Klebsiella pneumoniae

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1 b- Klebsiella pneumoniae 1, 2) 3) 4, 5) 1) 2) 3) 4) 5) b- (MBL) Klebsiella pneumoniae 539 g 46 SpO 2 ceftazidime, vancomycin, cefotaxime meropenem IMP-1 MBL K. pneumoniae PFGE 13 Key words: Klebsiella pneumoniae -b- meropenem 1) -b- (MBL) 4 b- MBL B b- b- Pseudomonas aeruginosa Serratia marcescens 2, 3) ( ) 1 5 TEL: FAX: elk16bm@yahoo.co.jp 4, 5) 6) (Neonatal intensive care unit: NICU) MBL Klebsiella pneumoniae NICU 6 Metallo-b-lactamase Klebsiella pneumonia 6 VITEK32 CLSI 7) 11

2 186 b-lactamase Metallo-b-lactamase 4 (IMP-1, IMP-2, VIM-1, VIM-2) primer PCR 8) IMP-1 K. pneumoniae 6 DNA Smith 9) XbaI (Bio-Rad Che# Mapper) Tenover 10) 200 V, pulse time initial time 3s,finaltime60s,14 22 h Table 1. Laboratory findings on onset Peripheral blood Blood gas Biochemistry WBC 28,000/ml ph Na meq/l stab 7 pco mmhg K 4.93 meq/l seg 30 po mmhg Cl 111 meq/l lymp 60 HCO mmol/l Glu 159 mg/dl mono 3 BE 5.8 mmol/l CRP 0.06 mg/dl RBC /ml Lac 15 mg/dl Hb 9.4 g/dl Ht 32.3 PLT /ml Fig. 1. Abdominal X-rays findings and abdominal operation views. 12

3 -b- Klebsiella pneumoniae g NICU g SIMV (Synchronized Intermittent Mandatory Ventilation) CRP 0.06 mg/dl (Table 1) X (Fig. 1A, B) piperacillin (PIPC) vancomycin (VCM) 10 NICU 47 NICU 80 cm 40 cm (Fig. 1C, D) K. pneumoniae Fig. 2 VCM ceftazidime (CAZ) cefotaxime (CTX) CRP 30 mg/dl CRP 54 Fig. 2. Clinical course. meropenem (MEPM) 61 MA K. pneumoniae VITEK32 Table 2 VITEK32 ampicillin (ABPC), cefazolin (CEZ) cefmetazole (CMZ) MIC CAZ 16 mg/ml PIPC, cefotiam (CTM), CTX Aztreonam (AZT) imipenem (IPM) MIC MBL AZT MIC 0.03 mg/ml MIC PIPC 8 mg/ml CTX MIC 16 mg/ml VITEK32 4 mg/ml ESBL 13

4 188 Table 2. Antimicrobial susceptibility test of K. pneumoniae MIC (mg/ml) MIC (mg/ml) VITEK32 Agar D VITEK32 Agar D ABPC GM 8 2 PIPC 8 8 AMK 2 CEZ MINO 2 2 CTM 16 8 CPFX CTX 4 16 LVFX CAZ ST 10 CPDX 32 CP 4 CFPM 2 CZOP 8 CPZ/SBT 16 CMZ FMOX 32 AZT IPM MEPM 0.5 Agar dilution method Fig. 3. Confirmation examination of Metallo-b-lactamase-producing. 14

5 -b- Klebsiella pneumoniae 189 Fig. 3A clavulanic acid (CVA) MBL b-lactam MBL K. pneumoniae MBL SMA (Fig. 3B) (Fig. 3C) MBL PCR IMP-1 MBL MBL MBL K. pneumoniae MBL K. pneumoniae 33 MBL MBL SMA 3 6 MBL K. pneumoniae PFGE (Fig. 4) MBL K. pneumoniae 6 MBL K. pneumoniae Infection Control Team (ICT) MRSA 30 MBL MBL 11 5 K. pneumoniae Enterobacter aerogenes 2 MBL K. pneumoniae E. aerogenes (Fig. 5) E. aerogenes Fig. 4. PFGE pattern of MBL-producing K. pneumonia isolated from six patients (1: A case of necrotizing enterocolitis). Fig. 5. A case which two kinds of Metallo-blactamase-producing bacteria are isolated (K. pneumoniae, E. aerogenes). 15

6 MBL MBL -b- (MBL) K. pneumoniae 1,500 g 11) DIC Paneth defensin, lysozyme, lectin s-iga overgrowth K. pneumoniae Escherichia coli, Clostridium spp. Enterobacter spp., Pseudomonas spp., Salmonella spp., Coagulase-negative staphylococci 12, 13) IMP-1 MBL CAZ 14) MIC D2 porin MBL D2 MIC 15) MBL MEPM MBL K. pneumoniae IPM MEPM MIC 0.5 mg/ml MBL 4 MIC 16) MBL CAZ MBL 1 MBL MBL CAZ IPM 1 MBL K. pneumoniae MBL MBL MBL MBL MBL K. pneumoniae NICU ABPC, gentamicin (GM), CMZ, amikacin (AMK) 3, 4 VCM 3 MBL MBL MBL MBL MBL MBL IMP-1 IMP-1 1) 16

7 -b- Klebsiella pneumoniae MBL K. pneumoniae E. aerogenes MRSA NICU MBL MBL ICT MBL 1) (BLNAR, ESBL, MBL, MDRP, MDR-TB) 56: ) b b- 82: ) Serratia marcescens IMP-1 -b- 76: ) Nishio, H., M. Komatsu, N. Shibata, et al Metallo-b-lactamase-producing Gram-negative bacilli: Laboratory-based surveillance in cooperation with 13 clinical laboratories in the Kinki region Japan. J. Clin. Microbiol. 42: ) Fukigai, S., J. Alba, S. Kimura, et al Nosocomial outbreak of genetically related IMP-1 beta-lactamase-producing Klebsiella pneumoniae in a general hospital in Japan. Int. J. Antimicrob. Agents 29(3): ) Ronald, N., J. Lalitagauri, M. Deshpande, J. M. Bell, et al Evalution of the contemporary occurrence rates of metallo-b-lactamases in multidrug-resistant Gram-negative bacilli in Japan: Report from the SENTRY Antimicrobial Surveillance Program ( ). Journal of Infection and Public Health 49(4): ) CLSI. 8) Metallo-b-lactamase 80: ) Smith, C. L., C. R. Cantor Purification, specific fragmentation, and separation of large DNA molecules. Methods Enzymol. 155: ) Tenover, F. C., R. Arbeit, V. Goering, P. Mickelse, B. M. Murray, D. Pershing, B. Swamnathan Interpreting chromosomal DNA restriction patterns produced by pulsed-field gel electrophoresis: Criteria for bacterial strain typing. J. Clin. Microbiol. 36: ) Kosloske, A. M Necrotizing enterocolitis. pp , In: Newborn Surgery, 2nd ed. (P. Puri, ed.). 12) (4): ) (9): ) Karen, B., G. A. Jacoby, A. A. Medeiros A functional classification scheme for b- lactamases and its correlation with molecular structure. Antimicrob. Agent Chemother. 39: ) Prog. Med. 18(11): ) Matsumura, N., S. Minami, Y. Watanabe, et al Role of permeability in the activities of b-lactams against Gram-negative bacteria which produce a group 3 b-lactamase. Antimicrob. Agent Chemother. 00:

8 192 A Study of Metallo-b-Lactamase-Producing Klebsilla pneumoniae from Neonatal Intensive Care Unit Kohta Katsuki 1, 2), Zenzo Nagasawa 3) 4, 5), Teturo Muratani 1) Deparment of Clinical Laboratory, National Hospital Organization, Kumamoto Medical Center 1 2) Deparment of Clinical Laboratory, National Hospital Organization, Saga Hospital 3) Depatment of Clinical Laboratory, Saga University Hospital 4) Kyurin Corporation 5) Department of Urology, School of Medicine, University of Occupational and Environmental Health We experienced a case which is suspected to be a hospital infection of Metallo-b-lactamase (MBL)- producing Klebsiella pneumoniae. The patient who became an origin of the infection is a girl whose birth weight was 539 g. On the 46 days of age she fell into the shock with the decline of SpO 2, abdominal distension and bloody stool. Under a diagnosis of necrotizing enterocolitis, the necrotic colon was removed and the artifical anus was made. This infection could not be controlled by medication of ceftazidim, vancomycin, or cefotaxime but by medication of meropenem, and her life was saved. IMP-1 type MBL-producing K. pneumoniae were isolated from the culture of her blood, ascites and stool. Because the MBL-producing K. pneumoniae were also isolated from two other infant, the hospital infection was suspected, and the stool culture was proceeded from all of the infants in this ward. Consequently the K. pneumoniae which was isolated from the 6 infants including the 3 infants above and the same electrophoretic pattern was obserbed by PFGE analysis. The prevention of contact infection was carried out, but the MBL-producing K. pneumoniae were isolated from 13 infants finally. Because the immune sysytem of prmature infants are immature, the spread of antibiotics resistant bacteria is a very serious problem. Careful monitorings of the antibiotics resistant bacterias are needed in Neonatal intensive care unit. 18