We report two cases of infantile diarrhea due to multidrug-resistant, NDM-1 metallo-beta-lactamase-producing Salmonella enterica serovar Agona from Pakistan. This study alerts toward possible risk of NDM-1 transmission to enteric fever pathogens and encourages microbiologists to consider active screening of carbapenem resistance in nontyphoidal Salmonella isolates

Bhawan, Pushpa

Day, Martin

Hopkins, Katie L

Irfan, Seema

Jabeen, Kauser

Khan, Erum

Meunier, Daniele

Nasir, Amna

Woodford, Neil

English

eCommons@AKU

eCommons@AKUDepartment of Pathology and Laboratory Medicine Medical College, PakistanJanuary 2015Clinical isolates of salmonella enterica serovaragona producing NDM-1 metallo-beta-lactamase:first report from PakistanSeema IrfanAga Khan University, seema.irfan@aku.eduErum Khanerum.khan@aku.eduKauser JabeenAga Khan University, kauser.jabeen@aku.eduPushpa BhawanKatie L. HopkinsSee next page for additional authorsFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_pathol_microbiolPart of the Microbiology Commons, and the Pathology CommonsRecommended CitationIrfan, S., Khan, E., Jabeen, K., Bhawan, P., Hopkins, K. L., Day, M., Nasir, A., Meunier, D., Woodford, N. (2015). Clinical isolates ofsalmonella enterica serovar agona producing NDM-1 metallo-beta-lactamase: first report from Pakistan. Journal of ClinicalMicrobiology, 53(1), 346-348.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_pathol_microbiol/793AuthorsSeema Irfan, Erum Khan, Kauser Jabeen, Pushpa Bhawan, Katie L. Hopkins, Martin Day, Amna Nasir, DanieleMeunier, and Neil WoodfordThis report is available at eCommons@AKU: https://ecommons.aku.edu/pakistan_fhs_mc_pathol_microbiol/793Clinical Isolates of Salmonella enterica Serovar Agona ProducingNDM-1 Metallo--Lactamase: First Report from PakistanSeema Irfan,a Erum Khan,a Kauser Jabeen,a Pushpa Bhawan,a Katie L. Hopkins,b Martin Day,b Amna Nasir,a Daniele Meunier,bNeil WoodfordbDepartment of Pathology Microbiology, The Aga Khan University, Karachi, Pakistana; Antimicrobial Resistance and Healthcare-Associated Infections Reference Unit, PublicHealth England, London, EnglandbWe report two cases of infantile diarrhea due to multidrug-resistant, NDM-1 metallo--lactamase-producing Salmonella en-terica serovar Agona from Pakistan. This study alerts toward possible risk of NDM-1 transmission to enteric fever pathogensand encourages microbiologists to consider active screening of carbapenem resistance in nontyphoidal Salmonella isolates.CASE REPORTCase 1 is a 9-month-old child fromNosheroferoz, a small townin Sindh, Pakistan, who presented to Aga Khan Hospital, Ka-rachi, with high-grade fever, vomiting, diarrhea, and abdominalpain. Stool microscopy revealed 10 leukocytes (WBC)/low-powerfield and mucous threads. The patient was admitted and startedon 10mg intravenous ciprofloxacin/kg of bodyweight twice a day.The patient became afebrile after 2 days of treatment and wasdischarged from the hospital on 10mg oral ciprofloxacin/kg twicea day for 5 days. Stool culture yielded carbapenem-resistant Sal-monella sp. (isolate 1a) that was susceptible only to azithromycin,fosfomycin, and colistin. On the follow-up visit, the child was stillpassing loose stools 5 or 6 times/day. A repeat stool culture yieldeda Salmonella sp. isolate (isolate 1b) with the same susceptibilityprofile as the first. Treatment was changed to 250 mg oral fosfo-mycin three times daily, and the patient finally improved.Case 2 is a 1-year-old child from Karachi who was admitted tothe Aga Khan Hospital, Karachi, with history of diarrhea andvomiting for 2 days. Stool microscopy revealed 20 WBC/low-power field with mucous threads. The patient was admitted andstarted on 65 mg intravenous ceftriaxone/kg once a day. Diarrheasubsided within 3 days of admission, and the patient was dis-charged on 10 mg oral ciprofloxacin/kg twice a day for 5 days.Stool culture grew a carbapenem-resistant Salmonella sp. (isolate2) susceptible only to azithromycin, fosfomycin, and colistin. Thispatient had no further follow-up at our hospital.Gastroenteritis caused by nontyphoidal Salmonella species(NTS) is a major public health problem worldwide. Children lessthan 2 years old are the main sufferers of enteritis caused by NTS(1). The majority of these infections are self-limiting; therefore,antimicrobial therapy is reserved for treatment of serious infec-tions only. Some patients may develop prolonged enteritis, andsepticemia and extraintestinal complications aremore commonlyseen in immunocompromised and malnourished populations,with an associated case fatality of 20 to 25% (2).Diarrheal diseases are very common in Pakistan. Laboratory-based surveillance data from our laboratory showed a 13% isola-tion rate of enteric bacterial pathogens, including Campylobacterspp., Salmonella spp., Shigella spp., andVibrio cholerae, from clin-ically suspected cases of diarrhea (3). The frequency of isolation ofSalmonella spp. among stool pathogens is 18.4%, and it is the thirdmost commonly isolated enteric pathogen in our setting (4). Re-ported rates of antimicrobial resistance in NTS vary geographi-cally. Resistance also varies between different serotypes and differ-ent antibiotics. Generally, low rates of resistance to ampicillin,chloramphenicol, and ciprofloxacin have been reported in Salmo-nella enterica serovar Enteritidis. In contrast, a higher rate of re-sistance has been reported in S. enterica serovar Typhimurium (5).With the emergence globally of ceftriaxone and quinolone resis-tance in NTS, empirical therapy for severe gastroenteritis and in-vasive infections has become challenging. Moreover, since theemergence of the NDM metallo--lactamase enzyme in entericorganisms, there has been a continuous threat of its spread into S.enterica (6). Two cases of diarrhea caused by NDM-positive S.enterica serovar Agona are presented in this report. A literaturesearch revealed few reports of carbapenem-resistant NTS; how-ever, the genes identified were either blaKPC, blaIMP, or blaVIM (7,8). In 2011 and 2012, two studies from the United States andReunion Island reported colonization with NDM-1-positive S.enterica serovars Senftenberg and Westhampton, respectively;however, the clinical significance of the reported isolateswas ques-tionable (9). Only one clinically significant infection has been re-ported, an NDM-1-producing S. enterica serovar Stanley fromChina (10). Our report is the first report of clinically significantNDM-1-producing S. enterica from the Indian subcontinent andthe first report of this enzyme in S. enterica serovar Agona.Bacterial culture, identification, susceptibility testing, and pre-liminary serotyping of all three isolates were performed at theclinical laboratory of the Aga Khan University Hospital, whileReceived 3 September 2014 Returned for modification 25 September 2014Accepted 29 October 2014Accepted manuscript posted online 5 November 2014Citation Irfan S, Khan E, Jabeen K, Bhawan P, Hopkins KL, Day M, Nasir A,Meunier D, Woodford N. 2015. Clinical isolates of Salmonella enterica serovarAgona producing NDM-1 metallo--lactamase: first report from Pakistan.J Clin Microbiol 53:346–348. doi:10.1128/JCM.02396-14.Editor: Y.-W. TangAddress correspondence to Seema Irfan, seema.irfan@aku.edu.Copyright © 2015, American Society for Microbiology. All Rights Reserved.doi:10.1128/JCM.02396-14CASE REPORT346 jcm.asm.org January 2015 Volume 53 Number 1Journal of Clinical Microbiologyadvance serotyping, PCR, sequencing, and pulsed-field gel elec-trophoresis (PFGE) were performed at Public Health England’sSalmonella Reference Section, United Kingdom. Samples wereprocessed by direct plating on MacConkey’s and xylose-lysine-deoxycholate agar and inoculating selenite F broth as an enrich-ment medium, which was subcultured the next day on Salmonellaand Shigella agar. Suspected colonies were identified by conven-tional biochemical methods as Salmonella spp. and confirmed byAPI 20E (bioMérieux, France). Initial serotyping of the isolatesrevealed that all three isolates belonged to Salmonella group B.Further serological identification was performed at Public HealthEngland’s Salmonella Reference Section, United Kingdom, andisolates were identified as S. enterica serovar Agona (4,12:f,g,s:)by using the Kauffmann-White scheme (11). Antimicrobial sus-ceptibilities were performed by the disk diffusion method andVitek 2 Compact system (bioMérieux, France) and interpretedaccording to Clinical and Laboratory Standards Institute guide-lines (12), shown in Table 1. For azithromycin susceptibility, Brit-ish Society of Antimicrobial and Chemotherapy breakpoints (13)for S. enterica serovar Typhi were used. The multidrug resistancepattern of these isolates is alarming, as the treatment options areextremely limited. Both isolates were tested for other treatmentoptions, like azithromycin, fosfomycin, and colistin. Both chil-dren received treatment for gastroenteritis; however, as the ma-jority of diarrheal infections are self-limiting, treatment successcould not be evaluated.All these isolates were tested for carbapenemase production byusing amodifiedHodge test (14) andwere also positive for blaNDMPCR, using primers 5=-GGG CAG TCG CTT CCA ACG GT-3=and 5=-GTA GTG CTC AGT GTC GGC AT-3= (15). Further con-firmation for the presence of an NDM carbapenemase gene andscreening for extended-spectrum-beta-lactamase (ESBL) geneswere performed using the commercial Check-MDRCT102 ESBL-carbapenemase microarray (Check-Points Health BV, Wagenin-gen, The Netherlands), which detected NDM carbapenemase, agroup 1CTX-MESBL, and a non-ESBLTEMgene. Gene sequenc-ing identified the NDM variant as NDM-1 in all three isolates. Sofar, NDM-1 has also been reported in other diarrheal agents, likeShigella spp. and Vibrio cholerae, from the Indian subcontinent,from the environmental water samples with potential contamina-tion from the sewage system (16). However, no NDM-1-positiveShigella spp. and Vibrio cholerae have been reported from Paki-stan. Similarly, this gene has not yet been identified in typhoidalsalmonellae. As the NDM-1 gene is already spreading in commu-nity Enterobacteriaceae isolates, like Escherichia coli and Klebsiellapneumoniae (4), there is real potential for this gene to spread intoenteric fever isolates.When analyzed by pulsed-field gel electrophoresis, the threeisolates shared identical profiles, as shown in Fig. 1. Moreover, S.enterica serovar Agona isolates of these two cases had similar an-tibiograms, suggesting they originated from a common source.However, because of the lack of laboratory-based data and activesurveillance of diarrheal diseases in the community, whether thesetwo isolates were part of a larger outbreak cannot be established.This study alerts toward possible risk of NDM-1 transmissionto enteric fever pathogens and emphasizesmicrobiologists to con-sider active screening of NTS isolates. Any carbapenem-resistantisolates should be further investigated for the presence of NDMenzymes and other carbapenemase genes. In addition, cliniciansare alerted to the emergence of these isolates, especially whentreating relapsing infections with Salmonella spp.In conclusion, there is need for active surveillance and screen-FIG 1 PFGE gel showing similarity of all three Salmonella enterica serovarAgona isolates. To digest the DNA, restriction enzyme XbaI (New EnglandBioLabs) was used, and the following PFGE conditions were applied: 2 to 64 sat 200 V for 22 h (17).TABLE 1MIC of Salmonella enterica serovar Agona isolates 1a and 1b(case 1) and isolate 2 (case 2), against various antibiotics determined bythe Vitek 2 Compact systemAntibioticMIC (g/ml)Isolate 1a Isolate 1b Isolate 2Ampicillin 32 32 32Amoxicillin-clavulanic acid 32 32 32Piperacillin-tazobactam 128 128 128Ceftriaxone 64 64 64Trimethoprim-sulfamethoxazole 320 320 320Gentamicin 16 16 16Ciprofloxacin 2 2 2Imipenem 8 8 16Meropenem 16 16 16Colistin 0.5 0.5 0.5Azithromycin 4 8 8Case ReportJanuary 2015 Volume 53 Number 1 jcm.asm.org 347Journal of Clinical Microbiologying of resistant Salmonella spp. in the region to avoid emergence ofNDM-1-positive typhoidal salmonella strains.REFERENCES1. Chen HM, Wang Y, Su LH, Chiu CH. 2013. Nontyphoid salmonellainfection: microbiology, clinical features, and antimicrobial therapy.Pediatr Neonatol 3:147–152. http://dx.doi.org/10.1016/j.pedneo.2013.01.010.2. Feasey NA, Dougan G, Kingsley RA, Heyderman RS, Gordon MA.2012. Invasive nontyphoidal salmonella disease: an emerging and ne-glected tropical disease in Africa. Lancet 379:2489–2499. http://dx.doi.org/10.1016/S0140-6736(11)61752-2.3. Irfan S, Ahmad A, Guhar D, Khan E, Malik F, Mahmood S, Zafar A.2010. Fluoroquinolone and macrolide co-resistance in clinical isolates ofCampylobacter species: a 15-year study in Karachi, Pakistan. EastMediterrHealth J 16:1226–1230.4. Sultan BA, Khan E, Hussain F, Nasir A, Irfan S. 2013. Effectiveness ofmodified Hodge test to detect NDM-1 carbapenemases: an experiencefrom Pakistan. J Pak Med Assoc 63:955–960.5. Su LH, Chiu CH, Chu C, Ou JT. 2004. Antimicrobial resistance innontyphoid Salmonella serotypes: a global challenge. Clin Infect Dis 39:546–551. http://dx.doi.org/10.1086/422726.6. Kumarasamy KK, Toleman MA, Walsh TR, Bagaria J, Butt F,Balakrishnan R, Chaudhary U, Doumith M, Giske CG, Irfan S, Krish-nan P, Kumar AV, Maharjan S, Mushtaq S, Noorie T, Paterson DL,Pearson A, Perry C, Pike R, Rao B, Ray U, Sarma JB, Sharma M,Sheridan E, Thirunarayan MA, Turton J, Upadhyay S, Warner M,Welfare W, Livermore DM, Woodford N. 2010. Emergence of a newantibiotic resistance mechanism in India, Pakistan, and the UK: a molec-ular, biological, and epidemiological study. Lancet Infect Dis 10:597–602.http://dx.doi.org/10.1016/S1473-3099(10)70143-2.7. Nordmann P, Poirel L, Mak JK, White PA, McIver CJ, Taylor P. 2008.Multidrug-resistant Salmonella strains expressing emerging antibiotic re-sistance determinants. Clin Infect Dis 46:324–325. http://dx.doi.org/10.1086/524898.8. Fischer J, Rodriguez I, Schmoger S, Friese A, Roesler U, Helmuth R,Guerra B. 2012. Salmonella enterica subsp. Enterica producing VIM-1carbapenemase isolated from livestock farms. J Antimicrob. Chemother68:478–480. http://dx.doi.org/10.1093/jac/dks393.9. Savard P, Gopinath R, Zhu W, Kitchel B, Rasheed JK, Tekle T, RobertsA, Ross T, Razeq J, Landrum BM, Wilson LE, Limbago B, Perl TM,Carroll KC. 2011. First NDM-positive Salmonella sp. strain identified intheUnited States. AntimicrobAgents Chemother 55:5957–5958. http://dx.doi.org/10.1128/AAC.05719-11.10. Huang J, Wang M, Ding H, Ye M, Hu F, Guo Q, Xu X, Wang M. 2013.New Delhi metallo--lactamase-1 in carbapenem resistant Salmonellastrain, China. Emerg Infect Dis 19:2049–2051. http://dx.doi.org/10.3201/eid1912.130051.11. Grimont PAD, Weill FX. 2007. Antigenic formulas of the Salmonellaserovars. WHO Collaborating Centre for Reference and Research on Sal-monella, Institut Pasteur, Paris, France.12. Clinical and Laboratory Standards Institute. 2014. Performance stan-dards for antimicrobial susceptibility testing; 24th informational supple-ment. CLSI M100-S24. CLSI, Wayne, PA.13. British Society of Antimicrobial and Chemotherapy. 2012. BSAC meth-ods for antimicrobial susceptibility testing, version 11.1. http://bsac.org.uk/wp-content/uploads/2012/02/Version-11.1-2012-Final-.pdf.14. Stuart CJ, Leverstein-Van Hall MA. 2010. Guideline for phenotypicscreening and confirmation of carbapenemases in Enterobacteriaceae. Int JAntimicrob Agents 36:205–210. http://dx.doi.org/10.1016/j.ijantimicag.2010.05.014.15. Mushtaq S, Irfan S, Sarma JB, Doumith M, Pike R, Pitout J, LivermoreDM, Woodford N. 2011. Phylogenetic diversity of Escherichia coli strainsproducing NDM-type carbapenemases. J Antimicrob. Chemother 66:2002–2005. http://dx.doi.org/10.1093/jac/dkr226.16. Walsh TR, Weeks J, Livermore DM, Toleman MA. 2011. Dissemi-nation of NDM-1 positive bacteria in the New Delhi environment andits implications for human health: an environmental point prevalencestudy. Lancet Infect Dis 11:355–362. http://dx.doi.org/10.1016/S1473-3099(11)70059-7.17. EUCAST. 2003. The Salm-gene project—a European collaboration for DNAfingerprinting for food-related salmonellosis. http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId401.Case Report348 jcm.asm.org January 2015 Volume 53 Number 1Journal of Clinical Microbiology

Clinical isolates of salmonella enterica serovar agona producing NDM-1 metallo-beta-lactamase: first report from Pakistan

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Clinical isolates of salmonella enterica serovar agona producing NDM-1 metallo-beta-lactamase: first report from Pakistan

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