Early dissemination of OXA-72-producing Acinetobacter baumannii strain in Colombia: a case report

b r a z j i n f e c t d i s . 2014;18(6):678–680

The

Brazilian

Journal

of

INFECTIOUS

DISEASES

w w w . e l s e v i e r . c o m / l o c a t e / b j i d

Case

report

Early

dissemination

of

OXA-72-producing

Acinetobacter

baumannii

_strain

_in

_Colombia:

_a

_case

report

Sandra

Yamile

Saavedra

_,

_Rodrigo

_Cayô

,

Ana

Cristina

Gales

,

Aura

Lucia

Leal

_,

_Carlos

_Humberto

_Saavedra

a_{MicrobiologyDepartment,MedicalSchool,UniversidadNacionaldeColombia,Bogota,Colombia}

b_{LaboratórioALERTA,DisciplinadeInfectologia,UniversidadeFederaldeSãoPaulo(UNIFESP),SãoPaulo,SP,Brazil} c_{MedicineDepartment,MedicalSchool,UniversidadNacionaldeColombia,Bogota,Colombia}

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Articlehistory:

Received5May2014 Accepted19May2014

Availableonline30August2014

Keywords:

Acinetobacterbaumannii

Carbapenem-resistance Oxacillinase

Colombia

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Nosocomialinfections caused by carbapenem-resistant Acinetobacter baumannii isolates havereachedepidemiclevelsinpastdecades.Currentlythismicroorganismis responsi-bleforoutbreaksofdifficulteradicationandwithhighmortalityratesworldwide.Weherein reportararecaseofanOXA-72-producingA.baumanniiisolatecolonizinga47-year-old malepatientwithperitonitisduetoabdominalstabwound,fouryearsearlierthanthefirst reportofthiscarbapenemaseinAcinetobacterpittiiinColombia.AlthoughOXA-72presents alowprevalencecomparedwithOXA-23,ourstudydemonstratedthatA.baumannii iso-latescarryingtheblaOXA-72genewerepresentinthehospitalenvironmentinColombiaand

couldactasareservoirforfurtherspreadtootherAcinetobacterspecies,likeA.pittii,causing carbapenem-resistance.

©2014ElsevierEditoraLtda.Allrightsreserved.

Introduction

Carbapenem-resistant Acinetobacter baumannii became a global health concern,1 _{especially in intensive care units} (ICUs).2 _{In Colombia, A. baumannii was the fifth most} fre-quentpathogencausingbloodstreaminfectionsbetweenthe years2001and2008atICUs,withanincreasedof40%inthe

∗ _{Correspondingauthorat:LaboratórioALERTA,UniversidadeFederaldeSãoPaulo–UNIFESP,RuaPedrodeToledo,781,6thfloor,Vila}

Clementino,04039-032SãoPaulo,SP,Brazil.

E-mailaddress:[email protected](R.Cayô).

carbapenemresistance.3_{Thisfactcouldpartiallybeexplained} by the spread of OXA-23-producing clones in Colombian hospitals.4_{Montealegreandcolleagues}5_{reported,forthefirst} timeinColombia,anOXA-72-producingAcinetobacterpittii iso-lated in2010fromacathetertipculture.Here,wedescribe acaseofOXA-72-producingA.baumanniistraincolonizinga patientwithperitonitisinColombia,fouryearsearlierthan thefirstreportedcase.5

http://dx.doi.org/10.1016/j.bjid.2014.05.017

brazj infect dis.2 0 1 4;18(6):678–680

679

Case

presentation

On January 20, 2006, a 47-year-old male patient was hos-pitalizedatatertiary teaching hospitallocalizedinBogota, Colombia,duetoanabdominalstabwound.Thepatientwas submittedtoexploratorylaparotomyandasegmentalsmall bowelresectionwasperformed.Antimicrobialtherapywith clindamycin(600mgivq8h)andamikacin(1givq24h)was administeredforsevendays,andthepatientwasdischarged ingood clinical conditionseightdays later.OnFebruary 2, 2006,the patient was readmitted dueto severe abdominal pain and a new exploratory laparotomy was carried out. Peritonitis wasdiagnosed secondary to asmall bowel per-foration.Peritonealfluidculturewasnotperformedatthat time.Antimicrobialtherapywithampicillin/sulbactam(3giv q6h)wasempiricallyprescribedandmaintainedforeightdays withclinicalimprovement.However,onFebruary9,2006,the patientpresentedwithvomit,severeabdominalpain,fever andleukocytosis. Anotherexploratory laparotomy was car-riedoutandthepresenceofmultipleintestinalperforations wasdiagnosed. The antimicrobialtherapywas replaced by meropenem(2givq8h)andthepatientwasthentransferred tothe ICU, where heremained for the next six days. The abdominalincisionhadbeenleftcompletelyopenand subse-quentlyintra-abdominallavageswereperformed.Inthetwo previousperitoneallavages, the cultureswerenegative.On February16,2006,afterthethirdperitoneallavage,the perit-onealcavitywasclosedandthepatientwastransferredtothe internalmedicine ward.Atthismoment,anon-fermenting Gram-negativecoccobacillusisolate(Acb7-31strain)was cul-turedfromthe peritonealfluid.Itwasinitiallyidentifiedas acarbapenem-resistantA.baumanniibyVITEK2automated system(bioMérieuxSA, Marcyl’Etoile, France).Thepatient wasdischargedat23rddayofhospitalizationingoodclinical conditions.

SpeciesidentificationbysequencinganalysisofRNA poly-merase ␤ subunit (rpoB) gene, as previously published,6 confirmed the identification of Acb7-31 strain as A. bau-mannii. Antimicrobial susceptibility was evaluated by CLSI brothmicrodilution,7_{exceptforamikacinandcolistinMICs} that were determined by Etest strips, according to the manufacturer’s recommendations (AB Biodisk, Solna, Swe-den).AccordingtoCLSIbreakpoints,8_{theAcb7-31isolatewas} susceptible to minocycline (MIC, ≤0.03mg/L), ciprofloxacin

(MIC, ≤0.125mg/L), colistin (MIC, 0.5mg/L), polymyxin B

(MIC, 0.5mg/L), amikacin (MIC, 2mg/L), gentamicin (MIC, 4mg/L),ceftazidime(MIC,8mg/L),cefotaxime(MIC,8mg/L), intermediate to levofloxacin (MIC, 4mg/L) and resistant to imipenem (MIC, 32mg/L), meropenem (MIC, 32mg/L), ampicillin-sulbactam (MIC, 32/16mg/L) and cefepime (MIC, 64mg/L). In order to evaluate the contribution of overex-pressionofeffluxpumpsintheresistancetocarbapenems, the MICs for imipenem and meropenem were also deter-mined in the presence of 15mg/L of the efflux pump inhibitor, Phe-Arg-␤-naphthylamide (PA␤N). Although a 4-fold decrease in the MICs for meropenem was observed in the presence of PA␤N (MICs, 32 to 8mg/L), the MICs for imipenem did not change significantly (MICs, 32 to 16mg/L).

Multiplex-PCR assays targeting carbapenem-hydrolyzing classD␤-lactamases(CHDLs)andmetallo-␤-lactamase(M␤Ls) encodinggeneswereperformed,aspreviouslypublished.9,10 The presence of blaOXA-51-like and blaOXA-24/40-like was

con-firmedbyPCR.DNAsequencingidentifiedtheblaOXA-24/40-like

amplicon as blaOXA-72 and revealed that it was flanked

byXerC/XerD-binding sites,a structureimplicatedwith its mobilization.11_{GenomicDNAdigestedwiththeendonuclease} I-Ceu-IandplasmidDNAfromAcb7-31strainwereseparated by PFGE, and subsequent Southern blot and hybridization

withblaOXA-72-specificprobeshowedthattheblaOXA-72 gene

waslocatedon aplasmid of∼20kb.Itseems thatthisisa

non-conjugativeplasmidsinceitwasnotsuccessfully trans-ferredbyconjugation.SimilarresultswereobservedbyBonnin andcolleagues12_{whodescribedthreeFrenchA.pittiiisolates} carrying the blaOXA-72 gene mediatedby anon conjugative

20-kbplasmid.Interesting,thesizesofplasmidscarryingthe

blaOXA-72geneinAcinetobacterspp.isolatesvariesconsiderably

inSouthAmerica,rangingfrom83kbto163kb,aspreviously reported.5,13,14

Conclusion

Despite its lower prevalence, OXA-72 had been present in Colombialonger thanwethought,sincetheAcb7-31strain was isolatedin2006inBogota, located462.4kmfrom Cali, where anOXA-72-producing A. pittiistrain was isolated in 2010.AlthoughtheAcb7-31strainwasconsideredasa colo-nizerstrain,ourstudydocumentedthatblaOXA-72waspresent

in the hospital environment and could act as a reservoir forfurtherspread tootherAcinetobacterspecies, likeA. pit-tii.Inaddition,theoverexpressionofeffluxpumpsseemsto contributeforincreasingmeropenemMICsforinhibitingthe Acb7-31strain.

Funding

ThisstudywasfinancedbyColcienciasCODE:11010416355, Agreement444andUniversidadNacionaldeColombiaCODE: 20201009713.

Conflicts

of

interests

A.C.G.recentlyreceivedresearchfundingand/orconsultation feesfrom AstraZeneca and ThermoFisherScientific.Other authorshavenothingtodeclare.

Acknowledgements

680

Garzón, Julia Quijano, Rafael Pérez Yepes), Hospital Militar Central(CarlosPérez,MatildeMéndez,MaríaNilseGonzález, DianaFerrucho,JuanPabloVelásquez),HospitalUniversitario SanIgnacio (CarlosÁlvarez,Beatriz Ariza), Hospital Simón Bolívar(ConstanzaCorrea,LuzJanethMárquez,William Clav-ijo),HospitalSanta Clara(José Roberto Tamara,Gloria Inés Gallo, Guillermo Ortiz), Hospital Universitario Clínica San Rafael(MartaPulido,RabelLobelo),HospitalUniversitarioLa Samaritana(JohanaOsorio,ElsaMarinaZubieta,EmilioRey), InstitutoNacionaldeCancerología(JorgeCortes,Claudia Patri-ciaArroyo,LuzMarinaMartínez,ElizabethRodríguez,Clara InésGómez),PoliclínicodelOlaya(JohanaCarolEstrada,Ana IsabelSánchez,CarlosHurtadoHurtado).

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