Silvia Bracco

Epidemic Diffusion of OXA-23-Producing Acinetobacter baumannii Isolates in Italy: Results of the First Cross-Sectional Countrywide Survey

ABSTRACT Carbapenem-resistant Acinetobacter baumannii (CRAb) is emerging worldwide as a public health problem in various settings. The aim of this study was to investigate the prevalence of CRAb isolates in Italy and to characterize their resistance mechanisms and genetic relatedness. A countrywide cross-sectional survey was carried out at 25 centers in mid-2011. CRAb isolates were reported from all participating centers, with overall proportions of 45.7% and 22.2% among consecutive nonreplicate clinical isolates of A. baumannii from inpatients (n = 508) and outpatients (n = 63), respectively. Most of them were resistant to multiple antibiotics, whereas all remained susceptible to colistin, with MIC50 and MIC90 values of ≤0.5 mg/liter. The genes coding for carbapenemase production were identified by PCR and sequencing. OXA-23 enzymes (found in all centers) were by far the most common carbapenemases (81.7%), followed by OXA-58 oxacillinases (4.5%), which were found in 7 of the 25 centers. In 6 cases, CRAb isolates carried both bla OXA-23-like and bla OXA-58-like genes. A repetitive extragenic palindromic (REP)-PCR technique, multiplex PCRs for group identification, and multilocus sequence typing (MLST) were used to determine the genetic relationships among representative isolates (n = 55). Two different clonal lineages were identified, including a dominant clone of sequence type 2 (ST2) related to the international clone II (sequence group 1 [SG1], SG4, and SG5) and a clone of ST78 (SG6) previously described in Italy. Overall, our results demonstrate that OXA-23 enzymes have become the most prevalent carbapenemases and are now endemic in Italy. In addition, molecular typing profiles showed the presence of international and national clonal lineages in Italy.

Characterization of resistance mechanisms and genetic relatedness of carbapenem-resistant Acinetobacter baumannii isolated from blood, Italy☆

The aim of this study was to characterize the resistance mechanisms and genetic relatedness of 21 carbapenem-resistant Acinetobacter baumannii blood isolates collected in Italy during a 1-year multicenter prospective surveillance study. Genes coding for carbapenemase production were identified by polymerase chain reaction (PCR) and sequencing. Pulsed-field gel electrophoresis (PFGE), multiplex PCRs for group identification, and multilocus sequence typing (MLST) were used to determine genetic relationships. Carbapenem resistance was consistently related to the production of oxacillinases, mostly the plasmid-mediated OXA-58 enzyme. Strains producing the OXA-23 enzyme (chromosomally mediated) were also detected. Seven PFGE clones were identified, some of which being related to international (ICL- I and ICL-II) or national clonal lineages. Multiplex PCRs identified 4 different groups (group 2 being dominant), further distinguishable in 6 sequence types by MLST. The heterogeneity of profiles highlights the diffusion of international and national clonal lineages in Italy. Continuous surveillance is needed for monitoring the spread of these worrisome strains equipped with multiple drug resistance mechanisms.

Acquisition of plasmid-borne blaIMP-19 gene by a VIM-1-positive Pseudomonas aeruginosa of the sequence type 235 epidemic lineage

Sir, Acquired metallo-b-lactamases (MBLs) are the most common acquired carbapenemases in Pseudomonas aeruginosa. They confer a broad-spectrum b-lactam resistance profile, including resistance to the antipseudomonal penicillins, cephalosporins and carbapenems, that is not antagonized by the available b-lactamase inhibitors. Most MBL-producing strains exhibit a multidrug resistance profile, also including resistance to non-b-lactams, due to the accumulation of additional resistance determinants. Although several types of acquired MBLs have been detected in P. aeruginosa, the IMPand VIM-type enzymes are currently the most widespread. A number of genes encoding these enzymes (e.g. blaVIM-1, blaVIM-2, blaVIM-4 and blaIMP-1) have become associated with high-risk clones, such as clonal complex (CC) 235 and CC111, which has promoted their dissemination in Europe and other continents. IMP-19 is an IMP allelic variant that was originally detected in Enterobacter cloacae (GenBank/EMBL accession no. AB201264) and P. aeruginosa (GenBank/EMBL accession no. AB184976) from Japan and, subsequently, in an Aeromonas caviae isolated in France. More recently, it has been reported in Achromobacter xylosoxidans and Acinetobacter spp. isolates from Japan. Here, we report on the first detection of the blaIMP-19 gene in Italy, in a multidrug-resistant (MDR) P. aeruginosa clinical isolate that also produced VIM-1 and belonged to the CC235 epidemic lineage. Research letters

Evolving beta-lactamase epidemiology in Enterobacteriaceae from Italian nationwide surveillance, October 2013: KPC-carbapenemase spreading among outpatients

Extended-spectrum beta-lactamases (ESBLs), AmpC-type beta-lactamases (ACBLs) and carbapenemases are among the most important resistance mechanisms in Enterobacteriaceae. This study investigated the presence of these resistance mechanisms in consecutive non-replicate isolates of Escherichia coli (n = 2,352), Klebsiella pneumoniae (n = 697), and Proteus mirabilis (n = 275) from an Italian nationwide cross-sectional survey carried out in October 2013. Overall, 15.3% of isolates were non-susceptible to extended-spectrum cephalosporins but susceptible to carbapenems (ESCR-carbaS), while 4.3% were also non-susceptible to carbapenems (ESCR-carbaR). ESCR-carbaS isolates were contributed by all three species, with higher proportions among isolates from inpatients (20.3%) but remarkable proportions also among those from outpatients (11.1%). Most ESCR-carbaS isolates were ESBL-positive (90.5%), and most of them were contributed by E. coli carrying blaCTX-M group 1 genes. Acquired ACBLs were less common and mostly detected in P. mirabilis. ESCR-carbaR isolates were mostly contributed by K. pneumoniae (25.1% and 7.7% among K. pneumoniae isolates from inpatients and outpatients, respectively), with blaKPC as the most common carbapenemase gene. Results showed an increasing trend for both ESBL and carbapenemase producers in comparison with previous Italian surveys, also among outpatients.

Erysipelothrix Rhusiopathiae Bacteremia without Endocarditis: Rapid Identification from Positive Blood Culture by MALDI-TOF Mass Spectrometry. A Case Report and Literature Review.

Erysipelothrix rhusiopathiae is a Gram-positive bacillus that is infrequently responsible for infections in humans. Three forms have been classified: a localized cutaneous form (erysipeloid) caused by traumatic penetration of E. rhusiopathiae, a generalized cutaneous form and a septicemic form. The latter type of disease has been previously associated with a high incidence of endocarditis. Here we report a case of E. rhusiopathiae bacteremia in a 74-year-old man, probably started from an erysipeloid form, in which endocarditis did not develop. This case presents some particular and uncommon features: i) no correlation with animal source; ii) correlation between bacteremia and erysipeloid lesion; iii) absence of endocarditis. MALDI-TOF mass spectrometry allowed to obtain a rapid identification (within 4 hours from bottle positivity) of E. rhusiopathiae. Together with direct antimicrobial susceptibility testing, this approach could improve the rate of appropriate therapy for bloodstream infections due to this fastidious pathogen.

Multicenter prospective study on the prevalence of colistin resistance in Escherichia coli : relevance of mcr-1 -positive clinical isolates in Lombardy, Northern Italy

Background The emergence of the plasmid-mediated colistin resistance mechanism in Escherichia coli has raised concern among public health experts as colistin is a last-line antimicrobial resort. The primary aim of the study was to investigate the prevalence of this resistance trait in E. coli isolates circulating in the Lombardy region, Northern Italy. The presence of mcr-type genes and their genetic relationship were also studied. Materials and methods A prospective study was performed during a 4-month period (May to August, 2016) in six acute care Hospitals. Consecutive nonduplicate clinical isolates of E. coli from any type of clinical specimen, with the exception of rectal swabs, were included in the study. Isolates that exhibited MIC values for colistin >2 mg/L were further investigated. Bacterial identification was obtained by matrix-assisted laser desorption ionization-time of flight mass spectrometry. Amplification of mcr-type genes (−1 to −5 variants) and microarray analysis were accomplished. Repetitive sequence-based PCR (Rep-PCR) and multilocus sequence typing (MLST) analysis were used for genotyping. Results Overall, 3,902 consecutive E. coli isolates (2,342 from outpatients, 1,560 from inpatients) were evaluated during the study period. Of them, 18/3,902 (0.5%), collected from 4/6 centers, showed resistance to colistin. These isolates were mostly obtained from urine of both outpatients (n=12) and inpatients (n=6). Colistin MIC values ranged from 4 to 8 mg/L. The mcr-1 gene was detected in 10/18 isolates (7 from outpatients, 3 from inpatients). Rep-PCR and MLST analysis revealed the presence of nine different clusters. Further mcr-type genes were not detected. Conclusion Resistance to colistin in E. coli clinical isolates appears low in our geographic area. With regard to mcr-1-positive isolates, they accounted for approximately 50% of colistin-resistant E. coli isolates, thus representing a relevant resistance mechanism in this context. Although overall limited, the presence of mcr-1 determinant in our region should not be ignored and great concern should be given to the continuous surveillance.

Evaluation of the in vitro activity of ceftobiprole against clinical isolates of Staphylococcus aureus

Background and aims: Ceftobiprole is a new cephalosporin characterized by a potent activity against Gram-positive and Gram-negative bacterial pathogens. It is noting that ceftobiprole has a strong affinity for penicillin binding proteins including PBP 2A, which mediates resistance to beta-lactams in methicillin (oxacillin)-resistant coagulase- negative staphylococci and Staphylococcus aureus (MRSA). The aim of the current study was to examine the antimicrobial activity of ceftobiprole against clinical isolates of S . aureus recently collected at our institution. Materials and methods: One hundred and forty blood isolates of S. aureus were evaluated, including methicillin-susceptible (MSSA, n=70) and MRSA (n=70) strains. Twenty additional MRSA isolates obtained from different sites (including skin and soft tissues, blood, and lower respiratory tract) and characterized by borderline susceptibility to vancomycin were also studied to assess the ability of ceftobiprole to overcome this worrisome trait. MIC values of ceftobiprole were determined by Etest strips and results were interpreted according to EUCAST guidelines. Results and conclusions: Study isolates were consistently susceptible to ceftobiprole, with MIC values ranging from 0.125 mg/L to 2 mg/L. Overall, MIC50 and MIC90 were 0.25 mg/L and 0.5 mg/L, respectively. Ceftobiprole showed in vitro activity against all S. aureus isolates, with small differences among groups selected on the basis of resistance to methicillin and/or reduced susceptibility to vancomycin. Thus, ceftobiprole appears a valid choice for treating infections caused by S. aureus , even when susceptibility results are not yet available. Additionally, ceftobiprole may be a valid option in the case of reduced susceptibility to vancomycin.