ST11 KPC-2 Klebsiella pneumoniae detected in Taiwan

AAC Accepts, published online ahead of print on 30 January 2012 Antimicrob. Agents Chemother. doi:10.1128/aac.05576-11 Copyright 2012, American Society for Microbiology. All Rights Reserved. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 ST11 KPC-2 Klebsiella pneumoniae detected in Taiwan Tsai-Ling Lauderdale National Institute of infectious Diseases and Vaccinology National Health Research Institutes, Zhunan, Taiwan Zhi-Yuan Shi Division of Infectious Diseases, Department of Internal Medicine, Veterans General Hospital-Taichung, Taichung, Taiwan School of Medicine, National Yang-Ming University, Taipei, Taiwan Chin-Fu Lin Department of Laboratory Medicine Veterans General Hospital-Taichung Taichung, Taiwan Jui-Fen Lai Mei-Jen Tan National Institute of infectious Diseases and Vaccinology National Health Research Institutes, Zhunan, Taiwan Jan-Tay Wang Division of Infectious Diseases, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Shan-Chwen Chang* Division of Infectious Diseases, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan *No. 7 Chung-Shan South Road, Taipei 100, Taiwan. Phone: 886-2-23123456 ext 5401 Fax: 886-2-23958721 E-mail: changsc@ntu.edu.tw 1

36 Running Title: KPC-producing Klebsiella pneumoniae in Taiwan 37 2

38 Keywords: Carbapenem-resistant Klebsiella pneumoniae, KPC carbapenemase, ST11. 39 3

40 In Taiwan, the majority of carbapenem-resistant Enterobacteriaceae (CRE) isolates exhibited 41 low-level carbapenem resistance, and except a few isolates with VIM or IMP-8 carbapenemase 42 (6, 7, 13), most were due to the production of extended spectrum β-lactamase (ESBL) and/or 43 AmpC β-lactamase plus outer membrane protein porin loss (2, 7, 14). To date, there has only 44 been one case of Klebsiella pneumoniae carbapenemases (KPC)-producing K. pneumoniae 45 reported in Taiwan from a patient who was hospitalized in China prior to being transferred back 46 to Taiwan. The isolate harbored KPC-2 but the genetic background of the strain was not 47 mentioned (3). 48 We report the detection of four KPC2-positive K. pneumoniae from two patients in another 49 hospital in Taiwan. Patient A was a 74-year-old Taiwanese male who was hospitalized in China 50 for emergency medical treatment due to sudden cardiac arrest in 2010. He was transferred back 51 to the coronary care unit (CCU) of a Taiwanese hospital 5 days later. He developed urinary tract 52 infection due to a CRKP isolate (CRKP1) five days after being admitted to the CCU. Two 53 additional CRKP isolates were recovered from the central venous catheter (CRKP3) and urine 54 (CRKP4) 5 weeks after admission. Unfortunately, he expired due to the occurrence of hematoma 55 rupture and shock. Patient B was an 87 year old Taiwanese male who was hospitalized in the 56 same CCU because of congestive heart failure during the same period. He developed pneumonia 57 and CRKP was recovered from the central venous catheter tip and from a sputum specimen one 4

58 day apart. Only his sputum isolate (CRKP2) was available for further workup. CRKP2 was 59 isolated 19 days after CRKP1. Patient B accepted hospice care later due to terminal stage of 60 congestive heart failure. 61 The pulsed field gel electrophoresis (PFGE) patterns of CRKP1 to CRKP4 isolates were 62 indistinguishable (data not shown). All four isolates had the same antibiogram and were resistant 63 to all tested β-lactams (Table 1), with high ertapenem, imipenem, and meropenem MICs (> 32 64 μg/ml), and were susceptible only to polymyxin B, tigecycline and 65 trimethoprim/sulfamethoxazole. All 4 were positive for bla KPC-2 as well as bla SHV-12 and bla CTX-M 66 and belong to sequence type 11 (ST11) (allelic profile 3-3-1-1-1-4) (5, 8, 9, 11). The plasmids of 67 CRKP1 and CRKP2 were introduced into Escherichia coli DH10B by electroporation. The 68 pcrkp1/dh10b and pcrkp2/dh10b electrotransformants became resistant to all tested 69 β-lactams including carbapenems (MIC 12- >32μg/mL), and were positive for bla KPC-2 and 70 bla SHV-12 but not bla CTX-M. Restriction fingerprinting patterns of plasmid DNAs from the 71 transformants were similar (Fig 1). 72 In Asia, KPC-producing K. pneumoniae was first detected in a 2004 isolate from China (12), 73 where KPC2-producing Enterobacteriaceae subsequently disseminated in different regions (1, 74 10, 15). ST11 was found to be the predominant KPC2-producing K. pneumoniae isolated from 75 multiple cities of China (10). Those ST11 isolates also carried a combination of SHV-type and 5

76 CTX-M type ESBLs and AmpC β-lactamase (10). 77 It is possible that patient A acquired the KPC-producing K. pneumoniae during his 78 hospitalization in China and the strain was then transmitted to patient B in the same ward in 79 Taiwan. Although the prevalence of carbapenem-resistant Enterobacteriaceae in Taiwan has 80 remained low (2, 7, 14), the emergence of KPC-producing K. pneumoniae is worrisome since 81 multidrug resistant Enterobacteriaceae are already prevalent in Taiwan, which necessitates 82 increased carbapenem use. Careful monitoring systems need to be implemented and should 83 include patients transferred from hospitals abroad. 84 6

85 Acknowledgements 86 This project was supported by an intramural grant from the National Health Research 87 Institutes, Zhunan, Taiwan (99-A1-CLPP01-014). 88 7

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138 139 140 Table 1. Minimum inhibitory concentrations (MICs) of four KPC-2 positive carbapenem-resistant Klebsiella pneumoniae clinical strains (CRKP1-CRKP4), DH10B Escherichia coli electrotransformants, and DH10B 141 142 143 144 145 MICs (μg/ml) a Antimicrobial agent CRKP1-CRKP4 K. pneumoniae Electrotransformants of DH10B b DH10B E. coli Amikacin >128 2 2 Ampicillin >256 >256 4 Aztreonam >256 >256 0.19 Cefepime 256 >256 0.064 Cefotaxime >256 >256 0.125 Cefoxitin >256 96 6 Ceftazidime >256 >256 0.38 Cefuroxime >256 >256 4 Ceftriaxone >256 >256 0.094 Ciprofloxacin >32 0.004 0.004 Ertapenem >32 32 0.008 Fosfomycin 128 1 1 Gentamicin >128 0.75 0.5 Imipenem 32 32 0.25 Meropenem >32 12-24 0.032 Piperacillin/tazobactam >256 >256 2 Polymyxin B 1.5 0.5 0.19 Tigecycline 1.0-1.5 0.25 0.19 TMP/SMX (SXT) C 0.5 0.047 0.047 β-lactamase genes detected: ESBL SHV-12 & CTX-M (gr. 9) SHV-12 Not detected AmpC Not detected Not detected Not detected Carbapenemase KPC-2 KPC-2 Not detected MHT d -Ertapenem Pos Pos Neg a MIC data shown are from Etest. All agents except fosfomycin were also tested by broth microdilution method (4). b pcrkp1/dh10b and pcrkp2/dh10b electrotransformants. c TMP/SMX (SXT), trimethoprim/sulfamethoxazole. d MHT, Modified Hodge Test. 11

146 147 Figure 1. M1 1 2 3 4 M2 23130 10200 8000 5991 5007 4000 9416 6557 4361 2961 2000 2322 2027 1600 1000 148 149 12

150 Figure legend. BglII (lanes 1 and 2) and SacI (lanes 3 and 4) restriction digest of plasmid DNAs 151 from DH10B E. coli electrotransformants, M1, 1 kb DNA ladder (bp); lanes 1 and 3 are from 152 pcrkp1/dh10b; lanes 2 and 4 are from pcrkp2/dh10b. CRKP1 and CRKP2 were isolated 153 from 2 patients of the same ward 19 days apart. M2, λ/hind III ladder. 13