BY OVOSI, JOSEPH OGIRIMA DEPT OF INTERNAL MEDICINE, CLINICAL PHARMACOLOGY UNIT, ABUTH,ZARIA DATE- 27TH OF JANUARY,2011

INTRODUCTION HISTORICAL PERSPECTIVE DEFINITIONS GENETICS OF RESISTANCE GENERAL MECHANISMS OF RESISTANCE CLASSES OF ANTIBIOTICS & RESISTANCE MECHANISM SCOPE OF THE PROBLEM IN OUR ENVIRONMENT STEMMING THE TIDE CONCLUSION

 

Bacteria is as old as antiquity They have evolved complex strategies to adapt to their niche Commercial antibiotic has revolutionarised disease chemotherapy The last 60 years has witnessed bacteria developing complex mechanisms to circumvent antibacterial action Origin of antibiotic resistance attributable to mans action

ALEXANDER FLEMMING,1945 it is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them, and the samething has occasionally happened in the body.,and by exposing his microbes to nonlethal quantities of the drug make them resistant

PRP MRSA ESBL

VRE MBL

VISA VRSA

1961

1967

1983

1986

1988

1996

2002

Penicillin All F-lactams

Vancomycin Carbapenem

3rd gen cephalosporin

Vancomycin and teicoplanin

Vancomycin and teicoplanin

Emergence

Spread

 

1945,it was found that 50% of Staph aureus was resistant to penicillin 1950,about 50% of E.coli was also found to be resistant to sulphonamides Hence, the war of bugs verses drugs Now, many multiply resistant spp of bacteria are seen,with the war now of superbugs verses drugs The development of resistant strains far outweigh the development of new drugs

 

 

ANTIBIOTIC RESISTANCE Ability of a bacterium or other microbes to survive or reproduce in the presence of antibiotic concentrations that were previously thought effective against them INNATE (INTRINSIC) RESISTANCE Resistance resulting from the normal genetic,structural or physiologic state of a bacterium

 

 

ACQUIRED RESISTANCE Result from altered cellular,physiologic and structural component of the organism which are caused by changes in the microbes genetic make up BIOLOGIC Vs CLINICAL RESISTANCE Biologic resistance refers to changes that result in the organism less susceptible to a particular antibiotic agent as previously observed Clinical resistance occurs when antimicrobial susceptibility has been lost to such an extent that the drug is no longer effective in clinical use

  

  

CHROMOSOMAL MUTATION Usually rare A single mutation in one bacteria xsome may result in synthesis of altered protein Usually provide cross resistance EXTRACHROMOSOMAL MUTATION Usually carried by plasmids or transposable elements Plasmid-bacteria acquire resistant gene from transmissible plasmids

 

 

Such plasmid encode resistant determinant to several unrelated families of antibiotic TEM-1 is the most common plasmid-mediated blactamase in gram ve bacteria,esp E. coli,N. gonorrhoea, and ampicilin resistant H. influenzae TRANSPOSON Resistant gene capable of jumping from one xsome to the other,or may integrate into a plasmid INTEGRONS Genetic elements where cassettes of resistance gene are organised into.

 

   

TRANSFORMATION Recipient cell uptake of free DNA released into the environment when another bacteria die and undergo lysis TRANSDUCTION Mediated by virus that infect bacteria CONJUGATION Involve cell to cell contact

 

 

Altered microbial target Target site is altered so as to have low affinity for antibiotic Decrease uptake or accumulation of the antibiotic Enzymatic degradation or modification of the antibiotic Circumvention of the consequence of antibiotic action Uncoupling of antibiotic agent-target interaction and subsequent effects on bacterial metabolism

Penicillin-binding proteins (PBPs)

Membrane-bound enzymes Catalyse final steps of peptidoglycan synthesis (transglycosylation and transpeptidation)

F-lactams
A ct on PBPs, inhibit transpeptidation Substrate analogues of D-Ala-D-Ala

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CELL WALL INHIBITORS Resistance by alteration in the binding site MRSA,MRSE Synthesise additional PBPs with lower affinity for b-lactams mecA gene code for additional PBPs Other organisms like Strep. Pneumonia,N. menigitidis and H. influenza may utilise this Resistance by alteration in access to the target site

 

In gram ve cells, porin undergoing mutation to decrease permeability of outer membrane Production of b-lactamases Catalyse the hydrolysis of b-lactam ring to yield microbiologically inactive products Gene may be found in xsome or plasmid Some enzymes specially target penicillins or cephalosporins,while others attack most blactamases and are called ESBL

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-lactamases

Active site Nucleotide sequence

Serine-enzymes

Zinc-enzymes

Four evolutionarily distinct molecular classes

 

 

Some b-lactam antibiotics ex. Carbapenems are b-lactam stable while ampicillins are b-lactam labile B-lactamase inhibitors like clavulanic acid,sulbactam,tazobactam contain b-lactam ring and are suicide inhibitors GLYCOPEPTIDES Are large molecules,which acts at earlier stage than blactams Difficult to penetrate Gram ve cells Bind to the terminal D alanine-d-alanine at the end of pentapeptide chain

Resistance is via altered glycopeptide target such as pentapeptide terminating in D- alanine d lactate,seen in lactobacillus, or D-alanine-d serine in E. gallinarium Acquired resistance has been recorded in in enterococcus, 1st reported in UK in 1986 Genes associated are van A,van B, van D which encode a ligase producing pentapeptides terminating in D-alanine-d lactate Glycopeptide resistance in Staph occurs by mutation or acquisition of plasmid from enterococci

  

  

FOSFOMYCIN Analogue of phosphoenoyl pyruvate Inhibit cytoplasmic enzyme enoyl pyruvate transferase,blocking the addition of phosphoenoylpyruvate to UDP-N-acetylmuramic acid. Resistance is via inhibition of transport into cell wall by glycerol phosphate BACITRACIN A cyclic peptide Interferes with dephosphorylation in the cycling of the lipid carrier that transfer peptidoglycan subunits

 

  

CYCLOSERINE A structural analogue of d-alanine,inhibit the incorporation of D-alanine into peptidoglycan pentapeptide by inhibiting alanine racemase,which converts L- alanine to D-alanine INH Inhibit synthesis of mycolic acid Its a product ,activated by kat G,mycobacterial catalase peroxidase Activated drug bind covalently with acyl carrier protein

AcpM and kasA(B-ketoacyl carrier protein synthetase) wich block mycolic acid synthesis Resistance is associated with mutations in overexpression of inhA ,which encodes an NADPH dependent acyl carrier protein reductase Also mutation in katG

 

 

AMINOGLYCOSIDES Bind to the 30s subunit,preventing binding of formylmethionine transferase,preventing the formation of initiation complex Also cause misreading of Mrna Mutation is by aminoglycoside modifying enzyme which are coded by plasmids or transposon Alteration in in binding site in the 30s subunit especially p12 protein

       

PHENICOLS Bind to 50s subunit,blocking the action of peptidyl transferase Resistance is via the inactivation of the drug by a plasmid mediated enzymatic process Chloramphenicol acetyltrasferase produced by resistant strain are intracellular Acetylated drug fail to bind to the ribosomal target TETRACYCLINES Prevents aminoacyltransfer RNA from entering the acceptor in 30s subunit Resistance is via efflux mechanism where a new cytoplasmic protein is synthesized

MACROLIDES,LINCOSAMIDE AND STREPTOGRAMINS Share overlapping binding sites,hence resistance is cross Erythromycin bind to 23s rRNA in the 50s subunit and block translocation stepn in protein synthesis,preventing the release of tRNA after peptide bond formation Resistance is via plasmid encoded mef or erm gene for efflux or alteration in the 23s rRNA

   

 

Alteration in the 23s is by methylation of adenine nucleotide in the RNA Efflux is only active against erythromycin Ketolides have higher affinity for the 23s OXAZOLIDINONES Inhibit protein in the 23s of the 30s subunit,preventing the formation 70s complex Resistance is rare and seen in enterococcus faecium FUSIDIC ACID

 

Steroid like compd Forms a stable complex with elongation factors EFGguanine diphosphate and ribosome Resistant mutant with altered EF-G

      

QUINOLONES Inhibit bacteria DNA gyrase and topoisomerases Resistance is chromosomally mediated Changes affect binding to target enzymes Also decreased uptake or active efflux RIFAMYCINS Binds to a DNA dependent RNA polymerase and block the synthesis of m RNA Resistance is via chromosomal mutation that alterd RNA polymerase target

 

  

SULPHONAMIDES Plasmid mediated or chromosomal mediated altered dihydropterate synthetase site TRIMETHOPRIM Inhibit dihydrofolate reductase Resistance is by plasmid mediated dihydrofolate reductase

  

NITROIMIDAZOLES Metronidazole, Enter the cell and reduced. The reduced form is responsible for DNA breakage Resistance likely due to decreased uptake or decrease cellular reductase activity

  

  

LIPOPEPTIDES Daptomycin is a lipopeptide antibiotic Act in calcium dependent way to insert and depolarise bacterial cytoplasmic membrane At presence,resistance is rare POLYMIXINS Resistance largely due to xsomally mediated alteration in cell membrane structure and uptake

Antibiotic -Lactams

Mechanism of action Inactivate PBPs (peptidoglycan synthesis)

Major resistance mechanisms -lactamases Low affinity PBPs Efflux pumps

Glycopeptides

Bind to precursor of peptidoglycan Inhibit protein synthesis (bind to 30S subunit)

Modification of precursor

Aminoglycosides

Modifying enzymes (add adenyl or Phosphate)

Macrolides

Inhibit protein synthesis (bind to 50S subunit)

Methylation of rRNA Efflux pumps

PBPs penicillin-binding proteins

Antibiotic resistance is not alien to our environment. Several studies conducted by eminent scholars revealed the stark reality: Iruka et al discovered that 56-100% of E. coli strains are resistant to one of ampicillin, chloramphenicol, tetracycline and streptomycin(1986-1998) Habib A.G.,in his workantibiotic resistance in the savannah also found resistance to E. coli to be 9196%.Resistance to other uropathogens Kliebsiella and proteus was put at 83-99% to cotrimoxazole,tetracycline

Olayinka et al:also discovered multi-drug resistance P.aeruginosa isolates in surgical units of ABUTH. 27. 8% were said to be resistant to ceftazidine,gentamycin,pefloxacin and ofloxacin Olusesan et al: did plasmid DNA analysis of resistant strains of S.typhii and paratyphii to 10 selected antibiotics in Zaria. They found 40-100% resistant to Ampicillin,Amoxycillin,Augmentin,Chloramphenic ol,Co-timoxazole

 WHAT

IS ABUTHs ANTIBIOTIC PRESCRIPTION POLICY?

Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

 

Prevent infection Diagnose and treat infection effectively Use antimicrobials wisely

Prevent transmission

Clinicians hold the solution!

Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

12 Break the chain 11 Isolate the pathogen Prevent Transmission 10 Stop treatment when cured 9 Know when to say no to vanco 8 Treat infection, not colonization Use Antimicrobials Wisely 7 Treat infection, not contamination 6 Use local data 5 Practice antimicrobial control 4 Access the experts Diagnose & Treat Effectively 3 Target the pathogen 2 Get the catheters out Prevent Infections 1 Vaccinate

12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults

12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults

Step 2: Get the catheters out

Scanning Electron Micrograph

 Link to: Biofilms and device-associated infections

12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults

Step 4: Access the experts

Inf cti
Healthcare Epidemiologists

s is s s ci lists Infection Control

Professionals

Clinical Pharmacists

Optimal Patient Care

Clinical Pharmacologists Surgical Infection Experts

Clinical Microbiologists

Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

Prevention IS PRIMARY!
Protect patientsprotect healthcare personnel promote quality healthcare! Division of Healthcare Quality Promotion National Center for Infections Diseases

 Link to: Division of Healthcare Quality Promotion Home Page

ERIC ARTHUR BLAIR(25TH JUNE,1903-21ST JANUARY,1950

THANK YOU ALL!!!