title: Evaluation of updated interpretative criteria for categorizing Klebsiella pneumoniae with reduced carbapenem susceptibility.
abstract: We studied the accuracy of various susceptibility testing methods, including the 2009, 2010, and updated 2010 CLSI recommendations, to identify Klebsiella pneumoniae isolates with reduced susceptibility to carbapenems associated with different mechanisms of resistance. Forty-three wild-type (WT) strains, 42 extended-spectrum β-lactamase (ESBL) producers, 18 ESBL producers with outer membrane porin protein loss (ESBL/Omp strains), and 42 blaKPC-possessing K. pneumoniae (KPC-Kp) isolates were evaluated. Imipenem (IPM), meropenem (MEM), ertapenem (ERT), and doripenem (DOR) were tested by broth microdilution (BMD), Etest, and disk diffusion (DD), and the modified Hodge test (MHT) was performed using IPM and MEM disks. Results were interpreted according to original as well as recently updated interpretative criteria. MHT was positive for all 42 KPC-Kp isolates and 10 of 18 ESBL/Omp strains and therefore had poor specificity in differentiating between KPC-Kp and ESBL/Omp isolates. Based on the updated CLSI standards, phenotypic susceptibility testing by BMD and DD differentiated most carbapenem-susceptible from carbapenem-nonsusceptible K. pneumoniae isolates without the need for MHT, while the Etest method characterized many KPC-Kp isolates as susceptible, and breakpoints may need to be lowered for this method. However, both the original and updated CLSI criteria do not adequately differentiate between isolates in the KPC-Kp group, which are unlikely to respond to carbapenem therapy, and those in the ESBL/Omp group, which are likely to respond to carbapenem therapy if MICs are within pharmacokinetic/pharmacodynamic targets. Further studies are required to determine if there is a clinical need to differentiate between KPC-Kp and ESBL/Omp groups.
authors.affiliation: Department of Medicine, Case Western Reserve University, School of Medicine, and Department of Pathology, University Hospitals Case Medical Center, 11100 Euclid Ave., Cleveland, OH 44106, USA.
authors.forename: Andrea
authors.initials: A
authors.lastname: Endimiani
authors.forename: Federico
authors.initials: F
authors.lastname: Perez
authors.forename: Saralee
authors.initials: S
authors.lastname: Bajaksouzian
authors.forename: Anne R
authors.initials: AR
authors.lastname: Windau
authors.forename: Caryn E
authors.initials: CE
authors.lastname: Good
authors.forename: Yuvraj
authors.initials: Y
authors.lastname: Choudhary
authors.forename: Andrea M
authors.initials: AM
authors.lastname: Hujer
authors.forename: Christopher R
authors.initials: CR
authors.lastname: Bethel
authors.forename: Robert A
authors.initials: RA
authors.lastname: Bonomo
authors.forename: Michael R
authors.initials: MR
authors.lastname: Jacobs
mesh_terms: D000900:Anti-Bacterial Agents / Q000494:pharmacology*; D001425:Bacterial Outer Membrane Proteins / Q000235:genetics; D015780:Carbapenems / Q000494:pharmacology*; D006801:Humans; D007711:Klebsiella pneumoniae / Q000145:classification* / Q000187:drug effects*; D008826:Microbial Sensitivity Tests / Q000379:methods; D018440:beta-Lactam Resistance; D001618:beta-Lactamases / Q000096:biosynthesis
chemical_list: D000900:Anti-Bacterial Agents; D001425:Bacterial Outer Membrane Proteins; D015780:Carbapenems; D001618:beta-Lactamases