Antimicrobial Resistance

Dr. Ng Woei Kean

Ph.D. (Molecular Medicine)
 Mechanisms of Resistance
I. Accumulation barriers to an antimicrobic due to
impermeability or active efflux
II. Alterations of an antimicrobic target, which
render it insusceptible
III. Inactivation of an antimicrobic by an enzyme
produced by the microorganism.
 I. Accumulation Barriers
• The cell wall, particularly the outer membrane, of
Gram-negative bacteria presents a formidable
barrier for access to the interior of the cell.
• Outer membrane protein porins restrict access
to interior of bacteria.
• Pseudomonas aeruginosa commonly develop
resistance to imipenem due to loss of the outer
membrane protein most important in its
penetration.
• Some antimicrobics must be actively transported
into the cell. Bacteria such as streptococci,
enterococci, and anaerobes, which lack the
necessary oxidative pathways for transport of
aminoglycosides, are resistant.
• Some bacteria have energy-dependent efflux
mechanisms that pump either tetracyclines or
fluoroquinolones from the cell.
Accumulation barrier resistance. A, B, C, and D molecules are external to the
cell wall. A molecules pass through and remain inside the cell, B molecules
are unable to pass because they cannot fit through any of the channels, C
molecules pass through but are pushed back out by an efflux pump, and D
molecules must be pulled through the wall by an active process.
 II. Altered Target
• Once in the cell, antimicrobics act by binding
and inactivating their target, which is typically a
crucial enzyme or ribosomal site.
• If the target (enzyme or ribosome) is altered in a
way that decreases its affinity for the
antimicrobic, the inhibitory effect will be
proportionately decreased.
• Alteration in transpeptidases (also called
penicillin-binding proteins, PBP), via gene
mutation, causes penicillin resistance.
• PBP alterations are the prime reason for
emergence of penicillin-resistant pneumococci
and methicillin-resistant Staphylococcus aureus
(MRSA).
• Some bacteria acquired resistance via synthesis
of new enzyme. Vancomycin-resistant
enterococci have enzyme systems that
substitute an amino acid in the terminal position
of the peptidoglycan side chain. Vancomycin
does not bind to the alternate amino acid, and
these strains are resistant.
• Resistance to sulfonamides occurs by
acquisition of new enzymes with low affinity for
these agents but still allows bacterial cells to
carry out their respective functions in the folate
synthesis pathway.
A normal transpeptidase is inactivated by penicillin, but penicillin no
longer attaches to those with altered binding sites. The transpeptidase
is still able to carry out its cross-linking function so the β-lactam is no
longer effective. Here, vancomycin is no longer able to bind to its
usual site, because another amino acid with a different shape has
been substituted.
 III. Enzymatic Inactivation
• Most powerful and robust of the resistance
mechanisms.
• The secreted enzymes by bacteria may disrupt
or chemically modify an antimicrobial agent.
• Two groups:
- β-lactamases
- Modifying enzymes
β-lactamases
• Break open the β -lactam ring and inactivate
various members of the β-lactam group.
• Penicillinase produced by S. aureus can
inactivate penicillin.
• Major type of β-lactamases: Gram-positive β-
lactamases, extended-spectrum β-lactamases
(ESBLs), metallo β-lactamases (MBL).
Modifying Enzymes
• Chemically modify antimicrobial agent
(particularly aminoglycosides) by acetylate,
adenylate, or phosphorylate hydroxyl or amino
groups.
• Chemically modified aminoglycoside no longer
binds to the ribosome.
Summary: Mechanisms of Resistance
 Genetic Origin of
Antimicrobial Resistance
• Most antimicrobial resistant microbes emerge as
a result of genetic change and subsequent
selection processes by antimicrobial agents.
• The inheritance can be either:
- Chromosomal resistance
- Extrachromosomal resistance
Chromosomal Resistance
• Due to spontaneous mutation in a locus that
controls susceptibility to a given antimicrobial
agent.
• The presence of the antimicrobial agent serves
as a selecting mechanism to suppress
susceptible organisms and favour the growth of
antimicrobial-resistant mutants.
• E.g. Mutation results in the loss of PBPs, making
such mutants resistant to β-lactam
antimicrobials.
Bacterial resistance to antibiotics:

Selection

Bacteria with various

antibiotics resistance
level

Antibiotics

When antibiotics is often been

use, mutant bacteria which is Final population
resistance will have selective
advantage to reproduce and Antibiotics resistance level
colonise the environment without
any competition.
Extrachromosomal Resistance
• Some plasmids carry genes for resistance to
one and often several antimicrobial antimicrobial
agents.
• Plasmid genes for antimicrobial resistance often
control the formation of enzymes capable of
destroying the antimicrobial agents.
• Plasmids determine resistance to penicillins and
cephalosporins by carrying genes for the
formation of β-lactamases.
• Plasmids code for enzymes that acetylate,
adenylate, or phosphorylate various
aminoglycosides
• Genetic material and plasmids can be
transferred by transduction, transformation, and
conjugation.
 Control of Resistance
• Use antimicrobics conservatively and specifically
in therapy.
• Use an adequate dosage and duration of
therapy to eliminate the infecting organism and
reduce the risk of selecting resistant variants.
• Select antimicrobics according to the proved or
anticipated known susceptibility of the infecting
strain whenever possible.
• Use narrow-spectrum rather than broad
spectrum antimicrobics when the specific
etiology of an infection is known, if possible.
• Use antimicrobic combinations when they are
known to prevent emergence of resistant
mutants.
• Use antimicrobics prophylactically only in
situations in which it has been proven valuable
and for the shortest possible time to avoid
selection of a resistant flora.
• Avoid environmental contamination with
antimicrobics.
• Rigidly apply careful, aseptic and handwashing
procedures to help prevent spread of resistant
organisms.
• Use containment isolation procedures for
patients infected with resistant organisms that
pose a threat to others, and use protective
precautions for those who are highly
susceptible.
• Epidemiologically monitor resistant organisms or
resistance determinants in an institution and
apply enhanced control measures if a problem
develops.
• Restrict the use of therapeutically valuable
antimicrobics for nonmedical purposes.