Improved Accuracy of Cefepime Susceptibility Testing for Extended-Spectrum-Beta-Lactamase-Producing Enterobacteriaceae with an On-Demand Digital Dispensing Method

Abstract

Extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae generally cannot be treated with penicillins and cephalosporins. However, some later-generation cephalosporins, including cefepime, are poorly hydrolyzed by specific ESBL enzymes, and certain strains demonstrate in vitro susceptibility to these agents, potentially affording additional treatment opportunities. Moreover, the ability to adjust both the dose and dosing interval of beta-lactam agents allows the treatment of strains with elevated MICs that were formerly classified in the intermediate range. The ability to treat strains with elevated cefepime MICs is codified in new susceptible dose-dependent (SDD) breakpoints promulgated by the Clinical and Laboratory Standards Institute. In the interest of validating and implementing new cefepime SDD criteria, we evaluated the performances of Vitek 2, disk diffusion, and a MicroScan panel compared to that of reference broth microdilution (BMD) during the testing of 64 strains enriched for presumptive ESBL phenotype (based on nonsusceptibility to ceftriaxone). Surprisingly, categorical agreement with BMD was only 47.6%, 57.1%, and 44.6% for the three methods, respectively. Given these findings, we tested the performance of the HP D300 inkjet-assisted broth microdilution digital dispensing method (DDM), which was previously described by our group as an at-will testing alternative. In contrast to commercial methods, DDM results correlated well with the reference method, with 86% categorical agreement, 91.1% evaluable essential agreement, and no major or very major errors. The reproducibility and accuracy of MIC determinations were statistically equivalent to BMD. Our results provide support for the use of the DDM as a BMD equivalent methodology that will enable hospital-based clinical laboratories to support cefepime MIC-based dosing strategies.

Keywords: ESBL; antimicrobial susceptibility testing; broth microdilution; cefepime; digital dispensing; extended-spectrum beta-lactamase producer; inkjet; susceptibility testing; susceptible dose dependent; verification.

FIG 1

Log₂ variance from modal MIC. The log₂ differences shown represent the number of 2-fold dilutions away from the modal MIC. A total of 95.5% of DDM (n = 150) and 93.2% of BMD measurements (n = 163) were within ± 1 twofold dilution of the modal MIC, respectively.