2011 185 -b- Klebsiella pneumoniae 1, 2) 3) 4, 5) 1) 2) 3) 4) 5) 22 8 27 23 5 9 -b- (MBL) Klebsiella pneumoniae 539 g 46 SpO 2 ceftazidime, vancomycin, cefotaxime meropenem IMP-1 MBL K. pneumoniae 2 3 6 PFGE 13 Key words: Klebsiella pneumoniae -b- meropenem 1) -b- (MBL) 4 b- MBL B b- b- Pseudomonas aeruginosa Serratia marcescens 2, 3) ( 860 0008) 1 5 TEL: 096 353 6501 FAX: 096 325 2519 E-mail: elk16bm@yahoo.co.jp 4, 5) 6) (Neonatal intensive care unit: NICU) MBL Klebsiella pneumoniae 2007 1 2008 3 NICU 6 Metallo-b-lactamase Klebsiella pneumonia 6 VITEK32 CLSI 7) 11
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 7.176 Na 140.1 meq/l stab 7 pco 2 63.2 mmhg K 4.93 meq/l seg 30 po 2 26.1 mmhg Cl 111 meq/l lymp 60 HCO 3 22.5 mmol/l Glu 159 mg/dl mono 3 BE 5.8 mmol/l CRP 0.06 mg/dl RBC 322 10 4 /ml Lac 15 mg/dl Hb 9.4 g/dl Ht 32.3 PLT 13.4 10 4 /ml Fig. 1. Abdominal X-rays findings and abdominal operation views. 12
-b- Klebsiella pneumoniae 187 23 0 2007 1 24 1 1 12 539 g NICU 2 47 46 908 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-1 237 1 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
188 Table 2. Antimicrobial susceptibility test of K. pneumoniae MIC (mg/ml) MIC (mg/ml) VITEK32 Agar D VITEK32 Agar D ABPC 32 128 GM 8 2 PIPC 8 8 AMK 2 CEZ 32 256 MINO 2 2 CTM 16 8 CPFX 0.5 0.06 CTX 4 16 LVFX 1 0.06 CAZ 16 64 ST 10 CPDX 32 CP 4 CFPM 2 CZOP 8 CPZ/SBT 16 CMZ 64 128 FMOX 32 AZT 8 0.03 IPM 4 0.5 MEPM 0.5 Agar dilution method Fig. 3. Confirmation examination of Metallo-b-lactamase-producing. 14
-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 3 29 4 10 2 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 7 2 1 8 9 1 10 3 2 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
190 2008 5 MBL 1 2 13 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
-b- Klebsiella pneumoniae 191 5 MBL K. pneumoniae E. aerogenes MRSA NICU MBL MBL ICT MBL 1) 2007. (BLNAR, ESBL, MBL, MDRP, MDR-TB) 56: 1387 1401. 2) 2008. -b- 1991 2005 15 -b- 82: 285 291. 3) 2002. 1991 2000 Serratia marcescens IMP-1 -b- 76: 246 250. 4) Nishio, H., M. Komatsu, N. Shibata, et al. 2004. 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: 5256 5263. 5) Fukigai, S., J. Alba, S. Kimura, et al. 2007. Nosocomial outbreak of genetically related IMP-1 beta-lactamase-producing Klebsiella pneumoniae in a general hospital in Japan. Int. J. Antimicrob. Agents 29(3): 306 310. 6) Ronald, N., J. Lalitagauri, M. Deshpande, J. M. Bell, et al. 2004. 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 (1998 2002). Journal of Infection and Public Health 49(4): 289 294. 7) CLSI. 8) 2006. Metallo-b-lactamase 80: 391 398. 9) Smith, C. L., C. R. Cantor. 1987. Purification, specific fragmentation, and separation of large DNA molecules. Methods Enzymol. 155: 449 467. 10) Tenover, F. C., R. Arbeit, V. Goering, P. Mickelse, B. M. Murray, D. Pershing, B. Swamnathan. 1995. Interpreting chromosomal DNA restriction patterns produced by pulsed-field gel electrophoresis: Criteria for bacterial strain typing. J. Clin. Microbiol. 36: 2233 2239. 11) Kosloske, A. M. 2003. Necrotizing enterocolitis. pp. 501 512, In: Newborn Surgery, 2nd ed. (P. Puri, ed.). 12) 2006. 216(4): 268 270. 13) 2009. 72(9): 1577 1582. 14) Karen, B., G. A. Jacoby, A. A. Medeiros. 1995. A functional classification scheme for b- lactamases and its correlation with molecular structure. Antimicrob. Agent Chemother. 39: 1211 1233. 15) 1998. Prog. Med. 18(11): 2681 2685. 16) Matsumura, N., S. Minami, Y. Watanabe, et al. 1999. Role of permeability in the activities of b-lactams against Gram-negative bacteria which produce a group 3 b-lactamase. Antimicrob. Agent Chemother. 00: 2084 2086. 17
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