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Volume 21, Number 6—June 2015
Letter

Response to Detection of New Delhi Metallo-β-Lactamase–Producing Bacteria, Brazil

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To the Editor: New Delhi metallo-β-lactamase (NDM) is an example of a successful antimicrobial drug resistance determinant and has become one of the most clinically significant carbapenemases. The gene blaNDM was first described in India in 2009. Its dispersion is epidemiologically linked to the Indian subcontinent, from which increased international transmission has been detected in nosocomial, community, and environmental isolates (1). Currently, the main acquired carbapenemases around the world are Klebsiella pneumoniae carbapenemase (KPC), oxacillinase-48 (OXA-48), and NDM. KPC is broadly detected and endemic to some areas; OXA-48 has been widely disseminated throughout European countries and has been reported in other regions. NDM is reported almost worldwide but did not successfully spread in most countries of Europe except the United Kingdom and recently, France, as has been found in Enterobacteriaceae (2) and in nonfermenting gram-negative bacilli, with progression toward rapid global prevalence.

NDM producers were detected most recently in South America (3). However, an increase in cases of NDM-producing bacteria has been noted. Carvalho-Assef et al. (4) described characterization of NDM in Brazil, in Providencia rettgeri isolated from a tissue sample excised from a patient in a hospital in Rio Grande do Sul state in southern Brazil, in 2013. Reports by Carvalho-Assef et al. (5) and Rozales et al. (6) have highlighted that P. rettgeri and isolates from the Enterobacter cloacae complex, clonally and nonclonally related, have been increasingly detected in the southern region of Brazil. In addition, retrospective studies have shown that NDM-1–producing Enterobacter have been present in Brazil since 2012 and have also been detected in Rio Grande do Sul (5). NDM-1–producing Morganella morganii (6), Escherichia coli, Klebsiella pneumoniae (7), Acinetobacter baumannii (8), and Citrobacter freundii (J. Campos, et al., https://www.escmid.org/escmid_library/online_lecture_library/?search=1&current_page=1&search_term=Citrobacter+freundii+NDM) have also been reported. Initial reports from Brazil also indicate that NDM producers have displayed characteristics such as co-resistance (5,9,10) and heteroresistance (11), but to date, occurrence in the community has not been reported. NDM producers were originally detected in the southern and southeastern regions of Brazil and have since moved into the northern states.

Brazil is a country of extremes that has industrialized and nonindustrialized regions, and this situation converges with social, economic, and infrastructure problems (e.g., sanitation and health care public services). This scenario is similar to the initial conditions that contributed to worldwide dissemination of NDM from the Indian subcontinent. Successful and widespread international high-risk clones and epidemic plasmids have been detected in Brazil and could have a critical role in rapid national expansion of NDM-encoding genes and NDM producers. Brazil is under imminent threat of national spread and prevalence of NDM.

Lessons learned from management of KPC-production bacteria will help infection prevention and control teams, clinicians, and microbiology laboratories in Brazil more effectively manage patients with infections caused by NDM producers. Moreover, because of knowledge gained associated with global KPC dissemination, including in Brazil, this country is better prepared to face the other β-lactamases emerging worldwide. Initiatives of regional agencies and the Brazilian Health Surveillance Agency include dissemination of risk alerts to health professionals and guidelines for technical standardization and management of multidrug-resistant bacterial infection. These alerts focus on NDM producers and specific prevention and control measures; therapeutic orientation; and interpretive criteria for the assessment of bacterial antimicrobial drug susceptibility. These efforts are aimed at rapid microbiology detection and clinical and epidemiologic measures to control infections caused by NDM producers and blaNDM dissemination (e.g., using simple tests to detect carbapenemases, searching for colonized patients, and evaluating/monitoring hospital discharge of patients after NDM infection).

Another type of mobilization was promoted during the 27th Brazilian Congress of Microbiology, 29 September–3 October, 2013 in Natal, Brazil, in which a special symposium was dedicated to discussing and improving NDM counterattacks ( http://www.sigeventos.com.br/sbmicrobiologia/admin/pro_lista_programa.asp?eveId=5&tipId=22 [in Portugese]). This symposium gathered a team of experts, including government representatives, to try to minimize the spread and effect of the entry of NDM into Brazil, as well as the future complications and consequences of national dissemination

These efforts are crucial and have strategic significance that affect major events in Brazil, such as the 2014 FIFA World Cup, which brought people from all around the world to all regions of Brazil, and the upcoming Games of the XXXI Olympiad, which will occur in Rio de Janeiro in August 2016. Also of importance to this issue are the geopolitical and economic characteristics of Brazil. Because of Brazil’s global influence related to national and international movement of people and products, broad prevalence of NDM producers in Brazil could contribute to acceleration of the global spread of blaNDM. Microbiologists, clinicians, and their respective organizations, as well as the government of Brazil, through its health and disease control agencies, should continue to strive to contain NDM dispersion and limit the possible global impact of the spread and prevalence of NDM producers in Brazil.

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Acknowledgment

This letter was based on our observations and reflections regarding antibiotic-resistant bacteria during studies supported by funding agencies: research grant 2012/14740-3, São Paulo Research Foundation (FAPESP). L.N. Andrade was supported by a postdoctoral fellowship, grant 2011/08892-2 and grant 2013/26188-6, São Paulo Research Foundation (FAPESP).

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Leonardo Neves AndradeComments to Author  and Ana Lúcia Costa Darini

Author affiliations: Universidade de São Paulo, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Ribeirão Preto, São Paulo, Brazil

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References

  1. Berrazeg  M, Diene  S, Medjahed  L, Parola  P, Drissi  M, Raoult  D, New Delhi metallo-beta-lactamase around the world: an eReview using Google Maps. Euro Surveillance. 2014;19(20). PubMed
  2. Nordmann  P, Poirel  L. The difficult-to-control spread of carbapenemase producers among Enterobacteriaceae worldwide. Clin Microbiol Infect. 2014;20:82130. DOIPubMed
  3. Escobar Pérez  JA, Olarte Escobar  NM, Castro-Cardozo  B, Valderrama Marquez  IA, Garzon Aguilar  MI, Martinez de la Barrera  L, Outbreak of NDM-1-producing Klebsiella pneumoniae in a neonatal unit in Colombia. Antimicrob Agents Chemother. 2013;57:195760. DOIPubMed
  4. Carvalho-Assef  AP, Pereira  PS, Albano  RM, Beriao  GC, Chagas  TP, Timm  LN, Isolation of NDM-producing Providencia rettgeri in Brazil. J Antimicrob Chemother. 2013;68:29567. DOIPubMed
  5. Carvalho-Assef  AP, Pereira  PS, Albano  RM, Beriao  GC, Tavares  CP, Chagas  TP, Detection of NDM-1, CTX-M-15 and qnrB4-producing Enterobacter hormaechei isolates in Brazil. Antimicrob Agents Chemother. 2014;58:24756. DOIPubMed
  6. Rozales  FP, Ribeiro  VB, Magagnin  CM, Pagano  M, Lutz  L, Falci  DR, Emergence of NDM-1-producing Enterobacteriaceae in Porto Alegre, Brazil. Int J Infect Dis. 2014;25:7981. DOIPubMed
  7. Carneiro  M, Goncalves  RA, de Souza  JG, Teixeira  CB, Krummenauer  EC, Machado  JA, New carbapenases in Brazil. Expert Rev Anti Infect Ther. 2014;12:1556. DOIPubMed
  8. Pillonetto  M, Arend  L, Vespero  EC, Pelisson  M, Chagas  TP, Carvalho-Assef  AP, First report of NDM-1–producing Acinetobacter baumannii sequence type 25 in Brazil. Antimicrob Agents Chemother. 2014;58:75924. DOIPubMed
  9. Pereira  PS, Borghi  M, Albano  RM, Lopes  JC, Silveira  MC, Marques  ED, Coproduction of NDM-1 and KPC-2 in Enterobacter hormaechei from Brazil. Microb Drug Resist. 2015;21:2346 .DOIPubMed
  10. Quiles  MG, Rocchetti  TT, Fehlberg  LC, Kusano  EJU, Chebabo  A, Pereira  RMG, Unusual association of NDM-1 with KPC-2 and armA among Brazilian Enterobacteriaceae isolates. Braz J Med Biol Res. 2015;48:1747. DOIPubMed
  11. Zavascki  AP, Falci  DR, da Silva  RC, Dalarosa  MG, Ribeiro  VB, Rozales  FP, Heteroresistance to carbapenems in New Delhi metallo-beta-lactamase-1-producing isolates: a challenge for detection? Infect Control Hosp Epidemiol. 2014;35:7512. DOIPubMed

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Cite This Article

DOI: 10.3201/eid2106.140113

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Table of Contents – Volume 21, Number 6—June 2015

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Please use the form below to submit correspondence to the authors or contact them at the following address:

Leonardo Neves Andrade, Universidade de São Paulo, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Departamento de Análises Clínicas, Toxicológicas e Bromatológicas,
Av. do Café, s/nº, Campus Universitário Bloco N–Sala 18A, Ribeirão Preto, SP, 14040-903
Brazil

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Page created: May 18, 2015
Page updated: May 18, 2015
Page reviewed: May 18, 2015
The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.
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