Table 3.
Clinical Characteristics and Outcomes, Microbiology, and Strain Data for Initial Infections Caused by Multidrug-Resistant Enterobacterales
| Patient | MDR-E GI Colonization | MDR-E Infection | MDR-E Isolate(s) | Genetic Relationship (Colonizing vs Infecting Strains) | Recurrence(s) | Outcome |
|---|---|---|---|---|---|---|
| CR-001 | Yes | Urinary tract infection | CR-Klebsiella oxytoca | Colonizing (n = 2) vs infecting (n = 1) strains | No | Alive at 5.8 years after transplant |
| KPC-3 | 6 SNP | |||||
| CR-035 | Yes | Pneumonia | CR-Klebsiella pneumoniae | Colonizing (n = 1) vs infecting (n = 1) strains | Late recurrence | Alive at 5.5 years after transplant |
| CG258 | 3 SNP | |||||
| KPC-3 | ||||||
| CR-038 | Yes | Pneumonia | CR-K. pneumoniae | Colonizing (n = 2) vs infecting (n = 4) strains | Multiple early and late recurrences | Alive at 5.5 years after transplant |
| CG258 | 3 SNP (2–7) | |||||
| KPC-3 | ||||||
| CR-041 | Yes | Peritonitis | CR-K. oxytoca | Colonizing (n = 1) vs infecting (n = 2) strains | No | Alive at 5.4 years after transplant |
| KPC-3 | 5 SNP (3–8) | |||||
| CR-048 | Yes | Pneumonia and empyema | CR-K. pneumoniae | Colonizing (n = 4) vs infecting (n = 2) strains | Late recurrence | Died 3.9 years after initial infections (died from recurrent KPC-K. pneumoniae infection) |
| CG258 | 4 SNP (2–6) | |||||
| KPC-3 | ||||||
| CR-096 | No | Pneumonia | CR-K. pneumoniae | No GI colonization | Early recurrence | Died 75 days after initial infection (died from recurrent CR-K. pneumoniae infection)a |
| CG258 | Initial (n = 2) vs recurrent infecting (n = 1) strains | |||||
| KPC-3 | 8 SNP (2–8) | |||||
| CR-145 | Yes | Chest wall infection | CR-K. quasi-pneumoniae | N/A (colonizing isolate not available for whole-genome sequencing) | No | Alive at 4.7 years after transplant |
| ST1224 | ||||||
| DHA-1 | ||||||
| CR-148 | No | Pneumonia | CR-K. pneumoniae | N/A | No | Alive at 4.7 years after transplant |
| CG258 | ||||||
| KPC-3 | ||||||
| CR-192 | Yes | Tracheo-bronchitis then pneumonia | CR-K. pneumoniae | Colonizing (n = 1) vs infecting (n = 2: 1 initial and 1 early recurrent) strains | Early and multiple late recurrences | Alive at 4.2 years after transplant |
| CG258 | 1 SNP (0–1) | |||||
| KPC-3 | ||||||
| CR-214 | Yes | Pneumonia | CR-K. pneumoniae | Colonizing (n = 1) vs infecting (n = 1) strains | No | Alive at 3.9 years after transplant |
| CG258 | 1 SNP | |||||
| KPC-8 | ||||||
| CR-047b | Yes | Urinary tract infection (CefR-E) and bacteremia CRE)c | Urine: CefR-E. cloacae | Colonizing (n = 1) vs infecting (n = 2) strains | Late recurrence | Alive at 5.4 years after transplant |
| Pre-transplant infection | CTX-M-15 and ACT-16 | 16 SNP (13–20) | ||||
| CefR-Enterobacter cloacae | Blood: CR-E. cloacae | |||||
| CTX-M-15 and ACT-16 | ||||||
| CR-186c | Yes | Bacteremia | CefR-K. pneumoniae | Colonizing (n = 2) vs infecting (n = 4: 1 initial and 3 early recurrent) strains | Early recurrence | Alive at 4.3 years after transplant |
| ST-38 | 2 SNP (0–6) | |||||
| Extended-spectrum β-lactamases -SHV | ||||||
| CR-183 | Yes | Pneumonia | CefR-K. oxytoca | Colonizing (n = 1) vs infecting (n = 1) strains | Early recurrence | Alive at 4.3 years after transplant |
| CTX-M | 14 SNP | |||||
| CR-070 | Nod | Pyelonephritis | CefR- Escherichia coli | Pre-transplant (n = 1) and post-transplant strains (n = 1) | Late recurrence | Alive at 5.2 years after transplant |
| CTX-M-15 | 3 SNP | |||||
| CR-128 | No | Intraabdominal abscess | CefR-E. coli | N/A | Died | Died from persistent infection (7 days after diagnosis) |
| CXT-M | ||||||
| CR-123 | Yes | UTI | CefR-K. pneumonia | Colonizing (n = 1) and infecting (n = 1) strains | No | Alive at 4.9 years after transplant |
| ST11 | 3 SNP | |||||
| CTX-M-14 | ||||||
| CR-013 | Yes | UTI | CefR-K. oxytoca | Colonizing (n = 2) vs infecting strains (n = 1) | Early recurrent infection | Alive at 5.6 years after transplant |
| DHA-1, OXY2-5, CTX-M-27 | 16 SNP (3–19) |
Definitions: early recurrence: culture positivity for the same CRE or CefR-E within 90 days of the initial clinical culture; late recurrence: culture positivity for the same CRE or CefR-E >90 days of the initial culture; duration of GI colonization: if a patient had ≥2 CefR-E or CRE GI colonization at 2 consecutive weeks immediately before discharge, the duration of GI colonization is denoted as greater than or equal to the number of days from the first date to the last date of GI colonization.
Abbreviations: CefR-E, third-generation cephalosporin-resistant Enterobacterales; CG, core group; cg, core genome; CR, carbapenem-resistance; CRE, carbapenem-resistant Enterobacterales; GI, gastrointestinal; KPC, Klebsiella pneumoniae carbapenemases; MDR-E, multidrug-resistant Enterobacterales; N/A, not applicable; SNP, single-nucleotide polymorphism; ST, strain type; UTI, urinary tract infection.
aThis patient (CR-096) died from septic shock; blood and lung cultures performed at autopsy grew CR-K. pneumoniae, and there was evidence of bowel necrosis with transmural gram-negative rod infiltration of the bowel wall.
bCR-047 was GI colonized with CefR-E. cloacae complex then developed E. cloacae urosepsis; the urine isolate was CefR, but the blood isolate was CR. Whole-genome sequencing (WGS) showed that CefR and CE-Enterobacter cloacae complex shared blaACT and CTX-M-15. Mechanism of CR is unclear from WGS data.
cCR-186 was GI colonized with CefR-K. pneumoniae 8 days after solid organ transplantation then with CR-K. pneumoniae 7 days later. She developed CefR-K. pneumoniae intraabdominal infection and bacteremia that was treated with drainage and meropenem. Twenty-six days after the initial infection (11 days after CR-K. pneumoniae GI colonization), she developed recurrent a intraabdominal abscess due to CR-K. pneumoniae; the second isolate acquired a new truncation of porin OmpK36.
dCR-070 had UTI and bacteremia due to CefR-E. coli 23 days before transplant.