ABSTRACT Introduction: Acinetobacter spp. is a relevant pathogen in Cuba. The Acinetobacter baumannii-calcoaceticus complex is the main cause of severe infections. It is frequently isolated in intensive care units (ICU) and exhibits high resistance to most available antibiotics, including carbapenems. Objective: To characterize the Acinetobacter isolates collected from patients admitted to Cuban hospitals. Methods: A retrospective study was conducted at the Healthcare-Associated Infections Laboratory of “Pedro Kourí” Tropical Medicine Institute. The study included 278 isolates from 21 hospitals located in 9 provinces, stored from June 2011 to July 2012 in the culture collection of the laboratory. Species identification was based on biochemical tests and the susceptibility to 18 antibiotics was determined by the Bauer-Kirby method, except for colistin, for which the E-test (epsilometric method) was used. The variables under analysis were: Acinetobacter species, type of sample, type of healthcare service, antimicrobial susceptibility, and antimicrobial multi-resistance categorization. Results: Acinetobacter baumannii-calcoaceticus complex prevailed, mainly in endotracheal fluid and blood samples. The ICU and the burn unit were the most affected healthcare services. High resistance percentages were observed to beta-lactams (76-94%), aminoglycosides (66-80%), and fluoroquinolones (60-89%). Tetracycline, doxycycline, and colistin were the most active antimicrobials. Multi-drug-resistance was observed in 73.5% of isolates, extensively-drug-resistance in 26.1%, and pan-drug-resistance in one isolate (0.4%). Conclusions: Infections by Acinetobacter spp. constitute a serious health problem in the Cuban hospitals. High resistance to available antibiotics characterizes the isolates, which evidences the need to constantly monitor antimicrobial susceptibility and to reinforce the control measures, mainly in the ICUs.

RESUMEN Introducción: Acinetobacter spp. constituye un patógeno relevante en Cuba. El complejo Acinetobacter baumannii-calcoaceticus es la principal especie causante de infecciones graves. Se aísla frecuentemente en las unidades de cuidados intensivos (UCI) y exhibe una elevada resistencia a la mayoría de los antibióticos disponibles, incluidos los carbapenémicos. Objetivo: Caracterizar los aislados de Acinetobacter obtenidos de pacientes ingresados en hospitales cubanos. Métodos: Se realizó un estudio retrospectivo en el Laboratorio de Infecciones Asociadas a la Asistencia Sanitaria del Instituto de Medicina Tropical Pedro Kourí, que incluyó 278 aislados conservados durante junio de 2011 a julio de 2012, pertenecientes a la colección de cultivos del laboratorio y procedentes de 21 hospitales, distribuidos en nueve provincias. Las especies se identificaron mediante pruebas bioquímicas y se determinó la susceptibilidad a 18 antibióticos por el método de Bauer-Kirby, excepto la colistina, cuya determinación se realizó por el E-test (método epsilométrico). Las variables analizadas fueron: especie de Acinetobacter, tipo de muestra, tipo de servicio hospitalario, susceptibilidad a los antimicrobianos y categorización de la multirresistencia a los antimicrobianos. Resultados: Predominó el complejo Acinetobacter baumannii-calcoaceticus, fundamentalmente en muestras de secreción endotraqueal y sangre. Las UCI y unidades de quemados fueron los servicios hospitalarios más afectados. Se detectaron porcentajes elevados de resistencia para los betalactámicos (76-94 %), aminoglucósidos (66-80 %) y fluoroquinolonas (60-89 %). La tetraciclina, doxiciclina y colistina resultaron los antimicrobianos más activos. El 73,5 % de los aislados fueron multidrogorresistentes, el 26,1 % extremodrogorresistentes y un aislado resultó pandrogorresistente (0,4 %). Conclusiones: Las infecciones provocadas por Acinetobacter spp. constituyen un grave problema de salud en los hospitales cubanos. Los aislados se caracterizaron por una elevada resistencia a los antibióticos disponibles y revelan la necesidad del monitoreo continuo de la susceptibilidad a los antimicrobianos, además del reforzamiento de las medidas de control, principalmente en las UCI.

Abstract INTRODUCTION Urinary tract infection is the second-leading reason for consults in primary health care. Bacterial urinary tract infections are the most common, of which Escherichia coli is the main etiologic agent. Antimicrobial resistance and multidrug resistance complicate effective community treatment, especially if resistance is caused by extended-spectrum beta-lactamase production. WHO recommends that antimicrobial susceptibility be evaluated in different regions of the world at different times. Community-acquired E. coli’s susceptibility to colistin has not yet been studied in Cuba, and mcr-1 gene screening is necessary. OBJECTIVE Evaluate community-acquired uropathogenic E. coli isolates’ susceptibility to antibiotics, including colistin, and identify extended-spectrum beta-lactamase–producing bacteria. METHODS We conducted a descriptive cross-sectional study that included 281 community-acquired uropathogenic E. coli isolates (153 from the Isle of Youth Special Municipality’s Hygiene, Epidemiology, and Microbiology Center and 128 from Microbiology Laboratories of 7 institutions in Havana) from June 2016 through July 2018. We used the disk diffusion method to determine susceptibility to ampicillin, ampicillin/sulbactam, cefazolin, trimethoprim/sulfamethoxazole, ciprofloxacin, nitrofurantoin and fosfomycin. The disk elution method was used to determine susceptibility to colistin. The combined disk method was used to identify extended-spectrum beta-lactamases. Estimates were made regarding the frequency and percentages of antimicrobial susceptibility and resistance, as well as multidrug-resistance patterns. RESULTS Of the 281 isolates, 68.3% (192/281) were resistant to ampicillin, 54.8% (154/281) were resistant to ciprofloxacin, and 49.5% (139/281) were resistant to trimethoprim/sulfamethoxazole. Resistance to colistin was not detected. On the other hand, 14.2% (40/281) were susceptible to the 8 antibiotics we evaluated, 22.1% (62/281) showed resistance to only 1 antibiotic, and 63.7% (179/281) were resistant to 2 or more antibiotics. In the extended-spectrum beta-lactamase determination, 34.5% (97/281) had inhibition zones ≤14 mm with cefazolin. Of those with inhibition zones, 64.9% (63/97) were positive in the phenotype test, and 35.1% (34/97) were negative. In extended-spectrum beta-lactamase–producing bacteria, 1.6% (1/63) were resistant to fosfomycin, and 3.2% (2/63) were resistant to nitrofurantoin. The most common multidrug-resistance pattern (22.9%; 30/131) was to ampicillin/sulbactam, ampicillin, cefazolin, ciprofloxacin, and trimethoprim/sulfamethoxazole. CONCLUSIONS Uropathogenic E. coli resistance to the antibiotics most frequently used in community medical practice is quite common, and extended-spectrum beta-lactamase–producing bacteria is the mechanism for beta-lactam antibiotic resistance. Multidrug-resistance patterns include resistance to the antibiotics most used in community-acquired infections. Fosfomycin and nitrofurantoin are the most active in extended-spectrum beta-lactamase producing bacteria. All the isolates were susceptible to colistin.

Abstract INTRODUCTION Carbapenem-resistant Acinetobacter baumannii is a complex health problem, causing difficulties in clinical–therapeutic management worldwide. It is of particular concern in Latin America, the Caribbean and China, where it is an emerging health problem. Carbapenemases produced by these organisms inactivate carbapenem antibiotics. Monitoring circulating genotypes’ geographic dispersion contributes to more effective control measures. However, exhaustive studies on carbapenem-resistant A. baumannii are scarce. OBJECTIVES Study the production of carbapenemases in clinical isolates of A. baumannii resistant to carbapenem antibiotics and the geographic distribution of the sequences circulating in China, Latin America and the Caribbean. DATA ACQUISITION We followed PRISMA indications. We carried out a systematic search in Pubmed, BVS and CKNI on papers on A. baumannii and carbapenemases published during 2015–2020 in English, Spanish and Chinese, and selected 29 cross-sectional studies that met the search criteria. Studies were evaluated using JBI Critical Appraisal tools, and quantitative data were collated for meta-analysis using the Metaprop library in Stata15. DEVELOPMENT OXA-type carbapenemases were detected in all studies; among A. baumannii resistant to carbapenem antibiotics, predominant types were OXA-23, OXA-24, OXA-54 and OXA-72; metallobetalactamases were identified less frequently than OXA carbapenemases. Only one clinical isolate producer of Class A carbapenemases (KPC) was identified in Colombia. In total, 41 sequence types were identified; in Latin America and the Caribbean the most common types were: ST79, ST25, ST1 and ST15; in China, the sequences ST195, ST208, ST191, ST368 and ST369 were the most prevalent. ST2 was found in both regions. CONCLUSIONS The most prevalent carbapenemases and sequence types vary by region, indicating different ancestral strains. Microbiological surveillance, antibiotic use optimization, adequate infection treatment and timely control strategies are essential for carbapenem-resistant A. baumannii prevention and control in geographies such as Latin America, the Caribbean and China where such resistance is an emerging health problem.

ABSTRACT Introduction: Extraintestinal Escherichia coli is one of the main pathogens causing infections associated to health care, with a high impact on health, due to its morbidity and mortality. Objective: Describe the clinical behavior of extraintestinal E. coli in Cuban hospitals, and determine antimicrobial resistance and betalactamase production. Methods: A descriptive cross-sectional study was conducted at the Microbiology National Reference Laboratory of Pedro Kourí Tropical Medicine Institute from May 2017 to June 2018. The study included 119 Escherichia coli isolates causing extraintestinal infections in 30 hospitals from various geographic areas in the country. Identification was based on the API 20E system, and determination of in vitro susceptibility to 16 antimicrobials on the automated system VITEK-2 and the disk diffusion method, except for colistin, for which the disk elution method was used. Phenotypical detection was also performed of AmpC extended-spectrum betalactamase and metallobetalactamase. Results: The most common disorders caused by extraintestinal E. coli were surgical wound infection (23.5%), bloodstream infection (20.7%), respiratory infections (17.6%), skin infections (16.8%) and urinary tract infection (12.6%). A predominance was found of resistance to betalactams, which ranged between 61.3% y 89.1%, whereas 79.8% and 80.5% of the isolates were resistant to trimethoprim / sulfamethoxazole and tetracycline, respectively. Amikacin, fosfomycin, colistin and carbapenemics displayed greater in vitro activity. 43.7% produced extended spectrum betalactamases, 7.6% plasmid AmpC and 0.8% metallobetalactamase. Conclusions: The low sensitivity of extraintestinal E. coli isolates to first-line antimicrobials and the detection of a metallobetalactamase producing isolate are evidence of the need to maintain continuous surveillance of this pathogen, for which the treatment options are ever more restricted.

RESUMEN Introducción: Escherichia coli extraintestinal constituye uno de los principales patógenos causantes de infecciones asociadas a la asistencia sanitaria con un alto impacto en la salud por su morbilidad y mortalidad. Objetivo: Describir el comportamiento clínico de E. coli extraintestinal en hospitales cubanos, así como determinar la resistencia antimicrobiana y la producción de betalactamasas. Métodos: Se realizó un estudio descriptivo de corte transversal, durante el período de mayo 2017 a junio 2018, en el Laboratorio Nacional de Referencia de Microbiología del Instituto de Medicina Tropical “Pedro Kourí" que incluyó 119 aislados de Escherichia coli causantes de infecciones extraintestinales en 30 hospitales de diferentes áreas geográficas del país. Se llevó a cabo la identificación mediante el sistema API 20E y la determinación de la susceptibilidad in vitro a 16 antimicrobianos por el sistema automatizado VITEK-2 y el método de difusión por disco, excepto para la colistina que se empleó el método de elución de disco. Se realizó, además, la detección fenotípica de betalactamasa de espectro extendido, de tipo AmpC y metalobetalactamasa. Resultados: E. coli extraintestinal causó con mayor frecuencia infección de herida quirúrgica (23,5 %), infección del torrente sanguíneo (20,7 %), infecciones respiratorias (17,6 %), infecciones de piel (16,8 %) e infección del tracto urinario (12,6 %). Predominó la resistencia a betalactámicos que osciló entre 61,3 % y 89,1 %, mientras que 79,8 % y 80,5 % de los aislados fueron resistentes a trimetoprim/sulfametoxazol y tetraciclina, respectivamente. La amikacina, la fosfomicina, la colistina y los carbapenémicos mostraron mayor actividad in vitro. El 43,7 % produjo betalactamasas de espectro extendido, 7,6 % AmpC plasmídica y 0,8 % metalobetalactamasa. Conclusiones: La escasa sensibilidad en los aislados de E. coli extraintestinal a los antimicrobianos de primera línea, así como la detección de un aislado productor de metalobetalactamasa evidencia la necesidad de mantener un monitoreo continuo de este patógeno para el cual las alternativas de tratamiento son cada vez más restringidas.

Introduction: the Klebsiella genus gives rise to many hospital outbreaks due to multi-drug-resistant strains on different continents and leads to increased morbidity and mortality. Objectives: to identify the Klebsiella species causing infections in Cuban hospitals, to determine the origin of isolates per service, their antimicrobial susceptibility and, to determine the production and type of extended-spectrum ß-lactamases (ESBLs) and the susceptibility of these isolations to several antimicrobials of therapeutic interest. Methods: a descriptive study was conducted on 448 Klebsiella spp. Isolates that were received in the national reference microbiology laboratory of "Pedro Kouri" Institute of Tropical Medicine from 40 hospitals located in 12 Cuban provinces during the 2010-2012 period. Species identification was based on conventional biochemical tests and mass spectrometry technique called MS MALDI-TOF. The susceptibility to 15 antimicrobials and the extended spectrum ß-lactamase production were determined by the E-test method and by the combined disks method, respectively, according to recommendations of the Institute of Clinical and Laboratory Standards. The polymerase chain reaction made it possible the detection of BlaESBL genes as indicated in the previously described protocol. Results: Klebsiella pneumoniae (95.4 %) was the prevalent species, followed by K. oxytoca (4.1%), and K. ozaenae (0.5 %). The isolates were mainly from the intensive care units (26.3 %), surgery (22 %), and neonatology (13%) services. The highest resistance rate was observed for cephalosporins (48-52 %), trimethoprim-sulfamethoxazole (49 %), gentamicin (43 %), nalidixic acid (38 %), and tetracycline (34 %). Fifty-two percent of the isolates were extended spectrum ß-lactamase producers, with CTX-M (82 %) and TEM (70 %) enzymes prevailing. Conclusions: This study shows the clinical impact of Klebsiella spp in Cuban hospitals, which is highly resistant to different antimicrobials. The production of extended spectrum ß-lactamases provides a significant resistance mechanism in Klebsiella in which carbapenems, piperacillin-tazobactam, cholistin and tigecycline play an important therapeutic role.

Introducción: el género Klebsiella causa brotes hospitalarios, por cepas multidrogorresistentes en diferentes continentes y conlleva a un aumento en la morbimortalidad. Objetivos: identificar las especies de Klebsiella causantes de infecciones en hospitales cubanos, determinar la procedencia de los aislamientos según el servicio, y la susceptibilidad antimicrobiana, conocer la prevalencia de aislamientos productores de ß-lactamasas de espectro extendido (BLEE), y tipos, así como la susceptibilidad de los mismos a diferentes antimicrobianos de interés terapéutico. Métodos: se realizó un estudio descriptivo en 448 aislamientos de Klebsiella spp. recibidos en el Laboratorio Nacional de Referencia de Microbiología del IPK (LRNM/IPK) procedentes de 40 hospitales de 12 provincias del país durante el período de 2010 a 2012. La identificación de las especies se realizó mediante pruebas bioquímicas convencionales y por la técnica de Espectrometría de masas MS MALDI-TOF. Se determinó la susceptibilidad a 15 antimicrobianos mediante el método E-test y la producción de BLEE mediante el método de discos combinados según las recomendaciones del Instituto de Estándares Clínicos y de Laboratorio. Los genes blaESBL se determinaron mediante la reacción en cadena de la polimerasa según protocolo descrito previamente. Resultados: la especie prevalente fue Klebsiella pneumoniae (95,1 %), seguida por K. oxytoca (4,5 %) y K. ozaenae (0,4 %). Los aislamientos procedieron, principalmente, de los servicios de Unidades de Cuidados Intensivos (26,3 %), cirugía (22 %) y neonatología (13 %). La mayor resistencia se observó para las cefalosporinas (48-52 %), trimetoprim-sulfametoxazol (49 %), gentamicina (43 %), ácido nalidíxico (38 %) y tetraciclina (34 %). El 52 % de los aislamientos fueron productores de BLEE y prevaleció la enzima CTX-M (82 %) y la TEM (70 %). Conclusiones: se evidencia la repercusión clínica de Klebsiella spp. en hospitales cubanos con elevada resistencia a diferentes antimicrobianos. La producción de BLEE es un mecanismo de resistencia importante en esta bacteria en las que los carbapenémicos, la piperacilina-tazobactam, la colistina, y la tigeciclina juegan un rol terapéutico importante.

Introduction: Klebsiella pneumoniae and the Acinetobacter baumannii-calcoaceticus complex represent important nosocomial pathogens worldwide. The patients admitted to the neonatology and the intensive care unit services suffer infections very frequently. Objectives: to characterize clinically and microbiologically Klebsiella and Acinetobacter isolates causing infections in Cuban pediatric hospitals. Methods: a descriptive longitudinal study of 152 clinical isolates (102 Klebsiella spp and 50 Acinetobacter spp), which caused nosocomial infections in children and were sent to the national reference laboratory of microbiology in "Pedro Kouri" Institute. The study was conducted from June 2011 to September 2012. The species were identified by biochemical tests. The susceptibility to 18 antimicrobials, the production of extended spectrum ?-lactamase (ESBL) and metallo-?-lactamases were determined according to the Clinical and Laboratory Standards Institute. Results: the most frequent infections in infants and children by Acinetobacter and Klebsiella were found in blood, endotracheal secretion and skin lesions.. Klebsiella pneumoniae (96 %) and Acinetobacter baumannii-calcoaceticus complexes (90%) were the most prevalent species and were frequently isolated in intensive care, neonatology and burned patient wards. Both pathogens showed high resistance to cephalosporins with 57 % of extended-spectrum betalactamase production in Klebsiella spp. Resistance to carbapenems was only detected in Acinetobacter (61 %) with 2 % of metallobetalactamse production. Acinetobacter spp. was more susceptible to tetracyclines and cholistin where Klebsiella spp was more susceptible to ciprofloxacin. In both pathogens, a high resistance to aminoglycosides (66% -75 %) and trimethoprim-sulfamethoxazole (45 %-60 %) was observed. Conclusions: Klebsiella pneumoniae and Acinetobacter baumannii-calcoaceticus complex represent a potential threat in pediatric services with few therapeutic options. The carbapenems remain the only alternative to severe infections caused by multidrug resistant Klebsiella spp and cholistin is the only choice to treat extreme multidrug resistant Acinetobacter spp infections.

Introducción: Klebsiella pneumoniae y el complejo Acinetobacter baumannii-calcoaceticus constituyen importantes patógenos nosocomiales a nivel mundial siendo más susceptibles los pacientes ingresados en neonatología y unidades de cuidados intensivos. Objetivos: caracterizar, desde el punto de vista clínico-microbiológico los aislamientos de los géneros Klebsiella y Acinetobacter causantes de infecciones en hospitales pediátricos cubanos. Métodos: se realizó un estudio descriptivo-longitudinal durante el período de Junio 2011-Septiembre 2012 que incluyó 152 aislamientos clínicos (102 de Klebsiella spp. y 50 de Acinetobacter spp) causantes de infecciones nosocomiales en niños y que fueron remitidos al Laboratorio Nacional de Referencia de Microbiología del Instituto ‘‘Pedro Kourí". La identificación de esta especie se realizó mediante pruebas bioquímicas. Se determinó la susceptibilidad a 18 antimicrobianos, la producción de β-lactamasas de espectro extendido (BLEE) y la de metalo-β-lactamasas (MBLs) según las normas del Instituto de Estandarización de Laboratorio Clínico (CLSI, por sus siglas en inglés). Resultados: las muestras más frecuentes de recuperación de Acinetobacter y Klebsiella fueron sangre, secreción endotraqueal y lesiones de piel. Klebsiella pneumoniae (96 %) y el complejo Acinetobacter baumannii-calcoaceticus (90 %) fueron las especies más prevalentes y se aislaron con mayor frecuencia en servicios de terapias, neonatología y quemado. Ambos patógenos mostraron elevada resistencia a las cefalosporinas con 57 % de producción de BLEE para el género Klebsiella spp. La resistencia a carbapenémicos solo se detectó en Acinetobacter spp (61 %) mediada por la producción de metalo-β-lactamasas en un 2 % de los aislamientos. La mayor susceptibilidad de este género se encontró para las tetraciclinas, mientras que el género Klebsiella spp. fue más susceptible a la ciprofloxacina. En ambos se observó resistencia elevada para los aminoglucósidos (66 %-75 %) y el trimetoprim-sulfametoxazol (45 %-60 %). Conclusiones: Klebsiella pneumoniae y el Complejo Acinetobacter baumannii-calcoaceticus constituyen un peligro potencial en servicios pediátricos con escasas opciones terapéuticas quedando como únicas alternativas los carbapenémicos para las infecciones por Klebsiella spp multidrogorresistentes y la colistina para las infecciones por Acinetobacter spp con extremadrogorresistencia.