scholarly journals Effect of Antibiotic Treatment on Establishment and Elimination of Intestinal Colonization by KPC-Producing Klebsiella pneumoniae in Mice

2011 ◽  
Vol 55 (6) ◽  
pp. 2585-2589 ◽  
Author(s):  
Federico Perez ◽  
Michael J. Pultz ◽  
Andrea Endimiani ◽  
Robert A. Bonomo ◽  
Curtis J. Donskey
Keyword(s):  
Klebsiella Pneumoniae ◽  
Antibiotic Treatment ◽  
Test Strain ◽  
Moderate Activity ◽  
Significant Activity ◽  
Intestinal Colonization ◽  
Oral Antibiotics ◽  
Content Type ◽  
Polymyxin E ◽  
The Impact

ABSTRACTAn understanding of the impact of antibiotics on the intestinal reservoir of KPC carbapenemase-producingKlebsiella pneumoniae(KPC-Kp) is important to prevent its emergence. We used a mouse model to examine the effect of antibiotic treatment on the establishment and elimination of intestinal colonization with KPC-Kp. Mice (10 per group) received subcutaneous antibiotics daily for 8 days. On day 3 of treatment, 103CFU of KPC-Kp was given orogastrically, and concentrations of KPC-Kp in stool were monitored. Additional experiments assessed the effects of antibiotic treatment on concentrations of total anaerobes andBacteroidesspp. in stool and the efficacy of orogastric gentamicin and polymyxin E in suppressing KPC-Kp colonization. Of four antibiotics with minimal activity against the KPC-Kp test strain (MIC ≥ 16 μg/ml), those that suppressed total anaerobes and bacteroides (i.e., clindamycin and piperacillin-tazobactam) promoted colonization by KPC-Kp (P< 0.001), whereas agents that did not suppress total anaerobes or bacteroides (i.e., ciprofloxacin and cefepime) did not (P= 0.35). Of two agents with moderate activity against the KPC-Kp test strain, ertapenem (MIC, 4 μg/ml) did not promote colonization by KPC-Kp, whereas tigecycline (MIC, 3 μg/ml) did (P< 0.001), despite not reducing levels of total anaerobes or bacteroides. Orogastric treatment with gentamicin and polymyxin E suppressed KPC-Kp to undetectable levels in the majority of mice. These data suggest that antibiotics that disturb the intestinal anaerobic microflora and lack significant activity against KPC-Kp promote colonization by this organism. The administration of nonabsorbed oral antibiotics may be an effective strategy to suppress colonization with KPC-Kp.

scholarly journals Oral DAV131, a Charcoal-Based Adsorbent, Inhibits Intestinal Colonization by β-Lactam-Resistant Klebsiella pneumoniae in Cefotaxime-Treated Mice

2013 ◽  
Vol 57 (11) ◽  
pp. 5423-5425 ◽  
Author(s):  
Nathalie Grall ◽  
Laurent Massias ◽  
Thu Thuy Nguyen ◽  
Sakina Sayah-Jeanne ◽  
Nicolas Ducrot ◽  
...  
Keyword(s):  
Klebsiella Pneumoniae ◽  
Intestinal Tract ◽  
Area Under The Curve ◽  
Resistant Bacteria ◽  
Intestinal Colonization ◽  
Colonization Resistance ◽  
Content Type ◽  
Resistant Strains ◽  
The Impact ◽  
Indigenous Microflora

ABSTRACTAntibiotics excreted into the intestinal tract, such as broad-spectrum cephalosporins, disrupt the indigenous microflora, affect colonization resistance (CR), and promote intestinal colonization by resistant bacteria. We tested whether oral DAV131, a charcoal-based adsorbent, would prevent colonization by a cefotaxime (CTX)-resistantKlebsiella pneumoniaestrain (PUG-2) in CTX-treated mice. Mice received CTX, saline, CTX and DAV131, or saline and DAV131 for 3 days before oral challenge with 106CFU of PUG-2. The fecal CTX concentrations and counts of PUG-2 were assayed. Fecal CTX disappeared when DAV131 was given concomitantly with CTX (P< 0.05), and the area under the curve of PUG-2 fecal density was significantly reduced (P< 0.01). In conclusion, reducing intestinal antibiotic exposure with DAV131 may reduce colonization by resistant strains during treatment compared to treatment with CTX only. This might open new possibilities for decreasing the impact of antibiotics on the intestinal microbiota during treatments.

scholarly journals Genome-Wide Screening for Enteric Colonization Factors in Carbapenem-Resistant ST258 Klebsiella pneumoniae

mBio ◽  
2019 ◽  
Vol 10 (2) ◽  
Author(s):  
Hea-Jin Jung ◽  
Eric R. Littmann ◽  
Ruth Seok ◽  
Ingrid M. Leiner ◽  
Ying Taur ◽  
...  
Keyword(s):  
Klebsiella Pneumoniae ◽  
Genetic Factors ◽  
Intestinal Lumen ◽  
Intestinal Colonization ◽  
Antibiotic Resistant ◽  
Content Type ◽  
Carbapenem Resistant ◽  
Gut Colonization ◽  
Colonization Factors

ABSTRACT A diverse, antibiotic-naive microbiota prevents highly antibiotic-resistant microbes, including carbapenem-resistant Klebsiella pneumoniae (CR-Kp), from achieving dense colonization of the intestinal lumen. Antibiotic-mediated destruction of the microbiota leads to expansion of CR-Kp in the gut, markedly increasing the risk of bacteremia in vulnerable patients. While preventing dense colonization represents a rational approach to reduce intra- and interpatient dissemination of CR-Kp, little is known about pathogen-associated factors that enable dense growth and persistence in the intestinal lumen. To identify genetic factors essential for dense colonization of the gut by CR-Kp, we constructed a highly saturated transposon mutant library with >150,000 unique mutations in an ST258 strain of CR-Kp and screened for in vitro growth and in vivo intestinal colonization in antibiotic-treated mice. Stochastic and partially reversible fluctuations in the representation of different mutations during dense colonization revealed the dynamic nature of intestinal microbial populations. We identified genes that are crucial for early and late stages of dense gut colonization and confirmed their role by testing isogenic mutants in in vivo competition assays with wild-type CR-Kp. Screening of the transposon library also identified mutations that enhanced in vivo CR-Kp growth. These newly identified colonization factors may provide novel therapeutic opportunities to reduce intestinal colonization by CR-Kp. IMPORTANCE Klebsiella pneumoniae is a common cause of bloodstream infections in immunocompromised and hospitalized patients, and over the last 2 decades, some strains have acquired resistance to nearly all available antibiotics, including broad-spectrum carbapenems. The U.S. Centers for Disease Control and Prevention has listed carbapenem-resistant K. pneumoniae (CR-Kp) as an urgent public health threat. Dense colonization of the intestine by CR-Kp and other antibiotic-resistant bacteria is associated with an increased risk of bacteremia. Reducing the density of gut colonization by CR-Kp is likely to reduce their transmission from patient to patient in health care facilities as well as systemic infections. How CR-Kp expands and persists in the gut lumen, however, is poorly understood. Herein, we generated a highly saturated mutant library in a multidrug-resistant K. pneumoniae strain and identified genetic factors that are associated with dense gut colonization by K. pneumoniae. This study sheds light on host colonization by K. pneumoniae and identifies potential colonization factors that contribute to high-density persistence of K. pneumoniae in the intestine.

scholarly journals A Large, Refractory Nosocomial Outbreak of Klebsiella pneumoniae Carbapenemase-Producing Escherichia coli Demonstrates Carbapenemase Gene Outbreaks Involving Sink Sites Require Novel Approaches to Infection Control

2018 ◽  
Vol 62 (12) ◽  
Author(s):  
V. Decraene ◽  
H. T. T. Phan ◽  
R. George ◽  
D. H. Wyllie ◽  
O. Akinremi ◽  
...  
Keyword(s):  
Escherichia Coli ◽  
Klebsiella Pneumoniae ◽  
Control Measures ◽  
Effective Control ◽  
Infection Prevention And Control ◽  
Content Type ◽  
E Coli ◽  
Incidence Trends ◽  
Carbapenemase Gene ◽  
The Impact

ABSTRACT Carbapenem-resistant Enterobacteriaceae (CRE) represent a health threat, but effective control interventions remain unclear. Hospital wastewater sites are increasingly being highlighted as important potential reservoirs. We investigated a large Klebsiella pneumoniae carbapenemase (KPC)-producing Escherichia coli outbreak and wider CRE incidence trends in the Central Manchester University Hospital NHS Foundation Trust (CMFT) (United Kingdom) over 8 years, to determine the impact of infection prevention and control measures. Bacteriology and patient administration data (2009 to 2017) were linked, and a subset of CMFT or regional hospital KPC-producing E. coli isolates (n = 268) were sequenced. Control interventions followed international guidelines and included cohorting, rectal screening (n = 184,539 screens), environmental sampling, enhanced cleaning, and ward closure and plumbing replacement. Segmented regression of time trends for CRE detections was used to evaluate the impact of interventions on CRE incidence. Genomic analysis (n = 268 isolates) identified the spread of a KPC-producing E. coli outbreak clone (strain A, sequence type 216 [ST216]; n = 125) among patients and in the environment, particularly on 2 cardiac wards (wards 3 and 4), despite control measures. ST216 strain A had caused an antecedent outbreak and shared its KPC plasmids with other E. coli lineages and Enterobacteriaceae species. CRE acquisition incidence declined after closure of wards 3 and 4 and plumbing replacement, suggesting an environmental contribution. However, ward 3/ward 4 wastewater sites were rapidly recolonized with CRE and patient CRE acquisitions recurred, albeit at lower rates. Patient relocation and plumbing replacement were associated with control of a clonal KPC-producing E. coli outbreak; however, environmental contamination with CRE and patient CRE acquisitions recurred rapidly following this intervention. The large numbers of cases and the persistence of blaKPC in E. coli, including pathogenic lineages, are of concern.

scholarly journals Low or High Doses of Cefquinome Targeting Low or High Bacterial Inocula Cure Klebsiella pneumoniae Lung Infections but Differentially Impact the Levels of Antibiotic Resistance in Fecal Flora

2014 ◽  
Vol 58 (3) ◽  
pp. 1744-1748 ◽  
Author(s):  
Maleck V. Vasseur ◽  
Michel Laurentie ◽  
Jean-Guy Rolland ◽  
Agnès Perrin-Guyomard ◽  
Jérôme Henri ◽  
...  
Keyword(s):  
Antibiotic Resistance ◽  
Klebsiella Pneumoniae ◽  
Gut Microbiota ◽  
Bacterial Infections ◽  
Day Treatment ◽  
Intestinal Flora ◽  
Clinical Signs ◽  
Fecal Flora ◽  
Content Type ◽  
The Impact

ABSTRACTThe combination of efficacious treatment against bacterial infections and mitigation of antibiotic resistance amplification in gut microbiota is a major challenge for antimicrobial therapy in food-producing animals. In rats, we evaluated the impact of cefquinome, a fourth-generation cephalosporin, on bothKlebsiella pneumoniaelung infection and intestinal flora harboring CTX-M-producingEnterobacteriaceae. Germfree rats received a fecal flora specimen from specific-pathogen-free pigs, to which a CTX-M-producingEscherichia colistrain had been added.K. pneumoniaecells were inoculated in the lungs of these gnotobiotic rats by using either a low (105CFU) or a high (109CFU) inoculum. Without treatment, all animals infected with the low or highK. pneumoniaeinoculum developed pneumonia and died before 120 h postchallenge. In the treated groups, the low-inoculum rats received a 4-day treatment of 5 mg/kg of body weight cefquinome beginning at 24 h postchallenge (prepatent phase of the disease), and the high-inoculum rats received a 4-day treatment of 50 mg/kg cefquinome beginning when the animals expressed clinical signs of infection (patent phase of the disease). The dose of 50 mg/kg targeting the highK. pneumoniaeinoculum cured all the treated rats and resulted in a massive amplification of CTX-M-producingEnterobacteriaceae. A dose of 5 mg/kg targeting the lowK. pneumoniaeinoculum cured all the rats and averted an outbreak of clinical disease, all without any amplification of CTX-M-producingEnterobacteriaceae. These findings might have implications for the development of new antimicrobial treatment strategies that ensure a cure for bacterial infections while avoiding the amplification of resistance genes of human concern in the gut microbiota of food-producing animals.

scholarly journals Antibiotic Pressure Is a Major Risk Factor for Rectal Colonization by Multidrug-Resistant Pseudomonas aeruginosa in Critically Ill Patients

2014 ◽  
Vol 58 (10) ◽  
pp. 5863-5870 ◽  
Author(s):  
Silvia Gómez-Zorrilla ◽  
Mariana Camoez ◽  
Fe Tubau ◽  
Elisabet Periche ◽  
Rosario Cañizares ◽  
...  
Keyword(s):  
Pseudomonas Aeruginosa ◽  
Cox Regression ◽  
Multidrug Resistant ◽  
Intestinal Colonization ◽  
Icu Patients ◽  
Content Type ◽  
Cox Regression Analysis ◽  
Icu Admission ◽  
Rectal Colonization ◽  
The Impact

ABSTRACTThe intestinal reservoir is central to the epidemiology ofPseudomonas aeruginosa, but the dynamics of intestinal colonization by different phenotypes have been poorly described. To determine the impact of antimicrobial exposure on intestinal colonization by multidrug-resistant (MDR) and extensively drug-resistant (XDR)P. aeruginosa, we screened intensive care unit (ICU) patients for rectal colonization on admission and at weekly intervals. During an 18-month study period, 414 ICU patients were enrolled, of whom 179 (43%) were colonized; 112 (63%) of these were identified at ICU admission and 67 (37%) during their ICU stay. At 10 days after ICU admission, the probabilities of carriage were 44%, 24%, and 24% for non-MDR, MDR-non-XDR, and XDRP. aeruginosastrains, respectively (log rank, 0.02). Pulsed-field gel electrophoresis showed 10 pairs of non-MDRP. aeruginosaand subsequent MDR-non-XDR strains isolated from the same patients to be clonally identical and another 13 pairs (8 MDR-non-XDR and 5 XDR) to be unrelated. There was one specific clone between the 8 MDR-non-XDR strains and an identical genotype in the 5 XDR isolates. The Cox regression analysis identified MDRP. aeruginosaacquisition as associated with the underlying disease severity (adjusted hazard ratio [aHR], 1.97; 95% confidence interval [CI], 1.22 to 3.18;P= 0.006) and prior use of fluoroquinolones (aHR, 1.02; 95% CI, 1.00 to 1.04;P= 0.039), group 2 carbapenems (aHR, 1.03; 95% CI, 1.00 to 1.07;P= 0.041), and ertapenem (aHR, 1.08; 95% CI, 1.02 to 1.14;P= 0.004). The epidemiology of MDRP. aeruginosais complex, and different clusters may coexist. Interestingly, ertapenem was found to be associated with the emergence of MDR isolates.

scholarly journals Clinically Relevant Plasmid-Host Interactions Indicate that Transcriptional and Not Genomic Modifications Ameliorate Fitness Costs of Klebsiella pneumoniae Carbapenemase-Carrying Plasmids

mBio ◽  
2018 ◽  
Vol 9 (2) ◽  
Author(s):  
Michelle M. C. Buckner ◽  
Howard T. H. Saw ◽  
Rachael N. Osagie ◽  
Alan McNally ◽  
Vito Ricci ◽  
...  
Keyword(s):  
Gene Expression ◽  
Antimicrobial Resistance ◽  
Klebsiella Pneumoniae ◽  
Selection Pressure ◽  
Natural Host ◽  
Fitness Costs ◽  
Content Type ◽  
Resistance Plasmids ◽  
The Impact ◽  
Plasmid Carriage

ABSTRACT The rapid dissemination of antimicrobial resistance (AMR) around the globe is largely due to mobile genetic elements, such as plasmids. They confer resistance to critically important drugs, including extended-spectrum beta-lactams, carbapenems, and colistin. Large, complex resistance plasmids have evolved alongside their host bacteria. However, much of the research on plasmid-host evolution has focused on small, simple laboratory plasmids in laboratory-adapted bacterial hosts. These and other studies have documented mutations in both host and plasmid genes which occur after plasmid introduction to ameliorate fitness costs of plasmid carriage. We describe here the impact of two naturally occurring variants of a large AMR plasmid (pKpQIL) on a globally successful pathogen. In our study, after pKpQIL plasmid introduction, no changes in coding domain sequences were observed in their natural host, Klebsiella pneumoniae . However, significant changes in chromosomal and plasmid gene expression may have allowed the bacterium to adapt to the acquisition of the AMR plasmid. We hypothesize that this was sufficient to ameliorate the associated fitness costs of plasmid carriage, as pKpQIL plasmids were maintained without selection pressure. The dogma that removal of selection pressure (e.g., antimicrobial exposure) results in plasmid loss due to bacterial fitness costs is not true for all plasmid/host combinations. We also show that pKpQIL impacted the ability of K. pneumoniae to form a biofilm, an important aspect of virulence. This study used highly relevant models to study the interaction between AMR plasmids and pathogens and revealed striking differences from results of studies done on laboratory-adapted plasmids and strains. IMPORTANCE Antimicrobial resistance is a serious problem facing society. Many of the genes that confer resistance can be shared between bacteria through mobile genetic elements, such as plasmids. Our work shows that when two clinically relevant AMR plasmids enter their natural host bacteria, there are changes in gene expression, rather than changes to gene coding sequences. These changes in gene expression ameliorate the potential fitness costs of carriage of these AMR plasmids. In line with this, the plasmids were stable within their natural host and were not lost in the absence of selective pressure. We also show that better understanding of the impact of resistance plasmids on fundamental pathogen biology, including biofilm formation, is crucial for fighting drug-resistant infections.

scholarly journals Impact of Antibiotic Treatment on the Burden of Nasal Staphylococcus aureus among Hospitalized Patients

2018 ◽  
Vol 62 (10) ◽  
Author(s):  
Anubhav Kanwar ◽  
Jennifer L. Cadnum ◽  
Annette L. Jencson ◽  
Curtis J. Donskey
Keyword(s):  
Staphylococcus Aureus ◽  
Antibiotic Treatment ◽  
Inhibitory Activity ◽  
Hospitalized Patients ◽  
Methicillin Resistant ◽  
Content Type ◽  
Treatment Regimens ◽  
Systemic Antibiotics ◽  
The Impact

ABSTRACT We examined the impact of systemic antibiotics on the burden of nasal Staphylococcus aureus in hospitalized patients. Of 1,482 patients, 237 (16%) had nasal methicillin-susceptible S. aureus (MSSA) and 92 (6%) had nasal methicillin-resistant S. aureus (MRSA) on admission. Treatment regimens that included agents with inhibitory activity against MRSA or MSSA significantly reduced the burden of carriage, whereas regimens lacking anti-MRSA activity, including fluoroquinolones, promoted MRSA overgrowth.

scholarly journals Effect of Surotomycin, a Novel Cyclic Lipopeptide Antibiotic, on Intestinal Colonization with Vancomycin-Resistant Enterococci and Klebsiella pneumoniae in Mice

2016 ◽  
Vol 60 (6) ◽  
pp. 3333-3339 ◽  
Author(s):  
Abhishek Deshpande ◽  
Kelly Hurless ◽  
Jennifer L. Cadnum ◽  
Laurent Chesnel ◽  
Lihong Gao ◽  
...  
Keyword(s):  
Klebsiella Pneumoniae ◽  
Oral Vancomycin ◽  
Gram Negative ◽  
Content Type ◽  
Orogastric Tube ◽  
Cyclic Lipopeptide ◽  
Vancomycin Resistant Enterococci ◽  
Vancomycin Resistant ◽  
Lipopeptide Antibiotic ◽  
The Impact

Surotomycin (formerly called CB-183,315) is a novel, orally administered cyclic lipopeptide antibacterial in development for the treatment ofClostridium difficileinfection (CDI) that has potent activity against vancomycin-resistant enterococci (VRE) but limited activity against Gram-negative bacilli, includingBacteroidesspp. We used a mouse model to investigate the impact of surotomycin exposure on the microbiome, and to test the consequences of the disruption on colonization by vancomycin-resistant enterococci (VRE) and extended-spectrum β-lactamase-producingKlebsiella pneumoniae(ESBL-KP), in comparison with the effects of oral vancomycin and metronidazole. Mice (8 per group) received saline, vancomycin, metronidazole, or surotomycin through an orogastric tube daily for 5 days and were challenged with 105CFU of VRE or ESBL-KP administered through an orogastric tube on day 2 of treatment. The concentrations of the pathogens in stool were determined during and after treatment by plating on selective media. A second experiment was conducted to determine if the antibiotics would inhibit established VRE colonization. In comparison to controls, oral vancomycin promoted VRE and ESBL-KP overgrowth in stool (8 log10to 10 log10CFU/g;P< 0.001), whereas metronidazole did not (<4 log10CFU/g;P> 0.5). Surotomycin promoted ESBL-KP overgrowth (>8 log10CFU/g;P, <0.001 for comparison with saline controls) but not VRE overgrowth. Surotomycin suppressed preexisting VRE colonization, whereas metronidazole and vancomycin did not. These results suggest that treatment of CDI with surotomycin could reduce levels of VRE acquisition and overgrowth from those with agents such as vancomycin and metronidazole. However, surotomycin and vancomycin may promote colonization by antibiotic-resistant Gram-negative bacilli.

scholarly journals Mortality Associated with Bacteremia Due to Colistin-Resistant Klebsiella pneumoniae with High-Level Meropenem Resistance: Importance of Combination Therapy without Colistin and Carbapenems

2017 ◽  
Vol 61 (8) ◽  
Author(s):  
Isabel Machuca ◽  
Belén Gutiérrez-Gutiérrez ◽  
Irene Gracia-Ahufinger ◽  
Francisco Rivera Espinar ◽  
Ángela Cano ◽  
...  
Keyword(s):  
Septic Shock ◽  
Regression Analysis ◽  
Combination Therapy ◽  
Klebsiella Pneumoniae ◽  
Cox Regression ◽  
Lower Mortality ◽  
Content Type ◽  
Cox Regression Analysis ◽  
High Level ◽  
The Impact

ABSTRACT Combination therapy including colistin and a carbapenem has been found to be associated with lower mortality in the treatment of bloodstream infections (BSI) due to KPC-producing Klebsiella pneumoniae when the isolates show a meropenem or imipenem MIC of <16 mg/liter. However, the optimal treatment of BSI caused by colistin- and high-level carbapenem-resistant KPC-producing K. pneumoniae is unknown. A prospective cohort study including episodes of bacteremia caused by colistin-resistant and high-level meropenem-resistant (MIC ≥ 64 mg/liter) KPC-producing K. pneumoniae diagnosed from July 2012 to February 2016 was performed. The impact of combination therapy on crude 30-day mortality was analyzed by Cox regression using a propensity score as a covariate to control for indication bias and in an inverse probability of treatment weighting (IPTW) cohort. The study sample comprised 104 patients, of which 32 (30.8%) received targeted monotherapy and 72 (69.2%) received targeted combination therapy; none of them received either colistin or a carbapenem. The 30-day crude mortality rate was 30.8% (43.8% in patients treated with monotherapy and 25% in patients receiving combination therapy). In the Cox regression analysis, 30-day mortality was independently associated with septic shock at BSI onset (hazard ratio [HR], 6.03; 95% confidence interval [CI], 1.65 to 21.9; P = 0.006) and admission to the critical care unit (HR, 2.87; 95% CI, 0.99 to 8.27; P = 0.05). Targeted combination therapy was associated with lower mortality only in patients with septic shock (HR, 0.14; 95% CI, 0.03 to 0.67; P = 0.01). These results were confirmed in the Cox regression analysis of the IPTW cohort. Combination therapy is associated with reduced mortality in patients with bacteremia due to colistin-resistant KPC-producing K. pneumoniae with high-level carbapenem resistance in patients with septic shock.

scholarly journals Effect of a Selective Decontamination of the Digestive Tract Regimen Including Parenteral Cefepime on Establishment of Intestinal Colonization with Vancomycin-Resistant Enterococcus spp. and Klebsiella pneumoniae in Mice

2006 ◽  
Vol 50 (7) ◽  
pp. 2537-2540 ◽  
Author(s):  
David L. Paterson ◽  
Usha Stiefel ◽  
Curtis J. Donskey
Keyword(s):  
Klebsiella Pneumoniae ◽  
Digestive Tract ◽  
Selective Decontamination ◽  
Vancomycin Resistant Enterococcus ◽  
Intestinal Colonization ◽  
Concurrent Administration ◽  
Gram Negative ◽  
Enterococcus Spp ◽  
Polymyxin E ◽  
Vancomycin Resistant

ABSTRACT In mice, a selective decontamination of the digestive tract regimen consisting of orogastric tobramycin, polymyxin E, and amphotericin B in combination with subcutaneous cefepime inhibited gram-negative bacilli, including Klebsiella pneumoniae, and did not promote vancomycin-resistant Enterococcus spp. (VRE) colonization. However, concurrent administration of subcutaneous ampicillin-sulbactam resulted in promotion of VRE.

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