First Reported Nosocomial Outbreak Of NDM-5-Producing Klebsiella pneumoniae In A Neonatal Unit In China

Figures & data

Table 1 Primers Used For Amplification Of The Resistance Genes Of K. pneumoniae In This Study

Resistance Gene	Primer	Size Of PCR Product (bp)	References
blaKPC	F: ATG TCA CTG TAT CGC CGT C	882	^Citation15
	R: TTA CTG CCC GTT GAC GCC
blaNDM	F: GAAGCTGAGCACCGCATTAG	982	^Citation16
	R: GGGCCGTATGAGTGATTGC
blaVIM	F: GCMCTTCTCGCGGAGATTGA	257	^Citation17
	R: TGCGCAGCACCRGGATAGA
blaOXA-48	F: TTGGTGGCATCGATTATCGG	743	^Citation18
	R: GAGCACTTCTTTTGTGATGGC
blaIMP	F: CTACCGCAGCAGAGTCTTTG	587	^Citation19
	R: AACCAGTTTTGCCTTACCAT
blaCTX-M1group	F: CAGCGCTTTTGCCGTCTAAGC	945	^Citation20
	F: GGCCCATGGTTAAAAAATCACTGC
blaCTX-M2 group	F: CTC AGA GCA TTC GCC GCT CA	848	^Citation20
	R: CCG CCG CAG CCA GAA TAT CC
blaCTX-M8group	F: ACTTCAGCCACACGGATTCA	1024	^Citation20
	R: CGA GTA CGT CAC GAC GAC TT
blaCTX-M9group	F: GTTACAGCCCTTCGGCGATGATTC	881	^Citation20
	R: GCGCATGGTGACAAAGAGAGTGCAA
blaSHV	F: CGCCGGGTTATTCTTATTTGTCGC	1017	^Citation20
	R: TCT TTCCGATGCCGCCGCCAGTCA
blaTEM	F: ATA AAATTCTTGAAGACGAAA	1080	^Citation20
	R: GACAGTTACCAATGCTTAATCA
blaCIT	F: TGGCCAGAACTGACAGGCAA	462	^Citation21
	R: TTTCTCCTGAACGTGGCTGG
blaMOX	F: GCTGCTCAAGGAGCACAGGAT	520	^Citation21
	R: CACATTGACATAGGTGTGGTGC
blaDHA	F: AACTTTCACAGGTGTGCTGGGT	405	^Citation21
	R: CCGTACGCATACTGGCTTTGC
blaEBC	F: TCGGTAAAGCCGATGTTGCGG	302	^Citation21
	R: CTTCCACTGCGGCTGCCAGTT
blaFOX	F: AACATGGGGTATCAGGGAGATG	190	^Citation21
	R: CAAAGCGCGTAACCGGATTGG

Table 2 Clinical Features Of The Neonates In This Study

Case	Sex	Pregnancy Duration (wk)	Birth wt (g)	Dates Of Hospital Stay	Date Isolate Identified	Specimen	Type(s) Of Infections	Antimicrobial Therapy	Clinical Outcome
1	M	35	3000	1 Sep–17 Sep 2015	10 Sep 2015	Sputum	NP, NRDS	MOX	Improvement
2	M	36	1600	2 Sep–28 Sep 2015	11 Sep 2015	Sputum	NRDS	MOX+CAZ	Improvement
3	M	40	3400	18 Dec 2015–13 Jan 2016	23 Dec 2015	Sputum	NP	CAZ	Improvement
4	F	42	3100	22 Dec 2015–6 Jan 2016	24 Dec 2015	Sputum	NP	CTX	Improvement
5	M	39	3500	30 Dec 2015–8 Jan 2016	31 Dec 2015	Sputum	NP	MOX+AMS	Improvement
6	F	40	3300	29 Dec 2015–7 Jan 2016	1 Jan 2016	Urine	NP	MOX+AMS	Improvement
7	F	40	3300	18 Jan −7 Feb 2016	26 Jan 2016	Sputum	NP	MOX+AMS	Improvement
8	M	39	3450	7 Feb −14 Mar 2016	8 Mar 2016	Blood	NP, NS	MOX +AMC	Improvement
9	F	38	3300	20 Jul–2 Aug 2016	29 Jul 2016	Sputum	NP, NRDS	CAZ	Improvement
10	M	34	1500	22 Aug–2 Oct 2016	27 Aug 2016	Sputum	NP, NRDS	CAZ+TZP	Improvement
11	M	35	2590	3 Sep–14 Sep 2016	4 Sep 2016	Sputum	NP	CAZ	Improvement
12	F	40	3000	10 Sep–20 Sep 2016	18 Sep 2016	Blood	NP, NS	MOX +AMC	Improvement

Abbreviations: M, male; F, female; NP, neonatal pneumonia; NRDS, neonatal respiratory distress syndrome; NS, neonatal sepsis; MOX, moxalactam; CAZ, ceftazidime; CTX, cefotaxime; AMS, amoxicillin-sulbactam; AMC, amoxicillin-clavulanate; TZP, piperacillin-tazobactam.

Table 3 Antibiotic Resistance Characteristics Of The 12 NDM-5-Positive K. pneumoniae Isolates And Their Corresponding Transconjugants

Isolate No.	Antimicrobial Resistance Genes			Minimum Inhibitory Concentration (μg/mL)
		MEM	IPM	ATM	CTX	CAZ	FEP	AM	CPFX	LE	AMC	TZP	SCF	SMZ-TMP	TG	PB
KP1	blaNDM-5, SHV-11, TEM-1	8	≥16	≥64	≥64	≥64	≥32	≤2	0.5	1	≥32	≥128	≥64	≤20	2	≤0.5
KP2	blaNDM-5, SHV-11, TEM-1	≥16	≥16	16	≥64	≥64	≥32	≤2	≤0.25	≤0.12	≥32	≥128	≥64	≤20	≤0.5	≤0.5
KP3	blaNDM-5, SHV-11, TEM-1	≥16	≥16	≥64	≥64	≥64	≥32	≤2	1	1	≥32	≥128	≥64	≤20	2	≤0.5
KP4	blaNDM-5, SHV-11, TEM-1	≥16	≥16	≥64	≥64	≥64	≥32	≤2	0.5	1	≥32	≥128	≥64	≤20	2	≤0.5
KP5	blaNDM-5, SHV-11, TEM-1	≥16	≥16	≥64	≥64	≥64	≥32	≤2	≤0.25	≤0.12	≥32	≥128	≥64	≤20	2	≤0.5
KP6	blaNDM-5, SHV-11, TEM-1	≥16	≥16	≥64	≥64	≥64	≥32	≤2	0.5	1	≥32	≥128	≥64	≤20	2	≤0.5
KP7	blaNDM-5, SHV-11, TEM-1	≥16	≥16	≥64	≥64	≥64	≥32	≤2	0.5	1	≥32	≥128	≥64	≤20	2	≤0.5
KP8	blaNDM-5, SHV-11, TEM-1	≥16	≥16	≥64	≥64	≥64	≥32	≤2	1	1	≥32	≥128	≥64	≤20	2	≤0.5
KP9	blaNDM-5, SHV-11, TEM-1	≥16	≥16	≥64	≥64	≥64	≥32	≤2	0.5	1	≥32	≥128	≥64	≤20	2	≤0.5
KP10	blaNDM-5, SHV-11, TEM-1	8	≥16	≥64	≥64	≥64	≥32	≤2	≤0.25	≤0.25	≥32	≥128	≥64	≤20	2	≤0.5
KP11	blaNDM-5, SHV-11, TEM-1	≥16	≥16	≥64	≥64	≥64	≥32	≤2	0.5	1	≥32	≥128	≥64	≤20	2	≤0.5
KP12	blaNDM-5, SHV-11, TEM-1	≥16	≥16	≥64	≥64	≥64	≥32	≤2	0.5	1	≥32	≥128	≥64	≤20	2	≤0.5
EC600-1	blaNDM-5	8	≥16	≤1	≥64	≥64	4	≤2	≤0.25	≤0.12	≥32	≥128	≥64	≤20	≤0.5	≤0.5
EC600-2	blaNDM-5	8	8	≤1	≥64	≥64	4	≤2	0.5	≤0.12	≥32	≥128	≥64	≤20	≤0.5	≤0.5
EC600-3	blaNDM-5	8	≥16	≤1	≥64	≥64	4	≤2	≤0.25	≤0.12	≥32	≥128	≥64	≤20	≤0.5	≤0.5
EC600-4	blaNDM-5	≥16	≥16	≤1	≥64	≥64	8	≤2	0.5	≤0.12	≥32	≥128	≥64	≤20	≤0.5	≤0.5
EC600-5	blaNDM-5	8	≥16	≤1	≥64	≥64	8	≤2	0.5	≤0.12	≥32	≥128	≥64	≤20	≤0.5	≤0.5
EC600-6	blaNDM-5	≥16	≥16	≤1	≥64	≥64	8	≤2	0.5	≤0.12	≥32	≥128	≥64	≤20	≤0.5	≤0.5
EC600-7	blaNDM-5	4	≥16	≤1	≥64	≥64	8	≤2	0.5	≤0.12	≥32	≥128	≥64	≤20	≤0.5	≤0.5
EC600-8	blaNDM-5	≥16	≥16	≤1	≥64	≥64	4	≤2	≤0.25	≤0.12	≥32	≥128	≥64	≤20	≤0.5	≤0.5
EC600-9	blaNDM-5	4	≥16	≤1	≥64	≥64	4	≤2	0.5	≤0.12	≥32	≥128	≥64	≤20	≤0.5	≤0.5
EC600-10	blaNDM-5	8	≥16	≤1	≥64	≥64	4	≤2	≤0.25	≤0.12	≥32	≥128	≥64	≤20	≤0.5	≤0.5
EC600-11	blaNDM-5	4	≥16	≤1	≥64	≥64	8	≤2	0.5	≤0.12	≥32	≥128	≥64	≤20	≤0.5	≤0.5
EC600-12	blaNDM-5	8	≥16	≤1	≥64	≥64	4	≤2	≤0.25	≤0.12	≥32	≥128	≥64	≤20	≤0.5	≤0.5
EC600		≤1	≤1	≤1	≤1	≤1	≤1	≤2	≤0.25	≤0.12	2	2	2	≤20	≤0.5	≤0.5

Abbreviations: MEM, meropenem; IPM, imipenem; ATM, aztreonam; CAZ, ceftazidime; CTX, cefotaxime; FEP, cefepime; AM, amikacin; CPFX, ciprofloxacin; LE, levofloxacin; AMC, amoxicillin-clavulanate; TZP, piperacillin/tazobactam; SCF, sulbactam/cefoperazone; SMZ-TMP, compound Sulfamethoxazole; TG, tigecycline; PB, polymixin B.

Figure 1 Dendrogram of PFGE profiles of 12 bla_NDM-5-positive Klebsiella pneumoniae isolates.

Figure 2 bla_NDM-5-carrying plasmid analysis (Top: S1-nuclease PFGE patterns; Bottom: Southern hybridization of the bla_NDM-5 probe, which was hybridized to the roughly 45 kb plasmid to confirm the presence of the resistant plasmid in the 12 ST337 carbapenem-resistant K. pneumoniae strains). Lane M: marker (Salmonella H9812); KP1 to KP12: Klebsiella pneumoniae outbreak strains.

Endimiani A, Carias LL, Hujer AM, et al. Presence of plasmid-mediated quinolone resistance in Klebsiella pneumoniae isolates possessing blaKPC in the United States. Antimicrob Agents Chemother. 2008;52(7):2680–2682. doi:10.1128/AAC.00158-0818426899

 PubMed Web of Science ®Google Scholar

Yang J, Chen Y, Jia X, et al. Dissemination and characterization of NDM-1-producing Acinetobacter pittii in an intensive care unit in China. Clin Microbiol Infect. 2012;18(12):E506–E513. doi:10.1111/1469-0691.1203523036089

 PubMed Web of Science ®Google Scholar

Tsakris A, Pournaras S, Woodford N, et al. Outbreak of infections caused by Pseudomonas aeruginosa producing VIM-1 carbapenemase in Greece. J Clin Microbiol. 2000;38(3):1290–1292.10699045

 PubMed Web of Science ®Google Scholar

Poirel L, Héritier C, Tolün V, Nordmann P. Emergence of oxacillinase-mediated resistance to imipenem in Klebsiella pneumoniae. Antimicrob Agents Chemother. 2004;48(1):15–22. doi:10.1128/aac.48.1.15-22.200414693513

 PubMed Web of Science ®Google Scholar

Senda K, Arakawa Y, Ichiyama S, et al. PCR detection of metallo-beta-lactamase gene (blaIMP) in gram-negative rods resistant to broad-spectrum beta-lactams. J Clin Microbiol. 1996;34(12):13.

 Web of Science ®Google Scholar

Yu Y, Ji S, Chen Y, et al. Resistance of strains producing extended-spectrum beta-lactamases and genotype distribution in China. J Infect. 2007;54(1):53–57. doi:10.1016/j.jinf.2006.01.01416533535

 PubMed Web of Science ®Google Scholar

Pérez-Pérez FJ, Hanson ND. Detection of plasmid-mediated AmpC beta-lactamase genes in clinical isolates by using multiplex PCR. J Clin Microbiol. 2002;40(6):2153–2162. doi:10.1128/JCM.40.6.2153-2162.200212037080

 PubMed Web of Science ®Google Scholar