Acinetobacter baumannii: a universal threat to public health?

Infectious risk assessment of unsafe handling practices and management of clinical solid waste

The present study was undertaken to determine the bacterial agents present in various clinical solid wastes, general waste and clinical sharp waste. The waste was collected from different wards/units in a healthcare facility in Penang Island, Malaysia. The presence of bacterial agents in clinical and general waste was determined using the conventional bacteria identification methods. Several pathogenic bacteria including opportunistic bacterial agent such as Pseudomonas aeruginosa, Salmonella spp., Klebsiella pneumoniae, Serratia marcescens, Acinetobacter baumannii, Staphylococcus aureus, Staphylococcus epidermidis, Enterococcus faecalis, Streptococcus pyogenes were detected in clinical solid wastes. The presence of specific pathogenic bacterial strains in clinical sharp waste was determined using 16s rDNA analysis. In this study, several nosocomial pathogenic bacteria strains of Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Lysinibacillus sphaericus, Serratia marcescens, and Staphylococcus aureus were detected in clinical sharp waste. The present study suggests that waste generated from healthcare facilities should be sterilized at the point of generation in order to eliminate nosocomial infections from the general waste or either of the clinical wastes.

Epidemiology, clinical characteristics and outcomes of extensively drug-resistant Acinetobacter baumannii infections among solid organ transplant recipients

BACKGROUND

Extensively drug-resistant Acinetobacter baumannii (XDR-Ab) has emerged as a major nosocomial pathogen, but optimal treatment regimens are unknown. Although solid organ transplant (SOT) recipients are particularly susceptible to XDR-Ab infections, studies in this population are limited. Our objectives were to determine the epidemiology, clinical characteristics and outcomes of XDR-Ab infections among SOT patients.

METHODS

A retrospective study of SOT recipients at our center who were colonized or infected with XDR-Ab between November 2006 and December 2011 was conducted. Among infected patients, the primary outcome was survival at 28 days. Secondary outcomes included survival at 90 days and clinical success at 28 days, and XDR-Ab infection recurrence.

RESULTS

XDR-Ab was isolated from 69 SOT patients, of whom 41% (28) and 59% (41) were colonized and infected, respectively. Infections were significantly more common among cardiothoracic than abdominal transplant recipients (p=0.0004). Ninety-eight percent (40/41) of patients had respiratory tract infections, most commonly ventilator-associated pneumonia (VAP; 88% [36/41]). Survival rates at 28 and 90 days were 54% (22/41) and 46% (19/41), respectively. Treatment with a colistin-carbapenem regimen was an independent predictor of 28-day survival (p=0.01; odds ratio=7.88 [95% CI: 1.60-38.76]). Clinical success at 28 days was achieved in 49% (18/37) of patients who received antimicrobial therapy, but 44% (8/18) of successes were associated with infection recurrence within 3 months. Colistin resistance emerged in 18% (2/11) and 100% (3/3) of patients treated with colistin-carbapenem and colistin-tigecycline, respectively (p=0.03).

CONCLUSIONS

XDR-Ab causes VAP and other respiratory infections following SOT that are associated with significant recurrence and mortality rates. Cardiothoracic transplant recipients are at greatest risk. Results from this retrospective study suggest that colistin-carbapenem combinations may result in improved clinical responses and survival compared to other regimens and may also limit the emergence of colistin resistance.

In vitro activity of tigecycline against Acinetobacter baumannii isolates from a teaching hospital in Malaysia

The In vitro susceptibility of clinical and environmental isolates of Acinetobacter baumannii to tigecycline and other antibiotics was determined by disk diffusion method. The E-test was used to determine the minimum inhibitory concentration (MIC). The growth curves of tigecycline treated environmental and clinical strains were established. Fifty-seven percent and 75% of the clinical and environmental isolates were MDR strains, respectively. Ninety-five percent of the clinical isolates were susceptible to tigecycline and 5% showed intermediate resistance with MIC ranging between 0.032 and 3 mg/l. Tigecycline susceptible and intermediate resistance among the environmental isolates were 40% and 60%, respectively, with a significantly lower MIC range of 0.5-4 mg/l. The bacterial growth curves demonstrated the higher ability of the environmental strains to tolerate the antibiotic effects than the clinical strains. The relatively high resistance profile among the environmental isolate suggests an insidious emergence of tigecycline resistance amongst A. baumannii. Strict infection control procedures are imperative to prevent the dissemination of tigecycline-resistant A. baumannii strains in the hospital environment.

Typing of nosocomial outbreaks of Acinetobacter baumannii by use of matrix-assisted laser desorption ionization-time of flight mass spectrometry

Matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) has been evaluated for the identification of multidrug-resistant Acinetobacter baumannii nosocomial outbreaks in comparison with the repetitive sequence-based PCR DiversiLab system. The results suggest that MALDI-TOF MS can be used for real-time detection of Acinetobacter outbreaks before results from DNA-based systems are available.

Risk factors for occurrence and 30-day mortality for carbapenem-resistant Acinetobacter baumannii bacteremia in an intensive care unit

To assess the risk factors for carbapenem-resistant Acinetobacter baumannii (CRAB) bacteremia and for 30-day mortality in patients with CRAB bacteremia in the intensive care unit (ICU), we conducted a retrospective study in the ICU at Severance Hospital in Korea from January 2008 to December 2009. Patients who acquired CRAB bacteremia in the ICU were enrolled as the case group and patients whose specimens of blood culture, sputum/endotracheal aspirate and urine revealed no AB were enrolled as controls. The case group comprised 106 patients and 205 patients were included as controls. Risk factors independently associated with CRAB bacteremia included prior chemotherapy or radiotherapy treatment (Odds ratio [OR], 3.6; P = 0.003), recent central venous catheter insertion (OR, 5.7; P < 0.001) or abdominal drainage insertion (OR, 21.9; P = 0.004), the number of antibiotics treated with (OR, 1.3; P = 0.016), and respiratory failure in the ICU (OR, 2.5; P = 0.035). The 30-day mortality was 79.8%. Renal failure during ICU stay was independently associated with 30-day mortality (OR, 3.7; P = 0.047). It is important to minimize invasive procedures, and to restrict excessive use of antibiotics, especially in immunocompromised patients, in order to prevent the development of CRAB bacteremia. Greater concern for CRAB bacteremia patients is needed when renal failure develops during ICU stay.

Identification of a general O-linked protein glycosylation system in Acinetobacter baumannii and its role in virulence and biofilm formation

Acinetobacter baumannii is an emerging cause of nosocomial infections. The isolation of strains resistant to multiple antibiotics is increasing at alarming rates. Although A. baumannii is considered as one of the more threatening “superbugs” for our healthcare system, little is known about the factors contributing to its pathogenesis. In this work we show that A. baumannii ATCC 17978 possesses an O-glycosylation system responsible for the glycosylation of multiple proteins. 2D-DIGE and mass spectrometry methods identified seven A. baumannii glycoproteins, of yet unknown function. The glycan structure was determined using a combination of MS and NMR techniques and consists of a branched pentasaccharide containing N-acetylgalactosamine, glucose, galactose, N-acetylglucosamine, and a derivative of glucuronic acid. A glycosylation deficient strain was generated by homologous recombination. This strain did not show any growth defects, but exhibited a severely diminished capacity to generate biofilms. Disruption of the glycosylation machinery also resulted in reduced virulence in two infection models, the amoebae Dictyostelium discoideum and the larvae of the insect Galleria mellonella, and reduced in vivo fitness in a mouse model of peritoneal sepsis. Despite A. baumannii genome plasticity, the O-glycosylation machinery appears to be present in all clinical isolates tested as well as in all of the genomes sequenced. This suggests the existence of a strong evolutionary pressure to retain this system. These results together indicate that O-glycosylation in A. baumannii is required for full virulence and therefore represents a novel target for the development of new antibiotics.

Multidrug resistant (MDR) Acinetobacter baumannii strains are an increasing cause of nosocomial infections worldwide. Due to the remarkable ability of A. baumannii to gain resistance to antibiotics, this bacterium is now considered to be a “superbug”. A. baumannii strains resistant to all clinically relevant antibiotics known have also been isolated. Although MDR A. baumannii continues to disseminate globally, very little is known about its pathogenesis mechanisms. Our experiments revealed that A. baumannii ATCC 17978 has a functional O-linked protein glycosylation system, which seems to be present in all strains of A. baumannii sequenced to date and several clinical isolates. We identified seven glycoproteins and elucidated the structure of the glycan moiety. A glycosylation-deficient strain was generated. This strain produced severely reduced biofilms, and exhibited attenuated virulence in amoeba, insect, and murine models. These experiments suggest that glycosylation may play an important role in virulence and may lay the foundation for new drug discovery strategies that could stop the dissemination of this emerging human pathogen, which has become a major threat for healthcare systems.

Purification and characterization of OXA-23 from Acinetobacter baumannii

Although the existence of bla(OXA-23) is reported in various parts of the world, the product of bla(OXA-23) gene, OXA-23, has not been purified and its kinetic properties are not known. In this study, OXA-23 of Acinetobacter baumannii isolated from Kocaeli University intensive care unit was characterized after purification using recombinant methods. Preliminary results showed that conventional protein purification methods were not effective for purification of OXA-23. Therefore, OXA-23 was fused to maltose-binding protein of Escherichia coli, the fused protein was expressed and purified to homogeneity. Kinetic properties of the pure protein were then studied with substrates e.g., imipenem, meropenem, cefepime, ceftazidime, ampicilline, piperacillin, penicillin G, and nitrocefin. Also clavulanic acid, tazobactam, and sulbactam concentrations that inhibit 50% of OXA-23 enzyme activity were calculated. Modelling of OXA-23 revealed its ionic surface structure, conformation in the fused form and its topology allowing us to make predictions for OXA-23 substrate specificity.

Comparison of the virulence potential of Acinetobacter strains from clinical and environmental sources

Several Acinetobacter strains have utility for biotechnology applications, yet some are opportunistic pathogens. We compared strains of seven Acinetobacter species (baumannii, Ab; calcoaceticus, Ac; guillouiae, Ag; haemolyticus, Ah; lwoffii, Al; junii, Aj; and venetianus, Av-RAG-1) for their potential virulence attributes, including proliferation in mammalian cell conditions, haemolytic/cytolytic activity, ability to elicit inflammatory signals, and antibiotic susceptibility. Only Ah grew at 10² and 10⁴ bacteria/well in mammalian cell culture medium at 37°C. However, co-culture with colonic epithelial cells (HT29) improved growth of all bacterial strains, except Av-RAG-1. Cytotoxicity of Ab and Ah toward HT29 was at least double that of other test bacteria. These effects included bacterial adherence, loss of metabolism, substrate detachment, and cytolysis. Only Ab and Ah exhibited resistance to killing by macrophage-like J774A.1 cells. Haemolytic activity of Ah and Av-RAG-1 was strong, but undetectable for other strains. When killed with an antibiotic, Ab, Ah, Aj and Av-RAG-1 induced 3 to 9-fold elevated HT29 interleukin (IL)-8 levels. However, none of the strains altered levels of J774A.1 pro-inflammatory cytokines (IL-1β, IL-6 and tumor necrosis factor-α). Antibiotic susceptibility profiling showed that Ab, Ag and Aj were viable at low concentrations of some antibiotics. All strains were positive for virulence factor genes ompA and epsA, and negative for mutations in gyrA and parC genes that convey fluoroquinolone resistance. The data demonstrate that Av-RAG-1, Ag and Al lack some potentially harmful characteristics compared to other Acinetobacter strains tested, but the biotechnology candidate Av-RAG-1 should be scrutinized further prior to widespread use.

Risk factors and clinical outcomes of patients with carbapenem-resistant Acinetobacter baumannii bacteremia

BACKGROUND

It is still controversial whether carbapenem-resistant Acinetobacter baumannii (CRAB) is an independent risk factor for mortality. This study aimed to determine the risk factors and outcomes of patients with CRAB bacteremia, compared to those with carbapenem-susceptible A. baumannii (CSAB) bacteremia.

METHODS

This retrospective cohort study was conducted in Taipei Veterans General Hospital, Taiwan. Patients with bacteremia due to A. baumannii during June 2002 and December 2007 were included.

RESULTS

A total of 62 patients with CRAB and 164 with CSAB bacteremia were included. Among these patients, the independent risk factors for acquiring CRAB bacteremia were hematological malignancy [odds ratio (OR): 4.04; 95% confidence interval (CI): 1.29-12.70; p = 0.017], previous use of cefepime (OR: 2.60; 95% CI 1.11-6.08; p = 0.028) and use of total parenteral nutrition (OR: 3.06; 95% CI 1.12-8.39; p = 0.029). The patients with CRAB bacteremia had higher mortality rate than those with CSAB bacteremia. However, multivariate analysis showed that among patients with A. baumannii bacteremia, acquisition of CRAB by itself was not an independent risk factor for 14-day mortality. Instead, the independent factors predicting14-day mortality were Acute Physiology and Chronic Health Evaluation (APACHE) score > 20 (OR: 6.33; 95% CI: 2.32-17.26; p < 0.001), shock (OR: 2.68; 95% CI: 1.11-6.23; p = 0.025) and inappropriate antimicrobial therapy (OR: 2.14; 95% CI: 1.01-4.53; p = 0.046).

CONCLUSION

Risk factors for CRAB bacteremia were hematological malignancies, previous use of cefepime and use of total parenteral nutrition. Acquisition of CRAB itself is not a poor prognostic factor for the patients with A. baumannii bacteremia.

Carbapenems: past, present, and future

In this review, we summarize the current "state of the art" of carbapenem antibiotics and their role in our antimicrobial armamentarium. Among the β-lactams currently available, carbapenems are unique because they are relatively resistant to hydrolysis by most β-lactamases, in some cases act as "slow substrates" or inhibitors of β-lactamases, and still target penicillin binding proteins. This "value-added feature" of inhibiting β-lactamases serves as a major rationale for expansion of this class of β-lactams. We describe the initial discovery and development of the carbapenem family of β-lactams. Of the early carbapenems evaluated, thienamycin demonstrated the greatest antimicrobial activity and became the parent compound for all subsequent carbapenems. To date, more than 80 compounds with mostly improved antimicrobial properties, compared to those of thienamycin, are described in the literature. We also highlight important features of the carbapenems that are presently in clinical use: imipenem-cilastatin, meropenem, ertapenem, doripenem, panipenem-betamipron, and biapenem. In closing, we emphasize some major challenges and urge the medicinal chemist to continue development of these versatile and potent compounds, as they have served us well for more than 3 decades.

[Emerging Acinetobacter baumannii infections and factors favouring their occurrence]

During the last decade, Acinetobacter baumannii (AB) has been increasingly responsible for infections occurring in three particular contexts (in terms of patients and environment). Community AB pneumonia is severe infections, mainly described around the Indian Ocean, and which mainly concern patients with major co-morbidities. AB is also responsible for infections occurring among soldiers wounded in action during operations conducted in Iraq or Afghanistan. Lastly, this bacterium is responsible for infections occurring among casualties from natural disasters like earthquakes and tsunamis. Those infections are often due to multidrug-resistant strains, which can be implicated in nosocomial outbreaks when patients are hospitalized in a local casualty department or during their repatriation thereafter. The source of the contaminations which lead to AB infections following injuries (warfare or natural disasters) is still poorly known. Three hypotheses are usually considered: a contamination of wounds with environmental bacteria, a wound contamination from a previous cutaneous or oropharyngeal endogenous reservoir, or hospital acquisition. The implication of telluric or agricultural primary reservoirs in human AB infections is a common hypothesis which remains to be demonstrated by further specifically designed studies.

Analysis of genes encoding penicillin-binding proteins in clinical isolates of Acinetobacter baumannii

There is limited information on the role of penicillin-binding proteins (PBPs) in the resistance of Acinetobacter baumannii to β-lactams. This study presents an analysis of the allelic variations of PBP genes in A. baumannii isolates. Twenty-six A. baumannii clinical isolates (susceptible or resistant to carbapenems) from three teaching hospitals in Spain were included. The antimicrobial susceptibility profile, clonal pattern, and genomic species identification were also evaluated. Based on the six complete genomes of A. baumannii, the PBP genes were identified, and primers were designed for each gene. The nucleotide sequences of the genes identified that encode PBPs and the corresponding amino acid sequences were compared with those of ATCC 17978. Seven PBP genes and one monofunctional transglycosylase (MGT) gene were identified in the six genomes, encoding (i) four high-molecular-mass proteins (two of class A, PBP1a [ponA] and PBP1b [mrcB], and two of class B, PBP2 [pbpA or mrdA] and PBP3 [ftsI]), (ii) three low-molecular-mass proteins (two of type 5, PBP5/6 [dacC] and PBP6b [dacD], and one of type 7 (PBP7/8 [pbpG]), and (iii) a monofunctional enzyme (MtgA [mtgA]). Hot spot mutation regions were observed, although most of the allelic changes found translated into silent mutations. The amino acid consensus sequences corresponding to the PBP genes in the genomes and the clinical isolates were highly conserved. The changes found in amino acid sequences were associated with concrete clonal patterns but were not directly related to susceptibility or resistance to β-lactams. An insertion sequence disrupting the gene encoding PBP6b was identified in an endemic carbapenem-resistant clone in one of the participant hospitals.

Quantitative impact of neutrophils on bacterial clearance in a murine pneumonia model

The rapid increase in the prevalence of antibiotic-resistant pathogens is a global problem that has challenged our ability to treat serious infections. Currently, clinical decisions on treatment are often based on in vitro susceptibility data. The role of the immune system in combating bacterial infections is unequivocal, but it is not well captured quantitatively. In this study, the impact of neutrophils on bacterial clearance was quantitatively assessed in a murine pneumonia model. In vitro time-growth studies were performed to determine the growth rate constants of Acinetobacter baumannii ATCC BAA 747 and Pseudomonas aeruginosa PAO1. The absolute neutrophil count in mice resulting from different cyclophosphamide preparatory regimens was determined. The dynamic change of bacterial (A. baumannii BAA 747) burden in mice with graded immunosuppression over 24 h was captured by a mathematical model. The fit to the data was satisfactory (r(2) = 0.945). The best-fit maximal kill rate (K(k)) of the bacterial population by neutrophils was 1.743 h(-1), the number of neutrophils necessary for 50% maximal killing was 190.8/μl, and the maximal population size was 1.8 × 10(9) CFU/g, respectively. Using these model parameter estimates, the model predictions were subsequently validated by the bacterial burden change of P. aeruginosa PAO1 at 24 h. A simple mathematical model was proposed to quantify the contribution of neutrophils to bacterial clearance and predict the bacterial growth/suppression in animals. Our results provide a novel framework to link in vitro and in vivo information and may be used to improve clinical treatment of bacterial infections.

Prevalence of OXA-type carbapenemase genes and genetic heterogeneity in clinical isolates of Acinetobacter spp. from Mangalore, India

The prevalence of OXA-type carbapenemase genes, ISAba1 insertion sequence, carbapenem resistance, biofilm forming ability and genetic heterogeneity in clinical isolates of Acinetobacter spp. from hospitals in Mangalore, South India was studied. Based on the presence of the bla(OXA-51) -like gene, the 62 isolates of Acinetobacter spp. were identified as 48 A. baumannii and 14 other Acinetobacter spp. The prevalence of bla(OXA-23) -like, bla(OXA-24) -like and bla(OXA-58) -like genes in A. baumannii was 47.9%, 22.9% and 4.2%, while in other Acinetobacter spp. it was 28.5%, 64.3% and 35.7% respectively. Several A. baumannii isolates (16/48) harbored the insertion sequence ISAba1 in the upstream region of the bla(OXA-23) -like gene. Resistance to meropenem was seen in 39.6% and 14.2% of A. baumannii and other Acinetobacter spp. isolates, respectively. The ability to form biofilm was observed to be higher among A. baumannii in comparison to other Acinetobacter spp. The present study shows that bla(OXA-23) -like genes are more common in A. baumannii,whereas bla(OXA-24) -like genes are common to other Acinetobacter spp. The study revealed genetic heterogeneity among the isolates, indicating multiple sources in the hospitals.

Multidrug resistant acinetobacter

Emergence and spread of Acinetobacter species, resistant to most of the available antimicrobial agents, is an area of great concern. It is now being frequently associated with healthcare associated infections. Literature was searched at PUBMED, Google Scholar, and Cochrane Library, using the terms ‘Acinetobacter Resistance, multidrug resistant (MDR), Antimicrobial Therapy, Outbreak, Colistin, Tigecycline, AmpC enzymes, and carbapenemases in various combinations. The terms such as MDR, Extensively Drug Resistant (XDR), and Pan Drug Resistant (PDR) have been used in published literature with varied definitions, leading to confusion in the correlation of data from various studies. In this review various mechanisms of resistance in the Acinetobacter species have been discussed. The review also probes upon the current therapeutic options, including combination therapies available to treat infections due to resistant Acinetobacter species in adults as well as children. There is an urgent need to enforce infection control measures and antimicrobial stewardship programs to prevent the further spread of these resistant Acinetobacter species and to delay the emergence of increased resistance in the bacteria.

Detection of OXA-type carbapenemases and integrons among carbapenem-resistant Acinetobactor baumannii in a teaching hospital in China

The increasing trend of carbapenem-resistance (CR) and multi-drug resistance (MDR) in A. baumannii worldwide has limited the therapeutic effectiveness of antibiotic therapy. The study was conducted to determine the prevalence of carbapenemases and integrons among the isolates of imipenem-resistant A. baumannii (IRAB). A total of 71 non-repetitive imipenem- resistant A. baumannii isolates were collected and tested for susceptibility to 17 antimicrobials. The modified Hodge test and EDTA-disc synergy test were performed for the screening of carbapenemases and metallo-β -lactamases (MBLs) production, respectively. Isolates were then subjected to multiplex-PCR targeting genes encoding for OXA-type carbapenemase, MBLs and integrases. Random amplified polymorphic DNA (RAPD) genotyping was performed to assess genetic relatedness. All isolates exhibited multi-drug resistant phenotype. Colistin was the most active antimicrobial agent tested. Seventy-one isolates (100%) demonstrated positive in the modified Hodge test. Thirty-nine isolates showed positive in the EDTA-disc synergy test, however, no MBL genes were detected. All strains possessed a bla(OXA-51) -like gene. The co-exis-tence of bla(OXA-51) -like/bla(OXA-23) -like/intI1, bla(OXA-51) -like/bla(OXA-23) -like, bla(OXA-51) -like/bla(OXA-24) -like was detected in 91.6% (n = 65), 5.6% (n = 4), 2.8% (n = 2), respectively. Analysis of the genetic con-text of bla(OXA-23) showed the presence of ISAba1 upstream of bla(OXA-23) . No ISAba1 was detected upstream of bla(OXA-51) . Two different gene cassettes were found in these strains, and a high prevalence of aacA4, aadA1 and catB8 genes was observed. RAPD of 71 isolates showed 7 genotypes. The strains were mainly recovered from patients in intensive care unit, neurosurgery and department of respiratory disease. These findings show that multi-drug resistance in A. baumannii is a common problem. This study also shows a high distribution of bla(OXA-23) -like and intI1 genes in imipenem-resistant A. baumannii isolates. The clonal spread played an important role in the increase of OXA-23 producing IRABs in the hospital environment.

Beyond Susceptible and Resistant, Part I: Treatment of Infections Due to Gram-Negative Organisms With Inducible β-Lactamases

Inactivation of β-lactams by the action of β-lactamase enzymes is the most common mode of resistance to these drugs among Gram-negative organisms. The genomes of some key clinical pathogens such as Enterobacter and Pseudomonas encode AmpC, an inducible chromosomal β-lactamase. The potent activity of AmpC against broad-spectrum β-lactams complicates treatment of organisms with this gene. Antibiotic exposure can select for mutants expressing high levels of this enzyme, leading to the emergence of resistant isolates and failure of therapy, even when the initial isolate is fully susceptible. The risk of selecting for resistant organisms varies according to the particular β-lactam used for treatment. This article reviews the microbiology of these enzymes, summarizes clinical data on the frequency emergence of resistance, and discusses considerations for antimicrobial treatment of these organisms.

Confronting multidrug-resistant Acinetobacter baumannii: a review

Multidrug-resistant Acinetobacter baumannii (MDR-AB) infections are difficult to treat owing to the extremely limited armamentarium. The present review reports all available treatment options against MDR-AB, including single molecules, combination schemes, and alternative modes of antimicrobial administration. Additionally, a group of recently reported peptides with anti-MDR-AB activity is described.

Potent and rapid bactericidal action of alyteserin-1c and its [E4K] analog against multidrug-resistant strains of Acinetobacter baumannii

The emergence of multidrug-resistant strains of Acinetobacter baumannii (MDRAB) constitutes a serious threat to public health and necessitates the discovery of new types of antimicrobial agents. Alyteserin-1c (GLKEIFKAGLGSLVKGIAAHVAS·NH(2)) is a cationic, α-helical peptide that was first isolated from skin secretions of the midwife toad Alytes obstetricans. Synthetic alyteserin-1c displayed potent activity against clinical isolates of MDRAB (minimum inhibitory concentration, MIC=5-10 μM; minimum bactericidal concentration, MBC=5-10 μM) while displaying low hemolytic activity against human erythrocytes (LD(50)=220 μM). Increasing the cationicity of alyteserin-1c by the substitution Glu(4)→Lys enhanced the potency against MDRAB (MIC=1.25-5 μM; MBC=1.25-5 μM) as well as decreasing hemolytic activity (HC(50)>400 μM). More than 99.9% of the bacteria were killed within 30 min by the [E4K] analog at a concentration of 1 × MBC. Increasing the cationicity of [E4K]alyteserin-1c further by the additional substitutions of Ala(8),Val(14) or Ala(18) by l-Lys did not enhance antimicrobial potency. Derivatives of [E4K]alyteserin-1c containing a palmitate group coupled either to α-amino group at the N-terminus or to ɛ-amino group on the Lys(18) residue of the [E4K,A18K] analog retained antimicrobial activity but showed dramatically increased hemolytic activities (>40- and >13-fold, respectively).

Deep neck abscess due to Acinetobacter baumannii infection

Acinetobacter baumannii strains are isolated in up to 1% of nosocomial infections mostly from intensive care units immunocompromised patients and are associated with high mortality rates. A baumannii infections include pneumonia, urinary tract infection, endocarditis, skin and soft-tissue infections, surgical-site infection, meningitis, osteomyelitis, and septicemia. We report an extremely rare case of deep neck abscess due to multidrug-resistant A baumannii infection. The isolate strain was analyzed by a repetitive sequence-based polymerase chain reaction typing method: the isolate profile was compared with other strains obtained from isolates recovered in the hospital in that period. Our patient underwent 2 neck explorations and antibiotic treatment (tigecycline 50 mg, twice per day). Five weeks after admission, the patient was discharged in good general conditions. Considering the other obtained strains, 4 different profiles were identified, one as prominent (profile A, 18 isolates), the index case (B), and 2 others (C, D) as divergent.

Carbapenem-resistant versus carbapenem-susceptible Acinetobacter baumannii bacteremia in a Greek intensive care unit: risk factors, clinical features and outcomes

BACKGROUND

There has been an increasing incidence of carbapenem-resistant Acinetobacter baumannii (CRAB) infections in recent years. The objective of this study was to determine specific risk factors for and outcome of bacteremia due to CRAB isolates among our ICU patients with A. baumannii bacteremia.

PATIENTS AND METHODS

Among 96 patients with ICU-acquired A. baumannii bacteremia, 30 patients with CRAB were compared with the remaining 66 with carbapenem-susceptible A. baumannii (CSAB) isolates.

RESULTS

Recent ventilator-associated pneumonia (VAP) due to CRAB (OR 16.74, 95% CI 3.16-88.79, p = 0.001) and a greater number of intravascular devices (OR 3.93, 95% CI 1.9-13.0, p = 0.025) were independently associated with CRAB bacteremia acquisition. Patients with CRAB bacteremia had a lower severity of illness on admission than those with CSAB. Although, by univariate analysis, patients with CRAB were more likely to have had exposure to colistin, carbapenems and linezolid, multivariate analysis did not revealed any significant association. The mortality was not different between patients with CRAB and CSAB bacteremia (43.3 vs. 46.9%, p = 0.740). Severity of organ failure (OR 1.42, 95% CI 1.20-1.67, p = 0.001), and increased white blood cell (WBC) count (OR 1.09, 95% CI 1.01-1.19, p = 0.036), at bacteremia onset were independently associated with mortality.

CONCLUSION

VAP due to CRAB and excess use of intravascular devices are the most important risk factors for CRAB bacteremia in our ICU. Severity of organ failure and WBC count at A. baumannii bacteremia onset are independently associated with mortality.

Differences in carbapenem resistance genes among Acinetobacterbaumannii, Acinetobacter genospecies 3 and Acinetobacter genospecies 13TU in Taiwan

A total of 81 clinical isolates of the three clinically important Acinetobacter spp., namely Acinetobacterbaumannii, Acinetobacter genospecies 3 and Acinetobacter genospecies 13TU, were analysed for differences in carbapenem resistance genes. Of the 81 isolates, 40 (49%) were resistant to carbapenems. Most A. baumannii isolates (47/53, 88.7%) contained the ISAba1-bla(OXA-51)-like gene and exhibited a higher minimum inhibitory concentration to imipenem than A. baumannii without the ISAba1 element. All four carbapenem-resistant A. genospecies 3 isolates contained bla(IMP-1) and an ISAba3-bla(OXA-58)-like gene. Three A. genospecies 13TU isolates contained an ISAba3-bla(OXA-58)-like and either a bla(IMP-1) or a bla(VIM-11) gene. The five bla(IMP-1)-containing strains were resistant to imipenem and were positive for metallo-beta-lactamase (MBL) activity by the Etest, and the two bla(VIM-11)-containing strains were susceptible to imipenem and were MBL-negative by Etest. Imipenem hydrolysis tests showed that the bla(IMP-1)-containing strains exhibited much higher imipenem-hydrolysing activity than the two bla(VIM-11)-containing strains. No transcripts of bla(VIM-11) or bla(OXA-58)-like genes were detected. Analysis of outer membrane proteins showed that OprD was absent in the only bla(IMP-1)-containing A. genospecies 13TU strain owing to the presence of a premature stop codon in the oprD gene. In summary, several differences were detected between the carbapenem resistance genes of clinical Acinetobacter spp. in Taiwan, and loss of OprD may be associated with imipenem resistance in A. genospecies 13TU.

Multiple lung abscesses due to acinetobacter infection: a case report

Acinetobacter species are well-known causes of nosocomial infections. Recent increasing evidence emphasize on the role of these pathogens in community-acquired infections.

We report a case of a 16-yr-old female with fever, sore throat, productive cough, malaise and the presence of lung consolidation with multiple abscesses on radiographic examination. The patient had no significant medical history. After a detailed diagnostic work-up the diagnosis of community acquired Acinetobacter pneumonia with multiple lung abscesses was made. The Acinetobacter stain was susceptible to a variety of antimicrobial agents and the patient's condition improved rapidly. A new computed tomography chest scan, three months later, confirmed full recovery.

The presence of lung abscesses due to Acinetobacter infection is an extremely uncommon manifestation of the disease. This case underlines the emergent role which these, often multi-drug resistant, bacteria may play in the future, perhaps in community infections as well.

In vitro synergistic activity of tigecycline and colistin against XDR-Acinetobacter baumannii

The emergence of extensive drug-resistant (XDR) Acinetobacter baumannii limits the therapeutic options and leads to high mortality in intensive care units. Combined antibiotic therapy is frequently recommended for the treatment of these infections. Colistin (CO) and tigecycline (TIG), alone or in combination with other antimicrobials, are the most commonly used antibiotics in the treatment of these resistant infections. In this study, the in vitro synergistic activity of TIG and CO were tested for 25 XDR-A. baumannii strains isolated from ventilator-associated pneumonia by the Etest method. Resistance to CO was not detected, whereas 8% of the strains were resistant to TIG. The TIG-CO combination was more synergistic than TIG-rifampin and CO-rifampin according to the fractional inhibitory concentration index. No antagonism was detected between the drugs in the study. There was no strong correlation between the activity of the combinations with reference to strains or genotypes. Our results suggest that the combined use of TIG and CO may be useful for the treatment of XDR-A. baumannii infections.

Enhancing antibiotic activity: a strategy to control Acinetobacter infections

OBJECTIVES

The emergence of antibiotic resistance has seriously diminished antibiotic efficacy and an increasing number of infections are becoming difficult to treat. One approach to the restoration of antibiotic activity is to administer them in conjunction with non-antibiotic compounds that depress resistance mechanisms. We describe the activity of ellagic and tannic acids as adjuvants that enhance the activity of aminocoumarin antibiotics against multidrug-resistant (MDR) Acinetobacter baumannii.

METHODS

Adjuvant activity of plant phenolics was tested using growth inhibition assays in combination with subinhibitory concentrations of novobiocin. The antibacterial susceptibilities of susceptible and MDR A. baumannii to a variety of antibiotics were determined in the absence and presence of ellagic and tannic acids. The effect of the adjuvants on bacterial outer membrane function was examined by using the fluorescence dye 1-N-phenylnaphthylamine (NPN). The efflux pump inhibition was measured by the intracellular accumulation of ethidium bromide (EtBr) and pyronin Y.

RESULTS

At 40 microM, ellagic and tannic acids enhanced the activity of novobiocin, coumermycin, chlorobiocin, rifampicin and fusidic acid against A. baumannii. There were no increases in the uptake of NPN or in the accumulation of EtBr after strains were treated with these adjuvants; however, the intracellular accumulation of pyronin Y by the treated cells was significantly increased, suggesting that ellagic and tannic acids act as efflux pump inhibitors.

CONCLUSIONS

Susceptibility of MDR A. baumannii to a variety of antibiotics was enhanced in the presence of ellagic and tannic acids. The use of such plant compounds might provide effective treatments for resistant Gram-negative bacterial infections.

Acinetobacter baumannii infection during pregnancy and puerperium

Acinetobacter baumannii is a multidrug-resistant bacterium that is normally a commensal pathogen. This bacterium can lead to severe complications such as pneumonia, fever and septicaemia, because of limited treatment options. This case report describes a cervical A. baumannii infection during pregnancy and puerperium in a case of a patient treated in our hospital, because of insufficiency of cervix diagnosed in the 28 + 3 week of gestation. In spite of antibiotic treatment, the patient developed increasing contractions and chorioamnionitis, resulting in caesarean section in the 31st week of gestation. Moreover, although being treated with carbapenems, the patient presented postpartal with fever and septic symptoms, which could only be treated by escalation of the dosage of the given carbapenem. In conclusion, A. baumannii can lead to premature contractions and can be associated with chorioamnionitis during pregnancy. Moreover, it can also cause septic complications in the puerperium associated with long duration of hospitalisation. The management and therapy of this vaginal infection during pregnancy and puerperium is a real challenge to gynaecologists and obstetricians.

GES-11, a novel integron-associated GES variant in Acinetobacter baumannii

New extended-spectrum beta-lactamase GES-11 was detected in Acinetobacter baumannii BM4674. The enzyme conferred resistance to beta-lactams, including aztreonam, and reduced susceptibility to carbapenems. The structural gene was part of a class 1 integron borne by self-transferable plasmid pIP847. GES-type beta-lactamases have not been reported previously in A. baumannii.