title: An Update of the Evolving Epidemic of blaKPC Carrying Klebsiella pneumoniae in Sicily, Italy, 2014: Emergence of Multiple Non-ST258 Clones.
abstract: BACKGROUND
  In Italy, Klebsiella pneumoniae carbapenemase producing K. pneumoniae (KPC-Kp) strains are highly endemic and KPC producing CC258 is reported as the widely predominating clone. In Palermo, Italy, previous reports have confirmed this pattern. However, recent preliminary findings suggest that an epidemiological change is likely ongoing towards a polyclonal KPC-Kp spread. Here we present the results of molecular typing of 94 carbapenem non susceptible K. pneumoniae isolates detected during 2014 in the three different hospitals in Palermo, Italy.
  
  
  RESULTS
  Ninety-four consecutive, non replicate carbapenem non susceptible isolates were identified in the three largest acute general hospitals in Palermo, Italy, in the six-month period March-August 2014. They were characterized by PCR for β-lactam, aminoglycoside and plasmid mediated fluoroquinolone resistance genetic determinants. The mgrB gene of the colistin resistant isolates was amplified and sequenced. Clonality was assessed by pulsed field gel electrophoresis and multilocus sequence typing. Eight non-CC258 sequence types (STs) were identified accounting for 60% of isolates. In particular, ST307 and ST273 accounted for 29% and 18% of isolates. CC258 isolates were more frequently susceptible to gentamicin and non-CC258 isolates to amikacin. Colistin non susceptibility was found in 42% of isolates. Modifications of mgrB were found in 32 isolates.
  
  
  CONCLUSIONS
  Concurrent clonal expansion of some STs and lateral transmission of genetic resistance determinants are likely producing a thorough change of the KPC-Kp epidemiology in Palermo, Italy. In our setting mgrB inactivation proved to substantially contribute to colistin resistance. Our findings suggest the need to continuously monitor the KPC-Kp epidemiology and to assess by a nationwide survey the possible shifting towards a polyclonal epidemic.
authors.affiliation: Department of Sciences for Health Promotion and Mother-Child Care "G. D'Alessandro", University of Palermo, Palermo, Italy.
authors.forename: Celestino
authors.initials: C
authors.lastname: Bonura
authors.affiliation: Department of Sciences for Health Promotion and Mother-Child Care "G. D'Alessandro", University of Palermo, Palermo, Italy.
authors.forename: Mario
authors.initials: M
authors.lastname: Giuffrè
authors.affiliation: Department of Sciences for Health Promotion and Mother-Child Care "G. D'Alessandro", University of Palermo, Palermo, Italy.
authors.forename: Aurora
authors.initials: A
authors.lastname: Aleo
authors.affiliation: Department of Sciences for Health Promotion and Mother-Child Care "G. D'Alessandro", University of Palermo, Palermo, Italy.
authors.forename: Teresa
authors.initials: T
authors.lastname: Fasciana
authors.affiliation: Laboratory of Microbiology, ARNAS "Civico, Di Cristina and Benfratelli", Palermo, Italy.
authors.forename: Francesca
authors.initials: F
authors.lastname: Di Bernardo
authors.affiliation: Laboratory of Microbiology, Azienda Ospedaliera Ospedali Riuniti "Villa Sofia-V. Cervello", Palermo, Italy.
authors.forename: Tomaso
authors.initials: T
authors.lastname: Stampone
authors.affiliation: Department of Sciences for Health Promotion and Mother-Child Care "G. D'Alessandro", University of Palermo, Palermo, Italy; Laboratory of Microbiology, Azienda Ospedaliero-Universitaria"Paolo Giaccone", Palermo, Italy.
authors.forename: Anna
authors.initials: A
authors.lastname: Giammanco
authors.affiliation: II Intensive Care Unit, ARNAS "Civico, Di Cristina and Benfratelli", Palermo, Italy.
authors.forename: Daniela Maria
authors.initials: DM
authors.lastname: Palma
authors.affiliation: Department of Sciences for Health Promotion and Mother-Child Care "G. D'Alessandro", University of Palermo, Palermo, Italy.
authors.forename: Caterina
authors.initials: C
authors.lastname: Mammina
mesh_terms: D000617:Aminoglycosides / Q000627:therapeutic use; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001426:Bacterial Proteins / Q000235:genetics* / Q000378:metabolism; D015780:Carbapenems / Q000627:therapeutic use; D002999:Clone Cells; D003091:Colistin / Q000627:therapeutic use; D004196:Disease Outbreaks; D024901:Drug Resistance, Multiple, Bacterial / Q000235:genetics; D016521:Electrophoresis, Gel, Pulsed-Field; D062665:Epidemiological Monitoring; D024841:Fluoroquinolones / Q000627:therapeutic use; D015870:Gene Expression; D006761:Hospitals; D006801:Humans; D015994:Incidence; D007558:Italy / Q000453:epidemiology; D007710:Klebsiella Infections / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology / Q000635:transmission; D007711:Klebsiella pneumoniae / Q000145:classification / Q000187:drug effects / Q000235:genetics* / Q000302:isolation & purification; D008565:Membrane Proteins / Q000235:genetics* / Q000378:metabolism; D058885:Multilocus Sequence Typing; D009154:Mutation; D010957:Plasmids / Q000737:chemistry / Q000378:metabolism*; D001618:beta-Lactamases / Q000235:genetics* / Q000378:metabolism
chemical_list: D000617:Aminoglycosides; D000900:Anti-Bacterial Agents; D001426:Bacterial Proteins; D015780:Carbapenems; D024841:Fluoroquinolones; D008565:Membrane Proteins; D001618:beta-Lactamases; C063912:carbapenemase; D003091:Colistin