JAC Advance Access originally published online on February 13, 2006
Journal of Antimicrobial Chemotherapy 2006 57(4):794-795; doi:10.1093/jac/dkl036
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Correspondence |
Inter-country transfer of Gram-negative organisms carrying the VIM-4 and OXA-58 carbapenem-hydrolysing enzymes
1 Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Australia; 2 Microbiology and Infectious Diseases Department, Women's and Children's Hospital, Adelaide, Australia; 3 Microbiology Department, Royal Melbourne Hospital, Melbourne, Australia
* Corresponding author. Tel: +61-3-9342-7000; Fax: +61-3-9342-7277; E-mail: antonpeleg{at}iprimus.com.au
Keywords: metallo-ß-lactamases , carbapenemases , Acinetobacter baumannii , Pseudomonas aeruginosa
Sir,
The widespread dissemination of acquired carbapenem-hydrolysing enzymes, particularly Ambler classes B [metallo-ß-lactamases (MBLs)] and D (oxacillinases), is of great clinical concern. Of the MBLs, the IMP and VIM types are the most frequent, with more than 20 countries reporting their presence.1 The VIM-4 enzyme was first described from a Pseudomonas aeruginosa isolate from Larissa, Greece,2 and, soon after, an outbreak occurred at that institution. The blaVIM-4 gene has also been reported from Italy and Poland, but thus far there have been no reports from Australia.1 The class D carbapenemases are now divided into four distinct phylogenetic clusters: OXA-23 (OXA-23 and OXA-27), OXA-24 (OXA-24, OXA-25, OXA-26 and OXA-40), OXA-58 and OXA-51. OXA-58 has recently been shown to contribute significantly to carbapenem resistance in Acinetobacter baumannii, especially when additional efflux mechanisms are expressed.3 This enzyme has now been reported from France, Spain, Turkey and Romania, and, more recently, from Australia4 and Greece.5 The role of international travel in the global dissemination of carbapenemase genes is often reported, but rarely has this been well illustrated.6
In October 2005, a 35-year-old female underwent an inter-hospital, inter-country transfer from an intensive care unit (ICU) in Athens, Greece, to our ICU. Five weeks before she had been hit by a car while walking and sustained multiple injuries, including an intra-cranial haemorrhage and long bone fractures. She remained in the ICU in Greece until transfer and was intubated and ventilated for 23 days. On arrival the patient had a central venous catheter (CVC), a radial arterial line, a urinary catheter and a tracheostomy in situ. Within 12 h of transfer, high fever developed with no clinical source of infection identified. Blood and urine cultures were obtained. Vascular lines and the urinary catheter were removed, empirical teicoplanin and tobramycin were started and strict infection control precautions were initiated.
The following day, P. aeruginosa was identified from urine cultures in the absence of significant pyuria. Susceptibility testing was performed using broth microdilution according to CLSI standards. The isolate was susceptible only to polymyxin B and was resistant to meropenem (MIC > 8 mg/L), imipenem (MIC > 8 mg/L), aztreonam (MIC > 16 mg/L), gentamicin (MIC > 8 mg/L), tobramycin (MIC > 16 mg/L), amikacin (MIC > 32 mg/L), ceftazidime (MIC > 16 mg/L), piperacillin/tazobactam (MIC > 64 mg/L), ticarcillin/clavulanate (MIC > 128 mg/L) and ciprofloxacin (MIC > 4 mg/L). The CVC tip cultures were also positive for a carbapenem-resistant A. baumannii, and this was soon followed (>2 h) by positive peripheral blood cultures for the same organism. These isolates were resistant to all tested antibiotics except for polymyxin B. The patient became afebrile within 72 h and all antibiotics were ceased. Recovery was made and no further infective complications ensued. Nosocomial transmission was not identified.
An Etest® MBL (AB Biodisk, Solna, Sweden) was performed on both Gram-negative genera, with the P. aeruginosa isolate testing positive according to the manufacturer's guidelines. To confirm the mechanism of carbapenem resistance the isolates underwent PCR testing for the detection of blaIMP and blaVIM MBL genes and class D carbapenemase genes (OXA-23 and OXA-24 cluster and OXA-58).7 Amplification products were identified for blaVIM in the P. aeruginosa isolate and blaOXA-58 in the A. baumannii isolate. Nucleotide sequencing confirmed the presence of the blaVIM-4 and blaOXA-58 genes in the P. aeruginosa and A. baumannii isolates, respectively, with a complete sequence identified for each gene.
To our knowledge, this is the first report of a blaVIM gene in Australia. blaIMP-4-carrying Gram-negative organisms have led to a significant outbreak in our geographic region,8 but the introduction of a second MBL type is a matter of concern. The finding of a blaOXA-58-carrying A. baumannii is of interest, as this gene has only recently been reported from an ICU in Athens, Greece.5 This case highlights the importance of international travel in the spread of antimicrobial resistance. The global emergence of carbapenemase genes is worrying and we believe that consideration should be given to isolating and screening all patients admitted to hospital from a foreign country for multidrug-resistant pathogens.
Transparency declarations
None to declare.
Acknowledgements
We would like to thank the physicians who cared for the patient and the microbiology staff at the Royal Melbourne Hospital for their processing of the specimen.
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