title: Introduction of OXA-48-producing Enterobacteriaceae to Israeli hospitals by medical tourism.
abstract: OBJECTIVE
  The carbapenemase OXA-48 has been reported from different Mediterranean countries. It is mostly encoded on a single plasmid in various Enterobacteriaceae species. We characterized the epidemiological and molecular features of OXA-48-producing Enterobacteriaceae (OPE) in Israel.
  
  
  METHODS
  Epidemiological investigation was conducted by the National Center for Infection Control. Genotyping was performed using multilocus sequence typing. The bla(OXA-48)-carrying plasmids were investigated using S1 endonuclease and restriction fragment length polymorphism (RFLP). Conjugation efficiency of the bla(OXA-48)-carrying plasmids was studied in a filter mating experiment.
  
  
  RESULTS
  Since 2007, four OPE-infected patients were identified, all non-Israeli (two Palestinian, one Jordanian and one Georgian). Three had prior hospitalization; two in Jordan and one in Georgia. The bla(OXA-48) gene was detected in three Escherichia coli strains belonging to different clonal complexes, one Klebsiella oxytoca and one Klebsiella pneumoniae sequence type 101, as previously reported from Tunisia and Spain. In all isolates, the bla(OXA-48) gene was located inside Tn1999.2 and was carried on a 60 kb plasmid with an identical RFLP pattern. The plasmid was able to conjugate from Klebsiella spp. to E. coli, and had a conjugation efficiency up to ~10000 times higher than that of pKpQIL.
  
  
  CONCLUSIONS
  OPE, introduced mainly by medical tourism, are an emerging threat to patients from affected Mediterranean countries. The bla(OXA-48)-carrying plasmid demonstrated remarkable conjugation efficiency, which is probably important in the success of its dissemination.
authors.affiliation: National Center for Infection Control, Israel Ministry of Health, Tel-Aviv, Israel. amosa@tasmc.health.gov.il
authors.forename: Amos
authors.initials: A
authors.lastname: Adler
authors.forename: Maya
authors.initials: M
authors.lastname: Shklyar
authors.forename: Mitchell J
authors.initials: MJ
authors.lastname: Schwaber
authors.forename: Shiri
authors.initials: S
authors.lastname: Navon-Venezia
authors.forename: Yacoub
authors.initials: Y
authors.lastname: Dhaher
authors.forename: Rotem
authors.initials: R
authors.lastname: Edgar
authors.forename: Ester
authors.initials: E
authors.lastname: Solter
authors.forename: Shmuel
authors.initials: S
authors.lastname: Benenson
authors.forename: Samira
authors.initials: S
authors.lastname: Masarwa
authors.forename: Yehuda
authors.initials: Y
authors.lastname: Carmeli
mesh_terms: D000328:Adult; D016000:Cluster Analysis; D016172:DNA Fingerprinting; D004755:Enterobacteriaceae / Q000145:classification / Q000201:enzymology* / Q000235:genetics / Q000302:isolation & purification; D004756:Enterobacteriaceae Infections / Q000453:epidemiology* / Q000382:microbiology; D005260:Female; D005838:Genotype; D006761:Hospitals; D006801:Humans; D007557:Israel / Q000453:epidemiology; D008297:Male; D057193:Medical Tourism; D008875:Middle Aged; D017720:Molecular Epidemiology; D058885:Multilocus Sequence Typing; D012150:Polymorphism, Restriction Fragment Length; D001618:beta-Lactamases / Q000378:metabolism*
chemical_list: D001618:beta-Lactamases