Nosocomial bloodstream infection and the emerging carbapenem-resistant pathogen Ralstonia insidiosa

Abstract

Background: Ralstonia picketti, Ralstonia mannitolilytica, and Ralstonia insidiosa have recently been regarded as emerging pathogens of infectious diseases, in particular as the pathogens responsible for nosocomial infection in immunocompromised patients. R. insidiosa differs from R. picketti and R. mannitolilytica, and its related infections are rarely reported.

Methods: Clinical data from two nosocomial bloodstream infection cases were extracted and analyzed. The causable isolates were identified by the VITEK 2 Compact system, matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS), and molecular identification methods using PCR with universal and species-specific primers. Antimicrobial susceptibility testing was performed using the broth microdilution method. Both of the isolates were subjected to whole genome sequencing using a HiSeq X10 Sequencer. Antimicrobial resistance genes, virulence factors, and plasmid replicons were identified from assembled genomes. A real-time RT-PCR experiment and a cloning experiment were conducted to explore the related class D β-lactamase-encoding genes.

Results: Both patients recovered under therapy with antibiotics. Isolates were initially misidentified as R. mannitolilytica by the VITEK 2 Compact system rather than R. insidiosa, as identified by both MALDI-TOF MS and 16S rRNA gene sequencing. Both isolates were resistant to aminoglycosides, β-lactams, and polymyxin B. One isolate harboring bla_OXA-570 was resistant to carbapenems. The whole genome sequencing data confirmed species identification based on average nucleotide identity (ANI) and revealed two variants of class D β-lactamase-encoding gene bla_OXA (bla_OXA-573 and bla_OXA-574). The real-time RT-PCR experiment showed no difference in gene expression between bla_OXA-570 and bla_OXA-573 in our strains. The cloning experiment showed that variant OXA-573 had no carbapenem hydrolase activity.

Conclusions: We described two cases of nosocomial bloodstream infection caused by R. insidiosa strains. MALDI-TOF MS was cost-effective for rapid species identification. Clinicians should be aware that R. insidiosa can be resistant to commonly used antibiotics, even carbapenems.

Keywords: Bloodstream infections; Carbapenem-resistant; Nosocomial infection; Ralstonia insidiosa; Whole genome sequencing.

Fig. 1

Phylogenetic tree based on core genome SNP. The tree was inferred using the maximum likelihood method under the GTRGAMMA model with a 1000-bootstrap test. Support values are colored based on confidence at internal nodes

Fig. 2

Comparative analysis among R. insidiosa genomes of our isolates and previously published strains ATCC 49129 and FC1138