Impact of carbapenem heteroresistance among clinical isolates of invasive Escherichia coli in Chongqing, southwestern China J.D. Sun, S.F. Huang, S.S.

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Impact of carbapenem heteroresistance among clinical isolates of invasive Escherichia coli in Chongqing, southwestern China J.D. Sun, S.F. Huang, S.S. Yang, S.L. Pu, C.M. Zhang, L.P. Zhang Clinical Microbiology and Infection Volume 21, Issue 5, Pages 469.e1-469.e10 (May 2015) DOI: 10.1016/j.cmi.2014.12.013 Copyright © 2014 European Society of Clinical Microbiology and Infectious Diseases Terms and Conditions

Fig. 1 Characteristics of clinical invasive Escherichia coli with heteroresistance traits on carbapenem disks. (a) Satellite colonies on the meropenem disk for some clinical isolates with heteroresistance to meropenem. (b) Zone phenomena on the imipenem disk for some clinical isolates with heteroresistance to imipenem. (c) Zone phenomena and satellite colonies on the ertapenem disk for some clinical strains with heteroresistance to ertapenem. (d) Zone phenomena and satellite colonies on carbapenem disks for some clinical isolates showing co-heteroresistance to meropenem, imipenem, and ertapenem. Clinical Microbiology and Infection 2015 21, 469.e1-469.e10DOI: (10.1016/j.cmi.2014.12.013) Copyright © 2014 European Society of Clinical Microbiology and Infectious Diseases Terms and Conditions

Fig. 2 Characteristics of clinical carbapenem-heteroresistant Escherichia coli isolates in the carbapenem MIC gradient strips. (a) Zone phenomena and satellite colonies in the ertapenem MIC gradient strips for some clinical strains with heteroresistance to ertapenem. (b) Zone phenomena and satellite colonies in the meropenem MIC gradient strips for some clinical isolates with heteroresistance to meropenem. (c) Satellite colonies observed in the imipenem MIC gradient strips for some clinical isolates with heteroresistance to imipenem. Clinical Microbiology and Infection 2015 21, 469.e1-469.e10DOI: (10.1016/j.cmi.2014.12.013) Copyright © 2014 European Society of Clinical Microbiology and Infectious Diseases Terms and Conditions

Fig. 3 Population analysis proﬁling (PAP) and pulsed-ﬁeld gel electrophoresis (PFGE) for isolates No. 1021 and No. 88. The x-axis shows the carbapenem concentration in micrograms per millilitre, which was used to select subpopulations with higher carbapenem resistance levels. The y-axis shows the frequency of bacterial cells as the logarithm of the CFUs per millilitre. (a–c) PAP for No. 1021, No. 88, and the standard carbapenem-susceptible Escherichia coli control isolate ATCC 25922, as plotted against the antibiotic concentrations of ertapenem (a), imipenem (b) and meropenem (c). PFGE patterns of the two isolates (d). Clinical Microbiology and Infection 2015 21, 469.e1-469.e10DOI: (10.1016/j.cmi.2014.12.013) Copyright © 2014 European Society of Clinical Microbiology and Infectious Diseases Terms and Conditions

Fig. 4 The stability of heteroresistance of isolates No. 1021 and No. 88. Population analysis proﬁling for the progeny strains of No. 1021 and No. 88 with heteroresistance to carbapenems. (a) Two derivatives of No. 1021 obtained by successive subculture selection of a single heteroresistant colony on ertapenem disks (the first and the second derivatives are illustrated). (b) Ten derivatives of No. 1021 obtained by successive subculture selection of a single heteroresistant colony on meropenem disks (the third, sixth, ninth and tenth derivatives are illustrated). (c) Nine derivatives of No. 88 obtained by successive subculture selection of a single heteroresistant colony on meropenem disks (the third, sixth and ninth derivatives are illustrated). Clinical Microbiology and Infection 2015 21, 469.e1-469.e10DOI: (10.1016/j.cmi.2014.12.013) Copyright © 2014 European Society of Clinical Microbiology and Infectious Diseases Terms and Conditions