Enterobacterales species other than Klebsiella pneumoniae also contribute to OXA-48 carbapenemase endemicity. We study the emergence of OXA-48-producing Kluyvera spp., which expresses the novel CTX-M-213, colonizing patients in our Hospital. Rectal swabs from patients admitted in four wards (March-2014-March 2016, R-GNOSIS project) were seeded on ESBL and CARB/OXA-48 chromogenic agar plates. Carbapenemases and ESBLs were characterized (PCR, sequencing, cloning, site-directed mutagenesis) and antibiotic susceptibility was determined. Clonal relatedness was established (XbaI-PFGE) and plasmid content was studied [transformation, S1-PFGE, SB-Hybridization, RFLP (DraI, HpaI) and PCR (incompatibility group and repA, traU and parA genes)]. Whole genome sequencing (WGS, IlluminaHISeq-2500) and further bioinformatics analysis of plasmids (PLACNET, Plasmid SPAdes) were performed. Patients' charts were reviewed. Six unrelated patients (median age 75 years, range 59-81; 4/6 male) colonized with OXA-48-Kluyvera spp. (>95% similarity PFGE-pattern) were detected. Nosocomial acquisition was demonstrated. In two patients, OXA-48-Kluyvera spp. co-existed with OXA-48-producing Raoultella ornithinolytica, K. pneumoniae and Escherichia coli. The blaOXA-48 gene was located on a ~60kb IncL plasmid related to IncL/M-pOXA-48a and the novel blaCTX-M-213 in a conserved chromosomal region of Kluyvera spp. isolates. CTX-M-213 different from CTX-M-13 (K56E) but conferring a similar β-lactam resistance profile, was identified. Genomic analysis also revealed a 177 kb IncF plasmid (class I integronsul1 and aadA2) and an 8 kb IncQ (IS4-blaFOX-8). We describe the first blaOXA-48 plasmid in Kluyvera spp. and the novel chromosomal CTX-M-213 enzyme and highlight further nosocomial dissemination of blaOXA-48 through clonal lineages or plasmids related to IncL/M-pOXA-48a.
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