Outlines 1. Antimicrobial © Classification of antibacterials e Antibiotics classes based on mode of action 2. Antimicrobial resistance e Mechanisms e MRSA, ESBL, MDRO, CRE 3. Antimicrobial stewardshipAntimicrobial - Definitions “Anti = against; mikros = litte; bios = life Any substance of natural, semisynthetic or synthetic origin that kills or inhibits the ‘growth of microorganisms but causes little or no damage to the host (selective toxicity). Can be classified as antibacterial, antifungal, antiparasitic or antiviral agents depending on the type of organisms targeted. Anti = against; biotikos = concerning life Asubstance produced by a microorganism that of a low concentration inhibits or kills other microorganisms. Do not include antimicrobial substances that are synthetic (sulphonamides and quinolones), or semisynthetic (methicillin and amoxicillin), or those which come from| plants (quercetin and alkaloids) or animals (lysozyme). All antibiotics are antimicrobial agents, but not all antimicrobial drugs are antibiotics. Univesity of Minne, AatimicoilRistance Leung Se, om ng ams om sua pharmacology antinssbiiantcromalraninsedutonClassification of Antibacterials Secret g Broad-spectrum vs Narrow-spectrum Pres een Effect on Bacteria Bacteriostatic vs Bactericidal + Inhibition of cell wall synthesis + Inhibition of protein synthesis + Inhibition of nucleic acid synthesis + Inhibition of cell membrane function + Inhibition of metabolic pathways Vor ete tertSaLes: EXAMPLES: erences ShenpentcosEXAMPLES: EXAMPLES: Chioramphenico! Aminogycosiges Enythromycin Betalaciams Ciindamycin Vancomycin ‘Sulfonamides ‘Quinotones Trimethoprim Rifampin Tetracycines ‘Metronidazolerasa Mode of Action Te Sindamyein Pencarnonacyicacd —Arineoyeoiiee Tigeoyeine ‘uinprnin Tethremycin FIGURE 17-1. Basic sites of antibiotic activity.Bacterial Cell Wall © Function: © Provide protection against osmotic lysis © Account for the shape of the cell © Confer rigidity upon bacteria (peptidoglycan) ‘Virulence factor (e.g. endotoxin) ~ Gram-positive Bacteria = Gram-negative BacteriaAntibacterial Agents that Inhibit Cell Wall Synthesis amt f 2tlactams Se so xe © Havea beta-lactam ringat the core of theirstructure. — saosouan © Bactericidal but only when bacteria are growing, Sti a La © Mode of action: block cross linking via binding to siege JR... penicillin-binding protein (PBP) ome 7 fcoraponame miperam BR Meropenem Deioonar Figure 102 fac ctuctres ard carck of commen used Teantcam antes. Te cre baeeacta ong is ngtgttod alow reach snare. Mecies fem Sars AA, Wht DO, er: ‘actor pat coer eelocubraroach Whingtn,, 104, AsitPess)ANTIMICROBIAL RESISTANCECHANISM OF RESIST ‘Antimicrobial inactivation Modify drug target in bacteria Reduce permeability in drug Export of drug from bacteria Bacteria produce enzymes that inactivate the drug Examples: 1 B-lactamases can inactivate penicillins Cephalosporins by cleaving the B-lactam ring of the drug Bacteria synthesize modified targets against which the drug has a reduced effect Examples: mutant protein in the 30S ribosomal subunit can result in resistance to streptomycin, [methylated 235 rRNA can result in resistance to erythromycin Bacteria reduce permeability to the drug such that an effective intracellular concentration of the drug is not achieved Examples: changes in porins can reduce the amount of penicillin entering the bacterium Bacteria actively export drugs using a “multidrug-resistance pump” (MDR pump, or “efflux” pump). ‘The MDR pump imports protons and exports a variety of foreign molecules including certain antibiotics, such as tetracyclin, sulfonamide and quinolone.~ GENETIC BASIS OF RESISTANCE * Chromosome-mediated * Plasmid mediated + Transposon mediatedA ehvomosomally-mediated resistance: mutant selection plasmid-mediated resistance: * = e Chromosome-mediated + Chromosomal resistance is due to a mutation in the gene that codes for either the target of the drug or the transport system in the membrane that controls the uptake of the drug. * Occurs less frequently than plasmnid- mediated. Plasmid mediated Very important from a clinical point of view for three reasons: (1) It occurs in many different species, especially gam negative rods. (2) Plasmids frequently mediate resistance to multiple drugs. (3) Plasmids have a high rate of transfer from one cell to another, usually by conjugation.Transposon wom ects + ‘Jumping genes” Pieces of DNA that move readily from one site to another either within or between the DNAs of bacteria, plasmids and bacteriophages. Not capable of independent replicationacterial Chromosome Vv: Bacterial Chromosome Located within the nucleoid Bacterial DNA that makes up the bacterial genome ‘The DNA is a single, circular molecule Lacks basic protein Bacterium Bacterial Plasmid chromosome Plasmid + Extrachromosomal double stranded circular DNA. that exist in the free state in the cytoplasm of bacteria, + Not essential for life + May confer on the host cell properties such as drug resistance and toxigenicity + Independent replication * Can be easily transferred from one cell to anotherTransfer of DNA between Bacteria (Horizontal Cell Transfer) * Conjugation + Transformation (purified DNA taken up by a cell) + Transduction (transferred by a virus from one cell to another) Tarctemabie taco “qabocenephoges Toqures cot oel crackB-lactams (peni cephalosporins, carbapenems, monobactams) Vancomycin Aminoglycosides Tetracyclines Cleavage by B-lactamase Altered targets (changes in the penicillin-binding proteins) Reduced permeability Efflux of drug out of the cell - e.g. P. aeruginosa Altered targets -Alteration in the molecular structure of cell wall precursor components decreases binding of vancomycin Target overproduction - excess peptidoglycan (Vancomycin-intermediate staphylococci) Modification of the drugs by plasmid-encoded phosphorylating (APH), adenylylating (ANT), and acetylating (AAC) enzymes Altered target (e.g. chromosomal mutation in the gene that codes for the target protein in the 30S subunit) Decreased permeability of the bacterium to the drug Increased efflux or impaired influx by an active transport protein pump Ribosomal protection due to production of proteins that interfere with binding site Enzymatic inactivationechanism of Resistance Antimicrobial Classes Tigecycline Macrolides, clindamycin, quinupristin Chloramphenicol Oxazolidinones Fluoroquinolones Rifampin Daptomycin Enhanced efflux Altered target (e.g. methylation of the rRNA) Enhanced efflux or reduced permeability of the cell membrane Enzyme inactivation (e.g. production of esterases that hydrolyse macrolides) Production of acetyltransferases that inactivate the drug, Altered target Altered target site (modification of bacterial DNA gyrase) Reduced permeability Enhanced efflux Altered target Altered targetechanism of Resistance Antimicrobial Classes a Sulphonamides + Altered target or lack of enzyme + Overproduction of PABA Trimethoprim + Altered target *+ Overproduction of dihydrofolate reductase + Reduced cell permeabilityBeta-Lactamases + Enzymes that open the beta-lactam ring, inactivating the antibiotic. + The B-lactamases produced by various gram-negative organism. * Clavulanic acid, tazobactam, sulbactam, and avibactam are penicillin analogues that bind strongly to B-lactamases and inactivate them. Bota tctamasa’ rp Nok PE \ Z ° of + Figure 10-8 Mod of bats lactamase enzyme activity, The enzyme eaves the beta-lactam ang, and the molecule can no longer bind 19 Penicair-bincing poitsins PPS) and is no longer ao tinh call wal ‘those. (Wedd trom Salyrs AA, Whit DD, ects: Bactoral patho- (genesis a molecular approach, Weshinglon, DC, 1904, ASM Press)eth Staphy aureus (MRSA) Methicillin resistance is mediated by PBP-2a, a penicillin-binding protein encoded by the mecA gene that permits the organism to grow and divide in the presence of methicillin and other beta-lactam antibiotics. The mecA gene is located on a mobile genetic element called staphylococcal chromosome cassette (SCCmec). PBP2a has a low affinity for beta-lactam antibiotics, resulting in resistance. Majority of HA-MRSA is associated with SCCmec types I, II and III and are multidrug resistant. In contrast, CA-MRSA strains have type IV or V SCCmec.Eaboratory diagnosis” + The CLSI clinical breakpoints for S. aureus are different than those for coagulase-negative staphylococci (CoNS) — see CLSI approved standard Mioo. + Oxacillin disk diffusion testing is not reliable for detecting oxacillin/ methicillin resistance. + Cefoxitin should be used as a surrogate for disk diffusion testing. Interpretive Criteria (in mm) for Cefoxitin Disk Diffusion Test S. gureus and S. 222mm, N/A 21mm lugdunensis Cons 225mm. N/A 24mmWhy are oxacillin and cefoxitin tested instead of methicillin? * Methicillin is no longer commercially available in the United States. * Oxacillin maintains its activity during storage better than methicillin. + However, cefoxitin is an even better inducer of the mecA gene, and tests using cefoxitin give more reproducible and accurate results than tests with oxacillin.MRSA - Treatment © Antibiotic of choice: vancomycin, daptomycin * Alternative agents: linezolid, ceftaroline © If mild infection, may consider trimethoprim-sulphamethoxazole, tetracyclines (such as doxycycline) or clindamycin. * Contact precautionExtended-spectrum beta-lactamases (ESBLs) Extended-spectrum beta-lactamases (ESBLs) are produced by several enteric bacteria, notably E. coli, Klebsiella, Enterobacter, and Proteus. ESBLs endow the bacteria with resistance to all penicillins, cephalosporins, and monobactams. + They can be inhibited by clavulanic acid, cephamycins (e.g. cefoxitin and cefotetan) or carbapenems.CAZ/CLA, CAZ, CTX, CTX/CLA © Cephalosporin/clavulanate combination disks Performed with confluent growth on Mueller-Hint ‘A difference of 5 mm between zone diameters of respective cephalosporin/clavulanate disks is conf * Broth microdilution - 3 twofold concentration de (MIC) of either cephalosporin in the presence of c! lone.¢ Third-generation cephalosporins and augmentin are kept 15-20 mm. apart, centre to centre, on inoculated Mueller-Hinton agar. e Aclear extension of the edge of the inhibition zone of cephalosporin toward augmentin disk (zone of enhancement) is interpreted as positive for ESBL production. Ceftazidime 30. Augmentin 20+10 Cefotaxime 30 wg Rawat Nal a) ended spectrum acanausin Gram Neue Hacer lo afer Di 05274Laboratory Detection of The E test ESBL strip carries two ea gradients: on the one end, cefotaxime; and on the opposite end, cefotaxime plus clavulanic acid. e Aratio of cefotaxime MIC to cri) cefotaxime-clavulanic acid MIC + equal to or greater than 8 eae indicates the presence of ESBL. Rawat Na a) ended specu ie Gram Neg acters ob ne i319): 269274Laboratory Detection of e Automated Systems (Vitek, Microscan) Pyrosequencing and microarray technologies - generally a task for a research laboratory \IESBLs - Treatment ¢ Carbapenems are the best antimicrobial agent for infections caused by ESBL producing organisms. ¢ However, piperacillin-tazobactam may be effective and a reasonable alternative for isolated UTIs given the much higher drug concentrations achieved in the urine compared with plasma. Contact precaution.AmpC Beta-lactamase © AmpC beta-lactamases are clinically important cephalosporinases encoded on the chromosomes of many of the Enterobacteriaceae and a few other organisms. © In many bacteria, AmpC enzymes are inducible and can be expressed at high levels by mutation. © Overexpression confers resistance to broad-spectrum cephalosporins including cefotaxime, ceftazidime, and ceftriaxone. ESBLs vs AmpCS © Can be chromosomally or plasmid mediated. [cepime va“AmpC Beta-lactamase oer Ty * Occur naturally in some bacteria, in which the enzymes are only formed and become effective when induced by Glactams (e.g. benzylpenicillin, ampicillin) + Include Enterobacter, Citrobacter freundii, Serratia, Morganella and Pseudomonas aeruginosa. Constant formation of the enzyme and lie on transmissible gene sections Transmissible Mostly detected in organisms without intrinsic AmpC gene (including E. coli, K. pneumoniae, Proteus mirabilis, Salmonella spp.)Carbapenem-resistant Enterobacterales (CRE) * Enterobacterales that test resistant to at least one of the carbapenem antibiotics (ertapenem, meropenem, doripenem, or imipenem) or produce a carbapenemase (an enzyme that can make them resistant to carbapenem antibiotics) are called CRE.Laboratory Testing of CRE Table 2A. Enterobacterales (Continued) ee Zone Diameter Breakpoits, eed Serene can at Content Ean as Ceo Imipenem | Meropenem Oe | ea cs 3 | Doripenem ys] = wa 1s] at mT A 3 Rrapanem TOs 25 Pat Carbapenemase-producing isolates of Enterobacterales usually test intermediate or resistant to one or more carbapenems using the current breakpoints as listed in Table 2ALaboratory Testing of CRE Two discs, and one disk is placed with EDTA. e Afj5 mm increase in zone diameter for disc added with EDTA vs without EDTA is suggestive of presence of metallo- [ilactamases.Posie: Meropenan ‘oo we 8 @) Na Jew © 7] Sm: wah meine stata the carbpenem action mithod (A). he edie etapeem ito atbapnet nation methodCRE - Treatment ¢ No definitive treatment as choice is difficult ° Choices: polymyxins, tigecycline, fosfomycin, aminoglycosides ° Contact precautionClindamycin-induced Becieianee © Gene involved: erm gene, which mediates the meth ribosomal RNA, thereby modifying the binding macrolides and clindamycin. © Clindamycin alone is a poor inducer of the met! bacterial isolates can appear falsely susceptible to ¢ Organisms to test: S. aureus, S. lugdunensis, CONS (in MH agar), S. pneumoniae, []- haemol! (in MHBA)Multidrug-Resistant (MDR)-Acinetobacter e Any Acinetobacter spp. testing non-susceptible (specifically, either resistant or intermediate) to at least one agent in at least 3 antimicrobial classes of the following 6 antimicrobial classes: ‘Aminoglycosides Amikacin, gentamicin, tobramycin Carbapenems Imipenem, meropenem, doripenem Fluoroquinolones Ciprofloxacin, levofloxacin Glactam/- lactamase Piperacillin, piperacillin/tazobactam inhibitor combination Cephalosporins Cefepime, ceftazidime Sulbactam Ampicillin/sulbatamANTIMICROBIAL STEWARDSHIP* Optimizing the use of antibiotics is critical to effectively treat infections, protect patients from harms caused by unnecessary antibiotic use, and combat antibiotic resistance. + Antimicrobial Stewardship Programs can help clinicians improve clinical outcomes and minimize harms by improving antibiotic prescribing. + Hospital antimicrobial stewardship programs can increase infection cure rates while reducing : Treatment failures IC. difficile infection Adverse effects Antibiotic resistance Q Hospital costs and lengths of stayThe basic principles of good stewardship are threefold: (1) Reduce inappropriate use of antibiotics, (2) Encourage targeted treatment with narrow spectrum antibiotics (3) Limit adverse effectsTABLE 10-1 Basic Principles of Anti icrobial Drug Stewards! Current Problems in the Use of Antibiotics Role of Antimicrobial Drug Stewardship in Mitigating These Problems Inappropriate use of 1. Use antibiotics only when a microbiologic diagnosis indicates effectiveness antibiotics 2. Empitic therapy should be tailored to the most likely pathogen(s) 3, Send appropriate cultures before starting antibiotics, Overuse of broad-spectrum _1.. Use narrow-spectrum antibiotics whenever possible antibiotics 2. Require approval for the use of advanced generation broad-spectrum antibiotics High rate of adverse effects 1. Stop antibiotics as soon as appropriate to reduce adverse effects, such as antibiotic-associated colitis caused by Clostridium diffe 2. Be aware ofthe effect ofthe patient’ renal function on the dose of antibiotic prescribed 43. Be aware of the patient's hypersensitivity to specific antibiotics 4. Determine whether the patient’s declared hypersensitivity is correct and clinically significant 5. Warn patients regarding certain idiosyncratic drug reactions, such as photosensitization