Enterobacteriaceae producing the KPC-2 carbapenemase from hospital sewage

Zhang, Xinzhuo; Lu, Xin-Jiang; Zong, Zhiyong

doi:10.1016/j.diagmicrobio.2012.02.007

Cited by 60 publications

(42 citation statements)

References 17 publications

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“…On the other hand, our previous study showed that CRE (Enterobacter and Klebsiella species) survived poorly in a hospital environment for 24 h and was infrequently isolated from environmental surfaces in rooms housing CRE-colonized/ infected patients (27); thus, the role of hospital environmental surfaces for CRE transmission is yet to be clarified. Some authors have described environmental reservoirs of CPE related to transmission in health care settings (28), including sinks (29,30), soap dispensers (24), and hospital wastewater systems (31,32).…”

Section: Discussionmentioning

confidence: 99%

A Prolonged Outbreak of KPC-3-Producing Enterobacter cloacae and Klebsiella pneumoniae Driven by Multiple Mechanisms of Resistance Transmission at a Large Academic Burn Center

Kanamori

Parobek

Juliano

et al. 2017

Antimicrob Agents Chemother

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Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacter cloacae has been recently recognized in the United States. Whole-genome sequencing (WGS) has become a useful tool for analysis of outbreaks and for determining transmission networks of multidrug-resistant organisms in health care settings, including carbapenem-resistant Enterobacteriaceae (CRE). We experienced a prolonged outbreak of CRE E. cloacae and K. pneumoniae over a 3-year period at a large academic burn center despite rigorous infection control measures. To understand the molecular mechanisms that sustained this outbreak, we investigated the CRE outbreak isolates by using WGS. Twenty-two clinical isolates of CRE, including E. cloacae (n ϭ 15) and K. pneumoniae (n ϭ 7), were sequenced and analyzed genetically. WGS revealed that this outbreak, which seemed epidemiologically unlinked, was in fact genetically linked over a prolonged period. Multiple mechanisms were found to account for the ongoing outbreak of KPC-3-producing E. cloacae and K. pneumoniae. This outbreak was primarily maintained by a clonal expansion of E. cloacae sequence type 114 (ST114) with distribution of multiple resistance determinants. Plasmid and transposon analyses suggested that the majority of bla was transmitted via an identical Tn4401b element on part of a common plasmid. WGS analysis demonstrated complex transmission dynamics within the burn center at levels of the strain and/or plasmid in association with a transposon, highlighting the versatility of KPCproducing Enterobacteriaceae in their ability to utilize multiple modes to resistance gene propagation.

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Section: Discussionmentioning

confidence: 99%

A Prolonged Outbreak of KPC-3-Producing Enterobacter cloacae and Klebsiella pneumoniae Driven by Multiple Mechanisms of Resistance Transmission at a Large Academic Burn Center

Kanamori

Parobek

Juliano

et al. 2017

Antimicrob Agents Chemother

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“…One hypothesis suggests that this reservoir is, in part, due to the use of large quantities of antimicrobial agents in hospitals, which leads to the selection of MDROs and the high likelihood of horizontal gene transfer within the hospital effluent (21). A number of previous surveillance and outbreak studies have focused either on hospital effluent and wastewater treatment plants (WWTPs) (19,(22)(23)(24) or on the internal hospital environment only (25). Those studies used PCR, pulsed-field gel electrophoresis (PFGE), and culture methods to track organisms and antimicrobial resistance genes.…”

mentioning

confidence: 99%

“…Sources of outbreaks are occasionally linked to aqueous locations such as sinks and drains (9)(10)(11)(12), where the presence of biofilms makes remediation challenging; sink engineering modifications have been proposed to tackle these problems (13,14). Beyond the sink, hospital sewage and wastewater are known reservoirs of CPOs around the world (15)(16)(17)(18)(19)(20). One hypothesis suggests that this reservoir is, in part, due to the use of large quantities of antimicrobial agents in hospitals, which leads to the selection of MDROs and the high likelihood of horizontal gene transfer within the hospital effluent (21).…”

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confidence: 99%

Genomic Analysis of Hospital Plumbing Reveals Diverse Reservoir of Bacterial Plasmids Conferring Carbapenem Resistance

Weingarten

Johnson

Conlan

et al. 2018

mBio

180

134

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The hospital environment is a potential reservoir of bacteria with plasmids conferring carbapenem resistance. Our Hospital Epidemiology Service routinely performs extensive sampling of high-touch surfaces, sinks, and other locations in the hospital. Over a 2-year period, additional sampling was conducted at a broader range of locations, including housekeeping closets, wastewater from hospital internal pipes, and external manholes. We compared these data with previously collected information from 5 years of patient clinical and surveillance isolates. Whole-genome sequencing and analysis of 108 isolates provided comprehensive characterization of bla KPC /bla NDM -positive isolates, enabling an in-depth genetic comparison. Strikingly, despite a very low prevalence of patient infections with bla KPC -positive organisms, all samples from the intensive care unit pipe wastewater and external manholes contained carbapenemase-producing organisms (CPOs), suggesting a vast, resilient reservoir. We observed a diverse set of species and plasmids, and we noted species and susceptibility profile differences between environmental and patient populations of CPOs. However, there were plasmid backbones common to both populations, highlighting a potential environmental reservoir of mobile elements that may contribute to the spread of resistance genes. Clear associations between patient and environmental isolates were uncommon based on sequence analysis and epidemiology, suggesting reasonable infection control compliance at our institution. Nonetheless, a probable nosocomial transmission of Leclercia sp. from the housekeeping environment to a patient was detected by this extensive surveillance. These data and analyses further our understanding of CPOs in the hospital environment and are broadly relevant to the design of infection control strategies in many infrastructure settings.IMPORTANCE Carbapenemase-producing organisms (CPOs) are a global concern because of the morbidity and mortality associated with these resistant Gramnegative bacteria. Horizontal plasmid transfer spreads the resistance mechanism to new bacteria, and understanding the plasmid ecology of the hospital environment can assist in the design of control strategies to prevent nosocomial infections. A 5-year genomic and epidemiological survey was undertaken to study the CPOs in the patient-accessible environment, as well as in the plumbing system removed from the patient. This comprehensive survey revealed a vast, unappreciated reservoir of CPOs in wastewater, which was in contrast to the low positivity rate in both the patient population and the patient-accessible environment. While there were few patient-environmental isolate associations, there were plasmid backbones common to both populations. These results are relevant to all hospitals for which CPO colonization may not yet be defined through extensive surveillance.

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“…Gram-negative bacteria bearing multiple bla genes (e.g., bla NDM , bla KPC , bla CTX-M , and bla SHV ) are a problem and are increasingly found in hospital wastewaters (4,9), together with other common and related drugresistant ARGs such as qnr (fluoroquinolone), erm (macrolide), sul (sulfonamides), and tet (tetracycline). High densities of MDR bacteria in hospital wastewaters could facilitate the propagation and dissemination of ARGs by horizontal gene transfer via plasmids, transposons, and integrons (8,(10)(11)(12).…”

mentioning

confidence: 99%

Occurrences and Characterization of Antibiotic-Resistant Bacteria and Genetic Determinants of Hospital Wastewater in a Tropical Country

Chen

et al. 2016

Antimicrob Agents Chemother

102

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e Wastewater discharged from clinical isolation and general wards at two hospitals in Singapore was examined to determine the emerging trends of antibiotic resistance (AR). We quantified the concentrations of 12 antibiotic compounds by analysis using liquid chromatography-tandem mass spectrometry (LC-MS/MS), antibiotic-resistant bacteria (ARB), the class 1 integrase gene (intI1), and 16 antibiotic resistance genes (ARGs) that confer resistance to 10 different clinically relevant antibiotics. A subset of 119 antibiotic-resistant isolates were phylogenetically classified and tested for the presence of ARGs encoding resistance to ␤-lactam antibiotics (bla NDM , bla KPC , bla SHV , bla CTX-M ), amikacin [aac(6=)-Ib], co-trimoxazole (sul1, sul2, dfrA), ciprofloxacin (qnrA, qnrB), and the intI1 gene. Among these resistant isolates, 80.7% were detected with intI1 and 66.4% were found to carry at least 1 of the tested ARGs. Among 3 sampled locations, the clinical isolation ward had the highest concentrations of ARB and the highest levels of ARGs linked to resistance to ␤-lactam (bla KPC ), co-trimoxazole (sul1, sul2, dfrA), amikacin [aac(6=)-Ib], ciprofloxacin (qnrA), and intI1. We found strong positive correlations (P < 0.05) between concentrations of bacteria resistant to meropenem, ceftazidime, amikacin, co-trimoxazole, and ciprofloxacin and abundances of bla KPC , aac(6=)-Ib, sul1, sul2, dfrA, qnrA, and intI1 genes.

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Enterobacteriaceae producing the KPC-2 carbapenemase from hospital sewage

Cited by 60 publications

References 17 publications

A Prolonged Outbreak of KPC-3-Producing Enterobacter cloacae and Klebsiella pneumoniae Driven by Multiple Mechanisms of Resistance Transmission at a Large Academic Burn Center

A Prolonged Outbreak of KPC-3-Producing Enterobacter cloacae and Klebsiella pneumoniae Driven by Multiple Mechanisms of Resistance Transmission at a Large Academic Burn Center

Genomic Analysis of Hospital Plumbing Reveals Diverse Reservoir of Bacterial Plasmids Conferring Carbapenem Resistance

Occurrences and Characterization of Antibiotic-Resistant Bacteria and Genetic Determinants of Hospital Wastewater in a Tropical Country

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