Chaaben, BM

Elahmer, O

Ghenghesh, KS

Hammami, A

Kraiem, AG

Zorgani, A

English

AJOL - African Journals Online

LETTER TO THE EDITORNew Delhi metallo-b-lactamase and OXA-48carbapenemases in Gram-negative bacilli isolatesin LibyaTo the EditorCarbapenems (i.e. ertapenem, imipenem, meropenem,and doripenem) are second line antimicrobials reservedto treat serious infections, including those caused by Gram-negative bacilli (GNB) producing extended-spectrumb-lactamses (ESBLs). ESBLs mediate resistance amongGNB to b-lactam drugs, including third generationcephalosporins. Emergence of carbapenemases-producingGNB (mainly Acinetobacter baumanii, Pseudomonasaeruginosa, and members of the family Enterobacteria-ceae) in the last decade is a serious health problemglobally. Carbapenemases are members of three molecu-lar groups of b-lactamases, Ambler class A, B (i.e.metallo b-lactamases [MBLs]), and D (i.e. oxacillinases)(1, 2). Recently, the novel carbapenemase New DelhiMBL (NDM) was reported for the first time in Tunisia inKlebsiella pneumoniae isolated from a female patienttransferred from Libya (3). However, there is littleinformation regarding genes associated with carbapenemresistance among GNB in Libya.Included in the study were eight GNB isolates that areresistant to at least one carbapenem (i.e. ertapenem)obtained in 2013 and 2014 from different clinical speci-mens from patients at the time an infection occurred.Patients were aged between 10 and 87 years (mean37.1years). Information about patients and the organismsisolated from them included in the study are shown inTable 1. In this prospective investigation, clinical speci-mens were collected under approved ethical standards,and the study was reviewed and approved by theAcademy of Graduate Studies, Tripoli, Libya.All specimens were cultured on plates of blood agar andMacConkey agar (Oxoid Ltd., Basingstoke, Hampshire,UK) and incubated at 378C for 2448 h. Isolated orga-nisms were identified to the species level and tested for theirsusceptibility to avariety of antimicrobial agents by the BDPhoenix Automated Microbiology System (PAMS, MSBDBiosciences, Sparks, MD, USA) as recommended by themanufacturer. PAMS provides antimicrobial susceptibilityresults as susceptible (S), intermediate susceptible (I), orresistant (R) and are interpreted according to Clinical andLaboratory Standards Institute criteria (4). Quality con-trol strains used included Escherichia coli ATCC 25922,K. pneumoniae ATCC 700603, and P. aeruginosa ATCC27853 (ATCC, LGC Standards S.r.l., Italy). Furthermore,six of the GNB isolates were tested phenotypically for theproduction of MBLs by the MIC Test Strip MBL(Liofilchem, Rosetodegli Abruzzi, Italy) as recommendedby the manufacturer.All eight isolateswere examined forgenes encoding ESBLsblaCTX-M, blaGES, blaVEB, blaPER, or blaBES and carbape-nemases blaKPC, blaVIM, blaNDM, or blaOXA-48 by poly-merase chain reaction (PCR) using primers and conditionsdescribed previously (5, 6). In addition, both A. baumaniiisolates were further tested for carbapenemase genesblaOXA-23-like, blaOXA-24/40-like, blaOXA-143-like, blaOXA-51-like,and blaOXA-58-like using PCR as above.All A. baumanii and Pseudomonas sp. isolates wereresistant to the three carbapenems as well as to nearly allother antimicrobials that were used. Only colisitin showedexcellent activity against the GNB isolates investigated(100% susceptible) followed by amikacin (50% susceptible).Furthermore, all organisms were multidrug resistant(MDR; resistance to three or more antimicrobial groups).Table 2 shows the antimicrobial susceptibility of theinvestigated GNB isolates.Of the ESBLs genes examined, blaCTX-M was detected inone K. pneumoniae and in the Enterobacter gergoviaeisolate, and blaGES in the P. aeruginosa isolate. OtherESBL genes examined were not detected in all eight GNBisolates. Of the carbapenemase genes investigated, blaNDMwas detected in one K. pneumoniae, and blaOXA-48 inE. gergoviae and in another K. pneumoniae isolate. Onthe other hand, the carbapenemase gene blaKPC was notdetected in all isolates investigated. Table 3 shows genesencoding ESBLs and carbapenemases in the GNB isolatesfrom Tripoli, Libya.Oxacillinases are mainly present in Acinetobacter sp. (7),and some of them are intrinsic to the organism (e.g. OXA-51) while others are acquired (e.g. OXA-23). blaOXA-23-likeand blaOXA-51-like were found in both A. baumanii isolates.Recently, Mathlouthi et al. (8) reported MDR A. bau-mannii isolates harboring blaOXA-23-like, blaOXA-24-like, andblaOXA-48-like genes in Libya.On the other hand, we identified OXA-48 in one K.pneumoniae as well as in the E. gergoviae isolate. Kocsiset al. (9) reported K. pneumoniae harboring OXA-48carbapenemase in a Libyan refugee in Italy. In addi-tion, several studies reported OXA-48 carbapenemase-producing K. pneumoniae in patients transferred fromLibyan Journal of MedicineLibyan Journal of Medicine 2015. # 2015 Abdulmajeed G. Kraiem et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), permitting all non-commercial use, distribution, and reproduction in anymedium, provided the original work is properly cited.1Citation: Libyan J Med 2015, 10: 29206 - http://dx.doi.org/10.3402/ljm.v10.29206(page number not for citation purpose)Table 2. Antimicrobial susceptibility and metallo-b-lactamases of Gram-negative bacilli isolates from different clinicalspecimens in Tripoli, LibyaAntimicrobial agentNo. Organism AM CN EP IP MP CX CR CT CZ CP AN PT TS CF LF CL MBLs1 Acinetobacter baumannii R R R R R R R R R R R R R R R S 2 Acinetobacter baumannii R R R R R R R R R R R R S R R S ND3 Pseudomonas aeruginosa R R R R R R R R I I I S R R R S 4 Pseudomonas putida R R R R R R R R R R R R R S S S 5 Escherichia coli S R R S S R R R S R R S R R R S 6 Klebsiella pneumoniae S S R R R R R R R R R R R R R S 7 Klebsiella pneumoniae S R R I R R R R R R R R S R R S 8 Enterobacter gergoviae S R R S R R R R R R R R S R R S NDAKamikacin, CNgentamicin, EPertapenem, IPimipenem, MPmeropenem, CXcefoxitin, CRcefuroxime, CTceftriaxone,CZceftazidime, CPcefepime, ANaztronam, PTpipracillin-tazobactam, TStrimethoprim-sulfamethoxazole, CFciprofloxacin,LFlevofloxacin, CLcolisitin. Ssusceptible, Iintermediate susceptible, Rresistant, MTLsmetallo b-lactamases testedphenotypically,  positive, negative, NDnot done.Table 3. Genes encoding extended-spectrum b-lactamases (ESBLs) and carbapenemases in Gram-negative bacilli from Tripoli,LibyaESBLs genesa Carbapenemase genesa,bNo. Organism blaCTX-M blaGES blaNDM blaVIM blaOXA-48 blaOXA-23-like blaOXA-51-like1 Acinetobacter baumannii N N N N N P P2 Acinetobacter baumannii N N N N N P P3 Pseudomonas aeruginosa N P N N N ND ND4 Pseudomonas putida N N N P N ND ND5 Escherichia coli N N N N N ND ND6 Klebsiella pneumoniae P N P N N ND ND7 Klebsiella pneumoniae N N N N P ND ND8 Enterobacter gergoviae P N N N P ND NDaESBLs genes blaVEB, blaPER and blaBES and carbapenemase gene blaKPC were not detected in all eight isolates tested.bCarbapenemases genes blaOXA-24/40-like, blaOXA-58-like and blaOXA-143 were not detected in both A. baumanii isolates examined.Nnegative, Ppositive, NDnot done.Table 1. Information about patients and their isolated organismsPatient Gender Age (years) Hospital/department Hospital admission Specimen Organism isolated1 Male 30 TMC/ICU Inpatient Endotracheal tube tip Acinetobacter baumannii2 Female 57 TMC/GSICU Inpatient Suction tip Acinetobacter baumannii3 Female 46 TMC/ICU Inpatient Sputum Pseudomonas aeruginosa4 Male 25 BPSH/ICU Inpatient Wound swab Pseudomonas putida5 Male 10 BPSH Outpatient Wound swab Escherichia coli6 Male 87 TMC Outpatient Ear swab Klebsiella pneumoniae7 Female 42 TMC/Endo Inpatient Bedsore swab Klebsiella pneumoniae8 Male 30 TMC/GSICU Inpatient Wound swab Enterobacter gergoviaeTMCTripoli Medical Center, BPSHBurn and Pediatric Surgery Hospital, ICUintensive care unit, GSICUgeneral surgical ICU,OPoutpatient, Endoendocrinology.TMC and BPSH are both located in Tripoli.Abdulmajeed G. Kraiem et al.2(page number not for citation purpose)Citation: Libyan J Med 2015, 10: 29206 - http://dx.doi.org/10.3402/ljm.v10.29206Libya to neighboring and European countries (e.g. Tunisia,Denmark, and Slovenia) (3, 1012). However, thereare no reports of blaOXA-48-positive K. pneumonia andE. gergoviae from Libya.Both blaCTX-M and blaNDM were detected in Klebsiellapneumoniae isolated from an ear swab from a femaleoutpatient with an ear infection. This isolate was alsopositive for MBLs by the phenotypic method used(Table 2). K. pneumoniae harboring blaNDM has not beenreported from Libya in the past.Genes coding for the ESBLs and carbapenemasestested were not detected in the E. coli isolate. However,the organism was ESBL-positive phenotypically (datanot shown), which may suggest that other ESBLs notinvestigated in this work might be responsible for itsresistance to the third generation cephalosporin.In conclusion, to the authors’ knowledge this isthe first report from Libya of K. pneumoniae harbor-ing blaNDM and blaCTX-M, K. pneumoniae harboringblaOXA-48, and E. gergoviae harboring blaOXA-48 andblaCTX-M. Emergence of MDR GNB harboring genescoding for carbapenemases will undoubtedly limit the useof carbapenems in treating serious infectious in thecountry and also in the nearby countries.Abdulmajeed G. KraiemPostgradaute AcademyTripoli, LibyaAbdulaziz ZorganiDepartment of Microbiology and ImmunologyFaculty of MedicineUniversity of TripoliTripoli, LibyaOmar ElahmerNational Centre for Disease ControlTripoli, LibyaAdnene HammamiCHU Habib BourguibaFaculté de MédecineAvenue ElferdaousSfax, TunisieBasma M. ChaabenCHU Habib BourguibaFaculté de MédecineAvenue ElferdaousSfax, TunisieKhalifa Sifaw GhengheshEl-Nakheel CompoundEl-Sherouk CityCairo, EgyptEmail: ghenghesh_micro@yahoo.comReferences1. Ambler RP. The structure of beta-lactamases. Philos Trans RSoc Lond B Biol Sci. 1980; 289: 32131.2. Bush K, Jacoby GA. Updated functional classification of beta-lactamases. Antimicrob Agents Chemother. 2010; 54: 96976.3. Nasr AB, Decré D, Compain F, Genel N, Barguellil F, Arlet G.Emergence of NDM-1 in association with OXA-48 in Klebsiellapneumoniae from Tunisia. Antimicrob Agents Chemother. 2013;57: 408990.4. Clinical and Laboratory Standards Institute (2012). Perfor-mance standards for antimicrobial susceptibility testing. Twenty-first informational supplement, Document M100-S22, Wayne, PA.5. Dallenne C, Da Costa A, Decré D, Favier C, Arlet G.Development of a set of multiplex PCR assays for the detectionof genes encoding important beta-lactamases in Enterobacte-riaceae. J Antimicrob Chemother. 2010; 65: 4905.6. Povilonis J, Seputiene V, Krasauskas R, Juskaite R, MiskinyteM, Suziedelis K, et al. Spread of carbapenem-resistant Acineto-bacter baumannii carrying a plasmid with two genes encodingOXA-72 carbapenemase in Lithuanian hospitals. J AntimicrobChemother. 2013; 68: 10006.7. Walther-Rasmussen J, Hoiby N. OXA-type carbapenemases.J Antimicrob Chemother. 2006; 57: 37383.8. Mathlouthi N, Areig Z, Al Bayssari C, Bakour S, Ali El SalabiA, Ben Gwierif S, et al. Emergence of carbapenem-resistantPseudomonas aeruginosa and Acinetobacter baumannii clinicalisolates collected from some Libyan hospitals. Microb DrugResist. 2015; 21: 33541.9. Kocsis E, Savio C, Piccoli M, Cornaglia G, Mazzariol A.Klebsiella pneumoniae harbouring OXA-48 carbapenemase ina Libyan refugee in Italy. Clin Microbiol Infect. 2013; 19:E40911.10. Lafeuille E, Decré D, Mahjoub-Messai F, Bidet P, Arlet G,Bingen E. OXA-48 carbapenemase-producing Klebsiella pneu-moniae isolated from Libyan patients. Microb Drug Resist.2013; 19: 4917.11. Hammerum AM, Larsen AR, Hansen F, Justesen US,Friis-Moller A, Lemming LE, et al. Patients transferred fromLibya to Denmark carried OXA-48-producing Klebsiellapneumoniae, NDM-1-producing Acinetobacter baumannii andmeticillin-resistant Staphylococcus aureus. Int J AntimicrobAgents. 2012; 40: 1912.12. Pirś M, Andlovic A, Cerar T, Žohar-Čretnik T, Kobola L,Kolman J, et al. A case of OXA-48 carbapenemase producingKlebsiella pneumoniae in a patient transferred to SloveniaNovember 2011. Euro Surveill. 2011; 16: 20042.Letter to the editorCitation: Libyan Journal of Medicine 2015, 10: 29206 - http://dx.doi.org/10.3402/ljm.v10.29206 3(page number not for citation purpose)

Letter to the Editor: New Delhi metallo- &#223; -lactamase and OXA-48 carbapenemases in Gram-negative bacilli isolates in Libya

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Letter to the Editor: New Delhi metallo- ß -lactamase and OXA-48 carbapenemases in Gram-negative bacilli isolates in Libya

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Letter to the Editor: New Delhi metallo- &#223; -lactamase and OXA-48 carbapenemases in Gram-negative bacilli isolates in Libya

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Letter to the Editor: New Delhi metallo- ß -lactamase and OXA-48 carbapenemases in Gram-negative bacilli isolates in Libya