This study was designed to investigate the infection rate of nosocomial Acinetobacter spp. in Khalifa hospital, Ajman. A retrospective study was carried out from 2005 to 2008. Bacteriological cultures were used to isolate the organisms by the DADE BEHRING Microscan® to identify the organisms and their antibiotic sensitivity.

1. Noon Gaweish
MLT

3.  What are nosocomial infections?
◦ Nosocomial infections are a result of
treatment in a hospital or a healthcare
service unit, but secondary to the patient’s
original condition.
◦ Usually first appears 48 hours or more
after hospital admission or within 30 days
after discharge.

4.  Most nosocomial infections that
occur are those of which the
micro-organisms are multi-drug
resistant.
 The most recent micro-organism
that has emerged as a multi-drug
resistant organism is
Acinetobacter spp.

5.  Aim of study:
◦ To explore the infection rate of
Acinetobacter isolates, some
epidemiological data, as well as,
antibiotic sensitivity Khalifa
hospital, Ajman.

6.  Characteristics:
◦ Acinetobacter spp. are aerobic
gram negative bacilli or
coccobacilli.
◦ They are oxidase negative,
catalase positive, strictly non-
motile saprophytes.

8.  Acinetobacter has many species in which few are considered clinically
important:
 1.Acinetobacter baumannii
2.Acinetobacter baylyi
3.Acinetobacter bouvetii
4.Acinetobacter calcoaceticus
5.Acinetobacter gerneri
6.Acinetobacter grimontii
7.Acinetobacter haemolyticus
8.Acinetobacter johnsonii
9. Acinetobacter junii
10.Acinetobacter lwoffii
11.Acinetobacter parvus
12.Acinetobacter radioresistens
13.Acinetobacter schindleri
14.Acinetobacter tandoii
15.Acinetobacter tjernbergiae
16.Acinetobacter towneri
17.Acinetobacter ursingii
 While there are many species of Acinetobacter and
all can cause human disease, A.baumannii accounts
for 80% of reported infections.

9.  Pathophysiology:
◦ Acinetobacter spp. are non-
pathogenic in nature but tend to
cause oppurtunistic infections in
patients who are immuno-
compromised or have stayed in the
hospital environment for a long
duration.

10. ◦ Acinetobacter spp. have many
virulence factors, some of which
are :
 1. Polysaccharide capsule
 2. Fimbriae
 3. Enzymic activities
 4. Iron acquisition
 5. Lipopolysaccharide (LPS)
 6. Slime production

11.  Clinical diseases:
◦ Acinetobacter spp. cause a variety of
diseases that are mainly involved in
organs or organ systems.
◦ Its colonization or infection sites usually
involve organ systems with a high fluid
content.

13. ◦ Aside from causing nosocomial
infections, Acinetobacter spp are al
involved in community-acquired
infections.
◦ The severity of such infections
depends on the site of infection and
degree of patient’s immune
competence related to underlying
disease.

14.  Epidemiology:
◦ They are non-fastidious saprophytes,
therefore they are widely distributed in
nature.
◦ Acinetobacter calcoaceticus’s habitat is
soil whereas Acinetobacter baumannii has
no natural habitat other than man.
◦ In general, Acinetobacter spp. inhabit
areas where there’s an abundant source of
soil.

15.  They have been found to be isolated from:
◦ food (hospital food)
◦ Ventilator equipments
◦ Suctioning equipments
◦ Infusion pumps
◦ Sinks
◦ Stainless steel trolleys
◦ Pillows
◦ Tap water
◦ Bed rails

17.  Lab diagnosis:
◦ Acinetobacter spp. grow rapidly on common,
relatively simple media, including nutrient
agars, trypticase soya agar and MacConkey
agar.
◦ They form gray to white colonies on blood
agar
◦ They form clear, colourless colonies typical of
a lactose negative enteric bacteria on
MacConkey agar.
◦ They are strictly aerobic and usually grow at
37C or even at higher temperatures with an
incubation period of 16-20 hours.

18. ◦ A variety of selective media have proven to
suppress the growth of other organisms to allow
the growth of Acinetobacter spp.
◦ Herellea agar is a selective media used for the
isolation and differentiation of gram positive and
Neisseria spp. from Acinetobacter spp.
◦ Leeds Acinetobacter Medium (LAM) is a
differential medium that inhibits the growth of
gram-positive organisms and other gram-
negative organism to allow the specific growth of
Acinetobacter spp.

19. Acinetobacter baumannii
On blood agar

20. ◦ Biochemically, Acinetobacter spp. do not ferment
carbohydrates nor convert nitrates to nitrites.
◦ They are oxidase negative.
◦ Acinetobacter has many species with a distinct
DNA hybridization group where on group
oxidizes glucose and the other is considered
non-glucose utilizing.
◦ Acinetobacter baumannii is non-hemolytic and
glucose utilizing.
◦ Acinetobacter Iwoffii is non-hemolytic and non-
glucose utilizing.
◦ Actinetobacter hemolyticus has beta-hemolysis
on blood agar.

21. ◦ Further testing includes:
 High fingerprinting with AFLP
 PCR-RFLP
 PCR

22.  Multi-drug resistance:
◦ An organism is considered resistant when
its growth in vitro is not inhibited by an
antimicrobial agent that has been
considered to eradicate the organism in
vivo.
◦ Being multi-drug resistant, the organism
would be resistant to at least three classes
of antibiotics.

23.  Causes of resistance:
◦ Administration of sub therapeutic doses of
antimicrobial therapy
◦ Drug overuse
◦ Abbreviated or interrupted courses of
treatment
◦ Poor penetration by the antimicrobial
agent.

24. ◦ Acinetobacter spp. are resistant to
broad-spectrum cephalosporins, 4-
quinolones, and to some extent the
carbapenems.
◦ This resistance could be due to the
inappropriate therapy that can lead
to Acinetobacter genes with
resistant characteristics.

25.  Treatment:
◦ Since Acinetobacter is a multi-drug
resistant organism, therapeutic
options for the infections it causes
are restricted.
◦ Carbapenems are recognized as the
gold-standard treatment.

26.  A number of 228 samples were
analyzed.
 Samples were collected from different
inpatients at different hospital sites
 The age of the patients ranged from
22 years to 95 years.
 They were hospitalized in Khalifa
hospital, Ajman between 2005 and
2008.

27.  Bacteriological cultures were obtained by
inoculating each sample into plate of Blood
agars (anaerobic and aerobic), MacConkey
agars, Chocolate agars, and cystine-lactose-
electrolyte-deficient agar (CLED).
 Plates were incubated at 37C for 24-48
hours.
 Grown organisms were counted, and in the
case of urine, the standard loop technique
was used.

28.  TheDADE BEHRING Microscan® is
used to identify the type of
bacteria
◦ And also, used for antibiotic
sensitivity.
 Confirmatorytests such as
oxidase was done.

29.  24 Acinetobacter positive cases were
determined from a total of 228 samples.
Acinetobacter
(10.5%)
Other nosocomial
infections (89.5%)

30.  These results comes in agreement with the
results reported by Katsaragakis ét al in
Greece which were 12.6% (52/411)
 Whereas a study in India reported by K.
Prashanth and S. Badrinath showed results of
41.8% (n=18).
 These results conclude that the
environmental conditions in Khalifa hospital
and Greece’s surgical unit are better than in
India.

31.  The rate of males infected was 62.5% and the
rate of females was 37.5%.
70
60
50
40
30
Males (62.5%)
20 Females (37.5%)
10
0
Acinetobacter
Infections

32.  Other studies conducted in Greece and France
showed a percentage of 51.9% and 68%
respectively.
 This concludes that men are more prone to
Acinetobacter spp infections due to their
exposure to outdoor activities.
 Also, during summer periods, men tend to
profuse more sweat which can be considered
as a risk factor to Acinetobacter infections.

33.  The table shows that 29.2% of the patient’s
age ranged from 61-70 years.
Acinetobacter Postive Cases
Age Group No. %
<20 0 0
21-30 6 25
31-40 0 0
41-50 2 8.3
51-60 1 4.2
61-70 7 29.2
71-80 4 16.7
>80 4 16.7

34.  Elderly patients who are hospitalized in the
hospital for long duration tend to exhibit
lower immunity.
 On the other hand, there were no cases of
Acinetobacter infection in the neonatal ICU
which comes in disagreement with a study
conducted in Brazil where 11 neonates out
of 22 had the infection.

35.  95.8% of the Acinetobacter spp. were
Acinetobacter baumannii.
100
80
60 A. baumannii
(95.8%)
40
A. Iwoffii
20 (4.2%)
0
Acinetobacter sp.

36.  Theseresults correlate with a
study conducted in India where A.
baumannii was the main
organism that caused
Acinetobacter infection.

37.  Infections were highest in the male wards of
the hospital with an infection rate of 50%.
50
40
PW+NICU (0%)
30 MW (50%)
Maternity (4.2%
20 FW (25%)
ICU (16.7%)
10 Other (4.2%)
0
Acinetobacter so. Infections

38.  These results come in disagreement with
studies conducted in France, Greece and India
where the organism was isolated from tertiary
care unit, surgical ICU and surgical ICU
respectively.
 Very little care may be provided in the male
ward of Khalifa hospital, Ajman
 Although there was 0% of Acinetobacter
infection in the NICU which concludes that
there is extra care in that site.

40.  Antibiotic sensitivity testing showed that
Acinetobacter spp. had a 95% resistance to
Cefazolin and Nitrofurontoin 90% resistance
to Ampicillin 10mg.
 Acinetobacter spp. exhibited 94.1%
susceptibility to Tobramycin and 82.6 %
sensitivity to Imipenem.

41. Specimens with
Acinetobacter sp
infection
Sample
No. %
Urine 9 37.5
Pus 4 16.7
Bed sore 4 16.7
Sputum 2 8.3
Ear swab 1 4.2
HVS 1 4.2
Tracheal 1 4.2
secretions
Peritoneal 1 4.2
Nasal 1 4.2
secretions

42.  The rate of isolated Acinetobacter spp.
infection was 37.5% in urine
specimens.
 This result could be due to the
inappropriate health care measures
they take in Khalifa hospital, Ajman.

43.  Acinetobacter spp. are organisms that
are non-pathogenic in nature.
 They are ubiquitous, non-fastidious
organisms therefore their outbreak
can be uncontrollable and fatal.

44.  To avoid Acinetobacter nosocomial infection
outbreaks in the hospital, certain health and
safety measures should be considered:
◦ Frequent hand-washing and gloves wearing.
◦ Use of face masks
◦ Surface sanitation.
◦ The use of aprons.
◦ Careful use of antibiotics or antimicrobial agents.
◦ Segregation of infection patients in private rooms.

45.  If such infections occurred in the
hospital, Tobramycin and Imipenem
are the drugs of choice.
 In addition, with appropriate nursing,
careful care for patients, and
providing a hygienic hospital
environment in the wards, catheter-
related infections can be prevented.

46.  http://en.wikipedia.org/wiki/Acinetobacter
 World journal of surgery,Daniel Villers et al 1998
 Epidimiological investigation of nosocomial Acinetobacter infections using arbitrarily primed
PCR and pulse firled gel electrophoresis, Prashanth K, Badrinath S 2006 & Kerr KG et al 2006
 An outbreak of Acinetobacter baumannii septicemia in neonatal intensive care unit of a
university hospital in brazil, Denise von dolinger de Brito ét al.
 http://books.google.co.uk/books?id=rawJaC1LoqEC&pg=PA34&lpg=PA34&dq=taxonomy+of+
acinetobacter+iwoffii&source=bl&ots=0NaMBXOnKP&sig=W5MvZj6nX_PGu7risigh_bbWraA&hl
=en&ei=MQ_vSZSzEKO7jAfV39QX&sa=X&oi=book_result&ct=result&resnum=9#PPA48,M1
 mackie and McCartney , Practical medical microbiology, Edited by J>G Collee/A.G. Fraser
 Essentials of diagnostic microbiology , Lisa Anne Shimeld
 http://www.cdc.gov/ncidod/dhqp/ar_acinetobacter.html
 http://deploymenthealthlibrary.fhp.osd.mil/products/Acinetobacter%20(1).pdf
 http://www.pubmedcentral.nih.gov/pagerender.fcgi?artid=264065&pageindex=4#page
 http://www.jmpiasi.ro/2004/12(3-4)/5.pdf
 http://www.horizonpress.com/acineto
 Bailey and Scott's - Diagnostic microbiology twelfth edition - Betty A. Forbes, Daniel F. Sahm,
Alice S. Weiddfeld

47.  http://books.google.co.uk/books?id=w40IEJtzNScC&pg=PA36&lpg=PA36&dq=Acinetobacter+serology+tests&s
ource=bl&ots=Smz3CkOw7M&sig=almSTM8mYXwZnskbyWWHoGhM9jw&hl=en&ei=As72SdT2GJDLjAf53c3DDA&
sa=X&oi=book_result&ct=result&resnum=4#PPA37,M1
 Mim's medical microbiology by Richard v Goering, Hazel m Dockrell, Mark Zuckerman, Derek wakelin, ivan m
Roitt, Cedroc Mims, Peter L Chiodini $th Edition
 http://en.wikipedia.org/wiki/Nosocomial_infection
 http://books.google.co.uk/books?id=Xbr0DGpJQ00C&pg=PA149&lpg=PA149&dq=enzymic+activities+in+Acin
etobacter&source=bl&ots=7KrrNh9Jyk&sig=rAjCA23ueOJcVh1-
MR5CH7On2fo&hl=en&ei=2jcESouXFZTMjAeH1uDdBA&sa=X&oi=book_result&ct=result&resnum=2
 http://books.google.co.uk/books?id=Eyc4sX6yWcoC&pg=PA71&lpg=PA71&dq=Acinetobacter+epidemiology&s
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 http://www.medscape.com/viewarticle/557767_3

 http://books.google.co.uk/books?id=mydBYyWOXYcC&pg=PA117&dq=antibiotics+in+Acinetobacter
 http://books.google.co.uk/books?id=Eyc4sX6yWcoC&pg=PA8&dq=Acinetobacter+resistance+to+drugs
 http://books.google.co.uk/books?id=NIhl1lClkVQC&pg=PA141&dq=Acinetobacter+resistance+to+drugs#PPA1
30,M1
 INTRO = http://jac.oxfordjournals.org/cgi/content/full/58/3/697
 http://resources.metapress.com/pdf-preview.axd?code=h4620k325u70472g&size=largest
 http://www.absoluteastronomy.com/topics/Acinetobacter
 http://www.thefreelibrary.com/Multidrug-resistant+Acinetobacter+extremity+infections+in+soldiers-
a0135117617

48.  I would like to start off by praising his All Mighty
Allah for providing me with the strength and faith
during my study. I would like to give my warm
thanks and endless appreciation to Dr. Moslih El
Moslih for his undivided attention and guidance
through this project. My dear thanks to Dr. Reem
head of Microbiology lab in Khalifa hospital,
Ajman for her patience and concern. I thank my
three best friends Mahra, Eman and Diana for
believing in me and supporting me all through
this project. Last but not least, I thank my
parents and family endlessly for making me a
better person and showering me with faith
through every step I take.

49. Questions ?
Thank you