Detection of blaOXA23 and blaNDM in Imipenem and Meropenem Resistant Pseudomonas

aeruginosa and Acinetobacter baumanii

EVANGELISTA, Isa Noelle C.

ORMITA, Mikaela Joy M.
PACIA, Carissa Jenelle
PATAWARAN, Mariah Ericka M.
RAMOS, Patricia Eriana M.
SANTOS, Jeanne Mari R.
SANTOS, Sheila Marie S.

CHAPTER 1: The Problem and Its Background

INTRODUCTION

Antibiotics are developed and produced to treat dangerous diseases caused by bacteria,
viruses and several others. However, antimicrobial resistance continuously develops naturally
over time. This development is caused by numerous factors like environmental changes,
chemical reactions, adaptation and genetic mutation of the microorganism which is accelerated
by the misuse and overuse of antibiotics. This results to the inability of antibiotics to cure
diseases due to the development of the different strains of microorganisms. As this is a growing
problem worldwide, multi-drug resistant (MDR) strains of bacteria can also be found here in the
Philippines. This study focuses on the drug resistance of Pseudomonas aeruginosa and
Acinetobacter baumanii, both of which causes nosocomial infections here in the Philippines.

Pseudomonas aeruginosa is the most common bacteria causing infections in humans. It is

a gram-negative microorganism which usually causes infections in humans with weakened
immune systems. It has the ability to survive in moist environments and is of medical importance
due to its developing resistance to several antibiotics as observed globally. Acinetobacter
baumanii on the other hand, is a non-fermenting aerobic gram-negative coccobacilli that has the
ability to survive under a wide range of environmental conditions. Because of this factor, is it
therefore a frequent cause of infection outbreaks. It is one of the significant pathogens in hospital
acquired infections. It generally infects patients of old age, with weak immunity, or under

immunosuppressive medications. It causes bacteremia, pneumonia, meningitis, urinary and

wound infections. This strain is also considered to be developing antimicrobial resistance.

Carbapenem is a member of the beta-lactam antibiotics. It has a broad-spectrum activity

and is the main drug used to treat infections caused by Pseudomonas aeruginosa and the first
choice agent for Acinetobacter baumanii. Carbapenem resistance is often encountered in
healthcare settings due to inadequate therapy. Medications made which has a substandard quality
could also be a factor, as well as irrational prescriptions. The mechanisms for the resistance is
due to hydrolysis by beta-lactamases, alterations in the outer membrane of protein and penicillin
binding proteins, increased activity of efflux pumps, production of oxa beta-lactamases or
changes in cell permeability. Carbapenemase genes are one of the most frequent mechanisms
reported in Pseudomonas aeruginosa.

The purpose of this study is to detect the resistance-causing genes bla OXA23 and blaNDM in
Pseudomonas aeruginosa and Acinetobacter baumanii, both of which should be resistant to
imipenem and meropenem.

STATEMENT OF THE PROBLEM

Multi-drug resistance is a growing threat not only in the Philippines, but also in other
countries worldwide. Despite the effort of the World Health Organization (WHO), as well as
local organizations like the Department of Health (DOH) and Philippine Association of Medical
Technologists (PAMET), to prevent and manage antimicrobial resistance, it is still occurring

rapidly because of genetic changes, misuse and overuse of antibiotics, irrational prescriptions,
lack of awareness of consumers and several other factors. This problem has negatively impacted
the society most especially those with weakened immune systems. In line with the growing
multi-drug resistance being observed here in the Philippines, this study's main problem is to
detect the resistant genes blaOXA23 and blaNDM in Pseudomonas aeruginosa and Acinetobacter
baumanii towards carbepenems, specifically imipenem and meropenem. This study intends to
find out from what source of specimen the said genes are most frequently isolated from to see
which strains and diseases are of top most priority to be researched on. Lastly, this study
compares the antibiotic resistance profile of blaOXA23 and blaNDM producing strains against those
that are non-producing. By conducting this, this study will be able to identify the cause of the
resistance in Pseudomonas aeruginosa and Acinetobacter baumanii through the use phenotypic
and genotypic methods. This will benefit the research society because this study will find out if
the strains are the cause of the antibacterial resistance or if there is another mechanism behind it.

OBJECTIVES OF THE STUDY

This study aims to detect the genes blaOXA23 and blaNDM in strains of Pseudomonas
aeruginosa and Acinetobacter baumanii resistant to carbapenem, specifically imipenem and
meropenem through the use of Polymerase Chain Reaction. It also aims to determine what
source of specimen blaOXA23 and blaNDM genes are frequently isolated from and in what
percentage. Lastly, it aims to compare the resistance profile of bla OXA23 and blaNDM producing
strains against those that are non-producing.

SIGNIFICANCE OF THE STUDY

As this study will aim to answer its objectives, it will aid the research community, and the
general public, in terms of providing additional data and reference that can be used for future
researches.

This study will further strengthen the scientific basis for the cause of the resistance of
Pseudomonas aeruginosa and Acinetobacter baumanii towards carbapenems, specifically to
imipenem and meropenem, especially since this will be a first in the Philippines. As the
prevalence of the carbapenem resistant bacteria in the Asia-Pacific region is high (Kiratisin et.
al., 2012), the results of this study will influence medical institutions to improve protocols
involved in addressing such resistance, thus conserving money (Hsueh et. al., 2011), time and
effort (Falagas & Kopterides, 2006), in order to put into minimum the casualties caused by the
organisms pathogenicity (Kiratisin et. al., 2012). This research will also expand knowledge and
update research findings regarding multi-drug resistance in the Philippines. It will also
strengthen campaigns of global and local organizations against misuse and overuse of antibiotics
as consumers lack awareness concerning the emergent multi-drug resistance, its causes, harmful
effects and impact nowadays and in the near future.

SCOPE AND LIMITATION

This research will focus on the detection of genes coding for resistance in imipenem and
meropenem resistant Pseudomonas aeruginosa and Acinetobacter baumanii. The said genes to

be detected are limited to bla OXA23 and blaNDM. The method of detection to be used will be
Polymerase Chain Reaction. Fifteen clinical samples from an unclassified tertiary hospital in
Manila, Philippines will be used. These clinical samples do not have a specific site of acquisition
but the highest frequency of isolation or the distributions of the genes in the clinical isolated
strains will be investigated.

DEFINITION OF TERMS

Acinetobacter baumanii is a gram-negative, aerobic, non-motile bacillus. It is an

opportunistic pathogen primarily associated with hospital acquired infections coupled with the
dramatic increase in the incidence of multi-drug resistant strains.
blaNDM New Delhi metallo -lactamase is a gene isolated from multi-drug bacterial
strains.
blaOXA23 This carbapenemase gene was first isolated in 1955 from Acinetobacter
baumanii. Carbapenem resistance was associated mainly with carriage of the blaOXA23 gene.
Carbapenem is a beta-lactam antimicrobial agent with an exceptionally broad
spectrum of activity. They act by inhibiting bacterial cell wall synthesis by binding to and
inactivating penicillin-binding proteins.
Imipenem is a prototype of carbapenem agent. It is co-administered with a renal
dehydropeptidase inhibitor, cilastatin, in order to prevent its renal metabolism in clinical use. It
has shown to provide effective monotherapy for septicemia, neutropenic fever, and intraabdominal, lower respiratory tract, genitourinary, gynecological, skin, soft tissues, bone and joint
infections.

Meropenem a broad spectrum antibacterial agent of the carbapenem family approved

for use in complicated intra-abdominal infection, complicated skin and skin structure infection,
bacterial meningitis, nosocomial pneumonia, septicemia, febrile neutropenia, bacterial
meningitis, complicated urinary tract infection, obstetric and gynecological infections, cystic
fibrosis patients with pulmonary exacerbations, and for the treatment of severe community
acquired pneumonia.
Multi-drug resistant (MDR) antimicrobial resistance shown by a species of
microorganism to multiple microbial drugs.
Pseudomonas aeruginosa is a gram-negative, aerobic, motile bacilli associated with
serious problems in patients hospitalized with cystic fibrosis, burns, and cancer. Case fatality is
50%.