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Li X, Fu M, Len Y, Xu C, Hu R, Zhou Y. Characteristics of the tmexC2-tmexD2-toprJ2 carrying of multi-drug resistant Hypervirulent Klebsiella Pneumoniae belonging ST29 and K212. J Glob Antimicrob Resist 2024:S2213-7165(24)00122-X. [PMID: 39002612 DOI: 10.1016/j.jgar.2024.06.014] [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: 03/29/2024] [Revised: 06/08/2024] [Accepted: 06/16/2024] [Indexed: 07/15/2024] Open
Abstract
BACKGROUND This study aimed to characterize a tigecycline-resistant Hypervirulent Klebsiella pneumoniae (HvKP) strain, identified as KLZT, carrying a tigecycline resistance gene cluster tmexC2-tmexD2-toprJ2 belonging to ST29 and serotype K212. MATERIALS AND METHODS Antimicrobial susceptibility and virulence phenotypes were assessed, followed by whole genome sequencing (WGS) using PacBio II and MiSeq sequencers. Genome annotation was conducted using the RAST server, and bioinformatics analysis revealed the genetic characteristics for this strain. RESULTS Antimicrobial and virulence phenotype testing indicated that K.pneumoniae strain KLZT can be considered as the Multi-Drug Resistant HvKP. WGS analysis showed that it has one 5,536,506 bp chromosome containing three plasmids in the size of 290963bp (pKLZT-1), 199,302bp (pKLZT-2) and 4820bp (pKLZT-3). KLZT was classified as ST29 and K212 serotype. Five (blaSHV-187, oqxA, oqxB, fosA6) and 6 resistance genes (tmexC2-tmxeD2-toprJ2, blaOXA-1, aac(6')-Ib-cr, catB3, arr-3 and blaLEN27) were identified from the chromosome and plasmid pKLZT-1, respectively. Resistance genes genetic context of plasmid pKLZT-1 analysis showed that tigecycline resistance gene cluster carrying region was flanked by umuC and umuD (umuD-hps-IS5-tmexC2-tmexD2-toprJ2-umuC) and other resistance genes and virulence factors (ureB, ureC and ureG) were carried by a (IS5075-Tn3-intI1 -aac(6')-Ib-cr-blaOXA-1-catB3-arr-3-blaLEN27-Tn3-ISkpn26-ureBCG- IS5075). CONCLUSIONS Here, we present the WGS of a Multi-Drug Resistant HvKP KLZT belonging to ST29 with capsular serotype K212 contains a muti-drug resistance plasmid.
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Affiliation(s)
- Xingming Li
- The First People's Hospital Of Neijiang, Neijiang, 641000, China; Department of Pathogenic Biology, School of Basic Medical Sciences, Southwest Medical University, Luzhou, 646000, China
| | - Min Fu
- The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, 445000, China
| | - Yaxu Len
- Department of Pathogenic Biology, School of Basic Medical Sciences, Southwest Medical University, Luzhou, 646000, China
| | - Changwen Xu
- Antibiotics Research and Re-evaluation Key Laboratory of Sichuan Province, School of Pharmacy, Chengdu University, Chengdu, 640000, China
| | - Renjing Hu
- Department of Laboratory Medicine, Jiangnan University Medical Center, Wuxi, 214000, China.
| | - Yingshun Zhou
- Department of Pathogenic Biology, School of Basic Medical Sciences, Southwest Medical University, Luzhou, 646000, China.
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2
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Esposito F, Cardoso B, Sellera FP, Sano E, Fuentes-Castillo D, Fontana H, Fuga B, Moura Q, Sato MI, Brandão CJ, Lincopan N. Expansion of healthcare-associated hypervirulent KPC-2-producing Klebsiella pneumoniae ST11/KL64 beyond hospital settings. One Health 2023; 17:100594. [PMID: 37448770 PMCID: PMC10336671 DOI: 10.1016/j.onehlt.2023.100594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 06/21/2023] [Accepted: 06/24/2023] [Indexed: 07/15/2023] Open
Abstract
The spread of carbapenemase-producing Klebsiella pneumoniae beyond hospital settings is a global critical issue within a public health and One Health perspective. Another worrisome concern is the convergence of virulence and resistance in healthcare-associated lineages of K. pneumoniae leading to unfavorable clinical outcomes. During a surveillance study of WHO critical priority pathogens circulating in an impacted urban river in São Paulo, Brazil, we isolate two hypermucoviscous and multidrug-resistant K. pneumoniae strains (PINH-4250 and PINH-4900) from two different locations near to medical centers. Genomic investigation revealed that both strains belonged to the global high-risk sequence type (ST) ST11, carrying the blaKPC-2 carbapenemase gene, besides other medically important antimicrobial resistance determinants. A broad virulome was predicted and associated with hypervirulent behavior in the Galleria mellonella infection model. Comparative phylogenomic analysis of PINH-4250 and PINH-4900 along to an international collection of publicly available genomes of K. pneumoniae ST11 revealed that both environmental strains were closely related to hospital-associated K. pneumoniae strains recovered from clinical samples between 2006 and 2018, in São Paulo city. Our findings support that healthcare-associated KPC-2-positive K. pneumoniae of ST11 clone has successfully expanded beyond hospital settings. In summary, aquatic environments can become potential sources of international clones of K. pneumoniae displaying carbapenem resistance and hypervirulent behaviors, which is a critical issue within a One Health perspective.
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Affiliation(s)
- Fernanda Esposito
- Department of Clinical Analysis, School of Pharmacy, University of São Paulo, São Paulo, Brazil
- One Health Brazilian Resistance Project (OneBR), Brazil
| | - Brenda Cardoso
- One Health Brazilian Resistance Project (OneBR), Brazil
- Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Fábio P. Sellera
- One Health Brazilian Resistance Project (OneBR), Brazil
- Department of Internal Medicine, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, Brazil
- School of Veterinary Medicine, Metropolitan University of Santos, Santos, Brazil
| | - Elder Sano
- One Health Brazilian Resistance Project (OneBR), Brazil
- Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Danny Fuentes-Castillo
- One Health Brazilian Resistance Project (OneBR), Brazil
- Departamento de Patología y Medicina Preventiva, Facultad de Ciencias Veterinarias, Universidad de Concepción, Chillán, Chile
| | - Herrison Fontana
- Department of Clinical Analysis, School of Pharmacy, University of São Paulo, São Paulo, Brazil
- One Health Brazilian Resistance Project (OneBR), Brazil
| | - Bruna Fuga
- Department of Clinical Analysis, School of Pharmacy, University of São Paulo, São Paulo, Brazil
- One Health Brazilian Resistance Project (OneBR), Brazil
- Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Quézia Moura
- Federal Institute of Education Science and Technology of Espírito Santo, Vila Velha, Brazil
| | - Maria I.Z. Sato
- Environmental Company of São Paulo State (CETESB), São Paulo, Brazil
| | - Carlos J. Brandão
- Environmental Company of São Paulo State (CETESB), São Paulo, Brazil
| | - Nilton Lincopan
- Department of Clinical Analysis, School of Pharmacy, University of São Paulo, São Paulo, Brazil
- One Health Brazilian Resistance Project (OneBR), Brazil
- Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
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3
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Molecular characterization of a hypermucoviscous, hypervirulent, and carbapenem-resistant ST15/K19 Klebsiella pneumoniae clone from human infection. J Glob Antimicrob Resist 2022; 31:80-81. [PMID: 36038122 DOI: 10.1016/j.jgar.2022.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/04/2022] [Accepted: 08/15/2022] [Indexed: 12/30/2022] Open
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4
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Tutelyan AV, Shlykova DS, Voskanyan SL, Gaponov AM, Pisarev VM. Molecular Epidemiology of Hypervirulent K. pneumoniae and Problems of Health-Care Associated Infections. Bull Exp Biol Med 2022; 172:507-522. [PMID: 35352244 PMCID: PMC8964242 DOI: 10.1007/s10517-022-05424-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Indexed: 12/25/2022]
Abstract
The review describes virulence factors of hypervirulent K. pneumoniae (hvKp) including genes determining its virulence and discusses their role in the development of health-care associated infections. The contribution of individual virulence factors and their combination to the development of the hypervirulence and the prospects of using these factors as biomarkers and therapeutic targets are described. Virulence factors of hvKp and “classical” K. pneumoniae strains (cKp) with no hypervirulence genes were compared. The mechanisms of biofilm formation by hvKp and high incidence of its antibiotic resistance are of particular importance for in health care institutions. Therefore, the development of methods for hvKp identification allowing early prevention of severe hvKp infection and novel approaches to abrogate its spreading are new challenges for epidemiology, infection diseases, and critical care medicine. New technologies including bacteriological and molecular studies make it possible to develop innovative strategies to diagnose and treat infection caused by hvKp. These include monitoring of both genetic biomarkers of hvKp and resistance plasmid that carry of virulence genes and antibiotic resistance genes, creation of immunological agents for the prevention and therapy of hvKp (vaccines, monoclonal antibodies) as well as personalized hvKp-specific phage therapies and pharmaceuticals enhancing the effect of antibiotics. A variety of approaches can reliably prepare our medicine for a new challenge: spreading of life-threatening health-care associated infections caused by antibiotic-resistant hvKp strains.
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Affiliation(s)
- A V Tutelyan
- Central Research Institute of Epidemiology, Federal Service for Surveillance on Consumer Rights Protection and Human Wellbeing, Moscow, Russia
| | - D S Shlykova
- Federal Research Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Sh L Voskanyan
- Central Research Institute of Epidemiology, Federal Service for Surveillance on Consumer Rights Protection and Human Wellbeing, Moscow, Russia
| | - A M Gaponov
- Central Research Institute of Epidemiology, Federal Service for Surveillance on Consumer Rights Protection and Human Wellbeing, Moscow, Russia.,Federal Research Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - V M Pisarev
- Central Research Institute of Epidemiology, Federal Service for Surveillance on Consumer Rights Protection and Human Wellbeing, Moscow, Russia. .,Federal Research Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia.
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5
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Chen X, Tang Q, Li X, Zheng X, Li P, Li M, Wu F, Xu Z, Lu R, Zhang W. Isolation, characterization, and genome analysis of bacteriophage P929 that could specifically lyase the KL19 capsular type of Klebsiella pneumoniae. Virus Res 2022; 314:198750. [DOI: 10.1016/j.virusres.2022.198750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 01/09/2023]
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6
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Cardoso B, Esposito F, Fontana H, Fuga B, Moura Q, Sano E, Sato MIZ, Brandão CJ, Oliveira FA, Levy CE, Lincopan N. Genomic analysis of a Kpi (pilus system)-positive and CTX-M-15-producing Klebsiella pneumoniae belonging to the high-risk clone ST15 isolated from an impacted river in Brazil. Genomics 2021; 114:378-383. [PMID: 34923088 DOI: 10.1016/j.ygeno.2021.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/27/2021] [Accepted: 12/14/2021] [Indexed: 11/04/2022]
Abstract
Convergence of resistance and virulence in Klebsiella pneumoniae is a critical public health issue worldwide. A multidrug-resistant CTX-M-15-producing K. pneumoniae (TIES-4900 strain) was isolated from a highly impacted urban river, in Brazil. The genome was sequenced by MiSeq Illumina platform and de novo assembled using Unicycler. In silico prediction was accomplished by bioinformatics tools. The size of the genome is 5.4 Mb with 5145 protein-coding genes. TIES-4900 strain belonged to the sequence type ST15, yersiniabactin sequence type YbST10, ICEKp4, KL24 (wzi-24) and O1v1 locus. Phylogenomics confirmed genomic relatedness with ST15 clones from human and animal hosts. Convergence of broad resistome (antibiotics, heavy-metals and biocides) and virulome, including the Kpi pilus system involved in host-pathogen interaction and persistence of ST15 clone to hospital environments, were predicted. Virulent behavior was confirmed in the Galleria mellonella infection model. This study may give genomic insights on the spread of critical-priority WHO pathogens beyond hospital settings.
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Affiliation(s)
- Brenda Cardoso
- Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil; One Health Brazilian Resistance Project (OneBR), Brazil
| | - Fernanda Esposito
- One Health Brazilian Resistance Project (OneBR), Brazil; Department of Clinical Analysis, School of Pharmacy, University of São Paulo, São Paulo, Brazil
| | - Herrison Fontana
- One Health Brazilian Resistance Project (OneBR), Brazil; Department of Clinical Analysis, School of Pharmacy, University of São Paulo, São Paulo, Brazil
| | - Bruna Fuga
- Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil; One Health Brazilian Resistance Project (OneBR), Brazil; Department of Clinical Analysis, School of Pharmacy, University of São Paulo, São Paulo, Brazil
| | - Quézia Moura
- Faculty of Health Sciences, Federal University of Grande Dourados, Mato Grosso do Sul, Brazil
| | - Elder Sano
- Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil; One Health Brazilian Resistance Project (OneBR), Brazil
| | - Maria I Z Sato
- Environmental Company of São Paulo State (CETESB), São Paulo, Brazil
| | - Carlos J Brandão
- Environmental Company of São Paulo State (CETESB), São Paulo, Brazil
| | | | - Carlos E Levy
- Hospital de Clínicas, Universidade Estadual de Campinas, Brazil
| | - Nilton Lincopan
- Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil; One Health Brazilian Resistance Project (OneBR), Brazil; Department of Clinical Analysis, School of Pharmacy, University of São Paulo, São Paulo, Brazil.
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7
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Cerdeira L, Nakamura-Silva R, Oliveira-Silva M, Sano E, Esposito F, Fuga B, Moura Q, Miranda CES, Wyres K, Lincopan N, Pitondo-Silva A. A novel hypermucoviscous Klebsiella pneumoniae ST3994-K2 clone belonging to Clonal Group 86. Pathog Dis 2021; 79:6373921. [PMID: 34550351 DOI: 10.1093/femspd/ftab047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/20/2021] [Indexed: 11/13/2022] Open
Abstract
Emergent hypervirulent Klebsiella pneumoniae has been responsible for severe diseases, representing a serious threat to public health. We report the whole-genome sequencing of a novel ST3994-K2 clone, a single locus variant of ST86 K2, which is considered a worrying hypervirulent clone that emerged in several parts of the world. The strain K. pneumonia Kpi144 was isolated in 2013 from a blood culture of a 69-year-old male patient admitted to a tertiary hospital in Teresina, state of Piauí, northeastern Brazil. The strain was susceptible to 41 antibiotics tested, presented hypermucoviscous phenotype and a virulent behavior was observed in the Galleria mellonella infection model. Moreover, the virulome showed several virulence genes. To the best of our knowledge, this is the first worldwide report of a novel ST3994-K2 K. pneumoniae clone, an SLV of ST86 K2, which is considered a worrying virulent clone that has emerged in several parts of the world, including South America and Brazil.
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Affiliation(s)
- Louise Cerdeira
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, VIC 3800, Australia.,Department of Vector Biology, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, United Kingdom
| | - Rafael Nakamura-Silva
- Postgraduate Program in Environmental Technology, University of Ribeirão Preto, Ribeirão Preto, CEP 14096-900, São Paulo, Brazil
| | - Mariana Oliveira-Silva
- Postgraduate Program in Environmental Technology, University of Ribeirão Preto, Ribeirão Preto, CEP 14096-900, São Paulo, Brazil
| | - Elder Sano
- Institute of Biomedical Sciences, University of São Paulo, São Paulo, CEP 05508-000, Brazil.,One Health Brazilian Resistance Project (OneBR), University of São Paulo, São Paulo, CEP 05508-000, Brazil
| | - Fernanda Esposito
- One Health Brazilian Resistance Project (OneBR), University of São Paulo, São Paulo, CEP 05508-000, Brazil.,Department of Clinical Analysis, School of Pharmacy, University of São Paulo, São Paulo, CEP 05508-000, Brazil
| | - Bruna Fuga
- Institute of Biomedical Sciences, University of São Paulo, São Paulo, CEP 05508-000, Brazil.,One Health Brazilian Resistance Project (OneBR), University of São Paulo, São Paulo, CEP 05508-000, Brazil
| | - Quézia Moura
- Federal Institute of Education, Science and Technology of Espírito Santo, Vila Velha, CEP 29106-010, Brazil
| | | | - Kelly Wyres
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, VIC 3800, Australia
| | - Nilton Lincopan
- Institute of Biomedical Sciences, University of São Paulo, São Paulo, CEP 05508-000, Brazil.,One Health Brazilian Resistance Project (OneBR), University of São Paulo, São Paulo, CEP 05508-000, Brazil.,Department of Clinical Analysis, School of Pharmacy, University of São Paulo, São Paulo, CEP 05508-000, Brazil
| | - André Pitondo-Silva
- Postgraduate Program in Environmental Technology, University of Ribeirão Preto, Ribeirão Preto, CEP 14096-900, São Paulo, Brazil.,Postgraduate Program in Dentistry, University of Ribeirão Preto, Ribeirão Preto, CEP 14096-900, São Paulo, Brazil
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8
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Nakamura-Silva R, Oliveira-Silva M, Furlan JPR, Stehling EG, Miranda CES, Pitondo-Silva A. Characterization of multidrug-resistant and virulent Klebsiella pneumoniae strains belonging to the high-risk clonal group 258 (CG258) isolated from inpatients in northeastern Brazil. Arch Microbiol 2021; 203:4351-4359. [PMID: 34110479 DOI: 10.1007/s00203-021-02425-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/31/2021] [Accepted: 06/02/2021] [Indexed: 12/24/2022]
Abstract
Multidrug-resistant (MDR) and hypervirulent Klebsiella pneumoniae (hvKp) clones have become a major threat to global public health. The clonal group 258 (CG258) is considered a high-risk CG and the K. pneumoniae strains belonging to it are often multi-resistant and to spread mainly in the hospital environment. This study aimed to characterize the antimicrobial resistance profile, virulence factors, and the clonal relationships among 13 K. pneumoniae strains belonging to CG258 from patients admitted to a tertiary hospital in Teresina, in the state of Piauí, northeastern Brazil. Ten strains were classified as MDR and three as extensively drug-resistant (XDR). Three different β-lactamase-encoding genes (blaKPC, blaOXA-1-like, and blaCTX-M-Gp1) and six virulence genes (fimH, ycfM, mrkD, entB, ybtS, and kfu) were detected. Moreover, two hypermucoviscous K. pneumoniae strains and one capsular K-type 2 were found. Multilocus sequence typing analysis revealed ten different sequence types (STs) (ST14, ST17, ST20, ST29, ST45, ST101, ST268, ST1800, ST3995, and ST3996) belonging to CG258, being two (ST3995 and ST3996) described for the first time in this study.
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Affiliation(s)
- Rafael Nakamura-Silva
- Postgraduate Program in Environmental Technology, Universidade de Ribeirão Preto, Ribeirão Preto, São Paulo, Brazil
| | - Mariana Oliveira-Silva
- Postgraduate Program in Environmental Technology, Universidade de Ribeirão Preto, Ribeirão Preto, São Paulo, Brazil
| | - João Pedro Rueda Furlan
- School of Pharmaceutical Sciences of Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Eliana Guedes Stehling
- School of Pharmaceutical Sciences of Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Carlos Eduardo Saraiva Miranda
- Postgraduate Program in Dentistry, Universidade de Ribeirão Preto, UNAERP. Bloco J, Laboratório 1. Av. Costábile Romano, 2201 - Ribeirânia, Ribeirão Preto, São Paulo, CEP: 14096-900, Brazil
| | - André Pitondo-Silva
- Postgraduate Program in Environmental Technology, Universidade de Ribeirão Preto, Ribeirão Preto, São Paulo, Brazil. .,Postgraduate Program in Dentistry, Universidade de Ribeirão Preto, UNAERP. Bloco J, Laboratório 1. Av. Costábile Romano, 2201 - Ribeirânia, Ribeirão Preto, São Paulo, CEP: 14096-900, Brazil.
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9
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Homeier-Bachmann T, Heiden SE, Lübcke PK, Bachmann L, Bohnert JA, Zimmermann D, Schaufler K. Antibiotic-Resistant Enterobacteriaceae in Wastewater of Abattoirs. Antibiotics (Basel) 2021; 10:antibiotics10050568. [PMID: 34065908 PMCID: PMC8150771 DOI: 10.3390/antibiotics10050568] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/08/2021] [Accepted: 05/09/2021] [Indexed: 11/16/2022] Open
Abstract
Antibiotic-resistant Enterobacteriaceae are regularly detected in livestock. As pathogens, they cause difficult-to-treat infections and, as commensals, they may serve as a source of resistance genes for other bacteria. Slaughterhouses produce significant amounts of wastewater containing antimicrobial-resistant bacteria (AMRB), which are released into the environment. We analyzed the wastewater from seven slaughterhouses (pig and poultry) for extended-spectrum β-lactamase (ESBL)-carrying and colistin-resistant Enterobacteriaceae. AMRB were regularly detected in pig and poultry slaughterhouse wastewaters monitored here. All 25 ESBL-producing bacterial strains (19 E. coli and six K. pneumoniae) isolated from poultry slaughterhouses were multidrug-resistant. In pig slaughterhouses 64% (12 of 21 E. coli [57%] and all four detected K. pneumoniae [100%]) were multidrug-resistant. Regarding colistin, resistant Enterobacteriaceae were detected in 54% of poultry and 21% of pig water samples. Carbapenem resistance was not detected. Resistant bacteria were found directly during discharge of wastewaters from abattoirs into water bodies highlighting the role of slaughterhouses for environmental surface water contamination.
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Affiliation(s)
- Timo Homeier-Bachmann
- Friedrich-Loeffler-Institut, Institute of Epidemiology, 17493 Greifswald-Insel Riems, Germany;
- Correspondence: ; Tel.: +49-38351-7-1505
| | - Stefan E. Heiden
- Institute of Pharmacy, University of Greifswald, 17489 Greifswald, Germany; (S.E.H.); (K.S.)
| | - Phillip K. Lübcke
- Friedrich-Loeffler-Institut, Institute of Epidemiology, 17493 Greifswald-Insel Riems, Germany;
- Institute of Pharmacy, University of Greifswald, 17489 Greifswald, Germany; (S.E.H.); (K.S.)
| | - Lisa Bachmann
- Leibniz-Institut für Nutztierbiologie, Institute of Nutritional Physiology “Oskar Kellner”, 18196 Dummerstorf, Germany;
| | - Jürgen A. Bohnert
- Friedrich Loeffler-Institute of Medical Microbiology, University Medicine Greifswald, 17475 Greifswald, Germany;
| | | | - Katharina Schaufler
- Institute of Pharmacy, University of Greifswald, 17489 Greifswald, Germany; (S.E.H.); (K.S.)
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10
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Morales-León F, Opazo-Capurro A, Caro C, Lincopan N, Cardenas-Arias A, Esposito F, Illesca V, Rioseco ML, Domínguez-Yévenes M, Lima CA, Bello-Toledo H, González-Rocha G. Hypervirulent and hypermucoviscous extended-spectrum β-lactamase-producing Klebsiella pneumoniae and Klebsiella variicola in Chile. Virulence 2020; 12:35-44. [PMID: 33372844 PMCID: PMC7781644 DOI: 10.1080/21505594.2020.1859274] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Convergence of virulence and antibiotic-resistance has been reported in Klebsiella pneumoniae, but not in Klebsiella variicola. We, hereby, report the detection and genomic characterization of hypervirulent and hypermucoviscous K. pneumoniae and K.variicola recovered in Chile from health-care associated infections, which displayed resistance to broad-spectrum cephalosporins. One hundred forty-six K. pneumoniae complex isolates were screened by hypermucoviscosity by the “string test.” Two hypermucoid isolates, one hypermucoviscous K. pneumoniae (hmKp) and one K. variicola (hmKv), were further investigated by whole-genome sequencing. In vivo virulence was analyzed by the Galleria mellonella killing assay. In silico analysis of hmKp UCO-494 and hmKv UCO-495 revealed the presence of multiple antibiotic-resistance genes, such as blaCTX-M-1, blaDHA-1 and blaLEN-25 among others clinically relevant resistance determinants, including mutations in a two-component regulatory system related to colistin resistance. These genetic features confer a multidrug-resistant (MDR) phenotype in both strains. Moreover, virulome in silico analysis confirmed the presence of the aerobactin gene iutA, in addition to yersiniabactin and/or colicin V encoding genes, which are normally associated to high virulence in humans. Furthermore, both isolates were able to kill G. mellonella and displayed higher virulence in comparison with the control strain. In summary, the convergence of virulence and the MDR-phenotype in K. pneumoniae complex members is reported for the first time in Chile, denoting a clinical problem that deserves special attention and continuous surveillance in South America.
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Affiliation(s)
- F Morales-León
- Laboratorio de Investigación en Agentes Antibacterianos, Facultad de Ciencias Biológicas, Universidad de Concepción , Concepción, Chile.,Millennium Nucleus for Collaborative Research on Bacterial Resistance , Chile.,Departamento de Farmacia, Universidad de Concepción, Concepción , Chile
| | - A Opazo-Capurro
- Laboratorio de Investigación en Agentes Antibacterianos, Facultad de Ciencias Biológicas, Universidad de Concepción , Concepción, Chile.,Millennium Nucleus for Collaborative Research on Bacterial Resistance , Chile
| | - C Caro
- Laboratorio de Investigación en Agentes Antibacterianos, Facultad de Ciencias Biológicas, Universidad de Concepción , Concepción, Chile.,Departamento de Farmacia, Universidad de Concepción, Concepción , Chile
| | - N Lincopan
- Department of Microbiology, Institute of Biomedical Sciences, Universidade de São Paulo , São Paulo, Brazil.,Department of Clinical Analysis, School of Pharmacy, Universidade de São Paulo , São Paulo, Brazil
| | - A Cardenas-Arias
- Department of Microbiology, Institute of Biomedical Sciences, Universidade de São Paulo , São Paulo, Brazil
| | - F Esposito
- Department of Microbiology, Institute of Biomedical Sciences, Universidade de São Paulo , São Paulo, Brazil.,Department of Clinical Analysis, School of Pharmacy, Universidade de São Paulo , São Paulo, Brazil
| | - V Illesca
- Unidad de Microbiología, Hospital Dr. Hernan Henriquez Aravena , Temuco, Chile
| | - M L Rioseco
- Laboratorio de Microbiologia, Hospital de Puerto Montt , Puerto Montt, Chile
| | - M Domínguez-Yévenes
- Laboratorio de Investigación en Agentes Antibacterianos, Facultad de Ciencias Biológicas, Universidad de Concepción , Concepción, Chile
| | - C A Lima
- Laboratorio de Investigación en Agentes Antibacterianos, Facultad de Ciencias Biológicas, Universidad de Concepción , Concepción, Chile.,Millennium Nucleus for Collaborative Research on Bacterial Resistance , Chile
| | - H Bello-Toledo
- Laboratorio de Investigación en Agentes Antibacterianos, Facultad de Ciencias Biológicas, Universidad de Concepción , Concepción, Chile.,Millennium Nucleus for Collaborative Research on Bacterial Resistance , Chile
| | - Gerardo González-Rocha
- Laboratorio de Investigación en Agentes Antibacterianos, Facultad de Ciencias Biológicas, Universidad de Concepción , Concepción, Chile.,Millennium Nucleus for Collaborative Research on Bacterial Resistance , Chile
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11
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Li Q, Zhu J, Kang J, Song Y, Yin D, Guo Q, Song J, Zhang Y, Wang S, Duan J. Emergence of NDM-5-Producing Carbapenem-Resistant Klebsiella pneumoniae and SIM-Producing Hypervirulent Klebsiella pneumoniae Isolated from Aseptic Body Fluid in a Large Tertiary Hospital, 2017-2018: Genetic Traits of blaNDM-Like and blaSIM-Like Genes as Determined by NGS. Infect Drug Resist 2020; 13:3075-3089. [PMID: 32943891 PMCID: PMC7481300 DOI: 10.2147/idr.s261117] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/28/2020] [Indexed: 01/10/2023] Open
Abstract
Purpose To characterize the clinical, resistance, and virulence features of carbapenem-resistant Klebsiella pneumonaie (CRKP) and hypervirulent Klebsiella pneumoniae (hvKP) and also provide an effective selection of drug in CRKP and hvKP treatment. Materials and Methods Twelve strains were collected and investigated these isolates for their antimicrobial susceptibility and molecular features. Resistance mechanisms, virulence-associated genes, multilocus sequence typing (MLST), and serotypes were detected by PCR and sequencing. Next general sequencing (NGS) was carried out to determine the features of carbapenem resistance and virulence. The synergistic activity of tigecycline–imipenem (TGC+IPM), tigecycline–meropenem (TGC+MEM), and tigecycline–aztreonam (TGC+ATM) combinations were performed by microdilution checkerboard method. Results Eleven CRKP and one hvKP strains were collected. All strains showed highly sensitive rates to tigecycline (TGC) and amikacin (AMK). NDM (33.3%, 4/12) was the main resistance mechanism and MLST assigned 3 of them to ST11. CTX-M-producing (n = 1) and KPC-2-producing (n = 1) isolates belonged to ST147 and ST11, respectively. The MICs of ATM and quinolones in NDM-1 CRKP and NDM-5 CRKP strains were different. The serotype of the majority strains was KL22KL137 (58.3%, 7/12), hvKP stain belonged to K64. CRKP strains harbored plasmid-mediated quinolone resistance genes (oqxA, oqxB, qnrS, qnrB), β-lactams (blaCTX-M-3), aminoglycosides, type I and type III fimbriae genes, siderophore genes, and transporter and pumps. SIM-producing ST1764 K64 showed typical features of hvKP, showing hypermucoviscosity phenotype. The virulence genes, including rmpA2, alls and aerobactin genes, linked to hvKP, were found in ST1764 hvKP. hvKP was sensitive to quinolone; also, oqxA gene was detected. All TGC combinations showed highly synergistic effects and TGC+IPM was more effective treatment. Conclusion We first identified the NDM-5-producing ST690 CRKP and SIM-producing ST1764 hvKP strains in Shanxi province. Tigecycline-carbapenem combinations were available treatments for CRKP.
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Affiliation(s)
- Qi Li
- Department of Pharmacy, School of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi, People's Republic of China
| | - Jiaying Zhu
- Department of Pharmacy, School of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi, People's Republic of China
| | - Jianbang Kang
- Department of Pharmacy, Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, People's Republic of China
| | - Yan Song
- Department of Pharmacy, Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, People's Republic of China
| | - Donghong Yin
- Department of Pharmacy, Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, People's Republic of China
| | - Qian Guo
- Department of Pharmacy, Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, People's Republic of China
| | - Junli Song
- Department of Pharmacy, Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, People's Republic of China
| | - Yan Zhang
- Department of Chief Executive, Willingmed Technology (Beijing) Co., Ltd, Beijing, Beijing, People's Republic of China
| | - Shuyun Wang
- Department of Pharmacy, Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, People's Republic of China
| | - Jinju Duan
- Department of Pharmacy, Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, People's Republic of China
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12
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Dos Anjos C, Sabino CP, Sellera FP, Esposito F, Pogliani FC, Lincopan N. Hypervirulent and hypermucoviscous strains of Klebsiella pneumoniae challenged by antimicrobial strategies using visible light. Int J Antimicrob Agents 2020; 56:106025. [PMID: 32450196 DOI: 10.1016/j.ijantimicag.2020.106025] [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: 02/12/2020] [Revised: 05/11/2020] [Accepted: 05/14/2020] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Infections caused by hypervirulent and/or hypermucoviscous Klebsiella pneumoniae (K. pneumoniae) strains are frequently reported worldwide. Since convergence of hypervirulence and drug-resistance emerged as a serious clinical problem, novel therapeutic strategies are worthy of investigation. In this regard, antimicrobial photodynamic therapy and blue light have proven to be effective against a broad-spectrum of clinically relevant pathogens but have never been tested for hypervirulent/hypermucoviscous strains. Thus, this study investigated the influence of hypermucoviscosity and hypervirulence over the photoinactivation efficacy of blue light alone or antimicrobial photodynamic therapy mediated by methylene blue and red light. METHODS Five clinical isolates of K. pneumoniae were screened for hypermucoviscosity by string test and for hypervirulence by a Galleria mellonella model of systemic infection. Strains were then challenged by both photoinactivation methods performed in vitro. All tests also included a non-hypervirulent/hypermucoviscous control strain for comparison. RESULTS All K. pneumoniae strains were effectively inactivated by both light-based antimicrobial strategies. Hypervirulent/hypermucoviscous strains exposed to photodynamic therapy presented rapid and consistent inactivation kinetics, while blue light led to slower and more variable inactivation kinetics. CONCLUSION Hypermucoviscosity and hypervirulence does not confer tolerance in K. pneumoniae against photoinactivation. Antimicrobial photodynamic therapy represents an interesting alternative to treat localised infections because it is a fast procedure with high effectiveness. On the other hand, antimicrobial blue light could be used to decontaminate hospital environments since no photosensitiser administration is required and harmful effects of ultraviolet light are avoided. Therefore, visible light-based strategies present great potential for the development of safe and effective antimicrobial technologies against such aggressive pathogens.
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Affiliation(s)
- Carolina Dos Anjos
- Department of Internal Medicine, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, Brazil.
| | - Caetano P Sabino
- BioLambda, Scientific and Commercial LTD, São Paulo, Brazil; Department of Clinical Analysis, Faculty of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil.
| | - Fábio P Sellera
- Department of Internal Medicine, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, Brazil
| | - Fernanda Esposito
- Department of Clinical Analysis, Faculty of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil
| | - Fabio C Pogliani
- Department of Internal Medicine, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, Brazil
| | - Nilton Lincopan
- Department of Clinical Analysis, Faculty of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil; Department of Microbiology, Instituto de Ciências Biomédicas, Universidade de São Paulo, São Paulo, Brazil
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13
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Yuan Y, Li Y, Wang G, Li C, Chang YF, Chen W, Nian S, Mao Y, Zhang J, Zhong F, Zhang L. bla NDM-5 carried by a hypervirulent Klebsiella pneumoniae with sequence type 29. Antimicrob Resist Infect Control 2019; 8:140. [PMID: 31452874 PMCID: PMC6701021 DOI: 10.1186/s13756-019-0596-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 08/12/2019] [Indexed: 12/24/2022] Open
Abstract
Background A carbapenem-resistant hypermucoviscous Klebsiella pneumoniae isolate was recovered from human sputum. Methods Whole genome sequencing of this isolate was carried out to reveal its clonal background, antimicrobial resistance determinants and virulence factors. Virulence assays were performed using wax moth larvae. The transfer of blaNDM-5 between bacterial strains was tested using conjugation. 59 genome assemblies of ST29 K. pneumoniae and 230 IncX3 plasmids regardless of the carriage of resistance gene were employed for phylogenetic analysis, respectively. Results The strain carried a virulence plasmid pVir-SCNJ1 bearing the virulence gene rmpA and exhibited a high virulence in wax moth. This hypervirulent strain belongs to sequence type 29 and carries blaNDM-5, which is located on a conjugative plasmid, designated pNDM5-SCNJ1, belonging to type IncX3. pNDM5-SCNJ1 was fully sequenced and shows high similarity with pNDM_MGR194, except some deletion inside the ISAba125 region. Phylogenetic analysis of IncX3 plasmids revealed that although blaNDM-5 can be evolved from blaNDM-1 via point mutations within some IncX3 plasmids, most of blaNDM-5-carrying IncX3 plasmids probably have acquired blaNDM-5 in multiple events. Conclusions In this study, we characterized a blaNDM-5-positive hypervirulent K. pneumoniae of sequence type 29 in China. Our results highlight the need for active surveillance on this lineage of carbapenem-resistant K. pneumoniae. Electronic supplementary material The online version of this article (10.1186/s13756-019-0596-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yi Yuan
- Department of Laboratory Medicine, The First People's Hospital of Neijiang, Neijiang, Sichuan China
| | - Ying Li
- 2Department of Immunology, School of Basic Medical Sciences, Southwest Medical University, Luzhou, Sichuan China
| | - Guangxi Wang
- 3Department of Pathogenic Biology, School of Basic Medical Sciences, Southwest Medical University, No.1 Section 1, Xiang Lin Road, Longmatan District, Luzhou, 646000 Sichuan China
| | - Chengwen Li
- 2Department of Immunology, School of Basic Medical Sciences, Southwest Medical University, Luzhou, Sichuan China
| | - Yung-Fu Chang
- 4Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY USA
| | - Wenbi Chen
- 3Department of Pathogenic Biology, School of Basic Medical Sciences, Southwest Medical University, No.1 Section 1, Xiang Lin Road, Longmatan District, Luzhou, 646000 Sichuan China
| | - Siji Nian
- 3Department of Pathogenic Biology, School of Basic Medical Sciences, Southwest Medical University, No.1 Section 1, Xiang Lin Road, Longmatan District, Luzhou, 646000 Sichuan China
| | - Yingyu Mao
- 3Department of Pathogenic Biology, School of Basic Medical Sciences, Southwest Medical University, No.1 Section 1, Xiang Lin Road, Longmatan District, Luzhou, 646000 Sichuan China
| | - Jinping Zhang
- 3Department of Pathogenic Biology, School of Basic Medical Sciences, Southwest Medical University, No.1 Section 1, Xiang Lin Road, Longmatan District, Luzhou, 646000 Sichuan China
| | - Fangcai Zhong
- Department of Laboratory Medicine, The First People's Hospital of Neijiang, Neijiang, Sichuan China
| | - Luhua Zhang
- 3Department of Pathogenic Biology, School of Basic Medical Sciences, Southwest Medical University, No.1 Section 1, Xiang Lin Road, Longmatan District, Luzhou, 646000 Sichuan China
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14
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Heinz E, Brindle R, Morgan-McCalla A, Peters K, Thomson NR. Caribbean multi-centre study of Klebsiella pneumoniae: whole-genome sequencing, antimicrobial resistance and virulence factors. Microb Genom 2019; 5:e000266. [PMID: 31038449 PMCID: PMC6562249 DOI: 10.1099/mgen.0.000266] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 03/21/2019] [Indexed: 12/14/2022] Open
Abstract
The surveillance of antimicrobial-resistant isolates has proven to be one of the most valuable tools to understand the global rise of multidrug-resistant bacterial pathogens. We report the first insights into the current situation in the Caribbean, where a pilot project to monitor antimicrobial resistance (AMR) through phenotypic resistance measurements combined with whole-genome sequencing was set up in collaboration with the Caribbean Public Health Agency (CARPHA). Our first study focused on Klebsiella pneumoniae, a highly relevant organism amongst the Gram-negative opportunistic pathogens worldwide causing hospital- and community-acquired infections. Our results show that not only carbapenem resistance, but also hypervirulent strains, are circulating in patients in the Caribbean. Our current data does not allow us to infer their prevalence in the population. We argue for the urgent need to further support AMR surveillance and stewardship in this almost uncharted territory, which can make a significant impact on the reduction of antimicrobial usage. This article contains data hosted by Microreact (https://microreact.org).
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Affiliation(s)
- Eva Heinz
- Wellcome Trust Sanger Institute, Hinxton, UK
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Richard Brindle
- Caribbean Public Health Agency, Port of Spain, Trinidad and Tobago
- University of Bristol, Bristol, UK
| | - Andrina Morgan-McCalla
- Caribbean Public Health Agency, Port of Spain, Trinidad and Tobago
- University of the West Indies, Mona, Jamaica
| | - Keisha Peters
- Caribbean Public Health Agency, Port of Spain, Trinidad and Tobago
| | - Nicholas R. Thomson
- Wellcome Trust Sanger Institute, Hinxton, UK
- London School of Hygiene and Tropical Medicine, London, UK
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15
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Catalán-Nájera JC, Barrios-Camacho H, Duran-Bedolla J, Sagal-Prado A, Hernández-Castro R, García-Méndez J, Morfín-OteroMorfín-Otero R, Velázquez-Larios MDR, Ortíz-Navarrete V, Gutierrez-Xicotencatl L, Alpuche-Aranda C, Silva-Sánchez J, Garza-Ramos U. Molecular characterization and pathogenicity determination of hypervirulent Klebsiella pneumoniae clinical isolates serotype K2 in Mexico. Diagn Microbiol Infect Dis 2019; 94:316-319. [PMID: 30857917 DOI: 10.1016/j.diagmicrobio.2019.01.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/11/2019] [Accepted: 01/18/2019] [Indexed: 01/20/2023]
Abstract
Hypervirulent Klebsiella pneumoniae have been rarely described in Latin America. This work describes the characterization of hypervirulent K. pneumoniae isolates capsular serotype K2 belonging to sequence types 86 and 380. The assays showed the hypervirulent K. pneumoniae highly virulent, which is determined by the plasmid borne virulence genes. At this time, the hypervirulent K. pneumoniae clinical isolates in Mexico are extensively susceptible to antibiotics.
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Affiliation(s)
- Juan Carlos Catalán-Nájera
- Centro de Investigación Sobre Enfermedades Infecciosas (CISEI), Instituto Nacional de Salud Pública (INSP), Cuernavaca, Morelos, México
| | - Humberto Barrios-Camacho
- Centro de Investigación Sobre Enfermedades Infecciosas (CISEI), Instituto Nacional de Salud Pública (INSP), Cuernavaca, Morelos, México
| | - Josefina Duran-Bedolla
- Centro de Investigación Sobre Enfermedades Infecciosas (CISEI), Instituto Nacional de Salud Pública (INSP), Cuernavaca, Morelos, México
| | - Alan Sagal-Prado
- Centro de Investigación Sobre Enfermedades Infecciosas (CISEI), Instituto Nacional de Salud Pública (INSP), Cuernavaca, Morelos, México
| | - Rigoberto Hernández-Castro
- Departamento Ecología de Agentes Patógenos, Hospital General "Dr. Manuel Gea González", Ciudad de México, México
| | - Jorge García-Méndez
- Departamento de Posgrado y Educación Médica Continua, Instituto Nacional de Cancerología, Ciudad de México, México
| | - Rayo Morfín-OteroMorfín-Otero
- Instituto de Patología Infecciosa y Experimental, Centro Universitario de Ciencias de la Salud, Hospital Civil de Guadalajara "Fray Antonio Alcalde", Universidad de Guadalajara, Guadalajara, Jalisco, México
| | | | - Vianney Ortíz-Navarrete
- Departamento de Biomedicina Molecular, Centro de Investigación y Estudios Avanzados (CINVESTAV), Ciudad de México, México
| | - Lourdes Gutierrez-Xicotencatl
- Centro de Investigación Sobre Enfermedades Infecciosas (CISEI), Instituto Nacional de Salud Pública (INSP), Cuernavaca, Morelos, México
| | - Celia Alpuche-Aranda
- Centro de Investigación Sobre Enfermedades Infecciosas (CISEI), Instituto Nacional de Salud Pública (INSP), Cuernavaca, Morelos, México
| | - Jesús Silva-Sánchez
- Centro de Investigación Sobre Enfermedades Infecciosas (CISEI), Instituto Nacional de Salud Pública (INSP), Cuernavaca, Morelos, México.
| | - Ulises Garza-Ramos
- Centro de Investigación Sobre Enfermedades Infecciosas (CISEI), Instituto Nacional de Salud Pública (INSP), Cuernavaca, Morelos, México.
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