Problem of Antibiotic Resistance

& Rational use of antibiotics

Dr. Naser Tadvi

Associate Prof., Pharmacology
 Objectives
What is antimicrobial resistance
Why antibacterial resistance is a concern
How antibacterials work
Mechanisms of resistance to antibacterials
Indian scenario
NDM-1
Strategies to contain resistance
Treatment of some resistant bacterial infections
Summary
 Introduction
Throughout history there has been a continual
battle between human beings and multitude
of micro-organisms that cause infection and
disease
 History
Nobel Lecture, December 11, 1945

Sir Alexander Fleming

The Nobel Prize in Physiology or Medicine 1945

In his 1945 Nobel Prize lecture, Fleming himself warned of

the danger of resistance
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
same thing has occasionally happened in the body
and by exposing his microbes to non-lethal
quantities of the drug make them resistant.
Timeline of Antibiotic Resistance
 Why resistance is a concern
Resistant organisms lead to treatment failure
Increased mortality
Resistant bacteria may spread in Community
Low level resistance can go undetected
Added burden on healthcare costs
Threatens to return to pre-antibiotic era
Selection pressure
 Drug Resistance

Drug resistance occurs in :

BACTERIAANTIBIOTIC RESISTANCE
Endoparasites
VirusesResistance to antiviral drugs
Fungi
Cancer cells
 Antibiotic Resistance
The concentration of drug at the site of
infection must inhibit the organism and also
remain below the level that is toxic to human
cells.

GOODMAN & GILMAN'S THE PHARMACOLOGICAL BASIS OF THERAPEUTICS - 11th Ed. (2006)
 Antibiotic Resistance

Defined as micro-organisms that are not

inhibited by usually achievable systemic
concentration of an antimicrobial agent with
normal dosage schedule and / or fall in the
minimum inhibitory concentration (MIC)
range.
Antibiotic Resistance (DR)
= MIC / MCC > Toxic Plasma Concentration
 Myths of Antibiotic Resistance
1. Drugs (antibiotics) cause organisms
antibiotic resistant.

2. Antibiotic resistant organisms are

more virulent
 Truth
Antibiotics select out the resistant strain
Faulty use of antibiotics or widespread use of
antibiotics increases the probability of such
selection.
Antibiotic resistant strains appear to be more
virulent because we cannot kill them or stop
their growth.
Mechanisms of action of antibiotics
 Mechanism Antibiotic Resistance

Intrinsic (Natural) Acquired

Genetic Methods

Chromosomal Methods Extra chromosomal Methods

Mutations Plasmids
 Antibiotic Resistance

Some microorganisms may born resistant,

some achieve resistance by mutation or some

have resistance thrust upon them by plasmids

Some are born great, some achieve greatness

or some have greatness thrust upon them
 Intrinsic Resistance

It occurs naturally.
1. Lack target :
No cell wall; innately resistant to penicillin
2. Innate efflux pumps:
Drug blocked from entering cell or export
of drug (does not achieve adequate internal
concentration). Eg. E. coli, P. aeruginosa
3. Drug inactivation:
Cephalosporinase in Klebsiella
 Acquired resistance

Mutations
It refers to the change in DNA structure of the
gene.
Occurs at a frequency of one per ten million cells.
Eg.Mycobacterium.tuberculosis,Mycobacterium
lepra , MRSA.
Often mutants have reduced susceptibility
 Plasmids
Extra chromosomal genetic elements can replicate
independently and freely in cytoplasm.
Plasmids which carry genes resistant ( r-genes) are called R-
plasmids.
These r-genes can be readily transferred from one R-plasmid to
another plasmid or to chromosome.
Much of the drug resistance encountered in clinical practice is
plasmid mediated
 Mechanisms of Resistance Gene Transfer

Transfer of r-genes from one bacterium to

another
Conjugation
Transduction
Transformation
Transfer of r-genes between plasmids within
the bacterium
By transposons
By Integrons
 Transfer of r-genes from one bacterium to another

Conjugation : Main mechanism for spread of resistance

The conjugative plasmids make a connecting tube
between the 2 bacteria through which plasmid itself
can pass.
Transduction : Less common method
The plasmid DNA enclosed in a bacteriophage is
transferred to another bacterium of same species.
Seen in Staphylococci , Streptococci
Transformation : least clinical problem.
Free DNA is picked up from the environment (i.e..
From a cell belonging to closely related or same strain.
 Mechanisms of Resistance Gene Transfer
Transposons
Transposons are sequences of DNA
that can move around different
positions within the genome of single
cell.

The donor plasmid containing the

Transposons, co-integrate with acceptor
plasmid. They can replicate during
cointegration

Both plasmids then separate and each

contains the r-gene carrying the
transposon.
Eg ; Staphylococci,Enterococci
 Mechanisms of Resistance Gene Transfer
Integrons
Integron is a large mobile DNA
can spread Multidrug resistance

Each Integron is packed with

multiple gene casettes, each
consisting of a resistance gene
attached to a small recognition site.

These genes encode several

bacterial functions including
resistance and virulence.

They cannot promote self transfer

 Biochemical mechanisms of antibiotic
resistance
Prevention of drug accumulation in the bacterium

Modification/protection of the target site

Use of alternative pathways for metabolic / growth

requirements

By producing an enzyme that inactivates the

antibiotic

Quorum sensing
 Decreased permeability: Porin Loss

Antibiotics normally enter bacterial cells via porin channels

in the cell wall

Antibiotic
Porin channel
into organism

Cell wall

Interior of organism
 Decreased permeability: Porin Loss
New porin channels in the bacterial cell wall do not allow
antibiotics to enter the cells

Antibiotic New porin channel

into organism

Cell wall

Interior of organism
 Efflux pumps
Cytoplasmic membrane transport proteins.

Major mechanism for resistance in Tetracyclines.

Some gram -ve bacteria inhibit the plasmid

mediated synthesis of porin channels ,which
obstructs the influx of hydrophilic Penicillins
eg.ampicillin

ATP Binding Cassette

Major facilitator superfamily
Multidrug and toxic compound exporter
Small multidrug resistance transporters
Resistance-nodulation-division
 Structurally modified antibiotic target site
Antibiotics normally bind to specific binding proteins on the
bacterial cell surface

Antibiotic

Binding Target site

Cell wall

Interior of organism
 Structurally modified antibiotic target site

Antibiotics are no longer able to bind to modified binding proteins

on the bacterial cell surface

Antibiotic
Modified target site

Cell wall

Changed site: blocked binding Interior of organism

 Modification/Protection of the Target site

Resistance resulting from altered target sites :

Target sites Resistant Antibiotics
Ribosomal point mutation Tetracyclines,Macrolides
, Clindamycin
Altered DNA gyrase Fluoroquinolones
Modified penicillin binding Penicillins
proteins (Strepto.pneumonia)
Mutation in DNA dependant Rifampicin
RNA polymerase
(M.tuberculosis)
 Antibiotic inactivation
Inactivating enzymes target antibiotics

Antibiotic

Enzyme
Binding Target site

Cell wall

Interior of organism
 Antibiotic inactivation
Enzymes bind to antibiotic molecules

Antibiotic Enzyme
binding

Enzyme Binding Target site

Cell wall

Interior of organism
 Antibiotic inactivation
Enzymes destroy antibiotics or prevent binding to target sites

Antibiotic Antibiotic altered,

destroyed binding prevented

Antibiotic

Enzyme Target site

Cell wall

Interior of organism
 By producing enzymes that inactivates antibiotic

a)Inactivation of b-lactam antibiotics

S. aureus, N. gonorrohoea, H.influenza, Produce b-
lactamase which cleaves -lactam ring

b)Inactivation of Chloramphenicol
Inactivated by chloramphenicol acetyltransferase .
Gram-ve (enzyme present constitutively hence higher
resistance) gram +ve bacteria (enzyme is inducible )

c)Inactivation of Aminoglycosides
Inactivated by acetyl, phospho & adenylyl transferases
Present in gram +ve and gram ve .
Use of alternative pathways for metabolic / growth
requirements

Resistance can also occur by alternate

pathway that bypasses the reaction inhibited
by the antibiotic.
Sulfonamide resistance can occur from
overproduction of PABA
 Drug Mechanism of resistance
Pencillins & B Lactamase cleavage of the Blactam ring
Cephalosporiins

Aminoglycosides Modification by phosphorylating, adenylating

and acetylating enzymes

Chloramphenicol Modification by acetylytion

Erythromycin Change in receptor by methylation of r RNA

Tetracycline Reduced uptake / increased export

Active export out of the cell & reduced affinity

Sulfonamides of enzymes
 Quorum sensing
Microbes communicate with each other and
exchange signaling chemicals (Autoinducers)
These autoinducers allow bacterial population
to coordinate gene expression for virulence,
conjugation, apoptosis, mobility and
resistance
 Why named quorum sensing
Single autoinducer from single microbe is
incapable of inducing any such change
But when its colony reaches a critical density
(quorum), threshold of autoinduction is
reached and gene expression starts
QS signal molecules AHL, AIP, AI-2 & AI-3 have
been identified in Gm-ve bacteria
AI-2 QS system is shared by GM+ve bacteria
also
 WHY INHIBIT QUORUM SENSING
Proved to be very potent method for bacterial virulence
inhibition.

Several QS inhibitors molecules has been synthesized which

include AHL, AIP, and AI-2 analogues

QS inhibitors have been synthesized and have been isolated

from several natural extracts such as garlic extract.

QS inhibitors have shown to be potent virulence inhibitor

both in in-vitro and in-vivo,using infection animal models.
Indian scenario
 Indian scenario
Lack of community awareness
Availability over the counter
Absence of central monitoring agency
In infants LRTI has taken over IMR due to
diarrhoeal diseases due to use of ORT
S. Pneumoniae fully resistant to cotrimoxazole
Still sensitive to penicillins, macrolides and
fluoroquinolones
 Enteric pathogens
Vibrio cholerae :
resistance to furazolidine, cotrimoxazole, nalidixic
acid
Tetracycline remains effective
Coliforms
ESBLs , extensive resistance to Beta lactum
antibiotics
Enteric fever
 STD
Penicillin and fluoroquinolone resistance is
widespread to gonorhhoea
Alternate drugs like Azithromycin and
cephalosporins should be used
Syphilis still susceptible to Penicillins
 Gram positive Cocci
Streptococci other than S. Pneumoniae
Resistant to tetracycline and macrolides (40%)
Still sensitive to penicillins
Staph Aureus
Methicillin resistance 50%-100%
Vancomycin resistance also increasing
 Mycobacteria
Multidrug resistance
Combined resistance to rifampicin and isoniazid
Extensively drug resistant TB
Additional acquisition of resistance to a
fluroquinolone and one of the three injectable
second line drugs (capreomycin, kanamycin and
amikacin)
Steady rise in these patients
 What is NDM-1?
NDM-1 stands for New Delhi metallo-beta-
lactamase, an enzyme produced by certain
strains of bacteria that have recently acquired
the genetic ability to make this compound.
The enzyme is active against other compounds
that beta-lactam ring like penicillins,
cephalosporins, and the carbapenems.
bacteria that produce NDM-1 are resistant to
all commonly used beta-lactam antibiotics,
including carbapenems.
 New Delhi metallo-beta-lactamase Why
everyone concerned ?
There are currently no
new drugs in the research
pipelines that aim to stop
NDM-1.To date, some
strains of E.coli and
Klebseilla pneumoniae
are known carriers of the
gene, but the gene can be
transmitted from one
strain of bacteria to
another through
horizontal gene
transfer.
 Naming the strain as New Delhi creates
controversy
The gene was named after New Delhi, the capital city
of India, as it was first described by Yong et al. in 2009
in a Swedish national who fell ill with an antibiotic-
resistant bacterial infection that he acquired in India .
The infection was unsuccessfully treated in a New Delhi
hospital and after the patient's repatriation to Sweden,
a carbapenem-resistant Klebsiella pneumoniae strain
bearing the novel gene was identified. The authors
concluded that the new resistance mechanism "clearly
arose in India, but there are few data arising from India
to suggest how widespread it is."
 Treatment
Many NDM-1 strains are resistant to all antibiotics
except for colistin.
Colistin is an older antibiotic that has not been
used much in recent decades, because it is
somewhat more toxic than other antibiotics.
A few NDM-1 strains have been sensitive to
tigecycline (Tygacil), but this agent should be used
cautiously in serious infections because it does not
achieve high levels in the bloodstream.
A few strains have also been sensitive to
aztreonam
 The spread of NDM-1 can be
contained with
..
The spread of NDM-1 within health-care
facilities can be curbed through strict
infection-control measures, including patient
isolation and hand washing.
Strategy to Contain Resistance
Develop new antibiotics
Bypass the drug resistance

Judicious use of the existing

antibiotics:
Containment of drug resistance
 New Antibiotic Development
Only 15 antibiotics of 167 under development
had a new mechanism of action with the
potential to combat of multidrug resistance.

Lack of incentive for

companies to develop
antibiotics.
 Hope is not exhausted.yet
Phage therapy
Use of the lytic enzymes found in mucus and
saliva
Agents that target type IIA topoisomerases
Antimicrobial peptides (AMPs), lipopeptides
(AMLPs) target bacterial membranes,
making it nearly impossible to develop
resistance (bacteria would have to totally
change their membrane composition).
 Alternate Approaches
Phage therapy
Phage Therapy is the therapeutic use of lytic bacteriophages to
treat pathogenic bacteria infections
Bacteriophages are viruses that invade bacterial cells and
disrupt bacterial metabolism and cause the bacterium to lyse.
Bacteriophage therapy is an important alternative to antibiotics
The success rate was 8095% with few gastrointestinal or
allergic side effects. British studies also demonstrated significant
efficacy of phages against Escherichia coli, Acinetobacter spp.,
Pseudomonas spp and Staphylococcus aureus.
Efflux Pump Inhibitors:
 Some newer antibiotics
Linezolid: targets 50S ribosome
Tigecycline: targets 30S ribosome
Daptomycin: depolarization of bacterial cell
membrane
Dalbavacin: inhibits cell wall synthesis
Telavacin: inhibition of cell wall synthesis and
disruption of membrane barrier function
Ceftibirole/ ceftaroline: cephalosporins
Iclaprim: inhibits Dihydrofolate reductase
 Judicious Use of Antibiotics
Can only contain antibiotic resistance
Cannot eliminate the possibility of
antibiotic development as resistance is
an evolutionary process
 Containment of Resistance
Containment of antibiotic resistance is a
multi-pronged program
Involves all stake holders
Physicans
Patients
Pharmaceuticals
 Factors of Antibiotic Resistance
Drug Related Environmental
Factors Factors

Antibiotic
Resistance

Prescriber
Patient Related
Related Factors
Factors
 1. Environmental Factors
Huge populations and overcrowding
Rapid spread by better transport facility
Poor sanitation
Increases community acquired resistance
Ineffective infection control program
Widespread use of antibiotics in animal husbandry
and agriculture and as medicated cleansing products
 2. Drug Related
Over the counter availability of antimicrobials

Counterfeit and substandard drug causing sub-

optimal blood concentration

Irrational fixed dose combination of

antimicrobials
Policy
Soaring use of antibiotics Decision at
Higher level
 3. Patient Related

Poor adherence of dosage Regimens

Poverty
Lack of sanitation concept
Lack of education
Patient
Self-medication
Counseling,
Misconception Awareness
Program
 Prescriber Related

Inappropriate use of available drugs

Increased empiric poly-antimicrobial use

Overuse of antimicrobials

Inadequate dosing

Lack of current knowledge and training

 Strategy of Containment
Antibiotic Resistance

Evolutionary Faulty Use of

Process Antibiotics

Hospital Acquired Hospital Environmental

Antibiotic Resistance Community Acquired
Antibiotic Resistance

Empirical Use Definitive Use

Use of antimicrobials before
pathogen responsible for a particular
illness or the susceptibility to a
particular antimicrobial is known
 Poor Clinical Practice

Poor clinical practice that fail to incorporate

the pharmacological properties of

antimicrobials amplify the speed of

development of drug resistance.

 Faulty Antibiotic Use
Antimicrobials are over prescribed
Available without prescription
 Over Prescribed Antibiotics
Clinician should first determine whether
antimicrobial therapy is warranted for a given
patient
 Empirical Microbial Selection
Is antimicrobial agents indicated on the
basis of clinical findings?

Or is it prudent to wait
until such clinical
findings become
apparent?
 Empirical Microbial Selection
Can some simple bed side test done to
confirm your suspicion?
Microscopy
Gram staining
 Empirical Microbial Selection
Have appropriate clinical
specimens been obtained to
establish a microbial diagnosis?
 Empirical Microbial Selection
What are the likely etiologic agents
for the patients illness?
 Empirical Microbial Selection
What measures should be taken to protect
individuals exposed to the index case to
prevent secondary cases (1), and what
measures should be implemented to prevent
further exposure (2)?

2 1
 Empirical Microbial Selection
Is there clinical evidence (e.g. from clinical
trials) that antimicrobial therapy will confer
clinical benefit for the patient?
(Evidence-based medicine)
 Definitive Treatment
1. Can a narrower spectrum agent be
substituted for initial empiric drug?
 Definitive Treatment (2)
1. Is one agent or combination of agents
necessary?
 Examples
-lactam + Aminoglycosides
Extended spectum Penicillins + -lactamase
Inhibitors
Anti-tubercular regimen
Anti-leprotic regimen
Co-trimoxazole
Sulphadoxin + pyrimethamine
Artemisinin based Combination Therapy (ACT) in
Malaria
 Definitive Treatment
What are the
optimum dose,
route of administration and
duration of therapy?
 Definitive treatment

What specific test to identify patients

who will not respond to treatment?
 Definitive Treatment

What adjunctive measures can be

undertaken to eradicate infection?
Vaccination
Steroid
Drainage of pus
Amputation
Removal of catheter
 Whos Work?

Microbiologist
Bacterial
sensitivity test
and find out
the possible
causes of Physician
development
Treat Infection
 Whos Work?

Microbiologist

Advise the proper

and adequate
antibiotics with
Physician
balancing the
economy of
hospital Pharmacologist
Hospital Acquired Drug Resistance
Hospital Antibacterial Policy
Hospital Antibiogram
Hospital specific antibacterial Resistance
Pattern
Identification of potential pathogen most
likely to cause infection
Previous antibacterial therapy
Prescription auditing
 Hospital Antibiotic Policy
To curb the common misuse and overuse of
antibiotics
Restricts the occurrence of antibacterial
resistance among the hospital strains
Controls the spread of such infections to
susceptible and critically ill patients in the
hospital and the subsequent infection into the
community.
Saves money for the patient and increases
patient satisfaction with decreased side effect.
 Hospital Antibiogram
A periodic summary of antimicrobial
susceptibilities of local bacterial isolates
submitted to the hospital's clinical
microbiology laboratory.
Used by clinicians to assess local susceptibility
rates, as an aid in selecting empiric antibiotic
therapy, and in monitoring resistance trends
over time within an institution
 Treatment options for selected highly
resistant bacteria
Sr. Organism Resistance Antibiotic used
No
1 E. Faecalis Penicillin Vancomycin, Ampicillin -SLB
2 MRSA Methicillin etc Linezolid , quinpristine,
Vancomycin dalfopristine , daptomycin,
telavacin
3 S. Epidermidis Methicillin Vancomycin + Rifampicin+
Gentamicin
4 S. Pneumoniae Penicillin G Ceftriaxone, cefotaxime,
Telithromycin
MIC>4 Vancomycin + Rifampicin
5 C. Jejuni FQ Macrolides, doxycycline,
clindamycin
 Treatment options for selected highly
resistant bacteria
Sr. Organism Resistance Antibiotic used
No
6 E. Coli Cotrimoxazole, Fosfomycin, Nitrofurantoin,
oral Ertapenum
cephalosporins ,
FQ
7 K III Gen Imipenum, Meropenum,
Pneumoniae Cephalosporins Colistin
& Ceftazidime
8 P. aeruginosa Imipenum, Antipseudomal
meropenum Aminoglycosides , Colistin,
Ceftazidime
 In our hospital antibiotics
Gm +ve bacteria recommended
First line Second line
Penicillin Vancomycin
Oxacillin Ofloxacin
Amoxy Clav Clindamycin
Cephalothin Clarithromycin
Erythromycin Linezolid
Cotrimoxazole
Ciprofloxacin
Gentamicin
 In our hospital antibiotics
Gm -ve bacteria recommended
First line Second line
Amoxy-clav Cefta Clav
Gentamicin Cefipime
Ciprofloxacin Imipenum
Ceftazidime Netilimycin
Cefuroxime Tobramycin
Cefazoline
Amikacin
 In our hospital antibiotics
MRSA recommended

Topical Fusidic acid

Vancomycin
Teicoplanin
Linezolid
Minocycline
Sparfloxacin
Rifampicin
 In our hospital antibiotics
P. Aeruginosa recommended
Piperacillin
Cefaperazone
Amikacin
Ciprofloxacin
Gatifloxacin
Tobramycin
Netilimycin
Cefipime
piperacillin Tazobactum
Ceftazidime
 Take Home Message
Target definitive therapy to known pathogen
Treat infection, not contamination
Treat infection, not colonization
Know when to say no to Vancomycin,
Carbepenems and Cephalosporin IV Generation
Isolate Pathogen
Break the chain of contagion Keep your hands
clean.
Start simple bed side test: Gram stain,
microscopy