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Zhou J, Yan G, Tang C, Liu J, Fu P, Ding L, Yang W, Guo Y, Wang C, Lu G, Hu F. Emergence of ceftazidime-avibactam resistance in bla KPC-33-harbouring ST11 Klebsiella pneumoniae in paediatric patient. Int J Antimicrob Agents 2024; 63:107163. [PMID: 38570018 DOI: 10.1016/j.ijantimicag.2024.107163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 03/24/2024] [Accepted: 03/27/2024] [Indexed: 04/05/2024]
Abstract
Carbapenem-resistant Klebsiella pneumoniae (CRKP) poses immense threats to the health of infected patients worldwide, especially children. This study reports the infection caused by CRKP in a paediatric intensive care unit (PICU) child and its drug-resistant mutation during the treatment. Twelve Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae strains were isolated from the child. Broth microdilution method, plasmid transformation assay, and whole genome sequencing (WGS) were performed to investigate the antimicrobial susceptibility, resistance mechanisms, and genetic structural features of CRKPs. The results showed that 12 strains were highly resistant to most available antimicrobial agents. Among them, K. pneumoniae FD11 and K. pneumoniae FD12 were resistant to ceftazidime-avibactam (CZA, MIC >64 mg/L) and restored the carbapenem susceptibility (Imipenem, MIC =0.25 mg/L; Meropenem, MIC =2 mg/L). The patient improved after treatment with CZA in combination with aztreonam. Plasmid transformation assay demonstrated that the blaKPC-33-positive transformant increased MICs of CZA by at least 33-fold and 8-fold compared with the recipient Escherichia coli DH5α and blaKPC-2-positive transformants. WGS analysis revealed that all strains belonged to the ST11-KL64 type and showed highly homologous (3-26 single nucleotide polymorphisms [SNPs]). A single base mutation (G532T) of blaKPC-2 resulted in a tyrosine to aspartic acid substitution at Ambler amino acid position 179 (D179Y), which conferred CZA resistance in K. pneumoniae. This is the first report of a drug-resistant mutation evolving into blaKPC-33 during the treatment of blaKPC-2-positive CRKP in paediatric-infected patients. It advises clinicians that routine sequential antimicrobial susceptibility testing and KPC genotyping are critical during CZA therapy in children infected with CRKP.
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Affiliation(s)
- Jinlan Zhou
- Intensive Care Unit, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Gangfeng Yan
- Intensive Care Unit, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Chengkang Tang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Ministry of Health, Shanghai, China
| | - Jing Liu
- Intensive Care Unit, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Pan Fu
- Department of Clinical Microbiology Laboratory, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Li Ding
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Ministry of Health, Shanghai, China
| | - Weiwei Yang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Ministry of Health, Shanghai, China
| | - Yan Guo
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Ministry of Health, Shanghai, China
| | - Chuanqing Wang
- Department of Clinical Microbiology Laboratory, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Guoping Lu
- Intensive Care Unit, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China; Shanghai Institute of Infectious Disease and Biosecurity, Fudan University, Shanghai, China.
| | - Fupin Hu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Ministry of Health, Shanghai, China.
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Wang C, Zhao J, Liu Z, Sun A, Sun L, Li B, Lu B, Liu Y, Cao B. In vivo Selection of Imipenem Resistance Among Ceftazidime-Avibactam-Resistant, Imipenem-Susceptible Klebsiella pneumoniae Isolate With KPC-33 Carbapenemase. Front Microbiol 2021; 12:727946. [PMID: 34630354 PMCID: PMC8496447 DOI: 10.3389/fmicb.2021.727946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 08/26/2021] [Indexed: 11/23/2022] Open
Abstract
We describe in vivo evolution of carbapenem and ceftazidime-avibactam resistance by analyzing four longitudinal Klebsiella pneumoniae clinical isolates from a patient with pneumonia following antimicrobial treatment. The patient had fever, cough associated with expectoration, and new infiltration was found on the chest CT. Antimicrobial susceptibility was determined, and whole genome sequencing (WGS) was performed to investigate its dynamic change of resistance phenotype. Population analysis profile was performed to investigate the population of Klebsiella pneumoniae. The infection started with a KPC-2-producing K. pneumoniae (ZRKP01, ceftazidime-avibactam-S/carbapenem-R). Then, after ceftazidime-avibactam treatment, the strain switched to D179Y mutant that is KPC-33 (ZRKP02, ceftazidime-avibactam-R/carbapenem-S), which restored carbapenem susceptibility. However, the restored carbapenem susceptibility in vivo was not stable and the subsequent use of imipenem against KPC-33-producing K. pneumoniae infection resulted in a reversion of KPC-2 producers (ZRKP03 and ZRKP04, ceftazidime-avibactam-S/carbapenem-R). Genetic analysis demonstrated that all four K. pneumoniae isolates belonged to sequence type 11and had identical capsular polysaccharide (KL47), identical porin genes, and same plasmid replicon types. Phylogenetic analysis indicated that four K. pneumoniae isolates showed a high degree of relatedness. Single nucleotide polymorphisms analysis indicated that the number of mutations observed in the KPC-33 isolate was more than in the wild-type KPC-2 isolates and the four KPC-Kp isolates evolved from a longitudinal evolution of K. pneumoniae harboring blaKPC-2 gene. This is the first report to observe the in vivo evolution of wild-type KPC-2 to KPC-33 and then the reversion to its original wild-type KPC-2. Through WGS, we demonstrated the role of selective pressure of antibiotic in the mutation and reversion of blaKPC genes, which leading to the dynamic change of KPC enzymes and the dynamic emergence of resistance to ceftazidime-avibactam and carbapenems. Statement: Recently, studies reported the emergence of ceftazidime-avibactam-resistant strains. The KPC mutations mediating ceftazidime-avibactam resistance are generally associated with the restoration of carbapenem susceptibility. However, clinical significance of this observation is unclear. In this manuscript, we demonstrate the role of selective pressure of antibiotic in the mutation and reversion of blaKPC genes, which leading to the dynamic change of KPC enzymes and the dynamic emergence of resistance to ceftazidime-avibactam and carbapenems. To the best of our knowledge, this is the first report to observe the in vivo evolution of wild-type KPC-2 to KPC-33 and then the reversion to its original wild-type KPC-2. It should be noted that understanding the clinical significance of this observation is of critical importance, and reversion to carbapenem susceptibility would not imply a potential role for carbapenems monotherapy. We hope our study will draw attention to clinicians, so that this agent can be used most effectively for the longest period of time.
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Affiliation(s)
- Chunlei Wang
- Laboratory of Clinical Microbiology and Infectious Diseases, China-Japan Friendship Hospital, Department of Pulmonary and Critical Care Medicine, Beijing, China.,Centre for Respiratory Diseases, China-Japan Friendship Hospital, Department of Pulmonary and Critical Care Medicine, Beijing, China.,Chinese Academy of Medical Science, Clinical Research Center of Respiratory Diseases, Institute of Respiratory Medicine, Beijing, China.,Clinical Center for Pulmonary Infections, Capital Medical University, Tsinghua University-Peking University Joint Center for Life Sciences, Beijing, China
| | - Jiankang Zhao
- Laboratory of Clinical Microbiology and Infectious Diseases, China-Japan Friendship Hospital, Department of Pulmonary and Critical Care Medicine, Beijing, China.,Centre for Respiratory Diseases, China-Japan Friendship Hospital, Department of Pulmonary and Critical Care Medicine, Beijing, China.,Chinese Academy of Medical Science, Clinical Research Center of Respiratory Diseases, Institute of Respiratory Medicine, Beijing, China.,Clinical Center for Pulmonary Infections, Capital Medical University, Tsinghua University-Peking University Joint Center for Life Sciences, Beijing, China
| | - Zhibo Liu
- Centre for Respiratory Diseases, China-Japan Friendship Hospital, Department of Pulmonary and Critical Care Medicine, Beijing, China.,Chinese Academy of Medical Science, Clinical Research Center of Respiratory Diseases, Institute of Respiratory Medicine, Beijing, China.,Clinical Center for Pulmonary Infections, Capital Medical University, Tsinghua University-Peking University Joint Center for Life Sciences, Beijing, China
| | - Aihua Sun
- Centre for Respiratory Diseases, China-Japan Friendship Hospital, Department of Pulmonary and Critical Care Medicine, Beijing, China.,Chinese Academy of Medical Science, Clinical Research Center of Respiratory Diseases, Institute of Respiratory Medicine, Beijing, China.,Clinical Center for Pulmonary Infections, Capital Medical University, Tsinghua University-Peking University Joint Center for Life Sciences, Beijing, China
| | - Lingxiao Sun
- Laboratory of Clinical Microbiology and Infectious Diseases, China-Japan Friendship Hospital, Department of Pulmonary and Critical Care Medicine, Beijing, China.,Centre for Respiratory Diseases, China-Japan Friendship Hospital, Department of Pulmonary and Critical Care Medicine, Beijing, China.,Chinese Academy of Medical Science, Clinical Research Center of Respiratory Diseases, Institute of Respiratory Medicine, Beijing, China.,Clinical Center for Pulmonary Infections, Capital Medical University, Tsinghua University-Peking University Joint Center for Life Sciences, Beijing, China
| | - Binbin Li
- Laboratory of Clinical Microbiology and Infectious Diseases, China-Japan Friendship Hospital, Department of Pulmonary and Critical Care Medicine, Beijing, China.,Centre for Respiratory Diseases, China-Japan Friendship Hospital, Department of Pulmonary and Critical Care Medicine, Beijing, China.,Chinese Academy of Medical Science, Clinical Research Center of Respiratory Diseases, Institute of Respiratory Medicine, Beijing, China.,Clinical Center for Pulmonary Infections, Capital Medical University, Tsinghua University-Peking University Joint Center for Life Sciences, Beijing, China
| | - Binghuai Lu
- Laboratory of Clinical Microbiology and Infectious Diseases, China-Japan Friendship Hospital, Department of Pulmonary and Critical Care Medicine, Beijing, China.,Centre for Respiratory Diseases, China-Japan Friendship Hospital, Department of Pulmonary and Critical Care Medicine, Beijing, China.,Chinese Academy of Medical Science, Clinical Research Center of Respiratory Diseases, Institute of Respiratory Medicine, Beijing, China.,Clinical Center for Pulmonary Infections, Capital Medical University, Tsinghua University-Peking University Joint Center for Life Sciences, Beijing, China
| | - Yingmei Liu
- Laboratory of Clinical Microbiology and Infectious Diseases, China-Japan Friendship Hospital, Department of Pulmonary and Critical Care Medicine, Beijing, China.,Centre for Respiratory Diseases, China-Japan Friendship Hospital, Department of Pulmonary and Critical Care Medicine, Beijing, China.,Chinese Academy of Medical Science, Clinical Research Center of Respiratory Diseases, Institute of Respiratory Medicine, Beijing, China.,Clinical Center for Pulmonary Infections, Capital Medical University, Tsinghua University-Peking University Joint Center for Life Sciences, Beijing, China
| | - Bin Cao
- Laboratory of Clinical Microbiology and Infectious Diseases, China-Japan Friendship Hospital, Department of Pulmonary and Critical Care Medicine, Beijing, China.,Centre for Respiratory Diseases, China-Japan Friendship Hospital, Department of Pulmonary and Critical Care Medicine, Beijing, China.,Chinese Academy of Medical Science, Clinical Research Center of Respiratory Diseases, Institute of Respiratory Medicine, Beijing, China.,Clinical Center for Pulmonary Infections, Capital Medical University, Tsinghua University-Peking University Joint Center for Life Sciences, Beijing, China
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