Cristina Bazet

Detection of class 1 and 2 integrons, extended-spectrum β-lactamases and qnr alleles in enterobacterial isolates from the digestive tract of Intensive Care Unit inpatients

In this study, we searched for extended-spectrum β-lactamases (ESBLs), class 1 and 2 integrons, and qnrA, qnrB and qnrS genes in 56 oxyimino-cephalosporin and/or ciprofloxacin-resistant enterobacterial isolates obtained from the gastrointestinal tract of patients admitted in an Intensive Care Unit in Uruguay. ESBLs were detected in 11 isolates (6 CTX-M-2, 3 CTX-M-9, 1 CTX-M-15 and 1 PER-2). qnr genes and integrons were detected in 5 and 24 isolates, respectively. Eight different antibiotic resistance gene cassettes were found within six different genetic arrangements. Two types of complex class 1 integrons carrying insertion sequence ISCR1 were found, one showing bla(CTX-M-2)-orf3 and the other qnrA1-ampR. Ten of the thirteen isolates carrying class 2 integrons presented the element IS5 inserted between intI2 and dfrA1, whereas another class 2 integron lacked the internal stop codon usually present in intI2. This is the first report of the occurrence of qnrA, qnrB and bla(CTX-M-9) in Uruguay. Dissemination of the different groups of CTX-M enzymes (i.e. groups 1, 2 and 9) appears to be a recent phenomenon in South America.

Ciprofloxacin-Resistant Enterobacteria Harboring the aac(6′)-Ib-cr Variant Isolated from Feces of Inpatients in an Intensive Care Unit in Uruguay

The presence of aac(6′)-Ib-cr is associated with decreased susceptibility to aminoglycosides (kanamycin, amikacin, and tobramycin) and to norfloxacin and ciprofloxacin (9). This allelic variant of aac(6′)-Ib was found to be linked to the extended-spectrum β-lactamase (ESBL) gene blaCTX-M-15 in isolates from many countries (4, 6, 7), while association of aac(6′)-Ib with the blaCTX-M-2 ESBL gene has been widely reported in Uruguay and Argentina (3, 11). In this work we looked for the presence of aac(6′)-Ib and the aac(6′)-Ib-cr variant and their putative ESBL coresistance markers in fecal isolates of enterobacteria resistant to ciprofloxacin and/or ceftazidime from inpatients in an intensive care unit (ICU) in Montevideo, Uruguay. From 1 March to 31 October 2006, 106 patients were admitted to this ICU and followed daily until discharge. Rectal swabs obtained at 1, 4, 7, 10, 13, and 16 days after admission were plated on MacConkey agar plus ceftazidime (4 mg/liter) or ciprofloxacin (2 mg/liter). Enterobacterial isolates were identified by classical methods, including only the first isolate of each bacterial species per patient in this study. Antibiotic resistance profiling, screening, and confirmatory testing for ESBL detection were performed by disk diffusion assay, and results were interpreted following the CLSI guidelines (2). A total of 58/106 patients (55.2%) were colonized with ciprofloxacin- and/or ceftazidime-resistant enterobacteria, and 68 isolates were included in this study. Of these, 48 were resistant to gentamicin and 24 to amikacin (Table ​(Table11). TABLE 1. Main characteristics of the 68 studied isolatesa All aminoglycoside-resistant isolates were screened for aac(6′)-Ib by PCR; amplicons were analyzed by restriction with BstF5I, as described by Park et al. (8). PCR products that were not digested by the enzyme [tentatively assigned to aac(6′)-Ib-cr] were confirmed to contain aac(6′)-Ib-cr by double-strand sequencing. Only two Escherichia coli isolates were positive for aac(6′)-Ib-cr detection. Recalling the observed links between blaCTX-M-15 and aac(6′)Ib-cr (4, 6, 7) and between aac(6′)Ib and blaCTX-M-2, the two aac(6′)-Ib-cr-positive isolates were further analyzed by PCR to detect CTX-M-1 and CTX-M-2 group ESBL genes using previously described primers (3, 5). Both isolates were positive only for CTX-M-1 group genes, identified as blaCTX-M-15 after sequencing. Both isolates were obtained at the time of patient admission into the ICU and showed identical pulsed-field gel electrophoresis patterns (10). Both patients were previously hospitalized before ICU admission, suggesting that this strain could be endemic in the hospital, where it could be horizontally transferred. All the other E. coli isolates yielded different pulsotypes (data not shown) compared with these. PCR assays for the detection of class 1 integrons and ISCR1 elements were performed according to the method of Di Conza et al. (3). Both isolates carried a class 1 integron containing the dfr17 and aadA5 gene cassettes, while ISCR1 elements were not detected. So far we have not been able to transfer these resistance genes, either by transformation or by conjugation. This is the first report of aac(6′)-Ib-cr in Uruguay. In accordance with a previous report (6), blaCTX-M-15 and aac(6′)-Ib-cr do not seem to be associated with class 1 integrons. Demonstration of a link to IS26 as previously reported (1) is pending.

Polyclonal endemicity of Acinetobacter baumannii in ventilated patients in an intensive care unit in Uruguay

OBJECTIVES To identify the mechanisms responsible for respiratory infections by Acinetobacter baumannii in intubated patients and risk factors for digestive colonization and infection by A. baumannii. METHODS We conducted a prospective study in an intensive care unit (ICU) between May 2005 and November 2006, including 175 consecutive patients at the beginning of invasive ventilation (day 1). We performed pharyngeal and rectal swabs on days 1, 4, 7, 10, 13, and 16. Respiratory samples were taken on days 1 and 7, or on suspicion of ventilator-associated pneumonia (VAP). RESULTS We detected 62 patients with A. baumannii digestive colonization and 20 cases of A. baumannii lower respiratory infection (14 VAP and six purulent tracheobronchitis (PTB)). Digestive colonization by A. baumannii was an independent risk factor for lower respiratory tract infections with that microorganism (p<0.0001; relative risk 8.71, 95% confidence interval 2.73-27.77). Respiratory and rectal A. baumannii isolates from the same patients were compared by enterobacterial repetitive intergenic consensus (ERIC)-PCR; in 9/11 cases (eight VAP and one PTB) results suggested events of exogenous pneumonia with previous colonization, whereas the remaining two cases (two PTB) were suggestive of exogenous infection without previous colonization. CONCLUSIONS In our unit the pathogenesis of VAP by A. baumannii is mixed, most cases corresponding to exogenous pneumonia with previous colonization.