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Putative horizontal transfer of carbapenem resistance between Klebsiella pneumoniae and Kluyvera ascorbata during abdominal infection: A case report


Otávio Hallal Ferreira Raro MSc1 , Daiana de Lima-Morales PhD2, Afonso Luis Barth PhD2, Tiago Galvão Paim PhD3, Mariana Preussler Mott MSc1, Cezar Vinícius Würdig Riche MSc1, Uirá Fernandes Teixeira PhD4, Fábio Luiz Waechter PhD4


and Cícero Armídio Gomes Dias PhD1 1Departamento de Ciências da saúde da Universidade Federal de Ciências da Saúde de Porto Alegre - UFCSPA, Porto Alegre, Rio Grande do Sul, Brazil, 2LABRESIS - Laborat´


— orio de Pesquisa em Resistência Bacteriana, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil, 3Instituto de


Biociências da Universidade Federal do Rio Grande do Sul – UFRGS, Porto Alegre, Rio Grande do Sul, Brazil, Brazil and 4Serviço de Cirurgia do Aparelho Digestivo da UFCSPA/Santa Casa – UFCSPA, Porto Alegre, Rio Grande do Sul, Brazil


To the Editor The emergence of KPC-producing Enterobacter has


led to the development of serious infections related to high levels of mortality and morbidity worldwide.1,2 The rapid spread of KPCs is linked to multiple elements, such as plasmid-borne genes and the dissemination by international travelers; these bacteria are frequently multidrug resistant, causing untreatable infections.3,4 Kluyvera spp is a genus of gram-negative rods of the Enterobacteriaceae family.5 Although it is a commensal of the human gut microbiota,6 Kluyvera spp has the potential to cause septic shock, urinary tract infections, catheter-associated bloodstream infections, and abdomi- nal infections.7 Here, we report a case of a plasmid-mediated hori- zontal transfer from a Klebsiella pneumoniae isolate to a Kluyvera ascorbata isolate during abdominal infection. The patient approved the data submission. A43-year-oldmale patientwas admitted to theHepatobiliary and


Pancreatic Surgical Division from a hospital in the South Region of Brazil in October 2016. He was asymptomatic but had an incidental type 1 biliary cyst that was discovered during ultrasonography. Magnetic resonance imaging (MRI) with cholangiopancreatography was performed for adequate evaluation and showed an abnormal pancreatobiliary junction, as well. In November 2016, the patient underwent a cholecystectomy and total resection of the cyst, with closure of distal part of the main bile duct inside the pancreas, accompanied by Roux-en-Y hepaticojejunostomy to provide proper


Author for correspondence: Otávio Hallal Ferreira Raro, E-mail: otaviohraro@gmail. com Cite this article: Raro OHF, et al. (2019). Putative horizontal transfer of carbapenem


resistance between Klebsiella pneumoniae and Kluyvera ascorbata during abdominal infection: A case report. Infection Control & Hospital Epidemiology, 40: 494–496, https:// doi.org/10.1017/ice.2019.26


© 2019 by The Society for Healthcare Epidemiology of America. All rights reserved.


biliary drainage. The pathology report showed no malignancy in surgical specimen. After 48 hours, the patient was evaluated with postoperative pancreatitis and signs of sepsis, therefore piperacillin/ tazobactam treatment was started. The patient continued to present clinical deterioration and needed parenteral nutrition; he was conse- quently transferred to the intensive care unit (ICU). Blood cultures were negative and abdominal computerized tomography (CT) showed abdominal collections. CT-guided drainage of pancreatic fluid was performed and cultures were negative. Nevertheless, anti- microbial treatment with meropenem was started and continued for 14 days without resolution. A second CT-guided drainage procedure was performed at the end of December, and the bacte- riological culture yielded a multisusceptible Enterococcus faecalis; a Kluyvera ascorbata resistant to ampicillin and second-generation cephalosporin but susceptible to carbapenem, and multidrug- resistant Klebsiella pneumoniae, including resistance to tigecycline and carbapenem. Antibiotics were adjusted to vancomycin, mero- penem, and ertapenemplus polymyxinBwith clinical improvement but without complete bacterial clearance. After 17 days, a third CT-guided drainage was performed, and the bacterial culture yielded 1 K. ascorbata isolate resistant to carbapenem. A fourth CT-guided drainage was performed after 15 days, and the culture yielded K. ascorbata susceptible to carbapenem and K. pneumoniae resistant to carbapenem. Antibiotic treatment was adjusted to polymyxin B, tigecycline, and sulfametoxazol-trimetoprim, and the patient was evaluated with signs of controlled infection. After 14 days, the antibiotic treatment was suspended, and a final CT showed no signs of abdominal collections. The patient was dis- charged and was followed as an outpatient.


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