MDRO in ICU

(Focus on Carbapenemase Producing Bacterias)

Introduction

The intensive care unit (ICU) often is called the epicenter of infections, due to its extremely
vulnerable population (reduced host defences deregulating the immune responses) and
increased risk of becoming infected through multiple procedures and use of invasive devices
distorting the anatomical integrity-protective barriers of patients (intubation, mechanical
ventilation, vascular access, etc.). In addition, several drugs may be administered, which also
predispose for infections, such as pneumonia, e.g., by reducing the cough and swallow
reflexes (sedatives, muscle relaxants) or by distorting the normal nonpathogenic bacterial
flora (e.g., stress ulcer prophylaxis)(Brusselaers et al, 2011)
Along with the problem of nosocomial infection goes the burden of multidrug
antimicrobial resistance (MDR). The ongoing emergence of resistance in the community and
hospital is considered a major threat for public health. Due to the specific risk profile of its
residents, the ICU also is deemed the epicenter of resistance development. The ICU has even
been described as a factory for creating, disseminating, and amplifying antimicrobial
resistance. (Brusselaers et al, 2011)
This burden of resistance, however, is probably more due to the higher rate of inappropriate
empiric antimicrobial treatment associated with infections caused by MDR pathogens than
with the virulence of particular MDR strains. (Brusselaers et al, 2011)

Important resistant pathogens

During the past decades, a shift in the MDR dilemma has been noted from gram-positive to
gram-negative bacteria, especially due to the scarceness of new antimicrobial agents active
against resistant gram-negative microorganisms. (Boucher et al, 2009)
Among gram-positive organisms, the most important resistant microorganisms in the ICU
are currently methicillin-(oxacillin-)-resistant Staphylococcus aureus, and vancomycin-
resistant enterococci (Boucher et al, 2009, Jones RN, 2001). In gram-negative bacteria, the
resistance is mainly due to the rapid increase of extended-spectrum Beta-lactamases (ESBLs)
in Klebsiella pneumonia, Escherichia coli, and Proteus mirabilis; high level third generation
cephalosporin -lactamase resistance among Enterobacter spp. and Citrobacter spp., and
MDR in Pseudomonas aeruginosa, Acinetobacter spp., and Stenotrophomonas maltophilia
(Jones RN, 2001)

Tabel 1. Multidrug-Resistant Bacterial Organisms Causing Major Clinical Problems. (Arias
and Murray, 2009)





The emergence of novel b-lactamases with direct carbapenem-hydrolyzing activity has
contributed to an increased prevalence of carbapenem resistant Enterobacteriaceae (CRE).
CRE are particularly problematic given the frequency with which Enterobacteriaceae cause
infections, the high mortality associated with infections caused by CRE, and the potential for
widespread transmission of carbapenem resistance via mobile genetic elements. (Gupta et al
2011).
Emergence and spread of carbapenem resistant Gram negative rods is a great concern,
especially in a resource limited country such as Pakistan, where treatment alternatives are
either unavailable or expensive/toxic with poor outcome. (Irfan et al, 2008)
Recent reports from our center have documented emergence and spread of carbapenem
resistance among multi-resistant non enterobacteriaceae including Acinetobacter species and
Pseudomonas aeruginosa. (Sarwari A, 2004; Noor A, 2005) Related trends in resistance
among P. aeruginosa have been observed in the national NNIS database (figure 3); among P.
Aeruginosa isolates recovered from ICU patients in 2003, the overall rate of resistance to
carbapenems was 20%, and that of resistance to third-generation cephalosporins and
quinolones was 30% (NNIS, unpublished data). ( McDonald, 2006)
Multidrug-Resistant Bacterial Organisms which cause major clinical problems are
summarized in table 1.

Mechanisms of resistance to Antibacterial agents

Bacteria may manifest resistance to antibacterial drugs through a variety of mechanisms.
Some species of bacteria are innately resistant to _1 class of antimicrobial agents. In such
cases, all strains of that bacterial species are likewise resistant to all the members of those
antibacterial classes. Of greater concern are cases of acquired resistance, where initially
susceptible populations of bacteria become resistant to an antibacterial agent and proliferate
and spread under the selective pressure of use of that agent. Several mechanisms of
antimicrobial resistance are readily spread to a variety of bacterial genera. First, the organism
may acquire genes encoding enzymes, such as _-lactamases, that destroy the antibacterial
agent before it can have an effect. Second, bacteria may acquire efflux pumps that extrude the
antibacterial agent from the cell before it can reach its target site and exert its effect. Third,
bacteria may acquire several genes for a metabolic pathway which ultimately produces
altered bacterial cell walls that no longer contain the binding site of the antimicrobial agent,
or bacteria may acquire mutations that limit access of antimicrobial agents to the intracellular
target site via downregulation of porin genes. Thus, normally susceptible populations of
bacteria may become resistant to antimicrobial agents through mutation and selection, or by
acquiring from other bacteria the genetic information that encodes resistance. The last event
may occur through 1 of several genetic mechanisms, including transformation, conjugation,
or transduction. Through genetic exchange mechanisms, many bacteria have become resistant
to multiple classes of antibacterial agents, and these bacteria with multidrug resistance
(defined as resistance to _3 antibacterial drug classes) have become a cause for serious
concern, particularly in hospitals and other healthcare institutions where they tend to occur
most commonly. As noted above, susceptible bacteria can acquire resistance to an
antimicrobial agent via new mutations.18 Such spontaneous mutations may cause resistance
by (1) altering the target protein to which the antibacterial agent binds by modifying or
eliminating the binding site (e.g., change in penicillin-binding protein 2b in pneumococci,
which results in penicillin resistance), (2) upregulating the production of enzymes that
inactivate the antimicrobial agent (e.g., erythromycin ribosomal methylase in staphylococci),
(3) downregulating or altering an outer membrane protein channel that the drug requires for
cell entry (e.g., OmpF in E coli), or (4) upregulating pumps that expel the drug from the cell
(efflux of fluoroquinolones in S aureus).18 In all of these cases, strains of bacteria carrying
resistance-conferring mutations are selected by antimicrobial use, which kills the susceptible
strains but allows the newly resistant strains to survive and grow. Acquired resistance that
develops due to chromosomal mutation and selection is termed vertical evolution.
Bacteria also develop resistance through the acquisition of new genetic material from other
resistant organisms. This is termed horizontal evolution, and may occur between strains of
the same species or between different bacterial species or genera. Mechanisms of genetic
exchange include conjugation, transduction, and transformation.18 For each of these
processes, transposons may facilitate the transfer and incorporation of the acquired resistance
genes into the hosts genome or into plasmids. During conjugation, a gram-negative
bacterium transfers plasmid-containing resistance genes to an adjacent bacterium, often via
an elongated proteinaceous structure termed a pilus, which joins the 2 organisms.
Conjugation among gram-positive bacteria is usually initiated by production of sex
pheromones by the mating pair, which facilitate the clumping of donor and recipient
organisms, allowing the exchange of DNA. During transduction, resistance genes are
transferred from 1 bacterium to another via bacteriophage (bacterial viruses). This is now
thought to be a relatively rare event. Finally, transformation, i.e., the process whereby
bacteria acquire and incorporate DNA segments from other bacteria that have released their
DNA complement into the environment after cell lysis, can move resistance genes into
previously susceptible strains.
Mutation and selection, together with the mechanisms of genetic exchange, enable many
bacterial species to adapt quickly to the introduction of antibacterial agents into their
environment. Although a single mutation in a key bacterial gene may only slightly reduce the
susceptibility of the host bacteria to that antibacterial agent, it may be just enough to allow its
initial survival until it acquires additional mutations or additional genetic information
resulting in fullfledged resistance to the antibacterial agent.18 However, in rare cases, a
single mutation may be sufficient to confer high-level, clinically significant resistance upon
an organism (e.g., high-level rifampin resistance in S aureus or high-level fluoroquinolone
resistance in Campylobacter jejuni). The following case studies, which involve 3 different
bacterial species, serve to illustrate several of the ways in which bacteria develop resistance
to antibacterial drugs and how different resistance mechanisms may interact to increase the
level or spectrum of resistance of an organism. (Tennover, 2006)

Carbapenem

Carbapenems are b-lactams that contain a fused b-lactam ring and a five-membered ring
system that differs from the penicillins in being unsaturated and containing a carbon atom
instead of the sulfur atom. This class of antibiotics has a broader spectrum of activity than do
most other b-lactam antibiotics. (Petri, 2006)
Imipenem is marketed in combination with cilastatin, a drug that inhibits the degradation of
imipenem by a renal tubular dipeptidase. The activity of imipenem is excellent in vitro for a
wide variety of aerobic and anaerobic microorganisms. Streptococci (including penicillin-
resistant S. pneumoniae), enterococci (excluding E. faecium and non-b-lactamase-producing
penicillin-resistant strains), staphylococci (including penicillinase-producing strains), and
Listeria all are susceptible. Although some strains of methicillin-resistant staphylococci are
susceptible, many strains are not. Activity is excellent against the Enterobacteriaceae,
including organisms that are cephalosporin-resistant by virtue of expression of chromosomal
or plasmid extended-spectrum b-lactamases. Most strains of Pseudomonas and Acinetobacter
are inhibited. X. maltophilia is resistant. Anaerobes, including B. fragilis, are highly
susceptible. (Petri, 2006)
Meropenem is similar to imipenem but has slightly greater activity against gram-negative
aerobes and slightly less activity against gram-positives. It is not significantly degraded by
renal dehydropeptidase and does not require an inhibitor. Ertapenem is less active than
meropenem or imipenem against P aeruginosa and acinetobacter species. It is not degraded
by renal dehydropeptidase.
A carbapenem is indicated for infections caused by susceptible organisms, eg, P aeruginosa,
which are resistant to other available drugs and for treatment of mixed aerobic and anaerobic
infections. Carbapenems are active against many highly penicillin-resistant strains of
pneumococci. A carbapenem is the -lactam antibiotic of choice for treatment of enterobacter
infections because it is resistant to destruction by the -lactamase produced by these
organisms; it is also the treatment of choice for infections caused by ESBL-producing gram-
negatives. Ertapenem is insufficiently active against P aeruginosa and should not be used to
treat infections caused by that organism. Imipenem or meropenem with or without an
aminoglycoside may be effective treatment for febrile neutropenic patients. (Katzung BG,
2006)
Doripenem has been shown to have potent inhibitory effects against P. aeruginosa isolates
(including difficult-to-treat strains), with a minimum inhibitory concentration that is 2 4
times lower than that of imipenem and meropenem. Doripenem has demonstrated significant
efficacy among patients with a high Acute Physiology and Chronic Health Evaluation II
score and advantageous clinical outcomes in patients with difficult-to-treat gram-negative
infection. (Mandel, 2009)

Carbapenemase: classification and epidemiology

Carbapenemases are enzymes that can efficiently hydrolyse most -lactams, including
carbapenems [4, 5]. (Paterson, 2005 and Queenan, 2007) Although known as
carbapenemases, many of these enzymes recognize almost all hydrolyzable -lactams, and
most are resilient against inhibition by all commercially viable -lactamase inhibitors.
(Queenan, 2007)
The most commonly used classification for carbapenemases is that defined by Ambler,
although the one by Bush-Jacoby is also used. The Ambler classification separates -
lactamases into four classes A-D, based on their molecular structure [5, 23]. Molecular
classes A, C, and D include the -lactamases with serine at their active site, whereas molecular
class B -lactamases are all metalloenzymes with an active-site zinc. Carbapenemases, -
lactamases with catalytic efficiencies for carbapenem hydrolysis, resulting in elevated
carbapenem MICs, include enzymes from classes A, B, and D. (Queenan, 2007)

Class A Carbapenemases
Class A carbapenemases are serine -lactamases and contain serine at their active site (Bush,
2010). A variety of class A carbapenemases have been described; some are chromosome
encoded (NmcA, Sme, IMI-1, SFC-1), and others are plasmid encoded (Klebsiella
pneumoniae carbapenemases [KPC], IMI-2, GES, derivatives), but all effectively hydrolyze
carbapenems and are partially inhibited by clavulanic acid (2). (Nordmann,2010)
KPC is the most frequently encountered Class A carbapenemase and, along with its variants
KPC-2 to KPC-13, which differ solely by amino-acid mutations, it has spread throughout the
USA and globally [2]. The blaKPC gene is plasmid-mediated and is transported in a Tn3-
based transposon, Tn4401, which makes it readily transferable between bacterial isolates
[25].
Following the first report of a K. pneumoniae isolate harbouring blaKPC from USA [1],
blaKPC, spread efficiently with patient mobility and disseminated across borders
internationally [26-28]. KPCs are predominantly found in Enterobacteriaceae, most
commonly in K. pneumoniae isolates, but have recently also been reported in non-
fermentative bacteria such as Pseudomonas spp. [29, 30] and Acinetobacter spp. [31]
(ECDC, 2011). Figue 1 shows worldwide distribution of Klebsiella pneumoniae
carbapenemase (KPC) producers.









Figure 1. A) Worldwide geographic distribution of Klebsiella pneumoniae carbapenemase
(KPC) producers. Gray shading indicates regions shown separately: B) distribution in the
United States; C) distribution in Europe; D) distribution in China. (Nordmann,2010)

The level of resistance to carbapenems of KPC producers may vary markedly; ertapenem is
the carbapenem that has the lowest activity (57), (Table 2). KPC producers are usually
multidrug resistant (especially to all -lactams), and therapeutic options for treating
KPCrelated infections remain limited (6) (Figure 2, panel A). Death rates attributed to
infections with KPC producers are high (>50%) (911). (Nordmann,2010)

Table 2. MIC range of carbapenems for Enterobacteriaceae that produce several types of
carbapenemases*


Class B Carbapenemases
Class B carbapenemases, also known as metallo--lactamases (MBLs), are zinc-dependent at
their active site. Originally, MBLs were described in non-fermentative bacteria such as
Pseudomonas spp. and Acinetobacter spp. [41, 42], and more recently have also been
described in Enterobacteriaceae [43, 44]. (ECDC, 2011).
Class B metallo--lactamases (MBLs) are mostly of the Verona integronencoded metallo--
lactamase (VIM) and IMP types The first acquired MBL, IMP-1, was reported in Serratia
marcescens in Japan in 1991 (13). Since then, MBLs have been described worldwide (2,12)
(Figure 3). Endemicity of VIM- and IMP-type enzymes has been reported in Greece, Taiwan,
and Japan (2,12), although outbreaks and single reports of VIM and IMP producers have been
reported in many other countries (Figure 3). These enzymes hydrolyze all -lactams except
aztreonam (12).Their activity is inhibited by EDTA but not by clavulanic acid (12). Most
MBL producers are hospital acquired and multidrug-resistant K.pneumoniae (2,12).
Resistance levels to carbapenems of MBL producers may vary (Table 1). Death rates
associated with MBL producers range from 18% to 67% (14). (Nordmann,2010).
In 2009, a novel MBL, the New Delhi MBL (NDM), was described [23, 24]. NDM was first
recognized in a K. Pneumoniae isolate from a Swedish patient who had received medical care
in India [24] and was soon recognized as an emerging mechanism of resistance in multiple
species of Enterobacteriaceae in the United Kingdom [23]. Many of the early cases in the
United Kingdom were associated with receipt of medical care in India or Pakistan [23, 25].
(Gupta et al 2011)
Kumarasamy et al (2010) found that among a convenience sample of Enterobacteriaceae
obtained from patients in India, between 31% and 55% of CRE isolates were NDM-producers
[25]. Many of the NDM-producing isolates from India were from patients with community-
onset infections.










Figure 2. Worldwide geographic distribution of Verona integronencoded metallo--
lactamase (VIM) and IMP enterobacterial producers. (Nordmann,2010).