Dissemination of amikacin resistance gene aphA6 in Acinetobacter spp

Healthcare Equipment and Personnel Reservoirs of Carbapenem-Resistant Acinetobacter baumannii Epidemic Clones in Intensive Care Units in a Tunisian Hospital

Carbapenem-resistant Acinetobacter baumannii (CRAB) strains can cause severe and difficult-to-treat infections in patients with compromised general health. CRAB strains disseminate rapidly in nosocomial settings by patient-to-patient contact, through medical devices and inanimate reservoirs. The occurrence of CRAB in patients residing in the intensive care units (ICUs) of the Sahloul University hospital in Sousse, Tunisia is high. The objective of the current study was to determine whether the surfaces of items present in five ICU wards and the medical personnel there operating could serve as reservoirs for CRAB strains. Furthermore, CRAB isolates from patients residing in the ICUs during the sampling campaign were analyzed for genome comparison with isolates from the ICUs environment. Overall, 206 items were screened for CRAB presence and 27 (14%) were contaminated with a CRAB isolate. The items were located in several areas of three ICUs. Eight of the 54 (15%) screened people working in the wards were colonized by CRAB on the hands. Patients residing in the ICUs were infected with CRAB strains sharing extensive genomic similarity with strains recovered in the nosocomial environment. The strains belonged to three sub-clades of the internationally disseminated clone (ST2). A clone emerging in the Mediterranean basin (ST85) was detected as well. The strains were OXA-23 or NDM-1 producers and were also pan-aminoglycoside resistant due to the presence of the armA gene. Hygiene measures are urgent to be implemented in the Sahloul hospital to avoid further spread of difficult-to-treat CRAB strains and preserve health of patients and personnel operating in the ICU wards.

Effect of Glucose Induction on Biofilm Density in Clinical Isolate Acinetobacter baumannii Patients in Intensive Care Unit of Dr. Soetomo Hospital, Surabaya

This study aimed to analyze the effect of glucose induction on the clinical isolate biofilm density of Acinetobacter baumannii. Thirteen clinical isolates of A. baumannii non biofilm forming were collected from non-DM patients who were treated at the ICU of Dr. Soetomo Hospital, Surabaya, was treated with the addition of 0.08% glucose, 0.15% glucose, 0.2% glucose, and 0.4% glucose in TSB growth media, followed by biofilm density examination with Tissue Culture Plate Method (TCPM) using 96 wells flatbottomed polyesterene tissue culture plate and read by autoreader ELISA with a wavelength of 630 nm (OD630). Biofilm density obtained was analyzed using ANOVA statistical analysis. The results of OD630 showed that the biofilm density increased significantly at the addition of 0.2% and 0.4% glucose. There was a significant increase in biofilm density at the addition of 0.2% and 0.4% glucose so that the management of blood sugar levels in ICU patients was needed before and when medical devices were installed.

Amikacin resistance due to the aphA6 gene in multi-antibiotic resistant Acinetobacter baumannii isolates belonging to global clone 1 from Iran

Background

TnaphA6-carrying repAci6 plasmids have been detected in Acinetobacter baumannii isolates belonging to global clones, GC1 and GC2, worldwide. Here, we examined whether RepAci6 plasmids family play a role in the dissemination of the aphA6 in GC1 A. baumannii isolates from Iran.

Results

We found that 22 isolates carried the repAci6 gene, suggesting that they contain a RepAci6 plasmid family. Using the primers linking the aphA6 gene to the backbone of repAci6 plasmid, it was revealed that 16 isolates from different hospitals harbored TnaphA6 on a repAci6 plasmid.

Conclusions

This study provides evidence for the dissemination of TnaphA6 on the plasmids encoding RepAci6 in Iranian A. baumannii isolates. Furthermore, it seems that TnaphA6 might be acquired by distinct plasmids separately as it was found to be located on the variants of repAci6 plasmids.

NDM Metallo-β-Lactamases and Their Bacterial Producers in Health Care Settings

New Delhi metallo-β-lactamase (NDM) is a metallo-β-lactamase able to hydrolyze almost all β-lactams. Twenty-four NDM variants have been identified in >60 species of 11 bacterial families, and several variants have enhanced carbapenemase activity. Klebsiella pneumoniae and Escherichia coli are the predominant carriers of bla _NDM, with certain sequence types (STs) (for K. pneumoniae, ST11, ST14, ST15, or ST147; for E. coli, ST167, ST410, or ST617) being the most prevalent. NDM-positive strains have been identified worldwide, with the highest prevalence in the Indian subcontinent, the Middle East, and the Balkans. Most bla _NDM-carrying plasmids belong to limited replicon types (IncX3, IncFII, or IncC). Commonly used phenotypic tests cannot specifically identify NDM. Lateral flow immunoassays specifically detect NDM, and molecular approaches remain the reference methods for detecting bla _NDM Polymyxins combined with other agents remain the mainstream options of antimicrobial treatment. Compounds able to inhibit NDM have been found, but none have been approved for clinical use. Outbreaks caused by NDM-positive strains have been reported worldwide, attributable to sources such as contaminated devices. Evidence-based guidelines on prevention and control of carbapenem-resistant Gram-negative bacteria are available, although none are specific for NDM-positive strains. NDM will remain a severe challenge in health care settings, and more studies on appropriate countermeasures are required.

Site-Specific Recombination at XerC/D Sites Mediates the Formation and Resolution of Plasmid Co-integrates Carrying a blaOXA-58- and TnaphA6-Resistance Module in Acinetobacter baumannii

Members of the genus Acinetobacter possess distinct plasmid types which provide effective platforms for the acquisition, evolution, and dissemination of antimicrobial resistance structures. Many plasmid-borne resistance structures are bordered by short DNA sequences providing potential recognition sites for the host XerC and XerD site-specific tyrosine recombinases (XerC/D-like sites). However, whether these sites are active in recombination and how they assist the mobilization of associated resistance structures is still poorly understood. Here we characterized the plasmids carried by Acinetobacter baumannii Ab242, a multidrug-resistant clinical strain belonging to the ST104 (Oxford scheme) which produces an OXA-58 carbapenem-hydrolyzing class-D β-lactamase (CHDL). Plasmid sequencing and characterization of replication, stability, and adaptive modules revealed the presence in Ab242 of three novel plasmids lacking self-transferability functions which were designated pAb242_9, pAb242_12, and pAb242_25, respectively. Among them, only pAb242_25 was found to carry an adaptive module encompassing an ISAba825-bla_OXA-58 arrangement accompanied by a TnaphA6 transposon, the whole structure conferring simultaneous resistance to carbapenems and aminoglycosides. Ab242 plasmids harbor several XerC/D-like sites, with most sites found in pAb242_25 located in the vicinity or within the adaptive module described above. Electrotransformation of susceptible A. nosocomialis cells with Ab242 plasmids followed by imipenem selection indicated that the transforming plasmid form was a co-integrate resulting from the fusion of pAb242_25 and pAb242_12. Further characterization by cloning and sequencing studies indicated that a XerC/D site in pAb242_25 and another in pAb242_12 provided the active sister pair for the inter-molecular site-specific recombination reaction mediating the fusion of these two plasmids. Moreover, the resulting co-integrate was found also to undergo intra-molecular resolution at the new pair of XerC/D sites generated during fusion thus regenerating the original pAb242_25 and pAb242_12 plasmids. These observations provide the first evidence indicating that XerC/D-like sites in A. baumannii plasmids can provide active pairs for site-specific recombination mediating inter-molecular fusions and intra-molecular resolutions. The overall results shed light on the evolutionary dynamics of A. baumannii plasmids and the underlying mechanisms of dissemination of genetic structures responsible for carbapenem and other antibiotics resistance among the Acinetobacter clinical population.

A GC1 Acinetobacter baumannii isolate carrying AbaR3 and the aminoglycoside resistance transposon TnaphA6 in a conjugative plasmid

Objectives

To locate the acquired antibiotic resistance genes, including the amikacin resistance transposon TnaphA6, in the genome of an Australian isolate belonging to Acinetobacter baumannii global clone 1 (GC1).

Methods

A multiply antibiotic-resistant GC1 isolate harbouring TnaphA6 was sequenced using Illumina HiSeq, and reads were used to generate a de novo assembly and determine multilocus sequence types (STs). PCR was used to assemble the AbaR chromosomal resistance island and a large plasmid carrying TnaphA6. Plasmid DNA sequences were compared with ones available in GenBank. Conjugation experiments were conducted.

Results

The A. baumannii GC1 isolate G7 was shown to include the AbaR3 antibiotic resistance island. It also contains an 8.7 kb cryptic plasmid, pAb-G7-1, and a 70 100 bp plasmid, pAb-G7-2, carrying TnaphA6. pAb-G7-2 belongs to the Aci6 Acinetobacter plasmid family. It encodes transfer functions and was shown to conjugate. Plasmids related to pAb-G7-2 were detected in further amikacin-resistant GC1 isolates using PCR. From the genome sequence, isolate G7 was ST1 (Institut Pasteur scheme) and ST231 (Oxford scheme). Using Oxford scheme PCR-based methods, the isolate was ST109 and this difference was traced to a single base difference resulting from the inclusion of the original primers in the gpi segment analysed.

Conclusions

The multiply antibiotic-resistant GC1 isolate G7 carries most of its resistance genes in AbaR3 located in the chromosome. However, TnaphA6 is on a conjugative plasmid, pAb-G7-2. Primers developed to locate TnaphA6 in pAb-G7-2 will simplify the detection of plasmids related to pAb-G7-2 in A. baumannii isolates.

Prospects for circumventing aminoglycoside kinase mediated antibiotic resistance

Aminoglycosides are a class of antibiotics with a broad spectrum of antimicrobial activity. Unfortunately, resistance in clinical isolates is pervasive, rendering many aminoglycosides ineffective. The most widely disseminated means of resistance to this class of antibiotics is inactivation of the drug by aminoglycoside-modifying enzymes (AMEs). There are two principal strategies to overcoming the effects of AMEs. The first approach involves the design of novel aminoglycosides that can evade modification. Although this strategy has yielded a number of superior aminoglycoside variants, their efficacy cannot be sustained in the long term. The second approach entails the development of molecules that interfere with the mechanism of AMEs such that the activity of aminoglycosides is preserved. Although such a molecule has yet to enter clinical development, the search for AME inhibitors has been greatly facilitated by the wealth of structural information amassed in recent years. In particular, aminoglycoside phosphotransferases or kinases (APHs) have been studied extensively and crystal structures of a number of APHs with diverse regiospecificity and substrate specificity have been elucidated. In this review, we present a comprehensive overview of the available APH structures and recent progress in APH inhibitor development, with a focus on the structure-guided strategies.

blaNDM-1 is a chimera likely constructed in Acinetobacter baumannii

Alignment of DNA sequences found upstream of aphA6 and all bla(NDM-1) genes displays 100% identity. This identity continues 19 bp into the bla(NDM-1) gene such that the first 6 amino acids of aphA6 and bla(NDM-1) are the same. Furthermore, the percent GC content (GC%) of aphA6 is considerably lower than that of bla(NDM-1) and the GC% within the bla(NDM-1) structural gene changes dramatically after the first 19 bp. This is unequivocal evidence that bla(NDM-1) is a chimera.

Novel plasmid and its variant harboring both a bla(NDM-1) gene and type IV secretion system in clinical isolates of Acinetobacter lwoffii

The spread of the bla(NDM-1) gene is gaining worldwide attentions. This gene is usually carried by large plasmids and has been discovered in diverse bacteria since it was originally found in Klebsiella pneumoniae. Here we report the complete sequences of a bla(NDM-1)-bearing plasmid, pNDM-BJ01, and its variant, pNDM-BJ02, isolated from clinical Acinetobacter lwoffii strains. The plasmid pNDM-BJ01 is 47.3 kb in size and cannot be classified into any known plasmid incompatibility group, thus representing a novel plasmid with an unknown maintenance mechanism. This plasmid contains both a bla(NDM-1) gene and a type IV secretion system (T4SS) gene cluster. The T4SS is assigned to the P-type T4SS group, which usually encode a short, rigid pilus, and the bla(NDM-1) gene is located within a composite transposon flanked by two insertion elements of ISAba125. Plasmid pNDM-BJ02 is nearly identical to pNDM-BJ01 except that one copy of the ISAba125 element is missing, and it is therefore regarded as a variant of pNDM-BJ01. Sequence alignment indicated that this bla(NDM-1)-containing composite transposon, which can also be captured by other mobile elements, was probably a product of multiple recombination events and can move as a whole by transposition.

Evolution of an incompatibility group IncA/C plasmid harboring blaCMY-16 and qnrA6 genes and its transfer through three clones of Providencia stuartii during a two-year outbreak in a Tunisian burn unit

During a 2-year period in 2005 and 2006, 64 multidrug-resistant Providencia stuartii isolates, including 58 strains from 58 patients and 6 strains obtained from the same tracheal aspirator, were collected in a burn unit of a Tunisian hospital. They divided into four antibiotypes (ATB1 to ATB4) and three SmaI pulsotypes (PsA to PsC), including 49 strains belonging to clone PsA (48 of ATB1 and 1 of ATB4), 11 strains to clone PsB (7 of ATB2 and 4 of ATB3), and 4 strains to clone PsC (ATB3). All strains, except for the PsA/ATB4 isolate, were highly resistant to broad-spectrum cephalosporins due to the production of the plasmid-mediated CMY-16 β-lactamase. In addition, the 15 strains of ATB2 and ATB3 exhibited decreased quinolone susceptibility associated with QnrA6. Most strains (ATB1 and ATB3) were gentamicin resistant, related to an AAC(6')-Ib' enzyme. All these genes were located on a conjugative plasmid belonging to the incompatibility group IncA/C(2) of 195, 175, or 100 kb. Despite differences in size and in number of resistance determinants, they derived from the same plasmid, as demonstrated by similar profiles in plasmid restriction analysis and strictly homologous sequences of repAIncA/C(2), unusual antibiotic resistance genes (e.g., aphA-6), and their genetic environments. Further investigation suggested that deletions, acquisition of the ISCR1 insertion sequence, and integron cassette mobility accounted for these variations. Thus, this outbreak was due to both the spread of three clonal strains and the dissemination of a single IncA/C(2) plasmid which underwent a remarkable evolution during the epidemic period.

Antimicrobial resistance of Acinetobacter spp. in Europe

Bacteria of the genus Acinetobacter are ubiquitous in nature. These organisms were invariably susceptible to many antibiotics in the 1970s. Since that time, acinetobacters have emerged as multiresistant opportunistic nosocomial pathogens. The taxonomy of the genus Acinetobacter underwent extensive revision in the mid-1980s, and at least 32 named and unnamed species have now been described. Of these, Acinetobacter baumannii and the closely related unnamed genomic species 3 and 13 sensu Tjernberg and Ursing (13TU) are the most relevant clinically. Multiresistant strains of these species causing bacteraemia, pneumonia, meningitis, urinary tract infections and surgical wound infections have been isolated from hospitalised patients worldwide. This review provides an overview of the antimicrobial susceptibilities of Acinetobacter spp. in Europe, as well as the main mechanisms of antimicrobial resistance, and summarises the remaining treatment options for multiresistant Acinetobacter infections.

Versatility of aminoglycosides and prospects for their future

Aminoglycoside antibiotics have had a major impact on our ability to treat bacterial infections for the past half century. Whereas the interest in these versatile antibiotics continues to be high, their clinical utility has been compromised by widespread instances of resistance. The multitude of mechanisms of resistance is disconcerting but also illuminates how nature can manifest resistance when bacteria are confronted by antibiotics. This article reviews the most recent knowledge about the mechanisms of aminoglycoside action and the mechanisms of resistance to these antibiotics.

Prevalence and in-vitro antimicrobial susceptibility patterns of Acinetobacter strains isolated from patients in intensive care units

Fifty-six Acinetobacter species strains (49 Acinetobacter baumanii, 5 Acinetobacter calcoaceticus, 2 Acinetobacter iwoffii) were detected using both conventional methods and gas chromatography of bacterial fatty acids with the MIDI Sherlock Microbial Identification System. The susceptibilities of these strains to 16 antimicrobial agents were investigated by the disc-diffusion method according to the National Committee for Clinical Laboratory Standards. The production of extended-spectrum beta-lactamases (ESBLs) and inducible beta-lactamases (IBLs) by the strains were investigated by the double-disc-synergy and disc-approximation methods, respectively. Imipenem was the most effective agent for Acinetobacter baumanii strains (95.9% of strains were sensitive), while meropenem and netilmicin showed moderate activity (87.7% and 79.6% of strains, respectively, responded). Acinetobacter baumanii strains were less sensitive to cefoperazone-sulbactam (53.1%), ofloxacin (51.0%), ciprofloxacin (42.8%), and amikacin (36.7%). Acinetobacter calcoaceticus and Acinetobacter iwoffii strains were sensitive to imipenem, meropenem and netilmicin. IBLs and ESBLs were produced, respectively, by 8.9% and 7.1% of all bacterial strains. The strains isolated were sufficiently sensitive to imipenem, but not to ofloxacin or ciprofloxacin, and were very resistant to amikacin.

Emergence and rapid spread of carbapenem resistance during a large and sustained hospital outbreak of multiresistant Acinetobacter baumannii

Beginning in 1992, a sustained outbreak of multiresistant Acinetobacter baumannii infections was noted in our 1,000-bed hospital in Barcelona, Spain, resulting in considerable overuse of imipenem, to which the organisms were uniformly susceptible. In January 1997, carbapenem-resistant (CR) A. baumannii strains emerged and rapidly disseminated in the intensive care units (ICUs), prompting us to conduct a prospective investigation. It was an 18-month longitudinal intervention study aimed at the identification of the clinical and microbiological epidemiology of the outbreak and its response to a multicomponent infection control strategy. From January 1997 to June 1998, clinical samples from 153 (8%) of 1,836 consecutive ICU patients were found to contain CR A. baumannii. Isolates were verified to be A. baumannii by restriction analysis of the 16S-23S ribosomal genes and the intergenic spacer region. Molecular typing by repetitive extragenic palindromic sequence-based PCR and pulsed-field gel electrophoresis showed that the emergence of carbapenem resistance was not by the selection of resistant mutants but was by the introduction of two new epidemic clones that were different from those responsible for the endemic. Multivariate regression analysis selected those patients with previous carriage of CR A. baumannii (relative risk [RR], 35.3; 95% confidence interval [CI], 7.2 to 173.1), those patients who had previously received therapy with carbapenems (RR, 4.6; 95% CI, 1.3 to 15.6), or those who were admitted into a ward with a high density of patients infected with CR A. baumannii (RR, 1.7; 95% CI, 1.2 to 2.5) to be at a significantly greater risk for the development of clinical colonization or infection with CR A. baumannii strains. In accordance, a combined infection control strategy was designed and implemented, including the sequential closure of all ICUs for decontamination, strict compliance with cross-transmission prevention protocols, and a program that restricted the use of carbapenem. Subsequently, a sharp reduction in the incidence rates of infection or colonization with A. baumannii, whether resistant or susceptible to carbapenems, was shown, although an alarming dominance of the carbapenem-resistant clones was shown at the end of the study.

Detection of carbapenemase-producing Acinetobacter baumannii in a hospital

Acinetobacter baumannii strains resistant to both imipenem (IPM) and ceftazidime (CAZ) were isolated from 1994 through 1996 at Gunma University Hospital. Nine isolates from different inpatients were examined for carbapenem-hydrolyzing activity and for the carbapemase gene bla(IMP) by the PCR method. All nine isolates were carbapenemase-producing strains that hydrolyzed IPM and that harbored bla(IMP). The bla(IMP) gene was transmissible by conjugation to an IPM-susceptible recipient strain of A. baumannii and conferred resistance to IPM, CAZ, cefotaxime (CTX), ampicillin (AMP), and piperacillin (PIP). Either intermediate or high-level resistance to amikacin (AMK) was transferred from two and five strains, respectively, concomitantly with bla(IMP), and gentamicin (GEN) resistance was also transferred in one instance of high-level AMK resistance. Comparative examination of clinical isolates for resistance patterns to nine drugs, IPM, CAZ, CTX, aztreonam, AMP, PIP, AMK, GEN, and norfloxacin, in addition to pulsed-field gel electrophoresis patterns with NotI-digested genomic DNA, confirmed nosocomial transmission of infections involving carbapenemase-producing A. baumannii strains.

The persistence and clonal spread of a single strain of Acinetobacter 13TU in a large Scottish teaching hospital

This study describes the persistence and spread of a single strain of Acinetobacter 13TU in a large Scottish teaching hospital. Acinetobacter spp. are reported with increasing frequency as a cause of nosocomial infection. The species most implicated in these infections is Acinetobacter baumannii. Following an outbreak of infection with Acinetobacter 13TU within the intensive therapy unit (ITU) of Edinburgh Royal Infirmary (ERI) during 1994-1995, the current epidemiological Acinetobacter situation within the hospital was monitored to determine whether or not control of infection procedures instigated at that time had been successful in controlling the outbreak. Sixty-eight strains of Acinetobacter spp were isolated from clinical specimens received from various wards in the ERI and other associated hospitals over a 7-month period. Each isolate was typed phenotypically by the API20NE system and genotypically by pulsed field gel electrophoresis (PFGE) in order to compare them with the previous outbreak strain. Fifty-three percent of the isolates collected were originally identified as A. junii by API 20 NE, of which 83% (mainly from ITU) were shown to be genotypically related to the previous outbreak strain. Subsequent tDNA fingerprinting of one of the original outbreak strains showed it to be a member of the genospecies 13TU and not A. junii as originally thought.

PCR detection of aminoglycoside resistance genes: a rapid molecular typing method for Acinetobacter baumannii

Aminoglycoside resistance is common among strains of Acinetobacter baumannii responsible for nosocomial infections, and inactivation of these antibiotics by enzymatic modification is the main mechanism. Different types of aminoglycoside acetyltransferases (AAC), nucleotidyltransferases (ANT), and phosphotransferases (APH) are synthesized by clinical isolates, and several enzymes can be produced by a single strain. Using a multiplex PCR procedure carried out on bacterial thermolysates, we analyzed the aminoglycoside resistance gene content of strains belonging to eight clusters identified by pulsed-field gel electrophoresis. In a single reaction were combined three primer pairs in order to amplify the genes coding for AAC(6')-Ih, AAC(3)-I, and AAC(3)-II, three primer pairs for the genes coding for ANT(2'')-I, APH(3')-VI, and rRNA 16S as internal control, and finally two primer pairs for the genes coding for AAC(6')-Ib and APH(3')-I. According to the aminoglycoside resistance gene patterns, the strains of the eight clusters were distributed into seven classes. This simple and rapid (< 8 h) fingerprinting technique could be a useful tool for the epidemiological investigation of A. baumannii nosocomial infections.

Spread of amikacin resistance in Acinetobacter baumannii strains isolated in Spain due to an epidemic strain

Sixteen amikacin-resistant clinical Acinetobacter baumannii isolates from nine different hospitals in Spain were investigated to determine whether the high incidence of amikacin-resistant A. baumannii was due to the dissemination of an amikacin-resistant strain or to the spread of an amikacin resistance gene. The epidemiological relationship studied by repetitive extragenic palindromic PCR and low-frequency restriction analysis of chromosomal DNA showed that the same clone was isolated in eight of nine hospitals, although other clones were also found. The strains were studied for the presence of the aph(3')-VIa and aac(6')-I genes, which encode enzymes which inactivate amikacin, by PCR. All 16 clinical isolates had positive PCRs with primers specific for the amplification of the aph(3')-VIa gene, whereas none had a positive reaction for the amplification of the aac(6')-I gene. Therefore, the high incidence of amikacin resistance among clinical A. baumannii isolates in Spain was mainly due to an epidemic strain, although the spread of the aph(3')-VI gene cannot be ruled out.

The increasing significance of outbreaks of Acinetobacter spp.: the need for control and new agents

Acinetobacter spp. are Gram-negative non-fermentative bacteria which may be isolated as commensals from human skin, throat and intestine but are also increasingly responsible for hospital infections. Owing to frequent changes in their taxonomy, their pathogenic role in humans has not been clear but today acinetobacter is considered to be a significant nosocomial pathogen in outbreaks of hospital infections predominantly in intensive care units. Nosocomial infections due to acinetobacter include urinary tract infections, bacteraemia, wound and burn infections, but also they are frequently isolated from ventilator-associated nosocomial pneumonia. The frequency of hospital outbreaks of acinetobacter infections has required the development of reliable typing methods. As well as conventional 'phenotypic' methods (serology, biotyping, phage typing), 'genotypic' systems (ribotyping, plasmid profiles, pulsed-field gel electrophoresis) have been utilized for strain identification. These typing systems should allow a better understanding of the epidemiology of acinetobacter in the hospital environment, e.g. sources, modes of transmission, and result in more efficient preventive measures. Acinetobacter infections are difficult to treat owing to their frequent multiple resistance to the antibiotics currently available for the treatment of nosocomial infections; various mechanisms of resistance to beta-lactams and amino-glycosides have been identified in the genus. Combination therapy is usually recommended for treatment of acinetobacter nosocomial infections and active antibacterials include imipenem, ceftazidime, amikacin and the newer fluoroquinolones. Careful in vitro testing of the activity of combinations of these drugs is recommended prior to their use.

Detection of aac(6')-I genes in amikacin-resistant Acinetobacter spp. by PCR

The distribution of aac(6')-I genes in 62 strains of Acinetobacter spp. resistant to amikacin, netilmicin, and tobramycin and susceptible to gentamicin, a phenotype compatible with synthesis of an AAC(6')-I enzyme, was studied by PCR and by DNA hybridization. Both methods gave similar results. Among the 51 Acinetobacter baumannii strains, aac(6')-Ib was found in 19 isolates and aac(6')-Ih was found in the remaining strains. The aac(6')-Ig gene was present in all 10 A. haemolyticus strains studied and was detected only in this species. A pair of degenerate oligonucleotides complementary to conserved regions of aac(6')-Ic, -Id, -If, -Ig, and -Ih enabled detection of these genes and also of aac(6')-Ij, recently recognized in Acinetobacter sp. strain 13.

Acinetobacter spp., saprophytic organisms of increasing pathogenic importance

Acinetobacter spp. are Gram-negative non-fermentative bacteria commonly present in soil and water as free-living saprophytes; they are isolated as commensals from skin, throat and various secretions of healthy people. There have been frequent changes in their taxonomy so that their pathogenic role in humans has been understood only recently: Acinetobacter has emerged as an important nosocomial pathogen involved in outbreaks of hospital infections. This ubiquitous organism can be recovered from the hospital environment, from colonized or infected patients or from staff (hand carriage). Acinetobacter as an opportunistic pathogen is involved in nosocomial urinary tract infections, bacteremia, wound and burn infections. Its predominant role is observed in nosocomial pneumonia, particularly in fan-associated pneumonia. Acinetobacters are responsible for difficult-to-treat infections due to their frequent multiple resistance to major antibiotics available for the treatment of nosocomial infections. Various mechanisms of resistance to beta-lactams and aminoglycosides have been recognized in these bacteria. Combination therapy is usually recommended for the treatment of nosocomial infections. The increasing pathogenic importance of Acinetobacter spp. and the increasing frequency of hospital outbreaks of acinetobacter infections has made the development of reliable typing methods imperative. Beside conventional "phenotypic" methods (serology, phage typing), genotypic systems (ribotyping, plasmid profiles, pulse-field gel electrophoresis) are currently advancing.

Characterization of the chromosomal aac(6')-Ij gene of Acinetobacter sp. 13 and the aac(6')-Ih plasmid gene of Acinetobacter baumannii

The amikacin resistance genes aac(6')-Ih of Acinetobacter baumannii BM2686 and aac(6')-Ij of Acinetobacter sp. 13 BM2689 encoding aminoglycoside 6'-N-acetyltransferases were characterized. The 441-bp coding sequences predict proteins with calculated masses of 16,698 and 16,677 Da, respectively. Analysis of the deduced amino acid sequences indicated that the proteins belonged to a subfamily of 6'-aminoglycoside acetyltransferase type I enzymes from gram-negative bacteria. The aac(6')-Ih gene of BM2686 was located on a 13.7-kb nonconjugative plasmid. The aac(6')-Ij gene from BM2689 was not transferable either by conjugation to Escherichia coli or A. baumannii or by transformation to Acinetobacter calcoaceticus. Plasmid DNA from BM2689 did not hybridize with an intragenic aac(6')-Ij probe. These results suggest a chromosomal location for this gene. The aac(6')-Ij gene was detected by DNA hybridization in all 28 strains of Acinetobacter sp. 13 tested but not in other Acinetobacter strains, including A. baumannii, proteolytic genospecies 4, 6, 14, 15, 16, and 17, and ungrouped strains. The aac(6')-Ih and -Ij probes did not hybridize in dot blot assays with DNA from members of the families Enterobacteriaceae and Pseudomonadaceae that produced 6'-N-acetyltransferases. These data suggest that the genes are confined to the Acinetobacter genus and that the aac(6')-Ij gene is species specific and may be used to identify Acinetobacter sp. 13.

Characterization of transposon Tn1528, which confers amikacin resistance by synthesis of aminoglycoside 3'-O-phosphotransferase type VI

Providencia stuartii BM2667, which was isolated from an abdominal abscess, was resistant to amikacin by synthesis of aminoglycoside 3'-O-phosphotransferase type VI. The corresponding gene, aph(3')-VIa, was carried by a 30-kb self-transferable plasmid of incompatibility group IncN. The resistance gene was cloned into pUC18, and the recombinant plasmid, pAT246, was transformed into Escherichia coli DH1 (recA) harboring pOX38Gm. The resulting clones were mixed with E. coli HB101 (recA), and transconjugants were used to transfer pAT246 by plasmid conduction to E. coli K802N (rec+). Analysis of plasmid DNAs from the transconjugants of K802N by agarose gel electrophoresis and Southern hybridization indicated the presence of a transposon, designated Tn1528, in various sites of pOX38Gm. This 5.2-kb composite element consisted of aph(3')-VIa flanked by two direct copies of IS15-delta and transposed at a frequency of 4 x 10(-5). It therefore appears that IS15-delta, an insertion sequence widely spread in gram-negative bacteria, is likely responsible for dissemination to members of the family Enterobacteriaceae of aph(3')-VIa, a gene previously confined to Acinetobacter spp.

Molecular epidemiology of two genes encoding 3-N-aminoglycoside acetyltransferases AAC(3)I and AAC(3)II among gram-negative bacteria from a Spanish hospital

The molecular epidemiology of the aacC1 and aacC2 genes, encoding 3-N-aminoglycoside acetyltransferases AAC(3)I and AAC(3)II, respectively, was studied by DNA-DNA hybridization. The sample included 315 gentamicin-resistant Gram-negative bacilli collected over a six-month period from patients attending a Spanish Hospital. The aminoglycoside resistance phenotype of these strains was also determined. The aacC1 probe hybridized with 39 strains, the aacC2 probe with 146 strains and both probes hybridized with 26 strains. The aacC1 gene was most frequently detected in Pseudomonas aeruginosa whereas the aacC2 gene was most frequently detected in enterobacteria and Acinetobacter spp. Strains harbouring aacC genes were isolated from both in- and outpatients with different infectious diseases, mainly urinary tract infections. As inferred from the results of Southern hybridization, both genes showed a wide horizontal dispersion among plasmids and bacteria.

Characterization of Acinetobacter haemolyticus aac(6')-Ig gene encoding an aminoglycoside 6'-N-acetyltransferase which modifies amikacin

The amikacin resistance gene acc(6')-Ig of Acinetobacter haemolyticus BM2685 encoding an aminoglycoside 6'-N-acetyltransferase was characterized. The gene was identified as a coding sequence of 438 bp corresponding to a protein with a calculated mass of 16,522 Da. Analysis of the deduced amino acid sequence suggested that it was the fourth member of a subfamily of aminoglycoside 6'-N-acetyltransferases. The resistance gene was not transferable either by conjugation to Escherichia coli or to Acinetobacter baumannii or by transformation into Acinetobacter calcoaceticus. Plasmid DNA from strain BM2685 did not hybridize with an intragenic aac(6')-Ig probe. These results suggest a chromosomal location for this gene. The gene was detected by DNA hybridization in all 20 strains of A. haemolyticus tested but not in 179 other Acinetobacter strains, including A. baumannii, A. lwoffii, A. junii, and A. johnsonii and genospecies 3, 6, 11, 13, 14, 15, 16, and 17, of which 162 were amikacin resistant. The probe did not hybridize in dot blot assays with DNAs purified from members of the families Enterobacteriaceae and Pseudomonadaceae that encode 6'-N-acetyltransferases. These data suggest that the aac(6')-Ig gene is species specific and may be used to identify A. haemolyticus.

Molecular genetics of aminoglycoside resistance genes and familial relationships of the aminoglycoside-modifying enzymes

The three classes of enzymes which inactivate aminoglycosides and lead to bacterial resistance are reviewed. DNA hybridization studies have shown that different genes can encode aminoglycoside-modifying enzymes with identical resistance profiles. Comparisons of the amino acid sequences of 49 aminoglycoside-modifying enzymes have revealed new insights into the evolution and relatedness of these proteins. A preliminary assessment of the amino acids which may be important in binding aminoglycosides was obtained from these data and from the results of mutational analysis of several of the genes encoding aminoglycoside-modifying enzymes. Recent studies have demonstrated that aminoglycoside resistance can emerge as a result of alterations in the regulation of normally quiescent cellular genes or as a result of acquiring genes which may have originated from aminoglycoside-producing organisms or from other resistant organisms. Dissemination of these genes is aided by a variety of genetic elements including integrons, transposons, and broad-host-range plasmids. As knowledge of the molecular structure of these enzymes increases, progress can be made in our understanding of how resistance to new aminoglycosides emerges.

In vitro antimicrobial production of beta-lactamases, aminoglycoside-modifying enzymes, and chloramphenicol acetyltransferase by and susceptibility of clinical isolates of Acinetobacter baumannii

Antimicrobial susceptibility testing was performed on 54 epidemiologically unrelated clinical isolates of Acinetobacter baumannii by using a standard agar dilution technique. On the basis of the in vitro activities, imipenem and doxycycline were the most active agents, whereas amikacin, isepamicin, and the new fluorquinolones ciprofloxacin and ofloxacin presented moderate activity. Cephalosporinase activity was found in 98% of the strains, whereas lactamases of TEM type 1 and one with a pI of 7 to 7.5 were present in 16 and 11% of the strains, respectively. Resistance to aminoglycosides was explained by the production of the three classes of aminoglycoside-modifying enzymes, with predominance of aminoglycoside-3'-phosphotransferase VI in 28% of the strains.

Characterization of a high-affinity iron transport system in Acinetobacter baumannii

Analysis of a clinical isolate of Acinetobacter baumannii showed that this bacterium was able to grow under iron-limiting conditions, using chemically defined growth media containing different iron chelators such as human transferrin, ethylenediaminedi-(o-hydroxyphenyl)acetic acid, nitrilotriacetic acid, and 2,2'-bipyridyl. This iron uptake-proficient phenotype was due to the synthesis and secretion of a catechol-type siderophore compound. Utilization bioassays using the Salmonella typhimurium iron uptake mutants enb-1 and enb-7 proved that this siderophore is different from enterobactin. This catechol siderophore was partially purified from culture supernatants by adsorption chromatography using an XAD-7 resin. The purified component exhibited a chromatographic behavior and a UV-visible light absorption spectrum different from those of 2,3-dihydroxybenzoic acid and other bacterial catechol siderophores. Furthermore, the siderophore activity of this extracellular catechol was confirmed by its ability to stimulate energy-dependent uptake of 55Fe(III) as well as to promote the growth of A. baumannii bacterial cells under iron-deficient conditions imposed by 60 microM human transferrin. Polyacrylamide gel electrophoresis analysis showed the presence of iron-regulated proteins in both inner and outer membranes of this clinical isolate of A. baumannii. Some of these membrane proteins may be involved in the recognition and internalization of the iron-siderophore complexes.

Epidemiological survey of genes encoding aminoglycoside phosphotransferases APH (3') I and APH (3') II using DNA probes

The epidemiological survey of APH (3') I and APH (3') II genes, at a time when the specific antibiotic pressure was very low, was carried out by DNA-DNA hybridization. The sample included 334 aminoglycoside resistant Gram-negative bacteria collected from patients of a General Hospital. Of these, 251 hybridized with the APH (3') I-probe and 19 with the APH (3') II-probe but only 190 strains showed high resistance levels (CIM greater than 64 micrograms/ml) for kanamycin, neomycin and paromomycin. These strains were isolated both from inpatients and outpatients with different infectious diseases. The APH (3') I-gene was dispersed among all the bacterial species and clinical specimens tested but the APH (3') II-gene was not found in Pseudomonas spp, Escherichia coli, Citrobacter freundii and Enterobacter cloacae, nor in infected catheters. Several plasmids of different sizes carrying APH (3') genes were detected among different bacteria. Plasmids along with transposable elements (the probes used in this work were developed from Tn906 and Tn5) and the high consumption of other antibiotics whose resistance is carried by these bacteria might be playing an important role in the maintenance and dispersion of APH (3') genes.

Molecular cloning and nucleotide sequencing of a novel aminoglycoside 6'-N-acetyltransferase gene from an R-plasmid of Salmonella typhimurium S24 isolated in Taiwan

A conjugative aminoglycoside resistance plasmid pST2 has been isolated from Escherichia coli K-12 14R525, which was mated with a clinical isolate of Salmonella typhimurium S24. A novel resistance gene of aminoglycoside 6'-N-acetyltransferase[AAC(6')] was cloned from plasmid pST2 on a 1,393 kilobase (kb) of SphI-SalI fragment into vector pACYC184 and pUC18. This novel AAC(6') gene in plasmid pST2 acetylated kanamycin, amikacin, dibekacin, tobramycin, gentamicin, netilmicin, and sisomicin. The complete nucleotide sequence of the novel AAC(6') gene and its neighboring sequences were also determined. Minicell experiments detected only one protein of 24.7 kilodaltons (kDa) translated from an open reading frame of the 618 base pairs (bp) gene.

Nosocomial spread of an amikacin resistance gene on both a mobilized, nonconjugative plasmid and a conjugative plasmid

Resistance to amikacin among members of the family Enterobacteriaceae at a hospital in Venezuela rose from 2% in 1979 to 5% in 1984 and 10% in 1985 as amikacin usage rose 20-fold to exceed gentamicin usage. Resistance to gentamicin remained at 25 to 27%. We examined the plasmids from 21 isolates obtained in 1984 and 1985. Nine of eleven in 1984 and three of ten in 1985 carried aacA and sul on a 3.8-kb BamHI fragment of pBWH300, a 10.4-kb nonconjugative plasmid that had been mobilized into strains of six species by at least two different coresident conjugative plasmids. Six 1985 isolates of two species carried these genes on a similar BamHI fragment of the 104-kb conjugative plasmid pBWH303. One isolate in 1984 and one in 1985 carried the 69-kb conjugative plasmid pBWH301, which had aacA as the promoter-proximal gene of an operon that also encompassed the cat and aadB resistance genes. Another conjugative plasmid, pBWH302, was found in a single isolate. It carried a different aacA allele on the functional transposon Tn654, which appeared to be closely related to Tn1331, a transposon previously isolated in Argentina and Chile. Increased selection may thus have led to dissemination of an endemic aacA allele on two endemic plasmids, one spread by mobilization, with occasional intrusion of additional aacA alleles from outside.