K. pneumoniae NDM-1

Metallo-ß-lactamase; E. coli (NDM-1)

Metallo-ß-lactamase; E. coli (NDM-1)

Wordwide distribution of carbapenemases Enterobacteriaceae

NDM-2013

- OXA-48 - OXA-47

- TEM-1 - SHV-2a - OmpK36-

Sept. 2001, Istanbul, Turkey …

K. pneumoniae 11978 UTI, previous meropenem treatment

MIC (mg/L)

the first OXA-type carbapenemase in enterics

Antibiotic E. coli DH10B DH10B (OXA-48)

MICs (mg/L)

Amoxicillin 4 >512

Amoxi/Clav 4 >512

Piperacillin 2 128

Pip/Tazo 2 128

Cephalothin 4 64

Cefotaxime 0.06 0.25

Ceftazidime 0.06 0.12

Cefepime 0.06 0.06

Aztreonam 0.12 0.06

Imipenem 0.06 2

Meropenem 0.06 0.25

Poirel et al – AAC 2004

The OXA-48 substrate profile

- OXA-48 - OXA-47

- TEM-1 - SHV-2a - OmpK36-

K. pneumoniae 11978 MIC (mg/L)

Antibiotic MIC mg/L(S/I/R) Ampicillin >128 R Amoxi-Clav >128 R Piperacillin 256 R Pip-Tazo 256 R Cefotaxime 1 S Ceftazidime 1 S Cefepime 1 S Imipenem 1 S Meropenem 1 S Ertapenem 2 R Ciprofloxacin 0.02 S Gentamicin 0.06 S Amikacin 2 S SXT >320 R Tigecycline 1 S Colistin 0.25 S

E. coli ECBZ-1

Giani et al – AAC 2012

- OXA-48

- TEM-1

Carbapenem susceptibility of OXA-48 producers*

Potron et al – Eurosurv 2013

N=101 isolates (67 K. pneumoniae, 24 E. coli, 10 E. cloacae)

* CLSI breakpoints

- OXA-48 - OXA-47

- TEM-1 - SHV-2a - OmpK36-

K. pneumoniae 11978 MIC (mg/L)

Antimicrobial susceptibility of OXA-48 producers*

Potron et al – Eurosurv 2013

N=107 isolates (68 Klebsiella spp., 24 E. coli, 10 E. cloacae, 3 Citrobacter spp., 1 P. rettgeri, 1 S. marcescens)

* CLSI breakpoints (EUCAST for tigecycline)

75% of ESBL producers

Diversity of ß-lactam resistance phenotypes of OXA-48+ strains

Antibiotic MIC mg/L Ampicillin >128 R Amoxi-Clav >128 R Piperacillin 256 R Pip-Tazo 256 R Cefotaxime 1 S Ceftazidime 1 S Cefepime 1 S Imipenem 1 S Meropenem 1 S Ertapenem 2 R

Antibiotic MIC mg/L Ampicillin >128 R Amoxi-Clav >128 R Piperacillin >256 R Pip/Tazo >256 R Cefotaxime >32 R Ceftazidime 64 R Cefepime 16 R Imipenem 2 S Meropenem 1 S Ertapenem 32 R

E. coli ECBZ-1 K. pneumoniae CM1 K. pneumoniae 11978

Antibiotic MIC mg/L Amoxicillin >512 R Amoxi-Clav >512 R Piperacillin >512 R Pip/Tazo 512 R Cefotaxime 64 R Ceftazidime 512 R Cefepime 32 R Imipenem 64 S Meropenem 64 S

Poirel et al – AAC 2004 Giani et al – unpublished Giani et al – AAC 2012

The carbapenem-hydrolyzing oxacillinase in Enterobacteriaceae: OXA-48

K. pneumoniae E. coli reference (OXA-48)

• OXA-48 hydrolyzes carbapenems, but spare ceftazidime and cefotaxime • Not sensitive to clavulanic acid

K. pneumoniae

Outbreak of Klebsiella pneumoniae producing OXA-48 in Rotterdam, Netherlands

AMX TIC PIP TZP

ETP TCC CAZ CF

FOX IPM AMC CTX

MOX MER ATM FEP GM AN TM RA

NET C SXT SSS

FOS TGC TE CS

CIP OFX NOR FT

98 infected patients, 27 deaths

Single OXA-48-like-producing isolates

Nationwide distribution of OXA-48-like-producing isolates Outbreaks of OXA-48-like-producing isolates

UK

Belgium Germany

France

Morocco

Tunisia

Algeria

Egypt

Israel

Lebanon

Turkey

Spain

Italy

India Senegal

The Netherlands

Jordan

Georgia

Lybia

Ireland

Sultanate of Oman

Slovenia

Russia

Kuwait

Switzerland

Clonality of OXA-48-like producers?

Ellis et al – DMID 2013 Lascols et al – AAC 2013 Mathers et al – JCM 2013 Oteo et al – JAC 2013 Oteo et al - AAC 2013

Nagano et al - JJID 2013 Balm et al – BMC ID 2013 Espedido et al – Plos ONE 2013 Stolle et al – JAC 2013 Dortet et al – CMI 2012

Poirel et al - JAC 2012 & Refs therein Brink et al – JCM 2013 Gomez et al – CMI 2013 Potron et al – Eurosurv 2013 Abdelaziz et al – JCM 2013 Huang et al – JAC 2013

E. coli

ST10 ST38 ST46 ST69 ST88 ST95 ST101 ST131 ST138 ST155 ST167 ST362 ST410

K. pneumoniae

ST11 ST13 ST14 ST15 ST16 ST17 ST20 ST25 ST29 ST35 ST37 ST43 ST45 ST101

ST147 ST152 ST199 ST307 ST336 ST353 ST376 ST383 ST392 ST395 ST405 ST432 ST437 ST496

ST617 ST648 ST746 ST963 ST1092 ST1196 ST1431 ST2969 ST2076

ST530 ST663 ST685 ST753 ST754 ST846 ST981 ST982 ST984 ST985 ST986 ST987 ST1027

Germany, Jun - Oct 2012 …

OXA-48-positive K. pneumoniae and E. coli from various infections / stools of 6 dogs from the same veterinary clinic

Species Positive strains

K. pneumoniae 227

E. coli 52

E. cloacae 29

Enterobacter spp. 2

Citrobacter spp. 26

Salmonella 1

Autres 6

Total 343

K. pneumoniae E. coli E. cloacae Enterobacter spp. Citrobacter spp. Salmonella Autres

66.2%

15.2%

8.5% 0.6% 7.6%

1.7%

0.2%

CNR Résistance aux Antibiotiques-Bicêtre

2012 – Carbapenemases-Enterobacteriaceae

OXA-48 257

KPC 40

NDM 26

VIM 18

IMP 0

IMI 2

Total 343

OXA-48 KPC NDM VIM IMI

74.9%

11.7%

7.6% 5.2% 0.6%

CNR Résistance aux Antibiotiques-Bicêtre

2012 – Carbapenemases-Enterobacteriaceae

Endemic

Interregional spread

Regional spread

Independent hospital outbreaks

Single hospital outbreaks

Sporadic occurrence

Not reported / no data

KPC

VIM

NDM

OXA-48

Spread of carbapenemase producers in Enterobacteriacae in Europe-2012

Canton R, Akova M, Carmeli Y, Giske CG, Glupczynski Y, Gniadkowski M, Livermore DM, Miriagou V, Naas T, Rossolini GM, Samuelsen ﾘ, Seifert H, Woodford N, Nordmann CMI, 2012

Susceptibility testing : imipenem, ertapenem, meropenem: CLSI, EUCAST guidelines

Phenotypic detection - Hodge test; modified Hodge test - Inhibition; EDTA, clavulanic acid, boronic acid… Carbapenem hydrolysis (UV spectrophotometry, Mass spectro) Molecular biology - Specific PCR , multiplex PCR +/- sequencing - Real time PCR - DNA Microarray

Detection of carbapenemase producers in infected samples

Susceptibility to carbapenems ?

Current debate on breakpoints

Principal - KPC inhibited by boronic acid or clavulanic acid - MBL inhibited by EDTA or dipicolinic acid

Tests available - Combined Test (ROSCO) : meropenem +/- cloxacillin or dipicolinic acid or boronic acid - E-test MBL - Inhibition by EDTA (« home-made » technique)

Imipenem + EDTA Imipenem alone

Inhibition tests

Combined-disk tests

IMP + EDTA

IMP