Uncovering genetic determinants of carbapenem resistance in Klebsiella pneumoniae

Carbapenem-resistant Klebsiella pneumoniae represents an urgent global health threat due to its increasing prevalence and high mortality rates, necessitating a comprehensive understanding of its resistance mechanisms. While key resistance mechanisms and their genetic determinants are known, such as beta- lactamases and porin mutations, the cause of resistance in many strains remains elusive. Moreover, other strains that carry known genetic carbapenem-resistance factors have been found to still be susceptible to carbapenems for unclear reasons. Further, strains can carry genetic elements which, while not conferring resistance directly, can promote resistance indirectly by accelerating its acquisition, such as through mutations in DNA repair systems or mobile genetic elements. To address these knowledge gaps, we propose a genome-wide association study (GWAS), with the aim of maximizing the discovery of gene variants associated with meropenem resistance, with experimental validation of candidates to identify true causal variants. We will overcome limitations of prior studies in the following ways: 1) We have compiled an expanded data set of publicly available K. pneumoniae genomes from strains isolated across a wide distribution of countries, with in hand access to >100 isolates upon which experimental validation studies will be performed. 2) We will perform comprehensive capture of genetic variants by employing a reference-free GWAS, utilizing unitigs, stretches of DNA sequence that represent the entire spectrum of genetic variation. 3) We will enhance statistical power to detect genetic variants with even subtle effects on resistance by using a quantitative, continuous minimum inhibitory concentration (MIC) phenotype to meropenem rather than a binary designation of resistant or susceptible. 4) We will reduce the number of false positives arising from correlation, or linkage disequilibrium (LD), with known carbapenemase and other known resistance factors by performing a conditional GWAS, where known factors are included as covariates. 5) We will further mitigate confounding effects due to population structure and LD, which cause non-random relationships between variants, by utilizing a pangenome-wide regression with an elastic net penalty. 6) Crucially, we will functionally validate our findings, which will include genetic variants associated with increased resistance, whether through direct or indirect mechanisms, as well as those that may restore susceptibility in strains already possessing known resistance factors. We will bridge the gap between GWAS findings and functional validation by leveraging our high-throughput experimental capabilities. This integrated approach promises to uncover novel mechanisms of carbapenem resistance, its acquisition, and susceptibility in K. pneumoniae, with the potential to inform the development of future diagnostics or therapeutic strategies.