Epidemiologie de la résistance chez les bactéries à Gram-négatif

Youri Glupczynski, MD, PhD

Clinical Microbiology Dept & Infection Control Unit National Reference Center for Monitoring of Antimicrobial Resistance

CHU Dinant-Godinne, UCL-Namur

Université Catholique de Louvain, Yvoir, Belgium

Recent evolution of β-lactamases

S.aureus

penicillinase

BLSE SHV/TEM

Carbapenemases

Penicillins

Amino-Penicillin oral cephalosporins

Inhibitors combinations

3 Generation cephalosporins

carbapenems Tigecycline

4 Generation cephalosporins

1943

1950

1960

1970

1980

1990

2010

TEM-1 SHV-1 OXA-1

Tn3 transposon Plasmid

CTX-M

AmpC

Inhibit Resist TEM

Epidemics Hysteria in hospitals

Plasmid: CMY, MOX, FOX, CAT, MIR

Epidemics, Endemics Hysteria in hospitals

Hysteria in community

Endemic panresistance No therapeutic options

Hysteria in globe

60% E.coli Ampi-R

Enterobacter Klebsiella BLSE

15% of E.coli BLSE AmpC+BLSE

Rivers bacteria, Animals (Farms/pets) Enterobacteriaceae carbapenemases AmpC+BLSE+porin loss

PANRESISTANCE

avibactam Vaccines Phages

Porins+AmpC

Selection

Mobilisation

ESAC

Local Therapeutic failure

Mutation Plasmid: carbapenemases KPC, MBL

Antibiotics into livestock Antibiotics into livestock, poultry, fish 70% of total ATB in USA is fed To healthy farm animals

BL 70 years ESBL: 30 years

Carbapenemases: 15 years

H. Rodriguez & Y Glupczynski submitted

06/06/13 Liège - certificat interuniversitaire 5

How does Industry address the problem ?

Cooper, Nature (2011) 472: 32; Boucher et al. CID (2013) 56:1685-94

Big Pharma:

• GlaxoSmithKline

• AstraZeneca

• Merck & Co

• (Pfizer)

X

Antimicrobial resistance surveillance in Europe EARS-Net Report 2013 www.ecdc.europa.eu

Escherichia coli: Percentage of invasive isolates with resistance to 3rd gen. cephalosporins in Europe (2013)

weighted mean resistance : 12.6% 5% (Iceland) – 39.6% (Bulgaria) 14 countries: <10% 12 countries: 10-25% 4 countries: >25%

Mean weighed Resistance: 9.5% in 2010 -> 12.6% in 2013 Increasing resistance trend in 17 countries 85-100% of C3G-R E. coli: ESBL-positive

8%

39.6%

38.9%

26.2%

29.7%

13.3%

Antimicrobial resistance surveillance in Europe EARS-Net Report 2013 www.ecdc.europa.eu

Escherichia coli: Percentage of invasive isolates with resistance to fluoroquinolones in Europe (2013)

weighted mean resistance : 22.5% 10.9% (Norway) – 51.9% (Cyprus) 18 countries: 10-25% 12 countries: >25%

Increasing resistance trend in 7 countries (2010-2013)

23%

42.2%

30.9%

34.9%

Antimicrobial resistance surveillance in Europe EARS-Net Report 2013 www.ecdc.europa.eu

Klebsiella pneumoniae: Percentage of invasive isolates with resistance to C3G in Europe (2013)

weighted mean resistance: 30% 0% (Iceland) – 70.1% (Greece) 5 countries: <10% 8 countries: 10-25% 8 countries: 25-50% 9 countries: >50%

Significantly increasing trend in 12 countries

15.3%

70.1%

69.6%

67.3%

55.1%

28%

65.2% 16%

19.8%

Antimicrobial resistance surveillance in Europe EARS-Net Report 2013 www.ecdc.europa.eu

Escherichia coli: Percentage of invasive isolates with combined resistance to Ceph 3G, fluoroquinolones and aminoglycosides

in Europe (2013)

weighted mean resistance: 4.6% 0.9% (Iceland) – 20.4% (Cyprus) 19 countries: <5% 5 countries: 5-10% 6 countries: 10-25%

Increasing resistance trend for 13 countries (2010-2013)

Transmission and spread of antimicrobial resistance

• Horizontal & vertical transmission: – Horizontal transmission: plasmid-mediated conjugation

– Vertical transmission: clonal transmission by normal cell division

Cytoplasmic bridge

Air bridge

Molecular spread of ESBLs

Organisme

donneur

Diffusion clonale

(vertical)

Transfert de plasmides

(horizontal)

Diffusion plasmide

& transposon

(verticale + horizontale)

Mobilisation de gènes de

résistances (transposition plasmide ->

chromosome)

Antibiotic consumption in Belgium

: ECDC: ESAC-Net Report: Surveillance of antimicrobial consumption

in Europe, 2010

Figure 9. Sales for food-producing species, including horses, in

mg/PCU, of the various veterinary antimicrobial classes, by

country, for 2010

Source: ESVAC report, Sales of veterinary antimicrobial agents in

19 EU/EEA countries: 2010

Epidemiology of CTX-M β-Lactamases

Incidence et proportion d’E. coli BLSE + dans les hôpitaux belges

• Augmentation x 2 de l’incidence/1000 adm des E. coli BLSE + (2005-2012)

• Proportion de E. coli BLSE + augmente de 50% (croissance annuelle 0,43%; test tendance linéaire p<0.001)

Surveillance NSIH ISP, Rapport 2012, B. Jans

16

CTX-M-1 group: 79% (CTX-M15: 85%) CTX-M-9 group: 16% CTX-M-2 group: 4%

Rodriguez-Villalobos H, J Antimicrob Chemother. 2011 Jan;66(1):37-47

17 17

60 Nursing Homes, 2791 residents

7,1%

6,7% 5,6%

6,5%

8,3%

11,5%

6,3% 7,1%

9,0%

5,3%

4,2%

Weighted Prevalence:

Belgium: 6.2 [5.6-6.9]

Flanders: 6.0 [5.2-6.9]

Wallonia: 5.1 [4.2-6.2]

Brussels: 11.0 [8.5-14]*

Crude prevalence: 7.1%

(range: 0-20%)

18

18

Graph provided by Béa Jans, Public Health Institute

Susceptibility of 398 ESBL-producing Enterobacteriaceae to 15 antibiotics (EUCAST criteria)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Perc

ent

Me

m

Imi

Ert

a

Co

li

Te

mo

Tig

e

Am

ik

Ge

nta

Ptz

Fe

p

Ca

z

Ctx

Cip

ro

Le

vo

SX

T

Susceptible

Intermediate

Resistant

70 % of isolates are co-resistant to ciprofloxacin and to cotrimoxazole

Ptz Caz Cip Mem Tige Genta

Ctx Fep Imi Temo Amik

MIC distributions of ESBLs-producing

Enterobacteriaceae in Belgian hospitals

MIC

100

90

75

50

25

10

0

0.002

0.004

0.008

0.016

0.03

0.06

0.125

0.25

0.5

1

2

4

8

16

32

64

128

256

512

MIC

s

CMI Ptz

CMI Ctx

CMI Caz

CMI Fep

CMI Cip

CMI Imi

CMI Mem

CMI Tem

CMI Tig

CMI Ami

CMI Gen

CLSI EUCAST

N=331

Glupczynski, ECCMID 2007

Clinical Outcome in Patients with ESBL-pos Klebsiella/E.coli Bacteremia

and Treated with Cephalosporin Therapy

8167

27

11

33

7389

19

0

20

40

60

80

100

<=1mg/L 2 mg/L 4 mg/L 8 mg/L

Failure

Success

D.Andes and W.Craig, Clin Microbiol Infect 2005; 11: 10-17

« In general, the exposure from usual regimens of C3 and C4 doesn’t achieve the PD target

For many of the ESBL organism currently classified as Susceptible »

Antimicrobial resistance surveillance in Europe EARS-Net Report 2013 www.ecdc.europa.eu

Klebsiella pneumoniae: Percentage of invasive isolates with combined resistance to Ceph 3G, fluoroquinolones and aminoglycosides

in Europe (2013)

weighted mean resistance: 20.9% 0% (Iceland) – 57.9% (Slovakia) 13 countries: <5% 6 countries: 5-10% 8 countries: 10-25% 3 countries: >50%

Increasing resistance trend for 9 countries Mean weighed resistance: 15.1% in 2010 => 20.9% in 2013

7%

57.9%

55.4%

52.5%

41.8%

22.9%

11.2%

6.9%

1.7%

7%

1.8% 0.4%

Antimicrobial resistance surveillance in Europe EARS-Net Report 2013 www.ecdc.europa.eu

Klebsiella pneumoniae: Percentage of invasive isolates with resistance to carbapenems in Europe (2013)

weighted mean resistance: 8.3% 0% – 59.4 % (Greece)

Significantly increasing trend in 6 countries (CZ, F, I, SP, GR, D) Mean weighed resistance: 4.6% in 2010 => 8.3% in 2013

20.5%

59.4%

34.3%

5.9%

0.5%

0.3%

0.7%

0.7%

1.6%

1.7%

1.8%

2.7%

Antimicrobial resistance surveillance in Europe

EARS-Net Report 2013

www.ecdc.europa.eu

Pseudomonas aeruginosa: Percentage of invasive

isolates with resistance to carbapenems in Europe

(2013)

weighted mean resistance : 17.6%

2.9% (Denmark) – 60.5% (Romania)

7 countries: < 10%

14 countries: 10-25%

9 countries: >25% 11%

43.8%

58.9% 17.2%

25.9%

5.8%

49.3%

32.3%

28%

30.2%

Antimicrobial resistance surveillance in Europe

EARS-Net Report 2013

www.ecdc.europa.eu

Pseudomonas aeruginosa: Percentage of invasive isolates with

resistance to > 3 classes* of ABs (MDR) in Europe (2013)

weighted mean resistance : 13%

0% (Estonia/Iceland) – 49.4%

(Romania)

16 countries: < 10%

11 countries: 10-25%

3 countries: >25%

11.3%

49.4%

36.1% 12.6%

24.5%

4.1%

39.3%

24%

23.3.%

* Pip/tazo, Cefta, FQs, Aminoglycosides, Carbapenems

3.4%

4% of isolates resistant to all tested agents (XDR)

1% of isolates resistant to colistin

CARBAPENEM RESISTANCE: MECHANISMS

Enterobacteriaceae Cephalosporinase/ESBL + porin loss

Carbapenemase

P. aeruginosa Porin loss

Up-regulated efflux

Carbapenemase

Acinetobacter spp. Cephalosporinase + porin loss

Carbapenemase

Carbapenemases Classification Enzyme Most Common Bacteria

Class A

(Serine)

SME (1-4)

IMI (1-2)

NMC-A

KPC (2-15)

GES (2-23)

Enterobacteriaceae (rare reports in P. aeruginosa)

Class B

(Zinc)

(metallo- -lactamase)

Chromosomal

IMP (1-44),

VIM (1-38),

GIM, SPM, SIM

NDM (1-10)

Bacteroides, Aeromonas, Steno

P. aeruginosa Enterobacteriaceae

Enterobacteriaceae Acinetobacter spp.

Class D (Serine) OXA (-23,40,58)

OXA -48 (-162, 181,

204, 232, 244,245, 247)

Acinetobacter spp.

Enterobacteriaceae

Transmission of resistance determinants

• bla genes mobilized from chromosomes to plasmids: – transposases, insertion sequences, integrases involved

– blaCTX-M mobilizes 10x more frequently than blaSHV & blaTEM

• Horizontal & vertical transmission of plasmids: – Horizontal transmission: plasmid-mediated conjugation

– Vertical transmission: clonal transmission by normal cell division

The molecular epidemiology of carbapenem resistance…in a nutshell

The genes move between plasmids (or chromosomes) ...and

The plasmids move between strains, species and genera ...and

The bacteria move between hosts and settings

Acquired transferable carbapenemases

• IMP- and VIM- types are integron associated

OXA-48 and KPC are IS and transposon associated

National surveillance data of CPE

Significant increase of proportion of confirmed CPE among referred Enterobacteriaceae isolates (2013 vs 2012: p=0.03; 2014 vs 2013: p=0.0002)

Suggests better detection methods and recognition abilities of CPE by laboratories (implementation of improved methods, breakpoints, markers…)

Active national surveillance program (NSIH-NRC)

Evolution of CPE isolates confirmed at the National Reference Centre,

Belgium, January 2007 – August 2014 (n=2544)

0

50

100

150

200

250

300

350

2007 2008 2009 2010 2011 2012 2013 2014Q2

n is

ola

tes

Year

Carbapenemase enzymes distribution of CPE confirmed at the NRC

OXA-48

KPC

NDM

VIM

Other

8 months

Comparison of the distribution of Enterobacteriaceae received in 2013 and in 2014Q2 (8 months)

32%

8%

4% 2% 0% 0%

54%

Total Enterobacteriaceae isolates in 2013 (n=651)

OXA-48

KPC

NDM

VIM

OXA-48 + KPC

OXA-48 + NDM

Negative

62% 13%

10%

6% 5%

4%

Total CPE isolates in 2013 (n=301)

K. pneumoniae (n=187)

E. coli (n=41)

E. cloacae (n=29)

K. oxytoca (n=18)

C. freundii (n=15)

Other (n=11)

36%

9% 7% 4% 1% 0%

43%

Total Enterobacteriaceae isolates received in 2014 (n=556)

OXA-48

KPC

NDM

VIM

OXA-427

KPC and OXA-48

Negative

39

Remark: For confidentiality reasons, the locations of the bullets representing individual hospitals do not correspond to the real location of the hospitals in the province.

Prevalence of CPE in Belgian hospitals

• Methodology: – Multicentric (24 hospitals)

– Clinical samples

– Identical standardized methodology/materials

– 3 months in 2012

– 4564 Enterobacteriaceae isolates screened

Huang TD et al. J Antimicrob Chemother. 2013;68:1832-7.

• Results: – Increased prevalence of CNSE : 3.1% (95% CI: 2.9%–4.2%) vs 0.4% (2011 EARS-net data)

– Low prevalence of CPE: 0.28% (95% CI: 0.13%–0.44%)

– 13 CPE isolates: mainly autochtonous (n=11) K. pneumoniae (n=11) OXA-48 (n=8)

– 8/24 centers at least one CPE isolate

Incidence of CPE in Belgian hospitals • Method:

– EuSCAPE network survey (36 countries) using standardized methodology: analysis ungoing (C. Glasner, H. Grundmann, EuSCAPE workgroup)

– 11 Belgian hospitals institutional activity data (admissions, patient-days) – Estimated incidence rates of clinical CPE (screening samples excluded) for

2013 and 2014 (Q2: January to August)

• Results:

n CPE cases CPE incidence per 10000 admissions CPE incidence per 10000 patient-days

Hospital 2013 2014Q2 2013 2014Q2 2013 2014Q2 A 6 5 1.76 2.20 0.26 0.32

B 17 14 5.81 7.17 0.88 1.08

C 10 10 5.16 7.75 0.64 0.96

D 2 4 0.55 1.65 0.09 0.28

E 5 4 9.39 11.27 0.84 1.00

F 3 1 0.89 0.44 0.11 0.05

G 3 7 1.11 3.87 0.19 0.66

H 3 7 0.48 1.67 0.06 0.22

I 14 22 3.46 8.17 0.49 1.16

J 0 5 0.00 2.69 0.00 0.35

K 0 0 0.00 0.00 0.00 0.00

Total 63 79 1.89 3.55 0.26 0.50

Rising incidence of clinical CPE isolates in Belgian hospitals (mean incidence rate nearly doubled in 2014Q2 compared to 2013)

Huang et al., ECCMID 2015

Carbapenemases:

the triple difficulty (DDD)

• Difficulty of detection in the clinic and in the laboratory

• Difficulty of treatment (owing to their multi-drug resistant character, with few drugs remaining active)

• Difficulty to limit transmission and spread and to control

outbreak (local, regional, national, pandemic)

Classical workflow for the detection of CPE

Clinical samples Screening samples

Culture isolates

Susceptibility screening

Phenotypic confirmation Molecular identification

Day 0

Day 1

Day >2

Day 2

1 3 42 5 6 7 8 9 10 11 12 13 1514 C+C- CiM 1716

blaADC

blaVIM

blaIMP

blaKPC

blaNDM

1 3 42 5 6 7 8 9 10 11 12 13 1514 C+C- CiM 17161 3 42 5 6 7 8 9 10 11 12 13 1514 C+C- CiM 1716

blaADCblaADC

blaVIMblaVIM

blaIMPblaIMP

blaKPCblaKPC

blaNDMblaNDM

blaOXA-48

Non selective culture Selective culture

MHT CDT (class A, B)

Carbapenems R Multidrug R

CPE medium

Faecal samples

Performance? Speed?

Are CPE always multidrug resistant? K. pneumoniae KPC-2+ K. pneumoniae VIM-1+ E. coli NDM-1+

Poirel et al. J Antimicrob Chemother 2012

Pictures from Belgian National Reference

Laboratory

E. coli OXA-48+

MDR XDR

OXA-48 CPE really MDR ? • 25% not R to C3G • 40% not R to >=3 classes AB

Difficult to detect!

Acquired MDR, XDR, PDR definitions.

Magiorakos et al. CMI 2011

Are CPE always resistant to carbapenems?

EUCAST susceptibility breakpoint (MEM MIC <=2 mg/L): 58% of CPE meropenem S EUCAST susceptibility breakpoint (ETP MIC <=0.5 mg/L): 10% of CPE carbapenems S Higher proportion of E. coli CPE carbapenems S (42%) vs K. pneumoniae CPE (7%); p<0.001

Huang et al. RICAI Nov 2014. Oral session O215

84

85

12

K. pneumoniae CPE (n=181)

7

14

15

E. coli CPE (n=36)

Meropenem MIC distribution of Enterobacteriaceae isolates in 2014Q2 (n=556)

CLSI

2014 S

EUCAST

2014 S

Overall, 2/3 of CPE are susceptible to meropenem by MIC testing (75% of OXA-48 have meropenem MIC < 2 mg/L)

K. pneumoniae M/11721: OXA-48 (invasive infection strain)

Belgian National External QC 2012/Q3 (n=145 labs)

Laboratory detection of CPE in Belgium

24

37

6

25

77

311

33

20

17

16

0102030405060708090

Autom

ates

Disc diffu

sion

Gra

dien

t MIC

strips

>1 m

etho

d

Method

report CPE

Edit results

Nr

lab

ora

tori

es

With permission from K. Vernelen Belgian National EQC (ISP-WIV)

50% did not look/report mechanism! Single method user report mechanism less frequently

6% of labs (private) did not routinely test carbapenems !

CPE undetected (underreported)?

detection abilities in routine laboratories?

Meropenem MIC: 0.5 µg/ml Imipenem MIC: 1 µg/ml Ertapenem MIC: 2-4 µg/ml

Clinical implication of CPE

Carbapenem

Resistant

Enterobacteriaceae

(CRE/CNSE)

Carbapenemase

Producing

Enterobacteriaceae

(CPE)

Therapy dead-end

Dissemination

Susceptibility Mechanism

Infection control (Ciobotaro P, AJIC 2011)

Treatment (Tzouvelekis , CMR 2012)

Detection

• Almost no new drugs • Toxicity/inefficiency

of old drugs (colistine, tigecycline…)

• Horizontal transmission (plasmids, transposons…)

• Vertical transmission (clones)

Outbreaks

Carbapenemase producing Enterobacteriacae

– High infection/colonization ratio:

• 9% in all hospital → 40% in ICU 1,2

– Infections are associated with 3-5

• Crude mortality: 30 to 44% (up to 70% for bacteremia)

• Risk x 3-4 mortality versus susceptible Enterobacteriacae

• Delay in adequate antibiotherapy5 (increase of the LOS)

3Borer et al ICHE 2009; 30: 972 4Schwaber et al Antimicrob Agents Chemother 2007;52:1028-33 5Patel et al ICHE 2008; 29: 1099 .

1Schechner et al CMI 2012 2Borer et al AJIC 2011

Susceptibility rates of CPE to antibiotics Which drugs do still remain active …. ?

Susceptibility of 63 MBL (VIM)-producing P. aeruginosa to 12 antibiotics by microdilution MIC

(CLSI interpretative criteria)

National reference centre for antibiotic resistant

Pseudomonas and Acinetobacter, activity report 7/2014

06/06/13 Liège - certificat interuniversitaire 65

Anti Gram-negative agents in the pipeline

company drug status Enterobact. P. aeruginosa Acinetob.

ESBL sCBP mCBP WT MDR mCBP WT MDR

Cubist ceftolozane/

tazobactam

III

cUTI/cIAI

Astra/

Cerexa

ceftazidime/

avibactam

III

cIAI

Astra/

Cerexa

ceftaroline/

avibactam

II

cUTI/cIAI

Merck imipenem/

MK7655

II

cUTI/cIAI

Achaogen plazomicin II

cUTI

Tetraphase eravacycline II

cIAI

Polymedix brilacidine II

ABSSSI

Boucher et al. CID (2013) 56:1685-94 sCBP: serine-carbapenemase; mCBP: metallo-carbapenemase

34 clinical studies (81% appropriate Rx on in vitro basis)

Tzouvelekis et al., CMR 2012; 25: 682-707

Importance of Infection control programs to reduce the spread of CRE

Israël (2006)

• Multidisciplinary infection control program (guidelines for

patient isolation, cohorting, environment cleaning, education of staff, computerization system for flagging of CR-KP carriers (provision of instructions)

• Increase in rate of active surveillance by rectal sample for

carriers from 20% to 89% (in 2006-8 and 2009-2010)

‒ of CRE incidence by 16x from 6.6/1000 patient to 0.5/1000 patient (p<0.001; sustained over 30 months)

‒ Decrease of rate of cross-infection from by 2-3x (6.6% in 2006-2008 to 2.7% in 2009-2010; (p <0.05)

Ciobotaro P, AJIC 2011: 39: 671-7

Carbapenem producing enterobacteriaceae (CPE) Risk factors and indications for screening

Absolute indications for screening: – Patients who received medical care abroad (last 6 months -CDC)

– Patients epidemiologically linked to previously unrecognized CRE carrier (roommate, shared HCW)

– Patients known as previously infected or colonized by CPE

Relative indication: – Functional dependency (low-level autonomy)

– Indwelling devices

– Prior hospitalization or transfer from LTFC

– Previous antibiotics

(several cures or long-lasting ABs in the last 3-6 months)

Geriatric wards !!!

Infection control interventions for the containment of CPE

Institute of Public Health - Bea Jans - Boudewijn Catry - Sophie Quoilin

Hôpital Bicêtre Paris

- Thierry Naas - Laurent Dortet - Gaëlle Cuzon

Teams & Collaboration

CHU Mont Godinne (UCL) National Reference Laboratory - Youri Glupczynski - Daniel Huang - Pierre Bogaerts - Caroline Bauraing - Catherine Berhin - Stéphanie Evrard - Warda Boucharhouf - Marion Massart - Martin Hoebeke - Samy Yunus

Hôpital Erasme (ULB) Associated Ref. laboratory

- Olivier Denis - Sandrine Roisin - Amélie Heinrichs - Ariane Deplano - Claire Nonhoff - Ricardo De Mendonca

Epidemiologie de la résistance aux antibiotiques

chez P. aeruginosa

0%

5%

10%

15%

20%

25%

<D7 >=D7

Most frequently isolated micro-organisms in early and late nosocomial pneumonia

1997-2002 (n=5119)

C. Suetens, IPH Seminar, 22/11/2002 Scientific Institute of Public Health

1. Imperméabilité de la

membrane externe (100

X > E. coli)

• Efflux : Au moins 12

systèmes...

• Cephalosporinase

chromosomique

• (Oxacillinase OXA-50

chromosomique)

Efflux

Membrane

externe PBP

Enzymes

Résistant… Naturellement

Résistance naturelle aux ß-lactamines chez P. aeruginosa

Résistance naturelle

• amoxicilline, C1G, C2G,

céfotaxime, ceftriaxone

• Faible perméabilité

membranaire

• Céphalosporinase

chromosomique inductible

• Efflux actif

ß-lactamines actives

• ticarcilline

ac.clavulanique

• pipéracilline

tazobactam

• ceftazidime

• céfépime

• aztréonam

• Imipénème/méropénème

Mécanismes de résistance acquise

aux -lactames chez P. aeruginosa

• Inactivation enzymatique

– Différentes -lactamases

(céphalosporinases, pénicillinases, BLSE, carbapenemases…)

• Imperméabilité de paroi

Mutation affectant le nombre ou la structure des porines

– OprD2 R isolée aux carbapénèmes (IMI > MERO)

– OprF R croisée entre -lactames et autres AB (Quinolones)

• Hyperexpression de systèmes de pompes à efflux actif

– types de pompes composées chacune de trois protéines – Mutation dans le système de régulation (gène répresseur)

– Résistance croisée affectant plusieurs familles d’AB

• Modification des cibles (très rares: altérations PBP3, PBP4)

Résistance acquise aux β-lactamines chez P. aeruginosa

Phénotype TIC TCC PIP PTZ CAZ FEP AZT IMP MER

Wild type S S S S S S S S S

Penicillinase R I/R I/R I/R S I/S S S S

Cephalosporin

ase (AmpC)

I/R R I/R I/R I/R S/I/R I/R S S

ESBL R R S/I S/I R R R S S

MBL R R I/R I/R R R S R R

Efflux I/R I/R S S S I/S I/R S I/S

Porin D2

deficiency

S S S S S S S I/R S/I

G. Vedel, JAC 2005; 56: 657-64

F. Bert, JCM 2003; 41: 3712-8

Antimicrobial resistance surveillance in Europe

EARS-Net Report 2013

www.ecdc.europa.eu

Pseudomonas aeruginosa: Percentage of invasive

isolates with resistance to carbapenems in Europe

(2013)

weighted mean resistance : 17.6%

2.9% (Denmark) – 60.5% (Romania)

7 countries: < 10%

14 countries: 10-25%

9 countries: >25% 11%

43.8%

58.9% 17.2%

25.9%

5.8%

49.3%

32.3%

28%

30.2%

Antimicrobial resistance surveillance in Europe

EARS-Net Report 2013

www.ecdc.europa.eu

Pseudomonas aeruginosa: Percentage of invasive isolates with

resistance to > 3 classes* of ABs (MDR) in Europe (2013)

weighted mean resistance : 13%

0% (Estonia/Iceland) – 49.4%

(Romania)

16 countries: < 10%

11 countries: 10-25%

3 countries: >25%

11.3%

49.4%

36.1% 12.6%

24.5%

4.1%

39.3%

24%

23.3.%

* Pip/tazo, Cefta, FQs, Aminoglycosides, Carbapenems

3.4%

4% of isolates resistant to all tested agents (XDR)

1% of isolates resistant to colistin

Proportion de P. aeruginosa MDR (cefta, mero, tobra/amika-R)

dans les hôpitaux Belges - 2008

Proportion de P. aeruginosa MDR par REGION (%): Prop. brute Moyenne Prop. Médiane Min./Max.

Total: 60 785/13357 5.9 3.2 2.0 0 – 16.4

Flandre: 30 531/7265 7.3 2.3 0.6 0 – 12.7

Wallonie: 19 116/4260 2.7 2.7 2.3 0 – 7.4

Bruxelles: 11 138/1832 7.5 6.5 5.4 0 – 16.4

Proportion de P. aeruginosa Mero-R par TAILLE DE L'HOPITAL (%):

< 200 lits: 13 26/727 3.6 2.8 2.0 0 – 13.6

200 – 399 lits: 25 93/3364 2.8 2.8 1.8 0 – 16.0

400 – 699 lits 13 51/3132 1.6 1.8 1.3 0 – 5.6

700 lits et plus: 9 615/6134 10.0 6.8 6.8 0 – 16.4

Proportion de P. aeruginosa i-R par DUREE MOYENNE DE SEJOUR (%):

< 7 jours 16 47/2719 1.7 2.2 2.3 0 – 5.4

7 à 8 jours: 31 625/8504 7.3 3.0 1.8 0 – 12.7

9 jours ou plus 13 113/2134 5.3 4.6 2.0 16.4

Rapport Institut Scientifique Santé Publique (ISP/WIV), 11/2009

Proportion de P. aeruginosa MDR dans les hôpitaux Belges - 2012

Rapport Institut Scientifique Santé Publique (ISP/WIV), 1/2014

Susceptibility of P. aeruginosa to antimicrobials: Belgian multicentre hospital survey

• 25 representative university affiliated and general hospitals in Belgium (8 Wallonia, 11 Flanders, 5 Brussels)

• Clinically significant non-repetitive isolates from samples taken >48 hrs after admission – Collection period: 1st semester 2010

– Blood, deep respiratory isolates, sterile body fluids, urine

– Maximum of 40 isolates/hospital

Belgian P. aeruginosa surveillance 2010 EUCAST breakpoints

S % I % R %

merop 89,0 2,5 8,4

piptazo 81,8 - 18,2

cefta 80,8 - 19,2

cefep 84,5 10,7 15,5

genta 88,6 - 11,4

tobra 88,3 - 11,7

amika 89,7 3,2 7,1

cipro 75,0 2,5 22,5

levo 72,2 5,0 22,7

77 (8.8%) isolates MDR : resistant to > 3 classes of agents

45 (5.1%) isolates MDR : R-ceftaz/cipro/tobra

Pseudomonas spp. and Acinetobacter spp. isolates referred to the National Reference

Centre in Belgium in 2013

National Reference Center for multidrug-resistant Pseudomonas spp. and Acinetobacter

spp. CHU Mont-Godinne, Yvoir, Belgium

2014-01-15

Species distribution (n=250) Pseudomonas spp. (n=181; 72.4%)

Acinetobacter spp. (n=69; 27.6%)

Carbapenemase enzymes distribution

Β-lactams resistance mechanisms in Pseudomonas isolates referred to the NRC in 2013 (n=181)

PFGE typing of 65 MDR P. aeruginosa isolates

collected in Belgian hospitals in 2013

National reference centre for antibiotic resistant

Pseudomonas and Acinetobacter, activity report 7/2014

MLST typing of MDR P. aeruginosa strains collected in Belgium in 2013

National reference centre for antibiotic resistant

Pseudomonas and Acinetobacter, activity report 7/2014

Epidemiologie de la résistance aux antibiotiques

chez Acinetobacter spp.

Genus Acinetobacter

32 described Acinetobacter groups or named species Bouvet and Grimont, 1986: Acinetobacter baumannii

A. calcoaceticus- A. baumannii complex (Gerner- Smidt, J. Clin. Microb., 1991) Acinetobacter baumannii Acinetobacter calcoaceticus Genomospecies sp. 3 Genomospecies sp. 13TU

Phenotypically difficult to distinguish 65-75% relatedness in DNA-DNA

hybridization

Gram-negative coccobacilli Non-fermenters Non motile, Oxidase – Strict aerobes

Identification: rDNA16S sequence, rpoB sequence, DNA restriction analysis 16S rDNA (ARDRA) , Maldi-TOF (>>> (semi-)automated systems (API20 NE, VITEK, Phoenix,….)

Nosocomial infections: A. baumannii, groups 13TU (A. nosocomialis) & sp 3 (A. pittii)

Ecological distribution of A. baumannii: undefined reservoir Colonization of hosp patients: cutaneous, digestive and pharyngeous flora

Significant nosocomial pathogen In immunocompromised patients or with underlying diseases

Mainly urinary infections, pneumomia, device-related infections(also bacteremia, meningitis, skin and wound infections)

Mainly ICU

1% of hospital pathogens. 10% of nosocomial pneumonia in ICU; 17-50% mortality for A. baumannii bacteremia

Outbreaks (+++); seasonal variations; 40% infected for 60% colonized

Recent reports of community acquired infections Pneumonia (rarely meningitis, cellulitis)

Alcohol abuse, diabetes, cancer, chronic lung diseases

Lowman W et al.,J. Med Microbiol. 2008 Garcia-Garmendia JL et al. Clin. Infect. Dis. 2001

Acinetobacter baumannii - Emergent Pathogen

Acinetobacter baumannii infections

• Propensity for clonal spread

• Persistence in the environment up to 12 months

• Involvement in hospital outbreaks, evolves in burst

• Endemicity in certain hospitals

• Resistance to multiple antimicrobial agents

• Many recent outbreaks have been caused by multidrug-

resistant (MDR) strains of A. baumannii

Stoeva et al., CMI. 2008 Quinteira et al. AAC. 2004 Manikal et al., CID 2000

Epidemiology of resistance: The extend of the problem (early 2000’s)

Carbapenem resistance

15 hospitals in Brooklyn 1 month: 419 A baumannii => 53% carbapenem-resistant

Efflux

Permeability PBP

• Low membrane permeability

(<5% in comparison to E. coli

for cefalotine)

• Several constitutive efflux

systems : described AdeABC...

• Overexpression of naturally-

and chromosomally- occurring ß-

lactamases

- cephalosporinase (AmpC)

- oxacillinases (OXA-51)

The secrets of success

β-Lactamases

Genetics of acquired resistance in A. baumannii

• Mutation

/Deletion

• Plasmid

• Transposon

• Integron

• permeability; porin deficiency • Overexpression of efflux • Cephalosporinase overexpressed

• Penicillinases • ESBLs • Carbapenemases • Extended spectrum Oxacillinases

intI1

5'CS 3'CS

Definition of multiresistance in Acinetobacter spp.

Criteria not standardized ! Resistance markers used in Belgium: - Ureidopenicillins (Pip/tazo) - Ceph 3 and/or 4 (Ceftazidime/Cefepime) - Carbapenems (Imipenem, Meropenem) - Aminoglycosides (Genta, Tobra, Amika) - Fluoroquinolones (Ciprofloxacin, levofloxacin, moxiflo) ( multi-drug resistant: > 3 out of 5 classes reported as resistant (or resistance/intermediate susceptibility to carbapenem alone)

Acquired resistance by ß-lactamase production in A. baumannii

Overproduction of cephalosporinase

Restricted spectrum penicillinases

ESBLs

Oxacillinases (OXA-23, -24, -58)

Carbapenemases (metallo-ß-lactamases; VIM, IMP, NDM)

peculiar ESBLs (GES/KPCs)

ß-lactamase-mediated high level resistance in A. baumannii

Extended-spectrum Carbapenems

cephalosporins

Overexpression AmpC + -

Clavulanate inhibited ESBL + -

Oxacillinases (OXA-23,40,58) - +

Class B metallo-enzymes + * ++

* Except aztreonam (if no other associated resistance mechanism)

Pseudomonas spp. and Acinetobacter spp. isolates referred to the National Reference

Centre in Belgium in 2013

National Reference Center for multidrug-resistant Pseudomonas spp. and Acinetobacter

spp. CHU Mont-Godinne, Yvoir, Belgium

2014-01-15

Carbapenemase enzymes distribution

Β-lactams resistance mechanisms in Acinetobacter isolates referred to the NRC in 2013 (n=69)

Proportion of MDR (carba-R) A. baumannii in Belgian hospitals in 2012

B. JANS, Rapport ISP_WIV 01/2014

Trends in proportion and incidence of MDR (carba-R) A. baumannii in belgian hospitals

B. Jans, Annual Report; 01/2014

IPH/EPI REPORTS Nr. 2013 - 037

Numéro de Dépôt: D/2013/2505/48

Epidemiology of MDR- and carbapenem-resistant Acinetobacter baumannii in Belgium:

Outbreak Time period Number of analyzed isolates Hospital Resistance mechanismOrigin index case PFGE type

Carbapenem resistant Ab outbreaks

1 09/2004 03/2005 9 A OXA-58 Greece 10

2 12/2006 03/2007 4 B OXA-23 Unknown 12

3 11/2006 12/2007 46 C OXA-23 Algeria 12

4 10/2007 12/2007 14 D OXA-23 Morocco 39

5 02/2008 08/2009 13 E OXA-23 Thailand 44

6 04/2008 06/2008 6 F OXA-23 France 39

7 04/2009 06/2009 5 G GES-12 Unknown Not analyzed

8 05/2009 08/2009 4 H OXA-23 France Not analyzed

9 07/2010 11/2010 53 I OXA-72 Algeria Not analyzed

10 09/2010 11/2010 4 J OXA-23 Unknown Not analyzed

Carbapenem susceptible Ab outbreaks

1 03/2007 6 K ADC overexpressed - Not analyzed

2 02/2008 4 L OXA-58 Morocco 42

3 06/2008 09/2008 5 B OXA-58 Greece 10

4 08/2008 10/2008 6 I PER-1 Unknown Not analyzed

A .Verroken, ECCMID 2011

Dice (Opt:0.50%) (Tol 0.8%-0.8%) (H>0.0% S>0.0%) [6.2%-89.0%]

PFGE Apa 23h (Marq OK)

10

0

90

80

70

60

PFGE Apa 23h (Marq OK)

5.0

0

10.0

0

20.0

0

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0

60.0

070.0

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0

80.0

0

90.0

0

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0

110.0

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0

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0529-2024

RUH 0875 clone Européen I (19.

GIL1

GIL2

GIL5

GIL6

GIL7

GIL4

GIL3

Ab2004

04-1638

04-2126

04-2263

05-1095

1008240888

40

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70006

080604495

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1022 00430-2

06/0062

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RUH0134 clone Européen II (19.

282-310261

080602616

080608219

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5547

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LUH 05875 clone Européen III

80213182

80217060

80218626

80213336

6301086

HM2

51514

080609271

15345

2008B041

19172 (oxa-23) ( CM7265226)

19174 (oxa-23) ( DG7271622)

19169 (oxa-23) ( GJ7294232)

19175 (oxa-23) ( SML7296631)

19173 (oxa-23) (DA7302849)

19168 (oxa-23) (djo7292673)

19176 (oxa-23) ( DJa7281926)

15518 (414-9659)

2008B051(oxa-23)

2008B053 (oxa-23)

2008B052 (oxa-23)

2008B048 (oxa-23)

2008B049 (oxa-23)

17528

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2008B040

2008B098

20160

20252

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2008B097

2008B099

2008B058 (oxa-23)

2008B056 (oxa-23)

2008B057 (oxa-23)

2008B055 (oxa-23)

2008B054 (oxa-23)

2008B018

2008B042

2008B023

2008B022

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39d

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OXA-58

PFGE patterns of A. baumannii isolates from Belgian hospitals (outbreaks 2008-2012)

Summary

- Marked trends towards increased carbapenem resistance and multi-drug resistance in A. baumannii worldwide (Important regional and local geographic variations in prevalence/incidence)

-Outbreaks with different clones (sometimes several clones concomittantly) occurring mostly in critically ill patients in ICU patients

-Pandemic spread of a few number of successful clones (OXA-23 European clones I and II)

-Outbreaks difficult to control (long-term survival in environment, great diversity of reservoirs that are difficult to identify)

-- Reversion of resistance is rare ; most MDR strains remained susceptible to polymyxins, sulbactam and to tetracycline analogues only

- Interpretated reading of antibiotic susceptibility testing in A. baumannii is difficult and molecular testing is necessary for confirmation of mechanisms owing to the lack of phenotypic tests (OXA carbapenemases)