Antimicrobial Therapy: Principles of Use Roger Finch, FRCP, FRCP(Edin), FRCPath, FFPM

Antimicrobial drugs have unique characteristics that distinguish them from other therapeutic agents. They are targeted primarily at invading microorganisms, against which they exhibit selective toxicity. Infection may occur at any site; therefore, therapeutic drugs must be distributed widely at appropriate concentrations. The risk to benefit ratio varies depending on the severity of the infection. Antibiotics that are used prophylactically must have a low side-effect profile. In addition to their action on infecting microorganisms, antibiotics often affect the normal flora of the skin and mucous membranes. This can result in superinfection and occasionally drug resistance, which may affect the patient and can have a wider ecological impact. Excessive or inappropriate use is linked to high rates of drug resistance. The following general principles of choice and use of antimicrobial agents apply to the treatment and chemoprophylaxis of bacterial, fungal, viral and parasitic infections. Clinical Assessment Ideally, the initial clinical assessment of the patient should be supported by laboratory investigations to establish a definitive microbiological diagnosis and to determine the susceptibility of the infection to various drugs. Clinical assessment can confidently predict a specific microbial aetiology in only a few infectious diseases.

Erysipelas is caused primarily by Streptococcus pyogenes; impetigo may be caused by S pyogenes or Staphylococcus aureus. The clinical manifestations of herpes simplex virus (HSV) infections are usually diagnostic. Streptococcus pneumoniae is the usual cause of community-acquired pneumonia, but other microorganisms must be considered (eg, methicillinresistant S aureus (MRSA) in nursing-home residents). Most of the common viral exanthems that are not preventable by immunization occur in childhood. Meningitis in infancy is usually caused by Neisseria meningitidis or S pneumoniae in countries where immunization has eliminated Haemophilus influenzae infection. In neonates, Escherichia coli and group B streptococci predominate. Dysuria and frequency accompanied by loin pain indicates acute pyelonephritis, which is usually caused by Gram-negative enteric pathogens

and for which an injectable cephalosporin, co-amoxiclav or ampicillin plus gentamicin in the presence of severe sepsis, is appropriate. A history of recent travel can suggest a possible microbial aetiology for acute gastroenteritis and alerts laboratory staff to undertake the appropriate investigations. Immunosuppression and profound immunodeficiency are important determinants of infection. The underlying deficiency (eg, HIV infection, neutropenia) also affects the clinical expression of the disease. Fever complicating neutropenia that fails to respond to broad-spectrum antibacterial drugs should prompt consideration of viral or fungal disease. When there is evidence of lung involvement clinically or radiographically, invasive pulmonary aspergillosis is highly likely, for which treatment with voriconazole or amphotericin is indicated. Laboratory Investigations Initially, most prescribing of antibiotics is empirical. It is important to establish the microbial cause of an infection in hospitalized and severely ill patients or when initial treatment is unsuccessful. Appropriate samples should be taken before beginning antimicrobial therapy, but this should not delay treatment. In certain life-threatening conditions (eg, meningococcal meningitis, septicaemia), prompt administration of penicillin in the community at the first medical assessment can be life-saving. This does not prevent subsequent precise microbial diagnosis; the CSF culture is often sterilized rapidly, yet the pathogen may still be visible in CSF or may be cultured from a throat swab, and bacterial DNA may be detectable by polymerase chain reaction analysis. Susceptibility provides valuable epidemiological information on antibiotic resistance trends in the community and in specific hospital environments (eg, ICU, transplant units, burns units). Drug resistance is also increasing in non-bacterial pathogens. Thymidine kinase-deficient mutants of HSV that are resistant to aciclovir are emerging. Candida albicans is exhibiting increasing resistance to fluconazole, and intrinsically resistant species (eg, Candida krusei) have become more common. The in vitro susceptibility of microorganisms does not necessarily equate with or reflect the clinical efficacy of drugs. Some pathogens (eg, Legionella pneumophila, Salmonella enterica serovar Typhi) are intracellular and, despite in vitro evidence that they are susceptible to a wide range of antibiotics, only drugs that concentrate intracellularly (eg, erythromycin, clarithromycin, ciprofloxacin and levofloxacin) are clinically effective. This emphasizes the need for good clinical trial data to guide treatment strategies.

Impact of Antibiotic Resistance One of the main pressures for change in prescribing practice is antibiotic resistance. Since antibiotics became widely available, there have been major changes in the susceptibility of many common target pathogens (Table 1). Resistance in Gram-negative bacteria such as coliforms, Pseudomonas aeruginosa and non-fermenters (eg, Acinetobacter spp.) occurs mainly in hospitals. Antibiotic resistance in hospitals commonly arises in high-dependency areas where the staff to patient ratio is high, patients are very ill and their normal defences are breached by, for example, mechanical ventilation. Resistance is also increasing in community pathogens such as E coli while rates have stabilized or declined for H influenzae and S pneumoniae.1 S pneumoniae with reduced susceptibility to penicillin is a global problem which has resulted in major changes in the management of serious pneumococcal infection.2 However, where conjugate pneumococcal vaccine has been introduced, resistance rates have also declined.3 Ampicillin and trimethoprim and, more worryingly, ciprofloxacin are becoming increasingly ineffective against urinary tract infection (UTI). There is no clear guidance on the incidence of antibiotic resistance at which alternative therapy is required. In the authors opinion, in UTI, a clinical failure rate of 10% or more that is shown to result from in vitro resistance indicates that alternative empirical therapy should be given. This is certainly the case in more serious and potentially life-threatening infections. Mechanisms of resistance: antibacterial drugs act at various sites (Figure 1) in the bacterium to inhibit growth; resistance may therefore occur by several mechanisms.

In resistant strains, the target site may be absent, lost or bypassed. Resistance may therefore be intrinsic, as in the case of the lack of activity of erythromycin or chloramphenicol against P aeruginosa. The drug may fail to reach its target site because of impaired permeability, enzymatic inactivation or substrate competition. In Gram-positive bacteria, the outer membrane is penetrated by passive diffusion; in Gram-negative bacteria, penetration is facilitated by protein channels (porins). Changes in the porin channels affect drug penetration.

Enzymatic inactivation is an important cause of drug resistance. It is best seen in the -lactam antibiotics (eg, penicillins, cephalosporins). -lactamase enzymes are present extracellularly in Gram-positive bacteria, but are found in the periplasmic space of Gram-negative bacteria. In the periplasmic space, penicillin-binding proteins are the receptor sites for -lactam antibiotics; changes in or absence of these binding proteins can cause drug resistance. In efflux resistance, the antibiotic (eg, tetracycline, macrolides, fluoroquinolones) is extruded from the cell by an energy-dependent mechanism.

Transfer resistance can be acquired genetically and transferred (Figure 2) to other organisms by:

conjugation (physical contact between two cells) transduction (transfer of genetic material by a bacterium-specific bacteriophage) transformation (uptake of free extracellular genetic material).

Conjugation is the best-known method by which plasmid DNA encoding drug resistance is transferred. Examples include plasmid-mediated ampicillin resistance in Haemophilus influenzae and multiple antibiotic resistance in Salmonella spp. Transposons can also encode for resistance and can translocate from plasmid or chromosome. Mode of Action The site and mode of action of antimicrobial drugs vary widely, and determine whether an agent is microbicidal or inhibitory against a pathogen. In most circumstances, this makes little difference to the response because host defences eliminate non-replicating pathogens. The clinical relevance of selecting cidal or static agents arises when dealing with infections in immunocompromised patients, particularly those with neutropenia. In moderate neutropenia (neutrophil count <0.5 109/L) or severe neutropenia (neutrophil count <0.1 109/L), bactericidal agents are essential. They are also indicated in bacterial meningitis. A cidal regimen is also required for the treatment of infective endocarditis; the infected plateletfibrin vegetation is a physical barrier to phagocytic cells and hence prolonged high bactericidal concentrations of drugs are mandatory. Pharmacokinetic Behaviour Oral drugs are absorbed principally from the stomach and proximal small bowel.

Absorption of acid-labile agents (eg, some -lactams), which are hydrolysed by gastric acid, can be improved by using enteric-coated preparations that delay drug release until they have passed through the stomach. Alternatively, a pro-drug can be used; this is inactive, but after ingestion undergoes hydrolysis to release the active drug (eg, some formulations of oral aminopenicillins). Most drugs are best absorbed on an empty stomach, but some (eg, co-amoxiclav, doxycycline, metronidazole) are better absorbed with food. Parenteral (intravenous) therapy is indicated:

in seriously ill patients when effective drug concentrations are required rapidly at the site of infection when oral administration is contraindicated by vomiting, recent gastrointestinal surgery or ileus with certain agents that are not absorbed from the gut (eg, aminoglycosides, glycopeptides).

Parenteral administration of antibiotics in the severely ill is not always justified. Agents that exhibit high bioavailability following oral administration (eg, fluoroquinolones) may be given by mouth even in the moderate-to-severely ill. This can result in significant cost savings. Intramuscular administration is declining in popularity. In patients who are in a state of cardiovascular collapse with poor tissue perfusion, tissue absorption of drugs is less reliable with intramuscular than with intravenous administration. Topical antimicrobial agents are poorly absorbed and are used only in the treatment of: superficial skin infections and dermatomycoses mucosal candidiasis superficial ocular infections and otitis externa intraocular infections MRSA decolonization Clostridium difficile infection (oral vancomycin). Relationship between dosing regimen and target microorganism: Figure 3 shows a typical dose response curve in relation to the minimum inhibitory concentration (MIC) of a hypothetical target organism. Concentration-dependent killing applies to aminoglycosides and quinolones; higher concentrations, though more rapidly bactericidal, are limited by safety. Aminoglycosides are now increasingly prescribed as a once-daily dose rather

than the former thrice-daily regimen. However, in selected patients there are few data available for once-daily dosing of aminoglycoside, and it is therefore inappropriate in endocarditis, cystic fibrosis, pregnancy and childhood, and in patients with profound neutropenia or established renal failure. Time-dependent killing is critical for -lactams (eg, penicillins, cephalosporins). Sustained concentrations of more than the MIC are more effective than intermittent high peaks. This can be refined by relating the area under the curve (AUC) to the MIC; this AUC:MIC ratio is a better predictor of -lactam performance. To maintain concentrations of -lactams in excess of the MIC of target pathogens, these drugs might theoretically be best administered by continuous infusion. Dosing regimens were formerly largely derived from knowledge of the pharmacokinetic profile, tissue penetration and the susceptibility of target organisms. However, they are increasingly determined according to pharmacokinetic/pharmacodynamic principles in which in vitro activity is mathematically linked to the pharmacokinetic profile as described above.4 This approach can be used to predict more accurately the unit dose and frequency of administration, and to define the regimen least likely to encourage emergence of resistant pathogens by avoiding sub-inhibitory concentrations. Protein binding antibiotics are generally bound to plasma albumin to varying degrees. Highly bound agents include flucloxacillin (95%) and fusidic acid (97%); these contrast with amoxicillin (20%) and ciprofloxacin (30%). Dissociation of drugs from the bound (inactive) to unbound (active) state is usually rapid. Evidence is accumulating from pharmacodynamic studies that highly bound agents are less satisfactory against organisms of marginal susceptibility. However, in most mild-to-moderate infections, the degree of protein binding has no discernible clinical impact. Post-antibiotic effect (PAE) is the time taken, in hours, for regrowth of a target organism in vitro following initial inhibition and subsequent removal of an antibiotic. There is variation between strains, but with Gram-negative bacilli (including P aeruginosa), the aminoglycosides and quinolones generally have a prolonged PAE, whereas most -lactams do not. The prolonged PAE observed with aminoglycosides is further supported for once-daily administration. Therapeutic index is the relationship between the therapeutic concentration of a drug and the toxic concentration. This index is usually high for penicillins and cephalosporins. With agents such as aminoglycosides and amphotericin, the potential for toxicity is greater; doses of these drugs must be calculated using an mg/kg schedule, and toxicity must be monitored clinically and biochemically during use. Therapeutic drug monitoring is essential in conventional treatment with aminoglycosides, to ensure that serum concentrations are therapeutic but not toxic. There is less need with once-daily administration and short courses, and in patients with stable renal function. Duration of Treatment There are very few infections for which the duration of treatment has been precisely defined. This reflects the fact that the endpoints for assessing response to therapy are

largely clinical rather than microbiological. Clinical features that are driven by the inflammatory response inevitably subside after microbial elimination. However, the following treatments are known to be effective, and partly reflect the inherent susceptibility of the target infection:

single-dose therapy with selected antibiotics in gonococcal urethritis, syphilis and uncomplicated symptomatic UTI penicillin for 4 or 6 weeks respectively in infective endocarditis caused by penicillin-sensitive viridans streptococci or enterococci 6-month course of treatment with rifampicin and isoniazid (plus ethambutol and/or pyrazinamide for the first few weeks) pending susceptibility data in pulmonary tuberculosis.

In most other conditions, the licensed conventional duration of therapy is 714 days, although a total of 5 days treatment is adequate in most situations. It has been customary to treat serious infections with parenteral agents and to change to oral therapy after a few days when the patient is stable and the fever has subsided. Combination Therapy A single agent is generally preferred to a multi-drug regimen. It reduces the risks of toxicity and interactions, and the cost of treatment. Some antibiotic combinations are antagonistic. For example, treatment of pneumococcal meningitis with penicillin and tetracycline is inferior to treatment with either antibiotic alone because the bacteriostatic action of tetracycline interferes with the bactericidal action of penicillin on dividing cells. However, there are circumstances in which combination therapy is appropriate and essential. Empirical therapy to cover several pathogens is a common indication for combination therapy. This applies particularly to acute and potentially life-threatening infections in which the range of potential pathogens cannot be defined or covered by a single agent.5 In severe community-acquired pneumonia, the combination of a broad-spectrum -lactam (co-amoxiclav or a cephalosporin such as cefuroxime, cefotaxime or ceftriaxone) and a macrolide (clarithromycin) administered parenterally is recommended in the British Thoracic Society guidelines.6 These regimens target both conventional respiratory pathogens and atypical organisms (eg, Legionella pneumophila, Mycoplasma pneumoniae). In peritonitis secondary to a perforated viscus, infection is usually with mixed aerobic and anaerobic microorganisms. Combined therapy with metronidazole and a broadspectrum aerobic Gram-negative agent (eg, cefotaxime, gentamicin, ciprofloxacin) provides cover against most pathogens. If enterococci may be present, ampicillin should also be given. Microbiological information obtained from samples taken at the time of admission may allow the drug regimen to be changed to a single agent later.

Following the recent rapid increase in severe invasive infections caused by MRSA, initial empirical therapy of severe sepsis in patients known to be colonized with MRSA or resident in a high-prevalence unit (including nursing homes) should include a glycopeptide (eg, vancomycin, teicoplanin) as part of a broad-spectrum regimen.7 This can be modified in the light of subsequent microbiological data. Synergism: occasionally, two drugs are prescribed that together have an inhibitory effect greater than that achieved by the individual components. An example is the use of penicillin and gentamicin to treat enterococcal endocarditis; the two agents are synergistic in vitro and clinically more effective than penicillin alone. This combination is also used to treat viridians streptococcal endocarditis when the MIC of penicillin exceeds 0.5 mg/L.8 Another example is the use of amphotericin with flucytosine as initial induction therapy in the treatment of cryptococcal meningitis complicating HIV infection; the combination is more rapidly fungicidal than monotherapy with fluconazole.9 Avoiding drug resistance: M tuberculosis exhibits naturally occurring low-incidence resistance to isoniazid (approximately 1 in 106 microorganisms) and rifampicin (approximately 1 in 108 microorganisms); should a single agent be inappropriately prescribed, initial clinical improvement is followed by relapse when the resistant strains multiply. Using a combination of rifampicin and isoniazid, the opportunity for drug-resistant strains to emerge is significantly reduced. To minimize the possibility that primary resistance to one of these agents will cause relapse, standard antituberculous regimens initially use at least three or four drugs until susceptibility information is available. Chemoprophylaxis is used widely in surgery and in medical conditions in which:

the risk of infection is predictable or the consequences of sepsis are profound the target organisms are predictably sensitive the prophylactic regimen is safe and well tolerated.

Short-course perioperative antibacterial prophylaxis is used widely in contaminated and clean-contaminated surgical procedures.10 For example, in colorectal surgery, chemoprophylaxis is directed against anaerobic and aerobic flora; co-amoxiclav or metronidazole, usually in combination with gentamicin or a broadspectrum cephalosporin, is begun about 1 hour before surgery.11 In other situations, the advantages of chemoprophylaxis are less clear. Although new indications are being suggested (eg, in clean elective procedures such as mastectomy and herniorrhaphy, in some types of keyhole surgery), perioperative chemoprophylaxis has not been widely used. This has been challenged on the basis of large studies of the pharmacoeconomics of infection. Medical prophylaxis: single-dose or short-course prophylaxis with rifampicin, ceftriaxone or ciprofloxacin (adults only) is used to prevent meningococcal infection in close contacts of patients with meningitis. In patients with asplenia/hyposplenism or previous rheumatic fever, long-term penicillin is given.12 Antibiotic prophylaxis is no longer routinely recommended for patients known to be at risk of infective

endocarditis.13 Finally, selected antibiotics and antifungals are used prophylactically in patients with malignant disease undergoing chemotherapy to cover periods of profound neutropenia.

Declaration of Interest

Professor Finch has received lecture fees (Bayer) and conference support (Astellas, Novartis, Wyeth) and holds consultancies with Astellas, Novartis, ABRI, Mayne Pharmaceticals, Glaxo SmithKline, Pfizer, Prolysis, Mutabilis and Menarini.

References 1. BSAC Resistance Surveillance Web site. www.bsacsurv.org. Accessed 28 July 2009. A complete list of references can be obtained upon request from the editor. 2009 Elsevier Ltd. Initially published in Medicine 2009;37:545550.

About the Author

Dr Finch is Professor of Infectious Diseases in the City Hospital and University of Nottingham, UK.

Antibiotic Resistance Geoff Scott, MD In an environment containing vast numbers of microorganisms saturated with or repeatedly exposed to antibiotics, Darwinian theory predicts the inevitable selection of resistant organisms. Following the introduction of a new antibiotic, resistant strains may be reported within as little as one year, and after a latent interval of some years, resistance increases dramatically and the value of the antibiotic for empirical therapy is reduced. (Antibiotic is a term technically used for natural products of fermentation and the synthetic molecules are called antimicrobials: however, the terms now seem to be used interchangeably). StaphylococcuS aureus is now almost uni-versally resistant to penicillina phenomenon first observed in hospital outbreaks of surgical sepsis in the late 1940s. This organism has shown a remarkable facility to become resistant to every antibiotic introduced, even vancomycin. Reduced sensitivity to van-comycin (vancomycinintermediate S aureus) is associated with a thick peptidoglycan cell wall. The complex gene cassette for vancomycin resistance in Enterococcus spp (vanA) can easily be transferred to S aureus in vitro and has now been detected in methicillinresistant S aureus (MRSA), making the organism fully resistant to glycopeptides. It is only a matter of time before strains are seen that are sensitive to only a small number of novel antibiotics in development and perhaps some of the older antibiotics (eg, tetracycline, chloramphenicol). In contrast, some organisms have not yet acquired resistance despite huge pressures; these include StreptococcuS pyogenes, Gram-positive anaerobes such as Clostridium spp and Peptostreptococcus spp and Neisseria meningitidis (to penicillin).

Almost all anaerobes were considered to be sensitive to metronidazole until recent reports from Spain, France and the USA suggested that resistant Bacteroides fragilis may soon become a serious problem. Ecology Resistance is driven by antibiotic use in human and agricultural/veterinary practice. Resistance selection occurs by spontaneous mutations occurring at a rate of 10-910-6 driven by the presence of antimicrobials. Resistance elements appear in saprophytic bacteria as a result of antibiotic use for growth promotion and protecting crops. When these are eaten, resistance may be transferred to human bacteria that are occasionally pathogenic. The likelihood of finding resistant organisms in the gut is related to the tonnage of antibiotic use in the country in which the individual resides, and depends on the ease with which a resistance mechanism can arise. Novel resistance is usually detected in different places in the world at about the same time, implying that antibiotic pressures are similar worldwide and that bacteria have limited means of dealing with the problem of survival. Following the appearance of one mutantresistant progeny, rapidly replicating bacteria can recolonize carrier sites in less than 24 hours. A resistant mutant of Mycobacterium tuberculosis, which replicates once every 24 hours, can recolonize diseased lung within two weeks. Once resistance has been selected, organisms transferred from person to person continue to be resistant. When the antibiotic pressure is removed, novel colonizing and infecting flora tend to revert to the sensitive phenotype. Some bacteria containing large resistance plasmids are considered unfit and seem to disappear from the clinical environment more easily than others. Resistance and Choice of Antibiotics The term antibiotic resistance implies that a particular antibiotic is ineffective in a clinical infection. This may be because the organism is inherently resistant to the antibiotic or because it is inaccessible. in vitro, resistance is defined by measuring the minimum inhibitory concentration (MIC) and the minimum bactericidal concentration (MBC) of the antibiotic against an organism, under ideal laboratory conditions, using appropriate controls to define the cut-off points between resistant, intermediate and sensitive. Methods of testing in the laboratory are problematic, however, and any result that does not correlate with clinical experience should be challenged. Low MIC and high MBC imply that an antibiotic is bacteriostatic; that is,

it inhibits the growth of an organism but is unable to kill it. Even with bactericidal antibiotics, killing in vivo normally requires an intact immune system. Thus, although bacteriostatic antibiotics are ineffective in neutropenic sepsis, bactericidal antibiotics may suppress infection only for it to recrudesce when the antibiotic is removed. This observation governs strategies for the management of such infections. Paradoxically, even when an organism is declared resistant to an antibiotic by in vitro tests, it may appear to be effective in clinical use; this may be because MIC/MBC can be exceeded in vivo by giving a sufficiently large dose. This is often seen in lower urinary tract infection and in the treatment of, for example, non-meningeal penicillinresistant pneumococcal infection with high-dose penicillin. Empirical treatment: management of an infection before bacteriology results are available depends on making the correct diagnosis and assessing the antibiotic sensitivities of the suspected organism or organisms from local epidemiological knowledge. Once culture results are known, it is usually another day before in vitro antibiotic sensitivities are available. This is a critical period in the management of an infected patient and explains why, in severe infections, broad-spectrum antibiotics are often chosen initially when the definitive diagnosis is uncertain and why withholding treatment may be life-threatening. This period is generally more protracted when an organism such as M tuberculosis is slow to grow in vitro. Delay in the treatment of tuberculous meningitis may lead to permanent neurological damage. Whether the correct antibiotics were chosen initially is known only weeks later. Mechanisms of Resistance Resistance may be inherent (eg, vancomycin against Gram-negative organisms, nitrofurantoin against Proteus spp) or acquired via genetic elements encoding three fundamental mechanisms:

production of inactivating enzymes change in the target site exclusion of the antibiotic from the target site (Figure 1). The last may occur by restriction of access through porins (only in Gram-negatives) or by active excretion.

Antibiotic-inactivating enzymes may be produced in vast excess, surrounding the organism (eg, -lactamase from S aureus), or in limited amounts in the periplasmic space of Gram-negatives. The effect in vivo is similar, but the latter organisms may appear sensitive in vitro. Classically, this is seen in Enterobacter spp resistant to extended-spectrum -lactam antibiotics such as piperacillin and cefotaxime; exposure of the organism to inducers such as penicillin, clavulanate, certain cephalosporins and imipenem may switch on the production of chromosomal (AmpC) -lactamases. The classical TEM (Escherichia coli) and SHV (Klebsiella spp) -lactamases (which inactivate ampicillin) have shown a remarkable ability to mutate to extendedspectrum forms (which inactivate cefoxitin and cefotetan) and to inhibitor resistance (not inhibited by clavulanate or tazobactam). ctx-M cefotaximase arose by escape from the chromosome of Kluyvera spp and is now widespread in Enterobacteriaceae including E coli.

Other classical inactivating enzymes include chloramphenicol acetyltransferase and aminoglycosidemodifying enzymes. Target site change may be a structural alteration preventing binding of an antibiotic, or a mechanism whereby the metabolic pathway that is normally inhibited is bypassed by an alternative one. This is seen in sulphonamide resistance and in methicillinresistant S aureus (MRSA), which has acquired a novel penicillin-binding protein from Staphylococcus scuiri. Important target site changes include topoisomerases II and IV (quinolones), subunit of DNA-dependent RNA polymerase (rifamycins) and methylation of 23S target (14/15-membered macrolides). Exclusion of antibiotic: porins are protein structures embedded in the outer bilipid membrane only of Gram-negative organisms.1 They control what passes into and out of the cell on the basis of molecular size and charge. Mutations in the genetic elements encoding porins (permeability mutations) may exclude one antibiotic or, more commonly, multiple antibiotics. Pseudomonas aeruginosa has two outer lipid membranes, produces -lactamases constitutively, and therefore tends to be more resistant than coliforms. Alternatively, organisms may actively excrete antibiotics, notably tetracyclines, macrolides and quinolones. Efflux pumps may be up-regulated, usually by exposure to the antibiotic in question. S aureus resistant to erythromycin by active excretion remains sensitive to clindamycin, but the more common target site mutation affects susceptibility to both antibiotics. Acquisition of Resistance Direct mutation of chromosomal genes may lead to resistance, and non-fatal mutations are passed to all progeny. Alternatively, small, mobile, circular pieces of DNA termed plasmids, which exist in the cytosol separately from the chromosome, may be passed from one bacterium to another (even to bacteria of different species) by various mechanisms such as direct transfer by type II pili (Figure 2) and phage transfer. Plasmids reproduce each time the organism divides and can probably be lost as easily as gained, given the correct environment. Transposons are large genetic elements often containing multiple genes necessary to confer phenotypic resistance. They may encode pheromones, which attract bacteria to each other and can be transferred on plasmids, generally being incorporated into the

chromosomal DNA of the new host. Free DNA from dead bacteria and even mammalian cells can be incorporated into bacterial chromosomes. A remarkable mechanism of resistance is seen in penicillin-resistant Streptococcus pneumoniae, which have incorporated a mosaic of genes into the chromosome from other resistant a-haemolytic streptococci (eg, Streptococcus milleri). Problematic Resistant Bacteria
Gram-positive organisms

MRSA has replaced methicillin-sensitive S aureus as the more common cause of hospital-associated sepsis in most parts of the world. The targets of the -lactam antibiotics are penicillin-binding proteins (PBPs), carboxypeptidases and transpeptidases, which catalyse bridging of pentapeptide subunits of peptidoglycan. All strains of MRSA already produce penicillinase, but they now have a new penicillin-binding protein (PBP2') that is not inhibited by methicillin and its congeners oxacillin and flucloxacillin. They are resistant to all -lactam antibiotics. The mecA gene encodes PBP2', but requires expression of several ancillary genes within a transposon for full expression. Thus, some strains with mecA may appear to be sensitive to methicillin in vitro. In addition, a plasmid encodes resistance to a variable number of other antibiotics. Strains with a tendency to spread easily and to predominate in hospitals are termed epidemic MRSA (EMRSA). The current epidemic of EMRSA15 or EMRSA16 in the UK started in 1994. In the laboratory, these are detected by their antibiogram, but other typing methods (eg, pulsed-field gel electrophoresis of chromosomal DNA) are needed to show that two strains are indistinguishable, thus implying a common parent organism and that cross-infection might have occurred. When a few patients in one or two wards acquire a novel strain, such an outbreak can easily be tracked and then controlled. When EMRSA strains become endemic (Figure 3), more general measures are needed to reduce the risk to patients admitted to the hospital. MRSA may become endemic in nursing homes, creating a pool for novel introduction into hospital; transfer of patients from ward to ward and colonization of staff leads to continued exposure of patients to new strains and helps maintain endemicity. Infection with MRSA is not untreatable. Strains are often (although not predictably) susceptible to gentamicin or other aminoglycosides, rifampicin, co-trimoxazole, chloramphenicol or ciprofloxacin, and sometimes to tetracyclines, macrolides, fusidic acid and pseudomonic acid. Note that rifampicin and fusidic acid should never be used alone because resistant mutants are selected very rapidly. MRSA is almost always susceptible to glycopeptides, although strains with reduced sensitivity to vancomycin have been occasionally described in patients with chronic colonization or infection who have been treated for several weeks.2 Some very rare strains of S aureus are dependent on vancomycin to allow them to grow. Penicillin-resistant S pneumoniae strains have shown a gradual phase-shift increase in MIC to penicillin over several years. MIC is about 0.001 mg/L in sensitive strains and 1 mg/L in resistant strains.3 This is achieved by changes in penicillin-binding proteins with lower affinities for -lactam antibiotics. In the UK, such strains currently represent about 4% of those causing invasive infection, but in some areas

(eg, Spain) the rate is as high as 50%. These strains are often resistant to many other useful antibiotics, including cephalosporins, chloramphenicol and erythromycin although this pattern is not predictable. Treatment with highdose penicillin is effective in pneumonia but not in meningitis caused by resistant strains, some of which are sensitive to secondgeneration and thirdgeneration cephalosporins. The mortality from severe pneumococcal pneumonia remains relatively constant regardless of whether the strain is resistant to penicillin, but meningitis caused by a resistant strain is more likely to be fatal. Splenectomized patients are advised to take life-long low-dose oral penicillin prophylaxis against the rare possibility of overwhelming pneumococcal sepsis. In the future, such prophylaxis may become less effective, but it is difficult to identify an alternative simple and safe regimen. Glycopeptide-resistant enterococci have become important causes of nosocomial postoperative infection in the USA. They are likely to cause sepsis and pneumonia only in severely ill patients in the UK. Strains are resistant to vancomycin with (vanA) or without (vanB) teicoplanin and other genes have now been discovered. These genes require the action of complex accessory genes for full expression: vanA encodes a structural change in the terminal amino acid of the pentapeptide chain of peptidoglycan, from D-ala to D-lac. This substitution prevents binding of vancomycin, enabling construction of the dipeptide bridges in peptidoglycan to continue. The complex gene cassette has formed over millennia and probably entered enterococci from an unusual anaerobe. The gene can be incorporated into S aureus, and the emergence of, say, a successful spreadable VMRSA will reflect the greatest threat to modern medicine which we can foresee.4 Typing indicates wide heterogeneity of strains of VRE, and that carriers usually harbour more than one strain. This implies that the transposon encoding vanA and the accessory genes is promiscuous and easily able to enter the hosts enterococci. These organisms are of low virulence. Infections with Enterococcus faecalis may respond to simple antibiotics such as amoxicillin but are generally resistant to all but a few new antibiotics such as linezolid. Colonization with enterococci is driven by cephalosporins and fluoroquinolones, to which enterococci are constitutively resistant.
Gram-negative organisms

In contrast to resistant Gram-positives, against which some old antibiotics or antibiotics in development are often active, some Gram-negative organisms (particularly non-glucose fermenters such as Pseudomonas, Stenotrophomonas and Acinetobacter spp), especially in ICUs, are resistant to every useful antibiotic and there are no new agents in development. Glucose fermenters: in terms of resistance and endemic/epidemic problems in ill, hospitalized patients, Klebsiella, Enterobacter and Serratia spp are more troublesome than E coli. They produce SHV-type -lactamases constitutively, and mutations lead to resistance to all -lactams other than the carbapenems (or occasionally aztreonam). They often lose susceptibility to quinolones and aminoglycosides and become essentially untreatable. Some strains of Salmonella enterica (particularly S Typhimurium), and the enteric salmonellae (eg, S Typhi) have acquired stable broad resistance to all useful antibiotics. These are now pandemic. Chromosomal AmpC -lactamases are seen in Citrobacter, Enterobacter, Serratia, Providencia, Hafnia and Aeromonas spp associated with a repressor gene. Derepressed mutants can produce high levels of -lactamase and plasmid-encoded AmpC genes have no associated repressor. This sort of resistance is very difficult to detect in the laboratory. Extended-spectrum -lactamases are often plasmid encoded and can move easily from one organism to another. They are often associated with multiple resistance (eg, to quinolones and aminoglycosides). Some contain a suicide plasmid which implies that the antibiotic pressure does not have to be present for the organism to survive. The antimicrobials of choice for multi-resistant coliforms remain the carbapenems. However, extensive use of these will result in more resistance problems through the proliferation of specific metallo--lactamases. Non-glucose fermenters: P aeruginosa has been replaced as a troublesome cause of nosocomial infection by other environmental and skin bacteria such as Acinetobacter baumannii var calcoaceticus. Some strains are resistant to all available antibiotics, others are sensitive only to carbapenems and some aminoglycosides (eg, amikacin) or colistin. In response to long-term antibiotic use over many years, Burkholderia cepacia tends to replace S aureus and P aeruginosa as colonizing flora in patients with cystic fibrosis. It may also show resistance to many antibiotics and can cause troublesome cross-infection. Neisseria spp: Neisseria gonorrhoeae is interesting in that different strains may exhibit the three mechanisms of resistance to penicillin (reduced permeability, changes in penicillin-binding proteins and -lactamase production). Each confers a stepwise increase in MIC, and there is no clear cut-off between sensitive and resistant strains. Many strains have become resistant to other oral drugs such as ciprofloxacin.

The current epidemic of ciprofloxacin resistance in the UK requires the use of empirical single-dose injectable ceftriaxone. N meningitidis has been slow to acquire resistance to penicillin, although a few strains isolated recently in Spain have slightly higher MICs than predicted. The value of sulphonamides was largely lost by the 1970s, and although chloramphenicol remains useful, second-generation cephalosporins (cefotaxime or ceftriaxone) seem to give the best results in clinical treatment. M tuberculosis: resistance to first-line antituberculosis agents has been a major problem in the re-emergence of tuberculosis. In some countries (eg, the states of the former USSR, and South Africa), multi-drug-resistant strains (resistant at least to rifampicin and isoniazid) are extremely common, especially in patients who have been treated previously. In the UK, lone resistance to isoniazid occurs in 5% (except in London, where there is currently an epidemic of one clone resistant to isoniazid that started in 1995 and has led to a resistance rate of 15% in affected areas), and to rifampicin, ethambutol and pyrazinamide in 1% or fewer. Multidrug-resistant strains account for 12%. Strains resistant to all are most commonly seen in London. Most patients can be treated satisfactorily with a standard 6-month regimen, but the results of routine antibiotic sensitivity tests are unknown for 516 weeks after sending specimens to the laboratory, and patients with resistant strains need more toxic second-line drugs and very prolonged courses of treatment. Rapid liquid culture and detection of genes encoding resistance are improving the speed of laboratory diagnosis. Strategies for Reducing the Impact of Resistance Antibiotic resistance is driven by antibiotic use. When antibiotics are superseded and therefore used less, strains resistant to these tend to disappear. In the community: in the UK, more than 80% of human use of antibiotics occurs in the community, mostly for respiratory tract infections. The Standing Medical Advisory Committee, in its report The Path of Least Resistance, made recommendations to reduce inappropriate prescribing.5

No antibiotics should be given for simple coughs and colds. Antibiotics should not be routinely prescribed for sore throats, unless there is evidence of streptococcal infection. (It is not possible to tell clinically whether a sore throat is viral or caused by S pyogenes.) Antibiotics are not routinely required for acute otitis media and sinusitis-like symptoms; if given, courses can be limited to 3 days.

In addition, 3 days treatment should suffice in otherwise healthy women with uncomplicated cystitis. This strategy has been useful in reducing prescribing by GPs, but anxiety has resulted from anecdotal reports of an increase in bacterial respiratory infections. In hospital, antibiotic use can be reduced by several means.

Routine use of antibiotics for surgical prophylaxis should be reduced to a minimum. Antibiotics should not be started immediately in all suspected infections. Certain patients (eg, those with febrile neutropenia or evidence of septicaemia) require urgent antibiotic therapy, but in many other cases (eg, mild pyrexia postoperatively), it is safe and ultimately preferable to withhold antibiotics until culture results are known or there is clear evidence of bacterial infection. An alternative is to discontinue antibiotics as soon as information is available suggesting that the problem is not bacterial or has resolved itself. This is called an antibiotic-stop policy, and the aim is to encourage doctors to actively review the need for antibiotics after, say, the second day, given information on cultures and surrogate markers that has by then become available. Certain antibiotics can be withheld from the hospital formulary. This is the main benefit of an agreed antibiotic policy. However, the choice of restricted antibiotics is likely to be decided more on the basis of cost rather than on the likely selection of resistance. (Restricted antibiotics may have to be used occasionally, however, when resistance to other available drugs has been selected.) In theory, antibiotics can be rotated such that, for example, predominantly penicillins are used at some times, and cephalosporins or quinolones at others. There is little clear scientific evidence that this has any effect, and major, complicated studies would be needed to determine the effect of change in use on both normal and infecting flora. However, it has been shown that, in a setting of heavy cephalosporin use, discontinuation of use of this class of drugs leads to a reduction in the risk of colonization with glycopeptideresistant enterococci and Clostridium difficile-associated diarrhoea.

Other strategies: development of resistance in human pathogens might be delayed if antibiotics were not used so widely in animal husbandry, particularly for growth promotion. The Future Resistance to antibiotics is one of the greatest threats to the success of modern medicine. It has recently become more serious because we can no longer be sure that any antibiotic chosen empirically will work, and because of the emergence of totally resistant bacteria. How to reduce resistance without simply discontinuing use of all antibiotics is a dilemma. We do not know to what degree antibiotic use must be reduced to decrease the selective pressure and allow reversion to colonization with more sensitive flora, nor do we know how to protect the few remaining drugs that can be used to treat resistant infections. Despite a decade of innovative exploration of bacterial genomes to identify novel potential targets for designer antimicrobials, no new agents have yet appeared.6 Doctors and vets should overcome their view that they have an inalienable right to prescribe empirical antibiotics, and should set targets for reduction of their own personal prescribing.

Declaration of Interest

None.

References 1. Pages JM, James CE, Winterhalter M. The porin and the permeating antibiotic: a selective diffusion barrier in gram-negative bacteria. Nat Rev Microbiol 2008;6:893903. 2. Hiramatsu K, Aritaka N, Hanaki H, et al. Dissemination in Japanese hospitals of strains of StaphylococcuS aureus heterogeneously resistant to vancomycin. Lancet 1997;350:16701673. 3. Richter SS, Heilman KP, Dohrn CL, Riahi F, Beekman SE, Doern GV. Changing epidemiology of antimicrobial-resistant Streptococcuspneumoniaein the United States 20042005. Clin Infect Dis 2009;48:e23 e33. 4. Werner G, Strommenger B, Witte W. Acquired vancomycin resistance in clinically relevant pathogens. Future Microbiol 2008;3:547562. 5. Standing Medical Advisory Committee, Department of Health. The Path of Least Resistance. London: HMSO, 1998. 6. Bumann D. Has nature already identified all useful antibacterial targets? Curr Opin Microbiol 2008;11:387392.

Further Reading

Baquero F, Blzquez J. Evolution of antibiotic resistance. Trends Ecol Evol 1997;12:482487.

Butler CC, Rollnick S, Kinnersley P, et al. Reducing antibiotics for respiratory tract symptoms in primary care: consolidating why and considering how. Br J Gen Pract 1998;48:18651870. Jacobs MR, Felmingham D, Appelbaum PC, et al. The Alexander Project 19982000. J Antimicrob Chemother 2003;52:229246. Lipsitch M, Bergstrom CT, Levin BR. The epidemiology of antibiotic resistance in hospitals: paradoxes and prescriptions. Proc Natl Acad Sci U S A 2000;97:1938 1943. Pitout JD, Laupland KB. Extended-spectrum -lactamaseproducing Enterobacteriaceae: an emerging public-health concern. Lancet Infect Dis 2008;8:159166. 2009 Elsevier Ltd. Initially published in Medicine 2009;37:551556.

About the Author

Dr Scott is a retired Consultant in Clinical Microbiology at University College London Hospitals, London, UK.