This study aimed to determine the mechanism of resistance to piperacillin–tazobactam (TZP) in Klebsiella pneumoniae bloodstream isolates that are susceptible to extended-spectrum cephalosporins (ESCs). Antibiotic susceptibility was determined for K. pneumoniae isolated from children with bacteremia. The β-lactamase genes were detected using a large-scale bla detection method (LARGE-SCALEblaFinder) and confirmed by sequencing analysis. The isolates were further characterized by β-lactamase activity assays and multilocus sequence typing. Among the 300 bloodstream isolates of K. pneumoniae, 11 (3.7%) were TZP resistant but ESC susceptible. The TZP minimum inhibitory concentrations (MICs) of the isolates ranged from 128/4 to >2,048/4 mg/L. Avibactam markedly inhibited piperacillin resistance, reducing the MICs to the range of ≤1 to 8 mg/L. Among the 11 isolates, four hyperproduced SHV-1 and two hyperproduced SHV-11, exhibiting 77- to 496-fold higher β-lactamase activity compared with the SHV-1- and SHV-11-producing reference strains that are susceptible to TZP. OXA-1 was coproduced in three isolates, and the remaining two isolates produced TEM-30. Transformants with recombinant plasmids carrying the β-lactamase genes demonstrated an increase in MICs of TZP. The TZP-resistant and ESC-susceptible isolates were not epidemiologically related. Hyperproduction of SHV-1 and SHV-11 represents a novel mechanism for reducing TZP activity in K. pneumoniae isolates resistant to ESCs. Continuous monitoring and investigation of TZP-resistant isolates are needed in the current era of high TZP consumption.
Get full access to this article
View all access options for this article.
References
1.
HarrisP.N., TambyahP.A, and PatersonD.L.. 2015. β-lactam and β-lactamase inhibitor combinations in the treatment of extended-spectrum β-lactamase producing Enterobacteriaceae: time for a reappraisal in the era of few antibiotic options? Lancet Infect. Dis. 15:475–485.
2.
HoritaN., ShibataY., WatanabeH., NamkoongH., and KanekoT.. 2017. Comparison of antipseudomonal β-lactams for febrile neutropenia empiric therapy: systematic review and network meta-analysis. Clin. Microbiol. Infect. 23:723–729.
3.
LeeJ., OhC.E, ChoiE.H, and LeeH.J.. 2013. The impact of the increased use of piperacillin/tazobactam on the selection of antibiotic resistance among invasive Escherichia coli and Klebsiella pneumoniae isolates. Int. J. Infect. Dis. 17:e638–e643.
4.
BantarC., VescoE., HeftC., SalamoneF., KrayeskiM., GomezH., CoassoloM.A, FiorilloA., FrancoD., ArangoC., DuretF., and OlivaM.E.. 2004. Replacement of broad-spectrum cephalosporins by piperacillin-tazobactam: impact on sustained high rates of bacterial resistance. Antimicrob. Agents Chemother. 48:392–395.
5.
KnudsenJ.D., and AndersenS.E.. 2014. A multidisciplinary intervention to reduce infections of ESBL- and AmpC-producing, gram-negative bacteria at a University Hospital. PLoS One, 9:e86457.
6.
BradyM., CunneyR., MurchanS., OzaA., and BurnsK.. 2016. Klebsiella pneumoniae bloodstream infection, antimicrobial resistance and consumption trends in Ireland: 2008 to 2013. Eur. J. Clin. Microbiol. Infect. Dis. 35:1777–1785.
7.
RyuS., KleinE.Y, and ChunB.C.. 2018. Temporal association between antibiotic use and resistance in Klebsiella pneumoniae at a tertiary care hospital. Antimicrob. Resist. Infect. Control, 7:83.
8.
DrawzS.M., and BonomoR.A.. 2010. Three decades of beta-lactamase inhibitors. Clin. Microbiol. Rev. 23:160–201.
9.
PatersonD.L., and BonomoR.A.. 2005. Extended-spectrum beta-lactamases: a clinical update. Clin. Microbiol. Rev. 18:657–686.
10.
SutherlandC.A., and NicolauD.P.. 2015. Susceptibility profile of ceftolozane/tazobactam and other parenteral antimicrobials against Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa from US Hospitals. Clin. Ther. 37:1564–1571.
11.
BakerT.M., RogersW., ChavdaK.D, WestbladeL.F, JenkinsS.G, NicolauD.P, KreiswirthB.N, CalfeeD.P, and SatlinM.J.. 2018. Epidemiology of bloodstream infections caused by Escherichia coli and Klebsiella pneumoniae that are piperacillin-tazobactam-nonsusceptible but ceftriaxone-susceptible. Open Forum Infect. Dis. 5:ofy300.
12.
StaintonS.M., ThabitA.K, KutiJ.L, AslanzadehJ., and NicolauD.P.. 2017. Prevalence, patient characteristics and outcomes of a novel piperacillin/tazobactam-resistant, pan-β-lactam-susceptible phenotype in Enterobacteriaceae: implications for selective reporting. Clin. Microbiol. Infect. 23:581–582.
13.
DuboisV., PoirelL., ArpinC., CoulangeL., BebearC., NordmannP., and QuentinC.. 2004. SHV-49, a novel inhibitor-resistant beta-lactamase in a clinical isolate of Klebsiella pneumoniae. Antimicrob. Agents Chemother. 48:4466–4469.
14.
ZhouX.Y., BordonF., SirotD., KitzisM.D, and GutmannL.. 1994. Emergence of clinical isolates of Escherichia coli producing TEM-1 derivatives or an OXA-1 beta-lactamase conferring resistance to beta-lactamase inhibitors. Antimicrob. Agents Chemother. 38:1085–1089.
15.
Clinical and Laboratory Standards Institute. 2015. Methods for Dilution Antimicrobial Susceptibility Tests for Bacteria That Grow Aerobically—Tenth Edition: Approved Standard M07-A10). Clinical and Laboratory Standards Institute, Wayne, PA.
16.
Clinical and Laboratory Standards Institute. 2015. Performance Standards for Antimicrobial Susceptibility Testing: Twenty-fifth Informational Supplement M100–S25. Clinical and Laboratory Standards Institute, Wayne, PA.
17.
Clinical and Laboratory Standards Institute. 2017. Performance Standards for Antimicrobial Susceptibility Testing: Twenty-seventh Informational Supplement M100–S27. Clinical and Laboratory Standards Institute, Wayne, PA.
18.
LeeJ.J., LeeJ.H, KwonD.B, JeonJ.H, ParkK.S, LeeC.R, and LeeS.H.. 2015. Fast and accurate large-scale detection of β-lactamase genes conferring antibiotic resistance. Antimicrob. Agents Chemother. 59:5967–5975.
19.
WuP.J., ShannonK., and PhillipsI.. 1994. Effect of hyperproduction of TEM-1 beta-lactamase on in vitro susceptibility of Escherichia coli to beta-lactam antibiotics. Antimicrob. Agents Chemother. 38:494–498.
20.
DiancourtL., PassetV., VerhoefJ., GrimontP.A, and BrisseS.. 2005. Multilocus sequence typing of Klebsiella pneumoniae nosocomial isolates. J. Clin. Microbiol. 43:4178–4182.
21.
CookeJ., StephensP., Ashiru-OredopeD., CharaniE., DrydenM., FryC., HandK., HolmesA., HowardP., JohnsonA.P, LivermoreD.M, MansellP., McNultyC.A, WellsteedS., HopkinsS., and SharlandM.. 2015. Longitudinal trends and cross-sectional analysis of English national hospital antibacterial use over 5 years (2008–13): working towards hospital prescribing quality measures. J. Antimicrob. Chemother. 70:279–285.
22.
MagillS.S., EdwardsJ.R, BeldavsZ.G, DumyatiG., JanelleS.J, KainerM.A, LynfieldR., NadleJ., NeuhauserM.M, RayS.M, RichardsK., RodriguezR., ThompsonD.L, and FridkinS.K.. 2014. Prevalence of antimicrobial use in US acute care hospitals, May-September 2011. JAMA, 312:1438–1446.
23.
MiróE., del CuerpoM., NavarroF., SabatéM., MirelisB., and PratsG.. 1998. Emergence of clinical Escherichia coli isolates with decreased susceptibility to ceftazidime and synergic effect with co-amoxiclav due to SHV-1 hyperproduction. J. Antimicrob. Chemother. 42:535–538.
24.
Pérez-MorenoM.O., Pérez-MorenoM., CarullaM., RubioC., JardíA.M, and ZaragozaJ.. 2004. Mechanisms of reduced susceptibility to amoxycillin-clavulanic acid in Escherichia coli strains from the health region of Tortosa (Catalonia, Spain). Clin. Microbiol. Infect. 10:234–241.
25.
SandersC.C., IaconisJ.P, BodeyG.P, and SamonisG.. 1988. Resistance to ticarcillin–potassium clavulanate among clinical isolates of the family Enterobacteriaceae: role of PSE-1 b-lactamase and high levels of TEM-1 and SHV-1 and problems with false susceptibility in disk diffusion tests. Antimicrob. Agents Chemother. 32:1365–1369.
26.
Livermore, D.M. 1995. beta-Lactamases in laboratory and clinical resistance. Clin. Microbiol. Rev. 8:557–584.
27.
SimpsonI.N., HarperP.B, and O'CallaghanC.H.. 1980. Principal beta-lactamases responsible for resistance to beta-lactam antibiotics in urinary tract infections. Antimicrob. Agents Chemother. 17:929–936.
28.
MartinezJ.L., CercenadoE., Rodriguez-CreixemsM., Vincente-PerezM.F, Delgado-IribarrenA., and BaqueroF.. 1987. Resistance to beta-lactam/clavulanate. Lancet, 2:1473.
29.
TurnerM.S., AnderssonP., BellJ.M, TurnidgeJ.D, HarrisT., and GiffardP.M.. 2009. Plasmid-borne blaSHV genes in Klebsiella pneumoniae are associated with strong promoters. J. Antimicrob. Chemother. 64:960–964.
30.
XiangX., ShannonK., and FrenchG.. 1997. Mechanism and stability of hyperproduction of the extended-spectrum beta-lactamase SHV-5 in Klebsiella pneumoniae. J. Antimicrob. Chemother. 40:525–532.
31.
GheorghiuR., YuanM., HallL.M, and LivermoreD.M.. 1997. Bases of variation in resistance to b-lactams in Klebsiella oxytoca isolates hyperproducing K1 beta-lactamase. J. Antimicrob. Chemother. 40:533–541.
32.
RiceL.B., CariasL.L, HujerA.M, BonafedeM., HuttonR., HoyenC., and BonomoR.A.. 2000. High-level expression of chromosomally encoded SHV-1 beta-lactamase and an outer membrane protein change confer resistance to ceftazidime and piperacillin-tazobactam in a clinical isolate of Klebsiella pneumoniae. Antimicrob. Agents Chemother. 44:362–367.
33.
MediavillaJ.R., SchneiderZ., NwaigweC., ChavdaK.D, ChenL., SatlinM., JenkinsS., NicolauD.P, and KreiswirthB.N.. 2015. Molecular characterization of piperacillin-tazobactam-resistant Escherichia coli susceptible to cephalosporins, monobactams, and carbapenems. Abstract presented at IDWeek 2015, San, Diego, October 7–11. Abstract no. P1181.
34.
FarmerT.H., DegnanB.A, and PayneD.J.. 1999. Penetration of beta-lactamase inhibitors into the periplasm of gram-negative bacteria. FEMS Microbiol. Lett. 176:11–15.
35.
PagèsJ.M., JamesC.E, and WinterhalterM.. 2008. The porin and the permeating antibiotic: a selective diffusion barrier in Gram-negative bacteria. Nat. Rev. Microbiol. 6:893–903.
36.
EhmannD.E., JahićH., RossP.L, GuR.F, HuJ., KernG., WalkupG.K, and FisherS.L.. 2012. Avibactam is a covalent, reversible, non-β-lactam β-lactamase inhibitor. Proc. Natl. Acad. Sci. U. S. A. 109:11663–11668.
37.
WuT.L., SiuL.K, SuL.H, LauderdaleT.L, LinF.M, LeuH.S, LinT.Y, and HoM.. 2001. Outer membrane protein change combined with co-existing TEM-1 and SHV-1 beta-lactamases lead to false identification of ESBL-producing Klebsiella pneumoniae. J. Antimicrob. Chemother. 47:755–761.
38.
NelsonK., HemarajataP., SunD., Rubio-AparicioD., TsivkovskiR., YangS., SebraR., KasarskisA., NguyenH., HansonB.M, LeopoldS., WeinstockG., LomovskayaO., and HumphriesR.M.. 2017. Resistance to ceftazidime-avibactam is due to transposition of KPC in a porin-deficient strain of Klebsiella pneumoniae with increased efflux activity. Antimicrob. Agents Chemother. 61:e00989-17.
39.
HumphriesR.M., and HemarajataP.. 2017. Resistance to ceftazidime-avibactam in Klebsiella pneumoniae due to porin mutations and the increased expression of KPC-3. Antimicrob. Agents Chemother. 61:e00537-17.
40.
CantónR., MorosiniM.I, de la MazaO.M, and de la PedrosaE.G.. 2008. IRT and CMT beta-lactamases and inhibitor resistance. Clin. Microbiol. Infect. 14:53–62.
41.
OrtegaA., OteoJ., Aranzamendi-ZaldumbideM., BartoloméR.M, BouG., CercenadoE., ConejoM.C, González-LópezJ.J, MarínM., Martínez-MartínezL., MerinoM., NavarroF., OliverA., PascualA., RiveraA., Rodríguez-BañoJ., WeberI., AracilB., and CamposJ.. 2012. Spanish multicenter study of the epidemiology and mechanisms of amoxicillin-clavulanate resistance in Escherichia coli. Antimicrob. Agents Chemother. 56:3576–3581.
42.
StapletonP., WuP.J, KingA., ShannonK., FrenchG., and PhillipsI.. 1995. Incidence and mechanisms of resistance to the combination of amoxicillin and clavulanic acid in Escherichia coli. Antimicrob. Agents Chemother. 39:2478–2483.
43.
SugumarM., KumarK.M, ManoharanA., AnbarasuA., and RamaiahS.. 2014. Detection of OXA-1 β-lactamase gene of Klebsiella pneumoniae from blood stream infections (BSI) by conventional PCR and in-silico analysis to understand the mechanism of OXA mediated resistance. PLoS One, 9:e91800.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
