240 prevalence and molecular characterization of fecal

Background: Intestinal carriers of ESBLs and carbapenemases play an important role in

dissemination of bacterial resistance worldwide. The increasing reporting of ESBL-producing

bacteria in Community Onset (CO) infections highlights the importance of recognizing and

characterizing the colonization burden of patients.

Methods: An analytical cross-sectional study was carried out during a 4-month period in 3

tertiary-care institutions in Colombia. Patients admitted to the emergency room with clinical

suspicion of Community Onset Urinary Tract Infections (CO-UTI) were included. After signing

the informed consent, patients had a rectal swab taken and a case report form filled out.

Antimicrobial susceptibility and ESBLs screening were tested using Broth Microdilution (BM)

method (Sensititre panels; TREK Diagnostic Systems, Westlake, OH); the results were

interpreted according to CLSI 2012 guidelines. Modified Hodge Test (MHT) was used for

carbapenemases screening. PCR for blaKPC, blaSHV, blaTEM, blaCTX-M, blaVIM, blaIMP, blaOXA-48, and

blaNDM was performed in positive isolates, followed by sequencing. Clonal relatedness was

done by automated rep-PCR (DiversiLab; bioMerieux) between the colonizing (5) and the

infecting (5) strains.

Results: From 54 Enterobacteriaceae obtained, 39% (21) were ESBL-positive isolates

corresponding to: E. coli (16), K. pneumoniae (4) and S. marcescens (1). ESBL-positive isolates

were 100% non-susceptible to ceftriaxone and cefotaxime, 86% to ceftazidime, 81% to

ciprofloxacin, 71% to trimethoprim-sulfamethoxazole, 62% to cefepime, and 10 % to

amikacin. The predominant ESBL was CTX-M-15 followed by SHV-12 enzymes. MHT was

positive in 3/54 isolates but only one encoded a KPC-2 enzyme. Two clones, 1 E. coli and 1 S.

marcescens, were colonizing and infecting one different patient each. Of note, the E.coli

clone harbored CTXM-15 and belonged to ST131. Intestinal colonization by ESBL-producing

Enterobacteriaceae was not statistically associated with a Healthcare-Associated Infection

(OR 1.24, CI 95% 0.31 – 4.67) neither with antibiotic treatment 3 months prior admission

(OR 1.14, CI 95% 0.35 – 3.69).

Conclusions: The high proportion of ESBL-producing Enterobacteriaceae among fecal

carriers is an important finding, especially due to the presence of the CTXM-15 enzyme

belonging to the ST131 in the setting of CO-UTI.

Maria V. Villegas, MD, MSc. Carrera 125 # 19 – 225 Cali, Colombia.

mariavirginia.villegas@gmail.com (572) 555-2164

Prevalence and Molecular Characterization of Fecal Carriage of ESBLs and Carbapenemases Producing Enterobacteriaceae in Adults with Suspected Community Onset Urinary Tract Infection

V.M. BLANCO1, M.N. PERENGUEZ1, A. CORREA1, J.J. MAYA1, G. MOTOA1, H. VARGAS2, A.Y. CELIS2, C.M. MONTOYA3, M. GARZON3, F. ROSSO4, L. MATTA5, J.P. QUINN6, M.V. VILLEGAS1 1Centro Internacional De Entrenamiento e Invest. Médicas (CIDEIM), Cali, Colombia. 2Secretaria Distrital de Salud, Bogotá, Colombia. 3Hosp. El Tunal, Bogotá, Colombia. 4Fund. Clínica Valle de Lili, Cali, Colombia. 5Clínica Universitaria Rafael Uribe Uribe, Cali, Colombia. 6AstraZeneca, Waltham, MA

MATERIALS & METHODS

CONCLUSIONS

REFERENCES

� Study Design: an analytical cross-sectional study was carried out during a 4-month period in

three tertiary-care hospital.

� Inclusion criteria: patients of all ages and both sexes who were admitted to the Emergency

Department with a probably diagnosis of CO-UTI.

� Exclusion criteria: UTI diagnosed after 72 hours of hospitalization.

� De�nitions:

� CO-UTI: a UTI detected outside of the hospital setting or before 72h of hospitalization

� Methods:

� For 24hrs a day, 7 days a week, a group of previously trained nurses identified all patients

admitted to the Emergency Department who met the inclusion criteria.

� After patients accepted and signed an informed consent form, a case report form was

filled out with epidemiological and clinical data.

� All participating patients were asked for a urine sample and a rectal swab in order to

perform a culture

� Antimicrobial susceptibility and ESBLs screening was done using Broth Microdilution (BM)

method in all positive Enterobacteriaceae (Sensititre panels; TREK Diagnostic Systems,

Westlake, OH); the results were interpreted according to CLSI 2012 guidelines.

� Modified Hodge Test (MHT) was used for carbapenemases screening.

� PCR for blaKPC, blaSHV, blaTEM, blaCTX-M, blaVIM, blaIMP, blaOXA-48, and blaNDM was performed in

positive isolates, followed by sequencing. Clonal relatedness was done by automated rep-

PCR (DiversiLab; bioMerieux) between the colonizing and the infecting strains.

� The high proportion of fecal carriage of CTX-M-15-producing Enterobacteriaceae in the

community is worrisome due to the probable dissemination in the community and in the

hospital once the patient is hospitalized.

� Detection of patients with fecal carriage of ESBLs plays an important role for an early

intervention to decrease its spread within the hospitals and between patients.

� Community-based transmission of ESBL would indicate a need for strengthening enhanced

surveillance programs

240

ACKNOWLEDGMENTS

We thank the staff of Hospital El Tunal, Clínica Universitaria Rafael Uribe Uribe, Fundación Clínica

Valle del Lili, Elsa P.De La Cadena for their support. This study was supported by a a research

grant from COLCIENCIAS (Contract 222951928995) and Merck Sharp & Dohme

[1] Valverde A, et al. J Clin Microbiol. 2004 Oct;42(10):4769-75. [2] Bonomo RA, et al. J Am Geriatr Soc. 2003 Apr;51(4):519-22. [3] Mirelis B, et al. Emerg Infect Dis. 2003 August; 9(8): 1024–1025. [4] Millar MR, et al. J. Antimicrob. Chemother.2001 47:605-610.

RESULTS

54 rectal isolates (+) Enterobacteriaceae

21 (39%)

ESBL (+)

16 E. coli

4 K. pneumoniae

1 S. marscenses

33 (61%) ESBL (-)

26 E.coli

3 K. pneumoniae

3 S. marscenses

2 E. cloacae BACKGROUND

Table 1. Molecular and Microbiological characteristics of ESBL-positive Enterobacteriaceae isolated from stool of patients with suspected CO-UTI

Isol

ate

No.

Age

Gen

der

Sp MIC

MHT PCR and sequencing results AMK ATM CAZ CRO CTX FEP CIP ETP NIT FOS SXT P/T AUG

5306 81y M eco >64 >32 >64 >32 >64 64 >4 8 ≤32 ≤32 >4/76 8/4 32/16 NEG CTXM-15 5410 73y F eco ≤4 >32 32 >32 >64 32 >4 ≤0.12 64 ≤32 >4/76 16/4 32/16 NEG CTXM-15 5957 76y F eco ≤4 32 8 >32 64 16 >4 ≤0.12 64 ≤32 4/76 8/4 ≤16/8 NEG CTXM-15 5405 54y F eco 8 >32 8 >32 >32 32 >4 ≤0.12 ≤32 ≤32 ≤2/38 16/4 32/16 NEG CTXM-15 5247 58y M sma ≤4 8 4 >32 >64 16 ≤0.25 ≤0.12 128 ≤32 >4/76 ≤1/4 32/16 ND CTXM-15/TEM 5251 58y M eco 8 32 16 >32 64 32 >4 2 >128 ≤32 ≤2/38 16/4 32/16 NEG CTXM-15/TEM 5642 ND ND eco 16 32 16 32 >64 16 >4 ≤0.12 ≤32 128 ≤2/38 16/4 32/16 NEG CTXM-15/TEM 5958 76y M eco 8 >32 32 >32 >64 32 >4 0.5 ≤32 ≤32 >4/76 16/4 64/32 POS CTXM-15/TEM 5525 71y F eco ≤4 32 8 >32 >64 16 >4 ≤0.12 ≤32 ≤32 ≤2/38 2/4 ≤16/8 NEG CTXM-15/TEM 5418 99y M eco ≤4 >32 16 >32 64 8 >4 ≤0.12 128 ≤32 >4/76 8/4 32/16 NEG CTXM-15/TEM/SHV 5299 26y F eco ≤4 32 16 4 2 ≤1 ≤0.25 0.25 ≤32 64 >4/76 2/4 ≤16/8 NEG SHV 5287 72y M kpn ≤4 >32 64 8 4 2 >4 ≤0.12 64 >128 >4/76 4/4 ≤16/8 NEG SHV 5640 12y F eco ≤4 8 8 >32 32 4 ≤0.25 ≤0.12 ≤32 ≤32 >4/76 4/4 64/32 NEG TEM 5312 65y F eco >64 >32 16 >32 >64 16 >4 8 ≤32 ≤32 >4/76 8/4 64/32 POS TEM 5626 93y M eco >64 >32 >64 >32 >64 32 >4 16 ≤32 ≤32 >4/76 64/4 64/32 POS TEM/ KPC-2 5219 66y F eco ≤4 16 16 2 2 ≤1 >4 ≤0.12 ≤32 ≤32 ≤2/38 ≤1/4 ≤16/8 NEG TEM/SHV 5243 67y F eco ≤4 16 8 2 2 1 >4 ≤0.12 ≤32 64 >4/76 ≤1/4 ≤16/8 NEG TEM/SHV 5246 44y M kpn 8 >32 >64 32 8 4 >4 ≤0.12 128 ≤32 >4/76 >128/4 64/32 NEG TEM/SHV 5728 77y F eco >64 >32 >64 >32 >64 128 >4 16 64 ≤32 >4/76 16/4 ≤16/8 NEG TEM/SHV 5223 10m M kpn ≤4 ≤2 0.5 32 32 16 >4 ≤0.12 >128 >128 >4/76 ≤1/4 ≤16/8 NEG NEG 5530 5m M kpn ≤4 4 1 16 8 8 ≤0.25 ≤0.12 64 ≤32 ≤2/38 2/4 ≤16/8 NEG NEG

RESULTS

Intestinal carriers of ESBLs and carbapenemases play an important role in the dissemination of

bacterial resistance worldwide. Few studies have evaluated fecal carriage of ESBL-producing

isolates during no-noutbreak situations and among patients in the community [1-4].

The increased prevalence of fecal carriage of ESBL-producing isolates in the community

highlights the importance of recognizing and characterizing the colonization burden of patients.

( S I R)

� The predominant ESBL was CTX-M-15.

� Modified Hodge Test was positive in 3/54 isolates but only one encoded a KPC-2 enzyme.

� Intestinal colonization by ESBL-producing Enterobacteriaceae was not statistically associated

with a Healthcare-Associated Infection (OR 1.24, CI 95% 0.31 – 4.67) neither with antibiotic

treatment 3 months prior admission (OR 1.14, CI 95% 0.35 – 3.69).