mWe conducted a prospective multicenter study in Spain to characterize the mechanisms of resistance to amoxicillin-clavulanate (AMC) in Escherichia coli. Up to 44 AMC-resistant E. coli isolates (MIC > 32/16 g/ml) were collected at each of the seven participant hospitals. Resistance mechanisms were characterized by PCR and sequencing. Molecular epidemiology was studied by pulsed-field gel electrophoresis (PFGE) and by multilocus sequence typing. Overall AMC resistance was 9.3%. The resistance mechanisms detected in the 257 AMC-resistant isolates were OXA-1 production (26.1%), hyperproduction of penicillinase (22.6%), production of plasmidic AmpC (19.5%), hyperproduction of chromosomic AmpC
Escherichia coli is an important etiologic agent for both nosocomial-and community-acquired infections in humans (9, 13, 22). Amoxicillin-clavulanate (AMC) is one of the most widely used antibiotics in many countries (3,11,15). In Spain, a 34.7% increase in community use of AMC was recorded from 2000 to 2006 (20). Recently, blood isolates of E. coli nonsusceptible to AMC increased from 9.3% (2003) Enzymatic mechanisms of E. coli resistance to AMC include hyperproduction of plasmid-mediated class A -lactamases such as TEM-1 and SHV-1 (18, 31), plasmid-mediated AmpC-type -lactamase (p-AmpC) (21), chromosomal AmpC -lactamase (c-AmpC) (21), production of inhibitor-resistant TEM (IRT) -lactamases (17, 27), plasmid-mediated -lactamase OXA-1 (32), and complex mutant TEM (CMT) enzymes than combine IRT-and extended-spectrum -lactamase (ESBL)-type substitutions (26).In spite of the significant increase in AMC use in the last several years, there is little recent information available about the prevalence of AMC resistance mechanisms in E. coli; most previous studies analyzed strains isolated more than 10 years ago from single hospitals in the United States (12, 28), France (16), and Spain (19,24). Accordingly, the aim of this prospective Spanish national multicenter study was to investigate the epidemiology and mechanisms of AMC resistance in clinical isolates of E. coli causing both community and nosocomial infections.
MATERIALS AND METHODS
Study design and bacterial isolates.A prospective multicenter study was designed to obtain E. coli isolates resistant to AMC (MIC of Ն 32/16 g/ml and/or disk inhibition zone of Յ13 mm according to the Clinical and Laboratory Standards Institute [CLSI]) (7) from clinical samples col-