Standard microbiological CX-4945 manufacturer procedures were followed for the different clinical specimens [17]. Bacterial isolates were identified and the initial antibiotic susceptibility testing was done using the Vitek automated system (Biomerieux, Durham, North Carolina, U.S.A.). The appropriate antibiotic panel for each type of specimen was used as recommended by the manufacturer. The breakpoints for antibiotic susceptibility were determined according to the guidelines of the Clinical

and Laboratory Standards Institute (CLSI) [17]. The antibiotics tested included amoxicillin/clavulanic acid, ampicillin, carbenicillin, cefazolin, ceftriaxone, cefuroxime, cephalothin, ceftazidime, ciprofloxacin, gentamicin, levofloxacin, minocycline, nalidixic acid, nitrofurantoin, norfloxacin, ticarcillin/clavulanic acid, tobramycin, trimethoprim/sulfamethoxazole and meropenem. The MDR strains of K. pneumoniae were classified as organisms showing resistance to at least three classes of antibiotics including ceftazidime [18]. Resistance to ceftazidime identified by Vitek was used as the initial screening test for the presence of ESBL which was confirmed by E-test (AB Biodisk, Solna, Sweden) and double-disc synergy test which were performed according to the manufacturer’s

instructions and CLSI guidelines [17], respectively. A positive double disc synergy test was defined as enhancement of the zones of inhibition for ceftazidime and cefotaxime in the presence MM-102 price of clavulanic acid. The MDR ESBL producing K. pneumoniae strains were assigned antibiotypes based on their resistance patterns. Pulsed Field Gel Electrophoresis Pulsed-field gel electrophoresis (PFGE) was used to determine the relatedness of the ESBL producing strains of K. pneumoniae. The PFGE was performed as described previously with modifications [19]. Electrophoresis was carried out in 0.5 × TBE buffer using the Chef Mapper XA pulsed

field electrophoresis system (Biorad, Hercules, California, U.S.A.). The conditions were 6 V/cm for 21 h at 12°C, with the pulse time ramped linearly from 1 s to 40 s. The molecular size marker included for comparison was Saccharomyces cerevisiae (Biorad, Hercules, Dichloromethane dehalogenase California, U.S.A.). Following electrophoresis the gels were stained with ethidium bromide and photographed under ultraviolet light. The banding patterns were compared based on the criteria described by Tenover et al [20]. Isolates were considered indistinguishable if their restriction patterns had the same number of corresponding bands of the same apparent size and closely related for differences of 3 bands. Isolates which differed by 4 or more bands were considered unrelated. The study was approved by the Ethics Committee in the Faculty of Medical Sciences of the University of the West Indies, Mona. Acknowledgements We thank Mrs Lois Rainford, Mrs Charmaine Parkes and our colleagues in the Bacteriology Section of the Microbiology Department, University of the West EX 527 Indies for their assistance. References 1.