Abstract
Multidrug-resistant gram-negative bacteria, such as carbapenem and colistin-resistant Klebsiella pneumoniae (ColR-CRKP), represent a major problem for health systems worldwide and have high lethality. This study investigated the genetic relationship, antimicrobial susceptibility profile, and resistance mechanisms to ColR-CRKP isolates from patients infected/colonized in a tertiary hospital in Salvador, Bahia/Brazil. From September 2016 to January 2018, 46 patients (56 ColR-CRKP positive cultures) were enrolled in the investigation but clinical and demographic data were obtained from 31 patients. Most of them were men (67.7%) and elderly (median age of 62 years old), and the median Charlson score was 3. The main comorbidities were systemic arterial hypertension (38.7%), diabetes (32.2%), and cerebrovascular disease (25.8%). The average hospitalization stay until ColR-CRKP identification in days were 35.12. A total of 90.6% used mechanical ventilation and 93.7% used a central venous catheter. Of the 31 patients who had the data evaluated, 12 had ColR-CRKP infection, and seven died (58.4%). Previous use of polymyxins was identified in 32.2% of the cases, and carbapenems were identified in 70.9%. The minimum inhibitory concentration (MIC) for colistin was > 16 μg/mL, with more than half of the isolates (55%) having a MIC of 256 μg/mL. The blaKPC gene was detected in 94.7% of the isolates, blaNDM in 16.0%, and blaGES in 1.7%. The blaOXA–48, blaVIM, and blaIMP genes were not detected. The mcr-1 test was negative in all 56 isolates. Alteration of the mgrB gene was detected in 87.5% (n = 49/56) of the isolates, and of these, 49.0% (24/49) had alteration in size probably due to IS903B, 22.4% (11/49) did not have the mgrB gene detected, 20.4% (10/49) presented the IS903B, 6.1% (3/49) had a premature stop codon (Q30*), and 2.1% (1/49) presented a thymine deletion at position 104 – 104delT (F35fs). The PFGE profile showed a monoclonal profile in 84.7% of the isolates in different hospital sectors, with ST11 (CC-258) being the most frequent sequence type. This study presents a prolonged outbreak of ColR-CRKP in which 83.9% of the isolates belonged to the same cluster, and 67.6% of the patients evaluated had not used polymyxin, suggesting the possibility of cross-transmission of ColR-CRKP isolates.
Highlights
Multidrug-resistant gram-negative bacteria, such as colistin and carbapenem-resistant Klebsiella pneumoniae, represent a major problem for healthcare systems worldwide and have a high lethality rate (Capone et al, 2013; Sabino et al, 2019)
We report a prolonged outbreak of ColR-CRKP in a large tertiary hospital in Salvador, Brazil
All bacterial isolates identified as ColR-CRKP by the Vitek R 2 system at the hospital laboratory were sent to the Federal University of Bahia (UFBA) to determine the minimum inhibitory concentration (MIC) for colistin by the broth microdilution assay (BMD), according to the criteria established by CLSI
Summary
Multidrug-resistant gram-negative bacteria, such as colistin and carbapenem-resistant Klebsiella pneumoniae, represent a major problem for healthcare systems worldwide and have a high lethality rate (Capone et al, 2013; Sabino et al, 2019). In 2009, due to the increase and spread of several multidrug-resistant bacteria around the world, K. pneumoniae along with other multidrug-resistant pathogens (Enterococcus faecium, Staphylococcus aureus, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.) were classified as “ESKAPE,” which are the most frequent microorganisms in healthcare-associated infections in the United States that tend to “escape” from antimicrobial treatments (Rice, 2008; Boucher et al, 2009). The Interagency Coordination Group on Antimicrobial Resistance reported in 2019 that multidrug-resistant bacteria could be responsible for the death per year of 10 million people worldwide in 2050. At least 700,000 people die a year worldwide due to multidrug-resistant bacteria (Interagency Coordination Group on Antimicrobial Resistance [IACG], 2019). Polymyxins (polymyxin B and polymyxin E/colistin) have become an alternative treatment for carbapenem-resistant Enterobacterales infections and, as a result, the emergence of polymyxin resistance has increased (Falagas and Kasiakou, 2005; Gonçalves et al, 2016; Karaiskos et al, 2017)
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