NDM-producing Enterobacteriaceae in Poland, 2012-14: inter-regional outbreak of Klebsiella pneumoniae ST11 and sporadic cases

Objectives: The objective of this study was to characterize New Delhi metallo-beta-lactamase (NDM)-producing Enterobacteriaceae isolates reported in Poland in 2012-14. Methods: Representative isolates were typed by PFGE and MLST. NDM and other beta-lactamase genes were amplified and sequenced. Plasmids with bla(NDM) genes were analysed by nuclease S1 plus hybridization profiling, by transfer assays and by PCR-based replicon typing. The bla(NDM) genetic context was studied by PCR mapping assays. Results: Of 374 cases of infection/colonization with NDM-positive Enterobacteriaceae identified in 2012-14, 370 cases in 40 hospitals, 10 outpatient clinics and 1 nursing home were associated with a Klebsiella pneumoniae outbreak with epicentres in PoznaA and Warsaw. The outbreak strain of K. pneumoniae ST11 was similar to an isolate from the Czech Republic from 2013. Like the Czech strain, many of the isolates had two bla(NDM-1)-carrying IncFII- and IncR-type plasmids of variable size, sharing a bla(NDM-1)-containing segment. The early isolates also produced CTX-M-15 co-encoded by the IncR-type plasmids, and differentiated later by extensive plasmid rearrangements. Four other NDM cases were reported in 2013, three being associated with arrivals from Montenegro, India or Afghanistan. The Indian Escherichia coli ST448 NDM-5 isolate revealed similarity to a recent isolate from Spain, including the bla(NDM) genetic context observed previously in E. coli strains in Poland and France (of Congolese and Indian origins, respectively). The Afghani Proteus mirabilis was the second isolate of this species with a chromosomal bla(NDM-1) location. Conclusions: The largest NDM outbreak in a non-endemic country has been observed, being an alarming phenomenon in resistance epidemiology in Poland.