Mechanisms of Bacterial Resistance to Antibiotics
Laura A. Dever, RPh, Terence S. Dermody, MD
The three fundamental mechanisms of antimicrobial resis-
tance are (1) enzymatic degradation of antibacterial drugs,
(2) alteration of bacterial proteins that are antimicrobial targets,
and (3) changes in membrane permeability to antibiotics. Antibi-
otic resistance can be either plasmid mediated or maintained on
the bacterial chromosome. The most important mechanism of
resistance to the penicillins and cephalosporins is antibiotic
hydrolysis mediated by the bacterial enzyme \g=b\-lactamase.The
expression of chromosomal \g=b\-lactamasecan either be induced
or stably derepressed by exposure to \g=b\-lactamdrugs. Methods to
overcome resistance to \g=b\-lactamantibiotics include the develop-
ment of new antibiotics that are stable to \g=b\-lactamaseattack and
the coadministration of \g=b\-lactamase inhibitors with \g=b\-lactam
drugs. Resistance to methicillin, which is stable to gram-positive
\g=b\-lactamase,occurs through the alteration of an antibiotic target
protein, penicillin-binding protein 2. Production of antibiotic-
modifying enzymes and synthesis of antibiotic-insensitive bac-
terial targets are the primary resistance mechanisms for the
other classes of antibiotics, including trimethoprim, the sulfon-
amides, the aminoglycosides, chloramphenicol, and the quino-
lone drugs. Reduced antibiotic penetration is also a resistance
mechanism for several classes of antibiotics, including the
\g=b\-lactamdrugs, the aminoglycosides, chloramphenicol, and the
quinolones.
(Arch Intern Med. 1991;151:886-895)
"Bacterial resistance to antimicrobial agents is becoming
increasingly important in clinical practice. While antibiot¬
ic resistance is more prevalent in bacteria causing nosocomial
infections, the prevalence of antibiotic-resistant pathogenic
organisms is also increasing in the community at large. ' Forty
years ago, Staphylococcus aureus was one of the more com¬
mon bacterial pathogens (especially in nosocomial infections)
and was easily eradicated by penicillin.2,3 At the same time,
infections with gram-negative organisms, such as Pseudomo-
nas aeruginosa and Serratia marcescens, were unusual and
were often thought to represent colonization rather than
infection.2 Tbday, most isolates of S aureus are resistant to
penicillin, and infections with gram-negative organisms are
common. In addition, many other bacterial pathogens have
developed resistance to a large number of antimicrobial
agents, and infections with these organisms can be difficult to
treat.
Bacteria have developed resistance to every antibiotic used
thus far, and there exist several different mechanisms by
which antibiotic resistance is mediated (Table). In this re¬
view, we will discuss the most important mechanisms of
Accepted for publication October 16,1990.
From the Pharmacy Department, New England Medical Center (Ms Dever);
Department of Microbiology and Molecular Genetics, Harvard Medical School
(Dr Dermody); and Department of Medicine, Brigham and Women's Hospital
(Dr Dermody), Boston, Mass. Dr Dermody is now with the Department of
Pediatric Infectious Diseases, Vanderbilt University Medical Center, Nash-
ville, Tenn.
Reprint requests to Department ofPediatric Infectious Diseases, Vanderbilt
University Medical Center, Nashville, TN 37232 (Dr Dermody).
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antimicrobial resistance, with emphasis on resistance to anti¬
biotics that inhibit cell-wall biosynthesis. The classification
system of gram-positive and gram-negative ß-lactamases will
be detailed, and nonenzymatically mediated ß-lactam resis¬
tance mechanisms will be described. We will also discuss
mechanisms of resistance to the other major classes of antibi¬
otics, including antagonists of folate synthesis, the aminogly-
cosides, chloramphenicol, and the quinolones.
RESISTANCE TO ß-LACTAM ANTIBIOTICS
Penicillins and cephalosporins are the two most commonly
used classes of ß-lactam antibiotics (Fig 1). Although both
these groups of agents contain a ß-lactam nucleus, they differ
in that penicillins contain a thiazolidine ß-lactam ring complex
and cephalosporins contain a dihydrothiazine ß-lactam ring
complex. The antibacterial effect of all ß-lactam antibiotics
depends on the capacity ofthe antibiotic to diffuse through the
cell membrane, the affinity of the antibiotic for its target
proteins, and the stability of the antibiotic against bacterial
degradation."
The mechanism ofaction of ß-lactam antibiotics is inhibition
of bacterial cell-wall synthesis. Bacterial cell walls are con¬
structed from alternating iV-acetylglucosamine and A/-acetyl-
muramic acid residues.5 Transpeptidation is the final step of
cell-wall synthesis and involves the transpeptidase-catalyzed
cross-linking of peptidoglycan chains. As shown in Fig 2,
transpeptidase-mediated hydrolysis of the ß-lactam bond
(CO—N) results in the inhibition of transpeptidation by the
covalent linkage of the ß-lactam drug to bacterial transpepti-
dase.5 Penicillin-binding proteins (PBPs) are bacterial pro¬
teins (carboxypeptidases and transpeptidases) responsible
for many of the enzymatic activities involved in cell-wall
synthesis, and they are the primary targets for ß-lactam
antibiotics.6 Binding of ß-lactam drugs to PBPs 1, 2, and 3
results in cell-wall lysis, disruption of cell shape, and inhibi¬
tion of cell division, respectively.7,8
ß-Lactam antibiotics can also inhibit bacterial growth by
mechanisms that do not solely involve the inhibition of cell-
wall synthesis. Inhibition of the formation of cell-wall precur¬
sors by ß-lactam antibiotics can result in autolysis through the
unsuppressed activity of murein hydrolases.6 Murein hydro-
lases are autolytic enzymes that cause nicks in the cell wall to
provide sites for new peptidoglycan synthesis during cell-wall
enlargement.9 The inhibition of cell-wall synthesis by ß-lac¬
tam antibiotics does not alter the activity of these enzymes.10
Therefore, bacterial autolysis can result from the effect of
osmotic pressure on the cell wall damaged by murein hydro¬
lases.9,10 In addition to lytic mechanisms, group A streptococci
and viridans streptococci do not undergo cell lysis in the
presence of ß-lactam drugs (autolysin defective) but can re¬
main susceptible to ß-lactam antibiotics by nonlytic mecha¬
nisms.11,12
The most common cause of resistance to ß-lactam drugs is
enzyme-mediated antibiotic degradation. Three classes of
 enzymes canhydrolyze ß-lactam antibiotics: (1) ß-lactamases, Several different schemes have been used to classify
(2) acylases, and (3) esterases (Fig 3).13 ß-Lactamase-medi- ß-lactamases. Richmond and Sykes identified five classes (I
ated hydrolysis resulting in degradation of the ß-lactam nu¬ through V) of gram-negative ß-lactamases on the basis of
cleus is the most important mechanism of bacterial resistance substrate affinity, isoelectric point, and inhibition data.20 En¬
to ß-lactam antibiotics. ß-Lactamases are produced by some zymes produced by gram-positive organisms (predominantly
gram-positive and all gram-negative bacteria.14,15 ß-Lacta¬ by S aureus) are distinct from those produced by gram-
mases produced by gram-positive organisms are excreted negative organisms. They have a different classification
extracellularly; those produced by gram-negative organisms scheme and are divided into four groups (A through D) pri¬
are usually concentrated in the periplasmic space and not marily by sérologie features.13,21
excreted.15,16 The ß-lactam bond, which is required for the Gram-negative bacilli produce both chromosomally en¬
activity of ß-lactam antibiotics, is also the target of ß-lacta- coded and plasmid-encoded ß-lactamases.18,21 Richmond-
mase attack. ß-Lactamases catalyze the hydrolysis of the Sykes class I and II ß-lactamases, broadly categorized as
ß-lactam bond to acidic derivatives that do not have antibac¬
terial properties (Fig 4).17"19
Genes encoding ß-lactamases can reside on the bacterial
chromosome or on plasmids; bacterial plasmids that encode O
D
proteins responsible for antibiotic resistance are referred to R-C-NH-
as resistance factors (R-factors). Plasmid-mediated resis¬
tance can be passed to distantly related bacterial species by Penicillins
conjugation, and the expression of these enzymes is usually y COOH
constitutive.8 In contrast, the expression of chromosomally
mediated ß-lactamases is usually not constitutive but can be
induced or derepressed by exposure to ß-lactam antibiotics.19 o
II
R-C-NH'
Mechanisms of Bacterial Resistance to Antimicrobial Agents
Cephalosporins
Drug/Drug Class Mechanism of Resistance
Penicillins and Enzymatic inactivation by ß-lactamase; enzymatic
cephalosporins modification by acylase and esterase; outer- COOH
membrane protein deletion; alteration of
penicillin-binding proteins O
Monobactams Enzymatic inactivation by ß-lactamase H
Carbapenems Enzymatic inactivation by ß-lactamase; R-C-NH.
outer-membrane protein deletion
Vancomycin Inhibition of glycopeptide access
Trimethoprim Increased production of dihydrofolate reductase; Monobactams
production of trimethoprim-insensitive Ov •v
dihydrofolate reductase S03H
Sulfonamides Increased production of p-aminobenzoic acid;
increased production of pteridine; increased
production of sulfonamide-insensitive
dihydropteroate synthetase OH
Aminoglycosides Enzymatic modification by acetylation,
phosphorylation, and nucleotidylation;
ribosomal alteration; diminished drug uptake ,NH
Chloramphenicol Enzymatic inactivation by acetylation; decreased Carbapenems •NHCl
drug permeability
Macrolides Enzymatic modification by esterase; alteration of
23S ribosomal RNA
Lincosamides Enzymatic modification by nucleotidylation or
phosphorylation; alteration of 23S ribosomal
RNA
Tetracyclines Active efflux preceded by chemical modification
Quinolones Alteration of subunit A of DNA gyrase; decreased
drug permeability Fig 1.—Structures of ß-lactam antibiotics. The ß-lactam ring (to the left
of the dashed line) is shared by all of these compounds.

Fig 2.—Inhibition of bacterial transpeptidase by penicillin.

S O
R-C-NH^ ^SV^CH3 Bacterial

>C-
CH3
-;-^
Transpeptidase
R-c-NH^
R C NH ^

N-'s."COOH
s9.
(/ C00H
Transpeptidase
'
II

Penicillin Penicilloyl Enzyme

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 cephalosporinases and penicillinases, respectively, are chro-
mosomally mediated.20 Induction of class I enzymes occurs
when expression of ß-lactamases increases in the presence of
a ß-lactam antibiotic (acting as an inducer) and declines to a
basal state after hydrolysis or removal of the inducing
agent.22,23 Citrobacter freundii, Enterobacter cloacae, and
P aeruginosa are examples of gram-negative bacteria that
produce class I ß-lactamases that are inducible.24"27 The admin¬
istration of strong ß-lactamase inducers, such as cefoxitin and
imipenem, can lead to the degradation of enzyme-labile ceph¬
alosporins when these drugs are given concomitantly.24,28,29
Stable derepression of class I ß-lactamase expression can
occur in bacterial mutants selected for ß-lactam resistance by
exposure to a ß-lactam drug. Stably derepressed mutants
R-C-NH CH3
J CH3
© IV enzymes are chromosomally mediated ß-lactamases pro¬
hyperproduce ß-lactamase despite removal of the inducing
ß-lactam antibiotic.24 ß-Lactam drugs that are weak ß-lacta¬
mase inducers can lyse organisms capable of ß-lactamase
induction but cannot inhibit bacterial mutants with stably
depressed ß-lactamase expression.22 Weak ß-lactamase in¬
ducers used to treat infections caused by P aeruginosa and
E cloacae can lead to ß-lactam resistance through stable
derepression of ß-lactamase expression.22 Cefotaxime, cefti-
zoxime, and ceftazidime are examples of weak ß-lactamase
inducers capable of selecting stably derepressed mutants.a
All of the class III ß-lactamases are plasmid encoded and
include the TEM-1, TEM-2, and SHV-1 ß-lactamases.20,21 Re¬
cently described TEM enzymes mediate the hydrolysis of
aztreonam and the extended-spectrum cephalosporins (eg,
cefotaxime and ceftazidime) and include TEM-3,30,31 TEM-4,32
TEM-7,33 and TEM-10.34 TEM enzymes that hydrolyze ex¬
tended-spectrum cephalosporins usually manifest selective
resistance to specific cephalosporins. Therefore, susceptibil¬
ity to a particular cephalosporin drug should not be interpret¬
ed as representative of an entire cephalosporin class.34 Class

O
°©—u' Penicillins
COOH
duced by Klebsiella.21 Class V enzymes are a heterogeneous
group of ß-lactamases and include the oxacillin-hydrolyzing
enzymes of Enterobacteriaceae (OXA-1, OXA-2, and OXA-3)
and the Pseudomonas-speciftc enzymes.20,21
Resistance to ß-lactam antibiotics can be inhibited through
II the chemical modification of ß-lactam drugs to improve stabil¬
R-C-NH-
ity against ß-lactamase hydrolysis. Aztreonam and imi-
o penem, each representing a unique ß-lactam antibiotic class,
© CH2-0 —
II
C-CH3
are two of the most promising new agents (Fig l).35,36 Az¬
treonam is a monobactam that is active only against gram-
w

negative aerobic organisms.37,38 It demonstrates an especially

COOH © high degree of stability to plasmid-encoded ß-lactamases38
and does not induce chromosomally encoded ß-lactamases.37
Cephalosporins Imipenem (A^-formimidoyl thienamycin) is a carbapenem and
is similar to aztreonam in that it is highly resistant to
Fig 3.—Sites for enzymatic degradation of penicillins and cephalospo¬ ß-lactamase degradation.36,39,40 Imipenem is degraded by renal
rins: ß-lactamase (1 ), acylase (2), and esterase (3). dihydropeptidase and must be coadministered with cilastatin,

Fig 4.—Reactions catalyzed by ß-lactamases resulting in the degradation of penicillins (top) and
cephalosporins (bottom).

O O
II II
R-C-NH R-C- NH

:.-«: ¿f=C Nc CH3

CH3
CH3 CH3

COOH O OH
| COOH
I_I
L_H__!

COOH

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 a dihydropeptidase inhibitor. Imipenem is active against a
large number of gram-positive, gram-negative, and anaerobic
organisms, including Bacteroides fragilis, Escherichia coli,
P aeruginosa, and S aureus.41*1 It is not affected by a perme¬
ability barrier and can readily enter into the periplasm. Al¬
though imipenem is stable against most plasmid-encoded and
chromosomally encoded ß-lactamases,15,36 zinc-containing ß-
lactamases that are capable of imipenem hydrolysis have been
identified in strains of Xanthomonas maltophilia44 and
B fragilis.45
The coadministration of a nonantimicrobial drug capable of
inhibiting ß-lactamase activity in conjunction with a ß-lactam
antibiotic is a strategy that has recently been used to over¬
come ß-lactamase-mediated resistance. Clavulanate and sul-
bactam, two prototype agents now in widespread use, both
act irreversibly to inhibit ß-lactamase activity4,14 (Fig 5). The
combination of either of these agents with ampicillin results in
antibacterial activity against ampicillin-resistant strains of
Bacteroides, E coli, Haemophilus influenzae, and S aur-
ews.4,46
Hydrolysis of clavulanate is followed by (1) formation of a
long-lived acyl-enzyme intermediate, (2) transient regenera¬
tion of free ß-lactamase, and then (3) irreversible ß-lactamase
inactivation through the formation of a covalent linkage be¬
tween the enzyme active site and the inhibitor.47,48 Hydrolysis
of sulbactam results in the formation of sulbactam fragments
that covalently bond to a site on the enzyme distinct from the
active site, causing irreversible enzyme inactivation.13 Clavu¬
lanate and sulbactam can inhibit plasmid-encoded ß-lacta¬
mases (Richmond-Sykes classes III and V) and chromosomal¬
ly encoded ß-lactamases (Richmond-Sykes classes II and IV)
of gram-negative bacteria and ß-lactamases of gram-positive
bacteria.46 Clavulanate and sulbactam are poor inhibitors of
class I enzymes4*"1;clavulanate induces these enzymes in
some bacteria, especially P aeruginosa and Enterobacter.m
Because of its capacity to induce ß-lactamase production,
clavulanate may antagonize the effect of ticarcillin on strains
of Morganella morganii and E cloacae that are capable of
induced ß-lactamase expression.50 In contrast to clavulanate,
sulbactam is a less potent inhibitor of most ß-lactamases.
However, sulbactam is a poor ß-lactamase inducer and thus
offers a distinct advantage over clavulanate.52
RESISTANCE TO METHICILLIN
Alteration ofthe ß-lactam nucleus has yielded many antimi¬
crobials (eg, methicillin, nafcillin, and oxacillin) with in¬
creased stability to gram-positive ß-lactamases. Resistance
to these agents does occur, however, and is independent of
ß-lactamase production. Methicillin-resistant strains of
S aureus are increasingly common in nosocomial53 infections
and have also been described in infections of intravenous-
drug abusers.54,55 Methicillin resistance is mediated through
the production of an altered PBP 2 (PBP 2a or PBP 2')f*58 that
has a much lower affinity for methicillin (and for most other
ß-lactam antibiotics) than does PBP 2.59
Methicillin-resistant S aureus can exhibit either high or low
levels of resistance. Whereas greater amounts of PBP 2a are
produced in high-level methicillin-resistant S aureus, there is
no correlation between PBP 2a production and minimum
inhibitory concentration.60 The expression of PBP 2a can ei¬
ther be induced by methicillin (or other ß-lactam antibiotics)
or be constitutive. A ß-lactamase plasmid is usually present in
inducible methicillin-resistant S aureus strains but absent in
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CHjOH
\*
"COO-K*
Clavulanate Potassium
•COO"Na+
Sulbactam Sodium
Fig 5.—Structures of clavulanate potassium and sulbactam sodium.
Both compounds are noncompetitive ß-lactamase inhibitors.
strains that express PBP 2a constitutively.56,61 Ordinarily,
within a given S aureus culture, few of the isolates express
methicillin resistance (heterogeneous resistance),62 but occa¬
sionally all of the isolates are resistant (homogeneous resis¬
tance).63 The level of methicillin resistance in culture does not
have clinical significance in that all of these isolates should be
considered resistant to methicillin.
A novel resistance mechanism has recently been described
in methicillin-resistant S aureus with low or borderline levels
of resistance to ß-lactam antibiotics. These methicillin-resis¬
tant strains do not express PBP 2a64,65 but possess PBPs that
have modified penicillin-binding capacities (particularly PBP
1 and PBP 2).ffi Compared with methicillin-resistant S aureus
strains that produce PBP 2a, the minimum inhibitory concen¬
trations of methicillin for methicillin-resistant S aureus with
modified penicillin-binding capacities are low, and therefore
these organisms generally remain susceptible to methicillin.
However, this mechanism of resistance could be an important
cause of methicillin resistance in the future.65
RESISTANCE TO ß-LACTAM ANTIBIOTICS
THROUGH REDUCED PENETRATION
Porin proteins in the outer membrane of gram-negative
bacteria form channels that allow the exchange of nutrients
and other substances (including antibiotics) between the ex¬
tracellular environment and the periplasmic space.66"68 For
ß-lactam antibiotics to bind PBPs, they must penetrate porin
channels in the outer membrane and traverse the periplasmic
space.69 Diffusion of some ß-lactam drugs through porin chan¬
nels is limited by the presence of bulky substituents on the
acyl side chain of the ß-lactam nucleus; diffusion of others is
limited by electrostatic charge.70 Changes in outer membrane
permeability serve to limit drug influx and decrease drug
availability to PBPs located on the inner membrane.23,68
Two outer membrane proteins (Omps) of E coli that have
been identified and characterized are OmpF and OmpC.66,70,71
 OH
\ HO

H>C \ . \ \ç_— CH2OH

H°CH3 \^°
CI

h0y-^/^ci O
%X
O
^/\/oh O CH3
11 H X H m
II I

I
H
h
CH2
i! H
TCH2

HN\\ h
A I
c=0
I
CH

HO / \ OH

HO

Fig 6.—Structure of vancomycin showing the site of the A/-substitution. R =

H in vancomycin.

An additional (mutant) channel, PhoE, is produced in mu¬ RESISTANCE TO VANCOMYCIN

tants of E coli deficient in OmpF and OmpC under conditions
of phosphate depletion.66 Of these three porin channels,
OmpF has the widest pore diameter and the highest perme¬
ability to ß-lactam drugs.71 Zwitterionic compounds (eg, am-
picillin, cefaclor, cephalexin, and imipenem) have much high¬
er penetration rates through OmpF than do anionic
compounds (eg, carbenicillin, cefamandole, cefuroxime, and
piperacillin).70 Permeability of zwitterionic compounds
through PhoE channels is poor; in contrast, anionic com¬
pounds have higher penetration rates through PhoE channels
than through OmpF channels.71 Escherichia coli mutants de¬
ficient in OmpF channels are resistant to ß-lactam antibiotics
as a consequence of reduced penetration through OmpC chan¬
nels produced by these organisms.70"72 In addition, enzymatic
degradation of ß-lactam antibiotics is more efficient in OmpF-
deficient mutants because of the slower drug penetration that
occurs through OmpC channels.68
Penetration of compounds through the outer membrane of
P aeruginosa is less than that of E coli, primarily because of
the low permeability of its porin channels.67 Impaired pene¬
tration appears to be the mechanism of imipenem resistance
exhibited by some strains of P aeruginosa.13 Loss of 45- to
48-kd Omps has been reported in strains of P aeruginosa that
are imipenem resistant.73"75 These proteins correspond to
porin channel D2 which is required for the penetration of
imipenem.74
Vancomycin is a glycopeptide antibiotic (Fig 6) that inhibits
bacterial cell-wall formation by the inhibition of peptidogly¬
can synthesis. It binds to the free carboxyl end of D-alanyl-D-
alanine of V-acetyl-muramyl-pentapeptide of the elongating
peptidoglycan chain.77,78 Vancomycin activity is limited to
gram-positive organisms, and the drug is especially useful in
the treatment of infections caused by methicillin-resistant
S aureus and penicillin-resistant strains of Enterococcus.™
Resistance to vancomycin has recently been observed in
Enterococcus faecium60^2 and Enterococcus faecalis.® In
these organisms, vancomycin resistance is plasmid mediated
and inducible.82^4 Although the mechanism of resistance is
poorly understood, novel cytoplasmic membrane proteins
have been identified in vancomycin-resistant strains of
Efaecium'1 and Efaecalis.^ It has been suggested that these
proteins block vancomycin access to the elongating peptido¬
glycan chain.81,83 Strains of Efaecium and Efaecalis that are
resistant to vancomycin maintain susceptibility to some N-
substituted vancomycin derivatives (eg, decyl-vancomycin,
p-octyloxybenzyl-vancomycin)
p-octylbenzyl-vancomycin,
(Figo).84
RESISTANCE TO THE FOLATE ANTAGONISTS:
TRIMETHOPRIM AND THE SULFONAMIDES
Trimethoprim and the sulfonamides act synergistically to
inhibit folate metabolism by blocking sequential steps in the

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p-Aminobenzoic Acid + Pteridine
Dihydropteroate
Synthetase
Sulfonamides h-**
S02NH Dihydropteroic Acid
T~\ Dihydrofolate
Synthetase
NH2
Sulfamethoxazole Dihydrofolic Acid
Dihydrofolate
Reductase
Trimethoprim r—**
OCH3 Tetrahydrofolic Acid
OCH3
OCH3
Fig 7.—Sites of inhibition of folate metabolism by sulfonamides and
trimethoprim. The action of these agents on two independent bio¬
chemical steps is responsible for the synergy observed with these
antibiotics.
folate synthesis pathway (Fig 7). Trimethoprim inhibits dihy¬
drofolate reductase, and the sulfonamides inhibit dihydro¬
pteroate synthetase.85,86 Bacteria are not able to take up pre¬
formed folie acid derivatives and cannot utilize host folie acid.
Therefore, bacterial production of tetrahydrofolic acid, which
is required for the synthesis of amino acids and nucleotides, is
entirely dependent on synthesis from pteridine and p-amino-
benzoicacid.85
The major cause of trimethoprim resistance is the produc¬
tion of an altered (plasmid-encoded) dihydrofolate reductase
that lacks the capacity to bind trimethoprim.87'91 Overproduc¬
tion of the normal (chromosomally encoded) dihydrofolate
reductase is an additional mechanism of trimethoprim resis¬
tance, particularly in E coli and Klebsiella pneumoniaef,SZlXI
Bacterial resistance to the sulfonamides may be caused by
increased production of p-aminobenzoic acid, increased syn¬
thesis of pteridine, and increased production of a sulfonamide-
resistant dihydropteroate synthetase.87,94 Most resistance to
sulfonamides, however, is due to an additional plasmid-en¬
coded dihydropteroate synthetase that has a lowered affinity
for sulfonamides.85,87,95 As is the case with ß-lactam antibiotics,
loss of inhibitory activity ofeither trimethoprim or the sulfon¬
amides can result from impaired penetration.87,98
RESISTANCE TO AMINOGLYCOSIDES
Aminoglycoside antibiotics inhibit the initiation of protein
synthesis and disrupt polypeptide chain elongation by induc¬
ing the incorporation of incorrect amino acids.96 Aminoglyco-
sides are classified into two groups, depending on whether
they contain 2-deoxystreptamine or streptidine (Fig 8).97
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Most aminoglycosides (amikacin, gentamicin, neomycin, ne-
tilmicin, and tobramycin) contain 2-deoxystreptamine; strep¬
tomycin contains streptidine. Aminoglycosides are hydro-
philic molecules that require active transport to gain entry
into bacteria.96 The primary mechanism of aminoglycoside
resistance is enzyme-mediated antibiotic modification. Alter¬
ation ofribosomal binding sites96 and diminished drug uptake98
are less common mechanisms of aminoglycoside resistance.
Aminoglycoside-modifying enzymes (AMEs) catalyze the
modification of either the amino or hydroxyl groups on amino-
cyclitol and aminoglycoside antibiotics (Fig S).m,S9 These en¬
zymes inactivate aminoglycosides by three mechanisms: (1)
acetylation, (2) nucleotidylation, and (3) phosphorylation.99"102
Bacterial AMEs of most gram-positive and gram-negative
organisms are plasmid encoded.97 Concentrations of AMEs in
the periplasmic space of gram-negative bacteria are usually
low.101 However, modification of aminoglycosides is efficient
because antibiotic uptake into the periplasmic space is slow,
and AME affinity for aminoglycosides is high.101 Each AME
inactivates a particular subset of the available aminoglycoside
antibiotics accounting for the varied spectra of aminoglyco¬
side resistance observed in clinical isolates.101
Aminoglycoside acylases inactivate aminoglycosides by
catalyzing the transfer of acetate from acetyl-coenzyme A to
an amino group on 2-deoxystreptamine-containing aminogly¬
cosides, such as amikacin, gentamicin, and neomycin.97,101
Aminoglycoside nucleotidyltransferases utilize adenosine tri-
phosphate and other nucleotide triphosphates as cofactors
and adenylylate hydroxyl groups on amikacin, gentamicin,
kanamycin, neomycin, spectinomycin, streptomycin, and to¬
bramycin.97 Aminoglycoside phosphotransferases catalyze
the transfer of a phosphate group to a hydroxyl group on
amikacin, gentamicin, kanamycin, neomycin, and tobramy¬
cin. 1M A single aminoglycoside can be altered at several differ¬
ent sites by the coupling of one or more AMEs, a process
resulting in the complete inactivation of the antibiotic.97100
Recently, strains of E faecalis and E faecium have been
reported that show high levels of aminoglycoside resistance
(minimum inhibitory concentration, >2000 mg/L).103 Effec¬
tive treatment of serious infections caused by these organ¬
isms requires the synergistic combination of ampicillin, peni¬
cillin, or vancomycin and an aminoglycoside.104"106 Enterococci
with high levels of aminoglycoside resistance can be especial¬
ly difficult to treat, as therapy with a cell-wall synthesis
inhibitor alone is usually not effective. Furthermore, entero¬
cocci that manifest high levels of aminoglycoside resistance
can exhibit resistance to several aminoglycosides simulta¬
neously.103107 However, individual aminoglycoside susceptibil¬
ity testing is advisable, since enterococci can demonstrate
high levels of aminoglycoside resistance to gentamicin, kana¬
mycin, tobramycin, and streptomycin despite only moderate
resistance to amikacin or netilmicin.103,108
RESISTANCE TO CHLORAMPHENICOL
Chloramphenicol inhibits bacterial protein synthesis by
binding to the 50S ribosomal subunit.109 The most common
mechanism of resistance to chloramphenicol is enzymatic
modification.110,111 Chloramphenicol acetyltransferase is an in-
ducible, plasmid-encoded enzyme that inactivates chloram¬
phenicol by acetylation (Fig 9).112"114 Decreased chlorampheni¬
col permeability has also been proposed to be a cause of
resistance in H influenzaem and Pseudomonas cepacia.116 In
chloramphenicol-resistant strains of H influenzae that do not
 C. D- AAC m
NH AAC (6')
II
NHCNH2 NH CH2NH2 CH2NH2

O/TON™"™2 APH (3')

(41)—MHOVH A
APH (3')

(4')—K3H^H /
}- OAjj)
V_/^APH (6)
~ANT(6)
ANT
AAC (2')
ANT
AAC (2') —* H2N
O
AAC (3)-AhT\^ AAC (3) -^hT\^
NH2
OH OH NH2
APH (5") —*HOÇH2 0 o
CH2OH

ANT (3") hoNíiv

ANT (2") —»OH
APH (3") APH (2")

Fig 8.—Aminoglycoside structures and sites for enzymatic modification. A, Spectinomycin; B, streptomy¬
cin; C, neomycin; and D, kanamycin B. Amikacin, gentamicin, and tobramycin are structurally related to
kanamycin B. AAC indicates aminoglycoside A/-acetyltransferase; AAD, aminoglycoside adenylyltrans-
ferase; ANT, aminoglycoside nucleotidyltransferase; and APH, aminoglycoside phosphotransferase
(modified from Phillips and Shannon97).

C-CHCI2 C-CHCI2
Chloramphenicol

OH
NH
Acetyltransferase VC
C—C- CH2OH OM-C —
C —

CH20 —

COCH3
OH H OH H

Chloramphenicol 3-O-Acetyl Chloramphenicol

Acetyl CoA

Fig 9.—Acetylation of chloramphenicol by chloramphenicol acetyltransferase. CoA indicates coenzyme

A.

produce chloramphenicol acetyltransferase, reduced quanti¬
ties of an Omp have been observed.115 It has been suggested
that the loss of this Omp in resistant strains results in de¬
creased chloramphenicol permeability.115
MECHANISMS OF RESISTANCE TO OTHER
CLASSES OF ANTIBIOTICS
Macrolide (erythromycin) and lincosamide (clindamycin)
antibiotics inhibit bacterial protein synthesis by binding to
the 50S ribosomal subunit.117 Resistance to these agents is
mediated by mechanisms similar to those responsible for
aminoglycoside resistance. Macrolide and lincosamide resis¬
tance is due to either alteration of the ribosomal target site
(adenine methylation in 23S ribosomal RNA)118 or enzyme-
mediated antibiotic modification.119
The tetracyclines act to inhibit bacterial protein synthesis
by binding to the 30S ribosomal subunit.120 Resistance to
tetracycline is also caused by enzymatic modification,121 and
alteration of this drug is followed by rapid efflux from the
cytoplasm.122,123 Tetracycline efflux, unaccompanied by enzy-
matic modification, does not confer resistance to this
drug.124,125
RESISTANCE TO QUINOLONES
The 6-fluoroquinolone antibiotics, ciprofloxacin and nor-
floxacin, were derived from nalidixic acid.126 These drugs
exhibit bactericidal activity against a wide range of gram-
positive and gram-negative bacteria, including some strains
of methicillin-resistant S aureus and P aeruginosa
(Fig 10).127"130 Quinolone antibiotics inhibit DNA gyrase, an
enzyme required for unwinding of the supercoiled bacterial
chromosome before DNA replication.131 DNA gyrase is com¬
posed of two A subunits (encoded by gyrA) and two B sub-
units (encoded by gyrB).1S2,133
Resistance to nalidixic acid and the 6-fluoroquinolone drugs
occurs through two independent mechanisms, and neither
mechanism is plasmid mediated.132 Although resistance to
nalidixic acid is mediated by the same mechanisms as resis¬
tance to the 6-fluoroquinolone antibiotics,134 resistance to nali¬
dixic acid is 100- to 1000-fold greater than resistance to the

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o As discussed in this review, bacteria have
II
.COOH
H.C^S,
I biotic degradation mediated by bacterial enzymes. Despite
C2H5
Nalidixic Acid
COOH
Norfloxacin
COOH
Ciprofloxacin
Fig 10.—Structures of nalidixic acid and the 6-fluoroquinolone com¬
pounds norfloxacin and ciprofloxacin.
6-fluoroquinolones.135 The most common mechanism of resis¬
tance to quinolone antibiotics is alteration of the target en¬
zyme. The A subunit of DNA gyrase is altered in quinolone-
resistant gyrA mutants so that it no longer binds the
antibiotic.136"138 Quinolone resistance also occurs through de¬
creased penetration.132 Quinolone antibiotics rapidly pene¬
trate the outer membrane of susceptible strains of E coli
through OmpF channels.139 Mutations in regulatory loci se¬
lected for ciprofloxacin (cfxB) and norfloxacin (nfxB) resis¬
tance, respectively, are associated with diminished drug pen¬
etration through decreased expression of OmpF.132,135,140
Alterations in outer membrane permeability have also been
reported in quinolone-resistant strains of P aeruginosa. The
precise mechanism of decreased quinolone permeability is not
known, but it cannot be attributed to a decrease in OmpF
expression.141,142 Quinolone antibiotics can be suitable alterna¬
tive agents in the treatment of some strains of methicillin-
resistant S aureus; however, high-level quinolone resistance
has recently been reported in strains of S aureus that are also
highly resistant to gentamicin143 and methicillin.143,144
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CONCLUSION
developed resis¬
tance to all classes of antimicrobial agents curently in use.
Furthermore, newer mechanisms of antibiotic resistance
have caused significant problems in the treatment of infec¬
tions caused by some bacteria, such as enterococci and Pseu-
domonas. New strategies to combat antibiotic resistance
include the modification of antibiotics now in use and the
coadministration of nonantibiotic drugs that can inhibit anti¬
these technological innovations, it is very likely that antibiot¬
ic resistance will continue to be an important clinical problem.
Several methods have been developed to decrease the risk of
infection with antibiotic-resistant organisms. These include
choosing an antibiotic with a narrow spectrum when a patho¬
gen is known, the use of short durations of antibiotic prophy¬
laxis, and limiting topical and oral therapy with drugs that
may have to be used parenterally. While it remains controver¬
sial whether the indiscriminate use of antibiotics actually
increases the emergence of drug-resistant pathogens, it
seems prudent to use these drugs carefully to prolong their
efficacy.
This study was supported in part by Physician-Scientist Award 5K11
AI00865 from the National Institute of Allergy and Infectious Diseases, Be-
thesda, Md (Dr Dermody).
We express our appreciation to Jerry Jones, PhD, James Maguire, MD,
Thomas O'Brien, MD, and Richard T. Scheife, PharmD, for essential discus¬
sions and reviews of the manuscript.
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