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CORRESPONDENCE
Year : 2011  |  Volume : 134  |  Issue : 3  |  Page : 392-395

Extended-spectrum β-lactamase producing Klebsiella pneumoniae from blood cultures in Puducherry, India


1 Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
2 Department of Medical Microbiology & Infectious Diseases, Erasmus University Medical Centre 3015 CE, Rotterdam, The Netherlands

Date of Web Publication30-Sep-2011

Correspondence Address:
J P Hays
Room L-247, Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Centre, 3015 CE, Rotterdam
The Netherlands
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Source of Support: None, Conflict of Interest: None


PMID: 21985825

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How to cite this article:
Parveen R M, Khan M A, Menezes G A, Harish B N, Parija S C, Hays J P. Extended-spectrum β-lactamase producing Klebsiella pneumoniae from blood cultures in Puducherry, India. Indian J Med Res 2011;134:392-5

How to cite this URL:
Parveen R M, Khan M A, Menezes G A, Harish B N, Parija S C, Hays J P. Extended-spectrum β-lactamase producing Klebsiella pneumoniae from blood cultures in Puducherry, India. Indian J Med Res [serial online] 2011 [cited 2019 Nov 20];134:392-5. Available from: http://www.ijmr.org.in/text.asp?2011/134/3/392/85589

Sir,

Extended-spectrum β-lactamases (ESBLs) are plasmid-mediated enzymes that confer resistance to all penicillins and cephalosporins, including the sulbactam and clavulanic acid combinations and monobactams such as aztreonam [1] . ESBLs are most commonly detected in Klebsiella pneumoniae, which is an opportunistic pathogen associated with severe infections in hospitalized patients, including immunocompromised hosts with severe underlying diseases [2] . ESBL producing K. pneumoniae was first reported in 1983 from Germany, with a steady worldwide increase in K. pneumoniae-mediated resistance against cephalosporins in the subsequent decades [3] .

Bloodstream infections associated with K. pneumoniae may arise as a consequence of pneumonia (community- and ventilator-acquired), the urinary tract, intra-abdominal pathologies, and central venous line-related infections [4] . However, though evidence shows that this pathogen is associated with nosocomial infections worldwide, relatively little information is currently available regarding ESBL producing K. pneumoniae isolates from southern India, and Puducherry in particular. Thus a molecular characterization study was performed on blood isolates of ESBL producing K. pneumoniae collected from a tertiary care hospital in Puducherry, India.

In this retrospective study, 39 non-repeat blood culture isolates of K. pneumoniae were collected during a 3 month period (June-August) in 2008. Isolates were obtained from patients admitted to 8 different wards at JIPMER (Jawaharlal Institute of Postgraduate Medical Education & Research), Puducherry, south India [Table 1]. Blood culture was performed using biphasic medium consisting of Brain Heart Infusion (BHI) agar and BHI broth with sodium polyanethol sulphonate as an anticoagulant. K. pneumoniae was identified using standard microbiological procedures [5] . The antimicrobial susceptibility profiles of ampicillin (10 μg), amikacin (30 μg), gentamicin (10 μg), piperacillin (100 μg), piperacillin/tazobactum (100/10 μg), cefoperazone/sulbactum (75/10 μg), cefoxitin (30 μg), cefotaxime (30 μg), ceftazidime (30 μg), ceftriaxone (30 μg), ciprofloxacin (5 μg) and meropenem (10 μg) (Hi-Media, Mumbai) were tested by disk diffusion methods as described by the Clinical and Laboratory Standards Institute (CLSI formerly NCCLS) [6] . Phenotypic evidence of ESBL production was tested by the combination disk method [6] . K. pneumoniae ATCC 700603 and  Escherichia More Details coli ATCC 25922 were used as controls. These controls were available from the Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry. Isolates were stabbed into semi-solid nutrient agar butts and were stored at 4 o C before retrieval for further investigation.
Table 1: Isolate number, patient age, ward of isolation and diagnosis of 39 patients presenting with K. pneumoniae blood stream infections in Puducherry between June and August 2008


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All 39 isolates were subjected to molecular analysis, with PCR screening and sequencing being performed to identify the β-lactamase resistance genes; bla TEM , blaSHV , blaOXA-1 group and blaCTX-M, as previously described [7],[8],[9],[10] . Additional sequencing primers were required for blaTEM PCR product sequencing ('Lagging strand 7' 5'-TTACTGTCATGCCATCC-3' and 'Lagging strand 3' 5'-AGAGAATTATGCAGTGC-3'). PCR primers corresponding to sequences downstream of blaCTX-M genes were also used ('M3 int upp' 5'-TCACCCAGCCTCAACCTAAG-3' and 'ORF1 pol M3' 5'-GCACCGACACCCTCACACCT-3') [11] . PCR products of blaCTX-M positive isolates were subjected to sequencing using primers 'CTX-M-1 fw multi' 5'-AAAAATCACTGCGCCAGTTC-3', 'CTX-M-1 multi (REV)F seq' 5'-AACGTGGCGATGAATAAGCT-3' and 'ORF1 pol M3' 5'-GCACCGACACCCTCACACCT-3'. A PCR-based replicon typing method was performed to study the relationship between the resistance plasmids present, with the individual plasmid types FIA, FIB, FIIs, A/C and I1 replicons being screened [12] . These replicon types are representative of the plasmid incompatibility groups circulating among Enterobacteriaceae[12] . Isolate genotyping was performed using pulsed field gel electrophoresis (PFGE) using the restriction enzyme XbaI. Cluster analysis was performed using the method of Dice and the unweighted pair group method with arithmetic mean (UPGMA; http://en.wikipedia.org/wiki/UPGMA ).

Of the 39 isolates investigated, 37 (94.8%) were found to be resistant to at least one of the third generation cephalosporins. Among these 37 isolates, 36 (97.2%) were found to be ESBL positive by phenotypic testing. Antibiotic susceptibility testing revealed that the majority of these 36 isolates were multidrug resistant exhibiting 95, 87 and 92 per cent resistance to gentamicin, ciprofloxacin and ceftriaxone, respectively. Of the 39 isolates, 21 per cent showed resistance to amikacin and only 5 per cent to meropenem. By PCR, of the 39 isolates, 32 (82%) were positive for blaTEM , 18 (46%) for blaSHV , 36 (92%) for blaCTX-M , and 32 (82%) for blaOXA-1 group, respectively. The sequenced amplicons of the isolates positive for blaCTX-M revealed the presence of blaCTX-M-15 in all isolates. PCR-based replicon typing revealed that only a single isolate harboured both FIA and FIB replicons carrying blaCTX-M-15 . Plasmids with FIIs, A/C and I1 replicons types were not detected. PFGE analysis showed that the 39 isolates belonged to 3 (non-clonal) major genotypic clusters with no obvious association between genotype and ward.

In recent years, a significant increase in ESBL producing Klebsiella spp. has been reported in India mostly identified using phenotypic methods [13],[14],[15],[16] . Further, according to our earlier report (January- July, 2006), 130 patients with K. pneumoniae blood stream infections were identified with a very high proportion of these, (126 or 97%), producing ESBLs [17] . From our current study, 44 per cent of K. pneumoniae isolates carried both blaTEM and blaSHV genes, 41 per cent a blaTEM gene only, and only 5 per cent a blaSHV gene. In the past 15 years, CTX-M-type ESBLs have become more prevalent worldwide [18],[19] . Among our blood culture isolates, a very high incidence of multiple ESBL-gene carriage was detected, with the most notable result being the presence of CTX-M-15 in 92 per cent of isolates, as well as the combination of CTX-M-15 resistance and OXA-1 resistance in 82 per cent and 36 per cent of isolates possessing TEM, SHV, CTX-M and OXA-1 resistance combined. Two isolates (5%) were also meropenem resistant, with carbapenems currently being considered the preferred antimicrobial agent for the treatment of serious infections caused by ESBL-producing K. pneumoniae in our hospital. This finding seriously limits treatment options, and causes great concern with respect to the adequate treatment and spread of ESBL resistant K. pneumoniae isolates both within hospitals and from the hospital environment to the community.

The spread of antimicrobial resistance in K. pneumoniae isolates is complicating the treatment of serious nosocomial infection worldwide, not least because resistance in K. pneumoniae is typically caused by the acquisition of plasmids containing multiple antimicrobial resistances (including genes coding for ESBL resistance) [20] . Molecular characterization of such ESBL-carrying isolates is essential in allowing hospitals to identify the source of these pathogenic bacteria, whilst providing useful information regarding the distribution of clonally related ('outbreak' strains) or non-related ESBL genotypes. Further, monitoring of the spread of individual β-lactamase genes and their associated genetic platforms (in particular plasmids), provides a means to monitor for the appearance of new ESBL enzymes and genotypes, as well as establishing the dominance of older established ESBL enzymes/ genotype combinations.

In conclusion, this study emphasizes the major role that CTX-M-15 plays in facilitating ESBL-mediated antimicrobial resistance in Puducherry, India, and reiterates its association with multiple antibiotic resistance determinants, including carbapenem resistance.


   Acknowledgment Top


This work was supported by a European Union FP6 project grant (DRESP2).

 
   References Top

1.Jacoby GA. Extended-spectrum â-lactamases and other enzymes providing resistance to oxyimino- â-lactams. Infect Dis Clin North Am 1997; 11 : 875-87.   Back to cited text no. 1
    
2.Podschun R, Ullmann U. Klebsiella spp. as nosocomial pathogens: epidemiology, taxonomy, typing methods, and pathogenicity factors. Clinc Microbiol Rev 1998; 11 : 589-603.  Back to cited text no. 2
    
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6.National Committee for Clinical Laboratory Standards. Performance standards for antimicrobial susceptibility testing- 9 th information supplement: M100-S17. Wayne, PA, USA: NCCLS; 2007.  Back to cited text no. 6
    
7.Lucet JC, Decre D, Fichelle A, Guillou ML, Pernet M, Blangy C, et al. Control of a prolonged outbreak of extended-spectrum â-lactamase-producing Enterobacteriaceae in a university hospital. Clin Infect Dis 1999; 29 : 1411-8.  Back to cited text no. 7
    
8.Tasli H, Bhar IH. Molecular characterization of TEM and SHV derived extended spectrum â-lactamases in hospital based Enterobacteriaceae in Turkey. Jpn J Infect Dis 2005; 58 : 162-7.   Back to cited text no. 8
    
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13.Mathur P, Kapil A, Das B, Dhawan B. Prevalence of extended spectrum â -lactamase producing Gram negative bacteria in a tertiary care hospital. Indian J Med Res 2002; 115 : 153-7.   Back to cited text no. 13
    
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16.Grover SS, Sharma M, Pasha ST, Singh G, Lal S. Antimicrobial susceptibility pattern and prevalence of extended spectrum â-lactamase (ESBLs) producing strains of Klebsiella pneumoniae from a major hospital in New Delhi. J Commun Dis 2004; 36 : 17-26.   Back to cited text no. 16
    
17.Harish BN, Menezes GA, Shekatkar S, Parija SC. Extended-spectrum beta-lactamase-producing Klebsiella pneumoniae from blood culture. J Med Microbiol 2007; 56 : 999-1000.   Back to cited text no. 17
    
18.Grover SS, Sharma M, Chattopadhya D, Kapoor H, Pasha ST, Singh G. Phenotypic and genotypic detection of ESBL mediated cephalosporin resistance in Klebsiella pneumoniae: emergence of high resistance against cefepime, the fourth generation cephalosporin. J Infect 2006; 53 : 279-88.   Back to cited text no. 18
    
19.Bonnet R, Sampaio JLM, Labia R, Champs D, Sirot D, Chanal C, et al. A novel CTX-M â-lactamase (CTX-M-8) in cefotaxime-resistant Enterobacteriaceae isolated in Brazil. Antimicrob Agents Chemother 2000; 44 : 1936-42.   Back to cited text no. 19
    
20.Paterson DL. Resistance in Gram-negative bacteria: Enterobacteriaceae. Am J Med 2006; 119 : 20-8.  Back to cited text no. 20
    



 
 
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