Carbapenem Resistance in Enterobacteriaceae

Jean B. Patel, PhD, (D)ABMM Leader, Antimicrobial Resistance Team

Division of Healthcare Quality Promotion

Carbapenems
Drug
Imipenem Meropenem Ertapenem Doripenem Route of Administration IV IV IM, IV IV

FDA Status
Cleared Cleared Cleared Application Submitted

Spectrum of Activity
Drug Imipenem Strep spp. & MSSA Enterobacteriaeae Nonfermentors Anaerobes

+ +
+ +

+ +
+ +

+ +
Limited activity

+ +
+ +

Meropenem
Ertapenem Doripenem

How are Carbapenems Used?

Uses by Clinical Syndrome Bacterial meningitis Hospital-associated sinusitis Sepsis of unknown origin Hospital-associated pneumonia Use by Clinical Isolate Acinetobacter spp. Pseudomonas aeruginosa Alcaligenes spp. Enterobacteriaceae

Mogenella spp. Serratia spp. Enterobacter spp. Citrobacter spp. ESBL or AmpC + E. coli and Klebsiella spp.

Reference: Sanford Guide

Emerging Carbapenem Resistance in Gram-Negative Bacilli

Significantly limits treatment options for lifethreatening infections

No new drugs for gram-negative bacilli

Emerging resistance mechanisms, carbapenemases are mobile,

Detection of carbapenemases and implementation of infection control practices are necessary to limit spread

Carbapenem Resistance: Mechanisms

Enterobacteriaceae Cephalosporinase + porin loss
Carbapenemase

P. aeruginosa

Porin loss
Up-regulated efflux Carbapenemase

Acinetobacter spp.

Cephalosporinase + porin loss Carbapenemase

Carbapenemases
Classification
Class A

Enzyme
KPC, SME, IMI, NMC, GES

Most Common Bacteria

Enterobacteriaceae
(rare reports in P. aeruginosa)

Class B IMP, VIM, (metallo-b-lactamse) GIM, SPM

P. aeruginosa Enterobacteriacea Acinetobacter spp. Acinetobacter spp.

Class D

OXA

Carbapenemases in the U.S.

Enzyme KPC
Metallo-b-lactamase OXA SME

Bacteria Enterobacteriaceae
P. aeruginosa Acinetobacter spp. Serratia marcesens

Klebsiella Pneumoniae Carbapenemase

KPC is a class A b-lactamase

Confers resistance to all b-lactams including extendedspectrum cephalosporins and carbapenems

Occurs in Enterobacteriaceae

Most commonly in Klebsiella pneumoniae Also reported in: K. oxytoca, Citrobacter freundii, Enterobacter spp., Escherichia coli, Salmonella spp., Serratia spp.,

Also reported in Pseudomonas aeruginosa (Columbia)

Susceptibility Profile of KPC-Producing K. pneumoniae

Antimicrobial Amikacin Amox/clav Ampicillin Aztreonam Cefazolin Cefpodoxime Cefotaxime Cetotetan Interpretation I R R R R R R R Antimicrobial Ciprofloxacin Ertapenem Gentamicin Imipenem Meropenem Pipercillin/Tazo Tobramycin Interpretation R R R R R R R Chloramphenicol R

Cefoxitin
Ceftazidime Ceftriaxone Cefepime

R
R R R

Trimeth/Sulfa
Polymyxin B Colistin Tigecycline

R
MIC >4mg/ml MIC >4mg/ml S

KPC Enzymes

Located on plasmids; conjugative and nonconjugative blaKPC is usually flanked by transposon sequences blaKPC reported on plasmids with:

Normal spectrum b-lactamases Extended spectrum b-lactamases Aminoglycoside resistance

KPCs in Enterobacteriaceae
Species
Klebsiella spp. Enterobacter spp. Escherichia coli Salmonella spp. Citrobacter freundii Serratia spp. Pseudomonas aeruginosa Columbia & Puerto Rico Sporadic occurrence

Comments
K. pneumoniae-cause of outbreaks K. oxytoca-sporadic occurrence

Geographical Distribution of KPC-Producers

Frequent Occurrence

Sporadic Isolate(s)

Geographical Distribution of KPC-Producers in New Jersey

KPC Outside of United States

France (Nass et al. 2005. AAC 49:4423-4424) Singapore (report from survey) Puerto Rico (ICAAC 2007) Columbia (Villegas et al. 2006. AAC 50:2880-2882 & ICAAC 07) Brazil (ICAAC 2007)

Israel (Navon-Venezia et al. 2006. AAC 50:3098-3101)

China (Wei Z, et al. 2007. AAC 51: 763-765)

Inter-Institutional & Inter-State Spread of KPC-Producing K. pneumoniae

Intra-institution, Interspecies KPC Plasmid Transfer

Cf Ko

Cf Ko

Laboratory Detection of KPCProducers

Problems:
1) Some isolates demonstrate low-level carbapenem resistance 2) Some automated systems fail to detect low-level resistance

Susceptibility of KPC-Producers to Imipenem

Imipenem

S*
No. of Isolates

60 40 20 0 1 2 4 8 MIC (mg/ml) 16 32 >32

*12% of isolates test susceptible to imipenem

Susceptibility of KPC-Producers to Meropenem

S*
No. of Isolates

Meropenem I

100 50 0 2 4 8 MIC (mg/ml) 16 >16

*9% of isolates test susceptible to meropenem

Susceptibility of KPC-Producers to Ertapenem

S
60
No. of Isolates

50 40 30 20 10 0 2 4 8 MIC (mg/ml) 16 >16

None of the isolates test susceptible to ertapenem

Can Carbapenem Susceptibility of I or R Detect KPC-Producers?

Sens/Spec (%) for Detection of KPC-mediated R* Method Ref BMD Imipenem 94/93 Meropenem 94/98 Ertapenem 97/89

Disk Diffusion
Etest Vitek Legacy Vitek 2 MicroScan Phoenix

42/96
55/96 55/96 71/98 74/96 81/96

71/96
58/96 52/98 48/96 84/98 61/98

97/82
90/84 N/A 94/93 100/89 N/A

*N = 76 K. pneum, K. oxy, E. coli; 31 KPC-producers & 45 non-KPC producers

CAP Results (D-05)

KPC-producing Klebsiella pneumoniae

Susceptible Results MIC Method Imipenem Meropenem Ertapenem 63 63 0 Disk Method 57 18 0

Carbapenem MIC 2 mg/ml to Detect KPC-producers

Sens/Spec (%) for Detection of KPC-mediated R*
Method Ref BMD Etest Vitek Legacy Vitek 2 Imipenem 100/93 84/89 NA 71/91 Meropenem 100/93 90/87 NA 93/89 Ertapenem 100/89 100/82 NA 93/89

MicroScan
Phoenix

100/93
74/96

100/93
87/93

NA
NA

*N = 76 K. pneum, K. oxy, E. coli; 31 KPC-producers & 45 non-KPC producers

When to Suspect a KPC-Producer

Enterobacteriaceae especially Klebsiella pneumoniae that are resistant to extendedspectrum cephalosporins:

MIC range for 151 KPC-producing isolates

Ceftazidime Ceftriaxone

Cefotaxime

32 to >64 mg/ml 64 mg/ml 64 mg/ml

Variable susceptibility to cefoxitin and cefepime

Reading Disk Diffusion & Etest

Phenotypic Tests for Carbapenemase Activity

Modified Hodge Test

100% sensitivity in detecting KPC; also positive when other carbapenemases are present 100% specificity

Procedure described by Lee et al. CMI, 7, 88-102. 2001.

Modified Hodge Test

Lawn of E. coli ATCC 25922 1:10 dilution of a 0.5 McFarland suspension

Test isolates

Imipenem disk
Described by Lee et al. CMI, 7, 88-102. 2001.

Modified Hodge Test

Preliminary results suggest that any of the three carbapenem disks work in the Modified Hodge Test

What Labs Should Do Now

Look for isolates of Enterobacteriaceae (especially K. pneumoniae), with carbapenem MIC 2 mg/ml or nonsusceptible to ertapenem by disk diffusion Consider confirmation by Modified Hodge Test Can submit initial isolate to CDC via NJ State Lab for confirmation by blaKPC PCR if KPC-producers not previously identified in hospitals isolate population Alert clinician and infection control practitioner to possibility of mobile carbapenemase in isolate

KPC Questions

If I have detect KPC-production, should I change susceptible carbapenem results to resistant?

Not enough data to make a clear recommendation Clinical outcomes data will be necessary

Testing Other Drugs

Tigecycline:

Test by Etest if possible disk diffusion tends to overcall resistance No CLSI breakpoint, but there are FDA breakpoint
2 mg/ml Intermediate = 4 mg/ml Resistant 8 mg/ml
Susceptible

Testing Other Drugs

Polymixin B or Colistin
Could test either, but colistin used clinically Disk diffusion test does not work dont use! Etest works well, but not FDA cleared Broth microdilution reference labs Breakpoints - none

2 mg/ml, normal MIC range MIC 4 mg/ml indicates increased resistance

MIC

Acknowledgements

Fred Tenover Roberta Carey Kamile Rasheed Kitty Anderson Brandon Kitchel Linda McDougal David Lonsway Jana Swenson

Arjun Srinivasan Susan Mikorski