Showing papers in "Journal of Antimicrobial Chemotherapy in 2002"
TL;DR: The authors currently face multiresistant infectious disease organisms that are difficult and, sometimes, impossible to treat successfully and must encourage the return of the susceptible commensal flora to curb the resistance problem.
Abstract: Antibiotic resistance has become a major clinical and public health problem within the lifetime of most people living today. Confronted by increasing amounts of antibiotics over the past 60 years, bacteria have responded to the deluge with the propagation of progeny no longer susceptible to them. While it is clear that antibiotics are pivotal in the selection of bacterial resistance, the spread of resistance genes and of resistant bacteria also contributes to the problem. Selection of resistant forms can occur during or after antimicrobial treatment; antibiotic residues can be found in the environment for long periods of time after treatment. Besides antibiotics, there is the mounting use of other agents aimed at destroying bacteria, namely the surface antibacterials now available in many household products. These too enter the environment. The stage is thus set for an altered microbial ecology, not only in terms of resistant versus susceptible bacteria, but also in terms of the kinds of microorganisms surviving in the treated environment. We currently face multiresistant infectious disease organisms that are difficult and, sometimes, impossible to treat successfully. In order to curb the resistance problem, we must encourage the return of the susceptible commensal flora. They are our best allies in reversing antibiotic resistance.
548 citations
TL;DR: It was demonstrated that expression of genes encoding both types of efflux pump were up-regulated during the course of biofilm formation and development, and antifungal susceptibilities of biofilms formed by a set of C. albicans mutant strains deficient in efflux pumps were investigated to determine their contribution to biofilm resistance.
Abstract: A main characteristic associated with microbial biofilms is their increased resistance to antimicrobial chemotherapies. However, at present very little is known about the phenotypic changes that occur during the transition from the planktonic to the biofilm mode of growth. Candida albicans biofilms displayed an organized three-dimensional structure, and consisted of a dense network of yeasts and filamentous cells deeply embedded in exopolymeric matrix. These biofilms were intrinsically resistant to fluconazole. Moreover, the resistance phenotype was maintained by sessile cells when resuspended as free-floating cells, thus demonstrating that biofilm integrity and the presence of exopolymeric material are not the sole determinants of biofilm resistance. Under planktonic conditions, one of the main mechanisms of azole resistance in C. albicans is through active efflux of these drugs mediated by ATP-binding cassette (ABC) transporters and major facilitators. In this study we used northern hybridization to monitor expression of genes belonging to two different types of efflux pump, the ABC transporters and major facilitators (encoded by CDR and MDR genes, respectively), in C. albicans populations under both planktonic and biofilm growth. It was demonstrated that expression of genes encoding both types of efflux pump were up-regulated during the course of biofilm formation and development. Moreover, antifungal susceptibilities of biofilms formed by a set of C. albicans mutant strains deficient in efflux pumps were investigated to determine their contribution to biofilm resistance. Remarkably, mutants carrying single and double deletion mutations in Delta(cdr)1, Delta(cdr)2, Delta(mdr)1, Delta(cdr)1/Delta(cdr)2 and Delta(mdr)1/Delta(cdr)1 were hypersusceptible to fluconazole when planktonic, but still retained the resistant phenotype during biofilm growth. These analyses demonstrate that C. albicans biofilm resistance is a complex phenomenon that cannot be explained by one mechanism alone, instead it is multifactorial and may involve different molecular mechanisms of resistance compared with those displayed by planktonic cells.
439 citations
TL;DR: Patients infected with MRSA tended to have more co-morbidities, longer lengths of stay (LOS) and greater exposure to antibiotics than MSSA-infected patients, and antimicrobial use in grammes was concordant with the exception of macrolides, which were not significant based on the number of grammes administered.
Abstract: Methicillin-resistant Staphylococcus aureus (MRSA) is a major nosocomial pathogen worldwide. To investigate an association between antimicrobial use and MRSA, a case control study of 121 patients infected with MRSA compared with 123 patients infected with methicillin-susceptible S. aureus (MSSA) was carried out. Antimicrobial use was analysed by three different logistic regression models: all beta-lactam antibiotics, beta-lactam antibiotics grouped in classes and antimicrobial use in grammes. Patients infected with MRSA tended to have more co-morbidities, longer lengths of stay (LOS) and greater exposure to antibiotics than MSSA-infected patients. Multivariate analysis identified levofloxacin [odds ratio (OR) 8.01], macrolides (OR 4.06), previous hospitalization (OR 1.95), enteral feedings (OR 2.55), surgery (OR 2.24) and LOS before culture (OR 1.03) as independently associated with MRSA infection. All models were concordant with the exception of macrolides, which were not significant based on the number of grammes administered. There were no significant differences in the types of infection or the attributed mortality in either group. MRSA-infected patients had a significantly longer LOS before infection [18.8 +/- 18.2 compared with 8.4 +/- 6.9 (P < 0.001)] and a significantly longer post-diagnosis LOS [27.8 +/- 32.9 compared with 18.6 +/- 21 (P = 0.01)] than MSSA-infected patients.
425 citations
TL;DR: The factors contributing to increased risk of carriage of potential respiratory pathogens, as well as to clinical infection and antimicrobial resistance, are summarized in this review.
Abstract: Studies have shown that colonization of the nasopharynx by potential respiratory pathogens Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis is established early in childhood, although rates vary greatly according to locality, sampling frequency, individual and social factors. Factors influencing colonization and elimination are not as yet fully understood, but adhesion to mucosal receptors and immune responses are implicated in addition to bacterial properties and colonization resistance dynamics. Colonization in children and adults has been intensively studied in various localities. Potential pathogens are more likely to colonize the nasopharynx of children prone to recurrent otitis media, where impaired local immunity and repeated exposure to respiratory pathogens are additional risk factors. Adults with chronic respiratory tract disease also have higher carriage rates. The factors contributing to increased risk of carriage of potential respiratory pathogens, as well as to clinical infection and antimicrobial resistance, are summarized in this review.
414 citations
TL;DR: Of the 200 known polyene agents, amphotericin B is the only one with toxicities that are sufficiently limited to permit intravenous administration, and has a relatively broad spectrum of action and is useful in treating cases of candidosis, cryptococcosis, histoplasmosis, blastomycosis, paracoccidioidomyCosis, coccidioidsomycotic, extracutaneous sporotrichosis and mucormycosis.
Abstract: Amphotericin B is a polyene macrolide antibiotic derived from the actinomycete Streptomyces nodosus. Of the 200 known polyene agents, amphotericin B is the only one with toxicities that are sufficiently limited to permit intravenous administration. All polyenes have a common mechanism of action in that they preferentially bind to ergosterol, the primary sterol in the fungal cell membrane. The consequence of this binding includes disruption of the osmotic integrity of the membrane, with leakage of intracellular potassium and magnesium, and also the disruption of oxidative enzymes in target cells. Amphotericin B has a relatively broad spectrum of action and is useful in treating cases of candidosis, cryptococcosis, histoplasmosis, blastomycosis, paracoccidioidomycosis, coccidioidomycosis, aspergillosis, extracutaneous sporotrichosis and mucormycosis, and some cases of hyalohyphomycosis and phaeohyphomycosis. Resistance (MIC > 2 mg/L) tends to be species-dependent and emerges uncommonly and slowly in isolates from patients treated with amphotericin B. These include some individual strains of Candida albicans, Candida tropicalis, Candida parapsilosis and Candida lusitaniae, which may acquire resistance during treatment. Some isolates of Scedosporium apiospermum, Fusarium spp. and Sporothrix schenckii also show primary resistance, whereas all strains of Scedosporium prolificans demonstrate resistance. The main problems associated with the use of conventional amphotericin B have always been due to its poor aqueous solubility and toxicity rather than antifungal resistance.
400 citations
TL;DR: The bactericidal effects of the phlorotannins were more pronounced than those of the catechins against food-borne pathogenic bacteria and were as effective against MRSA as against the other bacteria tested.
Abstract: The bactericidal activity of phlorotannins from brown algae against food-borne pathogenic bacteria (25 strains), methicillin-resistant Staphylococcus aureus (MRSA) (nine strains) and Streptococcus pyogenes (one strain) was examined and compared with that of catechins. In addition, the effect of the oral administration of phlorotannins on mice was investigated. Phlorotannins, which are oligomers of phloroglucinol, were extracted from thalli of the brown alga Ecklonia kurome and prepared by silicic acid chromatography. The bactericidal activity of polyphenols was determined using a broth microdilution method. Of the bacteria tested, Campylobacter spp. were the most susceptible to the phlorotannins. The MBCs of the crude phlorotannins, dieckol and 8,8'-bieckol (hexamers), and that of epigallocatechin gallate (EGCG) against Campylobacter jejuni were 50 mg/L, 0.03 micromol/mL and 0.03 micromol/mL, respectively. On the whole, the bactericidal effects of the phlorotannins were more pronounced than those of the catechins. The phlorotannins were as effective against MRSA as against the other bacteria tested. At twice the MBCs, all Vibrio parahaemolyticus were killed within 0.5-2 h. However, at the same concentration, catechins showed little bactericidal activity within 4 h. No effect on mice was observed with oral administration of the phlorotannins under the conditions tested.
384 citations
TL;DR: SPM-1 is a distinctly different metallo-beta-lactamase from VIM and IMP and, accordingly, represents a new subfamily of mobile metallo,beta, and lactamases, and possesses a unique loop of 23 residues that accounts for the higher molecular mass.
Abstract: The gene encoding the metallo-β-lactamase SPM-1 was cloned from a genomic library of Pseudomonas aeruginosa strain 48-1997A. The insert carrying spm-1 possessed a GC content of 47%, indicating that it is of non-Pseudomonas origin. Upstream of spm-1 there is a small open reading frame (ORF), which is homologous to the LysR family of proteins (69% identity to the LysR protein from Salmonella enterica serovar Typhimurium). Downstream of spm-1 there is the start of an ORF, the product of which shows close homology with the GroEL-type proteins from Xanthomonas campestris. No transmissible element could be identified upstream or down- stream of spm-1. The spm-1 gene is carried on a plasmid that can transform both Escherichia coli and P. aeruginosa to ceftazidime resistance. SPM-1 contains the classic metallo-β-lactamase zinc-binding motif HXHXD and shows the highest identity (35.5%) to IMP-1. SPM-1 is a distinctly different metallo-β-lactamase from VIM and IMP and, accordingly, represents a new subfamily of mobile metallo-β-lactamases. The predicted molecular weight of the protein was 27 515 Da, significantly higher than that of IMP (25 041 Da) or VIM (25 322 Da). SPM-1 possesses a unique loop of 23 residues that accounts for the higher molecular mass.
345 citations
TL;DR: The use of amphotericin B limited by dose-dependent nephrotoxicity is not a benign complication and its prevention is essential as mentioned in this paper, however, small prospective and randomized trials do not suggest a protective effect.
Abstract: The use of amphotericin B limited by dose-dependent nephrotoxicity. Elevated creatinine associated with amphotericin B is not only a marker for renal dysfunction, but is also linked to an increase in hospital costs and a substantial risk for the use of haemodialysis and a higher mortality rate. Therefore, amphotericin B nephrotoxicity is not a benign complication and its prevention is essential. Several manipulations have been proposed to minimize amphotericin B-induced nephrotoxicity. Mannitol and frusemide administration are reported to be protective based on anecdotal observational reports. Small prospective and randomized trials do not suggest a protective effect. Three new formulations have been developed in attempts to improve both efficacy and tolerability: amphotericin B in a lipid complex (ABLC; Abelcet); amphotericin B colloidal dispersion; and liposomal amphotericin B (AmBisome). Three prospective randomized studies have clearly shown that AmBisome is less nephrotoxic than amphotericin B. In a double-blind randomized trial significantly fewer patients receiving AmBisome had nephrotoxic effects. This significant reduction in azotaemia was also observed among subgroups of patients receiving concomitant therapy with nephrotoxic agents. Moreover, there were fewer patients with hypokalaemia in the group receiving AmBisome. A recent multicentre double-blind study has shown that AmBisome (3 or 5 mg/kg/day) has a better safety profile than Abelcet (5 mg/kg). Patients in both AmBisome treatment groups experienced less chills/rigors, less nephrotoxicity based on a doubling of serum creatinine, and fewer toxic reactions resulting in discontinuation of therapy. In conclusion, amphotericin B nephrotoxicity is observed frequently. It clearly increases patient mortality. Nephrotoxicity must be recognized early, based on tubular abnormalities and a mild increase in serum creatinine. Its prevention relies on the detection and suppression of risk factors and the use of AmBisome.
320 citations
302 citations
TL;DR: Prescribing should be based on pharmacodynamic principles that predict efficacy, bacterial eradication and prevention of resistance emergence, and Pharmacoeconomic analyses confirm that bacteriologically more effective antibiotics can reduce overall management costs, particularly with respect to consequential morbidity and hospital admission.
Abstract: Widespread, increasing antibiotic resistance amongst the major respiratory pathogens has compromised traditional therapy of the major infective respiratory syndromes, including bacterial pneumonia and acute exacerbations of chronic bronchitis. Guidelines for antibiotic prescribing dating from the 1980s to 1990s, which attempted to address such problems, were commonly too prescriptive and difficult to apply, and took little account of end-user practice or locally prevalent resistance levels. Further confusion was caused by conflicting recommendations emanating from differing specialty groups. The evidence that such guidelines benefited either clinical outcomes or treatment costs has been disputed. They have probably had little effect on resistance emergence. We report the recommendations of an independent, multi-national, inter-disciplinary group, which met to identify principles underlying prescribing and guideline formulation in an age of increasing bacterial resistance. Unnecessary prescribing was recognized as the major factor in influencing resistance and costs. Antibiotic therapy must be limited to syndromes in which bacterial infection is the predominant cause and should attempt maximal reduction in bacterial load, with the ultimate aim of bacterial eradication. It should be appropriate in type and context of local resistance prevalence, and optimal in dosage for the pathogen(s) involved. Prescribing should be based on pharmacodynamic principles that predict efficacy, bacterial eradication and prevention of resistance emergence. Pharmacoeconomic analyses confirm that bacteriologically more effective antibiotics can reduce overall management costs, particularly with respect to consequential morbidity and hospital admission. Application of these principles should positively benefit therapeutic outcomes, resistance avoidance and management costs and will more accurately guide antibiotic choices by both individuals and formulary/guideline committees.
286 citations
TL;DR: In animal models, AmBisome is effective in treating both intracellular (leishmaniasis and histoplasmosis) and extracellular (candidosis and aspergillosis) systemic infections and can be safely delivered at markedly high doses of amphotericin B for the treatment of systemic fungal infections.
Abstract: Amphotericin B is the treatment of choice for life-threatening systemic fungal infections such as candidosis and aspergillosis. To improve this drug's efficacy and reduce its acute and chronic toxicities, several lipid formulations of the drug have been developed, including AmBisome, a liposomal formulation of amphotericin B. The liposome is composed of high transition temperature phospholipids and cholesterol, designed to incorporate amphotericin B securely into the liposomal bilayer. AmBisome can bind to fungal cell walls, where the liposome is disrupted. The amphotericin B, after being released from the liposomes, is thought to transfer through the cell wall and bind to ergosterol in the fungal cell membrane. This mechanism of action of AmBisome results in its potent in vitro fungicidal activity while the integrity of the liposome is maintained in the presence of mammalian cells, for which it has minimal toxicity. In animal models, AmBisome is effective in treating both intracellular (leishmaniasis and histoplasmosis) and extracellular (candidosis and aspergillosis) systemic infections. Because of its low toxicity at the organ level, intravenous AmBisome can be safely delivered at markedly high doses of amphotericin B (1-30 mg/kg) for the treatment of systemic fungal infections. AmBisome has a circulating half-life of 5-24 h in animals, and in animal models appears to localize at sites of infection in the brain (cryptococcosis, aspergillosis, coccidioidomycosis), lungs (blastomycosis, paracoccidioidomycosis, aspergillosis) and kidneys (candidosis), delivering amphotericin B that remains bioavailable in tissues for several weeks following treatment.
TL;DR: These results can be explained by the necessity of a large polycation to penetrate the impermeable outer membrane of Gram-negative E. coli, while Gram-positive S. aureus is more easily penetrated by small molecules.
Abstract: Objectives: We have shown previously that a polycationic conjugate between poly-L-lysine and the photosensitizer chlorin e6 was effective in photodynamic inactivation (PDI) of both Gram- positive and Gram-negative bacteria. In this report we explore the relationship between the size of the polylysine chain and its effectiveness for mediating the killing of Gram-negative and Gram-positive bacteria. Methods: Conjugates were prepared by attaching precisely one chlorin e6 molecule to the α-amino group of poly-(e-benzyloxycarbonyl)lysines of average length eight and 37 lysine residues, followed by deprotection of the e-amino groups, and were characterized by iso-electric focusing. The uptake of these conjugates and free chlorin e6 by Gram-positive Staphylococcus aureus (ATCC 27659) and Gram-negative Escherichia coli (ATCC 29181) after washing was measured as a function of photosensitizer concentration (0-4 µM chlorin e6 equivalent) and incubation time. After incubation the bacteria were exposed to low fluences (10-40 J/cm 2 ) of 660 nm light delivered from a diode laser, and viability was assessed after serial dilutions by a colony- forming assay. Results: S. aureus and E. coli took up comparable amounts of the two conjugates, but free chlorin e6 was only taken up by S. aureus. After illumination S. aureus was killed in a fluence- dependent fashion when loaded with the 8-lysine conjugate and free chlorin e6 but somewhat less so with the 37-lysine conjugate. In contrast, PDI of E. coli was only effective with the 37-lysine conjugate at concentrations up to 4 µM. PDI using the 8-lysine conjugate and free chlorin e6 on E. coli was observed at a concentration of 100 µM. Transmission electron micrographs showed internal electron-lucent areas consistent with chromosomal damage. Conclusion: These results can be explained by the necessity of a large polycation to penetrate the impermeable outer membrane of Gram-negative E. coli, while Gram-positive S. aureus is more easily penetrated by small molecules. However, because S. aureus is more sensitive overall than E. coli the 37-lysine conjugate can effectively kill both bacteria.
TL;DR: 5. Villanueva, A., Arathoon, E. G., Gotuzzo, E., Berman, R. S., DiNubile, M. & Sable, C. A. (2001).
Abstract: 1103, p. 371. American Society for Microbiology, Washington, DC. 5. Villanueva, A., Arathoon, E. G., Gotuzzo, E., Berman, R. S., DiNubile, M. J. & Sable, C. A. (2001). A randomized double-blind study of caspofungin versus amphotericin for the treatment of candidal esophagitis. Clinical Infectious Diseases 33, 1529–35. 6. Moore, C. B., Oakley, K. L. & Denning, D. W. (2001). In vitro activity of a new echinocandin, LY303366, and comparison with fluconazole, flucytosine and amphotericin B against Candida species. Clinical Microbiology and Infection 7, 11–6. 7. Maesaki, S., Hossain, M. A., Miyazaki, Y., Tomono, K., Tashiro, T. & Kohno, S. (2000). Efficacy of FK463, a (1,3)-β-D-glucan synthase inhibitor, in disseminated azole-resistant Candida albicans infection in mice. Antimicrobial Agents and Chemotherapy 44,
TL;DR: This work underlines the fact that some CTX-M enzymes may hydrolyse ceftazidime and thus confer resistance to this expanded-spectrum cephalosporin in Enterobacteriaceae.
Abstract: The extended-spectrum beta-lactamase CTX-M-15 confers resistance to ceftazidime, unlike the majority of CTX-M-type enzymes. Kinetic parameters were determined from purified CTX-M-15 and CTX-M-3, which differ by the single amino acid substitution Asp-240 to Gly, according to the Ambler numbering of class A beta-lactamases. Relative molecular masses of CTX-M-15 and CTX-M-3 were approximately 29 kDa and pI values were 8.9 and 8.4, respectively. CTX-M-15 had higher affinities for beta-lactams (lower K(m) values) than those of CTX-M-3 but catalytic efficiency (k(cat)/K(m) values) was variable depending on the beta-lactam substrate. Only CTX-M-15 showed a measurable catalytic efficiency for ceftazidime. Clavulanic acid and tazobactam were good inhibitors of both enzymes. MICs of beta-lactams for Escherichia coli reference strains expressing cloned beta-lactamase genes in the same genetic background were similar except for ceftazidime. This work underlines the fact that some CTX-M enzymes may hydrolyse ceftazidime and thus confer resistance to this expanded-spectrum cephalosporin in Enterobacteriaceae.
TL;DR: In some patients with life-threatening mycosis who failed treatment with, or were intolerant to, amphotericin B, the lipid formulations were effective; further studies with comparable selected high-risk patients are warranted to clarify the usefulness and the indications of each of the formulations.
Abstract: Invasive fungal infections have been increasingly recognized as a major cause of morbidity and mortality in the immunocompromised host. Amphotericin B has a broad spectrum and has remained the drug of choice for life-threatening invasive fungal infections. However, adverse events, particularly renal insufficiency, are limiting factors in achieving an effective dose: the prescription of amphotericin B is a compromise between toxicity and efficacy. Lipid formulations offer a better therapeutic index by circumscribing amphotericin B toxicity. Three lipid formulations are available in most countries: AmBisome, the only true liposome; Abelcet, with a ribbon-like structure; and Amphocil/Amphotec, composed of disc-like structures. All these formulations contain amphotericin B, but they differ in shape, size, reticuloendothelial clearance, C(max), AUC and visceral diffusion. The impact of these differences in pharmacokinetics and pharmacodynamics on clinical efficacy is still unclear. Efficacy has been shown in neutropenic patients with fever of unknown origin, systemic candidosis, invasive aspergillosis, cryptococcal meningitis and a variety of other difficult-to-treat mycoses, such as Fusarium or Zygomycetes infections. The effective dose may vary from one formulation to the other and is c. 3-5 mg/kg/day. All formulations are less nephrotoxic than amphotericin B. In one randomized double-blind study, AmBisome 3 or 5 mg/kg/day was less nephrotoxic and gave fewer infusion-related events than Abelcet 5 mg/kg/day. Abelcet induces fewer infusion-related side effects than Amphocil. All formulations seem at least as effective as amphotericin B. In some patients with life-threatening mycosis who failed treatment with, or were intolerant to, amphotericin B, the lipid formulations were effective. Further studies with comparable selected high-risk patients are warranted to clarify the usefulness and the indications of each of the formulations. Cost is a factor limiting prescription in many institutions, where use is often restricted to patients intolerant of, or refractory to, amphotericin B.
TL;DR: The results of the PROTEKT surveillance study 1999-2000 emphasize the widespread evolution of resistance to a variety of antimicrobials amongst isolates of S. pneumoniae and demonstrate the potential of telithromycin as a therapeutic option for the treatment of community-acquired respiratory tract infections caused by this organism.
Abstract: The prevalence of resistance to a range of antimicrobials was determined for isolates of Streptococcus pneumoniae examined in the PROTEKT (Prospective Resistant Organism Tracking and Epidemiology for the Ketolide Telithromycin) surveillance study (1999-2000) using NCCLS testing methods and interpretative criteria. Of 3362 pneumococcal isolates collected from 69 centres in 25 countries, 22.1% overall were resistant to penicillin G, with the highest rates of resistance found among isolates from Asia (53.4%), France (46.2%) and Spain (42.1%). Erythromycin A resistance occurred in 31.1% of isolates overall with the highest rates found in Asia (79.6%), France (57.6%), Hungary (55.6%) and Italy (42.9%). Marked geographical differences in the prevalence of both penicillin G (the Netherlands 0%; South Korea 71.5%) and erythromycin A (Sweden 4.7%; South Korea 87.6%) resistance were observed. Asia was characterized by the highest prevalence of resistance, overall, with only eight of 19 antimicrobials (co-amoxiclav, linezolid, vancomycin, teicoplanin, quinupristin/dalfopristin, levofloxacin, moxifloxacin and telithromycin) retaining high activity against isolates of S. pneumoniae from this region. Notable rates of resistance to clarithromycin, azithromycin, co-trimoxazole and tetracycline were observed in the majority of countries submitting isolates of S. pneumoniae to the PROTEKT surveillance study. Fluoroquinolone resistance was low (1%), overall, although 14.3% of 70 isolates from Hong Kong were resistant to levofloxacin and moxifloxacin, all but one of these isolates belonging to a single clone of the 23F serotype. Although, at present, apparently limited to pockets of clonal spread, continued vigilance with regard to the evolution of fluoroquinolone resistance is indicated. Telithromycin (MIC(90) 0.12 mg/L; 99.9% of isolates susceptible) and lin- ezolid (MIC(90) 2 mg/L; 100% of isolates susceptible) were the two most active oral agents tested, both compounds retaining activity against isolates of fluoroquinolone-resistant S. pneumoniae. The results of the PROTEKT surveillance study 1999-2000 emphasize the widespread evolution of resistance to a variety of antimicrobials amongst isolates of S. pneumoniae and demonstrate the potential of telithromycin as a therapeutic option for the treatment of community-acquired respiratory tract infections caused by this organism.
TL;DR: Carbapenems, colistin and minocycline retained greatest activity against the Acinetobacter isolates collected, and Tigecycline was less active than minocy cline, but both agents overcame most tetracycline resistance.
Abstract: A survey was conducted of the antimicrobial susceptibilities of 595 Acinetobacter spp. isolated from routine clinical specimens in 54 sentinel laboratories throughout the UK during 2000. Isolates of the Acinetobacter baumannii complex (genomic groups 2, 3 and 13TU; n = 443) were distinguished from other genomic groups (n = 152) by PCR fingerprinting of tDNA spacer regions. MICs of amikacin, cefotaxime, ceftazidime, ciprofloxacin, colistin, gentamicin, imipenem, meropenem, minocycline, piperacillin, piperacillin/tazobactam, rifampicin, sulbactam and tetracycline were determined on IsoSensitest agar and interpreted, wherever possible, using BSAC breakpoints. Tigecycline (GAR-936), a new glycylcycline, was also tested. Resistance to cephalosporins, aminoglycosides and ciprofloxacin was widespread, but carbapenems, colistin, sulbactam, minocycline and tigecycline were each active against >80% of the isolates. Isolates of A. baumannii were more often resistant to cefotaxime, ceftazidime, piperacillin, piperacillin/tazobactam, ciprofloxacin, gentamicin and tetracyclines than those belonging to other genomic groups, but were less often resistant to colistin; no significant differences between genomic groups were noted in the susceptibilities to amikacin, carbapenems, rifampicin or sulbactam. The relative activities of the tetracyclines were minocycline > tigecycline > tetracycline. Thirteen carbapenem-resistant isolates (MICs > or =8 mg/L; 2.2%) were received from six centres; four centres sent single isolates; one sent three and one sent six. An allele of bla(IMP) was detected in one of these isolates, but the other 12 isolates either had carbapenemase-independent resistance, or undetectable carbapenemase activity combined with other resistance mechanisms. In conclusion, carbapenems, colistin and minocycline retained greatest activity against the Acinetobacter isolates collected. Tigecycline was less active than minocycline, but both agents overcame most tetracycline resistance.
TL;DR: In vitro data support in vitro data that suggest bactericidal activity of beta-lactams is optimized at concentrations approximately 4 x MIC, and should be validated by large prospective clinical trials.
Abstract: We conducted a prospective, open-label study to delineate a relationship between exposure and outcomes in 36 patients treated with cefepime. Twenty patients had documented Gram-negative infections. Timed blood and urine samples were obtained at steady state to determine pharmacokinetic and pharmacodynamic parameters. Microbiological success was significantly correlated with the proportion of the dosing interval that cefepime concentrations exceeded 4.3 x MIC. Our results support in vitro data that suggest bactericidal activity of beta-lactams is optimized at concentrations approximately 4 x MIC. These results should be validated by large prospective clinical trials.
TL;DR: The overall resistance ranged from: ampicillin 20-47%, mecillinam 0-7%, trimethoprim 10-28%, sulfamethizole 22-47% and nitrofurantoin 0-3%.
Abstract: Antibiotic resistance of urinary tract pathogens has increased worldwide. Our aim was to provide information regarding resistance patterns of Escherichia coli in urinary tract infections (UTIs) and E. coli bacteraemia in Denmark. The overall resistance ranged from: ampicillin 20-47%, mecillinam 0-7%, trimethoprim 10-28%, sulfamethizole 22-47% and nitrofurantoin 0-3%. In strains with sulfamethizole MICs > 2048 mg/L, 97% carried sulI, sulII or both genes, with sulII being the most common. Among the sulI gene-positive strains, 96% were intI 1 gene positive.
TL;DR: Methods of measuring compliance with antibiotics in the outpatient-based management of RTIs and research results are reviewed, as well as practical strategies for addressing non-compliance with antibiotic therapies for RTIs.
Abstract: Despite doctors' expectations, non-compliance is common in short-term antibiotic therapy of respiratory tract infections (RTIs). This phenomenon has profound practical implications. It leads to ineffective management, the deterioration of patients' health, hospital admissions, additional costs and the emergence of antibiotic-resistant microorganisms. This article reviews methods of measuring compliance with antibiotics in the outpatient-based management of RTIs and research results. Causes of non-compliance are also discussed. Factors influencing compliance are analysed, as well as practical strategies for addressing non-compliance with antibiotic therapies for RTIs. The influence of the frequency of doses on compliance is particularly stressed, as it has been observed that once daily dosing has almost a 100% compliance rate. As a number of once-daily antibiotic preparations are available now, the possibility of using once-daily schedules for improving compliance in RTI cases is stressed.
TL;DR: It is indicated that chequerboard dilution testing in RPMI medium may not reliably detect the attenuation of amphotericin B activity, and Etest was the simplest to use and yielded reproducible results for testing antifungal combinations.
Abstract: Currently, there is considerable debate regarding the best in vitro method for testing antifungal combinations against Candida spp. In this study, we compared the results obtained by chequerboard dilution, time-kill studies and Etest for several antifungal combinations against Candida spp. Three Candida albicans isolates (fluconazole MICs of 1.0, 32 and >256 mg/L) and three non-albicans Candida isolates (C. glabrata, C. tropicalis and C. krusei) were tested in RPMI 1640 medium. By chequerboard testing, the majority of antifungal combinations were found to be indifferent. Notably, antagonism was identified by time-kill studies and by Etest for combinations of amphotericin B-fluconazole, but it was not detected by the chequerboard method. Pre-exposure of isolates to fluconazole did not affect results of the Etest or chequerboard method, but it did increase the frequency of antagonism noted by time-kill methods. This study indicates that chequerboard dilution testing in RPMI medium may not reliably detect the attenuation of amphotericin B activity. Of the three methods, Etest was the simplest to use and yielded reproducible results for testing antifungal combinations.
TL;DR: The simple models tested in the present work can enable the analysis of the fitness of large numbers of antibiotic-resistant bacteria by using more realistic approaches than the in vitro competition assays currently used.
Abstract: Overproduction of multidrug resistance (MDR) efflux pumps is involved in the resistance to a wide range of compounds in bacteria. These determinants extrude antibiotics, but also bacterial metabolites like quorum-sensing signals. Non-regulated extrusion of bacterial metabolites might produce a metabolic burden, so that MDR-overproducing mutants could have a reduced fitness when compared with their parental strains. To test such a possibility, we have compared the behaviour of two MDR Pseudomonas aeruginosa in vitro selected mutants (nalB and nfxB) with their isogenic parental strain with respect to some properties with potential relevance for the survival in the environment and the virulence of this bacterial species. Overproduction of the MDR determinants MexABOprM (nalB mutant) and MexCDOprJ (nfxB mutant) decreased the survival in water, the production of phenazines and proteases, and the virulence (using a Caenorhabditis elegans model system) of the P. aeruginosa mutants. In contrast, the capability of forming biofilms was not impaired. The simple models tested in the present work can enable the analysis of the fitness of large numbers of antibiotic-resistant bacteria by using more realistic approaches than the in vitro competition assays currently used.
TL;DR: The results indicate that clarithromycin modified inflammation by sup-pressing IL-8 production and that clarityromycin may affect the expression of other genes through AP-1 and NF-kappa B.
Abstract: Erythromycin and other macrolides are effective for the treatment of chronic inflammatory airway diseases such as diffuse panbronchiolitis (DPB) and chronic sinusitis. The effect of macrolides in DPB is suggested to be anti-inflammatory rather than antibacterial. We investigated the effects of clarithromycin on interleukin-8 (IL-8) production using human peripheral monocytes and the human monocytic leukaemia cell line, THP-1. Bacterial extracts from Escherichia coli, Pseudomonas aeruginosa and Helicobacter pylori, as well as E. coli-derived lipopolysaccharide (LPS), induced IL-8 production. Clarithromycin suppressed this production in a dose-dependent manner in both monocytes and THP-1 cells (49.3-75.0% inhibition at 10 mg/L). A luciferase reporter gene assay with plasmids containing a serially deleted IL-8 promoter fragment showed that both the activator protein-1 (AP-1) and/or the nuclear factor-kappa B (NF-kapp aB) binding sequences were responsible for the LPS and clarithromycin responsiveness of the IL-8 promoter. Consistently, in an electromobility shift assay, LPS increased the specific binding of both AP-1 and NF-kappaB, whereas clarithromycin suppressed it. Moreover, LPS and clarithromycin regulated three other promoters that have either the NF-kappa B or the AP-1 binding sequences: two synthetic (pAP-1-Luc and pNF-kappa B-Luc) and one naturally occurring (ELAM-Luc). Our results indicate that clarithromycin modified inflammation by sup-pressing IL-8 production and that clarithromycin may affect the expression of other genes through AP-1 and NF-kappa B. In addition to treatment of airway diseases, the anti-inflammatory effect of macrolides may be beneficial for the treatment of other inflammatory diseases such as chronic gastritis caused by H. pylori.
TL;DR: In vitro activity of Melaleuca alternifolia (tea tree) oil against dermatophytes and filamentous fungi showed germinated conidia to be more susceptible than non-germinated Conidia, demonstrating that tea tree oil has both inhibitory and fungicidal activity.
Abstract: The in vitro activity of Melaleuca alternifolia (tea tree) oil against dermatophytes (n = 106) and filamentous fungi (n = 78) was determined. Tea tree oil MICs for all fungi ranged from 0.004% to 0.25% and minimum fungicidal concentrations (MFCs) ranged from <0.03% to 8.0%. Time-kill experiments with 1-4 x MFC demonstrated that three of the four test organisms were still detected after 8 h of treatment, but not after 24 h. Comparison of the susceptibility to tea tree oil of germinated and non-germinated Aspergillus niger conidia showed germinated conidia to be more susceptible than non-germinated conidia. These data demonstrate that tea tree oil has both inhibitory and fungicidal activity.
TL;DR: Variations in biofilm formation by, and antibiotic resistance of, Pseudomonas aeruginosa PAO1 and the quorum-sensing-deficient mutants PDO100, JP1, JP2 and JP2 were studied.
Abstract: Variations in biofilm formation by, and antibiotic resistance of, Pseudomonas aeruginosa PAO1 (wild type) and the quorum-sensing-deficient mutants PDO100 (∆rhlI), JP1 (∆lasI) and JP2 (∆lasI∆rhlI) were studied. For PAO1, the maximum-accumulation phase of biofilm formation began immediately and a plateau phase was reached after 24 h, whereas the quorumsensing mutants showed 36‐48 h lags before entering the maximum-accumulation phase. After 72 h, the cell density of the PAO1 biofilms was c. 0.8‐1.2 log greater than for the mutants. On a unit protein basis, total polysaccharide production was similar for PAO1 and PDO100, whereas JP1 and JP2 biofilms accumulated only c. 36% of the PAO1 level after 72 h. Fluorescent micrographs revealed that the PAO1 biofilms were much thicker than those of the quorum-sensingdeficient mutants. In the case of the PAO1 and PDO100 biofilms, most cells were attached to the top of the biofilm layer, whereas the bottom layer consisted predominantly of polysaccharides. The JP1 and JP2 biofilms were closely packed with cells, and little polysaccharide was visible. Cells in PAO1 biofilms were little affected by kanamycin, even at 100 mg/L, whereas those in PDO100 biofilms were susceptible to the highest concentration of kanamycin (100 mg/L) but not to lower concentrations (10 and 50 mg/L). In contrast, cells in JP1 and JP2 biofilms were susceptible to kanamycin at all three concentrations.
TL;DR: The results suggest that resistance mechanisms for metronidazole can be bypassed by nitazoxanides and tizoxanide, and that nitro-reduction and free radical production was a probable mode of action.
Abstract: The activities of the N-(nitrothiazolyl) salicylamide nitazoxanide and its metabolite tizoxanide were compared with metronidazole in vitro in microplates against six axenic isolates of Giardia intestinalis. Tizoxanide was eight times more active than metronidazole against metronidazole-susceptible isolates and twice as active against a resistant isolate. In 10 axenic isolates of Entamoeba histolytica, while tizoxanide was almost twice as active as metronidazole against more susceptible isolates, it was more than twice as active against less susceptible isolates. Fourteen metronidazole-susceptible isolates of Trichomonas vaginalis were 1.5 times more susceptible to tizoxanide, which was nearly five times as active against resistant isolates. Two highly metronidazole-resistant isolates retained complete susceptibility to tizoxanide, and one moderately resistant isolate showed reduced susceptibility. In all three organisms, nitazoxanide results paralleled those of tizoxanide. Analogues lacking the reducible nitro-group had similar low activities against susceptible G. intestinalis, E. histolytica and T. vaginalis, indicating that nitro-reduction and free radical production was a probable mode of action. Nitazoxanide and its metabolite tizoxanide are more active in vitro than metronidazole against G. intestinalis, E. histolytica and T. vaginalis. Although, like metronidazole, they depend on the presence of a nitro-group for activity, they retain some activity against metronidazole-resistant strains, particularly of T. vaginalis. The results suggest that resistance mechanisms for metronidazole can be bypassed by nitazoxanide and tizoxanide.
TL;DR: It is concluded that linezolid exhibits rapid penetration into bone, fat and muscle of patients undergoing hip arthroplasty, to achieve levels in excess of its MIC for susceptible organisms (< or=4 mg/L); therapeutic concentrations were maintained in the haematoma fluid that surrounds the operation site for >16 h.
Abstract: Twelve patients undergoing total hip replacement were given 600 mg of linezolid as a 20 min iv infusion along with conventional prophylaxis of 1 g of cefamandole immediately before surgery. Routine total hip arthroplasty was carried out, and at timed intervals during surgery samples of bone, fat, muscle and blood were collected for assay by high-performance liquid chromatography analysis. Samples of the haematoma fluid that formed around the operation site and further blood samples for assay were also collected at timed intervals following the operation. The penetration of linezolid into bone was rapid, with mean concentrations of 9.1 mg/L (95% CI 7.7-10.6 mg/L) achieved at 10 min after the infusion, decreasing to 6.3 mg/L (95% CI 3.9-8.6 mg/L) at 30 min. Correction for the simultaneous blood concentrations gave mean values for bone penetration of 51% at 10 min, 60% at 20 min and 47% at 30 min. Although the penetration of linezolid into fat was also rapid, mean concentrations and degree of penetration were c. 60% of those in bone; at 10 min they were 4.5 mg/L (95% CI 3.0-6.1 mg/L; penetration 27%); at 20 min they were 5.2 mg/L (95% CI 4.0-6.4 mg/L; penetration 37%); and at 30 min, 4.1 mg/L (95% CI 3.3-4.8 mg/L; penetration 31%). For muscle the corresponding values were 10.4 mg/L (95% CI 8.1-12.7 mg/L; penetration 58%) at 10 min, 13.4 mg/L (95% CI 10.2-16.5 mg/L; penetration 94%) at 20 min and 12.0 mg/L (95% CI 9.2-14.8 mg/L; penetration 93%) at 30 min. Mean concentrations of linezolid in the haematoma fluid drained from around the operation site were 8.2 mg/L at 6-8 h and 5.6 mg/L at 10-12 h after the infusion, and 7.0 mg/L at 2-4 h following a second 600 mg infusion given 12 h post-operatively. We conclude that linezolid exhibits rapid penetration into bone, fat and muscle of patients undergoing hip arthroplasty, to achieve levels in excess of its MIC for susceptible organisms ( 16 h.
TL;DR: Production of the VIM-2 enzyme presents an emerging threat of carbapenem resistance among Acinetobacter spp.
Abstract: Carbapenem-resistant Acinetobacter spp. used to be rare, but are increasingly isolated in Korea. Among 28 isolates of imipenem-resistant Acinetobacter spp. found in a Korean hospital in 1998 and 1999, 14 produced metallo-beta-lactamases. The bla(VIM-2) gene was detected, by PCR, in 11 and two isolates of Acinetobacter baumannii and Acinetobacter genomospecies 3, respectively, and bla(IMP-1) in one isolate of A. baumannii. The MICs of imipenem for the isolates were 8-32 mg/L. PFGE analysis of SmaI-digested genomic DNA gave identical patterns in eight of 11 bla(VIM-2)-positive A. baumannii isolates from respiratory specimens of ICU patients. The bla(VIM-2) gene cassettes in the isolates are identical to those from Pseudomonas aeruginosa isolates in Europe, but are inserted into new class I integrons In105 and In106. The attC site of the last cassette of the array in In106 is interrupted by the insertion of a putative class II intron. This is the first report of VIM-2 beta-lactamase-producing A. baumannii and Acinetobacter genomospecies 3. Production of the VIM-2 enzyme presents an emerging threat of carbapenem resistance among Acinetobacter spp. in Korea.
TL;DR: This approach is effective for screening P. aeruginosa for beta-lactamase gene carriage in epidemiological studies and for detecting new variants.
Abstract: Objective A method using PCR-restriction fragment length polymorphism was developed to identify Pseudomonas aeruginosa beta-lactamase genes. Methods Two hundred and fifty-nine P. aeruginosa isolates were screened by PCR with 11 primer pairs designed to detect genes encoding PSE, OXA, TEM and SHV enzymes. PSE and OXA gene variants were distinguished by restriction of PCR products with endonucleases recognizing sites involved in point mutations. Nucleotide sequences were verified for a few isolates by sequencing the PCR products. Results Four isolates produced extended-spectrum beta-lactamases (ESBLs) according to the double disc synergy test. PCR detecting bla(PSE) genes was positive in 162 (62.5%) isolates: 151 carried bla(PSE-1) and 11 carried a variant encoding an enzyme differing from PSE-1 by a single amino acid substitution (Pro102 to Ser). PCR detecting sequences for enzymes of the OXA-10 group was positive in 68 (26.3%) isolates: 31 carried bla(OXA-10), one carried bla(OXA-14) and 36 carried a new variant intermediate between bla(OXA-13) and bla(OXA-19). The bla(OXA-2) gene was identified in 13 (5%) isolates. Two other isolates carried bla(OXA-2) variants encoding ESBLs differing from OXA-2 by a single amino acid substitution (Asp150 to Tyr and Trp159 to Cys, respectively). PCR detecting sequences for enzymes of the OXA-1 group was positive in 12 (4.6%) isolates. A bla(TEM) gene was identified in five (1.9%) isolates (three bla(TEM-1), one bla(TEM-2), one bla(TEM-4)). Conclusion This approach is effective for screening P. aeruginosa for beta-lactamase gene carriage in epidemiological studies and for detecting new variants.
TL;DR: Microbial changes that result in resistance to biocides and antibiotics should cause concern, and the possibility of genetic linkage between genes for biocide resistance and those for antibiotic resistance is of equal significance.
Abstract: The term biocide includes disinfectants, antiseptics and preservatives. It does not include antibiotics, which, in spite of being biocides in the strictest sense, tend to be categorized separately. In recent years there has been a trend towards use of biocides in the home environment. These products have been marketed for decontamination of food preparation surfaces (e.g. Dettox), areas perceived to be microbially contaminated (e.g. toilets) and general improvement of cleanliness in the home. A product called Microban is a biocide (triclosan) that is incorporated into chopping boards, knife handles and Wellington boots. Other companies manufacture biocide-impregnated paint (Biocote) and toilet seats. Several workers have suggested that widespread use of biocides may impact on the prevalence of antibiotic-resistant microorganisms. What is the evidence that biocide use selects for antibiotic resistance? Biocide resistance was first recognized nearly 70 years ago by Heathman et al. 1 who identified chlorine resistance in Salmonella typhi, and antibiotic resistance was identified shortly after the availability of penicillin, but links between the two have only been recognized more recently. It is remarkable that there is a large amount of data on antibiotic resistance, with journals such as this one devoting many pages to papers describing resistance mechanisms and other journals devoted solely to the topic of antibiotic resistance. Yet there is a comparatively small number of workers worldwide who are investigating the mechanics of biocide resistance. Because biocides tend to act concurrently on multiple sites within the microorganism, resistance is often mediated by non-specific means. Efflux pumps have the potential to act on a range of chemically dissimilar compounds and have been implicated in both biocide-and antibiotic-resistant bacteria. Cell wall changes may also play a role in the observed cross-resistance between biocides and antibiotics , probably by reducing permeability. Microbial changes that result in resistance to biocides and antibiotics should therefore cause concern. However, of equal significance , is the possibility of genetic linkage between genes for biocide resistance and those for antibiotic resistance. McMurry & Levy 2 reported in 1998 that mutations in the enoyl reductase gene (fab1) of Escherichia coli were associated with resistance to triclosan. This work suggested that Fab1 is the target for triclosan but failed to demonstrate any significant reduction in susceptibility to antibiotics in strains with fab1 mutations. However, the same workers have demonstrated that Inh1 (the mycobacterial analogue of the Fab1 protein) is a common target for triclosan and isoniazid …