Revised AAC Version 2» New-Data Letter to the Editor ACCEPTED. Plasmid-Mediated Carbapenem-Hydrolyzing β-lactamase KPC-2 in

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1 AAC Accepts, published online ahead of print on 3 December 2007 Antimicrob. Agents Chemother. doi: /aac Copyright 2007, American Society for Microbiology and/or the Listed Authors/Institutions. All Rights Reserved Revised AAC Version 2» New-Data Letter to the Editor Plasmid-Mediated Carbapenem-Hydrolyzing β-lactamase KPC-2 in Word count: 524 (max 500) Klebsiella pneumoniae from Greece Emergence and dissemination of Enterobacteriaceae isolates harboring carbapenemases in various geographic regions represents a significant threat to the management of nosocomial infections. Carbapenem-hydrolyzing β-lactamases can be metallo β-lactamases, expanded-spectrum oxacillinases, or Ambler class A enzymes (5,9). The class A KPC β-lactamases hydrolyze all β-lactams except cephamycins. They are increasingly reported in enterobacterial species (mostly in Klebsiella pneumoniae) from the US, especially from New York City hospitals (1,2,4,5,12). Outside the US, single KPC-producing isolates of Enterobacteriacae or Pseudomonas aeruginosa have been reported from France, China, and Colombia, but an epidemic situation has been reported also from Israel (6-8,10,11). We report here a K. pneumoniae isolate that produced β-lactamase KPC- 2 from Greece. On July 17, 2007, a 22-year-old woman was hospitalized in the intensive care unit (ICU) of the hospital of Heraklion, Greece for severe cranial trauma with coma (Glasgow coma scale score at 7) and multiple cranial and costal fractures subsequent to a traffic accident. On August 10th, she was initially transferred to 1

2 the orthopedic ward and then to the ICU of the hospital of Meaux (France). The day of her admission, bacteriological screening and wound samples revealed pan- resistant Acinetobacter baumannii (only susceptible to colistin) and K. pneumoniae GR being resistant to all antibiotics except gentamicin according to disk diffusion susceptibility testing results (3). The patient was treated locally with antiseptics, and fortunately did not get a systemic infection with K. pneumoniae requiring antibiotic treatment. No other A. baumannii or K. pneumoniae isolates with similar antibiotic resistance patterns were recovered from the hospital during this same period of time. The MICs of β-lactams determined by the E-test method (AB BIODISK, Solna, Sweden) and interpreted according to CLSI (3) for K. pneumoniae GR showed MIC values of expanded-spectrum cephalosporins and carbapenems being only slightly modified after addition of clavulanic acid (Table 1). A crude β- lactamase extract of that isolate showed significant carbapenem hydrolyzing activity as measured spectrophotometrically (0.2, 0.06 and 0.05 µmol of imipenem, meropenem, and ertapenem, respectively /min /mg of total protein) (7,9). Plasmid analysis detected a ca. 75-kb self-conjugative plasmid that conferred a β-lactam resistance pattern for E. coli transconjugants consistent with a slightly clavulanic-acid inhibited carbapenemase (Table 1). A β-lactamase extract from a transconjugant culture subjected to analytical isoelectric focusing (9) identified two β-lactamases with pi values of 5.4 and 6.8. PCR experiments, with primers for detection of Ambler class A, class D and class B ß-lactamase genes (7,9), followed by sequencing identified β-lactamase genes coding for 2

3 carbapenemase KPC-2 (pi 6.8) and the narrow-spectrum TEM-1 (pi 5.4). Then, using a series of successive PCR primers, the 2.8-kb surrounding sequences of the bla KPC-2 gene were found to be identical to those surrounding for the same bla KPC-2 gene in a K. pneumoniae isolate from New York (7). Up to now, carbapenemases of KPC-type seemed to be limited to Israel in this Mediterranean region. This is the first evidence of its identification in Greece, a nearby located country. It remains to be determined to which level the spread of KPC-type enzymes contribute to the high-level of carbapenem-resistance that until now was supposed to be due only to class B carbapenemases (VIM-type enzymes). ACKNOWLEDGMENTS This work was funded by a grant from the Ministère de l Education Nationale et de la Recherche (UPRES-EA3539), Université Paris Sud, and by the European Community (6th PCRD, LSHM-CT ). REFERENCES 1. Bradford, P. A., S. Bratu, C. Urban, M. Visalli, N. Mariano, D. Landman, J. J. Rahal, S. Brooks, S. Cebular, and J. Quale Emergence of carbapenem-resistant Klebsiella species possessing the class A carbapenemhydrolyzing KPC-2 and inhibitor-resistant TEM-30 β-lactamases in New York city. Clin. Infect. Dis. 39: Bratu, S., S. Brooks, S. Burney, S. Kochar, J. Gupta, D. Landman, and J. Quale Detection and spread of Escherichia coli possessing the plasmidborne carbapenemase KPC-2 in Brooklyn, New York. Clin. Infect. Dis. 44:972-3

4 Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing; fifteenth informational supplement. M100- S15. Clinical and Laboratory Standards Institute, Wayne, Pa, USA Deshpande, L. M., R. N. Jones, T. R. Fritsche, and H. S. Sader Occurrence and characterization of carbapenemase-producing Enterobacteriaceae: report from the SENTRY Antimicrobial Surveillance Program ( ). Microb. Drug Resist. 12: Queenan, A. M., K. Bush Carbapenemases: the versatile β-lactamases. Clin. Microbiol. Rev. 20: Leavitt, A., S. Navon-Venezia, I. Chmelnitsky, M. J. Schwaber, and Y. Carmeli Emergence of KPC-2 and KPC-3 in carbapenem-resistant Klebsiella pneumoniae strains in an Israeli hospital. Antimicrob. Agents Chemother. 51: Naas, T., P. Nordmann, G. Vedel, and C. Poyart Plasmid-mediated carbapenem-hydrolyzing ß-lactamase KPC in a Klebsiella pneumoniae isolate from France. Antimicrob. Agents Chemother. 49: Navon-Venezia, S., I. Chmelnitsky, A. Leavitt, M. J. Schwaber, D. Schwartz, and Y. Carmeli Plasmid-mediated imipenem-hydrolyzing enzyme KPC-2 among multiple carbapenem-resistant Escherichia coli clones in Israel. Antimicrob. Agents Chemother. 50: Poirel, L., C. Héritier, V. Tolun, and P. Nordmann Emergence of oxacillinase-mediated resistance to imipenem in Klebsiella pneumoniae. Antimicrob. Agents Chemother. 48:

5 Villegas, M. V., K. Lolans, A. Correa, J. N. Kattan, J. A. Lopez, J. P. Quinn and Colombian Nosocomial Resistance Study Group First identification of Pseudomonas aeruginosa isolates producing a KPC-type carbapenem- hydrolyzing β-lactamase. Antimicrob. Agents Chemother. 51: 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. Agents Chemother. 51: Yigit, H., A. M. Queenan, G. J. Anderson, A. Domenech-Sanchez, J. W. Biddle, C.D. Steward, S. Ablerti, K. Bush, and F. C. Tenover Novel carbapenem-hydrolyzing β-lactamase KPC-1 from a carbapenem-resistant strain of Klebsiella pneumoniae. Antimicrob. Agents Chemother. 45: Gaelle Cuzon Thierry Naas* Service de Bactériologie-Virologie, Hôpital de Bicêtre, Assistance Publique/Hôpitaux de Paris, Faculté de Médecine Paris-Sud, Université Paris XI, Le Kremlin-Bicêtre, France Marie Claude Demachy Laboratoire de microbiologie, Centre Hospitalier de Meaux, 6-8 Rue Saint- Fiacre, Meaux. France Patrice Nordmann Faculté de Médecine Paris-Sud, Université Paris XI, Le Kremlin- Bicêtre, France 5

6 *Phone: Fax:

7 TABLE. MICs of β-lactams for K. pneumoniae GR, E. coli transconjugant and E. coli recipient strain. β-lactam(s) a K. pneumoniae GR MIC (µg/ml) E. coli J53 TcGR Amoxicillin >256 >256 4 Amoxicillin+CLA Ticarcillin >256 >256 2 Ticarcillin+CLA >256 >256 2 Piperacillin > Piperacillin+TZB > Cephalothin >256 >256 4 Cefoxitin Cefotaxime > Cefotaxime + CLA Ceftazidime > Ceftazidime + CLA Aztreonam > Aztreonam + CLA > Cefepime > Imipenem E. coli J5 7

8 Imipenem + CLA Meropenem Meropenem+ CLA Ertapenem Ertapenem + CLA Tigecycline Gentamicine Colistin a CLA, clavulanic acid at a fixed concentration of 2 µg/ml; TZB, tazobactam at fixed concentration of 4 µg/ml. 8