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Rodríguez-Guerrero E, Callejas-Rodelas JC, Navarro-Marí JM, Gutiérrez-Fernández J. Systematic Review of Plasmid AmpC Type Resistances in Escherichia coli and Klebsiella pneumoniae and Preliminary Proposal of a Simplified Screening Method for ampC. Microorganisms 2022; 10:microorganisms10030611. [PMID: 35336186 PMCID: PMC8954824 DOI: 10.3390/microorganisms10030611] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 02/01/2023] Open
Abstract
Beta-lactamase (BL) production is a major public health problem. Although not the most frequent AmpC type, AmpC-BL is increasingly isolated, especially plasmid AmpC-BL (pAmpC-BL). The objective of this study was to review information published to date on pAmpC-BL in Escherichia coli and Klebsiella pneumoniae, and on the epidemiology and detection methods used by clinical microbiology laboratories, by performing a systematic review using the MEDLINE PubMed database. The predictive capacity of a screening method to detect AmpC-BL using disks with cloxacillin (CLX) was also evaluated by studying 102 Enterobacteriaceae clinical isolates grown in CHROMID ESBL medium with the addition of cefepime (FEP), cefoxitin (FOX), ertapenem (ETP), CLX, and oxacillin with CLX. The review, which included 149 publications, suggests that certain risk factors (prolonged hospitalization and previous use of cephalosporins) are associated with infections by pAmpC-BL-producing microorganisms. The worldwide prevalence has increased over the past 10 years, with a positivity rate ranging between 0.1 and 40%, although AmpC was only detected when sought in a targeted manner. CMY-2 type has been the most prevalent pAmpC-BL-producing microorganism. The most frequently used phenotypic method has been the double-disk synergy test (using CLX disks or phenyl-boronic acid and cefotaxime [CTX] and ceftazidime) and the disk method combined with these inhibitors. In regard to screening methods, a 1-µg oxacillin disk with CLX showed 88.9% sensitivity, 100% specificity, 100% positive predictive value (PPV), 98.9% negative predictive value (NPV), and 98.9% validity index (VI). This predictive capacity is reduced with the addition of extended-spectrum beta-lactamases, showing 62.5% sensitivity, 100% specificity, 100% PPV, 93.5% NPV, and 94.1% VI. In conclusion, there has been a worldwide increase in the number of isolates with pAmpC-BL, especially in Asia, with CMY-2 being the most frequently detected pAmpC-BL-producing type of microorganism. Reduction in its spread requires routine screening with a combination of phenotypic methods (with AmpC inhibitors) and genotypic methods (multiplex PCR). In conclusion, the proposed screening technique is an easy-to-apply and inexpensive test for the detection of AmpC-producing isolates in the routine screening of multidrug-resistant microorganisms.
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Affiliation(s)
- Enrique Rodríguez-Guerrero
- Laboratory of Microbiology, Virgen de las Nieves University Hospital & ibs.Granada—Instituto de Investigación Biosanitaria de Granada, Avda. de las Fuerzas Armadas 2, 18014 Granada, Spain; (E.R.-G.); (J.M.N.-M.)
| | - Juan Carlos Callejas-Rodelas
- Department of Microbiology, School of Medicine, University of Granada & ibs.Granada—Instituto de Investigación Biosanitaria de Granada, Avenida de la Investigación 11, 18016 Granada, Spain;
| | - José María Navarro-Marí
- Laboratory of Microbiology, Virgen de las Nieves University Hospital & ibs.Granada—Instituto de Investigación Biosanitaria de Granada, Avda. de las Fuerzas Armadas 2, 18014 Granada, Spain; (E.R.-G.); (J.M.N.-M.)
| | - José Gutiérrez-Fernández
- Laboratory of Microbiology, Virgen de las Nieves University Hospital & ibs.Granada—Instituto de Investigación Biosanitaria de Granada, Avda. de las Fuerzas Armadas 2, 18014 Granada, Spain; (E.R.-G.); (J.M.N.-M.)
- Department of Microbiology, School of Medicine, University of Granada & ibs.Granada—Instituto de Investigación Biosanitaria de Granada, Avenida de la Investigación 11, 18016 Granada, Spain;
- Correspondence:
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Teng JLL, Luo R, Tang BSF, Fong JYH, Wang L, Jia L, Wong CKS, Chan E, Leung AWS, Siu GKH, Chiu TH, Fung AMY, Wu AKL, Yeung ML, Lau SKP, Woo PCY. High Prevalence and Mechanism Associated With Extended Spectrum Beta-Lactamase-Positive Phenotype in Laribacter hongkongensis. Front Microbiol 2021; 12:618894. [PMID: 33633706 PMCID: PMC7902055 DOI: 10.3389/fmicb.2021.618894] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 01/20/2021] [Indexed: 11/29/2022] Open
Abstract
In this study, we reported the prevalence and mechanism associated with the extended-spectrum beta-lactamase (ESBL)-positive phenotype in Laribacter hongkongensis isolated from patients and fish. Using the inhibition zone enhancement test, 20 (95.2%) of the 21 patient strains and 8 (57.1%) of the 14 fish strains were tested ESBL-positive. However, ESBL genes, including SHV, TEM, CTX-M, GES, and PER, were not detected in all of these 28 L. hongkongensis isolates. No ESBL gene could be detected in either the complete genome of L. hongkongensis HLHK9 or the draft genome of PW3643. PCR and DNA sequencing revealed that all the 35 L. hongkongensis isolates (showing both ESBL-positive and ESBL-negative phenotypes) were positive for the ampC gene. When the AmpC deletion mutant, HLHK9ΔampC, was subject to the zone enhancement test, the difference of zone size between ceftazidime/clavulanate and ceftazidime was less than 5 mm. When boronic acid was added to the antibiotic disks, none of the 28 “ESBL-positive” isolates showed a ≥ 5 mm enhancement of inhibition zone size diameter between ceftazidime/clavulanate and ceftazidime and between cefotaxime/clavulanate and cefotaxime. A high prevalence (80%) of ESBL-positive phenotype is present in L. hongkongensis. Overall, our results suggested that the ESBL-positive phenotype in L. hongkongensis results from the expression of the intrinsic AmpC beta-lactamase. Confirmatory tests should be performed before issuing laboratory reports for L. hongkongensis isolates that are tested ESBL-positive by disk diffusion clavulanate inhibition test.
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Affiliation(s)
- Jade L L Teng
- Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Ruibang Luo
- Department of Computer Science, The University of Hong Kong, Hong Kong, China
| | - Bone S F Tang
- Department of Pathology, Hong Kong Sanatorium and Hospital, Hong Kong, China
| | - Jordan Y H Fong
- Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Li Wang
- Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Lilong Jia
- Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Chloe K S Wong
- Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Elaine Chan
- Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Amy W S Leung
- Department of Computer Science, The University of Hong Kong, Hong Kong, China
| | - Gilman K H Siu
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong, China
| | - Tsz-Ho Chiu
- Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Ami M Y Fung
- Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Alan K L Wu
- Department of Clinical Pathology, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
| | - Man-Lung Yeung
- Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Susanna K P Lau
- Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Patrick C Y Woo
- Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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3
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Tamma PD, Doi Y, Bonomo RA, Johnson JK, Simner PJ. A Primer on AmpC β-Lactamases: Necessary Knowledge for an Increasingly Multidrug-resistant World. Clin Infect Dis 2020; 69:1446-1455. [PMID: 30838380 DOI: 10.1093/cid/ciz173] [Citation(s) in RCA: 169] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 02/26/2019] [Indexed: 12/13/2022] Open
Abstract
Understanding the nuances of AmpC β-lactamase-mediated resistance can be challenging, even for the infectious diseases specialist. AmpC resistance can be classified into 3 categories: (1) inducible chromosomal resistance that emerges in the setting of a β-lactam compound, (2) stable derepression due to mutations in ampC regulatory genes, or (3) the presence of plasmid-mediated ampC genes. This review will mainly focus on inducible AmpC resistance in Enterobacteriaceae. Although several observational studies have explored optimal treatment for AmpC producers, few provide reliable insights into effective management approaches. Heterogeneity within the data and inherent selection bias make inferences on effective β-lactam choices problematic. Most experts agree it is prudent to avoid expanded-spectrum (ie, third-generation) cephalosporins for the treatment of organisms posing the greatest risk of ampC induction, which has best been described in the context of Enterobacter cloacae infections. The role of other broad-spectrum β-lactams and the likelihood of ampC induction by other Enterobacteriaceae are less clear. We will review the mechanisms of resistance and triggers resulting in AmpC expression, the species-specific epidemiology of AmpC production, approaches to the detection of AmpC production, and treatment options for AmpC-producing infections.
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Affiliation(s)
- Pranita D Tamma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yohei Doi
- Department of Medicine, University of Pittsburgh, School of Medicine, Pennsylvania
| | - Robert A Bonomo
- Department of Medicine, The Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Case Western Reserve University, Ohio
| | - J Kristie Johnson
- Department of Pathology, University of Maryland School of Medicine, Baltimore
| | - Patricia J Simner
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Hong JS, Song W, Park HM, Oh JY, Chae JC, Shin S, Jeong SH. Clonal Spread of Extended-Spectrum Cephalosporin-Resistant Enterobacteriaceae Between Companion Animals and Humans in South Korea. Front Microbiol 2019; 10:1371. [PMID: 31275286 PMCID: PMC6591270 DOI: 10.3389/fmicb.2019.01371] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 05/31/2019] [Indexed: 11/24/2022] Open
Abstract
Extended-spectrum cephalosporin (ESC)-resistant Enterobacteriaceae is an increasingly important problem in both human and veterinary medicine. The aims of this study were to describe a comparative molecular characterization of Enterobacteriaceae carrying ESC resistance genes, encoding extended-spectrum β-lactamase (ESBL) and AmpC, isolated from human stool samples, rectal swabs from companion animals, and swabs from the environment of veterinarian hospitals in South Korea, and to examine their possible dissemination and transmission. The ESC resistance genes were identified by PCR and sequencing. Isolates with the predominant ESC resistance genes were assessed for their genetic relatedness by pulsed-field gel electrophoresis (PFGE) and multi-locus sequence typing. A total of 195 Escherichia coli and 41 Klebsiella pneumoniae isolates that exhibited ESC resistance were recovered on CHROMagar ESBL from human, companion animal, and the veterinary hospital environmental samples. In companion animals, most of the ESC resistance genes were blaCMY–2–like (26.4%), followed by blaCTX –M–55 (17.2%) and blaCTX–M–14 (16.1%), whereas blaCTX–M–15 (28.6%) was predominant in human samples. The epidemiological relatedness of isolates carrying ESC resistance genes, including 124 E. coli and 23 K. pneumoniae isolates carrying CMY-2-like, DHA-1-like, or/and CTX-M-type, were analyzed by PFGE. The pulsotypes of five E. coli isolates (three from dogs and two from humans) carrying blaCMY–2–like, which were attributed to sequence type 405, from different veterinary clinics showed >85% similarity. Our results indicate direct transmission and dissemination of ESC-resistant Enterobacteriaceae between humans and companion animals.
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Affiliation(s)
- Jun Sung Hong
- Department of Laboratory Medicine, Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, South Korea
| | - Wonkeun Song
- Department of Laboratory Medicine, Hallym University College of Medicine, Chuncheon, South Korea
| | - Hee-Myung Park
- Department of Veterinary Internal Medicine, Konkuk University College of Veterinary Medicine, Seoul, South Korea
| | - Jae-Young Oh
- Department of Veterinary Internal Medicine, Konkuk University College of Veterinary Medicine, Seoul, South Korea
| | - Jong-Chan Chae
- Division of Biotechnology, Chonbuk National University, Iksan, South Korea
| | - Saeam Shin
- Department of Laboratory Medicine, Hallym University College of Medicine, Chuncheon, South Korea
| | - Seok Hoon Jeong
- Department of Laboratory Medicine, Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, South Korea
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5
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Vinueza-Burgos C, Ortega-Paredes D, Narváez C, De Zutter L, Zurita J. Characterization of cefotaxime resistant Escherichia coli isolated from broiler farms in Ecuador. PLoS One 2019; 14:e0207567. [PMID: 30951531 PMCID: PMC6450624 DOI: 10.1371/journal.pone.0207567] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 03/27/2019] [Indexed: 12/16/2022] Open
Abstract
Antimicrobial resistance (AR) is a worldwide concern. Up to a 160% increase in antibiotic usage in food animals is expected in Latin American countries. The poultry industry is an increasingly important segment of food production and contributor to AR. The objective of this study was to evaluate the prevalence, AR patterns and the characterization of relevant resistance genes in Extended Spectrum β-lactamases (ESBL) and AmpC-producing E. coli from large poultry farms in Ecuador. Sampling was performed from June 2013 to July 2014 in 6 slaughterhouses that slaughter broilers from 115 farms totaling 384 flocks. Each sample of collected caeca was streaked onto TBX agar supplemented with cefotaxime (3 mg/l). In total, 176 isolates were analyzed for AR patterns by the disk diffusion method and for blaCTX-M, blaTEM, blaCMY, blaSHV, blaKPC, and mcr-1 by PCR and sequencing. ESBL and AmpC E. coli were found in 362 flocks (94.3%) from 112 farms (97.4%). We found that 98.3% of the cefotaxime-resistant isolates were multi-resistant to antibiotics. Low resistance was observed for ertapenem and nitrofurantoin. The most prevalent ESBL genes were the ones belonging to the blaCTX-M group (90.9%), specifically the blaCTX-M-65, blaCTX-M-55 and blaCTX-M-3 alleles. Most of the AmpC strains presented the blaCMY-2 gene. Three isolates showed the mcr-1 gene. Poultry production systems represent a hotspot for AR in Ecuador, possibly mediated by the extensive use of antibiotics. Monitoring this sector in national and regional plans of AR surveillance should therefore be considered.
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Affiliation(s)
- Christian Vinueza-Burgos
- Unidad de Investigación de Enfermedades Transmitidas por Alimentos y Resistencias a los Antibióticos, Facultad de Medicina Veterinaria y Zootecnia, Universidad Central del Ecuador, Quito, Ecuador
| | - David Ortega-Paredes
- Unidad de Investigación de Enfermedades Transmitidas por Alimentos y Resistencias a los Antibióticos, Facultad de Medicina Veterinaria y Zootecnia, Universidad Central del Ecuador, Quito, Ecuador
- Unidad de Investigaciones en Biomedicina, Zurita&Zurita Laboratorios, Quito, Ecuador
| | - Cristian Narváez
- Unidad de Investigación de Enfermedades Transmitidas por Alimentos y Resistencias a los Antibióticos, Facultad de Medicina Veterinaria y Zootecnia, Universidad Central del Ecuador, Quito, Ecuador
| | - Lieven De Zutter
- Department of Veterinary Public Health and Food Safety, Faculty of Veterinary, Ghent University, Merelbeke, Belgium
| | - Jeannete Zurita
- Unidad de Investigaciones en Biomedicina, Zurita&Zurita Laboratorios, Quito, Ecuador
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In vitro activity of flomoxef against extended-spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae in Korea. Diagn Microbiol Infect Dis 2018; 94:88-92. [PMID: 30658867 DOI: 10.1016/j.diagmicrobio.2018.11.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 11/18/2018] [Accepted: 11/21/2018] [Indexed: 11/21/2022]
Abstract
To find an alternative regimen for the treatment of extended-spectrum β-lactamase (EBSL)-producing Enterobacteriaceae infections, we examined the in vitro activity of flomoxef against Escherichia coli and Klebsiella pneumoniae having CTX-M-1 group and/or CTX-M-9 group ESBLs. Boronic acid disk methods and polymerase chain reaction amplification were used to detect for ESBL, and AmpC β-lactamase and AmpC β-lactamase co-producers were excluded. Minimum inhibitory concentrations (MICs) were determined for flomoxef by broth microdilution. One hundred seventy-six isolates (E. coli, n = 93 and K. pneumoniae, n = 83) were analyzed for susceptibility test. A total of 94.3% (166/176) of isolates were susceptible to flomoxef (MIC50/MIC90 were 0.5/8 μg/mL); 98.9% of the ESBL-producing E. coli (MIC50/MIC90 were 1/4 μg/mL) and 89.2% of the ESBL-producing K. pneumoniae (MIC50/MIC90 were 0.5/16 μg/mL) were susceptible to flomoxef. Flomoxef has good in vitro activity against ESBL-producing E. coli and K. pneumoniae and could be considered as an alternative for infections caused by these organisms.
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Tran QT, Maigre L, D'Agostino T, Ceccarelli M, Winterhalter M, Pagès JM, Davin-Regli A. Porin flexibility in Providencia stuartii : cell-surface-exposed loops L5 and L7 are markers of Providencia porin OmpPst1. Res Microbiol 2017; 168:685-699. [DOI: 10.1016/j.resmic.2017.05.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 05/10/2017] [Accepted: 05/19/2017] [Indexed: 12/16/2022]
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Vinueza-Burgos C, Cevallos M, Ron-Garrido L, Bertrand S, De Zutter L. Prevalence and Diversity of Salmonella Serotypes in Ecuadorian Broilers at Slaughter Age. PLoS One 2016; 11:e0159567. [PMID: 27414038 PMCID: PMC4944992 DOI: 10.1371/journal.pone.0159567] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 07/04/2016] [Indexed: 11/18/2022] Open
Abstract
Salmonella is frequently found in poultry and represent an important source for human gastrointestinal infections worldwide. The aim of this study was to investigate the prevalence, genotypes and antimicrobial resistance of Salmonella serotypes in broilers from Ecuador. Caeca content from 388 at random selected broiler batches were collected in 6 slaughterhouses during 1 year and analyzed by the ISO 6579/Amd1 protocol for the isolation for Salmonella. Isolates were serotyped and genotypic variation was acceded by pulsed field gel electrophoresis. MIC values for sulfamethoxazole, gentamicin, ciprofloxacin, ampicillin, cefotaxime, ceftazidime, tetracycline, streptomycin, trimethropim, chloramphenicol, colistin, florfenicol, kanamycin and nalidixic acid were obtained. Presence of blaCTX-M, blaTEM, blaSHV and blaCMY; and mcr-1 plasmid genes was investigated in resistant strains to cefotaxime and colistin respectively. Prevalence at batch level was 16.0%. The most common serotype was S. Infantis (83.9%) followed by S. Enteritidis (14.5%) and S. Corvallis (1.6%). The pulsed field gel electrophoresis analysis showed that S. Corvallis, S. Enteritidis and S. Infantis isolates belonged to 1, 2 and 12 genotypes respectively. S. Infantis isolates showed high resistance rates to 12 antibiotics ranging from 57.7% (kanamycin) up to 98.1% (nalidixic acid and sulfamethoxazole). All S. Enteritidis isolates showed resistance to colistin. High multiresistant patterns were found for all the serotypes. The blaCTX-M gene was present in 33 S. Infantis isolates while mcr-1 was negative in 10 colistin resistant isolates. This study provides the first set of scientific data on prevalence and multidrug-resistant Salmonella coming from commercial poultry in Ecuador.
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Affiliation(s)
| | - María Cevallos
- Facultad de Medicina Veterinaria y Zootecnia, Universidad Central del Ecuador, Quito, Ecuador
| | - Lenin Ron-Garrido
- Facultad de Medicina Veterinaria y Zootecnia, Universidad Central del Ecuador, Quito, Ecuador
- Centro Internacional de Zoonosis, Quito, Ecuador
| | - Sophie Bertrand
- National Reference Centre for Salmonella and Shigella, Bacterial Diseases Division, Communicable and Infectious Diseases, Scientific Institute of Public Health (WIV-ISP), Brussels, Belgium
| | - Lieven De Zutter
- Department of Veterinary Public Health and Food Safety, Faculty of Veterinary, Ghent University, Merelbeke, Belgium
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Active surveillance for multidrug-resistant Gram-negative bacteria in the intensive care unit. Pathology 2015; 47:575-9. [DOI: 10.1097/pat.0000000000000302] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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10
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Lee CH, Su LH, Chen FJ, Tang YF, Chien CC, Liu JW. Clinical and microbiologic characteristics of adult patients with recurrent bacteraemia caused by extended-spectrum β-lactamase-producing Escherichia coli or Klebsiella pneumoniae. Clin Microbiol Infect 2015; 21:1105.e1-8. [PMID: 26271718 DOI: 10.1016/j.cmi.2015.07.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 07/20/2015] [Accepted: 07/31/2015] [Indexed: 11/16/2022]
Abstract
The characteristics of patients with recurrent bacteraemia caused by extended-spectrum β-lactamase (ESBL)-producing Escherichia coli or Klebsiella pneumoniae (EK) are rarely described. Flomoxef belongs to the cephamycins group and demonstrates in vitro activity against ESBL-producing organisms. Whether flomoxef may be used for the treatment of such infections remains controversial. This retrospective case-control study enrolled adult patients who had bacteraemia caused by ESBL-EK during 2005-2011. Case patients were those who had more than one episode of ESBL-EK bacteraemia. Controls were those who were matched for age and interval time of blood sampling and had only one episode of ESBL-EK bacteraemia with subsequent bacteraemia episodes caused by other non-ESBL-EK bacteria. Pulsed-field gel electrophoresis and microbiologic profiles of the initial and subsequent ESBL-EK isolates were analysed. During the study period, 424 patients were found to have at least one positive blood culture after the first ESBL-EK bacteraemia episode, and 67 (15.8%) had a second episode of ESBL-EK bacteraemia. Bacteraemia resulting from vascular catheter-related infection (odds ratio, 3.24; 95% confidence interval, 1.31-8.05), and definitive therapy with flomoxef (odds ratio, 2.99; 95% confidence interval, 1.10-8.15) were both independent risk factors for the recurrence. Among the 56 patients with available ESBL-EK isolates for analysis, 38 (67.8%) were infected by genetically similar strains. In three of these 38 recurrent ESBL-EK bacteraemia cases caused by an identical strain, the minimum inhibitory concentrations of carbapenem for the subsequent K. pneumoniae isolates were fourfold or higher than the initial isolates. Recurrent bacteraemia was not uncommon in our patients with ESBL-EK bacteraemia, and most of the episodes were caused by identical strains.
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Affiliation(s)
- C-H Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - L-H Su
- Department of Laboratory Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan; Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - F-J Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Y-F Tang
- Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - C-C Chien
- Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - J-W Liu
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Al-Bayssari C, Dabboussi F, Hamze M, Rolain JM. Detection of expanded-spectrum β-lactamases in Gram-negative bacteria in the 21st century. Expert Rev Anti Infect Ther 2015; 13:1139-58. [PMID: 26162631 DOI: 10.1586/14787210.2015.1066247] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Emerging β-lactamase-producing-bacteria (ESBL, AmpC and carbapenemases) have become a serious problem in our community due to their startling spread worldwide and their ability to cause infections which are difficult to treat. Diagnosis of these β-lactamases is of clinical and epidemiological interest. Over the past 10 years, several methods have been developed aiming to rapidly detect these emerging enzymes, thus preventing their rapid spread. In this review, we describe the range of screening and detection methods (phenotypic, molecular and other) for detecting these β-lactamases but also whole genome sequencing as a tool for detecting the genes encoding these enzymes.
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Affiliation(s)
- Charbel Al-Bayssari
- Laboratoire Microbiologie Santé et Environnement (LMSE), Centre Azm pour la Recherche en Biotechnologie et ses Applications, Ecole Doctorale de Sciences et de Technologie, Université Libanaise, Tripoli, Liban
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12
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Kim NH, Han WD, Song KH, Seo HK, Shin MJ, Kim TS, Park KU, Ahn S, Yoo JS, Kim ES, Kim HB. Successful containment of carbapenem-resistant Enterobacteriaceae by strict contact precautions without active surveillance. Am J Infect Control 2014; 42:1270-3. [PMID: 25465255 DOI: 10.1016/j.ajic.2014.09.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 09/03/2014] [Accepted: 09/04/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Carbapenem-resistant Enterobacteriaceae (CRE) are a growing problem worldwide. Guidelines focus on carbapenemase-producing organisms, and little is known about whether strict adherence to infection control measures is effective for CRE without carbapenemase. During 2009, CRE increased markedly in a tertiary hospital, and enhanced infection control measures without active surveillance were adopted. METHODS Beginning in April 2010, enhanced antimicrobial stewardship, strict contact precautions, and cohort isolation were adopted. After September 2010, hand hygiene performance was prospectively monitored by active surveillance, and results were monthly fed back to medical personnel. Available carbapenem-resistant Escherichia coli (ECO) and carbapenem-resistant Klebsiella pneumoniae (KPN) isolated during 2008-2010 were characterized. Imipenem and meropenem minimal inhibitory concentrations were confirmed by E-test (AB biodisk, Solna, Sweden). Phenotypic screening assays and polymerase chain reaction (PCR) amplification of known β-lactamase and carbapenemase genes were performed. RESULTS From 3,511 ECO and 2,279 KPN, 44 (0.76%) were CRE (3 ECO, 41 KPN). CRE incidence rates rose from 1.61 in 2008 to 5.49 in 2009; they rose further to 9.81 per 100,000 patient days in early 2010. After adoption of strict infection control measures, CRE frequency fell back in 2011 and remained at baseline afterward. Phenotypic screening and PCR showed AmpC β-lactamase and extended spectrum β-lactamases with or without loss of porins; carbapenemases were not detected. CONCLUSION Enhanced infection control measures, even without active surveillance, seem effective to prevent further spread of CRE in a low-prevalence setting with mainly carbapenemase-nonproducing CRE.
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Chang J, Yu J, Lee H, Ryu H, Park K, Park YJ. Prevalence and characteristics of lactose non-fermenting Escherichia coli in urinary isolates. J Infect Chemother 2014; 20:738-40. [PMID: 25193040 DOI: 10.1016/j.jiac.2014.07.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 04/29/2014] [Accepted: 07/10/2014] [Indexed: 12/23/2022]
Abstract
Recently, serotype O75 was found to be prominent among the non-ST131 ciprofloxacin-resistant Escherichia coli, and they were all lactose non-fermenters. In this study, we investigated the prevalence and characteristics of lactose non-fermenters in urinary isolates of E. coli. A total of 167 E. coli isolates was collected. Antimicrobial susceptibility tests were determined by VITEK 2 (bioMerieux, France). The lactose non-fermenters underwent PCR-based O typing, multilocus sequence typing (MLST) analysis, phylogenetic grouping. For ciprofloxacin-resistant isolates, the resistance mechanisms were investigated. Thirty-three (19.7%) isolates were lactose non-fermenters and the ciprofloxacin resistance rate was significantly higher than in lactose fermenters (66.7% vs. 31.6%, P = 0.0002). According to the serotype, O75 was the most common (42.4%, 14/33) and was followed by O16 (5/33), O2 (4/33), O25b (3/33), O15 (1/33), O6 (1/33), O1 (1/33). All the O75 isolates were ciprofloxacin-resistant and belonged to ST1193. By MLST, they were resolved into 11 STs. ST1193 was the most common (14/33) and was followed by ST131 (8/33). Interestingly, 8 isolates of ST131 were divided into three O types [O16 (4 isolates), O25b (3), and non-typeable (1)]. The ciprofloxacin resistance rate was high in isolates of O75-ST1193 and O25b-ST131 but low in O16-ST131 and O2-ST95. All the ciprofloxacin-resistant isolates showed identical triple mutations in gyrA and parC but the serotype O25b isolates had an additional mutation in parC (E84V). Only one isolate harbored aac(6')-Ib-cr variant and no qnr gene was detected. Continuous monitoring of the prevalence and clonal composition of the lactose non-fermenters is needed.
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Affiliation(s)
- Jiyoung Chang
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, School of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jinkyung Yu
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, School of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyeyoung Lee
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, School of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyejin Ryu
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, School of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kanggyun Park
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, School of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yeon-Joon Park
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, School of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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Park YS, Bae IK, Kim J, Jeong SH, Hwang SS, Seo YH, Cho YK, Lee K, Kim JM. Risk factors and molecular epidemiology of community-onset extended-spectrum β-lactamase-producing Escherichia coli bacteremia. Yonsei Med J 2014; 55:467-75. [PMID: 24532519 PMCID: PMC3936615 DOI: 10.3349/ymj.2014.55.2.467] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
PURPOSE Inadequate empirical therapy for severe infections caused by extended-spectrum β-lactamase-producing Escherichia coli (ESBLEC) is associated with poor outcomes. This study was designed to investigate risk factors for community-onset ESBLEC bacteremia at admission to a tertiary care hospital. MATERIALS AND METHODS A case-control study was performed that included all episodes of ESBLEC bacteremia in the outpatient department or within 48 hours of admission from January 2005 to March 2009. Data on predisposing factors were collected. The molecular epidemiology of ESBLEC clinical isolates was also determined. RESULTS Among 25281 blood cultures, 60 episodes of ESBLEC bacteremia were studied, which accounted for 7% of all E. coli bacteremia at admission. Healthcare-associated infection [odds ratio (OR), 8.3; 95% confidence interval (CI), 2.4-28.7; p=0.001], malignancy (OR, 4.6; 95% CI, 1.3-16.3; p=0.018), urinary tract infection (OR, 139.1; 95% CI, 24.6-788.2; p<0.001), hepatobiliary infection (OR, 79.1; 95% CI, 13.5-463.8; p<0.001), third generation cephalosporin usage during preceding 3 months (OR, 16.4; 95% CI, 2.0-131.8; p=0.008), and severe sepsis/septic shock (OR, 73.7; 95% CI, 12.4-438.5; p<0.001) were determined as independent risk factors for community-onset ESBLEC bacteremia. The most common extended-spectrum β-lactamase (ESBL) gene identified was blaCTX-M-15 (n=31) followed by blaCTX-M-14 (n=23). CONCLUSION The most common types of ESBLs in E. coli causing community-onset bacteremia were CTX-M-15 and CTX-M-14 in Korea. By result of decision tree analysis, the empirical use of carbapenems is suggested only for patients with severe sepsis/septic shock, hepatobiliary infection, or healthcare-associated urinary tract infection.
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Affiliation(s)
- Yoon Soo Park
- Department of Internal Medicine, Gachon University, Gil Medical Center, Incheon, Korea
| | - Il Kwon Bae
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, Korea
| | - Juwon Kim
- Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seok Hoon Jeong
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, Korea
| | - Seung-sik Hwang
- Department of Social and Preventive Medicine, Inha University School of Medicine, Incheon, Korea
| | - Yiel-Hea Seo
- Department of Laboratory Medicine, Gachon University, Gil Medical Center, Incheon, Korea
| | - Yong Kyun Cho
- Department of Internal Medicine, Gachon University, Gil Medical Center, Incheon, Korea
| | - Kyungwon Lee
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, Korea
| | - June Myung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Mansouri S, Kalantar Neyestanaki D, Shokoohi M, Halimi S, Beigverdi R, Rezagholezadeh F, Hashemi A. Characterization of AmpC, CTX-M and MBLs types of β-lactamases in clinical isolates of Klebsiella pneumoniae and Escherichia coli producing Extended Spectrum β-lactamases in Kerman, Iran. Jundishapur J Microbiol 2014; 7:e8756. [PMID: 25147671 PMCID: PMC4138687 DOI: 10.5812/jjm.8756] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 01/23/2013] [Accepted: 02/19/2013] [Indexed: 11/16/2022] Open
Abstract
Background: Extended spectrum β-lactamases (ESBLs) and AmpC β-lactamases enzyme are major sources of resistance to β-lactam antibiotics especially in Enterobacteriaceae such as Escherichia coli and Klebsiella pneumoniae. Increasing frequency of the co-existence of ESBLs with AmpC-β-lactamases in bacteria is a serious threat for treating bacterial infections. Objectives: The aim of this study was to determine the presence of AmpC and CTX-M types of β-lactamases in clinical isolates of E. coli and K. pneumoniae producing ESBLs. Materials and Methods: Resistance to different antibiotics was determined using the standard disk diffusion method. ESBLs, MBLs and AmpC-β-lactamases were detected by the combination double disk test (CDDT) method and polymerase chain reaction (PCR) was used to determine blaCTX-M genes in the ESBLs and AmpC positive isolates. Results: The prevalence of ESBLs and AmpC-β-lactamase producer isolates was 181 (43.8%) and 133 (37.2%), respectively. The prevalence of blaCTX-M among isolates was 61 (14.7%). Conclusions: Outbreak of isolates co-expressing AmpC-β-lactamases and ESBLs can cause serious problems in the future, regarding the treatment of infections caused by these common enteric pathogens.
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Affiliation(s)
- Shahla Mansouri
- Department of Microbiology, School of Medicine, Kerman University of Medical Sciences, Kerman, IR Iran
| | - Davood Kalantar Neyestanaki
- Department of Microbiology, School of Medicine, Tehran University of Medical Sciences. Tehran, IR Iran
- Corresponding author: Davood Kalantar Neyestanaki, Department of Microbiology, School of Medicine, Tehran University of Medical Sciences, Tehran, IR Iran. Tel/Fax:+98-2188955810, E-mail:
| | - Mostafa Shokoohi
- Physiology Research Center, Kerman University of Medical Sciences, Kerman, IR Iran
| | - Shahnaz Halimi
- Department of Microbiology, School of Medicine, Tehran University of Medical Sciences. Tehran, IR Iran
| | - Reza Beigverdi
- Department of Microbiology, School of Medicine, Tehran University of Medical Sciences. Tehran, IR Iran
| | - Fereshteh Rezagholezadeh
- Department of Microbiology, School of Medicine, Tehran University of Medical Sciences. Tehran, IR Iran
| | - Ali Hashemi
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences. Tehran, IR Iran
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Kuo SC, Wang YC, Yang YS, Ti-Yin, Lin JC, Chang FY. Comparison of susceptibility of Enterobacteriaceae causing community-onset urinary tract infection to isepamicin and amikacin by the disc diffusion method. JOURNAL OF MEDICAL SCIENCES 2014. [DOI: 10.4103/1011-4564.147249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Draganov A, Wang D, Wang B. The Future of Boron in Medicinal Chemistry: Therapeutic and Diagnostic Applications. TOPICS IN MEDICINAL CHEMISTRY 2014. [DOI: 10.1007/7355_2014_65] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Kim J, Lee JY, Kim SI, Song W, Kim JS, Jung S, Yu JK, Park KG, Park YJ. Rates of fecal transmission of extended-spectrum β-lactamase-producing and carbapenem-resistant Enterobacteriaceae among patients in intensive care units in Korea. Ann Lab Med 2013; 34:20-5. [PMID: 24422191 PMCID: PMC3885768 DOI: 10.3343/alm.2014.34.1.20] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 08/12/2013] [Accepted: 10/17/2013] [Indexed: 02/02/2023] Open
Abstract
Background We investigated the rates of fecal transmission of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae (ESBL-E) and carbapenem-resistant Enterobacteriaceae (CRE) among patients admitted to intensive care units (ICUs). Methods From June to August 2012, rectal cultures were acquired from all patients at ICU admission. For patients not carrying ESBL-E or CRE at admission, follow-up cultures were performed to detect acquisition. A chromogenic assay was used to screen for ESBL-E and CRE. Bacterial species identification and antibiotic susceptibility tests were performed using the Vitek 2 system (bioMérieux, France). ESBL genotypes were determined by PCR, and clonal relatedness of the isolates was assessed by pulsed-field gel electrophoresis. Results Out of 347 ICU admissions, 98 patients were found to be carriers of ESBL-E (28.2%, 98/347). Follow-up cultures were acquired from 91 of the patients who tested negative for ESBL-E at admission; the acquisition rate in this group was 12.1% (11/91), although none was a nosocomial transmission. For CRE, the prevalence of fecal carriage was 0.3% (1/347), and the acquisition rate was 2.9% (4/140). None of the CRE isolates were carbapenemase-producers. Conclusions The high prevalence of ESBL-E carriage on admission (28.2%), coupled with rare nosocomial transmission and the very low carriage rate of CRE (0.3%), challenge the routine use of active surveillance in non-epidemic settings. Nevertheless, passive surveillance measures, such as rapid and accurate screening of clinical specimens, will be critical for controlling the spread of CRE.
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Affiliation(s)
- Jayoung Kim
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Daejeon St. Mary's Hospital, Daejeon, Korea
| | - Ji Young Lee
- Department of Infection Control, Seoul St. Mary's Hospital, Seoul, Korea
| | - Sang Il Kim
- Division of Infectious Disease, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Wonkeun Song
- Department of Laboratory Medicine, Hallym University College of Medicine, Seoul, Korea
| | - Jae-Seok Kim
- Department of Laboratory Medicine, Hallym University College of Medicine, Seoul, Korea
| | - Seungwon Jung
- Department of Laboratory Medicine, Hallym University College of Medicine, Seoul, Korea
| | - Jin Kyung Yu
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
| | - Kang Gyun Park
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
| | - Yeon-Joon Park
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
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Lee CH, Lee YT, Kung CH, Ku WW, Kuo SC, Chen TL, Fung CP. Risk factors of community-onset urinary tract infections caused by plasmid-mediated AmpC β-lactamase-producing Enterobacteriaceae. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2013; 48:269-75. [PMID: 24239065 DOI: 10.1016/j.jmii.2013.08.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 08/01/2013] [Accepted: 08/20/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND The AmpC β-lactamase (AmpC)-producing Enterobacteriaceae emerged worldwide. This study was conducted to determine the risk factors of community-onset urinary tract infections (UTIs) caused by plasmid-mediated AmpC-producing Enterobacteriaceae. METHODS Patients who were diagnosed as community-onset UTIs caused by Enterobacteriaceae in a tertiary-care teaching hospital from December 2010 to January 2012 were included. Extended-spectrum β-lactamase (ESBL)-producing isolates were excluded. We identified plasmid-mediated AmpC-producing Enterobacteriaceae both phenotypically (by disk potentiation test and double-disk synergy test) and genotypically (by Multiplex polymerase chain reaction (PCR) assay). The demographic data, clinical characteristics, and risk factors of acquisition were described. RESULTS Among the 323 non-ESBL-producing Enterobacteriaceae identified in community-onset UTIs, 50 isolates were phenotypically positive for AmpC. Escherichia coli was the most common AmpC-producing organism (60%), followed by Klebsiella pneumonia (8%), and Enterobacter cloacae and Proteus mirabilis (6% for each species). The independent risk factors for acquisition of AmpC-producing Enterobacteriaceae included prior history of cerebral vascular accident [odds ratio (OR) = 2.014; 95% confidence interval (CI) = 1.007-4.031; p = 0.0048], and prior use of fluoroquinolones (OR = 4.049; 95% CI = 1.759-9.319; p = 0.001) and cephamycin (OR = 9.683; 95% CI = 2.007-45.135; p = 0.004). AmpC-producing isolates were multidrug resistant. Carbapenems, cefepime, and piperacillin/tazobactam had the best in vitro efficacy. The most commonly identified plasmid-mediated AmpC gene was bla(CIT), followed by bla(DHA)/bla(EBC), and bla(MOx). CONCLUSION For community-onset UTIs, AmpC-producing Enterobacteriaceae should be suspected in those with prior history of cerebral vascular accident and prior use of antimicrobials. To treat these multiple-resistant isolates, carbapenems, cefepime, and piperacillin/tazobactam may be considered.
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Affiliation(s)
- Chi-Hung Lee
- Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University Hospital, Yilan, Taiwan
| | - Yi-Tzu Lee
- Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, School of Medicine, Taipei, Taiwan; Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Che-Hsuan Kung
- Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Internal Medicine, Taipei City Hospital, Zhongxing Branch, Taipei, Taiwan
| | - Wen-Wei Ku
- Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shu-Chen Kuo
- Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, School of Medicine, Taipei, Taiwan; National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan.
| | - Te-Li Chen
- Institute of Clinical Medicine, National Yang-Ming University, School of Medicine, Taipei, Taiwan
| | - Chang-Phone Fung
- Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, School of Medicine, Taipei, Taiwan
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Kung CH, Ku WW, Lee CH, Fung CP, Kuo SC, Chen TL, Lee YT. Epidemiology and risk factors of community-onset urinary tract infection caused by extended-spectrum β-lactamase-producing Enterobacteriaceae in a medical center in Taiwan: a prospective cohort study. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2013; 48:168-74. [PMID: 24064292 DOI: 10.1016/j.jmii.2013.08.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 07/21/2013] [Accepted: 08/13/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Extended-spectrum β-lactamase (ESBL)-producing pathogens have been increasingly identified in community-onset urinary tract infection (UTI). This study was conducted to determine the epidemiology and risk factors of community-onset UTI caused by ESBL-producing pathogens, and to determine the correlation of antimicrobial resistance with ESBL detected by phenotypic and genotypic methods. METHODS The study was conducted from December 2010 to January 2012. Patients with community-onset UTI caused by Enterobacteriaceae were enrolled from the emergency department. The production of ESBL was determined by the phenotypic method (using the combined disk test) or by the genotypic method (using polymerase chain reaction detection). The patients' medical records were reviewed and risk factors were analyzed by multivariate analysis. RESULTS A total of 376 patients were enrolled and 393 isolates from urine culture were analyzed. Escherichia coli was the most commonly isolated species (259/393 isolates; 65.9%), followed by Klebsiella pneumoniae (42/393 isolates; 10.7%). Fifty-three (13.5%) isolates were phenotypically positive for ESBL production. Nine (2.3%) isolates were phenotypically positive for both ESBL and AmpC β-lactamase (AmpC) production. Nasogastric tube placement [odds ratio (OR) 2.230; 95% confidence interval (CI) 1.244-3.997; p = 0.007] and hospitalization within the previous 3 months (OR 2.567, 95% CI 1.448-4.551, p = 0.001) were independently associated with the acquisition of ESBL-producing pathogens in community-onset UTI. The ESBL phenotype had a better correlation with resistance to third-generation cephalosporins, compared to the ESBL-positive genotype. CONCLUSION In our study, nasogastric tube placement and hospitalization within the previous 3 months were significantly associated with the acquisition of ESBL-producing pathogens in community-onset UTI.
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Affiliation(s)
- Che-Hsuan Kung
- Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Internal Medicine, Taipei City Hospital, Zhongxing Branch, Taipei, Taiwan
| | - Wen-Wei Ku
- Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chi-Hung Lee
- Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University Hospital, Yilan, Taiwan
| | - Chang-Phone Fung
- Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shu-Chen Kuo
- Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan
| | - Te-Li Chen
- Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yi-Tzu Lee
- Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
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Park MJ, Kim TK, Song W, Kim JS, Kim HS, Lee J. An Increase in the clinical isolation of acquired AmpC β-lactamase-producing Klebsiella pneumoniae in Korea from 2007 to 2010. Ann Lab Med 2013; 33:353-5. [PMID: 24003426 PMCID: PMC3756240 DOI: 10.3343/alm.2013.33.5.353] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 05/06/2013] [Accepted: 06/18/2013] [Indexed: 11/19/2022] Open
Abstract
We investigated the occurrence and genetic basis of AmpC β-lactamase (AmpC)-mediated antibiotic resistance, by examining Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis isolates at a university hospital, from 2007 to 2010. The ampC genes were detected by multiplex AmpC PCR, and AmpC-positive strains were subjected to DNA sequencing. Extended-spectrum β-lactamase (ESBL) production was assessed using the ESBL disk test based on the utilization of boronic acid. Carbapenem-resistant isolates were further investigated by the modified Hodge test, a carbapenemase inhibition test and SDS-PAGE experiments. AmpC expression was detected in 1.6% of E. coli (39 DHA-1, 45 CMY-2, and 1 CMY-1) isolates, 7.2% of K. pneumoniae (39 DHA-1, 45 CMY-2, and 1 CMY-1) isolates, and 2.5% of P. mirabilis (8 CMY-2 and 1 CMY-1) isolates. Of the 198 acquired AmpC producers, 58 isolates (29.3%) also produced an ESBL enzyme. Among the acquired AmpC-producing K. pneumoniae isolates, the minimum inhibitory concentration (MIC) MIC50/MIC90 values for cefoxitin, cefotaxime, cefepime, imipenem, and meropenem were >32/>32, 16/>32, 1/16, 0.25/0.5, and <0.125/0.125 µg/mL, respectively. The MIC values for carbapenem were ≥2 µg/mL for 2 K. pneumoniae isolates, both of which carried the blaDHA-1 gene with a loss of OmpK36 expression, but were negative for carbapenemase production. The acquisition of AmpC-mediated resistance in K. pneumoniae isolates increased, as did the proportion of AmpC and ESBL co-producers among the hospital isolates. The accurate identification of isolates producing AmpCs and ESBLs may aid in infection control and will assist physicians in selecting an appropriate antibiotic regimen.
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Affiliation(s)
- Min-Jeong Park
- Department of Laboratory Medicine, Hallym University College of Medicine, Chuncheon, Korea
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Tamma PD, Girdwood SCT, Gopaul R, Tekle T, Roberts AA, Harris AD, Cosgrove SE, Carroll KC. The use of cefepime for treating AmpC β-lactamase-producing Enterobacteriaceae. Clin Infect Dis 2013; 57:781-8. [PMID: 23759352 DOI: 10.1093/cid/cit395] [Citation(s) in RCA: 116] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AmpC β-lactamase-producing organisms are associated with significant morbidity and mortality. Induction of resistance to third-generation cephalosporins after exposure to these agents complicates treatment options and carbapenems are considered optimal therapy. The role of cefepime, however, remains unclear. Our objective was to compare clinical outcomes for patients receiving cefepime compared with meropenem for invasive infections caused by organisms expressing AmpC β-lactamases. METHODS Hospitalized patients with blood, bronchoalveolar lavage, or intra-abdominal fluid cultures growing Enterobacter spp, Serratia spp, or Citrobacter spp were evaluated using the cefotetan-boronic acid disk test and the cefotetan-cloxacillin Etest to identify organisms with AmpC β-lactamase production from February 2010 to January 2011. In patients with organisms hyperproducing AmpC β-lactamases (positive by both methods), clinical outcomes for patients receiving cefepime or meropenem therapy were compared. To minimize the possibility of treatment selection bias, 1:1 nearest neighbor propensity score matching was performed prior to regression analysis. RESULTS Of 399 patients meeting eligibility criteria, 96 (24%) had confirmed infections with AmpC β-lactamase-producing organisms. Propensity score matching of patients infected with AmpC β-lactamase-positive organisms treated with cefepime or meropenem yielded 32 well-balanced patient pairs with no difference in 30-day mortality (odds ratio, 0.63; 95% confidence interval [CI], .23-2.11; P = .36) or length of hospital stay after infection (relative risk, 0.96; 95% CI, .79-1.26; P = .56) between the 2 groups. CONCLUSIONS Cefepime may be a reasonable option for the treatment of invasive infections due to AmpC β-lactamase-producing organisms, particularly when adequate source control is achieved.
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Affiliation(s)
- Pranita D Tamma
- Department of Pediatrics, Division of Infectious Diseases, MHS Johns Hopkins Medical Institutions, 200 N Wolfe St, Baltimore, MD 21287, USA.
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Bakthavatchalu S, Shakthivel U, Mishra T. Detection of ESBL among AmpC producing enterobacteriaceae using inhibitor-based method. Pan Afr Med J 2013; 14:28. [PMID: 23504148 PMCID: PMC3597859 DOI: 10.11604/pamj.2013.14.28.1347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Accepted: 01/03/2013] [Indexed: 11/17/2022] Open
Abstract
Introduction The occurrence of multiple β-lactamases among bacteria only limits the therapeutic options but also poses a challenge. A study using boronic acid (BA), an AmpC enzyme inhibitor, was designed to detect the combined expression of AmpC β-lactamases and extended-spectrum β-lactamases (ESBLs) in bacterial isolates further different phenotypic methods are compared to detect ESBL and AmpC. Methods A total of 259 clinical isolates of Enterobacteriaceae were isolated and screened for ESBL production by (i) CLSI double-disk diffusion method (ii) cefepime- clavulanic acid method (iii) boronic disk potentiation method. AmpC production was detected using cefoxitin alone and in combination with boronic acid and confirmation was done by three dimensional disk methods. Isolates were also subjected to detailed antibiotic susceptibility test. Results Among 259 isolates, 20.46% were coproducers of ESBL and AmpC, 26.45% were ESBL and 5.40% were AmpC. All of the 53 AmpC and ESBL coproducers were accurately detected by boronic acid disk potentiation method. Conclusion The BA disk test using Clinical and Laboratory Standards Institute methodology is simple and very efficient method that accurately detects the isolates that harbor both AmpCs and ESBLs.
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Affiliation(s)
- Sasirekha Bakthavatchalu
- Department of Microbiology, Centre for Post Graduate Studies, Jain University, Bangalore, Karnataka--560 011, India
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Characterization of the modified Hodge test-positive isolates of Enterobacteriaceae in Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2013; 46:35-40. [DOI: 10.1016/j.jmii.2012.01.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Revised: 11/06/2011] [Accepted: 12/19/2011] [Indexed: 11/22/2022]
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Towards a phenotypic screening strategy for emerging β-lactamases in Gram-negative bacilli. Int J Antimicrob Agents 2013; 41:99-109. [DOI: 10.1016/j.ijantimicag.2012.07.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 06/15/2012] [Accepted: 07/05/2012] [Indexed: 11/18/2022]
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Park YJ, Song W. Strategies for Interpretive Standards of β-Lactams Susceptibility Testing and Identification of Extended-Spectrum β-Lactamases and Carbapenemases inEnterobacteriaceae. ANNALS OF CLINICAL MICROBIOLOGY 2013. [DOI: 10.5145/acm.2013.16.3.111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Yeon-Joon Park
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Wonkeun Song
- Department of Laboratory Medicine, Hallym University College of Medicine, Chuncheon, Korea
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Dissemination of multidrug-resistant Escherichia coli in Korean veterinary hospitals. Diagn Microbiol Infect Dis 2012; 73:195-9. [PMID: 22516765 DOI: 10.1016/j.diagmicrobio.2012.03.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Revised: 01/16/2012] [Accepted: 03/15/2012] [Indexed: 11/22/2022]
Abstract
This study was performed to investigate the prevalence of rectal colonization with multidrug-resistant Escherichia coli in dogs hospitalized at veterinary hospitals in Korea and to assess the molecular epidemiologic traits of this organism. A total of 63 unique E. coli isolates obtained from the rectal swabs of hospitalized dogs were analyzed. Genes encoding CTX-M extended-spectrum β-lactamases (ESBLs) and AmpC enzymes were detected in 21 (33.3%) and 15 (23.8%) canine E. coli isolates, respectively. Twelve canine E. coli isolates harbored both the genes encoding the CTX-M and AmpC enzymes. Six ESBL-producing E. coli isolates also carried the rmtB gene. All 24 E. coli isolates producing CTX-M ESBL and/or CMY-2 were resistant to ciprofloxacin. Furthermore, mutations were found in the gyrA and the parC genes. In most cases, the bla genes of the CTX-M ESBL and AmpC enzymes and the rmtB gene were localized to incompatibility group F (IncF) plasmids. Possible small clonal outbreaks are suggested because some E. coli isolates recovered in the same veterinary hospital were identified as identical sequence types and showed identical banding patterns in repetitive sequence-based polymerase chain reaction. The horizontal transfer of IncF plasmids and the clonal transfer of E. coli strains are suggested to play a role in the dissemination of antimicrobial resistance genes, and this transfer may occur across host species (i.e., between humans and dogs).
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Lee NY, Wu JJ, Lin SH, Ko WC, Tsai LH, Yan JJ. Characterization of carbapenem-nonsusceptible Klebsiella pneumoniae bloodstream isolates at a Taiwanese hospital: clinical impacts of lowered breakpoints for carbapenems. Eur J Clin Microbiol Infect Dis 2012; 31:1941-50. [PMID: 22249422 DOI: 10.1007/s10096-011-1525-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Accepted: 12/15/2011] [Indexed: 11/30/2022]
Abstract
This study was conducted in order to characterize carbapenem-nonsusceptible Klebsiella pneumoniae isolates and to evaluate the impacts of recently lowered interpretative breakpoints for carbapenems for Enterobacteriaceae. Among 152 K. pneumoniae bloodstream isolates suspected as AmpC or extended-spectrum β-lactamase (ESBL) producers, 58 (38.2%) isolates were currently interpreted as nonsusceptible to ertapenem, imipenem, or meropenem, and 42 (72.4%) of them were categorized as carbapenem-susceptible by the previous criteria. The high revision rate was associated with the predominance (79.3%) of DHA-1 among the carbapenem-nonsusceptible isolates due to both polyclonal and clonal spread. ESBLs were common (~57%) in both ertapenem-susceptible and -nonsusceptible isolates; however, 84.8% of the carbapenem-nonsusceptible isolates were also AmpC producers. The IMP-8 metallo-β-lactamase was detected in three isolates. Polyacrylamide gel electrophoresis suggested decreased OmpK35 expression in all but one ertapenem-nonsusceptible isolate, and genetic disruptions of ompK35 and ompK36 were detected in 30 and six ertapenem-nonsusceptible isolates, respectively. A comparison between patients infected by AmpC- or ESBL-producing ertapenem-susceptible (n=62) isolates and those with isolates revised as ertapenem-nonsusceptible (n=41) revealed more cases of malignancies (36.6% versus 14.5%; p=0.01) and higher Charlson score (p=0.033) among the patients with ertapenem-nonsusceptible isolates; however, the acquisition of an isolate revised as carbapenem-nonsusceptible was not identified as an independent mortality risk factor.
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Affiliation(s)
- N Y Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, 138 Sheng-Li Road, Tainan, 70428, Taiwan
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Shoorashetty RM, Nagarathnamma T, Prathibha J. Comparison of the boronic acid disk potentiation test and cefepime-clavulanic acid method for the detection of ESBL among AmpC-producing Enterobacteriaceae. Indian J Med Microbiol 2011; 29:297-301. [PMID: 21860114 DOI: 10.4103/0255-0857.83917] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
PURPOSE Extended spectrum β-lactamase (ESBL) and AmpC β-lactamase are important mechanisms of betalactam resistance among Enterobacteriaceae . The ESBL confirmation test described by Clinical Laboratory Standards Institute (CLSI) is in routine use. This method fails to detect ESBL in the presence of AmpC. Therefore, we compared two different ESBL detection methods against the CLSI confirmatory test. MATERIALS AND METHODS A total 200 consecutive clinical isolates of Enterobacteriaceae from various clinical samples were tested for ESBL production using (i) CLSI described phenotypic confirmatory test (PCT), (ii) boronic acid disk potentiation test and (iii) cefepime-CA disk potentiation method. AmpC confirmation was done by a modified three-dimensional test. RESULTS Among total 200 Enterobacteriaceae isolates, 82 were only ESBL producers, 12 were only AmpC producers, 55 were combined ESBL and AmpC producers, 14 were inducible AmpC producers and 37 isolates did not harboured any enzymes. The CLSI described PCT detected ESBL-producing organisms correctly but failed to detect 36.3% of ESBLs among combined enzyme producers. The boronic acid disk potentiation test reliably detected all ESBL, AmpC, and combined enzyme producers correctly. The cefepime-CA method detected all ESBLs correctly but another method of AmpC detection has to be adopted. CONCLUSION The use of boronic acid in disk diffusion testing along with the CLSI described PCT enhances ESBL detection in the presence of AmpC betalactamases.
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Affiliation(s)
- R M Shoorashetty
- Department of Microbiology, Pondicherry Institute of Medical Sciences, Ganapathichettikulam, Kalapet, Pondicherry, India
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Roh KH, Lee CK, Sohn JW, Song W, Yong D, Lee K. Isolation of a Klebsiella pneumoniae isolate of sequence type 258 producing KPC-2 carbapenemase in Korea. Korean J Lab Med 2011; 31:298-301. [PMID: 22016687 PMCID: PMC3190012 DOI: 10.3343/kjlm.2011.31.4.298] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Revised: 06/13/2011] [Accepted: 07/14/2011] [Indexed: 11/30/2022] Open
Abstract
Carbapenem-resistant Klebsiella pneumoniae isolates producing K. pneumoniae carbapenemases (KPC) were first reported in the USA in 2001, and since then, this infection has been reported in Europe, Israel, South America, and China. In Korea, the first KPC-2-producing K. pneumoniae sequence type (ST) 11 strain was detected in 2010. We report the case of a patient with a urinary tract infection caused by KPC-2-producing K. pneumoniae. This is the second report of a KPC-2-producing K. pneumoniae infection in Korea, but the multilocus sequence type was ST258. The KPC-2-producing isolate was resistant to all tested β-lactams (including imipenem and meropenem), amikacin, tobramycin, ciprofloxacin, levofloxacin, and trimethoprim-sulfamethoxazole, but was susceptible to gentamicin, colistin, polymyxin B, and tigecycline. The KPC-2-producing isolate was negative to phenotypic extended-spectrum β-lactamase (ESBL) and AmpC detection tests and positive to modified Hodge test and carbapenemase inhibition test with aminophenylboronic acid.
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Affiliation(s)
- Kyoung Ho Roh
- Department of Laboratory Medicine, Korea University College of Medicine, Seoul, Korea
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Kim Y, Bae IK, Jeong SH, Lee CH, Lee HK, Ahn J, Lee MK, Lee S, Lee K. Occurrence of IncFII plasmids carrying the bla(CTX-M-15) gene in Salmonella enterica serovar Enteritidis sequence type 11 in Korea. Diagn Microbiol Infect Dis 2011; 71:171-3. [PMID: 21840672 DOI: 10.1016/j.diagmicrobio.2011.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Revised: 05/02/2011] [Accepted: 05/04/2011] [Indexed: 11/19/2022]
Abstract
A total of 49 consecutive nonduplicate Salmonella isolates collected in a nationwide survey performed in 2009 in Korea were included in this study. Resistance gene, sizes, and replicon sequence types (RSTs) of R plasmids, and sequence types (STs) and XbaI-macrorestriction patterns of extended-spectrum β-lactamase (ESBL)-producing isolates were determined. Six Salmonella enterica serovar Enteritidis isolates of ST11 showed ESBL phenotypes, and the isolates harbored an incompatibility group FII plasmid of RST S1:A-:B- carrying the bla(CTX-M-15) gene.
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Affiliation(s)
- Yoonjung Kim
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, South Korea
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Wu JJ, Wang LR, Liu YF, Chen HM, Yan JJ. Prevalence and Characteristics of Ertapenem-ResistantKlebsiella pneumoniaeIsolates in a Taiwanese University Hospital. Microb Drug Resist 2011; 17:259-66. [DOI: 10.1089/mdr.2010.0115] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jiunn-Jong Wu
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University Medical College, Tainan, Taiwan
| | - Li-Rong Wang
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University Medical College, Tainan, Taiwan
- Department of Pathology, National Cheng Kung University Medical College and Hospital, Tainan, Taiwan
| | - Yi-Fang Liu
- Institute of Basic Medical Sciences, National Cheng Kung University Medical College, Tainan, Taiwan
| | - Hung-Mo Chen
- Department of Pathology, National Cheng Kung University Medical College and Hospital, Tainan, Taiwan
| | - Jing-Jou Yan
- Department of Pathology, National Cheng Kung University Medical College and Hospital, Tainan, Taiwan
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van der Bij AK, Mol M, van Westreenen M, Goessens WHF, Pitout JDD. The laboratory diagnosis of Pseudomonas aeruginosa that produce metallo-β-lactamases in a Dutch tertiary care centre. ACTA ACUST UNITED AC 2011; 43:596-602. [PMID: 21506891 DOI: 10.3109/00365548.2011.574148] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The laboratory detection of Pseudomonas aeruginosa that produce metallo-β-lactamases (MBLs) is not well defined in regions with a low prevalence of these enzymes. We report a study that developed ethylenediaminetetraacetic acid (EDTA) disk screen tests using doripenem, imipenem and meropenem and investigated the prevalence of these enzymes among clinical isolates of imipenem-resistant P. aeruginosa in Rotterdam during 2008-2009. METHODS Using strains with well-characterized β-lactamases and the Clinical and Laboratory Standards Institute (CLSI) disk methodology similar to extended-spectrum β-lactamase (ESBL) detection, inhibition zone diameters were determined in tests with doripenem, imipenem, and meropenem, alone and in combination with 370 μg of EDTA. These tests were compared with the MBL E-test. A positive test was a ≥5 mm increase in zone diameter in the presence of EDTA. RESULTS The imipenem EDTA disk screen test showed a sensitivity of 100% and a specificity of 90% in 96 recent clinical isolates. Imipenem in combination with doripenem performed better than imipenem alone, meropenem, and the MBL E-test (sensitivity of 100%; specificity of 95%). The majority of clinical isolates were isolated from patient respiratory specimens. Of the 96 imipenem-resistant P. aeruginosa isolated, 35 (36%) were positive for bla(VIM) genes. CONCLUSIONS The EDTA imipenem/doripenem disk test showed accurate and reproducible results with excellent sensitivity and specificity. It is simple to perform and interpret and can be easily introduced into the workflow of a clinical laboratory to screen for MBLs in imipenem-resistant P. aeruginosa. Due to its high specificity the test is also suitable for regions with a low prevalence of these enzymes.
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Affiliation(s)
- Akke K van der Bij
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Chromosome-encoded AmpC and CTX-M extended-spectrum β-lactamases in clinical isolates of Proteus mirabilis from Korea. Antimicrob Agents Chemother 2011; 55:1414-9. [PMID: 21282448 DOI: 10.1128/aac.01835-09] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Among 222 Proteus mirabilis clinical isolates collected from 17 hospitals in Korea in 2008, 28 (12.6%) and 8 (3.6%) isolates exhibited extended-spectrum β-lactamase (ESBL) and AmpC phenotypes, respectively. The most common type of ESBL gene identified by PCR and sequencing experiments was bla(CTX-M-14a) (n = 12). The bla(CTX-M-90) (n = 4), bla(CTX-M-15) (n = 3), bla(CTX-M-12) (n = 3), bla(CTX-M-2) (n = 2), bla(CTX-M-14b) (n = 1), bla(TEM-52) (n = 5), and bla(SHV-12) (n = 1) genes were also detected. Eight isolates carried an AmpC β-lactamase gene, such as bla(CMY-2) (n = 6) or bla(DHA-1) (n = 2). All bla genes encoding CTX-M-1- and CTX-M-9-type enzymes and all bla(CMY-2) genes were preceded by ISEcp1-like elements. The bla(CTX-M-2) gene found in two isolates was located on a complex class 1 integron. The bla(DHA-1) gene was preceded by a transcriptional regulator gene and was followed by phage shock protein genes. The bla(CTX-M) genes were located on the chromosome in 21 isolates. A plasmid location for the bla(CTX-M) gene was found in only four isolates: the bla(CTX-M-14a) gene was located on ∼150-kbp IncA/C plasmids in three isolates and on a ∼50-kbp IncN plasmid in one isolate. The bla(TEM-52) gene was located on ∼50-kbp IncN plasmids in all five isolates. The AmpC β-lactamase genes were located on the chromosome in seven of eight isolates; one isolate carried the bla(CMY-2) gene on a ∼150-kbp IncA/C plasmid. Our results show that a chromosomal location of CTX-M ESBL and AmpC β-lactamase genes in P. mirabilis is no longer an unusual phenomenon in hospital environments.
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CMY-2, CMY-8b, and DHA-1 plasmid-mediated AmpC β-lactamases among clinical isolates of Escherichia coli and Klebsiella pneumoniae from a university hospital, Thailand. Diagn Microbiol Infect Dis 2010; 68:271-7. [DOI: 10.1016/j.diagmicrobio.2010.06.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Revised: 06/02/2010] [Accepted: 06/25/2010] [Indexed: 11/21/2022]
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Park SD, Uh Y, Lee G, Lim K, Kim JB, Jeong SH. Prevalence and resistance patterns of extended-spectrum and AmpC β-lactamase in Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, and Salmonella serovar Stanley in a Korean tertiary hospital. APMIS 2010; 118:801-8. [PMID: 20854475 DOI: 10.1111/j.1600-0463.2010.02663.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A total of 100 clinical isolates of Escherichia coli (n = 35), Klebsiella pneumoniae (n = 63), Proteus mirabilis (n = 1), and Salmonella serovar Stanley (n = 1), showing resistance to cefoxitin, or returning positive in extended-spectrum β-lactamase (ESBL) by Clinical and Laboratory Standards Institute (CLSI) ESBL confirmatory method, were studied. The isolates were examined by the boronic acid (BA) disk test, polymerase chain reaction, and pulsed-field gel electrophoresis (PFGE) to investigate genetic similarities. The concurrence rates for ESBLs by the CLSI and the BA disk test were 97% for E. coli and 96.7% for K. pneumoniae. A total of 41 isolates showing cefoxitin resistance yielded all positive by the BA disk test. All the 33 K. pneumoniae isolates, which showed positive by the BA disk test, were carrying AmpC genes. The TEM and CTX-M types were predominant in E. coli and the SHV and the CIT and/or DHA types were predominant in K. pneumoniae. PFGE analysis showed almost 75% of genetic similarities among K. pneumoniae isolates producing ESBLs and/or AmpC β-lactamases (AmpCs) as each K. pneumoniae carried variable genes and showed variable antibiotic patterns. Clearly, the BA disk test was a useful method for the detection of ESBLs and AmpCs. In particular, cefoxitin resistance and BA-positive trait of K. pneumoniae do reflect the presence of AmpC genes in the organism.
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Affiliation(s)
- Soon Deok Park
- Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, Heungup-myun, Wonju-si, Kangwon-do, South Korea
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Yan JJ, Wu JJ, Lee CC, Ko WC, Yang FC. Prevalence and characteristics of ertapenem-nonsusceptible Escherichia coli in a Taiwanese university hospital, 1999 to 2007. Eur J Clin Microbiol Infect Dis 2010; 29:1417-25. [PMID: 20700614 DOI: 10.1007/s10096-010-1020-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2010] [Accepted: 07/23/2010] [Indexed: 11/29/2022]
Abstract
The present study was conducted to investigate the prevalence and characteristics of ertapenem-nonsusceptible (ETP-NS) Escherichia coli in a Taiwanese university. A total of 9,722 isolates collected in 1999, 2003, 2005, and 2007 were examined. Overall, 1.0% of all isolates from 66 patients were interpreted as ETP-NS on the basis of the disk diffusion test result. Most of these isolates were clonally unrelated and showed low-level ertapenem resistance, the production of CMY-2 cephalosporinase (86.4%), and decreased expression of the OmpF (97.0%) and/or OmpC (56.1%) porins. No carbapenemase was detected. The decreased porin expression was associated with disruptions of ompF or ompC in only about one-third of the ETP-NS isolates. During the study period, the prevalence of ETP-NS strains increased from 0.1 to 1.7%, accompanying an increase (0.8 to 17.6%) in the prevalence of CMY-2 producers. Coexistent or pre-existing clonally related ertapenem-susceptible (ETP-S) E. coli isolates were identified in 47.0% of all case patients, and almost all of the ETP-S isolates had the same β-lactamases as the ETP-NS isolates. Our study results suggest the restricted use of extended-spectrum cephalosporins to hinder the emergence and prevalence of carbapenem resistance in E. coli, which may arise by the accumulation of multiple resistance determinants.
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Affiliation(s)
- J J Yan
- Department of Pathology, National Cheng Kung University Medical College and Hospital, 138 Sheng-Li Road, Tainan, 70428, Taiwan.
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Lee JH, Bae IK, Lee SH. New definitions of extended-spectrum β-lactamase conferring worldwide emerging antibiotic resistance. Med Res Rev 2010; 32:216-32. [PMID: 20577973 DOI: 10.1002/med.20210] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Although there is no consensus of the precise definition of ESBL, three kinds of ESBL definitions have been proposed. First, the classical definition includes variants derived from TEM-1, TEM-2, or SHV-1; K1 (KOXY) of Klebsiella oxytoca. Second, the broadened definition has stretched the classical definition of ESBL to include: (1) β-lactamases (CTX-M-ESBLs, GES-ESBLs, and VEB-ESBLs), with spectra similar to those of TEM and SHV variants (designated as TEM- and SHV-ESBLs, respectively) but derived from other sources; (2) TEM and SHV variants with borderline ESBL activity; e.g., TEM-12; and (3) various β-lactamases conferring wider resistance than their parent types but not meeting the definition for group 2be; e.g., OXA-types (OXA-ESBLs) and mutant AmpC-types (AmpC-ESBLs), with increased activity against oxyimino-cephalosporins and with resistance to clavulanic acid. Third, the all-inclusive definition includes: (1) ESBL(A) (named for class A ESBLs); (2) ESBL(M) (miscellaneous ESBLs), which has been subdivided into ESBL(M-C) (class C; plasmid-mediated AmpC) and ESBL(M-D) (class D); and (3) ESBL(CARBA) (ESBLs with hydrolytic activity against carbapenems), which has been subdivided into ESBL(CARBA-A) (class A carbapenemases), ESBL(CARBA-B) (class B carbapenemases), and ESBL(CARBA-D) (class D carbapenemases). The consensus view about the ESBL definition is that the classical ESBL definition must be expanded to class A non-TEM- and non-SHV-ESBLs (CTX-M-, GES-, VEB-ESBLs, etc.). However, these three definitions evoke rational debate on the question "Which would be included in the category of ESBLs among AmpC-ESBLs, OXA-ESBLs, and/or carbapenemases?" Therefore, there is a great need for consensus in the precise definition of ESBL.
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Affiliation(s)
- Jung Hun Lee
- Drug Resistance Proteomics Laboratory, Department of Biological Sciences, Myongji University, San 38-2 Namdong, Yongin, Gyeonggido 449-728, Republic of Korea
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Lee W, Jung B, Hong SG, Song W, Jeong SH, Lee K, Kwak HS. Comparison of 3 phenotypic-detection methods for identifying plasmid-mediated AmpC beta-lactamase-producing Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis strains. Korean J Lab Med 2010; 29:448-54. [PMID: 19893354 DOI: 10.3343/kjlm.2009.29.5.448] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Plasmid-mediated AmpC beta-lactamases (PABLs) have been detected in the strains of Escherichia coli, Klebsiella spp., Proteus mirabilis, and Salmonella spp. PABLs may be difficult to detect and might interfere in the therapeutic and infection-control processes. Although several PABL-detection methods based on phenotypes have been reported, the Clinical and Laboratory Standards Institute currently does not recommend a routine detection method for PABLs. The aim of this study is to compare the performances of 3 phenotypic PABL detection methods. METHODS Total 276 non-duplicated clinical isolates of E. coli (N=97), K. pneumoniae (N=136), and P. mirabilis (N=43) were collected from 14 hospitals in Korea between April and June 2007 in a non-consecutive and non-random manner. Multiplex PCR was performed to detect the PABL genes. Further, 3 phenotypic detection methods-cephamycin-Hodge test, Tris-EDTA (TE) disk test, and combination-disk test with 3-aminophenylboronic acid (BA)-were performed using cefoxitin and cefotetan disks. RESULTS PABL genes were detected by multiplex PCR in 122/276 isolates, including 14/97 E. coli, 105/136 K. pneumoniae, and 3/43 P. mirabilis isolates. The combination-disk test with BA showed higher sensitivity (98.4%), specificity (92.2%), and efficiency (96.3%) than the cephamycin-Hodge (76.2%, 96.1%, and 88.6%, respectively) and the TE-disk (80.3%, 91.6%, and 87.9%, respectively) tests. CONCLUSIONS The combination-disk test with BA is a simple, efficient, and interpretable test that can be applicable in clinical laboratories involved in the detection of PABLs in clinical isolates of E. coli, K. pneumoniae, and P. mirabilis.
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Affiliation(s)
- Wookeun Lee
- Department of Laboratory Medicine, CHA University, Sungnam, Korea
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Broth microdilution method to detect extended-spectrum beta-lactamases and AmpC beta-lactamases in enterobacteriaceae isolates by use of clavulanic acid and boronic acid as inhibitors. J Clin Microbiol 2009; 47:3409-12. [PMID: 19710269 DOI: 10.1128/jcm.01141-09] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This study was designed to evaluate the performance of the broth microdilution (BMD) method to detect production of extended-spectrum beta-lactamases (ESBLs) and AmpC beta-lactamases in Enterobacteriaceae by using clavulanic acid (CA) and boronic acid (BA) as ESBL and AmpC beta-lactamase inhibitors, respectively. A total of 100 clinical isolates of Enterobacteriaceae were analyzed. Mueller-Hinton broth containing serial twofold dilutions of cefotaxime (CTX), ceftazidime (CAZ), aztreonam (ATM), or cefepime (FEP) with or without either or both CA and BA was prepared. An eightfold or greater decrease in the MIC of CTX, CAZ, ATM, or FEP in the presence of CA and BA was considered a positive result for ESBL and plasmid-mediated AmpC beta-lactamase (PABL), respectively. In tests with CA, expanded-spectrum beta-lactams containing BA (CTX-BA, CAZ-BA, ATM-BA, and FEP-BA) showed higher positive rates in detecting ESBL producers than those without BA. The combination of CTX- and CAZ-based BMD tests with CA and BA showed sensitivity and specificity of 100% for the detection of ESBLs and PABLs. The BMD testing could be applicable for routine use in commercially available semiautomated systems for the detection of ESBLs and PABLs in Enterobacteriaceae.
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Abstract
SUMMARY AmpC beta-lactamases are clinically important cephalosporinases encoded on the chromosomes of many of the Enterobacteriaceae and a few other organisms, where they mediate resistance to cephalothin, cefazolin, cefoxitin, most penicillins, and beta-lactamase inhibitor-beta-lactam combinations. In many bacteria, AmpC enzymes are inducible and can be expressed at high levels by mutation. Overexpression confers resistance to broad-spectrum cephalosporins including cefotaxime, ceftazidime, and ceftriaxone and is a problem especially in infections due to Enterobacter aerogenes and Enterobacter cloacae, where an isolate initially susceptible to these agents may become resistant upon therapy. Transmissible plasmids have acquired genes for AmpC enzymes, which consequently can now appear in bacteria lacking or poorly expressing a chromosomal bla(AmpC) gene, such as Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis. Resistance due to plasmid-mediated AmpC enzymes is less common than extended-spectrum beta-lactamase production in most parts of the world but may be both harder to detect and broader in spectrum. AmpC enzymes encoded by both chromosomal and plasmid genes are also evolving to hydrolyze broad-spectrum cephalosporins more efficiently. Techniques to identify AmpC beta-lactamase-producing isolates are available but are still evolving and are not yet optimized for the clinical laboratory, which probably now underestimates this resistance mechanism. Carbapenems can usually be used to treat infections due to AmpC-producing bacteria, but carbapenem resistance can arise in some organisms by mutations that reduce influx (outer membrane porin loss) or enhance efflux (efflux pump activation).
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Unreliable extended-spectrum beta-lactamase detection in the presence of plasmid-mediated AmpC in Escherichia coli clinical isolates. J Clin Microbiol 2008; 47:358-61. [PMID: 19109470 DOI: 10.1128/jcm.01687-08] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The emergence of extended-spectrum beta-lactamase (ESBL) and plasmid-mediated AmpC (pAmpC) enzymes in Escherichia coli raises concern regarding accurate laboratory detection and interpretation of susceptibility testing results. Twenty-six cefpodoxime ESBL screen-positive, cefoxitin-resistant E. coli clinical isolates were subjected to clavulanate ESBL confirmatory testing employing disk augmentation, Etest, and the BD Phoenix NMC/ID-132 panel. Phenotypic pAmpC production was assessed by boronic acid disk augmentation. ESBL and pAmpC genes were detected by gene amplification and sequencing. ESBL genes (SHV and/or CTX-M-type genes) were detected in only 7/26 ESBL screen-positive isolates. Of 23 aminophenylboronic acid screen-positive isolates, pAmpC genes were detected in 20 (CMY-2 or FOX-5 genes). High incidences of false-positive ESBL confirmatory results were observed for both clavulanate disk augmentation (9/19) and BD Phoenix (5/19). All were associated with the presence of pAmpC genes with or without TEM-1. Etest performed poorly, as the majority of interpretations were nondeterminable. In addition, false-negative ESBL confirmatory results were observed in isolates possessing concomitant ESBL and pAmpC genes for Etest (four of five), BD Phoenix (three of five), and disk augmentation (one of five). The results indicate poor performance of currently employed ESBL confirmatory methods in the setting of concomitant pAmpC. Some isolates with pAmpC and ESBL genes fell within the susceptible category to extended-spectrum cephalosporins, raising concern over currently employed breakpoints.
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The prevalence of plasmid-mediated AmpC beta-lactamases among clinical isolates of Escherichia coli and Klebsiella pneumoniae from five children's hospitals in China. Eur J Clin Microbiol Infect Dis 2008; 27:915-21. [PMID: 18449580 DOI: 10.1007/s10096-008-0532-4] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2007] [Accepted: 03/28/2008] [Indexed: 10/22/2022]
Abstract
The purpose of this study was to investigate the prevalence of plasmid-mediated AmpC beta-lactamases in Escherichia coli and Klebsiella pneumoniae from five children's hospitals in China. A total of 494 E. coli and 637 K. pneumoniae isolates were collected from five children's hospitals in China from 2005 to 2006. The isolates with decreased susceptibility to cefoxitin were subjected to confirmation test with 3-aminophenyl boronic acid. Polymerase chain reaction (PCR) amplification of the blaAmpC, blaTEM, blaCTXM, and blaSHV genes and their gene sequencing were performed. Transconjugants were achieved by conjugation experiments. Plasmid-mediated AmpC beta-lactamases were found in 10.1% of K. pneumoniae (64/637) and in 2.0% of E. coli (10/494) strains. The proportion of plasmid-mediated AmpC-producing strains significantly increased from 2005 (2.6%) to 2006 (9.3%) (p<0.001). The DHA-1-producing isolates were the most prevalent type (93.2%, 69/74). The sequences of blaDHA-1 genes were all identical to those from the GenBank. Strains of blaCMY-2 were isolated from five isolates (6.8%), which were all from E. coli. One sequence of blaCMY-2 differs from blaCMY-2 in the GenBank. Eighteen of the 74 (24.3%) AmpC-producing K. pneumoniae and E. coli isolates coproduced an extended-spectrum beta-lactamase (ESBL). Cefoxitin resistance was transferred to 15 of the 74 positive strains (20.3%). Our study has demonstrated the occurrence of plasmid-mediated AmpC beta-lactamases in E. coli and K. pneumoniae in Chinese pediatric patients and DHA-1 type AmpC enzymes had the highest prevalent rate. The CMY-2 AmpC beta-lactamases from the children's hospitals in China in this study are the first reported. Hence, continuous surveillance of the prevalence and evolution of AmpC beta-lactamase is important.
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Jeong SH, Song W, Park MJ, Kim JS, Kim HS, Bae IK, Lee KM. Boronic acid disk tests for identification of extended-spectrum beta-lactamase production in clinical isolates of Enterobacteriaceae producing chromosomal AmpC beta-lactamases. Int J Antimicrob Agents 2008; 31:467-71. [PMID: 18337065 DOI: 10.1016/j.ijantimicag.2007.12.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2007] [Revised: 11/15/2007] [Accepted: 12/23/2007] [Indexed: 11/25/2022]
Abstract
A study using boronic acid (BA) was designed to detect the extended-spectrum beta-lactamases (ESBLs) in Enterobacteriaceae producing chromosomal AmpC beta-lactamases. A total of 197 clinical isolates of Enterobacter spp. (n=100), Serratia marcescens (n=62) and Citrobacter freundii (n=35) were analysed. Genes encoding ESBLs were detected by polymerase chain reaction (PCR) amplification followed by direct sequencing of PCR products. The Clinical and Laboratory Standards Institute confirmatory test detected only 72.1% of the ESBL-producing isolates. When a > or =5mm increase in the zone diameter of either the cefotaxime/clavulanic acid and/or the ceftazidime/clavulanic acid disks tested in combination with BA versus cefotaxime and/or ceftazidime containing BA was considered to be a positive for ESBL, the method detected 60 (98.4%) of the 61 isolates that harboured ESBLs and showed no false-positive results for ESBL-non-producing isolates. In conclusion, the BA disk test is a highly sensitive and specific method for the detection of ESBLs in Enterobacteriaceae producing chromosomal AmpC beta-lactamases.
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Affiliation(s)
- Seok Hoon Jeong
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
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