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Kang SW, Park S, Kim AR, Han J, Lee J, Seo H, Sung H, Kim MN, Chang E, Bae S, Jung J, Kim MJ, Kim SH, Lee SO, Choi SH, Kim YS, Song EH, Chong YP. Clinical Characteristics of and Risk Factors for Subsequent Carbapenemase-producing Enterobacterales (CPE) Bacteraemia in Rectal CPE Carriers. Int J Antimicrob Agents 2023; 62:106959. [PMID: 37633425 DOI: 10.1016/j.ijantimicag.2023.106959] [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: 05/18/2023] [Revised: 08/15/2023] [Accepted: 08/18/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Due to high mortality and limited treatment options, the rise in carbapenemase-producing Enterobacterales (CPE) has become a major concern. This study aimed to evaluate the incidence and characteristics of subsequent CPE bacteraemia in rectal CPE carriers and investigate the risk factors for CPE bacteraemia compared with non-carbapenemase-producing (non-CP) Enterobacterales bacteraemia. METHODS A retrospective analysis was conducted on adult patients who were confirmed to have CPE colonisation by stool surveillance culture at a tertiary hospital from January 2018 to February 2022. All episodes of Enterobacterales bacteraemia up to 6 months after CPE colonisation were identified. RESULTS Of 1174 patients identified as rectal CPE carriers, 69 (5.8%; 95% CI 4.6-7.3%) experienced subsequent CPE bacteraemia during the 6 months after the diagnosis of CPE colonisation. Colonisation by a Klebsiella pneumoniae carbapenemase (KPC) producer (or CP-K. pneumoniae), colonisation by multiple CPE species, chronic kidney disease and haematological malignancy were independently associated with CPE bacteraemia in CPE carriers. When CPE carriers developed Enterobacterales bacteraemia, the causative agent was more frequently non-CP Enterobacterales than CPE (63.6% vs. 36.4%). Among these patients, colonisation with a KPC producer, CPE colonisation at multiple sites, shorter duration from colonisation to bacteraemia (< 30 days) and recent intraabdominal surgery were independent risk factors for CPE bacteraemia rather than non-CP Enterobacterales bacteraemia. CONCLUSIONS In CPE carriers, non-CP Enterobacterales were more often responsible for bacteraemia than CPE. Empirical antibiotic therapy for CPE should be considered when sepsis is suspected in a CPE carrier with risk factors for CPE bacteraemia.
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Affiliation(s)
- Sung-Woon Kang
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Somi Park
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - A Reum Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jaijun Han
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jiyoung Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyeonji Seo
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea; Division of Infectious Diseases, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Heungsup Sung
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Mi-Na Kim
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Euijin Chang
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seongman Bae
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jiwon Jung
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min Jae Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Ho Choi
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yang Soo Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Hee Song
- Departments of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Gangwon-do, Republic of Korea.
| | - Yong Pil Chong
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Wang Q, Lei C, Cheng H, Yang X, Huang Z, Chen X, Ju Z, Zhang H, Wang H. Widespread Dissemination of Plasmid-Mediated Tigecycline Resistance Gene tet(X4) in Enterobacterales of Porcine Origin. Microbiol Spectr 2022; 10:e0161522. [PMID: 36125305 PMCID: PMC9602804 DOI: 10.1128/spectrum.01615-22] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/17/2022] [Indexed: 12/31/2022] Open
Abstract
The emergence of the plasmid-mediated high levels of the tigecycline resistance gene has drawn worldwide attention and has posed a major threat to public health. In this study, we investigated the prevalence of the tet(X4)-positive Enterobacterales isolates collected from a pig slaughterhouse and farms. A total of 101 tigecycline resistance strains were isolated from 353 samples via a medium with tigecycline, of which 33 carried tet(X4) (9.35%, 33/353) and 2 carried tet(X6) (0.57%, 2/353). These strains belong to seven different species, with Escherichia coli being the main host bacteria. Importantly, this report is the first one to demonstrate that tet(X4) was observed in Morganella morganii. Whole-genome sequencing results revealed that tet(X4)-positive bacteria can coexist with other resistance genes, such as blaNDM-1 and cfr. Additionally, we were the first to report that tet(X4) and blaNDM-1 coexist in a Klebsiella quasipneumoniae strain. The phylogenetic tree of 533 tet(X4)-positive E. coli strains was constructed using 509 strains from the NCBI genome assembly database and 24 strains from this study, which arose from 8 sources and belonged to 135 sequence types (STs) worldwide. We used Nanopore sequencing to interpret the selected 21 nonclonal and representative strains and observed that 19 tet(X4)-harboring plasmids were classified into 8 replicon types, and 2 tet(X6) genes were located on integrating conjugative elements. A total of 68.42% of plasmids carrying tet(X4) were transferred successfully with a conjugation frequency of 10-2 to 10-7. These findings highlight that diverse plasmids drive the widespread dissemination of the tigecycline resistance gene tet(X4) in Enterobacterales of porcine origin. IMPORTANCE Tigecycline is considered to be the last resort of defense against diseases caused by broad-spectrum resistant Gram-negative bacteria. In this study, we systematically analyzed the prevalence and genetic environments of the resistance gene tet(X4) in a pig slaughterhouse and farms and the evolutionary relationship of 533 tet(X4)-positive Escherichia coli strains, including 509 tet(X4)-positive E. coli strains selected from the 27,802 assembled genomes of E. coli from the NCBI between 2002 and 2022. The drug resistance of tigecycline is widely prevalent in pig farms where tetracycline is used as a veterinary drug. This prevalence suggests that pigs are a large reservoir of tet(X4) and that tet(X4) can spread horizontally through the food chain via mobile genetic elements. Furthermore, tetracycline resistance may drive tigecycline resistance through some mechanisms. Therefore, it is important to monitor tigecycline resistance, develop effective control measures, and focus on tetracycline use in the pig farms.
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Affiliation(s)
- Qin Wang
- Key Laboratory of Bio-Resource and Eco-Environment of Ministry of Education, College of Life Sciences, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
- Animal Disease Prevention and Food Safety Key Laboratory of Sichuan Province, Chengdu, People’s Republic of China
| | - Changwei Lei
- Key Laboratory of Bio-Resource and Eco-Environment of Ministry of Education, College of Life Sciences, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
- Animal Disease Prevention and Food Safety Key Laboratory of Sichuan Province, Chengdu, People’s Republic of China
| | - Hansen Cheng
- Key Laboratory of Bio-Resource and Eco-Environment of Ministry of Education, College of Life Sciences, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
| | - Xue Yang
- Key Laboratory of Bio-Resource and Eco-Environment of Ministry of Education, College of Life Sciences, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
- Animal Disease Prevention and Food Safety Key Laboratory of Sichuan Province, Chengdu, People’s Republic of China
| | - Zheren Huang
- Key Laboratory of Bio-Resource and Eco-Environment of Ministry of Education, College of Life Sciences, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
- Animal Disease Prevention and Food Safety Key Laboratory of Sichuan Province, Chengdu, People’s Republic of China
| | - Xuan Chen
- Key Laboratory of Bio-Resource and Eco-Environment of Ministry of Education, College of Life Sciences, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
- Animal Disease Prevention and Food Safety Key Laboratory of Sichuan Province, Chengdu, People’s Republic of China
| | - Zijing Ju
- Key Laboratory of Bio-Resource and Eco-Environment of Ministry of Education, College of Life Sciences, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
- Animal Disease Prevention and Food Safety Key Laboratory of Sichuan Province, Chengdu, People’s Republic of China
| | - Haoyu Zhang
- Key Laboratory of Bio-Resource and Eco-Environment of Ministry of Education, College of Life Sciences, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
- Animal Disease Prevention and Food Safety Key Laboratory of Sichuan Province, Chengdu, People’s Republic of China
| | - Hongning Wang
- Key Laboratory of Bio-Resource and Eco-Environment of Ministry of Education, College of Life Sciences, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
- Animal Disease Prevention and Food Safety Key Laboratory of Sichuan Province, Chengdu, People’s Republic of China
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Combined effect of Polymyxin B and Tigecycline to overcome Heteroresistance in Carbapenem-Resistant Klebsiella pneumoniae. Microbiol Spectr 2021; 9:e0015221. [PMID: 34704782 PMCID: PMC8549724 DOI: 10.1128/spectrum.00152-21] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
We assessed the prevalence of polymyxin B (PMB)- and tigecycline (TGC)-heteroresistant Klebsiella pneumoniae isolates and investigated the combined effect of PMB and TGC against dual-heteroresistant K. pneumoniae. Ninety-five nonduplicated carbapenem-resistant K. pneumoniae (CRKP) clinical isolates were collected from a tertiary-care teaching hospital in China. PCR was used to detect the resistant genes among the CRKP isolates. Population analysis profiling (PAP) was carried out to evaluate the existence of heteroresistance. A time-kill assay of PMB combined with TGC was conducted against heteroresistant K. pneumoniae strains. Real-time PCR was performed to determine the pmrA, phoP, and acrB expression levels. Among them, 74 isolates (77.9%) were susceptible to TGC, and 90 isolates (94.7%) were susceptible to PMB. In addition, of the TGC-susceptible isolates, 49 strains (66.2%) exhibited heteroresistant phenotypes. All of the PMB-susceptible isolates showed heteroresistant phenotypes. Forty-six isolates (48.4%) were heteroresistant to both TGC and PMB. All of the isolates carried the blaKPC gene, and one strain carried both blaKPC and blaNDM genes. The time-kill assay revealed in four isolates that early bactericidal activity could be triggered by the combination of PMB and TGC, and there was no regrowth, even at a relatively lower concentration (0.125 mg/liter PMB with 1 mg/liter TGC). Upregulated expression of pmrA, phoP, and acrB indicated that heteroresistance could be related to two-component systems and the AcrAB-TolC efflux pump. The combination of PMB and TGC may be a treatment strategy for those infected with CRKP heteroresistant to PMB and/or TGC. IMPORTANCE Tigecycline and colistin are two of the last treatment options remaining for carbapenem-resistant Enterobacteriaceae. Unfortunately, tigecycline resistance and colistin heteroresistance are also increasing rapidly. In the current study, we identified a high prevalence of heteroresistance to both PMB and TGC among clinical isolates of carbapenem-resistant K. pneumoniae (CRKP). The resistant subpopulations could survive pressure from TGC or PMB but were killed by the combination at a relatively low dose. It is proposed that the combination of PMB and TGC may be a treatment strategy for patients who are infected with CRKP heteroresistant to PMB or TGC.
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Mao Y, Shi Q, Zhang P, Jiang Y, Yu Y. Effect of ramR loss-of-function insertion on tigecycline resistance in clinical isolates of carbapenem-resistant Klebsiella pneumoniae. J Glob Antimicrob Resist 2020; 21:410-413. [PMID: 32006749 DOI: 10.1016/j.jgar.2020.01.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 01/10/2020] [Accepted: 01/13/2020] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES Tigecycline is an antibacterial agent restricted for use against carbapenem-resistant Klebsiella pneumoniae (CRKP). This study aimed to identify the tigecycline resistance mechanism in clinical CRKP isolates obtained from a 60-year-old femalepatient during tigecycline treatment. METHODS Three K. pneumoniae isolates obtained during tigecycline treatment were subjected to antimicrobial susceptibility testing, pulsed-field gel electrophoresis (PFGE), multilocus sequence typing, and whole-genome sequencing and analysis. The function of ramR was confirmed by gene complementation. RESULTS Three K. pneumoniae isolates (W814, W112 and W113) were collected from the patient on Days 0, 10 and 13, respectively, of ongoing tigecycline treatment. Antimicrobial susceptibility testing showed resistance to all antibiotics except tigecycline and ceftazidime/avibactam. The tigecycline minimum inhibitory concentration (MIC) for strains W814 and W112 was 4 mg/L compared with 16 mg/L for strain W113. The three strains belonged to sequence type 11 (ST11) and had a similar PGFE pattern. Insertion sequence (IS) element ISKpn18 in ramR was identified in strain W113. A parent strain transformed with plasmid pCR2.1-Hyg carrying ramR enhanced tigecycline susceptibility, thus confirming that a loss-of-function insertion in ramR contributes to tigecycline resistance. CONCLUSION ISKpn18 insertion in the ramR gene contributes to the tigecycline resistance mechanism in the isolated K. pneumoniae strains.
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Affiliation(s)
- Yihan Mao
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China; Key Laboratory of Microbial Technology and Bioinformatics of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Qiucheng Shi
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China; Key Laboratory of Microbial Technology and Bioinformatics of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Ping Zhang
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China; Key Laboratory of Microbial Technology and Bioinformatics of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Yan Jiang
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China; Key Laboratory of Microbial Technology and Bioinformatics of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Yunsong Yu
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China; Key Laboratory of Microbial Technology and Bioinformatics of Zhejiang Province, Hangzhou, Zhejiang, China.
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MCR-1: a promising target for structure-based design of inhibitors to tackle polymyxin resistance. Drug Discov Today 2019; 24:206-216. [DOI: 10.1016/j.drudis.2018.07.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 07/10/2018] [Accepted: 07/16/2018] [Indexed: 11/18/2022]
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Wang Q, Zhang P, Zhao D, Jiang Y, Zhao F, Wang Y, Li X, Du X, Yu Y. Emergence of tigecycline resistance in Escherichia coli co-producing MCR-1 and NDM-5 during tigecycline salvage treatment. Infect Drug Resist 2018; 11:2241-2248. [PMID: 30519062 PMCID: PMC6239116 DOI: 10.2147/idr.s179618] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective Here, we report a case of severe infection caused by Escherichia coli that harbored mcr-1, blaNDM-5, and acquired resistance to tigecycline during tigecycline salvage therapy. Methods Antimicrobial susceptibility testing, Southern blot hybridization, and complete genome sequence of the strains were carried out. The genetic characteristics of the mcr-1 and blaNDM-5 plasmids were analyzed. The whole genome sequencing of mcr-1-containing plasmid was completed. Finally, putative single nucleotide polymorphisms and deletion mutations in the tigecycline-resistant strain were predicted. Results Three E. coli isolates were obtained from ascites, pleural effusion, and stool of a patient; they were resistant to almost all the tested antibiotics. The first two strains separated from ascites (E-FQ) and hydrothorax (E-XS) were susceptible to amikacin and tigecycline; however, the third strain from stool (E-DB) was resistant to tigecycline after nearly 3 weeks’ treatment with tigecycline. All three isolates possessed both mcr-1 and blaNDM-5. The blaNDM-5 gene was found on the IncX3 plasmid, whereas the mcr-1, fosA3 and blaCTX-M-14 were located on the IncHI2 plasmid. Mutations in acrB and lon were the reason for the resistance to tigecycline. Conclusion This is the first report of a colistin-, carbapenem-, and tigecycline-resistant E. coli in China. Tigecycline resistance acquired during tigecycline therapy is of great concern for us because tigecycline is a drug of last resort to treat carbapenem-resistant Gram-negative bacterial infections. Furthermore, the transmission of such extensively drug-resistant isolates may pose a great threat to public health.
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Affiliation(s)
- Qian Wang
- Department of General Practice, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Ping Zhang
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, China, .,Key Laboratory of Microbial Technology and Bioinformatics of Zhejiang Province, Hangzhou, China,
| | - Dongdong Zhao
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, China,
| | - Yan Jiang
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, China, .,Key Laboratory of Microbial Technology and Bioinformatics of Zhejiang Province, Hangzhou, China,
| | - Feng Zhao
- Department of Clinical Laboratory, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yanfei Wang
- Key Laboratory of Microbial Technology and Bioinformatics of Zhejiang Province, Hangzhou, China,
| | - Xi Li
- Centre of Laboratory Medicine, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Xiaoxing Du
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, China,
| | - Yunsong Yu
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, China, .,Key Laboratory of Microbial Technology and Bioinformatics of Zhejiang Province, Hangzhou, China,
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He F, Shi Q, Fu Y, Xu J, Yu Y, Du X. Tigecycline resistance caused by rpsJ evolution in a 59-year-old male patient infected with KPC-producing Klebsiella pneumoniae during tigecycline treatment. INFECTION GENETICS AND EVOLUTION 2018; 66:188-191. [PMID: 30268919 DOI: 10.1016/j.meegid.2018.09.025] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 09/14/2018] [Accepted: 09/26/2018] [Indexed: 10/28/2022]
Abstract
Carbapenem resistant Klebsiella pneumoniae (CRKP) nosocomial infection increased rapidly in recent years. By far, the anti-infection drugs for CRKP infection are limited. Tigecycline is one of the last resort treatments for CRKP infections. In this study, curative effect of tigecycline therapy was monitored in a 59-year-old male patient infected with KPC-producing K. pneumoniae. Consecutive clonal consistent K. pneumoniae isolates were cultured during tigecycline treatment. Whole genome sequencing of the isolates was performed, and bioinformatics analysis was further performed. Five isolates, four of which were susceptible and one resistant were collected. All of the isolates belong to Sequence Type 11 (ST11), and harbouring 11 gene sequences relevant to antibiotic resistance including blaKPC-2. One amino acid substitution V57L in rpsJ was identified in the tigecycline resistant isolates. Subsequent transformation experiment confirmed the contribution of the rpsJ variant (V57L) to reduced tigecycline susceptibility. To our knowledge, this study is the first report to provide direct in vivo evidence that evolution in the rpsJ gene can lead to tigecycline resistance in patients infected with KPC-producing K. pneumoniae during tigecycline treatment. This finding serves as a therapeutic warning as the rpsJ gene is on the chromosome of CRKP strains. Under selective pressure from tigecycline, the rpsJ mutation may occur and lead to tigecycline resistant.
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Affiliation(s)
- Fang He
- Department of Clinical Laboratory, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang 310014, China
| | - Qiucheng Shi
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Ying Fu
- Department of Clinical Laboratory, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Juan Xu
- Institute of Hygiene, Zhejiang Academy of Medical Sciences, Hangzhou, Zhejiang 310013, China
| | - Yunsong Yu
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Xiaoxing Du
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China.
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Zheng JX, Lin ZW, Sun X, Lin WH, Chen Z, Wu Y, Qi GB, Deng QW, Qu D, Yu ZJ. Overexpression of OqxAB and MacAB efflux pumps contributes to eravacycline resistance and heteroresistance in clinical isolates of Klebsiella pneumoniae. Emerg Microbes Infect 2018; 7:139. [PMID: 30068997 PMCID: PMC6070572 DOI: 10.1038/s41426-018-0141-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 06/21/2018] [Accepted: 07/03/2018] [Indexed: 01/04/2023]
Abstract
This study investigated the characteristics and mechanisms of eravacycline resistance and heteroresistance in clinical Klebsiella pneumoniae isolates. A total of 393 clinical K. pneumoniae isolates were collected and subjected to eravacycline and tigecycline MIC determinations using the agar dilution method. Eravacycline heteroresistance was assessed by a population analysis profile (PAP). The expression levels of efflux pumps and their regulators were determined by quantitative reverse-transcription PCR (qRT-PCR). This study identified 67 eravacycline-nonsusceptible isolates; among the extended-spectrum β-lactamase (ESBL)-positive isolates, eravacycline-nonsusceptible isolates were detected more frequently than tigecycline-nonsusceptible isolates (21.7% vs. 9.4%, p = 0.001). The study sample was observed to include 20 K. pneumoniae isolates with eravacycline heteroresistance. Compared to the reference strain, oqxA or oqxB overexpression was observed in nine eravacycline-nonsusceptible isolates (range, 35.64–309.02-fold) and 13 eravacycline-heteroresistant isolates (8.42–296.34-fold). The overexpression of macA or macB was detected in 12 eravacycline-heteroresistant isolates (3.23–28.35-fold). Overexpression of the efflux pump regulator gene ramA was observed in 11 eravacycline-nonsusceptible isolates (3.33–94.05-fold) and 18 eravacycline-heteroresistant isolates (3.89–571.70-fold). The eravacycline MICs were increased by one–fourfold by overexpression of oqxAB or macAB in three eravacycline-sensitive isolates. In conclusion, the overexpression of OqxAB and MacAB efflux pumps and the transcriptional regulator RamA were suggested to be involved in K. pneumoniae eravacycline resistance and heteroresistance.
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Affiliation(s)
- Jin-Xin Zheng
- Department of Infectious Diseases and the Key Lab of Endogenous Infection, Shenzhen Nanshan People's Hospital, Shenzhen University School of Medicine, No 89, Taoyuan Road, Nanshan District, 518052, Shenzhen, China.,Key Laboratory of Medical Molecular Virology of Ministries of Education and Health, School of Basic Medical Science and Institutes of Biomedical Sciences, Shanghai Medical College of Fudan University, 200032, Shanghai, China
| | - Zhi-Wei Lin
- Department of Infectious Diseases and the Key Lab of Endogenous Infection, Shenzhen Nanshan People's Hospital, Shenzhen University School of Medicine, No 89, Taoyuan Road, Nanshan District, 518052, Shenzhen, China
| | - Xiang Sun
- Department of Infectious Diseases and the Key Lab of Endogenous Infection, Shenzhen Nanshan People's Hospital, Shenzhen University School of Medicine, No 89, Taoyuan Road, Nanshan District, 518052, Shenzhen, China
| | - Wei-Hong Lin
- Key Laboratory of Medical Molecular Virology of Ministries of Education and Health, School of Basic Medical Science and Institutes of Biomedical Sciences, Shanghai Medical College of Fudan University, 200032, Shanghai, China
| | - Zhong Chen
- Department of Infectious Diseases and the Key Lab of Endogenous Infection, Shenzhen Nanshan People's Hospital, Shenzhen University School of Medicine, No 89, Taoyuan Road, Nanshan District, 518052, Shenzhen, China.,Key Laboratory of Medical Molecular Virology of Ministries of Education and Health, School of Basic Medical Science and Institutes of Biomedical Sciences, Shanghai Medical College of Fudan University, 200032, Shanghai, China
| | - Yang Wu
- Key Laboratory of Medical Molecular Virology of Ministries of Education and Health, School of Basic Medical Science and Institutes of Biomedical Sciences, Shanghai Medical College of Fudan University, 200032, Shanghai, China
| | - Guo-Bin Qi
- Key Laboratory of Medical Molecular Virology of Ministries of Education and Health, School of Basic Medical Science and Institutes of Biomedical Sciences, Shanghai Medical College of Fudan University, 200032, Shanghai, China
| | - Qi-Wen Deng
- Department of Infectious Diseases and the Key Lab of Endogenous Infection, Shenzhen Nanshan People's Hospital, Shenzhen University School of Medicine, No 89, Taoyuan Road, Nanshan District, 518052, Shenzhen, China
| | - Di Qu
- Key Laboratory of Medical Molecular Virology of Ministries of Education and Health, School of Basic Medical Science and Institutes of Biomedical Sciences, Shanghai Medical College of Fudan University, 200032, Shanghai, China.
| | - Zhi-Jian Yu
- Department of Infectious Diseases and the Key Lab of Endogenous Infection, Shenzhen Nanshan People's Hospital, Shenzhen University School of Medicine, No 89, Taoyuan Road, Nanshan District, 518052, Shenzhen, China.
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Hernández M, Quijada NM, Lorente LLU, de Frutos M, Rodríguez-Lázaro D, Eiros JM. Infrequent isolation of extensively drug-resistant (XDR) Klebsiella pneumoniae resistant to colistin in Spain. Int J Antimicrob Agents 2018; 51:531-533. [DOI: 10.1016/j.ijantimicag.2017.12.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 12/22/2017] [Accepted: 12/30/2017] [Indexed: 10/18/2022]
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Repurposing Zidovudine in combination with Tigecycline for treating carbapenem-resistant Enterobacteriaceae infections. Eur J Clin Microbiol Infect Dis 2017; 37:141-148. [DOI: 10.1007/s10096-017-3114-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 09/27/2017] [Indexed: 12/22/2022]
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Li P, Wang M, Li X, Hu F, Yang M, Xie Y, Cao W, Xia X, Zheng R, Tian J, Zhang K, Chen F, Tang A. ST37 Klebsiella pneumoniae: development of carbapenem resistance in vivo during antimicrobial therapy in neonates. Future Microbiol 2017; 12:891-904. [PMID: 28699768 DOI: 10.2217/fmb-2016-0165] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To investigate the mechanism leading to in vivo carbapenem resistance development in Klebsiella pneumoniae. Methods: Carbapenemase was detected using the modified carbapenem inactivation method. β-lactamases resistant genes were identified by PCR and sequencing. Clonal relatedness was evaluated by random amplified polymorphic DNA and multiple locus sequence typing. The relationship between sequence typing and resistant genes was analyzed by using the chi-squared test. Results: All ST37 carbapenem-resistant isolates were blaOXA-1 positive and all ST37 carbapenem-sensitive isolates were blaOXA-1 negative at Stage I. A significant relationship between carbapenem resistance and blaOXA-1 was observed. The blaOXA-1 -positive rate was significantly higher in ST37 K. pneumoniae than others. Conclusion: This is the first study about the development of carbapenem resistance in vivo potentially mediated by blaOXA-1 in ST37 K. pneumoniae among neonates.
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Affiliation(s)
- Pengling Li
- Department of Laboratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Min Wang
- Department of Laboratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Xianping Li
- Department of Laboratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Feihu Hu
- Department of Psychiatry, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Min Yang
- Department of Laboratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Yixin Xie
- Department of Laboratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Wei Cao
- Department of Laboratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Xiaomeng Xia
- Department of Obstetrics & Gynecology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Rong Zheng
- Department of Laboratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Jingjing Tian
- Department of Laboratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Kan Zhang
- Department of Laboratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Fang Chen
- Department of Laboratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Aiguo Tang
- Department of Laboratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
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12
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Lin YT, Huang YW, Huang HH, Yang TC, Wang FD, Fung CP. In vivo evolution of tigecycline-non-susceptible Klebsiella pneumoniae strains in patients: relationship between virulence and resistance. Int J Antimicrob Agents 2016; 48:485-491. [PMID: 27575728 DOI: 10.1016/j.ijantimicag.2016.07.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 06/26/2016] [Accepted: 07/02/2016] [Indexed: 10/21/2022]
Abstract
Tigecycline resistance among Klebsiella pneumoniae isolates has been increasingly reported. We aimed to investigate the relationship among in vivo acquisition of tigecycline resistance in K. pneumoniae clinical isolates, the underlying molecular mechanisms and bacterial virulence. Clinical isolates of K. pneumoniae from the same patient in a medical centre in Taiwan that were initially tigecycline-susceptible (TS) and then became tigecycline-non-susceptible (TNS) were identified. Clinical data were collected. All isolates were subjected to MIC determination by Etest, pulsed-field gel electrophoresis (PFGE), multilocus sequence typing (MLST), virulence factor determination, and growth rate and mouse lethality studies. Quantitative RT-PCR was performed to analyse acrA, oqxA, ramA and rarA expressions. The presence of mutations in acrR, ramR, oqxR and rpsJ were analysed by DNA sequencing. Five isogenic paired isolates were determined by PFGE fingerprinting. TNS K. pneumoniae appeared after treatment with a variety of antibiotics among patients infected with TS K. pneumoniae. TNS K. pneumoniae isolates were associated with upregulation of RamA and/or RarA and the corresponding AcrAB and/or OqxAB efflux pump(s), respectively. Various mutations in negative regulatory genes (ramR and oqxR) accounted for overexpression of ramA and rarA, respectively. Three of the five paired isolates showed similar growth rates and virulence between TS and TNS isolates. Two TNS K. pneumoniae strains belonging to capsular types K1 and K20 retained their high virulence. In conclusion, some TNS K. pneumoniae strains derived from TS isolates did not compromise their virulence. Dissemination of these highly pathogenic and resistant strains would be of major concern in the future.
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Affiliation(s)
- Yi-Tsung Lin
- Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Emergency and Critical Care Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Yi-Wei Huang
- Department of Biotechnology and Laboratory Science in Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsin-Hui Huang
- Department of Biotechnology and Laboratory Science in Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Tsuey-Ching Yang
- Department of Biotechnology and Laboratory Science in Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Fu-Der Wang
- Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chang-Phone Fung
- Division of Infectious Diseases, Sijhih Cathy General Hospital, New Taipei City, Taiwan
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13
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Osei Sekyere J, Govinden U, Bester LA, Essack SY. Colistin and tigecycline resistance in carbapenemase-producing Gram-negative bacteria: emerging resistance mechanisms and detection methods. J Appl Microbiol 2016; 121:601-17. [PMID: 27153928 DOI: 10.1111/jam.13169] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 04/13/2016] [Accepted: 05/02/2016] [Indexed: 01/31/2023]
Abstract
A literature review was undertaken to ascertain the molecular basis for tigecycline and colistin resistance mechanisms and the experimental basis for the detection and delineation of this resistance particularly in carbapenemase-producing Gram-negative bacteria. Pubmed, Google Scholar and Science Direct were searched with the keywords colistin, tigecycline, resistance mechanisms and detection methods. Trans-complementation and comparative MIC studies, mass spectrometry, chromatography, spectrofluorometry, PCR, qRT-PCR and whole genome sequencing (WGS) were commonly used to determine tigecycline and colistin resistance mechanisms, specifically modifications in the structural and regulatory efflux (acrAB, OqxAB, kpgABC adeABC-FGH-IJK, mexAB-XY-oprJM and soxS, rarA robA, ramRAB marRABC, adeLRS, mexRZ and nfxb) and lipid A (pmrHFIJFKLM, lpxA, lpxC lpxD and mgrB, pmrAB, phoPQ,) genes respectively. Mutations in the ribosomal 16S rRNA operon rrnBC, also yielded resistance to tigecycline through target site modifications. The mcr-1 gene conferring resistance to colistin was identified via WGS, trans-complementation and a murine thigh infection model studies. Common detection methods are mainly antibiotic sensitivity testing with broth microdilution while molecular identification tools are mostly PCR and WGS. Spectrofluorometry, MALDI-TOF MS, micro-array and real-time multiplex PCR hold much promise for the future as new detection tools.
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Affiliation(s)
- J Osei Sekyere
- Antimicrobial Research Unit, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - U Govinden
- Antimicrobial Research Unit, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - L A Bester
- Biomedical Resource Unit, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - S Y Essack
- Antimicrobial Research Unit, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
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14
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Current perspectives on tigecycline resistance in Enterobacteriaceae: susceptibility testing issues and mechanisms of resistance. Int J Antimicrob Agents 2016; 48:11-18. [DOI: 10.1016/j.ijantimicag.2016.04.017] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 03/31/2016] [Accepted: 04/02/2016] [Indexed: 11/23/2022]
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15
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Carraro A, Montin U, Violi P, Soldani F, Mazzi R, Merighi M, Kanani F, Concia E, Tedeschi U. Multidrug-resistant Combined Infections in a Liver Transplanted Patient: Case Report. EXP CLIN TRANSPLANT 2016; 16:340-343. [PMID: 27063638 DOI: 10.6002/ect.2015.0312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a case of successfully treated multiple liver abscesses in a liver-transplanted patient, sustained by combined multidrug-resistant infections. Two months after a liver transplant, a computed tomography scan revealed the presence of multiple abscesses in the liver graft. Blood cultures and abscessual liver fluid were both positive for acquired colistin- and carbapenem- resistant Klebsiella pneumoniae and an extended-spectrum of beta-lactamases-producing Enterobacter aerogenes. The treatment strategy consisted of different prolonged antimicrobial combinations and draining of the abscesses with complete recovery of the liver lesions.
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Affiliation(s)
- Amedeo Carraro
- Department of General Surgery and Odontoiatrics, Liver Transplant Unit, University Hospital of Verona, Verona, Italy, 37126
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16
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Abstract
Tetracyclines possess many properties considered ideal for antibiotic drugs, including activity against Gram-positive and -negative pathogens, proven clinical safety, acceptable tolerability, and the availability of intravenous (IV) and oral formulations for most members of the class. As with all antibiotic classes, the antimicrobial activities of tetracyclines are subject to both class-specific and intrinsic antibiotic-resistance mechanisms. Since the discovery of the first tetracyclines more than 60 years ago, ongoing optimization of the core scaffold has produced tetracyclines in clinical use and development that are capable of thwarting many of these resistance mechanisms. New chemistry approaches have enabled the creation of synthetic derivatives with improved in vitro potency and in vivo efficacy, ensuring that the full potential of the class can be explored for use against current and emerging multidrug-resistant (MDR) pathogens, including carbapenem-resistant Enterobacteriaceae, MDR Acinetobacter species, and Pseudomonas aeruginosa.
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17
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Sheng ZK, Wang W, Guo Q, Xu X, Wang M, Yang Y, Wang M. Emergence of tigecycline- and carbapenem-nonsusceptible Klebsiella pneumoniae ST11 clone in patients without exposure to tigecycline. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2015; 49:962-968. [PMID: 26692183 DOI: 10.1016/j.jmii.2015.10.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Revised: 10/25/2015] [Accepted: 10/27/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND/PURPOSE Currently, tigecycline-nonsusceptible Klebsiella pneumoniae (TNSKP) is mainly reported to emerge following clinical use of tigecycline and is usually polyclonal. This study aimed to characterize TNSKP isolated from patients without prior tigecycline use. METHODS Twenty-six TNSKP clinical isolates were collected, and carbapenemase and 16S rRNA methylase genes were identified by polymerase chain reaction and sequencing. Molecular typing was conducted by pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST). Clinical data of patients in the carbapenem-susceptible TNSKP group and the tigecycline- and carbapenem-nonsusceptible K. pneumoniae (TCNSKP) group were compared. RESULTS Of the 26 TNSKP isolates, eight contained both blaKPC-2 and 16S rRNA methylase genes. In the remaining 18 TNSKP isolates, no carbapenemase gene was detected, and only three had the 16S rRNA methylase gene. Among the 26 isolates, 24 distinct pulsotypes and 19 sequence types (STs) were identified by PFGE and MLST, respectively. Six of the eight TCNSKP were ST11, whereas the remaining 18 TNSKP isolates were assigned to 17 different STs. No patient received tigecycline prior to the isolation of TNSKP. By comparison, intensive care unit exposure, mechanical ventilation, prior β-lactam/β-lactamase use, and longer hospitalization were more common for the TCNSKP group than for the carbapenem-susceptible TNSKP group. CONCLUSION TNSKP can occur without tigecycline use, and TCNSKP ST11 is predominant among them. Further, this report proposes potential risk factors for the occurrence of carbapenem-nonsusceptibility in TNSKP.
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Affiliation(s)
- Zi-Ke Sheng
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Ministry of Health, Shanghai, China; Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Weixia Wang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Ministry of Health, Shanghai, China; Institute of Biomedical Science, Fudan University, Shanghai, China
| | - Qinglan Guo
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Ministry of Health, Shanghai, China
| | - Xiaogang Xu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Ministry of Health, Shanghai, China
| | - Minghua Wang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Ministry of Health, Shanghai, China
| | - Yang Yang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Ministry of Health, Shanghai, China
| | - Minggui Wang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Ministry of Health, Shanghai, China; Institute of Biomedical Science, Fudan University, Shanghai, China.
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18
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Niebel M, Quick J, Prieto AMG, Hill RLR, Pike R, Huber D, David M, Hornsey M, Wareham D, Oppenheim B, Woodford N, van Schaik W, Loman N. Deletions in a ribosomal protein-coding gene are associated with tigecycline resistance in Enterococcus faecium. Int J Antimicrob Agents 2015; 46:572-5. [PMID: 26364847 DOI: 10.1016/j.ijantimicag.2015.07.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 07/06/2015] [Accepted: 07/09/2015] [Indexed: 11/19/2022]
Abstract
Enterococcus faecium is an emerging nosocomial pathogen associated with antibiotic therapy in the hospital environment. Whole-genome sequences were determined for three pairs of related, consecutively collected E. faecium clinical isolates to determine putative mechanisms of resistance to tigecycline. The first isolates (1S, 2S and 3S) in each of the three pairs were sensitive to tigecycline [minimum inhibitory concentration (MIC) of 0.125 mg/L]. Following tigecycline therapy, the second isolate in each pair demonstrated increased resistance to tigecycline. Two isolates (1R and 2R) were resistant (MIC of 8 mg/L) and one isolate (3I) demonstrated reduced susceptibility (MIC of 0.5 mg/L). Mutations distinguishing each pair of sensitive and resistant isolates were determined through alignment to a reference genome and variant detection. In addition, a de novo assembly of each isolate genome was constructed to confirm mutations. A total of 16 mutations in eleven coding sequences were determined. Mutations in the rpsJ gene, which encodes a structural protein forming part of the 30S ribosomal subunit, were detected in each of the pairs. Mutations were in regions proximal to the predicted tigecycline-binding site. Predicted amino acid substitutions were detected in 1R and 3I. The resistant strains were additionally associated with deletions of 15 nucleotides (2R) and 3 nucleotides (1R). This study confirms that amino acid substitutions in rpsJ contribute towards reduced susceptibility to tigecycline and suggests that deletions may be required for tigecycline resistance in E. faecium.
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Affiliation(s)
- Marc Niebel
- Clinical Microbiology Department, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre (NIHR SRMRC), Queen Elizabeth Hospital, Birmingham, UK
| | - Joshua Quick
- National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre (NIHR SRMRC), Queen Elizabeth Hospital, Birmingham, UK; Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | - Ana Maria Guzman Prieto
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Robert L R Hill
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit, Reference Microbiology Services, Public Health England, Colindale, London, UK
| | - Rachel Pike
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit, Reference Microbiology Services, Public Health England, Colindale, London, UK
| | - Damon Huber
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | - Miruna David
- Clinical Microbiology Department, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Michael Hornsey
- Department of Life Sciences, University of Roehampton, London, UK
| | - David Wareham
- Blizard Institute, Queen Mary University London, London, UK
| | - Beryl Oppenheim
- Clinical Microbiology Department, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre (NIHR SRMRC), Queen Elizabeth Hospital, Birmingham, UK
| | - Neil Woodford
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit, Reference Microbiology Services, Public Health England, Colindale, London, UK
| | - Willem van Schaik
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Nicholas Loman
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK.
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19
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Amikacin prophylaxis and risk factors for surgical site infection after kidney transplantation. Transplantation 2015; 99:521-7. [PMID: 25254907 DOI: 10.1097/tp.0000000000000381] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Antibiotic prophylaxis plays a major role in preventing surgical site infections (SSIs). This study aimed to evaluate antibiotic prophylaxis in kidney transplantation and identify risk factors for SSIs. METHODS We evaluated all kidney transplantation recipients from January 2009 and December 2012. We excluded patients who died within the first 72 hr after transplantation, were undergoing simultaneous transplantation of another organ, or were below 12 years of age. The main outcome measure was SSI during the first 60 days after transplantation. RESULTS A total of 819 kidney transplants recipients were evaluated, 65% of whom received a deceased-donor kidney. The antibiotics used as prophylaxis included cephalosporin, in 576 (70%) cases, and amikacin, in 233 (28%). We identified SSIs in 106 cases (13%), the causative agent being identified in 72 (68%). Among the isolated bacteria, infections caused by extended-spectrum β-lactamase-producing Enterobacteriaceae predominated. Multivariate analysis revealed that the risk factors for post-kidney transplantation SSIs were deceased donor, thin ureters at kidney transplantation, antithymocyte globulin induction therapy, blood transfusion at the transplantation procedure, high body mass index, and diabetes mellitus. The only factor associated with a reduction in the incidence of SSIs was amikacin use as antibiotic prophylaxis. Factors associated with reduced graft survival were: intraoperative blood transfusions, reoperation, human leukocyte antigen mismatch, use of nonstandard immunosuppression therapy, deceased donor, post-kidney transplantation SSIs, and delayed graft function. CONCLUSION Amikacin prophylaxis is a useful strategy for preventing SSIs.
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20
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He F, Fu Y, Chen Q, Ruan Z, Hua X, Zhou H, Yu Y. Tigecycline susceptibility and the role of efflux pumps in tigecycline resistance in KPC-producing Klebsiella pneumoniae. PLoS One 2015; 10:e0119064. [PMID: 25734903 PMCID: PMC4348519 DOI: 10.1371/journal.pone.0119064] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 01/17/2015] [Indexed: 01/08/2023] Open
Abstract
KPC-producing Klebsiella pneumoniae isolates have emerged as important pathogens of nosocomial infections, and tigecycline is one of the antibiotics recommended for severe infections caused by KPC-producing K. pneumoniae. To identify the susceptibility profile of KPC-producing K. pneumoniae to tigecycline and investigate the role of efflux pumps in tigecycline resistance, a total of 215 KPC-producing K. pneumoniae isolates were collected. The minimum inhibitory concentration (MIC) of tigecycline was determined by standard broth microdilution tests. Isolates showing resistance to tigecycline underwent susceptibility test with efflux pump inhibitors. Expression levels of efflux pump genes (acrB and oqxB) and their regulators (ramA, marA, soxS and rarA) were examined by real-time PCR, and the correlation between tigecycline MICs and gene expression levels were analysed. Our results show that the tigecycline resistance rate in these isolates was 11.2%. Exposure of the tigecycline-resistant isolates to the efflux pump inhibitor NMP resulted in an obvious decrease in MICs and restored susceptibility to tigecycline in 91.7% of the isolates. A statistically significant association between acrB expression and tigecycline MICs was observed, and overexpression of ramA was found in three tigecycline-resistant isolates, further analysis confirmed ramR mutations existed in these isolates. Transformation of one mutant with wild-type ramR restored susceptibility to tigecycline and repressed overexpression of ramA and acrB. These data indicate that efflux pump AcrAB, which can be up-regulated by ramR mutations and subsequent ramA activation, contributed to tigecycline resistance in K. pneumoniae clinical isolates.
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Affiliation(s)
- Fang He
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310016, China
| | - Ying Fu
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310016, China
| | - Qiong Chen
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310016, China
| | - Zhi Ruan
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310016, China
| | - Xiaoting Hua
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310016, China
| | - Hua Zhou
- Department of Respiratory Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310003, China
| | - Yunsong Yu
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310016, China
- * E-mail:
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Delgado-Valverde M, Sojo-Dorado J, Pascual A, Rodríguez-Baño J. Clinical management of infections caused by multidrug-resistant Enterobacteriaceae. Ther Adv Infect Dis 2014; 1:49-69. [PMID: 25165544 DOI: 10.1177/2049936113476284] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Enterobacteriaceae showing resistance to cephalosporins due to extended-spectrum β-lactamases (ESBLs) or plasmid-mediated AmpC enzymes, and those producing carbapenemases have spread worldwide during the last decades. Many of these isolates are also resistant to other first-line agents such as fluoroquinolones or aminoglycosides, leaving few available options for therapy. Thus, older drugs such as colistin and fosfomycin are being increasingly used. Infections caused by these bacteria are associated with increased morbidity and mortality compared with those caused by their susceptible counterparts. Most of the evidence supporting the present recommendations is from in vitro data, animal studies, and observational studies. While carbapenems are considered the drugs of choice for ESBL and AmpC producers, recent data suggest that certain alternatives may be suitable for some types of infections. Combined therapy seems superior to monotherapy in the treatment of invasive infections caused by carbapenemase-producing Enterobacteriaceae. Optimization of dosage according to pharmacokinetics/pharmacodynamics data is important for the treatment of infections caused by isolates with borderline minimum inhibitory concentration due to low-level resistance mechanisms. The increasing frequency and the rapid spread of multidrug resistance among the Enterobacteriaceae is a true and complex public health problem.
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Affiliation(s)
- Mercedes Delgado-Valverde
- Infectious Diseases and Clinical Microbiology Unit, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Jesús Sojo-Dorado
- Infectious Diseases and Clinical Microbiology Unit, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Alvaro Pascual
- Infectious Diseases and Clinical Microbiology Unit, Hospital Universitario Virgen Macarena, and Department of Microbiology, University of Seville, Seville, Spain
| | - Jesús Rodríguez-Baño
- Infectious Diseases and Clinical Microbiology Unit, Hospital Universitario Virgen Macarena, Avda Dr Fedriani 3, 41009 Seville, Spain
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Papakonstantinou I, Angelopoulos E, Baraboutis I, Perivolioti E, Parisi M, Psaroudaki Z, Kampisiouli E, Argyropoulou A, Nanas S, Routsi C. Risk factors for tracheobronchial acquisition of resistant Gram-negative bacterial pathogens in mechanically ventilated ICU patients. J Chemother 2014; 27:283-9. [PMID: 24981117 DOI: 10.1179/1973947814y.0000000199] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
The aim of this study was to identify risk factors for tracheobronchial acquisition with the most common resistant Gram-negative bacteria in the intensive care unit (ICU) during the first week after intubation and mechanical ventilation. Tracheobronchial and oropharyngeal cultures were obtained at admission, after 48 hours, and after 7 days of mechanical ventilation. Patient characteristics, interventions, and antibiotic usage were recorded. Among 71 eligible patients with two negative bronchial cultures for resistant Gram-negative bacteria (at admission and within 48 hours), 41 (58%) acquired bronchial resistant Gram-negative bacteria by day 7. Acquisition strongly correlated with presence of the same pathogens in the oropharynx: Acinetobacter baumannii [odds ratio (OR) = 20·2, 95% confidence interval (CI): 5·5-73·6], Klebsiella pneumoniae (OR = 8·0, 95% CI: 1·9-33·6), and Pseudomonas aeruginosa (OR = 27, 95%: CI 2·7-273). Bronchial acquisition with resistant K. pneumoniae also was associated with chronic liver disease (OR = 3·9, 95% CI: 1·0-15·3), treatment with aminoglycosides (OR = 4·9, 95% CI: 1·4-18·2), tigecycline (OR = 4·9, 95% CI: 1·4-18·2), and linezolid (OR = 3·9, 95% CI: 1·1-15·0). In multivariate analysis, treatment with tigecycline and chronic liver disease were independently associated with bronchial resistant K. pneumoniae acquisition. Our results show a high incidence of tracheobronchial acquisition with resistant Gram-negative microorganisms in the bronchial tree of newly intubated patients. Oropharynx colonization with the same pathogens and specific antibiotics use were independent risk factors.
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23
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Pena I, Picazo JJ, Rodríguez-Avial C, Rodríguez-Avial I. Carbapenemase-producing Enterobacteriaceae in a tertiary hospital in Madrid, Spain: high percentage of colistin resistance among VIM-1-producing Klebsiella pneumoniae ST11 isolates. Int J Antimicrob Agents 2014; 43:460-4. [DOI: 10.1016/j.ijantimicag.2014.01.021] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 01/21/2014] [Accepted: 01/23/2014] [Indexed: 10/25/2022]
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Xie J, Wang T, Wang X, Cheng X, Dong H, Wang Y, Zheng X, Zhou L, Xing J, Dong Y. Quantitative analysis and pharmacokinetics study of tigecycline in human serum using a validated sensitive liquid chromatography with tandem mass spectrometry method. J Sep Sci 2014; 37:1396-403. [PMID: 24659422 DOI: 10.1002/jssc.201400152] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 03/13/2014] [Accepted: 03/15/2014] [Indexed: 11/06/2022]
Abstract
Tigecycline, a novel intravenously administered glycylcycline antibiotic, currently plays a key role in the management of complicated multiorganism infections. However, current liquid chromatography with tandem mass spectrometry methods briefly describe parameters and the only reported internal standard was sometimes difficult to obtain. In our study, an updated liquid chromatography with tandem mass spectrometry method for the quantitative analysis of tigecycline in human serum was developed. Sample preparation involved precipitation with 20% trichloroacetic acid. Chromatographic separation of tigecycline and tetracycline (internal standard) was achieved on a Hypersil GOLD C18 column using gradient elution. The selected reaction monitoring transitions were performed at m/z 586.1→513.2 for tigecycline and m/z 445.1→410.2 for tetracycline. The assay was linear over the concentration range of 5-2000 ng/mL. The intra- and interday precisions at three concentration levels (10, 100, and 1600 ng/mL) were <15% and their accuracies were within the range of 95.1-106.1%. The mean recovery ranged from 94.3 to 105.6% and the matrix effect from 92.1 to 97.6%. Tigecycline was stable under all tested conditions. This validated method was successfully applied to a pharmacokinetic study in critically ill patients. The data demonstrated that our method allows quantification of tigecycline in serum in a quick and reliable manner for widespread application.
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Affiliation(s)
- Jiao Xie
- Department of Pharmacy, The First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, China
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Dixit D, Madduri RP, Sharma R. The role of tigecycline in the treatment of infections in light of the new black box warning. Expert Rev Anti Infect Ther 2014; 12:397-400. [DOI: 10.1586/14787210.2014.894882] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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26
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Kontopidou F, Giamarellou H, Katerelos P, Maragos A, Kioumis I, Trikka-Graphakos E, Valakis C, Maltezou H. Infections caused by carbapenem-resistant Klebsiella pneumoniae among patients in intensive care units in Greece: a multi-centre study on clinical outcome and therapeutic options. Clin Microbiol Infect 2014; 20:O117-23. [DOI: 10.1111/1469-0691.12341] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 07/03/2013] [Accepted: 07/14/2013] [Indexed: 11/27/2022]
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Lin YT, Wang FD, Chan YJ, Fu YC, Fung CP. Clinical and microbiological characteristics of tigecycline non-susceptible Klebsiella pneumoniae bacteremia in Taiwan. BMC Infect Dis 2014; 14:1. [PMID: 24380631 PMCID: PMC3880458 DOI: 10.1186/1471-2334-14-1] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 12/09/2013] [Indexed: 11/26/2022] Open
Abstract
Background Resistance among Klebsiella pneumoniae to most antibiotics is on the rise. Tigecycline has been considered as one of the few therapeutic options available to treat multidrug-resistant bacteria. We investigated the clinical and microbiological characteristics of tigecycline non-susceptible K. pneumoniae bacteremia. Methods Adult patients with tigecycline non-susceptible K. pneumoniae bacteremia at a medical center in Taiwan over a 3-year period were enrolled. K. pneumoniae isolates were identified by the E-test using criteria set by the US Food and Drug Administration (FDA). Data on the clinical features of patients were collected from medical records. Genes for β-lactamases, antimicrobial susceptibilities and pulsed-field gel electrophoresis (PFGE) results were determined for all isolates. Results Of 36 patients, 27 had nosocomial bacteremia. Overall 28-day mortality was 38.9%. The MIC50 and MIC90 of tigecycline were 6 and 8 mg/L, respectively. No carbapenemase was detected among the 36 isolates. Twenty isolates carried extended spectrum β-lactamases and/or DHA-1 genes. No major cluster of isolates was found among the 36 isolates by PFGE. Intensive care unit onset of tigecycline non-susceptible Klebsiella pneumoniae bacteremia was the only independent risk factor for 28-day mortality. Conclusions The high mortality of patients with tigecycline non-susceptible K. pneumoniae bacteremia may suggest a critical problem. Further study to identify the possible risk factors for its development and further investigation of this type of bacteremia is necessary.
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Affiliation(s)
- Yi-Tsung Lin
- Division of Infectious Disease, Department of Medicine, Taipei Veterans General Hospital, No, 201, Sec, 2, Shih-Pai Road, Taipei, 112, Taiwan.
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Optimal tigecycline dosage regimen is urgently needed: results from a pharmacokinetic/pharmacodynamic analysis of tigecycline by Monte Carlo simulation. Int J Infect Dis 2013; 18:62-7. [PMID: 24246741 DOI: 10.1016/j.ijid.2013.09.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Revised: 09/10/2013] [Accepted: 09/11/2013] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The number of reported cases of resistance to tigecycline is increasing. The aim of this study was to evaluate the current standard tigecycline dosage regimen from a pharmacokinetic/pharmacodynamic (PK/PD) perspective. METHODS Pharmacokinetic parameters and microbiological data were analyzed by Monte Carlo simulation in an evaluation of effectiveness. RESULTS Tigecycline exhibits excellent in vitro antimicrobial activity, however the standard tigecycline dosing regimen fails to achieve the best outcome in vivo for the common drug-resistant strains, including Acinetobacter baumannii, Enterobacter spp, and Klebsiella pneumoniae. This may result in a lack of response to tigecycline therapy or to a further increase in the resistance rate. CONCLUSIONS In the absence of new drugs on the horizon, rather than using a single fixed dosing regimen, tigecycline dosing needs to be optimized in order to achieve the desired successful clinical response and to prevent an escalation in drug resistance.
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Clancy CJ, Chen L, Shields RK, Zhao Y, Cheng S, Chavda KD, Hao B, Hong JH, Doi Y, Kwak EJ, Silveira FP, Abdel-Massih R, Bogdanovich T, Humar A, Perlin DS, Kreiswirth BN, Hong Nguyen M. Epidemiology and molecular characterization of bacteremia due to carbapenem-resistant Klebsiella pneumoniae in transplant recipients. Am J Transplant 2013; 13:2619-33. [PMID: 24011185 PMCID: PMC3955300 DOI: 10.1111/ajt.12424] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 06/28/2013] [Indexed: 01/25/2023]
Abstract
We conducted a retrospective study of 17 transplant recipients with carbapenem-resistant Klebsiella pneumoniae bacteremia, and described epidemiology, clinical characteristics and strain genotypes. Eighty-eight percent (15/17) of patients were liver or intestinal transplant recipients. Outcomes were death due to septic shock (18%), cure (24%) and persistent (>7 days) or recurrent bacteremia (29% each). Thirty- and 90-day mortality was 18% and 47%, respectively. Patients who were cured received at least one active antimicrobial agent and underwent source control interventions. Forty-one percent (7/17) of patients had intra-abdominal infections; all except one developed persistent/recurrent bacteremia despite drainage. Two patients tolerated persistent bacteremia for >300 days. All patients except one were infected with sequence type 258 (ST258), K. pneumoniae carbapenemase (KPC)-2-producing strains harboring a mutant ompK35 porin gene; the exception was infected with an ST37, KPC-3-producing strain. Seventy-one percent (12/17) of patients were infected with ST258 ompK36 mutant strains. In two patients, persistent bacteremia was caused by two strains with different ompK36 genotypes. Three ompK36 mutations were associated with significantly higher carbapenem minimum inhibitory concentrations than wild-type ompK36. Pulse-field gel electrophoresis identified a single ST258 lineage; serial strains from individual patients were indistinguishable. In conclusion, KPC-K. pneumoniae bacteremia exhibited highly diverse clinical courses following transplantation, and was caused by clonal ST258 strains with different ompK36 genotypes.
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Affiliation(s)
- C. J. Clancy
- University of Pittsburgh, Pittsburgh, PA,XDR Pathogen Laboratory, University of Pittsburgh Medical Center, Pittsburgh, PA,Pittsburgh VA Healthcare System, Pittsburgh, PA
| | - L. Chen
- Public Health Research Institute, New Jersey Medical School-University of Medicine and Dentistry of New Jersey, Newark, NJ
| | - R. K. Shields
- University of Pittsburgh, Pittsburgh, PA,XDR Pathogen Laboratory, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Y. Zhao
- Public Health Research Institute, New Jersey Medical School-University of Medicine and Dentistry of New Jersey, Newark, NJ
| | - S. Cheng
- University of Pittsburgh, Pittsburgh, PA
| | - K. D. Chavda
- Public Health Research Institute, New Jersey Medical School-University of Medicine and Dentistry of New Jersey, Newark, NJ
| | - B. Hao
- University of Pittsburgh, Pittsburgh, PA,XDR Pathogen Laboratory, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - J. H. Hong
- University of Pittsburgh, Pittsburgh, PA
| | - Y. Doi
- University of Pittsburgh, Pittsburgh, PA
| | - E. J. Kwak
- University of Pittsburgh, Pittsburgh, PA
| | | | | | | | - A. Humar
- University of Pittsburgh, Pittsburgh, PA
| | - D. S. Perlin
- Public Health Research Institute, New Jersey Medical School-University of Medicine and Dentistry of New Jersey, Newark, NJ
| | - B. N. Kreiswirth
- Public Health Research Institute, New Jersey Medical School-University of Medicine and Dentistry of New Jersey, Newark, NJ
| | - M. Hong Nguyen
- University of Pittsburgh, Pittsburgh, PA,XDR Pathogen Laboratory, University of Pittsburgh Medical Center, Pittsburgh, PA,Corresponding author: M. Hong Nguyen,
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Nested case-control study of the emergence of tigecycline resistance in multidrug-resistant Klebsiella pneumoniae. Antimicrob Agents Chemother 2013; 57:5743-6. [PMID: 23979745 DOI: 10.1128/aac.00827-13] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We performed a nested case-control study (ratio of 1:4) on the emergence of tigecycline-resistant multidrug-resistant Klebsiella pneumoniae (TR-MDRKP) isolates among patients who initially presented with a tigecycline-susceptible MDRKP isolate. Out of 260 patients, 24 (9%) had a subsequent clinical culture positive for a TR-MDRKP isolate within the 90-day follow-up period. On logistic regression analyses, receipt of tigecycline (adjusted odds ratio [OR], 5.06; 95% confidence interval [CI], 1.80 to 14.23; P = 0.002) was the only independent predictor of subsequent isolation of a TR strain.
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Chen YH, Ko WC, Hsueh PR. Emerging resistance problems and future perspectives in pharmacotherapy for complicated urinary tract infections. Expert Opin Pharmacother 2013; 14:587-96. [PMID: 23480061 DOI: 10.1517/14656566.2013.778827] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Urinary tract infections (UTIs) are among the most common infectious diseases and contribute to high financial burden worldwide. Administration of appropriate antibiotic therapy is the key to achieving good therapeutic outcomes. The authors review the current status of global or regional epidemiology, especially on the antimicrobial resistance and several potential agents against complicated UTIs by multidrug-resistant (MDR) pathogens. AREAS COVERED The authors summarized the susceptibility status on several major surveillance programs on uropathogens, focusing on Enterobacteriaceae, Pseudomonas aeruginosa, Acinetobacter baumannii, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant enterococci. Besides, the current perspectives of several potential antimicrobials against MDR uropathogens available for UTIs were also reviewed. EXPERT OPINION High resistance to broad-spectrum antibiotics, especially to extended-spectrum β-lactams, carbapenems, and fluoroquinolones among uropathogens emerges as a critical problem in many countries. Appropriate antimicrobial stewardship and continuous surveillance are necessary to monitor the trends of susceptibility for main pathogens. For these MDR uropathogens, polymyxin, fosfomycin, tigecycline, nitrofurantoin, linezolid, and daptomycin might be potential treatments for patients with uncomplicated and complicated UTIs in some countries, although they might not be approved by their regulation. However, more clinical evidence and more extensive meta-analyses are needed to evaluate and confirm the effectiveness of their usage in countries with a high prevalence of multidrug resistance.
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Affiliation(s)
- Yen-Hsu Chen
- Kaohsiung Medical University, Kaohsiung Medical University Hospital, Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung, Taiwan
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Sun Y, Cai Y, Liu X, Bai N, Liang B, Wang R. The emergence of clinical resistance to tigecycline. Int J Antimicrob Agents 2013; 41:110-6. [DOI: 10.1016/j.ijantimicag.2012.09.005] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 09/07/2012] [Accepted: 09/07/2012] [Indexed: 02/09/2023]
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Carbapenemases in Klebsiella pneumoniae and other Enterobacteriaceae: an evolving crisis of global dimensions. Clin Microbiol Rev 2013; 25:682-707. [PMID: 23034326 DOI: 10.1128/cmr.05035-11] [Citation(s) in RCA: 834] [Impact Index Per Article: 75.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
SUMMARY The spread of Enterobacteriaceae, primarily Klebsiella pneumoniae, producing KPC, VIM, IMP, and NDM carbapenemases, is causing an unprecedented public health crisis. Carbapenemase-producing enterobacteria (CPE) infect mainly hospitalized patients but also have been spreading in long-term care facilities. Given their multidrug resistance, therapeutic options are limited and, as discussed here, should be reevaluated and optimized. Based on susceptibility data, colistin and tigecycline are commonly used to treat CPE infections. Nevertheless, a review of the literature revealed high failure rates in cases of monotherapy with these drugs, whilst monotherapy with either a carbapenem or an aminoglycoside appeared to be more effective. Combination therapies not including carbapenems were comparable to aminoglycoside and carbapenem monotherapies. Higher success rates have been achieved with carbapenem-containing combinations. Pharmacodynamic simulations and experimental infections indicate that modification of the current patterns of carbapenem use against CPE warrants further attention. Epidemiological data, though fragmentary in many countries, indicate CPE foci and transmission routes, to some extent, whilst also underlining the lack of international collaborative systems that could react promptly and effectively. Fortunately, there are sound studies showing successful containment of CPE by bundles of measures, among which the most important are active surveillance cultures, separation of carriers, and assignment of dedicated nursing staff.
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Abstract
PURPOSE OF REVIEW Multidrug-resistant (MDR) bacteria can cause serious infections in solid-organ transplant recipients. This review focuses on the role of MDR bacteria in posttransplant infections. RECENT FINDINGS The incidence of MDR bacterial infections among solid-organ transplant recipients is increasing steadily. There is wide variability in the specific MDR bacteria causing infection based on the organ transplanted, geography, timing with respect to transplantation, and additional risk factors. Rarely these infections can be transmitted via the transplanted organ. Prompt recognition and early appropriate treatment of MDR bacterial infections are especially critical in this immunosuppressed population. In order to promptly initiate appropriate antimicrobial therapy for these organisms, high-risk patients should receive appropriate broad-spectrum antibiotics. SUMMARY MDR bacterial infections vary widely and require careful antibiotic selection to reduce mortality.
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Park SY, Kang CI, Joo EJ, Ha YE, Wi YM, Chung DR, Peck KR, Lee NY, Song JH. Risk factors for multidrug resistance in nosocomial bacteremia caused by extended-spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae. Microb Drug Resist 2012; 18:518-24. [PMID: 22742454 DOI: 10.1089/mdr.2012.0067] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Increasing multidrug resistance (MDR) among extended-spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae (ESBL-EK) is of a great concern, because the therapeutic options are severely limited. Thus, we performed a case-control study to evaluate risk factors for MDR among nosocomial bacteremia caused by ESBL-EK. All adult patients with ESBL-EK bacteremia from January 2009 through December 2010 were identified at our institution. MDR was defined as ESBL-EK that demonstrated in vitro resistance to trimethoprim-sulfamethoxazole (TMP-SMX), fluoroquinolone (FQ), and gentamicin. Case patients were those with an MDR ESBL-EK isolate, and control patients were those with a non-MDR ESBL-EK isolate. Among a total of 123 ESBL-EK isolates (74 [60.2%] E. coli and 49 [39.8%] K. pneumoniae) causing nosocomial bacteremia, 33 (26.8%) cases were due to MDR ESBL-EK. In a univariate analysis, the factors significantly associated with acquisition of MDR ESBL-EK were neutropenia, immunosuppressant use, urinary tract infection, and prior use of antibiotics, especially FQ (all p<0.05). A multivariable analysis showed that a prior receipt of FQ (odds ratio [OR]=2.93; 95% confidence interval [CI]=1.07-8.01; p=0.036), percutaneous tube insertion (OR=4.04; 95% CI=1.56-10.75; p=0.005), and neutropenia (OR=4.22; 95% CI=1.56-11.45; p=0.005) were independent risk factors for MDR among ESBL-EK bacteremia in hospitalized patients. The CTX-M-15 enzyme was predominant in both the MDR ESBL-EK and non-MDR ESBL-EK groups (55% [11/20] vs. 55.6% [15/27]). Our data suggest that strategies designed to reduce MDR in ESBL-EK bacteremia should focus on limiting the use of FQ and minimizing invasive procedures such as tube insertion.
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Affiliation(s)
- So Yeon Park
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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In vivo emergence of tigecycline resistance in multidrug-resistant Klebsiella pneumoniae and Escherichia coli. Antimicrob Agents Chemother 2012; 56:4516-8. [PMID: 22644031 DOI: 10.1128/aac.00234-12] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Although resistance to tigecycline has been reported in surveillance studies, very few reports have described the emergence of resistance in vivo. We report two cases of patients with infections due to SHV-12-producing Klebsiella pneumoniae and K. pneumoniae carbapenemase-3 (KPC-3)-producing Escherichia coli, which developed tigecycline resistance in vivo after treatment. The reported limited experience underlines the risk of occurrence of a tigecycline MIC increase under treatment pressure.
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