Vera Manageiro

Spread of Extended-Spectrum β-Lactamase CTX-M-Producing Escherichia coli Clinical Isolates in Community and Nosocomial Environments in Portugal

ABSTRACT Of the 181 unduplicated Escherichia coli strains isolated in nine different hospitals in three Portuguese regions, 119 were extended-spectrum β-lactamase (ESBL)-CTX-M producers and were selected for phenotype and genotype characterization. CTX-M producer strains were prevalent among community-acquired infections (56%), urinary tract infections (76%), and patients ≥60 years old (76%). In MIC tests, all strains were resistant to cefotaxime, 92% were resistant to ceftazidime, 93% were resistant to quinolones, 89% were resistant to aminoglycoside, and 26% were resistant to trimethoprim-sulfamethoxazole; all strains were sensitive to carbapenems, and 92% of the strains had a multidrug resistance phenotype. Molecular methods identified 109 isolates harboring a blaCTX-M-15 gene, 1 harboring the blaCTX-M-32 gene (first identification in the country), and 9 harboring the blaCTX-M-14 gene. All isolates presented the ISEcp1 element upstream from the blaCTX-M genes; one presented the IS903 element (downstream of blaCTX-M-14 gene), and none had the IS26 element; 85% carried blaTEM-1B, and 84% also carried a blaOXA-30. Genetic relatedness analysis based on pulsed-field gel electrophoresis defined five clusters and indicated that 76% of all isolates (from cluster IV) corresponded to a single epidemic strain. Of the 47 strains from one hospital, 41 belonged to cluster IV and were disseminated in three main wards. CTX-M-producing E. coli strains are currently a problem in Portugal, with CTX-M-15 particularly common. This study suggests that the horizontal transfer of blaCTX-M genes, mediated by plasmids and/or mobile elements, contributes to the dissemination of CTX-M enzymes to community and hospital environments. The use of extended-spectrum cephalosporins, quinolones, and aminoglycosides is compromised, leaving carbapenems as the therapeutic option for severe infections caused by ESBL producers.

Occurrence of carbapenemase-producing Klebsiella pneumoniae and Escherichia coli in the European survey of carbapenemase-producing Enterobacteriaceae (EuSCAPE): a prospective, multinational study

BACKGROUND Gaps in the diagnostic capacity and heterogeneity of national surveillance and reporting standards in Europe make it difficult to contain carbapenemase-producing Enterobacteriaceae. We report the development of a consistent sampling framework and the results of the first structured survey on the occurrence of carbapenemase-producing Klebsiella pneumoniae and Escherichia coli in European hospitals. METHODS National expert laboratories recruited hospitals with diagnostic capacities, who collected the first ten carbapenem non-susceptible clinical isolates of K pneumoniae or E coli and ten susceptible same-species comparator isolates and pertinent patient and hospital information. Isolates and data were relayed back to national expert laboratories, which made laboratory-substantiated information available for central analysis. FINDINGS Between Nov 1, 2013, and April 30, 2014, 455 sentinel hospitals in 36 countries submitted 2703 clinical isolates (2301 [85%] K pneumoniae and 402 (15%) E coli). 850 (37%) of 2301 K pneumoniae samples and 77 (19%) of 402 E coli samples were carbapenemase (KPC, NDM, OXA-48-like, or VIM) producers. The ratio of K pneumoniae to E coli was 11:1. 1·3 patients per 10 000 hospital admissions had positive clinical specimens. Prevalence differed greatly, with the highest rates in Mediterranean and Balkan countries. Carbapenemase-producing K pneumoniae isolates showed high resistance to last-line antibiotics. INTERPRETATION This initiative shows an encouraging commitment by all participants, and suggests that challenges in the establishment of a continent-wide enhanced sentinel surveillance for carbapenemase-producing Enterobacteriaeceae can be overcome. Strengthening infection control efforts in hospitals is crucial for controlling spread through local and national health care networks. FUNDING European Centre for Disease Prevention and Control.

Spread of clinical extended-spectrum β-lactamase (CTX-M)-producing Escherichia coli isolates in community and nosocomial environments in Portugal

ABSTRACT Of the 181 unduplicated Escherichia coli strains isolated in nine different hospitals in three Portuguese regions, 119 were extended-spectrum β-lactamase (ESBL)-CTX-M producers and were selected for phenotype and genotype characterization. CTX-M producer strains were prevalent among community-acquired infections (56%), urinary tract infections (76%), and patients ≥60 years old (76%). In MIC tests, all strains were resistant to cefotaxime, 92% were resistant to ceftazidime, 93% were resistant to quinolones, 89% were resistant to aminoglycoside, and 26% were resistant to trimethoprim-sulfamethoxazole; all strains were sensitive to carbapenems, and 92% of the strains had a multidrug resistance phenotype. Molecular methods identified 109 isolates harboring a blaCTX-M-15 gene, 1 harboring the blaCTX-M-32 gene (first identification in the country), and 9 harboring the blaCTX-M-14 gene. All isolates presented the ISEcp1 element upstream from the blaCTX-M genes; one presented the IS903 element (downstream of blaCTX-M-14 gene), and none had the IS26 element; 85% carried blaTEM-1B, and 84% also carried a blaOXA-30. Genetic relatedness analysis based on pulsed-field gel electrophoresis defined five clusters and indicated that 76% of all isolates (from cluster IV) corresponded to a single epidemic strain. Of the 47 strains from one hospital, 41 belonged to cluster IV and were disseminated in three main wards. CTX-M-producing E. coli strains are currently a problem in Portugal, with CTX-M-15 particularly common. This study suggests that the horizontal transfer of blaCTX-M genes, mediated by plasmids and/or mobile elements, contributes to the dissemination of CTX-M enzymes to community and hospital environments. The use of extended-spectrum cephalosporins, quinolones, and aminoglycosides is compromised, leaving carbapenems as the therapeutic option for severe infections caused by ESBL producers.

Occurrence of extended-spectrum β-lactamases among isolates of Salmonella enterica subsp. enterica from food-producing animals and food products, in Portugal

A total of 1120 Salmonella spp. isolates, recovered from poultry, swine and food products of animal origin (bovine, swine and poultry) over the period of 2009-2011, were investigated in order to determine their serotype, susceptibility to a panel of eleven antimicrobials (A, ampicillin; Ct, cefotaxime; Cp, ciprofloxacin; Tm, trimethoprim; Su, sulfamethoxazole; C, chloramphenicol; S, streptomycin; G, gentamicin; T, tetracycline; NA, nalidixic acid; Fl, florfenicol), and the presence of resistance determinants of extended-spectrum cephalosporins. Overall, Salmonella Enteritidis was the most common serotype in all three animal species. In 618 isolates of poultry, 32.8% comprised S. Enteritidis, 18.3% Salmonella Havana and 16.5% Salmonella Mbandaka; in 101 isolates of pigs, 21.8% comprised Salmonella Rissen and Salmonella Typhimurium, 10.9% Salmonella Derby and Salmonella London. Salmonella I 4,[5],12:i:- was the most common serotype recovered from pork and beef food products comprising 32.6% and 30% of isolates respectively, followed by S. Rissen (26% and 24%) and S. Typhimurium (18.2% and 19%), respectively. In poultry products, S. Enteritidis was the most frequent serotype (62.7%), followed by S. Mbandaka (10.2%) and S. Derby (8.5%). Susceptibility profiles differed according to the origin of the isolates. Five multidrug resistant isolates (0.45%) were further characterized as extended-spectrum β-lactamase (ESBL) producers. Polymerase chain reaction and sequencing of the amplicons confirmed the presence of bla(CTX-M-1) (n = 2), bla(CTX-M-14) (n = 1), bla(CTX-M-15) (n = 1) and bla(CTX-M-32) (n = 1); bla(SHV-12) and bla(TEM-1) genes were also detected in two isolates of S. I 4,[5],12:i:-. Four isolates, two S. Havana and two S. I 4,[5],12:i:-, carried class 1 integrons and in three, two S. I 4,[5],12:i:- and one S. Havana, ISEcp1 was identified associated to bla(CTX-M-1), bla(CTX-M-32) and bla(CTX-M-14) genes. Additionally, in one S. I 4,[5],12:i:- isolate, orf477 was identified linked to bla(CTX-M-32). No plasmid mediated quinolone resistance-encoding genes were detected. Here, we report for the first time the presence of bla(CTX-M) genes in Salmonella enterica subsp enterica isolates recovered from poultry and food products of swine origin, in Portugal.

Assessing the molecular basis of transferable quinolone resistance in Escherichia coli and Salmonella spp. from food-producing animals and food products

Enterobacteriaceae resistant to quinolones frequently arise in animals, being easily disseminated through the food-chain. The aim of this study was to investigate the presence of plasmid-mediated quinolone resistance (PMQR) determinants in Salmonella spp. (n=183) and Escherichia coli (n=180) isolates, collected from food-producing animals and food products among swine, poultry, rabbits and cattle. All isolates were subjected to antimicrobial susceptibility testing and molecular screening of PMQR determinants. β-Lactamase-encoding genes, and the quinolone resistance determining region (QRDR) of gyrA, gyrB, parC and parE genes were also investigated in PMQR-positive isolates. Plasmid characterization was performed by conjugation, followed by replicon-typing. Genetic relatedness of PMQR-positive E. coli was examined by Multilocus Sequence Typing, while Salmonella was previously serotyped. The association of mobile genetic elements and PMQR was investigated through PCR mapping assays. Overall, 4.1% (15/363) isolates harbored qnrB2 (n=3), qnrB19 (n=3), and qnrS1 (n=9) genes. All but one isolate presented one to four mutations in QRDR of gyrA or parC genes, which is consistent with the range of MIC values detected (0.19-64 mg/L) for ciprofloxacin; 60% (9/15) of qnr-harboring isolates were non-susceptible to β-lactam antibiotics which was justified by the presence of β-lactamases from TEM (TEM-1, n=8; TEM-135, n=1) and SHV (SHV-108, n=1) families. Analysis of mobile genetic elements revealed that qnr genes were detected nearby relevant genetic elements like intI1, ISEcl2, IS26 and ISCR1 and enclosed in diverse Inc. type plasmids. This study illustrated the existence of Qnr-producing E. coli and Salmonella from food-producing animals, associated to specific mobile elements that might mediate their transference between species and among distinct settings.

Human, food and animal Campylobacter spp. isolated in Portugal: High genetic diversity and antibiotic resistance rates

Infections by Campylobacter jejuni and Campylobacter coli are considered the major cause of bacterial gastroenteritis in humans, with food being the main source of infection. In this study, a total of 196 Campylobacter strains (125 isolates from humans, 39 from retail food and 32 from food animal sources) isolated in Portugal between 2009 and 2012 were characterised by multilocus sequence typing (MLST) and flaA short variable region (SVR) typing. Susceptibility to six antibiotics as well as the mechanisms underlying antibiotic resistance phenotypes was also studied. Based on MLST typing, C. coli strains were genetically more conserved, with a predominant clonal complex (CC828), than C. jejuni strains. In contrast, C. coli isolates were genetically more variable than C. jejuni with regard to flaA-SVR typing. A high rate of resistance was observed for quinolones (100% to nalidixic acid, >90% to ciprofloxacin) and, in general, resistance was more common among C. coli, especially for erythromycin (40.2% vs. 6.7%). In addition, most isolates (86%) were resistant to multiple antimicrobial families. Besides the expected point mutations associated with antibiotic resistance, detected polymorphisms in the cmeABC locus likely play a role in the multiresistant phenotype. This study provides for the first time an overview of the genetic diversity of Campylobacter strains from Portugal. It also shows a worrying antibiotic multiresistance rate and the emergence of Campylobacter strains resistant to antibiotics of human use.

Genetic diversity and clonal evolution of carbapenem-resistant Acinetobacter baumannii isolates from Portugal and the dissemination of ST118

In this study, 116 multidrug-resistant Acinetobacter baumannii (MDR-Ab) isolates recovered in various regions of Portugal were studied. All isolates were non-susceptible to tigecycline; one isolate was also non-susceptible to colistin, making it a step closer to pandrug resistance. Among 72 isolates tested by PFGE, 98.6% carried bla(OXA-66), 1.4% bla(OXA-104), 77.8% bla(OXA-23), 23.6% bla(OXA-24), 18.1% bla(TEM-1) and 1.4% bla(CTX-M-15-like) genes. No OXA-58 or metallo-β-lactamase-encoding genes were detected. ISAba1 was found in 58/72 isolates (80.6%). Among these, ISAba1 was found upstream of bla(OXA-51-like) in 54 isolates. All but two of these isolates also carried ISAba1-bla(OXA-23), highlighting the coexistence of ISAba1-bla(OXA-51-like) and ISAba1-bla(OXA-23) genetic platforms, emphasising the importance of mobile genetic elements in the dissemination of carbapenem-hydrolysing class D β-lactamase genes. Tn2006-like and Tn2008-like, found within ST92 and ST118, may reflect either multiple genetic structures in the origin of bla(OXA-23) acquisition or interclonal complex evolution. These results indicate that there may exist different genetic origins for carbapenem resistance among MDR-Ab isolates. Six PFGE profiles were associated with three major sequence types, with ST118 (OXA-23- or OXA-24-producer) being widely disseminated since 2009. ST98 (described so far as endemic in Portugal) and ST92 (which co-existed with ST98 before 2009) appeared to have been gradually replaced by ST118. The new ST188 (OXA-104-producer) was detected for the first time in this country. Identification of an extensively drug-resistant ST118 and carbapenem-resistant ST92, ST98 and ST118 isolates, both in community and healthcare facilities, demonstrates the menace of A. baumannii-associated infections.

Clinically relevant multidrug resistant Salmonella enterica in swine and meat handlers at the abattoir.

The presence of multidrug resistant (MDR) Salmonella serotypes in slaughtered swine, carcasses, meat and meat handlers is scarcely evaluated. Recently we demonstrated that diverse Salmonella serotypes are frequently present in swine, pork meat and carcasses, and meat handlers at Portuguese abattoirs. Here we have characterized their antibiotic resistance phenotypes and genotypes, helping elucidate the flow of MDR Salmonella in the food chain. Testing 60 Salmonella isolates from different serotypes, the highest frequencies of resistance were observed for tetracycline (T) [70% (n=42/60), tet(A)/tet(B)/tet(G)], streptomycin (S) [63% (n=38/60), aadA2/strA/strB], sulfamethoxazole (Sul) [62% (n=37/60), sul1/sul2/sul3] and ampicillin (A) [57% (n=34/60), blaPSE-1/blaTEM]. Thirty-seven percent (n=22/60) carried class 1 integrons and multidrug resistance was frequently observed (63% n=38/60), including those serotypes common to human infections [S. Typhimurium 78% n=25/32; S. 4,[5],12:i:- 67% n=2/3; S. Rissen 75% (n=3/4); S. London 67% n=2/3; S. Derby 55%; n=6/11)]. The emergent S. 4,[5],12:i:- isolates were mostly characterized by ASSuT phenotype [blaTEM/strA-strB/sul2/tet(B)], typical of the European clone, while for the first time the ST phenotype [strA-strB-tet(A)-tet(B)] was also observed. Moreover, we report a first finding of a MDR phenotype in S. London [ANSSuT; blaTEM-strA-strB-sul2-tet(A)]. Our findings suggest that the abattoir environment and the slaughter operations seem not only to harbor MDR serotypes that originated in the pig reservoir, but also propagate them through cross-contamination processes, involving meat handlers. The present study suggests a probable relationship between swine and human salmonellosis throughout the food chain, which is of interest for epidemiological, animal health and public health purposes.

The Lys234Arg Substitution in the Enzyme SHV-72 Is a Determinant for Resistance to Clavulanic Acid Inhibition

ABSTRACT The new β-lactamase SHV-72 was isolated from clinical Klebsiella pneumoniae INSRA1229, which exhibited the unusual association of resistance to the amoxicillin-clavulanic acid combination (MIC, 64 μg/ml) and susceptibility to cephalosporins, aztreonam, and imipenem. SHV-72 (pI 7.6) harbored the three amino acid substitutions Ile8Phe, Ala146Val, and Lys234Arg. SHV-72 had high catalytic efficiency against penicillins (kcat/Km, 35 to 287 μM−1·s−1) and no activity against oxyimino β-lactams. The concentration of clavulanic acid necessary to inhibit the enzyme activity by 50% was 10-fold higher for SHV-72 than for SHV-1. Molecular-dynamics simulation suggested that the Lys234Arg substitution in SHV-72 stabilized an atypical conformation of the Ser130 side chain, which moved the Oγ atom of Ser130 around 3.5 Å away from the key Oγ atom of the reactive serine (Ser70). This movement may therefore decrease the susceptibility to clavulanic acid by preventing cross-linking between Ser130 and Ser70.

Role of SHV β-lactamase variants in resistance of clinical Klebsiella pneumoniae strains to β-lactams in an Algerian hospital

Three clinical Klebsiella pneumoniae strains, KpARG74, KpARG220 and KpARG185, isolated from a hospital in Algeria, carried the novel β-lactamases SHV-98, SHV-99 and SHV-100, respectively, and co-expressed TEM-1 and either CTX-M-3 or CTX-M-15. In contrast, transformed cells possessing the genes for these novel β-lactamases, i.e. EcDH5α-SHV-98, EcDH5α-SHV-99 and EcDH5α-SHV-100, respectively, carried unique sequence features of bla(SHV) gene variants, enabling oxyimino-cephalosporin susceptibility and confirming that none of the transformants exhibited extended-spectrum β-lactamase (ESBL) properties. SHV-100 is apparently functional, despite differing from the SHV-1 sequence by duplication of 13 amino acids. The SHV-99 enzyme differed from the parental SHV-1 by the amino acid substitution Asp104→Gly, which is an important position in the development of the ESBL phenotype in TEM β-lactamases. This is the first time, to our knowledge, that this mutation has been reported in clinically occurring isolates. Thus, kinetic characterization of the SHV-99 enzyme was performed. The SHV-99 enzyme showed higher affinity (K(m) of 196 µM), catalytic activity (k(cat) of 0.5 s⁻¹) and catalytic efficiency (k(cat)/K(m) of 0.003 µM⁻¹ s⁻¹) than SHV-1 β-lactamase against aztreonam. These results showed that the neutral glycine at residue 104 increased the affinity of the enzyme to aztreonam, but was unable to develop the ESBL phenotype in SHV enzymes. As the emergence of new threatening combinations of resistance determinants among nosocomial pathogens is further possible, this study has highlighted the need to reverse the spread of initial mutations.