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Mechanisms of Bacterial Resistance to Antibiotics

Laura A. Dever, RPh, Terence S. Dermody, MD

The three fundamental mechanisms of antimicrobial resis- antimicrobial resistance, with emphasis on resistance to anti¬
tance are (1) enzymatic degradation of antibacterial drugs, biotics that inhibit cell-wall biosynthesis. The classification
(2) alteration of bacterial proteins that are antimicrobial targets, system of gram-positive and gram-negative ß-lactamases will
and (3) changes in membrane permeability to antibiotics. Antibi- be detailed, and nonenzymatically mediated ß-lactam resis¬
otic resistance can be either plasmid mediated or maintained on
tance mechanisms will be described. We will also discuss
the bacterial chromosome. The most important mechanism of
resistance to the penicillins and cephalosporins is antibiotic
mechanisms of resistance to the other major classes of antibi¬
hydrolysis mediated by the bacterial enzyme \g=b\-lactamase.The otics, including antagonists of folate synthesis, the aminogly-
expression of chromosomal \g=b\-lactamasecan either be induced cosides, chloramphenicol, and the quinolones.
or stably derepressed by exposure to \g=b\-lactamdrugs. Methods to
overcome resistance to \g=b\-lactamantibiotics include the develop-
ment of new antibiotics that are stable to \g=b\-lactamaseattack and Penicillins and cephalosporins are the two most commonly
the coadministration of \g=b\-lactamase inhibitors with \g=b\-lactam used classes of ß-lactam antibiotics (Fig 1). Although both
drugs. Resistance to methicillin, which is stable to gram-positive these groups of agents contain a ß-lactam nucleus, they differ
\g=b\-lactamase,occurs through the alteration of an antibiotic target in that penicillins contain a thiazolidine ß-lactam ring complex
protein, penicillin-binding protein 2. Production of antibiotic- and cephalosporins contain a dihydrothiazine ß-lactam ring
modifying enzymes and synthesis of antibiotic-insensitive bac- complex. The antibacterial effect of all ß-lactam antibiotics
terial targets are the primary resistance mechanisms for the
other classes of antibiotics, including trimethoprim, the sulfon- depends on the capacity ofthe antibiotic to diffuse through the
cell membrane, the affinity of the antibiotic for its target
amides, the aminoglycosides, chloramphenicol, and the quino-
lone drugs. Reduced antibiotic penetration is also a resistance proteins, and the stability of the antibiotic against bacterial
mechanism for several classes of antibiotics, including the degradation."
\g=b\-lactamdrugs, the aminoglycosides, chloramphenicol, and the The mechanism ofaction of ß-lactam antibiotics is inhibition
quinolones. of bacterial cell-wall synthesis. Bacterial cell walls are con¬
(Arch Intern Med. 1991;151:886-895) structed from alternating iV-acetylglucosamine and A/-acetyl-
muramic acid residues.5 Transpeptidation is the final step of
cell-wall synthesis and involves the transpeptidase-catalyzed
cross-linking of peptidoglycan chains. As shown in Fig 2,
"Bacterial resistance to antimicrobial agents is becoming transpeptidase-mediated hydrolysis of the ß-lactam bond
increasingly important in clinical practice. While antibiot¬ (CO—N) results in the inhibition of transpeptidation by the
ic resistance is more prevalent in bacteria causing nosocomial covalent linkage of the ß-lactam drug to bacterial transpepti-
infections, the prevalence of antibiotic-resistant pathogenic dase.5 Penicillin-binding proteins (PBPs) are bacterial pro¬
organisms is also increasing in the community at large. ' Forty teins (carboxypeptidases and transpeptidases) responsible
years ago, Staphylococcus aureus was one of the more com¬ for many of the enzymatic activities involved in cell-wall
mon bacterial pathogens (especially in nosocomial infections) synthesis, and they are the primary targets for ß-lactam
and was easily eradicated by penicillin.2,3 At the same time, antibiotics.6 Binding of ß-lactam drugs to PBPs 1, 2, and 3
infections with gram-negative organisms, such as Pseudomo- results in cell-wall lysis, disruption of cell shape, and inhibi¬
nas aeruginosa and Serratia marcescens, were unusual and tion of cell division, respectively.7,8
were often thought to represent colonization rather than ß-Lactam antibiotics can also inhibit bacterial growth by
infection.2 Tbday, most isolates of S aureus are resistant to mechanisms that do not solely involve the inhibition of cell-
penicillin, and infections with gram-negative organisms are wall synthesis. Inhibition of the formation of cell-wall precur¬
common. In addition, many other bacterial pathogens have sors by ß-lactam antibiotics can result in autolysis through the
developed resistance to a large number of antimicrobial unsuppressed activity of murein hydrolases.6 Murein hydro-
agents, and infections with these organisms can be difficult to lases are autolytic enzymes that cause nicks in the cell wall to
treat. provide sites for new peptidoglycan synthesis during cell-wall
Bacteria have developed resistance to every antibiotic used enlargement.9 The inhibition of cell-wall synthesis by ß-lac¬
thus far, and there exist several different mechanisms by tam antibiotics does not alter the activity of these enzymes.10
which antibiotic resistance is mediated (Table). In this re¬ Therefore, bacterial autolysis can result from the effect of
view, we will discuss the most important mechanisms of osmotic pressure on the cell wall damaged by murein hydro¬
Accepted for publication October 16,1990. lases.9,10 In addition to lytic mechanisms, group A streptococci
From the Pharmacy Department, New England Medical Center (Ms Dever); and viridans streptococci do not undergo cell lysis in the
Department of Microbiology and Molecular Genetics, Harvard Medical School presence of ß-lactam drugs (autolysin defective) but can re¬
(Dr Dermody); and Department of Medicine, Brigham and Women's Hospital
(Dr Dermody), Boston, Mass. Dr Dermody is now with the Department of main susceptible to ß-lactam antibiotics by nonlytic mecha¬
Pediatric Infectious Diseases, Vanderbilt University Medical Center, Nash- nisms.11,12
ville, Tenn. The most common cause of resistance to ß-lactam drugs is
Reprint requests to Department ofPediatric Infectious Diseases, Vanderbilt
University Medical Center, Nashville, TN 37232 (Dr Dermody). enzyme-mediated antibiotic degradation. Three classes of

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enzymes canhydrolyze ß-lactam antibiotics: (1) ß-lactamases, Several different schemes have been used to classify
(2) acylases, and (3) esterases (Fig 3).13 ß-Lactamase-medi- ß-lactamases. Richmond and Sykes identified five classes (I
ated hydrolysis resulting in degradation of the ß-lactam nu¬ through V) of gram-negative ß-lactamases on the basis of
cleus is the most important mechanism of bacterial resistance substrate affinity, isoelectric point, and inhibition data.20 En¬
to ß-lactam antibiotics. ß-Lactamases are produced by some zymes produced by gram-positive organisms (predominantly
gram-positive and all gram-negative bacteria.14,15 ß-Lacta¬ by S aureus) are distinct from those produced by gram-
mases produced by gram-positive organisms are excreted negative organisms. They have a different classification
extracellularly; those produced by gram-negative organisms scheme and are divided into four groups (A through D) pri¬
are usually concentrated in the periplasmic space and not marily by sérologie features.13,21
excreted.15,16 The ß-lactam bond, which is required for the Gram-negative bacilli produce both chromosomally en¬
activity of ß-lactam antibiotics, is also the target of ß-lacta- coded and plasmid-encoded ß-lactamases.18,21 Richmond-
mase attack. ß-Lactamases catalyze the hydrolysis of the Sykes class I and II ß-lactamases, broadly categorized as
ß-lactam bond to acidic derivatives that do not have antibac¬
terial properties (Fig 4).17"19
Genes encoding ß-lactamases can reside on the bacterial
chromosome or on plasmids; bacterial plasmids that encode O
proteins responsible for antibiotic resistance are referred to R-C-NH-
as resistance factors (R-factors). Plasmid-mediated resis¬
tance can be passed to distantly related bacterial species by Penicillins
conjugation, and the expression of these enzymes is usually y COOH
constitutive.8 In contrast, the expression of chromosomally
mediated ß-lactamases is usually not constitutive but can be
induced or derepressed by exposure to ß-lactam antibiotics.19 o
Mechanisms of Bacterial Resistance to Antimicrobial Agents
Drug/Drug Class Mechanism of Resistance
Penicillins and Enzymatic inactivation by ß-lactamase; enzymatic
cephalosporins modification by acylase and esterase; outer- COOH
membrane protein deletion; alteration of
penicillin-binding proteins O
Monobactams Enzymatic inactivation by ß-lactamase H
Carbapenems Enzymatic inactivation by ß-lactamase; R-C-NH.
outer-membrane protein deletion
Vancomycin Inhibition of glycopeptide access
Trimethoprim Increased production of dihydrofolate reductase; Monobactams
production of trimethoprim-insensitive Ov •v
dihydrofolate reductase S03H
Sulfonamides Increased production of p-aminobenzoic acid;
increased production of pteridine; increased
production of sulfonamide-insensitive
dihydropteroate synthetase OH
Aminoglycosides Enzymatic modification by acetylation,
phosphorylation, and nucleotidylation;
ribosomal alteration; diminished drug uptake ,NH
Chloramphenicol Enzymatic inactivation by acetylation; decreased Carbapenems •NHCl
drug permeability
Macrolides Enzymatic modification by esterase; alteration of
23S ribosomal RNA
Lincosamides Enzymatic modification by nucleotidylation or
phosphorylation; alteration of 23S ribosomal
Tetracyclines Active efflux preceded by chemical modification
Quinolones Alteration of subunit A of DNA gyrase; decreased
drug permeability Fig 1.—Structures of ß-lactam antibiotics. The ß-lactam ring (to the left
of the dashed line) is shared by all of these compounds.

Fig 2.—Inhibition of bacterial transpeptidase by penicillin.

R-C-NH^ ^SV^CH3 Bacterial

R C NH ^

(/ C00H

Penicillin Penicilloyl Enzyme

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cephalosporinases and penicillinases, respectively, are chro- hyperproduce ß-lactamase despite removal of the inducing
mosomally mediated.20 Induction of class I enzymes occurs ß-lactam antibiotic.24 ß-Lactam drugs that are weak ß-lacta¬
when expression of ß-lactamases increases in the presence of mase inducers can lyse organisms capable of ß-lactamase
a ß-lactam antibiotic (acting as an inducer) and declines to a induction but cannot inhibit bacterial mutants with stably
basal state after hydrolysis or removal of the inducing depressed ß-lactamase expression.22 Weak ß-lactamase in¬
agent.22,23 Citrobacter freundii, Enterobacter cloacae, and ducers used to treat infections caused by P aeruginosa and
P aeruginosa are examples of gram-negative bacteria that E cloacae can lead to ß-lactam resistance through stable
produce class I ß-lactamases that are inducible.24"27 The admin¬ derepression of ß-lactamase expression.22 Cefotaxime, cefti-
istration of strong ß-lactamase inducers, such as cefoxitin and zoxime, and ceftazidime are examples of weak ß-lactamase
imipenem, can lead to the degradation of enzyme-labile ceph¬ inducers capable of selecting stably derepressed mutants.a
alosporins when these drugs are given concomitantly.24,28,29 All of the class III ß-lactamases are plasmid encoded and
Stable derepression of class I ß-lactamase expression can include the TEM-1, TEM-2, and SHV-1 ß-lactamases.20,21 Re¬
occur in bacterial mutants selected for ß-lactam resistance by cently described TEM enzymes mediate the hydrolysis of
exposure to a ß-lactam drug. Stably derepressed mutants aztreonam and the extended-spectrum cephalosporins (eg,
cefotaxime and ceftazidime) and include TEM-3,30,31 TEM-4,32
TEM-7,33 and TEM-10.34 TEM enzymes that hydrolyze ex¬
tended-spectrum cephalosporins usually manifest selective
resistance to specific cephalosporins. Therefore, susceptibil¬
R-C-NH CH3 ity to a particular cephalosporin drug should not be interpret¬
J CH3 ed as representative of an entire cephalosporin class.34 Class
© IV enzymes are chromosomally mediated ß-lactamases pro¬

°©—u' Penicillins
duced by Klebsiella.21 Class V enzymes are a heterogeneous
group of ß-lactamases and include the oxacillin-hydrolyzing
enzymes of Enterobacteriaceae (OXA-1, OXA-2, and OXA-3)
and the Pseudomonas-speciftc enzymes.20,21
Resistance to ß-lactam antibiotics can be inhibited through
II the chemical modification of ß-lactam drugs to improve stabil¬
ity against ß-lactamase hydrolysis. Aztreonam and imi-
o penem, each representing a unique ß-lactam antibiotic class,
© CH2-0 —
are two of the most promising new agents (Fig l).35,36 Az¬
treonam is a monobactam that is active only against gram-

negative aerobic organisms.37,38 It demonstrates an especially

COOH © high degree of stability to plasmid-encoded ß-lactamases38
and does not induce chromosomally encoded ß-lactamases.37
Cephalosporins Imipenem (A^-formimidoyl thienamycin) is a carbapenem and
is similar to aztreonam in that it is highly resistant to
Fig 3.—Sites for enzymatic degradation of penicillins and cephalospo¬ ß-lactamase degradation.36,39,40 Imipenem is degraded by renal
rins: ß-lactamase (1 ), acylase (2), and esterase (3). dihydropeptidase and must be coadministered with cilastatin,

Fig 4.—Reactions catalyzed by ß-lactamases resulting in the degradation of penicillins (top) and
cephalosporins (bottom).


:.-«: ¿f=C Nc CH3




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a dihydropeptidase inhibitor. Imipenem is active against a
large number of gram-positive, gram-negative, and anaerobic CHjOH
organisms, including Bacteroides fragilis, Escherichia coli,
P aeruginosa, and S aureus.41*1 It is not affected by a perme¬
ability barrier and can readily enter into the periplasm. Al¬ \*
though imipenem is stable against most plasmid-encoded and
chromosomally encoded ß-lactamases,15,36 zinc-containing ß-
lactamases that are capable of imipenem hydrolysis have been
identified in strains of Xanthomonas maltophilia44 and "COO-K*
B fragilis.45
The coadministration of a nonantimicrobial drug capable of Clavulanate Potassium
inhibiting ß-lactamase activity in conjunction with a ß-lactam
antibiotic is a strategy that has recently been used to over¬
come ß-lactamase-mediated resistance. Clavulanate and sul-
bactam, two prototype agents now in widespread use, both
act irreversibly to inhibit ß-lactamase activity4,14 (Fig 5). The
combination of either of these agents with ampicillin results in
antibacterial activity against ampicillin-resistant strains of
Bacteroides, E coli, Haemophilus influenzae, and S aur-
Hydrolysis of clavulanate is followed by (1) formation of a •COO"Na+
long-lived acyl-enzyme intermediate, (2) transient regenera¬
tion of free ß-lactamase, and then (3) irreversible ß-lactamase Sulbactam Sodium
inactivation through the formation of a covalent linkage be¬
tween the enzyme active site and the inhibitor.47,48 Hydrolysis Fig 5.—Structures of clavulanate potassium and sulbactam sodium.
of sulbactam results in the formation of sulbactam fragments Both compounds are noncompetitive ß-lactamase inhibitors.
that covalently bond to a site on the enzyme distinct from the
active site, causing irreversible enzyme inactivation.13 Clavu¬ strains that express PBP 2a constitutively.56,61 Ordinarily,
lanate and sulbactam can inhibit plasmid-encoded ß-lacta¬ within a given S aureus culture, few of the isolates express
mases (Richmond-Sykes classes III and V) and chromosomal¬ methicillin resistance (heterogeneous resistance),62 but occa¬
ly encoded ß-lactamases (Richmond-Sykes classes II and IV) sionally all of the isolates are resistant (homogeneous resis¬
of gram-negative bacteria and ß-lactamases of gram-positive tance).63 The level of methicillin resistance in culture does not
bacteria.46 Clavulanate and sulbactam are poor inhibitors of have clinical significance in that all of these isolates should be
class I enzymes4*"1;clavulanate induces these enzymes in considered resistant to methicillin.
some bacteria, especially P aeruginosa and Enterobacter.m A novel resistance mechanism has recently been described
Because of its capacity to induce ß-lactamase production, in methicillin-resistant S aureus with low or borderline levels
clavulanate may antagonize the effect of ticarcillin on strains of resistance to ß-lactam antibiotics. These methicillin-resis¬
of Morganella morganii and E cloacae that are capable of tant strains do not express PBP 2a64,65 but possess PBPs that
induced ß-lactamase expression.50 In contrast to clavulanate, have modified penicillin-binding capacities (particularly PBP
sulbactam is a less potent inhibitor of most ß-lactamases. 1 and PBP 2).ffi Compared with methicillin-resistant S aureus
However, sulbactam is a poor ß-lactamase inducer and thus strains that produce PBP 2a, the minimum inhibitory concen¬
offers a distinct advantage over clavulanate.52 trations of methicillin for methicillin-resistant S aureus with
RESISTANCE TO METHICILLIN modified penicillin-binding capacities are low, and therefore
these organisms generally remain susceptible to methicillin.
Alteration ofthe ß-lactam nucleus has yielded many antimi¬
However, this mechanism of resistance could be an important
crobials (eg, methicillin, nafcillin, and oxacillin) with in¬ cause of methicillin resistance in the future.65
creased stability to gram-positive ß-lactamases. Resistance
to these agents does occur, however, and is independent of RESISTANCE TO ß-LACTAM ANTIBIOTICS
ß-lactamase production. Methicillin-resistant strains of
S aureus are increasingly common in nosocomial53 infections Porin proteins in the outer membrane of gram-negative
and have also been described in infections of intravenous- bacteria form channels that allow the exchange of nutrients
drug abusers.54,55 Methicillin resistance is mediated through and other substances (including antibiotics) between the ex¬
the production of an altered PBP 2 (PBP 2a or PBP 2')f*58 that tracellular environment and the periplasmic space.66"68 For
has a much lower affinity for methicillin (and for most other ß-lactam antibiotics to bind PBPs, they must penetrate porin
ß-lactam antibiotics) than does PBP 2.59 channels in the outer membrane and traverse the periplasmic
Methicillin-resistant S aureus can exhibit either high or low space.69 Diffusion of some ß-lactam drugs through porin chan¬
levels of resistance. Whereas greater amounts of PBP 2a are nels is limited by the presence of bulky substituents on the
produced in high-level methicillin-resistant S aureus, there is acyl side chain of the ß-lactam nucleus; diffusion of others is
no correlation between PBP 2a production and minimum limited by electrostatic charge.70 Changes in outer membrane
inhibitory concentration.60 The expression of PBP 2a can ei¬ permeability serve to limit drug influx and decrease drug
ther be induced by methicillin (or other ß-lactam antibiotics) availability to PBPs located on the inner membrane.23,68
or be constitutive. A ß-lactamase plasmid is usually present in Two outer membrane proteins (Omps) of E coli that have
inducible methicillin-resistant S aureus strains but absent in been identified and characterized are OmpF and OmpC.66,70,71

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\ HO

H>C \ . \ \ç_— CH2OH

H°CH3 \^°

h0y-^/^ci O
^/\/oh O CH3
11 H X H m

i! H

HN\\ h

HO / \ OH


Fig 6.—Structure of vancomycin showing the site of the A/-substitution. R =

H in vancomycin.

An additional (mutant) channel, PhoE, is produced in mu¬ RESISTANCE TO VANCOMYCIN

tants of E coli deficient in OmpF and OmpC under conditions Vancomycin is a glycopeptide antibiotic (Fig 6) that inhibits
of phosphate depletion.66 Of these three porin channels, bacterial cell-wall formation by the inhibition of peptidogly¬
OmpF has the widest pore diameter and the highest perme¬ can synthesis. It binds to the free carboxyl end of D-alanyl-D-
ability to ß-lactam drugs.71 Zwitterionic compounds (eg, am- alanine of V-acetyl-muramyl-pentapeptide of the elongating
picillin, cefaclor, cephalexin, and imipenem) have much high¬ peptidoglycan chain.77,78 Vancomycin activity is limited to
er penetration rates through OmpF than do anionic
gram-positive organisms, and the drug is especially useful in
compounds (eg, carbenicillin, cefamandole, cefuroxime, and the treatment of infections caused by methicillin-resistant
piperacillin).70 Permeability of zwitterionic compounds S aureus and penicillin-resistant strains of Enterococcus.™
through PhoE channels is poor; in contrast, anionic com¬ Resistance to vancomycin has recently been observed in
pounds have higher penetration rates through PhoE channels Enterococcus faecium60^2 and Enterococcus faecalis.® In
than through OmpF channels.71 Escherichia coli mutants de¬ these organisms, vancomycin resistance is plasmid mediated
ficient in OmpF channels are resistant to ß-lactam antibiotics and inducible.82^4 Although the mechanism of resistance is
as a consequence of reduced penetration through OmpC chan¬
poorly understood, novel cytoplasmic membrane proteins
nels produced by these organisms.70"72 In addition, enzymatic have been identified in vancomycin-resistant strains of
degradation of ß-lactam antibiotics is more efficient in OmpF- Efaecium'1 and Efaecalis.^ It has been suggested that these
deficient mutants because of the slower drug penetration that
proteins block vancomycin access to the elongating peptido¬
occurs through OmpC channels.68 glycan chain.81,83 Strains of Efaecium and Efaecalis that are
Penetration of compounds through the outer membrane of resistant to vancomycin maintain susceptibility to some N-
P aeruginosa is less than that of E coli, primarily because of substituted vancomycin derivatives (eg, decyl-vancomycin,
the low permeability of its porin channels.67 Impaired pene¬ p-octyloxybenzyl-vancomycin)
tration appears to be the mechanism of imipenem resistance
exhibited by some strains of P aeruginosa.13 Loss of 45- to
48-kd Omps has been reported in strains of P aeruginosa that RESISTANCE TO THE FOLATE ANTAGONISTS:
are imipenem resistant.73"75 These proteins correspond to
porin channel D2 which is required for the penetration of Trimethoprim and the sulfonamides act synergistically to
imipenem.74 inhibit folate metabolism by blocking sequential steps in the

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Most aminoglycosides (amikacin, gentamicin, neomycin, ne-
p-Aminobenzoic Acid + Pteridine tilmicin, and tobramycin) contain 2-deoxystreptamine; strep¬
tomycin contains streptidine. Aminoglycosides are hydro-
Dihydropteroate philic molecules that require active transport to gain entry
Synthetase into bacteria.96 The primary mechanism of aminoglycoside
resistance is enzyme-mediated antibiotic modification. Alter¬
Sulfonamides h-** ation ofribosomal binding sites96 and diminished drug uptake98
are less common mechanisms of aminoglycoside resistance.
S02NH Dihydropteroic Acid Aminoglycoside-modifying enzymes (AMEs) catalyze the
modification of either the amino or hydroxyl groups on amino-
T~\ Dihydrofolate
cyclitol and aminoglycoside antibiotics (Fig S).m,S9 These en¬
zymes inactivate aminoglycosides by three mechanisms: (1)
acetylation, (2) nucleotidylation, and (3) phosphorylation.99"102
Bacterial AMEs of most gram-positive and gram-negative
Sulfamethoxazole Dihydrofolic Acid organisms are plasmid encoded.97 Concentrations of AMEs in
the periplasmic space of gram-negative bacteria are usually
Dihydrofolate low.101 However, modification of aminoglycosides is efficient
because antibiotic uptake into the periplasmic space is slow,
and AME affinity for aminoglycosides is high.101 Each AME
Trimethoprim r—** inactivates a particular subset of the available aminoglycoside
antibiotics accounting for the varied spectra of aminoglyco¬
side resistance observed in clinical isolates.101
OCH3 Tetrahydrofolic Acid
Aminoglycoside acylases inactivate aminoglycosides by
OCH3 catalyzing the transfer of acetate from acetyl-coenzyme A to
an amino group on 2-deoxystreptamine-containing aminogly¬
OCH3 cosides, such as amikacin, gentamicin, and neomycin.97,101
Aminoglycoside nucleotidyltransferases utilize adenosine tri-
Fig 7.—Sites of inhibition of folate metabolism by sulfonamides and phosphate and other nucleotide triphosphates as cofactors
trimethoprim. The action of these agents on two independent bio¬ and adenylylate hydroxyl groups on amikacin, gentamicin,
chemical steps is responsible for the synergy observed with these
antibiotics. kanamycin, neomycin, spectinomycin, streptomycin, and to¬
bramycin.97 Aminoglycoside phosphotransferases catalyze
the transfer of a phosphate group to a hydroxyl group on
amikacin, gentamicin, kanamycin, neomycin, and tobramy¬
folate synthesis pathway (Fig 7). Trimethoprim inhibits dihy¬ cin. 1M A single aminoglycoside can be altered at several differ¬
drofolate reductase, and the sulfonamides inhibit dihydro¬ ent sites by the coupling of one or more AMEs, a process
pteroate synthetase.85,86 Bacteria are not able to take up pre¬ resulting in the complete inactivation of the antibiotic.97100
formed folie acid derivatives and cannot utilize host folie acid. Recently, strains of E faecalis and E faecium have been
Therefore, bacterial production of tetrahydrofolic acid, which reported that show high levels of aminoglycoside resistance
is required for the synthesis of amino acids and nucleotides, is (minimum inhibitory concentration, >2000 mg/L).103 Effec¬
entirely dependent on synthesis from pteridine and p-amino- tive treatment of serious infections caused by these organ¬
benzoicacid.85 isms requires the synergistic combination of ampicillin, peni¬
The major cause of trimethoprim resistance is the produc¬ cillin, or vancomycin and an aminoglycoside.104"106 Enterococci
tion of an altered (plasmid-encoded) dihydrofolate reductase with high levels of aminoglycoside resistance can be especial¬
that lacks the capacity to bind trimethoprim.87'91 Overproduc¬ ly difficult to treat, as therapy with a cell-wall synthesis
tion of the normal (chromosomally encoded) dihydrofolate inhibitor alone is usually not effective. Furthermore, entero¬
reductase is an additional mechanism of trimethoprim resis¬ cocci that manifest high levels of aminoglycoside resistance
tance, particularly in E coli and Klebsiella pneumoniaef,SZlXI can exhibit resistance to several aminoglycosides simulta¬
Bacterial resistance to the sulfonamides may be caused by neously.103107 However, individual aminoglycoside susceptibil¬
increased production of p-aminobenzoic acid, increased syn¬ ity testing is advisable, since enterococci can demonstrate
thesis of pteridine, and increased production of a sulfonamide- high levels of aminoglycoside resistance to gentamicin, kana¬
resistant dihydropteroate synthetase.87,94 Most resistance to mycin, tobramycin, and streptomycin despite only moderate
sulfonamides, however, is due to an additional plasmid-en¬ resistance to amikacin or netilmicin.103,108
coded dihydropteroate synthetase that has a lowered affinity RESISTANCE TO CHLORAMPHENICOL
for sulfonamides.85,87,95 As is the case with ß-lactam antibiotics,
loss of inhibitory activity ofeither trimethoprim or the sulfon¬ Chloramphenicol inhibits bacterial protein synthesis by
amides can result from impaired penetration.87,98 binding to the 50S ribosomal subunit.109 The most common
mechanism of resistance to chloramphenicol is enzymatic
modification.110,111 Chloramphenicol acetyltransferase is an in-
Aminoglycoside antibiotics inhibit the initiation of protein ducible, plasmid-encoded enzyme that inactivates chloram¬
synthesis and disrupt polypeptide chain elongation by induc¬ phenicol by acetylation (Fig 9).112"114 Decreased chlorampheni¬
ing the incorporation of incorrect amino acids.96 Aminoglyco- col permeability has also been proposed to be a cause of
sides are classified into two groups, depending on whether resistance in H influenzaem and Pseudomonas cepacia.116 In
they contain 2-deoxystreptamine or streptidine (Fig 8).97 chloramphenicol-resistant strains of H influenzae that do not

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C. D- AAC m
NH AAC (6')

O/TON™"™2 APH (3')

(41)—MHOVH A
APH (3')

(4')—K3H^H /
}- OAjj)
V_/^APH (6)
AAC (2')
AAC (2') —* H2N
AAC (3)-AhT\^ AAC (3) -^hT\^
APH (5") —*HOÇH2 0 o

ANT (3") hoNíiv

ANT (2") —»OH
APH (3") APH (2")

Fig 8.—Aminoglycoside structures and sites for enzymatic modification. A, Spectinomycin; B, streptomy¬
cin; C, neomycin; and D, kanamycin B. Amikacin, gentamicin, and tobramycin are structurally related to
kanamycin B. AAC indicates aminoglycoside A/-acetyltransferase; AAD, aminoglycoside adenylyltrans-
ferase; ANT, aminoglycoside nucleotidyltransferase; and APH, aminoglycoside phosphotransferase
(modified from Phillips and Shannon97).


Acetyltransferase VC
C —

CH20 —


Chloramphenicol 3-O-Acetyl Chloramphenicol

Acetyl CoA

Fig 9.—Acetylation of chloramphenicol by chloramphenicol acetyltransferase. CoA indicates coenzyme


produce chloramphenicol acetyltransferase, reduced quanti¬ matic modification, does not confer resistance to this
ties of an Omp have been observed.115 It has been suggested drug.124,125
that the loss of this Omp in resistant strains results in de¬ RESISTANCE TO QUINOLONES
creased chloramphenicol permeability.115
The 6-fluoroquinolone antibiotics, ciprofloxacin and nor-
floxacin, were derived from nalidixic acid.126 These drugs
exhibit bactericidal activity against a wide range of gram-
Macrolide (erythromycin) and lincosamide (clindamycin) positive and gram-negative bacteria, including some strains
antibiotics inhibit bacterial protein synthesis by binding to of methicillin-resistant S aureus and P aeruginosa
the 50S ribosomal subunit.117 Resistance to these agents is (Fig 10).127"130 Quinolone antibiotics inhibit DNA gyrase, an
mediated by mechanisms similar to those responsible for enzyme required for unwinding of the supercoiled bacterial
aminoglycoside resistance. Macrolide and lincosamide resis¬ chromosome before DNA replication.131 DNA gyrase is com¬
tance is due to either alteration of the ribosomal target site posed of two A subunits (encoded by gyrA) and two B sub-
(adenine methylation in 23S ribosomal RNA)118 or enzyme- units (encoded by gyrB).1S2,133
mediated antibiotic modification.119 Resistance to nalidixic acid and the 6-fluoroquinolone drugs
The tetracyclines act to inhibit bacterial protein synthesis occurs through two independent mechanisms, and neither
by binding to the 30S ribosomal subunit.120 Resistance to mechanism is plasmid mediated.132 Although resistance to
tetracycline is also caused by enzymatic modification,121 and nalidixic acid is mediated by the same mechanisms as resis¬
alteration of this drug is followed by rapid efflux from the tance to the 6-fluoroquinolone antibiotics,134 resistance to nali¬
cytoplasm.122,123 Tetracycline efflux, unaccompanied by enzy- dixic acid is 100- to 1000-fold greater than resistance to the

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o As discussed in this review, bacteria have developed resis¬
II tance to all classes of antimicrobial agents curently in use.
.COOH Furthermore, newer mechanisms of antibiotic resistance
have caused significant problems in the treatment of infec¬
tions caused by some bacteria, such as enterococci and Pseu-
domonas. New strategies to combat antibiotic resistance
H.C^S, include the modification of antibiotics now in use and the
coadministration of nonantibiotic drugs that can inhibit anti¬
I biotic degradation mediated by bacterial enzymes. Despite
these technological innovations, it is very likely that antibiot¬
Nalidixic Acid ic resistance will continue to be an important clinical problem.
Several methods have been developed to decrease the risk of
infection with antibiotic-resistant organisms. These include
choosing an antibiotic with a narrow spectrum when a patho¬
gen is known, the use of short durations of antibiotic prophy¬
COOH laxis, and limiting topical and oral therapy with drugs that
may have to be used parenterally. While it remains controver¬
sial whether the indiscriminate use of antibiotics actually
increases the emergence of drug-resistant pathogens, it
seems prudent to use these drugs carefully to prolong their
This study was supported in part by Physician-Scientist Award 5K11
AI00865 from the National Institute of Allergy and Infectious Diseases, Be-
Norfloxacin thesda, Md (Dr Dermody).
We express our appreciation to Jerry Jones, PhD, James Maguire, MD,
Thomas O'Brien, MD, and Richard T. Scheife, PharmD, for essential discus¬
sions and reviews of the manuscript.
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