Positivity of ExoU Gene of Type III Secretion System and Fluoroquinolone Resistance of Psedomonas aeruginosa from Sputum of Nosocomial Pneumonia Patients in Sanglah Hospital, Bali

I Wayan Agus Gede Manik Saputra, Ni Made Mertaniasih, Ni Nengah Dwi Fatmawati

= http://dx.doi.org/10.20473/fmi.v54i2.8863
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Pseudomonas aeruginosa is one of the Gram-negative rods bacteria that frequently cause nosocomial pneumonia. One of the main virulent effector proteins on Type III secretion system (TTSS) of P. aeruginosa is Exoenzyme U ( ExoU). ExoU works as a phospholipase A2 activity and exhibits lung tissue injury effect in pneumonia. As an antibiotic that has activity against P. aeruginosa, fluoroquinolone resistance has increased as many as three fold since the last decade. Infections caused by P. aeruginosa that are fluoroquinolone resistant and positive for ExoU gene show worse clinical outcome. The aim of this study was to determine the positivity of ExoU gene TTSS and fluoroquinolone resistance of P. aeruginosa that isolated from sputum of nosocomial pneumonia patients in Sanglah Hospital, Bali. P. aeruginosa isolated from sputum of patient that diagnosed as nosocomial pneumonia, isolates had been identified phenotypically by Vitek2 Compact system (bioMérieux, Inc., Marcy-l'Etoile - France), and then continued by genotypic detection by PCR. The susceptibility testing of P. aeruginosa isolates to Ciprofloxacin were conducted by Vitek2 Compact, whereas ExoU genes were detected by PCR. Fifty-three P. aeruginosa isolates were identified in this study, in which 35 isolates (66.1%) had ExoU gene and 22 isolates (41.5%) were resistant to Ciprofloxacin. Based on nosocomial pneumonia type, the highest proportion of isolates genotipically ExoU+ and phenotypically Ciprofloxacin were on VAP group accounted for 57.1% and 54.5%, respectively. Chi-square analysis showed significant correlation between Ciprofloxacin resistance and ExoU gene (p=0.001). As a conclusion, the positivity of ExoU+ isolates were more likely found in Ciprofloxacin resistant group.


Pseudomonas aeruginosa; fluoroquinolone; ExoU; nosocomial pneumonia; sputum clinical isolates

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Ajayi T, Allmond LR, Sawa T, Wiener-kronish JP (2003). Single-nucleotide-polymorphism mapping of the Pseudomonas aeruginosa type III secretion toxins for development of a diagnostic multiplex PCR. J. Clin Microbiol 41, 3526-31

Allewelt M, Coleman FT, Grout M, Priebe GP, Pier GB (2000). Acquisition of expression of the Pseudomonas aeruginosa ExoU cytotoxin leads to increased bacterial virulence in a murine model of acute pneumonia and systemic spread. Infect. and Immun 68, 3998-4004

Chen G, Zhao Q, Zhu F, Chen R, Jin Y, Liu C, Pan X, Jin S, Wu W, Cheng Z (2016). Oligoribonuclease is required for the type III secretion system and pathogenesis of Pseudomonas aeruginosa. Microbiol. Research 188, 90-96

Chen F, Chen G, Liu Y, Jin Y, Cheng Z, Liu Y, Yang L, Jin S, Wu W (2017). Pseudomonas aeruginosa oligoribonuclease contributes to tolerance to cipro-floxacin by regulating pyocin biosynthesis. Anti-mcrob. Agents Chemother. doi:10.1128/AAC.02256-16.

Cho HH, Kwon KC, Kim S, Koo SH (2014). Correlation between virulence genotype and fluoro-quinolone resistance in carbapenem-resistant Pseudo-monas aeruginosa. Ann. Lab. Med 34, 286-92

Dalhoff A (2012). Global fluoroquinolone resistance epidemiology and implictions for clinical use. Interdis. Persp. Infect. Dis 2012, 1-37

Diaz MH, Hauser AR (2010). Pseudomonas aeruginosa cytotoxin ExoU is injected into phagocytic cells during acute pneumonia. Inf. and Immun 78, 1447-56

Diaz MR, King JM, Yahr TL (2011). Intrinsic and extrinsic regulation of type III secretion gene expres-sion in Pseudomonas aeruginosa. Front. in Microbiol 2, 1-10

Diaz MH, Shaver CM, King JD, Musunuri S, Kazzaz JA, Hauser AR (2008). Pseudomonas aeruginosa induces localized immunosuppression during pneumo-nia. Infect Immun 76, 4414-21

Dorman CJ (1990). DNA supercoiling and environ-mental regulation of gene expression in pathogenic bacteria. Infect Immun 59, 745-49

Dorman CJ, Bhriain NN, Higgins, CF (1990). DNA supercoiling and environmental regulation of viru-lence gene expression in Shigella flexneri. Nat 344, 789-91

El-Solh AA, Akinnusi ME, Wiener-Kronish JP, Lynch SV, Pineda LA, Szarpa K (2008). Persistent infection with Pseudomonas aeruginosa in ventilator associated pneumonia. Am. J. Respir Crit Care Med 178, 513-19

El-Solh AA, Hattemer A, Hauser AR, Alhajhusain A, Vora H (2012). Clinical outcomes of the type III Pseudomonas aeruginosa bacteremia. Crit Care Med 40, 1157-63

Feltman H, Jain M, Peterson L, Schulert G, Khan S, Hauser AR (2001). Prevalence of type III secretion genes in clinical and environmental isolates of Pseu-domonas aeruginosa. Microbiol 147, 2659-69

Fishman JA (2013). Nosocomial pneumonia. In Tobergte DR, and Curtis S. Fishman's Pulmonary Disease and Disorders. 4th ed. United States, McGraw Hill, 2273-90

Fleiszig SMJ, Evans DJ, Do N, Vallas V, Shin S, Mostov KE (1997). Epithelial cell polarity affects susceptibility to Pseudomonas aeruginosa invasion and cytotoxicity. Infect. and Immun 65, 2861-67

Gaynes R, Edwards JR (2005). Overview of nosocomial infections caused by gram-negative bacilli. Clin. Infect. Dis 41, 848-54

Hauser AR (2009). The type III secretion system of Pseudomonas aeruginosa: infection by injection. Nat. rev. Microbiol 7, 654-65

Hancock REW (1998). Resistance mechanisms in Pseudomonas aeruginosa and other nonfermentative Gram-negative Bacteria. Clin. Inf. Dis 27, S93-9

Hsu DI, Okamoto MP, Murthy R, Wong-Beringer A (2005). Fluoroquinolone-resistant Pseudomonas aeru-ginosa: Risk factors for acquisition and impact on outcomes'. J. Antimic. Chem. 55, 535-41

Hurley BP, McCormick BA (2008). Multiple roles of phospholipase A2 during lung infection and inflam-mation. Infect. and Immun 76, 2259-72

Kollef MH, Shorr A, Tabak YP, Gupta V, Liu LZ, Johannes RS (2005). Epidemiology and outcomes of health-care-associated pneumonia: results from a large us database of culture-positive pneumonia. Chest J 128, 3854-3862

Kirschnek S, Gulbins, E (2006). Phospholipase A2 functions in Pseudomonas aeruginosa - induced apoptosis. Inf. & Immun 74, 850-60

Le Berre R, Nguyen S, Nowak E, Kipnis E, Pierre M, Quenee L, Ader F, Lancel S, Courcol R, Guery BP, Faure K (2011). Relative contribution of three main virulence factors in Pseudomonas aeruginosa pneu-monia. Crit. care med 39, 2113-20

Little JW, Mount DW (1982). The SOS regulatory system of Escherichia coli. Cells. 29, 11-22

Lomholt JA, Poulsen K, Kilian M (2001). Epidemic population structure of Pseudomonas aeruginosa: Evidence for a clone that is pathogenic to the eye and that has a distinct combination of virulence factors. Inf & Immun 69, 6284-95

Matsuda K, Tsuji H, Asahara T, Kado Y, Nomoto K (2007). Sensitive quantitative detection of commensal bacteria by rRNA-targeted reverse transcription-PCR. Appl. and Env. Microbiol 73, 32-39

Micek ST, Wunderink RG, Kollef MH, Chen C, Rello J, Chastre J, Antonelli M, Welte T, Clair B, Helmut O, Calbo E, Torres A, Menichetti F, Schramm GE, Vandana M (2015). An international multicenter retrospective study of Pseudomonas aeruginosa noso-comial pneumonia: impact of multidrug resistance. Crit. Care 19, 219

Neuhauser MM, Weinstein RA, Rydman R, Danziger LH, Karam G, Quinn JP (2003). Antibiotic resistance among gram-negative bacilli in US intensive care units: implications for fluoroquinolone use. JAMA 289, 885-88

Patel JB, Cockerill F, Bradford PA, Eliopoulos GM, Hindler JA, Jenkins SG, Lewis JS, Limbago B, Miller LA, Nicolau DP, Mair P, Swenson JM, Traczewski MM, Turnidge JD, Weinstein M, and Zimmer BL (2015). M100-S25 performance standards for anti-microbial

Roy-Burman A, Savel RH, Racine S, Swanson BL, Revadigar NS, Fujimoto J, Sawa T, Frank DW, Wiener-Kronish JP (2001). Type III protein secretion is associated with death in lower respiration and systemic Pseudomonas aeruginosa infections. J. Infect Dis 2001, 1767-74

Sawa T (2014). The molecular mechanism of acute lung injury caused by Pseudomonas aeruginosa: from bacterial pathogenesis to host response. J. Intens. Care 2, 10

Sawa T, Shimizu M, Moriyama K, Wiener-Kronish JP (2014). Association between Pseudomonas aerugino-sa type III secretion, antibiotic resistance, and clinical outcome: A review. Crit. Care 18, 668

Sato H, and Frank DW, 2004. ExoU is a potent intracellular phospholipase. Mol. Microbiol 53, 1279-90

Shaver CM, Hauser AR (2004). Relative contributions of Pseudomonas aeruginosa ExoU, ExoS, and ExoT to virulence in the lung. Infect. & Immun 72, 6969-77

Tran QT, Nawas MS, Deck J, Foley S, Nguyen K, Cerniglia CE (2011). Detection of type III secretion system virulence and mutations in gyrA and ParC genes among quinolone-resistant strain of Pseudomo-nas aeruginosa from imported shrimp. Foodborne Path. & Dis 8, 451-53

Poole K (2000). Efflux mediated resistance to fluoro-quinolone in Gram-negative bacteria. Antimic Agents & Chemoth 44, 2233-41

Tumbarello M, De Pascale G, Trecarichi EM, Spanu T, Antonicelli F, Maviglia R, Pennisi MA, Bello G, Antonelli M (2013). Clinical outcomes of Pseudomo-nas aeruginosa pneumonia in intensive care unit patients. Intens. Care Med 39, 682-92

Veesenmeyer J, Hauser A, Lisboa T, Rello J (2010). Pseudomonas aeruginosa virulence and therapy: evolving translational strategies. Crit Care Med 37, 1777-86

Vincent JL, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H (2006). Sepsis occurrence in acutely ill patients investigators. Sepsis in European intensive care units: results of the SOAP study. Crit Care Med 34, 344-53

Wolfgang MC, Kulasekara BR, Liang X, Boyd D, Wu K, Yang Q, Lory S (2003). Conservation of genome content and virulence determinants among clinical and environmental isolates of Pseudomonas aeruginosa. Natl Acad of Sci USA 100, 8484-9

Wong-Beringer A, Wiener-Kronish J, Lynch S, Flanagan J (2008). Comparison of type III secretion system virulence among fluoroquinolone-susceptible and -resistant clinical isolates of Pseudomonas aeruginosa. J. Soc. of Clin. Microbiol and Infect. Dis. CMI, 330-336

Wu W, Jin S (2005). PtrB of Pseudomonas aeruginosa suppresses the type III secretion system under the stress of DNA damage. J. of Bacteriol 187, 6058-68

Zhanel GG, Decorby M, Adam H, Mulvey MR, Mccracken M, Nichol KA, Hoban DJ (2010). Preva-lence of antimicrobial-resistant pathogens in canadian hospitals: Results of the canadian ward surveillance study (CANWARD 2008). Antimic Agent & Chemoth 54, 4684-93

Zhu H, Conibear TCR, Bandara R, Aliwarga Y, Stapleton F, Willcox MDP (2006). Type III secretion system-associated toxins, proteases, serotypes, and antibiotic resistance of Pseudomonas aeruginosa isolates associated with keratitis. Curr Eye Research 31, 297-306


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