Carbapenems Resistance and optimal methods in detection of Carbapenemases

Dr.T.V.Rao MD
Carbapenems are lactam antibiotics, as are penicillins and cephalosporins, but differ from these other classes in their exact chemical structure. Carbapenem use has increased as a result of the rising resistance to cephalosporin antibiotics in Enterobacteriaceae (Escherichia coli, Klebsiella, Enterobacter, and related genera). Carbapenems continues to be only available option in many serious patients, and used with or without support of Microbiology Departments by Physicians. Growing resistance to Cephalosporins limiting the options of antibiotic therapy as the cephalosporin resistance is largely due to the spread of extended spectrum lactamases (ESBLs), which hydrolyse cephalosporins.1 ESBL producers are associated with poor clinical outcomes in severe infections: a meta-analysis found that bacteraemia caused by bacteria with these enzymes had 1.85-fold increased mortality , reflecting extended delays before effective therapy was initiated.2 ESBLs now occur in 1012% of E coli from in 5080% of those in India and China, with many ESBL producing strains also resistant to quinolones and aminoglycosides. Carbapenemases detection by Disc diffusion methods alone is not fully protective. Confirmatory testing for KPCproducing bacteria is recommended in geographical locations where Enterobacteriaceae are noted to have decreased susceptibility to Carbapenems or resistance to most non-carbapenem betalactams by routine testing. The most easily performed confirmatory test for KPCs is the modified Hodge test, which has been found to be 100% sensitive for the detection of a carbapenemases, although not specific for KPC production.; hence detection elevated MICs may be indicative to be definite about the emerging resistance and we have to depend on Minimal inhibitory concentration method from patients under critical care. To be fully protective and optimal, Molecular methods are the fastest and most reliable way to detect and identify carbapenemases. Nucleic acid amplification tests (NAATs) can definitively indicate and identify carbapenemases present. The use of NAATS provides more definitive result 48 hours quicker. Definite confirmation of KPC production requires molecular methods such as PCR, but these are costly and rarely available outside of reference laboratories knowing the resistance patterns of an organism have implications beyond just the treatment of the patient. A carbapenemases bearing GNB can spread throughout wards and hospitals and can claim the lives of many patients beyond the index case. This needs improvement of hygienic practices; because carbapenem resistance is a multi-mechanism process, they are capable of resisting many disinfection protocols. Barrier precautions must be put in place to prevent transmission to other patients. Email doctortvrao@gmail.com