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Acinetobacter baumannii
Acinetobacter baumannii
an update
Dr.T.V.Rao MD
Acinetobacter baumannii is a Gram negative bacteria. It is typically a short, almost round, rod-shape (coccobacillus). It can be an opportunistic pathogen in humans, affecting people with compromised immune systems and is becoming increasingly important as a hospital derived infection (nosocomial). It has also been isolated from soil and water samples in the environment.
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Current taxonomy
The genus Acinetobacter, as currently defined, comprises gram-negative, strictly aerobic, Nonfermenting, nonfastidious, nonmotile, catalase-positive, oxidase-negative bacteria with a DNA G+C content of 39% to 47%. Based on more recent taxonomic data, it was proposed that members of the genus Acinetobacter should be classified in the new family Moraxellaceae within the order
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Acinetobacter - Motionless The name, Acinetobacter, comes from the Latin word for "motionless," because they lack cilia or flagella with which to move. Most species are not significant sources of infection. However, one opportunistic species, Acinetobacter baumannii , is found primarily in hospitals and poses a risk to people who have supressed immunity:
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Acinetobacter a Emerging Multidrug Resistant Bacteria Since the 1970s, the spread of multidrugresistant (MDR) Acinetobacter strains among critically ill, hospitalized patients, and subsequent epidemics, have become an increasing cause of concern. Reports of community-acquired Acinetobacter infections have also increased over the past decade. A recent manifestation of MDR Acinetobacter that has attracted public attention is its association with infections in severely injured soldiers.
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Microbiology
Oxidase negative Nitrate negative Catalase positive Nonfermentative Nonmotile Strictly aerobic Gram negative coccobacillus
Sometimes difficult to decolorize
Morphology is distinctive
Ubiquitous:
Rod shaped during rapid growth and Coccobacillary in the stationary phase. Encapsulated (generally). Nonmotile (although they may exhibit twitching motility). Gram-negative organisms. Retention of crystal violet may result in incorrect identification as gram-positive cocci.
Microbiology
Widely distributed in nature (soil, water, food, sewage) & the hospital environment
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Biochemical Reactions
Oxidase negative
(opposite to Neisseria spp. or Moraxella spp.)
Biochemical Reactions
Acidify glucose (may enhance its ability to invade devitalized tissue). Grow at 44 C. Aerobic. Acinetobacter spp have the ability to use various sources of nutrition which accounts for its growth on routine laboratory media. This also explains its survival as an environmental pathogen.
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Colony Characters
Colonies are 1 to 2 mm, nonpigmented, domed, and muciod, with smooth to pitted surfaces. They can't reduce nitrate or to grow anaerobically (different from Enterobacteriaceae).
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Newer methods of Identification of different species Methods include high resolution fingerprinting with AFLP, PCR-RFLP with digestion of PCR amplified sequences, and analysis of various DNA sequences. Of these, AFLP analysis and amplified 16SrRNA ribosomal DNA restriction analysis have been validated with large numbers of strains of all described species. Nucleotide sequence based methods are expected to be the standard for identification in the near future.
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Metallo--lactamase (VIM, IMP): gene transfer, gene activation my insertion of an activation sequence (this is inserted upstream and switches on enzyme production) & mutation. OXA Carbapenemases (class D) difficult to detect. Cell permeability changes. Target (PBPs) change.
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Metallo--lactamases:
Common in the Far East, rare in Europe. Various VIM & IMP types (plasmid mediated). Extracts have been shown to hydrolyse imipenem. High incidence in Pseudomonas aeruginosa referred to the HPA.
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biofilms with enhanced antibiotic resistance and, more recently, that a chaperone-usher secretion system involved in Pilus assembly affects biofilm formation
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infected with Iraqnobacter (Acinetobacter baumannii) due to its spread throughout the military hospitals. Many times soldiers have survived hellacious trauma on the battlefield only to succumb to even more damage by an organism that has picked up antimicrobial resistance factors to the drugs primarily associated with treating them almost impossible.
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Microbiological Investigation
Acinetobacter baumannii isolates were presumptively identified by using morphology of the colonies, Gram staining, Oxidase and Catalase reactions, growth at 44C, and the API-20 NE System (BioMerieux, Lyon, France) Identification as A. baumannii was verified by restriction analysis of the 16S-23S ribosomal RNA intergenicspacer sequences,
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ICUs A potential source of Acinetobacter Infections The elucidation of potential risk factors for resistant strains of Acinetobacter is therefore an important task, and the use of alternative antibiotics should be considered in ICUs where these strains are endemic .
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Acinetobacter outbreaks
Detection of Acinetobacter Infections
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Treatment
Carbapenems (Imipenem and Meropenem) are the mainstay of treatment for antimicrobialresistant gram-negative infections, though Carbapenems-resistant Acinetobacter is increasingly reported. Resistance to the Carbapenems class of antibiotics makes multidrug-resistant Acinetobacter infections difficult, if not impossible, to treat.
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Multidrug-resistant A. baumannii is a common problem in many hospitals in the US and Europe. First line treatment is with a Carbapenems antibiotic such as imipenem, but carbapenem resistance is increasingly common. Other treatment options include Polymyxin, Tigecycline and Aminoglycosides.
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Origin of Iraqibacter
Where the Iraqibacter came from remains something of a mystery. Soil samples taken by researchers in Iraq and Kuwait came back negative. However, it was found thriving in the hospitals. When Iraqibacter was compared to MDRAB samples taken in Europe before the war, they were found to be identical (Silberman, 2007). Thus, scientists believe that the current outbreak originated from European sources. ( So MDRAB did exist before the Iraq War.)
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Acinetobacter Meningitis
Most cases are hospital-acquired Often associated with neurosurgical procedures Risk factors: Ventriculostomy Heavy use of antibiotics in the neurosurgical ICU
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X-ray view boxes Curtain rails Curtains Equipment carts Sinks Ventilator circuits Floor mops
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Extensive environmental contamination Highly antibiotic resistant High proportion of colonized patients Frequent contamination of the hands of healthcare workers
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Outbreak of multidrug resistant A. baumannii in a Dutch ICU involving 66 patients with an epidemic strain Nursing staff were cultured (nares & axilla, same swab)
15 nurses found to harbor epidemic strain All were culture negative when re-cultured (nose, throat, axilla, perineum)
Wagenvoort JHT et al. Eur J Clin Microbiol Infect Dis 2002;21:326-327.
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General Measures
Hand hygiene
Use of alcohol-based hand sanitizers
Preventing Acinetobacter Transmission in the ICU Outbreak Interventions Hand cultures Surveillance cultures Environmental cultures following terminal disinfection to document cleaning efficacy Cohorting Ask laboratory to save all isolates for molecular typing Healthcare worker education If transmission continues despite above interventions, closure of unit to new admissions
Contact precautions
Gowns/gloves Dedicate non-critical devices to patient room
Environmental decontamination Prudent use of antibiotics Avoidance of transfer of patients to Burn Unit from other ICUs
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Efficacy of Hand washing Agents against Acinetobacter Experimental study to access removal of A. baumannii from the hands of volunteers
103 CFU 99.97% (light contamination) 70% Ethyl alcohol 99.98% or 106 CFU (heavy 99.98% 10% Povidone-iodine contamination) 4% Chlorhexidine
Plain with soap either 99.81%
Cardoso CL et al. Am J Infect Control 1999;27:327-331. Dr.T.V.Rao MD
Removal Rate Agent Plain soap 70% Ethyl alcohol 10% Povidone-iodine 4% Chlorhexidine
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Removal Rate Light contamination Heavy contamination 99.97% 99.98% 99.98% 99.81% 92.40% 98.94% 98.48% 91.39%
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Agent Light contamination Heavy contamination Fingertips inoculated 92.40% 98.94% 98.48% 91.39%
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Why Dealing with A.baumannii infections is problematic. A. baumannii important cause of nosocomial infections, in ICUs (Clin Infect 2004;10:684 704) Treatment difficult because multi-resistant Colonized, infected patients point- sources of A. baumannii infections in healthcare settings Prolonged organism survival on environmental surfaces in hospitals contributes to protracted outbreaks
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CHROMagar Acinetobacter agar is the latest addition to the clinical range of chromogenic media developed by Dr.Alain Rambach.
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Simple and Scientific Hand Washing can reduce infections with A.baumannii too
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Programme Created by Dr.T.V.Rao MD for Medial and Health care Workers in the Developing World Email
doctortvrao@gmail.com
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