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Multidrug-resistant Acinetobacter spp. from hospital intensive care units in Brazilian Amazon

Abstract

Acinetobacter spp. are one of the main pathogens responsible for healthcare-associated infections and are associated with high rates of morbidity and mortality globally, mainly because of their high capacity to present and develop resistance to antimicrobials. To identify species of the Acinetobacter and their resistance profiles from samples collected from hospitalized patients, health professionals and hospital environmental sources in the intensive care units of different public reference hospitals in Porto Velho City, Rondônia, Western Brazilian Amazon. Isolates were identified using microbiological and molecular techniques. The antimicrobial susceptibility profile was determined by disk diffusion. A total of 201 Acinetobacter spp. isolates were identified, of which 47.3% originated from hospital structures, 46.8% from patients and 6% from healthcare professionals. A. baumannii and A. nosocomialis were the most prevalent, with frequency of 58.7% and 31.8%, respectively. Regarding the susceptibility profile, it was observed that 56.3% were classified as multidrug-resistant and 76.2% of the samples belonging to A. baumannii were resistant to carbapenems. In contrast, 96.9% were susceptible to polymyxin B and 91.3% to doxycycline. The data presented here can be used to guide and strengthen the control of multidrug-resistant infections caused by Acinetobacter spp., in addition to improving providing information from a traditionally unassisted region of Brazil.

Keywords
Antibiotic resistance profile; Acinetobacter spp.; Intensive care units; Porto Velho Brazilian Amazon

Introduction

Antimicrobial Resistance (AMR) is defined as the ability of a microorganism to resist the action of an antimicrobial agent designed to kill it and is considered a serious threat to global public health. It is estimated that if no action is taken, AMR could cause the death of approximately 10 million people worldwide by 2050.11 WHO. WHO Publishes List of Bacteria for Which New Antibiotics are Urgently Needed. World Health Organization. 2017. According to The Lancet, there were an estimated 1.27 million deaths attributable to resistance in 2019, and six pathogens (Escherichia coli, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa), were responsible for 929 deaths associated with AMR.22 Murray C.J., Ikuta K.S., Sharara F., Swetschinski L., Robles Aguilar G., Gray A., et al. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet. 2022;399:629-55.

AMR has caused great concern, especially in hospitals, because patients receiving healthcare or those with weakened immune systems are often at a higher risk of contracting an infection. In addition, antibiotic-resistant bacteria can spread within and between healthcare facilities and cause infections in patients, known as Healthcare-Associated Infections (HAIs), or disseminate into the community or environment (soil and water).33 CDC. Antibiotic Resistance Threats in the United States, 2019 [Internet]. Atlanta, Georgia; 2019 Nov. Available from: https://stacks.cdc.gov/view/cdc/82532.
https://stacks.cdc.gov/view/cdc/82532...
HAIs are a major public health challenge because their incidence can lead to increased length of stay, hospital costs, high morbidity and mortality rates, and AMR.44 Giroti A.L.B., Ferreira A.M., Rigotti M.A., de Sousa Á.F.L., Frota O.P., de Andrade D. Hospital infection control programs: assessment of process and structure indicators. Rev Esc Enferm USP. 2018;52:e03364.

The World Health Organization (WHO) estimates that 15 of 100 patients in low- and middle-income countries will acquire at least one HAI. In developed countries, approximately 30% of patients admitted to Intensive Care Units (ICUs) are affected by HAIs, and this may be 2-3 times higher in underdeveloped countries.55 WHO. Global Report on Infection Prevention and Control. 2022. Available from: http://apps.who.int/bookorders.
http://apps.who.int/bookorders...

The genus Acinetobacter is one of the main causes of HAIs and the five species that make up the Acinetobacter baumannii-calcoaceticus complex (A. baumannii. A. nosocomialis, A. pitti, A. seifertii and A. dijkshoorniae) are the most clinically relevant microorganisms.66 Castanheira M., Mendes R.E., Gales AC. Global epidemiology and mechanisms of resistance of Acinetobacter baumannii-calcoaceticus complex. Clin Infect Dis. 2023;76(Suppl 2):S166-S178.,77 Vijayakumar S., Biswas I., Veeraraghavan B. Accurate identification of clinically important Acinetobacter spp.: an update. Future Sci OA. 2019;5:FSO395. They are a frequent cause of outbreaks and are responsible for infections reported in ICUs, including sepsis, ventilator-related pneumonia, urinary tract infections, and surgical site infections.88 Perovic O., Duse A., Chibabhai V., Black M., Said M., Prentice E., et al. Acinetobacter baumannii complex, national laboratory-based surveillance in South Africa, 2017 to 2019. PLoS One. 2022;17:e0271355. In the United States, in 2017, Carbapenem-Resistant Acinetobacter caused an estimated 8500 infections in hospitalized patients.99 CDC. Antibiotic Resistance Threats in the United States, 2019. Atlanta, GA: U.S Department of health and human services, CDC; 2019. In Europe, according to the ECDC, it is among the 10 most frequently isolated microorganisms in ICU-acquired bloodstream infection.1010 European centre for disease prevention and control. Annual epidemiological report for 2019 - healthcare - associated infections acquired in intensive care units. In: ECDC. Annual epidemiological Report for 2018. Stockholm: ECDC; 2023. In Brazil, it was the second most isolated microorganism in bloodstream infections in adults ICUs.1111 ANVISA. Boletim segurança do paciente e qualidade em serviços de saúde n° 28 - avaliação dos indicadores nacionais de infecções relacionadas à assistência à saúde (iras) e resistência antimicrobiana (rm), ano de 2021. 2022.

Acinetobacter spp. are typically free-living saprophytes found nearly everywhere and are commonly distributed in the environment. They can be located in soil, water, sewage, humans, food, and animals. Furthermore, these bacteria can survive for long periods on dry surfaces under nutrient-limited conditions, thereby facilitating their persistence and transmission in both natural and hospital environments. Patients on mechanical ventilation, especially those with prolonged duration of hospitalization or ICU stay, have a greater degree of exposure to infected or colonized patients in the hospital and have an increased risk for the acquisition of Multidrug-Resistant (MDR) strains.1212 Almasaudi S.B. Acinetobacter spp. as nosocomial pathogens: epidemiology and resistance features. Vol. 25, Saudi Journal of Biological Sciences. Elsevier B.V.; 2018. p. 586-96.

The emergence of Acinetobacter spp. is due to their bacterial dissemination, a consequence of low adherence to infection control measures, especially MDR strains to antimicrobials, particularly carbapenems, which are the antibiotics of choice for treating infections caused by these pathogens.1313 McKay S.L., Vlachos N., Daniels J.B., Albrecht V.S., Stevens V.A., Rasheed J.K., et al. Molecular Epidemiology of Carbapenem-Resistant Acinetobacter baumannii in the United States, 2013-2017. Microbial Drug Resistance. 2022;28:645-53.

14 Jean SS, Harnod D., Hsueh P.R. Global Threat of Carbapenem-Resistant Gram-Negative Bacteria. Vol. 12, Frontiers in Cellular and Infection Microbiology. Frontiers Media S.A.; 2022.
-1515 Abalkhail A., Alslamah T. Institutional factors associated with infection prevention and control practices globally during the infectious pandemics in resource-limited settings. Vaccines. 2022;10:1811.

The most prevalent mechanism of resistance in Acinetobacter is the production of β-lactamases.1010 European centre for disease prevention and control. Annual epidemiological report for 2019 - healthcare - associated infections acquired in intensive care units. In: ECDC. Annual epidemiological Report for 2018. Stockholm: ECDC; 2023. Furthermore, members of the genus Acinetobacter tend to quickly develop resistance to antimicrobial agents, are intrinsically resistant to many antibiotics, and can acquire new resistance mechanisms, corroborating the high dissemination of MDR microorganisms, Extensive Drug Resistance (XDR), and pan-drug resistance.1111 ANVISA. Boletim segurança do paciente e qualidade em serviços de saúde n° 28 - avaliação dos indicadores nacionais de infecções relacionadas à assistência à saúde (iras) e resistência antimicrobiana (rm), ano de 2021. 2022.

Thus, in 2017 the WHO classified Carbapenem-Resistant Acinetobacter Baumannii (CRAB) as a critical priority for the discovery and development of new antibiotics. In Brazil, CRAB is highly prevalent, and the rates of infection by this pathogen have been progressively increasing, presenting relative incidence characteristics that vary according to hospital setting, geographical area, and intervention of hospital services.1212 Almasaudi S.B. Acinetobacter spp. as nosocomial pathogens: epidemiology and resistance features. Vol. 25, Saudi Journal of Biological Sciences. Elsevier B.V.; 2018. p. 586-96.,1313 McKay S.L., Vlachos N., Daniels J.B., Albrecht V.S., Stevens V.A., Rasheed J.K., et al. Molecular Epidemiology of Carbapenem-Resistant Acinetobacter baumannii in the United States, 2013-2017. Microbial Drug Resistance. 2022;28:645-53.

Therefore, the execution of projects regarding AMR is essential, especially in the Amazon region of Brazil, in which there are few studies aimed at the identification of Acinetobacter and its profile of AMR in the hospital environment, especially the ICU. This study aimed to identify species of the genus Acinetobacter and their resistance profiles from samples collected from hospitalized patients, health professionals, and hospital environmental sources in the ICU of different public reference hospitals in Porto Velho City, Rondônia, Western Brazilian Amazon, between 2017 and 2019.

Methods

Specimen collection and bacteriology

Clinical samples were collected from patients (oral cavity, armpit, tracheostomy secretion, wound secretion, urine, and blood) admitted to the ICU and health professionals (swab secretion of nasal mucosa and nails) of four reference hospitals in the public network of Porto Velho City, Rondônia, Brazil, named A, B, C, and D, between 2017 and 2019.

Swab samples from hospital environments, including beds, mechanical ventilation devices, computer keyboards, sinks, floors, operating room machines, water taps, and stretches, were collected from the ICU.

Samples were transported to the microbiology laboratory of the Oswaldo Cruz Rondônia Foundation within two hours of processing.

All clinical samples were seeded in blood agar (AS; HiMedia, India), McConkey (MC; Neogen, Brazil), chromogenic (CA; BD, Alemanha), and methylene blue eosin (EMB; HiMedia, India) media and incubated aerobically at 37±2 °C for 18-24 h.

The swabs from hospital structures and health professionals were cultured in Luria-Bertani Broth (LB; Kasvi, Italy) for 18-24 h at 37±2 °C, in an orbital shaker at a speed of 100 rpm and subsequently seeded on AS, CA, and EMB agar plates. All the colonies suspected to be Acinetobacter spp. were subjected to molecular identification.

Species identification

Thermal shock was used to extract genomic DNA from the suspected Acinetobacter spp.1414 Jean SS, Harnod D., Hsueh P.R. Global Threat of Carbapenem-Resistant Gram-Negative Bacteria. Vol. 12, Frontiers in Cellular and Infection Microbiology. Frontiers Media S.A.; 2022. PCR amplification of bacterial ribosomal DNA using primers 16SF (GYCCADACWCCTACGG) and 16S08R (CACGAGCTGACGAC) was performed for bacterial identification.1515 Abalkhail A., Alslamah T. Institutional factors associated with infection prevention and control practices globally during the infectious pandemics in resource-limited settings. Vaccines. 2022;10:1811. A negative control for was prepared using all reagents except the DNA template, and genomic DNA from E. coli O42 was used as a positive control. The amplicons were purified using a QIAquick Gel Extraction kit (Qiagen, Germany) according to the manufacturer's instructions.

Amplicons were quantified using a NanoDrop1000 (Thermo Fisher Scientific, Waltham, MA, USA). Sequencing was performed by the Sanger method on an ABI 3100 Prism DNA Sequencer (Applied Biosystems, Waltham, MA, USA). The sequences were treated using BioEdit Sequence Alignment Editor software (version 7.0) with a Phred quality score of 30. A consensus sequence was generated for each amplicon from each isolate. Species were identified by aligning the consensus sequences with a Basic Local Alignment Search Tool (BLAST) database.

Antimicrobial susceptibility testing

Antimicrobial susceptibility tests were performed using the disk diffusion method on Mueller-Hinton agar (KASVI) and commercial antimicrobial disks (Oxoid, UK) according to the guidelines of the Clinical and Laboratory Standards Institute (CLSI).1616 Bush K., Jacoby G.A. Updated functional classification of β-lactamases. Vol. 54, Antimicrob Agents Chemother. 2010. p. 969-76. The antibiotics tested were distributed into the following classes: quinolones (Levofloxacin [LEV 5 μg], Ciprofloxacin [CIP 5 μg]); Cephalosporins (Ceftriaxone [CRO 30 μg], Cefepime [FEP 30 μg], Cefotaxime [CTX 30 μg], Ceftazidime [CAZ 30 μg]); Carbapenems (Imipenem [IPM 10 μg], Meropenem [MEM 10 μg]); β-lactamase inhibitors (Ampicillin/Sulbactam [SAM 10/10 μg], Piperacillin/Tazobactam [TZP 110 μg; aminoglycosides (Amikacin [AMK 30 μg], Tobramycin [TOB 10 μg], Gentamicin [GEN 10 μg]) and tetracyclines (Doxycycline [DO 30 μg], Tetracycline [TET, 30 μg]).

For the susceptibility test to polymyxin B, a microdilution system was used to determine the Minimum Inhibitory Concentration (MIC) (Policimbac, Probac, Brazil), according to the manufacturer's instructions. E. coli ATCC 25922 and P. aeruginosa ATCC 27853 were used as quality control strains in all tests.

For MDR classification of Acinetobacter spp. isolates, the criteria described by Magiorakos et al. (2012) was used, which determines MDR as those isolates resistant to at least one representative of three or more classes of antibiotics.1717 Haji S.H., Aka S.T.H., Ali F.A. Prevalence and characterisation of carbapenemase encoding genes in multidrug-resistant Gram-negative bacilli. PLoS One. 2021;16:e0259005.

Statistical analysis

For data analysis, BioEstat 5.0 and Jamovi 1.8 software were used. Chi-square and Fisher's exact tests were used to analyze the nominal qualitative variables. Ordinal qualitative variables were analyzed using the Kruskal-Wallis test. When statistical significance was demonstrated, comparisons between groups were analyzed using the Tukey, Dunn, or Student-Newman-Keuls tests. The Shapiro-Wilk test was used for normality distribution. To measure the effect, an Odds Ratio (OR) test was used.

All results with a p-value ≤ 0.05 were considered statistically significant.

Ethical considerations

This study was approved by the Ethics Committee of the Tropical Medicine Research Center (Process n° 2.368.951).

Results

In the present study, 201 isolates of Acinetobacter spp. were identified, with 47.3% (95/201) originating from hospital structures, 46.8% (94/201) from patients, and 6% (12/201) from healthcare professionals. Table 1 shows the frequencies of each Acinetobacter spp. identified at each hospital and collection site. A. baumannii and A. nosocomialis were the most prevalent bacteria in the ICUs of the four hospitals studied, with 58.7% (118/201) and 31.8% (64/201), respectively. Other species were also identified such as A. calcoaceticus and A. pittii, both comprising 3.5% (7/201) of the isolates.

Table 1
Prevalence of Acinetobacter spp. species among Hospitals and collection sites.

Similarly, A. baumannii and A. nosocomialis were also frequently found in hospital structures, with percentages of 65.3% (62/95) and 27.4% (26/95), respectively, and were isolated mainly from beds and mechanical ventilation devices. A. baumannii was isolated in 59.6% (56/94) of the patient samples, with the oral cavity being the site of greater colonization (38.3%, 36/94), followed by the axillae (11.7%, 11/94), and tracheostomy (5.3%, 5/94). In samples from healthcare workers, A. nosocomialis was the most prevalent species, representing 83.3% (10/12) of the isolates, followed by A. calcoaceticus at 13.7% (2/12).

Of the 201 isolates identified, it was possible to evaluate the antimicrobial susceptibility profile of 183 due to the loss of viability in some samples during the study period. We observed that 60.7% (111/183) of the samples were resistant to ceftriaxone, 59.6% (109/183) to cefotaxime, 54.1% (99/183) to ceftazidime, and 51.9% (95/183) to cefepime. Furthermore, 76.2% of the samples (80/105) belonging to A. baumannii were resistant to carbapenems and 56.3% (103/183) of the evaluated samples were classified as MDR.

In contrast, 96.9% (156/183) of the isolates were sensitive to polymyxin B, 91.3% (167/183) to doxycycline, 82.5% (151/183) to tetracycline, 77% (141/183) to gentamicin, 75% (139/183) to tobramycin, 57.4% (105/183) to ampicillin-sulbactam, 52.5% (96/183) to imipenem, and 51.9% (95/183) to meropenem (Fig. 1).

Fig. 1
Susceptibility profile of Acinetobacter spp. against antimicrobials. Notes: APS, Ampicillin-sulbactam; PTZ, Piperacillin-tazobactam; CAZ, Ceftazidime; CPM, Cefepime; CTX, Cefotaxime; CRO, Ceftriaxone; MER, Meropenem; IPM, Imipenem; GEN, Gentamicin; TOB, Tobramycin; AMK, Amikacin; DOX, Doxycycline; TET, Tetracycline; CIP, Ciprofloxacin; LVX, Levofloxacin; PB, Polymyxin B.

Based on the results obtained (Table 2), Hospital A had a lower percentage of MDR Acinetobacter spp. (43.2%, 32/74) and hospital B there was a higher prevalence (75%, 54/72). By evaluating only Hospitals A and B, it can be inferred that strains isolated from Hospital B were four times more likely to present a MDR profile than those isolated from Hospital A (Odds Ratio = 3.9375, p= 0.0002).

Table 2
Resistance classification and percentage values of sensibility tests with Acinetobacter spp. isolated.

Similarly, samples of Acinetobacter spp. from hospitals structures showed the highest levels of MDR at 65.2% (58/89), followed by those from patients and healthcare professionals at 52.4% (43/82) and 16.6% (2/12), respectively. A. baumannii showed a significantly higher rate of MDR than the other species (p < 0.001), representing 90.3% (93/105) of samples.

Discussion

The genus Acinetobacter has emerged as a worldwide public health concern because of its ability to cause HAIs and resist currently available antimicrobial treatments. In the present study, we aimed to identify Acinetobacter spp. and the resistance profiles of samples collected from patients, health professionals, and hospital environmental sources in the ICUs of different public reference hospitals in the city of Porto Velho, the capital of Rondônia, Northern region of Brazil.

We found that A. baumanni and A. nosocomialis were the most prevalent species. Other species of clinical importance have also been isolated, most of which belong to the Acinetobacter baumannii-calcoaceticus complex. A. calcoaceticus has already been described in severe cases of human infections such as pneumonia.1818 Costa J.E.S., Nogueira K da S, Cunha CA da. Carbapenem-resistant bacilli in a hospital in southern Brazil: prevalence and therapeutic implications. Braz J Infect Dis. 2020;24:380-5.,1919 Li P., Yang C., Xie J., Liu N., Wang H., Zhang L., et al. Acinetobacter calcoaceticus from a fatal case of pneumonia harboring blaNDM-1 on a widely distributed plasmid. BMC Infect Dis. 2015;15:131 A. nosocomialis and A. pittii are clinically important, as they are often reported to be MDR species and cause serious infections in healthcare facilities.2020 Alam S., Brailsford S.R., Whiley R.A., Beighton D. PCR-based methods for genotyping Viridans Group Streptococci. J Clin Microbiol. 1999;37:2772-6.,2121 Arruda A., Ferreira G.S., Lima NC da S., Santos Júnior A dos, Custódio M.G.F., Benevides-Matos N., et al. A simple methodology to collect culturable bacteria from feces of Anopheles darlingi (Diptera: Culicidae). J Microbiol Methods. 2017;141:115-7.

The highest isolation rate of Acinetobacter spp. was from hospital environmental samples, with A. baumannii and A. nosocomialis being the most frequently isolated species and isolated mainly from beds and mechanical ventilation devices. Several studies have demonstrated the role of environmental surfaces near patients and the occurrence of A. baumannii XDR and MDR outbreaks in ICUs.2222 CLSI. M100 Performance Standards for Antimicrobial Susceptibility Testing A CLSI Supplement for Global Application. 32nd ed. 2022. Available from: www.clsi.org.
www.clsi.org...
Acinetobacter spp. have a strong ability to form biofilms, resist desiccation and sterilization, and thus persist in hospital environments.2323 Corbella X, Pujol M, Argerich MJ, Ayats J, Sendra M, Peña C, Ariza J. Environmental sampling of Acinetobacter baumannii: moistened swabs versus moistened sterelize gauze pads, Infect Control Hosp Epidemiol., 7, 1999, 458-460.,2424 NS Ravi, S Anandan, S Vijayakumar, R Gopi, BS Lopes and B Veeraraghavan, The potential of different molecular biology methods in tracking clones of Acinetobacter baumannii in an ICU setting, J Med Microbiol, 67 (9), 2018, 1340-1347, doi:10.1099/jmm.0.000797.
https://doi.org/10.1099/jmm.0.000797....
Furthermore, isolation from a ventilation device is directly related to the reported high prevalence of Acinetobacter spp. that cause ventilator-associated pneumonia.2525 Magiorakos A.P., Srinivasan A., Carey R.B., Carmeli Y., Falagas M.E., Giske C.G., 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(3):268-81.

In the current study, it was found that the highest number of Acinetobacter spp. from patients was from the oral cavity, which is consistent with previous studies that have shown that the oral cavity can act as a reservoir for pathogens causing severe lung disease.1919 Li P., Yang C., Xie J., Liu N., Wang H., Zhang L., et al. Acinetobacter calcoaceticus from a fatal case of pneumonia harboring blaNDM-1 on a widely distributed plasmid. BMC Infect Dis. 2015;15:131,2626 Atrouni A Al, Joly-Guillou ML, Hamze M., Kempf M. Reservoirs of non-baumannii Acinetobacter species. Vol. 7, Frontiers in Microbiology. Frontiers Media S.A.; 2016. A. baumannii was also observed in tracheostomy samples. Other studies have shown that infections at these surgical sites are the leading causes of morbidity and mortality in the ICU.2727 Cosgaya C., Ratia C., Marí-Almirall M., Rubio L., Higgins P.G., Seifert H., et al. In vitro and in vivo virulence potential of the emergent species of the acinetobacter baumannii (Ab) group. Front Microbiol. 2019;10:2429.,2828 Tajeddin E., Rashidan M., Razaghi M., Javadi S.S.S., Sherafat S.J., Alebouyeh M., et al. The role of the intensive care unit environment and health-care workers in the transmission of bacteria associated with hospital acquired infections. J Infect Public Health. 2016;9:13-23.

Contrary to data reported in the literature, Acinetobacter spp. were identified at low frequencies in samples from healthcare workers. This is a positive result, because approximately 80% of HAIs are currently associated with hand transmission.2929 Ibrahim S., Al-Saryi N., Al-Kadmy I.M.S., Aziz S.N. Multidrug-resistant Acinetobacter baumannii as an emerging concern in hospitals. Vol. 48, Molecular Biology Reports. Springer Science and Business Media B.V.; 2021. p. 6987-98.

High rates of bacteria not susceptible to combinatorial agents to β-lactams, cephalosporins, and carbapenems were observed. The MDR rates were >50%, with. A. baumannii being the species with the highest levels of resistance and MDR. Notably, A. baumannii has intrinsic resistance to several antimicrobials of the ꞵ-lactam class, justifying the high resistance rate to these antimicrobials in the present study.

In addition to intrinsic resistance, A. baumannii has a high capacity to develop resistance to virtually all classes of agents used in clinical practice, showing high rates of resistance to broad-spectrum β-lactams such as third generation cephalosporins and carbapenems. Resistance to carbapenems requires increased attention as they are one of the last therapeutic options for defense against gram-negative bacteria.1212 Almasaudi S.B. Acinetobacter spp. as nosocomial pathogens: epidemiology and resistance features. Vol. 25, Saudi Journal of Biological Sciences. Elsevier B.V.; 2018. p. 586-96.

The present study reported that 76.2% of A. baumannii samples were resistant to carbapenems, and >90% were classified as MDR. These results are similar to those of other Brazilian studies that demonstrated carbapenem resistance rates of 74%-100%.1313 McKay S.L., Vlachos N., Daniels J.B., Albrecht V.S., Stevens V.A., Rasheed J.K., et al. Molecular Epidemiology of Carbapenem-Resistant Acinetobacter baumannii in the United States, 2013-2017. Microbial Drug Resistance. 2022;28:645-53.,3030 Richards A.M., Abu Kwaik Y., Lamont R.J. Code blue: Acinetobacter baumannii, a nosocomial pathogen with a role in the oral cavity. Mol Oral Microbiol. 2015;30:2-15.

31 Nutman A., Temkin E., Lellouche J., Ben David D., Schwartz D., Carmeli Y. Detecting carbapenem-resistant Acinetobacter baumannii (CRAB) carriage: which body site should be cultured? Infect Control Hosp Epidemiol. 2020;41:965-7.
-3232 Cader S.H.A., Shah F.A., Nair S.K.G.R. Tracheostomy colonisation and microbiological isolates of patients in intensive care units-a retrospective study. World J Otorhinolaryngol Head Neck Surg. 2020;6:49-52. Thus, knowing the rates of CRAB is extremely relevant because these isolates are associated with high survivability and dissemination in the hospital environment when they colonize medical equipment and the hands of health professionals, as in the case of the present study, which is a propitious factor in the emergence of outbreaks.3333 Raveendra N., Rathnakara S.H., Haswani N., Subramaniam V. Bacterial biofilms on tracheostomy tubes. Indian J Otolaryngol Head Neck Surg. 2022;74:4995-9.

34 Assadian O., Harbarth S., Vos M., Knobloch J.K., Asensio A., Widmer A.F. Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review. J Hosp Infect. 2021;113:104-14.
-3535 Cortivo G.D., Gutberlet A., Ferreira J.A., Ferreira L.E., Deglmann R.C., Westphal G.A., et al. Antimicrobial resistance profiles and oxacillinase genes in carbapenem-resistant Acinetobacter baumannii isolated from hospitalized patients in Santa Catarina, Brazil. Rev Soc Bras Med Trop 2015;48:699-705.

Currently, therapeutic options for infections caused by CRAB isolates are limited. We observed a higher sensitivity of A. baumannii isolates to polymyxin B (97.9%), followed by antibiotics from the tetracycline (83.8%) and aminoglycoside (54%) classes. Polymyxins have been adopted as the antimicrobials of last resort to combat carbapenem-resistant strains and can be used alone or in combination with other antibiotics. Despite their high levels of susceptibility, polymyxins have the disadvantage of being neurotoxic and nephrotoxic. The emergence of resistant clinical isolates in other countries and Brazil is a concern, highlighting the need to monitor the susceptibility level to this drug.3636 Castilho S.R.A., Godoy C.S.D.M., Guilarde A.O., Cardoso J.L., André M.C.P., Junqueira-Kipnis A.P., et al. Acinetobacter baumannii strains isolated from patients in intensive care units in Goiânia, Brazil: molecular and drug susceptibility profiles. PLoS One. 2017;12:e0176790.,3737 Romanin P., Palermo R.L., Cavalini J.F., Fávaro L.D.S., De Paula-Petroli S.B., Fernandes E.V., et al. Multidrug- and extensively drug-resistant Acinetobacter baumannii in a Tertiary Hospital from Brazil- and importance of carbapenemase encoding genes and epidemic clonal complexes in a 10-year study. Microbial Drug Resistance. 2019;25(9):1365-73.

The tested tetracyclines also showed high sensitivity (> 80%). However, their use is not recommended, because Acinetobacter spp. are intrinsically resistant to tetracyclines and doxycyclines.3838 Nutman A., Lerner A., Schwartz D., Carmeli Y. Evaluation of carriage and environmental contamination by carbapenem-resistant Acinetobacter baumannii. Clini Microbiol Infect. 2016;22:949.e5-949.e7. In addition, we also tested ampicillin-sulbactam, which is within the CLSI recommendations, showing more than 50% sensitivity in our isolates. However, high error rates have been reported when using the disk-diffusion methodology to detect resistance to ampicillin-sulbactam.3939 Thom K.A., Rock C., Jackson S.S., Johnson J.K., Srinivasan A., Magder L.S., et al. Factors leading to transmission risk of Acinetobacter baumannii. Crit Care Med. 2017;45:e633-9.

Antibiotics in the aminoglycoside class showed the third highest susceptibility rate. In this study, we found that gentamicin, among the aminoglycosides, was more effective against Acinetobacter spp. isolates with lower levels of resistance than in other Brazilian studies.3131 Nutman A., Temkin E., Lellouche J., Ben David D., Schwartz D., Carmeli Y. Detecting carbapenem-resistant Acinetobacter baumannii (CRAB) carriage: which body site should be cultured? Infect Control Hosp Epidemiol. 2020;41:965-7.,3232 Cader S.H.A., Shah F.A., Nair S.K.G.R. Tracheostomy colonisation and microbiological isolates of patients in intensive care units-a retrospective study. World J Otorhinolaryngol Head Neck Surg. 2020;6:49-52. Although they present with nephrotoxicity and ototoxicity, these antibiotics are also used as alternatives against MDR microorganisms but have to be associated with another antimicrobial, usually a cephalosporin, fluoroquinolone, or carbapenem.4040 Rangel K., Chagas T.P.G., De-Simone S.G. Acinetobacter baumannii infections in times of COVID-19 pandemic. Pathogens. 2021;10:1006.

In Brazil, Technical Note n° 347/2021 ‒ CGLAB/DAEVS/SVS/MS presents guidelines for selecting antimicrobials to be tested and reports on antimicrobial sensitivity testing against carbapenem-resistant isolates of Acinetobacter spp. Based on this document, we highlighted the importance of creating institutional protocols with therapeutic steps, considering the site of infection, identifying the microorganism, and evaluating the sensitivity of the isolate.4141 Tsuji B.T., Landersdorfer C.B., Lenhard J.R., Cheah S.E., Thamlikitkul V., Rao G.G., et al. Paradoxical effect of polymyxin B: high drug exposure amplifies resistance in Acinetobacter baumannii. Antimicrob Agents Chemother. 2016;60:3913-20.

In conclusion, we report here for the first time the identification of Acinetobacter spp. from clinical samples of patients, health professionals, and hospital environments of ICUs of the four reference hospitals in the municipality of Porto Velho, Brazilian Amazon. Furthermore, we show that it is possible to establish the resistance profile of the eight identified species, with A. baumannii being the most predominant and associated with high rates of resistance and MDR. The MDR observed in environmental samples from ICUs highlights the potential for colonization and permanence at these sites, making it a possible reservoir for future outbreaks caused by these pathogens. Finally, we suggest that the data presented here can be used to guide and strengthen the control of MDR infections caused by Acinetobacter spp. in ICUs, as well as improve the current protocols and guidelines by providing information from a traditionally unassisted region of Brazil.

  • Funding
    This Study was financial support by Fundação Oswaldo Cruz - FIOCRUZ RÔNDONIA; Instituto Nacional de Epidemiologia na Amazônia Ocidental (INCT EpiAMO), do Centro de Pesquisa em Medicina Tropical - CEPEM/RO; Programa de Pesquisa para o SUS (PPSUS); Fundação de Amparo à Pesquisa do Estado de Rondônia

Acknowledgements

We are very grateful to Andrea Barbieri de Barros, Infectologist at Hospital de Base Ary Pinheiro of Porto Velho City, for her intense support; To the patients who participated in the study and to the Fundação Conrado Wessel in memorian of Erney Plessmann de Camargo.

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Publication Dates

  • Publication in this collection
    22 Jan 2024
  • Date of issue
    2023

History

  • Received
    19 June 2023
  • Accepted
    31 Oct 2023
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