Determining the Risk Factors for Nosocomial Multidrug-Resistant Acinetobacter Infections in Patients in Intensive Care Units and Genotyping of Isolates

Abstract

Objective: This study aimed to identify the risk factors for hospital-acquired Acinetobacter baumannii infections in an intensive care unit (ICU), delineate the antibiotic resistance profiles of isolates, and elucidate the clonal relationships among strains through genotypic analysis. Materials and Methods: This prospective case-control study was conducted between April 2011 and March 2012 and included 213 patients. The antibiotic susceptibility of Acinetobacter strains was evaluated using the Kirby–Bauer disk diffusion method. The DiversiLab system was used to determine the clonal relationships among A. baumannii strains. Results: The key independent risk factors for hospital-acquired A. baumannii infections included age, mechanical ventilator use, tracheotomy, percutaneous endoscopic gastrostomy (PEG), carbapenem administration, and nonuse of cephalosporins. High multi-antibiotic resistance was observed in 94% of the isolates. Furthermore, a substantial clonal closeness with an 86% clustering rate was observed among the isolates, with the largest cluster (P5) comprising 24 isolates persisting for approximately 14 months in the hospital setting. Conclusions: The findings indicate the need for targeted preventive measures against specific risk factors for A. baumannii infections in ICUs. The genotypic analysis revealed significant clonal spread, necessitating enhanced infection control strategies.

Keywords

• Acinetobacter infections
• genotype
• intensive care units

Yoğun Bakım Ünitesinde Nosokomiyal Çoklu İlaç Dirençli Acinetobacter Enfeksiyonları için Risk Faktörlerinin Belirlenmesi ve İzolatların Genotiplendirilmesi

Abstract

Amaç: Bu çalışma, Yoğun Bakım Ünitesi 'nde (YBÜ) hastane kaynaklı Acinetobacter baumannii enfeksiyonları ile ilişkili risk faktörlerini belirlemeyi, izolatların antibiyotik direnç profillerini çizmeyi ve genotipik analiz yoluyla suşlar arasındaki klonal ilişkileri aydınlatmayı amaçlamaktadır. Materyal ve Metot: Bu çalışma Nisan 2011 ile Mart 2012 tarihleri ​​arasında prospektif vaka-kontrol çalışması olarak yürütülmüş olup 213 hastayı kapsamaktadır. Acinetobacter suşlarının antibiyotik duyarlılıkları, Kirby–Bauer disk difüzyon yöntemi kullanılarak değerlendirilmiştir. A. baumannii suşları arasındaki klonal ilişkilerin belirlenmesi için DiversiLab sistemi kullanılmıştır. Bulgular: Hastane kaynaklı Acinetobacter enfeksiyonu için bağımsız anahtar risk faktörleri yaş, mekanik ventilatör kullanımı, trakeotomi, perkütan endoskopik gastrostomi (PEG) uygulaması, karbapenem verilmesi ve sefalosporin kullanılmamasıdır. İzolatların %94'ünde yüksek çoklu antibiyotik direnci gözlemlenmiştir. Ayrıca izolatlar arasında %86 oranında belirgin bir klonal yakınlık gözlenmiş, en büyük kümeyi (P5) yaklaşık 14 ay boyunca hastane ortamında süregelen 24 izolat oluşturmuştur. Sonuç: Bulgular, YBÜ'lerinde A. baumannii enfeksiyonları için belirli risk faktörlerine karşı hedeflenmiş önleyici tedbirlerin gerekliliğini vurgulamaktadır. Genotipik inceleme, artırılmış enfeksiyon kontrol stratejilerini gerektiren önemli bir klonal yayılımı ortaya koymaktadır.

Keywords

• Acinetobacter enfeksiyonları
• genotip
• yoğun bakım üniteleri

References

1. Fournier PE, Richet H. The epidemiology and control of Acinetobacter baumannii in health care facilities. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America. 2006;42(5):692-699. doi:10.1086/500202
2. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States 2019. https://ndc.services.cdc.gov/wp-content/uploads/Antibiotic-Resistance-Threats-in-the-United-States-2019.pdf. Accessed August 7, 2024.
3. Freire MP, de Oliveira Garcia D, Garcia CP, et al. Bloodstream infection caused by extensively drug-resistant Acinetobacter baumannii in cancer patients: high mortality associated with delayed treatment rather than with the degree of neutropenia. Clin Microbiol Infect. 2016;22(4):352-358. doi: 10.1016/j.cmi.2015.12.010
4. Ren J, Li X, Wang L, Liu M, Zheng K, Wang Y. Risk Factors and Drug Resistance of the MDR Acinetobacter Baumannii in Pneumonia Patients in ICU. Open Med (Wars). 2019;14:772-777. doi:10.1515/med-2019-0090
5. Falah F, Shokoohizadeh L, Adabi M. Molecular identification and genotyping of Acinetobacter baumannii isolated from burn patients by PCR and ERIC-PCR. Scars Burn Heal. 2019;5:2059513119831369. doi:10.1177/2059513119831369
6. Akavipat P, Thinkhamrop J, Thinkhamrop B, Sriraj W. Acute physiology and chronic health evaluation (APACHE) II score-the clinical predictor in neurosurgical intensive care unit. Acta Clin Croat. 2019;58(1):50-56. doi10.20471/acc.2019.58.01.07
7. Djuric O, Markovic-Denic L, Jovanovic B, Bumbasirevic V. Agreement between CDC/NHSN surveillance definitions and ECDC criteria in diagnosis of healthcare-associated infections in Serbian trauma patients. PLoS One. 2018;13(10):e0204893. doi:10.1371/journal.pone.0204893
8. Humphries R, Bobenchik AM, Hindler JA, Schuetz AN. Overview of changes to the clinical and laboratory standards institute performance standards for antimicrobial susceptibility testing, M100, 31st edition. J Clin Microbiol. 2021;59(12):e0021321. doi:10.1128/JCM.00213-21

9. Falagas ME, Kasiakou SK. Colistin: the revival of polymyxins for the management of multidrug-resistant gram-negative bacterial infections. Clin Infect Dis. 2005;40(9):1333-1341. doi:10.1086/429323
10. Accessdata.fda.gov. Tygacil (tigecycline) i.v. İnjection Label 2010. https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/021821s021lbl.pdf. Accessed June 26, 2024.
11. Falagas ME, Koletsi PK, Bliziotis IA. The diversity of definitions of multidrug-resistant (MDR) and pandrug-resistant (PDR) Acinetobacter baumannii and Pseudomonas aeruginosa. J Med Microbiol. 2006;55(12):1619-1629. doi:10.1099/jmm.0.46747-0
12. Aljindan R, Alsamman K, Elhadi N. ERIC-PCR genotyping of Acinetobacter baumannii isolated from different clinical specimens. Saudi J Med Med Sci. 2018;6(1):13-17. doi:10.4103/sjmms.sjmms_138_16
13. El-Kazzaz W, Metwally L, Yahia R, Al-Harbi N, El-Taher A, Hetta HF. Antibiogram, prevalence of OXA carbapenemase encoding genes, and rapd-genotyping of multidrug-resistant Acinetobacter baumannii incriminated in hidden community-acquired infections. Antibiotics (Basel). 2020;9(9):603. doi:10.3390/antibiotics9090603
14. Cetin ES, Durmaz R, Tetik T, et al. Epidemiologic characterization of nosocomial Acinetobacter baumannii infections in a Turkish university hospital by pulsed-field gel electrophoresis. Am J Infect Control. 2009;37(1):56-64. doi:10.1016/j.ajic.2008.01.010
15. Zarrilli R, Bagattini M, Migliaccio A, Esposito EP, Triassi M. Molecular epidemiology of carbapenem-resistant Acinetobacter baumannii in Italy. Ann Ig. 2021;33(5):401-409. doi:10.7416/ai.2020.2395.
16. Chilam J, Argimón S, Limas MT, et al. Philippines antimicrobial resistance surveillance program. genomic surveillance of Acinetobacter baumannii in the Philippines, 2013-2014. Western Pac Surveill Response J. 2021;12(4):1-15. doi:10.5365/wpsar.2021.12.4.863
17. Alnimr A, Alamri A, Alsultan A. Genetic diversity of imipenem-resistant Acinetobacter baumannii infections at an intensive care unit. Crit Care Res Pract. 2020;2020(1):3290316. doi:10.1155/2020/3290316
18. Alrahmany D, Omar AF, Alreesi A, Harb G, Ghazi IM. Acinetobacter baumannii infection-related mortality in hospitalized patients: risk factors and potential targets for clinical and antimicrobial stewardship interventions. Antibiotics (Basel). 2022;11(8):1086. doi:10.3390/antibiotics11081086
19. Kumar A, Chaudhry D, Goel N, Tanwar S. Epidemiology of intensive care unit-acquired infections in a tertiary care hospital of North India. Indian J Crit Care Med. 2021;25(12):1427-1433. doi:10.5005/jp-journals-10071-24058
20. Bisaro F, Shuman HA, Feldman MF, Gebhardt MJ, Pukatzki S. Acinetobacter baumannii ATCC 17978 encodes a microcin system with antimicrobial properties for contact-independent competition. Microbiology (Reading). 2023;169(6):001346. doi:10.1099/mic.0.001346
21. Kurihara MNL, Sales RO, Silva KED, Maciel WG, Simionatto S. Multidrug-resistant Acinetobacter baumannii outbreaks: a global problem in healthcare settings. Rev Soc Bras Med Trop. 2020;53:e20200248. doi:10.1590/0037-8682-0248-2020
22. Liu L, Liu B, Li W. Successful incidences of controlling multidrug-resistant, extensively drug-resistant, and nosocomial infection Acinetobacter baumannii using antibiotic stewardship, infection control programs, and environmental cleaning at a Chinese university hospital. infect drug resist. 2020;13:2557-2570. doi:10.2147/IDR.S260525
23. Hsu LY, Apisarnthanarak A, Khan E, Suwantarat N, Ghafur A, Tambyah PA. Carbapenem-resistant Acinetobacter baumannii and enterobacteriaceae in south and Southeast Asia. Clin Microbiol Rev. 2017;30(1):1-22. doi:10.1128/CMR.masthead.30-1
24. Karakonstantis S. A systematic review of implications, mechanisms, and stability of in vivo emergent resistance to colistin and tigecycline in Acinetobacter baumannii. J Chemother. 2021;33(1):1-11. doi:10.1080/1120009X.2020.1794393
25. Jo J, Ko KS. Tigecycline heteroresistance and resistance mechanism in clinical isolates of Acinetobacter baumannii. Microbiol Spectr. 2021;9(2):e0101021. doi:10.1128/Spectrum.01010-21
26. Cai Y, Chai D, Wang R, Liang B, Bai N. Colistin resistance of Acinetobacter baumannii: clinical reports, mechanisms and antimicrobial strategies. J Antimicrob Chemother. 2012;67(7):1607-1615. doi:10.1093/jac/dks084