1
|
Wang X, Liu J, Li A. Incidence and risk factors for subsequent infections among rectal carriers with carbapenem-resistant Klebsiella pneumoniae: a systematic review and meta-analysis. J Hosp Infect 2024; 145:11-21. [PMID: 38092302 DOI: 10.1016/j.jhin.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 11/23/2023] [Accepted: 12/05/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Carbapenem-resistant Klebsiella pneumoniae (CRKp) is a major pathogen causing nosocomial infections with a high mortality and poor prognosis. Gastrointestinal carriage has been acknowledged as the primary reservoir of CRKp infections. AIM To explore the incidence and risk factors associated with CRKp infection following colonization. METHODS The PubMed, Web of Science, and Cochrane Library databases were searched for relevant articles published between December 1998 and June 2023. Pooled estimates with a 95% confidence interval (CI) were calculated for the incidence rate, whereas pooled odds ratios (ORs) were calculated for the risk factors for which the OR was reported in three or more studies. FINDINGS Fourteen studies were included in the review with 5483 patients for the assessment of incidence, whereas seven of these studies with 2170 patients were included for the analysis of risk factors. In the meta-analysis, the incidence of CRKp infections after colonization was 23.2% (17.9-28.5). Additionally, three independent risk factors for subsequent CRKp infections were identified as admission to the intensive care unit (ICU) (2.59; 95% CI: 1.64-4.11), invasive procedures (2.53; 95% CI: 1.59-4.03), and multi-site colonization (6.24; 95% CI: 2.38-16.33). CONCLUSION This review reveals the incidence of CRKp infections in rectal carriers in different countries, emphasizing the role of rectal colonization with CRKp as an important source of nosocomial infections. Significantly, the risk factors indicated in this review can assist clinicians in identifying CRKp carriers with an elevated risk of subsequent infections, thereby enabling further measures to be taken to prevent nosocomial infections.
Collapse
Affiliation(s)
- X Wang
- Department of Critical Care Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - J Liu
- Department of Critical Care Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - A Li
- Department of Critical Care Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China.
| |
Collapse
|
2
|
Liu X, Gong L, Liu E, Li C, Wang Y, Liang J. Characterization of the Disinfectant Resistance Genes qacEΔ1 and cepA in Carbapenem-Resistant Klebsiella pneumoniae Isolates. Am J Trop Med Hyg 2024; 110:136-141. [PMID: 38081061 DOI: 10.4269/ajtmh.23-0247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 09/27/2023] [Indexed: 01/05/2024] Open
Abstract
The emergence and wide global spread of carbapenem-resistant Klebsiella pneumoniae (CRKP) isolates are of great concern. This multicenter study aimed to investigate the molecular characteristics of CRKP isolates from inpatients in Wuhan, China. From June 2018 to March 2019, 74 nonduplicated CRKP clinical isolates were collected from six hospitals in Wuhan. We determined the minimum inhibitory concentrations of 18 antibiotics and used real-time polymerase chain reaction to detect the presence of disinfectant resistance genes qacEΔ1 and cepA. Pulsed-field gel electrophoresis was conducted to assess the genetic relatedness of isolates. Among the 74 CRKP isolates, the rates of resistance to carbapenems were high: 93.2% to ertapenem, 90.5% to imipenem, and 87.8% to meropenem. All isolates were resistant to at least one carbapenem antibiotic. Of the 74 isolates, 64.9% (48/74) were positive for qacEΔ1 and 93.2% (69/74) for cepA. QacEΔ1 and cepA were detected concomitantly in 46 isolates (62.2%), whereas only 4.1% (3/74) had no disinfectant resistance genes. Pulsed-field gel electrophoresis analysis clustered the 46 CRKP strains co-producing qacEΔ1 and cepA into 15 different clonal clusters (Types A to O). The most common clonal clusters were Type C (41.3%), Type E (13.0%), and Type J (8.7%). The study showed high rates of resistance to most antibiotics and high frequency of qacEΔ1 and cepA in CRKP isolates. Specific clonal dissemination of CRKP was detected within the same hospital or between different hospitals. Therefore, medical institutions should choose and use disinfectants correctly to prevent the spread of CRKP.
Collapse
Affiliation(s)
- Xiaoli Liu
- Department of Disinfection and Pest Control, Wuhan Center for Disease Control and Prevention, Wuhan, China
| | - Lin Gong
- Department of Disinfection and Pest Control, Wuhan Center for Disease Control and Prevention, Wuhan, China
| | - Ernan Liu
- Department of Disinfection and Pest Control, Wuhan Center for Disease Control and Prevention, Wuhan, China
| | - Changfeng Li
- Discipline Inspection Division, Wuhan Center for Disease Control and Prevention, Wuhan, China
| | - Yimei Wang
- Department of Disinfection and Pest Control, Wuhan Center for Disease Control and Prevention, Wuhan, China
| | - Jiansheng Liang
- Department of Disinfection and Pest Control, Wuhan Center for Disease Control and Prevention, Wuhan, China
| |
Collapse
|
3
|
Magobo RE, Ismail H, Lowe M, Strasheim W, Mogokotleng R, Perovic O, Kwenda S, Ismail A, Makua M, Bore A, Phayane R, Naidoo H, Dennis T, Ngobese M, Wijnant W, Govender NP. Outbreak of NDM-1- and OXA-181-Producing Klebsiella pneumoniae Bloodstream Infections in a Neonatal Unit, South Africa. Emerg Infect Dis 2023; 29:1531-1539. [PMID: 37486166 PMCID: PMC10370860 DOI: 10.3201/eid2908.230484] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023] Open
Abstract
After an increase in carbapenem-resistant Klebsiella pneumoniae (CRKP) bloodstream infections and associated deaths in the neonatal unit of a South Africa hospital, we conducted an outbreak investigation during October 2019-February 2020 and cross-sectional follow-up during March 2020-May 2021. We used genomic and epidemiologic data to reconstruct transmission networks of outbreak-related clones. We documented 31 cases of culture-confirmed CRKP infection and 14 deaths. Two outbreak-related clones (blaNDM-1 sequence type [ST] 152 [n = 16] and blaOXA-181 ST307 [n = 6]) cocirculated. The major clone blaNDM-1 ST152 accounted for 9/14 (64%) deaths. Transmission network analysis identified possible index cases of blaOXA-181 ST307 in October 2019 and blaNDM-1 ST152 in November 2019. During the follow-up period, 11 new cases of CRKP infection were diagnosed; we did not perform genomic analysis. Sustained infection prevention and control measures, adequate staffing, adhering to bed occupancy limits, and antimicrobial stewardship are key interventions to control such outbreaks.
Collapse
|
4
|
Wang L, Zhu M, Yan C, Zhang Y, He X, Wu L, Xu J, Lu J, Bao Q, Hu Y, Xu T, Liang J. Class 1 integrons and multiple mobile genetic elements in clinical isolates of the Klebsiella pneumoniae complex from a tertiary hospital in eastern China. Front Microbiol 2023; 14:985102. [PMID: 36950157 PMCID: PMC10026359 DOI: 10.3389/fmicb.2023.985102] [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: 07/03/2022] [Accepted: 02/07/2023] [Indexed: 03/08/2023] Open
Abstract
Background The emergence of highly drug-resistant K. pneumoniae, has become a major public health challenge. In this work, we aim to investigate the diversity of species and sequence types (STs) of clinical Klebsiella isolates and to characterize the prevalence and structure of class 1 integrons. Methods Based on the whole genome sequencing, species identification was performed by 16S rRNA gene homology and average nucleotide identity (ANI) analysis. STs were determined in accordance with the international MLST schemes for K. pneumoniae and K. variicola. Integron characterization and comparative genomic analysis were performed using various bioinformatic tools. Results Species identification showed that the 167 isolates belonged to four species: K. pneumoniae, K. variicola subsp. variicola, K. quasipneumoniae and K. aerogenes. Thirty-six known and 5 novel STs were identified in K. pneumoniae, and 10 novel STs were identified in K. variicola subsp. variicola. Class 1 integrons were found in 57.49% (96/167) of the isolates, and a total of 169 resistance gene cassettes encoding 19 types of resistance genes, including carbapenem resistance gene (bla IPM-4) and class D β-lactamases gene (bla OXA-1 and bla OXA-10), were identified. Among the 17 complete genomes, 29 class 1 integrons from 12 groups were found, only 1 group was encoded on chromosomes. Interestingly, one plasmid (pKP167-261) carrying two copies of approximately 19-kb IS26-Int1 complex resistance region that contains an integron and a multidrug resistance gene fragment. Conclusion The results of this work demonstrated that the species and STs of the clinical Klebsiella isolates were more complex by the whole genome sequence analysis than by the traditional laboratory methods. Finding of the new structure of MGEs related to the resistance genes indicates the great importance of deeply exploring the molecular mechanisms of bacterial multidrug resistance.
Collapse
Affiliation(s)
- Lan Wang
- Medical Molecular Biology Laboratory, School of Medicine, Jinhua Polytechnic, Jinhua, China
| | - Mei Zhu
- Department of Clinical Laboratory, Zhejiang Hospital, Hangzhou, Zhejiang, China
| | - Chunxia Yan
- Medical Molecular Biology Laboratory, School of Medicine, Jinhua Polytechnic, Jinhua, China
| | - Yanfang Zhang
- Medical Molecular Biology Laboratory, School of Medicine, Jinhua Polytechnic, Jinhua, China
| | - Xuying He
- Medical Molecular Biology Laboratory, School of Medicine, Jinhua Polytechnic, Jinhua, China
| | - Lin Wu
- Medical Molecular Biology Laboratory, School of Medicine, Jinhua Polytechnic, Jinhua, China
| | - Jiefeng Xu
- Medical Molecular Biology Laboratory, School of Medicine, Jinhua Polytechnic, Jinhua, China
| | - Junwan Lu
- Medical Molecular Biology Laboratory, School of Medicine, Jinhua Polytechnic, Jinhua, China
| | - Qiyu Bao
- Medical Molecular Biology Laboratory, School of Medicine, Jinhua Polytechnic, Jinhua, China
- The Second Affiliated Hospital and Yuying Children’s Hospital, Wenzhou Medical University, Wenzhou, China
| | - Yunliang Hu
- The Second Affiliated Hospital and Yuying Children’s Hospital, Wenzhou Medical University, Wenzhou, China
| | - Teng Xu
- Institute of Translational Medicine, Baotou Central Hospital, Baotou, China
- *Correspondence: Teng Xu,
| | - Jialei Liang
- Medical Molecular Biology Laboratory, School of Medicine, Jinhua Polytechnic, Jinhua, China
- The Second Affiliated Hospital and Yuying Children’s Hospital, Wenzhou Medical University, Wenzhou, China
- Jialei Liang,
| |
Collapse
|
5
|
Liu X, Wang K, Chen J, Lyu J, Li J, Chen Q, Lin Y, Tian B, Song H, Li P, Gu B. Clonal Spread of Carbapenem-Resistant Klebsiella pneumoniae Sequence Type 11 in Chinese Pediatric Patients. Microbiol Spectr 2022; 10:e0191922. [PMID: 36453896 PMCID: PMC9769831 DOI: 10.1128/spectrum.01919-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 11/04/2022] [Indexed: 12/03/2022] Open
Abstract
Klebsiella pneumoniae often causes life-threatening infections in patients globally. Despite its notability, little is known about potential nosocomial outbreak and spread of K. pneumoniae among pediatric patients in low- and middle-income countries. Ninety-eight K. pneumoniae strains isolated from pediatric patients in a large general hospital in China between February 2018 and May 2019 were subjected to nanopore and Illumina sequencing and genomic analysis to elucidate transmission and genetic diversity. The temporal distribution patterns of K. pneumoniae revealed a cluster of sequence type 11 (ST11) strains comprising two clades. Most inferred transmissions were of clade 1, which could be traced to a common ancestor dating to mid-2017. An infant in the coronary care unit played a central role, potentially seeding transmission clusters in other wards. Major genomic changes during the outbreak included chromosomal mutations associated with virulence and gains and losses of plasmids encoding resistance. In summary, we report a nosocomial outbreak among pediatric patients caused by clonal dissemination of KPC-2-producing ST11 K. pneumoniae. Our findings highlight the value of whole-genome sequencing during outbreak investigations and illustrate that transmission chains can be identified during hospital stays. IMPORTANCE We report a nosocomial outbreak among pediatric patients caused by clonal dissemination of blaKPC-2-carrying ST11 K. pneumoniae. Strains of various sequence types coexist in the complex hospital environment; the quick emergence and spread of ST11 strains were mainly due to the plasmid-mediated acquisition of resistance genes. The spread of hospital infection was highly associated with several specific wards, suggesting the importance of genomic surveillance on wards at high risk of infection.
Collapse
Affiliation(s)
- Xiong Liu
- Chinese PLA Center for Disease Control and Prevention, Beijing, China
| | - Kaiying Wang
- Chinese PLA Center for Disease Control and Prevention, Beijing, China
| | - Jiali Chen
- China Medical University, Shenyang, China
| | - Jingwen Lyu
- Laboratory Medicine, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jinhui Li
- Chinese PLA Center for Disease Control and Prevention, Beijing, China
| | - Qichao Chen
- Chinese PLA Center for Disease Control and Prevention, Beijing, China
| | - Yanfeng Lin
- Chinese PLA Center for Disease Control and Prevention, Beijing, China
| | - Benshun Tian
- Laboratory Medicine, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Hongbin Song
- Chinese PLA Center for Disease Control and Prevention, Beijing, China
| | - Peng Li
- Chinese PLA Center for Disease Control and Prevention, Beijing, China
| | - Bing Gu
- Laboratory Medicine, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| |
Collapse
|
6
|
Li L, Wang R, Qiao D, Zhou M, Jin P. Tracking the Outbreak of Carbapenem-Resistant Klebsiella pneumoniae in an Emergency Intensive Care Unit by Whole Genome Sequencing. Infect Drug Resist 2022; 15:6215-6224. [PMID: 36324669 PMCID: PMC9621004 DOI: 10.2147/idr.s386385] [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: 08/19/2022] [Accepted: 10/19/2022] [Indexed: 11/05/2022] Open
Abstract
Purpose The spread of carbapenem-resistant Klebsiella pneumoniae (CRKP) has become a great threat to human health, especially in the intensive care unit. The aim of this study was to identify the origin and transmission route of a CRKP outbreak in an emergency intensive care unit (EICU), so as to provide prevention and control strategies for CRKP outbreak. Methods Between Mar and Jun 2018, 10 CRKP isolates from 5 patients in the EICU ward of Shanghai Ruijin hospital north were collected. Modified carbapenem inactivation method (mCIM) and whole-genome sequencing (WGS) were performed on all 10 CRKP isolates. By integrating the genomic and epidemiological data of our isolates and 9 CRKP isolates from an outbreak in another hospital, a putative transmission map was constructed. Results All 10 outbreak strains were carbapenemase positive in mCIM and belonged to the sequence type 11 (ST11) clone, harbored a set of resistance genes and virulence genes. The phylogenetic tree of CRKP isolates based on two outbreaks revealed that the initial isolate A1 in our EICU ward belonged to one branch of isolates in another hospital, this introductive isolate evolved and caused a subsequent outbreak in our EICU. Conclusion Integration of genomic and epidemiological data can yield a clear transmission map of CRKP outbreak. Monitoring the rapid evolution of CRKP at the early stage of outbreak, CRKP monitoring after patients are discharged, active surveillance of newly admitted patients, environmental hygiene and efficient antibiotic treatment may be the key to prevent and control of CRKP outbreak.
Collapse
Affiliation(s)
- Li Li
- Department of Clinical Laboratory, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, People’s Republic of China
| | - Renying Wang
- Department of Emergency, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, People’s Republic of China
| | - Dan Qiao
- Department of Clinical Laboratory, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, People’s Republic of China
| | - Min Zhou
- Department of Clinical Laboratory, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, People’s Republic of China
| | - Peipei Jin
- Department of Clinical Laboratory, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, People’s Republic of China,Correspondence: Peipei Jin, Department of Clinical Laboratory, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, 999 Xiwang Road, Shanghai, 201801, People’s Republic of China, Tel +86-21-67888999, Fax +86-21-64333548, Email
| |
Collapse
|
7
|
Bulman ZP, Tan X, Chu TY, Huang Y, Rana AP, Singh N, Flowers SA, Kyono Y, Kreiswirth BN, Chen L. Ceftazidime-avibactam based combinations against carbapenemase producing Klebsiella pneumoniae harboring hypervirulence plasmids. Comput Struct Biotechnol J 2022; 20:3946-3954. [PMID: 35950190 PMCID: PMC9352398 DOI: 10.1016/j.csbj.2022.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 07/08/2022] [Accepted: 07/08/2022] [Indexed: 12/02/2022] Open
Abstract
The combination of carbapenem resistance and hypervirulence in Klebsiella pneumoniae is an emerging and urgent threat due to its potential to resist common antibiotics and cause life-threatening infections in healthy hosts. This study aimed to evaluate the activity of clinically relevant antibiotic regimens against carbapenem-resistant K. pneumoniae with hypervirulence plasmids and to identify pathways associated with antibiotic tolerance using transcriptomics. We studied two carbapenem-resistant K. pneumoniae isolates, CDI694 and CDI231, both harboring hypervirulence plasmids. Time-kill and dynamic one-compartment pharmacokinetic/pharmacodynamic assays were used to assess ceftazidime/avibactam-based therapies. RNAseq was performed following 48 h of antibiotic exposure. Closed genomes of CDI694 and CDI231 were obtained; each isolate harbored carbapenem-resistance and hypervirulence (containing rmpA/rmpA2 and iut genes) plasmids. Ceftazidime/avibactam-based regimens were bactericidal, though both isolates continued to grow in the presence of antibiotics despite no shifts in MIC. Transcriptomic analyses suggested that perturbations to cell respiration, carbohydrate transport, and stress-response pathways contributed to the antibiotic tolerance in CDI231. Genes associated with hypervirulence and antibiotic resistance were not strongly impacted by drug exposure except for ompW, which was significantly downregulated. Treatment of carbapenem-resistant K. pneumoniae harboring hypervirulence plasmids with ceftazidime/avibactam-based regimens may yield a tolerant population due to altered transcription of multiple key pathways.
Collapse
Affiliation(s)
- Zackery P. Bulman
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois Chicago, Chicago, IL, USA
| | - Xing Tan
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois Chicago, Chicago, IL, USA
| | - Ting-Yu Chu
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, USA
| | - Yanqin Huang
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois Chicago, Chicago, IL, USA
| | - Amisha P. Rana
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois Chicago, Chicago, IL, USA
| | - Nidhi Singh
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois Chicago, Chicago, IL, USA
| | - Stephanie A. Flowers
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois Chicago, Chicago, IL, USA
| | - Yasuhiro Kyono
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois Chicago, Chicago, IL, USA
| | - Barry N. Kreiswirth
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, USA
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, NJ, USA
| | - Liang Chen
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, USA
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, NJ, USA
| |
Collapse
|
8
|
Muraya A, Kyany’a C, Kiyaga S, Smith HJ, Kibet C, Martin MJ, Kimani J, Musila L. Antimicrobial Resistance and Virulence Characteristics of Klebsiella pneumoniae Isolates in Kenya by Whole-Genome Sequencing. Pathogens 2022; 11:545. [PMID: 35631066 PMCID: PMC9144577 DOI: 10.3390/pathogens11050545] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 02/04/2023] Open
Abstract
Klebsiella pneumoniae is a globally significant opportunistic pathogen causing healthcare-associated and community-acquired infections. This study examined the epidemiology and the distribution of resistance and virulence genes in clinical K. pneumoniae strains in Kenya. A total of 89 K. pneumoniae isolates were collected over six years from five counties in Kenya and were analyzed using whole-genome sequencing and bioinformatics. These isolates were obtained from community-acquired (62/89) and healthcare-associated infections (21/89), and from the hospital environment (6/89). Genetic analysis revealed the presence of blaNDM-1 and blaOXA-181 carbapenemase genes and the armA and rmtF genes known to confer pan-aminoglycoside resistance. The most abundant extended-spectrum beta-lactamase genes identified were blaCTX-M-15 (36/89), blaTEM (35/89), and blaOXA (18/89). In addition, one isolate had a mobile colistin resistance gene (mcr-8). Fluoroquinolone resistance-conferring mutations in gyrA and parC genes were also observed. The most notable virulence factors were those associated with hyper-virulence (rmpA/A2 and magA), yersiniabactin (ybt), salmochelin (iro), and aerobactin (iuc and iutA). A total of 38 distinct sequence types were identified, including known global lineages ST14, ST15, ST147, and ST307, and a regional clone ST17 implicated in regional outbreaks. In addition, this study genetically characterized two potential hypervirulent isolates and two community-acquired ST147 high-risk clones that contained carbapenemase genes, yersiniabactin, and other multidrug resistance genes. These results demonstrate that the resistome and virulome of Kenyan clinical and hospital environmental K. pneumoniae isolates are diverse. The reservoir of high-risk clones capable of spreading resistance, and virulence factors have the potential to cause unmanageable infection outbreaks with high morbidity and mortality.
Collapse
Affiliation(s)
- Angela Muraya
- Department of Biochemistry, Jomo Kenyatta University of Agriculture and Technology, Nairobi P.O. Box 62000-00200, Kenya; (A.M.); (C.K.); (J.K.)
| | - Cecilia Kyany’a
- United States Army Medical Research Directorate-Africa, Village Market, Nairobi P.O. Box 606-00621, Kenya; (C.K.); (H.J.S.)
- Kenya Medical Research Institute, Nairobi P.O. Box 54840-00200, Kenya
| | - Shahiid Kiyaga
- Department of Immunology and Molecular Biology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala P.O. Box 7072, Uganda;
| | - Hunter J. Smith
- United States Army Medical Research Directorate-Africa, Village Market, Nairobi P.O. Box 606-00621, Kenya; (C.K.); (H.J.S.)
| | - Caleb Kibet
- Department of Biochemistry, Jomo Kenyatta University of Agriculture and Technology, Nairobi P.O. Box 62000-00200, Kenya; (A.M.); (C.K.); (J.K.)
- International Center for Insect Physiology and Ecology, Nairobi P.O. Box 30772-00100, Kenya
| | - Melissa J. Martin
- Multidrug-Resistant Organism Repository and Surveillance Network (MRSN), Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA;
| | - Josephine Kimani
- Department of Biochemistry, Jomo Kenyatta University of Agriculture and Technology, Nairobi P.O. Box 62000-00200, Kenya; (A.M.); (C.K.); (J.K.)
| | - Lillian Musila
- United States Army Medical Research Directorate-Africa, Village Market, Nairobi P.O. Box 606-00621, Kenya; (C.K.); (H.J.S.)
- Kenya Medical Research Institute, Nairobi P.O. Box 54840-00200, Kenya
| |
Collapse
|
9
|
Ngbede EO, Adekanmbi F, Poudel A, Kalalah A, Kelly P, Yang Y, Adamu AM, Daniel ST, Adikwu AA, Akwuobu CA, Abba PO, Mamfe LM, Maurice NA, Adah MI, Lockyear O, Butaye P, Wang C. Concurrent Resistance to Carbapenem and Colistin Among Enterobacteriaceae Recovered From Human and Animal Sources in Nigeria Is Associated With Multiple Genetic Mechanisms. Front Microbiol 2021; 12:740348. [PMID: 34690985 PMCID: PMC8528161 DOI: 10.3389/fmicb.2021.740348] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 09/09/2021] [Indexed: 01/01/2023] Open
Abstract
Resistance to last resort drugs such as carbapenem and colistin is a serious global health threat. This study investigated carbapenem and colistin resistance in 583 non-duplicate Enterobacteriaceae isolates utilizing phenotypic methods and whole genome sequencing (WGS). Of the 583 isolates recovered from humans, animals and the environment in Nigeria, 18.9% (110/583) were resistant to at least one carbapenem (meropenem, ertapenem, and imipenem) and 9.1% (53/583) exhibited concurrent carbapenem-colistin resistance. The minimum inhibitory concentrations of carbapenem and colistin were 2–32 μg/mL and 8 to >64 μg/mL, respectively. No carbapenem resistant isolates produced carbapenemase nor harbored any known carbapenemase producing genes. WGS supported that concurrent carbapenem-colistin resistance was mediated by novel and previously described alterations in chromosomal efflux regulatory genes, particularly mgrB (M1V) ompC (M1_V24del) ompK37 (I70M, I128M) ramR (M1V), and marR (M1V). In addition, alterations/mutations were detected in the etpA, arnT, ccrB, pmrB in colistin resistant bacteria and ompK36 in carbapenem resistant bacteria. The bacterial isolates were distributed into 37 sequence types and characterized by the presence of internationally recognized high-risk clones. The results indicate that humans and animals in Nigeria may serve as reservoirs and vehicles for the global spread of the isolates. Further studies on antimicrobial resistance in African countries are warranted.
Collapse
Affiliation(s)
- Emmanuel O Ngbede
- Department of Veterinary Microbiology, College of Veterinary Medicine, Federal University of Agriculture Makurdi, Makurdi, Nigeria
| | - Folasade Adekanmbi
- Department of Pathobiology, Auburn University College of Veterinary Medicine, Auburn, AL, United States
| | - Anil Poudel
- Department of Pathobiology, Auburn University College of Veterinary Medicine, Auburn, AL, United States
| | - Anwar Kalalah
- Department of Pathobiology, Auburn University College of Veterinary Medicine, Auburn, AL, United States
| | - Patrick Kelly
- Department of Biomedical Sciences, Ross University School of Veterinary Medicine, Basseterre, Saint Kitts and Nevis
| | - Yi Yang
- Yangzhou University College of Veterinary Medicine, Yangzhou, China
| | - Andrew M Adamu
- Department of Veterinary Public Health and Preventive Medicine, Faculty of Veterinary Medicine, University of Abuja, Abuja, Nigeria
| | - Salem T Daniel
- Department of Microbiology, College of Sciences, Federal University of Agriculture Makurdi, Makurdi, Nigeria
| | - Alex A Adikwu
- Department of Veterinary Public Health and Preventive Medicine, College of Veterinary Medicine, Federal University of Agriculture Makurdi, Makurdi, Nigeria
| | - Chinedu A Akwuobu
- Department of Veterinary Microbiology, College of Veterinary Medicine, Federal University of Agriculture Makurdi, Makurdi, Nigeria
| | - Paul O Abba
- Department of Medical Microbiology and Parasitology, Benue State University Teaching Hospital, Makurdi, Nigeria
| | - Levi M Mamfe
- Department of Veterinary Microbiology, College of Veterinary Medicine, Federal University of Agriculture Makurdi, Makurdi, Nigeria
| | - Nanven A Maurice
- Department of Diagnostics and Extension, National Veterinary Research Institute, Vom, Nigeria
| | - Mohammed I Adah
- Department of Veterinary Medicine, College of Veterinary Medicine, Federal University of Agriculture Makurdi, Makurdi, Nigeria
| | - Olivia Lockyear
- Department of Pathobiology, Auburn University College of Veterinary Medicine, Auburn, AL, United States
| | - Patrick Butaye
- Department of Biomedical Sciences, Ross University School of Veterinary Medicine, Basseterre, Saint Kitts and Nevis.,Department of Pathology, Bacteriology and Avian Diseases, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Chengming Wang
- Department of Pathobiology, Auburn University College of Veterinary Medicine, Auburn, AL, United States
| |
Collapse
|
10
|
Kong Y, Sun Q, Chen H, Draz MS, Xie X, Zhang J, Ruan Z. Transmission Dynamics of Carbapenem-Resistant Klebsiella pneumoniae Sequence Type 11 Strains Carrying Capsular Loci KL64 and rmpA/ rmpA2 Genes. Front Microbiol 2021; 12:736896. [PMID: 34690977 PMCID: PMC8529244 DOI: 10.3389/fmicb.2021.736896] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/10/2021] [Indexed: 11/29/2022] Open
Abstract
The presence and dissemination of carbapenem-resistant Klebsiella pneumoniae (CRKP) often cause life-threatening infections worldwide, but the therapeutic option is limited. In this study, whole-genome sequencing (WGS) was applied to assess the epidemiological characteristics and transmission dynamics of CRKP isolates recovered from two fetal outbreaks of nosocomial infections. Between April 2016 and March 2018, a total of 70 isolates of K. pneumoniae were collected from sterile samples in a tertiary hospital in Hangzhou, China. The minimal inhibitory concentrations (MICs) of 21 antimicrobial agents were determined using the broth microdilution methods. Pulsed-field gel electrophoresis (PFGE) was performed on 47 CRKP isolates, and 16 clonally related isolates were further characterized by Illumina sequencing. In addition, the complete genome sequences of three representative isolates (KP12, KP36, and KP37) were determined by Oxford Nanopore sequencing. The K. pneumoniae isolates were recovered from patients diagnosed with pulmonary infection, cancer, or encephalopathy. For all CRKP isolates, PFGE separated three clusters among all strains. The most predominant PFGE cluster contained 16 isolates collected from patients who shared close hospital units and represented a potential outbreak. All 16 isolates showed an extremely high resistance level (≥87.5%) to 18 antimicrobials tested but remain susceptible to colistin (CST). Multiple antimicrobial resistance and virulence determinants, such as the carbapenem resistance gene blaKPC-2, and genes encoding the virulence factor aerobactin and the regulator of the mucoid phenotype (rmpA and rmpA2), were observed in the 16 CRKP isolates. These isolates belonged to sequence type 11 (ST11) and capsular serotype KL64. A core genome single nucleotide polymorphism (cgSNP)-based phylogenetic analysis indicated that the 16 CRKP isolates could be partitioned into two separate clades (≤15 SNPs), suggesting the two independent transmission scenarios co-occurred. Moreover, a high prevalence of IncFIB/IncHI1B type virulence plasmid with the iroBCDN locus deleted, and an IncFII/IncR type blaKPC-2-bearing plasmid was co-harbored in ST11-KL64 CRKP isolates. In conclusion, our data indicated that the nosocomial dissemination of ST11-KL64 CRKP clone is a potential threat to anti-infective therapy. The development of novel strategies for surveillance, diagnosis, and treatment of this high-risk CRKP clone is urgently needed.
Collapse
Affiliation(s)
- Yingying Kong
- Department of Clinical Laboratory, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qingyang Sun
- Department of Clinical Laboratory, No. 903 Hospital of PLA Joint Logistic Support Force, Hangzhou, China
| | - Hangfei Chen
- Department of Clinical Laboratory, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Mohamed S Draz
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Xinyou Xie
- Department of Clinical Laboratory, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jun Zhang
- Department of Clinical Laboratory, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhi Ruan
- Department of Clinical Laboratory, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| |
Collapse
|
11
|
Xiong L, Su L, Tan H, Zhao W, Li S, Zhu Y, Lu L, Huang Z, Li B. Molecular Epidemiological Analysis of ST11-K64 Extensively Drug-Resistant Klebsiella pneumoniae Infections Outbreak in Intensive Care and Neurosurgery Units Based on Whole-Genome Sequencing. Front Microbiol 2021; 12:709356. [PMID: 34646245 PMCID: PMC8504482 DOI: 10.3389/fmicb.2021.709356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/18/2021] [Indexed: 11/13/2022] Open
Abstract
Klebsiella pneumoniae (Kp) is the primary causative bacteria for nosocomial infections and hospital outbreaks. In particular, extensively drug-resistant K. pneumoniae (XDRKp) causes severe clinical infections in hospitalized patients. Here, we used pulsed-field gel electrophoresis (PFGE), drug susceptibility tests, and the whole-genome sequencing (WGS) technology to examine genetic relatedness and phenotypic traits of the strains isolated during an outbreak period. Based on PFGE, a distinct clones cluster comprised of eight XDRKp was observed. These strains were confirmed as ST11-K64 via multiple-locus sequence typing database of Kp. The strains also had genes related to the regulation of biofilm biosynthesis (type 1 & 3 fimbriae, type IV pili biosynthesis, RcsAB, and type VI secretion system) and multiple drug resistance (β-lactamase and aminoglycoside antibiotic resistance). WGS data based on core-single nucleotide polymorphisms and epidemiological investigation showed that the neurosurgery unit was likely the source of the outbreak, the strain was likely to have been transmitted to the ICU through patients. In addition, the two highly probable transmission routes were in the ICU (exposure through shared hospital beds) and the neurosurgery units (all cases were treated by the same rehabilitation physician and were most likely infected during the physical therapy). Notably, the bed mattress had played a crucial transmission role of this outbreak, served as a pathogen reservoir.
Collapse
Affiliation(s)
- Liuxin Xiong
- Clinical Laboratory, The Second People's Hospital of Zhaoqing, Zhaoqing, China
| | - Lebin Su
- Microbiological Laboratory, Zhaoqing Center for Disease Control and Prevention, Zhaoqing, China
| | - Hanqing Tan
- Microbiological Laboratory, Zhaoqing Center for Disease Control and Prevention, Zhaoqing, China
| | - Wansha Zhao
- Microbiological Laboratory, Zhaoqing Center for Disease Control and Prevention, Zhaoqing, China
| | - Shuying Li
- Clinical Laboratory, The Second People's Hospital of Zhaoqing, Zhaoqing, China
| | - Yingmei Zhu
- Microbiological Laboratory, Zhaoqing Center for Disease Control and Prevention, Zhaoqing, China
| | - Limiao Lu
- Clinical Laboratory, The Second People's Hospital of Zhaoqing, Zhaoqing, China
| | - Zhiwei Huang
- Clinical Laboratory, The Second People's Hospital of Zhaoqing, Zhaoqing, China
| | - Baisheng Li
- Institute of Microbiology, Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China
| |
Collapse
|
12
|
Meijer SE, Harel N, Ben-Ami R, Nahari M, Yakubovsky M, Oster HS, Kolomansky A, Halutz O, Laskar O, Henig O, Stern A, Paran Y. Unraveling a Nosocomial Outbreak of COVID-19: The Role of Whole-Genome Sequence Analysis. Open Forum Infect Dis 2021; 8:ofab120. [PMID: 34631912 PMCID: PMC7989189 DOI: 10.1093/ofid/ofab120] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/09/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic poses many epidemiological challenges. The investigation of nosocomial transmission is usually performed via thorough investigation of an index case and subsequent contact tracing. Notably, this approach has a subjective component, and there is accumulating evidence that whole-genome sequencing of the virus may provide more objective insight. METHODS We report a large nosocomial outbreak in 1 of the medicine departments in our institution. Following intensive epidemiological investigation, we discovered that 1 of the patients involved was suffering from persistent COVID-19 while initially thought to be a recovering patient. She was therefore deemed to be the most likely source of the outbreak. We then performed whole-genome sequencing of the virus of 14 infected individuals involved in the outbreak. RESULTS Surprisingly, the results of whole-genome sequencing refuted our initial hypothesis. A phylogenetic tree of the samples showed multiple introductions of the virus into the ward, 1 of which led to a cluster of 10 of the infected individuals. Importantly, the results pointed in the direction of a specific index patient that was different from the 1 that arose from our initial investigation. CONCLUSIONS These results underscore the important added value of using whole-genome sequencing in epidemiological investigations as it may reveal unexpected connections between cases and aid in understanding transmission dynamics, especially in the setting of a pandemic where multiple possible index cases exist simultaneously.
Collapse
Affiliation(s)
- Suzy E Meijer
- Department of Infectious Diseases and Epidemiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noam Harel
- The Shmunis School of Biomedicine and Cancer Research, Tel Aviv University, Tel Aviv, Israel
- Edmond J. Safra Center for Bioinformatics at Tel Aviv University, Tel Aviv, Israel
| | - Ronen Ben-Ami
- Department of Infectious Diseases and Epidemiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Meital Nahari
- Department of Infectious Diseases and Epidemiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Yakubovsky
- Department of Infectious Diseases and Epidemiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Howard S Oster
- Department of Internal Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Albert Kolomansky
- Department of Internal Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ora Halutz
- Laboratory of Microbiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Laskar
- The Department of Infectious Diseases, Israel Institute for Biological Research, Ness-Ziona, Israel
| | - Oryan Henig
- Department of Infectious Diseases and Epidemiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adi Stern
- The Shmunis School of Biomedicine and Cancer Research, Tel Aviv University, Tel Aviv, Israel
- Edmond J. Safra Center for Bioinformatics at Tel Aviv University, Tel Aviv, Israel
| | - Yael Paran
- Department of Infectious Diseases and Epidemiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
13
|
Li J, Huang Z, Tang M, Min C, Xia F, Hu Y, Wang H, Zhou H, Zou M. Clonal Dissemination of Multiple Carbapenemase Genes in Carbapenem-Resistant Enterobacterales Mediated by Multiple Plasmids in China. Infect Drug Resist 2021; 14:3287-3295. [PMID: 34434053 PMCID: PMC8382312 DOI: 10.2147/idr.s327273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 07/30/2021] [Indexed: 11/23/2022] Open
Abstract
Background Carbapenem-resistant Enterobacterales (CRE) are rapidly increasing worldwide in last two decades and lead few antibiotics for treatment. The molecular epidemiology of CRE in China was investigated to provide basis for clinical rational use of antibiotics and prevent its spread. Methods All CRE isolates in this study were collected from 11 hospitals from October 2015 to July 2018. The isolates were subjected to antimicrobial susceptibility tests, PCR molecular identification, pulsed-field gel electrophoresis, and multilocus sequence typing. Results Among the 399 CRE isolates, 51.6% (206/399) harbored carbapenemase genes. Three carbapenemase genes were detected, namely bla KPC-2, bla NDM-1, and bla IMP at rates of 29.8% (119/399), 17.5% (70/399), and 4.0% (16/399), respectively. In Klebsiella pneumoniae (350) and Escherichia coli (26), bla KPC-2 (33.4%, 117/350) and bla NDM-1 (61.5%, 16/26) were the predominant genes. The most common genes in the CRE isolates were bla KPC (85.5%) and bla NDM-1 (76.5%) from adults and children, respectively. Particularly, ST11 K. pneumoniae with bla KPC-2 harbored by IncFII plasmids were distributed in both general and primary hospitals, suggesting a clonal transmission pattern at these sites. In addition, the clonal distribution of ST2407 K. pneumoniae with bla NDM-1 located on IncX3 plasmids and bla IMP-38-positive ST307 K. pneumoniae were detected in a children's hospital. Conclusion The distribution of carbapenemase genes differed among strains and age groups. Multiple carbapenemase genes in the CRE strains were clonally disseminated in the tested regions mediated by multiple plasmids. Therefore, CRE monitoring should be increased and measures should be adopted to prevent its transmission.
Collapse
Affiliation(s)
- Jun Li
- Department of Clinical Laboratory, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China
| | - Ziyan Huang
- Department of Clinical Laboratory, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China
| | - Mengli Tang
- Department of Clinical Laboratory, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China
| | - Changhang Min
- Department of Clinical Laboratory, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China
| | - Fengjun Xia
- Department of Clinical Laboratory, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China
| | - Yongmei Hu
- Department of Clinical Laboratory, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China
| | - Haichen Wang
- Department of Clinical Laboratory, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China
| | - Haijian Zhou
- State Key Laboratory for Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, 102206, People's Republic of China
| | - Mingxiang Zou
- Department of Clinical Laboratory, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China
| |
Collapse
|
14
|
Zeng L, Yang C, Zhang J, Hu K, Zou J, Li J, Wang J, Huang W, Yin L, Zhang X. An Outbreak of Carbapenem-Resistant Klebsiella pneumoniae in an Intensive Care Unit of a Major Teaching Hospital in Chongqing, China. Front Cell Infect Microbiol 2021; 11:656070. [PMID: 34150672 PMCID: PMC8208809 DOI: 10.3389/fcimb.2021.656070] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/14/2021] [Indexed: 11/13/2022] Open
Abstract
Background Due to the critical condition and poor immunity of patients, the intensive care unit (ICU) has always been the main hospital source of multidrug-resistant bacteria. In recent years, with the large-scale use of antibiotics, the detection rate and mortality of carbapenem-resistant Klebsiella pneumoniae (CRKP) have gradually increased. This study explores the molecular characteristics and prevalence of CRKP isolated from the ICU ward of a tertiary hospital in China. Methods A total of 51 non-duplicated CRKP samples isolated from the ICU were collected from July 2018-July 2020. The enzyme production of the strains was preliminarily screened by carbapenemase phenotypic test, and drug-resistant and virulence genes were detected by PCR. The transferability of plasmid was verified by conjugation test. The minimal inhibitory concentration (MIC) was determined by microbroth dilution method and genetic diversity was detected by multilocus sequence typing and pulsed-field gel electrophoresis. Results blaKPC-2 was the only carbapenemase detected. The major virulence genes were uge (100%), mrkD (94.1%), kpn (94.1%), and fim-H (72.5%), while wcag, ironB, alls and magA genes were not detected. One sequence type ST1373 strain, hypervirulent K. pneumoniae (hvKP), was detected. CRKP strains were highly resistant to quinolones, cephalosporins, aminoglycosides, and polymyxin, but susceptive to tigecycline and ceftazidime-avibactam. The success rate of conjugation was 12.2%, indicating the horizontal transfer of blaKPC-2 . Homology analysis showed that there was a clonal transmission of ST11 CRKP in the ICU of our hospital. Conclusion The present study showed the outbreak and dissemination in ICU were caused by ST11 CRKP, which were KPC-2 producers, and simultaneously, also carried some virulence genes. ST11 CRKP persisted in the ward for a long time and spread among different areas. Due to the widespread dispersal of the transferable blaKPC-2 plasmid, the hospital should promptly adopt effective surveillance and strict infection control strategies to prevent the further spread of CRKP. Ceftazidime-avibactam showed high effectiveness against CRKP and could be used for the treatment of ICU infections.
Collapse
Affiliation(s)
- Lingyi Zeng
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China.,Department of Microbiology, The First Affiliated Hospital of Jiamusi University, Jiamusi, China
| | - Chengru Yang
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China.,Department of Microbiology, The First Affiliated Hospital of Jiamusi University, Jiamusi, China
| | - Jisheng Zhang
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Kewang Hu
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China.,Department of Microbiology, The First Affiliated Hospital of Jiamusi University, Jiamusi, China
| | - Jingbo Zou
- Department of Microbiology, Yongchuan District Center for Disease Control and Prevention of Chongqing, Chongqing, China
| | - Jie Li
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Jianmin Wang
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Wan Huang
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Lining Yin
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China.,Department of Microbiology, The First Affiliated Hospital of Jiamusi University, Jiamusi, China
| | - Xiaoli Zhang
- Department of Microbiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China.,Department of Microbiology, The First Affiliated Hospital of Jiamusi University, Jiamusi, China
| |
Collapse
|
15
|
Genetic factors related to the widespread dissemination of ST11 extensively drug-resistant carbapenemase-producing Klebsiella pneumoniae strains within hospital. Chin Med J (Engl) 2021; 133:2573-2585. [PMID: 32969865 PMCID: PMC7722564 DOI: 10.1097/cm9.0000000000001101] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background Carbapenemase-producing Klebsiella pneumoniae (CP-Kp) poses distinct clinical challenges due to extensively drug resistant (XDR) phenotype, and sequence type (ST) 11 is the most dominant blaKPC-2-bearing CP-Kp clone in China. The purpose of this current retrospective study was to explore the genetic factors associated with the success of XDR CP-Kp ST11 strains circulated in the intensive care unit (ICU) of a Chinese tertiary hospital. Methods Six ST11 XDR CP-Kp strains were identified between May and December 2014 and validated by minimum inhibitory concentration examination, polymerase chain reaction, and pyrosequencing. The six ST11 XDR CP-Kp, as well as three multi-drug resistant (MDR) and four susceptible strains, were sequenced using single-molecule real-time method. Comprehensively structural and functional analysis based on comparative genomics was performed to identify genomic characteristics of the XDR ST11 CP-Kp strains. Results We found that ST11 XDR blaKPC-2-bearing CP-Kp strains isolated from inpatients spread in the ICU of the hospital. Functionally, genes associated with information storage and processing of the ST11 XDR CP-Kp strains were more abundant than those of MDR and susceptible strains, especially genes correlative with mobile genetic elements (MGEs) such as transposons and prophages. Structurally, eleven large-scale genetic regions taken for the unique genome in these ST11 XDR CP-Kp strains were identified as MGEs including transposons, integrons, prophages, genomic islands, and integrative and conjugative elements. Three of them were located on plasmids and eight on chromosomes; five of them were with antimicrobial resistance genes and eight with adaptation associated genes. Notably, a new blaKPC-2-bearing ΔΔTn1721-blaKPC-2 transposon, probably transposed and truncated from ΔTn1721-blaKPC-2 by IS903D and ISKpn8, was identified in all six ST11 XDR CP-Kp strains. Conclusion Our findings suggested that together with clonal spread, MGEs identified uniquely in the ST11 XDR CP-Kp strains might contribute to their formidable adaptability, which facilitated their widespread dissemination in hospital.
Collapse
|
16
|
Li P, Liang Q, Liu W, Zheng B, Liu L, Wang W, Xu Z, Huang M, Feng Y. Convergence of carbapenem resistance and hypervirulence in a highly-transmissible ST11 clone of K. pneumoniae: An epidemiological, genomic and functional study. Virulence 2021; 12:377-388. [PMID: 33356821 PMCID: PMC7834077 DOI: 10.1080/21505594.2020.1867468] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Co-occurrence of hypervirulence and KPC-2 carbapenem resistant phenotypes in a highly-transmissible ST11 clone ofKlebsiella pneumoniae has elicited deep concerns from public health stand point. To address this puzzle, we conducted a large-scale epidemiological, clinical and genomic study of K. pneumonia ST11 clones with both hypervirulence and carbapenem resistance in two tertiary hospitals in Zhejiang province. Most of the patients (15/23) were diagnosed with exclusively carbapenem-resistant K. pneumoniae (CRKP) infections. Ten death cases were reported, some of which are due to the failure of antibiotic therapies. As a result, we identified one new rare sequence types (ST449) to KPC-2-producing CRKP, in addition to the dominant ST11. These clinical isolates of K. pneumoniae are multi-drug resistant and possess a number of virulence factors. Experimental infections of wax moth larvae revealed the presence of hypervirulence at varied level, suggesting the complexity in bacterial virulence factors. However, plasmid curing assays further suggested that the rmpA2-virulence plasmid is associated with, but not sufficient for neither phenotypic hypermucoviscosity nor virulence of K. pneumoniae. Intriguingly, all the rmpA2 genes were found to be inactive due to genetic deletion. In total, we reported 21 complete plasmid sequences comprising 13 rmpA2-positive virulence plasmids and 8 bla KPC-2-harboring resistance plasmids. In addition to the prevalent pLVKP-like virulence plasmid variants (~178kb), we found an unexpected diversity among KPC-2-producing plasmids whose dominant form is IncFII-IncR type (~120kb), rather than the previously anticipated version of ~170kb. These findings provide an updated snapshot of convergence of hypervirulence and carbapenem resistance in ST11 K. pneumoniae.
Collapse
Affiliation(s)
- Ping Li
- Department of Pathogen Biology & Microbiology and Department of General Intensive Care Unit of the Second Affiliated Hospital, Zhejiang University School of Medicine , Hangzhou, Zhejiang China
| | - Qiqiang Liang
- Department of Pathogen Biology & Microbiology and Department of General Intensive Care Unit of the Second Affiliated Hospital, Zhejiang University School of Medicine , Hangzhou, Zhejiang China
| | - Wugao Liu
- Clinical Laboratory of Lishui People's Hospital , Lishui, China
| | - Beiwen Zheng
- The First Affiliated Hospital, Zhejiang University School of Medicine , Hangzhou, China
| | - Lizhang Liu
- Department of Pathogen Biology & Microbiology and Department of General Intensive Care Unit of the Second Affiliated Hospital, Zhejiang University School of Medicine , Hangzhou, Zhejiang China
| | - Wei Wang
- Clinical Laboratory of Lishui People's Hospital , Lishui, China
| | - Zhijiang Xu
- Clinical Laboratory, the Second Affiliated Hospital, Zhejiang University School of Medicine , Hangzhou, China
| | - Man Huang
- Department of Pathogen Biology & Microbiology and Department of General Intensive Care Unit of the Second Affiliated Hospital, Zhejiang University School of Medicine , Hangzhou, Zhejiang China
| | - Youjun Feng
- Department of Pathogen Biology & Microbiology and Department of General Intensive Care Unit of the Second Affiliated Hospital, Zhejiang University School of Medicine , Hangzhou, Zhejiang China.,Non-coding RNA and Drug Discovery Key Laboratory of Sichuan Province, Chengdu Medical College , Chengdu, China.,College of Animal Sciences, Zhejiang University , Hangzhou, China
| |
Collapse
|
17
|
Co-occurrence of three different plasmids in an extensively drug-resistant hypervirulent Klebsiella pneumoniae isolate causing urinary tract infection. J Glob Antimicrob Resist 2020; 23:203-210. [DOI: 10.1016/j.jgar.2020.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 08/14/2020] [Accepted: 09/01/2020] [Indexed: 11/17/2022] Open
|
18
|
Wang Y, Luo C, Du P, Hu J, Zhao X, Mo D, Du X, Xu X, Li M, Lu H, Zhou Z, Cui Z, Zhou H. Genomic Epidemiology of an Outbreak of Klebsiella pneumoniae ST471 Producing Extended-Spectrum β-Lactamases in a Neonatal Intensive Care Unit. Infect Drug Resist 2020; 13:1081-1090. [PMID: 32346299 PMCID: PMC7167269 DOI: 10.2147/idr.s236212] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 01/11/2020] [Indexed: 12/22/2022] Open
Abstract
Purpose Klebsiella pneumoniae producing extended-spectrum β-lactamases (ESBLs) causes nosocomial infections worldwide. The present study aimed to determine the molecular subtyping characteristics and antibiotic resistance mechanisms of ESBL-producing K. pneumoniae strains collected during an outbreak. Moreover, we attempted to reveal the fine transmission route of the strains within this outbreak using whole-genome sequencing (WGS). Methods Collecting cases and strain information were carried out. Outbreak-related strains were identified using pulsed-field gel electrophoresis (PFGE). The antibiotic susceptibility, drug-resistant genes, and molecular subtype characteristics of ESBL-producing K. pneumoniae were analyzed. The fine transmission route of the strains within this outbreak was revealed using WGS and minimum core genome (MCG) sequence typing. Results In mid-January, 2015, five cases of neonatal pneumonia caused by ESBL-producing K. pneumoniae were observed in the neonatal intensive care unit (NICU) of the Affiliated Hospital of Chifeng University, China. Eight ESBL-producing K. pneumoniae were isolated from these five cases, and two additional strains from another two cases were identified using PFGE. All ten isolates harbored bla CTX-M-15, bla TEM-1, bla SHV-108, and bla OXA-1 genes, and belonged to the sequence type 471 (ST471) clone. A putative transmission map was constructed via comprehensive consideration of genomic and epidemiological information. WGS identified the initial case and the "superspreader". The genomic epidemiological investigation revealed that the outbreak was caused by the introduction of the bacteria one month before the first case appeared. Conclusion As far as we know, this is the first report to describe the characteristics of an ST471 ESBL-producing K. pneumoniae outbreak. The data showed that epidemiological inferences could be greatly improved by interpretation in the context of WGS and that K. pneumoniae strains isolated from the same outbreak contain sufficient genomic differences to refine epidemiological linkages on the basis of genetic lineage. These findings suggested that integration of genomic and epidemiological data can help us to have a clearer understanding of when and how outbreaks occur, so as to better control nosocomial transmission.
Collapse
Affiliation(s)
- Yuan Wang
- Affiliated Hospital of Chifeng University, Chifeng 024005, People's Republic of China
| | - Chunyu Luo
- Affiliated Hospital of Chifeng University, Chifeng 024005, People's Republic of China
| | - Pengcheng Du
- Beijing Key Laboratory of Emerging Infectious Diseases, Institute of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, People's Republic of China
| | - Jinrui Hu
- State Key Laboratory for Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, People's Republic of China
| | - Xiaowei Zhao
- Affiliated Hospital of Chifeng University, Chifeng 024005, People's Republic of China
| | - Dianjun Mo
- Affiliated Hospital of Chifeng University, Chifeng 024005, People's Republic of China
| | - Xiaoli Du
- State Key Laboratory for Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, People's Republic of China
| | - Xin Xu
- Affiliated Hospital of Chifeng University, Chifeng 024005, People's Republic of China
| | - Man Li
- Affiliated Hospital of Chifeng University, Chifeng 024005, People's Republic of China
| | - Hong Lu
- Affiliated Hospital of Chifeng University, Chifeng 024005, People's Republic of China
| | - Zhiqiang Zhou
- Affiliated Hospital of Chifeng University, Chifeng 024005, People's Republic of China
| | - Zhigang Cui
- State Key Laboratory for Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, People's Republic of China
| | - Haijian Zhou
- State Key Laboratory for Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, People's Republic of China
| |
Collapse
|
19
|
Li J, Yu T, Tao XY, Hu YM, Wang HC, Liu JL, Zhou HJ, Zou MX. Emergence of an NDM-5-Producing Escherichia coli Sequence Type 410 Clone in Infants in a Children's Hospital in China. Infect Drug Resist 2020; 13:703-710. [PMID: 32184632 PMCID: PMC7054006 DOI: 10.2147/idr.s244874] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 02/15/2020] [Indexed: 12/14/2022] Open
Abstract
Purpose Outbreaks of infection due to carbapenem-resistant Enterobacterales (CRE), including New Delhi metallo-β-lactamase (NDM)-producing Escherichia coli, have been increasingly reported worldwide, primarily in adults and rarely in children. The goal of this study was to characterize an outbreak of infection caused by NDM-5-producing E. coli in a children’s hospital in China. Methods A total of 86 CRE isolates were collected from 85 hospitalized children between June 2017 and May 2018. These isolates were subjected to multiple phenotypic and molecular tests, including in vitro antimicrobial susceptibility testing, PCR, pulsed-field gel electrophoresis (PFGE), multilocus sequence typing (MLST), and whole-genome sequencing (WGS). Results Among the 86 CRE isolates, we identified 9 NDM-5-producing E. coli isolates, with 5 of them sharing the same PFGE pattern, same MLST type (ST410), same plasmid replicon type (IncFII), and nearly the same set of additional resistance genes. All 9 isolates were resistant to most antimicrobial agents, including carbapenems, cephalosporins, and levofloxacin, while being sensitive to trimethoprim/sulfamethoxazole, amikacin, tigecycline, and colistin. According to the clinical background, all 9 isolates were collected in a period of < 3 months from infants among whom there was overlap in the time of hospitalization. None of them had a travel history. Conclusion Our analysis suggests an outbreak of clonal dissemination, presumably due to nosocomial transmission. This study represents the first documented outbreak of NDM-5-producing E. coli mediated by IncFII in infants. Close monitoring is urgently needed to prevent and control the spread of this difficult-to-treat superbug.
Collapse
Affiliation(s)
- Jun Li
- Department of Clinical Laboratory, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China
| | - Ting Yu
- Department of Clinical Laboratory, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China
| | - Xiao-Yan Tao
- Department of Clinical Laboratory, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China
| | - Yong-Mei Hu
- Department of Clinical Laboratory, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China
| | - Hai-Chen Wang
- Department of Clinical Laboratory, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China
| | - Jian-Long Liu
- Department of Clinical Laboratory, Hunan Children's Hospital, Changsha, Hunan 410007, People's Republic of China
| | - Hai-Jian Zhou
- State Key Laboratory for Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, People's Republic of China
| | - Ming-Xiang Zou
- Department of Clinical Laboratory, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China
| |
Collapse
|
20
|
Zhao Y, Zhang X, Torres VVL, Liu H, Rocker A, Zhang Y, Wang J, Chen L, Bi W, Lin J, Strugnell RA, Zhang S, Lithgow T, Zhou T, Cao J. An Outbreak of Carbapenem-Resistant and Hypervirulent Klebsiella pneumoniae in an Intensive Care Unit of a Major Teaching Hospital in Wenzhou, China. Front Public Health 2019; 7:229. [PMID: 31552210 PMCID: PMC6736603 DOI: 10.3389/fpubh.2019.00229] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 07/30/2019] [Indexed: 12/13/2022] Open
Abstract
Carbapenem-resistant, hypervirulent Klebsiella pneumoniae (CR-hvKP) has recently emerged as a significant threat to public health. In this study, 29 K. pneumoniae isolates were isolated from eight patients admitted to the intensive care unit (ICU) of a comprehensive teaching hospital located in China from March 2017 to January 2018. Clinical information of patients was the basis for the further analyses of the isolates including antimicrobial susceptibility tests, identification of antibiotic resistance and virulence gene determinants, multilocus sequence typing (MLST), XbaI-macrorestriction by pulsed-field gel electrophoresis (PFGE). Selected isolates representing distinct resistance profiles and virulence phenotypes were screened for hypervirulence in a Galleria mellonella larvae infection model. In the course of the outbreak, the overall mortality rate of patients was 100% (n = 8) attributed to complications arising from CR-hvKP infections. All isolates except one (28/29, 96.6%) were resistant to multiple antimicrobial agents, and harbored diverse resistance determinants that included the globally prevalent carbapenemase blaKPC−2. Most isolates had hypervirulent genotypes being positive for 19 virulence-associated genes, including iutA (25/29, 86.2%), rmpA (27/29, 93.1%), ybtA (27/29, 93.1%), entB (29/29, 100%), fimH (29/29, 100%), and mrkD (29/29, 100%). MLST revealed ST11 for the majority of isolates (26/29, 89,7%). Infection assays demonstrated high mortality in the Galleria mellonella model with the highest LD50 values for three isolates (<105 CFU/mL) demonstrating the degree of hypervirulence of these CR-hvKP isolates, and is discussed relative to previous outbreaks of CR-hvKP.
Collapse
Affiliation(s)
- Yajie Zhao
- School of Laboratory Medicine and Life Science, Wenzhou Medical University, Wenzhou, China
| | - Xiucai Zhang
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Von Vergel L Torres
- Infection and Immunity Program, Department of Microbiology, Biomedicine Discovery Institute, Monash University, Melbourne, VIC, Australia
| | - Haiyang Liu
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Andrea Rocker
- Infection and Immunity Program, Department of Microbiology, Biomedicine Discovery Institute, Monash University, Melbourne, VIC, Australia
| | - Yizhi Zhang
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jiawei Wang
- Infection and Immunity Program, Department of Microbiology, Biomedicine Discovery Institute, Monash University, Melbourne, VIC, Australia
| | - Lijiang Chen
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wenzi Bi
- School of Medicine, The Fourth Affiliated Hospital of Zhejiang University, Jinhua, China
| | - Jie Lin
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Richard A Strugnell
- Department of Microbiology and Immunology, The Peter Doherty Institute, The University of Melbourne, Melbourne, VIC, Australia
| | - Siqin Zhang
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Trevor Lithgow
- Infection and Immunity Program, Department of Microbiology, Biomedicine Discovery Institute, Monash University, Melbourne, VIC, Australia
| | - Tieli Zhou
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jianming Cao
- School of Laboratory Medicine and Life Science, Wenzhou Medical University, Wenzhou, China
| |
Collapse
|
21
|
A core genome approach that enables prospective and dynamic monitoring of infectious outbreaks. Sci Rep 2019; 9:7808. [PMID: 31127153 PMCID: PMC6534532 DOI: 10.1038/s41598-019-44189-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 05/09/2019] [Indexed: 11/16/2022] Open
Abstract
Whole-genome sequencing is increasingly adopted in clinical settings to identify pathogen transmissions, though largely as a retrospective tool. Prospective monitoring, in which samples are continuously added and compared to previous samples, can generate more actionable information. To enable prospective pathogen comparison, genomic relatedness metrics based on single-nucleotide differences must be consistent across time, efficient to compute and reliable for a large variety of samples. The choice of genomic regions to compare, i.e., the core genome, is critical to obtain a good metric. We propose a novel core genome method that selects conserved sequences in the reference genome by comparing its k-mer content to that of publicly available genome assemblies. The conserved-sequence genome is sample set-independent, which enables prospective pathogen monitoring. Based on clinical data sets of 3436 S. aureus, 1362 K. pneumoniae and 348 E. faecium samples, ROC curves demonstrate that the conserved-sequence genome disambiguates same-patient samples better than a core genome consisting of conserved genes. The conserved-sequence genome confirms outbreak samples with high sensitivity: in a set of 2335 S. aureus samples, it correctly identifies 44 out of 44 known outbreak samples, whereas the conserved-gene method confirms 38 known outbreak samples.
Collapse
|
22
|
Prospective investigation of carbapenem-resistant Klebsiella pneumonia transmission among the staff, environment and patients in five major intensive care units, Beijing. J Hosp Infect 2019; 101:150-157. [DOI: 10.1016/j.jhin.2018.11.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 11/29/2018] [Indexed: 12/11/2022]
|