUS Children < 17 years old # SUS # TESTED UAH Site In/Out Patients % SUS & WWC pts; # SUS Adults >= 17 years old # TESTED Proteus mirabilis All Specimen Sources AMIK A/C AMP CZ CEPH CXM CTX CRO CIP GENT IMP NITRO TAZO TOB T/S UAH Site In/Out Patients % SUS & WWC patients # SUS ALL Ages # TESTED UAH Site In/Out Patients % SUS Children < 17 years old # SUS # TESTED UAH Site In/Out Patients % SUS & WWC pts; # SUS Adults >= 17 years old # TESTED Serratia marcescens All Specimen Sources AMIK A/C AMP CZ CEPH CXM CTX CRO CIP GENT IMP NITRO TAZO TOB T/S All Patients % SUS ALL Ages # SUS # TESTED % SUS Children < 17 years old # SUS # TESTED % SUS Adults >= 17 years old # SUS # TESTED % SUS UAH 3C3/3C4 # SUS # TESTED Page 12 of 21

14 Pseudomonas aeruginosa All Specimen Sources AMIK AZT CAZ CFP CIP GENT IMP MERO PIP TAZO TIM TOB All Patients % SUS ALL Ages # SUS # TESTED % SUS Children < 17 years old # SUS #TESTED % SUS Adults >= 17 years old # SUS #TESTED Non-CF Patients % SUS ALL Ages # SUS #TESTED % SUS Children < 17 years old # SUS #TESTED % SUS Adults >= 17 years old # SUS # TESTED CF Patients % SUS ALL Ages # SUS #TESTED % SUS Children < 17 years old # SUS #TESTED % SUS Adults >= 17 years old # SUS #TESTED % SUS UAH 3C3/3C4 # SUS #TESTED Quinolones: 29% of strains are resistant to ciprofloxacin. Carbapenems: 19% of total strains are resistant to imipenem. In CF patients imipenem and meropenem resistance is 22% and 14%, respectively. These rates reflect all CF patient isolates, which is a change from 2005 reporting, and is more representative of resistance in this patient population. Ureidopenicillins: 14% and 9% of strains are resistant to piperacillin and piperacillin-tazobactam, respectively. 19% of non-cf and 52% of CF patients are resistant to ticarcillinclavulanate. Ceftazidime: 15% of total isolates are resistant. In CF patients ceftazidime resistance dropped from 30% in 2003 to 14% in 2004 and has not changed significantly since then. Aminoglycosides: In non-cf patients gentamicin resistance is 12%, while tobramycin and amikacin resistance is ~5%. Gentamicin, tobramycin, and amikacin resistance in CF patients is 57%, 28%, and 51%, respectively. Page 13 of 21

15 Burkholderia cepacia complex All Specimen Sources CAZ CIP GENT IMP MERO TAZO T/S All isolates were CF Patients % SUS ALL Ages # SUS # TESTED Stenotrophomonas maltophilia All Specimen Sources DOXY TIM T/S All Patients % SUS ALL Ages # SUS # TESTED % SUS Children < 17 years old # SUS # TESTED % SUS Adults >= 17 years old # SUS # TESTED NON-CF Patients % SUS ALL Ages # SUS # TESTED % SUS Children < 17 years old # SUS # TESTED % SUS Adults >= 17 years old # SUS # TESTED CF Patients % SUS ALL Ages # SUS # TESTED % SUS Children < 17 years old # SUS # TESTED % SUS Adults >= 17 years old # SUS # TESTED % SUS UAH 3C3/3C4 # SUS # TESTED Trimethoprim-sulfamethoxazole: Overall resistance is 31%, which is relatively unchanged from 2005 (27%). Resistance in CF patients (31%) has increased from 2005 (19%) but these values are based on a small number of isolates (36% in 2004). Doxycycline: Overall resistance is 26%.

16 Acinetobacter baumanni complex All Specimen Sources A/C CAZ CIP GENT IMP TOB T/S % SUS ALL Ages # SUS # TESTED % SUS N/A Children < 17 years old # SUS # TESTED % SUS Adults >= 17 years old # SUS # TESTED Strains resistant to multiple antibiotics, including carbapenems, were isolated from seriously infected patients in Colistin susceptibility testing is now available for these strains. Haemophilus influenzae All Specimen Sources AMP A/C CTX CXM CRO CIP RIF SXT UAH Site In/Out Patients % SUS & WWC patients # SUS ALL Ages # TESTED UAH Site In/Out Patients % SUS Children < 17 years old # SUS # TESTED UAH Site In/Out Patients % SUS & WWC pts; # SUS Adults >= 17 years old # TESTED % SUS 67 N/A N/A UAH 3C3/3C4 # SUS # TESTED Page 15 of 21

17 Enterococcus species - Includes VRE isolates All Specimen Sources AMP CIP NITRO VANC GSYN UAH Site In/Out Patients % SUS & WWC patients # SUS ALL Ages # TESTED UAH Site In/Out Patients % SUS >99 91 Children < 17 years old # SUS # TESTED UAH Site In/Out Patients % SUS & WWC pts; # SUS Adults >= 17 years old # TESTED % SUS UAH 3C3/3C4 # SUS # TESTED % SUS UAH 3C2 # SUS # TESTED % SUS WWC Patients # SUS # TESTED Enterococcus species (VRE) All Specimen Sources AMP CIP LINEZ NITRO VANC GSYN UAH Site In/Out Patients % SUS & WWC patients # SUS Patients were all >= 17 years old # TESTED clinical isolates of vancomycin-resistant enterococci (VRE) were identified in Both VanA and VanB phenotypes were identified during a nosocomial outbreak that was ultimately controlled. Page 16 of 21

18 Staphylococcus aureus - Includes MRSA Isolates All Specimen Sources CZ CIP CLIN CLOX ERY GENT LEVO LINEZ NITRO PEN T/S VANC UAH Site In/Out Patients % SUS & WWC patients # SUS ALL Ages # TESTED UAH Site In/Out Patients % SUS Children < 17 years old # SUS # TESTED UAH Site In/Out Patients % SUS & WWC pts; # SUS Adults >= 17 years old # TESTED % SUS UAH 3C3/3C4 # SUS # TESTED % SUS UAH 3C2 # SUS # TESTED % SUS WWC # SUS # TESTED Staphylococcus aureus, MRSA Isolates only All Specimen Sources CZ CIP CLIN CLOX ERY GENT LEVO LINEZ NITRO PEN T/S VANC UAH Site In/Out Patients % SUS & WWC patients # SUS ALL Ages # TESTED UAH Site In/Out Patients % SUS Children < 17 years old # SUS # TESTED UAH Site In/Out Patients % SUS & WWC pts; # SUS Adults >= 17 years old # TESTED % SUS UAH 3C3/3C4 # SUS # TESTED The overall beta-lactam resistance of nosocomial S. aureus continues to increase due to the dramatic increase of methicillin-resistant S. aureus (MRSA); 4%, 7%, and 18% for 2004, 2005, and 2006, respectively. A total of 307 clinical MRSA isolates are included in the S. aureus antibiogram. MRSA is also largely resistant to quinolones, macrolides, clindamycin, and TMP/SMX. Page 17 of 21

19 Staphylococcus lugdunensis All Specimen Sources CZ CIP CLIN CLOX ERY GENT NITRO PEN T/S VANC UAH Site In/Out Patients % SUS & WWC patients # SUS ALL Ages # TESTED UAH Site In/Out Patients % SUS Children < 17 years old # SUS Insufficient numbers tested # TESTED UAH Site In/Out Patients % SUS & WWC pts; # SUS Adults >= 17 years old # TESTED Staphylococcus species, coagulase-negative All Specimen Sources CZ CIP CLIN CLOX ERY GENT NITRO PEN T/S VANC UAH Site In/Out Patients % SUS & WWC patients # SUS ALL Ages # TESTED UAH Site In/Out Patients % SUS Children < 17 years old # SUS # TESTED UAH Site In/Out Patients % SUS & WWC pts; # SUS Adults >= 17 years old # TESTED % SUS UAH 3C3/3C4 # SUS # TESTED Page 18 of 21

20 Streptococcus pneumoniae All Specimen Sources CXM CTX CRO CLIN ERY LEVO MERO PEN T/S VANC UAH Site In/Out Patients % SUS & WWC patients # SUS ALL Ages # TESTED UAH Site In/Out Patients % SUS Children < 17 years old # SUS # TESTED UAH Site In/Out Patients % SUS & WWC pts; # SUS Adults >= 17 years old # TESTED % SUS UAH 3C3/3C4 # SUS # TESTED Macrolides: 14% of strains are erythromycin-resistant (unchanged from 2005). In 1999 the percentage of erythromycin-resistant strains was 4%. This is consistent with National surveillance data, which indicates dramatically increasing macrolide resistance. Penicillin: <1% of strains were fully resistant to penicillin. Intermediate resistance has steadily decreased from 15% in 2003 to 5% in This most likely reflects an improvement in the appropriate use of beta-lactams for pneumococcal infections. Third-generation cephalosporins: No resistance has been observed to ceftriaxone and cefotaxime (unchanged since 2003). Quinolones: 1% of strains are resistant to levofloxacin. 5-year analysis of all invasive S. pneumoniae in Alberta indicates a significant increase (>10%) in isolates with reduced levofloxacin susceptibility. This trend may be attributed, in part, to the development of bacterial mutations that can increase the likelihood of clinical failure for patients on levofloxacin therapy, and the 7-valent vaccine. Page 19 of 21

21 Actinomyces species All Specimen Sources A/C CLIN IMP METR PEN UAH Site In/Out Patients % SUS & WWC patients # SUS ALL Ages # TESTED UAH Site In/Out Patients % SUS N/A Children < 17 years old # SUS # TESTED UAH Site In/Out Patients % SUS & WWC pts; # SUS Adults >= 17 years old # TESTED Bacteroides species, fragilis group All Specimen Sources A/C CLIN IMP METR PEN UAH Site In/Out Patients % SUS & WWC patients # SUS ALL Ages # TESTED UAH Site In/Out Patients % SUS Children < 17 years old # SUS Insufficient Numbers Tested (1) # TESTED UAH Site In/Out Patients % SUS & WWC pts; # SUS Adults >= 17 years old # TESTED Clostridium perfringens All Specimen Sources A/C CLIN IMP METR PEN UAH Site In/Out Patients % SUS & WWC patients # SUS ALL Ages # TESTED UAH Site In/Out Patients % SUS Children < 17 years old # SUS Insufficient Numbers Tested # TESTED UAH Site In/Out Patients % SUS & WWC pts; # SUS Adults >= 17 years old # TESTED Page 20 of 21

22 Candida albicans Sterile Site Sources AMB 5FC ITRA KETO FLUC VORI CASP UAH In/Out % Susc * * * and WWC and DKML MIC90** ALL Ages # Tested Candida glabrata Sterile Site Sources AMB 5FC ITRA KETO FLUC VORI CASP UAH In/Out % Susc * * * and WWC MIC90** ALL Ages # Tested Candida tropicalis Sterile Site Sources AMB 5FC ITRA KETO FLUC VORI CASP UAH In/Out % Susc * * * and WWC MIC90** ALL Ages # Tested Candida parapsilosis Sterile Site Sources AMB 5FC ITRA KETO FLUC VORI CASP UAH In/Out % Susc * * * and WWC MIC90** ALL Ages # Tested * Susceptible and resistant interpretations for Candida exist only for 5FC, ITRA, FLUC, and VORI ** MIC90 - minimum inhibitory concentration of 90% of isolates for each species Susceptibility results for Candida species are represented by sterile site isolates from UAH patients and Dynacare Kasper Medical Laboratories (DKML). C. albicans and C. glabrata comprise 80% of all candidal isolates (183) tested in 2006 (no change from 2005). Fluconazole resistance to C. glabrata (11%) remains comparable to global resistance rates using North American standards. However, European susceptibility standards would indicate that C. glabrata resistance is >70%. As such, it is recommended that fluconazole therapy for serious C. glabrata infections be directed cautiously and in consultation with Medical Microbiology and Infectious Disease services. Page 21 of 21