Emergence of tigecycline resistance amongst multi-drug resistant gram negative isolates in a multi-disciplinary hospital

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Letters to the Editor Christophe Guervilly* Service de Re´animation Me´dicale, Hoˆpital Nord, Assistance Publique Hoˆpitaux de Marseille, chemin des Bourrely, 13015 Marseille, France *Corresponding author. Tel.: þ33 0491965835; fax: þ33 0491965837. E-mail address: [email protected] Yanae ¨l Coisel Unite´ de re´animation et de transplantation, service d’anesthe´sie-re´animation B, Hoˆpital Saint-Eloi, Montpellier, France

Elizabeth Botelho-Nevers Service de Maladies Infectieuses et Tropicales, Hoˆpital Nord, Assistance Publique Hoˆpitaux de Marseille, France Stephanie Dizier Matthias Castanier Renaud Lepaul-Ercole Olivier Brissy Antoine Roch Jean-Marie Forel Laurent Papazian Service de Re´animation Me´dicale, Hoˆpital Nord, Assistance Publique Hoˆpitaux de Marseille, France 21 July 2010 Available online 27 July 2010 ª 2010 The British Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jinf.2010.07.013

Table 1

Emergence of tigecycline resistance amongst multi-drug resistant gram negative isolates in a multi-disciplinary hospital To the editor Tigecycline demonstrated excellent and sustained in vitro activity against a wide spectrum of contemporary Gram-positive and -negative pathogens from Asia-Western Pacific countries.1 Tigecycline was also known for its broad spectrum of activity against multi-drug resistant gramnegative and gram-positive pathogens.2 We report tigecycline resistant multi-drug resistant isolates within a short interval of its marketing in multi-speciality, tertiary care hospital in Delhi, the Indian capital metropolis. Isolates from patients with serious infections were characterized by their phenotypic and biochemical characterization. The antibiotics susceptibility was tested by disk diffusion method following the Clinical and Laboratory Standards Institute (CLSI) criteria. Multi-drug resistant Gram-negative (MDR) isolates included those resistant to meropenem, piperacillinetazobactam, cefepime, amoxicillineclavulanic acid, and amikacin. During 2009, among 1198 Gram-negative isolates, there were 12 MDR isolates, 8 had originated from urine and 4 from pulmonary tissues: Escherichia coli, 2, Klebsiella pneumoniae 9 and a solitary Proteus species. The MDR antibiotic susceptibility was of 10 isolates susceptible to tigecycline, 9 to chloramphenicol, 6 to ofloxacin, two each aztronam and ciprofloxacin and one each for rifampin, gentamicin and linezolid (Table 1). Tigecycline resistant K. pneumoniae were isolated from urine and pulmonary tissues: isolate from pulmonary tissue was susceptible to chloramphenicol, rifamcyin and ofloxacin, while from urine to chloramphenicol, nitrofurantoin, Cephalexin, ceftizoxime and cefuroxime. Tigecycline marketing started locally during 2007 and within a short interval, tigecycline resistant MDR isolates resistant to several categories of otherwise outstanding antibiotics are already in circulation. In all probability,

Susceptibility pattern of multi-drug resistant isolates at the Sant Parmanand Hospital during 2009.

Reference number

Source

Isolate

Susceptibility profile

99828 98717

Urine Urine

Klebsiella pnemoniae Klebsiella pnemoniae

97221 97256 92972

Urine Urine Pulmonary Tissues Pulmonary tissues Pulmonary tissues Urine Pulmonary tissue Urine Urine Urine

Klebsiella pnemoniae Klebsiella pnemoniae Klebsiella pnemoniae

Tigecycline, Chloramphenicol Aztreonam, Tigecycline, Chloramphenicol, Ciprofloxacin, Ofloxacin Chloramphenicol, Nitrofurantoin Tigecycline, Chloramphenicol, Ofloxacin Rifampin, Chloramphenicol, Ofloxacin

Klebsiella pnemoniae

Tigecycline, Chloramphenicol, Ofloxacin

Klebsiella pnemoniae

Tigecycline, Chloramphenicol

Proteus species Klebsiella pnemoniae

Tigecycline, Chloramphenicol, Ofloxacin Tigecycline, Gentamicin, Chloramphenicol, Ciprofloxacin

E. coli E. coli Klebsiella pnemoniae

Tigecycline, Ofloxacin Tigecycline, Nitrofurantoin Aztreonam, Linezolid, Tigecycline,

92601 90078 90234 88518 102419 100362 99779

Letters to the Editor with an over-the-counter availability of antimicrobials and no antibiotics policy around, clinicians are tempted to prescribe tigecycline expecting a swift and optimistic response. Circulation of tigecycline-susceptible/resistant MDR has limited the therapeutic options available for treatment of infections in residents in long term care facilities.3 Moreover, in a teaching hospital in India, the prevalence of MDR bacteria was 9.45% and the highest prevalence was seen in gastro-intestinal surgery department: E. coli and Klebsiella being the commonest isolates.4 Susceptibility profiles of local MDR isolates (Table 1) are captivating as the isolates were found to be susceptible to one or more not all that effective antibiotics. Such antimicrobial agents would never be the preference for clinicians managing patients with severe infections. Patients harboring MDR that were susceptible to rifampin or linezolid would have not been prescribed these antimicrobials as the empirical antibiotic therapy. Emergence of Tigecycline resistant MDR would leave no option with clinicians but to prescribe old antimicrobial agents. For example, in the present series there were ten MDR that were susceptible to tigecycline, while nine, to chloramphenicol. Chloramphenicol is known to be a broad spectrum antibiotic against gram-negative and -positive bacteria, though its idiosyncratic irreversible bone marrow depression would be an obstacle towards its frequent prescriptions. Moreover, common antibiotics from grampositives like linezolid, teicoplanin or rifamycin would not be all that pleasing to the clinicians. Last but not least, prospective replication, amplification and dissemination of Tigecycline resistant MDR in metropolitan cities with extensive influx of international tourists would be unfortunate. That would not only reduce the therapeutic options with clinicians locally but also in distant locations following inadvertent spread through international travelers.

Conflict of interest None.

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Ethical clearance Not required.

Fiscal support None.

References 1. Farrell DJ, Turnidge JD, Bell J, Sader HS, Jones RN. The in vitro evaluation of tigecycline tested against pathogens isolated in eight countries in the Asia-western pacific region (2008). J Infect 2010;60(6):440e51. 2. Doan TL, Fung HB, Mehta D, Riska PF. Tigecycline: a glycylcycline antimicrobial agent. Clin Ther 2006;28:107e1106. 3. O’Fallon E, Pop-Vicas A, D’Agata E. The emerging threat of multidrug-resistant gram-negative organisms in long-term care facilities. J Gerontol A Biol Sci Med Sci 2009 Jan;64(1): 138e41. Epub 2009 Jan 20. 4. Singh AV, Mishra B, Thakur A. Multidrug-resistant Gram-negative bacteria in postoperative infections. J Indian Med Assoc 2009 Mar;107(3):148e50. 163.

Subhash C. Arya* Nirmala Agarwal Sant Parmanand Hospital, 18 Alipore Road, Delhi 110054, India *Corresponding author. Tel.: þ91 11 981064469. E-mail address: [email protected] (S.C. Arya) 21 July 2010 Available online 27 July 2010 ª 2010 The British Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jinf.2010.07.012