Occurrence of Acinetobacter in two private tertiary hospitals in

Hinrichsen SL et al • Occurrence of Acinetobacter in two private tertiary hospitals in Northeastern Brazil
ARTIGO ORIGINAL/ ORIGINAL ARTICLE
Occurrence of Acinetobacter in two private tertiary
hospitals in Northeastern Brazil
Ocorrência de Acinetobacter em dois hospitais privados terciários no Nordeste, Brasil
Sylvia Lemos Hinrichsen1
Érica Falcão2
Tatiana Aguiar Santos Vilella3
Conceição Lira4
Bartolomeu José dos Santos Junior5
Pedro Weldef da Silva Cruz6
Rev Panam Infectol 2014;16(3):174-179
Recebido em 13/11/2013
Aprovado em 29/1/2014
Trabalho realizado no Núcleo de Ensino,
Pesquisa e Assistência em Infectologia,
Universidade Federal de Pernambuco,
Recife, PE, Brasil.
Médica Infectologista. Professora Adjunta da
Universidade de Pernambuco (UPE) e Universidade
Federal de Pernambuco (UFPE). Coordenadora
do Núcleo de Ensino, Pesquisa e Assistência em
Infectologia, Universidade Federal de Pernambuco,
Recife, PE, Brasil.
2
Biomédica. Coordenadora do Departamento de
Microbiologia, Cerpe Diagnósticos, Recife, PE, Brasil.
3
Farmacêutica e Biomédica. Mestrado em Medicina
Tropical. Assistente de pesquisa do Núcleo de Ensino,
Pesquisa e Assistência em Infectologia, Universidade
Federal de Pernambuco, Recife, PE, Brasil.
4
Enfermeira. Mestrado em Tecnologia ambiental.
Professora Assistente de Saúde Coletiva do Centro
Acadêmico de Vitória de Santo Antão da Universidade
Federal de Pernambuco, PE, Brasil.
5
Enfermeiro. Assistente de pesquisa do Núcleo de
Ensino, Pesquisa e Assistência em Infectologia,
Universidade Federal de Pernambuco, Recife, PE, Brasil.
6
Bacharel em Educação Física. Departamento de
Ciências da Saúde da Faculdade de Ciências Médicas,
Universidade de Pernambuco, Recife, PE, Brasil.
1
174
ABSTRACT
Background: Acinetobacter species infection has become a global
problem due to high mortality rates and increasing antibacterial
resistance leading to limited treatment options. It is crucial to monitor
emerging trends in occurrence of Acinetobacter at the local level
to support clinical decision making, infection-control interventions,
and antimicrobial-resistance containment strategies. Methods: a
prospective analysis began by surveying all positive Acinetobacter
species cultures processed by the microbiology laboratory between
February 1st 2008 to February 1st 2009 (Ethics Protocol Nº 348/07/
CEP-UFPE). The cultures, originated from various types of biological
material (blood, urine, tracheal, catheter and others) were processed
by Vitek® system (Biomerieux SA, France). A descriptive analysis for
relative frequency and prevalence was done. The incidence rate was
calculated per 1,000 admissions. Results: during the period of study
a total of 137 (Hospital A: 127; Hospital B=10) sample isolates
from 1,873 positive cultures (Hospital A: 1,518; Hospital B:355)
were positive for Acinetobacter (A. calcoaceticus – complex) and the
isolates were obtained from different body sites (Hospital A: tracheal
51.9% and Hospital B: blood 30%) from 11,540 hospitalized patients
(Hospital A/B = 9,110/2,430), from intensive care units ( Hospital
A/B= 76.3% / 40.0%). Multidrug resistance (MDR)[resistance to at
least ceftazidime-CAZ; timethoprim/sulfamethaxazol-TMP/SXT, and
quinolones/ciprofloxacin] was prevalent in both hospitals (Hospital
A: 86.0% / Hospital B: 53.0%), with high resistance to carbapenems
(Hospital A: 87.0%; Hospital B: 59.0%). Conclusions: this study
shows that Acinetobacter baumannii (A. calcoaceticus-baumannii
complex) was the isolated agent and evidences the importance
of Acinetobacter infection control due to its transmission from
person to person, during long periods of hospitalization related by
environmental contamination frequently associated with nosocomial
outbreaks.
Keywords: Acinetobacter species isolates; Nosocomial infections;
Multidrug resistance
Rev Panam Infectol 2014;16(3):174-179
RESUMO
Introdução: a infecção pela espécie Acinetobacter
tornou-se um problema global por causa de altas
taxas de mortalidade e aumento da resistência
antibacteriana, levando a limitar as opções de
tratamento. É importante monitorar as tendências
da ocorrência de Acinetobacter localmente para
dar suporte às decisões clínicas, intervenções no
controle de infecções e estratégias na contenção de
resistência aos antimicrobianos. Métodos: realizouse análise prospectiva por meio de um levantamento
de todas as culturas positivas de Acinetobacter,
processadas pelo laboratório de microbiologia entre
1º de Fevereiro de 2008 a 1º de fevereiro de 2009
(Protocolo do Comitê de Ética Nº 348/07/CEPUFPE). As culturas, provenientes de vários tipos de
material biológico (sangue, urina, cateter, traqueal
e outros) foram processadas pelo sistema Vitek®
(Biomerieux SA, França). Foi realizada uma análise
descritiva de freqüência relativa e prevalência. A taxa
de incidência foi calculada por 1.000 admissões.
Resultados: durante o período de estudo, um total
de 137 amostras (Hospital A: 127; Hospital B =
10) isoladas de 1.873 culturas positivas (Hospital
A: 1.518; Hospital B: 355) para Acinetobacter (A.
calcoaceticus – complex) e os isolados foram obtidos
a partir de diferentes locais do corpo (Hospital A:
51,97% traqueal e B Hospital: 30% de sangue)
de 11.540 pacientes hospitalizados (Hospital A /
B = 9110/2430), de unidades de terapia intensiva
(Hospital A / B = 76,3% / 40,0%). Multirresistência
(MDR) [resistência a pelo menos ceftazidimaCAZ; timethoprim / TMP-sulfamethaxazol SXT/, e
quinolonas ciprofloxacina] foi prevalente em ambos
os hospitais (Hospital A: 86,0% / Hospital B:
53,0%), com alta resistência aos carbapenêmicos
(Hospital a: 87,0%; Hospital B: 59,0%). Conclusões:
este estudo mostra que Acinetobacter baumannii
(A.calcoaceticus-complex) foi o agente isolado e
evidencia a importância do controle de infecção
para este microrganismo devido a sua transmissão
de pessoa à para pessoa, durante longos períodos de
hospitalização, além de sua relação com o ambiente
e frequente associação a surtos nosocomiais.
Palavras chave: Acinetobacter; Infecção
hospitalar; Resistência a
Múltiplos Medicamentos
INTRODUCTION
Acinetobacter (A. calcoaceticus - complex) is an
important cause of nosocomial infections in many
hospitals. It is difficult to control and treat infection
due to its high resistance in the environment and its
ability to develop resistance to antimicrobials(1-12).
The genus Acinetobacter is a gram-negative
bacillus, ubiquitous, strictly aerobic, non-fermenter,
undermannig, property, catalase positive and oxidose
negative. About 31 genomic species are described.
The three species phenotypically similar, they
belong to the compound A. calcoaceticus complex
– baumannii and they are responsible for outbreaks
which have been described in medical and surgical
wards, intensive care unit (ICU), in patients who
usually need more invasive procedures for long
periods of time, and frequently receive treatment with
antimicrobials. Many of these outbreaks could be
traced to environmental sources under dry conditions
such as formica surface, pillows, components of
ventilation equipment, tradutores or humidifiers (1-10,
13, 20-21,25-26)
.
Some of the mechanisms through which
Acinetobacter strains can acquire resistance to
antimicrobial compounds include beta-lactamasemediated hydrolisio, alteration of membrane proteins
and penicillin- binding proteins, and increased
efflux pum activity. And antimicrobial resistance
surveillance systems play an important role in
monitoring and reporting the sensitivity patterns of
this and other microorganisms(11-12,16,20,24,27).
The aim of this study was to evaluate the
distribution of Acinetobacter in two general tertiary
hospitals in Recife, Northeastern Brazil.
MATERIALS AND METHODS
Data collection: a prospective study was performed
with all Acinetobacter positive cultures processed
by the microbiology laboratory between February 1st
2008 to February 1st 2009 at two general private
tertiary hospitals in Recife, Pernambuco, northeastern
Brazil.
A database was created with the following
variables: types of biological material, including
urine, blood and other body sites and Acinetobacter
isolates distribution during the period of the study
and gender.
Laboratory tests: the cultures, originated from
various types of biological material (blood, urine,
tracheal, catheter and others) were processed by
R-Vitek® system (Biomerieux SA, France). Cultures
were processed in protocol accordance(14, 19).
Statistical analysis: a descriptive analysis for
relative frequency and prevalence has been done
using SPSS 10.0 software (p<=0,05). The incidence
rate was calculated per 1,000 admissions.
Ethics Committee: the study protocol was approved
by the Institutional Ethics Committee (Protocol No
348/07/CEP-UFPE).
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Hinrichsen SL et al • Occurrence of Acinetobacter in two private tertiary hospitals in Northeastern Brazil
RESULTS
During the period of the study a total of 137 (Hospital
A: 127; Hospital B=10) sample isolates from 1,873
positive cultures (Hospital A: 1,518; Hospital B:355)
were positive for Acinetobacter (A. calcoaceticus –
complex) and the isolates were obtained from different
body sites (Hospital A: tracheal 51.97% and Hospital
B: blood 30%) from 11,540 hospitalized patients (
Hospital A/B = 9,110/2,430), from intensive care
units ( Hospital A/B= 76.3% / 40.0%).The most
common species in both hospitals was Acinetobacter
baumannii (A. calcoaceticus – baumannii complex)
(Table 1).
The incidence of Acinetobacter was 13.9 per
1,000 admissions (Hospital A) and 4.1 per 1,000
admissions (Hospital B). Acinetobacter was isolated
more frequently from May to August in Hospital A and
february in Hospital B (Table 2).
In both hospitals the principal gender was female
(Hospital A: n=71, 55.9% and Hospital B: n=6. 60%).
Multidrug resistance (MDR)[resistance to at least
ceftazidime-CAZ; timethoprim/sulfamethaxazol-TMP/
SXT, and quinolones/ciprofloxacin] was prevalent
in both hospitals (Hospital A: 86.0% / Hospital
B; 53.0%), with high resistance to carbapenems
(Hospital A: 87.0%; Hospital B: 59%).
Table 1. Identification and biological materials sources of all 137 Acinetobacter baumannii (A. calcoaceticus complex)
Isolates.February, 2008 to February, 2009 in the Hospital A and Hospital B
Biological material
Hospital A
Blood
Urine
Tracheal
Cateter
Miscellaneous*
Total
15(11,81%)
16(12,59%)
66(51,97%)
9(7,08%)
21(16,53%)
127
(100%)
Biological material
Hospital B
Blood
Urine
Tracheal
Cateter
Miscellaneous*
Total
Acinetobacter baumannii (A.
calcoaceticus)
3(30%)
0(0,0%)
1(10%)
4(40%)
2(20%)
10
(100 %)
Acinetobacter baumannii (A.
calcoaceticus)
(*)Miscellaneous: wound material and others
Table 2. Acinetobacter baumannii (A.calcoaceticus)
distribution isolates per period of year (month). February,
2008 to February, 2009 in Hospital A.*
Month/year
Hospital A
2008
February
March
April
May
June
July
August
September
October
November
December
2009
January
February
Total
Frequency
n
%
6
3
6
12
17
16
15
7
9
13
8
4,7
2,4
4,7
9,7
13,4
12,6
11,8
5,5
7,1
10,2
6,2
7
8
127
5,5
6,2
100
(*) Period of year in Hospital B:
2008- February (n=2); May (n=1); November (n=2); December
(n=1):Total=6
2009- January (n=1); February (n=3): Total=4.
176
DISCUSSION
The number of nosocomial infections caused by
Acinetobacter species increased in recent years. In
particular, outbreaks due to Acinetobacter baumannii
(formerly Acinetobacter calcoaceticus) have frequently
been reported (1-11,18).
Many of these outbreaks could be traced to
environmental sources due to it is ability to survive
for long periods under dry conditions lasting from 7
to more 27-32 days/ years(1-11,18). And since surfaces
may influence the ability to survive, all experiments
were performed on surfaces typical of those in the
hospital environment(3,7,10,13,21,25-26).
One reason for this persistence may be the
resistance of Acinetobacter to many antibiotics due
to its propensity for developing multiple antimicrobial
resistance extremely rapidly. Generally, imipenem is
the most active agent against Acinetobacter species,
however, the description of imipenem– resistant
Acinetobacter strains is ecoming increasingly
common (4,8-9,11-12,16,23,27).
Bacteremia, followed by respiratory tract and
surgical wound infections, is the most significant
infection caused by Acinetobacter species,
Rev Panam Infectol 2014;16(3):174-179
particularly in intensive care units, where it is
opportunistic and therefore almost exclusively affects
predisposed patients who have undergone invasive
procedures. The Known risk factor for Acinetobacter
colonization/infection are prolonged hospital stay,
ICU stay, previous admission to another unit, enteral
feeding and previous use of third – generation
cephalosporins(9,11,16).
Handwashing is considered the most important
infection control procedure but has never been
required of suggested following casual contact with
the patient charts, writing note on a desk, pouring
a cup of coffee, answering the telephone, opening a
door in patient care area(1,3,5,10,13,25).
Colonization usually precedes infection. In order to
avoid colonization, the prevention of microorganism
dissemination is the target for the infection control.
Controlling the risk factors associated with colonization
and active surveillance measures (including swab
cultures, contact precautions, cohorts, environmental
control, patient decolonization, or antimicrobial
prophylaxis and prescription control) are important
actions for outbreak management(1,10,21,24,26-27).
Our results showed a major Acinetobacter isolates
prevalence in tracheal culture (51.97% -Hospital
A) and catheter culture (40% -Hospital B) probably
colonization could have occurred before bacteremia
and clinical features appeared. So, preventive
measures, such as diminishing the hospital length
stay to avoid harmful bacteria are essential and
complete disinfection of environment/equipments
and hand washing.
Another point to be monitored was the distribution
isolates per period of year (month) which helps the
infection control, particularly between colonized
patients (tracheal/ catheter isolates), founded in this
study.
Historically, Acinetobacter species have been
pathogens of humid climates. Since the 1970s,
Acinetobater infections have become an increasingly
common nosocomial problem in temperate
climates(15,17-18,28).
Recife is located in Northeast Brazil, has a
tropical climate, with warm to hot temperatures and
high relative humidity throughout the year. January
and February are the warmest months, with mean
temperatures ranging from 300C (860F) to 220C
(720F) with sun. July, the is a cloudier month, with
coolest temperatures (from 270C-860F to 210C
– 700F), and is the wettest month, receiving and
average of 388mm (15,3 in) of rain(29).
The driest and sunniest month is November, when
the maximum temperatures have around 300C (860F)
and an average of 36mm (1.4 in) of rain recorded(29).
In this study, there were more cases in Hospital
A during May to August and in November. And in
Hospital B there was no important relationship
between cases and period of year.
The reason may be the influence of the control of
the air conditioning (temperature and humidity) into
the hospital units.
Since in the hospitals are climate-controlled, the
influence of the environment outside the hospital
cannot have influence. Warmer weather leads to more
bacterial growth and humidity has a relationship in
Acinetobacter spp. Which could be reflections of
effects of environment but also presumably reflect
the outdoor environment as well?
Therefore the prevention of Acinetobacter
infection, beyond the importance of the control of
the environment cleanliness protocols, handwashing,
the importance of temperature and humidity controls
indoors through airconditioning equipment not
only of the cleanliness of the systems, but also the
temperature and humidity control become relevant.
In this analysis, there was a significant
increase in the percentage of isolates that were
tested against to antimicrobial agents in 4 major
classes of antimicrobials, also observed in others
studies(16,22,23,27).
It is important to know the susceptibility of
Acinetobacter to antimicrobials different among
countries and units in the same hospital. And these
differences may reflect a better infection control.
Patterns of antimicrobial usage and different
epidemiological situations, including antimicrobial
control measures and polices. The differences in
resistance patterns among isolates emphasize the
importance of local surveillance in determining
the most adequate infection control measures and
therapy for Acinetobacter infections.
We must acknowledge several limitation of our
review. First, we elected to review only a subset of the
available studies on ICU – acquired infections that
may have included data on Acinetobacter infections.
However, studies using another design including
randomized controlled trials, case-control studies,
and case reports would not be helpful in our attempt
to summarize the available data regarding the relative
frequency of isolation of Acinetobacter with ICU –
acquired pneumonia or bacteraemia.
Different methods were used among the studies
for determination of antimicrobial resistance and
thus observed differences in susceptibility may be
a consequence of methodology. In addition, results
from poorly standardized methods such as agar
diffusion tests may have lead to false interpretations.
Another limitation of our literature search for relevant
177
Hinrichsen SL et al • Occurrence of Acinetobacter in two private tertiary hospitals in Northeastern Brazil
studies on Acinetobacter infections is related to the
changes in taxonomic classification of Acinetobacter
spp. The majority of studies used methods that were
not able to unambiguously identify A. baumannii and
therefore it can not be excluded that Acinetobacter
genomic species 3 or 13 or even Acinetobacter spp.
Outside the A. calcoaceticus – A. baumannii complex
were misidentified (14-15,19,21).
It should be emphasized that data for the in vitro
susceptibility testing of Acinetobacter clinical isolates
were not available in most of the studies included in
our review for three important antibiotics with proven
activity against this organism. Indeed, only a few studies
reported results of isolates to meropenem, sulbactam,
and polymyxins B and E. In addition, the data confirm
that Acinetobacter spp.isolates are frequently resistant
to aminoglycosides and third generation cephalosporins,
which means that these antibiotics should be avoided
for the treatment of these infections.
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Corresponding author:
Sylvia Lemos Hinrichsen
Rua Jornalista Guerra de Holanda, 158, apt. 2601,
Casa Forte, Recife-PE, Brazil, ZIP: 52061-010
Telephone: +55- 81- 3268-9905
E-mail: [email protected]
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