Comparison of one-tube multiplex PCR, automated ribotyping and intergenic spacer (ITS) sequencing for rapid identification of Acinetobacter baumannii

Eradication of multidrug-resistant Acinetobacter baumannii from the respiratory tract with inhaled colistin methanesulfonate: a matched case-control study

Repeated isolation of multidrug-resistant Acinetobacter baumannii (MDRAB) from respiratory secretions poses a great challenge for infection control. We conducted a retrospective case-control study to evaluate the efficacy and adverse effect of inhaled colistin methanesulfonate (CMS) in the eradication of MDRAB from the respiratory tract. Patients who were admitted to Taipei Veterans General Hospital between February 2009 and June 2010, had at least two sets of monomicrobial culture of MDRAB from respiratory secretions, and remained in hospital for at least 14 days after the first isolation of MDRAB (index day) were included. Patients who received intravenous CMS were excluded. Patients who received CMS inhalation for ≥ 3 days were selected as cases whereas the controls were matched for age and Acute Physiology and Chronic Health Evaluation II score. Thirty-nine cases and controls were identified. The duration of CMS inhalation was 10.9 ± 3.6 days. The use of inhaled CMS was the only independent factor associated with the eradication of MDRAB within 14 days after the index day (OR 266.33; 95% CI 11.26-6302.18, p <0.001), and shortened the duration of MDRAB recovery from the respiratory tract by 13.3 ± 1.45 days. The adverse effects were similar for both groups. The increase of colistin minimal inhibitory concentrations in the last isolate compared with the index isolate from the same patient did not differ between the two groups. In conclusion, our study demonstrated that inhaled CMS enhanced the eradication of MDRAB from the respiratory tract without significant clinical adverse effect or impact on colistin resistance.

Imipenem: a potent inducer of multidrug resistance in Acinetobacter baumannii

This study investigated the progression of multidrug resistance upon exposure to imipenem in Acinetobacter baumannii. Eighteen A. baumannii strains, including two reference strains (ATCC 19606 and ATCC 17978), four clinical strains (AB56, AB242, AB273 and AB279) and 12 antibiotic-selected mutant strains, were used in this study. Imipenem-selected mutants were generated from imipenem-susceptible strains (ATCC 19606, ATCC 17978 and AB242) by multistep selection resistance. Amikacin-, ciprofloxacin-, colistin-, meropenem- and ceftazidime-selected mutants were also generated from the two reference strains and were used for comparison. Antibiotic susceptibilities in the absence and presence of the efflux pump inhibitors carbonyl cyanide m-chlorophenylhydrazone (CCCP) and 1-(1-naphthylmethyl)-piperazine (NMP) were examined in the three imipenem-selected mutants and the three clinical multidrug-resistant (MDR) isolates. Expression profiles of the antimicrobial resistance genes in the imipenem-selected mutants and their parental strains were also determined. The results showed that imipenem was more likely, compared with the other antibiotics, to induce a MDR phenotype in the two reference strains. Differences in OXA-51-like carbapenemase, efflux pumps or/and AmpC β-lactamase expression were observed in the three imipenem-selected mutants. Moreover, a reduction in imipenem or amikacin resistance was observed when the imipenem-selected mutants and clinical isolates were exposed to NMP and CCCP. This study concluded that imipenem might be a potent inducer of multidrug resistance in A. baumannii strains. OXA-51-like carbapenemase combined with other resistance mechanisms may contribute to the development of multidrug resistance in A. baumannii. Monitoring the use of carbapenems is required to reduce the spread of MDR A. baumannii in hospitals.

Clinical characteristics and outcomes of bacteremia due to different genomic species of Acinetobacter baumannii complex in patients with solid tumors

PURPOSE

Acinetobacter baumannii, Acinetobacter genomic species 3 (AGS 3), and Acinetobacter genomic species sensu Tjernberg and Ursing (AGS 13TU) are phenotypically indistinguishable and are often reported together as the A. baumannii complex (ABC). Few studies have investigated the difference in outcome caused by these different species, and all involved heterogeneous groups of patients. This study aimed to delineate whether there are differences in the clinical characteristics and outcome among patients with solid tumors and bacteremia caused by A. baumannii or two other non-baumannii ABC species (AGS 3 plus AGS 13TU).

METHODS

Patients with solid tumors and ABC bacteremia over a period of 5 years in a medical center were identified. The patient data were retrospectively reviewed and analyzed.

RESULTS

We identified 103 patients with ABC bacteremia during the study period. Bacteremia was due to A. baumannii in 30 patients, AGS 3 in 24 patients, and AGS 13TU in 49 patients. Among the 103 patients with ABC bacteremia, recent stay in the intensive care unit (ICU) (p = 0.008) was independently associated with the acquisition of A. baumannii bacteremia. Multivariate analysis revealed that bacteremia caused by A. baumannii (hazard ratio [HR] 2.990, 95% confidence interval [CI], 1.021-8.752, p = 0.046) and Acute Physiology and Chronic Health Evaluation (APACHE) II score ≥21 (HR 4.623, 95% CI 1.348-15.859, p = 0.015) were independent factors associated with 14-day mortality.

CONCLUSIONS

Infection with A. baumannii and a high APACHE II score (≥21) might be associated with poor outcome in patients with solid tumors and ABC bacteremia.

Spread of imipenem-resistant Acinetobacter baumannii of European clone II in Western China

The aim of this study was to investigate the distribution of resistance genes and the clonal relationship amongst imipenem-resistant Acinetobacter baumannii isolates from ten hospitals in Western China as well as to compare the molecular epidemiological data with those of isolates from two hospitals in Hangzhou and Beijing. Genes encoding OXA carbapenemases, metallo-β-lactamases, AmpC cephalosporinase and carbapenem resistance-associated outer membrane protein (CarO) were screened using polymerase chain reaction (PCR) and sequencing. PCR mapping was performed to determine whether insertion sequence ISAba1 elements preceded OXA carbapenemases and AmpC cephalosporinase. International clonal lineages were identified by sequence type multiplex PCR. Multilocus sequence typing (MLST) was performed to determine the sequence types (STs), and then eBURST algorithm was applied to assign clonal complexes (CCs). In this study, dissemination of acquired ISAba1 preceding the bla(OXA-23-like) gene was the predominant enzymatic resistance mechanism amongst 272 imipenem-resistant isolates. Five isolates harboured the carO gene disrupted by insertion of ISAba1 and three isolates lacked carO. All of the 36 representative isolates belonged to European clone II. Ten STs, including three novel types, were identified. These STs were clustered into CC92 and two distinct singletons. These observations suggest that imipenem-resistant A. baumannii of European clone II, which carries acquired ISAba1 preceding the bla(OXA-23-like) gene and belongs to CC92, has spread within Western China.

Acinetobacter calcoaceticus-Acinetobacter baumannii complex species in clinical specimens in Singapore

This study was performed to determine the prevalence, distribution of specimen sources, and antimicrobial susceptibility of the Acinetobacter calcoaceticus-Acinetobacter baumannii (Acb) species complex in Singapore. One hundred and ninety-three non-replicate Acb species complex clinical isolates were collected from six hospitals over a 1-month period in 2006. Of these, 152 (78·7%) were identified as A. baumannii, 18 (9·3%) as 'Acinetobacter pittii' [genomic species (gen. sp.) 3], and 23 (11·9%) as 'Acinetobacter nosocomialis' (gen. sp. 13TU). Carbapenem resistance was highest in A. baumannii (72·4%), followed by A. pittii (38·9%), and A. nosocomialis (34·8%). Most carbapenem-resistant A. baumannii and A. nosocomialis possessed the bla(OXA-23-like) gene whereas carbapenem-resistant A. pittii possessed the bla(OXA-58-like) gene. Two imipenem-resistant strains (A. baumannii and A. pittii) had the bla(IMP-like) gene. Representatives of carbapenem-resistant A. baumannii were related to European clones I and II.

In-vitro activity of polymyxin B, rifampicin, tigecycline alone and in combination against carbapenem-resistant Acinetobacter baumannii in Singapore

OBJECTIVE

Carbapenem-resistant Acinetobacter baumannii (CR-AB) is an emerging cause of nosocomial infections worldwide. Combination therapy may be the only viable option until new antibiotics become available. The objective of this study is to identify potential antimicrobial combinations against CR-AB isolated from our local hospitals.

METHODS

AB isolates from all public hospitals in Singapore were systematically collected between 2006 and 2007. MICs were determined according to CLSI guidelines. All CR-AB isolates were genotyped using a PCR-based method. Clonal relationship was elucidated. Time-kill studies (TKS) were conducted with polymyxin B, rifampicin and tigecycline alone and in combination using clinically relevant (achievable) unbound concentrations.

RESULTS

31 CR AB isolates were identified. They are multidrug-resistant, but are susceptible to polymyxin B. From clonal typing, 8 clonal groups were identified and 11 isolates exhibited clonal diversity. In single TKS, polymyxin B, rifampicin and tigecycline alone did not exhibit bactericidal activity at 24 hours. In combination TKS, polymyxin plus rifampicin, polymyxin B plus tigecycline and tigecycline plus rifampicin exhibited bactericidal killing in 13/31, 9/31 and 7/31 isolates respectively at 24 hours. Within a clonal group, there may be no consensus with the types of antibiotics combinations that could still kill effectively.

CONCLUSION

Monotherapy with polymyxin B may not be adequate against polymyxin B susceptible AB isolates. These findings demonstrate that in-vitro synergy of antibiotic combinations in CR AB may be strain dependant. It may guide us in choosing a pre-emptive therapy for CR AB infections and warrants further investigations.

Difference in imipenem, meropenem, sulbactam, and colistin nonsusceptibility trends among three phenotypically undifferentiated Acinetobacter baumannii complex in a medical center in Taiwan, 1997-2007

BACKGROUND

To determine whether the susceptibilities and the trends of nonsusceptibility of imipenem, meropenem, sulbactam, and colistin differed among Acinetobacter baumannii, Acinetobacter genomic species 3 (AGS 3), and Acinetobacter genomic species 13TU (AGS 13TU) over 11 years.

METHODS

A total of 1,039 nonduplicate blood isolates of A baumannii complex from bacteremic patients between 1997 and 2007 were collected at Taipei Veterans General Hospital and were identified to the species level using a multiplex polymerase chain reaction method and sequence analysis of 16S-23S intergenic spacer. The minimal inhibitory concentrations of antibiotics were determined by the agar dilution method.

RESULTS

The nonsusceptibility rates of carbepenems and sulbactam were highest in A baumannii, which also showed a trend toward increasing rate of carbapenems nonsusceptibility over the 11-year period of the study. AGS 13TU had the highest nonsusceptible rate to colistin, comparably increasing trend of carbapenem nonsusceptiblity as that of A baumannii, and is the only species with increasing sulbactam nonsusceptibility. AGS 3 had the lowest rate of nonsusceptibility to all four antimicrobial agents.

CONCLUSION

Although A baumannii had the highest nonsusceptibility rate to imipenem, meropenem, and sulbactam over the years, the higher rate of colistin nonsusceptibility and the emergence of nonsusceptibility of carbapenems and sulbactam in AGS 13TU suggested that this species might cause a great problem in the near future.

Predictors of mortality in surgical patients with Acinetobacter baumannii bacteremia

BACKGROUND

Acinetobacter baumannii has emerged as an important pathogen of nosocomial infection. The aim of this study was to evaluate the predictors of poor outcome in surgical patients with A baumannii bacteremia.

METHODS

We retrospectively recruited a total of 50 patients who developed A baumannii bacteremia within 2 weeks after surgery during a 113-month period. The primary outcome for this study was all-cause 14-day mortality. Clinical and laboratory data, antimicrobial susceptibility, treatment, and Sequential Organ Failure Assessment (SOFA) score were evaluated as possible predictors of outcome.

RESULTS

The 14-day mortality was 20% and there was no association between type of surgery and mortality. The SOFA score was the only independent predictor of 14-day mortality after adjustment for other variables. The calibration was acceptable (Hosmer-Lemeshow χ(2) = 3.65, p = 0.72) and the discrimination was good (area under the receiver operating characteristic curve: 0.80 ± 0.07, 95% confidence interval, 0.67-0.94). We found that a SOFA score ≥ 7 was a significant predictor of 14-day mortality in surgical patients with A baumannii bacteremia.

CONCLUSIONS

The SOFA score assessed at the onset of bacteremia is a reliable tool for predicting 14-day mortality in surgical patients with A baumannii bacteremia.

Emergence and dissemination of blaOXA-23-carrying imipenem-resistant Acinetobacter sp in a regional hospital in Taiwan

BACKGROUND

The distribution and characterization of OXA-type carbapenemases in Acinetobacter sp in Taiwan has less been reported. The aim of the study was to investigate the molecular epidemiology and OXA-type carbapenemase genes in a regional hospital in Taiwan.

METHODS

Imipenem-resistant Acinetobacter sp were collected between 2005 and 2007 in a regional hospital. Genotyping was performed by pulsed-field gel electrophoresis. OXA-type carbapenemase genes were determined by multiplex polymerase chain reaction (PCR) and gene sequencing.

RESULTS

A total of 136 isolates were collected. Fifty-six pulsotypes were identified. None of the pulsotypes established predominance throughout the 3-year period. Multiplex PCR of blaOXA genes showed that 99% (135/136) of the Acinetobacter sp possessed blaOXA51-like genes. The coexistences of blaOXA51-like/blaOXA-23-like and blaOXA51-like/blaOXA-24-like were detected in 19% (26/136) and 1% (2/136) of the isolates, respectively. Among blaOXA-23-like gene-carrying isolates, two isolates (Pulsotypes 18 and 20) were found in 2006 and the remainder (n=24), including Pulsotypes 27 (n=18), 29 (n=1), 52 (n=3), and 53 (n=2), were found in 2007. Sequencing performed on the 26 representative isolates confirmed the presence of the blaOXA-23 carbapenemase gene. Analysis of the genetic content of blaOXA-23 showed that these genes were presumably chromosomal and associated with the upstream-located insertion sequence ISAba1.

CONCLUSIONS

The emergence and imminent widespread of blaOXA-23-carrying imipenem-resistant Acinetobacter sp appeared in Taiwan during the period from 2006 to 2007.

Prediction of patient outcome from Acinetobacter baumannii bacteremia with Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE) II scores

OBJECTIVE

Acinetobacter baumannii is an important nosocomial pathogen associated with a high mortality rate. However, no objective and quantitative severity scores are available for the severity stratification. We aimed to assess the effectiveness of SOFA and APACHE II scores calculated at the onset of bacteremia in predicting the mortality of patients with A. baumannii bacteraemia.

PATIENTS AND METHODS

A total of 110 patients with A. baumannii bacteremia were included in this retrospective study during the 40-month study period. Information including clinical and laboratory data was collected.

RESULTS

Multivariate analysis showed that both SOFA and APACHE II scores were independent outcome predictors after adjustment for other parameters. Goodness-of-fit was good for SOFA and APACHE II, and both models displayed excellent AUROCs (SOFA: 0.83 ± 0.06, APACHE II: 0.82 ± 0.08 in predicting 14-day mortality; SOFA: 0.85 ± 0.04, APACHE II: 0.81 ± 0.04 in predicting in-hospital mortality). There was no significant difference in the predictions of the two scoring systems, and the scores were highly correlated (r(2)=0.724, p <0.001). We found that SOFA >8, APACHE II >29 and SOFA >7, APACHE II >23 are associated with significantly higher 14-day and in-hospital mortality rates, respectively.

CONCLUSION

SOFA and APACHE II scores assessed at the onset of bacteremia are reliable risk stratifying tools in predicting 14-day and in-hospital mortality in A. baumannii bacteremia. For ease of calculation, the use of SOFA rather than APACHE II score to predict mortality of A. baumannii bacteremia might have clinical application.

Increasing imipenem resistance and dissemination of the ISAba1-associated blaOXA-23 gene among Acinetobacter baumannii isolates in an intensive care unit

The antibiotic susceptibility of Acinetobacter calcoaceticus-Acinetobacter baumannii complex strains recovered from the intensive care unit (ICU) of West China Hospital, Sichuan, PR China, from 2006 to 2009 was investigated. The identification of A. baumannii and analysis of carbapenemase-encoding genes and their relationship with ISAba1 were performed by PCR. Furthermore, a DiversiLab repetitive extragenic palindromic sequence-based PCR (rep-PCR) microbial typing system and a multilocus sequence typing (MLST) scheme were applied to assess the genetic relationship of the isolates. The results showed that the antibiotic susceptibility of the A. calcoaceticus-A. baumannii complex isolates changed and imipenem resistance increased rapidly between 2006 and 2009. The blaOXA-51-like and ISAba1-associated blaOXA-23 genes were prevalent in the imipenem-resistant A. baumannii isolates. However, the blaOXA-58-like gene was found in only one isolate and no metallo-β-lactamase genes were detected. The representative multidrug-resistant A. baumannii isolates were identified as one cluster by rep-PCR fingerprinting and belonged to the clonal complex 92 (CC92) according to MLST. These findings indicate a situation of increasing resistance and wide distribution of class D β-lactamase genes, especially the acquired ISAba1-associated blaOXA-23 gene, in A. baumannii isolates in the ICU of West China Hospital, probably caused by expansion of the CC92 clone.

In vitro antibiotic synergy in extensively drug-resistant Acinetobacter baumannii: the effect of testing by time-kill, checkerboard, and Etest methods

This study examined the in vitro effects of polymyxin B, tigecycline, and rifampin combinations on 16 isolates of extensively drug-resistant Acinetobacter baumannii, including four polymyxin-resistant strains. In vitro synergy was demonstrated in 19 (40%) of a possible 48 isolate-antibiotic combinations by time-kill methods, 8 (17%) by checkerboard methods, and only 1 (2%) by Etest methods. There was only slight agreement between Etest and checkerboard methods and no agreement between results obtained by other methods.

DnaK and GroEL are induced in response to antibiotic and heat shock in Acinetobacter baumannii

We studied the expression of DnaK and GroEL in Acinetobacter baumannii cells (strains ATCC 19606 and RS4) under stress caused by heat shock or antibiotics. A Western blot assay showed that DnaK and GroEL levels increased transiently more than 2-fold after exposure of bacterial cells to heat shock for 20 min at 50 °C. Heat induction of DnaK and GroEL was blocked completely when an inhibitor of transcription, rifampicin, was added 1 min before a temperature upshift to 50 °C, suggesting that the induction of these chaperones depends on transcription. A. baumannii cells pretreated at 45 °C for 30 min were better able to survive at 50 °C for 60 min than cells pretreated at 37 °C, indicating that A. baumannii is able to acquire thermotolerance. DnaK and GroEL were successfully induced in cells pre-incubated with a subinhibitory concentration of streptomycin. Moreover, bacterial cells pretreated for 30 min at 45 °C were better able to survive streptomycin exposure than cells pretreated at physiological temperatures. DnaK expression was upregulated in a multidrug-resistant strain of A. baumannii (RS4) in the presence of different antimicrobials (ampicillin+sulbactam, cefepime, meropenem and sulphamethoxazole+trimethoprim). This study is to the best of our knowledge the first to show that A. baumannii DnaK and GroEL could play an important role in the stress response induced by antibiotics.

Emergence and Distribution of Plasmids Bearing the blaOXA-51-like gene with an upstream ISAba1 in carbapenem-resistant Acinetobacter baumannii isolates in Taiwan

The bla(OXA-51)-like gene with an upstream ISAba1 (ISAba1-bla(OXA-51)-like gene) was originally found on the chromosomes of carbapenem-resistant or -susceptible Acinetobacter baumannii isolates. However, a plasmid-borne ISAba1-bla(OXA-51)-like gene has recently been identified in Acinetobacter genomic species 13TU and several A. baumannii isolates in Taiwan, and all of the isolates are carbapenem resistant. This study aimed to characterize the plasmids bearing the ISAba1-bla(OXA-51)-like gene and their significance in A. baumannii. Among the 117 ISAba1-bla(OXA-51)-like-harboring isolates collected from 10 hospitals in Taiwan, 58 isolates (49.6%) from 24 clones had the genes located on plasmids that likely originated from a common progenitor. Among the 58 isolates, four had additional copy of the ISAba1-bla(OXA-51)-like gene on their chromosomes. Based on the analysis of these four isolates, the plasmid-located ISAba1-bla(OXA-51)-like gene appeared to be acquired via one-ended transposition (Tn6080). The isolates with a plasmid bearing the ISAba1-bla(OXA-51)-like gene had higher rates of resistance to imipenem (98% versus 46.6%; P < 0.001) and meropenem (98% versus 69%; P = 0.019) than those with the genes chromosomally encoded, which is most likely due to increased gene dosage provided by the higher copy number of associated plasmids. Transformation with a recombinant plasmid harboring only the ISAba1-bla(OXA-51)-like gene was enough to confer a high level of carbapenem resistance to A. baumannii, eliminating the possible contribution of other factors on the original plasmids. This study demonstrated that the carbapenem resistance-associated plasmids carrying the ISAba1-bla(OXA-51)-like gene are widespread in A. baumannii strains in Taiwan.

Distribution of blaOXA-carrying imipenem-resistant Acinetobacter spp. in 3 hospitals in Taiwan

We investigated the molecular epidemiology and OXA-type carbapenemase genes of 83 imipenem-resistant Acinetobacter spp. collected from 2 university hospitals (hospitals A and B) and a regional hospital (hospital C) during 2007 in Taiwan. Genotyping by pulsed-field gel electrophoresis identified 51 pulsotypes. None of the pulsotypes established predominance throughout the 3 hospitals. Multiplex polymerase chain reaction of blaOXA genes showed that 100% (18/18), 91%(31/34), and 100% (31/31) of the Acinetobacter spp. collected from hospital A, B, and C, respectively, possessed blaOXA-51-like genes. None of the strains carrying blaOXA-23-like and blaOXA-24-like genes were found in hospital A. The coexistences of blaOXA-51-like/blaOXA-23-like and blaOXA-51-like/blaOXA-24-like genes detected in hospitals B and C were 26% (9/34) and 12% (4/34) and 58% (18/31) and 3% (1/31), respectively. Among blaOXA-23-like gene-carrying isolates collected from hospitals, clonal spread of strains carrying the blaOXA-23 gene was detected in the regional hospital but not the other 2 university hospitals. The results suggest that interhospital dissemination of imipenem-resistant Acinetobacter spp. was not found in these hospitals. The increasing percentage of OXA-23 in OXA-type carbapenemases in Acinetobacter spp. from the regional hospitals to medical centers deserves further attention in Taiwan.

Bacteremia due to Acinetobacter genomic species 10

Six patients with Acinetobacter genomic species 10 bacteremia were identified. The clinical features of the patients, phenotypic and genotypic identifications, antimicrobial susceptibilities, and genes flanking ISAba1 of the bacteria were described. The results revealed that this bacterium is a potentially lethal pathogen that can cause health care-associated infections in debilitated patients.

Differences in phenotypic and genotypic characteristics among imipenem-non-susceptible Acinetobacter isolates belonging to different genomic species in Taiwan

In this study, we investigated the distribution of genes encoding various carbapenemases as well as their association with carbapenem resistance in clinical isolates of Acinetobacter genomic species from Taiwan. A total of 129 imipenem-non-susceptible and 79 imipenem-susceptible isolates were examined, of which 185 (88.9%) were Acinetobacter baumannii. Among the 185 A. baumannii isolates, imipenem non-susceptibility was more common in isolates with ISAba1-bla(OXA-51-like) (72/75; 96%), bla(OXA-58-like) (33/33; 100%) or bla(OXA-24-like) (7/7; 100%) than in isolates with only bla(OXA-51-like) (4/72; 5.6%). A metallo-beta-lactamase (MBL) gene was present in two isolates of imipenem-resistant A. baumannii, and bla(OXA-58-like) was also present in these isolates. A total of 18% and 1% of imipenem-non-susceptible isolates of A. baumannii were resistant to tigecycline and colistin, respectively. Among the 23 isolates of non-baumannii Acinetobacter spp., bla(OXA-58-like) and MBL genes were widely disseminated in the imipenem-resistant isolates, and isolates with bla(OXA-58-like) and MBL genes had higher imipenem minimum inhibitory concentrations than those with bla(OXA-58-like) alone. Although the rate of non-susceptibility to colistin was 26.7% among the imipenem-non-susceptible isolates of non-baumanniiAcinetobacter, 93.3% and 100% were susceptible to ciprofloxacin and tigecycline, respectively. In conclusion, different isolates of imipenem-non-susceptible A. baumannii and non-baumanniiAcinetobacter contained different carbapenemases and had different antimicrobial susceptibilities.

Investigation of carbapenem-resistant Acinetobacter baumannii isolates in a district hospital in Taiwan

A total of 34 Acinetobacter baumannii isolates from a district hospital in Taiwan were identified with carbapenem-hydrolyzing oxacillinase OXA-66/OXA-51-like. In addition, 26 of 28 carbapenem-resistant isolates harbored plasmid-encoded bla(OXA-23)-like genes. Twenty of 28 carbapenem-resistant isolates mapped to the major genotype cluster A of carbapenemase producer by pulsed-field gel electrophoresis.

Genotype and antibiotic susceptibility patterns of drug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii isolates in Taiwan

Rapid and accurate identification of the drug susceptibility profile of clinical strains is very important for controlling bacterial infections and determining the antibiotic therapy. The objective of this study was to investigate the spectrum of the correlation between phenotypic and genetic characters of the drug-resistant clinical isolates. A total of 133 clinical isolates, including 76 Acinetobacter baumannii and 57 Pseudomonas aeruginosa, were examined for their antibiotic susceptibility by the method of disc diffusion. Among them, most of the isolates were multiresistant, and 80% of the strains showed phenotypic resistance to beta-lactam antibiotics. Using PCR analysis, among the several types of beta-lactamases, TEM was the most prevalent, and OXA was the second most prevalent. The integron harbored was identified by conserved segment PCR, and 50% of the test isolates carried integrons with various gene cassette sizes inserted. The results obtained from this study reveal that the majority of these isolates displayed multiple drug resistance phenotypes that were associated with their mutational gene profiles.

Dissemination of multidrug-resistant, class 1 integron-carrying Acinetobacter baumannii isolates in Taiwan

In this study, 283 multidrug-resistant Acinetobacter baumannii (MDR-AB) bloodstream isolates were collected between 1996 and 2004, from three teaching hospitals located in different regions of Taiwan. Susceptibility data showed that strains carrying class 1 integrons were significantly more resistant (p <0.01) to all tested antibiotics (except aztreonam and chloramphenicol) than strains lacking integrons, Seven types of gene cassette were identified among these strains, including two that have not been previously reported. The vast majority of the cassettes encoded aminoglycoside resistance genes, including aacA4, aacC1, aac(6')-II, aadA1, aadA2, aadA4 and aadDA1. Sixteen distinct ribotypes were identified in MDR-AB isolates carrying class 1 integrons. Only one strain was found to produce an extended-spectrum beta-lactamase, i.e. VEB-3. In the 18 imipenem-resistant strains, two carbapenenmase genes, bla(VIM-11) and bla(OXA-58), were found concomitantly in one isolate. An island-wide epidemic clone and an endemic clone from a hospital located in the northern region were identified by ribotyping. On the basis of the susceptibility data among the different ribogroups, the epidemic clone was associated more significantly with resistance to cefepime and ampicillin-sulbactam than was the endemic clone. In conclusion, the presence of class 1 integrons was significantly associated with resistance in MDR-AB, and the epidemic, class 1 integron-carrying MDR-AB clone was found to be widespread in Taiwan.

Antibiotic Resistance in Gram-negative Bacilli: A Singapore Perspective

Introduction: Antibiotic resistance in gram-negative bacilli is an area of increasing importance. This prospective study was performed to survey antibiotic resistance in Escherichia coli (E. coli), Klebsiella spp., Pseudomonas aeruginosa and Acinetobacter spp. over a 1-year period. Materials and Methods: Non-duplicate isolates of E. coli, Klebsiella spp., P. aeruginosa and Acinetobacter spp. were collected from participating Singapore hospitals during defined collection periods in 2006 and 2007. Confirmatory identification and antibiotic susceptibility testing were performed at Changi General Hospital. Minimum inhibitory concentrations (MIC) to a defined panel of antibiotics were determined using microbroth dilution methods. The presence of extended-spectrum beta lactamases and AmpC beta-lactamases in Enterobacteriaceae was determined by phenotypic methods, and susceptibility results were defined using current breakpoints from the Clinical Laboratory Standards Institute (CLSI). Results: Seven hundred and forty-six gram-negative bacilli were received for testing. Resistance to extended-spectrum cephalosporins was present in a third of Enterobacteriaceae isolates, and extended-spectrum beta-lactamases (ESBL) carriage was present in 19.6% and 30.1% of E. coli and Klebsiella pneumoniae, respectively. AmpC enzymes were also detected in 8.5% and 5.6% of E. coli and K. pneumoniae isolates respectively. All Enterobacteriaceae were susceptible to imipenem and meropenem. The most active antibiotics against P. aeruginosa were amikacin, meropenem and piperacillin-tazobactam. A third of P. aeruginosa showed reduced susceptibility to polymyxin B. Carbapenem resistance was significantly higher in Acinetobacter baumannii (70.5%) than in other Acinetobacter species (25.0%). The most active antibiotic against A. baumannii was polymyxin B. Conclusion: Antibiotic resistance is prevalent in gram-negative bacilli isolated from Singapore hospitals. The MIC testing surveillance programme complemented susceptibility data from wider laboratory-based surveillance, and has revealed emerging mechanisms of antibiotic resistance. Keywords: Enterobacteriaceae, Acinetobacter baumannii, Pseudomonas aeruginosa, Microbial sensitivity tests

Acinetobacter baylyi as a pathogen for opportunistic infection

There are no previous reports of human infection due to Acinetobacter baylyi. In this study, we report on six patients with bacteremia due to A. baylyi, based on analysis of the 16S-23S rRNA intergenic spacer and the 16S rRNA gene. All six patients had multiple underlying diseases. The infection was nosocomially acquired in five patients. The six clinical isolates had similar ribopatterns, suggesting a clonal relationship. Compared to the reference strain, the clinical isolates were more resistant to antimicrobial agents, especially beta-lactam antibiotics. In three of the isolates, they may have undetermined plasmid mediated class C type beta-lactamases because of the positive results in a double-disk synergy test using 3-aminophenylboronic acid. Two of the clinical isolates retained a level of natural transformability similar to that of the reference strain. None of the patients died, although only three of them received appropriate antimicrobial therapy. This study demonstrates that A. baylyi is a potential human pathogen that can cause nosocomial infection in immunocompromised patients.

Acquisition of a plasmid-borne blaOXA-58 gene with an upstream IS1008 insertion conferring a high level of carbapenem resistance to Acinetobacter baumannii

The oxacillinase gene was reported to confer limited resistance to carbapenem in Acinetobacter baumannii. In this study, we have demonstrated that an A. baumannii clinical isolate harboring a plasmid, pTVICU53, has 11,037 bp encoding 13 open reading frames. A bla(OXA-58) gene with an upstream insertion of truncated ISAba3 (DeltaISAba3) and IS1008 was found in this plasmid. DeltaISAba3and IS1008 provided two independent promoters for the transcription control of the bla(OXA-58) gene. The transformation of pTVICU53 or a shuttle vector bearing IS1008-DeltaISAba3-bla(OXA-58) to different A. baumannii recipients can increase their MICs of carbapenem 64- to 256-fold. The deletion of promoters provided by IS1008 resulted in dramatic decreases in bla(OXA-58) transcription and a 32- to 64-fold reduction in the carbapenem MIC. These findings highlight that A. baumannii might develop carbapenem resistance with a single transformation step, taking up a plasmid containing a genetic construct with a potentially high level of transcription of the bla(OXA-58) gene.

Unique organization of the 16S-23S intergenic spacer regions of strains of Acinetobacter baylyi provides a means for its identification from other Acinetobacter species

This paper extends an earlier report on rrn operon characteristics in members of the genus Acinetobacter. It describes a systematic approach towards developing and validating a protocol for elucidating how the intergenic spacer regions (ISR) in Acinetobacter baylyi strains are organized and allows the numbers of long and short ISRs to be determined. Experimental data confirmed the in silico predictions based on available A. baylyi rrn sequence data. All were shown to possess three long ISRs and 4 short ISRs, differing in most cases in length by about 90nt. However, the ISR arrangement in A. baylyi strain 93A2 was different. Although it also possessed 4 SISRs and three LISRs, their length difference was less (39nt) which was confirmed from its ISR sequence data. Primer sets for PCR identification of A. baylyi could then be determined. Applying the same approach to other species of Acinetobacter showed none shared the same ISR organization as A. baylyi. Its value in typing members of this genus is discussed.