Newsletter No.

15 December 2003

Australian Society for

Antimicrobials
A Review of Antibiotic Prophylaxis at a Sydney Teaching Hospital
P Valeh, N Gilroy, M Poynten, T Gottlieb
Background
The use of systemic peri-operative antibiotic
prophylaxis (PAP) in elective joint
replacement surgery has been demonstrated
to significantly lower the rate of prosthetic
joint infections.1,2 Surveys have shown that
compliance with PAP (that is, the percentage
administered in accordance with international standards), though better in
orthopaedic surgery compared with other
types of surgery, varies from 59.3% - 91.3%.3
Due to the diversity of guidelines for PAP in
joint replacement surgery, with the majority
suggesting < 24 - 48 hours of prophylaxis,
multiple protocols have been adopted by
individual orthopaedic surgeons at our
institution.
We aimed to determine the compliance of
individual surgeons teams with their own
PAP protocols, identify poorly supported
PAP practices based on a review of the
literature and compare PAP in elective joint
replacement surgery at our institution against
the recently revised Therapeutic Antibiotic
Guidelines.4

Methods
A retrospective survey of medical records of
patients who had undergone elective hip or
knee joint replacements between June 2001
and June 2002 at Concord Repatriation
General Hospital (a 550 bed teaching
hospital affiliated with the University of
Sydney), was undertaken. Each surgeon who
performed these operations had their own
documented protocol for antibiotic

prophylaxis in joint replacement surgery

(Table 1). A sample of 88 (36%) of 241
records of patients who had elective joint
replacement were surveyed using a
standardised form. Information collected
included patient demographics, methicillin
resistant Staphylococcus aureus (MRSA)
status, operative details including the
surgeon performing the procedure, the
presence of invasive devices (including indwelling urinary catheters (IDCs) and PAP
details (Table 2). The antibiotic prophylaxis

The protocols promoted

longer duration of
antibiotic use than
recommended
protocol of the surgeon performing surgery
and compliance with this protocol for each
case of joint replacement was reviewed. Data
analysis was performed using the Epi Info 6
statistical programme (Centers for Disease
Control).

Dept of Microbiology and Infectious

Diseases, Concord Hospital, Sydney
protocols (surgeon Cs) specified both the
recommended dose and dosing interval for
cephalothin; the other protocols specified the
interval appropriate for cephazolin. However
despite this, the actual cephalothin dosing
interval was inappropriate in only 4.5%
(4/88) of cases. The duration of cephalothin
administration was generally 48 hours and
the median number of doses was 8 (range 5 20).

Gentamicin
Overall, 44.3% (39/88) of patients received a
single dose of gentamicin in theatre as PAP
for operative catheterisation. However 10/39
patients given gentamicin did not have an
IDC. Only 5 of these patients were operated
on by one of the two surgeons (Table 2)
whose protocols called for gentamicin
administration irrespective of IDC status.
Figure 1 summarises the initial dose of
gentamicin given as PAP. Appropriateness of
dosing could not be assessed.
>80mg
120 - 180mg

10.20%

180mg

28.20%

Results
Cephalosporins
The -lactam antibiotic, cephalothin, was the
only first generation cephalosporin, provided
by pharmacy and hence used in PAP by all of
the surgeons surveyed, despite their
individual
protocols
recommending
cephazolin. Only one of the surgical

Also in this issue

VanB gene in faecal anaerobes .......................................................................... 4
Susceptibility testing of Staphylococcus lugdunensis........................................ 5
NHMRC grants for research into antimicrobial agents ..................................... 6
Picture QUIZ ...................................................................................................... 7
Susceptibility testing of yeasts........................................................................... 8
Stability of home intravenous antibiotics .......................................................... 9
Antimicrobials 2004, Sydney........................................................................... 11

61.50%

Figure 1. Gentamicin dose given in

elective dose replacement surgery

Indwelling urinary catheters

The timing of gentamicin dosing in relation
to urinary catheter insertion or removal is not
clearly stated in any of the surveyed
protocols. Two surgeons (D & F) recommend
a single dose of gentamicin (80mg) as PAP in
catheterised patients - 55.5% (5/9) of

ASA Newsletter, December 2003

surgeon D and only 10.5% (2/19) of surgeon Fs patients

received PAP in accordance with their protocols.
56.8% of patients (50/88) had an indwelling urinary
catheter (IDC) inserted in theatre preoperatively. Of this
number, 29 were given IV gentamicin at the time of IDC
insertion; most of these patients (25/29) received 160 mg of
gentamicin, with the remainder being administered 80 mg.
A majority (24/29) of these patients were given an
additional, lower dose of gentamicin (80 mg) at the time of
IDC removal.
Most (64.7%) of the 21 catheterised patients who did not
receive gentamicin at the time of IDC insertion later
received at least one dose of gentamicin either in relation to
IDC removal or subsequent recatheterisation.
Finally, of the 12/50 catheterised patients who received >1
dose of gentamicin post-operatively, one was administered
2 different doses of gentamicin within the time interval of
8 hours and the method of administration of gentamicin
was unclear in 5/40 patients: the same dose was ordered to
be given as either intravenously or intramuscularly without
clarification as to which method was actually utilised.

Drainage devices

Table 2. Patient characteristics and operative details.

Patient Characteristics
Median age (range)

Sex

74 (18 - 90)
Cases

(%)

53
35

(60.2%)
(39.8%)

10 / 88
5/10
2/10
3/10

(11.3%)

No. of preoperative screens

83/ 88

(94.3%)

MRSA positive

0/ 83

(0%)

Male
Female

-lactam allergy
rash
anaphylaxis
not specified
MRSA Status

Operative details
Arthroplasty type
Primary
Revision #

Hip

Knee*

Total

(%)

28
11

42
7

70/88
18/88

(79.5%)
(20.4%)

50 arthroplasties were cemented and of this

number, 31 used antibiotic- impregnated cement.

In the protocols of 4/6 surgeons, PAP duration (IV and oral

follow-on therapy) was guided by drain tube removal. Most
patients (87/88) had drains inserted intra-operatively. Of
this number, all had PAP ceased within 24 hours of drain
removal.

Operation duration

Oral antibiotics

Median (range)

109.5 mins (47 - 375)

Number of operations > 240 mins##

5/88

(5.6%)

Invasive devices

Cases

(%)

Oral cephalexin was used in 10/88 patients, but whether the

intention was to treat or prevent infection could not be
ascertained.

Drain tubes

87/88

(98%)

Median insertion duration (range)

1 day

(1 - 3)

Indwelling urinary catheter

50/88

(56.8%)

Tourniquet application

Median insertion duration (range)

3 days

(1 - 11)

Tourniquet application was used exclusively in patients

undergoing knee arthroplasties. None of these patients
received a larger dose of a PAP antibiotic and the timing of
the administration of the 1st dose of the PAP in relation to
the application of a tourniquet was unable to be accurately
determined.

* Tourniquets were used exclusively in knee replacement surgery

# All operations except 1 were one-stage revisions
## Additional doses of intraoperative antibiotics were not administered in any of
these prolonged operations.

Table 1. Individual surgeons prophylaxis protocols compared to Antibiotic Guidelines.

ANTIBIOTIC

DOSE AT
INDUCTION

DOSE POST- OP

DURATION

INDWELLING URINARY
CATHETER

cephazolin

1g

1g 8/24 IV

Until drain removed

cephalexin (if not on IV cephazolin) 48 hours after IDC removal

cephazolin
cephalexin

1g

1g 8/24 IV
500mg 6/24 orally

12 hrs after drain removal If required

trimethoprim

cephalothin*
gentamicin*

1g
160mg

1g 6/24 IV
160mg daily IV

1 dose after drain removal

Total 3 doses

no prophylaxis recorded

cephazolin

1g

1g 8/24 IV

One day

gentamicin 80mg IV x1

cephazolin
gentamicin
or other antibiotic

1g

cephalothin

1g

Australian
Guidelines

cephalothin OR
cephazolin

2g
1g

Until 1 dose given after drain removal

1g 12/24 IV
as prescribed by surgeon

8 doses
Single dose at induction
Repeat dose if operation > 3 hours

gentamicin (dose not specified)

gentamicin 80mg IV x1
no prophylaxis recommended

* No antibiotics for revision TJR until after intra-op specimens taken

ASA Newsletter, December 2003

Allergies
Two patients with a history suggestive of
type 1 hypersensitivity reaction to penicillin
were prescribed and administered
cephalothin as PAP.

Discussion
The surveyed antibiotic prophylaxis
protocols were directed at junior medical
staff who often lack the experience
necessary to make informed judgements
about antibiotic administration. Outdated
and ambiguous surgical protocols can be the
source of confusion and inconsistent
medical management of patients.

Antibiotic choice and duration

1st generation cephalosporins have been
shown to have good serum and bone
concentrations, are active against bacteria
responsible for up to 80% of prosthetic joint
infections, and have a low toxicity profile.5
The recently updated Australian
Antibiotic
Therapeutic
Guidelines
recommend IV cephalothin (2g) or
cephazolin (1g) as prophylaxis for elective
joint replacement surgery, with the dose
given at the time of induction of
anaesthesia.4 Other literature suggests that
dosing of up to 24 hours is appropriate6;
prolonged use is not associated with reduced
infection rates but may result in increased
rates of acquisition of MRSA7.
The choice of cephalothin was appropriate
amongst all of the surgeons; the dosage used
was 1g and the post-operative duration of
administration was mostly 48 hours.
Although only two of the six protocols
examined accommodated the hospital
pharmacy formulary change from cephazolin to cephalothin, only one recognised
and recommended the appropriate dose
interval. Despite this, in the majority of
cases where the PAP protocol recommended
8-hourly cephazolin, cephalothin was substituted and prescribed at the appropriate
dose interval.
The use of gentamicin both in PAP and
related to IDC manipulation was the area of
greatest discrepancy from the protocols in
the operations surveyed. The dosage and
method of administration of gentamicin was
inconsistent in both the surgical protocols
(Table 1) and in clinical practice, with no
standardised consideration given to either
the patients weight or creatinine clearance
in determining gentamicin dosage - a factor
that can affect both efficacy and toxicity.
The benefit of the routine use of gentamicin
in uncomplicated urinary catheterisation
remains debatable.8 The Australian
guidelines do not recommend the routine

ASA Newsletter, December 2003

use of gentamicin in PAP4, however single

doses are recommended by others.9
In none of the 5 operations surveyed which
were more than 4 hours in duration, were
additional doses of antibiotics given after
the PAP at induction of anaesthesia. A
review of the literature supports the use of
additional doses of antibiotics in long
operations.9 For operations more than 3
hours in duration, the Australian
guidelines recommend the administration
of a second dose of the b-lactam PAP.4
Extending PAP until invasive drainage
devices are removed, a consideration in four
of the six surveyed protocols, is of unproven
benefit,10 and more likely to promote
MRSA colonisation.7

Compliance with the

existing protocols was
inconsistent and protocols
were potentially confusing
for resident staff to
follow
Tourniquet application
Evidence exists in the literature to support
the administration of antibiotics no less than
5 minutes prior to the application of a
tourniquet.11 All patients were given PAP
prior to tourniquet application, however the
time from PAP administration to tourniquet
inflation was not sufficiently accurately
documented to enable this aspect of PAP
management to be studied. A review of the
literature identified one study which demonstrated a significant reduction in peak bone
levels of cephazolin in knee replacement
surgery (where tourniquets are routinely
used), compared to hip replacement surgery.
The authors of this study recommend
doubling the dose of cephazolin at induction
in order to achieve comparable bone levels
in knee surgery.12 None of the patients to
whom an intraoperative tourniquet was
applied were given more than 1g of cephalothin, and the Australian guidelines
recommend 2g of cephalothin as PAP.4

Drug allergies

MRSA status
None of the PAP surgical protocols made
specific recommendations for PAP in
patients colonised with MRSA. The recent
guidelines recommend the use of IV
vancomycin. Interestingly, screening for
MRSA colonisation in elective surgery (that
is, in patients without risk factors for MRSA
colonisation) did not yield any positive
cultures.

Conclusions
In short, compliance with the existing PAP
protocols was inconsistent and potentially
confusing for resident staff to follow at our
hospital. The PAP protocols promoted
longer duration of antibiotic use than
recommended; most guidelines were
ambiguous with respect to gentamicin use
and did not account for several important
patient and operative factors such as the
patients weight and renal function. The
Therapeutic Antibiotic guidelines are an
ideal frame-work on which to improve
existing PAP protocols. Such best-practice
guidelines, if adopted unit-wide, would
improve resident prescribing, and promote a
more rational and regimented approach to
antibiotic use.

References
1. Hill C. et al. Lancet 1981;1:795-796.
2. Espehaug B. et al. J Bone & Joint Surg
(British) 1997;79:590-595 .
3. Dettendofer M. et al. Infection
2002;30:164-167.
4. Antibiotic Guidelines Writing Group.
Therapeutic Guidelines: Antibiotic
Version 12. Melbourne: Therapeutic
Guidelines Ltd; 2003.
5. McEniery D.W. et al. Drugs
1987;34 (Suppl 2)216-239
6. Mauerhan D.R. et al. J Bone & Joint Surg
1994; 76:39-45
7. Muller A.A. et al. Clin Infect Dis
2003;36:971-8
8. Mickelson J.D. et al. NEJM
1988;319:321-326
9. Vogley H.C. et al. Reviews in Medical
Microbiology 2000;11:223-231
10. Gillespie W.J., Clin Infect Dis
1997;25:1310-1317
11. Friedman R.J. et al. Clin Ortho & Related
Research 1990;260:17-23
12. Cunha B.A. et al. Infection 1984;12:80-84

Cephalosporins were given to patients with

a history suggestive of anaphylaxis to
penicillins. The Australian guidelines
recommend the use of IV vancomycin or
teicoplanin instead, as -lactam antibiotics are contraindicated in such
patients.4

Correlating the detection of vanB genes in faeces to the presence of vancomycinresistant enterococci (VRE): interference by vanB-containing anaerobes

S.A. Ballard , E.A. Grabsch , S. Xie , P.D.R. Johnson , M.L. Grayson

1

1,2

1,2

Depts of Infectious Diseases and Microbiology, Austin and Repatriation Medical Centre, Melbourne.
2
Dept of Medicine, University of Melbourne, Melbourne.

Introduction
VRE colonisation and infection is
increasingly common in Australian
hospitals. Acquired vancomycin resistance
in enterococci encoded by the vanB operon
explains the majority of VRE isolates, and
the vanB2 allele linked to a Tn1549-like
element appears to dominate.1,2
Recently, the presence of the vanB operon
has been described in organisms other than
enterococci. These organisms include
Streptococcus bovis isolated from a stool
swab and four unrelated anaerobic
organisms isolated from faecal samples.7,9
Three of these organisms were from the
genus Clostridium and the fourth from the
genus Eggerthella. In both reports, the
patients
were
undergoing
routine
surveillance for VRE.
Many multiplex PCR protocols and primer
sets have been developed for the detection
of van genes in pure isolates of enterococci
(reviewed in reference 4). Although
conventional culture methods for the
detection of VRE are sensitive, the time
required to isolate organisms takes 3-5 days.
More recently, PCR protocols have been
described for the direct detection of van
genes from clinical samples or enrichment
broth cultures.5,6,8 However, the presence of
vanB in non-VRE isolates could lead to an
unacceptably high false positive rate when
screening by PCR for VRE carriage.
In this study, we set out to assess the
sensitivity (and specificity) of three vanB
PCR protocols on three different enrichment
broth cultures of faeces to identify both
VRE carriage and vanB gene carriage in a
mixed culture. In a random sample of those
specimens that were VRE culture negative /
vanB PCR positive, attempts were made to
isolate the source of the vanB signal to
establish the impact vancomycin resistant
organisms, other than enterococci, might
have on the performance of a vanB PCR for
detection of VRE.

Methods
Three growth media (anaerobic brain heart
infusion broth, AnO2 BHI; aerobic brain
heart infusion broth, BHI; and enterococcosel broth, EB) were used to culture
faecal specimens from 59 well-characterised

patients (12 vanB VRE culture positive and

47 VRE culture negative). Enrichment broth
cultures were screened for the presence of
vanB using three different PCR protocols.
Carriage of VRE was reconfirmed on all
broth cultures. Specimens positive for vanB
by PCR, but VRE culture negative were
further assessed for the presence of other
vanB containing organisms.

Results
The sensitivity and specificity of vanB PCR
protocols for the detection of VRE in
enrichment broths were as follows:

BHI broth

Primer/ PCR
A: Stinear et

al 9

B: Bell et al1
C: Dutka-Malen et

al 3

should be taken interpreting the results of

PCR-based detection of VRE when using
enrichment broth cultures as the presence of
vanB-containing anaerobes may cause false
positive results in PCR.

References
1. Bell et al. J. Clin. Microbiol. 1998;36;21872190.
2. Berry et al. Abstract no. 22, 3rd Annual
Meeting of the Australian Society of
Antimicrobials, Sydney, Australia, 2002
3. Dutka-Malen et al. J. Clin. Microbiol.
1995;33: 24-27

AnO2BHI broth

EB broth

Sensitivity

Specificity

Sensitivity

Specificity

Sensitivity

Specificity

92%

49%

92%

43%

100%

51%

92%

60%

92%

45%

92%

83%

67%

96%

59%

94%

17%

100%

While primer/PCR protocol A and B

gave the best sensitivity, primer C had the
best specificity for VRE. Six Gram-positive
anaerobic bacilli from the order

vanB-containing
anaerobes may cause
false positive results in
PCR-based detection of
VRE directly from faecal
specimens
Clostridiales were isolated from 5
specimens that were vanB PCR positive but
VRE
culture
negative.
Isolates
demonstrated the presence of the vanB
operon linked to a Tn1549 - like transposon.

Conclusions
The sensitivity of PCR detection of
vanB/VRE carriage directly from faecal
specimens is dependent on the primer set
and media used. Moreover, as the sensitivity
of the vanB PCR protocol increases, so the
specificity of the test for VRE decreases
with the primer/PCR protocol of Bell et al.,
providing the best balance of sensitivity and
specificity. Since carriage of vanB is not the
exclusive domain of enterococci, care

4. Facklam et al. In M.S. Gilmore (ed.), The

Enterococci. ASM Press, Washington, D.C,
2002.
5. Lu et al. Epidemiol. Infect. 2001;126:357363.
6. Palladino et al.
J. Clin. Microbiol.
2003;41:2483-2486
7. Poyart et al. Antimicrob. Agents. Chemother.
1997;41:24-29.
8. Satake et al. J. Clin. Microbiol.
1997;35:2325-2330
9. Stinear et al. Lancet 2001;357:855-856

2003 AstraZeneca ASA

ICAAC Travel Award
Congratulations to Susan Ballard, of the
Dept of Infectious Diseases at the Austin
and Repatriation Medical Centre in
Victoria. She was the winner of the 2003
AstraZeneca ASA ICAAC Travel Award
for her ICAAC (Interscience Conference
on Antimicrobial Agents and Chemotherapy) abstract. The Award consisted of
a return economy airfare, accommodation
and conference registration to attend
ICAAC, and will be offered again in
2004. The next ICAAC is in Washington
DC in November 2004. ASA members
who wish to apply for the award are
invited to submit their ICAAC abstracts to
the ASA secretary, Dr Keryn Christiansen
at keryn.christiansen@health.wa.gov.au
prior to the ICAAC abstract closing date.
We thank AstraZeneca for their ongoing
support.

ASA Newsletter, December 2003

The inability of the NCCLS disc diffusion oxacillin interpretive breakpoint

for Staphylococcus aureus to reliably detect oxacillin susceptible
Staphylococcus lugdunensis

Cheryll McCullough, Geoffrey Coombs, Sandra Rodgers

and Keryn Christiansen
Dept of Microbiology and Infectious Diseases, Royal Perth Hospital, Western Australia

Introduction
Staphylococcus lugdunensis was first
described by Freney et al in 1988 and is now
widely accepted as a significant pathogen,
although there continues to be a problem of
low awareness of the organism among
clinicians and laboratory staff. It is a
coagulase negative staphylococcus that
more closely resembles S aureus in its
pathogenicity. It has been implicated in a
variety of infections including endocarditis,
septicaemia, breast abscesses, orthopaedic,
skin and soft tissue infections.
In 1999, NCCLS introduced an oxacillin
interpretive breakpoint for disc diffusion
testing of coagulase negative staphylococci
(CNS). However this breakpoint was
established primarily for S epidermidis and
may not be suitable for other CNS (eg S
lugdunensis)

NCCLS guidelines for

staphylococci

not shown to carry mecA or do not produce

PBP2a should be reported as oxacillin
susceptible.
Most laboratories, however, do not have
access to molecular methods for the
detection of the mecA gene, and the
accuracy of phenotypic assays for the
detection of PBP2a in CNS has not been
determined. As the NCCLS CNS disc
diffusion oxacillin breakpoints often
misclassify mecA gene negative strains as
oxacillin resistant, we investigated if the

Oxacillin susceptibility
testing of S lugdunensis
can be determined by MIC
testing on MHA with 2%
NaCl added using NCCLS
S aureus interpretive
breakpoints

Table 1. Prior to 1999 - Single NCCLS breakpoint for all staphylococci

Ox Disc
(zone diameter)

OX MIC

Interpretation

mecA gene

> 12mm
??

> 4mg/L
??

RESISTANT

DETECTED

> 13mm
??

> 2mg/L
??

SUSCEPTIBLE

NOT DETECTED

Table 2. 1999 - Introduction of CNS breakpoint by NCCLS

Ox Disc
(zone diameter)

OX MIC

Interpretation

mecA gene

> 17mm
??

> 0.5mg/L
??

RESISTANT

DETECTED

> 18mm
??

> 0.25mg/L
??

SUSCEPTIBLE

NOT DETECTED

In 2002 - NCCLS added the following

comment to the guidelines for interpreting
oxacillin zone diameters: Interpretive
criteria for CNS correlate with the mecA
gene for S epidermidis. These criteria may
overcall resistance for other CNS eg S
lugdunensis or S saprophyticus. For serious
infections with CNS other than S.
epidermidis, testing for mecA or the protein
expressed by mecA, the penicillin binding
protein 2a (PBP2a) may be appropriate for
strains with zone diameters in the intermediate or resistant range. Isolates that are

ASA Newsletter, December 2003

NCCLS S aureus disc diffusion breakpoint

may be more reliable for detecting oxacillin
susceptible S lugdunensis. Although S
lugdunensis is generally considered
oxacillin susceptible, in January 2003 a
mecA gene positive strain with an oxacillin
MIC of >256mg/L was reported (Tee et al,
2003).

Method
From March 1998 to February 2003, 70
clinical isolates of S lugdunensis were

collected at Royal Perth Hospital and the

Womens and Childrens Hospital in Perth,
Western Australia. All isolates were
identified by a phenotypic disc method or by
bioMrieux ID32 STAPH API. A multiplex
PCR for the presence of mecA and nuc gene
was performed on all isolates. Oxacillin
susceptibility testing was performed by
Kirby-Bauer disc diffusion using NCCLS
interpretive guidelines (M100-S12 Jan
2002) and oxacillin minimum inhibitory
concentrations (MICs) were determined
using Etest (AB Biodisk) on Mueller
Hinton Agar (MHA) with 2% NaCl added.

Results
MecA / nuc gene PCR testing (n = 70)
All isolates were mecA and nuc gene
negative.
Kirby-Bauer Disc Diffusion testing (n = 70)
Using the CNS oxacillin interpretive
> 18mm = susceptible), only
breakpoint (??
3 isolates (4%) were classified as oxacillin
susceptible.

Using the S aureus oxacillin interpretive

> 13mm = susceptible), 47
breakpoint (??
isolates (67%) were classified as oxacillin
susceptible.
Minimum Inhibitory Concentration (MIC)
(n = 67)

Using the CNS oxacillin interpretive

> 0.25mg/l = susceptible),
breakpoint (??
only 1 isolate (1%) was classified as
oxacillin susceptible.
Using the S aureus oxacillin interpretive
> 2mg/l = susceptible), all 67
breakpoint (??
isolates (100%) were classified as
oxacillin susceptible.

Discussion
The NCCLS CNS disc diffusion and MIC
oxacillin interpretive breakpoints were not
suitable for S lugdunensis.
Although the NCCLS S aureus disc
diffusion oxacillin interpretive breakpoint
was not reliable for S lugdunensis, the
NCCLS MIC interpretive breakpoint
correctly classified all isolates as oxacillin
susceptible.

Conclusions
Clinically significant CNS requiring
susceptibility testing should be fully
identified.
NCCLS CNS and S aureus disc diffusion
interpretive breakpoints for oxacillin are
not reliable for S lugdunensis.
Oxacillin susceptibility testing of S
lugdunensis can be determined by mecA
gene PCR or by MIC testing on Mueller
Hinton Agar with 2% NaCl added using
NCCLS S aureus interpretive breakpoints.

Acknowledgements
Dr Michelle Porter from the Womens and
Childrens Hospital and Dr Sue Benson
from St John of God Pathology for
supplying clinical isolates.

References
Freney J, Brun Y, Bes M et al. Staphylococcus
lugdunensis sp. nov. and Staphylococcus
schleiferi sp. nov., two species from human
clinical specimens. Int J Syst Bacteriol.
1988;38:168-172
Tee WS, Soh SY, Lin R, Loo LH.
Staphylococcus lugdunensis carrying the
mecA gene causes catheter-associated
bloodstream infection in premature neonate
J Clin Micro 2003;41:519-520
NCCLS. Performance Standards for
Antimicrobial Susceptibility Testing; Twelfth
Informational Supplement. NCCLS document
M100-S12, Jan 2002. Vol.22 No 1
NCCLS. Performance Standards for
Antimicrobial Susceptibility Testing; Ninth
Informational Supplement. NCCLS document
M100-S9, Jan 1999. Vol.19 No 1
NCCLS. Performance Standards for
Antimicrobial Susceptibility Testing; Eighth
Informational Supplement. NCCLS document
M100-S8, Jan 1998. Vol.18 No 1

2003 NHMRC project grants awarded for research

into antimicrobial agents
Years

Total
funding

Multidrug resistance in hospital strains

of Golden Staph

$490,500

Ron Skurray
Melissa Brown

Control of multidrug resistance genes in

hospital strains of Golden Staph

$451,750

Lesley Roy
Jonathan Carapetis
Graham Reynolds
Judy Simpson
Elisabeth Hodson

Do long-term antibiotics prevent urinary

tract infection?

$367,725

Ron Skurray
Neville Firth
Stephen Kwong

Antibiotic resistance in hospital strains

of Golden Staph

$425,250

Shelley Walton
James McCarthy
Bart Carrie
Deborah Holt

Drug resistance in scabies

$506,625

Nicholas Graves
Peter Collignon
Michael Whitby
Diana Battistuta
Frances Birrell
Tony Pettitt

What should be done to prevent

bloodstream infections in hospitalised
patients?

$117,000

Development of lactobacilli as pathogen

killers

$267,750

Nigel Stocks
John Turnidge
Alan Crockett
Anthony Veale

Acute bronchitis in general practice: can

antibiotics help some patients?

$388,875

Roger Nation
Jian Li
John Turnidge
Kingsley Coulthard
Robert Milne
Craig Rayner

Improving use of an old last-line

antibiotic

$262,125

Ways of improving the use of a last-line

antibiotic

$133,513

Investigators

Lay Title

Melissa Brown
Ron Skurray

Mark Turner

Craig Rayner

$3,411,113

TOTAL FUNDING

2003 BioMrieux ASA Identifying Resistance award

Congratulations to Cheryll McCullough of the Dept of Microbiology and Infectious Diseases at the Royal
Perth Hospital, the winner of the 2003 BioMrieux ASA Identifying Resistance award. This award is
given to an individual ASA member for the best proffered paper (oral or poster) at the ASA annual
scientific meeting on the identification of bacterial resistance to antimicrobials in a routine clinical setting.
It consists of A$1000 cash prize, a commemorative plaque, and a travel award (flights, accommodation
and registration) to attend the next ASA annual scientific meeting. This award will be offered again in
2004 and all abstracts submitted for the ASA 2004 meeting on the identification of bacterial resistance to
antimicrobials in a routine clinical setting will be considered for this award. We thank BioMrieux for
their ongoing support.

ASA Newsletter, December 2003

Picture Quiz

n July 2003, an elderly man presented to

hospital with a purulent discharge from a
suprapubic catheter site.
This was
swabbed for culture.
The swab was inoculated onto horse blood
agar and MacConkey plates. After 24 hours
incubation at 35 C, there was a pure growth of
S aureus and Group G Streptococcus. Figure 1
shows a disc susceptibility test for S aureus
(penicillin 10 ug disc on the left, tetracycline
10 ug disc on the right). Figure 2 shows an
oxacillin E test for S aureus.
Comment on the disc sensitivity patterns in
Figure 1.
Comment on the E test result in Figure 2.

Figure 1

What needs to be done to sort out this

finding?
Please email your responses to the ASA
Newsletter Editor Wendy Munckhof at
w e n d y _ m u n c k h o f @ h e a l t h . q l d . g o v. a u .
Answers will be published in the next issue,
and correct responses will be acknowledged.
Picture quiz provided by Dr Joan L Faoagali
and Jan Bodman, Royal Brisbane Hospital.
Photographs by Cassy Faux.

Figure 2

NEWSLETTER CONTRIBUTIONS
Submission of articles for possible publication or letters
to the editor should be sent to:
Dr Wendy Munckhof,
ASA Newsletter Editor,
Infection Management Services Southern Queensland,
Princess Alexandra Hospital,
Ipswich Rd, Woolloongabba,
Brisbane, QLD 4102
Telephone: (07) 3240 5920
Facsimile: (07) 3240 5540
Email: wendy_munckhof@health.qld.gov.au

ASA Newsletter, December 2003

ASA SUBSCRIPTIONS
Subscriptions should be sent to:
Geoffrey Coombs
ASA Treasurer
Dept. of Microbiology & Infectious Diseases,
Royal Perth Hospital
GPO Box X2213
Perth WA 6001
Telephone: (08) 9224 2446
Facsimile: (08) 9224 1989
Email:geoffrey.coombs@health.wa.gov.au

Answer to Picture Quiz from ASA newsletter No. 14 Sept. 2003

On the right is a photo of an isolate of Candida albicans
from a mouth swab of an AIDS patient with oral candidiasis.
A RPMI agar plate has been incubated aerobically for 48
hours at 35 C. The disc is a Fluconazole 25 mg NeoSensitab
and the Etest is for Fluconazole.
Please read the Etest MIC for Fluconazole.
Fluconazole MIC is 0.05 mg/ml or 1.0 mg/ml.
According to current NCCLS recommendations, when
should Etests be read for yeasts?
The recommended incubation time for yeast Etests is 48
hours. However the new revised NCCLS M27-A2
document does provide 24 hr QC ranges, so that tests for
Candida may be read at 24 hrs.
Why is trailing seen with the Etest and not the disc?
Etests commonly overestimate the yeast MIC for
Fluconazole due to trailing. Trailing can also occur in disc
methods for yeast Fluconazole susceptibility testing but is
less common. The reason for trailing MICs is unknown.
How common is it for Candida albicans to have trailing
end points when tested against fluconazole?
When read at 48 hrs, 20% of Candida albicans strains
show trailing end points when tested against Fluconazole.

Reference
NCCLS Reference method for broth dilution antifungal susceptibility
testing of yeasts; approved standard - Second edition. NCLLS
document M27-A2 [Vol 22 No. 15 August 2002]. This replaces M27A [Vol. 17 No. 9].
Picture quiz and answers provided by David Ellis, Womens &
Childrens Hospital, Adelaide.

ASA Hospital Antibiotic Usage Survey reminder

SA is conducting the third Antibiotic

Usage Survey in major hospitals
around Australia, following previous
surveys in 1986 and 1992. Survey forms
were sent to Chief Pharmacists, Infectious
Disease Physicians and / or Clinical
Microbiologists in major hospitals around the
country in January 2002 and have
subsequently been resent.
Thank you to the 32 hospitals that have
returned completed the 2-page survey forms.
Unfortunately, 17 hospitals have still not
replied to date. Could any ASA members on
staff at these hospitals please ensure they do
so! Data cannot be analysed until most of
these hospitals return completed surveys.
Please contact Dr Mike Whitby (07) 3240
2595) if you need another survey form.
This is a list of the hospitals that were sent
the survey.
ACT
The Canberra Hospital
NT
Royal Darwin Hospital

NSW
Westmead Hospital
St Vincents Hospital
Prince of Wales Hospital
St George Hospital
Nepean Hospital
Royal Prince Alfred Hospital
Concord Repatriation General Hospital
Wollongong & Port Kembla Hospital
Royal North Shore Hospital
John Hunter Hospital
Liverpool Hospital
New Childrens Hospital Westmead
VIC:
Alfred Hospital
Monash Medical Centre
Royal Childrens Hospital
Royal Womens Hospital
Western Hospital
Box Hill Hospital
Geelong Hospital
Royal Melbourne Hospital
St Vincents Hospital
Austin & Repatriation Medical Centre
QLD:
Toowoomba Hospital
Rockhampton Hospital

Mater Public Hospital

Royal Brisbane Hospital
Princess Alexandra Hospital
Prince Charles Hospital
QE II Hospital
Gold Coast Hospital
Ipswich Hospital
Mackay Base Hospital
Townsville General Hospital
Cairns Base Hospital
SA:
The Queen Elizabeth Hospital
Repatriation General Hospital
Royal Adelaide Hospital
Womens and Childrens Hospital
Flinders Medical Centre
Modbury Hospital
Lyell McEwin Health Service
WA
Royal Perth Hospital
Princess Margaret Hospital for Children
Sir Charles Gardiner Hospital
Fremantle Hospital
TAS
Royal Hobart Hospital
Launceston Public Hospital

ASA Newsletter, December 2003

Stability of some commonly used home intravenous antibiotics

Henry K. Lie , Julia Carroll
1

Senior Pharmacist, Centralised Intravenous Additive Services (CIVAS), Dept of Pharmacy, King Edward Memorial
Hospital for Women and Princess Margaret Hospital for Children, Womens and Childrens Health Service, Perth
2

Senior Pharmacist, Alternative Site Infusion Service (ASIS), Infection Management Service,
Princess Alexandra Hospital, Brisbane
STABILITY in
elastomeric devicesb

DRUG

DILUENT

STABILITY in syringesa

Aciclovir 500mg

NaCl 0.9%,
Water for injection (WFI)

7 days at room temperature.1,2

29 days at room temperature.3
Refrigeration causes crystallisation of drug Refrigeration causes
crystallisation of drug

Amikacin 2.5mg/mL

NaCl 0.9%

14 days refrigerated4,5,6

Amoxicillin 10-50mg/mL

NaCl 0.9%

Unstable (3-8 hours stability only at room temperature, up to 3 days

refrigerated) 7,8,9

Ampicillin 125 mg/ml

WFI

Unstable, similar to amoxicillin at room temperature, up to 2 days

refrigerated10

Aztreonam 20mg/mL

WFI
NaCl 0.9%

7 days refrigerated11,12

14 days refrigerated,
30 days frozen13

Benzyl Penicillin 3g
Cefotaxime 100mg/mL

Sodium citrate 4%
WFI

14 days refrigerated14
7 days refrigerated. 3 months at -20C
plus 7 days refrigerated when thawed.
Once thawed, should not be refrozen10,16

7 days refrigerated15
10 days refrigerated.
30 days frozen plus 24hours
post thawing.13

Cefepime 100mg/mL

WFI

3 months at -20C plus 7 days refrigerated

when thawed. Once thawed, should not be
refrozen17,18

14 days refrigerated3

Cefoxitin 2g
Ceftazidime 100mg/mL

WFI
WFI

7 days refrigerated19
7 days refrigerated. 3 months at -20C
plus 7 days refrigerated when thawed.
Once thawed, should not be refrozen16,20

10 days refrigerated13
7 days refrigerated13

Ceftriaxone 100mg/mL

WFI

7 days refrigerated. 3 months at -20C plus 10 days refrigerated.

7 days refrigerated when thawed. Once
30 days frozen plus 24 hours
thawed, should not be refrozen21,22
post thawing.13

Cephazolin 1g

WFI

7 days refrigerated.19 3 months at -20C

plus 7 days refrigerated. Once thawed,
should not be refrozen.11,16,19,23

Dicloxacillin
Flucloxacillin 100mg/mL

WFI
WFI

Unsuitable for home IV use due to particle precipitation

7 days refrigerated10
Manufacturer states 3 days
refrigeration.

Gentamicin 10mg/mL
Meropenem 50mg/mL

NaCl 0.9%
WFI

14 days refrigerated24
6 months at -60C25 48 hours
refrigerated25

Teicoplanin

WFI

Unstable in plastic due to leaching of silicone particles.

Manufacturer recommends storage in glass vial or glass syringe for up to
7 days refrigerated27

Ticarcillin/Clavulanic
Acid 100mg/mL

WFI

7 days refrigerated.3 months at -20C

plus 7 days refrigerated when thawed.
Once thawed, should not be refrozen16

7 days refrigerated3

Tobramycin

Diluted to 30mL with

NaCl 0.9%

14 days refrigerated28

10 days refrigerated13

Vancomycin 5mg/mL

NaCl 0.9%

3 months refrigerated29

14 days refrigerated3

10 days refrigerated,
30 days frozen3

10 days refrigerated,
30 days frozen plus 24 hours
post thawing.13

10 days refrigerated13
4 days refrigerated plus 6
hours at room temperature26

Footnote. Refrigeration refers to 2- 8C

ASA Newsletter, December 2003

a. Information on stability in syringes

supplied by Henry K Lie of the
Princess Margaret Hospital for
Children (PMH) CIVAS department,
Perth. This department routinely
supply home antibiotics for cystic
fibrosis patients, cancer patients, and
patients
with
cellulitis
and
osteomyelitis. The antibiotics are first
diluted using either normal saline or in
most cases water for infusion to 30mL.
These are supplied in 30mL Braun
syringes which fit into a springfusor
and are infused over 15 minutes (2 to 3
times daily). The antibiotics are
supplied in ready to use syringes
usually one week at a time, depending
on stability. Most commonly used
home antibiotics are stable in the
refrigerator for at least one week with
the following exceptions: amoxicillin
(2-3 days), ampicillin (2-3 days),
meropenem (2 days), aciclovir (stored
at room temperature) and dicloxacillin
(unsuitable for home use due to particle
precipitation).
b. Information on stability in elastomeric devices supplied by Julia Carroll
of the Princess Alexandra Hospital
Alternative Site Infusion Service
(ASIS). This service supplies
antibiotics in elastomeric devices for in
the home administration, mostly for
adult patients with surgical wound
infections, osteomyelitis, synovitis,
cellulitis, diabetic foot infections, and
occasionally for cystic fibrosis
patients. Antibiotics requiring reconstitution are reconstituted with water for
injection (exception being Benzyl
Penicillin which is reconstituted with a
Sodium Citrate buffer) and added to
elastomeric devices filled with required
amount of normal saline.
Most
antibiotics are infused over 24 hours in
disposable elastomeric devices or
programmable pumps, with the
exceptions vancomycin (infused over 2
hours) and aminoglycosides (infused
over 30 - 60 minutes). All preparation
is carried out in a clean room in a
vertical laminar flow cabinet. An
additional concern with stability in
elastomeric devices is stability at 31 C
over 24 hours, 31 C being skin
temperature under clothing.
The
devices are worn in a waist pouch. This
demand for stability at higher than
normal room temperature accounts for
some of the differences in stability
compared with syringes.
10

References
1. Zhang YP, Trissel LA, Martinez JF, et
al. Stability of acyclovir sodium 1, 7,
and 10mg/mL in 5% dextrose injection
and 0.9% sodium chloride injection. Am
J Health-Syst Pharm 1998;55:574-577.
2. Gupta VD, Pramar Y, and Bethea C.
Stability of acyclovir sodium in
dextrose and sodium chloride injections.
J Clin Pharm Ther 1989; 14: 451-456.
3. Guidelines for the administration of
drugs using the Homepump /
Homepump Eclipse disposable
elastomeric infusion systems. Lake
Forest, CA: I-Flow Corporation; 1996.
4. Kaplan MA, Coppola WP, Nunning
BC, et al. Pharmaceutical properties and
stability of amikacin: part 1. Curr Ther
Res 1976;20:352-358.
5. Nunning BC and Granatek AP. Physical
compatibility and chemical stability of
amikacin sulfate in large-volume
parenteral solutions, part ii. Curr Ther
Res Clin Exp 1976;20:359-368.
6. Zbrozek AS, Marble DA, Bosso JA, et
al. Compatibility and stability of
clindamycin phosphate-aminoglycoside
combinations within polypropylene
syringes. Drug Intell Clin Pharm
1987:21:806-810.
7. Cook B, Hill SA, Lynn B. The stability
of amoxycillin sodium in intravenous
infusion fluids. J Clin Hosp Pharm
1982;7:245-250
8. Lynn B. The stability and administration
of intravenous penicillins. Br J Intraven
Ther 1981;2:22-39
9. Needle R, Sizer T (Eds). The CIVAS
Handbook - The Centralised
Intravenous Additive Services
Reference. The Pharmaceutical Press,
London, 1998.
10. Ahmed ST, Parkinson R. The stability
of drugs in pre-filled syringes:
flucloxacillin, ampicillin, cefuroxime,
cefotaxime, and ceftazidime. Hosp
Pharm Pract 1992;2:285-289.

15. Drug stability guidelines for use with

the Secure Medical Medflo Elastomeric
Infusion system. Mudelein, IL: Secure
Medical: 1994.
16. McEvoy GK (ed). AHFS Drug
Information 2003. American Society of
Health-System Pharmacists, Bethesda.
17. Stewart JT, Maddox FC, Warren FW.
Stability of cefepime hydrochloride in
polypropylene syringes. Am J HealthSyst Pharm 1999; 56:1134.
18. Stewart JT, Warren FW, Maddox FC.
Stability of cefepime hydrochloride
injection in polypropylene syringes at 20C, 4C, and 22-24C. Am J Health
Syst Pharm 1999; 56:457-459.
19. Borst DL, Sesin GP, Cersosimo RJ.
Stability of selected beta-lactam
antibiotics stored in plastic syringes.
NITA 1987;10:368-372.
20. Stewart JT, et al. Stability of
ceftazidime in plastic syringes and glass
vials under various storage conditions.
Am J Hosp Pharm 1992;49:2765-2768.
21. Plumridge RJ, Rieck AM, Annus TP, et
al. Stability of ceftriaxone sodium in
polypropylene syringes at -20, 4 and
20C. Am J Health-Syst Pharm
1996;53:2320-2323.
22. OConnell C, Sabra K, Scott K.
Stability of reconstituted ceftriaxone
solution in polypropylene syringes. Eur
Hosp Pharm 1996; 2:47-48.
23. Carone SM, Bornstein M, Coleman DL,
et al. Stability of frozen solutions of
cefazolin sodium. Am J Hosp Pharm
1976;33:639-641.
24. Parkinson R, et al. The stability of
drugs in prefilled syringes. Hosp Pharm
Pract 1991;1:243-252
25. Lim CB. Stability of meropenem in
various intravenous fluids. Abstract for
the 24th Federal Conference of the
Society of Hospital Pharmacists of
Australia, 1999.
26. Kramer I. Stability of meropenem in
elastomeric portable infusion devices.
Eur Hosp Pharm 1997;3:168-171.

11. Physicians Desk Reference, 53rd

edition. Medical Economics Company.
Montvale, New Jersey, 1999.

27. Aventis Pharma. Personal

communication, 2003.

12. James MJ, Riley CM. Stability of

intravenous admixtures of aztreonam
and ampicillin. Am J Hosp Pharm
1985;42:1095-1100.

28. Seitz DJ, Archambault JF, Kresel JJ, et

al. Stability of tobramycin sulfate in
plastic syringes. Am J Hosp Pharm
1980; 37:1614-1615

13. Intermate / infusor drug stability

information. Deerfield, IL: Baxter
Healthcare Corporation; 1999.

29. Wood MJ, Lund R, Beavan M. Stability

of vancomycin in plastic syringes
measured by high-performance liquid
chromatography. J Clin Pharm Ther
1995;20:760-763.

14. Allwood MC, Brown PW. The stability

of benzylpenicillin injections. Pharm J
1991; 247 (Suppl):R12.

ASA Newsletter, December 2003

ANTIMICROBIALS 2004
PROGRAM
Novotel Brighton-Le-Sands, Sydney
Thursday 26th - 28th February, 2004
Plenary Speakers
Steven J Projan
New Drug Development
Director of Antibacterial Research,
Wyeth-Ayerst Research,
New York, USA
Steve has co-written over 60 original
scientific papers and has several areas of
interest including antimicrobial chemotherapy and resistance, genomics, microbial pathogenesis, and biotechnology. In
recent years his research has included
investigating antibiotic resistance in
bacteria from magpies and rabbits from
west Wales; identifying compounds that
inhibit the last steps of cell wall
biosynthesis; and using genomics to
detect novel antibacterial targets and
drugs. Steve is an enthusiastic orator
who brings both optimism and a fresh
approach to the conquest against
antimicrobial resistance.
In the words of Steve Projan.
Steven J Projan, PhD (Columbia 1990,
Molecular Genetics) is widely known for
his dilettantish approach to bacterial
pathogenicity,
antimicrobial
drug
resistance and anti-infective drug
discovery. Since 1988 he has directed a
group of dedicated scientists in antibacterial drug discovery at Wyeth
Research in Pearl River, New York, who
clearly deserve better. Dr Projan
identified tigecycline (GAR-936) as a
potential clinical candidate in 1994 by
blind dumb luck and fortunate timing, he
hopes to parlay that success into a
lucrative career in drug discovery and
standup comedy.

John Perfect
Antifungal Developments
Director
of
the
Mycology
Interdisciplinary Research Unit,
Professor of Medicine and Associate
Professor of Microbiology,
Duke Medical Center, North Carolina,
USA
John has over 200 published papers in
peer-reviewed journals to his credit and
has also co-authored a book on
ASA Newsletter, December 2003

Cryptococcus neoformans. John is a

member of numerous professional
societies and committees including the
American Society of Microbiology and
ISHAM. He is also an active researcher
in the field of medical mycology and a
lecturer on medical infectious diseases,
mycology and tropical medicine.

laboratory. The workshop will include

audience participation.

Ivan Bastian

Updated conference and accommodation

information will also be on the website

Laboratory and clinical aspects of

MDR TB in high- and low-prevalence
settings
Clinical Microbiology
IMVS, South Australia

Consultant,

Ivan is the laboratory representative for

the Australian National Tuberculosis
Advisory Committee which has recently
drafted guidelines for Australian mycobacteriology laboratories. His works in
the field of tuberculosis extend internationally including assisting with drug
susceptibility testing in East Timor, East
Java and the Pacific Islands. In 1998,
Ivan was awarded a Neil Hamilton
Fairley Fellowship to investigate improved diagnostics for tuberculosis in
low resource countries. Subsequently, he
has reviewed prison TB services in
Moldovia for Caritas Luxemburg and
worked in a TB prison laboratory in
Siberia. In 2000, Ivan was an editor for
the publication Multidrug-Resistant
Tuberculosis.

ESBL Workshop
Extended spectrum beta-lactamases
(ESBLs) originally detected in
Klebsiella pneumoniae and Escherichia
coli are now being detected in other
species of Enterobacteriaceae and Gram
negative
glucose
nonfermenters
throughout the world. New types are
emerging such as CTX-M and plasmidborne AmpC beta-lactamases. What is
the epidemiology of ESBLs in Australia
and what are the clinical implications?
When should laboratories test for these
organisms and what methods should be
used?
The ESBL workshop will discuss these
and other issues including discussion on
what confirmatory molecular tests are
available for the diagnostic microbiology

Registration and abstract

submission
Via conference website:
www.icms.com.au/asa2004

Dates to remember
Deadline for abstract submission:
19th December 2003
Abstract notification:
31st December, 2003
Close of early bird registration:
19th December 2003
(persons submitting accepted abstracts
will be able to register at early bird rate)
Accommodation booking deadline:
16th January, 2004

Antimicrobials 2004 Travel

Awards
Travel awards are available for ASA
members presenting a proffered paper
(oral or poster) at the conference. The
awards consist of return economy class
airfare, accommodation, conference
registration and a ticket to the Meeting
Dinner. Applicants should forward a
copy of their abstract to the Secretary
(keryn.christiansen@health.wa.gov.au)
before 19th December 2003.

2004 BioMrieux ASA

Identifying Resistance Travel
Award
This is awarded to an ASA member on
the basis of a proffered paper (oral or
poster) presented during Antimicrobials
2004 dealing with the identification of
bacterial resistance to antimicrobials in a
routine clinical setting. The award
consists of a A$1000 cash prize, a
commemorative plaque, and flights,
accommodation and registration for the
recipient to attend Antimicrobials 2005.
The award will be announced during the
ASA Meetings Dinner.

11

PRELIMINARY PROGRAM
Antimicrobials 2004 SYDNEY 26 - 28 FEBRUARY 2004 Novotel, Brighton Beach, Sydney
THURSDAY
0900 - 1000

FRIDAY

SATURDAY

Plenary 1

Plenary 2

Plenary 3

New Drug Development

Antifungal Developments

Laboratory and Clinical Aspects of

Steve Projan

John Perfect

MDR TB in High-and-Low Prevalence Settings

Ivan Bastian

MORNING TEA

1000 - 1030
1030 - 1200

Symposium 1

Symposium 3

Symposium 5

All Things Fungal

Genetics of Resistance 101

Who Benefits from Controlling Resistance

Current Perspectives on Fungal Infections

(Tania Sorrell)

Basic Principles (Ruth Hall)

Lessons from the Fields (Steve Powles)

Macrolide Resistance (Julian Rood)

Software Solutions (James Black)

Efflux Pumps (Melissa Brown)

The Industry? (Steve Projan)

What we know about Antifungal Therapies

(John Perfect)
Antifungal Prophylaxis - When and with What?

(Ken Bradstock)

1200 - 1400

LUNCH
POSTERS (Authors in Attendance)

LUNCH
Pfizer Pharmaceuticals Symposium

LUNCH
POSTERS

POSTERS
1400 - 1530

Proffered Papers 1

Proffered Papers 2

(six speakers)

(Six speakers)

ESBL Workshop
Introduction: The Expanding Spectrum of the
Extended Spectrums (Jan Bell)
Clinical Impact of ESBLs (John Turnidge)

AFTERNOON TEA

1530 - 1600
1600 - 1730

Symposium 2

Symposium 4

ESBL Workshop (cont)

Therapy of Emerging Diseases

State of the Art: Management of

Phenotypic Tests (Jan Bell)

Anthrax (Richard Lawrence)

Staphylococcal Infections -

Confirmatory/Molecular Tests (Phil Giffard)

SARS and other Respiratory Viruses

The ASA Guidelines

Question Time

(John Mills)

Introduction (Iain Gosbell)

Four Fatal Fungi -

Bacteraemia (David Mitchell)

Scedosporium/Fusarium/Penicillium/

Implant/Skin Soft Tissue (Sally Roberts)

Zygomycetes (John Perfect)

Pharmacokinetic/Pharmacodynamic
Considerations (Craig Rayner)

1730 - 1830

AGM

1830 - 1930

Welcome Reception

1900 - 2330

Conference Dinner

12

ASA Newsletter, December 2003