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Lei TY, Liao BB, Yang LR, Wang Y, Chen XB. Hypervirulent and carbapenem-resistant Klebsiella pneumoniae: A global public health threat. Microbiol Res 2024; 288:127839. [PMID: 39141971 DOI: 10.1016/j.micres.2024.127839] [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: 06/06/2024] [Revised: 07/08/2024] [Accepted: 07/13/2024] [Indexed: 08/16/2024]
Abstract
The evolution of hypervirulent and carbapenem-resistant Klebsiella pneumoniae can be categorized into three main patterns: the evolution of KL1/KL2-hvKp strains into CR-hvKp, the evolution of carbapenem-resistant K. pneumoniae (CRKp) strains into hv-CRKp, and the acquisition of hybrid plasmids carrying carbapenem resistance and virulence genes by classical K. pneumoniae (cKp). These strains are characterized by multi-drug resistance, high virulence, and high infectivity. Currently, there are no effective methods for treating and surveillance this pathogen. In addition, the continuous horizontal transfer and clonal spread of these bacteria under the pressure of hospital antibiotics have led to the emergence of more drug-resistant strains. This review discusses the evolution and distribution characteristics of hypervirulent and carbapenem-resistant K. pneumoniae, the mechanisms of carbapenem resistance and hypervirulence, risk factors for susceptibility, infection syndromes, treatment regimens, real-time surveillance and preventive control measures. It also outlines the resistance mechanisms of antimicrobial drugs used to treat this pathogen, providing insights for developing new drugs, combination therapies, and a "One Health" approach. Narrowing the scope of surveillance but intensifying implementation efforts is a viable solution. Monitoring of strains can be focused primarily on hospitals and urban wastewater treatment plants.
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Affiliation(s)
- Ting-Yu Lei
- College of Pharmaceutical Science, Dali University, Dali 671000, China.
| | - Bin-Bin Liao
- College of Pharmaceutical Science, Dali University, Dali 671000, China.
| | - Liang-Rui Yang
- First Affiliated Hospital of Dali University, Yunnan 671000, China.
| | - Ying Wang
- College of Pharmaceutical Science, Dali University, Dali 671000, China.
| | - Xu-Bing Chen
- College of Pharmaceutical Science, Dali University, Dali 671000, China.
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2
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El Naggar NM, Shawky RM, Serry FME, Emara M. Investigating the relationship between carbapenemase production and biofilm formation in Klebsiella pneumoniae clinical isolates. BMC Res Notes 2024; 17:49. [PMID: 38360658 PMCID: PMC10870607 DOI: 10.1186/s13104-024-06708-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 01/26/2024] [Indexed: 02/17/2024] Open
Abstract
OBJECTIVE Carbapenemase production and biofilm formation in K. pneumoniae are crucial factors influencing the pathogenicity and antibiotic resistance of this bacterium. This study investigated the interplay between carbapenemase production and biofilm formation in K. pneumoniae clinical isolates. RESULTS The distribution of biofilm-forming ability significantly differed between carbapenemase-producing (CP-Kp) (n = 52) isolates and carbapenemase-nonproducing (CN-Kp) isolates (n = 37), suggesting a potential link between carbapenemase production and biofilm formation. All the blaNDM-1-harbouring isolates demonstrated biofilm formation, with varying levels classified as strong (33.33%), moderate (22.22%), or weak (44.45%). blaNDM-1 and blaKPC-coharbouring isolates did not exhibit strong or moderate biofilm formation. blaNDM-1 and blaOXA-48-coharbouring isolates were predominantly moderate (48.65%), followed by weak (32.43%), with none showing strong biofilm production. These findings suggest a correlation between the presence of carbapenemases and biofilm-forming ability; however, the heterogeneity in biofilm-forming abilities associated with different carbapenemase types and the absence of strong biofilm producers in the detected carbapenemase combinations prompt a closer look at the complex regulatory mechanisms governing biofilm formation in CP-Kp isolates.
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Affiliation(s)
- Nora M El Naggar
- Faculty of Pharmacy, Department of Microbiology and Immunology, Helwan University, POX 11795, Ain Helwan, Cairo, Egypt
| | - Riham M Shawky
- Faculty of Pharmacy, Department of Microbiology and Immunology, Helwan University, POX 11795, Ain Helwan, Cairo, Egypt
| | - Fathy M E Serry
- Faculty of Pharmacy, Department of Pharmaceutical Microbiology, Zagazig University, Zagazig, Egypt
| | - Mohamed Emara
- Faculty of Pharmacy, Department of Microbiology and Immunology, Helwan University, POX 11795, Ain Helwan, Cairo, Egypt.
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3
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Truglio M, Sivori F, Cavallo I, Abril E, Licursi V, Fabrizio G, Cardinali G, Pignatti M, Toma L, Valensise F, Cristaudo A, Pimpinelli F, Di Domenico EG. Modulating the skin mycobiome-bacteriome and treating seborrheic dermatitis with a probiotic-enriched oily suspension. Sci Rep 2024; 14:2722. [PMID: 38302693 PMCID: PMC10834955 DOI: 10.1038/s41598-024-53016-0] [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: 10/19/2023] [Accepted: 01/25/2024] [Indexed: 02/03/2024] Open
Abstract
Seborrheic dermatitis (SD) affects 2-5% of the global population, with imbalances in the skin microbiome implicated in its development. This study assessed the impact of an oily suspension containing Lactobacillus crispatus P17631 and Lacticaseibacillus paracasei I1688 (termed EUTOPLAC) on SD symptoms and the skin mycobiome-bacteriome modulation. 25 SD patients were treated with EUTOPLAC for a week. Symptom severity and skin mycobiome-bacteriome changes were measured at the start of the treatment (T0), after seven days (T8), and three weeks post-treatment (T28). Results indicated symptom improvement post-EUTOPLAC, with notable reductions in the Malassezia genus. Concurrently, bacterial shifts were observed, including a decrease in Staphylococcus and an increase in Lactobacillus and Lacticaseibacillus. Network analysis highlighted post-EUTOPLAC instability in fungal and bacterial interactions, with increased negative correlations between Malassezia and Lactobacillus and Lacticaseibacillus genera. The study suggests EUTOPLAC's potential as a targeted SD treatment, reducing symptoms and modulating the mycobiome-bacteriome composition.
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Affiliation(s)
- Mauro Truglio
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, 00144, Rome, Italy
| | - Francesca Sivori
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, 00144, Rome, Italy
| | - Ilaria Cavallo
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, 00144, Rome, Italy
| | - Elva Abril
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, 00144, Rome, Italy
| | - Valerio Licursi
- Institute of Molecular Biology and Pathology, National Research Council of Italy, 00185, Rome, Italy
| | - Giorgia Fabrizio
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, 00144, Rome, Italy
- Department of Biology and Biotechnology C. Darwin, Sapienza University of Rome, 00185, Rome, Italy
| | - Giorgia Cardinali
- Cutaneous Physiopathology, San Gallicano Dermatological Institute, IRCCS, 00144, Rome, Italy
| | | | - Luigi Toma
- Medical Directorate, IRCCS Regina Elena National Cancer Institute, 00144, Rome, Italy
| | - Floriana Valensise
- Clinical Dermatology, San Gallicano Dermatological Institute, IRCCS, 00144, Rome, Italy
| | - Antonio Cristaudo
- Clinical Dermatology, San Gallicano Dermatological Institute, IRCCS, 00144, Rome, Italy
| | - Fulvia Pimpinelli
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, 00144, Rome, Italy.
| | - Enea Gino Di Domenico
- Department of Biology and Biotechnology C. Darwin, Sapienza University of Rome, 00185, Rome, Italy.
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4
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Aghamohammad S, Khazani Asforooshani M, Malek Mohammadi Y, Sholeh M, Badmasti F. Decoding the genetic structure of conjugative plasmids in international clones of Klebsiella pneumoniae: A deep dive into blaKPC, blaNDM, blaOXA-48, and blaGES genes. PLoS One 2023; 18:e0292288. [PMID: 37971980 PMCID: PMC10653425 DOI: 10.1371/journal.pone.0292288] [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: 06/20/2023] [Accepted: 09/17/2023] [Indexed: 11/19/2023] Open
Abstract
Carbapanem-resistant Klebsiella pneumoniae is a globally healthcare crisis. The distribution of plasmids carrying carbapenemase genes among K. pneumoniae poses a serious threat in clinical settings. Here, we characterized the genetic structure of plasmids harboring major carbapenemases (e.g. blaKPC, blaNDM, blaOXA-48-like, and blaGES) from K. pneumoniae using bioinformatics tools. The plasmids carrying at least one major carbapenemase gene were retrieved from the GenBank database. The DNA length, Inc type, and conjugal apparatus of these plasmids were detected. Additionally, allele types, co-existence, co-occurrence of carbapenemase genes, gene repetition, and sequence types of isolates, were characterized. There were 2254 plasmids harboring carbapenemase genes in the database. This study revealed that blaKPC-2, blaNDM-1, blaOXA-48, and blaGES-5 were the most prevalent allele types. Out of 1140 (50%) plasmids were potentially conjugative. IncFII, IncR, IncX3, and IncL replicon types were predominant. The co-existence analysis revealed that the most prevalent of other resistance genes were blaTEM-1 (related to blaKPC), blaOXA-232 (related to blaOXA-48), bleMBL (related to blaNDM), and aac (6')-Ib4 (related to blaGES). The co-occurrence of carbapenemases was detected in 42 plasmids while 15 plasmids contained carbapenemase gene repetitions. Sequence alignments highlighted that plasmids carrying blaKPC and blaOXA-48-like were more homogeneous whereas the plasmids carrying blaNDM were divergent. It seems that K. pneumoniae utilizes diversity of genetic flexibility and recombination for resistance against carbapenems. The genetic structure of the plasmids showed that class I and III, Tn3 family, Tn5403 family derivatives, and Tn7-like elements were strongly associated with carbapenemases. The mobilizable plasmids carrying carbapenemases play an important role in the spread of these genes. In addition, gene repetition maybe is related to carbapenem heteroresistance. According to MST (minimum spanning tree) results, the majority of plasmids belonged to sequence type (ST) 11, ST14, and ST12. These international clones have a high capacity to acquire the carbapenemase-containing plasmids.
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Affiliation(s)
| | - Mahshid Khazani Asforooshani
- Department of Bacteriology, Pasteur Institute of Iran, Tehran, Iran
- Department of Microbiology, Faculty of Biological Sciences, Alzahra University, Tehran, Iran
| | | | - Mohammad Sholeh
- Department of Bacteriology, Pasteur Institute of Iran, Tehran, Iran
| | - Farzad Badmasti
- Department of Bacteriology, Pasteur Institute of Iran, Tehran, Iran
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Pu D, Zhao J, Chang K, Zhuo X, Cao B. "Superbugs" with hypervirulence and carbapenem resistance in Klebsiella pneumoniae: the rise of such emerging nosocomial pathogens in China. Sci Bull (Beijing) 2023; 68:2658-2670. [PMID: 37821268 DOI: 10.1016/j.scib.2023.09.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/19/2023] [Accepted: 09/26/2023] [Indexed: 10/13/2023]
Abstract
Although hypervirulent Klebsiella pneumoniae (hvKP) can produce community-acquired infections that are fatal in young and adult hosts, such as pyogenic liver abscess, endophthalmitis, and meningitis, it has historically been susceptible to antibiotics. Carbapenem-resistant K. pneumoniae (CRKP) is usually associated with urinary tract infections acquired in hospitals, pneumonia, septicemias, and soft tissue infections. Outbreaks and quick spread of CRKP in hospitals have become a major challenge in public health due to the lack of effective antibacterial treatments. In the early stages of K. pneumoniae development, HvKP and CRKP first appear as distinct routes. However, the lines dividing the two pathotypes are vanishing currently, and the advent of carbapenem-resistant hypervirulent K. pneumoniae (CR-hvKP) is devastating as it is simultaneously multidrug-resistant, hypervirulent, and highly transmissible. Most CR-hvKP cases have been reported in Asian clinical settings, particularly in China. Typically, CR-hvKP develops when hvKP or CRKP acquires plasmids that carry either the carbapenem-resistance gene or the virulence gene. Alternatively, classic K. pneumoniae (cKP) may acquire a hybrid plasmid carrying both genes. In this review, we provide an overview of the key antimicrobial resistance mechanisms, virulence factors, clinical presentations, and outcomes associated with CR-hvKP infection. Additionally, we discuss the possible evolutionary processes and prevalence of CR-hvKP in China. Given the wide occurrence of CR-hvKP, continued surveillance and control measures of such organisms should be assigned a higher priority.
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Affiliation(s)
- Danni Pu
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100730, China; Laboratory of Clinical Microbiology and Infectious Diseases, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing 100029, China; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing 100029, China
| | - Jiankang Zhao
- Laboratory of Clinical Microbiology and Infectious Diseases, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing 100029, China; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing 100029, China
| | - Kang Chang
- Laboratory of Clinical Microbiology and Infectious Diseases, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing 100029, China; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing 100029, China
| | - Xianxia Zhuo
- Laboratory of Clinical Microbiology and Infectious Diseases, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing 100029, China; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing 100029, China; Department of Pulmonary and Critical Care Medicine, Capital Medical University, Beijing 100069, China
| | - Bin Cao
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100730, China; Laboratory of Clinical Microbiology and Infectious Diseases, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing 100029, China; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing 100029, China; Department of Pulmonary and Critical Care Medicine, Capital Medical University, Beijing 100069, China; Tsinghua University-Peking University Joint Center for Life Sciences, Beijing 100084, China.
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6
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Li L, Li S, Wei X, Lu Z, Qin X, Li M. Infection with Carbapenem-resistant Hypervirulent Klebsiella Pneumoniae: clinical, virulence and molecular epidemiological characteristics. Antimicrob Resist Infect Control 2023; 12:124. [PMID: 37953357 PMCID: PMC10642049 DOI: 10.1186/s13756-023-01331-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 11/05/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND Carbapenem-resistant hypervirulent Klebsiella pneumoniae (CR-hvKP) is gradually becoming the dominant nosocomial pathogens in the healthcare setting. METHODS A retrospective study was conducted on patients with CR-KP from July 2021 to May 2022 in a teaching hospital. We identified bacterial isolates, collected the clinical data, and performed antimicrobial susceptibility testing, hypermucoviscosity string test, antimicrobial and virulence-associated genotype, as well as multi-locus sequence typing. CR-hvKP was defined as the presence of some combination of rmpA and/or rmpA2 with iucA, iroB, or peg-344. SPSS was used for data analysis. Univariate logistic regression analyses were used for risk factor and all statistically significant variables were included in the multivariate model. Statistical significance was taken to be P < 0.05. RESULTS A total of 69 non-duplicated CR-KP isolates were collected, 27 of which were CR-hvKP. Out of the 69 CR-KP strains under investigation, they were distributed across 14 distinct sequence types (STs), wherein ST11 exhibited the highest prevalence, constituting 65.2% (45/69) of the overall isolates. The principal carbapenemase genes identified encompassed blakpc-2, blaNDM-1, and blaOXA-48, with blakpc-2 prevailing as the predominant type, accounting for 73.9% (51/69). A total of 69 CR-KP strains showed high resistance to common clinical antibiotics, with the exception of ceftazidime/avibactam. The ST11 (P = 0.040), ST65 (P = 0.030) and blakpc-2 ST11 clones (P = 0.010) were found to be highly related to hvKp. Regarding the host, tracheal intubation (P = 0.008), intracranial infection (P = 0.020) and neutrophil count (P = 0.049) were significantly higher in the patients with CR-hvKP. Multivariate analysis showed tracheal intubation to be an independent risk factor for CR-hvKP infection (P = 0.030, OR = 4.131). According to the clinical data we collected, tracheal intubation was performed mainly in the elderly with severe underlying diseases, which implied that CR-hvKP has become prevalent among elderly patients with comorbidities. CONCLUSIONS The prevalence of CR-hvKP may be higher than expected in the healthcare setting. CR-hvKP is gradually becoming the dominant nosocomial pathogen, and its prevalence and treatment will be a major challenge. It is essential to enhance clinical awareness and management of CR-hvKP infection.
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Affiliation(s)
- Linlin Li
- Key Laboratory of Clinical Laboratory Medicine of Guangxi Department of Education, Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Shan Li
- Key Laboratory of Clinical Laboratory Medicine of Guangxi Department of Education, Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xianzhen Wei
- Key Laboratory of Clinical Laboratory Medicine of Guangxi Department of Education, Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Zhaolu Lu
- Key Laboratory of Clinical Laboratory Medicine of Guangxi Department of Education, Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xue Qin
- Key Laboratory of Clinical Laboratory Medicine of Guangxi Department of Education, Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Meng Li
- Key Laboratory of Clinical Laboratory Medicine of Guangxi Department of Education, Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, China.
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Cavallo I, Oliva A, Pages R, Sivori F, Truglio M, Fabrizio G, Pasqua M, Pimpinelli F, Di Domenico EG. Acinetobacter baumannii in the critically ill: complex infections get complicated. Front Microbiol 2023; 14:1196774. [PMID: 37425994 PMCID: PMC10325864 DOI: 10.3389/fmicb.2023.1196774] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/05/2023] [Indexed: 07/11/2023] Open
Abstract
Acinetobacter baumannii is increasingly associated with various epidemics, representing a serious concern due to the broad level of antimicrobial resistance and clinical manifestations. During the last decades, A. baumannii has emerged as a major pathogen in vulnerable and critically ill patients. Bacteremia, pneumonia, urinary tract, and skin and soft tissue infections are the most common presentations of A. baumannii, with attributable mortality rates approaching 35%. Carbapenems have been considered the first choice to treat A. baumannii infections. However, due to the widespread prevalence of carbapenem-resistant A. baumannii (CRAB), colistin represents the main therapeutic option, while the role of the new siderophore cephalosporin cefiderocol still needs to be ascertained. Furthermore, high clinical failure rates have been reported for colistin monotherapy when used to treat CRAB infections. Thus, the most effective antibiotic combination remains disputed. In addition to its ability to develop antibiotic resistance, A. baumannii is also known to form biofilm on medical devices, including central venous catheters or endotracheal tubes. Thus, the worrisome spread of biofilm-producing strains in multidrug-resistant populations of A. baumannii poses a significant treatment challenge. This review provides an updated account of antimicrobial resistance patterns and biofilm-mediated tolerance in A. baumannii infections with a special focus on fragile and critically ill patients.
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Affiliation(s)
- Ilaria Cavallo
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - Alessandra Oliva
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Rebecca Pages
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - Francesca Sivori
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - Mauro Truglio
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - Giorgia Fabrizio
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - Martina Pasqua
- Department of Biology and Biotechnology "C. Darwin" Sapienza University of Rome, Rome, Italy
| | - Fulvia Pimpinelli
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - Enea Gino Di Domenico
- Department of Biology and Biotechnology "C. Darwin" Sapienza University of Rome, Rome, Italy
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8
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Danielsen AS, Franconeri L, Page S, Myhre AE, Tornes RA, Kacelnik O, Bjørnholt JV. Clinical outcomes of antimicrobial resistance in cancer patients: a systematic review of multivariable models. BMC Infect Dis 2023; 23:247. [PMID: 37072711 PMCID: PMC10114324 DOI: 10.1186/s12879-023-08182-3] [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: 07/27/2022] [Accepted: 03/17/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Infections are major causes of disease in cancer patients and pose a major obstacle to the success of cancer care. The global rise of antimicrobial resistance threatens to make these obstacles even greater and hinder continuing progress in cancer care. To prevent and handle such infections, better models of clinical outcomes building on current knowledge are needed. This internally funded systematic review (PROSPERO registration: CRD42021282769) aimed to review multivariable models of resistant infections/colonisations and corresponding mortality, what risk factors have been investigated, and with what methodological approaches. METHODS We employed two broad searches of antimicrobial resistance in cancer patients, using terms associated with antimicrobial resistance, in MEDLINE and Embase through Ovid, in addition to Cinahl through EBSCOhost and Web of Science Core Collection. Primary, observational studies in English from January 2015 to November 2021 on human cancer patients that explicitly modelled infection/colonisation or mortality associated with antimicrobial resistance in a multivariable model were included. We extracted data on the study populations and their malignancies, risk factors, microbial aetiology, and methods for variable selection, and assessed the risk of bias using the NHLBI Study Quality Assessment Tools. RESULTS Two searches yielded a total of 27,151 unique records, of which 144 studies were included after screening and reading. Of the outcomes studied, mortality was the most common (68/144, 47%). Forty-five per cent (65/144) of the studies focused on haemato-oncological patients, and 27% (39/144) studied several bacteria or fungi. Studies included a median of 200 patients and 46 events. One-hundred-and-three (72%) studies used a p-value-based variable selection. Studies included a median of seven variables in the final (and largest) model, which yielded a median of 7 events per variable. An in-depth example of vancomycin-resistant enterococci was reported. CONCLUSIONS We found the current research to be heterogeneous in the approaches to studying this topic. Methodological choices resulting in very diverse models made it difficult or even impossible to draw statistical inferences and summarise what risk factors were of clinical relevance. The development and adherence to more standardised protocols that build on existing literature are urgent.
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Affiliation(s)
- Anders Skyrud Danielsen
- Department of Microbiology, Oslo University Hospital, Oslo, Norway.
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Léa Franconeri
- Department of Infection Control and Preparedness, Norwegian Institute of Public Health, Oslo, Norway
- ECDC Fellowship Programme, Field Epidemiology Path (EPIET), European Centre for Disease Prevention and Control, (ECDC), Stockholm, Sweden
| | - Samantha Page
- Department of Infection Control and Preparedness, Norwegian Institute of Public Health, Oslo, Norway
| | | | - Ragnhild Agathe Tornes
- The Library for the Healthcare Administration, Norwegian Institute of Public Health, Oslo, Norway
| | - Oliver Kacelnik
- Department of Infection Control and Preparedness, Norwegian Institute of Public Health, Oslo, Norway
| | - Jørgen Vildershøj Bjørnholt
- Department of Microbiology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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9
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Miuțescu B, Vuletici D, Burciu C, Turcu-Stiolica A, Bende F, Rațiu I, Moga T, Sabuni O, Anjary A, Dalati S, Ungureanu BS, Gadour E, Horhat FG, Popescu A. Identification of Microbial Species and Analysis of Antimicrobial Resistance Patterns in Acute Cholangitis Patients with Malignant and Benign Biliary Obstructions: A Comparative Study. Medicina (B Aires) 2023; 59:medicina59040721. [PMID: 37109679 PMCID: PMC10141179 DOI: 10.3390/medicina59040721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/29/2023] [Accepted: 04/03/2023] [Indexed: 04/08/2023] Open
Abstract
Background and Objectives: Acute cholangitis (AC) is still lethal if not treated promptly and effectively. Biliary drainage, also known as source control, has been acknowledged as the backbone treatment for patients with AC; nonetheless, antimicrobial therapy allows these patients to undergo non-emergent drainage procedures. This retrospective study aims to observe the bacterial species involved in AC and analyze the antimicrobial resistance patterns. Materials and Methods: Data were collected for four years, comparing patients with benign and malignant bile duct obstruction as an etiology for AC. A total of 262 patients were included in the study, with 124 cases of malignant obstruction and 138 cases of benign obstruction. Results: Positive bile culture was obtained in 192 (73.3%) patients with AC, with a higher rate among the benign group compared with malignant etiologies (55.7%.vs 44.3%). There was no significant difference between the Tokyo severity scores in the two study groups, identifying 34.7% cases of malignant obstruction with Tokyo Grade 1 (TG1) and 43.5% cases of TG1 among patients with benign obstruction. Similarly, there were no significant differences between the number of bacteria types identified in bile, most of them being monobacterial infections (19% in the TG1 group, 17% in the TG2 group, and 10% in the TG3 group). The most commonly identified microorganism in blood and bile cultures among both study groups was E. coli (46.7%), followed by Klebsiella spp. (36.0%) and Pseudomonas spp. (8.0%). Regarding antimicrobial resistance, it was observed that significantly more patients with malignant bile duct obstruction had a higher percentage of bacterial resistance for cefepime (33.3% vs. 11.7%, p-value = 0.0003), ceftazidime (36.5% vs. 14.5%, p-value = 0.0006), meropenem (15.4% vs. 3.6%, p-value = 0.0047), and imipenem (20.2% vs. 2.6%, p-value < 0.0001). Conclusions: The positive rate of biliary cultures is higher among patients with benign biliary obstruction, while the malignant etiology correlates with increased resistance to cefepime, ceftazidime, meropenem, and imipenem.
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Affiliation(s)
- Bogdan Miuțescu
- Department of Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
- Advanced Regional Research Center in Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy, 30041 Timisoara, Romania
| | - Deiana Vuletici
- Department of Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
- Advanced Regional Research Center in Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy, 30041 Timisoara, Romania
| | - Călin Burciu
- Department of Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
- Advanced Regional Research Center in Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy, 30041 Timisoara, Romania
| | - Adina Turcu-Stiolica
- Department of Pharmacoeconomics, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Felix Bende
- Department of Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
- Advanced Regional Research Center in Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy, 30041 Timisoara, Romania
| | - Iulia Rațiu
- Department of Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
- Advanced Regional Research Center in Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy, 30041 Timisoara, Romania
| | - Tudor Moga
- Department of Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
- Advanced Regional Research Center in Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy, 30041 Timisoara, Romania
| | - Omar Sabuni
- Faculty of General Medicine, Altinbas University, Dilmenler Cd., 34217 Istanbul, Turkey
| | - Adnan Anjary
- Faculty of General Medicine, Yeditepe University, Kayısdagı Cd., 34755 Istanbul, Turkey
| | - Sami Dalati
- Faculty of General Medicine, Baskent University, Fatih Sultan, 06790 Ankara, Turkey
| | - Bogdan Silviu Ungureanu
- Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Eyad Gadour
- Department of Gastroenterology, King Abdulaziz Hospital-National Guard Health Affairs, Al Ahsa 31982, Saudi Arabia
- Department of Medicine, Zamzam University College, Khartoum 11113, Sudan
| | - Florin George Horhat
- Multidisciplinary Research Center on Antimicrobial Resistance (MULTI-REZ), Microbiology Department, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Alina Popescu
- Department of Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
- Advanced Regional Research Center in Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy, 30041 Timisoara, Romania
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Mohammadi M, Saffari M, Siadat SD, Hejazi SH, Shayestehpour M, Motallebi M, Eidi M. Isolation, characterization, therapeutic potency, and genomic analysis of a novel bacteriophage vB_KshKPC-M against carbapenemase-producing Klebsiella pneumoniae strains (CRKP) isolated from Ventilator-associated pneumoniae (VAP) infection of COVID-19 patients. Ann Clin Microbiol Antimicrob 2023; 22:18. [PMID: 36829156 PMCID: PMC9955523 DOI: 10.1186/s12941-023-00567-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/15/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND Carbapenem-resistant Klebsiella pneumoniae (CRKP) is a significant clinical problem, given the lack of therapeutic options. The CRKP strains have emerged as an essential worldwide healthcare issue during the last 10 years. Global expansion of the CRKP has made it a significant public health hazard. We must consider to novel therapeutic techniques. Bacteriophages are potent restorative cases against infections with multiple drug-resistant bacteria. The Phages offer promising prospects for the treatment of CRKP infections. OBJECTIVE In this study, a novel K. pneumoniae phage vB_KshKPC-M was isolated, characterized, and sequenced, which was able to infect and lyse Carbapenem-resistant K. pneumoniae host specifically. METHODS One hundred clinical isolates of K. pneumoniae were collected from patients with COVID-19 associated with ventilator-associated acute pneumonia hospitalized at Shahid Beheshti Hospital, Kashan, Iran, from 2020 to 2021. Initially, all samples were cultured, and bacterial isolates identified by conventional biochemical tests, and then the ureD gene was used by PCR to confirm the isolates. The Antibiotic susceptibility test in the disc diffusion method and Minimum inhibitory concentrations for Colistin was done and interpreted according to guidelines. Phenotypic and molecular methods determined the Carbapenem resistance of isolates. The blaKPC, blaNDM, and blaOXA-23 genes were amplified for this detection. Biofilm determination of CRKP isolates was performed using a quantitative microtiter plate (MTP) method. The phage was isolated from wastewater during the summer season at a specific position from Beheshti Hospital (Kashan, Iran). The sample was processed and purified against the bacterial host, a CRKP strain isolated from a patient suffering from COVID-19 pneumoniae and resistance to Colistin with high potency for biofilm production. This isolate is called Kp100. The separated phages were diluted and titration by the double overlay agar plaque assay. The separate Phage is concentrated with 10% PEG and stored at -80 °C until use. The phage host range was identified by the spot test method. The purified phage morphology was determined using a transmission electron microscope. The phage stability tests (pH and temperature) were analyzed. The effect of cationic ions on phage adsorption was evaluated. The optimal titer of bacteriophage was determined to reduce the concentration of the CRKP strain. One-step growth assays were performed to identify the purified phage burst's latent cycle and size. The SDS-PAGE was used for phage proteins analysis. Phage DNA was extracted by chloroform technique, and the whole genome of lytic phage was sequenced using Illumina HiSeq technology (Illumina, San Diego, CA). For quality assurance and preprocessing, such as trimming, Geneious Prime 2021.2.2 and Spades 3.9.0. The whole genome sequence of the lytic phage is linked to the GenBank database accession number. RASTtk-v1.073 was used to predict and annotate the ORFs. Prediction of ORF was performed using PHASTER software. ResFinder is used to assess the presence of antimicrobial resistance and virulence genes in the genome. The tRNAs can-SE v2.0.6 is used to determine the presence of tRNA in the genome. Linear genome comparisons of phages and visualization of coding regions were performed using Easyfig 2.2.3 and Mauve 2.4.0. Phage lifestyles were predicted using the program PHACTS. Phylogenetic analysis and amino acid sequences of phage core proteins, such as the major capsid protein. Phylogenies were reconstructed using the Neighbor-Joining method with 1000 bootstrap repeat. HHpred software was used to predict depolymerase. In this study, GraphPad Prism version 9.1 was used for the statistical analysis. Student's t-test was used to compare the sets and the control sets, and the significance level was set at P ≤ 0.05. RESULTS Phage vB_KshKPC-M is assigned to the Siphoviridae, order Caudovirales. It was identified as a linear double-stranded DNA phage of 54,378 bp with 50.08% G + C content, had a relatively broad host range (97.7%), a short latency of 20 min, and a high burst size of 260 PFU/cell, and was maintained stable at different pH (3-11) and temperature (45-65 °C). The vB_KshKPC-M genome contains 91 open-reading frames. No tRNA, antibiotic resistance, toxin, virulence-related genes, or lysogen-forming gene clusters were detected in the phage genome. Comparative genomic analysis revealed that phage vB_KshKPC-M has sequence similarity to the Klebsiella phages, phage 13 (NC_049844.1), phage Sushi (NC_028774.1), phage vB_KpnD_PeteCarol (OL539448.1) and phage PWKp14 (MZ634345.1). CONCLUSION The broad host range and antibacterial activity make it a promising candidate for future phage therapy applications. The isolated phage was able to lyse most of the antibiotic-resistant clinical isolates. Therefore, this phage can be used alone or as a phage mixture in future studies to control and inhibit respiratory infections caused by these bacteria, especially in treating respiratory infections caused by resistant strains in sick patients.
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Affiliation(s)
- Mehrdad Mohammadi
- Department of Microbiology and Immunology, Faculty of Medicine, Kashan University of Medical Sciences, Pezeshk Blvd, Qotbe Ravandi Blvd, Kashan, 8715973449, Iran.
| | - Mahmood Saffari
- Department of Microbiology and Immunology, Faculty of Medicine, Kashan University of Medical Sciences, Pezeshk Blvd, Qotbe Ravandi Blvd, Kashan, 8715973449, Iran.
| | - Seyed Davar Siadat
- grid.420169.80000 0000 9562 2611Tuberculosis and Pulmonary Research Department, Pasteur Institute of Iran, Tehran, Iran ,grid.420169.80000 0000 9562 2611Microbiology Research Center (MRC), Pasteur Institute of Iran, Tehran, Iran
| | - Seyed Hossein Hejazi
- grid.411036.10000 0001 1498 685XDepartment of Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Shayestehpour
- grid.444768.d0000 0004 0612 1049Department of Microbiology and Immunology, Faculty of Medicine, Kashan University of Medical Sciences, Pezeshk Blvd, Qotbe Ravandi Blvd, Kashan, 8715973449 Iran
| | - Mitra Motallebi
- grid.444768.d0000 0004 0612 1049Department of Microbiology and Immunology, Faculty of Medicine, Kashan University of Medical Sciences, Pezeshk Blvd, Qotbe Ravandi Blvd, Kashan, 8715973449 Iran
| | - Milad Eidi
- grid.412266.50000 0001 1781 3962Department of Medical Genetics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
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Heydarian N, Wouters CL, Neel A, Ferrell M, Panlilio H, Haight T, Gu T, Rice CV. Eradicating Biofilms of Carbapenem-Resistant Enterobacteriaceae by Simultaneously Dispersing the Biomass and Killing Planktonic Bacteria with PEGylated Branched Polyethyleneimine. ChemMedChem 2023; 18:e202200428. [PMID: 36542457 PMCID: PMC9899318 DOI: 10.1002/cmdc.202200428] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 11/21/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
Carbapenem-resistant Enterobacteriaceae (CRE) are emerging pathogens that cause variety of severe infections. CRE evade antibiotic treatments because these bacteria produce enzymes that degrade a wide range of antibiotics including carbapenems and β-lactams. The formation of biofilms aggravates CRE infections, especially in a wound environment. These difficulties lead to persistent infection and non-healing wounds. This creates the need for new compounds to overcome CRE antimicrobial resistance and disrupt biofilms. Recent studies in our lab show that 600 Da branched polyethyleneimine (BPEI) and its derivative PEG350-BPEI can overcome antimicrobial resistance and eradicate biofilms in methicillin-resistant S. aureus, methicillin-resistant S. epidermidis, P. aeruginosa, and E. coli. In this study, the ability of 600 Da BPEI and PEG350-BPEI to eradicate carbapenem-resistant Enterobacteriaceae bacteria and their biofilms is demonstrated. We show that both BPEI and PEG350-BPEI have anti-biofilm efficacy against CRE strains expressing Klebsiella pneumoniae carbapenemases (KPCs) and metallo-β-lactamases (MBLs), such as New Delhi MBL (NDM-1). Furthermore, our results illustrate that BPEI affects planktonic CRE bacteria by increasing bacterial length and width from the inability to proceed with normal cell division processes. These data demonstrate the multi-functional properties of 600 Da BPEI and PEG350-BPEI to reduce biofilm formation and mitigate virulence in carbapenem-resistant Enterobacteriaceae.
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Affiliation(s)
- Neda Heydarian
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, OK 73019
| | - Cassandra L. Wouters
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, OK 73019
| | - Andrew Neel
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, OK 73019
| | - Maya Ferrell
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, OK 73019
| | - Hannah Panlilio
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, OK 73019
| | - Tristan Haight
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, OK 73019
| | - Tingting Gu
- Department of Biology, 730 Van Vleet Oval, Room 314, University of Oklahoma, Norman, OK 73019, USA
| | - Charles V. Rice
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, OK 73019
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12
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Liu W, Chen G, Dou K, Yi B, Wang D, Zhou Q, Sun Y. Eugenol eliminates carbapenem-resistant Klebsiella pneumoniae via reactive oxygen species mechanism. Front Microbiol 2023; 14:1090787. [PMID: 36876091 PMCID: PMC9978153 DOI: 10.3389/fmicb.2023.1090787] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 01/09/2023] [Indexed: 02/18/2023] Open
Abstract
Multidrug-resistant (MDR) bacterial infections have gained increasing attention due to the high incidence rates and high mortality, especially for the carbapenem-resistant Klebsiella pneumoniae (CRKP) infection that can cause severe complications (e.g., pneumonia and sepsis) in multiple organs. Therefore, the development of new antibacterial agents against CRKP is imperative. Inspired by natural plant antibacterial agents with broad-spectrum antibacterial properties, the antibacterial/biofilm activity of eugenol (EG) on CRKP and their underlying mechanisms are investigated in our work. It is found that EG exhibits remarkable inhibitory effects on planktonic CRKP in a dose-dependent fashion. Meanwhile, the destruction of membrane integrity induced by the formation of reactive oxygen species (ROS) and glutathione reduction results in the leakage of bacterial cytoplasmic components, including DNA, β-galactosidase, and protein. Moreover, when EG contacts with bacterial biofilm, the whole thickness of the dense biofilm matrix decreases, and the integrity is destroyed. Overall, this work verified that EG could eliminate CRKP via ROS-induced membrane rupture, which offers vital evidence to explain the antibacterial ability of EG against CRKP.
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Affiliation(s)
- Wei Liu
- Department of Critical Care Medicine, College of Medicine, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Guang Chen
- Department of Critical Care Medicine, College of Medicine, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Keke Dou
- Department of Stomatology, The Affiliated Hospital of Qingdao University, Qingdao University, Institute for Translational Medicine, Qingdao, China
| | - Bingcheng Yi
- School of Rehabilitation Sciences and Engineering, University of Health and Rehabilitation Sciences, Qingdao, China
| | - Danyang Wang
- Department of Stomatology, The Affiliated Hospital of Qingdao University, Qingdao University, Institute for Translational Medicine, Qingdao, China
| | - Qihui Zhou
- School of Rehabilitation Sciences and Engineering, University of Health and Rehabilitation Sciences, Qingdao, China
| | - Yunbo Sun
- Department of Critical Care Medicine, College of Medicine, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
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13
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Wang Q, Chen M, Ou Q, Zheng L, Chen X, Mao G, Fang J, Jin D, Tang X. Carbapenem-resistant hypermucoviscous Klebsiella pneumoniae clinical isolates from a tertiary hospital in China: Antimicrobial susceptibility, resistance phenotype, epidemiological characteristics, microbial virulence, and risk factors. Front Cell Infect Microbiol 2022; 12:1083009. [PMID: 36619764 PMCID: PMC9811262 DOI: 10.3389/fcimb.2022.1083009] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022] Open
Abstract
Hypervirulent and multidrug-resistant Klebsiella pneumoniae poses a significant threat to public health. We aimed to determine the common carbapenemase genotypes and the carriage patterns, main antibiotic resistance mechanisms, and in vitro susceptibility of clinical isolates of carbapenem-resistant K. pneumoniae (CRKP) to ceftazidime/avibactam (CZA) for the reasonable selection of antimicrobial agents and determine whether hypermucoviscous (HMV) phenotype and virulence-associated genes are key factors for CRKP colonization and persistence. Antibiotics susceptibility of clinical CRKP isolates and carbapenemase types were detected. CRKP isolates were identified as hypermucoviscous K. pneumoniae (HMKP) using the string test, and detection of virulence gene was performed using capsular serotyping. The bla KPC-2, bla NDM, bla IMP, and/or bla OXA-48-like were detected in 96.4% (402/417) of the isolates, and the bla KPC-2 (64.7%, 260/402) was significantly higher (P<0.05) than those of bla NDM (25.1%), bla OXA-48-like (10.4%), and bla IMP (4.2%). Carriage of a single carbapenemase gene was observed in 96.3% of the isolates, making it the dominant antibiotic resistance genotype carriage pattern (P < 0.05). Approximately 3.7% of the isolates carried two or more carbapenemase genotypes, with bla KPC-2 + bla NDM and bla NDM + bla IMP being the dominant multiple antibiotic resistance genotype. In addition, 43 CRKP isolates were identified as HMKP, with a prevalence of 10.3% and 2.7% among CRKP and all K. pneumoniae isolates, respectively. Most clinical CRKP isolates were isolated from elderly patients, and carbapenemase production was the main mechanism of drug resistance. Tigecycline and polymyxin B exhibited exceptional antimicrobial activity against CRKP isolates in vitro. Furthermore, bla KPC-2, bla NDM, and bla OXA-48-like were the main carbapenemase genes carried by the CRKP isolates. CZA demonstrated excellent antimicrobial activity against isolates carrying the single bla KPC-2 or bla OXA-48-like genotype. Capsular serotype K2 was the main capsular serotype of the carbapenem-resistant HMKP isolates. Survival rates of Galleria mellonella injected with K. pneumoniae 1-7 were 20.0, 16.7, 6.7, 23.3, 16.7, 3.3, and 13.3, respectively. Therefore, worldwide surveillance of these novel CRKP isolates and carbapenem-resistant HMKP isolates as well as the implementation of stricter control measures are needed to prevent further dissemination in hospital settings.
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Affiliation(s)
- Qiang Wang
- Department of Clinical Laboratory, the Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Mengyuan Chen
- Department of Clinical Laboratory, the Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Qian Ou
- Department of Basic Medical Sciences, Zhejiang University School of Medicine, Hangzhou, China
| | - Lina Zheng
- Department of Clinical Laboratory, the Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Xuejing Chen
- Department of Clinical Laboratory, the Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Guofeng Mao
- Department of Clinical Laboratory, Shaoxing People’s Hospital, Shaoxing, China
| | - Jiaqi Fang
- Department of Clinical Medicine, Zhejiang University City College, School of Medicine, Hangzhou, China,*Correspondence: Xiaofang Tang, ; Dazhi Jin, ; Jiaqi Fang,
| | - Dazhi Jin
- School of Laboratory Medicine, Hangzhou Medical College, Hangzhou, China,Key Laboratory of Biomarkers and In Vitro Diagnosis Translation of Zhejiang Province, Hangzhou, China,*Correspondence: Xiaofang Tang, ; Dazhi Jin, ; Jiaqi Fang,
| | - Xiaofang Tang
- Department of Cadre Health Care, Zhejiang Hospital, Hangzhou, China,*Correspondence: Xiaofang Tang, ; Dazhi Jin, ; Jiaqi Fang,
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14
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Mulani MS, Kumkar SN, Pardesi KR. Characterization of Novel Klebsiella Phage PG14 and Its Antibiofilm Efficacy. Microbiol Spectr 2022; 10:e0199422. [PMID: 36374021 PMCID: PMC9769620 DOI: 10.1128/spectrum.01994-22] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 10/19/2022] [Indexed: 11/16/2022] Open
Abstract
The increasing frequency of infections caused by multidrug-resistant Klebsiella pneumoniae demands the development of unconventional therapies. Here, we isolated, characterized, and sequenced a Klebsiella phage PG14 that infects and lyses carbapenem-resistant K. pneumoniae G14. Phage PG14 showed morphology similar to the phages belonging to the family Siphoviridae. The adsorption curve of phage PG14 showed more than 90% adsorption of phages on a host within 12 min. A latent period of 20 min and a burst size of 47 was observed in the one step growth curve. Phage PG14 is stable at a temperature below 30°C and in the pH range of 6 to 8. The PG14 genome showed no putative genes associated with virulence and antibiotic resistance. Additionally, it has shown lysis against 6 out of 13 isolates tested, suggesting the suitability of this phage for therapeutic applications. Phage PG14 showed more than a 7-log cycle reduction in K. pneumoniae planktonic cells after 24 h of treatment at a multiplicity of infection (MOI) of 10. The phage PG14 showed a significant inhibition and disruption of biofilm produced by K. pneumoniae G14. The promising results of this study nominate phage PG14 as a potential candidate for phage therapy. IMPORTANCE Klebsiella pneumoniae is one of the members of the ESKAPE (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) group of pathogens and is responsible for nosocomial infections. The global increase of carbapenem-resistant K. pneumoniae has developed a substantial clinical threat because of the dearth of therapeutic choices available. K. pneumoniae is one of the commonly found bacteria responsible for biofilm-related infections. Due to the inherent tolerance of biofilms to antibiotics, there is a growing need to develop alternative strategies to control biofilm-associated infections. This study characterized a novel bacteriophage PG14, which can inhibit and disrupt the K. pneumoniae biofilm. The genome of phage PG14 does not show any putative genes related to antimicrobial resistance or virulence, making it a potential candidate for phage therapy. This study displays the possibility of treating infections caused by multidrug-resistant (MDR) isolates of K. pneumoniae using phage PG14 alone or combined with other therapeutic agents.
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Affiliation(s)
- Mansura S. Mulani
- Department of Microbiology, Savitribai Phule Pune University, Pune, Maharashtra, India
- Abeda Inamdar Senior College, Pune, Maharashtra, India
| | - Shital N. Kumkar
- Department of Microbiology, Savitribai Phule Pune University, Pune, Maharashtra, India
| | - Karishma R. Pardesi
- Department of Microbiology, Savitribai Phule Pune University, Pune, Maharashtra, India
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15
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Hu Q, Chen J, Sun S, Deng S. Mortality-Related Risk Factors and Novel Antimicrobial Regimens for Carbapenem-Resistant Enterobacteriaceae Infections: A Systematic Review. Infect Drug Resist 2022; 15:6907-6926. [PMID: 36465807 PMCID: PMC9717588 DOI: 10.2147/idr.s390635] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/09/2022] [Indexed: 08/27/2023] Open
Abstract
OBJECTIVE Carbapenem-resistant Enterobacteriaceae (CRE) has become a significant public health problem in the last decade. We aimed to explore the risk factors of mortality in patients with CRE infections and to focus on the current evidence on antimicrobial regimens for CRE infections, particularly from the perspective of mortality. METHODS A systematic literature review was performed by searching the databases of EMBASE, PubMed, and the Cochrane Library to identify studies that evaluated mortality-related risk factors and antimicrobial regimens for CRE infections published from 2012 to 2022. RESULTS In total, 33 and 28 studies were included to analyze risk factors and antibiotic treatment, respectively. The risk factors most frequently reported as significantly associated with CRE mortality were antibiotic use (92.9%; 26/28 studies), comorbidities (88.7%; 23/26 studies), and hospital-related factors (82.8%; 24/29 studies). In 10 studies that did not contain ceftazidime/avibactam (CAZ-AVI) therapy, seven demonstrated significantly lower mortality in combination therapy than in monotherapy. However, 5 of 6 studies identified no substantial difference between CAZ-AVI monotherapy and CAZ-AVI combination therapy. Six studies reported substantially lower mortality in CAZ-AVI regimens than in other regimens. CONCLUSION Several risk factors, particularly antibiotic use and patients' comorbidities, are strong risk factors for CRE mortality. The optimal regimen for CRE infections remains controversial. Combination therapy should be considered when carbapenems, colistin, tigecycline, or aminoglycosides are administered. CAZ-AVI appears to be a promising antibiotic for CRE infections. Most importantly, treatment should be individualized according to the source and severity of the disease or other highly related risk factors.
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Affiliation(s)
- Qin Hu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Hospital Institute Administration, Central South University, Changsha, People’s Republic of China
- Xiangya Health Development Research Center, Changsha, People’s Republic of China
| | - Jinglan Chen
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- The Hunan Institute of Pharmacy Practice and Clinical Research, Changsha, People’s Republic of China
| | - Shusen Sun
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Department of Pharmacy Practice, College of Pharmacy and Health Sciences, Western New England University, Springfeld, MA, USA
| | - Sheng Deng
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- The Hunan Institute of Pharmacy Practice and Clinical Research, Changsha, People’s Republic of China
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16
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Binaymotlagh R, Del Giudice A, Mignardi S, Amato F, Marrani AG, Sivori F, Cavallo I, Di Domenico EG, Palocci C, Chronopoulou L. Green In Situ Synthesis of Silver Nanoparticles-Peptide Hydrogel Composites: Investigation of Their Antibacterial Activities. Gels 2022; 8:700. [PMID: 36354608 PMCID: PMC9689897 DOI: 10.3390/gels8110700] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 08/23/2023] Open
Abstract
The present paper investigated the synthesis of peptide-based hydrogel composites containing photo-generated silver nanoparticles (AgNPs) obtained in the presence and absence of honey as tensile strength enhancer and hydrogel stabilizer. Fmoc-Phe and diphenylalanine (Phe2) were used as starting reagents for the hydrogelator synthesis via an enzymatic method. In particular, we developed an in situ one-pot approach for preparing AgNPs inside peptide hydrogels using a photochemical synthesis, without any toxic reducing agents, with reaction yields up to 30%. The structure and morphology of the nanohybrids were characterized with different techniques such as FESEM, UV-Vis, DLS, SAXS and XPS. Moreover, the antibacterial activity of these hybrid biomaterials was investigated on a laboratory strain and on a clinical isolate of Staphylococcus aureus. Results demonstrated that honey increased both swelling ability and also mechanical stability of the hydrogel. Finally, a higher antibacterial effect of AgNPs in the hybrid was observed in the presence of honey. In particular, AgNPs/hgel and AgNPs/hgel-honey showed an enhanced antibacterial activity (3.12 mg/L) compared to the free form of AgNPs, alone or in combination with honey (6.25 mg/L) for both S. aureus strains.
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Affiliation(s)
- Roya Binaymotlagh
- Department of Chemistry, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
| | - Alessandra Del Giudice
- Department of Chemistry, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
| | - Silvano Mignardi
- Department of Earth Sciences, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
| | - Francesco Amato
- Department of Chemistry, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
| | - Andrea Giacomo Marrani
- Department of Chemistry, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
| | - Francesca Sivori
- Microbiology and Virology, IRCCS San Gallicano Institute, via E. Chianesi, 53, 00144 Rome, Italy
| | - Ilaria Cavallo
- Microbiology and Virology, IRCCS San Gallicano Institute, via E. Chianesi, 53, 00144 Rome, Italy
| | - Enea Gino Di Domenico
- Department of Biology and Biotechnology “C. Darwin”, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
| | - Cleofe Palocci
- Department of Chemistry, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
- Research Center for Applied Sciences to the Safeguard of Environment and Cultural Heritage (CIABC), Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
| | - Laura Chronopoulou
- Department of Chemistry, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
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Clinical and Molecular Characterizations of Carbapenem-Resistant Klebsiella pneumoniae Causing Bloodstream Infection in a Chinese Hospital. Microbiol Spectr 2022; 10:e0169022. [PMID: 36190403 PMCID: PMC9603270 DOI: 10.1128/spectrum.01690-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Bloodstream infection (BSI) caused by carbapenem-resistant Klebsiella pneumoniae (CRKP) is a serious and urgent threat for hospitalized patients. This study aims to describe the clinical and molecular characteristics of CRKP causing BSI in a tertiary-care hospital in Beijing, China. A total of 146 CRKP strains and 39 carbapenem-susceptible K. pneumoniae (CSKP) strains collected in the hospital from 2017 to 2020 were sent for whole-genome sequencing. Univariate and multivariate analyses were used to evaluate risk factors for in-hospital mortality of CRKP-BSI cases. Thirty (20.5%) of 146 CRKP-BSI patients and three (7.7%) of 39 CSKP-BSI patients died at discharge (χ2 = 3.471, P = 0.062). Multivariate logistic regression analysis indicated that age and use of urinary catheters were independent risk factors for the death of CRKP-BSI. The 146 CRKP isolates belonged to 9 sequence types (STs) and 11 serotypes, while the 39 CSKP isolates belonged to 23 STs and 27 serotypes. The mechanism of carbapenem resistance for all the CRKP strains was the acquisition of carbapenemase, mainly KPC-2 (n = 127). There were 2 predominant serotypes for ST11 CRKP, namely, KL47 (n = 82) and KL64 (n = 42). Some virulent genes, including rmpA2, iucABCD and iutA, and repB gene, which was involved in plasmid replication, were detected in all ST11-KL64 strains. Evolutionary transmission analysis suggested that ST11 CRKP strains might have evolved from KL47 into KL64 and were accompanied by multiple outbreak events. This study poses an urgent need for enhancing infection control measures in the hospital, especially in the intensive care unit where the patients are at high-risk for acquiring CRKP-BSI. IMPORTANCE CRKP-BSI is demonstrated to cause high mortality. In this study, we demonstrated that ST11 CRKP strains might carry many virulent genes. Meanwhile, outbreak events occurred several times in the strains collected. Carbapenemase acquisition (mainly KPC-2 carbapenemase) was responsible for carbapenem resistance of all the 146 CRKP strains. As 2 predominant strains, all ST11-KL64 strains, but not ST11-KL47 strains, carried rmpA2, iucABCD, iutA, as well as a plasmid replication initiator (repB). Our study suggested that the occurrence of region-specific recombination events manifested by the acquisition of some virulence genes might contribute to serotype switching from ST11-KL47 to ST11-KL64. The accumulation of virulent genes in epidemic resistant strains poses a great challenge for the prevention and treatment of BSI caused by K. pneumoniae in high-risk patients.
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El-Kady RAEH, Elbaiomy MA, Elnagar RM. Molecular Mechanisms Mediating Ceftazidime/Avibactam Resistance Amongst Carbapenem-Resistant Klebsiella pneumoniae Isolates from Cancer Patients. Infect Drug Resist 2022; 15:5929-5940. [PMID: 36247738 PMCID: PMC9558567 DOI: 10.2147/idr.s384972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022] Open
Abstract
Background A growing body of evidence suggests that ceftazidime/avibactam (CZA) is a potential therapeutic option for carbapenem-resistant Klebsiella pneumoniae (CRKP) infections; however, resistant strains are increasingly emerged worldwide. Herein, we deemed to investigate the susceptibility profile of CRKP isolates from cancer patients to CZA and to identify the underlying resistance mechanisms. Methods Clinical samples were obtained from adult patients admitted to the Oncology Center of Mansoura University, Mansoura, Egypt. The antibiotic susceptibility pattern of K. pneumoniae isolates to different antibiotics was tested by the modified Kirby Bauer's disc diffusion method. Minimum inhibitory concentrations of CZA were assessed using broth microdilution method. Screening for carbapenemase-producing strains was achieved by the modified Hodge test. Multiplex polymerase chain reactions (PCRs) were conducted for uncovering of carbapenemase-encoding genes (blaKPC, blaVIM, blaIMP, blaNDM-1 , and blaOXA-48 ), and outer membrane porin genes (ompK35 and ompK36). Results A total of 12 CZA-resistant isolates were identified out of 47 CRKP isolates (25.5%). The MIC50 and MIC90 of CZA against CRKP were 1 and 64 µg/mL, respectively. Risk factors for CZA resistance included chronic kidney disease, mechanical ventilation, longer length of hospital stay, and ICU admission. The multivariate logistic regression demonstrated that longer length of hospital stay (P=0.03) was the only independent predictor for acquisition of CZA-resistant isolates. The leading mechanism for CZA resistance was sustained by blaKPC (50%), meanwhile 16.7% and 8.3% of the CZA-resistant isolates harbored blaOXA-48 and blaOXA-48 /blaNDM-1 , respectively. The MBL-encoding genes blaNDM-1 and blaIMP were detected in 16.7% and 8.3% of the isolates, respectively. Absence of both ompK35 and ompK36 was observed in 58.3% of the CZA-resistant isolates. Conclusion CZA has displayed superior in vitro activity against CRKP isolates in comparison to other antibiotics; however, thorough molecular characterization of resistant strains is highly recommended in future studies to detect and monitor the emergence of further tackling strains.
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Affiliation(s)
- Rania Abd El-Hamid El-Kady
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Mansoura University, Mansoura, Egypt,Department of Pathological Sciences, Fakeeh College for Medical Sciences, Jeddah, Kingdom of Saudi Arabia,Correspondence: Rania Abd El-Hamid El-Kady, Department of Pathological Sciences, Fakeeh College for Medical Sciences, P.O. Box 2537, Jeddah, 21461, Kingdom of Saudi Arabia, Tel +966 569849897, Email
| | | | - Rasha Mokhtar Elnagar
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Cavallo I, Lesnoni La Parola I, Sivori F, Toma L, Koudriavtseva T, Sperduti I, Kovacs D, D’Agosto G, Trento E, Cameli N, Mussi A, Latini A, Morrone A, Pimpinelli F, Di Domenico EG. Homocysteine and Inflammatory Cytokines in the Clinical Assessment of Infection in Venous Leg Ulcers. Antibiotics (Basel) 2022; 11:antibiotics11091268. [PMID: 36140047 PMCID: PMC9495878 DOI: 10.3390/antibiotics11091268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/07/2022] [Accepted: 09/16/2022] [Indexed: 11/16/2022] Open
Abstract
Inflammation and biofilm-associated infection are common in chronic venous leg ulcers (VU), causing deep pain and delayed healing. Albeit important, clinical markers and laboratory parameters for identifying and monitoring persistent VU infections are limited. This study analyzed 101 patients with infected (IVU) and noninfected VUs (NVU). Clinical data were collected in both groups. The serum homocysteine (Hcys) and inflammatory cytokines from the wound fluid were measured. In addition, microbial identification, antibiotic susceptibility, and biofilm production were examined. IVU were 56 (55.4%) while NVU were 45 (44.5%). IVUs showed a significant increase in the wound's size and depth compared to NVUs. In addition, significantly higher levels of interleukin (IL)-6, IL-10, IL17A, and tumor necrosis factor-alpha (TNF-α) were found in patients with IVUs compared to those with NVUs. Notably, hyperhomocysteinemia (HHcy) was significantly more common in patients with IVUs than NVUs. A total of 89 different pathogens were identified from 56 IVUs. Gram-negative bacteria were 51.7%, while the Gram-positives were 48.3%. At the species level, Staphylococcus aureus was the most common isolate (43.8%), followed by Pseudomonas aeruginosa (18.0%). Multidrug-resistant organisms (MDROs) accounted for 25.8% of the total isolates. Strong biofilm producers (SBPs) (70.8%) were significantly more abundant than weak biofilm producers (WBP) (29.2%) in IVUs. SBPs were present in 97.7% of the IVUs as single or multispecies infections. Specifically, SBPs were 94.9% for S. aureus, 87.5% for P. aeruginosa, and 28.6% for Escherichia coli. In IVU, the tissue microenvironment and biofilm production can support chronic microbial persistence and a most severe clinical outcome even in the presence of an intense immune response, as shown by the high levels of inflammatory molecules. The measurement of local cytokines in combination with systemic homocysteine may offer a novel set of biomarkers for the clinical assessment of IVUs caused by biofilm-producing bacteria.
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Affiliation(s)
- Ilaria Cavallo
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, 00144 Rome, Italy
| | | | - Francesca Sivori
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, 00144 Rome, Italy
| | - Luigi Toma
- Department of Research, Advanced Diagnostics, and Technological Innovation, Translational Research Area, IRCCS Regina Elena National Cancer Institute, 00144 Rome, Italy
| | | | - Isabella Sperduti
- Biostatistics, IRCCS Regina Elena National Cancer Institute, 00144 Rome, Italy
| | - Daniela Kovacs
- Cutaneous Physiopathology, San Gallicano Dermatological Institute, IRCCS, 00144 Rome, Italy
| | - Giovanna D’Agosto
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, 00144 Rome, Italy
| | - Elisabetta Trento
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, 00144 Rome, Italy
| | - Norma Cameli
- Department of Dermatology, San Gallicano Dermatological Institute, IRCCS, 00144 Rome, Italy
| | - Anna Mussi
- Department of Dermatology, San Gallicano Dermatological Institute, IRCCS, 00144 Rome, Italy
| | - Alessandra Latini
- Department of Dermatology, San Gallicano Dermatological Institute, IRCCS, 00144 Rome, Italy
| | - Aldo Morrone
- Scientific Direction, San Gallicano Institute, IRCCS, 00144 Rome, Italy
| | - Fulvia Pimpinelli
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, 00144 Rome, Italy
| | - Enea Gino Di Domenico
- Department of Biology and Biotechnology “C. Darwin”, Sapienza University, 00185 Rome, Italy
- Correspondence:
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Di Domenico EG, Oliva A, Guembe M. The Current Knowledge on the Pathogenesis of Tissue and Medical Device-Related Biofilm Infections. Microorganisms 2022; 10:microorganisms10071259. [PMID: 35888978 PMCID: PMC9322301 DOI: 10.3390/microorganisms10071259] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/13/2022] [Accepted: 06/16/2022] [Indexed: 02/04/2023] Open
Abstract
Biofilm is the trigger for the majority of infections caused by the ability of microorganisms to adhere to tissues and medical devices. Microbial cells embedded in the biofilm matrix are highly tolerant to antimicrobials and escape the host immune system. Thus, the refractory nature of biofilm-related infections (BRIs) still represents a great challenge for physicians and is a serious health threat worldwide. Despite its importance, the microbiological diagnosis of a BRI is still difficult and not routinely assessed in clinical microbiology. Moreover, biofilm bacteria are up to 100–1000 times less susceptible to antibiotics than their planktonic counterpart. Consequently, conventional antibiograms might not be representative of the bacterial drug susceptibility in vivo. The timely recognition of a BRI is a crucial step to directing the most appropriate biofilm-targeted antimicrobial strategy.
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Affiliation(s)
- Enea Gino Di Domenico
- Department of Biology and Biotechnology “C. Darwin”, Sapienza University of Rome, 00185 Rome, Italy;
| | - Alessandra Oliva
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185 Rome, Italy;
| | - María Guembe
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain
- Correspondence: ; Tel.: +34-914-269-595
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21
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Sivori F, Cavallo I, Kovacs D, Guembe M, Sperduti I, Truglio M, Pasqua M, Prignano G, Mastrofrancesco A, Toma L, Pimpinelli F, Morrone A, Ensoli F, Di Domenico EG. Role of Extracellular DNA in Dalbavancin Activity against Methicillin-Resistant Staphylococcus aureus (MRSA) Biofilms in Patients with Skin and Soft Tissue Infections. Microbiol Spectr 2022; 10:e0035122. [PMID: 35416701 PMCID: PMC9045124 DOI: 10.1128/spectrum.00351-22] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/01/2022] [Indexed: 12/15/2022] Open
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) has become the leading cause of skin and soft tissue infections (SSTIs). Biofilm production further complicates patient treatment, contributing to increased bacterial persistence and antibiotic tolerance. The study aimed to explore the efficacy of different antibiotics on biofilm-producing MRSA isolated from patients with SSTI. A total of 32 MRSA strains were collected from patients with SSTI. The MIC and minimal biofilm eradication concentration (MBEC) were measured in planktonic and biofilm growth. The study showed that dalbavancin, linezolid, and vancomycin all inhibited MRSA growth at their EUCAST susceptible breakpoint. Of the MRSA strains, 87.5% (n = 28) were strong biofilm producers (SBPs), while only 12.5% (n = 4) were weak biofilm producers (WBPs). The MBEC90 values for dalbavancin were significantly lower than those of linezolid and vancomycin in all tested strains. We also found that extracellular DNA (eDNA) contributes to the initial microbial attachment and biofilm formation. The amount of eDNA differed among MRSA strains and was significantly higher in those isolates with high dalbavancin and vancomycin tolerance. Exogenously added DNA increased the MBEC90 and protection of biofilm cells from dalbavancin activity. Of note, the relative abundance of eDNA was higher in MRSA biofilms exposed to MBEC90 dalbavancin than in untreated MRSA biofilms and those exposed to sub-MIC90. Overall, dalbavancin was the most active antibiotic against MRSA biofilms at concentrations achievable in the human serum. Moreover, the evidence of a drug-related increase of eDNA and its contribution to antimicrobial drug tolerance reveals novel potential targets for antibiofilm strategies against MRSA. IMPORTANCE Staphylococcus aureus is the most common cause of skin and soft tissue infections (SSTIs) worldwide. In addition, methicillin-resistant S. aureus (MRSA) is increasingly frequent in postoperative infections and responsible for a large number of hospital readmissions and deaths. Biofilm formation by S. aureus is a primary risk factor in SSTIs, due to a higher antibiotic tolerance. Our study showed that the biofilm-forming capacity varied among MRSA strains, although strong biofilm producers were significantly more abundant than weak biofilm producer strains. Notably, dalbavancin demonstrated a potent antibiofilm activity at concentrations achievable in human serum. Nevertheless, dalbavancin activity was affected by an increased concentration of extracellular DNA in the biofilm matrix. This study provides novel insight for designing more targeted therapeutic strategies against MRSA and to prevent or eradicate harmful biofilms.
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Affiliation(s)
- Francesca Sivori
- Microbiology and Virology, IRCCS San Gallicano Dermatological Institute, Rome, Italy
| | - Ilaria Cavallo
- Microbiology and Virology, IRCCS San Gallicano Dermatological Institute, Rome, Italy
| | - Daniela Kovacs
- Cutaneous Physiopathology, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - Maria Guembe
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Isabella Sperduti
- Biostatistical Unit-Clinical Trials Center, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Mauro Truglio
- Cutaneous Physiopathology, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - Martina Pasqua
- Department of Biology and Biotechnology “C. Darwin”, Sapienza University, Rome, Italy
| | - Grazia Prignano
- Microbiology and Virology, IRCCS San Gallicano Dermatological Institute, Rome, Italy
| | | | - Luigi Toma
- Department of Research, Advanced Diagnostics, and Technological Innovation, Translational Research Area, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Fulvia Pimpinelli
- Microbiology and Virology, IRCCS San Gallicano Dermatological Institute, Rome, Italy
| | - Aldo Morrone
- Scientific Direction, IRCCS San Gallicano Dermatological Institute, Rome, Italy
| | - Fabrizio Ensoli
- Microbiology and Virology, IRCCS San Gallicano Dermatological Institute, Rome, Italy
| | - Enea Gino Di Domenico
- Microbiology and Virology, IRCCS San Gallicano Dermatological Institute, Rome, Italy
- Department of Biology and Biotechnology “C. Darwin”, Sapienza University, Rome, Italy
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22
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Tuncer G, Aktas Z, Basaran S, Cagatay A, Eraksoy H. Biofilm formation of panresistant Klebsiella pneumoniae. Future Microbiol 2022; 17:723-735. [PMID: 35443798 DOI: 10.2217/fmb-2021-0108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Introduction: The authors aimed to investigate the biofilm-forming features of panresistant Klebsiella pneumoniae (PRKp). Material & methods: The biofilm formations were shown under light microscope and laser scanning confocal microscopy. The optical densities of the wells were measured and classified according to biofilm-forming capacities. Results: The ratio of biofilm-forming K. pneumoniae was established to be 100%. All isolates were found to form high-level biofilms in classification compared with positive and negative controls. No significant difference was detected in the biofilm-forming capacities of K. pneumoniae strains isolated from different sample types. Conclusion: No previous study associated with PRKp isolates was identified in the literature search. There is a need for different approaches characterizing the biofilm-forming features of PRKp.
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Affiliation(s)
- Gulsah Tuncer
- Department of Infectious Diseases & Clinical Microbiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, 34104, Turkey
| | - Zerrin Aktas
- Department of Microbiology & Clinical Microbiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, 34104, Turkey
| | - Seniha Basaran
- Department of Infectious Diseases & Clinical Microbiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, 34104, Turkey
| | - Atahan Cagatay
- Department of Infectious Diseases & Clinical Microbiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, 34104, Turkey
| | - Haluk Eraksoy
- Department of Infectious Diseases & Clinical Microbiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, 34104, Turkey
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23
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Mendes G, Ramalho JF, Bruschy-Fonseca A, Lito L, Duarte A, Melo-Cristino J, Caneiras C. First Description of Ceftazidime/Avibactam Resistance in an ST13 KPC-70-Producing Klebsiella pneumoniae Strain from Portugal. Antibiotics (Basel) 2022; 11:antibiotics11020167. [PMID: 35203770 PMCID: PMC8868070 DOI: 10.3390/antibiotics11020167] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/25/2022] [Accepted: 01/25/2022] [Indexed: 12/17/2022] Open
Abstract
The combination of ceftazidime/avibactam (CZA) is a novel β-lactam/β-lactamase inhibitor with activity against Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacterales. Emerging cases caused by CZA-resistant strains that produce variants of KPC genes have already been reported worldwide. However, to the best of our knowledge, no CZA-resistant strains were reported in Portugal. In September 2019, a K. pneumoniae CZA-resistant strain was collected from ascitic fluid at a surgery ward of a tertiary University Hospital Center in Lisboa, Portugal. The strain was resistant to ceftazidime/avibactam, as well as to ceftazidime, cefoxitin, gentamicin, amoxicillin/clavulanic acid, and ertapenem, being susceptible to imipenem and tigecycline. A hypermucoviscosity phenotype was confirmed by string test. Whole-genome sequencing (WGS) analysis revealed the presence of an ST13 KPC70-producing K. pneumoniae, a KPC-3 variant, differing in two amino-acid substitutions (D179Y and T263A). The D179Y mutation in the KPC Ω-loop region is the most common amino-acid substitution in KPC-2 and KPC-3, further leading to CZA resistance. The second mutation causes a KPC-70 variant in which threonine replaces alanine (T263A). The CZA-resistant strain showed the capsular locus KL3 and antigen locus O1v2. Other important virulence factors were identified: fimbrial adhesins type 1 and type 3, as well as the cluster of iron uptake systems aerobactin, enterobactin, salmochelin, and yersiniabactin included in integrative conjugative element 10 (ICEKp10) with the genotoxin colibactin cluster. Herein, we report the molecular characterization of the first hypervirulent CZA-resistant ST13 KPC-70-producing K. pneumoniae strain in Portugal. The emergence of CZA-resistant strains might pose a serious threat to public health and suggests an urgent need for enhanced clinical awareness and epidemiologic surveillance.
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Affiliation(s)
- Gabriel Mendes
- Microbiology Research Laboratory on Environmental Health (EnviHealthMicro Lab), Institute of Environmental Health (ISAMB), Faculty of Medicine, Universidade de Lisboa (ULisboa), 1649-028 Lisboa, Portugal; (G.M.); (J.F.R.)
| | - João F. Ramalho
- Microbiology Research Laboratory on Environmental Health (EnviHealthMicro Lab), Institute of Environmental Health (ISAMB), Faculty of Medicine, Universidade de Lisboa (ULisboa), 1649-028 Lisboa, Portugal; (G.M.); (J.F.R.)
| | - Ana Bruschy-Fonseca
- Microbiology Laboratory, Clinical Pathology Department, Centro Hospitalar Universitário Lisboa Norte, 1649-035 Lisboa, Portugal; (A.B.-F.); (L.L.); (J.M.-C.)
| | - Luís Lito
- Microbiology Laboratory, Clinical Pathology Department, Centro Hospitalar Universitário Lisboa Norte, 1649-035 Lisboa, Portugal; (A.B.-F.); (L.L.); (J.M.-C.)
| | - Aida Duarte
- Faculty of Pharmacy, Universidade de Lisboa (ULisboa), 1649-033 Lisboa, Portugal;
- Egas Moniz Interdisciplinary Research Center, Egas Moniz University Institute, 2829-511 Monte da Caparica, Portugal
| | - José Melo-Cristino
- Microbiology Laboratory, Clinical Pathology Department, Centro Hospitalar Universitário Lisboa Norte, 1649-035 Lisboa, Portugal; (A.B.-F.); (L.L.); (J.M.-C.)
- Institute of Microbiology, Faculty of Medicine, Universidade de Lisboa (ULisboa), 1649-028 Lisboa, Portugal
| | - Cátia Caneiras
- Microbiology Research Laboratory on Environmental Health (EnviHealthMicro Lab), Institute of Environmental Health (ISAMB), Faculty of Medicine, Universidade de Lisboa (ULisboa), 1649-028 Lisboa, Portugal; (G.M.); (J.F.R.)
- Faculty of Pharmacy, Universidade de Lisboa (ULisboa), 1649-033 Lisboa, Portugal;
- Institute of Preventive Medicine and Public Health, Faculty of Medicine, Universidade de Lisboa (ULisboa), 1649-028 Lisboa, Portugal
- Correspondence:
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24
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Alaidaroos BA. Rare Actinomycetes from Undiscovered Sources as a Source of Novel Antimicrobial Agents to Control Multidrug-Resistant Bacteria. INTERNATIONAL JOURNAL OF PHARMACEUTICAL RESEARCH AND ALLIED SCIENCES 2022. [DOI: 10.51847/dpfaj9fiep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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25
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Liao W, Huang N, Zhang Y, Sun Y, Chen T, Zeng W, Chen L, Wen H, Cao J, Zhou T. Comparison of Carbapenem-Resistant Klebsiella pneumoniae Strains Causing Intestinal Colonization and Extraintestinal Infections: Clinical, Virulence, and Molecular Epidemiological Characteristics. Front Public Health 2021; 9:783124. [PMID: 34926395 PMCID: PMC8678278 DOI: 10.3389/fpubh.2021.783124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 11/12/2021] [Indexed: 12/19/2022] Open
Abstract
Carbapenem-resistant Klebsiella pneumonia (CRKP) infections has become a concerning threat. However, knowledge regarding the characteristics of intestinal CRKP isolates is limited. This study aimed to investigate and compare the clinical, virulence and molecular epidemiological characteristics of intestinal colonization and extraintestinal infections CRKP strains. The clinical characteristics were investigated retrospectively. Polymerase chain reaction was used to investigate the capsular serotype, virulence genes and carbapenemase genes. Capsular polysaccharide quantification assay, serum resistance assay, biofilm formation assay, and infection model of Galleria mellonella larvae were performed to compare the virulence and pathogenicity. Besides, multilocus-sequence-typing (MLST) and pulsed-field-gel-electrophoresis (PFGE) were conducted to explore the homology of intestinal CRKP isolates. A total of 54 intestinal CRKP isolates were included. The main capsular serotypes were K14, K64, and K19. C-reactive protein and the proportion of ICU isolation of the infection group were significantly higher than that of the colonization group (P < 0.05). The carrier rates of various virulence genes of CRKP in the infection group were mostly higher than those in the colonization group, wherein the carrier rates of peg-344 and rmpA were significantly different (P < 0.05). There was no significant difference in capsular polysaccharides, antiserum ability, biofilm formation ability between the two group (P > 0.05), but the lethality of the infection group to Galleria mellonella was significantly higher than that of the colonization group (P < 0.05). The MLST categorized the 54 isolates into 13 different sequence types. PFGE revealed that homology among the 54 CRKP strains was <80%. This study suggested that the CRKP strains in the infection group had higher virulence than those in the colonization group. The development of CRKP isolates colonizing in the intestine should be addressed in future clinical surveillance.
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Affiliation(s)
- Wenli Liao
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.,Department of Laboratory, Yongzhou Central Hospital, Yongzhou, China
| | - Na Huang
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ying Zhang
- Department of Medical Lab Science, School of Laboratory Medicine and Life Science, Wenzhou Medical University, Wenzhou, China
| | - Yao Sun
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Tao Chen
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Weiliang Zeng
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Liqiong Chen
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hong Wen
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jianming Cao
- Department of Medical Lab Science, School of Laboratory Medicine and Life Science, Wenzhou Medical University, Wenzhou, China
| | - Tieli Zhou
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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26
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Di Domenico EG, Marchesi F, Cavallo I, Toma L, Sivori F, Papa E, Spadea A, Cafarella G, Terrenato I, Prignano G, Pimpinelli F, Mastrofrancesco A, D’Agosto G, Trento E, Morrone A, Mengarelli A, Ensoli F. The Impact of Bacterial Biofilms on End-Organ Disease and Mortality in Patients with Hematologic Malignancies Developing a Bloodstream Infection. Microbiol Spectr 2021; 9:e0055021. [PMID: 34406812 PMCID: PMC8552682 DOI: 10.1128/spectrum.00550-21] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 07/22/2021] [Indexed: 11/20/2022] Open
Abstract
Bacterial bloodstream infection (BSI) represents a significant complication in hematologic patients. However, factors leading to BSI and progression to end-organ disease and death are understood only partially. The study analyzes host and microbial risk factors and assesses their impact on BSI development and mortality. A total of 96 patients with hematological malignancies and BSI were included in the study. Host-associated risk factors and all causes of mortality were analyzed by multivariable logistic regression at 30 days after BSI onset of the first neutropenic episode. The multidrug-resistant profile and biofilm production of bacterial isolates from primary BSI were included in the analysis. Median age was 60 years. The underlying diagnoses were acute leukemia (55%), lymphoma (31%), and myeloma (14%). A total of 96 bacterial isolates were isolated from BSIs. Escherichia coli was the most common isolate (29.2%). Multidrug-resistant bacteria caused 10.4% of bacteremia episodes. Weak biofilm producers (WBPs) were significantly (P < 0.0001) more abundant (72.2%) than strong biofilm producers (SBPs) (27.8%). Specifically, SBPs were 7.1% for E. coli, 93.7% for P. aeruginosa, 50% for K. pneumoniae, and 3.8% for coagulase-negative staphylococci. Mortality at day 30 was 8.3%, and all deaths were attributable to Gram-negative bacteria. About 22% of all BSIs were catheter-related BSIs (CRBSIs) and mostly caused by Gram-positive bacteria (79.0%). However, CRBSIs were not correlated with biofilm production levels (P = 0.75) and did not significantly impact the mortality rate (P = 0.62). Conversely, SBP bacteria were an independent risk factor (P = 0.018) for developing an end-organ disease. In addition, multivariate analysis indicated that SBPs (P = 0.013) and multidrug-resistant bacteria (P = 0.006) were independent risk factors associated with 30-day mortality. SBP and multidrug-resistant (MDR) bacteria caused a limited fraction of BSI in these patients. However, when present, SBPs raise the risk of end-organ disease and, together with an MDR phenotype, can independently and significantly concur at increasing the risk of death. IMPORTANCE Bacterial bloodstream infection (BSI) is a significant complication in hematologic patients and is associated with high mortality rates. Despite improvements in BSI management, factors leading to sepsis are understood only partially. This study analyzes the contribution of bacterial biofilm on BSI development and mortality in patients with hematological malignancies (HMs). In this work, weak biofilm producers (WBPs) were significantly more abundant than strong biofilm producers (SBPs). However, when present, SBP bacteria raised the risk of end-organ disease in HM patients developing a BSI. Besides, SBPs, together with a multidrug-resistant (MDR) phenotype, independently and significantly concur at increasing the risk of death in HM patients. The characterization of microbial biofilms may provide key information for the diagnosis and therapeutic management of BSI and may help develop novel strategies to either eradicate or control harmful microbial biofilms.
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Affiliation(s)
- Enea Gino Di Domenico
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - Francesco Marchesi
- Hematology and Stem Cell Transplant Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Ilaria Cavallo
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - Luigi Toma
- Department of Research, Advanced Diagnostics, and Technological Innovation, Translational Research Area, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Francesca Sivori
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - Elena Papa
- Hematology and Stem Cell Transplant Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Antonio Spadea
- Hematology and Stem Cell Transplant Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Giuseppina Cafarella
- Hematology and Stem Cell Transplant Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Irene Terrenato
- Biostatistics and Bioinformatic Unit, Scientific Direction, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Grazia Prignano
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - Fulvia Pimpinelli
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | | | - Giovanna D’Agosto
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - Elisabetta Trento
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - Aldo Morrone
- Scientific Direction, IRCCS San Gallicano Institute, Rome, Italy
| | - Andrea Mengarelli
- Hematology and Stem Cell Transplant Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Fabrizio Ensoli
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
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