Antimicrobial-resistant bacteria in the community setting

Methicillin-resistant Staphylococcus aureus: A public health issue with economic consequences

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) has become endemic worldwide in hospitals, and community-associated MRSA is spreading into the community at large.

OBJECTIVES

To estimate the current cost of MRSA in Canada and to assess the magnitude of this public health issue.

METHODS

An extensive review of the literature was conducted to gather epidemiology, health care resource utilization and cost data for MRSA in Canadian settings. The current MRSA burden was estimated using available cost data and the most recent epidemiology data.

RESULTS

The rate of MRSA in Canadian hospitals increased from 0.46 to 5.90 per 1000 admissions between 1995 and 2004, while community-associated MRSA continued to spread into the community. Patients harbouring MRSA required prolonged hospitalization (average 26 days of isolation per patient), special control measures, expensive treatments and extensive surveillance. Total cost per infected MRSA patient averaged $12,216, with hospitalization being the major cost driver (81%), followed by barrier precautions (13%), antimicrobial therapy (4%) and laboratory investigations (2%). The most recent epidemiological data, combined with available cost data, suggest that direct health care cost attributable to MRSA in Canada, including cost for management of MRSA-infected and-colonized patients and MRSA infrastructure, averaged $82 million in 2004 and could reach $129 million in 2010.

CONCLUSION

MRSA is a costly public health issue that needs to be tackled if the growing burden of this disease in Canadian hospitals and in the community is to be limited.

Interaction mode of a symmetric Trp-rich undeca peptide PST11-RK with lipid bilayers

To better understand the mode of action of the antimicrobial peptide PST11-RK, we investigated its (1) bactericidal kinetics, (2) ability to induce bacterial membrane depolarization, (3) ability to bind to liposomes, (4) cis/trans prolyl isomerization, (5) lipid binding kinetics and (6) translocation across lipid bilayers. Our findings suggest that PST11-RK acts mainly by collapsing the cytoplasmic membrane potential; it first attaches to the membrane via cationic C- and N-terminal residues and then inserts its central hydrophobic residues into the lipid interior. In addition, it seems likely that cis/trans isomerization facilitates the translocation of PST11-RK across the lipid bilayer, where it may interact with secondary intracellular targets.

Allosteric inhibition of Staphylococcus aureus D-alanine:D-alanine ligase revealed by crystallographic studies

D-alanine:D-alanine ligase (DDl) is an essential enzyme in bacterial cell wall biosynthesis and an important target for developing new antibiotics. It catalyzes the formation of D-alanine:D-alanine dipeptide, sequentially by using one D-alanine and one ATP as substrates for the first-half reaction, and a second D-alanine substrate to complete the reaction. Some gain of function DDl mutants can use an alternate second substrate, causing resistance to vancomycin, one of the last lines of defense against life-threatening Gram-positive infections. Here, we report the crystal structure of Staphylococcus aureus DDl (StaDDl) and its cocrystal structures with 3-chloro-2,2-dimethyl-N-[4(trifluoromethyl)phenyl]propanamide (inhibitor 1) (Ki=4 microM against StaDDl) and with ADP, one of the reaction products, at resolutions of 2.0, 2.2, and 2.6 A, respectively. The overall structure of StaDDl can be divided into three distinct domains. The inhibitor binds to a hydrophobic pocket at the interface of the first and the third domain. This inhibitor-binding pocket is adjacent to the first D-alanine substrate site but does not overlap with any substrate sites. An allosteric inhibition mechanism of StaDDl by this compound was proposed. The mechanism provides the basis for developing new antibiotics targeting D-alanine:D-alanine ligase. Because this compound only interacts with residues from the first D-alanine site, inhibitors with this binding mode potentially could overcome vancomycin resistance.

Presence of new mecA and mph(C) variants conferring antibiotic resistance in Staphylococcus spp. isolated from the skin of horses before and after clinic admission

Because of the frequency of multiple antibiotic resistance, Staphylococcus species often represent a challenge in incisional infections of horses undergoing colic surgery. To investigate the evolution of antibiotic resistance patterns before and after preventative peri- and postoperative penicillin treatment, staphylococci were isolated from skin and wound samples at different times during hospitalization. Most staphylococci were normal skin commensals and belonged to the common coagulase-negative group. In some cases they turned out to be opportunistic pathogens present in wound infections. MICs were determined for 12 antibiotics, and antibiotic resistance genes were detected by microarray. At hospital admission, horses harbored staphylococci that were susceptible to antibiotics or resistant to one group of drugs, mainly due to the presence of new variants of the methicillin and macrolide resistance genes mecA and mph(C), respectively. After 3 days, the percentage of Staphylococcus isolates displaying antibiotic resistance, as well as the number of resistance genes per isolate, increased moderately in hospitalized horses without surgery or penicillin treatment but dramatically in hospitalized horses after colic surgery as well as penicillin treatment. Staphylococcus species displaying multiple resistance were found to harbor mainly genes conferring resistance to beta-lactams (mecA and blaZ), aminoglycosides [str and aac(6')-Ie-aph(2')-Ia], and trimethoprim [dfr(A) and dfr(D)]. Additional genes conferring resistance to macrolides [mph(C), erm(C), and erm(B)], tetracycline [tet(K) and tet(M)], chloramphenicol [cat(pC221) and cat(pC223)], and streptothricin (sat4) appeared in several strains. Hospitalization and preventive penicillin use were shown to act as selection agents for multidrug-resistant commensal staphylococcal flora.

Use of germicides in the home and the healthcare setting: is there a relationship between germicide use and antibiotic resistance?

BACKGROUND

The spread of antibiotic-resistant pathogens represents an increasing threat in healthcare facilities. Concern has been expressed that the use of surface disinfectants and antiseptics may select for antibiotic-resistant pathogens.

OBJECTIVE

To review the scientific literature on whether there is a link between use of germicides (ie, disinfectants and antiseptics) and bacterial resistance to antibiotics. In addition, we will review whether antibiotic-resistant bacteria exhibit altered susceptibility to germicides that are recommended for use as disinfectants or antiseptics.

DESIGN

A review of the appropriate scientific literature.

RESULTS

In the laboratory, it has been possible to develop bacterial mutants with reduced susceptibility to disinfectants and antiseptics that also demonstrate decreased susceptibility to antibiotics. However, the antibiotic resistance described was not clinically relevant because the test organism was rarely a human pathogen, the altered level of antimicrobial susceptibility was within achievable serum levels for the antibiotic, or the antibiotic tested was not clinically used to treat the study pathogen. Similarly, wild-type strains with reduced susceptibility to disinfectants (principally, quaternary ammonium compounds) and antiseptics (principally, triclosan) have been reported. However, because the concentration of disinfectants used in the healthcare setting greatly exceeds the concentration required to kill strains with reduced susceptibility to disinfectants, the clinical relevance of these observations is questionable.

CONCLUSION

To date, there is no evidence that using recommended antiseptics or disinfectants selects for antibiotic-resistant organisms in nature. Disinfectants and antiseptics should be used when there are scientific studies demonstrating benefit or when there is a strong theoretical rationale for using germicides.

Crystal structure of nicotinic acid mononucleotide adenylyltransferase from Staphyloccocus aureus: structural basis for NaAD interaction in functional dimer

Bacterial nicotinic acid mononucleotide adenylyltransferase (NaMNAT; EC 2.7.7.18) encoded by the nadD gene, is essential for cell survival and is thus an attractive target for developing new antibacterial agents. The NaMNAT catalyzes the transfer of an adenylyl group of ATP to nicotinic acid mononucleotide (NaMN) to form nicotinic acid dinucleotide (NaAD). Two independently derived, high-resolution structures of Staphylococcus aureus NaMNAT-NaAD complexes establish the conserved features of the core dinucleotide-binding fold with other adenylyltransferases from bacteria to human despite a limited sequence conservation. The crystal structures reveal that the nicotinate carboxylates of NaAD are recognized by interaction with the main-chain amides of Thr85 and Tyr117, a positive helix dipole and two bridged-water molecules. Unlike other bacterial adenylyltransferases, where a partially conserved histidine residue interacts with the nicotinate ring, the Leu44 side-chain interacts with the nicotinate ring by van der Waals contact. Importantly, the S. aureus NaMNAT represents a distinct adenylyltransferase subfamily identifiable in part by common features of dimerization and substrate recognition in the loop connecting beta5 to beta6 (residues 132-146) and the additional beta6 strand. The unique beta6 strand helps orient the residues in the loop connecting beta5 to beta6 for substrate/product recognition and allows the beta7 strand structural flexibility to make key dimer interface interactions. Taken together, these structural results provide a molecular basis for understanding the coupled activity and recognition specificity for S. aureus NaMNAT and for rational design of selective inhibitors.

Antibiotic prophylaxis in chemotherapy-induced neutropenia: time to reconsider

The use of antibiotic prophylaxis in neutropenic patients remains controversial. The main arguments against prophylaxis are the lack of survival benefit and the risk of inducing antibiotic resistance. At present, clinical guidelines advise against routine use of antibiotic prophylaxis and current practice is to commence broad-spectrum antibiotics at the onset of fever in the neutropenic patient. However hospitalization, investigations and treatment all impact on resources as well as affecting patient quality of life, often resulting in chemotherapy delays and dose reductions. The benefits of prophylactic antibiotics have been emphasized by two major double-blind, placebo controlled trials with levofloxacin with very significant reductions in all infection-related events. Furthermore, the meta-analysis confirms a survival advantage and this is greatest with the use of fluoroquinolones. These benefits must be weighed against the problem of emerging antibiotic resistance. It has been shown that antibiotic prophylaxis does induce resistant organisms, but some studies have shown that the impact on clinical outcomes may not be as great as expected. Current evidence supports antibiotic prophylaxis with fluoroquinolones in acute leukaemia and high-dose chemotherapy patients, commencing at the same time as chemotherapy. Febrile episodes are much commoner with the first cycle in patients with solid tumours or lymphoma having moderately myelosuppressive chemotherapy, and these patients should be offered prophylaxis for at least the first cycle of chemotherapy. Further work is ongoing to facilitate the selection of patients with the greatest chance of benefit so that prophylaxis can be used efficiently.