Acinetobacter baumannii: emergence of a successful pathogen. Clin Microbiol Rev. 2008;21:538-582. [PMID: 18625687 DOI: 10.1128/cmr.00058-07]

[Emerging multidrug-resistant microorganisms among travelers returning to France and persons repatriated from foreign hospitals]

The spread of multidrug-resistant bacteria has become a major problem in France in recent years, owing to increasing antibiotic exposure, growing international exchanges, repatriation of hospitalized French patients, and treatment of French and foreign travelers in French hospitals. This article examines how different pathogens may become endemic in France.

[Emerging multidrug-resistant microorganisms among travelers returning to France and persons repatriated from foreign hospitals]

The spread of multidrug-resistant bacteria has become a major problem in France in recent years, owing to increasing antibiotic exposure, growing international exchanges, repatriation of hospitalized French patients, and treatment of French and foreign travelers in French hospitals. This article examines how different pathogens may become endemic in France.

The role of genomics in the identification, prediction, and prevention of biological threats

In all likelihood, it is only a matter of time before our public health system will face a major biological threat, whether intentionally dispersed or originating from a known or newly emerging infectious disease. It is necessary not only to increase our reactive “biodefense,” but also to be proactive and increase our preparedness. To achieve this goal, it is essential that the scientific and public health communities fully embrace the genomic revolution, and that novel bioinformatic and computing tools necessary to make great strides in our understanding of these novel and emerging threats be developed. Genomics has graduated from a specialized field of science to a research tool that soon will be routine in research laboratories and clinical settings. Because the technology is becoming more affordable, genomics can and should be used proactively to build our preparedness and responsiveness to biological threats. All pieces, including major continued funding, advances in next-generation sequencing technologies, bioinformatics infrastructures, and open access to data and metadata, are being set in place for genomics to play a central role in our public health system.

Has the era of untreatable infections arrived?

Antibiotic resistance is a major public health concern, with fears expressed that we shortly will run out of antibiotics. In reality, the picture is more mixed, improving against some pathogens but worsening against others. Against methicillin-resistant Staphylococcus aureus (MRSA)--the highest profile pathogen--the range of treatment options is expanding, with daptomycin, linezolid and tigecycline all launched, and telavancin, ceftobiprole, ceftaroline and dalbavancin anticipated. There is a greater problem with enterococci, especially if, as in endocarditis, bactericidal activity is needed and the isolate has high-level aminoglycoside resistance; nevertheless, daptomycin, telavancin and razupenem all offer cidal potential. Against Enterobacteriaceae, the rapid and disturbing spread of extended-spectrum beta-lactamases, AmpC enzymes and quinolone resistance is forcing increased reliance on carbapenems, with resistance to these slowly accumulating via the spread of metallo-, KPC and OXA-48 beta-lactamases. Future options overcoming some of these mechanisms include various novel beta-lactamase-inhibitor combinations, but none of these overcomes all the carbapenemase types now circulating. Multiresistance that includes carbapenems is much commoner in non-fermenters than in the Enterobacteriaceae, depending mostly on OXA carbapenemases in Acinetobacter baumannii and on combinations of chromosomal mutation in Pseudomonas aeruginosa. No agent in advanced development has much to offer here, though there is interest in modified, less-toxic, polymyxin derivatives and in the siderophore monobactam BAL30072, which has impressive activity against A. baumannii and members of the Burkholderia cepacia complex. A final and surprising problem is Neisseria gonorrhoeae, where each good oral agent has been eroded in turn and where there is now little in reserve behind the oral oxyimino cephalosporins, to which low-level resistance is emerging.

Heteroresistance to meropenem in carbapenem-susceptible Acinetobacter baumannii

The characteristics of carbapenem heteroresistance were studied in 14 apparently carbapenem-susceptible Acinetobacter baumannii isolates. The MICs for carbapenems were determined, and the isolates were genotyped by pulsed-field gel electrophoresis (PFGE) and sequence typing (ST). Population analysis, testing of the stability of the heteroresistant subpopulations, and time-killing assays were performed. The agar dilution MICs of both imipenem and meropenem for the native isolates ranged from 0.25 to 4 mg/liter. The isolates belonged to nine PFGE types and exhibited seven ST allelic profiles. Population analysis revealed subpopulations that grew in the presence of imipenem at concentrations of up to 8 mg/liter and meropenem at concentrations of up to 32 mg/liter. The meropenem-heteroresistant subpopulations of 11 isolates exhibited stable resistance with MICs that ranged from 16 to >32 mg/liter; their PFGE profiles were identical to those of the native isolates. Time-kill assays with meropenem revealed less pronounced killing for 10 isolates. These findings indicate that meropenem pressure can produce meropenem-heteroresistant subpopulations that might subsequently select for highly resistant strains.

Endemic and epidemic acinetobacter species in a university hospital: an 8-year survey

The prevalence of the currently known Acinetobacter species and related trends of antimicrobial resistance in a Dutch university hospital were studied. Between 1999 and 2006, Acinetobacter isolates from clinical samples were collected prospectively. Isolates were analyzed by amplified fragment length polymorphism fingerprinting. For species identification, a profile similarity cutoff level of 50% was used, and for strain identification, a cutoff level of 90% was used. Susceptibility for antimicrobial agents was tested by disk diffusion by following the CLSI guideline. The incidences of Acinetobacter isolates ranged from 1.7 to 3.7 per 10,000 patients per year, without a trend of increase, during the study years. Twenty different species were distinguished. Acinetobacter baumannii (27%) and Acinetobacter genomic species (gen. sp.) 3 (26%) were the most prevalent. Other species seen relatively frequently were Acinetobacter lwoffii (11%), Acinetobacter ursingii (4%), Acinetobacter johnsonii (4%), and Acinetobacter junii (3%). One large cluster of A. baumannii, involving 31 patients, and 16 smaller clusters of various species, involving in total 39 patients, with at most 5 patients in 1 cluster, occurred. Overall, 37% of the A. baumannii isolates were fully susceptible to the tested antibiotics. There was a borderline significant (P = 0.059) trend of decreasing susceptibility. A. baumannii was the Acinetobacter species causing the largest burden of multiple-antibiotic resistance and transmissions in the hospital.

Role of AbeS, a novel efflux pump of the SMR family of transporters, in resistance to antimicrobial agents in Acinetobacter baumannii

In this study, a chromosomally encoded putative drug efflux pump of the SMR family, named AbeS, from a multidrug-resistant strain of Acinetobacter baumannii was characterized to elucidate its role in antimicrobial resistance. Expression of the cloned abeS gene in hypersensitive Escherichia coli host KAM32 resulted in decreased susceptibility to various classes of antimicrobial agents, detergents, and dyes. Deletion of the abeS gene in A. baumannii confirmed its role in conferring resistance to these compounds.

OXA-143, a novel carbapenem-hydrolyzing class D beta-lactamase in Acinetobacter baumannii

A carbapenem-resistant Acinetobacter baumannii strain was isolated in Brazil in 2004 in which no known carbapenemase gene was detected by PCR. Cloning experiments, followed by expression in Escherichia coli, gave an E. coli recombinant strain expressing a novel carbapenem-hydrolyzing class D beta-lactamase (CHDL). OXA-143 showed 88% amino acid sequence identity with OXA-40, 63% identity with OXA-23, and 52% identity with OXA-58. It hydrolyzed penicillins, oxacillin, meropenem, and imipenem but not expanded-spectrum cephalosporins. The bla(OXA-143) gene was located on a ca. 30-kb plasmid. After transformation into reference strain A. baumannii ATCC 19606, it conferred resistance to carbapenems. Analysis of the genetic environment of bla(OXA-143) revealed that it was associated with neither insertion sequences nor integron structures. However, it was bracketed by similar replicase-encoding genes at both ends, suggesting acquisition through a homologous recombination process. This study identified a novel class D beta-lactamase involved in carbapenem resistance in A. baumannii. This enzyme is the first member of a novel subgroup of CHDLs whose prevalence remains to be determined.

Production of cell-cell signalling molecules by bacteria isolated from human chronic wounds

AIM

To (i) identify chronic wound bacteria and to test their ability to produce acyl-homoserine-lactones (AHLs) and autoinducer-2 (AI-2) cell-cell signalling molecules and (ii) determine whether chronic wound debridement samples might contain these molecules.

METHODS AND RESULTS

Partial 16S rRNA gene sequencing revealed the identity of 46 chronic wound strains belonging to nine genera. Using bio-reporter assays, 69.6% of the chronic wound strains were inferred to produce AI-2, while 19.6% were inferred to produce AHL molecules. At least one strain from every genus, except those belonging to the genera Acinetobacter and Pseudomonas, were indicated to produce AI-2. Production of AI-2 in batch cultures was growth-phase dependent. Cross-feeding assays demonstrated that AHLs were produced by Acinetobacter spp., Pseudomonas aeruginosa and Serratia marcescens. Independent from studies of the bacterial species isolated from wounds, AHL and/or AI-2 signalling molecules were detected in 21 of 30 debridement samples of unknown microbial composition.

CONCLUSION

Chronic wound bacteria produce cell-cell signalling molecules. Based on our findings, we hypothesize that resident species generally produce AI-2 molecules, and aggressive transient species associated with chronic wounds typically produce AHLs. Both these classes of cell-cell signals are indicated to be present in human chronic wounds.

SIGNIFICANCE AND IMPACT OF THE STUDY

Interbacterial cell-cell signalling may be an important factor influencing wound development and if this is the case, the presence of AHLs and AI-2 could be used as a predictor of wound severity. Manipulation of cell-cell signalling may provide a novel strategy for improving wound healing.

Identification of bacterial DNA in neutrocytic and non-neutrocytic cirrhotic ascites by means of a multiplex polymerase chain reaction

BACKGROUND

Even though bacterial cultures of ascitic fluid are negative in up to 65% of the cases of spontaneous bacterial peritonitis (SBP); bacterial DNA (bactDNA) has been frequently detected in episodes of SBP as well as in culture-negative non-neutrocytic ascites.

AIMS

To evaluate multiplex polymerase chain reaction (PCR) for pathogen identification in SBP and to determine the prevalence of ascitic bactDNA and its prognostic relevance in hospitalized patients with liver cirrhosis.

METHODS

Ascitic fluid from 68 consecutive patients who underwent diagnostic paracentesis was analysed for polymorphonuclear leucocyte (PMN) count, bacterial culture and bactDNA. BactDNA was identified by gel analysis after multiplex PCR of selectively enriched prokaryotic nucleic acids. Correlations of bactDNA status with PMN count, bacterial culture result and 3-month mortality were determined for neutrocytic and for non-neutrocytic ascites.

RESULTS

11/68 patients presented with an elevated ascitic PMN count. BactDNA was detected in 5/5 culture-positive neutrocytic samples, in 1/6 culture-negative neutrocytic samples and in 8/56 culture-negative non-neutrocytic samples. Three-month mortality did not differ with respect to ascitic bactDNA status (7/14 vs. 14/47, P=0.162). 3-month mortality was increased in the presence of ascitic bactDNA for patients older than 65 years (4/5 vs. 4/14, P=0.046) and for patients with a model for end-stage liver disease score >15 (7/10 vs. 9/30, P=0.025).

CONCLUSIONS

Identification of ascitic bactDNA is an appropriate alternative to bacterial ascite culture for pathogen identification in patients at risk for SBP. Its prognostic relevance as a proposed marker of bacterial translocation for certain risk groups has to be further evaluated.

Acinetobacter: an old friend, but a new enemy

Acinetobacter emerged as a significant nosocomial pathogen during the late 1970s, probably as a consequence, at least in part, of increasing use of broad-spectrum antibiotics in hospitals. Most clinically significant isolates belong to the species Acinetobacter baumannii or its close relatives, with many infections concentrated in intensive care, burns or high dependency units treating severely ill or debilitated patients. Large outbreaks can occur in such units, involving the infection or colonisation of numerous patients by specific epidemic strains of A. baumannii. Recently, a particular problem has concerned cross-infection of injured military patients repatriated from combat regions of the world (e.g. Iraq and Afghanistan). Carbapenems have previously been the treatment of choice for infected patients, but increasing reports worldwide now describe A. baumannii isolates resistant to all conventional antimicrobial regimens. Data to support therapeutic use of the limited number of new antimicrobial agents (e.g. tigecycline) with in-vitro activity against these pathogens are still very limited. Detailed advice concerning prevention and control of outbreaks caused by multidrug-resistant strains of acinetobacter is available from the UK Health Protection Agency. In addition to antibiotic prescribing policies and audit, these measures focus on reinforcing standard infection control procedures and precautions, with particular attention to thorough cleaning of patient areas to take account of the long-term survival of acinetobacter after drying and inadequate disinfection. Despite these measures, the problem continues to escalate, with many hospitals worldwide now reporting outbreaks caused by multidrug-resistant strains of acinetobacter.

The pgaABCD locus of Acinetobacter baumannii encodes the production of poly-beta-1-6-N-acetylglucosamine, which is critical for biofilm formation

We found that Acinetobacter baumannii contains a pgaABCD locus that encodes proteins that synthesize cell-associated poly-beta-(1-6)-N-acetylglucosamine (PNAG). Both a mutant with an in-frame deletion of the pga locus (S1Deltapga) and a transcomplemented strain (S1Deltapga-c) of A. baumannii were constructed, and the PNAG production by these strains was compared using an immunoblot assay. Deleting the pga locus resulted in an A. baumannii strain without PNAG, and transcomplementation of the S1Deltapga strain with the pgaABCD genes fully restored the wild-type PNAG phenotype. Heterologous expression of the A. baumannii pga locus in Escherichia coli led to synthesis of significant amounts of PNAG, while no polysaccharide was detected in E. coli cells harboring an empty vector. Nuclear magnetic resonance analysis of the extracellular polysaccharide material isolated from A. baumannii confirmed that it was PNAG, but notably only 60% of the glucosamine amino groups were acetylated. PCR analysis indicated that all 30 clinical A. baumannii isolates examined had the pga genes, and immunoblot assays indicated that 14 of the 30 strains strongly produced PNAG, 14 of the strains moderately to weakly produced PNAG, and 2 strains appeared to not produce PNAG. Deletion of the pga locus led to loss of the strong biofilm phenotype, which was restored by complementation. Confocal laser scanning microscopy studies combined with COMSTAT analysis demonstrated that the biovolume, mean thickness, and maximum thickness of 16-h and 48-h-old biofilms formed by wild-type and pga-complemented A. baumannii strains were significantly greater than the biovolume, mean thickness, and maximum thickness of 16-h and 48-h-old biofilms formed by the S1Deltapga mutant strain. Biofilm-dependent production of PNAG could be an important virulence factor for this emerging pathogen that has few known virulence factors.

Outbreak of carbapenem-resistant Acinetobacter baumannii carrying the carbapenemase OXA-23 in a German university medical centre

A prolonged outbreak of carbapenem-resistant Acinetobacter baumannii in a German university medical centre in 2006 was investigated; the investigation included a descriptive epidemiological analysis, a case-control study, environmental sampling, molecular typing of A. baumannii isolates using PFGE and repetitive-sequence-based PCR (rep-PCR) typing, and detection of OXA-type carbapenemases by multiplex PCR. Thirty-two patients acquired the outbreak strain in five intensive care units (ICUs) and two regular wards at a tertiary care hospital within 10 months. The outbreak strain was resistant to penicillins, cephalosporins, ciprofloxacin, gentamicin, tobramycin, imipenem and meropenem, and carried the bla(OXA-23)-like gene. Based on PFGE and rep-PCR typing, it was shown to be related to the pan-European A. baumannii clone II. The most likely mode of transmission was cross-transmission from colonized or infected patients via the hands of health-care workers, with the severity of disease and intensity of care (therapeutic intervention scoring system 28 score >median) being independently associated with acquisition of the outbreak strain (odds ratio 6.67, 95 % confidence interval 1.55-36.56). Control of the outbreak was achieved by enforcement of standard precautions, education of personnel, screening of ICU patients for carbapenem-resistant A. baumannii and cohorting of patients. This is believed to be the first report of an outbreak of A. baumannii carrying the carbapenemase OXA-23 in Germany.

Triclosan resistance in clinical isolates of Acinetobacter baumannii

The susceptibility to triclosan of 732 clinical Acinetobacter baumannii isolates obtained from 25 hospitals in 16 cities in China from December 2004 to December 2005 was screened by using an agar dilution method. Triclosan MICs ranged between 0.015 and 16 mg l(-1), and the MIC(90) was 0.5 mg l(-1), lower than the actual in-use concentration of triclosan. Twenty triclosan-resistant isolates (MICs >or=1 mg l(-1)) were characterized by antibiotic susceptibility, clonal relatedness, fabI mutation, fabI expression, and efflux pump phenotype and expression to elucidate the resistance mechanism of A. baumannii to triclosan. The resistance rates of triclosan-resistant isolates to imipenem, levofloxacin, amikacin and tetracycline were higher than those of triclosan-sensitive isolates. Triclosan resistance was artificially classified as low level (MICs 1-2 mg l(-1)) or high level (MICs >or=4 mg l(-1)). High-level triclosan resistance could be explained by a Gly95Ser mutation of FabI, whilst wild-type fabI was observed to be overexpressed in low-level resistant isolates. Active efflux did not appear to be a major reason for acquired triclosan resistance, but acquisition of resistance appeared to be dependent on a background of intrinsic triclosan efflux.

Resistance to colistin in Acinetobacter baumannii associated with mutations in the PmrAB two-component system

The mechanism of colistin resistance (Col(r)) in Acinetobacter baumannii was studied by selecting in vitro Col(r) derivatives of the multidrug-resistant A. baumannii isolate AB0057 and the drug-susceptible strain ATCC 17978, using escalating concentrations of colistin in liquid culture. DNA sequencing identified mutations in genes encoding the two-component system proteins PmrA and/or PmrB in each strain and in a Col(r) clinical isolate. A colistin-susceptible revertant of one Col(r) mutant strain, obtained following serial passage in the absence of colistin selection, carried a partial deletion of pmrB. Growth of AB0057 and ATCC 17978 at pH 5.5 increased the colistin MIC and conferred protection from killing by colistin in a 1-hour survival assay. Growth in ferric chloride [Fe(III)] conferred a small protective effect. Expression of pmrA was increased in Col(r) mutants, but not at a low pH, suggesting that additional regulatory factors remain to be discovered.

Antibiotic resistance in clinical isolates of Acinetobacter baumannii, Pseudomonas aeruginosa, and Staphylococcus aureus does not impact sensitivity to human beta defensin 4

Antibiotic usage is essential for infection control but hastens emergence of antibiotic resistant microbes. In particular, Acinetobacter baumannii is an important pathogen because of its heightened ability to acquire drug resistance. The need for novel antibacterial agents led us to evaluate the sensitivity of drug-resistant bacteria to the antimicrobial activity of human beta defensin 4 (HBD-4). Clinical isolates of A. baumannii (N=14), Pseudomonas aeruginosa (N=15), and Staphylococcus aureus (N=20), including 10 methicillin-resistant (MRSA) isolates, were examined. All bacterial strains were susceptible to HBD-4 antimicrobial activity, with no correlation between antibiotic resistance and HBD-4 sensitivity. The results demonstrate that antibiotic resistant microorganisms, including MRSA, can be inhibited by HBD-4, which may represent an effective therapeutic agent for infections involving drug-resistant microorganisms.

Carbapenem-resistant Acinetobacter baumannii outbreak at university hospital

Nineteen clonally related imipenem-resistant Acinetobacter baumannii isolates were recovered from eight intensive care unit patients. All isolates harboured bla_OXA-51-like β-lactamase genes and showed the absence of 22 kDa fraction in outer membrane porin profile analysis. It suggests a combination of two mechanisms as responsible for carbapenem–resistant phenotypes.

The Acinetobacter baumannii 19606 OmpA protein plays a role in biofilm formation on abiotic surfaces and in the interaction of this pathogen with eukaryotic cells

The ability of Acinetobacter baumannii to adhere to and persist on surfaces as biofilms could be central to its pathogenicity. The production of pili and a biofilm-associated protein and the expression of antibiotic resistance are needed for robust biofilm formation on abiotic and biotic surfaces. This multistep process also depends on the expression of transcriptional regulatory functions, some of which could sense nutrients available to cells. This report extends previous observations by showing that although outer membrane protein A (OmpA) of A. baumannii 19606 plays a partial role in the development of robust biofilms on plastic, it is essential for bacterial attachment to Candida albicans filaments and A549 human alveolar epithelial cells. In contrast to abiotic surfaces, the interaction with biotic surfaces is independent of the CsuA/BABCDE-mediated pili. The interaction of A. baumannii 19606 with fungal and epithelial cells also results in their apoptotic death, a response that depends on the direct contact of bacteria with these two types of eukaryotic cells. Furthermore, the bacterial adhesion phenotype correlates with the ability of bacteria to invade A549 epithelial cells. Interestingly, the killing activity of cell-free culture supernatants proved to be protease and temperature sensitive, suggesting that its cytotoxic activity is due to secreted proteins, some of which are different from OmpA.

Regulation of Acinetobacter baumannii biofilm formation

Acinetobacter baumannii is a Gram-negative opportunistic nosocomial pathogen. This microorganism survives in hospital environments despite unfavorable conditions such as desiccation, nutrient starvation and antimicrobial treatments. It is hypothesized that its ability to persist in these environments, as well as its virulence, is a result of its capacity to form biofilms. A. baumannii forms biofilms on abiotic surfaces such as polystyrene and glass as well as biotic surfaces such as epithelial cells and fungal filaments. Pili assembly and production of the Bap surface-adhesion protein play a role in biofilm initiation and maturation after initial attachment to abiotic surfaces. Furthermore, the adhesion and biofilm phenotypes of some clinical isolates seem to be related to the presence of broad-spectrum antibiotic resistance. The regulation of the formation and development of these biofilms is as diverse as the surfaces on which this bacterium persists and as the cellular components that participate in this programmed multistep process. The regulatory processes associated with biofilm formation include sensing of bacterial cell density, the presence of different nutrients and the concentration of free cations available to bacterial cells. Some of these extracellular signals may be sensed by two-component regulatory systems such as BfmRS. This transcriptional regulatory system activates the expression of the usher-chaperone assembly system responsible for the production of pili, needed for cell attachment and biofilm formation on polystyrene surfaces. However, such a system is not required for biofilm formation on abiotic surfaces when cells are cultured in chemically defined media. Interestingly, the BfmRS system also controls cell morphology under particular culture conditions.

Management of meningitis due to antibiotic-resistant Acinetobacter species

Acinetobacter meningitis is becoming an increasingly common clinical entity, especially in the postneurosurgical setting, with mortality from this infection exceeding 15%. Infectious Diseases Society of America guidelines for therapy of postneurosurgical meningitis recommend either ceftazidime or cefepime as empirical coverage against Gram-negative pathogens. However, assessment of the pharmacodynamics of these cephalosporins in cerebrospinal fluid suggests that recommended doses will achieve pharmacodynamic targets against fewer than 10% of contemporary acinetobacter isolates. Thus, these antibiotics are poor options for suspected acinetobacter meningitis. From in vitro and pharmacodynamic perspectives, intravenous meropenem plus intraventricular administration of an aminoglycoside may represent a superior, albeit imperfect, regimen for suspected acinetobacter meningitis. For cases of meningitis due to carbapenem-resistant acinetobacter, use of tigecycline is not recommended on pharmacodynamic grounds. The greatest clinical experience rests with use of polymyxins, although an intravenous polymyxin alone is inadvisable. Combination with an intraventricularly administered antibiotic plus removal of infected neurosurgical hardware appears the therapeutic strategy most likely to succeed in this situation. Unfortunately, limited development of new antibiotics plus the growing threat of multidrug-resistant acinetobacter is likely to increase the problems posed by acinetobacter meningitis in the future.

AbaR5, a large multiple-antibiotic resistance region found in Acinetobacter baumannii

A multiply antibiotic-resistant Acinetobacter baumannii strain, 3208, contains the aacC1-orfP-orfP-orfQ-aadA1 gene cassette array; sul1, tetA(A), and aphA1b genes; and a mer operon in a large region containing a novel transposon, Tn6020, and segments of Tn1696, Tn21, Tn1721, and Tn5393. This region is part of a genomic resistance island, AbaR5, related to and found in the same chromosomal position as AbaR1. This strain is the first European clone I isolate detected in Australia.

Genetic basis of resistance to aminoglycosides in Acinetobacter spp. and spread of armA in Acinetobacter baumannii sequence group 1 in Korean hospitals

A total of 75 Acinetobacter isolates resistant to all available aminoglycosides obtained from 2 Korean hospitals were studied for the genetic basis of resistance to aminoglycosides. The MIC(50) and MIC(90) of Acinetobacter baumannii isolates (n = 61) to amikacin, gentamicin, isepamycin spectinomycin, streptomycin, and tobramycin were higher than those of Acinetobacter genomic species 13TU isolates (n = 14). Genes encoding aminoglycoside-modifying enzymes, ant(3")-Ia, aac(6')-Ib, aph(3')-1a, aac(3)-Ia, and aph(3')-VI, and 16S ribosomal RNA (rRNA) methylase armA were detected. ant(3")-Ia and aac(6')-Ib were commonly detected in both Acinetobacter spp., but armA and aph(3")-Ia were only detected in A. baumannii. armA was located on the plasmids. A. baumannii isolates carrying armA were classified into 7 pulsotypes but belonged to sequence group 1. The combination of aminoglycoside-modifying enzymes is responsible for the moderate-level resistance to aminoglycosides in Acinetobacter genomic species 13TU, whereas armA is responsible for the high-level resistance to aminoglycosides in A. baumannii sequence group 1.

Galleria mellonella as a model system to study Acinetobacter baumannii pathogenesis and therapeutics

Nonmammalian model systems of infection such as Galleria mellonella (caterpillars of the greater wax moth) have significant logistical and ethical advantages over mammalian models. In this study, we utilize G. mellonella caterpillars to study host-pathogen interactions with the gram-negative organism Acinetobacter baumannii and determine the utility of this infection model to study antibacterial efficacy. After infecting G. mellonella caterpillars with a reference A. baumannii strain, we observed that the rate of G. mellonella killing was dependent on the infection inoculum and the incubation temperature postinfection, with greater killing at 37 degrees C than at 30 degrees C (P = 0.01). A. baumannii strains caused greater killing than the less-pathogenic species Acinetobacter baylyi and Acinetobacter lwoffii (P < 0.001). Community-acquired A. baumannii caused greater killing than a reference hospital-acquired strain (P < 0.01). Reduced levels of production of the quorum-sensing molecule 3-hydroxy-C(12)-homoserine lactone caused no change in A. baumannii virulence against G. mellonella. Treatment of a lethal A. baumannii infection with antibiotics that had in vitro activity against the infecting A. baumannii strain significantly prolonged the survival of G. mellonella caterpillars compared with treatment with antibiotics to which the bacteria were resistant. G. mellonella is a relatively simple, nonmammalian model system that can be used to facilitate the in vivo study of host-pathogen interactions in A. baumannii and the efficacy of antibacterial agents.

In vivo selection of reduced susceptibility to carbapenems in Acinetobacter baumannii related to ISAba1-mediated overexpression of the natural bla(OXA-66) oxacillinase gene

Two clonally related Acinetobacter baumannii isolates, A1 and A2, were obtained from the same patient. Isolate A2, selected after an imipenem-containing treatment, showed reduced susceptibility to carbapenems. This resistance pattern was related to insertion of the ISAba1 element upstream of the naturally occurring bla(OXA-66) carbapenemase gene as demonstrated by sequencing, reverse transcription-PCR analysis, and inactivation of the bla(OXA-66) gene.

Rapid determination of quinolone resistance in Acinetobacter spp

In the treatment of serious bacterial infections, the rapid institution of appropriate antimicrobial chemotherapy may be lifesaving. Choosing the correct antibiotic or combination of antibiotics is becoming very important, as multidrug resistance is found in many pathogens. Using a collection of 75 well-characterized multidrug-resistant (MDR) Acinetobacter sp. isolates, we show that PCR followed by electrospray ionization mass spectrometry (PCR/ESI-MS) and base composition analysis of PCR amplification products can quickly and accurately identify quinolone resistance mediated by mutations in the quinolone resistance-determining regions of gyrA and parC, two essential housekeeping genes. Single point mutations detected by PCR/ESI-MS in parC (found in 55/75 of the isolates) and in gyrA (found in 66/75 of the isolates) correlated with susceptibility testing and sequencing. By targeting resistance determinants that are encoded by genes with highly conserved DNA sequences (e.g., gyrA and parC), we demonstrate that PCR/ESI-MS can provide critical information for resistance determinant identification and can inform therapeutic decision making in the treatment of Acinetobacter sp. infections.

Utility of peptide nucleic acid fluorescence in situ hybridization for rapid detection of Acinetobacter spp. and Pseudomonas aeruginosa

The utility of peptide nucleic acid fluorescence in situ hybridization (PNA FISH) for the detection of Acinetobacter spp. and Pseudomonas aeruginosa was evaluated on broth suspensions and spiked blood cultures of ATCC strains and clinical isolates with select gram-negative rods. After testing 60 clinical isolates, PNA FISH had a sensitivity and specificity of 100% and 100%, respectively, for Acinetobacter spp. and 100% and 95%, respectively, for P. aeruginosa. PNA FISH was able to detect both pathogens simultaneously and directly from spiked blood cultures.

Nosocomial outbreak of infection with multidrug-resistant Acinetobacter baumannii in a medical center in Taiwan

OBJECTIVE

To investigate a nosocomial outbreak of infection with multidrug-resistant (MDR) Acinetobacter baumannii in the intensive care units at China Medical University Hospital in Taiwan.

DESIGN

Prospective outbreak investigation.

SETTING

Three intensive care units in a 2,000-bed university hospital in Taichung, Taiwan.

METHODS

Thirty-eight stable patients in 3 intensive care units, all of whom had undergone an invasive procedure, were enrolled in our study. Ninety-four A. baumannii strains were isolated from the patients or the environment in the 3 intensive care units, during the period from January 1 through December 31, 2006. We characterized A. baumannii isolates by use of repetitive extragenic palindromic-polymerase chain reaction (REP-PCR) and random amplified polymorphic DNA (RAPD) fingerprinting. The clinical characteristics of the source patients and the environment were noted.

RESULTS

All of the clinical isolates were determined to belong to the same epidemic strain of MDR A. baumannii by the use of antimicrobial susceptibility tests, REP-PCR, and RAPD fingerprinting. All patients involved in the infection outbreak had undergone an invasive procedure. The outbreak strain was also isolated from the environment and the equipment in the intensive care units. Moreover, an environmental survey of one of the intensive care units found that both the patients and the environment harbored the same outbreak strain.

CONCLUSION

The outbreak strain of A. baumannii might have been transmitted among medical staff and administration equipment. Routine and aggressive environmental and equipment disinfection is essential for preventing recurrent outbreaks of nosocomial infection with MDR A. baumannii.

Iron acquisition functions expressed by the human pathogen Acinetobacter baumannii

Acinetobacter baumannii is a gram-negative bacterium that causes serious infections in compromised patients. More recently, it has emerged as the causative agent of severe infections in military personnel wounded in Iraq and Afghanistan. This pathogen grows under a wide range of conditions including iron-limiting conditions imposed by natural and synthetic iron chelators. Initial studies using the type strain 19606 showed that the iron proficiency of this pathogen depends on the expression of the acinetobactin-mediated iron acquisition system. More recently, we have observed that hemin but not human hemoglobin serves as an iron source when 19606 isogenic derivatives affected in acinetobactin transport and biosynthesis were cultured under iron-limiting conditions. This finding is in agreement with the observation that the genome of the strain 17978 has a gene cluster coding for putative hemin-acquisition functions, which include genes coding for putative hemin utilization functions and a TonBExbBD energy transducing system. This system restored enterobactin biosynthesis in an E. coli ExbBD deficient strain but not when introduced into a TonB mutant. PCR and Southern blot analyses showed that this hemin-utilization gene cluster is also present in the 19606 strain. Analysis of the 17978 genome also showed that this strain harbors genes required for acinetobactin synthesis and transport as well as a gene cluster that could code for additional iron acquisition functions. This hypothesis is in agreement with the fact that the inactivation of the basD acinetobactin biosynthetic gene did not affect the growth of A. baumannii 17978 cells under iron-chelated conditions. Interestingly, this second iron uptake gene cluster is flanked by perfect inverted repeats and includes transposase genes that are expressed transcriptionally. Also interesting is the observation that this additional cluster could not be detected in the type strain 19606, an observation that suggests some significant differences in the iron uptake capacity between these two A. baumannii strains. Transposome mutagenesis of the strain 19606 resulted in the isolation of a derivative unable to grow under iron-chelated conditions. Gene mapping and protein analysis together with complementation assays showed that a protein related to SecA, which is a component of the Sec protein secretion system in a wide range of bacteria, is needed at least for the production of the BauA acinetobactin outer membrane receptor. Furthermore, this derivative was unable to use hemin as an iron source under limiting conditions. Taken together, these results indicate that A. baumannii expresses siderophore-mediated and hemin acquisition functions, although different isolates differ in their iron acquisition capacity. Unexpectedly, the ability of this pathogen to acquire iron depends on the expression of a SecA protein secretion function, which has not been associated with iron acquisition in bacteria.

Acinetobacter baumannii invades epithelial cells and outer membrane protein A mediates interactions with epithelial cells

Background

Acinetobacter baumannii is a nosocomial pathogen of increasing importance, but the pathogenic mechanism of this microorganism has not been fully explored. This study investigated the potential of A. baumannii to invade epithelial cells and determined the role of A. baumannii outer membrane protein A (AbOmpA) in interactions with epithelial cells.

Results

A. baumannii invaded epithelial cells by a zipper-like mechanism, which is associated with microfilament- and microtubule-dependent uptake mechanisms. Internalized bacteria were located in the membrane-bound vacuoles. Pretreatment of recombinant AbOmpA significantly inhibited the adherence to and invasion of A. baumannii in epithelial cells. Cell invasion of isogenic AbOmpA^- mutant significantly decreased as compared with wild-type bacteria. In a murine pneumonia model, wild-type bacteria exhibited a severe lung pathology and induced a high bacterial burden in blood, whereas AbOmpA^- mutant was rarely detected in blood.

Conclusion

A. baumannii adheres to and invades epithelial cells. AbOmpA plays a major role in the interactions with epithelial cells. These findings contribute to the understanding of A. baumannii pathogenesis in the early stage of bacterial infection.

Prokaryote-eukaryote interactions identified by using Caenorhabditis elegans

Prokaryote-eukaryote interactions are ubiquitous and have important medical and environmental significance. Despite this, a paucity of data exists on the mechanisms and pathogenic consequences of bacterial-fungal encounters within a living host. We used the nematode Caenorhabditis elegans as a substitute host to study the interactions between two ecologically related and clinically troublesome pathogens, the prokaryote, Acinetobacter baumannii, and the eukaryote, Candida albicans. After co-infecting C. elegans with these organisms, we observed that A. baumannii inhibits filamentation, a key virulence determinant of C. albicans. This antagonistic, cross-kingdom interaction led to attenuated virulence of C. albicans, as determined by improved nematode survival when infected with both pathogens. In vitro coinfection assays in planktonic and biofilm environments supported the inhibitory effects of A. baumannii toward C. albicans, further showing a predilection of A. baumannii for C. albicans filaments. Interestingly, we demonstrate a likely evolutionary defense by C. albicans against A. baumannii, whereby C. albicans inhibits A. baumannii growth once a quorum develops. This counteroffensive is at least partly mediated by the C. albicans quorum-sensing molecule farnesol. We used the C. elegans-A. baumannii-C. albicans coinfection model to screen an A. baumannii mutant library, leading to the identification of several mutants attenuated in their inhibitory activity toward C. albicans. These findings present an extension to the current paradigm of studying monomicrobial pathogenesis in C. elegans and by use of genetic manipulation, provides a whole-animal model system to investigate the complex dynamics of a polymicrobial infection.

Genetic basis of multidrug resistance in Acinetobacter baumannii clinical isolates at a tertiary medical center in Pennsylvania

A total of 49 unique clinical isolates of multidrug-resistant (MDR) Acinetobacter baumannii identified at a tertiary medical center in Pittsburgh, Pennsylvania, between August 2006 and September 2007 were studied for the genetic basis of their MDR phenotype. Approximately half of all A. baumannii clinical isolates identified during this period qualified as MDR, defined by nonsusceptibility to three or more of the antimicrobials routinely tested in the clinical microbiology laboratory. Among the MDR isolates, 18.4% were resistant to imipenem. The frequencies of resistance to amikacin and ciprofloxacin were high at 36.7% and 95.9%, respectively. None of the isolates was resistant to colistin or tigecycline. The presence of the carbapenemase gene bla(OXA-23) and the 16S rRNA methylase gene armA predicted high-level resistance to imipenem and amikacin, respectively. bla(OXA-23) was preceded by insertion sequence ISAba1, which likely provided a potent promoter activity for the expression of the carbapenemase gene. The structure of the transposon defined by ISAba1 differed from those reported in Europe, suggesting that ISAba1-mediated acquisition of bla(OXA-23) may occur as an independent event. Typical substitutions in the quinolone resistance-determining regions of the gyrA and parC genes were observed in the ciprofloxacin-resistant isolates. Plasmid-mediated quinolone resistance genes, including the qnr genes, were not identified. Fifty-nine percent of the MDR isolates belonged to a single clonal group over the course of the study period, as demonstrated by pulsed-field gel electrophoresis.