Spread of Streptococcus pneumoniae Serotype 8-ST63 Multidrug-Resistant Recombinant Clone, Spain - Volume 20, Number 11—November 2014 - Emerging Infectious Disease journal - CDC

FULL-TEXT ►

Spread of Streptococcus pneumoniae Serotype 8-ST63 Multidrug-Resistant Recombinant Clone, Spain - Volume 20, Number 11—November 2014 - Emerging Infectious Disease journal - CDC

Volume 20, Number 11—November 2014

Research

Spread of Streptococcus pneumoniae Serotype 8-ST63 Multidrug-Resistant Recombinant Clone, Spain

On This Page

• Materials and Methods
• Results
• Discussion
• Suggested Citation

Figures

• Figure 1
• Figure 2
• Figure 3
• Figure 4

Tables

• Table

Downloads

• PDF[860 KB - 9 pgs]

Carmen Ardanuy , Adela G. de la Campa, Ernesto García, Asunción Fenoll, Laura Calatayud, Emilia Cercenado, Emilio Pérez-Trallero, Emilio Bouza, and Josefina Liñares

Author affiliations: Hospital Universitari de Bellvitge–Universitat de Barcelona–Fundació Privada Institut d'Investigació Biomèdica de Bellvitge, Barcelona, Spain (C. Ardanuy, L. Calatayud, J. Liñares); Centros de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain (C. Ardanuy, A.G. de la Campa, A. Fenoll, L. Calatayud, E. Cercenado, E. Pérez-Trallero, E. Bouza, E. García, J. Liñares); Instituto de Salud Carolos II, Madrid (A. G. de la Campa, A. Fenoll); Consejo Superior de Cientificas, Madrid (A.G. de la Campa, E. García);Hospital Gregorio Marañón–Universidad Complutense, Madrid (E. Cercenado, E. Bouza); Hospital Universitario Donostia, Donostia, Spain (E. Pérez-Trallero)

Suggested citation for this article

Abstract

Since 2004, a total of 131 isolates of Streptococcus pneumoniae multidrug-resistant invasive serotype 8 have been detected in Spain. These isolates showed resistance to erythromycin, clindamycin, tetracycline, and ciprofloxacin. All isolates were obtained from adult patients and shared a common genotype (sequence type [ST]63; penicillin-binding protein 1a [pbp1a], pbp2b, and pbp2x gene profiles; ermB and tetM genes; and a ParC-S79F change). Sixty-eight isolates that required a ciprofloxacin MIC ≥16 μg/mL had additionalgyrA gene changes. Serotype 8-ST63 pbp2x sequences were identical with those of antimicrobial drug–susceptible serotype 8-ST53 isolates. Serotype 8-ST63 pbp2b sequences were identical with those of the multidrug-resistant Sweden 15A-ST63 clone. Recombination between the capsular locus and flanking regions of an ST53 isolate (donor) and an ST63 pneumococcus (recipient) generated the novel 15A-ST63 clone. One recombination point was upstream of pbp2x and another was within pbp1a. A serotype 8-ST63 clone was identified as a cause of invasive disease in Spain.

Streptococcus pneumoniae is a frequent cause of community-acquired pneumonia, meningitis, bacteremia, and otitis media in children. The diverse biochemical composition of the capsular polysaccharide results in ≥94 serotypes (1). However, only a few serotypes cause most invasive disease episodes worldwide. Serotype 8 pneumococci cause invasive pneumococcal disease in adults and have been occasionally associated with outbreaks. Nevertheless, isolates of this serotype are rarely found in children as a cause of invasive disease or as colonizers of the nasopharynx (2,3). Few lineages have been identified among serotype 8 pneumococci; the major clone is Netherlands 8-ST53, which has been detected worldwide and is typically susceptible to antimicrobial drugs (4).

The capsular polysaccharide is the major virulence factor of pneumococci and usually determines their ability to act as invasive or colonizing microorganisms (3). In addition to exhibiting the capsule, pneumococci can show low or high genetic diversity, but genotype–serotype association is common. However, this association could be disrupted because of capsular switching caused mainly by recombination of capsular genetic loci. This finding could be a sporadic event, but the recombinant occasionally spreads and could cause pneumococcal disease.

Capsular switching was associated with emergence of a serotype 19A variant of a formerly serotype 4 clone (5) related to immunity pressure sustained after a 7-valent pneumococcal conjugate vaccine was introduced into the United States. This well-known phenomenon was the origin of the major penicillin-resistant clone (serotype 14 variant of the Spain 9V-ST156 clone), which caused invasive pneumococcal disease in Spain in the 2000s (4,6).

Data from the Spanish Reference Laboratory for Pneumococci, which has received pneumococci from Spain since 1979, showed rates of 2.5% to 6.5% for serotype 8 invasive isolates in the last 3 decades. These rates did not show any association with introduction of therapeutic or preventive measures (7,8). Over these decades, serotype 8 pneumococci were usually susceptible to antimicrobial drugs, although some isolates were resistant to erythromycin or tetracycline. Moreover, serotype 8 pneumococci were isolated mainly from adult patients (7,8). However, since 2004, serotype 8 pneumococci have been identified that showed resistance to erythromycin, clindamycin, tetracycline, and ciprofloxacin.

In the present study, we analyzed the evolution and molecular epidemiology of these multidrug-resistant serotype 8 pneumococci. We determined whether the increase in these isolates was associated with dissemination of a new recombinant clone (serotype 8-ST63) capable of causing invasive pneumococcal disease in different areas of Spain.

Dr Ardanuy is a clinical microbiologist and researcher at the Microbiology Department, Hospital Univesitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain. Her research interests are molecular epidemiology and antimicrobial drug resistance in bacteria.

Acknowledgments

We thank Imperial College, London, for use of the S. pneumoniae MLST website (supported by the Wellcome Trust), and Montserrat Alegre and Meritxell Cubero for excellent technical support.

This study was supported by a grant from Fondo de Investigaciones Sanitarias de la Seguridad Social (PI11/00763), Plan Nacional de I + D + I of the Ministerio de Ciencia e Innovación of Spain (BIO2011-25343), and Centros de Investigación Biomédica en Red (CIBER) de Enfermedades Respiratorias (CIBERES-CB06/06/0037), an initiative of the Instituto de Salud Carlos III, Madrid, Spain. C.A., A.F., and J.L. received support from Pfizer for a project independent of the present study.

References

1. Calix JJ, Porambo RJ, Brady AM, Larson TR, Yother J, Abeygunwardana C, Biochemical, genetic and serological characterization of two capsule subtypes among Streptococcus pneumoniae serotype 20 strains: discovery of a new pneumococcal serotype. J Biol Chem. 2012;287:27885–94.DOIPubMed
2. Sleeman KL, Griffiths D, Shackley F, Diggle L, Gupta S, Maiden MC, Capsular serotype-specific attack rates and duration of carriage of Streptococcus pneumoniae in a population of children. J Infect Dis. 2006;194:682–8. DOIPubMed
3. Sjöström K, Spindler C, Ortqvist A, Kalin M, Sandgren A, Kühlmann-Berenzon S, Clonal and capsular types decide whether pneumococci will act as a primary or opportunistic pathogen. Clin Infect Dis. 2006;42:451–9. DOIPubMed
4. Ardanuy C, Tubau F, Pallares R, Calatayud L, Domínguez MA, Rolo D, Epidemiology of invasive pneumococcal disease among adult patients in Barcelona before and after pediatric 7-valent pneumococcal conjugate vaccine introduction, 1997–2007. Clin Infect Dis. 2009;48:57–64.DOIPubMed
5. Brueggemann AB, Pai R, Crook DW, Beall B. Vaccine escape recombinants emerge after pneumococcal vaccination in the United States. PLoS Pathog. 2007;3:e1628–36.
6. Coffey TJ, Daniels M, Enright MC, Spratt BG. Serotype 14 variants of the Spanish penicillin-resistant serotype 9V clone of Streptococcus pneumoniae arose by large recombinational replacements of the cpsA-pbp1a region. Microbiology. 1999;145:2023–31. DOIPubMed
7. Fenoll A, Jado I, Vicioso D, Pérez A, Casal J. Evolution of Streptococcus pneumoniae: serotypes and antibiotic resistance in Spain. Update (1990 to 1996). J Clin Microbiol. 1998;36:3447–54 .PubMed
8. Fenoll A, Granizo JL, Aguilar L, Giménez MJ, Aragoneses-Fenoll L, Hanquet G, Temporal trends of invasive Streptococcus pneumoniae serotypes and antimicrobial resistance patterns in Spain from 1979 to 2007. J Clin Microbiol. 2009;47:1012–20. DOIPubMed
9. McGee L, McDougal L, Zhou J, Spratt BG, Tenover FC, George R, Nomenclature of major antimicrobial-resistant clones of Streptococcus pneumoniae defined by the pneumococcal molecular epidemiology network. J Clin Microbiol. 2001;39:2565–71. DOIPubMed
10. Sá-Leão R, Tomasz A, de Lencastre H. Multilocus sequence typing of Streptococcus pneumoniae clones with unusual drug resistance patterns: genetic backgrounds and relatedness to other epidemic clones. J Infect Dis. 2001;184:1206–10. DOIPubMed
11. Clinical and Laboratory Standard Institute. Methods for dilution antimicrobial susceptibility test for bacteria that growth aerobically. 8th ed. Vol. 29. Approved standard. CLSI/NCCLS document M7–A8. Wayne (PA): The Institute; 2009.
12. Clinical and Laboratory Standard Institute. Performance standards for antimicrobial susceptibility testing; Twenty-first informational supplement. Vol. 31. CLSI/NCCLS document M100–S21. Wayne (PA): The Institute; 2011.
13. Enright MC, Spratt BG. A multilocus sequence typing scheme for Streptococcus pneumoniae: identification of clones associated with serious invasive disease. Microbiology. 1998;144:3049–60. DOIPubMed
14. du Plessis M, Bingen E, Klugman KP. Analysis of penicillin-binding protein genes of clinical isolates of Streptococcus pneumoniae with reduced susceptibility to amoxicillin. Antimicrob Agents Chemother. 2002;46:2349–57. DOIPubMed
15. Gherardi G, Whitney CG, Facklam RR, Beall B. Major related sets of antibiotic-resistant pneumococci in the United States as determined by pulsed-field gel electrophoresis and pbp1a-pbp2b-pbp2x-dhf restriction profiles. J Infect Dis. 2000;181:216–29. DOIPubMed
16. Calatayud L, Ardanuy C, Tubau F, Rolo D, Grau I, Pallarés R, Serotype and genotype replacement among macrolide-resistant invasive pneumococci in adults: mechanisms of resistance and association with different transposons. J Clin Microbiol. 2010;48:1310–6. DOIPubMed
17. Alonso R, Galimand M, Courvalin P. An extended PCR-RFLP assay for detection of parC, parE and gyrA mutations in fluoroquinolone-resistantStreptococcus pneumoniae. J Antimicrob Chemother. 2004;53:682–3. DOIPubMed
18. Pan XS, Ambler J, Mehtar S, Fisher LM. Involvement of topoisomerase IV and DNA gyrase as ciprofloxacin targets in Streptococcus pneumoniae.Antimicrob Agents Chemother. 1996;40:2321–6 .PubMed
19. de la Campa AG, Balsalobre L, Ardanuy C, Fenoll A, Pérez-Trallero E, Liñares J. Spanish Pneumococcal Infection Study Network G03/103. Fluoroquinolone resistance in penicillin-resistant Streptococcus pneumoniae clones, Spain. Emerg Infect Dis. 2004;10:1751–9. DOIPubMed
20. Dopazo J, Mendoza A, Herrero J, Caldara F, Humbert Y, Friedli L, Annotated draft genomic sequence from a Streptococcus pneumoniae type 19F clinical isolate. Microb Drug Resist. 2001;7:99–125. DOIPubMed
21. Sanz JC, Cercenado E, Marín M, Ramos B, Ardanuy C, Rodríguez-Avial I, Multidrug-resistant pneumococci (serotype 8) causing invasive disease in HIV+ patients. Clin Microbiol Infect. 2011;17:1094–8. DOIPubMed
22. de la Campa AG, Ardanuy C, Balsalobre L, Pérez-Trallero E, Marimón JM, Fenoll A, Changes in fluoroquinolone-resistant Streptococcus pneumoniaeafter 7-valent conjugate vaccination, Spain. Emerg Infect Dis. 2009;15:905–11. DOIPubMed
23. Sá-Leão R, Pinto F, Aguiar S, Nunes S, Carriço JA, Frazão N, Analysis of invasiveness of pneumococcal serotypes and clones circulating in Portugal before widespread use of conjugate vaccines reveals heterogeneous behavior of clones expressing the same serotype. J Clin Microbiol.2011;49:1369–75. DOIPubMed
24. Coffey TJ, Dowson CG, Daniels M, Zhou J, Martin C, Spratt BG, Horizontal transfer of multiple penicillin-binding protein genes, and capsular biosynthetic genes, in natural populations of Streptococcus pneumoniae. Mol Microbiol. 1991;5:2255–60. DOIPubMed
25. Wyres KL, Lambertsen LM, Croucher NJ, McGee L, von Gottberg A, Liñares J, Pneumococcal capsular switching: a historical perspective. J Infect Dis.2013;207:439–49. DOIPubMed
26. Pernot L, Chesnel L, Le Gouellec A, Croize J, Vernet T, Dideberg O, A PBP2X from a clinical isolate of Streptococcus pneumoniae exhibits an alternative mechanism for reduction of susceptibility to β-lactam antibiotics. J Biol Chem. 2004;279:16463–70. DOIPubMed
27. Moore MR, Gertz RE Jr, Woodbury RL, Barkocy-Gallagher GA, Schaffner W, Lexau C, Population snapshot of emergent Streptococcus pneumoniaeserotype 19A in the United States, 2005. J Infect Dis. 2008;197:1016–27. DOIPubMed
28. Ardanuy C, Rolo D, Fenoll A, Tarragó D, Calatayud L, Liñares J. Emergence of a multidrug-resistant clone (ST320) among invasive serotype 19A pneumococci in Spain. J Antimicrob Chemother. 2009;64:507–10. DOIPubMed
29. Wolter N, du Plessis M, von Gottberg A, de Gouveia L, Klugman KP. Molecular characterization of emerging non-levofloxacin-susceptible pneumococci isolated from children in South Africa. J Clin Microbiol. 2009;47:1319–24. DOIPubMed
30. Ho P-L, Que T-L, Chiu SS, Yung RWH, Ng T-K, Tsang DNC, Fluoroquinolone and other antimicrobial resistance in invasive pneumococci, Hong Kong, 1995−2001. Emerg Infect Dis. 2004;10:1250–7. DOIPubMed
31. de Cueto M, Rodríguez JM, Soriano MJ, López-Cerero L, Venero J, Pascual A. Fatal levofloxacin failure in treatment of a bacteremic patient infected with Streptococcus pneumoniae with a preexisting parC mutation. J Clin Microbiol. 2008;46:1558–60. DOIPubMed
32. Campos J, Ferech M, Lázaro E, de Abajo F, Oteo J, Stephens P, Surveillance of outpatient antibiotic consumption in Spain according to sales data and reimbursement data. J Antimicrob Chemother. 2007;60:698–701. DOIPubMed

Figures

• Figure 1. Streptococcus pneumoniae serotype 8 among invasive pneumococci isolated from adults in Spain, 2003−2012.
• Figure 2. A) Pulsed-field gel electrophoresis patterns of chromosomal DNA of Streptococcus pneumoniae isolates after digestion with SmaI. Lane 1, Sweden 15A-ST63 (American Type Culture Collection [ATCC] BAA-661); lanes 2−5, serotype...
• Figure 3. Nucleotide sequence variations in the penicillin-binding protein 1A (pbp1a) gene of Streptococcus pneumoniae. Row 1, S. pneumoniae R6; row 2, serotype (Ser) 8-ST53; row 3, serotype 8-ST63; row 4,...
• Figure 4. Chromosome location of the recombination region located upstream of the penicillin-binding protein 2x (pbp2x) gene of Streptococcus pneumoniae (A) and antimicrobial drug resistance determinants, capsular loci of the putative...

Table

• Table. Primers used to map the putative recombination event upstream of the pbp2x gene of Streptococcus pneumoniae, Spain, 2004–2012

Suggested citation for this article: Ardanuy C, de la Campa AG, García E, Fenoll A, Calatayud L, Cercenado E, et al. Spread of Streptococcus pneumoniaeserotype 8-ST63 multidrug-resistant recombinant clone, Spain. Emerg Infect Dis [Internet]. 2014 Nov [date cited].http://dx.doi.org/10.3201/eid2011.131215

DOI: 10.3201/eid2011.131215