Final upgrading: Extreme-drug-resistant (XDR) Acinetobacter baumannii carrying blaOXA-23 in a patient with acute necrohaemorrhagic pancreatitis Luísa Vieira.

Final upgrading: Extreme-drug-resistant (XDR)

Acinetobacter baumannii carrying blaOXA-23 in a patient with acute necrohaemorrhagic pancreatitis

Luísa Vieira Peixe

REQUIMTE. Laboratório de Microbiologia, Faculdade de Farmácia, Universidade do Porto, Portugal

Hospitals

Food and animal production environment

Humans community

Environment

VRE, Enterobacteriaceae- PL/TEM-

52; PL/CTX-M-15, Pseudomonas-

VIM

Enterococcus

gentaR,

Tn1546

PL/CTX-M-14; PL/CTX-M-15 (Enterobacteriaceae)

VRE-CC17

Acinetobacter OXA-23

Salmonella-intI1 OXA-30, sul3 Enterobacteriaceae- PL/TEM-52

Salmonella-intI1MDR, Enterobacteriaceae- PL/TEM-52

Goals

Strategies

Characterization of bacteria, genes and mobile genetic

elements from different ecological niches

(1) Emergence and International dissemination of MDR strains: VRE, ESBL-producing Enterobacteriaceae, Carbapenemase-producing Pseudomonas and Acinetobacter, Salmonella MDR

(2) New genetic structures carrying antibiotic resistance genes driving co-selection and maintenance of resistant bacteria, e.g., In100

(3) Interchange of genetic elements/bacteria between different ecological nichesFood producing animals and food of animal origin are a reservoir of clinically relevant clones/resistance genes

Worrisome contribution of hospital sewage for aquatic environmental contamination by resistant bacteria

We Evidenced:

Epidemiology study of antibiotic resistant bacteria in order to implement containment measures, methodologies for their detection, and design of new compounds

REQUIMTE- Microbiology Research Group Goals

AAC.2008.52:1001JAC.2008. (In press)AAC.2007.51:1545CMI. 2006. 12:1131JAC.2006.58:297CMI.2006.12:1047 JAC.2005.56:1139EID.2005.11:1985AAC. 2005. 49:836AAC.2007.51:3465 AAC. 2005. 49:451 JAC. 2007.60:1370AAC.2004.48:3613AEM.2006.72:3743 AAC. 2005. 49:2140AEM.2005.71:3364CMI.2004.10:755AAC.2006.50:3220

Main Achievements

Acinetobacter baumannii - Emergent Pathogen

Acinetobacter on the news!

Significant nosocomial pathogen Especially in immunocompromised patients or with underlying diseases Mainly Pneumonia (also bacteremia, meningitis, skin and wound infections) Mainly ICU 64% of mortality rates associated to severe nosocomial infections

Recent reports of community acquired infections Pneumonia (rarely meningitis, cellulitis) Alcohol abuse, diabetis, cancer, or bronchopulmonary diseases Possible Vector role

Lowman W et al.,J. Med Microbiol. 2008Garcia-Garmendia JL et al. Clin. Infect. Dis. 2001

Acinetobacter baumannii - Emergent Pathogen

Genus Acinetobacter

32 described Acinetobacter groups or named species

Bouvet and Grimont, 1986: Acinetobacter baumannii

A. calcoaceticus- A. baumanii complex (Gerner- Smidt, J. Clin. Microb., 1991)

Acinetobacter baumanniiAcinetobacter calcoaceticusGenomic species 3TUGenomic species 13TU

Phenotypically difficult to distinguish65-75% relatedness in DNA-DNA

hybridization

Gram-negative coccobacillus Non-fermentersOxidase –Strict aerobes

Identification: rDNA16S sequence, rpoB sequence, DNA restriction analysis 16S rDNA (ARDRA)

Nosocomial infections: A. baumannii, groups 13TU & 3

Ecological distribution of A. baumannii: undefined reservoir

WHY?

Important factor for their pathogenic potential: efficient means of horizontal gene transfer(?)

Survival capabilities

Acquisition of virulence genes

Ability to acquire resistance to antibiotics

Acinetobacter baumannii - Emergent Pathogen

A. baylyi ADP1, A. baumannii AYE and A. baumannii SDF chromosomes. (PLOS One, 2008)

?

Acinetobacter baumannii - Emergent Pathogen

Ability to acquire resistance to antibiotics

An 86-kb Resistance Island in epidemic A. baumannii Strain AYE45 resistance genes

Acinetobacter baumanii infections- major epidemiological features

Propensity for clonal spread Involvement in hospital outbreaks Endemicity in certain hospitals Resistance to multiple antimicrobial agents

Many recent outbreaks have been caused by multidrug-resistant (MDR) strains of A. baumannii

Stoeva et al., CMI. 2008Quinteira et al. AAC. 2004Manikal et al., CID 2000

Perez et al., AAC. 2007.Meropenem Yearly Susceptibility Test Information Collection [MYSTIC], 2004. Asensio et al., Enferm. Infecc. Microb. Clin. 2008 Lolans et al., AAC. 2006

Acinetobacter isolates resistant to carbapenems

37%

Carbapenem resistance in Acinetobacter baumannii

Impaired permeability related to porin changes

Penicillin binding protein modifications

Metallo-β-lactamases (Ambler class B β-lactamases) IMP, VIM, SIM [IMP-5 (one isolate Portugal)]

Carbapenem-hydrolyzing oxacillinases (Ambler class D β-lactamases)

OXA-23 (23,27,49) OXA-23 (23,27,49)

OXA-58OXA-58

OXA-40/24 (25,26,40)OXA-40/24 (25,26,40)

Acquired Carbapenem-Hydrolyzing Oxacillinases

Three diferent groups

Plasmidic /Chromosomal location

99%

99%60%

<48%

Distribution of OXA-23,-25,-26,-27,-40/24,-58

Acquired Carbapenem-Hydrolyzing Oxacillinases

OXA-23 (23,27,49) OXA-23 (23,27,49) OXA-58OXA-58OXA-40/24 (25,26,40)OXA-40/24 (25,26,40)

Chromosomal or, mostly, plasmid location

Quinteira et al, AAC 2007

Poirel & Nordman, CMI 2006Lolans et al, AAC 2006

OXA-40 plasmid located in A. baumannii and A. haemolyticus

Qi et al, AAC 2008

OXA-40 distribution in Portugal

1- HPA, Penafiel Index Case – 1995 OXA-33 (accession no. AY082394) => OXA-40

Da Silva et al., 1999 JCM

2- HGSA, Porto3- HUC, Coimbra4- HSM, Lisboa5- CHCB, Covilhã6- CHCR, Caldas da Rainha

Da Silva et al., 2004 JAC

12

3

4

5

6

OXA-40 A. baumannii Iberian clone

OXA-23 -A. baumannii producers in Portugal• 2006

• 2 isolates; one patient - Hosp. S.Teotónio

• 37 years old woman with a history of alcohol abuse. • Diagnostic: necrohaemorrhagic pancreatitis• Therapy: meropenem+ fluconazol• Day 9: Imipenem-resistant Ac. baumannii blood and intraperitoneal liquid • Ampicillin and amikacin, given for nineteen days • Isolation of XDR A. baumannii from intraperitoneal liquid • Pancreatic abcess resected• The patient was discharged after 18 weeks of hospitalization.

R S R R R RR R R R R R

β-lactams Amikacin Gentamicin Ciprofloxacin Tigecycline Colistin

PCR and sequencing revealed bla OXA23

Chromosomal location of bla OXA23

(I-Ceu-I analysis)

2006-2007:• Outbreak 2006- Hosp. Pedro Hispano (n=8)• Outbreak 2007- Hosp., Amarante (n=7)• Hosp. Sto António (n=1)

(bronchial secretions; urine; blood) 1

234

5

R S/R S/R R R R

Tigecycline Colistinβ-lactams Amikacin Gentamicin Ciprofloxacin

2007: 1 patient (Community)1 patient (Community)

R R R R R S

β-lactams Amikacin Gentamicin Ciprofloxacin Tigecycline Colistin

OXA-23 -A. baumannii producers in Portugal

(pus)

PFGE and MLST:

OXA-23 producing clone

Conclusions Emergence of OXA-23 producing A. baumannii in

portuguese hospitalised patients

Spread of an OXA-23 producing clone Associated to outbreaks and sporadic cases In an ambulatory patient which can further promote

community dissemination With an enlarged resistance profile

An alarming XDR (Extreme Drug Resistant) isolate, that evolved during therapy with ampiciliin and amikacin.

Less resistant strains were already able to disseminate throughout Iberia, causing mortality events.

Acknowledgments

Filipa Grosso Sandra QuinteiraCarla NovaisElisabete MachadoPatrícia AntunesAna Raquel FreitasRaquel Branquinho

Francisco Freitas (Hosp. S. Teotónio, Viseu) Helena Ramos (Centro Hospitalar do Porto, Porto) Luis Grañeda (Centro Hospitalar Cova da Beira, Covilhã) Mariana Viana (Hospital de Amarante) Luísa Cavaleiro e Valquíria Alves (Hospital Pedro Hispano, Matosinhos) Miguel Monteiro