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Antonelli A, Cuffari S, Casciato B, Giani T, Rossolini GM. Evaluation of the Vitek® Reveal™ system for rapid antimicrobial susceptibility testing of Gram-negative pathogens, including ESBL, CRE and CRAB, from positive blood cultures. Diagn Microbiol Infect Dis 2024; 110:116503. [PMID: 39197326 DOI: 10.1016/j.diagmicrobio.2024.116503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 08/02/2024] [Accepted: 08/21/2024] [Indexed: 09/01/2024]
Abstract
Blood culture (BC) remains the reference diagnostic tool for bloodstream infections but is hampered by long turn-around time (TAT). This study evaluated the Vitek® Reveal™ (VR) system for rapid antimicrobial susceptibility testing (AST) with 72 cases of monomicrobial BCs (55 Enterobacterales, 12 Pseudomonas aeruginosa and 5 Acinetobacter baumannii), including isolates producing carbapenemases and/or extended-spectrum β-lactamases. VR returned AST results with a mean TAT of 5.4 h. Compared to a conventional workflow based on broth microdilution, VR exhibited essential agreement (EA) and category agreement (CA) >90 % in most cases, except with meropenem for Enterobacterales (CA, 85.5 %), piperacillin/tazobactam for P. aeruginosa (EA, 83.3 %), and trimethoprim/sulfamethoxazole for A. baumannii (CA and EA, 80 %). Bias exhibited an underestimation trend with ceftazidime/avibactam (-78.9 %) and ceftazidime (-50 %) for Enterobacterales and P. aeruginosa, respectively. Overall, VR appears an interesting tool to decrease TAT of the BC workflow, although further evaluation with some antibiotic-pathogen combinations would be warranted.
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Affiliation(s)
- Alberto Antonelli
- Department of Experimental and Clinical Medicine, University of Florence, Italy; Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy; NARR Joint Laboratory for Antimicrobial Resistance Research and Control, University of Florence-IRCCS Don Gnocchi Foundation, Florence, Italy
| | - Sara Cuffari
- Department of Experimental and Clinical Medicine, University of Florence, Italy; Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
| | - Benedetta Casciato
- Department of Experimental and Clinical Medicine, University of Florence, Italy; Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
| | - Tommaso Giani
- Department of Experimental and Clinical Medicine, University of Florence, Italy; Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy; NARR Joint Laboratory for Antimicrobial Resistance Research and Control, University of Florence-IRCCS Don Gnocchi Foundation, Florence, Italy
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Italy; Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy; NARR Joint Laboratory for Antimicrobial Resistance Research and Control, University of Florence-IRCCS Don Gnocchi Foundation, Florence, Italy.
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Giordano C, Barnini S. Glycine restores the sensitivity to antibiotics in multidrug-resistant bacteria. Microbiol Spectr 2024; 12:e0016424. [PMID: 38888315 PMCID: PMC11302245 DOI: 10.1128/spectrum.00164-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 05/05/2024] [Indexed: 06/20/2024] Open
Abstract
The management of infections caused by multiresistant bacteria has become of fundamental importance for any medical practice. Glycine is the most common and the simplest non-essential amino acid in humans. Glycine is very effective in improving health and supporting growth and wellbeing of humans and animals. Instead, for many bacteria, high concentrations of glycine induce lysis or deep morphological alterations. The effect of glycine on multidrug resistant (MDR) microorganisms has not yet been extensively researched. The present study was conducted 1) to establish the effect of glycine on different nosocomial pathogens isolated during routine diagnostic investigations; 2) to determine the minimum inhibitory concentration of glycine and the type of activity performed (bacteriostatic or bactericidal) on representative isolates; 3) to test the interaction between glycine and meropenem, cefiderocol, or colistin. The data reported here show a dose-dependent activity of glycine on bacteria and its bactericidal activity on MDR bacteria. Furthermore, we found that the action of glycine restores in vitro the susceptibility of multiresistant nosocomial pathogens to the tested antibiotics.IMPORTANCEAntimicrobial resistance is a constantly growing concern throughout the world, and Italy is among the Western countries where antimicrobial resistance is most widespread. In Tuscany, carbapenemase-producing Enterobacterales are now even endemic. In this study, we challenged some resistant bacteria with a well-known molecule, glycine, the antibacterial properties of which have been known since the past century. This study could bring new insights into combining antibiotics with the simplest of all amino acids. The restoration of sensitivity to the aforementioned antibiotics by a natural compound, already used for clinical purposes, is of extreme importance in an era of proliferation of multiresistant bacteria. The in vivo use of this amino acid in evaluating its effectiveness against infections should be investigated. The low cost of this molecule can also make it easy to use even in low-income countries.
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Affiliation(s)
- Cesira Giordano
- Microbiology Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Simona Barnini
- Microbiology Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
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Wang S, Ma S, Sun S, Wang Q, Ding Q, Jin L, Chen F, Yin G, Wu X, Wang R, Wang H. Global evolutionary dynamics of virulence genes in ST11-KL47 carbapenem-resistant Klebsiella pneumoniae. Int J Antimicrob Agents 2024; 64:107245. [PMID: 38906484 DOI: 10.1016/j.ijantimicag.2024.107245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 06/06/2024] [Accepted: 06/12/2024] [Indexed: 06/23/2024]
Abstract
ST11-KL47 is a hypervirulent carbapenem-resistant Klebsiella pneumoniae (CRKP) that is highly prevalent in China and poses a major public health risk. To investigate the evolutionary dynamics of virulence genes in this subclone, we analysed 78 sequenced isolates obtained from a long-term study across 29 centres from 17 cities in China. Virulence genes were located in large hybrid pNDM-Mar-like plasmids (length: ∼266 kilobases) rather than in classical pK2044-like plasmids. These hybrid plasmids, derived from the fusion of pK2044 and pNDM-Mar plasmids mediated by insertion sequence (IS) elements (such as ISKpn28 and IS26), integrated virulence gene fragments into the chromosome. Analysis of 217 sequences containing the special IncFIB (pNDM-Mar) replicon using public databases indicated that these plasmids typically contained T4SS-related and multiple antimicrobial resistance genes, were present in 24 countries, and were found in humans, animals, and the environment. Notably, the chromosomal integration of virulence genes was observed in strains across five countries across two continents. In vivo and in vitro models showed that the large hybrid plasmid increased the host fitness cost while increasing virulence. Conversely, virulence genes transferred to chromosomes resulted in increased fitness and lower virulence. In conclusion, virulence genes in the plasmids of ST11-KL47 CRKP are evolving, driven by adaptive negative selection, to enable vertical chromosomal inheritance along with conferring a survival advantage and low pathogenicity.
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Affiliation(s)
- Shuyi Wang
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China; Institute of Medical Technology, Peking University Health Science Center, Beijing, China
| | - Shuai Ma
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China; Institute of Medical Technology, Peking University Health Science Center, Beijing, China
| | - Shijun Sun
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Qi Wang
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Qi Ding
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Longyang Jin
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Fengning Chen
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Guankun Yin
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Xingyu Wu
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Ruobing Wang
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Hui Wang
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China; Institute of Medical Technology, Peking University Health Science Center, Beijing, China.
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Giannella M, Pascale R, Viale P. Progression From Carriage to Bloodstream Infection and Fatality by Different Enterobacterales Species, Carbapenemases, and Host Settings: Deciphering the Melting Pot. Clin Infect Dis 2024; 79:30-32. [PMID: 38447000 DOI: 10.1093/cid/ciae109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 03/04/2024] [Indexed: 03/08/2024] Open
Affiliation(s)
- Maddalena Giannella
- Infectious Diseases Unit, Istituto di Ricovero e Cura a Carattere Scientifico Azienda Ospedaliero-Universitaria di Bologna
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Renato Pascale
- Infectious Diseases Unit, Istituto di Ricovero e Cura a Carattere Scientifico Azienda Ospedaliero-Universitaria di Bologna
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Pierluigi Viale
- Infectious Diseases Unit, Istituto di Ricovero e Cura a Carattere Scientifico Azienda Ospedaliero-Universitaria di Bologna
- Department of Medical and Surgical Sciences, University of Bologna, Italy
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Antonelli A, Coppi M, Bonaiuto C, Giovacchini N, Grifoni C, Vaggelli G, Pupillo R, Vannetti F, Farese A, Viaggi B, Pollini S, Rossolini GM. Pseudomonas aeruginosa producing FIM-1-metallo-β-lactamase: emergence and cross-transmission in a long-term acute care rehabilitation hospital. Antimicrob Agents Chemother 2024; 68:e0057424. [PMID: 38899928 PMCID: PMC11232380 DOI: 10.1128/aac.00574-24] [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: 04/19/2024] [Accepted: 05/25/2024] [Indexed: 06/21/2024] Open
Abstract
FIM-1 metallo-β-lactamase was previously detected in sporadic Pseudomonas aeruginosa clinical isolates. Here, we report on FIM-1-positive P. aeruginosa from two patients who had shared the same ward in a long-term acute care rehabilitation hospital. Whole-genome sequencing analysis revealed close relatedness of these isolates, which belonged to an ST235 sublineage (clade 8/14) different from those previously reported. Results highlighted the occurrence of clonal diversity among FIM-positive strains and the possibility of their cross-transmission in some healthcare settings.
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Affiliation(s)
- Alberto Antonelli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
- NARR Joint Laboratory for Antimicrobial Resistance Research and Control, University of Florence-IRCCS Don Gnocchi Foundation, Florence, Italy
| | - Marco Coppi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
- NARR Joint Laboratory for Antimicrobial Resistance Research and Control, University of Florence-IRCCS Don Gnocchi Foundation, Florence, Italy
| | - Chiara Bonaiuto
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
| | - Nicla Giovacchini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
| | - Camilla Grifoni
- NARR Joint Laboratory for Antimicrobial Resistance Research and Control, University of Florence-IRCCS Don Gnocchi Foundation, Florence, Italy
- Severe Brain Injuries Unit, IRCCS Don Gnocchi Foundation, Florence, Italy
| | - Guendalina Vaggelli
- Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
| | - Roberto Pupillo
- Medical Direction, IRCCS Don Gnocchi Foundation, Florence, Italy
| | | | - Alberto Farese
- Infectious and Tropical Diseases Unit, Careggi University Hospital, Florence, Italy
| | - Bruno Viaggi
- Intensive Care Unit for Neurological Injuries, Careggi University Hospital, Florence, Italy
| | - Simona Pollini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
- NARR Joint Laboratory for Antimicrobial Resistance Research and Control, University of Florence-IRCCS Don Gnocchi Foundation, Florence, Italy
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
- NARR Joint Laboratory for Antimicrobial Resistance Research and Control, University of Florence-IRCCS Don Gnocchi Foundation, Florence, Italy
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Liang B, Chen Y, Liang Z, Li X, Cai H, Lai H, Zhong H, Xie Y, Huang L, Gao F, Long Y. Molecular characteristics and evaluation of the phenotypic detection of carbapenemases among Enterobacterales and Pseudomonas via whole genome sequencing. Front Cell Infect Microbiol 2024; 14:1357289. [PMID: 39027138 PMCID: PMC11254758 DOI: 10.3389/fcimb.2024.1357289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 06/20/2024] [Indexed: 07/20/2024] Open
Abstract
Background/purposes The continuously increasing carbapenem resistance within Enterobacterales and Pseudomonas poses a threat to public health, nevertheless, the molecular characteristics of which in southern China still remain limited. And carbapenemase identification is a key factor in effective early therapy of carbapenem-resistant bacteria infections. We aimed to determine the molecular characteristics of these pathogens and compare commercial combined disc tests (CDTs) with the modified carbapenem inactivation method (mCIM) and EDTA-CIM (eCIM) in detecting and distinguishing carbapenemases using whole genome sequencing (WGS). Methods A total of 78 Enterobacterales, 30 Pseudomonas were obtained from two tertiary hospitals in southern China. Susceptibility tests were conducted using an automated VITEK2 compact system with confirmation via the Kirby-Bauer method. The WGS was conducted on all clinical isolates and the molecular characteristics were analyzed by screening the whole genome sequences. CDTs with or without cloxacillin, mCIM, and eCIM, were performed and compared by taking WGS results as the benchmark. Results A total of 103 carbapenem non-susceptible and 5 carbapenem susceptible bacteria were determined, with Klebsiella pneumoniae (42.7%), Pseudomonas aeruginosa (23.3%) and Escherichia coli (18.4%) being most prevalent. Carbapenemase genes were detected in 58 (56.3%) of the 103 carbapenem-non-susceptible clinical isolates, including 46 NDM, 6 KPC, 3 IMP, 1 IPM+VIM,1NDM+KPC, and 1 OXA-181. Carbapenemase-producing isolates were detected more frequently in Enterobacterales (76.3%). Among K. pneumoniae, the major sequence types were st307 and st11, while among E. coli and P. aeruginosa, the most prevalent ones were st410 and st242 respectively. For carbapenemase detection in Enterobacterales, the mCIM method achieved 100.00% (95% CI, 92.13-100.00%) sensitivity and 94.44% (70.63-99.71%) specificity (kappa, 0.96); for Pseudomonas, detection sensitivity was 100% (5.46-100.00%), and 100% (84.50-100.00%) specificity (kappa, 0.65). Commercial CDT carbapenemase detection sensitivity for Enterobacterales was 96.49% (86.84-99.39%), and 95.24% (74.13-99.75%) specificity (kappa, 0.90); for Pseudomonas, carbapenemase detection sensitivity was 100.00% (5.46-100.00%) and 37.93% (21.30-57.64%) specificity (kappa, 0.04). When cloxacillin testing was added, CDT specificity reached 84.61% (64.27-94.95%). Conclusion The molecular epidemiology of carbapenem-non-susceptible isolates from pediatric patients in Southern China exhibited distinctive characteristics. Both the mCIM-eCIM combination and CDT methods effectively detected and differentiated carbapenemases among Enterobacterales isolates, and the former performed better than CDT among Pseudomonas.
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Affiliation(s)
- Bingshao Liang
- Clinical Laboratory, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Yuou Chen
- KingMed School of Laboratory Medicine, Guangzhou Medical University, Guangzhou, China
| | - Zhuwei Liang
- Clinical Laboratory, Guangdong Provincial Second Hospital of Traditional Chinese Medicine (Guangdong Provincial Engineering Technology Research Institute of Traditional Chinese Medicine), Guangzhou, China
| | - Xueying Li
- Clinical Laboratory, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Hao Cai
- Clinical Laboratory, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Hanyu Lai
- Clinical Laboratory, The First People’s Hospital of Zhaoqing, Zhaoqing, China
| | - Huamin Zhong
- Clinical Laboratory, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Yongqiang Xie
- Clinical Laboratory, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Lianfen Huang
- Clinical Laboratory, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Fei Gao
- Clinical Laboratory, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Yan Long
- Clinical Laboratory, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
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Amábile-Cuevas CF, Lund-Zaina S. Non-Canonical Aspects of Antibiotics and Antibiotic Resistance. Antibiotics (Basel) 2024; 13:565. [PMID: 38927231 PMCID: PMC11200725 DOI: 10.3390/antibiotics13060565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/09/2024] [Accepted: 05/29/2024] [Indexed: 06/28/2024] Open
Abstract
The understanding of antibiotic resistance, one of the major health threats of our time, is mostly based on dated and incomplete notions, especially in clinical contexts. The "canonical" mechanisms of action and pharmacodynamics of antibiotics, as well as the methods used to assess their activity upon bacteria, have not changed in decades; the same applies to the definition, acquisition, selective pressures, and drivers of resistance. As a consequence, the strategies to improve antibiotic usage and overcome resistance have ultimately failed. This review gathers most of the "non-canonical" notions on antibiotics and resistance: from the alternative mechanisms of action of antibiotics and the limitations of susceptibility testing to the wide variety of selective pressures, lateral gene transfer mechanisms, ubiquity, and societal factors maintaining resistance. Only by having a "big picture" view of the problem can adequate strategies to harness resistance be devised. These strategies must be global, addressing the many aspects that drive the increasing prevalence of resistant bacteria aside from the clinical use of antibiotics.
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Affiliation(s)
| | - Sofia Lund-Zaina
- Department of Public Health, University of Southern Denmark, Campusvej 55, 5230 Odense, Denmark
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Talat A, Khan F, Khan AU. Genome analyses of colistin-resistant high-risk bla NDM-5 producing Klebsiella pneumoniae ST147 and Pseudomonas aeruginosa ST235 and ST357 in clinical settings. BMC Microbiol 2024; 24:174. [PMID: 38769479 PMCID: PMC11103832 DOI: 10.1186/s12866-024-03306-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 04/15/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Colistin is a last-resort antibiotic used in extreme cases of multi-drug resistant (MDR) Gram-negative bacterial infections. Colistin resistance has increased in recent years and often goes undetected due to the inefficiency of predominantly used standard antibiotic susceptibility tests (AST). To address this challenge, we aimed to detect the prevalence of colistin resistance strains through both Vitek®2 and broth micro-dilution. We investigated 1748 blood, tracheal aspirate, and pleural fluid samples from the Intensive Care Unit (ICU), Neonatal Intensive Care Unit (NICU), and Tuberculosis and Respiratory Disease centre (TBRD) in an India hospital. Whole-genome sequencing (WGS) of extremely drug-resitant (XDR) and pan-drug resistant (PDR) strains revealed the resistance mechanisms through the Resistance Gene Identifier (RGI.v6.0.0) and Snippy.v4.6.0. Abricate.v1.0.1, PlasmidFinder.v2.1, MobileElementFinder.v1.0.3 etc. detected virulence factors, and mobile genetic elements associated to uncover the pathogenecity and the role of horizontal gene transfer (HGT). RESULTS This study reveals compelling insights into colistin resistance among global high-risk clinical isolates: Klebsiella pneumoniae ST147 (16/20), Pseudomonas aeruginosa ST235 (3/20), and ST357 (1/20). Vitek®2 found 6 colistin-resistant strains (minimum inhibitory concentrations, MIC = 4 μg/mL), while broth microdilution identified 48 (MIC = 32-128 μg/mL), adhering to CLSI guidelines. Despite the absence of mobile colistin resistance (mcr) genes, mechanisms underlying colistin resistance included mgrB deletion, phosphoethanolamine transferases arnT, eptB, ompA, and mutations in pmrB (T246A, R256G) and eptA (V50L, A135P, I138V, C27F) in K. pneumoniae. P. aeruginosa harbored phosphoethanolamine transferases basS/pmrb, basR, arnA, cprR, cprS, alongside pmrB (G362S), and parS (H398R) mutations. Both strains carried diverse clinically relevant antimicrobial resistance genes (ARGs), including plasmid-mediated blaNDM-5 (K. pneumoniae ST147) and chromosomally mediated blaNDM-1 (P. aeruginosa ST357). CONCLUSION The global surge in MDR, XDR and PDR bacteria necessitates last-resort antibiotics such as colistin. However, escalating resistance, particularly to colistin, presents a critical challenge. Inefficient colistin resistance detection methods, including Vitek2, alongside limited surveillance resources, accentuate the need for improved strategies. Whole-genome sequencing revealed alarming colistin resistance among K. pneumoniae and P. aeruginosa in an Indian hospital. The identification of XDR and PDR strains underscores urgency for enhanced surveillance and infection control. SNP analysis elucidated resistance mechanisms, highlighting the complexity of combatting resistance.
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Affiliation(s)
- Absar Talat
- Medical Microbiology and Molecular Biology Lab, Interdisciplinary Biotechnology Unit, Aligarh Muslim University, Aligarh, 202002, India
| | - Fatima Khan
- Microbiology Department, JNMC and Hospital, Aligarh Muslim University, Aligarh, 202002, India
| | - Asad U Khan
- Medical Microbiology and Molecular Biology Lab, Interdisciplinary Biotechnology Unit, Aligarh Muslim University, Aligarh, 202002, India.
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Posteraro B, De Maio F, Motro Y, Menchinelli G, De Lorenzis D, Marano RBM, Aljanazreh B, Errico FM, Massaria G, Spanu T, Posteraro P, Moran-Gilad J, Sanguinetti M. In-depth characterization of multidrug-resistant NDM-1 and KPC-3 co-producing Klebsiella pneumoniae bloodstream isolates from Italian hospital patients. Microbiol Spectr 2024; 12:e0330523. [PMID: 38411998 PMCID: PMC10986569 DOI: 10.1128/spectrum.03305-23] [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: 09/07/2023] [Accepted: 02/04/2024] [Indexed: 02/28/2024] Open
Abstract
Bloodstream infection (BSI) caused by carbapenem-resistant Klebsiella pneumoniae (KP) poses significant challenges, particularly when the infecting isolate carries multiple antimicrobial resistance (AMR) genes/determinants. This study, employing short- and long-read whole-genome sequencing, characterizes six New Delhi metallo-β-lactamase (NDM) 1 and KP carbapenemase (KPC) 3 co-producing KP isolates, the largest cohort investigated in Europe to date. Five [sequence type (ST) 512] and one (ST11) isolates were recovered from patients who developed BSI from February to August 2022 or February 2023 at two different hospitals in Rome, Italy. Phylogenetic analysis revealed two distinct clusters among ST512 isolates and a separate cluster for the ST11 isolate. Beyond blaNDM-1 and blaKPC-3, various AMR genes, indicative of a multidrug resistance phenotype, including colistin resistance, were found. Each cluster-representative ST512 isolate harbored a blaNDM-1 plasmid (IncC) and a blaKPC-3 plasmid [IncFIB(pQil)/IncFII(K)], while the ST11 isolate harbored a blaNDM-1 plasmid [IncFII(pKPX1)] and a blaKPC-3 plasmid [IncFIB(K)/IncFII(K)]. The blaNDM-1 plasmids carried genes conferring resistance to clinically relevant antimicrobial agents, and the aminoglycoside resistance gene aac(6')-Ib was found on different plasmids. Colistin resistance-associated mgrB/pmrB gene mutations were present in all isolates, and the yersiniabactin-encoding ybt gene was unique to the ST11 isolate. In conclusion, our findings provide insights into the genomic context of blaNDM-1/blaKPC-3 carbapenemase-producing KP isolates.IMPORTANCEThis study underscores the critical role of genomic surveillance as a proactive measure to restrict the spread of carbapenemase-producing KP isolates, especially when key antimicrobial resistance genes, such as blaNDM-1/blaKPC-3, are plasmid borne. In-depth characterization of these isolates may help identify plasmid similarities contributing to their intra-hospital/inter-hospital adaptation and transmission. Despite the lack of data on patient movements, it is possible that carbapenem-resistant isolates were selected to co-produce KP carbapenemase and New Delhi metallo-β-lactamase via plasmid acquisition. Studies employing long-read whole-genome sequencing should be encouraged to address the emergence of KP clones with converging phenotypes of virulence and resistance to last-resort antimicrobial agents.
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Affiliation(s)
- Brunella Posteraro
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche Addominali ed Endocrino Metaboliche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Flavio De Maio
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Yair Motro
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Giulia Menchinelli
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Desy De Lorenzis
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Roberto B. M. Marano
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Bessan Aljanazreh
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Federica Maria Errico
- GVM - Ospedale San Carlo di Nancy, Laboratorio di Analisi Chimico-Cliniche e Microbiologiche, Rome, Italy
| | | | - Teresa Spanu
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Patrizia Posteraro
- GVM - Ospedale San Carlo di Nancy, Laboratorio di Analisi Chimico-Cliniche e Microbiologiche, Rome, Italy
| | - Jacob Moran-Gilad
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Maurizio Sanguinetti
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Diab H, Rahy K, Jisr T, El Chaar M, Abboud E, Tokajian S. Phenotypic and molecular characterization of multi-drug resistant Klebsiella spp. isolates recovered from clinical settings. INFECTION, GENETICS AND EVOLUTION : JOURNAL OF MOLECULAR EPIDEMIOLOGY AND EVOLUTIONARY GENETICS IN INFECTIOUS DISEASES 2024; 119:105583. [PMID: 38484958 DOI: 10.1016/j.meegid.2024.105583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/08/2024] [Accepted: 03/10/2024] [Indexed: 03/18/2024]
Abstract
Klebsiella pneumoniae is a Gram-negative bacterium that colonizes the gastrointestinal tract and nasopharynx with many being linked to nosocomial infections. Extended-spectrum β-lactamases (ESBL)-producing and carbapenem-resistant K. pneumoniae is recognized by the World Health Organization (WHO) as a critical public health concern. In this study, whole-genome sequencing (WGS) - based analysis was performed to understand the molecular epidemiology of multi-drug resistant Klebsiella spp. clinical isolates. Genome comparison, multi-locus sequence typing (MLST), pulsed-field gel electrophoresis (PFGE), and whole-genome-SNP-based phylogenetic analysis (wg-SNP) were used for in-depth molecular characterization. in silico typing was used to determine the resistance genes, virulence factors, Inc. groups, and capsular types. All except one isolate were non-susceptible to meropenem and 89% were non-susceptible to ertapenem and imipenem. blaNDM, blaOXA-48, and blaKPC were the detected carbapenemases with blaNDM-1 found in half of the sequenced genomes. Resistance to colistin was detected in one isolate and was linked to several genetic alterations in crrB, pmrB, and pmrC genes. The most common plasmid type was IncFIB followed by IncR, and the Type 3 fimbriae, encoded by the mrkABCDF operon, was conserved among all isolates. The most common sequence- (ST) and K-type detected were ST147 and K64. The prevelance and the genomic relatedness of ST147 isolates, as shown by the data from SNP-based phylogenetic analysis, PFGE, and genomic clustering, may be an outbreak marker. However, this can only be validated through a more comprehensive study encompassing a wider sampling scheme and over an extended timeframe.
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Affiliation(s)
- Hassan Diab
- Department of Natural Sciences, Lebanese American University, P.O. Box 36, Byblos, Lebanon
| | - Kelven Rahy
- Department of Computer Science and Mathematics, Lebanese American University, P.O. Box 36, Byblos, Lebanon
| | - Tamima Jisr
- Clinical Laboratory Department, Makassed General Hospital, P.O.Box 11-6301, Beirut, Lebanon
| | - Mira El Chaar
- Faculty of Health Sciences, University of Balamand, P.O.Box: 55251, Beirut, Lebanon
| | - Edmond Abboud
- Middle East Institute of Health Hospital, Clinical Laboratory Department, P.O.Box 60-387, Bsalim, Lebanon
| | - Sima Tokajian
- Department of Natural Sciences, Lebanese American University, P.O. Box 36, Byblos, Lebanon.
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Turton JF, Perry C, McGowan K, Turton JA, Hope R. Klebsiella pneumoniae sequence type 147: a high-risk clone increasingly associated with plasmids carrying both resistance and virulence elements. J Med Microbiol 2024; 73:001823. [PMID: 38629482 PMCID: PMC11084618 DOI: 10.1099/jmm.0.001823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 03/18/2024] [Indexed: 04/19/2024] Open
Abstract
Introduction. The first hybrid resistance/virulence plasmid, combining elements from virulence plasmids described in hypervirulent types of Klebsiella pneumoniae with those from conjugative resistance plasmids, was described in an isolate of sequence type (ST) 147 from 2016. Subsequently, this type has been increasingly associated with these plasmids.Hypothesis or gap statement. The extent of carriage of hybrid virulence/resistance plasmids in nosocomial isolates of K. pneumoniae requires further investigation.Aim. To describe the occurrence of virulence/resistance plasmids among isolates of K. pneumoniae received by the UK reference laboratory, particularly among representatives of ST147, and to compare their sequences.Methodology. Isolates received by the laboratory during 2022 and the first half of 2023 (n=1278) were screened for virulence plasmids by PCR detection of rmpA/rmpA2 and typed by variable-number tandem repeat analysis. Twenty-nine representatives of ST147 (including a single-locus variant) from seven hospital laboratories were subjected to long-read nanopore sequencing using high-accuracy q20 chemistry to provide complete assemblies.Results. rmpA/rmpA2 were detected in 110 isolates, of which 59 belonged to hypervirulent K1-ST23, K2-ST86 and K2-ST65/375. Of the remainder, representatives of ST147 formed the largest group, with 22 rmpA/rmpA2-positive representatives (out of 47 isolates). Representatives were from 19 hospital laboratories, with rmpA/rmpA2-positive isolates from 10. Nanopore sequencing of 29 representatives of ST147 divided them into those with no virulence plasmid (n=12), those with non-New Delhi metallo-β-lactamase (NDM) virulence plasmids (n=6) and those carrying bla NDM-5 (n=9) or bla NDM-1 (n=2) virulence plasmids. These plasmids were of IncFIB(pNDM-Mar)/IncHI1B(pNDM-MAR) replicon types. Most of the non-NDM virulence plasmids were highly similar to the originally described KpvST147L_NDM plasmid. Those carrying bla NDM-5 were highly similar to one another and to previously described plasmids in ST383 and carried an extensive array of resistance genes. Comparison of the fully assembled chromosomes indicated multiple introductions of ST147 in UK hospitals.Conclusion. This study highlights the high proportion of representatives of ST147 that carry IncFIB(pNDM-Mar)/IncHI1B(pNDM-MAR) hybrid resistance virulence plasmids. It is important to be aware of the high probability that representatives of this type carry these plasmids combining resistance and virulence determinants and of the consequent increased risk to patients.
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Affiliation(s)
- Jane F. Turton
- HealthCare Associated Infections, Fungal, Antimicrobial Resistance, Antimicrobial Use and Sepsis Division, UK Health Security Agency, 61, Colindale Avenue, London NW9 5HT, UK
| | - Claire Perry
- Public Health Microbiology, UK Health Security Agency, 61, Colindale Avenue, London NW9 5HT, UK
| | - Kim McGowan
- Public Health Microbiology, UK Health Security Agency, 61, Colindale Avenue, London NW9 5HT, UK
| | - Jack A. Turton
- HealthCare Associated Infections, Fungal, Antimicrobial Resistance, Antimicrobial Use and Sepsis Division, UK Health Security Agency, 61, Colindale Avenue, London NW9 5HT, UK
| | - Russell Hope
- HealthCare Associated Infections, Fungal, Antimicrobial Resistance, Antimicrobial Use and Sepsis Division, UK Health Security Agency, 61, Colindale Avenue, London NW9 5HT, UK
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Loconsole D, Sallustio A, Sacco D, Santantonio M, Casulli D, Gatti D, Accogli M, Parisi A, Zagaria R, Colella V, Centrone F, Chironna M. Genomic surveillance of carbapenem-resistant Klebsiella pneumoniae reveals a prolonged outbreak of extensively drug-resistant ST147 NDM-1 during the COVID-19 pandemic in the Apulia region (Southern Italy). J Glob Antimicrob Resist 2024; 36:260-266. [PMID: 38280719 DOI: 10.1016/j.jgar.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/22/2023] [Accepted: 01/18/2024] [Indexed: 01/29/2024] Open
Abstract
OBJECTIVES The recent worldwide spread of New Delhi metallo-beta-lactamase-producing Klebsiella pneumoniae (NDM-KP) in health-care settings remains a concern. The aim of the study was to describe an outbreak of extensively drug-resistant ST147 NDM-1-KP in the Apulia region of Southern Italy that occurred between 2020 and 2022 through genomic surveillance of carbapenem-resistant Enterobacterales. METHODS A total of 459 carbapenem-resistant KP isolates collected from patients hospitalised with bloodstream infections were tested using a commercial multiplex real-time polymerase chain reaction to identify carbapenemase genes. A subset of 27 isolates was subjected to whole-genome sequencing. Core-genome multilocus sequence typing was performed by analysing a panel of 4884 genes. RESULTS Molecular testing revealed that 104 (22.6%) isolates carried the carbapenemase NDM gene. Phylogenetic analysis of the 27 isolates subjected to whole-genome sequencing revealed high genetic relatedness among strains. All isolates were resistant to all first-line antibiotics. Virulome analysis identified the ybt locus, the two well-recognised virulence factors iucABCDiutA and rmpA, and the genes encoding the type 3 pilus virulence factor. Plasmids IncFIB(pkPHS1), IncFIB(pNDM-Mar), IncFIB(pQil), IncHI1B(pNDM-MAR), IncR, and Col(pHAD28) were identified in all isolates. Moreover, further analysis identified the IncFIB-type plasmid carrying the NDM-1 genes. CONCLUSION The increasing circulation of extensively drug-resistant NDM-1 ST147 KP strains in Southern Italy in recent years is worrisome, because these clones pose a real risk, particularly in hospital settings. Genomic surveillance is a crucial tool for early identification of emerging threats such as the spread of high-risk pathogens. Rapid infection control measures and antimicrobial stewardship are key to preventing further spread of hypervirulent KP strains.
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Affiliation(s)
- Daniela Loconsole
- Department of Interdisciplinary Medicine, Hygiene Section, University of Bari, Bari, Italy
| | - Anna Sallustio
- Hygiene Unit, Azienda Ospedaliero-Universitaria Consorziale Policlinico di Bari, Bari, Italy
| | - Davide Sacco
- Department of Interdisciplinary Medicine, Hygiene Section, University of Bari, Bari, Italy
| | - Marilina Santantonio
- Hygiene Unit, Azienda Ospedaliero-Universitaria Consorziale Policlinico di Bari, Bari, Italy
| | - Daniele Casulli
- Hygiene Unit, Azienda Ospedaliero-Universitaria Consorziale Policlinico di Bari, Bari, Italy
| | - Domenico Gatti
- Hygiene Unit, Azienda Ospedaliero-Universitaria Consorziale Policlinico di Bari, Bari, Italy
| | - Marisa Accogli
- Hygiene Unit, Azienda Ospedaliero-Universitaria Consorziale Policlinico di Bari, Bari, Italy
| | - Antonio Parisi
- Experimental Zooprophylactic Institute of Apulia and Basilicata, Foggia, Italy
| | - Riccardo Zagaria
- Department of Interdisciplinary Medicine, Hygiene Section, University of Bari, Bari, Italy
| | - Vito Colella
- Department of Interdisciplinary Medicine, Hygiene Section, University of Bari, Bari, Italy
| | - Francesca Centrone
- Hygiene Unit, Azienda Ospedaliero-Universitaria Consorziale Policlinico di Bari, Bari, Italy
| | - Maria Chironna
- Department of Interdisciplinary Medicine, Hygiene Section, University of Bari, Bari, Italy.
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13
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Tascini C, Coppi M, Antonelli A, Niccolai C, Bartolini A, Pecori D, Sartor A, Giani T, Rossolini GM. In vivo evolution to high-level cefiderocol resistance of NDM-1-producing Klebsiella pneumoniae, followed by intra-hospital cross-transmission. Clin Microbiol Infect 2024; 30:398-400. [PMID: 37979689 DOI: 10.1016/j.cmi.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/06/2023] [Accepted: 11/08/2023] [Indexed: 11/20/2023]
Affiliation(s)
- Carlo Tascini
- Infectious Diseases Clinic, Department of Medicine, University of Udine, Udine, Italy
| | - Marco Coppi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
| | - Alberto Antonelli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
| | - Claudia Niccolai
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
| | - Andrea Bartolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
| | - Davide Pecori
- Infectious Diseases Clinic, Department of Medicine, University of Udine, Udine, Italy
| | - Assunta Sartor
- Clinical Microbiology, Udine University Hospital, Udine, Italy
| | - Tommaso Giani
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy.
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14
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Antonelli A, Coppi M, Bonaiuto C, Giovacchini N, Vaggelli G, Farese A, Pollini S, Rossolini GM. Novel resistance ICEs carrying the blaFIM-1 metallo-β-lactamase gene from an ST235 Pseudomonas aeruginosa sublineage. Antimicrob Agents Chemother 2024; 68:e0120523. [PMID: 38206043 PMCID: PMC10848763 DOI: 10.1128/aac.01205-23] [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: 09/18/2023] [Accepted: 11/29/2023] [Indexed: 01/12/2024] Open
Abstract
FIM-1 is an acquired metallo-β-lactamase identified in a multidrug-resistant Pseudomonas aeruginosa (index strain FI-14/157) of clinical origin isolated in 2007 in Florence, Italy. Here we report on a second case of infection by FIM-1-positive P. aeruginosa (FI-17645), which occurred in 2020 in the same hospital. Both FIM-1-positive strains exhibited resistance to all anti-Pseudomonas antibiotics except colistin and cefiderocol. Comparative genomic characterization revealed that the two FIM-positive strains were closely related [core genome difference, 16 single nucleotide polymorphisms (SNPs)], suggesting a local circulation of similar strains. In the FI-14/157 index strain, the blaFIM-1 gene was associated with an ISCR19-like element that likely contributed to its capture downstream an integron platform inserted aboard a Tn21-like transposon, named Tn7703.1, which was associated with a large integrative and conjugative element (ICE) named ICE7705.1, integrated into an att site located within the 3'-end of tRNAGly CCC gene of the P. aeruginosa chromosome. In strain FI-17645, blaFIM-1 was associated with a closely related ICE, named ICE7705.2, integrated in the same chromosomal site. Similar ICE platforms, lacking the blaFIM-1-containing region, were detected in other ST235 P. aeruginosa strains from different geographic areas, suggesting a common ancestry and underscoring the role of these elements in the dissemination of resistance genes in P. aeruginosa. Sequence database mining revealed two draft P. aeruginosa genomes, one from Italy and one from the USA (both isolated in 2012), including a contig with blaFIM-1, suggesting that this resistance gene could have a broader distribution than originally anticipated.
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Affiliation(s)
- Alberto Antonelli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy
| | - Marco Coppi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy
| | - Chiara Bonaiuto
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy
| | - Nicla Giovacchini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Guendalina Vaggelli
- Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy
| | - Alberto Farese
- Infectious and Tropical Diseases Unit, Florence Careggi University Hospital, Florence, Italy
| | - Simona Pollini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy
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15
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Karakonstantis S, Rousaki M, Vassilopoulou L, Kritsotakis EI. Global prevalence of cefiderocol non-susceptibility in Enterobacterales, Pseudomonas aeruginosa, Acinetobacter baumannii, and Stenotrophomonas maltophilia: a systematic review and meta-analysis. Clin Microbiol Infect 2024; 30:178-188. [PMID: 37666449 DOI: 10.1016/j.cmi.2023.08.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 08/14/2023] [Accepted: 08/30/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Cefiderocol is a last resort option for carbapenem-resistant (CR) Gram-negative bacteria, especially metallo-β-lactamase-producing Pseudomonas aeruginosa and CR Acinetobacter baumannii. Monitoring global levels of cefiderocol non-susceptibility (CFDC-NS) is important. OBJECTIVES To systematically collate and examine studies investigating in vitro CFDC-NS and estimate the global prevalence of CFDC-NS against major Gram-negative pathogens. DATA SOURCES PubMed and Scopus, up to May 2023. STUDY ELIGIBILITY CRITERIA Eligible were studies reporting CFDC-NS in Enterobacterales, P. aeruginosa, A. baumannii, or Stenotrophomonas maltophilia clinical isolates. RISK-OF-BIAS ASSESSMENT Two independent reviewers extracted study data and assessed the risk of bias on the population, setting, and measurement (susceptibility testing) domains. DATA SYNTHESIS Binomial-Normal mixed-effects models were applied to estimate CFDC-NS prevalence by species, coresistance phenotype, and breakpoint definition (EUCAST, CLSI, and FDA). Sources of heterogeneity were investigated by subgroup and meta-regression analyses. RESULTS In all, 78 studies reporting 82 035 clinical isolates were analysed (87% published between 2020 and 2023). CFDC-NS prevalence (EUCAST breakpoints) was low overall but varied by species (S. maltophilia 0.4% [95% CI 0.2-0.7%], Enterobacterales 3.0% [95% CI 1.5-6.0%], P. aeruginosa 1.4% [95% CI 0.5-4.0%]) and was highest for A. baumannii (8.8%, 95% CI 4.9-15.2%). CFDC-NS was much higher in CR Enterobacterales (12.4%, 95% CI 7.3-20.0%) and CR A. baumannii (13.2%, 95% CI 7.8-21.5%), but relatively low for CR P. aeruginosa (3.5%, 95% CI 1.6-7.8%). CFDC-NS was exceedingly high in New Delhi metallo-β-lactamase-producing Enterobacterales (38.8%, 95% CI 22.6-58.0%), New Delhi metallo-β-lactamase-producing A. baumannii (44.7%, 95% CI 34.5-55.4%), and ceftazidime/avibactam-resistant Enterobacterales (36.6%, 95% CI 22.7-53.1%). CFDC-NS varied considerably with breakpoint definition, predominantly among CR bacteria. Additional sources of heterogeneity were single-centre investigations and geographical regions. CONCLUSIONS CFDC-NS prevalence is low overall, but alarmingly high for specific CR phenotypes circulating in some institutions or regions. Continuous surveillance and updating of global CFDC-NS estimates are imperative while cefiderocol is increasingly introduced into clinical practice. The need to harmonize EUCAST and CLSI breakpoints was evident.
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Affiliation(s)
- Stamatis Karakonstantis
- Internal Medicine Department, Infectious Diseases Division, University Hospital of Heraklion, Crete, Greece
| | - Maria Rousaki
- Master of Public Health Program, Department of Social Medicine, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Loukia Vassilopoulou
- 2nd Department of Internal Medicine, Venizeleio-Pananeio General Hospital, Heraklion, Crete, Greece
| | - Evangelos I Kritsotakis
- Laboratory of Biostatistics, Department of Social Medicine, School of Medicine, University of Crete, Heraklion, Crete, Greece; School of Health and Related Research, Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, UK.
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16
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Merla C, Kuka A, Mileto I, Petazzoni G, Gaiarsa S, De Vitis D, Ardizzone M, Corbella M, Baldanti F, Cambieri P. One-year surveillance for hypervirulent Klebsiella pneumoniae detected carbapenem-resistant superbugs. Microbiol Spectr 2024; 12:e0329223. [PMID: 38289935 PMCID: PMC10913487 DOI: 10.1128/spectrum.03292-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/25/2023] [Indexed: 02/01/2024] Open
Abstract
Hypervirulent Klebsiella pneumoniae (hvKp) can cause infections in clinically healthy people, such as young and immunocompetent patients. Genes involved in the capsule synthesis or those encoding the siderophores have been adopted as predictors of hvKp. Certain sequence types, such as ST23 and ST86, have been associated with hvKp strains, too. The aim of this study was to investigate the presence of hvKp among 354 K. pneumoniae strains isolated from clinical samples of patients admitted to an Italian 900-bed hospital between 21 May 2021 and April 2022. All the isolates were screened by PCR for the amplification of virulence loci. Whole genome sequencing was performed in strains tested positive for at least one target gene. Thirteen out of 354 (3.7%) were hvKp. Five were wild type and belonged to the hypervirulent clones ST23, ST86, ST5, and ST375 and to the new clone ST6310. Six strains carried the blaKPC gene: three belonged to ST101, two to ST512, and one to ST395. Two isolates were ST147 and carried the blaNDM gene. Although hvKp isolation is not frequent, their presence should be systematically investigated to avoid the spreading of both virulent strains and strains with combined increase in virulence and resistance to antibiotics. PCR-based protocols are essential for surveillance of these strains, which do not always show a recognizable phenotype. Moreover, hvKp strains were isolated also from patients without history of recent foreign travels, indicating an increased spreading of these strains as well as an underestimated of their circulation so far.IMPORTANCEKlebsiella pneumoniae is a healthcare-associated pathogen frequently resistant to antibiotics. Hypervirulent strains of pneumoniae (hvKp) can spread from the primary site of infection to multiple sites causing life-threatening infections also in young otherwise healthy individuals. This study described the isolation of 13 isolates of K. pneumoniae with increased virulence in a large tertiary hospital over a 1-year period. Among them, eight strains were multidrug resistant and hypervirulent. Although these hypervirulent strains are still rare in Italy, their presence is particularly concerning since they can cause difficult-to-treat life-threatening infections. Moreover, not all the hypervirulent isolates were positive by the string test, so hvKp isolates were not always phenotypically detectable. Molecular biology techniques such as PCR amplification and next generation sequencing are therefore necessary for the detection of hvKp isolates, and surveillance programs exploiting molecular techniques are highly desirable.
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Affiliation(s)
- C Merla
- Struttura Complessa di Microbiologia e Virologia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - A Kuka
- Struttura Complessa di Microbiologia e Virologia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - I Mileto
- Struttura Complessa di Microbiologia e Virologia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Scuola di Specializzazione in Microbiologia e Virologia, Università degli Studi di Pavia, Pavia, Italy
| | - G Petazzoni
- Struttura Complessa di Microbiologia e Virologia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Dipartimento di Scienze Clinico-Chirurgiche, Diagnostiche e Pediatriche, Università degli Studi di Pavia, Pavia, Italy
| | - S Gaiarsa
- Struttura Complessa di Microbiologia e Virologia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - D De Vitis
- Struttura Complessa di Microbiologia e Virologia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - M Ardizzone
- Struttura Complessa di Microbiologia e Virologia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - M Corbella
- Struttura Complessa di Microbiologia e Virologia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - F Baldanti
- Struttura Complessa di Microbiologia e Virologia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Dipartimento di Scienze Clinico-Chirurgiche, Diagnostiche e Pediatriche, Università degli Studi di Pavia, Pavia, Italy
| | - P Cambieri
- Struttura Complessa di Microbiologia e Virologia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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17
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Kim SJ, Shin JH, Kim H, Ko KS. Roles of crrAB two-component regulatory system in Klebsiella pneumoniae: growth yield, survival in initial colistin treatment stage, and virulence. Int J Antimicrob Agents 2024; 63:107011. [PMID: 37863340 DOI: 10.1016/j.ijantimicag.2023.107011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 10/09/2023] [Accepted: 10/14/2023] [Indexed: 10/22/2023]
Abstract
OBJECTIVES Alternation of the colistin resistance-regulating two-component regulatory system (crrAB) is a colistin-resistance mechanism in Klebsiella pneumoniae (K. pneumoniae), but its role in bacteria is not fully understood. METHODS Twelve colistin-susceptible K. pneumoniae clinical isolates were included in this study: six crrAB-positive and six crrAB-negative. We deleted the crrAB genes from two crrAB-positive isolates and complemented them. We measured the growth yields by determining growth curves in lysogeny broth and minimal media with or without Fe2+. In vitro selection rates for colistin resistance were determined by exposure to colistin, and survival rates against high concentrations of colistin (20 mg/L) at the early stage of growth (20 min) were investigated. Virulence was determined using a serum bactericidal assay and Galleria mellonella larval infection. RESULTS The presence of crrAB was not associated with colistin resistance and did not increase the in vitro selection rate of colistin resistance after exposure. The growth yield of crrAB-positive isolates was higher in lysogeny broth media and increased when Fe2+ was added to minimal media. The crrAB-positive isolates showed higher survival rates in the early stages of exposure to high colistin concentrations. Decreased serum resistance was identified in the crrAB-deleted mutants. More G. mellonella larvae survived when infected by crrAB-deleted mutants, and higher survival rates of bacteria were identified within the larvae infected with wild-type than crrAB-deletant isolates. CONCLUSION Through rapid response to external signals, crrAB would provide advantages for K. pneumoniae survival by increasing the final growth yield and initial survival against colistin treatment. This may partly contribute to the bacterial virulence.
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Affiliation(s)
- Sun Ju Kim
- Department of Microbiology, Sungkyunkwan University School of Medicine, Suwon, Republic of Korea; School of Pharmacy, Sungkyunkwan University, Suwon, Republic of Korea
| | - Jong Hyun Shin
- Department of Microbiology, Sungkyunkwan University School of Medicine, Suwon, Republic of Korea
| | - Hyunkeun Kim
- Department of Microbiology, Sungkyunkwan University School of Medicine, Suwon, Republic of Korea
| | - Kwan Soo Ko
- Department of Microbiology, Sungkyunkwan University School of Medicine, Suwon, Republic of Korea.
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18
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Diamant I, Adani B, Sylman M, Rahav G, Gal-Mor O. The transcriptional regulation of the horizontally acquired iron uptake system, yersiniabactin and its contribution to oxidative stress tolerance and pathogenicity of globally emerging salmonella strains. Gut Microbes 2024; 16:2369339. [PMID: 38962965 PMCID: PMC11225919 DOI: 10.1080/19490976.2024.2369339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 06/12/2024] [Indexed: 07/05/2024] Open
Abstract
The bacterial species Salmonella enterica (S. enterica) is a highly diverse pathogen containing more than 2600 distinct serovars, which can infect a wide range of animal and human hosts. Recent global emergence of multidrug resistant strains, from serovars Infantis and Muenchen is associated with acquisition of the epidemic megaplasmid, pESI that augments antimicrobial resistance and pathogenicity. One of the main pESI's virulence factors is the potent iron uptake system, yersiniabactin encoded by fyuA, irp2-irp1-ybtUTE, ybtA, and ybtPQXS gene cluster. Here we show that yersiniabactin, has an underappreciated distribution among different S. enterica serovars and subspecies, integrated in their chromosome or carried by different conjugative plasmids, including pESI. While the genetic organization and the coding sequence of the yersiniabactin genes are generally conserved, a 201-bp insertion sequence upstream to ybtA, was identified in pESI. Despite this insertion, pESI-encoded yersiniabactin is regulated by YbtA and the ancestral Ferric Uptake Regulator (Fur), which binds directly to the ybtA and irp2 promoters. Furthermore, we show that yersiniabactin genes are specifically induced during the mid-late logarithmic growth phase and in response to iron-starvation or hydrogen peroxide. Concurring, yersiniabactin was found to play a previously unknown role in oxidative stress tolerance and to enhance intestinal colonization of S. Infantis in mice. These results indicate that yersiniabactin contributes to Salmonella fitness and pathogenicity in vivo and is likely to play a role in the rapid dissemination of pESI among globally emerging Salmonella lineages.
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Affiliation(s)
- Imbar Diamant
- The Infectious Diseases Research Laboratory, Sheba Medical Center, Tel-Hashomer, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Boaz Adani
- The Infectious Diseases Research Laboratory, Sheba Medical Center, Tel-Hashomer, Israel
| | - Meir Sylman
- The Infectious Diseases Research Laboratory, Sheba Medical Center, Tel-Hashomer, Israel
| | - Galia Rahav
- The Infectious Diseases Research Laboratory, Sheba Medical Center, Tel-Hashomer, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ohad Gal-Mor
- The Infectious Diseases Research Laboratory, Sheba Medical Center, Tel-Hashomer, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Clinical Microbiology and Immunology, Tel Aviv University, Tel Aviv, Israel
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19
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Di Pilato V, Pollini S, Miriagou V, Rossolini GM, D'Andrea MM. Carbapenem-resistant Klebsiella pneumoniae: the role of plasmids in emergence, dissemination, and evolution of a major clinical challenge. Expert Rev Anti Infect Ther 2024; 22:25-43. [PMID: 38236906 DOI: 10.1080/14787210.2024.2305854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/11/2024] [Indexed: 01/31/2024]
Abstract
INTRODUCTION Klebsiella pneumoniae is a major agent of healthcare-associated infections and a cause of some community-acquired infections, including severe bacteremic infections associated with metastatic abscesses in liver and other organs. Clinical relevance is compounded by its outstanding propensity to evolve antibiotic resistance. In particular, the emergence and dissemination of carbapenem resistance in K. pneumoniae has posed a major challenge due to the few residual treatment options, which have only recently been expanded by some new agents. The epidemiological success of carbapenem-resistant K. pneumoniae (CR-Kp) is mainly linked with clonal lineages that produce carbapenem-hydrolyzing enzymes (carbapenemases) encoded by plasmids. AREAS COVERED Here, we provide an updated overview on the mechanisms underlying the emergence and dissemination of CR-Kp, focusing on the role that plasmids have played in this phenomenon and in the co-evolution of resistance and virulence in K. pneumoniae. EXPERT OPINION CR-Kp have disseminated on a global scale, representing one of the most important contemporary public health issues. These strains are almost invariably associated with complex multi-drug resistance (MDR) phenotypes, which can also include recently approved antibiotics. The heterogeneity of the molecular bases responsible for these phenotypes poses significant hurdles for therapeutic and diagnostic purposes.
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Affiliation(s)
- Vincenzo Di Pilato
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Simona Pollini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
| | - Vivi Miriagou
- Laboratory of Bacteriology, Hellenic Pasteur Institute, Athens, Greece
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
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20
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Mileto I, Petazzoni G, Corbella M, Gaiarsa S, Merla C, Kuka A, Ramus M, Terulla C, Brandolini M, Piralla A, Cambieri P, Baldanti F. Rapid spread of a novel NDM-producing clone of Klebsiella pneumoniae CC147, Northern Italy, February to August 2023. Euro Surveill 2023; 28:2300522. [PMID: 37855902 PMCID: PMC10588309 DOI: 10.2807/1560-7917.es.2023.28.42.2300522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 10/18/2023] [Indexed: 10/20/2023] Open
Abstract
New Delhi metallo-beta-lactamase (NDM)-producing Klebsiella pneumoniae (Kp) ST147 caused a large multi-hospital outbreak in Italy from 2018 to 2021. We describe a new ST6668 NDM-producing Kp clone, belonging to CC147, which rapidly spread across hospitals in the Pavia province (Northern Italy) from February to August 2023. Genomic analyses revealed that ST6668 is different from ST147 and fast evolving. As shown here, genomic surveillance programmes are useful for tracking the spread of new clones with reduced susceptibility to most antibiotics.
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Affiliation(s)
- Irene Mileto
- Microbiology and Virology Unit, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
- Specialization School of Microbiology and Virology, University of Pavia, Pavia, Italy
- These authors have contributed equally
| | - Greta Petazzoni
- Microbiology and Virology Unit, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- These authors have contributed equally
| | - Marta Corbella
- Microbiology and Virology Unit, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Stefano Gaiarsa
- Microbiology and Virology Unit, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Cristina Merla
- Microbiology and Virology Unit, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Angela Kuka
- Microbiology and Virology Unit, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Marina Ramus
- Microbiology and Virology Unit, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
- Specialization School of Microbiology and Virology, University of Pavia, Pavia, Italy
| | | | - Micaela Brandolini
- ASST Pavia, Ospedale Unificato Broni-Stradella, Internal Medicine Unit, Stradella, Italy
| | - Antonio Piralla
- Microbiology and Virology Unit, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Patrizia Cambieri
- Microbiology and Virology Unit, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
- These authors contributed equally to the work and share the last authorship
| | - Fausto Baldanti
- Microbiology and Virology Unit, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- These authors contributed equally to the work and share the last authorship
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21
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Emeraud C, Mahamat A, Jousset AB, Bernabeu S, Goncalves T, Pommier C, Girlich D, Birer A, Rodriguez C, Pawlotsky JM, Naas T, Bonnin RA, Dortet L. Emergence and rapid dissemination of highly resistant NDM-14-producing Klebsiella pneumoniae ST147, France, 2022. Euro Surveill 2023; 28:2300095. [PMID: 37855905 PMCID: PMC10588306 DOI: 10.2807/1560-7917.es.2023.28.42.2300095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 06/26/2023] [Indexed: 10/20/2023] Open
Abstract
BackgroundSince 2021, an emergence of New Delhi metallo-β-lactamase (NDM)-14-producing Klebsiella pneumoniae has been identified in France. This variant with increased carbapenemase activity was not previously detected in Enterobacterales.AimWe investigated the rapid dissemination of NDM-14 producers among patients in hospitals in France.MethodsAll NDM-14-producing non-duplicate clinical isolates identified in France until June 2022 (n = 37) were analysed by whole genome sequencing. The phylogeny of NDM-14-producers among all K. pneumoniae sequence type (ST) 147 reported in France since 2014 (n = 431) was performed. Antimicrobial susceptibility testing, conjugation experiments, clonal relationship and molecular clock analysis were performed.ResultsThe 37 NDM-14 producers recovered in France until 2022 belonged to K. pneumoniae ST147. The dissemination of NDM-14-producing K. pneumoniae was linked to a single clone, likely imported from Morocco and responsible for several outbreaks in France. The gene bla NDM-14 was harboured on a 54 kilobase non-conjugative IncFIB plasmid that shared high homology with a known bla NDM-1-carrying plasmid. Using Bayesian analysis, we estimated that the NDM-14-producing K. pneumoniae ST147 clone appeared in 2020. The evolutionary rate of this clone was estimated to 5.61 single nucleotide polymorphisms per genome per year. The NDM-14 producers were highly resistant to all antimicrobials tested except to colistin, cefiderocol (minimum inhibitory concentration 2 mg/L) and the combination of aztreonam/avibactam.ConclusionHighly resistant NDM-14 producing K. pneumoniae can rapidly spread in healthcare settings. Surveillance and thorough investigations of hospital outbreaks are critical to evaluate and limit the dissemination of this clone.
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Affiliation(s)
- Cécile Emeraud
- Department of Bacteriology-Hygiene, Bicêtre Hospital, Assistance Publique - Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- UMR-1184, INSERM, University Paris-Saclay, CEA, Faculty of Medicine, Le Kremlin-Bicêtre, France
- French National Reference Center for Antibiotic Resistance, Le Kremlin-Bicêtre, France
| | - Aba Mahamat
- Corsica Centre for Healthcare-Associated Infections Control and Prevention, Hôpital Eugénie, Ajaccio, France
| | - Agnès B Jousset
- Department of Bacteriology-Hygiene, Bicêtre Hospital, Assistance Publique - Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- UMR-1184, INSERM, University Paris-Saclay, CEA, Faculty of Medicine, Le Kremlin-Bicêtre, France
- French National Reference Center for Antibiotic Resistance, Le Kremlin-Bicêtre, France
| | - Sandrine Bernabeu
- Department of Bacteriology-Hygiene, Bicêtre Hospital, Assistance Publique - Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- UMR-1184, INSERM, University Paris-Saclay, CEA, Faculty of Medicine, Le Kremlin-Bicêtre, France
| | - Tania Goncalves
- Department of Bacteriology-Hygiene, Bicêtre Hospital, Assistance Publique - Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Camille Pommier
- Department of Bacteriology-Hygiene, Bicêtre Hospital, Assistance Publique - Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Delphine Girlich
- UMR-1184, INSERM, University Paris-Saclay, CEA, Faculty of Medicine, Le Kremlin-Bicêtre, France
| | - Aurélien Birer
- Centre National de Référence de la Résistance aux antibiotiques, Service de Bactériologie, CHU Gabriel-Montpied, Clermont-Ferrand, France
| | - Christophe Rodriguez
- Université Paris-Est-Créteil (UPEC), Créteil, France
- Department of Virology, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
- INSERM U955, Team Viruses, Hepatology, Cancer, Créteil, France
| | - Jean-Michel Pawlotsky
- Université Paris-Est-Créteil (UPEC), Créteil, France
- Department of Virology, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
- INSERM U955, Team Viruses, Hepatology, Cancer, Créteil, France
| | - Thierry Naas
- Department of Bacteriology-Hygiene, Bicêtre Hospital, Assistance Publique - Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- UMR-1184, INSERM, University Paris-Saclay, CEA, Faculty of Medicine, Le Kremlin-Bicêtre, France
- French National Reference Center for Antibiotic Resistance, Le Kremlin-Bicêtre, France
| | - Rémy A Bonnin
- UMR-1184, INSERM, University Paris-Saclay, CEA, Faculty of Medicine, Le Kremlin-Bicêtre, France
- French National Reference Center for Antibiotic Resistance, Le Kremlin-Bicêtre, France
| | - Laurent Dortet
- Department of Bacteriology-Hygiene, Bicêtre Hospital, Assistance Publique - Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- UMR-1184, INSERM, University Paris-Saclay, CEA, Faculty of Medicine, Le Kremlin-Bicêtre, France
- French National Reference Center for Antibiotic Resistance, Le Kremlin-Bicêtre, France
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22
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Fabricci M, Trinca A, Talotti L, Busetti M, Fotakis EA, Merakou C, Koncan R, Ghiotti A, Negri C, Di Maso V, Bosco M, Antonelli A, Coppi M, Rossolini GM, Giuliani C, Scarpis E, Gregoretti B, Licastro D, Luzzati R, Costantino V. A urokinase-associated outbreak of Ralstonia mannitolilytica bloodstream infections in haemodialysis patients in north-eastern Italy, January to April 2023. Euro Surveill 2023; 28:2300328. [PMID: 37440346 PMCID: PMC10347894 DOI: 10.2807/1560-7917.es.2023.28.28.2300328] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 07/13/2023] [Indexed: 07/15/2023] Open
Abstract
An outbreak of Ralstonia mannitolilytica bloodstream infections occurred in four hospitals in north-eastern Italy, involving 20 haemodialysis patients with tunnelled central vascular catheter access. We identified as the outbreak source a batch of urokinase vials imported from India contaminated with R. mannitolilytica. Whole genome sequences of the clinical and urokinase strains were highly related, and only urokinase-treated patients were reported with R. mannitolilytica infections (attack rate = 34%; 95% confidence interval: 22.1-47.4). Discontinuation of the contaminated urokinase terminated the outbreak.
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Affiliation(s)
| | - Anaïs Trinca
- Clinical Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Luca Talotti
- Clinical Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Marina Busetti
- Microbiology Unit, Trieste University Hospital (ASUGI), Trieste, Italy
| | - Emmanouil Alexandros Fotakis
- ECDC Fellowship Programme, Field Epidemiology path (EPIET), European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
- Italian National Institute of health (ISS), Rome, Italy
| | - Christina Merakou
- Italian National Institute of health (ISS), Rome, Italy
- ECDC fellowship Programme, Public Health Microbiology path (EUPHEM), European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
| | - Raffaella Koncan
- Clinical Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | | | - Camilla Negri
- Medical Directorate, Gorizia and Monfalcone Hospital (ASUGI), Gorizia and Monfalcone, Italy
| | - Vittorio Di Maso
- Nephrology and Dialysis Unit, Trieste University Hospital (ASUGI), Trieste, Italy
| | - Manuela Bosco
- Nephrology and Dialysis Unit, Gorizia and Monfalcone Hospital (ASUGI), Gorizia and Monfalcone, Italy
| | - Alberto Antonelli
- Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Marco Coppi
- Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Gian Maria Rossolini
- Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Claudia Giuliani
- Medical Directorate, Palmanova Hospital (ASUFC), Palmanova, Italy
| | - Enrico Scarpis
- Medical Directorate, Palmanova Hospital (ASUFC), Palmanova, Italy
| | - Barbara Gregoretti
- Medical Directorate, Trieste University Hospital (ASUGI), Trieste, Italy
| | | | - Roberto Luzzati
- Infectious Diseases Unit, Trieste University Hospital (ASUGI), Trieste, Italy
- Clinical Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Venera Costantino
- Microbiology Unit, Trieste University Hospital (ASUGI), Trieste, Italy
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23
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Arcari G, Carattoli A. Global spread and evolutionary convergence of multidrug-resistant and hypervirulent Klebsiella pneumoniae high-risk clones. Pathog Glob Health 2023; 117:328-341. [PMID: 36089853 PMCID: PMC10177687 DOI: 10.1080/20477724.2022.2121362] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
For people living in developed countries life span is growing at a faster pace than ever. One of the main reasons for such success is attributable to the introduction and extensive use in the clinical practice of antibiotics over the course of the last seven decades. In hospital settings, Klebsiella pneumoniae represents a well-known and commonly described opportunistic pathogen, typically characterized by resistance to several antibiotic classes. On the other hand, the broad wedge of population living in Low and/or Middle Income Countries is increasing rapidly, allowing the spread of several commensal bacteria which are transmitted via human contact. Community transmission has been the original milieu of K. pneumoniae isolates characterized by an outstanding virulence (hypervirulent). These two characteristics, also defined as "pathotypes", originally emerged as different pathways in the evolutionary history of K. pneumoniae. For a long time, the Sequence Type (ST), which is defined by the combination of alleles of the 7 housekeeping genes of the Multi-Locus Sequence Typing, has been a reliable marker of the pathotype: multidrug-resistant clones (e.g. ST258, ST147, ST101) in the Western world and hypervirulent clones (e.g. ST23, ST65, ST86) in the Eastern. Currently, the boundaries separating the two pathotypes are fading away due to several factors, and we are witnessing a worrisome convergence in certain high-risk clones. Here we review the evidence available on confluence of multidrug-resistance and hypervirulence in specific K. pneumoniae clones.
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Affiliation(s)
- Gabriele Arcari
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
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24
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Zarras C, Karampatakis T, Pappa S, Iosifidis E, Vagdatli E, Roilides E, Papa A. Genetic Characterization of Carbapenem-Resistant Klebsiella pneumoniae Clinical Isolates in a Tertiary Hospital in Greece, 2018-2022. Antibiotics (Basel) 2023; 12:976. [PMID: 37370295 DOI: 10.3390/antibiotics12060976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 05/23/2023] [Accepted: 05/25/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Carbapenem-resistant Klebsiella pneumoniae (CRKP) is a serious public health issue. The study aimed to identify the antimicrobial resistance and accessory genes, the clonal relatedness, and the evolutionary dynamics of selected CRKP isolates recovered in an adult and pediatric intensive care unit of a tertiary hospital in Greece. METHODS Twenty-four CRKP isolates recovered during 2018-2022 were included in the study. Next-generation sequencing was performed using the Ion Torrent PGM Platform. The identification of the plasmid content, MLST, and antimicrobial resistance genes, as well as the comparison of multiple genome alignments and the identification of core genome single-nucleotide polymorphism sites, were performed using various bioinformatics software. RESULTS The isolates belonged to eight sequence types: 11, 15, 30, 35, 39, 307, 323, and 512. A variety of carbapenemases (KPC, VIM, NDM, and OXA-48) and resistance genes were detected. CRKP strains shared visually common genomic regions with the reference strain (NTUH-K2044). ST15, ST323, ST39, and ST11 CRKP isolates presented on average 17, 6, 16, and 866 recombined SNPs, respectively. All isolates belonging to ST15, ST323, and ST39 were classified into distinct phylogenetic branches, while ST11 isolates were assigned to a two-subclade branch. For large CRKP sets, the phylogeny seems to change approximately every seven SNPs. CONCLUSIONS The current study provides insight into the genetic characterization of CRKP isolates in the ICUs of a tertiary hospital. Our results indicate clonal dispersion of ST15, ST323, and ST39 and highly diverged ST11 isolates.
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Affiliation(s)
- Charalampos Zarras
- Department of Microbiology, Medical Faculty, School of Health Sciences, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece
- Microbiology Department, Hippokration General Hospital, 546 42 Thessaloniki, Greece
| | - Theodoros Karampatakis
- Department of Microbiology, Medical Faculty, School of Health Sciences, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece
| | - Styliani Pappa
- Department of Microbiology, Medical Faculty, School of Health Sciences, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece
| | - Elias Iosifidis
- Infectious Disease Unit, 3rd Department of Pediatrics, Medical Faculty, School of Health Sciences, Hippokration General Hospital, 546 42 Thessaloniki, Greece
| | - Eleni Vagdatli
- Microbiology Department, Hippokration General Hospital, 546 42 Thessaloniki, Greece
| | - Emmanuel Roilides
- Infectious Disease Unit, 3rd Department of Pediatrics, Medical Faculty, School of Health Sciences, Hippokration General Hospital, 546 42 Thessaloniki, Greece
| | - Anna Papa
- Department of Microbiology, Medical Faculty, School of Health Sciences, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece
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25
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Rödel J, Pfeifer Y, Fischer MA, Edel B, Stoll S, Pfister W, Löffler B. Screening of Klebsiella pneumoniae Isolates for Carbapenemase and Hypervirulence-Associated Genes by Combining the Eazyplex ® Superbug CRE and hvKp Assays. Antibiotics (Basel) 2023; 12:959. [PMID: 37370278 DOI: 10.3390/antibiotics12060959] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 05/22/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023] Open
Abstract
The acquisition of hypervirulence-associated genes by carbapenemase-producing Klebsiella pneumoniae is being increasingly observed, and easy-to-use diagnostic tests are needed for the surveillance of the hypervirulent K. pneumoniae (hvKp). In this pilot study, 87 K. pneumoniae isolates from invasive infections collected in 2022 and 2023 were analysed using the LAMP-based eazyplex® Superbug CRE and hvKp assays for the simultaneous identification of carbapenemases and virulence genes (rmpA/A2, iuC, iroC, ybt, clb). Nine isolates showed a Kleborate virulence score of 4 or 5 (10.3%). The time for the results of the eazyplex® assays ranged from 6.5 to 13 min, and the total turnaround time, including sample preparation, was less than 30 min. Five isolates, three of which produced New Delhi metallo-beta lactamase (NDM), were subjected to whole-genome sequencing (WGS) analysis for further characterisation. The eazyplex® test results for beta-lactamase and virulence genes were confirmed. The eazyplex® hvKp, currently only available as a Research Use Only assay, may be a useful tool for the rapid identification of hvKp without significant additional workload when combined with the eazyplex® Superbug CRE assay for the detection of carbapenemases.
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Affiliation(s)
- Jürgen Rödel
- Institute of Medical Microbiology, Jena University Hospital, Friedrich Schiller University, 07747 Jena, Germany
| | - Yvonne Pfeifer
- Division Nosocomial Pathogens and Antibiotic Resistance, Department of Infectious Diseases, Robert Koch Institute, 38855 Wernigerode, Germany
| | - Martin A Fischer
- Division Nosocomial Pathogens and Antibiotic Resistance, Department of Infectious Diseases, Robert Koch Institute, 38855 Wernigerode, Germany
| | - Birgit Edel
- Institute of Medical Microbiology, Jena University Hospital, Friedrich Schiller University, 07747 Jena, Germany
| | - Sylvia Stoll
- Institute of Medical Microbiology, Jena University Hospital, Friedrich Schiller University, 07747 Jena, Germany
| | - Wolfgang Pfister
- Department of Hospital Hygiene, Sophien-und Hufeland-Klinikum, 99425 Weimar, Germany
| | - Bettina Löffler
- Institute of Medical Microbiology, Jena University Hospital, Friedrich Schiller University, 07747 Jena, Germany
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26
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Capitani V, Arcari G, Oliva A, Sacco F, Menichincheri G, Fenske L, Polani R, Raponi G, Antonelli G, Carattoli A. Genome-Based Retrospective Analysis of a Providencia stuartii Outbreak in Rome, Italy: Broad Spectrum IncC Plasmids Spread the NDM Carbapenemase within the Hospital. Antibiotics (Basel) 2023; 12:antibiotics12050943. [PMID: 37237846 DOI: 10.3390/antibiotics12050943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/15/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
Providencia stuartii is a member of the Morganellaceae family, notorious for its intrinsic resistance to several antibiotics, including last-resort drugs such as colistin and tigecycline. Between February and March 2022, a four-patient outbreak sustained by P. stuartii occurred in a hospital in Rome. Phenotypic analyses defined these strains as eXtensively Drug-Resistant (XDR). Whole-genome sequencing was performed on the representative P. stuartii strains and resulted in fully closed genomes and plasmids. The genomes were highly related phylogenetically and encoded various virulence factors, including fimbrial clusters. The XDR phenotype was primarily driven by the presence of the blaNDM-1 metallo-β-lactamase alongside the rmtC 16S rRNA methyltransferase, conferring resistance to most β-lactams and every aminoglycoside, respectively. These genes were found on an IncC plasmid that was highly related to an NDM-IncC plasmid retrieved from a ST15 Klebsiella pneumoniae strain circulating in the same hospital two years earlier. Given its ability to acquire resistance plasmids and its intrinsic resistance mechanisms, P. stuartii is a formidable pathogen. The emergence of XDR P. stuartii strains poses a significant public health threat. It is essential to monitor the spread of these strains and develop new strategies for their control and treatment.
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Affiliation(s)
- Valerio Capitani
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185 Rome, Italy
| | - Gabriele Arcari
- Department of Molecular Medicine, Sapienza University of Rome, 00161 Rome, Italy
| | - Alessandra Oliva
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185 Rome, Italy
| | - Federica Sacco
- Department of Molecular Medicine, Sapienza University of Rome, 00161 Rome, Italy
| | - Gaia Menichincheri
- Department of Molecular Medicine, Sapienza University of Rome, 00161 Rome, Italy
| | - Linda Fenske
- Bioinformatics and Systems Biology, Justus-Liebig-University Giessen, 35390 Giessen, Germany
| | - Riccardo Polani
- Department of Molecular Medicine, Sapienza University of Rome, 00161 Rome, Italy
| | - Giammarco Raponi
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185 Rome, Italy
| | - Guido Antonelli
- Department of Molecular Medicine, Sapienza University of Rome, 00161 Rome, Italy
| | - Alessandra Carattoli
- Department of Molecular Medicine, Sapienza University of Rome, 00161 Rome, Italy
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Riccobono E, Salvetti S, Coppi M, Montenora I, Di Pilato V, Rossolini GM. Citrobacter freundii resistant to novel β-lactamase inhibitor combinations and cefiderocol, co-producing class A, B and D carbapenemases encoded by transferable plasmids. J Antimicrob Chemother 2023:7173996. [PMID: 37207353 DOI: 10.1093/jac/dkad150] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 05/02/2023] [Indexed: 05/21/2023] Open
Abstract
OBJECTIVES To characterize a carbapenem-resistant Citrobacter freundii (Cf-Emp) co-producing class A, B and D carbapenemases, resistant to novel β-lactamase inhibitor combinations (BLICs) and cefiderocol. METHODS Carbapenemase production was tested by an immunochromatography assay. Antibiotic susceptibility testing (AST) was performed by broth microdilution. WGS was performed using short- and long-read sequencing. Transfer of carbapenemase-encoding plasmids was assessed by conjugation experiments. RESULTS Cf-Emp was isolated on selective medium for carbapenem-resistant Enterobacterales from the surveillance rectal swab taken at hospital admission from a patient of Moroccan origin. Cf-Emp produced three different carbapenemases, including KPC-2, OXA-181 and VIM-1, and was resistant to all β-lactams including carbapenems, novel BLICs (ceftazidime/avibactam, meropenem/vaborbactam and imipenem/relebactam) and cefiderocol. MIC of aztreonam/avibactam was 0.25 mg/L. The strain belonged to ST22, one of the C. freundii lineages of global diffusion, known to be associated with carbapenemase production. Each carbapenemase gene was located aboard a different plasmid (named pCf-KPC, pCf-OXA and pCf-VIM, respectively), which also carried other clinically relevant resistance genes, such as armA (pCf-KPC), blaSHV-12 (pCf-VIM) and qnrS1 (pCf-OXA). Transferability to Escherichia coli J53 by conjugation was observed for all plasmids. CONCLUSIONS The finding of enterobacterial strains carrying multiple carbapenemase genes on transferable plasmids is alarming, because similar strains could provide an important reservoir for disseminating these clinically relevant resistance determinants.
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Affiliation(s)
- Eleonora Riccobono
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Sara Salvetti
- Microbiology Unit, San Giuseppe Hospital, Empoli, Florence, Italy
| | - Marco Coppi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Clinical Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
| | | | - Vincenzo Di Pilato
- Clinical Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Clinical Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
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Dey S, Gaur M, Sykes EME, Prusty M, Elangovan S, Dixit S, Pati S, Kumar A, Subudhi E. Unravelling the Evolutionary Dynamics of High-Risk Klebsiella pneumoniae ST147 Clones: Insights from Comparative Pangenome Analysis. Genes (Basel) 2023; 14:genes14051037. [PMID: 37239397 DOI: 10.3390/genes14051037] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 04/20/2023] [Accepted: 04/25/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND The high prevalence and rapid emergence of antibiotic resistance in high-risk Klebsiella pneumoniae (KP) ST147 clones is a global health concern and warrants molecular surveillance. METHODS A pangenome analysis was performed using publicly available ST147 complete genomes. The characteristics and evolutionary relationships among ST147 members were investigated through a Bayesian phylogenetic analysis. RESULTS The large number of accessory genes in the pangenome indicates genome plasticity and openness. Seventy-two antibiotic resistance genes were found to be linked with antibiotic inactivation, efflux, and target alteration. The exclusive detection of the blaOXA-232 gene within the ColKp3 plasmid of KP_SDL79 suggests its acquisition through horizontal gene transfer. The association of seventy-six virulence genes with the acrAB efflux pump, T6SS system and type I secretion system describes its pathogenicity. The presence of Tn6170, a putative Tn7-like transposon in KP_SDL79 with an insertion at the flanking region of the tnsB gene, establishes its transmission ability. The Bayesian phylogenetic analysis estimates ST147's initial divergence in 1951 and the most recent common ancestor for the entire KP population in 1621. CONCLUSIONS Present study highlights the genetic diversity and evolutionary dynamics of high-risk clones of K. pneumoniae. Further inter-clonal diversity studies will help us understand its outbreak more precisely and pave the way for therapeutic interventions.
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Affiliation(s)
- Suchanda Dey
- Centre for Biotechnology, School of Pharmaceutical Sciences, Siksha 'O' Anusandhan (Deemed to be University), Bhubaneswar 751003, India
| | - Mahendra Gaur
- Centre for Biotechnology, School of Pharmaceutical Sciences, Siksha 'O' Anusandhan (Deemed to be University), Bhubaneswar 751003, India
| | - Ellen M E Sykes
- Department of Microbiology, University of Manitoba, Winnipeg, MB R3T2N2, Canada
| | - Monica Prusty
- School of Biotechnology, Kalinga Institute of Industrial Technology, Bhubaneswar 751024, India
| | - Selvakumar Elangovan
- School of Biotechnology, Kalinga Institute of Industrial Technology, Bhubaneswar 751024, India
| | - Sangita Dixit
- Centre for Biotechnology, School of Pharmaceutical Sciences, Siksha 'O' Anusandhan (Deemed to be University), Bhubaneswar 751003, India
| | | | - Ayush Kumar
- Department of Microbiology, University of Manitoba, Winnipeg, MB R3T2N2, Canada
| | - Enketeswara Subudhi
- Centre for Biotechnology, School of Pharmaceutical Sciences, Siksha 'O' Anusandhan (Deemed to be University), Bhubaneswar 751003, India
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Agosta M, Bencardino D, Argentieri M, Pansani L, Sisto A, Ciofi Degli Atti ML, D'Amore C, Bagolan P, Iacobelli BD, Magnani M, Raponi M, Perno CF, Andreoni F, Bernaschi P. Clonal Spread of Hospital-Acquired NDM-1-Producing Klebsiella pneumoniae and Escherichia coli in an Italian Neonatal Surgery Unit: A Retrospective Study. Antibiotics (Basel) 2023; 12:antibiotics12040642. [PMID: 37107005 PMCID: PMC10135170 DOI: 10.3390/antibiotics12040642] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/15/2023] [Accepted: 03/22/2023] [Indexed: 04/29/2023] Open
Abstract
This article reports a rapid and unexpected spread of colonization cases of NDM-1 carbapenemase-producing Klebsiella pneumoniae and Escherichia coli in a neonatal surgical unit (NSU) at Bambino Gesù Children's Hospital in Rome, Italy. Between the 16th of November 2020 and the 18th of January 2021, a total of 20 NDM-1 carbapenemase-producing K. pneumoniae (n = 8) and E. coli (n = 12) were isolated from 17 out of 230 stool samples collected from neonates admitted in the aforementioned ward and time period by an active surveillance culture program routinely in place to monitor the prevalence of colonization/infection with multidrug-resistant Gram-negative microorganisms. All strains were characterized by antimicrobial susceptibility testing, detection of resistance determinants, PCR-based replicon typing (PBRT) and multilocus-sequence typing (MLST). All isolates were highly resistant to most of the tested antibiotics, and molecular characterization revealed that all of them harbored the blaNDM-1 gene. Overall, IncA/C was the most common Inc group (n = 20/20), followed by IncFIA (n = 17/20), IncFIIK (n = 14/20) and IncFII (n = 11/20). MLST analysis was performed on all 20 carbapenemase-producing Enterobacterales (CPE) strains, revealing three different Sequence Types (STs) among E. coli isolates, with the prevalence of ST131 (n = 10/12; 83%). Additionally, among the 8 K. pneumoniae strains we found 2 STs with the prevalence of ST37 (n = 7/8; 87.5%). Although patient results were positive for CPE colonization during their hospital stay, infection control interventions prevented their dissemination in the ward and no cases of infection were recorded in the same time period.
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Affiliation(s)
- Marilena Agosta
- Microbiology and Diagnostic Immunology Unit, Department of Diagnostic and Laboratory Medicine, Bambino Gesù Children's Hospital, IRCCS, 00163 Rome, Italy
| | - Daniela Bencardino
- Department of Biomolecular Sciences, University of Urbino "Carlo Bo", 61032 Fano, Italy
| | - Marta Argentieri
- Microbiology and Diagnostic Immunology Unit, Department of Diagnostic and Laboratory Medicine, Bambino Gesù Children's Hospital, IRCCS, 00163 Rome, Italy
| | - Laura Pansani
- Microbiology and Diagnostic Immunology Unit, Department of Diagnostic and Laboratory Medicine, Bambino Gesù Children's Hospital, IRCCS, 00163 Rome, Italy
| | - Annamaria Sisto
- Microbiology and Diagnostic Immunology Unit, Department of Diagnostic and Laboratory Medicine, Bambino Gesù Children's Hospital, IRCCS, 00163 Rome, Italy
| | | | - Carmen D'Amore
- Clinical Pathways and Epidemiology Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Pietro Bagolan
- Neonatal Surgery Unit, Medical and Surgical Department of the Fetus-Newborn-Infant, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Barbara Daniela Iacobelli
- Neonatal Surgery Unit, Medical and Surgical Department of the Fetus-Newborn-Infant, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Mauro Magnani
- Department of Biomolecular Sciences, University of Urbino "Carlo Bo", 61032 Fano, Italy
| | - Massimiliano Raponi
- Health Directorate, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Carlo Federico Perno
- Microbiology and Diagnostic Immunology Unit, Department of Diagnostic and Laboratory Medicine, Bambino Gesù Children's Hospital, IRCCS, 00163 Rome, Italy
| | - Francesca Andreoni
- Department of Biomolecular Sciences, University of Urbino "Carlo Bo", 61032 Fano, Italy
- Clinical Pathology Unit, Azienda Sanitaria Territoriale, 61029 Urbino, Italy
| | - Paola Bernaschi
- Microbiology and Diagnostic Immunology Unit, Department of Diagnostic and Laboratory Medicine, Bambino Gesù Children's Hospital, IRCCS, 00163 Rome, Italy
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Hallal Ferreira Raro O, Nordmann P, Dominguez Pino M, Findlay J, Poirel L. Emergence of Carbapenemase-Producing Hypervirulent Klebsiella pneumoniae in Switzerland. Antimicrob Agents Chemother 2023; 67:e0142422. [PMID: 36853006 PMCID: PMC10019205 DOI: 10.1128/aac.01424-22] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/19/2023] [Indexed: 03/01/2023] Open
Abstract
Increasing occurrence of multidrug-resistant (MDR) and hypervirulent (hv) Klebsiella pneumoniae (MDR-hvKp) convergent clones is being observed. Those strains have the potential of causing difficult-to-treat infections in healthy adults with an increased capacity for mortality. It is therefore crucial to track their dissemination to prevent their further spread. The aim of our study was to investigate the occurrence of carbapenemase-producing hvKp isolates in Switzerland and to determine their genetic profile. A total of 279 MDR carbapenemase-producing K. pneumoniae from patients hospitalized all over Switzerland was investigated, and a rate of 9.0% K. pneumoniae presenting a virulence genotype was identified. Those isolates produced either KPC, NDM, or OXA-48 and had been either recovered from rectal swabs, urine, and blood. A series of previously reported K. pneumoniae clones such as ST23-K1, ST395-K2, and ST147-K20 or ST147-K64 were identified. All the isolates defined as MDR-hvKp (4.7%) possessed the aerobactin and the yersiniabactin clusters. The ST23-K1s were the only isolates presenting the colibactin cluster and achieved higher virulence scores. This study highlights the occurrence and circulation of worrisome MDR-hvKp and MDR nonhypervirulent K. pneumoniae (MDR-nhv-Kp) isolates in Switzerland. Our findings raise an alert regarding the need for active surveillance networks to track and monitor the spread of such successful hybrid clones representing a public health threat worldwide.
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Affiliation(s)
- Otávio Hallal Ferreira Raro
- Medical and Molecular Microbiology, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
| | - Patrice Nordmann
- Medical and Molecular Microbiology, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
- Swiss National Reference Center for Emerging Antibiotic Resistance (NARA), University of Fribourg, Fribourg, Switzerland
- Institute for Microbiology, University Hospital, Lausanne, Switzerland
| | - Manuel Dominguez Pino
- Medical and Molecular Microbiology, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
| | - Jacqueline Findlay
- Medical and Molecular Microbiology, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
| | - Laurent Poirel
- Medical and Molecular Microbiology, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
- Swiss National Reference Center for Emerging Antibiotic Resistance (NARA), University of Fribourg, Fribourg, Switzerland
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He W, Gao M, Lv L, Wang J, Cai Z, Bai Y, Gao X, Gao G, Pu W, Jiao Y, Wan M, Song Q, Chen S, Liu JH. Persistence and molecular epidemiology of bla NDM-positive Gram-negative bacteria in three broiler farms: A longitudinal study (2015-2021). JOURNAL OF HAZARDOUS MATERIALS 2023; 446:130725. [PMID: 36630875 DOI: 10.1016/j.jhazmat.2023.130725] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 11/15/2022] [Accepted: 01/03/2023] [Indexed: 06/17/2023]
Abstract
Although carbapenems have not been approved for animal use, blaNDM-positive bacteria (NPB) are increasingly being detected in farm animals. It is important to investigate the routes and underlying mechanisms of evolution and transmission of animal-borne NPB. In this study, NPB recovered from chicken feces and environmental samples in three adjacent broiler farms were investigated. We found that 13.0% of Escherichia coli strains recovered from chicken feces during the period 2015-2016 carried the blaNDM gene. In 2017-2021, however, as many as 55.8% chicken and environmental samples collected during the breeding period were found to harbor NPB. Importantly, such strains were detectable in samples from farmland (10.3%, 8/78), vegetable fields (7.3%, 3/41), and environment of chicken farms (25.6%, 41/160) which had been left vacant for a long period of time. Intriguingly, different sequence types of NPB became dominant in different years. Both clonal dissemination of NPB and horizontal transmission of blaNDM-bearing plasmids were observed among different farms and among the environment niches inside and outside the farm houses. Worryingly, transmission of NPB and blaNDM-bearing plasmids between these farms and other places was also observed. All in all, our results suggested the persistence of NPB in chickens and farm environments, presumably due to extensive contamination by exogenous materials and transmission of NPB within the farm system. These events were aggravated by the increase in antibiotic usage and poor sanitary conditions in the farm houses. Stringent control measures should be implemented to arrest transmission of animal-borne NPB to the environment and the community.
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Affiliation(s)
- Wanyun He
- College of Veterinary Medicine, Key Laboratory of Zoonosis of Ministry of Agricultural and Rural Affairs, Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, National Risk Assessment Laboratory for Antimicrobial Resistance of Microorganisms in Animals, South China Agricultural University, Guangzhou, China
| | - Mingyi Gao
- College of Veterinary Medicine, Key Laboratory of Zoonosis of Ministry of Agricultural and Rural Affairs, Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, National Risk Assessment Laboratory for Antimicrobial Resistance of Microorganisms in Animals, South China Agricultural University, Guangzhou, China
| | - Luchao Lv
- College of Veterinary Medicine, Key Laboratory of Zoonosis of Ministry of Agricultural and Rural Affairs, Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, National Risk Assessment Laboratory for Antimicrobial Resistance of Microorganisms in Animals, South China Agricultural University, Guangzhou, China
| | - Jing Wang
- Key Laboratory of Prevention and Control of Biological Hazard Factors (Animal Origin) for Agrifood Safety and Quality, Ministry of Agriculture of China, Yangzhou University, Yangzhou, China
| | - Zhongpeng Cai
- College of Veterinary Medicine, Key Laboratory of Zoonosis of Ministry of Agricultural and Rural Affairs, Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, National Risk Assessment Laboratory for Antimicrobial Resistance of Microorganisms in Animals, South China Agricultural University, Guangzhou, China
| | - Yuman Bai
- College of Veterinary Medicine, Key Laboratory of Zoonosis of Ministry of Agricultural and Rural Affairs, Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, National Risk Assessment Laboratory for Antimicrobial Resistance of Microorganisms in Animals, South China Agricultural University, Guangzhou, China
| | - Xun Gao
- College of Veterinary Medicine, Key Laboratory of Zoonosis of Ministry of Agricultural and Rural Affairs, Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, National Risk Assessment Laboratory for Antimicrobial Resistance of Microorganisms in Animals, South China Agricultural University, Guangzhou, China
| | - Guolong Gao
- College of Veterinary Medicine, Key Laboratory of Zoonosis of Ministry of Agricultural and Rural Affairs, Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, National Risk Assessment Laboratory for Antimicrobial Resistance of Microorganisms in Animals, South China Agricultural University, Guangzhou, China
| | - Wenxian Pu
- College of Veterinary Medicine, Key Laboratory of Zoonosis of Ministry of Agricultural and Rural Affairs, Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, National Risk Assessment Laboratory for Antimicrobial Resistance of Microorganisms in Animals, South China Agricultural University, Guangzhou, China
| | - Yanxiang Jiao
- College of Veterinary Medicine, Key Laboratory of Zoonosis of Ministry of Agricultural and Rural Affairs, Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, National Risk Assessment Laboratory for Antimicrobial Resistance of Microorganisms in Animals, South China Agricultural University, Guangzhou, China
| | - Miao Wan
- College of Veterinary Medicine, Key Laboratory of Zoonosis of Ministry of Agricultural and Rural Affairs, Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, National Risk Assessment Laboratory for Antimicrobial Resistance of Microorganisms in Animals, South China Agricultural University, Guangzhou, China
| | - Qianhua Song
- College of Veterinary Medicine, Key Laboratory of Zoonosis of Ministry of Agricultural and Rural Affairs, Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, National Risk Assessment Laboratory for Antimicrobial Resistance of Microorganisms in Animals, South China Agricultural University, Guangzhou, China
| | - Sheng Chen
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Kowloon, Hong Kong, SAR China.
| | - Jian-Hua Liu
- College of Veterinary Medicine, Key Laboratory of Zoonosis of Ministry of Agricultural and Rural Affairs, Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, National Risk Assessment Laboratory for Antimicrobial Resistance of Microorganisms in Animals, South China Agricultural University, Guangzhou, China; Guangdong Laboratory for Lingnan Modern Agriculture, Guangzhou, China.
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Estimation, Evaluation and Characterization of Carbapenem Resistance Burden from a Tertiary Care Hospital, Pakistan. Antibiotics (Basel) 2023; 12:antibiotics12030525. [PMID: 36978392 PMCID: PMC10044297 DOI: 10.3390/antibiotics12030525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 03/09/2023] Open
Abstract
Carbapenem resistance has become major concern in healthcare settings globally; therefore, its monitoring is crucial for intervention efforts to halt resistance spread. During May 2019–April 2022, 2170 clinical strains were characterized for antimicrobial susceptibility, resistance genes, replicon and sequence types. Overall, 42.1% isolates were carbapenem-resistant, and significantly associated with Klebsiella pneumoniae (K. pneumoniae) (p = 0.008) and Proteus species (p = 0.043). Carbapenemases were detected in 82.2% of isolates, with blaNDM-1 (41.1%) associated with the ICU (p < 0.001), cardiology (p = 0.042), pediatric medicine (p = 0.013) and wound samples (p = 0.041); blaOXA-48 (32.6%) was associated with the ICU (p < 0.001), cardiology (p = 0.008), pediatric medicine (p < 0.001), general surgery (p = 0.001), general medicine (p = 0.005) and nephrology (p = 0.020); blaKPC-2 (5.5%) was associated with general surgery (p = 0.029); blaNDM-1/blaOXA-48 (11.4%) was associated with general surgery (p < 0.001), and wound (p = 0.002), urine (p = 0.003) and blood (p = 0.012) samples; blaOXA-48/blaVIM (3.1%) was associated with nephrology (p < 0.001) and urine samples (p < 0.001). Other detected carbapenemases were blaVIM (3.0%), blaIMP (2.7%), blaOXA-48/blaIMP (0.1%) and blaVIM/blaIMP (0.3%). Sequence type (ST)147 (39.7%) represented the most common sequence type identified among K. pneumoniae, along with ST11 (23.0%), ST14 (15.4%), ST258 (10.9%) and ST340 (9.6%) while ST405 comprised 34.5% of Escherichia coli (E. coli) isolates followed by ST131 (21.2%), ST101 (19.7%), ST10 (16.0%) and ST69 (7.4%). Plasmid replicon types IncFII, IncA/C, IncN, IncL/M, IncFIIA and IncFIIK were observed. This is first report describing the carbapenem-resistance burden and emergence of blaKPC-2-ST147, blaNDM-1-ST340 and blaNDM-1-ST14 in K. pneumoniae isolates and blaNDM-1-ST69 and blaNDM-1/blaOXA-48-ST69 in E. coli isolates coharboring extended-spectrum beta-lactamases (ESBLs) from Pakistan.
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Liu C, Du P, Yang P, Lu M, Shen N. Fusion plasmid enhanced the endemic extensively drug resistant Klebsiella pneumoniae clone ST147 harbored bla OXA-48 to acquire the hypervirulence and cause fatal infection. Ann Clin Microbiol Antimicrob 2023; 22:11. [PMID: 36788555 PMCID: PMC9927049 DOI: 10.1186/s12941-022-00551-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/20/2022] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Klebsiella Pneumoniae (Kp) sequence type (ST) 147 has emerged globally and spread rapidly, particularly the extensively drug resistant (XDR) isolates. However, the infections caused by this subtype is rare reported in China for now. The clinical, microbiological and genomic characteristics are unclear. METHODS A systemic retrospective study was conducted in a Chinese tertiary hospital. Clinical information of the infection cases was collected, and whole-genome sequencing and phenotypic experiments were performed on the ST147 isolates. The resistance and virulence genes were identified, and the plasmids harboring these genes were further studied. RESULTS Six ST147 isolates from six patients among 720 available clincial Kp isolates were detected. Notably, two isolates, PEKP4035 and PEKP4265, represented both XDR and hypervirulence by acquiring blaOXA-48, blaCTX-M-15 and key virulence genes, iucA + rmpA2, representing no fitness cost and resulting fatal infection. Four of the six ST147 isolates presented with more nucleotide differences, whereas the PEKP4035 and PEKP4265 both isolated from the intensive care unit possessed 20 single nucleotide polymorphisms among one year, indicating the prolonged survive and transmission. Interestingly, the two isolates harbored the same fused plasmid composed of sul2 and iucA + rmpA2, which might be generated by recombination of a plasmid like KpvST101_OXA-48 with the pLVPK plasmid via IS26. Besides, two ~ 70 kb plasmids conferring multiple-drug resistance were also identified among the two isolates, which presented resistance genes including blaOXA-48, blaCTX-M-16, strA and strB. Interestingly, we reported that blaCTX-M-15, a common resistance gene within ST147, has successfully transferred into the chromosome by ISEcp1. CONCLUSIONS XDR hypervirulent ST147 Kp is emerging, suggesting enhanced surveillance is essential.
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Affiliation(s)
- Chao Liu
- grid.411642.40000 0004 0605 3760Department of Infectious Disease, Peking University Third Hospital, Beijing, China ,grid.411642.40000 0004 0605 3760Center of Infectious Disease, Peking University Third Hospital, Beijing, China
| | | | - Ping Yang
- grid.411642.40000 0004 0605 3760Department of Pulmonary and Critical Care Medicine, Peking University Third Hospital, Beijing, China ,grid.11135.370000 0001 2256 9319Institute of Medical Technology, Peking University Health Science Center, Beijing, China
| | - Ming Lu
- Department of Infectious Disease, Peking University Third Hospital, Beijing, China. .,Center of Infectious Disease, Peking University Third Hospital, Beijing, China. .,Department of Pulmonary and Critical Care Medicine, Peking University Third Hospital, Beijing, China.
| | - Ning Shen
- Department of Infectious Disease, Peking University Third Hospital, Beijing, China. .,Center of Infectious Disease, Peking University Third Hospital, Beijing, China. .,Department of Pulmonary and Critical Care Medicine, Peking University Third Hospital, Beijing, China. .,Institute of Medical Technology, Peking University Health Science Center, Beijing, China.
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Morici P, Rizzato C, Ghelardi E, Rossolini GM, Lupetti A. Sensitization of KPC and NDM Klebsiella pneumoniae To Rifampicin by the Human Lactoferrin-Derived Peptide hLF1-11. Microbiol Spectr 2023; 11:e0276722. [PMID: 36537823 PMCID: PMC9927577 DOI: 10.1128/spectrum.02767-22] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
A synergistic effect of non-bactericidal concentrations of the human lactoferrin (hLF)-derived peptide hLF1-11 and rifampicin against multidrug-resistant KPC (Klebsiella pneumoniae carbapenemase)-producing K. pneumoniae has been previously shown. The present study focuses on the mechanism(s) underlying this synergistic effect. The contribution of hLF1-11 and rifampicin to the synergistic effect was evaluated by killing assays with KPC K. pneumoniae cells incubated with hLF1-11 and, after washing, with rifampicin, or vice versa. Cell membrane permeability and polarization upon exposure to hLF1-11 and/or rifampicin were evaluated by ethidium bromide (EtBr) and DiBAC4(3) (bis-1,3-dibutylbarbituric acid trimethine oxonol) permeability, respectively. The effect of carbonyl cyanide m-chlorophenyl hydrazone (CCCP), an uncoupler of oxidative phosphorylation, was also evaluated. KPC K. pneumoniae cells were effectively killed after prior exposure to rifampicin for 30 to 60 min followed by treatment with hLF1-11, while no antibacterial activity was observed when cells were incubated with hLF1-11 first and then with rifampicin. EtBr accumulation increased upon exposure to hLF1-11 or the combination of hLF1-11 and rifampicin, but not upon exposure to rifampicin alone. Moreover, hLF1-11 induced a dose-dependent membrane depolarization. As expected, the antibacterial activity of hLF1-11 alone or combined with rifampicin was significantly reduced in the presence of CCCP. Furthermore, hLF1-11 and rifampicin were synergistic also against a colistin-resistant NDM (New Delhi metallo-β-lactamase)-producing K. pneumoniae strain. The results suggest that rifampicin was accumulated by KPC cells during the 30-to-60-min incubation and that the addition of hLF1-11 sensitized bacterial cells to rifampicin by inducing a transient loss of membrane potential and increased cell membrane permeability, thus facilitating the entrance and retention of rifampicin into the cytoplasm. IMPORTANCE The present study describes a synergistic effect between rifampicin, an impermeable hydrophobic antibiotic with an intracellular target, and an hLF1-11, an antimicrobial peptide derived from human lactoferrin, against multidrug-resistant Klebsiella pneumoniae. Carbapenem-resistant K. pneumoniae has recently caused an outbreak in Tuscany, Italy, thus pressing the need for the development of new treatment options. The mechanisms underlying such a synergistic effect have been studied. The results suggest that the synergistic effect was due to the transient loss of membrane potential induced by hLF1-11 and the subsequent increase in cell membrane permeability which allowed rifampicin to enter the bacterial cell. Therefore, it is likely that a sub-inhibitory concentration of hLF1-11 can efficiently permeabilize K. pneumoniae cells to rifampicin, allowing the antibiotic to reach its intracellular target. These results encourage further exploration of possible applications of this synergistic combination in the treatment of K. pneumoniae infections.
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Affiliation(s)
- Paola Morici
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Cosmeri Rizzato
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Emilia Ghelardi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Clinical Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy
| | - Antonella Lupetti
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
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Schultze T, Hogardt M, Velázquez ES, Hack D, Besier S, Wichelhaus TA, Rochwalsky U, Kempf VAJ, Reinheimer C. Molecular surveillance of multidrug-resistant Gram-negative bacteria in Ukrainian patients, Germany, March to June 2022. Euro Surveill 2023; 28:2200850. [PMID: 36695452 PMCID: PMC9817211 DOI: 10.2807/1560-7917.es.2023.28.1.2200850] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BackgroundSince the beginning of the war in Ukraine in February 2022, Ukrainians have been seeking shelter in other European countries.AimWe aimed to investigate the prevalence and the molecular epidemiology of multidrug-resistant Gram-negative (MDRGN) bacteria and meticillin-resistant Staphylococcus aureus (MRSA) in Ukrainian patients at admittance to the University Hospital Frankfurt, Germany.MethodsWe performed screening and observational analysis of all patients from March until June 2022. Genomes of MDRGN isolates were analysed for antimicrobial resistance, virulence genes and phylogenetic relatedness.ResultsWe included 103 patients (median age: 39 ± 23.7 years), 57 of whom were female (55.3%; 95% confidence interval (CI): 45.2-5.1). Patients were most frequently admitted to the Department of Paediatrics (29/103; 28.2%; 95% CI: 19.7-37.9). We found 34 MDRGN isolates in 17 of 103 patients (16.5%; 95% CI: 9.9-25.1). Ten patients carried 21 carbapenem-resistant (CR) bacteria, five of them more than one CR isolate. Four of six patients with war-related injuries carried eight CR isolates. In six of 10 patients, CR isolates caused infections. Genomic characterisation revealed that the CR isolates harboured at least one carbapenemase gene, bla NDM-1 being the most frequent (n = 10). Core genome and plasmid analysis revealed no epidemiological connection between most of these isolates. Hypervirulence marker genes were found in five of six Klebsiella pneumoniae CR isolates. No MRSA was found.ConclusionHospitals should consider infection control strategies to cover the elevated prevalence of MDRGN bacteria in Ukrainian patients with war-related injuries and/or hospital pre-treatment and to prevent the spread of hypervirulent CR isolates.
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Affiliation(s)
- Tilman Schultze
- Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany,University Centre of Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany,University Centre of Competence for Infection Control of the State of Hesse, Frankfurt am Main, Frankfurt Main, Germany
| | - Michael Hogardt
- Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany,University Centre of Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany,University Centre of Competence for Infection Control of the State of Hesse, Frankfurt am Main, Frankfurt Main, Germany
| | - Erwin Sanabria Velázquez
- Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany,University Centre of Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany,University Centre of Competence for Infection Control of the State of Hesse, Frankfurt am Main, Frankfurt Main, Germany
| | - Daniel Hack
- Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany,University Centre of Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany,University Centre of Competence for Infection Control of the State of Hesse, Frankfurt am Main, Frankfurt Main, Germany
| | - Silke Besier
- Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany,University Centre of Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany,University Centre of Competence for Infection Control of the State of Hesse, Frankfurt am Main, Frankfurt Main, Germany
| | - Thomas A Wichelhaus
- Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany,University Centre of Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany,University Centre of Competence for Infection Control of the State of Hesse, Frankfurt am Main, Frankfurt Main, Germany
| | - Ulrich Rochwalsky
- Department of Paediatrics, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Volkhard AJ Kempf
- Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany,University Centre of Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany,University Centre of Competence for Infection Control of the State of Hesse, Frankfurt am Main, Frankfurt Main, Germany
| | - Claudia Reinheimer
- Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany,University Centre of Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany,University Centre of Competence for Infection Control of the State of Hesse, Frankfurt am Main, Frankfurt Main, Germany
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Ganbold M, Seo J, Wi YM, Kwon KT, Ko KS. Species identification, antibiotic resistance, and virulence in Enterobacter cloacae complex clinical isolates from South Korea. Front Microbiol 2023; 14:1122691. [PMID: 37032871 PMCID: PMC10076837 DOI: 10.3389/fmicb.2023.1122691] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/21/2023] [Indexed: 04/11/2023] Open
Abstract
This study aimed to identify the species of Enterobacter cloacae complex (ECC) isolates and compare the genotype, antibiotic resistance, and virulence among them. A total of 183 ECC isolates were collected from patients in eight hospitals in South Korea. Based on partial sequences of hsp60 and phylogenetic analysis, all ECC isolates were identified as nine species and six subspecies. Enterobacter hormaechei was the predominant species (47.0%), followed by Enterobacter kobei, Enterobacter asburiae, Enterobacter ludiwigii, and Enterobacter roggenkampii. Multilocus sequence typing analysis revealed that dissemination was not limited to a few clones, but E. hormaechei subsp. xiangfangensis, E. hormaechei subsp. steigerwaltii, and E. ludwigii formed large clonal complexes. Antibiotic resistance rates were different between the ECC species. In particular, E. asburiae, E. kobei, E. roggenkampii, and E. cloacae isolates were highly resistant to colistin, whereas most E. hormaechei and E. ludwigii isolates were susceptible to colistin. Virulence was evaluated through serum bactericidal assay and the Galleria mellonella larvae infection model. Consistency in the results between the serum resistance and the G. mellonella larvae infection assay was observed. Serum bactericidal assay showed that E. hormaechei, E. kobei, and E. ludwigii were significantly more virulent than E. asburiae and E. roggenkampii. In this study, we identified the predominant ECC species in South Korea and observed the differences in antibiotic resistance and virulence between the species. Our findings suggest that correct species identification, as well as continuous monitoring is crucial in clinical settings.
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Affiliation(s)
- Michidmaral Ganbold
- Department of Microbiology, Sungkyunkwan University School of Medicine, Suwon, Republic of Korea
| | - Jungyu Seo
- Department of Microbiology, Sungkyunkwan University School of Medicine, Suwon, Republic of Korea
| | - Yu Mi Wi
- Division of Infectious Diseases, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Ki Tae Kwon
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Kwan Soo Ko
- Department of Microbiology, Sungkyunkwan University School of Medicine, Suwon, Republic of Korea
- *Correspondence: Kwan Soo Ko,
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La Bella G, Lopizzo T, Lupo L, Angarano R, Curci A, Manti B, La Salandra G, Mosca A, De Nittis R, Arena F. In vitro activity of ceftazidime/avibactam against carbapenem-nonsusceptible Klebsiella penumoniae isolates collected during the first wave of the SARS-CoV-2 pandemic: a Southern Italy, multicenter, surveillance study. J Glob Antimicrob Resist 2022; 31:236-238. [PMID: 36208851 PMCID: PMC9533593 DOI: 10.1016/j.jgar.2022.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/13/2022] [Accepted: 09/28/2022] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Carbapenemase-producing Enterobacterales (CPE) represent a serious threat for human health being frequently resistant to most of available antibiotics classes. Recently, ceftazidime/avibactam (CAZ/AVI) has been approved for treatment of infections by Gram-negative bacteria, including class A CPE (including KPC-producing K. pneumoniae). Following CAZ/AVI commercialization, resistance to this combination has been reported. The aim of this study was to evaluate the prevalence of CAZ/AVI resistance among carbapenem-resistant K. pneumoniae(CR-Kp) isolates recovered from bloodstream infections (BSI) and hospital-acquired pneumonia (HAP), representative of the contemporary southern Italy epidemiology, during the first pandemic wave of SARS-CoV-2. METHODS From Jan...20-Jun...20, 4 Laboratories, collected all consecutive, non-replicated CR-Kp from BSIs and HAPs. All isolates were subjected to i) MALDI-ToF identification; ii) antimicrobial susceptibility testing by microdilution method. CAZ/AVI resistant (CAZ/AVI-R) isolates were screened for presence of most common carbapenemase genes and subjected to whole genome sequencing for characterization. RESULTS A total of 89 isolates were collected. The majority of strains retained susceptibility to colistin, gentamicin and amikacin. Three strains (3/89, 3,4%) were CAZ/AVI-R (MIC range 16/4-64/4 mg/L). Among CAZ/AVI-R, one was KPC-type producer (an ST101) while the remaining where NDM-type and VIM-type producers and belonged to ST147, and ST45, respectively. CONCLUSION During the pandemic period, in southern Italy, CAZ/AVI resistance remained infrequent but high-risk Klebsiella pneumoniae epidemic clones, producing the KPC-31 variant and class B carbapenamases were reported from some of the included centers.
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Affiliation(s)
- Gianfranco La Bella
- Istituto Zooprofilattico Sperimentale della Puglia e della Basilicata, Foggia, Italy,Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Teresa Lopizzo
- Clinical Pathology and Microbiology Unit, AOR San Carlo, Potenza, Italy
| | - Laura Lupo
- Clinical Pathology and Microbiology Unit, Vito Fazzi Hospital, Lecce, Italy
| | - Rosa Angarano
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Anna Curci
- Clinical Pathology and Microbiology Unit, AOR San Carlo, Potenza, Italy
| | - Barbara Manti
- Clinical Pathology and Microbiology Unit, Vito Fazzi Hospital, Lecce, Italy
| | - Giovanna La Salandra
- Istituto Zooprofilattico Sperimentale della Puglia e della Basilicata, Foggia, Italy
| | - Adriana Mosca
- Department of Interdisciplinary Medicine, Microbiology Section, University of Bari Aldo Moro, Bari, Italy
| | - Rosella De Nittis
- Microbiology and Virology Unit, AOU Policlinico Riuniti, Foggia, Italy
| | - Fabio Arena
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy,Microbiology and Virology Unit, AOU Policlinico Riuniti, Foggia, Italy,IRCCS Fondazione Don Carlo Gnocchi ONLUS, Florence, Italy,Corresponding author
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Cortegiani A, Ingoglia G, Ippolito M, Girardis M, Falcone M, Pea F, Pugliese F, Stefani S, Viale P, Giarratano A. Empiric treatment of patients with sepsis and septic shock and place in therapy of cefiderocol: a systematic review and expert opinion statement. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2022. [PMCID: PMC9361889 DOI: 10.1186/s44158-022-00062-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Carbapenem-resistant Gram-negative bacteria are frequent causes of sepsis and septic shock in intensive care unit (ICU) and thus considered a public health threat. Until now, the best available therapies consist of combinations of preexisting or new antibiotics with β-lactamase inhibitors (either new or preexisting). Several mechanisms of resistance, especially those mediated by metallo-β-lactamases (MBL), are responsible for the inefficacy of these treatments, leaving an unmet medical need. Intravenous cefiderocol has been recently approved by the American Food and Drug Administration (FDA) and European Medicines Agency (EMA) for the treatment of complicated urinary tract infections and nosocomial pneumonia due to Gram-negative, when limited therapeutical options are available. In addition, its ability to hijack bacterial iron uptake mechanisms makes cefiderocol stable against the whole Ambler β-lactamase inhibitors and increases the in vitro efficacy against Gram-negative pathogens (e.g., Enterobacterales spp., Pseudomonas aeruginosa, and Acinetobacter baumannii). Trials have already demonstrated their non-inferiority to comparators. In 2021, ESCMID guidelines released a conditional recommendation supporting the use of cefiderocol against metallo-β-lactamase-producing Enterobacterales and against Acinetobacter baumannii. This review provides the opinion of experts about the general management of empiric treatment of patients with sepsis and septic shock in the intensive care unit and detects the proper place in therapy of cefiderocol considering recent evidence sought through a systematic search.
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Deciphering variable resistance to novel carbapenem-based β-lactamase-inhibitor combinations in a multiclonal outbreak by KPC carbapenemase-producing Klebsiella pneumoniae resistant to ceftazidime/avibactam. Clin Microbiol Infect 2022; 29:537.e1-537.e8. [PMID: 36414199 DOI: 10.1016/j.cmi.2022.11.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/27/2022] [Accepted: 11/13/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Carbapenemase-producing Enterobacterales represent a major cause of difficult-to-treat infections world-wide. Novel β-lactam/β-lactamase inhibitor combinations, including ceftazidime/avibactam (CZA), meropenem/vaborbactam (MVB), and imipenem/relebactam (IMR), represented a break-through in the treatment of some carbapenemase-producing Enterobacterales infections. However, acquired resistance to these agents has been reported in Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacterales. Herein, we reported an outbreak caused by CZA-resistant, KPC-producing Klebsiella pneumoniae (KPC-Kp), which was also variably resistant to carbapenem-based β-lactam/β-lactamase inhibitor combinations. METHODS Bacterial isolates were subjected to antimicrobial susceptibility testing, whole-genome sequencing, determination of blaKPC gene dosage, and analysis of carbapenemase activity. RESULTS Overall, 15 KPC-Kp, nine CZA-resistant (CZAR), and six CZA-susceptible isolates were collected from an outbreak involving six patients in a neurorehabilitation facility. Of the nine CZAR isolates, seven were also resistant to MVB and one was also resistant to IMR. Whole-genome sequencing revealed that the outbreak was multi-clonal, with CZAR KPC-Kp belonging to the ST101, ST1519, and two ST512 sub-lineages, which were involved in two independent transmission clusters. Resistance to CZA was primarily mediated by overproduction of KPC-3 associated with increased gene dosage, a mechanism accounting for cross-resistance to MVB in most cases, and to IMR in a single KPC-Kp isolate; multiple OmpK36 aletarions were also detected. Mutated KPC (KPC-53) was detected in a single case. Positivity for CZAR KPC-Kp was inconstantly associated with previous CZA exposure. CONCLUSIONS In this multi-clonal outbreak of KPC-Kp, the overproduction of KPC-3 was the leading mechanism of cross-resistance to CZA and MVB, whereas resistance to IMR appeared less affected. The emergence and dissemination of similar resistance mechanisms may have relevant clinical and diagnostic implications, and their surveillance is warranted.
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Coppi M, Antonelli A, Niccolai C, Bartolini A, Bartolini L, Grazzini M, Mantengoli E, Farese A, Pieralli F, Mechi MT, Di Pilato V, Giani T, Rossolini GM. Nosocomial outbreak by NDM-1-producing Klebsiella pneumoniae highly resistant to cefiderocol, Florence, Italy, August 2021 to June 2022. Euro Surveill 2022; 27:2200795. [PMID: 36305334 PMCID: PMC9615416 DOI: 10.2807/1560-7917.es.2022.27.43.2200795] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 10/26/2022] [Indexed: 09/29/2023] Open
Abstract
A nosocomial outbreak by cefiderocol (FDC)-resistant NDM-1-producing Klebsiella pneumoniae (NDM-Kp) occurred in a large tertiary care hospital from August 2021-June 2022 in Florence, Italy, an area where NDM-Kp strains have become endemic. Retrospective analysis of NDM-Kp from cases observed in January 2021-June 2022 revealed that 21/52 were FDC-resistant. The outbreak was mostly sustained by clonal expansion of a mutant with inactivated cirA siderophore receptor gene, which exhibited high-level resistance to FDC (MIC ≥ 32 mg/L) and spread independently of FDC exposure.
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Affiliation(s)
- Marco Coppi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy
| | - Alberto Antonelli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy
| | - Claudia Niccolai
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Andrea Bartolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Laura Bartolini
- Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy
| | - Maddalena Grazzini
- Hospital Infection Prevention and Control Unit, Florence Careggi University Hospital, Florence, Italy
| | - Elisabetta Mantengoli
- Hospital Infection Prevention and Control Unit, Florence Careggi University Hospital, Florence, Italy
- Infectious and Tropical Diseases Unit, Florence Careggi University Hospital, Florence, Italy
| | - Alberto Farese
- Infectious and Tropical Diseases Unit, Florence Careggi University Hospital, Florence, Italy
| | - Filippo Pieralli
- Subintensive Care Unit, Florence Careggi University Hospital, Florence, Italy
| | - Maria Teresa Mechi
- Hospital Infection Prevention and Control Unit, Florence Careggi University Hospital, Florence, Italy
| | - Vincenzo Di Pilato
- Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Tommaso Giani
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy
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Hao J, Zhang B, Deng J, Wei Y, Xiao X, Liu J. Emergence of a Hypervirulent Tigecycline-Resistant Klebsiella pneumoniae Strain Co-producing blaNDM–1 and blaKPC–2 With an Uncommon Sequence Type ST464 in Southwestern China. Front Microbiol 2022; 13:868705. [PMID: 35572689 PMCID: PMC9100695 DOI: 10.3389/fmicb.2022.868705] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 03/21/2022] [Indexed: 11/29/2022] Open
Abstract
Emergence of blaNDM–1 and blaKPC–2 co-producing Klebsiella pneumoniae strains is currently attracting widespread attention, but little information is available about their tigecycline resistance, virulence, and prevalence in Southwest China. In July 2021, an extensively drug-resistant K. pneumoniae strain AHSWKP25 whose genome contained both blaNDM–1 and blaKPC–2 genes was isolated from the blood of a patient with the malignant hematological disease in Luzhou, China. We investigated the resistance profiles of AHSWKP25 using microbroth dilution, agar dilution, modified carbapenemase inactivation (mCIM), and EDTA-modified carbapenemase inactivation methods (eCIM). The virulence of AHSWKP25 was assessed through string tests, serum killing assays, and a Galleria mellonella larval infection model. Conjugation and plasmid stability experiments were conducted to determine the horizontal transfer capacity of plasmids. And efflux pump phenotype test and real-time quantitative reverse transcription-PCR (RT-PCR) were used to determine its efflux pump activity. Sequencing of AHSWKP25 determined that AHSWKP25 belonged to ST464, which is resistant to antibiotics such as carbapenems, tetracycline, fluoroquinolones, tigecycline, and fosfomycin. The efflux pump phenotype tests and RT-PCR results demonstrated that efflux pumps were overexpressed in the AHSWKP25, which promoted the tigecycline resistance of the bacteria. AHSWKP25 also showed hypervirulence and serum resistance in vitro model. AHSWKP25 carried several different plasmids that contained blaNDM–1, blaKPC–2, and mutated tet(A) genes. Sequence alignment revealed that the plasmids carrying blaNDM–1 and blaKPC–2 underwent recombination and insertion events, respectively. We demonstrated that an X3 plasmid carrying blaNDM–1 was transferred from pSW25NDM1 to E. coli J53. We also identified missense mutations in the ramR, rcsA, lon, and csrD genes of AHSWKP25. Our results highlighted the potential of blaNDM–1 and blaKPC–2 co-producing K. pneumoniae strains to further develop antimicrobial resistance and hypervirulent phenotypes, but measures should be taken to closely monitor and control the spread of superbugs with multidrug-resistant phenotypes and hypervirulence.
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Affiliation(s)
- Jingchen Hao
- Department of Laboratory Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Bangqin Zhang
- Department of Laboratory Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jiamin Deng
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yueshuai Wei
- Department of Laboratory Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xue Xiao
- Department of Laboratory Medicine, Southwest Medical University, Luzhou, China
| | - Jinbo Liu
- Department of Laboratory Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- *Correspondence: Jinbo Liu,
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