Chemotherapy

Resistance to Anti-microbial Agents

By:
Mr. Shivsharan B. Dhadde
Drug resistance:
• Drug resistance refers to unresponsiveness of a microorganism to an AMA,
and is akin to the phenomenon of tolerance seen in higher organisms.

Natural resistance
• Some microbes have always been resistant to certain AMAs. They lack the
metabolic process or the target site which is affected by the particular drug.

• This is generally a group or species characteristic, e.g. gram-negative

bacilli are normally unaffected by penicillin G, or M. tuberculosis is
insensitive to tetracyclines.

• This type of resistance does not pose a significant clinical problem.

Acquired resistance

• Acquired resistance is the development of resistance by an organism (which was

sensitive before) due to the use of an AMA over a period of time. This can
happen with any microbe and is a major clinical problem.

• Successful antimicrobial therapy of an infection ultimately depends on the

concentration of antibiotic at the site of infection. This concentration must be
sufficient to inhibit growth of the offending microorganism.

• If host defenses are intact and active, a minimum inhibitory effect, such as that
provided by bacteriostatic agents may be sufficient. On the other hand, if host
defenses are impaired, antibiotic-mediated killing may be required to eradicate
the infection.
• The concentration of drug at the site of infection not only must inhibit the
organism but also must remain below the level that is toxic to human cells.
• If this can be achieved, the microorganism is considered susceptible to the
antibiotic.

• If an inhibitory or bactericidal concentration exceeds that which can be achieved

safely in vivo, then the microorganism is considered resistant to that drug.
• Resistance to an antibiotic can be the result of one or more mechanisms. Three
general mechanisms which are responsible for bacterial resistance to an antimicrobial
agent are:

a) The sufficient concentration of drug to eradicate the organism does not reach its
target;
b) The drug loses its activity, or
c) Alteration of drug target
The sufficient concentration of drug to eradicate the organism
does not reach its target;
• The outer membrane of gram-negative bacteria is a permeable barrier that excludes
large polar molecules from entering the cell. Small polar molecules, including many
antibiotics, enter the cell through protein channels called porins.

• Absence of, mutation in, or loss of a favored porin channel can slow the rate of
drug entry into a cell or prevent entry altogether, effectively reducing drug
concentration at the target site.

• If the target is intracellular and the drug requires active transport across the cell
membrane, a mutation or phenotypic change that shuts down this transport
mechanism can confer resistance.

• Bacteria also have efflux pumps that can transport drugs out of the cell. Resistance
to numerous drugs, including tetracycline, chloramphenicol, fluoroquinolones,
macrolides, and b-lactam antibiotics, is mediated by an efflux pump mechanism.
The drug loses its activity (Drug inactivation)
• Bacterial resistance to aminoglycosides and to b-lactam antibiotics usually
is due to production of an aminoglycoside-modifying enzyme or b-
lactamase, respectively.

• A variation of this mechanism is failure of the bacterial cell to activate a

prodrug.

• This is the basis of the most common type of resistance to isoniazid in M.

tuberculosis.

Alteration of drug target

• This may be due to mutation of the natural target (e.g., fluoroquinolone
resistance), target modification (e.g., ribosomal protection type of resistance
to macrolides and tetracyclines), or acquisition of a resistant form of the
native, susceptible target (e.g., staphylococcal methicillin resistance caused
by production of a low-affinity penicillin-binding protein)
• Bacterial resistance can happen with any microbe and is a major clinical
problem.

• However, development of resistance is dependent on the microorganism as

well as the drug.

• Resistance may be developed by mutation or gene transfer.

Mutation
• It is a stable and heritable genetic change that occurs spontaneously and
randomly among microorganisms. It is not induced by the AMA.

• Any sensitive population of a microbe contains a few mutant cells which

require higher concentration of the AMA for inhibition.

• These are selectively preserved and get a chance to proliferate when the
sensitive cells are eliminated by the AMA.

• Thus, in time it would appear that a sensitive strain has been replaced by a
resistant one, e.g. when a single antitubercular drug is used.
Gene transfer
Transfer of infectious resistance from one organism to another can occur by:

Transduction
• Transduction is acquisition of bacterial DNA from a phage (a virus that
propagates in bacteria) that has incorporated DNA from a previous host
bacterium within its outer protein coat.

• If the DNA includes a gene for drug resistance, the newly infected bacterial
cell may acquire resistance.

• Transduction is particularly important in the transfer of antibiotic resistance

among strains of S. aureus.

Transformation.
• Transformation is the uptake and incorporation into the host genome by
homologous recombination of free DNA released into the environment by
other bacterial cells.

• Transformation is the molecular basis of penicillin resistance in pneumococci

and Neisseria.
• Penicillin-resistant pneumococci produce altered penicillin-binding proteins
(PBPs) that have low-affinity binding of penicillin.

• Nucleotide sequence analysis of the genes encoding these altered PBPs

indicates that they are mosaics in which blocks of foreign DNA from a
closely related species of streptococcus have been imported and
incorporated into the resident PBP gene.

Conjugation.
• Conjugation is gene transfer by direct cell-to-cell contact through a sex pilus or
bridge.

• This complex and fascinating mechanism for the spread of antibiotic resistance is
extremely important because multiple resistance genes can be transferred in a single
event.

• The transferable genetic material consists of two different sets of plasmid-encoded

genes that may be on the same or different plasmids.

• One set encodes the actual resistance; the second encodes genes necessary for the
bacterial conjugation process.
• Conjugative plasmids tend to be rather large. They combine elements of plasmid
DNA rolling-circle replication (only a single strand is transferred, and it replicates
in the host) with a type IV bacterial secretion system.

• Plasmid transfer requires an origin of transfer demarcating the site within the
plasmid where transfer will occur, DNA replicating enzymes, and coupling proteins
that direct the DNA across two cell membranes on its way from the host into the
recipient. Genes encoding the resistance determinants may be located on
transposons.

• Conjugation with genetic exchange between nonpathogenic and pathogenic

microorganisms probably occurs in the GI tracts of human beings and animals.

• The efficiency of transfer is low; however, antibiotics can exert a powerful selective
pressure to allow emergence of the resistant strain.

• Genetic transfer by conjugation is common among gram-negative bacilli, and

resistance is conferred on a susceptible cell as a single event.
Cross resistance
• Acquisition of resistance to one AMA conferring resistance to another AMA, to
which the organism has not been exposed, is called cross resistance.

• This is more commonly seen between chemically or mechanistically related drugs,

e.g. resistance to one sulfonamide means resistance to all others, and resistance to
one tetracycline means insensitivity to all others. Such cross resistance is often
complete.

• However, resistance to one aminoglycoside may not extend to another, e.g.

gentamicin-resistant strains may respond to amikacin.

• Sometimes unrelated drugs show partial cross resistance, e.g. between tetracyclines
and chloramphenicol, between erythromycin and lincomycin.

• Cross resistance may be two-way, e.g. between erythromycin and clindamycin and
vice versa, or one-way, e.g. development of neomycin resistance by
enterobacteriaceae makes them insensitive to streptomycin but many streptomycin-
resistant organisms remain susceptible to neomycin.
Prevention of drug resistance
It is of utmost clinical importance to curb development of drug resistance.
• No indiscriminate and inadequate or unduly prolonged use of AMAs should be made.
This would minimize the selection pressure and resistant strains will get less chance
to preferentially propagate. For acute localized infections in otherwise healthy
patients, symptom determined shorter courses of AMAs are being advocated now.

• Prefer rapidly acting and selective (narrowspectrum) AMAs whenever possible;

broad-spectrum drugs should be used only when a specific one cannot be determined
or is not suitable.

• Use combination of AMAs whenever prolonged therapy is undertaken, e.g.

tuberculosis, SABE.

• Infection by organisms notorious for developing resistance, e.g. Staph. aureus, E.

coli, M. tuberculosis, Proteus, etc. must be treated intensively.