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Update on the Epidemiology, Treatment, and Outcomes of Carbapenem-Resistant Acinetobacter Infections

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Update on the Epidemiology, Treatment, and Outcomes of Carbapenem-Resistant Acinetobacter Infections Review Article www.cmj.ac.kr Update on the Epidemiology, Treatment, and Outcomes of Carbapenem-resistant Acinetobacter infections Uh Jin Kim, Hee Kyung Kim, Joon Hwan An, Soo Kyung Cho, Kyung-Hwa Park and Hee-Chang Jang* Department of Infectious Diseases, Chonnam National University Medical School, Gwangju, Korea Carbapenem-resistant Acinetobacter species are increasingly recognized as major no- Article History: socomial pathogens, especially in patients with critical illnesses or in intensive care. received 18 July, 2014 18 July, 2014 The ability of these organisms to accumulate diverse mechanisms of resistance limits revised accepted 28 July, 2014 the available therapeutic agents, makes the infection difficult to treat, and is associated with a greater risk of death. In this review, we provide an update on the epidemiology, Corresponding Author: resistance mechanisms, infection control measures, treatment, and outcomes of carba- Hee-Chang Jang penem-resistant Acinetobacter infections. Department of Infectious Diseases, Chonnam National University Medical Key Words: Acinetobacter baumannii; Colistin; Drug therapy School, 160, Baekseo-ro, Dong-gu, Gwangju 501-746, Korea This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial TEL: +82-62-220-6296 License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, FAX: +82-62-225-8578 distribution, and reproduction in any medium, provided the original work is properly cited. E-mail: [email protected] INTRODUCTION species by their phenotypic traits is difficult, and identi- fication of individual species by use of current automated Acinetobacter species are aerobic gram-negative bacilli or manual commercial systems will require further con- that are ubiquitous in natural environments such as soil firmation testing. Nowadays, with advancements in mo- and water. These species are occasionally found as com- lecular bacterial taxonomy, particularly 16S rDNA se- mensals on the skin and throat and in secretions of healthy quencing and DNA-DNA hybridization, species can be dis- people. It was previously believed that Acinetobacter spe- tinguished more accurately. Currently, the genus Acineto- cies were not a common human pathogen and that they bacter contains 34 formally named species (Table 1).2 were uncommon causes of infection. However, Acineto- Among the Acinetobacter species, Acinetobacter bau- bacter species are now one of the most common organisms isolated from hospital environments and hospitalized 1 patients. Acinetobacter species have excellent biofilm- TABLE 1. Updated list of validated named species of Acinetobacter producing ability and intrinsic and acquired resistance to various antibiotic agents, all of which facilitate their sur- Commonly found human pathogens A. baumannii (genospecies 2) vival in hospital environments. For these reasons, Acineto- A. nosocomialis (genospecies 13TU) bacter species are frequently found on the skin and in the A. pittii (genospecies 3) respiratory and urinary tracts of hospitalized patients. A. calcoaceticus (genospecies 1) Uncommon organisms in clinical infections MICROBIOLOGY AND TAXONOMY A. baylyi A. guillouiae A. lwoffii A. soli A. beijerinckii A. gyllenbergii A. nectaris A. tandoii The genus Acinetobacter belongs to the subclass A. bereziniae A. haemolyticus A. parvus A. tjernbergiae γ-Proteobacteria, family Moraxellaceae, and comprises a A. boissieri A. harbinensis A. puyangensis A. towneri heterogeneous group of aerobic nonhemolytic gram-neg- A. bouvetii A. indicus A. qingfengensis A. ursingii ative coccobacilli, which are usually found in diploid for- A. brisouii A. johnsonii A. radioresistens A. venetianus A. gerneri A. junii A. rudis mation or chains of variable length. Acinetobacter spp. are a oxidase-negative, catalase-positive, indole-negative, and A. grimontii A. kookii A. schindleri nitrate-negative. However, identification of individual aSynonym of A. junii. http://dx.doi.org/10.4068/cmj.2014.50.2.37 Ⓒ Chonnam Medical Journal, 2014 37 Chonnam Med J 2014;50:37-44 Update on the Epidemiology, Treatment, and Outcomes of Carbapenem-resistant Acinetobacter Infections mannii, Acinetobacter pittii (genospecies 3), and Acineto- Acinetobacter species to acquire antibiotic resistance, lead- bacter nosocomialis (genospecies 13TU) (together forming ing to MDR and even PDR.12 There are many mechanisms the “A. baumannii complex”) are closely related; they are of antibiotic resistance; here we discuss only resistance to considered important nosocomial pathogens and account carbapenem and colistin. for most clinically significant infections. These three spe- Resistance to carbapenems is often mediated by serine cies together with another closely related Acinetobacter oxacillinases (OXAs; Amber class D), which are encoded by species commonly found in the natural environment, the blaOXA-23, blaOXA-40, blaOXA-58, and metallo-β-lactamases Acinetobacter calcoaceticus, are grouped under the term (MBLs; Amber class B) genes of the VIM, IMP, and SIM “A. calcoaceticus-A. baumannii complex” (ACB complex). families.13,14 OXAs are not inhibited by clavulanic acid and have been found in most regions of the world, whereas PATHOGENESIS MBLs mediate resistance to carbapenems and all other β-lactamases, with the exception of aztreonam.14,15 Carb- Acinetobacter was initially considered to be an organism apenem resistance in A. baumannii isolates is most fre- of low virulence, and little is known about its virulence quently due to OXA production, whereas MBL production mechanisms and host responses. Several specific potential is more prevalent in non-baumannii Acinetobacter isol- virulence mechanisms related to the ability of Acineto- ates.13,16 In A. baumannii, the level of carbapenem resist- bacter species to adhere to, colonize, and invade human epi- ance provided by OXAs is considerably lower than that thelial cells have been identified. However, despite recent mediated by MBLs. In particular, some of these enzymes advances, many questions regarding the virulence and do not hydrolyze meropenem. pathogenesis of Acinetobacter species remain unanswered. The Acinetobacter mechanism of resistance to colistin dif- The pathogenic determinants include pilus-mediated bi- fers from the usual mechanism in gram-negative patho- ofilm formation,3 an outer membrane protein A associated gens,17 and investigations of these additional regulatory with apoptosis in human cells,4,5 an iron-acquisition sys- factors are ongoing. Currently, two main hypotheses re- tem,5,6 lipopolysaccharides,7 and a quorum-sensing sys- garding the resistance mechanisms exist. The first is the tem.8 Biofilm formation can be considered a key virulence loss of lipopolysaccharide,18 and the second is a mutation factor of many A. baumannii isolates, including carbape- nem-resistant strains. A biofilm constitutes living bacteria attached to a surface as sessile communities,9 which en- TABLE 2. Antimicrobial categories and agents used to define mul- ables bacteria to withstand host immune defense mecha- tidrug resistance (MDR), extreme drug resistance (XDR), and nisms, antibiotics, and hydrodynamic shear forces. This al- pandrug resistance (PDR) in Acinetobacter species lows A. baumannii to colonize and persist on biotic and Antimicrobial category Antimicrobial agent abiotic surfaces, causing infections associated with in- Aminoglycosides Gentamicin dwelling medical devices. Recent studies have shown that Tobramycin ACB complex species are threefold more likely to form a bio- Amikacin film at a liquid-solid interface than are non-ACB complexes o 10 Netilmicin at 25 C (80-91% versus 5-24%). Antipseudomonal carbapenems Imipenem Meropenem RESISTANCE MECHANISMS Doripenem Antipseudomonal fluoroquinolones Ciprofloxacin Acinetobacter species are a common cause of nosocomial Levofloxacin infections, and some Acinetobacter isolates are resistant to Antipseudomonal penicillins Piperacillin-tazobactam all or almost all β-lactam antibiotics, aminoglycosides, and +β-lactamase inhibitors Ticarcillin-clavulanic acid quinolones. However, controversy exists over the terms Extended-spectrum cephalospor- Cefotaxime “multidrug resistance” (MDR), “extreme drug resistance” ins Ceftriaxone Ceftazidime (XDR), and “pandrug resistance” (PDR) in gram-negative Cefepime pathogens, and a consensus on their definitions is needed. Folate pathway inhibitors Trimethoprim-sulfametho- The most recent recommended updated definitions are as 11 xazole follows: MDR refers to a pathogen being nonsusceptible Penicillins+β-lactamase inhibitors Ampicillin-sulbactam to at least one agent in more than three antimicrobial Polymyxins Colistin categories. XDR refers to a pathogen being nonsusceptible Polymyxin B to at least one agent in all but less than two categories. PDR Tetracyclines Tetracycline refers to a pathogen being nonsusceptible to all anti- Doxycycline microbial agents (Table 2). Minocycline Resistance mechanisms include inherent antibiotic re- MDR: nonsusceptible to ≥1 agent in ≥3 antimicrobial categories, sistance, antimicrobial-degrading enzymes, efflux pumps, XDR: nonsusceptible to ≥1 agent in all but ≤2 categories, PDR: target modification, and porin deficiency. The most im- nonsusceptible to all antimicrobial agents listed. portant mechanism, however, is the endless capacity of Adapted from reference 11. 38 Uh Jin Kim, et al in the genes encoding the PmrA and B proteins, which are ance accounts for 65% of A. baumannii pneumonia in the
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