First Report of an OXA-48-and CTX-M-213-Producing Kluyvera Species Clone Recovered from Patients Admitted in a University Hospital in Madrid, Spain

Enterobacterales species other than Kiebsiella pneumoniae also contribute to OXA-48 carbapenemase endemicity. We studied the emergence of an OXA-48-producing Kluyvera species clone, which expresses the novel CTX-M-213 enzyme, colonizing patients in our hospital. Rectal swabs from patients admitted in four wards (March 2014 to March 2016; R-GNOSIS project) were seeded onto Chromo ID-ESBL) and Chrom-CARB/OXA-48 chromogenic agar plates. Carbapenemases and extended-spectrum beta-lactamases (ESBLs) were characterized (PCR, sequencing, cloning, and site-directed mutagenesis), and antibiotic susceptibility was determined. Clonal relatedness was established (Xbal pulsed-field gel electrophoresis [XbalPFGE]), and plasmid content was studied (transformation, S1 nuclease digestionPFGE, SB-hybridization, restriction fragment length polymorphism [RFLP] analysis [Dral and Hpal], and PCR [incompatibility group and repA, trot), and parA genes]). Whole-genome sequencing (WGS) (Illumina HiSeq-2500) and further bioinformatics analysis of plasmids (PLACNET and plasmidSPAdes) were performed. Patients' charts were reviewed. Six unrelated patients (median age, 75 years [range, 59 to 81 years); 4/6 male patients) colonized with OXA-48-producing Kluyvera species isolates (>95% similarity of the PFGE pattern) were identified. Nosocomial acquisition was demonstrated. In two patients, OXA-48-producing Kluyvera species isolates coexisted with OXA-48-producing Raoultella ornithinolytica, K pneumoniae, and Escherichia coll. The bla(OXA-48)( )gene was located on an similar to 60-kb IncL plasmid related to IncUM-pOXA-48a and the novel bla(CTX-M-213) gene in a conserved chromosomal region of Kluyvera species isolates. CTX-M-213, different from CTX-M-13 (K56E) but conferring a similar ti-lactam resistance profile, was identified. Genomic analysis also revealed a 177-kb IncF plasmid (class I integron harboring sull and aadA2) and an 8-kb IncQ plasmid (1S4-bla(Fox-8)). We describe the first bla(OXA-48 )plasmid in Kluyvera spp. and the novel chromosomal CTX-M-213 enzyme and highlight further nosocomial dissemination of bla(OXA-48 ) through clonal lineages or plasmids related to IncUM-pOXA-48a.