Molecular Epidemiology of Ciprofloxacin-Resistant Extended-Spectrum β-Lactamase–ProducingKlebsiella pneumoniaein Taiwan

Impact on quinolone resistance of plasmid-mediated quinolone resistance gene and mutations in quinolone resistance-determining regions in extended spectrum beta lactamase-producing Klebsiella pneumoniae isolated from urinary tract infection patients

Klebsiella pneumoniae is a typical pathogen in urinary tract infections (UTI), and the emergence of extended spectrum beta-lactamase (ESBL)-producing strains has been frequently reported, accompanied by higher quinolone resistance rates. There are two major mechanisms of quinolone resistance, mutations in quinolone resistance-determining regions (QRDR) and the presence of the plasmid-mediated quinolone resistance (PMQR) genes. This study aimed to investigate quinolone resistance among 105 ESBL-producing K. pneumoniae specimens isolated from UTI patients in Indonesia. These were characterized for antimicrobial resistance to nalidixic acid, ciprofloxacin and levofloxacin, QRDR mutations in gyrA and parC and the presence of PMQR genes. We found that 84.8% of the collected isolates were resistant to at least one of the quinolones. QRDR mutation in gyrA was observed in 49.5% of these strains and parC mutations in 61.0%. PMQR genes were identified in 84.8% of strains. The QRDR mutations clearly had a greater effect on resistance than the PMQR genes. In conclusion, we found high quinolone resistance rates in Indonesian ESBL-producing K. pneumoniae, in which QRDR mutation played a major role.

Predominance and clonal spread of CTX-M-15 in cefotaxime-resistant Klebsiella pneumoniae in Korea and their association with plasmid-mediated quinolone resistance determinants

INTRODUCTION

β-lactams and fluoroquinolones are extensively used worldwide in the treatment of infections caused by Enterobacterales. In this study, we investigated the prevalence of extended-spectrum β-lactamases (ESBL), their correlation with plasmid-mediated quinolone resistance determinants (PMQR) and clonal distribution among the cefotaxime-resistant K. pneumoniae isolates.

METHODS

In Korea, a total of 429 K. pneumoniae collected in 2015 were studied. Antimicrobial susceptibility test for cefotaxime, ciprofloxacin and levofloxacin was performed by broth microdilution method. By PCR and/or sequencing, mutations in gyrA and parC genes, PMQR genes and ESBL were identified. Multilocus-sequence-type (MLST) was determined for isolates harboring CTX-M-15.

RESULTS

Among the 149 K. pneumoniae showing cefotaxime MICs of >1 μg/ml, 142 (95.3%) isolates were ESBL-producers and CTX-M-15 was predominant (99 isolates). Among the 142 ESBL-producers, mutations in gyrA and parC were found in 112 (78.9%) and 93 isolates (65.5%), respectively. PMQR genes were detected in 141 isolates and the non-susceptibility rate to ciprofloxacin and levofloxacin was 95.1% (135/142) and 82.4% (117/142), respectively. The most frequently found PMQR combination was qnrB-aac(6')-Ib-cr-oqxAB, (58/142, 40.8%). By MLST, four major STs/CC: ST48, ST392, ST307 and CC15 accounted for 67% of the CTX-M-15 producers and the prevalence of qnrB was significantly higher in these four major STs/CC than other groups (P = 0.004). Of note, we found the additive effect of PMQR genes; the more PMQR genes, the higher ciprofloxacin MICs.

CONCLUSIONS

CTX-M-15 was predominant among the cefotaxime-resistant K. pneumoniae and co-harboring CTX-M-15 and PMQR genes, especially qnrB, seems to contribute the spread of high risk clones.

Prevalence of plasmid-mediated quinolone resistance in Escherichia coli isolated from diseased animals in Taiwan

Escherichia coli (E. coli) is a zoonotic pathogen that often causes diarrhea, respiratory diseases or septicemia in animals. Fluoroquinolones are antimicrobial agents used to treat pathogenic E. coli infections. In this study, 1,221 E. coli strains were isolated between March, 2011 and February, 2014. The results of the antimicrobial susceptibility testing showed a high prevalence of quinolone resistance. The antimicrobial resistance rates of these E. coli isolates to nalidixic acid (NAL) were 72.0% in swine, 81.9% in chickens, 81.0% in turkeys, 64.0% in ducks and 73.2% in geese. Among these isolates, the positive rate for the plasmid-mediated quinolone resistance (PMQR) determinant was 14.8% (181/1,221); the detection rate for qnrS1 was the highest (10.2%), followed by aac(6')-Ib-cr (4.5%) and qnrB2 (0.3%). The quinolone-resistance determining regions (QRDRs) analysis for the PMQR-positive isolates showed that the strains with mutations at codon 83 or 87 in GyrA were resistant to NAL. To the best of our knowledge, this is the first report of occurrence of qnrB2, qnrS1 and aac(6')-Ib-cr genes and high frequency (56.4%; 102/181) of mutation in gyrA or parC among PMQR-positive E. coli strains derived from diseased animals in Taiwan.

Characterization of Extended-Spectrum β-Lactamase-Carrying Plasmids in Clinical Isolates of Klebsiella pneumoniae from Taiwan

We analyzed the replicon types, sizes, and restriction fragment length polymorphism (RFLP) typing of plasmids carrying extended-spectrum β-lactamase (ESBL) genes in Klebsiella pneumoniae isolates from Taiwan. Fifty-one Escherichia coli transconjugant strains with plasmids from ESBL-producing K. pneumoniae from the Taiwan Surveillance of Antimicrobial Resistance III Program in 2002 were included. All the 51 plasmids carried a bla_CTX-M gene, the majority of which were bla_CTX-M-3 (28/51 [54.9%]). Plasmids ranged in size from 126 to 241 kb by S1 nuclease digestion and subsequent pulsed-field gel electrophoresis, and the most common plasmid size (37.3%) was 161-170 kb. The most common replicon type of plasmids was incompatibility group (Inc)A/C (60.8%). The IncA/C plasmids all carried bla_CTX-M (bla_{CTX-M-3, -14, -15}), and some also carried bla_SHV (bla_{SHV-5, -12}) genes. All 51 plasmids could be typed with PstI, and 27 (52.9%) belonged to 10 clusters. Thirty-eight of the 51 plasmids were typable with BamHI, and 21 plasmids (55.3%) fell into 7 clusters. Plasmids in the same cluster belonged to the same incompatibility group, with the exception of cluster C6. In conclusion, IncA/C plasmids are the main plasmid type responsible for the dissemination of ESBL genes of K. pneumoniae from Taiwan. RFLP with PstI possessed better discriminatory power than that with BamHI and PCR-based replicon typing for ESBL-carrying plasmids in K. pneumoniae in this study. Greater than 50% of plasmids fell into clusters, and >60% of cluster-classified plasmids were present in clonally unrelated isolates, indicating that horizontal transfer of plasmids plays an important role in the spread of ESBL genes.

Plasmid-mediated quinolone resistance

Three mechanisms for plasmid-mediated quinolone resistance (PMQR) have been discovered since 1998. Plasmid genes qnrA, qnrB, qnrC, qnrD, qnrS, and qnrVC code for proteins of the pentapeptide repeat family that protects DNA gyrase and topoisomerase IV from quinolone inhibition. The qnr genes appear to have been acquired from chromosomal genes in aquatic bacteria, are usually associated with mobilizing or transposable elements on plasmids, and are often incorporated into sul1-type integrons. The second plasmid-mediated mechanism involves acetylation of quinolones with an appropriate amino nitrogen target by a variant of the common aminoglycoside acetyltransferase AAC(6')-Ib. The third mechanism is enhanced efflux produced by plasmid genes for pumps QepAB and OqxAB. PMQR has been found in clinical and environmental isolates around the world and appears to be spreading. The plasmid-mediated mechanisms provide only low-level resistance that by itself does not exceed the clinical breakpoint for susceptibility but nonetheless facilitates selection of higher-level resistance and makes infection by pathogens containing PMQR harder to treat.

SOS response and its regulation on the fluoroquinolone resistance

Bacteria can survive fluoroquinolone antibiotics (FQs) treatment by becoming resistant through a genetic change-mutation or gene acquisition. The SOS response is widespread among bacteria and exhibits considerable variation in its composition and regulation, which is repressed by LexA protein and derepressed by RecA protein. Here, we take a comprehensive review of the SOS gene network and its regulation on the fluoroquinolone resistance. As a unique survival mechanism, SOS may be an important factor influencing the outcome of antibiotic therapy in vivo.

Prolonged clonal spreading and dynamic changes in antimicrobial resistance of Escherichia coli ST68 among patients who stayed in a respiratory care ward

From 2007 to 2009, we collected a total of 83 bacteraemic isolates of Escherichia coli with reduced susceptibility or resistance to third-generation cephalosporins (TGCs). Isolates were genotyped by PFGE and multilocus sequence typing (MLST). The PFGE patterns revealed two highly correlated clusters (cluster E: nine isolates; cluster G: 22 isolates) associated with this prolonged clonal spreading. Compared with cluster E isolates, cluster G isolates were significantly more likely to harbour aac(6')-Ib-cr (P<0.05), and most of these isolates were isolated during a later year than cluster E isolates (P<0.05). By MLST analysis, 94% of cluster E and G isolates (29/31) were ST68. Although no time or space clustering could be identified by the conventional hospital-acquired infection monitoring system, E. coli cases caused by cluster E and G isolates were significantly associated with having stayed in our hospital's respiratory care ward (P<0.05). Isolates obtained from patients who had stayed in the respiratory care ward had a significantly higher rate of aac(6')-Ib-cr and blaCTX-M-14 positivity, and were more likely to belong to ST68/S68-like (all P<0.05). To our knowledge, this is the first report of prolonged clonal spreading caused by E. coli ST68 associated with a stay in a long-term care facility. Using epidemiological investigations and PFGE and MLST analyses, we have identified long-term clonal spreading caused by E. coli ST68, with extra antimicrobial-resistance genes possibly acquired during the prolonged spreading period.

Molecular analysis of ciprofloxacin resistance mechanisms in Malaysian ESBL-producing Klebsiella pneumoniae isolates and development of mismatch amplification mutation assays (MAMA) for rapid detection of gyrA and parC mutations

Ninety-three Malaysian extended-spectrum β-lactamase (ESBL)-producing Klebsiella pneumoniae isolates were investigated for ciprofloxacin resistance. Two mismatch amplification mutation (MAMA) assays were developed and used to facilitate rapid detection of gyrA and parC mutations. The isolates were also screened for plasmid-mediated quinolone resistance (PMQR) genes including aac(6′)-Ib-cr, qepA, and qnr. Ciprofloxacin resistance (MICs 4– ≥ 32 μg/mL) was noted in 34 (37%) isolates, of which 33 isolates had multiple mutations either in gyrA alone (n = 1) or in both gyrA and parC regions (n = 32). aac(6′)-Ib-cr was the most common PMQR gene detected in this study (n = 61), followed by qnrB and qnrS (n = 55 and 1, resp.). Low-level ciprofloxacin resistance (MICs 1-2 μg/mL) was noted in 40 (43%) isolates carrying qnrB accompanied by either aac(6′)-Ib-cr (n = 34) or a single gyrA 83 mutation (n = 6). Ciprofloxacin resistance was significantly associated with the presence of multiple mutations in gyrA and parC regions. While the isolates harbouring gyrA and/or parC alteration were distributed into 11 PFGE clusters, no specific clusters were associated with isolates carrying PMQR genes. The high prevalence of ciprofloxacin resistance amongst the Malaysian ESBL-producing K. pneumoniae isolates suggests the need for more effective infection control measures to limit the spread of these resistant organisms in the hospital.

Genotypic characteristics of multidrug-resistant Escherichia coli isolates associated with urinary tract infections

Escherichia coli is an important pathogen involved in community-acquired urinary tract infections (CA-UTIs). In this study, we analyzed the prevalence of frequently occurring genes and the distribution of integrons in 51 multidrug-resistant (MDR) E. coli isolates associated with CA-UTIs. The clonality of these strains was investigated by phylogrouping, multi-locus sequence typing, and pulsed-field gel electrophoresis (PFGE). All these strains were found to produce two or more resistance determinants, ceftazidime-hydrolyzing CTX-M-type extended-spectrum β-lactamases (ESBLs) and plasmid-mediated quinolone resistance determinants were the most prevalent (92.2% and 51.0%, respectively). A sulfhydryl variable-61-producing E. coli strain was identified for the first time in China. The prevalence of class 1 integrons was 54.9%, class 2 integrons were detected in three isolates but no isolate contained a class 3 integron. Phylogenetic group D was the dominant, observed in 70.6% of the isolates. PFGE analysis revealed a high level of diversity. Twenty-four distinctive sequence types (STs) including four major STs (ST648, ST224, ST38, and ST405) were identified. To our knowledge, this is the first report on the characterization of MDR E. coli isolates associated with CA-UTIs in China; our results suggest that an MDR D-ST648 clone producing CTX-M-ESBLs has emerged as a major clone in the community setting.

Outcome of nonadherence to antimicrobial treatment guidelines in ambulatory patients with acute cystitis: a nationwide population-based study

OBJECTIVE

The recurrence rate after acute cystitis treatment failure with inappropriate antimicrobials remains unclear. The goal of this study was to explore the relationship between cystitis recurrence and nonadherence of antimicrobial prescriptions to national guidelines using a nationwide population-based data set.

METHODS

This was a retrospective longitudinal observational cohort study that was conducted using the clinical records of the National Health Insurance Research Database in Taiwan from 2006-2007. After excluding patients younger than 18 years of age, with concurrent infections, urinary tract anomaly, and no antimicrobial treatment, the remaining study population included 36,395 patients with acute cystitis. We evaluated the hazard ratio (HR) of cystitis recurrence within 28 days between the adherence and nonadherence groups using Cox proportional hazard regression analysis.

RESULTS

Adherence to antimicrobial prescription guidelines was the factor that most strongly influenced acute cystitis recurrence, with a HR of 0.91 (95% confidence interval 0.87-0.95) after adjusting for all variables. The incidence rate of acute cystitis in patients receiving antimicrobials adherent to national guidelines was 59.78 per 10,000 person-days. The results of the likelihood ratio test indicated that age, sex, and guideline nonadherence were significant risk factors for recurrent cystitis. The percentage of first-generation cephalosporin prescription was 31.61%, making it the most frequently prescribed guideline-recommended drug.

CONCLUSION

Acute cystitis patients with or without multiple chronic comorbidities should be treated with antimicrobials that adhere to recommended guidelines to attain a better therapeutic outcome.

First Report of bla(IMP-8) in Raoultella planticola

Two carbapenem-resistant Raoultella planticola clinical isolates were isolated from patients with pneumonia and Port-A catheter-related bacteremia, respectively, in Taiwan. These isolates remained susceptible to fluoroquinolone, aminoglycoside, and colistin. Though the two isolates had the same antibiogram, plasmidic carbapenemase blaIMP-8, class 1 integron cassette (dfrA12-orfF-aadA2), and qnrB2, they had different pulsed-field gel electrophoresis patterns, plasmid sizes, and outer membrane protein loss profiles. To our knowledge, this is the first report of blaIMP-8 found in R. planticola. Interestingly, blaIMP-8 is the most common carbapenemase found in Klebsiella pneumoniae in Taiwan. In the literature, carbapenemase genes in R. planticola in each country were also found in carbapenem-resistant Enterobacteriaceae in the same country.

Risk factors for multidrug resistance in nosocomial bacteremia caused by extended-spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae

Increasing multidrug resistance (MDR) among extended-spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae (ESBL-EK) is of a great concern, because the therapeutic options are severely limited. Thus, we performed a case-control study to evaluate risk factors for MDR among nosocomial bacteremia caused by ESBL-EK. All adult patients with ESBL-EK bacteremia from January 2009 through December 2010 were identified at our institution. MDR was defined as ESBL-EK that demonstrated in vitro resistance to trimethoprim-sulfamethoxazole (TMP-SMX), fluoroquinolone (FQ), and gentamicin. Case patients were those with an MDR ESBL-EK isolate, and control patients were those with a non-MDR ESBL-EK isolate. Among a total of 123 ESBL-EK isolates (74 [60.2%] E. coli and 49 [39.8%] K. pneumoniae) causing nosocomial bacteremia, 33 (26.8%) cases were due to MDR ESBL-EK. In a univariate analysis, the factors significantly associated with acquisition of MDR ESBL-EK were neutropenia, immunosuppressant use, urinary tract infection, and prior use of antibiotics, especially FQ (all p<0.05). A multivariable analysis showed that a prior receipt of FQ (odds ratio [OR]=2.93; 95% confidence interval [CI]=1.07-8.01; p=0.036), percutaneous tube insertion (OR=4.04; 95% CI=1.56-10.75; p=0.005), and neutropenia (OR=4.22; 95% CI=1.56-11.45; p=0.005) were independent risk factors for MDR among ESBL-EK bacteremia in hospitalized patients. The CTX-M-15 enzyme was predominant in both the MDR ESBL-EK and non-MDR ESBL-EK groups (55% [11/20] vs. 55.6% [15/27]). Our data suggest that strategies designed to reduce MDR in ESBL-EK bacteremia should focus on limiting the use of FQ and minimizing invasive procedures such as tube insertion.