title: Resistance to Fluoroquinolone by a Combination of Efflux and Target Site Mutations in Enteroaggregative Escherichia coli Isolated in Korea.
abstract: OBJECTIVE
  Enteroaggregative Escherichia coli (EAEC) was recently reported as a major diarrheagenic pathogen in infant and adult travelers, both in developing and developed countries. EAEC strains are known to be highly resistant to antibiotics including quinolones. Therefore in this study we have determined the various mechanisms of quinolone resistance in EAEC strains isolated in Korea.
  
  
  METHODS
  For 26 EAEC strains highly resistant to fluoroquinolone, minimal inhibitory concentrations for fluoroquinolones were determined, mutations in the quinolone target genes were identified by PCR and sequencing, the presence of transferable quinolone resistance mechanism were identified by PCR, and the contribution of the efflux pump was determined by synergy tests using a proton pump inhibitor. The expression levels of efflux pump-related genes were identified by relative quantification using real-time PCR.
  
  
  RESULTS
  Apart from two, all tested isolates had common mutations on GyrA (Ser83Leu and Ser87Gly) and ParC (Ser80Gln). Isolates EACR24 and EACR39 had mutations that have not been reported previously: Ala81Pro in ParC and Arg157Gly in GyrA, respectively. Increased susceptibility of all the tested isolates to ciprofloxacin and norfloxacin in the presence of the pump inhibitor implies that efflux pumps contributed to the resistance against fluoroquinolones. Expression of the efflux pump-related genes, tolC, mdfA, and ydhE, were induced in isolates EACR 07, EACR 29, and EACR 33 in the presence of ciprofloxacin.
  
  
  CONCLUSIONS
  These results indicate that quinolone resistance of EAEC strains mainly results from the combination of mutations in the target enzyme and an increased expression of efflux pump-related genes. The mutations Ala81Pro in ParC and Arg157Gly in GyrA have not been reported previously the exact influence of these mutations should be investigated further.
authors.affiliation: Division of Enteric Diseases, Korea National Institute of Health, Osong, Korea.
authors.forename: Jun-Young
authors.initials: JY
authors.lastname: Kim
authors.forename: Se-Mi
authors.initials: SM
authors.lastname: Jeon
authors.forename: Hyungjun
authors.initials: H
authors.lastname: Kim
authors.forename: Nara
authors.initials: N
authors.lastname: Lim
authors.forename: Mi-Sun
authors.initials: MS
authors.lastname: Park
authors.forename: Seong-Han
authors.initials: SH
authors.lastname: Kim
keywords: aac(6')-Ib-cr; efflux pump; enteroaggregative Escherichia coli; fluoroquinolone; gyrA; parC; qnr