Problem of emergence of carbapenemase and how to control its spread

1. The emerging threat posed by carbapenemase producing enterobacteria & how to address it Dr. Ashok Rattan Fortis Clinical Research Ltd.

2. Thienamycin Streptomyces cattleya Imipenem cilastatin Meropenem Ertapenem Doripenem + In 1 : 1 ratio

6. Carabpenemases: a problem in waiting ? David M Livermore & Neil Woodford Current Opinion in Microbiology 2000; 3: 489 - 495 Natural resistance Acquired resistance

7. Bush 2010 : Distribution of β lactamases according to function Most Carbapenemases can Hydrolyze ALL Beta lactam antibiotics

9. Classification 2d 3 2f Functional Group - - + APBA Inhibition - + - EDTA Inhibition - - + Aztreonam Hydrolysis Serine Zn ++ Serine Active site D B A Molecular Class

11. Serine β lactamases: Kleb. pneumoniae All β lactams USA A KPC Kleb pn. carbapenamase Ps. Imipenem & extended spectrum cephalosporins French Guiana A GES Guiana Extended spectrum Scotland Europe USA Country Acinetobacter, Ps. Carbapenems (weak) D OXA Oxacillin hydrolysing Enterobacter spp Carbapenem, aztreonam but not 3 rd gen cephalosporins A NMC – A, IMI Non metallo carbapenamse Serratia marcescens Carbapenem, aztreonam but not 3 rd gen cephalosporins A SME Serratia marcesance enzyme Organisms Spectrum of activity Ambler Class Enzyme

12. Metallo β lactamases (Zn at active site) Kleb pneu, E. coli Pan R India, UK B NDM New Delhi South Korea Germany Brazil Italy Japan Country Acinetobacter, Ps. Pan R B SIM Souel Ps. Pan R B GIM German Ps Pan R B SPM Sao Paulo Ps. , Acinetobacter Pan R, may be S to aztreonam B VIM (12) Verona Ps., Acinetobacter All β lactams B IMP (18) Imipenem Japan Organisms Spectrum of activity Ambler Class Enzyme

13. March of Carbapenemases Lancet Infect Dis 2010; 10: 597–602 Published Online August 11, 2010 1985 1986 1990 1995 2000 2008 2010 Imipenem launched Chromosomal R in Ps IMP in Japan VIM in Verona KPC in USA NDM 1 Clinical Microbiology and Infection, Volume 16 Number 12, December 2010 Castanheira M et al: Anti Agents Chem 2010 SENTRY Program Out of 39 strains collected from India in 2006 15 strains had NDM 1 10 strains carried OXA 48 variant 2 strains carried VIM 6 Multiple PFGE patterns

17. Location of Bla KPC gene

25. Laboratory Detection Clinical and Laboratory Standards Institute breakpoints: 2009 & 2010 Revised Break Points 2010 < 15 < 19 16-18 20-22 19-21 > 22 > 23 > 8 > 1 4 0.5 2 < 1 < 0.25 ERT < 13 < 19 14-15 20-22 16-21 > 22 > 23 > 16 > 4 8 2 2-4 < 1 < 1 MEM < 13 < 19 14-15 20-22 NA > 16 > 23 > 16 > 4 8 2 2-4 < 1 < 1 IPM R I MHT S R I MHT S DD breakpoints (mm) MIC breakpoint (ug/ml) Agent

28. Screening for CRE

29. Screening for CRE carriage Sample Select Differentiate TSB + carbapenem disk

30. CHROMagar ESBL & KPC Panagea T et al : Evaluation of CHROMagar TM KPC for the detection of carbapenemase-producing Enterobacteriaceae in rectal surveillance cultures. International JournalofAntimicrobialAgents xxx (2010) xxx–xxx Randall LP et al: Evaluation of CHROMagar CTX, a novel medium for isolating CTX-M-ESBL-positive Enterobacteriaceae while inhibiting AmpC-producing strains. Journal of Antimicrobial Chemotherapy (2009) 63, 302–308

32. Double Disk Picao RC et al: MBL detection: Double Disk Synergy vs Combined Disk. JCM 2008; 46: 2028 - 2037

33. Combined Disk Doi Y et al. Single disk method for detecting KPC by use of a Boronic acid compound. JCM 2008; 46: 4083 - 4086

34. E test Walsh T et al. Evaluation of a new Etest for detecting MLB in routine clinical testing. JCM 2002; 40: 2755 - 2759

35. Pasteran F et al. Controlling false positive results in MHT.. JCM 2010; 48: 1323 - 1332

36. Pasteran F et al. Controlling false positive results in MHT.. JCM 2010; 48: 1323 - 1332

37. Pasteran F et al. Controlling false positive results in MHT.. JCM 2010; 48: 1323 - 1332 False Positive

38. MASUDA ASSAY

39. Phenotypic Detection N N N OXA Y N N MBL N Y N KPC N Y Y Amp C N N N ESBL Inhibited by Cloxacillin Boronic acid EDTA/DPA Enzyme

40. Sensitivity & specificity of phenotypic methods 77 100 Carbapenemase Modified Hodge 80 100 MBL EDTA 100 100 MBL DPA 100 80 Amp C APBA+ CLX 98 100 KPC APBA Specificity Sensitivity β lactamase Test

41. Genotypic detection of CRE Mendes RE et al: RT PCR for MBL JCM 2007; 45: 544 - 547

42. Naaz T et al: Evaluation of a DNA Microarray, the Check-Points ESBL/KPC Array, for Rapid Detection of TEM, SHV, and CTX-M Extended-Spectrum β-Lactamases and KPC Carbapenemases. Anti Agents Chemother 2010; 54: 3086 - 3092

44. Guideline for phenotypic screening and confirmation of carbapenemases in Enterobacteriaceae 2010 Dutch Working Party on the Detection of Highly Resistant Microorganisms Clinical isolates

45. Algorithm for disk diffusion synergy tests to detect C arbapenem N on S usceptible E nterobacteriaceae APBA = aminophenyl boronic acid ( β lactamase inhibitor) DPA = dipicolinic acid (metal chelating agent)

49. We may not be able to stop the emergence of Super bugs but we CAN