BACTERIAL RESISTANCE TO
ANTIBIOTICS
Reham Samir, PhD P 18
1
• Antibiotic resistance occurs when bacteria
develop the ability to beat the drugs designed
to kill them.
• When bacteria become resistant, antibiotics
cannot fight them, and the bacteria multiply.
• Overuse and misuse of antibiotics allows the
development of antibiotic-resistant bacteria
• Antibiotic resistance is one of the most urgent
threats to the public’s health. 2
Types of bacterial resistance
Intrinsic, inherent or innate resistance Acquired resistance
1. The intrinsic properties of the M.O are 1. The M.O which was previously
responsible for resisting the AB. sensitive, becomes resistant after
e.g. Intrinsic resistance to gram-negative exposure to certain antibiotic.
bacteria is thought to be associated with the
outer cell membrane, preventing certain
antibiotics from reaching their intracellular
targets, which are absent in Gram-positive
cells.
2. Occurs by mutations in
chromosome or via Horizontal
2. Chromosomally-mediated.
Gene Transfer (plasmids,
transposons).
3. It depends on the previous antibiotic
3. It’s Independent on previous antibiotic
exposure
exposure.
3
Three genetic elements are
responsible for acquiring resistance
1. Chromosomal mutations:
Changes occur in the DNA sequence (point or frame shift) could
result in development of antibiotic resistance through mutation in
certain genes followed by natural selection.
2. Plasmids:
• Plasmids are circular DNA that exist in the cell separated from
the chromosome.
• A plasmid can carry a genes encoding resistance to one or
more antibiotics.
• Acquisition of a single plasmid can make a bacterium resistant to
many different types of antibiotics. 4
Horizontal gene
transfer
• Genes can be transferred
between bacterial cells by
conjugation, transduction
or transformation.
• Conjugation is the
predominant mechanism
for plasmids. 5
6
3. Transposons:
They are jumping genetic elements capable of transferring or
transposing independently from one DNA molecule
(chromosomes or plasmids) to another. The central region of the
transposon often codes for antibiotic resistance genes.
7
Examples of different types of acquired resistance
Chromosomally Plasmid Transposon mediated
mediated mediated resistance
resistance resistance
Methicillin Aminoglycoside Single:
Quinolones s, ampicillin, chloramphenicol,
Rifampicin Aminocyclitols tetracycline
β-lactams Multiple:
Tetracyclines Ampicillin + streptomycin +
Sulphonamides, sulphonamide
Trimethoprim
Chloramphenic
ol
Erythromycin
Fusidic acid
8
Biochemical mechanisms of resistance
1- Decreased permeability of the antibiotic due to alterations in
membrane structure.
2- Presence of proteins functioning as efflux pumps that actively
remove antibiotic molecules from the cytoplasm to the
outside.
3- Production of enzymes, which inactivate antibiotics, either
through destruction or alteration of the antibiotic molecule.
4- Alterations in the target site, which reduce the binding of
antibiotics, but allow the target to retain its normal function.
5- Overproduction of the target site so that higher antibiotic
concentrations are required to exert significant antibacterial
action.
In certain species, an enzyme or metabolic pathway may be
absent, rendering the microorganism resistant to antibiotics 9
effective against other bacterial species.
10
Mechanism Example Comment
of
resistance
Impermeability •Some β-lactam antibiotics •Mutational loss of porins
to antibiotic
•Aminoglycoside antibiotics •Reduced ability of cells to
uptake the drug
•Tetracycline, fusidic acid •Plasmid-mediated
and decreased drug
Chloramphenicol accumulation
•Novobiocin, actinomycin, •Difficulty in entering
erythromycin and Gram-negative bacteria
rifampicin 11
Mechanism Example Comment
of resistance
Efflux Tetracyclines Energy-dependent efflux of
accumulated drug
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Mechanism or Example Comment
resistance
Enzymatic •Some β-lactam •(β-lactamase) Hydrolysis of
inactivation antibiotics the β-lactam ring
•Chloramphenicol •Chloramphenicol acyl
transferase (CAT) Conversion
to an inactive compound
•Some •Alteration of the antibiotic
aminoglycoside by phosphorylation,
antibiotics adenylylation or acetylation.
13
Mechanism Example Comment
of
resistance
Decreased β-lactam antibiotics Altered penicillin binding
affinity of proteins (PBP)
target
enzyme Sulphonamides Altered dihydropetroate
(alteration of synthetase
the target
site) Trimethoprim Altered dihydrofolate
reductase
Fusidic acid Altered translocation factor 14
Mechanism Example Comment
of
resistance
Decreased Streptomycin Altered 30S ribosomal subunit
affinity of
target enzyme Erythromycin Altered 50S ribosomal subunit
(alteration of
the target Tetracycline Altered 30S ribosomal subunit
site)
Glycopeptides Altered peptidoglycans precursors
with lower affinity (D-Ala-D-Ala)
Quinolones Altered gyrase
Rifampicin Altered RNA polymerase 15
Mechanism of Example Comment
resistance
Overproduction Sulphonamide Overproduction of p-amino
of the target site benzoic acid (PABA)
or metabolite
Trimethoprim Overproduction of
dihydrofolate reductase
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Resistance to β-Lactams
Acquired resistance to β-lactam antibiotics can
occur by three different mechanisms:
1- Reduced permeability.
2- Inactivation of the antibiotic (β-Lactamase)
3- Alteration of the target site (Transpeptidase or
penicillin binding protein (PBP)
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Resistance to β-Lactams
1- Changes in the outer membrane porins of Gram-negative
bacteria, reducing the penetration of β-lactams.
2- β-lactamases which hydrolyse the cyclic amide bond in the
antibiotic molecule producing penicilloic acid, which is unable
to bind to penicillin-binding proteins. A similar reaction occurs
with cephalosporins. β-lactamases are either plasmid,
transposon or chromosomal encoded. The origin of these is
unclear but they may have diverged from existing PBPs.
Chromosomal enzymes are either constitutive or inducible by
β-lactams. Mutations in regulatory genes can lead to
constitutive high levels of expression. In Gram-negative
organisms, β-lactamases are found in the periplasmic space
where they inactivate β-lactams before the antibiotics can
bind to their PBP targets on the cytoplasmic membrane. In
Gram-positive organisms, however, β-lactamases are excreted 18
extracellularly
Resistance to β-Lactams
3- Alterations in PBPs which affect binding of β-Iactams.
Clinically, one of the most important examples of β-
lactam resistance is the methicillin-resistant Staph.
aureus (MRSA) strains. These are causing increasing
concern in hospitals, especially because methicillin
resistance is often accompanied by multiple resistance
to unrelated antibiotics. Methicillin resistance is due
to a novel PBP with low affinity for β-lactams. It is
capable of functioning when all other PBPs have been
inhibited and is sufficient to catalyze all the reactions
necessary for cell growth.
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Multidrug resistance pumps
• Acquired low-level multiple antibiotic
resistance (MAR) to many unrelated antibiotics
by efflux is reported in recent years. Mutants
resistant to low levels of chloramphenicol,
tetracyclines, rifampicin, penicillins and
quinolones, due to impaired uptake of the
antibiotics have been identified and are
widespread among bacteria, Increased active
efflux of the drugs has been shown to be 20
important in this type of resistance.
The problem of antibiotic resistance
• Antibiotic resistance is of increasing concern and is the most
common cause of treatment failure in bacterial infectious
diseases.
• Infections with antibiotic-resistant bacteria leads to the use of
more expensive and often more toxic drugs, increased length
of infection and subsequent hospital stay.
• The problem is not confined to nosocomial bacteria but also
community-acquired pathogens have become resistant to key
antibiotics.
• The appearance of MRSA must serve as a warning signal.
Vancomycin (or teicoplanin) is often the only antibiotic
effective against some MRSA strains. Acquisition of
vancomycin resistance by MRSA would leave a health disaster.
(VRSA strains exist now). 21
• Pan drug resistant strains of Acinetobacter baumannii
endangers the antibiotics era.
Bacterial resistance to antibiotics could be
overcome by:
1- Designing new drugs that are unsusceptible to the
enzyme attack (-lactamase resistant penicillin e.g.
cloxacillin).
2- Designing new drugs that will inactivate the enzyme
concerned thereby protecting susceptible antibiotics
(-lactamase inhibitors e.g. clavulinic acid, sulbactam
and tazobactam).
3- Development of new antibiotics (modification of an
already existing ones.
4-Development of natural peptides with antibacterial
activity to overcome the low penetration in case of
Gram-negative bacteria. 22
5- Drug combinations
Drug combinations P 22
• A combination of two antibacterial agents may produce the following
responses.
• Synergism, 1 + 1 > 2
• Additive effect, 1 + 1 = 2
• Antagonism (interference), 1 + 1 < 2
• The advantages of clinical synergism:
1. To obtain a wider spectrum of activity for treatment of mixed
infections as in life-threatening serious abdominal sepsis situations
where mixed aerobic and anaerobic infections exist. The use of
metronidazole in combination with either an aminoglycoside or a
broad-spectrum cephalosporin is essential.
2. To prevent the emergence of resistant organisms as in combined
antituberculus therapy and in treatment of Staph. aureus infections
with fusidic acid and flucloxacillin.
3. To reduce the dosage of a toxic drug as in treatment of meningitis
caused by the fungus Cryptococcus by amphotericin with 5-
flucytosine. 23
4. To protect the effect of an antibiotic as the case with β-lactamase
inhibitor and an appropriate β-lactamase-labile penicillin.
Antimicrobial Resistance:
Key Prevention Strategies
Susceptible Pathogen
Antimicrobial-Resistant
Pathogen Pathogen
Prevent Prevent
Transmission Infection
Infection
Antimicrobial
Resistance
Effective
Optimize Diagnosis
& Treatment
Use
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Antimicrobial Use
Antibiotic policies P23
Are Guidelines to provide the prescriber with a range
of agents appropriate to the patient needs to ensure
the unnecessary use i.e. abuse of antibiotics. In order
1. To prevent the development resistance to antibiotic.
2. To reduce antibiotic toxicity.
3. To reduce the cost of antibiotic use.
4. To provide the patient with optimal antibacterial
therapy
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The general principles include the following:
1- Unless there is a valid reason for giving an antibiotic, the
patient would probably be better without it: it include the
following
A. Treatment of known or suspected infection based on a
clear clinical and bacteriological diagnosis e.g. in tonsilitis
the suspected bacteria is Streptococcus sp. and penicillin
treatment is indicated.
B. Prevention of bacterial infection: There are a few definite
indications for prophylactic administration of antibacterial
drugs e.g. patients who can develop rheumatic fever need
to be protected, especially during childhood, from
Streptococcus pyogenes and so penicillin can safely be
given in prolonged low dosage for prophylaxis.
- Pre-operative prophylaxis, starting just before operations
involving the intestine, particularly the GIT, and continued
for a few days, can reduce the frequency of wound in-
fection. 26
- Prophylactic administration of penicillin for patients at
special risk of developing gas-gangrene as in major trauma
with soil contamination.
2- In general it is bad treatment to use broad-spectrum antibiotics
when an infective condition can be treated with a more specific
agent.
3- In cases when immediate drug treatment is necessary, and
initial treatment has to be based on guesses, all specimens
necessary for the isolation of the causative organism should be
collected before treatment is started otherwise isolation is
delayed or become difficult.
4- It is essential to use bactericidal and not bacteriostatic therapy
when the patient’s immunological defenses are seriously
impaired, or when the infection is overwhelming. An important
example is bacterial endocarditis.
5- There are situations in which it is essential to use combination
of antimicrobial drugs e.g. in treatment of tuberculosis, to
reduce the emergence of resistance.
6- For treatment of superficial infections it is important to use
either antiseptic or antibiotics which are rarely or never used
systemically e.g. a spray of neomycin, bacitracin and polymyxin. 27
7- Antibiotic should be given in the proper dose for long enough
period then stop treatment or change to another drug if the
patient is not responding well to the initial drug. Some times
prolonged treatment is required e.g. in treatment of
tuberculosis.
8- Avoid the use of antibiotics as food supplement for animals
and avoid liberation of antibiotic powders and solutions into the
environment.
9- To reduce the emergence of antibiotic-resistant strains in
hospitals, use antibiotics in rotation and keep a particular
antibiotics for use only on special occasions.
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