Andrea M. Hujer

Barry N. Kreiswirth

Carta

Clinical and Laboratory Standards Institute

David L. Paterson

David van Duin

Federico Perez

Hansen

Liang Chen

Marshall

Norman

Park

Paterson

Peter Coakley

Philip N. Rather

Philip Toltzis

Robert A. Bonomo

Rodriguez-Martinez

Sorensen

Steven H. Marshall

Susan D. Rudin

Viau

Wong

Yuan

Crossref

Antimicrobial Agents and Chemotherapy

OqxAB, a Quinolone and Olaquindox Efflux Pump, Is Widely Distributed among Multidrug-Resistant Klebsiella pneumoniae Isolates of Human Origin

Perez, Federico

Rudin, Susan D.

Marshall, Steven H.

Coakley, Peter

Chen, Liang

Kreiswirth, Barry N.

Rather, Philip N.

Hujer, Andrea M.

Toltzis, Philip

van Duin, David

Paterson, David L.

Bonomo, Robert A.

University of Queensland eSpace

OqxAB, a Quinolone and Olaquindox Efflux Pump, Is Widely
Distributed among Multidrug-Resistant Klebsiella pneumoniae Isolates
of Human Origin
Federico Perez,a,b Susan D. Rudin,a,b Steven H. Marshall,a Peter Coakley,e Liang Chen,f Barry N. Kreiswirth,f Philip N. Rather,g
Andrea M. Hujer,b Philip Toltzis,h David van Duin,i David L. Paterson,j Robert A. Bonomoa,b,c,d
Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USAa; Department of Medicine,b Department of Molecular
Biology and Microbiology,c and Department of Pharmacology,d Case Western Reserve University School of Medicine, Cleveland, Ohio, USA; Division of Infectious Diseases
and HIV Medicine, University Hospitals Case Medical Center, Cleveland, Ohio, USAe; Public Health Research Institute, University of Medicine and Dentistry of New Jersey,
Newark, New Jersey, USAf; Emory University School of Medicine, Atlanta, Georgia, USAg; Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USAh; Cleveland Clinic,
Cleveland, Ohio, USAi; University of Queensland, Brisbane, Australiaj
Use of antibiotics among livestock contributes to the selectionand dissemination of multidrug resistant (MDR) bacteria
(1). Olaquindox and carbadox are quinoxaline derivatives with
antibacterial properties that prevent dysentery and enhance
weight gain in suckling pigs (2). Resistance to quinoxalines is me-
diated by the efflux pumpOqxAB, which also extrudes antibiotics
such as chloramphenicol and fluoroquinolones (3). The gene en-
coding this efflux pump, oqxAB, was initially detected within plas-
mid pOLA52, which was found in Escherichia coli isolated from
swine manure (4). Dissemination of oqxAB has been noted in
Salmonella species, and the original genetic reservoir of oqxABwas
traced to the chromosome of Klebsiella pneumoniae (5, 6). Sur-
prisingly, OqxAB has been reported only in clinical isolates of K.
pneumoniae from China, South Korea, and Spain (7–9).
Like other Enterobacteriaceae, K. pneumoniae is able to colo-
nize and cause infection in animals and humans. As isolates har-
boring extended-spectrum -lactamases (ESBLs) and Klebsiella
pneumoniae carbapenemases (KPCs) have become so prevalent,
we hypothesized that OqxAB may be widely present among these
clinically relevant types of K. pneumoniae.
Isolates were screened by PCR for the oqxA gene (forward
primer, 5=-GCGTCTCGGGATACATTGAT-3=; reverse primer,
5=-GGCGAGGTTTTGATAGTGGA-3=) and, if positive, were also
screened for oqxB (forward primer, 5=-CTGGGCTTCTCGCTGA
ATAC-3=; reverse primer, 5=-CAGGTACACCGCAAACACTG-
3=). Known positive strains were used as controls. Resistance to
ciprofloxacin (as a representative fluoroquinolone) was recorded
for each isolate, using a breakpoint of 4 g/ml (10). Sequence
typewas establishedusing themultilocus sequence typing (MLST)
scheme developed at the Institut Pasteur (http://www.pasteur.fr
/recherche/genopole/PF8/mlst/Kpneumoniae.html).
The following sets of isolates were studied (Table 1): (i) K.
pneumoniae isolates harboring blaKPC (n 12) collected in a pe-
diatric long-term-care facility in northeast Ohio in 2004 (11), (ii)
K. pneumoniae isolates harboring blaKPC (n 36) obtained from
acute-care hospitals in northeast Ohio in 2012, (iii) K. pneu-
moniae isolates harboring blaKPC (n 43) obtained between 2004
and 2011 from the mid-Atlantic states of the United States (New
Jersey, New York, Pennsylvania), and (iv) ESBL-producing K.
pneumoniae isolates (n 16) with a variety of blaSHV, blaTEM, and
blaCTX-M genes, collected in the 1990s from Taiwan, Australia,
Argentina, Belgium, Turkey, South Africa, and the United States
(12).
The prevalence of oqxAB varied widely in the different sets of
strains (Table 1). Among KPC-producing K. pneumoniae isolates
from northeast Ohio, oqxAB was present in 100%. This included
contemporary isolates from acute-care facilities that were also
quinolone resistant and belonged to sequence type (ST) 258, as
well as isolates from a pediatric long-term-care facility that were
quinolone susceptible and belonged to ST 36. Among KPC-pro-
ducing K. pneumoniae isolates from the mid-Atlantic, the genes
Published ahead of print 1 July 2013
Address correspondence to Robert A. Bonomo, robert.bonomo@va.gov.
Copyright © 2013, American Society for Microbiology. All Rights Reserved.
doi:10.1128/AAC.00725-13
TABLE 1 Presence of oqxAB in diverse clinical isolates of Klebsiella pneumoniae
Location, yr of isolation
No. of
isolates Source(s) Sequence type(s)
Acquired -lactamase (bla) gene
type(s)
Prevalence of
oqxAB (%)
% with
ciprofloxacin
resistance (MIC
 4 g/ml)
Pediatric long-term-care facility, northeast
Ohio, 2004
12 Stool ST 36 KPC-3 100 0
Acute-care hospitals, northeast Ohio, 2012 36 Blood, urine, sputum ST 258 KPC-2, KPC-3 100 100
Acute-care hospitals, New York, New
Jersey, Pennsylvania, 2004–2011
31 Blood, urine, sputum ST 258 KPC-2, KPC-3 71 96.8
Acute-care hospitals, New York, New
Jersey, Pennsylvania, 2006–2009
6 Urine, sputum ST 134, ST 234, ST 379,
ST 429
KPC-2, KPC-3 83.3 83.3
Acute-care hospitals, New York, New
Jersey, Pennsylvania, 2006–2009
6 Urine Not determined KPC-3, KPC-4, KPC-5 100 33.3
Hospitals in Taiwan, Australia, Argentina,
Belgium, Turkey, South Africa, and the
United States, 1996–1997
16 Blood Not determined TEM-10, SHV-2, SHV-5, CTX-M-2,
CTX-M-3
87.5 Not determined
LETTER TO THE EDITOR
4602 aac.asm.org Antimicrobial Agents and Chemotherapy p. 4602–4603 September 2013 Volume 57 Number 9
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were present in 71% (22/31) of ST 258 isolates and 91.7% (11/12)
of other non-ST 258 types; 96.8% and 58.3% of these isolates were
ciprofloxacin resistant, respectively. Also, oqxAB was present in
87.5% (14/16) of international ESBL-producing K. pneumoniae
isolates.
Our survey indicates that OqxAB, an efflux pump found in
isolates of veterinary origin, is highly prevalent in diverse clinical
MDR K. pneumoniae strains isolated from humans, including
KPC-producing K. pneumoniae isolates of ST 258. Furthermore,
its presence in K. pneumoniae isolated more than a decade ago
suggests widespread dissemination. The association of the OqxAB
efflux pump with a diverse set of substrates, including fluoro-
quinolones, commonly used in humans, may contribute to the
MDR profile of K. pneumoniae. The occult dissemination of this
efflux pump gene adds to the constellation of resistance determi-
nants already circulating in Enterobacteriaceae.
ACKNOWLEDGMENTS
This work was supported by funds and facilities provided by the Louis
Stokes Cleveland Department of Veterans Affairs Medical Center, by the
VISN 10 Geriatric Research, Education and Clinical Care Center (VISN
10) of theDepartment of Veterans Affairs, and by theNational Institute of
Allergy and Infectious Diseases of the National Institutes of Health (NIH)
under award numbers R01AI072219, R01AI063517, and R01AI100560 to
R.A.B. B.N.K. is supported by the NIH under award numbers
R01AI090155 and R21AI06551. F.P. and D.V.D. are supported by the
Clinical and Translational Science Collaborative of Cleveland under grant
number UL1TR000439 from the National Center for Advancing Transla-
tional Sciences (NCATS) component of the NIH and NIH Roadmap for
Medical Research. P.N.R. is supported by Merit Review and Research
Career Scientist awards from the Department of Veterans Affairs.
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Letter to the Editor
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OqxAB, a quinolone and olaquindox efflux pump, is widely distributed among multidrug-resistant Klebsiella pneumoniae isolates of human origin

http://espace.library.uq.edu.au/view/UQ:325354/UQ325354_OA.pdf

OqxAB, a quinolone and olaquindox efflux pump, is widely distributed among multidrug-resistant Klebsiella pneumoniae isolates of human origin

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