(Plasmid mediated) Carbapenemases. Timothy R. Walsh, Cardiff University, Wales

Transcription

1 (Plasmid mediated) Carbapenemases Timothy R. Walsh, Cardiff University, Wales

2 What is a carbapenemase? How much carbapenem do they need to breakdown before they are called a carbapenemase? ESBL-enzymes have relatively low hydrolytic capacities of carbapenems, we suggest that only enzymes demonstrating imipenemase activity (Kcat/Vmax) of greater than 1 (μm-1 S-1) (Redefining extended-spectrum -lactamases: balancing science and clinical need. Giske et al. JAC :1-4)

3 Are carbapenemases ESBLs? moving on from 1989 GES-1, GES-2, GES-3, GES-4, GES-5 and GES-6 and GES- 7 are ESBLs GES-2, GES-4, GES-5 and GES-6 are carbapenemases!!!!!!!!!!!!!!!!!!!!!!! AND GES-5 is referred to in the literature as an ESBL (Redefining extended-spectrum -lactamases: balancing science and clinical need. Giske et al. JAC :1-4)

4 Carbapenemase Groups KPC (class A) serine BL GES (class A) serine BL OXA (class D) serine BL Metallo- -lactamases (class B)

5 bla KPC genes 10 derivatives (15/05/09) First identified in 1996 (USA) Found in USA, Puerto Rico, Israel, Colombia, Brazil, Argentina, China (Citrobacter freundii, E. coli and Serratia marcescens), Sweden, Norway, UK Greece/Turkey Associated with Tn3-type transposon (Tn4401) ( The real threat of Klebsiella pneumonia carbapenemase producing bacteria Nordmann, Cuzon & Nass Lancet 9:228-36)

6 OXA-type carbapenemases 1. Walther-Rasmussen & Hoiby JAC. 57: Poirel, L & Nordmann, P CMI. 12: Poirel, L., Nass, T, Nordmann, P (in press) different variants (14/05/09) Note: OXA24 and OXA40 are the same. (

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8 Do they always mediate resistance to carbapenems? Table Susceptibility profile of metallo -β-lactamase producing enterobacterial isolates. MIC, μg/ml Klebsiella pneumoniae, Enterobacter cloacae Klebsiella oxytoca, Escherichia coli, Method, antibiotic KPMBL-A (n= 14) ECLMBL-1 (n = 2) ECLMBL-2 (n = 2) ECLMBL-3 (n= 2) ECLMBL-4 (n = 1) ECLMBL-5 (n = 1) ECLMBL-6 (n = 3) KOMBL-1 (n = 1) ECMBL-1 (n = 1) Microdilution Piperacillin-tazobactam >64/4 >64/4 >64/4 >64/4 >64/4 >64/4 >64/4 >64/4 >64/4 Ceftazidime >16 >16 >16 >16 >16 >16 >16 >16 >16 Cefotaxime >8 >8 >8 >8 >8 >8 >8 >8 >8 Cefepime 8 to >16 16 to >16 >16 16 to >16 2 >16 16 to >16 >16 16 Imipenem 1 to > to Meropenem 1 to to Tato et al., CID. 45:

9 Table Susceptibility profiles of the 17 gram-negative isolates carrying the bla VIM-1 gene. MIC, μg/ml Case Isolate IPM MEM ERT COL CIP GEN TIG Antimicrobial resistance phenotype a ESBL presence 1 Enterobacter cloacae ATM, ERT No 2 Klebsiella pneumoniae ATM, TOB, TET, CIP Yes 3 K. pneumoniae ATM, TOB, TET, CIP Yes 4 K. pneumoniae ATM, TOB, CIP Yes 5 K. pneumoniae > ATM, MEM, ERT, TOB, TET, CIP Yes 6 Enterobacter aerogenes > TOB, CIP No 7 K. pneumoniae ND > TOB, TET, CIP No 8 K. pneumoniae > ATM, MEM, ERT, TOB, CIP Yes 9 K. pneumoniae > ATM, TOB, TET, CIP Yes 10 K. pneumoniae ND ND ND 0.5 ATM, ERT, TOB, CIP Yes 11 K. pneumoniae > ATM, TOB, AMK, CIP Yes 12 K. pneumoniae 8 > > ATM, IPM, MEM, ERT, TOB, AMK, CIP Yes 13 Klebsiella oxytoca TOB, TET, CIP No 14 K. pneumoniae > ATM, IPM, MEM, ERT, TOB, TET, CIP Yes 15 K. pneumoniae >32 >32 > > ATM, IPM, MEM, ERT, TOB, TET, AMK, CIP Yes 16 K. pneumoniae 8 32 > > ATM, MEM, ERT, TOB, AMK, CIP Yes 17 K. pneumoniae > ATM, ERT, TOB, TET, CIP Yes Souli et al., CID. 46:

10 In-vivo significance of MBLs mediating subcarbapenem breakpoint MICs Isolate Kp-S Kp-1a Kp-1b Kp-R Imi Mer Daikos et al., CMI. 13:

11 Do they normally mediate resistance to cefotaxime and ceftazidime?

12 Do they always mediate resistance to cefotaxime and ceftazidime? Table Susceptibility profile of metallo -β-lactamase producing enterobacterial isolates. MIC, μg/ml Klebsiella pneumoniae, Enterobacter cloacae Klebsiella oxytoca, Escherichia coli, Method, antibiotic KPMBL-A (n= 14) ECLMBL-1 (n = 2) ECLMBL-2 (n = 2) ECLMBL-3 (n= 2) ECLMBL-4 (n = 1) ECLMBL-5 (n = 1) ECLMBL-6 (n = 3) KOMBL-1 (n = 1) ECMBL-1 (n = 1) Microdilution Piperacillin-tazobactam >64/4 >64/4 >64/4 >64/4 >64/4 >64/4 >64/4 >64/4 >64/4 Ceftazidime >16 >16 >16 >16 >16 >16 >16 >16 >16 Cefotaxime >8 >8 >8 >8 >8 >8 >8 >8 >8 Cefepime 8 to >16 16 to >16 >16 16 to >16 2 >16 16 to >16 >16 16 Imipenem 1 to > to Meropenem 1 to to Tato et al., CID. 45:

13 Where are they normally found? PSA ACB Coliforms KPC GES OXA VIM- MBL ++ +/- + IMP- MBL ++ +/- + SPM- MBL NDM- MBL

14 bla KPC genes 10 derivatives (15/05/09) First identified in 1996 (USA) Found in USA, Puerto Rico, Israel, Colombia, Brazil, Argentina, China (Citrobacter freundii, E. coli and Serratia marcescens), Sweden, Norway, UK Greece/Turkey Associated with Tn3-type transposon (Tn4401) ( The real threat of Klebsiella pneumonia carbapenemase producing bacteria Nordmann, Cuzon & Nass Lancet 9:228-36)

15 Species Distribution of Class D Carbapenemases Cluster 1 plasmid mediated (Scaife et al., JAC : ). Also, chromosome encoded in Proteus mirabilis (Bonnet et al., AAC. Cluster 46: ). Back to plasmid? (Niumsup et al., Jpn. J. infect Dis. 62:152-4) Cluster 2 First identified as chromosomal but now both chromosomal and plasmid (Quinteira et al., AAC. 51: ). Found recently in Ps. aeruginosa on a plasmid (Poirel, personal communication, Sevillano et al., Pathol Biol) OXA-48 Found in K. pneumoniae in Mediterranean basin on plasmids IncN (Poirel et al., AAC. 48:15-22). Now spread to E. coli and Citrobacter spp. OXA-58 plasmid mediated and found only in Acinetobacter spp. (mainly A. baumannii)

16 Global Distribution of OXA-type Carbapenemases Cluster 1 e.g. OXA-23 Cluster 2 e.g. OXA24-26, 40 etc. OXA-48 OXA-58

17 Where are MBLs found??? Pseudomonas aeruginosa Acinetobacter spp. Enterobacteriaceae metallo- -lactamases mimic ESBLs on many issues not least detection in Enterobacteriaceae

18 Location of Mobile MBL- Containing Organisms IMP VIM SPM-1 GIM-1 AIM-1 SIM-1 NDM-1 DIM-1 TMB-1 KHM-1 DIM-1 Poirel and Nordmann (unpublished data) TMB-1 El Salabi, Toleman and Walsh (unpublished data)

19 Transfer of genes via human populations typified by blandm-1 K. pneumoniae E. coli C. freundii S. marcescens K. pneumoniae E. coli

20 Are carbapenemase genes mainly found on plasmids and is it important?

21 Conjugation

22 Plasmid mediated MBLs what species are they found in? IMP 1-24 (integron) VIM (integron) (VIM-1 versus VIM-2 group!) SPM-1 GIM-1 (integron) SIM-1 (integron) AIM-1 NDM-1 (integron) KMH-1 (?) (Sekiguchi et al., AAC : ) DIM-1 (integron) (Poirel & Nordmann personal communication) TMB-1 (integron) (El Salabi et al. unpublished)

23 Different means of transmission within the same city (Warsaw, Poland) blavim-2 mostly found on plasmids blavim-4 exclusively chromosomal (Patzer and Toleman, unpublished data)

24 A)_ TraK MerR MerT MerP KfrA MerA TraJ MerD TraI MerE Orf-2 TrbJ TnpR TrbK TrbL RepA p Pseudomonas plasmids contain environmental bacterial scaffolds carrying resistance genes success of VIM-2 ParC Orf215 p ParA1 ParE p TnpM IncP-like Orf217 ParA IntI Vim7 OrfL1 B) MerR MerT MerP MerA MerD MerE orf2 TnpR Tn 501-like RepA ParC orf215 ParA1 orf217 ParA Truncated tra regioniintact Sta region Replication/maintenance oriv TnpA IS aac blavim7 IntI TnpM Tn3-like Transposon TrbL TrbK TrbJ Unknown TraI TraJ TraK KfrA (Li et al., AAC : ) Transfer region orit

25 Transfer of genes via human populations typified by blandm-1 K. pneumoniae E. coli C. freundii S. marcescens K. pneumoniae E. coli

26 Are they an indicator of an MDR phenotype? YES! Resistance profile usually includes aminoglycosides, all -lactams, fluoroquinolones

27 Genetic Elements in standard class 1 integrons INT aaca7 INT blavim-2 blavim-2 aaca4 aacc1 aaca4 qaceδ1/sul qaceä1/sul Resistance to: Aminoglycosides -lactams Sulphamethoxazole Disinfectants

28 A efflux pump Δldh ΔblaDHA-1 ΔPAI blandm-1 ΔIS26 ΔTn3 (1-2kb) Int1 arr-2 erec aada1 cmla7 qaceδ1 ISCR1 (1-4kb) B ISEcP1 blacmy-4 blc

29 Is there a limit to how much foreign DNA a bug can carry? We don t know!!

30 Fournier et al Comparative genomics of multi-drug resistance in Acinetobacter baumannii. Genetics. 2: 62-72

31 How complicated can it get? We don t know but mathematically it is likely to increase

32 Resistance/transfer occurs as a direct response to antibiotic usage? Transfer? quinolones? Spread of Resistance - probably

33 Is there a link between resistance and virulence? We don t know BUT!

34 Lavigne et al., CMI

35 Carbapenemase Detection? Media, media, media!!!! DDS test Hodge Test Disk inhibitor test Inhibitor panels (false positive) Etest

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38 General principal of substrate and inhibitor combinations. For ESBLs: Clavulanic acid Sulbactum Tazobactum

39 Enterobacter cloace IMP8 Klebsiella pneumoniae IMP-1 Klebsiella pneumoniae VIM-1 Escherichia coli ATCC 25922

40 What should we look out for? PSA ACB Coliforms CTX High R High R R CTZ High R High R R Ertapenem R R I/R Imipenem R S/I/R S/I/R Meropenem R S/I/R S/I/R

41 What should we look out for? Battling against the complexities of BLs! Phoenix results CTX and CTZ resistance Ertapenem intermediate resistance

42 The only thing I am certain about is that I know nothing! (Aristotle) -And even then I m not sure! (Baquero 2008)