1
|
Das BJ, Singha KM, Wangkheimayum J, Chanda DD, Bhattacharjee A. Occurrence of blaOXA-116 Carbapenemase in Escherichia coli ST2519 of Clinical Origin: A Report from Northeast India. Microb Drug Resist 2024; 30:399-406. [PMID: 39093870 DOI: 10.1089/mdr.2024.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024] Open
Abstract
Carbapenem-resistant Escherichia coli pose a significant threat to global public health due to the dearth of available treatment options, resulting in infections with high mortality and morbidity. The study aimed to investigate the mechanism of carbapenem resistance in a carbapenem non-susceptible E. coli isolate recovered from an urinary tract infection patient admitted to a tertiary referral hospital, through whole-genome sequencing using Illumina NovaSeq 6000 platform. Carbapenemase production followed by antibiotic susceptibility testing were performed following Clinical Laboratory Standard Institute guidelines. Polymerase chain reaction targeting carbapenemase genes was performed followed by an investigation of horizontal transferability. The Center for Genomic Epidemiology database was used to analyze the sequenced data. ST2519 E. coli BJD_EC1808 with a genome size of 5.8 Mb harbored Col440I plasmid and a chromosomally located blaOXA-116 gene with an IS18 element upstream, along with multiple antibiotic resistance genes conferring clinical resistance toward beta-lactams, aminoglycosides, amphenicols, sulfonamides, tetracyclines, trimethoprim, rifampin, macrolide, and streptogramin antibiotics and antiseptics. E. coli ST2519 harboring blaOXA-116 associated with a mobile genetic element exhibiting carbapenem resistance is a public health threat due to its limiting effect on the therapeutic usage of carbapenem and their dissemination into carbapenem non-susceptible phenotypes will contribute to carbapenem resistance burden and, therefore, warrants urgent monitoring and clinical intervention.
Collapse
Affiliation(s)
| | - K Melson Singha
- Department of Microbiology, Silchar Medical College and Hospital, Silchar, India
| | | | | | | |
Collapse
|
2
|
Borde K, Kareem MA, Sharma RM, Dass SM, Ravi V, Mathai D. In vitro activity of cefiderocol against comparators (ceftazidime-avibactam, ceftazidime-avibactam/ aztreonam combination, and colistin) against clinical isolates of meropenem-resistant Klebsiella pneumoniae from India. Microbiol Spectr 2023; 11:e0084723. [PMID: 37737637 PMCID: PMC10580817 DOI: 10.1128/spectrum.00847-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/04/2023] [Indexed: 09/23/2023] Open
Abstract
Cefiderocol (FDC), a novel siderophore drug, is active against Gram-negative bacteria producing carbapenemases, including metallo-beta-lactamases. The objective of this study is to compare the in vitro activity of FDC with ceftazidime-avibactam (CZA), CZA/aztreonam (AT) combination, and colistin (CST), in clinical isolates of meropenem-resistant (MER-R) Klebsiella pneumoniae. From the 2,052 clinical specimens submitted for culture testing, 245 K. pneumoniae isolates were recovered within a 6-month period in 2021. One hundred three non-duplicate, non-outbreak, MER-R (minimum inhibitory concentration, MIC >4 µg/mL) strains were included in the study. Identification and susceptibility were performed using VITEK-2 (bioMérieux). Meropenem-susceptible isolates (n = 10) served as controls. For FDC, broth microdilution (BMD) was performed after in-house standardization. Disk diffusion (Liofilchem, Italy) and broth microdilution (ComASP, STC, Liofilchem, Italy) were used for susceptibility testing of CZA and CST, respectively. Synergy testing for CZA and AT was performed using disk approximation method. CLSI breakpoints were used for the interpretation of the results. For FDC, MIC50 and MIC90 were 2 and 8 µg/mL, respectively. A total of 80% of isolates were susceptible to FDC, 26.2% of isolates were susceptible to CZA, synergy testing with CZA/AT was positive for 74 (72%) of the isolates, and 89.3% were intermediate to CST. Nine (8.7%) were susceptible only to FDC. FDC is active in vitro against MER-R K. pneumoniae >CZA/AT > CZA > CST, as observed in this study, applying CLSI criteria. Clinico-microbiological studies should be performed to assess the clinical efficacy of this novel drug in this region with a high prevalence of carbapenem resistance among Gram-negative organisms. IMPORTANCE Management of infections with multi-drug resistant Klebsiella pneumoniae is a major challenge in hospital settings, with few treatment options. In this study, the authors aim to assess the in vitro susceptibility of these clinical isolates to cefiderocol, a novel siderophore. Comparators are colistin, ceftazidime-avibactam, and ceftazidime-avibactam/aztreonam synergy, which are currently available options for treatment in this region. Baseline-resistance rates against cefiderocol are higher than those in the previously published studies, with MIC50 and MIC90 at 2 and 8 µg/mL, respectively.
Collapse
Affiliation(s)
- Kalyani Borde
- Department of Microbiology, Apollo Institute of Medical Sciences and Research, Hyderabad, India
| | - M. A. Kareem
- Department of Microbiology, Apollo Institute of Medical Sciences and Research, Hyderabad, India
| | - Ratna Mani Sharma
- Department of Microbiology, Apollo Institute of Medical Sciences and Research, Hyderabad, India
| | - S. Manick Dass
- Department of Microbiology, Apollo Institute of Medical Sciences and Research, Hyderabad, India
| | - Vedantham Ravi
- Department of Microbiology, Apollo Institute of Medical Sciences and Research, Hyderabad, India
| | - Dilip Mathai
- Department of Internal Medicine and Adult Infectious Diseases, Apollo Institute of Medical Sciences and Research, Hyderabad, India
| |
Collapse
|
3
|
Das BJ, Singha KM, Wangkheimayum J, Chanda DD, Bhattacharjee A. Emergence of carbapenem-resistant enterobacterales co-harboring bla OXA-78 and bla OXA-58 from India. Ann Clin Microbiol Antimicrob 2023; 22:79. [PMID: 37679795 PMCID: PMC10486080 DOI: 10.1186/s12941-023-00635-6] [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: 06/05/2023] [Accepted: 08/29/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Carbapenem-Resistant Enterobacterales (CRE) has been categorized as pathogens of critical priority by World Health organization (WHO) as they pose significant threat to global public health. Carbapenemase production considered as the principal resistance mechanism against carbapenems and with the recent surge and expansion of carbapenemases and its variants among clinically significant bacteria in India, the present study reports expansion blaOXA-78 and blaOXA-58 of in CRE of clinical origin. METHODS Bacterial isolates were collected from a tertiary referral hospital and identified through VITEK® 2 Compact automated System (Biomerieux, France). Rapidec® Carba NP (Biomerieux, France) was used to investigate carbapenemase production followed by antibiotic susceptibility testing through Kirby-Bauer Disc Diffusion method and agar dilution method. Class D carbapenemase genes were targeted through PCR assay followed by investigation of horizontal transmission of blaOXA-58 and blaOXA-78. Whole genome sequencing was carried out using Illumina platform to investigate the genetic context of blaOXA-58 and blaOXA-78 genes and further characterization of the CRE isolates. RESULTS The carbapenem-resistant Escherichia coli (BJD_EC456) and Serratia marcescens (BJD_SM81) received during the study from the tertiary referral hospital were isolated from sputum and blood samples respectively. PCR assay followed by whole genome sequencing revealed that the isolates co-harbor blaOXA-58 and blaOXA-78, a variant of blaOXA-51. Horizontal transfer of blaOXA-58 and blaOXA-78 genes were unsuccessful as these genes were located on the chromosome of the study isolates. Transposon Tn6080 was linked to blaOXA-78 in the upstream region while the insertion sequences ISAba26 and ISCfr1 were identified in the upstream and downstream region of blaOXA-58 gene respectively. In addition, both the isolates were co-harboring multiple antibiotic resistance genes conferring clinical resistance towards beta-lactams, aminoglycosides, fluroquinolones, sulphonamides, tetracyclines. BJD_EC180 belonged to ST2437 while BJD_SM81 was of an unknown sequence type. The nucleotide sequences of blaOXA-78 (OQ533021) and blaOXA-58 (OQ533022) have been deposited in GenBank. CONCLUSIONS The study provides a local epidemiological information regarding carbapenem resistance aided by transposon and insertion sequences associated blaOXA-78 and blaOXA-58 genes associated and warrants continuous monitoring to prevent their further dissemination into carbapenem non-susceptible strains thereby contributing to carbapenem resistance burden which is currently a global concern.
Collapse
Affiliation(s)
- Bhaskar Jyoti Das
- Department of Microbiology, Assam University, Silchar, Dist : Cachar, 788011 Assam India
| | - K. Melson Singha
- Department of Microbiology, Silchar Medical College and Hospital, Silchar, Dist : Cachar, Assam, PIN : 788014 India
| | | | - Debadatta Dhar Chanda
- Department of Microbiology, Silchar Medical College and Hospital, Silchar, Dist : Cachar, Assam, PIN : 788014 India
| | - Amitabha Bhattacharjee
- Department of Microbiology, Assam University, Silchar, Dist : Cachar, 788011 Assam India
| |
Collapse
|
4
|
Rajendran S, Gopalakrishnan R, Tarigopula A, Kumar DS, Nambi PS, Sethuraman N, Chandran C, Ramakrishnan N, Ramasubramanian V. Xpert Carba-R Assay on Flagged Blood Culture Samples: Clinical Utility in Intensive Care Unit Patients with Bacteremia Caused by Enterobacteriaceae. Indian J Crit Care Med 2023; 27:655-662. [PMID: 37719341 PMCID: PMC10504648 DOI: 10.5005/jp-journals-10071-24533] [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: 07/15/2023] [Accepted: 08/18/2023] [Indexed: 09/19/2023] Open
Abstract
Introduction and background Rapid molecular diagnostics to predict carbapenem resistance well before the availability of routine drug sensitivity testing (DST) can serve as an antimicrobial stewardship tool in the context of high rates of Carbapenem-resistant Enterobacteriaceae (CRE). Materials and methods A retrospective observational study of patients more than 18 years of age on whom Xpert Carba-R (FDA approved for rectal swab specimen) was done on gram-negative bacteria (GNB) flagged blood culture samples, in an Indian intensive care unit between January 2015 and November 2018. We analyzed the performance of Xpert Carba-R in comparison with routine DST. Results A total of 164 GNBs were isolated from 160 patients. Klebsiella pneumoniae and Escherichia coli were the predominant isolates. Carba-R was positive in 35.36% of samples and 45.34% were carbapenem-resistant (CR) on routine DST. The distribution of the CR gene was: Oxacillinase (OXA) (50%), NDM (32.7%) followed by OXA and NDM co-expression (15.51%). The sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, positive predictive value, and negative predictive value of Carba-R were 90.74, 93.15, 13.25, 0.10, 83.58 and 96.31% for Enterobacteriaceae. The median time to obtain the Carba-R report was 30 hours 34 minutes vs 74 hours and 20 minutes for routine DST. Based on the Carba-R report, 9.72% of patients had escalation and 27.08% had de-escalation of antibiotics. Conclusion Xpert Carba-R serves as a rapid diagnostic tool for predicting carbapenem resistance in intensive care unit patients with bacteremia caused by Enterobacteriaceae. How to cite this article Rajendran S, Gopalakrishnan R, Tarigopula A, Kumar DS, Nambi PS, Sethuraman N, et al. Xpert Carba-R Assay on Flagged Blood Culture Samples: Clinical Utility in Intensive Care Unit Patients with Bacteremia Caused by Enterobacteriaceae. Indian J Crit Care Med 2023;27(9):655-662.
Collapse
Affiliation(s)
- Surendran Rajendran
- Department of Infectious Diseases, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - Ram Gopalakrishnan
- Department of Infectious Diseases, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - Anil Tarigopula
- Department of Molecular Laboratory Services, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - D Suresh Kumar
- Department of Infectious Diseases, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - P Senthur Nambi
- Department of Infectious Diseases, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - Nandini Sethuraman
- Department of Microbiology, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - Chitra Chandran
- Department of Molecular Diagnostics, Apollo Hospitals, Chennai, Tamil Nadu, India
| | | | - V Ramasubramanian
- Department of Infectious Diseases, Apollo Hospitals, Chennai, Tamil Nadu, India
| |
Collapse
|
5
|
Zhang Y, Yang X, Liu C, Huang L, Shu L, Sun Q, Zhou H, Huang Y, Cai C, Wu X, Chen S, Zhang R. Increased clonal dissemination of OXA-232-producing ST15 Klebsiella pneumoniae in Zhejiang, China from 2018 to 2021. Infect Dis Poverty 2023; 12:25. [PMID: 36949496 PMCID: PMC10031881 DOI: 10.1186/s40249-023-01051-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 01/03/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND OXA-232-producing Klebsiella pneumoniae was first identified in China in 2016, and its clonal transmission was reported in 2019. However, there are no prevalence and genotypic surveillance data available for OXA-232 in China. Therefore, we investigated the trends and characteristics of OXA-232 type carbapenemase in Zhejiang Province, China from 2018 to 2021. METHODS A total of 3278 samples from 1666 patients in the intensive care units were collected from hospitals in Zhejiang Province from 2018 to 2021. Carbapenem-resistant isolates were initially selected by China Blue agar plates supplemented with 0.3 μg/ml meropenem, and further analyzed by matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry identification, immune colloidal gold technique, conjugation experiment, antimicrobial susceptibility testing and whole genome sequencing. RESULTS A total of 79 OXA-producing strains were recovered, with the prevalence increased from 1.8% [95% confidence interval (CI): 0.7-3.7%] in 2018 to 6.0% (95% CI: 4.4-7.9%) in 2021. Seventy-eight strains produced OXA-232 and one produced OXA-181. The blaOXA-232 gene in all strains was located in a 6141-bp ColKP3-type non-conjugative plasmid and the blaOXA-181 gene was located in a 51,391-bp ColKP3/IncX3-type non-conjugative plasmid. The blaOXA-232-producing K. pneumoniae was dominated (75/76) by isolates of sequence type 15 (ST15) that differed by less than 80 SNPs. All OXA-producing strains (100%, 95% CI: 95.4-100.0%) were multidrug-resistant. CONCLUSIONS From 2018 to 2021, OXA-232 is the most prevalent OXA-48-like derivative in Zhejiang Province, and ST15 K. pneumoniae isolates belonging to the same clone are the major carriers. The transmission of ColKP3-type plasmid to E. coli highlighted that understanding the transmission mechanism is of great importance to delay or arrest the propagation of OXA-232 to other species.
Collapse
Affiliation(s)
- Yanyan Zhang
- Department of Clinical Laboratory, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xuemei Yang
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Kowloon, Hong Kong, China
| | - Congcong Liu
- Department of Clinical Laboratory, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ling Huang
- Department of Clinical Laboratory Medicine, Maternal and Child Health Hospital of Yuhang District, Hangzhou, China
| | - Lingbin Shu
- Department of Clinical Laboratory, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qiaoling Sun
- Department of Clinical Laboratory, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hongwei Zhou
- Department of Clinical Laboratory, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yonglu Huang
- Department of Clinical Laboratory, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chang Cai
- College of Animal Science and Technology, Zhejiang Agricultural and Forestry University, Hangzhou, China
| | - Xiaoyan Wu
- The Clinical Laboratory, Jiaxing Second Hospital, Jiaxing, China
| | - Sheng Chen
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Kowloon, Hong Kong, China
| | - Rong Zhang
- Department of Clinical Laboratory, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
| |
Collapse
|
6
|
Das S. The crisis of carbapenemase-mediated carbapenem resistance across the human-animal-environmental interface in India. Infect Dis Now 2023; 53:104628. [PMID: 36241158 DOI: 10.1016/j.idnow.2022.09.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 09/11/2022] [Accepted: 09/30/2022] [Indexed: 01/19/2023]
Abstract
Carbapenems are the decision-making antimicrobials used to combat severe Gram-negative bacterial infections in humans. Carbapenem resistance poses a potential public health emergency, especially in developing countries such as India, accounting for high morbidity, mortality, and healthcare cost. Emergence and transmission of plasmid-mediated "big five" carbapenemase genes including KPC, NDM, IMP, VIM and OXA-48-type among Gram-negative bacteria is spiralling the issue. Carbapenemase-producing carbapenem-resistant organisms (CP-CRO) cause multi- or pan-drug resistance by co-harboring several antibiotic resistance determinants. In addition of human origin, animals and even environmental sites are also the reservoir of CROs. Spillage in food-chains compromises food safety and security and increases the chance of cross-border transmission of these superbugs. Metallo-β-lactamases, mainly NDM-1 producing CROs, are commonly shared between human, animal and environmental interfaces worldwide, including in India. Antimicrobial resistance (AMR) surveillance using the One Health approach has been implemented in Europe, the United-Kingdom and the United-States to mitigate the crisis. This concept is still not implemented in most developing countries, including India, where the burden of antibiotic-resistant bacteria is high. Lack of AMR surveillance in animal and environmental sectors underestimates the cumulative burden of carbapenem resistance resulting in the silent spread of these superbugs. In-depth indiscriminate AMR surveillance focusing on carbapenem resistance is urgently required to develop and deploy effective national policies for preserving the efficacy of carbapenems as last-resort antibiotics in India. Tracking and mapping of international high-risk clones are pivotal for containing the global spread of CP-CRO.
Collapse
Affiliation(s)
- Surojit Das
- Biomedical Laboratory Science and Management, Vidyasagar University, Midnapore 721102, West Bengal, India.
| |
Collapse
|
7
|
Yadav B, Mohanty S, Behera B. Occurrence and Genomic Characteristics of Hypervirulent Klebsiella pneumoniae in a Tertiary Care Hospital, Eastern India. Infect Drug Resist 2023; 16:2191-2201. [PMID: 37077254 PMCID: PMC10108904 DOI: 10.2147/idr.s405816] [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: 02/08/2023] [Accepted: 03/29/2023] [Indexed: 04/21/2023] Open
Abstract
Purpose This study was conducted to find out the occurrence of hypervirulent Klebsiella pneumoniae (hvKP) isolates from different clinical specimens in a tertiary care hospital of eastern India and investigate the distribution of virulence factors, capsular serotypes and antibiogram profile. The distribution of carbapenemase-encoding genes in convergent (hvKP and carbapenem-resistant) isolates was also studied. Materials and methods A total of 1004 K. pneumoniae isolates were obtained from different clinical specimens from August 2019 to June 2021 and hvKP isolates were identified using the string test. Genes of capsular serotypes K1, K2, K5, K20, K54 and K57, virulence-associated genes, rmpA, rmpA2, mrkD, allS, iroN, iutA, iuc, kfuB and ybtS, and carbapenemase-encoding genes, NDM-1, OXA-48, OXA-181, and KPC, were evaluated by polymerase chain reaction. Antimicrobial susceptibility was determined primarily by the VITEK-2 Compact automated platform (bioMérieux, Marcy-l'Étoile, France) and supplemented by disc-diffusion/EzyMIC (HiMedia, Mumbai, India) wherever needed. Results Out of 1004 isolates, 33 (3.3%) were hvKP. Most frequent capsular serotype was K2 in 11 (33.3%). Amongst virulence genes, mrkD, iutA and kfuB were detected most frequently in 93.9%, 84.8% and 63.6% isolates respectively. Classical Klebsiella pneumoniae isolates were significantly more resistant than hvKP to cephalosporins, amoxicillin-clavulanic acid, and fluoroquinolones (p < 0.05). Carbapenem resistance was seen in 10 hvKP convergent isolates with the most prevalent carbapenemase-encoding gene being OXA-48 and OXA-181 in 50% isolates. Conclusion There is a need for continued surveillance of hvKP strains in view of the impending threat of a global spread of convergent strains.
Collapse
Affiliation(s)
- Bhuvan Yadav
- Department of Microbiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Srujana Mohanty
- Department of Microbiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
- Correspondence: Srujana Mohanty, Department of Microbiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India, Tel +9438884124, Email
| | - Bijayini Behera
- Department of Microbiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| |
Collapse
|
8
|
Nayak G, Behera B, Mahapatra A, Tripathy S, Biswal J. Molecular Detection of Carbapenemase Enzymes Directly from Positive Blood Cultures Using Xpert Carba-R. J Lab Physicians 2022; 14:365-368. [PMID: 36119431 PMCID: PMC9473928 DOI: 10.1055/s-0042-1744238] [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: 11/22/2022] Open
Abstract
Objective The performance of Xpert Carba-R assay for the direct identification of carbapenemases directly from positive blood culture vials was evaluated. Materials and Methods In total, 176 positively flagged blood culture vials, yielding carbapenem-resistant GNB (CR-GNB), were enrolled for the detection and differentiation of blaKPC, blaNDM, blaVIM, blaOXA-48, and blaIMP using Xpert Carba-R. Results Klebsiella pneumoniae (76/176, 43.1%), Acinetobacter baumannii complex (67/176, 38%), and Escherichia coli (29/176,16.4%) were the predominant isolates. Overall, NDM production was the commonest (61/176, 34.6%), followed by the co-production of NDM + OXA-48 and the absence of any CR gene (44/176, 25%), followed by OXA-48 (27/176, 15.3%). In CR K. pneumoniae , the co-production of NDM + OXA-48 was most frequent (34/76, 44.7%), whereas in the A. baumannii complex , no CR gene was detected in the majority of isolates (38/67, 56.7%). bla NDM was the commonest gene in E. coli (18/29, 62%) and A. baumannii complex (26/67, 38.8%). Conclusion Xpert Carba-R can identify the molecular mechanism of CR within hours after a blood culture turns positive and, thus, has the potential for optimization of antimicrobial therapy, choosing appropriate novel β-lactam combination agents, as well as infection control interventions.
Collapse
Affiliation(s)
- Gayatree Nayak
- Department of Microbiology, All India Institute of Medical Sciences, Bhubaneswar, Orissa, India
| | - Bijayini Behera
- Department of Microbiology, All India Institute of Medical Sciences, Bhubaneswar, Orissa, India
| | - Ashoka Mahapatra
- Department of Microbiology, All India Institute of Medical Sciences, Bhubaneswar, Orissa, India
| | - Swagata Tripathy
- Department of Anaesthesiology & Critical Care Medicine, All India Institute of Medical Sciences, Bhubaneswar, Orissa, India
| | - Jyoti Biswal
- Department of Infection Control Nursing, All India Institute of Medical Sciences, Bhubaneswar, Orissa, India
| |
Collapse
|
9
|
Occurrence of blaOXA-48 type carbapenemase in Escherichia coli with coexisting resistance determinants: A report from India. GENE REPORTS 2022. [DOI: 10.1016/j.genrep.2021.101459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
10
|
Das BJ, Wangkheimayum J, Singha KM, Bhowmik D, Dhar (Chanda) D, Bhattacharjee A. Propagation of blaKPC-2 within two sequence types of Escherichia coli in a tertiary referral hospital of northeast India. GENE REPORTS 2021. [DOI: 10.1016/j.genrep.2021.101283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
11
|
Ssekatawa K, Byarugaba DK, Nakavuma JL, Kato CD, Ejobi F, Tweyongyere R, Eddie WM. Prevalence of pathogenic Klebsiella pneumoniae based on PCR capsular typing harbouring carbapenemases encoding genes in Uganda tertiary hospitals. Antimicrob Resist Infect Control 2021; 10:57. [PMID: 33736698 PMCID: PMC7977577 DOI: 10.1186/s13756-021-00923-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 03/02/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Klebsiella pneumoniae is an opportunistic pathogen that has been implicated as one of commonest cause of hospital and community acquired infections. The K. pneumoniae infections have considerably contributed to morbidity and mortality in patients with protracted ailments. The capacity of K. pneumoniae to cause diseases depends on the presence of an array virulence factors. Coexistence and expression of virulence factors and genetic determinants of antibiotic resistance complicates treatment outcomes. Thus, emergence of pathogenic MDR K. pneumoniae poses a great threat to the healthcare system. However, the carriage of antibiotic resistance among pathogenic K. pneumoniae is yet to be investigated in Uganda. We sought to investigate the carbapenem resistance profiles and pathogenic potential based on capsular serotypes of K. pneumoniae clinical isolates. METHODS This was a cross sectional study involving use of archived Klebsiella pneumoniae isolates collected between January and December, 2019 at four tertiary hospitals in Uganda. All isolates were subject to antimicrobial susceptibility assays to determine phenotypic antibiotic resistance, pentaplex PCR to detect carbapenemases encoding genes and heptaplex PCR to identify capsular serotypes K1, K2, K3, K5, K20, K54 and K57. RESULTS The study found an overall phenotypic carbapenem resistance of 23.3% (53/227) and significantly higher genotypic resistance prevalence of 43.1% (98/227). Over all, the most prevalent gene was blaOXA-48-like (36.4%), followed by blaIMP-type (19.4%), blaVIM-type (17.1%), blaKPC-type (14.0%) and blaNDM-type (13.2%). blaVIM-type and blaOXA-48-like conferred phenotypic resistance in all isolates and 38.3% of isolates that harbored them respectively. Capsular multiplex PCR revealed that 46.7% (106/227) isolates were pathogenic and the predominantly prevalent pathotype was K5 (18.5%) followed by K20 (15.1%), K3 (7.1%), K2 (3.1%) and K1 (2.2%). Of the 106 capsular serotypes, 37 expressed phenotypic resistance; thus, 37 of the 53 carbapenem resistant K. pneumoniae were pathogenic. CONCLUSION The high prevalence of virulent and antibiotic resistant K. pneumoniae among clinical isolates obtained from the four tertiary hospital as revealed by this study pose a great threat to healthcare. Our findings underline the epidemiological and public health risks and implications of this pathogen.
Collapse
Affiliation(s)
- Kenneth Ssekatawa
- College of Veterinary Medicine, Animal Resources and Biosecurity, Makerere University, P. O. Box 7062, Kampala, Uganda
- Department of Biochemistry, Faculty of Biomedical Sciences, Kampala International University-Western Campus, P. O. Box 71, Bushenyi, Uganda
- Africa Center Excellence in Materials Product Development and Nanotechnology (MAPRONANO ACE), College of Engineering Design Art and Technology, Makerere University, P. O. Box 7062, Kampala, Uganda
| | - Denis K. Byarugaba
- College of Veterinary Medicine, Animal Resources and Biosecurity, Makerere University, P. O. Box 7062, Kampala, Uganda
| | - Jesca L. Nakavuma
- College of Veterinary Medicine, Animal Resources and Biosecurity, Makerere University, P. O. Box 7062, Kampala, Uganda
| | - Charles D. Kato
- College of Veterinary Medicine, Animal Resources and Biosecurity, Makerere University, P. O. Box 7062, Kampala, Uganda
| | - Francis Ejobi
- College of Veterinary Medicine, Animal Resources and Biosecurity, Makerere University, P. O. Box 7062, Kampala, Uganda
| | - Robert Tweyongyere
- College of Veterinary Medicine, Animal Resources and Biosecurity, Makerere University, P. O. Box 7062, Kampala, Uganda
| | - Wampande M. Eddie
- College of Veterinary Medicine, Animal Resources and Biosecurity, Makerere University, P. O. Box 7062, Kampala, Uganda
| |
Collapse
|
12
|
Azam M, Gaind R, Yadav G, Sharma A, Upmanyu K, Jain M, Singh R. Colistin Resistance Among Multiple Sequence Types of Klebsiella pneumoniae Is Associated With Diverse Resistance Mechanisms: A Report From India. Front Microbiol 2021; 12:609840. [PMID: 33692764 PMCID: PMC7937630 DOI: 10.3389/fmicb.2021.609840] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 01/22/2021] [Indexed: 12/25/2022] Open
Abstract
Background: The resistance to colistin and carbapenems in Klebsiella pneumoniae infections have been associated with increased morbidity and mortality worldwide. A retrospective observational study was conducted to determine the prevalence and molecular events contributing to colistin resistance. Methods: Clinical samples were screened for colistin resistance and underlying mechanisms were studied by PCR-based amplification and sequence analysis of genes of two-component regulatory system (phoPQ and pmrAB), regulatory transmembrane protein-coding mgrB, and mobilized colistin resistance genes (mcr-1-8). Gene expression of pmrC and pmrK was analyzed by qRT-PCR, and the genetic relationship was assessed by MLST. The putative effect of amino-acid substitutions was predicted by a combination of bioinformatics tools. Results: Of 335 Klebsiella spp. screened, 11 (3.2%) were identified as colistin-resistant (MIC range, 8 to >128 μg/ml). K. pneumoniae isolates belonged to clonal complex-11 (CC11) with sequence types (STs): 14, 16, 43, 54, 147 and 395, whereby four isolates conferred three novel STs (3986, 3987 and 3988) profiles. Sequence analysis revealed non-synonymous potentially deleterious mutations in phoP (T151A), phoQ (del87–90, del263–264, L30Q, and A351D), pmrA (G53S), pmrB (D150V, T157P, L237R, G250C, A252G, R315P, and Q331H), and mgrB (C28G) genes. The mgrB gene in three strains was disrupted by insertion sequences encoding IS1-like and IS5/IS1182 family-like transposase genes. All 11 isolates showed an elevation in the transcription level of pmrC gene. Mobilized colistin-resistance (mcr) genes were not detected. All but one of the colistin-resistant isolates was also resistant to carbapenems; β-lactamase genes blaNDM-1-like, blaOXA-48-like, and blaCTX-M-like were detected in eight, five, and nine isolates, respectively. Conclusion: All the studied colistin- and carbapenem-resistant K. pneumoniae isolates were genetically distinct, and various mechanisms of colistin resistance were detected, indicating its spontaneous emergence in this bacterial species.
Collapse
Affiliation(s)
- Mudsser Azam
- ICMR-National Institute of Pathology, New Delhi, India
| | - Rajni Gaind
- Department of Microbiology, VMMC and Safdarjung Hospital, New Delhi, India
| | - Gulshan Yadav
- ICMR-National Institute of Pathology, New Delhi, India
| | - Amit Sharma
- Department of Microbiology, VMMC and Safdarjung Hospital, New Delhi, India
| | - Kirti Upmanyu
- ICMR-National Institute of Pathology, New Delhi, India
| | - Manisha Jain
- Department of Microbiology, VMMC and Safdarjung Hospital, New Delhi, India
| | - Ruchi Singh
- ICMR-National Institute of Pathology, New Delhi, India
| |
Collapse
|
13
|
Adesanya OA, Igwe HA. Carbapenem-resistant Enterobacteriaceae (CRE) and gram-negative bacterial infections in south-west Nigeria: a retrospective epidemiological surveillance study. AIMS Public Health 2020; 7:804-815. [PMID: 33294483 PMCID: PMC7719558 DOI: 10.3934/publichealth.2020062] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/25/2020] [Indexed: 11/18/2022] Open
Abstract
Background Carbapenem-resistant Enterobacteriaceae (CRE) are often responsible for severe, life-threatening infections and they represent a critical threat to the available antibiotic agents and to global health. An understanding of the epidemiology of these infections will be indispensable to the development of appropriate case management as well as infection prevention and control (IPC) measures in any healthcare setting. Objectives The objective of this study was to investigate and describe the epidemiology of carbapenem-resistant Enterobacteriaceae (CRE) and other gram-negative bacteria in a tertiary hospital in south west Nigeria using routinely collected microbiological laboratory data. Methods A retrospective collection of microbiological laboratory records from the January to June 2018 was performed. All culture and antimicrobial susceptibility test results of patients who required laboratory tests were collected. Other information collected include: patient demographics, clinical specimen types and the requesting hospital department. The data was analyzed using SPSS Windows version 24. Comparison between categorical variables was done using chi-square tests while independent sample t-test was used to determine significant mean differences between groups. A p < 0.05 was taken to be statistically significant. Results The prevalence of carbapenem-resistance among Enterobacteriaceae and gram-negative bacteria isolates was 22% (n = 39/177). Of these, 35.9% (n = 14) were Klebsiella pneumonia, 30.8% (n = 12) were Pseudomonas aeruginosa and 15.4% (n = 6) were Klebsiella oxytoca. 87.2% (n = 34) of these were also multi-drug resistant, with a mean total resistance score of 3.92 (SD = ± 1.44). There were differences observed in proportion of carbapenem-resistance across clinical specialties and age groups; however, these differences were not statistically significant. Independent sample t-test revealed that carbapenem-resistant isolates exhibited more drug resistance than carbapenem-sensitive isolates (3.93 vs. 2.30; p < 0.001). Conclusion Carbapenem resistance is an important threat to the current antibiotic armory. Active surveillance, particularly in the healthcare setting is required to identify high risk groups, inform better treatment options and infection prevention and control measures.
Collapse
Affiliation(s)
- Oluwafolajimi Adetoye Adesanya
- Institute for Advanced Medical Research and Training (IAMRAT), College of Medicine, University of Ibadan, Ibadan, Nigeria.,Department of Clinical Microbiology and Parasitology, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Hilda Amauche Igwe
- Department of Clinical Microbiology and Parasitology, College of Medicine, University of Ibadan, Ibadan, Nigeria
| |
Collapse
|
14
|
Rising Threat of OXA-48 and other Carbapenemase Encoding Genes among Carbapenem Resistant Enterobacteriaceae in India. JOURNAL OF PURE AND APPLIED MICROBIOLOGY 2020. [DOI: 10.22207/jpam.14.3.30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Members of Enterobacteriaceae family are responsible for both community and hospital acquired infections. Because of development of antimicrobial resistance carbapenem has remained as last resort of drug for treatment of infections caused by these bacteria.Mechanism for development of this resistance in carbapenem resistant Enterobacteriaceae (CRE) may due to production of carbapenemases, efflux mechanism or loss of outer membrane porins.The most common carbapenemase enzymes are Class A – KPC, Class B – NDM, VIM and IMP and Class D oxacillinase(OXA-48 like enzymes).In India, most prevalent carbapenemase encoding gene is NDM-1but there is rising threat of OXA-48 prevalence. Unlike the phenotypic methods, the genotypic methods are useful to discriminate the type of carbapenemase enzyme, specifically for OXA-48 like enzymes. Total 170 CRE isolates were subjected for multiplex PCR study for their molecular characterization. Of the 170 CRE isolates,68.2 % (n=116) were positive for NDM-1 gene while 44.1 % (n= 75) of the isolates showed presence of OXA-48 gene. VIM (2.3%), KPC (1.7 %) were responsible for carbapenemase production while none of the isolates showed presence of IMP gene. NDM-1 and OXA-48 coexisted in 21.2 % (n=36) of the total isolates. OXA-48 causes weak hydrolysis of carbapenem because of which it is under reported with routine diagnostic methods. Early detection of OXA-48 and other carbapenemase encoding genes, helps for contact precautions and effective therapy which prevents further escalation and horizontal spread of CRE.
Collapse
|
15
|
Sahu C, Pal S, Patel SS, Singh S, Gurjar M, Ghoshal U. Phenotypic synergy testing of ceftazidime-avibactam with aztreonam in a university hospital having high number of metallobetalactamase producing bacteria. Infect Dis (Lond) 2020; 52:801-807. [PMID: 32628575 DOI: 10.1080/23744235.2020.1788224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Ceftazidime-avibactam combination with aztreonam and role of rapid synergy reporting has not been widely evaluated. Also the synergy correlation with various betalactamases has not been widely studied. METHODS We studied phenotypic synergy testings and molecular detection of betalactamases in our university hospital where we have large number of mellatobetalactmase producing bacteria. We tested two phenotypic synergy methods for ceftazidime-avibactam with aztreonam (Disc-E strip method, E strip-Agar method) for rapid reporting to clinicians (153 isolates). The treatment (colistin, ceftazidime-avibactam, ceftazidime-avibactam with aztreonam) was guided as indicated in the synergy testings. The resistance genes in bacteria were identified by polymerase chain reaction (PCR) and correlated with synergy results. RESULTS The highest synergy was seen in Klebsiella pneumoniae by Disc-E strip and E strip-Agar method (86% and 84% respectively). About 70% of Pseudomonas aeruginosa and 29% of Escherichia coli showed synergy. Molecular methods revealed multiple resistance gene combinations and bla NDM (96%) was predominant gene in isolates showing synergy. Among isolates that were sensitive to ceftazidime-avibactam, the predominant genes were bla OXA-48 and bla IMP. Rapid laboratory reporting led to proper utilization of antibiotic combinations. CONCLUSIONS Ceftazidime-avibactam and aztreonam rapid synergy testing will be highly beneficial in treatment of infections by metallobetalactamase producing resistant bacteria, especially K. pneumoniae and P. aeruginosa.
Collapse
Affiliation(s)
- Chinmoy Sahu
- Department of Microbiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Sourav Pal
- Department of Microbiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Sangram Singh Patel
- Department of Microbiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Sanjay Singh
- Department of Microbiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Ujjala Ghoshal
- Department of Microbiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| |
Collapse
|
16
|
Gupta V, Singh M, Datta P, Goel A, Singh S, Prasad K, Chander J. Detection of various beta-Lactamases in Escherichia coli and Klebsiella sp.: A study from Tertiary Care Centre of North India. Indian J Med Microbiol 2020; 38:390-396. [PMID: 33154252 DOI: 10.4103/ijmm.ijmm_20_253] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objective The emergence of carbapenem-resistant Escherichia coli and Klebsiella species is a global threat. We aimed to compare two phenotypic methods and evaluate the genotypic method for the detection of beta-lactamases produced by E. coli and Klebsiella spp. Materials and Methods One hundred and twenty-six E. coli and Klebsiella isolates were examined for phenotypic production of beta-lactamases by using disc diffusion, combined disc test (CDT) and modified carbapenem inactivation method (mCIM). All strains were also studied for the presence of various genes by polymerase chain reaction. Results Out of 126 isolates, 96% of the isolates were extended-spectrum β-lactamase (ESBL) producers based on the presence of various ESBL genes. CDT method showed higher number of total (89%) carbapenemases in comparison to mCIM (81%). Among carbapenemases none of the isolates were Klebsiella pneumoniae carbapenemase producer by CDT, while 69% isolates were metallo-beta-lactamase (MBL) producers. Another method, mCIM/ethylene diamine tetraacetic acid mCIM showed 100% agreement for MBL detection. As regards, AmpC and class D carbapenemases; 0.04% and 16% positivity was detected, respectively, based on CDT method. Molecular analysis revealed 91% of the isolates harbouring carbapenemase genes. blaNDMwas the most common gene detected followed byblaOXA-48. Nine of the blaNDM-positive isolates also possessed blaOXA-48gene. Conclusion Our finding shows high percentages of ESBL and carbapenemases in E. coli and Klebsiella spp. Among phenotypic methods, CDT seems to be a better choice as prevalence of carbapenemases shows lots of variation in our country. For Class B enzymes, both CDT and mCIM/eCIM can be used in the routine laboratories.
Collapse
Affiliation(s)
- Varsha Gupta
- Department of Microbiology, Government Medical College and Hospital, Chandigarh, India
| | - Meenakshi Singh
- Department of Microbiology, Government Medical College and Hospital, Chandigarh, India
| | - Priya Datta
- Department of Microbiology, Government Medical College and Hospital; Department of Parasitology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anku Goel
- Department of Microbiology, Government Medical College and Hospital, Chandigarh, India
| | - Sanjay Singh
- Department of Microbiology, Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kashinath Prasad
- Department of Microbiology, Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Jagdish Chander
- Department of Microbiology, Government Medical College and Hospital, Chandigarh, India
| |
Collapse
|
17
|
Detection of Klebsiella pneumoniae Carbapenemase (KPC) Producing Enterobacteriaceae Isolates from Various Clinical Samples in a Rural Health Setup. JOURNAL OF PURE AND APPLIED MICROBIOLOGY 2020. [DOI: 10.22207/jpam.14.1.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
18
|
Wyres KL, Nguyen TNT, Lam MMC, Judd LM, van Vinh Chau N, Dance DAB, Ip M, Karkey A, Ling CL, Miliya T, Newton PN, Lan NPH, Sengduangphachanh A, Turner P, Veeraraghavan B, Vinh PV, Vongsouvath M, Thomson NR, Baker S, Holt KE. Genomic surveillance for hypervirulence and multi-drug resistance in invasive Klebsiella pneumoniae from South and Southeast Asia. Genome Med 2020; 12:11. [PMID: 31948471 DOI: 10.1101/557785v1.full] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 12/12/2019] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Klebsiella pneumoniae is a leading cause of bloodstream infection (BSI). Strains producing extended-spectrum beta-lactamases (ESBLs) or carbapenemases are considered global priority pathogens for which new treatment and prevention strategies are urgently required, due to severely limited therapeutic options. South and Southeast Asia are major hubs for antimicrobial-resistant (AMR) K. pneumoniae and also for the characteristically antimicrobial-sensitive, community-acquired "hypervirulent" strains. The emergence of hypervirulent AMR strains and lack of data on exopolysaccharide diversity pose a challenge for K. pneumoniae BSI control strategies worldwide. METHODS We conducted a retrospective genomic epidemiology study of 365 BSI K. pneumoniae from seven major healthcare facilities across South and Southeast Asia, extracting clinically relevant information (AMR, virulence, K and O antigen loci) using Kleborate, a K. pneumoniae-specific genomic typing tool. RESULTS K. pneumoniae BSI isolates were highly diverse, comprising 120 multi-locus sequence types (STs) and 63 K-loci. ESBL and carbapenemase gene frequencies were 47% and 17%, respectively. The aerobactin synthesis locus (iuc), associated with hypervirulence, was detected in 28% of isolates. Importantly, 7% of isolates harboured iuc plus ESBL and/or carbapenemase genes. The latter represent genotypic AMR-virulence convergence, which is generally considered a rare phenomenon but was particularly common among South Asian BSI (17%). Of greatest concern, we identified seven novel plasmids carrying both iuc and AMR genes, raising the prospect of co-transfer of these phenotypes among K. pneumoniae. CONCLUSIONS K. pneumoniae BSI in South and Southeast Asia are caused by different STs from those predominating in other regions, and with higher frequency of acquired virulence determinants. K. pneumoniae carrying both iuc and AMR genes were also detected at higher rates than have been reported elsewhere. The study demonstrates how genomics-based surveillance-reporting full molecular profiles including STs, AMR, virulence and serotype locus information-can help standardise comparisons between sites and identify regional differences in pathogen populations.
Collapse
Affiliation(s)
- Kelly L Wyres
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, 3004, Australia
| | - To N T Nguyen
- Hospital of Tropical Diseases, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Margaret M C Lam
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, 3004, Australia
| | - Louise M Judd
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, 3004, Australia
| | | | - David A B Dance
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- London School of Hygiene and Tropical Medicine, London, UK
| | - Margaret Ip
- Department of Microbiology, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Abhilasha Karkey
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Patan Academy of Health Sciences, Oxford University Clinical Research Unit, Kathmandu, Nepal
| | - Clare L Ling
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
| | - Thyl Miliya
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Paul N Newton
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Amphone Sengduangphachanh
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
| | - Paul Turner
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Balaji Veeraraghavan
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Phat Voong Vinh
- Hospital of Tropical Diseases, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Manivanh Vongsouvath
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
| | - Nicholas R Thomson
- London School of Hygiene and Tropical Medicine, London, UK
- Wellcome Trust Sanger Institute, Hinxton, Cambridge, UK
| | - Stephen Baker
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID) Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0AW, UK.
| | - Kathryn E Holt
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, 3004, Australia
- London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
19
|
Wyres KL, Nguyen TNT, Lam MMC, Judd LM, van Vinh Chau N, Dance DAB, Ip M, Karkey A, Ling CL, Miliya T, Newton PN, Lan NPH, Sengduangphachanh A, Turner P, Veeraraghavan B, Vinh PV, Vongsouvath M, Thomson NR, Baker S, Holt KE. Genomic surveillance for hypervirulence and multi-drug resistance in invasive Klebsiella pneumoniae from South and Southeast Asia. Genome Med 2020; 12:11. [PMID: 31948471 PMCID: PMC6966826 DOI: 10.1186/s13073-019-0706-y] [Citation(s) in RCA: 157] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 12/12/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Klebsiella pneumoniae is a leading cause of bloodstream infection (BSI). Strains producing extended-spectrum beta-lactamases (ESBLs) or carbapenemases are considered global priority pathogens for which new treatment and prevention strategies are urgently required, due to severely limited therapeutic options. South and Southeast Asia are major hubs for antimicrobial-resistant (AMR) K. pneumoniae and also for the characteristically antimicrobial-sensitive, community-acquired "hypervirulent" strains. The emergence of hypervirulent AMR strains and lack of data on exopolysaccharide diversity pose a challenge for K. pneumoniae BSI control strategies worldwide. METHODS We conducted a retrospective genomic epidemiology study of 365 BSI K. pneumoniae from seven major healthcare facilities across South and Southeast Asia, extracting clinically relevant information (AMR, virulence, K and O antigen loci) using Kleborate, a K. pneumoniae-specific genomic typing tool. RESULTS K. pneumoniae BSI isolates were highly diverse, comprising 120 multi-locus sequence types (STs) and 63 K-loci. ESBL and carbapenemase gene frequencies were 47% and 17%, respectively. The aerobactin synthesis locus (iuc), associated with hypervirulence, was detected in 28% of isolates. Importantly, 7% of isolates harboured iuc plus ESBL and/or carbapenemase genes. The latter represent genotypic AMR-virulence convergence, which is generally considered a rare phenomenon but was particularly common among South Asian BSI (17%). Of greatest concern, we identified seven novel plasmids carrying both iuc and AMR genes, raising the prospect of co-transfer of these phenotypes among K. pneumoniae. CONCLUSIONS K. pneumoniae BSI in South and Southeast Asia are caused by different STs from those predominating in other regions, and with higher frequency of acquired virulence determinants. K. pneumoniae carrying both iuc and AMR genes were also detected at higher rates than have been reported elsewhere. The study demonstrates how genomics-based surveillance-reporting full molecular profiles including STs, AMR, virulence and serotype locus information-can help standardise comparisons between sites and identify regional differences in pathogen populations.
Collapse
Affiliation(s)
- Kelly L Wyres
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, 3004, Australia
| | - To N T Nguyen
- Hospital of Tropical Diseases, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Margaret M C Lam
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, 3004, Australia
| | - Louise M Judd
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, 3004, Australia
| | | | - David A B Dance
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- London School of Hygiene and Tropical Medicine, London, UK
| | - Margaret Ip
- Department of Microbiology, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Abhilasha Karkey
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Patan Academy of Health Sciences, Oxford University Clinical Research Unit, Kathmandu, Nepal
| | - Clare L Ling
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
| | - Thyl Miliya
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Paul N Newton
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Amphone Sengduangphachanh
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
| | - Paul Turner
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Balaji Veeraraghavan
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Phat Voong Vinh
- Hospital of Tropical Diseases, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Manivanh Vongsouvath
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
| | - Nicholas R Thomson
- London School of Hygiene and Tropical Medicine, London, UK
- Wellcome Trust Sanger Institute, Hinxton, Cambridge, UK
| | - Stephen Baker
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID) Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0AW, UK.
| | - Kathryn E Holt
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, 3004, Australia
- London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
20
|
Pragasam AK, Veeraraghavan B, Shankar BA, Bakthavatchalam YD, Mathuram A, George B, Chacko B, Korula P, Anandan S. Will ceftazidime/avibactam plus aztreonam be effective for NDM and OXA-48-Like producing organisms: Lessons learnt from In vitro study. Indian J Med Microbiol 2019; 37:34-41. [PMID: 31424008 DOI: 10.4103/ijmm.ijmm_19_189] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Introduction Carbapenem resistance (CR) in Klebsiella pneumoniae is mainly mediated by bla NDM and bla OXA-48 carbapenemases. Newer Food and Drug Administration-approved antimicrobial ceftazidime/avibactam (C/A) has a potent activity against bla OXA-48-like producers. However, its activity is limited in organisms co-producing bla NDM and bla OXA-48-like. Addition of aztreonam (ATM) to C/A potentially expands the spectrum of coverage for carbapenemase co-producers. With this, we aimed to determine the synergistic activity of combination of C/A plus ATM against bla NDM, bla OXA-48-like and co-producers of bla NDM + bla OXA-48-like producing CR Klebsiella pneumoniae (CRKp). Materials and Methods A total of 12 isolates of CRKp-harbouring genes encoding bla NDM and bla OXA-48-like were tested. Minimum inhibitory concentrations (MICs) were determined for several antimicrobial agents, including C/A (0.5-8 μg/ml) by broth microdilution method. Checkerboard assay was performed for the combination of C/A plus ATM at varying concentrations. Fold differences in the MIC of C/A with and without addition of ATM were determined to infer synergistic effects. Results MIC of C/A and ATM ranged from 0.5 to >8 μg/ml and 64 to 2048 μg/ml, respectively. Two isolates were susceptible to C/A with MIC of 0.5 and 1 μg/ml, while others were resistant with MIC of >8 μg/ml. Synergistic effects of >8-fold MIC difference in C/A MIC were noted with addition of ATM at 4 μg/ml. This was observed for all CRKp with profiles of bla NDM, bla OXA-48-like and co-producers of bla NDM + bla OXA-48-like genes, which was a promising effect. Notably, all five of the colistin-resistant CRKp were inhibited with >8-fold MIC difference in the combination of C/A plus ATM at 4 μg/ml. Conclusion With the increasing burden of CRKp, the use of C/A with ATM combination seems to be very promising, especially for bla NDM, bla OXA-48-like and co-producers of bla NDM + bla OXA-48like carbapenemases.
Collapse
Affiliation(s)
- Agila Kumari Pragasam
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Balaji Veeraraghavan
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Baby Abirami Shankar
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Alice Mathuram
- Department of General Medicine Unit-1, Christian Medical College, Vellore, Tamil Nadu, India
| | - Biju George
- Department of Haematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Binila Chacko
- Department of Medical Intensive Care Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - Pritish Korula
- Department of Division of Critical Care, Christian Medical College, Vellore, Tamil Nadu, India
| | - Shalini Anandan
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
| |
Collapse
|
21
|
Abstract
Surveillance studies have shown that OXA-48-like carbapenemases are the most common carbapenemases in Enterobacterales in certain regions of the world and are being introduced on a regular basis into regions of nonendemicity, where they are responsible for nosocomial outbreaks. OXA-48, OXA-181, OXA-232, OXA-204, OXA-162, and OXA-244, in that order, are the most common enzymes identified among the OXA-48-like carbapenemase group. OXA-48 is associated with different Tn1999 variants on IncL plasmids and is endemic in North Africa and the Middle East. OXA-162 and OXA-244 are derivatives of OXA-48 and are present in Europe. OXA-181 and OXA-232 are associated with ISEcp1, Tn2013 on ColE2, and IncX3 types of plasmids and are endemic in the Indian subcontinent (e.g., India, Bangladesh, Pakistan, and Sri Lanka) and certain sub-Saharan African countries. Overall, clonal dissemination plays a minor role in the spread of OXA-48-like carbapenemases, but certain high-risk clones (e.g., Klebsiella pneumoniae sequence type 147 [ST147], ST307, ST15, and ST14 and Escherichia coli ST38 and ST410) have been associated with the global dispersion of OXA-48, OXA-181, OXA-232, and OXA-204. Chromosomal integration of bla OXA-48 within Tn6237 occurred among E. coli ST38 isolates, especially in the United Kingdom. The detection of Enterobacterales with OXA-48-like enzymes using phenotypic methods has improved recently but remains challenging for clinical laboratories in regions of nonendemicity. Identification of the specific type of OXA-48-like enzyme requires sequencing of the corresponding genes. Bacteria (especially K. pneumoniae and E. coli) with bla OXA-48, bla OXA-181, and bla OXA-232 are emerging in different parts of the world and are most likely underreported due to problems with the laboratory detection of these enzymes. The medical community should be aware of the looming threat that is posed by bacteria with OXA-48-like carbapenemases.
Collapse
|
22
|
Peirano G, Matsumura Y, Nobrega D, Pitout JDD. A Cost-Effective Method for Identifying Enterobacterales with OXA-181. J Clin Microbiol 2019; 57:e01281-19. [PMID: 31462547 PMCID: PMC6813009 DOI: 10.1128/jcm.01281-19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 08/26/2019] [Indexed: 02/07/2023] Open
Abstract
OXA-181 is the second most common global OXA-48-like carbapenemase and is endemic in the Indian subcontinent. Molecular studies have shown that Enterobacterales with OXA-181 are often introduced into regions of nonendemicity. Distinguishing OXA-181 from other OXA-48-like enzymes often requires sequencing, which is rather expensive and time-consuming. A specific PCR (i.e., OXA181PCR) for the detection of blaOXA-181 was validated using a global collection (n = 315) of bacteria with well-characterized carbapenemases and showed 100% sensitivity and specificity (95% confidence interval [CI], 94.1 to 100 and 98.6 to 100, respectively) for detecting bacteria with OXA-181. The OXA181PCR subsequently gave positive results on 58/160 (36%) Enterobacterales with OXA-48-like carbapenemases from the 2015 INFORM surveillance program. The blaOXA-181-positive Enterobacterales were present in 9 countries spanning 5 continents, illustrating the global distribution of OXA-181. This methodology can easily be incorporated into molecular surveillance programs to provide accurate information about the prevalence of OXA-181. A loop-mediated isothermal amplification (LAMP)-OXA48 assay overall performed well for detecting OXA-48-like enzymes but showed poor specificity due to false-positive results with non-OXA carbapenemases.
Collapse
Affiliation(s)
- Gisele Peirano
- Division of Microbiology, Alberta Public Laboratories, Cummings School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Pathology and Laboratory Medicine, Cummings School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Yasufumi Matsumura
- Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Diego Nobrega
- Department of Production Animal Health, Faculty of Veterinary Medicine, University of Calgary, Alberta, Canada
| | - Johann D D Pitout
- Division of Microbiology, Alberta Public Laboratories, Cummings School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Pathology and Laboratory Medicine, Cummings School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Microbiology, Immunology, and Infectious Diseases, Cummings School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
| |
Collapse
|
23
|
Jaggi N, Chatterjee N, Singh V, Giri SK, Dwivedi P, Panwar R, Sharma AP. Carbapenem resistance in Escherichia coli and Klebsiella pneumoniae among Indian and international patients in North India. Acta Microbiol Immunol Hung 2019; 66:367-376. [PMID: 31438725 DOI: 10.1556/030.66.2019.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The aim of the study was to find out the carbapenem resistance rate and prevalence of different carbapenemase genes in Klebsiella pneumoniae and Escherichia coli from a North Indian corporate hospital that receives both Indian and international patients. A total of 528 clinical isolates of E. coli and K. pneumoniae were included in the study. All isolates that were found resistant to carbapenems by MIC testing (Vitek II Compact®) were screened for NDM, OXA-48, VIM, and KPC genes by PCR. Sequencing of NDM gene and transmissibility by conjugation assay were checked on 22 randomly selected NDM-positive isolates. One hundred and fifty-six isolates (29.54%) were carbapenem-resistant. The rate of carbapenem resistance was significantly higher in K. pneumoniae as compared to E. coli (53.9% vs. 15.6%; p < 0.05). The NDM gene was found in 34.6% (54/156), OXA-48 in 31.4% (49/156), co-expression of NDM + OXA-48 in 15.3% (24/156) of the carbapenem-resistant isolates. VIM and KPC were absent in all isolates. NDM gene was significantly more prevalent in E. coli than K. pneumoniae (p < 0.05). All the tested isolates formed transconjugants and NDM-5 was the most common variant in both species (15/22). The presence of plasmid-based NDM calls for stricter surveillance measures in our hospital settings.
Collapse
Affiliation(s)
- Namita Jaggi
- 1 Laboratory Services, Artemis Hospitals, Gurugram, India
| | | | - Vyoma Singh
- 1 Laboratory Services, Artemis Hospitals, Gurugram, India
| | | | | | - Rajesh Panwar
- 1 Laboratory Services, Artemis Hospitals, Gurugram, India
| | | |
Collapse
|
24
|
Prevalence and Characterization of Multi Drug Resistant Gram Negative Bacilli Isolates from a Tertiary Care Centre of Western U.P., India. JOURNAL OF PURE AND APPLIED MICROBIOLOGY 2019. [DOI: 10.22207/jpam.13.2.45] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
25
|
Jean SS, Lee NY, Tang HJ, Lu MC, Ko WC, Hsueh PR. Carbapenem-Resistant Enterobacteriaceae Infections: Taiwan Aspects. Front Microbiol 2018; 9:2888. [PMID: 30538692 PMCID: PMC6277544 DOI: 10.3389/fmicb.2018.02888] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 11/12/2018] [Indexed: 01/12/2023] Open
Abstract
Carbapenem-resistant Enterobacteriaceae (CRE), a major resistance concern emerging during the last decade because of significantly compromising the efficacy of carbapenem agents, has currently become an important focus of infection control. Many investigations have shown a high association of CRE infections with high case-fatality rates. In Taiwan, a few surveys observed that a significant proportion (29–47%) of the CR-Klebsiella pneumoniae isolates harbored a plasmidic allele encoding K. pneumoniae carbapenemases (KPC, especially KPC-2). A significant increase in the number of oxacillinase (OXA)-48-like carbapenemases among CR-K. pneumoniae isolates was observed between 2012 and 2015. By striking contrast, isolates of CR-Escherichia coli and CR-Enterobacter species in Taiwan had a much lower percentage of carbapenemase production than CR-K. pneumoniae isolates. This differs from isolates found in China as well as in the India subcontinent. Apart from the hospital setting, CRE was also cultured from the inpatients from communities or long-term care facilities (LTCF). Therefore, implementation of regular CRE screening of LTCF residents, strict disinfectant use in nursing homes and hospital settings, and appropriate control of antibiotic prescriptions is suggested to alleviate the spread of clinical CRE isolates in Taiwan. Although there are some promising new antibiotics against CRE, such as ceftazidime-avibactam, meropenem-vaborbactam, aztreonam-avibactam and cefiderocol, these agents are not available in Taiwan currently. Therefore, in order to effectively decrease case-fatality rates among patients with the infections owing to carbapenemase-producing CRE isolates, combination antibiotic schemes, including colistin (or amikacin) and/or tigecycline in combination with an anti-pseudomonal carbapenem agent, remain the mainstay for treating clinical CRE infections.
Collapse
Affiliation(s)
- Shio-Shin Jean
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Emergency Medicine and Department of Emergency and Critical Care Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Nan-Yao Lee
- Department of Internal Medicine, National Cheng Kung University Medical College and Hospital, Tainan, Taiwan
| | - Hung-Jen Tang
- Department of Medicine, Chi Mei Medical Center, Tainan, Taiwan.,Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Min-Chi Lu
- Department of Microbiology and Immunology, School of Medicine, China Medical University, Taichung, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Medical College and Hospital, Tainan, Taiwan
| | - Po-Ren Hsueh
- Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.,Department Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| |
Collapse
|