Get 20M+ Full-Text Papers For Less Than $1.50/day. Subscribe now for You or Your Team.

Learn More →

Successful control of a neonatal outbreak caused mainly by ST20 multidrug-resistant SHV-5-producing Klebsiella pneumoniae, Greece

Successful control of a neonatal outbreak caused mainly by ST20 multidrug-resistant... Background: Extended spectrum beta-lactamase-producing Klebsiella pneumoniae (ESBL-Kp) infection can cause significant morbidity and mortality in neonates. We investigated a nosocomial ESBL-Kp outbreak in a neonatal intensive care unit (NICU) of the University Hospital of Larissa (UHL), Central Greece. Methods: A total of sixty-four ESBL-Kp were studied; twenty six isolates were recovered from the NICU and were compared with thirty-eight randomly selected isolates from different wards of the hospital during the period March- December 2012. All isolates were characterized by antimicrobial susceptibility testing, ESBL-production by double-disk synergy test, molecular typing using BOX-PCR, whereas selected isolates were further characterized by beta lactamase and virulence gene content, multilocus sequence typing and phylogenetic analysis. All neonates affected by ESBL-Kp were put under strict contact isolation, along with appropriate infection control measures. Results: The outbreak strain of ST20 multidrug-resistant SHV-5-producing K. pneumoniae was identified in all infected (n = 13) and three colonized neonates. A novel ST (ST1114) was also identified among SHV-5 producers (n = 10) recovered from nine colonized infants, but it was not related with ST20. Both STs were identified only in the NICU and not in other wards of the hospital. No ESBL-Kp were isolated from the hands of the nursing staff and the environment. Although we were not able to identify the source of the outbreak, no ESBL-Kp were isolated in the NICU after this period and we assumed that the outbreak was successfully controlled. All neonates received parenteral nutrition and most of them were delivered by caesarean section and showed low gestational age (<32 weeks) and low birth weights (<1500 g). Conclusion: According to our knowledge, this is the first description of an outbreak of multidrug-resistant SHV-5 producing K. pneumoniae assigned to ST20. Keywords: Outbreak, Klebsiella pneumoniae, ESBL, NICU, Molecular typing Background either from the mother to child at birth, or acquired du- Klebsiella pneumoniae is an opportunistic pathogen re- ring nursery by person-to-person transmission, via the sponsible for nosocomial infections. The microorganisms hands of the nursing staff and the contaminated equip- are isolated more frequently from the stool, umbilical cord ment, food or the environment. and the oropharynx. Bloodstream infections caused by In K. pneumoniae, acquired resistance to penicillins, K. pneumoniae are also often reported in the neonatal in- broad spectrum cephalosporins and monobactams, except tensive care units (NICUs) [1]. Transmission can occur for carbapenems and cephamycins can be mediated by the production of extended-spectrum beta-lactamases (ESBLs). The most widespread ESBLs belong to the TEM, SHV and * Correspondence: petinaki@med.uth.gr CTX-M families [2-5]. Choice of antibiotic therapy may be Department of Microbiology, University Hospital of Larissa, Larissa, Greece limited if the organism produces an ESBL, particularly for Department of Microbiology, Medical School, University of Thessaly, Biopolis, Larissa, Greece pneumonias. Nosocomial outbreaks of extended-spectrum Full list of author information is available at the end of the article © 2014 Mavroidi et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Mavroidi et al. BMC Pediatrics 2014, 14:105 Page 2 of 8 http://www.biomedcentral.com/1471-2431/14/105 beta-lactamase-producing K. pneumoniae (ESBL-Kp) with environmental contamination by ESBL-Kp was also car- increased morbidity and mortality have been frequently re- ried out. All aforementioned surveillance cultures (1258 ported, mostly in debilitated, hospitalized patients in the in- cultures in total) were directly inoculated on MacCon- tensive care units (ICUs) and neonatal units [2-11]. key agar plates. Recovered ESBL-Kp organisms were During 2012, the emergence and spread of ESBL-Kp was stored at −80°C in Trypticase Soy Broth containing 10% documented in the neonatal intensive care unit (NICU) of (v/v) glycerol for further analysis. theUniversityHospitalofLarissa (UHL), CentralGreece. We report here, the epidemiological features, molecular Detection of beta-lactamase and virulence genes characterization of the beta-lactamase and virulence gene Total DNA from all ESBL-Kp was extracted using the content, molecular epidemiology by BOX-PCR and multi- Quick-gDNA TM MiniPrep kit (ZYMO RESEARCH locus sequence typing (MLST), and control measures for Corp., USA). Detection by PCR of beta-lactamase (bla) the outbreak of multidrug-resistant SHV-5 producers. genes encoding KPC-, VIM-, TEM-, OXA- and CTX-M- type enzymes was performed, as described previously [14]. Methods The intrinsic SHV-1 and SHV-5-type enzymes were differ- Setting and definition of cases entiated by PCR, as described previously [15]. Sequences of The UHL serves as one of the main (600-beds) tertiary the PCR products were determined in both strands. Pro- care hospitals in the district of Thessaly, (1,000,000 inhabi- duction of the respective beta-lactamases was confirmed by tants). The NICU of UHL receives approximately 750 ad- isoelectric focusing (IEF) [14]. The presence of the fimH, missions per year and it has six rooms (40 beds) for ugeE, wabG, ureA, magA, allS and rmpA virulence genes newborns of age less than or equal to 28 days. Outbreak wasassessed by PCR, asdescribed previously [16]. cases were defined by isolation of an ESBL-Kp strain from any culture of infected neonates in the NICU. Infection Genotyping and phylogenetic analysis was defined by clinical and laboratory criteria and require- Molecular typing was performed by BOX-PCR and Multilo- ment for antimicrobial therapy, while, colonization by the cus Sequence Typing (MLST), as described previously absence of relevant symptoms. We note that no routine [17,18]. Allele numbers and sequence types (STs) were screening for ESBL-Kp has been performed in the NICU assigned and new STs were deposited on the Institut Pasteur before the onset of the outbreak because infections caused France K. pneumoniae MLST database (www.pasteur.fr/ by these microorganisms were very rare in the NICU mlst). Phylogenetic analysis was performed by the neighbor- (Petinaki, unpublished data). joining tree algorithm usingthe MEGA software [19]. Identification of isolates and antimicrobial susceptibility Collection of clinical data testing Before obtaining the clinical information of the neo- Identification to the species level and antimicrobial sus- nates, approval was received by the Ethics Committee of ceptibility testing of the isolates has been performed by the UHL, which is represented by the Infection Control the Vitek-2 Advanced Expert system (BioMerieux Inc., Committee (number of permission 1234). Clinical re- Marcy l’ Etoile, France), according to the interpretive cri- cords from the neonates were collected and reviewed in- teria of the Clinical and Laboratory Standards Institute- cluding the following data: date and place of birth, date CLSI [12]. Phenotypic screening for ESBL production was of admission in the NICU, length of stay in the NICU, performed by the double-disk synergy test (DDST) and for birth weight, sex, vaginal or caesarean delivery, gesta- carbapenemase production by the meropenem-boronate tional age, age (days after birth) at first isolation of combined disk test, as described previously [3,13]. ESBL-Kp, surgical procedures, intubation, use of central venous catheters, placement of chest tubes, parenteral Bacterial isolates and surveillance cultures nutrition, antimicrobial therapy and use of intralipids. Overall, a total of 64 non-carbapenemase-producing ESBL- Kp collected from March to December 2012 in UHL Results and discussion were analyzed; 26 of them were consecutively recovered Outbreak description and infection control interventions th from various clinical specimens in the NICU, whereas The onset of the outbreak was recognised on the 5 the remaining isolates (n = 38) were randomly collected March 2012 when two ESBL-Kp isolates were recovered from different wards of the hospital during the same from the blood and urine samples of two twin neonates period,soastofurther investigatethe extent andthe born at the maternity unit of the UHL. These isolates were th th epidemiology of the outbreak. recovered on the 13 and 18 day after admission of the During September to December 2012, repeated surveys twins in the NICU, suggesting acquisition of these isolates th of rectal and pharyngeal swabs were obtained from neo- in the NICU. Another case was detected on the 30 nates on a weekly basis. Screening of nursing staff and March and two more cases at the beginning of April. Mavroidi et al. BMC Pediatrics 2014, 14:105 Page 3 of 8 http://www.biomedcentral.com/1471-2431/14/105 On the 15th April, a special team (one microbiologist (n = 16) or CTX-M-3 (n = 3) producers and one isolate and two nurses) was formed to coordinate the manage- coproduced SHV-5 and CTX-M-15. All neonatal ESBL- ment of the outbreak, providing specific recommendations, Kp were also positive for the presence of fimH, ugeE, such as cohorting of infants, limited rotation of the staff, wabG and ureA, but negative for the magA, allS and encouraging effective hand hygiene, safe disposal of diapers rmpA virulence genes. into specific bags, daily cleaning of the surfaces and soiled articles with soap and water, followed by disinfection with Antimicrobial susceptibility testing and molecular typing a dilute solution of chlorine containing bleach and chlor- The 64 ESBL-Kp were assigned to 15 different BOX-PCR hexidine (Acrylan, Kosmidis Company, Athens, Greece). profiles. Among 32 representative isolates of the major No new cases were detected between May and June, and BOX-PCR profiles and all the isolates with unique profiles, despite the control measures, three new cases were de- we have identified 13 MLST STs; five of them were novel tected from July to August 2012. During this period, we STs. The antimicrobial susceptibility patterns of the iso- noted that the ratio of nurse/patients was 1:7 at the time of lates and the STs of the four major BOX-PCR profiles the outbreak because of understaffing because of summer identified among the 64 ESBL-Kp are shown in Table 1. leaves (usual ratio, 1:4). Thus, from March to August 2012, All neonatal ESBL-Kp displayed multidrug-resistance a total of 8 ESBL-Kp were detected in an equal number phenotypes, including resistance to penicillins, ceftazidime, of neonates. and aztreonam, tobramycin and gentamycin (Table 1). st On the 1 September 2012, a surveillance protocol was ST20 (BOX-PCR pattern P1) was identified among 16 implemented for all neonates affected by ESBL-Kp in a ESBL-Kp recovered from 13 infected and three colonized weekly basis. From September to December 2012, five neonates. ST20 has been previously identified among new- more infected neonates were identified, whereas 13 ESBL- borns affected by ESBL-Kp, which produced CTXM-15 in Kp were recovered from 12 colonized infants. Four ESBL- Spain [20]. A novel ST (ST1114) was identified in nine neo- Kp were recovered from blood cultures within the first nates colonized by ESBL-Kp (n = 10) of the BOX-PCR pat- three weeks of November, and therefore infection control ternsP2(n=8),P3(n=1) andP4(n=1) (Figure1). The38 measures were intensified. On the 1st December, three co- ESBL-Kp recovered from the other wards of UHL were dis- horts of infants were established: the first group included tributed into two major clusters, P5 (n = 12) and P6 (n = all infants infected or colonized with ESBL-Kp which were 16) profiles (Table 1, Figure 1), which were assigned to cared for by designated nurses and placed on contact pre- ST258 and ST101, respectively. ST258 has been identified cautions until hospital discharge in a separate nursery, the mostly among carbapenemase-producing K. pneumoniae second group included infants with exposure to case- worldwide (including Greece), whereas ST101 has been infants, but with negative surveillance cultures, which previously reported among carbapenemase-producing K. were cared for by another group of designated nurses, pneumoniae in Italy and Korea [3,21-23]. andathirdgroup of newlyadmittedinfants were cared Neonatal ESBL-Kp of ST20 and ST1114 were not gen- for in a separate room by another group of designated etically related, each comprising a separate lineage on nurses. Furthermore, the antibiotic policy in the NICU has the neighbor-joining tree (Figure 1). Furthermore, ST20 changed; restriction of third-generation cephalosporins and ST1114 were not found among non-carbapenemase- was enforced and imipenem was used for infants with sus- producing ESBL-Kp recovered from other wards of the pected sepsis. Multidisciplinary meetings were held twice hospital. Although SHV-5 producers were distributed into weekly to discuss the ongoing investigation and compli- six different MLST STs, there was no genetic relatedness ance with the infection control measures. From September among the neonatal and the other strains (Figure 1). to December 2012, a total of 18 ESBL-Kp were detected Therefore, transmission of SHV-5 producers from the in 5 infected and 12 colonized neonates. NICU to other wards, or vice versa, was not documented. ESBL- Kp have not been isolated from the hands of The differences in the antibiotic resistance profiles of the nursing staff and environmental samples. No other the neonatal ESBL-Kp with those recovered from other cases were detected until now and we assumed that the wards of the hospital (Table 1) and the presence of two outbreak was successfully controlled. distinct bacterial clones among ESBL-Kp in the NICU, the ST20 and ST1114 clones (corresponding to BOX-PCR Characterization of beta-lactamase and virulence profiles P1 and P2, respectively), which were not genetic- gene content ally related to each other or other ESBL-Kp isolated from All 26 neonatal ESBL-Kp were positive only for both the other wards of the hospital (Table 1, Figure 1), indicate SHV-5 and TEM-1 beta-lactamases, as shown by PCR that ESBL-Kp should have been imported in two different and IEF. Among the 38 ESBL-Kp collected from other occasions and disseminated only in the NICU. wards of the hospital, 18 isolates were SHV-12 (n = 12) As all of the infected neonates and only three colonized or SHV-5 (n = 6) producers, 19 isolates were CTX-M-15 neonates were affected by ST20 ESBL-Kp, we considered Mavroidi et al. BMC Pediatrics 2014, 14:105 Page 4 of 8 http://www.biomedcentral.com/1471-2431/14/105 Table 1 Antimicrobial susceptibility patterns of the four major BOX-PCR profiles of ESBL-Kp in a NICU, Larissa, Greece BOX-PCR MLSTST MIC range (mg/L) profile AMP AMP/SUL CTX CAZ ATM IMP MER ERT CIP TOB GM TSX NICU (n = 26) P1 (16) ST20 ≥32 ≤2− 16 ≤1− ≥64 8- ≥64 8- ≥64 ≤1 ≤0.25 ≤0.5 ≤0.25 ≥16 ≥16 ≤20 P2 (8) ST1114 ≥32 ≤2 ≤2− ≥64 16- ≥64 4- ≥64 ≤1 ≤0.25 ≤0.5 ≤0.25 ≥16 ≥16 ≤20 Non-NICU (n = 38) P5 (12) ST258 ≥32 8- ≥32 16 ≥64 ≥64 ≤1 ≤0.25 ≤0.5 ≥4 ≤1-16 ≥16 ≤20- ≥320 P6 (16) ST101 ≥32 ≥32 ≥64 16- ≥64 32- ≥64 ≤1 ≤0.25 ≤0.5 ≥48- ≥16 ≤1-8 ≤20- ≥320 In parenthesis, the number of isolates identified in each of the four major BOX-PCR profiles is shown. AMP: ampicillin, AMP/SUL: ampicillin/sulbactam, ATM: aztreonam, CAZ: ceftazidime, CIP: ciprofloxacin, CTX: cefotaxime, ERT: ertapenem, GM: gentamycin, IMP: imipenem, MER: meropenem, TOB: tobramycin, TSX: trimethoprim/sulfamethoxazol. that this clone was the main cause of the outbreak in environment. It could be hypothesized that some of the theNICU. Thetime-course of theoutbreak ofST20 mothers of the neonates were carriers of ESBL-Kp and ESBL-Kp is shown in Figure 2. ESBL-Kp of ST1114 were that they were the source of the neonatal infections or col- identified in the NICU from September to December onizations. However, screening for colonization of the 2012, when surveillance cultures were obtained from the mothers of the neonates was not performed in this study. neonates. However, we cannot exclude the possibility that the ST1114 ESBL-Kp were circulating in the NICU among Clinical characteristics of the outbreak colonized infants before the surveillance period. Neverthe- A retrospective review of clinical data of the neonates af- less, we were not able to identify the source of the import- fected ESBL-Kp was performed (Table 2). Of the 16 (13 ation of ESBL-Kp in the NICU, as no ESBL-Kp were infected and three colonized) neonates affected by the out- isolated either from the hands of the nursing staff or the break strain of ST20 ESBL-Kp, 11 neonates were born in Figure 1 Neighbor-joining tree of the STs of the 32 representative ESBL-Kp. For each isolate, the MLST ST, the BOX-PCR profile and the beta-lactamase content are indicated. Mavroidi et al. BMC Pediatrics 2014, 14:105 Page 5 of 8 http://www.biomedcentral.com/1471-2431/14/105 Figure 2 Time-course of the outbreak of ST20 ESBL-Kp. The sex (F: female, M: male) and the infection (I) or colonization (C) status of each infant is indicated. Case 4, indicated with a different colour scheme, has died. The time of first isolation of ST20 SHV-5 producers for each infant is indicated with an asterisk. the maternity unit of UHL, whereas the remaining neo- the virulence gene content among ESBL-Kp belonging to nates were admitted to UHL from the general hospital of ST20 and ST1114 were observed, but several other viru- Larissa or different private maternity clinics of the prefec- lence characteristics (e.g. the mucoid phenotype, aerobac- ture of Thessaly. One infected neonate has died. Fourteen tin production, capsular serotype) are associated with the of the 16 neonates were delivered by caesarean section type of infection in K. pneumoniae, as reported previously and they showed low gestational age (≤32 weeks) and low [28]. As shown in Table 2, no differences in the clinical birth weight (≤1500 g). All neonates had received paren- characteristics of the neonates affected by ST20 and teral nutrition. Several risk factors, such as intubation ST1114 ESBL-Kp were observed. (n = 13), placement of central venous catheters (n = 11) In our study, surveillance cultures were obtained during and chest tubes (n = 4) were also documented. Low gesta- the outbreak period (from September- December 2012). tional age, low birth weight and use of invasive devices The percentage of new carriers out of the total amount have been reported previously among the risk factors for that were screened during the out break period (12 colo- acquiring ESBL-producing Enterobacteriaceae in NICUs nized infants out of 62 infants screened from September [6,24-27]. to December 2012) was 19.35%. Surveillance has stopped As mentioned previously, of the 25 neonates affected by by the end of December of 2012, as no new infections by ESBL-Kp and 16 neonates affected by ST20 ESBL-Kp, 13 ESBL-Kp were detected after the end of December 2012 (52% and 81.2%, respectively) developed an infection, and onwards, only a small percentage of ST20 ESBL-Kp whereas ST1114 was identified only among colonized pa- were detected in colonized infants (3 out of 16 ST20 tients (Table 2). Thus, ST20 ESBL-Kp showed high infec- ESBL-Kp) during the outbreak period, and no infections tiousness compared with ST1114 ESBL-Kp. Furthermore, were caused by ST1114 ESBL-Kp. The best time to screen four out of 16 (25%) ST20 ESBL-Kp were recovered from neonates is arguable and high compliance with the surveil- bloodstream infections. These observations could be at- lance protocol is essential for success. Nevertheless, it has tributed to differences either in the virulence potential of been shown recently that continuous long-term surveil- the STs or in the clinical characteristics of the infants af- lance and neonatal cohorting are associated with a marked fected by ST20 and ST1114 ESBL-Kp. No differences in decrease in the spread of ESBL-KP within the NICU [27]. Mavroidi et al. BMC Pediatrics 2014, 14:105 Page 6 of 8 http://www.biomedcentral.com/1471-2431/14/105 Table 2 Clinical characteristics of the neonates affected by ESBL-Kp in a NICU, Larissa, Greece a b c Cases Birth date Admission Gestational Age at first Length of Weight at Gender Inborn/Outborn Source Infected/ Delivery Risk Outcome date age at birth isolation of stay (days) birth (g) colonized factors (weeks) ESBL-Kp (days) Neonates affected by ST20 ESBL-Kp 1 February 23 February 23 27 10 120 1000 M Inborn ET Infected CS PN, IT,CVC Discharged 2 February 23 February 23 27 10 85 1070 F Inborn Urine Infected CS PN, IT,CVC Discharged 3 March 17 March 17 31 13 21 1220 F Inborn Urine Infected CS PN Discharged 4 March 28 March 28 26 34 145 790 F Outborn ET Infected CS PN, IT, CVC Died 5 April 19 April 20 38 4 35 3380 M Outborn ET Infected CS PN, IT, CVC, CT Discharged 6 July 8 July 8 32 11 34 1360 F Outborn Eye Infected CS PN, IT, Discharged 7 August 6 August 6 28 3 70 1255 F Inborn Catheter Infected CS PN, IT, CVC, CT Discharged 8 August 6 August 6 28 11 55 1000 F Inborn ET Infected CS PN, IT, ET, CVC Discharged 9 August 31 August 31 28 22 154 800 M Inborn FC Colonized CS PN, IT, CVC Discharged 10 October 13 October 13 28 35 126 960 M Inborn FC Colonized CS PN, IT, CVC, CT Discharged 11 October 15 October 15 31 25 44 1500 M Inborn Blood Infected VD PN, IT, CVC Discharged 12 October 27 October 27 31 6 40 580 M Outborn Blood Infected CS PN, IT, CVC Discharged 13 October 31 October 31 28 20 93 1120 F Outborn Blood Infected CS PN, IT, CVC Discharged 14 November 2 November 2 30 7 40 1350 F Outborn Blood Infected CS PN Discharged 15 November 16 November 16 32 32 49 1365 F Inborn Urine Infected VD PN, IT Discharged 16 December 6 December 09 35 10 21 2270 M Outborn FC Colonized CS PN Discharged Range: 26–38 Range: 3–35 Range: 21–154 Range: 580–3380 Mean: 30 Mean: 15.8 Mean: 70.8 Mean: 1313.8 Neonates affected by ST1114 ESBL-Kp 17 September 5 September 5 28 25 35 850 F Inborn FC Colonized CS PN Discharged 18 September 15 September 15 27 17 80 1000 M Outborn FC Colonized CS PN, IT, CVC Discharged 19 October 5 October 5 30 15 45 750 F Inborn FC Colonized CS PN Discharged 20 October 27 October 27 31 25 56 1000 F Inborn FC Colonized CS PN,CVC Discharged 21 October 31 October 31 28 30 118 1040 F Outborn FC Colonized CS PN, ΙΤ,CVC Discharged 22 November 5 November5 28 12 114 980 F Outborn FC Colonized VD PN, ΙΤ,CVC Discharged 23 November 15 November 15 27 35 90 1070 F Inborn FC Colonized VD PN, ΙΤ,CVC Discharged 24 December 22 December22 34 4 27 1480 F Outborn FC Colonized CS PN Discharged 25 December 28 December 28 31 2 27 1480 F Outborn FC Colonized CS PN Discharged Range: 27–34 Range: 2–35 Range: 27–118 Range: 750–1480 Mean: 29.3 Mean: 18.3 Mean: 65.7 Mean: 1072.2 F: female, M: male. ET: endotracheal tube, FC: Fecal carriage. CS: caesarean section, VD: vaginal delivery. CT: chest tubes, CVC: central venous catheters, IT: intubation, PN: parenteral nutrition. Mavroidi et al. BMC Pediatrics 2014, 14:105 Page 7 of 8 http://www.biomedcentral.com/1471-2431/14/105 Conclusions 6. Rettedal S, Lohr IH, Natas O, Giske CG, Sundsford A, Oymar K: First outbreak of extended-spectrum b-lactamase producing Klebsiella pneumoniae in a In the present study, we described an outbreak occurred Norwegian neonatal intensive care unit associated with contaminated during a nine-months period in 2012 at the NICU of UHL breast mik and reslved by strict cohorting. APMIS 2012, 120:612–621. caused mainly by multidrug-resistant SHV-5 producers of 7. Lee SY, Park YJ, Yu JK, Jung S, Kim Y, Jeong SH, Arakawa Y: Prevalence of acquired fosfomycin resistance among extended-spectrum b-lactamase- ST20 recovered from 13 infected and three colonized neo- producing Escherichia coli and Klebsiella pneumoniae clinical isolates in nates, whereas a novel ST (ST1114) was identified only Korea and IS26-composite transposon surrounding fosA3. J Antimicrob among colonized neonates. A retrospective study of the Chemother 2012, 67:2843–2847. 8. Lee SY, Park YJ, Yu JK, Jung S, Kim Y, Jeong SH, Arakawa Y: International clones clinical data of the neonates affected by ESBL-Kp has re- of Klebsiella pneumoniae and Escherichia coli with extended-spectrum b- vealed that all neonates had received parenteral nutrition lactamases in a Czech Hospital. J Clin Microbiol 2009, 47:3353–3357. and most of them were delivered by caesarean section and 9. Gruteke P, Goessens W, van Gils J, Peerbooms P, Lemmens-den Toom N, van Santen-Verheuvel M: Profiles of resistance associated with integrons, showed low birth weights. To our knowledge, this is the the extended-spectrum b-lactamase SHV-5 gene, and a multidrug efflux first report of SHV-5 producers assigned to ST20. The pump of Klebsiella pneumoniae causing a nosocomial outbreak. J Clin emergence of ST20 and ST1114 SHV-5 producers in the Microbiol 2003, 41:1161–1166. 10. Prodinger WM, Fille M, Bauernfeind A, Stemplinger I, Amann S, Pfausler B, NICU, along with the presence of various previously re- Lass-Florl C, Dierich MP: Molecular epidemiology of Klebsiella pneumoniae ported STs (e.g. ST101, ST258) and six novel STs among producing SHV-5 beta-lactamase: parallel outbreaks due to multiple plas- SHV-5/12 or CTXM-3/15 producers in other wards of mid transfer. J Clin Microbiol 1996, 34:564–568. 11. Shannon KP, King A, Phillips I, Nicolas MH, Philippon A: Importation of UHL indicate the ongoing evolution of ESBL-producing organisms producing broad-spectrum SHV-group b-lactamases into the K. pneumoniae in our area. United Kingdom. J Antimicrob Chemother 1990, 25:343–351. 12. Clinical and Laboratory Standards Institute: Performance Standards for Abbreviations Antimicrobial Susceptibility Testing: Twenty-first Informational Supplement DDST: Double-disk synergy test; ESBL: Extended-spectrum beta-lactamase; M100-S21. 2011, Wayne, PA, USA. ESBL-Kp: Extended-spectrum beta-lactamase-producing Klebsiella pneumo- 13. Miriagou V, Cornaglia G, Edelstein M, Galani I, Giske CG, Gniadkowski M, niae; ICU: Intensive care unit; MLST: Multilocus sequence typing; Malamou-Lada E, Martinez-Martinez L, Navarro F, Nordmann P, Peixe L, NICU: Neonatal intensive care unit; UHL: University hospital of Larissa. Pournaras S, Rossolini GM, Tsakris A, Vatopoulos A, Cantón R: Acquired carbapenemases in Gram-negative bacterial pathogens: detection and Competing interests surveillance issues. Clin Microbiol Infect 2010, 16:112–122. The authors declare that they have no competing interests. 14. Papagiannitsis CC, Tryfinopoulou K, Giakkoupi P, Pappa O, Polemis M, Tzelepi E, Tzouvelekis LS, Carbapenemase Study Group, Vatopoulos AC: Authors’ contributions Diversity of acquired β-lactamases amongst Klebsiella pneumoniae in EP, AM, and VM conceived and designed the study. AM wrote the first draft Greek hospitals. Int J Antimicrob Agents 2012, 39:178–180. of the paper and other co-authors contributed to the final draft. AL and AM 15. Pałucha A, Mikiewicz B, Hryniewicz W, Gniadkowski M: Concurrent performed the experiments. AG, MG and KG were responsible for managing outbreaks of extended-spectrum beta-lactamase-producing organisms the clinical data. EP, AG, AM and VM conducted the interpretation of data. of the family Enterobacteriaceae in a Warsaw hospital. J Antimicrob All authors read and approved the final manuscript. Chemother 1999, 44:489–499. 16. Brisse S, Fevre C, Passet V, Issenhuth-Jeanjean S, Tournebize R, Diancourt L, Acknowledgements Grimont P: Virulent clones of Klebsiella pneumoniae: identification and We thank the team of curators of the Institut Pasteur MLST system (Paris, evolutionary scenario based on genomic and phenotypic France) for importing novel alleles, profiles and/or isolates at http://www. characterization. PLoS ONE 2009, 4:e4982. pasteur.fr/mlst. 17. Yang A, Yen C: PCR Optimization of BOX-A1R PCR for microbial source track- ing of Escherichia coli in waterways. J Exp Microbiol Immunol 2012, 16:85–89. Author details 18. Diancourt L, Passet V, Verhoef J, Grimont PAD, Brisse S: Multilocus Department of Microbiology, University Hospital of Larissa, Larissa, Greece. sequence typing of Klebsiella pneumoniae nosocomial isolates. J Clin Neonatal Intensive Unit, University Hospital of Larissa, Larissa, Greece. Microbiol 2005, 43:4178–4182. Laboratory of Bacteriology, Hellenic Pasteur Institute, Athens, Greece. 19. Tamura K, Dudley J, Nei M, Kumar S: MEGA4: Molecular Evolutionary Genetics Department of Microbiology, Medical School, University of Thessaly, Biopolis, Analysis (MEGA) software version 4.0. MolBiolEvol 2007, 24:1596–1599. Larissa, Greece. 20. Oteo J, Cuevas O, Lopez-Rodriguez I, Banderas- Florido A, Vindel A, Perez- Vazquez M: Emergence of CTX-M-15-producing Klebsiella pneumoniae of Received: 17 March 2014 Accepted: 8 April 2014 multilocus sequence types 1, 11, 14, 17, 20, 35 and 36 as pathogens and Published: 17 April 2014 colonizers in newborns and adults. J Antimicrob Chemother 2009, 64:524–528. 21. Ruiz-Garbajosa P, Curiao T, Tato M, Gijón D, Pintado V, Valverde A, Baquero F, References Morosini MI, Coque TM, Cantón R: Multiclonal dispersal of KPC genes following 1. Gastmeier P, Loui A, Stamm-Balderjahn S, Hansen S, Zuschneid I, Sohr D, the emergence of non-ST258 KPC-producing Klebsiella pneumoniae clones in Behnke M, Obladen M, Vonberg RP, Rüden H: Outbreaks in neonatal intensive Madrid, Spain. JAntimicrobChemother 2013, 68:2487–2492. care units-they are not like others. Am J Infect Control 2007, 35:172–176. 22. Kitchel B, Rasheed JK, Patel JB, Srinivasan A, Navon-Venezia S, Carmeli Y, 2. Coque TM, Baquero F, Canton R: Increasing prevalence of ESBL-producing Brolund A, Giske CG: Molecular epidemiology of KPC-producing Klebsiella Enterobacteriaceae in Europe. Euro Surveill 2008, 47:19044. pneumoniae isolates in the United States: clonal expansion of multilocus 3. Rupp ME, Fey PD: Extended spectrum b-lactamase (ESBL)-producing sequence type 258. Antimicrob Agents Chemother 2009, 53:3365–3370. Enterobacteriaceae: considerations for diagnosis, prevention and drug 23. Mammina C, Bonura C, Aleo A, Fasciana T, Brunelli T, Pesavento G, Degl’ treatment. Drugs 2003, 63:353–365. Innocenti R, Nastasi A: Sequence type 101 (ST101) as the predominant 4. Woodford N, Turton JF, Livermore DM: Multiresistant Gram-negative carbapenem non-susceptible Klebsiella pneumoniae clone in an acute bacteria: the role of high-risk clones in the dissemination of antibiotic general hospital in Italy. Int J Antimicrob Agents 2012, 9:539–547. resistance. FEMS Microbiol Rev 2011, 35:736–755. 24. Gupta A, Della-Latta P, Todd B, San Gabriel P, Haas J, Wu F, Rubenstein D, 5. Peirano G, Hun King Sang J, Pitondo–Silva A, Laupland KB, Pitout JD: Saiman L: Outbreak of extended-spectrum beta-lactamase-producing Molecular epidemiology of extended-spectrum-b-lactamase-producing Klebsiella pneumoniae in a neonatal intensive care unit linked to artificial Klebsiella pneumoniae over a 10 year period in Calgary, Canada. nails. Infect Control Hosp Epidemiol 2004, 25:210–215. J Antimicrob Chemother 2012, 67:1114–1120. Mavroidi et al. BMC Pediatrics 2014, 14:105 Page 8 of 8 http://www.biomedcentral.com/1471-2431/14/105 25. Cantey JB, Sreeramoju P, Jaleel M, Treviño S, Gander R, Hynan LS, Hill J, Brown C, Chung W, Siegel JD, Sànchez PJ: Prompt control of an outbreak caused by extended-spectrum-β-lactamase-producing Klebsiella pneumoniae in an intensive care unit. J Pediatr 2013, 163:672–679. 26. Giuffrè M 1, Cipolla D, Bonura C, Geraci DM, Aleo A, Di Noto S, Nociforo F, Corsello G, Mammina C: Outbreak of colonizations by extended-spectrum β-lactamase-producing Escherichia coli sequence type ST131 in a neonatal intensive care unit, Italy. Antimicrob Resist Infect Control 2013, 2:8–15. 27. Benenson S, Levin PD, Block C, Adler A, Ergaz Z, Peleg O, Minster N, Gross I, Schaffer K, Moses AE, Cohen MJ: Continuous surveillance to reduce extended-spectrum β-lactamase Klebsiella pneumoniae colonization in the neonatal intensive care unit. Neonatology 2013, 103:155–160. 28. Yu VL, Hansen DS, Ko WC, Sagnimeni A, Klugman KP, von Gottberg A, Goossens H, Wagener MM, Benedi VJ, and the International Klebsiella Study group: Virulence characteristics of Klebsiella and clinical manifestations of Klebsiella pneumoniae bloodstream infections. Emerg Infect Dis 2007, 13:986–993. doi:10.1186/1471-2431-14-105 Cite this article as: Mavroidi et al.: Successful control of a neonatal outbreak caused mainly by ST20 multidrug-resistant SHV-5-producing Klebsiella pneumoniae, Greece. BMC Pediatrics 2014 14:105. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Pediatrics Springer Journals

Successful control of a neonatal outbreak caused mainly by ST20 multidrug-resistant SHV-5-producing Klebsiella pneumoniae, Greece

Loading next page...
 
/lp/springer-journals/successful-control-of-a-neonatal-outbreak-caused-mainly-by-st20-IgD3R75Psh

References (63)

Publisher
Springer Journals
Copyright
Copyright © 2014 by Mavroidi et al.; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; Pediatrics; Internal Medicine
eISSN
1471-2431
DOI
10.1186/1471-2431-14-105
pmid
24742105
Publisher site
See Article on Publisher Site

Abstract

Background: Extended spectrum beta-lactamase-producing Klebsiella pneumoniae (ESBL-Kp) infection can cause significant morbidity and mortality in neonates. We investigated a nosocomial ESBL-Kp outbreak in a neonatal intensive care unit (NICU) of the University Hospital of Larissa (UHL), Central Greece. Methods: A total of sixty-four ESBL-Kp were studied; twenty six isolates were recovered from the NICU and were compared with thirty-eight randomly selected isolates from different wards of the hospital during the period March- December 2012. All isolates were characterized by antimicrobial susceptibility testing, ESBL-production by double-disk synergy test, molecular typing using BOX-PCR, whereas selected isolates were further characterized by beta lactamase and virulence gene content, multilocus sequence typing and phylogenetic analysis. All neonates affected by ESBL-Kp were put under strict contact isolation, along with appropriate infection control measures. Results: The outbreak strain of ST20 multidrug-resistant SHV-5-producing K. pneumoniae was identified in all infected (n = 13) and three colonized neonates. A novel ST (ST1114) was also identified among SHV-5 producers (n = 10) recovered from nine colonized infants, but it was not related with ST20. Both STs were identified only in the NICU and not in other wards of the hospital. No ESBL-Kp were isolated from the hands of the nursing staff and the environment. Although we were not able to identify the source of the outbreak, no ESBL-Kp were isolated in the NICU after this period and we assumed that the outbreak was successfully controlled. All neonates received parenteral nutrition and most of them were delivered by caesarean section and showed low gestational age (<32 weeks) and low birth weights (<1500 g). Conclusion: According to our knowledge, this is the first description of an outbreak of multidrug-resistant SHV-5 producing K. pneumoniae assigned to ST20. Keywords: Outbreak, Klebsiella pneumoniae, ESBL, NICU, Molecular typing Background either from the mother to child at birth, or acquired du- Klebsiella pneumoniae is an opportunistic pathogen re- ring nursery by person-to-person transmission, via the sponsible for nosocomial infections. The microorganisms hands of the nursing staff and the contaminated equip- are isolated more frequently from the stool, umbilical cord ment, food or the environment. and the oropharynx. Bloodstream infections caused by In K. pneumoniae, acquired resistance to penicillins, K. pneumoniae are also often reported in the neonatal in- broad spectrum cephalosporins and monobactams, except tensive care units (NICUs) [1]. Transmission can occur for carbapenems and cephamycins can be mediated by the production of extended-spectrum beta-lactamases (ESBLs). The most widespread ESBLs belong to the TEM, SHV and * Correspondence: petinaki@med.uth.gr CTX-M families [2-5]. Choice of antibiotic therapy may be Department of Microbiology, University Hospital of Larissa, Larissa, Greece limited if the organism produces an ESBL, particularly for Department of Microbiology, Medical School, University of Thessaly, Biopolis, Larissa, Greece pneumonias. Nosocomial outbreaks of extended-spectrum Full list of author information is available at the end of the article © 2014 Mavroidi et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Mavroidi et al. BMC Pediatrics 2014, 14:105 Page 2 of 8 http://www.biomedcentral.com/1471-2431/14/105 beta-lactamase-producing K. pneumoniae (ESBL-Kp) with environmental contamination by ESBL-Kp was also car- increased morbidity and mortality have been frequently re- ried out. All aforementioned surveillance cultures (1258 ported, mostly in debilitated, hospitalized patients in the in- cultures in total) were directly inoculated on MacCon- tensive care units (ICUs) and neonatal units [2-11]. key agar plates. Recovered ESBL-Kp organisms were During 2012, the emergence and spread of ESBL-Kp was stored at −80°C in Trypticase Soy Broth containing 10% documented in the neonatal intensive care unit (NICU) of (v/v) glycerol for further analysis. theUniversityHospitalofLarissa (UHL), CentralGreece. We report here, the epidemiological features, molecular Detection of beta-lactamase and virulence genes characterization of the beta-lactamase and virulence gene Total DNA from all ESBL-Kp was extracted using the content, molecular epidemiology by BOX-PCR and multi- Quick-gDNA TM MiniPrep kit (ZYMO RESEARCH locus sequence typing (MLST), and control measures for Corp., USA). Detection by PCR of beta-lactamase (bla) the outbreak of multidrug-resistant SHV-5 producers. genes encoding KPC-, VIM-, TEM-, OXA- and CTX-M- type enzymes was performed, as described previously [14]. Methods The intrinsic SHV-1 and SHV-5-type enzymes were differ- Setting and definition of cases entiated by PCR, as described previously [15]. Sequences of The UHL serves as one of the main (600-beds) tertiary the PCR products were determined in both strands. Pro- care hospitals in the district of Thessaly, (1,000,000 inhabi- duction of the respective beta-lactamases was confirmed by tants). The NICU of UHL receives approximately 750 ad- isoelectric focusing (IEF) [14]. The presence of the fimH, missions per year and it has six rooms (40 beds) for ugeE, wabG, ureA, magA, allS and rmpA virulence genes newborns of age less than or equal to 28 days. Outbreak wasassessed by PCR, asdescribed previously [16]. cases were defined by isolation of an ESBL-Kp strain from any culture of infected neonates in the NICU. Infection Genotyping and phylogenetic analysis was defined by clinical and laboratory criteria and require- Molecular typing was performed by BOX-PCR and Multilo- ment for antimicrobial therapy, while, colonization by the cus Sequence Typing (MLST), as described previously absence of relevant symptoms. We note that no routine [17,18]. Allele numbers and sequence types (STs) were screening for ESBL-Kp has been performed in the NICU assigned and new STs were deposited on the Institut Pasteur before the onset of the outbreak because infections caused France K. pneumoniae MLST database (www.pasteur.fr/ by these microorganisms were very rare in the NICU mlst). Phylogenetic analysis was performed by the neighbor- (Petinaki, unpublished data). joining tree algorithm usingthe MEGA software [19]. Identification of isolates and antimicrobial susceptibility Collection of clinical data testing Before obtaining the clinical information of the neo- Identification to the species level and antimicrobial sus- nates, approval was received by the Ethics Committee of ceptibility testing of the isolates has been performed by the UHL, which is represented by the Infection Control the Vitek-2 Advanced Expert system (BioMerieux Inc., Committee (number of permission 1234). Clinical re- Marcy l’ Etoile, France), according to the interpretive cri- cords from the neonates were collected and reviewed in- teria of the Clinical and Laboratory Standards Institute- cluding the following data: date and place of birth, date CLSI [12]. Phenotypic screening for ESBL production was of admission in the NICU, length of stay in the NICU, performed by the double-disk synergy test (DDST) and for birth weight, sex, vaginal or caesarean delivery, gesta- carbapenemase production by the meropenem-boronate tional age, age (days after birth) at first isolation of combined disk test, as described previously [3,13]. ESBL-Kp, surgical procedures, intubation, use of central venous catheters, placement of chest tubes, parenteral Bacterial isolates and surveillance cultures nutrition, antimicrobial therapy and use of intralipids. Overall, a total of 64 non-carbapenemase-producing ESBL- Kp collected from March to December 2012 in UHL Results and discussion were analyzed; 26 of them were consecutively recovered Outbreak description and infection control interventions th from various clinical specimens in the NICU, whereas The onset of the outbreak was recognised on the 5 the remaining isolates (n = 38) were randomly collected March 2012 when two ESBL-Kp isolates were recovered from different wards of the hospital during the same from the blood and urine samples of two twin neonates period,soastofurther investigatethe extent andthe born at the maternity unit of the UHL. These isolates were th th epidemiology of the outbreak. recovered on the 13 and 18 day after admission of the During September to December 2012, repeated surveys twins in the NICU, suggesting acquisition of these isolates th of rectal and pharyngeal swabs were obtained from neo- in the NICU. Another case was detected on the 30 nates on a weekly basis. Screening of nursing staff and March and two more cases at the beginning of April. Mavroidi et al. BMC Pediatrics 2014, 14:105 Page 3 of 8 http://www.biomedcentral.com/1471-2431/14/105 On the 15th April, a special team (one microbiologist (n = 16) or CTX-M-3 (n = 3) producers and one isolate and two nurses) was formed to coordinate the manage- coproduced SHV-5 and CTX-M-15. All neonatal ESBL- ment of the outbreak, providing specific recommendations, Kp were also positive for the presence of fimH, ugeE, such as cohorting of infants, limited rotation of the staff, wabG and ureA, but negative for the magA, allS and encouraging effective hand hygiene, safe disposal of diapers rmpA virulence genes. into specific bags, daily cleaning of the surfaces and soiled articles with soap and water, followed by disinfection with Antimicrobial susceptibility testing and molecular typing a dilute solution of chlorine containing bleach and chlor- The 64 ESBL-Kp were assigned to 15 different BOX-PCR hexidine (Acrylan, Kosmidis Company, Athens, Greece). profiles. Among 32 representative isolates of the major No new cases were detected between May and June, and BOX-PCR profiles and all the isolates with unique profiles, despite the control measures, three new cases were de- we have identified 13 MLST STs; five of them were novel tected from July to August 2012. During this period, we STs. The antimicrobial susceptibility patterns of the iso- noted that the ratio of nurse/patients was 1:7 at the time of lates and the STs of the four major BOX-PCR profiles the outbreak because of understaffing because of summer identified among the 64 ESBL-Kp are shown in Table 1. leaves (usual ratio, 1:4). Thus, from March to August 2012, All neonatal ESBL-Kp displayed multidrug-resistance a total of 8 ESBL-Kp were detected in an equal number phenotypes, including resistance to penicillins, ceftazidime, of neonates. and aztreonam, tobramycin and gentamycin (Table 1). st On the 1 September 2012, a surveillance protocol was ST20 (BOX-PCR pattern P1) was identified among 16 implemented for all neonates affected by ESBL-Kp in a ESBL-Kp recovered from 13 infected and three colonized weekly basis. From September to December 2012, five neonates. ST20 has been previously identified among new- more infected neonates were identified, whereas 13 ESBL- borns affected by ESBL-Kp, which produced CTXM-15 in Kp were recovered from 12 colonized infants. Four ESBL- Spain [20]. A novel ST (ST1114) was identified in nine neo- Kp were recovered from blood cultures within the first nates colonized by ESBL-Kp (n = 10) of the BOX-PCR pat- three weeks of November, and therefore infection control ternsP2(n=8),P3(n=1) andP4(n=1) (Figure1). The38 measures were intensified. On the 1st December, three co- ESBL-Kp recovered from the other wards of UHL were dis- horts of infants were established: the first group included tributed into two major clusters, P5 (n = 12) and P6 (n = all infants infected or colonized with ESBL-Kp which were 16) profiles (Table 1, Figure 1), which were assigned to cared for by designated nurses and placed on contact pre- ST258 and ST101, respectively. ST258 has been identified cautions until hospital discharge in a separate nursery, the mostly among carbapenemase-producing K. pneumoniae second group included infants with exposure to case- worldwide (including Greece), whereas ST101 has been infants, but with negative surveillance cultures, which previously reported among carbapenemase-producing K. were cared for by another group of designated nurses, pneumoniae in Italy and Korea [3,21-23]. andathirdgroup of newlyadmittedinfants were cared Neonatal ESBL-Kp of ST20 and ST1114 were not gen- for in a separate room by another group of designated etically related, each comprising a separate lineage on nurses. Furthermore, the antibiotic policy in the NICU has the neighbor-joining tree (Figure 1). Furthermore, ST20 changed; restriction of third-generation cephalosporins and ST1114 were not found among non-carbapenemase- was enforced and imipenem was used for infants with sus- producing ESBL-Kp recovered from other wards of the pected sepsis. Multidisciplinary meetings were held twice hospital. Although SHV-5 producers were distributed into weekly to discuss the ongoing investigation and compli- six different MLST STs, there was no genetic relatedness ance with the infection control measures. From September among the neonatal and the other strains (Figure 1). to December 2012, a total of 18 ESBL-Kp were detected Therefore, transmission of SHV-5 producers from the in 5 infected and 12 colonized neonates. NICU to other wards, or vice versa, was not documented. ESBL- Kp have not been isolated from the hands of The differences in the antibiotic resistance profiles of the nursing staff and environmental samples. No other the neonatal ESBL-Kp with those recovered from other cases were detected until now and we assumed that the wards of the hospital (Table 1) and the presence of two outbreak was successfully controlled. distinct bacterial clones among ESBL-Kp in the NICU, the ST20 and ST1114 clones (corresponding to BOX-PCR Characterization of beta-lactamase and virulence profiles P1 and P2, respectively), which were not genetic- gene content ally related to each other or other ESBL-Kp isolated from All 26 neonatal ESBL-Kp were positive only for both the other wards of the hospital (Table 1, Figure 1), indicate SHV-5 and TEM-1 beta-lactamases, as shown by PCR that ESBL-Kp should have been imported in two different and IEF. Among the 38 ESBL-Kp collected from other occasions and disseminated only in the NICU. wards of the hospital, 18 isolates were SHV-12 (n = 12) As all of the infected neonates and only three colonized or SHV-5 (n = 6) producers, 19 isolates were CTX-M-15 neonates were affected by ST20 ESBL-Kp, we considered Mavroidi et al. BMC Pediatrics 2014, 14:105 Page 4 of 8 http://www.biomedcentral.com/1471-2431/14/105 Table 1 Antimicrobial susceptibility patterns of the four major BOX-PCR profiles of ESBL-Kp in a NICU, Larissa, Greece BOX-PCR MLSTST MIC range (mg/L) profile AMP AMP/SUL CTX CAZ ATM IMP MER ERT CIP TOB GM TSX NICU (n = 26) P1 (16) ST20 ≥32 ≤2− 16 ≤1− ≥64 8- ≥64 8- ≥64 ≤1 ≤0.25 ≤0.5 ≤0.25 ≥16 ≥16 ≤20 P2 (8) ST1114 ≥32 ≤2 ≤2− ≥64 16- ≥64 4- ≥64 ≤1 ≤0.25 ≤0.5 ≤0.25 ≥16 ≥16 ≤20 Non-NICU (n = 38) P5 (12) ST258 ≥32 8- ≥32 16 ≥64 ≥64 ≤1 ≤0.25 ≤0.5 ≥4 ≤1-16 ≥16 ≤20- ≥320 P6 (16) ST101 ≥32 ≥32 ≥64 16- ≥64 32- ≥64 ≤1 ≤0.25 ≤0.5 ≥48- ≥16 ≤1-8 ≤20- ≥320 In parenthesis, the number of isolates identified in each of the four major BOX-PCR profiles is shown. AMP: ampicillin, AMP/SUL: ampicillin/sulbactam, ATM: aztreonam, CAZ: ceftazidime, CIP: ciprofloxacin, CTX: cefotaxime, ERT: ertapenem, GM: gentamycin, IMP: imipenem, MER: meropenem, TOB: tobramycin, TSX: trimethoprim/sulfamethoxazol. that this clone was the main cause of the outbreak in environment. It could be hypothesized that some of the theNICU. Thetime-course of theoutbreak ofST20 mothers of the neonates were carriers of ESBL-Kp and ESBL-Kp is shown in Figure 2. ESBL-Kp of ST1114 were that they were the source of the neonatal infections or col- identified in the NICU from September to December onizations. However, screening for colonization of the 2012, when surveillance cultures were obtained from the mothers of the neonates was not performed in this study. neonates. However, we cannot exclude the possibility that the ST1114 ESBL-Kp were circulating in the NICU among Clinical characteristics of the outbreak colonized infants before the surveillance period. Neverthe- A retrospective review of clinical data of the neonates af- less, we were not able to identify the source of the import- fected ESBL-Kp was performed (Table 2). Of the 16 (13 ation of ESBL-Kp in the NICU, as no ESBL-Kp were infected and three colonized) neonates affected by the out- isolated either from the hands of the nursing staff or the break strain of ST20 ESBL-Kp, 11 neonates were born in Figure 1 Neighbor-joining tree of the STs of the 32 representative ESBL-Kp. For each isolate, the MLST ST, the BOX-PCR profile and the beta-lactamase content are indicated. Mavroidi et al. BMC Pediatrics 2014, 14:105 Page 5 of 8 http://www.biomedcentral.com/1471-2431/14/105 Figure 2 Time-course of the outbreak of ST20 ESBL-Kp. The sex (F: female, M: male) and the infection (I) or colonization (C) status of each infant is indicated. Case 4, indicated with a different colour scheme, has died. The time of first isolation of ST20 SHV-5 producers for each infant is indicated with an asterisk. the maternity unit of UHL, whereas the remaining neo- the virulence gene content among ESBL-Kp belonging to nates were admitted to UHL from the general hospital of ST20 and ST1114 were observed, but several other viru- Larissa or different private maternity clinics of the prefec- lence characteristics (e.g. the mucoid phenotype, aerobac- ture of Thessaly. One infected neonate has died. Fourteen tin production, capsular serotype) are associated with the of the 16 neonates were delivered by caesarean section type of infection in K. pneumoniae, as reported previously and they showed low gestational age (≤32 weeks) and low [28]. As shown in Table 2, no differences in the clinical birth weight (≤1500 g). All neonates had received paren- characteristics of the neonates affected by ST20 and teral nutrition. Several risk factors, such as intubation ST1114 ESBL-Kp were observed. (n = 13), placement of central venous catheters (n = 11) In our study, surveillance cultures were obtained during and chest tubes (n = 4) were also documented. Low gesta- the outbreak period (from September- December 2012). tional age, low birth weight and use of invasive devices The percentage of new carriers out of the total amount have been reported previously among the risk factors for that were screened during the out break period (12 colo- acquiring ESBL-producing Enterobacteriaceae in NICUs nized infants out of 62 infants screened from September [6,24-27]. to December 2012) was 19.35%. Surveillance has stopped As mentioned previously, of the 25 neonates affected by by the end of December of 2012, as no new infections by ESBL-Kp and 16 neonates affected by ST20 ESBL-Kp, 13 ESBL-Kp were detected after the end of December 2012 (52% and 81.2%, respectively) developed an infection, and onwards, only a small percentage of ST20 ESBL-Kp whereas ST1114 was identified only among colonized pa- were detected in colonized infants (3 out of 16 ST20 tients (Table 2). Thus, ST20 ESBL-Kp showed high infec- ESBL-Kp) during the outbreak period, and no infections tiousness compared with ST1114 ESBL-Kp. Furthermore, were caused by ST1114 ESBL-Kp. The best time to screen four out of 16 (25%) ST20 ESBL-Kp were recovered from neonates is arguable and high compliance with the surveil- bloodstream infections. These observations could be at- lance protocol is essential for success. Nevertheless, it has tributed to differences either in the virulence potential of been shown recently that continuous long-term surveil- the STs or in the clinical characteristics of the infants af- lance and neonatal cohorting are associated with a marked fected by ST20 and ST1114 ESBL-Kp. No differences in decrease in the spread of ESBL-KP within the NICU [27]. Mavroidi et al. BMC Pediatrics 2014, 14:105 Page 6 of 8 http://www.biomedcentral.com/1471-2431/14/105 Table 2 Clinical characteristics of the neonates affected by ESBL-Kp in a NICU, Larissa, Greece a b c Cases Birth date Admission Gestational Age at first Length of Weight at Gender Inborn/Outborn Source Infected/ Delivery Risk Outcome date age at birth isolation of stay (days) birth (g) colonized factors (weeks) ESBL-Kp (days) Neonates affected by ST20 ESBL-Kp 1 February 23 February 23 27 10 120 1000 M Inborn ET Infected CS PN, IT,CVC Discharged 2 February 23 February 23 27 10 85 1070 F Inborn Urine Infected CS PN, IT,CVC Discharged 3 March 17 March 17 31 13 21 1220 F Inborn Urine Infected CS PN Discharged 4 March 28 March 28 26 34 145 790 F Outborn ET Infected CS PN, IT, CVC Died 5 April 19 April 20 38 4 35 3380 M Outborn ET Infected CS PN, IT, CVC, CT Discharged 6 July 8 July 8 32 11 34 1360 F Outborn Eye Infected CS PN, IT, Discharged 7 August 6 August 6 28 3 70 1255 F Inborn Catheter Infected CS PN, IT, CVC, CT Discharged 8 August 6 August 6 28 11 55 1000 F Inborn ET Infected CS PN, IT, ET, CVC Discharged 9 August 31 August 31 28 22 154 800 M Inborn FC Colonized CS PN, IT, CVC Discharged 10 October 13 October 13 28 35 126 960 M Inborn FC Colonized CS PN, IT, CVC, CT Discharged 11 October 15 October 15 31 25 44 1500 M Inborn Blood Infected VD PN, IT, CVC Discharged 12 October 27 October 27 31 6 40 580 M Outborn Blood Infected CS PN, IT, CVC Discharged 13 October 31 October 31 28 20 93 1120 F Outborn Blood Infected CS PN, IT, CVC Discharged 14 November 2 November 2 30 7 40 1350 F Outborn Blood Infected CS PN Discharged 15 November 16 November 16 32 32 49 1365 F Inborn Urine Infected VD PN, IT Discharged 16 December 6 December 09 35 10 21 2270 M Outborn FC Colonized CS PN Discharged Range: 26–38 Range: 3–35 Range: 21–154 Range: 580–3380 Mean: 30 Mean: 15.8 Mean: 70.8 Mean: 1313.8 Neonates affected by ST1114 ESBL-Kp 17 September 5 September 5 28 25 35 850 F Inborn FC Colonized CS PN Discharged 18 September 15 September 15 27 17 80 1000 M Outborn FC Colonized CS PN, IT, CVC Discharged 19 October 5 October 5 30 15 45 750 F Inborn FC Colonized CS PN Discharged 20 October 27 October 27 31 25 56 1000 F Inborn FC Colonized CS PN,CVC Discharged 21 October 31 October 31 28 30 118 1040 F Outborn FC Colonized CS PN, ΙΤ,CVC Discharged 22 November 5 November5 28 12 114 980 F Outborn FC Colonized VD PN, ΙΤ,CVC Discharged 23 November 15 November 15 27 35 90 1070 F Inborn FC Colonized VD PN, ΙΤ,CVC Discharged 24 December 22 December22 34 4 27 1480 F Outborn FC Colonized CS PN Discharged 25 December 28 December 28 31 2 27 1480 F Outborn FC Colonized CS PN Discharged Range: 27–34 Range: 2–35 Range: 27–118 Range: 750–1480 Mean: 29.3 Mean: 18.3 Mean: 65.7 Mean: 1072.2 F: female, M: male. ET: endotracheal tube, FC: Fecal carriage. CS: caesarean section, VD: vaginal delivery. CT: chest tubes, CVC: central venous catheters, IT: intubation, PN: parenteral nutrition. Mavroidi et al. BMC Pediatrics 2014, 14:105 Page 7 of 8 http://www.biomedcentral.com/1471-2431/14/105 Conclusions 6. Rettedal S, Lohr IH, Natas O, Giske CG, Sundsford A, Oymar K: First outbreak of extended-spectrum b-lactamase producing Klebsiella pneumoniae in a In the present study, we described an outbreak occurred Norwegian neonatal intensive care unit associated with contaminated during a nine-months period in 2012 at the NICU of UHL breast mik and reslved by strict cohorting. APMIS 2012, 120:612–621. caused mainly by multidrug-resistant SHV-5 producers of 7. Lee SY, Park YJ, Yu JK, Jung S, Kim Y, Jeong SH, Arakawa Y: Prevalence of acquired fosfomycin resistance among extended-spectrum b-lactamase- ST20 recovered from 13 infected and three colonized neo- producing Escherichia coli and Klebsiella pneumoniae clinical isolates in nates, whereas a novel ST (ST1114) was identified only Korea and IS26-composite transposon surrounding fosA3. J Antimicrob among colonized neonates. A retrospective study of the Chemother 2012, 67:2843–2847. 8. Lee SY, Park YJ, Yu JK, Jung S, Kim Y, Jeong SH, Arakawa Y: International clones clinical data of the neonates affected by ESBL-Kp has re- of Klebsiella pneumoniae and Escherichia coli with extended-spectrum b- vealed that all neonates had received parenteral nutrition lactamases in a Czech Hospital. J Clin Microbiol 2009, 47:3353–3357. and most of them were delivered by caesarean section and 9. Gruteke P, Goessens W, van Gils J, Peerbooms P, Lemmens-den Toom N, van Santen-Verheuvel M: Profiles of resistance associated with integrons, showed low birth weights. To our knowledge, this is the the extended-spectrum b-lactamase SHV-5 gene, and a multidrug efflux first report of SHV-5 producers assigned to ST20. The pump of Klebsiella pneumoniae causing a nosocomial outbreak. J Clin emergence of ST20 and ST1114 SHV-5 producers in the Microbiol 2003, 41:1161–1166. 10. Prodinger WM, Fille M, Bauernfeind A, Stemplinger I, Amann S, Pfausler B, NICU, along with the presence of various previously re- Lass-Florl C, Dierich MP: Molecular epidemiology of Klebsiella pneumoniae ported STs (e.g. ST101, ST258) and six novel STs among producing SHV-5 beta-lactamase: parallel outbreaks due to multiple plas- SHV-5/12 or CTXM-3/15 producers in other wards of mid transfer. J Clin Microbiol 1996, 34:564–568. 11. Shannon KP, King A, Phillips I, Nicolas MH, Philippon A: Importation of UHL indicate the ongoing evolution of ESBL-producing organisms producing broad-spectrum SHV-group b-lactamases into the K. pneumoniae in our area. United Kingdom. J Antimicrob Chemother 1990, 25:343–351. 12. Clinical and Laboratory Standards Institute: Performance Standards for Abbreviations Antimicrobial Susceptibility Testing: Twenty-first Informational Supplement DDST: Double-disk synergy test; ESBL: Extended-spectrum beta-lactamase; M100-S21. 2011, Wayne, PA, USA. ESBL-Kp: Extended-spectrum beta-lactamase-producing Klebsiella pneumo- 13. Miriagou V, Cornaglia G, Edelstein M, Galani I, Giske CG, Gniadkowski M, niae; ICU: Intensive care unit; MLST: Multilocus sequence typing; Malamou-Lada E, Martinez-Martinez L, Navarro F, Nordmann P, Peixe L, NICU: Neonatal intensive care unit; UHL: University hospital of Larissa. Pournaras S, Rossolini GM, Tsakris A, Vatopoulos A, Cantón R: Acquired carbapenemases in Gram-negative bacterial pathogens: detection and Competing interests surveillance issues. Clin Microbiol Infect 2010, 16:112–122. The authors declare that they have no competing interests. 14. Papagiannitsis CC, Tryfinopoulou K, Giakkoupi P, Pappa O, Polemis M, Tzelepi E, Tzouvelekis LS, Carbapenemase Study Group, Vatopoulos AC: Authors’ contributions Diversity of acquired β-lactamases amongst Klebsiella pneumoniae in EP, AM, and VM conceived and designed the study. AM wrote the first draft Greek hospitals. Int J Antimicrob Agents 2012, 39:178–180. of the paper and other co-authors contributed to the final draft. AL and AM 15. Pałucha A, Mikiewicz B, Hryniewicz W, Gniadkowski M: Concurrent performed the experiments. AG, MG and KG were responsible for managing outbreaks of extended-spectrum beta-lactamase-producing organisms the clinical data. EP, AG, AM and VM conducted the interpretation of data. of the family Enterobacteriaceae in a Warsaw hospital. J Antimicrob All authors read and approved the final manuscript. Chemother 1999, 44:489–499. 16. Brisse S, Fevre C, Passet V, Issenhuth-Jeanjean S, Tournebize R, Diancourt L, Acknowledgements Grimont P: Virulent clones of Klebsiella pneumoniae: identification and We thank the team of curators of the Institut Pasteur MLST system (Paris, evolutionary scenario based on genomic and phenotypic France) for importing novel alleles, profiles and/or isolates at http://www. characterization. PLoS ONE 2009, 4:e4982. pasteur.fr/mlst. 17. Yang A, Yen C: PCR Optimization of BOX-A1R PCR for microbial source track- ing of Escherichia coli in waterways. J Exp Microbiol Immunol 2012, 16:85–89. Author details 18. Diancourt L, Passet V, Verhoef J, Grimont PAD, Brisse S: Multilocus Department of Microbiology, University Hospital of Larissa, Larissa, Greece. sequence typing of Klebsiella pneumoniae nosocomial isolates. J Clin Neonatal Intensive Unit, University Hospital of Larissa, Larissa, Greece. Microbiol 2005, 43:4178–4182. Laboratory of Bacteriology, Hellenic Pasteur Institute, Athens, Greece. 19. Tamura K, Dudley J, Nei M, Kumar S: MEGA4: Molecular Evolutionary Genetics Department of Microbiology, Medical School, University of Thessaly, Biopolis, Analysis (MEGA) software version 4.0. MolBiolEvol 2007, 24:1596–1599. Larissa, Greece. 20. Oteo J, Cuevas O, Lopez-Rodriguez I, Banderas- Florido A, Vindel A, Perez- Vazquez M: Emergence of CTX-M-15-producing Klebsiella pneumoniae of Received: 17 March 2014 Accepted: 8 April 2014 multilocus sequence types 1, 11, 14, 17, 20, 35 and 36 as pathogens and Published: 17 April 2014 colonizers in newborns and adults. J Antimicrob Chemother 2009, 64:524–528. 21. Ruiz-Garbajosa P, Curiao T, Tato M, Gijón D, Pintado V, Valverde A, Baquero F, References Morosini MI, Coque TM, Cantón R: Multiclonal dispersal of KPC genes following 1. Gastmeier P, Loui A, Stamm-Balderjahn S, Hansen S, Zuschneid I, Sohr D, the emergence of non-ST258 KPC-producing Klebsiella pneumoniae clones in Behnke M, Obladen M, Vonberg RP, Rüden H: Outbreaks in neonatal intensive Madrid, Spain. JAntimicrobChemother 2013, 68:2487–2492. care units-they are not like others. Am J Infect Control 2007, 35:172–176. 22. Kitchel B, Rasheed JK, Patel JB, Srinivasan A, Navon-Venezia S, Carmeli Y, 2. Coque TM, Baquero F, Canton R: Increasing prevalence of ESBL-producing Brolund A, Giske CG: Molecular epidemiology of KPC-producing Klebsiella Enterobacteriaceae in Europe. Euro Surveill 2008, 47:19044. pneumoniae isolates in the United States: clonal expansion of multilocus 3. Rupp ME, Fey PD: Extended spectrum b-lactamase (ESBL)-producing sequence type 258. Antimicrob Agents Chemother 2009, 53:3365–3370. Enterobacteriaceae: considerations for diagnosis, prevention and drug 23. Mammina C, Bonura C, Aleo A, Fasciana T, Brunelli T, Pesavento G, Degl’ treatment. Drugs 2003, 63:353–365. Innocenti R, Nastasi A: Sequence type 101 (ST101) as the predominant 4. Woodford N, Turton JF, Livermore DM: Multiresistant Gram-negative carbapenem non-susceptible Klebsiella pneumoniae clone in an acute bacteria: the role of high-risk clones in the dissemination of antibiotic general hospital in Italy. Int J Antimicrob Agents 2012, 9:539–547. resistance. FEMS Microbiol Rev 2011, 35:736–755. 24. Gupta A, Della-Latta P, Todd B, San Gabriel P, Haas J, Wu F, Rubenstein D, 5. Peirano G, Hun King Sang J, Pitondo–Silva A, Laupland KB, Pitout JD: Saiman L: Outbreak of extended-spectrum beta-lactamase-producing Molecular epidemiology of extended-spectrum-b-lactamase-producing Klebsiella pneumoniae in a neonatal intensive care unit linked to artificial Klebsiella pneumoniae over a 10 year period in Calgary, Canada. nails. Infect Control Hosp Epidemiol 2004, 25:210–215. J Antimicrob Chemother 2012, 67:1114–1120. Mavroidi et al. BMC Pediatrics 2014, 14:105 Page 8 of 8 http://www.biomedcentral.com/1471-2431/14/105 25. Cantey JB, Sreeramoju P, Jaleel M, Treviño S, Gander R, Hynan LS, Hill J, Brown C, Chung W, Siegel JD, Sànchez PJ: Prompt control of an outbreak caused by extended-spectrum-β-lactamase-producing Klebsiella pneumoniae in an intensive care unit. J Pediatr 2013, 163:672–679. 26. Giuffrè M 1, Cipolla D, Bonura C, Geraci DM, Aleo A, Di Noto S, Nociforo F, Corsello G, Mammina C: Outbreak of colonizations by extended-spectrum β-lactamase-producing Escherichia coli sequence type ST131 in a neonatal intensive care unit, Italy. Antimicrob Resist Infect Control 2013, 2:8–15. 27. Benenson S, Levin PD, Block C, Adler A, Ergaz Z, Peleg O, Minster N, Gross I, Schaffer K, Moses AE, Cohen MJ: Continuous surveillance to reduce extended-spectrum β-lactamase Klebsiella pneumoniae colonization in the neonatal intensive care unit. Neonatology 2013, 103:155–160. 28. Yu VL, Hansen DS, Ko WC, Sagnimeni A, Klugman KP, von Gottberg A, Goossens H, Wagener MM, Benedi VJ, and the International Klebsiella Study group: Virulence characteristics of Klebsiella and clinical manifestations of Klebsiella pneumoniae bloodstream infections. Emerg Infect Dis 2007, 13:986–993. doi:10.1186/1471-2431-14-105 Cite this article as: Mavroidi et al.: Successful control of a neonatal outbreak caused mainly by ST20 multidrug-resistant SHV-5-producing Klebsiella pneumoniae, Greece. BMC Pediatrics 2014 14:105. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit

Journal

BMC PediatricsSpringer Journals

Published: Apr 17, 2014

There are no references for this article.