Integron-mediated multidrug resistance in a global collection of nontyphoidal Salmonella enterica isolates

Diversity among human non-typhoidal salmonellae isolates from Zimbabwe

BACKGROUND

Non-typhoidal Salmonella infections are an important public health problem in sub-Saharan Africa, especially among children and HIV-seropositive patients in whom they may cause invasive disease.

METHODS

In order to better understand the epidemiology of Salmonella infections in southern Africa we typed, using serotyping, phage typing and multilocus sequence typing, 167 non-typhoidal Salmonella strains isolated from human clinical specimens during 1995-2000.

RESULTS

The most common serovars were Salmonella Typhimurium DT56/ST313, Salmonella Enteritidis PT4 and Salmonella Isangi ST216. Isolates of Salmonella Isangi showed a multidrug-resistant phenotype that was resistant to extended-spectrum cephalosporins. Twelve new sequence types and six new serotypes of Salmonella were identified.

CONCLUSIONS

Given the diversity detected in the study it seems likely that many new variants of S. enterica are extant in Zimbabwe and by implication across sub-Saharan Africa. We have demonstrated the presence in Zimbabwe of a multidrug-resistant strain of the serovar Salmonella Isangi and demonstrated the diversity of Salmonella circulating in one sub-Saharan African country. Further studies on the characteristics of Salmonella Isangi isolates from Zimbabwe, including plasmid typing and genotyping, are essential if effective control of the spread of this potential pathogen in sub-Saharan Africa is to be achieved.

Identification and characterization of class 1 integrons among atypical enteropathogenic Escherichia coli isolated from children under 5 years of age

BACKGROUND AND OBJECTIVES

The therapeutic options for diseases caused by Escherichia coli are limited. In this study we investigated the presence of virulence factors among Enteropathogenic Escherichia coli (EPEC) strains and their antibiotic resistance patterns. The isolates were also checked for the presence of class1 integrons and gene cassettes.

MATERIALS AND METHODS

This study included 70 EPEC strains isolated from children. Antimicrobial resistance patterns were determined using diffusion methods. The broth microdilution methods was used to determine the minimum inhibitory concentration. PCR was used to detect eaeA, bfpA genes. The 5' and 3' conserved sequences (CSs) of class 1 integrons and intI gene were amplified to investigate the presence of integrons and gene cassettes.

RESULTS

Antimicrobial susceptibility testing showed that 4 (5.7%), 3 (4.2%), and 2 (2.8 %) isolates were resistant to ampicillin, trimethoprim-sulfamethoxazole, and ceftazidime, respectively. Resistance rates to ciprofloxacin and aztreonam were 1.4%. Thirteen (18.5%) isolates showed resistance to tetracycline, and 4 (5.7%) were kanamycin resistant. Class I integron detected in 22 (31.4%) isolates. All the gene cassettes found in class I integrons corresponded to different variants of dfr and aadA genes.

CONCLUSION

Prevalence of class I integrons in EPEC strains was high. Presence of aadA and dfr gene cassettes in integrons represents high distribution of resistance determinants in EPEC strains.

Antimicrobial resistance patterns and characterization of integrons in clinical isolates of Shigella from China

One hundred fifty-three Shigella isolates were examined for multiple antibiotic resistance phenotypes and prevalence of class 1 and class 2 integron sequences. The gene cassettes dfrA17-aadA5, dfrA12-orfF-aadA2, and arr-3-aacA4 were found in typical class 1 integrons. The gene cassettes blaOXA-1-aadA1 and dfrA1-sat1-aadA1 were detected in atypical class 1 integrons and in class 2 integrons, respectively. This is the first report of arr-3-aacA4 cassette detected in typical class 1 integrons among Shigella isolates. Rates of antibiotic resistance were different between integron-positive and integron-negative strains (P < 0.05), and all integron-positive isolates were resistant to at least 3 different antimicrobial agents. Typical class 1 integron-positive isolates showed higher resistance rates to cefotaxime and ciprofloxacin than did integron-negative ones (P < 0.05). Typical class 1 integrons and β-lactamase genes were found in conjugative plasmids, otherwise class 2 and atypical class 1 integrons were located on chromosome. This study demonstrated the wide distribution of class 1 integrons in Shigella spp., which may lead resistance to cefotaxime and ciprofloxacin in China.

The role of the st313-td gene in virulence of Salmonella Typhimurium ST313

Multidrug-resistant Salmonella enterica serovar Typhimurium ST313 has emerged in sub-Saharan Africa causing severe infections in humans. Therefore, it has been speculated that this specific sequence type, ST313, carries factors associated with increased pathogenicity. We assessed the role in virulence of a gene with a yet unknown function, st313-td, detected in ST313 through comparative genomics. Additionally, the structure of the genomic island ST313-GI, harbouring the gene was determined. The gene st313-td was cloned into wild type S. Typhimurium 4/74 (4/74-C) as well as knocked out in S. Typhimurium ST313 02–03/002 (Δst313-td) followed by complementation (02-03/002-C). Δst313-td was less virulent in mice following i.p. challenge than the wild type and this phenotype could be partly complemented in trans, indicating that st313-td plays a role during systemic infection. The gene st313-td was shown not to affect invasion of cultured epithelial cells, while the absence of the gene significantly affects uptake and intracellular survival within macrophages. The gene st313-td was proven to be strongly associated to invasiveness, harboured by 92.5% of S. Typhimurium blood isolates (n = 82) and 100% of S. Dublin strains (n = 50) analysed. On the contrary, S. Typhimurium isolates of animal and food origin (n = 82) did not carry st313-td. Six human, non-blood isolates of S. Typhimurium from Belarus, China and Nepal harboured the gene and belonged to sequence types ST398 and ST19. Our data showed a global presence of the st313-td gene and in other sequence types than ST313. The gene st313-td was shown to be expressed during logarithmic phase of growth in 14 selected Salmonella strains carrying the gene. This study reveals that st313-td plays a role in S. Typhimurium ST313 pathogenesis and adds another chapter to understanding of the virulence of S. Typhimurium and in particular of the emerging sequence type ST313.

Genetic mechanisms of antimicrobial resistance identified in Salmonella enterica, Escherichia coli, and Enteroccocus spp. isolated from U.S. food animals

The prevalence of antimicrobial resistance (AR) in bacteria isolated from U.S. food animals has increased over the last several decades as have concerns of AR foodborne zoonotic human infections. Resistance mechanisms identified in U.S. animal isolates of Salmonella enterica included resistance to aminoglycosides (e.g., alleles of aacC, aadA, aadB, ant, aphA, and StrAB), β-lactams (e.g., bla_{CMY−2, TEM−1, PSE−1}), chloramphenicol (e.g., floR, cmlA, cat1, cat2), folate pathway inhibitors (e.g., alleles of sul and dfr), and tetracycline [e.g., alleles of tet(A), (B), (C), (D), (G), and tetR]. In the U.S., multi-drug resistance (MDR) mechanisms in Salmonella animal isolates were associated with integrons, or mobile genetic elements (MGEs) such as IncA/C plasmids which can be transferred among bacteria. It is thought that AR Salmonella originates in food animals and is transmitted through food to humans. However, some AR Salmonella isolated from humans in the U.S. have different AR elements than those isolated from food animals, suggesting a different etiology for some AR human infections. The AR mechanisms identified in isolates from outside the U.S. are also predominantly different. For example the extended spectrum β-lactamases (ESBLs) are found in human and animal isolates globally; however, in the U.S., ESBLs thus far have only been found in human and not food animal isolates. Commensal bacteria in animals including Escherichia coli and Enterococcus spp. may be reservoirs for AR mechanisms. Many of the AR genes and MGEs found in E. coli isolated from U.S. animals are similar to those found in Salmonella. Enterococcus spp. isolated from animals frequently carry MGEs with AR genes, including resistances to aminoglycosides (e.g., alleles of aac, ant, and aph), macrolides [e.g., erm(A), erm(B), and msrC], and tetracyclines [e.g., tet(K), (L), (M), (O), (S)]. Continuing investigations are required to help understand and mitigate the impact of AR bacteria on human and animal health.

High prevalence of antibiotic resistance and molecular characterization of integrons among Shigella isolates in Eastern China

A total of 747 Shigella isolates were collected from hospitals in Jiangsu Province of China. Susceptibilities to antimicrobials and integrons were tested. A total of 78.3% of S. flexneri isolates and a total of 74.3% S. sonei isolates were resistant to at least three antibiotics. Of the Shigella isolates, 74.7% had integron I and 82.6% had integron II. The conjunction of the high prevalence of integrons in Shigella and high resistance to antimicrobials will lead to rapid dissemination of resistant genes in this region.

Potential international spread of multidrug-resistant invasive Salmonella enterica serovar enteritidis

In developing countries, Salmonella enterica serovar Enteritidis causes substantial illness and death, and drug resistance is increasing. Isolates from the United Kingdom containing virulence-resistance plasmids were characterized. They mainly caused invasive infections in adults linked to Africa. The common features in isolates from these continents indicate the role of human travel in their spread.

Comparative study of class 1 integron, ampicillin, chloramphenicol, streptomycin, sulfamethoxazole, tetracycline (ACSSuT) and fluoroquinolone resistance in various Salmonella serovars from humans and animals

A total of 499 Salmonella isolates including 9 serovars from humans and various animal hosts were collected to compare prevalence of integron and antimicrobial resistance. The integron and gene cassette were detected by PCR, and then the gene cassette type was further determined by sequencing and restriction fragment length polymorphism (RFLP) analysis. The antimicrobial susceptibility test was conducted by disk diffusion method. The positivity percentage of class 1 integron and the diversity of gene cassettes carried by integron were quite different in various Salmonella serovars, especially comparing those from animals to humans. After sequencing and RFLP analysis, it was identified eight gene cassette types. The gene cassette type D carrying ampicillin/streptomycin resistance genes was the most common one (42.2%) in the integron-positive isolates. More diversity of gene cassette types was identified in humans comparing to that in animals. Several gene cassette types were identified for the first time in some Salmonella serovars. In this study, 31.5% (157/499) of the isolates were multi-resistant to ampicillin, chloramphenicol, streptomycin, sulfamethoxazole, and tetracycline (ACSSuT). S. Choleraesuis isolates with the cassette type A1, but S. Typhimurium isolates with the cassette type E1, were frequently associated with ACSSuT-resistant (80.6% and 72.7%, respectively). There was a significant association between the presence of class 1 integron and quinolone resistance in S. Choleraesuis isolates, but not in S. Typhimurium. Our findings imply that transmission efficiency of various gene cassettes through the integron could be different in various Salmonella serovars.

Multilocus sequence typing as a replacement for serotyping in Salmonella enterica

Salmonella enterica subspecies enterica is traditionally subdivided into serovars by serological and nutritional characteristics. We used Multilocus Sequence Typing (MLST) to assign 4,257 isolates from 554 serovars to 1092 sequence types (STs). The majority of the isolates and many STs were grouped into 138 genetically closely related clusters called eBurstGroups (eBGs). Many eBGs correspond to a serovar, for example most Typhimurium are in eBG1 and most Enteritidis are in eBG4, but many eBGs contained more than one serovar. Furthermore, most serovars were polyphyletic and are distributed across multiple unrelated eBGs. Thus, serovar designations confounded genetically unrelated isolates and failed to recognize natural evolutionary groupings. An inability of serotyping to correctly group isolates was most apparent for Paratyphi B and its variant Java. Most Paratyphi B were included within a sub-cluster of STs belonging to eBG5, which also encompasses a separate sub-cluster of Java STs. However, diphasic Java variants were also found in two other eBGs and monophasic Java variants were in four other eBGs or STs, one of which is in subspecies salamae and a second of which includes isolates assigned to Enteritidis, Dublin and monophasic Paratyphi B. Similarly, Choleraesuis was found in eBG6 and is closely related to Paratyphi C, which is in eBG20. However, Choleraesuis var. Decatur consists of isolates from seven other, unrelated eBGs or STs. The serological assignment of these Decatur isolates to Choleraesuis likely reflects lateral gene transfer of flagellar genes between unrelated bacteria plus purifying selection. By confounding multiple evolutionary groups, serotyping can be misleading about the disease potential of S. enterica. Unlike serotyping, MLST recognizes evolutionary groupings and we recommend that Salmonella classification by serotyping should be replaced by MLST or its equivalents.

Microbiologists have used serological and nutritional characteristics to subdivide pathogenic bacteria for nearly 100 years. These subdivisions in Salmonella enterica are called serovars, some of which are thought to be associated with particular diseases and epidemiology. We used MultiLocus Sequence-based Typing (MLST) to identify clusters of S. enterica isolates that are related by evolutionary descent. Some clusters correspond to serovars on a one to one basis. But many clusters include multiple serovars, which is of public health significance, and most serovars span multiple, unrelated clusters. Despite its broad usage, serological typing of S. enterica has resulted in confusing systematics, with a few exceptions. We recommend that serotyping for strain discrimination of S. enterica be replaced by a DNA-based method, such as MLST. Serotyping and other non-sequence based typing methods are routinely used for detecting outbreaks and to support public health responses. Moving away from these methods will require a major shift in thinking by public health microbiology laboratories as well as national and international agencies. However, a transition to the routine use of MLST, supplemented where appropriate by even more discriminatory sequence-based typing methods based on entire genomes, will provide a clearer picture of long-term transmission routes of Salmonella, facilitate data transfer and support global control measures.

Analysis of antimicrobial resistance genes detected in multiple-drug-resistant Escherichia coli isolates from broiler chicken carcasses

Multi-drug-resistant (MDR) bacteria in food animals are a potential problem in both animal and human health. In this study, MDR commensal Escherichia coli isolates from poultry were examined. Thirty-two E. coli isolates from broiler carcass rinses were selected based on their resistance to aminoglycosides, β-lactams, chloramphenicols, tetracyclines, and sulfonamide antimicrobials. Microarray analysis for the presence of antimicrobial resistance and plasmid genes identified aminoglycoside [aac(6), aac(3), aadA, aph, strA, and strB], β-lactam (bla(AmpC), bla(TEM), bla(CMY), and bla(PSE-1)), chloramphenicol (cat, flo, and cmlA), sulfamethoxazole (sulI and sulII), tetracycline [tet(A), tet(C), tet(D), and tetR], and trimethoprim (dfrA) resistance genes. IncA/C plasmid core genes were detected in 27 isolates, while IncHI1 plasmid genes were detected in one isolate, indicating the likely presence of these plasmids. PCR assays for 18 plasmid replicon types often associated with MDR in Enterobacteriaceae also detected one or more replicon types in all 32 isolates. Class I integrons were investigated by PCR amplification of the integrase I gene, intI1, and the cassette region flanked by conserved sequences. Twenty-five isolates were positive for the intI1 gene, and class I integrons ranging in size from ~1,000 to 3,300 bp were identified in 19 of them. The presence of class I integrons, IncA/C plasmid genes, and MDR-associated plasmid replicons in the isolates indicates the importance of these genetic elements in the accumulation and potential spread of antimicrobial resistance genes in the microbial community associated with poultry.

The antibiotic resistance characteristics of non-typhoidal Salmonella enterica isolated from food-producing animals, retail meat and humans in South East Asia

Antimicrobial resistance is a global problem. It is most prevalent in developing countries where infectious diseases remain common, the use of antibiotics in humans and animals is widespread, and the replacement of older antibiotics with new generation antibiotics is not easy due to the high cost. Information on antibiotic resistance phenotypes and genotypes of Salmonella spp. in food animals and humans in different countries and geographic regions is necessary to combat the spread of resistance. This will improve the understanding of antibiotic resistance epidemiology, tracing of new emerging pathogens, assisting in disease treatment, and enhancing prudent use of antibiotics. However, the extent of antibiotic resistance in food-borne pathogens and humans in many developing countries remains unknown. The goal of this review is to discuss the current state of antibiotic resistance of non-typhoid Salmonella spp. in food-producing animals, retail meat and humans from South East Asia. It is focused on resistance characteristics of traditional and "critically important" antibiotics in this region, and the emergence of multidrug resistant strains and genetic elements that contribute to the development of multidrug resistance, including integrons and the Salmonella Genomic Island (SGI).

Phenotypic and genotypic characterization of Salmonella enterica recovered from poultry meat in Tunisia and identification of new genetic traits

Thirty-seven Salmonella enterica isolates obtained from poultry meat in Tunisia were included in this study for characterization of antibiotic resistance mechanisms. High percentages of resistance were detected to ampicillin, sulfonamides, tetracycline, nalidixic acid, and streptomycin (32.4%-89.2%), and lower percentages to amoxicillin-clavulanic acid, kanamycin, amikacin, trimethoprim-sulfamethoxazol, and chloramphenicol (2.7%-18.9%). All strains showed susceptibility to ceftazidime, cefotaxime, gentamicin, and ciprofloxacin. Class 1 integrons were detected in 30% of Salmonella isolates, and four different gene cassette arrangements were detected, including genes implicated in resistance to aminoglycosides (aadA1 and aadA2) and trimethoprim (dfrA1). Four different Pc variants (PcW, PcH1, PcH1(TTN-10), PcW(TGN-10)) with inactive P2 have been found among these isolates. Integron-positive isolates were ascribed to eight different serotypes. A Salmonella Schwarzengrund isolate harbored a new class 1 integron containing the qacH-dfrA1b-aadA1b-catB2 gene cassette arrangement, with the very unusual PcH1(TTN-10) promoter, which has been registered in GenBank (accession no. HQ874651). Different plasmid replicon types were demonstrated among integron-positive isolates: IncI1 (8 isolates), IncN (8), IncP (2), IncFIB (2), and IncFII (2). Ten different pulsed-field gel electrophoresis profiles were detected among the 11 integron-positive isolates and 8 different sequence types were identified by multilocus sequence typing, one of them (registered as ST867) was new, detected in 3 Salmonella Zanzibar isolates. A high diversity of clones is observed among poultry Salmonella isolates and a high proportion of them show a multiresistant phenotype with very diverse mobile genetic structures that could be implicated in bacterial dissemination in different environments.

Serotypes, antibiotic resistance, and class 1 integrons in Salmonella isolates from pediatric cases of enteritis in Tehran, Iran

The present study was conducted to investigate serotype distribution, antimicrobial resistance patterns, carriage of class 1 integron, and clonality of Salmonella strains isolated from patients aged 0-12 years in Tehran, Iran, during 2007-2008. A total of 139 Salmonella isolates were studied. Salmonella serotypes Enteritidis, Infantis, and Typhimurium included 84.9% of isolates, Enteritidis accounting for 41.7%. The most prevalent resistances were to doxycycline (64.7%), nalidixic acid (61.2%), tetracycline (51.8%), and streptomycin (42.8%). Fifty-three (38.1%) isolates contained class 1 integron. Eight different gene cassettes were identified, aadA1 being the most frequently encountered. Pulsed-field gel electrophoresis showed that integron-positive Salmonella strains belonging to serotypes Infantis, Enteritidis, and Typhimurium were attributed to two, three, and five different pulsotypes, respectively. The findings indicated that the distribution and drug resistance pattern of most prevalent Salmonella serotypes were broadly similar to that reported globally from human isolates. Presence of class 1 integrons was common among Salmonella serotypes in Tehran, Iran. Concurrent clonal expansion and horizontal transmission events seem to contribute to increase in drug resistance prevalence among Salmonella serotypes.

Transferable class 1 and 2 integrons in Escherichia coli and Salmonella enterica isolates of human and animal origin in Lithuania

Antibiotic-resistant Escherichia coli (n = 191) and Salmonella enterica (n = 87) isolates of human and animal origin obtained in Lithuania during 2005-2008 were characterized for the presence and diversity of class 1 and 2 integrons. E. coli isolates were obtained from patients with urinary tract infections (UTIs) (n = 59) and both healthy and diseased farm animals, including poultry (n = 54), swine (n = 35), and cattle (n = 43). Isolates of non-typhoidal S. enterica were recovered from salmonellosis patients (n = 37) and healthy animals, including poultry (n = 31) and swine (n = 19). The presence of integrons, their gene cassette structure, and genome location were investigated by polymerase chain reaction, restriction fragment-length polymorphism, DNA sequencing, Southern blot hybridization, and conjugation experiments. Forty percent of the E. coli and 11% of the S. enterica isolates carried class 1 integrons, whereas class 2 integrons were found in E. coli isolates (9%) only. The incidence of integrons in human UTIs and cattle isolates was most frequent (p < 0.01). A total of 23 different gene cassettes within 15 different variable regions were observed. Seven different integron types, all of them transferable by conjugation, were common for isolates from human infections and for one or more groups of animal isolates. The most prevalent integron types contained arrays dfrA1-aadA1 (36%), dfrA17-aadA5 (23%), and dfrA1-sat1-aadA1 (78%). Two E. coli isolates from humans with UTIs harbored class 1 integron on conjugative plasmid with the novel array type of 4800 bp/dfrA17-aadA5Δ-IS26-ΔintI1-aadB-aadA1-cmlA residing on the Tn21-like transposon. Three S. enterica isolates from swine contained class 1 integron with the newly observed array type of 1800 bp/aadA7-aadA7. Integrons of 10 different types of both classes were located on transferable plasmids in E. coli and S. enterica. Our study demonstrated the existence of a considerable and common pool of transferable integrons in E. coli and S. enterica present in clinical and livestock environment in Lithuania.

Characterization of antimicrobial resistance of recent Salmonella enterica serovar Gallinarum isolates from chickens in South Korea

Salmonella enterica serovar Gallinarum isolates (n=105) from chickens in South Korea between 2002 and 2007 were tested for antimicrobial susceptibility by determining minimum inhibitory concentrations of 16 antimicrobials, and their predominant resistance profiles were genetically characterized. Most isolates (99/105; 94.3%) were resistant to nalidixic acid and resistant/intermediately resistant to fluoroquinolones, and 63.8% (67/105) of the isolates were resistant to three or more antimicrobials. Forty-two quinolone-resistant isolates, of which the quinolone resistance-determining regions of the gyrA genes were sequenced, contained a substitution of a Ser to a Phe or Tyr at position 83 (71.4%), or a substitution of an Asp to an Asn, Gly, or Tyr at position 87 (28.6%). Fifty-seven sulphamethoxazole-resistant isolates were tested for the presence of class 1 integrons by polymerase chain reaction, and their resistance gene cassettes were analysed by sequencing. Three different class 1 integrons containing the resistance-gene insert aadA (52.6%; n=30), aadB (12.3%; n=7), or aadB-aadA (12.3%; n=7) were identified. Most isolates harbouring the integron containing aadB-aadA displayed resistance to all three aminoglycosides tested and also showed increased resistance to fluoroquinolones. These findings suggest that fluoroquinolone resistance may be epidemiologically linked to multiple aminoglycoside resistance.

Novel integron gene cassette arrays identified in a global collection of multi-drug resistant non-typhoidal Salmonella enterica

Investigation of integron carriage in a global collection of multi-drug resistant Salmonella enterica identified 3 unique class 1 integron gene cassette arrays not previously reported in this species. The present study used PCR and DNA sequence analysis to characterize the structure of these gene cassette arrays. A approximately 4.0 kb integron containing the gene cassette array arr2/cmlA5/bla (OXA10) /aadA1 was found in isolates belonging to serovars Isangi and Typhimurium from South Africa. A approximately 6.0 kb integron containing the gene cassettes aac(6')IIc/ereA2/IS1247/aac/arr/ereA2 was found in isolates belonging to serovar Heidelberg from the Philippines. In this gene cassette array, the insertion sequence, IS1247, and two putative resistance genes, disrupt the erythromycin resistance gene cassette. Finally, a approximately 6.0 kb integron containing the gene cassette qacH/dfrA32/ereA1/aadA2/cmlA/aadA1 was found in serovar Stanley isolates from Taiwan. This integron, which has not been previously reported in any bacterial species, contains a new dihydrofolate reductase gene cassette sequence designated dfrA32, with only 90% sequence similarity to previously reported dfrA cassettes. The S. enterica integrons described in the present study represent novel collections of resistance genes which confer multi-drug resistance and have the potential to be widely disseminated among S. enterica as well as other bacterial species.

Characterization of a new metallo-beta-lactamase gene, bla(NDM-1), and a novel erythromycin esterase gene carried on a unique genetic structure in Klebsiella pneumoniae sequence type 14 from India

A Swedish patient of Indian origin traveled to New Delhi, India, and acquired a urinary tract infection caused by a carbapenem-resistant Klebsiella pneumoniae strain that typed to the sequence type 14 complex. The isolate, Klebsiella pneumoniae 05-506, was shown to possess a metallo-beta-lactamase (MBL) but was negative for previously known MBL genes. Gene libraries and amplification of class 1 integrons revealed three resistance-conferring regions; the first contained bla(CMY-4) flanked by ISEcP1 and blc. The second region of 4.8 kb contained a complex class 1 integron with the gene cassettes arr-2, a new erythromycin esterase gene; ereC; aadA1; and cmlA7. An intact ISCR1 element was shown to be downstream from the qac/sul genes. The third region consisted of a new MBL gene, designated bla(NDM-1), flanked on one side by K. pneumoniae DNA and a truncated IS26 element on its other side. The last two regions lie adjacent to one another, and all three regions are found on a 180-kb region that is easily transferable to recipient strains and that confers resistance to all antibiotics except fluoroquinolones and colistin. NDM-1 shares very little identity with other MBLs, with the most similar MBLs being VIM-1/VIM-2, with which it has only 32.4% identity. As well as possessing unique residues near the active site, NDM-1 also has an additional insert between positions 162 and 166 not present in other MBLs. NDM-1 has a molecular mass of 28 kDa, is monomeric, and can hydrolyze all beta-lactams except aztreonam. Compared to VIM-2, NDM-1 displays tighter binding to most cephalosporins, in particular, cefuroxime, cefotaxime, and cephalothin (cefalotin), and also to the penicillins. NDM-1 does not bind to the carbapenems as tightly as IMP-1 or VIM-2 and turns over the carbapenems at a rate similar to that of VIM-2. In addition to K. pneumoniae 05-506, bla(NDM-1) was found on a 140-kb plasmid in an Escherichia coli strain isolated from the patient's feces, inferring the possibility of in vivo conjugation. The broad resistance carried on these plasmids is a further worrying development for India, which already has high levels of antibiotic resistance.