Tsai Ling Lauderdale

EMERGENCE OF REDUCED SUSCEPTIBILITY AND RESISTANCE TO FLUOROQUINOLONES IN ESCHERICHIA COLI IN TAIWAN AND CONTRIBUTIONS OF DISTINCT SELECTIVE PRESSURES

ABSTRACT A survey of 1,203 Escherichia coli isolates from 44 hospitals in Taiwan revealed that 136 (11.3%) isolates were resistant to fluoroquinolones and that another 261 (21.7%) isolates had reduced susceptibility. Resistance was more common in isolates responsible for hospital-acquired (mostly in intensive care units) infections (17.5%) than in other adult inpatient (11.4%; P = 0.08) and outpatient isolates (11.9%; P > 0.1). Similarly, reduced susceptibility was more common in isolates responsible for hospital-acquired infections (30.9%) than in other adult inpatient (21.0%; P = 0.04) and outpatient (21.4%; P = 0.06) isolates. Isolates from pediatric patients were less likely to be resistant (1.3 versus 12.0%; P < 0.01) but were nearly as likely to have reduced susceptibility (17.7 versus 21.9%;P > 0.1) as nonpediatric isolates. There was an inverse relationship in the proportion of isolates that were resistant versus the proportion that had reduced susceptibility among isolates from individual hospitals (R = 0.031; P < 0.05). In an analysis of isolates from two hospitals, all 9 resistant strains possessed double point mutations ingyrA and all 19 strains with reduced susceptibility strains had single point mutations; no mutations were found among fully susceptible strains. Risk factors for resistance included underlying cancer (odds ratio [OR], 83; 95% confidence interval [CI95], 7.3 to 2,241; P < 0.001), exposure to a quinolone (OR, undefined; P = 0.02), and exposure to a nonquinolone antibiotic (OR, 20; CI95, 2.2 to 482; P < 0.001); underlying cancer was the only independent risk factor (OR, 83; CI95, 8.6 to 807; P < 0.001). There were no significant associations between any of these factors and reduced susceptibility. Whereas acute and chronic quinolone use in cancer patients is a major selective pressure for resistance, other undetermined but distinct selective pressures appear to be more responsible for reduced susceptibility to fluoroquinolones in E. coli.

Prevalence of and Risk Factors for Colonization by Methicillin-Resistant Staphylococcus aureus among Adults in Community Settings in Taiwan

ABSTRACT In order to determine the prevalence of methicillin (meticillin)-resistant Staphylococcus aureus (MRSA) colonization among adults in community settings in Taiwan and identify its risk factors, we conducted the present study. For a 3-month period, we enrolled all adults who attended mandatory health examinations at three medical centers and signed the informed consent. Nasal swabs were taken for the isolation of S. aureus. For each MRSA isolate, we performed multilocus sequence typing, identification of the staphylococcal cassette chromosome mec, tests for the presence of the Panton-Valentine leukocidin gene, and tests for drug susceptibilities. Risk factors for MRSA colonization were determined. The results indicated that the MRSA colonization rate among adults in the community settings in Taiwan was 3.8% (119/3,098). Most MRSA isolates belonged to sequence type 59 (84.0%). Independent risk factors for MRSA colonization included the presence of household members less than 7 years old (P < 0.0001) and the use of antibiotics within the past year (P = 0.0031). Smoking appeared to be protective against MRSA colonization (P < 0.0001).

Vancomycin-Resistant Enterococci from Humans and Retail Chickens in Taiwan with Unique VanB Phenotype-vanA Genotype Incongruence

ABSTRACT Vancomycin resistant enterococci (VRE) with VanB phenotype-vanA genotype incongruence were found in all 39 VRE isolated from chicken carcasses and four human VRE isolates in Taiwan. Three identical mutations in the vanS gene were found in the VanB phenotype-vanA genotype VRE sequenced. This finding indicates possible transmission of glycopeptide resistance among different hosts.

Copy Number Change of the NDM-1 Sequence in a Multidrug-Resistant Klebsiella pneumoniae Clinical Isolate

The genetic features of the antimicrobial resistance of a multidrug resistant Klebsiella pneumoniae strain harboring bla NDM-1 were investigated to increase our understanding of the evolution of NDM-1. The strain, KPX, came from a Taiwanese patient with a hospitalization history in New Delhi. Complete DNA sequencing was performed; and the genes responsible for antimicrobial resistance were systematically examined and isolated by library screening. KPX harbored two resistance plasmids, pKPX-1 and pKPX-2, which are 250-kb and 141-kb in size, respectively, with bla NDM-1 present on pKPX-1. The plasmid pKPX-1 contained genes associated with the IncR and IncF groups, while pKPX-2 belonged to the IncF family. Each plasmid carried multiple antimicrobial resistance genetic determinants. The gene responsible for resistance to carbapenems was found on pKPX-1 and that for resistance to aztreonam was found on pKPX-2. To our surprise, we discovered that bla NDM-1 exists on pKPX-1 as multiple copies in the form of tandem repeats. Amplification of bla NDM-1 was found to occur by duplication of an 8.6-kb unit, with the copy number of the repeat varying from colony to colony. This repeat sequence is identical to that of the pNDM-MAR except for two base substitutions. The copy number of bla NDM-1 of colonies under different conditions was assessed by Southern blotting and quantitative PCR. The bla NDM-1 sequence was maintained in the presence of the antimicrobial selection; however, removal of antimicrobial selection led to the emergence of susceptible bacterial populations with a reduced copy number or even the complete loss of the bla NDM-1 sequence. The dynamic nature of the NDM-1 sequence provides a strong argument for judicious use of the broad-spectrum antimicrobials in order to reduce the development and spread of antimicrobial resistance among pathogens.

Complete Sequences of Two Plasmids in a blaNDM-1-Positive Klebsiella oxytoca Isolate from Taiwan

ABSTRACT Genetic determinants of a blaNDM-1-positive, multidrug-resistant bacterial isolate that caused active infection was investigated by DNA sequencing. Two plasmids, pKOX_NDM1 and pKOX-R1, were identified for the Klebsiella oxytoca strain E718. Sequence annotation revealed a blaNDM-1 gene in pKOX_NDM1 and two extended-spectrum β-lactamase producers (blaCTX-M-3 and blaSHV-12) and a wide array of resistance genes in pKOX-R1. These findings highlight the difficulty in treating multidrug-resistant bacterial infections and the potential danger of emerging resistant enterobacteria.

Molecular characterization and clonal genetic diversity of methicillin-resistant Staphylococcus aureus of pig origin in Taiwan

Livestock-associated methicillin-resistant Staphylococcus aureus (LA-MRSA) is an emerging public health threat. The aims of this study were to identify nasal carriage of MRSA in finishing pigs from different geographical areas of Taiwan and to compare the genetic features of LA-MRSA with other countries. A total of 299 swine nasal samples were collected from 11 counties in western Taiwan with 220 identified MRSA isolates characterized by spa, SCCmec, MLST, pulsed-field gel electrophoresis (PFGE), antibiogram, and Panton-Valentine leukocidin (PVL) toxin genes. A widespread LA-MRSA clone, ST9-t899-PVL-negative, was detected as the predominant (91.6%) clone in Taiwan pigs, and a novel spa type t7616 was identified. Most isolates carried SCCmec type V but lacked ccrC gene (98.8%), a particular feature that was observed for the first time. The integration of minimum spanning trees (MST) based on a PFGE distance matrix and geographical information showed high genetic diversity among ST9-t899 isolates with three unique subpopulations identified in two counties that are nearby each other. Multidrug resistance (MDR) was prevalent in isolates from different counties with more than 80% resistance to erythromycin, ciprofloxacin, gentamicin, tetracycline, and clindamycin. In conclusion, this study reported the first identified LA-MRSA clone of MDR-ST9-t899-V lacking ccrC dominant in pig farms in western Taiwan that differed from ST398 in Europe and North America. Close monitoring of this MDR unique clone is warranted to survey its spread from livestock to humans.

Characteristics and virulence factors of livestock associated ST9 methicillin-resistant Staphylococcus aureus with a novel recombinant staphylocoagulase type

Livestock-associated methicillin-resistant Staphylococcus aureus (LA-MRSA) sequence type 9 (ST9) is a potential source of zoonotic infection for humans. In this study, we investigated and compared the virulence profiles of MRSA ST9 isolates from healthy swine and human clinical origins. A total of 152 MRSA ST9 isolates, including 147 LA-MRSA isolates and 5 human clinical isolates, were studied for the accessory gene regulator (agr) and 20 enterotoxin genes (se), exfoliatoxin gene, and tst gene. The evolutionary history of staphylocoagulase (SC) in Taiwan MRSA ST9 was reconstructed based on phylogenetic and population genetics. The predominant type of LA-MRSA ST9 isolates (78.9%) was agr-II that differed from the predominant agr-I human clinical MRSA strains in Taiwan and the LA-MRSA ST398 lineage from Europe. Forty-nine percent of the LA-MRSA ST9 isolates carried a combination of enterotoxin gene cluster-2 (egc-2, seg, sei, sem, sen, seo, and seu) and tst. In addition, the Taiwan LA-MRSA ST9 and the human clinical ST9-MRSA contained a novel SC XIc subtype and had a unique history of evolution indicating a recent common ancestor. These findings suggest a cross-species transmission of this emerging ST9-SC XIc MRSA between swine and human.

Colonisation of fluoroquinolone-resistant Haemophilus influenzae among nursing home residents in southern Taiwan

Fluoroquinolones have been widely used to treat respiratory tract infections, but fluoroquinolone resistance in Haemophilus influenzae has remained rare. In 2007, prospective surveillance cultures of throat swabs and sputum were conducted every two months on 150 residents of four nursing homes in southern Taiwan. Forty-eight H. influenzae isolates were obtained from 30 (20%) residents. All isolates were non-b serotype and 27 (56.3%) possessed beta-lactamases. Resistance to levofloxacin [minimum inhibitory concentration (MIC) >2 microg/mL] and moxifloxacin (MIC >1 microg/mL) was found in 20 (41.7%) and 21 (43.8%) isolates, respectively. High level levofloxacin and moxifloxacin resistance (MIC >32 microg/mL) was detected in 19 (39.6%) and 15 (31.3%) isolates, respectively. Among 150 residents, those with urinary catheterisation (P=0.018) and tracheostomy tubes (P=0.029) were independently associated with airway colonisation by moxifloxacin-resistant H. influenzae. Among 30 residents with carriage of H. influenzae, no factor was significantly associated with moxifloxacin resistance. Pulsed-field gel electrophoresis of the isolates revealed 14 distinct types. Two major clones accounted for 29 isolates, 27 of which were obtained from 13 residents in one nursing home. All but two of the fluoroquinolone-resistant isolates belonged to these two major clones. This study highlights the emergence of fluoroquinolone-resistant H. influenzae and its clonal spread among nursing home residents in southern Taiwan. Further studies on clinical implications and the extent of fluoroquinolone non-susceptibility and resistance are needed.

Complete Genome Sequence of Klebsiella oxytoca E718, a New Delhi Metallo-β-Lactamase-1-Producing Nosocomial Strain

We report the complete genome sequence of Klebsiella oxytoca E718, a New Delhi metallo-β-lactamase-1 (NDM-1)-producing strain isolated from a renal transplant patient. The genome contains a 6,097,032-bp chromosome and two multidrug resistance plasmids with sizes of 324,906 bp and 110,781 bp.

Predisposing factors for oropharyngeal colonization of yeasts in human immunodeficiency virus-infected patients: A prospective cross-sectional study

BACKGROUND Oropharyngeal candidiasis continues to be a major opportunistic infection in human immunodeficiency virus (HIV)-infected patients. The objectives of this study were to investigate the prevalence, associated factors, and microbiologic features for oropharyngeal yeast colonization in HIV-infected patients. METHODS From October to December 2009, consecutive HIV-infected patients older than 18 years were recruited in this study. Demographic information, underlying conditions, and clinical histories were collected. Oropharyngeal swab cultures for yeasts and antifungal drug susceptibilities of the isolates were performed. RESULTS Of the 105 HIV-infected patients, 54 (51.4%) were colonized with yeasts, including 11 patients (20.4%) with more than one species. Among the 68 isolates, Candida albicans accounted for 73.5%, followed by Candida tropicalis (5.9%), Candida glabrata (5.9%), and Candida dubliniensis (4.4%). There were 7.5% and 6% Candida isolates resistant to fluconazole and voriconazole, respectively. All of the Candida isolates were susceptible to amphotericin B. A higher prevalence of yeast colonization was noted in patients with a CD4 cell count ≤200 cells/μL (p = 0.032). Multivariate regression analysis showed that intravenous drug use was an independent associated factor for oropharyngeal yeast colonization (odds ratio, 5.35; 95% confidence interval, 1.39-20.6; p = 0.015), as well as protease inhibitor-containing antiretroviral therapy (odds ratio, 3.59; 95% confidence interval, 1.41-9.12; p = 0.007). CONCLUSION Despite previous studies showing that protease inhibitors decreased Candida adhesion to epithelial cells in vitro, the current study found protease inhibitor-containing antiretroviral therapy predisposed to oropharyngeal yeast colonization in HIV-infected patients.