CARBAPENEMASE PRODUCING ENTEROBACTERIACEAE

Transcription

1 CARBAPENEMASE PRODUCING ENTEROBACTERIACEAE Veroniek Saegeman Veroniek Saegeman UZLeuven

2 Carbapenemase producing Enterobacteriaceae (CPE) Introduction on antibiotic resistance Classification of ß-lactamases Definition and history of ESBL/CPE Laboratory diagnosis of CPE Reporting of results Belgian CPE epidemiology Outcome of CPE infections

3 Introduction resistance- UK MRSA bacteraemia decreasing (UK) CTX-M E. coli bacteraemia quinolone + cephalosporin resistance increasing Livermore, 2012

4 Introduction resistance- Belgium Invasive S. aureus isolates resistant (R/total N ) to methicillin in Belgium, Invasive E. coli isolates resistant (R/total N ) to 3 cephalosporins - fluoroquinolones in Belgium, EA RSn et,20 11

5 Introduction resistance Impact on infection and resistance by Newly prosperous countries (eg. India, China) Increased migration between countries Globalised market for goods and services Overuse of antibiotics in agriculture (China) Contamination of food with multiresistant bacteria 18% of drinking water contaminated with faecal flora (India) NDM carrying nonfermenters and Enterobacteriaceae in surface water River sediment: Fluoroquinolone concentrations > those in serum of a treated patient Modern sophisticated hospitals offering complex procedures to medical tourists global spread of multiresistant strains

6 Introduction resistance -Europe K. pneumoniae, 3 cephalosporin R, 2011 K. pneumoniae, carbapenem R, 2011 EARS-net, 2013

7 Introduction resistance - Europe Carbapenemase-producing Enterobacteriaceae up to January 2012 Canton R, 2012

8 Classification ß-lactamases Ambler molecular classification 4 major classes: A to D Protein homology (aminoacid similarity) Class A, C and D: serine ß-lactamases Class B: metallo ß-lactamases (Zn) Drawz and Bonomo, 2010 Bush-Jacoby-Medeiros functional classification Functional similarities: substrate and inhibitor profile 3 main groups, multiple subgroups Immediate relevance for microbiologist, physician

9 Adapted from Bush and Jacoby, 2010 Classification ß-lactamases Ambler/Bush-Jacoby-Medeiros classification Ambler Bush-Jacoby- Medeiros Preferred substrates Inhibited by clavulanate Representative enzyme(s) A (serine penicillinases) 2a Penicillins + PC1 from S. aureus 2b Penicillins, narrow-spectrum cephalosporins + TEM-1, TEM-2, SHV-1 2be Penicillins, narrow-spectrum and extended- spectrum cephalosporins + SHV-2 to SHV-6, TEM-3 to TEM-26, CTX-Ms BEL-1, VEB-1, PER-1 2br Penicillins TEM-30, SHV-72, SHV-10 2c Penicillins, carbenicillin + PSE-1 2e Extended-spectrum cephalosporins + FEC-1, CepA 2f Penicillins, cephalosporins, carbapenems ± KPC-2, SME-1, NMC-A B (metallo-β-lactamases) 3 Most β-lactams, including carbapenems IMP-1, VIM-1, NDM-1, CcrA, and BcII (B1); CphA (B2); L1(B3) C (cephalosporinases) 1 Cephalosporins AmpC, CMY-2, ACT-1 D (oxacillinases) 2d Penicillins, cloxacillin ± OXA-1, OXA-10 2de Extended-spectrum cephalosporins ± OXA-11, OXA-15 2df carbapenems ± OXA-23, OXA-48, OXA-40, OXA-58

10 Reaction scheme class A betalactamase Drawz and Bonomo, 2010

11 History of ESBL Plasmid mediated ß-lactamase 1960: TEM-1 E. coli (Greece) Spread to Enterobacteriaceae, Pseudomonas aeruginosa, R to ampicillin, 1 cephalosporin Chromosomal encoded ß-lactamase SHV-1 K. pneumoniae R to ampicillin, 1 cephalosporin 1980s: introduction of oxyimino-cephalosporins 1985: plasmid encoded SHV-2 in K. ozaenae (Germany) Increased activity spectrum: penicillins, 1-3 cephalosporins ESBL 1989: Plasmid mediated ESBL CTX-M ~ AmpC Kluyvera ascorbata Hydrolysis cefotaxime > ceftazidime Worldwide spread

12 History of ESBL TEM ESBLs: aminoacid substitutions at limited N positions Bradford, 2001

13 History of ESBL Most SHV ESBLs: mutants of Gly238 serine Bradford, 2001

14 History of ESBL CTX-M plasmid dissemination and clonal success Distribution of CTX-M ß-lactamases Davies and Davies, 2010

15 Definition ESBL Betalactamases Resistance to penicillins, 1, 2, 3 en 4 cephalosporins, aztreonam (excl cephamycins and carbapenem) Inhibition by betalactamase inhibitors eg. clavulanic acid

16 Definition and history of CPE Carbapenemase producing Enterobacteriaceae (CPE) Class A betalactamases R to penicillins, cephalosporins, aztreonam, carbapenem S (R) to betalactamase inhibitors Chromosomal encoded: SME, NMC, IMI 1982: Serratia marcescens: carbapenem R 3-4 cephalosporin S No mobile genetic element association single incidents, rare Plasmide encoded: KPC, GES 1996: K. pneumoniae: KPC R to 3-4 cephalosporins Transferable plasmids Other Enterobacteriaceae (and Pseudomonas aeruginosa)

17 Definition and history of CPE Class B metallobetalactamases R to penicillins, cephalosporins, carbapenems R to betalactamase inhibitors S to aztreonam Inhibited by metal ion chelators (eg. EDTA) First: chromosomal encoded: B. cereus, S. maltophilia Not easily transferred 1990: detection of metallobetalactamases associated with integrons when in transposons, plasmids transfer to other species VIM, IMP, GIM Eg. Japan: P. aeruginosa: IMP s: spread to Enterobacteriaceae

18 Definition and history of CPE Class D OXA-type betalactamases (weak) carbapenemase activity, R to penicillins, early cephalosporins Inhibitor resistant Aztreonam S 1993: 1 oxacillinase with carbapenemase activity Acinetobacter baumannii: OXA-23 Spread of particular clones 2004: Enterobacteriaceae (K. pneumoniae) Plasmidal spread OXA-48 < 50% identity with other OXA-members

19 Definition and history of CPE

20 Laboratory diagnosis of CPE Algorithm for CPE screening in UZLeuven Rectal Eswab Growth on (chromogenic) agar Malditof ID + Vitek AST Meropenem 1.0 mg/l or Meropenem 0.5 mg/l and temocillin 32 mg/l KPC/MBL disks Etest meropenem +/- temocillin Modified Hodge test

21 Laboratory diagnosis of CPE Screening (chromogenic) media Enrichment broth? author Number of samples method Sensitivity (%) Specifity (%) Wilkinson KM et al, stool samples; 200 isolates Brilliance CRE ChromID Car ba ChromID ESBL Colorex KPC (CHROMagar KPC) T SB + ertapenem 10 µ g Girlich etal, isolates SUPERCA RBA Brilliance CRE CHROMagar KPC Perry etal, stool samples ID Car ba (prototype) Colorex KPC Vrioni etal, rectal swabs CDC-protocol: TSB-E-Mc BHI-E-ESBL ChromID ESBL ChromID Car ba prototype Mc-M Si ngh et al, surveillance rectal swabs CHROMagar ESBL blakpc PCR Dévigne etal, characterized strains ChromID OXA-48 + ChromID CA RBA Colorex KPC Brilliance CRE

22 Laboratory diagnosis of CPE Screening (chromogenic) media Enrichment broth? No extra CPE recovered (N=55, UZLeuven) OXA-48 selective agar: UZLeuven data CPE OXA-48 groei kleur OXA blauwgrijs OXA blauwgrijs OXA roze OXA blauwgrijs OXA blauwgrijs OXA blauwgrijs OXA blauwgrijs OXA blauwgrijs OXA-48; ESBL +++ blauwgrijs NDM-1; ESBL (CTX-M-15); AmpC (CMY-58) 0 / KPC-2 like 0 / VIM 0 / VIM-2 KPC IMP-13 0 / OXA beige OXA-72 0 / OXA beige GES 0 / ESBL (SHV 238S + 240K) 0 / ESBL (TEM-24) 0 / ESBL (CTX-M 1, TEM WT); AmpC (ACT/MIR) 0 / ESBL (TEM 104K + 164S) 0 / AmpC (ACT/MIR) 0 / Hannosset S, 2013

23 Laboratory diagnosis of CPE Algorithm for CPE screening in UZLeuven Growth on chromogenic agar Malditof ID + Vitek AST Woodford et al, 2010

24 Laboratory diagnosis of CPE Algorithm for CPE screening KPC/MBL disk test: interpretation Meropenem + boronic acid Meropenem + dipicolinic acid Meropenem + cloxacillin Temocillin MIC > 128 µg/ml KPC Meropenem 10 µg 4 mm < 5 mm < 5 mm variable MBL Meropenem 10 µg < 5 mm 5 mm < 5 mm yes OXA-48 AmpC + porin loss ESBL + porin loss Meropenem 10 µg < 5 mm < 5 mm < 5 mm yes Meropenem 10 µg 4 mm EN < 5 mm 5 mm variable Meropenem 10 µg < 5 mm < 5 mm < 5 mm no

25 Laboratory diagnosis of CPE Algorithm for CPE screening Phenotypical KPC/MBL disks positive Confirmation PCRs on isolate: In-house (multiplex endpoint) CheckPoints: Ligation RT-PCR or microarray on swab/faeces sample: GeneXpert multiplex Real-time VIM, NDM, KPC, OXA-48 (end 2013) Alternative quick tests UV spectrophotometry Malditof MS Carba NP test

26 Laboratory diagnosis of CPE Malditof MS: detection of meropenem degradation products Wang L et al, Anal Bioanal Chem 2013, April 13

27 Laboratory diagnosis of CPE Carba NP test: carbapenem hydrolysis Bacteria + lysis buffer: 30 incubation centrifugate Supernatans + phenol red ph 7.8, ZnSO4, imipenem Incubation at 37 C for max 2 hrs Yellow = carbapenemase production 100% sensitivity 100% specificity Nordmann P; Poirel L, Dortet L. Emerg Infect Dis September;18(9):

28 Reporting results EUCAST 2013 ESBL The cephalosporin breakpoints for Enterobacteriaceae will detect all clinically important resistance mechanisms (including ESBL and plasmid mediated AmpC). Some isolates that produce beta-lactamases are susceptible or intermediate to 3rd or 4th generation cephalosporins with these breakpoints and should be reported as tested, i.e. the presence or absence of an ESBL does not in itself influence the categorisation of susceptibility. In many areas, ESBL detection and characterisation is recommended or mandatory for infection control purposes. CPE The carbapenem breakpoints for Enterobacteriaceae will detect all clinically important resistance mechanisms (including the majority of carbapenemases). Some isolates that produce carbapenemase are categorised as susceptible with these breakpoints and should be reported as tested, i.e. the presence or absence of a carbapenemase does not in itself influence the categorisation of susceptibility. In many areas, carbapenemase detection and characterisation is recommended or mandatory for infection control purposes. CLSI 2013 ESBL When using current interpretive criteria, routine ESBL testing is no longer necessary before reporting results, ie it is no longer necessary to edit results for cephalosporins, aztreonam, or penicillins from S to R However, ESBL testing may still be useful for epidemiological and infection control purposes CPE If using current interpretive criteria, MHT does not need to be performed other than for epidemiological and infection control purposes and no change in the interpretation of carbapenem susceptibility test results is required for MHT-positive isolates. CPE producing isolates usually test I/R to 1 carbapenems using the current interpretive criteria + usually test R to 1 3 cephalosporin Leclercq et al, CMI 2013; CLSI M100-S23, 2013

29 Reporting results Guidance Breakpoints (mg/l) to 2011 from 2011 To 2011 From 2011 EUCAST For ESBL producers, edit cephalosporin S to I and I to R Report as found CTX/CRO S 1 R > 2 FEP S 1 R > 8 CAZ S 1 R > 8 IPM/MEM S 2 R > 8 CTX/CRO S 1 R > 2 FEP S 1 R > 4 CAZ S 1 R > 4 IPM/MEM S 2 R > 8 CLSI Test for ESBL by clavulanate synergy or carbapenemas es by Hodge test; report ESBL producers as cephalosporin resistant No test for ESBL or carbapene mase report as found S 8 R > 64 S 8 R > 32 S 8 R > 32 S 4 R > 16 S 1 R > 4 S 8 R > 32 S 4 R > 16 S 1 R > 4 Livermore, 2012

30 Jaarraport ESBL en CPE, B Jans & Y Gluczynski, NSIH 2011 CPE epidemiology in Belgium 2007: Sporadic cases September 2008 K. pneumoniae, VIM-1: import from Greece June 2010 E. coli, NDM-1: import from Pakistan and Balkan > 2010: Nosocomial outbreaks

31 CPE epidemiology in Belgium Species and carbapenemase type Rapport CPE 2012, website NSIH 2013

32 CPE epidemiology in Belgium OXA-48 K pneumoniae Resistant to Temocillin Amoxicillin-clavulanic acid Piperacillin-tazobactam Susceptible low level R to Meropenem 3-4 cephalosporins bla OXA48 located on a single self-transferable 62 Kb IncL/M type plasmid In numerous clonal lineages Horizontal gene transfer main mechanism of spread in K pneumoniae Bauraing C et al, ECCMID 2013

33 Rapport CPE 2012, website NSIH 2013 CPE epidemiology in Belgium Geographic distribution of carbapenemase cases 8-10% import

34 Rapport CPE 2012, website NSIH 2013 CPE epidemiology in Belgium Patient characteristics

35 Rapport CPE 2012, website NSIH 2013 CPE epidemiology in Belgium Patient characteristics

36 Rapport CPE 2012, website NSIH 2013 CPE epidemiology in Belgium Risk profile OXA-48: elderly population with colonisation Geriatric wards KPC-2: elderly population with infection Intensive care and high risk units Screening indications Recent hospitalization / stay abroad Recent stay in hospital / home care facility in Belgium? (50% of CPE cases)

37 Outcome of infections with CPE Hussein et al, J Hosp Infect 2013;83: day survival of 317 patients with carbapenem resistant (KPC 56%) versus carbapenem susceptible (KPS 71%) K pneumoniae bacteremia (OR 1.3) Daikos et al, AAC 2009;53: day survival of 162 patients with VIM-neg,VIM-pos carbapenem S VIM-pos carbapenem R K pneumoniae BSI Independent risk factors fatal outcome: carbapenem resistance Severe underlying disease Advanced age

38 Outcome of infections with CPE A: combination R/ of 2 active drugs of which 1 is carbapenem (MIC 4 µg/ml) 8.3% failure rate B: combination R/ of 2 active drugs without carbapenem 29% C: mono aminoglycoside 24% D: mono carbapenem (MIC 4 µg/ml 25% 34 clinical studies: 294 infections with CPE K. pneumoniae outcome according to treatment regimen E: mono tigecyclin 35.7% F: mono colistin 47.2% G: inappropriate R/ 54% Tzoulevekis et al, CMR 2012;25:682

39 Outcome of infections with CPE BAPCOC recommendations 2012 Tzoulevekis et al, CMR 2012;25:682 In case meropenem MIC>8 µg/ml combination therapy with colistin, tigecyclin, aminoglycosides

40 The future Livermore, 2012