There are 3 common carbapenemase classes: class A includes Klebsiella pneumoniae carbapenemase

(KPC); class B is metallo-β-lactamases (MBL), includ-ing Verona integron-encoded metallo-β-lactamase (VIM), New Delhi metallo-β-lactamase (NDM) and imipenemase (IMP); and class D includes oxacillin-ases (OXA), including OXA-48–like carbapenemases. In Spain, all 3 of these classes have been reported in recent studies (1–4). A multicenter study of Enterobac-terales carbapenemase-producing gram-negative bac-teria (CPGNB), isolated from urine specimens, found a prevalence of 1.6%. OXA-48 was the most prevalent, followed by KPC and MBL (5).

In Andalusia, a region in the south of Spain with a population of ≈8.4 million people, The PIRASOA

(https://www.iavante.es/es/programa-pirasoa) program was designed to prevent and control healthcare-associated infections and promote the appropriate use of antimicrobials, covering the en-tire area of the Andalusia public healthcare system, which includes 34 hospitals in 8 provinces. Data col-lected through PIRASOA during 2014–2018 provid-ed an opportunity for us to study and understand the epidemiology of carbapenemase-producing bac-teria in Andalusia.

The StudyDuring January 2014–December 2018, microbiology laboratories in the hospitals included in the PIRA-SOA program voluntarily submitted CPGNB de-tected according to EUCAST screening criteria (6) to the PIRASOA reference laboratory. We identified the isolates using MALDI-TOF Biotyper (Bruker Dalton-ics, https://www.bruker.com). Antimicrobial sus-ceptibility testing was performed by microdilution (Microscan; Beckman Coulter, https://www.beck-mancoulter.com) and interpreted according to EU-CAST breakpoints (7). We determined the inhibition of carbapenemase activity by using inhibitors (dip-icolinic acid, phenyl-boronic acid, and cloxacillin). In addition, we tested all the isolates with the β-CARBA test (Bio-Rad, https://www.bio-rad.com) and, from January 2018, also with the NG-test CARBA 5 (NG Biotech, https://ngbiotech.com). All isolates with a positive or indeterminate result from phenotypic screening were tested by PCR and sequencing (Mac-rogen, https://dna.macrogen.com) (blaKPC, blaOXA-48, blaVIM, blaIMP, blaNDM, blaOXA-23,24/40,58) or by whole ge-nome sequencing on a MiSeq system (Illumina, https://www.illumina.com), which became avail-able in October 2017. We evaluated genetic related-ness by pulsed-field gel electrophoresis (CHEF DR-II system; Bio-Rad); isolates of <2 bands difference were assigned to the same cluster. We determined

Carbapenemase-Producing Gram-Negative Bacteria in

Andalusia, Spain, 2014–2018Inmaculada López-Hernández, Mercedes Delgado-Valverde,

Felipe Fernández-Cuenca, Lorena López-Cerero, Jesús Machuca, Álvaro Pascual

2218 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 26, No. 9, September 2020

DISPATCHES

Author affiliations: Laboratorio PIRASOA, Hospital Universitario Virgen Macarena, Seville, Spain (I. Lopez-Hernandez, M. Delgado-Valverde, F. Fernández-Cuenca, L. López-Cerero, J. Machuca, Á. Pascual); Instituto de Biomedicina de Sevilla IBIS, Hospital Universitario Virgen Macarena, Consejo Superior de Investigaciones Científicas, Universidad de Sevilla, Seville (I. López-Hernández, M. Delgado-Valverde, F. Fernández- Cuenca, L. López-Cerero, J. Machuca, Á. Pascual); Red Española de Investigación en Patología Infecciosa (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain (I. López-Hernández, M. Delgado-Valverde, F. Fernández-Cuenca, L. López-Cerero, J. Machuca, Á. Pascual); Universidad de Sevilla, Seville (Á. Pascual).

DOI: https://doi.org/10.3201/eid2609.191772

The emergence and spread of carbapenemase-producing gram-negative bacteria is a major public health concern. We used data collected from microbiology laboratories as part of the PIRASOA program during 2014–2018 to study the epidemiology of carbapenemase-producing bacteria in Andalusia, Spain. Our findings highlight the importance of ongoing surveillance and epidemiologic studies for these bacteria.

Carbapenemase-Producing Gram-Negative Bacteria

multilocus sequence typing using PCR and sequenc-ing or whole-genome sequencing data (https://cge.cbs.dtu.dk/services/MLST).

During the study period, we analyzed 2,005 gram-negative isolates of which 1,243 (62%) were carbapenemase producers. Among those 1,243 iso-lates, clinical specimens (64%, 791/1,243) comprised the predominant source, followed by surveillance (31%, 387/1,243) and environmental samples (5%, 65/1,243). The most common species were K. pneu-moniae (45%, 560/1,243), Acinetobacter baumannii (34%, 425/1,243), and K. oxytoca (7%, 83/1,243).

KPC-3 was the most common carbapenemase we found (249; 20%); 96% of the KPC-3 was detected in K. pneumoniae belonging to clones sequence type (ST) 512 or ST258. In contrast, KPC-2, which comprised only 1.8% (23), was found in multiple species. Among OXA-48–like carbapenemases, which comprised 19% (254) of carbapenemases, 87% (221/254) were found in K. pneumoniae, 70% (155/221) of those in clones ST11, ST15, ST392, or ST307.

Over the course of the study period, we observed an increase in MBL carbapenemases, with a note-worthy increase in 2018 (Table 1; Figure 1). Klebsiella was most prevalent MBL, comprising 53% (157/294), almost equally distributed between K. pneumoniae and K. oxytoca, followed by Pseudomonas aeruginosa (20%, 60/294) and Enterobacter cloacae (14%, 42/294). The distribution of each MBL enzyme type varied significantly. We found 39% (77/197) of VIM in K. oxytoca, 80% (45/56) of NDM in K. pneumoniae, and 73% (30/41) of IMP in P. aeruginosa. OXA-23 (49%, 208/425) was the most common carbapenemase pro-ducer in A. baumannii, followed by OXA-58 (38%, 162/425), and OXA-24/40 (13%, 55/425). OXA-23 and OXA 24/40 isolates belonged predominantly to clone ST2. OXA-58 producers were detected in mul-tiple clones. We summarize the distribution of car-bapenemases among CPGNB in this study in Table 2.

Geographically, carbapenemase producers were found in 32 hospitals distributed throughout 8 prov-inces of the region, with KPC detected in 26 hospitals,

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 26, No. 9, September 2020 2219

Table 1. Distribution of carbapenemase-producing gram-negative bacteria by year, Andalusia, Spain, 2014–2018

Carbapenemase Bacteria Year

2014 2015 2016 2017 2018 VIM Klebsiella pneumoniae 0 0 9 9 15

K. oxytoca 1 13 12 19 32 Escherichia coli 0 2 1 3 2 Enterobacter cloacae 0 4 4 10 15 Citrobacter freundii 0 1 3 2 2 C. amalonaticus 0 0 1 0 0 Pseudomonas aeruginosa 1 0 0 0 29 P. putida 0 0 0 3 3 Acinetobacter spp 0 0 0 1 0

IMP K. pneumoniae 0 0 0 0 2 E. coli 0 0 0 0 1 E. cloacae 0 0 0 2 5 C. freundii 0 1 0 0 0 P. aeruginosa 0 2 0 10 18

NDM K. pneumoniae 0 0 1 7 37 E. coli 0 0 1 1 3 E. cloacae 0 0 2 0 0 Acinetobacter spp 0 0 0 0 1 A. baumannii 0 0 0 2 1

KPC K. pneumoniae 35 71 61 54 38 K. oxytoca 0 0 0 0 2 E. coli 0 0 0 0 3 E. cloacae 0 0 2 3 2 C. freundii 0 0 0 1 0

OXA-48 K. pneumoniae 35 26 39 77 44 K. oxytoca 0 0 0 1 3 E. coli 6 3 0 1 3 E. cloacae 1 1 0 0 5 C. freundii 0 1 0 1 3 K. aerogenes 0 0 0 0 4

OXA-23 A. baumannii 38 30 19 67 54 OXA-58 A. baumannii 15 25 46 38 36 OXA-24/40 A. baumannii 1 33 12 7 1 IMI E. cloacae 0 0 0 0 1 IMP, imipenemase; KPC, Klebsiella pneumoniae carbapenemase; MBL, metallo-β-lactamases; NDM, New Delhi metallo-beta-lactamase; OXA, oxacillinases; VIM, Verona integron-encoded metallo-β-lactamase.

DISPATCHES

followed by OXA-48–like in 23 and MBL in 18 (Ap-pendix Figure). Sequence type was available for 1,181 of 1,243 (95%) isolates. Some circulating high-risk clones were detected in K. pneumoniae, E. cloacae, Esch-erichia coli, A. baumannii, and P. aeruginosa. The com-binations of species, carbapenemase variants, and se-quence types are listed in the Appendix Table.

Six isolates (0.5%) produced 2 types of carbapene-mase: Five isolates combined VIM-1 with either OXA-48 (K. oxytoca ST206 and E. cloacae ST114), OXA-245 (Citrobacter freundii ST63), IMP-8 (E. cloacae ST242), or NDM-1 (C. freundii ST170). The remaining isolate was E. coli ST617 harboring NDM-5 and OXA-48. Accord-ing to pulsed-field gel electrophoresis, 765 of 1,243 isolates (62%) were included in 23 clusters submitted from 22 hospitals (Figure 2).

ConclusionsOur results provide an overview of the molecular epidemiology of CPGNB in Andalusia. The predomi-nance of K. pneumoniae as a producer of all classes of carbapenemases is noteworthy, reflecting its role in disseminating carbapenemases in the region. KPC-3 and OXA-48 were the carbapenemases most frequent-ly detected. KPC-3 was almost exclusively associated with K. pneumoniae and importantly with high-risk clones ST512 and ST258 considered endemic in other European countries (8–10). Like KPC-3, OXA-48 was predominantly found in K. pneumoniae, but it began appearing in other species in 2018, which raises con-cerns about the control of this carbapenemase in the region. In addition, the high-risk clones of OXA-48–producing K. pneumoniae, ST11, ST15, ST392, ST307,

2220 Emerging Infectious Diseases • www.cdc.gov/eid •Vol. 26, No. 9, September 2020

Figure 1. Distribution of carbapenemase types recovered in Andalusia, 2014–2018. IMP, imipenemase; KPC, Klebsiella pneumoniae carbapenemase; MBL, metallo-β-lactamases; NDM, New Delhi metallo-beta-lactamase; OXA, oxacillinases; VIM, Verona integron-encoded metallo-β-lactamase.

Table 2. Distribution of carbapenemases by species, Andalusia, Spain, 2014–2018*

Species

K. p. K. o. E. coli Enterobacter

cloacae C. f. C. a. Pseudomonas

aeruginosa P.

putida Acinetobacter

spp. A.

baumannii K. a. VIM-1 33 77 8 33 8 1 1 5 1 0 0 VIM-2 0 0 0 0 0 0 29 1 0 0 0 IMP-8 2 0 1 6 1 0 14 0 0 0 0 IMP-16 0 0 0 0 0 0 9 0 0 0 0 IMP-23 0 0 0 0 0 0 7 0 0 0 0 NDM-1 6 0 0 2 0 0 0 0 1 3 0 NDM-7 39 0 1 0 0 0 0 0 0 0 0 NDM-5 0 0 4 0 0 0 0 0 0 0 0 IMP-22 0 0 0 1 0 0 0 0 0 0 0 KPC-3 248 0 0 1 0 0 0 0 0 0 0 KPC-2 10 2 3 6 1 0 0 0 0 0 0 OXA-48 205 4 12 7 4 0 0 0 0 0 4 OXA-23 0 0 0 0 0 0 0 0 0 208 0 OXA-58 0 0 0 0 0 0 0 0 0 160 0 OXA-24/40 0 0 0 0 0 0 0 0 0 54 0 OXA-245 15 0 1 0 1 0 0 0 0 0 0 OXA-181 1 0 0 0 0 0 0 0 0 0 0 KPC-31 1 0 0 0 0 0 0 0 0 0 0 IMI-1 0 0 0 1 0 0 0 0 0 0 0 Total 560 83 30 57 15 1 60 6 2 425 4 *C. f., Citrobacter freundii; C. a., Citrobacter amalonaticus; E., Escherichia; K. a., Klebsiella aerogenes; K. o., K. oxytoca; K. p., Klebsiella pneumoniae. IMP, imipenemase; KPC, Klebsiella pneumoniae carbapenemase; MBL, metallo-β-lactamases; NDM, New Delhi metallo-beta-lactamase; OXA, oxacillinases; VIM, Verona integron-encoded metallo-β-lactamase.

Carbapenemase-Producing Gram-Negative Bacteria

differed from those for KPC-3, showing that specific clones have a role in the dissemination of specific car-bapenemases in this region.

We found a significant temporal change in the epidemiology of MBL with a clear upward trend as-sociated with several outbreaks in 2018. Findings from recent studies from Spain reflect the emergence of MBL in different CPGNB species (4,11,12). VIM was the MBL most frequently detected and, most of the VIM-producing bacteria were detected as part of clusters. IMP was almost exclusively found in P. aeru-ginosa isolates, showing the importance of this species in the dissemination of this carbapenemase; it was as-sociated with different clusters in a single hospital and each variant was associated with a specific clone: IMP-8/ST348, IMP-23/ST175 and IMP-16/ST253. An increase in NDM was observed in 2018 associated with a large outbreak produced by K. pneumoniae ST11 NDM-7 in a single hospital.

In A. baumanni, OXA-23 and OXA-58 were the most common carbapenemases. ST2 was the pre-dominant clone according to previous studies (13). A

remarkable finding was the detection of A. baumannii ST85 harboring NDM-1 for the first time in Spain (14). The increase of carbapenemases in E. coli is a finding that could have epidemiologic significance because E. coli spread in the community more readily than other species and could begin to establish carbapenemases in the community. It is also remarkable that 7 of 23 clusters were detected in the same hospital, reflecting the burden of antimicrobial resistance in this hospital. This issue remains serious, and additional efforts for infection control should be made.

One limitation of this work is that, because sub-mission of isolates is not mandatory, underreporting is likely. Nevertheless, we have evidence that most relevant isolates are routinely submitted. Further-more, this study reinforces the importance of sub-mitting all multidrug-resistant isolates to a reference laboratory because the information provided using molecular techniques makes the rapid detection of clusters and high-risk clones possible, which in turn, contributes to the success of infection prevention and control programs.

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 26, No. 9, September 2020 2221

Figure 2. Characteristics of clusters of carbapenemase-producing gram negative bacteria, Andalusia, 2014–2018. Hospitals are identified by number: Almería ,1, 2, 5; Cádiz, 7, 8, 9; Córdoba, 6, 11, 12; Granada, 4, 13; Huelva, 20; Jaén, 10, 21; Málaga, 17, 18, 19; Sevilla, 3, 14, 15, 16. Ab, Acinetobacter baumannii; CTX-M, Cefotaximase-Munich; Eclo, Enterobacter cloacae; IMP, imipenemase; Kox, Klebsiella oxytoca; KPC, Klebsiella pneumoniae carbapenemase; Kpn, Klebsiella pneumoniae; MBL, metallo-β-lactamases; NDM, New Delhi metallo-beta-lactamase; OXA, oxacillinases; Pae, Pseudomonas aeruginosa; Pp, Pseudomonas putida; ST, sequence type; VIM, Verona integron-encoded metallo-β-lactamase.

DISPATCHES

In summary, our study shows dissemination and establishment of CPGNB in Andalusia, including high-risk clones of different species. These findings demonstrate the importance of continuing surveil-lance programs and epidemiologic studies to detect and investigate the spread of carbapenemase-produc-ing bacteria, particularly in Andalusia, which is a re-gion predisposed to the introduction of new lineages because of tourism and migration pathways.

About the AuthorDr. López-Hernández is a clinical microbiologist in the Unit of Infectious Diseases and Clinical Microbiology of the Virgen Macarena University Hospital, Seville, Spain. Her research interest is antimicrobial resistance mechanisms in bacteria.

References 1. Pérez-Vazquez M, Oteo-Iglesias J, Sola-Campoy PJ,

Carrizo-Manzoni H, Bautista V, Lara N, et al.; Spanish Antibiotic Resistance Surveillance Program Collaborating Group. Characterization of carbapenemase-producing Klebsiella oxytoca in Spain, 2016–2017. Antimicrob Agents Chemother. 2019;63:e02529–18. https://doi.org/10.1128/AAC.02529-18

2. Arana DM, Ortega A, González-Barberá E, Lara N, Bautista V, Gómez-Ruíz D, et al.; Spanish Antibiotic Resistance Surveillance Programme Collaborating Group. Carbapenem-resistant Citrobacter spp. isolated in Spain from 2013 to 2015 produced a variety of carbapenemases including VIM-1, OXA-48, KPC-2, NDM-1 and VIM-2. J Antimicrob Chemother. 2017;72:3283–7. https://doi.org/ 10.1093/jac/dkx325

3. Del Barrio-Tofiño E, Zamorano L, Cortes-Lara S, López-Causapé C, Sánchez-Diener I, Cabot G, et al.; GEMARA-SEIMC/REIPI Pseudomonas study Group. Spanish nationwide survey on Pseudomonas aeruginosa antimicrobial resistance mechanisms and epidemiology. J Antimicrob Chemother. 2019;74:1825–35. https://doi.org/ 10.1093/jac/dkz147

4. Nowak J, Zander E, Stefanik D, Higgins PG, Roca I, Vila J, et al.; MagicBullet Working Group WP4. High incidence of pandrug-resistant Acinetobacter baumannii isolates collected from patients with ventilator-associated pneumonia in Greece, Italy and Spain as part of the MagicBullet clinical trial. J Antimicrob Chemother. 2017;72:3277–82. https://doi.org/10.1093/jac/dkx322

5. García-Castillo M, García-Fernández S, Gómez-Gil R, Pitart C, Oviaño M, Gracia-Ahufinger I, et al.; iCREST Study Group. Activity of ceftazidime-avibactam against

carbapenemase-producing Enterobacteriaceae from urine specimens obtained during the infection-carbapenem resistance evaluation surveillance trial (iCREST) in Spain. Int J Antimicrob Agents. 2018;51:511–5. https://doi.org/ 10.1016/j.ijantimicag.2018.01.011

6. EUCAST Guidelines for detection of resistance mechanisms and specific resistances of clinical and/or epidemiological importance, version 2.0 [cited 2 Jan 2018]. http://www.eucast.org/fileadmin/src/media/PDFs/EUCAST_files/Resistance_mechanisms/EUCAST_detection_of_resistance_mechanisms_170711.pdf

7. EUCAST. Breakpoint tables for interpretation of MICs and zone diameters, version 8.0, 2018 [cited 11 July 2017]. http://www.eucast.org/fileadmin/src/media/PDFs/EUCAST_files/ Breakpoint_tables/v_8.1_Breakpoint_Tables.pdf

8. David S, Reuter S, Harris SR, Glasner C, Feltwell T, Argimon S, et al.; EuSCAPE Working Group; ESGEM Study Group. Epidemic of carbapenem-resistant Klebsiella pneumoniae in Europe is driven by nosocomial spread. Nat Microbiol. 2019;4:1919–29. https://doi.org/10.1038/ s41564-019-0492-8

9. Ferrari C, Corbella M, Gaiarsa S, Comandatore F, Scaltriti E, Bandi C, et al. Multiple Klebsiella pneumoniae KPC clones contribute to an extended hospital outbreak. Front Microbiol. 2019;10:2767. https://doi.org/10.3389/fmicb.2019.02767

10. Becker L, Kaase M, Pfeifer Y, Fuchs S, Reuss A, von Laer A, et al. Genome-based analysis of carbapenemase-producing Klebsiella pneumoniae isolates from German hospital patients, 2008–2014. Antimicrob Resist Infect Control. 2018;7:62. https://doi.org/10.1186/s13756-018-0352-y

11. Espinal P, Miró E, Segura C, Gómez L, Plasencia V, Coll P, et al. First description of blaNDM-7 carried on an IncX4 plasmid in Escherichia coli ST679 isolated in Spain. Microb Drug Resist. 2018;24:113–9. https://doi.org/10.1089/mdr.2017.0039

12. Villa J, Carretero O, Viedma E, Lora-Tamayo J, Mingorance J, Chaves F. Emergence of NDM-7-producing multi-drug- resistant Enterobacter hormaechei sequence type ST-78 in Spain: a high-risk international clone. Int J Antimicrob Agents. 2019;53:533–4. https://doi.org/10.1016/ j.ijantimicag.2018.11.009

13. Hamidian M, Nigro SJ. Emergence, molecular mechanisms and global spread of carbapenem-resistant Acinetobacter baumannii. Microb Genom. 2019;5:5. https://doi.org/ 10.1099/mgen.0.000306

14. Fernández-Cuenca F, Pérez-Palacios P, Galán-Sánchez F, López-Cerero L, López-Hernández I, López Rojas R, et al. First identification of blaNDM-1 carbapenemase in blaOXA-94- producing Acinetobacter baumannii ST85 in Spain. Enferm Infecc Microbiol Clin. 2020;38:11–5. https://doi.org/10.1016/ j.eimc.2019.03.008

Address for correspondence: I. López-Hernández, Department of Microbiology, School of Medicine, Av Sánchez Pizjuán s/n, 41009, Seville, Spain; email: inlopezh@us.es

2222 Emerging Infectious Diseases • www.cdc.gov/eid •Vol. 26, No. 9, September 2020

Page 1 of 5

Article DOI: https://doi.org/10.3201/eid2609.191772

Carbapenemase-Producing Gram Negative Bacteria in Andalusia, Spain, 2014–2018

Appendix

Appendix Table. Distribution of carbapenemase and STs among the 1243 isolates included in the study

Species Clone

Carbapenemase VIM -1

VIM -2

IMP -8

IMP -16

IMP -23

IMP -22

NDM -1

NDM -7

NDM -5

KPC -3

KPC -2

KPC -31

IMI -1

OXA -48

OXA -245

OXA -181

OXA -23

OXA -58

OXA -24/40 Total

Klebsiella pneumoniae

ST525 6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6 ST111 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST37 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST307 1 0 0 0 0 0 4 3 0 1 3 0 0 22 0 0 0 0 0 34 ST17 1 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 3 ST22 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 ST395 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 2 ST348 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST36 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST25 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST514 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST2856 1 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 4 ST15 11 0 0 0 0 0 0 0 0 0 0 0 0 66 3 0 0 0 0 80 ST128 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST11 1 0 0 0 0 0 0 35 0 0 0 0 0 41 4 0 0 0 0 81 ST392 0 0 1 0 0 0 0 0 0 0 0 0 0 19 0 0 0 0 0 20 ST202 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 ST13 1 0 0 0 0 0 0 0 0 0 0 0 0 5 0 0 0 0 0 6 ST321 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST152 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 ST1079 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST1308 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST464 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 ST512 0 0 0 0 0 0 0 0 0 209 0 1 0 0 0 0 0 0 0 210 ST258 0 0 0 0 0 0 0 0 0 31 0 0 0 0 0 0 0 0 0 31 ST753 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 ST147 0 0 0 0 0 0 0 0 0 5 1 0 0 8 0 0 0 0 0 14 ST836 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 ST899 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 ST1 0 0 0 0 0 0 0 0 0 0 0 0 0 3 2 0 0 0 0 5

Page 2 of 5

Species Clone

Carbapenemase VIM -1

VIM -2

IMP -8

IMP -16

IMP -23

IMP -22

NDM -1

NDM -7

NDM -5

KPC -3

KPC -2

KPC -31

IMI -1

OXA -48

OXA -245

OXA -181

OXA -23

OXA -58

OXA -24/40 Total

ST431 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 ST251 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 ST974 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 ST405 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 ST391 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 ST225 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 ST34 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 ST16 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 ST1963 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 ST981 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 ST340 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 ST1732 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 ST2262 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 2 ST3358 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 0 3 ST3362 0 0 0 0 0 0 0 0 0 0 0 0 0 9 0 0 0 0 0 9 ST1562 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 ST846 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 ST3360 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 2 ST442 0 0 0 0 0 0 0 0 0 0 0 0 0 5 0 0 0 0 0 5 ST716 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 NA 0 0 0 0 0 0 0 0 0 2 0 0 0 8 0 0 0 0 0 10

K. oxytoca

ST145 24 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 25 ST36 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 14 ST170 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 ST27 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 ST213 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST202 22 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 24 ST206 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST82 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST214 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 ST95 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 NA 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9

K. aerogenes ST93 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 3 ST153 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1

Escherichia coli ST1193 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 ST145 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST348 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST8327 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST141 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 ST88 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST410 0 0 0 0 0 0 0 0 2 0 3 0 0 0 0 0 0 0 0 5 ST617 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 ST69 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 ST1340 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 ST12 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 NA 5 0 0 0 0 0 0 0 0 0 0 0 0 9 1 0 0 0 0 15 ST78 19 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 21

Page 3 of 5

Species Clone

Carbapenemase VIM -1

VIM -2

IMP -8

IMP -16

IMP -23

IMP -22

NDM -1

NDM -7

NDM -5

KPC -3

KPC -2

KPC -31

IMI -1

OXA -48

OXA -245

OXA -181

OXA -23

OXA -58

OXA -24/40 Total

Enterobacter cloacae

ST111 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 ST932 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 2 ST90 2 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 3 ST114 2 0 1 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 5 ST528 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST96 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 2 ST50 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST413 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST50 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST242 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 ST24 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 ST110 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 ST991 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 ST74 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 ST108 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 ST32 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 ST1107 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 ST113 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 ST901 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 NA 2 0 0 0 0 0 0 0 0 0 1 0 0 2 0 0 0 0 0 5

Citrobacter freundii

ST8 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 ST22 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST44 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST63 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST170 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST408 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST410 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ST112 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 2 ST261 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 ST425 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 NA 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 3

C. amalonatycus NA 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 Pseudomonas aeruginosa

ST253 0 0 0 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 ST348 0 0 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 14 ST175 0 28 0 0 7 0 0 0 0 0 0 0 0 0 0 0 0 0 0 35 ST308 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 NA 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

P. putida ST15 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 NA 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Acinetobacter baumannii

ST307 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 15 0 0 15 ST85 0 0 0 0 0 0 3 0 0 0 0 0 0 0 0 0 8 0 0 11 ST2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 170 83 49 302 ST98 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 21 0 21 ST829 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 ST745 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 55 0 56 ST32 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 ST164 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 2

Page 4 of 5

Species Clone

Carbapenemase VIM -1

VIM -2

IMP -8

IMP -16

IMP -23

IMP -22

NDM -1

NDM -7

NDM -5

KPC -3

KPC -2

KPC -31

IMI -1

OXA -48

OXA -245

OXA -181

OXA -23

OXA -58

OXA -24/40 Total

NA 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11 1 4 16 Acinetobacter spp. ST119 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1

NA 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 Total 167 30 24 9 7 1 12 40 4 249 22 1 1 236 17 1 208 160 54 1243

Page 5 of 5

Appendix Figure. Geographic distribution of carbapenemase types.