Various combinations of Carbapenemase production in community-acquired clinical isolates in Nepal

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Abstract Background Carbapenems are at the forefront of managing infections caused by multidrug-resistant organisms (MDROs). These antibiotics are destroyed by carbapenemase enzymes, produced by the infecting bacteria. Klebsiella pneumoniae Carbapenemase (KPC), New Delhi Metallo - β lactamase (NDM), Verona integron-encoded Metallo β lactamase (VIM), OXA-48, and IMP are the commonest carbapenemases reported. Since these resistance phenotypes are related to hospitals, their place in the community is actually unclear and unexpected. Our case series is, therefore, crucial to reveal the significant production of multiple carbapenemases in these alarmingly resistant community-acquired isolates recovered from three patients. Case presentation We confirmed carbapenemase production by using the modified Hodge test (MHT) and Xpert Carba R. NDM, KPC and OXA-48 carbapenemase production, VIM, NDM, KPC, and OXA carbapenemase production, and IMP, VIM, NDM, and OXA carbapenemase production were demonstrated in Case 1, Case 2, and Case 3, respectively. Escherichia coli was isolated from blood and urine samples of case 1. The isolate was susceptible to colistin, tigecycline, and fosfomycin. Due to the development of acute kidney injury, treatment with colistin combined with tigecycline was stopped and Inj. Fosfomycin was started intravenously. After completion of antimicrobial therapy, the patient successfully recovered. Blood and sputum cultures of Case 2 with community-acquired pneumonia, yielded multidrug-resistant Klebsiella pneumonia . The strain was carbapenemase producer and susceptible to tigecycline and colistin solely. Treatment with intravenous colistin and tigecycline resulted in a good clinical outcome. E. coli was recovered from both the ascitic fluid and the blood of Case 3.The pathogen was susceptible to both colistin and tigecycline. After the modification of treatment modality from intravenous imipenem to tigecycline, the patient began to improve on the third day of therapy. Conclusions Our results are noteworthy in emphasizing the growing resistance profiles of gram-negative bacteria in the community and show an epidemiological link between healthcare settings and the community. These bacteria are easily transmissible by mobile genetic elements (MGEs), compelling us to rely on last-resort drugs like colistin, tigecycline, or fosfomycin for better therapeutic management. Accordingly, we used these drugs in combination, and all three patients were cured.

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