Antibiotic Efficacy in Escherichia coli and Klebsiella pneumoniae Under Nutrient Limitation and Effectiveness of Colistin-Based Antibiotic Combinations to Eradicate Persister Cells.

Persister cells are responsible for recurrent or chronic infections resulting in antibiotic treatment failure. We aimed to investigate antibiotic efficacy in Escherichia coli and Klebsiella pneumoniae strains with limited metabolic activity. Bacterial cells cultured in nutrient-limited media showed characteristic persister phenotypes, including low intracellular ATP concentration, maintenance of antibiotic susceptibility, and an increase of (p)ppGpp levels. Amikacin showed no bactericidal activity under nutrient limitation conditions; however, metabolism-dependent ciprofloxacin exhibited metabolism-independent activity. The activity of colistin was metabolism-dependent, but it was retained under limited nutrient conditions. Nutrient limitation and antibiotic stress were related to the SOS response through recA expression in all four strains of E. coli and K. pneumoniae. However, the mRNA expression patterns of relA and spoT (associated with (p)ppGpp synthesis) and hpf and rpoS (downstream target genes of (p)ppGpp signaling) varied according to bacterial species, strain, and antibiotics, indicating diverse responses to nutrient stress in various persister cells. We also investigated the efficacy of antibiotic combinations to eradicate persister cells. As a result, colistin-based combinations were effective in the eradication of both E. coli and K. pneumoniae persister cells. In this study, persister cells were shown to be induced by metabolic stress, reducing antibiotic efficacy. We identified that combinations of colistin with amikacin or ciprofloxacin were effective to eliminate E. coli and K. pneumoniae persister cells.

Colistin Resistance and Extensive Genetic Variations in PmrAB and PhoPQ in Klebsiella Pneumoniae Isolates from South Korea.

We investigated the colistin resistance of Klebsiella pneumoniae blood isolates from South Korea. Among 252 K. pneumoniae isolates, only 11 (4.4%) demonstrated colistin resistance, of which, one was resistant to all antibiotics but tigecycline. Multilocus sequence typing analysis revealed ten sequence types among the 11 colistin-resistant isolates, indicating independent occurrence of colistin resistance in K. pneumoniae. To understand the mechanism of colistin resistance, amino acid variations in PmrAB, PmrD, PhoPQ, and MgrB were investigated. Amino acid substitutions were identified in all the colistin-resistant K. pneumoniae isolates. Particularly, extensive alterations in the genes associated with colistin resistance were shared in four colistin-resistant isolates, suggesting recombination between these genes of unrelated isolates. Our results suggest that genetic recombination is responsible for colistin resistance in some K. pneumoniae isolates.

Whole-plasmid analysis of NDM-1-producing Acinetobacter seifertii isolate and its fitness in several Acinetobacter species.

OBJECTIVES: The aim of this study is to characterize an NDM-1-producing Acinetobacter seifertii isolates from a patient in South Korea. METHODS: Antibiotic susceptibility testing and genotyping using multigene sequencing were performed and whole plasmid sequences were determined. RESULTS: The genotype of A. seifertii was ST1899, and was resistant to ceftazidime, trimethoprim-sulfamethoxazole, and piperacillin-tazobactam, in addition to carbapenem. blaNDM-1 was surrounded by ISAba125 insertion sequence within the structure of Tn125 in the 47 kb-sized plasmid. The plasmid exhibited a structure similar to that of other plasmids of diverse Acinetobacter species found worldwide. Transconjugation and growth curve indicated that the plasmid was adapted to A. seifertii rather than other closely related Acinetobacter species. CONCLUSION: Acquisition of the carbapenem resistance by horizontal transfer of the blaNDM-1-carrying plasmid from another Acinetobacter species with no growth defect.

Species identification, antibiotic resistance, and virulence in Enterobacter cloacae complex clinical isolates from South Korea.

This study aimed to identify the species of Enterobacter cloacae complex (ECC) isolates and compare the genotype, antibiotic resistance, and virulence among them. A total of 183 ECC isolates were collected from patients in eight hospitals in South Korea. Based on partial sequences of hsp60 and phylogenetic analysis, all ECC isolates were identified as nine species and six subspecies. Enterobacter hormaechei was the predominant species (47.0%), followed by Enterobacter kobei, Enterobacter asburiae, Enterobacter ludiwigii, and Enterobacter roggenkampii. Multilocus sequence typing analysis revealed that dissemination was not limited to a few clones, but E. hormaechei subsp. xiangfangensis, E. hormaechei subsp. steigerwaltii, and E. ludwigii formed large clonal complexes. Antibiotic resistance rates were different between the ECC species. In particular, E. asburiae, E. kobei, E. roggenkampii, and E. cloacae isolates were highly resistant to colistin, whereas most E. hormaechei and E. ludwigii isolates were susceptible to colistin. Virulence was evaluated through serum bactericidal assay and the Galleria mellonella larvae infection model. Consistency in the results between the serum resistance and the G. mellonella larvae infection assay was observed. Serum bactericidal assay showed that E. hormaechei, E. kobei, and E. ludwigii were significantly more virulent than E. asburiae and E. roggenkampii. In this study, we identified the predominant ECC species in South Korea and observed the differences in antibiotic resistance and virulence between the species. Our findings suggest that correct species identification, as well as continuous monitoring is crucial in clinical settings.

Detection of colistin-resistant populations prior to antibiotic exposure in KPC-2-producing Klebsiella pneumoniae clinical isolates.

Although colistin is frequently regarded as the antibiotic of last resort in treating carbapenem-resistant Klebsiella pneumoniae, colistin heteroresistance may in part be associated with antibiotic treatment failure. However, we do not know how widespread the colistin heteroresistance is in carbapenem-resistant K. pneumoniae isolates. In this study, we performed colistin disc diffusion assays, E-tests, and population analysis profiling for KPC-2-producing K. pneumoniae isolates to identify colistin heteroresistance. Although no colistin-resistant colonies were detected by the disc diffusion test and E-test, a colistin-resistant subpopulation was identified in population analysis profiling in all colistin-susceptible, KPC-2-producing K. pneumoniae isolates. Colistin-resistant subpopulations were also identified even when isolates had no colistin exposure. The ratio of colistin-resistant subpopulations to the total population increased as the exposure concentration of colistin increased. In in vitro time-kill assays, regrowth was observed in all isolates after 2 h upon exposure to colistin. We identified common amino acid alterations in PhoQ, PhoP, and PmrB in colistin-resistant subpopulations from some isolates, but no substitutions were found in most resistant subpopulations from other isolates. In all colistin-resistant subpopulations, overexpression of PhoQ and PbgP was observed. In this study, we demonstrated that colistin heteroresistance may be common in KPC-2-producing K. pneumoniae isolates, which could not be detected in the disc diffusion method and E-test. Colistin heteroresistance may cause colistin treatment failure in part and may evolve into resistance. Thus, development of more reliable diagnostic methods is required to detect colistin heteroresistance.

Fecal Carriage of Antimicrobial-Resistant Enterobacteriaceae in Healthy Korean Adults.

The spread of antibiotic-resistant Enterobacteriaceae in the community is one of the main challenges for antibiotic treatment of community-onset infections. We evaluated the microbiological and molecular characteristics of stool samples from adults with comprehensive health examinations. Of 109 fecal samples, bacterial growth was observed in 86 samples and 61 gram-negative bacterial isolates were identified, of which 45 were Escherichia coli isolates (73.8%). Two isolates of Raoultella showed imipenem resistance, and both E. coli and Citrobacter freundii showed intermediate resistance to imipenem. Colistin resistance was identified in isolates of Klebsiella variicola and Salmonella subterranean, but no isolates carried mcr-1. As for E. coli genotypes, 35 sequence types were identified. blaTEM-1, blaTEM-30, and blaCTX-M were identified in 15, 1, and 4 E. coli isolates, respectively. In addition, all four Klebsiella pneumoniae isolates carried blaSHV. Many genotypes that have been identified in isolates causing human infections were found in isolates in this study. There is a need to control the rise and spread of antibiotic-resistant pathogens by fecal carriage.