Essential sites of biologic lucidity

1. Essential sites of biologic lucidity ID Special Grand Rounds Jeremy Storm, DO and Jack Stapleton, MD 10/13/2011

2. Questions ESBL and K. pneumoniae carbapenemase What is the epidemiology of ESBL and KPC? What risk factors predispose to ESBL and KPC? What are the outcomes associated with ESBL/KPC and/or does ESBL/KPC alter bacterial virulence?

3. The Past Beta-lactamases are enymes that hydrolyze the beta-lactam ring of penicillins and narrow spectrum cephalosporins by covalently binding the carbonyl moiety of the ring and hydrolyzing its amide bond First identified in Greece in 1960�s and named TEM (after patient named Temoniera) TEM-1, TEM-2, SHV-1, OXA-1 Susceptible to beta-lactam / lactamase inhibitor combinations (clavulonate, tazobactacm, sulbactam) higher order cephalosporins, cephamycins (cefoxitin and cefotetan), monobactams (aztreonam), carbapenems (imipenem, ertapenem, meropenem) Serine at binding site Bradford PA. ESBL�s in the 21st Century: characterization, epidemiology, and detection of this important resistance threat. Clin Microbiol Rev. 2001;14(4):933

4. The Past Medeiros AM. Evolution and dissemination of Beta-lactamases by generations of beta-lactam antibiotics. Clin Infect Dis. 1997;24(Supplement 1):19-45

5. The Past Early ESBL�s First ESBL identified in Germany 1983, termed SHV-2, isolated from Klebsiella Quickly spread in Enterobacteriaceae throughout Europe via plasmid transfer Klebsiella, E. coli, Enterobacter, Citrobacter, Morganella, Proteus, Providencia, Salmonella, Shigella, Serratia Resistant to penicillins, higher order cephalosporins (oxyiminocephalosporins - ceftriaxone, cefotaxime, ceftazidime), and monobactams Susceptible to beta-lactamase / inhibitors, cephamycins, and carbepenems Knothe HP (et al). Transferable resistance to cefotaxime, cefoxitin, cefamandole, and cefuroxime in clinical isolates of Klebsiella pneumoniae and Serratia marcescens. Infection. 1983;6:315-317

6. The Past Risk factors for ESBL colonization/infection Environmental reservoirs Endemic regions - India, Africa, Middle East, Asia, US Environmental (animal/food/water) reservoirs Asymptomatic faecal carriage LTACH/Nursing Facilities Global dissemination of robust strains E. coli ST131 carrying CTX-M +/- others Travel to endemic regions Patient Risk Factors Prior antibiotic therapy (cephalosporins) Contact with healthcare Medical comorbidities (advanced age, DM, CKD, dialysis, incontinence, UTI, Apache score), devices (mechanical ventilation, foley, gastrostomy tubes, IV lines) immunosuppression (DM, transplant, cancer/chemotherapy) -Oteo J, et al. Curr Opin Infect Dis. 2010;23:320-326 -Peirano G. Int J Antimicrob Agents. 2010;35:316-321 -Rodriguez-Bano J, et al. Clin Infect Dis. 2010;50:40-48 -Qureshi ZA, et al. Clin Microbiol Infect. 2011;1-7

7. The Past First North American ESBL (TEM-12) identified 1986 in E. coli TEM ESBL�s subsequently identified throughout US in 1988, including Boston (TEM-10), Chicago (TEM-10), Stanford Hospital, New York (TEM-26) 5 main TEM ESBL�s with 4 point mutations at positions 104, 164, 238, 240 Derived from TEM-1 SHV ESBL�s in Western Hemisphere first identified in Chile (1990), New York (1993) 6 major SHV ESBL�s with 7 point mutations, including at positions 238 and 240 Ongoing spread of ESBL�s throughout US and globally 1990-2000�s Today over 160 TEM�s and 100 SHV�s Bush K. ESBL�s in North America, 1987-2006. Clin Micro Infect. 2008;14(1):134-143

9. The Present CTX-M CTX-M ESBL first reported in Japan in 1986 Initially named TOHO-1, later changed to CTX-M �active on cefotaxime, first isolated in Munich� high substrate preference for cefotaxime and ceftriaxone (less ceftazidime) blaCTX-M thought to arise from Kluyvera spp environmental pathogen Carried on mobile genetic elements ISEcp1, ISCR1 of various plasmids (IncF primarily) Resistant to penicillins, most cephalosporins, and aztreonam Susceptible to carbapenems and cephamycins Variable susceptibility to beta-lactamase inhibitors (tazobactam>clavulonate>sulbactam) Peirano G. Molecular epidemiology of E. coli producing CTX-M Beta-lactamases: the worldwide emergence of clone ST131 O25:H4. Int J Antimicrob Agents. 2010;35:316-321

10. The Present Global dissemination of E. coli ST131 carrying CTX-M-15 (2000-present) CTX-M-15 derived from CTX-M-3 (of CTX-M-1 cluster) and result of Asp?Gly substitution at position 240 Currently, the most widespread CTX-M First detected in E. coli in India (2001) ST131 often associated with multiple drug resistance mechanisms or genetic elements, including: Beta-lactamases: TEM-1, OXA-1, CTX-M-15, SHV-12, CMY-2 (ampC plasmid) aac(6�)-Ib-cr (aminoglycoside modifying enzyme) floroquinolone resistance (chromosomal mutations>plasmid) +/- resistance to chloramphenicol, trimethoprim-sulfamethoxazole, tetracyclines

11. The Present CTX-M-15 The predominant ESBL in Enterobacteriaceae in US since 2004 �MYSTIC� trial (10-15 US medical centers between 1999-2008) 80% participating US hospitals reported ESBL�s CTX-M ESBL identified in 38.8% of ESBL + isolates Increasing rates of antibiotic resistance in Enterobacteriaceae (Klebsiella > E. coli) during study period Rhomberg PR, et al. Summary trends for the Meropenem Yearly Susceptibility Test Information Collection Program: a 10-year experience in the United States (1999-2008). Diag Microbiol Inf Dis. 2009;65:414-426

12. The Present

13. The Present

14. The Present

15. The Present CTX-M identified in 87% of ESBL isolates Chicago community hospitals in 2008, with 53% being E. coli ST131 Peirano G. Molecular epidemiology of E. coli producing CTX-M Beta-lactamases: the worldwide emergence of clone ST131 O25:H4. Int J Antimicrob Agents. 2010;35:316-321 Of 3,004 gram negative bacilli collected from intra-abdominal infections in Asia-Pacific region 2007, 42.2% E. coli and 35.8% Klebsiella spp., respectively, were ESBL + - ESBL rates in India: E. coli (79%), Klebsiella pneumoniae (69%), and Klebsiella oxytoca (100%) - ESBL E. coli rates: China (55.0%) and Thailand (50.8%) Hawser SP, et al. Emergence of high levels of ESBL producing gram-negative bacilli in the Asia-Pacific region: data from the SMART program, 2007. Antimicrob Agents Chemother, August, 2009;53(8):3280-3284

16. The Present Pathogenesis � E. coli ST131 An established clone when CTX-M introduced Geographic plasmid and resistance / ESBL variation Multiple virulence factors such as usp, ompT, sat, iutA, and malX specific to the clone ST131, others (fimH, fyuA, traT, etc.) Adhesins, siderophores, hemolysins, toxins, LPS, capsule Yee, et al - Majority of ST131 isolates belonged to phylogenetic subgroup B2, which is known to be a highly virulent Contained all virulence genes of papA, fimH, fyuA, iutA, kpsM II, and traT; only three isolates from other phylogenetic groups contained all these genes Addiction systems contributing to plasmid maintenance in their host might aid clone ST131 A toxin-antitoxin addiction system helps maintain plasmids in bacteria during host replication by removal of plasmid-free cells resulting from segregation or replication defects pemKI, ccdAB, srnBC, others -Shin J, et al. Comparison of CTX-M-14- and CTX-M-15-producing Escherichia coli and Klebsiella pneumoniae isolates from patients with bacteremia. J Infect. July, 2011;63(1):39-47 - Yee MY, et al. Dissemination of ST131 and ST393 community-onset, ciprofloxacin-resistant Escherichia coli clones causing urinary tract infections in Korea. J Infect. Feb, 2010;60(2):146-153

17. The Present Outcomes - ESBL Of patients in Spain with community onset E. coli bacteremia in 2004-2006, 7.3% were ESBL + and 87% harbored CTX-M ESBL E. coli bacteremia associated with increased 14 day mortality vs. controls (~ 17% vs. 8%) Rodriguez-Bano J, et al. Community-onset bacteremia due to ESBL producing E. coli: risk factors and prognosis. Clin Infect Dis, 2010;50:40-48 3 northeastern US hospitals between 2005-2008 Increased 28 day mortality due to ESBL E. coli bacteremia (~27.5% vs. 19.5%) Qureshi ZA, et al. Clinical characteristics of bacteremia caused by ESBL Enterobacteriaceae in the era of CTX-M-type and KPC-type beta-lactamases.Clin Microbiol Infect. epublished August, 2011

18. The Present #ESBL Positive Isolates, UIHC 2003-2010

19. The Present %ESBL Positive Isolates, UIHC 2003-2010

20. ESBL Detection Made Easy!

21. The Present ESBL detection CLSI recommended in 2009 lowering susceptibility MIC breakpoints for Enterobacteriaceae: Due to rising ESBL and KPC rates, difficulty with beta-lactamase detection, etc. Cefazolin and ceftriaxone from 8 (microgram/mL) to 1 Ceftazidime and aztreonam from 8 to 4 Ertapenem from 4 to 0.5 Wang P. Susceptibility of ESBL producing Enterobacteriaceae according to new CLSI breakpoints. J Clin Microbiol. Sept, 2011;49(9):3127-3131 All 382 strains susc to cefazolin, cefotaxime, and ceftriaxone ~90% of ESBL + Proteus spp. (PCR+) reported as susc to ceftazidime, cefepime, and aztreonam ~45% of ESBL E. Coli reported as susc to ceftazidime and cefepime ~20% of ESBL K. pneumoniae reported as susc to cefepime

22. The Present AmpC beta-lactamases (�cephalosporinases�) Inherent in many gram negative species (chromosome) Enterobacter spp., Acinetobacter, Citrobacter spp., Serratia spp., Morganella Resistant to most penicillins, beta-lactam / lactamase inhibitors, cephalosporins, and aztreonam Susceptible to carbapenems and cefepime (poor inducer) Cause inducible beta-lactam resistance Plasmid-mediated AmpC beta-lactamases Similar to chromosomal AmpC (from which they are derived), with the exception that they are uninducible Jacoby GA. AmpC Beta-lactamases. Clin Microbiol Rev. 2009;22(1):161-182

23. The Present Carbapenem resistance Mechanisms: High level production of chromosomal ampC cephalosporinase Coupled with decreased membrane permeability due to porin loss/alteration Production of beta-lactamases or metallo-beta-lactamases capable of hydrolyzing carbapenems IMI-1, OXA, VIM, IMP-1, Nmc-A, Sme-1, CfiA, NDM Alteration of target proteins (PBP) for carbapenems Increased drug efflux KPC (K. pneumoniae carbapenemase)

24. The Present Metallo-beta-lactamases 2nd class of beta-lactamases, first identified in 1960�s IMP, VIM, SIM, AIM, KHM, DIM, NDM Inactivated by metal chelators / EDTA (distinguishes from serine beta-lactamases) Found in Enterobacteriaceae (Klebsiella, Citrobacter), Pseudomonas, Acinetobacter, Stenotrophomonas, B. fragilis, Aeromonas, others Global dissemination of VIM and NDM 1990�s-present Resistant to all beta-lactams, cephalosporins, beta-lactamase inhibitors, +/- carbapenems Susceptible to polymyxins/colistin (except Proteus), +/- carbapenems, tigecycline (except Pseudomonas), monobactams, +/- fosfomycin Resistance to floroquinolones and aminoglycosides variable Cornaglia G, et al. Metallo-beta-lactamases: a last frontier for beta-lactams? Lancet Inf Dis. May, 2011;11:381-393

25. The Present KPC-1 First identified in K. pneumoniae strain from N. Carolina 1996 Novel carbapenemase Classified as Class A carbapenemase, although more genetic variability compared to others in group (which have >90% genetic similarity) 45% DNA similarity to SME-1 (from Serratia marcescens) Also identified were 3 porin genes (OmpK35-37), and the beta-lactamases SHV-29 and TEM-1 Resistant to penicillins, cephalosporins, monobactams, aminoglycosides, carbapenems, tmp/smx, chloramphenicol Clavulonate combined with imipenem and meropenem resulted in susceptible MIC�s, however the same was not true for beta-lactamase inhibitors when combined with penicillins Yigit H, et al. Novel carbaenem-hydrolyzing beta-lactamase, KPC-1, from a carbapenem resistant strain of K. pneumoniae. Antimicrob Agents Chemother. 2001;45(4):1151-1161

26. The Present Risk factors for KPC colonization/infection Environmental reservoirs Endemic regions NE United States, Israel/Middle East, Europe, South America ???Animal/food reservoirs ???Asymptomatic faecal carriage LTACH/Nursing Facilities Global dissemination of robust strains Klebsiella pneumoniae ST258 carrying KPC-2/3 Travel to endemic regions Patient Risk Factors Prior antibiotic therapy (cephalosporins and carbapenems) Contact with healthcare Medical comorbidities (advanced age, DM, CKD, dialysis, incontinence, UTI, Apache score), devices (mechanical ventilation, foley, gastrostomy tubes) immunosuppression (DM, transplant), prior MDR organism -Won SY, et al. Clin Infect Dis. 2011;53:532-540 -Nordman P, et al. Emerg Infect Dis. 2011;17(10)1791-1798 -Qureshi ZA, et al. Clin Microbiol Infect. 2011;1-7

27. The Present Pathogenesis � KPC producing K. pneumoniae Virulence factors Fimbriae, adhesins, capsule, LPS, pili, siderophores Lcn2-resistant siderophore Ybt (Yersiniabactin) Lcn2 is a siderophore scavenger secreted by neutrophils / mucosal surfaces Ybt is a is an Lcn2 resistant siderophore, and is a risk factor for K. pneumoniae infection Ybt+ K. pneumoniae represent a a substantial subset of clinical isolates and are overrepresented among ESBL K. pneumoniae, including the epidemic KPC clone ST258 Effective transmission of KPC via Tn4401 in clinical K. pneumoniae isolates including epidemic strain ST258 -Bachman MA, et al. K. pneuomoniae Yersiniabctin promotes respiratory tract infection through evasion of lipocalin 2. Infect Immun. August, 2011;79(8):3309-3316 -Podschun R, et al. Klebsiella spp. As nosocomial pathogens: epidemiology, taxonomy, typing methods, and pathogenecity factors. Clin Microbiol Rev. 1998;11(4):589-603

28. The Present Global dissemination of KPC via Tn4401 and KP ST258 Tn4401 identified by Naas T., et al 2008 A 10 kB Tn3 based transposon, associated with the tnpA transposase, tnpR resolvase, blaKPC, and two insertion sequences (ISKpn6 and ISKpn7) Highly conserved and present in all KPC containing organisms and from different geographic regions (GenBank) 3 isotypes (a, b, c) varying in size by 100-200 bp Plasmid mediated transfer (types vary) ST258 often associated with TEM and SHV ESBL�s Naas T, et al. Genetic structures at the origin of acquisition of the beta-lactamase blaKPC gene. Antimicrob Agents Chemother. 2008;52(4):1257-1263.

29. The Present KPC 2 and 3 identified in 0.57% clinical Enterobacteriaceae isolates from US 1999-2005 28 K. pneumoniae �New York 7 Citrobacter freudii � New York and Delaware 2 K. oxytoca � Arkansas 4 Enterobacter spp. � New York 3 E. coli � New York and Ohio 1 Serratia marsescens � New York Others � Pseudomonas aeruginosa, Salmonella spp. Deshpande LM, et al. Emergence of serine carbapenemases (KPC and SME) among clinical strains of Enterobactiaceae isolated in US medical centers: report from the MYSTIC program (1999-2005). Diagn Microbiol Infect Dis. 2006;56:367-372

31. The Present New York City � the �hot-bed� 17 K. pneumoniae isolates from NY Presbyterian 2007 12 KPC-2, 5 KPC-3 ***10/17 strain type 258 ***blaKPC identified with transposon Tn4401 isotypes in all isolates, although diverse plasmid backgrounds Now at least 10 KPC variants Predominantly found in Klebsiella and other Enterobacteriaceae, but also in Pseudomonas aeruginosa and Acinetobacter Spread of KPC in Enterobacteriaceae globally, including US (ST258), Asia (ST11 China), Israel (ST340, ST277, ST376), Europe (ST258), S. America (ST437 Brazil), Canada (ST258) Most K. pneumoniae ST�s point mutants of ST258 All KPC located on Tn4401 isotypes (majority KPC 2 and 3) Mataseje LF, et al. Plasmid comparison and molecular analysis of K. pneumoniae harbouring blaKPC from NYC and Toronto. J Antimicrob Chemother. 2011;66:1273-1277

33. Detection of KPC � Also Easy!

34. The Present �Emergence of Rapid Regional Spread of K. pneumoniae Carbapenemase producing Enterobacteriaceae� Won SY, et al. Clin Infect Dis. September, 2011 Outbreak investigation in Chicago area after a patient from a LTACH transferred to Rush University Med Center identified with KPC producing K. pneumoniae bacteremia in 2008 42 cases (+ specimens, any site), including 6 cases of bacteremia +/- urosepsis Extensive community dissemination associated with LTACH-A Death or discharge to hospice in 40% patients with KPC infxn

35. The Present Case Definition and Case Finding Cases identified through retrospective surveillance of 5 regional and hospital micro lab databases, serving 15 acute care hospitals (91% beds) and 123 LTACH (100% beds) in 4 adjacent counties b/n 5/2008-12/2008 Active Surveillance 1 LTACH (�A�) screened all pts for KPC Enterobacteriaceae Micro Methods ID/susc determined by automated systems, and carbapenem susc confirmed by manual microbroth dilution All carbapenem isolates tested for blaKPC by PCR Strain typing performed by PFGE and MLST Record Review Of 42 + samples/cases, 33 charts available for review Exposure Network Analysis Examine relationship of patients to healthcare institutions as opposed to other patients (clinical records from 8 index hospitals and 1 LTACH)

40. The Present Of 42 cases, 33 records available for review 31 K. pneumoniae (all ST258), 2 E. coli 6 cases bacteremia +/- urosepsis, 12 urine, 1 urine and rectal, 12 sputum or trach aspirate, 5 wound, 4 rectal swab only 60% cases linked to LTACH-A and 25% acquiring KPC there 12% susc imipenem, 0% susc merop/ertap, 100% susc colistin, 94% susc gent, 12% susc amikacin, 6% susc tmp/smx, 49% susc tigecycline ***Interviews with infection preventionists and lab personnel at several facilities during period 1 indicated that susceptibility patterns of KPC Enterobacteriaceae were consistently misinterpreted as ESBL production and therefore that introduction of KPC to the region was not recognized

41. The Present Outcomes � KPC Won SY, et al. Emergence of Rapid Regional Spread of K. pneumoniae Carbapenemase producing Enterobacteriaceae Clin Infect Dis. September, 2011;53:532-540 40% (8/20) patients with KPC infection died or discharged to hospice 15% (3/20) patients with KPC colonization died or discharged to hospice Qureshi ZA, et al. Clinical Characteristics of Bacteremia caused by ESBL producing Enterobacteriaceae in the era of CTX-M type and KPC-type beta-lactamases. Clin Microbiol Infect. 2011;epublished:1-7 Mortality of KPC positive vs. KPC negative K. pneumo 47% vs. 28% Mortality associated w/ inadequate empiric therapy, APACHE score, malignancy, bacteremia while in ICU 65% of patients with ESBL or KPC did not receive appropriate initial abx (OR 13.12, p<0.001)

42. The Present Outcomes � KPC Zarkotou O, et al. Predictors of mortality in patients with bloodstream infections caused by KPC-producing Klebsiella pneumoniae and impact of appropriate antimicrobial treatment. Clin Mirobiol Infect. 2011;epublished:1-6 Of 53 patients with KPC K. pneumo bacteremia, all cause mortality was 53%, and infection mortality 34% Age, APACHE, Severe Sepsis associated with increased mortality Appropriate antimicrobial therapy (and combination therapy) associated with improved survival Other studies (ESBL and KPC): APACHE, sepsis severity, inappropriate antibiotics associated with increased mortality

43. Where does the present meet future? Puture? Fresent?

44. The Future Hu F, et al. Emergence of carbapenem resistant Enterobacteriaceae clinical isolates from a teaching hospital in Shanghai, China. J Med Microbiol. September, 2011 13% of K. pneumoniae and 33% C. freundii in 2009 resistant to carbapenems Chen S, et al. High prevalence of KPC-2 type carbapenemase coupled with CTX-M-type ESBL in carbapenem resistant K. pneumoniae in a teaching hospital in China. Antimicrob Agents Chemother. May, 2011 60% of KPC + isolates also + for CTX-M 14 or 15 ~13% of K. pneumoniae and 33% Citrobacter freundii carbapenem resistant Peirano G, et al. The characteristics of NDM-1 producing E. coli that belong to the successful and virulent clone ST131. Antimicrob Agents Chemother. June, 2011

45. The Future

46. The Future Morris D, et al. Production of KPC-2 carbapenemase by E. coli clinical isolate belonging to the International ST131 Clone. Antimicrob Agents Chemother. October, 2011 Multiple similar cases Chen S, et al. Independent emergence of Colistin-resistant Enterobacteriaceae clinical isolates without colistin treatment. J Clin Microbiol. September, 2011 4 KPC K. pneumoniae also colistin resistant, without known colistin exposure

48. The Future Treatment options Antibiotics � what�s old is new again Polymyxins/colistin (except Proteus) Fosfomycin Tigecycline (except Pseudomonas) Carbapenems (for susc ESBL�s and metallo-beta-lactamases) ***Combination therapy: combo of the above, floroquinolone, aminoglycoside, beta-lactam + beta-lactamase inhibitors Infection control measures (? regional) Limiting antimicrobial overuse / pressure

49. The Future Treatment Pournaras S, et al. Activity of tigecycline alone and in combination with colistin and meropenem against Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacteriaceae strains by time-kill assay. Int J Antimicrob Agents. March, 2011;37(3)244-247 Tigecycline + colistin synergistic and bactericidal Zarkotou O, et al. Predictors of mortality in patients with bloodstream infections caused by KPC producing K. pneumoniae and impact of appropriate antimicrobial therapy. Clin Microbiol Infect. epublished March, 2011 Improved survival with combinations of active antimicrobials (colistin + tigecycline most common)

50. Questions ESBL and KPC Epidemiology / molecular biology of ESBL and KPC? Endemicity + resistance + dispersion = regional and global spread Risk factors for colonization / infection? Similar between ESBL and KPC ? recent antibiotics, LTACH/NH, immunosuppression, comorbidities (DM, CKD/HD, age), medical devices Differences in pathogenesis / outcomes? Both associated with worse outcomes � related to inappropriate initial antibiotic choice and illness severity of patient ? Better outcomes with combination therapy For E. coli ST131, multiple virulence factors, effective plasmid transfer drug resistance transfer, intro of CTX-M For K. pneumoniae ST258, spread of an effective transposon (Tn4401) carrying KPC, virulence factors (Ybt, others?)

52. In Conclusion You can never really forget the past �A nickel isn�t worth a dime today� Know where you are today �We�re lost, but we�re making great time� It helps to know where you are going �The future ain�t what it used to be� It matters! �The other teams could make trouble for us if they win�