Enzyme Patterns and Factors Associated with Mortality among Patients with Carbapenem Resistant Acinetobacter Baumannii (CRAB) Bacteremia: Real World Evidence from a Tertiary Center in India
Parikshit S Prayag, Sampada A Patwardhan, Rasika S Joshi, Shweta P Panchakshari, Tejashree Rane, Amrita P Prayag
Citation Information :
Prayag PS, Patwardhan SA, Joshi RS, Panchakshari SP, Rane T, Prayag AP. Enzyme Patterns and Factors Associated with Mortality among Patients with Carbapenem Resistant Acinetobacter Baumannii (CRAB) Bacteremia: Real World Evidence from a Tertiary Center in India. Indian J Crit Care Med 2023; 27 (9):663-668.
Introduction: In the Indian setting, antimicrobial resistance in A. baumannii is a considerable problem, especially in intensive care units (ICUs). Due to the limited data, clinicians are left with very few choices except polymyxins for treating serious infections caused by A. baumannii. There is sparse data regarding the local mechanisms of resistance. Given the current therapeutic challenges, it is critical to know the local enzymatic patterns and antibiograms.
Materials and methods: A retrospective analysis of 50 episodes of bacteremia caused by CRAB. We analyzed the enzyme patterns and the susceptibility rates to various antibiotics.
Results: The resistance rates for amikacin, tigecycline, minocycline, and fluoroquinolones were 88, 82, 50, and 88% respectively. OXA-23 was the most commonly isolated enzyme (86% of the isolates produced OXA-23) followed by OXA-51 and NDM. The overall mortality was high (58%). On univariate analysis, pneumonia, and higher Pitt's bacteremia score were significantly associated with mortality (p = 0.04 and p = 0.001 respectively). Of the total patients who received combination therapy, a majority (58%) received polymyxin plus meropenem. Combination therapy using polymyxins as a backbone was not associated with reduced mortality (p = 0.1).
Conclusion:A. baumannii is associated with significant morbidity and mortality, as shown in our study. The rates of resistance for aminoglycosides were very high, and minocycline showed better susceptibility rates in comparison with tigecycline. In our study, OXA-23 and NDM remained the most important enzymes. The routine use of the combination of polymyxin and meropenem may not offer a significant advantage over monotherapy.
Hsu LY, Apisarnthanarak A, Khan E, Suwantarat N, Ghafur A, Tambyah PA. Carbapenem-resistant Acinetobacter baumannii and Enterobacteriaceae in South and SouthEast Asia. Clin Microbiol Rev 2017;30(1):1–22. DOI: 10.1128/CMR.masthead.30-1.
Annual report (January 2021 to December 2021) of the Antimicrobial Resistance Research & Surveillance Network (AMRSN), Division of epidemiology and communicable diseases, Indian Council of Medical Research 2021;6.
Vijayakumar S, Mathur P, Kapil A, Das BK, Ray P, Gautam V, et al. Molecular characterization & epidemiology of carbapenem-resistant Acinetobacter Baumannii collected across India. Indian J Med Res 2019;149(2):240–246. DOI: 10.4103/ijmr.IJMR_2085_17.
Park SY, Choo JW, Kwon SH, Yu SN, Lee EJ, Kim TH, et al. Risk factors for mortality in patients with Acinetobacter baumannii bacteremia. Infect Che mother 2013;45(3):325–330. DOI: 10.3947/ic.2013.45.3.325.
Bosch X, Rovira M, Sitges M, Domènech A, Ortiz-Pérez JT, de Caralt TM, et al. Enalapril and carvedilol for preventing chemotherapy-induced left ventricular systolic dysfunction in patients with malignant hemopathies: the OVERCOME trial (preventiOn of left Ventricular dysfunction with Enalapril and caRvedilol in patients submitted to intensive ChemOtherapy for the treatment of Malignant hEmopathies). J Am Coll Cardiol 2013;61(23):2355–2362. DOI: 10.1016/j.jacc.2013.02.072.
Yang Y, Xu Q, Li T, Fu Y, Shi Y, Lan P, et al. OXA-23 is a prevalent mechanism contributing to sulbactam resistance in diverse Acinetobacter baumannii clinical strains. Antimicrob Agents Chemother 2019;63(1):e01676–e016718.
Upadhyay S, Khyriem AB, Bhattacharya P, Bhattacharjee A, Joshi SR. High-level aminoglycoside resistance in Acinetobacter baumannii recovered from intensive care unit patients in Northeastern India. Indian J Med Microbiol 2018;36(1):43–48. DOI: 10.4103/ijmm.IJMM_17_225.
Clark JA, Burgess DS. Plazomicin: A new aminoglycoside in the fight against antimicrobial resistance. Ther Adv Infect Dis 202;7:2049936120952604. DOI: 10.1177/2049936120952604.
Seifert H, Stefanik D, Sutcliffe JA, Higgins PG. In-vitro activity of the novel fluorocycline eravacycline against carbapenem non-susceptible Acinetobacter baumannii. Int J Antimicrob Agents 2018;51(1):62–64. DOI: 10.1016/j.ijantimicag.2017.06.022.
Behera B, Mohanty S, Sahu S, Praharaj AK. In vitro Activity of fosfomycin against Multidrug-resistant urinary and nonurinary Gram-negative isolates. Indian J Crit Care Med 2018;22(7):533–536. DOI: 10.4103/ijccm.IJCCM_67_18.
Durand-Réville TF, Guler S, Comita-Prevoir J, Chen B, Bifulco N, Huynh H, et al. ETX2514 is a broad-spectrum β-lactamase inhibitor for the treatment of drug-resistant Gram-negative bacteria including Acinetobacter baumannii. Nature microbiology 2017;2(9):1-0.
Chandran S, Manokaran Y, Vijayakumar S, Shankar BA, Bakthavatchalam YD, Dwarakanathan HT, et al. Enhanced bacterial killing with a combination of sulbactam/minocycline against dual carbapenemase-producing Acinetobacter baumannii. Eur J Clin Microbiol Infect Dis 2023;42(5):645–651. DOI: 10.1007/s10096-023-04583-z.
Liu CP, Shih SC, Wang NY, Wu AY, Sun FJ, Chow SF, et al. Risk factors of mortality in patients with carbapenem-resistant Acinetobacter baumannii bacteremia. J Microbiol Immunol Infect 2016;49(6):934–940. DOI: 10.1016/j.jmii.2014.10.006.
Paul M, Daikos GL, Durante-Mangoni E, Yahav D, Carmeli Y, Benattar YD, et al. Colistin alone versus colistin plus meropenem for treatment of severe infections caused by carbapenem-resistant Gram-negative bacteria: An open-label, randomised controlled trial. Lancet Infect Dis 2018;18(4):391–400. DOI: 10.1016/S1473-3099(18)30099-9.
Makris D, Petinaki E, Tsolaki V, Manoulakas E, Mantzarlis K, Apostolopoulou O, et al. Colistin versus colistin combined with ampicillin-sulbactam for multiresistant Acinetobacter baumannii ventilator-associated pneumonia treatment: An open-label prospective study. Indian J Crit Care Med 2018;22(2):67–77. DOI: 10.4103/ijccm.IJCCM_302_17.
Kengkla K, Kongpakwattana K, Saokaew S, Apisarnthanarak A, Chaiyakunapruk N. Comparative efficacy and safety of treatment options for MDR and XDR Acinetobacter baumannii infections: A systematic review and network meta-analysis. J Antimicrob Chemother 2018;73(1):22–32. DOI: 10.1093/jac/dkx368.