Multidrug-resistant Acinetobacter baumannii infections: looming threat in the Indian clinical setting

ABSTRACT

Introduction

The recent increase in multidrug-resistant strains of A. baumannii has increased the incidences of ventilator-associated pneumoniae, catheter-associated urinary tract infections, and central line-associated blood stream infections, together increasing hospital stay, treatment cost, and mortality. Resistance genes blaOXA and blaNDM are dominant in India. Carbapenem-resistant A. baumannii (CRAB) International clone-2 (IC-2) are rising in India. High dependency on carbapenems and last-resort combination of tigecycline and polymyxins have aggravated outcomes. Despite nursing barriers, ward closure, environmental disinfections etc for detecting and controlling transmission, MDR isolates and CRAB nosocomial outbreaks continue. Treatment cost overruns by AMR adversely affect 80% of Indians without insurance cover.

Area covered

This narrative review will cover epidemiology, resistance pattern, genetic diversity, device-related infection, cost, and mortality due to multidrug-resistant and CRAB in India. A comprehensive literature search in PubMed and Google Scholar using appropriate keywords at different time points yielded relevant articles.

Expert opinion

It is challenging to enforce policies to control MDR A. baumannii in India. Government and hospitals should enforce stringent infection control measures, surveillance, and antimicrobial stewardship to prevent further spread and emergence of more virulent and resistant strains. Knowledge on antibiotic resistance mechanisms can help design novel antibiotics that can evade, resistance.

KEYWORDS:

• Prevalence
• multidrug-resistantAcinetobacter baumannii
• carbapenem-resistantAcinetobacter baumannii
• molecular characterization
• β-lactamases
• biofilms
• device-associated-hospital-acquired infections
• cost
• mortality
• infection surveillance

Article highlights

• Multidrug-resistant A. baumannii infections are increasing across Indian healthcare settings.

• Carbapenem-resistant A. baumannii (CRAB) are of grave significance to public health world-wide because of their association with high treatment costs, morbidity, and mortality.

• CRAB strains show resistance toward last-resort antibiotics such as tigecyclines and polymyxins.

• Studies from India have shown considerable diversity in antimicrobial resistance genes related to β-lactamases, expression of efflux proteins, persistence on surfaces, and extensive biofilm production in multiple strains.

• The infection control measures in India are sluggish, thereby increasing device-related infections in ICU’s and other hospital settings.

• Antimicrobial stewardship programs must be intensified to avoid escalation of highly resistant A. baumannii infections, potentially taking us closer to the post-antibiotic era.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Author contributions

All authors have substantially contributed to the conception and design of the review article and interpreting the relevant literature, and have been involved in writing the review article or revised it for intellectual content.

Abbreviations

• WHO = World Health Organization

• CDC = Centers for Disease Control and Prevention

• A. b complex = Acinetobacter baumannii complex

• CRAB = Carbapenem-resistant Acinetobacter baumannii

• MDR = Multidrug-resistant

• AMR = Antimicrobial resistance

• USA = United States of America

• DA-HAI = Device-associated-hospital-acquired infection

• VAP = Ventilator-associated pneumonia

• CLABSI = Central line-associated bloodstream infection

• CAUTI = Catheter-associated urinary tract infection

• AMRSN = Antimicrobial Resistance Surveillance & Research Network

• ICMR = Indian Council of Medical Research

• INICC = International Nosocomial Infection Control Consortium

• HAI = Hospital-acquired infections

• ICU = Intensive care units

• BSI = Blood stream infections

• UTI = Urinary tract infections

• AGs = Aminoglycosides

• FQs = Fluoroquinolones

• GCs = Generation cephalosporins

• OmpA = Outer membrane protein-A

• MBL = Metallo-β-lactamase

• NDM = New Delhi metallo-β-lactamase

• IC2 = International clone 2

• OXA = Oxacillinase

• XDR = Extensive drug-resistant

• MOSER = Multicenter Observational Study to Evaluate Epidemiology and Resistance

• COVID-19 = Coronavirus disease 2019

• ESBLs = Extended spectrum beta-lactamases

• KPC = Klebsiella pneumoniae carbapenamases

• blaVIM = blaVerona imipenemase metallo-β-lactamase

• blaIMP = blaImipenemase IMP metallo-β-lactamase

• blaTEM = blaTemoniera metallo-β-lactamase

• blaSHV = blasulphydryl variable metallo-β-lactamase

• blaOXA = blaOxacillin-Hydrolyzing β-lactamase

• bfmR gene = biofilmR gene

• USD = United States dollar

• AMSP = Antimicrobial stewardship program

• HICPAC = Healthcare Infection Control Practices Advisory Committee

• EARS-Net = European Antimicrobial Resistance Surveillance System Network

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This paper was not funded.