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Snyman Y, Whitelaw AC, Maloba MR, Hesseling AC, Newton-Foot M. Corrigendum: Carriage of colistin-resistant Gram-negative bacteria in children from communities in Cape Town (Tuberculosis child multidrug-resistant preventive therapy trial sub-study). S Afr J Infect Dis 2022; 37:409. [PMID: 35815222 PMCID: PMC9257722 DOI: 10.4102/sajid.v37i1.409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Yolandi Snyman
- Division of Medical Microbiology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Andrew C. Whitelaw
- Division of Medical Microbiology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Motlatji R.B. Maloba
- Department of Medical Microbiology, Faculty of Health Science, University of the Free State, Bloemfontein, South Africa
- National Health Laboratory Service, Universitas Hospital, Bloemfontein, South Africa
| | - Anneke C. Hesseling
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Mae Newton-Foot
- Division of Medical Microbiology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
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Dramowski A, Aiken AM, Rehman AM, Snyman Y, Reuter S, Grundmann H, Scott JAG, de Kraker MEA, Whitelaw A. Mortality associated with third-generation cephalosporin resistance in Enterobacteriaceae bloodstream infections at one South African hospital. J Glob Antimicrob Resist 2022; 29:176-184. [PMID: 35283332 PMCID: PMC9200643 DOI: 10.1016/j.jgar.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/03/2022] [Accepted: 03/04/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Enterobacteriaceae are common pathogens causing bloodstream infection (BSI) in sub-Saharan Africa and frequently express third-generation cephalosporin (3GC) resistance; however, the impact of 3GC resistance on clinical outcomes is rarely studied. METHODS We conducted a single-site prospective cohort study at Tygerberg Hospital, Cape Town, South Africa to examine the feasibility of measuring impacts of 3GC resistance in Enterobacteriaceae BSI. We included patients with 3GC-susceptible and 3GC-resistant BSIs and matched each BSI patient to two uninfected patients. We determined the concordance of initial antibiotic treatment with the corresponding isolate's susceptibility profile. We performed exploratory impact analysis using multivariable regression models. RESULTS Between 1 June 2017 and 31 January 2018, we matched 177 Enterobacteriaceae BSI patients to 347 uninfected patients. Among these BSIs, 35% were phenotypically 3GC resistant. Parameters describing clinical comorbidity showed strong associations with mortality. We found that 18% of 3GC-R and 3% of 3GC-S BSI patient received non-concordant initial therapy. In multivariable Cox regression, we found a mortality impact over their matched patients for both 3GC-R (cause-specific hazard ratio 23.77; 95% CI 5.12-110.3) and 3GC-S (HR 7.49; 95%CI 3.08-18.19) BSI. There was a nonsignificant ratio of these ratios (HR 3.18; 95% CI 0.54-18.70), limited by the small sample size. CONCLUSION This form of impact estimation was feasible in one hospital in South Africa where 3GC-R status was associated with non-concordant initial antibiotic treatment. There was a possible increase in mortality among individuals with 3GC-resistant Enterobacteriaceae, but with broad confidence intervals. These analytical approaches could be applied to larger datasets to improve precision of estimates.
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Affiliation(s)
- Angela Dramowski
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Alexander M Aiken
- Infectious Disease Epidemiology Department, London School of Hygiene and Tropical Medicine.
| | - Andrea M Rehman
- Infectious Disease Epidemiology Department, London School of Hygiene and Tropical Medicine
| | - Yolandi Snyman
- Department of Medical Microbiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Sandra Reuter
- Institute for Infection Prevention and Hospital Epidemiology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Hajo Grundmann
- Institute for Infection Prevention and Hospital Epidemiology, Medical Center, University of Freiburg, Freiburg, Germany
| | - J Anthony G Scott
- Infectious Disease Epidemiology Department, London School of Hygiene and Tropical Medicine
| | - Marlieke E A de Kraker
- Infection Control Program and WHO Collaborating Center on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Andrew Whitelaw
- Department of Medical Microbiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Snyman Y, Whitelaw AC, Maloba MRB, Hesseling AC, Newton-Foot M. Carriage of colistin-resistant Gram-negative bacteria in children from communities in Cape Town (Tuberculosis child multidrug-resistant preventive therapy trial sub-study). S Afr J Infect Dis 2021; 36:241. [PMID: 34485500 PMCID: PMC8378148 DOI: 10.4102/sajid.v36i1.241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/10/2020] [Indexed: 11/16/2022] Open
Abstract
Colistin is a last-resort antibiotic against multidrug-resistant, Gram-negative bacteria. Colistin resistance has been described in the clinical settings in South Africa. However, information on carriage of these bacteria in communities is limited. This study investigated gastrointestinal carriage of colistin-resistant Escherichia coli and Klebsiella spp. and mcr genes in children from communities in Cape Town. Colistin-resistant E. coli was isolated from two participants (4%, 2/50), and mcr-1-mcr-9 genes were not detected. Gastrointestinal carriage of colistin-resistant Enterobacterales was rare; however, continuous extensive surveillance is necessary to determine the extent of carriage and its contribution to resistance observed in clinical settings.
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Affiliation(s)
- Yolandi Snyman
- Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Andrew C Whitelaw
- Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Motlatji R B Maloba
- Department of Medical Microbiology, Faculty of Health Science, University of the Free State, Bloemfontein, South Africa.,National Health Laboratory Service, Universitas Hospital, Bloemfontein, South Africa
| | - Anneke C Hesseling
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Mae Newton-Foot
- Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
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Snyman Y, Whitelaw AC, Barnes JM, Maloba MRB, Newton-Foot M. Characterisation of mobile colistin resistance genes (mcr-3 and mcr-5) in river and storm water in regions of the Western Cape of South Africa. Antimicrob Resist Infect Control 2021; 10:96. [PMID: 34187559 PMCID: PMC8244157 DOI: 10.1186/s13756-021-00963-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 05/26/2021] [Indexed: 11/21/2022] Open
Abstract
Background Colistin is regarded as a last-resort antimicrobial against multi-drug resistant Gram-negative bacteria (GNB), therefore the dissemination of colistin resistance in the environment is of great concern. Horizontal transfer of mobile colistin resistance (mcr) genes to potential pathogens poses a serious problem. This study aimed to describe the presence of colistin resistant GNB and mcr genes in river and storm water in regions of the Western Cape. Methods Water samples were collected from three rivers during May 2019 and January 2020 and two storm water samples were collected in November 2019. Colistin resistant GNB were cultured on MacConkey agar containing colistin and identified by MALDI-TOF. Colistin resistance was confirmed using broth microdilution (BMD). mcr-1-5 genes were detected by PCR performed directly on the water samples and on the colistin resistant isolates. mcr functionality was assessed by BMD after cloning the mcr genes into pET-48b(+) and expression in SHuffle T7 E. coli. Results mcr-5.1 and various mcr-3 gene variants were detected in the Plankenburg-, Eerste- and Berg rivers and in storm water from Muizenberg, and only mcr-5.1 was detected in storm water from Fish Hoek. Colistin resistant GNB were isolated from all of the water sources. Aeromonas spp. were the most common colistin resistant organisms detected in the water sources; 25% (6/24) of colistin resistant Aeromonas spp. isolated from the Berg river contained novel mcr-3 variants; mcr-3.33 (n = 1), mcr-3.34 (n = 1) mcr-3.35 (n = 1) mcr-3.36 (n = 2) and mcr-3.37 (n = 1), which were confirmed to confer colistin resistance. Conclusions The mcr-5.1 and mcr-3 colistin resistance gene variants were present in widely dispersed water sources in regions of the Western Cape. The mcr genes were only detected in water sampled downstream of and alongside communities, suggesting that their presence is driven by human influence/contamination. This is the first documentation of mcr-3 and mcr-5 gene variants in any setting in South Africa. Spill-over of these genes to communities could result in horizontal gene transfer to pathogenic bacteria, exacerbating the challenge of controlling multidrug resistant GNB infections. Supplementary Information The online version contains supplementary material available at 10.1186/s13756-021-00963-2.
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Affiliation(s)
- Yolandi Snyman
- Division of Medical Microbiology, Department of Pathology, Stellenbosch University, Cape Town, South Africa.
| | - Andrew C Whitelaw
- Division of Medical Microbiology, Department of Pathology, Stellenbosch University, Cape Town, South Africa.,National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Jo M Barnes
- Division of Community Health, Department Epidemiology, Stellenbosch University, Cape Town, South Africa
| | - Motlatji R B Maloba
- Department of Medical Microbiology, University of the Free State, Bloemfontein, South Africa.,National Health Laboratory Service, Universitas Hospital, Bloemfontein, South Africa
| | - Mae Newton-Foot
- Division of Medical Microbiology, Department of Pathology, Stellenbosch University, Cape Town, South Africa.,National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
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Snyman Y, Reuter S, Whitelaw AC, Stein L, Maloba MRB, Newton-Foot M. Characterisation of mcr-4.3 in a colistin-resistant Acinetobacter nosocomialis clinical isolate from Cape Town, South Africa. J Glob Antimicrob Resist 2021; 25:102-106. [PMID: 33757821 DOI: 10.1016/j.jgar.2021.03.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 02/11/2021] [Accepted: 03/01/2021] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Colistin resistance in Acinetobacter spp. is increasing, resulting in potentially untreatable nosocomial infections. Plasmid-mediated colistin resistance is of particular concern due to its low fitness cost and potential transferability to other bacterial strains and species. This study investigated the colistin resistance mechanism in a clinical Acinetobacter nosocomialis isolate from Cape Town, South Africa. METHODS A colistin-resistant A. nosocomialis isolate was identified from a blood culture in 2017. PCR and Illumina whole-genome sequencing (WGS) were performed to identify genes and mutations conferring resistance to colistin. Plasmid sequencing was performed on an Oxford Nanopore platform. mcr functionality was assessed by broth microdilution after cloning the mcr gene into pET-48b(+) and expressing it in SHuffle® T7 Escherichia coli and after curing the plasmid using 62.5 mg/L acridine orange. RESULTS The colistin minimum inhibitory concentration (MIC) of the A. nosocomialis isolate was 16 mg/L. The mcr-4.3 gene was detected by PCR and WGS. No other previously described colistin resistance mechanism was found by WGS. The mcr-4.3 gene was identified on a 24 024-bp RepB plasmid (pCAC13a). Functionality studies showed that recombinant mcr-4.3 did not confer colistin resistance in E. coli. However, plasmid curing of pCAC13a restored colistin susceptibility in A. nosocomialis. CONCLUSION We describe the first detection of a plasmid-mediated mcr-4.3 gene encoding colistin resistance in A. nosocomialis and the first detection of mcr-4.3 in a clinical isolate in Africa. Recombinant expression of mcr-4.3 did not confer colistin resistance in E. coli, suggesting that its functionality may be RepB plasmid-dependent or species-specific.
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Affiliation(s)
- Yolandi Snyman
- Division of Medical Microbiology, Department of Pathology, Stellenbosch University, Cape Town, South Africa.
| | - Sandra Reuter
- Institute for Infection Prevention and Hospital Epidemiology, Medical Center University of Freiburg, Freiburg, Germany
| | - Andrew Christopher Whitelaw
- Division of Medical Microbiology, Department of Pathology, Stellenbosch University, Cape Town, South Africa; National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Lisa Stein
- Division of Medical Microbiology, Department of Pathology, Stellenbosch University, Cape Town, South Africa
| | - Motlatji Reratilwe Bonnie Maloba
- Department of Medical Microbiology, University of the Free State, Bloemfontein, South Africa; National Health Laboratory Service, Universitas Hospital, Bloemfontein, South Africa
| | - Mae Newton-Foot
- Division of Medical Microbiology, Department of Pathology, Stellenbosch University, Cape Town, South Africa; National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
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Snyman Y, Whitelaw AC, Reuter S, Maloba MRB, Newton-Foot M. Colistin Resistance Mechanisms in Clinical Escherichia coli and Klebsiella spp. Isolates from the Western Cape of South Africa. Microb Drug Resist 2021; 27:1249-1258. [PMID: 33571049 DOI: 10.1089/mdr.2020.0479] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Objectives: Colistin is a last-resort antibiotic for the treatment of carbapenem-resistant Gram-negative infections. Colistin resistance thus poses a threat to human health. Colistin resistance is most commonly encoded by mutations in chromosomal pmrA, pmrB, phoP, phoQ, ccrB, and mgrB genes, and the presence of plasmid-mediated mcr genes. This study describes colistin resistance mechanisms in clinical Enterobacterales isolates from the Western Cape, South Africa. Results: Escherichia coli (n = 22) and Klebsiella spp. (n = 7) isolates, from nine health care facilities, were confirmed to be colistin resistant during 2016 and 2017. mcr-1 was present in 55% (12/22) of E. coli and 71% (5/7) of Klebsiella spp. isolates. Colistin resistance mutations in pmrB were identified in 8/10 mcr-negative E. coli isolates using whole-genome sequencing, with pmrB Pro-94→Gln being the most frequent with presence in 4 isolates. One mcr-negative Klebsiella spp. isolate had a complete deletion of the mgrB and one contained an insertion sequence (IS1) in mgrB. Conclusion: A reduction in the proportion of colistin-resistant isolates harboring mcr-1 from 2016 to 2017 was observed. Colistin-resistant E. coli attributed by chromosomal mutations in pmrB in 2017 were mostly clonal related, which contrasts with the 2016 unrelated mcr-1-positive isolates. The diverse strains, hospitals, and resistance mechanisms may suggest that selective pressure is the main driver of colistin resistance.
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Affiliation(s)
- Yolandi Snyman
- Division of Medical Microbiology, Department of Pathology, Stellenbosch University, Cape Town, South Africa
| | - Andrew Christopher Whitelaw
- Division of Medical Microbiology, Department of Pathology, Stellenbosch University, Cape Town, South Africa.,National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Sandra Reuter
- Institute for Infection Prevention and Hospital Epidemiology, Medical Center University of Freiburg, Freiburg, Germany
| | - Motlatji Reratilwe Bonnie Maloba
- Department of Medical Microbiology, University of the Free State, Bloemfontein, South Africa.,National Health Laboratory Service, Universitas Hospital, Bloemfontein, South Africa
| | - Mae Newton-Foot
- Division of Medical Microbiology, Department of Pathology, Stellenbosch University, Cape Town, South Africa.,National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
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Snyman Y, Whitelaw AC, Reuter S, Dramowski A, Maloba MRB, Newton-Foot M. Clonal expansion of colistin-resistant Acinetobacter baumannii isolates in Cape Town, South Africa. Int J Infect Dis 2019; 91:94-100. [PMID: 31765820 DOI: 10.1016/j.ijid.2019.11.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 11/17/2019] [Accepted: 11/18/2019] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVES To describe colistin-resistant Acinetobacter baumannii isolates in Cape Town, South Africa. METHODS A. baumannii isolates identified on Vitek 2 Advanced Expert System were collected from Tygerberg Hospital referral laboratory between 2016 and 2017. Colistin resistance was confirmed using broth microdilution and SensiTest. mcr-1-5 were detected using PCR and strain typing was performed by rep-PCR. Whole genome sequencing (WGS) was performed on a subset of isolates to identify chromosomal colistin resistance mechanisms and strain diversity using multilocus sequence typing (MLST) and pairwise single nucleotide polymorphism analyses. RESULTS Twenty-six colistin-resistant and six colistin-susceptible A. baumannii were collected separately based on Vitek susceptibility; 20/26 (77%) were confirmed colistin-resistant by broth microdilution. Four colistin-resistant isolates were isolated in 2016 and 16 in 2017, from five healthcare facilities. Thirteen colistin-resistant isolates and eight colistin-susceptible isolates were identical by rep-PCR and MLST (ST1), all from patients admitted to a tertiary hospital during 2017. The remaining colistin-resistant isolates were unrelated. CONCLUSIONS An increase in colistin-resistant A. baumannii isolates from a tertiary hospital in 2017 appears to be clonal expansion of an emerging colistin-resistant strain. This strain was not detected in 2016 or from other hospitals. Identical colistin-susceptible isolates were also isolated, suggesting relatively recent acquisition of colistin resistance.
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Affiliation(s)
- Yolandi Snyman
- Division of Medical Microbiology, Department of Pathology, Stellenbosch University, Cape Town, South Africa.
| | - Andrew Christopher Whitelaw
- Division of Medical Microbiology, Department of Pathology, Stellenbosch University, Cape Town, South Africa; National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Sandra Reuter
- Institute for Infection Prevention and Hospital Epidemiology, Medical Centre, University of Freiburg, Freiburg, Germany
| | - Angela Dramowski
- Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Motlatji Reratilwe Bonnie Maloba
- Department of Medical Microbiology, University of the Free State, Bloemfontein, South Africa; National Health Laboratory Service, Universitas Hospital, Bloemfontein, South Africa
| | - Mae Newton-Foot
- Division of Medical Microbiology, Department of Pathology, Stellenbosch University, Cape Town, South Africa; National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
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Newton-Foot M, Snyman Y, Maloba MRB, Whitelaw AC. Plasmid-mediated mcr-1 colistin resistance in Escherichia coli and Klebsiella spp. clinical isolates from the Western Cape region of South Africa. Antimicrob Resist Infect Control 2017; 6:78. [PMID: 28785405 PMCID: PMC5543748 DOI: 10.1186/s13756-017-0234-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 07/25/2017] [Indexed: 12/02/2022] Open
Abstract
Background Colistin is a last resort antibiotic for the treatment of carbapenem-resistant Gram negative infections. Until recently, mechanisms of colistin resistance were limited to chromosomal mutations which confer a high fitness cost and cannot be transferred between organisms. However, a novel plasmid-mediated colistin resistance mechanism, encoded by the mcr-1 gene, has been identified, and has since been detected worldwide. The mcr-1 colistin resistance mechanism is a major threat due to its lack of fitness cost and ability to be transferred between strains and species. Surveillance of colistin resistance mechanisms is critical to monitor the development and spread of resistance.This study aimed to determine the prevalence of the plasmid-mediated colistin resistance gene, mcr-1, in colistin-resistant E. coli and Klebsiella spp. isolates in the Western Cape of South Africa; and whether colistin resistance is spread through clonal expansion or by acquisition of resistance by diverse strains. Methods Colistin resistant E. coli and Klebsiella spp. isolates were collected from the NHLS microbiology laboratory at Tygerberg Hospital. Species identification and antibiotic susceptibility testing was done using the API® 20 E system and the Vitek® 2 Advanced Expert System™. PCR was used to detect the plasmid-mediated mcr-1 colistin resistance gene and REP-PCR was used for strain typing of the isolates. Results Nineteen colistin resistant isolates, including 12 E. coli, six K. pneumoniae and one K. oxytoca isolate, were detected over 7 months from eight different hospitals in the Western Cape region. The mcr-1 gene was detected in 83% of isolates which were shown to be predominantly unrelated strains. Conclusions The plasmid-mediated mcr-1 colistin resistance gene is responsible for the majority of colistin resistance in clinical isolates of E. coli and Klebsiella spp. from the Western Cape of South Africa. Colistin resistance is not clonally disseminated; the mcr-1 gene has been acquired by several unrelated strains of E. coli and K. pneumoniae. Acquisition of mcr-1 by cephalosporin- and carbapenem-resistant Gram negative bacteria may result in untreatable infections and increased mortality. Measures need to be implemented to control the use of colistin in health care facilities and in agriculture to retain its antimicrobial efficacy.
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Affiliation(s)
- Mae Newton-Foot
- Division of Medical Microbiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Cape Town, South Africa.,National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Yolandi Snyman
- Division of Medical Microbiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Cape Town, South Africa
| | - Motlatji Reratilwe Bonnie Maloba
- Division of Medical Microbiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Cape Town, South Africa.,National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Andrew Christopher Whitelaw
- Division of Medical Microbiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Cape Town, South Africa.,National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
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