Acinetobacter Sepsis Among Out-born Neonates Admitted to Neonatal Unit in Pediatric Emergency of a Tertiary Care Hospital in North India

Detection of AdeAB, TetA, and TetB efflux pump genes in clinical isolates of tetracycline-resistant Acinetobacter baumannii from patients of Suez Canal University Hospitals

BACKGROUND

Acinetobacter baumannii is an opportunistic bacteria associated primarily with hospital-acquired infections. Its tendency to acquire or donate resistance genes to neighboring bacteria is a major concern. Tetracyclines have shown promise in treating A. baumannii infections, but tetracycline resistance is growing globally in A. baumannii isolates.

OBJECTIVES

The study aimed to study (1) the prevalence of multidrug-resistant (MDR) A. baumannii infections at Suez Canal University Hospitals, (2) the distribution of efflux pump genes AdeA &B, TetA, and TetB, and (3) the effect of efflux pump inhibitor (CCCP) on tetracycline-resistant isolates.

METHODS

Clinical samples (457) were collected (blood, urine, sputum, ETA, pus, and pleural fluid), followed by A. baumannii isolation and identification, PCR detection of efflux pump genes, and detection of tetracycline susceptibility and its MIC before and after treatment with the efflux pump inhibitor (CCCP).

RESULTS

A total of 31 A. baumannii isolates were recovered (6.78%). The highest rate of isolation was from the ICU (48.3%) from the ET aspirate samples (48.3%). The efflux system AdeA and TetB genes were distributed in 100% of isolates, whereas AdeB was found in 93.5% of isolates and the TetA gene in 87.1% of isolates. All A. baumannii isolates were MDR showing resistance to three or more classes of antibiotics. 45% of the isolates showed a 4-fold reduction of MIC and 12.9% showed a 2-fold reduction in the MIC.

CONCLUSIONS

Efflux pump is an important mechanism for tetracycline resistance among A. baumannii isolates.

Neonatal Late-Onset Sepsis Due to Acinetobacter baumannii: A Case Report

Late-onset sepsis (LOS) is commonly associated with pathogens acquired in hospital or community settings and carries a significant risk of morbidity and mortality in neonates. We present a case of a late preterm neonate, born at 36 weeks and 2 days with low birth weight (1700 g), who was admitted to the neonatal intensive care unit (NICU) and developed LOS on the fourth day of life. LOS was diagnosed in the context of fever and lethargy, mild thrombocytopenia, leukopenia, and lymphopenia, and was caused by multidrug-resistant (MDR) Acinetobacter baumannii, confirmed through blood culture. Initial empirical treatment with vancomycin and gentamicin was adjusted to gentamicin and meropenem based on the antibiogram, resulting in a swift and favorable clinical and laboratory response. This case, a rare occurrence in our NICU, provides an opportunity to discuss the etiology, risk factors, and clinical presentation of LOS related to Acinetobacter baumannii, as well as to highlight the growing concern of MDR microorganisms in the NICU setting.

Deciphering the impact of Acinetobacter baumannii on human health, and exploration of natural compounds as efflux pump inhibitors to treat multidrug resistance

Acinetobacter baumannii is an ESKAPE pathogen and threatens human health by generating infections with high fatality rates. A. baumannii leads to a spectrum of infections such as skin and wound infections, endocarditis, meningitis pneumonia, septicaemia and urinary tract infections. Recently, strains of A. baumannii have emerged as multidrug-resistant (MDR), meaning they are resistant to at least three different classes of antibiotics. MDR development is primarily intensified by widespread antibiotic misuse and inadequate stewardship. The World Health Organization (WHO) declared A. baumannii a precarious MDR species. A. baumannii maintains the MDR phenotype via a diverse array of antimicrobial metabolite-hydrolysing enzymes, efflux of antibiotics, impermeability and antibiotic target modification, thereby complicating treatment. Hence, a deeper understanding of the resistance mechanisms employed by MDR A. baumannii can give possible approaches to treat antimicrobial resistance. Resistance-nodulation-cell division (RND) efflux pumps have been identified as the key contributors to MDR determinants, owing to their capacity to force a broad spectrum of chemical substances out of the bacterial cell. Though synthetic inhibitors have been reported previously, their efficacy and safety are of debate. As resistance-modifying agents, phytochemicals are ideal choices. These natural compounds could eliminate the bacteria or interact with pathogenicity events and reduce the bacteria's ability to evolve resistance. This review aims to highlight the mechanism behind the multidrug resistance in A. baumannii and elucidate the utility of natural compounds as efflux pump inhibitors to deal with the infections caused by A. baumannii.

Dramatic increase in antimicrobial resistance in ESKAPE clinical isolates over the 2010-2020 decade in India

RATIONALE AND OBJECTIVES

ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) constitute a threat to humans worldwide. India is now the most populous country. The goal was to investigate the evolution of the rates of antimicrobial resistance in ESKAPE pathogens across India over the 2010-20 decade.

METHODS

The data (89 studies) were retrieved from the Medline PubMed repository using specific keywords.

RESULTS

The study of 20 177 ESKAPE isolates showed that A. baumannii isolates were the most represented (35.9%, n = 7238), followed by P. aeruginosa (25.3%, n = 5113), K. pneumoniae (19.5%, n = 3934), S. aureus (16.3%, n = 3286), E. faecium (2.6%, n = 517) and Enterobacter spp. (0.4%, n = 89). A notable increase in the resistance rates to antimicrobial agents occurred over the 2010-20 decade. The most important levels of resistance were observed in 2016-20 for A. baumannii (90% of resistance to the amoxicillin-clavulanate combination) and K. pneumoniae (81.6% of resistance to gentamycin). The rise in β-lactamase activities was correlated with an increase in the positivity of Gram-negative isolates for β-lactamase genes.

CONCLUSIONS

This review highlighted that, in contrast to developed countries that kept resistance levels under control, a considerable increase in resistance to various classes of antibiotics occurred in ESKAPE pathogens in India over the 2010-2020 decade.

Genomic islands and their role in fitness traits of two key sepsis-causing bacterial pathogens

To survive and establish a niche for themselves, bacteria constantly evolve. Toward that, they not only insert point mutations and promote illegitimate recombinations within their genomes but also insert pieces of 'foreign' deoxyribonucleic acid, which are commonly referred to as 'genomic islands' (GEIs). The GEIs come in several forms, structures and types, often providing a fitness advantage to the harboring bacterium. In pathogenic bacteria, some GEIs may enhance virulence, thus altering disease burden, morbidity and mortality. Hence, delineating (i) the GEIs framework, (ii) their encoded functions, (iii) the triggers that help them move, (iv) the mechanisms they exploit to move among bacteria and (v) identification of their natural reservoirs will aid in superior tackling of several bacterial diseases, including sepsis. Given the vast array of comparative genomics data, in this short review, we provide an overview of the GEIs, their types and the compositions therein, especially highlighting GEIs harbored by two important pathogens, viz. Acinetobacter baumannii and Klebsiella pneumoniae, which prominently trigger sepsis in low- and middle-income countries. Our efforts help shed some light on the challenges these pathogens pose when equipped with GEIs. We hope that this review will provoke intense research into understanding GEIs, the cues that drive their mobility across bacteria and the ways and means to prevent their transfer, especially across pathogenic bacteria.

Factors Associated With Culture-proven Neonatal Sepsis and Resistance to First-line Antibiotics in Indonesia

BACKGROUND

Neonatal sepsis is one of the leading causes of neonatal morbidity and mortality in low- and middle-income countries. Blood culture positivity rates and antibiotic resistance pattern of neonatal sepsis differs across various regions. This study aims to identify clinical cofactors associated with blood culture-proven neonatal sepsis and in vitro resistance to first-line antibiotics (ampicillin and gentamicin) from cases originating in a tertiary healthcare center in Surabaya, Indonesia.

METHODS

A retrospective cohort study was conducted from January 2020 to August 2022 by utilizing secondary data collected from standardized electronic medical records. Microbiologic characteristics and associated factors were statistically analyzed using multivariable logistic regression.

RESULTS

Across 266 neonatal sepsis cases, 46.9% were culture-proven and 79.2% of confirmed sepsis were resistant to first-line antibiotics. The most common isolated pathogen is Klebsiella pneumoniae , followed by coagulase-negative Staphylococci , Acinetobacter baumannii and Enterobacter cloacae . Extremely preterm delivery [adjusted odds ratio (aOR): 5.813; 95% confidence interval (CI): 1.70-19.91] and late-onset sepsis (aOR: 9.165; 95% CI: 5.12-16.40) were associated with culture-proven neonatal sepsis. Increased odds of resistance to first-line antibiotics were identified in extremely preterm (<28 weeks) or very-preterm delivery (28 to <32 weeks) (aOR: 50.80; 95% CI: 1.66-1554.21 and aOR: 45.679; 95% CI: 3.22-647.46, respectively), cesarean section (aOR: 4.149; 95% CI: 1.04-16.53) and an absence of antenatal corticosteroid use (aOR: 0.233; 95% CI: 0.07-0.76).

CONCLUSIONS

The association between clinical cofactors with culture-proven sepsis and antibiotic resistance emphasizes the importance for clinicians to adjust empirical antibiotic regimens based on the local antibiogram and resource availability.

Aerobic Bacterial Profile of Sepsis and Its Antibiotic Susceptibility Pattern Among Patients in a Rural Tertiary Care Center

Background Bloodstream infections (BSI) are one of the most life-threatening infections associated with high morbidity and mortality. Early diagnosis with appropriate and timely treatment improves the patient outcome. The recent surge in multidrug-resistant (MDR) strains is a matter of concern. This study aims to determine the bacterial etiology and antibiotic sensitivity pattern in BSI among different age groups. Materials and methods The microbiological data of blood culture and sensitivity between April 2019 and April 2021 were extracted from the laboratory records and analyzed for the bacterial profile and antibiotic sensitivity pattern. Results Out of the total 3893 blood cultures received during the study period from April 2019 to April 2021, 194 pathogens were isolated, accounting for a prevalence of 4.98%. Among 194 patients with culture-proven BSI, 54.12% (105/194) were adults, and 45.87% (89/194) were children. Of these 194 bacterial isolates, 58.76% (114/194) were gram-negative bacteria, and 41.24% (80/194) were gram-positive bacteria. With regard to the bacteria isolated, Enterococcus species with 23.71% (46/194) and Acinetobacter species with 22.16% (43/194) were the most common bacteria. The prevalence of MDR was 59.27% (115/194). Notable MDR types were methicillin-resistant Staphylococcus aureus (MRSA) in 15/22 (68.2%) and extended-spectrum beta-lactamase (ESBL) producers in 15/48 (31.25%) cases. Conclusion There is a significant geographical diversity of bacteria causing sepsis and their antibiotic susceptibility pattern. Recent trends show that multidrug-resistant gram-negative bacilli are the predominant isolates causing BSI. Increased antibiotic resistance is leading to treatment failure and poor clinical outcomes. Hence, there is a need to monitor antibiotic resistance among patients with BSI.

Acinetobacter baumannii Early-Onset Sepsis After Home Delivery Into Toilet Water

Early-onset sepsis (EOS) is an important cause of morbidity and mortality in newborns, usually caused by pathogens acquired intrapartum. We present the case of a term neonate born by home delivery in the toilet, after an unsupervised pregnancy. He developed a culture-proven early-onset sepsis caused by Acinetobacter baumannii. This was the first case of neonatal sepsis by this pathogen in our unit. The microorganism was susceptible to all antibiotics tested. The neonate was treated empirically with ampicillin and cefotaxime and completed 21 days of directed therapy with meropenem, as meningitis could not be excluded. During the clinical course, the newborn developed severe and persistent thrombocytopenia and neutropenia. In this report, we discuss the etiology behind this clinical presentation. We intend to raise awareness for the consideration of Acinetobacter baumannii as a potential pathogen in EOS, particularly in the presence of adverse birth circumstances.

Covid-period-associated changes in organism profile of neonatal sepsis in a tertiary center from East India

INTRODUCTION

Neonatal sepsis is a major cause of morbidity and mortality with a higher burden from the low- and middle-income countries. The coronavirus disease 2019 (Covid 19) pandemic has impacted healthcare in various ways including healthcare-associated infections (HAI). The objective of the present study was to determine changes in organism profile and incidence rates of HAI in neonates admitted to the index hospital during the pandemic and compared it with the data from the pre-pandemic period.

MATERIALS AND METHODS

The study design was a retrospective, observational analysis of data from neonates with culture-positive sepsis, in a tertiary care children's hospital, between January 2018 and December 2021. Pre-Covid (January 2018 to December 2019) and Covid period data (January 2020 to December 2021) were analyzed for the significance of change.

RESULTS

The prevalence of culture-positive sepsis, in pre-Covid and Covid periods, was 19.55% [95% confidence interval (95% CI) 17.13-21.52)] and 18.36% (CI 16.05-20.74), respectively. HAI rates/1000 patient days increased slightly during the Covid pandemic [7.2% (95% CI 6.98-10.08) to 9.8% (95% CI 9.78-13.67)] mainly due to an increase in fungal HAI (26% pre- vs. 41.5% Covid period). However, the proportion of Gram-negative (GN) infections fell significantly (70.5% vs. 48.6%) during the same period. In the pre-Covid period, Klebsiella followed by Burkholderia cepacia, Acinetobacter spp and Pseudomonas, were the major HAI isolates. During the Covid period, there was a decline in these isolates and Burkholderia spp was not detected. All fungal isolates were Candida species. The case fatality ratio (CFR) from HAI decreased significantly from 38% to 15.45%, mainly due to a decrease in GN HAI.

CONCLUSION

During Covid pandemic, there was a significant decline in GN HAI and CFR from HAI, due to improved compliance with infection control measures in the neonatal intensive care unit (NICU). At the same time, there was a rise in the fungal HAI, possibly because of a higher proportion of premature, and sick neonates with longer hospital stay and more invasive procedures. Consolidations of gains in infection control and restriction of invasive procedures could help to minimize HAI in NICUs.

Nonfermenting, Gram-Negative Bacilli Causing Neonatal Sepsis in Odisha, India: Four-Year Surveillance

Introduction

In India, blood culture-positive sepsis results in mortality in 33%-35% of affected neonates. Nonfermenting Gram-negative bacilli (NFGNB), particularly Acinetobacter baumannii and Burkholderia cepacia commonly cause hospital-acquired infection.

Materials and methods

We performed a subgroup analysis as part of a prospective study conducted in a neonatal intensive care unit in a tertiary care hospital in Odisha, India, between January 2017 and December 2020. Neonates with blood culture-positive sepsis caused by NFGNB were enrolled in this study. Demographic characteristics of the neonates, clinical features of sepsis, complications, need for supportive care, and blood culture sensitivity patterns were recorded and analyzed.

Results

A total of 168 organisms were isolated in blood cultures during our study period, of which 48 (29%) were NFGNB species. Among these 48 species, A. baumannii (37.5%) and B. cepacia (33.3%) were the most common NFGNB in our study. Neonates with sepsis commonly exhibited feeding intolerance (64.5%), circulatory insufficiency that necessitated vasopressor treatment (54.1%), disseminated intravascular coagulopathy (35.4%), seizures (33.3%), and the need for respiratory support (56.2%). NFGNB were multidrug-resistant (MDR) in 70.8% of cases, and 93.7% of B. cepacia and 55.5% of A. baumannii were MDR.

Conclusions

A. baumannii and B. cepacia are NFGNB commonly isolated in neonatal cases of blood culture-positive sepsis. The prevalence of MDR NFGNB sepsis is gradually increasing, which poses a threat to neonates. Strict aseptic precautions and antibiotic stewardship are thus mandatory in perinatal practice.

Epidemiology, microbiological profile, and outcome of culture positive sepsis among outborn neonates at a tertiary hospital in Northern India

AIMS AND OBJECTIVES

To study the epidemiology, microbiological profile, and outcome of culture positive sepsis among outborn neonates at a tertiary care teaching hospital in Northern India.

MATERIALS AND METHODS

Neonates (n = 406) with blood culture positive sepsis were enrolled prospectively over a period of 1 year (February 2018-January 2019). Demographic details, clinical features, microbiological profile, antibiotic sensitivity pattern, treatment, and outcome were recorded.

RESULTS

The mean (±SD) age at presentation was 2.4 (±0.6) days and 2/3rd were males. The mean (±SD) gestation was 35.5 (±3.4) weeks, birth weight was 2215 (±219) g, and 42.4% were preterm. The proportion of neonates with early and late onset sepsis were 69% and 31%, respectively. Predominant isolates were Gram-negative (46.5%), Gram-positive (27.6%) organisms, and yeast (25.9%). Klebsiella pneumoniae (46.5%), Acinetobacter baumannii (17.5%), and Escherichia coli (8%) were common Gram-negative; and coagulase negative Staphylococcus (CONS) (70%), Staphylococcus aureus (13.4%), and Enterococcus (12.5%) were common Gram-positive organisms. Among Gram-negative organisms, the antibiotic sensitivity pattern was ciprofloxacin 45%, cephalosporins 15-40%, aminoglycosides 20-42%, piperacillin-tazobactam 49%, carbapenems 34-51%, tetracyclines 55-70%, doxycycline 55%, chloramphenicol 42%, and colistin 98%; and among Gram-positive organisms were methicillin 30%, clindamycin 52%, vancomycin 100%, teicoplanin 98%, and linezolid 99%. The survival rate was 60.3%. The neonates with Gram-negative sepsis had higher requirement of oxygen, mechanical ventilation, and vasoactive drugs; had more complications; and lower survival (50.3% vs. 72.3%, p= .003) when compared to Gram-positive sepsis.

CONCLUSIONS

Gram-negative organisms were commonest cause of neonatal sepsis, had low sensitivity to commonly used antibiotics, and associated with poor outcome.