Carbapenem-resistant Escherichia coli and Klebsiella pneumoniae in Taiwan

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1 Carbapenem-resistant Escherichia coli and Klebsiella pneumoniae in Taiwan An Infection Control Emergency Speaker: L Kristopher Siu Principal Investigator Division of Infectious Diseases National Institute of Infectious Diseases and Vaccinology National Health Research Institutes

2 Do Not Catch General Attention In Taiwan

3 Becoming a Political Issues

4 Rapid transmission of NDM-1 producers P Nordmann et al EID 2011;17:

5 Global distribution of Klebsiella pneumoniae carbapenemase (KPC) producers P Nordmann et al EID 2011;17:

6 Global distribution of VIM and IMP producers P Nordmann et al EID 2011;17:

7 Geographic distribution of OXA-48 type producers P Nordmann et al EID 2011;17:

8 Carbapenemases described worldwide Classification Enzyme Most Common Bacteria Class A KPC, SME, IMI, NMC, GES Enterobacteriaceae Class B (metallo-β- lactamase) IMP, VIM, GIM, SPM, NDM P aeruginosa Enterobacteriacea Acinetobacter spp Class D OXA Acinetobacter spp

9 Carbapenems in clinically available Drug Route of Administration Imipenem Meropenem Ertapenem Doripenem IV IV IM, IV IV Major use was in multiple drugs resistant bacteria that was encountered

10 Mechanisms of Carbapenem Resistance 1 Carbapenemase 2 Cephalosporinase (AmpC or ESBL) combined with outmembrane porin loss 3 Up-regulated efflux 4 Decreased affinity of the penicillin binding proteins

11 The threats of increasing incidence of Carbapenem-Resistant Enterobacteriaceae 1 Significantly limits treatment options for lifethreatening infections 2 Carbapenem-resistant Enterobacteriaceae are normally resistant to other class of antibiotics 3 Rapid spread of resistance due to carbapenemases genes are mobile

12 What is the situation in Taiwan?

13 TSAR (Taiwan Surveillance of Antimicrobial Resistance) A national biennial surveillance program Target: clinical isolates from inpatients and outpatients The same 26 hospitals participated in TSAR III to TSAR VII TSAR Collection time No of Hospitals I Oct-Dec II Mar-May III Jul-Sep S M N E Accredited Hospitals in Taiwan (2010) Hospitals Total TSAR Medical Centers Regional Hospitals Local Hospitals (was a RH) IV Jul-Sep V Jul-Sep VI Jul-Sep VII Jul-Sep * Population: 224 mil *Area: 142 x 394 km Medical center Regional Hosp Local Hosp

14 Imipenem-Resistance (resistant & intermediate) in Escherichia coli and Klebsiella pneumoniae (<1% overall) 2 Based on old CLSI 2009 criteria K pneumoniae E coli % 1 0 TSAR III (2002) TSAR IV (2004) TSAR V (2006) TSAR VI (2008) TSAR VII (2010) All isolates (including ICU, non-icu & OPD) in each round of TSAR - E coli, 1000 to 1500 isolates per year - K pneumoniae, isolates per year

15 Imipenem-Resistance (resistant & intermediate) in Escherichia coli and Klebsiella pneumoniae Based on new CLSI 2010, June criteria % TSAR III (2002) K pneumoniae E coli TSAR IV (2004) TSAR V (2006) TSAR VI (2008) TSAR VII (2010) % TSAR III (2002) K pneumoniae E coli TSAR IV (2004) TSAR V (2006) TSAR VI (2008) TSAR VII (2010) All isolates (including ICU, non-icu & OPD) ICU isolates only

16 Mechanisms of Carbapenem Resistance Reported in Taiwan

17 Carbapenemases reported in Taiwan before 2010 Enzyme Metallo-β-lactamase (IMP-8, VIM-2) Metallo-β-lactamase (VIM-2, VIM-3, VIM-11, IMP-8) OXA Bacteria Enterobacteriaceae P aeruginosa Acinetobacter spp

18 Changing susceptibility to carbapenem resistance during hospitalization in E coli Patient Isolate PFGE AmpC/ESBL MIC (μg/ml) Omp IMP MP F C A A-1-S 1 CMY-2, CTX-M A-2-R 1a CMY-2, CTX-M-14 > 32 > 32 B B-1-S 2 CMY-2, CTX-M B-2-R 2 CMY-2, CTX-M-14 > 32 > 32 C C-1-S 3 CMY C-11-R 3 CMY-2, SHV D D-1-S 4 CMY D-4-R 4 CMY-2 > 32 > 32 E E-1-S 5 CMY E-4-R 5 CMY-2 > 32 8 F F-1-S 6 CMY F-4-R 6 CMY-2 > G G-6-S 7 CMY G-11-R 7 CMY H H-3-S 8 CMY-2, CTX-M H-5-R 8 CMY-2, CTX-M-27 > 32 8 J Chemother (2009)

19 Changing susceptibility to carbapenem resistance during hospitalization in K pneumoniae Patient Isolate PFGE AmpC/ESBL MIC (μg/ml) Omp IMP MP ETP K35 K36 A A-1-S 1 DHA-1, SHV-12, CTX-M A-3-R 1a DHA-1, SHV-12, CTX-M-14 > 32 8 > 32 A-4-R 1a DHA-1, SHV-12, CTX-M-14 > 32 > 32 > 32 A-6-S 1b DHA-1, SHV-12, CTX-M B B-1-S 2 CTX-M B-2-S 2a CTX-M B-4-R 3 DHA-1, SHV > 32 C C-2-R 4 DHA-1, SHV > 32 C-4-S 4a DHA-1, SHV D D-2-S 5 CTX-M D-3-R 6 DHA-1, SHV-5 > 32 > 32 > 32 E E-2-S 7 SHV-33, CTX-M E-3-R 8 CMY-2, CTX-M-14 > 32 > 32 > 32 E-4-R 8 CMY-2, CTX-M-14 > 32 > 32 > 32 E-5-R 8a CMY-2, CTX-M-14 > 32 > 32 > 32 E-6-S 9 CMY-2, CTX-M Microbial Drug Resistant (2010)

20 New Carbapenemases reported in Taiwan in Wu HS et al 2010 First identification of a patient colonized with Klebsiella pneumoniae carrying blandm-1 in Taiwan J Chin Med Assoc, 73: pp (Isolate from 2010) 2 Chung KP et al 2011 Arrival of Klebsiella pneumoniae carbapenemase (KPC)-2 in Taiwan J Antimicrob Chemother 66: (Isolate from 2010)

21 What are the major mechanisms Mentoring program for Carbapenem resistance and epidemiology of carbapenem-resistant in K pneumoniae and E coli using isolates collection in 2012 (supported by CDC) K pneumoniae and E coli in Taiwan after the global reports on rapid spreading of Carbapenamses in 2010?

22 Antimicrobial susceptibility testing Antimicrobial agents tested (broth dilution test) Cefazolin Ertapenem Gentamicin Ceftriaxone Doripenem Amikacin Cefotaxime Imipenem Ciprofloxacin Ceftazidime Meropenem Colistin Cefepime CTX/CLA Tigecycline* Cefoxitin CAZ/CLA TMP/SMX *Etest strip for Tigecycline

23 Detection of β-lactamases Class A Carbapenemases ( KPC, IMI, SME, GES, NMC) ESBL (CTX-Group 1 2 9, SHV, TEM) Class B Metallo (NDM, VIM, IMP) Class C AmpC (DHA, CMY, ACT) Class D OXA (OXA-48)

24 Outer membrane profile E coli K pneumoniae OmpC OmpF OmpA WT F C C/F OmpK35 OmpK36 OmpA WT /36

25 Mentoring program for Carbapenem resistance in K pneumoniae and E coli in Major mechanism to cause carbapenem resistance was concomitance of ESBL or AmpC b-lactamases with outer membrane proins lost 2 In 2010, no outbreak (according to PFGE) or increasing incidences KPC or NDM was observed Lee CM et al 2012 Outbreak of Klebsiella pneumoniae carbapenemase-2-producing K pneumoniae sequence type 11 in Taiwan in 2011 Antimicrob Agents Chemother 56: (Isolates from 2011) Monthly Monitoring of Carbapenem resistance in K puenmoniae and E coli was then started in 2012

26 Interpretive criteria of carbapenems for Enterobacteriaceae 2010 criteria June (μg/ml) Susceptible Intermediate Resistance Ertapenem Imipenem Meropenem Doripenem criteria (μg/ml) Ertapenem* criteria (μg/ml) Ertapenem Imipenem Meropenem Doripenem 1 2 4

27 Antimicrobial susceptibility Antimicrobial resistance : Δ35/36 > Δ36 > Δ35 WT

28 Monthly Monitoring of Carbapenem resistance in K puenmoniae and E coli was then started in 2012 Isolates CRE Criteria Non-repeat IPM or MEM 2mg/ml E coli and K pneumoniae No limitation in isolation sites 29

29 Monthly Monitoring of Carbapenem resistance in K puenmoniae and E coli (CDC program projects) Carbapenem Non- Suscepetibility (MIC 2μg/ml for imipenem or meropenem) K pneumoniae E coli 2012 (17 hospitals) (19 hospitals) Total

30 Carbapenem non-susceptible E coli isolates in 2012 and 2013 Antibiotics MIC range Carbapenem non susceptible Ecoli 2012 ( n=51 isolates) 2013 (n=63 isolates)* MIC 50 MIC 90 R (%) MIC range MIC 50 MIC 90 R (%) P value Ertapenem 1-8 >= >005 Imipenem >005 Meropenem >005 Doripenem >005 Amikacin >005 Gentamicin >005 Cefazolin >005 Cefotaxime >005 Cefoxitin >005 Ceftazidime >005 Cefepime >005 Ciprofloxacin >005 Tigecycline >005 Colistin >005 SXT >005

31 Carbapenem non-susceptible KP in 2012 and 2013 Antibiotics Carbapenem non-susceptible K pneumonia 2012 (n=290 isolates) 2013 (n=350 isolates) P value MIC range MIC 50 MIC 90 R (%) MIC range MIC 50 MIC 90 R (%) Ertapenem Imipenem Meropenem >005 Doripenem >005 Amikacin Gentamicin Cefazolin >005 Cefotaxime >005 Cefoxitin >005 Ceftazidime >005 Cefepime >005 Ciprofloxacin >005 Tigecycline >005 Colistin >005 SXT >005 34

32 Resistance mechanisms in Carbapenem non-susceptible Ecoli b-lactamases a 2012(n=51 isolates) Outer membrane profile 2013 ( n=63 isolates) Carbapenemase F/C C F C/F F/C C F C/F KPC NDM IMP AmpC CMY DHA ESBL only CTX-M SHV others a 多數菌株產生多個 β-lactamase, 統計時採單一計算為原則 ( 不重複 ), 優先計算 carbapenemase, 其次是 AmpC, 最後是 ESBL, 詳細順序如表所列, 由上而下

33 Jaccard (Opt:050%) (Tol 10%-10%) (H>00% S>00%) [00%-1000%] XbaI 24H XbaI 24H E8 E40 E41 E16 E13 E17 E22 E23 E35 E32 E33 E29 E37 E5 E6 E46 E44 E45 E26 E3 E51 E9 E47 E53 E42 E43 E11 E18 E2 E12 E38 E39 E30 E28 E15 E52 E48 E49 E31 E34 E19 E7 E36 E25 E20 Kao C C C C Kao C Kao C C VGH Kao PFGE of carbapenem-resistant E coli in %

34 PFGE of CREC in %

35 Resistance mechanisms in Carbapenem non-susceptible KP β-lactamases a Outer membrane profile 2012 (N = 290) 2013(N = 350) 35/ /36 35/ /36 Carbapenemases KPC(2,3,17) NDM IMP VIM AmpC DHA CMY ESBLs CTX-M-9 group CTX-M-1 group SHV-type (SHV ,5,12,28,31,120) Others

36 PFGE of 52 KPC-producing K pneumoniae in % All were KPC-2 except one KPC- 17 (E-12)

37 PFGE of 350 CRKP in %

38 PFGE of 89 KPC- producing CRKP in % All were KPC-2 except one KPC-3 (B-151)

39 Interim summary 1 IMP-8 and VIM-1 are the two carbapenemases that were found in both in 2012 and 2013 and were at low prevalence Import of KPC and NDM-1 had been observed in CMY-2 or DHA-1 in combination with OmpK35/36 lost in K pneumoniae or with OmpF/C lost in E coli were, at least, the two major mechanisms involved in carbapenem resistance in Taiwan 3 Our PFGE data showed that KP and E coli are genetically divers but clonal spread of KPC-2 carrying KP was found in 2012 and are increasing in 2013 becoming an endemic problem in Taiwan 4 Unknown mechanism may involve for carbapenem resistance

40 Completed plasmid sequence of KPC-2 K penumoniae 1 From CR-KP 2 blakpc-2, blashv-11 3 No arma 4 A truncated version of IncFII replicon (without tra/trb and repfiik-1 loci)

41 Completed plasmid sequence of KPC-2 E coli 1 From CR-Ec 2 blakpc-2, blacmy-2, blactx-m-3, blatem Region caused unstable transferability 3 Chimera of IncI, incn, incf replicons

42 Comparison of the blakpc-2 regions A conserved 36-kb region containing the complete transfer operon (locus tra-trb) embedded in pkp048 and pkpn101-it is completely missing in pkpc_lk30 and therefore the plasmid lost its ability in conjugation

43 Discussion 1 Although KPC-2 plasmid from E coli were isolated in the same carbapenam resistance monitoring program and KPC-2 carrying K pneumoniae clonal spreading were observed, the plasmid in E coli was highly different to the KPC-2 plasmid in K pneumoniae 2 The KPC-2 plasmid in E coli was able to transfer its plasmid into other E coli but the region shuffion may affect the efficiency of plasmid transferability 3 The Genetic deficiency due to truncated version of IncFII replicon may lead to the inability of plasmid transferability The lost of complete transfer operon (locus tra-trb) embedded in pkp048 may lead the plasmid lost its ability in conjugation and also why the outbreak of KPC-2 carrying KP was confined 4 The isolation of NDM-1 from infected patients is alarming because of its highly effective transferability in conjungation and cross species transferring

44 Thank you for your attentions!