ESBLs: From Soil to Suppurationbsac.org.uk/wp-content/uploads/2012/02/Peter-Hawkey...from China wide...
Transcript of ESBLs: From Soil to Suppurationbsac.org.uk/wp-content/uploads/2012/02/Peter-Hawkey...from China wide...
PROFESSOR PETER M. HAWKEY
Health Protection Agency West Midlands Public Health Laboratory, Heart of England
NHS Foundation Trust, B5 9SS
The University of BirminghamEdgbaston, B15 2TT
[email protected];[email protected]
ESBLs: From Soil to Suppuration
BSAC Spring MeetingTuesday 7th April 2009
International Convention Centre, Birmingham
• I have called this principle, by which each slight variation, if useful, is preserved, “Natural Selection”
• Resistant bugs live
• Sensitive ones die
‘The plough is one of the most ancient and valuable of man’s inventions; but long before he existed, the land was in fact regularly ploughed, and continues to be ploughed by earthworms’
Charles Darwin, 1881
Proportion of 3rd generation cephalosporins resistant to E. coli isolates, EARSS data
20062001
Taken from Canton and Coque, Curr Opin Micro 2006, 9: 466-475
Endemicity of CTX-M
The CTX‐M pandemic, how did it all start . . . ?
1989, Paris, Institut Gustave Roussy
Cancer patient isolate of E. coli
Resistant to cefotaxime, ceftazidime; sensitive to cefoxitin
Transferable 85 kb plasmid
Called MEN‐1
Bernard, et al, 1992, JAC, 29:590
The plot thickens . . .
• MEN‐1 shown to be identical to CTX‐M‐1 described in Germany from an isolate of E.coli 1989a
• CTX‐M‐2 described in S. typhimurium from Argentina in 1992b
• CTX‐M‐2 then foundc
Israel (1992)Paraguay (1994)Argentina (1994) E.coli / P. mirabilis
K. pneumoniae
a Bauernfeind, et al, 1992, Infection, 18:294b Bauernfeind et al, 1992, Infection, 20:158
c Bauernfeind, et al, 1996, AAC, 40: 509
CTX-M-1 Group
CTX-M-2 Group
CTX-M-9 Group
CTX-M-8/25/26 Group
CTX‐M like β‐lactamases in Kluyvera
K. ascorbata KLUA‐1
K. cryocrescens KLUC‐1
K. georgiana KLUG‐1
Poirel, et al, AAC, 46, 4038
By producing root hairs, plants increase
root length and surface area
Organisms no./g soil Biomass g/m2
Bacteria 108 – 109 40 – 500
Actinomycetes 107 – 107 40 – 500
Fungi 105 – 106 100 – 1,500
Algae 104 – 105 1 ‐ 50
Soil microflora
Extra-radicle hyphal development is less extensive in AM fungi than in EM fungi
The principle benefit of mycorrhizae is a large enhancement of the absorptive surface area of the root system. The extensive network of gossamer mycorrhizal hyphae can increase the root's effective surface area by several orders of magnitude. In fact, several kilometers of hyphae have been found in a liter of soil.
Diffusion shell: volume of soil around root that is depletedin nutrient concentrations due to uptake
Ions that diffuse rapidly (‘mobile nutrients’) have diffusion shells with larger radii than ions that diffuse slowly (‘immobile nutrients’)
Mobilisation of blaCTX-M
• ISEcp1 – IS1380 family mobilises by one ended transposition.blaCTX-M 1, 3, 10, 14, & 15
• Class I integron associated ISCR1 rolling circle transposition, not as a cassetteblaCTX-M 1, 14 & 9
• Bacteriophage related sequences have been found adjacent to
Genetic environment of blaKLUA-1 gene encoding the β-lactamase produced by K. ascorbata strain CIP 82.95T.
Humeniuk, C., et al, 2002, AAC, 46:3045-9
Schematic map of the potential structure in natural plasmid pILT-3 of K. pneumoniae ILT-
3
Poirel, et al, AAC, Jan 2005, 447-50
Schematic map of the complex class 1 integron carrying the blaCTX-M-14 gene
on plasmid pAJE0508
Bae, et al, AAC, Aug 2007, 3017-19
Hospital Community
00s
90s
80s
60s/70s
CTX-M
Kluyvera
CTX-ME
CTX-M EEK
TEM/SHV
TEM/SHV
E/K
EKE E.coli Klebsiellae
TEM/SHV ESBL
K E
TEM/SHV ESBL K
Mutation Gene Transfer
Unexpected things can happen with sex in bacteria!
• Evolution of ESBLs by mutation of existing β‐lactamase genes
VERSUS
• Importation of β‐lactamase gene giving ESBL spectrum from Kluyvera spp. (environmental bacteria)
17th July 2004:broadsheets discover CTX-M
0
5
10
15
20
25
90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06
Cipro
3 gen ceph
both
% R
esis
tant
E. coli from blood & CSF susceptibilities, HPA data
0
2
4
6
8
10
12
14
% positive
2001 2002 2003 2004 2005 2006year
ESBLESBL CTX-M
BSAC UK bacteraemia susceptibility surveyE. coli resistance
www.bsacsurv.org+ (226) (230) (228) (228) (227) (223)
+ number of strains
Proportion of CTX-M+ve Strains of Total Resistant to 3GC’s isolated from Hospital and
Community, Birmingham UK.
050
100150200250300350
1999
2000(Jul-Dec)
2001
2002
2003
2004
Total number ofisolates resisant to3GC
Proportion positivefor CTX-M
0
20
40
60
80
100
19992000 (Jul-Dec)
20012002
20032004
YEAR
% C
TX
-M p
ositi
ve E.coli
K pneumoniae
K. oxytoca
Enterobacter sp
Distribution of CTX-M genes in different species of Enterobacteriaceae from clinical samples from
hospital and community – Birmingham, UK
RAPD genotyping Birmingham CTX-M 15 E.coli
The ST131 E. coli clone includes epidemic strain A
Lau, et al, 2008, JAC , 62: 1241-44
Year Country % (n) ESBL Reference
1999 Pakistan 35 (200) Zaman, Pak Armed Forces Med J, 1999
1999 China, Japan, Taiwan, Singapore, Philippine
>20 (2193) Bell, Diagn Microbiol Infect Dis, 2002
1999 Hong Kong 11‐13 (1174) Ho, APMIS, 2000
2002 India 68 (678) Mathur, Ind J Med Res, 2002
2002 Pakistan 48 (400) Shah, New Microbiol, 2002
2002 Pakistan 40 (2840) Jabeen, J Pak Med Assoc, 2005
Asian Countries with High Prevalence of ESBL phenotype
Hubli
VaranasiAligarh
Characterisation of bla CTX‐M in India
130 isolates of E. coli and K. pneumoniae selected as resistant to 3GCs
95/130 (73%) carried bla CTX‐M
All PCR positive were bla CTX‐M‐15
• China is dominated by bla CTX‐M
genotypes 14, 9 & 3
• Only 4/399 genotyped isolates from China wide survey bla CTX‐M15*
*Yu, et al, J. Infect 2007, 54: 53-7
Prevalence & genotype of bla CTX‐M
from Hunan Province 2004/5
bla CTX‐M genotype
Species ESBL/Total 3 15 14 9
E. coli 50/160 6 6 35 1K. pneumoniae 47/110 8 12 13 1E. cloacae 31/98 10 2 3 3Citro. freundii 7/17 5 0 0 0
Liu, et al 2009 J.A.C. March 18th epub.
Seattle Washington
Orange,
California
Omaha, Nebraska
Denver, Colorado
Houston, Texas
Lexington, KY
Cleveland, Ohio
Little Rock,
Arkansas
New Brunswick, NJ
New York, NYSalt Lake City,
UT
CTX-M-15CTX-M-14CTX-M-3
Castanheira, et al, Micro. D. Resist., 2008
Global ESBL TrendsPer Region
Observer, 29th March 2009
Schematic map of the complex class 1 integron carrying the blaCTX-M-14 gene
on plasmid pAJE0508
Bae, et al, AAC, Aug 2007, 3017-19
Diagram of mill and reed bed system
Gaze, et al, AAC, May 2005, 1802-07
Relative resistance to DTDMAC and CTAB at 50 µg/ml
Gaze, et al, AAC, May 2005, 1802-07
Incidence of int11, qaE, and qacE∆1
Gaze, et al, AAC, May 2005, 1802-07
Gaze, et al, AAC, May 2005, 1802-07
Incidence of int11, qaE, and qacE∆1
Identification of isolates
Gaze, et al, AAC, May 2005, 1802-07
Gaze, et al, AAC, May 2005, 1802-07
Identification of isolates
WATER
SOIL
FARM ANIMALS
Xenobiotics e.g. QACs
FOOD
SEWAGEHUMANS GUT/FLORA
Veterinary Antibiotics
Clinical Antibiotics
Flow of antibiotic resistance genes in E. coli in the biosphere
Li Xu
Thomas Ling Craig Munday
Vicki Ensor Jian hui Xiong
mmm
Mohammed Shahid
Where did it all go wrong?
“I spent a lot of money on booze, birds and fast cars. The rest I just squandered”
George Best
CTX‐M‐3 & ‐15: effect of Asp240Gly
Vmax (%) MIC (mg/L)
M‐3 M‐15 M‐3 M‐15
C’tax 100 100 64 128
C’taz <0.01 1.3 1 64
C’pirome 3 80 ‐ ‐
Aztreonam 50 1 4 64
Rasmussen & Hoiby, Can J Micro 2004, 50, 137
02468
101214161820
% resistant
2001 2002 2003 2004 2005 2006
cefotaximeceftazidimeciprofloxacingentamicin
BSAC UK bacteraemia susceptibility surveyKlebsiella
www.bsacsurv.org
**
* No data available
+ number of strains
+ (146) (169) (155) (170) (164) (176)year
Meta-analysis of delay in effective therapy in in ESBL-producing versus non-ESBL-producing Enterobacteriaceae bacteraemia
Schwaber & Carmelli, 2007, J Antimicrob Chemother, 60: 913-20
Meta-analysis of mortality in ESBL-producing versus non-ESBL-producing Enterobacteriaceae bacteraemia
Schwaber & Carmelli, 2007, J Antimicrob Chemother, 60: 913-20
Estimated world populations by July 2006
China 1,313,973,713
India 1,095,351,995
World 6,525,170,264
ANTRES project
Antibiotic resistance in Peru and Bolivia
• Large scale survey of faecal E. coli in pre‐school healthy children
• 1st January 2002, reported 2005
• ESBL rate 0.1% 1.7% due to CTX‐M spread
Pallecchi, et al, 2007, AAC, 51: 2720
Pallecchi, et al, 2007, AAC, 51: 2720
Geographic distribution of CTX-M E.coli, 2005 ANTARES study
CTX‐M group
Type No Antibiotic resistance co‐transferred
Plasmid Inc group
CTX‐M‐2 CTX‐M‐2 8 GEN A/C; I1
4 GEN TET SXT F VII
2 GEN TET A/C
1 TET A/C
1 GEN SXT ‐
CTX‐M‐56 2 GEN A/C
CTX‐M‐9 CTX‐M‐14 8 NONE I1
CTX‐M‐24 2 NONE I1
CTX‐M‐1 CTX‐M‐15 6 NONE
1 TET CIP* FII
1 TET CIP* GEN FII
* aac (6')–Ib‐cr
Pallecchi, L., et al, 2007, AAC, 51: 2720‐5
“Human history has become more and more a race between education and catastrophe.”
H.G. Wells The Outline of History
The Problem with CTX-M……
• Rapid and wide dissemination – most prevalent ESBL worldwide
• Most important resistance determinant threatening use of β-lactams
• Dominance observed in both community andnosocomial settings
• Multiresistance - complicates treatment of previously uncomplicated infection
• Drives earlier and wider use of carbapenems
Mortality rates (21 day) in 97 ESBL-BSI patients treated with antimicrobial agents to which the infecting organism displayed in vitro susceptibility
Tumbarello, M., 2007, Antimicrob Agents Chemother 51: 1987-94
Structures of the studied molecules
Matagne, et al, Biochem 1993, 293, 607-11
Effect of temocillin against KPC producing bacteria from 2 states in USA
MIC Temocillin mg/L
8 16 32 64 1281 x 104 K. pneumoniae (30) 12 15 3
E. coli (3) 1 21 x 106 K. pneumoniae (30) 1 3 15 10 1
E. coli (3) 1 1 1
Adams-Haduch, et al, AAC (2009) epub 30th March
Tigecycline for Acinetobacter spp infections review
• 22 microbiological studies of 2,384 isolates (1906 Acb)
• 90% susceptibility (MIC ≤ 2mg/L)
• Efficacy 42 severely ill patients (31 resp. Infections, 8 bacteria)
• Tigecycline med in combination in 28/42 patients – effective in 32/42
Karageorgopoulos, et al, JAC (2008); 62:45-55
Colistin resistant K. pneumoniae in Greek ICUs
• Heavy empirical use of colistin
• 18 isolates from 13 patients over 16/12
• Long stay (median: 69 days), old (mean: 70 yrs)Long course colistin (median: 27 days)
• 2 bacterias, 1 VAP, 2 CSSTI
Antoniadou, et al, JAC (2007) 59: 786-90
Polymyxins (A‐E) – Colistin (A‐B)
• Mixtures of cyclic peptides –colistimethate for i.v. Use
• Variation in potency of different preperations, hydrolysed to colistin variably in patient
• Colycin (Forest Labs) 240‐480 mg colistimethate/day (Usually 2 doses)
Landman, et al, Clin Micro Revs (2008) 21: 449-65
Temocillin• Developed and marketed by Beechams in
1980’s
• 6 x methoxy derivative of ticarcillin → +++ β‐lactamase stability
• Staxxx to serine activated β‐lactamase e.g. CTX‐M, TEM, SHV, ESBLs
• No selection fro depressed AmpC production
• Probably little C. difficile selection
• Burkholderia cepacia susceptible (mode MIC 32 mg/L)
But....
• Withdrawn because of low sales
• Temocillin has no activity against Pseudomonas anaerobes or Gram positive bacteria
• Better with continuous infusion – serum levels ≥ 16 mg/L
• Most experience in UTI, but also BelgiumVAP (non Pseudomonas spp)
Polymyxins
Finch, et al, Antibiotic & Chemotherapy, 8th Edition, 2003, pp409
Use of cephalosporins to treat ESBL in China ‐ but all CTX‐M 14/3 no OXA‐1 so....
22 cases of bacteremia Survival %
ceftasidime (7) 86imipenem/cilastatin (8)
86cefoperazone/sulbactam (7) 72
Cao, et al, Diag. Micro. & ID (2006) 56:351-7
Sulbactam
• Has intrinsic activity against A. baumannii
• Early studeis showed high rates of susceptibility a
‐ declined recently b
• Has been used in pneumonia with moderate effect a CID (1996) 22:1026
b JAC (2007) 59:583
Future Approaches
• Trinem (Tricyclic carbapenem) – most discontinued but LK‐157 structureal analogue.
• Inhibits Class A & C β‐lactamase but not stable to carbapenemases.
LK-157
Paukner, et al, AAC (2009) 505-11
Odds & Sods
Nitrofuratonin
Fosfomycin
Amikacin
Mecillinam (± clavulanic acid)
CARBAPENEM ANTIBIOTICS...
Resistance mechanisms to carbapenems
• Intrinsic carbapenemases L1 • Loss of porin D2• Efflux pumps MexE-F-OprN • Class A&D carbapenemase KPC-2, OXA-23• Class B carbapenemase IMP,VIM
Endemic KPC Sporadic cases of KPC
Distribution of KPC in 2009
The future . . .
• CTX‐M dominant now– Will a new gunslinger emerge?
• In view of CTX‐M’s genetic mobility and in prevalence in China/India will rates continue to climb
• CTX‐M could assume same faecal flora/carriage rates as TEM
• The impact of ESBLs on empirical therapy of serious GNB sepsis – loss of third generation cephalosporins, quinolones, aminoglycocides,massive increase in use of carbapenems.
• New agents . . . .
Antibacterial resistance rates of genetically diverse cephalosporin-resistant E.coli from 3 geographically distinct centres in India
No and % resistant
Ensor, V.M., et al, 2006, J Antimicrob Chemother, 58:1260-3
Community acquired UTI at JNMC Hospital, Aligarh, IndiaAugust 2004‐July 2005
920 MSU tested in outpatient clinics
10.8% gave significant growth, 100 significant isolates
Resistance %
n ESBL COT NFX GEN AMK
E. coli 61 34% 76 69 64 51
K. pneumoniae 22 22% 53 47 53 35
Relative resistance to DTDMAC and CTAB at 50 ug/ml
Gaze, et al, AAC, May 2005, 1802-07
Geographical locations of the centers that have isolated Escherichia coli harboring the following ESBL: CTX-M group 1 (#), CTX-M group 9 (§ ), other CTX-M groups ( †).
Galas, et al, 2008, Antimicrob Agents Chemother, 52: 786-9
Centres (Sites)
BJ (3)
SH (3)
ZJ (5)
WH (2)
HN (4)
GZ (5)
HK (1)7 Centres ( 23 Institutions/laboratories)
Study Sites
Susceptibility of community isolates of E. coli collected in 2002-3 in China
0 0
14.4
2.7
8
17.3
4.6
29.1
7.1
50.6
2.4
39.4
0
10
20
30
40
50
Perc
ent
Ertapene
mIm
ipenem
Cefotaxim
eCefta
zidim
eCefep
ime
Cefoperazo
neCefoperz
one/sul
Amoxycilli
n/cla
Piperacilli
n/taz
Ciproflo
xacin
Amikacin
Gentam
icin
Ling, et al, 2006, Antimicrob Agents Chemother; 50: 374-8.
E. coli n=953 (% resistant)
ESBLs in UK E. coli: 2003-4
• increasing reference requests for ESBL confirmation in E.coli
– most expressing phenotype consistent with CTX-M enzymes
– including isolates from community-acquired UTIs
– little recent hospital contact
Bacterial Isolates
• Aligarh, N India, July – August 2005– 1857 samples– 143 E.coli or K. pneumoniae– 74 3GC R (51.7%)
• 4 week stored samples 2003-2004 (n=47)• 19 isolates (10 E.coli, 9 K. pneumoniae) from
Hubli and Varanasi
The arbuscular mycorrhizal structure is much less conspicuous than that of ectomycorrhizae. Both types have external hyphae, but arbuscular mycorrhizae do not form a fungal sheath around the root.
Comparison of Arbuscular mycorrhizae and Ectomycorrhizae, the two major types of mycorrhizae globally
Nutrient Mechanism of nutrient supply (% of total absorbed)
RootInterception
Mass Flow
Diffusion
Sedge tundra (Natural ecosystem)
Nitrogen - 0.5 99.5Phosphorus - 0.7 99.3Potassium - 6 94Calcium - 250 0
Magnesium - 83 17
Corn crop (Agricultural ecosystem)Nitrogen 1 79 (NO3
-) 20Phosphorus 2 4 94Potassium 2 18 80Calcium 150 413 0
Magnesium 33 244 0
Sulfur 5 95 0
Iron - 53 -
Manganese - 133 0
Zinc - 33 -
Boron - 350 0
Copper - 400 0
Molybdenum - 200 0
In both natural andagricultural ecosystems,
diffusion is the most important mechanism
for growth limiting nutrients
Mass flow isimportant for
nutrients that are
or required in smallamounts
abundant in soil,
Arbuscular mycorrhizae, typical of many herbaceous plants‐ effective in phosphorus acquisition
‐ also in mitigating water stress
Clover root infected with arbuscular mycorrhizal fungi. The intricately branched arbuscules (arb) are sites of nutrient exchange with the plant cells; the vesicles (ves) are fungal storage bodies; the swelling at the point of fungal entry into the root is termed an
appressorium (ap). Plant root hairs (rh) also are shown.
By producing root hairs, plants increase root length and surface area