Vol.:(0123456789)1 3 European Journal of Clinical Microbiology & Infectious Diseases (2023) 42:1275–1280 https://doi.org/10.1007/s10096-023-04651-4 BRIEF REPORT Three separate acquisitions of blaNDM‑1 in three different bacterial species from a single patient L. F. Mataseje1 · J. Pitout2,3,4 · M. Croxen2,5,6,7 · M. R. Mulvey1 · T. C. Dingle2,3 Received: 26 May 2023 / Accepted: 7 August 2023 / Published online: 9 September 2023 © The Author(s) 2023 Abstract To investigate the acquisition and relatedness of New Delhi Metallo-beta-lactamase among multiple separate species from one patient. Five isolates from three species (Pseudomonas aeruginosa; Pa, Acinetobacter baumannii; Ab and Proteus mirabilis; Pm) suspected of harbouring a carbapenemase were investigated by phenotype (antimicrobial susceptibilities) and whole genome sequencing. Epidemiological data was collected on this patient. Three different carbapenemase genes were detected; blaVIM-1 (Pa; ST773), blaOXA-23 (Ab, ST499) and blaNDM-1 identified in all isolates. NDM regions were found chromosomally integrated in all isolates. Data showed no evidence of NDM-1 transfer within this patient suggesting the enzyme was acquired in three separate events. Keywords Carbapenemases · Canada · New Delhi metallo-beta-lactamase · Pseudomonas · Acientobacter · Proteus Brief report Gram-negative bacteria, most notably Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii were among the six most com- mon antimicrobial-resistant (AMR) pathogens identified in a global 2019 report [1]. Carbapenem resistance due to carbapenemases is of concern as transfer between differ- ent bacterial species through mobile genetic elements, such as transposons and transmissible/conjugative plasmids are common [2]. Out-of-country hospitalization is an important risk factor for colonization or infection with carbapenemase-producing organisms (CPOs) [3, 4]. In Canada, patients with interna- tional travel one year prior were significantly more likely to have extensively drug-resistant carbapenemase-producing Enterobacteriales (XDR-CPE) than a non-XDR-CPE [5]. It is essential to rapidly identify patients colonized or infected by CPOs and place them on appropriate infection control precautions. In June 2022, an elderly female with a lower urinary tract infection, hydronephrosis, and hyperglycemic crisis was admitted to the hospital. She was medevacked from a medical centre in Egypt where she was admitted in May 2022, with urosepsis secondary to a retained renal stone. She received ampicillin/sulbactam, ceftriaxone, meropenem, and moxifloxacin during her stay in Egypt. The patient was immediately placed on contact precautions. She did not receive antibiotics and no secondary spread was documented during her hospital stay in Canada. Routine admission screening for antimicrobial-resistant organisms (hospitalization >24 hours outside of Canada within 6 months) was performed using rectal swabs which were sent to the clinical laboratory. Growth of three differ- ent Gram-negative bacteria was obtained on CHROMID® CARBA SMART Agar (bioMérieux Canada, Saint-Laurent, Quebec) and identified as A. baumannii, P. aeruginosa, and Proteus mirabilis respectively. These isolates were referred to the National Microbiology Laboratory (NML) in Winnipeg for carbapenemase testing. Subsequently, * T. C. Dingle Tanis.Dingle@albertaprecisionlabs.ca 1 National Microbiology laboratory, Winnipeg, MB, Canada 2 Alberta Precision Laboratories, Public Health Laboratory, 3030 Hospital Drive N.W, Calgary, AB T2N 4W4, Canada 3 University of Calgary, Calgary, AB, Canada 4 University of Pretoria, Pretoria, Gauteng, South Africa 5 University of Alberta, Edmonton, AB, Canada 6 Li Ka Shing Institute of Virology, University of Alberta, Edmonton, AB, Canada 7 Women and Children’s Health Research Institute, University of Alberta, Edmonton, AB, Canada http://crossmark.crossref.org/dialog/?doi=10.1007/s10096-023-04651-4&domain=pdf 1276 European Journal of Clinical Microbiology & Infectious Diseases (2023) 42:1275–1280 1 3 Ta bl e 1 P he no ty pi c an d ge no ty pi c da ta o n al l i so la te s c ol le ct ed fr om a si ng le p at ie nt . M IC s w er e in te rp re te d us in g C LS I M 10 0, 3 2nd E di tio n. M IC s d id n ot d iff er b et w ee n pa irs o f P . m ira bi lis o r P. a er ug in os a is ol at es In tr p in te rp re ta tio n, S su sc ep tib le , I in te rm ed ia te , R re si st an t, IR in tri ns ic al ly re si st an t, N I n o in te rp re ta tio n, IR in tri ns ic re si st an ce Si te o f i so la tio n N 22 -0 13 47 (A .b au m an ni i) N 22 -0 21 20 (P .m ira bi lis ) N 22 -0 13 45 (P .m ira bi lis ) N 22 -0 16 90 (P .a er ug in os a) N 22 -0 17 52 (P .a er ug in os a) Re ct al S w ab Pe rit on ea l fl ui d Re ct al S w ab Re ct al S w ab U rin e In fe ct io n/ C ol on iz at io n C ol on iz at io n In fe ct io n C ol on iz at io n C ol on iz at io n In fe ct io n Se ns iti tre C A N 1M SF M IC (m g/ L) In trp M IC (m g/ L) In trp M IC (m g/ L) In trp A m ik ac in > 32 R > 32 R > 32 R A zt re on am IR - > 16 R 4 S C ef ep im e > 16 R > 16 R > 16 R C ef ta zi di m e > 16 R > 16 R > 16 R C ef ta zi di m e/ av ib ac ta m > 16 N I > 16 R > 16 R C ef to lo zo ne /ta zo ba ct am > 8 N I > 8 R > 8 R C ef tri ax on e > 32 R > 32 R IR - C ip ro flo xa ci n > 2 R > 2 R > 2 R C ol ist in < = 1 I IR - 2 I D ox yc yc lin e < = 4 S > 8 R > 8 N I Er ta pe ne m IR - > 2 R IR - G en ta m ic in > 8 R > 8 R > 8 R Im ip en em /re le ba ct am > 8 N I > 8 N I > 8 R Le vo flo xa ci n > 4 R > 4 R > 4 R M er op en em > 16 R > 16 R > 16 R M er op en em /v ab or ba ct am > 8 N I > 8 R > 8 N I M in oc yc lin e < = 4 S > 8 R > 8 N I Pi pe ra ci lli n/ ta zo ba ct am > 64 R 64 R > 64 R Pl az om ic in > 8 N I > 8 R > 8 N I Ti ge cy cl in e < = 0. 5 N I IR - IR - To br am yc in > 8 R > 8 R > 8 R Tr im et ho pr im /s ul fa m et h- ox az ol e > 4 R > 4 R IR - D at a fro m W G S Se qu en ce ty pe 49 9 N o sc he m e N o sc he m e 77 3 77 3 A M R g en es aa c( 6’ )- Ib -c r, aa c( 6’ )- Ib 3, a ph (3 ”) -I b, ap h( 3’ )-V I, ap h( 3’ )-V Ia , a ph (6 )- Id , a rm A , A R R- 3, b la A D C -2 5, bl aG ES -3 5, b la N D M -1 , b la O X A -2 3, bl aO X A -9 5, c m lA 1, d fr A 7, m ph (E ), m sr (E ), qa cE , s ul 1, su l2 aa c( 6’ )- Ib , a ac (6 ’) -I b- cr , a ad A 1, an t(2 ”) -I a, a ph (3 ’) -I a, a ph (3 ’) -V I, ar m A , b la N D M -1 , b la V EB -6 , c at , df rA 1, d fr A 5, m ph (A ), m ph (E ), m sr (E ), qa cE , q nr A 1, q nr S1 , s ul 1, te t(A ), te t(J ) aa c( 6’ )- Ib , a ac (6 ’) -I b- cr , a ad A 1, an t(2 ”) -I a, a ph (3 ’) -V I, ar m A , bl aN D M -1 , b la V EB -6 , c at , d fr A 1, df rA 5, m ph (E ), m sr (E ), qa cE , qn rA 1, q nr S1 , s ul 1, te t(A ), te t(J ) aa dA 11 , a ph (3 ’) -I Ib , b la N D M -1 , bl aO X A -3 95 , b la PA O , c at B 7, fo sA , qa cE , q nr V C 1, rm tB , s ul 1, su l1 , te t(G ) aa c( 6’ )- Il, a ad A 11 , a ad A 2b , an t(2 ”) -I a, a ph (3 ’) -I Ib , a ph (3 ’) - V I, bl aN D M -1 , b la O X A -3 92 , bl aO X A -3 95 , b la PA O , bl aV IM -1 , c at B 7, fo sA , q ac E, qn rV C 1, q nr V C 1, rm tB , s ul 1, te t(G ) Pl as m id F in de r d at a no ne d et ec te d no ne d et ec te d no ne d et ec te d no ne d et ec te d no ne d et ec te d 1277European Journal of Clinical Microbiology & Infectious Diseases (2023) 42:1275–1280 1 3 carbapenem-resistant P. aeruginosa (from urine) and P. mirabilis (from peritoneal fluid) were obtained within 7 days. A total of five isolates from the three species harbour- ing a carbapenemase were sent for whole genome sequenc- ing (WGS). Antimicrobial susceptibilities were determined (Sensititre, panel CANMSF1), which showed extensive drug resistance (XDR) in all isolates by Canadian recommenda- tions [6] using CLSI M100, 32nd edition interpretive criteria (Table 1). DNA was extracted using Qiagen DNeasy kits (Qiagen, Toronto, Canada) and sequenced on an Illumina NextSeq™ platform. MinION (Nanopore Technologies, Oxford, UK) sequencing was conducted using the rapid kit (SQK-RBK 004) on R9.4 flowcells and run on Guppy 6.3.7 using the super accurate base-calling model. De novo hybrid assemblies were done using Unicycler 0.4.7 [7]. Assembled sequence data was analyzed for Multi Locus Sequence Typ- ing (MLST), antimicrobial resistance genes, and plasmid typing using the StarAMR tool (https:// github. com/ phac- nml/ stara mr). Overall, three carbapenemases were detected; blaVIM-1 (in one of two P. aeruginosa), blaOXA-23 (A. baumannii, two copies), and blaNDM-1 (P. aeruginosa, A. baumannii, P. mirabilis). Interestingly, blaGES-35 was identified from the A. baumannii isolate. The blaGES-35 sequence was available on NCBI and identified from a K. pneumoniae and an A. baumannii isolate (accession WP_111273848, AWN81339). A report from Egypt also mentions the identification of this variant [8]. There were no mutations in the Omega Loop (guanine was present at amino acid position 170) known to be characteristic of carbapenemase activity in blaGES- variants [9]. It most closely resembles blaGES-22 a known β-lactamase [10] and differs by one amino acid within a region not shown to contribute to carbapenemase activity. The A. baumannii belonged to ST499Pas, which has recently been described as the emerging dominant non-clonal com- plex 2 carbapenem-resistant A. baumannii lineage in US hospitals [11]. The isolate in this study harboured two copies of blaOXA-23, one on a plasmid and one on the chromosome. Though not an uncommon occurrence, one study showed blaOXA-23 co-occurrence on chromosomes and plasmids altered bacterial phenotypes that are important for bacte- rial fitness such as better competitive growth, serum toler- ance, and biofilm formation capacity [12]. Additionally, this isolate harboured both blaOXA-23 and blaGES-35 on an 80Kb plasmid (pN22-01347_B) belonging to rep group RP-T1 [13]. Using PLASDB (https:// ccb- micro be. cs. uni- saarl and. de/ plsdb/) it was found that plasmids from USA [14] and Germany contained genetic content highly similar to pN22- 01347_B, with the exception of a 2.8Kb region harbouring blaOXA-23 (accession numbers CP008707, CP087311; Fig- ure S1a). This 2.8Kb region was associated with a partial Tn2007 composite transposon previously shown to be asso- ciated with blaOXA-23 dissemination [15, 16]. Like previous reports [11, 14] pN22-01347_B contained a resistance island characterized by flanking 5-bp direct repeats of a 439-bp miniature inverted-repeat transposable element (MITE)- like sequence. This 6 Kb island was inserted between an integrase and the transposition protein TniB and included the resistance genes aac(6’)-lb3, blaGES-35, aph(3’)-Vla, drfA7, qacE-delta, and sul1. The presence of these resist- ance genes in a putatively mobile genetic element could greatly enhance resistance spread to other bacteria. Both P. aeruginosa isolates belonged to ST773, sero- group O11. Core single nucleotide variant (SNV) analysis was conducted using the SNVPhly workflow [17], where 5 SNV differences (representing 99% of the genome) were observed between the core genome of the two isolates. Inter- estingly, blaVIM-1 was only found in one isolate (N22-01752) on a 450Kb circular plasmid (pN22-01752_A). When query- ing pN22-01752_A against the PLASDB similar plasmids were found belonging to IncP-2-type megaplasmids (rang- ing ~350–550Kb) isolated from China (NZ_CP073083) and Poland (NZ_MT732183, NZ_MT732197) among other countries (Fig. S1b). These are known to be associated with metallo-beta-lactamase-producing P. aeruginosa and have been identified in clinical and environmental isolates worldwide [18, 19]. Previous work on these IncP-2-type plasmids has shown its contribution in driving the dissemi- nation of multi-drug resistance in P. aeruginosa [18, 19] Indeed, pN22-01752_A harboured the AMR genes; aac(6’)- ll, aadA11 and A2b, ant(2”)-la, aph(3’)-VI, blaVIM-1, blaOXA-392-like, qacE, qnrVC1 and sul1. This plasmid was not present in the second P. aeruginosa isolate. When investigating P. mirabilis, no plasmids were observed and only 2 SNVs were observed in the core genome (representing 99% of the genome) between the two isolates. Additionally, one isolate (N22-02120) contained two separate regions (6.2Kb and 6.4Kb) each flanked by IS26 and containing additional resistance genes (qacE-delta, sul1, mph(A), aph(3’)-la) not present in the other P.mirablis. Important to the pathogenesis of P. mirabilis is the presence of several virulence factors that aid in adhesion and con- tribute to biofilm formation (MR/P, PMF, and UCA) which results in severe urinary tract infection [20]. Additional viru- lence factors such as phosphate transport (Pst), proteobac- tin (Pbt), and nonribosomal synthetase (NRPS) have been described in P. mirabilis [21]. Using the Virulence factors database (VFDB) (http:// www. mgc. ac. cn/ cgi- bin/ VFs/ v5/ main. cgi) we identified previously described virulence genes [20, 21] including mrpA-J, UCA, hpmA/B, zapA, pmfA,C-E, pbtA,B,D-I, nrpA,B,G,R-T. NDM regions were found chromosomally integrated in all isolates and were compared as shown in Fig. 1. Data showed the presence of a partial Tn125 in the A. baumannii isolate, which contained flanking copies of ISAba125 in addition to cutA, dsbC, trpF, and ble. Tn125 has been well described in A. https://github.com/phac-nml/staramr https://github.com/phac-nml/staramr https://ccb-microbe.cs.uni-saarland.de/plsdb/ https://ccb-microbe.cs.uni-saarland.de/plsdb/ http://www.mgc.ac.cn/cgi-bin/VFs/v5/main.cgi http://www.mgc.ac.cn/cgi-bin/VFs/v5/main.cgi 1278 European Journal of Clinical Microbiology & Infectious Diseases (2023) 42:1275–1280 1 3 baumannii and linked to the dissemination of blaNDM-1 in this species [22]. The P. mirabilis blaNDM-1 region differed by the insertion of IS630 between ISAba125 and blaNDM-1 as well as the presence of IS26 adjacent to cutA (Fig. 1). This region and the surrounding 25 Kb in the P. mirabilis isolates were similar to several K. pneumoniae NDM plasmids described in NCBI (accession numbers CP050380, ON081621, MW911671), possibly suggesting a partial plasmid integration event into the P. mirabilis genome. Unfortunately, we could not iden- tify specific genetic artifacts of where in the chromosome this occurred. The P. aeruginosa isolates had no similarity in surrounding NDM regions to either the P. mirabilis or the A. baumannii. Here blaNDM-1 was found inserted between two copies of a truncated IS91-like sequence. Similar to reports of NDM-1 harbouring P. aeruginosa ST773 [23] and ST234 [24] here, we observed blaNDM-1 on a putative integrative conjuga- tive element (ICE) with a type four secretion system. The ICE was 116997bp flanked by attL and attR 23bp direct repeats inserted into tRNA. Overall, the NDM analysis in the vari- ous species suggested the patient acquired bacteria harbouring blaNDM-1 in three separate events. Although the occurrence of multiple carbapenemases within a single patient has been commonly reported [25–27], it is important to highlight this case for several reasons. First, the A. baumannii isolate was shown to be an emerging clonal lineage (ST499) and contained duplicated copies of blaOXA-23, which has been previously shown to provide advantages to the fitness of the isolate [11]. Second, this patient also harboured a P. aeruginosa isolate that contained a previously described multi-resistant plasmid known to contribute to the dissemi- nation of resistance genes in this species. Though the goal of this study was to investigate the relationship of blaNDM-1 across these isolates we revealed a complex collection of XDR pathogenic bacterial species that have the potential to rapidly spread multi-drug resistance within a hospital site. Supplementary Information The online version contains supplemen- tary material available at https:// doi. org/ 10. 1007/ s10096- 023- 04651-4. Acknowledgements We would like to thank Ken Fakharuddin for his technical expertise and the Genomics Core Facility for Illumina sequencing. Funding This project was funded by the Public Health Agency of Canada. Data availability Sequence data was uploaded to NCBI (BioProject PRJNA948358). Declarations Ethical approval Ethics approval was obtained through the University of Calgary Conjoint Health Research Ethics Board (REB17-1010_ REN5). Competing interests The authors declare no competing interests. Fig. 1 Schematic representation of NDM regions aligned between the three bacterial species in this study. Green represents resistance genes, blue represents mobile genetic elements and black are all other CDSs https://doi.org/10.1007/s10096-023-04651-4 1279European Journal of Clinical Microbiology & Infectious Diseases (2023) 42:1275–1280 1 3 Open Access This article is licensed under a Creative Commons Attri- bution 4.0 International License, which permits use, sharing, adapta- tion, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. References 1. Antimicrobial Resistance Collaborators (2022) Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet 399:629–655. https:// doi. org/ 10. 1016/ S0140- 6736(21) 02724-0 2. Pitout JDD, Nordmann P, Poirel L (2015) Carbapenemase-produc- ing Klebsiella pneumoniae, a key pathogen set for global nosoco- mial dominance. Antimicrob Agents Chem 59:5873–5884. https:// doi. org/ 10. 1128/ AAC. 01019- 15 3. van der Bij AK, Pitout JDD (2012) The role of international travel in the worldwide spread of multiresistant Enterobacteriaceae. J Antimicrob Chemother 67:2090–2100. https:// doi. org/ 10. 1093/ jac/ dks214 4. Chan WW, Peirano G, Smyth DJ, Pitout JDD (2013) The charac- teristics of Klebsiella pneumoniae that produce KPC-2 imported from Greece. Diagn Microbiol Infect Dis 75:317–319. https:// doi. org/ 10. 1016/j. diagm icrob io. 2012. 12. 003 5. Bartoszko JJ, Mitchell R, Katz K et al (2022) Characterization of extensively drug-resistant (XDR) Carbapenemase-producing enterobacterales (CPE) in Canada from 2019 to 2020. Microbiol Spectr 10:e00975–e00922. https:// doi. org/ 10. 1128/ spect rum. 00975- 22 6. German GJ, Gilmour M, Tipples G et al (2018) Canadian recom- mendations for laboratory interpretation of multiple or extensive drug resistance in clinical isolates of Enterobacteriaceae, Acine- tobacter species and Pseudomonas aeruginosa. Can Commun Dis Rep 44:29–34. https:// doi. org/ 10. 14745/ ccdr. v44i0 1a07 7. Wick RR, Judd LM, Gorrie CL, Holt KE (2017) Completing bacterial genome assemblies with multiplex MinION sequenc- ing. Microb Genom 3:e000132. https:// doi. org/ 10. 1099/ mgen.0. 000132 8. Fam NS, Gamal D, Mohamed SH et al (2020) Molecular charac- terization of Carbapenem/Colistin-resistant Acinetobacter bau- mannii clinical isolates from Egypt by whole-genome sequenc- ing. Infect Drug Resist 13:4487–4493. https:// doi. org/ 10. 2147/ IDR. S2888 65 9. Stewart NK, Smith CA, Frase H et al (2015) Kinetic and struc- tural requirements for carbapenemase activity in GES-type β-lactamases. Biochemistry 54:588–597. https:// doi. org/ 10. 1021/ bi501 052t 10. Castanheira M, Costello SE, Woosley LN et al (2014) Evalu- ation of Clonality and Carbapenem Resistance Mechanisms among Acinetobacter baumannii-Acinetobacter calcoaceticus Complex and Enterobacteriaceae Isolates Collected in Euro- pean and Mediterranean Countries and Detection of Two Novel β-Lactamases, GES-22 and VIM-35. Antimicrobial Agents and Chem 58:7358–7366. https:// doi. org/ 10. 1128/ AAC. 03930- 14 11. Iovleva A, Mustapha MM, Griffith MP et al (2022) Carbape- nem-resistant Acinetobacter baumannii in U.S. hospitals: diver- sification of circulating lineages and antimicrobial resistance. mBio 13:e0275921. https:// doi. org/ 10. 1128/ mbio. 02759- 21 12. Wang Z, Li H, Zhang J, Wang H (2021) Co-occurrence of blaOXA-23 in the chromosome and plasmid: increased fitness in Carbapenem-resistant Acinetobacter baumannii. Antibiotics 10:1196. https:// doi. org/ 10. 3390/ antib iotic s1010 1196 13. Lam MMC, Koong J, Holt KE et al (2022) Detection and typ- ing of plasmids in Acinetobacter baumannii using rep genes encoding replication initiation proteins. Microbiol Spectr 11(1):e02478-22. https:// doi. org/ 10. 1128/ spect rum. 02478- 22 14. Gallagher LA, Ramage E, Weiss EJ et al (2015) Resources for genetic and genomic analysis of emerging pathogen Acinetobacter baumannii. J Bacteriol 197:2027–2035. https:// doi. org/ 10. 1128/ JB. 00131- 15 15. Corvec S, Poirel L, Naas T et al (2007) Genetics and expression of the carbapenem-hydrolyzing oxacillinase gene blaOXA-23 in Acinetobacter baumannii. Antimicrob Agents Chemother 51:1530–1533. https:// doi. org/ 10. 1128/ AAC. 01132- 06 16. Mugnier PD, Poirel L, Naas T, Nordmann P (2010) Worldwide dissemination of the blaOXA-23 Carbapenemase gene of Acine- tobacter baumannii1. Emerg Infect Dis 16:35–40. https:// doi. org/ 10. 3201/ eid16 01. 090852 17. Petkau A, Mabon P, Sieffert C et al (2017) SNVPhyl: a single nucleotide variant phylogenomics pipeline for microbial genomic epidemiology. Microb Genom 3:e000116. https:// doi. org/ 10. 1099/ mgen.0. 000116 18. Cazares A, Moore MP, Hall JPJ et al (2020) A megaplasmid family driving dissemination of multidrug resistance in Pseu- domonas. Nat Commun 11:1370. https:// doi. org/ 10. 1038/ s41467- 020- 15081-7 19. Urbanowicz P, Bitar I, Izdebski R et al (2021) Epidemic territorial spread of IncP-2-type VIM-2 Carbapenemase-encoding megaplas- mids in nosocomial Pseudomonas aeruginosa populations. Anti- microb Agents Chemother 65:e02122–e02120. https:// doi. org/ 10. 1128/ AAC. 02122- 20 20. Beltrão EMB, de Oliveira ÉM, Scavuzzi AML et  al (2022) Virulence factors of Proteus mirabilis clinical isolates carrying blaKPC-2 and blaNDM-1 and first report blaOXA-10 in Brazil. J Infect Chemother 28:363–372. https:// doi. org/ 10. 1016/j. jiac. 2021. 11. 001 21. Schaffer JN, Pearson MM (2015) Proteus mirabilis and urinary tract infections. Microbiol Spectr 3(5). https:// doi. org/ 10. 1128/ micro biols pec. UTI- 0017- 2013 22. Poirel L, Bonnin RA, Boulanger A et al (2012) Tn125-related acquisition of blaNDM-like genes in Acinetobacter baumannii. Antimicrob Agents Chemother 56:1087–1089. https:// doi. org/ 10. 1128/ AAC. 05620- 11 23. Khan A, Shropshire WC, Hanson B et al (2020) Simultaneous infection with Enterobacteriaceae and Pseudomonas aerugi- nosa harboring multiple carbapenemases in a returning traveler colonized with Candida auris. Antimicrob Agents Chemother 64:e01466–e01419. https:// doi. org/ 10. 1128/ AAC. 01466- 19 24. Urbanowicz P, Izdebski R, Baraniak A et al (2019) Pseudomonas aeruginosa with NDM-1, DIM-1 and PME-1 β-lactamases, and RmtD3 16S rRNA methylase, encoded by new genomic islands. J Antimicrob Chemother 74:3117–3119. https:// doi. org/ 10. 1093/ jac/ dkz262 25. Ham DC, Mahon G, Bhaurla SK et al (2021) Gram-negative bac- teria harboring multiple Carbapenemase genes, United States, 2012–2019. Emerg Infect Dis 27:2475–2479. https:// doi. org/ 10. 3201/ eid27 09. 210456 http://creativecommons.org/licenses/by/4.0/ https://doi.org/10.1016/S0140-6736(21)02724-0 https://doi.org/10.1016/S0140-6736(21)02724-0 https://doi.org/10.1128/AAC.01019-15 https://doi.org/10.1128/AAC.01019-15 https://doi.org/10.1093/jac/dks214 https://doi.org/10.1093/jac/dks214 https://doi.org/10.1016/j.diagmicrobio.2012.12.003 https://doi.org/10.1016/j.diagmicrobio.2012.12.003 https://doi.org/10.1128/spectrum.00975-22 https://doi.org/10.1128/spectrum.00975-22 https://doi.org/10.14745/ccdr.v44i01a07 https://doi.org/10.1099/mgen.0.000132 https://doi.org/10.1099/mgen.0.000132 https://doi.org/10.2147/IDR.S288865 https://doi.org/10.2147/IDR.S288865 https://doi.org/10.1021/bi501052t https://doi.org/10.1021/bi501052t https://doi.org/10.1128/AAC.03930-14 https://doi.org/10.1128/mbio.02759-21 https://doi.org/10.3390/antibiotics10101196 https://doi.org/10.1128/spectrum.02478-22 https://doi.org/10.1128/JB.00131-15 https://doi.org/10.1128/JB.00131-15 https://doi.org/10.1128/AAC.01132-06 https://doi.org/10.3201/eid1601.090852 https://doi.org/10.3201/eid1601.090852 https://doi.org/10.1099/mgen.0.000116 https://doi.org/10.1099/mgen.0.000116 https://doi.org/10.1038/s41467-020-15081-7 https://doi.org/10.1038/s41467-020-15081-7 https://doi.org/10.1128/AAC.02122-20 https://doi.org/10.1128/AAC.02122-20 https://doi.org/10.1016/j.jiac.2021.11.001 https://doi.org/10.1016/j.jiac.2021.11.001 https://doi.org/10.1128/microbiolspec.UTI-0017-2013 https://doi.org/10.1128/microbiolspec.UTI-0017-2013 https://doi.org/10.1128/AAC.05620-11 https://doi.org/10.1128/AAC.05620-11 https://doi.org/10.1128/AAC.01466-19 https://doi.org/10.1093/jac/dkz262 https://doi.org/10.1093/jac/dkz262 https://doi.org/10.3201/eid2709.210456 https://doi.org/10.3201/eid2709.210456 1280 European Journal of Clinical Microbiology & Infectious Diseases (2023) 42:1275–1280 1 3 26. Mataseje LF, Chen L, Peirano G et al (2022) Klebsiella pneu- moniae ST147: and then there were three carbapenemases. Eur J Clin Microbiol Infect Dis 41:1467–1472. https:// doi. org/ 10. 1007/ s10096- 022- 04514-4 27. Meletis G, Chatzidimitriou D, Malisiovas N (2015) Double- and multi-carbapenemase-producers: the excessively armored bacilli of the current decade. Eur J Clin Microbiol Infect Dis 34:1487– 1493. https:// doi. org/ 10. 1007/ s10096- 015- 2379-9 Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. https://doi.org/10.1007/s10096-022-04514-4 https://doi.org/10.1007/s10096-022-04514-4 https://doi.org/10.1007/s10096-015-2379-9 Three separate acquisitions of blaNDM-1 in three different bacterial species from a single patient Abstract Brief report Anchor 4 Acknowledgements References