Arrival of the rare carbapenemase OXA-204 in Canada causing a multispecies outbreak over 3 years.

Objectives: To investigate a persistent multispecies OXA-204 outbreak occurring simultaneously in multiple distant hospitals in the province of Quebec, Canada. Methods: OXA-204 carbapenemase-producing Enterobacterales (CPE) isolated from multiple hospitals between January 2016 and October 2018 were included in the study. An epidemiological inquiry was conducted in order to elucidate possible transmission routes and a putative source. Isolates were characterized by standardized antibiotic susceptibility testing and by WGS, using Illumina short-read data and MinION long-read data. Results: The outbreak comprised 65 patients and 82 isolates from four hospital sites. Most patients were >= 65years old, had multiple comorbidities and had received antibiotics recently. The infection to colonization ratio was 1:20. No persistent environmental reservoir was identified. The most frequent organism was Citrobacter freundii (n=78), followed by Klebsiella spp. (n=3) and Escherichia coli (n=1). WGS analysis showed 77/78 C. freundii isolates differing by 0-26 single nucleotide variants (SNVs). Results of WGS analysis showed bla(OXA-204) was present on three plasmids types (IncX1, IncA/C-2 and IncFII/FIB/A/C-2) and on a prophage. All C. freundii isolates harboured multiple copies of bla(OXA-204), both on the chromosome and a plasmid. Plasmid IncFII/FIB/A/C-2 was observed in all three species. Conclusions: Transfer of OXA-204 plasmids likely occurred between species within the same patient, highlighting the plasticity of these plasmids and potential for widespread dissemination. OXA-204 carbapenemase has been introduced into Quebec and has rapidly disseminated. Although the infection to colonization ratio was low in this outbreak, this carbapenemase has been associated with severe infection elsewhere.