Karbapenem dirençli Klebsiella pneumoniae suşlarının moleküler epidemiyolojisi

Yıl 2019, Cilt: 24 Sayı: 1, 1 - 7, 30.01.2019

İsmail Davarcı Seniha Şenbayrak Sebahat Aksaray Mücahide Esra Koçoğlu Mert Ahmet Kuşkucu Mustafa Samastı

https://doi.org/10.21673/anadoluklin.423081

Cited By: 4

Öz

Amaç

Karbapeneme dirençli Klebsiella pneumoniae enfeksiyonları, azalan tedavi imkanlarıyla birlikte önemli bir klinik sorun haline gelmiştir. Bu çalışmada, İstanbul’da elde edilen K. pneumoniae izolatlarındaki karbapenem direnç oranlarını ve buna sebep olan direnç genlerini incelemek amaçlanmıştır.

Gereç ve Yöntemler

Bu prospektif çalışmaya, Temmuz 2013—Temmuz 2014 döneminde hastanemize kabul edilen hastalardan elde edilen toplam 1452 K. pneumoniae izolatı dahil edilmiştir. Mikroorganizmaların tanımlanması ve antimikrobiyal duyarlılık testi için VITEK-2 (bioMérieux, MarcyI’Ѐtoile, Fransa) kullanılmıştır. VITEK-2 otomatize sistem ile karbapenem direnci saptanan suşların ertapenem gradient testi ile de ertapeneme dirençli olduğu bulunmuştur. Karbapenem direncine sebep olan genler real time-polymerase chain reaction ile araştırılmıştır. 

Bulgula

1452 K. pneumoniae izolatının 45’i (%3,1) karbapeneme dirençliydi. Bunların 32’si (%71,1) blaOXA-48-pozitif, 9’u (%20) blaNDM-pozitif, 1’i (%2,2) blaVIM-1-pozitifti. Hiçbirinde blaKPC ve blaIMP-1 geni mevcut değildi. Karbapenemaz üreten K. pneumonae izolatlarının en duyarlı olduğu antimikrobiyaller amikasin ve gentamisin idi.

Tartışma ve Sonuç

Hastanemizde karbapenem direncine sebep olan çeşitli mekanizmalar bulunmaktadır ve blaOXA-48 geninin %71,1 oranında görülmesi dikkat çekicidir. Bu direncin hızla yayılması ve enzimatik direnç genlerinin aktarımı yoluyla yönetimi zor hastane salgınlarına yol açması mümkündür. Bu nedenle enfeksiyon kontrolünde doğru ve hızlı laboratuvar tanı önemlidir. Daha hızlı sonuçlar elde etmek için moleküler yöntemler de fenotipik yöntemler gibi hastane altyapısına dahil edilmelidir.

Anahtar Kelimeler

Direnç geni, karbapenem direnci, Klebsiella pneumoniae

Molecular Epidemiology of Carbapenem-resistant Klebsiella pneumoniae Isolates

Öz

Aim

Carbapenem-resistant Klebsiella pneumoniae infection has become an important clinical problem with reduced therapeutic options. This study aimed to investigate the carbapenem resistance rates and responsible resistance genes in K. pneumoniae isolates derived from clinical samples collected in Istanbul.

Materials and Methods

This prospective study included a total of 1452 K. pneumoniae isolates from patients admitted to our hospital between July 2013 and July 2014. VITEK-2 (bioMérieux, MarcyI’Ѐtoile, France) was used for microbial identification and antimicrobial susceptibility testing. The carbapenem-resistant isolates identified by VITEK-2 were also found to be resistant to ertapenem by the ertapenem gradient test. Resistance mechanisms of the carbapenem-resistant isolates were investigated using real time-polymerase chain reaction.

Results

Of the 1452 K. pneumoniae isolates, 45 (3.1%) were carbapenem-resistant. Of these, 32 (71.1%) were blaOXA-48-positive, 9 (20%) blaNDM-positive, and 1 (2.2%) blaVIM-1-positive. None had the genes blaKPC and blaIMP-1. The greatest susceptibility by the isolated carbapenemase-producing K.pneu moniae was shown to the antimicrobials amikacin and gentamicin.

Discussion and Conclusion

In our hospital, there are several mechanisms causing carbapenem resistance, and the blaOXA-48 positivity rate of 71.1% is significant. This resistance may spread rapidly and, through enzymatic resistance gene transfer, lead to hospital epidemics difficult to manage. For this reason, accurate and rapid laboratory diagnosis is important in infection control. For faster results, molecular methods, as well as phenotypic methods, must be included in the hospital infrastructure

Anahtar Kelimeler

Carbapenem resistance, Klebsiella pneumoniae, resistance gene

Kaynakça

• Baran I, Aksu N. Phenotypic and genotypic characteristics of carbapenem-resistant Enterobacteriaceae in a tertiary-level reference hospital in Turkey. Ann Clin Microbiol Antimicrob 2016;15(1):20.
• Doumith M, Ellington MJ, Livermore DM, Woodford N. Molecular mechanisms disrupting porin expression in ertapenem-resistant Klebsiella and Enterobacter spp. clinical isolates from the UK. J Antimicrob Chemother 2009;63(4):659-67.
• Pasteran F, Mendez T, Guerriero L, Rapoport M, Corso A. Sensitive screening tests for suspected class A carbapenemase production in species of Enterobacteriaceae. J Clin Microbiol 2009;47(6):1631-9.
• Crowley B, Benedí VJ, Doménech-Sánchez A. Expression of SHV-2 beta-lactamase and of reduced amounts of OmpK36 porin in Klebsiella pneumoniae results in increased resistance to cephalosporins and carbapenems. Antimicrob Agents Chemother 2002;46(11):3679-82.
• Cohen Stuart J, Leverstein-Van Hall MA. Guideline for phenotypic screening and confirmation of carbapenemases in Enterobacteriaceae. Int J Antimicrob Agents 2010;36(3):205-10.
• Horan TC, Andrus M, Dudeck MA. CDC/NHSN Surveillance definition of healthcare-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36(5):309-32.
• Wayne PA. Performance Standards for antimicrobial susceptibility testing, 23rd informational supplement. CLSI document M100-S23. Clinical and Laboratory Standards Institute. 2013.
• Ciftci IH, Karakece E, Asik G, Demiray T, Er H. Karbapenem Direncli Klebsiella pneumoniae Suslarinda Oxa-48 ve Kpc Varliginin Arastirilmasi. Ankem Derg 2013;27(2):49-54.
• Poirel L, Héritier C, Tolün V, Nordmann P. Emergence of Oxacillinase-Mediated Resistance to Imipenem in Klebsiella pneumoniae. Antimicrob Agents Chemother 2004;48(1):15–22.
• European Antimicrobial Resistance Surveillance System, http://www.hpsc.ie/hpsc/A-Z/Microbiology Antimicrobial Resistance/ European Antimicrobial Resistance Surveillance System EARSS/(accessed in February 2011).
• Gur D, Hascelik G, Aydin N, Telli M, Gultekin M, Ogulnç D, et al. Antimicrobial resistance in Gram-negative hospital isolates: results of the Turkish HITIT-2 Surveillance Study of 2007. J Chemother 2009;21(4):383-9.
• Lascols C, Peirano G, Hackel M, Laupland KB, Pitout JD. Surveillance and Molecular Epidemiology of Klebsiella pneumoniae isolates that produce carbapenemases: first report of OXA-48-like enzymes in North America. Antimicrob Agents Chemother 2012;57(1):130-6.
• Aktas Z, Kayacan CB, Schneider I, Can B, Midilli K, Bauernfeind A. Carbapenem-hydrolyzing oxacillinase, OXA-48, persists in Klebsiella pneumoniae in Istanbul, Turkey. Chemotherapy 2008;54(2): 101-6.
• Hrabák J, Študentová V, Walková R, Zemlicková H, Jakubu V, Chudácková E. Detection of NDM-1, VIM-1, KPC, OXA-48, and OXA-162 Carbapenemases by Matrix-Assisted Laser Desorption Ionization–time of flight mass spectrometry. J Clin Microbiol 2012;50(7):2441-3.
• Demir Y, Zer Y, Karaoglan I. Investigation of VIM, IMP, NDM-1, KPC AND OXA-48 enzymes in Enterobacteriaceae strains. Pak J Pharm Sci 2015;28:1127–33.
• Grundmann H, Glasner C, Albiger B, Aanensen DM, Tomlinson CT, Andrasević AT, et al. Occurrence of carbapenemase-producing Klebsiella pneumoniae and. Escherichia coli in the European survey of carbapenemase-producing Enterobacteriaceae (EuSCAPE): a prospective, multinational study. Lancet Infect Dis 2017;17(2):153-63.
• Djahmi N, Dunyach-Remy C, Pantel A, Dekhil M, Sotto A, Lavigne JP. Epidemiology of carbapenemase-producing Enterobacteriaceae and Acinetobacter baumannii in Mediterranean countries. Biomed Res Int 2014;2014:305784.
• Tsakris A, Poulou A, Bogaerts P, Dimitroulia E, Pournaras S, Glupczynski Y. Evaluation of a new phenotypic OXA-48 disk test for differentiation of OXA-48 carbapenemase-producing Enterobacteriaceae clinical isolates. J Clin Microbiol 2015;53(4):1245–51.
• Nordmann P, Poirel L. The difficult-to-control spread of carbapenemase producers among Enterobacteriaceae worldwide. Clin Microbiol Infect 2014;20(9):821–30.
• Poirel L, Potron A, Nordmann P. OXA-48-like carbapenemases: the phantom menace. J Antimicrob Chemother 2012;67(7):1597-606.
• Fursova NK, Astashkin EI, Knyazeva AI, Kartsev NN, Leonova ES, Ershova ON, et al. The spread of bla OXA-48 and bla OXA-244 carbapenemase genes among Klebsiella pneumoniae, Proteus mirabilis and Enterobacter spp. isolated in Moscow, Russia. Ann Clin Microbiol Antimicrob 2015;14(1):46.
• Arana DM, Saez D, García-Hierro P, Bautista V, Fernández-Romero S, Ángel de la Cal M, et al. Concurrent interspecies and clonal dissemination of OXA-48 carbapenemas. Clin Microbiol Infect 2015;21(2):148.e1-4.
• Yong D, Toleman MA, Giske CG, Cho HS, Sundman K, Lee K, et al. Characterization of a new metallo-β-lactamase gene, blaNDM-1, and a novel erythromycin esterase gene carried on a unique genetic structure in Klebsiella pneumoniae sequence type 14 from India. Antimicrobial agents and chemotherapy 2009;53(12); 5046-54.
• Wang JT, Wu UI, Lauderdale TLY, Chen MC, Li SY, Hsu LY, et al. Carbapenem-nonsusceptible Enterobacteriaceae in Taiwan. PLoS One 2015;10(3):e0121668.
• Sahin K, Tekin A, Ozdas S, Akin D, Yapislar H, Dilek AR, et al. Evaluation of carbapenem resistance using phenotypic and genotypic techniques in Enterobacteriaceae isolates. Ann Clin Microbiol Antimicrob 2015;14(1):44.
• Yildirim I, Ceyhan M, Gur D, Mugnaioli C, Rossolini GM. First detection of VIM-1 type metallo-beta-lactamase in a multidrug-resistant Klebsiella pneumoniae clinical isolate from Turkey also producing the CTX-M-15 extended-spectrum beta-lactamase. J Chemother 2007;19(4):467-8.
• Yigit H, Queenan AM, Anderson GJ, Domenech-Sanchez A, Biddle JW, Steward CD, et al. Novel carbapenemhydrolyzing β-lactamase, KPC-1, from a carbapenem-resistant strain of Klebsiella pneumoniae. Antimicrob Agents Chemother 2001;45(4):1151-61.
• Yigit H, Queenan AM, Rasheed JK, Biddle JM, Domenech-Sanchez A, Alberti S, et al. Carbapenem resistant strain of Klebsiella oxytoca harboring carbapenem-hydrolyzing β-lactamase KPC-2. Antimicrob Agents Chemother 2003;47(12):3881-9.
• Patel JB, Rasheed JK, Kitchel B. Carbapenemases in enterobacteriaceae: activity, epidemiology, and laboratory detection. Clinical Microbiology Newsletter 2009;31(8):55-62.
• Kaiser RM, Castanheira M, Jones RN, Tenover F, Lynfield R. Trends in Klebsiella pneumoniae carbapenemase-positive K.pneumoniae in US hospitals: report from the 2007-2009 SENTRY Antimicrobial Surveillance Program. Diagn Microbiol Infect Dis 2013;76(3):356-60.
• Senda K, Arakawa Y, Ichiyama S, Nakashima K, Ito H, Ohsuka S, et al. PCR detection of metallo-b-lactamase gene (blaIMP) in gram-negative rods resistant to broadspectrum b-lactams. J Clin Microbiol 1996;34(12):2909-13.
• Shibata N, Doi Y, Yamane K, Yagi T, Kurokawa H, Shibayama K, et al. PCR typing of genetic determinants for metallo- β-lactamases and integrases carried by gram-negative bacteria isolated in Japan, with focus on the class 3 integron. J Clin Microbiol 2003;41(12):5407-13.
• Aktas Z, Bal C, Midilli K, Poirel L, Nordmann P. First IMP-1-producing Klebsiella pneumoniae isolate in Turkey. Clin Microbiol Infect 2006;12(7):695-6.
• Pollett S, Miller S, Hindler J, Uslan D, Carvalho M, Humphries RM. Phenotypic and molecular characteristics of carbapenem-resistant Enterobacteriaceae in a health care system in Los Angeles, California, from 2011 to 2013. J Clin Microbiol 2014;52(11):4003-9.