1. Acinetobacter was found in soil and discovered in 1911 by M.W Beijerinch German Microbiologist ,is a Gram negative bacteria belonging to the wider class ofGammaproteobacteria The name of acinteobacter is coming from Greek words [ + + ()] which meaning (non motile rod ) It naturally inhabits water and soil, and has also been isolated from foods and arthropods . It has allots of species and causing allots of diseases for human and Animals . commonly found on the skin of healthy humans as normal floraa , also AC infections is broad and includes infection associated with tropical environments, wars and natural disasters, and hospital outbreaks in temperate climates . Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013.

2. Acinetobacter baumanni , Since it was isolated and discovered in 1970s, the spread of multidrug-resistant (MDR) Acinetobacter strains among critically ill, hospitalized patients, and subsequent epidemics, have become an increasing cause of concern world wide . Reports of community-acquired Acinetobacter infections have also increased over the past decade in some parts of the world like south Asia and Australia . Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 3. Microbiology Grame negative Coccobacilli Strictely aerobic non motile (my exhibit twitching motility ). Nitrate and Oxidase negative Catalase positive and non fermenting Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 4. Description and Morphology Rod shaped Encapsulated (generally). Frequently arranged in pairs . Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 5. Epidemiological view :- Global pockets of Acinetobacter baumannii infections Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 6. Acinetobacter in Wars Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 7. Since Operation of Iraqi War began in 2003, more than 700 US soldiers have been infected or colonized with Acinetobacter baumannii. A significant number of additional cases have been found in the Canadian and British armed forces, and among wounded Iraqi people it was called Iragi Bacter , also it was the most common gram negative bacillus contaminated wounds during the Vietnam war as well . Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 8. Mode of Transmission Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 9. PATHOGENESIS Factors contribute to acinetobacter virulence 1- organism can survive under dry and neutral condition for long period can survive for months, making Nosocomial transmission extremely difficult to control. 2-one third of strains produce polysaccharide capsule that works with cell wall liposccharide to prevent complement activation also delay phagocytosis . 3-colonization in the lung is facilitated by ability to adhere to bronchial epithelial surface by fimbriae and also subsequent formation of biofilms . Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 10. Major infections due to Acinetobacter Hospital acquired Pneumonia Ventilator-associated pneumonia Urinary tract Infection Bloodstream infection meningitis Skin/wound / Bone infections Endocarditis Peritonitis in Peritoneal Dialysis Pt s . Ventriculitis Endophthamitis and Periorbital Cellulitis. Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 11. Hospital Acquired Pneumonia occurs predominantly in intensive care unit (ICU) patients who require mechanical ventilation. occur in previously colonized patients . associated with mortality rates of 35 to 70 % . Patients are usually elderly and immuncompromised patients . Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 12. Community Acquired pneumonia It is uncommon form of AC infection ,most commonly occur in southeast Asia and Australia . It sever , rapid fulminant infection , characterized by Bacteremia , ARDS , DIC , Respiratory failure and death . Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 13. Bloodstream infection AC infection accounts for 1.5 to 2.4 % of nosocomial bloodstream infections . The most frequent sources of Acinetobacter bacteremia are vascular catheters and the respiratory tract . Less common primary sites include wounds and the urinary tract Risk factors for Ac infection include ICU , mechanical ventilation, prior surgery, prior use of broad-spectrum antibiotics, immunosuppression, trauma, burns, malignancy, central venous catheters, invasive procedures, and prolonged hospital stay Septic shock develops in up to one-third of patients with AC bacteremia . mortality ranges from 20 to 60 % . Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 14. Acinetobacter Meningitis Most cases are hospital-acquired Often associated with neurosurgical procedures like Craniotomy Risk factors: Heavy use of antibiotics in the neurosurgical ICUs . CSF leak Intracranial Hemorrhage Mortality ranges from 20 to 30 % . Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 15. Skin and Wounds Infections Acinetobacter may contaminate surgical and traumatic wounds, leading to severe soft tissue infection that can also progress to osteomyelitis. surgical wound infections with Acinetobacter are frequently related to the presence of prosthetic material and usually require extensive debridement. Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 16. Urinary Tract Infection urinary tract can become colonized readily with AC , particularly in the setting of indwelling urinary catheters the incidence of infection is low , In a review of 5000 urinary tract infections in medical intensive care units in the United States, 1.6 % was due to Acinetobacter, 95 % of these infections were associated with urinary catheters . Community-acquired urinary tract infection can occur but is rare . In the absence of other signs or symptoms of infection, isolation of Acinetobacter may be attributed to colonization. Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 17. Diagnosis It is very important to distinguish between colonization and infection . As an example, Acinetobacter isolated from sputum of a ventilated patient is more likely to represent colonization than infection in the absence of fever, leukocytosis, increased respiratory secretions or oxygen consumption , need for additional respiratory support, or a new abnormality on chest imaging. Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 18. Documented mechanisms of resistance in Acinetobacter baumannii -Lactamase The most prevalent mechanism of -lactam resistance in A. baumannii is enzymatic degradation by -lactamases AmpC B-lactamases it is chromosomally encoded enzyme produce by AC b . Cephalosporinases enzymes produce by AC b , make it resistant to broad spectrum Cephalosporin's Cefepime and carbapenems appear to be stable in response to these enzymes . Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 19. Carbapenems Carbapenemase is one of B-lactamses that can produce by AC, has ability to hydroloza Cabapenems and other Penciilins and Cephalosporins . Carbapenemases are members of the molecular class A, B, and D beta-lactamases. Class A and D enzymes have a serine-based hydrolytic mechanism class D carbapenemases consist of OXA-type beta-lactamases frequently detected in Acinetobacter baumannii The first identified OXA-type enzyme with carbapenem-hydrolyzing activity was isolated from A. baumannii strain in 1985 in Edinburgh, Scotland . Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 20. Others Aminoglycosides There is a genes coding for aminoglycoside-modifying enzymes within class 1 integrons is highly prevalent in multidrug-resistant AC. This emerging resistance mechanism impairs aminoglycoside binding to its target site and confers high-level resistance to all clinically useful aminoglycosides, including gentamicin, tobramycin, and amikacin Also there is documented resistant to Quinolones , Tetracycline's . Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 21. Tratment of MDR Acinetobacter There is view list of Antibiotics that can be use in treatment of MDR AC infection Colistin Tigecycline Polymyxin B. Carbapenems Amikacin. Rifampin. Minocycline . Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 22. General approach for Antibiotics use Empiric antibiotic therapy for Acinetobacter, before results of antimicrobial susceptibility testing are available, should be selected based on local susceptibility data . In general, it should consist of a broad spectrum cephalosporin, a combinationbeta-lactam/beta-lactamase inhibitor , or a carbapenem. For empiric therapy of patients with Acinetobacter infection in a location where resistance to the chosen antibiotic is high, suggest is to adde second agent like An antipseudomonal fluoroquinolone, an aminoglycoside, or colistin are second agent option . Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 23. Once results of antimicrobial susceptibility testing are available, a regimen can be chosen from among the active agents. Agent with the narrowest spectrum of activity is strongly recommended. For patients with infections due to extensively-drug resistant Acinetobacter, therapeutic options are generally limited to polymyxins (colistin, or polymyxin E, and polymyxin B) and tigecycline. For such patients, suggest is to using a second agent in addition to polymyxins or tigecycline. Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 24. Pneumonia Inhaled colistin may be used in selected patients. especially patients with severe pneumonia with MDR Acinetobacter that , since intravenous colistin yields low lung concentration. Among three studies evaluating inhaled colistin as adjunctive therapy to i.v Antibiotics for ventilator-associated pneumonia with drug-resistant gram- negative bacilli, predominantly A. baumannii, the pooled response rate was 80 %. Although in one series of 17 patients with Acinetobacter pneumonia, clinical improvement with inhaled colistin without active systemic antibiotics was observed in 57 % of cases . Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 25. it is favor to use inhaled colistin in such patients only with concomitant administration of i.v antibiotics. * The main adverse effect of inhaled colistin is bronchoconstriction. Inhaled polymyxin B is an alternative agent; there are reports of successful treatment of multidrug- resistant respiratory infections with inhaled and systemic polymyxin B. Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 26. Bloodstream infection Because tigecycline rapidly enters tissues following administration, resulting in low serum levels, it may not be an appropriate choice for extensively drug-resistant Acinetobacter bacteremia. Additionally, bloodstream infections with drug-resistant isolates are associated with particularly poor outcomes, regardless of therapy. In one study, treatment with colistin did not reduce mortality in patients with bacteremia due to multidrug-resistant Acinetobacter compared to mortality rates prior to the availability of colistin in that institution . If the bacteremia is associated with an intravascular catheter, that device should be removed . The duration of therapy is typically 10 to 14 days. Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 27. Meningitis variable CSF penetration of antibiotic agents further limits the therapeutic choices for Acinetobacter CNS infections. Additional considerations include the possible use of intrathecal antibiotics for drug-resistant isolates and the removal of CNS devices, if present. Of the first line agents, the carbapenems most reliably enter into the CSF, particularly when inflammation of the meninges is minimal . Because of the association between high dose imipenem and seizures and the limited clinical experience with doripenem, meropenem is the most appropriate choice of the carbapenems. Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. . 28. For carbapenem-resistant isolates, polymyxins have been used with some success. Meropenem dose should be 2 g every eight hours. If susceptible, ceftazidime or cefepime can also be used at meningeal doses When colistin is administered intravenously, there is moderate penetration of inflamed meninges and spinal fluid levels reach approximately 25 % of serum levels , for this reason, intrathecal or intraventricular colistin in the setting of central nervous system infections with drug-resistant Acinetobacter can be used . Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 29. Colistin can be administered intraventricularly or intrathecally, usually in conjunction with an active intravenous agent, if possible . Complications of intraventricular and intrathecal colistin include aseptic chemical meningitis . The treatment of Acinetobacter meningitis is usually at least for three weeks. The response should be assessed clinically . Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 30. Skin, soft tissue, and bone infection The initial approach to empiric and directed antimicrobial therapy of skin, soft tissue, and bone infections caused by Acinetobacter is the same as that for Acinetobacter infections in generality . debridement of affected tissue, particularly in the case of osteomyelitis, may be necessary for optimal control of the infection. The usual duration of therapy for skin and soft tissue infections is 10 to 14 days or until local signs of infection have resolved. Patients with osteomyelitis should be treated for 4 to 6 weeks following surgical debridement. Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 31. Urinary tract infection Treatment for infection should only be initiated if a positive culture is accompanied by pyuria and systemic signs or symptoms in the absence of another source of infection. Tigecycline has poor excretion in the urinary tract. Given this, along with the observed increased risk of mortality with tigecycline use , this agent should only be used when no other options are available. If present, any urinary catheter should be removed , duration of therapy is typically 10 to 14 days. Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 32. Preventing Acinetobacter Transmission Hand hygiene Use of alcohol-based hand sanitizers Contact precautions Gowns/gloves Environmental decontamination Prudent use of antibiotics Alcohol-based products containing chlorhexidine should be considered the hand hygiene agents of choice. Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 33. Message Take to Home Acinetobacter spp . can colonize almost any human body site either transiently or as normal flora. A. baumannii is an emerging opportunistic pathogen in healthcare setting as one of most important MDROs . MDR AC baumannii is associated with high mortality and being difficult to treat , especially in an immunocompromised patient Control requires good hand hygiene, barrier precautions & environmental decontamination and Staff Education . Rationale use of Antibiotics can decrease emerging of MDROs . Differentiate between colonization and infection is vital for safety of patient form unwanted SE of Antibiotics and for proper use of antibiotics . For patients with infections due to extensively-drug resistant Acinetobacter, therapeutic options are generally limited to polymyxins (colistin, or polymyxin E, and polymyxin B) and tigecycline. Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 34. Resources Center for Disease Control and Prevention http://www.cdc.gov . Infectious Diseases Society of America (IDSA) www.idsociety.org Journal of Clinical Microbiology http://jcm.asm.org/ Up to date .com www.uptodate.com www.google.com . Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013. 35. Thank You for Attending Dr.Hythum Salah H.Mohamed KAMC-IM-ID-Riyadh-December 2013.