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

<i>Pseudomonas aeruginosa</i> 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 <i>P. aeruginosa</i>. 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 <i>P. aeruginosa</i> using imipenem/relebactam. The method was developed using a retrospective and a prospective collection of 419 <i>P</i>. <i>aeruginosa</i> 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 <i>P. aeruginosa</i>. Besides, implementation of the method in routine laboratory screening would facilitate the correct use of imipenem/relebactam to treat <i>P. aeruginosa</i> 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 <i>Pseudomonas aeruginosa</i>. Taking advantage of the mechanism of action and the high efficacy of the newly developed β-lactam/β-lactamase inhibitor combination imipenem/relebactam against <i>P. aeruginosa</i>, 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 <i>P. aeruginosa</i> infections.