High Prevalence of New Delhi Metallo-β-Lactamase-1 (NDM-1) Producers among Carbapenem-Resistant Enterobacteriaceae in Kuwait

Wafaa Y Jamal 1, M John Albert 1, Vincent O Rotimi 1

Affiliations

31 March 2016

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doi: 10.1371/journal.pone.0152638

Abstract

The aim of the study was to determine the prevalence of New Delhi metallo-β lactamase-1 (NDM-1) producing Enterobacteriaceae in Kuwait over a one year period. Consecutive Enterobacteriaceae isolates with reduced susceptibility to carbapenems were collected from four government hospitals in Kuwait from January-December 2014. Their susceptibility to 18 antibiotics was performed by determining the minimum inhibitory concentration. Isolates resistant to carbapenems were tested by PCR for resistant genes. Finger printing of the positive isolates was done by DiversiLab®. Clinical data of patients harboring NDM-1 positive isolates were analyzed. A total of 764 clinically significant Enterobacteriaceae isolates were studied. Of these, 61 (8%) were carbapenem-resistant. Twenty one out of these 61 (34.4%) were NDM-1-producers. All patients positive for NDM-1-carrying bacteria were hospitalized. About half were females (11/21 [52.3%]), average age was 53.3 years and the majority were Kuwaitis (14/21 [66.6%]). Six patients (28.5%) gave a history of travel or healthcare contact in an endemic area. Mortality rate was relatively high (28.6%). The predominant organism was Klebsiella pneumoniae (14 [66.6%]) followed by E. coli (4 [19%]). All NDM-1-positive isolates were resistant to meropenem, ertapenem, cefotaxime, cefoxitin and ampicillin, while 95.2% were resistant to imipenem, cefepime, and piperacillin-tazobactam. They were multidrug resistant including resistance to tigecycline, but 90% remained susceptible to colistin. About two-thirds of isolates (61.9%) co-produced-extended spectrum β-lactamases. During the study period, an outbreak of NDM-1 positive K. pneumoniae occurred in one hospital involving 3 patients confirmed by DiversiLab® analysis. In conclusion, NDM-1-producing Enterobacteriaceae is a growing healthcare problem with increasing prevalence in Kuwait, especially in hospitalized patients, leaving few therapeutic options. A high prevalence of NDM-1 necessitates the implementation of strict infection control to prevent the spread of these organisms.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interest exist.

Figures

Fig 1. Genetic relatedness analysis of 14 Klebsiella pneumoniae isolates with DiversiLab® using repetitive sequence-based polymerase chain reaction (rep-PCR). Dendrogram and computer-generated image of rep-PCR banding patterns are shown. Vertical lines indicate similarities of 95% and 98%. MAK W21 = Mubarak Al Kabeer hospital ward 21; MAK ICU = Mubarak Al Kabeer hospital intensive care unit; Amiri W9 = Amiri hospital ward 9; MAK W23 = Mubarak Al Kabeer hospital ward 23; IBS W3 = Ibn Sina hospital ward 3; IBS W2 = Ibn Sina hospital ward 2; IBS ICU = Ibn Sina hospital intensive care unit; MAK Ped ICU = Mubarak Al Kabeer hospital pediatric intensive care unit; MAK W 12 = Mubarak Al Kabeer hospital ward 12; Amiri W7 = Amiri hospital ward 7; MAK W26 = Mubarak Al Kabeer hospital ward 26

Fig 1. Genetic relatedness analysis of 14 Klebsiella pneumoniae isolates with DiversiLab® using repetitive sequence-based polymerase chain reaction (rep-PCR). Dendrogram and computer-generated image of rep-PCR banding patterns are shown. Vertical lines indicate similarities of 95% and 98%. MAK W21 = Mubarak Al Kabeer hospital ward 21; MAK ICU = Mubarak Al Kabeer hospital intensive care unit; Amiri W9 = Amiri hospital ward 9; MAK W23 = Mubarak Al Kabeer hospital ward 23; IBS W3 = Ibn Sina hospital ward 3; IBS W2 = Ibn Sina hospital ward 2; IBS ICU = Ibn Sina hospital intensive care unit; MAK Ped ICU = Mubarak Al Kabeer hospital pediatric intensive care unit; MAK W 12 = Mubarak Al Kabeer hospital ward 12; Amiri W7 = Amiri hospital ward 7; MAK W26 = Mubarak Al Kabeer hospital ward 26

Fig 2. Genetic relatedness analysis of 4 E. coli strains by DiversiLab® using repetitive sequence-based polymerase chain reaction (rep-PCR). Dendrogram and computer-generated image of rep-PCR banding patterns are shown. Vertical lines indicate similarities of 95% and 98%. MAK W21 = Mubarak Al Kabeer hospital ward; MAK W20 = Mubarak Al Kabeer hospital ward 20; MAK W14 Mubarak Al Kabeer hospital ward 14; MAK W 9 = Mubarak Al Kabeer hospital ward 9

Fig 2. Genetic relatedness analysis of 4 E. coli strains by DiversiLab® using repetitive sequence-based polymerase chain reaction (rep-PCR). Dendrogram and computer-generated image of rep-PCR banding patterns are shown. Vertical lines indicate similarities of 95% and 98%. MAK W21 = Mubarak Al Kabeer hospital ward; MAK W20 = Mubarak Al Kabeer hospital ward 20; MAK W14 Mubarak Al Kabeer hospital ward 14; MAK W 9 = Mubarak Al Kabeer hospital ward 9

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