ESCMID Online Lecture Library

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1 E. coli producing extendedspectrum β lactamases Luis Martínez Martínez Dept. Molecular Biology, University of Cantabria Service of Microbiology Hosp. Univ. Marqués de Valdecilla Santander, Spain Barcelona November 21, 2013

2 Escherichia coli and extended-spectrum beta-lactamases 2093 references (107 reviews) 1051 references in the last 5 years (41 reviews)

3 MICROBIOLOGICAL ASPECTS 1. Concept and Types 2. Detection 3. Molecular Epidemiology: Incidences and Trends 4. Co-resistance: Data and causes 5. Pathogenicity-Virulence 6. Mobile elements and genetic backgrounds 7. Transmission: Healthy humans, patients, animals, environment,, ) 8. Clinical aspects, including Prognosis and Treatment

4 ESBLs Enzymes that hydrolyze MOST penicillins and cephalosporins, including oxyimino-β-lactam compounds (cefuroxime, third- and fourth-generation cephalosporins and aztreonam) but NOT cephamycins or carbapenems. MOST ESBLs belong to the Ambler class A of β- lactamases and are inhibited by serine β-lactamase inhibitors (clavulanic acid and others)

5 ESBLs Naas T et al., CMI 2008, suppl 1:42

6 blaesbl (or Inhibitor-Resistant/Broad Spectrum) alleles TEM-type: 215 (213) variants SHV-type: 182 (178) variants CTX-M-type: 150 (148) variants OXA-type: 16 variants As of November, 2013

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8 EUCAST: BREAKPOINTS (2013)

9 CLSI: BREAKPOINTS

10 EUCAST: BREAKPOINTS (2013) The cephalosporin breakpoints for Enterobacteriaceae will detect all clinically important resistance mechanisms (including ESBL and plasmid mediated AmpC). Some strains that produce beta-lactamases are susceptible or intermediate to 3rd or 4th generation cephalosporins with these breakpoints and should be reported as found, i.e. the presence or absence of an ESBL DOES NOT IN ITSELF INFLUENCE THE CATEGORIZATION of susceptibility. In many areas, ESBL detection and characterization is recommended or mandatory for infection control purposes.

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12 Detection and Reporting β-lactam resistance phenotypes in E. coli and K. pneumoniae in Spain 57 Laboratories Automated methods: 61.4% MicroScan WalkAway (n = 43,8%) Vitek 2 (n = 14,1%) Phoenix (n = 3,5) Semiautomated systems: 31.6% Wider (n = 28,1%) MicroScan AutoScan (3,5%) 91% of laboratories recognized all ESBL producers correctly 47.4% of laboratories correctly recognized all AmpC (+) strains. (More common mistake: reported as ESBL producers and penicillinase hyperproducers in 7.6 % and 5.8% respectively) Conejo MC et al, DMID 2008, 317

13 Detection of ESBL with Vitek 2 in E. coli producing CTX-M AST N-054 card: Ampicillin, amoxicillin/clavulanic acid, piperacillin, piperacillin/tazobactam, cefuroxime, cefalotin, cefotaxime, ceftazidime, cefipime, cefoxitin, ertapenem, meropenem, aztreonam Donaldson H et al, JAC :1015

14 Unreliable detection of ESBL in E. coli producing pampc with Phoenix Robberts FJL et al, JCM 2009, 358

15 E. coli CTX-M14 plus CMY-2 MH-cloxacillin 250

16 y r a c e L e lin n O D or I M h t C u S a E by r b i L e r tu

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19 3. Extended-spectrum β-lactamase-producing Enterobacteriaceae

20 R 2012 E. coli CF3G-R R+I EARSS:

21 CHANGES IN ESBL-E. coli EPIDEMIOLOGY IN SEVILLE, SPAIN ( ) Hospitalised Non- Hospitalised

22 Community Hospital Díaz MA, EIMC 2009, 503

23 Pitout JD, LID 2008, 159

24 25/11/2013 REP-PCR E. coli

25 ESBL FAMILIES (%) IN E. coli AGENT TEM SHV SHV CTX-M CTX-M CTX-M CTX-M CTX-M

26 EID 2008, Phylogenetic group B2 MLST: ST131 Related ERIC PCR/PFGE pattern Serotype O25:H4 AmpC EC6 Ciprofloxacin resistance blaoxa-1, aac(6 )-Ib-cr, blatem-1 Similar virulence profile

27 GEIH-BLEE 2006: ESBL- E. coli CTX-M-15 (+): n=37 isolates (14.2%) Clonal group O25b-ST131: 32/37 (86.5%) Centers with these isolates: 15/42 (35.7%) Díaz MA, EIMC 2009, 503

28 MAJOR CLONES OF EXTRAINTESTINAL E. coli IN SPAIN 5 centers. February consecutive E. coli from extraintestinal clinical samples Phylogenetic groups, sequence types (STs), serotypes, virulence genes, PFGE profiles, antimicrobial resistance ESBL O25b-B2-ST131, O15-D-ST393 and CGA-D-ST69: 19% 37% of SXT-R plus CIP-R 34% of aminoglycoside-r 30% of MDR. ESBL-producing isolates: 7% ST131: CTX-M-15 (9%) ST393: CTX-M-14 (6%) ST69: No ESBL producers Blanco J et al, JAC 2011

29 ST131: SIX ESBL types ST10: FIVE ESBL types ST23: FOUR ESBL types

30 E. coli ESBL(+): Resistance (%) AGENT Cefotaxime (100) (100) Ceftazidime (100) (100) Cefepime (100) (100) Cefoxitin Cefotetan Imipenem, Meropenem 0 0 Ertapenem NT 0 Amoxicillin-Clavulanate Piperacillin-Tazobactam Ciprofloxacin Gentamicin Tobramycin Amikacin Cotrimoxazole

31 bla CTX-M-19 IRL IRL IRR IRL IRR IRR int1 aaca4 cmla7 qace 1 iron tr. sul1 orf1 tnpa bla tnpa gene orf1 Tn1721 ISEcp1B IS903C ORF513 orfl005 IS3000 int1 drfa aada2 qace 1 sul1 bla CTX-M-9 Tn1721 qace 1 sul1 Poirel et al., Antimicrob Agents Chemother Sabaté et al., AAC 2002, 46:

32 BMC Microbiol 2013, submitted

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35 MN4 (CTX-M-67) IMP 32 mg/l MPM 8 mg/l Oteo J et al, IJAA 2008

36 OMP PROFILES OF E. coli [BLEE +] FROM CLINICAL ORIGIN 25/11/2013 Hernández JR et al, SEIMC 2002

37 Santander: Belén Ruiz del Castillo Jorge Calvo Carlos Ruiz de Alegría Maria Eliecer Cano Cristina Rodríguez Elena Román Fernando de la Cruz Mapi Garcillán Seville: Álvaro Pascual Jesús Rodríguez-Baño José R. Hernández Carmen Conejo Sofía Ballesta Miguel A. Díaz José M. Rodríguez Lorena López Boston: Geroge A. Jacoby Mallorca: Javier Benedí Sebastián Albertí Santiago Hernández Antonio Doménech Barcelona Carmen Ardanuy Josefina Liñares Multiple Local Investigators Rafael Cantón, Fernando Baquero, Teresa Coque, Juan C. Galán Ferrán Navarro, Elisenda Miró Germán Bou Carmen Torres, Elena Ruiz Jorge Blanco José Campos, Jesús Oteo Alessandra Carattoli Beatriz Guerra GEIH-SEIMC & REIPI Groups