blaCTX-M-27–Encoding Escherichia coli Sequence Type 131 Lineage C1-M27 Clone in Clinical Isolates, Germany

We examined extended-spectrum β-lactamase–producing isolates from livestock, humans, companion animals, food, and the environment during 2009–2016 in Germany for the presence of CTX-M-27 allele within Escherichia coli sequence type (ST) 131. E. coli ST131 C1-M27 was exclusively present in humans; its incidence increased from 0% in 2009 to 45% in 2016.

We examined extended-spectrum β-lactamase-producing isolates from livestock, humans, companion animals, food, and the environment during 2009-2016 in Germany for the presence of CTX-M-27 allele within Escherichia coli sequence type (ST) 131. E. coli ST131 C1-M27 was exclusively present in humans; its incidence increased from 0% in 2009 to 45% in 2016.
D uring the past 20 years, Escherichia coli sequence type (ST) 131 has emerged as a prevalent vehicle for extended-spectrum β-lactamases (ESBL) worldwide. Particularly prevalent are isolates of the clade ST131 C/ H30R, which frequently are associated with urinary tract infections and bacteremia (1,2). Although the ESBL production of the predominant subgroup ST131 C2/H30Rx is conferred by the CTX-M-15 allele, the emerging subgroup C1 often is associated with other CTX-M alleles, such as CTX-M-14 and CTX-M-27 (3). An increase in C1/H30R ST131 isolates was initially reported among clinical isolates in Japan; most of those were identified as members of the recently defined clade C1-M27 (90% of C1/H30R) (3). More recently, a dramatic rise from 0% to 65% in the incidence of ST131 C1/H30R bla CTX-M-27 isolates in the fecal carriage of children in France during 2010-2015 was reported (4). In addition, ST131 isolates harboring bla CTX-M-27 have been reported sporadically from other countries (3). We examined ESBL-producing isolates from livestock, humans, companion animals, food, and the environment during 2009-2016 in Germany for the CTX-M-27 allele.
We analyzed a representative subset of 953 sequenced isolates from a collection of 4,386 nonrepetitive ESBL-producing E. coli, which were obtained through 2 national research networks investigating the incidence of antimicrobial resistance: ESBL and Fluoroquinolone Resistance in Enterobacteriaceae (RESET) and German Center for Infection Research (DZIF) in Germany (online Technical Appendix 1, https:// wwwnc.cdc.gov/EID/article/23/10/17-0938-Techapp1.xlsx). In silico multilocus sequence typing (MLST) identified 159 (17%) of the 953 isolates as ST131 (online Technical Appendix 2, https://wwwnc.cdc.gov/EID/article/23/10/17-0938-Techapp2.pdf). The most prevalent ESBL genes in the studied isolates were bla CTX Because recent reports have documented an increase in the number of C1-M27 clade isolates in Japan and France, we investigated bla CTX-M-27 -encoding ST131 isolates in more detail. All ST131 isolates with bla CTX-M-27 were of serogroup O25b and harbored a fimH30 allele, except for 1 isolate that was of serogroup O16 and carried a fimH41 allele. Recently, the M27PP1 prophage-like region was defined as a specific marker for C1-M27 clade (3,4). This region was present in 23 of 24 bla CTX-M-27 -harboring isolates. Phylogenomic analysis revealed that these 23 isolates belong to clade C1/ H30R (online Technical Appendix 2 Figure).
Core genome phylogenetic comparisons of all C/H30R ST131 isolates, based on alignment to the closed genome of E. coli ST131 lineage C1-M27 isolate H105, revealed an average of 292 single-nucleotide polymorphisms (SNPs). In contrast, isolates within the C1-M27 clade were separated by <100 SNPs. Comparative analyses of 13 isolates reported from Japan showed that these isolates share ≈85% of the genome with those from Germany. Isolates from both countries exhibit an average difference of 59 SNPs, indicating clonality and possible evolution from a single common ancestor (online Technical Appendix 2). Metadata of the C1-M27 isolates showed 19 of 24 isolates were obtained in 2015 and 2016, indicating recent emergence.
Our results provide evidence for the recent emergence of ST131 subgroup fimH30-O25b, clade C1-M27, harboring bla CTX-M-27 , in Germany and reinforce observations made elsewhere. The data suggest an ongoing shift in CTX-M alleles associated with ST131 infections worldwide that now warrants further attention.
Angiostrongylus cantonensis, the rat lungworm, is the most common infectious cause of eosinophilic meningoencephalitis worldwide. This parasite is endemic to Southeast Asia and the Pacific Islands, and its global distribution is increasing. We report A. cantonensis meningoencephalitis in a 12-monthold boy in Tennessee, USA, who had not traveled outside of southwestern Tennessee or northwestern Mississippi. I n 2016, a 12-month-old, fully vaccinated boy was admitted to a hospital in Memphis, Tennessee, USA, for evaluation of 18 days of daily fever, irritability, decreased oral intake, and emesis. His medical history was unremarkable, and he had no known contact with sick persons. He had not traveled outside the area comprising southwestern Tennessee and northwestern Mississippi. He lived in a nonagricultural rural area and was exposed to a vaccinated family dog. Wild rats had been observed in and around the home, and rat droppings had been found in the child's bed. Raccoons were seen on the property; however, contact, either direct or through fomites such as latrines, was not reported. During a 17-day period, 2 evaluations by his primary care physician and 4 emergency department visits resulted in the diagnosis of fever of unknown origin and inpatient admission.
A cerebrospinal fluid (CSF) sample taken by lumbar puncture on day 20 of illness showed eosinophil-predominant pleocytosis, mild hypoglycorrhacia, and a mildly elevated protein level (Table). Magnetic resonance imaging of the brain and spine showed scattered areas of restricted diffusion throughout the brain parenchyma, leptomeningeal enhancement, and multifocal nodular enhancement along the ventral portion of multiple spinal levels. Serologic testing was negative for Toxocara canis/cati, Strongyloides stercoralis, Ehrlichia chaffeenis, Rickettsia rickettsiae, Epstein-Barr virus, HIV, and Toxoplasma gondii; a rapid plasma reagin was also negative. Tuberculin skin testing was negative. Results of CSF PCR for Streptococcus pneumoniae, herpes simplex virus, and enteroviruses were negative; CSF cryptococcal antigen testing was also negative. Due to concern for infection with Baylisascaris procyonis, the raccoon roundworm, physicians prescribed albendazole and dexamethasone. The patient's temperature returned to normal, and his symptoms resolved. Upon discharge, he was to complete 3 weeks of albendazole and tapering doses of corticosteroids. Attending physicians repeated lumbar punctures on days 28, 41, and 56 (Table).
Physicians sent samples (CSF and serum) taken on day 20 to the Centers for Disease Control and Prevention (Atlanta, GA, USA) to test for B. procyonis roundworms and samples taken on day 56 to test for Angiostrongylus cantonensis, the rat lungworm. Results were negative for B. procyonis but positive for A. cantonensis. In addition, serum samples obtained at the time of the initial lumbar puncture were positive for A. cantonensis antibodies by investigational whole-worm Western blot.
The first documented human infection with A. cantonensis worms occurred in 1944 in Taiwan. Since then, >2,800 cases among humans have been reported; most have been in Southeast Asia and the Pacific islands (1; online Technical Appendix, https://wwwn.cdc.gov/EID/ article/23/10/17-0978-Techapp1.pdf). In the late 1950s, the first report of human A. cantonensis infection in the