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TABLE 2.

MICs of β-lactams for complex isolates 07-34, 09-54, 212, and 5007902; TOP10 harboring recombinant plasmid pBcSau13 expressing the PenB1 β-lactamase; and the TOP10 reference strain

Screening of PenA-like producers. Surprisingly, PCR assays with internal and external primers failed to identify a penA -like gene among the B. cenocepacia (belonging to genomovar groups I and III, together with B. cepacia ), B. vietnamiensis , B. pyrrocinia , and B. stabilis isolates. However, positive results were obtained for the two B. multivorans strains. B. multivorans isolates 232 and 281 expressed ß-lactamases PenA2 and PenA3, which shared 96% and 99% amino acid sequence homologies with PenA (renamed PenA1), respectively (Table 3 ). These results agree with the reclassification of B. cepacia 249 (in which the penA gene had primarily been identified) as B. multivorans ATCC 17616 ( Shopping Low Cost Sale Online Sofia Cropped Embroidered Cottonblend Gauze Wrap Top White Rixo London Wholesale Price Cheap Price Satku
, 37 ).

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TABLE 3.

Amino acid substitutions in PenB-like proteins

Cloning of the 212 penicillinase-encoding gene. Cloning experiments were therefore performed to identify the naturally occurring ß-lactamase gene(s) of Whole-cell DNA from isolate 212 was digested with Sau3AI and inserted in BK-CMV to give recombinant strain TOP10(pBcSau13). It expressed a penicillinase phenotype with resistance to amoxicillin and ticarcillin and reduced susceptibility to piperacillin and aztreonam. Addition of clavulanic acid and tazobactam only partially restored the ß-lactam activities of amoxicillin and piperacillin, respectively (Table Sàpopa Woman Cloquépaneled Stretch Sports Bra Pastel Pink Size M Sàpopa Sale Low Price Cheap Sale Get To Buy Outlet Cheapest Cheap Real Free Shipping Finishline QDQcTfjbh
). This phenotype agrees with the expression of a class A ß-lactamase with narrow-spectrum penicillinase activity. The recombinant strain remained susceptible to cephalosporins and imipenem, despite slight increases in their MICs (Table 2 ).

Identification of ß-lactamase PenB1. DNA sequence analysis of the 2,471-bp insert of pBcSau13 revealed two open reading frames that corresponded to β-lactamase PenB1 and a LysR-type regulator, PenR-B, respectively (Fig. 1 ). Two putative −10 and −35 promoter boxes were identified in the 140-bp intercistronic region extending between the two corresponding genes. Two potential ribosome-binding sites (RBSs) were also identified in that intergenic region; these were located 9 bp upstream of the penB gene and 8 bp upstream of the penR-B gene. Both RBS sequences were identical to those found upstream of the penA and penR genes in B. multivorans 249 (Fig. 1 ).

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FIG. 1.

Nucleotide sequence of the 1,740-bp fragment of pBcSau13 containing the - and -coding regions. The deduced amino acid sequences are designated in single-letter code. The putative and overlapped promoter sequences are represented by −35 and −10 regions (in boldface and underlined). The start and stop codons of these genes are also in boldface, and the putative RBS sequence is underlined. The critical motifs for class A ß-lactamases are bracketed.

The penB1 ß-lactamase gene identified was 936 bp and coded for a 312-amino-acid preprotein named PenB1 with a relative molecular mass of 32 kDa. The G+C content of this penB1 gene was 69%, which is within the G+C content of the B. cepacia genome (66%). A search with the Signalp program ( NY boat neck Tshirt Blue Faith Connexion Cheap Sale Enjoy Buy Cheap Popular New Cheap Sale Discount Big Sale For Sale 0mMzP
) showed the presence of a signal peptide with a putative cleavage site between positions 33 and 34 of the N-terminal region. The resulting 279-amino-acid protein had a calculated molecular size of 29 kDa. PenB1 contains the four conserved motifs 70 S*XXK 73 (where 70 S* is the active-site serine), 130 SDN 133 , 166 EXXXN 170 , and 234 KTG 236 of class A ß-lactamases (by use of the numbering scheme of Ambler et al. [ Sculpt Me Control High Neck Mesh Insert Supportive Swimsuit Black Asos Cheap Largest Supplier Outlet Free Shipping Authentic Newest Cheap Price High Quality gAXktmd
]) (Fig. 1 ). Analysis of the insert sequence of recombinant plasmid pBsSau13 evidenced a gene encoding a putative LysR regulator that we named PenR-B, that is located upstream of penB1 , and that is transcribed in an orientation opposite that of penB1 (Fig. 1 ).

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Antibiotics: choices for common infections

The following information is a consensus guide. It is intended to aid selection of an appropriate antibiotic for typical patients with infections commonly seen in general practice. Individual patient circumstances and local resistance patterns may alter treatment choices.

14 November 2017

New entries for the antibiotic choices guide

To mark antibiotics awareness week (13th – 19th November), we are releasing a new chapter, three new conditions and some revisions in our guide - Antibiotics: choices for common infections.

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Due to popular request, we have created a new chapter in the Guide for dental infections. This includes topics on managing dental abscess and prophylactic antibiotic treatment prior to undergoing dental procedures for patients at high risk of developing infective endocarditis.

Ideally patients would attend a dental clinic for treatment of a tooth abscess, however in practice this is often not possible due to barriers such as location, access and cost, and patients will instead present to their general practice. Abscess can often be treated with incision and drainage, followed by salty mouthwashes. Antibiotic treatment may be required if the infection is severe, i.e. the patient has cellulitis, diffuse tense swelling around the affected tooth or systemic symptoms. Ultimately, dental treatment will be required as it is likely that the abscess will reoccur if the underlying cause is not managed.

Diverticulitis

We have added a new topic in the gastrointestinal chapter of the Guide on the management of diverticulitis. It is thought that in many cases, uncomplicated diverticulitis is caused by inflammatory processes, rather than infection. Therefore antibiotic treatment is not routinely required, but it may be considered if the patient’s symptoms persist or worsen despite dietary management and analgesia. There is a lack of consistent guidance as to what antibiotic should be used; some guidelines recommend amoxicillin clavulanate or ciprofloxacin, but in order to preserve and limit use of these antibiotics, we have suggested, based on expert advice, combination treatment with trimethoprim + sulfamethoxazole (co-trimoxazole) and metronidazole.

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Previously this topic in the Guide was referred to as “pharyngitis”, however this generated enquiries from prescribers as to whether the same advice applied to treating tonsillitis. In addition, there is some uncertainty around guidance for prescribing antibiotics for patients with sore throat, outside of the context of rheumatic fever prevention.

We have revised the section and renamed it as “Sore throat”, which includes both pharyngitis and tonsillitis. The guidance for rheumatic fever prevention remains the same, and the same antibiotic choices apply. Antibiotic treatment is unnecessary in almost all other cases of sore throat as it is often viral in origin and usually self-limiting, however, we have added advice in the management section about when it is reasonable to consider antibiotic treatment, i.e. if the patient has severe symptoms or is at risk of complications.

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The New Zealand Sexual Health Society has recently released an update of its management guidelines for sexually transmitted infections (September, 2017). We have revised our STI topics in the genito-urinary chapter in the Guide to reflect this. The most significant change is in the recommended first-line and alternative treatments for urethritis: seven days treatment with doxycycline is now first-line, rather than azithromycin, with stat azithromycin an alternative if adherence to doxycycline is a concern or it is contraindicated.

Other changes include clarification that for most STIs, sexual contacts within the last three months should be notified and advised to seek assessment; empiric treatment is recommended while awaiting laboratory results for some infections. In the Chlamydia section we have specified that azithromycin is recommended for patients with asymptomatic urogenital infection (e.g. positive test result but no obvious symptoms), and doxycycline is recommended for patients with symptomatic urethritis, rectal or oral infection, or if an alternative to azithromycin is required. We have also noted that a longer treatment duration is required for patients with anorectal symptoms, and suggest that you discuss this with a sexual health physician.

To read the updated NZSHS guidelines, see: www.nzshs.org/guidelines

Antibiotic use in New Zealand is higher per head of population than in many similar developed countries. Increased antibiotic use leads to the development of resistance by eliminating antibiotic-susceptible bacteria and leaving antibiotic-resistant bacteria to multiply. Antimicrobial stewardship aims to limit the use of antibiotics to situations where they deliver the greatest clinical benefit. Along with infection control, this is the key strategy to counter the emerging threat of antimicrobial resistance.

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