Molecular characterization of multidrug-resistant (MDR) Pseudomonas aeruginosa isolated in a burn center

Antimicrobial resistance profile, biofilm forming capacity and associated factors of multidrug resistance in Pseudomonas aeruginosa among patients admitted at Tikur Anbessa Specialized Hospital and Yekatit 12 Hospital Medical College in Addis Ababa, Ethiopia

BACKGROUND

Pseudomonas aeruginosa is one of the leading causes of nosocomial infections and the most common multidrug-resistant pathogen. This study aimed to determine antimicrobial resistance patterns, biofilm-forming capacity, and associated factors of multidrug resistance in P. aeruginosa isolates at two hospitals in Addis Ababa, Ethiopia.

METHODS

A cross-sectional study was conducted from August 2022 to August 2023 at Tikur Anbessa Specialized Hospital and Yekatit 12 Hospital Medical College. Culture and identification of P. aeruginosa were done using standard microbiological methods. An antimicrobial susceptibility test was done by Kirby-Bauer disk diffusion according to CLSI recommendations. The microtiter plate assay method was used to determine biofilm-forming capacity. SPSS version 25 was used for data analysis. Bivariate and multivariable logistic regression were used to assess factors associated with multidrug resistance in P. aeruginosa. The Spearman correlation coefficient (rs = 0.266)) was performed to evaluate the relationship between biofilm formation and drug resistance.

RESULTS

The overall prevalence of P. aeruginosa was 19.6%. High levels of resistance were observed for ciprofloxacin (51.8%), ceftazidime (50.6%), and cefepime (48.2%). The level of multidrug-resistance was 56.6%. The isolates showed better susceptibility to ceftazidime-avibactam (95.2%) and imipenem (79.5%). Overall, 95.2% of P. aeruginosa were biofilm-producing isolates, and 27.7% and 39.8% of isolates were strong and moderate biofilm producers, respectively. A positive correlation and statistically significant relationship was observed between resistance to multiple drugs and the level of biofilm formation (rs = 0.266; p-value = 0.015). Previous history of exposure to ciprofloxacin (OR, 5.1; CI, 1.12-24.7, p-value, 0.032) was identified as an independent associated factor for multidrug resistance in P. aeruginosa.

CONCLUSION

The present study indicates an association between multidrug resistance in P. aeruginosa and its biofilm formation capabilities. Additionally, over half of the isolates were resistant to multiple drugs, with prior use of ciprofloxacin linked to the development of multidrug-resistance. These findings suggest that antibiotic stewardship programs in hospital settings may be beneficial in addressing resistance.

Molecular Epidemiology of Pseudomonas aeruginosa in Brazil: A Systematic Review and Meta-Analysis

BACKGROUND

Globally, Pseudomonas aeruginosa is a high-priority opportunistic pathogen which displays several intrinsic and acquired antimicrobial resistance (AMR) mechanisms, leading to challenging treatments and mortality of patients. Moreover, its wide virulence arsenal, particularly the type III secretion system (T3SS) exoU+ virulotype, plays a crucial role in pathogenicity and poor outcome of infections. In depth insights into the molecular epidemiology of P. aeruginosa, especially the prevalence of high-risk clones (HRCs), are crucial for the comprehension of virulence and AMR features and their dissemination among distinct strains. This study aims to evaluate the prevalence and distribution of HRCs and non-HRCs among Brazilian isolates of P. aeruginosa.

METHODS

A systematic review and meta-analysis were conducted on studies published between 2011 and 2023, focusing on the prevalence of P. aeruginosa clones determined by multilocus sequence typing (MLST) in Brazil. Data were extracted from retrospective cross-sectional and case-control studies, encompassing clinical and non-clinical samples. The analysis included calculating the prevalence rates of various sequence types (STs) and assessing the regional variability in the distribution of HRCs and non-HRCs.

RESULTS

A total of 872 samples were analyzed within all studies, of which 298 (34.17%) were MLST typed, identifying 78 unique STs. HRCs accounted for 48.90% of the MLST-typed isolates, with ST277 being the most prevalent (100/298-33.55%), followed by ST244 (29/298-9.73%), ST235 (13/298-4.36%), ST111 (2/298-0.67%), and ST357 (2/298-0.67%). Significant regional variability was observed, with the Southeast region showing a high prevalence of ST277, while the North region shows a high prevalence of MLST-typed samples and HRCs.

CONCLUSIONS

Finally, this systematic review and meta-analysis highlight the role of P. aeruginosa clones in critical issue of AMR in P. aeruginosa in Brazil and the need of integration of comprehensive data from individual studies.

Antibacterial and antibiofilm activities of selenium nanoparticles-antibiotic conjugates against anti-multidrug-resistant bacteria

The crucial demand to overcome the issue of multidrug resistance is required to refine the performance of antibiotics. Such a process can be achieved by fastening them to compatible nanoparticles to obtain effective pharmaceuticals at a low concentration. Thus, selenium nanoparticles (Se NPs) are considered biocompatible agents that are applied to prevent infections resulting from bacterial resistance to multi-antibiotics. The current evaluated the effectiveness of Se NPs and their conjugates with antibiotics such as amikacin (AK), levofloxacin (LEV), and piperacillin (PIP) against Pseudomonas aeruginosa (P. aeruginosa). In addition, the study determined the antibacterial and antibiofilm properties of Se NPs and their conjugates with LEV against urinary tract pathogens such as Staphylococcus aureus (S. aureus), Enterococcus faecalis (E. faecalis), P. aeruginosa, and Escherichia coli (E. coli). The result of minimum inhibitory concentration (MIC) and minimal bactericidal concentration (MBC) for eight isolates of P. aeruginosa revealed that the conjugation of Se NPs with AK, LEV, and PIP resulted in a reduction in the concentration of antibiotic-conjugated Se NPs. The concentration was found to be about 10-20 times lower than that of bare antibiotics. The MIC of the Se NPs with LEV (i.e., Se NPs:LEV) for S. aureus, E. faecalis, P. aeruginosa, and E. coli was found to be 1.4:0.5, 0.7:0.25, 22:8, and 11:4 µg/mL, respectively. The results of the half-maximal inhibitory concentration (IC50) demonstrated that Se NPs:LEV conjugate have inhibited 50 % of the mature biofilms of S. aureus, E. faecalis, P. aeruginosa, and E. coli at a concentration of 27.5 ± 10.5, 18.8 ± 3.1, 40.6 ± 10.7, and 21.6 ± 3.3 µg/mL, respectively compared to the control. It has been suggested that the antibiotic-conjugated Se NPs have great potential for biomedical applications. The conjugation of Se NPs with AK, LEV, and PIP increases the antibacterial potency against resistant pathogens at a low concentration.

Polymer-Based Functional Materials Loaded with Metal-Based Nanoparticles as Potential Scaffolds for the Management of Infected Wounds

Wound infection due to bacterial invasion at the wound site is one of the primary challenges associated with delayed wound healing. Microorganisms tend to form biofilms that protect them from harm, leading to their multidrug resistance. The alarming increase in antibiotic resistance poses a threat to wound healing. Hence, the urgent need for novel wound dressing materials capable of managing bacterial infection is crucial for expediting wound recovery. There is considerable interest in polymeric wound dressings embedded with bioactive substances, such as metal-based nanoparticles, as potential solutions for treating microbially infected wounds. Metal-based nanoparticles have been widely used for the management of infected wounds due to their broad antimicrobial efficacy. This review focuses on polymer-based and bioactive wound dressings loaded with metal-based nanoparticles like silver, gold, magnesium oxide, or zinc oxide. When compared, zinc oxide-loaded dressings exhibited higher antibacterial activity against Gram-positive strains and silver nanoparticle-loaded dressings against gram-negative strains. However, wound dressings infused with both nanoparticles displayed a synergistic effect against both strains of bacteria. Furthermore, these dressings displayed antibiofilm activity and the generation of reactive oxygen species while accelerating wound closure both in vitro and in vivo.

Distribution of blaOXA-10, blaPER-1, and blaSHV genes in ESBL-producing Pseudomonas aeruginosa strains isolated from burn patients

Pseudomonas aeruginosa is resistant to a wide range of extended spectrum-lactamases (ESBLs) antibiotics because it produces several kinds of ESBLs. The goal of the current investigation was to identify the bacteria that produce extended spectrum -lactamases and the genes that encode three different ESBLs, such as blaOXA-10, blaPER-1 and blaSHV genes in Pseudomonas aeruginosa isolated from burn patients. In this investigation, 71 Pseudomonas aeruginosa isolates were isolated from burn wounds in Burn and Plastic Surgery Hospital, Duhok City between July 2021 to June 2022. For the purpose of finding the blaOXA-10, blaPER-1, and blaSHV ESBL expressing genes, Polymerase Chain Reaction (PCR) was used. Among 71 Pseudomonas aeruginosa isolates, 26.36% (29/71) were isolated from males and 38.18% (42/71) from females, and 76.06% (54/71) of the isolates were multidrug resistant. They exhibited higher resistance against Piperacillin with resistance rates of 98.59%. Among the ESBL-producing isolates tested, blaOXA-10 was found in 59.26% (32), blaPER-1 was found in 44.44% (24), and blaSHV was found in 11.11% (6). All isolates must undergo antimicrobial susceptibility testing because only a few numbers of the available antibiotics are effective for the treatment of this bacterium. This will prevent the development of resistance in burn units and aids in the management of the treatment plan.

Burden of severe infections due to carbapenem-resistant pathogens in intensive care unit

Intensive care units (ICU) for various reasons, including the increasing age of admitted patients, comorbidities, and increasingly complex surgical procedures (e.g., transplants), have become "the epicenter" of nosocomial infections, these are characterized by the presence of multidrug-resistant organisms (MDROs) as the cause of infection. Therefore, the perfect match of fragile patients and MDROs, as the cause of infection, makes ICU mortality very high. Furthermore, carbapenems were considered for years as last-resort antibiotics for the treatment of infections caused by MDROs; unfortunately, nowadays carbapenem resistance, mainly among Gram-negative pathogens, is a matter of the highest concern for worldwide public health. This comprehensive review aims to outline the problem from the intensivist's perspective, focusing on the new definition and epidemiology of the most common carbapenem-resistant MDROs (Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacterales) to emphasize the importance of the problem that must be permeating clinicians dealing with these diseases.

Anti-Pseudomonas aeruginosa Vaccines and Therapies: An Assessment of Clinical Trials

Pseudomonas aeruginosa is a Gram-negative opportunistic pathogen that causes high morbidity and mortality in cystic fibrosis (CF) and immunocompromised patients, including patients with ventilator-associated pneumonia (VAP), severely burned patients, and patients with surgical wounds. Due to the intrinsic and extrinsic antibiotic resistance mechanisms, the ability to produce several cell-associated and extracellular virulence factors, and the capacity to adapt to several environmental conditions, eradicating P. aeruginosa within infected patients is difficult. Pseudomonas aeruginosa is one of the six multi-drug-resistant pathogens (ESKAPE) considered by the World Health Organization (WHO) as an entire group for which the development of novel antibiotics is urgently needed. In the United States (US) and within the last several years, P. aeruginosa caused 27% of deaths and approximately USD 767 million annually in health-care costs. Several P. aeruginosa therapies, including new antimicrobial agents, derivatives of existing antibiotics, novel antimicrobial agents such as bacteriophages and their chelators, potential vaccines targeting specific virulence factors, and immunotherapies have been developed. Within the last 2-3 decades, the efficacy of these different treatments was tested in clinical and preclinical trials. Despite these trials, no P. aeruginosa treatment is currently approved or available. In this review, we examined several of these clinicals, specifically those designed to combat P. aeruginosa infections in CF patients, patients with P. aeruginosa VAP, and P. aeruginosa-infected burn patients.

Antimicrobial resistance and biofilm formation capacity among Acinetobacter baumannii strains isolated from patients with burns and ventilator-associated pneumonia

BACKGROUND

Acinetobacter baumannii is a pathogen responsible for nosocomial infections, especially in patients with burns and ventilator-associated pneumonia (VAP). The aims of this study was to compare the biofilm formation capacity, antimicrobial resistance patterns and molecular typing based on PFGE (Pulsed-Field Gel Electrophoresis) in A. baumannii isolated from burn and VAP patients.

MATERIALS AND METHODS

A total of 50 A. baumannii isolates were obtained from burn and VAP patients. In this study, we assessed antimicrobial susceptibility, biofilm formation capacity, PFGE fingerprinting, and the distribution of biofilm-related genes (csuD, csuE, ptk, ataA, and ompA).

RESULTS

Overall, 74% of the strains were multidrug resistant (MDR), and 26% were extensively drug-resistant (XDR). Regarding biofilm formation capacity, 52%, 36%, and 12% of the isolates were strong, moderate, and weak biofilm producers. Strong biofilm formation capacity significantly correlated with XDR phenotype (12/13, 92.3%). All the isolates harbored at least one biofilm-related gene. The most prevalent gene was csuD (98%), followed by ptk (90%), ataA (88%), ompA (86%), and csuE (86%). Harboring all the biofilm-related genes was significantly associated with XDR phenotype. Finally, PFGE clustering revealed 6 clusters, among which cluster No. 2 showed a significant correlation with strong biofilm formation and XDR phenotype.

CONCLUSION

Our findings revealed the variable distribution of biofilm-related genes among MDR and XDR A. baumannii isolates from burn and VAP patients. A significant correlation was found between strong biofilm formation capacity and XDR phenotype. Finally, our results suggested that XDR phenotype was predominant among strong-biofilm producer A. baumannii in our region.

Isolation and Characterization of Lytic Pseudomonas aeruginosa Bacteriophages Isolated from Sewage Samples from Tunisia

Bacteriophages could be a useful adjunct to antibiotics for the treatment of multidrug-resistant Pseudomonas aeruginosa infections. In this study, lytic P. aeruginosa myoviruses PsCh, PsIn, Ps25, and Ps12on-D were isolated from Tunisian sewage samples. Phage Ps12on-D displayed an adsorption time of ~10 min, a short latency period (~10 min), and a large burst size (~115 PFU per infected cell) under standard growth conditions. All phages were active at broad temperature (4 °C to 50 °C) and pH (3.0 to 11.0) ranges and were able to lyse a wide variety of P. aeruginosa strains isolated from clinical and environmental samples worldwide. Illumina sequencing revealed double-stranded DNA genomes ranging from 87,887 and 92,710 bp with high sequence identity to Pseudomonas phage PAK_P1. All four phages based on sequence analysis were assigned to the Pakpunavirus genus. The presented characterization and preclinical assessment are part of an effort to establish phage therapy treatment as an alternative strategy for the management of multidrug-resistant P. aeruginosa infections in Tunisia.

Metagenomic features of bioburden serve as outcome indicators in combat extremity wounds

Battlefield injury management requires specialized care, and wound infection is a frequent complication. Challenges related to characterizing relevant pathogens further complicates treatment. Applying metagenomics to wounds offers a comprehensive path toward assessing microbial genomic fingerprints and could indicate prognostic variables for future decision support tools. Wound specimens from combat-injured U.S. service members, obtained during surgical debridements before delayed wound closure, were subjected to whole metagenome analysis and targeted enrichment of antimicrobial resistance genes. Results did not indicate a singular, common microbial metagenomic profile for wound failure, instead reflecting a complex microenvironment with varying bioburden diversity across outcomes. Genus-level Pseudomonas detection was associated with wound failure at all surgeries. A logistic regression model was fit to the presence and absence of antimicrobial resistance classes to assess associations with nosocomial pathogens. A. baumannii detection was associated with detection of genomic signatures for resistance to trimethoprim, aminoglycosides, bacitracin, and polymyxin. Machine learning classifiers were applied to identify wound and microbial variables associated with outcome. Feature importance rankings averaged across models indicated the variables with the largest effects on predicting wound outcome, including an increase in P. putida sequence reads. These results describe the microbial genomic determinants in combat wound bioburden and demonstrate metagenomic investigation as a comprehensive tool for providing information toward aiding treatment of combat-related injuries.

Nucleotide substitutions in the mexR, nalC and nalD regulator genes of the MexAB-OprM efflux pump are maintained in Pseudomonas aeruginosa genetic lineages

Pseudomonas aeruginosa has different resistant mechanisms including the constitutive MexAB-OprM efflux pump. Single nucleotide polymorphisms (SNPs) in the mexR, nalC, and nalD repressors of this efflux pump can contribute to antimicrobial resistance; however, it is unknown whether these changes are mainly related to genetic lineages or environmental pressure. This study identifies SNPs in the mexR, nalC, and nalD genes in clinical and environmental isolates of P. aeruginosa (including high-risk clones). Ninety-one P. aeruginosa strains were classified according to their resistance to antibiotics, typified by multilocus sequencing, and mexR, nalC, and nalD genes sequenced for SNPs identification. The mexAB-oprM transcript expression was determined. The 96.7% of the strains were classified as multidrug resistant. Eight strains produced serine carbapenemases, and 11 strains metallo-β-lactamases. Twenty-three new STs and high-risk clones ST111 and ST233 were identified. SNPs in the mexR, nalC, and nalD genes revealed 27 different haplotypes (patterns). Sixty-two mutational changes were identified, 13 non-synonymous. Haplotype 1 was the most frequent (n = 40), and mainly identified in strains ST1725 (33/40), with 57.5% pan drug resistant strains, 36.5% extensive drug resistant and two strains exhibiting serin-carbapenemases. Haplotype 12 (n = 9) was identified in ST233 and phylogenetically related STs, with 100% of the strains exhibiting XDR and 90% producing metallo-β-lactamases. Haplotype 5 was highly associated with XDR and related to dead when compared to ST1725 and ST233 (RRR 23.34; p = 0.009 and RRR 32.01; p = 0.025). A significant relationship between the mexR-nalC-nalD haplotypes and phylogenetically related STs was observed, suggesting mutational changes in these repressors are highly maintained within genetic lineages. In addition, phylogenetically related STs showed similar resistant profiles; however, the resistance was (likely or partly) attributed to the MexAB-OprM efflux pump in 56% of the strains (only 45.05% showed mexA overtranscription), in the remaining strains the resistance could be attributed to carbapenemases or mechanisms including other pumps, since same SNPs in the repressor genes gave rise to different resistance profiles.

Phenotype and genetic determination of resistance to common disinfectants among biofilm-producing and non-producing Pseudomonas aeruginosa strains from clinical specimens in Iran

BACKGROUND

Pseudomonas aeruginosa is a common pathogen in Hospitalized patients, and its various resistance mechanisms contribute to patient morbidity and mortality. The main aims of the present study were to assess the susceptibility of biofilm-producing and non-producing P. aeruginosa isolates to the five commonly used Hospital disinfectants, to evaluate the synergistic effect of selected disinfectants and Ethylene-diamine-tetra acetic acid (EDTA), and the effect of exposure to sub-inhibitory concentrations of Sodium hypochlorite on antimicrobial susceptibility test.

RESULTS

The results showed that sodium hypochlorite 5% and Ethanol 70% were the most and least effective disinfectants against P. aeruginosa, respectively. The addition of EDTA significantly increased the effectiveness of the selected disinfectants. The changes in the antibiotic-resistance profiles after exposure to sub-inhibitory concentrations of disinfectants were observed for different classes of antibiotics (Carbapenems, Aminoglycosides, Cephalosporins, Fluoroquinolones). As well as near the all isolates harbored efflux pump genes and 117 (97.5%) of isolates produced biofilm.

CONCLUSION

In the current study, the mixture of disinfectant and EDTA were the most suitable selection to disinfect Hospital surfaces and instruments. Also, it was clear that exposure to sub-inhibitory concentrations of Sodium hypochlorite results in resistance to some antibiotics in P. aeruginosa species. Strong and intermediate biofilm formers belonged to MDR/XDR strains. Future studies should include more complex microbial communities residing in the Hospitals, and more disinfectants use in Hospitals.

Molecular analysis of Pseudomonas aeruginosa strains isolated from cystic fibrosis patients

Pseudomonas aeruginosa is a severe bacterial pathogen. Due to the genetic flexibility among strains, chronic airways infection can lead to mortality among cystic fibrosis (CF) patients. It is essential to develop patient-specific therapy which will rely on phenotypic and genomic diversity. The primary objective of this study was to assess the genomic variability of P. aeruginosa strains, using two different molecular techniques for tracking the epidemiological transmissions. This study applied a multiple-locus variable-number tandem-repeat (VNTR) analysis (MLVA) for an efficient genotyping of clinical P. aeruginosa strains isolated from CF patients and compared results with a TRS-PCR typing. The percentage similarity analysis was performed using the categorical multi-state coefficient and UPGMA method. Based on the MLVA and TRS-PCR group assessment, 43 P. aeruginosa strains/variants were detected among the 63 clinical isolates from eight CF patients. The study of P. aeruginosa isolates has revealed that during chronic bacterial infections, CF patients harbor different P. aeruginosa strains or variants within the same host over the years. P. aeruginosa genotypes diversity may result from infection with several strains and result from a microevolution process of an initially acquired strain. The TRS-PCR method proposed in this work can complement the MLVA scheme. It can also be used as a preliminary method for genetic typing of P. aeruginosa isolates in CF patients.

Molecular epidemiology and carbapenem resistance of Pseudomonas aeruginosa isolated from patients with burns

OBJECTIVE

The aim of this study was to investigate the molecular epidemiology and carbapenem resistance mechanisms of Pseudomonas aeruginosa isolated from patients with burns in Azerbaijan, Iran.

METHOD

Pseudomonas aeruginosa was isolated from 38 patients with burns. Disk diffusion and agar dilution methods were used to determine antibiotic susceptibility patterns. The overproduction of AmpC β-lactamase and efflux pumps were detected by phenotypic methods. The presence of carbapenemase-encoding genes was detected by multiplex polymerase chain reaction (PCR). Expression of the OprD gene and MexAB efflux pumps were also evaluated with real-time PCR. Random amplified polymorphic DNA typing (RAPD-PCR) was used for genotyping of carbapenem-resistant Pseudomonas aeruginosa (CRPA).

RESULTS

Minimum inhibitory concentration (MIC) assays demonstrated high levels of resistance to all classes of antibiotics except colistin and polymyxin B. The initial screening by carbapenem disks indicated 24 isolates (63.15%) as CRPA. Different mechanisms of carbapenem resistance were observed, including carbapenemase production (8.4%), overexpression of AmpC (25%) and decreased expression of OprD (75%). The overexpression of MexAB efflux pumps was detected in 19 (79.1%) isolates by phenotypic assay or real-time PCR. The resistance to carbapenem was multifactorial in most cases (58.3%). The RAPD genotyping revealed different patterns with nine clusters.

CONCLUSION

According to our results, the prevalence of CRPA is at an alarming level. Our results did not demonstrate an epidemic clone. The most common mechanism of carbapenem resistance was decreased expression of OprD. Therefore, we suggest a reconsideration in the management of CRPA infections of patients in our burn care hospital in Azerbaijan, Iran.

The Evaluation of Antibiotic Resistance and nalB Mutants in Pseudomonas eruginosa Isolated from Burnt Patients of Shohada Mehrab Yazd Hospital Burn Ward

Background

Due to extensive damage to the skin, burn victims may acquire life-threatening infections. Though the skin primarily protects against microbial invasions, a large number of bacteria, fungi, and viruses can be isolated from burn patients, specifically Pseudomonas aeruginosa, a gram-negative bacterium with both intrinsic and acquired antibiotic resistance (AR) properties. nalB mutations can be found on the mexR in the P. aeruginosa chromosome. This mutation can induce overexpression of the mexAB-oprMoperon, and affect the MexAB-OprM efflux pump, which removes antimicrobial agents from the bacterial cell. Identifying nalB mutants can be useful for monitoring factors affecting AR.

Methods

In this study, 70 P. aeruginosa isolates identified from burn patients and antibacterial sensitivity was evaluated using the Kirby-Bauer method. We also investigated nalB mutations in samples using molecular methods including Polymerase reaction chain (PCR) and Sequencing.

Results

We identified nalB mutations in 16 isolates. We also found that the increasing effect of nalB mutants induces hyper production activity of MexAB-OprM resulting in AR. Overall, these findings compliment the findings of previous reports.

Conclusion

According to the resistance patterns of the samples, both Amikacin and Ciprofloxacin showed the highest resistance (%). Further, the relationship between Ciprofloxacin resistance and nalB mutations was statistically significant (p= 0.016). The results confirm that the increasing effect of nalB mutants on hyper production activity of MexAB-OprM leads to AR.

High prevalence of atypical virulotype and genetically diverse background among Pseudomonas aeruginosa isolates from a referral hospital in the Brazilian Amazon

Pseudomonas aeruginosa is an opportunistic pathogen causing different types of infections, particularly in intensive care unit patients. Characteristics that favor its persistence artificial environments are related to its high adaptability, wide arsenal of virulence factors and resistance to several antimicrobial classes. Among the several virulence determinants, T3SS stands as the most important due to the clinical impact of exoS and exoU genes in patient’s outcome. The molecular characterization of P. aeruginosa isolates helps in the comprehension of transmission dynamics and enhance knowledge of virulence and resistance roles in infection process. In the present study, we investigated virulence and resistance properties and the genetic background of P. aeruginosa isolated from ICUs patients at a referral hospital in Brazilian Amazon. A total of 54 P. aeruginosa isolates were characterized by detecting 19 virulence-related genes, antimicrobial susceptibility testing, molecular detection of β-lactamase-encoding genes and genotyping by MLST and rep-PCR. Our findings showed high prevalence of virulence-related markers, where 53.7% of the isolates presented at least 17 genes among the 19 investigated (P = 0.01). The rare exoS⁺/exoU⁺ cytotoxic virulotype was detected in 55.6% of isolates. Antimicrobial susceptibility testing revealed percentages of antibiotic resistance above 50% to carbapenems, cephalosporins and fluoroquinolones associated to MDR/XDR isolates. Isolates harboring both bla_SPM-1 and bla_OXA genes were also detected. Genotyping methods demonstrated a wide genetic diversity of strains spread among the different intensive care units, circulation of international MDR/XDR high-risk clones (ST111, ST235, ST244 and ST277) and emergence of seven novel MLST lineages. Finally, our findings highlight the circulation of strains with high virulence potential and resistance to antimicrobials and may be useful on comprehension of pathogenicity process, treatment guidance and establishment of strategies to control the spread of epidemic P. aeruginosa strains.

Virulence Constitution of Multi-Drug-Resistant Pseudomonas aeruginosa in Upper Egypt

Purpose

Ventilator-associated pneumonia caused by Pseudomonas aeruginosa (P. aeruginosa) is a major health-care problem. In this study, we explored the epidemiology of virulence determinants among multi-drug-resistant (MDR) clinical P. aeruginosa isolates from hospitalized patients with ventilator-associated pneumonia in intensive care units in Upper Egypt.

Patients and Methods

MDR P. aeruginosa isolates were screened for the presence of eight virulence factors and typed by ERIC-PCR.

Results

A total of 39 clinical MDR isolates were selected out of 173 isolated P. aeruginosa showing a combination of adhesion and cytotoxicity virulence patterns, with the detection of aprA, exoU, exoS, lasB, algD, toxA in 74.3%, 58.9%, 46.1%, 41.2%, 30.7%, 20.5% of the isolates, respectively. The MDR isolates were grouped into 13 different virulence profiles according to the pattern of virulence gene distribution. exoU genotype was more predominant among the P. aeruginosa isolates with more than 48% of the isolates harboring this gene alone, 7% harboring both exoU and exoS and 43.5% harboring exoS gene. An intermediate degree of diversity was detected by ERIC-PCR typing where the isolates were clustered in 7 major groups, indicating possible cross-infection within the hospital.

Conclusion

Our results highlight the increased frequency of virulent P. aeruginosa isolates with a shift to the more virulent cytotoxic exoU genotype. Further hospital infection-control measures are mandatory to control the hospital cross-transmission of these highly virulent isolates. This study could vastly be a help to develop efficient treatment policies against P. aeruginosa induced ventilator-associated pneumonia.

Characterization of carbapenem-resistant but cephalosporin-susceptible Pseudomonas aeruginosa

In this study, mechanisms of carbapenem resistance in carbapenem-resistant but cephalosporin-susceptible (Car-R/Ceph-S) Pseudomonas aeruginosa were investigated. A total of 243 P. aeruginosa isolates were studied. The disk diffusion and agar dilution methods were used for determination of antibiotic susceptibility patterns. AmpC and efflux pump overproductions were detected by phenotypic methods. The presence of carbapenemase-encoding genes was detected by polymerase chain reaction (PCR). The expression of OprD, MexAB-OprM, and MexXY-OprM efflux pumps was assessed by real-time PCR. According to disk diffusion method, altogether 116 P. aeruginosa isolates (47.7%) were carbapenem-resistant and among them, 23 isolates (19.8%) were cephalosporin-susceptible. Carbapenemase producer was not detected. Overexpression of AmpC was detected in one (4.3%) isolate that was ceftazidime-susceptible but cefepime-resistant. Overexpression of MexAB-OprM and MexXY-OprM efflux pumps was detected in 12 (60.9%) and 16 (68.8%) of isolates, respectively. A total of 16 (68.8%) isolates showed decreased expression of OprD. The Car-R/Ceph-S P. aeruginosa did not develop by carbapenemase production. The resistance to carbapenem was mediated in our clinical isolates by decreased expression of OprD and overexpression of MexAB-OprM and MexXY-OprM efflux systems or the combination of these mechanisms.

A systematic review and meta-analysis on Exo-toxins prevalence in hospital acquired Pseudomonas aeruginosa isolates

INTRODUCTION

Pseudomonas aeruginosa (PA) is an opportunistic pathogen that produces widespread and often overwhelming infections. Among different virulence factors, toxins are important bacterial agent which increases PA pathogenesis especially in immunocompromised patients. The aim of this meta-analysis was to determine the prevalence of exotoxin production in PA isolates in the world. Also according to the importance of drug resistance in isolates with more pathogenicity this estimation was conducted in resistant isolates.

METHODS

A systematic search was conducted in international database like PubMed, Scopus, Web of Science and Embase up to December 2018. Joanna Briggs Institute Checklist was used to evaluate the quality assessment of studies. Random effect model was applied to pool the prevalence data. Stata 13 software was used to analyze the data.

RESULTS

Total of 58 eligible studies that fulfilled the inclusion criteria of the study were selected for qualitative synthesis. Among exotoxins; the highest prevalence was related to exoT (0.83 (CI95%: 0.64-0.96)). Lowest prevalence rate was seen in exoU with estimated prevalence 0.32 (CI95%: 0.24-0.41). In Carbapenem resistance isolates exoA and exoT had the highest prevalence (1.00 (CI95%: 0.98-1.00)).

CONCLUSION

This first meta-analysis on PA isolates with toxin potency indicated high prevalence of exotoxin production in clinical isolates of PA which is an alarming point as a clinical aspect. It was found that the ExoT has the most prevalence rate among toxins. The results of simultaneous evaluation of exotoxins and antimicrobial resistance can develop treatment policies against PA infections in hospitals and hospitalized patients.

Epidemiology and antibiotic resistance trends in clinical isolates of Pseudomonas aeruginosa from Rio de janeiro - Brazil: Importance of mutational mechanisms over the years (1995-2015)

Pseudomonas aeruginosa is a major health concern globally and treating infections caused by MDR-isolates unarguably a humongous challenge that remains an unmet need in modern medicine. To determine patterns and mechanisms of antimicrobial resistance and its spread over the years in Rio de Janeiro, Brazil, 88 P. aeruginosa isolates were selected from 1995 to 2015. Phenotypic and genotypic characterization of antimicrobial resistance was evaluated and isolates were submitted to clonality by PFGE and MLST. PFGE analysis showed a great variability of clonal groups mainly over the past 10 years of this study. STs predominant in the early years (ST804, ST1860, ST487 and ST1602) associated to multidrug resistance (MDR) phenotype were replaced by ST277, ST244, ST1945, ST1791 with extensive drug resistance (XDR) in last years, with significant increase in resistance to carbapenems, fluoroquinolones and aminoglycosides. Colistin resistance was detected in 3.5%. The main mechanisms of antimicrobial resistance were mutational mechanisms (mutations in oprD, mexT and gyrA genes). We found the ESBL genes bla_TEM (n = 2), bla_SHV (n = 3) and bla_CTX (n = 1).The carbapenemases genes was present in ST277 (bla_SPM, n = 3), ST1560 (bla_KPC, n = 3) and ST1944 (bla_KPC, n = 2). The 16S RNA methylase gene (rmtD) was found in five isolates belonged to ST277. In conclusion, molecular epidemiological investigation reveals an increase of antimicrobial resistance in P. aeruginosa over 21 years in Rio de Janeiro with higher population structure and occurrence of high risk clone in the last years. The mutational mechanisms of resistance were present in all XDR isolates.

High incidence of type III secretion system associated virulence factors (exoenzymes) in Pseudomonas aeruginosa isolated from Iranian burn patients

Objective

The present study aimed to determine the prevalence of virulence factors and antimicrobial resistance profile of Pseudomonas aeruginosa strains isolated from Iranian burn patients.

Results

This cross-sectional study performed on 100 P. aeruginosa isolates which were recovered from burn wound specimens in 2014–2015. All presumptive isolates were identified by standard microbiologic tests. Antimicrobial susceptibility test was carried out by disk diffusion method. The presence of virulence genes was determined by PCR method. Antibiotic susceptibility results revealed that the isolates were mostly susceptible to amikacin (61%), ceftazidime (60%), and imipenem (55%). Moreover, 59% of the isolates were multi-drug resistance (MDR). The most prevalent MDR pattern was aminoglycosides–penicillins–fluoroquinolones–carbapenems (15%). The presence of exoT, exoY, exoS and exoU genes was detected in 100%, 100%, 59%, and 41% of the tested isolates, respectively. Results points out the pattern of MDR and genetic diversity of type III secretion system among P. aeruginosa strains isolated from the burn population. Overall, the association of MDR and the presence of the specific virulence genes can be a predictive marker for the persistence of these isolates in the hospitals and subsequently a worse clinical condition for the affected patients.

Photodynamic antimicrobial activity of new porphyrin derivatives against methicillin resistant Staphylococcus aureus

Methicillin resistant Staphylococcus aureus (MRSA) with multiple drug resistance patterns is frequently isolated from skin and soft tissue infections that are involved in chronic wounds. Today, difficulties in the treatment of MRSA associated infections have led to the development of alternative approaches such as antimicrobial photodynamic therapy. This study aimed to investigate photoinactivation with cationic porphyrin derivative compounds against MRSA in in-vitro conditions. In the study, MRSA clinical isolates with different antibiotic resistance profiles were used. The newly synthesized cationic porphyrin derivatives (P_M, P_E, P_PN, and P_PL) were used as photosensitizer, and 655 nm diode laser was used as light source. Photoinactivation experiments were performed by optimizing energy doses and photosensitizer concentrations. In photoinactivation experiments with different energy densities and photosensitizer concentrations, more than 99% reduction was achieved in bacterial cell viability. No decrease in bacterial survival was observed in control groups. It was determined that there was an increase in photoinactivation efficiency by increasing the energy dose. At the energy dose of 150 J/cm² a survival reduction of over 6.33 log₁₀ was observed in each photosensitizer type. While 200 μM P_M concentration was required for this photoinactivation, 12.50 μM was sufficient for P_E, P_PN, and P_PL. In our study, antimicrobial photodynamic therapy performed with cationic porphyrin derivatives was found to have potent antimicrobial efficacy against multidrug resistant S. aureus which is frequently isolated from wound infections.

Comparative genomics of clinical strains of Pseudomonas aeruginosa strains isolated from different geographic sites

The large and complex genome of Pseudomonas aeruginosa, which consists of significant portions (up to 20%) of transferable genetic elements contributes to the rapid development of antibiotic resistance. The whole genome sequences of 22 strains isolated from eye and cystic fibrosis patients in Australia and India between 1992 and 2007 were used to compare genomic divergence and phylogenetic relationships as well as genes for antibiotic resistance and virulence factors. Analysis of the pangenome indicated a large variation in the size of accessory genome amongst 22 stains and the size of the accessory genome correlated with number of genomic islands, insertion sequences and prophages. The strains were diverse in terms of sequence type and dissimilar to that of global epidemic P. aeruginosa clones. Of the eye isolates, 62% clustered together within a single lineage. Indian eye isolates possessed genes associated with resistance to aminoglycoside, beta-lactams, sulphonamide, quaternary ammonium compounds, tetracycline, trimethoprims and chloramphenicols. These genes were, however, absent in Australian isolates regardless of source. Overall, our results provide valuable information for understanding the genomic diversity of P. aeruginosa isolated from two different infection types and countries.

Association between possession of ExoU and antibiotic resistance in Pseudomonas aeruginosa

Virulent strains of Pseudomonas aeruginosa are often associated with an acquired cytotoxic protein, exoenzyme U (ExoU) that rapidly destroys the cell membranes of host cells by its phospholipase activity. Strains possessing the exoU gene are predominant in eye infections and are more resistant to antibiotics. Thus, it is essential to understand treatment options for these strains. Here, we have investigated the resistance profiles and genes associated with resistance for fluoroquinolone and beta-lactams. A total of 22 strains of P. aeruginosa from anterior eye infections, microbial keratitis (MK), and the lungs of cystic fibrosis (CF) patients were used. Based on whole genome sequencing, the prevalence of the exoU gene was 61.5% in MK isolates whereas none of the CF isolates possessed this gene. Overall, higher antibiotic resistance was observed in the isolates possessing exoU. Of the exoU strains, all except one were resistant to fluoroquinolones, 100% were resistant to beta-lactams. 75% had mutations in quinolone resistance determining regions (T81I gyrA and/or S87L parC) which correlated with fluoroquinolone resistance. In addition, exoU strains had mutations at K76Q, A110T, and V126E in ampC, Q155I and V356I in ampR and E114A, G283E, and M288R in mexR genes that are associated with higher beta-lactamase and efflux pump activities. In contrast, such mutations were not observed in the strains lacking exoU. The expression of the ampC gene increased by up to nine-fold in all eight exoU strains and the ampR was upregulated in seven exoU strains compared to PAO1. The expression of mexR gene was 1.4 to 3.6 fold lower in 75% of exoU strains. This study highlights the association between virulence traits and antibiotic resistance in pathogenic P. aeruginosa.

Molecular characterization of clinical and environmental Pseudomonas aeruginosa isolated in a burn center

In burn centers, Pseudomonas aeruginosa acts as a major cause of nosocomial infections. Therefore, this study aimed to characterize molecularly P. aeruginosa isolates collected from environmental samples and burn patients. A total of 78 strains (including 58 clinical and 20 environmental isolates) of the P. aeruginosa were collected from Beasat hospital of Hamadan, west of Iran, and was identified using API 20NE. The disk diffusion method according to the CLSI was applied for determination of the antimicrobial resistance. Moreover, the microtiter plate test was used for the quantification of Biofilm formation. The genomic features of the isolated strains was evaluated using Pulsed Field Gel Electrophoresis (PFGE). We found that 94.8% of clinical and 80% environmental isolates were capable of forming biofilm. The rate of MDR in clinical and environmental isolates was 51.7% and 40%, respectively. A significant relationship was observed between biofilm formation capability and multiple drug resistance (p < 0.05). PFGE typing showed 11 different clusters with two major clusters A with 30 (38.5%) and B with 14 (17.9%) members, containing up to 56.4% of all isolates. There was no relationship between biofilm formation ability and antibiotic resistance patterns with PFGE patterns. According to the results, the clonal spread of environmental P. aeruginosa isolates is associated with clinical isolates, and both environmental and clinical isolates are attributed to a high prevalence of the antibiotic resistance and biofilm formation ability. This study highlighted that the prevention programs should be implemented in the hospital environment to control the spread of P. aeruginosa in burn units.

Molecular Typing and Carbapenem Resistance Mechanisms of Pseudomonas aeruginosa Isolated From a Chinese Burn Center From 2011 to 2016

Pseudomonas aeruginosa is the leading cause of infection in burn patients. The increasing carbapenem resistance of P. aeruginosa has become a serious challenge to clinicians. The present study investigated the molecular typing and carbapenem resistance mechanisms of 196 P. aeruginosa isolates from the bloodstream and wound surface of patients in our burn center over a period of 6 years. By multilocus sequence typing (MLST), a total of 58 sequence types (STs) were identified. An outbreak of ST111, a type that poses a high international risk, occurred in 2014. The isolates from wound samples of patients without bacteremia were more diverse and more susceptible to antibiotics than strains collected from the bloodstream or the wound surface of patients with bacteremia. Importantly, a large proportion of the patients with multisite infection (46.51%) were simultaneously infected by different STs in the bloodstream and wound surface. Antimicrobial susceptibility testing of these isolates revealed high levels of resistance to carbapenems, with 35.71% susceptibility to imipenem and 32.14% to meropenem. To evaluate mechanisms associated with carbapenem resistance, experiments were conducted to determine the prevalence of carbapenemase genes, detect alterations of the oprD porin gene, and measure expression of the ampC β-lactamase gene and the mexB multidrug efflux gene. The main mechanism associated with carbapenem resistance was mutational inactivation of oprD (88.65%), accompanied by overexpression of ampC (68.09%). In some cases, oprD was inactivated by insertion sequence element IS1411, which has not been found previously in P. aeruginosa. These findings may help control nosocomial P. aeruginosa infections and improve clinical practice.

Genome-scale metabolic modeling of responses to polymyxins in Pseudomonas aeruginosa

Background

Pseudomonas aeruginosa often causes multidrug-resistant infections in immunocompromised patients, and polymyxins are often used as the last-line therapy. Alarmingly, resistance to polymyxins has been increasingly reported worldwide recently. To rescue this last-resort class of antibiotics, it is necessary to systematically understand how P. aeruginosa alters its metabolism in response to polymyxin treatment, thereby facilitating the development of effective therapies. To this end, a genome-scale metabolic model (GSMM) was used to analyze bacterial metabolic changes at the systems level.

Findings

A high-quality GSMM iPAO1 was constructed for P. aeruginosa PAO1 for antimicrobial pharmacological research. Model iPAO1 encompasses an additional periplasmic compartment and contains 3022 metabolites, 4265 reactions, and 1458 genes in total. Growth prediction on 190 carbon and 95 nitrogen sources achieved an accuracy of 89.1%, outperforming all reported P. aeruginosa models. Notably, prediction of the essential genes for growth achieved a high accuracy of 87.9%. Metabolic simulation showed that lipid A modifications associated with polymyxin resistance exert a limited impact on bacterial growth and metabolism but remarkably change the physiochemical properties of the outer membrane. Modeling with transcriptomics constraints revealed a broad range of metabolic responses to polymyxin treatment, including reduced biomass synthesis, upregulated amino acid catabolism, induced flux through the tricarboxylic acid cycle, and increased redox turnover.

Conclusions

Overall, iPAO1 represents the most comprehensive GSMM constructed to date for Pseudomonas. It provides a powerful systems pharmacology platform for the elucidation of complex killing mechanisms of antibiotics.

Extensive colonization with carbapenemase-producing microorganisms in Romanian burn patients: infectious consequences from the Colectiv fire disaster

Health care of severe burn patients is highly specialized and may require international patient transfer. Burn patients have an increased risk of developing infections. Patients that have been hospitalized in countries where carbapenemase-producing microorganisms (CPMO) are endemic may develop infections that are difficult to treat. In addition, there is a risk on outbreaks with CPMOs in burn centers. This study underlines that burn patients may extensively be colonized with CPMOs, and it provides best practice recommendations regarding clinical microbiology and infection control. We evaluated CPMO-carriage and wound colonization in a burn patient initially treated in Romania, and transported to the Netherlands. The sequence types and acquired beta-lactamase genes of highly-resistant microorganisms were derived from next generation sequencing data. Next, we searched literature for reports on CPMOs in burn patients. Five different carbapenemase-producing isolates were cultured: two unrelated OXA-48-producing Klebsiella pneumoniae isolates, OXA-23-producing Acinetobacter baumanii, OXA-48-producing Enterobacter cloacae, and NDM-1-producing Providencia stuartii. Also, multi-drug resistant Pseudomonas aeruginosa isolates were detected. Among the sampling sites, there was high variety in CPMOs. We found 46 reports on CPMOs in burn patients. We listed the epidemiology of CPMOs by country of initial treatment, and summarized recommendations for care of these patients based on these reports and our study.

A 5-year Survey Reveals Increased Susceptibility to Glycopeptides for Methicillin-Resistant Staphylococcus aureus Isolates from Staphylococcus aureus Bacteremia Patients in a Chinese Burn Center

Methicillin-resistant Staphylococcus aureus (MRSA) infections are prevalent in burn wards, and are especially serious in S. aureus bacteremia (SAB) patients. Glycopeptides and daptomycin are effective against MRSA infections, but MIC creeps can reduce their efficacy. Our object was to perform a molecular epidemiological investigation of S. aureus isolates in our burn center and to evaluate MICs for antimicrobials against SAB-associated MRSA isolates. A total of 259 S. aureus isolates, obtained from August 2011 to July 2016, were used in this study. Multiple molecular typing was used for molecular epidemiological analysis. E-tests were used to determine MICs of vancomycin, teicoplanin, and daptomycin for SAB-associated MRSA isolates. MIC values were stratified by collection date or source and compared. Spearman's test was used to analyze MICs correlations amongst tested antimicrobials. ST239-MRSA-III-t030-agrI clone was found to be dominant in both SAB and non-SAB patients, and significantly more in SAB patients (P < 0.0001). SAB-MRSA isolates exhibited decreased MICs for vancomycin, teicoplanin, and daptomycin during the 5-year period. Compared to those isolated from catheters or wounds, SAB-MRSA isolates from the bloodstream were less susceptible to vancomycin and daptomycin, but more susceptible to teicoplanin. MICs Correlation was found only between vancomycin and daptomycin in MRSA isolates from the bloodstream (rho = 0.250, P = 0.024). In conclusion, our results suggest that MRSA infections are still serious problems in burn centers. In contrast to most other studies, we observed increased susceptibility to glycopeptides and daptomycin against SAB-associated MRSA in our center from 2011 to 2016, suggesting the use of glycopeptides does not lead to MIC creeps. Isolates from different sites of the body may exhibit different levels of susceptibility and change trend over time for different antimicrobials, antimicrobials selection for MRSA infections should be considered comprehensively.

[Pseudomonas aeruginosa in dermatology]

Pseudomonas aeruginosa, a ubiquitous Gram-negative bacillus characterized by its greenish color and sweetish smell, is at the origin of potentially severe forms of dermatosis, such as ecthyma gangrenosum which marks immunosuppression or reveals blood-poisoning, especially in children. It frequently colonizes chronic wounds and serious burns, and spongiotic or acantholytic dermatosis, especially when severe or localized in skinfolds. It requires special care because of its high resistance to antibiotics and antiseptics. It can also involve folliculitis favored by water sports or a nail disorder (chloronychia).

Pseudomonas aeruginosa Type III Secretory Toxin ExoU and Its Predicted Homologs

Pseudomonas aeruginosa ExoU, a type III secretory toxin and major virulence factor with patatin-like phospholipase activity, is responsible for acute lung injury and sepsis in immunocompromised patients. Through use of a recently updated bacterial genome database, protein sequences predicted to be homologous to Ps. aeruginosa ExoU were identified in 17 other Pseudomonas species (Ps. fluorescens, Ps. lundensis, Ps. weihenstephanensis, Ps. marginalis, Ps. rhodesiae, Ps. synxantha, Ps. libanensis, Ps. extremaustralis, Ps. veronii, Ps. simiae, Ps. trivialis, Ps. tolaasii, Ps. orientalis, Ps. taetrolens, Ps. syringae, Ps. viridiflava, and Ps. cannabina) and 8 Gram-negative bacteria from three other genera (Photorhabdus, Aeromonas, and Paludibacterium). In the alignment of the predicted primary amino acid sequences used for the phylogenetic analyses, both highly conserved and nonconserved parts of the toxin were discovered among the various species. Further comparative studies of the predicted ExoU homologs should provide us with more detailed information about the unique characteristics of the Ps. aeruginosa ExoU toxin.