scholarly journals A study on Nalidixic Acid Resistant Salmonella among the patients attending Shree Birendra Hospital

2012 ◽  
Vol 10 (2) ◽  
pp. 1-3 ◽  
Author(s):  
Raina Chaudhary ◽  
Khagendra Sijapati ◽  
Sunil Kumar Singh
Keyword(s):  
Nalidixic Acid ◽  
Salmonella Enterica ◽  
Enteric Fever ◽  
Brain Heart Infusion ◽  
Public Health Problem ◽  
Diffusion Method ◽  
Disc Diffusion ◽  
Diffusion Test ◽  
Sensitivity Pattern

Introduction: Enteric fever is the commonest public health problem in developing countries like Nepal. Multi Drug Resistant Salmonella isolates are in vitro susceptible to Quinolone but exhibited a higher Minimum Inhibitory Concentration in vivo. Such phenomenon can be demonstrated by simple disc diffusion test of Nalidixic Acid which shows resistance. This study is conducted to determine prevalence of Nalidixic Acid Resistant Salmonella with their anti biotic sensitivity pattern at Shree Birendra Hospital, Chauni, kathmandu. Method: Of total 3945 blood samples from the patients suspected to have enteric fever were collected during the period of January 2011 to August 2011. Then it was mixed with Brain Heart Infusion , further processed according to standard methodology and their anti microbial susceptibility was performed by Kirby-Bauer disc diffusion method. Results: From 3945 samples, 280 (7.09%) showed positi ve growth, 114 (40.7%) Salmonella enterica serotype Typhi and 166 (59.2%) Salmonella enterica serotype Paratyphi A. a total of 221 (78.92%) were Nalidixic Acid Resistant Salmonella, all these strains were sensitive to Ciprofloxcin and Ofloxacin in disc diffusion test. Conclusion: Study showed a higher frequency of Nalidixic Acid Resistant Salmonella among the patients. screening of Nalidixic Acid disc diffusion test must be done as routine work for determination of low level resistance of Quinolone so as to decide the drug for the treatment of enteric fever. DOI: http://dx.doi.org/10.3126/mjsbh.v10i2.6453 Medical Journal of Shree Birendra Hospital July-Dec 2011 10(2) 1-3

ANTIMICROBIAL SUSCEPTIBILITY IN CULTURE POSITIVE ENTERIC FEVER

2019 ◽  
Vol 3 (7) ◽  
Author(s):  
Dr. Manish Kulshrestha ◽  
Dr. Anjali Kulshrestha
Keyword(s):  
Bone Marrow ◽  
Blood Culture ◽  
Nalidixic Acid ◽  
Antimicrobial Susceptibility ◽  
Salmonella Enterica ◽  
Enteric Fever ◽  
Multidrug Resistant ◽  
Bone Marrow Culture ◽  
Diffusion Method ◽  
Culture Positive

INTRODUCTION: Enteric fever includes typhoid and paratyphoid fever. Peak incidence is seen in children 5–15 years of age; but in regions where the disease is highly endemic, as in India, children younger than 5 years of age may have the highest infection rates. There are about 22 million new typhoid cases occur each year. Young children in poor, resource limited areas, who make up the majority of the new cases and there is a mortality figures of 215,000 deaths annually. A sharp decline in the rates of complications and mortality due to typhoid fever is observed as a result of introduction of effective antibiotic therapy since 1950s. MDR-ST became endemic in many areas of Asia, including India soon after multidrug-resistant strains of Salmonella enterica serotype typhi (MDR-ST) that were resistant to all the three first-line drugs then in use, namely chloramphenicol, amoxycillin and co-trimoxazole emerged in early 1990s. MATERIAL AND METHODS: Only blood culture or bone marrow culture positive cases were included. The patients with culture isolated enteric fever were included in the study. Antimicrobial susceptibility testing was carried out by disk diffusion method using antibiotic discs. The analysis of the antimicrobial susceptibility was carried out as per CLSI interpretative guidelines. RESULTS: A total of 82 culture positive cases were included in the present study. 80 culture isolates were from blood culture and 2 from the bone marrow culture. Salmonella entericasubspecies enterica serovartyphi (S typhi) was isolated from 67 (81.70%) patients while Salmonella enterica subspecies entericaserovarparatyphi (S paratyphi A) was isolated from 13 (15.85%) cases and 2 (2.44%) were Salmonella enterica subspecies entericaserovarschottmuelleri (S paratyphi B). Of the 82 cases 65(79.3%) isolates were resistant to ciprofloxacin, 17 (20.7%) were resistant to nalidixic acid, one (1.2%) case each was resistant to Cefotaxime and ceftriaxone, 2 (2.4%) were resistant to chloramphenicol, 10 (12.2%) were resistant and to cotrimoxazole 3 (3.7%) were resistant. CONCLUSION: In a culture positive cases 65(79.3%) isolates were resistant to ciprofloxacin and 17 (20.7%) were resistant to nalidixic acid. Multidrug resistant isolates were 65(79.3%).

scholarly journals Susceptibility to patterns of ciprofloxacin among nalidixic acid-resistant Salmonella isolates collected in Banepa, Nepal from enteric fever patients

2016 ◽  
Vol 89 (2) ◽  
Author(s):  
Girija Roka ◽  
Subash Pandaya ◽  
Md. Reyad-ul Ferdous ◽  
Manson Pandey ◽  
Naba Raj Pokhrel ◽  
...  
Keyword(s):  
Nalidixic Acid ◽  
Salmonella Enterica ◽  
Enteric Fever ◽  
Inhibitory Concentration ◽  
Acid Resistance ◽  
Dilution Method ◽  
Disc Diffusion ◽  
Antimicrobial Sensitivity ◽  
Broth Dilution ◽  
Nalidixic Acid Resistance

The present study determined the susceptibility to ciprofloxacin of nalidixic acid resistant <em>Salmonella</em> (NARS) isolated from enteric fever patients at Scheer Memorial Hospital, Banepa, Nepal, from June 2012 to December 2012. The antimicrobial sensitivity to nalidixic acid and ciprofloxacin was determined using modified Kirby-Bauer disc diffusion and broth dilution method according to the guidelines of the Clinical and Laboratory Standard Institute. <em>Salmonella</em> was isolated from 34 out of 992 (3.43%) blood cultures collected during the study period, and 10 (29.4%) isolates were identified as <em>Salmonella enterica</em> serotype Typhi, while 24 (70.6%) were identified as <em>Salmonella enterica</em> serotype Paratyphi. Out of the total isolates, 31 (91.2%) were nalidixic acid-resistant <em>Salmonella</em> (NARS). Among NARS, the minimum inhibitory concentration values for ciprofloxacin ranged from 0.25 to 2 mg/L and were constantly higher than those shown by the nalidixic acid-susceptible <em>Salmonella</em>. Therefore, in typhoid <em>Salmonella</em> nalidixic acid resistance may be the indicator of decreased susceptibility to ciprofloxacin.

scholarly journals Is Antimicrobial Resistance Pattern of Enteric Fever Changing in Kathmandu Valley?

2013 ◽  
Vol 32 (3) ◽  
pp. 221-228
Author(s):  
Ganesh Kumar Rai ◽  
Subhana Karki ◽  
Bina Prajapati
Keyword(s):  
Antimicrobial Resistance ◽  
Nalidixic Acid ◽  
Enteric Fever ◽  
Public Health Problem ◽  
Salmonella Typhi ◽  
Resistance Pattern ◽  
Kathmandu Valley ◽  
Sensitivity Testing ◽  
Antimicrobial Sensitivity ◽  
Sensitivity Pattern

Introduction: Enteric fever is a public health problem in developing countries including Nepal. Antimicrobial sensitivity pattern of Salmonella sp causing enteric fever is changing over time and also differs according to geographical location. Periodic surveillance of antimicrobial resistance of Salmonella sp is mandatory for management of enteric fever rationally. The objective of this study was to analyze the resistance pattern of Salmonella sp to commonly used antimicrobials. Materials and Methods: This was a retrospective study undertaken reviewing the records of blood isolates of Salmonella sp over one year period at Kanti Children’s Hospital, Nepal. Antimicrobial sensitivity testing was done following Kirby Bauer’s disk diffusion technique using Muller Hinton agar. Results: Salmonella typhi was found to be 100% resistance to ampicillin and resistance to nalidixic acid and ciprofloxacin was also high. The resistance to chloramphenicol and ofloxacin was low. No resistance was found to amoxicillin, ceftriaxone, cefotaxime and amikacin. However, among the sensitive isolates of Salmonella typhi intermediate sensitivity to ceftriaxone and ceftazidime was reported to be high. Among the isolates of S paratyphi A, the resistance to nalidixic acid was 100% followed by 75% to ciprofloxacin. No resistance was found to chloramphenicol, ceftriaxone, cefixime, amikacin and low resistance to amoxicillin and ofloxacin. Among the sensitive isolates of S paratyphi A, majority of them were only moderately sensitive to cefotaxime and ceftazidime and about 1/3 of the organisms had only intermediate sensitivity to ceftriaxone. Conclusiion: Commonly used parenteral third generation cephalosporins, first line drugs like chloramphenicol and amoxicillin and ofloxacin among fluoroquinolones were found to be effective in vitro in treating enteric fever. However, Salmonella typhi was found to be highly resistant to the most frequently used drugs like ciprofloxacin and cefixime and Salmonella paratyphi A to ciprofloxacin. A comparative chart of antimicrobial sensitivity of enteric fever in children over 10 year period from different hospitals of Kathmandu valley is also presented in the study. DOI: http://dx.doi.org/10.3126/jnps.v32i3.6625 J. Nepal Paediatr. SocVol.32(3) 2012 221-228

Current Fluoroquinolone Susceptibility Criteria for Salmonella Needs Re-evaluation

2012 ◽  
Vol 10 (1) ◽  
pp. 66-71 ◽  
Author(s):  
D Acharya ◽  
S Malla ◽  
DR Bhatta ◽  
N Adhikari ◽  
SP Dumre
Keyword(s):  
Nalidixic Acid ◽  
Enteric Fever ◽  
Susceptibility Testing ◽  
Break Point ◽  
Resistance Rate ◽  
Diffusion Method ◽  
Dilution Method ◽  
Agar Dilution Method ◽  
Disc Diffusion ◽  
Zone Diameter

Background Disc diffusion technique is the routine susceptibility testing procedure for isolates of enteric fever, the most common clinical diagnosis among febrile patients in Nepal. Objective To evaluated the current fluoroquinolones (FQs) susceptibility criteria and nalidixic acid screening test in Salmonella enterica serovar Typhi and Paratyphi A. Methods S. Typhi and Paratyphi A strains isolated from 443 suspected enteric fever patients visiting National Public Health Laboratory (NPHL) during April through October 2008 were analyzed. All isolates were confirmed by standard microbiological procedures including serotyping. Antibiotic susceptibility testing was performed by using Kirby Bauer disc diffusion method and Clinical and Laboratory Standards Institute (CLSI) approved interpretive criteria. Agar dilution method was used to determine Minimum Inhibitory Concentration (MIC) of ciprofloxacin, ofloxacin and nalidixic acid. Result Out of 41 Salmonella isolates, 80.49% were nalidixic acid resistant, with S. Paratyphi A showing higher resistance rate (88.23%) compared to S. Typhi (75%). The difference in both MIC and zone diameter in nalidixic acid susceptible and nalidixic acid resistant isolates was found to be significant (P < 0.001) and decreased susceptibility to FQs was strongly correlated (sensitivity and specificity of 100%) with resistance to nalidixic acid. Regression analysis of MIC against zone diameter based on the current CLSI recommended guidelines suggests that accommodation of current susceptible and resistant MIC requires increase in the zone diameter of ciprofloxacin and ofloxacin. Conclusion Before using these drugs for management of enteric fever, appropriate identification of Salmonella isolates with reduced susceptibility to FQs is essential to limit the possible treatment failure and development of highly resistant strains. The current FQs susceptibility break point criteria for Salmonella need re-evaluation. KATHMANDU UNIVERSITY MEDICAL JOURNAL  VOL.10 | NO. 1 | ISSUE 37 | JAN - MAR 2012 | 24-29DOI: http://dx.doi.org/10.3126/kumj.v10i1.6909

scholarly journals Comparision of Antibiotic Susceptility of Levofloxacin with Other Commonly Tested Antibiotics Against Salmonella Enterica Serovar (Typhi And Paratyphi A)

2014 ◽  
Vol 3 (1) ◽  
pp. 19-21
Author(s):  
A Chhetri ◽  
A Manandhar ◽  
Y Shah ◽  
RC Simkhada ◽  
R Paudyal ◽  
...  
Keyword(s):  
Nalidixic Acid ◽  
Salmonella Enterica ◽  
Antibiotic Susceptibility ◽  
Enteric Fever ◽  
Clinical Laboratory ◽  
Acid Resistance ◽  
Fluoroquinolone Resistance ◽  
Diffusion Method ◽  
Salmonella Enterica Serovar Typhi ◽  
Antibiotic Susceptibility Test

Background: Increasing antibiotic resistance of bacteria is a global problem. Fluoroquinolones are recommended as first line therapy for children and adults infected with Salmonella enterica serovar Typhi and Paratyphi A. The purpose of this study was to compare the antibiotic susceptibility pattern of different classes of antibiotics with levofloxacin from blood samples of suspected enteric fever patients visiting Birhospital, Kathmandu. Methods: Antibiotic susceptibility test was performed by Kirby-Bauerdisc diffusion method as per Clinical Laboratory Standards Institute guideline. Results: Among 50 isolates of Salmonella enterica, 39 (78%) were S.Typhi and 11 (22%) were S. Paratyphi A. All the isolates were tested against antibiotics, and all isolates were found sensitive to chloramphenicol and ceftriaxone whereas 3 isolates of S. Typhi were resistant to ciprofloxacin and 1 was resistant to levofloxacin. Fluoroquinolone resistant S. ParatyphiA was not observed. Among the 10 (20%) multi drug resistant isolates, only 1 isolate was resistant to levofloxacin which was S. Typhi. Both S.Typhi (96.7%) and S. Paratyphi A (89.4%) were resistant to Nalidixic acid. Conclusion: High level of nalidixic acid resistance and even some fluoroquinolone resistance showed that the treatment of the enteric fever cannot be relied on the fluoroquinolones. Nepal Journal of Medical Sciences | Volume 03 | Number 01 | January-June 2014 | Page 19-21 DOI: http://dx.doi.org/10.3126/njms.v3i1.10344

scholarly journals Ciprofloxacin susceptibility of Salmonella enteric serovar Typhi and Paratyphi A from blood samples of suspected enteric fever patients

2012 ◽  
Vol 1 (1) ◽  
pp. 9-13 ◽  
Author(s):  
D Adhikari ◽  
D Acharya ◽  
P Shrestha ◽  
R Amatya
Keyword(s):  
Salmonella Enterica ◽  
Enteric Fever ◽  
Diffusion Method ◽  
Dilution Method ◽  
Agar Dilution Method ◽  
Disc Diffusion ◽  
Salmonella Spp ◽  
Blood Samples ◽  
Antibiotic Susceptibility Test

INTRODUCTION: Enteric fever caused by Salmonella enterica serovars Typhi and Paratyphi A is the common clinical diagnosis among febrile patients presenting to hospital in Nepal. The aim of this study was to evaluate the ciprofloxacin (CIP) and other antibiotics susceptibility patterns of Salmonella enterica serovars Typhi and Paratyphi A from blood samples of suspected enteric fever patients visiting KIST Medical College, Kathmandu. MATERIALS AND METHODS: Antibiotic susceptibility test was performed by Kirby Bauer disc diffusion method as per CLSI guidelines whereas MIC determination of ciprofloxacin was performed by agar dilution method. RESULTS: Altogether 64 presumptive Salmonella spp. were isolated from 840 blood samples of suspected enteric fever patients, of which 41 were S. Typhi and 23 were S. Paratyphi A. All Salmonella spp. isolates were sensitive to ceftriaxone and ofloxacin whereas 4 isolates were resistant to ciprofloxacin. One isolates each of S. Typhi and S. Paratyphi A were multidrug resistant. Fifty five isolates of Salmonella spp. were resistant to nalidixic acid (NA) with higher rate in S. Paratyphi A (91.3%) compared to S. Typhi (82.9%). MIC determination of ciprofloxacin revealed that majority of the isolates were resistant to ciprofloxacin and 2 isolates were resistant with MIC value of 4 µg/ml and 8 µg/ml. Importantly, we found simultaneous presence of NA resistance and decreased susceptibility to CIP suggesting that resistance to NA is a reliable indicator of decreased CIP susceptibility. CONCLUSIONS: Disc diffusion test failed to detect the reduced susceptibility of ciprofloxacin. Hence the MIC determination of ciprofloxacin against Salmonella spp. isolates would be important.  DOI: http://dx.doi.org/10.3126/ijim.v1i1.6938Int J Infect Microbiol 2012;1(1):9-13

scholarly journals Antimicrobial resistance among blood culture isolates of Salmonella enterica in New Delhi

2013 ◽  
Vol 7 (11) ◽  
pp. 788-795 ◽  
Author(s):  
Sarika Jain ◽  
Tulsi Das Chugh
Keyword(s):  
Antimicrobial Resistance ◽  
Nalidixic Acid ◽  
Antimicrobial Susceptibility ◽  
Salmonella Enterica ◽  
Enteric Fever ◽  
Automated System ◽  
Diffusion Method ◽  
New Delhi ◽  
Third Generation ◽  
First Choice

Introduction: Enteric fever is a global public health problem, especially in developing countries. Antimicrobial resistance is a major issue enteric fever management. This study examined current pattern of antimicrobial susceptibility among Salmonella enterica isolates from enteric fever cases at a tertiary care centre in New Delhi, India. Methodology: Blood cultures from patients with enteric fever during January 2010- July 2012 were processed using the BACTEC automated system. Antimicrobial susceptibility was tested using Kirby Bauer’s disc diffusion method and/or Phoenix 100 automated system. Results: Of 344 isolates of Salmonella enterica, 266 (77.3%) were S. Typhi, 77 (22.4%) were S. Paratyphi A, and one (0.3%) was S. Paratyphi B. Resistance to nalidixic acid (NAR) (96.7%) was most common, followed by ciprofloxacin (37.9%), and azithromycin (7.3%). Multi-drug resistance was observed only in S. Typhi (3.4%). Among NAR strains, 61.8% were sensitive, 11.1% were moderately sensitive, and 23.9% were resistant to ciprofloxacin (0.8%, 57.4%, and 37.9% respectively according to revised CLSI breakpoint criteria for ciprofloxacin). Resistance to third-generation cephalosporin was found in seven (2%) strains of S. enterica. Conclusion: Increasing rates of nalidixic acid, fluoroquinolone and azithromycin resistance among S. enterica, particularly in S. Paratyphi A strains, is of concern, as S. Paratyphi A infection is becoming increasingly common and is not prevented by current vaccinations. Our results favour use of cefexime or possibly chloramphenicol as first choice for uncomplicated enteric fever. MICs for third-generation cephalosporins and susceptibility pattern must be closely monitored in view of its emerging resistance among Salmonella enterica.

scholarly journals Antimicrobial sensitivity patterns of salmonella typhi in children

2016 ◽  
Vol 15 (3) ◽  
pp. 416-418
Author(s):  
Md Khoyber Ali ◽  
Shahin Sultana
Keyword(s):  
Blood Culture ◽  
Nalidixic Acid ◽  
Medical Science ◽  
Antibiotic Sensitivity ◽  
Public Health Problem ◽  
Salmonella Typhi ◽  
Diffusion Method ◽  
Sensitivity Testing ◽  
Antimicrobial Sensitivity ◽  
Sensitivity Pattern

Background: Enteric fever is an important public health problem in developing countries including Bangladesh. A changing antibiotic sensitivity pattern of Salmonella typhi and emergence of resistance has increased to a great concern. Objective: Aim of the study was to investigate the antibiotic sensitivity pattern of Salmonella typhi. Methods: A total of 181 Salmonella typhi samples from 5 to 15 years age group were collected from blood culture during the period of October to December 2014 from IBN SINA Hospital, Dhaka, Bangladesh. Specimens from the blood culture were identified by standard procedures as needed. Antimicrobial susceptibility testing was performed by disk diffusion method according to ‘The Clinical Laboratory Standard Institute’ guidelines. Results: Among the tested antibiotics, S. typhi was susceptible to ceftriaxone 100%, followed by cefixime and gentamicin 99.4%, ciprofloxacin 98.6%, cotrimoxazole 88.9%, azithromycin 88.4 % and least susceptible antibiotic was Ampicillin 62.5% and nalidixic acid 5%. Conclusion: The antimicrobial sensitivity testing showed that the Salmonella typhi were highly sensitive (>88%) to most of the drugs used in this study, whereas nalidixic acid showed only 5% sensitivity. So this study indicates that ceftriaxone, cefixime, gentamicin and ciprofloxacin can be used as a first line therapy and nalidixic acid should be avoided for treatment.Bangladesh Journal of Medical Science Vol.15(3) 2016 p.416-418

scholarly journals In vitro activity of azithromycin in Salmonella isolates from Pakistan

2011 ◽  
Vol 5 (05) ◽  
pp. 391-395 ◽  
Author(s):  
Farhana Butt ◽  
Faisal Sultan
Keyword(s):  
Salmonella Enterica ◽  
Enteric Fever ◽  
Therapeutic Option ◽  
Close Correlation ◽  
Salmonella Typhi ◽  
Public Health Issue ◽  
Disc Diffusion ◽  
Paratyphi B ◽  
High Level

Introduction: Enteric fever is caused by Salmonella enterica serovars Typhi and Paratyphi A, B and C. It is a significant public health issue in Pakistan, which is exacerbated by a high level of resistance some isolates display to drugs routinely used in treatment. Azithromycin may be a treatment option for such isolates. Methodology: We determined the minimum inhibitory concentrations (MICs) of Salmonella Typhi and Paratyphi isolates against azithromycin in an attempt to gauge its feasibility as a therapeutic option. The MICs were also compared with corresponding disc diffusion zone sizes to see if there was consistency between the two tests. We tested 45 Salmonella enterica isolates using E-tests for MIC detection and azithromycin discs with a concentration of 15µg/ml for disc diffusion testing. Results: Salmonella Typhi, Salmonella Paratyphi A, and Salmonella Paratyphi C isolates demonstrated MICs of 2-12mg/L against azithromycin, suggesting that the antibiotic could be used for therapeutic purposes. For Salmonella Paratyphi B, the MICs were 2-48 mg/L. The higher MIC indicates a need for caution when considering use of azithromycin for Salmonella Paratyphi B infections without first testing for the MIC. There was a close correlation between MICs and zone sizes which was statistically significant. Conclusions: Our results indicate azithromycin is a potential therapeutic option for enteric fever. Standardized laboratory testing methods and interpretation for azithromycin  against Salmonella enterica would allow laboratories to report upon this antibiotic with confidence.

scholarly journals Increased resistance to Nalidixic acid and Ciprofloxacin in Salmonella isolates from the Sub Himalayan region

2017 ◽  
Vol 5 (9) ◽  
pp. 4025
Author(s):  
Suruchi Bhagra ◽  
Atal Sood ◽  
DigVijay Singh ◽  
Anil Kanga
Keyword(s):  
Nalidixic Acid ◽  
Salmonella Enterica ◽  
Surrogate Marker ◽  
Acid Resistance ◽  
Diffusion Method ◽  
Disc Diffusion ◽  
Diffusion Technique ◽  
Global Concern ◽  
Ciprofloxacin Resistance

Background: During the last two decades, increased resistance to nalidixic acid and ciprofloxacin has become a cause of global concern. The present study was undertaken to ascertain nalidixic acid and ciprofloxacin resistance in Salmonella isolates from our region. To know the true pattern of ciprofloxacin resistance by determining the minimum inhibitory concentration (MIC) through E-test.Methods: All the Salmonella isolates recovered from blood cultures were screened for nalidixic acid resistance using 30µg disc by the Kirby Bauer disc diffusion method. Ciprofloxacin susceptibility was done both by disc diffusion and MIC using CLSI breakpoints.Results: We analysed a total of 80 Salmonella isolates during the last three years. Salmonella enterica serovar Typhi was the predominant serovar in 51 (64.8%) isolates, followed by Salmonella enterica serovar Paratyphi A comprising 28 (36.2%) isolates. Amongst the total isolates 78 (97.5%) were nalidixic acid resistant. Of these 54 (67.5%) showed intermediate susceptibility and 9 (11.2%) were ciprofloxacin resistant by the disc diffusion technique. On the contrary 29 (36.2%) had decreased susceptibility to ciprofloxacin; while a larger number 38 (47.5%) were detected resistant to ciprofloxacin on determination of MIC by the E-test.Conclusions: Screening for nalidixic acid acts as a surrogate marker to detect ciprofloxacin resistance. However, the true pattern of ciprofloxacin resistance can be determined by calculating the MIC by the E-test.

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