Carbapenem-resistant Klebsiella pneumoniae outbreak with monoclonal spread: Evaluation of resistance genes and ceftazidime-avibactam susceptibility

Abstract

Purpose: The aim of this study was to investigate ceftazidime-avibactam (CAZ-AVI) susceptibility, carbapenemase genes, and clonal relationship in carbapenem-resistant Klebsiella pneumoniae (CrKp) isolates.

Methods: A total of 28 non-repetitive CrKp isolates with positive carbapenemase production determined by the modified carbapenem inactivation method (mCIM), were included in the study. Identification of the isolates was performed with MALDI-TOF MS (VITEK-MS, bioMerieux, France). The automated system (VITEK-2, bioMerieux) and gradient diffusion test (Etest, bioMerieux) were used to determine antibiotic susceptibility. The mCIM was performed according to CLSI (2021) recommendations. CAZ-AVI susceptibility was carried out using the standard disc diffusion method. Results were evaluated according to EUCAST 2022 criteria. The bla_OXA-48, bla_NDM, bla_KPC, bla_IMP and bla_VIM genes were investigated by multiplex PCR. The clonal relationship between isolates was determined by both AP-PCR and PFGE methods.

Results: Of the total 28 isolates, 89.3% were susceptible to CAZ-AVI. bla_OXA-48 gene was found in 85.7% of the isolates, bla_OXA-48+bla_NDM gene in 10.7%, and bla_NDM gene in 3.6%. bla_KPC, bla_IMP and bla_VIM genes were not detected. Three clusters with three different genotypes were determined by the PFGE method. The largest cluster was Genotype A (n:24), followed by Genotype B (n:3), and Genotype C (n:1). AP-PCR was highly compatible with PFGE. The isolates of Genotype A, mostly from the intensive care unit (ICU), were evaluated as outbreak strains with monoclonal dissemination.

Conclusions: OXA-48 remains the most frequently detected enzyme in CrKp strains in our country. The ceftazidime-avibactam susceptibility rate of 89.3% indicates that this antibiotic is still effective against CrKp isolates. The unnoticed outbreak detected in our study revealed the severity of intra-hospital cross-contamination affecting different wards, including the ICU. Therefore, in order to limit the spread of CrKp isolates, it is of great importance to implement strict infection control measures, and molecular surveillance programs, especially in the ICU.

Keywords: Carbapenem resistant K. pneumoniae; Carbapenemase genes; Ceftazidime-avibactam; Clonal relationship.