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Liu N, Tang B, Wang H, Chen X, Wen P, Wang Z, Chen X, Guo X, Gou J, Song Y. Coexistence of a novel NDM-1-encoding MDR plasmid and an IMP-4-encoding IncN-IncU hybrid plasmid in a clinical isolate of Citrobacter freundii BC73. Front Microbiol 2024; 15:1388651. [PMID: 39077736 PMCID: PMC11285197 DOI: 10.3389/fmicb.2024.1388651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 06/28/2024] [Indexed: 07/31/2024] Open
Abstract
Objectives To investigate the genetic characteristics and transmission mechanism of the NDM-1-, IMP-4-, and SHV-12-producing multidrug-resistant (MDR) clinical isolate, Citrobacter freundii BC73. Methods C. freundii BC73 was isolated from a urine specimen of a urological patient diagnosed with bladder cancer at a Chinese teaching hospital. Antimicrobial susceptibility testing was carried out using DL-120E susceptibility cards and DL-96A system. Whole genome sequencing (WGS) of the isolate was performed using the Illumina and Oxford Nanopore platforms to analyze the genetic context of drug resistance genes and plasmid characteristics. The phylogenetic tree was constructed and visualized by KSNP3.0 software and iTOL5.0 online database. Results C. freundii isolate BC73 co-carrying bla NDM-1, bla IMP-4 and bla SHV-12 were multidrug-resistant. bla NDM-1 and bla IMP-4 were located on a novel IncFIB-like plasmid, pCFBC1, and an IncN-IncU hybrid plasmid, pCFBC2, respectively. The transferability of bla NDM-1 and bla IMP-4 from C. freundii BC73 to E. coli J53 was successfully demonstrated. The genetic context of the bla NDM-1 and bla IMP-4 genes were ISCR27-groEL-∆groES-cutA-dsbD-trpF-ble MBL-bla NDM-1-∆ISAba125-IS3000 and intI1-bla IMP-4-Kl.pn.13-mobC-IS6100, respectively. Additionally, two extensive transposition units (MGE1 in pCFBC1, MGE2 in pCFBC2) were identified and numerous antimicrobial resistance genes were discovered on it. Conclusion To our knowledge, our study represents the first characterization of a ST22 C. freundii isolate co-harboring bla NDM-1, bla IMP-4, and bla SHV-12, obtained from a urine sample. The dissemination of this MDR isolate should be of close concern in future clinical surveillance.
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Affiliation(s)
- Na Liu
- Translational Medicine Research Center, Zhengzhou People’s Hospital, The Fifth Clinical College of Henan University of Chinese Medicine, Zhengzhou, China
| | - Biao Tang
- Key Laboratory of Systems Health Science of Zhejiang Province, School of Life Science, Hangzhou Institute for Advanced Study, University of Chinese Academy of Sciences, Hangzhou, China
| | - Hui Wang
- Translational Medicine Research Center, Zhengzhou People’s Hospital, The Fifth Clinical College of Henan University of Chinese Medicine, Zhengzhou, China
| | - Xiangyang Chen
- Department of Laboratory Medicine, Zhengzhou People’s Hospital, The Fifth Clinical College of Henan University of Chinese Medicine, Zhengzhou, China
| | - Peipei Wen
- Translational Medicine Research Center, Zhengzhou People’s Hospital, The Fifth Clinical College of Henan University of Chinese Medicine, Zhengzhou, China
| | - Zhaorui Wang
- Translational Medicine Research Center, Zhengzhou People’s Hospital, The Fifth Clinical College of Henan University of Chinese Medicine, Zhengzhou, China
| | - Xu Chen
- Translational Medicine Research Center, Zhengzhou People’s Hospital, The Fifth Clinical College of Henan University of Chinese Medicine, Zhengzhou, China
| | - Xiaobing Guo
- Department of Laboratory Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jianjun Gou
- Department of Laboratory Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yinsen Song
- Translational Medicine Research Center, Zhengzhou People’s Hospital, The Fifth Clinical College of Henan University of Chinese Medicine, Zhengzhou, China
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Monte DFM, Gonzalez-Escalona N, Cao G, Pedrosa GTDS, Saraiva MMS, Balkey M, Jin Q, Brown E, Allard M, Macarisin D, Magnani M. Genomic analysis of a cAmpC (CMY-41)-producing Citrobacter freundii ST64 isolated from patient. Lett Appl Microbiol 2024; 77:ovae010. [PMID: 38327245 DOI: 10.1093/lambio/ovae010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/24/2024] [Accepted: 02/06/2024] [Indexed: 02/09/2024]
Abstract
Antibiotic resistance in Citrobacter freundii is a public health concern. This study evaluated the closed genome of a C. freundii isolated from the stool of a hospitalized patient initially related to a Salmonella outbreak. Confirmation of the isolate was determined by whole-genome sequencing. Nanopore sequencing was performed using a MinION with a Flongle flow cell. Assembly using SPAdes and Unicycler yielded a closed genome annotated by National Center for Biotechnology Information Prokaryotic Genome Annotation Pipeline. Genomic analyses employed MLST 2.0, ResFinder4.1, PlasmidFinder2.1, and VFanalyzer. Phylogenetic comparison utilized the Center for Food Safety and Applied Nutrition (CFSAN)-single nucleotide polymorphism pipeline and Genetic Algorithm for Rapid Likelihood Inference. Antimicrobial susceptibility was tested by broth microdilution following Clinical and Laboratory Standards Institute criteria. Multi-locus sequence type in silico analysis assigned the C. freundii as sequence type 64 and the blaCMY-41 gene was detected in resistome investigation. The susceptibility to antibiotics, determined using Sensititre® plates, revealed resistance to aztreonam, colistin, cefoxitin, amoxicillin/clavulanic acid, sulfisoxazole, ampicillin, and streptomycin. The genetic relatedness of the C. freundii CFSAN077772 with publicly available C. freundii genomes revealed a close relationship to a C. freundii SRR1186659, isolated in 2009 from human stool in Tanzania. In addition, C. freundii CFSAN077772 is nested in the same cluster with C. freundii clinical strains isolated in Denmark, Mexico, Myanmar, and Canada, suggesting a successful intercontinental spread.
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Affiliation(s)
- Daniel F M Monte
- Department of Animal Science, College for Agricultural Sciences, Federal University of Paraiba (CCA/UFPB), Areia, PB 58397000, Brazil
| | - Narjol Gonzalez-Escalona
- Division of Microbiology, Office of Regulatory Science, Center for Food Safety and Applied Nutrition, US Food and Drug Administration,, College Park, MD 20740, USA
| | - Guojie Cao
- Division of Microbiology, Office of Regulatory Science, Center for Food Safety and Applied Nutrition, US Food and Drug Administration,, College Park, MD 20740, USA
| | - Geany Targino de Souza Pedrosa
- Laboratory of Microbial Processes in Foods, Department of Food Engineering, Federal University of Paraíba, João Pessoa, PB 58059900, Brazil
| | - Mauro M S Saraiva
- São Paulo State University (Unesp), School of Agricultural and Veterinarian Sciences, Jaboticabal, SP 14884-900, Brazil
| | - Maria Balkey
- Division of Microbiology, Office of Regulatory Science, Center for Food Safety and Applied Nutrition, US Food and Drug Administration,, College Park, MD 20740, USA
| | - Qing Jin
- Division of Microbiology, Office of Regulatory Science, Center for Food Safety and Applied Nutrition, US Food and Drug Administration,, College Park, MD 20740, USA
| | - Eric Brown
- Division of Microbiology, Office of Regulatory Science, Center for Food Safety and Applied Nutrition, US Food and Drug Administration,, College Park, MD 20740, USA
| | - Marc Allard
- Division of Microbiology, Office of Regulatory Science, Center for Food Safety and Applied Nutrition, US Food and Drug Administration,, College Park, MD 20740, USA
| | - Dumitru Macarisin
- Division of Microbiology, Office of Regulatory Science, Center for Food Safety and Applied Nutrition, US Food and Drug Administration,, College Park, MD 20740, USA
| | - Marciane Magnani
- Laboratory of Microbial Processes in Foods, Department of Food Engineering, Federal University of Paraíba, João Pessoa, PB 58059900, Brazil
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Abban MK, Ayerakwa EA, Mosi L, Isawumi A. The burden of hospital acquired infections and antimicrobial resistance. Heliyon 2023; 9:e20561. [PMID: 37818001 PMCID: PMC10560788 DOI: 10.1016/j.heliyon.2023.e20561] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/21/2023] [Accepted: 09/29/2023] [Indexed: 10/12/2023] Open
Abstract
The burden of Hospital care-associated infections (HCAIs) is becoming a global concern. This is compounded by the emergence of virulent and high-risk bacterial strains such as "ESKAPE" pathogens - (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter species), especially within Intensive care units (ICUs) that house high-risk and immunocompromised patients. In this review, we discuss the contributions of AMR pathogens to the increasing burden of HCAIs and provide insights into AMR mechanisms, with a particular focus on last-resort antibiotics like polymyxins. We extensively discuss how structural modifications of surface-membrane lipopolysaccharides and cationic interactions influence and inform AMR, and subsequent severity of HCAIs. We highlight some bacterial phenotypic survival mechanisms against polymyxins. Lastly, we discuss the emergence of plasmid-mediated resistance as a phenomenon making mitigation of AMR difficult, especially within the ICUs. This review provides a balanced perspective on the burden of HCAIs, associated pathogens, implication of AMR and factors influencing emerging AMR mechanisms.
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Affiliation(s)
- Molly Kukua Abban
- West African Centre for Cell Biology of Infectious Pathogens, P.O. Box LG 54, Volta Road, University of Ghana, Legon, Accra, Ghana
- Department of Biochemistry, Cell and Molecular Biology, College of Basic and Applied Sciences, P.O. Box LG 54, Volta Road, University of Ghana, Legon, Accra, Ghana
| | - Eunice Ampadubea Ayerakwa
- West African Centre for Cell Biology of Infectious Pathogens, P.O. Box LG 54, Volta Road, University of Ghana, Legon, Accra, Ghana
- Department of Biochemistry, Cell and Molecular Biology, College of Basic and Applied Sciences, P.O. Box LG 54, Volta Road, University of Ghana, Legon, Accra, Ghana
| | - Lydia Mosi
- West African Centre for Cell Biology of Infectious Pathogens, P.O. Box LG 54, Volta Road, University of Ghana, Legon, Accra, Ghana
- Department of Biochemistry, Cell and Molecular Biology, College of Basic and Applied Sciences, P.O. Box LG 54, Volta Road, University of Ghana, Legon, Accra, Ghana
| | - Abiola Isawumi
- West African Centre for Cell Biology of Infectious Pathogens, P.O. Box LG 54, Volta Road, University of Ghana, Legon, Accra, Ghana
- Department of Biochemistry, Cell and Molecular Biology, College of Basic and Applied Sciences, P.O. Box LG 54, Volta Road, University of Ghana, Legon, Accra, Ghana
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Liu L, Zhang L, Zhou H, Yuan M, Hu D, Wang Y, Sun H, Xu J, Lan R. Antimicrobial Resistance and Molecular Characterization of Citrobacter spp. Causing Extraintestinal Infections. Front Cell Infect Microbiol 2021; 11:737636. [PMID: 34513738 PMCID: PMC8429604 DOI: 10.3389/fcimb.2021.737636] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 08/03/2021] [Indexed: 12/19/2022] Open
Abstract
Objectives This prospective study was carried out to investigate molecular characteristics and antimicrobial susceptibility patterns of Citrobacter spp. from extraintestinal infections. Methods Forty-six clinical Citrobacter spp. isolates were isolated from hospital patients with extraintestinal infections and analyzed by multilocus sequence typing (MLST) using seven housekeeping genes. Antimicrobial susceptibility testing was performed by disk diffusion method according to the Clinical and Laboratory Standards Institute (CLSI) recommendations. Adhesion and cytotoxicity to HEp-2 cells were assessed. Results The 46 clinical Citrobacter spp. isolates were typed into 38 sequence types (STs), 9 of which belonged to four clonal complexes (CCs). None of the isolates shared the same ST or CCs with isolates from other countries or from other parts of China. Over half of the isolates were multidrug-resistant (MDR), with 17/26 C. freundii, 5/6 C. braakii, and 3/14 C. koseri isolates being MDR. Moreover, four isolates were carbapenem resistant with resistance to imipenem or meropenem. Among eight quinolone resistant C. freundii, all had a mutation in codon 59 (Thr59Ile) in quinolone resistance determining region of the gyrA gene. Only a small proportion of the isolates were found to be highly cytotoxic and adhesive with no correlation to sample sources. Conclusions There was a diverse range of Citrobacter isolates causing extraintestinal infections and a high prevalence of MDR.
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Affiliation(s)
- Liyun Liu
- State Key Laboratory of Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Research Units of Discovery of Unknown Bacteria and Function (2018RU010), Chinese Academy of Medical Sciences, Beijing, China
| | - Ling Zhang
- Microbiology Department, Maanshan Center for Clinical Laboratory, Ma'anshan, China
| | - Haijian Zhou
- State Key Laboratory of Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Research Units of Discovery of Unknown Bacteria and Function (2018RU010), Chinese Academy of Medical Sciences, Beijing, China
| | - Min Yuan
- State Key Laboratory of Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Research Units of Discovery of Unknown Bacteria and Function (2018RU010), Chinese Academy of Medical Sciences, Beijing, China
| | - Dalong Hu
- State Key Laboratory of Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Research Units of Discovery of Unknown Bacteria and Function (2018RU010), Chinese Academy of Medical Sciences, Beijing, China
| | - Yonglu Wang
- Microbiology Department, Maanshan Center for Disease Control and Prevention, Ma'anshan, China
| | - Hui Sun
- State Key Laboratory of Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Research Units of Discovery of Unknown Bacteria and Function (2018RU010), Chinese Academy of Medical Sciences, Beijing, China
| | - Jianguo Xu
- State Key Laboratory of Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Research Units of Discovery of Unknown Bacteria and Function (2018RU010), Chinese Academy of Medical Sciences, Beijing, China
| | - Ruiting Lan
- School of Biotechnology and Biomolecular Sciences, University of New South Wales, Sydney, NSW, Australia
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Babiker A, Evans DR, Griffith MP, McElheny CL, Hassan M, Clarke LG, Mettus RT, Harrison LH, Doi Y, Shields RK, Van Tyne D. Clinical and Genomic Epidemiology of Carbapenem-Nonsusceptible Citrobacter spp. at a Tertiary Health Care Center over 2 Decades. J Clin Microbiol 2020; 58:e00275-20. [PMID: 32554477 PMCID: PMC7448640 DOI: 10.1128/jcm.00275-20] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 06/10/2020] [Indexed: 12/16/2022] Open
Abstract
Carbapenem-nonsusceptible Citrobacter spp. (CNSC) are increasingly recognized as health care-associated pathogens. Information regarding their clinical epidemiology, genetic diversity, and mechanisms of carbapenem resistance is lacking. We examined microbiology records of adult patients at the University of Pittsburgh Medical Center (UMPC) Presbyterian Hospital (PUH) from 2000 to 2018 for CNSC, as defined by ertapenem nonsusceptibility. Over this time frame, the proportion of CNSC increased from 4% to 10% (P = 0.03), as did daily defined carbapenem doses/1,000 patient days (6.52 to 34.5; R2 = 0.831; P < 0.001), which correlated with the observed increase in CNSC (lag = 0 years; R2 = 0.660). Twenty CNSC isolates from 19 patients at PUH and other UPMC hospitals were available for further analysis, including whole-genome short-read sequencing and additional antimicrobial susceptibility testing. Of the 19 patients, nearly all acquired CNSC in the health care setting and over half had polymicrobial cultures containing at least one other organism. Among the 20 CNSC isolates, Citrobacter freundii was the predominant species identified (60%). CNSC genomes were compared with genomes of carbapenem-susceptible Citrobacter spp. from UPMC and with other publicly available CNSC genomes. Isolates carrying genes encoding carbapenemases (blaKPC-2,blaKPC-3, and blaNDM-1) were also long-read sequenced, and their carbapenemase-encoding plasmid sequences were compared with one another and with publicly available sequences. Phylogenetic analysis of 102 UPMC Citrobacter genomes showed that CNSC from our setting did not cluster together. Similarly, a global phylogeny of 64 CNSC genomes showed a diverse population structure. Our findings suggest that both local and global CNSC populations are genetically diverse and that CNSC harbor carbapenemase-encoding plasmids found in other Enterobacterales.
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Affiliation(s)
- Ahmed Babiker
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Microbial Genomic Epidemiology Laboratory, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Daniel R Evans
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Marissa P Griffith
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Microbial Genomic Epidemiology Laboratory, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Christi L McElheny
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mohamed Hassan
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Lloyd G Clarke
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Roberta T Mettus
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lee H Harrison
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Microbial Genomic Epidemiology Laboratory, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Graduate School of Public Health, University of Pittsburgh, Pennsylvania, USA
| | - Yohei Doi
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ryan K Shields
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Daria Van Tyne
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Chi X, Guo J, Zhou Y, Xiao T, Xu H, Lv T, Chen C, Chen J, Zheng B. Complete-Genome Sequencing and Comparative Genomic Characterization of an IMP-4 Producing Citrobacter freundii Isolate from Patient with Diarrhea. Infect Drug Resist 2020; 13:1057-1065. [PMID: 32341658 PMCID: PMC7166059 DOI: 10.2147/idr.s244683] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 03/19/2020] [Indexed: 12/31/2022] Open
Abstract
Background Citrobacter freundii is the most common class of pathogens in the genus Citrobacter and is an important pathogen associated with certain underlying diseases or immune dysfunction. The aim of this study was to elucidate the resistance mechanism of clinically derived carbapenem-resistant C. freundii isolate and to characterize the genetic environment and delivery pattern of the IncN1 plasmid carrying the blaIMP-4 gene from C. freundii isolate. Materials and Methods We identified a clinical isolate of C. freundii L91 carrying blaIMP-4 and performed phylogenetic analysis by whole-genome sequencing. The complete genomic sequence of L91 was obtained using the Illumina HiSeq 4000-PE150 and PacBio RS II platforms. Antimicrobial susceptibility testing was determined by the VITEK 2 system. Plasmid characteristics were presented by S1-pulsed-field gel electrophoresis (PFGE), Southern blotting and conjugation experiments. Results S1-PFGE, Southern blot and conjugation assay confirmed the presence of blaIMP-4 genes on a conjugative plasmid in this isolate. C. freundii L91 and transconjugant L91-E. coli 600 strains both showed resistance to carbapenems. In silico analysis further showed that pIMP-4-L91 is an IncN1 plasmid with a length of 51,042 bp. Furthermore, blaIMP-4 gene was found encoded in the blaIMP-4-qacG2-aacA4-catB3 cassette array within a class 1 integron. A conserved structure sequence (ΔISKpn27-blaIMP-4-ΔISSen2-hp-hp-IS6100) was found in the upstream and downstream of the blaIMP-4. Conclusion We performed a comprehensive phylogenetic analysis of carbapenemase-resistant C. freundii and elucidated the resistance mechanism of clinically derived C. freundii L91. Not only that, we also found that the blaIMP-4 gene is located on the IncN1 plasmid and has a horizontal transfer function and a certain ability to spread. To lower the risk of the dissemination of such C. freundii isolates in clinical settings, more surveillance is needed in the future.
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Affiliation(s)
- Xiaohui Chi
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China.,Department of Environment and Health, School of Public Health, Shandong University, Jinan, People's Republic of China
| | - Jing Guo
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Yanzi Zhou
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Tingting Xiao
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Hao Xu
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Tao Lv
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Chunlei Chen
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Jian Chen
- Intensive Care Unit, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Beiwen Zheng
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
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Iovene MR, Pota V, Galdiero M, Corvino G, Lella FMD, Stelitano D, Passavanti MB, Pace MC, Alfieri A, Franco SD, Aurilio C, Sansone P, Niyas VKM, Fiore M. First Italian outbreak of VIM-producing Serratia marcescensin an adult polyvalent intensive care unit, August-October 2018: A case report and literature review. World J Clin Cases 2019. [DOI: 10.12998/wjcc.v7.i21.3518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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8
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Iovene MR, Pota V, Galdiero M, Corvino G, Di Lella FM, Stelitano D, Passavanti MB, Pace MC, Alfieri A, Di Franco S, Aurilio C, Sansone P, Niyas VKM, Fiore M. First Italian outbreak of VIM-producing Serratia marcescens in an adult polyvalent intensive care unit, August-October 2018: A case report and literature review. World J Clin Cases 2019; 7:3535-3548. [PMID: 31750335 PMCID: PMC6854422 DOI: 10.12998/wjcc.v7.i21.3535] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/14/2019] [Accepted: 07/27/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Carbapenem-resistant Enterobacteriaceae has become a significant public health concern as hospital outbreaks are now being frequently reported and these organisms are becoming difficult to treat with the available antibiotics.
CASE SUMMARY An outbreak of VIM-producing Serratia marcescens occurred over a period of 11 wk (August, 1 to October, 18) in patients admitted to the adult polyvalent intensive care unit of the University of Campania “Luigi Vanvitelli” located in Naples. Four episodes occurred in three patients (two patients infected, and one patient colonized). All the strains revealed the production of VIM.
CONCLUSION After three decades of carbapenem antibiotics use, the emergence of carbapenem-resistance in Enterobacteriaceae has become a significant concern and a stricter control to preserve its clinical application is mandatory. This is, to our knowledge, the first outbreak of VIM-producing Serratia marcescens in Europe. Surveillance policies must be implemented to avoid future outbreaks.
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Affiliation(s)
- Maria Rosaria Iovene
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples 80138, Italy
| | - Vincenzo Pota
- Department of Women, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples 80138, Italy
| | - Massimiliano Galdiero
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples 80138, Italy
| | - Giusy Corvino
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples 80138, Italy
| | - Federica Maria Di Lella
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples 80138, Italy
| | - Debora Stelitano
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples 80138, Italy
| | - Maria Beatrice Passavanti
- Department of Women, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples 80138, Italy
| | - Maria Caterina Pace
- Department of Women, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples 80138, Italy
| | - Aniello Alfieri
- Department of Women, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples 80138, Italy
| | - Sveva Di Franco
- Department of Women, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples 80138, Italy
| | - Caterina Aurilio
- Department of Women, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples 80138, Italy
| | - Pasquale Sansone
- Department of Women, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples 80138, Italy
| | | | - Marco Fiore
- Department of Women, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples 80138, Italy
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Hand Colonization with Gram-Negative Organisms of Healthcare Workers Accessing the Cardiac Intensive Care Unit: A Cross-Sectional Study at the Uganda Heart Institute. Crit Care Res Pract 2019; 2019:6081954. [PMID: 31687206 PMCID: PMC6811803 DOI: 10.1155/2019/6081954] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 09/05/2019] [Indexed: 11/25/2022] Open
Abstract
Background Hands of healthcare workers (HCWs) are vehicles for pathogens responsible for healthcare-associated infections (HAIs). Following the identification of Gram-negative organisms (GNOs) in all cases of HAIs in the cardiac intensive care unit (ICU), we sought to determine the burden of hand colonization with GNOs among healthcare workers who access the cardiac ICU. Methods We retrospectively reviewed results from surveillance cultures of fingertip imprints of HCWs who access the cardiac ICU at the Uganda Heart Institute. We collected data on staff category, isolates, and susceptibility to antibiotics. We analyzed the data using Microsoft Excel, and the results are summarized in proportions and percentages and presented in charts and tables. Results Fifty-six healthcare workers participated in the surveillance. 21 were ICU clinicians, 21 non-ICU clinicians, and 14 nonclinicians. GNOs were cultured in 19 (33.9%) HCWs, in which 8/19 (42.1%) were non-ICU clinicians, 6/19 (31.2%) ICU clinicians, and 5/19 (26.3%) nonclinicians. 32 isolates were identified, of which 47%, 28%, and 25% were cultured from non-ICU clinicians, nonclinicians, and ICU clinicians, respectively. Predominant isolates were Acinetobacter (34%), Citrobacter (21.9%), and Pseudomonas (21.9%). Antimicrobial resistance ranged from 4% to 90%. 9/28 (32.1%) isolates, predominantly Acinetobacter species (spp), were carbapenem resistant. 8/28 (28.6%) isolates, predominantly Citrobacter spp, were multidrug resistant. Resistance to ciprofloxacin and cefepime was low at 3.6% and 4.4%, respectively. Conclusion Gram-negative organisms, predominantly Acinetobacter, Citrobacter, and Pseudomonas spp, were prevalent on the hands of HCWs who access the cardiac ICU irrespective of the staff category. Antimicrobial resistance was high, with multidrug resistance and carbapenem resistance common among Citrobacter spp and Acinetobacter spp, respectively. Resistance to cefepime and ciprofloxacin was low.
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10
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Ambretti S, Bassetti M, Clerici P, Petrosillo N, Tumietto F, Viale P, Rossolini GM. Screening for carriage of carbapenem-resistant Enterobacteriaceae in settings of high endemicity: a position paper from an Italian working group on CRE infections. Antimicrob Resist Infect Control 2019; 8:136. [PMID: 31423299 PMCID: PMC6693230 DOI: 10.1186/s13756-019-0591-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 07/31/2019] [Indexed: 12/11/2022] Open
Abstract
Introduction A variety of national and international guidelines exist around the management of carbapenem resistant Enterobacteriaceae (CREs), but some of these are several years old and do not reflect current epidemiology and they also do not necessarily give pragmatic advice around active surveillance of CREs in countries with a high burden of cases and limited resources. This paper aims to provide a best practice position paper to guide active surveillance in a variety of scenarios in these settings, and discusses which patients should be screened, what methods could be used for screening, and how results might influence infection prevention interventions. Methods This paper was developed as a result of a series of meetings of expert opinion leaders representing the major infectious disease and infection prevention societies in Italy and having the endorsement of AMCLI (Italian Association of Clinical Microbiology) and SITA (Italian Society for Anti-infective Therapy). There was no attempt to undertake a full systematic review of the evidence, as it was felt that this was inadequate to inform a pragmatic view on the best way forward based on current epidemiology and infection rates. Key recommendations Key recommendations focus on the urgent need to promote measures to prevent transmission and infection, focusing on high risk patients and clinical areas, as well as outbreak situations. Active surveillance leading to appropriate infection prevention precautions plays a major role in this. Conclusions There are limited national or international guidelines giving pragmatic advice on the most appropriate measures for active surveillance and management of colonized patients in a high-burden setting such as Italy. While individual hospitals and regions will need to formulate their own policies based on local epidemiology, this position paper attempts to highlight current best practice in this area and provide pragmatic advice for clinicians, infection prevention staff, and healthcare managers.
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Affiliation(s)
- Simone Ambretti
- 1Unit of Clinical Microbiology, St Orsola-Malpighi University Hospital, Bologna, Via Massarenti 9, 40138 Bologna, Italy
| | - Matteo Bassetti
- 2Infectious Diseases Clinic, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Pierangelo Clerici
- Microbiological Unit, Department of Laboratory Medicine and Diagnostics Biotecnology, Azienda Socio Sanitaria Territoriale Ovest Milanese, Via Giovanni Paolo II, 2025 Legnano, Mi Italy
| | - Nicola Petrosillo
- 4National Institute for Infectious Diseases "L. Spallanzani", IRCCS-, Rome, Italy
| | - Fabio Tumietto
- 5Infectious Diseases Unit, Department of Medical and Surgical Sciences, S.Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
| | - Pierluigi Viale
- 5Infectious Diseases Unit, Department of Medical and Surgical Sciences, S.Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
| | - Gian Maria Rossolini
- 6Department of Experimental and Clinical Medicine, University of Florence, and Clinical Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy
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11
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Interplay among IncA and bla KPC-Carrying Plasmids in Citrobacter freundii. Antimicrob Agents Chemother 2019; 63:AAC.02609-18. [PMID: 30858205 DOI: 10.1128/aac.02609-18] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 03/01/2019] [Indexed: 12/23/2022] Open
Abstract
We report two KPC-producing Citrobacter freundii isolates from unrelated patients. In one case, bla KPC-2 was harbored on a novel variant of a Tn4401 transposon of an IncN plasmid conjugated together with a coresident IncA plasmid, whereas in the other one, bla KPC-3 was on a Tn4401a transposon located on an IncX3-IncA self-conjugative plasmid fusion. The interplay among plasmids carrying bla KPC and the coresident IncA plasmids offers new information on plasmids coresident within clinically relevant enterobacteria.
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12
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Rödel J, Mellmann A, Stein C, Alexi M, Kipp F, Edel B, Dawczynski K, Brandt C, Seidel L, Pfister W, Löffler B, Straube E. Use of MALDI-TOF mass spectrometry to detect nosocomial outbreaks of Serratia marcescens and Citrobacter freundii. Eur J Clin Microbiol Infect Dis 2019; 38:581-591. [PMID: 30680577 DOI: 10.1007/s10096-018-03462-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 12/26/2018] [Indexed: 12/13/2022]
Abstract
MALDI-TOF mass spectrometry (MS) may be used as a rapid typing method for nosocomial pathogens. Here, we evaluated MALDI-TOF MS for discrimination of hospital outbreak-related clusters of Serratia marcescens and carbapenemase-producing Citrobacter freundii. Thirty-three S. marcescens isolates collected from neonatal intensive care unit (NICU) patients, and 23 C. freundii isolates including VIM-positive isolates from a hospital colonization outbreak were measured by Vitek MS. Consensus spectra of each isolate were clustered using SARAMIS software. Genotyping was performed by whole-genome sequencing (WGS). First, a set of 21 S. marcescens isolates from 2014 with seven genotypes including three monoclonal clusters was used for the evaluation of MALDI-TOF typing. MS clustering was largely in agreement with genotyping results when the similarity cut-off for clonal identity was set on 90%. MALDI-TOF cluster analysis was then investigated for the surveillance of S. marcescens in the NICU in 2017 and demonstrated the introduction of new strains into the hospital and nosocomial transmissions. MS analysis of the C. freundii outbreak in 2016 revealed a monoclonal cluster of VIM-positive isolates and the separation of epidemiologically non-related VIM-positive and negative isolates. Two additional VIM-positive Citrobacter isolates from food samples were closely related to the large monoclonal cluster. WGS confirmed the MS results. MALDI-TOF MS may be used as a first-line typing tool for S. marcescens and C. freundii to detect transmission events in the hospital because isolates of an identical WGS type were grouped into the same MS cluster.
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Affiliation(s)
- Jürgen Rödel
- Institute of Medical Microbiology, Jena University Hospital, Jena, Germany.
| | | | - Claudia Stein
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Monika Alexi
- Institute of Medical Microbiology, Jena University Hospital, Jena, Germany
| | - Frank Kipp
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Birgit Edel
- Institute of Medical Microbiology, Jena University Hospital, Jena, Germany
| | - Kristin Dawczynski
- Unit Neonatology, Department of Paediatrics, Jena University Hospital, Jena, Germany
| | - Christian Brandt
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | | | - Wolfgang Pfister
- Institute of Medical Microbiology, Jena University Hospital, Jena, Germany
| | - Bettina Löffler
- Institute of Medical Microbiology, Jena University Hospital, Jena, Germany
| | - Eberhard Straube
- Institute of Medical Microbiology, Jena University Hospital, Jena, Germany
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13
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Qian C, Du Y, Li H, Wu P, Wang L, Wei Y, Cao H, Yin Z, Zhang Y, Zhu Y, Guo X, Liu B. Development of rapid and simple experimental and in silico serotyping systems for Citrobacter. Future Microbiol 2018; 13:1511-1522. [PMID: 30099919 PMCID: PMC6240886 DOI: 10.2217/fmb-2018-0187] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Aim: Members of the genus Citrobacter are important opportunistic pathogens responsible for high mortality rate. Therefore, in this study, we aimed to develop efficient and accurate Citrobacter typing schemes for clinical detection and epidemiological surveillance. Materials & methods: Using genomic and experimental analyses, we located the O-antigen biosynthesis gene clusters in Citrobacter genome for the first time, and used comparative genomic analyses to reveal the specific genes in different Citrobacter serotypes. Results: Based on the specific genes in O-antigen biosynthesis gene clusters of Citrobacter, we established experimental and in silico serotyping systems for this bacterium. Conclusion: Both serotyping tools are reliable, and our observations are biologically and clinically relevant for understanding and managing Citrobacter infection.
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Affiliation(s)
- Chengqian Qian
- Key Laboratory of Molecular Microbiology & Technology, Ministry of Education, Tianjin Economic-Technological Development Area, Tianjin, PR China.,TEDA Institute of Biological Sciences & Biotechnology, Nankai University, Tianjin Economic-Technological Development Area, Tianjin, PR China.,Tianjin Key Laboratory of Microbial Functional Genomics, Tianjin Economic-Technological Development Area, Tianjin, PR China
| | - Yuhui Du
- Key Laboratory of Molecular Microbiology & Technology, Ministry of Education, Tianjin Economic-Technological Development Area, Tianjin, PR China.,TEDA Institute of Biological Sciences & Biotechnology, Nankai University, Tianjin Economic-Technological Development Area, Tianjin, PR China.,Tianjin Key Laboratory of Microbial Functional Genomics, Tianjin Economic-Technological Development Area, Tianjin, PR China
| | - Huiying Li
- Key Laboratory of Molecular Microbiology & Technology, Ministry of Education, Tianjin Economic-Technological Development Area, Tianjin, PR China.,TEDA Institute of Biological Sciences & Biotechnology, Nankai University, Tianjin Economic-Technological Development Area, Tianjin, PR China.,Tianjin Key Laboratory of Microbial Functional Genomics, Tianjin Economic-Technological Development Area, Tianjin, PR China
| | - Pan Wu
- Key Laboratory of Molecular Microbiology & Technology, Ministry of Education, Tianjin Economic-Technological Development Area, Tianjin, PR China.,TEDA Institute of Biological Sciences & Biotechnology, Nankai University, Tianjin Economic-Technological Development Area, Tianjin, PR China.,Tianjin Key Laboratory of Microbial Functional Genomics, Tianjin Economic-Technological Development Area, Tianjin, PR China
| | - Lu Wang
- Key Laboratory of Molecular Microbiology & Technology, Ministry of Education, Tianjin Economic-Technological Development Area, Tianjin, PR China.,TEDA Institute of Biological Sciences & Biotechnology, Nankai University, Tianjin Economic-Technological Development Area, Tianjin, PR China.,Tianjin Key Laboratory of Microbial Functional Genomics, Tianjin Economic-Technological Development Area, Tianjin, PR China
| | - Yi Wei
- Key Laboratory of Molecular Microbiology & Technology, Ministry of Education, Tianjin Economic-Technological Development Area, Tianjin, PR China.,TEDA Institute of Biological Sciences & Biotechnology, Nankai University, Tianjin Economic-Technological Development Area, Tianjin, PR China.,Tianjin Key Laboratory of Microbial Functional Genomics, Tianjin Economic-Technological Development Area, Tianjin, PR China
| | - Hengchun Cao
- Key Laboratory of Molecular Microbiology & Technology, Ministry of Education, Tianjin Economic-Technological Development Area, Tianjin, PR China.,TEDA Institute of Biological Sciences & Biotechnology, Nankai University, Tianjin Economic-Technological Development Area, Tianjin, PR China.,Tianjin Key Laboratory of Microbial Functional Genomics, Tianjin Economic-Technological Development Area, Tianjin, PR China
| | - Zhiqiu Yin
- Key Laboratory of Molecular Microbiology & Technology, Ministry of Education, Tianjin Economic-Technological Development Area, Tianjin, PR China.,TEDA Institute of Biological Sciences & Biotechnology, Nankai University, Tianjin Economic-Technological Development Area, Tianjin, PR China.,Tianjin Key Laboratory of Microbial Functional Genomics, Tianjin Economic-Technological Development Area, Tianjin, PR China
| | - Yang Zhang
- Key Laboratory of Molecular Microbiology & Technology, Ministry of Education, Tianjin Economic-Technological Development Area, Tianjin, PR China.,TEDA Institute of Biological Sciences & Biotechnology, Nankai University, Tianjin Economic-Technological Development Area, Tianjin, PR China.,Tianjin Key Laboratory of Microbial Functional Genomics, Tianjin Economic-Technological Development Area, Tianjin, PR China
| | - Yiming Zhu
- Key Laboratory of Molecular Microbiology & Technology, Ministry of Education, Tianjin Economic-Technological Development Area, Tianjin, PR China.,TEDA Institute of Biological Sciences & Biotechnology, Nankai University, Tianjin Economic-Technological Development Area, Tianjin, PR China.,Tianjin Key Laboratory of Microbial Functional Genomics, Tianjin Economic-Technological Development Area, Tianjin, PR China
| | - Xi Guo
- Key Laboratory of Molecular Microbiology & Technology, Ministry of Education, Tianjin Economic-Technological Development Area, Tianjin, PR China.,TEDA Institute of Biological Sciences & Biotechnology, Nankai University, Tianjin Economic-Technological Development Area, Tianjin, PR China.,Tianjin Key Laboratory of Microbial Functional Genomics, Tianjin Economic-Technological Development Area, Tianjin, PR China
| | - Bin Liu
- Key Laboratory of Molecular Microbiology & Technology, Ministry of Education, Tianjin Economic-Technological Development Area, Tianjin, PR China.,TEDA Institute of Biological Sciences & Biotechnology, Nankai University, Tianjin Economic-Technological Development Area, Tianjin, PR China.,Tianjin Key Laboratory of Microbial Functional Genomics, Tianjin Economic-Technological Development Area, Tianjin, PR China
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14
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Arana DM, Ortega A, González-Barberá E, Lara N, Bautista V, Gómez-Ruíz D, Sáez D, Fernández-Romero S, Aracil B, Pérez-Vázquez M, Campos J, Oteo J. Carbapenem-resistant Citrobacter spp. isolated in Spain from 2013 to 2015 produced a variety of carbapenemases including VIM-1, OXA-48, KPC-2, NDM-1 and VIM-2. J Antimicrob Chemother 2018; 72:3283-3287. [PMID: 29029114 DOI: 10.1093/jac/dkx325] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 08/04/2017] [Indexed: 11/12/2022] Open
Abstract
Objectives There is little information about carbapenemase-producing (CP) Citrobacter spp. We studied the molecular epidemiology and microbiological features of CP Citrobacter spp. isolates collected in Spain (2013-15). Methods In total, 119 isolates suspected of being CP by the EUCAST screening cut-off values were analysed. Carbapenemases and ESBLs were characterized using PCR and sequencing. The genetic relationship among Citrobacter freundii isolates was studied by PFGE. Results Of the 119 isolates, 63 (52.9%) produced carbapenemases, of which 37 (58.7%) produced VIM-1, 20 (31.7%) produced OXA-48, 12 (19%) produced KPC-2, 2 (3.2%) produced NDM-1 and 1 (1.6%) produced VIM-2; 9 C. freundii isolates co-produced VIM-1 plus OXA-48. Fourteen isolates (22.2%) also carried ESBLs: 8 CTX-M-9 plus SHV-12, 2 CTX-M-9, 2 SHV-12 and 2 CTX-M-15. Fifty-seven isolates (90.5%) were C. freundii, 4 (6.3%) were Citrobacter koseri, 1 (1.6%) was Citrobacter amalonaticus and 1 (1.6%) was Citrobacter braakii. By EUCAST breakpoints, eight (12.7%) of the CP isolates were susceptible to the four carbapenems tested. In the 53 CP C. freundii analysed by PFGE, a total of 44 different band patterns were observed. Four PFGE clusters were identified: cluster 1 included eight isolates co-producing VIM-1 and OXA-48; blaVIM-1 was carried in a class 1 integron (intI-blaVIM-1-aacA4-dfrB1-aadA1-catB2-qacEΔ1/sul1) and blaOXA-48 was carried in a Tn1999.2 transposon. Conclusions We observed the clonal and polyclonal spread of CP Citrobacter spp. across several Spanish geographical areas. Four species of Citrobacter spp. produced up to five carbapenemase types, including co-production of VIM-1 plus OXA-48. Some CP Citrobacter spp. isolates were susceptible to the four carbapenems tested, a finding with potential clinical implications.
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Affiliation(s)
- David M Arana
- Servicio de Microbiología del Hospital Universitario de Getafe, Getafe, Madrid, Spain.,Laboratorio de Referencia e Investigación en Resistencia a Antibióticos e Infecciones Relacionadas con la Asistencia Sanitaria, Centro Nacional de Microbiología, Majadahonda, Madrid, Spain
| | - Adriana Ortega
- Laboratorio de Referencia e Investigación en Resistencia a Antibióticos e Infecciones Relacionadas con la Asistencia Sanitaria, Centro Nacional de Microbiología, Majadahonda, Madrid, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
| | - Eva González-Barberá
- Servicio de Microbiología del Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Noelia Lara
- Laboratorio de Referencia e Investigación en Resistencia a Antibióticos e Infecciones Relacionadas con la Asistencia Sanitaria, Centro Nacional de Microbiología, Majadahonda, Madrid, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
| | - Verónica Bautista
- Laboratorio de Referencia e Investigación en Resistencia a Antibióticos e Infecciones Relacionadas con la Asistencia Sanitaria, Centro Nacional de Microbiología, Majadahonda, Madrid, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
| | - Dolores Gómez-Ruíz
- Servicio de Microbiología del Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - David Sáez
- Laboratorio de Referencia e Investigación en Resistencia a Antibióticos e Infecciones Relacionadas con la Asistencia Sanitaria, Centro Nacional de Microbiología, Majadahonda, Madrid, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
| | - Sara Fernández-Romero
- Laboratorio de Referencia e Investigación en Resistencia a Antibióticos e Infecciones Relacionadas con la Asistencia Sanitaria, Centro Nacional de Microbiología, Majadahonda, Madrid, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
| | - Belén Aracil
- Laboratorio de Referencia e Investigación en Resistencia a Antibióticos e Infecciones Relacionadas con la Asistencia Sanitaria, Centro Nacional de Microbiología, Majadahonda, Madrid, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
| | - María Pérez-Vázquez
- Laboratorio de Referencia e Investigación en Resistencia a Antibióticos e Infecciones Relacionadas con la Asistencia Sanitaria, Centro Nacional de Microbiología, Majadahonda, Madrid, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
| | - José Campos
- Laboratorio de Referencia e Investigación en Resistencia a Antibióticos e Infecciones Relacionadas con la Asistencia Sanitaria, Centro Nacional de Microbiología, Majadahonda, Madrid, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
| | - Jesús Oteo
- Laboratorio de Referencia e Investigación en Resistencia a Antibióticos e Infecciones Relacionadas con la Asistencia Sanitaria, Centro Nacional de Microbiología, Majadahonda, Madrid, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
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15
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Chen CM, Huang M, Wu HJ, Guo MK, Wu LT. Identification of CFE-2, a new plasmid-encoded AmpC β-lactamase from a clinical isolate of Citrobacter freundii. Int J Antimicrob Agents 2018; 52:421-424. [PMID: 29944954 DOI: 10.1016/j.ijantimicag.2018.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 03/13/2018] [Accepted: 06/16/2018] [Indexed: 10/28/2022]
Abstract
A clinical isolate of Citrobacter freundii (JA99) obtained from a bile culture of a Taiwanese patient was found to produce a plasmid-encoded β-lactamase conferring resistance to oxyimino-cephalosporins and cephamycins. Resistance arising from production of the β-lactamase could be transferred by conjugation with an IncW plasmid (pJA99) into Escherichia coli J53. The substrate and inhibition profiles of this enzyme resembled that of an AmpC β-lactamase. The resistance gene of pJA99, cloned and expressed in E. coli DH5α, was shown to contain an open reading frame showing 92% amino acid identity with the plasmid-encoded enzyme CFE-1 of E. coli KU6400. DNA sequence analysis also identified a gene upstream of ampC in pJA99 whose sequence was 95.0% identical to the ampR gene from E. coli KU6400. In addition, orf1, the fumarate operon (frdABCD), blc, lolB and repB surrounding the ampR-ampC genes in C. freundii were identified. This DNA fragment was absent in other Citrobacter spp. Therefore, we describe a new plasmid-encoded AmpC β-lactamase, named CFE-2. This study highlights the emergence of broad-spectrum cephalosporin resistance in C. freundii owing to a new type of AmpC β-lactamase.
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Affiliation(s)
- Chih-Ming Chen
- Department of Health Food, Chung Chou University of Science and Technology, Changhua, Taiwan; Division of Infectious Diseases, Department of Internal Medicine, Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan
| | - Mei Huang
- Division of Infectious Diseases, Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan
| | - Hwa-Jene Wu
- Department of Laboratory Medicine, Buddhist Tzu Chi Medical Foundation, Taiwan
| | - Ming-Kai Guo
- Graduate Institute of Biomedical Sciences and Department of Microbiology, China Medical University, Taichung, Taiwan
| | - Lii-Tzu Wu
- Graduate Institute of Biomedical Sciences and Department of Microbiology, China Medical University, Taichung, Taiwan.
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16
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Matsumura Y, Peirano G, Devinney R, Bradford PA, Motyl MR, Adams MD, Chen L, Kreiswirth B, Pitout JDD. Genomic epidemiology of global VIM-producing Enterobacteriaceae. J Antimicrob Chemother 2018; 72:2249-2258. [PMID: 28520983 DOI: 10.1093/jac/dkx148] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 04/19/2017] [Indexed: 12/21/2022] Open
Abstract
Background International data on the molecular epidemiology of Enterobacteriaceae with VIM carbapenemases are limited. Methods We performed short read (Illumina) WGS on a global collection of 89 VIM-producing clinical Enterobacteriaceae (2008-14). Results VIM-producing (11 varieties within 21 different integrons) isolates were mostly obtained from Europe. Certain integrons with bla VIM were specific to a country in different species and clonal complexes (CCs) (In 87 , In 624 , In 916 and In 1323 ), while others had spread globally among various Enterobacteriaceae species (In 110 and In 1209 ). Klebsiella pneumoniae was the most common species ( n = 45); CC147 from Greece was the most prevalent clone and contained In 590 -like integrons with four different bla VIM s. Enterobacter cloacae complex was the second most common species and mainly consisted of Enterobacter hormaechei ( Enterobacter xiangfangensis , subsp. steigerwaltii and Hoffmann cluster III). CC200 (from Croatia and Turkey), CC114 (Croatia, Greece, Italy and the USA) and CC78 (from Greece, Italy and Spain) containing bla VIM-1 were the most common clones among the E. cloacae complex. Conclusions This study highlights the importance of surveillance programmes using the latest molecular techniques in providing insight into the characteristics and global distribution of Enterobacteriaceae with bla VIM s.
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Affiliation(s)
- Yasufumi Matsumura
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Gisele Peirano
- Departments of Pathology & Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada.,Division of Microbiology, Calgary Laboratory Services, Calgary, Alberta, Canada
| | - Rebekah Devinney
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | | | | | - Mark D Adams
- Department of Medical Microbiology, J. Craig Venter Institute, La Jolla, CA, USA
| | - Liang Chen
- Public Research Institute TB Center, New Jersey Medical School, Rutgers University, Newark, NJ, USA
| | - Barry Kreiswirth
- Public Research Institute TB Center, New Jersey Medical School, Rutgers University, Newark, NJ, USA
| | - Johann D D Pitout
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada.,Departments of Pathology & Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada.,Division of Microbiology, Calgary Laboratory Services, Calgary, Alberta, Canada.,Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
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17
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van Loon K, Voor In 't Holt AF, Vos MC. A Systematic Review and Meta-analyses of the Clinical Epidemiology of Carbapenem-Resistant Enterobacteriaceae. Antimicrob Agents Chemother 2018; 62:e01730-17. [PMID: 29038269 PMCID: PMC5740327 DOI: 10.1128/aac.01730-17] [Citation(s) in RCA: 146] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 09/29/2017] [Indexed: 01/23/2023] Open
Abstract
Carbapenem-resistant Enterobacteriaceae (CRE) are major health care-associated pathogens and responsible for hospital outbreaks worldwide. To prevent a further increase in CRE infections and to improve infection prevention strategies, it is important to summarize the current knowledge about CRE infection prevention in hospital settings. This systematic review aimed to identify risk factors for CRE acquisition among hospitalized patients. In addition, we summarized the environmental sources/reservoirs and the most successful infection prevention strategies related to CRE. A total of 3,983 potentially relevant articles were identified and screened. Finally, we included 162 studies in the systematic review, of which 69 studies regarding risk factors for CRE acquisition were included in the random-effects meta-analysis studies. The meta-analyses regarding risk factors for CRE acquisition showed that the use of medical devices generated the highest pooled estimate (odds ratio [OR] = 5.09; 95% confidence interval [CI] = 3.38 to 7.67), followed by carbapenem use (OR = 4.71; 95% CI = 3.54 to 6.26). To control hospital outbreaks, bundled interventions, including the use of barrier/contact precautions for patients colonized or infected with CRE, are needed. In addition, it is necessary to optimize the therapeutic approach, which is an important message to infectious disease specialists, who need to be actively involved in a timely manner in the treatment of patients with known CRE infections or suspected carriers of CRE.
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Affiliation(s)
- Karlijn van Loon
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Anne F Voor In 't Holt
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Margreet C Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Sundin OH, Mendoza-Ladd A, Zeng M, Diaz-Arévalo D, Morales E, Fagan BM, Ordoñez J, Velez P, Antony N, McCallum RW. The human jejunum has an endogenous microbiota that differs from those in the oral cavity and colon. BMC Microbiol 2017; 17:160. [PMID: 28716079 PMCID: PMC5513040 DOI: 10.1186/s12866-017-1059-6] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 06/26/2017] [Indexed: 02/07/2023] Open
Abstract
Background The upper half of the human small intestine, known as the jejunum, is the primary site for absorption of nutrient-derived carbohydrates, amino acids, small peptides, and vitamins. In contrast to the colon, which contains 1011–1012 colony forming units of bacteria per ml (CFU/ml), the normal jejunum generally ranges from 103 to 105 CFU per ml. Because invasive procedures are required to access the jejunum, much less is known about its bacterial microbiota. Bacteria inhabiting the jejunal lumen have been investigated by classical culture techniques, but not by culture-independent metagenomics. Results The lumen of the upper jejunum was sampled during enteroscopy of 20 research subjects. Culture on aerobic and anaerobic media gave live bacterial counts ranging from 5.8 × 103 CFU/ml to 8.0 × 106 CFU/ml. DNA from the same samples was analyzed by 16S rRNA gene-specific quantitative PCR, yielding values from 1.5 × 105 to 3.1 × 107 bacterial genomes per ml. When calculated for each sample, estimated bacterial viability ranged from effectively 100% to a low of 0.3%. 16S rRNA metagenomic analysis of uncultured bacteria by Illumina MiSeq sequencing gave detailed microbial composition by phylum, genus and species. The genera Streptococcus, Prevotella, Veillonella and Fusobacterium, were especially abundant, as well as non-oral genera including Escherichia, Klebsiella, and Citrobacter. The jejunum was devoid of the genera Alistipes, Ruminococcus, Faecalibacterium, and other extreme anaerobes abundant in the colon. In patients with higher bacterial loads, there was no significant change in microbial species composition. Conclusions The jejunal lumen contains a distinctive bacterial population consisting primarily of facultative anaerobes and oxygen-tolerant obligate anaerobes similar to those found in the oral cavity. However, the frequent abundance of Enterobacteriaceae represents a major difference from oral microbiota. Although a few genera are shared with the colon, we found no evidence for retrograde movement of the most abundant colonic microbes to the jejunum. Some individuals had much higher bacterial loads, but this was not correlated with decreases in bacterial species diversity or other evidence of dysbiosis. Electronic supplementary material The online version of this article (doi:10.1186/s12866-017-1059-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Olof H Sundin
- Department of Biomedical Sciences, Texas Tech University Health Sciences Center at El Paso, El Paso, 79905, TX, USA.
| | - Antonio Mendoza-Ladd
- Department of Internal Medicine, Division of Gastroenterology, Texas Tech University Health Sciences Center at El Paso, El Paso, 79905, TX, USA
| | - Mingtao Zeng
- Department of Biomedical Sciences, Texas Tech University Health Sciences Center at El Paso, El Paso, 79905, TX, USA
| | - Diana Diaz-Arévalo
- Department of Biomedical Sciences, Texas Tech University Health Sciences Center at El Paso, El Paso, 79905, TX, USA
| | - Elisa Morales
- Department of Biomedical Sciences, Texas Tech University Health Sciences Center at El Paso, El Paso, 79905, TX, USA
| | - B Matthew Fagan
- Department of Biomedical Sciences, Texas Tech University Health Sciences Center at El Paso, El Paso, 79905, TX, USA
| | - Javier Ordoñez
- Biostatistics Unit, Texas Tech University Health Sciences Center at El Paso, El Paso, 79905, TX, USA
| | - Philip Velez
- Department of Biomedical Sciences, Texas Tech University Health Sciences Center at El Paso, El Paso, 79905, TX, USA
| | - Nishaal Antony
- Department of Internal Medicine, Division of Gastroenterology, Texas Tech University Health Sciences Center at El Paso, El Paso, 79905, TX, USA
| | - Richard W McCallum
- Department of Internal Medicine, Division of Gastroenterology, Texas Tech University Health Sciences Center at El Paso, El Paso, 79905, TX, USA
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Villa J, Arana DM, Viedma E, Perez-Montarelo D, Chaves F. Characterization of mobile genetic elements carrying VIM-1 and KPC-2 carbapenemases in Citrobacter freundii isolates in Madrid. Int J Med Microbiol 2017; 307:340-345. [PMID: 28711315 DOI: 10.1016/j.ijmm.2017.07.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/28/2017] [Accepted: 07/02/2017] [Indexed: 11/18/2022] Open
Abstract
Carbapenemase producing Citrobacter freundii (CPCF) infections are still uncommon in European countries. Here we report a molecular study conducted in a tertiary care facility in southern Madrid, Spain, from 2009 to 2014 to investigate the epidemiology of CPCF. The blaIMP-1,blaIMP-2,blaKPC,blaNDM,blaOXA-48,blaVIM-1 and blaVIM-2 genes were screened by PCR. Molecular typing was carried out by Pulsed-field gel electrophoresis analysis (PFGE) and multilocus sequence typing (MLST). Whole genome sequencing (WGS) was performed to characterize the resistome and the mobile genetic elements associated with the carbapenems resistance of CPCF. A total of 11/521 (2.1%) isolates had reduced susceptibility to carbapenems. PCR amplification revealed the presence of blaVIM-1 in 10 isolates and blaKPC-2 in 2 isolates. One C. freundii isolate co-harbored blaVIM-1 and blaKPC-2 genes. PFGE and MLST assigned 10 different clonal, 4 previously reported (ST11, ST18, ST22 and ST64) and 6 new STs (ST89, ST90, ST91, ST92, ST92 and ST94). The blaVIM-1 gene was part of In624 (intI1-blaVIM-1-aacA4-dfrB1-aadA1-catB2-qacEΔ1/sul1). In 3 of these isolates, plasmid-mediated quinolone resistance genes (qnrA1 and qnrB4) were present in its downstream region, taking part of a complex class 1 integron ([In624:ISCR1:qnrB4-blaDHA-1] and [In624:ISCR1:qnrA1]). On the other hand, the blaKPC-2 gene was associated with a Tn3-based transposon. The dissemination of the blaVIM-1 gene among various clones suggests a successful horizontal transfer of integron carrying elements that play a dominant role in the development of multidrug resistance in Enterobacteriaceae.
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Affiliation(s)
- Jennifer Villa
- Servicio de Microbiología, Hospital Universitario 12 de Octubre, Madrid, Spain.
| | - David M Arana
- Servicio de Microbiología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Esther Viedma
- Servicio de Microbiología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Fernando Chaves
- Servicio de Microbiología, Hospital Universitario 12 de Octubre, Madrid, Spain
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Majewski P, Wieczorek P, Łapuć I, Ojdana D, Sieńko A, Sacha P, Kłoczko J, Tryniszewska E. Emergence of a multidrug-resistant Citrobacter freundii ST8 harboring an unusual VIM-4 gene cassette in Poland. Int J Infect Dis 2017; 61:70-73. [PMID: 28602727 DOI: 10.1016/j.ijid.2017.05.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 05/25/2017] [Accepted: 05/26/2017] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES The growing incidence of multidrug-resistant (MDR) bacteria is an emerging challenge in modern medicine. The utility of carbapenems, which are considered 'last-line' agents, is being diminished by the growing incidence of various resistance mechanisms in Gram-negative bacteria. A molecular investigation was performed of an MDR carbapenem-resistant Citrobacter freundii of sequence type 8 (ST8) isolated from a hematology patient with acute myeloid leukemia. METHODS Multilocus sequence typing and analysis of the nucleotide sequence of the class I integron were performed using PCR and Sanger sequencing. Transformation of the resistance plasmid isolated following the alkaline lysis method was performed using chemically competent E. coli TOP10. RESULTS Molecular analysis of the carbapenem-resistant C. freundii revealed the presence of the VIM-4 isoenzyme located on the ∼55-kb transferable resistance plasmid. Interestingly, the blaVIM-4 gene was inserted into an unusual gene cassette containing a 169-bp direct repeat of the 3' segment of the blaVIM-4 gene. CONCLUSIONS All unusual gene cassettes containing VIM-DR (direct repeat) described thus far have been harbored by non-fermenters, i.e., Acinetobacter and Pseudomonas, underscoring the importance of resistance determinant mobility, which may go even beyond genus, family, and order boundaries. Great efforts need to be taken to explore pathways of resistance to 'last-resort' antimicrobials, especially among clinically relevant pathogens.
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Affiliation(s)
- Piotr Majewski
- Department of Microbiological Diagnostics and Infectious Immunology, Medical University of Bialystok, Bialystok, Poland.
| | - Piotr Wieczorek
- Department of Microbiological Diagnostics and Infectious Immunology, Medical University of Bialystok, Bialystok, Poland
| | - Izabela Łapuć
- Department of Hematology, Medical University Hospital of Bialystok, Bialystok, Poland
| | - Dominika Ojdana
- Department of Microbiological Diagnostics and Infectious Immunology, Medical University of Bialystok, Bialystok, Poland
| | - Anna Sieńko
- Department of Microbiological Diagnostics and Infectious Immunology, Medical University of Bialystok, Bialystok, Poland
| | - Paweł Sacha
- Department of Microbiological Diagnostics and Infectious Immunology, Medical University of Bialystok, Bialystok, Poland
| | - Janusz Kłoczko
- Department of Hematology, Medical University Hospital of Bialystok, Bialystok, Poland
| | - Elżbieta Tryniszewska
- Department of Microbiological Diagnostics and Infectious Immunology, Medical University of Bialystok, Bialystok, Poland
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Liu LH, Wang NY, Wu AYJ, Lin CC, Lee CM, Liu CP. Citrobacter freundii bacteremia: Risk factors of mortality and prevalence of resistance genes. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2017; 51:565-572. [PMID: 28711438 DOI: 10.1016/j.jmii.2016.08.016] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 08/25/2016] [Accepted: 08/26/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND/PURPOSE Multidrug-resistant strains of Citrobacter have emerged, which carry Amp-C β-lactamase (Amp-C), broad-spectrum β-lactamase, extended-spectrum β-lactamase (ESBL), and other resistance mechanisms. These strains are associated with a higher rate of in-hospital mortality. The object of this study is to determine the mortality risk factors, susceptibility pattern to antibiotics, and prevalence of resistance genes in patients with Citrobacter freundii bacteremia. METHODS From January 2009 to December 2014, blood isolates of C. freundii were collected in MacKay Memorial Hospital, Taipei, Taiwan. PCR technique and sequencing were performed for resistance genes. Pulsed-field gel electrophoresis (PFGE) was done using XbaI restriction enzyme. The clinical characteristics and risk factors for mortality are demonstrated. RESULTS The 36 blood isolates of C. freundii belonged to 32 different PFGE pulsotypes, and 15 isolates (41.7%) were polymicrobial. The most common source of infection was intra-abdominal origin (61.1%), followed by unknown sources (22.2%), the urinary tract (8.3%), intravascular catheter (5.6%), and soft tissue (2.8%). High degree of antibiotic resistance was noted for cefazolin (100%), cefoxitin (97.2%), and cefuroxime (66.7%). The blaTEM-1 resistance gene was present in 16.7% isolates. 72.2% isolates carried blaAmpC and 5.6% isolates carried ESBL genes (blaSHV-12 or blaCTX-M-15). Multivariate analysis indicated that the independent risk factor for 28-day mortality was carrying the blaTEM-1 resistance gene. CONCLUSION For patients with C. freundii bacteremia, carrying the blaTEM-1 resistance gene was an independent risk factor for 28-day mortality. Carbapenems, fourth-generation cephalosporins, amikacin, and quinolones are still reliable agents for drug-resistant strains.
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Affiliation(s)
- Li-Hsiang Liu
- Division of Infectious Diseases, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Nai-Yu Wang
- Section of Microbiology, Department of Medical Research, MacKay Memorial Hospital, Taipei, Taiwan
| | - Alice Ying-Jung Wu
- Division of Infectious Diseases, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chih-Chen Lin
- Division of Infectious Diseases, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chun-Ming Lee
- Division of Infectious Diseases, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan; Division of Infectious Diseases, Department of Internal Medicine, St. Joseph's Hospital, Yunlin County, Taiwan; MacKay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan.
| | - Chang-Pan Liu
- Division of Infectious Diseases, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan; Section of Microbiology, Department of Medical Research, MacKay Memorial Hospital, Taipei, Taiwan; MacKay Medical College, Taipei, Taiwan.
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Maraki S, Vardakas KZ, Mavromanolaki VE, Kyriakidou M, Spais G, Kofteridis DP, Samonis G, Falagas ME. In vitro susceptibility and resistance phenotypes in contemporary Citrobacter isolates in a University Hospital in Crete, Greece. Infect Dis (Lond) 2017; 49:532-539. [PMID: 28276281 DOI: 10.1080/23744235.2017.1297896] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Data on Citrobacter spp. susceptibility are scarce. We sought to study the evolution in the susceptibility of 385 Citrobacter spp. at the University Hospital of Heraklion, Crete, Greece during a six-year period (2010-2015). METHODS Non-duplicate strains isolated from inpatients (intensive care unit, oncology, surgery, internal medicine, paediatrics) and outpatients were studied using Vitek 2. Phenotypic confirmatory tests were applied for detection of β-lactamases and aminoglycoside modifying enzymes. RESULTS C. freundii (172, 44.7%) and C. koseri (166, 43.1%) were the most commonly isolated species. C. braakii (34), C. amalonaticus (6), C. youngae (6) and C. sedlakii (1) were the remaining isolates. Colistin and fosfomycin were the most active antibiotics (both 99.2%) followed by carbapenems (99%) aminoglycosides (96.6-98.4%), tigecycline (96.1%), cefepime (94.8%), ciprofloxacin (94.3%), tetracycline (92.7%), trimethoprim/sulphamethoxazole (91.4%), chloramphenicol (88.1%), piperacillin/tazobactam (86.5%) and 3rd generation cephalosporins (85.7%). C. freundii were more resistant than C. koseri. Antibiotic resistance did not increase during the study period for most antibiotics. Lower susceptibility to all antibiotics was observed among multi-drug resistant (MDR) strains. AmpC was the most common resistant mechanism (10.9%); carbapenemases (1.3%) and aminoglycoside modifying enzymes (2.9%) were also detected. All AmpC producers were resistant to cephalosporins but not to carbapenems. In all but one isolates aminoglycoside resistance was accompanied by acquired β-lactamases. CONCLUSIONS Although Citrobacter species in general were susceptible, antibiotic susceptibility testing is required for the detection of resistant isolates.
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Affiliation(s)
- Sofia Maraki
- a Department of Clinical Microbiology , University Hospital of Heraklion , Heraklion , Greece
| | - Konstantinos Z Vardakas
- b Alfa Institute of Biomedical Sciences (AIBS) , Athens , Greece.,c Department of Internal Medicine-Infectious Diseases , Iaso General Hospital , Athens , Greece
| | | | - Margarita Kyriakidou
- e Department of Applied Mathematics and Physics , National Technical University of Athens , Athens , Greece
| | - George Spais
- e Department of Applied Mathematics and Physics , National Technical University of Athens , Athens , Greece
| | - Diamantis P Kofteridis
- d Department of Internal Medicine , University of Crete School of Medicine , Heraklion , Greece
| | - George Samonis
- d Department of Internal Medicine , University of Crete School of Medicine , Heraklion , Greece
| | - Matthew E Falagas
- b Alfa Institute of Biomedical Sciences (AIBS) , Athens , Greece.,c Department of Internal Medicine-Infectious Diseases , Iaso General Hospital , Athens , Greece.,f Department of Medicine , Tufts University School of Medicine , Boston , MA , USA
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23
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Santos C, Ramalheira E, Da Silva G, Mendo S. Genetically unrelated multidrug- and carbapenem-resistant Citrobacter freundii detected in outpatients admitted to a Portuguese hospital. J Glob Antimicrob Resist 2016; 8:18-22. [PMID: 27915087 DOI: 10.1016/j.jgar.2016.09.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 09/13/2016] [Accepted: 09/22/2016] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Non-clonal, carbapenem- and multidrug-resistant Citrobacter freundii isolates were collected from unrelated outpatients admitted to a Portuguese hospital emergency department. One patient lived in a nursing home and was never hospitalised, whereas the other patient was repeatedly hospitalised in this hospital. The aim of this study was to unveil the molecular mechanisms associated with the carbapenem resistance of these isolates and to assess its potential dissemination. METHODS Isolate identification was performed by VITEK®2 and was confirmed by 16S rDNA sequencing. The clonal relationship of the isolates was evaluated by repetitive element palindromic PCR (rep-PCR). Antibiotic susceptibility was determined using the automatic VITEK®2 AES system and disk diffusion assay. β-Lactamases, porins and mobile genetic elements were characterised by PCR and sequencing. Pulsed-field gel electrophoresis (PFGE) and Southern blot hybridisation were used to determine the genetic location of integrons, and their transferability was tested by conjugation. RESULTS No genetic relatedness was found, suggesting different origins of the isolates. In isolate Cf254 a VIM-2 carbapenemase integrated in In58 was detected, located in a high-frequency conjugative IncL/M plasmid that also carried CTX-M-15 and CMY-39 genes. VIM-1 in isolate Cf872 was chromosomal. This is the first description in Portugal of VIM carbapenemases in C. freundii. Loss/alteration of porins was also detected. CONCLUSIONS Emergence of carbapenem-resistant Enterobacteria is not confined to the nosocomial environment. Community-acquired strains appear to be in circulation between inpatients and outpatients, spreading carbapenem resistance genes by horizontal gene transfer.
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Affiliation(s)
- Cátia Santos
- CESAM and Department of Biology, University of Aveiro, Campus de Santiago, 3810 Aveiro, Portugal.
| | - Elmano Ramalheira
- Centro Hospitalar do Baixo Vouga, Avenida Artur Ravara, 3810 Aveiro, Portugal
| | - Gabriela Da Silva
- Faculty of Pharmacy and Centre for Neurosciences and Cell Biology, University of Coimbra, 3000 Coimbra, Portugal
| | - Sónia Mendo
- CESAM and Department of Biology, University of Aveiro, Campus de Santiago, 3810 Aveiro, Portugal
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French CE, Coope C, Conway L, Higgins JPT, McCulloch J, Okoli G, Patel BC, Oliver I. Control of carbapenemase-producing Enterobacteriaceae outbreaks in acute settings: an evidence review. J Hosp Infect 2016; 95:3-45. [PMID: 27890334 DOI: 10.1016/j.jhin.2016.10.006] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 10/08/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND In recent years, infections with carbapenemase-producing Enterobacteriaceae (CPE) have been increasing globally and present a major public health challenge. AIM To review the international literature: (i) to describe CPE outbreaks in acute hospital settings globally; and (ii) to identify the control measures used during these outbreaks and report on their effectiveness. METHODS A systematic search of MEDLINE and EMBASE databases, abstract lists for key conferences and reference lists of key reviews was undertaken, and information on unpublished outbreaks was sought for 2000-2015. Where relevant, risk of bias was assessed using the Newcastle-Ottawa scale. A narrative synthesis of the evidence was conducted. FINDINGS Ninety-eight outbreaks were eligible. These occurred worldwide, with 53 reports from Europe. The number of cases (CPE infection or colonization) involved in outbreaks varied widely, from two to 803. In the vast majority of outbreaks, multi-component infection control measures were used, commonly including: patient screening; contact precautions (e.g. gowns, gloves); handwashing interventions; staff education or monitoring; enhanced environmental cleaning/decontamination; cohorting of patients and/or staff; and patient isolation. Seven studies were identified as providing the best-available evidence on the effectiveness of control measures. These demonstrated that CPE outbreaks can be controlled successfully using a range of appropriate, commonly used, infection control measures. However, risk of bias was considered relatively high for these studies. CONCLUSION The findings indicate that CPE outbreaks can be controlled using combinations of existing measures. However, the quality of the evidence base is weak and further high-quality research is needed, particularly on the effectiveness of individual infection control measures.
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Affiliation(s)
- C E French
- University of Bristol, Bristol, UK; NIHR Health Protection Research Unit in Evaluation of Interventions at University of Bristol, Bristol, UK
| | - C Coope
- NIHR Health Protection Research Unit in Evaluation of Interventions at University of Bristol, Bristol, UK; Public Health England, Bristol, UK.
| | - L Conway
- NIHR Health Protection Research Unit in Evaluation of Interventions at University of Bristol, Bristol, UK; Public Health England, Bristol, UK
| | - J P T Higgins
- University of Bristol, Bristol, UK; NIHR Health Protection Research Unit in Evaluation of Interventions at University of Bristol, Bristol, UK
| | | | - G Okoli
- University of Bristol, Bristol, UK
| | | | - I Oliver
- NIHR Health Protection Research Unit in Evaluation of Interventions at University of Bristol, Bristol, UK; Public Health England, Bristol, UK
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Hammerum AM, Hansen F, Nielsen HL, Jakobsen L, Stegger M, Andersen PS, Jensen P, Nielsen TK, Hansen LH, Hasman H, Fuglsang-Damgaard D. Use of WGS data for investigation of a long-term NDM-1-producing Citrobacter freundii outbreak and secondary in vivo spread of blaNDM-1 to Escherichia coli, Klebsiella pneumoniae and Klebsiella oxytoca. J Antimicrob Chemother 2016; 71:3117-3124. [PMID: 27494919 DOI: 10.1093/jac/dkw289] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 05/19/2016] [Accepted: 06/20/2016] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES An outbreak of NDM-1-producing Citrobacter freundii and possible secondary in vivo spread of blaNDM-1 to other Enterobacteriaceae were investigated. METHODS From October 2012 to March 2015, meropenem-resistant Enterobacteriaceae were detected in 45 samples from seven patients at Aalborg University Hospital, Aalborg, Denmark. In silico resistance genes, Inc plasmid types and STs (MLST) were obtained from WGS data from 24 meropenem-resistant isolates (13 C. freundii, 6 Klebsiella pneumoniae, 4 Escherichia coli and 1 Klebsiella oxytoca) and 1 meropenem-susceptible K. oxytoca. The sequences of the meropenem-resistant C. freundii isolates were compared by phylogenetic analyses. In vitro susceptibility to 21 antimicrobial agents was tested. Furthermore, in vitro conjugation and plasmid characterization was performed. RESULTS From the seven patients, 13 highly clonal ST18 NDM-1-producing C. freundii were isolated. The ST18 NDM-1-producing C. freundii isolates were only susceptible to tetracycline, tigecycline, colistin and fosfomycin (except for the C. freundii isolates from Patient 2 and Patient 7, which were additionally resistant to tetracycline). The E. coli and K. pneumoniae from different patients belonged to different STs, indicating in vivo transfer of blaNDM-1 in the individual patients. This was further supported by in vitro conjugation and detection of a 154 kb IncA/C2 plasmid with blaNDM-1. Patient screenings failed to reveal any additional cases. None of the patients had a history of recent travel abroad and the source of the blaNDM-1 plasmid was unknown. CONCLUSIONS To our knowledge, this is the first report of an NDM-1-producing C. freundii outbreak and secondary in vivo spread of an IncA/C2 plasmid with blaNDM-1 to other Enterobacteriaceae.
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Affiliation(s)
- Anette M Hammerum
- Department of Microbiology and Infection Control, Statens Serum Institut, Copenhagen, Denmark
| | - Frank Hansen
- Department of Microbiology and Infection Control, Statens Serum Institut, Copenhagen, Denmark
| | - Hans Linde Nielsen
- Department of Clinical Microbiology, Aalborg University Hospital, Aalborg, Denmark
| | - Lotte Jakobsen
- Department of Microbiology and Infection Control, Statens Serum Institut, Copenhagen, Denmark
| | - Marc Stegger
- Department of Microbiology and Infection Control, Statens Serum Institut, Copenhagen, Denmark.,Pathogen Genomics Division, Translational Genomics Research Institute (TGen), Flagstaff, AZ, USA
| | - Paal S Andersen
- Department of Microbiology and Infection Control, Statens Serum Institut, Copenhagen, Denmark.,Pathogen Genomics Division, Translational Genomics Research Institute (TGen), Flagstaff, AZ, USA.,Veterinary Disease Biology, University of Copenhagen, Copenhagen, Denmark
| | - Paw Jensen
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark
| | | | | | - Henrik Hasman
- Department of Microbiology and Infection Control, Statens Serum Institut, Copenhagen, Denmark
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Stier C, Paganini M, de Souza H, Costa L, dos Santos G, Cruz E. Active surveillance cultures: comparison of inguinal and rectal sites for detection of multidrug-resistant bacteria. J Hosp Infect 2016; 92:178-82. [DOI: 10.1016/j.jhin.2015.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 11/07/2015] [Indexed: 01/03/2023]
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KPC-Like Carbapenemase-Producing Enterobacteriaceae Colonizing Patients in Europe and Israel. Antimicrob Agents Chemother 2015; 60:1912-7. [PMID: 26711772 DOI: 10.1128/aac.02756-15] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 12/18/2015] [Indexed: 01/03/2023] Open
Abstract
In a 2008-2011 survey, 17,945 patients in 18 hospital units in Europe and Israel were screened for carriage of Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacteriaceae, resulting in identification of 124 positive patients. The isolates were dominated by Klebsiella pneumoniae sequence type 258 (ST258) KPC-2 and ST512 KPC-3, mainly from Greece and Italy, respectively, whereas Israeli isolates were of diverse species, clones, and KPC variants. Various blaKPC platforms were observed, among which IncFIIK-FIBK plasmids with blaKPC-2/-3 genes in the Tn4401a transposon prevailed.
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Antonelli A, D'Andrea MM, Vaggelli G, Docquier JD, Rossolini GM. OXA-372, a novel carbapenem-hydrolysing class D β-lactamase from aCitrobacter freundiiisolated from a hospital wastewater plant. J Antimicrob Chemother 2015; 70:2749-56. [DOI: 10.1093/jac/dkv181] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 06/03/2015] [Indexed: 11/13/2022] Open
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Papagiannitsis CC, Izdebski R, Baraniak A, Fiett J, Herda M, Hrabák J, Derde LPG, Bonten MJM, Carmeli Y, Goossens H, Hryniewicz W, Brun-Buisson C, Gniadkowski M, Grabowska A, Nikonorow E, Dautzenberg MJ, Adler A, Kazma M, Navon-Venezia S, Malhotra-Kumar S, Lammens C, Legrand P, Annane D, Chalfine A, Giamarellou H, Petrikkos GL, Nardi G, Balode A, Dumpis U, Stammet P, Arag I, Esteves F, Muzlovic I, Tomic V, Mart AT, Lawrence C, Salomon J, Paul M, Lerman Y, Rossini A, Salvia A, Samso JV, Fierro J. Survey of metallo-β-lactamase-producing Enterobacteriaceae colonizing patients in European ICUs and rehabilitation units, 2008–11. J Antimicrob Chemother 2015; 70:1981-8. [DOI: 10.1093/jac/dkv055] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 02/07/2015] [Indexed: 11/13/2022] Open
Affiliation(s)
- C. C. Papagiannitsis
- National Medicines Institute, Warsaw, Poland
- Faculty of Medicine in Plzeň, Charles University in Prague, Plzeň, Czech Republic
| | - R. Izdebski
- National Medicines Institute, Warsaw, Poland
| | - A. Baraniak
- National Medicines Institute, Warsaw, Poland
| | - J. Fiett
- National Medicines Institute, Warsaw, Poland
| | - M. Herda
- National Medicines Institute, Warsaw, Poland
| | - J. Hrabák
- Faculty of Medicine in Plzeň, Charles University in Prague, Plzeň, Czech Republic
| | - L. P. G. Derde
- University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Y. Carmeli
- Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
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Evaluation of carbapenem-resistant Enterobacteriaceae in an Italian setting: Report from the trench. INFECTION GENETICS AND EVOLUTION 2015; 30:8-14. [DOI: 10.1016/j.meegid.2014.11.025] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 11/22/2014] [Accepted: 11/24/2014] [Indexed: 01/04/2023]
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Abstract
Antimicrobial resistance, including multidrug resistance (MDR), is an increasing problem globally. MDR bacteria are frequently detected in humans and animals from both more- and less-developed countries and pose a serious concern for human health. Infections caused by MDR microbes may increase morbidity and mortality and require use of expensive drugs and prolonged hospitalization. Humans may be exposed to MDR pathogens through exposure to environments at health-care facilities and farms, livestock and companion animals, human food, and exposure to other individuals carrying MDR microbes. The Centers for Disease Control and Prevention classifies drug-resistant foodborne bacteria, including Campylobacter, Salmonella Typhi, nontyphoidal salmonellae, and Shigella, as serious threats. MDR bacteria have been detected in both meat and fresh produce. Salmonellae carrying genes coding for resistance to multiple antibiotics have caused numerous foodborne MDR outbreaks. While there is some level of resistance to antimicrobials in environmental bacteria, the widespread use of antibiotics in medicine and agriculture has driven the selection of a great variety of microbes with resistance to multiple antimicrobials. MDR bacteria on meat may have originated in veterinary health-care settings or on farms where animals are given antibiotics in feed or to treat infections. Fresh produce may be contaminated by irrigation or wash water containing MDR bacteria. Livestock, fruits, and vegetables may also be contaminated by food handlers, farmers, and animal caretakers who carry MDR bacteria. All potential sources of MDR bacteria should be considered and strategies devised to reduce their presence in foods. Surveillance studies have documented increasing trends in MDR in many pathogens, although there are a few reports of the decline of certain multidrug pathogens. Better coordination of surveillance programs and strategies for controlling use of antimicrobials need to be implemented in both human and animal medicine and agriculture and in countries around the world.
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Affiliation(s)
- Marjorie E Doyle
- Food Research Institute, University of Wisconsin , Madison, Wisconsin
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Peter S, Wolz C, Kaase M, Marschal M, Schulte B, Vogel W, Autenrieth I, Willmann M. Emergence of Citrobacter freundii carrying IMP-8 metallo-β-lactamase in Germany. New Microbes New Infect 2014; 2:42-5. [PMID: 25356340 PMCID: PMC4184589 DOI: 10.1002/nmi2.36] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 12/22/2013] [Accepted: 01/14/2014] [Indexed: 11/08/2022] Open
Abstract
Metallo-β-lactamases (MBLs) in Enterobacteriaceae are an increasing problem worldwide. This report describes the isolation of Citrobacter freundii carrying IMP-8 MBL from three patients during the period from March 2012 until March 2013 in Germany. The blaIMP-8 enzyme is predominantly found in Asia, where IMP-8 has spread to various enterobacterial species causing serious infections. To our best knowledge, this is the first report of blaIMP-8 habouring Enterobacteriaceae in Europe.
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Affiliation(s)
- S Peter
- Institute of Medical Microbiology and Hygiene, University of Tübingen Tübingen, Germany ; German Centre for Infection Research (DZIF), partner site Tübingen Tübingen, Germany
| | - C Wolz
- Institute of Medical Microbiology and Hygiene, University of Tübingen Tübingen, Germany ; German Centre for Infection Research (DZIF), partner site Tübingen Tübingen, Germany
| | - M Kaase
- National Reference Laboratory for Multidrug Resistant Gram-negative Bacteria, Department of Medical Microbiology, Ruhr University Bochum Bochum, Germany
| | - M Marschal
- Institute of Medical Microbiology and Hygiene, University of Tübingen Tübingen, Germany ; German Centre for Infection Research (DZIF), partner site Tübingen Tübingen, Germany
| | - B Schulte
- Institute of Medical Microbiology and Hygiene, University of Tübingen Tübingen, Germany ; German Centre for Infection Research (DZIF), partner site Tübingen Tübingen, Germany
| | - W Vogel
- Medical Centre, Department of Haematology, Oncology, Immunology, Rheumatology and Pulmonology, University of Tübingen Tübingen, Germany
| | - I Autenrieth
- Institute of Medical Microbiology and Hygiene, University of Tübingen Tübingen, Germany ; German Centre for Infection Research (DZIF), partner site Tübingen Tübingen, Germany
| | - M Willmann
- Institute of Medical Microbiology and Hygiene, University of Tübingen Tübingen, Germany ; German Centre for Infection Research (DZIF), partner site Tübingen Tübingen, Germany
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