Lisa Balraj

814005637
Biol 3961
Medical Microb – Journal report

1. The evidence provided states that bacterial resistance to our antibiotic

arsenal is not a new phenomenon as multiple resistance determinants
have been found in bacteria isolated from the environments that have
been separated from human activity for millions of years. ESBLs enzymes
found in Enterobacteriaceae were discovered as early as the 1980s, which
also contributed to antibiotic resistance.
2. Humans have contributed to the current “antibiotic crisis” by reflecting
the rapid expansion, diversification and extension of host range for
multitude of resistance determinants under selection pressure from the
widespread use of antibiotics. This man made crisis threatens many of the
advances in modern medicine as well as our ability to treat commonly
encountered infectious diseases such as UTIs (Urinary Tract Infections)
that has approximately 150-250 million cases globally per year. As a
result, antimicrobial resistance increased in bacteria. Two examples are
E.coli and Klebsiella pneumonia that are two gram negative bacteria that
became resistant to carbapenem antibiotics. This was because of
globalization and increased travelling.
3. As mentioned in the review article, approximately 40-50% of women and
5% of men will develop a UTI at least once during their lifetime. The
attribute cost of UTI medical expenses in the USA alone has been
estimated to a range from US$1.6 billion to $3.5 billion yearly if broader
societal costs are also considered. As a result of their high prevalence,
UTIs are a major contributor to global antibiotic use and resistance.
4. Extended spectrum 𝛽-lactamases (ESBLs) are enzymes that confer
resistance to most beta-lactam antibiotics, which includes penicillins,
caphalosporins and monobactam aztreonam. E.coli and Klebsiella
pneumonia are two bacteria that are characterized by the ability to
inactivate the most frequently used antibiotics (ceftriaxone/ceftazidime)
via the process of hydrolysis.
5. There are 4 classes of 𝛽-lactamases:
 Class A* 𝛽-lactamases≠
 Has serine residues
 Caphalosporinase activity and resistance to 3GCs is the key
features
 Inhibited by clavulanate-tazobactam in vitro (except KPC)
 Arises from mutations in parent narrow
spectrum/captured from environmental bacteria eg. CTX-M
 Is transmissible on mobile genetic elements such as
plasmid carrying multiple other resistance determinants.
 Are most common in Escherichia coli (E.coli), Klebsiella spp
and Proteus spp.
 Examples are ESBLs (TEM, SHV variants, CTX-M),
Carbapenemase (KPC)
 Class B* 𝛽-lactamases≠
 Has metal ions (Zn2+)
 Have carbapenemase activity
 Not inhibited by clavulanate/tazobactam
 Aztreonam not hydrolyzed by class B 𝛽-lactamases
 Highly transmissible on plasmids carrying multiple other
resistant determinants
 E.coli, Klebsiella spp but described in many
Enterobacteriaceae and Acinetobacter spp.
 Intrinsic carbapenem resistance in stenotrophomonas
maltophilia via class B enzymes (L-1)
 Example: Carbapenemase (IMP, NDM, VIM)
 Class C* 𝛽-lactamases≠
 Aka AmpC enzymes
 Broad cephalosporinase activity including 3GC but
cefepime stable
 Not inhibited effectively by clavulanate or tazobactam
 Chromosomally encoded in many species; inducible in some
Enterobacteriacaea
 Mutation in regulatory genes involved in cell wall recycling
  Increasing plasmid AmpC
 Transmission described
 Enterobacter cloacae, E.aerogenes, Serratia marcescens,
Citrobacter freundil, Pseudomonas aeruginosa, Providencia
spp. and Morganella morganii all has inducible AmpC
enzymes that are chromosomally encoded
 Plasmid mediated AmpC increasing in E.coli
 Example: Caphalosporinase(CMY, DHA, ACT)
 Class D* 𝛽-lactamases≠
 Oxacillinases that can have carbapenemase activity
 Weakly inhibited by clavulanate
 Can be acquired or naturally occurring chromosomal genes
 Acinetobacter baumanii (OXA-23, OXA-48)
 Example: carbapenemase (OXA-type)
6. Other types of antibiotics resistance covered in the paper are:
 Efflux pumps and porin mutations
- it is a membrane transport system to extrude multiple
antimicrobials/mutations in outer membrane proteins to
hinder entry into active drug.
- Via mutations, porin changes or loss can occur
- Pseudomonas aeruginosa, Acinetobacter baumanii and
Enterobacteriaceae have these
 Target site mutations
- methylation of 16s rRNA with high levels of resistance
- They are carried by plasmids often mediated by rmtA ad
related genes.
- Common in Klebsiella pneumonia
- Some examples are Methylases: RmtA, RmtB or ArmA.
 Altered DHPS
- Essential for folate synthesis in bacteria; leads to sulphonamide
resistance and altered DHFR with loss of inhibition by
trimethoprim.
- Sul1 part of class 1 integron
 - Plasmid borne dhfrI and dhfrII genes
- Common in E.coli and Stenotrophomonas maltophilia
 DNA gyrase
- prevents activity of quinolones
- often single mutations in quinolones resistance determining
region (QRDR) on gyrA gene
- examples: point mutations in gyrA, gyrB, gyrC and pare genes
 protein binding of quinolone active site, low level resistance
- protein binding encoded by plasmid mediated qnr genes
- common species are E.coli, Klebsiella spp, Salmonella spp
- examples are: qnrA, anrB, qnrC, qnrD and qnrS
 overproduction of enzymes
- mutations in promotor regions results in increase production
of DHFR and trimethoprim resistance.
 Drug modification
- Acetylation, nucleotidylation and phosphorylation of
aminoglycosides.
- Some can also inactivate fluoroquinolones
- Examples are: AAC(2’), ANT(2”), APH(2”)
 Treatment of CAUTIs (Catheter-associated urinary tract infections)
- bacteria can enter bladder through extra luminal route
- indwelling urinary catheter bypasses the normal host defenses
along urethra
- once the bacteria gains entry they form biofilm on surfaces of
the catheter; becomes encased in a polymeric matrix (gives
protection)
- organisms go into bladder from perineum through biofilm.
Biofilm forms rapidly on external surfaces
 treatment of TRUBP (Transrectal ultrasonography guided biopsy
of the prostate
- due to selective pressure in rectal flora, fluoroquinolones is
resistant
- results of travelling to where fluoroquinolone resistance is high
7. The main antibiotics used in the treatment of UTIs are Carbapenems. The
emergence and spread of carbapenem resistance will be the reason for
carbapenem antibiotics to become ineffective in terms of treatment
making it more complicated to treat the infection. So now, a new drug will
need to be developed to treat UTIs. A lot of time and money will need to
be invested into developing this new drug within a short period of time.
Even if new drug is made, it will not completely stop the bacterial stains
from getting microbial resistance and hence this process can occur over
and over.
8. Multi drug resistance varies in gram-negative uropathogens around the
world. It is clear that the prevalence of antibiotic resistance in gram-
negative uropathogens varies as stated in the report. For instance,
quinolone resistance in urinary E.coli from China, India and Vietnam has
been reported to be as high as 70% with around 60% of strains expressed
in ESBLs as compared to countries such as Australia, where the rates of
resistance is significantly lower. From a survey that was carried out in the
year 2012, 4.2% of E.coli causing infections were resistant to third
generation cephalosporins and 6.9% were resistant to fluoroquinolones.
Even when compared to regions such as Greece, the resistance was 59.4%
in K.pneumoniae and 0.2% in Netherlands. Figures 2, 3 and 4 also show
some developing countries that had little to no prevalence. This was a
result of the strict policies about the use and distribution of the
antibiotics.
9. Because of the production of enzymes such as KPC type, NDM type and
OXA-48 type 21. Carbapenem resistance rises in areas that have a high
prevalence of ESBLs or AmpC beta lactamases and the increase of the
activities of the efflux pumps.
10. Fimbriae are UPEC virulence factor of which there are many types.
Fimbriae functions to prevent the adherence mechanism represent an
attractive anti virulence strategy. Type 1 fimbriae can bind to alpha-D-
mannosylated glycoproteins within the bladder, enhance colonization,
involved in bladder cells invasion and the development of biofilms via
intracellular bacterial communities and induce host responses. Bacteria
 such as Proteus mirabilis are able to create types of fimbriae that can
cause UTIs. In addition to adherence, bacterial pathogens that
successfully colonize UI and cause UTI must possess a virulence arsenal
that enables them to avoid host-killing mechanisms. These include
antimicrobial peptides and exfoliation of host cells.
11. Patients with indwelling urinary catheters are a big reservoir of
antimicrobial resistant uropathogens. These patients are also exposed to
antibiotics and are at risk of cross transmission of multi drug resistant
pathogens. Once they are colonized, these catheters patients are
vulnerable to both symptomatic CAUTI and obviously long term
colonization. The catheter bypasses the normal host defenses along the
urethra, giving microorganisms that colonize the perineum direct access
to the bladder. Bacteria can also enter the bladder through extra luminal
route along external surfaces of the catheter. Once microorganisms get
access to the catheterized UI, they form biofilm, which is encased in a
polymeric matrix that provides protection against host immune defenses.
It was also notes that the intraluminal route of entry was as common as
the extraluminal route for gam negative bacterial infections whilst gram-
positive bacterial infections were more frequently associated with
colonization via extraluminal route.
12. One of the most effective methods to prevent CAUTI is to reduce the
duration of catheterization, which included the use of electronic or nurse
driven reminder systems. Strategies using antiseptic irrigation of the
catheterized bladder, antiseptic lubricants or tropical therapies for metal
care were not effective. Prevention of CAUTI would be an important step
in reducing reservoir of nosocomial MDR gram-negative organisms in
hospitals and nursing homes all around the world.
13. Methods that deal with resistance associated with TRUBP are
periprocedural antimicrobial therapy and broader spectrum prophylaxis.
Many agents are used by periprocedural antimicrobial therapy one of
which is oral fluoroquinolones because of their high bioavailability, less
time consuming with the peak serum concs and they are able to break
though the prostatic tissue. Microbial agents that are used to treat this
 infection are aminoglysides, metronidazole or clindamycin. Even the first,
second and third generation cephalosporins and trimethoprim
sulfamethoxazole. When taken along with amikacin and added
fluoroquinolone based treatments, the TRUBP infections are less risky.
Carbapenems when taken is shown to reduce the risk of TRUBP infections
and last but not least oral administration of a 3g dosage of fosfomycin
trometamol.
14. Four agents that are used to treat UTI are nitrofurantoin, fosfomycin,
pivmecillinam and trimethoprim sulfamethoxazole. Trimethoprim
sulfamethoxazole of all was recommended for patients with early
pyelonephritis. Women with acute cystitis the treatment duration ranges
from a single dose for fosfomycin, 3 days for trimethoprim
sulfamethoxazole/ fluoroquinolones and 5 days for notrofurantoin. Men
on the other hand should not exceed 14 days of antibiotic therapy.
15. A novel method, based on the concept of bacterial interference, was
developed for the management of recurrent UTI, which stated that
bacteria with low virulence compete with and protect against
colonization and infections, by pathogens. This was experiment first with
E.coli 83972, which was well adapted for growth, which established
persistent colonies, and outcompeting UPEC strains that can be used to
pre coat urinary catheters as another novel method. FimH and PapG
adhesions vaccines give protection as seen with primate models of UTIs.
Also together with vaccines they provided a framework to come up with
new prevention strategies.