ACINETOBACTER

DR. VINEETA BAXLA

JRA – 2, MICROBIOLOGY
DEPT.
RIMS, RANCHI
INTRODUCTION

 The genus Acinetobacter contains strictly aerobic, gram negative

coccobacillary organisms that are non-motile, oxidase negative, nitrate
negative and do not ferment sugars.

 The name Acinetobacter comes from the Latin word for “motionless”
because they lack cilia or flagella.

 They are free living saprophytes present in soil and water.

 Recently emerged as a major cause of health care-associated infections

because of the of the extent of its antimicrobial resistance and its
propensity to cause large, often multifacility, nosocomial outbreaks.
CLASSIFICATION

 Domain – Bacteria
 Phylum – Pseudomonadota
 Class – Gammaproteobacteria
 Order – Pseudomonadales
 Family – Moraxellaceae
 Genus – Acinetobacter
Within the genus commonly isolated strains in clinical
laboratories are called Acinetobacter calcoaceticus-
baumannii complex which is subdivided as :
1. A. baumannii – pathogenic strain, glucose
metabolized oxidatively, citrate positive.
2. A. lwofii – commensal, glucose negative, citrate
negative, non hemolytic strain.
3. A. hemolyticus – hemolytic strain
 MORPHOLOGY

 They are 1-1.5 × 1.5-2.5 µm in

size, often appearing in pairs,
mimicking Neisseriae in
appearance.
 Short, broad gram-negative
rods in the rapid growth phase
but assume a more
coccobacillary shape in the
stationary phase.
 Non-motile
 encapsulated
 Colony character : obligate aerobe, grows well on
ordinary medium. On MacConkey agar – colonies of A.
baumannii are 2-3 mm, non lactose fermenting (with
faint pink tint) circular, translucent, shiny, butyrous in
consistency
Blood agar : 1-2mm, hemolytic in case of hemolytic
strain, or non hemolytic, domed with smooth to pitted
surface.
VIRULENCE FACTORS

 Biofilm formation — Colonization of environmental surfaces is promoted by

adhesion via pili and the subsequent formation of biofilms. Biofilm-
associated protein (Bap) is needed for biofilm maintenance and maturation
. Bap is also important for colonization as it facilitates adherence to cells.
High biofilm producing strains are less sensitive to desiccation than low
biofilm producing strains; thus, biofilm production seems critical
for Acinetobacter’s well-established ability to survive under dry conditions.
 Outer membrane protein A (OmpA) — Production of OmpA is essential for
making an intact biofilm. It is also essential for adherence to epithelial
cells. It induces cell apoptosis by entering the cell and stimulating the
release of cytochrome C and apoptosis-inducing factor. OmpA also helps
bind Factor H, which is an inhibitor of the alternative complement
pathway .
 K1 capsule — Approximately one-third of strains produce a
polysaccharide capsule that works with the cell wall
liposaccharide to prevent complement activation. The capsule
may also delay phagocytosis.
 Siderophore-mediated iron-acquisition system
— Acinetobacter can survive iron-deficient conditions for long
periods of time. This is due to its "acinetobactin," a catechol
siderophore that can sequester iron from the host.
 Fimbriae — As mentioned above, fimbriae help attach the
organism to environmental surfaces. They also help colonize
biotic surfaces, such as bronchial epithelial cells .
 PATHOGENESIS
 The intrusion of a microorganism requires cell-to-cell adhesion to establish
infection.

 A. baumannii possesses a hydrophobic ability that provides attachment to

foreign materials such as plastics used in intravascular devices.

 Outer membrane protein A (OmpA) is associated with improving adhesion,

specifically to the epithelial cells of the respiratory tract. It localizes in the
mitochondria and nuclei and induces expression of proapoptotic molecule
cytochrome c, resulting in cell death.

 A. baumannii evades alternative complement pathway-mediated killing by

neutralizing factor H, a key regulator of the alternative complement pathway, with
the help of OmpA. This phenomenon is known as the serum resistance of A.
baumannii.
 OmpA induces differentiation of CD4 +, activation, and maturation of dendritic cells, and
causes their premature apoptosis.

 Secretion of outer membrane vesicles that contain different virulence-related proteins

(proteases, phospholipases, superoxide dismutase, and catalase) at the infection site
accelerates the local innate immune response and ultimately leads to tissue damage.

 The outer membrane vesicles also augment biofilm formation on abiotic surfaces.

 The polysaccharide capsule plays a central role in guarding bacteria against

phagocytosis by the host’s innate immune system. Lipopolysaccharides (LPSs) of A.
baumannii consist of an O-antigen, the carbohydrate core, and a lipid A moiety. LPS is a
chemotactic agent that recruits inflammatory cells and compels them to release their
cytotoxic material.

 The ability of A. baumannii to form biofilms on biotic and abiotic surfaces is a

well-studied mechanism of resistance. To survive in unfavorable conditions, it
becomes metabolically inert in the deeper layers of biofilms. Poor penetration
and the inability of antibiotics to act on metabolically inert bacteria augment its
virulence.
Documented mechanism of
resistance in A.baumannii
 Aminoglycosides – modifying enzymes
 Broad spectrum β-lactamases
 Carbapenamases
 Quantitative or qualitative changes in outer
membrane porins
 Altered penicillin-binding proteins
 Mechanisms for resistance to
carbapenems
 Metallo-β-lactamase (VIM, IMP) : gene transfer, gene activation
by insertion of an activation sequence (inserted upstream and
switches on enzyme production) and mutation.
 OXA Carbapenemases (class D) – difficult to detect.
 Cell permeability changes
 Target (PBPs) changes.
 Clinical manifestations

Hospital-acquired pneumonia

• Acinetobacter pneumonia occurs predominantly

in the intensive care unit (ICU) patients who
require mechanical ventilation and tends to be
characterized by a late-onset.

• Other clinical manifestations

of Acinetobacter pneumonia are similar to those
reported for hospital-acquired pneumonia in
general such as dyspnea, productive cough,
fever, chest pain, asymmetrical expansion of the
chest, diminished resonance, egophony, etc.
Community-acquired pneumonia

• Community-acquired Acinetobacter pneumonia is

typically characterized by a fulminant illness with an
abrupt onset and rapid progression to respiratory
failure and hemodynamic instability.
• Septic shock ensues in around one-third of patients.
Bloodstream infection

• Acinetobacter accounts for 1.5 to 2.4 percent of nosocomial

bloodstream infections.
• Risk factors for Acinetobacter bloodstream infection include
intensive care, mechanical ventilation, prior surgery, prior
use of broad-spectrum antibiotics, immunosuppression,
trauma, burns, malignancy, central venous catheters,
invasive procedures, and prolonged hospital stay
• Fever may be the only manifestation of the bacteremia.
Septic shock develops in up to one-third of patients
with Acinetobacter bacteremia.
Endocarditis

• Acinetobacter spp are a rare cause of infective

endocarditis in the native and prosthetic heart.
• Acinetobacterendocarditis is typically characterized by
an acute onset with an aggressive course.
• Mortality tends to be higher in the setting of native
valve endocarditis than prosthetic valve endocarditis,
likely because of the low index of suspicion leading to
delayed treatment in such cases.
Meningitis
• Acinetobacter is an infrequent cause of nosocomial
meningitis.
• Risk factors include neurosurgical procedures,
cerebrospinal fluid (CSF) leak, prior antibiotic
therapy, and intracranial hemorrhage
• Mortality ranges from 20 to 30 percent; neurologic
deficits in surviving patients can be severe.
• Most patients with Acinetobacter meningitis present
with fever, meningeal signs, and/or seizures.
• Cerebral spinal fluid (CSF) typically demonstrates
pleocytosis with neutrophilic predominance,
elevated protein concentration, and a low CSF-to-
serum glucose ratio. Other clinical manifestations
of Acinetobacter central nervous system infections
are similar to those reported for meningitis in
general.
Skin, soft tissue, and bone infection
• Acinetobacter may contaminate surgical and traumatic
wounds, leading to severe soft tissue infection that can
also progress to osteomyelitis.
• Acinetobacter has rarely been associated with
community-acquired or hospital-acquired skin infections
such as cellulitis and folliculitis as well as skin
abscesses and necrotizing fasciitis.
• Traumatic wound infections due to multidrug-
resistant Acinetobacter complex have been increasingly
recognized after war injuries; environmental
contamination of field hospitals appears to play an
important role in these infections.
• Most Acinetobacter skin infections start with a skin
break. Cellulitis starts as a well-demarcated edematous
patch with erythema, often having a peau d’orange
appearance. It then transforms into a sandpaper-like
lesion characterized by numerous vesicles that might
later evolve into hemorrhagic bullae.
Other infections
• Acinetobacter can cause colonization or infection of the eye. Colonization has
been observed in contact lens wearers. Ocular infection can include corneal
ulcers, endophthalmitis, periorbital cellulitis, and infection after penetrating
trauma.

• Acinetobacter can cause nosocomial sinusitis in patients admitted to the

intensive care unit; mechanical ventilation is the most important predisposing
factor Acinetobacter sinusitis has been associated with the development of
pneumonia, as the infected sinuses serve as reservoirs for dissemination to
the lower respiratory tract.

• Acinetobacter peritonitis has been described in patients undergoing

peritoneal dialysis. The most common manifestations are abdominal pain and
a cloudy dialysate.
EPIDEMIOLOGY

 The epidemiology of Acinetobacter infections is broad

and includes infection associated with tropical
environments, wars and natural disasters, and
hospital outbreaks in temperate climates.

 Since the 1970s, Acinetobacter infections have

become an increasingly common nosocomial problem
in temperate climates.
 Dramatic multihospital outbreaks have been described in the
United States, Europe, South America, Africa, Asia, and the
Middle East. As an example, a monoclonal outbreak of a
carbapenemase producing (OXA-40) Acinetobacter was described
in the greater Chicago area in 2005; subsequently, at least five
hospitals, three long-term care facilities, and more than 200
patients were affected by this outbreak
 Community acquired Acinetobacter infection has been reported
in Australia and Asia; in Australia, community-acquired
pneumonia occurs more frequently during the wet (monsoon)
season. In tropical northern Australia, A. baumannii accounts for
10 percent of cases of severe community-acquired pneumonia.
 Wartime Acinetobacter infections
have been reported during the Korean
War, the Vietnam War, and the wars in
Iraq and Afghanistan, and resistance
rates are high.
 In one study, A. baumannii accounted
for 63 percent of all bacterial isolates
recovered from war wounds in US
troops situated in Iraq and
Afghanistan between 2007 and 2008.
 Transmission of: acinetobacter

 Acinetobacter can spread

from
person to person (infected or
colonized patients), contact
with contaminated surfaces
of
exposure to the environment.
Risk factors include:

 Hospitalization
 Significant co-morbidity
 Mechanical ventilation
 Cardio respiratory failure
 Previous infection
 Antimicrobial therapy
 CVP lines
 Urinary catheters
Laboratory diagnosis

Specimen Collection
 A. baumannii has been isolated from blood, sputum, skin, pleural
fluid, and urine, usually in device-associated infections.
Blood
1. Collect blood by strict aseptic technique.
2. Clean the rubber stopper of the blood culture bottle with an alcohol
pad.
3. Inoculate blood into blood culture bottles.
4. Label the blood culture bottles with the date, name, and hospital
number of the patient and send the specimens to the laboratory
5. Keep inoculated bottles at 37oC or at room temperature.
Sputum

1. Give the patient a sterile wide-mouthed screw-capped

container.
2. Instruct the patient to inhale deeply 2–3 times and
cough out deep from the chest.
3. Open the container and spit the sputum into the
bottle. Avoid saliva or nasal secretions.
4. Close the container for further processing.
 Bronchoalveolar Lavage (BAL) and Bronchial Washings

1. Collect bronchial samples by injecting a variable volume of

saline through a bronchoscope channel and aspirate in 3–4
aliquots.
2. Collect the aspirate in sterile disposable red-capped 40 mL
wide-mouthed container or sterile bottles.
3. Collect bronchial washings by aspirating small amounts of
instilled saline from the large airways of the respiratory tract.
4. Store the samples in sterile disposable 40 mL wide-mouthed
containers or if from ICU in sterile 100 mL bottles.
Perform Gram’s staining
 Acinetobacter spp. appear Gram-negative and coccobacilli in shape.
1. Take samples from the collected tubes which showed Gram-negative
coccobacilli in the Gram stain.

2. Streak samples with a sterile disposable inoculation loop on nutrient

agar, MacConkey agar, or blood agar plates.

3. Incubate the inoculated plates at 37oC under aerobic conditions.

4. Colony morphology on nutrient agar, blood agar, and MacConkey agar

plates has to be observed and documented.
• On nutrient agar, non-mucoid, opaque, and circular colonies will
be observed.
 On blood agar, nonhemolytic, opaque, circular, and gray color
colonies will be observed.
 On MacConkey agar, non-lactose, fermenting, opaque, and
circular colonies will be observed.
Biochemical reaction

• Cytochrome oxidase test - Negative

 Mannitol motility medium - Mannitol not fermented and Non-motile

• Triple sugar iron agar - Alkaline butt and slant; No H2S or gas

• Indole test - Negative for indole

• Citrate utilization test - Citrate positive

• Urease test - Negative

TREATMENT

• Although carbapenems are effective antibiotics to treat

A.baumannii infections, the rate of carbapenem
resistant A.baumannii isolates has been increasing gradually.
• Imipenem or ceftazidime combined with aminoglycosides is used for
serious infections.
• Only a few effective antibiotic options are available to treat MDR A.
baumannii infections. To combat MDR or pandrug-resistant (PDR) A.
baumannii, which are resistant to all available antibiotics,
combination therapies, including colistin/imipenem,
colistin/meropenem, colistin/rifampicin, colistin/tigecycline,
colistin/sulbactam, colistin/teicoplanin, and imipenem/sulbactam,
have been extensively studied.
 PREVENTION

 Hand hygiene

 Contact precaution

 Active screening

 Environmental surface
disinfections

 decolonization