BACTERIAL

RESISTANCE TO
ANTIMICROBIA
LS

DR. RYAN OLMEDO

1ST YEAR RESIDENT, MHARSMC IM DEPARTMENT
DEFINITION OF RESISTANCE
DEFINITIONS

 RESISTANCE – reduction in or loss of an agent’s antibacterial effect

 DIFFERENT ACTIONS OF ANTIMICROBIAL AGENTS
 Inhibition of bacterial growth

 Killing of the bacterial cell

 RESISTANCE MECHANISMS – properties of or alterations in the bacterium resulting in resistance

 MINIMUM INHIBITORY CONCENTRATIONS – lowest drug concentration that inhibits the growth of bacteria
MINIMUM INHIBITORY CONCENTRATION INTERPRETATION

 SUSCEPTIBLE – predicts a likely clinical response to an appropriately dosed antimicrobial drug by a patient infected by
an organism
 INTERMEDIATE SUSCEPTIBILITY

 RESISTANT – poor or no clinical response to the drug

MECHANISMS OF RESISTANCE
BROAD CATEGORIES OF MECHANISMS OF BACTERIAL
RESISTANCE

 Alteration or bypassing of targets that exhibit reduced binding of the drug

 Altered access of the drug to its target by reductions in uptake or increases in active efflux

 Drug modifications that decreases its activity

 Mutations in the bacterial chromosomal genes occurring spontaneously during bacterial DNA replication
 Acquisition of new genes by DNA transfer from other bacteria or uptake of exogenous DNA
SOURCES OF NEW BACTERIAL GENES

 Self-replicating plasmids or other DNA elements transferred from other bacteria

 TRANSFORMATION – recombining fragments of environmental DNA taken from related bacterial species into own
bacterial chromosomes (Streptococcus pneumoniae, Neisseria gonorrhoeae)
BETA-LACTAMS
BASIC CONCEPTS

 MECHANISM OF ACTION: inhibits bacterial cell wall biosynthesis by binding to cell-wall transpeptidases
(PENICILLIN-BINDING PROTEINS)
 MECHANISM OF RESISTANCE: degradation by beta-lactamases (break down of the core beta-lactam ring)
 Chromosomally encoded beta-lactamases
 Physiologically induced by exposure to certain beta-lactams

 Constitutive expression through mutations in genes encoding the regulators of expression of a beta-lactamase gene

 Plasmid encoded beta-lactamases – constitutive expression

BETA LACTAMASES

 GRAM POSITIVE BACTERIA: secreted into the extracellular environment

 GRAM NEGATIVE BACTERIA: secreted into the periplasmic space between the cytoplasmic and outer membranes
 Access of beta-lactams to their target PBPs and beta-lactamases require diffusion across porin channels across the outer membrane
 SLOW DIFFUSION: additional mechanism that enhances drug degradation
 Effected by decreasing the number of porin diffusion channels by mutations
PLASMID-ENCODED BETA-LACTAMASES

 Staphylococcus aureus: Most strains have plasmid-encoded beta-lactamases that degrade penicillin but not semisynthetic
penicillins (Oxacillin, Nafcillin)
 Gram-negative bacteria: plasmid-encoded
 EARLIEST: able to inactivate all penicillins and most early-generation cephalosporins
 ESBL: degrades later-generation cephalosporins (Ceftriaxone, Cefotaxime, Ceftazidime, Cefepime), monobactams (Aztreonam)
 CARBAPENEMASES: degrade carbapenems and most if not all other beta-lactams
 KPCs (Klebsiella pneumoniaea Carbapenemases) – most widespread (found in E. coli, K. pneumoniae)

 New Delhi metallo-beta-lactamases

 OXA-48
 HYBRID MECHANISM: high levels of expression of ESBL or AmpC enzyme + reduced porin diffusion channels
 Pseudomonas aeruginosa
 Mutations leading to reductions in the OprD diffusion channels for Imipenem

 Increased expression of efflux pumps that can remove Meropenem from the bacterial cell
CHROMOSOMAL BETA-LACTAMASES

 K. pneumoniae – preferentially degrades penicillins but not cephalosporins

 Enterobacter and related genera (AmpC) – degrade almost all cephalosporins (expressed in small amounts)
 EXCEPTIONS: Cefoxitin, Cefepime – stable to AmpC
 CEFEPIME RESISTANCE – develop through combined effects of mutations causing increased AmpC production and decreased porin
diffusion channels
MECHANISM: ALTERATIONS IN PBPS

 S. pneumoniae, N. gonorrhoeae, N. meningitidis: recombination of transformed DNA from related species resulting in
mosaic PBPs with lower affinity for penicillin
 N. gonorrhoeae: increased expression of efflux pump and porin mutation

 Staphylococcus: mec gene -> PBP2a – bypass target that reduces beta-lactam effect on other PBPs
 CEFTAROLINE: effective against PBP2a (active against MRSA)
 RESISTANCE: mutations in mec gene that reduces activity to Ceftaroline
CEFIDEROCOL

 Novel cephalosporin with enhanced stability to beta-lactamases

 CATECHOL SIDE GROUP – active transport across bacterial cell by siderophore iron uptake pathways

 ACTIVITY: beta-lactam resistant gram-negative bacteria

 REDUCED SUSCEPTIBILITY – in strains with mutations in multiple iron transport genes

INHIBITORS OF BETA-LACTAMASES

 CLAVULANATE + Amoxicillin, Ticarcillin

 SULBACTAM + Ampicillin

 TAZOBACTAM + Piperacillin, Ceftolozane

 AVIBACTAM + Ceftazidime

 VABORBACTAM + Meropenem

 RELEBACTAM + Imipenem

 MECHANISM: inhibit plasmid-encoded beta-lactamases

 AVIBACTAM, VABORBACTAM, RELEBACTAM: inhibit AmpC, some carbapenemases (except metallo-carbapenemases)
GLYCOPEPTIDES AND LIPOGLYCOPEPTIDES
BASIC CONCEPTS

 MECHANISM OF ACTION: inhibit cell wall synthesis by binding to terminal 2 D-Ala on the cell wall peptidoglycan
stem peptides of the peptidoglycan cross-links  blocks cross-linking enzymes and glycosyltransferases
VAN GENES

 Confers enterococci with resistance to VANCOMYCIN

 Originated in organisms that naturally produce Vancomycin – example of plasmid transmission of resistance

 MECHANISM OF RESISTANCE
 D-Ala-D-Lactate production at the end of the peptidoglycan stem peptide  1000-fold lesser affinity for Vancomycin than D-Ala-D-Ala
 Reduction of normal D-Ala-D-Ala terminated peptides
INTERMEDIATE RESISTANCE PHENOTYPE TO VANCOMYCIN

 Commonly found in Staphylococcus aureus

 MECHANISM: chromosomal mutations  thickened and poorly cross-linked cell wall containing additional D-Ala-D-
Ala-terminated stem peptides at a site distant from the cell membrane  impedes access to proximal binding sites
 UNSTABLE – strains return to susceptibility in the absence of vancomycin selection pressure

 OTHER SIMILAR ANTIMICROBIALS AFFECTED BY THIS RESISTANCE PATTERN

 Televancin
 Dalbavancin
 Oritavancin
AMINOGLYCOSIDES
BASIC CONCEPTS

 MECHANISM OF ACTION: inhibit protein synthesis by binding to either 30S or 50S bacterial ribosomal subunits

 MECHANISM OF RESISTANCE
 Acquisition of plasmid genes encoding transferases that modify aminoglycosides (acetylation, adenylation, phosphatidylation) to decrease
affinity for 30S or 50S
 AMIKACIN < GENTAMYCIN OR TOBRAMYCIN

 PLAZOMICIN: remains active

 Methylases encoded by plasmids – methylate 16S rRNA of 30S (binding site of all aminoglycosides)
 Single ribosomal protein mutation
 P. aeruginosa – regulatory gene mutation  increased expression of chromosomally encoded efflux pump (MexY)
TETRACYCLINES
BASIC CONCEPTS

 MECHANISM: bind the 16S rRNA of the 30S ribosomal subunits at a different binding site from aminoglycosides to
inhibit protein synthesis
 MECHANISM OF RESISTANCE:
 plasmid-mediated
 Active efflux pumps (general for all tetracyclines)

 Proteins protecting ribosomes (tetracycline)

 Chromosomally-encoded efflux pumps

 Mutations causing overexpression of broad-spectrum efflux pumps (Proteus sp)
 Plasmid-encoded tetracycline modification mechanism
MACROLIDES, KETOLIDES, LINCOSAMIDES,
STREPTOGRAMINS
BASIC CONCEPTS

 MECHANISM: inhibits bacterial protein synthesis by binding to 23S rRNA of 50S ribosomal subunit (active vs. gram-
positive bacteria)
 RESISTANCE MECHANISM
 Erm methylases that modify the binding site induced by exposure to most macrolides (not ketolides)
 QUINUPRISTIN-DALFOPRISTIN becomes bacteriostatic instead of bactericidal

 TELITHROMYCIN: remains active by binding at an additional binding site in the presence of some methylases

 Acquired active efflux pumps (streptococci, staphylococci)

 Plasmid-acquired, drug-modifying enzymes (staphylococci)
 23S rRNA binding site mutations (common in mycobacteria, Helicobacter pylori, Treponema)
CHLORAMPHENICOL
BASIC CONCEPTS

 MECHANISM: inhibits bacterial protein synthesis by binding to 23S rRNA of 50S subunit at site overlapping with
macrolide-binding site
 ADVERSE EFFECT: rare but potentially severe bone marrow toxicity

 MECHANISM OF RESISTANCE: plasmid-encoded drug-modifying acetyltransferases inducible by drug exposure

 Plasmid-encoded ribosomal methylase (staphylococci)
 Plasmid-encoded efflux pumps (gram-negative bacteria)
 Other pumps affecting chloramphenicol and oxazolidinones (gram-positive bacteria)
OXAZOLIDINONES
BASIC CONCEPTS

 MECHANISM: active against gram-positive bacteria ONLY by inhibiting protein synthesis by binding to 23S rRNA of
50S subunit at distinct site overlapping with chloramphenicol-binding site
 RESISTANCE MECHANISM
 Mutations in multiple copies of the 23S rRNA genes that reduce drug binding to the ribosome (enterococci > staphylococci)
 Plasmid-acquired ribosomal methylase – enables ribosomal alteration at a site conferring resistance (S. aureus, coagulase-negative
staphylococci)
 Plasmid-encoded active efflux pump (Enterococcus faecalis)
PLEUROMUTILINS
BASIC CONCEPTS

 MECHANISM: inhibit protein synthesis by binding to peptidyltransferase center in 50S subunit (active against gram-
positive bacteria, Haemophilus influenzae, Moraxella catarrhalis, other atypical respiratory pathogens like Mycoplasma
pneumoniae, Legionella)
 RESISTANCE MECHANISM
 Mutations in L3 and L4 proteins of the 50S ribosomal subunit  binding site alteration
 Plasmid-encoded Cfr methylase  disruption of binding site
 Vga transporters
MUPIROCIN
BASIC CONCEPTS

 INDICATIONS: topical formulation for the elimination of S. aureus nasal carriage

 MECHANISM: inhibits protein synthesis by targeting bacterial Leu-tRNA synthetase

 RESISTANCE MECHANISM
 Mutation in bacterial Leu-tRNA synthetase
 Plasmid-encoded resistant tRNA synthetase that bypasses drug inhibition of the native synthetase
SULFONAMIDES AND TRIMETHOPRIM
BASIC CONCEPTS

 MECHANISM: inhibits folate biosynthesis pathway

 SULFONAMIDES: para-aminobenzoic acid analogues that competitively inhibits DIHYDROPTEROATE SYNTHETASE
 TRIMETHOPRIM: inhibits DIHYDROFOLATE REDUCTASE

 RESISTANCE MECHANISM
 Mutation in target enzymes
 Plasmid-acquired genes encoding resistant enzymes
 Limited resistance due to drug efflux or drug modification
QUINOLONES
BASIC CONCEPTS

 MECHANISM: synthetic inhibitors of bacterial DNA synthesis by binding to DNA gyrase and DNA topoisomerase IV
and stabilizing enzyme-DNA complexes that forms a barrier to DNA replication
 RESISTANCE MECHANISM
 Chromosomal mutations leading to target enzyme alterations
 Mutations that increase expression of native broad-spectrum efflux pumps
 Acquired genes from multidrug resistance plasmids that can a) protect target enzymes, b) modifying some quinolones (ciprofloxacin,
norfloxacin), c) generating an efflux of quinolones
 Enhances selection of mutations in chromosomal target genes with exposure to quinolones
RIFAMPIN, RIFABUTIN
BASIC CONCEPTS

 MECHANISM: inhibit mRNA transcription and gene expression by targeting bacterial RNA polymerase (limited to
gram-positive bacteria)
 RESISTANCE MECHANISM
 Single mutations in the beta subunit of RNA polymerase (high level resistance) – requires combination with other antimicrobials to reduce
likelihood of high-level resistance
METRONIDAZOLE
BASIC CONCEPTS

 MECHANISM: direct bactericidal effect by being converted to reactive drug derivatives that nonspecifically damage
cytoplasmic proteins and nucleic acids
 RESISTANCE MECHANISM
 Bacteroides – rare resistance pattern – in strains that lack endogenous activating nitroreductase or that have acquired nim genes responsible
for reduction of DNA-damaging nitroso intermediates to an inactive derivative
 Active efflux
 Enhanced DNA repair mechanism
NITROFURANTOIN
BASIC CONCEPTS

 INDICATIONS: treatment of lower urinary tract infection (adequate drug concentrations are only in urine)

 MECHANISM: involve generation of reactive derivative molecules that damage DNA and ribosomes

 RESISTANCE MECHANISM E. coli

 Series of mutations that progressively decrease the nitroreductase activity required for generating active nitrofuran metabolites
 DRAWBACK: impaired bacterial growth
POLYMIXINS
BASIC CONCEPTS

 INDICATIONS: infections due to resistant Enterobacterales, P. aeruginosa, Acinetobacter

 MECHANISM: cationic cyclic peptide molecules that bind negatively charged lipopolysaccharides on the gram-negative
bacterial outer membrane  subsequent disruption and permeabilization of both outer-membrane and cytoplasmic-
membrane structure
 RESISTANCE MECHANISM: uncommon
 Mutations that cause reductions in the negative charge of gram-negative bacterial cell surface  reducing binding of the positively charged
colistin
 mcr-1 – plasmid-mediated gene encoding a phosphoethanolamine transferase that reduces cell surface negative charge
DAPTOMYCIN
BASIC CONCEPTS

 INDICATIONS: active against gram-positive bacteria

 MECHANISM: interacts with and disrupts the cytoplasmic membrane in a calcium-dependent manner
(BACTERICIDAL)
 RESISTANCE MECHANISM – infrequently found in some S. aureus strains with intermediate vancomycin
susceptibility from patients treated with vancomycin and not exposed to daptomycin AND enterococci
 Mutations in several genes that can alter cell membrane charge and structure that reduces binding
 Acquired susceptibility to beta-lactams (MRSA) – requires treatment in combination with nafcillin or ceftaroline
EPIDEMIOLOGY OF RESISTANCE
GENERAL PRINCIPLES

 Prevalence of resistance can vary greatly in different geographic areas and even at different institutions in the same area
 SPECIFIC LOCAL DATA on the occurrence of various types of resistance – important component of choice of antimicrobials for empiric
treatment of infection

 IMPORTANT: obtain appropriate samples for culture or other diagnostic modalities and susceptibility testing prior to
administration of antimicrobials
 IMPORTANT: rapid and sensitive diagnostic methods and prompt communication of their results to clinicians to inform
best choices of antimicrobials
FACTORS AFFECTING OVERALL RESISTANCE PREVALENCE

 Extent of resistance reservoirs in the patient population

 Selection pressures from the use of antimicrobials that favor resistant strains

 The extent by which resistance is amplified by transmission of resistant strains to patients from their environment or
other persons, either directly or indirectly via the contaminated hands of health care workers when hand hygiene and
other infection control practices are not adequately followed
 HISTORY: prior antibiotic treatment, prior infection with resistant pathogens, prior hospitalizations
PRINCIPLES IN PREVENTING ANTIMICROBIAL RESISTANCE

 Appropriate use of antimicrobials (avoid their use in situations in which they are not needed)

 Uses of shortest course of therapy sufficient for successful clinical outcome

 Implementation of antimicrobial stewardship programs

 Careful and consistent infection control practices in short and long-term care institutions
CURRENT DATA ON ANTIMICROBIAL RESISTANCES

 Data based on US Centers for Disease Control and Prevention

 >2.8 million resistant bacterial infections per year
 35,900 deaths

 URGENT: increasing occurrence worldwide and often highly resistant to multiple drugs, with few antimicrobials
available for treatment
 Resistant N. gonorrhoeae – ease of spread from person to person with few active agents available
 Clostridioides difficile – resistance linked to antibacterial use (disruption of normal GI microbiome) and to its ability to spread in health care
environments
FIVE CORE ACTIONS

 INFECTION PREVENTION AND CONTROL – focus on implementation of evidence-based activities to reduce risks and incidence
of device-related infections overall and on improvement of compliance with infection control practices that prevent transmission of
resistant pathogens from one person to another
 TRACKING AND DATA – increase reporting and sharing of the occurrence of resistance to enhance epidemiologic data and inform
targeting of preventive interventions
 ANTIBIOTIC USE AND ACCESS – antimicrobial stewardship programs with specific components to track usage and educate
clinicians on appropriate use, reduction of inappropriate use of antimicrobials in outpatient settings (particularly in cases of upper
respiratory illnesses that are commonly viral in etiology)
 VACCINES, THERAPEUTICS AND DIAGNOSTICS – enhanced regulatory pathways for drug approval, new technologies for rapid
detection of resistance and susceptibility
 ENVIRONMENT AND SANITATION – health interventions addressing issues regarding reservoirs of resistant bacteria and
resistance genes on mobile genetic elements in agriculture and food production and domestic animals
REFERENCES

 Loscalzo, Kasper, Longo, Fauci, Hauser, Jameson. (2022). Harrison’s Principles of Internal Medicine (21st
Edition, Vol. 2). McGraw-Hill Education.