Review paper

CLINICAL INTENSIVE CARE 1999; 10: 211-218

Antibiotic resistance and the new antibiotic agents

Introduction Antibiotic resistance has emerged as a serious threat to patient care over the last decade, particularly in the Intensive Care Unit (ICU) environment. The rapid growth of antibiotic resistance has resulted in multi-resistant organisms that produce infections which are increasingly difficult to treat with antibiotics currently available. The debate about the problem of antibiotic usage and resistance has extended beyond the diagnosis and management of infection and into the public arena. New surveillance systems for antibiotic resistance have been set up by the WHO1 and CDC.2 In the UK a subcommittee of the House of Lords Science and Technology Committee has produced a report on antimicrobial resistance and also recommended strategies to control antibiotic use.3 Magnitude of the problem Antibiotic resistance in Gram positive cocci has become a particular threat and is an increasing challenge to the effective management of infection in hospitals. There has been a great increase in the incidence of methicillin resistant Staphylococcus aureus (MRSA) in England and Wales.3 Following the rise in methicillin resistant isolates in 1995 there were simultaneous increases in resistance to erythromycin, gentamicin and ciprofloxacin. Rates of multiresistance to these unrelated drugs were much higher among MRSA than methicillin sensitive isolates and it is these multiresistant strains that occur and spread within the hospital environment.4,5 Multi-resistant enterococci have also emerged

in the last two decades. High-level gentamicin resistance occurred in 19796 and was followed by numerous reports of nosocomial infection in the 1980s.7 Outbreaks of nosocomial infections with penicillin resistant strains of Enterococcus faecalis and Enterococcus faecium appeared in the late 1980s8 followed by reports of vancomycin multi-resistant enterococci in Europe9,10 and the USA.11 Antimicrobial resistance amongst respiratory pathogens has been rising globally over the last 15 years. Penicillin resistant strains of the common respiratory pathogens (Streptococcus pneumoniae (Fig. 1), Haemophilus influenzae and Moraxella catarrhalis) are being increasingly isolated in many countries, with a prevalence of over 25% of isolates in some cases. Similar prevalences are reported for macrolide resistance in S. pneumoniae.12 Multi-resistant Mycobacterium tuberculosis

Imperial College School of Medicine, Department of Infectious Diseases, Hammersmith Hospital, London W12 ONN, UK SV Want, A Holmes Correspondence to: Dr S.V. Want, Imperial College School of Medicine, Department of Infectious Diseases, Hammersmith Hospital, London W12 ONN, UK. Tel: +44 208 383 2084; Fax: +44 208 383 3394; E-mail: [email protected]

1999 BIOS Scientific Publishers Limited

Figure 1. Penicillin E-test on pneumococci showing resistant subpopulation. E test consists of a preformed antimicrobial gradient on a plastic strip. Reagent strip is placed onto the surface of an inoculated agar plate. Result is read at the point where the elipse of bacterial growth intersects with the gradient. Penicillin sensitive pneumococci MIC = 0.01 0.1 mg/l. (MIC = minimum inhibitory concentration). Penicillin resistant pneumococci MIC = >32 mg/l.
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has emerged as an increasingly important cause of morbidity and death since 1998. In the USA, Europe and Latin America, highly resistant strains have caused institutional outbreaks with high fatality rates and high transmission rates.13 Mortality is high and reached 44% in a study in HIV negative patients despite individualized treatment.13 The mortality rate in HIV positive patients can be as high as 8090%. Clearly, rapid detection of such resistance is vital for the health of the individual and for infection control.3 Many of the Gram negative rods act as opportunistic pathogens in hospitals. Rates of resistance vary according to species with Enterobacter spp, Klebsiella spp and Pseudomonas aeruginosa showing greater inherent or acquired resistance. Acinetobacter spp and Stenotrophomonas maltophilia are environmental Gram negative bacteria that have become significant pathogens in the ICU, and heavy antibiotic use has played a part in their emergence. Some strains of S. maltophilia are now resistant to all currently available antibiotics.14 Rates of resistance in Gram negative rods are higher in Southern Europe, much of Asia and the Americas. Highest rates are often found where use of antimicrobial agents is unrestricted in both medicine and agriculture e.g. SE Asia, Turkey and Argentina.3 Antibiotic resistance is greatest where use of antimicrobial agents is heaviest and the major problem areas in hospitals therefore include intensive care and transplant units.15,16 A European prevalence study showed that 20.6% of ICU patients had an ICU-acquired infection.15 The nosocomial infection rates among ICU patients are 510 times higher than among general ward patients.17,18 ICU patients are also subjected to invasive support activities that increase the risk of nosocomial infection necessitating further antibiotic treatment thus enhancing the risk of selecting resistance. Resistant organisms are most commonly found in ventilated patients.19 Ventilator-associated pneumonia caused by resistant bacteria is an important problem and often follows previous exposure to antibiotics.20 There is a growing need for rational antibiotic prescribing and antibiotic control policies in the ICU combined with effective infection control strategies to limit the transmission of resistant organisms. In the meantime newer antibiotics are being developed in an attempt to circumvent the mechanisms of resistance that are emerging. Mechanisms of antibiotic resistance Mechanisms of resistance can be classified into four main groups. (i) Antibiotic modification results in the antibiotic being unable to act on its target. For example -lactam antibiotics may be destroyed enzymatically by -lactamases that cleave the -lactam ring. These enzymes are widespread among many bacterial species (Gram positive and Gram negative) and show varied degrees of inhibition by -lactam inhibitors such as clavulanic acid.21 Most -lactamases act to some degree against both penicillins and cephalosporins; others are more specific, cephalosporinases (e.g. AmpC enzyme found in Enterobacter spp) or penicillinases (e.g. S. aureus penicillinase).

(ii) Protection of the target from antibiotic action by preventing the antibiotic from entering the cell or acquiring the ability to pump out the antibiotic. -lactam antibiotics gain access to Gram negative bacteria through porins. Lack of the specific D2 porin in P. aeruginosa results in imipenem resistance. This mechanism is also seen with low level resistance to fluoroquinolones and aminoglycosides. Increased efflux via an energy-requiring transport pump is a mechanism for resistance to tetracyclines and is encoded by a wide range of related genes. (iii) Alteration of the target so that it is no longer recognised by the antibiotic. Most strains of S. pneumoniae are highly susceptible to both penicillins and cephalosporins but can acquire DNA from other bacteria which changes the enzyme responsible for cell wall synthesis. As a result the bacteria develop a low affinity for penicillins and hence become resistant.22 (iv) Acquisition of an alternative metabolic pathway, bypassing the antibiotics site of action. The alternative penicillin binding protein (PBP2a) produced by MRSA is an example of this. The protein is encoded by the mecA gene and because PBP2a is not inhibited by antibiotics such as flucloxacillin the cell continues to synthesise peptidoglycan and hence has a structurally sound cell wall.23 A further example of this type of resistance is shown by vancomycin resistant bacteria.24 In enterococci sensitive to vancomycin the normal target of vancomycin is a cell wall precursor that contains a pentapeptide that has a D-alanine terminus to which the vancomycin binds, preventing further cell wall synthesis. If an enterococcus acquires the van A gene cluster it can make an alternative cell wall precursor ending in D-alanineD-lactate to which vancomycin does not bind. Selective pressure for antibiotic resistance Antibiotic resistance can be intrinsic or acquired, the latter occurring by mutation or taking up of resistance genes from other bacteria. Resistance genes are carried on plasmids (small loops of DNA) that may be passed between bacteria, but may also occur on the bacterial chromosome. More rapid transfer of resistance genes occurs by transposons (small units of DNA) that move easily from one DNA molecule to another. In addition resistance genes can be transferred by viruses (bacteriophages). Over use of various antibiotics has caused a selective pressure on bacteria giving rise to the evolution and rapid spread of highly resistant strains. The widespread use of cephalosporins has promoted the proliferation of E. faecalis in the gut, which is resistant to these drugs. Previous therapy with antibiotics (not only vancomycin) is common in the majority of patients colonised or infected with multi-resistant enterococci.25 Vancomycin resistance in enterococci has been classified into four phenotypes Van A, B, C and D. The Van A resistance mechanism is the most worrying, as it is plasmidmediated and confers high-level resistance to vancomycin and teicoplanin.26 The transfer of glycopeptide resistance from the E. faecalis to S. aureus was demonstrated in the laboratory27 and has now been reported clinically.28,29

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The introduction of lactamase stable penicillins (methicillin, flucloxacillin) to treat penicillin resistant S. aureus was followed by the emergence of methicillin resistant S. aureus (MRSA). The use of gentamicin led to the emergence of gentamicin resistant MRSA. Subsequently a series of epidemic MRSA (EMRSA) have evolved and spread. These organisms are currently susceptible to the glycopeptides but recent reports from Japan, the USA and France describe strains of MRSA with intermediate resistance to the glycopeptides.28,29 The newer fluoroquinolones with increased activity against pneumococci have been recommended in North America for the treatment of pneumococcal infections, including community acquired pneumonia, acute bacterial exacerbations of chronic bronchitis and sinusitis.30 A recent report from Canada now describes the increasing prevalence of pneumococci with reduced susceptibility to fluoroquinolones, probably as a result of selective pressure from the increased use.30 The development of resistance as a result of antibiotic use in animals is a major problem. Inappropriate antibiotic use with poor control promotes resistance. Resistant bacteria selected in animals may be transferred directly to man via the food chain or may transfer their resistance genes to human pathogens.3 Ironically, existing antibiotic compounds used in agriculture are being re-evaluated for their potential use in medicine. The streptogramins were initially used as growth promoters in poultry and pigs, but a mixture of two streptogramins is now licensed for human use to treat pneumococcal disease and other Gram positive infections. Among the orthomycins, avilamycin has also been widely used as a growth promoter for animals. Currently under development for human use is a closely related group the everinomycins; they have good activity against staphylococci, enterococci and streptococci. New antibiotics (Table 1) The development of new antimicrobial agents attempts to keep up with the changing mechanisms of resistance. Many antibiotics have been launched in the last 10 years but all are derivatives of existing drugs. Resistance to these is often widespread so the potential exists for rapid development of resistance to the new antibiotic. No new class of antibiotic has been licensed in the past 15 years. Streptogramins These consist of two structurally unrelated components (A & B) that bind to separate sites on the bacterial ribosome and interact synergistically. Quinupristin/dalfopristin (SynercidR), the first intravenous streptogramin, belongs to the macrolidelincosamide-streptogramin group of antibiotics and has recently been licensed in the UK. It has activity against a broad variety of multi-resistant Gram positive cocci, including methicillin, lincosamide, and erythromycin resistant strains of coagulase negative staphylococci and S. aureus.31 The

drug is also active against glycopeptide resistant S. aureus and Enterococci.32 Quinupristin/dalfopristin is not active in vitro against Gram negative enteric bacilli or P. aeruginosa. Cross resistance has not been reported between quinupristin/ dalfopristin and glycopeptides, fluoroquinolones or lactam antibiotics.31 Fluoroquinolones Fluoroquinolones were launched in the mid-1980s and are all structurally similar to nalidixic acid, the first member of the group. They have a broad spectrum of activity, favourable pharmacokinetics and excellent safety profile in adults. Further fluoroquinolones were developed with enhanced activity against staphylococci, streptococci and anaerobes. Although active against methicillin sensitive S. aureus they are not effective against MRSA. The newer fluoroquinolones have an increasingly useful role for treating penicillin resistant S. pneumonia. Moxifloxacin (to be licensed in the UK imminently) is less potent than the early fluoroquinolones against Enterobacteriaceae and only weakly active against P. aeruginosa. However, it is one of the most potent fluoroquinolones against Gram positive bacteria, including MRSA, enterococci and pneumococci (penicillin sensitive and penicillin resistant strains) with equivalent activity to ciprofloxacin against Legionella spp and superior activity against Chlamydia spp and Mycoplasma pneumoniae.33 Ketolides These compounds are semi-synthetic derivatives of macrolides. They have good activity against S. aureus they are also very effective against penicillin resistant S. pneumoniae and b lactamase producing H. influenzae. They have improved activity, compared to erythromycin A, against glycopeptide-resistant Enterococcus spp.34 Oxazolidinones This is a completely new class of agents that are entirely synthetic. They are protein synthetase inhibitors and their antibacterial action is bacteriostatic. Although resistance to oxazolidinones can occur by a single step mutation, this is not associated with cross-resistance to other antibiotic classes.35 They have activity against Gram positive organisms including Enterococcus spp., MRSA, M. tuberculosis and Bacteroides spp.36,37 These compounds can be administered by both intravenous and oral routes. Everninomycin Everninomycin is a glycopeptide antibiotic that is an analogue of everninomycin D, the major antibiotic component of the everninomycin complex of antibiotics. Although the structure is well documented the mode of action

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Table 1. New antibiotics under development. Compound Class/Manufacturer IV /oral Where Licensed Spectrum of Activity MRSA GRE Mechanism of action Pen R Pneumo + Multi. resis. Gram neg. rods Inhibit DNA synthesis

Novel quinolones Levofloxacin Grepafloxacin Clinafloxacin Moxifloxacin Dalfopristin/ quinupristin (SynercidR) Everminomycin Glycylcyclines Oxazolidonones Eperezolid Linezolid
* E. faecium not E. faecalis

Quinolones/ Pfizer Wellcome Park-Davis Bayer

Europe IV and oral Withdrawn Oral Oral UK France

+/-

Virginiamycin// IV Rhone-Poulenc Rorer

+*

Protein synthesis inhibitors

Novel/ScheringPlough Tetracycline/Wyeth Novel/Pharmacia Upjohn

IV IV IV and oral

USA; Phase 3 End of phase 3 Phase 3

+ + +

+ + +

+ + +

+/-

Unknown
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Disruption of cell wall complex Protein synthesis inhibitors

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is unknown. Unlike most oligosaccharides, everninomycin has a low nephrotoxic potential and is active against multiple drug resistant Gram positive bacteria including MRSA and VRE.38 Semisynthetic glycopeptides BI 397 is a semisynthetic derivative of the natural glycopeptide A40926 (similar to teicoplanin).39 It is currently the subject of laboratory research but not yet under clinical trial. In vitro it is more active against staphylococci than teicoplanin and vancomycin; against streptococci (including penicillin resistant strains) it has comparable activity to teicoplanin and better activity than vancomycin; against vancomycin resistant enterococci expressing Van A type resistance, there is no activity. The compound has a serum half-life longer than either vancomycin or teicoplanin and it has previously been shown to be highly potent in animal models of infection. This supports the possibility the compound can be therapeutically effective at lower doses and at longer treatment intervals than those currently used for vancomycin and teicoplanin.40 Glycylcyclines These are a new class of semisynthetic tetracyclines.41 They have been produced by modification of the D-ring of minocycline. This modification overcomes the two major mechanisms responsible for tetracycline resistance i.e. active efflux of the drug out of the cell and protection of the ribosomes by the production of cytoplasmic proteins.42 This extends the spectrum of these agents to include multiresistant strains such as MRSA, VRE and penicillin resistant pneumococci.43 Daptomycin Daptomycin is a semisynthetic lipopeptide antibiotic derived from Streptomyces roseosporus. It has potent activity in vitro against Gram positive organisms including MRSA and VRE. It exerts a rapid bactericidal effect by dissipating the transmembrane electrochemical potential by either biofilm disruption or inhibition of the proton pump.44 Daptomycin is primarily eliminated from the body via the urine suggesting that it may be useful in the treatment of Gram positive urinary tract infections. The future New strategies for antibiotic development may become available with the advance of genomics and the sequencing of the bacterial chromosome may reveal new sites for antibiotics to target. More efficient methods for drug synthesis and recombinant DNA methods have accelerated the

discovery of new antibiotics. In addition methods of screening new antibiotics have improved enabling pharmaceutical companies to test vast numbers of compounds daily. Novel mechanisms for antibacterial activity are under investigation. Current research is looking at ways of blocking the action of t-RNA synthetases, enzymes essential for the synthesis of protein in bacteria. These have been identified in S. aureus and S. pneumoniae and several compounds (not yet in clinical trial) have been developed. Research is also examining the potential of targeting the quorum sensing mechanism of bacterial populations. At critical concentrations bacteria can communicate by quorum sensing and as a result they can regulate their population density. Interference with this control process may provide a way of switching off virulence genes in bacteria.45 Cationic peptides (also called defensins) are short chain peptides produced by macrophages46 and neutrophils47 and are also found in the skins of frogs and insects.48 Examples of these agents include cecropins48, melittin49, magainins50 and epidermin.51 Their activity is against the bacterial cell membrane but they may potentially damage the mammalian cells. A magainin is currently under clinical trial as a topical agent for skin infections.50 Vaccine development is another approach to the problem. New formulations of the pneumococcal vaccine are effective in children under 2 years of age.52 There have also been recent advances in improving the meningococcal vaccine with the production of a conjugate vaccine against meningococcal serogroup C polysaccharide. 53 Progress against other pathogens has been poor and the large numbers of pathogens encountered in nosocomial infections probably precludes a vaccine approach. New antimicrobial agents or combinations of existing antimicrobial agents will continue to provide selective pressures which will result in the continued emergence of resistance. It is vital that an approach to reduce selective pressures for the development of resistance by the more prudent use of antimicrobial agents in humans and animals is adopted.3 Effective infection control practice will also reduce the burden of nosocomial infections and the transmission of resistant organisms and therefore reduce the need for antibiotic usage. In addition rapid diagnostic techniques might reduce the use of inappropriate antimicrobial agents or enable the use of narrow spectrum antibiotics. Shortening the duration of antimicrobial therapy or avoiding its longterm use might provide other ways of reducing antimicrobial resistance.54 In the hospital environment the use of antibiotics and the emergence of antibiotic resistance are most concentrated in the ICU, which also contains a particularly vulnerable patient population. A multidisciplinary strategy to control antibiotic resistance is essential. This will include the development and implementation of local antibiotic policies, the rapid detection and reporting of the antibiotic resistant strains, improved surveillance and effective infection control measures to prevent transmission of resistant bacteria.

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Acknowledgements The authors wish to thank W. Lawson, Infectious Diseases Pharmacist at Hammersmith Hospitals NHS Trust. References
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