ANTIMICROBIAL AGENTS AND CHEMOTHERAPY, Nov. 1995, p. 2516–2519 Vol. 39, No.

11
0066-4804/95/$04.0010
Copyright q 1995, American Society for Microbiology

Resistance to Ceftriaxone and Other b-Lactams in Bacteria

Isolated in the Community
F. W. GOLDSTEIN,1* Y. PÉAN,2 J. GERTNER,2 AND THE VIGIL’ROC STUDY GROUP†
Laboratoire de Microbiologie Médicale, Fondation Hôpital Saint-Joseph, 75674 Paris Cédex 14,1 and
Laboratoire de Bactériologie, Hôpital International de l’Université de Paris, 75014 Paris,2 France
Received 25 January 1995/Returned for modification 5 April 1995/Accepted 25 August 1995

The incidence of bacterial species and their susceptibilities to ceftriaxone and other b-lactams from patients
with community-acquired infections were evaluated in a multicenter study over a 4-month period. A total of
5,768 bacterial isolates were classified according to whether the patient had been previously hospitalized or had
received antibiotic treatment. The most relevant findings were the presence of 33.8% penicillin-resistant

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Streptococcus pneumoniae isolates, 25% b-lactamase-producing Haemophilus influenzae isolates, and 36.4%
amoxicillin-resistant Escherichia coli isolates. All of these bacteria were fully susceptible to ceftriaxone. Nos-
ocomial multiply-resistant bacteria, and particularly methicillin-resistant S. aureus, were found, as expected,
at a higher frequency among previously hospitalized patients. However, such bacteria may be present in the
community; their incidence is high in particular clinical settings, and such bacteria should be considered when
one is choosing a first-line therapy for the treatment of severe infections.

Bacteria responsible for community-acquired infections the linkage between previous antibiotic usage, hospitalization,
have developed resistance to many antibacterial agents, par- and bacterial resistance.
ticularly oral b-lactams, emphasizing the need for more effec-
tive compounds. For this reason, ceftriaxone, an extended- MATERIALS AND METHODS
spectrum cephalosporin, was released in the community in
1988 for the treatment of severe infections or infections caused Collection of bacterial strains. All nonduplicate gram-positive and gram-
by multiply-resistant strains. negative bacteria isolated from clinical specimens during February through April
Several reports have documented the incidence of resistance 1993 by the 25 participating centers were included in the investigation. The
bacteria were identified in each center according to usual procedures (8). Only
to extended-spectrum cephalosporins in bacteria isolated from specimens yielding a significant number of a recognized pathogen were consid-
patients with nosocomial infections (2–7, 9, 10). The aim of the ered for the study.
study described here was to delineate the bacteria responsible Susceptibility testing. All centers performed disk susceptibility testing as fol-
for community-acquired infections, determine their suscepti- lows. For staphylococci, penicillin G, oxacillin, amoxicillin-clavulanic acid, and
ceftriaxone were tested on Mueller-Hinton agar at 308C. For members of the
bilities to ceftriaxone and other selected b-lactams, and study family Enterobacteriaceae, amoxicillin, amoxicillin-clavulanic acid, ticarcillin,
cephalothin, cefuroxime, cefoxitin, cefixime, cefpodoxime, ceftriaxone, ceftazi-
dime, and aztreonam were tested on Mueller-Hinton agar at 378C.
Extended-spectrum b-lactamases were detected by the double disk diffusion
method (9), which demonstrated a synergistic effect between the association of
* Corresponding author. Mailing address: Laboratoire de Microbi- amoxicillin-clavulanic acid and either ceftriaxone, ceftazidime, or aztreonam.
ologie Médical, Fondation Hôpital Saint-Joseph, 185 rue Raymond For streptococci, amoxicillin, cephalothin, cefpodoxime, cefixime, and ceftri-
Losserand, 75674 Paris Cédex 14, France. axone were tested on Mueller-Hinton agar supplemented with 5% horse blood
† The members of the Vigil’Roc Study Group include (all locations (Diagnostics Pasteur). Oxacillin was included for the detection of penicillin-
are in France) P. Scaviner (Laboratoire d’Analyses Médicale [LAM] resistant Streptococcus pneumoniae. The MICs of penicillin G and ceftriaxone
were determined on the same media for all of the strains with an inhibition zone
Scaviner, 29287-Brest); L. Deshayes-Lartigue (Laboratoire Central de
of ,25 mm on plates with oxacillin disks. The inoculum (103 to 104 CFU per
Biologie Médicale [LCBM], 86004-Poitiers); J. Moussion and J. Mous- spot) was deposited with a Steers device. Plates were incubated for 18 h in air.
sion (Laboratoire d’Analyses et de Biologie Médicale [LABM], 31200- For Haemophilus spp., Neisseria spp., and Branhamella spp., amoxicillin,
Toulouse); P. Corteel (LAM Corteel et Luitaud, 78000-Versailles); S. amoxicillin-clavulanic acid, cephalothin, cefixime, and ceftriaxone were tested on
Grelat et J. M. Sarzier (LAMB Hubac et Loubat, 26240-Saint-Vallier); chocolate agar polyvitex (IsoVitaleX; Diagnostics Pasteur, Marnes-la-Coquette,
J. P. Lepargneur (LAM des Carmes, 31000-Toulouse); P. Masson France). Incubation was for 18 to 24 h at 378C in air for all bacteria except
(Laboratoire Evic-Ceba, 33295-Blanquefort); P. Picard (Laboratoire Neisseria gonorrhoeae (which was incubated under CO2). b-Lactamase produc-
Picard-Bitoum, 93200-Saint-Denis); J. M. Kunzelmann and B. Mas- tion was detected with nitrocefin disks (cefinase; bioMérieux, Lyon, France). The
disks and agar were from Diagnostics Pasteur. Three reference strains were
soubre (LAM du Progrès, 42000-Saint-Etienne); V. Napoly (LAM
d’Eylau, 75016 Paris); I. Fermon, and E. Lefebvre (LB Lerche-Fer-
mon, 62100-Calais); J. L. Mounard (LAM Mounard-Baurepaire,
63400-Chamalières); U. Gojon (LAM Gojon, 74000-Annecy); P. Blan- TABLE 1. Origins of the clinical specimens
chon, J. Masset, J. Muraine, and J. C. Grignon (LAM, 86000-Poitiers);
R. Viard-Gaudin and G. Forestier (Laboratoire Viard-Gaudin, 38000- Origin No. of isolates % of isolates
Grenoble); X. Germain (LAM Brignon-Thomas, 54000-Nancy); P. Urine 2,909 58
Laudat (Laboratoire Arnaud, 37010-Tours); V. Schuh and A. M. Genital 738 14.3
Christophe (LAM, 68000-Strasbourg); B. Balmayer and J. Sestilange Ear, eye, throat 254 5
(Laboratoire Sestilange, 72000-Le Mans); F. Lahiani (Laboratoire Pus 181 3.5
Galliéni, 93110-Rosny-sous-Bois); J. C. Valentin (LAM, 74000-An- Stool 148 2.9
necy); J. Y. Bert (LAM, 34000-Montpellier); P. Diesnis (LAM Respiratory tract 121 2.3
Ronchese-Diesnis, 06000-Nice); P. Florange and C. Brosset (LAM Others 722 14
Florange, 74240-Gaillard); A. Nahmani (LAM Nahmani, 92700-Co- Total 5,156 100
lombes); and C. Quercia and J. L. Français (LAM, 92700-Colombes).

2516
VOL. 39, 1995 CEFTRIAXONE AND b-LACTAM RESISTANCE 2517

TABLE 2. Microorganisms isolated receive any antibiotic, 874 patients received at least one anti-
No. of isolates from patients with the
biotic, 709 patients had been hospitalized or had a contact with
following characteristics: Medical Center during the last 6 months, and no reliable data
Microorganism could be obtained for 1,524 patients.
(no. isolated) No exposure Prior exposure
to antibiotics to antibiotics Unknown
Strains collected. During the 4-month study period, 5,768
or hospitals or hospitals bacteria were collected. A total of 2,238 (38.8%) strains were
isolated from patients not previously hospitalized or treated
Enterobacteriaceae (2,952) 1,061 987 904 with an antibiotic, 946 (16.4%) strains were from patients who
Streptococci (715) 310 189 216
Staphylococcus aureus (448) 184 141 123
had received antibiotics during the previous 3 months, and 748
Haemophilus spp.a (152) 33 40 79 (13%) strains were from patients hospitalized during the pre-
CNSb (120) 52 31 37 vious 6 months. No data could be obtained for 1,836 (31.8%)
Streptococcus pneumoniae (93) 30 33 30 strains.
Origins of the clinical specimens. Strains from specimens
Yeasts (250) 112 65 73 from patients with urinary tract and genital infections repre-
Enterococci (224) 82 67 75 sented 58 and 14.3% of the isolates, respectively, as presented
Mycoplasmas (174) 73 51 50
in Table 1. Table 2 lists the microorganisms isolated from these
Pseudomonas spp.c (132)

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22 53 57
Gardnerella vaginalis (120) 60 25 35
Others (388) 219 12 157
Total (5,768) 2,238 1,694 1,836
a
A total of 112 H. influenzae isolates.
b
CNS, coagulase-negative staphylococci.
c
A total of 125 P. aeruginosa isolates.
included for quality control: Escherichia coli ATCC 25922 (a susceptible strain),
Klebsiella pneumoniae CF 104 (a TEM-3-producing strain) (9), and E. coli RM
3346 (a high-level cephalosporinase producer from the St. Joseph Hospital,
Paris, France) (4).
The antibiotics tested are available either in the community (amoxicillin,
amoxicillin-clavulanic acid, cefuroxime, cefixime, cefpodoxime, ceftriaxone) or
only in hospitals (ceftazidime, aztreonam, ticarcillin, cefoxitin). Susceptibility
breakpoints, according to the French Antibiogram Committee (1), were as fol-
lows: amoxicillin and amoxicillin-clavulanic acid, ¶4 mg/ml; ticarcillin, ¶16 mg/
ml; cefoxitin, ¶8 mg/ml; cefuroxime axetil, cefpodoxime, and cefixime, ¶1 mg/ml;
ceftriaxone, cefazidime, and aztreonam, ¶4 mg/ml. The MICs of penicillin G,
amoxicillin, and ceftriaxone for S. pneumoniae were determined on Mueller-
Hinton agar supplemented with 5% horse blood with an inoculum of 104 CFU
per spot and after 18 h of incubation in air.
Storage of the strains. All ceftriaxone-resistant bacteria, oxacillin-resistant
staphylococci, streptococci, Neisseria spp., Branhamella spp., and Haemophilus
spp. were sent to the St. Joseph Hospital for control purposes. About 20% of the
susceptible staphylococci and members of the family Enterobacteriaceae, selected
at random, were also sent for comparative purposes.
Storage and analysis of the data. All patients were asked whether they had
received any antibiotic during the previous 3 months and whether they stayed in,
consulted for, or worked in a hospital during the previous 6 months. All infor-
mation concerning treatment and strains (origin, species, inhibition zone diam-
eters) were collected on a notebook computer (Psion Serie III; Aware, Paris,
France) by each participating center. The data were electronically transferred at
the end of the study to a central database (Paradox 3-0; Borland, Vélizy, France).
RESULTS
Patients. A total of 5,156 patients entered the study; 2,049
(39.7%) patients were not previously hospitalized and did not
specimens. As expected, Pseudomonas, Enterobacter, Citro-
bacter, Serratia, and indole-positive Proteus isolates species
were isolated at an increased frequency from previously hos-
pitalized patients.
The following microorganisms, which were not included in
the antibacterial spectrum of ceftriaxone, were not studied
further: enterococci, Pseudomonas spp., mycoplasmas, Gard-
nerella spp., and yeasts.
The antibiotics received by the 874 patients were b-lactams
(46.9%), fluoroquinolones (20.5%), macrolides (10.2%), co-
trimoxazole (7.9%), tetracyclines (3.7%), and others (9.5%).
Penicillins (including inhibitor combinations) represented 72%
of the b-lactams.
Susceptibility studies: results of quality control. Consider-
ing the results for the three control strains and the 11 antibi-
otics tested, 66% of the 33 antibiotic-control strain combina-
tions gave standard deviations of ¶3.0 mm and 94% gave
standard deviations of ¶4.0 mm.
(i) Members of the family Enterobacteriaceae. The global
activities of the 10 b-lactam antibiotics against all isolates are
presented in Table 3. Resistance to amoxicillin reached 36.4%
in E. coli. Only 44.2% of the amoxicillin-resistant strains were
fully susceptible to the formulation amoxicillin-clavulanic acid.
K. pneumoniae isolates producing extended-spectrum b-lac-
tamases (five strains; inactivating ceftriaxone) were isolated
from patients staying in a nursing home.
All of the ceftriaxone-resistant strains among bacteria pro-
ducing an inducible cephalosporinase (Citrobacter, Enter-
obacter, and Serratia spp. and indole-positive Proteus spp.) were
from recently hospitalized patients.
(ii) Staphylococci. Methicillin resistance was detected in 54
of 448 Staphylococcus aureus strains (12%), with a significantly
(P , 0.001) higher frequency among strains from previously
hospitalized patients. Twenty strains (5.9%) were from pa-
tients who were never hospitalized or who never had contact

TABLE 3. Global activities of 10 b-lactam antibiotics against members of the family Enterobacteriaceae

Total no. % Resistanta

Species
of isolates Amx Tic Amc Cxm Cfm Cpd Fox Atm Caz Cro

Escherichia coli 2,249 36.4b 35.5b 10.3b 0.9 0.9 0.9 0.9 0 0 0
Klebsiella pneumoniae 107 92.5 88.9 8.4 4.7 4.7 4.7 2.8 4.7 4.7 4.7
Proteus mirabilis 249 16.1 10.8 2.8 2.4 0.4 0.4 0.4 0 0 0
Indole-positive Proteus spp. 22 86.4 50 45.5 31.8 9.1 13.6 9.1 9.1 4.5 4.5
Enterobacter, Serratia, and Citrobacter spp. 28 89.8 45.4 67 52.3 41 41 62.5 9 9 9
a
Abbreviations: Amx, amoxicillin; Tic, ticarcillin; Amc, amoxicillin-clavulanic acid; Cxm, cefuroxime; Cfm, cefixime; Cpd, cefpodoxime; Fox, cefoxitin; Atm,
aztreonam; Caz, ceftazidime; Cro, ceftriaxone.
b
Significantly higher percentage of resistance among isolates from patients with prior exposure to antibiotics or hospitals.
2518 GOLDSTEIN ET AL.
TABLE 4. MICs of penicillin G, amoxicillin, and ceftriaxone for the S. pneumoniae isolates tested
Group Antibiotic
,0.01
Penicillin susceptible (n 5 60) Penicillin G 36
Amoxicillin 50
Ceftriaxone 49
Penicillin resistant (n 5 31) Penicillin G
Amoxicillin
Ceftriaxone
with a hospital; 31.5% of the strains from patients not previ-
ously treated or hospitalized were susceptible to penicillin G,
in contrast to 21.9% of strains from patients who received an
antibiotic and 10.1% of strains from previously hospitalized
patients.
(iii) S. pneumoniae. Of the 91 S. pneumoniae strains tested,
33.8% were resistant to penicillin (MICs, Ä0.1 mg/ml); 50% of
these penicillin-resistant strains had high-level resistance
(MICs, .1 mg/ml). The amoxicillin MIC was #2 mg/ml for all
of the penicillin-resistant strains, and the ceftriaxone MIC was
¶1 mg/ml (Table 4). The MICs of all of the other b-lactams
were higher (data not shown). The MICs of cefuroxime, cef-
podoxime, and cefixime were greater than the highest level
achievable in serum for about 23, 56, and 76% of the penicillin-
resistant S. pneumoniae strains, respectively. The prevalence of
penicillin resistance was identical for isolates from patients
previously treated and/or hospitalized.
(iv) Other streptococci. All of the streptococcal strains were
susceptible to the b-lactams tested.
(vi) Haemophilus influenzae. Among the 112 H. influenzae
isolates, 25% were b-lactamase producers. b-Lactamase-pro-
ducing strains were isolated at a significantly higher frequency
(P , 0.001) from patients who were previously hospitalized or
who had previously received an antibiotic (16 of 39) than from
the other patients (2 of 32). No data were obtained for 41
strains. All of the H. influenzae strains were fully susceptible to
amoxicillin-clavulanic acid, aztreonam, and all of the cephalo-
sporins tested.
DISCUSSION
The study described here is the first study performed on a
large scale in the community in France to differentiate bacte-
rial species and antibiotic susceptibility according to previous
hospitalization or antibiotic treatment. It should be clear, how-
ever, that these data do not represent the true prevalence of
community-acquired infections but only those infections in
which the clinician needed the help of the laboratory, such as
severe infections and treatment failures.
About 14% of the specimens were obtained from patients
previously hospitalized and 24% were from patients who had
received an antibiotic during the previous 3 months; these two
aspects must be taken into account when considering empiric
antibiotic treatment for community-acquired infections. As ex-
pected, methicillin-resistant S. aureus, Enterobacter spp., Citro-
bacter spp., and Pseudomonas aeruginosa were isolated more
frequently from patients who had been hospitalized during the
last 6 months or from elderly patients staying in nursing homes.
This was particularly obvious when considering resistance to
various b-lactams, including ceftriaxone; all of the ceftriaxone-
resistant strains, including K. pneumoniae producing extended-
spectrum b-lactamases, were isolated from such patients.
ANTIMICROB. AGENTS CHEMOTHER.
No. of isolates for which MIC (mg/ml) was:
0.03 0.06 0.1 0.25 0.5 1 2
21 3
10
11
1 3 1 10 16
1 3 2 1 1 18 4
5 1 1 23
Members of the family Enterobacteriaceae isolated from pre-
viously hospitalized patients or patients treated with b-lactams
during the previous 3 months were significantly more resistant
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to aminopenicillins and narrow-spectrum cephalosporins (data
not shown). The most striking finding was the presence of
methicillin-resistant S. aureus isolates in 20 (5.9%) patients
who had not been previously hospitalized. Because methicillin-
resistant S. aureus strains represent 40 to 50% of all S. aureus
isolates in many hospitals, long-term carriage of such strains
might be responsible for the transmission of methicillin-resis-
tant S. aureus from one patient to another one in the commu-
nity.
The relatively high incidence of penicillin-resistant S. pneu-
moniae and b-lactamase-producing H. influenzae is another
important finding. b-Lactams with poor activity against these
strains, such as some oral cephalosporins for S. pneumoniae or
amoxicillin for H. influenzae, should no longer be considered
first-line therapeutic agents.
What are the conclusions of this study? Multiply-resistant
nosocomial bacteria were found in the community; this might
be due to the fact that patients carry resistant strains acquired
in the hospital, because of the spread of these strains to other
patients, or because of the selection of resistant bacteria under
antibiotic treatment.
Resistance to b-lactams might be quite high in these partic-
ular clinical settings and should be taken into account for the
treatment of severe infections.
Because of the occurrence of more than 33% penicillin-
resistant S. pneumoniae isolates, 25% b-lactamase-producing
H. influenzae isolates, and 36% amoxicillin-resistant E. coli
isolates, community-acquired bacteria should not be consid-
ered fully susceptible to all b-lactams.
ACKNOWLEDGMENTS
This study was supported by Produits Roche, Neuilly/Seine, France.
We thank Marie-Françoise Emirian and Marie-Louise Guerrier for
technical assistance and Monique Boda for secretarial assistance.
REFERENCES
1. Acar, J., E. Bergogne-Bérézin, J. M. Brogard, Y. Chabbert, R. Cluzel, P.
Courvalin, H. Dabernat, H. Drugeon, L. Dubreuil, J. Duval, J. P. Flandrois,
J. Fleurette, F. W. Goldstein, M. Meyran, C. Morel, A. Philippon, J. Sirot,
C. J. Soussy, A. Thabaut, and M. Véron. 1993. Communiqué 1993 du Comité
de l’Antibiogramme de la Société Française de Microbiologie. Pathol. Biol.
41:741–748.
2. Arlet, G., M. J. Sanson-le Pors, M. Rouveau, G. Fournier, O. Marie, B.
Schlemmer, and A. Philippon. 1990. Outbreak of nosocomial infections due
to Klebsiella pneumoniae producing SHV-4 beta-lactamase. Eur. J. Clin.
Microbiol. Infect. Dis. 9:797–803.
3. Brun-Buisson, C., P. Legrand, A. Philippon, F. Montravers, M. Ansquer,
and J. Duval. 1987. Transferable enzymatic resistance to third-generation
cephalosporins during nosocomial outbreak of multiresistant Klebsiella pneu-
moniae. Lancet ii:302–306.
4. Goldstein, F. W., Y. Péan, A. Rosato, J. Gertner, L. Gutmann, and the
VOL. 39, 1995
Vigil’Roc Study Group. 1993. Characterization of ceftriaxone-resistant
Enterobacteriaceae: a multicentre study in 26 French hospitals. J. Anti-
microb. Chemother. 32:595–603.
5. Jacoby, G. A., and A. A. Medeiros. 1991. More extended-spectrum b-lacta-
mases. Antimicrob. Agents Chemother. 35:1697–1704.
6. Jarlier, V., M.-H. Nicolas, G. Fournier, and A. Philippon. 1988. Extended-
spectrum b-lactamases conferring transferable resistance to newer b-lactam
agents in Enterobacteriaceae: hospital prevalence and susceptibility pat-
terns. Rev. Infect. Dis. 10:867–878.
7. Kitzis, M. D., D. Billot-Klein, F. W. Goldstein, R. Williamson, G. Tran Van
Nhieu, J. Carlet, J. F. Acar, and L. Gutmann. 1988. Dissemination of the
novel plasmid-mediated b-lactamase CTX-1, which confers resistance to
broad-spectrum cephalosporins, and its inhibition by b-lactamase inhibitors.
Antimicrob. Agents Chemother. 32:9–14.
CEFTRIAXONE AND b-LACTAM RESISTANCE 2519
8. Lennette, E. H., A. Balows, W. J. Hausler, Jr., and J. P. Truant (ed.). 1980.
Manual of clinical microbiology, 3rd ed. American Society for Microbiology,
Washington, D.C.
9. Sirot, D., F. W. Goldstein, C. J. Soussy, A. L. Courtieu, M. O. Husson, J.
Lemozy, M. Meyran, C. Morel, R. Perez, C. Quentin-Noury, M. E. Reverdy,
J. M. Scheftel, M. Rosembaum, and Y. Rezvani. 1992. Resistance to cefo-
taxime and seven other b-lactams in members of the family Enterobacteri-
aceae: a 3-year survey in France. Antimicrob. Agents Chemother. 36:1677–
1681.
10. Sirot, D., J. Sirot, R. Labia, A. Morand, P. Courvalin, A. Darfeuille-
Michaud, R. Perroux, and R. Cluzel. 1987. Transferable resistance to third-
generation cephalosporins in clinical isolates of Klebsiella pneumoniae: iden-
tification of CTX-1, a novel b-lactamase. J. Antimicrob. Chemother. 20:323–
334.
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