Table 5). A previous study reported that the insertion sequences IS1, IS5, IS10, and IS903 insert into the promoter and coding regions of ompK35 and ompK36 (Supplementary Table 1). Imipenem-resistant isolates containing blaSHV-12 and blaDHA-1 are obtained from IS5 insertion in ompK36 from Korea and Taiwan [15] [49] . IS26, IS5, IS903, and IS1 insertion in ompK36 increases resistance to cefoxitin [50] . Following meropenem induction, all isolates with an insertion sequence in ompK36 exhibited reduced susceptibility to imipenem (2- to 7.9-fold increase) and meropenem (16- to 43.5-fold increase) and increased resistance to ertapenem (42.6- to 173.9-fold increase) (Table 5), suggesting that only OmpK36 is responsible for ertapenem resistance due to its small molecular weight. Despite the presence of IS1, IS5, and IS903 in all isolates, only KP08, KP15, and KP16 developed ertapenem resistance from a single insertion sequence in each ertapenem-resistant strain. These results imply a strain-dependent activation of the insertion sequence. Furthermore, the MIC levels of ertapenem and the inhibition zone of cephalosporins are associated with the insertion type and site.

5. Conclusion

In clinical isolates, ESBL or AmpC-producing isolates associated with carbapenem resistance were more common with deficiency in OmpK35, not OmpK36. The isolate dependent IS1, IS5, and IS903 were able to insert into ompK36 to cause resistance to ertapenem and reduced susceptibility to imipenem and carbapenem.


The authors would like to acknowledge funding of the Chiayi Branch, Taichung Veterans General Hospital (RVHCY101013 and RVHCY102003), Taiwan.

Conflicts of Interest

The authors declare no conflicts of interest.


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