title: Outbreak of OXA-48 carbapenemase-producing Klebsiella pneumoniae in Greece involving an ST11 clone.
abstract: OBJECTIVE
  First detected in Enterobacteriaceae isolates in Turkey, the OXA-48 carbapenemase has gradually disseminated in the wider Mediterranean area and Europe. Despite reports from other European regions, until now no such isolates have been detected in Greece. We describe the characteristics of the first outbreak caused by OXA-48-producing Klebsiella pneumoniae in Greece.
  
  
  METHODS
  From December 2011 to March 2012, 13 ertapenem-resistant K. pneumoniae isolates, which were positive by the modified Hodge test while remaining negative by phenotypic screening for metallo-β-lactamase (MBL) and KPC production, were recovered from nine patients. Patient records were retrieved to access patterns of acquisition. Resistance genes were identified by PCR and sequencing. ompK35, ompK36 and the genetic environment of the bla(OXA-48) gene were investigated. Plasmid profiling, conjugation experiments, PFGE and multilocus sequence typing (MLST) were performed.
  
  
  RESULTS
  All isolates harboured the bla(OXA-48) gene along with the bla(CTX-M-15) and bla(OXA-1) genes. The bla(OXA-48) gene was located on a self-transferable IncL/M-type plasmid of ~62 kb, which harboured no other resistance genes. IS1999 was located upstream of the bla(OXA-48) gene. Genetic disruptions of the ompK35 and ompK36 genes were not detected. The isolates belonged to a unique PFGE clone and MLST assigned them to sequence type ST11. All cases were characterized as hospital acquired and none of them was linked to immigration or history of travel in endemic areas.
  
  
  CONCLUSIONS
  Carbapenem resistance due to MBL and KPC carbapenemases is currently on an endemic scale in Greece and this report highlights the wider undetected dissemination of yet another carbapenemase in this region.
authors.affiliation: Department of Microbiology, Medical School,  University of Athens, Athens,  Greece.
authors.forename: Evangelia
authors.initials: E
authors.lastname: Voulgari
authors.forename: Olympia
authors.initials: O
authors.lastname: Zarkotou
authors.forename: Kyriaki
authors.initials: K
authors.lastname: Ranellou
authors.forename: Drosos E
authors.initials: DE
authors.lastname: Karageorgopoulos
authors.forename: Georgia
authors.initials: G
authors.lastname: Vrioni
authors.forename: Vasiliki
authors.initials: V
authors.lastname: Mamali
authors.forename: Katerina
authors.initials: K
authors.lastname: Themeli-Digalaki
authors.forename: Athanassios
authors.initials: A
authors.lastname: Tsakris
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001426:Bacterial Proteins / Q000235:genetics / Q000302:isolation & purification; D003001:Cloning, Molecular; D004196:Disease Outbreaks; D024901:Drug Resistance, Multiple, Bacterial / Q000235:genetics*; D005260:Female; D006115:Greece / Q000453:epidemiology; D006801:Humans; D007710:Klebsiella Infections / Q000453:epidemiology* / Q000235:genetics*; D007711:Klebsiella pneumoniae / Q000235:genetics* / Q000302:isolation & purification; D008297:Male; D008875:Middle Aged; D055815:Young Adult; D001618:beta-Lactamases / Q000235:genetics* / Q000302:isolation & purification
chemical_list: D001426:Bacterial Proteins; D001618:beta-Lactamases; C063912:carbapenemase; C108449:oxacillinase