Journal of Antimicrobial Chemotherapy Advance Access published May 15, 2014
J Antimicrob Chemother doi:10.1093/jac/dku170
Detection of pan drug-resistant Acinetobacter baumannii in Germany Stephan Go¨ttig1*, Teresa M. Gruber1, Paul G. Higgins2, Maik Wachsmuth1, Harald Seifert2 and Volkhard A. J. Kempf1 Institute of Medical Microbiology and Infection Control, Hospital of the Johann Wolfgang von Goethe University, Frankfurt am Main, Germany; 2Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Cologne, Germany *Corresponding author. Tel: +49-6301-7165; Fax: +49-6301-83431; E-mail: [email protected]
Keywords: multidrug resistance, colistin, OXA-23, minocycline
Sir, In December 2013, a carbapenem-resistant Acinetobacter baumannii was recovered from routine skin and rectum swabs from a patient during admission screening. The patient had been on a repatriation transport to Australia after previous hospitalization in Greece due to Waterhouse –Friderichsen syndrome as a result of severe meningococcal septicaemia. At the stop-over in Germany he presented with a decreased level of consciousness, multiple decubitus ulcers (grade IV) and reduced general condition and was admitted to the Internal Medicine Intensive Care Unit at the Hospital of the Johann Wolfgang von Goethe University in Frankfurt. Infection parameters were elevated, although a definite infection focus could not be established. Empirical anti-infective therapy with colistin, meropenem, linezolid, fosfomycin and caspofungin was initiated. The patient recovered after 1 week and could be transferred. Susceptibility testing of the A. baumannii isolate using the Etest method revealed non-susceptibility to all antibiotic groups where breakpoints have been defined for Acinetobacter spp. by either EUCAST or CLSI (penicillins/b-lactamase inhibitors, extended-spectrum cephalosporins, carbapenems, fluoroquinolones, aminoglycosides, tetracyclines, folate pathway inhibitors and polymyxins), including colistin, with an MIC of 128 mg/L (Table 1).1,2 The A. baumannii isolate was thus categorized as pan drug-resistant (PDR) in accordance with the guidelines defined by the international expert committee of the European Centre for Disease Prevention and Control (ECDC) and CDC.3 First reports of PDR A. baumannii emerged in 2001 and a nosocomial outbreak with PDR A. baumannii in 2002 was reported from Spain.4,5 However, in many other studies the term PDR was used inappropriately since important antibiotics such as colistin and ampicillin/sulbactam were not tested.3,6 Notably, the isolate remained intermediately susceptible to minocycline with an MIC
Table 1. Antibiotic susceptibility of A. baumannii isolated from a colonized patient admitted at the Hospital of the Johann Wolfgang von Goethe University in Frankfurt, Germany, in December 2013
Antimicrobial category Penicillins+b-lactamase inhibitors
Antimicrobial agent
ampicillin/ sulbactamb piperacillin/ tazobactamb ticarcillin/ clavulanic acidb Extended-spectrum cefotaxime cephalosporins ceftriaxone ceftazidime cefepime Carbapenems imipenem meropenem doripenem Fluoroquinolones ciprofloxacin levofloxacin Aminoglycosides gentamicin amikacin tobramycin netilmicin Tetracyclines tigecycline tetracycline doxycycline minocycline Folate pathway inhibitors trimethoprim/ sulfamethoxazole Polymyxins polymyxin B colistin Others chloramphenicol fosfomycin
MIC (mg/L)
Susceptibilitya
.256
R
.256
R
.256
R
.32 .32 .256 .256 .32 .32 .32 .32 .32 .256 .256 .256 .256 8 .256 128 8 .32
R R R R R R R R R R R R R R R R I R
16 128 .256 .256
R R R R
R, resistant; I, intermediately susceptible. a MICs were interpreted according to breakpoints for Acinetobacter spp. set by EUCAST and CLSI.1,2 MICs of tigecycline, chloramphenicol and fosfomycin were interpreted according to breakpoints for Enterobacteriaceae set by EUCAST. b b-Lactamase inhibitors sulbactam, tazobactam and clavulanic acid were used at a fixed concentration of 4, 4 and 2 mg/L, respectively, as recommended by EUCAST.
# The Author 2014. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: [email protected]
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of 8 mg/L. Interestingly, previous studies reported in vitro activity of minocycline, an old, rarely used tetracycline derivative, against .70% of multidrug-resistant (MDR) A. baumannii.7 Detection of carbapenemases by PCR for acquired b-lactamase (bla) genes encoding VIM, IMP, NDM, KPC and OXA-23, -40, -48, -58, -143 and -235 using whole-cell DNA and subsequent sequencing revealed the presence of the carbapenemase blaOXA-23.8 PFGE
Research letter
Acknowledgements We thank Rebecca A. Kaufmann and Julian Sommer for excellent technical assistance.
Funding This work was supported by the Frankfurt Initiative for Microbial Sciences (FIMS). S. G. was supported by the programme ‘Frankfurter Forschungsfo¨rderung (FFF)’ by the Faculty of Medicine of the Johann Wolfgang von Goethe University, Frankfurt.
2 of 2
Transparency declarations None to declare.
References 1 EUCAST. Clinical Breakpoint Tables (v 3.1). http://www.eucast.org/ clinical_breakpoints/ (4 April 2014, date last accessed). 2 Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing: Twenty-third Informational Supplement M100-S23. CLSI, Wayne, PA, USA, 2013. 3 Magiorakos AP, Srinivasan A, Carey RB et al. Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect 2012; 18: 268–81. 4 Valencia R, Arroyo LA, Conde M et al. Nosocomial outbreak of infection with pan-drug-resistant Acinetobacter baumannii in a tertiary care university hospital. Infect Control Hosp Epidemiol 2009; 30: 257– 63. 5 Urban C, Mariano N, Rahal JJ et al. Polymyxin B-resistant Acinetobacter baumannii clinical isolate susceptible to recombinant BPI21 and cecropin P1. Antimicrob Agents Chemother 2001; 45: 994–5. 6 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: 1619– 29. 7 Higgins PG, Dammhayn C, Hackel M et al. Global spread of carbapenemresistant Acinetobacter baumannii. J Antimicrob Chemother 2010; 65: 233– 8. 8 Higgins PG, Lehmann M, Seifert H. Inclusion of OXA-143 primers in a multiplex polymerase chain reaction (PCR) for genes encoding prevalent OXA carbapenemases in Acinetobacter spp. Int J Antimicrob Agents 2010; 35: 305. 9 Adams-Haduch JM, Onuoha EO, Bogdanovich T et al. Molecular epidemiology of carbapenem-nonsusceptible Acinetobacter baumannii in the United States. J Clin Microbiol 2011; 49: 3849 –54. 10 Schleicher X, Higgins PG, Wisplinghoff H et al. Molecular epidemiology of Acinetobacter baumannii and Acinetobacter nosocomialis in Germany over a 5-year period (2005–2009). Clin Microbiol Infect 2013; 19: 737–42.
Downloaded from http://jac.oxfordjournals.org/ at Universidade Estadual de Maringá on May 21, 2014
and subsequent blaOXA-23 detection by Southern hybridization suggested a chromosomal location for the OXA-23 gene. A 3.5 kb sequence obtained by primer walking revealed that it was located in transposon Tn2008 (GenBank accession number HQ008358) and embedded in the chromosomal lysE gene (locus tag ADU58354). Molecular strain typing was performed by semi-automated, repetitive sequence-based PCR (rep-PCR) using the DiversiLab platform (bioMe´rieux, Nu¨rtingen, Germany). Our isolate grouped with the international clone (IC) 2, also known as European clone 2.7 Furthermore, subtyping of the chromosomally located intrinsic OXA-51-like bla gene identified blaOXA-66, which is also associated with IC2. IC2 accounts for 50% of all isolates worldwide and can therefore be considered as the most successful and widespread clonal lineage of A. baumannii.7,9 There are no German national surveys of A. baumannii carbapenem resistance rates. However, in smaller surveys it has been shown that carbapenem resistance, although not prevalent, is most often associated with IC2 isolates.10 Furthermore, in contrast to the PDR isolate, carbapenem-resistant isolates belonging to IC2 are usually susceptible to minocycline, tigecycline and polymyxins.7,10 This is the first report of a PDR A. baumannii isolate in Germany. Since PDR Gram-negatives will further disseminate and no treatment options are left, rigorous screening and pre-emptive isolation of patients with a history of medical treatment in a country where MDR Gram-negatives are endemic seems indispensable.
J Antimicrob Chemother doi:10.1093/jac/dku170
Detection of pan drug-resistant Acinetobacter baumannii in Germany Stephan Go¨ttig1*, Teresa M. Gruber1, Paul G. Higgins2, Maik Wachsmuth1, Harald Seifert2 and Volkhard A. J. Kempf1 Institute of Medical Microbiology and Infection Control, Hospital of the Johann Wolfgang von Goethe University, Frankfurt am Main, Germany; 2Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Cologne, Germany *Corresponding author. Tel: +49-6301-7165; Fax: +49-6301-83431; E-mail: [email protected]
Keywords: multidrug resistance, colistin, OXA-23, minocycline
Sir, In December 2013, a carbapenem-resistant Acinetobacter baumannii was recovered from routine skin and rectum swabs from a patient during admission screening. The patient had been on a repatriation transport to Australia after previous hospitalization in Greece due to Waterhouse –Friderichsen syndrome as a result of severe meningococcal septicaemia. At the stop-over in Germany he presented with a decreased level of consciousness, multiple decubitus ulcers (grade IV) and reduced general condition and was admitted to the Internal Medicine Intensive Care Unit at the Hospital of the Johann Wolfgang von Goethe University in Frankfurt. Infection parameters were elevated, although a definite infection focus could not be established. Empirical anti-infective therapy with colistin, meropenem, linezolid, fosfomycin and caspofungin was initiated. The patient recovered after 1 week and could be transferred. Susceptibility testing of the A. baumannii isolate using the Etest method revealed non-susceptibility to all antibiotic groups where breakpoints have been defined for Acinetobacter spp. by either EUCAST or CLSI (penicillins/b-lactamase inhibitors, extended-spectrum cephalosporins, carbapenems, fluoroquinolones, aminoglycosides, tetracyclines, folate pathway inhibitors and polymyxins), including colistin, with an MIC of 128 mg/L (Table 1).1,2 The A. baumannii isolate was thus categorized as pan drug-resistant (PDR) in accordance with the guidelines defined by the international expert committee of the European Centre for Disease Prevention and Control (ECDC) and CDC.3 First reports of PDR A. baumannii emerged in 2001 and a nosocomial outbreak with PDR A. baumannii in 2002 was reported from Spain.4,5 However, in many other studies the term PDR was used inappropriately since important antibiotics such as colistin and ampicillin/sulbactam were not tested.3,6 Notably, the isolate remained intermediately susceptible to minocycline with an MIC
Table 1. Antibiotic susceptibility of A. baumannii isolated from a colonized patient admitted at the Hospital of the Johann Wolfgang von Goethe University in Frankfurt, Germany, in December 2013
Antimicrobial category Penicillins+b-lactamase inhibitors
Antimicrobial agent
ampicillin/ sulbactamb piperacillin/ tazobactamb ticarcillin/ clavulanic acidb Extended-spectrum cefotaxime cephalosporins ceftriaxone ceftazidime cefepime Carbapenems imipenem meropenem doripenem Fluoroquinolones ciprofloxacin levofloxacin Aminoglycosides gentamicin amikacin tobramycin netilmicin Tetracyclines tigecycline tetracycline doxycycline minocycline Folate pathway inhibitors trimethoprim/ sulfamethoxazole Polymyxins polymyxin B colistin Others chloramphenicol fosfomycin
MIC (mg/L)
Susceptibilitya
.256
R
.256
R
.256
R
.32 .32 .256 .256 .32 .32 .32 .32 .32 .256 .256 .256 .256 8 .256 128 8 .32
R R R R R R R R R R R R R R R R I R
16 128 .256 .256
R R R R
R, resistant; I, intermediately susceptible. a MICs were interpreted according to breakpoints for Acinetobacter spp. set by EUCAST and CLSI.1,2 MICs of tigecycline, chloramphenicol and fosfomycin were interpreted according to breakpoints for Enterobacteriaceae set by EUCAST. b b-Lactamase inhibitors sulbactam, tazobactam and clavulanic acid were used at a fixed concentration of 4, 4 and 2 mg/L, respectively, as recommended by EUCAST.
# The Author 2014. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: [email protected]
1 of 2
Downloaded from http://jac.oxfordjournals.org/ at Universidade Estadual de Maringá on May 21, 2014
1
of 8 mg/L. Interestingly, previous studies reported in vitro activity of minocycline, an old, rarely used tetracycline derivative, against .70% of multidrug-resistant (MDR) A. baumannii.7 Detection of carbapenemases by PCR for acquired b-lactamase (bla) genes encoding VIM, IMP, NDM, KPC and OXA-23, -40, -48, -58, -143 and -235 using whole-cell DNA and subsequent sequencing revealed the presence of the carbapenemase blaOXA-23.8 PFGE
Research letter
Acknowledgements We thank Rebecca A. Kaufmann and Julian Sommer for excellent technical assistance.
Funding This work was supported by the Frankfurt Initiative for Microbial Sciences (FIMS). S. G. was supported by the programme ‘Frankfurter Forschungsfo¨rderung (FFF)’ by the Faculty of Medicine of the Johann Wolfgang von Goethe University, Frankfurt.
2 of 2
Transparency declarations None to declare.
References 1 EUCAST. Clinical Breakpoint Tables (v 3.1). http://www.eucast.org/ clinical_breakpoints/ (4 April 2014, date last accessed). 2 Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing: Twenty-third Informational Supplement M100-S23. CLSI, Wayne, PA, USA, 2013. 3 Magiorakos AP, Srinivasan A, Carey RB et al. Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect 2012; 18: 268–81. 4 Valencia R, Arroyo LA, Conde M et al. Nosocomial outbreak of infection with pan-drug-resistant Acinetobacter baumannii in a tertiary care university hospital. Infect Control Hosp Epidemiol 2009; 30: 257– 63. 5 Urban C, Mariano N, Rahal JJ et al. Polymyxin B-resistant Acinetobacter baumannii clinical isolate susceptible to recombinant BPI21 and cecropin P1. Antimicrob Agents Chemother 2001; 45: 994–5. 6 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: 1619– 29. 7 Higgins PG, Dammhayn C, Hackel M et al. Global spread of carbapenemresistant Acinetobacter baumannii. J Antimicrob Chemother 2010; 65: 233– 8. 8 Higgins PG, Lehmann M, Seifert H. Inclusion of OXA-143 primers in a multiplex polymerase chain reaction (PCR) for genes encoding prevalent OXA carbapenemases in Acinetobacter spp. Int J Antimicrob Agents 2010; 35: 305. 9 Adams-Haduch JM, Onuoha EO, Bogdanovich T et al. Molecular epidemiology of carbapenem-nonsusceptible Acinetobacter baumannii in the United States. J Clin Microbiol 2011; 49: 3849 –54. 10 Schleicher X, Higgins PG, Wisplinghoff H et al. Molecular epidemiology of Acinetobacter baumannii and Acinetobacter nosocomialis in Germany over a 5-year period (2005–2009). Clin Microbiol Infect 2013; 19: 737–42.
Downloaded from http://jac.oxfordjournals.org/ at Universidade Estadual de Maringá on May 21, 2014
and subsequent blaOXA-23 detection by Southern hybridization suggested a chromosomal location for the OXA-23 gene. A 3.5 kb sequence obtained by primer walking revealed that it was located in transposon Tn2008 (GenBank accession number HQ008358) and embedded in the chromosomal lysE gene (locus tag ADU58354). Molecular strain typing was performed by semi-automated, repetitive sequence-based PCR (rep-PCR) using the DiversiLab platform (bioMe´rieux, Nu¨rtingen, Germany). Our isolate grouped with the international clone (IC) 2, also known as European clone 2.7 Furthermore, subtyping of the chromosomally located intrinsic OXA-51-like bla gene identified blaOXA-66, which is also associated with IC2. IC2 accounts for 50% of all isolates worldwide and can therefore be considered as the most successful and widespread clonal lineage of A. baumannii.7,9 There are no German national surveys of A. baumannii carbapenem resistance rates. However, in smaller surveys it has been shown that carbapenem resistance, although not prevalent, is most often associated with IC2 isolates.10 Furthermore, in contrast to the PDR isolate, carbapenem-resistant isolates belonging to IC2 are usually susceptible to minocycline, tigecycline and polymyxins.7,10 This is the first report of a PDR A. baumannii isolate in Germany. Since PDR Gram-negatives will further disseminate and no treatment options are left, rigorous screening and pre-emptive isolation of patients with a history of medical treatment in a country where MDR Gram-negatives are endemic seems indispensable.
