Importation of KPC-2-producing Escherichia coli from India.

Sir, The production of carbapenem-hydrolysing b-lactamases is increasingly reported in Enterobacteriaceae. Among the different types of carbapenemases, the emergence of the Ambler class A KPC-type b-lactamases is of great concern, since those enzymes hydrolyse all b-lactams with the exception of cephamycins. Enterobacterial isolates producing KPC-type b-lactamases were reported in many areas in the USA and subsequently worldwide. The rapid dissemination of KPC enzymes among different enterobacterial species is related to the localization of blaKPC genes on transferable broad host range plasmids and their association with a transposon. This dissemination has also been linked with a ‘successful’ international clone of KPC-producing Klebsiella pneumoniae of sequence type (ST) 258. Early in 2011, a middle-aged patient was transferred from a hospital in Mumbai, India, to the hospital of Dinan, France. The patient suffered from pleurisy due to Streptococcus pneumoniae for which he had received a combination of imipenem, vancomycin and piperacillin/tazobactam in India. Upon admission, a rectal swab revealed the presence of a multidrug-resistant Escherichia coli (designated strain GRU) with reduced susceptibility to carbapenems. No secondary local transmission occurred at the Dinan hospital following the rapid implementation of strict infection control measures. The antibiogram determined by the disc diffusion method and MICs determined by Etest (AB bioMerieux, Solna, Sweden) and interpreted according to the CLSI guidelines revealed that E. coli strain GRU was resistant to all penicillins and expandedspectrum cephalosporins, to ertapenem (MIC .32 mg/L) and to meropenem (MIC 8 mg/L) and was of intermediate susceptibility to imipenem (MIC 1.5 mg/L). The isolate was susceptible to tetracycline and fosfomycin, and MICs of tigecycline and colistin were 1 and 0.5 mg/L, respectively. However, it was resistant at a high level to all fluoroquinolones (MICs .256 mg/L). Molecular investigations performed as described previously identified the blaKPC-2 gene. Isolate GRU also harboured the blaTEM-1 and blaOXA-1 genes. Plasmid location of the blaKPC-2 gene was confirmed by electroporation of a plasmid DNA preparation obtained by the Kieser method into E. coli TOP10 with selection on Trypticase soy plates containing ampicillin (100 mg/L). Molecular and phenotypic analysis of the E. coli transformant confirmed that blaKPC-2 was located on an 20 kb plasmid. The blaKPC-2-positive plasmid was non-typeable using PCR-based replicon typing. No other antibiotic resistance marker was co-transferred. PCR mapping performed as described showed that the blaKPC-2 gene was part of the Tn4401 transposon. It is noteworthy that E. coli GRU additionally harboured a gene encoding the 16S rRNA methylase ArmA, conferring high-level resistance to all aminoglycosides (MICs of gentamicin, netilmicin, kanamycin and tobramycin .256 mg/L). Interestingly, KPC-2and ArmAproducing Enterobacter cloacae and K. pneumoniae isolates have been reported in China and Poland. Multilocus sequence typing (MLST) performed according to the protocol described on the E. coli MLST web site (http://www.pasteur.fr/recherche/ genopole/PF8/mlst/EColi.html) showed that E. coli GRU belonged to ST101, recently reported to be the most frequent NDM-1-producing E. coli clone in the UK and Pakistan. That study reported a KPC-producing E. coli originating from India. It remains to be determined to what extent the spread of KPC-type enzymes will contribute to the problem of carbapenem resistance in India, which currently is commonly regarded as reflecting the dissemination of the NDM-1 carbapenemase.