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First case of resistance to tigecycline by Klebsiella pneumoniae in a European University HospitalIK Neonakis1, K Stylianou2, E Daphnis2, S Maraki11Department of Clinical Bacteriology, Parasitology, Zoonoses and Geographical Medicine , University Hospital of Heraklion, 71110 Heraklion, Crete, Greece2Department of Nephrology, University Hospital of Heraklion, PO Box 1352, 71110 Heraklion, Crete, GreeceDate of Submission07-Nov-2000Date of Acceptance16-Dec-2010Date of Web Publication7-Feb-2011Correspondence Address:I K NeonakisDepartment of Clinical Bacteriology, Parasitology, Zoonoses and Geographical Medicine , University Hospital of Heraklion, 71110 Heraklion, Crete GreeceDOI: 10.4103/0255-0857.76535PMID:21304206How to cite this article:Neonakis IK, Stylianou K, Daphnis E, Maraki S. First case of resistance to tigecycline by Klebsiella pneumoniae in a European University Hospital. Indian J Med Microbiol 2011;29:78-9How to cite this URL:Neonakis IK, Stylianou K, Daphnis E, Maraki S. First case of resistance to tigecycline by Klebsiella pneumoniae in a European University Hospital. Indian J Med Microbiol serial online 2011 cited2011 Jul 21;29:78-9. Available from:/text.asp?2011/29/1/78/76535Dear Editor,Currently carbapenem-resistant Klebsiella pneumoniae is one of the most problematic pathogens, as treatment has largely been limited to colistin (COL) and tigecycline (TIG). Here we present the first case of TIG-resistance in our region.A 62-years old female with an end-stage renal disease secondary to adult dominant polycystic kidney disease (in haemodialysis for 15 years) was recurrently (12 times only in 2010) admitted due to cholangitis. Among others her prior medical history included chronic hypertension, hysterectomy (1986), recurrent pyogenic cholangitis since 2004, endoscopic sphincterotomy of Vaters ampulla and gallstones removal (2005), bilateral nephrectomy due to recurrent infections (2006) and open cholecystectomy and choledocholithotomy due to gallstones (2009). Over the last year, a variety of Gram-negative (including imipenem- and COL-resistant Acinetobacter baumannii, Pseudomonas aeruginosa and K. pneumoniae) and Gram-positive microbia (including vancomycin-resistant Enterococcus faecium) have been isolated and TIG was extensively used. K. pneumoniae was isolated from a pigtail catheter sample. Vitek-2 (bioMerieux) revealed resistance to all antimicrobials including resistance to TIG (8 mg/L) with the exception of gentamicin (=1 mg/L) and COL (=0.5 mg/L). The precise MIC was further determined to be 24 mg/L with the E-test (AB Biodisk). A regiment including COL was administered and currently the patient is stable and considered for double liver and kidney transplantation.Resistance to tigecycline has been attributed to overexpression of efflux pumps such as the AcrAB RND-type efflux pump. Until now there have only been sporadic reports on TIG-resistant K. pneumoniae isolates worldwide 1,2,3 . Greece has been shown to be a hot spot of antimicrobial resistance 4 . During 2008, in our Hospital IMP-non-susceptibility rate of K. pneumoniae reached 50% and among the IMP-resistant isolates 24% was also resistant to COL 5 . For these cases, TIG was the salvage therapy as no TIG-resistance had been previously noticed. The development of TIG-resistance is an issue of great concern and will probably lead to deaths due to untreatable infections. Appropriate policies should be urgently designed and implemented. References1.Garrison MW, Mutters R, Dowzicky MJ. In vitro activity of tigecycline and comparator agents against a global collection of Gram-negative and Gram-positive organisms: tigecycline Evaluation and Surveillance Trial 2004 to 2007. Diagn Microbiol Infect Dis. 2009;65:288-99.PUBMEDFULLTEXT2.Elemam A, Rahimian J, Mandell W. Infection with Panresistant Klebsiella pneumoniae: A Report of 2 Cases and a Brief Review of the Literature. Clin Inf Dis 2009; 49:271-4.3.Papaparaskevas J, Tzouvelekis LS, Tsakris A, Pittaras TE, Legakis NJ; Hellenic Tigecycline Study Group. In vitro activity of tigecycline against 2423 clinical isolates and comparison of the available interpretation breakpoints. Diagn Microbiol Infect Dis. 2010;66:187-94.4.Neonakis I, Gikas A, Scoulica E, Manios A, Georgiladakis A, Tselentis Y. Evolution of aminoglycoside resistance phenotypes of four Gram-negative bacteria: an 8-year survey in a University Hospital in Greece. Int J Antimicrob Agents 2003;22:526-531.PUBMEDFULLTEXT5.Neonakis IK, Samonis G, H. Messaritakis H, Baritaki S, Georgiladakis A, Maraki