We may soon be facing the end of the "antibiotic era." The initial and seemingly unstoppable success of antibiotics, the fruit of human ingenuity, has been countered by an escalation of resistance mechanisms in bacteria. This crisis has been described as an "unwinnable war" (www.wellcome.org). The statistics compiled as a result of surveillance efforts illustrate the emergence of many genera of bacteria that are resistant to all antibiotics (57, 60). The genus Acinetobacter epitomizes this trend and deserves close attention. Acinetobacter spp. display mechanisms of resistance to all existing antibiotic classes as well as a prodigious capacity to acquire new determinants of resistance (7). The increasing recovery in the clinic of multidrug-resistant (MDR) Acinetobacter baumannii is a frightening reality (112). This review summarizes the worldwide emergence of antibiotic-resistant A. baumannii as a nosocomial pathogen and focuses on its mechanisms of resistance against selected antibiotics. It concludes with a summary of current strategies in the treatment of MDR A. baumannii and offers perspectives on the control of this global public health threat. GLOBAL EPIDEMIOLOGY A. baumannii is a nonfermentative, gram-negative, nonmotile, oxidase-negative bacillus, whose natural reservoir still remains to be determined. Nevertheless, it is found in many health care environments and is a very effective human colonizer in the hospital (www.cdc.gov). The combination of its environmental resilience and its wide range of resistance determinants renders it a successful nosocomial pathogen (137). As such, A. baumannii is emerging as a cause of numerous global outbreaks (213), displaying ever-increasing rates of resistance (Tables 1 and 2; Fig. 1). There are reports of MDR A.

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Military medical facilities treating patients injured in Iraq and Afghanistan have identified a large number of multidrug-resistant (MDR)Acinetobacter baumannii isolates. In order to anticipate the impact of these pathogens on patient care, we analyzed the antibiotic resistance genes responsible for the MDR phenotype in Acinetobacter sp. isolates collected from patients at the Walter Reed Army Medical Center (WRAMC). Susceptibility testing, PCR amplification of the genetic determinants of resistance, and clonality were determined. Seventy-five unique patient isolates were included in this study: 53% were from bloodstream infections, 89% were resistant to at least three classes of antibiotics, and 15% were resistant to all nine antibiotics tested. Thirty-seven percent of the isolates were recovered from patients nosocomially infected or colonized at the WRAMC. Sixteen unique resistance genes or gene families and four mobile genetic elements were detected. In addition, this is the first report of bla OXA-58 -like and bla PER -like genes in the U.S. MDR A. baumannii isolates with at least eight identified resistance determinants were recovered from 49 of the 75 patients. Molecular typing revealed multiple clones, with eight major clonal types being nosocomially acquired and with more than 60% of the isolates being related to three pan-European types. This report gives a "snapshot" of the complex genetic background responsible for antimicrobial resistance in Acinetobacter spp. from the WRAMC. Identifying genes associated with the MDR phenotype and defining patterns of transmission serve as a starting point for devising strategies to limit the clinical impact of these serious infections.

The gram-negative enteric bacterium Proteus mirabilis is a frequent cause of urinary tract infections in individuals with long-term indwelling catheters or with complicated urinary tracts (e.g., due to spinal cord injury or anatomic abnormality). P. mirabilis bacteriuria may lead to acute pyelonephritis, fever, and bacteremia. Most notoriously, this pathogen uses urease to catalyze the formation of kidney and bladder stones or to encrust or obstruct indwelling urinary catheters. Here we report the complete genome sequence of P. mirabilis HI4320, a representative strain cultured in our laboratory from the urine of a nursing home patient with a long-term (>30 days) indwelling urinary catheter. The genome is 4.063 Mb long and has a G؉C content of 38.88%. There is a single plasmid consisting of 36,289 nucleotides. Annotation of the genome identified 3,685 coding sequences and seven rRNA loci. Analysis of the sequence confirmed the presence of previously identified virulence determinants, as well as a contiguous 54-kb flagellar regulon and 17 types of fimbriae. Genes encoding a potential type III secretion system were identified on a low-G؉C-content genomic island containing 24 intact genes that appear to encode all components necessary to assemble a type III secretion system needle complex. In addition, the P. mirabilis HI4320 genome possesses four tandem copies of the zapE metalloprotease gene, genes encoding six putative autotransporters, an extension of the atf fimbrial operon to six genes, including an mrpJ homolog, and genes encoding at least five iron uptake mechanisms, two potential type IV secretion systems, and 16 two-component regulators.Proteus mirabilis is not a common cause of urinary tract infections (UTI) in normal hosts (65). Surveys of uncomplicated cystitis or acute pyelonephritis show that P. mirabilis causes only a few percent of cases. Even in patients with recurrent UTI, the incidence of infection by this organism is only a few percentage points higher. However, this organism infects a very high proportion of patients with complicated urinary tracts, that is, urinary tracts with functional or anatomic abnormalities or with chronic instrumentation. In these patients, not only does this bacterium cause cystitis and acute pyelonephritis (20-22, 65, 73), but the production of urinary stones, a hallmark of infection with this organism (23), further compromises the already complicated urinary tract. P. mirabilis has sporadically been reported to be a causative agent of bacteremia and nosocomial infections (59); additional evidence suggests that this species is associated with rheumatoid arthritis (62).

The Gram-negative pathogen Acinetobacter baumannii strain M2 was found to exhibit a robust surface motility on low-percentage (0.2-0.4 %) agar plates. These patterns of motility were dramatically different depending on whether Difco or Eiken agar was used. Motility was observed in many, but not all, clinical and environmental isolates. The use of drop collapse assays to demonstrate surfactant production was unsuccessful, and the role of surfactants in A. baumannii M2 motility remains unclear. Surface motility was impaired by an insertion in pilT, encoding a gene product that is often required for retraction of the type IV pilus. Motility was also dependent on quorum sensing, as a null allele in the abaI autoinducer synthase decreased motility, and the addition of exogenous N-(3-hydroxy)-dodecanoylhomoserine lactone (3-OH C 12 -HSL) restored motility to the abaI mutant. Transposon mutagenesis was used to identify additional genes required for motility and revealed loci encoding various functions: non-ribosomal synthesis of a putative lipopeptide, a sensor kinase (BfmS), a lytic transglycosylase, O-antigen biosynthesis (RmlB), an outer membrane porin (OmpA) and de novo purine biosynthesis (PurK). Two of the above genes required for motility were highly activated by quorum sensing, and may explain, in part, the requirement for quorum sensing in motility.