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1

Antimicrobial Susceptibility of Enterococci

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The antimicrobial susceptibilities of 175 E. faecalis and 67 E. faecium strains were examined by using the disk agar diffusion (DAD) method in accordance with the Clinical and Laboratory Standards Institute (CLSI) guidelines.17 18 Erythromycin (15 µg), Tetracycline (30 µg), Ciprofloxacin (5 µg), Vancomycin (30 µg), Teicoplanin (30 µg), Norfloxacin (10 µg), Nitrofurantoin (300 µg), Quinopristin-Dalfopristin [Synercid (15 µg)] (Mast Co., UK), Chloramphenicol (30 µg), Gentamicin (10 µg), Linezolid (30 µg), and Ampicillin (10 µg) (HiMedia Mumbai Co., India) were used for antimicrobial susceptibility testing (AST).
In addition, minimum inhibitory concentrations (MIC) of the glycopeptide antibiotics i.e. Vancomycin and Teicoplanin (Sigma-Aldrich, Poole, Co., UK) against the E. faecalis and E. faecium isolates were determined using the microdilution broth method.17 18
E. faecalis ATCC 29212 (Vancomycin sensitive), E. faecalis ATCC 51299 (vanB positive), E. faecalis E206 (vanA positive) were used as quality control.
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Antibiotic susceptibility testing of urine isolates

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Positive urine cultures were processed for antimicrobial susceptibility testing on Mueller-Hinton agar plates, using the Kirby-Bauer disk diffusion method, according to the CLSI guideline (14 ). Gram-negative bacteria were evaluated against amikacin, nitrofurantoin, cotrimoxazol, cephalotin, gentamycin, ceftriaxon, nalidixic, cefixime, ciprofloxacin, tetracyclin, pipracillin and imipenem (Mast Co., England).
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3

Antibiotic Susceptibility Patterns of P. aeruginosa

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At first, the susceptibility pattern of P. aeruginosa isolates to ceftazidime-avibactam (30µg/20µg) and ceftolozane-tazobactam (30µg/10µg) (MAST Co. UK) was assayed using disk diffusion method (Kirby-Bauer). Then, the susceptibility patterns of the ceftazidime-avibactam and ceftolozane-tazobactam resistant isolates to the other antibiotics, including imipenem (10μg), ertapenem (10μg), cefotaxime (30μg), cefoxitin (30µg), ceftazidime (30µg), cefepime (30µg), amikacin (30μg), gentamicin (10μg), ciprofloxacin (5μg), nitrofurantoin (300µg), levofloxacin (10μg), aztreonam (10μg), and fosfomycin (200µg) (MAST Co, UK), were evaluated.10 (link) For performing disk diffusion method, isolates were cultured on Muller-Hinton agar plates (Merck, Germany) and the other procedures were performed according to the CLSI recommendations.11
P. aeruginosa ATCC 27853 was used as a control strain.
After disk diffusion, Minimum Inhibitory Concentration (MIC) of the resistant isolates to both CZA and C/T in disk diffusion was measured. MIC was assessed using the microdilution broth method, according to the recommendations of CLSI.11 Then, MIC of selected antibiotics including imipenem, ceftazidime, amikacin, aztreonam, and ciprofloxacin was evaluated against the resistant isolates to both CZA and C/T. In this assay, E. coli ATCC 25922 and P. aeruginosa ATCC 27853 were used as control strains.
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Antibiotic Susceptibility Testing of Isolates

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Antibiotic susceptibility testing of the isolates was carried out on Mueller-Hinton (MH) agar (Merck, Germany) by the Kirby-Bauer method, according to the Clinical and Laboratory Standards Institute (CLSI) guidelines [18] . The antibiotics were as follows: amikacin (30μg), cefotaxime (30μg), ceftazidime (30 μg), ciprofloxacin (5μg), co-trimoxazole (25μg), gentamicin (10μg), imipenem (10μg), nitrofurantoin (30μg), nalidixic acid (30μg) cefepime (30μg), ceftriaxone (30μg) and norfloxacin (10μg) (Mast Co, Merseyside, UK). The MDR isolates were determined according to previous definition [15] (link). The Escherichia coli ATCC 25922 was used as a quality control strain.
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5

Antibiotic Susceptibility of Enterococcus spp.

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Antibiotic susceptibility testing of 175 E. faecalis strains and 67 E. faecium strains was performed using Kirby-Bauer disk diffusion method on Muller-Hinton agar in according to the Clinical and Laboratory Standards Institute (CLSI) guidelines (14 ). Antimicrobial agents used in this study were included: vancomycin (30 μg), teicoplanin (30 μg), tetracycline (30 μg), erythromycin (15 μg), norfloxacin (10 μg), ciprofloxacin (5 μg), nitrofurantoin (300 μg), quinopristin-dalfopristin [synercid (15 μg)] (Mast co., UK), chloramphenicol (30 μg), linezolid (30 μg), gentamicin (10 μg), and ampicillin (10 μg) (HiMedia Mumbai Co., India).
Determination of minimum inhibitory concentration (MIC) of the glycopeptide antibiotics i.e. vancomycin and teicoplanin (Sigma-Aldrich, Poole, Co., UK) for E. faecalis and E. faecium isolates was done using microdilution broth method and Cation Adjustment Muller Hinton Broth (CAMHB) medium according to the CLSI guidelines (14 ). The E. faecalis ATCC 29212 (vancomycin sensitive), E. faecalis ATCC 51299 (vanB positive), E. faecalis E206 (vanA positive) were used as quality control strains for performing antimicrobial tests.
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6

Antibiotic Susceptibility Profiling of Isolates

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Antibiotic susceptibility of all isolates to ampicillin, amoxicillin-clavulanate, cefoxitin, cefixime, ceftazidime, ceftriaxone, cefotaxime, cefepime, ciprofloxacin, ofloxacin, nalidixic acid, aztreonam, tetracycline, gentamicin, trimethoprim/sulfamethoxazole, nitrofurantoin, and imipenem (Mast Co., UK) was carried out on Muller-Hinton agar (Oxoid Co., UK) using the disk diffusion method as recommended by the Clinical and Laboratory Standards Institute (CLSI).10
E. coli ATCC 25,922 was used as the quality control strain for antibacterial susceptibility testing. The isolates non-susceptible to ≥1 agent at least three of antibiotic categories were defined as MDR.11 (link)
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7

Antibiotic Resistance Profiling of Enterococcus

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Antibiotic resistance phenotypes of the strains to 11 antibiotics were determined by disk diffusion (Kirby-Bauer) method according to the standard recommendation of the Clinical and Laboratory Standards Institute criteria [38] . Resistance to daptomycin was also tested using the E-test strip (Lio lchem®, Italy). E. faecalis ATCC 29212 and Staphylococcus aureus ATCC 25923 were used as quality control strains. The antibiotic panels used were as follows: penicillin G (10 units), ampicillin (10 µg), vancomycin (30 µg), tetracycline (30 µg), minocycline (30 µg), cipro oxacin (5 µg), levo oxacin (5 µg), gati oxacin (5 µg), nitrofurantoin (300 µg), gentamicin (120 µg) and linezolid (30 µg) (Mast Group Ltd., United Kingdom).
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