JAC Advance Access originally published online on November 20, 2007
Journal of Antimicrobial Chemotherapy 2008 61(2):455-457; doi:10.1093/jac/dkm455
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Research letters |
Intercontinental travels of patients and dissemination of plasmid-mediated carbapenemase KPC-3 associated with OXA-9 and TEM-1
1 Service de Microbiologie Médicale, Institut Gustave Roussy, 39 rue Camille Desmoulins, 94805 Villejuif Cedex, France 2 Université Pierre et Marie Curie-Paris 6, EA 2392, Laboratoire de Bactériologie, Paris, France 3 Service de Réanimation, Institut Gustave Roussy, 39 rue Camille Desmoulins, 94805 Villejuif Cedex, France 4 Assistance Publique—Hôpitaux de Paris, Hôpital Tenon, Service de Bactériologie, Paris, France
* Correspondence address. Service de Bactériologie, Hôpital Tenon, 4 rue de la Chine, 75970 Paris Cedex 20, France. Tel: +33-1-56-01-70-18; E-mail: guillaume.arlet{at}tnn.aphp.fr
Keywords: β-lactamases , carbapenems , Enterobacter cloacae
Among β-lactam antibiotics, carbapenems are those that have the highest stability towards the hydrolytic activity of most of the innate natural and acquired extended-spectrum β-lactamases prevalent within bacterial species involved in clinical practice. However, emergence of acquired carbapenem-hydrolysing β-lactamases, i.e. carbapenemases, which were first recognized in the early 1990s in some isolates of opportunistic Gram-negative bacilli, has been increasingly reported from various parts of the world during the last decade.1 Carbapenem-hydrolysing β-lactamases can be metallo-β-lactamases, expanded-spectrum oxacillinases or Ambler class A enzymes.1,2 KPC β-lactamases are class A carbapenemases, which were first detected in 2001 in a Klebsiella pneumoniae isolate from North Carolina.3 Soon afterwards, several reports documented the emergence of Enterobacteriaceae strains from various species producing KPC-2 and KPC-3 β-lactamase variants in the eastern USA and recently disseminated in other countries worldwide, such as France, Columbia, Israel and China.2
A 31-year-old man was admitted to the intensive care unit of the Institut Gustave-Roussy in November 2005 with sepsis related to intra-abdominal suppuration. The patient had previously undergone a total gastrectomy for intractable gastric bleeding episodes during a trip to New York and had stayed for 3 weeks in the intensive care unit of a local hospital. Blood cultures taken at admission in our hospital yielded a K. pneumoniae isolate fully susceptible to antimicrobial agents usually active against this species. Specimens taken during subsequent surgical debridement of abdominal abscesses yielded an Enterobacter cloacae isolate resistant to all β-lactam antibiotics including imipenem (Table 1), aminoglycosides, sulphonamides and fluoroquinolones and an Enterococcus faecium isolate resistant to ampicillin and vancomycin, and which carried the vanA gene (detected by PCR).
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A double disc diffusion assay with imipenem and amoxicillin/clavulanate discs showed a small increase in imipenem activity against the E. cloacae isolate, whereas no synergistic effect was observed with EDTA (data not shown), thus excluding the presence of a metallo-β-lactamase. Using ceftazidime (2 mg/L)/sodium azide (400 mg/L) as selective agent and azide-resistant Escherichia coli C600 as recipient strain, a conjugative experiment was performed. It allowed the transfer en bloc of resistance to β-lactam antibiotics including imipenem (Table 1), aminoglycosides and sulphonamides. Plasmid analysis showed that both the clinical and the transconjugant strains carried a unique plasmid, more than 126 kb in size.
The gene encoding for KPC β-lactamase was detected by PCR in both the donor and recipient strains. Sequencing of the amplified fragment showed it to display 100% identity with blaKPC-3 (GenBank accession number AF395881). PCR amplification with specific primers and sequencing analysis showed that both the clinical isolate and the transconjugant carried blaTEM-1.
The genetic environment of these β-lactamase-encoding genes was further investigated using a cloning approach. Total DNA of the transconjugant strain was partially digested with the endonuclease Sau3A, and fragments were ligated into a pACYC184 vector (Fermentas, St Rémy Les Chevreuse, France) before transformation of the recipient strain, E. coli DH10B. By selection on medium supplemented with ceftazidime (2 mg/L), we obtained a clone resistant to imipenem (Table 1) that produced the KPC-3 enzyme. Analysis of the blaKPC-3 cloning fragment (GenBank accession number AM774409) showed that blaKPC-3 displayed the same genetic environment as blaKPC-2 in Salmonella Cubana 4707 (GenBank accession number AF481906). By selection on ticarcillin (50 mg/L), we obtained two different phenotypes of resistance to β-lactams. Sequencing of the inserts showed the presence of blaTEM-1 or blaOXA-9 (Table 1). Accurate intragenic region amplifications of the OXA-9 fragment suggested blaTEM-1 and blaOXA-9 to be part of Tn1331, as has been previously described for the multiresistance plasmid pJHCMW1 of K. pneumoniae (GenBank accession number AF479774).4
This is the first KPC-3 β-lactamase-producing E. cloacae strain recovered from a patient in France. Interestingly, a KPC-2-producing K. pneumoniae strain has been recently recovered from another patient admitted to a hospital in Paris.5 A common feature of these two patients was that they stayed in intensive care units of New York City hospitals before their admission to a French hospital. More recently, K. pneumoniae and E. coli isolates harbouring blaKPC-2 were reported in Columbia, Israel and China, with no discernible linkage to the USA.2 Furthermore, as recently described, our KPC-producing strain was found to accumulate other β-lactam resistance enzymes (OXA-9 and TEM-1).2
Emergence of KPC β-lactamase-producing strains of Enterobacteriaceae and, recently, of Pseudomonaceae is worrisome, because they are resistant to all β-lactam antibiotics and often also to most other classes of the available antibacterial agents.2 Moreover, some reports have focused on the ability of some KPC β-lactamase-producing K. pneumoniae strains to cause outbreaks in medical centres in New York City.6
Evidence of intercontinental transfer of KPC β-lactamase-producing strains through patient travel stresses the risk for the rapid worldwide dissemination of these recently recognized carbapenemases.
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 Top Funding Transparency declarationsReferences |
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This work was partially funded by grants from the Faculté de Médecine Pierre et Marie Curie, Université Paris 6 and from the European Community (6th PCRD Contract: LSHM-CT 2003-503335).
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Transparency declarations |
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TopFundingTransparency declarationsReferences |
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None to declare.
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TopFundingTransparency declarationsReferences |
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1 Nordmann P, Poirel L. Emerging carbapenemases in Gram-negative aerobes. Clin Microbiol Infect (2002) 8:321–31.[CrossRef][Web of Science][Medline]
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Walther-Rasmussen J, Hoiby N. Class A carbapenemases. J Antimicrob Chemother (2007) 60:470–82.
3
Yigit H, Queenan AM, Anderson GJ, et al. Novel carbapenem-hydrolyzing β-lactamase, KPC-1, from a carbapenem-resistant strain of Klebsiella pneumoniae. Antimicrob Agents Chemother (2001) 45:1151–61.
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Sarno R, McGillivary G, Sherratt DJ, et al. Complete nucleotide sequence of Klebsiella pneumoniae multiresistance plasmid pJHCMW1. Antimicrob Agents Chemother (2002) 46:3422–7.
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Naas T, Nordmann P, Vedel G, et al. Plasmid-mediated carbapenem-hydrolyzing β-lactamase KPC in a Klebsiella pneumoniae isolate from France. Antimicrob Agents Chemother (2005) 49:4423–4.
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Woodford N, Tierno PM Jr, Young K, et al. Outbreak of Klebsiella pneumoniae producing a new carbapenem-hydrolyzing class A β-lactamase, KPC-3, in a New York medical center. Antimicrob Agents Chemother (2004) 48:4793–9.
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