Surveillance of Enterobacteriaceae from Diabetic Foot Infections in a Tunisian Hospital: Detection of E. coli- ST131- bla CTX-M-15 and K. pneumoniae -ST1- bla NDM-1 Strains
Restricted accessResearch articleFirst published online August, 2024
Surveillance of Enterobacteriaceae from Diabetic Foot Infections in a Tunisian Hospital: Detection of E. coli- ST131- bla CTX-M-15 and K. pneumoniae -ST1- bla NDM-1 Strains
The study determined the prevalence, antimicrobial resistant (AMR) determinants, and genetic characteristics of Escherichia coli and Klebsiella pneumoniae isolates from patients with diabetic foot infection (DFI) in a Tunisian hospital. A total of 26 Escherichia spp. and Klebsiella spp. isolates were recovered and identified by MALDI-TOF-MS. Antimicrobial susceptibility testing, the detection of AMR determinants and Shiga-like toxin genes, phylogenetic grouping, and molecular typing were performed. Twelve E. coli, 10 K. pneumoniae, 3 K. oxytoca, and 1 E. hermanii were isolated. A multidrug-resistant phenotype was detected in 65.4% of the isolates. About 30.8% of isolates were extended-spectrum β-lactamase (ESBL) producers and mainly carried blaCTX-M-15 and blaCTX-M-14 genes. One blaNDM-1-producing K. pneumoniae-ST1 strain was identified. Class 1 integrons were detected in 11 isolates and 5 gene cassette arrangements were noted: dfrA1+aadA1 (n = 1), dfrA12+aadA2 (n = 3), and dfrA17+aadA5 (n = 1). Other non-β-lactam resistance genes detected were as follows (number of isolates): aac(3')-II (3), aac(6')–Ib-cr(8), qnrB (2), qnrS (4), cmlA (2), floR (4), sul1 (11), sul2 (11), and sul3 (2). The phylogroup B1 was the most frequent (41.7%) among E. coli, and two ESBL-producing isolates corresponded to the ST131-B2 lineage. The ESBL- and carbapenemase-producing Enterobacteriaceae in DFIs are described for the first time in Tunisia.
Get full access to this article
View all access options for this article.
References
1.
UnnikrishnanR, AnjanaRM, MohanV. Diabetes mellitus and its complications in India. Nat Rev Endocrinol, 2016; 12(6):357–370; doi: 10.1038/nrendo.2016.53
2.
EdmondsM, ManuC, VasP. The current burden of diabetic foot disease. J Clin Orthop Trauma, 2021; 17:88–93; doi: 10.1016/j.jcot.2021.01.017
3.
NickinsonATO, BridgwoodB, HoughtonJSM, et al.A systematic review investigating the identification, causes, and outcomes of delays in the management of chronic limb-threatening ischemia and diabetic foot ulceration. J Vasc Surg, 2020; 71(2):669–681.e2; doi: 10.1016/j.jvs.2019.08.229
4.
YellinJI, GaeblerJA, ZhouFF, et al.Reduced hospitalizations and amputations in patients with diabetic foot ulcers treated with cyclical pressurized topical wound oxygen therapy: Real-world outcomes. Adv Wound Care (New Rochelle), 2022; 11(12):657–665; doi: 10.1089/wound.2021.0118
5.
BandykDF. The diabetic foot: Pathophysiology, evaluation, and treatment. Semin Vasc Surg, 2018; 31(2–4):43–48; doi: 10.1053/j.semvascsurg.2019.02.001
6.
Cortes-PenfieldNW, ArmstrongDG, BrennanMB, et al.Evaluation and management of diabetes-related foot infections. Clin Infect Dis, 2023; 77(3):e1–e13; doi: 10.1093/cid/ciad255
7.
TurzańskaK, AdesanyaO, RajagopalA, et al.Improving the management and treatment of diabetic foot infection: Challenges and research opportunities. Int J Mol Sci, 2023; 24(4):3913; doi: 10.3390/ijms24043913
8.
RajabAAH, HegazyWAH. What’s old is new again: Insights into diabetic foot microbiome. World J Diabetes, 2023; 14(6):680–704; doi: 10.4239/wjd.v14.i6.680
9.
HitamSAS, HassanSA, ManingN. The significant association between polymicrobial diabetic foot infection and its severity and outcomes. Malays J Med Sci, 2019; 26(1):107–114; doi: 10.21315/mjms2019.26.1.10
10.
KatzDE, FriedmanND, OstrovskiE, et al.Diabetic foot infection in hospitalized adults. J Infect Chemother, 2016; 22(3):167–173; doi: 10.1016/j.jiac.2015.12.007
11.
SaleemZ, HassaliMA, GodmanB, et al.Point prevalence surveys of antimicrobial use: A systematic review and the implications. Expert Rev anti Infect Ther, 2020; 18(9):897–910; doi: 10.1080/14787210.2020.1767593
12.
PeiranoG, PitoutJDD. Extended-spectrum β-lactamase-producing enterobacteriaceae: Update on molecular epidemiology and treatment options. Drugs, 2019; 79(14):1529–1541; doi: 10.1007/s40265-019-01180-3
13.
PatelSC, JanglaSM, PillaiR, et al.Prevalence of Extended Spectrum Beta-lactamase (ESBL) producing Enterobacteriaceae from clinical samples in a tertiary care hospital in Mumbai. IJMR, 2019; 6(2):153–157; doi: 10.18231/j.ijmr.2019.033
14.
OnduruOG, MkakosyaRS, AboudS, et al.Genetic determinants of resistance among ESBL-producing Enterobacteriaceae in community and hospital settings in East, Central, and Southern Africa: A systematic review and meta-analysis of prevalence. Can J Infect Dis Med Microbiol, 2021; 2021:5153237; doi: 10.1155/2021/5153237
15.
LiuB, LiY, WangB, et al.Research progress of CTX-M type extended-spectrum B-lactamases. Journal of Henan Agricultural Sciences, 2019; 48(12):1–7.
16.
CastanheiraM, SimnerPJ, BradfordPA. Extended-spectrum β-lactamases: An update on their characteristics, epidemiology and detection. JAC Antimicrob Resist, 2021; 3(3):dlab092; doi: 10.1093/jacamr/dlab092
17.
CantónR, González-AlbaJM, GalánJC. CTX-M Enzymes: Origin and Diffusion. Front Microbiol, 2012; 3:110; doi: 10.3389/fmicb.2012.00110
18.
MamloukK, Boutiba-Ben BoubakerI, GautierV, et al.Emergence and outbreaks of CTX-M beta-lactamase-producing Escherichia coli and Klebsiella pneumoniae strains in a Tunisian hospital. J Clin Microbiol, 2006; 44(11):4049–4056; doi: 10.1128/JCM.01076-06
19.
JouiniA, Ben SlamaK, VinuéL, et al.Detection of unrelated Escherichia coli strains harboring genes of CTX-M-15, OXA-1, and AAC(6')-Ib-cr enzymes in a Tunisian hospital and characterization of their integrons and virulence factors. J Chemother, 2010; 22(5):318–323; doi: 10.1179/joc.2010.22.5.318
20.
Ben SlamaK, Ben SallemR, JouiniA, et al.Diversity of genetic lineages among CTX-M-15 and CTX-M-14 producing Escherichia coli strains in a Tunisian hospital. Curr Microbiol, 2011; 62(6):1794–1801; doi: 10.1007/s00284-011-9930-4
21.
RodriguesC, MachadoE, FernandesS, et al.Different Escherichia coli B2-ST131 clades (B and C) producing extended-spectrum β-lactamases (ESBL) colonizing residents of Portuguese nursing homes. Epidemiol Infect, 2017; 145(15):3303–3306; doi: 10.1017/S0950268817002266
22.
PietschM, IrrgangA, RoschanskiN, et al.Whole genome analyses of CMY-2-producing Escherichia coli isolates from humans, animals and food in Germany. BMC Genomics, 2018; 19(1):601; doi: 10.1186/s12864-018-4976-3
23.
JohnsonJR, JohnstonB, ClabotsC, et al.Escherichia coli sequence type ST131 as the major cause of serious multidrug-resistant E. coli infections in the United States. Clin Infect Dis, 2010; 51(3):286–294; doi: 10.1086/653932
De AngelisG, Del GiacomoP, PosteraroB, et al.Molecular mechanisms, epidemiology, and clinical importance of β-lactam resistance in Enterobacteriaceae. IJMS, 2020; 21(14):5090; doi: 10.3390/ijms21145090
27.
UçkayI, BerliM, SendiP, et al.Principles and practice of antibiotic stewardship in the management of diabetic foot infections. Curr Opin Infect Dis, 2019; 32(2):95–101; doi: 10.1097/QCO.0000000000000530
28.
MaJ, SongX, LiM, et al.Global spread of carbapenem-resistant Enterobacteriaceae: Epidemiological features, resistance mechanisms, detection and therapy. Microbiol Res, 2023; 266:127249; doi: 10.1016/j.micres.2022.127249
29.
CLSI. Performance Standards for Antimicrobial Susceptibility Testing Twenty-Third Informational Supplement; CLSI Document; CLSI: Orlando, FL, USA; 2020; p. M100-S23.
30.
MagiorakosAP, SrinivasanA, CareyRB, et al.Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: An international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect, 2012; 18(3):268–281; doi: 10.1111/j.1469-0691.2011.03570.x
31.
Martínez-ÁlvarezS, SanzS, OlarteC, et al.Antimicrobial resistance in Escherichia coli from the broiler farm environment, with detection of SHV-12-producing strains. Antibiotics (Basel), 2022; 11(4):444; doi: 10.3390/antibiotics11040444
32.
SáenzY, BriñasL, DomínguezE, et al.Mechanisms of resistance in multiple-antibiotic-resistant Escherichia coli strains of human, animal, and food origins. Antimicrob Agents Chemother, 2004; 48(10):3996–4001; doi: 10.1128/AAC.48.10.3996-4001.2004
33.
CarvalhoI, ChenoufNS, CarvalhoJA, et al.Multidrug-resistant Klebsiella pneumoniae harboring extended spectrum β-lactamase encoding genes isolated from human septicemias. PLoS One, 2021; 16(5):e0250525; doi: 10.1371/journal.pone.0250525
34.
SáenzY, VinuéL, RuizE, et al.Class 1 integrons lacking qacEΔ1 and sul1 genes in Escherichia coli isolates of food, animal and human origins. Vet Microbiol, 2010; 144(3-4):493–497; doi: 10.1016/j.vetmic.2010.01.026
35.
ClermontO, ChristensonJK, DenamurE, et al.The clermont Escherichia coli phylo-typing method revisited: Improvement of specificity and detection of new phylo-groups. Environ Microbiol Rep, 2013; 5(1):58–65; doi: 10.1111/1758-2229.12019
36.
DoumithM, DayM, CiesielczukH, et al.Rapid identification of major Escherichia coli sequence types causing urinary tract and bloodstream infections. J Clin Microbiol, 2015; 53(1):160–166; doi: 10.1128/JCM.02562-14
ScheutzF, TeelLD, BeutinL, et al.Multicenter evaluation of a sequence-based protocol for subtyping Shiga toxins and standardizing Stx nomenclature. J Clin Microbiol, 2012; 50(9):2951–2963; doi: 10.1128/JCM.00860-12
39.
KhaldiZ, NaymeK, BourjilatF, et al.Detection of ESBLs and carbapenemases among Enterobacteriaceae isolated from diabetic foot infections in Ouargla, Algeria. J Infect Dev Ctries, 2022; 16(11):1732–1738; doi: 10.3855/jidc.16660
40.
ZubairM, MalikA, AhmadJ. Study of plasmid-mediated extended-spectrum β-lactamase-producing strains of Enterobacteriaceae, isolated from diabetic foot infections in a North Indian tertiary-care hospital. Diabetes Technol Ther, 2012; 14(4):315–324; doi: 10.1089/dia.2011.0197
41.
KamelNA, AboshanabKM, AbouelwafaMM, et al.Plasmid mediated extended spectrum betalactamase producing strains of Enterobacteriaceae isolated from diabetic foot infections in Egypt. Arch Clin Microbiol, 2013; 4(4):1; doi: 10.3823/269
42.
BellazregF, GuiguaA, FerjaniA, et al.Correlation between superficial and intra-operative specimens in diabetic foot infections: Results of a cross-sectional Tunisian study. Afr Health Sci, 2019; 19(3):2505–2514; doi: 10.4314/ahs.v19i3.26
43.
Ben MoussaM, KhalfallahM, Boutiba-Ben BoubakerI, et al.Bacteriological and therapeutic profile of diabetic foot infection: A prospective study of 100 patients. Tunis Med, 2016; 94(2):95–101.
44.
HammamiM, LahianiD, GuemriB, et al.Les infections du pied diabétique: Étude de 136 cas. Ann. Endocrino, 2015; 76(4):552; doi: 10.1016/j.ando.2015.07.852
45.
SonST, HanSK, LeeTY, et al.The microbiology of diabetic foot infections in Korea. J Wound Management Res, 2017; 13(1):8–12; doi: 10.22467/jwmr.2017.00108
46.
SekharS, VyasN, UnnikrishnanM, et al.Antimicrobial susceptibility pattern in diabetic foot ulcer: A pilot study. Ann Med Health Sci Res, 2014; 4(5):742–745; doi: 10.4103/2141-9248.141541
47.
SannathimmappaMB, NambiarV, AravindakshanR. A crosssectional study to evaluate the knowledge and attitude of medical students concerning antibiotic usage and antimicrobial resistance. Int J Acad Med, 2021; 7(2):113–119; doi: 10.4103/IJAM.IJAM_57_20
48.
DawaiwalaI, AwaghadeS, KolhatkarP, et al.Microbiological pattern, antimicrobial resistance and prevalence of MDR/XDR organisms in patients with diabetic foot infection in an Indian tertiary care hospital. Int J Low Extrem Wounds, 2023; 22(4):695–703; doi: 10.1177/15347346211038090
49.
BabypadminiS, AppalarajuB. Extended-spectrum β-lactamases in urinary isolates of Escherichia coli and Klebsiella pneumoniae - prevalence and susceptibility pattern in a tertiary care hospital. Indian J Med Microbiol, 2004; 22(3):172–174.
50.
AnanthakrishnanAN, KanungoR, KumarA, et al.Detection of extended spectrum β-lactamase producers among surgical wound infections and burn patients in JIPMER. Indian J Med Microbiol, 2004; 18(4):160–165.
51.
GadepalliR, DhawanB, SreenivasV, et al.A clinico-microbiological study of diabetic foot ulcers in an Indian tertiary care hospital. Diabetes Care, 2006; 29(8):1727–1732; doi: 10.2337/dc06-0116
52.
VaraiyaAY, DograJD, KulkarniMH, et al.Extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella pneumoniae in diabetic foot infections. Indian J Pathol Microbiol, 2008; 51(3):370–372; doi: 10.4103/0377-4929.42513
53.
WoldeteklieAA, KebedeHB, AbdelaAA, et al.Prevalence of extended-spectrum β-lactamase and carbapenemase producers of gram-negative bacteria, and methicillin-resistant Staphylococcus aureus in isolates from diabetic foot ulcer patients in Ethiopia. Infect Drug Resist, 2022; 15:4435–4441; doi: 10.2147/IDR.S371431
54.
MottaRN, OliveiraMM, MagalhãesPS, et al.Plasmid-mediated extended-spectrum beta-lactamase-producing strains of Enterobacteriaceae isolated from diabetes foot infections in a Brazilian diabetic center. Braz J Infect Dis, 2003; 7(2):129–134; doi: 10.1590/s1413-86702003000200006
55.
KumarMS, LakshmiV, RajagopalanR. Occurrence of extended spectrum beta-lactamases among Enterobacteriaceae spp. isolated at a tertiary care institute. Indian J Med Microbiol, 2006; 24(3):208–211.
56.
SaltogluN, ErgonulO, TulekN, et al.Influence of multidrug resistant organisms on the outcome of diabetic foot infection. Int J Infect Dis, 2018; 70:10–14; doi: 10.1016/j.ijid.2018.02.013
57.
MachadoC, TeixeiraS, FonsecaL, et al.Evolutionary trends in bacteria isolated from moderate and severe diabetic foot infections in a Portuguese tertiary center. Diabetes Metab Syndr, 2020; 14(3):205–209; doi: 10.1016/j.dsx.2020.02.010
58.
ShahiSK, SinghVK, KumarA. Detection of Escherichia coli and associated β-lactamases genes from diabetic foot ulcers by multiplex PCR and molecular modeling and docking of SHV-1, TEM-1, and OXA-1 β-lactamases with clindamycin and piperacillin-tazobactam. PLoS One, 2013; 8(7):e68234; doi: 10.1371/journal.pone.0068234
59.
ChaudhryWN, BadarR, JamalM, et al.Clinico-microbiological study and antibiotic resistance profile of mecA and ESBL gene prevalence in patients with diabetic foot infections. Exp Ther Med, 2016; 11(3):1031–1038; doi: 10.3892/etm.2016.2996
60.
LiuCM, SteggerM, AzizM, et al.Escherichia coli ST131-H22 as a foodborne uropathogen. mBio, 2018; 9(4):e00470-18; doi: 10.1128/mBio.00470-18
61.
DziriO, DziriR, MaraoubA, et al.Characterization of O25b-ST131 Escherichia coli Clone Producing CTX-M-15, DHA-4, and CMY-42 in Urinary Tract Infections in a Tunisian Island. Microb Drug Resist, 2020; 26(7):741–746; doi: 10.1089/mdr.2019.0076
62.
MaamarE, FerjaniS, JendoubiA, et al.High Prevalence of Gut Microbiota Colonization with Broad-Spectrum Cephalosporin Resistant Enterobacteriaceae in a Tunisian Intensive Care Unit. Front Microbiol, 2016; 7:1859; doi: 10.3389/fmicb.2016.01859
63.
FerjaniS, SaidaniM, EnnigrouS, et al.Multidrug resistance and high virulence genotype in uropathogenic Escherichia coli due to diffusion of ST131 clonal group producing CTX-M-15: An emerging problem in a Tunisian hospital. Folia Microbiol (Praha), 2014; 59(3):257–262; doi: 10.1007/s12223-013-0292-0
64.
ClermontO, DhanjiH, UptonM, et al.Rapid detection of the O25b-ST131 clone of Escherichia coli encompassing the CTX-M-15-producing strains. J Antimicrob Chemother, 2009; 64(2):274–277; doi: 10.1093/jac/dkp194
65.
Rocha-GraciaRC, Cortés-CortésG, Lozano-ZarainP, et al.Faecal Escherichia coli isolates from healthy dogs harbour CTX-M-15 and CMY-2 β-lactamases. Vet J, 2015; 203(3):315–319; doi: 10.1016/j.tvjl.2014.12.026
66.
ZającM, SztromwasserP, BortolaiaV, et al.Occurrence and Characterization of mcr-1-Positive Escherichia coli Isolated From Food-Producing Animals in Poland, 2011–2016. Front Microbiol, 2019; 10:1753; doi: 10.3389/fmicb.2019.01753
67.
MhayaA, TrabelsiR, AillerieS, et al.Detection of Clones B2-ST131-C2 and A-ST617 in Escherichia coli Producing Both CTX-M-15 and CTX-M-27 from Tunisian Community Patients. Antibiotics (Basel), 2022; 11(10):1329; doi: 10.3390/antibiotics11101329
68.
MalutaRP, LogueCM, CasasMR, et al.Overlapped sequence types (STs) and serogroups of avian pathogenic (APEC) and human extra-intestinal pathogenic (ExPEC) Escherichia coli isolated in Brazil. PLoS One, 2014; 9(8):e105016; doi: 10.1371/journal.pone.0105016
69.
RamadanH, JacksonCR, FryeJG, et al.Antimicrobial Resistance, Genetic Diversity and Multilocus Sequence Typing of Escherichia coli from Humans, Retail Chicken and Ground Beef in Egypt. Pathogens, 2020; 9(5):357; doi: 10.3390/pathogens9050357
70.
SaïdaniM, HammamiS, KammounA, et al.Emergence of carbapenem-resistant OXA-48 carbapenemase-producing Enterobacteriaceae in Tunisia. J Med Microbiol, 2012; 61(Pt 12):1746–1749; doi: 10.1099/jmm.0.045229-0
71.
Ben HelalR, DziriR, ChedlyM, et al.Occurrence and Characterization of Carbapenemase-Producing Enterobacteriaceae in a Tunisian Hospital. Microb Drug Resist, 2018; 24(9):1361–1367; doi: 10.1089/mdr.2018.0013
72.
DziriO, DziriR, Ali El SalabiA, et al.Carbapenemase Producing Gram-Negative Bacteria in Tunisia: History of Thirteen Years of Challenge. Infect Drug Resist, 2020; 13:4177–4191; doi: 10.2147/IDR.S259562
73.
KhanAU, NordmannP. NDM-1-producing Enterobacter cloacae and Klebsiella pneumoniae from diabetic foot ulcers in India. J Med Microbiol, 2012; 61(Pt 3):454–456; doi: 10.1099/jmm.0.039008-0
74.
YeS, NiL, WangS, et al.Identification of an NDM-1-producing Klebsiella pneumoniae from diabetic foot ulcer in China. Infect Dis (Lond), 2018; 50(6):460–462; doi: 10.1080/23744235.2017.1407038
75.
SaseedharanS, SahuM, ChaddhaR, et al.Epidemiology of diabetic foot infections in a reference tertiary hospital in India. Braz J Microbiol, 2018; 49(2):401–406; doi: 10.1016/j.bjm.2017.09.003
76.
HusseinAI, AhmedAM, SatoM, et al.Characterization of integrons and antimicrobial resistance genes in clinical isolates of Gram-negative bacteria from Palestinian hospitals. Microbiol Immunol, 2009; 53(11):595–602; doi: 10.1111/j.1348-0421.2009.00168.x
77.
MalekMM, AmerFA, AllamAA, et al.Occurrence of classes I and II integrons in Enterobacteriaceae collected from Zagazig University Hospitals, Egypt. Front Microbiol, 2015; 6:601; doi: 10.3389/fmicb.2015.00601
78.
JouiniA, KlibiA, KmihaS, et al.Lineages, Virulence Gene Associated and Integrons among Extended Spectrum β-Lactamase (ESBL) and CMY-2 Producing Enterobacteriaceae from Bovine Mastitis, in Tunisia. Pathogens, 2022; 11(8):948; doi: 10.3390/pathogens11080948
