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Year : 2021  |  Volume : 9  |  Issue : 3  |  Page : 104-105

Complexity of carbapenem resistance reporting in a critically ill cancer patient: A noteworthy practice point

1 Department of Microbiology, ACTREC Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
2 Department of Microbiology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India

Date of Submission16-Apr-2022
Date of Acceptance01-May-2022
Date of Web Publication22-Jul-2022

Correspondence Address:
Dr. Sujata Lall
Department of Microbiology, ACTREC, Tata Memorial Centre, Homi Bhabha National Institute, Kharghar 410210, Navi Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpsic.jpsic_16_22

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How to cite this article:
Lall S, Bhat V, Biswas S. Complexity of carbapenem resistance reporting in a critically ill cancer patient: A noteworthy practice point. J Patient Saf Infect Control 2021;9:104-5

How to cite this URL:
Lall S, Bhat V, Biswas S. Complexity of carbapenem resistance reporting in a critically ill cancer patient: A noteworthy practice point. J Patient Saf Infect Control [serial online] 2021 [cited 2023 Jun 7];9:104-5. Available from: https://www.jpsiconline.com/text.asp?2021/9/3/104/351735

The emergence and spread of multi-drug-resistant nonfermenting Gram-Negative bacilli in intensive care units (ICU), especially in immunocompromised group of patients, presents a major threat in hospitals.[1] Carbapenems, once rated as the wonder drug for life-threatening infections are losing their efficacy due to the emergence of resistance due to various mechanisms and genes such as, IMP, KPC, NDM, VIM, and OXA-48 like.[2] Patients infected with such strains are more likely to present with morbidity and mortality as carbapenems still remain as empirical treatment for critically ill patients in ICUs. In addition, resistance gene transfer can occur between Gram-negative organisms, which increases the risk of carbapenemase spread in general. Acinetobacter spp. is a challenging threat to hospitalised patients because it frequently contaminates health-care facility surfaces and shared medical equipment.[3] If not addressed through infection control measures, including rigorous cleaning and disinfection, outbreaks in hospitals and nursing homes can occur. Rapid and accurate identification of carbapenem-resistant Acinetobacter clinical isolates, particularly in the most vulnerable patient populations, is critical to reducing the risk of mortality, length of hospitalisation and associated costs. We hereby present an observation during reporting of such an isolate from a cancer patient admitted postoperatively in ICU.

A 71-year-old male patient operated for carcinoma descending colon by left hemicolectomy and Hartmann procedure in February 2021 was admitted in May 2021 for Hartmann reversal procedure. Postoperatively in ICU, he was administered meropenem, teicoplanin and levofloxacin. On the post-operative day 8, a diagnosis of acute hypercapnic respiratory failure and pneumonia was made, and tracheal secretions were sent for routine bacteriological culture. On Gram's staining moderate pus cells, Gram-positive cocci and Gram-negative bacilli were seen. The specimen was inoculated on blood agar and Mac Conkey agar for 24 h at 37°C. 10^5 cfu/ml of Acinetobacter baumannii were grown. For antibiotic susceptibility testing, disc diffusion method on Mueller–Hinton agar was performed as per CLSI 2021 guidelines using inoculum equivalent to 0.5 Mc Farland standard. CLSI interpretive breakpoints were used to determine the susceptibility pattern of the organism. The organism was resistant to all the antibiotics, including imipenem and meropenem (zone diameter 6). The organism was further tested by Vitek 2 Biomeriux Automated identification system for identification and sensitivity testing as a part of our laboratory protocol for testing samples of critically ill patients. The automated system reported it as sensitive to imipenem (minimum inhibitory concentration ≤2) and intermediate to meropenem (minimum inhibitory concentration 4). Non-direct bronchoalveolar lavage of the same patient was received after 48 h for BioFire FilmArray pneumonia panel multiplex polymerase chain reaction (PCR) reporting, which also reported Acinetobacter 10^5 cfu/ml along with detection of CTX-M and NDM resistance gene, highlighting extended-spectrum β-lactamase and carbapenem resistance, respectively. To remove the inconclusiveness for imipenem and meropenem reporting, the E test was performed for MIC testing by using gradient strips which showed the organism as resistant (32 MIC) to both imipenem and meropenem. Sensitivity testing was again performed on VITEK on the same isolate was done which reported it as resistant to imipenem and meropenem (MIC 8). We reported Acinetobacter as resistant to carbapenem class of drugs and the line of treatment was shifted from meropenem to colistin, ceftazidime-avibactam and teicoplanin.

Reporting of carbapenem class of drugs for critically ill patients in a cancer centre is crucial from both patient and infection control point of view. The inference derived from this case which may serve as a valuable practice point is that it becomes prudent to interpret and inform carbapenems as resistant when presented with such testing discrepancies, which for the most part are substantially showing the results to be on the resistant side. The investigation of such isolates for confirming the sensitivity status must be done meanwhile using different platforms (manual and automation) and using different principles. Such cautious and judicious reporting might not be an overrepresentation of facts as it would be helpful for carbapenem resistance detection and surveillance, which is an integral part of hospital infection control (HIC) practices. Furthermore, the simple technique of using disc diffusion testing using the new clinical and laboratory standards institute breakpoints, in this case, gave equivalent results to multiplex PCR which calls attention towards such basic laboratory techniques which serve a long way in patient care and HIC in the absence of non-availability of advanced automated methods or relatively labour intensive tests practices. More such observations from different centres are required that focus on the actual onsite dilemmas faced in the laboratory so that the reporting ambiguity can be removed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Datta S, Wattal C. Carbapenemase producing Gram negative bacteria in tertiary health care setting: Therapeutic challenges. JIMSA 2010;23:17-20.  Back to cited text no. 1
Awkey PM, Livermore DM. Carbapenem antibiotics for serious infections. Br Med J 2012;344:e3236.  Back to cited text no. 2
Papp-Wallace KM, Endimiani A, Taracila MA, Bonomo RA. Carbapenems: Past, present, and future. Antimicrob Agents Chemother 2011;55:4943-60.  Back to cited text no. 3


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