Antibiotic Susceptibility of Clinical Burkholderia pseudomallei Isolates in Northeast Thailand from 2015 to 2018 and the Genomic Characterization of <i>β</i> -Lactam-Resistant Isolates

Melioidosis is an often fatal infection in tropical regions caused by an environmental bacterium, <i>Burkholderia pseudomallei</i> Current recommended melioidosis treatment requires intravenous β-lactam antibiotics such as ceftazidime (CAZ), meropenem (MEM) or amoxicillin-clavulanic acid (AMC) and oral trimethoprim-sulfamethoxazole. Emerging antibiotic resistance could lead to therapy failure and high mortality. We performed a prospective multicentre study in northeast Thailand during 2015-2018 to evaluate antibiotic susceptibility and characterize β-lactam resistance in clinical <i>B. pseudomallei</i> isolates. Collection of 1,317 <i>B. pseudomallei</i> isolates from patients with primary and relapse infections were evaluated for susceptibility to CAZ, imipenem (IPM), MEM and AMC. β-lactam resistant isolates were confirmed by broth microdilution method and characterized by whole genome sequence analysis, <i>penA</i> expression and β-lactamase activity. The resistant phenotype was verified via <i>penA</i> mutagenesis. All primary isolates were IPM-susceptible but we observed two CAZ-resistant and one CAZ-intermediate resistant isolates, two MEM-less susceptible isolates, one AMC-resistant and two AMC-intermediate resistant isolates. One of 13 relapse isolates was resistant to both CAZ and AMC. Two isolates were MEM-less susceptible. Strains DR10212A (primary) and DR50054E (relapse) were multi-drug resistant. Genomic and mutagenesis analyses supplemented with gene expression and β-lactamase analyses demonstrated that CAZ-resistant phenotype was caused by PenA variants: P167S (N=2) and <i>penA</i> amplification (N=1). Despite the high mortality rate in melioidosis, our study revealed that <i>B. pseudomallei</i> isolates had a low frequency of β-lactam resistance caused by <i>penA</i> alterations. Clinical data suggest that resistant variants may emerge in patients during antibiotic therapy and be associated with poor response to treatment.