Prevalence of Extended-Spectrum Beta-Lactamase and Carbapenemase Genes in Clinical Isolates of Escherichia coli in Myanmar: Dominance of bla NDM-5 and Emergence of bla OXA-181

Abstract

The increasing trend of Escherichia coli producing extended-spectrum beta-lactamases (ESBLs) and carbapenemases is a global public health concern. In this study, prevalence and molecular characteristics of E. coli harboring ESBL and carbapenemase genes were investigated for 426 isolates derived from various clinical specimens in a teaching hospital in Yangon, Myanmar, for the 1-year period beginning January 2016. A total of 157 isolates (36.9%) were ESBL producers and harbored CTX-M-1 group genes (146 isolates; bla_CTX-M-15, bla_CTX-M55) or CTX-M-9 group genes (11 isolates; bla_CTX-M-14, bla_CTX-M-27). Carbapenem resistance was detected in 35 isolates (8.2%), among which 26 isolates had carbapenemase genes encoding NDM-1 (2 isolates), NDM-4 (6 isolates), NDM-5 (14 isolates), NDM-7 (3 isolates), and OXA-181 (2 isolates). bla_NDM-5 was identified in phylogenetic groups A, B1, and D isolates belonging to various genotypes (ST101, ST354, ST405, ST410, ST1196) associated with bla_TEM-1, bla_CTX-M-15, bla_OXA-181, bla_CMY-2, bla_CMY-6, bla_CMY-42, qnrB, qnrS, or aac6′-Ib-cr. While two isolates with bla_OXA-181 belonged to phylogenetic group A-ST410, one isolate had also bla_NDM-5, as well as bla_CTX-M-15 and bla_CMY-2, and the other harbored bla_CMY-42 and aac6′-Ib-cr, showing different resistance patterns. Phylogenetic group B2 isolates examined were classified into mostly ST131 and had solely bla_CTX-M-15 or bla_CTX-M-27, harboring more virulence factors than other phylogenetic groups. The present study revealed high prevalence of ESBL genes represented by bla_CTX-M-15 and dominance of bla_NDM-5 among NDM genes, disseminating to various E. coli clones. Notably, carbapenemase gene encoding OXA-181 was first identified in Myanmar, suggesting its spread together with NDM genes.

Introduction

Escherichia coli is a common human pathogen causing a wide range of both community- and hospital-acquired infections, while this bacterium constitutes an inhabitant of normal flora of the intestinal tract. Emergence and increase of E. coli that is resistant to beta-lactam antibiotics raise morbidity and mortality with social costs, which has been posing a global public health concern.^1,2 The most common mechanism of beta-lactam resistance is hydrolysis of these substances mediated by beta-lactamases. On the basis of activity profile with specific substrates, beta-lactamases can be classified into four major groups, penicillinases, cephalosporinases, extended-spectrum beta-lactamases (ESBLs), and carbapenemases.³ ESBLs hydrolyze all the beta-lactams, except carbapenems, and are inactivated by clavulanic acid. Rates of Enterobacteriaceae producing ESBLs are globally increasing, through multiple factors, including horizontal gene transfer of plasmids, successful E. coli clones, food animals, and human migration.⁴ The most common ESBL types have been described as TEM, SHV, and CTX-M, among which CTX-M is dominant and has become disseminated globally, with CTX-M-14 and CTX-M-15 being the major genotypes.⁴

Subsequent to the worldwide prevalence of ESBLs, carbapenem resistance in E. coli and other Gram-negative rods have become remarkable, associated with the increased use of carbapenems.³ Because carbapenems have been used as a last-resort option for treatment of infections caused by drug-resistant bacteria, occurrence of carbapenem resistance has been an important public health threat. Carbapenem resistance in Enterobacteriaceae is primarily mediated by carbapenemases, and in some cases synergistic activity with ESBLs or AmpC beta-lactamases, together with porin loss.^5,6 Plasmid-mediated carbapenemases identified in Gram-negative bacteria includes Ambler class A (KPC, IMI, GES types), B (NDM, IMP, VIM types), and D (OXA types) enzymes.³ Particularly, class B carbapenemases, that is, metallo-beta-lactamases, exhibit a broad spectrum of activity to all penicillins, cephalosporins, and carbapenems, except for aztreonam. Among this group, NDM is regarded as an emerging carbapenemase, of which the prototype NDM-1 gene was first identified in 2008 in a patient previously hospitalized in New Delhi, India, and thereafter Gram-negative bacteria producing NDM-1 have been reported almost worldwide, although their prevalence vary in the country.⁷

Prevalence and molecular epidemiological feature of E. coli and other Gram-negative bacteria producing ESBL and carbapenemase have been studied mostly in developed countries, but limited information is available from developing countries. In Myanmar, resistance profiles and prevalence of ESBLs among Enterobacteriaceae, including E. coli from blood stream infections, were reported,^8,9 revealing rates of ESBL and carbapenemase as 38% and 14% of all Gram-negative isolates, respectively, with detection of CTX-M-15 type and NDM-4 and NDM-7 genes. However, these studies focused on only isolates from bacteremia, and genotypes and other genetic traits of E. coli had not been analyzed. Another study on eight E. coli isolates in Myanmar clarified genetic characteristics of plasmids harboring carbapenemases encoding NDM-1, NDM-4, NDM-5, and NDM-7.¹⁰ Nevertheless, epidemiological background and prevalence of bla_NDM types were remained to be determined.

The present study was conducted in 2016 in Yangon, Myanmar, to investigate prevalence and genetic characteristics of E. coli harboring ESBL and/or carbapenemase genes among recent clinical isolates derived from various specimens. We report, in this study, dominance of NDM-5 gene among bla_NDM, and first identification of OXA-181 gene in Myanmar, together with sequence types (STs) and other genetic traits of E. coli harboring beta-lactamase genes.

Materials and Methods

Bacterial isolates

A total of 426 nonduplicate consecutive clinical isolates of E. coli derived from patients with extraintestinal infections were analyzed. These isolates were collected from the North Okkalapa General Hospital (NOGH), a teaching hospital of University of Medicine 2, Yangon (Yangon, Myanmar), for 1 year from January to December 2016. The main source of the isolates was urine (n = 168), followed by wound swab (n = 87), sputum (n = 80), high vaginal swab (HVS, n = 43), pus (n = 25), blood (n = 19), throat swab (n = 3), and pleural fluid (n = 1). The median age of patients was 48 years (ranging from 19 days to 95 years of age), and sex ratio (female/male) of patients was 1.6 (264/162). Initial bacterial identification was performed by a conventional method, and isolates were stored in MicroBank (Pro-Lab Diagnostics, Richmond Hill, Canada) at −80°C and recovered when they were analyzed. This study was approved by the Research Ethics Committee of University of Medicine 2, Yangon.

Susceptibility testing, detection of ESBL producers

For the all E. coli isolates, antimicrobial susceptibility test was performed by the disk diffusion method. Drug resistance was judged according to zone size by criteria recommended by the Clinical Laboratory Standard Institute (CLSI).¹¹ Antimicrobials tested were amikacin (10 g), gentamicin (10 g), levofloxacin (5 g), sulfamethoxazole/trimethoprim (1.25/23.75 g), amoxicillin/clavulanate (20/10 g), cefotaxime (30 g), ceftazidime (30 g), ceftriaxone (30 g), cefoperazone/sulbactam (75/30 g), and meropenem (10 g; Oxoid). E. coli strain ATCC25922 was used as a standard strain for quality control standard. To detect ESBL producer, double-disk synergy test was employed by using cefotaxime/clavulanic acid disk (30/10 g) and ceftazidime/clavulanic acid disk (30/10 g) for all the isolates showing resistance to ceftriaxone, ceftazidime, or cefotaxime. For representative isolates, antimicrobial susceptibility was measured by broth microdilution test using Dry Plate “Eiken” DP31 (Eiken Chemical Co., Tokyo, Japan). Minimum inhibitory concentrations (MCIs) in the limited ranges against 18 antimicrobial agents (piperacillin, cefazolin, cefotiam, cefotaxime, ceftazidime, flomoxef, cefpodoxime, cefepime, ampicillin/sulbactam, aztreonam, imipenem, meropenem, gentamicin, amikacin, fosfomycin, minocycline, sulfamethoxazole/trimethoprim, and levofloxacin) were measured. Resistance and susceptibility were distinguished according to the breakpoints defined in the CLSI guidelines.¹¹

Detection and characterization of ESBL, carbapenemase, and AmpC genes

The presence of bla_CTX-M, bla_TEM, bla_SHV was confirmed by multiplex polymerase chain reaction (PCR) as previously reported.¹² Four bla_CTX-M subgroups (group 1, 2, 9, and 8/25/26) were discriminated by multiplex PCR assay as previously described.¹³ For all the isolates showing resistance to meropenem, the presence of carbapenemase genes (bla_NDM, bla_VIM, bla_IMP, bla_SPM, bla_AIM, bla_GIM, bla_BIC, bla_SIM, bla_DIM, bla_KPC, bla_IMI, bla_GES, and bla_OXA-48) were analyzed by PCR using primers and conditions as described previously.^14–16 In addition, six families of AmpC beta-lactamase genes were detected by multiplex PCR as described by Pérez-Pérez and Hanson.¹⁷ Full-length nucleotide sequences of bla_TEM, bla_CTX-M, carbapenemase genes, and AmpC genes were determined by direct sequencing from PCR products, and their subtypes were analyzed by BLAST search available at the NCBI website (http://blast.ncbi.nih.gov/Blast.cgi). Primers used for PCR and sequencing are listed in Supplementary Table S1 (Supplementary Data are available online at www.liebertpub.com/mdr).

Genetic analysis of ESBLs/carbapenemase-producing E. coli

For all the isolates with ESBL/carbapenemase genes, four main phylogenetic groups of E. coli (A, B1, B2, and D) were discriminated by triplex PCR method as described by Clermont et al.¹⁸ Identification of plasmid-mediated determinant of quinolone resistance genes (aac-6′-Ib-cr, qnrA, qnrB, qnrC, qnrD, qnrS, oqxAB, and qepA) and detection of O25b allele were performed for all the ESBL/carbapenemase-producing E. coli isolates by multiplex/uniplex PCR using primers and conditions as described previously.^19,20 Genes encoding virulence factors of E. coli that are mostly associated with extraintestinal infections, including adhesins, toxins, capsule, and siderophore, were detected by multiplex or uniplex PCR using primers described by several literatures.^21–29 ST of E. coli based on Achtman scheme of multilocus sequence typing (http://mlst.warwick. ac.uk) was assigned by determination of partial sequence of seven housekeeping genes (adk, fumC, gyrB, icd, mdh, purA, and recA).³⁰

GenBank accession numbers

The nucleotide sequence of beta-lactamase genes encoding NDM-1, -4, -5, and -7; OXA-181; CTX-M-15, -55, -14, and -27; TEM-1; and CMY-2, -4, -;6, -42, and -146 were deposited in the GenBank database under accession numbers MF464369-MF464378, and MF577052-MF577056, respectively (Supplementary Table S2).

Results

Among a total of 426 E. coli isolates, 157 isolates (36.9%) were ESBL producers and harbored bla_CTX-M genes assigned mostly to CTX-M-1 group (93%; 146/157), among which genotypes of CTX-M-15 and CTX-M-55 were identified (Table 1). Remaining 11 isolates (7%) had CTX-M-9 group genes, which were genotyped as CTX-M-14 and CTX-M-27. TEM-type beta-lactamase gene was detected in 104 isolates (66%), together with bla_CTX-M. Isolates with bla_CTX-M were assigned into four phylogenetic groups, with B1 being the least, and derived at higher rates from blood, pus, wound swab, sputum, and urine (>37%) (Table 2). ESBL-positive E. coli from urine (63 isolates) mainly belonged to phylogenetic groups D (20), A (17), and B2 (16), whereas those from wound swab (36 isolates) to A (12) and B2 (10) (Supplementary Table S3). Among ESBL-positive isolates, the most prevalent plasmid-mediated quinolone resistance gene was aac-6′-Ib-cr (59%; 93/157), followed by qnrB and qnrS. O25b allele was detected only in phylogenetic group B2 isolates (60%; 25/42).

Table 1.

Prevalence of β-Lactamase Genes and Plasmid-Mediated Quinolone Resistance Genes in Extended-Spectrum Beta-Lactamases and/or Carbapenemase-Producing Escherichia coli Isolates (n = 162)

	Phylogenetic group
β-lactamase gene (genotype)/PMQR determinant/O25b allele	A (n = 48)	B1 (n = 26)	B2 (n = 42)	D (n = 46)	Total
CTX-M	46	24	42	45	157
CTX-M-1 group	43	24	34	45	146^a
CTX-M-9 group	3	0	8	0	11^b
CTX-M+TEM	31	19	20	34	104
NDM	7	11	0	7	25
NDM-1	1	0	0	1	2
NDM-4	3	3	0	0	6
NDM-5	3	5	0	6	14
NDM-7	0	3	0	0	3
OXA-181	2	0	0	0	2
AmpC^c	17	12	5	16	50
PMQR^d
aac-6′-Ib-cr	31	16	21	25	93
qnrB	25	15	12	27	79
qnrS	16	7	3	7	33
O25b allele	0	0	25	0	25

Among 49 isolates examined, 47 and 2 isolates were classified into CTX-M-15 and CTX-M-55, respectively.

CTX-M-27, eight isolates; CTX-M-14, three isolates.

All the AmpC genes detected were classified into CIT family.

The following genes were not detected in any strain: qnrA, qnrC, qnrD, qepA, oqxAB.

PMQR, plasmid-mediated quinolone resistance.

Table 2.

Frequencies of Escherichia coli Isolates with Extended-Spectrum Beta-Lactamases/Carbapenemase Genes in Each Clinical Specimen

	Clinical specimens (%)
Beta-lactamase gene	Blood (n = 19)	Pus (n = 25)	Wound swab (n = 87)	Sputum (n = 80)	Throat swab (n = 3)	Urine (n = 168)	HVS (n = 43)	Total (n = 426)^a
ESBL	9 (47.4)	7 (100)	36 (41.4)	33 (41.3)	1 (33.3)	63 (37.5)	8 (18.6)	157
CTX-M-1 group	9	7	33	32	0	58	7	146
CTX-M-9 group	0	0	3	1	1	5	1	11
Carbapenemase	2 (10.5)	0 (0)	7 (8.0)	3 (3.8)	0 (0)	13 (7.7)	1 (2.3)	26
NDM	2	0	6	3	0	13	1	25
NDM-1	0	0	1	1	0	0	0	2
NDM-4	1	0	0	1	0	4	0	6
NDM-5	1	0	5	1	0	6	1	14
NDM-7	0	0	0	0	0	3	0	3
OXA-181	0	0	1	0	0	1^b	0	2
AmpC	4	0	14	12	0	19	1	50

An isolate from pleural fluid having no ESBL/carbapenemase gene was not included in Table 2.

A bla_OXA-181-positive isolate had also NDM-5 gene.

ESBL, extended-spectrum beta-lactamase; HVS, high vaginal swab.

Resistance to carbapenem was detected in 35 isolates (8.2%; 35/426), among which 26 isolates (6.1%; 26/426) harbored carbapenemase genes that were identified as bla_NDM or bla_OXA-181. Twenty carbapenemase-producing isolates had also ESBL gene encoding CTX-M-15 or CTX-M-55. bla_NDM genes in 25 isolates were subtyped into NDM-1, NDM-4, NDM-5, and NDM-7 genes, with NDM-5 being dominant (56%), followed by NDM-4 (24%). NDM genes were identified most frequently in phylogenetic group B1, whereas no carbapenemase gene was found in group B2. OXA-181 gene was detected only in phylogenetic group A isolates. Carbapenemase gene-positive isolates were derived mostly from urine and wound swab, whereas the remaining were from blood, sputum, and HVS.

Representative 36 E. coli isolates harboring ESBL/carbapenemase genes from the four phylogenetic groups, different clinical specimens, were selected for further genetic analysis (Table 3). Phylogenetic group B2 E. coli with bla_CTX-M-15 or bla_CTX-M-27 (15 isolates examined) mostly belonged to ST131. These isolates were mostly derived from the internal medicine ward, but isolated sporadically from January to December 2016. All the eight isolates with CTX-M-27 gene and two isolates with CTX-M-15 had six or more virulence factors, but showed resistance to generally less number of antimicrobial agents than phylogenetic groups A, B1, and D. Two isolates with NDM-1 gene were assigned to ST215 belonging to ST10 complex (phylogenetic group A) and ST4111, a single locus variant of ST405 (phylogenetic group D). Three isolates with NDM-4 gene were classified into ST361, ST101, and ST156 (phylogenetic groups A and B1), having less number of virulence factors. The most dominant NDM-5 gene was detected in ST410 (phylogenetic group A), ST101 and ST1196 (phylogenetic group B1), ST354 and ST405 (phylogenetic group D) isolates, and often associated with AmpC genes (bla_CMY-2, bla_CMY-6, bla_CMY-42, bla_CMY-146). Three NDM-7 gene-positive isolates were assigned to ST448, and two of them harbored bla_CMY-42 and aac6′-Ib-cr. OXA-181 gene was identified in two ST410 isolates of phylogenetic group A (isolates N19 and N73). Isolate N73 had also bla_NDM-5, as well as other beta-lactamase genes bla_CTX-M-15, bla_TEM-1, and bla_CMY-2, exhibiting more spectrum of drug resistance than another isolate N19.

Table 3.

Genotypes, Virulence Factors, and Antimicrobial Resistance Profile of Representative 36 Escherichia coli Isolates

Isolate ID	Age/sex	Specimen	Phylogenetic group/O25b allele	ST complex	ST	PMQR genes	β-lactamase gene (bla)	Virulence factors (adhesin, toxin, capsule, siderophore, miscellaneous) ^a	Resistance profile ^b
N40	60/M	Sputum	A	ST23 Cplx	ST410	aac6′-Ib-cr	CTX-M-15, TEM-1, CMY-2		PIP, CFZ, CTM, CTX, CAZ, FEP, FMX, CPD, ATM, GEN, MIN, SXT, LVX, SAM
N73	59/M	Urine	A	ST23 Cplx	ST410	qnrS	CTX-M-15, TEM-1, NDM-5, CMY-2, OXA-181	kpsMTIII, traT	PIP, CEZ, CTM, CTX, CAZ, FEP, FMX, CPD, ATM, IPM, MEM, GEN, AMK, MIN, SXT, LVX, SAM
N19	19/M	Wound swab	A	ST23 Cplx	ST410	aac6′-Ib-cr, qnrS	TEM-1, CMY-42, OXA-181	ibeA, traT	PIP, CFZ, CTM, CTX, FEP, FMX, CPD, ATM, SAM, LVX
N191	32/F	Wound swab	A	ST23 Cplx	ST410		CTX-M-15, TEM-1	kpsMTIII	PIP, CFZ, CTM, CTX, CAZ, FEP, FMX, CPD, ATM, GEN, MIN, SXT, LVX, SAM
N84^c	59/M	Sputum	A	ST10 Cplx	ST215	aac6′-Ib-cr	CTX-M-55, TEM-1, NDM-1	traT, kpsMTK5, astA	CTX, CAZ, CRO, AMC, CFP/SUL, GEN, AMK, MEM, SXT, LVX
N69^c	35/M	Sputum	A		ST361		TEM-1, NDM-4, CMY-42	traT, kpsMTK5, hra, astA	CTX, CAZ, CRO, AMC, CFP/SUL, GEN, AMK, MEM, SXT, LVX
N74	49/F	Blood	B1	ST101 Cplx	ST101		CTX-M-15, TEM-1, NDM-4, CMY-42	hra, traT	PIP, CEZ, CTM, CTX, CAZ, FEP, FMX, CPD, ATM, IPM, MEM, GEN, AMK, MIN, SXT, LVX, SAM
N21	61/M	Urine	B1	ST448 Cplx	ST448	aac6′-Ib-cr	CTX-M-15, TEM-1, NDM-7, CMY-42	kpsMTIII, kpsMTK5, PAI, pic, traT	PIP, CFZ, CTM, CTX, CAZ, FEP, FMX, CPD, ATM, IPM, MEM, SXT, LVX, SAM
N78	82/M	Urine	B1	ST448 Cplx	ST448	aac6′-Ib-cr, qnrS	TEM-1, NDM-7, CMY-42	kpsMTII, kpsMTIII	PIP, CFZ, CTM, CTX, CAZ, FEP, FMX, CPD, ATM, IMP, MEM, GEN, MIN, SXT, LVX, SAM
N194	71/M	Urine	B1	ST448 Cplx	ST448	qnrB	CTX-M-55, NDM-7	hra, traT	PIP, CFZ, CTM, CTX, CAZ, FEP, FMX, CPD, ATM, IMP, MEM, GEN, MIN, SXT, LVX, SAM
N80	79/F	Urine	B1	ST156 Cplx	ST156	aac6′-Ib-cr, qnrB	CTX-M-15, TEM-1, NDM-4	kpsMTIII, astA	PIP, CFZ, CTM, CTX, CAZ, CPD, ATM, MEM, GEN, AMK, MIN, SXT, LVX, SAM
N112	44/F	Urine	B1	ST156 Cplx	ST156		CTX-M-14, TEM-1	fyuA	PIP, CFZ, CPD, MIN, SXT, LVX
N220	19/M	Urine	B1	ST101 Cplx	ST101	aac6′-Ib-cr, qnrB	CTX-M-15, TEM-1, NDM-5	fyuA, hra, kpsMTII, kpsMTIII, usp	PIP, CFZ, CTM, CTX, CAZ, FEP, FMX, CPD, ATM, IMP, MEM, GEN, AMK, MIN, SXT, LVX, SAM
N202	60/M	Wound swab	B1		ST1196	aac6′-Ib-cr, qnrB	CTX-M-15, TEM-1, NDM-5	kpsMTIII, pic, traT	PIP, CFZ, CTM, CTX, CAZ, FMX, CPD, ATM, IPM, MEM, GEN, AMK, SXT, LVX, SAM
N230	52/F	Wound swab	B1	ST101 Cplx	ST101		CTX-M-15, TEM-1, CMY-4	fyuA, hra	PIP, CEZ, CTM, CTX, CAZ, FEP, FMX, CPD, ATM, GEN, AMK, SXT, LVX, SAM
N33	58/M	Blood	B2, O25b	ST131 Cplx	ST131		CTX-M-15	chuA, fyuA, traT, usp	PIP, CFZ, CTM, CTX, CPD, SXT, LVX
N229	30/F	HVS	B2, O25b	ST131 Cplx	ST131	aac6′-Ib-cr	CTX-M-15	chuA, traT	PIP, CEZ, CTM, CTX, CAZ, FEP, FMX, CPD, ATM, GEN, SXT, LVX
N126	53/F	Sputum	B2, O25b	ST131 Cplx	ST131	aac6′-Ib-cr, qnrB	CTX-M-15	chuA, kpsMTII, kpsMTK5, traT	PIP, CFZ, CTM, CTX, CAZ, FEP, CPX, ATM, SXT, LVX
N161	46/M	Sputum	B2, O25b	ST131 Cplx	ST131		CTX-M-27	chuA, fyuA, iha, kpsMTII, kpsMTIII, kpsMTK5, sat, traT, usp	PIP, CEZ, CTX, CPD, SXT, LVX
N165	36/F	Throat swab	B2, O25b	ST131 Cplx	ST131		CTX-M-27	afa/draBC, chuA, fyuA, iha, hlyA, kpsMTIII, kpsMTK5, papAH, PAI, sat, traT, usp	PIP, CEZ, CTM, CTX, CAZ, FEP, FMX, CPD, ATM, IPM, MEM, GEN, AMK, MIN, SXT, LVX, SAM
N211	67/F	Urine	B2, O25b	ST131 Cplx	ST131	aac6′-Ib-cr	CTX-M-15	chuA, fyuA, iha, kpsMTII, kpsMTK5, papAH, PAI, traT, usp	PIP, CFZ, CTM, CTX, CAZ, CPD, ATM, SXT, LVX, SAM
N68	31/F	Urine	B2, O25b	ST131 Cplx	ST6302^d	aac6′-Ib-cr	CTX-M-15	chuA, fyuA, traT, usp	PIP, CFZ, CTM, CTX, CAZ, FEP, CPD, ATM, GEN, SXT, LVX
N107	57/F	Urine	B2	ST131 Cplx	ST131		CTX-M-27	afa/draBC, chuA, fyuA, iha, hlyA, kpsMTII, kpsMTIII, kpsMTK5, papC, papAH, PAI, sat, traT, usp	PIP, CFZ, CTX, CPD, GEN, SXT, SAM
N108	47/F	Urine	B2	ST131 Cplx	ST131		CTX-M-15	afa/draBC, chuA, fimH, fyuA, iha, hlyA, kpsMTII, kpsMTIII, kpsMTK5, papC, papAH, PAI, sat, traT, usp	PIP, CFZ, CTX, CPD
N118	33/F	Urine	B2	ST131 Cplx	ST131		CTX-M-27, TEM-1	afa/draBC, chuA, fyuA, hlyA, papAH, papC, sat, traT, usp	PIP, CEZ, CTM, CTX, CPD, GEN, SXT
N139	82/F	Urine	B2, O25b	ST131 Cplx	ST131		CTX-M-27, TEM-1	chuA, fyuA, kpsMTIII, kpsMTK5, traT, usp	PIP, CEZ, CPD, SXT
N141	58/F	Urine	B2, O25b	ST131 Cplx	ST131		CTX-M-27	chuA, fyuA, iha, kpsMTII, kpsMTIII, kpsMTK5, PAI, sat, traT, usp	PIP, CEZ, CTX, CPD, SXT, LVX
N60	51/F	Wound swab	B2, O25b		ST648-TLV^e	aac6′-Ib-cr	CTX-M-15, TEM-1	chuA, traT	PIP, CEZ, CTX, CPD, SXT, LVX, SAM
N163	50/M	Wound swab	B2, O25b	ST131 Cplx	ST131		CTX-M-27	chuA, fyuA, iha, kpsMTII, kpsMTIII, kpsMTK5, PAI, sat, traT, usp	PIP, CFZ, CTM, CTX, CPD, GEN, LVX
N145	46/M	Wound swab	B2, O25b	ST131 Cplx	ST131		CTX-M-27	chuA, iha, kpsMTII, kpsMTK5, sat, traT, usp	PIP, CEZ, CTM, CTX, CPD, SXT, LVX
N205	34/M	Blood	D	ST405 Cplx	ST405		TEM-1, NDM-5, CMY-146	chuA, fyuA, hra, kpsMTIII, PAI, traT	PIP, CFZ, CTM, CTX, CAZ, FMX, CPD, ATM, IPM, MEM, SXT, LVX, SAM
N72	67/F	Sputum	D	ST354 Cplx	ST354		CTX-M-15, TEM-1, NDM-5, CMY-42	chuA, hra, pic, traT	PIP, CFZ, CTM, CTX, CAZ, FMX, CPD, ATM, IPM, MEM, GEN, AMK, MIN, SXT, LVX, SAM
N204	66/M	Sputum	D	ST354 Cplx	ST354	qnrS	CTX-M-55, TEM-1	chuA, fyuA, ibe, kpsMTII	PIP, CFZ, CTM, CTX, CAZ, CPD, ATM, GEN, SXT, LVX
N154	30/F	Urine	D	ST405 Cplx	ST405	aac6′-Ib-cr	CTX-M-15, TEM-1, NDM-5, CMY-6	chuA, fyuA, kpsMTIII, traT	PIP, CEZ, CTM, CTX, CAZ, FEP, FMX, CPD, ATM, IPM, MEM, GEN, AMK, MIN, SXT, LVX, SAM
N82	69/M	Urine	D	ST405 Cplx	ST405	aac6′-Ib-cr	CTX-M-15, TEM-1, NDM-5	chuA, fyuA, kpsMTII, kpsMTIII, kpsMTK5, traT	PIP, CFZ, CTM, CTX, CAZ, FEP, FMX, CPD, ATM, MEM, GEN, AMK, MIN, SXT, LVX, SAM
N83	75/F	Wound swab	D	ST405 Cplx	ST4111^f	aac6′-Ib-cr, qnrB	CTX-M-15, TEM-1, NDM-1	chuA, fyuA, kpsMTII, kpsMTIII, kpsMTK5, traT	PIP, CEZ, CTM, CTX, CAZ, FEP, FMX, CPD, ATM, IPM, MEM, GEN, AMK, SXT, LVX, SAM

fimH was detected in all the isolates. None of the isolates has the following genes: sfa/focDC, kpsMT-K1, cdtB, focG, cnf1, iroN, iutA, ireA, vat, clbB.

Resistance to individual antimicrobial agent was judged according to the guidelines of CLSI. For antimicrobials whose resistance is not defined by CLSI guidelines, EUCAST breakpoints (CTM, FMX, >16 mg/ml) were used.

For these two isolates, only data from disc diffusion test of eight antimicrobials were available.

Single locus variant of ST131.

Triple locus variant (allelic profile: 92-4-77-96-7-58-29) of ST648 (92-4-87-96-70-58-2).

Single locus variant of ST405.

AMC, amoxicillin/clavulanic acid; AMK, amikacin; ATM, aztreonam; CAZ, ceftazidime; CFP/SUL, cefoperazone/sulbactam; CFZ, cefazolin; CLSI, Clinical Laboratory Standard Institute; CPD, cefpodoxime; CRO, ceftriaxone; CTM, cefotiam; CTX, cefotaxime; FEP, cefepime; FMX, flomoxef; FOF, fosfomycin; GEN, gentamicin; IPM, imipenem; LVX, levofloxacin; MEM, meropenem; MIN, minocycline; PIP, piperacillin; SAM, ampicillin/sulbactam; ST, sequence type; SXT, sulfamethoxazole/trimethoprim.

Discussion

The present study first elucidated in Myanmar overall prevalence of ESBL (36.9%) and carbapenemase genes (6.1%) among clinical isolates of E. coli in a hospital for 1-year period. The ESBL rate in our present study was comparable to those among Enterobacteriaceae isolates in other Southeast Asian countries (19–55%; overall rate, 39%).³¹ Higher proportions of ESBL and carbapenemase in E. coli (50% and 15%, respectively)⁹ described in a previous report in Myanmar appear to be due to blood samples as isolation source. Similarly, in the present study, positive rates of carbapenemase and ESBL genes were the highest in blood isolates of those in other specimens. In our study, ESBL genes were identified as bla_CTX-M, mostly assigned to CTX-M-1 group and found in all the four phylogenetic groups, with bla_CTX-M-15 being the major genotype, which is predominant globally together with bla_CTX-M-14.⁴ Furthermore, the prevalence of phylogenetic group B2-ST131 E. coli producing CTX-M-15, a pandemic clone causing extraintestinal infections,^32,33 was confirmed in Myanmar, as has been reported in other Southeastern Asian countries.³⁴ Of note, CTX-M-27 gene was identified in eight phylogenetic group B2-ST131 E. coli isolates mostly with O25b allele. bla_CTX-M-27, belonging to CTX-M-9 group in which bla_CTX-M-14 represents the epidemiologically major type,⁴ is a variant of bla_CTX-M-14 with a single-nucleotide/amino acid difference that confers more potent resistance to ceftazidime compared with bla_CTX-M-14.³⁵ An increasing trend of bla_CTX-M-27 has been described in Asia^36,37 and Europe,^38,39 associated with identification of a lineage among bla_CTX-M-27-carrying ST131-O25b E. coli that has potential for global spread.^40,41 Therefore, the presence of ST131 E. coli with bla_CTX-M-27 in Myanmar warrants more attention.

The present study revealed prevalence of four genotypes of bla_NDM in Myanmar, among which bla_NDM-5 was the most dominant, followed by bla_NDM-4, bla_NDM-7, and bla_NDM-1. Since the first identification of NDM-1 in 2008, worldwide attention was attracted to this most recently described carbapenemase because of its rapid dissemination among Enterobacteriaceae and Acinetobacter spp. clinical isolates, as well as those colonizing humans and contaminating environments.^7,41 The main reservoir of NDM producers is Indian subcontinent, whereas the secondary reservoir is considered the Balkan regions and the Middle East.⁷ Among the 17 NDM variants identified to date, NDM-1 has been the most dominant in India and other countries. However, since the first description in 2011, NDM-5 has been increasingly detected in South Asia,^42,43 East Asia,^44–46 Australia,⁴⁷ United States,⁴⁸ Europe,^49,50 and North Africa,⁵¹ showing comparable rate to NDM-1 or the second most NDM-type in some reports.^42,52 The dominance of bla_NDM-5 in Myanmar may reflect the same global trend of dissemination and increase of this NDM type.

NDM-4 differs from NDM-1 by a single amino acid substitution at position 154 (Met→Leu),⁵³ whereas NDM-5 and NDM-7 by two amino acid substitutions, including the same one as detected in NDM-4.⁴³ The M154L substitution in NDM-4 was shown to confer increased hydrolytic activity toward carbapenems and several cephalosporins compared with that of NDM-1,⁵³ and similarly, reduced susceptibility to carbapenems was described for NDM-5 and NDM-7.^54,55 Such increased resistance phenotype may be a factor for selective spread of E. coli with the variants NDM-4, -5, and -7.

E. coli harboring bla_NDM-5 has been genotyped as at least 13 STs to date, among which ST167 appears to be the most common.⁵⁴ In the present study, bla_NDM-5-carrying E. coli belonged to five STs (ST101, ST354, ST405, ST410, ST1196), among which three STs (ST101, ST354, ST1196) have not yet been reported previously, suggesting efficient dissemination of NDM-5 gene over different E. coli clones. ST405 was reported in isolates producing NDM-4 or NDM-5 in India,⁴² Myanmar,¹⁰ and Italy,⁵⁰ and ST410 E. coli previously reported in Myanmar had bla_NDM-5 or bla_NDM-7.¹⁰ E. coli of clones ST101, ST405, and ST410, in which bla_NDM-5 was detected in the present study, have been known to harbor bla_NDM-1.⁵⁶ Furthermore, bla_NDM-4 was found in ST101 in the previous report in Myanmar,¹⁰ and detected in ST405 and ST410 in Asia,^57,58 suggesting that these lineages are prone to acquire bla_NDM-encoding plasmid.

In contrast, three E. coli isolates with bla_NDM-7 detected in our study were all assigned to ST448, which was different from those recently reported in Myanmar (ST410)¹⁰ as well as first report of NDM-7-producing E. coli (ST167), which was isolated in a patient having a travel history to Myanmar.⁵⁹ The presence of bla_NDM-7 in the single ST suggested that NDM-7 might have been increasing through clonal spread of E. coli with this gene. NDM-7-producing ST448 E. coli was described in a patient in Kuwait with travel history to India,⁶⁰ whereas ST940 belonging to clonal complex 448 E. coli having bla_NDM-7 was isolated in France.⁶¹ Although the origin of the ST448 E. coli is unknown, the Kuwaiti isolate harbored also bla_CMY-42 and aac6′-Ib-cr,⁶⁰ as found in the two ST448 Myanmarese isolates, suggesting their possible relatedness to India.

A remarkable finding in the present study was the first detection of bla_OXA-181 in Myanmar in two E. coli isolates belonging to ST410, and notably, an isolate (N73) had both bla_OXA-181 and bla_NDM-5. Since the identification of this carbapenemase gene in India in 2007, it has been found in Enterobacteriaceae almost worldwide, and frequently detected in isolates from patients with travel history to the Indian subcontinent.⁶² The OXA-181 carbapenemase gene has been detected mainly in Klebsiella pneumoniae, with some reports on coproduction of NDM-5 and OXA-181.^63,64 Although limited information is available for E. coli, detection of bla_OXA-181 was reported in isolates in China (ST410),⁶⁵ Egypt (ST410),⁶⁶ United States (ST410),⁶⁷ and Thailand (ST5),⁶⁸ which harbored also bla_CTX-M-15, bla_CMY-2, aac6′-Ib-cr, and qnrS. The Egyptian isolate had both OXA-181 and NDM-5 carbapenemase genes.⁶⁶ These genetic traits are similar to those in the two ST410 E. coli isolates in Myanmar in the present study. As the OXA-181 gene in the Chinese isolate was carried on a transmissible plasmid linked to qnrS1,⁶⁵ attention should also be given to bla_OXA-181 in surveillance of carbapenem-resistant E. coli.

In summary, we clarified the prevalence of ESBL and carbapenemase genes among E. coli and their molecular epidemiological traits in Myanmar. The dominance of bla_NDM-5 and emergence of bla_OXA-181 highlight the need for further surveillance of beta-lactamase genes in E. coli and to develop interventions to control their dissemination.

Footnotes

Acknowledgment

This study was supported in part by JSPS (Japan Society for the Promotion of Science) KAKENHI Grant No. 17H04664.

Disclosure Statement

The authors of this article have no commercial associations that might create a conflict of interest in connection with the submitted article.

References

Giske

C.G.

, Monnet

D.L.

, Cars

, and Carmeli

. 2008. Clinical and economic impact of common multidrug-resistant gram-negative bacilli. Antimicrob. Agents Chemother., 52:813–821.

Pitout

J.D.

, and Laupland

K.B.

. 2008. Extended-spectrum beta-lactamase-producing Enterobacteriaceae: an emerging public-health concern. Lancet Infect. Dis., 8:159–166.

Nordmann

, Dortet

, and Poirel

. 2012. Carbapenem resistance in Enterobacteriaceae: here is the storm! Trends Mol. Med., 18:263–272.

Bevan

E.R.

, Jones

A.M.

, and Hawkey

P.M.

. 2017. Global epidemiology of CTX-M β-lactamases: temporal and geographical shifts in genotype. J. Antimicrob. Chemother., 72:2145–2155.

Tzouvelekis

L.S.

, Markogiannakis

, Psichogiou

, Tassios

P.T.

, and Daikos

G.L.

. 2012. Carbapenemases in Klebsiella pneumoniae and other Enterobacteriaceae: an evolving crisis of global dimensions. Clin. Microbiol. Rev., 25:682–707.

Yang

, Wang

, Sun

, Chen

, Xu

, and Chen

. 2010. Phenotypic and genotypic characterization of Enterobacteriaceae with decreased susceptibility to carbapenems: results from large hospital-based surveillance studies in China. Antimicrob. Agents Chemother., 54:573–577.

Dortet

, Poirel

, and Nordmann

. 2014. Worldwide dissemination of the NDM-type carbapenemases in Gram-negative bacteria. Biomed Res. Int., 2014:249856.

Myat

T.O.

, Prasad

, Thinn

K.K.

, Win

K.K.

, Htike

W.W.

, Zin

K.N.

, Murdoch

D.R.

, and Crump

J.A.

. 2014. Bloodstream infections at a tertiary referral hospital in Yangon, Myanmar. Trans. R. Soc. Trop. Med. Hyg., 108:692–698.

Myat

T.O.

, Hannaway

R.F.

, Zin

K.N.

, Htike

W.W.

, Win

K.K.

, Crump

J.A.

, Murdoch

D.R.

, and Ussher

J.E.

. 2017. ESBL- and carbapenemase-producing Enterobacteriaceae in patients with bacteremia, Yangon, Myanmar, 2014. Emerg. Infect. Dis., 23:857–859.

10.

Sugawara

, Akeda

, Sakamoto

, Takeuchi

, Motooka

, Nakamura

, Hagiya

, Yamamoto

, Nishi

, Yoshida

, Okada

, Zin

K.N.

, Aye

M.M.

, Tonomo

, and Hamada

. 2017. Genetic characterization of bla_NDM-harboring plasmids in carbapenem-resistant Escherichia coli from Myanmar. PLoS One, 12:e0184720.

11.

Clinical and Laboratory Standards Institute (CLSI). 2014. Performance Standards for Antimicrobial Susceptibility Testing; Twenty-Fourth Informational Supplement, M100-S24. Clinical and Laboratory Standards Institute (CLSI), Wayne, PA.

12.

Monstein

H.J.

, Ostholm-Balkhed

, M.V.

Nilsson

, Nilsson

, Dornbusch

, and Nilsson

L.E.

. Multiplex PCR amplification assay for the detection of blaSHV, blaTEM and blaCTX-M genes in Enterobacteriaceae. APMIS, 115:1400–1408.

13.

, Ensor

, Gossain

, Nye

, and Hawkey

. 2005. Rapid and simple detection of blaCTX-M genes by multiplex PCR assay. J. Med. Microbiol., 54:1183–1187.

14.

Queenan

A.M.

, and Bush

. 2007. Carbapenemases: the versatile beta-lactamases. Clin. Microbiol. Rev., 20:440–458.

15.

Poirel

, Walsh

T.R.

, Cuvillier

, and Nordmann

. 2011. Multiplex PCR for detection of acquired carbapenemase genes. Diagn. Microbiol. Infect. Dis., 70:119–123.

16.

Österblad

, Kirveskari

, Hakanen

A.J.

, Tissari

, Vaara

, and Jalava

. 2012. Carbapenemase-producing Enterobacteriaceae in Finland: the first years (2008–11). J. Antimicrob. Chemother., 67:2860–2864.

17.

Pérez-Pérez

F.J.

, and Hanson

N.D.

. 2002. Detection of plasmid-mediated AmpC beta-lactamase genes in clinical isolates by using multiplex PCR. J. Clin. Microbiol., 40:2153–2162.

18.

Clermont

, Bonacorsi

, and Bingen

. 2000. Rapid and simple determination of the Escherichia coli phylogenetic group. Appl. Environ. Microbiol., 66:4555–4558.

19.

Ciesielczuk

, Hornsey

, Choi

, Woodford

, and Wareham

D.W.

. 2013. Development and evaluation of a multiplex PCR for eight plasmid-mediated quinolone-resistance determinants. J. Med. Microbiol., 62:1823–1827.

20.

Clermont

, Lavollay

, Vimont

, Deschamps

, Forestier

, Branger

, Denamur

, and Arlet

. 2008. The CTX-M-15-producing Escherichia coli diffusing clone belongs to a highly virulent B2 phylogenetic subgroup. J. Antimicrob. Chemother., 61:1024–1028.

21.

Bauer

R.J.

, Zhang

, Foxman

, Siitonen

, Jantunen

M.E.

, Saxen

, and Marrs

C.F.

. 2002. Molecular epidemiology of 3 putative virulence genes for Escherichia coli urinary tract infection-usp, iha, and iroN (E. coli). J. Infect. Dis., 185:1521–1524.

22.

Bidet

, Bonacorsi

, Clermont

, De Montille

, Brahimi

, and Bingen

. 2005. Multiple insertional events, restricted by the genetic background, have led to acquisition of pathogenicity island IIJ96-like domains among Escherichia coli strains of different clinical origins. Infect. Immun., 73:4081–4087.

23.

Johnson

J.R.

, and Stell

A.L.

. 2000. Extended virulence genotypes of Escherichia coli strains from patients with urosepsis in relation to phylogeny and host compromise. J. Infect. Dis., 181:261–272.

24.

Johnson

J.R.

, Russo

T.A.

, Tarr

P.I.

, Carlino

, Bilge

S.S.

, Vary

J.C.

Jr. , and Stell

A.L.

. 2000. Molecular epidemiological and phylogenetic associations of two novel putative virulence genes, iha and iroN (E. coli), among Escherichia coli isolates from patients with urosepsis. Infect. Immun., 68:3040–3047.

25.

Johnson

J.R.

, Gajewski

, Lesse

A.J.

, and Russo

T.A.

. 2003. Extraintestinal pathogenic Escherichia coli as a cause of invasive nonurinary infections. J. Clin. Microbiol., 41:5798–5802.

26.

Johnson

J.R.

, Johnston

, Kuskowski

M.A.

, Nougayrede

J.P.

, and Oswald

. 2008. Molecular epidemiology and phylogenetic distribution of the Escherichia coli pks genomic island. J. Clin. Microbiol., 46:3906–3911.

27.

Pilarczyk-Zurek

, Chmielarczyk

, Gosiewski

, Tomusiak

, Adamski

, Zwolinska-Wcislo

, Mach

, Heczko

P.B.

, and Strus

. 2013. Possible role of Escherichia coli in propagation and perpetuation of chronic inflammation in ulcerative colitis. BMC Gastroenterol. 13:61 DOI: 10.1186/1471-230X-13-61.

28.

Restieri

, Garriss

, Locas

M.C.

, and Dozois

C.M.

. 2007. Autotransporter-encoding sequences are phylogenetically distributed among Escherichia coli clinical isolates and reference strains. Appl. Environ. Microbiol., 73:1553–1562.

29.

Yamamoto

, and Echeverria

. 1996. Detection of the enteroaggregative Escherichia coli heat-stable enterotoxin 1 gene sequences in enterotoxigenic E. coli strains pathogenic for humans. Infect. Immun., 64:1441–1445.

30.

Wirth

, Falush

, Lan

, Colles

, Mensa

, Wieler

L.H.

, Karch

, Reeves

P.R.

, Maiden

M.C.

, Ochman

, and Achtman

. 2006. Sex and virulence in Escherichia coli: an evolutionary perspective. Mol. Microbiol., 60:1136–1151.

31.

Suwantarat

, and Carroll

K.C.

. 2016. Epidemiology and molecular characterization of multidrug-resistant Gram-negative bacteria in Southeast Asia. Antimicrob. Resist. Infect. Control, 5:15.

32.

Nicolas-Chanoine

M.H.

, Blanco

, Leflon-Guibout

, Demarty

, Alonso

M.P.

, Caniça

M.M.

, Park

Y.J.

, Lavigne

J.P.

, Pitout

, and Johnson

J.R.

. 2008. Intercontinental emergence of Escherichia coli clone O25:H4-ST131 producing CTX-M-15. J. Antimicrob. Chemother., 61:273–281.

33.

Rogers

B.A.

, Sidjabat

H.E.

, and Paterson

D.L.

. 2011. Escherichia coli O25b-ST131: a pandemic, multiresistant, community-associated strain. J. Antimicrob. Chemother., 66:1–14.

34.

Cha

M.K.

, Kang

C.I.

, Kim

S.H.

, Thamlikitkul

, So

T.M.

, Ha

Y.E.

, Chung

D.R.

, Peck

K.R.

, and Song

J.H.

. 2017. Emergence and dissemination of ST131 Escherichia coli isolates among patients with hospital-acquired pneumonia in Asian countries. Microb. Drug Resist., 23:79–82.

35.

Bonnet

, Recule

, Baraduc

, Chanal

, Sirot

, De Champs

, and Sirot

. 2003. Effect of D240G substitution in a novel ESBL CTX-M-27. J. Antimicrob. Chemother., 52:29–35.

36.

Matsumura

, Johnson

J.R.

, Yamamoto

, Nagao

, Tanaka

, Takakura

, and Ichiyama

; Kyoto–Shiga Clinical Microbiology Study Group; Kyoto-Shiga Clinical Microbiology Study Group. 2015. CTX-M-27- and CTX-M-14-producing, ciprofloxacin-resistant Escherichia coli of the H30 subclonal group within ST131 drive a Japanese regional ESBL epidemic. J. Antimicrob. Chemother., 70:1639–1649.

37.

Zhong

Y.M.

, Liu

W.E.

, Liang

X.H.

, Li

Y.M.

, Jian

Z.J.

, and Hawkey

P.M.

. 2015. Emergence and spread of O16-ST131 and O25b-ST131 clones among faecal CTX-M-producing Escherichia coli in healthy individuals in Hunan Province, China. J. Antimicrob. Chemother., 70:2223–2227.

38.

Birgy

, Levy

, Bidet

, Thollot

, Derkx

, Béchet

, Mariani-Kurkdjian

, Cohen

, and Bonacorsi

. 2016. ESBL-producing Escherichia coli ST131 versus non-ST131: evolution and risk factors of carriage among French children in the community between 2010 and 2015. J. Antimicrob. Chemother., 71:2949–2956.

39.

Matsumura

, Pitout

J.D.

, Gomi

, Matsuda

, Noguchi

, Yamamoto

, Peirano

, DeVinney

, Bradford

P.A.

, Motyl

M.R.

, Tanaka

, Nagao

, Takakura

, and Ichiyama

. 2016. Global Escherichia coli sequence type 131 clade with bla_CTX-M-27 gene. Emerg. Infect. Dis., 22:1900–1907.

40.

Ghosh

, Doijad

, Falgenhauer

, Fritzenwanker

, Imirzalioglu

, and Chakraborty

. 2017. bla_CTX-M-27-encoding Escherichia coli sequence type 131 lineage C1-M27 clone in clinical isolates, Germany. Emerg. Infect. Dis., 23:1754–1756.

41.

Toleman

M.A.

, Bugert

J.J.

, and Nizam

S.A.

. 2015. Extensively drug-resistant New Delhi metallo-β-lactamase-encoding bacteria in the environment, Dhaka, Bangladesh, 2012. Emerg. Infect. Dis., 21:1027–1030.

42.

Ranjan

, Shaik

, Mondal

, Nandanwar

, Hussain

, Semmler

, Kumar

, Tiwari

S.K.

, Jadhav

, Wieler

L.H.

, and Ahmed

. 2016. Molecular epidemiology and genome dynamics of New Delhi metallo-β-lactamase-producing extraintestinal pathogenic Escherichia coli strains from India. Antimicrob. Agents Chemother., 60:6795–6805.

43.

Rahman

, Shukla

S.K.

, Prasad

K.N.

, Ovejero

C.M.

, Pati

B.K.

, Tripathi

, Singh

, Srivastava

A.K.

, and Gonzalez-Zorn

. 2014. Prevalence and molecular characterisation of New Delhi metallo-β-lactamases NDM-1, NDM-5, NDM-6 and NDM-7 in multidrug-resistant Enterobacteriaceae from India. Int. J. Antimicrob. Agents, 44:30–37.

44.

Nakano

, Nakano

, Hikosaka

, Kawakami

, Matsunaga

, Asahara

, Ishigaki

, Furukawa

, Suzuki

, Shibayama

, and Ono

. 2014. First report of metallo-β-lactamase NDM-5-producing Escherichia coli in Japan. Antimicrob. Agents Chemother., 58:7611–7612.

45.

Park

, Park

S.D.

, Lee

M.H.

, Kim

S.H.

, Lim

, Lee

, Woo

H.J.

, Kim

H.W.

, Yang

J.Y.

, Eom

Y.B.

, Moon

, Uh

, and Kim

J.B.

. 2016. The first report of NDM-5-producing uropathogenic Escherichia coli isolates in South Korea. Diagn. Microbiol. Infect. Dis., 85:198–199.

46.

Chen

, Gong

, Walsh

T.R.

, Lan

, Wang

, Zhang

, Mai

, Ni

, Lu

, Xu

, and Li

. 2016. Infection by and dissemination of NDM-5-producing Escherichia coli in China. J. Antimicrob. Chemother., 71:563–565.

47.

Wailan

A.M.

, Paterson

D.L.

, Caffery

, Sowden

, and Sidjabat

H.E.

. 2015. Draft genome sequence of NDM-5-producing Escherichia coli sequence type 648 and genetic context of bla_NDM-5 in Australia. Genome Announc., 3:e00194-15.

48.

Mediavilla

J.R.

, Patrawalla

, Chen

, Chavda

K.D.

, Mathema

, Vinnard

, Dever

L.L.

, and Kreiswirth

B.N.

. 2016. Colistin- and carbapenem-resistant Escherichia coli harboring mcr-1 and bla_NDM-5, causing a complicated urinary tract infection in a patient from the United States. MBio, 7:e01191-16.

49.

Hornsey

, Phee

, and Wareham

D.W.

. 2011. A novel variant, NDM-5, of the New Delhi metallo-β-lactamase in a multidrug-resistant Escherichia coli ST648 isolate recovered from a patient in the United Kingdom. Antimicrob. Agents Chemother., 55:5952–5954.

50.

Bitar

, Piazza

, Gaiarsa

, Villa

, Pedroni

, Oliva

, Nucleo

, Pagani

, Carattoli

, and Migliavacca

. 2017. ST405 NDM-5 producing Escherichia coli in Northern Italy: the first two clinical cases. Clin. Microbiol. Infect., 23:489–490.

51.

Sassi

, Loucif

, Gupta

S.K.

, Dekhil

, Chettibi

, and Rolain

J.M.

. 2014. NDM-5 carbapenemase-encoding gene in multidrug-resistant clinical isolates of Escherichia coli from Algeria. Antimicrob. Agents Chemother., 58:5606–5608.

52.

, Xu

, Wang

, Xue

, Zhou

, Zhang

, Ma

, Zhao

, Li

, Zhang

, Shi

, Wang

, Jia

, Hao

, Wang

, Zou

, Liu

, Qiu

, Song

, and Sun

. 2017. Diversity of New Delhi metallo-beta-lactamase-producing bacteria in China. Int. J. Infect. Dis., 55:92–95.

53.

Nordmann

, Boulanger

A.E.

, and Poirel

. 2012. NDM-4 metallo-β-lactamase with increased carbapenemase activity from Escherichia coli. Antimicrob. Agents Chemother., 56:2184–2186.

54.

Zhu

Y.Q.

, Zhao

J.Y.

, Xu

, Zhao

, Jia

, and Li

Y.N.

. 2016. Identification of an NDM-5-producing Escherichia coli sequence type 167 in a neonatal patient in China. Sci. Rep., 6:29934.

55.

Göttig

, Hamprecht

A.G.

, Christ

, Kempf

V.A.

, and Wichelhaus

T.A.

. 2013. Detection of NDM-7 in Germany, a new variant of the New Delhi metallo-β-lactamase with increased carbapenemase activity. J. Antimicrob. Chemother., 68:1737–1740.

56.

Mushtaq

, Irfan

, Sarma

J.B.

, Doumith

, Pike

, Pitout

, Livermore

D.M.

, and Woodford

. 2011. Phylogenetic diversity of Escherichia coli strains producing NDM-type carbapenemases. J. Antimicrob. Chemother., 66:2002–2005.

57.

Jakobsen

, Hammerum

A.M.

, Hansen

, and Fuglsang-Damgaard

. 2014. An ST405 NDM-4-producing Escherichia coli isolated from a Danish patient previously hospitalized in Vietnam. J. Antimicrob. Chemother., 69:559–560.

58.

Qin

, Zhou

, Zhang

, Tao

, Ye

, Chen

, Xu

, Wang

, and Feng

. 2016. First identification of NDM-4-producing Escherichia coli ST410 in China. Emerg. Microbes Infect., 5:e118.

59.

Cuzon

, Bonnin

R.A.

, and Nordmann

. 2013. First identification of novel NDM carbapenemase, NDM-7, in Escherichia coli in France. PLoS One, 8:e61322.

60.

Pál

, Ghazawi

, Darwish

, Villa

, Carattoli

, Hashmey

, Aldeesi

, Jamal

, Rotimi

, Al-Jardani

, Al-Abri

S.S.

, and Á. Sonnevend. 2017. Characterization of NDM-7 carbapenemase-producing Escherichia coli isolates in the Arabian Peninsula. Microb. Drug Resist., 23:871–878.

61.

van der Mee-Marquet

, Diene

S.M.

, Chopin

, Goudeau

, and François

. 2016. Enigmatic occurrence of NDM-7 enzyme in the community. Int. J. Antimicrob. Agents, 47:505–507.

62.

Castanheira

, Deshpande

L.M.

, Mathai

, Bell

J.M.

, Jones

R.N.

, and Mendes

R.E.

. 2011. Early dissemination of NDM-1- and OXA-181-producing Enterobacteriaceae in Indian hospitals: report from the SENTRY Antimicrobial Surveillance Program, 2006–2007. Antimicrob. Agents Chemother., 55:1274–1278.

63.

Balm

M.N.

, La

M.V.

, Krishnan

, Jureen

, Lin

R.T.

, and Teo

J.W.

. 2013. Emergence of Klebsiella pneumoniae co-producing NDM-type and OXA-181 carbapenemases. Clin. Microbiol. Infect., 19:E421–E423.

64.

Cho

S.Y.

, Huh

H.J.

, Baek

J.Y.

, Chung

N.Y.

, Ryu

J.G.

, Ki

C.S.

, Chung

D.R.

, Lee

N.Y.

, and Song

J.H.

. 2015. Kbsiella pneumoniae co-producing NDM-5 and OXA-181 carbapenemases, South Korea. Emerg. Infect. Dis., 21:1088–1089.

65.

Liu

, Feng

, Wu

, Xie

, Wang

, Zhang

, Chen

, and Zong

. 2015. First report of OXA-181-producing Escherichia coli in China and characterization of the isolate using whole-genome sequencing. Antimicrob. Agents Chemother., 59:5022–5025.

66.

Gamal

, Fernández-Martínez

, El-Defrawy

, Ocampo-Sosa

A.A.

, and Martínez-Martínez

. 2016. First identification of NDM-5 associated with OXA-181 in Escherichia coli from Egypt. Emerg. Microbes Infect., 5:e30.

67.

Hasassri

M.E.

, Boyce

T.G.

, Norgan

, Cunningham

S.A.

, Jeraldo

P.R.

, Weissman

, Patel

, Banerjee

, Pogue

J.M.

, and Kaye

K.S.

. 2016. An immunocompromised child with bloodstream infection caused by two Escherichia coli strains, one harboring NDM-5 and the other harboring OXA-48-like carbapenemase. Antimicrob. Agents Chemother., 60:3270–3275.

68.

Lunha

, Chanawong

, Lulitanond

, Wilailuckana

, Charoensri

, Wonglakorn

, Saenjamla

, Chaimanee

, Angkititrakul

, and Chetchotisakd

. 2016. High-level carbapenem-resistant OXA-48-producing Klebsiella pneumoniae with a novel OmpK36 variant and low-level, carbapenem-resistant, non-porin-deficient, OXA-181-producing Escherichia coli from Thailand. Diagn. Microbiol. Infect. Dis., 85:221–226.

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