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Figure S1. Origin of the 107 German carbapenemase-producing K. pneumoniae isolates. Regions are shown, where isolates originated from. Isolates from Saxony could not be elucidated further due to the lack of additional geographic information. Number of isolates is given by the size of the circle (see legend). Image is from: © Bundesamt für Kartographie und Geodäsie, Frankfurt am Main, Germany. Figure S2. Virulence gene content in 107 carbapenemase-producing K. pneumonaie isolates from Germany. Data are given in % of isolates showing possession of the corresponding gene cluster. The graph shows four most frequent virulence genes identified in more than one single isolate. Figure S3. Detailed view of the ML tree concerning ST258/ST512 – carbapenemase-producing K. pneumoniae isolates from Germany, 2008-2014. The image shows a subtree of Fig. 3 containing 52 isolates of ST258 (light violett) and ST512 (grey). Colour codes of the inner ring designate the corresponding carbapenemase type, the outer designates the wzi allele (see legend). Figure S4. ML tree of NGS-based analysis of German K. pneumoniae isolates and isolates from an international collection - detailed view of the cluster ST258/ST512 isolates. The image shows a subtree of Fig. 4 containing 66 isolates of ST258 and ST512. Colour codes of the inner ring correspond to the origin of strains, the middle ring to the carbapenemase KPC-2 or KPC-3, and the outer ring demonstrates the wzi allele type. (PPTX 1367 kb)

Table S2. Names and sequences of used primers for MLST and PCR amplification of virulence genes and β-lactamase genes. Table S3. Identified virulence genes in K. pneumoniae isolate no. 316/15 (ST23, OXA-48). Table S4. Identified wzi alleles from NGS data of 107 carbapenemase-producing K. pneumoniae from Germany. (DOCX 35 kb)

Public health interventions to control the current epidemic of carbapenem-resistant Klebsiella pneumoniae rely on a comprehensive understanding of its emergence and spread over a wide range of geographical scales. We analysed the genome sequences and epidemiological data of >1,700 K. pneumoniae samples isolated from patients in 244 hospitals in 32 countries during the European Survey of Carbapenemase-Producing Enterobacteriaceae. We demonstrate that carbapenemase acquisition is the main cause of carbapenem resistance and that it occurred across diverse phylogenetic backgrounds. However, 477 of 682 (69.9%) carbapenemase-positive isolates are concentrated in four clonal lineages, sequence types 11,15,101, 258/512 and their derivatives. Combined analysis of the genetic and geographic distances between isolates with different beta-lactam resistance determinants suggests that the propensity of K. pneumoniae to spread in hospital environments correlates with the degree of resistance and that carbapenemase-positive isolates have the highest transmissibility. Indeed, we found that over half of the hospitals that contributed carbapenemase-positive isolates probably experienced within-hospital transmission, and interhospital spread is far more frequent within, rather than between, countries. Finally, we propose a value of 21 for the number of single nucleotide polymorphisms that optimizes the discrimination of hospital clusters and detail the international spread of the successful epidemic lineage, ST258/512.

Table S2. Names and sequences of used primers for MLST and PCR amplification of virulence genes and β-lactamase genes. Table S3. Identified virulence genes in K. pneumoniae isolate no. 316/15 (ST23, OXA-48). Table S4. Identified wzi alleles from NGS data of 107 carbapenemase-producing K. pneumoniae from Germany. (DOCX 35 kb)

Figure S1. Origin of the 107 German carbapenemase-producing K. pneumoniae isolates. Regions are shown, where isolates originated from. Isolates from Saxony could not be elucidated further due to the lack of additional geographic information. Number of isolates is given by the size of the circle (see legend). Image is from: © Bundesamt für Kartographie und Geodäsie, Frankfurt am Main, Germany. Figure S2. Virulence gene content in 107 carbapenemase-producing K. pneumonaie isolates from Germany. Data are given in % of isolates showing possession of the corresponding gene cluster. The graph shows four most frequent virulence genes identified in more than one single isolate. Figure S3. Detailed view of the ML tree concerning ST258/ST512 – carbapenemase-producing K. pneumoniae isolates from Germany, 2008-2014. The image shows a subtree of Fig. 3 containing 52 isolates of ST258 (light violett) and ST512 (grey). Colour codes of the inner ring designate the corresponding carbapenemase type, the outer designates the wzi allele (see legend). Figure S4. ML tree of NGS-based analysis of German K. pneumoniae isolates and isolates from an international collection - detailed view of the cluster ST258/ST512 isolates. The image shows a subtree of Fig. 4 containing 66 isolates of ST258 and ST512. Colour codes of the inner ring correspond to the origin of strains, the middle ring to the carbapenemase KPC-2 or KPC-3, and the outer ring demonstrates the wzi allele type. (PPTX 1367 kb)

Background: Multidrug-resistant Gram-negative bacteria (MRGN) and the infections they cause are a serious threat and a challenge to the healthcare system. This particularly applies to carbapenem-resistant Gram-negative bacteria (CRGN). Currently, the introduction of a nationwide mandatory notification system for CRGN in Germany is under consideration. Against this background, this paper presents an analysis of the mandatory reporting system for CRGN in effect since November 2011 in the federal state of Hesse (Germany). Materials and methods: All carbapenem-resistant Gram-negative bacteria and the detected carbapenemases reported to the public health department of the city of Frankfurt am Main, Hesse, Germany, on the basis of the mandatory notification system were analyzed. Results: 827 CRGN cases were reported to the public health department of Frankfurt/Main between April 2012 and December 2015. The following bacterial species were reported: Pseudomonas spp. (n=268), Acinetobacter spp. (n=183), Klebsiella spp. (n=195), Enterobacter spp. (n=77), Escherichia coli (n=75) and others (n=29). Between 2012 and 2015, a reduction of the CRGN reports was noticed, mainly due to changes in the reporting of Pseudomonas spp. Between 2012 and 2015, the total number of notifications decreased slightly, although the number of reported CRGN in screening samples increased, thus giving no indication of a decreased testing frequency. For 10.5% of the patients, the place of residence was not Germany, 18.0% of the patients had previously stayed in hospitals abroad, often in countries with a high CRGN prevalence. CRGN bacteria were reported from all of Frankfurt’s hospitals, and 3.9% were reported from out-patient care facilities. Carbapenemases were detected and reported in 251 CRGN bacteria, including 73 OXA-48, 76 OXA-23, 56 NDM subtypes, and 21 KPC subtypes. There have been no major epidemiological signs of outbreak scenarios. Discussion: CRGN bacteria are already widespread in patients from hospitals and out-patient care facilities. Clearly, infection control measurements should therefore not only include hospital patients but also those receiving out-patient care. Screening strategies focused on patients from foreign countries with high MRGN prevalence is not sufficient, as only 10.5% of MRGN patients resided in those countries, and only 18% of the patients had been previously treated in a foreign hospital. In a public health context, infection control measures should therefore encompass broader screening strategies., Hintergrund: Multiresistente gramnegative Stäbchenbakterien (MRGN) und dadurch verursachte Infektionen sind eine Bedrohung und große Herausforderung für das Gesundheitswesen. Das betrifft insbesondere Carbapenem-resistente gramnegative Bakterien (CRGN). Derzeit wird überlegt, eine bundesweite Meldepflicht für CRGN in Deutschland einzuführen. Vor diesem Hintergrund wird eine Analyse der seit Ende 2011 in Hessen geltenden Meldepflicht für CRGN vorgelegt. Material und Methode: Alle dem Gesundheitsamt Frankfurt auf der Grundlage der Hessischen Meldepflicht gemeldeten Erreger mit Resistenz gegen Carbapeneme (4MRGN nach KRINKO) und der nachgewiesenen Carbapenemasen werden vorgestellt. Ergebnisse: Von April 2012 bis Dezember 2015 erreichten das Gesundheitsamt 827 Nachweise von CRGN, darunter 268 Nachweise von Pseudomonas spp., 183 Nachweise von Acinetobacter spp., 195 Klebsiella spp., 77 Enterobacter spp., 75 Escherichia coli und 29 andere. Von 2012 bis 2015 ist insgesamt ein leichter Rückgang der Meldungen erkennbar, bedingt im Wesentlichen durch eine Änderung der Meldepflicht für P. aeruginosa. Über die Jahre hat der Anteil der gemeldeten Nachweise aus Screeningproben zugenommen, d.h. es liegt kein Hinweis auf eine abnehmende Untersuchungsfrequenz vor. Fast 10,5% der Patienten hatten ihren Wohnsitz im Ausland, 18% hatten einen vorangegangenen Klinikaufenthalt im Ausland angegeben, häufig in Ländern mit bekannt hohem CRGN-Risiko. CRGN wurden aus allen Frankfurter Kliniken gemeldet, 3,9% auch aus ambulanten Einrichtungen. Bei 251 CRGN-Bakterien wurden Carbapenemasen nachgewiesen und gemeldet, darunter u.a. 73 OXA-48-, 76 OXA-23-, 56 NDM-, 21 KPC-Subtypen. Hinweise auf größere Ausbrüche ergaben sich nicht. Diskussion: Der Nachweis von CRGN bei Patienten in allen Kliniken und auch in ambulanten Praxen zeigt, dass diese Erreger schon weit verbreitet sind. Nicht nur in der Klinik, sondern auch im ambulanten Bereich muss mit dieser Problematik sachgerecht umgegangen werden. Ein Screening allein bei Patienten mit Auslandsanamnese greift zu kurz, da nur bei ca. 10,5% der Patienten mit CRGN der Wohnort im Ausland liegt und nur bei ca. 18% der Patienten ein vorausgehender Aufenthalt in einem ausländischen Krankenhaus stattgefunden hatte. Aus krankenhaushygienischen Gründen müssen deshalb umfassendere Screening-Konzepte entwickelt werden., GMS Hygiene and Infection Control; 11:Doc10