<clinical_study>
  <!-- This xml conforms to an XML Schema at:
    https://clinicaltrials.gov/ct2/html/images/info/public.xsd -->
  <required_header>
    <download_date>ClinicalTrials.gov processed this data on September 20, 2023</download_date>
    <link_text>Link to the current ClinicalTrials.gov record.</link_text>
    <url>https://clinicaltrials.gov/ct2/show/NCT01725841</url>
  </required_header>
  <id_info>
    <org_study_id>200809012R</org_study_id>
    <nct_id>NCT01725841</nct_id>
  </id_info>
  <brief_title>The Prevalence of Extend-Spectrum β-Lactamase (ESBL) Producing Isolates Among Common Enterobacteriaceae in Taiwan</brief_title>
  <official_title>The Prevalence of Extend-Spectrum β-Lactamase (ESBL) Producing Isolates Among Common Enterobacteriaceae in Taiwan</official_title>
  <sponsors>
    <lead_sponsor>
      <agency>National Taiwan University Hospital</agency>
      <agency_class>Other</agency_class>
    </lead_sponsor>
  </sponsors>
  <source>National Taiwan University Hospital</source>
  <oversight_info>
    <has_dmc>Yes</has_dmc>
  </oversight_info>
  <brief_summary>
    <textblock>
      Resistance to broad-spectrum cephalosporins through the acquisition and expression of&#xD;
      Extended-Spectrum β-lactamase (ESBL) among Enterobacteriacea is increasing. The clinical&#xD;
      implications of ESBLs are extremely serious and sensitive diagnostic methods are urgently&#xD;
      needed to guide therapy, monitor resistance development and implement intervention&#xD;
      strategies. Conventionally, detection of expression of ESBLs was based on reduction of&#xD;
      ceftazidime of cefotaxime MICs by ≥ 3 two fold dilutions in the presence of clavulanic acid.&#xD;
      However, the use of the above method was limited to cover only some of the bacterial species,&#xD;
      including predominantly E. coli and Klebsiella spp., or tested strains which were all&#xD;
      transconjugants generated in vitro. ESBLs are now reported in a growing number of genera&#xD;
      other than E. coli or Klebsiella spp., and Serratia marcescens.&#xD;
&#xD;
      Carbapenems, including ertapenem, imipenem and meropenem, are the drugs of choice used for&#xD;
      severe ESBL-producing bacterial infections. Failure to detect ESBL at the presence of AmpC&#xD;
      β-lactamase might result in an important clinical concern because 4th generation&#xD;
      cephalosporins, which are stable to AmpC β-lactamase, is not a drug of choice for severe&#xD;
      infections caused by ESBLs-producing isolates. Fluoroquinolone-resistance in ESBL-producing&#xD;
      Enterobacteriacea is common. In this study, the investigators will use isolates of&#xD;
      Enterobacteriacea collected from different hospitals (isolates offered by the Taiwan&#xD;
      Surveillance of Antimicrobial Resistance [TSAR] program) to investigate the susceptibility of&#xD;
      ertapenem and five other antimicrobial agents against ESBLs-producing Enterobacteriacea.&#xD;
    </textblock>
  </brief_summary>
  <detailed_description>
    <textblock>
      Materials and Methods&#xD;
&#xD;
        1. Collection of bacterial isolates&#xD;
&#xD;
           The staffs in National Health Research Institute have established a long term&#xD;
           surveillance of antimicrobial resistance from 22 to 44 hospitals distributed in all&#xD;
           parts of Taiwan-Taiwan Surveillance of Antimicrobial Resistance (TSAR) since 1998. It&#xD;
           has been conducted five times in year 1998, 2000, 2002, 2004, and 2006 and were named as&#xD;
           TSAR-I, TSAR-II, TSAR-III, TSAR-IV and TSAR-V. In this study, isolates of&#xD;
           Enterobacteriaceas from TSAR-IV will be recruited. Each 50 isolates of Escherichia coli,&#xD;
           Klebsiella pneumoniae, Proteus mirabilis, Enterobacter cloacae, Serratia marcescens, and&#xD;
           Morganella morganii will be enrolled (about 10% of the TSAR IV collected isolates) for&#xD;
           the following microbiological studies.&#xD;
&#xD;
           Isolates will be divided to ESBL-producing or non-producing groups by screening tests.&#xD;
           All the available isolates were identified to the species or genus level by means of&#xD;
           conventional methods. Isolates with same species recovered from the same an individual&#xD;
           patient, are considered one isolate. The isolates were all stored at -70℃ in trypticase&#xD;
           soy broth (Difco Laboratories, Detroit, MI) supplemented with 15% glycerol before being&#xD;
           tested.&#xD;
&#xD;
        2. Data Collection&#xD;
&#xD;
           Information collected for each isolate included: collection date, test date,&#xD;
           identification, site of infection, hospital unit of the patient, and whether the isolate&#xD;
           was acquired in the community (i.e., specimen obtained &lt;48 hours after admission), the&#xD;
           length of patient's hospital stay. The susceptibility of all the isolated against&#xD;
           targeted antimicrobial agents will be determined by their Minimum Inhibitory&#xD;
           Concentration (MIC values) follow the CLSI breakpoints for respective antimicrobial&#xD;
           agent.&#xD;
&#xD;
        3. Antimicrobial susceptibility testing&#xD;
&#xD;
             -  Inoculums preparation Sterile saline (0.85% NaCl), suitable buffer or broth for&#xD;
                inoculums preparation, depending on the organism. The CLSI inoculums procedure for&#xD;
                aerobes and other microorganisms should be used. 0.5 McFarland turbidity will be&#xD;
                used as the standard for aerobes.&#xD;
&#xD;
             -  Inoculation Use sterile loops/swabs to obtain optimal amount of inoculums&#xD;
                suspension. Swab the entire agar surface three times; rotating the plate&#xD;
                approximately 90 degrees each time to ensure an even distribution of inoculums.&#xD;
                Allow excess moisture to be absorbed for about 10-15 minutes so that the surface is&#xD;
                completely dry before applying E test strips.&#xD;
&#xD;
             -  Application of E test strips Ensure that the inoculated agar surface is completely&#xD;
                dry before applying E test strips. Use a Etest applicator or use a forceps to grip&#xD;
                the handle of the strip (are labeled E) and place them on to the inoculated agar&#xD;
                surface, ensuring that the MIC scale is facing upwards and that the concentration&#xD;
                maximum is nearest to the rim of the plate. Make sure the whole strip is in&#xD;
                complete contact with the agar surface. Once applied, the strip cannot be moved&#xD;
                because of the instantaneous release of antibiotic into the agar. It is recommended&#xD;
                to apply 4-6 different E test strips onto a 150 m agar plate. In this study, the E&#xD;
                test strips of six antimicrobial agents, including cefepime, cefepime plus&#xD;
                clavulanic acid (for the identification of ESBL producing isolates), ciprofloxacin,&#xD;
                cefmetazole, amikacin, tigecycline will be applied in addition to ertapenem.&#xD;
&#xD;
             -  Incubation The incubation temperature and atmosphere used must be optimal for&#xD;
                growth of particular bacterial species and the antibiotic being tested. CLSI&#xD;
                recommend 35℃/16-18 hours/ambient atmosphere for non-fastidious aerobes and&#xD;
                facultative anaerobes.&#xD;
&#xD;
             -  Reading of the MIC After complete the period of incubation and when bacterial&#xD;
                growth become distinctly visible, read the MIC value at the point of intersection&#xD;
                between the inhibition ellipse edge and the E test strip. Use the E test reading&#xD;
                Guide and other technical guides to correctly read different patterns. Etest strip&#xD;
                (AB Biodisk, Solna, Sweden) containing cefepime (MIC test range, 0.25-16 mg/L) and&#xD;
                cefepime (MIC test range, 0.064-4 mg/L) plus 4 mg/L clavulanic acid will be used to&#xD;
                detect the expression of ESBL according to the manufacturer's instruction.reduction&#xD;
                of MIC by ≥3 two-fold dilutions in the presence of clavulanic acid is indicator of&#xD;
                ESBL production. Deformation of the ellipses or the presence of &quot;phantom&quot; zone is&#xD;
                also indicator of ESBL production even if the MIC ratio is &lt;8 or can not be read.&#xD;
&#xD;
             -  Quality control In order to check the system with respect to correct handing,&#xD;
                quality and consistency of materials and methods, test quality control strains with&#xD;
                the antibiotics concerned. S. pneumoniae and H. influenzae can be determined by&#xD;
                broth microdilution under ambient incubation. The following organisms are included&#xD;
                as control strains: S. aureus ATCC 29213, E. faecalis ATCC 29212, S. pneumoniae&#xD;
                ATCC 49619, E. coli ATCC 25922, E. coli ATCC 35218, K. pneumoniae ATCC 700603, and&#xD;
                P. aeruginosa ATCC 27853. For every 500 Etests performed, a control test including&#xD;
                the above 5 control strains will be done.&#xD;
&#xD;
             -  Molecular studies Isolates with expression of ESBLs will be further typed using&#xD;
                Pulsed field gel electrophoresis (PFGE) method. The detailed procedures of PFGE and&#xD;
                the interpretations of PFGE banding patterns are as the description in our previous&#xD;
                report (13).&#xD;
&#xD;
      Data Analysis&#xD;
&#xD;
      Isolates are categorized into susceptible, intermediate, and resistant according to the&#xD;
      guidelines provided by the CLSI. Isolates intermediate or resistant to antimicrobial agents&#xD;
      are also categorized as nonsusceptible to the agents. The rates of nonsusceptibility among&#xD;
      major bacterial pathogens will be analyzed according to the different sites of infection and&#xD;
      origin of the isolates. The associations between geographic area, hospital types from whom&#xD;
      these isolates were obtained against the antimicrobial susceptibility will be analyzed.&#xD;
    </textblock>
  </detailed_description>
  <overall_status>Completed</overall_status>
  <start_date>April 2009</start_date>
  <completion_date type="Actual">September 2009</completion_date>
  <primary_completion_date type="Actual">August 2009</primary_completion_date>
  <study_type>Observational</study_type>
  <has_expanded_access>No</has_expanded_access>
  <study_design_info>
    <time_perspective>Retrospective</time_perspective>
  </study_design_info>
  <primary_outcome>
    <measure>To determine the prevalence of ESBL-producing among Enterobacteriaceae isolates in Taiwan</measure>
    <time_frame>3 months</time_frame>
  </primary_outcome>
  <enrollment type="Actual">300</enrollment>
  <condition>Enterobacteriaceae Infections</condition>
  <biospec_retention>None Retained</biospec_retention>
  <biospec_descr>
    <textblock>
      bacterial isolates&#xD;
    </textblock>
  </biospec_descr>
  <eligibility>
    <study_pop>
      <textblock>
        ENTEROBACTERIACEAE FROM TSAR COLLECTION&#xD;
      </textblock>
    </study_pop>
    <sampling_method>Probability Sample</sampling_method>
    <gender>All</gender>
    <minimum_age>N/A</minimum_age>
    <maximum_age>N/A</maximum_age>
    <healthy_volunteers>No</healthy_volunteers>
  </eligibility>
  <overall_official>
    <last_name>Shan-Chwen Chang, Ph.D.</last_name>
    <role>Principal Investigator</role>
    <affiliation>Vice President, National Taiwan University Hospital</affiliation>
  </overall_official>
  <location>
    <facility>
      <name>National Taiwan University Hospital</name>
      <address>
        <city>Taipei</city>
        <zip>100</zip>
        <country>Taiwan</country>
      </address>
    </facility>
  </location>
  <location_countries>
    <country>Taiwan</country>
  </location_countries>
  <verification_date>November 2012</verification_date>
  <study_first_submitted>October 8, 2009</study_first_submitted>
  <study_first_submitted_qc>November 8, 2012</study_first_submitted_qc>
  <study_first_posted type="Estimate">November 14, 2012</study_first_posted>
  <last_update_submitted>November 8, 2012</last_update_submitted>
  <last_update_submitted_qc>November 8, 2012</last_update_submitted_qc>
  <last_update_posted type="Estimate">November 14, 2012</last_update_posted>
  <responsible_party>
    <responsible_party_type>Sponsor</responsible_party_type>
  </responsible_party>
  <keyword>To determine the prevalence of ESBL-producing among Enterobacteriaceae isolates in Taiwan</keyword>
  <keyword>To determine the susceptibility of ertapenem and other antimicrobial agents against Enterobacteriaceae isolates with and without expression of ESBLs</keyword>
  <keyword>To determine the molecular typing of the Enterobacteriaceae isolates with expression of ESBLs</keyword>
  <keyword>To analyze the association between geographic area, hospital types against the antimicrobial susceptibility</keyword>
  <condition_browse>
    <!-- CAUTION:  The following MeSH terms are assigned with an imperfect algorithm            -->
    <mesh_term>Enterobacteriaceae Infections</mesh_term>
  </condition_browse>
  <!-- Results have not yet been posted for this study                                          -->
</clinical_study>


download date: ClinicalTrials.gov processed this data on September 20, 2023
link text: Link to the current ClinicalTrials.gov record.
url: https://clinicaltrials.gov/ct2/show/NCT01725841
org study id: 200809012R
nct id: NCT01725841
lead sponsor: 
has dmc: Yes
Resistance to broad-spectrum cephalosporins through the acquisition and expression of
      Extended-Spectrum β-lactamase (ESBL) among Enterobacteriacea is increasing. The clinical
      implications of ESBLs are extremely serious and sensitive diagnostic methods are urgently
      needed to guide therapy, monitor resistance development and implement intervention
      strategies. Conventionally, detection of expression of ESBLs was based on reduction of
      ceftazidime of cefotaxime MICs by ≥ 3 two fold dilutions in the presence of clavulanic acid.
      However, the use of the above method was limited to cover only some of the bacterial species,
      including predominantly E. coli and Klebsiella spp., or tested strains which were all
      transconjugants generated in vitro. ESBLs are now reported in a growing number of genera
      other than E. coli or Klebsiella spp., and Serratia marcescens.

      Carbapenems, including ertapenem, imipenem and meropenem, are the drugs of choice used for
      severe ESBL-producing bacterial infections. Failure to detect ESBL at the presence of AmpC
      β-lactamase might result in an important clinical concern because 4th generation
      cephalosporins, which are stable to AmpC β-lactamase, is not a drug of choice for severe
      infections caused by ESBLs-producing isolates. Fluoroquinolone-resistance in ESBL-producing
      Enterobacteriacea is common. In this study, the investigators will use isolates of
      Enterobacteriacea collected from different hospitals (isolates offered by the Taiwan
      Surveillance of Antimicrobial Resistance [TSAR] program) to investigate the susceptibility of
      ertapenem and five other antimicrobial agents against ESBLs-producing Enterobacteriacea.
Materials and Methods

        1. Collection of bacterial isolates

           The staffs in National Health Research Institute have established a long term
           surveillance of antimicrobial resistance from 22 to 44 hospitals distributed in all
           parts of Taiwan-Taiwan Surveillance of Antimicrobial Resistance (TSAR) since 1998. It
           has been conducted five times in year 1998, 2000, 2002, 2004, and 2006 and were named as
           TSAR-I, TSAR-II, TSAR-III, TSAR-IV and TSAR-V. In this study, isolates of
           Enterobacteriaceas from TSAR-IV will be recruited. Each 50 isolates of Escherichia coli,
           Klebsiella pneumoniae, Proteus mirabilis, Enterobacter cloacae, Serratia marcescens, and
           Morganella morganii will be enrolled (about 10% of the TSAR IV collected isolates) for
           the following microbiological studies.

           Isolates will be divided to ESBL-producing or non-producing groups by screening tests.
           All the available isolates were identified to the species or genus level by means of
           conventional methods. Isolates with same species recovered from the same an individual
           patient, are considered one isolate. The isolates were all stored at -70℃ in trypticase
           soy broth (Difco Laboratories, Detroit, MI) supplemented with 15% glycerol before being
           tested.

        2. Data Collection

           Information collected for each isolate included: collection date, test date,
           identification, site of infection, hospital unit of the patient, and whether the isolate
           was acquired in the community (i.e., specimen obtained <48 hours after admission), the
           length of patient's hospital stay. The susceptibility of all the isolated against
           targeted antimicrobial agents will be determined by their Minimum Inhibitory
           Concentration (MIC values) follow the CLSI breakpoints for respective antimicrobial
           agent.

        3. Antimicrobial susceptibility testing

             -  Inoculums preparation Sterile saline (0.85% NaCl), suitable buffer or broth for
                inoculums preparation, depending on the organism. The CLSI inoculums procedure for
                aerobes and other microorganisms should be used. 0.5 McFarland turbidity will be
                used as the standard for aerobes.

             -  Inoculation Use sterile loops/swabs to obtain optimal amount of inoculums
                suspension. Swab the entire agar surface three times; rotating the plate
                approximately 90 degrees each time to ensure an even distribution of inoculums.
                Allow excess moisture to be absorbed for about 10-15 minutes so that the surface is
                completely dry before applying E test strips.

             -  Application of E test strips Ensure that the inoculated agar surface is completely
                dry before applying E test strips. Use a Etest applicator or use a forceps to grip
                the handle of the strip (are labeled E) and place them on to the inoculated agar
                surface, ensuring that the MIC scale is facing upwards and that the concentration
                maximum is nearest to the rim of the plate. Make sure the whole strip is in
                complete contact with the agar surface. Once applied, the strip cannot be moved
                because of the instantaneous release of antibiotic into the agar. It is recommended
                to apply 4-6 different E test strips onto a 150 m agar plate. In this study, the E
                test strips of six antimicrobial agents, including cefepime, cefepime plus
                clavulanic acid (for the identification of ESBL producing isolates), ciprofloxacin,
                cefmetazole, amikacin, tigecycline will be applied in addition to ertapenem.

             -  Incubation The incubation temperature and atmosphere used must be optimal for
                growth of particular bacterial species and the antibiotic being tested. CLSI
                recommend 35℃/16-18 hours/ambient atmosphere for non-fastidious aerobes and
                facultative anaerobes.

             -  Reading of the MIC After complete the period of incubation and when bacterial
                growth become distinctly visible, read the MIC value at the point of intersection
                between the inhibition ellipse edge and the E test strip. Use the E test reading
                Guide and other technical guides to correctly read different patterns. Etest strip
                (AB Biodisk, Solna, Sweden) containing cefepime (MIC test range, 0.25-16 mg/L) and
                cefepime (MIC test range, 0.064-4 mg/L) plus 4 mg/L clavulanic acid will be used to
                detect the expression of ESBL according to the manufacturer's instruction.reduction
                of MIC by ≥3 two-fold dilutions in the presence of clavulanic acid is indicator of
                ESBL production. Deformation of the ellipses or the presence of "phantom" zone is
                also indicator of ESBL production even if the MIC ratio is <8 or can not be read.

             -  Quality control In order to check the system with respect to correct handing,
                quality and consistency of materials and methods, test quality control strains with
                the antibiotics concerned. S. pneumoniae and H. influenzae can be determined by
                broth microdilution under ambient incubation. The following organisms are included
                as control strains: S. aureus ATCC 29213, E. faecalis ATCC 29212, S. pneumoniae
                ATCC 49619, E. coli ATCC 25922, E. coli ATCC 35218, K. pneumoniae ATCC 700603, and
                P. aeruginosa ATCC 27853. For every 500 Etests performed, a control test including
                the above 5 control strains will be done.

             -  Molecular studies Isolates with expression of ESBLs will be further typed using
                Pulsed field gel electrophoresis (PFGE) method. The detailed procedures of PFGE and
                the interpretations of PFGE banding patterns are as the description in our previous
                report (13).

      Data Analysis

      Isolates are categorized into susceptible, intermediate, and resistant according to the
      guidelines provided by the CLSI. Isolates intermediate or resistant to antimicrobial agents
      are also categorized as nonsusceptible to the agents. The rates of nonsusceptibility among
      major bacterial pathogens will be analyzed according to the different sites of infection and
      origin of the isolates. The associations between geographic area, hospital types from whom
      these isolates were obtained against the antimicrobial susceptibility will be analyzed.
time perspective: Retrospective
measure: To determine the prevalence of ESBL-producing among Enterobacteriaceae isolates in Taiwan
time frame: 3 months
bacterial isolates
study pop: 
sampling method: Probability Sample
gender: All
minimum age: N/A
maximum age: N/A
healthy volunteers: No
last name: Shan-Chwen Chang, Ph.D.
role: Principal Investigator
affiliation: Vice President, National Taiwan University Hospital
facility: 
country: Taiwan
responsible party type: Sponsor
mesh term: Enterobacteriaceae Infections