CARBAPENEMASE PRODUCING …...Introduction resistance - Europe Canton R, 2012...
Transcript of CARBAPENEMASE PRODUCING …...Introduction resistance - Europe Canton R, 2012...
CARBAPENEMASE PRODUCING ENTEROBACTERIACEAE
Veroniek Saegeman UZLeuven
Veroniek Saegeman
• Introduction on antibiotic resistance • Classification of ß-lactamases • Definition and history of ESBL/CPE • Laboratory diagnosis of CPE • Reporting of results • Belgian CPE epidemiology • Outcome of CPE infections
Carbapenemase producing Enterobacteriaceae (CPE)
Introduction resistance- UK
Livermore, 2012
MRSA bacteraemia decreasing (UK)
E. coli bacteraemia quinolone + cephalosporin
resistance increasing
CTX-M
Introduction resistance- Belgium
EARS net, 2011
• Invasive S. aureus isolates resistant (R/total N°) to methicillin in Belgium, 2001 – 2011
• Invasive E. coli isolates resistant (R/total N°) to 3° cephalosporins - fluoroquinolones in Belgium, 2001 – 2011
Introduction resistance • Impact on infection and resistance by
• Newly prosperous countries (eg. India, China) • Increased migration between countries • Globalised market for goods and services
• Overuse of antibiotics in agriculture (China) • Contamination of food with multiresistant bacteria • 18% of drinking water contaminated with faecal flora (India)
• NDM carrying nonfermenters and Enterobacteriaceae in surface water
• River sediment: Fluoroquinolone concentrations > those in serum of a treated patient
• Modern sophisticated hospitals offering complex procedures to ‘medical tourists’ global spread of multiresistant strains
Introduction resistance -Europe
K. pneumoniae, 3° cephalosporin R, 2011
EARS-net, 2013
K. pneumoniae, carbapenem R, 2011
Introduction resistance - Europe
Canton R, 2012 Carbapenemase-producing Enterobacteriaceae up to January 2012
Classification ß-lactamases • Ambler molecular classification
• 4 major classes: A to D • Protein homology (aminoacid similarity) • Class A, C and D:
serine ß-lactamases • Class B: metallo ß-lactamases (Zn)
• Bush-Jacoby-Medeiros functional classification
• Functional similarities: substrate and inhibitor profile • 3 main groups, multiple subgroups • Immediate relevance for microbiologist, physician
Drawz and Bonomo, 2010
Classification ß-lactamases Ambler/Bush-Jacoby-Medeiros classification
Ambler Bush-Jacoby-Medeiros Preferred substrates Inhibited by
clavulanate Representative enzyme(s)
A (serine penicillinases) 2a Penicillins + PC1 from S. aureus
2b Penicillins, narrow-spectrum cephalosporins + TEM-1, TEM-2, SHV-1
2be Penicillins, narrow-spectrum and extended- spectrum cephalosporins +
SHV-2 to SHV-6, TEM-3 to TEM-26, CTX-Ms
BEL-1, VEB-1, PER-1
2br Penicillins − TEM-30, SHV-72, SHV-10
2c Penicillins, carbenicillin + PSE-1
2e Extended-spectrum cephalosporins + FEC-1, CepA
2f Penicillins, cephalosporins, carbapenems ± KPC-2, SME-1, NMC-A
B (metallo-β-lactamases) 3 Most β-lactams, including carbapenems − IMP-1, VIM-1, NDM-1, CcrA, and BcII (B1); CphA (B2); L1(B3)
C (cephalosporinases) 1 Cephalosporins − AmpC, CMY-2, ACT-1
D (oxacillinases) 2d Penicillins, cloxacillin ± OXA-1, OXA-10
2de Extended-spectrum cephalosporins ± OXA-11, OXA-15
2df carbapenems ± OXA-23, OXA-48, OXA-40, OXA-58
Adapted from Bush and Jacoby, 2010
Reaction scheme class A betalactamase
Drawz and Bonomo, 2010
History of ESBL • Plasmid mediated ß-lactamase
• 1960: TEM-1 E. coli (Greece) • Spread to Enterobacteriaceae, Pseudomonas
aeruginosa,… • R to ampicillin, 1° cephalosporin
• Chromosomal encoded ß-lactamase • SHV-1 K. pneumoniae
• R to ampicillin, 1° cephalosporin
• 1980s: introduction of oxyimino-cephalosporins • 1985: plasmid encoded SHV-2 in K. ozaenae (Germany)
• Increased activity spectrum: penicillins, 1°-3° cephalosporins ESBL
• 1989: Plasmid mediated ESBL
• CTX-M ~ AmpC Kluyvera ascorbata • Hydrolysis cefotaxime > ceftazidime • Worldwide spread
TEM ESBLs: aminoacid substitutions at limited N° positions
History of ESBL
Bradford, 2001
History of ESBL
Most SHV ESBLs: mutants of Gly238 serine Bradford, 2001
History of ESBL • CTX-M
• plasmid dissemination and clonal success
Davies and Davies, 2010 Distribution of CTX-M ß-lactamases
Definition ESBL
• Betalactamases • Resistance to penicillins, 1°, 2°, 3° en 4° cephalosporins,
aztreonam (excl cephamycins and carbapenem) • Inhibition by betalactamase inhibitors eg. clavulanic acid
Definition and history of CPE Carbapenemase producing Enterobacteriaceae (CPE)
• Class A betalactamases
• R to penicillins, cephalosporins, aztreonam, carbapenem • S (R) to betalactamase inhibitors
• Chromosomal encoded: SME, NMC, IMI
• 1982: Serratia marcescens: carbapenem R • 3-4° cephalosporin S • No mobile genetic element association single incidents,
rare
• Plasmide encoded: KPC, GES • 1996: K. pneumoniae: KPC • R to 3-4° cephalosporins • Transferable plasmids • Other Enterobacteriaceae (and Pseudomonas aeruginosa)
Definition and history of CPE
• Class B metallobetalactamases • R to penicillins, cephalosporins, carbapenems • R to betalactamase inhibitors • S to aztreonam • Inhibited by metal ion chelators (eg. EDTA)
• First: chromosomal encoded: B. cereus, S. maltophilia
• Not easily transferred • 1990: ↑ detection of metallobetalactamases associated with
integrons when in transposons, plasmids transfer to other species • VIM, IMP, GIM • Eg. Japan: P. aeruginosa: IMP-1 1990s: spread to
Enterobacteriaceae
Definition and history of CPE
• Class D OXA-type betalactamases • (weak) carbapenemase activity, R to penicillins, early
cephalosporins • Inhibitor resistant • Aztreonam S
• 1993: 1° oxacillinase with carbapenemase activity • Acinetobacter baumannii: OXA-23 • Spread of particular clones
• 2004: Enterobacteriaceae (K. pneumoniae)
• Plasmidal spread • OXA-48 • < 50% identity with other OXA-members
Definition and history of CPE
Laboratory diagnosis of CPE • Algorithm for CPE screening in UZLeuven
Growth on (chromogenic) agar
Malditof ID + Vitek AST
Meropenem ≥ 1.0 mg/L or Meropenem ≥ 0.5 mg/L and temocillin ≥ 32 mg/L
KPC/MBL disks Etest meropenem +/- temocillin
Modified Hodge test
Rectal Eswab
Laboratory diagnosis of CPE • Screening (chromogenic) media • Enrichment broth?
author Number of samples
method Sensitivity (%)
Specifity (%)
Wilkinson KM et al, 2012
100 stool samples; 200 isolates
Brilliance CRE ChromID Carba ChromID ESBL Colorex KPC (CHROMagar KPC) TSB + ertapenem 10 µg
80 94 97 72 89
63 83 13 74 38
Girlich et al, 2012 142 isolates SUPERCARBA Brilliance CRE CHROMagar KPC
96.5 76.3 43
60.7 57.1 67.8
Perry et al, 2011 200 stool samples ID Carba (prototype) Colorex KPC
100 97
93 96
Vrioni et al, 2012 200 rectal swabs CDC-protocol: TSB-E-Mc BHI-E-ESBL ChromID ESBL ChromID Carba prototype Mc-M
89.1 92.4 92.4 92.4 89.1
86.4 93.3 84.7 96.9 85.2
Singh et al, 2012 95 surveillance rectal swabs
CHROMagar ESBL blaKPC PCR
77.3 97.0
100 96.6
Dévigne et al, 2013 202 characterized strains
ChromID OXA-48 + ChromID CARBA Colorex KPC Brilliance CRE
99 75 61
89 89 84
Laboratory diagnosis of CPE • Screening (chromogenic) media • Enrichment broth? No extra CPE recovered (N=55, UZLeuven) • OXA-48 selective agar: UZLeuven data
CPE OXA-48 groei kleur OXA-48 ++++ blauwgrijs OXA-48 ++++ blauwgrijs OXA-48 ++++ roze OXA-48 +++ blauwgrijs OXA-48 ++ blauwgrijs OXA-48 +++ blauwgrijs OXA-48 ++ blauwgrijs OXA-48 +++ blauwgrijs
OXA-48; ESBL +++ blauwgrijs
NDM-1; ESBL (CTX-M-15); AmpC (CMY-58) 0 / KPC-2 like 0 / VIM 0 / VIM-2
KPC
IMP-13 0 / OXA-23 +++ beige OXA-72 0 / OXA-58 +++ beige
GES 0 / ESBL (SHV 238S + 240K) 0 / ESBL (TEM-24) 0 /
ESBL (CTX-M 1, TEM WT); AmpC (ACT/MIR) 0 / ESBL (TEM 104K + 164S) 0 / AmpC (ACT/MIR) 0 / Hannosset S, 2013
Laboratory diagnosis of CPE • Algorithm for CPE screening in UZLeuven
Growth on chromogenic agar
Malditof ID + Vitek AST
Woodford et al, 2010
Laboratory diagnosis of CPE • Algorithm for CPE screening • KPC/MBL disk test: interpretation
Meropenem + boronic acid
Meropenem + dipicolinic acid
Meropenem + cloxacillin
Temocillin
MIC > 128 µg/mL
KPC Meropenem 10 µg ≥ 4 mm < 5 mm < 5 mm variable
MBL Meropenem
10 µg
< 5 mm ≥ 5 mm < 5 mm yes
OXA-48 Meropenem 10 µg < 5 mm < 5 mm < 5 mm yes
AmpC + porin loss
Meropenem 10 µg
≥ 4 mm EN < 5 mm ≥ 5 mm variable
ESBL + porin loss
Meropenem 10 µg < 5 mm < 5 mm < 5 mm no
Laboratory diagnosis of CPE • Algorithm for CPE screening
• Alternative ‘quick’ tests • UV spectrophotometry • Malditof MS • Carba NP test
Phenotypical KPC/MBL disks positive
Confirmation PCRs • on isolate:
• In-house (multiplex endpoint) • CheckPoints: Ligation RT-PCR or micro-array
• on swab/faeces sample: • GeneXpert multiplex Real-time VIM, NDM, KPC, OXA-48 (end 2013)
•…
Laboratory diagnosis of CPE Malditof MS: detection of meropenem degradation products
Wang L et al, Anal Bioanal Chem 2013, April 13
Laboratory diagnosis of CPE Carba NP test: carbapenem hydrolysis
Nordmann P; Poirel L, Dortet L. Emerg Infect Dis. 2012 September;18(9):1503-1507
Bacteria + lysis buffer: 30’ incubation ↓ centrifugate
Supernatans ↓
+ phenol red pH 7.8, ZnSO4, imipenem Incubation at 37°C for max 2 hrs
↓ Yellow = carbapenemase production 100% sensitivity 100% specificity
Reporting results
Leclercq et al, CMI 2013; CLSI M100-S23, 2013
EUCAST 2013
ESBL The cephalosporin breakpoints for Enterobacteriaceae will detect all clinically important resistance mechanisms (including ESBL and
plasmid mediated AmpC). Some isolates that produce beta-lactamases are susceptible or intermediate to 3rd or 4th generation cephalosporins with these breakpoints and should be reported as tested, i.e. the presence or absence of an ESBL does not in itself
influence the categorisation of susceptibility. In many areas, ESBL detection and characterisation is recommended or mandatory for infection control purposes.
CPE The carbapenem breakpoints for Enterobacteriaceae will detect all clinically important resistance mechanisms (including the majority of carbapenemases). Some isolates that produce carbapenemase are categorised as susceptible with these breakpoints and should be reported as tested, i.e. the presence or absence of a carbapenemase does not in itself influence the categorisation of susceptibility.
In many areas, carbapenemase detection and characterisation is recommended or mandatory for infection control purposes.
CLSI 2013
ESBL When using current interpretive criteria, routine ESBL testing is no longer necessary before reporting results , ie it is no longer
necessary to edit results for cephalosporins, aztreonam, or penicillins from S to R However, ESBL testing may still be useful for epidemiological and infection control purposes
CPE If using current interpretive criteria, MHT does not need to be performed other than for epidemiological and infection control purposes and no change in the interpretation of carbapenem susceptibility test results is required for MHT-positive isolates.
CPE producing isolates usually test I/R to ≥ 1 carbapenems using the current interpretive criteria + usually test R to ≥ 1 3° cephalosporin
Reporting results
Livermore, 2012
Guidance Breakpoints (mg/L)
to 2011 from 2011 To 2011 From 2011
EUCAST
For ESBL producers, edit cephalosporin S to I and I to R
Report as found
CTX/CRO S ≤ 1 R > 2
FEP S ≤ 1 R > 8
CAZ S ≤ 1 R > 8
IPM/MEM
S ≤ 2 R > 8
CTX/CRO S ≤ 1 R > 2
FEP S ≤ 1 R > 4
CAZ S ≤ 1 R > 4
IPM/MEM S ≤ 2 R > 8
CLSI
Test for ESBL by clavulanate synergy or carbapenemases by Hodge test; report ESBL producers as cephalosporin resistant
No test for ESBL or
carbapenemase
report as found
S ≤ 8
R > 64
S ≤ 8
R > 32
S ≤ 8
R > 32
S ≤ 4
R > 16
S ≤ 1 R > 4
S ≤ 8 R > 32
S ≤ 4 R > 16
S ≤ 1 R > 4
CPE epidemiology in Belgium • 2007: Sporadic cases • September 2008
• K. pneumoniae, VIM-1: import from Greece • June 2010
• E. coli, NDM-1: import from Pakistan and Balkan • > 2010: Nosocomial outbreaks
Jaarraport ESBL en CPE, B Jans & Y Gluczynski, NSIH 2011
CPE epidemiology in Belgium • Species and carbapenemase type
Rapport CPE 2012, website NSIH 2013
CPE epidemiology in Belgium • OXA-48 K pneumoniae
Bauraing C et al, ECCMID 2013
Resistant to • Temocillin • Amoxicillin-clavulanic acid • Piperacillin-tazobactam Susceptible – low level R to • Meropenem • 3-4° cephalosporins
blaOXA48 located on a single self-transferable 62 Kb IncL/M type plasmid In numerous clonal lineages Horizontal gene transfer main mechanism of spread in K pneumoniae
CPE epidemiology in Belgium • Geographic distribution of carbapenemase cases
Rapport CPE 2012, website NSIH 2013
8-10% import
CPE epidemiology in Belgium • Patient characteristics
Rapport CPE 2012, website NSIH 2013
CPE epidemiology in Belgium • Patient characteristics
Rapport CPE 2012, website NSIH 2013
CPE epidemiology in Belgium • Risk profile
• OXA-48: elderly population with colonisation • Geriatric wards
• KPC-2: elderly population with infection • Intensive care and high risk units
• Screening indications
• Recent hospitalization / stay abroad • Recent stay in hospital / home care facility in Belgium?
(50% of CPE cases)
Rapport CPE 2012, website NSIH 2013
Outcome of infections with CPE
Hussein et al, J Hosp Infect 2013;83:307
30-day survival of 317 patients with carbapenem resistant (KPC – 56%) versus carbapenem susceptible (KPS – 71%) K pneumoniae bacteremia (OR 1.3)
Daikos et al, AAC 2009;53:1868
14-day survival of 162 patients with VIM-neg,VIM-pos carbapenem S VIM-pos carbapenem R K pneumoniae BSI Independent risk factors fatal outcome: carbapenem resistance Severe underlying disease Advanced age
Outcome of infections with CPE
A: combination R/ of 2 active drugs of which 1 is carbapenem (MIC ≤4 µg/mL) 8.3% failure rate B: combination R/ of 2 active drugs without carbapenem 29% C: mono aminoglycoside 24% D: mono carbapenem (MIC ≤4 µg/mL 25% E: mono tigecyclin 35.7% F: mono colistin 47.2% G: inappropriate R/ 54%
Tzoulevekis et al, CMR 2012;25:682
34 clinical studies: 294 infections with CPE K. pneumoniae outcome according to treatment regimen
Outcome of infections with CPE
http://www.nsih.be/surv_carba/carbapenemase_nl.asp
Tzoulevekis et al, CMR 2012;25:682
BAPCOC recommendations 2012
In case meropenem MIC>8 µg/mL combination therapy with colistin, tigecyclin, aminoglycosides
The future
Livermore, 2012