Enferm Infecc Microbiol Clin. 2014;32(7):441442

www.elsev ier .es /e imc

Brief report

Presen es acarbap pn

J.M. Rodr roa,

R. Gomeza Departamentb Servicio de Mc Unidad de En a, Sevi

a r t i c l e i n f o

Article history:Received 11 NAccepted 24 FAvailable onlin

Keywords:PMQRqnrCarbapenemsblaOXA-48

a b s t r a c t

Palabras clave:Resistencia a qplsmidosqnrCarbapenemsblaOXA-48

Introductio

KlebsiellaEnterobacteand opportcarbapenemcant problefor transfeare due to

CorresponE-mail add

http://dx.doi.o0213-005X/

Document downloaded from http://zl.elsevier.es, day 03/09/2014. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.ovember 2013ebruary 2014e 18 April 2014

A study is presented on the presence of quinolone resistance qnrB1 genes in clinical isolates belongingto the largest series of infections caused by OXA-48-producing Klebsiella pneumoniae in a single-centreoutbreak in Spain. Evidence is also provided, according to in vitro results, that there is a possibility ofco-transfer of plasmid harbouring blaOXA-48 with an other plasmid harbouring qnrB1 in presence of lowantibiotic concentrations of uoroquinolones, showing the risk of multi-resistance screening.

2013 Elsevier Espaa, S.L.U. and Sociedad Espaola de Enfermedades Infecciosas y MicrobiologaClnica. All rights reserved.

Coexistencia de los genes de resistencia a quinolonas y carbapenmicos, qnrB1y blaOXA-48, en aislados clnicos de Klebsiella pneumoniae en Espana

uinolonas mediada por

r e s u m e n

En este estudio caracterizamos la presencia del gen de resistencia a quinolonas qnrB1 en aislados clnicospertenecientes a la mayor serie de Klebsiella pneumoniae productora de OXA-48 en un brote de un nicohospital en Espana. Este trabajo ofrece evidencias, mediante ensayos de conjugacin in vitro, de que esposible la cotransferencia de plasmidos que albergan blaOXA-48 junto con otros plsmidos que contienenqnrB1 en presencia de bajas concentraciones de uoroquinolonas, mostrando el riesgo de seleccin decorresistencias.

2013 Elsevier Espaa, S.L.U. y Sociedad Espaola de Enfermedades Infecciosas y MicrobiologaClnica. Todos los derechos reservados.

n

pneumoniae is a gram-negative rod of the familyriaceae and a common cause of community, nosocomialunistic infections. An emerging association betweens and uoroquinolone (FQ) resistance is a signi-

m in managing such infections. The main mechanismsrable carbapenem resistance in this microorganismthe emergence of carbapenemases (MBL, KPC and

ding author.ress: jmrodriguez@us.es (J.M. Rodrguez Martnez).

OXA-48-like groups).1 Several low-level plasmid-mediated FQresistance (PMQR) mechanisms have been described to date in K.pneumoniae: Qnr proteins, the Aac(6)-Ib-cr enzyme, the plasmid-mediated efux pumps, QepA and OqxAB.2 Since the increase inMIC values produced by these plasmid determinants is less thanthe concentrations commonly used in commercial panels, it is dif-cult to detect this sort of mechanism in routine practice usingcommercial microdilution panels.

OXA-48 is a carbapenem-hydrolysing oxacillinase that wasrst described in a clinical isolate of K. pneumoniae and then,OXA-48-producing Enterobacteriaceaehavebeen isolated in severalcountries in Northern Africa, the Middle East and Europe. It isnot easy to ascertain the real prevalence of OXA-48-producing

rg/10.1016/j.eimc.2014.02.0132013 Elsevier Espaa, S.L.U. and Sociedad Espaola de Enfermedades Infecciosas y Microbiologa Clnica. All rights reserved.ce of quinolone resistance to qnrB1 genenemase in clinical isolates of Klebsiella

guez Martneza,, P. Daz-de Albac,a, Lopez-Cere-Gilb, A. Pascuala,c

o de Microbiologa, Universidad de Sevilla, Sevilla, Spainicrobiologa, Hospital Universitario La Paz, Madrid, Spainfermedades Infeccionas y Microbiologa Clnica, Hospital Universitario Virgen Macarennd blaOXA-48eumoniae in Spainc, G. Ruiz-Carrascosob,

lla, Spain

442 J.M. Rodrguez Martnez et al. / Enferm Infecc Microbiol Clin. 2014;32(7):441442

Table 1MICs of FQ and carbapenems for K. pneumoniae 971 and 471 strains and derived transconjugants (TC) in E. coli J53 AzR coding for QnrB1, with or without OXA-48.

Antimicrobial agents MICs (mg/L)

K. pneumoniae 971 TC 971(QnrB1+OXA-48)

TC 971(QnrB1)

K. pneumoniae 471 TC 471(QnrB1+OXA-48)

TC 471 (QnrB1) E. coli J53AzR

Nalidixic aci 16 16 2CiprooxaciLevooxacin 5Moxioxacin 5NoroxacinImipenemMeropenemErtapenem

enterobactein the cliniMIC valuesblaCTX-M-15 atant to carseries of inin a single-predominanboured blaTIn additionthe isolatesacid suscepHerein wetwo strains

Methods

K. pneumdifferent cloisolates wethe other on

Whole-camplicatioqnrD, qnrVCbands comped and coFurthermornot identifythe two iso

LocalisatblaCTX-M-15by (i) Southwith theKieusing Esche100mg/L so0.5mg/L of

Results and

K. pneumbility to FQ

Transcontions and thonly reduceized with qlocated on ajugants wihybridizedwith ERT);carbapenem

plasmercealsoesidCIPCIP cenesity ge res(Rep122)blaOfar a

ssocilasmsedsuggepid

vitrorbouencethersele

-48,asmiding c

t of

auth

nces

ann Piaceaelevitzance:PardoM, Roella pntal-wiguez-Msmid-17:14guez-M

Document downloaded from http://zl.elsevier.es, day 03/09/2014. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.d 16 16 16 16n 2 0.25 0.25 1

0.5 0.125 0.125 0.20.5 0.25 0.25 0.24 1 1 44 1 0.25 21 0.5 0.015 24 1 0.015 2

ria since it is difcult sometimes to detect it routinelycal microbiology laboratory due to low carbapenems. Bacteria expressing blaOXA-48 also commonly expressnd have permeability defects; only then they are resis-bapenems, particularly ertapenem (ERT). The largestfections caused by OXA-48-producing K. pneumoniaecentre outbreak was recently reported in Spain.3 Thet clone was assigned sequence type (ST) 405 and har-

EM-1, blaSHV-76, blaCTX-M-15, blaOXA-1 and blaOXA-48 genes.to the multiresistant genetic background, the 78.5% ofof this clone showed a pattern compatible (nalidixic

tible and reduced susceptibility to FQ) with qnr genes.characterize the additional determinants detected onobtained at the beginning of this outbreak (May 2011).

oniae 471 and 971 were selected and belonged to twones (ST405 and a sporadic clone) of this outbreak. Both

re recovered from clinical samples: one from urine ande from a wound sample.ell DNA of these isolates was used as a template for PCRn. Screening for PMQR genes (qnrA, qnrB, qnrS, qnrC,, qepA, oqxAB and aac(6)-Ib-cr) was performed.4 DNAatible with qnrB, aac(6)-Ib-cr and oqxAB were identi-

nrmed by sequencing (with qnrB identied as qnrB1).e, the QRDR sequences of the gyrA and parC genes didmutations associated with FQ resistance in either of

lates.ion of the qnrB, aac(6)-Ib-cr, oqxA, oqxB, blaOXA-48 andgenes (plasmidic and/or chromosomal)wasdeterminedern-blotusingelectroporatedplasmidextractsobtainedsermethod;andby (ii) conjugation (performed3 times)richia coli J53 AzR and selection on plates containingdium azide combined with 0.03, 0.06, 0.125, 0.25 orciprooxacin (CIP) and/or 0.25mg/L of ERT.5

discussion

oniae 471 and 971 isolates showed reduced suscepti-(Table 1) but remained susceptible to nalidixic acid.jugants were obtained in the three selection condi-

70-kbSixty ptainedused; bat lowhigheroqxB gpatibilpositivtein P(JN714

Theand, asbeen aboth pPCR-bawhichIncL/Mby inmid hain presbut furrisk ofblaOXAent pla(includ

Conic

The

Refere

1. Nordmbacter

2. Strahiresist

3. Pano-RilloKlebsihospi

4. RodriA. Pla2011;

5. Rodri

ree patterns were observed: (1) transconjugants withd susceptibility to FQ and cephalosporins that hybrid-nrB1, aac(6)-Ib-cr and blaCTX-M-15, all of which weresingle 180-kbplasmid (selectedwith FQ); (2) transcon-

th only reduced susceptibility to carbapenems thatwith blaOXA-48 located into a 70-kb plasmid (selectedand (3) transconjugants with reduced susceptibility tos, cephalosporins and FQ carrying the two 180- and

Cuenca F, eextended-spcrob Chemo

6. Poirel L, Bomid coding2012;56:55

7. GlupczynskGrard M, eresistant En2012;39:160.25 0.25 0.0080.125 0.125 0.0150.25 0.25 0.0151 1 0.061 0.25 0.250.25 0.015 0.0151 0.015 0.008

ids (selected with CIP plus ERT or only CIP) (Table 1).nt of the transconjugants selected using only FQs con-blaOXA-48 gene, independently of concentration of CIPes the frequency of conjugationwas higher (104105)concentrations (0.030.125mg/L) when compared tooncentrations (106107 for 0.250.5mg/L). oqxA andshowed a chromosomal location. Non-typeable incom-roups were associated with blaOXA-48 plasmids and ault was obtained with a PCR for phage replication pro-P).6 blaoxa-48 was associated with Tn1999.2 transposonand qnrB1 was located near to ISCR1.2,7

XA-48 gene has mainly been described in K. pneumoniaes we are aware, this is the rst time that blaOXA-48 hasated with the PMQR qnrB1 gene. This data indicate thatidswere conjugative. Plasmid size, non-typeabilitywithreplicon typing and a positive RepP result are featuresest a relationship with the previously characterizedemic plasmid encoding OXA-48. Here we add evidence,assay, that it is possible for the co-transfer of plas-ring blaOXA-48 with another plasmid harbouring qnrB1of low concentrations of FQ. We have only tested FQ,

experiments with other antibiotics could also show thecting for co-resistances. It should be noted that qnrB1,ac(6)-Ib-crandblaCTX-M-15 wereassociated in twodiffer-s, which together conferred resistance to FQ,-lactamsarbapenems) and aminoglycosides.

interest

ors declare no conict of interest.

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