Results and experience of BARN ESBL project. Marina Ivanova and project team Tallinn

Transcription

1 Results and experience of BARN ESBL project Marina Ivanova and project team Tallinn

2 Aim of the project Improvement of detection and surveillance of resistance caused by extended spectrum betalactamase (ESBL) in Enterobacteriaceae in Baltic region (Estonia, Latvia, Lithuania and St Petersburg area of Russia). Why ESBL?

3 1. Beta-lactams are most widely used AB group

4 2. Incidence is increasing rapidly (compared to MRSA, VRE etc)

5 Insufficient data on ESBL epidemiology of Baltic region

6 K. pneumoniae resistant to 3 GC incidence is increasing

7 3. Many different types/genes and regional differencies

8 4. Rapid spread of new types

9 5. Colonisation of healthy people 24 of 100 travellers were colonised by ESBL pos E. coli and 5 of 21 remained colonised for longer than 6 months after the travel

10 6. Higher mortality and costs of treatment

11 Aims of the project in detail 1. Introduction and evaluation of phenotypic screening and confirmation algorithms of ESBLs (incl ESBL-A, ESBL-CARBA and ESBL-M) 2. Detection of main phenotypic and molecular markers in E. coli and K. pneumoniae strains resistant to 3rd generation cephalosporins in Baltic region 3. Creation of culture collection of resistant E. coli and K. pneumoniae strains for future studies 4. Improvement of antimicrobial resistance detection and resistance surveillance in Baltic region 5. Educational and scientific cooperation between EU (Baltic and Nordic states) and Russia

12 Project history: activities Feb st BARN WS: presentation of project proposal March to Sept 2011: Estonian Pilot study (4 labs) Nov 2011: 2nd BARN WS: participants meeting, final protocol Jan - May 2012: study period Introduction of ESBL screening/confirmation methods Collection of strains and data in local labs Meetings in St. Petersburg and Vilnius 12

13 Project history: activities June-Sept 2012: Collection of strains and data to study center ID- MALDI-TOF Extraction of DNA Master students training in Stockholm 2013 ECCMID posters preparation and presentation Final meeting in Tallinn Final report to BARN Initiatives for involvement of new countries Preparation of publications 13

14 21 labs/hospitals Collaboration

15 Strains/data collecting coordinators Jolanta Miciuleviciene, Lithuania, Vilnius (City) University Hospital Ruta Ambrazaitiene, Vilnius University Hospital Gintaras Makstutis, Siaulai Hospital Arta Balode, Latvia, Pauls Stradins University Dace Rudzite, Riga East Clinical University hospital Tatjana Djundika, Liepaja Hospital Lidia Kaftyreva, Russia, St. Petersburg Pasteur Institute Svetlana Egorova, St. Petersburg Pasteur Institute Nataliya Vedernikova, St. Petersburg Hospital 4 Lidia Lipskaya, St. Petersburg Hospital 40 Olga Morozova, St. Petersburg Children's hospital 1 Tatyana Kurchikova St. Petersburg Children's hospital 17 Maria Paysetchkaya, St. Petersburg Children's hospital 5 Marina Smirnova, St. Petersburg Hospital 16 Irina Konovalenko, St. Petersburg Hospital 31 Marina Ivanova, Estonia, ITKH Svetlana Rudenko, PERH Kaisa Kirs, LTKH Krista Lõivukene, TÜK Natalja Kamõnina, IVKH

16 Scientific support and activities Estonia-Sweden-Norway Barbro Olsson Liljequist, Petra Edquist SmittskyddsInstitutet Paul Naaber Stavanger University Hospital Paul Naaber, Epp Sepp, Siiri Kõljalg, Marina Ivanova Tartu University Anastasia Pavelkovich, Jana Lillo, Kristiine Pai Master students

17 Outputs, results Optimization of lab diagnostics and detection of resistance mechanisms Sustainable and integrated surveillance network base for ESBLs in Baltic-Nordic region Scientific publications about ESBL epidemiology in Baltic region National guidelines (for labs and IC - isolation).

18 Collection of strains 970 ESBL screening positive strains ( screened) 433 strains of E. coli 537 strains of K. pneumoniae January May 2012 Clinical isolates, 1 per patient

19 Collection ID check All strains were checked with MALDI Biotyper Microflex LT (Bruker Daltonics) Only confirmed (EC and KP) strains were included into collection

20 AST and phenotypical resistance screening ESBL A, ESBL M, ESBL CARBA first EC and KP isolates, meeting the criteria for ESBL phenotypical screening Screening (3 gen cefalosporins ceftazidim, cefotaxim NS) Screening (carbapenems ertapenem, meropenem NS)

21 Options for ESBL screening Options Antibiotic(s) Methods Interpretation (screening positive) 1. recommended Ceftazidime AND cefotaxime (ceftriaxone can be used instead of cefotaxime) 2. alternative VITEK or other expert system 3.Carbapenemase screening Ertapenem Meropenem Imipenem or or Disk diffusion or MIC Etest or MIC automated system e.g. VITEK Disk diffusion or MIC Any non-susceptible (i.e. Ceftazidime or cefotaxime or ceftriaxone) Non-susceptible (ceftazidime or cefotaxime or ceftriaxone) or VITEK alert for possible ESBL/AmpC Any non-susceptible

22 Comments: S1-S3: Screening tests 1-3; L1-L3: Microbial lists 1-3; T1-T4: Confirmation tests 1-4; R1-7: Lab reports to clinicians and infection control 1-7 KR AmpC: Chromosomal AmpC; PL AmpC: Plasmid AmpC D-test/ Cefox (S1) Irrespective of screening results Cefpodoxime < S OR Cefotaxime and/or Ceftazidime < S (S2) Ertapenem and/or Meropenem and/or Imipenem MIK <S (S3) L3 Enterobacter spp. C. freundii M. morganii H. alvei Serratia spp. Providencia spp. L1 most common: E. coli K. pneumoniae P. mirabilis Salmonella spp. Shigella spp. L2 K. oxytoca P. vulgaris C. koseri L3 Enterobacter spp. C. freundii M. morganii H. alvei Serratia spp. Providencia spp. AmpC test (T1) ESBL test (T2) ESBL test (T3) MBL, KPC, AmpC (T4) POS NEG or Nondetectabl e POS Ceftaz idime ESBL POS POS NEG or Nondetectable MBL POS KPC POS AmpC NEG KPC NEG AmpC POS E. coli Shigella KR/PL AmpC (R1) K. oxytoca K. pneumoniae P. mirabilis Salmonella spp. PL AmpC (R2) KR AmpC (R3) ESBL (R4) ESBL and KR AmpC (R5) KR AmpC (R3) MBL (R6) KPC (R7) AmpC + porin (R1/2/3)

23 Algorithm for detection of ESBL A (= ESBL inhibited by clavulanic acid) CTX-R or CAZ-R E.coli, K.pneumoniae, P.mirabilis, Salmonella spp., Shigella spp. K.oxytoca, P.vulgaris, C.koseri Other Enterobacteriaceae ESBL A-test (clavulanic acid) Chromosomal betalactamase Often chromosomal beta-lactamase Positive = ESBL A ESBL A-test only if CAZ-R ESBL A-test if resistant to >= 2 nonbetalactams Negative => Perform ESBL M - test Genotyped by PCR for CTX-M, SHV, TEM or other

24 Algoritm for detection of aquired (plasmidmediated) AmpC (=ESBL M ) ESBL A-negative and CTX/CAZ-R; E.coli, K.pneumoniae, (P.mirabilis, Salmonella spp., Shigella spp.) ESBL M-test positive (CAZ- CLOX synergy) ESBL M-test negative (no synergy) E.coli and Shigella spp. : PCR to differentiate between plasmid- or chromosomally-mediated Different mechanism (loss of porins, PBP alterations etc) K.pneumoniae, P.mirabilis, Salmonella spp. do not possess chrom. AmpC, therefore they have aquired AmpC Genotyped by PCR for pampc; CIT and DHA are most common

25 Algorithm for detection of carbapenemases (=ESBL CARBA ) Meropenem I/R using DD, or MIC > 0.5 mg/l Synergy with boronic acid but not cloxacillin Synergy with boronic acid and cloxacillin Synergy only with dipicolinic acid (DPA) No synergy = KPC (class A carbapenemase) = AmpC and loss of porins = Metallobetalactamase (e.g. VIM, IMP, NDM) = ESBL and loss of porin, or OXA-48

26 ROSCO test evaluation results

27 Diagnostic tests from Rosco

28 Diagnostic tests for ESBL M from Rosco CTX30 CAZ30+CLOX CTX30+CLOX CAZ30

29 Diagnostic tests for ESBL CARBA from Rosco

30 Molecular analysis of the collection Practical training of students in SmittskyddsInstitutet ESBL genes detection ESBL A (CTX-M, SHV, TEM) ESBL M (AmpC) ESBL CARBA (NDM, KPC )

31 ECCMID 2013 posters presented Epidemiology of Extended Spectrum Beta Lactamases producing E. coli and K. pneumoniae in the Baltic Sea Region Differences in virulence factors of E. coli isolated from the Baltic Sea Region The molecular epidemiology of Extended Spectrum Beta Lactamases producing E. coli and K. pneumoniae in the Baltic Sea Region Detection of carbapenem non-susceptible E. coli and K. pneumoniae in the Baltic Sea Region

32 Further analysis of the data Sensitivity of different screening agents and criteria (needs additional tests and work) Strains without confirmed mechanisms of resistance (phenotypically and/or genes) MIC distributions in different ESBL classes? Comparison of different fenotypical methods for detecton of resistance mechanisms?