Carbapenemase-producing Enterobacteriaceae: Overview of a major public health challenge = Entérobactéries et carbapénémases : bilan et enjeux d’un problème de santé publique majeur

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Carbapenemase-producing

Enterobacteriaceae:

Overview

of

a

major

public

health

challenge

Entérobactéries

et

carbapénémases

:

bilan

et

enjeux

d’un

problème

de

santé

publique

majeur

P. Nordmann

a,b,∗ a_Inserm_U914,_{Kremlin-Bicêtre,}_France

b_Unité_de_{microbiologie}_médicale_et_{moléculaire,}_département_de_médecine,_faculté_des_sciences,_université_de_Fribourg,_Fribourg,_Switzerland

Abstract

Bacterialresistancetoantibioticshasbecomeamajorsourceofconcernforpublichealth.Enterobacteriaceaeareamongthemostcommonhuman pathogens,causingcommunity-acquiredaswellashospital-acquiredinfections.Carbapenem-resistantEnterobacteriaceaehavebeenincreasingly reportedworldwidesincetheirfirstidentificationmorethan20yearsago.Threemainclassesofcarbapenemaseshavebeenidentified:Ambler classAbeta-lactamase(KPC),classB(metallo-enzymes),andclassD(OXA-48type).Klebsiellapneumoniaecarbapenemases(KPC)wasfirst reportedintheUnitedStatesinthelate1990sandsincethenworldwide,withamarkedendemicityintheUnitedStates,Greece,andnowItaly. CarbapenemaseNDM-1(NewDelhimetallo-beta-lactamase-1)isoneofthemostrecentlyreportedmetallo-enzymes.Ithasspreadwidelyinthe Indiansub-continentandnowworldwide.Carbapenemasesoftheoxacillinase-48type(OXA-48)havebeenidentifiedmostlyinMediterranean andsouthernEuropeancountrieswitharapidspread.Anearlyandquickidentificationofcarbapenemase-producinginfectedpatients,butalsoof carriers,ismandatorytopreventthespreadofthesehighlyresistantpathogens.Theearlyidentificationofcarriersandimplementingofcohorting strategiesistheonlymeanstopreventnosocomialoutbreakscausedbycarbapenemase,withveryfew,ifany,therapeuticoptions.

Keywords: Enterobacteriaceae;Carbapenemase; Metallo-beta-lactamase;OxacillinaseOXA-48;NewDelhimetallo-beta-lactamase-1;Klebsiella pneumoniae

carbapenemase

Résumé

Larésistancebactérienneauxantibiotiquesestd’incidencecroissantenotammentparmilesentérobactériesquisontlesbactériespathogènes lesplusfréquentespourl’Hommeetsontlasourcedenombreusesinfectionscommunautairesetnosocomiales.Desentérobactériesrésistantes auxcarbapénèmesontétérapportéesavecunefréquencecroissantedanslemondedepuisleurpremièredescriptionilyaplusde20ans.Trois principalesclassesdecarbapénémasesontétédécrites:classeA(KPC),classeB(métallo-enzymes)etclasseD(OXA-48).Depuisleurpremière descriptionauxÉtats-Unisàlaﬁndesannées1990,lescarbapénémasesKlebsiellapneumoniae(KPC)ontétéobservéessurlescinqcontinents.La plusforteendémicitésesitueauxÉtats-Unis,enGrèce,etplusdernièrementenItalie.Parmilescarbapénémasesdugroupedesmétallo-enzymes, NewDelhimetallo-beta-lactamase-1(NDM-1)estdedescriptionplusrécente.Elleauneprévalencetrèsélevéedansl’ensembledusous-continent indien.Les carbapénémases detypeoxacillinase-48(OXA-48) ontétérapportéesessentiellement danslepourtour delaMéditerranéeeten EuropeduSudoùleurdiffusionestparticulièrementrapide.Pourprévenirl’extensiondeladiffusiondecesbactériespathogènesmultirésistantes, l’identiﬁcationprécoceetrapidedessujetsinfectés,maisaussidespatientsporteurs,devientunenécessité.Ellepermetlamiseenœuvred’une stratégied’isolementparcohortingquireprésententl’uniquemoyend’éviterlapropagationd’épidémiesnosocomialescauséespardessouches productricesdecarbapénémases,pourlesquelleslespossibilitésthérapeutiquessontlimitées.

Motsclés:Entérobactéries;Carbapénémases;Métallo-␤-lactamase;Oxacillinase-48;NewDelhimetallo-beta-lactamase-1;Klebsiellapneumoniaecarbapénémase

∗_{Correspondence.}

E-mailaddress:patrice.nordmann@unifr.ch

Published in 0pGHFLQHHW0DODGLHV,QIHFWLHXVHV± which should be cited to refer to this work.

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Bacterialresistancetoantibioticshasbecomeamajorsource of concern for public health. The reality of this menacewas fully acknowledged byworlddecision makersin2013 atthe DavosEconomicForum(Switzerland).Withassubtitle“Health andhubris”,the global pressreleaseatthe endof thisforum presentsthesizeoftheriskinthefollowingterms“Hugestrides forwardinhealthhavelefttheworlddangerouslycomplacent. Risingresistancetoantibioticscouldpushoverburdenedhealth systems to the brink, while a hyper-connected world allows pandemicstospread.Thisriskcasedraws ontheconnections between antibiotic resistance, chronic disease andthe failure oftheinternationalintellectualpropertyregime,recommending moreinternationalcollaborationanddifferentfundingmodels”. TheriskforEuropewasassessedﬁnanciallyat1.5billioneuros. Theseverityofthismenaceisampliﬁedbythefactthatresearch fornewantibioticagentsiscurrentlystalled.Itmaybepossible that nototallynewagentactiveagainstmultiresistantbacteria willbeputonthemarketinaclosefuture.The20thcenturywas “the centuryofantibiotics”,markedbythediscoveryandthe continuousdevelopmentofnewmoreandmoreactive antibi-otics,butnonewfamilyhasbeenavailableforclinicianssince lipopeptidesin1987.

Virologistshavediscoverednumerousvirusesintheprevious 3 decades:HIV,hepatitisvirus,SARS,orthenewﬂuviruses; atthesametimemanyagentsactiveonsomeoftheseviruses weredevelopedandtheantiviraltherapeuticarsenalhasnever stoppedgrowing.Conversely,inbacteriology,wehaveselected strainsresistanttoallantibioticsamongthemostfrequent bac-terial species —Enterobacteriaceae— without being able to developagentscapableofdestroyingthemoreffective strate-giestopreventtheirextension.Thesecarbapenemase-producing Enterobacteriaceaeareprogressivelyspreadingthroughoutthe world[1].

1. Generalfeaturesandclassiﬁcation

Theenterobacterialcarbapenemasesdifferfromtheextended spectrum beta-lactamases (ESBL) which include (CTX-M), which hydrolyze or inactivate the beta-lactams and 2nd and 3rdgenerationcephalosporins,butnotcarbapenems.Most car-bapenemases hydrolyze beta-lactamsandcephalosporins, but alsomonobactamsandcarbapenems,sothatnobeta-lactamcan remaineffective(Fig.1).

TheAmblerclassificationproposedin1980isbasedon analo-giesofthepeptidesequence;beta-lactamasesareclassifiedin4 groups,AtoD.GroupsA,C,andDenzymesareserine-enzymes, whilethoseofgroupBaremetallo-enzymes.Carbapenemases mainlybelongto3greatgroupsofbeta-lactamases,A,B,andD, thedifferencesofwhichhavenotonlyageneticandbiochemical interest,butalsoaclinicalone,becausetheprofileofresistance andtheepidemiologyofthesestrainsdiffer.

The ﬁrstgroup,calledAmblerclassA,isthat of penicilli-nases.ThemostcommonisKPC(Klebsiellapneumoniae car-bapenemase),butthereareothers,suchasSerratiaMarcescens

(SME), non-metallo carbapanemase (NMC), imipenemase (IMI),Guyana extended-spectrum-lactamase(GES),etc. First identiﬁedinthe1980s,theyareenzymestheactivityspectrum

Fig.1.ActivityspectrumofcarbapenemasesinEnterobacteriaceae.

Spectred’activitédescarbapénémasesdesentérobactéries.

ofwhichextendstocarbapenems.Theyremaininhibited,atleast invitro,bybeta-lactamaseinhibitors,especiallyclavulanicacid. Thesecond group,classB,is thatof metallo-proteins,one ofthelatestofwithalargespreadisNDM-1.These metallo-proteinshydrolyzeallantibiotics,exceptaztreonam.Thethird group, classD, is that of oxacillinases, OXA-48 derivatives. Theyhydrolyzepenicillins,1stgenerationcephalosporins,and carbapenems;theyareresistanttobeta-lactamaseinhibitors,and weakly activeagainst 2nd and 3rdgeneration cephalosporins such ascefotaxime or ceftazidime,andhydrolyzeonlypartly carbapenems.

Noneofthebeta-lactamaseinhibitorscurrentlyavailable,nor eventhenewinhibitorsunderdevelopment,allowinhibitingthe 3groupsofcarbapenemases.

2. Groupofpenicillinases:KPC

Theterm KPC,forK.pneumoniaecarbapenemase,is rela-tivelyinadequatebecausetheseareenzymesthegenesofwhich transferveryeasilyfromanenterobacteriumtoanother, what-everthetype, andthusarenotlimited toK.pneumoniae.The strainsexpressingKPCareresistanttoallbeta-lactams,butalso resistanttomostoftheotherantibioticsfamilies.

ClassA carbapenemases have been identified sporadically in clinical isolates clinical since the 1980s; they were most oftenchromosomalenzymes.Astraincarryingaplasmid car-bapenemase,KPC-1, was first observedinNorth Carolina in 1996 [2]. KPCstrains remained rare inthe USA until 2005, whenKPC-producingEnterobacteriaceaewereidentifiedin out-breaks,inseveralNewYorkandNewJerseyhospitals.Aspread was thenobservedthroughoutNorthAmerica [3,4].In 2012, morethan1,200strainsofK.pneumoniaeproducingKPCtype enzymeswereisolatedfrombloodculturesinaNewYork teach-inghospital,provingtheirlargespread(P.Nordmann,personal communication).Thismenacehasnowbeentakenintoaccount at the highest level in the USAwhere majorresearch grants havebeenattributedbythefederalauthoritiestofightagainst thismajorpublichealthcarechallenge.

KPCstrainshavespreadlargely,asallentericbacteria,via colonized patients and air transportation [5]. After the East coastof the USA, KPCplasmid strains were isolated almost

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everywhereintheworld:inFrancefortheﬁrsttimein2005in apatientcomingbackfromNewYorkwherehehadundergone bilateralnephrostomy[6];inIsrael[7,8];inChinaandTaiwan

[9,10]; in South America: in Columbia in a Pseudomonas aeruginosastrain[11],inBrazil[12,13],inArgentina[14]...) and of course in most European countries [15]. The main endemicfocus in Europeis located inGreece [15–17]. Italy, affectedshortlyafterGreece,comessecond[18],butScotland

[19],Germany[20],Belgium[21],Finland[22],Scandinavian countries[23],Switzerland [24]are alsoaffected, viaGreece andItalymostoften.Mostofthecolonizedpatientsreportedin FrancecomefromItaly [25].Nevertheless,atthistime,there arefewepidemicfociinFranceandtheirextensionislimited.

Therearemanycirculatingstrains,evenifsomeclonesare ratherpredominant,especiallySTtypeST-258.Thegenes car-ryingresistanceenzymesarelocatedontransposons,whichgive themanadditionaldegreeofbacterialplasticity[26].

3. Metallo-enzymes

One of the currently best known metallo-beta-lactamases isNDM-1 (for NewDelhimetallo-beta-lactamase), described for the ﬁrst timein 2009ina Swedishpatientof Indian ori-gin,hospitalizedinSwedenaftercomingbackfromNewDelhi

[27].TheK.pneumoniaestrainwasisolatedinurine.TheNDM strains are usually resistant to almost all antibiotics, except totigecyclineandcolistin.Britishauthors wereableto deter-mine that the main reservoirs of these resistant strains were locatedintheIndiansub-continent:India,Pakistan,Bangladesh, and Sri Lanka. These beta-lactamases were later identiﬁed invariousspecies of Enterobacteriaceae:notonlyKlebsiella,

but also Escherichia coli, the most frequent of community-acquiredEnterobacteriaceae,inAcinetobacterbaumannii,then inP.aeruginosa.Asigniﬁcantspread,evenifmorelimited,was observed inGreat Britain, which has closebonds withIndia andPakistan[28,29].Thepublicationoftheseresultswas con-sideredas possiblydetrimentalfor theIndianeconomy,since managing foreignpatients is animportant sourceof revenue. ABritishtelevisionjournalistcollectedsamplesinNewDelhi atwaterdeliverypoints.Theanalysisofthesesamplesproved thattapwater(includingdrinkabletapwater)andrainwater con-tainedbacteriacarryingNDM-1,notonlyEnterobacteriaceae,

Stenotrophomonas maltophilia,andPseudomonasstrains,but alsocholericvibrions[30].

WhydidthesestrainsappearintheIndiansub-continentand now reached such a highprevalence? In fact, all the factors possiblypromotingthisemergencecanbefound.

First,strongselectionpressure:allantibioticsaresoldfreely inIndiaandtheiruseisrarelycontrolled.Indiaistodaytheﬁrst nationfortheproductionofgenericdrugsintheworld.Generic ertapenemandimipenemmanufacturedlocallyareeasily avail-able.Thereportedconsumptionofcarbapenemspercapitain Indiais 8 times higher thanthat of the Netherlands; the true consumptionisprobably25timeshigher.

Second,theenvironmentischaracterizedbythenon-respect of elementary hygiene rules, especially concerning water. A great proportion of people present withchronicdiarrhea and

themortalityduetointestinalinfectionsisoneofthehighestin theworld.

Third,thetransmissionandspreadofstrainsispromotedby over-population:1.4billionpeopleliveinIndiainslightlymore than3millionkm2,6timesthesizeofFrance.Thispromiscuity enhancestherisksofperson-to-persontransmissionofintestinal bacteria.Thehightemperaturesandhighhumidityareespecially favorableforbacterialovergrowth,especiallyinthesouthofthe country.

Thespreadofstrainsinthecommunityisimportant,sothat colonizationof travellersis possibleevenif theywerenot in directcontactwithhealthcare. Thespreadof carbapenemase-producing strains is currently massive in the Indian sub-continent:the prevalenceofcarriageisestimatedat5to15%

[31].

The impact of intercontinental travels is well illustrated by the epidemiology: the spread of NDM-1 strains overlaps almostexactly the contours of the old British Empire where manyIndianorPakistaniexpatriatelive:GreatBritain,Canada, theUSA,SouthAfrica,Kenya,Saudi Arabia,Gulf countries, Malaysia, Australia,etc. [32,33]. This is the case especially inEnglish-speaking Africa whereas French-speakingregions are still relatively not affected, likewise in Spanish-speaking countriesofSouthAmerica.

InEuropeandespeciallyinFrance,severalNDM-1strains, most coming from the Indian reservoir, havebeen identiﬁed

[34,35]. Even if the rare NDM-1 strains identiﬁed in France are not a public healthcare challenge yet, the emergence of

K.pneumoniaeNDM-1strainswithoutanylinkwiththeIndian sub-continent has already been reported in France and in Morocco[36,37].Isthisanisolatedphenomenonorthe begin-ningofabroaderspreadofthesestrains?Aworldwidespreadof theseNDMstrains,similartothoseobservedwithinafewyears fortheESBLproducingstrainsoftheCTX-Mtypewouldbea catastrophe.

BesidesK.pneumoniaeandE.coli,NDMproducingstrains havebeen identiﬁed inmanybacterial species: Enterobacter, Serratia,Citrobacter,Pseudomonas,Acinetobacter,etc.These arenotparticularlyvirulentstrains;asymptomaticcarriagemay persist for morethan a year, but severe invasive, septicemia orneurosurgical infectionsmaydevelopandraise unsolvable therapeuticissues.

The may concern with NDM resistance is that it is now carried byE.coli, ubiquitousand non-nosocomial bacterium, themostfrequentofallbacteria,theﬁrstpathogenresponsible for community-acquired infections,the ﬁrst cause of urinary tract infections and bacterial diarrhea [28]. Controlling such community-acquiredbacteriaisalmostimpossible.Ahospital canbeclosedbutnotcommunitylife.

Genetically,thesestrainscanassociateupto20determinants ofchromosomalplasmidresistance[38].

4. GroupofOXA-48-typeoxacillinases

Oxacillinases (Ambler classD) account for the greatest numberof multiresistant strainscurrentlydetected inFrance. The genescome fromplasmids and strainsmay host several

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Fig.2.WorldwidespreadofOXA-48producingstrains.

DiffusiondessouchesOXA-48danslemonde.

resistancegenes,especiallyOXA-48andCTX-M.The contam-inationreservoirisinthiscasemuchclosertoFrance,inNorth Africa, Libya,Egypt, theMiddle East,andTurkey.Thereare increasedrisksrelatedtopoliticalandsanitaryupheavalsinthese countries (Fig.2).Thehistoricalandpoliticalbondsbetween Franceandthesenationsexplaintheimportantspreadofthese strainsinourcountry.

TheOXA-48geneisveryunusually(inbacteriology)most often locatedon asingleplasmid,whichhas spreadinmany differentEnterobacteriaceaestrainsandspecies[39].

5. AvoidingtheItalianscenario

In2012,theFrenchNationalReferenceCenter(Bicêtre) iden-tiﬁed343strainsproducingacarbapenemaseamongthe1,485 strains receivedwithamoreorless markedresistanceto car-bapenems.MostofthemwereKlebsiella,butalsoE.coli(Fig.3). Thisevolutionisamatterofconcernsinceitprovesthe extra-hospital spread. Resistance is primarily of the OXA-48type (75%), andlessfrequently KPC(12%) andNDM(8%). Car-bapenemasesVeronaimipenemase(VIM)(5%)andIMI(<1%) remainaminority.

The objective for France is to avoid the Italian scenario, wherewasobservedin2010theveryrapidspreadofresistant strains (source: European Center for Disease Prevention and Control;AntimicrobialresistancesurveillanceinEurope2010. Annual report. EARS-Net. ECDC, 2011). Before, in 2009, these strainswere isolated almost exclusively inGreece,and in 2010 the rate of resistant strains rose from less than 5% tomorethan10and25%,within ayear.All Italianhospitals —in Rome, Milan, Verona, Venice— now have to face the endemicity ofKPCstrains[15].Itisthusmostimportantthat

any patienthospitalized inItaly be screenedon admissionin theFrenchhospitalsystem[40].

6. Rapiddiagnosis

Theimplementationof screeningandisolationmeasuresis allthemoreeffectiveifthediagnosisof colonizationismade early.TheCarbaNPtest,arapiddiagnostictest,wasdeveloped by ourteam [41].It is asimple colorimetric testthat identi-ﬁesanycarbapenemaseactivity.Thetechniqueisveryeasyto implementanddoesnotrequiremolecularbiology.Henceitis cheap(2to3euros) andmaybedevelopedinanycountryor structurewithlimited resources.Theresultisobtained inless than2hours,withaspeciﬁcityandasensitivityof100%,which israreforabiologicaltest.TheCarbaNPtesthasbeenadopted

Fig.3.Carbapenemase-producingstrainsinFrancein2012.

SouchesproductricesdecarbapénémasesenFranceen2012.

FrenchNationalReferenceCenter,Bicêtre

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already in several countries,France, Singapore, Hong Kong, Italy,Belgium,GreatBritain,Germany,Switzerland,theMayo Clinic(USA),etc.

7. Perspectives

Even ifwerefusetoconsiderthecatastrophescenario,the prospects for antibiotherapyinthe next3yearsare relatively pessimistic.ContrarytowhatwasobservedforStaphylococcus aureus,thereversionofEnterobacteriaceaeresistanceseemsto be extremely rare or null. What may be feared is the evolu-tion from multipleresistances to panresistance. And there is awell-demonstratedrelationshipbetweenantibioticresistance and increased mortality of infection. Furthermore, the aging population,thedevelopmentofintensivecare,oforgan trans-plantations,ofanticanceroustreatmentsareallfactorsleading toanincreaseofimmunodepression,makingpatientsideal tar-gets for carbapenemase-producing Enterobacteriaceae. These are evolvingfrom the statusof strictly nosocomialtothat of community-acquiredbacteria,rendering no-effectiveisolation measuresappliedonlyonhealthcareinstitutions.

Policiesforthecontrolleduseofanti-infectiousdrugsremain mandatorytotrytostopthehospitalspreadofthese multiresis-tantbacteria,buthygienemeasuresatthesourceofpreventionof crosstransmissionarecapital.Allhospitalizedpatientscoming from aforeigncountrythantransferred totheFrench health-caresystemshouldbescreened.Cohortingproceduresshould beimplementedas earlyaspossibleandverystrictlyas soon astheyareindicated.Itishighlyprobablethatspecializedunits willsoonhavetobesetupinthelargehospitals,withastrict geographicseparationanddedicatedpersonnel.Thesemultidrug resistantbacteriashouldbemanagedliketheSARSvirusorﬂu mutants; it isapublic healthcareobligation. Thesemultidrug resistant bacteria should be considered with the utmost cau-tion,evenifEnterobacteriaceaebacterialspeciesarewellknown

(E.coli,K.pneumoniae,etc.)andbelongforthegreaternumber tothecommensalﬂora.

Thedangers ofhubrisonhumanhealth

Health is a critical system that is constantly being challenged, be it by emerging pandemics or chronic illnesses. Scientiﬁc discoveries and emerging technologies allow us to face such challenges,butthemedicalsuccessesofthepast century may also be creating a false sense of security.Arguably,oneofthemosteffectiveand common means to protect human life –the use of antibacterial and antimicrobial compounds (antibiotics)–maynolongerbereadily available in the near future. Every dose of antibiotics createsselectiveevolutionarypressures,assome bacteriasurvivetopassonthegeneticmutations that enabled them to do so. Until now, new antibioticshavebeendevelopedtoreplaceolder,

increasingly ineffective ones. However, human innovation may no longer be outpacing bacte-rialmutation.Noneofthenewdrugscurrentlyin thedevelopmentpipelinemaybeeffectiveagainst certainnewmutationsofkillerbacteriathatcould turn into a pandemic. Are there ways to stimu-latethedevelopmentofnewantibioticsaswellas alignincentives to prevent their overuse, or are weindangerofreturningtoapre-antibioticerain whichascratchcouldbepotentiallyfatal?

GlobalRisks2013reportoftheWorldEconomicForum.Full reportavailableathttp://www.weforum.org/globalrisks2013.

Disclosureofinterest

Theauthordeclaresthathehasnoconﬂictsofinterest con-cerningthisarticle.

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