Clonal Dissemination of Extended-Spectrum β-Lactamase (ESBL)-Producing Klebsiella pneumoniae Isolates in a Korean Hospital
01 Feb 2008-Journal of Korean Medical Science (Korean Academy of Medical Sciences)-Vol. 23, Iss: 1, pp 53-60
TL;DR: A new multilocus sequence typing (MLST) scheme for K. pneumoniae based on five housekeeping genes was developed and was evaluated for 43 ESBL-producing isolate from an outbreak as well as 38 surveillance isolates from Korea and also a reference strain.
Abstract: In this study, we investigated the molecular characteristics of extended-spectrum β-lactamase (ESBL)-producing Klebsiella pneumoniae isolates that were recovered from an outbreak in a Korean hospital. A new multilocus sequence typing (MLST) scheme for K. pneumoniae based on five housekeeping genes was developed and was evaluated for 43 ESBL-producing isolates from an outbreak as well as 38 surveillance isolates from Korea and also a reference strain. Overall, a total of 37 sequence types (STs) and six clonal complexes (CCs) were identified among the 82 K. pneumoniae isolates. The result of MLST analysis was concordant with that of pulsedfield gel electrophoresis. Most of the outbreak isolates belonged to a certain clone (ST2), and they produced SHV-1 and CTX-M14 enzymes, which was a different feature from that of the K. pneumoniae isolates from other Korean hospitals (ST20 and SHV-12). We also found a different distribution of CCs between ESBL-producing and -nonproducing K. pneumoniae isolates. The MLST method we developed in this study could provide unambiguous and well-resolved data for the epidemiologic study of K. pneumoniae. The outbreak isolates showed different molecular characteristics from the other K. pneumoniae isolates from other Korean hospitals.
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TL;DR: The findings reveal the "silent" dissemination of bla(KPC-3) as part of Tn4401b on a mobile plasmid in Northeast Ohio nearly a decade ago and establish the first report, to the authors' knowledge, of K. pneumoniae containing bla-3 in an LTCF caring for neurologically impaired children and young adults.
Abstract: Long-term care facilities (LTCFs) are essential components of healthcare delivery to many patients. Unfortunately, LTCFs are also recognized as “reservoirs of antibiotic resistance” [1]. In the past 3 decades numerous outbreaks of multidrug-resistant gram-negative and gram-positive organisms have been described in LTCFs [2, 3]. The spread of antibiotic-resistant pathogens transmitted from LTCFs to wider healthcare delivery systems that serve a large region is now appreciated as a major challenge in the design of effective infection control and antibiotic utilization strategies in the care of the elderly [4]. Among gram-negative bacteria, Escherichia coli– and Klebsiella pneumoniae–producing extended-spectrum β-lactamases (ESBLs), as well as carbapenem-resistant Acinetobacter baumannii and Pseudomonas aeruginosa, are the most significant threats in this setting [5–10]. Especially concerning has been the national and global spread of carbapenem-resistant K. pneumoniae harboring blaKPC, belonging to sequence type (ST) 258 [7, 11, 12].
Although not as well documented as in adult patients, antibiotic-resistant gram-negative organisms are present in healthcare settings serving children, including pediatric LTCFs [13–16]. In a surveillance study examining the antibiotic susceptibility of normal flora of children residing in an LTCF in Cleveland, Ohio, nearly 40% of subjects were colonized with resistant bacteria, and >60% of organisms were resistant to >2 antibiotics tested [14]. Invasive devices were found to be a significant risk factor for colonization by resistant gram-negative bacteria [14].
Little is known about the spread of blaKPC harboring strains or whether the same risk factors are present in children and adults. Unfortunately, the clinical detection of blaKPC is undermined by heterogeneous expression of carbapenem resistance. Ertapenem minimum inhibitory concentrations (MICs) are the most sensitive for detection of K. pneumoniae carbapenemase (KPC) but may lack specificity, and therefore additional phenotypic tests (ie, modified Hodge test and boronic acid disk) have been devised [17–20]. MICs of carbapenems are dependent not only on the presence and the level of expression of blaKPC but also on changes in outer membrane proteins [7, 21, 22].
In this study we describe the “silent dissemination” and earliest report of KPC-producing K. pneumoniae in an LTCF caring for children and young adults with neurodevelopmental impairments. As part of a study conducted in 2004 to determine the risk of stool colonization by extended-spectrum cephalosporin-resistant gram-negative bacteria, we identified 12 strains of K. pneumoniae that exhibited nonsusceptibility to extended-spectrum cephalosporins. Reassessment of carbapenem MICs using recently revised breakpoints uncovered carbapenem resistance. Genetic analysis revealed that a single sequence type not previously reported to contain blaKPC had disseminated as early as 2004 in Northeast Ohio in this LTCF. Introduction of blaKPC into our region occurred before the description of the spread of ST 258, recognition of Tn4401, the KQ element, or the mobile genetic elements harboring this carbapenemase gene [23, 24].
76 citations
TL;DR: MLST and PFGE analyses showed that ST11 was dominant in ESBL-producing K. pneumoniae isolates causing UTI and in those causing bacteraemia and has been prevalent in Korean hospitals.
Abstract: To investigate the antimicrobial resistance, extended-spectrum β-lactamases (ESBLs) and clones of Klebsiella pneumoniae isolates causing bacteraemia or urinary tract infection (UTI) in Korea, a total of 406 K. pneumoniae isolates from patients with bacteraemia (221 isolates) and UTI (185 isolates) were collected from 10 tertiary-care Korean hospitals from July 2006 to October 2007. In vitro antimicrobial susceptibility testing was performed for all isolates and ESBL production was tested. Multilocus sequence typing (MLST) analyses were performed to characterize genotypes of ESBL-producing K. pneumoniae isolates. PFGE was performed for sequence type 11 (ST11) isolates. Forty-seven UTI isolates (25.4 %) produced ESBLs, while 30 bacteraemia isolates (13.6 %) produced ESBLs (P=0.002). Among 77 ESBL-producing isolates, thirty-two (41.6 %) produced SHV-type ESBLs. bla
CTX-M genes such as bla
CTX-M-14 and bla
CTX-M-15 were detected in 36.4 %. MLST and PFGE analyses showed that ST11 was dominant in ESBL-producing K. pneumoniae isolates causing UTI (57.4 %) and in those causing bacteraemia (70.0 %) and has been prevalent in Korean hospitals. ST11 isolates harbour a combination of different ESBL genes. The ST11 clone of ESBL-producing K. pneumoniae isolates prevails in Korea, but most isolates might acquire ESBL genes independently or several different clones might be distributed in Korea.
73 citations
Cites background or result from "Clonal Dissemination of Extended-Sp..."
...SHV-12 is the most common ESBL in K. pneumoniae isolates from Korean hospitals followed by SHV-31, SHV-32 and TEM-52 and also CTX-M-type ESBLs, CTX-M-3, CTX-M-12, CTX-M-14 and CTX-M-15 (Bae et al., 2007; Jeong et al., 2004; Kim et al., 2005; Ko et al., 2008a; Ryoo et al., 2005)....
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...Resistance rates of clinical K. pneumoniae isolates in a previous (June–August 2005) investigation were similar to those in the present study (Ko et al., 2008a)....
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...Previously, we reported the clonal dissemination of ESBLproducing K. pneumoniae isolates in an intensive care unit in a Korean hospital based on PFGE and multilocus sequence typing (MLST) (Ko et al., 2008b)....
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...In Korea, the prevalence of extended-spectrum b-lactamases (ESBLs) in clinical Klebsiella pneumoniae isolates has been reported to be 17.7–30.0 % (Jeong et al., 2004; Kim et al., 2005; Ko et al., 2008a)....
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TL;DR: Prevalence and characteristics of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae in Korean hospitals were assessed and the most prevalent ESBLs were SHV-12 and CTX-M-14 in K. pneumoniae and E. coli, respectively.
62 citations
Journal Article•
TL;DR: A PCR-based assay that can simultaneously detect and differentiate five different types of nosocomial bacterial pathogens was developed and resulted in 100% for both positive and negative predictive values.
Abstract: A PCR-based assay that can simultaneously detect and differentiate five different types of nosocomial bacterial pathogens was developed. Six pairs of selected primers targeting femA (132 bp) and mecA (310 bp) of methicillin-resistant Staphylococcus aureus, gltA (722 bp) of Acinetobacter baumannii, phoA (903 bp) of Escherichia coli, mdh (364 bp) of Klebsiella pneumoniae and oprL (504 bp) of Pseudomonas aeruginosa were used in this study. The conditions were optimized for the multiplex PCR to ensure specific amplification of the selected targets. Sensitivity and specificity tests were also carried out using a blind test approach on 50 bacterial cultures and resulted in 100% for both positive and negative predictive values.
61 citations
Cites background from "Clonal Dissemination of Extended-Sp..."
...Klebsiella pneumoniae is also an opportunistic, Gram negative bacteria responsible for up to 10% of nosocomial infections (Prathiba et al., 2004; Diancourt et al., 2005; Ko et al., 2008)....
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TL;DR: Carapenem resistance in clinical isolates of Klebsiella pneumoniae from Korea was mainly due to a combination of DHA-1 AmpC β-lactamase coupled with the loss of OmpK35 and/or OMPK36 and was associated with poor clinical outcome.
Abstract: This study investigated the molecular mechanisms of carbapenem resistance in clinical isolates of Klebsiella pneumoniae from Korea and the clinical outcomes of resistant K. pneumoniae infection. Sixteen K. pneumoniae isolates showing resistance to carbapenems collected from a tertiary-care hospital were examined for the mechanisms of carbapenem resistance. PCR and sequencing experiments detected the bla
DHA-1 AmpC β-lactamase gene in all 16 clinical isolates, whilst the bla genes of extended-spectrum β-lactamases were detected in 12 of 16 isolates. SDS-PAGE experiments indicated that all the isolates lacked the 35 kDa and/or 36 kDa outer-membrane proteins (OMPs). Sequence analysis of the corresponding OMP genes revealed various alterations. PFGE analysis demonstrated that there were no major clonal relationships among the K. pneumoniae isolates. However, multilocus sequence typing experiments showed that all isolates shared the same sequence type (ST), ST11, except for one isolate of ST48. The crude mortality rate of infected patients was 81.8 %. Carbapenem resistance was mainly due to a combination of DHA-1 AmpC β-lactamase coupled with the loss of OmpK35 and/or OmpK36 and was associated with poor clinical outcome.
60 citations
Cites background from "Clonal Dissemination of Extended-Sp..."
...pneumoniae isolates of 37 STs, indicating that the observed high concentration of ST11 is a peculiar phenomenon (Ko et al., 2008)....
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...A survey performed in four Korean hospitals during 2004–2005 detected only four isolates of ST11 among 82 ESBL-producing K. pneumoniae isolates of 37 STs, indicating that the observed high concentration of ST11 is a peculiar phenomenon (Ko et al., 2008)....
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TL;DR: This research presents a novel, scalable and scalable approach that allows for real-time assessment of the severity of the infection and its impact on patients’ health.
Abstract: FRED C. TENOVER,* ROBERT D. ARBEIT, RICHARD V. GOERING, PATRICIA A. MICKELSEN, BARBARA E. MURRAY, DAVID H. PERSING, AND BALA SWAMINATHAN National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia 30333; Veterans Affairs Medical Center, Boston, Massachusetts 02130; Creighton University, Omaha, Nebraska 68178; Stanford University Medical Center, Stanford, California 94305; University of Texas Medical School, Houston, Texas 77030; and Mayo Clinic, Rochester, Minnesota 55905
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...The PFGE patterns were interpreted with using the published criteria (20)....
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TL;DR: Multilocus sequence typing (MLST), which exploits the unambiguous nature and electronic portability of nucleotide sequence data for the characterization of microorganisms, can be applied to almost all bacterial species and other haploid organisms, including those that are difficult to cultivate.
Abstract: Traditional and molecular typing schemes for the characterization of pathogenic microorganisms are poorly portable because they index variation that is difficult to compare among laboratories. To overcome these problems, we propose multilocus sequence typing (MLST), which exploits the unambiguous nature and electronic portability of nucleotide sequence data for the characterization of microorganisms. To evaluate MLST, we determined the sequences of ≈470-bp fragments from 11 housekeeping genes in a reference set of 107 isolates of Neisseria meningitidis from invasive disease and healthy carriers. For each locus, alleles were assigned arbitrary numbers and dendrograms were constructed from the pairwise differences in multilocus allelic profiles by cluster analysis. The strain associations obtained were consistent with clonal groupings previously determined by multilocus enzyme electrophoresis. A subset of six gene fragments was chosen that retained the resolution and congruence achieved by using all 11 loci. Most isolates from hyper-virulent lineages of serogroups A, B, and C meningococci were identical for all loci or differed from the majority type at only a single locus. MLST using six loci therefore reliably identified the major meningococcal lineages associated with invasive disease. MLST can be applied to almost all bacterial species and other haploid organisms, including those that are difficult to cultivate. The overwhelming advantage of MLST over other molecular typing methods is that sequence data are truly portable between laboratories, permitting one expanding global database per species to be placed on a World-Wide Web site, thus enabling exchange of molecular typing data for global epidemiology via the Internet.
3,695 citations
"Clonal Dissemination of Extended-Sp..." refers background or methods in this paper
...It has been applied successfully for the epidemiologic characterization of a variety of clinically important bacterial pathogens, such as Streptococcus pneumoniae, Staphylococcus aureus, Enterococcus faecium, Neisseria meningitidis, and Campylobacter jejuni (9-13)....
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...To overcome the limitations of the band-based typing methods, multilocus sequence typing (MLST) has been developed, which is a nucleotide sequence-based method for bacterial or fungal typing (8-10)....
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...Out of several molecular typing methods, MLST is becoming popular owing to its several advantages over the other typing methods, which have been discussed repeatedly elsewhere; a high level of discrimination, it is unambiguous and reproducible, and its scalable nature resulting from use of nucleotide sequences, it has electronic portability via the Internet, it can easily analyze the generated data, and it has a wide applicability (9, 10, 22, 23)....
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TL;DR: A multilocus sequence typing (MLST) scheme has been developed for Staphylococcus aureus and provides an unambiguous method for assigning MRSA and MSSA isolates to known clones or assigning them as novel clones via the Internet.
Abstract: A multilocus sequence typing (MLST) scheme has been developed for Staphylococcus aureus. The sequences of internal fragments of seven housekeeping genes were obtained for 155 S. aureus isolates from patients with community-acquired and hospital-acquired invasive disease in the Oxford, United Kingdom, area. Fifty-three different allelic profiles were identified, and 17 of these were represented by at least two isolates. The MLST scheme was highly discriminatory and was validated by showing that pairs of isolates with the same allelic profile produced very similar SmaI restriction fragment patterns by pulsed-field gel electrophoresis. All 22 isolates with the most prevalent allelic profile were methicillin-resistant S. aureus (MRSA) isolates and had allelic profiles identical to that of a reference strain of the epidemic MRSA clone 16 (EMRSA-16). Four MRSA isolates that were identical in allelic profile to the other major epidemic MRSA clone prevalent in British hospitals (clone EMRSA-15) were also identified. The majority of isolates (81%) were methicillin-susceptible S. aureus (MSSA) isolates, and seven MSSA clones included five or more isolates. Three of the MSSA clones included at least five isolates from patients with community-acquired invasive disease and may represent virulent clones with an increased ability to cause disease in otherwise healthy individuals. The most prevalent MSSA clone (17 isolates) was very closely related to EMRSA-16, and the success of the latter clone at causing disease in hospitals may be due to its emergence from a virulent MSSA clone that was already a major cause of invasive disease in both the community and hospital settings. MLST provides an unambiguous method for assigning MRSA and MSSA isolates to known clones or assigning them as novel clones via the Internet.
2,809 citations
TL;DR: β-Lactamases continue to be the leading cause of resistance to β-lactam antibiotics among gram-negative bacteria and are now found in a significant percentage of Escherichia coli and Klebsiella pneumoniae strains in certain countries.
Abstract: β-Lactamases continue to be the leading cause of resistance to β-lactam antibiotics among gram-negative bacteria. In recent years there has been an increased incidence and prevalence of extended-spectrum β-lactamases (ESBLs), enzymes that hydrolyze and cause resistance to oxyimino-cephalosporins and aztreonam. The majority of ESBLs are derived from the widespread broad-spectrum β-lactamases TEM-1 and SHV-1. There are also new families of ESBLs, including the CTX-M and OXA-type enzymes as well as novel, unrelated β-lactamases. Several different methods for the detection of ESBLs in clinical isolates have been suggested. While each of the tests has merit, none of the tests is able to detect all of the ESBLs encountered. ESBLs have become widespread throughout the world and are now found in a significant percentage of Escherichia coli and Klebsiella pneumoniae strains in certain countries. They have also been found in other Enterobacteriaceae strains and Pseudomonas aeruginosa. Strains expressing these β-lactamases will present a host of therapeutic challenges as we head into the 21st century.
2,676 citations
"Clonal Dissemination of Extended-Sp..." refers background in this paper
...Its importance in clinical settings is increasing due to its ability to produce extended-spectrum -lactamase (ESBL) (3)....
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...It has been reported that ESBL-producing organisms tend to be multidrug-resistant and they have an increased risk of treatment failure (3, 4)....
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TL;DR: Klebsiella pathogenicity factors such as capsules or lipopolysaccharides are presently considered to be promising candidates for vaccination efforts that may serve as immunological infection control measures.
Abstract: Bacteria belonging to the genus Klebsiella frequently cause human nosocomial infections. In particular, the medically most important Klebsiella species, Klebsiella pneumoniae, accounts for a significant proportion of hospital-acquired urinary tract infections, pneumonia, septicemias, and soft tissue infections. The principal pathogenic reservoirs for transmission of Klebsiella are the gastrointestinal tract and the hands of hospital personnel. Because of their ability to spread rapidly in the hospital environment, these bacteria tend to cause nosocomial outbreaks. Hospital outbreaks of multidrug-resistant Klebsiella spp., especially those in neonatal wards, are often caused by new types of strains, the so-called extended-spectrum-β-lactamase (ESBL) producers. The incidence of ESBL-producing strains among clinical Klebsiella isolates has been steadily increasing over the past years. The resulting limitations on the therapeutic options demand new measures for the management of Klebsiella hospital infections. While the different typing methods are useful epidemiological tools for infection control, recent findings about Klebsiella virulence factors have provided new insights into the pathogenic strategies of these bacteria. Klebsiella pathogenicity factors such as capsules or lipopolysaccharides are presently considered to be promising candidates for vaccination efforts that may serve as immunological infection control measures.
2,286 citations
"Clonal Dissemination of Extended-Sp..." refers background in this paper
...Klebsiella pneumoniae is a relevant opportunistic pathogen that accounts for up to 10% of all nosocomial infections (1, 2)....
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