MULTI DRUG

RESISTANT
BACTERIA
Dr.T.V.Rao MD

Dr.T.V.Rao MD 1
A Tribute to - Fleming and Penicillin

Dr.T.V.Rao MD 2
 Brief History of Antibiotics
• 1928- Penicillin discovered by Fleming
• • 1932- Sulfonamide antimicrobial activity discovered ( Erlich)
• • 1935- First unsuccessful attempt to use Sulfonamide to treat
• • a case of meningitis
• • 1943- Drug companies begin mass production of penicillin
• • 1948- Cephalosporins precursor sent to Oxford for synthesis
• • 1952- Erythromycin derived from Streptomyces erythreus
• • 1956- Vancomycin introduced for penicillin resistant
staphylococcus

Dr.T.V.Rao MD 3
 Recent Antibiotics in Use
• • 1962- Quinolone antibiotics
first discovered
• • 1970s- Linezolid discovered
but not pursued
• • 1980s- Fluorinated
Quinolones introduced,
making then clinically useful
• • 2000- Linezolid introduced
into clinical practice

Dr.T.V.Rao MD 4
 The Magic Bullets
• Antibiotics revolutionised medicine
• The first antibiotic, penicillin, was discovered by Alexander
Fleming in 1929
• It was later isolated by Florey and Chain
• It was not extensively used until the 2nd World War when it was
used to treat war wounds
• After 2nd World War many more antibiotics were developed
• Today about 150 types are used
• Most are inhibitors of the protein synthesis, blocking the 70S
ribosome, which is characteristic of prokaryotes

© 2008 Paul Billiet ODWS Dr.T.V.Rao MD 5

 Survival of the Fittest.
Darwin’s theory rules the Microbes
• Various microorganisms
have survived for
thousands of years by their
being able to adapt to
antimicrobial agents. They
do so via spontaneous
mutation or by DNA
transfer. These
microorganisms employ
several mechanisms in
attaining multidrug
resistance
Dr.T.V.Rao MD 6
 Resistance
• It took less than 20 years for,
bacteria to show signs of
resistance
• Staphylococcus aureus, which
causes blood poisoning and
pneumonia, started to show
resistance in the 1950s
• Today there are different
strains of S. aureus resistant to
every form of antibiotic in use

S Dr.T.V.Rao MD 7
 Multiple drug resistance
• Multiple drug resistance or
Multidrug resistance is a
condition enabling a disease-
causing organism to resist
distinct drugs or chemicals of a
wide variety[1] of structure and
function targeted at
eradicating the organism.
Organisms that display
multidrug resistance can be
pathologic cells, including
bacterial .

Dr.T.V.Rao MD 8
 MDRO: Definition
• Multidrug-Resistant Organisms (MDROs) are
defined as microorganisms that are resistant to one
or more classes of antimicrobial agents.

• Three most common MDROs are:

1. Methicillin-Resistant Staph aureus (MRSA)
2. Vancomycin Resistant Enterococci: (VRE)
3. Extended Spectrum Beta-Lactamase producing
Enterobacteriaceae. (ESBLs)

CDC: Management of Multidrug-Resistant Organisms in Healthcare Settings, Healthcare Infection Control Advisory Committee, Jane D. Siegel et. al. pg 7-12
Dr.T.V.Rao MD 9
 Antibiotic Pressure and Resistance in Bacteria
What is it ?
• ”Selectionpressure of antibiotics has
led to the emergence of antibiotic-
resistant bacteria.”

•Antibiotics can effect bacteria unrelated to

the targeted infectious agent; these may be
“normal” flora, leading to the emergence of
resistant mutants inhabiting the same
environment.

Baquero et al., International Report 1996;23:819

Dr.T.V.Rao MD 10
 Settings that Promote Drug Resistance

Day-care centers

Long term care
facilities

Homeless
shelters

Jails

Dr.T.V.Rao MD 11
 Location contributing to Drug
Resistance

Intensive care
units

Oncology units

Dialysis units

Rehab units

Transplant units

Burn units
Dr.T.V.Rao MD 12
 Transposons & Integrons
• Resistance genes are often associated with
transposons, genes that easily move from one
bacterium to another
• Many bacteria also possess integrons, pieces of DNA
that accumulate new genes
• Gradually a strain of a bacterium can build up a whole
range of resistance genes
• This is multiple resistance
• These may then be passed on in a group to other
strains or other species
Dr.T.V.Rao MD 13
Dr.T.V.Rao MD 14
 Antibiotics promote resistance
• If a patient taking a course of antibiotic treatment does not
complete it
• Or forgets to take the doses regularly,
• Then resistant strains get a chance to build up
• The antibiotics also kill innocent bystanders bacteria which are
non-pathogens
• This reduces the competition for the resistant pathogens
• The use of antibiotics also promotes antibiotic resistance in non-
pathogens too
• These non-pathogens may later pass their resistance genes on
to pathogens
Dr.T.V.Rao MD 15
ODWS
 Multi-resistance

• Multi-resistance
• Multi-resistance to different antibiotics generally results from a
combination of different independent mechanisms of resistance. -P
aeruginosa is a type of multi-resistant bacteria. It is resistant to β-lactams,
• including third-generation cephalosporins, quinolones, chloramphenicol,
and Tetracycline's. (natural resistance)
• -Methicillin-resistant strains have become resistant to most antibiotics
and with a high frequency of high resistance. (acquired)
• Cross-resistance
• Cross-resistance Occurs generally in antibiotics of the same family.
• -Cross-resistance between penicillin's, more widely between all the β-
lactams

Dr.T.V.Rao MD 16
 Consequences of Antimicrobial Resistance
• Compromised therapy of
human infections
• • Serious complications for
elderly and children
• • Increased length of therapy
and more doctor visits
• • Prolonged hospital stay and
significant increase of
treatment cost
• “Bacterial resistance is a major
threat to public health”

Dr.T.V.Rao MD 17
 DNA gyrase DNA-directed RNA
polymerase
Quinolones
Cell wall synthesis Rifampin
ß-lactams &
Glycopeptides
(Vancomycin) DNA
THFA mRNA
Trimethoprim
Protein synthesis
Ribosomes inhibition
Folic acid
synthesis DHFA 50 50 50
Macrolides &
30 30 30
Lincomycins
Sulfonamides
PABA
Protein synthesis
Protein synthesis inhibition
mistranslation Tetracyclines
Aminoglycosides
Cohen. Science 1992; 257:1064 Dr.T.V.Rao MD 18
 Causes of Resistance in MDROs
•Enzymatic degradation
•Mutation at binding site
•Down regulation of
outer membrane
proteins
•Efflux pumps
•Transduction of genes

Dr.T.V.Rao MD 19
 Mechanisms of Resistance: Efflux
• Active, energy dependent pumps cause efflux of drugs
Efflux pump
Outer membrane

PG layer

Bacterial Cytosol

drug
Dr.T.V.Rao MD 20
 Antibiotic Pressure and Resistance in Bacteria
Why is it important?
• Antibiotic resistance has developed in almost all classes of
bacteria of pathogenic potential.
• Resistance in organisms of low virulence can emerge as
important pathogens.
• The development of resistant bacteria has driven
pharmaceutical research to develop more potent, broad-
spectrum antibiotics.
• Use of these in turn, has fueled the appearance of
bacteria with newer modes of resistance.

Dr.T.V.Rao MD 21
INCREASING PREVALENCE OF ANTIMICROBIAL
RESISTANT MICROBES
•Hospital-acquired
infections
• Methicillin-resistant
staphylococci
• Vancomycin-resistant
staphylococci
• Vancomycin-resistant
enterococci
• ESC-resistant Gram-
negative bacteria
• Azole-resistant Candida
Dr.T.V.Rao MD 22
 1.Methicillin-Resistant Staph aureus
(MRSA)
• These are organisms that are
not sensitive to common
penicillin based drugs such as
methicillin, amoxicillin,
penicillin, oxacillin1
• Normal flora- lives on human
skin, noses, vaginal tract
• May cause infections if enters
the body
• Contagious- through person to
person contact
• Treatment - Vancomycin

Dr.T.V.Rao MD 23
Vancomycin Resistant Enterococci (VRE)
• Enterococci resistant to
Vancomycin
• Present in human body such as
urinary tract and GI tract.
• Contagious
• Hospital patients can get it
from contact via health care
providers.
• Normal flora that may cause
disease especially in vulnerable
populations:
• Eg elderly, children and
immunocompromised patients.

Dr.T.V.Rao MD 24
 Vancomycin Resistant Enterococci (VRE)
• VRE include:
• Enterococcus faecalis
• Enterococcus faecium
• Treated with Synercid
(quinupristin and
dalfopristin)

• VRE can live on surfaces

for up to 7 days!!!
• Haemophilus influenzae
lives about 2 days

Dr.T.V.Rao MD 25
 VRE prevention
• Standard precautions
• Hand hygiene
• Personal Protective
Equipment (PPE)
• Needle stick and sharps
injury prevention.
• Cleaning & disinfection
• Respiratory hygiene (Cough
Etiquette)
• Waste disposal
• Safe injection practices

Dr.T.V.Rao MD
Center for Disease Control and Prevention: http://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf Accessed June 17th 2009 26
 Extended Spectrum Beta-Lactamase producing
Enterobacteriaceae. (ESBL)

• ESBLs are plasmid-mediated beta lactamases described in gram

negative bacilli2
• Eg. Klebsiella, Acinetobacter
• MOA – hydrolysis of beta- lactam ring in
• Penicillin's
• Narrow spectrum cephalosporins
• Beta-lactamase inhibitors inhibit ESBL producing strains
• Clavulanic acid
• Sulbactam
• Tazobactam.

Dr.T.V.Rao MD 27
 Enzymatic degradation of ESBLs:
Mechanisms of β-lactamase
Penicillin drug
H H
R N S R N
CH3 S CH3
CH3 CH3
O N O N
OH H OH
O O H2O
OH O
O O
CH2 CH2
β-lactamase β-lactamase
OH
CH2

β-lactamase
H
OH R N S CH3
CH2 CH3
+ O N
β-lactamase H OH
Hydrolysis of Oxyimino group O
OH
O
Dr.T.V.Rao MD
Inactivated drug 28
 Other Drug Resistant Diseases
• Extensively-Drug Resistant Tuberculosis (XDR-TB)
• This is a TB causing organism that is resistant to almost all
drugs that are used to treat TB.
• Isoniazid
• Rifampin
• Fluoroquinolones
• At least one of: Amikacin, kanamycin, capreomycin
• The main cuasitive organism is Mycobacterium tuberculosis3
• Contagious through droplets but slower than viral infection
such as flu

Dr.T.V.Rao MD 29
 CDC Reports
Three Enterobacteriaceae isolates
carrying a newly described
resistance mechanism, the New
Delhi metallo-beta-lactamase
(NDM-1) , were identified from
three U.S. states at the CDC
antimicrobial susceptibility
laboratory. This is the first
report of NDM-1 in the United
States, and the first report of
metallo-beta-lactamase carriage
among Enterobacteriaceae in the
United States

Dr.T.V.Rao MD 30
 CDC reports the new genetic mechanisms
• The isolate, Klebseilla pneumoniae 05-
506, was shown to possess a metallo-
beta-lactamase (MBL) but was
negative for previously known MBL
genes. Gene libraries and
amplification of class 1 integrons
revealed three resistance-conferring
regions; the first contained
bla(CMY-4) flanked by ISEcP1
and blc. The second region of 4.8 kb
contained a complex class 1 integron
with the gene cassettes arr-2, a new
erythromycin esterase gene; ereC;
aadA1; and cmlA7

Dr.T.V.Rao MD 31
 Genetic origin of the NDM-1
• An intact ISCR1 element was shown to be downstream from
the qac/sul genes. The third region consisted of a new MBL
gene, designated bla(NDM-1), flanked on one side by K.
pneumoniae DNA and a truncated IS26 element on its other
side. The last two regions lie adjacent to one another, and all
three regions are found on a 180-kb region that is easily
transferable to recipient strains and that confers resistance
to all antibiotics except fluoroquinolones and colistin. NDM-1
shares very little identity with other MBLs, with the most
similar MBLs being VIM-1/VIM-2, with which it has only 32.4%
identity.

Dr.T.V.Rao MD 32
 Molecular configuration of NDM-1
• NDM-1 also has an
additional insert between
positions 162 and 166 not
present in other MBLs.
NDM-1 has a molecular
mass of 28 kDa, is
monomeric, and can
hydrolyze all beta-lactams
except aztreonam.
Compared to VIM-2, NDM-1
displays tighter binding to
most Cephalosporins.
Dr.T.V.Rao MD 33
NDM genetic coding differs from other recent
isolates
• Compared to VIM-2, NDM-1 displays tighter binding to
most cephalosporins, in particular, cefuroxime,
cefotaxime, and cephalothin (cefalotin), and also to the
penicillins. NDM-1 does not bind to the carbapenems as
tightly as IMP-1 or VIM-2 and turns over the carbapenems
at a rate similar to that of VIM-2. In addition to K.
pneumoniae 05-506, bla(NDM-1) was found on a 140-kb
plasmid in an Escherichia coli strain isolated from the
patient's feces, inferring the possibility of in vivo
conjugation

Dr.T.V.Rao MD 34
 Antibiotic use and Major abuse
•Viral infections are
not stopped by
antibiotics
•Yet doctors still
prescribe (or are
coerced into
prescribing)
antibiotics to treat
them
Dr.T.V.Rao MD 35
 INCREASING PREVALENCE OF ANTIMICROBIAL
RESISTANT MICROBES
• Community-acquired
infections
• Multidrug resistant pneumococci
• Drug-resistant H. influenzae
• FQ- and ESC-resistant Salmonella
• Multidrug resistant Shigella
• FQ-resistant gonococci
• Multidrug-resistant M.
tuberculosis
• Drug-resistant malaria
• Drug-resistant HIV

Dr.T.V.Rao MD 36
 Nosocomial infections – Attains Higher Resistance.
•Major nosocomial pathogens increasingly resistant
to antimicrobial drugs include Escherichia coli,
Staphylococcus aureus, coagulase-negative
staphylococci, Enterococcus species, and
Pseudomonas aeruginosa . Infections from
methicillin- resistant staphylococci, vancomycin-
resistant enterococci (VRE), and aminoglycoside-
resistant Pseudomonas spp. are becoming
common.

Dr.T.V.Rao MD 37
 Antibiotic Misuse – Consequences.
• Large amounts of antibiotics used for human therapy, as
well as for farm animals and even for fish in aquaculture,
resulted in the selection of pathogenic bacteria resistant
to multiple drugs. Multidrug resistance in bacteria may be
generated by one of two mechanisms. First, these
bacteria may accumulate multiple genes, each coding for
resistance to a single drug, within a single cell. This
accumulation occurs typically on resistance (R) plasmids.
Second, multidrug resistance may also occur by the
increased expression of genes that code for multidrug
efflux pumps, extruding a wide range of drugs.
Dr.T.V.Rao MD 38
Bacteria attains Resistance by Complex
Mechanisms
• # No longer relying on a
glycoprotein cell wall
• # Enzymatic deactivation of
antibiotics
• # Decreased cell wall
permeability to antibiotics
• # Altered target sites of
antibiotic
• # Efflux mechanisms to remove
antibiotics[3]
• # Increased mutation rate as a
stress response[4
Dr.T.V.Rao MD 39
 Gene Transfers play a Major rule in Antibiotic
Resistance
• Many different bacteria now exhibit
multidrug resistance, including
staphylococci, enterococci,
gonococci, streptococci, salmonella,
Mycobacterium tuberculosis and
others. In addition, some resistant
bacteria are able to transfer copies of
DNA that codes for a mechanism of
resistance to other bacteria, thereby
conferring resistance to their
neighbors, which then are also able to
pass on the resistant gene. This
process is called horizontal gene
transfer.

Dr.T.V.Rao MD 40
 Role of clinical Microbiology Laboratories
• The clinical laboratory
has several critical roles
in controlling hospital-
acquired infections:
accurately identifying
nosocomial pathogens,
detecting unexpected
antimicrobial-drug
resistance, and
epidemiologic typing

Dr.T.V.Rao MD 41
 Antibiotic Pressure and Resistance in Bacteria
What factors promote their development and spread ?

Alteration of normal flora

Practices contributing to misuse

of antibiotics

Settings that foster drug

resistance

Failure to follow infection control

principles

Dr.T.V.Rao MD 42
 Practices Contributing to
Misuse of Antibiotics

Inappropriate specimen

selection and collection

Inappropriate clinical tests

Failure to use

stains/smears

Failure to use cultures and

susceptibility tests

Dr.T.V.Rao MD 43
Inappropriate Antibiotic Use
Use of antibiotics with no clinical indication (eg, for
viral infections)

Use of broad spectrum antibiotics when not

indicated
Inappropriate choice of empiric antibiotics
• Lack of quality control in manufacture or outdated
antimicrobial
• Inadequate surveillance or defective susceptibility
assays
• Poverty or war
• Use of antibiotics in foods
Dr.T.V.Rao MD 44
Inappropriate Drug Regimen

Inappropriate dose - ineffective

concentration of antibiotics at site of
infection

Inappropriate route - ineffective

concentration of antibiotics at site of
infection

Inappropriate duration

Dr.T.V.Rao MD 45
Newer methods too have limitations
• Most new rapid tests are
not yet helpful for infection
control purposes, and
automated systems for
bacterial identification and
susceptibility testing are
not as reliable as desired
for detecting organisms
with emerging drug
resistance

Dr.T.V.Rao MD 46
 Microbiology Laboratories to Play
Greater Role
• A microbiology laboratory
fully equipped to
cooperate in the
management of
nosocomial infections will
also have the necessary
infrastructure to act as a
sentinel to detect new
antimicrobial agent
resistance

Dr.T.V.Rao MD 47
 Implication of MDROs
•Increase hospital
stay
•Average 3-5
additional days
•Increase hospital
costs
•Increase morbidity
and mortality
Dr.T.V.Rao
CDC: Management of Multidrug-Resistant Organisms in Healthcare Settings, HealthcareMD
Infection Control Advisory Committee, Jane D. Siegel et. al. pg 7-12 48
 MDROs prevention
•Observe the universal standard precautions
•Practice 200% percent safety rule
•Good hygiene practice
•Frequent hand wash
•Cover cuts and scrapes
•Do not share personal items eg razors
•Do not pressure doctors for antibiotics
•Finish all antibiotic medications
•Health care providers to wash hands before touching
patients Dr.T.V.Rao MD 49

•Isolation for serious cases

 Proposals to Combat Antimicrobial
Resistance
•Speed development
of new antibiotics
•Track resistance data
nationwide
•Restrict antimicrobial
use
•Direct observed
dosing (TB)
Dr.T.V.Rao MD 50
Proposals to Combat Antimicrobial Resistance
•Use more
narrow
spectrum
antibiotics
•Use
antimicrobial
cocktails
Dr.T.V.Rao MD 51
 Limiting Antibiotic Resistance
• Use antibiotics only for
bacterial infections
• Identify the causative organism
if possible
• Use the right antibiotic; do not
rely on broad-range antibiotics
• Not stop antibiotics as soon as
symptoms improve; finish the
full course
• Not use antibiotics for most colds,
coughs, bronchitis, sinus infections,
and eye infections, which are caused
by viruses.

Dr.T.V.Rao MD 52
 Physicians Can Impact
Other clinicians

Patients

Optimize patient evaluation Optimize consultations with other

Adopt judicious antibiotic clinicians
prescribing practices Use infection control measures
Immunize patients Educate others about judicious use
Dr.T.V.Rao MD
of antibiotics 53
 Future – Developing New Antibiotics
•Antimicrobial peptides
•Broad spectrum antibiotics from plants and
animals
• Squalamine (sharks)
• Protegrin (pigs)
• Magainin (frogs)
•Antisense agents
•Complementary DNA or peptide nucleic acids that
binds to a pathogen's virulence gene(s) and
prevents transcription
Dr.T.V.Rao MD 54
 World Health Day 2011
• For World Health Day 2011, WHO
will launch a worldwide campaign
to safeguard these medicines for
future generations.
Antimicrobial
resistance - the theme
of World Health Day 2011
- and its global spread, threatens the
continued effectiveness of many
medicines used today to treat the
sick, while at the same time it risks
jeopardizing important advances
being made against major infectious
killers.

Dr.T.V.Rao MD 55
Hand Washing is A Great Investment in Controlling
Multi Drug Resistant Strains

Dr.T.V.Rao MD 56
The Programme is dedicated to Ignaz
PH Semmelweis

Dr.T.V.Rao MD 57
• The Programme is created by Dr.T.V.Rao MD
for ‘ e ‘ learning resources on Awareness on
Implications of Antibiotic Misuse and
Consequces.
•Email
•doctortvrao@gmail.com

Dr.T.V.Rao MD 58