Forewarned is forearmed: antibiotic resistance gene surveillance in critical care

Resistance mechanisms in Enterobacteriaceae

Enterobacteriaceae are responsible for a large proportion of serious, life-threatening infections and resistance to multiple antibiotics in these organisms is an increasing global public health problem. Mutations in chromosomal genes contribute to antibiotic resistance, but Enterobacteriaceae are adapted to sharing genetic material and much important resistance is due to 'mobile' resistance genes. Different mobile genetic elements, which have different characteristics, are responsible for capturing these genes from the chromosomes of a variety of bacterial species and moving them between DNA molecules. If transferred to plasmids, these resistance genes are then able to be transferred 'horizontally' between different bacterial cells, including different species, and well as being transferred 'vertically' during cell division. Carriage of several resistance genes on the same plasmid enables a bacterial cell to acquire multi-resistance in a single step and means that spread of one resistance gene may be co-selected for by use of antibiotics other than those to which it confers resistance. Many different mobile genes conferring resistance to each class of antibiotic have been identified, complicating detection of the factors responsible for a particular resistance phenotype, especially when changes in chromosomal genes may also confer or contribute to resistance. Understanding the mechanisms of antibiotic resistance, and the means by which these mechanisms can evolve and disseminate, is important for developing ways to efficiently track the spread of resistance and to optimise treatment.

Immediate appearance of plasmid-mediated resistance to multiple antibiotics upon antibiotic selection: an argument for systematic resistance epidemiology

We describe a conjugative plasmid appearing in a bacteremic clone of Escherichia coli immediately upon exposure to the antibiotics for which it encoded resistance. Effective antibiotic choice was made possible by prior screening for this plasmid. Surveillance for transmissible resistance plasmids may be clinically important.

Gram-negative sepsis in the intensive care unit: avoiding therapeutic failure

PURPOSE OF REVIEW

The purpose of this review is to examine some of the latest concepts in the management of sepsis and septic shock in the Intensive Care environment, with a focus on Gram-negative infections.

RECENT FINDINGS

Recent developments in adjunctive therapies for sepsis and septic shock are discussed including protocol-driven therapies, the importance of timely appropriate antimicrobials and the growing threat and implications of rising Gram-negative antimicrobial resistance.

SUMMARY

The balance between the most effective and the most responsible prescribing is difficult to strike, but recognition of the impact of antibiotic failure makes it even more important to consider how we husband the microflora of the ICU. New therapeutic options are somewhat limited but goal-directed protocol-driven approaches linked with sound knowledge of the microflora and our impact upon it as an ecosystem is essential.

A class 1 integron present in a human commensal has a hybrid transposition module compared to Tn402: evidence of interaction with mobile DNA from natural environments

In a survey of class 1 integrons from human stools, an unusual class 1 integron from a strain of Enterobacter cloacae was isolated and characterized in detail. Sequence analysis of a fosmid containing the class 1 integron revealed a complex set of transposons which included two Tn402-like transposons. One of these transposons, Tn6007, included a class 1 integron with two non-antibiotic-resistance-type gene cassettes and a complete transposition module. This tni module is a hybrid with a boundary within the res site compared to Tn402, implying that a site-specific recombination event generated either Tn6007 or Tn402. The second Tn402-like transposon, Tn6008, possesses neither a mer operon nor an integron, and most of its tni module has been deleted. Tn6007, Tn6008, and the 2,478 bases between them, collectively designated Tn6006, have transposed into a Tn5036/Tn3926-like transposon as a single unit. Tn6006, Tn6007, and Tn6008 could all transpose as discrete entities. Database analysis also revealed that a version of Tn6008 was present in the genome of Xanthomonas campestris pv. vesicatoria. Overall, the E. cloacae isolate further demonstrated that functional class 1 integrons/transposons are probably common in bacterial communities and have the potential to add substantially to the problem of multidrug-resistant nosocomial infections.

Beta-lactam resistance in the gram negatives: increasing complexity of conditional, composite and multiply resistant phenotypes

The greatest impact of microbiology data on clinical care is in the critically ill. Unfortunately, this is also the area in which microbiology laboratories are most often non-contributive. Attempts to move to rapid, culture-independent diagnostics are driven by the need to expedite urgent results. This is difficult in Gram-negative infection because of the complexity of the antibiotic resistance phenotype. Here, we discuss resistance to modern beta-lactams as a case in point. Recent outbreaks of transmissible carbapenem resistance among Gram-negative enteric pathogens in Sydney and Melbourne serve to illustrate the pitfalls of traditional phenotypical approaches. A better understanding of the epidemiology and mosaic nature of antibiotic resistance elements in the microflora is needed for us to move forward.

IMP-4 and OXA beta-lactamases in Acinetobacter baumannii from Singapore

OBJECTIVE

To compare the incidence of carbapenemase genes in Acinetobacter baumannii between two time periods.

METHODS

We studied 114 isolates of imipenem-resistant A. baumannii collected over two 5 month periods (in 1996 and 2001). Isolates showing carbapenemase activity by plate bioassay were screened for carbapenemase genes using PCR. Chromosomal DNA from strains carrying carbapenemase genes was subjected to PFGE after digestion with ApaI.

RESULTS

The incidence of imipenem-resistant A. baumannii in our hospital rose from 1.1 per 1000 admissions in 1996 to 2.3 per 1000 admissions in 2001. However, the number of carbapenemase-producing A. baumannii rose only slightly in 2001 (0.8 per 1000 admissions) compared to 1996 (0.5 per 1000 admissions). Of 44 isolates with carbapenemase activity, 4 isolates carried bla(IMP-4), 5 carried bla(OXA-58), and 40 carried bla(OXA-23). In addition, most isolates carried a bla(OXA-51)-type beta-lactamase gene. All strains with bla(IMP-4), also carried bla(OXA-58) and bla(PSE-1), but not bla(OXA-51)-type beta-lactamase genes. PCR analysis repeated on seven recent isolates of susceptible A. baumannii showed only the presence of bla(OXA-51)-type beta-lactamase genes. A total of five novel bla(OXA-51)-type beta-lactamase genes (bla(OXA-88),-91,-93,-94, and -95) and one new bla(OXA-58)-type beta-lactamase gene (bla(OXA-96)) were found.

CONCLUSIONS

The incidence of carbapenemase genes did not vary significantly between the two study periods. There is a wide diversity of OXA genes in A. baumannii in Singapore. The most common carbapenemase gene found in our study was bla(OXA-23).