Resistance and heteroresistance to colistin among clinical isolates of Acinetobacter baumannii

Impact of Antimicrobial Stewardship and Infection Prevention and Control Programmes on Antibiotic Usage and A. baumannii resistance: A 2016-2023 Multicentre Prospective Study

Objective

This study assesses the efficacy of antimicrobial stewardship (AMS) and infection prevention and control programmes (IPCP) in guiding the use of antibiotics and the control of A. baumannii (AB) resistance at multiple medical centres.

Methods

We evaluated the effectiveness of the policy on antibiotic consumption and AB resistance by determining the relationship between the defined daily doses (DDD) for antibiotics - or alcohol-based hand gel (ABHG) consumption - and the incidence of carbapenem-resistant AB (CR-AB), multidrug-resistant AB (MDR-AB) and extensively drug-resistant AB (XDR-AB) at two medical centers from 2016-2023.

Results

In total, 4057 AB isolates were collected; 64.95% of the AB isolates were CR, 59.48% were MDR and 1.41% were XDR. The major categories of the AB clinical strains collected were extracted primarily from patients' respiratory tract specimens, the ICU wards and patients over 65 years old, accounting for 76.98%, 67.98% and 63.72%, respectively. The incidence of CR-AB, MDR-AB and XDR-AB based on AMS and IPCP measures ranged from 70.04% to 58.42% (P<0.0001), 64.26% to 52.16% (P<0.0001) and 2.27% to 0.60% (P=0.0167), respectively. The DDD of total antibiotics administered per 1000 patient days (PD) decreased significantly from 51.25±4.22 to 40.92±2.48 (P<0.0001), and ABHG consumption per 1000 PD increased significantly from 5.25±0.98 to 13.51±5.12 (P<0.0001). We found a statistically significant positive correlation between the DDD of antibiotic consumption and the incidence of CR-AB, MDR-AB and XDR-AB (r=0.9755 and P<0.0001, r=0.9571 and P=0.0002, r=0.9230 and p=0.0011, respectively). In addition, a statistically negative correlation was found between ABHG consumption and the incidence of CR-AB, MDR-AB, and XDR-AB (r=-0.9473 and P=0.0004, r=-0.9123 and P=0.0016, r=-0.9138 and P=0.0015, respectively).

Conclusion

Comprehensive AMS and IPCP intervention measures can successfully achieve a sustained amelioration in the resistance and transmission of CR-AB, MDR-AB and XDR-AB, which are regarding potential applicability to other hospitals.

A Systematic Review and Meta-Analysis of Molecular Characteristics on Colistin Resistance of Acinetobacter baumannii

BACKGROUND

This study aimed to determine the molecular epidemiology of colistin-resistant A. baumannii in the last ten years and the frequency of gene regions related to pathogenesis, to compare the methods used to detect genes, and to confirm colistin resistance.

METHODS

This meta-analysis study was conducted under Preferred Reporting Items for Systematic Reviews and Meta-Analysis Guidelines. In the meta-analysis, research articles published in English and Turkish in electronic databases between January 2012 and November 2023 were examined. International Business Machines (IBM) Statistical Package for the Social Sciences (SPSS) Statistics for Macbook (Version 25.0. Armonk, NY, USA) was used for statistical analysis. The Comprehensive Meta-Analysis (CMA) (Version 3.0. Biostat, NJ, USA) program was used for heterogeneity assessment in the articles included in the meta-analysis.

RESULTS

After evaluating the studies according to the elimination criteria, 18 original articles were included. Among colistin-resistant strains, blaOXA-51 positivity was 243 (19.61%), blaOXA-23 was 113 (9.12%), blaOXA-58 was 7 (0.56%), blaOXA-143 was 15 (1.21%), and blaOXA-72 was seen in two (0.16%) strains. The positivity rates of pmrA, pmrB, and pmrC were found to be 22 (1.77%), 26 (2.09%), and 6 (0.48%). The mcr-1 rate was found to be 91 (7.34%), the mcr-2 rate was 78 (6.29%), and the mcr-3 rate was 82 (6.61%).

CONCLUSIONS

The colistin resistance rate in our study was found to be high. However, only some research articles report and/or investigate more than one resistance gene together. Additionally, it may be challenging to explain colistin resistance solely by expressing resistance genes without discussing accompanying components such as efflux pumps, virulence factors, etc.

Multi-drug Resistant Acinetobacter baumannii: Phenotypic and Genotypic Resistance Profiles and the Associated Risk Factors in Teaching Hospital in Jordan

BACKGROUND

This study aimed to determine the prevalence of Antimicrobial Resistance Genes (ARGs), with a focus on colistin resistance in clinical A. baumannii, as well as the risk factors associated with A. baumannii infection in Jordanian patients.

METHODS

In total, 150 A. baumannii isolates were obtained from patients at a teaching hospital. The isolates were tested for antimicrobial susceptibility using disc diffusion and microdilution methods. PCR amplification was used to detect ARGs, and statistical analysis was conducted to evaluate the influence of identified risk factors on the ARGs acquisition.

RESULTS

More than 90% of A. baumannii isolates were resistant to monobactam, carbapenem, cephalosporins, Fluoroquinolones, penicillin, and β-lactam agents. Moreover, 20.6% of the isolates (n = 31) were colistin-resistant. Several ARGs were also detected in A. baumannii isolates. Univariate analysis indicated that risk factors and the carriage of ARGs were significantly associated P ≤ (0.05) with gender, invasive devices, immunodeficiency, systemic diseases, tumors, and covid-19. Logistic regression analysis indicated seven risk factors, and three protective factors were associated with the ARGs (armA, strA, and strB) P ≤ (0.05). In contrast, tetB and TEM were associated with 2 risk factors each P ≤ (0.05).

CONCLUSION

Our study indicates a high prevalence of MDR A. baumannii infections in ICU patients, as well as describing the case of colistin-resistant A. baumannii for the first time in Jordan. Additionally, the risk factors associated with ARGs-producing A. baumannii infections among ICU patients suggest a rapid emergence and spread of MDR A. baumannii without adequate surveillance and control measures.

Heteroresistance to colistin in wild-type Klebsiella pneumoniae isolates from clinical origin

IMPORTANCE

Colistin is one of the last remaining therapeutic options for dealing with Enterobacteriaceae. Unfortunately, heteroresistance to colistin is also rapidly increasing. We described the prevalence of colistin heteroresistance in a variety of wild-type strains of Klebsiella pneumoniae and the evolution of these strains with colistin heteroresistance to a resistant phenotype after colistin exposure and withdrawal. Resistant mutants were characterized at the molecular level, and numerous mutations in genes related to lipopolysaccharide formation were observed. In colistin-treated patients, the evolution of K. pneumoniae heteroresistance to resistance phenotype could lead to higher rates of therapeutic failure.

In vitro activity and adaptation strategies of eravacycline in clinical Enterococcus faecium isolates from China

Eravacycline (Erava) is a synthetic fluorocycline with potent antimicrobial activity against a wide range of Gram-positive bacteria. This study aimed to investigate the in vitro antimicrobial activity and resistance mechanism of Erava in clinical E. faecium isolates from China. Erava minimum inhibitory concentrations (MICs) against clinical E. faecium isolates-including those resistant to linezolid (LZD) or harboring the tetracycline (Tet) resistance genes was ≤0.25 mg l^-1. Moreover, our data indicated that clinical isolates of E. faecium with Erava MIC 0.25 mg l^-1 were predominantly shown to belong to Sequence-type 78 (ST78) and ST80. The prevalence of Erava heteroresistance in clinical E. faecium strain was 2.46% (3/122). The increased Erava MIC values of heteroresistance-derived E. faecium clones could be significantly reduced by efflux pump inhibitors (EPIs). Furthermore, comparative proteomics results showed that efflux pumps lmrA, mdlA, and mdlB contributed significantly to the acquisition of Erava resistance in E. faecium. In addition, a genetic mutation in 16 S rRNA (G190A) were detected in resistant E. faecium isolates induced by Erava. In summary, Erava exhibits potent in vitro antimicrobial activity against E. faecium, but mutation of Tet target sites and elevated expression of efflux pumps under Erava selection results in Erava resistance.

Colistin Resistance Onset Strategies and Genomic Mosaicism in Clinical Acinetobacter baumannii Lineages

The treatment of multidrug-resistant Gram-negative infections is based on colistin. As result, COL-resistance (COL-R) can develop and spread. In Acinetobacter baumannii, a crucial step is to understand COL-R onset and stability, still far to be elucidated. COL-R phenotypic stability, onset modalities, and phylogenomics were investigated in a clinical A. baumannii sample showing a COL resistant (COL^R) phenotype at first isolation. COL-R was confirmed by Minimum-Inhibitory-Concentrations as well as investigated by Resistance-Induction assays and Population-Analysis-Profiles (PAPs) to determine: (i) stability; (ii) inducibility; (iii) heteroresistance. Genomics was performed by Mi-Seq Whole-Genome-Sequencing, Phylogenesis, and Genomic Epidemiology by bioinformatics. COL^RA. baumannii were subdivided as follows: (i) 3 A. baumannii with stable and high COL MICs defining the “homogeneous-resistant” onset phenotype; (ii) 6 A. baumannii with variable and lower COL MICs displaying a “COL-inducible” onset phenotype responsible for adaptive-resistance or a “subpopulation” onset phenotype responsible for COL-heteroresistance. COL-R stability and onset strategies were not uniquely linked to the amount of LPS and cell envelope charge. Phylogenomics categorized 3 lineages clustering stable and/or unstable COL-R phenotypes with increasing genomic complexity. Likewise, different nsSNP profiling in genes already associated with COL-R marked the stable and/or unstable COL-R phenotypes. Our investigation finds out that A. baumannii can range through unstable or stable COL^R phenotypes emerging via different “onset strategies” within phylogenetic lineages displaying increasing genomic mosaicism.

Synergistic Activity and Biofilm Formation Effect of Colistin Combined with PFK-158 Against Colistin-Resistant Gram-Negative Bacteria

Purpose

The emergence of colistin resistance among Gram-negative bacteria (GNB) poses a serious public health threat. Therefore, it is necessary to enhance the antibacterial activity of colistin through the combination with other drugs. In this study, we demonstrated the synergistic activity and the possible synergy mechanism of colistin with PFK-158 against colistin-resistant GNB, including non-fermenting bacteria and Enterobacteriaceae.

Patients and Methods

Thirty-one colistin-resistant GNB, including Pseudomonas aeruginosa (n = 9), Acinetobacter baumannii (n = 5), Escherichia coli (n = 8) and Klebsiella pneumoniae (n = 9), were collected as the experimental strains and the minimum inhibitory concentrations (MICs) of colistin, other routine antimicrobial agents and PFK-158 against all strains were determined by the broth microdilution method. The synergistic activity of colistin with PFK-158 was assessed by the checkerboard assay and time-kill assay. The biofilm formation assay and scanning electron microscopy were used to demonstrate the biofilm formation effect of colistin with PFK-158 against colistin-resistant GNB.

Results

The results of the checkerboard assay showed that when colistin was used in combination with PFK-158, synergistic activity was observed against the 31 colistin-resistant GNB. The time-kill assay presented a significant killing activity of colistin with PFK-158 against the 9 colistin-resistant GNB selected randomly, including Pseudomonas aeruginosa (n = 6), Acinetobacter baumannii (n = 1), Escherichia coli (n = 1), and Klebsiella pneumoniae (n = 1). The biofilm formation assay and scanning electron microscopjihy showed that colistin with PFK-158 can effectively suppress the formation of biofilm and reduce the cell arrangement density of biofilm against most experimental strains.

Conclusion

The results of the performed experiments suggest that the combination of colistin and PFK-158 may be a potential new choice as a new antibiofilm group for the treatment of infections caused by the colistin-resistant GNB.

Discerning the role of polymicrobial biofilms in the ascent, prevalence, and extent of heteroresistance in clinical practice

Antimicrobial therapy is facing a worrisome and underappreciated challenge, the phenomenon of heteroresistance (HR). HR has been gradually documented in clinically relevant pathogens (e.g. Pseudomonas aeruginosa, Staphylococcus aureus, Burkholderia spp., Acinetobacter baumannii, Klebsiella pneumoniae, Candida spp.) towards several drugs and is believed to complicate the clinical picture of chronic infections. This type of infections are typically mediated by polymicrobial biofilms, wherein microorganisms inherently display a wide range of physiological states, distinct metabolic pathways, diverging refractory levels of stress responses, and a complex network of chemical signals exchange. This review aims to provide an overview on the relevance, prevalence, and implications of HR in clinical settings. Firstly, related terminologies (e.g. resistance, tolerance, persistence), sometimes misunderstood and overlapped, were clarified. Factors generating misleading HR definitions were also uncovered. Secondly, the recent HR incidences reported in clinically relevant pathogens towards different antimicrobials were annotated. The potential mechanisms underlying such occurrences were further elucidated. Finally, the link between HR and biofilms was discussed. The focus was to recognize the presence of heterogeneous levels of resistance within most biofilms, as well as the relevance of polymicrobial biofilms in chronic infectious diseases and their role in resistance spreading. These topics were subject of a critical appraisal, gaining insights into the ascending clinical implications of HR in antimicrobial resistance spreading, which could ultimately help designing effective therapeutic options.

Molecular Characterization of Carbapenem/Colistin-Resistant Acinetobacter baumannii Clinical Isolates from Egypt by Whole-Genome Sequencing

PURPOSE

The rise of carbapenem-resistant A. baumannii (CRAB) is considered a public health problem limiting the treatment options. Our current work studied the emergence and mechanisms of colistin-resistance among CRAB isolates in Egypt.

MATERIALS AND METHODS

Seventeen clinically recovered A. baumannii were identified and screened for their antimicrobial susceptibilities using VITEK-2 system. Colistin susceptibility was evaluated using broth microdilution, and characterization of carbapenem/colistin resistance determinants was performed using whole-genome sequencing (Illumina MiSeq).

RESULTS

About 52.9% (9/17) were colistin-resistant. PCR results revealed that all isolates carried bla OXA-51-like genes, bla OXA-23-like was detected in 82.3% (14/17) and bla NDM in 23.5% (4/17). Two isolates harboured bla GES-35 and bla OXA-23. Furthermore, genome analysis of seven isolates revealed six belonged to international clone 2 (IC2) while the remaining isolate was a singleton (ST158), representing a clone circulating in Mediterranean/Middle Eastern countries.

CONCLUSION

The emergence and high incidence of colistin-resistance among CRAB clinical isolates in Egypt are alarming because it further limits therapy options and requires prudent antimicrobial stewardship and stringent infection control measures. Whole-genome sequence analyses suggest that the resistance to colistin was associated with multiple mutations in the pmrCAB genes. The high incidence of the high-risk lineage IC2 harbouring bla OXA-23-like as well as bla NDM is also of concern.

Colistin heteroresistance in Acinetobacter spp.: systematic review and meta-analysis of the prevalence and discussion of the mechanisms and potential therapeutic implications

BACKGROUND

Colistin is one of the few remaining options for carbapenem-resistant Acinetobacter baumannii (A. baumannii); however, emergence of resistance from heteroresistant populations is possible. This review aimed to systematically search and consolidate the literature on the prevalence, mechanisms and therapeutic implications of colistin heteroresistance in Acinetobacter spp.

METHODS

A systematic search was conducted in PubMed and Scopus. The pooled prevalence of colistin heteroresistance was calculated using meta-analysis of proportions with the Freeman-Tukey transformation and the random-effects (DerSimonian and Laird) method.

RESULTS

Based on 15 studies the prevalence of colistin heteroresistance was 33% (95% CI 16-53%) but considerable heterogeneity was observed (I² = 96%, P < 0.001). Prior exposure to colistin was associated with a higher proportion of resistant subpopulations. Colistin heteroresistance may result from chromosomal mutations in resistant subpopulations (predominantly in PmrAB and lpx genes) resulting in lipopolysaccharide modification or loss, or overexpression of efflux pumps. No dosage scheme of colistin monotherapy can prevent the emergence of resistant subpopulations in vitro, but few studies have reported in vivo emergence of resistance from heteroresistant A. baumannii during treatment, and studies examining the correlation between heteroresistance and clinical/microbiological outcomes are lacking. Several colistin-based combinations have been shown in vitro to prevent the emergence of the resistant subpopulations but none have been translated so far into clinical benefit. Reasons for this discrepancy are discussed.

CONCLUSIONS

Colistin heteroresistance was common but highly variable between studies. The impact of colistin heteroresistance (frequency of emergent resistance during treatment and correlation with treatment outcomes) requires further study.

Antibiotic Resistance Profiles, Molecular Mechanisms and Innovative Treatment Strategies of Acinetobacter baumannii

Antibiotic resistance is one of the biggest challenges for the clinical sector and industry, environment and societal development. One of the most important pathogens responsible for severe nosocomial infections is Acinetobacter baumannii, a Gram-negative bacterium from the Moraxellaceae family, due to its various resistance mechanisms, such as the β-lactamases production, efflux pumps, decreased membrane permeability and altered target site of the antibiotic. The enormous adaptive capacity of A. baumannii and the acquisition and transfer of antibiotic resistance determinants contribute to the ineffectiveness of most current therapeutic strategies, including last-line or combined antibiotic therapy. In this review, we will present an update of the antibiotic resistance profiles and underlying mechanisms in A. baumannii and the current progress in developing innovative strategies for combating multidrug-resistant A. baumannii (MDRAB) infections.