Antimicrobial resistance in <i>Enterobacteriaceae</i> in Brazil: focus on β-lactams and polymyxins

Sampaio, Jorge Luiz Mello; Gales, Ana Cristina

doi:10.1016/j.bjm.2016.10.002

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Brazilian Journal of Microbiology

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Medical Microbiology • Braz. J. Microbiol. 47 (Suppl. 1) • Dec 2016 • https://doi.org/10.1016/j.bjm.2016.10.002 copy

Antimicrobial resistance in Enterobacteriaceae in Brazil: focus on β-lactams and polymyxins

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

During the last 30 years there has been a dissemination of plasmid-mediated β-lactamases in Enterobacteriaceae in Brazil. Extended spectrum β-lactamases (ESBL) are widely disseminated in the hospital setting and are detected in a lower frequency in the community setting. Cefotaximases are the most frequently detected ESBL type and Klebsiella pneumoniae is the predominant species among ESBL producers. Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae became widely disseminated in Brazil during the last decade and KPC production is currently the most frequent resistance mechanism (96.2%) in carbapenem resistant K. pneumoniae. To date KPC-2 is the only variant reported in Brazil. Polymyxin B resistance in KPC-2-producing K. pneumoniae has come to an alarming rate of 27.1% in 2015 in São Paulo, the largest city in Brazil. New Delhi metallo-β-lactamase was detected in Brazil in 2013, has been reported in different Brazilian states but are not widely disseminated. Antimicrobial resistance in Enterobacteriaceae in Brazil is a very serious problem that needs urgent actions which includes both more strict adherence to infection control measures and more judicious use of antimicrobials.

Keywords:
ESBL; KPC; NDM; Extended spectrum β-lactamases; New Delhi metallo-β-lactamase; Klebsiella pneumoniae carbapenemase; Polymyxin B; Colistin; Antimicrobial resistance; Carbapenemases; Brazil; Enterobacteriaceae

Enzyme	Species
BES-1	Serratia marcescens ⁹9 Bonnet R, Sampaio JL, Chanal C, et al. A novel class A extended-spectrum beta-lactamase (BES-1) in Serratia marcescens isolated in Brazil. Antimicrob Agents Chemother. 2000;44(11):3061-3068.
CTX-M-1	K. pneumoniae ¹⁴14 Peirano G, Seki LM, Val Passos VL, et al. Carbapenem-hydrolysing beta-lactamase KPC-2 in Klebsiella pneumoniae isolated in Rio de Janeiro, Brazil. J Antimicrob Chemother. 2009;63(2):265-268.
CTX-M-2	Enterobacter aerogenes¹²12 Nogueira Kda S, Conte D, Maia FV, et al. Distribution of extended-spectrum beta-lactamase types in a Brazilian tertiary hospital. Rev Soc Bras Med Trop. 2015;48(2):162-169.^,¹⁵15 Nogueira Kda S, Paganini MC, Conte A, et al. Emergence of extended-spectrum beta-lactamase producing Enterobacter spp. in patients with bacteremia in a tertiary hospital in southern Brazil. Enferm Infecc Microbiol Clin. 2014;32(2):87-92.; Enterobacter cloacae¹²12 Nogueira Kda S, Conte D, Maia FV, et al. Distribution of extended-spectrum beta-lactamase types in a Brazilian tertiary hospital. Rev Soc Bras Med Trop. 2015;48(2):162-169.^,¹⁶16 Minarini LA, Poirel L, Trevisani NA, et al. Predominance of CTX-M-type extended-spectrum beta-lactamase genes among enterobacterial isolates from outpatients in Brazil. Diagn Microbiol Infect Dis. 2009;65(2):202-206.; Escherichia coli¹²12 Nogueira Kda S, Conte D, Maia FV, et al. Distribution of extended-spectrum beta-lactamase types in a Brazilian tertiary hospital. Rev Soc Bras Med Trop. 2015;48(2):162-169.^,¹⁶16 Minarini LA, Poirel L, Trevisani NA, et al. Predominance of CTX-M-type extended-spectrum beta-lactamase genes among enterobacterial isolates from outpatients in Brazil. Diagn Microbiol Infect Dis. 2009;65(2):202-206. 17 Andrade LN, Minarini LA, Pitondo-Silva A, et al. Determinants of beta-lactam resistance in meningitis-causing Enterobacteriaceae in Brazil. Can J Microbiol. 2010;56(5):399-407. 18 Berman H, Barberino MG, Moreira ED, et al. Distribution of strain type and antimicrobial susceptibility of Escherichia coli isolates causing meningitis in a large urban setting in Brazil. J Clin Microbiol. 2014;52(5):1418-1422. 19 Minarini LA, Camargo IL, Pitondo-Silva A, et al. Multilocus sequence typing of uropathogenic ESBL-producing Escherichia coli isolated in a Brazilian community. Curr Microbiol. 2007;55(6):524-529. 20 Queiroz ML, Antunes P, Mourao J, et al. Characterization of extended-spectrum beta-lactamases, antimicrobial resistance genes, and plasmid content in Escherichia coli isolates from different sources in Rio de Janeiro, Brazil. Diagn Microbiol Infect Dis. 2012;74(1):91-94. 21 Dropa M, Balsalobre LC, Lincopan N, et al. Complex class 1 integrons harboring CTX-M-2-encoding genes in clinical Enterobacteriaceae from a hospital in Brazil. J Infect Dev Ctries. 2015;9(8):890-897.^-²²22 Peirano G, Asensi MD, Pitondo-Silva A, et al. Molecular characteristics of extended-spectrum beta-lactamase-producing Escherichia coli from Rio de Janeiro, Brazil. Clin Microbiol Infect. 2011;17(7):1039-1043.; Klebsiella pneumoniae¹⁴14 Peirano G, Seki LM, Val Passos VL, et al. Carbapenem-hydrolysing beta-lactamase KPC-2 in Klebsiella pneumoniae isolated in Rio de Janeiro, Brazil. J Antimicrob Chemother. 2009;63(2):265-268.^,¹⁶16 Minarini LA, Poirel L, Trevisani NA, et al. Predominance of CTX-M-type extended-spectrum beta-lactamase genes among enterobacterial isolates from outpatients in Brazil. Diagn Microbiol Infect Dis. 2009;65(2):202-206.^,²¹21 Dropa M, Balsalobre LC, Lincopan N, et al. Complex class 1 integrons harboring CTX-M-2-encoding genes in clinical Enterobacteriaceae from a hospital in Brazil. J Infect Dev Ctries. 2015;9(8):890-897.^,²³23 de Oliveira Garcia D, Doi Y, Szabo D, et al. Multiclonal outbreak of Klebsiella pneumoniae producing extended-spectrum beta-lactamase CTX-M-2 and novel variant CTX-M-59 in a neonatal intensive care unit in Brazil. Antimicrob Agents Chemother. 2008;52(5):1790-1793. 24 Lopes AC, Veras DL, Lima AM, et al. bla(CTX-M-2) and bla(CTX-M-28) extended-spectrum beta-lactamase genes and class 1 integrons in clinical isolates of Klebsiella pneumoniae from Brazil. Mem Inst Oswaldo Cruz. 2010;105(2):163-167. 25 Ramos PI, Picao RC, Almeida LG, et al. Comparative analysis of the complete genome of KPC-2-producing Klebsiella pneumoniae Kp13 reveals remarkable genome plasticity and a wide repertoire of virulence and resistance mechanisms. BMC Genomics. 2014;15:54-69. 26 Andrade LN, Vitali L, Gaspar GG, et al. Expansion and evolution of a virulent, extensively drug-resistant (polymyxin B-resistant), QnrS1-, CTX-M-2-, and KPC-2-producing Klebsiella pneumoniae ST11 international high-risk clone. J Clin Microbiol. 2014;52(7):2530-2535. 27 Bueno MF, Francisco GR, O’Hara JA, et al. Coproduction of 16S rRNA methyltransferase RmtD or RmtG with KPC-2 and CTX-M group extended-spectrum beta-lactamases in Klebsiella pneumoniae. Antimicrob Agents Chemother. 2013;57(5):2397-2400. 28 Cabral AB, Melo Rde C, Maciel MA, et al. Multidrug resistance genes, including bla(KPC) and bla(CTX)-M-2, among Klebsiella pneumoniae isolated in Recife, Brazil. Rev Soc Bras Med Trop. 2012;45(5):572-578.^-²⁹29 Do Carmo Filho JR, Silva RM, Castanheira M, et al. Prevalence and genetic characterization of blaCTX-M among Klebsiella pneumoniae isolates collected in an intensive care unit in Brazil. J Chemother. 2008;20(5):600-603.; K. oxytoca²¹21 Dropa M, Balsalobre LC, Lincopan N, et al. Complex class 1 integrons harboring CTX-M-2-encoding genes in clinical Enterobacteriaceae from a hospital in Brazil. J Infect Dev Ctries. 2015;9(8):890-897.; Morganella morganii¹⁶16 Minarini LA, Poirel L, Trevisani NA, et al. Predominance of CTX-M-type extended-spectrum beta-lactamase genes among enterobacterial isolates from outpatients in Brazil. Diagn Microbiol Infect Dis. 2009;65(2):202-206.^,²¹21 Dropa M, Balsalobre LC, Lincopan N, et al. Complex class 1 integrons harboring CTX-M-2-encoding genes in clinical Enterobacteriaceae from a hospital in Brazil. J Infect Dev Ctries. 2015;9(8):890-897.; Proteus mirabilis⁸8 Bonnet R, Sampaio JL, Labia R, et al. A novel CTX-M beta-lactamase (CTX-M-8) in cefotaxime-resistant Enterobacteriaceae isolated in Brazil. Antimicrob Agents Chemother. 2000;44(7):1936-1942.^,¹⁷17 Andrade LN, Minarini LA, Pitondo-Silva A, et al. Determinants of beta-lactam resistance in meningitis-causing Enterobacteriaceae in Brazil. Can J Microbiol. 2010;56(5):399-407.^,²¹21 Dropa M, Balsalobre LC, Lincopan N, et al. Complex class 1 integrons harboring CTX-M-2-encoding genes in clinical Enterobacteriaceae from a hospital in Brazil. J Infect Dev Ctries. 2015;9(8):890-897.; Providencia stuartii¹⁶16 Minarini LA, Poirel L, Trevisani NA, et al. Predominance of CTX-M-type extended-spectrum beta-lactamase genes among enterobacterial isolates from outpatients in Brazil. Diagn Microbiol Infect Dis. 2009;65(2):202-206.^,²¹21 Dropa M, Balsalobre LC, Lincopan N, et al. Complex class 1 integrons harboring CTX-M-2-encoding genes in clinical Enterobacteriaceae from a hospital in Brazil. J Infect Dev Ctries. 2015;9(8):890-897.^,³⁰30 Zavascki AP, Carvalhaes CG, da Silva GL, et al. Outbreak of carbapenem-resistant Providencia stuartii in an intensive care unit. Infect Control Hosp Epidemiol. 2012;33(6):627-630.; Salmonella typhimurium³¹31 Fernandes SA, Paterson DL, Ghilardi-Rodrigues AC, et al. CTX-M-2-producing Salmonella typhimurium isolated from pediatric patients and poultry in Brazil. Microb Drug Resist. 2009;15(4):317-321.; S. marcescens¹⁷17 Andrade LN, Minarini LA, Pitondo-Silva A, et al. Determinants of beta-lactam resistance in meningitis-causing Enterobacteriaceae in Brazil. Can J Microbiol. 2010;56(5):399-407.
CTX-M-3	E. coli ²²22 Peirano G, Asensi MD, Pitondo-Silva A, et al. Molecular characteristics of extended-spectrum beta-lactamase-producing Escherichia coli from Rio de Janeiro, Brazil. Clin Microbiol Infect. 2011;17(7):1039-1043.
CTX-M-8	Citrobacter amalonaticus⁸8 Bonnet R, Sampaio JL, Labia R, et al. A novel CTX-M beta-lactamase (CTX-M-8) in cefotaxime-resistant Enterobacteriaceae isolated in Brazil. Antimicrob Agents Chemother. 2000;44(7):1936-1942.; Enterobacter cloacae⁸8 Bonnet R, Sampaio JL, Labia R, et al. A novel CTX-M beta-lactamase (CTX-M-8) in cefotaxime-resistant Enterobacteriaceae isolated in Brazil. Antimicrob Agents Chemother. 2000;44(7):1936-1942.; E. aerogenes⁸8 Bonnet R, Sampaio JL, Labia R, et al. A novel CTX-M beta-lactamase (CTX-M-8) in cefotaxime-resistant Enterobacteriaceae isolated in Brazil. Antimicrob Agents Chemother. 2000;44(7):1936-1942.; E. coli¹²12 Nogueira Kda S, Conte D, Maia FV, et al. Distribution of extended-spectrum beta-lactamase types in a Brazilian tertiary hospital. Rev Soc Bras Med Trop. 2015;48(2):162-169.^,¹⁶16 Minarini LA, Poirel L, Trevisani NA, et al. Predominance of CTX-M-type extended-spectrum beta-lactamase genes among enterobacterial isolates from outpatients in Brazil. Diagn Microbiol Infect Dis. 2009;65(2):202-206.^,²²22 Peirano G, Asensi MD, Pitondo-Silva A, et al. Molecular characteristics of extended-spectrum beta-lactamase-producing Escherichia coli from Rio de Janeiro, Brazil. Clin Microbiol Infect. 2011;17(7):1039-1043.; K. pneumoniae¹⁴14 Peirano G, Seki LM, Val Passos VL, et al. Carbapenem-hydrolysing beta-lactamase KPC-2 in Klebsiella pneumoniae isolated in Rio de Janeiro, Brazil. J Antimicrob Chemother. 2009;63(2):265-268.
CTX-M-9	Citrobacter freundii¹⁶16 Minarini LA, Poirel L, Trevisani NA, et al. Predominance of CTX-M-type extended-spectrum beta-lactamase genes among enterobacterial isolates from outpatients in Brazil. Diagn Microbiol Infect Dis. 2009;65(2):202-206.; E. cloacae¹⁰10 Bonnet R, Dutour C, Sampaio JL, et al. Novel cefotaximase (CTX-M-16) with increased catalytic efficiency due to substitution Asp-240->Gly. Antimicrob Agents Chemother. 2001;45(8):2269-2275.^,¹²12 Nogueira Kda S, Conte D, Maia FV, et al. Distribution of extended-spectrum beta-lactamase types in a Brazilian tertiary hospital. Rev Soc Bras Med Trop. 2015;48(2):162-169.; E. coli¹⁰10 Bonnet R, Dutour C, Sampaio JL, et al. Novel cefotaximase (CTX-M-16) with increased catalytic efficiency due to substitution Asp-240->Gly. Antimicrob Agents Chemother. 2001;45(8):2269-2275.^,¹²12 Nogueira Kda S, Conte D, Maia FV, et al. Distribution of extended-spectrum beta-lactamase types in a Brazilian tertiary hospital. Rev Soc Bras Med Trop. 2015;48(2):162-169.^,¹⁶16 Minarini LA, Poirel L, Trevisani NA, et al. Predominance of CTX-M-type extended-spectrum beta-lactamase genes among enterobacterial isolates from outpatients in Brazil. Diagn Microbiol Infect Dis. 2009;65(2):202-206.^,²⁰20 Queiroz ML, Antunes P, Mourao J, et al. Characterization of extended-spectrum beta-lactamases, antimicrobial resistance genes, and plasmid content in Escherichia coli isolates from different sources in Rio de Janeiro, Brazil. Diagn Microbiol Infect Dis. 2012;74(1):91-94.; K. pneumoniae¹⁶16 Minarini LA, Poirel L, Trevisani NA, et al. Predominance of CTX-M-type extended-spectrum beta-lactamase genes among enterobacterial isolates from outpatients in Brazil. Diagn Microbiol Infect Dis. 2009;65(2):202-206.
CTX-M-14	E. coli ¹⁸18 Berman H, Barberino MG, Moreira ED, et al. Distribution of strain type and antimicrobial susceptibility of Escherichia coli isolates causing meningitis in a large urban setting in Brazil. J Clin Microbiol. 2014;52(5):1418-1422. ^, ³²32 Cergole-Novella MC, Guth BE, Castanheira M, et al. First description of bla(CTX-M-14)- and bla(CTX-M-15)-producing Escherichia coli isolates in Brazil. Microb Drug Resist. 2010;16(3):177-184.
CTX-M-15	E. aerogenes¹²12 Nogueira Kda S, Conte D, Maia FV, et al. Distribution of extended-spectrum beta-lactamase types in a Brazilian tertiary hospital. Rev Soc Bras Med Trop. 2015;48(2):162-169.; E. cloacae¹²12 Nogueira Kda S, Conte D, Maia FV, et al. Distribution of extended-spectrum beta-lactamase types in a Brazilian tertiary hospital. Rev Soc Bras Med Trop. 2015;48(2):162-169.^,³³33 Seki LM, Pereira PS, de Souza Conceicao M, et al. Molecular epidemiology of CTX-M producing Enterobacteriaceae isolated from bloodstream infections in Rio de Janeiro, Brazil: emergence of CTX-M-15. Braz J Infect Dis. 2013;17(6):640-646.; E. coli¹⁸18 Berman H, Barberino MG, Moreira ED, et al. Distribution of strain type and antimicrobial susceptibility of Escherichia coli isolates causing meningitis in a large urban setting in Brazil. J Clin Microbiol. 2014;52(5):1418-1422.^,²²22 Peirano G, Asensi MD, Pitondo-Silva A, et al. Molecular characteristics of extended-spectrum beta-lactamase-producing Escherichia coli from Rio de Janeiro, Brazil. Clin Microbiol Infect. 2011;17(7):1039-1043.^,³²32 Cergole-Novella MC, Guth BE, Castanheira M, et al. First description of bla(CTX-M-14)- and bla(CTX-M-15)-producing Escherichia coli isolates in Brazil. Microb Drug Resist. 2010;16(3):177-184.^,³⁴34 Peirano G, van der Bij AK, Freeman JL, et al. Characteristics of Escherichia coli sequence type 131 isolates that produce extended-spectrum beta-lactamases: global distribution of the H30-Rx sublineage. Antimicrob Agents Chemother. 2014;58(7):3762-3767.; K. pneumoniae²⁷27 Bueno MF, Francisco GR, O’Hara JA, et al. Coproduction of 16S rRNA methyltransferase RmtD or RmtG with KPC-2 and CTX-M group extended-spectrum beta-lactamases in Klebsiella pneumoniae. Antimicrob Agents Chemother. 2013;57(5):2397-2400.^,³³33 Seki LM, Pereira PS, de Souza Conceicao M, et al. Molecular epidemiology of CTX-M producing Enterobacteriaceae isolated from bloodstream infections in Rio de Janeiro, Brazil: emergence of CTX-M-15. Braz J Infect Dis. 2013;17(6):640-646.^,³⁵35 Tollentino FM, Polotto M, Nogueira ML, et al. High prevalence of bla(CTX-M) extended spectrum beta-lactamase genes in Klebsiella pneumoniae isolates from a tertiary care hospital: first report of bla(SHV-12), bla(SHV-31), bla(SHV-38), and bla(CTX-M-15) in Brazil. Microb Drug Resist. 2011;17(1):7-16.
CTX-M-16	E. coli¹⁰10 Bonnet R, Dutour C, Sampaio JL, et al. Novel cefotaximase (CTX-M-16) with increased catalytic efficiency due to substitution Asp-240->Gly. Antimicrob Agents Chemother. 2001;45(8):2269-2275.; E. cloacae¹⁰10 Bonnet R, Dutour C, Sampaio JL, et al. Novel cefotaximase (CTX-M-16) with increased catalytic efficiency due to substitution Asp-240->Gly. Antimicrob Agents Chemother. 2001;45(8):2269-2275.
CTX-M-28	K. pneumoniae²⁴24 Lopes AC, Veras DL, Lima AM, et al. bla(CTX-M-2) and bla(CTX-M-28) extended-spectrum beta-lactamase genes and class 1 integrons in clinical isolates of Klebsiella pneumoniae from Brazil. Mem Inst Oswaldo Cruz. 2010;105(2):163-167.; K. oxytoca²¹21 Dropa M, Balsalobre LC, Lincopan N, et al. Complex class 1 integrons harboring CTX-M-2-encoding genes in clinical Enterobacteriaceae from a hospital in Brazil. J Infect Dev Ctries. 2015;9(8):890-897.
CTX-M-59	E. aerogenes¹⁵15 Nogueira Kda S, Paganini MC, Conte A, et al. Emergence of extended-spectrum beta-lactamase producing Enterobacter spp. in patients with bacteremia in a tertiary hospital in southern Brazil. Enferm Infecc Microbiol Clin. 2014;32(2):87-92.; E. cloacae¹⁵15 Nogueira Kda S, Paganini MC, Conte A, et al. Emergence of extended-spectrum beta-lactamase producing Enterobacter spp. in patients with bacteremia in a tertiary hospital in southern Brazil. Enferm Infecc Microbiol Clin. 2014;32(2):87-92.; E. coli²⁰20 Queiroz ML, Antunes P, Mourao J, et al. Characterization of extended-spectrum beta-lactamases, antimicrobial resistance genes, and plasmid content in Escherichia coli isolates from different sources in Rio de Janeiro, Brazil. Diagn Microbiol Infect Dis. 2012;74(1):91-94.^,²¹21 Dropa M, Balsalobre LC, Lincopan N, et al. Complex class 1 integrons harboring CTX-M-2-encoding genes in clinical Enterobacteriaceae from a hospital in Brazil. J Infect Dev Ctries. 2015;9(8):890-897.^,²⁷27 Bueno MF, Francisco GR, O’Hara JA, et al. Coproduction of 16S rRNA methyltransferase RmtD or RmtG with KPC-2 and CTX-M group extended-spectrum beta-lactamases in Klebsiella pneumoniae. Antimicrob Agents Chemother. 2013;57(5):2397-2400.; K. pneumoniae²¹21 Dropa M, Balsalobre LC, Lincopan N, et al. Complex class 1 integrons harboring CTX-M-2-encoding genes in clinical Enterobacteriaceae from a hospital in Brazil. J Infect Dev Ctries. 2015;9(8):890-897.^,²³23 de Oliveira Garcia D, Doi Y, Szabo D, et al. Multiclonal outbreak of Klebsiella pneumoniae producing extended-spectrum beta-lactamase CTX-M-2 and novel variant CTX-M-59 in a neonatal intensive care unit in Brazil. Antimicrob Agents Chemother. 2008;52(5):1790-1793.^,²⁷27 Bueno MF, Francisco GR, O’Hara JA, et al. Coproduction of 16S rRNA methyltransferase RmtD or RmtG with KPC-2 and CTX-M group extended-spectrum beta-lactamases in Klebsiella pneumoniae. Antimicrob Agents Chemother. 2013;57(5):2397-2400.
CTX-M-74	E. cloacae ¹⁶16 Minarini LA, Poirel L, Trevisani NA, et al. Predominance of CTX-M-type extended-spectrum beta-lactamase genes among enterobacterial isolates from outpatients in Brazil. Diagn Microbiol Infect Dis. 2009;65(2):202-206.
CTX-M-75	P. stuartii ¹⁶16 Minarini LA, Poirel L, Trevisani NA, et al. Predominance of CTX-M-type extended-spectrum beta-lactamase genes among enterobacterial isolates from outpatients in Brazil. Diagn Microbiol Infect Dis. 2009;65(2):202-206.
CTX-M-131	P. stuartii ³⁶36 Dropa M, Ghiglione B, Matte MH, et al. Molecular and biochemical characterization of CTX-M-131, a natural Asp240Gly variant derived from CTX-M-2, produced by a Providencia rettgeri clinical strain in Sao Paulo, Brazil. Antimicrob Agents Chemother. 2015;59(3):1815-1817.
GES-1	K. pneumoniae ³⁷37 Correa L, Martino MD, Siqueira I, et al. A hospital-based matched case-control study to identify clinical outcome and risk factors associated with carbapenem-resistant Klebsiella pneumoniae infection. BMC Infect Dis. 2013;13:80-87.
GES-7	K. pneumoniae ³⁸38 Dropa M, Balsalobre LC, Lincopan N, et al. Emergence of Klebsiella pneumoniae carrying the novel extended-spectrum beta-lactamase gene variants bla(SHV-40), bla(TEM-116) and the class 1 integron-associated bla(GES-7) in Brazil. Clin Microbiol Infect. 2010;16(6):630-632.
PER-2	E. cloacae ¹²12 Nogueira Kda S, Conte D, Maia FV, et al. Distribution of extended-spectrum beta-lactamase types in a Brazilian tertiary hospital. Rev Soc Bras Med Trop. 2015;48(2):162-169. ^, ¹⁵15 Nogueira Kda S, Paganini MC, Conte A, et al. Emergence of extended-spectrum beta-lactamase producing Enterobacter spp. in patients with bacteremia in a tertiary hospital in southern Brazil. Enferm Infecc Microbiol Clin. 2014;32(2):87-92.
SHV-2	K. pneumoniae; E. coli ²²22 Peirano G, Asensi MD, Pitondo-Silva A, et al. Molecular characteristics of extended-spectrum beta-lactamase-producing Escherichia coli from Rio de Janeiro, Brazil. Clin Microbiol Infect. 2011;17(7):1039-1043.
SHV-4	K. pneumoniae ³⁹39 Mendes C, Kiffer C, Segura A, et al. Klebsiella pneumoniae with multiple antimicrobial resistance. Braz J Infect Dis. 2004;8(1):109-111.
SHV-5	E. cloacae¹⁶16 Minarini LA, Poirel L, Trevisani NA, et al. Predominance of CTX-M-type extended-spectrum beta-lactamase genes among enterobacterial isolates from outpatients in Brazil. Diagn Microbiol Infect Dis. 2009;65(2):202-206.; E. coli¹⁶16 Minarini LA, Poirel L, Trevisani NA, et al. Predominance of CTX-M-type extended-spectrum beta-lactamase genes among enterobacterial isolates from outpatients in Brazil. Diagn Microbiol Infect Dis. 2009;65(2):202-206.^,¹⁹19 Minarini LA, Camargo IL, Pitondo-Silva A, et al. Multilocus sequence typing of uropathogenic ESBL-producing Escherichia coli isolated in a Brazilian community. Curr Microbiol. 2007;55(6):524-529.^,²¹21 Dropa M, Balsalobre LC, Lincopan N, et al. Complex class 1 integrons harboring CTX-M-2-encoding genes in clinical Enterobacteriaceae from a hospital in Brazil. J Infect Dev Ctries. 2015;9(8):890-897.; K. pneumoniae¹⁶16 Minarini LA, Poirel L, Trevisani NA, et al. Predominance of CTX-M-type extended-spectrum beta-lactamase genes among enterobacterial isolates from outpatients in Brazil. Diagn Microbiol Infect Dis. 2009;65(2):202-206.
SHV-12	E. aerogenes¹²12 Nogueira Kda S, Conte D, Maia FV, et al. Distribution of extended-spectrum beta-lactamase types in a Brazilian tertiary hospital. Rev Soc Bras Med Trop. 2015;48(2):162-169.^,¹⁵15 Nogueira Kda S, Paganini MC, Conte A, et al. Emergence of extended-spectrum beta-lactamase producing Enterobacter spp. in patients with bacteremia in a tertiary hospital in southern Brazil. Enferm Infecc Microbiol Clin. 2014;32(2):87-92.; E. cloacae¹²12 Nogueira Kda S, Conte D, Maia FV, et al. Distribution of extended-spectrum beta-lactamase types in a Brazilian tertiary hospital. Rev Soc Bras Med Trop. 2015;48(2):162-169.^,¹⁵15 Nogueira Kda S, Paganini MC, Conte A, et al. Emergence of extended-spectrum beta-lactamase producing Enterobacter spp. in patients with bacteremia in a tertiary hospital in southern Brazil. Enferm Infecc Microbiol Clin. 2014;32(2):87-92.; K. pneumoniae²¹21 Dropa M, Balsalobre LC, Lincopan N, et al. Complex class 1 integrons harboring CTX-M-2-encoding genes in clinical Enterobacteriaceae from a hospital in Brazil. J Infect Dev Ctries. 2015;9(8):890-897.^,²⁵25 Ramos PI, Picao RC, Almeida LG, et al. Comparative analysis of the complete genome of KPC-2-producing Klebsiella pneumoniae Kp13 reveals remarkable genome plasticity and a wide repertoire of virulence and resistance mechanisms. BMC Genomics. 2014;15:54-69.^,³⁵35 Tollentino FM, Polotto M, Nogueira ML, et al. High prevalence of bla(CTX-M) extended spectrum beta-lactamase genes in Klebsiella pneumoniae isolates from a tertiary care hospital: first report of bla(SHV-12), bla(SHV-31), bla(SHV-38), and bla(CTX-M-15) in Brazil. Microb Drug Resist. 2011;17(1):7-16.
SHV-27	K. pneumoniae ²¹21 Dropa M, Balsalobre LC, Lincopan N, et al. Complex class 1 integrons harboring CTX-M-2-encoding genes in clinical Enterobacteriaceae from a hospital in Brazil. J Infect Dev Ctries. 2015;9(8):890-897. ^, ⁴⁰40 Corkill JE, Cuevas LE, Gurgel RQ, et al. SHV-27, a novel cefotaxime-hydrolysing beta-lactamase, identified in Klebsiella pneumoniae isolates from a Brazilian hospital. J Antimicrob Chemother. 2001;47(4):463-465.
SHV-28	K. pneumoniae ²¹21 Dropa M, Balsalobre LC, Lincopan N, et al. Complex class 1 integrons harboring CTX-M-2-encoding genes in clinical Enterobacteriaceae from a hospital in Brazil. J Infect Dev Ctries. 2015;9(8):890-897. ^, ⁴¹41 Veras DL, Alves LC, Brayner FA, et al. Prevalence of the bla (SHV) gene in Klebsiella pneumoniae isolates obtained from hospital and community infections and from the microbiota of healthy individuals in Recife, Brazil. Curr Microbiol. 2011;62(5):1610-1616.
SHV-31	K. pneumoniae ³⁵35 Tollentino FM, Polotto M, Nogueira ML, et al. High prevalence of bla(CTX-M) extended spectrum beta-lactamase genes in Klebsiella pneumoniae isolates from a tertiary care hospital: first report of bla(SHV-12), bla(SHV-31), bla(SHV-38), and bla(CTX-M-15) in Brazil. Microb Drug Resist. 2011;17(1):7-16.
SHV-38	K. pneumoniae ³⁵35 Tollentino FM, Polotto M, Nogueira ML, et al. High prevalence of bla(CTX-M) extended spectrum beta-lactamase genes in Klebsiella pneumoniae isolates from a tertiary care hospital: first report of bla(SHV-12), bla(SHV-31), bla(SHV-38), and bla(CTX-M-15) in Brazil. Microb Drug Resist. 2011;17(1):7-16.
SHV-40	K. pneumoniae ³⁸38 Dropa M, Balsalobre LC, Lincopan N, et al. Emergence of Klebsiella pneumoniae carrying the novel extended-spectrum beta-lactamase gene variants bla(SHV-40), bla(TEM-116) and the class 1 integron-associated bla(GES-7) in Brazil. Clin Microbiol Infect. 2010;16(6):630-632.
SHV-45	K. pneumoniae ²¹21 Dropa M, Balsalobre LC, Lincopan N, et al. Complex class 1 integrons harboring CTX-M-2-encoding genes in clinical Enterobacteriaceae from a hospital in Brazil. J Infect Dev Ctries. 2015;9(8):890-897.
SHV-55	K. pneumoniae ²¹21 Dropa M, Balsalobre LC, Lincopan N, et al. Complex class 1 integrons harboring CTX-M-2-encoding genes in clinical Enterobacteriaceae from a hospital in Brazil. J Infect Dev Ctries. 2015;9(8):890-897.
SHV-108	K. pneumoniae ⁴¹41 Veras DL, Alves LC, Brayner FA, et al. Prevalence of the bla (SHV) gene in Klebsiella pneumoniae isolates obtained from hospital and community infections and from the microbiota of healthy individuals in Recife, Brazil. Curr Microbiol. 2011;62(5):1610-1616.
SHV-122	K. pneumoniae ⁴¹41 Veras DL, Alves LC, Brayner FA, et al. Prevalence of the bla (SHV) gene in Klebsiella pneumoniae isolates obtained from hospital and community infections and from the microbiota of healthy individuals in Recife, Brazil. Curr Microbiol. 2011;62(5):1610-1616.
TEM-15	K. pneumoniae ²¹21 Dropa M, Balsalobre LC, Lincopan N, et al. Complex class 1 integrons harboring CTX-M-2-encoding genes in clinical Enterobacteriaceae from a hospital in Brazil. J Infect Dev Ctries. 2015;9(8):890-897.
TEM-115	K. pneumoniae ²¹21 Dropa M, Balsalobre LC, Lincopan N, et al. Complex class 1 integrons harboring CTX-M-2-encoding genes in clinical Enterobacteriaceae from a hospital in Brazil. J Infect Dev Ctries. 2015;9(8):890-897.
TEM-116	K. pneumoniae ³⁸38 Dropa M, Balsalobre LC, Lincopan N, et al. Emergence of Klebsiella pneumoniae carrying the novel extended-spectrum beta-lactamase gene variants bla(SHV-40), bla(TEM-116) and the class 1 integron-associated bla(GES-7) in Brazil. Clin Microbiol Infect. 2010;16(6):630-632.
TEM-135	E. cloacae ¹²12 Nogueira Kda S, Conte D, Maia FV, et al. Distribution of extended-spectrum beta-lactamase types in a Brazilian tertiary hospital. Rev Soc Bras Med Trop. 2015;48(2):162-169.

Species	Location (City, State)	MLST
C. freundii	AL⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.; Duque de Caxias, RJ⁶⁰60 Andrade LN, Curiao T, Ferreira JC, et al. Dissemination of blaKPC-2 by the spread of Klebsiella pneumoniae clonal complex 258 clones (ST258, ST11, ST437) and plasmids (IncFII, IncN, IncL/M) among Enterobacteriaceae species in Brazil. Antimicrob Agents Chemother. 2011;55(7):3579-3583.; GO⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.; RJ⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.	-
E. aerogenes	CE⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.; DF⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.; PE⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.
E. cloacae	CE⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.; DF⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.; GO⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.; MG⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.; Porto Alegre, RS⁶⁰60 Andrade LN, Curiao T, Ferreira JC, et al. Dissemination of blaKPC-2 by the spread of Klebsiella pneumoniae clonal complex 258 clones (ST258, ST11, ST437) and plasmids (IncFII, IncN, IncL/M) among Enterobacteriaceae species in Brazil. Antimicrob Agents Chemother. 2011;55(7):3579-3583.^,⁶¹61 Ribeiro VB, Andrade LN, Linhares AR, et al. Molecular characterization of Klebsiella pneumoniae carbapenemase-producing isolates in southern Brazil. J Med Microbiol. 2013;62(Pt 11):1721-1727.; Rio de Janeiro⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.^,⁶²62 Quiles MG, Rocchetti TT, Fehlberg LC, et al. Unusual association of NDM-1 with KPC-2 and armA among Brazilian Enterobacteriaceae isolates. Braz J Med Biol Res. 2015;48(2):174-177.	-
E. gergoviae	Recife, PE⁶³63 Almeida AC, de Castro KK, Fehlberg LC, et al. Carbapenem-resistant Enterobacter gergoviae harbouring blaKPC-2 in Brazil. Int J Antimicrob Agents. 2014;44(4):369-370.	-
E. hormaechei	Rio de Janeiro⁶⁴64 Pereira PS, Borghi M, Albano RM, et al. Coproduction of NDM-1 and KPC-2 in Enterobacter hormaechei from Brazil. Microb Drug Resist. 2015;21(2):234-236.	-
E. coli	BA⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.; DF⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.; MG⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.; Recife, PE⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.^,⁶⁵65 Almeida AC, de Sa Cavalcanti FL, Vilela MA, et al. Escherichia coli ST502 and Klebsiella pneumoniae ST11 sharing an IncW plasmid harbouring the bla(KPC-2) gene in an Intensive Care Unit patient. Int J Antimicrob Agents. 2012;40(4):374-376.; Rio de Janeiro, RJ⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.^,⁶⁶66 D'Alincourt Carvalho-Assef AP, Leao RS, da Silva RV, et al. Escherichia coli producing KPC-2 carbapenemase: first report in Brazil. Diagn Microbiol Infect Dis. 2010;68(3):337-338.	ST2⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.; ST39⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.; ST43⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.; ST305⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.; ST479⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.; ST502⁶⁵65 Almeida AC, de Sa Cavalcanti FL, Vilela MA, et al. Escherichia coli ST502 and Klebsiella pneumoniae ST11 sharing an IncW plasmid harbouring the bla(KPC-2) gene in an Intensive Care Unit patient. Int J Antimicrob Agents. 2012;40(4):374-376.; ST629⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.; ST630⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.; ST631⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.; ST632⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.
K. pneumoniae	AL⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.; AM⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.; Brasília, DF⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.; Campo Grande, MS⁶⁸68 Chang MR, Biberg CA, Lopes FA, et al. The first report of infection with Klebsiella pneumoniae carrying the bla(kpc) gene in State of Mato Grosso do Sul, Brazil. Rev Soc Bras Med Trop. 2013;46(1):114-115.^,⁶⁹69 Biberg CA, Rodrigues AC, do Carmo SF, et al. KPC-2-producing Klebsiella pneumoniae in a hospital in the Midwest region of Brazil. Braz J Microbiol. 2015;46(2):501-504.; CE⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.; ES⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.^,⁷⁰70 Seki LM, Pereira PS, de Souza Mda P, et al. Molecular epidemiology of KPC-2-producing Klebsiella pneumoniae isolates in Brazil: the predominance of sequence type 437. Diagn Microbiol Infect Dis. 2011;70(2):274-277.; Florianópolis, SC⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.^,⁷¹71 Zavascki AP, Zoccoli CM, Machado AB, et al. KPC-2-producing Klebsiella pneumoniae in Brazil: a widespread threat in waiting? Int J Infect Dis. 2010;14(6):pe539-pe540.; Franca, SP⁶⁰60 Andrade LN, Curiao T, Ferreira JC, et al. Dissemination of blaKPC-2 by the spread of Klebsiella pneumoniae clonal complex 258 clones (ST258, ST11, ST437) and plasmids (IncFII, IncN, IncL/M) among Enterobacteriaceae species in Brazil. Antimicrob Agents Chemother. 2011;55(7):3579-3583.; GO⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.^,⁷⁰70 Seki LM, Pereira PS, de Souza Mda P, et al. Molecular epidemiology of KPC-2-producing Klebsiella pneumoniae isolates in Brazil: the predominance of sequence type 437. Diagn Microbiol Infect Dis. 2011;70(2):274-277.; João Pessoa, PB⁷²72 Fehlberg LC, Carvalho AM, Campana EH, et al. Emergence of Klebsiella pneumoniae-producing KPC-2 carbapenemase in Paraiba, Northeastern Brazil. Braz J Infect Dis. 2012;16(6):577-580.; Lageado, RS⁷³73 Zavascki AP, Machado AB, de Oliveira KR, et al. KPC-2-producing Enterobacter cloacae in two cities from Southern Brazil. Int J Antimicrob Agents. 2009;34(3):286-288.; MA⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.; MG⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.^,⁷⁰70 Seki LM, Pereira PS, de Souza Mda P, et al. Molecular epidemiology of KPC-2-producing Klebsiella pneumoniae isolates in Brazil: the predominance of sequence type 437. Diagn Microbiol Infect Dis. 2011;70(2):274-277.; PE⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.^,⁷⁰70 Seki LM, Pereira PS, de Souza Mda P, et al. Molecular epidemiology of KPC-2-producing Klebsiella pneumoniae isolates in Brazil: the predominance of sequence type 437. Diagn Microbiol Infect Dis. 2011;70(2):274-277.; PI⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.; Porto Alegre, RS⁶¹61 Ribeiro VB, Andrade LN, Linhares AR, et al. Molecular characterization of Klebsiella pneumoniae carbapenemase-producing isolates in southern Brazil. J Med Microbiol. 2013;62(Pt 11):1721-1727.^,⁷³73 Zavascki AP, Machado AB, de Oliveira KR, et al. KPC-2-producing Enterobacter cloacae in two cities from Southern Brazil. Int J Antimicrob Agents. 2009;34(3):286-288.^,⁷⁴74 Rodrigues Perez LR, Dias CG. Emergence of infections due to a polymyxin B-resistant KPC-2-producing Klebsiella pneumoniae in critically ill patients: what is the role of a previous colonization? Infect Control Hosp Epidemiol. 2016;37(2):240-241.; Recife, PE²⁸28 Cabral AB, Melo Rde C, Maciel MA, et al. Multidrug resistance genes, including bla(KPC) and bla(CTX)-M-2, among Klebsiella pneumoniae isolated in Recife, Brazil. Rev Soc Bras Med Trop. 2012;45(5):572-578.^,⁵⁶56 Monteiro J, Santos AF, Asensi MD, et al. First report of KPC-2-producing Klebsiella pneumoniae strains in Brazil. Antimicrob Agents Chemother. 2009;53(1):333-334.^,⁶⁵65 Almeida AC, de Sa Cavalcanti FL, Vilela MA, et al. Escherichia coli ST502 and Klebsiella pneumoniae ST11 sharing an IncW plasmid harbouring the bla(KPC-2) gene in an Intensive Care Unit patient. Int J Antimicrob Agents. 2012;40(4):374-376.^,⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.^,⁷⁵75 Martins WM, Almeida AC, Nicoletti AG, et al. Coproduction of KPC-2 and QnrB19 in Klebsiella pneumoniae ST340 isolate in Brazil. Diagn Microbiol Infect Dis. 2015;83(4):375-376.; Ribeirão Preto, SP²⁶26 Andrade LN, Vitali L, Gaspar GG, et al. Expansion and evolution of a virulent, extensively drug-resistant (polymyxin B-resistant), QnrS1-, CTX-M-2-, and KPC-2-producing Klebsiella pneumoniae ST11 international high-risk clone. J Clin Microbiol. 2014;52(7):2530-2535.^,⁶⁰60 Andrade LN, Curiao T, Ferreira JC, et al. Dissemination of blaKPC-2 by the spread of Klebsiella pneumoniae clonal complex 258 clones (ST258, ST11, ST437) and plasmids (IncFII, IncN, IncL/M) among Enterobacteriaceae species in Brazil. Antimicrob Agents Chemother. 2011;55(7):3579-3583.; Rio de Janeiro, RJ¹⁴14 Peirano G, Seki LM, Val Passos VL, et al. Carbapenem-hydrolysing beta-lactamase KPC-2 in Klebsiella pneumoniae isolated in Rio de Janeiro, Brazil. J Antimicrob Chemother. 2009;63(2):265-268.^,⁶⁰60 Andrade LN, Curiao T, Ferreira JC, et al. Dissemination of blaKPC-2 by the spread of Klebsiella pneumoniae clonal complex 258 clones (ST258, ST11, ST437) and plasmids (IncFII, IncN, IncL/M) among Enterobacteriaceae species in Brazil. Antimicrob Agents Chemother. 2011;55(7):3579-3583.^,⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.^,⁷⁶76 Leao RS, Pereira RH, Folescu TW, et al. KPC-2 carbapenemase-producing Klebsiella pneumoniae isolates from patients with cystic fibrosis. J Cyst Fibros. 2011;10(2):140-142.; São Paulo, SP²⁷27 Bueno MF, Francisco GR, O’Hara JA, et al. Coproduction of 16S rRNA methyltransferase RmtD or RmtG with KPC-2 and CTX-M group extended-spectrum beta-lactamases in Klebsiella pneumoniae. Antimicrob Agents Chemother. 2013;57(5):2397-2400.^,⁷⁷77 Pavez M, Mamizuka EM, Lincopan N. Early dissemination of KPC-2-producing Klebsiella pneumoniae strains in Brazil. Antimicrob Agents Chemother. 2009;53(6):2702. 78 Beirao EM, Furtado JJ, Girardello R, et al. Clinical and microbiological characterization of KPC-producing Klebsiella pneumoniae infections in Brazil. Braz J Infect Dis. 2011;15(1):69-73. 79 Bergamasco MD, Barroso Barbosa M, de Oliveira Garcia D, et al. Infection with Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae in solid organ transplantation. Transpl Infect Dis. 2012;14(2):198-205.^-⁸⁰80 Bartolleti F, Seco BM, Capuzzo Dos Santos C, et al. Polymyxin B resistance in carbapenem-resistant Klebsiella pneumoniae, Sao Paulo, Brazil. Emerg Infect Dis. 2016;22(10):1849-1851.	ST11²⁶26 Andrade LN, Vitali L, Gaspar GG, et al. Expansion and evolution of a virulent, extensively drug-resistant (polymyxin B-resistant), QnrS1-, CTX-M-2-, and KPC-2-producing Klebsiella pneumoniae ST11 international high-risk clone. J Clin Microbiol. 2014;52(7):2530-2535.^,⁶⁰60 Andrade LN, Curiao T, Ferreira JC, et al. Dissemination of blaKPC-2 by the spread of Klebsiella pneumoniae clonal complex 258 clones (ST258, ST11, ST437) and plasmids (IncFII, IncN, IncL/M) among Enterobacteriaceae species in Brazil. Antimicrob Agents Chemother. 2011;55(7):3579-3583.^,⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.^,⁷⁰70 Seki LM, Pereira PS, de Souza Mda P, et al. Molecular epidemiology of KPC-2-producing Klebsiella pneumoniae isolates in Brazil: the predominance of sequence type 437. Diagn Microbiol Infect Dis. 2011;70(2):274-277.^,⁸⁰80 Bartolleti F, Seco BM, Capuzzo Dos Santos C, et al. Polymyxin B resistance in carbapenem-resistant Klebsiella pneumoniae, Sao Paulo, Brazil. Emerg Infect Dis. 2016;22(10):1849-1851.; ST13⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.; ST16⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.^,⁷⁰70 Seki LM, Pereira PS, de Souza Mda P, et al. Molecular epidemiology of KPC-2-producing Klebsiella pneumoniae isolates in Brazil: the predominance of sequence type 437. Diagn Microbiol Infect Dis. 2011;70(2):274-277.; ST17⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.; ST19⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.; ST25⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.^,⁷⁰70 Seki LM, Pereira PS, de Souza Mda P, et al. Molecular epidemiology of KPC-2-producing Klebsiella pneumoniae isolates in Brazil: the predominance of sequence type 437. Diagn Microbiol Infect Dis. 2011;70(2):274-277.; ST55⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.; ST70⁷⁰70 Seki LM, Pereira PS, de Souza Mda P, et al. Molecular epidemiology of KPC-2-producing Klebsiella pneumoniae isolates in Brazil: the predominance of sequence type 437. Diagn Microbiol Infect Dis. 2011;70(2):274-277.; ST101⁷⁰70 Seki LM, Pereira PS, de Souza Mda P, et al. Molecular epidemiology of KPC-2-producing Klebsiella pneumoniae isolates in Brazil: the predominance of sequence type 437. Diagn Microbiol Infect Dis. 2011;70(2):274-277.; ST138⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.; ST258⁶⁰60 Andrade LN, Curiao T, Ferreira JC, et al. Dissemination of blaKPC-2 by the spread of Klebsiella pneumoniae clonal complex 258 clones (ST258, ST11, ST437) and plasmids (IncFII, IncN, IncL/M) among Enterobacteriaceae species in Brazil. Antimicrob Agents Chemother. 2011;55(7):3579-3583.; ST323⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.; ST340⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.^,⁷⁵75 Martins WM, Almeida AC, Nicoletti AG, et al. Coproduction of KPC-2 and QnrB19 in Klebsiella pneumoniae ST340 isolate in Brazil. Diagn Microbiol Infect Dis. 2015;83(4):375-376.; ST423⁷⁰70 Seki LM, Pereira PS, de Souza Mda P, et al. Molecular epidemiology of KPC-2-producing Klebsiella pneumoniae isolates in Brazil: the predominance of sequence type 437. Diagn Microbiol Infect Dis. 2011;70(2):274-277.; ST437⁶⁰60 Andrade LN, Curiao T, Ferreira JC, et al. Dissemination of blaKPC-2 by the spread of Klebsiella pneumoniae clonal complex 258 clones (ST258, ST11, ST437) and plasmids (IncFII, IncN, IncL/M) among Enterobacteriaceae species in Brazil. Antimicrob Agents Chemother. 2011;55(7):3579-3583.^,⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.^,⁷²72 Fehlberg LC, Carvalho AM, Campana EH, et al. Emergence of Klebsiella pneumoniae-producing KPC-2 carbapenemase in Paraiba, Northeastern Brazil. Braz J Infect Dis. 2012;16(6):577-580.^,⁸⁰80 Bartolleti F, Seco BM, Capuzzo Dos Santos C, et al. Polymyxin B resistance in carbapenem-resistant Klebsiella pneumoniae, Sao Paulo, Brazil. Emerg Infect Dis. 2016;22(10):1849-1851.; ST442⁷⁰70 Seki LM, Pereira PS, de Souza Mda P, et al. Molecular epidemiology of KPC-2-producing Klebsiella pneumoniae isolates in Brazil: the predominance of sequence type 437. Diagn Microbiol Infect Dis. 2011;70(2):274-277.; ST443⁷⁰70 Seki LM, Pereira PS, de Souza Mda P, et al. Molecular epidemiology of KPC-2-producing Klebsiella pneumoniae isolates in Brazil: the predominance of sequence type 437. Diagn Microbiol Infect Dis. 2011;70(2):274-277.; ST756⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.; ST757⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.; ST758⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.; ST759⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.; ST760⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.; ST837⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.; ST838⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.; ST839⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.; ST840⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.; ST841⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.; ST842⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.; ST855⁶⁷67 Pereira PS, de Araujo CF, Seki LM, et al. Update of the molecular epidemiology of KPC-2-producing Klebsiella pneumoniae in Brazil: spread of clonal complex 11 (ST11, ST437 and ST340). J Antimicrob Chemother. 2013;68(2):312-316.
K. oxytoca	Recife, PE⁸¹81 Almeida AC, Cavalcanti FL, Martins WM, et al. First description of KPC-2-producing Klebsiella oxytoca in Brazil. Antimicrob Agents Chemother. 2013;57(8):4077-4078.; RJ⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.; MG⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.	-
K. georgiana	Porto Alegre, PA⁸²82 Ribeiro VB, Zavascki AP, Nodari CS, et al. Detection of blaKPC-2 in a carbapenem-resistant Kluyvera georgiana. J Antimicrob Chemother. 2012;67(11):2776-2777.	-
M. morganii	MG⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.	-
P. agglomerans	RJ⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.	-
P. mirabilis	Recife, PE⁸³83 Cabral AB, Maciel MA, Barros JF, et al. Detection of bla KPC-2 in Proteus mirabilis in Brazil. Rev Soc Bras Med Trop. 2015;48(1):94-95.	-
P. stuartii	Recife, PE⁸⁴84 Aires CA, Almeida AC, Vilela MA, et al. Selection of KPC-2-producing Providencia stuartii during treatment for septicemia. Diagn Microbiol Infect Dis. 2016;84(1):95-96.; MG⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.	-
S. marcescens	Duque de Caxias, RJ⁶⁰60 Andrade LN, Curiao T, Ferreira JC, et al. Dissemination of blaKPC-2 by the spread of Klebsiella pneumoniae clonal complex 258 clones (ST258, ST11, ST437) and plasmids (IncFII, IncN, IncL/M) among Enterobacteriaceae species in Brazil. Antimicrob Agents Chemother. 2011;55(7):3579-3583.; Porto Alegre, RS⁶¹61 Ribeiro VB, Andrade LN, Linhares AR, et al. Molecular characterization of Klebsiella pneumoniae carbapenemase-producing isolates in southern Brazil. J Med Microbiol. 2013;62(Pt 11):1721-1727.; Recife, PE⁵⁹59 Tavares CP, Pereira PS, Marques Ede A, et al. Molecular epidemiology of KPC-2-producing Enterobacteriaceae (non-Klebsiella pneumoniae) isolated from Brazil. Diagn Microbiol Infect Dis. 2015;82(4):326-330.^,⁸⁵85 Margate E, Magalhaes V, Fehlberg LC, et al. KPC-producing Serratia marcescens in a home-care patient from Recife, Brazil. Rev Inst Med Trop Sao Paulo. 2015;57(4):359-360.; Dourados, MS⁵²52 Silva KE, Cayo R, Carvalhaes CG, et al. Coproduction of KPC-2 and IMP-10 in carbapenem-resistant Serratia marcescens isolates from an outbreak in a Brazilian Teaching Hospital. J Clin Microbiol. 2015;53(7):2324-2328.	-

Sociedade Brasileira de Microbiologia USP - ICB III - Dep. de Microbiologia, Sociedade Brasileira de Microbiologia, Av. Prof. Lineu Prestes, 2415, Cidade Universitária, 05508-900 São Paulo, SP - Brasil, Ramal USP 7979, Tel. / Fax: (55 11) 3813-9647 ou 3037-7095 - São Paulo - SP - Brazil
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[1] *Corresponding authors. sampaio@usp.br (J.L. Sampaio), ana.gales@gmail.com (A.C. Gales).