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Jiménez-Castellanos JC, Waclaw B, Meynert A, McAteer SP, Schneiders T. Rapid evolution of colistin resistance in a bioreactor model of infection of Klebsiella pneumoniae. Commun Biol 2024; 7:794. [PMID: 38951173 PMCID: PMC11217424 DOI: 10.1038/s42003-024-06378-0] [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: 03/16/2023] [Accepted: 05/23/2024] [Indexed: 07/03/2024] Open
Abstract
Colistin remains an important antibiotic for the therapeutic management of drug-resistant Klebsiella pneumoniae. Despite the numerous reports of colistin resistance in clinical strains, it remains unclear exactly when and how different mutational events arise resulting in reduced colistin susceptibility. Using a bioreactor model of infection, we modelled the emergence of colistin resistance in a susceptible isolate of K. pneumoniae. Genotypic, phenotypic and mathematical analyses of the antibiotic-challenged and un-challenged population indicates that after an initial decline, the population recovers within 24 h due to a small number of "founder cells" which have single point mutations mainly in the regulatory genes encoding crrB and pmrB that when mutated results in up to 100-fold reduction in colistin susceptibility. Our work underlines the rapid development of colistin resistance during treatment or exposure of susceptible K. pneumoniae infections having implications for the use of cationic antimicrobial peptides as a monotherapy.
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Affiliation(s)
- Juan-Carlos Jiménez-Castellanos
- Chemical Biology of Antibiotics, Centre for Infection & Immunity (CIIL), Pasteur Institute, INSERM U1019-CNRS UMR 9017, Lille, France
| | - Bartlomiej Waclaw
- School of Physics and Astronomy, The University of Edinburgh, JCMB, Edinburgh, UK.
- Dioscuri Centre for Physics and Chemistry of Bacteria, Institute of Physical Chemistry, Warsaw, Poland.
| | - Alison Meynert
- MRC Human Genetics Unit, MRC Institute of Genetics and Cancer, The University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Sean P McAteer
- Department of Bacteriology, The Roslin Institute and R(D) SVS, The University of Edinburgh, Easter Bush Campus, Midlothian, Edinburgh, UK
| | - Thamarai Schneiders
- Centre for Inflammation Research, Institute of Regeneration and Repair, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK.
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Sánchez-León I, Pérez-Nadales E, Marín-Sanz JA, García-Martínez T, Martínez-Martínez L. Heteroresistance to colistin in wild-type Klebsiella pneumoniae isolates from clinical origin. Microbiol Spectr 2023; 11:e0223823. [PMID: 37962370 PMCID: PMC10714954 DOI: 10.1128/spectrum.02238-23] [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: 05/29/2023] [Accepted: 10/13/2023] [Indexed: 11/15/2023] Open
Abstract
IMPORTANCE Colistin is one of the last remaining therapeutic options for dealing with Enterobacteriaceae. Unfortunately, heteroresistance to colistin is also rapidly increasing. We described the prevalence of colistin heteroresistance in a variety of wild-type strains of Klebsiella pneumoniae and the evolution of these strains with colistin heteroresistance to a resistant phenotype after colistin exposure and withdrawal. Resistant mutants were characterized at the molecular level, and numerous mutations in genes related to lipopolysaccharide formation were observed. In colistin-treated patients, the evolution of K. pneumoniae heteroresistance to resistance phenotype could lead to higher rates of therapeutic failure.
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Affiliation(s)
- Irene Sánchez-León
- Maimonides Biomedical Research Institute of Cordoba, Cordoba, Spain
- Department of Agricultural Chemistry, Edaphology and Microbiology, University of Cordoba, Cordoba, Spain
| | - Elena Pérez-Nadales
- Maimonides Biomedical Research Institute of Cordoba, Cordoba, Spain
- Department of Agricultural Chemistry, Edaphology and Microbiology, University of Cordoba, Cordoba, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Juan Antonio Marín-Sanz
- Maimonides Biomedical Research Institute of Cordoba, Cordoba, Spain
- Department of Computer Sciences, University of Cordoba, Cordoba, Spain
| | - Teresa García-Martínez
- Department of Agricultural Chemistry, Edaphology and Microbiology, University of Cordoba, Cordoba, Spain
| | - Luis Martínez-Martínez
- Maimonides Biomedical Research Institute of Cordoba, Cordoba, Spain
- Department of Agricultural Chemistry, Edaphology and Microbiology, University of Cordoba, Cordoba, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Clinical Unit of Microbiology, Reina Sofía University Hospital, Cordoba, Spain
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3
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Jia X, Yin Z, Zhang W, Du S. The Efficacy and Influencing Factors of Polymyxin B in High-Level Carbapenem-Resistant Klebsiella pneumoniae Infections. Infect Drug Resist 2023; 16:4177-4187. [PMID: 37396067 PMCID: PMC10314750 DOI: 10.2147/idr.s409090] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/30/2023] [Indexed: 07/04/2023] Open
Abstract
Background Polymyxin B (PMB) is a remedial treatment for carbapenem-resistant Klebsiella pneumoniae (CRKP) infection; however, there is a paucity of reports on the treatment of high-level CRKP infections with polymyxin B. Studies are needed to explore its treatment efficacy and associated influencing factors. Methods Patients with high-level CRKP infections treated with PMB during hospitalization from June 2019 to June 2021 in a hospital were retrospectively studied, and risk factors affecting the efficacy were explored by subgroup analysis. Results A total of 92 patients were enrolled, and the results showed that the PMB-based regimen had a bacterial clearance rate of 45.7%, an all-cause discharge mortality rate of 22.8%, and an incidence of acute kidney injury (AKI) of 27.2% for high-level CRKP treatment. The combination of β-lactams other than carbapenems facilitated bacterial clearance, and the combination of electrolyte disturbances and higher APACHE II scores was detrimental to microbial clearance. Risk factors for all-cause discharge mortality were advanced age, concomitant antifungal drugs, concomitant tigecycline and incidence of AKI. Conclusion PMB-based regimens are an effective option for the treatment of high-level CRKP infections. However, the optimal dose of treatment and the choice of combination regimens need to be explored in further studies.
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Affiliation(s)
- Xuedong Jia
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
- The Precision Clinical Pharmacy Key Laboratory of Henan Province, Zhengzhou, People’s Republic of China
| | - Zhao Yin
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
- The Precision Clinical Pharmacy Key Laboratory of Henan Province, Zhengzhou, People’s Republic of China
| | - Wan Zhang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
- The Precision Clinical Pharmacy Key Laboratory of Henan Province, Zhengzhou, People’s Republic of China
| | - Shuzhang Du
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
- The Precision Clinical Pharmacy Key Laboratory of Henan Province, Zhengzhou, People’s Republic of China
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4
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Sánchez-León I, García-Martínez T, Diene SM, Pérez-Nadales E, Martínez-Martínez L, Rolain JM. Heteroresistance to Colistin in Clinical Isolates of Klebsiella pneumoniae Producing OXA-48. Antibiotics (Basel) 2023; 12:1111. [PMID: 37508209 PMCID: PMC10375995 DOI: 10.3390/antibiotics12071111] [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: 05/31/2023] [Revised: 06/21/2023] [Accepted: 06/26/2023] [Indexed: 07/30/2023] Open
Abstract
Heteroresistance to colistin can be defined as the presence of resistant subpopulations in an isolate that is susceptible to this antibiotic. Colistin resistance in Gram-negative bacteria is more frequently related to chromosomal mutations and insertions. This work aimed to study heteroresistance in nine clinical isolates of Klebsiella pneumoniae producing OXA-48 and to describe genomic changes in mutants with acquired resistance in vitro. Antimicrobial susceptibility was determined by broth microdilution (BMD) and heteroresistance by population analysis profiling (PAP). The proteins related to colistin resistance were analyzed for the presence of mutations. Additionally, PCR of the mgrB gene was performed to identify the presence of insertions. In the nine parental isolates, the PAP method showed colistin heteroresistance of colonies growing on plates with concentrations of up to 64 mg/L, corresponding to stable mutant subpopulations. The MICs of some mutants from the PAP plate containing 4×MIC of colistin had absolute values of ≤2 mg/L that were higher than the parental MICs and were defined as persistent variants. PCR of the mgrB gene identified an insertion sequence that inactivated the gene in 21 mutants. Other substitutions in the investigated mutants were found in PhoP, PhoQ, PmrB, PmrC, CrrA and CrrB proteins. Colistin heteroresistance in K. pneumoniae isolates was attributed mainly to insertions in the mgrB gene and point mutations in colistin resistance proteins. The results of this study will improve understanding regarding the mechanisms of colistin resistance in mutants of K. pneumoniae producing OXA-48.
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Affiliation(s)
- Irene Sánchez-León
- Maimonides Biomedical Research Institute of Cordoba, 14004 Cordoba, Spain
- Department of Agricultural Chemistry, Edaphology and Microbiology, Agrifood Campus of International Excellence CeiA3, University of Cordoba, 14014 Cordoba, Spain
| | - Teresa García-Martínez
- Department of Agricultural Chemistry, Edaphology and Microbiology, Agrifood Campus of International Excellence CeiA3, University of Cordoba, 14014 Cordoba, Spain
| | - Seydina M Diene
- Microbes Evolution Phylogeny and Infections (MEPHI), IRD, APHM, IHU Méditerranée Infection, Faculté de Médecine et de Pharmacie, Aix-Marseille-University, 13005 Marseille, France
| | - Elena Pérez-Nadales
- Maimonides Biomedical Research Institute of Cordoba, 14004 Cordoba, Spain
- Department of Agricultural Chemistry, Edaphology and Microbiology, Agrifood Campus of International Excellence CeiA3, University of Cordoba, 14014 Cordoba, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Luis Martínez-Martínez
- Maimonides Biomedical Research Institute of Cordoba, 14004 Cordoba, Spain
- Department of Agricultural Chemistry, Edaphology and Microbiology, Agrifood Campus of International Excellence CeiA3, University of Cordoba, 14014 Cordoba, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Clinical Unit of Microbiology, Reina Sofía University Hospital, 14004 Cordoba, Spain
| | - Jean-Marc Rolain
- Microbes Evolution Phylogeny and Infections (MEPHI), IRD, APHM, IHU Méditerranée Infection, Faculté de Médecine et de Pharmacie, Aix-Marseille-University, 13005 Marseille, France
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5
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Li Z, Liu X, Lei Z, Li C, Zhang F, Wu Y, Yang X, Zhao J, Zhang Y, Hu Y, Shen F, Wang P, Yang J, Liu Y, Lu B. Genetic Diversity of Polymyxin-Resistance Mechanisms in Clinical Isolates of Carbapenem-Resistant Klebsiella pneumoniae: a Multicenter Study in China. Microbiol Spectr 2023; 11:e0523122. [PMID: 36847569 PMCID: PMC10100843 DOI: 10.1128/spectrum.05231-22] [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: 01/12/2023] [Accepted: 02/06/2023] [Indexed: 03/01/2023] Open
Abstract
Polymyxin has been the last resort to treat multidrug-resistant Klebsiella pneumonia. However, recent studies have revealed that polymyxin-resistant carbapenem-resistant Klebsiella pneumonia (PR-CRKP) emerged due to the mutations in chromosomal genes or the plasmid-harboring mcr gene, leading to lipopolysaccharide modification or efflux of polymyxin through pumps. Further surveillance was required. In the present study we collected PR-CRKP strains from 8 hospitals in 6 provinces/cities across China to identify the carbapenemase and polymyxin resistance genes and epidemiological features by whole-genome sequencing (WGS). The broth microdilution method (BMD) was performed to determine the MIC of polymyxin. Of 662 nonduplicate CRKP strains, 15.26% (101/662) were defined as PR-CRKP; 10 (9.90%) were confirmed as Klebsiella quasipneumoniae by WGS. The strains were further classified into 21 individual sequence types (STs) by using multilocus sequence typing (MLST), with ST11 being prevalent (68/101, 67.33%). Five carbapenemase types were identified among 92 CR-PRKP, blaKPC-2 (66.67%), blaNDM-1 (16.83%), blaNDM-5 (0.99%), blaIMP-4 (4.95%), and blaIMP-38 (0.99%). Notably, 2 PR-CRKP strains harbored both blaKPC-2 and blaNDM-1. The inactivation of mgrB, associated significantly with high-level polymyxin resistance, was mainly caused by the insertion sequence (IS) insertion (62.96%, 17/27). Furthermore, acrR was inserted coincidently by ISkpn26 (67/101, 66.33%). The deletion or splicing mutations of crrCAB were significantly associated with ST11 and KL47 (capsule locus types), and diverse mutations of the ramR gene were identified. Only one strain carried the mcr gene. In summary, the high IS-inserted mgrB inactivation, the close relationship between ST11 and the deletion or splicing mutations of the crrCAB, and the specific features of PR-K. quasipneumoniae constituted notable features of our PR-CRKP strains in China. IMPORTANCE Polymyxin-resistant CRKP is a serious public health threat whose resistance mechanisms should be under continuous surveillance. Here, we collected 662 nonduplicate CRKP strains across China to identify the carbapenemase and polymyxin resistance genes and epidemiological features. Polymyxin resistance mechanism in 101 PR-CRKP strains in China were also investigated, 9.8% of which (10/101) were K. quasipneumoniae, as determined via WGS, and inactivation of mgrB remained the most crucial polymyxin resistance mechanism, significantly related to high-level resistance. Deletion or splicing mutations of crrCAB were significantly associated with ST11 and KL47. Diverse mutations of the ramR gene were identified. The plasmid complementation experiment and mRNA expression analysis further confirmed that the mgrB promoter and ramR played a critical role in polymyxin resistance. This multicenter study contributed to the understanding of antibiotic resistance forms in China.
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Affiliation(s)
- Ziyao Li
- China-Japan Friendship Institute of Clinical Medical Sciences, Beijing, China
- Laboratory of Clinical Microbiology and Infectious Diseases, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xinmeng Liu
- Laboratory of Clinical Microbiology and Infectious Diseases, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Zichen Lei
- China-Japan Friendship Institute of Clinical Medical Sciences, Beijing, China
- Laboratory of Clinical Microbiology and Infectious Diseases, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Chen Li
- Laboratory of Clinical Microbiology and Infectious Diseases, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
- Liuyang Traditional Chinese Medicine Hospital, Changsha, Hunan, China
| | - Feilong Zhang
- Laboratory of Clinical Microbiology and Infectious Diseases, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Yongli Wu
- Laboratory of Clinical Microbiology and Infectious Diseases, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xinrui Yang
- Laboratory of Clinical Microbiology and Infectious Diseases, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jiankang Zhao
- Laboratory of Clinical Microbiology and Infectious Diseases, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Yulin Zhang
- Laboratory of Clinical Microbiology and Infectious Diseases, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Yanning Hu
- Laboratory of Clinical Microbiology and Infectious Diseases, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Fangfang Shen
- Heping Hospital affiliated with Changzhi Medical College, Changzhi, Shanxi, China
| | - Pingbang Wang
- The People’s Hospital of Liuyang, Changsha, Hunan, China
| | - Junwen Yang
- Department of Laboratory Medicine, Zhengzhou Key Laboratory of Children’s Infection and Immunity, Children’s Hospital Affiliated with Zhengzhou University, Zhengzhou, Henan, China
| | - Yulei Liu
- Department of Laboratory Medicine, Beijing Anzhen Hospital, Beijing, China
| | - Binghuai Lu
- China-Japan Friendship Institute of Clinical Medical Sciences, Beijing, China
- Laboratory of Clinical Microbiology and Infectious Diseases, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
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Sheng Q, Hou X, Wang Y, Wang N, Deng X, Wen Z, Li D, Li L, Zhou Y, Wang J. Naringenin Microsphere as a Novel Adjuvant Reverses Colistin Resistance via Various Strategies against Multidrug-Resistant Klebsiella pneumoniae Infection. JOURNAL OF AGRICULTURAL AND FOOD CHEMISTRY 2022; 70:16201-16217. [PMID: 36530172 DOI: 10.1021/acs.jafc.2c06615] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
The efficacy of colistin, the last option against multidrug-resistant (MDR) Gram-negative bacteria, is severely threatened by the prevalence of plasmid- or chromosome-mediated colistin resistance genes. Herein, naringenin has dramatically restored colistin sensitivity against colistin-resistant Klebsiella pneumoniae infection without affecting bacterial viability, inducing resistance and causing obvious cell toxicity. Mechanism analysis reveals that naringenin potentiates colistin activity by multiple strategies including inhibition of mobilized colistin resistance gene activity, repression of two-component system regulation, and acceleration of reactive oxygen species-mediated oxidative damage. A lung-targeted delivery system of naringenin microspheres has been designed to facilitate naringenin bioavailability, accompanied by an effective potentiation of colistin for Klebsiella pneumoniae infection. Consequently, a new recognition of naringenin microspheres has been elucidated to restore colistin efficacy against colistin-resistant Gram-negative pathogens, which may be an effective strategy of developing potential candidates for MDR Gram-negative bacteria infection.
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Affiliation(s)
- Qiushuang Sheng
- State Key Laboratory for Zoonotic Diseases, Key Laboratory for Zoonosis Research, Ministry of Education, College of Veterinary Medicine, Jilin University, Changchun 130012, China
| | - Xiaoning Hou
- State Key Laboratory for Zoonotic Diseases, Key Laboratory for Zoonosis Research, Ministry of Education, College of Veterinary Medicine, Jilin University, Changchun 130012, China
| | - Yang Wang
- Beijing Key Laboratory of Detection Technology for Animal-Derived Food Safety, College of Veterinary Medicine, China Agricultural University, Beijing 100107, China
| | - Nan Wang
- State Key Laboratory for Zoonotic Diseases, Key Laboratory for Zoonosis Research, Ministry of Education, College of Veterinary Medicine, Jilin University, Changchun 130012, China
| | - Xuming Deng
- State Key Laboratory for Zoonotic Diseases, Key Laboratory for Zoonosis Research, Ministry of Education, College of Veterinary Medicine, Jilin University, Changchun 130012, China
| | - Zhongmei Wen
- Department of Respiratory Medicine, Center for Pathogen Biology and Infectious Diseases, Key Laboratory of Organ Regeneration and Transplantation of the Ministry of Education, The First Hospital of Jilin University, Changchun 130021, Jilin, China
| | - Dan Li
- Department of Respiratory Medicine, Center for Pathogen Biology and Infectious Diseases, Key Laboratory of Organ Regeneration and Transplantation of the Ministry of Education, The First Hospital of Jilin University, Changchun 130021, Jilin, China
| | - Li Li
- State Key Laboratory for Zoonotic Diseases, Key Laboratory for Zoonosis Research, Ministry of Education, College of Veterinary Medicine, Jilin University, Changchun 130012, China
| | - Yonglin Zhou
- College of Veterinary Medicine, Jilin University, Changchun 130012, China
| | - Jianfeng Wang
- Wang-College of Veterinary Medicine, Jilin University, Changchun 130012, China
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7
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Ballaben AS, Galetti R, Ferreira JC, Paziani MH, Kress MRVZ, Garcia DDO, Silva PD, Doi Y, Darini ALC, Andrade LN. Different virulence genetic context of multidrug-resistant CTX-M- and KPC-producing Klebsiella pneumoniae isolated from cerebrospinal fluid. Diagn Microbiol Infect Dis 2022; 104:115784. [DOI: 10.1016/j.diagmicrobio.2022.115784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 06/30/2022] [Accepted: 07/22/2022] [Indexed: 11/03/2022]
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8
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Gomez-Simmonds A, Annavajhala MK, Tang N, Rozenberg FD, Ahmad M, Park H, Lopatkin AJ, Uhlemann AC. Population structure of blaKPC-harbouring IncN plasmids at a New York City medical centre and evidence for multi-species horizontal transmission. J Antimicrob Chemother 2022; 77:1873-1882. [PMID: 35412609 PMCID: PMC9633718 DOI: 10.1093/jac/dkac114] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 03/14/2022] [Indexed: 06/10/2024] Open
Abstract
BACKGROUND Carbapenem-resistant Enterobacterales (CRE) are highly concerning MDR pathogens. Horizontal transfer of broad-host-range IncN plasmids may contribute to the dissemination of the Klebsiella pneumoniae carbapenemase (KPC), spreading carbapenem resistance among unrelated bacteria. However, the population structure and genetic diversity of IncN plasmids has not been fully elucidated. OBJECTIVES We reconstructed blaKPC-harbouring IncN plasmid genomes to characterize shared gene content, structural variability, and putative horizontal transfer within and across patients and diverse bacterial clones. METHODS We performed short- and long-read sequencing and hybrid assembly on 45 CRE isolates with blaKPC-harbouring IncN plasmids. Eight serial isolates from two patients were included to assess intra-patient plasmid dynamics. Comparative genomic analysis was performed to assess structural and sequence similarity across plasmids. Within IncN sublineages defined by plasmid MLST and kmer-based clustering, phylogenetic analysis was used to identify closely related plasmids. RESULTS Comparative analysis of IncN plasmid genomes revealed substantial heterogeneity including large rearrangements in serial patient plasmids and differences in structure and content across plasmid clusters. Within plasmid sublineages, core genome content and resistance gene regions were largely conserved. Closely related plasmids (≤1 SNP) were found in highly diverse isolates, including ten pST6 plasmids found in eight bacterial clones from three different species. CONCLUSIONS Genomic analysis of blaKPC-harbouring IncN plasmids revealed the presence of several distinct sublineages as well as substantial host diversity within plasmid clusters suggestive of frequent mobilization. This study reveals complex plasmid dynamics within a single plasmid family, highlighting the challenge of tracking plasmid-mediated transmission of blaKPC in clinical settings.
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Affiliation(s)
- Angela Gomez-Simmonds
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, 630 W 168th St, New York NY 10032, USA
| | - Medini K Annavajhala
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, 630 W 168th St, New York NY 10032, USA
| | - Nina Tang
- Barnard College, Columbia University, 3009 Broadway, New York NY 10027, USA
| | - Felix D Rozenberg
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, 630 W 168th St, New York NY 10032, USA
| | - Mehrose Ahmad
- Barnard College, Columbia University, 3009 Broadway, New York NY 10027, USA
| | - Heekuk Park
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, 630 W 168th St, New York NY 10032, USA
| | - Allison J Lopatkin
- Barnard College, Columbia University, 3009 Broadway, New York NY 10027, USA
- Data Science Institute, Columbia University, 550 W 120th St, New York NY 10027, USA
| | - Anne Catrin Uhlemann
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, 630 W 168th St, New York NY 10032, USA
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9
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Wong Fok Lung T, Charytonowicz D, Beaumont KG, Shah SS, Sridhar SH, Gorrie CL, Mu A, Hofstaedter CE, Varisco D, McConville TH, Drikic M, Fowler B, Urso A, Shi W, Fucich D, Annavajhala MK, Khan IN, Oussenko I, Francoeur N, Smith ML, Stockwell BR, Lewis IA, Hachani A, Upadhyay Baskota S, Uhlemann AC, Ahn D, Ernst RK, Howden BP, Sebra R, Prince A. Klebsiella pneumoniae induces host metabolic stress that promotes tolerance to pulmonary infection. Cell Metab 2022; 34:761-774.e9. [PMID: 35413274 PMCID: PMC9081115 DOI: 10.1016/j.cmet.2022.03.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/18/2022] [Accepted: 03/22/2022] [Indexed: 12/21/2022]
Abstract
K. pneumoniae sequence type 258 (Kp ST258) is a major cause of healthcare-associated pneumonia. However, it remains unclear how it causes protracted courses of infection in spite of its expression of immunostimulatory lipopolysaccharide, which should activate a brisk inflammatory response and bacterial clearance. We predicted that the metabolic stress induced by the bacteria in the host cells shapes an immune response that tolerates infection. We combined in situ metabolic imaging and transcriptional analyses to demonstrate that Kp ST258 activates host glutaminolysis and fatty acid oxidation. This response creates an oxidant-rich microenvironment conducive to the accumulation of anti-inflammatory myeloid cells. In this setting, metabolically active Kp ST258 elicits a disease-tolerant immune response. The bacteria, in turn, adapt to airway oxidants by upregulating the type VI secretion system, which is highly conserved across ST258 strains worldwide. Thus, much of the global success of Kp ST258 in hospital settings can be explained by the metabolic activity provoked in the host that promotes disease tolerance.
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Affiliation(s)
| | - Daniel Charytonowicz
- Department of Genetics and Genomic Sciences, Mt. Sinai Icahn School of Medicine, New York, NY 10029, USA
| | - Kristin G Beaumont
- Department of Genetics and Genomic Sciences, Mt. Sinai Icahn School of Medicine, New York, NY 10029, USA
| | - Shivang S Shah
- Department of Pediatrics, Columbia University, New York, NY 10032, USA
| | - Shwetha H Sridhar
- Department of Genetics and Genomic Sciences, Mt. Sinai Icahn School of Medicine, New York, NY 10029, USA
| | - Claire L Gorrie
- Department of Microbiology and Immunology, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC 3000, Australia
| | - Andre Mu
- Department of Microbiology and Immunology, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC 3000, Australia
| | - Casey E Hofstaedter
- Department of Microbial Pathogenesis, University of Maryland, Baltimore, MD 21201, USA
| | - David Varisco
- Department of Microbial Pathogenesis, University of Maryland, Baltimore, MD 21201, USA
| | | | - Marija Drikic
- Department of Biological Sciences, University of Calgary, Calgary, T2N 1N4, Canada
| | - Brandon Fowler
- Microbiome & Pathogen Genomics Collaborative Center, Columbia University, New York, NY 10032, USA
| | - Andreacarola Urso
- Department of Pediatrics, Columbia University, New York, NY 10032, USA
| | - Wei Shi
- Department of Pediatrics, Columbia University, New York, NY 10032, USA
| | - Dario Fucich
- Department of Pediatrics, Columbia University, New York, NY 10032, USA
| | - Medini K Annavajhala
- Department of Medicine, Columbia University, New York, NY 10032, USA; Microbiome & Pathogen Genomics Collaborative Center, Columbia University, New York, NY 10032, USA
| | - Ibrahim N Khan
- Department of Pediatrics, Columbia University, New York, NY 10032, USA
| | - Irina Oussenko
- Department of Genetics and Genomic Sciences, Mt. Sinai Icahn School of Medicine, New York, NY 10029, USA
| | - Nancy Francoeur
- Department of Genetics and Genomic Sciences, Mt. Sinai Icahn School of Medicine, New York, NY 10029, USA
| | - Melissa L Smith
- Department of Genetics and Genomic Sciences, Mt. Sinai Icahn School of Medicine, New York, NY 10029, USA
| | - Brent R Stockwell
- Department of Chemistry, Columbia University, New York, NY 10027, USA; Department of Biological Sciences, Columbia University, New York, NY 10027, USA
| | - Ian A Lewis
- Department of Biological Sciences, University of Calgary, Calgary, T2N 1N4, Canada
| | - Abderrahman Hachani
- Department of Microbiology and Immunology, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC 3000, Australia
| | | | - Anne-Catrin Uhlemann
- Department of Medicine, Columbia University, New York, NY 10032, USA; Microbiome & Pathogen Genomics Collaborative Center, Columbia University, New York, NY 10032, USA
| | - Danielle Ahn
- Department of Pediatrics, Columbia University, New York, NY 10032, USA
| | - Robert K Ernst
- Department of Microbial Pathogenesis, University of Maryland, Baltimore, MD 21201, USA
| | - Benjamin P Howden
- Department of Microbiology and Immunology, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC 3000, Australia; Microbiological Diagnostic Unit Public Health Laboratory, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC 3000, Australia
| | - Robert Sebra
- Department of Genetics and Genomic Sciences, Mt. Sinai Icahn School of Medicine, New York, NY 10029, USA; Sema4: A Mount Sinai Venture, Stamford, CT 06902, USA
| | - Alice Prince
- Department of Pediatrics, Columbia University, New York, NY 10032, USA.
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10
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Bray AS, Smith RD, Hudson AW, Hernandez GE, Young TM, George HE, Ernst RK, Zafar MA. MgrB-Dependent Colistin Resistance in Klebsiella pneumoniae Is Associated with an Increase in Host-to-Host Transmission. mBio 2022; 13:e0359521. [PMID: 35311534 PMCID: PMC9040857 DOI: 10.1128/mbio.03595-21] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/08/2022] [Indexed: 12/22/2022] Open
Abstract
Due to its high transmissibility, Klebsiella pneumoniae is one of the leading causes of nosocomial infections. Here, we studied the biological cost of colistin resistance, an antibiotic of last resort, in this opportunistic pathogen using a murine model of gut colonization and transmission. Colistin resistance in K. pneumoniae is commonly the result of the inactivation of the small regulatory protein MgrB. Without a functional MgrB, the two-component system PhoPQ is constitutively active, leading to an increase in lipid A modifications and subsequent colistin resistance. Using an isogenic mgrB deletion mutant (MgrB-), we demonstrate that the mutant's colistin resistance is not associated with a fitness defect under in vitro growth conditions. However, in our murine model of K. pneumoniae gastrointestinal (GI) colonization, the MgrB- colonizes the gut poorly, allowing us to identify a fitness cost. Moreover, the MgrB- mutant has higher survival outside the host compared with the parental strain. We attribute this enhanced survivability to dysregulation of the PhoPQ two-component system and accumulation of the master stress regulator RpoS. The enhanced survival of MgrB- may be critical for its rapid host-to-host transmission observed in our model. Together, our data using multiple clinical isolates demonstrate that MgrB-dependent colistin resistance in K. pneumoniae comes with a biological cost in gut colonization. However, this cost is mitigated by enhanced survival outside the host and consequently increases its host-to-host transmission. Additionally, it underscores the importance of considering the entire life cycle of a pathogen to determine the actual biological cost associated with antibiotic resistance. IMPORTANCE The biological cost associated with colistin resistance in Klebsiella pneumoniae was examined using a murine model of K. pneumoniae gut colonization and fecal-oral transmission. A common mutation resulting in colistin resistance in K. pneumoniae is a loss-of-function mutation of the small regulatory protein MgrB that regulates the two-component system PhoPQ. Even though colistin resistance in K. pneumoniae comes with a fitness defect in gut colonization, it increases bacterial survival outside the host enabling it to transmit more effectively to a new host. The enhanced survival is dependent upon the accumulation of RpoS and dysregulation of the PhoPQ. Hence, our study expands our understanding of the underlying molecular mechanism contributing to the transmission of colistin-resistant K. pneumoniae.
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Affiliation(s)
- Andrew S. Bray
- Department of Microbiology and Immunology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Richard D. Smith
- Department of Microbial Pathogenesis, University of Maryland, Baltimore, Baltimore, Maryland, USA
- Department of Pathology, University of Maryland, Baltimore, Baltimore, Maryland, USA
| | - Andrew W. Hudson
- Department of Microbiology and Immunology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Giovanna E. Hernandez
- Department of Microbiology and Immunology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Taylor M. Young
- Department of Microbiology and Immunology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | | | - Robert K. Ernst
- Department of Microbial Pathogenesis, University of Maryland, Baltimore, Baltimore, Maryland, USA
| | - M. Ammar Zafar
- Department of Microbiology and Immunology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
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11
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Elias R, Spadar A, Phelan J, Melo-Cristino J, Lito L, Pinto M, Gonçalves L, Campino S, Clark TG, Duarte A, Perdigão J. A phylogenomic approach for the analysis of colistin resistance associated genes in Klebsiella pneumoniae, its mutational diversity and implications for phenotypic resistance. Int J Antimicrob Agents 2022; 59:106581. [DOI: 10.1016/j.ijantimicag.2022.106581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/17/2022] [Accepted: 03/27/2022] [Indexed: 11/05/2022]
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12
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Characterization of Amino Acid Substitution W20S in MgrB Involved in Polymyxin Resistance in Klebsiella pneumoniae. Microbiol Spectr 2022; 10:e0176621. [PMID: 35171013 PMCID: PMC8849082 DOI: 10.1128/spectrum.01766-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In the major human pathogen Klebsiella pneumoniae, MgrB inactivation by disruptive insertion sequence (IS) elements and mutations leading to early termination are known to play an important role in polymyxin resistance. In this study, we examined a collection of invasive blaKPC-2-producing K. pneumoniae isolates belonging to the high-risk clone sequence type 258 (ST258) displaying high rates of resistance to many antimicrobials, including polymyxins. We identified a deleterious substitution (W20S) in MgrB and confirmed by genetic complementation analysis that this variant was inactive, leading to increased polymyxin B and colistin MICs. IMPORTANCE Carbapenem-resistant Gram-negative bacteria are designated critical pathogens by the World Health Organization. Polymyxins (i.e., polymyxin B and colistin) are last-resort antibiotics and particularly useful against these multidrug-resistant bacteria. In Klebsiella pneumoniae, the inactivation of MgrB, a negative regulator of PhoPQ, was shown to be the major pathway leading to colistin resistance. While gene disruption by insertion sequence (IS) elements and mutations leading to early termination (stop codons) are frequent, deleterious mutations are not observed frequently and have not been characterized. Here, we identified a deleterious substitution (W20S) in MgrB among a collection of bloodstream infection, blaKPC-2-producing K. pneumoniae sequence type 258 (ST258) isolates, displaying high rates of resistance to polymyxins and associated with a high mortality rate. The dissemination of such a MgrB-W20S mutation leading to polymyxin resistance within the ST258 high-risk clone background is problematic and thus warrants particular attention.
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13
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Chen X, Tian J, Luo C, Wang X, Li X, Wang M. Cell Membrane Remodeling Mediates Polymyxin B Resistance in Klebsiella pneumoniae: An Integrated Proteomics and Metabolomics Study. Front Microbiol 2022; 13:810403. [PMID: 35222333 PMCID: PMC8866958 DOI: 10.3389/fmicb.2022.810403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 01/14/2022] [Indexed: 11/26/2022] Open
Abstract
Polymyxin B (PB) is introduced into the clinic as the last-line therapy against carbapenem-resistant Klebsiella pneumoniae (CRKP). Unfortunately, increased resistance to PB in Klebsiella pneumoniae (K. pneumoniae) has threatened global health. Resistance of K. pneumoniae to PB was induced by passaging in serial concentrations of PB and determined by microbroth dilution method. Growth characteristics of induced strains including growth curve, reversibility of resistance, and biofilm formation (crystal violet staining method) were measured. This study employed TMT-labeled quantitative proteomics and LC-MS/MS metabolomics analysis to investigate the key biological processes associated with PB resistance in K. pneumoniae. A total of 315 differentially expressed proteins (DEPs) were identified, of which 133 were upregulated and 182 were downregulated in the PB-resistant K. pneumoniae. KEGG enrichment analysis revealed that the DEPs were mainly involved in ATP-binding cassette (ABC) transporters and cationic antimicrobial peptide (CAMP) resistance. Proteins related to central carbon metabolism were inhibited in the PB-resistant K. pneumoniae, but proteins mediating LPS modification were activated. Transcriptional levels of CAMP resistance-related proteins were significantly different between PB-susceptible and -resistant K. pneumoniae. PB treatment led to an increase in reactive oxygen species (ROS) levels of K. pneumoniae. Metabolomics data demonstrated that 23 metabolites were significantly upregulated in PB-resistant K. pneumoniae and 5 were downregulated. The differential metabolites were mainly lipids, including glycerophospholipids, sphingolipids, and fatty acids. Exposure to PB resulted in increased level of phospholipid transport gene mlaF in K. pneumoniae. Our study suggested that membrane remodeling and inhibited central carbon metabolism are conducive to the development of PB resistance in K. pneumoniae.
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14
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Fordham SME, Mantzouratou A, Sheridan E. Prevalence of insertion sequence elements in plasmids relating to mgrB gene disruption causing colistin resistance in Klebsiella pneumoniae. Microbiologyopen 2022; 11:e1262. [PMID: 35212479 PMCID: PMC8796155 DOI: 10.1002/mbo3.1262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 01/04/2022] [Indexed: 12/05/2022] Open
Abstract
Colistin is a last resort antibiotic for the treatment of carbapenemase producing Klebsiella pneumoniae. The disruption of the mgrB gene by insertion sequences (ISs) is a mechanism mediating colistin resistance. Plasmids encode mobilizable IS elements which integrate into the mgrB gene in K. pneumoniae causing gene inactivation and colistin resistance. The species prevalence of mgrB-gene disrupting insertion elements ISL3 (ISKpn25), IS5 (ISKpn26), ISKpn14, and IS903B present on plasmids were assessed. IS containing plasmids were also scanned for antimicrobial resistance genes, including carbapenem resistant genes. Plasmids encoding ISs are abundant in K. pneumoniae. IS903B was found in 28 unique Inc groups, while ISKpn25 was largely carried by IncFIB(pQil) plasmids. ISKpn26 and ISKpn14 were most often found associated with IncFII(pHN7A8) plasmids. Of the 34 unique countries which contained any of the IS elements, ISKpn25 was identified from 26. ISKpn26, ISKpn14, and IS903B ISs were identified from 89.3%, 44.9%, and 23.9% plasmid samples from China. Plasmids carrying ISKpn25, ISKpn14, and ISKpn26 IS have a 4.6-, 6.0-, and 6.6-fold higher carbapenemase gene count, respectively, relative to IS903B-carrying plasmids. IS903B bearing plasmids have a 20-, 5-, and 5-fold higher environmental source isolation count relative to ISKpn25, ISKpn14, and ISKpn26 bearing plasmids. ISKpn25 present on IncFIB(pQil) sourced from clinical settings is established across multiple countries, while ISKpn26, ISKpn14, and IS903B appear most often in China. Carbapenemase presence in tandem with IS elements may help promote an extensively drug resistant profile in K. pneumoniae limiting already narrow treatment options.
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Affiliation(s)
| | - Anna Mantzouratou
- Department of Life & Environmental SciencesBournemouth UniversityPooleUK
| | - Elizabeth Sheridan
- Department of Medical MicrobiologyUniversity Hospitals Dorset NHS Foundation Trust, Poole HospitalPooleUK
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15
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Huang W, Zhang J, Zeng L, Yang C, Yin L, Wang J, Li J, Li X, Hu K, Zhang X, Liu B. Carbapenemase Production and Epidemiological Characteristics of Carbapenem-Resistant Klebsiella pneumoniae in Western Chongqing, China. Front Cell Infect Microbiol 2022; 11:775740. [PMID: 35071036 PMCID: PMC8769044 DOI: 10.3389/fcimb.2021.775740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 12/13/2021] [Indexed: 11/29/2022] Open
Abstract
Background This study aimed to determine the molecular characteristics of carbapenem-resistant Klebsiella pneumoniae (CRKP) isolates in a hospital in western Chongqing, southwestern China. Methods A total of 127 unique CRKP isolates were collected from the Yongchuan Hospital of Chongqing Medical University, identified using a VITEK-2 compact system, and subjected to microbroth dilution to determine the minimal inhibitory concentration. Enterobacteriaceae intergenic repeat consensus polymerase chain reaction and multilocus sequence typing were used to analyze the homology among the isolates. Genetic information, including resistance and virulence genes, was assessed using polymerase chain reaction. The genomic features of the CRKP carrying gene blaKPC-2 were detected using whole-genome sequencing. Results ST11 was the dominant sequence type in the homology comparison. The resistance rate to ceftazidime-avibactam in children was much higher than that in adults as was the detection rate of the resistance gene blaNDM (p < 0.0001). Virulence genes such as mrkD (97.6%), uge (96.9%), kpn (96.9%), and fim-H (84.3%) had high detection rates. IncF (57.5%) was the major replicon plasmid detected, and sequencing showed that the CRKP063 genome contained two plasmids. The plasmid carrying blaKPC-2, which mediates carbapenem resistance, was located on the 359,625 base pair plasmid IncFII, together with virulence factors, plasmid replication protein (rep B), stabilizing protein (par A), and type IV secretion system (T4SS) proteins that mediate plasmid conjugation transfer. Conclusion Our study aids in understanding the prevalence of CRKP in this hospital and the significant differences between children and adults, thus providing new ideas for clinical empirical use of antibiotics.
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Affiliation(s)
- Wan Huang
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Jisheng Zhang
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Lingyi Zeng
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China.,Department of Microbiology, Jiaxing Maternity and Child Health Care Hospital, Jiaxing, China
| | - Chengru Yang
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China.,Department of Microbiology, The First Affiliated Hospital of Jiamusi University, Jiamusi, China
| | - Lining Yin
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China.,Department of Microbiology, The First Affiliated Hospital of Jiamusi University, Jiamusi, China
| | - Jianmin Wang
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Jie Li
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Xinhui Li
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Kewang Hu
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China.,Department of Microbiology, Affiliated Hangzhou Xixi Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaoli Zhang
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China.,Department of Microbiology, The First Affiliated Hospital of Jiamusi University, Jiamusi, China
| | - Beizhong Liu
- Central Laboratory of Yongchuan Hospital, Chongqing Medical University, Chongqing, China
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16
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Ekelund O, Klokkhammer Hetland MA, Høyland Löhr I, Schön T, Somajo S. Rapid high-resolution detection of colistin resistance in Gram-negative bacteria using flow cytometry: a comparison with broth microdilution, a commercial screening test and WGS. J Antimicrob Chemother 2021; 76:3183-3191. [PMID: 34477846 PMCID: PMC8598304 DOI: 10.1093/jac/dkab328] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 08/08/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Even though both EUCAST and CLSI consider broth microdilution (BMD) as the reference method for antimicrobial susceptibility testing (AST) of colistin, the method exhibits potential flaws related to properties of the colistin molecule. OBJECTIVES To develop a flow cytometry method (FCM) for colistin AST and to validate it against BMD, a commercial screening test and WGS. METHODS Colistin-mediated loss of membrane integrity in Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter spp. was detected with the fluorescent probe YoPro-1 by FCM. An international collection of 65 resistant and 109 susceptible isolates were analysed and the colistin concentration required to reach the EC50 was compared with the BMD MIC and the presence of genotypic resistance markers. RESULTS The overall FCM sensitivity and specificity for colistin resistance was 89% and 94%, with E. coli > K. pneumoniae > P. aeruginosa, whereas the performance for Acinetobacter spp. was poor. All tested E. coli were correctly categorized. Three K. pneumoniae isolates with genotypic findings consistent with colistin resistance were detected by FCM but not BMD. Compared with BMD, FCM delivered AST results with a 75% reduction of time. CONCLUSIONS Here, we present a rapid FCM-based AST assay for qualitative and quantitative testing of colistin resistance in E. coli and K. pneumoniae. The assay revealed probable chromosomal colistin resistance in K. pneumoniae that was not detected by BMD. If confirmed, these results question the reliability of BMD for colistin testing.
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Affiliation(s)
- Oskar Ekelund
- Department of Clinical Microbiology, Växjö Central Hospital, Växjö, Sweden.,Department of Clinical Microbiology, Blekinge County Hospital, Karlskrona, Sweden
| | - Marit Andrea Klokkhammer Hetland
- Department of Medical Microbiology, Stavanger University Hospital, Stavanger, Norway.,Department of Biological Sciences, Faculty of Mathematics and Natural Sciences, University of Bergen, Bergen, Norway
| | - Iren Høyland Löhr
- Department of Medical Microbiology, Stavanger University Hospital, Stavanger, Norway
| | - Thomas Schön
- Department of Biomedical and Clinical Sciences, Division of Infectious Diseases, Linköping University, Sweden.,Department of Infectious Diseases, Kalmar County Hospital, Sweden and Linköping University Hospital, Sweden
| | - Sofia Somajo
- Department of Clinical Microbiology, Blekinge County Hospital, Karlskrona, Sweden
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17
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Binsker U, Käsbohrer A, Hammerl JA. Global colistin use: A review of the emergence of resistant Enterobacterales and the impact on their genetic basis. FEMS Microbiol Rev 2021; 46:6382128. [PMID: 34612488 PMCID: PMC8829026 DOI: 10.1093/femsre/fuab049] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 10/04/2021] [Indexed: 02/06/2023] Open
Abstract
The dramatic global rise of MDR and XDR Enterobacterales in human medicine forced clinicians to the reintroduction of colistin as last-resort drug. Meanwhile, colistin is used in the veterinary medicine since its discovery, leading to a steadily increasing prevalence of resistant isolates in the livestock and meat-based food sector. Consequently, transmission of resistant isolates from animals to humans, acquisition via food and exposure to colistin in the clinic are reasons for the increased prevalence of colistin-resistant Enterobacterales in humans in the last decades. Initially, resistance mechanisms were caused by mutations in chromosomal genes. However, since the discovery in 2015, the focus has shifted exclusively to mobile colistin resistances (mcr). This review will advance the understanding of chromosomal-mediated resistance mechanisms in Enterobacterales. We provide an overview about genes involved in colistin resistance and the current global situation of colistin-resistant Enterobacterales. A comparison of the global colistin use in veterinary and human medicine highlights the effort to reduce colistin sales in veterinary medicine under the One Health approach. In contrast, it uncovers the alarming rise in colistin consumption in human medicine due to the emergence of MDR Enterobacterales, which might be an important driver for the increasing emergence of chromosome-mediated colistin resistance.
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Affiliation(s)
- Ulrike Binsker
- Department Biological Safety, German Federal Institute for Risk Assessment, Berlin, Germany
| | - Annemarie Käsbohrer
- Department Biological Safety, German Federal Institute for Risk Assessment, Berlin, Germany.,Department for Farm Animals and Veterinary Public Health, Institute of Veterinary Public Health, University of Veterinary Medicine Vienna, Vienna, Austria
| | - Jens A Hammerl
- Department Biological Safety, German Federal Institute for Risk Assessment, Berlin, Germany
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18
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Xia GL, Jiang RL. Efficacy and safety of polymyxin B in carbapenem-resistant gram-negative organisms infections. BMC Infect Dis 2021; 21:1034. [PMID: 34607561 PMCID: PMC8488323 DOI: 10.1186/s12879-021-06719-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 09/21/2021] [Indexed: 11/17/2022] Open
Abstract
Objective To investigate how to use polymyxin B rationally in order to produce the best efficacy and safety in patients with carbapenem-resistant gram-negative organisms (CRO) infection. Methods The clinical characteristics and microbiological results of 181 patients caused by CRO infection treated with polymyxin B in the First Affiliated Hospital from July 2018 to May 2020 were retrospectively analyzed. The bacterial clearance rate, clinical efficacy, adverse drug reactions and 28 days mortality were evaluated. Results The overall effective rate of 181 patients was 49.72%, the total bacterial clearance rate was 42.0%, and the 28 day all-cause mortality rate was 59.1%. The effective rate and bacterial clearance rate in the group of less than 24 h from the isolation of CRO to the use of polymyxin B were significantly higher than those in the group of more than 24 h. Logistics multivariate regression analysis showed that the predictive factors for effective treatment of CRO with polymyxin B were APACHEII score, duration of polymyxin B treatment, combination of polymyxin B and other antibiotics, and bacterial clearance. 17 cases (9.36%) of acute kidney injury were considered as polymyxin B nephrotoxicity and 4 cases (23.5%) recovered after polymyxin B withdrawal. After 14 days of polymyxin B use, 3 cases of polymyxin B resistance appeared, and there were 2 cases of polymyxin B resistance in the daily dose 1.5 mg/kg/day group. Conclusion For CRO infection, the treatment of polymyxin B should be early, combined, optimal dose and duration of treatment, which can achieve better clinical efficacy and microbial reactions, and reduce the adverse reactions and drug resistance.
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Affiliation(s)
- G L Xia
- Department of Intensive Care Unit, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine), Hangzhou, China
| | - R L Jiang
- Department of Intensive Care Unit, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine), NO. 54 Youdian Road, Hangzhou, 310006, China.
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19
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Genotyping of paired KPC-producing Klebsiella pneumoniae isolates with and without divergent polymyxin B susceptibility profiles. Braz J Microbiol 2021; 52:1981-1989. [PMID: 34460074 DOI: 10.1007/s42770-021-00600-5] [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: 04/26/2021] [Accepted: 08/19/2021] [Indexed: 10/20/2022] Open
Abstract
Polymyxins are still used mainly in treating infections caused by carbapenem-resistant Klebsiella pneumoniae worldwide. The most frequent mechanism of acquired resistance to polymyxins in Gram-negative bacilli is the occurrence of mutations in chromosomal genes regulating operons responsible for lipopolysaccharide modification. As we observed at Santa Casa de São Paulo hospital the occurrence of infections caused by isolates resistant to polymyxins in patients previously treated with this antimicrobial, and new infections caused by the same polymyxin-susceptible species, in this study, we aimed to determine the clonality of consecutive K. pneumoniae isolates from the same patients and characterize the molecular determinants of polymyxin resistance in paired or clonal isolates. A total of 24 pairs and one trio of K. pneumoniae isolates were included in this study. Species identification was achieved by mass spectrometry and multiplex PCR. Polymyxin B minimal inhibitory concentrations were determined by broth microdilution. Clonality was evaluated using pulsed-field gel electrophoresis. The presence of insertions in mgrB gene was tested by PCR, and mutations on pmrA, pmrB, phoP, and phoQ were evaluated by PCR and complete nucleotide sequencing. A fraction of 23.8% of strains resistant to polymyxin B had an insertion in mgrB. Amino acid substitution F204L in PmrB may be implicated in polymyxin resistance. Substitutions T246A and R256G in PmrB were not implicated in polymyxin resistance. In this study, polymyxin resistance after a first susceptible isolate was detected was most frequently due to an infection caused by a distinct clone.
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20
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Mills JP, Rojas LJ, Marshall SH, Rudin SD, Hujer AM, Nayak L, Bachman MA, Bonomo RA, Kaye KS. Risk Factors for and Mechanisms of COlistin Resistance Among Enterobacterales: Getting at the CORE of the Issue. Open Forum Infect Dis 2021; 8:ofab145. [PMID: 34285928 PMCID: PMC8286092 DOI: 10.1093/ofid/ofab145] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/31/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Despite the recent emergence of plasmid-mediated colistin resistance, the epidemiology and mechanisms of colistin-resistant Enterobacterales (CORE) infections remain poorly understood. METHODS A case-case-control study was conducted utilizing routine clinical isolates obtained at a single tertiary health system in Ann Arbor, Michigan. Patients with CORE isolates from January 1, 2016, to March 31, 2017, were matched 1:1 with patients with colistin-susceptible Enterobacterales (COSE) and uninfected controls. Multivariable logistic regression was used to compare clinical and microbiologic features of patients with CORE and COSE to controls. A subset of available CORE isolates underwent whole-genome sequencing to identify putative colistin resistance genes. RESULTS Of 16 373 tested clinical isolates, 166 (0.99%) were colistin-resistant, representing 103 unique patients. Among 103 CORE isolates, 103 COSE isolates, and 102 uninfected controls, antibiotic exposure in the antecedent 90 days and age >55 years were predictors of both CORE and COSE. Of 33 isolates that underwent whole-genome sequencing, a large variety of mutations associated with colistin resistance were identified, including 4 mcr-1/mcr-1.1 genes and 4 pmrA/B mutations among 9 Escherichia coli isolates and 5 mgrB and 3 PmrA mutations among 8 Klebsiella pneumoniae isolates. Genetic mutations found in Enterobacter species were not associated with known phenotypic colistin resistance. CONCLUSIONS Increased age and prior antibiotic receipt were associated with increased risk for patients with CORE and for patients with COSE. Mcr-1, pmrA/B, and mgrB were the predominant colistin resistance-associated mutations identified among E. coli and K. pneumoniae, respectively. Mechanisms of colistin resistance among Enterobacter species could not be determined.
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Affiliation(s)
- John P Mills
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Laura J Rojas
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Steve H Marshall
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Susan D Rudin
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Andrea M Hujer
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Luke Nayak
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael A Bachman
- Department of Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Robert A Bonomo
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
- Departments of Pharmacology, Molecular Biology and Microbiology, Biochemistry, and Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Cleveland, Ohio, USA
| | - Keith S Kaye
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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21
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A Bibliometric Meta-Analysis of Colistin Resistance in Klebsiella pneumoniae. Diseases 2021; 9:diseases9020044. [PMID: 34202931 PMCID: PMC8293170 DOI: 10.3390/diseases9020044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/15/2021] [Accepted: 06/15/2021] [Indexed: 11/16/2022] Open
Abstract
Colistin is a last resort antibiotic medication for the treatment of infections caused by carbapenem-resistant Klebsiella pneumoniae. In recent years, various mechanisms have been reported to mediate colistin resistance in K. pneumoniae. This study reports a bibliometric analysis of published articles retrieved from the Scopus database relating to colistin resistance in K. pneumoniae. The research trends in colistin resistance and mechanisms of resistance were considered. A total of 1819 research articles published between 1995 and 2019 were retrieved, and the results indicated that 50.19% of the documents were published within 2017–2019. The USA had the highest participation with 340 (14.31%) articles and 14087 (17.61%) citations. Classification based on the WHO global epidemiological regions showed that the European Region contributed 42% of the articles while the American Region contributed 21%. The result further indicated that 45 countries had published at least 10 documents with strong international collaborations amounting to 272 links and a total linkage strength of 735. A total of 2282 keywords were retrieved; however, 57 keywords had ≥15 occurrences with 764 links and a total linkage strength of 2388. Furthermore, mcr-1, colistin resistance, NDM, mgrB, ceftazidime-avibactam, MDR, combination therapy, and carbapenem-resistant Enterobacteriaceae were the trending keywords. Concerning funders, the USA National Institute of Health funded 9.1% of the total research articles, topping the list. The analysis indicated poor research output, collaboration, and funding from Africa and South-East Asia and demands for improvement in international research collaboration.
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22
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Zeng L, Yang C, Zhang J, Hu K, Zou J, Li J, Wang J, Huang W, Yin L, Zhang X. An Outbreak of Carbapenem-Resistant Klebsiella pneumoniae in an Intensive Care Unit of a Major Teaching Hospital in Chongqing, China. Front Cell Infect Microbiol 2021; 11:656070. [PMID: 34150672 PMCID: PMC8208809 DOI: 10.3389/fcimb.2021.656070] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/14/2021] [Indexed: 11/13/2022] Open
Abstract
Background Due to the critical condition and poor immunity of patients, the intensive care unit (ICU) has always been the main hospital source of multidrug-resistant bacteria. In recent years, with the large-scale use of antibiotics, the detection rate and mortality of carbapenem-resistant Klebsiella pneumoniae (CRKP) have gradually increased. This study explores the molecular characteristics and prevalence of CRKP isolated from the ICU ward of a tertiary hospital in China. Methods A total of 51 non-duplicated CRKP samples isolated from the ICU were collected from July 2018-July 2020. The enzyme production of the strains was preliminarily screened by carbapenemase phenotypic test, and drug-resistant and virulence genes were detected by PCR. The transferability of plasmid was verified by conjugation test. The minimal inhibitory concentration (MIC) was determined by microbroth dilution method and genetic diversity was detected by multilocus sequence typing and pulsed-field gel electrophoresis. Results blaKPC-2 was the only carbapenemase detected. The major virulence genes were uge (100%), mrkD (94.1%), kpn (94.1%), and fim-H (72.5%), while wcag, ironB, alls and magA genes were not detected. One sequence type ST1373 strain, hypervirulent K. pneumoniae (hvKP), was detected. CRKP strains were highly resistant to quinolones, cephalosporins, aminoglycosides, and polymyxin, but susceptive to tigecycline and ceftazidime-avibactam. The success rate of conjugation was 12.2%, indicating the horizontal transfer of blaKPC-2 . Homology analysis showed that there was a clonal transmission of ST11 CRKP in the ICU of our hospital. Conclusion The present study showed the outbreak and dissemination in ICU were caused by ST11 CRKP, which were KPC-2 producers, and simultaneously, also carried some virulence genes. ST11 CRKP persisted in the ward for a long time and spread among different areas. Due to the widespread dispersal of the transferable blaKPC-2 plasmid, the hospital should promptly adopt effective surveillance and strict infection control strategies to prevent the further spread of CRKP. Ceftazidime-avibactam showed high effectiveness against CRKP and could be used for the treatment of ICU infections.
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Affiliation(s)
- Lingyi Zeng
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China.,Department of Microbiology, The First Affiliated Hospital of Jiamusi University, Jiamusi, China
| | - Chengru Yang
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China.,Department of Microbiology, The First Affiliated Hospital of Jiamusi University, Jiamusi, China
| | - Jisheng Zhang
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Kewang Hu
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China.,Department of Microbiology, The First Affiliated Hospital of Jiamusi University, Jiamusi, China
| | - Jingbo Zou
- Department of Microbiology, Yongchuan District Center for Disease Control and Prevention of Chongqing, Chongqing, China
| | - Jie Li
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Jianmin Wang
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Wan Huang
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Lining Yin
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China.,Department of Microbiology, The First Affiliated Hospital of Jiamusi University, Jiamusi, China
| | - Xiaoli Zhang
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China.,Department of Microbiology, The First Affiliated Hospital of Jiamusi University, Jiamusi, China
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23
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Risk factors and mechanisms of in vivo emergence of colistin resistance in carbapenem-resistant Klebsiella pneumoniae. Int J Antimicrob Agents 2021; 57:106342. [PMID: 33864932 DOI: 10.1016/j.ijantimicag.2021.106342] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 03/07/2021] [Accepted: 04/03/2021] [Indexed: 11/21/2022]
Abstract
Colistin is one of the last-resort antibiotics for treating carbapenem-resistant Klebsiella pneumoniae (CRKP). However, colistin resistance in CRKP poses a global antimicrobial crisis, as therapeutic options are limited. We investigated risk factors for in vivo emergence of colistin resistance in CRKP and explored the underlying resistance mechanisms. We conducted this matched case-control study of patients with sequential CRKP clinical strains at a medical centre in Taiwan between October 2016 and June 2019. The case group included patients with an index colistin-resistant CRKP (ColR-CRKP) strain and a previous colistin-susceptible CRKP (ColS-CRKP) counterpart. The control group encompassed patients with both an index and previous ColS-CRKP strains. Cases and controls were matched according to the time at risk, and conditional logistic regression was used to evaluate potential risk factors. Alterations in genes associated with resistance were compared between ColR-CRKP and ColS-CRKP strains. We identified 24 CRKP cases with in vivo-emergent colistin resistance, matched in a 1:2 ratio with controls. Multivariate analysis showed that colistin exposure is the only independent risk factor predisposing to colistin resistance (adjusted odds ratio = 19.09, 95% confidence interval 1.26-290.45; P = 0.034). Alteration in the mgrB gene was the predominant mechanism for emergent colistin resistance (17/24; 71%). In conclusion, colistin use is a risk factor for in vivo emergence of colistin resistance in CRKP. Given the lack of a rapid and reliable method to detect colistin resistance in daily practice, physicians should be vigilant for the emergence of resistance during colistin treatment.
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24
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Vrancianu CO, Dobre EG, Gheorghe I, Barbu I, Cristian RE, Chifiriuc MC. Present and Future Perspectives on Therapeutic Options for Carbapenemase-Producing Enterobacterales Infections. Microorganisms 2021; 9:730. [PMID: 33807464 PMCID: PMC8065494 DOI: 10.3390/microorganisms9040730] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 03/26/2021] [Accepted: 03/30/2021] [Indexed: 12/26/2022] Open
Abstract
Carbapenem-resistant Enterobacterales (CRE) are included in the list of the most threatening antibiotic resistance microorganisms, being responsible for often insurmountable therapeutic issues, especially in hospitalized patients and immunocompromised individuals and patients in intensive care units. The enzymatic resistance to carbapenems is encoded by different β-lactamases belonging to A, B or D Ambler class. Besides compromising the activity of last-resort antibiotics, CRE have spread from the clinical to the environmental sectors, in all geographic regions. The purpose of this review is to present present and future perspectives on CRE-associated infections treatment.
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Affiliation(s)
- Corneliu Ovidiu Vrancianu
- Microbiology Immunology Department, Faculty of Biology, University of Bucharest, 050095 Bucharest, Romania; (C.O.V.); (E.G.D.); (I.B.); (M.C.C.)
- The Research Institute of the University of Bucharest, 050095 Bucharest, Romania
| | - Elena Georgiana Dobre
- Microbiology Immunology Department, Faculty of Biology, University of Bucharest, 050095 Bucharest, Romania; (C.O.V.); (E.G.D.); (I.B.); (M.C.C.)
| | - Irina Gheorghe
- Microbiology Immunology Department, Faculty of Biology, University of Bucharest, 050095 Bucharest, Romania; (C.O.V.); (E.G.D.); (I.B.); (M.C.C.)
- The Research Institute of the University of Bucharest, 050095 Bucharest, Romania
| | - Ilda Barbu
- Microbiology Immunology Department, Faculty of Biology, University of Bucharest, 050095 Bucharest, Romania; (C.O.V.); (E.G.D.); (I.B.); (M.C.C.)
- The Research Institute of the University of Bucharest, 050095 Bucharest, Romania
| | - Roxana Elena Cristian
- Department of Biochemistry and Molecular Biology, Faculty of Biology, University of Bucharest, 050095 Bucharest, Romania;
| | - Mariana Carmen Chifiriuc
- Microbiology Immunology Department, Faculty of Biology, University of Bucharest, 050095 Bucharest, Romania; (C.O.V.); (E.G.D.); (I.B.); (M.C.C.)
- The Research Institute of the University of Bucharest, 050095 Bucharest, Romania
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25
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Garcia E, Diep JK, Sharma R, Hanafin PO, Abboud CS, Kaye KS, Li J, Velkov T, Rao GG. Evaluation Strategies for Triple-Drug Combinations against Carbapenemase-Producing Klebsiella Pneumoniae in an In Vitro Hollow-Fiber Infection Model. Clin Pharmacol Ther 2021; 109:1074-1080. [PMID: 33548079 PMCID: PMC8048493 DOI: 10.1002/cpt.2197] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/11/2021] [Indexed: 12/15/2022]
Abstract
Mounting antimicrobial resistance to carbapenemase‐producing Klebsiella pneumoniae (CPKP) highlights the need to optimize currently available treatment options. The objective of this study was to explore alternative dosing strategies that limit the emergence of resistance to preserve the utility of last‐line antibiotics by: (i) evaluating the pharmacodynamic (PD) killing activity of simulated humanized exposures to monotherapy and two‐drug and three‐drug combinations against CPKP bacterial isolates with different resistance mechanisms; and (ii) optimizing polymyxin B (PMB) exposure simulated in the three‐drug combination regimens to maximize the killing activity. Two CPKP clinical isolates (BAA2146 (NDM‐1) and BRKP76 (KPC‐2)) were evaluated over 168 hours using a hollow‐fiber infection model simulating clinically relevant PMB, fosfomycin, and meropenem dosing regimens. PMB‐based three‐drug combinations were further optimized by varying the initial exposure (0–24 hours) or maintenance dose received over the duration of treatment. The area under the bacterial load‐versus‐time curve (AUCFU) was used to determine PD activity. Overall reductions in PMB exposure ranged from 2 to 84%. BAA2146 and BRKP76 had median (range) AUCFUs of 11.0 (10.6–11.6) log10 CFU hour/mL and 7.08 (7.04–11.9) log10 CFU hour/mL, respectively. The PMB “front loaded” 2.5 mg/kg/day + 0.5 mg/kg maintenance dose in combination with meropenem and fosfomycin was a promising regimen against BRKP76, with an overall reduction in PMB exposure of 56% while still eradicating the bacteria. Tailored triple‐combination therapy allows for the optimization of dose and treatment duration of last‐line agents like PMB to achieve adequate drug exposure and appropriate PD activity while minimizing the emergence of resistance.
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Affiliation(s)
- Estefany Garcia
- UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - John K Diep
- UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Rajnikant Sharma
- UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Patrick O Hanafin
- UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Cely S Abboud
- Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil
| | - Keith S Kaye
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jian Li
- Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Tony Velkov
- Department of Pharmacology and Therapeutics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Gauri G Rao
- UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
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26
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Zhang B, Yu B, Zhou W, Wang Y, Sun Z, Wu X, Chen S, Ni M, Hu Y. Mobile Plasmid Mediated Transition From Colistin-Sensitive to Resistant Phenotype in Klebsiella pneumoniae. Front Microbiol 2021; 12:619369. [PMID: 33658985 PMCID: PMC7917065 DOI: 10.3389/fmicb.2021.619369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 01/27/2021] [Indexed: 12/12/2022] Open
Abstract
Multidrug-resistant bacteria, including carbapenem-resistant Klebsiella pneumoniae (CRKP), are becoming an increasing health crisis worldwide. For CRKP, colistin is regarded as "the last treatment option." In this study, we isolated a clinical CRKP strain named as K. pneumoniae R10-341. Phenotyping analysis showed that this strain could transit from a colistin-sensitive to a resistant phenotype by inserting an IS4 family ISKpn72 element into the colistin-resistance associated mgrB gene. To investigate the mechanism of this transition, we performed genome sequencing analysis of the colistin-sensitive parental strain and found that 12 copies of ISKpn72 containing direct repeats (DR) are located on the chromosome and 1 copy without DR is located on a multidrug-resistant plasmid pR10-341_2. Both types of ISKpn72 could be inserted into the mgrB gene to cause colistin-resistance, though the plasmid-derived ISKpn72 without DR was in higher efficiency. Importantly, we demonstrated that colistin-sensitive K. pneumoniae strain transferred with the ISKpn72 element also obtained the ability to switch from colistin-sensitive to colistin-resistant phenotype. Furthermore, we confirmed that the ISKpn72-containing pR10-341_2 plasmid was able to conjugate, suggesting that the ability of causing colistin-resistant transition is transferable through common conjugation. Our results point to new challenges for both colistin-resistance detection and CRKP treatment.
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Affiliation(s)
- Baoyue Zhang
- CAS Key Laboratory of Special Pathogens and Biosafety, Center for Biosafety Mega-Science, Wuhan Institute of Virology, Chinese Academy of Sciences, Wuhan, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Bing Yu
- Department of Pathogen Biology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Zhou
- CAS Key Laboratory of Special Pathogens and Biosafety, Center for Biosafety Mega-Science, Wuhan Institute of Virology, Chinese Academy of Sciences, Wuhan, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Yue Wang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ziyong Sun
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaojun Wu
- Department of Respiratory and Critical Medicine, Renmin Hospital of Wuhan University, Wuhan, China
| | - Shiyun Chen
- CAS Key Laboratory of Special Pathogens and Biosafety, Center for Biosafety Mega-Science, Wuhan Institute of Virology, Chinese Academy of Sciences, Wuhan, China
| | - Ming Ni
- Department of Infectious Diseases, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yangbo Hu
- CAS Key Laboratory of Special Pathogens and Biosafety, Center for Biosafety Mega-Science, Wuhan Institute of Virology, Chinese Academy of Sciences, Wuhan, China
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27
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Gomez-Simmonds A, Annavajhala MK, McConville TH, Dietz DE, Shoucri SM, Laracy JC, Rozenberg FD, Nelson B, Greendyke WG, Furuya EY, Whittier S, Uhlemann AC. Carbapenemase-producing Enterobacterales causing secondary infections during the COVID-19 crisis at a New York City hospital. J Antimicrob Chemother 2021; 76:380-384. [PMID: 33202023 PMCID: PMC7717307 DOI: 10.1093/jac/dkaa466] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/19/2020] [Indexed: 11/23/2022] Open
Abstract
Background Patients with COVID-19 may be at increased risk for secondary bacterial infections with MDR pathogens, including carbapenemase-producing Enterobacterales (CPE). Objectives We sought to rapidly investigate the clinical characteristics, population structure and mechanisms of resistance of CPE causing secondary infections in patients with COVID-19. Methods We retrospectively identified CPE clinical isolates collected from patients testing positive for SARS-CoV-2 between March and April 2020 at our medical centre in New York City. Available isolates underwent nanopore sequencing for rapid genotyping, antibiotic resistance gene detection and phylogenetic analysis. Results We identified 31 CPE isolates from 13 patients, including 27 Klebsiella pneumoniae and 4 Enterobacter cloacae complex isolates. Most patients (11/13) had a positive respiratory culture and 7/13 developed bacteraemia; treatment failure was common. Twenty isolates were available for WGS. Most K. pneumoniae (16/17) belonged to ST258 and encoded KPC (15 KPC-2; 1 KPC-3); one ST70 isolate encoded KPC-2. E. cloacae isolates belonged to ST270 and encoded NDM-1. Nanopore sequencing enabled identification of at least four distinct ST258 lineages in COVID-19 patients, which were validated by Illumina sequencing data. Conclusions While CPE prevalence has declined substantially in New York City in recent years, increased detection in patients with COVID-19 may signal a re-emergence of these highly resistant pathogens in the wake of the global pandemic. Increased surveillance and antimicrobial stewardship efforts, as well as identification of optimal treatment approaches for CPE, will be needed to mitigate their future impact.
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Affiliation(s)
- Angela Gomez-Simmonds
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, 630 W 168th St, New York City, NY 10032, USA
| | - Medini K Annavajhala
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, 630 W 168th St, New York City, NY 10032, USA
| | - Thomas H McConville
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, 630 W 168th St, New York City, NY 10032, USA
| | - Donald E Dietz
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, 630 W 168th St, New York City, NY 10032, USA
| | - Sherif M Shoucri
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, 630 W 168th St, New York City, NY 10032, USA
| | - Justin C Laracy
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, 630 W 168th St, New York City, NY 10032, USA
| | - Felix D Rozenberg
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, 630 W 168th St, New York City, NY 10032, USA
| | - Brian Nelson
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, 630 W 168th St, New York City, NY 10032, USA
| | - William G Greendyke
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, 630 W 168th St, New York City, NY 10032, USA
| | - E Yoko Furuya
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, 630 W 168th St, New York City, NY 10032, USA
| | - Susan Whittier
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, 630 W 168th St, New York City, NY 10032, USA
| | - Anne-Catrin Uhlemann
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, 630 W 168th St, New York City, NY 10032, USA
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28
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Okanda T, Haque A, Koshikawa T, Islam A, Huda Q, Takemura H, Matsumoto T, Nakamura S. Characteristics of Carbapenemase-Producing Klebsiella pneumoniae Isolated in the Intensive Care Unit of the Largest Tertiary Hospital in Bangladesh. Front Microbiol 2021; 11:612020. [PMID: 33519767 PMCID: PMC7844882 DOI: 10.3389/fmicb.2020.612020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/04/2020] [Indexed: 11/30/2022] Open
Abstract
For addressing the issue of antimicrobial drug resistance in developing countries, it is important to investigate the characteristics of carbapenemase-producing organisms. We aimed to genetically characterize a carbapenemase-producing Klebsiella pneumoniae (CPKP) isolated in the intensive care unit of a tertiary hospital in Bangladesh. The number of CPKP isolates were 43/145 (30%), of which pandrug-resistant (PDR) strains were 14%. These carbapenemases were New Delhi metallo-beta-lactamase (NDM)-1 (53%), NDM-5 (14%), oxacillinase (OXA)-181 (12%), OXA-232 (10%), NDM-5 + OXA-181 (5%), and NDM-5 + OXA-232 (2%). Many CPKP isolates harbored a variety of resistance genes, and the prevalence of 16S rRNA methyltransferase was particularly high (91%). The 43 CPKP isolates were classified into 14 different sequence types (STs), and the common STs were ST34 (26%), ST147 (16%), ST11 (9%), ST14 (9%), ST25 (7%), and ST231 (7%). In this study, PDR strains were of three types, ST147, ST231, and ST14, and their PDR rates were 57, 33, and 25%, respectively. The spread of the antimicrobial drug resistance of CPKP in Bangladesh was identified. In particular, the emergence of PDR is problem, and there may be its spread as a superbug of antimicrobial treatment.
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Affiliation(s)
- Takashi Okanda
- Department of Microbiology, Tokyo Medical University, Tokyo, Japan.,Department of Microbiology, St. Marianna University School of Medicine, Kawasaki, Japan.,Department of Infectious Diseases, International University of Health and Welfare, Narita, Japan
| | - Anwarul Haque
- Department of Infectious Diseases, International University of Health and Welfare, Narita, Japan
| | - Takuro Koshikawa
- Department of Microbiology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Amirul Islam
- Department of Anesthesia, Analgesia and Intensive Care Medicine, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Qumrul Huda
- Department of Anesthesia, Analgesia and Intensive Care Medicine, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Hiromu Takemura
- Department of Microbiology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Tetsuya Matsumoto
- Department of Infectious Diseases, International University of Health and Welfare, Narita, Japan
| | - Shigeki Nakamura
- Department of Microbiology, Tokyo Medical University, Tokyo, Japan
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29
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Doi Y, van Duin D. Polymyxin Resistance in Klebsiella pneumoniae: Complexity at Every Level. Clin Infect Dis 2020; 70:2092-2094. [PMID: 31513703 DOI: 10.1093/cid/ciz627] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 07/08/2019] [Indexed: 12/18/2022] Open
Affiliation(s)
- Yohei Doi
- Division of Infectious Diseases, University of Pittsburgh, School of Medicine, Pennsylvania.,Center for Innovative Antimicrobial Therapy, University of Pittsburgh, School of Medicine, Pennsylvania.,Departments of Microbiology and Infectious Diseases, Fujita Health University, Toyoake, Japan
| | - David van Duin
- Division of Infectious Diseases, University of North Carolina, Chapel Hill
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Silva DMD, Faria-Junior C, Nery DR, Oliveira PMD, Silva LDOR, Alves EG, Lima GRDCEC, Pereira AL. Insertion sequences disrupting mgrB in carbapenem-resistant Klebsiella pneumoniae strains in Brazil. J Glob Antimicrob Resist 2020; 24:53-57. [PMID: 33246210 DOI: 10.1016/j.jgar.2020.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/20/2020] [Accepted: 11/03/2020] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES This study aimed to characterise insertional mutations disturbing themgrB gene in carbapenem-resistant Klebsiella pneumoniae (CRKp). METHODS A total of 118 clinical CRKp isolates were surveyed for polymyxin resistance and insertion sequence (IS) elements disruptingmgrB. RESULTS Of the 118 isolates, 78 (66.1%) displayed polymyxin resistance, of which 54% (42/78) hadmgrB::IS inserts. Sequencing analyses showed 13 insertion sites in mgrB. mgrB::ISSen4(IS3) was observed for the first time in CRKp. CONCLUSIONS Ten different IS elements disruptedmgrB, with a predominance (76%) of IS5 sequences.
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Affiliation(s)
- Daniely Martins da Silva
- Campus of Ceilândia, University of Brasília, Centro Metropolitano, Conjunto A, Ceilândia Sul, Brasília (DF), CEP: 72220-275, Brazil
| | - Célio Faria-Junior
- Central Laboratory for Public Health (LACEN-DF), SGAN 601, Asa Norte, Brasília (DF), CEP: 70830-010, Brazil
| | - Danielly Rocha Nery
- Campus of Ceilândia, University of Brasília, Centro Metropolitano, Conjunto A, Ceilândia Sul, Brasília (DF), CEP: 72220-275, Brazil
| | - Pâmela Maria de Oliveira
- Campus of Ceilândia, University of Brasília, Centro Metropolitano, Conjunto A, Ceilândia Sul, Brasília (DF), CEP: 72220-275, Brazil
| | | | - Everton Giovanni Alves
- Central Laboratory for Public Health (LACEN-DF), SGAN 601, Asa Norte, Brasília (DF), CEP: 70830-010, Brazil
| | | | - Alex Leite Pereira
- Campus of Ceilândia, University of Brasília, Centro Metropolitano, Conjunto A, Ceilândia Sul, Brasília (DF), CEP: 72220-275, Brazil.
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McConville TH, Annavajhala MK, Giddins MJ, Macesic N, Herrera CM, Rozenberg FD, Bhushan GL, Ahn D, Mancia F, Trent MS, Uhlemann AC. CrrB Positively Regulates High-Level Polymyxin Resistance and Virulence in Klebsiella pneumoniae. Cell Rep 2020; 33:108313. [PMID: 33113377 PMCID: PMC7656232 DOI: 10.1016/j.celrep.2020.108313] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 09/16/2020] [Accepted: 10/05/2020] [Indexed: 12/20/2022] Open
Abstract
Polymyxin resistance (PR) threatens the treatment of carbapenem-resistant Klebsiella pneumoniae (CRKP) infections. PR frequently arises through chemical modification of the lipid A portion of lipopolysaccharide. Various mutations are implicated in PR, including in three two-component systems—CrrA/B, PmrA/B, and PhoP/Q—and the negative regulator MgrB. Few have been functionally validated. Therefore, here we adapt a CRISPR-Cas9 system to CRKP to elucidate how mutations in clinical CRKP isolates induce PR. We demonstrate that CrrB is a positive regulator of PR, and common clinical mutations lead to the addition of both 4-amino-4-deoxy-L-arabinose (L-Ara4N) and phosophethanolamine (pEtN) to lipid A, inducing notably higher polymyxin minimum inhibitory concentrations than mgrB disruption. Additionally, crrB mutations cause a significant virulence increase at a fitness cost, partially from activation of the pentose phosphate pathway. Our data demonstrate the importance of CrrB in high-level PR and establish important differences across crrB alleles in balancing resistance with fitness and virulence. McConville et al. leverage CRISPR-Cas to demonstrate that mutations in crrB induce high-level polymyxin resistance in Klebsiella pneumoniae via the addition of L-Ara4N and pEtN to lipid A. CrrB mutations also increase virulence while conferring a fitness cost and alter carbon metabolism through activation of the pentose phosphate pathway.
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Affiliation(s)
- Thomas H McConville
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Medini K Annavajhala
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Marla J Giddins
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Nenad Macesic
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA; Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, 3004 VIC, Australia
| | - Carmen M Herrera
- Departments of Infectious Diseases, College of Veterinary Medicine, University of Georgia, Athens, GA 30602, USA
| | - Felix D Rozenberg
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Gitanjali L Bhushan
- Division of Pediatric Critical Care, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Danielle Ahn
- Division of Pediatric Critical Care, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Filippo Mancia
- Department of Physiology, Columbia University, New York, NY 10032, USA
| | - M Stephen Trent
- Departments of Infectious Diseases, College of Veterinary Medicine, University of Georgia, Athens, GA 30602, USA
| | - Anne-Catrin Uhlemann
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA.
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32
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Wang G, Zhao G, Chao X, Xie L, Wang H. The Characteristic of Virulence, Biofilm and Antibiotic Resistance of Klebsiella pneumoniae. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17176278. [PMID: 32872324 PMCID: PMC7503635 DOI: 10.3390/ijerph17176278] [Citation(s) in RCA: 157] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/18/2020] [Accepted: 08/26/2020] [Indexed: 02/07/2023]
Abstract
Klebsiella pneumoniae is an important gram-negative opportunistic pathogen that causes a variety of infectious diseases, including urinary tract infections, bacteremia, pneumonia, and liver abscesses. With the emergence of multidrug-resistant (MDR) and hypervirulent K. pneumoniae (hvKP) strains, the rapid spread of these clinical strains in geography is particularly worrying. However, the detailed mechanisms of virulence and antibiotic resistance in K. pneumoniae are still not very clear. Therefore, studying and elucidating the pathogenic mechanisms and drug resistance mechanism of K. pneumoniae infection are important parts of current medical research. In this paper, we systematically summarized the virulence, biofilm, and antibiotic tolerance mechanisms of K. pneumoniae, and explored the application of whole genome sequencing and global proteomics, which will provide new clues for clinical treatment of K. pneumoniae.
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Affiliation(s)
| | | | | | - Longxiang Xie
- Correspondence: (L.X.); (H.W.); Tel.: +86-0371-22892960 (L.X.)
| | - Hongju Wang
- Correspondence: (L.X.); (H.W.); Tel.: +86-0371-22892960 (L.X.)
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33
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Cheung CHP, Dulyayangkul P, Heesom KJ, Avison MB. Proteomic Investigation of the Signal Transduction Pathways Controlling Colistin Resistance in Klebsiella pneumoniae. Antimicrob Agents Chemother 2020; 64:AAC.00790-20. [PMID: 32457105 PMCID: PMC7526815 DOI: 10.1128/aac.00790-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 05/19/2020] [Indexed: 12/15/2022] Open
Abstract
Colistin resistance in Klebsiella pneumoniae is predominantly caused by mutations that increase expression of the arn (also known as pbg or pmrF) operon. Expression is activated by the PhoPQ and PmrAB two-component systems. Constitutive PhoPQ activation occurs directly by mutation or following loss of MgrB. PhoPQ may also cross-activate PmrAB via the linker protein PmrD. Using proteomics, we show that MgrB loss causes a wider proteomic effect than direct PhoPQ activation, suggesting additional targets for MgrB. Different mgrB mutations cause different amounts of Arn protein production, which correlated with colistin MICs. Disruption of phoP in an mgrB mutant had a reciprocal effect to direct activation of PhoQ in a wild-type background, but the regulated proteins showed almost total overlap. Disruption of pmrD or pmrA slightly reduced Arn protein production in an mgrB mutant, but production was still high enough to confer colistin resistance; disruption of phoP conferred wild-type Arn production and colistin MIC. Activation of PhoPQ directly or through mgrB mutation did not significantly activate PmrAB or PmrC production, but direct activation of PmrAB by mutation was able to do this, and also activated Arn production and conferred colistin resistance. There was little overlap between the PmrAB and PhoPQ regulons. We conclude that under the conditions used for colistin susceptibility testing, PhoPQ-PmrD-PmrAB cross-regulation is not significant and that independent activation of PhoPQ or PmrAB is the main reason that Arn protein production increases above the threshold required for colistin resistance.
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Affiliation(s)
| | - Punyawee Dulyayangkul
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
| | - Kate J Heesom
- University of Bristol Proteomics Facility, Bristol, United Kingdom
| | - Matthew B Avison
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
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34
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Aye SM, Galani I, Yu H, Wang J, Chen K, Wickremasinghe H, Karaiskos I, Bergen PJ, Zhao J, Velkov T, Giamarellou H, Lin YW, Tsuji BT, Li J. Polymyxin Triple Combinations against Polymyxin-Resistant, Multidrug-Resistant, KPC-Producing Klebsiella pneumoniae. Antimicrob Agents Chemother 2020; 64:e00246-20. [PMID: 32393492 PMCID: PMC7526826 DOI: 10.1128/aac.00246-20] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 05/05/2020] [Indexed: 02/06/2023] Open
Abstract
Resistance to polymyxin antibiotics is increasing. Without new antibiotic classes, combination therapy is often required. We systematically investigated bacterial killing with polymyxin-based combinations against multidrug-resistant (including polymyxin-resistant), carbapenemase-producing Klebsiella pneumoniae Monotherapies and double- and triple-combination therapies were compared to identify the most efficacious treatment using static time-kill studies (24 h, six isolates), an in vitro pharmacokinetic/pharmacodynamic model (IVM; 48 h, two isolates), and the mouse thigh infection model (24 h, six isolates). In static time-kill studies, all monotherapies (polymyxin B, rifampin, amikacin, meropenem, or minocycline) were ineffective. Initial bacterial killing was enhanced with various polymyxin B-containing double combinations; however, substantial regrowth occurred in most cases by 24 h. Most polymyxin B-containing triple combinations provided greater and more sustained killing than double combinations. Standard dosage regimens of polymyxin B (2.5 mg/kg of body weight/day), rifampin (600 mg every 12 h), and amikacin (7.5 mg/kg every 12 h) were simulated in the IVM. Against isolate ATH 16, no viable bacteria were detected across 5 to 25 h with triple therapy, with regrowth to ∼2-log10 CFU/ml occurring at 48 h. Against isolate BD 32, rapid initial killing of ∼3.5-log10 CFU/ml at 5 h was followed by a slow decline to ∼2-log10 CFU/ml at 48 h. In infected mice, polymyxin B monotherapy (60 mg/kg/day) generally was ineffective. With triple therapy (polymyxin B at 60 mg/kg/day, rifampin at 120 mg/kg/day, and amikacin at 300 mg/kg/day), at 24 h there was an ∼1.7-log10 CFU/thigh reduction compared to the starting inoculum for all six isolates. Our results demonstrate that the polymyxin B-rifampin-amikacin combination significantly enhanced in vitro and in vivo bacterial killing, providing important information for the optimization of polymyxin-based combinations in patients.
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Affiliation(s)
- Su Mon Aye
- Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Irene Galani
- Fourth Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Heidi Yu
- Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Jiping Wang
- Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Ke Chen
- Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Hasini Wickremasinghe
- Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Ilias Karaiskos
- First Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, Athens, Greece
| | - Phillip J Bergen
- Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Jinxin Zhao
- Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Tony Velkov
- Department of Pharmacology & Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia
| | - Helen Giamarellou
- First Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, Athens, Greece
| | - Yu-Wei Lin
- Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Brian T Tsuji
- Laboratory for Antimicrobial Pharmacodynamics, NYS Centre of Excellence in Bioinformatics & Life Sciences, Buffalo, New York, USA
| | - Jian Li
- Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
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D'Apolito D, Arena F, Conte V, De Angelis LH, Di Mento G, Carreca AP, Cuscino N, Russelli G, Iannolo G, Barbera F, Pasqua S, Monaco F, Cardinale F, Rossolini GM, Conaldi PG, Douradinha B. Phenotypical and molecular assessment of the virulence potential of KPC-3-producing Klebsiella pneumoniae ST392 clinical isolates. Microbiol Res 2020; 240:126551. [PMID: 32652494 DOI: 10.1016/j.micres.2020.126551] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 06/28/2020] [Accepted: 07/03/2020] [Indexed: 12/31/2022]
Abstract
Klebsiella pneumoniae is a Gram-negative bacterium of clinical importance, due to its resistance to several antibiotic classes. We have identified 4 clinical isolates of K. pneumoniae sequence type (ST) 392 KPC-3-producing strains from patients at the Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IRCCS-ISMETT), a Southern Italian transplantation health facility, during a routine surveillance for carbapenemase-producing Enterobacterales from in-house clinical samples. Since those were among, to the best of our knowledge, the first KPC-producing K. pneumoniae ST392 isolated in Europe, we assessed their virulence potential, to understand if this particular ST can become an endemic clinical threat. ST392 isolates were investigated to assess their virulence potential, namely resistance to human sera, formation of abiotic biofilms, adhesion to biotic surfaces, exopolysaccharide production and in vivo pathogenesis in the wax moth Galleria mellonella animal model. ST392-belonging strains were highly resistant to human sera. These strains also have a high capacity to form abiotic biofilms and high levels of adhesion to the human epithelial colorectal adenocarcinoma HT-29 cell line. An increase of transcriptional levels of genes involved in serum resistance (aroE and traT) and adhesion (pgaA) was observed when compared with the Klebsiella quasipneumoniae subsp. similipneumoniae strain ATCC 700603 reference strain. Infection of G. mellonella larvae with ST392 clinical isolates showed that the latter were not highly pathogenic in this model. Together, our results indicate that ST392 isolates have the potential to become a strain of clinical relevance, especially in health settings where patients are immunosuppressed, e.g., transplant recipients.
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Affiliation(s)
| | - Fabio Arena
- Dipartimento di Medicina Clinica e Sperimentale, Università di Foggia, Foggia, Italy; IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy
| | - Viola Conte
- Dipartimento di Biotecnologie Mediche, Università degli Studi di Siena, Siena, Italy
| | | | | | | | | | | | | | | | | | | | | | - Gian Maria Rossolini
- Dipartimento di Medicina Sperimentale e Clinica, Università degli Studi di Firenze, Florence, Italy; SOD Microbiologia e Virologia, Azienda Ospedaliera Universitaria Careggi Florence, Italy
| | | | - Bruno Douradinha
- Fondazione Ri.MED, Palermo, Italy; IRCCS-ISMETT, Palermo, Italy.
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Fodor A, Abate BA, Deák P, Fodor L, Gyenge E, Klein MG, Koncz Z, Muvevi J, Ötvös L, Székely G, Vozik D, Makrai L. Multidrug Resistance (MDR) and Collateral Sensitivity in Bacteria, with Special Attention to Genetic and Evolutionary Aspects and to the Perspectives of Antimicrobial Peptides-A Review. Pathogens 2020; 9:pathogens9070522. [PMID: 32610480 PMCID: PMC7399985 DOI: 10.3390/pathogens9070522] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/23/2020] [Accepted: 06/23/2020] [Indexed: 12/18/2022] Open
Abstract
Antibiotic poly-resistance (multidrug-, extreme-, and pan-drug resistance) is controlled by adaptive evolution. Darwinian and Lamarckian interpretations of resistance evolution are discussed. Arguments for, and against, pessimistic forecasts on a fatal “post-antibiotic era” are evaluated. In commensal niches, the appearance of a new antibiotic resistance often reduces fitness, but compensatory mutations may counteract this tendency. The appearance of new antibiotic resistance is frequently accompanied by a collateral sensitivity to other resistances. Organisms with an expanding open pan-genome, such as Acinetobacter baumannii, Pseudomonas aeruginosa, and Klebsiella pneumoniae, can withstand an increased number of resistances by exploiting their evolutionary plasticity and disseminating clonally or poly-clonally. Multidrug-resistant pathogen clones can become predominant under antibiotic stress conditions but, under the influence of negative frequency-dependent selection, are prevented from rising to dominance in a population in a commensal niche. Antimicrobial peptides have a great potential to combat multidrug resistance, since antibiotic-resistant bacteria have shown a high frequency of collateral sensitivity to antimicrobial peptides. In addition, the mobility patterns of antibiotic resistance, and antimicrobial peptide resistance, genes are completely different. The integron trade in commensal niches is fortunately limited by the species-specificity of resistance genes. Hence, we theorize that the suggested post-antibiotic era has not yet come, and indeed might never come.
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Affiliation(s)
- András Fodor
- Department of Genetics, University of Szeged, H-6726 Szeged, Hungary;
- Correspondence: or (A.F.); (L.M.); Tel.: +36-(30)-490-9294 (A.F.); +36-(30)-271-2513 (L.M.)
| | - Birhan Addisie Abate
- Ethiopian Biotechnology Institute, Agricultural Biotechnology Directorate, Addis Ababa 5954, Ethiopia;
| | - Péter Deák
- Department of Genetics, University of Szeged, H-6726 Szeged, Hungary;
- Institute of Biochemistry, Biological Research Centre, H-6726 Szeged, Hungary
| | - László Fodor
- Department of Microbiology and Infectious Diseases, University of Veterinary Medicine, P.O. Box 22, H-1581 Budapest, Hungary;
| | - Ervin Gyenge
- Hungarian Department of Biology and Ecology, Faculty of Biology and Geology, Babeș-Bolyai University, 5-7 Clinicilor St., 400006 Cluj-Napoca, Romania; (E.G.); (G.S.)
- Institute for Research-Development-Innovation in Applied Natural Sciences, Babeș-Bolyai University, 30 Fântânele St., 400294 Cluj-Napoca, Romania
| | - Michael G. Klein
- Department of Entomology, The Ohio State University, 1680 Madison Ave., Wooster, OH 44691, USA;
| | - Zsuzsanna Koncz
- Max-Planck Institut für Pflanzenzüchtungsforschung, Carl-von-Linné-Weg 10, D-50829 Köln, Germany;
| | | | - László Ötvös
- OLPE, LLC, Audubon, PA 19403-1965, USA;
- Institute of Medical Microbiology, Semmelweis University, H-1085 Budapest, Hungary
- Arrevus, Inc., Raleigh, NC 27612, USA
| | - Gyöngyi Székely
- Hungarian Department of Biology and Ecology, Faculty of Biology and Geology, Babeș-Bolyai University, 5-7 Clinicilor St., 400006 Cluj-Napoca, Romania; (E.G.); (G.S.)
- Institute for Research-Development-Innovation in Applied Natural Sciences, Babeș-Bolyai University, 30 Fântânele St., 400294 Cluj-Napoca, Romania
- Centre for Systems Biology, Biodiversity and Bioresources, Babeș-Bolyai University, 5-7 Clinicilor St., 400006 Cluj-Napoca, Romania
| | - Dávid Vozik
- Research Institute on Bioengineering, Membrane Technology and Energetics, Faculty of Engineering, University of Veszprem, H-8200 Veszprém, Hungary; or or
| | - László Makrai
- Department of Microbiology and Infectious Diseases, University of Veterinary Medicine, P.O. Box 22, H-1581 Budapest, Hungary;
- Correspondence: or (A.F.); (L.M.); Tel.: +36-(30)-490-9294 (A.F.); +36-(30)-271-2513 (L.M.)
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37
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Human MAIT cell cytolytic effector proteins synergize to overcome carbapenem resistance in Escherichia coli. PLoS Biol 2020; 18:e3000644. [PMID: 32511236 PMCID: PMC7302869 DOI: 10.1371/journal.pbio.3000644] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 06/18/2020] [Accepted: 05/18/2020] [Indexed: 02/07/2023] Open
Abstract
Mucosa-associated invariant T (MAIT) cells are abundant antimicrobial T cells in humans and recognize antigens derived from the microbial riboflavin biosynthetic pathway presented by the MHC-Ib-related protein (MR1). However, the mechanisms responsible for MAIT cell antimicrobial activity are not fully understood, and the efficacy of these mechanisms against antibiotic resistant bacteria has not been explored. Here, we show that MAIT cells mediate MR1-restricted antimicrobial activity against Escherichia coli clinical strains in a manner dependent on the activity of cytolytic proteins but independent of production of pro-inflammatory cytokines or induction of apoptosis in infected cells. The combined action of the pore-forming antimicrobial protein granulysin and the serine protease granzyme B released in response to T cell receptor (TCR)-mediated recognition of MR1-presented antigen is essential to mediate control against both cell-associated and free-living, extracellular forms of E. coli. Furthermore, MAIT cell-mediated bacterial control extends to multidrug-resistant E. coli primary clinical isolates additionally resistant to carbapenems, a class of last resort antibiotics. Notably, high levels of granulysin and granzyme B in the MAIT cell secretomes directly damage bacterial cells by increasing their permeability, rendering initially resistant E. coli susceptible to the bactericidal activity of carbapenems. These findings define the role of cytolytic effector proteins in MAIT cell-mediated antimicrobial activity and indicate that granulysin and granzyme B synergize to restore carbapenem bactericidal activity and overcome carbapenem resistance in E. coli. Mucosa-associated invariant T (MAIT) cells are abundant antimicrobial T cells in humans that recognize bacterial metabolites. This study shows that MAIT cells exert potent antimicrobial activity against both cell-associated and extracellular forms of Escherichia coli, including strains that are resistant to the last resort antibiotics carbapenems.
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38
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Macesic N, Bear Don't Walk OJ, Pe'er I, Tatonetti NP, Peleg AY, Uhlemann AC. Predicting Phenotypic Polymyxin Resistance in Klebsiella pneumoniae through Machine Learning Analysis of Genomic Data. mSystems 2020; 5:e00656-19. [PMID: 32457240 PMCID: PMC7253370 DOI: 10.1128/msystems.00656-19] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 05/01/2020] [Indexed: 02/06/2023] Open
Abstract
Polymyxins are used as treatments of last resort for Gram-negative bacterial infections. Their increased use has led to concerns about emerging polymyxin resistance (PR). Phenotypic polymyxin susceptibility testing is resource intensive and difficult to perform accurately. The complex polygenic nature of PR and our incomplete understanding of its genetic basis make it difficult to predict PR using detection of resistance determinants. We therefore applied machine learning (ML) to whole-genome sequencing data from >600 Klebsiella pneumoniae clonal group 258 (CG258) genomes to predict phenotypic PR. Using a reference-based representation of genomic data with ML outperformed a rule-based approach that detected variants in known PR genes (area under receiver-operator curve [AUROC], 0.894 versus 0.791, P = 0.006). We noted modest increases in performance by using a bacterial genome-wide association study to filter relevant genomic features and by integrating clinical data in the form of prior polymyxin exposure. Conversely, reference-free representation of genomic data as k-mers was associated with decreased performance (AUROC, 0.692 versus 0.894, P = 0.015). When ML models were interpreted to extract genomic features, six of seven known PR genes were correctly identified by models without prior programming and several genes involved in stress responses and maintenance of the cell membrane were identified as potential novel determinants of PR. These findings are a proof of concept that whole-genome sequencing data can accurately predict PR in K. pneumoniae CG258 and may be applicable to other forms of complex antimicrobial resistance.IMPORTANCE Polymyxins are last-resort antibiotics used to treat highly resistant Gram-negative bacteria. There are increasing reports of polymyxin resistance emerging, raising concerns of a postantibiotic era. Polymyxin resistance is therefore a significant public health threat, but current phenotypic methods for detection are difficult and time-consuming to perform. There have been increasing efforts to use whole-genome sequencing for detection of antibiotic resistance, but this has been difficult to apply to polymyxin resistance because of its complex polygenic nature. The significance of our research is that we successfully applied machine learning methods to predict polymyxin resistance in Klebsiella pneumoniae clonal group 258, a common health care-associated and multidrug-resistant pathogen. Our findings highlight that machine learning can be successfully applied even in complex forms of antibiotic resistance and represent a significant contribution to the literature that could be used to predict resistance in other bacteria and to other antibiotics.
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Affiliation(s)
- Nenad Macesic
- Division of Infectious Diseases, Columbia University Irving Medical Center, New York, New York, USA
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia
| | | | - Itsik Pe'er
- Department of Computer Science, Columbia University, New York, New York, USA
| | - Nicholas P Tatonetti
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
| | - Anton Y Peleg
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia
- Infection and Immunity Program, Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Anne-Catrin Uhlemann
- Division of Infectious Diseases, Columbia University Irving Medical Center, New York, New York, USA
- Microbiome & Pathogen Genomics Core, Columbia University Irving Medical Center, New York, New York, USA
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