Rapid prediction of carbapenemases in Pseudomonas aeruginosa by imipenem/relebactam and MALDI-TOF MS

Abstract

Pseudomonas aeruginosa is a major nosocomial pathogen commonly involved in multidrug-resistant (MDR) infections that are very difficult to treat. Imipenem/relebactam is a new carbapenem/β-lactamase inhibitor combination with robust activity against P. aeruginosa. However, resistance is increasingly reported, and rapid detection is, therefore, crucial so that appropriate treatments can be prescribed. We have developed a rapid MALDI TOF-MS-based method that can accurately predict the presence of carbapenemases in P. aeruginosa using imipenem/relebactam. The method was developed using a retrospective and a prospective collection of 419 P. aeruginosa isolates (including recombinant isolates and WGS-characterized clinical strains) encompassing the most important β-lactam resistance mechanisms. The MALDI TOF-MS method is based on the detection of the hydrolysis of imipenem in the presence or absence of relebactam, measuring modifications in the mass spectra of imipenem after incubation with bacteria. The method was evaluated against a retrospective collection and then validated against 250 prospectively collected clinical isolates, showing a 98% (246/250) agreement between the phenotype and the MALDI-TOF MS hydrolysis result and a 100% accordance with the β-lactam resistance genotype. Some errors in detecting GES-producing isolates and in detecting different mutational resistance mechanisms associated with imipenem/relebactam resistance (MICs ranging from 4 to 8 mg/L) were observed. All results were obtained within 1 hour, positioning the MALDI-TOF-based test as a rapid and easy-to-perform method for detection of carbapenemases (except GES enzymes) in P. aeruginosa. Besides, implementation of the method in routine laboratory screening would facilitate the correct use of imipenem/relebactam to treat P. aeruginosa infections.IMPORTANCEWhile several rapid diagnostic methods have been developed for the detection of ESBLs and carbapenemases to improve treatment decision-making in Enterobacterales, there is a lack of approaches to rapidly identify resistance mechanisms and predict β-lactam susceptibility in Pseudomonas aeruginosa. Taking advantage of the mechanism of action and the high efficacy of the newly developed β-lactam/β-lactamase inhibitor combination imipenem/relebactam against P. aeruginosa, we developed a WGS-guided, MALDI-TOF-based algorithm that accurately predicts the presence of carbapenemase enzymes in this bacterium and aids in forecasting the imipenem/relebactam susceptibility profile. The implementation of this method in routine laboratory testing would provide significant support in the rapid decision-making for the use of imipenem/relebactam in severe P. aeruginosa infections.

Keywords: MALDI-TOF; Pseudomonas aeruginosa; antimicrobial resistance; clinical microbiology; imipenem/relebactam.

Fig 1

Workflow of MALDI-TOF samples is obtained from imipenem/relebactam susceptibility 1. Sample processing: samples are obtained from infected patients; pathogens are cultured and further genotypically and phenotypically characterized. The same isolates are analyzed by MALDI-TOF MS. 2. Spectra acquisition: The mass spectra profiles of imipenem and imipenem/relebactam are obtained by MALDI-TOF MS and uploaded within the Clover MSDAS platform to produce an automated susceptibility result. 3. Spectra analysis: The mass spectra profiles undergo preprocessing, imipenem mass listing, RH calculation, normalization, quality control checks, and label assignment, and a clinical report is finally provided within minutes with a table of results and a scatter plot and box plot for further imaging. Results are ready for clinical validation.

Fig 2

Variation of the MALDI-TOF MS RH for imipenem with different concentrations of relebactam.