Characterization of extended-spectrum beta-lactamase-producing salmonella enterica serotype brunei and heidelberg at the hussein dey hospital in algiers (algeria).
Characterization of extended-spectrum
beta-lactamase-producing Salmonella enterica serotype
Brunei and Heidelberg at the Hussein Dey hospital in
Rachida Kermas, Abdelaziz Touati, Lucien Brasme, Elisabeth Le
Magrex-Debar, Sadjia Mehrane, Fran¸cois-Xavier Weill, Christophe De Champs
To cite this version:
Rachida Kermas, Abdelaziz Touati, Lucien Brasme, Elisabeth Le Magrex-Debar, SadjiaMehrane, et al. Characterization of extended-spectrum beta-lactamase-producing Salmonellaenterica serotype Brunei and Heidelberg at the Hussein Dey hospital in Algiers (Alge-ria).
Foodborne Pathogens and Disease, Mary Ann Liebert, 2012, 9 (9), pp.803-8.
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FOODBORNE PATHOGENS AND DISEASEVolume 9, Number 9, 2012ª Mary Ann Liebert, Inc.
Characterization of Extended-Spectrum
Beta-Lactamase–Producing Salmonella enterica
Serotype Brunei and Heidelberg at the Hussein
Dey Hospital in Algiers (Algeria)
Rachida Kermas,1 Abdelaziz Touati,1 Lucien Brasme,2 Elisabeth Le Magrex-Debar,2
Sadjia Mehrane,3 Franc¸ois-Xavier Weill,4 and Christophe De Champs2
The purpose of this work was to study the genetic determinants responsible for extended-spectrum cephalosporin(ESC) resistance of Salmonella collected during the period of 1995–2008 at the Hussein Dey hospital in Algiers (Algeria).
Fourteen ESC-resistant Salmonella isolates were tested towards 22 antimicrobial agents. Polymerase chain reaction(PCR) and sequencing were used to determine the underlying genetic determinants responsible for the extended-spectrum beta-lactamase (ESBL) phenotypes. Enterobacterial Repetitive Intergenic Consensus PCR was employed totype the isolates. All tested isolates were resistant to ticarcillin, ticarcillin-clavulanate, piperacillin, cefuroxime,aztreonam, ceftazidime, cefotaxime (except two isolates), cefepime, and cefpirome. PCR and DNA sequencingidentified these ESBLs as TEM-48 (n = 6), TEM-4 (n = 3), CTX-M-15 (n = 4), and one new TEM, designated TEM-188.
Thus, continued surveillance for the presence of ESBL-producing (non-typhoidal) salmonellae in Algeria is essential.
TEM (Ait Mhand et al., 2002), SHV (Hammami et al., 1991),PER (Casin et al., 2003), OXA (Hanson et al., 2002), and CTX-
Nontyphoidal salmonellae are one of the principal M (Tamang et al., 2011); and plasmid-mediated AmpC type
pathogens implicated in foodborne gastroenteritis
enzymes, including DHA-1 (Barnaud et al., 1998), CMY-2
worldwide. Animals and their products, particularly meat,
(Koeck et al., 1997), and ACC-1 (Rhimi-Mahjoubi et al.,
chicken eggs, and milk, are major sources of human infection.
The incidence of non-typhoidal Salmonella infections has in-
In Algeria, ESBLs have been identified in nosocomial iso-
creased considerably in many countries, but with marked
lates of various Enterobacteriaceae, such as Escherichia coli,
differences among countries (Makanera et al., 2003). Although
Klebsiella pneumoniae, and Enterobacter cloacae (Touati et al.,
antimicrobials are not usually recommended in cases of Sal-
2006; Iabadene et al., 2008; Messai et al., 2008; Ramdani-
monella enterocolitis, they are crucial in systemic infections.
Bouguessa et al., 2011). However, only a few reports on the
Extraintestinal infectious complications, including meningi-
presence of these enzymes in Salmonella have been published
tis, sepsis, and bacteremia, are more common in infants and
(Naas et al., 2005, 2011; Touati et al., 2008; Iabadene et al., 2009;
the elderly, and in immunocompromised patients. In these
Bouzidi et al., 2011).
potentially life-threatening cases, the antibiotics of choice are
In this study, we characterized the ESBLs in a collection of
fluoroquinolones and extended-spectrum cephalosporins
ESC-resistant Salmonella isolated from 1995 to 2008 at the
(ESCs). Salmonella spp. resistant to ESCs have been recognized
Hussein Dey hospital in Algiers (Algeria).
since 1988 and are increasing in prevalence worldwide. This isof particular concern for the treatment of salmonellosis in
children, because fluoroquinolones should not be used in this
age group (Kruger et al., 2004; Yates and Amyes, 2005).
Salmonella has been found to express a wide variety of
A collection of 14 non-duplicate ESC-resistant Salmonella
extended-spectrum beta-lactamase (ESBL) types, including
enterica isolates were examined. They were obtained from
1De´partement de Microbiologie, FSNV, Universite´ A/MIRA de Be´jaia, Be´jaia, Algeria.
2Laboratoire de Bacte´riologie–Virologie-Hygie ne Hospitalie re, CHU Reims, Hoˆpital Robert DEBRE, Avenue du Ge´ne´ral Koenig, and
EA4687 SFR CAP-Sante´ (FED 4231), Universite´ de Reims-Champagne-Ardenne, Reims, France.
3Laboratoire Central de Biologie Clinique, CHU HUSSEIN DEY, Alger, Algeria.
4Institut Pasteur, Centre National de Re´fe´rence des Salmonella, Unite´ des Bacte´ries Pathoge nes Ente´riques, Paris, France.
KERMAS ET AL.
stool samples of children between 1995 and 2008 at the Hus-
CCA-3') and 405F (5'-GTGGCGATGAATAAGCTGA-3')/
sein Dey hospital in Algiers (Algeria).
CTX-M1-B2 (5'-CCGTTTCCGCTATTACAA-3') were used to
Selenite enrichment broth was inoculated with stool sam-
amplify the blaCTX-M gene (Dutour et al., 2002; Brasme et al.,
ples and incubated for 24 h at 37°C. The enrichment broth was
2007). The PCR program consisted of an initial denaturation
subcultured onto Hektoen agar and incubated for 24 h at
step at 94°C for 3 min, followed by 30 cycles of DNA dena-
37°C. The suspicious colonies were biochemically identified
turation at 94°C for 30 s, primer annealing (at 55°C for SHV,
by using the API 20E identification system (BioMe´rieux,
55°C for TEM, and 51°C for CTX-M) for 30 s, and primer ex-
Marcy l'E´toile, France).
tension at 72°C for 1 min, with a final extension step at 72°C
All isolates were serotyped at the French National Re-
for 7 min. PCR products were sequenced by Sanger's dideoxy
ference Center for Salmonella (Institut Pasteur, Paris, France)
chain termination procedure on an Applied Biosystems 3730
on the basis of somatic O, phase 1 flagellar, and phase 2 fla-
XL DNA analyser using the BigDye Terminator v3.1 Cycle
gellar antigens by agglutination tests with antisera (BioRad,
Sequencing Kit (Applied Biosystems, Foster City, CA). PCR
Marnes-la-coquette, France). The serotypes were designated
amplicons of blaTEM genes were cloned by using the pDrive
according to the White-Kauffman-Le Minor scheme.
cloning Vector 3.85 kb and the Qiagen PCR cloning kit (Qia-
The following b-lactamase–producing isolates were used
gen, Courtabeuf, France) according to the manufacturer's in-
as control isolates: Enterobacter aerogenes CF 2403 for TEM;
structions. The insert sequences were determined by direct
K. pneumoniae KpS12 for SHV; E. coli MEN, E. coli 27, and
sequencing with primers designed with the SP6 promoter and
K. pneumoniae Bhe CD13 for CTX-M, K. pneumoniae Kp760 for
T7 promoter of the pDrive cloning vector surrounding inserts.
DHA-1, E. coli TN13 for CMY-2, K. pneumoniae 1734 for FOX,
DNA sequencing was performed as described above. The
K. pneumoniae SLK54 for ACC, and E. coli C600 pMG231for MIR.
DNA alignments and deduced amino acid sequences were
These control isolates were kindly provided by Guilaume Arlet
examined using the BLAST program (Altshul et al., 1990).
(Service de Bacte´riologie, Hoˆpital Tenon AP-HP, Paris, France).
Detection of plasmid-mediated blaAmp-C was performed by
using multiplex PCR as described previously (Perez-Perez
Susceptibility testing and ESBL detection
et al., 2002).
Disk diffusion susceptibility tests for aztreonam, ticarcillin,
piperacillin, amoxicillin-clavulanate, ticarcillin-clavulanate, ce-foxitin, cefpirome, cefepime, piperacillin-tazobactam, cefurox-
Salmonella isolates with the same antibiotype were typed by
ime, imipenem, tobramycin, amikacin, gentamicin, kanamycin,
Enterobacterial Repetitive Intergenic Consensus (ERIC) PCR
sulfonamide, trimethoprim-sulfamethoxazole, nalidixic acid,
using ERIC1 (5¢-ATGTAAGCTCCTGGGGATTCAC-3¢) and
ciprofloxacin, tetracycline, and chloramphenicol (BioRad,
Hercules, CA) were performed according to the recommen-
Whole-cell DNA of isolates was extracted using the QIAmp
dations of the Antibiogram Committee of the French Society for
DNA mini kit (Qiagen). The ERIC-PCR parameters were as
Microbiology (Anonymous, 2010). Minimum inhibitory con-
follows: initial denaturation at 95°C for 7 min; 30 cycles of
centrations (MICs) for amoxicillin, cefotaxime, ceftazidime,
denaturation at 92°C for 30 s, annealing at 50°C for 1 min, and
and ceftriaxone were determined by Etest (AB BIODISK, Solna,
extension at 65°C for 8 min; followed by a final extension at
Sweden) performed on Mueller–Hinton agar plates as re-
65°C for 16 min (Cao et al., 2008). PCR amplicons were re-
commended by the manufacturer. Escherichia coli ATCC 25922
solved on 1% agarose gel containing ethidium bromide by
were used as the control. The results were interpreted accord-
horizontal electrophoresis in Tris-borate-EDTA buffer. Gels
ing to the recommendations of the Antibiogram Committee of
were visualized under UV light with Bio-Profil (Vilbert
the French Society for Microbiology (Anonymous, 2010). ESBL
Lourmat, Torcy, France).
production was detected by a double-disk synergy test (DDST)and was performed by placing disks of ceftazidime, cefotax-
ime, and aztreonam at a distance of 20 mm (center to center)
Fourteen isolates belonging to Salmonella enterica serotypes
from a disk with amoxicillin/clavulanic acid (20/10 lg). En-
Brunei (10 isolates) and Heidelberg (4 isolates) were isolated
hancement of the inhibition zone between the disks containing
and serotyped in the laboratory and confirmed at the Pasteur
clavulanic acid and cefotaxime, ceftazidime, or aztreonam in-
Institute in Paris, France.
dicated the ESBL production ( Jarlier et al., 1988).
All isolates exhibited resistance or decreased susceptibili-
ties to ticarcillin, ticarcillin-clavulanate, piperacillin, cefurox-
ime, aztreonam, ceftazidime, cefotaxime, cefepime, and
Total DNA was extracted by using the QIAmp DNA mini
cefpirome (Table 1). They remained susceptible to imipenem,
kit (Qiagen, Courtaboeuf, France) according to the instruc-
cefoxitin, and piperacillin-tazobactam. The DDS test was
tions of the manufacturer.
positive for all of these isolates.
Detection of b-lactamase genes (including blaTEM, blaSHV,
MICs determination showed that Salmonella Brunei exam-
and blaCTX-M) was carried out by polymerase chain reaction
ined were resistant to amoxicillin (MIC > 256 lg/mL), cefta-
(PCR) using specific primers: TEM-A (5'-TAAAATTCTT
zidime (MIC = 64 lg/mL), cefotaxime (MIC = 16 lg/mL), and
GAAGACG-3') and TEM-B (5'-TTACCAATGCTTAATCA-3')
ceftriaxone (MIC = 6 lg/mL). For Salmonella Heidelberg iso-
were used to amplify the blaTEM genes (Chanal et al., 2000),
lates, resistance was observed for all isolates (amoxicillin,
and SHV-F(5'-ATGCGTTATATTCGCCTGTG-3') and SHV-R
MIC > 256 lg/mL; ceftazidime, MIC = 48 lg/mL; cefotaxime,
(5'-TTAGCGTTGCCAGTGCTCGA-3') were used for the
MIC > 32 lg/mL; ceftriaxone, MIC > 32 lg/mL).
blaSHV genes (Kojima et al., 2005). CTX-M1-A2 (5'-CTTCCA
All isolates were resistant to gentamicin and tobramycin.
The isolates of Salmonella Brunei were resistant to kanamycin
Table 1. Characteristics of Algerian Clinical Isolates of Salmonella Brunei and Salmonella Heidelberg Resistant to Broad-Spectrum Cephalosporins
23/04/1997 Neonatology 19 [R] 6 [R] 6 [R] 19 [I] 22 [I] 21 [I] 19 [R] 12 [R] 25 [I] 12 [R] 25 [S] 35 [S] 30 [S] GEN, TOB, KAN, AMK
20/09/1994 Neonatology 11 [R] 6 [R] 6 [R] 24 [S] 21 [I] 21 [I] 23 [I] 24 [I] 25 [I] 17 [R] 28 [S] 35 [S] 30 [S] GEN, TOB, KAN
19/03/2008 Neonatology 16 [R] 6 [R] 6 [R] 19 [I] 22 [I] 20 [I] 19 [R] 12 [R] 23 [I] 10 [R] 23 [S] 35 [S] 31 [S] GEN, TOB, KAN, AMK, SUL TEM-48
18 [R] 6 [R] 6 [R] 19 [I] 22 [I] 20 [I] 19 [R] 12 [R] 23 [I] 14 [R] 23 [S] 36 [S] 30 [S] GEN, TOB, KAN, AMK, SUL TEM-48
25/06/1998 Neonatology 17 [R] 6 [R] 6 [R] 19 [I] 22 [I] 21 [I] 20 [R] 12 [R] 23 [I] 10 [R] 23 [S] 35 [S] 29 [S] GEN, TOB, KAN, AMK, SUL TEM-48
19/03/2008 Neonatology 18 [R] 6 [R] 6 [R] 19 [I] 22 [I] 21 [I] 20 [R] 11 [R] 23 [I] 10 [R] 23 [S] 34 [S] 30 [S] GEN, TOB, KAN, AMK, SUL TEM-48
12/12/1995 Neonatology 18 [R] 6 [R] 6 [R] 19 [I] 21 [I] 20 [I] 19 [R] 12 [R] 23 [I] 10 [R] 23 [S] 35 [S] 30 [S] GEN, TOB, KAN, AMK, SUL TEM-48
26/07/1998 Neonatology 18 [R] 6 [R] 6 [R] 19 [I] 22 [I] 21 [I] 19 [R] 12 [R] 24 [I] 11 [R] 23 [S] 35 [S] 30 [S] GEN, TOB, KAN, AMK
12/02/1995 Neonatology 18 [R] 6 [R] 6 [R] 19 [I] 22 [I] 21 [I] 19 [R] 12 [R] 24 [I] 11 [R] 23 [S] 36 [S] 31 [S] GEN, TOB, KAN, AMK, SUL TEM-48
22/03/1998 Neonatology 19 [R] 6 [R] 6 [R] 19 [I] 23 [I] 22 [I] 20 [R] 11 [R] 25 [I] 10 [R] 25 [S] 36 [S] 31 [S] GEN, TOB, KAN
6 [R] 6 [R] 24 [S] 11 [R] 9 [R]
22 [R] 12 [R] 11 [R] 14 [R] 26 [S] 36 [S] 31 [S] GEN, TOB, NAL
6 [R] 6 [R] 24 [S] 14 [R] 10 [R] 22 [R] 12 [R] 10 [R] 14 [R] 26 [S] 35 [S] 30 [S] GEN, TOB, NAL
6 [R] 6 [R] 24 [S] 14 [R] 10 [R] 22 [R] 12 [R] 10 [R] 13 [R] 28 [S] 35 [S] 30 [S] GEN, TOB, NAL
6 [R] 6 [R] 24 [S] 13 [R] 10 [R] 25 [R] 12 [R] 8 [R]
14 [R] 26 [S] 35 [S] 30 [S] GEN, TOB, NAL
CXM, cefuroxime; TIC, ticarcillin; PIP, piperacillin; AMC, co-amoxiclav; FEP, cefipime; CPO, cefpirome; TCC, ticarcillin-clavulanate; ATM, aztreonam; CTX, cefotaxime; CAZ, ceftazidime; TZP,
piperacillin/tazobactam; IMP, imipenem; FOX, cefoxitin; GEN, gentamicin; TOB, tobramycin; KAN, kanamycin; AMK, amikacin; SUL, sulfonamides; NAL, nalidixic acid.
KERMAS ET AL.
and amikacin (except isolates of S9 and S12). Resistance to
b-lactamase, which differed from the TEM-1 b-lactamase se-
nalidixic acid was observed in all isolates of Salmonella Hei-
quence by four substitutions (Leu21Phe, Glu104Lys, Gly238-
delberg. All of the isolates were susceptible to ciprofloxacin,
Ser, and Thr265Met), was first reported for E. coli in France by
cotrimoxazole, tetracycline, and chloramphenicol.
Paul et al. (1989). This enzyme was described in an isolate of
TEM consensus PCR assays gave the expected PCR frag-
Salmonella collected during a French national survey in 1998
ments for the 10 isolates of Salmonella Brunei (Table 1), and
(De Champs et al., 2000) and reported in isolates of Salmonella
CTX-M amplifications were positive for the four isolates of
serotype Mbandaka in Tunisia (Makanera et al., 2003). This
Salmonella Heidelberg. SHV and plasmid-mediated blaAmp-C
was the first reported identification of the TEM-4 ESBL in
amplification was negative.
Algerian Salmonella Brunei.
Three isolates of Salmonella Brunei (S9, S12, and S22) har-
The amino acid substitutions of the sequence of TEM-48
bored the blaTEM-4 gene, and the blaTEM-48 gene was found in
compared to the TEM-1 b-lactamase sequence were Leu21-
six isolates of Salmonella Brunei (S15, S16, S18, S20, S21, and
Phe, Gly238Ser, Glu240Lys, and Thr265Met. TEM-48 was first
S23). The four isolates of Salmonella Heidelberg were found to
described in K. pneumoniae isolates in Poland (Gniadkowski
et al., 1998).
One isolate of Salmonella Brunei (S10) was found to produce
CTX-M-15 was identified in different Salmonella serotypes,
a new TEM. This protein has been designated TEM-188
but to our knowledge, this is the first report of CTX-M-15 in
Salmonella Heidelberg isolates. CTX-M-15–producing Salmo-
number JN211012). The new TEM b-lactamase differed from
nella isolates were reported in different serotypes in Algeria,
TEM-1 by three substitutions: Leu21Phe, Gly238Ser, and
including Infantis (Naas et al., 2011) and Kedougou (Touati
Glu240Lys. These substitutions are identical to those found in
et al., 2008). The four isolates of Salmonella Heidelberg were
TEM-48. However, TEM-48 has an additional substitu-
found resistant to nalidixic acid, but susceptible to fluor-
tion, Thr265Met. Isolates producing TEM-48 and TEM-188
oquinolones. PCR for the plasmid-mediated mechanisms was
showed identical antibiotypes (Table 1), suggesting that the
negative for the four isolates, suggesting that the nalidixic acid
substitution Thr265Met in TEM-48 has no effect on b-lactam
resistance was probably mediated by mutations in topo-
The ERIC-PCR method was applied to the six TEM-48–
All isolates were resistant to gentamycin and tobramycin,
producing Salmonella Brunei isolates and the four CTX-M-15–
and eight isolates of Salmonella Brunei were resistant to ami-
producing–Salmonella Heidelberg. Two ERIC-PCR patterns
kacine. According to resistance levels conferred by the
were observed: one for the six Salmonella Brunei and a second
methylases (amikacin MICs > 256 lg/mL) (Naas et al., 2009,
one for the four Salmonella Heidelberg.
2011), the presence of methylases in our isolates was unlikelysince diameter obtained with the amikacin disc was 12–14 mm. Aminoglycosides resistance was likely due to ami-
There are a number of commonly identified serotypes of
PCR-mediated genome fingerprinting based on ERIC or
Salmonella associated with human infections. In the United
Repetitive Element (REP) has been found useful for the typing
States, the most common serovars were Typhimurium, En-
of outbreak and sporadic Salmonella isolates (Merino et al.,
teritidis, Newport, Heidelberg, and Javiana. In other parts of
the world, there are some differences in the predominant
Nosocomial outbreaks due to ESBLs-producing Salmonella
serovars associated with disease. In the European Union,
have been described in many countries, such as the outbreak
Enteritidis is the predominant serovar. In many parts of Asia,
in Tunisia due to TEM-4–producing Salmonella Mbandaka
Choleraesuis is one of the top serovars. Salmonella Brunei has
(Makanera et al., 2003). The great majority of them have in-
been rarely reported from animals, animal food products, and
volved pediatric wards and especially neonatology units. In
patients with human salmonellosis (Foley and Lynne, 2007).
the community, many outbreaks have been reported and
In our study, 10 isolates of Salmonella Brunei were recov-
were largely foodborne outbreaks (Arlet et al., 2006). The
ered from infants during the period of 1995 to 2008 whereas
presence of different enzymes in the same species could be
the four Salmonella Heidelberg were recovered only in Octo-
due to the transfer of different plasmids to a unique clonal
ber 2008. Unfortunately, data of the commonly identified se-
isolate. Even an insufficient discrimination between the iso-
rotypes in Algeria were not available.
lates by ERIC-PCR cannot be ruled out; the weak prevalence
The largest subset of the population for which antibiotic
of these serovars was an argument for a common source of the
susceptibility of Salmonella is a major concern is children. Al-
isolates. The two clonal isolates observed in our study were
though, gastroenteritis is the most frequent clinical manifes-
recovered throughout the 13-year study period. The Salmo-
tation, systemic infections are common, and even cases of
nella Brunei–producing TEM-48 isolates were recovered from
meningitis have been reported. Such serious infections are
neonatology ward, except one isolate recovered from the
most common in children and the elderly. Antibiotic therapy is
cradle ward, whereas the Salmonella Heidelberg–producing
strongly recommended in such cases (Arlet et al., 2006). ESCs
CTX-M-15 isolates were isolated in the cradle ward in which
are commonly used to treat patient with invasive infections or
the age of children is about 3 months. These observations
severe diarrhea caused by salmonellae; however, during the
indicated that gastrointestinal infections were caused mainly
past years ESC-resistant Salmonellae have frequently been re-
by clonally related Salmonella serotype isolates, and clonal
ported worldwide, including north Africa (Ahmed et al., 2009;
spread was responsible for their dissemination.
Ohmani et al., 2010; Bouzenoune et al., 2011; Naas et al., 2011).
Salmonellosis is most often attributed to the consumption
The first Salmonella isolates with ESBLs in Africa were
of contaminated foods such as poultry, beef, pork, eggs, milk,
identified in 1988 in Tunisia (Hammami et al., 1991). TEM-4
seafood, nut products, and fresh produce contaminated with
ESBL IN SALMONELLA BRUNEI AND SALMONELLA HEIDELBERG
Salmonella (Foley and Lynne, 2007). In this study, food as a
Salmonella enteritidis by ERIC-PCR. World J Gastroenterol
source was excluded because milk was commercially pre-
pared. Therefore, a horizontal transmission of the isolates had
Casin I, Hanau-Berc¸ot B, Podglajen I, Vahaboglu H, Collatz E.
probably occurred, and we cannot exclude child contamina-
Salmonella enterica serovar Typhimurium bla(PER-1)-carrying
tion by their mothers or nurses.
plasmid pSTI1 encodes an extended-spectrum aminoglycoside
In summary, this study demonstrates the emergence of a
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Lincolnshire Wolds Area of Outstanding Natural Beauty Management Plan Strategic Environmental Assessment Strategic Environmental Assessment Appendix A June 2011 Produced on behalf of; Lincolnshire County Council; East Lindsey District Council; West Lindsey District Council; and North East Lincolnshire Council and partners Prepared by; The Lincolnshire Wolds Countryside Service and Lincolnshire Wolds Joint Advisory Committee
Photomedicine and Laser Surgery Volume 00, Number 00, 2009ª Mary Ann Liebert, Inc.Pp. 1–6DOI: 10.1089=pho.2009.2484 Combination 830-nm and 633-nm Light-Emitting Diode Phototherapy Shows Promise in the Treatment of Recalcitrant Psoriasis: Preliminary Findings Glynis Ablon, M.D., FAAD Background and Objectives: Psoriasis is one of the major problems facing dermatologists worldwide. Planararrays of light-emitting diodes (LEDs) have recently attracted attention in the treatment of difficult dermato-logical entities, 830 nm in near infrared (near-IR) and 633 nm in visible red. This study was designed to assess theefficacy of combination 830-nm and 633-nm LED phototherapy in the treatment of recalcitrant psoriasis. Subjectsand Methods: Nine informed and consenting patients with psoriasis were enrolled in this preliminary study,(3 men, 6 women, mean age 34.3, skin types I to IV). All had chronic psoriasis, which in most cases had provedresistant to conventional treatments. They were treated sequentially with LED arrays delivering continuous-wave 830 nm (near-IR) and 633 nm (red) in two 20-min sessions over 4 or 5 weeks, with 48 h between sessions(830 nm, 60 J=cm2; 633 nm, 126 J=cm2). Results: All patients completed their LED regimens (4 requiring 1 regi-men, 5 requiring a second). Follow-up periods were from 3 to 8 months, except in two patients who were lost tofollow-up. Clearance rates at the end of the follow-up period ranged from 60% to 100%. Satisfaction wasuniversally very high. Conclusions: The antiinflammatory effects of LED energy at 830 nm and 633 nm have beenwell documented, as has their use in wound healing. LED phototherapy is easy to apply, pain free and side-effect free, and is well tolerated by patients of all skin types. The promising results of this preliminary studywarrant a proper controlled double-blind study with a larger patient population.