Improved Blue Carba test and Carba NP test for detection and classification of major Class A and B carbapenemases, including dual producers, among Gram-negative bacilli
Authors: Maccari Lucía , Ceriana Paola , Granchetti Hugo Norberto , Pezzaniti Antonella Viviana , Lucero Celeste , Rapoport Melina , Menocal Alejandra , Corso Alejandra , Pasteran Fernando 
Published: June 2024

ABSTRACT

Prompt and precise identification of carbapenemase-producing organisms is crucial for guiding clinical antibiotic treatments and limiting transmission. Here, we propose modifying the Blue Carba test (BCT) and Carba NP-direct (CNPd) to identify molecular carbapenemase classes, including dual carbapenemase strains, by adding specific Class A and Class B inhibitors. We tested 171 carbapenemase-producing Gram-negative bacilli strains—21 in Class A (KPC, NMC, SME), 58 in Class B (IMP, VIM, NDM, SPM), and 92 with dual carbapenemase production (KPC+NDM, KPC+IMP, KPC+VIM), all previously positive with BCT or CNPd. We also included 13 carbapenemase non-producers. β-lactamases were previously characterized by PCR. The improved BCT/CNPd methods detect imipenem hydrolysis from an imipenem-cilastatin solution, using pH indicators and Class A (avibactam) and/or Class B (EDTA) inhibitors. Results were interpreted visually based on color changes. CNPd achieved 99.4% sensitivity and 100% specificity in categorizing carbapenemases, while BCT had 91.8% sensitivity and 100% specificity. Performance varied by carbapenemase classes: both tests classified all Class A-producing strains. For Class B, the CNP test identified 57/58 strains (98.3%), whereas the BCT test, 45/58 strains (77.6%), with non-fermenters posing the greatest detection challenge. For Classes A plus B dual producers, both tests performed exceptionally well, with only one indeterminate strain for the BCT. The statistical comparison showed both methods had similar times to a positive result, with differences based on the carbapenemase class or bacterial group involved. This improved assay rapidly distinguishes major Class A or Class B carbapenemase producers among Gram-negative bacilli, including dual-class combinations, in less than 2 hours.

IMPORTANCE
Rapid and accurate identification of carbapenemase-producing organisms is of vital importance in guiding appropriate clinical antibiotic treatments and curbing their transmission. The emergence of negative bacilli carrying multiple carbapenemase combinations during and after the severe acute respiratory syndrome coronavirus 2 pandemic has posed a challenge to the conventional biochemical tests typically used to determine the specific carbapenemase type in the isolated strains. Several initiatives have aimed to enhance colorimetric methods, enabling them to independently identify the presence of Class A or Class B carbapenemases. Notably, no previous efforts have been made to distinguish both classes simultaneously. Additionally, these modifications have struggled to differentiate between carriers of multiple carbapenemases, a common occurrence in many Latin American countries. In this study, we introduced specific Class A and Class B carbapenemase inhibitors into the Blue Carba test (BCT) and Carba NP-direct (CNP) colorimetric assays to identify the type of carbapenemase, even in cases of multiple carbapenemase producers within these classes. These updated assays demonstrated exceptional sensitivity and specificity (≥ 90%) all within a rapid turnaround time of under 2 hours, typically completed in just 45 minutes. These in-house enhancements to the BCT and CNP assays present a rapid, straightforward, and cost-effective approach to determining the primary carbapenemase classes. They could serve as a viable alternative to molecular biology or immuno-chromatography techniques, acting as an initial diagnostic step in the process.