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Klebsiella pneumoniae (ST1519) producing KPC-19 carbapenemase in a patient undergoing selective digestive decontamination before liver transplantation

2017; Elsevier BV; Volume: 24; Issue: 2 Linguagem: Inglês

10.1016/j.cmi.2017.08.009

1469-0691

Anna Rita Centonze, Anna Maria Azzini, Romualdo Mazzi, Mara Merighi, Ercole Concia, Annarita Mazzariol,

Pneumocystis jirovecii pneumonia detection and treatment

Here we describe a patient colonized by a Klebsiella pneumoniae strain harbouring a novel carbapenemase who underwent liver transplantation after selective digestive decontamination (SDD) [[1]Safdar N. Said Adnan Lucey M.R. The role of selective digestive decontamination for reducing infection in patients undergoing liver transplantation: a systematic review and meta-analysis.Liver Transpl. 2004; 10: 817-827Crossref PubMed Scopus (95) Google Scholar]. The galenic preparation contained effective drugs, as subsequently reported by a susceptibility test and confirmed by the microdilution method. Early in 2013, a 52-year-old patient with postalcoholic decompensated liver cirrhosis classified as B8 by the Child-Pugh score and with a 3-month mortality risk of 19.6% as assessed by a score of 24 by the Model for End Stage Liver Disease—Serum Na (MELD-Na) underwent evaluation for liver transplantation. The pretransplant infectious disease checklist included a surveillance rectal swab in order to identify enteric colonization with Gram-negative rods harbouring extended-spectrum β-lactamase (ESBL) and/or carbapenemases. Surveillance cultures were performed on ESBL Agar ChromID plates (bioMérieux, Marcy l'Étoile, France) plus an ertapenem disk (10 μg/mL). Carbapenemase production was confirmed by the CarbaNP test [[2]Nordmann P. Poirel L. Dortet L. Rapid detection of carbapenemase producing Enterobacteriaceae.Emerg Infect Dis. 2012; 18: 1503-1507Crossref PubMed Scopus (577) Google Scholar]. The patient was found to be colonized with a K. pneumoniae (MDR 53 strain) carbapenemase producer, as shown by two separate rectal swabs. The patient was not considered suitable for transplantation and initiated a 7-day SDD regimen with an oral gel formulation of colistin (polymyxin E) 100 000 UI/10 mL plus gentamicin (1.6 mg/10 mL). The patient received 5 mL every 6 hours in association with 5 mL every 6 hours of colistin oral solution (1 000 000 UI/5 mL) plus 4 mL every 6 hours of gentamicin oral solution (20 mg/mL) [[3]Saidel-Odes L. Polachek H. Paled N. Riesenberg K. Schlaeffer F. Trabelsi Y. et al.A randomized, double-blind, placebo-controlled trial of selective digestive decontamination using oral gentamicin and oral polymyxin E for eradication of carbapenem-resistant Klebsiella pneumoniae carriage.Infect Control Hosp Epidemiol. 2012; 33: 14-19Crossref PubMed Scopus (157) Google Scholar]. A month later, the prescribed antibiotic regimen was completed, and surveillance rectal swabs were negative for carbapenemase-producing K. pneumoniae. The patient received a liver transplant and received perisurgical antibiotic prophylaxis with colistin (9 MU loading dose, continuing with 4.5 MU 12 hours after every 12 hours), tigecycline (100 mg loading dose, continuing 12 hours later with 50 mg every 12 hours) and meropenem (2 g every 12 hours), all starting 24 hours before transplantation and with 3 days' total treatment duration. Blood samples taken during the surgical procedure and a pretransplant rectal swab were negative. Nevertheless, the surveillance rectal swab a week after transplantation was positive for K. pneumoniae carbapenemase producer (MDR 136 isolate), as it was again a month later (MDR 345 isolate). Strains isolated before and after transplant were compared for antimicrobial susceptibility as well as for carbapenemase production and genotype. MICs for carbapenems and colistin were performed by the microdilution method and were interpreted in accordance with the latest European Committee on Antimicrobial Susceptibility Testing (EUCAST) criteria (http://www.eucast.org/fileadmin/src/media/PDFs/EUCAST_files/Breakpoint_tables). All of them had MICs for meropenem, imipenem and ertapenem higher than 128 mg/L. The MIC for colistin was 0.5 mg/L and for tigecycline was 1 mg/L. All strains were susceptible to gentamicin (MIC 1 mg/L). Secondary resistance to gentamicin and colistin following SDD was not detected. Investigation of genes encoding for carbapenemases (KPC, MBL, OXA type) was performed by PCR following a published protocol [[4]Dallenne C. Da Costa A. Decré D. Favier C. Arlet G. Development of a set of multiplex PCR assays for the detection of genes encoding important β-lactamases in Enterobacteriaceae.J Antimicrob Chemother. 2010; 65: 490-495Crossref PubMed Scopus (1151) Google Scholar]. The blaKPC gene was detected in all three strains. After sequencing, all amplicons showed an N291T substitution compared to the KPC-3 enzyme. This new enzyme was named KPC-19 (http://www.lahey.org/studies); its GenBank accession number is KJ775801. Strains were typed by multilocus sequence typing (MLST). MLST was performed for all three isolates. Their profile was new and corresponded to ST1519, and a number was assigned (http://www.pasteur.fr/mlst). The new profile differs from ST512 as a result of allele rpoB: ST1519 had the rpoB allele 9 instead of 1. The strains isolated before and after liver transplantation shared the same new ST1519 and harboured a new enzyme, KPC-19, which was different from the KPC-3 enzyme endemic in our hospital, harboured by the ST512. An important limitation of our report is that we were not able to test if pre- and post-SDD colonizing K. pneumoniae were the same strains because we did not perform whole genome sequencing of the strains. It is worth noting, however, that SDD allowed for a safe transplantation procedure and did not select a strain resistant to the drugs that were used. All authors report no conflicts of interest relevant to this letter.