Presentation on theme: "Final upgrading: Extreme-drug-resistant (XDR) Acinetobacter baumannii carrying blaOXA-23 in a patient with acute necrohaemorrhagic pancreatitis Luísa Vieira."— Presentation transcript:
1Final upgrading: Extreme-drug-resistant (XDR) Acinetobacter baumannii carrying blaOXA-23 in a patient with acute necrohaemorrhagic pancreatitisLuísa Vieira PeixeREQUIMTE. Laboratório de Microbiologia, Faculdade de Farmácia, Universidade do Porto, Portugal
2REQUIMTE- Microbiology Research Group Goals Goals Epidemiology study of antibiotic resistant bacteria in order to implement containment measures, methodologies for their detection, and design of new compoundsHospitalsFood and animal production environmentHumans communityEnvironmentVRE, Enterobacteriaceae- PL/TEM-52; PL/CTX-M-15, Pseudomonas-VIMEnterococcus gentaR,Tn1546PL/CTX-M-14; PL/CTX-M-15 (Enterobacteriaceae)VRE-CC17Acinetobacter OXA-23Salmonella-intI1 OXA-30, sul3 Enterobacteriaceae- PL/TEM-52Salmonella-intI1MDR, Enterobacteriaceae- PL/TEM-52StrategiesCharacterization of bacteria, genes and mobile genetic elements from different ecological nichesAAC :1001JAC (In press)AAC :1545CMI :1131JAC :297CMI :1047 JAC :1139EID :1985AAC :836AAC : AAC :451JAC :1370AAC :3613AEM :3743AAC :2140AEM :3364CMI :755AAC :3220Main Achievements(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 genesWorrisome contribution of hospital sewage for aquatic environmental contamination by resistant bacteriaWe Evidenced:
3Acinetobacter baumannii - Emergent Pathogen Acinetobacter on the news!Although a plethora(some would say a surfeit1) of immunologicaland molecular techniques is available for thediscrimination of pathogen isolates, many aspectsof pathogen diversity remain poorly described andincompletely understood. One of the microrganisms that catch our atention is Acinetobacter, mainly resulting from the clinical relevance of this genus in the last decade.
4Acinetobacter baumannii - Emergent Pathogen Significant nosocomial pathogenEspecially in immunocompromised patients or with underlying diseasesMainly Pneumonia (also bacteremia, meningitis, skin and wound infections)Mainly ICU64% of mortality rates associated to severe nosocomial infectionsRecent reports of community acquired infectionsPneumonia (rarely meningitis, cellulitis)Alcohol abuse, diabetis, cancer, or bronchopulmonary diseasesPossible Vector roleACINETOBACTER BAUMANNI IS NOW RECOGNIZED AS ONE OF THE KEY MULTI-DRUG RESISTANT ORGANISM REPRESENTING MAJOR CHALLENGES TO HOSPITALS WORLDWIDEMost infections occur in immunocompromised individuals, and the strain A. baumannii is the second most commonly isolated nonfermenting bacteria in human specimens.Acinetobacter is frequently isolated in nosocomial infections and is especially prevalent in intensive care unitsNEVERTHELESS, RECENTLY REPORTS LINK ACINTOBACTER TO COMMUNITY ACQUIRED INFECTIONS.Infections by A. baumannii are considered a worrisome phenomenon particularly affecting hospitalized patients, thus being commonly associated with a significantly increase in mortality 5. Wilson S, Knipe C, Zieger M, Gabehart K, Goodman J, Volk H, Sood R. Direct costs of multidrug-resistant Acinetobacter baumannii in the burn unit of a public teaching hospital. Am. J Infect Control. 2004;32:342–344.Clinical significanceAcinetobacter species are generally considered nonpathogenic to healthy individuals. However, several species persist in hospital environments and cause severe, life-threatening infections in compromised patients. The spectrum of antibiotic resistances of these organisms together with their survival capabilities make them a threat to hospitals as documented by recurring outbreaks both in highly developed countries and elsewhere. An important factor for their pathogenic potential is probably an efficient means of horizontal gene transfer even though such a mechanism has so far only been observed and analyzed in Acinetobacter baylyi, a species that lives in the soil and has never been associated with infections.Acinetobacter is frequently isolated in nosocomial infections and is especially prevalent in intensive care units, where both sporadic cases as well as epidemic and endemic occurrence is common. A. baumannii is a frequent cause of nosocomial pneumonia, especially of late-onset ventilator associated pneumonia. It can cause various other infections including skin and wound infections, bacteremia, and meningitis, but A. lwoffi is mostly responsible for the latter. A. baumannii can survive on the human skin or dry surfaces for weeks.Lowman W et al.,J. Med Microbiol. 2008Garcia-Garmendia JL et al. Clin. Infect. Dis. 2001
5Genus Acinetobacter 32 described Acinetobacter groups or named species Gram-negative coccobacillusNon-fermentersOxidase –Strict aerobes32 described Acinetobacter groups or named speciesBouvet and Grimont, 1986: Acinetobacter baumanniiA. calcoaceticus- A. baumanii complex (Gerner- Smidt, J. Clin. Microb., 1991)Acinetobacter baumanniiAcinetobacter calcoaceticusGenomic species 3TUGenomic species 13TUPhenotypically difficult to distinguish65-75% relatedness in DNA-DNA hybridizationA. baumannii, together with three other closely related Acinetobacter spp., Acinetobacter calcoaceticus and Acinetobacter genomicspecies 3 and 13TU, have been grouped together in the ‘A. calcoaceticus–A. baumannii. complex’ because they are very similarphenotypically and are often impossible to differentiate. A. baumannii and Acinetobacter genomic species 13TU are responsible for mostnosocomial infections, while Acinetobacter genomic species 3 is implicated less often in clinical Disease and A. calcoaceticus is an environmentalorganism that has been isolated rarely from clinical specimens.Micrococcus calcoaceticus – M.W. Beijrinck, 1911Acinetobacter calcoaceticusAcinetobacter- 32 speciesOutros métodos de identificação: Raman spectrometry, MALDI TOF Mass Spectrometry, recA, e gyrB sequenceNosocomial infections: A. Baumanni, 13 TU, & 3Identification: rDNA16S sequence, rpoB sequence, DNA restriction analysis 16S rDNA (ARDRA)Nosocomial infections: A. baumannii, groups 13TU & 3Ecological distribution of A. baumannii: undefined reservoir
6Acinetobacter baumannii - Emergent Pathogen WHY?Important factor for their pathogenic potential: efficient means of horizontal gene transfer(?)Survival capabilitiesAcquisition of virulence genesAbility to acquire resistance to antibioticsA. baylyi ADP1, A. baumannii AYE and A. baumannii SDF chromosomes. (PLOS One, 2008)?baumannii SDF chromosomes was isolated from a human body louseMulti-drug resistant human clinical isolate strain AYE responsible for a nationwide outbreak in France in 2001
7An 86-kb Resistance Island in epidemic A. baumannii Strain AYE Acinetobacter baumannii - Emergent Pathogen Ability to acquire resistance to antibioticsThis study led to the discovery in the AYE genome of an 86-kb region called a resistance “island”—the largest identified to date—that contains a cluster of 45 resistance genes. The homologous location in the susceptible strain, curiously, exhibited a 20-kb genomic island that is devoid of resistance markers. This ability to “switch” its genomic structure probably explains the unmatched speed at which A. baumannii captures resistance markers when under antibacterial pressure, such as is found in hospital intensive care units.An 86-kb Resistance Island in epidemic A. baumannii Strain AYE45 resistance genes
8Acinetobacter baumanii infections- major epidemiological features Propensity for clonal spreadInvolvement in hospital outbreaksEndemicity in certain hospitalsResistance to multiple antimicrobial agentsMany recent outbreaks have been caused by multidrug-resistant (MDR) strains of A. baumanniiSimilar to methicillin-resistant Staphylococcus aureus, major epidemiological features of these organisms include their propensity for clonal spread, their involvement in hospital outbreaks, and their resistance to multiple antimicrobial agents [2–6]. Many recent outbreaks have been caused by multidrug-resistant (MDR) strains of A. baumannii and have occurred in intensive care units where the extensive use of antibiotics may have contributed to the selection of highly resistant strains [7,8]Stoeva et al., CMI. 2008Quinteira et al. AAC. 2004Manikal et al., CID 2000
9Acinetobacter isolates resistant to carbapenems 37%In USA, A. Baumanni is na increasing cause of nosocomial infection in ICU.City wide outbreak of MDR Ab (42%) resistant to IP.Asensio et al. Provide useful information about trends in the prevalence of infections caused by carbapenem-resistant A. Baumannnii in Spanish hospitals. Following A DOWNWARD TREND BETWEEN 1997 AND 2002, THEY NOTE THAT CARBAPENEM-RESISTANCE HAS SINCE RISEN AGAIN, REACHING 37% IN 2005.Most notably, 14.6% of infections were considered communiy-acquired.Rodriguez-Bano presented a 3.6%...Perez et al., AACMeropenem Yearly Susceptibility Test Information Collection [MYSTIC], 2004.Asensio et al., Enferm. Infecc. Microb. Clin. 2008Lolans et al., AAC. 2006
10Carbapenem resistance in Acinetobacter baumannii Impaired permeability related to porin changesPenicillin binding protein modificationsMetallo-β-lactamases (Ambler class B β-lactamases) IMP, VIM, SIM [IMP-5 (one isolate Portugal)]Carbapenem-hydrolyzing oxacillinases (Ambler class D β-lactamases)MANY OF THESE NOSOCOMIAL ISOLATES ARE MULTIDRUG RESISTANT INCLUDING TO CARBAPENEMSSEVERAL MECHANISMS CONTRIBUTE TO CARBAPENEM RESISTANCE, NAMELY IMPERMEABILITY, PBP MODIFICATIONS , METALLO BETA LACTAMASE PRODUCTION AND WITH AN INCREASING RELEVANCE, THE PRODUCTION CARPENEM HYDROLIZING OXACILLINASES .
11Acquired Carbapenem-Hydrolyzing Oxacillinases Three diferent groupsOXA-58<48%99%OXA-23 (23,27,49)60%99%OXA-40/24 (25,26,40)Plasmidic /Chromosomal location
12Acquired Carbapenem-Hydrolyzing Oxacillinases Distribution of OXA-23,-25,-26,-27,-40/24,-58OXA-23 (23,27,49)OXA-58OXA-40/24 (25,26,40)Chromosomal or, mostly, plasmid locationHERE YOU HAVE THE WORLD DISTRIBUTION OF THE ACQUIRED OXACILLINASES(NICE TALKS ON THIS TOPICS WERE GIVEN BY LAURENT POIREL AND PATRICE NORDMANN IN THE LAST DAYS OF THIS EXCELENT EIGTHEEN ECCMID.)AS YOU CAN SEE THE MOST DISSEMINATED OXACILLINASE IS OXA FIFTY EIGHT AND OXA TWENTY THREE MOSTLY PLASMID LOCATEDTHE OXA FORTY ENZYME WAS FIRST IDENTIFIED IN ACINETOBACTER BAUMANNII ISOLATES FROM IBERIAN PATIENTS AND LATELY IN UNITED STATES.RECENTLY WE DESCRIBED THE PLASMIDIC LOCATION OF OXA-FORTY BOTH IN ACINETOBACTER BAUMANNII AND IN ACINETOBACTER HAEMOLYTICUS FROM PORTUGAL.OXA-40 plasmid located inA. baumannii and A. haemolyticusPoirel & Nordman, CMI 2006Lolans et al, AAC 2006Quinteira et al, AAC 2007Qi et al, AAC 2008
13OXA-40 distribution in Portugal 1234561- HPA, PenafielIndex Case – 1995OXA-33 (accession no. AY082394) => OXA-40Da Silva et al., 1999 JCM2- HGSA, Porto3- HUC, Coimbra4- HSM, Lisboa5- CHCB, Covilhã6- CHCR, Caldas da RainhaDa Silva et al., 2004 JACIN PORTUGAL, THE FIRST DESCRIPTION OF A CARBAPENEMASE- PRODUCING ACINETOBACTER BAUMANNII WAS IN NINETEEN NINETY FIVE FROM A HOSPITAL ON THE NORTH.SOON AFTER, AN INCREASING NUMBER OF ISOLATES FROM DIFFERENT HOSPITALS THROUGHOUT OUR COUNTRY WERE PROGRESSIVELY OBSERVED ALL OVER THE LAST YEARS.ALL ISOLATES WERE CLONALLY RELATED AND OXA FORTY PRODUCERS BELONGING TO THE IBERIAN CLONEOXA-40 A. baumannii Iberian clone
14OXA-23 -A. baumannii producers in Portugal 20062 isolates; one patient - Hosp. S.Teotónio37 years old woman with a history of alcohol abuse.Diagnostic: necrohaemorrhagic pancreatitisTherapy: meropenem+ fluconazolDay 9: Imipenem-resistant Ac. baumannii blood and intraperitoneal liquidAmpicillin and amikacin, given for nineteen daysIsolation of XDR A. baumannii from intraperitoneal liquidPancreatic abcess resectedThe patient was discharged after 18 weeks of hospitalization.I-Ceu-I corta no gene rrlPCR and sequencing revealed bla OXA23Chromosomal location of bla OXA23(I-Ceu-I analysis)
15OXA-23 -A. baumannii producers in Portugal :Outbreak Hosp. Pedro Hispano (n=8)Outbreak Hosp., Amarante (n=7)Hosp. Sto António (n=1)(bronchial secretions; urine; blood)52007: 1 patient (Community)2431Subsequentemente bforam encontardos produtores em diferente hospitais todosdomesmo clone, tb disseminado em esopanha=Iberian clone. Um dos hospitais em que a incidencia de resiste aos carabapene os e mto elevada foi o hosp objecto deste estudo(pus)PFGE and MLST:OXA-23 producing clone
16ConclusionsEmergence of OXA-23 producing A. baumannii in portuguese hospitalised patientsSpread of an OXA-23 producing cloneAssociated to outbreaks and sporadic casesIn an ambulatory patient which can further promote community disseminationWith an enlarged resistance profileAn 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.the inactivity of the antimicrobial agents colistin and tigecycline, recently used as a last therapeutic options for MDR A. baumannii infections.
17Acknowledgments 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 MonteiroFilipa GrossoSandra QuinteiraCarla NovaisElisabete MachadoPatrícia AntunesAna Raquel FreitasRaquel Branquinho