title: First Canadian outbreak of Enterobacteriaceae-expressing Klebsiella pneumoniae carbapenemase type 3.
abstract: BACKGROUND
  Organisms expressing Klebsiella pneumoniae carbapenemase (KPC) are found in several regions worldwide but are rarely detected in Canada. The first outbreak of KPC-expressing strains of Enterobacteriaceae clinical isolates in a university-affiliated hospital intensive care unit (ICU) in Canada is described.
  
  
  METHODS
  Enterobacteriaceae isolates that were flagged by the Vitek 2 (bioMérieux, France) system as possible carbapenemase producers were subjected to the modified Hodge test. Modified Hodge test-positive organisms were analyzed by pulsed-field gel electrophoresis, tested for KPC and other beta-lactamase genes by polymerase chain reaction analysis and underwent subsequent nucleic acid sequencing. Antimicrobial susceptibility profiles were determined by Vitek 2 and Etest (bioMérieux, France). A chart review was conducted to establish epidemiological links.
  
  
  RESULTS
  During the study period, 10 unique Enterobacteriaceae isolates expressing KPC were detected from nine ICU patients. Five patients had infections (three pneumonias, one surgical site infection, one urinary tract infection). Isolates included Escherichia coli (5), Klebsiella oxytoca (2), Serratia marcescens (2) and Citrobacter freundii (1). Polymerase chain reaction analysis and sequencing confirmed the presence of KPC-3 in all isolates; four also carried TEM, two CTX-M and one CMY-2. The imipenem minimum inhibitory concentrations as determined by Etest ranged from 0.75 μg/mL to ≥32 μg/mL. Pulsed field gel electrophoresis clonal patterns and patient location in the ICU revealed presumptive horizontal transmission events.
  
  
  CONCLUSIONS
  In the present study, Enterobacteriaceae isolates with KPC are emerging and can result in serious infections. The KPC gene can spread via plasmids to different genera of the Enterobacteriaceae family. The dissemination of KPC in Enterobacteriaceae and the consequences for treatment and infection control measures warrant a high degree of vigilance among clinicians and microbiologists.
authors.affiliation: McGill University Health Centre, Montreal;
authors.forename: Victor
authors.initials: V
authors.lastname: Leung
authors.forename: Vivian G
authors.initials: VG
authors.lastname: Loo
authors.forename: Charles
authors.initials: C
authors.lastname: Frenette
authors.forename: Marc-Christian
authors.initials: MC
authors.lastname: Domingo
authors.forename: Anne-Marie
authors.initials: AM
authors.lastname: Bourgault
authors.forename: Michael R
authors.initials: MR
authors.lastname: Mulvey
authors.forename: Hugh G
authors.initials: HG
authors.lastname: Robson
keywords: Beta-lactamases KPC; Carbapenemase; Disease outbreaks