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 Algiers (Algeria).
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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DOI: 10.1089/fpd.2012.1159 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 Bacterial isolates 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.
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, PCR fingerprinting 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 Isolation date 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 27/03/2008 Cradle 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 26/10/2008 Cradle 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 26/10/2008 Cradle 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 16/10/2008 Cradle 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 03/10/2008 Cradle 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.
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 produce CTX-M-15.
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.
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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

Combination 830-nm and 633-nm light-emitting diode phototherapy shows promise in the treatment of recalcitrant psoriasis: preliminary findings

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.