Harvesting and amplifying gene cassettes confers cross-resistance to critically important antibiotics.

Amikacin and piperacillin/tazobactam are frequent antibiotic choices to treat bloodstream infection, which is commonly fatal and most often caused by bacteria from the family Enterobacterales. Here we show that two gene cassettes located side-by-side in and ancestral integron similar to In37 have been "harvested" by insertion sequence IS26 as a transposon that is widely disseminated among the Enterobacterales. This transposon encodes the enzymes AAC(6')-Ib-cr and OXA-1, reported, respectively, as amikacin and piperacillin/tazobactam resistance mechanisms. However, by studying bloodstream infection isolates from 769 patients from three hospitals serving a population of 1.2 million people in South West England, we show that increased enzyme production due to mutation in an IS26/In37-derived hybrid promoter or, more commonly, increased transposon copy number is required to simultaneously remove these two key therapeutic options; in many cases leaving only the last-resort antibiotic, meropenem. These findings may help improve the accuracy of predicting piperacillin/tazobactam treatment failure, allowing stratification of patients to receive meropenem or piperacillin/tazobactam, which may improve outcome and slow the emergence of meropenem resistance. Author summary: Piperacillin/tazobactam and amikacin are common antibiotic choices for treating bloodstream infections, which are potentially lethal and predominantly caused by the bacterium Escherichia coli. By studying a large collection of bloodstream E. coli we show that dual resistance to piperacillin/tazobactam and amikacin is unexpectedly common. We explain this by showing that two resistance genes are circulating widely as part of a transposon. We show that genetic changes in the transposon, most commonly an increase in the number of copies of the transposon in the genome, are required to confer co-resistance to both antibiotics. Hence we have identified an important, emerging, mobile genetic element with the potential to compromise therapy by two commonly used antibiotics for bloodstream infection. We also show how this knowledge might be used to improve the sensitivity of tests for piperacillin/tazobactam resistance by integrating the results of amikacin resistance testing, reducing treatment failure and sparing last resort antibiotics. [ABSTRACT FROM AUTHOR]