Scholarly article on topic 'Emergence of NDM-1-producing Enterobacteriaceae in Porto Alegre, Brazil'

Emergence of NDM-1-producing Enterobacteriaceae in Porto Alegre, Brazil Academic research paper on "Biological sciences"

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Abstract of research paper on Biological sciences, author of scientific article — Franciéli P. Rozales, Vanessa B. Ribeiro, Cibele M. Magagnin, Mariana Pagano, Larissa Lutz, et al.

Summary Objectives To evaluate the emergence of New Delhi metallo-β-lactamase 1 (NDM-1)-producing Enterobacteriaceae isolates in Brazil. Methods From April to October 2013, following the detection of the first NDM-1-producing isolate, a surveillance study was performed for the detection of bla NDM-1 among Enterobacteriaceae isolates with reduced susceptibility to carbapenems in 17 hospitals of Porto Alegre, Brazil. Real-time PCR was used to determine the presence of carbapenemase genes, which were further sequenced. Clonal relatedness was assessed by pulsed-field gel electrophoresis (PFGE). Results A total of 1134 isolates were evaluated. bla NDM-1 was detected in 11 (0.97%) isolates: nine Enterobacter cloacae complex (eight belonging to a single clone recovered from two distinct hospitals and the other strain from a third hospital) and two Morganella morganii (belonging to a single clone recovered from one hospital). Most isolates presented high-level resistance to carbapenems. Conclusions NDM-1-producing Enterobacteriaceae have emerged rapidly in the hospitals of the Brazilian city where they were first detected. The emergence of NDM-1 in Brazil is of great concern, since it is a severe threat to antimicrobial therapy against Enterobacteriaceae in this country.

Academic research paper on topic "Emergence of NDM-1-producing Enterobacteriaceae in Porto Alegre, Brazil"

International Journal of Infectious Diseases 25 (2014) e79-e81

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International Journal of Infectious Diseases

journal homepage www.elsevier.com/locate/ijid

Short Communication

Emergence of NDM-1-producing Enterobacteriaceae in Porto Alegre, Brazil

CrossMark

Franciéli P. Rózales a,b, Vanessa B. Ribeiroa,b, Cibele M. Magagninb,c, Mariana Paganoa,b, Larissa Lutz d, Diego R. Falcie, Adao Machadof, Afonso L. Barth a,b, Alexandre P. Zavasckig,h'*

a Programa de Pos Graduagao em Ciencias Farmacéutica, Faculdade de Farmacia, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil b Laboratorio de Pesquisa em Resistencia Bacteriana (LABRESIS), Centro de Pesquisa Experimental, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil

c Programa de Pos Graduacao em Ciencias Medicas, Faculdade de Medicina, UFRGS, Porto Alegre, Brazil d Unidade de Microbiología, Servico de Patologia Clínica, HCPA, Porto Alegre, Brazil e Infection Control Service Hospital Nossa Senhora da Conceicao, Porto Alegre, Brazil fInfection Control Service Hospital Beneficiencia Portuguesa, Porto Alegre, Brazil

g Infectious Diseases Service, Hospital de Clínicas de Porto, 2350 Ramiro Barcelos St, 90035-903, Porto Alegre, Brazil h Department of Internal Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil

ARTICLE INFO

SUMMARY

Article history:

Received 17 December 2013 Received in revised form 7 January 2014 Accepted 7 January 2014 Corresponding Editor: Eskild Petersen, Aarhus, Denmark

Keywords: NDM-1

Carbapenemase

Resistance

Epidemiology

Objectives: To evaluate the emergence of New Delhi metallo-p-lactamase 1 (NDM-1 )-producing Enterobacteriaceae isolates in Brazil.

Methods: From April to October 2013, following the detection of the first NDM-1-producing isolate, a surveillance study was performed for the detection of blaNDM-1 among Enterobacteriaceae isolates with reduced susceptibility to carbapenems in 17 hospitals of Porto Alegre, Brazil. Real-time PCR was used to determine the presence of carbapenemase genes, which were further sequenced. Clonal relatedness was assessed by pulsed-field gel electrophoresis (PFGE).

Results: A total of 1134 isolates were evaluated. blaNDM-1 was detected in 11 (0.97%) isolates: nine Enterobacter cloacae complex (eight belonging to a single clone recovered from two distinct hospitals and the other strain from a third hospital) and two Morganella morganii (belonging to a single clone recovered from one hospital). Most isolates presented high-level resistance to carbapenems. Conclusions: NDM-1-producing Enterobacteriaceae have emerged rapidly in the hospitals of the Brazilian city where they were first detected. The emergence of NDM-1 in Brazil is of great concern, since it is a severe threat to antimicrobial therapy against Enterobacteriaceae in this country. © 2014 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-

nc-nd/3.0/).

1. Introduction

Carbapenems have been used for many years as the antibiotics of last resort for the treatment of nosocomial infections caused by Enterobacteriaceae. Resistance to these drugs in Enterobacteriaceae has emerged worldwide, mostly driven by the production of carbapenemases, particularly Klebsiella pneumoniae carbapenemase 2 (KPC-2) and, more recently, New Delhi metallo-b-lactamase 1 (NDM-1).1 The dissemination of carbapenemase-producing isolates in many countries is of increasing concern, since

* Corresponding author. Tel./fax: +55 51 33598152. E-mail address: azavascki@hcpa.ufrgs.br (A.P. Zavascki).

the treatment of carbapenem-resistant isolates is extremely

difficult owing to the few options that remain available for clinical

1 2 use.1'2

NDM-1 mediated by carbapenemases is the most common class B carbapenemase in Enterobacteriaceae and has been detected increasingly in several countries.3 In 2013, the first case of NDM-1 in Brazil was reported in a Providencia rettgeri isolate in the city of Porto Alegre.4 Considering the potential for an outbreak at the institution where this case was detected, and the possibility that NDM-1 could also be present in other hospitals, surveillance cultures were performed in many of the regional institutions for the detection of this carbapenemase. We report the emergence of blaNDM-1 in Enterobacteriaceae isolates in hospitals from this region of Brazil.

http://dx.doi.org/10.1016/j.ijid.2014.01.005

1201-9712/© 2014 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).

Table 1

Phenotypic characteristics and molecular typing of NDM-1-producing Enterobacteriaceae isolates

Minimum inhibitory concentration (mg/ml) - Etest

MHT EDTA

No. Datea Hospital Isolate15 Specimen IPM MEM ERT DOR SAM PTZ CRO FEP CIP ATM GEN AMK PMB TGC FOS IPM MEM PFGE

1 Apr 1 E. cloacae complex Sink swab >32 >32 >32 >32 >256 >256 >32 >256 >32 >256 >256 32 0.125 1.5 192 P P P A

2 Apr 1 E. cloacae complex Rectal swab >32 >32 >32 >32 >256 >256 >32 >256 4 64 1.5 8 0.75 1.5 768 P P P A

3 Apr 1 E. cloacae complex Rectal swab >32 >32 >32 >32 >256 >256 >32 >256 >32 >256 >256 12 0.25 6 >1024 P P P A

4 May 1 E. cloacae complex Rectal swab >32 >32 >32 >32 >256 >256 >32 >256 >32 64 12 12 0.38 2 >1024 P P P A

5 Aug 2 E. cloacae complex Urine 12 8 32 8 >256 >256 >32 >256 >32 32 >256 12 0.5 1 >1024 P P P A

6 Aug 3 E. cloacae complex CSF 12 32 >32 16 >256 >256 >32 192 >32 32 >256 >256 0.38 0.38 64 P P P B

7 Sept 1 M. morganii Rectal swab >32 24 1.5 24 >256 >256 >32 16 >32 3 128 12 >1024 4 >1024 N P P MAc

8 Sept 1 M. morganii Surgical wound 24 1 0.38 3 >256 32 >32 6 >32 2 96 12 >1024 4 >1024 N P P MAc

9 Sept 2 E. cloacae complex Rectal swab >32 >32 >32 12 >256 >256 >32 >256 6 >256 64 8 0.38 1 96 N P P A

10 Sept 1 E. cloacae complex Rectal swab >32 >32 >32 >32 >256 >256 >32 >256 >32 >256 32 6 0.38 1 384 N P P A

11 Oct 1 E. cloacae complex Rectal swab >32 >32 >32 >32 >256 >256 >32 >256 >32 >256 >256 24 1.5 2 256 N P P A

MHT, modified Hodge test; EDTA, combined disk with ethylenediaminetetraacetic acid; IPM, imipenem; MEM, meropenem; ERT, ertapenem; DOR, doripenem; SAM, ampicillin-sulbactam; PTZ, piperacillin-tazobactam; CRO, ceftriaxone; FEP, cefepime; CIP ciprofloxacin; ATM, aztreonam; GEN, gentamicin; AMK, amikacin; PMB, polymyxin B; TGC, tigecycline; FOS, fosfomycin; N, negative; P, positive; CSF, cerebrospinal fluid. a Month of 2013.

b E. cloacae, Enterobacter cloacae; M. morganii, Morganella morganii. c Clonally identical Morganella morganii.

F.P. Rozales et al. /International Journal of Infectious Diseases 25 (2014) e79-e81

2. Materials and methods

From April to October 2013, following the detection of the index case (P. rettgeri), we investigated the presence of NDM-1 carbapenemase among Enterobacteriaceae isolates with reduced susceptibility to carbapenems5 recovered from 17 hospitals of Rio Grande do Sul, the southern-most state of Brazil. All isolates were recovered from patient clinical or surveillance cultures (rectal swabs and hospital environment swabs) and were sent to the Laboratorio de Pesquisa em Resistencia Bacteriana of the Hospital de Clinicas de Porto Alegre (a reference laboratory for the detection of bacterial resistance in the region) for the detection of the blaNDM gene.

The following genes were evaluated by multiplex highresolution melting (HRM) real-time PCR, as described previously by Monteiro et al.:6 blaNDM, blaKPC, blaVIM, blaGES, blaOXA-48, and b/aIMP. Briefly, the DNA was extracted using a rapid method based on thermal shock and lysis of components other than nucleic acids, and the RT-PCR was carried out using a MeltDoctor HRM Master Mix (Applied Biosystems) in a StepOne Real-Time PCR System instrument (Applied Biosystems). Gene sequencing was performed and GenBank was used to access the blaNDM sequences deposited to date. BioEdit software was used to compare the similarity between sequences.

The isolates in which the presence of the blaNDM gene was confirmed were also submitted to the modified Hodge test (MHT) and combined disk tests with ethylenediaminetetraacetic acid (EDTA).5,7 The minimum inhibitory concentrations (MIC) were determined by Etest in blaNDM-positive isolates.

Clonal relatedness among NDM-1-producers was assessed by DNA macrorestriction using XBal followed by pulsed-field gel electrophoresis (PFGE), and was analyzed according to the criteria of Tenover et al.8

3. Results

A total of 1134 isolates were analyzed. The presence of blaNDM was confirmed in 11 (0.97%) Enterobacteriaceae isolates from three distinct hospitals (all in Porto Alegre city), and sequencing revealed the presence of blaNDM-1 in all isolates. No patient with an NDM-1-producing isolate had visited or had been hospitalized in a foreign country. The phenotypic and molecular characterization of the isolates is shown in Table 1.

4. Discussion

We detected the presence of blaNDM-1 in Enterobacter cloacae complex and Morganella morganii isolates, two species different to the one first reported. Six of the nine NDM-producing E. cloacae complex isolates were recovered from the same institution where the index P. rettgeri (the first case in Brazil) was detected. All six of these isolates presented an indistinguishable macrorestriction profile, which was also the same as that of the other two isolates recovered from another hospital, providing evidence of an initial horizontal dissemination of one strain among hospitalized patients of distinct institutions in Porto Alegre. The other E. cloacae complex isolate, obtained from a third institution in this city, was clonally unrelated to the major strain. Among all E. cloacae complex isolates, a similar susceptibility profile was observed against b-lactams drugs, demonstrating high-level resistance; however, a distinct profile was found for other non-b-lactam antimicrobial agents, including aminoglycosides and tigecycline.

It is of note that NDM-1 was mainly detected in Enterobacter cloacae complex, which comprised only 11.3% of the isolates evaluated. In fact, worldwide, NDM-1 has mostly been reported in K. pneumoniae and Escherichia coli, however this gene was not

detected in any isolate of those species, despite the fact that K. pneumoniae comprised 59.1% of the isolates with reduced susceptibility to carbapenems (76.6% were KPC-2-producing isolates; data not shown). Escherichia coli with reduced susceptibility to carbapenems corresponded to only 3.5% of the isolates, and in 50.0% of the isolates the reduced susceptibility to carbapenems was due to KPC-2 production (data not shown), and none to NDM-1.

We also detected blaNDM-1 in two M. morganii isolates, an organism in which this gene has only rarely been described.9,10 The potential dissemination of NDM-1-producing M. morganii isolates is of great concern, since this organism is intrinsically resistant to polymyxins and tigecycline, which are the agents of last resort against carbapenemase-producing isolates.

Of note, the combined disk assay with EDTA was able to detect all NDM-1- producing isolates, reinforcing its sensitivity in the detection of metallo-ß-lactamases. On the other hand, the MHT failed to detect the presence of carbapenemase activity in isolates of M. morganii.

In summary, our study demonstrated that following the first detection of an NDM-1-producing Enterobacteriaceae in Brazil, other NDM-1-producing isolates from two different species have been detected in a short period of time in distinct institutions. Considering that KPC-2-producing isolates are highly endemic in Brazil, our findings are of major concern, since the emergence of NDM-1 is a severe threat to antimicrobial therapy against Enterobacteriaceae in this country.

Acknowledgements

We are grateful to Laura C. Antochevis, Fabiane R. Vieira, and Pablo Born Bubols for their technical support. This work was supported by the Fundo de Incentivo a Pesquisa e Eventos do Hospital de Clinicas de Porto Alegre, Coordenacao de Aper-feicoamento de Pessoal de Nivel Superior, Fundacao de Amparo a Pesquisa do Estado do Rio Grande do Sul, and National Council for Scientific and Technological Development (CNPq), Ministry of Science and Technology, Brazil.

Conflict of interest: The authors have no conflict of interest to declare.

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