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JAC Advance Access originally published online on September 9, 2009
Journal of Antimicrobial Chemotherapy 2009 64(5):1102-1110; doi:10.1093/jac/dkp327
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© The Author 2009. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Original research

Emergence of blaKPC-containing Klebsiella pneumoniae in a long-term acute care hospital: a new challenge to our healthcare system

Andrea Endimiani1,2, John M. DePasquale3,4, Sandra Forero3, Federico Perez1,2, Andrea M. Hujer1, Daneshia Roberts-Pollack3, Paul D. Fiorella3, Nancy Pickens3, Brandon Kitchel5, Aida E. Casiano-Colón6, Fred C. Tenover5,{dagger} and Robert A. Bonomo1,2,7,8,*

1 Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, 10701 East Blvd, Cleveland, OH 44106, USA 2 Department of Medicine, Case Western Reserve School of Medicine, 10900 Euclid Ave., Cleveland, OH 44106, USA 3 Florida Department of Health, 4052 Bald Cypress Way, Bin-A-12, Tallahassee, FL 32399-1720, USA 4 Office of Workforce and Career Development, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Atlanta, GA 30333, USA 5 Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Atlanta, GA 30333, USA 6 Integrated Regional Laboratories, 5361 NW 33rd Ave., Fort Lauderdale, FL 33309, USA 7 Department of Pharmacology, Case Western Reserve School of Medicine, 10900 Euclid Ave., Cleveland, OH 44106, USA 8 Department of Molecular Biology and Microbiology, Case Western Reserve School of Medicine, 10900 Euclid Ave., Cleveland, OH 44106, USA

Received 28 July 2009; returned 4 August 2009; revised 10 August 2009; accepted 11 August 2009

* Corresponding author. Department of Veterans Affairs Medical Center, 10701 East Blvd, Cleveland, OH 44106, USA. Tel: +1-216-7913800, ext. 4399; Fax: +1-216-2313482; E-mail: robert.bonomo{at}med.va.gov

Objectives: To characterize isolates of Klebsiella pneumoniae producing KPC carbapenemase (KPC-Kp) associated with an outbreak in a long-term acute care hospital (LTACH) in South Florida.

Methods: During 21 March to 20 April 2008, 241 K. pneumoniae isolates detected at Integrated Regional Laboratories (Ft. Lauderdale, FL) for which the ertapenem MICs were ≥4 mg/L were studied. PCR, cloning and sequence analysis were used to detect blaKPC and to characterize the β-lactamase and outer membrane proteins (Omps). The expression level of KPC enzymes was studied by immunoblotting. Genetic relatedness of isolates was investigated with rep-PCR and PFGE. Clinical records of patients were investigated.

Results: Seven KPC-Kp strains were isolated from different patients located at a single LTACH, with a further three isolates being recovered from patients at different hospitals. All KPC-Kp isolates in patients from the LTACH and from one hospital patient were genetically related and shared PFGE patterns that clustered with known sequence type (ST) 258 strains. These strains were highly resistant to carbapenems (MICs ≥ 32 mg/L) due to an increased level of KPC expression and loss of Omps. Rectal colonization was documented in all LTACH patients with KPC-Kp isolates. Treatment failures were common (crude mortality rate of 69%). Active surveillance and enhanced infection control practices terminated the KPC-Kp outbreak.

Conclusions: The detection of KPC-Kp in an LTACH represents a serious infection control and therapeutic challenge in a new clinical setting. The speed at which the epidemic of KPC-Kp is spreading in our healthcare system mandates urgent action.

Keywords: LTCF , porins , carbapenemases , Enterobacteriaceae , outbreak

{dagger} Present address: Cepheid, 904 Caribbean Drive, Sunnyvale, CA 94089, USA.


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