Outbreak of carbapenem-resistant Klebsiella pneumoniae: two-year epidemiologic follow-up in a tertiary hospital

Abstract

This study describes a carbapenem-resistant Klebsiella pneumoniae (CRKP) outbreak that occurred from October 2008-December 2010. Polymerase chain reaction assays were performed to detect the bla KPC gene and molecular typing was performed using pulsed-field gel electrophoresis (PFGE) The emergence of strains of multidrug-resistant Klebsiella pneumoniae has been reported with increasing frequency in several countries worldwide. Carbapenem-resistant K. pneumoniae (CRKP) can cause nosocomial infections and outbreaks with high mortality rates (Maltezou 2009). Such infections occur mainly in patients admitted to Intensive Care Units (ICU) with several underlying diseases and histories of having received prolonged courses of antibiotics (Maltezou 2009). Several resistance mechanisms have been described. Carbapenemase production (KPC), metallo-β-lactamase (MBL) and porin loss, combined with the production of extended-spectrum beta-lactamase (ESBL), are described as the most common mechanisms of carbapenem resistance (Souli et al. 2008, Peirano et al. 2009).Control measures, including contact precautions for infected or colonised patients and active surveillance in high-risk units, have been recommended as strategies to control CRKP outbreaks (Ben-David et al. 2010). In our hospital, CRKP had never been detected until October 2008. The objectives of this study were to describe the epidemiological findings in a CRKP outbreak and to verify the existence of clones that are present in other hospitals in the state of São Paulo (SP).Hospital Brigadeiro is a public, tertiary-care teaching hospital that is part of the Brazilian National Health Care System. It has the following specialised clinics: Oncology, Haematology, Bone Marrow Transplantation, Nephrology, Renal and Liver Transplant Units, ICU in The isolates evaluated in the hospital's laboratory were sent to the Adolfo Lutz Institute, a public health laboratory, to confirm our initial identification of CRKP, to assay for the production of carbapenemases and to determine the level of genetic relatedness between samples.K. pneumoniae was confirmed by classical phenotypic methods. Disk-diffusion tests were performed to determine susceptibility to antimicrobials, according to the Clinical and Laboratory Standards Institute (CLSI 2010). Isolates were screened for the ESBL phenotype by the standard double-disk synergy test and KPC was screened both by evaluating breakpoints and using modified Hodge test, again according to CLSI guidelines (2010).Minimal inhibitory concentrations (MICs) were determined by E-test (AB Biodisk, Solna, Sweden) for the following antimicrobial drugs: ceftazidime, cefotaxime, cefotaxime plus clavulanic acid, cefepime, aztreonam, ertapenem, imipenem, meropenem, piperacillin/tazobactam, gentamicin, amikacin, tigecycline tobramycin and polymyxin (CLSI 2010). Imipenem plus ethylenediamine tetraacetic acid (EDTA) strips were used to detect the presence of metallo-beta-lactamases. Tigecycline and polymyxin B were evaluated using breakpoints for Enterobacteri...

Antimicrobial susceptibility pattern of Klebsiella pneumoniae in the period 2013-2017

“…Studies conducted in Spain, from 2010 to 2014, indicate resistance to imipenem 1.7%, ciprofloxacin 20.1%, gentamicin 10.4% and amikacin 1.9%, which is significantly lower than in our study [22]. When we compare the results of our study with available data from the National Reference Laboratory, we can notice a slight increase in resistance to amixocillin/clavulanic acid from 92.8% in 2013. to 100% in 2014 in our study [23].…”

“…The study conducted at the Clinic of Infectious Diseases of the CCV in the period from 2012 to 2014, showed no resistance to Klebsiella pneumoniae to carbapenems, except for one isolate in 2013 that was resistant [16]. In this study, resistance to trimethopime/ sulfamethoxazole, a drug that has been widely used in general practice in urinary infections, is about 50%, while data from Korea indicate a significantly lower percentage of resistance to this antibiotic (18%) [23]. The high percentage of resistance to trimethoprim/ sulfamethoxazole is most likely due to a large use of this drug in the treatment of urinary infections.…”

Secular trends in Klebsiella pneumoniae isolated in a tertiary-care hospital: increasing prevalence and accelerated decline in antimicrobial susceptibility

“…Although polymixins were reintroduced in clinical practice a few years ago to combat multi-resistant Gram-negative bacilli, they have shown a slow and progressive reduction in activity against carbapenemase-producing K. pneumoniae, which in some studies has reached resistance rates that exceed 20% (25) (26) . Hetero-resistance to colistin, which is used more extensively, as well as the long-term therapy with polymixins are factors favoring the selection of strains resistant to these drugs (27) .…”

Multifactorial chromosomal variants regulate polymyxin resistance in extensively drug-resistant Klebsiella pneumoniae

“…Polymyxin B and colistin (polymyxin E) are now one of the last viable therapeutic options [ 3 ]. Unfortunately, resistance to this last-line antibiotic class is an increasing global burden, with countries particularly impacted including Asia (South Korea [ 4, 5 ], India [ 6, 7 ]), Europe (Greece [ 8–10 ]), Italy [ 10, 11 ]) and Latin America (Brazil [ 12, 13 ]). Mortality is influenced by polymyxin resistance typically occurring on a multidrug-resistant (MDR) or XDR background; nephrotoxicity leads to suboptimal dosing as well as inadequacies in detection of heteroresistance [ 10, 14 ].…”