Pandrug-resistant Acinetobacter baumannii causing nosocomial infections in a university hospital, Taiwan

New Shuttle Vectors for Real-Time Gene Expression Analysis in Multidrug-Resistant Acinetobacter Species: In Vitro and In Vivo Responses to Environmental Stressors

The Acinetobacter genus includes species of opportunistic pathogens and harmless saprophytes. The type species, Acinetobacter baumannii, is a nosocomial pathogen renowned for being multidrug resistant (MDR). Despite the clinical relevance of infections caused by MDR A. baumannii and a few other Acinetobacter spp., the regulation of their pathogenicity remains elusive due to the scarcity of adequate genetic tools, including vectors for gene expression analysis. Here, we report the generation and testing of a series of Escherichia coli-Acinetobacter promoter-probe vectors suitable for gene expression analysis in Acinetobacter spp. These vectors, named pLPV1Z, pLPV2Z, and pLPV3Z, carry both gentamicin and zeocin resistance markers and contain lux, lacZ, and green fluorescent protein (GFP) reporter systems downstream of an extended polylinker, respectively. The presence of a toxin-antitoxin gene system and the high copy number allow pLPV plasmids to be stably maintained even without antibiotic selection. The pLPV plasmids can easily be introduced by electroporation into MDR A. baumannii belonging to the major international lineages as well as into species of the Acinetobacter calcoaceticus-A. baumannii complex. The pLPV vectors have successfully been employed to study the regulation of stress-responsive A. baumannii promoters, including the DNA damage-inducible uvrABC promoter, the ethanol-inducible adhP and yahK promoters, and the iron-repressible promoter of the acinetobactin siderophore biosynthesis gene basA A lux-tagged A. baumannii ATCC 19606^T strain, carrying the iron-responsive pLPV1Z::PbasA promoter fusion, allowed in vivo and ex vivo monitoring of the bacterial burden in the Galleria mellonella infection model.IMPORTANCE The short-term adaptive response to environmental cues greatly contributes to the ecological success of bacteria, and profound alterations in bacterial gene expression occur in response to physical, chemical, and nutritional stresses. Bacteria belonging to the Acinetobacter genus are ubiquitous inhabitants of soil and water though some species, such as Acinetobacter baumannii, are pathogenic and cause serious concern due to antibiotic resistance. Understanding A. baumannii pathobiology requires adequate genetic tools for gene expression analysis, and to this end we developed user-friendly shuttle vectors to probe the transcriptional responses to different environmental stresses. Vectors were constructed to overcome the problem of antibiotic selection in multidrug-resistant strains and were equipped with suitable reporter systems to facilitate signal detection. By means of these vectors, the transcriptional response of A. baumannii to DNA damage, ethanol exposure, and iron starvation was investigated both in vitro and in vivo, providing insights into A. baumannii adaptation during stress and infection.

Population Pharmacokinetics and Pharmacodynamics Modeling To Optimize Dosage Regimens of Sulbactam in Critically Ill Patients with Severe Sepsis Caused by Acinetobacter baumannii

Sulbactam is being considered as an alternative concomitant medication with other effective antibiotics for the treatment of multidrug-resistant (MDR) Acinetobacter baumannii infections. Pathophysiological changes in critically ill patients with severe sepsis, resulting in altered pharmacokinetic (PK) patterns for antibiotics, are important factors in determining therapeutic success. The aims of this study were (i) to examine the population PK parameters and (ii) to assess the probability of target attainment (PTA) for sulbactam in patients with severe sepsis caused by A. baumannii PK studies were carried out following administration of 2 g of sulbactam every 12 h on the 4th day of drug administration in 27 patients, and a Monte Carlo simulation was performed to determine the PTA of achieving 40% exposure time during which the plasma drug concentration remained above the MIC (T_>MIC) and 60% T_>MIC The central and peripheral volumes of distribution were 14.56 and 9.55 liters, respectively, and total clearances of sulbactam were 2.26 liters/h and 7.64 liters/h in patients aged >65 years and ≤65 years, respectively. The high PTAs (≥90%) for targets of 40% T_>MIC and 60% T_>MIC with a MIC of 4 μg/ml were observed when sulbactam was administered by a 4-h infusion of 1 g every 12 h and 1 g every 8 h, respectively. Sulbactam would be an alternative antibiotic option to coadminister with colistin for the treatment of infections caused by MDR A. baumannii However, for pathogens with MICs of >4 μg/ml, higher dosage regimens of sulbactam are required.

Clinical response and outcome of pneumonia due to multi-drug resistant Acinetobacter baumannii in critically ill patients

BACKGROUND AND OBJECTIVES

The frequency of multi-drug resistant Acinetobacter spp. infections is increasing in Iran. Considering availability of limited therapeutic options, clinical response and outcome of ventilator-associated pneumonia due to multi-drug resistant A.baumannii were evaluated in critically ill patients.

MATERIALS AND METHODS

In this prospective study, 29 patients with carbapenem resistance A. baumannii ventilator-associated pneumonia were enrolled. Endotracheal aspirate specimens were analyzed according to the clinical and laboratory standard institute instructions in the hospital's microbiology laboratory. Demographics, clinical, microbiological and laboratory findings were collected for each patient during the treatment course. Therapeutic empirical regimen, change in antibiotic regimen following receiving antibiogram results, clinical and microbiological responses, duration of ICU stay and outcome were collected for each recruited individual.

RESULTS

All of A. baumanii isolates were resistant to pipracillin-tazobactam, ceftriaxon, amikacin and ciprofloxacin. The resistance rate of A. baumanii species was 41.4% for ampicillin/sulbactabm and 93.1% for meropenem. Patients received either meropenem/colistin (51.7%) or meropenem/ampicillin-sulbactam (48.3%) as the treatment regimens based on the antimicrobial susceptibility patterns of isolates. Ventilator-associated pneumonia clinical response, improvement and failure achieved in 15 (51.7%), 8 (27.6%) and 6 (20.7%) of the patients respectively. Microbiological eradication and intermediate status were observed in 9/29 (31%) and 11/29 (37.9%) of patients, respectively.

CONCLUSION

The antibiotic regimens showed comparable efficacy in treatment of VAP due to MDR A. baumannii but mortality rate was high. Considering widespread and high mortality rates associated with MDR infections, applying infection control and antibiotic stewardship programs in hospitals are essential.

Severe pneumonia in the elderly: a multivariate analysis of risk factors

Pneumonia is the second leading reason for hospitalization of medicare beneficiaries. The mortality rate is high, especially in the elderly. In this study, we aimed to determine the risk factors associated with severe pneumonia in the elderly. Retrospective study was conducted and data of old patients with severe pneumonia were collected. They were divided into two groups: the experiment group (death group) and the control (living group). The general situation, underlying diseases, laboratory tests, types of etiology, imaging analysis and treatment situation of patients were analyzed and compared. Univariate analysis and logistic multivariate regression analysis were used to screen the related and independent risk factors for the diagnosis of severe pneumonia in the elderly. In univariate analysis, there were many factors had statistical significance including chronic kidney disease, electrolyte disturbance, low phosphorus and so on. Result of logistic multivariate regression analysis showed pro-BNP level and serum prealbumin were independent risk factors. In sputum culture, the relevance ratio of acinetobacter baumannii was the highest in gram negative bacteria followed by klebsiella pneumoniae. In gram positive bacteria, the relevance ratio of staphylococcus aureus was the highest. In conclusion, the analysis on risk factors for severe pneumonia has great clinical significance on improving the prognosis.

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.

Antimicrobial susceptibility patterns of the gram-negative bacteria isolated from septicemia in Children's Medical Center, Tehran, Iran

INTRODUCTION

The choice of antimicrobial treatment for septicemia is often empirical and based on the knowledge of local anti-microbial activity patterns of the most common bacteria causing such bloodstream infections. The current study aimed to study the prevalence of bacterial pathogens causing septicemia and their antimicrobial resistant profiles in hospital admitted patients.

METHODS

This cross sectional study done at Children's Medical Center, Tehran, Iran. We examined 168 bacterial strains isolated from 186 clinically diagnosed septicemia cases refereed at Children's Medical Center, Tehran, Iran. Over a period of twelve months from July 2010 to 2011 July. 11446 blood samples from patients of clinically suggestive septicemia were evaluated.

RESULTS

Bacterial strains were isolated from 910 (7.95%) of blood cultures. Gram-negative bacteria identified were Pseudomonas species (20.5%), Pseudomonas aeruginosa (1.86%), Salmonella spp (1.09%), Acinetobacter naumannii (8.13%), Escherichia coli (4.06%), Klebsiella spp (5.16%). Gram-negative pathogens were more than gram positive in bloodstream infections. Antimicrobial susceptibility testing was done according to Clinical and Laboratory Standards Institute (CLSI, USA) guidelines against: amikacin ampicillin, amoxicillin, amoxiclav, cefuroxime, cefotaxime, ceftazidime, cefoperazone tetracycline, chloramphenicol, ciprofloxacin, gentamicin. Resistanc to different antibiotics in the most important isolated bacteria were: 32.1%, 10.8%, 87.8%, 96%, 39.1%, 35.2, 49.4%, 69%, 80.02%, 22%, 59%, 30.1% respectively, for Pseudomonas spp, 32%, 3.7%, 84.2%, 83.2%, 80.1%, 75.4%, 44.8%, 45.2%, 33.3%, 19%, 34.1, 11.5% respectively for Acinetobacter species.

DISCUSSION

Resistant to majority of the antimicrobial agents for several pathogens implicated in bloodstream infections, particularly in Gram-negative bacteria, can make complication in treatment of infection cause by them.

Acinetobacter baumannii: An emerging pathogenic threat to public health

Over the last three decades, Acinetobacter has gained importance as a leading nosocomial pathogen, partly due to its impressive genetic capabilities to acquire resistance and partly due to high selective pressure, especially in critical care units. This low-virulence organism has turned into a multidrug resistant pathogen and now alarming healthcare providers worldwide. Acinetobacter baumannii (A. baumannii) is a major species, contributing about 80% of all Acinetobacter hospital-acquired infections. It disseminates antibiotic resistance by virtue of its extraordinary ability to accept or donate resistance plasmids. The procedures for breaking the route of transmission are still proper hand washing and personal hygiene (both the patient and the healthcare professional), reducing patient’s biofilm burden from skin, and judicious use of antimicrobial agents. The increasing incidence of extended-spectrum beta-lactamases and carbapenemases in A. baumannii leaves almost no cure for these “bad bugs”. To control hospital outbreaks of multidrug resistant-Acinetobacter infection, we need to contain their dissemination or require new drugs or a rational combination therapy. The optimal treatment for multidrug-resistant A. baumannii infection has not been clearly established, and empirical therapy continues to require knowledge of susceptibility patterns of isolates from one’s own institution. This review mainly focused on general features and introduction to A. baumannii and its epidemiological status, potential sources of infection, risk factors, and strategies to control infection to minimize spread.

[Emerging Acinetobacter baumannii infections and factors favouring their occurrence]

During the last decade, Acinetobacter baumannii (AB) has been increasingly responsible for infections occurring in three particular contexts (in terms of patients and environment). Community AB pneumonia is severe infections, mainly described around the Indian Ocean, and which mainly concern patients with major co-morbidities. AB is also responsible for infections occurring among soldiers wounded in action during operations conducted in Iraq or Afghanistan. Lastly, this bacterium is responsible for infections occurring among casualties from natural disasters like earthquakes and tsunamis. Those infections are often due to multidrug-resistant strains, which can be implicated in nosocomial outbreaks when patients are hospitalized in a local casualty department or during their repatriation thereafter. The source of the contaminations which lead to AB infections following injuries (warfare or natural disasters) is still poorly known. Three hypotheses are usually considered: a contamination of wounds with environmental bacteria, a wound contamination from a previous cutaneous or oropharyngeal endogenous reservoir, or hospital acquisition. The implication of telluric or agricultural primary reservoirs in human AB infections is a common hypothesis which remains to be demonstrated by further specifically designed studies.

Isolation and genetic characterization of metallo-β-lactamase and carbapenamase producing strains of Acinetobacter baumannii from patients at Tehran hospitals

BACKGROUND AND OBJECTIVE

Carbapenems are therapeutic choice against infections caused by gram-negative bacilli including strains of Acinetobacter baumannii. Resistance to these antibiotics is mediated by efflux pumps, porins, PBPs and ß-lactamases. The aim of this study was to determine the possibility of existence of MBLs, OXAs and GES-1 betalactamase genes among clinical isolates of Acinetobacter collected from Tehran hospitals.

MATERIAL AND METHODS

Two hundred and three Acinetobacter isolates were collected from patient at Tehran hospitals. The isolates were identified using biochemical tests. The susceptibility to different antibiotics was evaluated by disk diffusion method and MICs of imipenem were determined using Micro broth dilution method (CLSI). PCR was performed for detection of bla(VIM-2), bla(SPM-1), bla(IMP-2), bla(GES-1), bla(OXA-51), bla(OXA-23) betalactamase genes. Clonal relatedness was estimated by PFGE with the restriction enzyme SmaI.

RESULTS AND CONCLUSION

Of 100 isolates of imipenem resistant Acinetobacter spp. collected from Tehran hospitals in 2009 and 2010, 6 isolates produced metallo-beta-lactamases and 94 isolates produced OXA-type carbapenemase. The bla(SPM-1), bla(GES-1), bla(OXA-51), bla(OXA-23) genes were detected by PCR among 6, 2, 94 and 84 isolates of A. baumannii, respectively. The MICs of isolates to imipenem were 8-128 µg/mL. PFGE analysis of 29 bla(OXA-51) and bla(OXA-23)-positive A. baumannii isolates gave 6 different patterns. This is the first report of SPM-1 and GES-1 beta-lactamase producing A. baumannii. Production of the OXA-23, OXA-51, GES-1 and SPM-1 enzyme presents an emerging threat of carbapenem resistance among A. baumannii in Iran.

Loss of the 29-kilodalton outer membrane protein in the presence of OXA-51-like enzymes in Acinetobacter baumannii is associated with decreased imipenem susceptibility

Carbapenem resistance in Acinetobacter baumannii is increasing these days. We investigated the roles of outer membrane proteins and efflux pumps in carbapenem resistance of A. baumannii which showed no carbapenemase activity in modified Hodge test. Among 58 carbapenem-resistant isolates collected from the Korea University Medical Center between January 2002 and March 2006, 17 isolates showed negative results in modified Hodge test. In outer membrane protein analysis, loss of the 29-kDa protein band was related with higher imipenem minimum inhibitory concentrations especially in the presence of OXA-51-like enzymes. Efflux pump-mediated carbapenem resistance was found in one out of the 17 isolates (5.9%). All of the 58 carbapenem-resistant strains and 5 of the 10 carbapenem-susceptible strains had OXA-51-like carbapenemase genes, suggesting that OXA-51-like enzymes may be naturally existing in A. baumannii and have very weak carbapenem hydrolyzing activity.

Genotype and antibiotic susceptibility patterns of drug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii isolates in Taiwan

Rapid and accurate identification of the drug susceptibility profile of clinical strains is very important for controlling bacterial infections and determining the antibiotic therapy. The objective of this study was to investigate the spectrum of the correlation between phenotypic and genetic characters of the drug-resistant clinical isolates. A total of 133 clinical isolates, including 76 Acinetobacter baumannii and 57 Pseudomonas aeruginosa, were examined for their antibiotic susceptibility by the method of disc diffusion. Among them, most of the isolates were multiresistant, and 80% of the strains showed phenotypic resistance to beta-lactam antibiotics. Using PCR analysis, among the several types of beta-lactamases, TEM was the most prevalent, and OXA was the second most prevalent. The integron harbored was identified by conserved segment PCR, and 50% of the test isolates carried integrons with various gene cassette sizes inserted. The results obtained from this study reveal that the majority of these isolates displayed multiple drug resistance phenotypes that were associated with their mutational gene profiles.

In vitro activities of tigecycline, ertapenem, isepamicin, and other antimicrobial agents against clinically isolated organisms in Taiwan

This study evaluated the in vitro activities of tigecycline, ertapenem, isepamicin, and other comparators against 861 bacterial isolates recovered from patients treated in three major teaching hospitals in 2003. MICs to antimicrobial agents were determined by the agar dilution method. High rates of oxacillin resistance (58%) in Staphylococcus aureus (60 isolates), and vancomycin resistance (21%) and quinupristin-dalfopristin non-susceptibility (39%) in Enterococcus faecium (34 isolates) were found. Carbapenems had excellent in vitro activities (>or=98% susceptibility) against the 419 isolates of Enterobacteriaceae, with the MIC(50) and MIC(90) of imipenem, meropenem, and ertapenem being 0.25 and 4 mg/L, 0.03 and 0.12 mg/L, and 0.03 and 0.5 mg/L, respectively. For, Pseudomonas aeruginosa (74 isolates) and Burkholderia cepacia (21 isolates), meropenem (MIC(90), 0.25, 2, and 4 mg/L, respectively) had better in vitro activities than imipenem (MIC(90), 8, 4, and 32 mg/L, respectively) and ertapenem (MIC(90), 0.5, >32, and 32 mg/L, respectively). Isepamicin had a similar activity with amikacin against all Enterobacteriaceae, Pseudomonas aeruginosa, B. cepacia, and Acinetobacter baumannii, except for C. freundii isolates in which isepamicin had an eight-fold activity better than amikacin. Tigecycline had excellent in vitro activities against all isolates tested (MIC(90), <or=1 mg/L) including 14 pandrugresistant A. baumannii isolates (MICs, 1-4 mg/L), except for Proteus mirabilis (59 isolates; MIC(90), 8 mg/L), Bacteroides fragilis (60 isolates; MIC(90), 8 mg/L), P. aeruginosa (MIC(90), 16 mg/L), and B. cepacia (21 isolates; MIC(90), 16 mg/L). Tigecycline, carbapenems, and isepamicin exhibited better or comparable in vitro activities against a wide spectrum of commonly encountered bacteria than other comparator antimicrobials and may represent therapeutic options for infections due to multidrug-resistant pathogens.

Genotypic Characterization of Carbapenem-NonsusceptibleAcinetobacterspp. Isolated in Latin America

The principal aim of this study was to evaluate the genomic diversity among the imipenem-nonsusceptible Acinetobacter spp. (INSA) collected from the Latin American medical centers within the SENTRY Antimicrobial Surveillance Program. The INSA isolates were collected from patients with bloodstream infections, who were hospitalized in seven Latin American countries between 1997 and 1999. For epidemiologic comparison, 20 carbapenem-susceptible Acinetobacter spp. (CSA) isolates were collected in the same period of time from the respective medical centers. A total of 23 Acinetobacter spp. isolates exhibiting imipenem MIC values of >/=8 microg/ml were typed by ribotyping, an automated molecular method. The isolates showing an identical ribogroup were also typed by pulsed-field gel electrophoresis (PFGE). The antimicrobial susceptibility to various antimicrobial agents was evaluated using a reference broth microdilution technique. Among the INSA isolates, 13 distinct ribogroups were observed, whereas 16 ribogroups were detected among the CSA. Nearly 57% of the INSA belonged to only four ribogroups. Identical ribogroups and PFGE patterns were observed among INSA and CSA isolates collected from medical centers located in different countries (Brazil and Argentina). Our results showed: (1) a higher genomic variability among the CSA; (2) presence of epidemic clones among INSA isolates encountered in Latin American medical centers; and (3) spread of INSA and CSA epidemic clones between Latin American countries.