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Raro OHF, Bouvier M, Kerbol A, Poirel L, Nordmann P. MultiRapid ATB NP test for detecting concomitant susceptibility and resistance of last-resort novel antibiotics available to treat multidrug-resistant Enterobacterales infections. Int J Antimicrob Agents 2024; 64:107206. [PMID: 38754526 DOI: 10.1016/j.ijantimicag.2024.107206] [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: 02/12/2024] [Revised: 04/23/2024] [Accepted: 05/09/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Recently developed therapeutics against Gram-negative bacteria include the β-lactam-β-lactamase inhibitor combinations ceftazidime-avibactam (CZA), meropenem-vaborbactam (MEV), and imipenem-relebatam (IPR), and the siderophore cephalosporin cefiderocol (FDC). The aim of this study was to develop a test for rapid identification of susceptibility/resistance to CZA, MEV, IPR, and FDC for Enterobacterales in a single test for rapid clinical decision making. METHODS The MultiRapid ATB NP test is based on the detection of glucose metabolism occurring after bacterial growth in the presence of defined concentrations of CZA, MEV, IPR, and FDC, followed by visual detection of colour change of the pH indicator red phenol (red to yellow) generated by the acidification of the medium upon bacterial growth. This test is performed in 96-well microplates. The MultiRapid ATB NP test was evaluated using 78 Enterobacterales isolates and compared to the reference method broth microdilution. RESULTS The MultiRapid ATB NP test displayed 97.0% (confidence interval [CI] 92.6-98.8) sensitivity, 97.7% (CI 94.3-99.1) specificity, and 97.4% (CI 95.0-98.7) accuracy. The results were obtained after 3 h of incubation at 35 °C ± 2 °C, representing at least a 15-h gain-of-time compared with currently used antimicrobial susceptibility testing methods. CONCLUSION The MultiRapid ATB NP test provided accurate results for the concomitant detection of susceptibility/resistance to CZA, MEV, IPR, and FDC in Enterobacterales, independent of the resistance mechanism. This test may be suitable for implementation in any microbiology routine laboratory.
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Affiliation(s)
- Otávio Hallal Ferreira Raro
- Medical and Molecular Microbiology, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
| | - Maxime Bouvier
- Medical and Molecular Microbiology, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland; Swiss National Reference Centre for Emerging Antibiotic Resistance (NARA), University of Fribourg, Fribourg, Switzerland
| | - Auriane Kerbol
- Swiss National Reference Centre for Emerging Antibiotic Resistance (NARA), University of Fribourg, Fribourg, Switzerland
| | - Laurent Poirel
- Medical and Molecular Microbiology, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland; Swiss National Reference Centre for Emerging Antibiotic Resistance (NARA), University of Fribourg, Fribourg, Switzerland
| | - Patrice Nordmann
- Medical and Molecular Microbiology, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland; Swiss National Reference Centre for Emerging Antibiotic Resistance (NARA), University of Fribourg, Fribourg, Switzerland; Institute for Microbiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
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Liang B, Chen Y, Liang Z, Li X, Cai H, Lai H, Zhong H, Xie Y, Huang L, Gao F, Long Y. Molecular characteristics and evaluation of the phenotypic detection of carbapenemases among Enterobacterales and Pseudomonas via whole genome sequencing. Front Cell Infect Microbiol 2024; 14:1357289. [PMID: 39027138 PMCID: PMC11254758 DOI: 10.3389/fcimb.2024.1357289] [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: 12/17/2023] [Accepted: 06/20/2024] [Indexed: 07/20/2024] Open
Abstract
Background/purposes The continuously increasing carbapenem resistance within Enterobacterales and Pseudomonas poses a threat to public health, nevertheless, the molecular characteristics of which in southern China still remain limited. And carbapenemase identification is a key factor in effective early therapy of carbapenem-resistant bacteria infections. We aimed to determine the molecular characteristics of these pathogens and compare commercial combined disc tests (CDTs) with the modified carbapenem inactivation method (mCIM) and EDTA-CIM (eCIM) in detecting and distinguishing carbapenemases using whole genome sequencing (WGS). Methods A total of 78 Enterobacterales, 30 Pseudomonas were obtained from two tertiary hospitals in southern China. Susceptibility tests were conducted using an automated VITEK2 compact system with confirmation via the Kirby-Bauer method. The WGS was conducted on all clinical isolates and the molecular characteristics were analyzed by screening the whole genome sequences. CDTs with or without cloxacillin, mCIM, and eCIM, were performed and compared by taking WGS results as the benchmark. Results A total of 103 carbapenem non-susceptible and 5 carbapenem susceptible bacteria were determined, with Klebsiella pneumoniae (42.7%), Pseudomonas aeruginosa (23.3%) and Escherichia coli (18.4%) being most prevalent. Carbapenemase genes were detected in 58 (56.3%) of the 103 carbapenem-non-susceptible clinical isolates, including 46 NDM, 6 KPC, 3 IMP, 1 IPM+VIM,1NDM+KPC, and 1 OXA-181. Carbapenemase-producing isolates were detected more frequently in Enterobacterales (76.3%). Among K. pneumoniae, the major sequence types were st307 and st11, while among E. coli and P. aeruginosa, the most prevalent ones were st410 and st242 respectively. For carbapenemase detection in Enterobacterales, the mCIM method achieved 100.00% (95% CI, 92.13-100.00%) sensitivity and 94.44% (70.63-99.71%) specificity (kappa, 0.96); for Pseudomonas, detection sensitivity was 100% (5.46-100.00%), and 100% (84.50-100.00%) specificity (kappa, 0.65). Commercial CDT carbapenemase detection sensitivity for Enterobacterales was 96.49% (86.84-99.39%), and 95.24% (74.13-99.75%) specificity (kappa, 0.90); for Pseudomonas, carbapenemase detection sensitivity was 100.00% (5.46-100.00%) and 37.93% (21.30-57.64%) specificity (kappa, 0.04). When cloxacillin testing was added, CDT specificity reached 84.61% (64.27-94.95%). Conclusion The molecular epidemiology of carbapenem-non-susceptible isolates from pediatric patients in Southern China exhibited distinctive characteristics. Both the mCIM-eCIM combination and CDT methods effectively detected and differentiated carbapenemases among Enterobacterales isolates, and the former performed better than CDT among Pseudomonas.
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Affiliation(s)
- Bingshao Liang
- Clinical Laboratory, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Yuou Chen
- KingMed School of Laboratory Medicine, Guangzhou Medical University, Guangzhou, China
| | - Zhuwei Liang
- Clinical Laboratory, Guangdong Provincial Second Hospital of Traditional Chinese Medicine (Guangdong Provincial Engineering Technology Research Institute of Traditional Chinese Medicine), Guangzhou, China
| | - Xueying Li
- Clinical Laboratory, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Hao Cai
- Clinical Laboratory, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Hanyu Lai
- Clinical Laboratory, The First People’s Hospital of Zhaoqing, Zhaoqing, China
| | - Huamin Zhong
- Clinical Laboratory, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Yongqiang Xie
- Clinical Laboratory, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Lianfen Huang
- Clinical Laboratory, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Fei Gao
- Clinical Laboratory, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Yan Long
- Clinical Laboratory, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
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Nordmann P, Bouvier M, Delaval A, Tinguely C, Poirel L, Sadek M. Rapid Detection of Ceftazidime/Avibactam Susceptibility/Resistance in Enterobacterales by Rapid CAZ/AVI NP Test. Emerg Infect Dis 2024; 30:255-261. [PMID: 38270160 PMCID: PMC10826745 DOI: 10.3201/eid3002.221398] [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] [Indexed: 01/26/2024] Open
Abstract
We developed a novel culture-based test, the Rapid CAZ/AVI NP test, for rapid identification of ceftazidime/avibactam susceptibility/resistance in Enterobacterales. This test is based on glucose metabolization upon bacterial growth in the presence of a defined concentration of ceftazidime/avibactam (128/53 μg/mL). Bacterial growth is visually detectable by a red to yellow color change of red phenol, a pH indicator. A total of 101 well characterized enterobacterial isolates were used to evaluate the test performance. This test showed positive percent agreement of 100% and negative percent agreement of 98.5% with overall percent agreement of 99%, by comparison with the MIC gradient strip test (Etest) taken as the reference standard method. The Rapid CAZ/AVI NP test had only 1.5% major errors and 0% extremely major errors. This test is rapid (result within 2 hours 45 minutes), reliable, affordable, easily interpretable, and easy to implement in clinical microbiology laboratories without requiring any specific equipment.
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Zarras C, Iosifidis E, Simitsopoulou M, Pappa S, Kontou A, Roilides E, Papa A. Neonatal Bloodstream Infection with Ceftazidime-Avibactam-Resistant blaKPC-2-Producing Klebsiella pneumoniae Carrying blaVEB-25. Antibiotics (Basel) 2023; 12:1290. [PMID: 37627710 PMCID: PMC10451261 DOI: 10.3390/antibiotics12081290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 07/23/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Although ceftazidime/avibactam (CAZ/AVI) has become an important option for treating adults and children, no data or recommendations exist for neonates. We report a neonatal sepsis case due to CAZ/AVI-resistant blaKPC-2-harboring Klebsiella pneumoniae carrying blaVEB-25 and the use of a customized active surveillance program in conjunction with enhanced infection control measures. METHODS The index case was an extremely premature neonate hospitalized for 110 days that had been previously treated with multiple antibiotics. Customized molecular surveillance was implemented at hospital level and enhanced infection control measures were taken for early recognition and prevention of outbreak. Detection and identification of blaVEB-25 was performed using next-generation sequencing. RESULTS This was the first case of a bloodstream infection caused by KPC-producing K. pneumoniae that was resistant to CAZ/AVI without the presence of a metalo-β-lactamase in the multiplex PCR platform in a neonate. All 36 additional patients tested (12 in the same NICU and 24 from other hospital departments) carried wild-type blaVEB-1 but they did not harbor blaVEB-25. CONCLUSION The emergence of blaVEB-25 is signal for the horizontal transfer of plasmids at hospital facilities and it is of greatest concern for maintaining a sharp vigilance for the surveillance of novel resistance mechanisms. Molecular diagnostics can guide appropriate antimicrobial therapy and the early implementation of infection control measures against antimicrobial resistance.
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Affiliation(s)
- Charalampos Zarras
- Microbiology Department, Hippokration Hospital, 54642 Thessaloniki, Greece;
- Department of Microbiology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (S.P.); (A.P.)
| | - Elias Iosifidis
- Infectious Disease Unit, 3rd Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Hippokration Hospital, 54642 Thessaloniki, Greece; (M.S.); (E.R.)
- Basic and Translational Research Unit, Special Unit for Biomedical Research and Education, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Maria Simitsopoulou
- Infectious Disease Unit, 3rd Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Hippokration Hospital, 54642 Thessaloniki, Greece; (M.S.); (E.R.)
- Basic and Translational Research Unit, Special Unit for Biomedical Research and Education, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Styliani Pappa
- Department of Microbiology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (S.P.); (A.P.)
| | - Angeliki Kontou
- 1st Department of Neonatology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece;
| | - Emmanuel Roilides
- Infectious Disease Unit, 3rd Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Hippokration Hospital, 54642 Thessaloniki, Greece; (M.S.); (E.R.)
- Basic and Translational Research Unit, Special Unit for Biomedical Research and Education, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Anna Papa
- Department of Microbiology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (S.P.); (A.P.)
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Afolayan AO, Rigatou A, Grundmann H, Pantazatou A, Daikos G, Reuter S. Three Klebsiella pneumoniae lineages causing bloodstream infections variably dominated within a Greek hospital over a 15 year period. Microb Genom 2023; 9:mgen001082. [PMID: 37642647 PMCID: PMC10483420 DOI: 10.1099/mgen.0.001082] [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: 02/16/2023] [Accepted: 07/18/2023] [Indexed: 08/31/2023] Open
Abstract
Carbapenem-resistant Klebsiella pneumoniae (CRKP) has emerged as a major clinical and public health threat. The rapid dissemination of this pathogen is driven by several successful clones worldwide. We aimed to investigate the CRKP clonal lineages, their antibiotic resistance determinants and their potential transmissions in a tertiary care hospital located in Athens, Greece. Between 2003 and 2018, 392 CRKP isolates from bloodstream infections were recovered from hospitalized patients. Whole genome sequencing (WGS) was performed on the Illumina platform to characterize 209 of these isolates. In total, 74 % (n=155) of 209 isolates belonged to three major clonal lineages: ST258 (n=108), ST147 (n=29) and ST11 (n=18). Acquired carbapenemase genes were the mechanisms of resistance in 205 isolates (bla KPC, n=123; bla VIM, n=56; bla NDM, n=20; bla OXA-48, n=6). Strong associations (P=0.0004) were observed between carbapenemase genes and clonal lineages. We first isolated bla VIM-1-carrying ST147 strains during the early sampling period in 2003, followed by the emergence of bla KPC-2-carrying ST258 in 2006 and bla NDM-1-carrying ST11 in 2013. Analysis of genetic distances between the isolates revealed six potential transmission events. When contextualizing the current collection with published data, ST147 reflected the global diversity, ST258 clustered with isolates representing the first introduction into Europe and ST11 formed a distinct geographically restricted lineage indicative of local spread. This study demonstrates the changing profile of bloodstream CRKP in a tertiary care hospital over a 15 year period and underlines the need for continued genomic surveys to develop strategies to contain further dissemination. This article contains data hosted by Microreact.
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Affiliation(s)
- Ayorinde O. Afolayan
- Institute for Infection Prevention and Control, Medical Center - University of Freiburg, Freiburg, Germany
| | | | - Hajo Grundmann
- Institute for Infection Prevention and Control, Medical Center - University of Freiburg, Freiburg, Germany
| | | | - George Daikos
- First Department of Medicine, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Sandra Reuter
- Institute for Infection Prevention and Control, Medical Center - University of Freiburg, Freiburg, Germany
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Zarras C, Karampatakis T, Pappa S, Iosifidis E, Vagdatli E, Roilides E, Papa A. Genetic Characterization of Carbapenem-Resistant Klebsiella pneumoniae Clinical Isolates in a Tertiary Hospital in Greece, 2018-2022. Antibiotics (Basel) 2023; 12:976. [PMID: 37370295 DOI: 10.3390/antibiotics12060976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 05/23/2023] [Accepted: 05/25/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Carbapenem-resistant Klebsiella pneumoniae (CRKP) is a serious public health issue. The study aimed to identify the antimicrobial resistance and accessory genes, the clonal relatedness, and the evolutionary dynamics of selected CRKP isolates recovered in an adult and pediatric intensive care unit of a tertiary hospital in Greece. METHODS Twenty-four CRKP isolates recovered during 2018-2022 were included in the study. Next-generation sequencing was performed using the Ion Torrent PGM Platform. The identification of the plasmid content, MLST, and antimicrobial resistance genes, as well as the comparison of multiple genome alignments and the identification of core genome single-nucleotide polymorphism sites, were performed using various bioinformatics software. RESULTS The isolates belonged to eight sequence types: 11, 15, 30, 35, 39, 307, 323, and 512. A variety of carbapenemases (KPC, VIM, NDM, and OXA-48) and resistance genes were detected. CRKP strains shared visually common genomic regions with the reference strain (NTUH-K2044). ST15, ST323, ST39, and ST11 CRKP isolates presented on average 17, 6, 16, and 866 recombined SNPs, respectively. All isolates belonging to ST15, ST323, and ST39 were classified into distinct phylogenetic branches, while ST11 isolates were assigned to a two-subclade branch. For large CRKP sets, the phylogeny seems to change approximately every seven SNPs. CONCLUSIONS The current study provides insight into the genetic characterization of CRKP isolates in the ICUs of a tertiary hospital. Our results indicate clonal dispersion of ST15, ST323, and ST39 and highly diverged ST11 isolates.
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Affiliation(s)
- Charalampos Zarras
- Department of Microbiology, Medical Faculty, School of Health Sciences, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece
- Microbiology Department, Hippokration General Hospital, 546 42 Thessaloniki, Greece
| | - Theodoros Karampatakis
- Department of Microbiology, Medical Faculty, School of Health Sciences, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece
| | - Styliani Pappa
- Department of Microbiology, Medical Faculty, School of Health Sciences, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece
| | - Elias Iosifidis
- Infectious Disease Unit, 3rd Department of Pediatrics, Medical Faculty, School of Health Sciences, Hippokration General Hospital, 546 42 Thessaloniki, Greece
| | - Eleni Vagdatli
- Microbiology Department, Hippokration General Hospital, 546 42 Thessaloniki, Greece
| | - Emmanuel Roilides
- Infectious Disease Unit, 3rd Department of Pediatrics, Medical Faculty, School of Health Sciences, Hippokration General Hospital, 546 42 Thessaloniki, Greece
| | - Anna Papa
- Department of Microbiology, Medical Faculty, School of Health Sciences, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece
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Findlay J, Poirel L, Bouvier M, Gaia V, Nordmann P. Resistance to ceftazidime-avibactam in a KPC-2-producing Klebsiella pneumoniae caused by the extended-spectrum beta-lactamase VEB-25. Eur J Clin Microbiol Infect Dis 2023; 42:639-644. [PMID: 36877262 PMCID: PMC10105652 DOI: 10.1007/s10096-023-04582-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 02/26/2023] [Indexed: 03/07/2023]
Abstract
Carbapenem-resistant Enterobacterales, including KPC-producing Klebsiella pneumoniae, represent a major threat to public health due to their rapid spread. The beta-lactam/beta-lactamase inhibitor (BL/BLI) combination ceftazidime-avibactam (CAZ-AVI) has recently been introduced and shown to exhibit excellent activity toward multidrug-resistant KPC-producing Enterobacterales strains. However, CAZ-AVI-resistant K. pneumoniae isolates are being increasingly reported, mostly corresponding to producers of KPC variants that confer resistance to CAZ-AVI but at a cost of carbapenem resistance. We have characterized here, both phenotypically and genotypically, a clinical CAZ-AVI- and carbapenem-resistant KPC-2 K. pneumoniae isolate co-producing the inhibitor-resistant extended-spectrum beta-lactamase VEB-25.
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Affiliation(s)
- Jacqueline Findlay
- Medical and Molecular Microbiology, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland.
| | - Laurent Poirel
- Medical and Molecular Microbiology, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
- Swiss National Reference Center for Emerging Antibiotic Resistance (NARA), University of Fribourg, Fribourg, Switzerland
- Institute for Microbiology, University of Lausanne and University Hospital Centre, Lausanne, Switzerland
| | - Maxime Bouvier
- Swiss National Reference Center for Emerging Antibiotic Resistance (NARA), University of Fribourg, Fribourg, Switzerland
| | - Valeria Gaia
- Servizio Di Microbiologia EOLAB, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Patrice Nordmann
- Medical and Molecular Microbiology, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
- Swiss National Reference Center for Emerging Antibiotic Resistance (NARA), University of Fribourg, Fribourg, Switzerland
- Institute for Microbiology, University of Lausanne and University Hospital Centre, Lausanne, Switzerland
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Nichols WW, Lahiri SD, Bradford PA, Stone GG. The primary pharmacology of ceftazidime/avibactam: resistance in vitro. J Antimicrob Chemother 2023; 78:569-585. [PMID: 36702744 DOI: 10.1093/jac/dkac449] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
This article reviews resistance to ceftazidime/avibactam as an aspect of its primary pharmacology, linked thematically with recent reviews of the basic in vitro and in vivo translational biology of the combination (J Antimicrob Chemother 2022; 77: 2321-40 and 2341-52). In Enterobacterales or Pseudomonas aeruginosa, single-step exposures to 8× MIC of ceftazidime/avibactam yielded frequencies of resistance from <∼0.5 × 10-9 to 2-8 × 10-9, depending on the host strain and the β-lactamase harboured. β-Lactamase structural gene mutations mostly affected the avibactam binding site through changes in the Ω-loop: e.g. Asp179Tyr (D179Y) in KPC-2. Other mutations included ones proposed to reduce the permeability to ceftazidime and/or avibactam through changes in outer membrane structure, up-regulated efflux, or both. The existence, or otherwise, of cross-resistance between ceftazidime/avibactam and other antibacterial agents was also reviewed as a key element of the preclinical primary pharmacology of the new agent. Cross-resistance between ceftazidime/avibactam and other β-lactam-based antibacterial agents was caused by MBLs. Mechanism-based cross-resistance was not observed between ceftazidime/avibactam and fluoroquinolones, aminoglycosides or colistin. A low level of general co-resistance to ceftazidime/avibactam was observed in MDR Enterobacterales and P. aeruginosa. For example, among 2821 MDR Klebsiella spp., 3.4% were resistant to ceftazidime/avibactam, in contrast to 0.07% of 8177 non-MDR isolates. Much of this was caused by possession of MBLs. Among 1151 MDR, XDR and pandrug-resistant isolates of P. aeruginosa from the USA, 11.1% were resistant to ceftazidime/avibactam, in contrast to 3.0% of 7452 unselected isolates. In this case, the decreased proportion susceptible was not due to MBLs.
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Affiliation(s)
| | - Sushmita D Lahiri
- Infectious Diseases and Vaccines, Johnson & Johnson, Cambridge, MA, USA
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Current and Potential Therapeutic Options for Infections Caused by Difficult-to-Treat and Pandrug Resistant Gram-Negative Bacteria in Critically Ill Patients. Antibiotics (Basel) 2022; 11:antibiotics11081009. [PMID: 35892399 PMCID: PMC9394369 DOI: 10.3390/antibiotics11081009] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 07/15/2022] [Accepted: 07/24/2022] [Indexed: 11/18/2022] Open
Abstract
Carbapenem resistance in Gram-negative bacteria has come into sight as a serious global threat. Carbapenem-resistant Gram-negative pathogens and their main representatives Klebsiella pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa are ranked in the highest priority category for new treatments. The worrisome phenomenon of the recent years is the presence of difficult-to-treat resistance (DTR) and pandrug-resistant (PDR) Gram-negative bacteria, characterized as non-susceptible to all conventional antimicrobial agents. DTR and PDR Gram-negative infections are linked with high mortality and associated with nosocomial infections, mainly in critically ill and ICU patients. Therapeutic options for infections caused by DTR and PDR Gram-negative organisms are extremely limited and are based on case reports and series. Herein, the current available knowledge regarding treatment of DTR and PDR infections is discussed. A focal point of the review focuses on salvage treatment, synergistic combinations (double and triple combinations), as well as increased exposure regimen adapted to the MIC of the pathogen. The most available data regarding novel antimicrobials, including novel β-lactam-β-lactamase inhibitor combinations, cefiderocol, and eravacycline as potential agents against DTR and PDR Gram-negative strains in critically ill patients are thoroughly presented.
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Machuca I, Guzmán-Puche J, Pérez-Nadales E, Gracia-Ahufinger I, Mendez A, Cano A, Castón JJ, Domínguez A, Torre-Cisneros J, Martínez-Martínez L. Community-acquired bacteremia by Klebsiella pneumoniae producing KPC-3 and resistant to ceftazidime/avibactam. J Glob Antimicrob Resist 2022; 30:399-402. [PMID: 35878781 DOI: 10.1016/j.jgar.2022.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 07/04/2022] [Accepted: 07/16/2022] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVES To describe the clinical and microbiological features of a case of community-acquired infection by KPC-producing K. pneumoniae (KPCKP) resistant to ceftazidime/avibactam (CAZ-AVI). METHODS Identification of microorganisms was performed with MALDI Biotyper CA System (BrukerDaltonics, Madrid, Spain). Antimicrobial susceptibility testing was performed using Sensitre EURGNCOL panels (Thermo Fisher Scientific, Madrid, Spain) and gradient strips (Etest, bioMérieux, Madrid, Spain) in the case of CAZ-AVI, using EUCAST breakpoints for interpretation. Whole Genome Sequencing of blood culture and rectal swab isolates was performed using the Illumina NovaSeq 6000 sequencing system, with 2 × 150-bp paired-end reads (Illumina Inc). RESULTS Blood culture and rectal swab KPCKP isolates were resistant to carbapenems and to CAZ-AVI. The blood culture isolate showed susceptibility to trimethoprim-sulfamethoxazole (TMP-SMX) but the rectal swab culture isolate was resistant to this antibiotic. Both isolates belonged to clonal lineage ST512, harboured a single copy of blaKPC-3 gene, and showed 16 Single Nucleotide Polymorphism (SNP) between them and 38 SNPs with regards to the first KPC-3 producing K. pneumoniae isolated in our hospital in an initial outbreak in 2012. Genome-wide resistome analysis revealed the presence of a IncFIB(K) plasmid harbouring sul1 and dfrA12 genes only in the rectal swab culture isolate, which may explain its resistance to TMP-SMX. CONCLUSIONS Resistance to ceftazidime-avibactam is an emerging nosocomial problem. This case shows that CAZ-AVI-resistant KPCKP strains may disseminate into the community and cause serious infections.
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Affiliation(s)
- I Machuca
- Unit of Infectious Diseases, Reina Sofía University Hospital, Cordoba, Spain; Maimonides Biomedical Research Institute of Cordoba, Reina Sofía University Hospital, University of Cordoba (IMIBIC/HURS/UCO), Cordoba, Spain
| | - J Guzmán-Puche
- Unit of Microbiology, Reina Sofía University Hospital, Cordoba, Spain; Maimonides Biomedical Research Institute of Cordoba, Reina Sofía University Hospital, University of Cordoba (IMIBIC/HURS/UCO), Cordoba, Spain
| | - E Pérez-Nadales
- Maimonides Biomedical Research Institute of Cordoba, Reina Sofía University Hospital, University of Cordoba (IMIBIC/HURS/UCO), Cordoba, Spain
| | - I Gracia-Ahufinger
- Unit of Microbiology, Reina Sofía University Hospital, Cordoba, Spain; Maimonides Biomedical Research Institute of Cordoba, Reina Sofía University Hospital, University of Cordoba (IMIBIC/HURS/UCO), Cordoba, Spain
| | - A Mendez
- Maimonides Biomedical Research Institute of Cordoba, Reina Sofía University Hospital, University of Cordoba (IMIBIC/HURS/UCO), Cordoba, Spain
| | - A Cano
- Unit of Infectious Diseases, Reina Sofía University Hospital, Cordoba, Spain
| | - J J Castón
- Unit of Infectious Diseases, Reina Sofía University Hospital, Cordoba, Spain; Maimonides Biomedical Research Institute of Cordoba, Reina Sofía University Hospital, University of Cordoba (IMIBIC/HURS/UCO), Cordoba, Spain
| | - A Domínguez
- Department of Anesthesiology, Resuscitation and Therapeutics of pain, Reina Sofía University Hospital, Cordoba, Spain
| | - J Torre-Cisneros
- Unit of Infectious Diseases, Reina Sofía University Hospital, Cordoba, Spain; Maimonides Biomedical Research Institute of Cordoba, Reina Sofía University Hospital, University of Cordoba (IMIBIC/HURS/UCO), Cordoba, Spain; Department of Medical and Surgical Sciences, University of Cordoba, Cordoba, Spain.
| | - L Martínez-Martínez
- Unit of Microbiology, Reina Sofía University Hospital, Cordoba, Spain; Maimonides Biomedical Research Institute of Cordoba, Reina Sofía University Hospital, University of Cordoba (IMIBIC/HURS/UCO), Cordoba, Spain; Department of Agricultural Chemistry, Soil Science and Microbiology, University of Cordoba, Cordoba, Spain
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11
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The Role of Colistin in the Era of New β-Lactam/β-Lactamase Inhibitor Combinations. Antibiotics (Basel) 2022; 11:antibiotics11020277. [PMID: 35203879 PMCID: PMC8868358 DOI: 10.3390/antibiotics11020277] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/17/2022] [Accepted: 02/17/2022] [Indexed: 02/06/2023] Open
Abstract
With the current crisis related to the emergence of carbapenem-resistant Gram-negative bacteria (CR-GNB), classical treatment approaches with so-called “old-fashion antibiotics” are generally unsatisfactory. Newly approved β-lactam/β-lactamase inhibitors (BLBLIs) should be considered as the first-line treatment options for carbapenem-resistant Enterobacterales (CRE) and carbapenem-resistant Pseudomonas aeruginosa (CRPA) infections. However, colistin can be prescribed for uncomplicated lower urinary tract infections caused by CR-GNB by relying on its pharmacokinetic and pharmacodynamic properties. Similarly, colistin can still be regarded as an alternative therapy for infections caused by carbapenem-resistant Acinetobacter baumannii (CRAB) until new and effective agents are approved. Using colistin in combination regimens (i.e., including at least two in vitro active agents) can be considered in CRAB infections, and CRE infections with high risk of mortality. In conclusion, new BLBLIs have largely replaced colistin for the treatment of CR-GNB infections. Nevertheless, colistin may be needed for the treatment of CRAB infections and in the setting where the new BLBLIs are currently unavailable. In addition, with the advent of rapid diagnostic methods and novel antimicrobials, the application of personalized medicine has gained significant importance in the treatment of CRE infections.
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12
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Paul M, Carrara E, Retamar P, Tängdén T, Bitterman R, Bonomo RA, de Waele J, Daikos GL, Akova M, Harbarth S, Pulcini C, Garnacho-Montero J, Seme K, Tumbarello M, Lindemann PC, Gandra S, Yu Y, Bassetti M, Mouton JW, Tacconelli E, Baño JR. European Society of clinical microbiology and infectious diseases (ESCMID) guidelines for the treatment of infections caused by Multidrug-resistant Gram-negative bacilli (endorsed by ESICM -European Society of intensive care Medicine). Clin Microbiol Infect 2021; 28:521-547. [PMID: 34923128 DOI: 10.1016/j.cmi.2021.11.025] [Citation(s) in RCA: 379] [Impact Index Per Article: 126.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 11/28/2021] [Accepted: 11/29/2021] [Indexed: 12/16/2022]
Abstract
SCOPE These ESCMID guidelines address the targeted antibiotic treatment of 3rd generation cephalosporin-resistant Enterobacterales (3GCephRE) and carbapenem-resistant Gram-negative bacteria, focusing on the effectiveness of individual antibiotics and on combination vs. monotherapy. METHODS An expert panel was convened by ESCMID. A systematic review was performed including randomized controlled trials and observational studies, examining different antibiotic treatment regimens for the targeted treatment of infections caused by the 3GCephRE, carbapenem-resistant Enterobacterales (CRE), carbapenem-resistant Pseudomonas aeruginosa (CRPA) and carbapenem-resistant Acinetobacter baumanni (CRAB). Treatments were classified as head-to-head comparisons between individual antibiotics and monotherapy vs. combination therapy regimens, including defined monotherapy and combination regimens only. The primary outcome was all-cause mortality, preferably at 30 days and secondary outcomes included clinical failure, microbiological failure, development of resistance, relapse/recurrence, adverse events and length of hospital stay. The last search of all databases was conducted in December 2019, followed by a focused search for relevant studies up until ECCMID 2021. Data were summarized narratively. The certainty of the evidence for each comparison between antibiotics and between monotherapy vs. combination therapy regimens was classified by the GRADE recommendations. The strength of the recommendations for or against treatments was classified as strong or conditional (weak). RECOMMENDATIONS The guideline panel reviewed the evidence per pathogen, preferably per site of infection, critically appraising the existing studies. Many of the comparisons were addressed in small observational studies at high risk of bias only. Notably, there was very little evidence on the effects of the new, recently approved, beta-lactam beta-lactamase inhibitors on infections caused by carbapenem-resistant Gram-negative bacteria. Most recommendations are based on very-low and low certainty evidence. A high value was placed on antibiotic stewardship considerations in all recommendations, searching for carbapenem-sparing options for 3GCephRE and limiting the recommendations of the new antibiotics for severe infections, as defined by the sepsis-3 criteria. Research needs are addressed.
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Affiliation(s)
- Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel; Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Elena Carrara
- Division of Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Pilar Retamar
- Departamento de Medicina, Universidad de Sevilla, Sevilla, Spain; Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena/ Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain
| | - Thomas Tängdén
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Roni Bitterman
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel; Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Robert A Bonomo
- Department of Medicine, Pharmacology, Molecular Biology and Microbiology, Biochemistry, Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, OH, USA; Medical Service, Research Service, and GRECC, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH, USA;; VAMC Center for Antimicrobial Resistance and Epidemiology, Cleveland, OH, USA
| | - Jan de Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - George L Daikos
- First Department of Medicine, National and Kapodistrian University of Athens
| | - Murat Akova
- Hacettepe University School of Medicine, Department Of Infectious Diseases, Ankara, Turkey
| | - Stephan Harbarth
- Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Celine Pulcini
- Université de Lorraine, APEMAC, Nancy, France; Université de Lorraine, CHRU-Nancy, Infectious Diseases Department, Nancy, France
| | | | - Katja Seme
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Slovenia
| | - Mario Tumbarello
- Department of Medical Biotechnologies, University of Siena, Italy
| | | | - Sumanth Gandra
- Division of Infectious Diseases, Washington University School of Medicine in St. Louis, Missouri, USA
| | - Yunsong Yu
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Laboratory of Microbial Technology and Bioinformatics of Zhejiang Province, Hangzhou, China; Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Matteo Bassetti
- Department of Health Sciences, University of Genoa, 16132 Genoa, Italy; Clinica Malattie Infettive, San Martino Policlinico Hospital, Genoa, Italy
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | - Evelina Tacconelli
- Division of Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, Verona, Italy; Division of Infectious Diseases, Department of Internal Medicine I, German Center for Infection Research, University of Tübingen, Tübingen, Germany; German Centre for Infection Research (DZIF), Clinical Research Unit for Healthcare Associated Infections, Tübingen, Germany.
| | - Jesus Rodriguez Baño
- Departamento de Medicina, Universidad de Sevilla, Sevilla, Spain; Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena/ Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain
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13
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Moreira NK, Caierão J. Ceftazidime-avibactam: are we safe from class A carbapenemase producers' infections? Folia Microbiol (Praha) 2021; 66:879-896. [PMID: 34505209 DOI: 10.1007/s12223-021-00918-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/29/2021] [Indexed: 01/14/2023]
Abstract
Recently, new combinations of β-lactams and β-lactamase inhibitors became available, including ceftazidime-avibactam, and increased the ability to treat infections caused by carbapenem-resistant Enterobacterales (CRE). Despite the reduced time of clinical use, isolates expressing resistance to ceftazidime-avibactam have been reported, even during treatment or in patients with no previous contact with this drug. Here, we detailed review data on global ceftazidime-avibactam susceptibility, the mechanisms involved in resistance, and the molecular epidemiology of resistant isolates. Ceftazidime-avibactam susceptibility remains high (≥ 98.4%) among Enterobacterales worldwide, being lower among extended-spectrum β-lactamase (ESBL) producers and CRE. Alterations in class A β-lactamases are the major mechanism involved in ceftazidime-avibactam resistance, and mutations are mainly, but not exclusively, located in the Ω loop of these enzymes. Modifications in Klebsiella pneumoniae carbapenemase (KPC) 3 and KPC-2 have been observed by many authors, generating variants with different mutations, insertions, and/or deletions. Among these, the most commonly described is Asp179Tyr, both in KPC-3 (KPC-31 variant) and in KPC-2 (KPC-33 variant). Changes in membrane permeability and overexpression of efflux systems may also be associated with ceftazidime-avibactam resistance. Although several clones have been reported, ST258 with Asp179Tyr deserves special attention. Surveillance studies and rationale use are essential to retaining the activity of this and other antimicrobials against class A CRE.
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Affiliation(s)
- Natália Kehl Moreira
- Programa de Pós-Graduação Em Ciências Farmacêuticas, Faculdade de Farmácia, Universidade Federal Do Rio Grande Do Sul, Avenida Ipiranga, Porto Alegre, RS, 2752, 90610-000, Brazil.
| | - Juliana Caierão
- Programa de Pós-Graduação Em Ciências Farmacêuticas, Faculdade de Farmácia, Universidade Federal Do Rio Grande Do Sul, Avenida Ipiranga, Porto Alegre, RS, 2752, 90610-000, Brazil
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14
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Xu M, Zhao J, Xu L, Yang Q, Xu H, Kong H, Zhou J, Fu Y. Emergence of transferable ceftazidime-avibactam resistance in KPC-producing Klebsiella pneumoniae due to a novel CMY AmpC β-lactamase in China. Clin Microbiol Infect 2021; 28:136.e1-136.e6. [PMID: 34044150 DOI: 10.1016/j.cmi.2021.05.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 05/11/2021] [Accepted: 05/13/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To evaluate the molecular mechanisms of ceftazidime/avibactam (CAZ/AVI) resistance in six Klebsiella pneumoniae strains that co-produce K. pneumoniae carbapenemase (KPC)-2 and a novel variant of CMY cephalosporinase in a Chinese hospital. METHODS Antimicrobial susceptibility was determined by broth microdilution. Whole-genome sequencing (WGS) was performed to investigate potential resistance determinants. Plasmid conjugation, electroporation, S1 nuclease pulsed-field gel electrophoresis (S1-PFGE) hybridization and cloning experiment were carried out to investigate the resistance plasmids and genes. RESULTS A high level of CAZ/AVI resistance was observed in six KPC-Kp strains (MIC 128 mg/L). Five strains were isolated in 2015 and one in 2016, before the approval of CAZ/AVI in China. Sequence analysis indicated that all the strains belonged to sequence type (ST) 11 and uniformly carried a novel CMY AmpC β-lactamase gene, designated blaCMY-172. When compared with CMY-2, CMY-172 has a deletion of three consecutive amino acids (K290, V291 and A292) in the R2-loop region and a non-synonymous amino acid substitution at position 346 (N346I). The blaCMY-172-bearing plasmid, pKPCZA02_4, was 93.3 Kb, IncI1-I type, and conjugative; blaCMY-172 was located in an IS1294-mediated transposon. Plasmid conjugation and DNA fragment cloning proved that blaCMY-172 was responsible for CAZ/AVI resistance. CONCLUSIONS Our study identified conjugative plasmid-mediated blaCMY-172 as a new mechanism for CAZ/AVI resistance in clinical KPC-Kp strains. Careful monitoring of CAZ/AVI susceptibility is imperative for preventing the spread of the resistance gene.
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Affiliation(s)
- Min Xu
- Department of Laboratory Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jun Zhao
- Department of Respiratory Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Li Xu
- Department of Clinical Laboratory, Yangzhou Centre for Disease Control and Prevention, Yangzhou, China
| | - Qing Yang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Centre for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hao Xu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Centre for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Haishen Kong
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Centre for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianying Zhou
- Department of Respiratory Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
| | - Yiqi Fu
- Department of Respiratory Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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15
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Galani I, Karaiskos I, Giamarellou H. Multidrug-resistant Klebsiella pneumoniae: mechanisms of resistance including updated data for novel β-lactam-β-lactamase inhibitor combinations. Expert Rev Anti Infect Ther 2021; 19:1457-1468. [PMID: 33945387 DOI: 10.1080/14787210.2021.1924674] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Multi-drug-resistant Klebsiella pneumoniae is currently one of the most pressing emerging issues in bacterial resistance. Treatment of K.pneumoniae infections is often problematic due to the lack of available therapeutic options, with a relevant impact in terms of morbidity, mortality and healthcare-associated costs. Soon after the launch of Ceftazidime-Avibactam, one of the approved new β-lactam/β-lactamase inhibitor combinations, reports of ceftazidime-avibactam-resistant strains developing resistance during treatment were published. Being a hospital-associated pathogen, K.pneumoniae is continuously exposed to multiple antibiotics resulting in constant selective pressure, which in turn leads to additional mutations that are positively selected.Areas covered: Herein the authors present the K.pneumoniae mechanisms of resistance to different antimicrobials, including updated data for ceftazidime-avibactam.Expert opinion: K.pneumoniae is a nosocomial pathogen commonly implicated in hospital outbreaks with a propensity for antimicrobial resistance toward mainstay β-lactam antibiotics and multiple other antibiotic classes. Following the development of drug resistance and understanding the mechanisms involved, we can improve the efficacy of current antimicrobials, by applying careful stewardship and rational use to preserve their potential utility. The knowledge on antibiotic resistance mechanisms should be used to inform the design of novel therapeutic agents that might not be subject to, or can circumvent, mechanisms of resistance.
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Affiliation(s)
- Irene Galani
- Medicine, Infectious Diseases Laboratory, 4thDepartment of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Ilias Karaiskos
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, Athens, Greece
| | - Helen Giamarellou
- 1 Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, Athens, Greece
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16
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Di Bella S, Giacobbe DR, Maraolo AE, Viaggi V, Luzzati R, Bassetti M, Luzzaro F, Principe L. Resistance to ceftazidime/avibactam in infections and colonisations by KPC-producing Enterobacterales: a systematic review of observational clinical studies. J Glob Antimicrob Resist 2021; 25:268-281. [PMID: 33895414 DOI: 10.1016/j.jgar.2021.04.001] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 03/29/2021] [Accepted: 04/13/2021] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES Ceftazidime/avibactam (CAZ-AVI), approved in 2015, is an important first-line option for Klebsiella pneumoniae carbapenemase-producing Enterobacterales (KPC-E). Although still uncommon, resistance to CAZ-AVI has emerged and may represent a serious cause of concern. METHODS We performed a systematic literature review of clinical and microbiological features of infections and colonisations by CAZ-AVI-resistant KPC-E, focused on the in vivo emergence of CAZ-AVI resistance in different clinical scenarios. RESULTS Twenty-three papers were retrieved accounting for 42 patients and 57 isolates, mostly belonging to K. pneumoniae ST258 harbouring D179Y substitution in the KPC enzyme. The USA, Greece and Italy accounted for 80% of cases. In one-third of isolates resistance was not associated with previous CAZ-AVI exposure. Moreover, 20% of the strains were colistin-resistant and 80% were extended-spectrum β-lactamase (ESBL)-producers. The majority of infected patients had severe underlying diseases (39% cancer, 22% solid-organ transplantation) and 37% died. The abdomen, lung and blood were the most involved infection sites. Infections by CAZ-AVI-resistant strains were mainly treated with combination therapy (85% of cases), with meropenem being the most common (65%) followed by tigecycline (30%), gentamicin (25%), colistin (25%) and fosfomycin (10%). Despite the emergence of resistance, 35% of patients received CAZ-AVI. CONCLUSION Taken together, these data highlight the need for prompt susceptibility testing including CAZ-AVI for Enterobacterales, at least in critical areas. Resistance to CAZ-AVI is an urgent issue to monitor in order to improve both empirical and targeted CAZ-AVI use as well as the management of patients with infections caused by CAZ-AVI-resistant strains.
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Affiliation(s)
- Stefano Di Bella
- Clinical Department of Medical, Surgical and Health Sciences. Trieste University, Trieste, Italy.
| | | | | | - Valentina Viaggi
- Clinical Microbiology and Virology Unit, 'A. Manzoni' Hospital, Lecco, Italy
| | - Roberto Luzzati
- Clinical Department of Medical, Surgical and Health Sciences. Trieste University, Trieste, Italy
| | - Matteo Bassetti
- Clinica Malattie Infettive, Ospedale Policlinico San Martino IRCCS, Genoa, Italy; Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Francesco Luzzaro
- Clinical Microbiology and Virology Unit, 'A. Manzoni' Hospital, Lecco, Italy
| | - Luigi Principe
- Clinical Microbiology and Virology Unit, 'A. Manzoni' Hospital, Lecco, Italy
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17
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Papp-Wallace KM, Mack AR, Taracila MA, Bonomo RA. Resistance to Novel β-Lactam-β-Lactamase Inhibitor Combinations: The "Price of Progress". Infect Dis Clin North Am 2020; 34:773-819. [PMID: 33011051 DOI: 10.1016/j.idc.2020.05.001] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Significant advances were made in antibiotic development during the past 5 years. Novel agents were added to the arsenal that target critical priority pathogens, including multidrug-resistant Pseudomonas aeruginosa and carbapenem-resistant Enterobacterales. Of these, 4 novel β-lactam-β-lactamase inhibitor combinations (ceftolozane-tazobactam, ceftazidime-avibactam, meropenem-vaborbactam, and imipenem-cilastatin-relebactam) reached clinical approval in the United States. With these additions comes a significant responsibility to reduce the possibility of emergence of resistance. Reports in the rise of resistance toward ceftolozane-tazobactam and ceftazidime-avibactam are alarming. Clinicians and scientists must make every attempt to reverse or halt these setbacks.
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Affiliation(s)
- Krisztina M Papp-Wallace
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs, 151W, 10701 East Boulevard, Cleveland, OH 44106, USA.
| | - Andrew R Mack
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs, 151W, 10701 East Boulevard, Cleveland, OH 44106, USA
| | - Magdalena A Taracila
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs, 151W, 10701 East Boulevard, Cleveland, OH 44106, USA
| | - Robert A Bonomo
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs, 151W, 10701 East Boulevard, Cleveland, OH 44106, USA.
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18
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Abstract
PURPOSE OF REVIEW To describe current antimicrobial resistance in ESKAPE Gram-negative microorganisms and their situation in the ICUs, the implication of the so-called high-risk clones (HiRCs) involved in the spread of antimicrobial resistance as well as relevance of the COVID-19 pandemic in the potential increase of resistance. RECENT FINDINGS Extended-spectrum and carbapenemase producing Enterobacterales and multidrug and extensive drug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii have increased worldwide. Sequence type (ST)131 Escherichia coli, ST258, ST11, ST10, ST147 and ST307 Klebsiella pneumoniae, ST111, ST175, ST235 and ST244 P. aeruginosa HiRCs are responsible for this increase in the ICUs, and some of them are implicated in the emergence of resistance mechanisms affecting new antimicrobials. A similar situation can be found with European clonal complex 1 and clonal complex 2 of A. baumannii. The high use of antimicrobials during the COVID-19 pandemic, particularly in ICUs, might have a negative influence in future trends of antimicrobial resistance. SUMMARY The increase of antimicrobial resistance in ICUs is mainly due to the spread of HiRCs and is exemplified with the ESKAPE Gram-negative microorganisms. The COVID-19 pandemic might have a negative impact in the increase of antimicrobial resistance and should be monitored through specific surveillance studies in ICUs.
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Nafplioti K, Souli M, Adamou P, Moraitou E, Giannopoulou P, Chra P, Damala M, Vogiatzakis E, Trikka-Graphakos E, Baka V, Prifti E, Antoniadou A, Galani I. Characterization of 16S rRNA methylase genes in Enterobacterales and Pseudomonas aeruginosa in Athens Metropolitan area, 2015-2016. Eur J Clin Microbiol Infect Dis 2020; 40:111-121. [PMID: 32794063 DOI: 10.1007/s10096-020-04006-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/31/2020] [Indexed: 10/23/2022]
Abstract
The aim of this study was to characterize the 16S rRNA methylase (RMT) genes in aminoglycoside-resistant Enterobacterales and Pseudomonas aeruginosa isolates in 2015-2016 in hospitals in Athens, Greece. Single-patient, Gram-negative clinical isolates resistant to both amikacin and gentamicin (n = 292) were consecutively collected during a two-year period (2015-2016) in five tertiary care hospitals in Athens. RMT genes were detected by PCR. In all RMT-producing isolates, ESBL and carbapenemase production was confirmed by PCR, and the clonal relatedness and the plasmid contents were also characterized. None of the 138 P. aeruginosa isolates harbored any of the RMT genes surveyed although some were highly resistant to aminoglycosides (MICs > = 512 mg/L). Among 154 Enterobacterales, 31 Providencia stuartii (93.9%), 42 Klebsiella pneumoniae (37.8%), six Proteus mirabilis (75%), and two Escherichia coli (100%) isolates were confirmed as highly resistant to amikacin, gentamicin, and tobramycin with MICs ≥ 512 mg/L, harboring mainly the rmtB (98.8%). All were carbapenemase producers. P. stuartii, P. mirabilis, and E. coli produced VIM-type carbapenemases. K. pneumoniae produced KPC- (n = 34, 81.0%), OXA-48 (n = 4, 9.5%), KPC- and VIM- (n = 3, 7.1%), or only VIM-type (n = 1, 2.4%) enzymes. Two groups of similar IncC plasmids were detected one harboring rmtB1, blaVEB-1, blaOXA-10, and blaTEM-1, and the other additionally blaVIM-1 and blaSHV-5. Among RMT-producing Enterobacterales, rmtB1 predominated and was associated with carbapenemase-encoding gene(s). Similar IncC plasmids carrying a multiresistant region, including ESBL genes, and in the case of VIM-producing isolates, the blaVIM-1, were responsible for this dissemination. The co-dissemination of these genes poses a public health threat.
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Affiliation(s)
- Konstantina Nafplioti
- 4th Department of Internal Medicine, Infectious Diseases Laboratory, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Maria Souli
- 4th Department of Internal Medicine, Infectious Diseases Laboratory, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Panagiota Adamou
- 4th Department of Internal Medicine, Infectious Diseases Laboratory, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Eleni Moraitou
- Department of Clinical Microbiology, Sotiria General Hospital of Chest Diseases, Athens, Greece
| | | | - Paraskevi Chra
- Microbiology Department, Korgialenio Benakio Hellenic Red Cross Hospital, Athens, Greece
| | - Maria Damala
- Microbiology Department, "Alexandra" General Hospital of Athens, Athens, Greece
| | - Evangelos Vogiatzakis
- Department of Clinical Microbiology, Sotiria General Hospital of Chest Diseases, Athens, Greece
| | | | - Vasiliki Baka
- Microbiology Department, Korgialenio Benakio Hellenic Red Cross Hospital, Athens, Greece
| | - Eleni Prifti
- Microbiology Department, "Alexandra" General Hospital of Athens, Athens, Greece
| | - Anastasia Antoniadou
- 4th Department of Internal Medicine, Infectious Diseases Laboratory, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Irene Galani
- 4th Department of Internal Medicine, Infectious Diseases Laboratory, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece. .,University General Hospital "ATTIKON", Rimini 1, 124 62, Chaidari, Greece.
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Galani I, Karaiskos I, Souli M, Papoutsaki V, Galani L, Gkoufa A, Antoniadou A, Giamarellou H. Outbreak of KPC-2-producing Klebsiella pneumoniae endowed with ceftazidime-avibactam resistance mediated through a VEB-1-mutant (VEB-25), Greece, September to October 2019. ACTA ACUST UNITED AC 2020; 25. [PMID: 31992391 PMCID: PMC6988274 DOI: 10.2807/1560-7917.es.2020.25.3.2000028] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
From September to October 2019, seven patients colonised or infected with a ceftazidime-avibactam (CZA)-resistant Klebsiella pneumoniae carbapenemase (KPC)-2-producing K. pneumoniae were detected in two intensive care units of a Greek general hospital. The outbreak strain was sequence type (ST)147 and co-produced KPC-2 and the novel plasmid-borne Vietnamese extended-spectrum β-lactamase (VEB)-25 harbouring a K234R substitution associated with CZA resistance. Epidemiological investigations revealed that the resistance was probably acquired by horizontal transmission independently from previous CZA exposure.
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Affiliation(s)
- Irene Galani
- Infectious Diseases Laboratory, 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Ilias Karaiskos
- 1st Internal Medicine & Infectious Diseases Department, Hygeia General Hospital, Athens, Greece
| | - Maria Souli
- Infectious Diseases Laboratory, 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Lamprini Galani
- 1st Internal Medicine & Infectious Diseases Department, Hygeia General Hospital, Athens, Greece
| | - Aikaterini Gkoufa
- 1st Internal Medicine & Infectious Diseases Department, Hygeia General Hospital, Athens, Greece
| | - Anastasia Antoniadou
- Infectious Diseases Laboratory, 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Helen Giamarellou
- 1st Internal Medicine & Infectious Diseases Department, Hygeia General Hospital, Athens, Greece
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