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Development of ertapenem resistance in a patient with mediastinitis caused by an extended-spectrum beta-lactamase producing Klebsiella pneumoniae.

¹ Paris VII, Harvard Medical School;

² Hopital Bichat, AP-HP;

³ Institut Pasteur, Paris;

⁴ Fondation Hopital Saint Joseph

⁵ E-mail: dskurnik{at}rics.bwh.harvard.edu

Received April 28, 2009
Accepted September 7, 2009

To study the clinical and microbiological features associated with a carbapenem-resistant K. pneumoniae isolate that has been selected in vivo by an ertapenem-containing regimen in a patient with mediastinitis despite high blood and mediastinal levels of ertapenem. Carbapenem-resistance was characterized by conjugation, PCR, DNA sequencing and analysis of outer-membrane proteins. The isolates susceptible and resistant to the carbapenems were compared by ribotyping and PFGE. Resistance to all available beta-lactams was most probably due to combined production of extended spectrum beta-lactamase CTX-M-15 and loss of OmpK36 porin. The results of ribotyping and PFGE suggest that the carbapenem resistant strain was a derivative of the original mediastinal isolate rather than a superinfecting isolate. This observation stresses the risk of selection of pan-penem resistant strains of enterobacteria when ertapenem is used for the treatment of severe infections due to ESBL producing enterobacteria.