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Isolation of seven distinct carbapenemase-producing Gram-negative organisms from a single patient

Sir, Carbapenemase-producing organisms (CPO) continue to spread around the globe at an alarming rate. People travelling to, and especially hospitalized in, areas that have high prevalence rates of MDR organisms (MDRO), such as ESBLand carbapenemaseproducing Gram-negative organisms, are at risk of acquiring these bacteria and subsequent colonization or infection. In low-prevalence countries, such as New Zealand (NZ), this risk factor has recently been identified for the first cases of Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae reported in NZ. Current reports of CPO in NZ are rare, with a low number of patients found to have cocarriage of more than two CPO and coproducing strains infrequently encountered. Here, we report the isolation of seven distinct CPO, together with an ESBL-producing Pseudomonas aeruginosa and Proteus mirabilis with an ACC-type AmpC b-lactamase, from a patient recently returned to NZ from a Romanian hospital. In November 2015, a NZ tourist was transferred to Christchurch Hospital after spending 2 months hospitalized in Bucharest, Romania. Due to travel history, screening samples were collected on admission. For detection of ESBL/CPO, faeces, multiple burn wound swabs and urine and tracheal aspirate samples were cultured onto CHROM Agar ESBL/VRE (Fort Richard Laboratories, NZ) as well as MacConkey agar with a 10 mg meropenem disc placed in the first quadrant. For MRSA, nose, groin and perineum swabs were placed in an in-house enrichment broth before subculturing onto MRSA Select (Bio-Rad, France). For VRE screening, faeces were also pre-enriched before subculturing onto VRE Select (Bio-Rad). Isolates were identified using MALDITOF (Bruker Daltonics, USA). Antimicrobial susceptibility testing was performed with PhoenixTM (BD Diagnostics, USA) or MIC gradient strips (bioMérieux, France or Liofilchem, Italy) using EUCAST breakpoints. Initial laboratory investigation included phenotypic ESBL detection, CarbaNP and GeneXpert Carba-R (Cepheid, USA), as previously described. All unique carbapenem-resistant P. mirabilis were sent to the ESR national reference laboratory for identification of b-lactamase genes by PCR and sequencing and strain typing by PFGE. In total, seven distinct CPO were isolated from samples taken on admission and day 4 catheter urine: two distinct OXA-23-likeproducing Acinetobacter baumannii strains; OXA-48-producing K. pneumoniae; K. pneumoniae coproducing OXA-48 and NDM-1; KPC-2-producing K. pneumoniae; NDM-1-producing Providencia stuartii; and VIM-2-producing P. aeruginosa (Table 1). In addition, the VEB-1 ESBL gene was identified in a further carbapenemresistant P. aeruginosa, which is the first VEB-1-producing P. aeruginosa reported in NZ. The P. mirabilis was found to be carrying blaACC cephalosporinase, which is the first description of blaACC from NZ. PFGE demonstrated that any isolates of the same species were distinct (data not shown). No VRE or MRSA were found in any sample. All CPO, as well as the ESBL-producing P. aeruginosa, expressed broad-range multidrug resistance, leaving alarmingly few treatment options (Table 1). Although no isolates were pan-resistant, the NDM-1-producing P. stuartii was susceptible to only fosfomycin and colistin was the only option for both P. aeruginosa strains and one of the OXA-23-like-producing A. baumannii strains. Interestingly, both OXA-23-like-producing A. baumannii strains displayed high-level carbapenem resistance, despite the ISAba1 being detected in only one of the strains. Cocarriage of multiple CPO from a single patient has been reported by other authors. Ding et al. reported the identification of four distinct CPO in a patient from eastern China, with Escherichia coli, K. pneumoniae, Enterobacter aerogenes and A. baumannii carrying blaNDM-1, blaKPC-2, blaIMP-1 and blaOXA-23, respectively. Similarly, Hammerum et al. detected four carbapenemases (NDM-7, OXA-181, NDM-5 and OXA-23) in three different Gram-negative species, in a patient who was transferred to Denmark from a hospital in India. A total of six CPO were reported by Drieux et al. in a patient who was transferred from Greece to France; however, only two different carbapenemases (KPC-2 and VIM-1) were found amongst five bacterial species. The prevalence and dissemination of CPO in some countries can be difficult to ascertain due to several factors including a lack of national standards for patient screening, inadequate laboratory detection protocols and non-mandatory reporting. The 2013 European surveillance data suggested only sporadic cases of CPO in Romania; however, by 2015 the rating for Romania had escalated to inter-regional spread and the true burden may be underestimated. We would suggest that the collective finding of seven distinct CPO from a single patient is highly unusual and would imply a heavy burden of a diverse variety of CPO in Romania. This study highlights the risk that patients who have been hospitalized in endemic countries pose for the importation of CPO into lowprevalence countries. In order to reduce the spread of MDRO, it is imperative that all patients with recent hospitalization overseas, possibly extending to recent travel to CPO-endemic areas, be screened for MDRO on admission to NZ hospitals and that laboratories have sensitive and robust procedures to rapidly identify CPO. J Antimicrob Chemother 2017; : 317–319 72