bla_OXA-181–positive Klebsiella pneumoniae, Singapore

Suggested citation for this article
To the Editor: Nordmann et al. (1) raised concern over the global spread of carbapenemase-producing Enterobacteriaceae. In their article, they called attention to the oxacillinase-48 (OXA-48) type carbapenemases because bacteria that produce these enzymes do not have a distinctive antimicrobial drug susceptibility profile, and there is less awareness of this mechanism of carbapenem resistance. We report the recent isolation of bla_OXA-181–positive Klebsiella pneumoniae from 2 patients from Bangladesh who were admitted to separate hospitals in Singapore within a short period of each other.
The first patient was a 64-year-old man who had a recent heart attack and was transferred from a hospital in Dhaka, Bangladesh, to a hospital in Singapore for treatment for pancytopenia. He had no other history of recent travel. While in Bangladesh, the patient had Pseudomonas spp. bacteremia and had received meropenem and vancomycin. In Singapore, his antimicrobial drug treatment regimen was changed to ciprofloxacin, linezolid, and amikacin. Blood samples obtained on the day of admission were cultured and grew a vancomycin-resistant Enterococcus spp. and a carbapenem-resistant K. pneumoniae (isolate DB53879_11).
Two days after admission, when the results of his blood culture were known, the patient’s antimicrobial drug treatment regimen was changed to oral linezolid (600 mg every 12 hours), intravenous tigecycline (initially 50 mg every hour but later increased to 100 mg every 12 hours), and intravenous polymyxin E (initially 3 MU/d but later increased to 3 MU every 12 hours). Blood cultured for K. pneumoniae showed positive results for 5 days after the patient was hospitalized before clearing.
Isolate DB53879_11 was resistant to many antimicrobial drugs as determined by Etest (bioMérieux, Marcy l’Etoile, France) (Table). It was strongly positive for carbapenemase production as determined by use of a modified Hodge test (2) and showed a negative result with the KPC + MBL Confirm ID Kit (Rosco Diagnostica A/S, Taastrup, Denmark).
Using PCR, we amplified and sequenced a product identical to the complete sequence of bla_OXA-181. Primers designed for known flanking regions of bla_OXA-181 (GenBank accession no. JN205800) failed to amplify any product. Like described isolates (3–5), DB53879_11 was also positive for bla_OXA-1 and bla_CTX-M-15, but it also was positive for bla_CMY-4. An attempt to transfer bla_OXA-181 to azide-resistant Escherichia coli J53 by plate mating was unsuccessful.
Two weeks after we received the specimen from the first patient, we were referred 2 carbapenem-resistant K. pneumoniae strains isolated from sputum (isolate DX1083_11) and blood (isolate BL21479_11) from a 30 year-old man admitted to another hospital in Singapore. He had been treated in the same hospital in Dhaka as the first patient for multiorgan failure secondary to dengue shock syndrome. Antimicrobial drug susceptibility phenotypes and resistance gene complements for DX1083_11 and BL21479_11were similar to those for the isolate from the first patient. The second patient received intravenous tigecycline, polymyxin B, and meropenem.
All 3 isolates were identical when tested by random amplification of polymorphic DNA (6) and by pulsed-field gel electrophoresis after restriction endonuclease digestion of chromosomal DNA with SpeI. Multilocus sequence typing showed that DX1083_11 belonged to sequence type 14 (www.pasteur.fr/recherche/genopole/PF8/mlst/Kpneumoniae.html

). This sequence type is the same as that for bla_OXA-181–positive K. pneumoniae reported from New Zealand (3). Both patients died of their illnesses.
OXA-181 is a close relative of OXA-48 from which it differs by 4 aa (4). bla_OXA-181–positive K. pneumonia infections were first described in India but imported cases have since been described in Oman, the Netherlands, and New Zealand (3–5,7). We were unable to confirm the original source of these isolates, and continuous surveillance for carbapenemase producers in our hospital has not uncovered any bla_OXA-181–positive isolates since 1996. To our knowledge, there are no reports of bla_OXA-181–positive isolates in Bangladesh. However, this country borders India, which is a source of bla_OXA-181–positive Enterobacteriaceae. These cases highlight potential problems that may arise from medical tourism (the rapidly increasing practice of traveling across international borders to obtain health care) and document the expanding range of a newly emerging mechanism of carbapenem resistance.

Tse H. Koh

, Delphine Y.H. Cao, Kian S. Chan, Limin Wijaya, Stewart B.G. Low, Mun S. Lam, Eng E. Ooi, and Li-Yang Hsu

Author affiliations: National University of Singapore, Singapore (T.H. Koh, L.-Y. Hsu); Singapore General Hospital, Singapore (T.H. Koh, D.Y.H. Cao, K.S. Chan, L. Wijaya); Mount Alvernia Hospital, Singapore (S.B.G. Low); Mount Elizabeth Medical Centre, Singapore (M.S. Lam); and Duke–National University of Singapore–Graduate Medical School, Singapore (E.E. Ooi)

Acknowledgment

We thank Tan Peck Lay and Ong Lan Huay for technical assistance and Zerrin Aktas for providing the K. pneumoniae bla_OXA-48–positive control strain.

References

Nordmann P, Naas T, Poirel L. Global spread of carbapenemase-producing Enterobacteriaceae. Emerg Infect Dis. 2011;17:1791–8.PubMed
Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing. Document M100–S21. 21st informational supplement. Wayne (PA): The Institute; 2011.
Williamson DA, Heffernan H, Sidjabat H, Roberts SA, Paterson DL, Smith M, Intercontinental transfer of OXA-181–producing Klebsiella pneumoniae into New Zealand. J Antimicrob Chemother. 2011;66:2888–90. DOI PubMed
Potron A, Nordmann P, Lafeuille E, Al Maskari Z, Al Rashdi F, Poirel L. Characterization of OXA-181, a carbapenem-hydrolyzing class D β-lactamase from Klebsiella pneumoniae. Antimicrob Agents Chemother. 2011;55:4896–9. DOI PubMed
Castanheira M, Deshpande LM, Mathai D, Bell JM, Jones RN, Mendes RE. Early dissemination of NDM-1- and OXA-181–producing Enterobacteriaceae in Indian hospitals: report from the SENTRY Antimicrobial Surveillance Program, 2006–2007. Antimicrob Agents Chemother. 2011;55:1274–8. DOI PubMed
Vogel L, Jones G, Triep S, Koek A, Dijkshoorn L. RAPD typing of Klebsiella pneumoniae, Klebsiella oxytoca, Serratia marcescens and Pseudomonas aeruginosa isolates using standardized reagents. Clin Microbiol Infect. 1999;5:270–6. DOI PubMed
Kalpoe JS, Al Naiemi N, Poirel L, Nordmann P. Detection of an ambler class D OXA-48-type β-lactamase in a Klebsiella pneumoniae strain in the Netherlands. J Med Microbiol. 2011;60:677–8. DOI PubMed

Table

Table. Antimicrobial drug susceptibilities of 3 bla_OXA-181–positive Klebsiella pneumoniae isolates, Singapore

Suggested citation for this article: Koh TH, Cao DYH, Chan KS, Wijaya L, Low SBG, Lam MS, et al. bla_OXA-181–positive Klebsiella pneumoniae, Singapore [letter]. Emerg Infect Dis [serial on the Internet]. 2012 Sep [date cited]. http://dx.doi.org/10.3201/eid1809.111727

DOI: 10.3201/eid1809.111727