Characterisation of CTX-M-β-lactamases in enterobacteriaceaeae in hospitals in Kuwait
Introduction: In this decade, the CTX-M family of enzymes are considered to be the most common type of extended-spectrum β-lactamases (ESBLs). The production of these Class A β-lactamases are noted to be most prevalent in the Enterobacteriaceaeae family. Many global reports indicated that CTX-M-15, of the CTX-M-1 group, is a growing concern, causing resistance to different classes of antibiotics. Worrisome trends of the spread of this enzyme have been indicated in nosocomial and community settings worldwide. Moreover, the same predicament is faced along the Middle East area, especially in the absence of restricted antibiotic usage policies. Many reports from Kuwait indicated the spread of a multi-drug resistant (MDR) blaCTX-M-15 gene in different hospitals. blaCTX-M-15 genes are often known to be carried on large transferable plasmids. Usually, the mobilization of these plasmid-encoded enzymes is carried out by insertion sequence like ISEcp1. Aims: This work aims to investigate the distribution of blaCTX-M genes in five major hospitals in Kuwait and to study and analyse the genetic environment of the described blaCTX-M genes. Materials and methods: One hundred and seven isolates of E. coli (84) (78.50%) and K. pneumoniae (23) (21.49%) were collected between 2006 and 2010 from five distantly located hospitals in Kuwait. All of the collected isolates were identified as ESBL-producers using Vitek 2 system. The production of cefotaximases was detected using disc diffusion with cefotaxime and clavulanic acid according to Clinical and Laboratory Standards Institute (CLSI) criteria. Conformation of CTX-M production was maintained by PCR amplification and further sequencing. The minimum inhibitory concentrations (MICs) of the collected isolates were determined by the double dilutions agar method described by the CLSI. Four different classes of antibiotics were used (aminoglycosides, different generations of cephalosporins, fluoroquinolones, and 3 different carbapenems). The genotypic relatedness of the collected strains was assessed by the use of an enhanced Pulsedfield gel electrophoresis (PFGE) method. Further amplifications with primer walking and simplex PCR were done to seek the genetic context of the MDR strains. S1 nuclease was used to size plasmids carrying the described blaCTX-M genes and conjugation studies were implemented to detect the transferability of the plasmids carrying the reported blaCTX-M genes. Results: All of the collected strains showed to be ESBL-producers and in particular cefotaximases-producers. Upon amplification, CTX-M-1 group was the only CTX-Mgroup present in the collected strains. When sequenced, blaCTX-M-15 was found to be the most prevalent. In addition, strains carrying the blaCTX-M-3 gene were identified, these have previously been found in the Middle East; however, this thesis has the first descriptions of blaCTX-M-28, blaCTX-M-55, and blaCTX-M-117 in this region. After the determination of the MICs of the collected strains, 94 (87.85%) were resistant to cefepime, 107 (100%) to cefotaxime, 48 (44.85%) to cefoxitin, 78 (72.89%) ciprofloxacin, and 71 (66.35%) to gentamicin. All of the strains were susceptible to carbapenems. Twenty-eight strains (26.2%) showed MDR pattern. With the enhanced PFGE method, only 22 isolates exhibited banding patterns that allowed grouping them into 10 distinct PFGE clusters. Notably, strains sharing ≥85% were from the same hospitals (isolates 1 with 2, 21 with 22, and 91 with 92 from the maternity hospital (M), 52 with 53 from Kuwait Oil Company hospital (KOC), 78 with 79 and 83 with 84 from Infectious Diseases Hospital (IDH), 97 with 98 and 95 with 96 from Al-Amiri hospital(A) ). Primer walking and simplex PCR experiments used for the genetic environment studies yielded 7 different genetic constructions for the described blaCTX-M genes. All of the described blaCTX-M genes were carried on plasmids ranging in size from 60 – 271 kb. Only 3 of the selected strains were of IncFII and the rest wereindeterminate. Possibly, two blaCTX-M-15 genes are likely to be carried on the chromosome. All of the described blaCTX-M genes are considered to be transferable except for blaCTX-M-28. The sizes of the conjugative plasmids and incompatibility groups are the same as their parental plasmids. Conclusion: In conclusion, blaCTX-M-15 is the most common ESBL gene found in Kuwaiti hospitals. It is also causing a MDR pattern with resistance to 3 different generations of cephalosporins and to two other classes (aminoglycosides and gentamicin), but sensitive to carbapenems. This led to restricting the treatment option into carbapenems. Antibiotic selective pressure could have played a major role in the development of blaCTX-M-15 derivatives such as blaCTX-M-28, blaCTX-M-55, and blaCTX-M-117. The probable explanation of the spread of blaCTX-M-15 is horizontal gene transfer carried by ISEcp1 and the conjugative properties of the plasmids carrying blaCTX-M-15. Variability of the genetic environments obtained explains the nonconditional existence of ISEcp1 to the ‘’W’’ region. Absence of the ISEcp1 in one of the reported structures of blaCTX-M-15 genetic contexts is noted. Therefore, the existence of blaCTX-M-15 could be due to the presence of another insertion sequences downstream or as a part of a larger gene cassette.