Yonsei Med J.  2016 May;57(3):641-646. 10.3349/ymj.2016.57.3.641.

The Resistance Mechanism and Clonal Distribution of Tigecycline-Nonsusceptible Klebsiella pneumoniae Isolates in Korea

• Ahn C
• Yoon SS
• Yong TS
• Jeong SH
• Lee K

• KMID: 2374083
• DOI: http://doi.org/10.3349/ymj.2016.57.3.641

Abstract

PURPOSE
Tigecycline is one of the drugs used to treat multi-drug resistant Klebsiella pneumoniae (K. pneumoniae) infections, including complicated skin and soft tissue infections, complicated intra-abdominal infection, and community-acquired pneumonia in the Republic of Korea. However, since its commercial release, K. pneumoniae resistance against tigecycline has been reported, and there is a serious concern about the spread of tigecycline resistant bacteria.
MATERIALS AND METHODS
In this study, we collected and analyzed 342 isolates from 23 hospitals in the Republic of Korea to determine the mechanisms of tigecycline susceptibility and their clonal types. The hospitals include several from each province in the Republic of Korea, except Jeju, an island province, and nonsusceptibility among the isolates was tested by the disk diffusion method. In our lab, susceptibility was checked again using the broth dilution method, and clonal types were determined using the multilocus sequence typing protocol. Real-time PCR was performed to measure the ramR mutation in the isolates nonsusceptible to tigecycline, which would suggest an increased expression of the AcrAB multidrug pump.
RESULTS
Fifty-six K. pneumoniae isolates were found to be nonsusceptible, 16% of the 342 collected. Twenty-seven and nine isolates of the tigecycline nonsusceptible isolates had mutations in the ramR and rpsJ genes, respectively; while 18 nonsusceptible isolates harbored the tetA gene. Comparison of isolates with and without ramR mutation showed a significant statistical difference (p<0.05) for expression of AcrAB. Moreover, the most common clonal types, as observed in our study, appear to be ST11 and ST789.
CONCLUSION
Several dominate clonal types infer tigecycline resistance to K. pneumoniae, including ST11, ST768, ST15, ST23, ST48, and ST307. There does not seem to be a transferrable medium, such as plasmid, for the resistance yet, although mutation of the ramR gene may be a common event, accounting for 48% of the nonsusceptibility in this study.

Keyword

Tigecycline; Klebsiella pneumoniae; ramR

MeSH Terms

Anti-Bacterial Agents/*pharmacology/therapeutic use
Bacterial Proteins
*Drug Resistance, Bacterial
Humans
Klebsiella Infections/*drug therapy
Klebsiella pneumoniae/*drug effects/genetics/*isolation & purification
Microbial Sensitivity Tests
Minocycline/*analogs & derivatives/pharmacology/therapeutic use
Multilocus Sequence Typing
Plasmids
Polymerase Chain Reaction
Real-Time Polymerase Chain Reaction
Republic of Korea
Anti-Bacterial Agents
Bacterial Proteins
Minocycline

Reference

1. Giamarellou H, Poulakou G. Multidrug-resistant Gram-negative infections: what are the treatment options? Drugs. 2009; 69:1879–1901.

2. Docobo-Pérez F, Nordmann P, Domínguez-Herrera J, López-Rojas R, Smani Y, Poirel L, et al. Efficacies of colistin and tigecycline in mice with experimental pneumonia due to NDM-1-producing strains of Klebsiella pneumoniae and Escherichia coli. Int J Antimicrob Agents. 2012; 39:251–254.

3. Lin YT, Wang FD, Chan YJ, Fu YC, Fung CP. Clinical and microbiological characteristics of tigecycline non-susceptible Klebsiella pneumoniae bacteremia in Taiwan. BMC Infect Dis. 2014; 14:1.

4. Sun Y, Cai Y, Liu X, Bai N, Liang B, Wang R. The emergence of clinical resistance to tigecycline. Int J Antimicrob Agents. 2013; 41:110–116.

5. Akiyama T, Presedo J, Khan AA. The tetA gene decreases tigecycline sensitivity of Salmonella enterica isolates. Int J Antimicrob Agents. 2013; 42:133–140.

6. Tuckman M, Petersen PJ, Projan SJ. Mutations in the interdomain loop region of the tetA(A) tetracycline resistance gene increase efflux of minocycline and glycylcyclines. Microb Drug Resist. 2000; 6:277–282.

7. Villa L, Feudi C, Fortini D, García-Fernández A, Carattoli A. Genomics of KPC-producing Klebsiella pneumoniae sequence type 512 clone highlights the role of ramR and ribosomal S10 protein mutations in conferring tigecycline resistance. Antimicrob Agents Chemother. 2014; 58:1707–1712.

8. Hentschke M, Wolters M, Sobottka I, Rohde H, Aepfelbacher M. ramR mutations in clinical isolates of Klebsiella pneumoniae with reduced susceptibility to tigecycline. Antimicrob Agents Chemother. 2010; 54:2720–2723.

9. Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing: 21st informational supplement (M100-S21). Wayne, PA: CLSI;2011.

10. Chiu SK, Wu TL, Chuang YC, Lin JC, Fung CP, Lu PL, et al. National surveillance study on carbapenem non-susceptible Klebsiella pneumoniae in Taiwan: the emergence and rapid dissemination of KPC-2 carbapenemase. PLoS One. 2013; 8:e69428.

11. Ovejero CM, Hidalgo L, Gutierrez B, Carrilero L, Santos-Lopez A, Thomas-Lopez D, et al. Human adapted Klebsiella pneumoniae ST11 and ST147 resistant to tigecycline from pet animal. In : Poster presentado en Med-Vet-Net Association International Scientific Conference 2013; 2013 Jun 24-25; Lyngby.

12. Rubio FG, Oliveira VD, Rangel RM, Nogueira MC, Almeida MT. Trends in bacterial resistance in a tertiary university hospital over one decade. Braz J Infect Dis. 2013; 17:480–482.

13. Spanu T, De Angelis G, Cipriani M, Pedruzzi B, D'Inzeo T, Cataldo MA, et al. In vivo emergence of tigecycline resistance in multidrug-resistant Klebsiella pneumoniae and Escherichia coli. Antimicrob Agents Chemother. 2012; 56:4516–4518.

14. Landman D, Bratu S, Kochar S, Panwar M, Trehan M, Doymaz M, et al. Evolution of antimicrobial resistance among Pseudomonas aeruginosa, Acinetobacter baumannii and Klebsiella pneumoniae in Brooklyn, NY. J Antimicrob Chemother. 2007; 60:78–82.

15. Pakzad I, Zayyen Karin M, Taherikalani M, Boustanshenas M, Lari AR. Contribution of AcrAB efflux pump to ciprofloxacin resistance in Klebsiella pneumoniae isolated from burn patients. GMS Hyg Infect Control. 2013; 8:Doc15.

16. Bialek-Davenet S, Leflon-Guibout V, Tran Minh O, Marcon E, Moreau R, Nicolas-Chanoine MH. Complete deletion of the ramR gene in an in vitro-selected mutant of Klebsiella pneumoniae overexpressing the AcrAB efflux pump. Antimicrob Agents Chemother. 2013; 57:672–673.

17. Seecoomar GD, Marmol BC, Kwon DH. Promoter deletions of Klebsiella pneumoniae carbapenemase (KPC)-encoding genes (bla_KPC-2) and efflux pump (AcrAB) on β-lactam susceptibility in KPC-producing Enterobacteriaceae. FEMS Microbiol Lett. 2013; 348:120–126.

18. Padilla E, Llobet E, Doménech-Sánchez A, Martínez-Martínez L, Bengoechea JA, Albertí S. Klebsiella pneumoniae AcrAB efflux pump contributes to antimicrobial resistance and virulence. Antimicrob Agents Chemother. 2010; 54:177–183.

19. Shin SY, Bae IK, Kim J, Jeong SH, Yong D, Kim JM, et al. Resistance to carbapenems in sequence type 11 Klebsiella pneumoniae is related to DHA-1 and loss of OmpK35 and/or OmpK36. J Med Microbiol. 2012; 61(Pt 2):239–245.

20. Ko KS, Lee JY, Baek JY, Suh JY, Lee MY, Choi JY, et al. Predominance of an ST11 extended-spectrum beta-lactamase-producing Klebsiella pneumoniae clone causing bacteraemia and urinary tract infections in Korea. J Med Microbiol. 2010; 59(Pt 7):822–828.

21. Qi Y, Wei Z, Ji S, Du X, Shen P, Yu Y. ST11, the dominant clone of KPC-producing Klebsiella pneumoniae in China. J Antimicrob Chemother. 2011; 66:307–312.