Mechanisms involved in the development of resistance to fluoroquinolones in Escherichia coli isolates

High prevalence of nalidixic acid resistant, ciprofloxacin susceptible phenotype among clinical isolates of Escherichia coli and other Enterobacteriaceae

Therapeutic failure of infections during their treatment with quinolones has been often described. This may be due to the development of resistance during treatment of an infecting strain which already had diminished susceptibility to quinolones, even though the initial MIC did not exceed the breakpoint. In this study the prevalence of the nalidixic acid resistant, ciprofloxacin susceptible phenotype among Enterobacteriaceae was analyzed. The results showed that 113 out of 151 (74.83%) strains of the Enterobacteriaceae with diminished susceptibility to ciprofloxacin (MICs from 0.06 to 1 microg/ml) were resistant to nalidixic acid (MICs > 32 microg/ml). The Escherichia coli strains presenting this phenotype already have a mutation in the amino acid codon Ser-83 of the gyrA gene, so that the possibility of developing a second mechanism of resistance during treatment is very high.

Enrofloxacin resistance in Escherichia coli isolated from dogs with urinary tract infections

OBJECTIVE

To assess the strain heterogeneity of enrofloxacin-resistant Escherichia coli associated with urinary tract infections in dogs at a veterinary medical teaching hospital (VMTH). In addition, strains from other veterinary hospitals in California were compared with the VMTH strains to assess the geographic distribution of specific enrofloxacin-resistant E. coli isolates.

DESIGN

Bacteriologic study.

SAMPLE POPULATION

56 isolates of E. coli from urine samples (43 isolates from dogs at the VMTH, 13 isolates from dogs from other veterinary clinics in California).

PROCEDURES

Pulsed field gel electrophoresis was performed on 56 isolates of E. coli from urine samples from 56 dogs. All 56 isolates were tested for susceptibility to amoxicillin, chloramphenicol, enrofloxacin, tetracycline, trimethoprim-sulphamethoxazole, cephalexin, and ampicillin. Enrofloxacin usage data from 1994 to 1998 were obtained from the VMTH pharmacy.

RESULTS

Several strains of enrofloxacin-resistant E. coli were collected from urine samples from the VMTH, and strains identical to those from the VMTH were collected from other veterinary clinics in California. For the isolates that did share similar DNA banding patterns, variable antibiotic resistance profiles were observed.

CONCLUSIONS AND CLINICAL RELEVANCE

The increased occurrence of enrofloxacin-resistant E. coli from urine samples from dogs at the VMTH was not likely attributable to a single enrofloxacin-resistant clone but may be attributed to a collective increase in enrofloxacin resistance among uropathogenic E. coli in dogs in general.

Quinolone molecular structure-activity relationships: what we have learned about improving antimicrobial activity

Recently, understanding of how molecular modifications of the core quinolone structure affect(s) antimicrobial agent activity has progressed rapidly. Three positions (2, 3, and 4) cannot be changed without a significant loss of biological activity. Furthermore, it appears that a cyclopropyl group is optimal at position 1. Substituents at positions 5 and 8 affect planar configuration, and either a methyl or methoxy appear optimal at these sites. Hydrogen and amino groups have been investigated as useful substituents at position 6, replacing the fluorine of the fluoroquinolones. Interestingly, in vitro activity enhancement observed with alterations at positions 5 and 6 is not always accompanied by improved in vivo action. For all these modifications, the substituents at positions 7 and 8 are critical for potent antimicrobial activity. Optimizing overall molecular configuration enhances the number of intracellular targets for antimicrobial action (R-8) and impedes the efficiency of efflux proteins (R-7) that diminish intracellular penetration.

Molecular epidemiology and mutations at gyrA and parC genes of ciprofloxacin-resistant Escherichia coli isolates from a Taiwan medical center

Sixty-five ciprofloxacin-resistant clinical Escherichia coli isolates were collected from a Taiwan Medical Center from December 1998 to February 1999. All 65 clinical isolates were resistant (MICs > or = 4 microg/mL) to the following fluoroquinolones: ofloxacin, levofloxacin, sparfloxacin, and trovafloxacin. These isolates were cross-resistant to chloramphenicol (65 isolates, 100%), tetracycline (65 isolates, 100%), cefuroxime (64 isolates, 98.5%), ampicillin (57 isolates, 87.7%), gentamicin (53 isolates, 81.5%), and cephalothin (24 isolates, 36.9%). Pulsed-field gel electrophoresis (PFGE) revealed a high diversity among the genomes of these isolates and indicated that clonal spread was not responsible for the prevalence of ciprofloxacin resistance in the hospital. Sequencing of the polymerase chain reaction (PCR) amplified products of the quinolone resistance determining regions (QRDRs) of gyrA and parC showed that all isolates carrying double mutations in gyrA at codon 83 and 87 and at least one parC mutation at codon 80 and/or 84. The mutation at codon 83 of GyrA from serine to leucine (S83L) was present in all the clinical isolates. The most prevalent pattern was the S83L mutation and the mutation at codon 87 from an aspartate to an asparagine (D87N) of GyrA plus a mutation from a serine to an isoleucine (S80I) at codon 80 of ParC (63.2%). This indicated that the presence of high-level resistance to quinolones in clinical E. coli isolates were associated with mutations at hot spots, codon 83 and 87 in GyrA and followed by subsequent mutation in either codon 80 and/or 84 in ParC.

Interaction between DNA gyrase and quinolones: effects of alanine mutations at GyrA subunit residues Ser(83) and Asp(87)

DNA gyrase is a target of quinolone antibacterial agents, but the molecular details of the quinolone-gyrase interaction are not clear. Quinolone resistance mutations frequently occur at residues Ser(83) and Asp(87) of the gyrase A subunit, suggesting that these residues are involved in drug binding. Single and double alanine substitutions were created at these positions (Ala(83), Ala(87), and Ala(83) Ala(87)), and the mutant proteins were assessed for DNA supercoiling, DNA cleavage, and resistance to a number of quinolone drugs. The Ala(83) mutant was fully active in supercoiling, whereas the Ala(87) and the double mutant were 2.5- and 4- to 5-fold less active, respectively; this loss in activity may be partly due to an increased affinity of these mutant proteins for DNA. Supercoiling inhibition and cleavage assays revealed that the double mutant has a high level of resistance to certain quinolones while the mutants with single alanine substitutions show low-level resistance. Using a drug-binding assay we demonstrated that the double-mutant enzyme-DNA complex has a lower affinity for ciprofloxacin than the wild-type complex. Based on the pattern of resistance to a series of quinolones, an interaction between the C-8 group of the quinolone and the double-mutant gyrase in the region of residues 83 and 87 is proposed.

gyrA mutations associated with quinolone resistance in Bacteroides fragilis group strains

Mutations in the gyrA gene contribute considerably to quinolone resistance in Escherichia coli. Mechanisms for quinolone resistance in anaerobic bacteria are less well studied. The Bacteroides fragilis group are the anaerobic organisms most frequently isolated from patients with bacteremia and intraabdominal infections. Forty-four clinafloxacin-resistant and-susceptible fecal and clinical isolates of the B. fragilis group (eight Bacteroides fragilis, three Bacteroides ovatus, five Bacteroides thetaiotaomicron, six Bacteroides uniformis, and 22 Bacteroides vulgatus) and six ATCC strains of the B. fragilis group were analyzed as follows: (i) determination of susceptibility to ciprofloxacin, levofloxacin, moxifloxacin, and clinafloxacin by the agar dilution method and (ii) sequencing of the gyrA quinolone resistance-determining region (QRDR) located between amino acid residues equivalent to Ala-67 through Gln-106 in E. coli. Amino acid substitutions were found at hotspots at positions 82 (n = 15) and 86 (n = 8). Strains with Ser82Leu substitutions (n = 13) were highly resistant to all quinolones tested. Mutations in other positions of gyrA were also frequently found in quinolone-resistant and -susceptible isolates. Eight clinical strains that lacked mutations in their QRDR were susceptible to at least two of the quinolones tested. Although newer quinolones have good antimicrobial activity against the B. fragilis group, quinolone resistance in B. fragilis strains can be readily selected in vivo. Mutational events in the QRDR of gyrA seem to contribute to quinolone resistance in Bacteroides species.

Enhanced expression of the multidrug efflux pumps AcrAB and AcrEF associated with insertion element transposition in Escherichia coli mutants Selected with a fluoroquinolone

The development of fluoroquinolone resistance in Escherichia coli may be associated with mutations in regulatory gene loci such as marRAB that lead to increased multidrug efflux, presumably through activation of expression of the AcrAB multidrug efflux pump. We found that multidrug-resistant (MDR) phenotypes with enhanced efflux can also be selected by fluoroquinolones from marRAB- or acrAB-inactivated E. coli K-12 strains having a single mutation in the quinolone-resistance-determining region of gyrA. Mutant 3-AG100MKX, obtained from a mar knockout strain after two selection steps, showed enhanced expression of acrB in a reverse transcriptase PCR associated with insertion of IS186 into the AcrAB repressor gene acrR. In vitro selection experiments with acrAB knockout strains yielded MDR mutants after a single step. Enhanced efflux in these mutants was due to increased expression of acrEF and associated with insertion of IS2 into the upstream region of acrEF, presumably creating a hybrid promoter. These observations confirm the importance of efflux-associated nontarget gene mutations and indicate that transposition of genetic elements may have a role in the development of fluoroquinolone resistance in E. coli.

Genetic characterization of highly fluoroquinolone-resistant clinical Escherichia coli strains from China: role of acrR mutations

The genetic basis for fluoroquinolone resistance was examined in 30 high-level fluoroquinolone-resistant Escherichia coli clinical isolates from Beijing, China. Each strain also demonstrated resistance to a variety of other antibiotics. PCR sequence analysis of the quinolone resistance-determining region of the topoisomerase genes (gyrA/B, parC) revealed three to five mutations known to be associated with fluoroquinolone resistance. Western blot analysis failed to demonstrate overexpression of MarA, and Northern blot analysis did not detect overexpression of soxS RNA in any of the clinical strains. The AcrA protein of the AcrAB multidrug efflux pump was overexpressed in 19 of 30 strains of E. coli tested, and all 19 strains were tolerant to organic solvents. PCR amplification of the complete acrR (regulator/repressor) gene of eight isolates revealed amino acid changes in four isolates, a 9-bp deletion in another, and a 22-bp duplication in a sixth strain. Complementation with a plasmid-borne wild-type acrR gene reduced the level of AcrA in the mutants and partially restored antibiotic susceptibility 1.5- to 6-fold. This study shows that mutations in acrR are an additional genetic basis for fluoroquinolone resistance.

In vitro selected fluoroquinolone-resistant mutants of Citrobacter freundii: analysis of the quinolone resistance acquisition

Ten quinolone-resistant mutants of Citrobacter freundii, which were selected in vitro with fluoroquinolones from two clinical isolates, were studied. The parent isolates were susceptible to quinolones in spite of showing a single substitution in the GyrB (His-417 --> Leu). No change was observed in the outer membrane proteins or in the lipopolysaccharide in any of the ten mutants studied with respect to their parent isolates. The development of quinolone resistance in selected mutants was associated with the appearance of a substitution in the GyrA (Thr-83 --> Ile) in nine of the ten mutants plus enhanced active efflux in all of them.

Decreased permeability and enhanced proton-dependent active efflux in the development of resistance to quinolones in Morganella morganii

Five quinolone-resistant strains were developed from a clinical Morganella morganii isolate (M1 strain) which was susceptible to nalidixic acid and fluoroquinolones. All five in vitro selected mutants showed diminished norfloxacin accumulation and two of them also decreased the expression of the AgO in the outer membrane lipopolysaccharide with respect to their parent strain and to the M. morganii NCTC-235 type strain. Likewise, the M1 strain did not express a 37-38 kDa protein and accumulated less norfloxacin than the M. morganii NCTC-235 strain. The decreased norfloxacin uptake in the five mutants compared with the M. morganii NCTC-235 strain was due to an enhanced proton-dependent active efflux plus a pre-existent decreased expression of a 37-38 kDa protein in the parent strain.