id000099
10.3205/id000099
urn:nbn:de:0183-id0000993
Case Report
Challenges in laboratory diagnosis and antibiotic treatment options for a newly described Pseudomonas aeruginosa class A beta-lactamase type GES-62 strain
Pham
Pham
Thanh Tuyen
TT
Department für Labormedizin, Abteilung III, Labor für Bakteriologie, Halle University Hospital, Magdeburger Straße 6, 06112 Halle (Saale), GermanyDepartment of Laboratory Medicine, Unit III, Clinical Bacteriology Laboratory, Halle University Hospital, Halle (Saale), Germany
pham.medizin@gmail.com
author
Mungard
Mungard
Nils
N
Department of Anesthesiology, Halle University Hospital, Halle (Saale), Germany
author
Pfennigwerth
Pfennigwerth
Niels
N
National Reference Centre for Multidrug-Resistant Gram-Negative Bacteria, Department Medical Microbiology, Ruhr-University Bochum, Germany
author
Eisfeld
Eisfeld
Jessica
J
National Reference Centre for Multidrug-Resistant Gram-Negative Bacteria, Department Medical Microbiology, Ruhr-University Bochum, Germany
author
Gaterman
Gaterman
Sören
S
National Reference Centre for Multidrug-Resistant Gram-Negative Bacteria, Department Medical Microbiology, Ruhr-University Bochum, Germany
author
Ehrhardt
Ehrhardt
Sandra
S
Department of Laboratory Medicine, Unit III, Clinical Bacteriology Laboratory, Halle University Hospital, Halle (Saale), Germany
author
Lazarevic
Lazarevic
Milica
M
Department of Laboratory Medicine, Unit III, Clinical Bacteriology Laboratory, Halle University Hospital, Halle (Saale), Germany
author
Weber
Weber
Ines
I
Department of Laboratory Medicine, Unit III, Clinical Bacteriology Laboratory, Halle University Hospital, Halle (Saale), Germany
author
Lenz-Vogt
Lenz-Vogt
Sylke
S
Department of Laboratory Medicine, Unit III, Clinical Bacteriology Laboratory, Halle University Hospital, Halle (Saale), Germany
author
Martzsch
Martzsch
Nadine
N
Department of Laboratory Medicine, Unit III, Clinical Bacteriology Laboratory, Halle University Hospital, Halle (Saale), Germany
author
Groß
Groß
Sebastian
S
Department of Anesthesiology, Halle University Hospital, Halle (Saale), Germany
author
Ebert
Ebert
Daniel
D
Department of Anesthesiology, Halle University Hospital, Halle (Saale), Germany
author
Banach-Schmelzer
Banach-Schmelzer
Marta
M
Department of Anesthesiology, Halle University Hospital, Halle (Saale), Germany
author
Krieger
Krieger
Stephan
S
Department of Anesthesiology, Halle University Hospital, Halle (Saale), Germany
author
Pantke-Zidarova
Pantke-Zidarova
Desislava
D
Department of Anesthesiology, Halle University Hospital, Halle (Saale), Germany
author
Beese
Beese
Matthias
M
Department of Anesthesiology, Halle University Hospital, Halle (Saale), Germany
author
Yerken
Yerken
Askar
A
Department of Anesthesiology, Halle University Hospital, Halle (Saale), Germany
author
Avila-Castillo
Avila-Castillo
David
D
Department of Anesthesiology, Halle University Hospital, Halle (Saale), Germany
author
Stoevesandt
Stoevesandt
Dietrich
D
Department of Radiology, Halle University Hospital, Halle (Saale), Germany
author
Bucher
Bucher
Michael
M
Department of Anesthesiology, Halle University Hospital, Halle (Saale), Germany
author
Karrasch
Karrasch
Matthias
M
Department of Laboratory Medicine, Unit III, Clinical Bacteriology Laboratory, Halle University Hospital, Halle (Saale), Germany
author
German Medical Science GMS Publishing House
Düsseldorf
610
20251210
engl
This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License.
Dieser Artikel ist ein Open-Access-Artikel und steht unter den Lizenzbedingungen der Creative Commons Attribution 4.0 License (Namensnennung).
2195-8831
13
GMS Infectious Diseases
GMS Infect Dis
09
Antibiotic resistance is a major challenge in modern healthcare, as it severely limits the choice of treatment options. In particular, carbapenemase mediated carbapenem resistance in Pseudomonas aeruginosa poses an emerging health risk worldwide. Here, we discovered a hitherto unknown variant of the class A beta-lactamase type GES in a P. aeruginosa strain by whole genome sequencing. This multidrug-resistant strain was isolated from bronchoalveolar lavage samples of a 61-year-old man, who suffered from respiratory insufficiency resulting from pneumonia. Ultimately, the patient succumbed to his condition, as there were no further treatment strategies. Given the high drug resistance of P. aeruginosa and its increasing role in severe infections, the implementation of methods for the rapid detection of carbapenemases is essential for optimizing therapeutic strategies and preventing nosocomial outbreaks.
Case descriptionCarbapenem-mediated resistance, particularly in beta-lactamase-producing Pseudomonas aeruginosa strains, represents a global threat within hospital settings , , . A 61-year-old male patient was admitted to our university hospital with respiratory insufficiency resulting from pneumonia. Initially, he was treated with piperacillin-tazobactam. Axial and coronal non-contrast computed tomography (CT) imaging upon admission revealed multiple infiltrates in the right upper lobe and bilateral lower lobes of the lungs (Figure 1 ). The patient’s anti-infective therapy was adjusted to meropenem, while benzylpenicillin was concurrently prescribed to treat his streptococcal urinary infection. Due to the rapid onset of acute respiratory distress syndrome (ARDS) and sepsis, extracorporeal membrane oxygenation (ECMO) was initiated in our intensive care unit (ICU). During his hospitalization, a multidrug- and carbapenem-resistant P. aeruginosa strain was isolated from bronchoalveolar lavage (BAL) samples, prompting an escalation of the antimicrobial therapy to cefiderocol (Table 1 ). Despite intensive clinical <![CDATA[treatment, the</PlainText></TextGroup> patient succumbed to his condition four weeks after admission with persistently elevated infection parameters and progressive clinical deterioration, as there were no further treatment options.</Pgraph></TextBlock>
<TextBlock name="Methods and results" linked="yes">
<MainHeadline>Methods and results</MainHeadline><Pgraph>First, the <Mark2>P. aeruginosa</Mark2> strain was isolated from BAL samples and was cultured on blood agar plates for 24 h at 37°C and 5% CO<Subscript>2</Subscript>. Pathogen identification was done with mass spectrometry (VITEK MS, bioMérieux, France). Then, antimicrobial susceptibility testing was carried out with an automated microbial testing system (VITEK 2 XL and VITEK 2 Advanced Expert System, bioMérieux, France) and gradient tests (Liofilchem, Italy). The minimum inhibitory concentration (MIC) of antibiotics was interpreted as either susceptible (S), increased exposure (I) or resistant (R) (Table 1 <ImgLink imgNo="1" imgType="table" />), according to EUCAST breakpoints. Thus, the <Mark2>P. aeruginosa</Mark2> isolate was classified as a multi-drug resistant gram-negative bacterium and as carbapenem resistant (Table 1 <ImgLink imgNo="1" imgType="table" />).</Pgraph><Pgraph>While the carbapenemase rapid test (Coris BioConcept, Belgium; testing for KPC, NDM, VIM, IMP, OXA-48-like) and modified Hodge tests for imipenem, meropenem and ertapenem were negative, the MBL gradient test was positive. This incongruence and high minimum inhibitory concentrationx (MICs) prompted us to further analyze the <Mark2>P. aeruginosa</Mark2> isolate on a genotypic level. The multiplex PCR (testing for KPC, IMP, VIM, NDM, OXA-48-like; Xpert Carba-R, Cepheid) and the loop-mediated isothermal amplification (LAMP) system (testing for KPC, NDM, OXA-48-like, VIM, OXA-181-like; eazyplex SuperBug compl<TextGroup><PlainText>ete C</PlainText></TextGroup>, Amplex Diagnostics), conducted in our clinical laboratory, did not detect any carbapenemases. Concurrently, the strain was subjected to whole-genome sequencing (WGS) at the German National Reference Centre for Multidrug-Resistant Gram-Negative Bacteria (Bochum), where a hitherto unknown variant of the GES-family <TextLink reference="4"></TextLink>, <TextLink reference="5"></TextLink>, <TextLink reference="6"></TextLink>, <TextLink reference="7"></TextLink>, <TextLink reference="8"></TextLink>, <TextLink reference="9"></TextLink> of carbapenemases was identified (Figure 2 <ImgLink imgNo="2" imgType="figure" />). Retrospective testing in our laboratory using an additional carbapenemase LAMP system (testing for IMP, IMI, GES, and GIM; eazyplex SuperBug Expert, AmplexDiagnostics) further confirmed the presence <TextGroup><PlainText>of the</PlainText></TextGroup> GES carbapenemase.</Pgraph><Pgraph>Finally, the new enzyme was designated as class A beta-lactamase GES-62 by NCBI, and was published in the respective database (GenBank: PQ117759.1) <TextLink reference="4"></TextLink>, <TextLink reference="5"></TextLink>.</Pgraph></TextBlock>
<TextBlock name="Discussion and conclusion" linked="yes">
<MainHeadline>Discussion and conclusion</MainHeadline><Pgraph>Carbapenem resistance in <Mark2>P. aeruginosa</Mark2> is multifactorial <TextLink reference="10"></TextLink>. Key resistance mechanisms contributing to its nosocomial dissemination include reduced outer membrane permeability, overexpression of drug efflux pumps and the production of inducible beta-lactamases <TextLink reference="11"></TextLink>, <TextLink reference="12"></TextLink>, <TextLink reference="13"></TextLink>, <TextLink reference="14"></TextLink>, <TextLink reference="15"></TextLink>, <TextLink reference="16"></TextLink>. Moreover, <Mark2>P. aeruginosa</Mark2> has the ability to acquire resistance via mutations, further complicating treatment strategies <TextLink reference="13"></TextLink>. In this context, the identified class A beta-lactamase GES-62 demonstrated the ability to inactivate carbapenems by hydrolyzing the beta-lactam bond of the antibiotic <TextLink reference="17"></TextLink>. Notably, its protein sequence shows high similarity to that of GES-5, a variant known for its clinical relevance and importance <TextLink reference="17"></TextLink>, <TextLink reference="18"></TextLink>. This alignment suggests that GES-62 may exhibit a similar resistance potential. However, detailed analysis of its enzymatic activity is subject for future studies. In contrast, the first identified member of the GES family lacks carbapenemase activity due to its limited carbapenem turnover capacity <TextLink reference="17"></TextLink>, <TextLink reference="18"></TextLink>.</Pgraph><Pgraph>In clinical laboratories carbapenemases are detected on a phenotypic (disk diffusion test, MBL E-tests, modified Hodge Test, mass spectrometry) and on a molecular level (PCR, DNA sequencing) <TextLink reference="19"></TextLink>. Implementing both simple and sophisticated screening methods can help detect carbapenemases rapidly, which is crucial for the patient’s treatment and for hospital hygiene measures <TextLink reference="15"></TextLink>. For <Mark2>P. aeruginosa</Mark2> literature <TextLink reference="15"></TextLink>, <TextLink reference="20"></TextLink> recommends to use the inexpensive and simple combined disk method with imipenem and cloxacillin that allows to discriminate between carbapenemase positive and negative strains. Although this screening method was not employed in our laboratory, its implementation is recommended for future diagnostic workflows to quickly screen for carbapenemase producers.</Pgraph><Pgraph>In conclusion, this case highlights the importance and limitations of conventional carbapenemase detection methods, which may fail to identify emerging or uncommon variants. WGS remains the gold standard for comprehensive resistance gene profiling. Early and accurate detection of such carbapenemases is crucial for guiding effective treatment of patients, and preventing and controlling nosocomial infections.</Pgraph></TextBlock>
<TextBlock name="Notes" linked="yes">
<MainHeadline>Notes</MainHeadline><SubHeadline>Authors’ contributions</SubHeadline><Pgraph>T. T. Pham and N. Mungard contributed equally.</Pgraph><SubHeadline>Competing interests</SubHeadline><Pgraph>The authors declare that they have no competing interests.</Pgraph></TextBlock>
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<Caption><Pgraph><Mark1>Table 1: MICs of antibiotics tested against the GES-62 carbapenemase producing </Mark1><Mark1><Mark2>P. aeruginosa</Mark2></Mark1><Mark1> strain. MIC: minimum inhibitory concentration, EUCAST: European Committee on Antimicrobial Susceptibility Testing, S: susceptible, R: resistant</Mark1></Pgraph></Caption>
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<Caption><Pgraph><Mark1>Figure 1: CT imaging of patient’s chest at hospital admission. Upper left panel: Axial non-contrast CT image showing infiltrates in the upper and lower lobes of the right lung. Upper right panel: Coronal non-contrast CT image demonstrating infiltrates in the upper right and both lower lobes of the lung. Lower panel: 3D reconstruction of the CT showing the relative sparing of the left upper lobe.</Mark1></Pgraph></Caption>
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<Caption><Pgraph><Mark1>Figure 2: Class A beta-lactamase GES-62 in </Mark1><Mark1><Mark2>Pseudomonas aeruginosa</Mark2></Mark1><Mark1> (strain NRZ-97947) [21]. Class A beta-lactamase GES-62 protein sequence (287 amino acids). GES-62 contains a single amino acid substitution at position 130 compared with the sequence of GES-5 [22], i.e., T130A (marked in bold).</Mark1></Pgraph></Caption>
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