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In this study, the association between antimicrobial susceptibility, PCR ribotype and presence of the ermB gene in clinical isolates of Clostridium difficile was investigated. PCR ribotyping and ermB gene PCR were performed on 131 C. difficile isolates. The susceptibility of these isolates to metronidazole, vancomycin, piperacillin/tazobactam (TZP), clindamycin, moxifloxacin and rifaximin was also determined. Use of antibiotics within the previous 2 months was documented. Resistance rates to clindamycin, moxifloxacin and rifaximin were 67.9%, 62.6% and 19.1%, respectively. No metronidazole, vancomycin or TZP resistance was detected. Previous exposure to moxifloxacin was significantly correlated with resistance to this antibiotic, but prior use of clindamycin was not significantly correlated with clindamycin resistance. Sixty-four strains (48.9%) carried the ermB gene, of which all but one (98.5%) were resistant to clindamycin. The clindamycin resistance rates of the common PCR ribotypes (018, 017 and 001) were 91.4%, 100% and 84.2%, respectively, and their moxifloxacin resistance rates were 91.4%, 95.0% and 78.9%, respectively. Resistance rates to rifaximin were 5.7% and 95.0% in ribotype 018 and 017 strains, whilst none of the 001 strains were resistant to rifaximin. In conclusion, the common ribotypes 018, 017 and 001 of C. difficile have high rates of resistance to clindamycin and moxifloxacin, but differ greatly in the frequency of rifaximin resistance.
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Preterm birth before the 37th gestational week is most frequently caused by infection. The agents are aerobic and anaerobic bacteria. Infection usually ascends from the vagina. Microorganisms entering the choriodecidual space induce pro-inflammatory cytokines, which trigger prostaglandin synthesis and contraction activity of the uterus. Cytokines can also release proteases, which cause premature outflow of the amnionic fluid. Screening of vaginal infections is indicated in all cases of imminent preterm parturition and in the group of risk pregnancies. Screening on Streptococcus B is indicated to all pregnant women in the gravidity weeks 35 to 37. Beside streptococcus infections with the risk of disease of the neonate being 2 to 3 per 1000 of vital newborns, bacterial vaginosis caused by Gardnerela vaginalis is frequently diagnosed. Effective treatment of symptomatic cases of the advanced pregnancy is five days long administration of Metronidazol or Clindamycin--vaginal crème. Another frequent cause of the preterm birth is chlamydial infection. The best contemporary treatment is Azitromycine for five days. Therapy of women without symptoms of the imminent preterm parturition does not decrease its occurrence. It is therefore not recommended as well as is not recommended the therapy of pregnant women with asymptomatic bacterinuria. Beside the classical cultivations, detection of antibodies, DNA analysis and serum infection markers (leucocytes, C-reactive protein), detection of pro- inflammatory cytokines in the serum and in the vaginal secret (IL-6, IL-8, TNFalpha etc.) are used to diagnose vaginal infections.
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Commonly used antibiotics were compared for their ability to induce Clostridium difficile enterocecitis and death in hamsters. Susceptibility to infection with C. difficile was measured by calculating 50% lethal doses (in CFU) for hamsters for various intervals after antibiotic treatment. Infection occurred after very small doses of C. difficile were given to hamsters treated with clindamycin, ampicillin, flucloxacillin, and cefuroxime; there was little difference between the antibiotics in the degree of susceptibility that they induced. A large difference in the duration of susceptibility was observed, however, with susceptibility being temporary following ampicillin, flucloxacillin, and cefuroxime administration but long-lived following clindamycin administration. A larger dose of ampicillin, multiple doses of ampicillin, and a combination of antibiotics had comparatively small effects on the duration of susceptibility. C. difficile growth and toxin production in in vitro suspensions of cecal contents were found to correlate closely with in vivo hamster infectivity. A persisting loss of colonization resistance following antibiotic treatment may be a type of postantibiotic effect. Although these results cannot be applied directly to humans, they suggest lines of further investigation into how antibiotics may differ in producing risks of C. difficile infection and pseudomembranous colitis in patients.
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Macrolide resistance has been widely studied in Streptococcus pyogenes and Streptococcus pneumoniae although not in viridans group streptococci (VGS). We studied 30 blood culture isolates of viridans group streptococci (25 resistant to erythromycin: 10 S. mitis, 8 S. milleri, 6 S. sanguis and 1 S. salivarius; and 5 susceptible: 2 S. mitis, 2 S. milleri and 1 S. sanguis). We carried out a double-disk test and determined MICs. The susceptibility testing was carried out by agar dilution for 14-, 15- and 16-member lactone ring macrolides, as well as for clindamycin and quinupristin-dalfopristin. Fifty-six percent of the erithromycin-resistant strains (6 S. mitis, 6 S. milleri and 2 S. sanguis) showed an MLS(B) phenotype, with a high level of intrinsic resistance to all the macrolides studied and clindomycin; 28% were of the M phenotype (4 S. sanguis, 2 S. mitis and 1 S. salivarius). We found a third resistance phenotype, which was present in 4 strains with MICs of 2-8 microg/ml, with resistance to macrolides and different degrees of resistance to clindamycin. All isolates were fully susceptible to quinupristin-dalfopristin. The MLS(B) and M phenotypes initially described in S. pyogenes and S. pneumoniae are also observed in VGS.
Pharmacokinetics is the study of the absorption, distribution and elimination of a drug in the body. Applied to antibiotic therapy it gives information on the concentrations of antibiotic that reach the bacteria at a given time at their site of multiplication for a given dose and route of administration. The future of an antibiotic within a body is largely related to passive transfer. This can be compared to the dialysis of molecules across a semi-permeable membrane, the passage from one side to the other being a function of the concentration of molecules in the "upstream" side, the size of the molecules and their own particular transfer speed. The final result is affected by 1) the partition coefficient itself related to the degree of aqueous and lipid solubility of the molecules, 2) the degree of ionisation of the molecules, non-ionised molecules being the only ones to be transferred, 3) protein binding as only the unbound fraction is biologically active and capable of diffusing across the membranes, 4) by the interplay of the combined phenomena of resorption, distribution and elimination. Penicillins and macrolides are the antibiotics of choice in broncho-pulmonary infections. The tetracyclines and the sulfamethoxazole-trimethoprim combination come second. The combination of a beta-lactam, an aminoglycoside and/or metronidazole are reserved for the most severe infections. The lung is a particularly well vascularised organ, the pulmonary concentrations of the antibiotic may equal the serum levels. But the concentration in the bronchial secretions only reaches 55% of the serum levels for clindamycin, 25 to 30% for aminoglycosides, minocycline and bacampicillin, 20% for cephalosporins and doxycycline and less than 10% for ampicillin and erythromycin. Only oleandomycine, spiramycin and trimethoprim are present in concentrations equal to those in the serum.
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Tonsillectomy is a common operation performed in children and young adults. Pain and post-operation haemorrhage are its most common complications. This study was designed to evaluate the efficacy of topical antibiotics in reducing throat pain after tonsillectomy in adult patients.
We included 19 trials (5839 randomised participants); seven compared penicillin with cephalosporins, six compared penicillin with macrolides, three compared penicillin with carbacephem, one trial compared penicillin with sulphonamides, one trial compared clindamycin with ampicillin, and one trial compared azithromycin with amoxicillin in children. All included trials reported clinical outcomes. Reporting of randomisation, allocation concealment, and blinding was poor in all trials. The overall quality of the evidence assessed using the GRADE tool was low for the outcome 'resolution of symptoms' in the intention-to-treat (ITT) analysis and very low for the outcomes 'resolution of symptoms' of evaluable participants and for adverse events. We downgraded the quality of evidence mainly due to lack of (or poor reporting of) randomisation or blinding, or both, heterogeneity, and wide confidence intervals (CIs).There was a difference in symptom resolution in favour of cephalosporins compared with penicillin (evaluable patients analysis odds ratio (OR) for absence of resolution of symptoms 0.51, 95% CI 0.27 to 0.97; number needed to treat to benefit (NNTB) 20, N = 5, n = 1660; very low quality evidence). However, this was not statistically significant in the ITT analysis (OR 0.79, 95% CI 0.55 to 1.12; N = 5, n = 2018; low quality evidence). Clinical relapse was lower for cephalosporins compared with penicillin (OR 0.55, 95% CI 0.30 to 0.99; NNTB 50, N = 4, n = 1386; low quality evidence), but this was found only in adults (OR 0.42, 95% CI 0.20 to 0.88; NNTB 33, N = 2, n = 770). There were no differences between macrolides and penicillin for any of the outcomes. One unpublished trial in children found a better cure rate for azithromycin in a single dose compared to amoxicillin for 10 days (OR 0.29, 95% CI 0.11 to 0.73; NNTB 18, N = 1, n = 482), but there was no difference between the groups in ITT analysis (OR 0.76, 95% CI 0.55 to 1.05; N = 1, n = 673) or at long-term follow-up (evaluable patients analysis OR 0.88, 95% CI 0.43 to 1.82; N = 1, n = 422). Children experienced more adverse events with azithromycin compared to amoxicillin (OR 2.67, 95% CI 1.78 to 3.99; N = 1, n = 673). Compared with penicillin carbacephem showed better symptom resolution post-treatment in adults and children combined (ITT analysis OR 0.70, 95% CI 0.49 to 0.99; NNTB 14, N = 3, n = 795), and in the subgroup analysis of children (OR 0.57, 95% CI 0.33 to 0.99; NNTB 8, N = 1, n = 233), but not in the subgroup analysis of adults (OR 0.75, 95% CI 0.46 to 1.22, N = 2, n = 562). Children experienced more adverse events with macrolides compared with penicillin (OR 2.33, 95% CI 1.06 to 5.15; N = 1, n = 489). Studies did not report on long-term complications so it was unclear if any class of antibiotics was better in preventing serious but rare complications.
Aerococcus urinae is a Gram-positive bacterium that can cause invasive infection, including infectious endocarditis (IE), mainly in older men. A. urinae is often misclassified in routine diagnostic laboratories. Through searches in the laboratory databases we identify 16 isolates of A. urinae causing bacteraemia during a 6-year period in southern Sweden, indicating that bacteraemia with A. urinae occurs in at least three cases per million inhabitants per year. The identity of isolates was confirmed by sequencing of the 16S rRNA genes and antibiotic susceptibility testing identified two ciprofloxacin-resistant isolates. A. urinae was the only significant pathogen isolated in all cases. Fifteen of the 16 patients were male, 15/16 were more than 70 years old, and 12/16 had underlying urological conditions. Though a urinary tract focus was suspected in the majority of cases, the bacterium was rarely found in urinary samples. Nine patients fulfilled the criteria for severe sepsis and an additional four fulfilled the criteria for sepsis. Only one fatality was recorded. Patients were treated mainly with beta-lactam antibiotics but fluoroquinolones and clindamycin were also used. Three cases of IE were diagnosed and these were complicated by spondylodiscitis in one case and by septic embolization to the brain in one case. An increased awareness of A. urinae is crucial to establishing its role as an important pathogen in older men with urinary tract disease.
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Invasive neonatal GBS isolates were collected from laboratories across New Zealand (n=107) and Australia (n=74) over two time periods (1992-1994 and 2002-2004 in New Zealand; 1982-2001 and 2002-2006 in Australia) and subjected to standard antibiotic susceptibility testing. A nested sub-study in New Zealand examined antibiotic susceptibilities of 112 maternal colonising GBS isolates during 2003-2004.
Despite increasing resistance in the pneumococcus over the past 30 years, there are few cases of treatment failure of non-meningeal infections with high-dosage parenteral penicillin G, which still remains highly effective for many pneumococcal diseases. This is reflected by the new 2008 CLSI breakpoints for parenteral penicillin G of susceptible, =2 microg/ml, intermediate, 4 microg/ml, and resistant, >/=8 microg ml, for non-meningeal infections. For meningitis and oral penicillin V use, the old penicillin breakpoints of susceptible, =0.06 microg/ml, intermediate, 0.12 - 1 microg/ml, and resistant, >/=2 microg/ml, will remain in place. Clinically relevant susceptibility breakpoints have also been developed for virtually all relevant antimicrobial agents used to treat pneumococcal diseases, based on clinical studies and pharmacokinetic and pharmacodynamic parameters. Although pneumococcal resistance to beta-lactams, macrolides and co-trimoxazole is now common worldwide, we are still able to treat almost all pneumococcal infections adequately. An exception is the oral treatment of multidrug-resistant serotype 19A strains in children in the USA, as these are resistant to amoxicillin, oral cephalosporins, macrolides, clindamycin and co-trimoxazole. While there is a need to develop new agents, judicious use of antimicrobial agents is the best long-term approach. Empiric treatment guidelines should reflect the emerging threats from increased drug resistance and the possibility of increased virulence in replacement serotypes following vaccine use. Compliance with guidelines by physicians and patients is important to prevent further development of resistance.
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Nasal colonization with community acquired methicillin resistant Staphylococcus aureus (CA-MRSA) is being increasingly reported, especially in places where people are in close contact and in reduced hygiene, such as day-care centers. In this study we investigated the frequency of MRSA colonization and their antibiotic susceptibility patterns in 1-6 years old children of day-care centers in Hamadan, West of Iran.Five hundred nasal swabs were collected from children of 27 day-care centers that had no risk factors for colonization by S. aureus. The specimens were cultured for isolation of S. aureus by standard methods. Antimicrobial susceptibility testing was performed according to the Clinical and Laboratory Standards Institute (CLSI) guidelines. For evaluation of the frequency of erythromycin induced clindamycin resistance, disk approximation test (D-test) was applied.Totally, 148 (29.6%) children were colonized by S. aureus. Out of 260 male, 94 (36.2%) and of 240 female, 54 (22.5%) cases were nasal carriers of S. aureus (P value = 0.001). Six (4.1%) of the 148 S. aureus isolated from children were MRSA strains. None of MRSA and methicillin susceptible S. aureus (MSSA) was resistant to vancomycin and clindamycin. Three of the 6 strains of MRSA and 7 (4.9%) of the 142 MSSA strains were resistant to erythromycin, and D-test was positive in all of them.We conclude that the rate of colonization by S. aureus is high in children attending day-care centers but colonization with MRSA is not common in our areas. Clindamycin or trimethoprim-sulfamethoxazol could be used in mild to moderataly severe diseases caused by CA-MRSA. However, if the CA-MRSA isolates are erythromycin resistant, D-test should be carried out for detection of inducible clindamycin resistance.
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There were no statistically significant differences in cure rates for oral metronidazole (84.2%), metronidazole vaginal gel (75.0%), or clindamycin vaginal cream (86.2%) (chi 2 = 1.204, df = 2, P = .548) using traditional clinical and laboratory criteria. Cure rates were lower based on DNA testing, indicating that Gardnerella vaginalis may remain after a clinical cure. This would explain cases of recurrent disease. Posttreatment vulvovaginal candidiasis was experienced by 12.5% of subjects treated with oral metronidazole, 14.8% of subjects treated with clindamycin vaginal cream, and 30.4% of subjects treated with metronidazole vaginal gel (chi 2 = 2.607, df = 2, P = .272).
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To determine the CA-MRSA rates and antibiotic susceptibilities in this region.
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A microbiological survey has been carried out on 179 healthy, child-bearing aged, non-pregnant women, with the aim to evaluate the incidence of anaerobic non-spore forming bacteria in the normal vaginal flora. This group of bacteria has been isolated in 50.3% of women, with a clear prevalence of "anaerobic Streptococci " and Bacteroides, followed by Fusobacterium and Veillonella. No Propionibacterium, Eubacterium or Bifidobacterium have been isolated. According to many Authors the non-spore forming anaerobes must be considered opportunistic bacteria, responsible of many infections of the female genital tract, especially when associated with other aerobic or facultative bacteria. Antibiograms have demonstrated a wide spectrum of activity of chloramphenicol and clindamycin; although not widely distributed, antibacterial activity have also shown metronidazole, penicillins, cephalosporins and lincomycin.
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MRSA positive ear cultures in the presence of tympanostomy tubes were identified in 41 patients (6.3%). The average age was 2.9 years old. In all cases, culture results indicated sensitivity to trimethoprim/sulfamethoxazole and gentamicin; resistance to fluoroquinolones and clindamycin occurred in 87.8% and 61.0% of cases, respectively. Fluoroquinolone and sulfacetamide ototopical medications were found to be associated with successful otorrhea resolution (p=0.005 and 0.009, respectively). Adjunctive therapy with oral antibiotics, bactrim and clindamycin (p=0.172 and 0.877, respectively), did not improve resolution rates with medical treatment. Tympanostomy tube removal was more successful than medical therapy alone (p<0.0001).
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To compare the effects of subinhibitory concentrations of amoxicillin, ceftriaxone, azithromycin, clarithromycin, erythromycin, telithromycin, clindamycin, ciprofloxacin, moxifloxacin, tobramycin and doxycycline on pneumolysin production by a macrolide-susceptible strain and two macrolide-resistant strains [erm(B) or mef(A)] of Streptococcus pneumoniae.
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Prospective non-randomised study.
Methicillin-resistant Staphylococcus aureus (MRSA) has recently emerged as a common cause of infection in children in many parts of the world. The epidemiology of community-acquired MRSA (CA-MRSA) among healthy children has been recently described. However, little is known about CA-MRSA in children with underlying medical conditions.
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One hundred five Staphylococcus aureus infections occurring in 79 children who were seen in a private office practice were evaluated for response to antibiotic therapy. The value of in vitro disk susceptibility testing in directing antibiotic selection in treatment failures was also examined. Of the total episodes studied, the types of infection studied included vesicular pyoderma (48%), secondary pyoderma (13%), bullous pyoderma (5%), furunculosis (14%), carbunculosis (12%), cellulitis (3%), suppurative otitis media (4%), and paronychia (2%). Comparative treatment efficacy was obtained with perioral erythromycin estolate and erythromycin ethylsuccinate, cefaclor and cephalexin, and clindamycin hydrochloride and dicloxacillin sodium. Penicillin V potassium, ampicillin, and topical bacitracin were generally ineffective. In 23 patients, 27/105 infections were initial treatment failures. Antibiotic disk susceptibility testing predicted these clinical failures and/or the antibiotic that would produce a clinical response in 21 of these 23 patients, suggesting that this office procedure can be of considerable value.
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Neonatal neosporosis is a challenging disease to diagnose in neonatal and young puppies because the first signs of this condition may not be strongly suggestive of an infectious aetiology. Within two weeks of birth, three of four pups died with a subacute clinical course, some with dyspnea, some with diarrhoea and some with neurologic signs. Neosporosis was diagnosed post-mortem, but only after microscopic examination of tissues collected at necropsy. Histological findings consisted of (i) necrotizing, diffuse interstitial pneumonia associated with intralesional protozoa and (ii) necrotizing multifocal myocarditis with mineralization and intralesional protozoa. No significant alterations were found in the cerebrum or cerebellum (spinal cord was not examined). Immunohistochemistry confirmed protozoal stages and cysts were Neospora caninum. Immunohistochemistry for Toxoplasma gondii was negative. Lung and heart were the most severely affected tissues with large numbers of free zoites, BAG5 positive bradyzoites and tissue cysts of N. caninum further confirmed by N. caninum-specific quantitative real-time PCR. One affected pup which displayed knuckling, ataxia and diarrhoea were treated with trimethoprim sulfadiazine and clindamycin, and made a complete recovery. This surviving pup (at 8 weeks-of-age) and dam were both positive for N. caninum antibody (reciprocal titres 4096 and 256, respectively). Three other intact bitches on the same property were seropositive for N. caninum, suggesting horizontal transmission and a common source of infection, possibly due to consumption of infected meat. Analysis using microsatellite-10 (MS10) demonstrated that multiple strains of N. caninum were present. It was likely that all MS10 N. caninum strains were transplacentally transmitted from dam to pups. This is the first time that multiple N. caninum strains have been demonstrated to be vertically transmitted in dogs. N. caninum should be considered in the differential diagnosis for acute to subacute death in neonatal pups even when neurological signs suggestive of neosporosis are absent.
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Therapeutic options for rosacea include topical agents, oral therapies, laser and light treatments, and surgical procedures. Topical therapies play a critical role in the treatment of patients with papulopustular rosacea and erythematotelangiectatic rosacea, and have the ability to effectively minimize certain manifestations of the disease, including papules, pustules, and erythema. The 3 primary agents for the topical treatment of rosacea are metronidazole, azelaic acid, and sodium sulfacetamide-sulfur. Each of these therapies is approved for the treatment of rosacea and has been validated by multiple studies. Additional topical therapies including benzoyl peroxide, clindamycin, retinoids, topical steroids, calcineurin inhibitors, and permethrin are not approved for the treatment of rosacea and play variable roles in the management of this condition.
After the introduction of the NICE guideline there was a highly significant 78.6% reduction (P < 0.001) in prescribing of antibiotic prophylaxis, from a mean 10,277 (SD 1068) prescriptions per month to 2292 (SD 176). Evidence that the general upward trend in cases of infective endocarditis before the guideline was significantly altered after the guideline was lacking (P = 0.61). Using a non-inferiority test, an increase in the number of cases of 9.3% or more could be excluded after the introduction of the guideline. Similarly an increase in infective endocarditis related deaths in hospital of 12.3% or more could also be excluded.
A perioral impetigo lesion occurred on day 14 of life in a preterm male infant (1,065 g, 30 weeks of gestational age). Empiric antibiotic therapy with cefotaxime and vancomycin was given for 6 days and led to complete resolution. A Staphylococcus aureus strain was isolated. After a symptom-free interval a relapse was noted on day 26 of life. Despite restarting the antibiotic therapy immediately the initial lesion expanded, and disseminated flaccid blisters on an erythematous base appeared within a few hours. On histological examination the cleavage was in the level of the granular layer. There was no mucosal involvement, and the Nikolsky I sign was positive. The antibiotic therapy was changed to a combination of cefotaxime, flucloxacillin and clindamycin which rapidly stopped progression of the exfoliation. Supportive therapy included adequate analgesia, parenteral rehydration, and application of local antiseptics. The preterm infant completely recovered. In the primary lesion an ETA-producing Staphylococcus aureus strain was isolated. Nasal microtrauma by a nasogastric tube was assumed to have caused the fulminant disease. At the same time, no other Staphylococcus aureus infections were seen in our Department of Neonatology.
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A total of 312 clinical beta-hemolytic streptococcal isolates (Streptococcus pyogenes, group A = 63; Streptococcus agalactiae, group B = 145; group C = 50; group F = 27; group G = 27) were examined for susceptibility to 23 and 24 antimicrobial drugs with the Bauer-Kirby agar disk diffusion and the agar dilution method, respectively. Sheep blood Mueller-Hinton agar served as the reference medium. Wilkins-Chalgren agar supported optimal growth of group A and B, but not of all group C, F, and G streptococci. The group A streptococci were susceptible to all beta-lactam antibiotics, clindamycin, chloramphenicol, rifampin, teicoplanin, and vancomycin, but resistant to cotrimoxazole, fusidic acid, and, except for 2 strains, to fosfomycin. Resistance (R)/intermediate susceptibility (I) rates (R/I%) to ciprofloxacin (0/2%), ofloxacin (1/2%), erythromycin (1.6/0%), and clarithromycin (0/1%) were low. Higher resistance rates were noted with tetracyclines (doxycycline 23.8/15.9%; tetracycline 39.7/3.2%). Among the group B streptococcal isolates, one strain was resistant against oxacillin and of intermediate susceptibility to penicillin G and cefoxitin. All isolates were susceptible to teicoplanin and rifampin. Conversely, all group B isolates were resistant to cotrimoxazole and fusidic acid; 69% and 51% of these isolates were susceptible to fosfomycin and rifampin, respectively. R/I rates of the group B streptococcal isolates were low for ciprofloxacin and ofloxacin (0/0.7%), clindamycin (0.7/0%), erythromycin (1.4/ 3.5%), clarithromycin (1.4/0%), and chloramphenicol (0.7/0%). Resistance to tetracyclines was significant (doxycycline: 72.4/2.1%; tetracycline; 74.5/1.4%). Among the non-A, non-B beta-hemolytic streptococci, 2 group C strains were resistant to oxacillin and showed intermediate susceptibility to penicillin G. All isolates were susceptible to third and fourth-generation cephalosporins, imipenem, chloramphenicol, rifampin, teicoplanin, and vancomycin. R/I rates to the other antimicrobial drugs were: ciprofloxacin (3.9/1.9%), ofloxacin (2.9/1.9%), clindamycin (2.9/1%), erythromycin (5.8/0%), clarithromycin (3.8/2.9%), and cotrimoxazole (16.4/3.9%). Resistance against tetracyclines was more frequent (doxycycline: 18.3/2.9%; tetracycline: 20.2/6.7%). On the basis of various minor discrepancies between MIC and disk diffusion test results, it is proposed that the current NCCLS inhibition zone (diameter, mm) criteria indicative of intermediate susceptibility of beta-hemolytic streptococci be changed for the following antimicrobial drugs: ampicillin: 22-27 mm (only for group A and B beta-hemolytic streptococci); ciprofloxacin: 16-18 mm; clindamycin: 15-18 mm; doxycycline: 17-19 mm; tetracycline: 17-19 mm, and erythromycin: 14-19 mm.