GR13-type plasmids in Acinetobacter potentiate the accumulation and horizontal transfer of diverse accessory genes

Carbapenem resistance and other antibiotic resistance genes (ARGs) can be found in plasmids in Acinetobacter, but many plasmid types in this genus have not been well-characterised. Here we describe the distribution, diversity and evolutionary capacity of rep group 13 (GR13) plasmids that are found in Acinetobacter species from diverse environments. Our investigation was prompted by the discovery of two GR13 plasmids in A. baumannii isolated in an intensive care unit (ICU). The plasmids harbour distinct accessory genes: pDETAB5 contains blaNDM-1 and genes that confer resistance to four further antibiotic classes, while pDETAB13 carries putative alcohol tolerance determinants. Both plasmids contain multiple dif modules, which are flanked by pdif sites recognised by XerC/XerD tyrosine recombinases. The ARG-containing dif modules in pDETAB5 are almost identical to those found in pDETAB2, a GR34 plasmid from an unrelated A. baumannii isolated in the same ICU a month prior. Examination of a further 41 complete, publicly available plasmid sequences revealed that the GR13 pangenome consists of just four core but 1086 accessory genes, 123 in the shell and 1063 in the cloud, reflecting substantial capacity for diversification. The GR13 core genome includes genes for replication and partitioning, and for a putative tyrosine recombinase. Accessory segments encode proteins with diverse putative functions, including for metabolism, antibiotic/heavy metal/alcohol tolerance, restriction-modification, an anti-phage system and multiple toxin-antitoxin systems. The movement of dif modules and actions of insertion sequences play an important role in generating diversity in GR13 plasmids. Discrete GR13 plasmid lineages are internationally disseminated and found in multiple Acinetobacter species, which suggests they are important platforms for the accumulation, horizontal transmission and persistence of accessory genes in this genus.

Microbiological Profile, Antimicrobial Susceptibility, and Outcome Among Patients Admitted to Addis Ababa Intensive Care Units; a Cross-sectional Study.

Background: ICU infections are major health care problems affecting millions globally each year. ICU mortality of infectious patients is increasing and as high as 14.31% to 45.4%. The objective of this study was to determine microbiological culture profile, their antimicrobial susceptibility and treatment outcome of patients admitted to intensive care units.Methods and materials: An institutional based cross sectional study was conducted in all patients with microbiological culture and susceptibility results after admission to intensive care units from January 2019 to December 2019. A modified, pretested questionnaire was used to collect data and analyzed using SPSS version 25. Correlation and regression analysis was done for association. P value of <0.05 with CI of 95% was taken as clinically significant.Results: A total of 106 patients with 173 culture results were analyzed. Majority 68(64.2%) were males and the mean age of the patients were 35.08 ± 1.6 years. The most common source of infection was the pulmonary system 84(54.5%) followed by urinary tract infection 26(16.9%). Forty-four (25.43%) of cultures had growth. Gram negative microorganisms were identified in 35(68.63%) of isolates and Acinetobacter species accounts for 10(28.57%) followed by Klebsiella pneumonia and E. coli 7(13.725%) each. Generally, higher resistance was observed with cephalosporins and penicillins, whereas sensitivity to carbapenems, PIP/TAZ, and amikacin was satisfactory. The mortality associated with intensive care infections was found to be 32.1%.Conclusion: This study revealed that the mortality rate associated with ICU infection was 32.1%. Early identification, targeted provision of antimicrobials based on microbiological culture and susceptibility result has to be implemented to have better outcome. Designs of future multicenter and large studies are crucial to improve outcome of critically ill patients.

Cleaning and disinfecting surfaces in hospitals and long-term care facilities for reducing hospital and facility-acquired bacterial and viral infections: A systematic review

Background: Multiply drug-resistant organisms (MDROs) in hospitals and long-term care facilities (LTCFs) of particular concern include meticillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus, multidrug-resistant Acinetobacter species and extended spectrum beta-lactamase producing organisms. Respiratory viruses include influenza and SARS-CoV-2. Aim: To assess effectiveness of cleaning and disinfecting surfaces in hospitals and LTCFs. Methods: CINAHL, Cochrane CENTRAL Register of Controlled Trials, EMBASE, Medline, and Scopus searched inception to 28 June 2021, no language restrictions, for randomized controlled trials, cleaning, disinfection, hospitals, LTCFs. Abstracts and titles were assessed and data abstracted independently by two authors. Findings: Of fourteen c-RCTs in hospitals and LTCFs, interventions in ten were focused on reducing patient infections of four MDROs and/or healthcare-associated infections (HAIs). In four c-RCTs patient MDRO and/or HAI rates were significantly reduced with cleaning and disinfection strategies including bleach, quaternary ammonium detergents, ultraviolet irradiation, hydrogen peroxide vapour and copper-treated surfaces or fabrics. Of three c-RCTs focused on reducing MRSA rates, one had significant results and one on Clostridioides difficile had no significant results. Heterogeneity of populations, methods, outcomes and data reporting precluded meta-analysis. Overall risk of bias assessment was low but high for allocation concealment, and GRADE assessment was low risk. No study assessed biofilms. Conclusions: Ten c-RCTs focused on reducing multiple MDROs and/or HAIs and four had significant reductions. Three c-RCTs reported only patient MRSA colonization rates (one significant reductions), and one focused on Clostridioides difficile (no significant differences). Standardised primary and secondary outcomes are required for future c-RCTs including detailed biofilm cleaning/disinfection interventions.

Case Report on Guillain-Barre Syndrome (GBS) in Adult

Introduction: Guillain-Barre-syndrome is when the immune system attacks the peripheral nervous system were disease progresses to trembling and muscle weakness in both hands and legs, which progress to upper body and arms. Clinical Findings: High grade intermittent fever, low back pain, B/L LL weak, urinary incontinence which is intermittent in nature. Diagnostic Evaluation: Neurological examination- revealed B/L UL and LL weakness, acute onset of quadriparesis. X-Ray – revealed normal sinus rhythm. CSF examination – revealed No RBC; No pus cell; No Organism seen. Lab investigation – Hb% 10%, total RBC count 4.45, total WBC 10400, total platelet 2.33, SGOT 226 SGPT 83, Peripheral Smear RBCs - Normocytic Normochromic platelets adequate smear no Haemoparasite seen. Blood Culture: revealed Growth of Acinetobacter species. Therapeutic Intervention: Inj. Optineurone 1gm, Inj.Pantop 40mg, Tab.PCM,Inj. Tramadol 500mg, Immunoglobin (Ig) 100ml , physiotherapy and supportive therapy. Outcome: The symptoms and clinical state of the patient improved over time. The patient's weakness began to improve after 5 days of IV-Ig therapy. Conclusion: The patient was hospitalised to the neurosurgery ICU AVBRH on 05/06/20 with the known case of guillain-barre syndrome-(GBS). After receiving therapy, she showed significant progress.

Comparison of Colistin MIC by Microbroth Dilution, E-Test and Vitek-2, in Isolates of Acinetobacter spp. Isolated from Bloodstream Infections

Background: Acinetobacter species are leading cause of nosocomial infections, causing significant morbidity and mortality globally including India. Being persistent in the hospital environment and rapidly developing resistance to a wide variety of antibiotics are the most important features of this pathogen. The present study aimed to compare Colistin MIC of Acinetobacter species isolated from the blood samples by E test and Vitek 2 to the standard broth micro dilution test. Methodology: Two antibiotic susceptibility test methods, The Vitek-2 and the E test, against the reference broth micro dilution method in terms of the various parameters such as Reproducibility, reliability, cost and time effectiveness. Data obtained from the current study regarding antimicrobial resistance of Acinetobacter species recovered from clinical specimens referred to microbiology laboratory of SKIMS and was analyzed by using SPSS20.0. Results: Out of 100 isolates of Acinetobacter species analyzed from blood specimens the distribution of Acinetobacter species according to different clinical diagnosis of patients 89% were A. baumannii and 11% were A. lwoffii. Seventy three percent of them were from males and 27% of them were from females with a mean age of 39.6 (SD±27.46). Regarding the specimen and isolate sources, the majority were from ICU (54%), Surgical ward (26%), Medical ward (16%) and 4% from Outpatient department of SKIMS. Significant descending trends of antimicrobial resistance was shown for Amoxicillin/Clavulanic acid, Cefoperazone/ Sulbactam combination, Cotrimoxazole (100%), Levofloxacin (92%) Piperacillin/Tazobactam, Ciprofloxacin (90%), Cephalosporins (>80%), Imipenem and Meropenem (76%), Amikacin (68%), Gentamycin (67%), Tigecycline (11%) and 0% for Colistin respectively. Conclusion: from the study it could be concluded that the best reference method for testing susceptibility to the Polymyxins still remains to be defined. However, in routine clinical practice in most regions worldwide, where a reference method can hardly be implemented, the interpretation of Colistin susceptibility should preferably be based on results of automated systems such as Vitek-2 or the E test. The micro broth Dilution method remains the most reliable and reproducible, however most tedious and time-consuming method. Colistin remains a very effective, least resisted drug for MDR Acinetobacter species as compared by all the three methods. Keywords: Acinetobacter species; Antimicrobial resistance; Colistin; E test and Vitek 2.

Microbiological profile and antibiotic vulnerability of bacterial isolates

The development of multiple types of infections in patients admitted to the oncology ward is quite obvious. The infection accompanying mortality in cancer patients is attributed majorly to bacteria and then to fungi. Infections can be successful if an appropriate antibiotic is used based on the knowledge of their sensitivity pattern as well as commonly occurring bacteria. A retrospective study was designed to assess numerous bacteria isolated from infections in cancer patients reported to oncology centers of tertiary care hospitals in the Makkah region, Saudi Arabia. Total, 678 cancer patients were enrolled during this study. The clinical isolates were obtained from urine, blood, respiratory samples, soft tissues and skin areas. The processing of the samples was done in accordance with the “Standard Microbiology Laboratory Operating Procedures”. The identification of the isolated was done to their species and vulnerability tests were done as per the guidelines of “Clinical Laboratory Standards Institute”. During this study, 300 samples were acquired from both medical and surgical oncology wards and were cultured during the study period. Klebsiella pneumonia, Staphylococcus aureus, Acinetobacter species, Escherichia coli and Pseudomonas aeruginosa were the microbes that were encountered mostly. The resistance against various antibiotics was found to be encountered by Acinetobacter species whereas resistance against fluoroquinolones, cephalosporin and carbapenems was >50%, found to be encountered by K. pneumonia. There was 43.80% resistance was found against methicillin by the Staph. aureus species. This study concludes that an enhanced antibiotic resistance was found by gram-negative bacilli specifically, E. coli, K. pneumonia and Acinetobacter species. The resistance pattern was not found remarkably in gram-positive strains although, MRSA frequency is found to be upsurged.

Bacterial coinfections and secondary infections in COVID-19 patients from a tertiary care hospital of northern India: Time to adhere to culture-based practices

Objective: Bacterial co-pathogens are common in various viral respiratory tract infections, leading to increased disease severity and mortality. Still, they are understudied during large outbreaks and pandemics. This study was conducted to highlight the overall burden of these infections in COVID-19 patients admitted to our tertiary care hospital, along with their antibiotic susceptibility patterns. Material and methods: During the six-month study period, clinical samples (blood samples, respiratory samples, and sterile body fluids, including cerebrospinal fluid [CSF]) of COVID-19 patients with suspected bacterial coinfections (at presentation) or secondary infections (after 48 hours of hospitalization) were received and processed for the same. Results: Clinical samples of 814 COVID-19 patients were received for bacterial culture and susceptibility. Out of the total patient sample, 75% had already received empirical antibiotics before the samples were sent for analysis. Overall, 17.9% of cultures were positive for bacterial infections. Out of the total patients with bacterial infection, 74% (108/146) of patients had secondary bacterial infections (after 48 hours of hospitalization) and 26% (38/146) had bacterial coinfections (at the time of admission). Out of the 143 total isolates obtained, the majority (86%) were gram-negative organisms, of which Acinetobacter species was the commonest organism (35.6%), followed by Klebsiella pneumoniae (18.1%). The majority (50.7%) of the pathogenic organisms reported were multidrug resistant. Conclusion: The overall rate of secondary bacterial infections (SBIs) in our study was lower (7.9%) than reported by other studies. A rational approach would be to adhere to the practice of initiating culture-based guidance for antibiotics and to restrict unnecessary empirical antimicrobial therapy.

Antimicrobial resistance in wastewater of Yangon Region, Myanmar from one health perspective

Background: Antibiotic resistance is an emerging concern both for public and animal health globally and also threatens the achievements of modern medicine. This study aimed to generate the baseline data of drug resistance pathogens in diversity of waste water of Yangon Region, Myanmar.Methods: A cross-sectional descriptive study was conducted from January to July 2021. A total of forty samples of wastewater (two samples each from ten hospitals, one sample each from five poultry farms, five aquacultures and ten community drains) were aseptically collected, transported in ice box and processed following standard procedure for bacterial isolation and detection of antibiotic sensitivity pattern. Identification and antibiotic susceptibility testing of isolated colonies were done by VITEK 2 compact system.Results: A total of 106 bacterial isolates were identified and 50% were from hospitals, 31.1%were from community drains and 9.4% each from poultry farms and aquacultures. The most frequently identified isolates were Enterobacteriaceae (65.1%) followed by Acinetobacter species (11.3%) and Pseudomonas species (8.5%). Among the isolated organisms, ESBL producers and Carbapenemase producer were 7.5% and 0.9% respectively. ESBL producers (62.5%) were resistant to cefuroxime, cefuroxime-axetil, cefotaxime, ceftriaxone and minocycline. Carbapenem resistant Enterobacteriaceae was multidrug resistant but sensitive to amikacin, tigecycline and cefaclor.Conclusions: The proportion of antibiotic resistant bacteria are higher in hospital wastewater than other sites. Hence proper treatment plant for hospital wastewater should be installed and need to mitigate antibiotic resistance with a ‘one-health’ approach.

Incidence of emerging multidrug-resistant organisms and its impact on the outcome in the pediatric intensive care

Background Healthcare-associated infections (HCAI) are a worldwide threat in intensive care units particularly in the pediatric intensive care units with a major cause of morbidity and mortality among this age group. The aim of the study is to determine the prevalence and risk factors predisposing to multidrug-resistant organisms (MDROs) infections among pediatric intensive care unit (PICU) patients at Ain Shams Pediatric University Hospitals as well as determining mortality and morbidity rates along with the length of stay at PICU. Results Culture results revealed that of the 282 patients evaluated, only 26 (9.2%) were MDROs (half of the affected patients had Acinetobacter species (50%) and the rest of them were free, 256 (90.8%). Our study revealed that the majority of MDROs were isolated from sputum in more than half of the patients 19/32 (59.3%) followed by whole blood in 10/32 (31.2%) and urine in 3/32 (9.4%). Pulmonary system was the most common affected site and was mainly colonized by MDR Acinetobacter (71.4%) followed by MDR Klebsiella (41.6%). Regarding MDR risk factors in our PICU, multivariate logistic regression analyses showed significant relationship between MDROs and age under 1 year (odds ratio [OR] 2.4554; 95% confidence interval [95% CI] (1.072–5.625); p = 0.043) and underlying pulmonary disease (OR 2.417; 95% CI (1.014–5.761); p = 0.592). A statistically significant higher mortality was detected in patients colonized with MDROs 9/26 (34.6%) versus MDROs non-colonized patients 32/256 (12.5%) [P=0.002]. Moreover, MDROs infection has negative significant risk with discharged patients ([OR] 0.269; [95% CI] (0.111–0.656); p = 0.002). Additionally, patients infected with MDROs did have significantly greater PICU stay than those non-infected [median (IQR), 16.5 (10.7–22), 5 (4–8), P=0.00] and have longer ventilation [median (IQR), 15.5 (10–18), 3 (2–10), P=0.00]. Conclusion Prevalence of MDROs (9.2%) was low among PICU cases at Ain Shams University Hospitals. Most common MDROs were Acinetobacter and Klebsiella followed by pseudomonas species. The frequency of gram-negative organisms is much more common than gram-positive organisms. An increasing rate of antimicrobial resistance with increasing mortality and morbidity among PICU patients is observed worldwide; even for new categories, so, strict infection control programs should be implemented.

High antibiotic resistance and mortality with Acinetobacter species in a tertiary hospital, Nepal

SETTING: Nepal Mediciti Hospital, Bhainsepati, Lalitpur, NepalOBJECTIVES: To determine antimicrobial resistance patterns, and the number and proportion of multidrug-resistant (MDR-) and extensively drug-resistant (XDR-) cases among all patients with Acinetobacter isolates between September 2018 and September 2019.DESIGN: This was a hospital laboratory-based, cross-sectional studyRESULTS: Acinetobacter spp. (n = 364) were more common in respiratory (n = 172, 47.3%) and invasive samples such as blood, body fluids (n = 95, 26.1%). Sensitivity to AWaRe (Access, Watch and Reserve) Group antibiotics (tigecycline, polymyxin B, colistin) remained high. MDR (resistance to at least three classes of antimicrobial agents) (n = 110, 30.2%) and XDR (MDR plus carbapenem) (n = 87, 23.9%) isolates were most common in the Watch Group of antibiotics and found in respectively 99 (31.0%) and 78 (24.5%) patients (n = 319). Infected patients were more likely to be aged >40 years (n = 196, 61.4%) or inpatients (n = 191, 59.9%); 76 (23.8%) patients had an unfavourable outcome, including death (n = 59, 18.5%).CONCLUSION: A significant proportion of MDR and XDR isolates was found; nearly one patient in five died. Robust hospital infection prevention and control measures (particularly for respiratory and invasive procedures) and routine surveillance are needed to reduce infections and decrease the mortality rate. Tigecycline, polymyxin B and colistin should be cautiously used only in MDR and XDR cases.