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Journal of Clinical Microbiology, March 2003, p. 1161-1166, Vol. 41, No. 3
0095-1137/03/$08.00+0     DOI: 10.1128/JCM.41.3.1161-1166.2003
Copyright © 2003, American Society for Microbiology. All Rights Reserved.

Patterns of Resistance Associated with Integrons, the Extended-Spectrum ß-Lactamase SHV-5 Gene, and a Multidrug Efflux Pump of Klebsiella pneumoniae Causing a Nosocomial Outbreak

Paul Gruteke,1,2* Wil Goessens,3 Jan van Gils,2 Paul Peerbooms,1 Nicole Lemmens-den Toom,3 Marga van Santen-Verheuvel,4 Alex van Belkum,3 and Henri Verbrugh3

Municipal Public Health Laboratory, Amsterdam,1 Zuiderzee Hospital, Lelystad,2 University Hospital Rotterdam, Rotterdam ,3 National Institute for Public Health and the Environment, Bilthoven, The Netherlands4

Received 21 March 2002/ Returned for modification 10 July 2002/ Accepted 24 October 2002

Multiresistant Klebsiella pneumoniae caused a nosocomial outbreak. Resistance patterns of the presumed outbreak isolates varied among and within patients. In order to control the outbreak, screening for extended-spectrum ß-lactamase (ESBL)-producing K. pneumoniae was commenced. A number of susceptible K. pneumoniae strains were stored to serve as controls in genetic strain typing. Typing by pulsed-field gel electrophoresis proved the clonality of the strains in the recognized outbreak patients. Typing of the control strains by pulsed-field gel electrophoresis showed that at least one patient had been missed by the ESBL screening procedure. Further genetic typing confirmed the presence of the SHV-5 ESBL gene in all but one of the outbreak strains. Variable presence of integrons that carried the aminoglycoside resistance genes aadB and aadA2 was found. A gyrA mutation in codon 83 was present in all outbreak strains tested, despite considerable differences in ciprofloxacin MICs. The MICs of ciprofloxacin and the chemically unrelated drug cefoxitin were correlated (r = 0.86, P < 0.01) and were compatible with the overexpression of an efflux pump in a subset of the outbreak strains. We conclude that outbreak strains that express an ESBL gene only at a low level may pass unnoticed in a screening procedure, when the laboratory is unaware of variable ESBL expression. In this particular outbreak, screening for strains for which ciprofloxacin MICs were >=0.25 µg/ml would in retrospect have been the most sensitive method for detection of the K. pneumoniae outbreak strain.

* Corresponding author. Mailing address: Municipal Public Health Laboratory Amsterdam, Nieuwe Achtergracht 100, P.O. Box 2200, 1000 CE Amsterdam, The Netherlands. Phone: 31 20 5555 275. Fax: 31 20 5555 629. E-mail: pgruteke{at}gggd.amsterdam.nl.

Journal of Clinical Microbiology, March 2003, p. 1161-1166, Vol. 41, No. 3
0095-1137/03/$08.00+0     DOI: 10.1128/JCM.41.3.1161-1166.2003
Copyright © 2003, American Society for Microbiology. All Rights Reserved.



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