Acinetobacter baumannii: The Emergence of

a Dangerous Multidrug-Resistant Pathogen

From MicrobeWiki, the student-edited microbiology resource

This is a curated page. Report corrections to Microbewiki.

By: Kerri-Lynn Conrad

Figure 1. A colored SEM depiction of Acinetobacter baumannii, an emerging multidrug-resistant pathogen

that causes opportunistic infections associated with high mortality rates.

Contents
[hide]

 1 Introduction

 2 Genome Structure

 3 Cell Structure

 4 Metabolism

 5 Epidemiology

 6 Pathology

 7 Multidrug-Resistance

o 7.1 Resistance to Tetracycline Antibiotics

o 7.2 Resistance to Polymixin Antibiotics

o 7.3 Resistance to Quinolone Antibiotics

 8 Implications for Hospitals

 9 Future Work

 10 References

Introduction
Figure 2. SEM depiction of a cluster of gram-negative, non-motile, rod bacteria Acinetobacter baumannii.

A. baumannii (Figure 1) is a pathogenic species of bacteria whose spread has recently gained
worldwide attention, most notably after outbreaks in United States military hospitals in Iraq and
Afghanistan. The alarming rate by which A. baumannii has attained resistance to most classes
of known antibiotics poses a great threat to our containment of the infection. A. baumannii can
rapidly modify transmembrane proteins and efflux pumps to prevent current antibiotics from
penetrating its inner membrane and executing their mechanism of action. Furthermore, the
enhanced ability of A. baumannii (Figure 2) to obtain DNA from the external environment has
allowed the species to obtain novel drug and heavy metal ion resistance genes. With
resistance documented to all known classes of antibiotics, as well as cellular mechanisms that
prevent dessication and the action of antimicrobials, the world is in great need of innovative
pharmaceuticals and antimicrobials that can eliminate this dangerous pathogen.

Genome Structure

Figure 3. The genome of Acinetobacter baumannii consists of 3,976,746 base pairs. Several
pathogenicity islands were identified in the genome through sequence homology comparisons.

The genome of Acinetobacter baumannii (Figure 3) is a singular circular chromosome,

accompanied by two plasmids, though this number can vary depending on the strain (3). The
genome contains 3,976,746 base pairs and is composed of 3830 open reading frames.
Approximately 17.2% of the open-reading frames are located within putative alien islands,
highlighting Acinetobacter baumannii’s remarkable ability to incorporate foreign DNA into its
genome (1).

Acinetobacter baumannii has several genes that permit it to pick up foreign DNA from its
environment, as well as other microbes. These genes include PilQ, ComE, and PilF,
commonly found in gram-negative bacteria, as well as closely related species Acinetobacter
baylyi. Interestingly, the genome of Acinetobacter baumannii lacks a gene for ComP, a gene
for a membrane transporter important for foreign DNA uptake in many species. Nonetheless,
the ComEA gene of A. baumannii codes for a transmembrane protein that can bind foreign
DNA in the environment and transport it to the internal environment of the cell where it can be
incorporated into the genome. One study has suggested that the ComEA gene or possibly
even the type IV pilus of A. baumannii allow it to effectively obtain foreign DNA from the
environment, thus eliminating the need for the ComP gene found in many other species (1).

Closely tied to A. baumanniii’s ability to obtain foreign DNA for incorporation into its own
genome are the putative alien islands (pAs) that permit the pathogenicity of A. baumanniii,
distinguishing it from other Acinetobacter species. pAs obtained from the environment or from
other species can possess a variety of functions. Nevertheless, many of the pAs that remain
preserved in the A. baumannii genome are responsible for pathogenic and virulence factors,
and are deemed PAIs. Of the approximately 28 pAs in the A. baumannii genome, 12 share
significant sequence identity with virulence genes in other species of bacteria. The largest of
these PAIs is a 133,740 base pair island containing several transposons, integrases, and eight
genes with significant sequence homology to Legionella/Coxiella Type IV virulence/secretion
apparatus (1). Seven of the twelve PAIs contain genes that encode proteins or efflux pumps
that confer drug resistance to A. baumanniii, although many strains of A. baumanniidevelop
additional drug resistance genes through the evolutionary pressures of treatment with
pharmaceuticals (1).

In addition to the virulence-conferring genes of the A. baumannii PAIs, the pAs obtained by
the bacterium from the outside environment include genes for heavy metal resistance, iron
metabolism, quorum sensing capabilities, lipid metabolism, amino acid uptake, and genes for
the breakdown of xenobiotics (1).

Of paramount importance to the pathogenic potential of A. baumannii are the plethora of

antibiotic resistance genes contained within its genome. The AYE strain of A. baumannii has a
86,190 base pair PAI inserted into its genome that contains 45 of its 52 drug resistance genes
(2). Similarly, a more recent isolate, the ATCC17978 strain of A. baumannii contains a 13,277
base pair PAI that contains 74 drug resistance genes, 32 efflux pumps, 11 genes related to
drug/metabolite transporters (DMTs), as well as 26 genes encoding resistance to a variety of
heavy metals, including copper, cadmium, zinc, and arsenic (1). The drug resistance genes on
the PAI of this strain confer resistance to several classes of antibiotics, including β -lactams,
aminoglycosides, fluoroquinolones, chloramphenicol, tetracycline, and rifampin (2). Genomic
comparisons of the AYE and ATCC17978 A. baumannii strains suggest that the ATCC17978
strain has disposed of some of the drug resistance genes observed in the AYE strain in order
to evolve a potent drug resistance cassette observed in its genomically inserted PAI (1). It is
clear from these genomic analyses that the ability to obtain foreign DNA from environmental
sources has proven immensely important in the development of A. baumannii pathogenesis. It
is likely that this pathogen will continue to optimize its virulent potential through the attainment,
integration, and use of foreign genes.

Cell Structure

Figure 4. Acinetobacter baumannii membrane transporter PilQ allows initial entry of foreign DNA into the
cell. Foreign DNA is then bound by protein ComE and is directed to cytoplasmic membrane transporter
ComA.

A. baumannii is a gram-negative, non-motile, rod-shaped bacterium. Like other species

of Acinetobacter, A. baumannii contains a cell envelope with multiple layers, including an outer
membrane and inner cytoplasmic membrane separated by a layer of periplasmic space (4).

Unique to A. baumannii is the small amount of porins in the cell membrane. In bacterial cells,
porins allow for the transport of various molecules across the lipid membrane. Various cellular
functions and consequences have been attributed to the presence of porins in the membrane,
some helpful and others detrimental to subsistence. In some cases, porins can permit cells to
adhere to other bacterial cells (such as in the formation of biofilms). Nonetheless, porins can
allow the entry of antibiotic and other antimicrobial compounds across the cell membrane and
into the cytoplasm, where they disrupt normal enzymatic processes or destroy cellular
structures and organelles (5). The decreased porin expression observed in A. baumannii has
been viewed as another mechanism by which this pathogen sustains resistance to antibiotics
and antimicrobial agents, by simply preventing these compounds from entering the cell. For
example, A. baumannii has been able to become resistant to imipenem and carbapenem
antibiotics by eliminating several porins, including porin CarO, as well as another porin that
seems to share significant sequence homology with the OprD porin found in other gram
negative bacteria (6,7).

In addition to porins, scattered in the membrane of A. baumannii are efflux pumps that allow
for the removal of organic compounds, as well as antibiotic or antimicrobial agents that could
prove detrimental to the cell. There are several classes of efflux pumps, however, the majority
of drug efflux pumps found in A. baumannii belong to either the Major Facilitator Superfamily
(MFS) or the Resistance-Nodulation-Division (RND) family. These efflux pumps operate by
proton motive force expulsion (5).

Also found in the cell membrane of A. baumannii are protein channels and transporters
involved in the uptake of foreign DNA (Figure 4). Located in the outer membrane is PilQ,
which allows initial entry of foreign DNA. The DNA is then bound by ComE, and is transported
through the periplasmic space by PilE, or the type IV pilus to the ComA transmembrane
protein located in the inner membrane. Transport through ComA allows the DNA to enter the
cytoplasm of A. baumannii. Once inside the cell, this foreign DNA is either degraded,
integrated into the genome, or exists as a plasmid (1).

Of particular interest with regard to the cellular structure of A. baumannii is the bacteria’s outer
membrane protein A (OmpA). OmpA has been associated with the ability of A. baumannii to
form biofilms on both biological surfaces such as the human skin, as well as abiotic
environments such as catheters and shunts (8). Furthermore, OmpA is believed to be a major
component of the mechanism by which A. baumannii invades epithelial cells. OmpA allows A.
baumannii to adhere and invade epithelial cells by a zipper-like mechanism that involves the
motion of both microtubules and microfilaments (9).

Metabolism
A. baumannii are aerobic, non-fermentative, catalase-positive and oxidase-negative bacteria
(10). Like other A. baumannii species, they are unable to reduce nitrate to nitrite. They obtain
nitrogen from ammonium and nitrate salts. They are able to use various organic compounds
for metabolism and energy production, including sugars, fatty acids, some amino acids,
unbranched hydrocarbon chains, and some aromatic compounds (including aromatic amino
acids). The use of sugars as a carbon source for metabolic pathways by A. baumannii is
restricted to D-glucose, D-ribose, D-xylose, and L-arabinose (4).

D-glucose is metabolized by A. baumannii through the Etner-Doudoroff pathway. Pentoses

used by A. baumannii in metabolism are degraded by an aldose dehydrogenase. The oxidized
pentoic acids are then converted to α-ketoglutarate through several steps involving
dehydration and dehydrogenation mechanisms (4).

The tri-carboxylic acid cycle in A. baumannii is similar to cycles observed in other

proteobacteria. Several of the enzymes involved in TCA cycle steps have been purified
from A. baumannii. The bacterium’s citrate synthase is composed of four identical subunits. A.
baumannii’s aconitase has been shown to form glyoxylate from a citrate substrate. In addition
to these enzymes, two NADP linked isocitrate dehydrogenases have been isolated, and are
induced by glyoxylate or pyruvate. Finally, the α-ketoglutarate dehydrogenase complex of A.
baumannii functions as it does in the TCA cycle of other organisms, with ATP exhibiting an
inhibitory effect on the action of the complex, whereas ADP or AMP increase its activity and
appropriately lower the Km of the enzyme (4).

A. baumannii can degrade aromatic compounds through the β-ketoadipate pathway, involving
β-ketoadipate enol-lactone hydrolase and β-ketoadipate succinyl -CoA transferase as the
primary metabolizing enzymes. Through this pathway, aromatic compounds are ultimately
converted to succinic acid and acetyl-CoA (4).

A. baumannii uses the cytochrome system in its electron transport pathways, demonstrated by
complete inhibition of NADH oxidase activity when the cells were treated with cyanide.
Cytochrome a1, cytochrome a2, cytochrome b1, cytochrome c, as well as flavin have been
shown to play a role in the electron transport pathways and cellular respiration of A.
baumannii (4).

In nucleic acid metabolism, A. baumannii must use uracil as pyrimidine in both RNA and DNA
synthesis. Because A. baumannii lacks the thymine phosphorylase and thymidine kinase
enzymes, it cannot incorporate thymine into DNA molecules (4).

Epidemiology

Figure 5. Several regions around the world are attempting to deal with outbreaks of Acinetobacter
baumannii infection. Although Acinetobacter baumannii has been a problem in hospitals for many years,
the pathogen started to receive attention after the rise in infections among soldiers serving in Iraq and
Afghanistan.

A. baumannii causes approximately 2% to 10% of gram-negative bacterial infections observed

in the United States and Europe (Figure 5)(2). Most infections are observed in health care
settings, such as hospitals and nursing homes. Cases of A. baumannii infection have
increased dramatically in the United States between 2002 and 2007 (12). These infections
often involve immune-compromised patients. Major risk factors for A. baumannii infection
include invasive procedures, such as those that involve mechanical ventilation devices,
catheters, or shunts, open wounds, immune system impairment, long-term hospitalization, as
well as the use of antibiotic and antimicrobial agents, to which A. baumannii can gain rapid
resistance (11).

Non-specific nutritional requirements and resistance to desiccation permit A. baumannii to

grow in various environments, and therefore initial contact with the pathogen preceding
infection can be made in a variety of ways. A. baumannii is a natural inhabitant of the human
skin flora. Human skin to skin contact has been suggested as a possible means of
transmission of A. baumannii, especially in clinical settings (for example, transmission from a
physician to an immune compromised patient without proper aseptic technique). However,
further research is needed to confirm this route of transmission (11). Other studies have
shown the ability of A. baumannii to colonize food including some raw fruits and vegetables,
as well as some species of arthropods (11, 16). As a result of the food colonization studies, it
has been suggested that another means of transmission may be through hospital food, as in
some intensive care units digestive tract colonization accounts for 41% of A. baumannii cases
(15).

The primary means of transmission is hypothesized to be the result of A.

baumannii colonization on abiotic surfaces, such as plastic catheters and mechanical
ventilators. Particularly high rates of transmission and infection are observed in hospital
intensive care units, as would be expected with the highly compromised conditions patients
would attain in order to warrant admission into the ICU (11, 13). In one study conducted in
Spain, more than 90% of A. baumannii infections were acquired through hospitalization, while
only 4% of infections were obtained from settings outside the hospital. Of the A.
baumannii cases investigated, 39% were respiratory infections, 24% were abscess infections,
and 23% were urinary tract infections. A. baumannii infection of the bloodstream was
observed in only 3% of case studies (14). Another study conducted over a ten year period in
the New England region suggested there may be seasonality to A. baumannii infection, with
most infections occurring in the July through October period. Most of the A.
baumannii infections during this period resulted in pneumonia or bloodstream infection (17).

Few studies have been performed on the mortality rates associated with A.
baumannii infection. One study performed in a hospital intensive care unit suggested that A.
baumannii infection resulted in a 7.8% increase in mortality among these patients. However,
the statistical relevance of these findings has been challenged (11, 18). In a separate study, A.
baumannii infection was shown to have no relevant effect on patient mortality rate.
However, A. baumannii infection was shown to prolong a patient’s hospital stay by 4.5 days
(19).

A. baumannii infection has been an epidemiological concern in hospitals for many years.
Additionally, A. baumannii was the bacterium most isolated from open wounds during the
Vietnam War. However, it wasn’t until the outbreaks of A. baumannii infection among soldiers
serving in Iraq and Afghanistan that the pathogen garnered public attention. Between January
2002 and August 2004, A. baumannii was isolated from the blood of 102 soldiers being
treated in military health care facilities. All of the soldiers had served in either the Afghanistan
or Iraq regions, and it is believed that the majority of the cases were obtained through infection
of open wounds (11).

Pathology
Figure 6. Acinetobacter baumannii can be found in the natural microbial flora of the human skin.
However, some pathogenic strains can infect the human respiratory tract, open wounds, or the
bloodstream. Acinetobacter baumannii's resistance to many antibiotics and diverse metabolism allows it
to subsist in various environments.

Although the exact molecular mechanism by which A. baumannii gains entry into host cells
has yet to be elucidated, many theories suggest the use of outer membrane proteins. As
stated previously, it is believed that OmpA, the most abundant cell membrane protein of A.
baumannii, allows the bacteria enter epithelial cells by means of a zipper-like mechanism ( a
form of receptor-mediated entry). In this mechanism, OmpA interacts with host cell membrane
receptors. After OmpA binds to the receptor, the A. baumannii cell is surrounded and enclosed
by the host cell membrane by means of cytoskeletal rearrangement involving the
rearrangement of actin and components of the cellular membrane (9). Outer membrane
protein 38 (Omp38) has also been suggested as another protein involved in the pathogenesis
of A. baumannii. In a recent study, Omp38 was purified from A. baumannii and localized to the
mitochondrial membrane of host epithelial cells. Omp38 also induced apoptosis of epithelial
cells as a result mitochondrial disintegration upon Omp38 localization with the mitochondrial
membrane. The results observed with purified Omp38 were replicated when the cells were
infected with standard A. baumannii cells. This study promotes the idea that Omp38
contributes to the pathogenesis of A. baumannii by disintegrating the mitochondrial
membrane, causing the release of pro-apoptotic molecules, eventually leading to host cell
death (20).
A. baumannii can infect all organs, however infections are most often found in organs that
have high fluid content, such as the lungs and associated respiratory structures, the bladder
and other urinary tract structures, and the peritoneal fluid of the abdominal cavity (Figure 6)
(11). The risk of infection increases dramatically when medical devices such as ventilators,
endotracheal intubators, and catheters are inserted into these bodily tracts (21).

The most dangerous pathological consequences of A. baumannii result when the microbe
infects the respiratory tract. Infection of the respiratory tract often results in a severe case of
pneumonia for the patient. Symptoms of these A. baumannii- induced pneumonia cases are
similar to those of other respiratory infections, including high fever or hypothermia, rigors,
change in the color of septum, chest pain, and shortness of breath (21). Mortality rate from A.
baumannii-induced pneumonia can range from 40-64% if the bacteria can be isolated from the
blood or pleural effusions during the time of illness (21). Treating these cases of pneumonia
has proven difficult for health care practitioners, as A. baumannii strains have gained
resistance to most classes of antibiotics since the 1970’s. Nonetheless, a recent study found
that imipenem antibiotics proved most effective in treating A. baumannii associated
pneumonia. However, because imipenem resistance is increasing within A. baumannii strains,
it has been found that intravenous administration of colistin is an effective alternative, although
not preferred because of the compound’s nephrotoxic effect (22).

Multidrug-Resistance

Figure 7. In a study conducted in four community hospitals on Acinetobacter baumannii infections in

patients over the age of 60, the pathogen gained resistance to all 8 antibiotic classes tested in only five
years.

A. baumannii’s role as a dangerous emerging pathogen is most directly associated with its
ability to quickly develop resistance to antibiotic and antimicrobial compounds (Figure 7).
There are several mechanisms by which A. baumannii has been able to develop resistance to
most classes of antibiotics. By reducing porin expression, increasing expression of certain
transmembrane efflux pumps, and acquiring foreign DNA from the environment, including
plasmids with a multitude of antibiotic resistance genes, enable A. baumannii to survive even
the most aggressive pharmaceutical treatments (23, 24). Mechanisms of resistance to
selected classes of antibiotics are detailed below.

Resistance to Tetracycline Antibiotics

A. baumannii have two transmembrane efflux pumps, TetA and TetB that allow for the efflux of
tetracycline and closely related minocycline antibiotics (25). A. baumannii also has the TetM
gene, whose protein product protects the bacterium’s ribosome from the action of tetracycline
antibiotics (26).

Resistance to Polymixin Antibiotics

Colistin, described above in the treatment of A. baumannii associated pneumonia is an
example of a Polymixin antibiotic. This class of antibiotics is the last means of defense
against A. baumannii infection, because of the damaging effect these compounds can have on
the kidneys. Recent studies have detailed cases of A. baumannii infection that did not respond
to treatment with colistin or Polymixin B (27, 28). It is hypothesized that A. baumannii has
become resistant to these antibiotics by modifying certain liposaccharide compounds in the
cell membrane, preventing binding of the antibiotic to the cell membrane, as observed in
Polymixin resistant strains of E. coli and Salmonella (29). Polymixin resistant A.
baumannii strains show the great need for the development of new antibiotic agents.

Resistance to Quinolone Antibiotics

A. baumannii has developed resistance to quinolone antibiotics by modifying its DNA gyrase
enzyme, lowering the affinity of the antibiotic for the DNA-gyrase complex (30).

Implications for Hospitals

Figure 8. Acinetobacter baumannii infections among immune compromised patients is a major problem in
hospitals. Susceptible patients often obtain the infection from hospital equipment, staff members, or other
patients.

Several epidemiological studies have confirmed that most cases of A. baumannii are obtained
in hospitals or other healthcare facilities (14). Additionally, most cases are associated with
long-term hospital stays or admittance to intensive care units. Without proper sterilization
techniques, A. baumannii can colonize medical equipment and supplies. The identification
of A. baumannii as an inhabitant of the skin flora suggests the possibility that this pathogen
can be transmitted to patients from physical contact with their healthcare providers (11). The
conditions that would warrant patient hospitalization are closely associated with immune
impairment. The high concentrations of immune compromised patients, coupled with ideal
growing surfaces (catheters, shunts, ventilators), and the physical contact required for
adequate care make hospitals ideal environments for the spread of A. baumannii. The
resistance of this microbe to most classes of antibiotics has made outbreaks of A.
baumannii within hospitals even more frightening for patients and healthcare providers alike.

To avoid an epidemic of A. baumannii in hospital settings, appropriate measures must be

taken to ensure that the medical devices that are inserted into the biological tracts of patients
are sterilized effectively (Figure 8). Furthermore, practitioners must ensure that they are using
sterile technique with all procedures. One study found that one hospital’s attempt to reduce
person to person transmission by re-training staff members in proper glove changing and
disposal, as well as a review of general sterile practice resulted in a decrease in cases of A.
baumannii resulting from person to person transmission (31).
Future Work

It is with great urgency that novel pharmaceuticals be developed to combat multidrug-resistant

strains of A. baumannii. However, this is no easy task. In 2010, 1040 new FDA approved
drugs were screened for effectiveness in treating A. baumannii infections. Only 5 of these
drugs (Thimerosal, Doxycycline, Polymyxin B sulphate, Rifaximin and Tyrothricin) showed
antibacterial activity when A. baumannii was treated (32). Although these agents did
eliminate A. baumannii infection, these drugs are all classic antibiotics; the initial aim of the
study was to identify antimicrobial agents that A. baumannii would have a more difficult time
developing resistance to. Nonetheless, none of the FDA-approved antimicrobial compounds
tested had an effect on A. baumannii (32). Further research into the development of novel
antimicrobial agents needs to continue in order to control outbreaks of A. baumannii.

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Edited by Kerri-Lynn Conrad, student of Joan Slonczewski for BIOL 238 Microbiology,
2011, Kenyon College.

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