Carbapenem-resistant _{CTX-M-type}, _{CTX-M-1}, _{CTX-M-9}, and the genes _{SHV}, _{TEM}, _{KPC-2}, _{NDM-1}, _{OXA-48}, _{IMP}, and _{VIM-1} was detected with the PCR method. Clonality was evaluated by Multi Locus Sequence Typing (MLST) and Pulsed Field Gel Electrophoresis (PFGE). Six (40%) strains were of XDR (Extensively Drug-Resistant) phenotype, and nine (60%) of the isolates exhibited MDR (Multidrug-Resistant) phenotype. The range of carbapenem minimal inhibitory concentrations (MICs, μg/mL) was as follows doripenem (16 to >32), ertapenem (> 32), imipenem (4 to > 32), and meropenem (> 32). PCR and sequencing confirmed the _{CTX-M-15}, _{KPC-2}, _{OXA-48}, and _{VIM-1} genes in all strains. The isolates formed one large PFGE cluster (clone A). MLST assigned them to the emerging high-risk clone of ST147 (CC147) pandemic lineage harboring the _{OXA-48} gene. This study showed that the

#### Keywords

- clonal dissemination
- carbapenem-resistant
- hospital
- PFGE
- MLST

With the ever-growing antibiotic resistance,

Currently, the spread of carbapenem-resistant

Frequently, carbapenems serve as the last resort in the effective treatment of serious infections caused by multidrug-resistant bacteria. Enzymes that hydrolyze carbapenems, called carbapenemases, are the major cause of carbapenem resistance (Matsumura et al. 2017). The molecular classes A, B, and D carbapenemases are rapidly disseminated worldwide, challenging the treatment of Gram-negative infections (Nordmann and Poirel 2014). Recent reports have demonstrated that various carbapenem-hydrolyzing enzymes are disseminated worldwide in CRKP isolates. The fast evolution of carbapenem resistance quickly evolved in

The majority of KPC-producing microorganisms also express β-lactamases and possess genes conferring resistance to other antimicrobials, i.e. aminoglycosides, fluoroquinolones, or co-trimoxazole (Nordmann and Poirel 2014). The resistance rates vary significantly across countries; MDR

In 2011, the National Reference Center for Susceptibility Testing (NRCTS) and the KPC-PL Study Group published the first report from Poland that presented the molecular characteristics of

Given the abovementioned data and the increased frequency of isolation of CRKP strains from the hospital environment, we conducted a microbiological and molecular characterization of carbapenem-resistant

Demographic data and characteristics of the fourteen patients with

Patient ID/Isolate no. | Age (years)/sex | Hospital ward(s) | Date of isolation | Type of specimen | Status (type) of colonization/infection | Duration of hospitalization (days) | Underlying conditions | Antimicrobial used prior to isolation of carbapenemase producer(s) | Antimicrobial used as treatment for infections | Outcome Alive/Dead |
---|---|---|---|---|---|---|---|---|---|---|

3 | 74/M | OAIT | 08/03/2018 | Rectal swab | Colonization | 03/01-14/04/2018 (102 days) | Abdominal Aortic Aneurysm (AAA) | Ciprofloxacin + Gentamycin + Itraconazole | Metronidazole | Dead |

6965 | 60/F | OAIT | 28/02/2018 | Rectal swab | Colonization | 08/02-01/04/2018 (53 days) | Tuberculosis, Chronic Obstructive Pulmonary Disease (COPD) | Colistin + Voriconazole | – | Dead |

6976/1 | 45/M | OAIT | 01/03/2018 | Rectal swab | Colonization | 21/02-29/03/2018 (37 days) | Guillain-Barré Syndrome (GBS) | Colistin + Linezolid | Ampicillin/sulbactam + Amikacin | Alive |

1 | 67/F | OAIT | 07/03/2018 | Rectal swab | Colonization | 02/03-29/06/2018 (112 days) | COPD, diabetes, hypertension | Ceftriaxone + Levofloxacin | – | Dead |

6968 (index case) | 63/M | NR | 28/02/2018 | Rectal swab | Colonization | 16/02-31/03/2018 (44 days) | Hypertension, atherosclerosis | Ceftriaxone + Metronidazole | – | Alive |

2 | 69/M | NR | 07/03/2018 | Rectal swab | Colonization | 23/02-28/03/2018 (34 days) | Post-stroke conditions | – | – | Alive |

4 | 43/M | NR | 08/03/2018 | Rectal swab | Colonization | 26/02-12/03/2018 (15 days) | Hypertension | Ceftriaxone + Metronidazole | – | Dead |

154/25428 | 61/M | NR | 30/07/2018 | Rectal swab | Colonization | 04/07-06/08/2018 (34 days) | Stroke | – | – | Dead |

7/25804 | 70/M | NR | 04/08/2018 | Rectal swab | Colonization | 25/07-02/08/2018 (9 days) | Stroke | Amoxicillin/clavulanic acid | – | Alive |

11/25808 | 50/F | NR | 04/08/2018 | Rectal swab | Colonization | 23/07-03/08/2018 (12 days) | Stroke | – | – | Alive |

13/25810 | 77/M | NR | 04/08/2018 | Rectal swab | Colonization | 22/07-09/08/2018 (19 days) | Hypertension, ischemic heart disease | Amoxicillin/clavulanic acid | – | Alive |

6 | 70/F | REU | 09/03/2018 | Rectal swab | Colonization | 26/02-14/03/2018 (17 days) | Diabetes, metastatic lung cancer | – | – | Alive |

7 | 78/F | REU | 09/03/2018 | Rectal swab | Colonization | 27/02-16/03/2018(18 days) | Rheumatoid Arthritis (RA), hemorrhagic diathesis, coronary disease, peptic ulcer disease, hypertension, atherosclerosis, gout | Imipenem | Vancomycin | Alive |

5 | 90/F | REU | 08/03/2018 | Rectal swab | Colonization | 03.03-17.03.2018 (14 days) | Atherosclerosis, acute arterial thrombosis of the lower extremity | Meropenem + Amikacin | – | Alive |

_{SHV} and _{TEM}. CTX-Mplex PCR was used to detect _{CTX-M-type}, _{CTX-M-1}, and _{CTX-M-9} (Xu et al. 2005).

_{KPC-2}, _{NDM-1}, _{OXA-48}, _{IMP}, and _{VIM-1}) was confirmed using the PCR method (Bukavaz et al. 2018).

^{®} BAA664™) and ^{®} BAA-1705™ were used as reference markers. PFGE banding patterns were compared using BioNumerics v.6.5 (Applied Maths, Belgium) software. The relatedness was determined by the unweighted pair group method using the average linkages (UPGMA), and the similarity of bands was calculated using the Dice coefficient.

Antimicrobial resistance profiles of the studied

Patient ID/Isolate no. | 3 | 6965 | 6976/1 | 6976/2 | 1 | 6968 | 2 | 4 | 154/25428 | 7/25804 | 11/25808 | 13/25810 | 6 | 7 | 5 | ||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

Antibiotics: | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | |

Penicillins | Amoxicillin/Clavulanic acid | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R |

Ampicillin | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | |

Cephalosporins | Cefaclor | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R |

Cefuroxime | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | |

Cefotaxime | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | |

Cefotaxime/Cefotaxime + clavulanic acid | >16/>1 | R | >16/>1 | R | >16/>1 | R | >16/>1 | R | >16/>1 | R | >16/>1 | R | >16/>1 | R | >16/>1 | R | >16/>1 | R | >16/>1 | R | >16/>1 | R | >16/>1 | R | >16/>1 | R | >16/>1 | R | >16/>1 | R | |

Ceftazidime | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | |

Ceftazidime/Ceftazidime + clavulanic acid | >34/>4 | R | >34/>4 | R | >34/>4 | R | >34/>4 | R | >34/>4 | R | >34/>4 | R | 34/>4 | R | >34/>4 | R | >34/>4 | R | >34/>4 | R | >34/>4 | R | >34/>4 | R | >34/>4 | R | >34/>4 | R | >34/>4 | R | |

Cefepime | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | |

Carbapenems | Doripenem | >32 | R | 16 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R |

Ertapenem | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | |

Imipenem | >32 | R | >32 | R | 16 | R | 16 | R | >32 | R | >32 | R | >32 | R | >32 | R | >12 | R | 4 | S | 4 | S | 8 | I | >32 | R | >32 | R | >32 | R | |

Meropenem | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | |

Quinolone | Ciprofloxacin | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R |

Aminoglycosides | Amikacin | 4 | S | 8 | S | 32 | R | 32 | R | 8 | S | 12 | R | 6 | S | 4 | S | 8 | S | 8 | S | 8 | S | 8 | S | 12 | R | 6 | S | 6 | S |

Gentamycin | 64 | R | 64 | R | 64 | R | 64 | R | 64 | R | 64 | R | 64 | R | 64 | R | 64 | R | 64 | R | 64 | R | 64 | R | 64 | R | 64 | R | 64 | R | |

Netylmycin | 128 | R | 4 | I | 64 | R | 64 | R | 128 | R | 32 | R | 16 | R | 16 | R | 12 | R | 16 | R | 16 | R | 16 | R | 32 | R | 16 | R | 16 | R | |

Tobramycin | 64 | R | 64 | R | 32 | R | 32 | R | 64 | R | 64 | R | 64 | R | 64 | R | 32 | R | 64 | R | 64 | R | 64 | R | 64 | R | 64 | R | 64 | R | |

Other | Aztreonam | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R |

Colistin | 0.50 | S | 0.75 | S | 0.125 | S | 0.125 | S | 0.50 | S | 0.50 | S | 0.50 | S | 0.50 | S | 0.50 | S | 0.50 | S | 0.75 | S | 0.50 | S | 0.50 | S | 0.50 | S | 0.50 | S | |

Tetracycline | 32 | R | 128 | R | 8 | R | 8 | R | 32 | R | 32 | R | 32 | R | 8 | R | >256 | R | >256 | R | >256 | R | >256 | R | 8 | R | 8 | R | 128 | R | |

Tigecycline | 2 | R | 8 | R | 4 | R | 4 | R | 2 | R | 2 | R | 2 | R | 4 | R | 0.75 | R | 0.75 | R | 1.0 | R | 2 | R | 4 | R | 4 | R | 8 | R | |

Trimethoprim/Sulfamethoxazole | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | |

Fosfomycin | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | R>256 | R | >256 | R | >256 | R | >256 | R | >256 | R |

_{KPC-2}, _{OXA-48}, _{VIM-1} in all 15 of the _{CTX-M} variant

in all 15 strains was _{CTX-M-15}. The results are presented in Fig. 2. No isolate was found to be positive for _{SHV}, _{TEM}, _{NDM-1}, and _{IMP}.

Moreover, an MLST analysis allowed us to classify all isolates as the sequence type ST147 (allelic profile: 3-4-6-1-7-4-38) belonging to the CC147 clonal complex. It confirmed clonal relationships between the isolates.

The presented work stems from the problem of clonal dissemination of KPC-2, VIM-1, and OXA-48-producing

This study’s subject was a particular group of microorganisms classified as bacterial alarm agents (BCA) of particular virulence or resistance, i.e., carbapenemase-producing _{KPC}) are located on the Tn4401 transposon located on plasmids with different types of replicons (IncF, IncL/M, ColE1, IncR, and IncX3). These plasmids show the ability to conjugate and propagate the _{KPC} genes to new bacterial populations (Baraniak et al. 2011).

On the other hand, the most important families of the MBL acquired are the enzymes IMP and VIM occurring both in non-fermenting and intestinal bacilli. The _{IMP} and _{VIM} genes always exist as cassettes inserted into integrons. In turn, integrons can be located on transposons and move with them between DNA molecules (Izdebski et al. 2018b). ESβL enzymes exist mainly as acquired, plasmid-encoded β-lactamases. ESβL-encoding genes are often located on conjugation plasmids (IncFII, IncI), including those with a broad host range (IncA/C, IncL/M). It allows them to spread rapidly, also between strains belonging to different species. Frequently noted are encoded by _{CTX-M} genes ESβL enzymes, active against cefotaxime CTX-M and localized on plasmids in

The isolates’ antibiotic susceptibility testing confirmed the β-lactamase antibiotics resistance profile typical for carbapenemase producers, as presented elsewhere (Zacharczuk et al. 2011; Guo et al. 2016; Izdebski et al. 2018a). All strains expressed high-level resistance to doripenem, ertapenem, meropenem, although they showed varying levels of resistance to imipenem. Ertapenem is the carbapenem that has been suggested as most suitable for detecting the presence of _{KPC}, which was confirmed by high MIC values for ertapenem (> 32 μg/ml) in the present study. The presence of KPC does not always result in expression of _{KPC-2} gene in all three isolates. Imipenem and meropenem resistance of other strains might have resulted from decreased outer membrane permeability or other β-lactamases providing a synergistic effect with KPC (Protonotariou et al. 2018). The strains’ resistance to third-generation cephalosporins confirmed this hypothesis similarly to the various β-lactamases production by

The _{KPC-2}, _{OXA-48}, and _{VIM-1} carbapenemase encoding genes and an additional _{CTX-M-15} cefotaximase encoding genes have been found to coexist in all the strains concerned. Lee et al. (2016) found that _{VIM} genes. The VIM-producing

The strains containing OXA-48 β-lactamases provide another example of rapid immigration of harmful microorganisms to Europe from their endemic regions, mostly eastern and southern Mediterranean countries (Egypt, Morocco, and Turkey). OXA-48-like-positive strains cause hospital outbreaks of epidemics in Belgium, France, Netherlands, Germany, Spain, and other countries (Nordmann and Poirel 2014; Grundmann et al. 2017). In the most recent report developed by OXA-48-PL Study Group monitoring the

The high MIC values (> 256 μg/ml) for cefotaxime may suggest that the strains produced CTX-M β-lactamases. Multiplex PCR and sequencing have confirmed _{CTX-M-15} presence in all isolates. The presence of various CTX-M β-lactamases in _{SHV} or _{TEM} have been identified among the isolates. These results are in line with the persisting trend of diminished prevalence of hospital-associated _{CTX-M-type} ESβLs, consequently resulting in the predominance of CTX-M-producing strains (Calbo and Garau 2015).

Among non-β-lactam antibiotics, colistin has shown the highest activity towards the strains concerned. Similar results have been published by other authors (Zacharczuk et al. 2011). Among aminoglycosides, amikacin showed the highest activity. The vast majority of strains (92.8%) were susceptible to amikacin, unlike in China, where total

The present analysis has shown a relatively high percentage of isolates resistant to tigecycline (42.8%), a synthetic minocycline analogue with a broad spectrum of activity. The antibiotic is successfully applied to treat infections caused by multi-resistant bacterial strains, including

Genetic similarity of CRKP isolates was determined by comparing PFGE profiles (Han et al. 2013). This method has been widely used by European and non-European research teams that study epidemic outbreaks of

Because of the clonal nature of the isolates studied, the clinical data about their origin was reviewed to examine whether the same clonal type was circulating in the three various hospital wards. The study focused mainly on stroke patients or patients suffering from cardiovascular complications who were transferred to multiple-bed hospital rooms in Stroke Recovery Units, which were the only places where they were in touch. Moreover, it is plausible that the neurology ward played a major role in disseminating the bacteria throughout the hospital. The spread of the pathogen isolates across three different hospital wards could imply that the personnel who can access all hospital wards freely, unlike the patients and their relatives, might have transmitted the infections. Scientific literature emphasizes the role of hospitalization (and its duration) in the process of bacterial colonization. The frequency of gastrointestinal colonization with

#### Antimicrobial resistance profiles of the studied K. pneumoniae isolates.

Patient ID/Isolate no. | 3 | 6965 | 6976/1 | 6976/2 | 1 | 6968 | 2 | 4 | 154/25428 | 7/25804 | 11/25808 | 13/25810 | 6 | 7 | 5 | ||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

Antibiotics: | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | MIC (pg/ml) | R/I/S | |

Penicillins | Amoxicillin/Clavulanic acid | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R |

Ampicillin | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | |

Cephalosporins | Cefaclor | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R |

Cefuroxime | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | |

Cefotaxime | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | |

Cefotaxime/Cefotaxime + clavulanic acid | >16/>1 | R | >16/>1 | R | >16/>1 | R | >16/>1 | R | >16/>1 | R | >16/>1 | R | >16/>1 | R | >16/>1 | R | >16/>1 | R | >16/>1 | R | >16/>1 | R | >16/>1 | R | >16/>1 | R | >16/>1 | R | >16/>1 | R | |

Ceftazidime | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | |

Ceftazidime/Ceftazidime + clavulanic acid | >34/>4 | R | >34/>4 | R | >34/>4 | R | >34/>4 | R | >34/>4 | R | >34/>4 | R | 34/>4 | R | >34/>4 | R | >34/>4 | R | >34/>4 | R | >34/>4 | R | >34/>4 | R | >34/>4 | R | >34/>4 | R | >34/>4 | R | |

Cefepime | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | |

Carbapenems | Doripenem | >32 | R | 16 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R |

Ertapenem | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | |

Imipenem | >32 | R | >32 | R | 16 | R | 16 | R | >32 | R | >32 | R | >32 | R | >32 | R | >12 | R | 4 | S | 4 | S | 8 | I | >32 | R | >32 | R | >32 | R | |

Meropenem | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | |

Quinolone | Ciprofloxacin | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R |

Aminoglycosides | Amikacin | 4 | S | 8 | S | 32 | R | 32 | R | 8 | S | 12 | R | 6 | S | 4 | S | 8 | S | 8 | S | 8 | S | 8 | S | 12 | R | 6 | S | 6 | S |

Gentamycin | 64 | R | 64 | R | 64 | R | 64 | R | 64 | R | 64 | R | 64 | R | 64 | R | 64 | R | 64 | R | 64 | R | 64 | R | 64 | R | 64 | R | 64 | R | |

Netylmycin | 128 | R | 4 | I | 64 | R | 64 | R | 128 | R | 32 | R | 16 | R | 16 | R | 12 | R | 16 | R | 16 | R | 16 | R | 32 | R | 16 | R | 16 | R | |

Tobramycin | 64 | R | 64 | R | 32 | R | 32 | R | 64 | R | 64 | R | 64 | R | 64 | R | 32 | R | 64 | R | 64 | R | 64 | R | 64 | R | 64 | R | 64 | R | |

Other | Aztreonam | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R |

Colistin | 0.50 | S | 0.75 | S | 0.125 | S | 0.125 | S | 0.50 | S | 0.50 | S | 0.50 | S | 0.50 | S | 0.50 | S | 0.50 | S | 0.75 | S | 0.50 | S | 0.50 | S | 0.50 | S | 0.50 | S | |

Tetracycline | 32 | R | 128 | R | 8 | R | 8 | R | 32 | R | 32 | R | 32 | R | 8 | R | >256 | R | >256 | R | >256 | R | >256 | R | 8 | R | 8 | R | 128 | R | |

Tigecycline | 2 | R | 8 | R | 4 | R | 4 | R | 2 | R | 2 | R | 2 | R | 4 | R | 0.75 | R | 0.75 | R | 1.0 | R | 2 | R | 4 | R | 4 | R | 8 | R | |

Trimethoprim/Sulfamethoxazole | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | >32 | R | |

Fosfomycin | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | >256 | R | R>256 | R | >256 | R | >256 | R | >256 | R | >256 | R |

#### Demographic data and characteristics of the fourteen patients with K. pneumoniae co-producing KPC-2, OXA-48, VIM-1 and CTX-M-15 during the outbreak.

Patient ID/Isolate no. | Age (years)/sex | Hospital ward(s) | Date of isolation | Type of specimen | Status (type) of colonization/infection | Duration of hospitalization (days) | Underlying conditions | Antimicrobial used prior to isolation of carbapenemase producer(s) | Antimicrobial used as treatment for infections | Outcome Alive/Dead |
---|---|---|---|---|---|---|---|---|---|---|

3 | 74/M | OAIT | 08/03/2018 | Rectal swab | Colonization | 03/01-14/04/2018 (102 days) | Abdominal Aortic Aneurysm (AAA) | Ciprofloxacin + Gentamycin + Itraconazole | Metronidazole | Dead |

6965 | 60/F | OAIT | 28/02/2018 | Rectal swab | Colonization | 08/02-01/04/2018 (53 days) | Tuberculosis, Chronic Obstructive Pulmonary Disease (COPD) | Colistin + Voriconazole | – | Dead |

6976/1 | 45/M | OAIT | 01/03/2018 | Rectal swab | Colonization | 21/02-29/03/2018 (37 days) | Guillain-Barré Syndrome (GBS) | Colistin + Linezolid | Ampicillin/sulbactam + Amikacin | Alive |

1 | 67/F | OAIT | 07/03/2018 | Rectal swab | Colonization | 02/03-29/06/2018 (112 days) | COPD, diabetes, hypertension | Ceftriaxone + Levofloxacin | – | Dead |

6968 (index case) | 63/M | NR | 28/02/2018 | Rectal swab | Colonization | 16/02-31/03/2018 (44 days) | Hypertension, atherosclerosis | Ceftriaxone + Metronidazole | – | Alive |

2 | 69/M | NR | 07/03/2018 | Rectal swab | Colonization | 23/02-28/03/2018 (34 days) | Post-stroke conditions | – | – | Alive |

4 | 43/M | NR | 08/03/2018 | Rectal swab | Colonization | 26/02-12/03/2018 (15 days) | Hypertension | Ceftriaxone + Metronidazole | – | Dead |

154/25428 | 61/M | NR | 30/07/2018 | Rectal swab | Colonization | 04/07-06/08/2018 (34 days) | Stroke | – | – | Dead |

7/25804 | 70/M | NR | 04/08/2018 | Rectal swab | Colonization | 25/07-02/08/2018 (9 days) | Stroke | Amoxicillin/clavulanic acid | – | Alive |

11/25808 | 50/F | NR | 04/08/2018 | Rectal swab | Colonization | 23/07-03/08/2018 (12 days) | Stroke | – | – | Alive |

13/25810 | 77/M | NR | 04/08/2018 | Rectal swab | Colonization | 22/07-09/08/2018 (19 days) | Hypertension, ischemic heart disease | Amoxicillin/clavulanic acid | – | Alive |

6 | 70/F | REU | 09/03/2018 | Rectal swab | Colonization | 26/02-14/03/2018 (17 days) | Diabetes, metastatic lung cancer | – | – | Alive |

7 | 78/F | REU | 09/03/2018 | Rectal swab | Colonization | 27/02-16/03/2018(18 days) | Rheumatoid Arthritis (RA), hemorrhagic diathesis, coronary disease, peptic ulcer disease, hypertension, atherosclerosis, gout | Imipenem | Vancomycin | Alive |

5 | 90/F | REU | 08/03/2018 | Rectal swab | Colonization | 03.03-17.03.2018 (14 days) | Atherosclerosis, acute arterial thrombosis of the lower extremity | Meropenem + Amikacin | – | Alive |

_{KPC-2} and _{OXA-48} producing

_{K})

_{CTX-M} genes by multiplex PCR assay