Infrequent colonization with multiple and highly ...

Infrequent colonization with multiple and highly resistant bacteria: 2642 carbapenemase-producing Enterobacteriaceae, carbapenemase-producing Pseudomonas aeruginosa, carbapenemase-producing Acinetobacter baumannii and glycopeptide resistant Enterococcus faecium Delphine 1

1 Girlich,

Patrice

1,2,3,4 Nordmann,

Hervé

5 Lécuyer,

Patrick

5 Berche,

Anne

6 Marmorat-Khuong, ,

Investigate the occurrence of colonization and infection with multiple highly resistant bacteria of more than four different genus, in two patients transferred from a foreign country

Methods Screening of ESBL-producing Enterobacteriaceae, carbapenemase producers, and vancomycin-resistant enterococci (VRE) was done using selective culture media, i.e ChromID ESBL (bioMérieux), ChromID Carba Smart (bioMérieux), and VRE medium (bioMérieux), respectively. ESBL production was confirmed using the ESBL NDP test. Carbapenemase production was confirmed using Carba NP test for Enterobacteriaceae and P. aeruginosa, and the CarbAcineto NP test for A. baumannii. PCR amplifications followed by sequencing were performed on whole-cell DNA for molecular characterization of the antibiotic resistance mechanism. Patient A Patient B

K. pneumoniae KPC-2

K. pneumoniae OXA-48

A. baumannii OXA-23

A. baumannii OXA-23

and Laurent

1,2 Dortet

Results

P. aeruginosa VIM-4

Country of initial Patient Species hospitalization A Vietnam A. baumannii P. aeruginosa K. pneumoniae K. pneumoniae     E. faecium B Morocco A. baumannii P. aeruginosa P. rettgeri     K. pneumoniae

P. rettgeri NDM-1

Clinical sample

β-lactamase contenta

PDP PDP Rectal swab Rectal swab Rectal swab PDP Urine and blood culture Urine Rectal swab

OXA-23 IMP-1 KPC-2, CTX-M-15, TEM-1, SHV-1, OXA-1 CTX-M-15, TEM-1, SHV-1, OXA-1 None OXA-23 VIM-4 NDM-1, CTX-M-15, SHV-12, TEM-1, OXA-48, CTX-M-15, OXA-9

PDP, Distal Protected Pulmonary sample, aCarbapenemase are bolded, ESBL are underlined

In June 2014, a 33-years old French man (Patient A) was admitted in a Vietnamese hospital after a suicide attempt. After 10 days of hospitalization in Vietnam, the patient was transferred to a French hospital where distal protected pulmonary samples were withdrawn and grew with two carbapenemase producers, an OXA-23 producing A. baumannii and an IMP-1 producing P. aeruginosa. The OXA-23 p r o d u c i n g A . b auman n i i a l s o p r o d u c e d t h e aminoglycoside methylase ArmA and remained susceptible to colistin only. The IMP-1- producing P. aeruginosa remained susceptible to colistin and amikacin only. Results of rectal screening samples revealed that the patient was also colonized with a KPC-2-producing K. pneumoniae, an ESBL-producing (CTX-M-15) K. pneumoniae and a VanA positive glycopeptide resistant Enterococcus faecium.

Discussion E. faecium VanA

Gaëlle

2 Cuzon,

INSERM U914 « Emerging Resistance to Antibiotic », 2 Associated National Reference Center to Antibiotic Resistance, Le Kremlin-Bicêtre, France, 3 Medical and Molecular Microbiology Unit, University of Fribourg, 4 Hôpital Fribourgeoishôpital Cantonal, Fribourg, Switzerland, 5 Bacteriology-Virology-Hygiene unit, Necker-Enfants Malades Hospital, Assistance Publique / Hôpitaux de Paris, Paris, France, 6 Centre Hospitalier de Saint-Denis, Saint-Denis, France

Objectives

P. aeruginosa IMP-1

Isabelle

6 Gros,

Non-β-lactam resistance determinants ArmA AAC6’-Ib-cr, QnrB AAC6’-Ib-cr, QnrB VanA AAC6’-Ib-cr, QnrB AAC6’-Ib-cr, QnrB

The Patient B was a 66-years old French woman who was admitted in the intensive care unit in Morocco following multiple trauma due to a road accident. After 3 weeks of hospitalization, she was transferred to a French hospital where systematic screening of carbapenemase-producing Enterobacteriaceae using rectal swabs revealed the presence of an OXA-48-producing K. pneumoniae. After 24 hours, this patient developed a pyelonephritis due to a P. aeruginosa producing a VIM-4 carbapenemase and a bronchitis due to an OXA-23-producing A. baumannii. The patient was treated for a total of 14 days with amikacin (7 days), fosfomycin (10 days) and colistin (14 days). Although apyrexia was obtained withing three days, fever reappeared under colistin treatment (after 11 days of treatment). Accordingly, a colistin-resistant Providentia rettgeri isolate (natural resistance) producing an NDM-1 carbapenemase was isolated from three successive urine samples recovered by urinary catheter from this same patient. The urinary catheter was removed and the patient received two doses of amikacin, leading to a apyrexia.

Two cases of multi-colonized and infected patients are reported carrying more than four different highly resistant bacteria, i.e. carbapenemase-producing Enterobacteriaceae, carbapenemase-producing Pseudomonas aeruginosa, carbapenemase- producing Acinetobacter baumannii and glycopeptide-resistant E. faecium. It emphasizes the importance of large screening of transferred patients in the infection control measures.