The spread and clinical impact of ST14CC-PBP3 type IIb/A, a clonal group of non- typeable Haemophilus influenzae with chromosomally mediated β-lactam resistance—a prospective observational study  V. Månsson, D. Skaare, K. Riesbeck, F. Resman  Clinical Microbiology and Infection  Volume 23, Issue 3, Pages 209.e1-209.e7 (March 2017) DOI: 10.1016/j.cmi.2016.11.006 Copyright © 2016 European Society of Clinical Microbiology and Infectious Diseases Terms and Conditions

Fig. 1 Identification of ST14CC-PBP3IIb/A isolates. To identify ST14CC-PBP3IIb/A isolates, a simplified multilocus sequence typing (MLST) scheme (using only the adk and recA gene) was adopted in combination with ftsI gene sequencing and translation. All rPBP3 non-typeable Haemophilus influenzae (NTHi) isolates with adk 5 and recA 5 (the adk and recA alleles of ST14) and PBP3IIb/A were considered ST14CC-PBP3IIb/A. One isolate had adk 5 and recA 5, but a completely different PBP3 substitution pattern (Gly490→Glu, Asn526→Lys and Ala530→Ser). All isolates with adk 5 and PBP3IIb/A also had recA 5. A randomly selected subset of ST14CC-PBP3IIb/A isolates (n=9) were confirmed ST14 by full MLST, to validate the typing scheme. Clonality of ST14CC-PBP3IIb/A isolates was further confirmed by coherent antibiotic susceptibility by disc diffusion testing for trimethoprim-sulfamethoxazole (R), nalidixic acid (S) and tetracycline (S) and analysis of ftsI sequences. Of β-lactam susceptible isolates (n=193), about half (n=91) were evaluated with the MLST-PBP3 typing scheme. Only three isolates had adk 5 and of these, all carried wild-type PBP3 and none had recA 5. Non-ST14CC-PBP3IIb/A rPBP3 isolates and the randomly selected β-lactam susceptible isolates were used to identify control patient cohorts to evaluate the clinical impact of ST14CC-PBP3IIb/A. Clinical Microbiology and Infection 2017 23, 209.e1-209.e7DOI: (10.1016/j.cmi.2016.11.006) Copyright © 2016 European Society of Clinical Microbiology and Infectious Diseases Terms and Conditions

Fig. 2 The spread of ST14CC-PBP3IIb/A in southern Skåne. Available postcodes of patients suffering from infections by ST14CC-PBP3IIb/A 2010 (n=13), 2011 (n=37) and 2012 (n=26), respectively, were plotted on maps. The proportion of patients with addresses in central Malmö (the only large urban area in the region, indicated) increased during the study years. Patients residing in inner-city Malmö constituted 15% (n=2), 27% (n=10) and 69% (n=18) of cases in 2010, 2011 and 2012, respectively. Clinical Microbiology and Infection 2017 23, 209.e1-209.e7DOI: (10.1016/j.cmi.2016.11.006) Copyright © 2016 European Society of Clinical Microbiology and Infectious Diseases Terms and Conditions