Ellie JC Goldstein Diane M. Citron C. Vreni Merriam Kerin L Tyrrell

AAC Accepts, published online ahead of print on 1 October 2012 Antimicrob. Agents Chemother. doi:10.1128/aac.01794-12 Copyright 2012, American Society for Microbiology. All Rights Reserved. 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Revised v 9-16-12; Submitted 8-28-12 Ceftaroline vs. Animal Bite Isolates: Comparative in vitro activity vs. 243 isolates including 156 Pasteurella species. Ellie JC Goldstein Diane M. Citron C. Vreni Merriam Kerin L Tyrrell From the R.M. Alden Research Laboratory 1, Culver City, CA 90230 and the David Geffen School of Medicine at UCLA 2, Los Angeles, CA 90073. Correspondent: Ellie JC Goldstein MD 2021 Santa Monica Blvd, Suite # 740 East Santa Monica, CA 90404 310-315-1511 Fax: 310-315-3662 ejcgmd@aol.com Words: Abstract, 214; Text 1,138 Running title: Ceftaroline vs. Pasteurella and animal bite isolates 32

2 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 Abstract Background: More than 5 million Americans are bitten by animals, usually dogs, annually. Bite patients comprise ~1 % of all emergency department visits (300,000/year) and approximately 10,000 require hospitalization and IV antibiotics. Ceftaroline is the bioactive component of the prodrug Ceftaroline fosamil, which is FDA approved for acute bacterial skin and skin structure infections (ABSSSI) including those containing methicillin-resistant Staphylococcus aureus (MRSA). There are no in vitro data about the activity of ceftaroline vs. Pasteurella multocida ssp. multocida, and ssp. septica, other Pasteurella spp, or other bite wound isolates. We therefore studied the in vitro activity of ceftaroline vs. 243animal bite isolates. Methods: MICs were determined using the broth microdilution method according to CLSI guidelines. Comparator drugs included cefazolin, ceftriaxone, ertapenem, ampicillin-sulbactam, azithromycin, doxycycline and sulfamethoxazole-trimethoprim. Results: Ceftaroline was the most active agent against all 5 Pasteurella species, including P. multocida ssp. multocida and ssp. septica with a maximum MIC of <0.008 μg/ml, more active than ceftriaxone and ertapenem (MIC 90s, <.015 μg/ml) and more active than cefazolin (MIC 90, 0.5 μg/ml) doxycycline (0.125 µg/ml), azithromycin (0.5 μg/ml), ampicillin-sulbactam (0.125 μg/ml) and SXT (0.125 μg/ml). Ceftaroline was also very active against all S. aureus (MIC 90, 0.125 μg/ml), other Staphylococcus and Streptococcus species with a maximum MIC of 0.125 μg/ml against all bite isolates tested. Conclusions: Ceftaroline has potential clinical utility against infections involving P. multocida, other Pasteurella species and aerobic gram-positive isolates including S. aureus.

3 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 In 2011 the Humane Society of the United States estimated that 78.2 million dogs and 86.4 million cats were kept as pets in 62% of American housholds (19). Bites occur in 4.7 million Americans yearly which extrapolates to one of every two Americans being bitten in their lifetime, usually by a dog (14-16). Animal bite wounds account for 800,000 medical visits annually, and comprise approximately 1% of all emergency department visits (29). It has been estimated that 3-18% of dog bites and 28-80% of cat bites will become infected (29). Of the 300,000 bite patients who visit an Emergency Department, approximately 10,000 will require hospitalization and intravenous antibiotics. (24,27). Bite wounds that require attention are often those to the extremities, especially the person s dominant hand and those caused by larger dogs, which can exert more than 450 pounds/inch 2 of pressure with their jaws, leading to extensive crush injury(14,15,18, 27). While there are a plethora of bacteria isolated from animal bite wounds (2, 27). Pasteurella species are present in 75% of infected cat bite wounds (54% P. multocida ssp multocida and 28% P. multocida ssp septica) and in 50% of infected dog bite wounds (P. canis, 50%, P multocida ssp multocida 12% and P. multocida ssp septica 10%) (27). However, the emergence of MRSA (USA 300 clone) isolated in infections shared between pets and human handlers (22), raises the issue of do severe animal bite wounds require MRSA coverage. Currently recommended regimens include amoxicillin-clavulanate orally, and ampicillinsulbactam, carbapenems and cefoxitin intravenously (26) all of which lack MRSA activity. 74 75 76 Ceftaroline fosamil, which is FDA approved for acute bacterial skin and skin structure infections (ABSSSI) including those containing methicillin-resistant Staphylococcus aureus (MRSA). There are scant data about the activity of ceftaroline vs. Pasteurella multocida ssp. multocida,

4 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 and ssp. septica, other Pasteurella spp, or other bite isolates. Ge et al. (13) reported the in vitro activity of ceftaroline against 22 not-fully-speciated P. multocida isolates and found it to have good activity. As there are no data about the activity of ceftaroline against the specific Pasteurella species including Pasteurella multocida ssp. multocida, P. multocida ssp. septica, P. dagmatis, P. canis, P. stomatis or other Pasteurella spp., nor on its activity against other bite isolates, including Staphylococcus sp. and Streptococcus sp., we therefore studied the in vitro activity of ceftaroline against 243 animal bite isolates including 156 Pasteurella strains Materials & Methods Bacterial strains: The organisms were recovered from clinical human samples, identified by standard methods (21) and stored in 20% skim milk at 70 o C. They were taken from the freezer and transferred at least twice on blood agar to ensure purity and good growth. Broth dilution tests: Broth microdilution trays were prepared in-house using the Quick-Spense apparatus (Sandy Spring Instrument Co. Inc., Germantown, MD.), 100µl/well, and frozen at - 70 o C until used. Cell paste from 48h hour cultures was suspended in brucella broth and further diluted in 8.5% saline and added to the trays with an inoculator device for a final concentration of 1-5 X 10 5 CFU/ml. Trays for Pasteurella and streptococci were supplemented with 3% lysed horse blood. Colony counts were determined on every 10 th panel. 95 96 97 All testing was conducted according to procedures in the CLSI M-7 A 9, and M45-A2 documents (7, 8). Control organisms included P. multocida ssp multocida ATCC 12947, P. multocida ssp septica ATCC 51688, E. coli ATCC 25922 and S. aureus ATCC 29213.

5 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 Drugs included ceftaroline, cefazolin, ceftriaxone, ertapenem, ampicillin-sulbactam, azithromycin, doxycycline and sulfamethoxazole-trimethoprim that are commonly used in the treatment of ABSSSSIs. Ceftaroline was obtained from Cerexa Pharmaceuticals, and other drugs were obtained from Sigma (St. Louis MO) or USP (Rockville, MD) and reconstituted according to the manufacturers instructions. The MIC was defined as the lowest concentration that yielded no visible growth. Results Results of the comparative in vitro activity of ceftaroline against the study isolates are shown in Table 1. Ceftaroline was the most active agent against all 5 Pasteurella species, including P. multocida ssp. multocida and ssp. septica with a maximum MIC of <0.008 μg/ml. It was more active than ceftriaxone and ertapenem (MIC 90 s, < 0.015 μg/ml) and more active than cefazolin (MIC 90, 0.5 μg/ml) doxycycline (0.125 μg/ml), azithromycin (0.5 μg/ml), ampicillin-sulbactam (0.125 μg/ml) and SXT (0.125 μg/ml). Ceftaroline was also very active against all S. aureus (MIC 90, 0.125 μg/ml), other Staphylococcus and Streptococcus species with a maximum MIC of 0.125 μg/ml against all bite isolates tested. The QC strains P. multocida ssp multocida ATCC 12947 and P. multocida ssp septica ATCC 51688 were each run three times and the ceftaroline MIC was <0.008 μg/ml in each occasion. Discussion The selection of antimicrobial therapy for infected animal bite wounds must include activity against the components of the biting animals oral flora including P. multocida and its subspecies. The susceptibility of P. multocida can be problematic to the clinician as in vitro susceptibility of oral first generation cephalosporins cannot be inferred from their susceptibility

6 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 to intravenous cefazolin (17). In addition, dogs and cats can harbor MRSA in their nasal passages and orally (1, 20). The transmission of epidemic, potentially invasive MRSA clones between companion animals such as dogs and cats and their owners, household members and veterinarians has become increasingly reported (4, 10). Consequently, the potential for MRSA to be a component of infected animal bite wounds is cause for concern (22). Currently recommended regimens (26) do not include MRSA coverage in their recommendations and have not, to our knowledge been clinically reported. With up to 20% of the population being colonized with MRSA, the potential for MRSA to be introduced via the victims own skin flora also needs to be considered. Ceftaroline fosamil, was FDA approved in October 2010, for acute bacterial skin and skin structure infections (ABSSSI) including those containing methicillin-resistant Staphylococcus aureus (MRSA), but scant data exists about its activity against P. multocida, other Pasteurella species and animal bite isolates in general. Ge et al. (13) reported ceftaroline to be active in vitro against 22 Pasteurella multocida isolates form Luxembourg but gives little clinical data about their source. Our in vitro study suggests that ceftaroline has excellent activity (all susceptible to < 0.06 μg/ml) against all Pasteurella strains including P. multocida ssp multocida, P. multocida ssp septica, P. canis, P. dagmatis, and P. stomatis. Ceftaroline was also very active against all the S. aureus strains (all susceptible to <0.25 μg/ml), S. epidermidis, S. intermedius and S. warnerii strains (all susceptible to <0.125 μg/ml) and streptococci (all susceptible to < 0.03 μg/ml). These MIC values compared favorably to those of all the other study agents. Ceftaroline has variable activity against anaerobic bacteria (6) with good activity against anaerobic gram-positive cocci and beta-lactamase negative gram-negative bacilli but poor activity against the B. fragilis group, which are rare animal bite pathogens (27).

7 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 S. intermedius is a coagulase positive Staphylococcus species that is part of the canine oral flora and has been isolated from infected dog bite wounds (28). It was isolated from 39% of 135 canine gingival cultures frequently from indoor breeds weighing < 40 lbs, while S. aureus was isolated from larger (>40lbs), outdoor working breeds (28). S. intermedius can yield a falsepositive rapid penicillin binding protein 2a latex test and can be misidentified as MRSA (23). Adding to the confusion amongst canine isolates is the description of methicillin-resistant S. pseudintermedius (3,5, 12) which has emerged as a worldwide veterinary canine pathogen. Our in vitro data shows ceftaroline to have good activity against S. pseudintermedius. Our results against the more typical gram-positive cocci studied is similar to those previously reported (11, 13, 25). Azithromycin, which has an FDA indication for uncomplicated skin and soft tissue infections, and has a breakpoint of < 1 µg/ml for P. multocida, (8) had an MIC 90 of 1 µg/ml against P. multocida ssp multocida and 0.5 µg/ml against P. multocida ssp septica. The MIC breakpoint for azithromycin against staphylococci is <1 ug/ml for EUCAST (9) and < 2 µg/ml by CLSI standards and the MIC 90 for all our staphylococci strains tested was 2 µg/ml suggesting some caution in its use for infected animal bite wounds. Ceftaroline has potential clinical utility against infections involving P. multocida, other Pasteurella species and aerobic gram-positive isolates including S. aureus. 163 164 165 166 Acknowledgements: This study was supported by a grant from Forest Laboratories. We thank Eliza Leoncio for excellent technical assistance and Alice E Goldstein for various forms of assistance.

8 167 References 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 1. Abdel-Moein, K.A., M. El-Hairi, and A. Samir. 2011. Methicillin-resistant Staphylococcus aureus: An emerging pathogen of pets in Egypt with a Public Health burden. Trandbound. Emerg. Dis. Doi:10,1111/j.1865-1682:2011.01273.x. 2. Abrahamian, F.A., and E.J.C. Goldstein. 2011. The bacteriology of animal bite wounds. Clin. Micro. Rev. 24:231-246. 3. Bannoehr, J. and L. Guardabassi. 2012. Staphylococcus pseudointermedius in the dog: taxonomy, diagnostics, ecology, epidemiology and pathogenicity. Vet. Dermatol. Doi:10.1111/j.1365-3164.2012.0104.x 4. Bender, J.B., K.C. Waters, J. Nerby, K.E. Olsen and S. Jawahir. 2012. Methicillinresistant Staphylococcus aureus (MRSA) isolated from pets living in households with MRSA-infected children. Clin. Infect. Dis. 54:449-450. 5. Bond, R., and A. Loeffler. 2012. What s happened to Staphylococcus intermedius? Taxonomic revision and emergence of multi-drug resistance. J. Small Anim. Pract. Doi. 10.1111/j.1748-5827.2011.0165.x 6. Citron, D.M., K.L. Tyrrell, C.V. Merriam, and E.J.C. Goldstein. 2010. In vitro activity of ceftaroline against 623 diverse strains of anaerobic bacteria. Antimicrob. Agents Chemother. 54:1627-1631. 7. CLSI. 2012 Methods for dilution antimicrobial susceptibility tests for bacteria that grow aerobically; approved standard ninth edition. CLSI document M07-A9. Clinical and Laboratory Standards Institute. Wayne, Pa. 8. CLSI. 2012. Methods for antimicrobial dilution and disk susceptibility testing of infrequently isolated of fastidious bacteria; approved standard second. CLSI document M45-A2. Clinical and Laboratory Standards Institute. Wayne, Pa. 9. European Committee on Antimicrobial Susceptibility Testing. Clinical breakpoints, bacteria v. 2.0. Breakpoint tables for interpretation of MICs and zone diameters. http://www.eucast.org/clinical_breakpoints/ accessed 8-5-12. 10. Ferreira J.P., K.L. Anderson, M.T. Correa, L. Lyman, F. Ruffin, L.B. Reller and V.G. Fowler Jr. 2011PLoS One 6:e26978. Doi:10.1371/journal.pone0026978. 11. Flamm, R., H.S. Sader, D. Farrell, and R.N. Jones. 2012. Summary of ceftaroline activity against pathogens in the United States, 2010: Report from assessing worldwide

9 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 antimicrobial resistance evaluation (AWARE) surveillance program. Antimicrob. Agents Chemother. 56:2933-2940. 12. Frank, L.A., and A. Loeffler. 2012. Methicillin-resistant Staphylococcus pseudointermedius: clinical challenge and treatment options. Vet. Dermatol. Doi:10.1111/j. 1365-3164. 01047.x 13. Ge, Y., D. Biek, G.H. Talbot, and D.F. Sahm. 2008. In vitro profiling of ceftaroline against a collection of recent bacterial clinical isolates from across the United States. Antimicrob. Agents Chemother. 52:3398-3407. 14. Goldstein, E.J.C., D.M. Citron, and S.M. Finegold. 1980. Dog bite wounds and infection: A prospective clinical study. Ann. Emerg. Med. 9:508-512. 15. Goldstein, E.J.C., D.M. Citron, B. Wield, U. Blachman, V.L. Sutter, T.A. Miller, and S.M. Finegold. 1978. Bacteriology of human and animal bite wounds. J. Clin. Microbiol. 8:667-672. 16. Goldstein, E.J.C..1992. Bite wounds and infection. Clin Infect Dis.14:633-640. 17. Goldstein, E.J.C., D.M. Citron, and G.A. Richwald. 1988. Lack of efficacy of oral forms of certain cephalosporins, erythromycin, and oxacillin against Pasteurella multocida. Antimicrob. Agents Chemother. 32:213-215. 18. Holmquist, L., and A. Elixhauser. 2010. Emergency department visits and inpatient stays involving dog bites, 2008: Statistical brief #101. Healthcare Cost and Utilization Project Statistical Briefs (Internet), Rockville (MD). Agency for Healthcare Policy and Research (US). PMID:2143205. 19. The Humane Society of the United States. American Pet Products Manufacturers Association (APPMA) 2011-2012 National Pet Owners Survey. http://www.americanpetproducts.org/press_industrytrends.asp accessed 5-5-12 20. Loeffler, A., A.K. Boag, J. Sung, J.A. Lindsay, L. Guardabassi, A. Dalsgaard, H. Smith, K.B. Stevens, and D.H. Lloyd. 2005. Prevalence of methicillin-resistant Staphylococcus aureus among staff and pets in a small animal referral hospital in the UK. J. Antimicrob. Chemother. 56:692-697.. 21. Murray, P.R. and E.J. Baron. eds. 2007. Manual of clinical microbiology. ASM Press. Washington, D.C. 22. Oehler, R.L., A.P. Velez, M. Mizrachi, J. Lamarche, and S. Gompf. 2009. Biterelated and septic syndromes caused by cats and dogs. Lancet Infect. Dis. 9:439-447.

10 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 23. Pottumurthy, S., J.M., Schapiro, J.L. Prentoce, Y.B. Houze, S. Swanzy, F.C. Fang, and B.T. Cookson. 2004. Clinical isolates of Staphylococcus intermedius masquerading as methicillin-resistant Staphylococcus aureus. J. Clin. Microbiol. 42:5881-5884. 24. Sacks, J.J., M. Kresnow, and B. Houston. 1996. Dog bites: how big a problem? Inj. Prev. 2:52-54. 25. Saravolatz, L.D., G. Stein, and L.B. Johnson. 2011. Ceftaroline: A novel cephalosporin with activity against methicillin-resistant Staphylococcus aureus. Clin. Infect. Dis. 52:1156-1163. 26. Stevens D.L., A.L. Bisno, H. F. Chambers, P. Dellinger, E.J.C. Goldstein, S.L. Gorbach, J.V. Hirschmann, S. Kaplan, J.G. Montoya, and J.C. Wade. IDSA: 2011 Update to the 2005 Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections. Clin. Infect. Dis. In Press. 27. Talan, D.A., D.M. Citron, F.A. Abrahamian, G.J. Moran, E.J.C. Goldstein and the Emergency Medicine Animal Bite Infection Study Group. 1999. The bacteriology and management of dog and cat bite wound infections presenting to Emergency Departments. N. Engl. J. Med. 340:85-92. 28. Talan, D., D. Staatz, A. Staatz, E.J.C. Goldstein, K. Singer, and G.B. Overturf. 1989. Staphylococcus intermedius in canine gingiva and canine inflicted human wound infections: Laboratory characterization of a newly recognized zoonotic pathogen. J. Clin. Microbiol. 27:78-81. 29. Weiss, H.B., D.J. Friedman, and J.H. Cohen. 1998. Incidence of dog bite injuries treated in Emergency Departments. J. Amer. Med. Assoc. 279:51-53.

11 258 259 260 261 262 Table 1. Comparative In vitro activity of ceftaroline and 7 other agents against 243 animal bite wound isolates including 156 Pasteurella species. MIC (ug/ml) Organism/ No. IsolatesAgent range 50% 90% P. canis 23 263 264 265 266 267 268 269 270 271 P. dagmatis 13 Ceftaroline <0.008 <0.008 <0.008 Cefazolin 0.06-0.5 0.25 0.5 Ceftriaxone <0.015 <0.015 <0.015 Ampicillin-sulbactam <0.015-0.125 0.03 0.06 Ertapenem <0.015 <0.015 <0.015 Azithromycin 0.06-0.125 0.125 0.125 Doxycycline 0.08-0.125 0.125 0.125 SMX-TMP 0.03-0.125 0.03 0.06 Downloaded from http://aac.asm.org/ 272 273 274 275 276 277 Ceftaroline <0.008 <0.008 <0.008 Cefazolin 0.125-0.5 0.25 0.5 Ceftriaxone <0.015 <0.015 <0.015 Ampicillin-sulbactam 0.03-0.06 0.06 0.06 Ertapenem <0.015 <0.015 <0.015 Azithromycin 0.03-0.125 0.06 0.06 on June 30, 2018 by guest 278 Doxycycline 0.125 0.125 0.125 279 SMX-TMP 0.03-0.125 0.06 0.06 280 P. stomatis 20 281 Ceftaroline <0.008 <0.008 <0.008 282 Cefazolin 0.125-0.5 0.25 0.5

12 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 Ceftriaxone <0.015 <0.015 <0.015 Ampicillin-sulbactam 0.03-0.06 0.06 0.06 Ertapenem <0.015 <0.015 <0.015 Azithromycin 0.03-0.125 0.06 0.06 Doxycycline 0.125 0.125 0.125 SMX-TMP 0.03-0.125 0.06 0.06 P. multocida ssp multocida 50 Ceftaroline <0.008 <0.008 <0.008 Cefazolin 0.06-1 0.5 0.5 Ceftriaxone <0.015 <0.015 <0.015 Ampicillin-sulbactam <0.015-0.125 0.06 0.125 Ertapenem <0.015-0.03 <0.015 <0.015 Azithromycin 0.03-1 0.25 1 Doxycycline 0.06-0.5 0.125 0.125 SMX-TMP 0.015-0.125 0.06 0.125 P. multocida ssp septica 50 Ceftaroline <0.008 <0.008 <0.008 Cefazolin 0.125-1 0.5 0.5 Ceftriaxone <0.015-0.6 <0.015 <0.015 Ampicillin-sulbactam 0.03-0.125 0.125 0.125 Ertapenem <0.015 <0.015 <0.015 Azithromycin 0.03-1 0.125 1 Doxycycline 0.06-0.25 0.125 0.125 SMX-TMP 0.015-0.25 0.06 0.125

13 307 S. aureus 30 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 Ceftaroline 0.06-0.25 0.125 0.125 Cefazolin 0.06-2 0.5 0.5 Ceftriaxone 1-16 2 2 Ampicillin-sulbactam <0.015-1 0.5 1 Ertapenem 0.06-0.5 0.06 0.125 Azithromycin 1-2 2 2 Doxycycline 0.03-2 0.06 0.125 SMX-TMP 0.06-0.125 0.06 0.125 S. epidermidis 12 Ceftaroline 0.03-0.125 0.03 0.125 Cefazolin 0.125-4 0.25 4 Ceftriaxone 1->16 1 16 Ampicillin-sulbactam 0.015-2 0.125 1 Ertapenem 0.06-8 0.125 2 Azithromycin 2 2 2 Doxycycline 0.06-8 0.125 1 SMX-TMP 0.06-8 0.125 0.25 Staphylococcus species * 15 Ceftaroline 0.015-0.125 0.06 0.06 Cefazolin 0.06-16 0.25 1 Ceftriaxone 1-16 2 4 Ampicillin-sulbactam 0.03-1 0.06 0.5 Ertapenem 0.06-1 0.125 0.125

14 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 Azithromycin 1-4 2 2 Doxycycline 0.03-2 0.06 0.125 SMX-TMP 0.06-0.25 0.125 0.25 Streptococcus sanguis 10 Ceftaroline` <0.008-0.015 <0.006 0.015 Cefazolin 0.06-0.5 0.25 0.5 Ceftriaxone 0.03-0.5 0.125 0.25 Ampicillin-sulbactam 0.015-0.06 0.03 0.06 Ertapenem 0.03-0.125 0.03 0.06 Azithromycin 0.015-1 0.06 1 Doxycycline 0.06-8 0.125 4 SMX-TMP <0.008-0.06 0.03 0.06 Streptococcus intermedius /10 Ceftaroline <0.008-0.015 <0.008 0.015 Cefazolin 0.125-1 0.25 1 Ceftriaxone 0.06-0.25 0.125 0.25 Ampicillin-sulbactam 0.015-0.25 0.03 0.06 Ertapenem <0.015-0.25 0.03 0.06 Azithromycin <0.008-1 0.06 0.5 Doxycycline 0.03-8 0.06 0.125 SMX-TMP 0.015-2 0.06 1 Streptococcus mitis 10 Ceftaroline <0.008-0.03 0.015 0.015 Cefazolin 0.03-2 0.5 2

15 355 356 357 358 359 360 361 362 363 364 365 Ceftriaxone 0.125-1 0.25 0.5 Ampicillin-sulbactam <0.008-1 0.125 0.25 Ertapenem <015-0.25 0.125 0.125 Azithromycin 0.03-1 0.06 1 Doxycycline 0.06-2 0.125 1 SMX-TMP 0.25->8 1 8 Staph species: S. cohnii, 2; S.pseudintermedius, 5, S. felis 1 S. warneri, 7. QC Ceftaroline P. multocida ssp multocida ATCC 12947 P.multocida ssp septica ATCC 51688 Downloaded from http://aac.asm.org/ on June 30, 2018 by guest