Multidrug-resistant Acinetobacter infections: an emerging challenge to clinicians

Bioaerosol Sampling Devices and Pretreatment for Bacterial Characterization: Theoretical Differences and a Field Experience in a Wastewater Treatment Plant

Studies on bioaerosol bacterial biodiversity have relevance in both ecological and health contexts, and molecular methods, such as 16S rRNA gene-based barcoded sequencing, provide efficient tools for the analysis of airborne bacterial communities. Standardized methods for sampling and analysis of bioaerosol DNA are lacking, thus hampering the comparison of results from studies implementing different devices and procedures. Three samplers that use gelatin filtration, swirling aerosol collection, and condensation growth tubes for collecting bioaerosol at an aeration tank of a wastewater treatment plant in Trieste (Italy) were used to determine the bacterial biodiversity. Wastewater samples were collected directly from the untreated sewage to obtain a true representation of the microbiological community present in the plant. Different samplers and collection media provide an indication of the different grades of biodiversity, with condensation growth tubes and DNA/RNA shieldTM capturing the richer bacterial genera. Overall, in terms of relative abundance, the air samples have a lower number of bacterial genera (64 OTUs) than the wastewater ones (75 OTUs). Using the metabarcoding approach to aerosol samples, we provide the first preliminary step toward the understanding of a significant diversity between different air sampling systems, enabling the scientific community to orient research towards the most informative sampling strategy.

Associated Risk Factors and Clinical Outcomes of Bloodstream Infections among COVID-19 Intensive Care Unit Patients in a Tertiary Care Hospital

Introduction

The COVID-19 infection is an ongoing public health crisis causing millions of deaths worldwide. COVID-19 patients admitted to the intensive care unit (ICU) are more vulnerable to acquire secondary bloodstream infections (sBSIs) which cause a significant morbidity and mortality. Thus, we aim to assess the risk factors of sBSIs and outcomes in COVID-19 ICU patients.

Methods

One hundred blood culture samples with growth (cases) and other 100 blood culture with no growth(controls) were collected.. All the demographic data, laboratory data and antimicrobial resistance pattern were analysed . Blood culture bottle received in the Microbiology laboratory were loaded into Automated blood culture system. Flagged bottles were processed for final identification by MALDI TOF and automated antibiotic susceptibility testing. Flagged bottles were processed for final identification by MALDI TOF and automated antibiotic susceptibility testing.

Results

Raised C-reactive protein (CRP) (P = 0.0035), interleukin-6 (P = 0.0404), mechanical ventilation (MV) (P = 0.024), prior antimicrobial exposure (P = 0.002), longer ICU stay with median 11 days (P = 0.022), and higher mortality rate (P = 0.001) were significantly associated with the BSI. A significant proportion of BSIs were Gram-negative bacteria (n = 115) such as Acinetobacter baumannii 38 (33%) and Klebsiella pneumoniae 30 (26%). Monomicrobial organisms in blood yielded a higher proportion in our study 72 (72%). The highest resistance for Acinetobacter species (50) was observed with ceftazidime 29 (96.6%) amikacin 48 (96%), meropenem 48 (96%), cefotaxime 47 (94%), ciprofloxacin 46 (92%), and netilmicin 46 (92%). K. pneumoniae was highly resistant to cefotaxime 29 (96.6%), ceftazidime 29 (96.6%), ciprofloxacin 22 (73.3%), and cefuroxime 21 (70%). Among Gram-positive organisms, Enterococcus species showed that a resistance for high-level gentamicin and penicillin was 66.6%.

Conclusions

Raised CRP, need of MV, prior antimicrobial exposure, and longer ICU stay should alarm clinicians for BSI. Hence, our study highlights the associated risk factors for BSI and emphasizes adherence to hospital infection control policies and antibiotic stewardship program.

Resistance mechanisms for Gram-negative bacteria-specific lipopeptides, turnercyclamycins, differ from that of colistin

IMPORTANCE

Bacterial resistance to antibiotics is a crisis. Acinetobacter baumannii is among the CDC urgent threat pathogens in part for this reason. Lipopeptides known as turnercyclamycins are produced by symbiotic bacteria that normally live in marine mollusks, where they may be involved in shaping their symbiotic niche. Turnercyclamycins killed Gram-negative pathogens including drug-resistant Acinetobacter, but how do the mechanisms of resistance compare to other lipopeptide drugs? Here, we define resistance from a truncation of MlaA, a protein involved in regulating bacterial membrane phospholipids. Intriguingly, this resistance mechanism only affected one turnercyclamycin variant, which differed only in two atoms in the lipid tail of the compounds. We could not obtain significant resistance to the second turnercyclamycin variant, which was also effective in an infection model. This study reveals an unexpected subtlety in resistance to lipopeptide antibiotics, which may be useful in the design and development of antibiotics to combat drug resistance.

Antibiotic Resistance and Genetic Variability of Acinetobacter spp. from Wastewater Treatment Plant in Kokšov-Bakša (Košice, Slovakia)

This study investigated the genetic variability and antibiotic resistance of Acinetobacter community depending on the stage of wastewater treatment in Kokšov-Bakša for the city of Košice (Slovakia). After cultivation, bacterial isolates were identified by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS), and their sensitivity to ampicillin, kanamycin, tetracycline, chloramphenicol and ciprofloxacin was examined. Acinetobacter spp. and Aeromonas spp. dominated bacterial populations in all wastewater samples. We identified 12 different groups based on protein profiling, 14 genotypes by amplified ribosomal DNA restriction analysis and 11 Acinetobacter species using 16S rDNA sequence analysis within Acinetobacter community, which showed significant variability in their spatial distribution. While Acinetobacter population structure changed during the wastewater treatment, the prevalence of antibiotic-resistant strains did not significantly vary depending on the stage of wastewater treatment. The study highlights the role of a highly genetically diverse Acinetobacter community surviving in wastewater treatment plants as an important environmental reservoir assisting in the further dissemination of antibiotic resistance in aquatic systems.

Characterization of Acinetobacter baumannii Isolated from Raw Milk

Acinetobacter baumannii (A. baumannii) is an opportunistic pathogen associated with nosocomial infections. In this study, 100 raw milk samples were collected from Qena, Egypt, and subjected to conventional and molecular assays to determine the presence of A. baumannii and investigate their antimicrobial resistance and biofilm formation. Our findings revealed that, among the 100 samples, Acinetobacter spp. were found in 13 samples based on CHROM agar results. We further characterized them using rpoB and 16S-23SrRNA sequencing and gyrB multiplex PCR analysis and confirmed that 9 out of the 13 Acinetobacter spp. isolates were A. baumannii and 4 were other species. The A. baumannii isolates were resistant to β-lactam drugs, including cefotaxime (44%), ampicillin-sulbactam and levofloxacin (33.3% for each), imipenem, meropenem and aztreonam (22.2% for each). We observed different antimicrobial resistance patterns, with a multi-antibiotic resistant (MAR) index ranging from 0.2 to 0.3. According to the PCR results, bla_OXA-51 and bla_OXA-23 genes were amplified in 100% and 55.5% of the A. baumannii isolates, respectively, while the bla_OXA-58 gene was not amplified. Furthermore, the metallo-β-lactamases (MBL) genes bla_IMP and bla_NDM were found in 11.1% and 22.2% of isolates, respectively, while bla_VIM was not amplified. Additionally, eight A. baumannii isolates (88.8%) produced black-colored colonies on Congo red agar, demonstrating their biofilm production capacity. These results showed that, besides other foodborne pathogens, raw milk should also be examined for A. baumannii, which could be a public health concern.

Hospital Urinary Tract Infections in Healthcare Units on the Example of Mazovian Specialist Hospital Ltd

Microbiological diagnostics is of great importance in limiting the spread of nosocomial infections. The information on etiological agents of infections and their susceptibility to antibiotics enables a quick response in the case of a suspected epidemic outbreak. The aim of this study is to analyze the incidence of nosocomial urinary tract infections among patients hospitalized in hospital wards over a period of 2 years and to determine the predominant etiological agent depending on the method of clinical specimen collection. Data from the Mazovian Specialist Hospital (MSH) in Radom constitute the material for the preparation of this study. Urine was collected using two methods. The first one was the method of collecting urine from the central stream, while the second method was urine collected from patients with a urinary catheter in place. The statistical calculations were conducted using the statistical software. Based on hospital data, it was shown that 5,870 urine tests were performed during the period under review, of which 2,070 were positive. The number of positive results in 2021 decreased by 2.84% compared to that in 2020. On the basis of the statistical analysis, differences in the occurrence of multiple strains were observed between catheter-based and midstream urine collection. Differences were observed especially for Acinetobacter baumannii, Candida albicans, Escherichia coli, and Pseudomonas aeruginosa. A. baumannii, C. albicans, and P. aeruginosa were significantly more frequently found in urine samples collected through the catheter than from the midstream. Furthermore, E. coli (51.56%) and Enterococcus species (25.46%) were more frequent when collected from the middle stream than when urine was collected through a catheter. However, for the strain K. pneumoniae, the results were comparable when urine was collected from catheterized patients (13.83%) and from midstream (13.35%). Urinary tract infection among hospitalized patients of the Mazovian Specialist Hospital in Radom was diagnosed quite frequently. In 2021, 32 more urine cultures were performed than in 2020. In the analyzed period, among all ordered urine cultures, 35.27% of samples were positive.

Dynamic Gene Clusters Mediating Carbapenem-Resistant Acinetobacter baumannii Clinical Isolates

Acinetobacter baumanni (A. baumannii), a nonfermenting Gram-negative bacterium, has recently been associated with a broad range of nosocomial infections. To gain more meaningful insight into the problem of nosocomial illnesses caused by the multidrug-resistant (MDR) A. baumannii, as well as the factors that increase the risk of catching these infections, this investigation included a total of 86 clinical A. baumannii infections. Repetitive extragenic palindromic (REP)-PCR was used to investigate imipenem-resistant A. baumannii isolates for dynamic gene clusters causing carbapenem resistance. Four distinct A. baumannii lineages were found in the REP-PCR-DNA fingerprints of all isolates, with 95% of the samples coming from two dominant lineages. Imipenem, amikacin, and ciprofloxacin were less effective against genotype (A) isolates because of enhanced antibiotic tolerance. Lastly, to gain more insight into the mode of action of imipenem, we explored the binding affinity of imipenem toward different Acinetobacter baumannii OXA beta-lactamase class enzymes.

Anti-biofilm and anti-virulence effects of zerumbone against Acinetobacter baumannii

Acinetobacter baumannii is a multidrug-resistant opportunistic pathogen that affects patients with a compromised immune system and is becoming increasingly important as a hospital-derived infection. This pathogen is difficult to treat owing to its intrinsic multidrug resistance and ability to form antimicrobial-tolerant biofilms. In the present study, we aimed to assess the potential use of zerumbone as a novel anti-biofilm and/or anti-virulence agent against A. baumannii. The results showed that zerumbone at sub-inhibitory doses decreased biofilm formation and disrupted established A. baumannii biofilms. The zerumbone-induced decrease in biofilm formation was dose-dependent based on the results of microtitre plate biofilm assays and confocal laser scanning microscopy. In addition, our data validated the anti-virulence efficacy of zerumbone, wherein it significantly interfered with the motility of A. baumannii. To support these phenotypic results, transcriptional analysis revealed that zerumbone downregulated the expression of biofilm- and virulence-associated genes (adeA, adeB, adeC and bap) in A. baumannii. Overall, our findings suggested that zerumbone might be a promising bioactive agent for the treatment of biofilm- and virulence-related infections caused by multidrug-resistant A. baumannii.

A plethora of carbapenem resistance in Acinetobacter baumannii: no end to a long insidious genetic journey

Acinetobacter baumannii, notorious for causing nosocomial infections especially in patients admitted to intensive care unit (ICU) and burn units, is best at displaying resistance to all existing antibiotic classes. Consequences of high potential for antibiotic resistance has resulted in extensive drug or even pan drug resistant A. baumannii. Carbapenems, mainly imipenem and meropenem, the last resort for the treatment of A. baumannii infections have fallen short due to the emergence of carbapenem resistant A. baumannii (CRAB). Though enzymatic degradation by production of class D β-lactamases (Oxacillinases) and class B β-lactamases (Metallo β-lactamases) is the core mechanism of carbapenem resistance in A. baumannii; however over-expression of efflux pumps such as resistance-nodulation cell division (RND) family and variant form of porin proteins such as CarO have been implicated for CRAB inception. Transduction and outer membrane vesicles-mediated transfer play a role in carbapenemase determinants spread. Colistin, considered as the most promising antibacterial agent, nevertheless faces adverse effects flaws. Cefiderocol, eravacycline, new β-lactam antibiotics, non-β-lactam-β-lactamase inhibitors, polymyxin B-derived molecules and bacteriophages are some other new treatment options streamlined.

Treatment outcomes of Acinetobacter baumannii -associated pneumonia and/or bacteraemia at the intensive care unit of Universitas Academic Hospital, Bloemfontein, South Africa

Background

Nosocomial infection with multidrug-resistant (MDR) Acinetobacterbaumannii is associated with high mortality rates and the optimal treatment regimen is uncertain.

Objectives

To compare outcomes, as well as ICU and in-hospital survival rates of patients with A. baumannii pneumonia and/or bacteraemia who were treated with colistin monotherapy v. colistin/tigecycline combination therapy

Methods

This was a retrospective cross-sectional study of patients admitted to the multidisciplinary ICU of Universitas Academic Hospital, Bloemfontein, South Africa, between 1 January 2018 and 31 December 2019.

Results

Sixteen patients were included in the study. Nine patients were treated with a combination of colistin and tigecycline, while 7 patients were treated with colistin only. Seven out of 9 (77.8%) patients in the colistin/tigecycline combination therapy group were treated successfully and survived until discharge from ICU, as opposed to 2 out of 7 (28.6%) in the colistin monotherapy group (relative risk (RR) 2.7; 95% CI 0.80 - 9.24). Five out of 9 (55.6%) in the colistin/tigecycline combination therapy group v. 2 out of 7 (28.6%) in the colistin monotherapy group survived until discharge from hospital (RR 1.94; 95% CI 0.53 - 7.20).

Conclusion

Although ICU survival in patients with A. baumannii infection was better when treated with colistin/tigecycline combination therapy compared with colistin monotherapy, a statistically significant difference could not be detected. Adequately powered prospective clinical trials are required to detect statistically significant differences in treatment outcomes.

Antibiotic Resistance Mechanisms and Their Transmission in Acinetobacter baumannii

The discovery of penicillin over 90 years ago and its subsequent uptake by healthcare systems around the world revolutionised global health. It marked the beginning of a golden age in antibiotic discovery with new antibiotics readily discovered from natural sources and refined into therapies that saved millions of lives. Towards the end of the last century, the rate of discovery slowed to a near standstill. The lack of discovery is compounded by the rapid emergence and spread of bacterial pathogens that exhibit resistance to multiple antibiotic therapies and threaten the sustainability of global healthcare systems. Acinetobacter baumannii is an opportunistic pathogen whose prevalence and impact has grown significantly over the last 20 years. It is recognised as a barometer of the antibiotic resistance crisis due to the diverse array of mechanisms by which it can become resistant.

Acinetobacter spp. in food and drinking water - A review

Acinetobacter spp. has emerged as a pathogen of major public health concern due to their increased resistance to antibiotics and their association with a wide range of nosocomial infections, community-acquired infections and war and natural disaster-related infections. It is recognized as a ubiquitous organism however, information about the prevalence of different pathogenic species of this genus in food sources and drinking water is scarce. Since the implementation of molecular techniques, the role of foods as a source of several species, including the Acinetobacter baumannii group, has been elucidated. Multidrug resistance was also detected among Acinetobacter spp. isolated from food products. This highlights the importance of foods as potential sources of dissemination of Acinetobacter spp. between the community and clinical environments and reinforces the need for further investigations on the potential health risks of Acinetobacter spp. as foodborne pathogens. The aim of this review was to summarize the published data on the occurrence of Acinetobacter spp. in different food sources and drinking water. This information should be taken into consideration by those responsible for infection control in hospitals and other healthcare facilities.

ASPIRATION BRONCHOPNEUMONIA BY ACINETOBACTER BAUMANNII IN A WILDLIFE EUROPEAN HARE (LEPUS EUROPAEUS) IN BRAZIL

Acinetobacter baumannii is a major cause of illness in hospitalized patients and the most important and common pathogen in nosocomial outbreaks worldwide. In animals, A. baumannii has been associated with respiratory infections in a group of minks, leading to pneumonia and acute mortality. This report documents a case of aspiration bronchopneumonia in a wild European hare caused by A. baumannii. A free-ranging, adult male European hare was submitted to necropsy after acute trauma due to being hit by a car. Its lungs showed consolidation with abscess in the middle and cranial lobes. Histopathologic evaluation revealed liquefactive necrosis associated with neutrophilic infiltration, cellular debris, plant material, and bacterial myriads surrounded by moderate neutrophils, macrophages, multinucleated giant cells, lymphocytes, and plasma cell inflammation. Acinetobacter baumannii was isolated from lung tissue.

Postoperative multidrug-resistant Acinetobacter baumannii meningitis successfully treated with intravenous doxycycline and intraventricular gentamicin: A case report

BACKGROUND

Multidrug-resistant Acinetobacter baumannii (MDRAB) has emerged as an increasingly important pathogen that causes nosocomial meningitis. However, MDRAB-associated nosocomial meningitis is rarely reported in children.

CASE SUMMARY

We report the case of a 1-year-old girl with a choroid plexus papilloma, who developed postoperative nosocomial meningitis due to MDRAB. The bacterial strain was sensitive only to tigecycline and colistin, and showed varying degrees of resistance to penicillin, amikacin, ceftriaxone, cefixime, cefotaxime, ciprofloxacin, levofloxacin, gentamicin, meropenem, imipenem, and tobramycin. She was cured with intravenous doxycycline and intraventricular gentamicin treatment.

CONCLUSION

Doxycycline and gentamicin were shown to be effective and safe in the treatment of a pediatric case of MDRAB meningitis.

Survival of carbapenem-resistant Acinetobacter baumannii bacteremia: colistin monotherapy versus colistin plus meropenem

Objective

The aim of this study was to compare clinical outcomes between patients with carbapenem-resistant Acinetobacter baumannii (CRAB) bacteremia treated with colistin monotherapy and those treated with colistin plus meropenem.

Methods

We retrospectively evaluated data from 71 patients with CRAB bacteremia treated from November 2006 to February 2018. Predictors of 14-day mortality were determined through logistic regression analysis.

Results

Our study cohort included 40 bacteremia patients (44.6 %) treated with colistin monotherapy and 31 (55.4 %) treated with colistin plus meropenem. Overall 14-day mortality tended to be higher with monotherapy rather than combination therapy (47.5% vs 25.8%). The latter also showed a tendency for higher clinical success rate compared with monotherapy (61.3% vs 40.0%). Logistic regression analysis showed that Pitt bacteremia score, pneumonia, and combination therapy were significantly associated with mortality. In patients with higher Pitt bacteremia score (≥4), mortality was significantly higher with monotherapy compared with combination therapy (66.7% vs 27.8%). In patients with lower Pitt bacteremia score (≤3), mortality was similar between the two treatment groups (26.3% vs 23.1%).

Conclusion

Treatment with colistin plus meropenem improves survival in critically-ill patients with CRAB.

Antimicrobial susceptibility pattern of Acinetobacter isolates from patients in Kenyatta National Hospital, Nairobi, Kenya

Introduction

Infection due to multidrug-resistant microorganisms is a growing threat in healthcare settings. Acinetobacter species specifically A. baumannii is increasingly becoming resistant to most antimicrobial agents recommended for treatment. This study aimed to determine the antimicrobial susceptibility pattern of Acinetobacter species isolated from patients in Kenyatta National Hospital.

Methods

We conducted a retrospective study based on VITEK 2 (BioMérieux) electronic records capturing identification and antimicrobial susceptibility of Acinetobacter isolates from patient samples analyzed between 2013 and 2015 at Kenyatta National Hospital microbiology laboratory. Generated data were analyzed using WHONET and SPSS.

Results

A total of 590 Acinetobacter isolates were analyzed. 85% of the isolates tested were multi-drug resistant (MDR). Among the 590 isolates, 273 (46%) were from tracheal aspirates and 285 (48%) from the critical care unit. A. baumannii was the most frequently isolated species with high susceptibility to amikacin (77%) and poor susceptibility to ciprofloxacin (69-76%), tobramycin (37%) and meropenem (27%). Both A. lwoffii and A. haemolyticus had high susceptibility to amikacin (80-100%) and meropenem (75-100%).

Conclusion

A. baumannii is resistant to commonly administered antibiotics. There is need for continuous antimicrobial resistance surveillance especially in health care facilities and strengthening of antibiotic stewardship programmes which will contribute to enhancement of infection control policies.

Acinetobacter spp. as nosocomial pathogens: Epidemiology and resistance features

The genus Acinetobacter is a major cause of nosocomial infections; it is increasingly being associated with various epidemics and has become a widespread concern in a variety of hospitals worldwide. Multi-antibiotic resistant Acinetobacter baumannii, is now recognized to be of great clinical significance. Numerous reports relay to the spread of A. baumannii in the hospital settings which leads to enhanced nosocomial outbreaks associated with high death rates. However, many other Acinetobacter spp. also can cause nosocomial infections. This review focused on the role of Acinetobacter spp. as nosocomial pathogens in addition to their persistence, antimicrobial resistance patterns and epidemiology.

The Use of Colistin in Multidrug-Resistant Infections

This feature examines the recent rise of colistin use in multidrug-resistant infections and puts it in perspective of its historical use in terms of its safety and tolerability profile. In addition, limitations of using colistin as a first-line agent due to risk of colistin resistance and cases of pandrug resistance are discussed.

Lettuce and fruits as a source of multidrug resistant Acinetobacter spp

The role of ready-to-eat products as a reservoir of pathogenic species of Acinetobacter remains unclear. The objective of the present study was to evaluate the presence of Acinetobacter species in lettuces and fruits marketed in Portugal, and their susceptibility to antimicrobials. Acinetobacter spp. were isolated from 77.9% of the samples and these microorganisms were also found as endophytes (i.e. present within the plant tissue) in 12 of 20 samples of lettuces analysed. Among 253 isolates that were identified as belonging to this genus, 181 presented different PFGE profiles, representing different strains. Based on the analysis of the partial sequence of rpoB, 175 strains were identified as members of eighteen distinct species and the remaining six strains may represent five new candidate species since their rpoB sequence similarities with type strains were less than 95%. Acinetobacter calcoaceticus and Acinetobacter johnsonii were the most common species, both with the frequency of 26.5%; and 11% of the strains belong to the Acinetobacter baumannii group (i.e. A. baumannii, Acinetobacter pittii, Acinetobacter seifertii and Acinetobacter nosocomialis), which is most frequently associated with nosocomial infections. Overall, the strains were least susceptible to piperacillin (80.1%), piperacillin-tazobactam (64.1%), ceftazidime (43.1%), ciprofloxacin (16.6%), trimethoprim-sulfamethoxazole (14.9%), imipenem (14.4%) and colistin (13.3%). The most active antimicrobials were minocycline and tetracycline, with 0.6% and 3.9% of strains resistant, respectively. About 29.8% of the strains were classified as multidrug-resistant (MDR), 4.4% as extensively drug-resistant (XDR) and the prevalence of MDR strains within the A. baumannii group (25%) was similar to other species (30.4%). The presence of clinically important species as well as MDR strains in lettuces and fruits may be a threat to public health considering that they may transmit these pathogens to environments such as the community and hospital settings.

Distribution and expression of the Ade multidrug efflux systems in Acinetobacter baumannii clinical isolates

One hundred Acinetobacter baumannii clinical isolates were examined for inhibitory effect of reserpine and carbonyl cyanide m-chlorophenylhydrazone (CCCP) on the antimicrobial susceptibility and expression of 4 resistant-nodulation-cell division (RND)-type multidrug efflux systems, including AdeABC, AdeDE, AdeIJK, and AdeFGH, using RT-PCR. Ten A. baumannii isolates expressing AdeABC, AdeIJK, or AdeFGH were randomly selected for determination of transcription level and regulatory mutations. While all the isolates were resistant to multiple drugs, the reserpine and CCCP experiment showed that the multidrug resistance phenotype in most A. baumannii isolates was associated with efflux pumps. Most isolates expressed at least one of the RND-type efflux pumps tested (97%). AdeIJK expression was most common (97%), but none of the isolates produced AdeDE. Fifty-two percent of the A. baumannii isolates simultaneously produced up to 3 RND-type efflux systems (i.e., AdeABC, AdeFGH, and AdeIJK). No good correlation between the expression of RND-type efflux pumps and the type of antimicrobial resistance was observed. Overexpression of AdeABC, AdeIJK, and AdeFGH was not always related to the presence of mutations in their corresponding regulatory genes. This study highlights (i) the universal presence of the RND-type efflux pumps with variable levels of expression level among the A. baumannii in this collection and (ii) the complexity of their regulation of expression.

Genetic Mechanisms of Antimicrobial Resistance of Acinetobacter baumannii

OBJECTIVE

To summarize published data identifying known genetic mechanisms of antibiotic resistance in Acinetobacter baumannii and the correlating phenotypic expression of antibiotic resistance.

DATA SOURCES

MEDLINE databases (1966-July 15, 2010) were searched to identify original reports of genetic mechanisms of antibiotic resistance in A. baumannii.

DATA SYNTHESIS

Numerous genetic mechanisms of resistance to multiple classes of antibiotics are known to exist in A. baumannii, a gram-negative bacterium increasingly implicated in nosocomial infections. Mechanisms may be constitutive or acquired via plasmids, integrons, and transposons. Methods of resistance include enzymatic modification of antibiotic molecules, modification of antibiotic target sites, expression of efflux pumps, and downregulation of cell membrane porin channel expression. Resistance to β-lactams appears to be primarily caused by β-lactamase production, including extended spectrum β-lactamases (b/aTEM, blaSHV, b/aTX-M,b/aKPC), metallo-β-lactamases (blaMP, blaVIM, bla, SIM), and most commonly, oxacillinases (blaOXA). Antibiotic target site alterations confer resistance to fluoroquinolones (gyrA, parC) and aminoglycosides (arm, rmt), and to a much lesser extent, β-lactams. Efflux pumps (tet, ade, abe) contribute to resistance against β-lactams, tetracyclines, fluoroquinolones, and aminoglycosides. Finally, porin channel deletion (carO, oprD) appears to contribute to β-lactam resistance and may contribute to rarely seen polymyxin resistance. Of note, efflux pumps and porin deletions as solitary mechanisms may not render clinical resistance to A. baumannii.

CONCLUSIONS

A. baumannii possesses copious genetic resistance mechanisms. Knowledge of local genotypes and expressed phenotypes for A. baumannii may aid clinicians more than phenotypic susceptibilities reported in large epidemiologic studies.

Biofilm Formation Caused by Clinical Acinetobacter baumannii Isolates Is Associated with Overexpression of the AdeFGH Efflux Pump

Chronic wound infections are associated with biofilm formation, which in turn has been correlated with drug resistance. However, the mechanism by which bacteria form biofilms in clinical environments is not clearly understood. This study was designed to investigate the biofilm formation potency of Acinetobacter baumannii and the potential association of biofilm formation with genes encoding efflux pumps, quorum-sensing regulators, and outer membrane proteins. A total of 48 clinically isolated A. baumannii strains, identified by enterobacterial repetitive intergenic consensus (ERIC)-PCR as types A-II, A-III, and A-IV, were analyzed. Three representative strains, which were designated A. baumannii ABR2, ABR11, and ABS17, were used to evaluate antimicrobial susceptibility, biofilm inducibility, and gene transcription (abaI, adeB, adeG, adeJ, carO, and ompA). A significant increase in the MICs of different classes of antibiotics was observed in the biofilm cells. The formation of a biofilm was significantly induced in all the representative strains exposed to levofloxacin. The levels of gene transcription varied between bacterial genotypes, antibiotics, and antibiotic concentrations. The upregulation of adeG correlated with biofilm induction. The consistent upregulation of adeG and abaI was detected in A-III-type A. baumannii in response to levofloxacin and meropenem (1/8 to 1/2× the MIC), conditions which resulted in the greatest extent of biofilm induction. This study demonstrates a potential role of the AdeFGH efflux pump in the synthesis and transport of autoinducer molecules during biofilm formation, suggesting a link between low-dose antimicrobial therapy and a high risk of biofilm infections caused by A. baumannii. This study provides useful information for the development of antibiofilm strategies.

Infections Caused by Acinetobacter baumannii in Recipients of Hematopoietic Stem Cell Transplantation

Acinetobacter baumannii (A. baumannii) is a Gram-negative, strictly aerobic, non-fermentative coccobacillus, which is widely distributed in nature. Recently, it has emerged as a major cause of health care-associated infections (HCAIs) in addition to its capacity to cause community-acquired infections. Risk factors for A. baumannii infections and bacteremia in recipients of hematopoietic stem cell transplantation include: severe underlying illness such as hematological malignancy, prolonged use of broad-spectrum antibiotics, invasive instrumentation such as central venous catheters or endotracheal intubation, colonization of respiratory, gastrointestinal, or urinary tracts in addition to severe immunosuppression caused by using corticosteroids for treating graft versus host disease. The organism causes a wide spectrum of clinical manifestations, but serious complications such as bacteremia, septic shock, ventilator-associated pneumonia, extensive soft tissue necrosis, and rapidly progressive systemic infections that ultimately lead to multi-organ failure and death are prone to occur in severely immunocompromised hosts. The organism is usually resistant to many antimicrobials including penicillins, cephalosporins, trimethoprim-sulfamethoxazole, almost all fluoroquinolones, and most of the aminoglycosides. The recently increasing resistance to carbapenems, colistin, and polymyxins is alarming. Additionally, there are geographic variations in the resistance patterns and several globally and regionally resistant strains have already been described. Successful management of A. baumannii infections depends upon appropriate utilization of antibiotics and strict application of preventive and infection control measures. In uncomplicated infections, the use of a single active beta-lactam may be justified, while definitive treatment of complicated infections in critically ill individuals may require drug combinations such as colistin and rifampicin or colistin and carbapenem. Mortality rates in patients having bacteremia or septic shock may reach 70%. Good prognosis is associated with presence of local infection, absence of multidrug resistant strain, and presence of uncomplicated infection while poor outcome is associated with severe underlying medical illness, bacteremia, septic shock, multi-organ failure, HCAIs, admission to intensive care facilities for higher levels of care, and culture of certain aggressive genotypes of A. baumannii.

Efficacy and safety of polymyxins for the treatment of Acinectobacter baumannii infection: a systematic review and meta-analysis

BACKGROUND

Multi-drug resistance among Acinetobacter baumannii increases the need for polymyxins. We conducted a meta-analysis aimed to assess the efficacy and safety of polymyxins for the treatment of Acinetobacter baumannii infection.

METHODS

We searched PUBMED, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), CNKI, Chinese Biomedical Literature Database up to November 1, 2013, to identify published studies, and we searched clinical trial registries to identify completed unpublished studies. Randomized controlled trials and cohort studies were considered for inclusion. Data were extracted on clinical response, microbiological response, mortality, length of stay and adverse events.

RESULTS

12 controlled studies, comparing 677 patients, were included. Although clinical (odds ratio 1.421, 95% confidence interval 0.722-2.797) and microbiological (OR 1.416, 95% CI 0.369-5.425) response rates favored the polymyxins group, these differences were not significant. Treatment with polymyxins vs. controls did not affect hospital mortality (OR 0.506, 95% CI 0.101-2.536), lengths of hospital stay (standard mean difference -0.221, 95% CI 0.899-0.458) or nephrotoxicity (OR 1.192, 95% CI 0.436-3.261). The combination of polymyxins with other antibiotics achieved similar clinical response rates to its monotherapy regimen (OR 0.601, 95% CI 0.320-1.130).

CONCLUSIONS

Our results suggest that polymyxins may be as safe and as efficacious as standard antibiotics for the treatment of A. baumannii infection. There is no strong evidence that combination regimen of polymyxins is superior to monotherapy regimen.

Identification of novel regulatory small RNAs in Acinetobacter baumannii

Small RNA (sRNA) molecules are non-coding RNAs that have been implicated in regulation of various cellular processes in living systems, allowing them to adapt to changing environmental conditions. Till date, sRNAs have not been reported in Acinetobacter baumannii (A. baumannii), which has emerged as a significant multiple drug resistant nosocomial pathogen. In the present study, a combination of bioinformatic and experimental approach was used for identification of novel sRNAs. A total of 31 putative sRNAs were predicted by a combination of two algorithms, sRNAPredict and QRNA. Initially 10 sRNAs were chosen on the basis of lower E- value and three sRNAs (designated as AbsR11, 25 and 28) showed positive signal on Northern blot. These sRNAs are novel in nature as they do not have homologous sequences in other bacterial species. Expression of the three sRNAs was examined in various phases of bacterial growth. Further, the effect of various stress conditions on sRNA gene expression was determined. A detailed investigation revealed differential expression profile of AbsR25 in presence of varying amounts of ethidium bromide (EtBr), suggesting that its expression is influenced by environmental or internal signals such as stress response. A decrease in expression of AbsR25 and concomitant increase in the expression of bioinformatically predicted targets in presence of high EtBr was reverberated by the decrease in target gene expression when AbsR25 was overexpressed. This hints at the negative regulation of target genes by AbsR25. Interestingly, the putative targets include transporter genes and the degree of variation in expression of one of them (A1S_1331) suggests that AbsR25 is involved in regulation of a transporter. This study provides a perspective for future studies of sRNAs and their possible involvement in regulation of antibiotic resistance in bacteria specifically in cryptic A. baumannii.

In vitro activity of rifampicin alone and in combination with imipenem against multidrug-resistant Acinetobacter baumannii harboring the blaOXA-72 resistance gene

BACKGROUND

The growing incidence of multidrug resistance (MDR) in bacteria is an emerging challenge in the treatment of infections. Acinetobacter baumannii is an opportunistic pathogen prone to exhibit MDR that contributes significantly to nosocomial infections, particularly in severely ill patients. Thus, we performed research on rifampicin activity against selected MDR OXA-72 carbapenemase-producing A. baumannii strains. Since it is widely accepted that rifampicin should not be used as monotherapy in order to avoid the rapid development of rifampicin resistance, we evaluated the efficacy of combination therapy with imipenem.

METHODS

Minimal inhibitory concentrations (MICs) of both rifampicin and imipenem were determined by use of the broth microdilution method. Evaluations of the interactions between rifampicin and imipenem were performed by analysis of the fractional inhibitory concentration index (∑FIC), determined using the checkerboard titration method.

RESULTS

All tested isolates showed full susceptibility to rifampicin. The checkerboard method revealed synergism in 5 isolates (29%) and an additive effect in another 5 isolates (29%); no difference was reported in the remaining 7 isolates (41%). Strains moderately resistant to imipenem (MIC ≤ 64 mg/l) tended to show synergy or additive interaction.

CONCLUSIONS

We conclude that in vitro synergism or an additive interaction between rifampicin and imipenem most likely occurs in A. baumannii strains showing moderate resistance to imipenem (MIC ≤ 64 mg/l). Moreover, utilizing this combination in the therapy of infections caused by strains exhibiting higher levels of resistance (MIC > 64 mg/l) is not recommended since in this setting imipenem could not prevent the development of rifampicin resistance.

Antibiotic resistance and expression of resistance-nodulation-division pump- and outer membrane porin-encoding genes in Acinetobacter species isolated from Canadian hospitals

BACKGROUND

Bacterial pathogens belonging to the genus Acinetobacter cause serious infections in immunocompromised individuals that are very difficult to treat due to their extremely high resistance to many antibiotics.

OBJECTIVE

To investigate the role of resistance-nodulation-division (RND) pumps and porins in the antibiotic resistance of Acinetobacter species collected from Canadian hospitals.

METHODS

Clinical isolates of Acinetobacter species collected from Canadian hospitals were analyzed for the expression of genes encoding RND pumps (adeB, adeG, adeJ, AciBau_2746 and AciBau_2436) and outer membrane porins (carO, 33 kDa porin and oprD) using quantitative reverse transcription (qRT) polymerase chain reaction. Species identification of the isolates was performed using a multiplex polymerase chain reaction method for gyrB.

RESULTS

The expression of RND pump-encoding genes was widespread in the clinical isolates of Acinetobacter species, with each of the isolates expressing at least one RND pump. adeG was found to be overexpressed in all of the isolates, while adeB was found to be overexpressed in only two isolates. Among the porin-encoding genes, the expression of carO was considerably downregulated among the majority of isolates.

CONCLUSION

The present study was the first to analyze the expression of RND pump- and porin-encoding genes in the clinical isolates of Acinetobacter species from Canadian hospitals. The overexpression of genes encoding RND pumps and the downregulation of genes encoding porins was common in clinical isolates of Acinetobacter species from Canadian hospitals, with the AdeFGH pump being the most commonly expressed RND pump.

Treatment options for multidrug-resistant bacteria

As a consequence of antibiotic overuse and misuse, nosocomial infections caused by multidrug-resistant bacteria represent a physician's nightmare throughout the world. No newer antimicrobials active against Pseudomonas aeruginosa, the main multidrug-resistant nosocomial pathogen, are available or under investigation. The only exceptions are linezolid, some newer glycopeptides (dalbavancin, oritavancin and telavancin) and daptomycin (a lipopeptide), which are active against methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) strains, as well as tigecycline, a potent in vitro glycylcycline against MRSA, VRE, Acinetobacter baumannii and entended-spectrum beta-lactamase (ESBL)+ Enterobacteriaceae. Colistin, an antibiotic of the 1950s has been rediscovered by intensive care unit physicians for use against ESBL+ Enterobacteriaceae, as well as against multidrug-resistant P. aeruginosa and A. baumannii isolates. Although success rates with colistin range between 50 and 73%, almost all studies are retrospective. Immunostimulation efforts against S. aureus are still under development. As antibiotic research and development stagnate, rational policies for prescribing existing antibiotics plus strict infection control are the current mainstay efforts for preventing and combating multidrug-resistant bacterial infections.

Successful management of nosocomial ventriculitis and meningitis caused by extensively drug-resistant Acinetobacter baumannii in Austria

Nosocomial infections caused by the Gram-negative coccobacillus Acinetobacter baumannii have substantially increased over recent years. Because Acinetobacter is a genus with a tendency to quickly develop resistance to multiple antimicrobial agents, therapy is often complicated, requiring the return to previously used drugs. The authors report a case of meningitis due to extensively drug-resistant A baumannii in an Austrian patient who had undergone neurosurgery in northern Italy. The case illustrates the limits of therapeutic options in central nervous system infections caused by extensively drug-resistant pathogens.

The human milk protein-lipid complex HAMLET sensitizes bacterial pathogens to traditional antimicrobial agents

The fight against antibiotic resistance is one of the most significant challenges to public health of our time. The inevitable development of resistance following the introduction of novel antibiotics has led to an urgent need for the development of new antibacterial drugs with new mechanisms of action that are not susceptible to existing resistance mechanisms. One such compound is HAMLET, a natural complex from human milk that kills Streptococcus pneumoniae (the pneumococcus) using a mechanism different from common antibiotics and is immune to resistance-development. In this study we show that sublethal concentrations of HAMLET potentiate the effect of common antibiotics (penicillins, macrolides, and aminoglycosides) against pneumococci. Using MIC assays and short-time killing assays we dramatically reduced the concentrations of antibiotics needed to kill pneumococci, especially for antibiotic-resistant strains that in the presence of HAMLET fell into the clinically sensitive range. Using a biofilm model in vitro and nasopharyngeal colonization in vivo, a combination of HAMLET and antibiotics completely eradicated both biofilms and colonization in mice of both antibiotic-sensitive and resistant strains, something each agent alone was unable to do. HAMLET-potentiation of antibiotics was partially due to increased accessibility of antibiotics to the bacteria, but relied more on calcium import and kinase activation, the same activation pathway HAMLET uses when killing pneumococci by itself. Finally, the sensitizing effect was not confined to species sensitive to HAMLET. The HAMLET-resistant respiratory species Acinetobacter baumanii and Moraxella catarrhalis were all sensitized to various classes of antibiotics in the presence of HAMLET, activating the same mechanism as in pneumococci. Combined these results suggest the presence of a conserved HAMLET-activated pathway that circumvents antibiotic resistance in bacteria. The ability to activate this pathway may extend the lifetime of the current treatment arsenal.

Efficacy of tigecycline/colistin combination in a pneumonia model caused by extensively drug-resistant Acinetobacter baumannii

Due to increasing drug resistance, available antimicrobial options are limited in the treatment of Acinetobacter baumannii infections. Particularly in cases caused by extensively drug-resistant (XDR) A. baumannii, combination regimens must also be taken into consideration. In this study, the efficacies of tigecycline, colistin and tigecycline/colistin combination on bacterial counts in lung tissue were investigated in a rat pneumonia model. One A. baumannii strain resistant to all antimicrobial agents except tigecycline and colistin was selected for the study. In vivo studies revealed a >3 log reduction in bacterial counts in the tigecycline, colistin and combination groups at 24 h and 48 h compared with the control group. No significant differences were determined between colistin, tigecycline and combination groups (P>0.05). On the other hand, differences between treatment groups and the control group were statistically significant (P=0.01). A greater reduction in bacterial counts was observed at 48 h compared with 24 h in the tigecycline group than in the colistin group (P=0.038 and P=0.139, respectively); the most significant decrease between 24 h and 48 h was observed in the combination group (P=0.014). Despite detection of in vitro synergistic activity in this study, no statistically significant differences were found between colistin, tigecycline and combination treatments in terms of efficacy on bacterial counts in lung tissue. In the treatment of infections with a high mortality rate such as pneumonia caused by XDR A. baumannii, combining tigecycline with colistin during the first 48 h and continuing treatment with one of these agents seems a rational approach.

Combination antibiotic therapy for empiric and definitive treatment of gram-negative infections: insights from the Society of Infectious Diseases Pharmacists

The widespread emergence of antibiotic-resistant gram-negative organisms has compromised the utility of current treatment options for severe infections caused by these pathogens. The rate of gram-negative multidrug resistance is worsening, threatening the effectiveness of newer broad-spectrum antibiotic agents. Infections associated with multidrug-resistant Pseudomonas aeruginosa, Acinetobacter baumannii, and Enterobacteriaceae are having a substantial impact on hospital costs and mortality rates. The potential for these resistant gram-negative nosocomial pathogens must always be a primary consideration when selecting antibiotic therapy for critically ill patients. Empiric combination therapy directed at gram-negative pathogens is a logical approach for patients with suspected health care-associated infections, particularly those with risk factors for infections caused by multidrug-resistant pathogens. Although in vitro synergy tests have shown potential benefits of continued combination therapy, convincing clinical data that demonstrate a need for combination therapy once susceptibilities are known are lacking. Thus, deescalation to a single agent once susceptibilities are known is recommended for most patients and pathogens. Use of polymyxins, often in combination with other antimicrobials, may be necessary for salvage therapy.

Prolonged triple therapy for persistent multidrug-resistant Acinetobacter baumannii ventriculitis

PURPOSE

A case of persistent multidrug-resistant (MDR) Acinetobacter baumannii ventriculitis successfully treated with a prolonged and novel combination of antimicrobials is reported.

SUMMARY

A 38-year-old, 84-kg Caucasian woman with a recent history of craniotomy was admitted with nausea, fever, headache, photophobia, and drainage from her craniotomy incision. She underwent a repeat craniotomy on hospital day 4 with abscess debridement and repair of a cerebrospinal fluid leak. Cultures grew MDR A. baumannii, coagulase-negative Staphylococcus species, and methicillin-resistant Staphylococcus aureus. Based on the limited published pharmacokinetic and pharmacodynamic data for colistin, we determined a favorable outcome with i.v. colistin monotherapy was unlikely and decided to treat the patient with simultaneous i.v. and intraventricular colistin, as well as intraventricular tobramycin and i.v. rifampin. She was treated with a total of 36 days of intraventricular colistin, 40 days of intraventricular tobramycin, 51 days of i.v. colistin and rifampin, and 56 days i.v. vancomycin for infection that persisted despite multiple debridements. The patient had subsequent improvement in clinical manifestations and eradication of infection. She was subsequently discharged to an acute rehabilitation facility on hospital day 77 with posttreatment sequelae including mental impairment and renal failure requiring hemodialysis. Follow-up visits revealed significant improvement in her mental status, speech, and strength on the side not affected by the stroke.

CONCLUSION

Prolonged combination therapy with intraventricular colistin and tobramycin plus i.v. colistin, rifampin, and vancomycin led to the resolution of a persistent central nervous system infection caused by MDR A. baumannii.