ANTIMIROBIAL RESISTANCE

With the current widespread overuse of antibiotics, we are forcing bacteria to genetically change to survive. This
antibiotic Darwinism has led to numerous highly resistant strains of bacteria that now threaten
to create a Post-Antibiotic Era.

Several factors are associated with emergence of resistance among organisms.(more detail in Fig. 33-1. )

1. Widespread, inappropriate use of broad-spectrum antibiotics, especially in daycare centers and ICUs.
(e.g. treatment of viral illnesses with antibiotics).
2) Use of antibiotics in animal husbandry and fisheries to prevent infection and increase animal growth.
3) Excessive use of antimicrobial preparations in soaps and cleaning solutions in non-healthcare
facilities.
4) Increased numbers of immunocompromised patients requiring prolonged courses of antibiotics.
5) Prolonged survival of debilitated patients.
6) International travel promoting the movement of resistant bacteria (e.g. Mycobacterium tuberculosis).
7) Poverty leading to inadequate antibiotic usage because of the increasing expense of adequate antimicrobial
therapy.

MECHANISM OF BACTERIAL GENETIC VARIABILITY

Genetic variability is essential in order for microbial evolution to occur. There are 3 basic
mechanisms of genetic variability leading to resistance among bacteria.
1) Point mutations may occur in a nucleotide base pair, which is referred to as
microevolutionary
change. These mutations may alter the target site of an antimicrobial agent, interfering
with its activity.
2) Macroevolutionary change results in rearrangements of large segments of DNA as a
single event. These rearrangements may include inversions, duplications, insertions,
deletions or transposition of large sequences of DNA from one location of a bacterial
chromosome to another.
3) Acquisition of foreign DNA carried by plasmids, bacteriophages or transposable genetic
elements These foreign elements give the organism the ability to adapt to antimicrobial
activity.

MECHANISMS OF ANTIMICROBIAL RESISTANCE

This genetic variability can be further separated into more specific resistance
mechanisms. These mechanisms
of resistance are as follows:
1) Enzymatic inhibition of antibiotics leading to antibiotic inactivity.
2) Alterations of bacterial membranes to prevent entry of antibiotics into bacteria.
3) Promotion of antibiotic efflux which actively pumps the antibiotics out of the bacteria.
4) Alterations of bacterial protein targets which make these targets unrecognizable to
antibiotics.
Specific examples include:
• Alterations of ribosomal target sites
•Alterations of cell wall precursor targets
• Alterations of critical enzymes
5) Bypass of antibiotic inhibition allowing bacteria to find alternate pathways to survive
when one
pathway is blocked by an antibiotic.
Enzymatic Inhibition
-most common
-Eg., Staphylococcus aureus' resistance to beta-lactam antibiotics (e.g. penicillin) is
due mainly to the production of beta-lactamases, enzymes that inactivate these antibiotics
by splitting the beta-lactam ring.  add beta-lactamase inh. Such as clavulanic acid
-Enterococci and gram-negative bacilli resistance to aminoglycosides is also commonly
due to modifying enzymes that are coded by genes on plasmids or the chromosome.

Alterations of Bacterial Membranes

Outer Membrane Permeability:
-Many penicillins have activity against gram-+ bacteria but not against gram-ve bacteria
because gram-negative bacteria have a lipid bilayer that acts as a barrier to the
penetration
of antibiotics into the cell.
-Only when these penicillins are able to get inside the cell are they able to work.
-Passage of hydrophilic (water-soluble) antibiotics through this outer membrane is
facilitated by the presence of porins, proteins that form water-filled diffusion channels
through which antibiotics can travel.
-Mutations resulting in the loss of specific porins can occur and may lead to increased
resistance to penicillins.
-Pseudomonas aeruginosa resistance to imipenem is a perfect example of this mechanism.
Inner Membrane Permeability:
-Aminoglycosides require active electron transport ("proton motive force") which means
that a positively charged aminoglycoside molecule is "pulled" across cytoplasmic
membranes of the internal negatively charged cell.
-The energy generation or the proton motive force that is required for substrate transport
into the cell may be altered in mutants resistant to aminoglycosides.
-Staphylococcus resistant to aminoglycosides is an example

Promotion of Antibiotic Efflux

- primary mechanism for decreased accumulation of tetracycline is due mainly to active
efflux of the antibiotic
across the cell membrane.
-Decreased uptake of tetracycline from outside the cell also accounts for decreased
accumulation of tetracycline inside resistant cells.
-Tetracycline resistance genes are generally inducible by subtherapeutic concentrations of
tetracycline which emphasizes the importance of adequate dosing.
-Pseudomonas aeruginosa and Staphylococcus aureus are bugs that display this type of
resistance to tetracycline.

Alterations of Bacterial Protein Targets

a)Alterations of Ribosomal Target Sites: Resistance to a wide variety of antiribosomal

agents, including
tetracyclines, macrolides, clindamycin, and the amino glycosides, may result from
alteration of ribosomal
binding sites.
-Failure of the antibiotic to bind to its target sites on the ribosome disrupts its ability to
inhibit
protein synthesis and cell growth.
-Ribosomal resistance to streptomycin NB but fairly uncommon with gentamicin,
tobramycin and amikacin.
-Ribosomal resistance can also be associated with decreased intracellular accumulation of
the drug.
-Examples include Staphylococcus aureus and Enterococci species reistance to
macrolides.

b) Alterations of Cell Wall Precursor Targets:

-Resistance of Enterococci to vancomycin classified as A, B, or C based on levels of
resistance.
-Class A resistance is considered high level resistance and is associated with the vanA
gene. The vanA gene is carried on a plasmid and encodes an inducible protein that is
involved in cell wall synthesis in E. Coli. These proteins are responsible for synthesizing
peptidoglycan precursors that have a different amino acid sequence from the normal cell
wall peptidoglycan. This newly modified peptidoglycan binds glycopeptide antibiotics with
reduced affinity, thus leading to resistance to vancomycin and teicoplanin.
-Classes B (vanB) and C (vanC) resistance phenotypes are considered to have moderate
and low-level resistance respectively.
-The recent detection of decreased susceptibility to vancomycin among Staph aureus is
also quite scary.

c)Alterations of Critical Enzymes: Beta-lactam antibiotics inhibit bacteria by binding

covalently to penicillin
binding proteins (PBPs) also called transpeptidases in the cytoplasmic membrane.
- These target proteins are necessary for the synthesis of the peptidoglycan that forms the
cell wall of bacteria. -Alterations of PBPs thatprevent successful binding can lead to beta-
lactam resistance.
-In gram-positive bacteria, resistance to beta-lactam antibiotics may be associated either
with a decrease in the affinity of the PBP for the antibiotic or with a decrease in the
number of PBPs produced by the bacterium.

Bypass of Antibiotic Inhibition

- development of auxotrophs, which have growth factor requirements different from those
of the wild strain.
-These mutants require substrates that normally are synthesized by the target enzymes,
and thus, if the enzyme is blocked and the substrates are present in the environment, the
organisms are
able to grow despite inhibition of the synthetic enzyme.
-This is particularly concerning because the bacteria is able to create additional pathways
to meet growth requirements in response to a particular pathway being blocked by the antibiotic.
- For example, "thymidine dependent" bacteria like enterococci are able to utilize exogenous supplies of
thymidine for enzyme activity and are thus highly resistant to trimethoprim which blocks endogenous production
of thymidine by bacterial enzymes.

DECREASING ANTIMICROBIAL RESISTANCE

1) Withhold antibiotics in situations where they are not likely to benefit the patient for self-limited
viral infections such as "the common cold". Symptomatic treatment and supportive measures are
the most appropriate care and antibacterial agents are not indicated.
2) Use the narrowest spectrum antimicrobial agent possible to treat an infection. Eg a semisynthetic penicillin
or oral penicillin better for staph infection than broad spectrum fluoroquinolone or cephalosporin.
3) Base decisions about broadness of empiric antibiotic coverage on the severity of illness.
Eg. if patient is clinically stable and not at risk for significant morbidity if a resistant pathogen is not treated
immediately,  begin a narrow spectrum agent while awaiting culture and susceptibility data.
4) prevention of infection through careful hygiene, especially handwashing and other
measures to control the spread of pathogens. It sounds really simple, but proper and adequate handwashing by
healthcare professionals can prevent many cases of infection due to virulent and antibiotic-resistant pathogens.
5) Utilize education to achieve therapeutic and preventative goals. Patients and families should be
counseled as to when antibiotics are needed, how to take them correctly and for the proper duration.
Education can also be used to foster earlier detection of therapeutic failure, which may be critical when treating
patients who may be infected with antibiotic-resistant pathogens. Our communities must be cautioned against
buying cleaning products with antimicrobial properties as well as using feed lot antibiotics.