ST11 KPC-2 Klebsiella pneumoniae detected in Taiwan

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1 AAC Accepts, published online ahead of print on 30 January 2012 Antimicrob. Agents Chemother. doi: /aac Copyright 2012, American Society for Microbiology. All Rights Reserved ST11 KPC-2 Klebsiella pneumoniae detected in Taiwan Tsai-Ling Lauderdale National Institute of infectious Diseases and Vaccinology National Health Research Institutes, Zhunan, Taiwan Zhi-Yuan Shi Division of Infectious Diseases, Department of Internal Medicine, Veterans General Hospital-Taichung, Taichung, Taiwan School of Medicine, National Yang-Ming University, Taipei, Taiwan Chin-Fu Lin Department of Laboratory Medicine Veterans General Hospital-Taichung Taichung, Taiwan Jui-Fen Lai Mei-Jen Tan National Institute of infectious Diseases and Vaccinology National Health Research Institutes, Zhunan, Taiwan Jan-Tay Wang Division of Infectious Diseases, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Shan-Chwen Chang* Division of Infectious Diseases, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan *No. 7 Chung-Shan South Road, Taipei 100, Taiwan. Phone: ext 5401 Fax: changsc@ntu.edu.tw 1

2 36 Running Title: KPC-producing Klebsiella pneumoniae in Taiwan 37 2

3 38 Keywords: Carbapenem-resistant Klebsiella pneumoniae, KPC carbapenemase, ST

4 40 In Taiwan, the majority of carbapenem-resistant Enterobacteriaceae (CRE) isolates exhibited 41 low-level carbapenem resistance, and except a few isolates with VIM or IMP-8 carbapenemase 42 (6, 7, 13), most were due to the production of extended spectrum β-lactamase (ESBL) and/or 43 AmpC β-lactamase plus outer membrane protein porin loss (2, 7, 14). To date, there has only 44 been one case of Klebsiella pneumoniae carbapenemases (KPC)-producing K. pneumoniae 45 reported in Taiwan from a patient who was hospitalized in China prior to being transferred back 46 to Taiwan. The isolate harbored KPC-2 but the genetic background of the strain was not 47 mentioned (3). 48 We report the detection of four KPC2-positive K. pneumoniae from two patients in another 49 hospital in Taiwan. Patient A was a 74-year-old Taiwanese male who was hospitalized in China 50 for emergency medical treatment due to sudden cardiac arrest in He was transferred back 51 to the coronary care unit (CCU) of a Taiwanese hospital 5 days later. He developed urinary tract 52 infection due to a CRKP isolate (CRKP1) five days after being admitted to the CCU. Two 53 additional CRKP isolates were recovered from the central venous catheter (CRKP3) and urine 54 (CRKP4) 5 weeks after admission. Unfortunately, he expired due to the occurrence of hematoma 55 rupture and shock. Patient B was an 87 year old Taiwanese male who was hospitalized in the 56 same CCU because of congestive heart failure during the same period. He developed pneumonia 57 and CRKP was recovered from the central venous catheter tip and from a sputum specimen one 4

5 58 day apart. Only his sputum isolate (CRKP2) was available for further workup. CRKP2 was 59 isolated 19 days after CRKP1. Patient B accepted hospice care later due to terminal stage of 60 congestive heart failure. 61 The pulsed field gel electrophoresis (PFGE) patterns of CRKP1 to CRKP4 isolates were 62 indistinguishable (data not shown). All four isolates had the same antibiogram and were resistant 63 to all tested β-lactams (Table 1), with high ertapenem, imipenem, and meropenem MICs (> μg/ml), and were susceptible only to polymyxin B, tigecycline and 65 trimethoprim/sulfamethoxazole. All 4 were positive for bla KPC-2 as well as bla SHV-12 and bla CTX-M 66 and belong to sequence type 11 (ST11) (allelic profile ) (5, 8, 9, 11). The plasmids of 67 CRKP1 and CRKP2 were introduced into Escherichia coli DH10B by electroporation. The 68 pcrkp1/dh10b and pcrkp2/dh10b electrotransformants became resistant to all tested 69 β-lactams including carbapenems (MIC 12- >32μg/mL), and were positive for bla KPC-2 and 70 bla SHV-12 but not bla CTX-M. Restriction fingerprinting patterns of plasmid DNAs from the 71 transformants were similar (Fig 1). 72 In Asia, KPC-producing K. pneumoniae was first detected in a 2004 isolate from China (12), 73 where KPC2-producing Enterobacteriaceae subsequently disseminated in different regions (1, 74 10, 15). ST11 was found to be the predominant KPC2-producing K. pneumoniae isolated from 75 multiple cities of China (10). Those ST11 isolates also carried a combination of SHV-type and 5

6 76 CTX-M type ESBLs and AmpC β-lactamase (10). 77 It is possible that patient A acquired the KPC-producing K. pneumoniae during his 78 hospitalization in China and the strain was then transmitted to patient B in the same ward in 79 Taiwan. Although the prevalence of carbapenem-resistant Enterobacteriaceae in Taiwan has 80 remained low (2, 7, 14), the emergence of KPC-producing K. pneumoniae is worrisome since 81 multidrug resistant Enterobacteriaceae are already prevalent in Taiwan, which necessitates 82 increased carbapenem use. Careful monitoring systems need to be implemented and should 83 include patients transferred from hospitals abroad. 84 6

7 85 Acknowledgements 86 This project was supported by an intramural grant from the National Health Research 87 Institutes, Zhunan, Taiwan (99-A1-CLPP01-014). 88 7

8 89 REFERENCES Cai, J. C., H. W. Zhou, R. Zhang, and G. X. Chen Emergence of Serratia 91 marcescens, Klebsiella pneumoniae, and Escherichia coli isolates possessing the 92 plasmid-mediated carbapenem-hydrolyzing β-lactamase KPC-2 in intensive care units of 93 a Chinese hospital. Antimicrob. Agents Chemother. 52: Chia, J. H., L. H. Su, M. H. Lee, A. J. Kuo, N. Y. Shih, L. K. Siu, and T. L. Wu Development of high-level carbapenem resistance in Klebsiella pneumoniae among 96 patients with prolonged hospitalization and carbapenem exposure. Microb. Drug Resist : Chung, K. P., S. P. Tseng, Y. T. Huang, T. H. Tsai, L. J. Teng, and P. R. Hsueh Arrival of Klebsiella pneumoniae carbapenemase (KPC)-2 in Taiwan. J. Antimicrob. 100 Chemother. 66: CLSI Performance Standards for Antimicrobial Susceptibility Testing; 102 Twenty-First Infromational Supplement. M100-S21. Clinical and Laboratory Standards 103 Institute. Wayne, PA Diancourt, L., V. Passet, J. Verhoef, P. A. Grimont, and S. Brisse Multilocus 105 sequence typing of Klebsiella pneumoniae nosocomial isolates. J Clin Microbiol :

9 Lee, M. F., C. F. Peng, H. J. Hsu, and Y. H. Chen Molecular characterisation of 108 the metallo-β-lactamase genes in imipenem-resistant Gram-negative bacteria from a 109 university hospital in southern Taiwan. Int J Antimicrob Agents 32: Liu, Y. F., J. J. Yan, W. C. Ko, S. H. Tsai, and J. J. Wu Characterization of 111 carbapenem-non-susceptible Escherichia coli isolates from a university hospital in 112 Taiwan. J. Antimicrob. Chemother. 61: Monstein, H. J., A. Ostholm-Balkhed, M. V. Nilsson, M. Nilsson, K. Dornbusch, and 114 L. E. Nilsson Multiplex PCR amplification assay for the detection of bla SHV, 115 bla TEM and bla CTX-M genes in Enterobacteriaceae. APMIS 115: Perez-Perez, F. J., and N. D. Hanson Detection of plasmid-mediated AmpC 117 β-lactamase genes in clinical isolates by using multiplex PCR. J. Clin. Microbiol : Qi, Y., Z. Wei, S. Ji, X. Du, P. Shen, and Y. Yu ST11, the dominant clone of 120 KPC-producing Klebsiella pneumoniae in China. J. Antimicrob. Chemother. 66: Queenan, A. M., and K. Bush Carbapenemases: the versatile β-lactamases. Clin. 122 Microbiol. Rev. 20: Wei, Z. Q., X. X. Du, Y. S. Yu, P. Shen, Y. G. Chen, and L. J. Li Plasmid-mediated KPC-2 in a Klebsiella pneumoniae isolate from China. Antimicrob. 9

10 125 Agents Chemother. 51: Yan, J. J., W. C. Ko, S. H. Tsai, H. M. Wu, and J. J. Wu Outbreak of infection 127 with multidrug-resistant Klebsiella pneumoniae carrying bla(imp-8) in a university 128 medical center in Taiwan. J. Clin. Microbiol. 39: Yan, J. J., J. J. Wu, C. C. Lee, W. C. Ko, and F. C. Yang Prevalence and 130 characteristics of ertapenem-nonsusceptible Escherichia coli in a Taiwanese university 131 hospital, 1999 to Eur. J. Clin. Microbiol. Infect. Dis. 29: Zhang, R., X. D. Wang, J. C. Cai, H. W. Zhou, H. X. Lv, Q. F. Hu, and G. X. Chen Outbreak of Klebsiella pneumoniae carbapenemase 2-producing Klebsiella 134 pneumoniae with high qnr prevalence in a Chinese hospital. J. Med. Microbiol :

11 Table 1. Minimum inhibitory concentrations (MICs) of four KPC-2 positive carbapenem-resistant Klebsiella pneumoniae clinical strains (CRKP1-CRKP4), DH10B Escherichia coli electrotransformants, and DH10B MICs (μg/ml) a Antimicrobial agent CRKP1-CRKP4 K. pneumoniae Electrotransformants of DH10B b DH10B E. coli Amikacin > Ampicillin >256 >256 4 Aztreonam >256 > Cefepime 256 > Cefotaxime >256 > Cefoxitin > Ceftazidime >256 > Cefuroxime >256 >256 4 Ceftriaxone >256 > Ciprofloxacin > Ertapenem > Fosfomycin Gentamicin > Imipenem Meropenem > Piperacillin/tazobactam >256 >256 2 Polymyxin B Tigecycline TMP/SMX (SXT) C β-lactamase genes detected: ESBL SHV-12 & CTX-M (gr. 9) SHV-12 Not detected AmpC Not detected Not detected Not detected Carbapenemase KPC-2 KPC-2 Not detected MHT d -Ertapenem Pos Pos Neg a MIC data shown are from Etest. All agents except fosfomycin were also tested by broth microdilution method (4). b pcrkp1/dh10b and pcrkp2/dh10b electrotransformants. c TMP/SMX (SXT), trimethoprim/sulfamethoxazole. d MHT, Modified Hodge Test. 11

12 Figure 1. M M

13 150 Figure legend. BglII (lanes 1 and 2) and SacI (lanes 3 and 4) restriction digest of plasmid DNAs 151 from DH10B E. coli electrotransformants, M1, 1 kb DNA ladder (bp); lanes 1 and 3 are from 152 pcrkp1/dh10b; lanes 2 and 4 are from pcrkp2/dh10b. CRKP1 and CRKP2 were isolated 153 from 2 patients of the same ward 19 days apart. M2, λ/hind III ladder. 13

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