LETTERS

Previously reported babesiosis

cases in children have been mostly
acquired by blood transfusion (10).
The patient had no history of trans-
fusions with blood products and had
never traveled outside his home town
before disease onset. Although he
and his parents did not recall any tick
bites, he was at high risk for expo-
sure to ticks because he often played
with his dog, which frequently went
outdoors in a tick-infested forested
area. The dog may have transmitted a
Babesia sp.infected tick to the pa-
tient. However, ticks from the dog
were not available for identifcation
and testing.
The patient in our study was pre-
sumed to be healthy and immunocom-
petent, which indicates that Babesia
species can cause infections even in
healthy persons. Babesiosis should be
considered in the differential diagno-
sis of patients with a history of tick
exposure and prolonged and irregu-
lar fever. Blood smear evaluation for
intraerythrocytic parasites should be
considered.
The patient was treated with
azithromycin and atovaquone and the
parasites were cleared within 1 month.
This combined treatment was well
tolerated and effective, and it can be
recommended as an alternative treat-
ment to the commonly used therapy of
quinine and clindamycin (1).
This study was supported by the Nat-
ural Science Foundation of China (grants
81130086, 30400364, and 30872196) and
the Special Fund for Health Research in
the Public Interest (grant 201202019).
Yi Sun, Shao-Gang Li,
Jia-Fu Jiang, Xin Wang,
Yuan Zhang, Hong Wang,
and Wu-Chun Cao
Author affliations: Beijing Institute of
Microbiology and Epidemiology, Beijing,
China (Y. Sun, J.-F. Jiang, X. Wang, Y.
Zhang, H. Wang, W.-C. Cao); and Capital
Medical University, Beijing (S.-G. Li)
DOI: http://dx.doi.org/10.3201/eid2005/121034
References
1. Vannier E, Krause PJ. Human babesiosis.
N Engl J Med. 2012;366:2397407.
http://dx.doi.org/10.1056/NEJMra1202018
2. Herwaldt BL, Cacci S, Gherlinzoni F,
Aspck H, Slemenda SB, Piccaluga P,
et al. Molecular characterization of a
nonBabesia divergens organism caus-
ing zoonotic babesiosis in Europe. Emerg
Infect Dis. 2003;9:9428. http://dx.doi.
org/10.3201/eid0908.020748
3. Hselbarth K, Tenter AM, Brade V,
Krieger G, Hunfeld KP. First case of
human babesiosis in Germany: clini-
cal presentation and molecular char-
acterisation of the pathogen. Int J Med
Microbiol. 2007;297:197204. http://
dx.doi.org/10.1016/j.ijmm.2007.01.002
4. Su GG, Zhao NF, Ye XX. A case report of
babesiosis [in Chinese]. Chinese Journal
of Zoonoses. 2002;18:112.
5. Yao LN, Wei R, Zeng CY, Li ZH,
Zhang X, Lei Y, et al. Pathogen identifca-
tion and clinical diagnosis for one case in-
fected with Babesia [in Chinese]. Zhong-
guo Ji Sheng Chong Xue Yu Ji Sheng
Chong Bing Za Zhi. 2012;30:11821.
6. Zhou X, Li SG, Chen SB, Wang JZ,
Xu B, Zhou HJ, et al. Co-infections with
Babesia microti and Plasmodium parasites
along the ChinaMyanmar border. Infect
Dis Poverty. 2013;2:24. http://dx.doi.
org/10.1186/2049-9957-2-24
7. Qi C, Zhou D, Liu JZ, Cheng ZQ, Zhang L,
Wang L, et al. Detection of Babesia diver-
gens using molecular methods in anemic
patients in Shandong Province, China.
Parasitol Res. 2011;109:2415. http://
dx.doi.org/10.1007/s00436-011-2382-8
8. Armstrong PM, Katavolos P, Caporale DA,
Smith RP, Spielman A, Telford SR III.
Diversity of Babesia infecting deer ticks
(Ixodes dammini). Am J Trop Med Hyg.
1998;58:73942.
9. Hunfeld KP, Lambert A, Kampen H,
Albert S, Epe C, Brade V, et al. Serop-
revalence of Babesia infections in humans
exposed to ticks in midwestern Germany.
J Clin Microbiol. 2002;40:24316. http://
dx. doi. org/10. 1128/JCM. 40. 7. 2431-
2436.2002
10. Fox LM, Wingerter S, Ahmed A,
Arnold AP, Chou J, Rhein L, et al.
Neonatal babesiosis: case report and
review of the literature. Pediatr Infect
Dis J. 2006;25:16973. http://dx.doi.
org/10.1097/01.inf.00001 95438.09628.b0
Address for correspondence: Wu-Chun
Cao, State Key Laboratory of Pathogen and
Biosecurity, Beijing Institute of Microbiology
and Epidemiology. 20 Dongda St, Fengtai
District, Beijing 100071, China; email:
[email protected]
Extended-
Spectrum
-Lactamases in
Escherichia coli
and Klebsiella
pneumoniae in
Gulls, Alaska, USA
To the Editor: Resistance to
-lactam antibacterial drugs has spread
rapidly, particularly through the CTX-
M -lactamase enzymes (CTX-M) (1).
Although CTX-Ms are geographically
widely distributed, reports of extended-
spectrum -lactamase (ESBL) dissem-
ination are few from remote regions.
In 2008, we reported phenotypic resis-
tance traits in Escherichia coli isolates
in 8.2% of wild birds sampled in the
Arctic (2). We sampled approximately
260 wild birds, mainly gulls and geese,
but found no ESBL-harboring isolates
(J. Bonnedahl et al., unpub. data). Here
we report results of our 2010 study at
Barrow, Alaska, USA, a follow up to
our 2005 study in which we found van-
comycin-resistant enterococci (VRE)
with clear traits of human origin in
glaucous gulls (3). Our fndings show
a remarkable change, not in VRE dis-
semination, which is fairly unchanged,
but in the emergence of ESBLs and
general resistance of E. coli isolates.
We collected 150 fecal samples
from a population of adult gulls resid-
ing close to a landfll site. For a de-
scription of general resistance levels
(4,5), susceptibility of 1 randomly se-
lected E. coli isolate per sample (137
isolated from 150 samples) was test-
ed to a set of 10 antibacterial agents.
Nearly half (48%) of the 137 E. coli
isolates were resistant to at least 1 of
the drugs tested. Resistance to 1 or
2 antimicrobial agents was found in
32% and 13% of the tested isolates,
respectively, and resistance to >3
was found in 3% of isolates (online
Technical Appendix Table, wwwnc.
cdc.gov/EID/article/20/5/13-0325-
Techapp1.pdf).
Emerging Infectious Diseases www.cdc.gov/eid Vol. 20, No. 5, May 2014 897
LETTERS
We analyzed samples for presence
of VRE (3). Seven (4.7%) E. faecium
isolates were found, all of which har-
bored both the vanA and the esp genes
(found in isolates of the CC17 lineage)
(3). No other VRE were found.
To investigate the presence of
ESBL-producing bacteria, we con-
ducted a selective screen as described
(6). ESBL-producing bacteria were
found (E. coli and K. pneumoniae),
and ESBL genes (bla
CTX-M
, bla
SHV
,
and bla
TEM
) in ESBL-positive isolates
were analyzed (6). We found 33 E.
coli and 35 K. pneumoniae ESBL-
producing isolates in 55 samples (12
samples had >1 unique isolate), a to-
tal of 37% of ESBL-harboring sam-
ples (Table).
We performed multi-locus se-
quence typing (MLST) on ESBL-
producing E. coli isolates (4). Isolates
were of described sequence types
(STs) (ST131 [12 isolates], ST38 [10],
ST405 [3], and ST10 [1]), and of pre-
viously undescribed STs (designated
ST2253 [1 isolate] and ST2967 [6 iso-
lates]) (Table).
In our 2005 study in Barrow, gen-
eral resistance was relatively low, and
no ESBL was found; surprisingly, how-
ever, 2 VRE isolates of a human clonal
lineage were found (3; M. Drobni et al.,
unpub. data). Since then, resistance dis-
semination, particularly that of ESBLs,
has exploded globally (1). In 2010, we
found a high level of general resistance;
48% of randomly selected E. coli iso-
lates displayed resistance toward >1
antibacterial drugs. This level is similar
to the level we found in gulls in France
in 2008, an area with high current and
historical clinical antibacterial drug
use and where birds have close contact
with human activities (4).
We screened samples for VRE
and ESBL-producing bacteria. The
prevalence of VRE decreased from
6% in 2005 to 4.7% in the current
study (3), indicating a slow decline or
stability in VRE. ESBL, on the other
hand, was not found in the 2005 study
(M. Drobni et al., unpub. data) but
emerged in 37% of samples carrying
E. coli and/or K. pneumoniae harbor-
ing ESBLs. In the study from France,
only 9.4% of birds carried ESBLs (4),
although a study of gulls in Portugal
during 20072008 reported an ESBL
carriage of 32% (7), more similar to
results of our current study but in con-
trast also because they investigated
gulls from a highly populated area.
E. coli isolates mainly carried
bla
CTX-M-14
or bla
TEM-19
, whereas K.
pneumoniae isolates mainly carried
bla
CTX-M-15
, bla
SHV-12
, or bla
SHV-102
. To
our knowledge, ESBLs in E. coli and
K. pneumoniae have not been reported
from Alaska, but in two 10-year per-
spective reports from Canada (8,9),
similar patterns and genotypes are re-
ported in E. coli and K. pneumoniae in
clinical isolates (mainly from samples
of persons with urinary tract infections
and urosepsis). Our MLST of E. coli
indicated 4 known STs; ST10, ST38,
ST131, and ST405, all very common
in the material from Canada (8), and
major STs responsible for CTX-M dis-
semination worldwide (1). Two novel
STs were found; several isolates were
designated to 1 of them. We conclude
that the relatively limited variation in
clonal variants (STs) and ESBL geno-
types is a consequence of recent intro-
duction from connecting areas, such
as Canada, possibly directly by bird
migration or human activities, of a
few resistant clones, followed by a lo-
cal clonal expansion. This conclusion
is supported by our 2005 study show-
ing no ESBLs and by studies showing
where different clones might have been
introduced continuously for long peri-
ods, such as our study in France (4),
which display a much larger diversity.
The dissemination of ESBLs to
Barrow is part of this global pattern,
and it is safe to say that humans and
wildlife share resistant E. coli fora.
When areas such as remote parts of
Alaska are affected, global coverage
is imminent.
This work was supported fnancially
by the Swedish Research Council (2008-
6892); the Health Research Council of
Southeast Sweden; and the Department of
Medical Sciences, Uppsala University.
898 Emerging Infectious Diseases www.cdc.gov/eid Vol. 20, No. 5, May 2014

Table. Characterization of Escherichia coli and Klebsiella pneumoniae ESBL-producing
isolates, Barrow, Alaska, USA*
Isolates, no.
bla genotype
MLST profile CTX-M SHV TEM
E. coli
12 14 1 ST38 (ST2253)
11 14 ST131 (ST10)
5 19 ST2967
3 27 ST405
1 15 ST131
1 1 ST2967
K. pneumoniae
4 15 12 1 ND
5 12 1 ND
2 12 ND
2 102 19 ND
8 102 ND
1 19 ND
4 15 1 1 ND
1 2 ND
*ESBL, extended-spectrum -lactamase; MLST, multilocus sequence type; ST, sequence type; ND,
no data.
E. coli comprised 33 isolates from 32 samples. K. pneumoniae comprised 35 isolates from 35
samples. and 12 samples were both E. coli and K. pneumoniae ESBL-harboring isolates but did not
display horizontal transfer resulting from deviating resistance genotypes.
One of the isolates harbored a novel MLST allele, giving the novel ST2253 (deposited in the E. coli
MLST database at the ERI, University College, Cork, Ireland.
(http://mlst.ucc.ie/mlst/mlst/dbs/Ecoli/).
One of the isolates had ST10; the remaining 10 had ST131.
Isolates harbored a novel MLST allele, rendering the novel ST2967 (deposited in the MLST
database). The single isolate with only bla
TEM-1
may contain undetected ESBL genes because of the
non-ESBL phenotype of TEM-1.

LETTERS
Jonas Bonnedahl,
Jorge Hernandez, Johan Stedt,
Jonas Waldenstrm,
Bjrn Olsen, and Mirva Drobni
Author affliations: Linnaeus University,
Kalmar, Sweden (J. Bonnedahl,
J. Hernandez, J. Stedt, J. Waldenstrm);
Kalmar County Hospital, Kalmar
(J Bonnedahl, J. Hernandez); and Uppsala
University, Uppsala, Sweden (J. Hernan-
dez, B. Olsen, M. Drobni)
DOI: http://dx.doi.org/10.3201/eid2005.130325
References
1. Naseer U, Sundsfjord A. The CTX-M
conundrum: dissemination of plasmids
and Escherichia coli clones. Microb Drug
Resist. 2011;17:8397. http://dx.doi.
org/10.1089/mdr.2010.0132
2. Sjlund M, Bonnedahl J, Hernandez J,
Bengtsson S, Cederbrant G, Pinhassi J,
et al. Dissemination of multidrug-resistant
bacteria into the Arctic. Emerg Infect Dis.
2008;14:702. http://dx.doi.org/10.3201/
eid1401.070704
3. Drobni M, Bonnedahl J, Hernandez J,
Haemig P, Olsen B. Vancomycin-resistant
enterococci, Point Barrow, Alaska, USA.
Emerg Infect Dis. 2009;15:8389. http://
dx.doi.org/10.3201/eid1505.081219
4. Bonnedahl J, Drobni M, Gauthier-Clerc M,
Hernandez J, Granholm S, Kayser Y, et al.
Dissemination of Escherichia coli with
CTX-M type ESBL between humans and
yellow-legged gulls in the south of France.
PLoS ONE. 2009;4:e5958. http://dx.doi.
org/10.1371/journal.pone.0005958
5. Gordon DM. Geographical structure
and host specifcity in bacteria and the
implications for tracing the source of
coliform contamination. Microbiology.
2001;147:107985.
6. Bonnedahl J, Drobni P, Johansson A,
Hernandez J, Melhus , Stedt J, et al.
Characterization, and comparison, of hu-
man clinical and black-headed gull (Larus
ridibundus) extended-spectrum beta-lac-
tamase-producing bacterial isolates from
Kalmar, on the southeast coast of Sweden.
J Antimicrob Chemother. 2010;65:1939
44. http://dx.doi.org/10.1093/jac/dkq222
7. Simes RR1, Poirel L, Da Costa PM,
Nordmann P. Seagulls and beaches as res-
ervoirs for multidrug-resistant Escherichia
coli. Emerg Infect Dis. 2010;16:1102.
http://dx.doi.org/10.3201/eid1601.090896
8. Peirano G, van der Bij AK, Gregson DB,
Pitout JD. Molecular epidemiology over
an 11-year period (2000 to 2010) of ex-
tended-spectrum -lactamaseproducing
Escherichia coli causing bacteremia in
a centralized Canadian region. J Clin
Microbiol. 2012;50:2949. http://dx.doi.
org/10.1128/JCM.06025-11
9. Peirano G, Sang JH, Pitondo-Silva A,
Laupland KB, Pitout JD. Molecular
epidemiology of extended-spectrum-
lactamase-producing Klebsiella pneu-
moniae over a 10 year period in Cal-
gary, Canada. J Antimicrob Chemoth-
er. 2012;67:111420. http://dx.doi.
org/10.1093/jac/dks026
Address for correspondence: Mirva Drobni,
Department of Medical Sciences/Section of
Clinical Microbiology and Infectious Diseases,
Uppsala University Hospital, SE-751 85
Uppsala, Sweden; email: mirva.drobni@
medsci.uu.se
Staphylococcus
aureus Carrying
mecC Gene in
Animals and Urban
Wastewater, Spain
To the Editor: A new methicillin
resistance mechanism gene, a diver-
gent mecA homologue named mecC
(formerly mecA
LGA251
), was recently
described in Staphylococcus aureus
(1). Methicillin-resistant S. aureus
(MRSA) isolates carrying mecC have
been recovered from humans, rumi-
nants, pets, and other animals such
as rats, seals, and guinea pigs (13).
It has been suggested that mecC-car-
rying MRSA isolates might not be de-
tected by using MRSA selective me-
dia (4). For mecC-carrying S. aureus
isolates, cefoxitin MICs of 464 mg/L
have been demonstrated (12,4), val-
ues that would normally include sus-
ceptible isolates, according to the epi-
demiologic cutoff value established by
the European Committee on Antibi-
otic Susceptibility Testing (EUCAST;
www.eucast.org). mecC-carrying S.
aureus isolates have been classifed
as heteroresistant (5), and MICs can
be affected by the drug-susceptibility
testing method used (1,5).
These observations led us to
retrospectively investigate the pres-
ence of mecC gene in a set of 361
mecA-negative S. aureus isolates
collected during 20092012 (Table),
independently of their susceptibility
to cefoxitin. Isolates were recovered
from healthy carriers in livestock (n
= 39), from wild animals (n = 254),
and from wastewater (effuents) from
an urban sewage plant (n = 68). Spe-
cifc amplifcation of the mecC gene
was performed as described (6). The
mecC-carrying S. aureus isolates were
tested by broth microdilution using
Microtiter EUST plates (Trek Diag-
nostic Systems, East Grinstead, UK)
for susceptibility to benzylpenicillin,
cefoxitin, chloramphenicol, cipro-
foxacin, clindamycin, erythromycin,
forfenicol, fusidic acid, gentamicin,
kanamycin, linezolid, mupirocin, ri-
fampin, sulfamethoxazole, strepto-
mycin, quinupristin-dalfopristin, tet-
racycline, thiamulin, trimethoprim,
and vancomycin. Additionally, sus-
ceptibility to oxacillin was determined
by using microScan Gram Positive
Combo panel 37 (Siemens, Erlangen,
Germany). MICs were interpreted ac-
cording to EUCAST epidemiologic
cutoff values.
mecC was detected in a total of 4
isolates from wild boar (n = 1), fallow
deer (n = 2), and urban wastewater (n
= 1); these isolates represent 1% of
the 361 tested isolates. The 3 isolates
recovered from animals were suscep-
tible to all antimicrobial drugs tested
other than -lactams and to oxacillin
(MICs 0.51 mg/L) but were resistant
to penicillin (MICs 0.52 mg/L). Two
of the isolates were resistant to cefoxi-
tin (MICs 8 and 16 mg/L) and the third
was susceptible (MIC 4 mg/L). The
wastewater isolate was resistant to
penicillin (MIC 2 mg/L) and erythro-
mycin (MIC 16 mg/L) and susceptible
to all other antimicrobial drugs tested,
including cefoxitin (MIC 4 mg/L) and
oxacillin (MIC 0.25 mg/L).
Emerging Infectious Diseases www.cdc.gov/eid Vol. 20, No. 5, May 2014 899