Study title:

Prevalence of Acinetobacter spp. in ICU in Misurata Central Hospital, a

retrospective study of the clinical isolates collected during the period from 2009
to 2023.
NB: The medical departments involved and the exact period of the study will depend on the availability of the clinical isolates
and associated documentation.

Definitions and meanings:

- Frequency: Is the number of times an event or observation happened in an

experiment or study.
- Prevalence: Is the proportion of persons in a population who have a particular
disease or attribute at a specified point in time or over a specified period of time.
Prevalence includes all cases, both new and preexisting, in the population at the specified time.
- Point prevalence is the proportion of people with a particular disease at a particular
time point.
- Period prevalence: Refers to prevalence measured over an interval of time. It is the
proportion of persons with a particular disease or attribute at any time during the
interval.
- Prevalence of a disease = (All new and pre-existing cases during a given time period / Population
during the same time period) X 100
Prevalence of an attribute = (Persons having a particular attribute during a given time period /
Population during the same time period) X 100
- Incidence: Incidence includes only the new cases in the population at the specified
time.
- Prospective study: A prospective study watches for outcomes, such as the
development of a disease, during the study period and relates this to other factors
such as suspected risk or protection factor(s). The study usually involves taking a
cohort of subjects and watching them over a long period.
- Retrospective study: A retrospective study looks backwards and examines
exposures to suspected risk or protection factors in relation to an outcome that is
established at the start of the study. Most sources of error due to confounding and
bias are more common in retrospective studies than in prospective studies. For this
reason, retrospective investigations are often criticized.
- Clinical bacterial isolates: Bacteria isolated from a specimen (e.g., stool, blood,
food, sputum, urine, pus, …).
- Gram-positive bacteria: Gram-positive bacteria are bacteria that give a positive
result in the Gram stain test, which is traditionally used to quickly classify bacteria
into two broad categories according to their type of cell wall.

Gram-positive bacteria take up the crystal violet stain used in the test, and then appear
to be purple-colored when seen through an optical microscope. This is because the
thick peptidoglycan layer in the Gram-positive bacterial cell wall retains
the stain after it is washed away from the rest of the sample, in the decolorization
stage of the test.

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 Violet-stained gram-positive cocci and pink-stained gram-negative bacilli

- Gram-negative bacteria: Gram-negative bacteria cannot retain the violet stain

after the decolorization step; alcohol used for decolorization degrades the outer
membrane of gram-negative cells, making the cell wall more porous and incapable
of retaining the crystal violet stain. Their peptidoglycan layer is much thinner and
sandwiched between an inner cell membrane and a bacterial outer membrane,
causing them to take up the counterstain (safranin or fuchsine) and appear red or
pink.

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 Cell wall of Gram-negative bacteria (has thin peptidoglycan layer and has outer membrane)

- Acinetobacter:
 Is a non-fermenting Gram-negative coccobacillus with a high capacity to
colonize the human body and the environmental reservoirs and it is associated
with a high morbidity and a high mortality rate especially in
immunocompromised patients.

Acinetobacter

 Acinetobacter is an opportunistic pathogen known for its intrinsic resistance to

antibiotics and greater ability to rapidly acquire resistance genes.
 Because it, generally, has resistance to several antibiotics and multidrug-
resistant, Acinetobacter baumannii is becoming a global threat.
- Non-fastidious bacteria: Bacteria that do not require any special conditions or
substances for their growth.
- Previous antibiotic exposures: Defined as any antibiotic prescribed in the 90 days
before the positive culture (isolate) is obtained.
- E test (previously known as the Epsilometer test): Is a test used for determination
of antimicrobial sensitivity by placing a strip impregnated with antimicrobials onto
an agar plate. A strain of bacterium or fungus will not grow near a concentration
of antibiotic or antifungal if it is sensitive. For some microbial and antimicrobial
combinations, the results can be used to determine a minimum inhibitory

3
 concentration (MIC). Etest is a proprietary system manufactured by bioMérieux. It
is a laboratory test used in healthcare settings to help guide physicians by
indicating what concentration of antimicrobial could successfully be used to treat
patients' infections.

- Disk diffusion test: It is a test which is used for determination of susceptibility of

an organism based upon the zone of inhibition of the organism seeded (cultured)
onto an agar plate by using radial diffusion of an antimicrobial from a paper disk
impregnated with the drug.

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- Multidrug resistant (MDR) Acinetobacter baumannii: When Acinetobacter is
resistant to three or more classes of antibiotics represented by piperacillin /
tazobactam combination, ceftazidime, imipenem, ciprofloxacin, aminoglycosides
and colistin.
 Piperacillin = Antipseudomonal penicillin (pinicillins are ẞ-lactam antibiotics.
 Tazobactam = ẞ-lactamase enzyme inhibitor.
 Ceftazidime = 3rd-generation cephalosporin (cephalosporins are ẞ-lactam antibiotics).
 Imipenem = carbapenem antibiotic (carbapenems are ẞ-lactam antibiotics).
 Ciprofloxacin = fluoroquinolone antibiotic (they inhibit bacterial DNA synthesis).
 Aminoglycosides e.g. gentamicin, kanamycin, netlmicin, streptomycin, …..
 Colistin (polymyxin E): It is a surface active agent which penetrates into and disrupts the
bacterial cell membrane. Colistin is polycationic and has both hydrophobic and lipophilic
moieties. It interacts with the bacterial cytoplasmic membrane, changing its permeability
(detergent effect). This effect is bactericidal. Polymyxins are nephrotoxic and neurotoxic and
usually are recommended to be given locally for treatment of wound or burn infections caused
by Gram-negative bacteria, but incase of A. baummannii, the should be given intravenous
(I.V.).
- Inanimate surfaces: Not endowed with life or spirit.
- Desiccation: The process of drying or desiccating something or the state of being
or becoming dried up, also removal or loss of moisture thorough drying.
-

Introduction:

- Acinetobacter is a non-fermenting Gram negative coccobacillus with a high

capacity to colonize the human body and the environmental reservoirs (1).
- It has become over the past three decades a major associated medical care
infections agent with a high morbidity and a high mortality rate especially in
immunocompromised patients ranging from 26.5 to 91%(2)(3)(4)(5).
- It was demonstrated that among Acinetobacter species, A. baumannii is the main
cause of Acinetobacter infections with antibiotic-resistance rate being very high
causing more serious infections than other species of Acinetobacter(6).

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- In general, the Acinetobacter isolates are known for their resistance to various
antibiotics despite their weak virulence limiting the control and infections
treatment due to these microorganisms(7)(8)(9)(10)(11).
- The Acinetobacter infection prevalence is variable depending on the geographical
localization and the patient’s socio-economic status(12)(13)(14).
- In an international study on the prevalence of infections in ICUs in 75 countries(15),
the mean isolation rate of Acinetobacter was (8.8%). In this study, the
Acinetobacter infections rate in different regions was: 19.2% in Asia; 17.1% in
Eastern Europe; 14.8% in Africa; 13.8% in Central and South America; 5.6% in
Western Europe; 4.4% in Oceania and 3.7% in North America(16).
- In South African HIV-positive patients, the prevalence was 15%(17) and it was 13%
in Canadian burn care units(18).
- A study carried out in an Indian hospital reported that the rate of A. baumannii
constituted 9.4% of all Gram-negative rods throughout the hospital and 22.6% in
the ICUs(19).
- In Pakistan the isolation rate of Acinetobacter species was 4.2%(20).
- In Morocco, a retrospective study from 2002 to 2005 showed that Acinetobacter
baumannii represented 13.63% of clinical isolates from blood cultures in the
intensive care units (ICUs)(21) and in another Moroccan study(22), it represented
6.74% of all Gram-negative bacilli.
- In Libya, a retrospective study analyzed 4286 clinical isolates recovered from
routine cultures performed in the microbiology laboratory from wounds and
abscesses swabs, urine, blood culture, and others, derived from different wards
(burn units, paediatric burn, plastic units) and burns ICU patients admitted to
Burns and Plastic Surgery Center in Tripoli-Libya during the years 2008 and 2009,
a total of 167 Acinetobacter baumannii strains were collected. The overall
proportion of Acinetobacter baumannii isolates among all clinical isolates was
found to be 3.5% during the year 2008 and 4.2% during the year 2009 (3.89%
during 2008 and 2009). In this study, it was also found that the ICU A. baumannii
isolates exhibited higher level of resistance to imipenem (71.6%) and meropenem
(73.4%) compared to non-ICU isolates (isolates from other departments) which
was 42.6% resistant to imipenem and 44.6% resistant to meropenem (P<0.01).
- Another study in Libya done to characterize the molecular support of carbapenem-
resistant A. baumannii of clinical isolates recovered from Tripoli Medical Center
(TMC) and Burn and Plastic Surgery hospital in Tripoli, where bacterial isolates
identified by matrix-assisted laser desorption/ionization time-of-flight mass
spectrometry (MALDI-TOF/MS) and antibiotic testing was performed using disk
diffusion and E test methods and carbapenem-resistance determinants were studied
by PCR amplification and sequencing, it was found that all of the 36 imipenem-
resistant isolates tested were identified as A. baumannii. The blaOXA-23 gene was
detected in 29 strains (80.6%) and the metallo-ẞ-lactamase blaNDM-1 gene was
detected in eight isolates (22.2%). This study concluded that there is a
dissemination of the multidrug-resistant (MDR) A. baumannii in these 2 Libyan
hospitals mainly by production of OXA-23 and NDM-1 carbapenemases. Further

6
 typing of the isolates by multilocus sequencing typing (MLST) revealed several
sequence types (STs) with the imipenem-resistant A. baumannii ST2 was the
predominant clone (44.4%, 16 isolates out of 36)(23).
- In another study in Libya, a total of 108 A. baumannii isolates were identified and
characterized and antibiotic susceptibility test was performed using automated
system, also carbapenem-resistance determinants were studied phenotypically
using three different techniques: metallo-β-lactamase (MBL) E-test; chromogenic
culture media and modified Hodge test (MHT). Polymerase chain reaction (PCR)
amplification was used to determine the presence of metallo-β-lactamase blaNDM-
1, blaOXA-23, blaOXA-48 and blaOXA-51 genes among isolates. The overall
resistance prevalence was extremely high for aminoglycosides, fluoroquinolones,
cephalosporens and carbapenems (93.2-100%), all isolates were susceptible to
colistin (polymyxin E). In addition, 97.5% of isolates were identified as multidrug-
resistance (MDR). Varying degree of phenotypic detection of carbapenems was
determined; highest levels of carbapenems were detected using chromogenic media
(75.5%) compared with MBL E-test (45.5%) and MHT (71.4%). The carbapenem-
resistance-encoding genes detected were blaNDM1 (70.6%), blaOXA-23 (84%),
blaOXA-48 (46.2%) and blaOXA-51 (73.1%); the highest carbapenem genes were
demonstrated in Burn and Plastic Surgery Hospital, Tripoli (73.7%). The co-
occurrence of blaNDM-1, blaOXA-23 and blaOXA-48 genes were demonstrated in
(30/119; 25.2%) showing dissemination of carbapenems resistance MDR A.
baumannii in hospitals. MLST analysis for A. baumannii isolates revealed also the
presence of multiple clones and those belonging to ST1 and ST2 were the most
frequent . This study concluded that the high prevalence of NDM-1 and OXA-23
contribute to antibiotic resistance in Libyan hospitals and represents the high
incidence of carbapenemases in an autochthonous MDR A. baumannii isolated
from patients in Libya, indicating that there is a longstanding infection control
problem in these hospitals(24).
- In a recent study in Libya, the molecular epidemiology of 21 carbapenem-resistant
Acinetobacter baumannii isolates from Tripoli Medical Centre and Burn and
Plastic surgery hospital were investigated and assessed for their relative fitness.
Core genome multilocus sequence typing (MLST) revealed five inter-hospital
transmission clusters. Three clusters were associated with the international clones
(IC) IC1, IC2, and IC7. Carbapenem-resistance was associated with blaOXA-23,
blaGES-11, or blaNDM-1. Compared to that of A. baumannii DSM 30008, the
doubling time was similar over 10 h, but after 16 h, half the isolates grew to higher
densities, suggesting a fitness advantage(25).

Factors enhancing spread of Acinetobacter spp.:

7
- A. baumannii mainly causes pulmonary, urinary tract, bloodstream or surgical
wound infections. Major risk factors include invasive procedures, such as the use
of mechanical ventilation, central venous or urinary catheters, and broad-spectrum
antimicrobials.
- Some studies have reported that this microorganism which has emerged worldwide
as a pathogen causing serious infections in hospitalized patients has the ability to
persist in the environment for a long period of time, colonize patients or healthy
subjects and can develop into a true infection at any time(26).
- The increasing prevalence of Acinetobacter spp. is probably related to non-
compliance with the recommendations for mastery the hospital environment(27),
lack in hands hygiene and misuse of antibiotics(28).
- Since hand transmission is a major factor in the spread of this pathogen(29), hand
hygiene and disinfection of equipment/environment are the two most important
factors to control and prevent the outbreak of an epidemic Acinetobacter.
- Several studies have shown that the high frequency of A. baumannii pneumonia is
associated with mechanical ventilation resulting in extended stays in ICUs, the
rapid development of resistance to commonly used antibiotics and a high mortality
ranging from 45.6 to 84.3%(30)(31).
- The Acinetobacter spp. infections are generally involved in anatomical sites with a
high fluid content manifested by pneumonia, bacteremia, urinary tract infection,
meningitis and wound infection(32).
- The high proportion and the high resistance of these microorganisms in ICUs are
related to the existence of numerous risk factors associated with Acinetobacter
infection such as immunocompromised persons, longer duration of stay in
hospitals, invasive devices use on patients, the broad spectrum antibiotics therapy,
possible and frequent contaminations and cross transmission of this bacteria
through environmental reservoirs and hands of healthcare workers(33)(34).

Treatment and resistance to antibiotics:

- Carbapenems (imipenem, meropenem) remain one of the most important

therapeutic options for infections with Acinetobacter baumannii despite the fact
that carbapenem-resistant strains are increasing(35).
- Acinetobacter is an opportunistic pathogen known for its intrinsic resistance to
antibiotics and greater ability to rapidly acquire resistance genes as mobile genetic
elements (plasmids, transposons, integrons cassettes and insertion sequences)(36)(37)
(38)
.
- Multidrug-resistant (MDR) Acinetobacter baumannii is becoming a global threat
with a therapeutic impasse increasingly described in literature(39)(40)(41).
- Several authors have confirmed the high prevalence of these infections associated
with high resistance in ICUs(42)(43)(44)(45). The high proportion and the high resistance
of these microorganisms in ICUs are related to the existence of numerous risk
factors associated with Acinetobacter infection such as immunocompromised
persons, longer duration of stay in hospitals, invasive devices use on patients, the

8
 broad spectrum antibiotics therapy, possible and frequent contaminations and cross
transmission of this bacteria through environmental reservoirs and hands of
healthcare workers(46)(47).
- Acinetobacter baumannii, generally, has resistance to several antibiotics.
According to the literature data, the resistance rate varies from 31.8 to 92.1% to
ceftazidime; 8.8 to 89.9% vs imipenem, from 12.2 to 89.9% vs Piperacillin /
Tazobactam combination, from 28.8 to 91.6% vs fluoroquinolones and 30 to
90.3% vs aminoglycosides(48)(49)(50)(51)(52) but colistin (polymyxin E) is often the only
effective treatment option whereas some Acinetobacter strains develop resistance
to colistin(53)(54)(55)(56)(57). Resistance to colistin was estimated to 5.3% in the United
States(58); 2.7% in South Africa(59); 1.2% in India(60) and 0.9% in Tunisia(61) and
0.5% in Saudi Arabia(62). In Morocco, the Acinetobacter’s antibiotic resistance rates
were 50.3 to 68.7% for ceftazidime, 23.8 to 42.6% for the imipenem, 17 to 77.5%
for aminoglycosides, 65 to 68% for ciprofloxacin and no clinical isolates were
resistant to colistin(63)(64)(65).
- In a Libyan study, the resistance was 62.3 to 98.8% throughout the studied
hospitals (Tripoli Medical Centre and Burn and Plastic Surgery Hospital, Tripoli),
71.6-100% in the ICUs and from 42.6 to 96.2% in the other units [Ziglam H, Elahmer
O, Amri S, Shareef F, Grera A,Labeeb M, Zorgani A. Antimicrobial resistance patterns
among Acinetobacter baumannii isolated from burn intensive care unit in Tripoli, Libya.
IAJAA. 2012;2 (3):1-8].
- Three types of enzymes capable of hydrolysing carbapenems have been reported in
A. baumannii, belonging to class A (blaGES-14 and blaKPC), class B (blaIMP,
blaVIM, blaSIM-1 and blaNDM) and class D (blaOXA-23-like, blaOXA-24-like,
blaOXA-51-like, blaOXA-58-like, blaOXA-104, blaOXA-143, blaOXA-164 and
blaOXA-182) [K. Lee et al. Improved performance of the modified Hodge test
with MacConkey agar for screening carbapenemase-producing Gram-negative
bacilli. J Microbiol Methods (2010)].
- Carbapenem-resistance in A. baumannii is often due to the expression of OXA
carbapenemase types, Metallo-beta-lactamases (MBL) carbapenemase and the
impermeability associated with mutations altering the expression of porins and
efflux pumps [Özgür ES, Horasan ES, Karaca K, Ersöz G , Atis S N, Kaya A. Ventilator-
associated pneumonia due to extensive drugresistant Acinetobacter baumannii: Risk
factors, clinical features, and outcomes. Am J Infect Control. 2014; 42:206- 8; Perez F,
Hujer AM, Hujer KM, Decker BK, Rather PN, Bonomo [Link] Challenge of Multidrug-
Resistant Acinetobacter baumannii. Antimicrob Agents Chemother. 2007 ; 51(10):3471-
84].
- The aminoglycosides resistance in Acinetobacter spp. involves the production of
aminoglycosides modifying enzymes and genes encoding these enzymes can be
acquired through plasmids, transposons or integrons [Özgür ES, Horasan ES, Karaca K,
Ersöz G , Atis S N, Kaya A. Ventilator-associated pneumonia due to extensive
drugresistant Acinetobacter baumannii: Risk factors, clinical features, and outcomes. Am
J Infect Control. 2014; 42:206- 8; Jaggi N, Sissodia P, Sharma L. Acinetobacter baumannii

9
 isolates in a tertiary care hospital: Antimicrobial resistance and clinical significance. J
Microbiol Infect Dis. 2012; 2(2): 57- 63].
- Colistin (polymyxin E) is the most active antibiotic against Acinetobacter. Some
studies have reported that no clinical isolate of Acinetobacter was resistant to
colistin [Somily AM, Absar MM, Arshad MZ, Al Aska AI, Shakoor ZA, Fatani AJ, Siddiqui
YM, Murray TS. Antimicrobial susceptibility patterns of multidrug resistant Pseudomonas
aeruginosa and Acinetobacter baumannii against carbapenems, colistin, and tigecycline.
Saudi Med J. 2012; 33 (7): 750- 755; Elouennass M, Bajou T, Lemnouer AH, Foissaud V,
Hervé V, Baaj AJ. Acinetobacter baumannii : étude de la sensibilité des souches isolées à
l’hôpital militaire d’instruction MohammedV, Rabat, Maroc. Med Mal Infect. 2003;
33:361– 364] but resistance to colistin has been described in India, South Africa and
Korea [Jaggi N, Sissodia P, Sharma L. Acinetobacter baumannii isolates in a tertiary care
hospital: Antimicrobial resistance and clinical significance. J Microbiol Infect Dis. 2012;
2(2): 57- 63; Ko KS, Suh JY, Kwon KT, Jung SI, Park KH, Kang CI, Chung DR, Peck KR, Song
JH. High rates of resistance to colistin and Polymixin B in subgroups of Acinetobacter
baumannii isolates from Korea. J Antimicrob Chemother. 2007; 60(5):1163- 1167].
- Several studies confirmed that colistin remains the only option for empirical
treatment of serious Acinetobacter infections in cases where this bacterium is
strongly suspected to be resistant to other antibiotics [Shareek PS, Sureshkumar D,
Ramgopalakrishnan, Ramasubramanian V, Ghafur KA, Thirunarayanan MA. Antibiotic
Sensitivity Pattern of Blood Isolates of Acinetobacter Species in a Tertiary Care Hospital: A
Retrospective Analysis. Am J Infect Dis. 2012; 8 (1): 65-69; Ben Haj Khalifa A, Khedher M.
Profil de sensibilité aux antibiotiques des souches d’Acinetobacter baumannii isolées
dans la région de Mahdia. Med Mal Infect. 2010 ; 40 :126– 128].
- The mechanism of resistance to colistin is rare and may be explained by the loss of
lipopolysaccharide and/or deployment of a system of two component regulatory
PmrAB [Moffatt JH, Harper M, Harrison P, Hale JD, Vinogradov E, Seemann T, Henry R,
Crane B, St Michael F, Cox AD, Adler B, Nation RL, Li J, Boyce JD. Colistin Resistance in
Acinetobacter baumannii Is Mediated by Complete Loss of Lipopolysaccharide
Production. Antimicrob Agents Chemother. 2010; 4971– 4977; Adams MD, Nickel GC,
Bajaksouzian S, Lavender H, Murthy AR, Jacobs MR, Bonomo [Link] to Colistin in
Acinetobacter baumannii Associated with Mutations in the PmrAB TwoComponent
System. Antimicrob Agents Chemother. 2009; 53(9): 3628-3634].
- Rifampicin was very effective (but less than colistin). Synergy between colistin
and rifampicin or anti-Pseudomonas carbapenem is described in some studies
[Fishbain J, Peleg [Link] of Acinetobacter Infections. Clin Infect Dis. 2010;
51(1):79–84].

Aims of the study:

To my knowledge, depending on Google search, there is no study which examined the

prevalence of Acinetobacter baumannii in Misurata Central Hospital, and even
though, a frequent continuous surveillance is required due to the rapid and continuous
mutational changes in the genetic material of this bacterium. This study is going to be
conducted to determine:

10
- The Gram-negative bacteria clinical isolates frequency among all the collected
isolates obtained from samples (sputum, urine, blood, wound swaps) ordered for
infection diagnosis from hospitalized patients admitted to ICU department of
Misurata Hospital during the period from 2011 to 2023.
- The Acinetobacter spp. clinical isolates frequency among all of the Gram-negative
bacteria clinical isolates.
- The clinical isolates antibiotic susceptibility pattern among all the Acinetobacter
spp. clinical isolates, whenever antibiotic sensitivity tests are done.

Methods:

Setting:

This study is going to be conducted in Misurata Central Hospital, a teaching hospital

with about 150-bed, located in the city of Misurata, the third city in Libya in terms of
population. The hospital is composed from departments of the different medical
specialties including ICU department, as well as laboratory and imagery departments.

Type of the study:

It is a retrospective study to analyze the clinical isolates of Acinetobacter spp.

obtained from samples (sputum, urine, blood, stool, wound swaps) collected for
culture and antibiotic sensitivity for infection diagnosis in hospitalized patients
admitted to ICU between 2011 to 2023. Multiple cultures of the same organism from
the same patient will be excluded, and only the last culture of each patient will be
included.

Isolation cultures and identification: (According to the laboratory protocol)

- Isolation of Acinetobacter was performed by culturing on blood agar and

bromocresol purple lactose agar, and identification of clinical isolates was
performed by the classical bacteriological techniques:
 Gram-stain, direct examination and biochemical test of orientation (catalase
and oxidase tests) (C. Héritier, L. Poirel, P. Fournier, J. Claverie, D. Raoult and P.
Nordmann. Characterization of the naturally occurring oxacillinase of Acinetobacter
baumannii. Antimicrob Agents Chemother. 2005. 49: 4174-4179) .
 Biochemical characters using API 20NE galleries (Biomérieux, Marcy l'Etoile,
France) for identification at the species level.

Antibiotic susceptibility: (According to the laboratory protocol)

- Minimal inhibitory concentrations (MICs) were performed by agar dilution method

and interpreted according to the Clinical and Laboratory Standards Institute (CLSI)
guidelines against all isolates to determine the susceptibility of these isolates to
antibiotics (Clinical laboratory Standard Institute. Performance standards for
antimicrobial susceptibility testing, 19th informational supplement, M100-S19.
Wayne, PA: CLSI. 2009). The antibiotic classes tested included: imipenem (10µg),

11
 meropenem (10µg), gentamicin (10µg), ciprofloxacin (5µg), fusidic acid (10µg),
amikacin (30µg), trimethoprim (25µg), cefepime (30µg), ceftazidime (30 µg),
ceftriaxone (30 µg), cefotaxime (10 µg), and amoxicillin-clavulanic acid (30µg).
Isolates showing intermediate level of susceptibility classified as resistant. MDR
A. baumannii defined as resistance to more than three classes of antibiotics.
Escherichia coli ATCC 25922 and ATCC 35218 and Pseudomonas aeruginosa
ATCC 27853 will be used as quality controls in each susceptibility determination.

OR (according to what was done in the Laboratory)

- The study of antibiotic susceptibility will be performed by the disc diffusion

method on Mueller-Hinton agar plates, and interpreted as recommended by the
antibiogram committee of the French Society of Microbiology in their 2014
recommendations. The antibiotic discs to be tested include: ticarcillin, ticarcillin-
clavulanate , piperacillin, piperacillin-tazobactam, cefepime, ceftazidime,
imipenem, amikacin, gentamicin, tobramycin, netilmicin, ciprofloxacin,
sulfamethoxazole-trimethoprime, polymyxins and colistin. The reading of the
antibiograms was performed using the OSIRIS expert system. The resistance to
colistin was confirmed by the determination of the Minimum Inhibitory
Concentrations (MICs) using the E-test method (Biomérieux, Marcy l’Etoile,
France) according to the manufacturer´s recommendations. All isolates of
Acinetobacter resistant to three or more classes of antibiotics represented by
piperacillin / tazobactam, ceftazidime, imipenem, ciprofloxacin, aminoglycosides
and colistin were considered as MDR [Al-Mously N, Hakawi A. Acinetobacter
baumannii bloodstream infections in a tertiary hospital:Antimicrobial resistance
surveillance. Int J Infect Control. 2013; 9 (2):1- 8; Queenan AM, Pillar CM, Deane J, Sahm
DF, Lynch AS, Flamm RK, Peterson J, Davies TA. Multidrug resistance among
Acinetobacter spp. in the USA and activity profile of key agents: results from Capital
Surveillance 2010. Diagn Microbiol Infect Dis. 2012 ;73(3):267-70; Garnacho-Montero J,
Amaya-Villar R. Multiresistant Acinetobacter baumannii infections: epidemiology and
management. Curr Opin Infect Dis. 2010; 23(4): 332- 339].

Statistical analysis:

The statistical analysis is going to be performed using the SPSS Statistics. The Chi
square test will be used to compare the percentages of Acinetobacter infection
prevalence, resistance rates and MDR comparisons. Only the last culture identified as
A baumannii positive per patient is going to be included in the analysis. The p values
less than 0.05 will be considered statistically significant.

References:

1- Obeidat N, Jawdat F, Al-Bakri AG, Shehabi AA. Major biologic characteristics of

Acinetobacter baumannii isolates from hospital environmental and patients’ respiratory
tract sources. Am J Infect Control. 2014; 42(4):401-4.

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2- Punpanich W, Nithitamsakun N, Treeratweeraphong V, Suntarattiwong P. Risk factors for
carbapenem nonsusceptibility and mortality in Acinetobacter baumannii bacteremia in
children. Int J Infect Dis. 2012;16(11):e811- e815.
3- Özgür ES, Horasan ES, Karaca K, Ersöz G , Atis S N, Kaya A. Ventilator-associated
pneumonia due to extensive drug-resistant Acinetobacter baumannii: Risk factors, clinical
features, and outcomes. Am J Infect Control. 2014; 42:206- 8.
4- Shields RK, Kwak EJ, Potoski BA, Doi Y, Adams-Haduch JM, Silviera FP, Toyoda Y, Pilewski
JM, Crespo M, Pasculle AW, Clancy CJ, Nguyen MH. High mortality rates among solid
organ transplant recipients infected with extensively drug-resistant Acinetobacter
baumannii: using in vitro antibiotic combination testing to identify the combination of a
carbapenem and colistin as an effective treatment regimen. Diagn Microbiol Infect Dis.
2011;70(2):246–252.
5- Turkoglu M, Mirza E, Tunçcan OG, Erdem GU, Dizbay M, Yagci M, Aygencel G, Türköz
Sucak G. Acinetobacter baumannii infection in patients with hematologic malignancies in
intensive care unit: Risk factors and impact on mortality. J Crit Care. 2011; 26(5):460–467 .
6- Chuang YC, Sheng WH, Li SY, Lin YC, Wang JT, Chen YC, Chang SC. Influence of
genospecies of Acinetobacter baumannii complex on clinical outcomes of patients with
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