Acquired carbapenemases in Gram-negative bacterial pathogens: detection and surveillance issues

Acquired carbapenemases are emerging resistance determinants in Gram-negative pathogens, including Enterobacteriaceae, Pseudomonas aeruginosa and other Gram-negative non-fermenters. A consistent number of acquired carbapenemases have been identified during the past few years, belonging to either molecular class B (metallo-beta-lactamases) or molecular classes A and D (serine carbapenemases), and genes encoding these enzymes are associated with mobile genetic elements that allow their rapid dissemination in the clinical setting. Therefore, detection and surveillance of carbapenemase-producing organisms have become matters of major importance for the selection of appropriate therapeutic schemes and the implementation of infection control measures. As carbapenemase production cannot be simply inferred from the resistance profile, criteria must be established for which isolates should be suspected and screened for carbapenemase production, and for which tests (phenotypic and/or genotypic) should be adopted for confirmation of the resistance mechanism. Moreover, strategies should be devised for surveillance of carbapenemase producers in order to enable the implementation of effective surveillance programmes. The above issues are addressed in this article, as a follow-up to an expert meeting on acquired carbapenemases that was recently organized by the ESCMID Study Group for Antibiotic Resistance Surveillance.

Cyanobacteria and bacteria co-occurrence in a wastewater treatment plant: absence of allelopathic effects

Fifty-one cyanobacteria strains, belonging to Phormidium autumnale, Planktothrix mougeotii, Limnotrix sp. and Synechocystis sp. species, were isolated during a twelve months period, from a Wastewater Treatment Plant (WWTP) located in the north of Portugal. Isolated strains and environmental samples were analyzed by Polymerase Chain Reaction (PCR) technique to evaluate the presence of the genes linked to the biosynthesis of the cyanotoxins, microcystin (MC), nodularin (NOD) and cylindrospermopsin (CYN). Even though none of the isolated strains contained the genes responsible for these toxins production, the use of PCR in the water samples detected the mcyE gene, in the biological treatment tank, and the result of its sequence revealed 92% of maximum identity with the microcystin gene. ELISA assay confirmed the presence of the toxin with values of 0.60 μg MC-LR eq/l. The effects of extracts of the cyanobacteria strains on bacteria isolated from the WWTP, revealed that none of the tested strains inhibited or reduced the bacterial growth. This may indicate that those prokaryote communities may have co-evolved in a way that success of both cyanobacteria and bacteria was achieved.

Clonal expansion within clonal complex 2 and spread of vancomycin-resistant plasmids among different genetic lineages of Enterococcus faecalis from Portugal

OBJECTIVES

The aim of this study was to assess the diversity of Enterococcus faecalis populations recovered in different regions of Portugal during the last decade (1996-2007) and to analyse their genetic elements associated with vancomycin resistance.

METHODS

Forty E. faecalis isolates (22 vancomycin-susceptible and 18 vancomycin-resistant) representing disseminated and/or multiresistant strains from different sources (humans, animals and the environment) were characterized by PFGE and multilocus sequence typing. Genes encoding putative virulence markers and the backbone of Tn1546 were investigated by PCR. Plasmid analysis included determination of size, content (S1 hybridization) and comparison of restriction fragment length polymorphism patterns.

RESULTS

The 40 E. faecalis isolates (22 PFGE types) mostly clustered within the worldwide-spread clonal complexes (CCs) CC2 (13 ST6 mostly corresponding to an epidemic strain, where ST stands for sequence type), CC21 (3 ST21, 1 ST22 and 1 ST224) and ST16 (n = 7), but also comprised ST159, ST35, ST19, ST26, ST30, ST41, ST55, ST59, ST117, ST160 and ST200. CC2 and CC21 were isolated from both hospital and community settings. Similar Tn1546-like elements encoding VanA were found on related plasmids within strains belonging to different clonal lineages and recovered in distinct hospitals over several years.

CONCLUSIONS

The predominance of E. faecalis CC2 is mainly due to the dissemination of a particular clone persistently recovered for 11 years. The presence in the community of specific strains belonging to major clonal lineages highlights the role of community-associated hosts as possible reservoirs of putative human pathogenic enterococci. Both clonal expansion and dissemination of epidemic conjugative VanA plasmids seem to join forces in the establishment of pathogenic E. faecalis strains.

Prevalence and spread of extended-spectrum beta-lactamase-producing Enterobacteriaceae in Europe

Extended-spectrum beta-lactamases (ESBLs) represent a major threat among resistant bacterial isolates. The first types described were derivatives of the TEM-1, TEM-2 and SHV-1 enzymes during the 1980s in Europe, mainly in Klebsiella pneumoniae associated with nosocomial outbreaks. Nowadays, they are mostly found among Escherichia coli isolates in community-acquired infections, with an increasing occurrence of CTX-M enzymes. The prevalence of ESBLs in Europe is higher than in the USA but lower than in Asia and South America. However, important differences among European countries have been observed. Spread of mobile genetic elements, mainly epidemic plasmids, and the dispersion of specific clones have been responsible for the increase in ESBL-producing isolates, such as those with TEM-4, TEM-24, TEM-52, SHV-12, CTX-M-9, CTX-M-14, CTX-M-3, CTX-M-15 and CTX-M-32 enzymes.

Dissemination of clonally related Escherichia coli strains expressing extended-spectrum beta-lactamase CTX-M-15

E. coli ST131 and ST405 and multidrug-resistant IncFII plasmids may determine spread of this lactamase.

We analyzed 43 CTX-M-15–producing Escherichia coli isolates and 6 plasmids encoding the bla_CTX-M-15 gene from Canada, India, Kuwait, France, Switzerland, Portugal, and Spain. Most isolates belonged to phylogroups B2 (50%) and D (25%). An EC-B2 strain of clonal complex sequence type (ST) 131 was detected in all countries; other B2 isolates corresponded to ST28, ST405, ST354, and ST695 from specific areas. EC-D strains were clonally unrelated but isolates from 3 countries belonged to ST405. All CTX-M-15 plasmids corresponded to IncFII group with overrepresentation of 3 HpaI-digested plasmid DNA profiles (A, B and C; 85–120kb, similarity >70%). Plasmid A was detected in EC-B2 strains (ST131, ST354, or ST405), plasmid C was detected in B2 and D strains, and plasmid B was confined to worldwide-disseminated ST131. Most plasmids contained bla_OXA-1, aac(6′)-Ib-cr, and bla_TEM-1. Worldwide dissemination of CTX-M-15 seems to be determined by clonal complexes ST131 and ST405 and multidrug-resistant IncFII plasmids.

High diversity of extended-spectrum beta-lactamases among clinical isolates of Enterobacteriaceae from Portugal

OBJECTIVES

To investigate the occurrence and the diversity of Ambler class A ESBLs among Enterobacteriaceae from different Portuguese clinical settings over a 2 year period (2002-04).

METHODS

One hundred and nine extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae isolates from five geographically distant health institutions in Portugal were studied. ESBLs were characterized by isoelectric focussing, PCR and further sequencing. Antibiotic susceptibility testing, transfer of resistance genes and clonal diversity were determined by standard procedures. Plasmid relatedness was established by comparison of random amplified polymorphic DNA (RAPD) patterns.

RESULTS

ESBLs were identified as TEM (46%), SHV (30%), CTX-M (22%) and GES (2%) types; TEM-24, TEM-52, SHV-12 and CTX-M-15 enzymes being the most frequently found. Inter-hospital dissemination of epidemic strains harbouring the most prevalent ESBLs was detected, including the TEM-24-producing Enterobacter aerogenes European epidemic clone. Conjugative transfer of ESBLs was achieved for 67% of isolates and epidemic plasmids containing specific bla genes were detected (bla(CTX-M-15) and bla(TEM-24)). We describe two new ESBLs, SHV-90 (A187T, G238S and E240K) and SHV-91 (P20S and E240K), and a new TEM-type enzyme conferring a phenotype resembling that of a complex mutant TEM beta-lactamase, designated as TEM-154 (M69L and R164S). The broad-spectrum beta-lactamases SHV-26, SHV-36 and TEM-110 were first observed in our country.

CONCLUSIONS

We describe a complex ESBL epidemiology in Portugal, including widespread dissemination of known strains and plasmids coding for TEM-24 and CTX-M-15 enzymes as observed in other European countries.

Preservation of integron types among Enterobacteriaceae producing extended-spectrum beta-lactamases in a Spanish hospital over a 15-year period (1988 to 2003)

The variable presence of integrons among extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae species (0 to 66%) is described. Association between bla(ESBL) and integrons occurred when these are linked to specific ESBL-type genes (In60 bearing ISCR1 and bla(CTX-M-9)) or when ESBL genes were superimposed onto selected plasmids carrying integrons. Some integrons were identical to those found during decades worldwide, illustrating the preservation of the genetic elements carrying them.

Dissemination of sul3-containing elements linked to class 1 integrons with an unusual 3' conserved sequence region among Salmonella isolates

A sul3 domain (IS440-sul3-orf1-IS26) was found linked to an unusual 3' conserved sequence region (qacH) of class 1 integrons and detected among nontyphoid Salmonella isolates (n=47) from different sources. Three types of integrons differing in the gene cassette array (dfrA12-orfF-aadA2-cmlA1-aadA1, dfrA12-orfF-aadA2/1, and estX-psp-aadA2-cmlA1-aadA1) were found associated with this sul3 domain. They were associated with particular clones and specific high-molecular-weight plasmids.

Illegal use of nitrofurans in food animals: Contribution to human salmonellosis?

Recent observations in Portugal of a remarkable incidence (65%) of Salmonella isolates from several sources (predominantly human and poultry) with decreased susceptibility to nitrofurantoin (MIC > or =64 mg/L), mostly comprising serogroup D isolates of Salmonella Enteritidis belonging to different phage types, suggest that illegal use of nitrofurans, especially in the poultry industry, might have contributed to the selection and prevalence of S. Enteritidis in food animals, and consequently to human salmonellosis in Portugal. Indiscriminate use of nitrofurans might also be implicated in the emergence of two multiresistant Salmonella Typhimurium clones disseminated throughout the country.

Emergence and dissemination of Enterobacteriaceae isolates producing CTX-M-1-like enzymes in Spain are associated with IncFII (CTX-M-15) and broad-host-range (CTX-M-1, -3, and -32) plasmids

The spread of CTX-M-1-like enzymes in Spain is associated with particular plasmids of broad-host-range IncN (blaCTX-M-32, blaCTX-M-1), IncL/M (blaCTX-M-1), and IncA/C2 (blaCTX-M-3) or narrow-host-range IncFII (blaCTX-M-15). The identical genetic surroundings of blaCTX-M-32 and blaCTX-M-1 and their locations on related 40-kb IncN plasmids indicate the in vivo evolution of this element.

Dissemination and persistence of blaCTX-M-9 are linked to class 1 integrons containing CR1 associated with defective transposon derivatives from Tn402 located in early antibiotic resistance plasmids of IncHI2, IncP1-alpha, and IncFI groups

This study analyzes the diversity of In60, a class 1 integron bearing CR1 and containing bla(CTX-M-9), and its association with Tn402, Tn21, and classical conjugative plasmids among 45 CTX-M-9-producing clinical strains (41 Escherichia coli strains, 2 Klebsiella pneumoniae strains, 1 Salmonella enterica strain, and 1 Enterobacter cloacae strain). Forty-five patients in a Spanish tertiary care hospital were studied (1996 to 2003). The diversity of In60 and association of In60 with Tn402 or mercury resistance transposons were investigated by overlapping PCR assays and/or hybridization. Plasmid characterization included comparison of restriction fragment length polymorphism patterns and determination of incompatibility group by PCR-based replicon typing, sequencing, and hybridization. CTX-M-9 plasmids belonged to IncHI2 (n = 26), IncP-1alpha (n = 10), IncFI (n = 4), and IncI (n = 1) groups. Genetic platforms containing bla(CTX-M-9) were classified in six types in relation to the In60 backbone and in eight subtypes in relation to Tn402 derivatives. They were associated with Tn21 sequences when located in IncP-1alpha or IncHI2 plasmids. Our study identified bla(CTX-M-9) in a high diversity of CR1-bearing class 1 integrons linked to different Tn402 derivatives, often to Tn21, highlighting the role of recombination events in the evolution of antibiotic resistance plasmids. The presence of bla(CTX-M-9) on broad-host-range IncP-1alpha plasmids might contribute to its dissemination to hosts that were not members of the family Enterobacteriaceae.

Multiniche screening reveals the clinically relevant metallo-beta-lactamase VIM-2 in Pseudomonas aeruginosa far from the hospital setting: an ongoing dispersion process?

A screening study of the presence of metallo-beta-lactamases (IMP and VIM types and SPM-1) in isolates from different nonhospital sources was conducted, and it revealed the presence of bla(VIM-2), associated with the In58 class 1 integron, in two unrelated Pseudomonas aeruginosa strains from aquatic habitats. The results suggest that the hospital setting was the possible origin of these bla(VIM-2)-carrying strains.

Characterization of antimicrobial resistance and class 1 and 2 integrons in Salmonella enterica isolates from different sources in Portugal

OBJECTIVES

The antimicrobial resistance profiles of 1183 Salmonella isolates collected during 2002-2003 from several sources (human, food products and environment) were evaluated. The occurrence, distribution and cassette content of class 1 and 2 integrons among the sulphonamide-resistant population, as well as the role of particular clones to the spread of these genetic elements, were investigated.

METHODS

The isolates were examined for susceptibility to antimicrobial agents. The characterization of class 1 and 2 integrons was investigated using PCR, PCR-RFLP (restriction fragment length polymorphism) and sequencing in the sulphonamide-resistant isolates. Conjugation assays and clonality analysis by PFGE were performed.

RESULTS

The most common resistance phenotypes were to nalidixic acid, tetracycline, streptomycin, sulfamethoxazole and ampicillin (ranging from 31% to 17%). Resistance to sulphonamides (n=200) was associated with resistance to other antimicrobial agents, with 75% of the isolates carrying one or two class 1 integrons while only 3% simultaneously carried class 1 and 2 integrons. Integrons were observed among at least 11 serotypes (mainly Typhimurium) and in a reduced number of PFGE clones (20). Eight class 1 integron types were found, with the aadA genes (aadA1, aadA2 and aadA5) alone or downstream of a trimethoprim (dfrA1, dfrA12 and dfrA17) or a beta-lactamase resistance gene (blaoxa-30) and the blaPSE-1 gene alone. Most of the class 1 integron types were shared by several clones from the same or different serotypes obtained either from humans or food products of animal origin, especially pork products. However, some Typhimurium-specific integrons were found: aadA2 plus blaPSE-1 and blaoxa-30-aadA1.

CONCLUSIONS

Apart from the hypothetical contribution of the conjugative transfer of integrons, the incidence of Salmonella carrying these genetic units seems to rely on the ability of certain clones to spread or persist in particular animal niches. Our data suggest that food-producing animals might be simultaneously considered as a reservoir of clones and integrons carrying antibiotic resistance genes, thus making the food chain, especially pork products, a possible source of multidrug-resistant isolates in humans.

Beta-nitrostyrene derivatives as potential antibacterial agents: a structure-property-activity relationship study

A multidisciplinary project was developed, combining the synthesis of a series of beta-nitrostyrene derivatives and the determination of their physicochemical parameters (redox potentials, partition coefficients), to the evaluation of the corresponding antibacterial activity. A complete conformational analysis was also performed, in order to get relevant structural information. Subsequently, a structure-property-activity (SPAR) approach was applied, through linear regression analysis, aiming at obtaining a putative correlation between the physicochemical parameters of the compounds investigated and their antibacterial activity (both against standard strains and clinical isolates). The beta-nitrostyrene compounds displayed a lower activity towards all the tested bacteria relative to the beta-methyl-beta-nitrostyrene analogues. This was observed particularly for the 3-hydroxy-4-methoxy-beta-methyl-beta-nitrostyrene (IVb) against the Gram-positive bacteria (Staphylococcus aureus, Enterococcus faecalis and Enterococcus faecium). The SPAR results revealed the existence of a clear correlation between the redox potentials and the antibacterial activity of the series of beta-nitrostyrene derivatives under study.

Integron content of extended-spectrum-beta-lactamase-producing Escherichia coli strains over 12 years in a single hospital in Madrid, Spain

The contribution of integrons to the dissemination of extended-spectrum beta-lactamases (ESBL) was analyzed on all ESBL-producing Escherichia coli isolates from 1988 to 2000 at Ramon y Cajal Hospital. We studied 133 E. coli pulsed-field gel electrophoresis types: (i) 52 ESBL-producing clinical strains (C-ESBL) (16 TEM, 9 SHV, 21 CTX-M-9, 1 CTX-M-14, and 5 CTX-M-10); (ii) 43 non-ESBL blood clinical strains (C-nESBL); and (iii) 38 non-ESBL fecal isolates from healthy volunteers (V-nESBL). Class 1 integrons were more common among C-ESBL (67%) than among C-nESBL (40%) or V-nESBL (26%) (P < 0.001) due to the high number of strains with bla(CTX-M-9), which is linked to an In6-like class 1 integron. Without this bias, class 1 integron occurrence would be similar in C-ESBL and C-nESBL groups (47% versus 40%). Occurrence of class 2 integrons was similar among clinical and community isolates (13 to 18%). No isolates contained class 3 integrons. The relatively low rate of class 1 integrons within transferable elements carrying bla(TEM) (23%) or bla(SHV) (33%) and the absence of class 2 integrons in all ESBL transconjugants mirror the assembly of translocative pieces containing bla(TEM) or bla(SHV) on local available transferable elements lacking integrons. The low diversity of class 1 integrons (seven types recovered in all groups) might indicate a wide dissemination of specific genetic elements in which they are located. In our environment, the spread of genetic elements encoding ESBL has no major impact on the dispersion of integrons, nor do integrons have a major impact on the spread of ESBL, except when bla(ESBL) genes are within an integron platform such as bla(CTX-M-9).