Novel genetic context of multiple bla OXA-58 genes in Acinetobacter genospecies 3.

OBJECTIVES: The detection in Acinetobacter genospecies 3 isolates of OXA-type carbapenemases, resulting in reduced susceptibility to carbapenem antibiotics, is increasingly reported. We identified an Acinetobacter genospecies 3 isolate carrying the gene for OXA-58 and aimed to resolve the genetic environment surrounding the bla(OXA-58) gene. METHODS: Species identification was confirmed by 16S-23S rRNA restriction analysis. MICs of imipenem, meropenem and ertapenem were determined, and the isolate was screened by PCR for bla(OXA-23-like), bla(OXA-40-like), bla(OXA-51-like) and bla(OXA-58-like) genes. The sequence surrounding bla(OXA-58) was determined through amplification by inverse PCR and genome walking followed by sequencing. Genetic localization was investigated by Southern blotting. RESULTS: Isolate A164 was confirmed as belonging to Acinetobacter genospecies 3 and had reduced susceptibility to the carbapenems. The isolate was found to encode two bla(OXA-58) genes that may have been duplicated by the insertion sequence ISAba125, two copies of which were inserted into ISAba3 elements. The bla(OXA-58) genes appear to be plasmid borne. CONCLUSIONS: This is the first report of beta-lactamase duplication in Acinetobacter genospecies 3 and of gene duplication mediated by ISAba125.

Genetic diversity of carbapenem-resistant isolates of Acinetobacter baumannii in Europe.

In total, 96 carbapenem-resistant isolates of Acinetobacter baumannii were obtained from 25 hospitals in 17 European countries. Imipenem MICs ranged from <4 to 128 mg/L on retesting by Etest, with MICs > or =16 mg/L being associated with the carriage of genes encoding at least one other class D carbapenemase in addition to the intrinsic OXA-51-like enzyme. Molecular typing results obtained by random amplified polymorphic DNA analysis, followed by pulsed-field gel electrophoresis (PFGE) of ApaI-digested chromosomal DNA, were highly congruent, with 17 different PFGE types being delineated at a cut-off similarity level of 85%. With few exceptions, multiple isolates from a single hospital belonged to the same PFGE type. Seven sequence groups were identified among the 96 A. baumannii isolates, with the majority of isolates (n = 81) belonging to the previously defined sequence groups 1 and 2, which each included eight PFGE types. These two multinational lineages included the previously defined European clones II and I, respectively, but the problem of resistant A. baumannii in Europe appeared not to be confined solely to these two European clones. Rather, two broader lineages of carbapenem-resistant A. baumannii now seem to be spreading throughout Europe.

OXA-51-like beta-lactamases and their association with particular epidemic lineages of Acinetobacter baumannii.

Sixty diverse clinical Acinetobacter baumannii isolates of worldwide origin were assigned to sequence groups, based on a multiplex PCR for the ompA, csuE and bla(OXA-51-like) genes. The majority (77%) of isolates belonged to sequence groups 1 and 2 (SG1 and SG2), with sequence group 3 (SG3) and non-grouped isolates accounting for the remainder. The isolates were not closely related according to pulsed-field gel electrophoresis (PFGE), and the majority were sensitive to imipenem and meropenem. The construction of a linkage map of OXA-51-like beta-lactamase sequence relationships revealed two closely related clusters of enzymes, one focused around OXA-66 and the other around OXA-69. Isolates belonging to SG1 encoded an enzyme from the OXA-66 cluster, while those belonging to SG2 encoded an enzyme from the OXA-69 cluster. All SG3 isolates encoded OXA-71, which does not form part of a close enzyme grouping. Major multinational lineages accounted for a significant proportion of A. baumannii clinical isolates, and the evolution of the OXA-51-like enzymes appears to be an ongoing process.

Emergence and spread of carbapenem-resistant strains of Acinetobacter baumannii in a tertiary-care hospital in Poland.

This study analysed the occurrence of carbapenem resistance among Acinetobacter baumannii isolates from a tertiary-care hospital in Poland, together with the molecular epidemiology of these isolates and the risk-factors for their acquisition and possible nosocomial spread. The medical charts of 21 patients with Acinetobacter infection or colonisation revealed that A. baumannii isolates were obtained most frequently from intensive care unit and surgical patients (particularly those receiving transplantation surgery). First isolation occurred, on average, on day 21 following admission (range 5-45 days). Infection with Acinetobacter contributed directly to the death of seven patients. Several patients were infected with more than one strain, and molecular typing revealed the co-circulation of three predominant clones, of which two belonged to the Acinetobacter lineages designated as European clones I and II. All three clones encoded an OXA-51-type carbapenemase, but were negative for carbapenemases belonging to the OXA-23, OXA-24 and OXA-58 families. The OXA-51 gene was found in both resistant and susceptible isolates, and was not associated directly with carbapenem resistance. Etests with imipenem and imipenem plus EDTA indicated production of a metallo-beta-lactamase (MBL) in carbapenem-resistant isolates. PCRs for IMP-type MBLs were negative, but PCR using consensus primers for VIM-type MBLs were positive for carbapenem-resistant isolates belonging to the European clone II lineage. The occurrence of a VIM-type MBL in association with one of the epidemic lineages of A. baumannii is a cause for concern. Further studies are needed to evaluate possible inter-hospital spread of resistant A. baumannii strains in Poland.

Report of the Consensus Conference on Antibiotic Resistance; Prevention and Control (ARPAC).

Antimicrobial resistance is a key public health concern in Europe. It is known that there are significant variations in the prevalence of resistance across Europe, and methods to reduce the problem are also assumed to vary significantly. The 'Antibiotic Resistance; Prevention and Control (ARPAC)' Concerted Action project was funded by the European Commission and conducted by four study groups of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID). The project established a network of European hospitals and collated data on antimicrobial resistance prevalence, antimicrobial susceptibility testing methods, typing methods employed, antimicrobial use, antibiotic policies and practices, and infection control policies and practices. The ARPAC Consensus Conference, entitled 'Control of antibiotic resistance in European hospitals-informing future evidence-based practice', was held in Amsterdam in November 2004. The conference was co-hosted by the European Commission, ESCMID and the Dutch Working Party on Antibiotic Policy (SWAB). Key ARPAC findings were presented and discussed in the context of the worldwide situation. The conference delivered a set of high-priority recommendations likely to have a significant impact on antimicrobial resistance. This report summarises these recommendations.

Prevalence of Acinetobacter baumannii and other Acinetobacter spp. in faecal samples from non-hospitalised individuals.

In total, 226 individuals from the community were investigated for faecal carriage of Acinetobacter spp. by broth enrichment culture, followed by growth on blood agar and/or Leeds Acinetobacter Medium (LAM). Acinetobacter baumannii was isolated on both LAM and blood agar from one of 100 specimens in the UK and one of 126 specimens in The Netherlands. The predominant species were Acinetobactor johnsonii and genomic sp. 11, which were cultured from 22 and five specimens, respectively. A. baumannii did not seem to be widespread in the faecal flora of individuals in the community.

Cloning of the type VII trimethoprim-resistant dihydrofolate reductase gene and identification of a specific DNA probe.

A 1.3 kb HindIII fragment encoding the type VII trimethoprim-resistant dihydrofolate reductase gene was cloned into pBR322. Unidirectional deletion of this cloned fragment with exonuclease III identified the start of the dihydrofolate reductase gene. An internal 300bp EcoRV fragment was identified which could be used as a specific non-radioactive DNA probe to distinguish bacteria carrying the type VII gene from those carrying genes encoding other known dihydrofolate reductase types.

Isolation and characterisation of Haemophilus influenzae type b mutants defective in transferrin-binding and iron assimilation.

The quinone antibiotic streptonigrin was used to select mutants of Haemophilus influenzae type b defective in human transferrin binding. Compared with the parent wild-type strain (JKP1), mutant JKP5 was unable to bind transferrin whilst mutant JKP4 showed reduced binding. JKP5 appeared to lack an approximately 72 kDa transferrin-binding protein. Unlike JKP1, neither JKP4 nor JKP5 were able to acquire iron from human transferrin but their ability to use a variety of other iron and haem compounds as iron sources was unaffected. Such mutants should prove useful in further elucidating the mechanism of transferrin iron-acquisition and its contribution to the virulence of H. influenzae.

Clinical importance and antibiotic resistance of Acinetobacter spp. Proceedings of a symposium held on 4-5 November 1996 at Eilat, Israel.

Members of the genus Acinetobacter, particularly multiresistant strains of A. baumannii, are implicated in a wide spectrum of nosocomial infections, including bacteraemia, secondary meningitis and urinary tract infection, but have now assumed a particularly important role as agents of nosocomial pneumonia in intensive care units (ICUs). Rapid genotyping methods for the identification and typing of these organisms have allowed a better appreciation of the epidemiology and survival of these organisms in the hospital environment. Their emergence as significant pathogens seems to be related partly to their survival ability and partly to their ability to develop resistance rapidly to the major groups of antibiotics, resulting in a considerable selective advantage in environments (such as ICUs) with widespread and heavy uses of antibiotics. Molecular and biochemical mechanisms of resistance to the major beta-lactam, aminoglycoside and quinolone groups of antibiotics have now been elucidated in some detail for these organisms, and experimental models, including a mouse model of A. baumannii pneumonia, have been developed to examine the efficacy of different therapeutic regimens for difficult-to-treat-infections caused by these bacteria. 'Non-classic' antibiotic combinations--such as ticarcillin with clavulanic acid and sulbactam--seem to show promise for treating systemic infections caused by otherwise multiresistant strains, but revised screening procedures in the pharmaceutical industry may be required in the near future to select novel compounds with activity against multiresistant Acinetobacter spp. and other emerging gram-negative, non-fermentative bacilli in general.

Evaluation of a PCR-immunoassay technique for detection of Neisseria meningitidis in cerebrospinal fluid and peripheral blood.

A multiplex PCR-immunoassay for the rapid diagnosis of bacterial meningitis from cerebrospinal fluid (CSF) or peripheral blood was compared with conventional microbiological techniques used in the routine diagnostic laboratory. The multiplex PCR was designed to detect simultaneously a universal conserved sequence coding for bacterial 16S rRNA and the Neisseria meningitidis porA gene. The PCR-immunoassay had a detection limit of (3-5) x 10(2) cfu/ml (equivalent to 1-3 cfu/PCR) with spiked CSF or blood samples, compared with (3-5) x 10(3) cfu/ml for PCR followed by conventional agarose gel electrophoresis for detection of PCR products. Of 294 CSF samples from patients suspected on clinical grounds of suffering from meningitis, the PCR-immunoassay detected bacterial DNA in 29 CSF samples, 15 of which were also positive for N. meningitidis DNA. The 29 positive CSF samples comprised 25 samples that were also reported positive and four that were reported negative by conventional methodology; the latter four were all positive for N. meningitidis by the PCR-immunoassay. Of 173 peripheral blood samples examined, the PCR-immunoassay detected bacterial DNA in 18 samples, 14 of which were also positive for N. meningitidis DNA. In comparison, only 10 samples were reported positive for N. meningitidis by conventional methodology. All negative PCR-immunoassay results correlated with those obtained by conventional methodology for both CSF and blood samples. The sensitivity and speed of the PCR-immunoassay system indicated that it could be used as a routine diagnostic test for meningococcal meningitis, enabling a diagnosis to be made within 4 h of receipt of the specimen.

A rapid immunoassay method for the direct detection of PCR products: application to detection of TEM beta-lactamase genes.

A rapid immunoassay for the detection of specific PCR products is described in which a positive PCR amplification result is detected, usually in less than 5 min, by applying a few drops of the diluted PCR end-product to a small immunoassay sample device. The method was evaluated in comparison with conventional susceptibility tests and isoelectric focusing (IEF) for the detection of TEM-family beta-lactamase genes in 477 Escherichia coli isolates from urine samples. Of 187 isolates identified as presumptive TEM beta-lactamase producers by conventional methods, 185 generated a positive signal in the PCR immunoassay system. Two further signal-positive isolates were recognised when the PCR was repeated. In addition, one of the 276 ampicillin-susceptible isolates gave a positive signal in repeated PCR-immunoassay experiments despite being ampicillin susceptible and failing to give a TEM-type enzyme band in iso-electric focusing experiments.

Analysis by pulsed-field gel electrophoresis of insertion mutations in the transferrin-binding system of Haemophilus influenzae type b.

A mutagenesis system involving the insertion of a non-transposable antibiotic resistance gene cassette was used to generate stable mutations in the chromosome of Haemophilus influenzae type b strain Eagan. The mutations generated were shown by pulsed-field gel electrophoresis (PFGE) to have unique SmaI fingerprint patterns and to be located randomly on the chromosome. Of 700 insertion mutants screened, 29 had stable insertions resulting in constitutive expression of transferrin-binding proteins (TBPs). The high proportion of such mutants indicated that numerous regulatory loci could influence the expression of this phenotype. Five such regulatory mutations were analysed in detail by PFGE and DNA hybridisation and were shown to be located at five different chromosomal loci, although three of the five loci were located on the same 330-kb SmaI fragment of the wild-type strain Eagan chromosome. This fragment also contains several important virulence determinants, including the capb locus, and one of the five constitutive mutants had concomitantly lost the ability to synthesise a type-b capsule. No DNA homology was demonstrated between H. influenzae chromosomal fragments separated by PFGE and DNA probes for the TBPs from Neisseria meningitidis, but the possibility of shared regulatory mechanisms controlling the expression of TBPs in these two species remains to be investigated.

Clinical and epidemiological features of an outbreak of acinetobacter infection in an intensive therapy unit.

Sporadic examples of infection with multi-resistant Acinetobacter spp. have occurred in Nottingham hospitals since at least 1977, punctuated by more prolonged outbreaks involving larger numbers of patients, particularly those confined to the intensive therapy unit (ITU) with severe underlying disease. In the most recent outbreak, 11 patients were infected with multi-resistant Acinetobacter strains and 26 patients were colonised. Four of the infected patients died directly or indirectly from infection with multi-resistant Acinetobacter spp., either while in the ITU or after discharge to a general ward. The mean interval from admission to the first isolation of a multi-resistant Acinetobacter strain was 6.7 and 12.1 days in the infected and colonised groups, respectively. Multi-resistant Acinetobacter strains were isolated most frequently from the respiratory tract, and eight patients had probable or suspected pneumonia caused by a multi-resistant Acinetobacter sp. All infected patients were treated with imipenem, with or without an aminoglycoside, except one patient who died before a diagnosis of acinetobacter infection was confirmed. Multi-resistant Acinetobacter spp. were isolated from various environmental sites in the ITU, and patient and environmental isolates were found to be related closely by biotyping, antibiograms, pulsed-field gel electrophoresis of chromosomal fingerprints and ribotyping. The outbreak was controlled ultimately by transfer of infected or colonised patients to an isolation cubicle, cohort nursing, emphasis on the importance of hand washing before and after patient contact and when handling case notes, and the use of disposable aprons and gowns during patient contact.(ABSTRACT TRUNCATED AT 250 WORDS)

Molecular epidemiology of aminoglycoside resistance in Acinetobacter spp.

Most aminoglycoside resistance in Acinetobacter spp. involves production of aminoglycoside-modifying enzymes. Previous studies have shown that the genes encoding these enzymes can be present on plasmids, transposons or within integron-type structures. To determine whether particular mechanisms of aminoglycoside resistance have developed in strains from specific geographical locations (with subsequent clonal spread), or whether common mechanisms have been acquired by genotypically distinct clinical isolates of Acinetobacter spp. throughout the world, a genotypically heterogeneous collection of 24 multiresistant clinical isolates of Acinetobacter spp. from 15 hospitals in 11 countries worldwide was studied. All were resistant to two or more aminoglycoside antibiotics. The full aminoglycoside resistance profile was determined for each isolate, allowing a putative enzyme content to be inferred, with subsequent confirmation of enzyme content and genetic location by polymerase chain reaction (PCR) and hybridisation techniques. All produced at least one aminoglycoside-modifying enzyme, most commonly AAC(3)-I and ANT(3'')-I in various combinations. Other enzymes found were AAC(3)-II, AAC(6')-I, ANT(2''), APH(3')-I and APH(3')-VI. None was confined to strains from a particular geographical area. Nine isolates transferred resistance mediated by AAC(3)-I, ANT(2'')-I, APH(3')-I or APH(3)'-VI by conjugation to a sensitive strain of A. baumannii, but most resistance was non-transferable. PCR mapping revealed an integron location in six isolates for the aac(3)-Ia gene and in three isolates for the ant(3'')-Ia gene. Overall, the study demonstrated that similar aminoglycoside-modifying enzymes are found in unrelated isolates of Acinetobacter spp., and that particular genes are not restricted to specific areas of the world. The demonstration of certain genes on plasmids and integrons emphasises the probable importance of these structures in the dissemination of certain types of aminoglycoside resistance in Acinetobacter spp.

Transferrin-binding ability of invasive and commensal isolates of Haemophilus spp.

Haemophilus influenzae type b expresses an inducible siderophore-independent iron-acquisition system that depends on a direct interaction between human transferrin and specific iron-regulated transferrin-binding outer-membrane proteins. To evaluate the importance of this iron-acquisition system amongst haemophili, 156 isolates of Haemophilus spp. (78 commensal isolates and 78 isolates from invasive infections) were examined for their ability to bind transferrin. Of the 78 invasive isolates, all of which were H. influenzae type b, 71 (91%) were capable of binding transferrin, with 57 (73%) binding transferrin constitutively (i.e., even when grown in an iron-sufficient medium). In contrast, only 11 (14%) of the commensal isolates bound transferrin constitutively, with a further 16 (21%) binding transferrin only after growth in an iron-deficient medium. Of the 27 commensal strains that were capable of binding transferrin, 12 were H. parainfluenzae biotype III, 14 were non-typable H. influenzae, and one was H. parahaemolyticus. None of the H. influenzae type b invasive or commensal isolates showed evidence of siderophore production, but 50 (66%) of the remaining 76 commensal isolates appeared to produce an iron chelator. Thus, while not a universal characteristic, detectable transferrin-binding was associated strongly with H. influenzae type b isolates from invasive infections, and was also recognised for the first time in isolates of H. parainfluenzae and H. parahaemolyticus.

Direct comparison of two commercially available computer programs for analysing DNA fingerprinting gels.

Randomly amplified polymorphic DNA (RAPD) fingerprints were generated with M13 and DAF4 primers for 25 isolates of Acinetobacter spp. obtained from 16 different hospitals situated in 12 countries. The overall robustness of the algorithms and the reproducibility of the cluster analysis results generated by two commercially available computer programs (GelCompar and DENDRON) for analysing DNA fingerprinting gels were tested by examining the same set of fingerprinting data independently in two laboratories with the different software packages. Both programs were efficient at recognising and grouping strains with closely similar RAPD fingerprints, i.e., strains which might be expected to have a close epidemiological or evolutionary relationship. However, the relationships suggested for less closely related strains showed considerable variation in terms of the overall similarity or percentage correlation values suggested by the programs. It was concluded that both programs were useful tools for indicating close genotypic relationships between individual strains, but that epidemiological conclusions based on the similarity or correlation values (or the dendrograms derived from them) obtained for less closely related strains should be treated with considerable caution.

Increase in incidence of resistance to ampicillin, chloramphenicol and trimethoprim in clinical isolates of Salmonella serotype Typhimurium with investigation of molecular epidemiology and mechanisms of resistance.

Antimicrobial resistance patterns of Salmonella serotype Typhimurium isolates obtained during the period 1987-1994 were examined and the molecular epidemiology and the mechanisms of resistance to ampicillin, chloramphenicol and trimethoprim were investigated in 24 strains isolated during 1994. Resistance to ampicillin increased from 18% to 78%, to chloramphenicol from 15% to 78%, to tetracycline from 53% to 89% and to co-trimoxazole from 3% to 37%, whereas resistance to norfloxacin remained at 0%. Of Salmonella serotype Typhimurium strains isolated during 1994, all ampicillin-resistant strains had an MIC > 256 mg/L, except one strain in which the MIC was 64 mg/L. Twelve strains (52%) had a TEM-type beta-lactamase, nine (39%) a CARB-type beta-lactamase and two strains (8%) had an OXA-type beta-lactamase. Chloramphenicol acetyl-transferase activity was detected in only nine (47%) of 19 chloramphenicol resistant strains, whereas all eight trimethoprim-resistant strains produced a dihydrofolate reductase type Ia enzyme. Three different epidemiological groups were defined by either low-frequency restriction analysis of chromosomal DNA and pulsed-field gel electrophoresis or repetitive extragenic palindromic-PCR. The latter technique provided an alternative, rapid and powerful genotyping method for S. Typhimurium. Although quinolones provide a good therapeutic alternative, the multiresistance of S. Typhimurium is of public health concern and it is important to continue surveillance of resistance levels and their mechanisms.

Development and evaluation of a PCR-based immunoassay for the rapid detection of methicillin-resistant Staphylococcus aureus.

A multiplex polymerase chain reaction (PCR), involving detection of the mecA and femB genes, was combined with a novel immunoassay system capable of detecting specific PCR products. The resulting PCR-immunoassay was evaluated in comparison with conventional microbiological techniques used in the routine diagnostic laboratory for the rapid identification of methicillin-resistant Staphylococcus aureus (MRSA), either in pure culture or in overnight broth cultures obtained following enrichment of patient screening swabs. Among the 480 purified isolates of staphylococci and 246 enrichment broths examined, only one 'false-negative' result was obtained by PCR, compared with 18 'false-negative' results obtained by conventional methodology and demonstrated by further conventional examination. Five demonstrable 'false-positive' results were obtained by conventional methodology, compared with a possible 10 by the PCR-immunoassay, although it was not certain that these 10 PCR results were true 'false positives' as, by definition, MRSA could not be isolated by conventional methodology. The results indicated that the routine diagnostic laboratory was encountering difficulties in identifying MRSA correctly, and that the conventional microbiological techniques lacked sensitivity. Overall, the PCR technique was more accurate and sensitive than conventional methodology in detecting MRSA, and results were available within 24 h of screening swabs arriving in the laboratory, compared with a minimum of 48-72 h by conventional techniques. The immunoassay system added to the usefulness of the method by allowing the detection of specific PCR products within 5 min of completing the PCR, without the normal additional step of agarose gel electrophoresis.

Comparison of rapid automated laser fluorescence analysis of DNA fingerprints with four other computer-assisted approaches for studying relationships between Acinetobacter baumannii isolates.

The relationships between isolates suggested by a novel DNA typing method (RAPD-ALFA) that combines randomly amplified polymorphic DNA with automated on-line laser fluorescence analysis of DNA fragments were compared with those suggested by four other computer-assisted typing strategies (biotyping, antibiogram typing, pulsed-field gel analysis of chromosomal fingerprints and arbitrarily-primed DNA amplification with three different primers) for 25 isolates of Acinetobacter baumannii obtained from 12 different hospitals in four countries over a period of 12 years. The results obtained by cluster analysis with two different software packages confirmed that the relationships suggested by RAPD-ALFA were robust and essentially similar to those suggested by the other more laborious computer-assisted typing methods. The technique of RAPD-ALFA appears to offer the possibility of routine on-line molecular identification and typing of isolates from particular hospital wards or units (e.g., intensive care units), and could, therefore, play a key role in the early recognition and prevention of outbreaks of infection.

Identification and cloning of the type IIIa plasmid-encoded dihydrofolate reductase gene from trimethoprim-resistant gram-negative bacteria isolated in Britain.

A clinical strain of Escherichia coli isolated in Nottinghamshire in 1980 was shown to harbour the type IIIa trimethoprim-resistant dihydrofolate reductase gene, previously identified on only one occasion, in New Zealand in 1979. The gene was identified by hybridisation with an 855-bp type III gene probe and its classification as a type IIIa dihydrofolate reductase was confirmed by detailed biochemical analysis of the enzyme product. The dihydrofolate reductase was identical in size and isoelectric point with the original type IIIa enzyme and shared similar inhibitory and kinetic profiles. The trimethoprim resistance gene was subsequently cloned and the type IIIa dihydrofolate reductase gene was localised to a 700-bp EcoRI-PstI fragment. This smaller fragment may prove to be a more specific DNA probe for the future identification of type IIIa dihydrofolate reductase genes.