Epidemiology and clinical relevance of microbial resistance determinants versus anti-Gram-positive agents

A New Theranostic Platform Against Gram-Positive Bacteria Based on Near-Infrared-Emissive Aggregation-Induced Emission Nanoparticles

Infections induced by Gram-positive bacteria pose a great threat to public health. Antibiotic therapy, as the first chosen strategy against Gram-positive bacteria, is inevitably associated with antibiotic resistance selection. Novel therapeutic strategies for the discrimination and inactivation of Gram-positive bacteria are thus needed. Here, a specific type of aggregation-induced emission luminogen (AIEgen) with near-infrared fluorescence emission as a novel antibiotic-free therapeutic strategy against Gram-positive bacteria is proposed. With the combination of a positively charged group into a highly twisted architecture, self-assembled AIEgens (AIE nanoparticles (NPs)) at a relatively low concentration (5 µm) exhibited specific binding and photothermal effect against living Gram-positive bacteria both in vitro and in vivo. Moreover, toxicity assays demonstrated excellent biocompatibility of AIE NPs at this concentration. All these properties make the AIE NPs as a novel generation of theranostic platform for combating Gram-positive bacteria and highlight their promising potential for in vivo tracing of such bacteria.

Nanomaterials as drug delivery systems with antibacterial properties: current trends and future priorities

Introduction:Despite extensive advances in the production and synthesis of antibiotics, infectious diseases are one of the main problems of the 21st century due to multidrug-resistant (MDR) distributing in organisms. Therefore, researchers in nanotechnology have focused on new strategies to formulate and synthesis the different types of nanoparticles (NPs) with antimicrobial properties.Areas covered:The present review focuses on nanoparticles which are divided into two groups, organic (micelles, liposomes, polymer-based and lipid-based NPs) and inorganic (metals and metal oxides). NPs can penetrate the cell wall then destroy permeability of cell membrane, the structure and function of cell macromolecules by producing of reactive oxygen species (ROS) and eventually kill the bacteria. Moreover, their characteristics and mechanism in various bacteria especially MDR bacteria and finally their biocompatibility and the factors affecting their activity have been discussed.Expert opinion:Nanotechnology has led to higher drug absorption, targeted drug delivery and fewer side effects. NPs can overcome MDR through affecting several targets in the bacteria cell and synergistically increase the effectiveness of current antibiotics. Moreover, organic NPs with regard to their biodegradability and biocompatibility characteristics can be suitable agents for medical applications. However, they are less stable in environment in comparison to inorganic NPs.

Prevalence of infectious multi-drug resistant bacteria isolated from immunocompromised patients in Tunisia

OBJECTIVES

A retrospective study was conducted in the Bone Marrow Transplant Center of Tunisia during a period of 10 years (from 2002 to 2011) in order to report the prevalence of infectious multi-drug resistant bacteria.

METHODS

Bacterial identification was carried on the basis of biochemical characteristics and API identification systems. Antibiotic susceptibility was tested by disc diffusion method on Muller-Hinton agar.

RESULTS

During the study period, 34.5% of 142 Klebsiella pneumoniae strains and 11.46% of 218 Escherichia coli strains were extended-spectrum beta-lactamase (ESBL) producers. Also, 32.8% of 210 strains of Pseudomonas aeruginosa were imipenem and/or ceftazidime resistant and 20.75% of 106 strains of Staphylococcus aureus were methicillin resistant. A rising trend was observed for the prevalence of the selected multidrug resistant bacteria.

CONCLUSION

These findings may have important clinical implications in prophylaxis and selection of antibiotic treatment. Continuous surveillance is needed, especially for onco-hematological patients.

Genome sequencing analysis of Streptomyces coelicolor mutants that overcome the phosphate-depending vancomycin lethal effect

Background

Glycopeptide antibiotics inhibit bacterial cell-wall synthesis, and are important for the treatment of infections caused by multi drug-resistant strains of enterococci, streptococci and staphylococci. The main mechanism by which bacteria resist the action of glycopeptides is by producing a modified cell-wall in which the dipeptide D-Alanine-D-Alanine is substituted by D-Alanine-D-Lactate or D-Alanine-D-Serine. Recently, it has been shown that inorganic phosphate (Pi) induces hypersensitivity to vancomycin in Streptomyces coelicolor (which is highly resistant to the antibiotic in low-Pi media). This finding was surprising because the bacterium possesses the entire set of genes responsible for vancomycin resistance (VR); including those coding for the histidine kinase/response regulator pair VanS/VanR that activates the system.

Results

This work shows that high Pi amounts in the medium hamper the activation of the van promoters and consequently inhibit VR in S. coelicolor; i.e. the repression effect being stronger when basic or acidic forms of the nutrient are used. In addition, this work shows that lysozyme resistance is also highly regulated by the Pi concentration in the medium. At least five different mutations contribute to the overcoming of this repression effect over VR (but not over lysozyme resistance). Therefore, the interconnection of VR and lysozyme resistance mechanisms might be inexistent or complex. In particular, two kinds of mutant in which Pi control of VR has been lost (one class expresses the van genes in a constitutive manner; the other retains inducibility by vancomycin) have been isolated and further characterized in this study. Sequencing revealed that the first class of mutation conferred a single amino acid substitution in the second transmembrane helix of the VanS protein; whereas the other class hampered the expression or activity of a putative homolog (SCO1213) to the staphylococcal GatD protein. Complementation, phenotypic and bioinformatics analyses identified SCO1213, and its upstream gene (i.e. murT), as relevant genetic determinants involved with VR in S. coelicolor.

Conclusion

The genomic approach of this study together with other genetic and phenotypic analyses has allowed the identification of the uncharacterized murT-gatD Streptomyces genes and the characterization of their involvement with the Pi control of VR in S. coelicolor.

Electronic supplementary material

The online version of this article (10.1186/s12864-018-4838-z) contains supplementary material, which is available to authorized users.

National Survey of Practices to Prevent Methicillin-Resistant Staphylococcus aureus and Multidrug-Resistant Acinetobacter baumannii in Thailand

Background

We evaluated the extent to which hospital characteristics, infection control practices, and compliance with prevention bundles impacted multidrug-resistant organism (MDRO) infections in Thai hospitals.

Methods

From 1 January 2014 to 30 November 2014, we surveyed all Thai hospitals with an intensive care unit and ≥250 beds. Infection control practices for methicillin-resistant Staphylococcus aureus (MRSA) and multidrug-resistant Acinetobacter baumannii (MDR-AB) were assessed. Linear regression was used to examine associations between hospital characteristics and prevention bundle compliance and changes in MDRO infection rates.

Results

A total of 212 of 245 (86.5%) eligible hospitals responded. Most hospitals regularly used several fundamental infection control practices for MRSA and MDR-AB (ie, contact precautions, private room/cohorting, hand hygiene, environmental cleaning, and antibiotic stewardship); advanced infection control practices (ie, active surveillance, chlorhexidine bathing, decolonization for MRSA, and hydrogen peroxide vaporizer for MDR-AB) were used less commonly. Facilities with ≥75% compliance with the MRSA prevention bundle experienced a 17.4% reduction in MRSA rates (P = .03). Although the presence of environmental cleaning services (41.3% reduction, P = .01) and a microbiology laboratory (82.8% reduction, P = .02) were among characteristics associated with decreases in MDR-AB rates, greater compliance with the MDR-AB prevention bundle did not lead to reductions in MDR-AB rates.

Conclusions

Although fundamental MRSA and MDR-AB control practices are used regularly in most Thai hospitals, compliance with more comprehensive bundled prevention approaches is suboptimal. Improving compliance with bundled infection prevention approaches and promoting the integration of certain hospital factors into infection control efforts may help reduce MDRO infections in Thai hospitals.

Old antimicrobials and Gram-positive cocci through the example of infective endocarditis and bone and joint infections

The management of some serious infections such as infective endocarditis (IE) and bone and joint infections (BJIs) caused by Gram-positive cocci (GPC) is complex and requires great responsiveness and effective antimicrobials with high bioavailability in heart valves or bone tissues. Treatment of these infections requires the use of a higher dosage that may result in increased toxicity or the use of new promising antimicrobials to control the infection. However, use of these new antimicrobials could still bring about new toxicity and resistance. Another approach may be the 'comeback' of old antimicrobials, which is evaluated in this review in the treatment of IE and BJIs caused by GPC.

Dalbavancin for the treatment of paediatric infectious diseases

To review the topics of interest related to the use of dalbavancin in paediatric patients. PubMed was used to search for all of the studies published over the last 15 years using the key word "dalbavancin". A total of 36 manuscripts were selected, and due to the limited pediatric experience a further research was performed in order to identify clinical trials ongoing. Three studies that concerned children were found in clinicaltrials.gov. This review considers also the manuscripts published on the adult population in order to highlight the gaps requiring further research at pediatric age. Dalbavancin has emerged as a promising agent against resistant Gram-positive invasive infections. It is approved in the United States and Europe for the treatment of adult patients with acute bacterial skin and skin structure infections (SSTIs). Compared to other available antibiotics that are active against multi-resistant bacteria, the advantages of dalbavancin include a lower potential for drug interactions and the possibility of fewer required doses due to a longer half-life. Pharmacokinetic characteristics of dalbavacin are attractive for its clinical impact, especially for children who may avoid prolonged hospitalization and central venous access. However, further studies are needed to establish its appropriate paediatric dosage before it can be licensed for use in newborns and children. For younger patients, at a time when infections due to multidrug-resistant Gram-positive pathogens are increasing, dosage, efficacy and safety data for dalbavancin are needed to ensure the highest antimicrobial efficacy while also minimizing the risk of adverse events.

Macrolones Are a Novel Class of Macrolide Antibiotics Active against Key Resistant Respiratory Pathogens In Vitro and In Vivo

As we face an alarming increase in bacterial resistance to current antibacterial chemotherapeutics, expanding the available therapeutic arsenal in the fight against resistant bacterial pathogens causing respiratory tract infections is of high importance. The antibacterial potency of macrolones, a novel class of macrolide antibiotics, against key respiratory pathogens was evaluated in vitro and in vivo MIC values against Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus, and Haemophilus influenzae strains sensitive to macrolide antibiotics and with defined macrolide resistance mechanisms were determined. The propensity of macrolones to induce the expression of inducible erm genes was tested by the triple-disk method and incubation in the presence of subinhibitory concentrations of compounds. In vivo efficacy was assessed in a murine model of S. pneumoniae-induced pneumonia, and pharmacokinetic (PK) profiles in mice were determined. The in vitro antibacterial profiles of macrolones were superior to those of marketed macrolide antibiotics, including the ketolide telithromycin, and the compounds did not induce the expression of inducible erm genes. They acted as typical protein synthesis inhibitors in an Escherichia coli transcription/translation assay. Macrolones were characterized by low to moderate systemic clearance, a large volume of distribution, a long half-life, and low oral bioavailability. They were highly efficacious in a murine model of pneumonia after intraperitoneal application even against an S. pneumoniae strain with constitutive resistance to macrolide-lincosamide-streptogramin B antibiotics. Macrolones are the class of macrolide antibiotics with an outstanding antibacterial profile and reasonable PK parameters resulting in good in vivo efficacy.

Antimicrobial resistance pattern of Gram-positive bacteria during three consecutive years at the nephrology ward of a tertiary referral hospital in Shiraz, Southwest Iran

Objective:

The aim of the present study was to determine the pattern of antimicrobial resistance of Gram-positive bacteria during three consecutive years at the nephrology ward of Namazi Hospital in Shiraz, Southwest of Iran.

Methods:

During a 3-year period from 2013 to 2015, data of all biological samples of hospitalized patients at the adult nephrology ward of Namazi Hospital were sent to the central laboratory for identification of Gram-positive microorganisms and subsequently, their antimicrobial susceptibility testing by Kirby–Bauer disc diffusion method were analyzed in a retrospective manner.

Findings:

Coagulase-negative Staphylococci (CONS) (38.5%), Staphylococcus aureus (25.4%), and Enterococcus spp. (23.8%) were the most common isolated Gram-positive bacteria from all biological samples. All Enterococcus spp. isolates within the 3 years were resistant to oxacillin. The rate of vancomycin-resistant enterococci (VRE) increased from 40.63% in 2013 to 72.73% in 2015. Enterococcus spp. resistance rates to aminoglycosides during 3 years were above 85%. The frequencies of oxacillin-resistant S. aureus (ORSA) in 2013, 2014, and 2015 were 95.24%, 80.95%, and 36.36%, respectively. Two out of 11 (6.67%) S. aureus isolates were resistant to vancomycin. More than 90% of CONS were sensitive to vancomycin within the study period. The frequency of gentamicin-resistant CONS ranged from 40% to 57.14%.

Conclusion:

The rates of ORSA, VRE, and aminoglycoside-resistant CONS as well as Enterococcus spp. in our clinical setting were considerably high and concerning. These may be due to the failure or lack of infection control activities and antimicrobial selection pressure.

Construction of a virtual Mycobacterium tuberculosis consensus genome and its application to data from a next generation sequencer

BACKGROUND

Although Mycobacterium tuberculosis isolates are consisted of several different lineages and the epidemiology analyses are usually assessed relative to a particular reference genome, M. tuberculosis H37Rv, which might introduce some biased results. Those analyses are essentially based genome sequence information of M. tuberculosis and could be performed in sillico in theory, with whole genome sequence (WGS) data available in the databases and obtained by next generation sequencers (NGSs). As an approach to establish higher resolution methods for such analyses, whole genome sequences of the M. tuberculosis complexes (MTBCs) strains available on databases were aligned to construct virtual reference genome sequences called the consensus sequence (CS), and evaluated its feasibility in in sillico epidemiological analyses.

RESULTS

The consensus sequence (CS) was successfully constructed and utilized to perform phylogenetic analysis, evaluation of read mapping efficacy, which is crucial for detecting single nucleotide polymorphisms (SNPs), and various MTBC typing methods virtually including spoligotyping, VNTR, Long sequence polymorphism and Beijing typing. SNPs detected based on CS, in comparison with H37Rv, were utilized in concatemer-based phylogenetic analysis to determine their reliability relative to a phylogenetic tree based on whole genome alignment as the gold standard. Statistical comparison of phylogenic trees based on CS with that of H37Rv indicated the former showed always better results that that of later. SNP detection and concatenation with CS was advantageous because the frequency of crucial SNPs distinguishing among strain lineages was higher than those of H37Rv. The number of SNPs detected was lower with the consensus than with the H37Rv sequence, resulting in a significant reduction in computational time. Performance of each virtual typing was satisfactory and accorded with those published when those are available.

CONCLUSIONS

These results indicated that virtual CS constructed from genome sequence data is an ideal approach as a reference for MTBC studies.

Daptomycin in paediatrics: current knowledge and the need for future research

To overcome the problems stemming from antimicrobial resistance, there have been several attempts to develop new antimicrobials in recent years. Of the highly potent drugs targeting resistant Gram-positive bacteria, daptomycin has a number of attractive characteristics that suggest its possible use in the treatment of serious infections due to these organisms. Although several pharmacokinetic and clinical studies in adults have provided data to determine how this drug should be prescribed to obtain the maximal clinical efficacy without significant risks of severe adverse events, we have not yet solved all of the problems related to the use of this antibiotic in paediatric patients. In this paper, the resolved and lingering problems of daptomycin treatment in newborns and children are reviewed and discussed. Studies have indicated that daptomycin is a promising therapeutic option for the treatment of paediatric diseases caused by MDR Gram-positive bacilli. However, before daptomycin can be licensed for use in newborns and children, further studies are needed to establish the appropriate dosages for paediatric patients of different ages. The data collected in adults can only be transferred to children older than 12 years, and the information available is not sufficient to determine the dosage that will assure the highest antimicrobial efficacy with only marginal risks of adverse events in younger patients. Thus, studies in neonates and younger infants are urgently needed to permit the use of daptomycin in the first months of life, a period in which infections due to MDR Gram-positive pathogens are increasing.

Biochemical insights into the function of phage G1 gp67 in Staphylococcus aureus

Bacteriophage (phage) are among the most diverse and abundant life forms on Earth. Studies have recently used phage diversity to identify novel antimicrobial peptides and proteins. We showed that one such phage protein, Staphylococcus aureus (Sau) phage G1 gp67, inhibits cell growth in Sau by an unusual mechanism. Gp67 binds to the host RNA polymerase (RNAP) through an interaction with the promoter specificity σ subunit, but unlike many other σ-binding phage proteins, gp67 does not disrupt transcription at most promoters. Rather, gp67 prevents binding of another RNAP domain, the α-C-terminal domain, to upstream A/T-rich elements required for robust transcription at rRNA promoters. Here, we discuss additional biochemical insights on gp67, how phage promoters escape the inhibitory function of gp67, and methodological advancements that were foundational to our work.

Antibiotic use and emerging resistance: how can resource-limited countries turn the tide?

Antibiotic resistance is a global crisis driven by appropriate and inappropriate antibiotic use to treat human illness and promote animal growth. The antimicrobial resistance epidemic continues to spread due to the triple threat of unfettered access, minimal product regulation and oversight of antibiotic prescription, and lack of clinical diagnostic tools to support antibiotic de-escalation in low-resource settings. In high-resource settings, evidence-based strategies have improved the appropriateness of antibiotic use, limiting the spread of drug-resistant organisms and reducing hospital-associated infections, strategies which may also be effective to stop the spread of resistance in resource-poor countries. Current research and surveillance efforts on antimicrobial resistance and hospital-associated infections in low-resource settings are extremely limited and largely focused on intensive care units. Many challenges exist to improving antibiotic use and infection control in resource-limited settings, and turning the tide requires intensifying research and surveillance, antimicrobial stewardship, and developing new bedside diagnostic tools for bacterial infections and antimicrobial susceptibility.

Targeting imperfect vaccines against drug-resistance determinants: a strategy for countering the rise of drug resistance

The growing prevalence of antimicrobial resistance in major pathogens is outpacing discovery of new antimicrobial classes. Vaccines mitigate the effect of antimicrobial resistance by reducing the need for treatment, but vaccines for many drug-resistant pathogens remain undiscovered or have limited efficacy, in part because some vaccines selectively favor pathogen strains that escape vaccine-induced immunity. A strain with even a modest advantage in vaccinated hosts can have high fitness in a population with high vaccine coverage, which can offset a strong selection pressure such as antimicrobial use that occurs in a small fraction of hosts. We propose a strategy to target vaccines against drug-resistant pathogens, by using resistance-conferring proteins as antigens in multicomponent vaccines. Resistance determinants may be weakly immunogenic, offering only modest specific protection against resistant strains. Therefore, we assess here how varying the specific efficacy of the vaccine against resistant strains would affect the proportion of drug-resistant vs. -sensitive strains population-wide for three pathogens--Streptococcus pneumoniae, Staphylococcus aureus, and influenza virus--in which drug resistance is a problem. Notably, if such vaccines confer even slightly higher protection (additional efficacy between 1% and 8%) against resistant variants than sensitive ones, they may be an effective tool in controlling the rise of resistant strains, given current levels of use for many antimicrobial agents. We show that the population-wide impact of such vaccines depends on the additional effect on resistant strains and on the overall effect (against all strains). Resistance-conferring accessory gene products or resistant alleles of essential genes could be valuable as components of vaccines even if their specific protective effect is weak.

Surveillance and management of multidrug-resistant microorganisms

Multidrug-resistant organisms are an established and growing worldwide public health problem and few therapeutic options remain available. The traditional antimicrobials (glycopeptides) for multidrug-resistant Gram-positive infections are declining in efficacy. New drugs that are presently available are linezolid, daptomicin and tigecycline, which have well-defined indications for severe infections, and talavancin, which is under Phase III trial for hospital-acquired pneumonia. Unfortunately the therapies available for multidrug-resistant Gram-negatives, including carbapenem-resistant Pseudomonas aeruginosa, Acinetobacter baumannii and Enterobacteriaceae, are limited to only colistin and tigecycline. Both of these drugs are still not registered for severe infections, such as hospital acquired pneumonia. Consequently, as confirmed by scientific evidence, a multidisciplinary approach is needed. Surveillance, infection control procedures, isolation and antimicrobial stewardship should be implemented to reduce multidrug-resistant organism diffusion.

Practices to prevent multidrug-resistant Acinetobacter baumannii and methicillin-resistant Staphylococcus aureus in Thailand: a national survey

BACKGROUND

Multidrug-resistant organisms (MDRO) are increasing challenges for health care institutions worldwide, and there are many factors associated with their distribution.

OBJECTIVES

We conducted a national survey of Thai hospitals with 1 or more intensive care units and ≥250 hospital beds to evaluate hospital characteristics and current practices to minimize the endemic burden of multidrug-resistant (MDR) Acinetobacter baumannii (AB) and methicillin-resistant Staphylococcus aureus (MRSA).

METHODS

Research nurses collected survey data from participating hospitals between January 1 and April 30, 2011. Data collection focused on hospital characteristics and practices to prevent endemic MDR-AB and MRSA; logistic regression analyses were used to assess associations between hospital characteristics and infection prevention control (IPC) interventions.

RESULTS

There was an 80% survey response (N = 204) from 256 eligible hospitals. Endemic MDR-AB and MRSA were reported in 184 (90%) and 100 (40%) hospitals, respectively. The most frequently reported IPC interventions were contact isolation, hand hygiene campaigns, and antimicrobial stewardship; active surveillance, chlorhexidine gluconate bathing, and multifaceted interventions were uncommon. By multivariate analysis, having a physician as the lead infection control professional and participation in a collaborative effort to prevent MDR organisms were associated with multifaceted interventions to reduce MDR-AB, and medical school affiliation and participating in a collaborative effort to prevent MDR organisms were associated with multifaceted interventions to reduce MRSA.

CONCLUSION

Multifaceted interventions to reduce, if not prevent, MDR-AB and MRSA were infrequently reported from Thai hospitals. Our survey findings provide baseline data for IPC interventions for MDR-AB and MRSA. Future efforts that correlate IPC interventions and MDRO trends will help develop evidence-based practices in these resource-limited settings.

Antimicrobial resistance and virulence: a successful or deleterious association in the bacterial world?

Hosts and bacteria have coevolved over millions of years, during which pathogenic bacteria have modified their virulence mechanisms to adapt to host defense systems. Although the spread of pathogens has been hindered by the discovery and widespread use of antimicrobial agents, antimicrobial resistance has increased globally. The emergence of resistant bacteria has accelerated in recent years, mainly as a result of increased selective pressure. However, although antimicrobial resistance and bacterial virulence have developed on different timescales, they share some common characteristics. This review considers how bacterial virulence and fitness are affected by antibiotic resistance and also how the relationship between virulence and resistance is affected by different genetic mechanisms (e.g., coselection and compensatory mutations) and by the most prevalent global responses. The interplay between these factors and the associated biological costs depend on four main factors: the bacterial species involved, virulence and resistance mechanisms, the ecological niche, and the host. The development of new strategies involving new antimicrobials or nonantimicrobial compounds and of novel diagnostic methods that focus on high-risk clones and rapid tests to detect virulence markers may help to resolve the increasing problem of the association between virulence and resistance, which is becoming more beneficial for pathogenic bacteria.

Novel 3-O-carbamoyl erythromycin A derivatives (carbamolides) with activity against resistant staphylococcal and streptococcal isolates

A novel series of 3-O-carbamoyl erythromycin A derived analogs, labeled carbamolides, with activity versus resistant bacterial isolates of staphylococci (including macrolide and oxazolidinone resistant strains) and streptococci are reported. An (R)-2-aryl substituent on a pyrrolidine carbamate appeared to be critical for achieving potency against resistant strains. Crystal structures showed a distinct aromatic interaction between the (R)-2-aryl (3-pyridyl for 4d) substituent on the pyrrolidine and G2484 (G2505, Escherichia coli) of the Deinococcus radiodurans 50S ribosome (3.2Å resolution).

Endolysins as antimicrobials

Peptidoglycan (PG) is the major structural component of the bacterial cell wall. Bacteria have autolytic PG hydrolases that allow the cell to grow and divide. A well-studied group of PG hydrolase enzymes are the bacteriophage endolysins. Endolysins are PG-degrading proteins that allow the phage to escape from the bacterial cell during the phage lytic cycle. The endolysins, when purified and exposed to PG externally, can cause "lysis from without." Numerous publications have described how this phenomenon can be used therapeutically as an effective antimicrobial against certain pathogens. Endolysins have a characteristic modular structure, often with multiple lytic and/or cell wall-binding domains (CBDs). They degrade the PG with glycosidase, amidase, endopeptidase, or lytic transglycosylase activities and have been shown to be synergistic with fellow PG hydrolases or a range of other antimicrobials. Due to the coevolution of phage and host, it is thought they are much less likely to invoke resistance. Endolysin engineering has opened a range of new applications for these proteins from food safety to environmental decontamination to more effective antimicrobials that are believed refractory to resistance development. To put phage endolysin work in a broader context, this chapter includes relevant studies of other well-characterized PG hydrolase antimicrobials.

Antimicrobial resistance in internal medicine wards

Antimicrobial resistance is a global medical problem, affecting most bacterial pathogens. The major challenges are currently posed by methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), Enterobacteriaceae producing extended-spectrum-beta-lactamases (ESBL) and carbapenemases, and multi-resistant strains of Pseudomonas aeruginosa and Acinetobacter baumannii. Therapeutic options are very limited and, in some cases, virtually unavailable. This article provides an overview of the recent epidemiological trends exhibited by the most important multi-resistant pathogens, and of the treatment options that are currently available for these infections.

Evaluation of a daptomycin dose-optimization protocol

PURPOSE

The impact of an institutional protocol intended to improve daptomycin dosing for vancomycin-resistant enterococci (VRE) infections was investigated.

SUMMARY

Daptomycin has been reported to have optimal activity against VRE at weight-based doses of ≥8 mg/kg. As part of an initiative to optimize daptomycin dosing for all indications and regimens, a large medical center implemented a protocol restricting daptomycin prescribing to infectious-diseases specialists and a nomogram recommending elevated daptomycin dosing for all VRE infections, with baseline and weekly creatinine phosphokinase (CPK) determinations during daptomycin therapy. Protocol implementation was preceded by educational efforts targeting medical and pharmacy staff. A retrospective study was conducted to compare prescribing behavior and safety monitoring rates during the 12 months before and 16 months after protocol implementation; the baseline characteristics of the preimplementation cohort (n = 95) and postimplementation cohort (n = 72) were similar. The mean daptomycin doses before and after the protocol was implemented were 453 mg (6.1 mg/kg) and 576 mg (7.6 mg/kg), respectively. After protocol implementation, there were significant increases in the proportion of patients who received doses of ≥8 mg/kg (52% in the postimplementation period versus 4% in the preimplementation period, p < 0.05) and in the rate of baseline CPK assessment (64% versus 43%, p < 0.05).

CONCLUSION

Implementation of a daptomycin dosing protocol by a multidisciplinary antimicrobial stewardship team optimized treatment by increasing the mean dose of daptomycin administered to hospitalized adults with non-urinary VRE infections and improved the rate of safety monitoring.

Isolation of Staphylococcus Aureus and Progression of Periodontal Lesions in Aggressive Periodontitis

This work evaluates whether isolation and toxicity of subgingival Staphylococcus aureus strains correlate with progression of periodontal lesions and whether isolates are characterized by a specific genomic background. The study involved 165 subjects affected by generalized aggressive periodontitis. Three sets of samples of supragingival and subgingival plaque were obtained at 45-day intervals from active and non-active sites, to detect S. aureus. Susceptibility to antibiotics, the presence of 17 genes, genomic restriction profiles and multilocus sequence typing (MLST) were performed to characterize all isolates. S. aureus was detected in 37.6% of the subjects. Subgingival colonization rates were 66.1% and 12.9% for active and non-active sites, respectively ( P<0.01). Supragingival and subgingival isolates were shown to be distinct by molecular genotyping and DNA fingerprint analysis. MLST showed that isolates were not genetically related and no sequence type was predominant in any of the two locations. These data demonstrate that S. aureus is associated with the progression of aggressive periodontitis and that a specific set of characters is necessary for the bacterium to colonize subgingival sites. Comparative analysis of genomic structure and genetic-related data suggest that the periodontal environment could promote genetic evolution of strains.

Differential effect of prior influenza infection on alveolar macrophage phagocytosis of Staphylococcus aureus and Escherichia coli: involvement of interferon-gamma production

The influenza A virus is one of the main causes of respiratory infection. Although influenza virus infection alone can result in pneumonia, secondary bacterial infection combined with the virus is the major cause of morbidity and mortality. Interestingly, while influenza infection increases susceptibility to some bacteria, including Streptococcus pneumoniae, Staphylococcus aureus (S. aureus), and Haemophilus influenzae, other bacteria such as Escherichia coli (E. coli) and Klebsiella pneumoniae are not associated with influenza infection. The reason for this discrepancy is not known. In this study, it was found that prior influenza virus infection inhibits murine alveolar macrophage phagocytosis of S. aureus but not of E. coli. Here, the mechanism for this inhibition is elucidated: prior influenza virus infection strongly increases interferon gamma (IFN-γ) production. Furthermore, it was shown that IFN-γ differentially affects alveolar macrophage phagocytosis of S. aureus and E. coli. The findings of the present study explain how influenza virus infection increases susceptibility to some bacteria, such as S. aureus, but not others, and provides evidence that IFN-γ might be a promising target for protecting the human population from secondary bacterial infection by influenza.

MRSA new treatments on the horizon: current status

There is a choice of anti-MRSA antibiotic available with proven efficacy in the treatment of complicated skin and skin structure infection (cSSSI). Additional anti-MRSA antibiotics are in development, which have the potential to influence how such infections are managed. The emergence of resistance to current anti-MRSA agents, toxicity, and general lack of oral agents with proven efficacy for deep seated infection justify the development of new agents. However, there is a relative dearth of information specific to patients with orthopaedic-related infection. Combination therapy is often used in these patients, although there is a paucity of controlled trial data to support particular antibiotic combinations. As the choice of anti-MRSA agents increases, so does the need to identify which are best for the large variety of infections included in the group of cSSSIs. This is particular true for infections occurring in orthopaedic patients where poorly vascularised tissue, trauma or implanted prosthetic material, pose specific challenges.

In vitro time-kill analysis of oritavancin against clinical isolates of methicillin-resistant Staphylococcus aureus with reduced susceptibility to daptomycin

Oritavancin exhibited lower MIC(50) values (0.03 and 0.5 mg/L) than comparators against methicillin-resistant Staphylococcus aureus (MRSA, n = 50) and vancomycin-intermediate SA strains (n = 60). At subtherapeutic concentrations, oritavancin demonstrated rapid (within 9 h) and concentration-dependent bactericidal activity against daptomycin nonsusceptible (DNS) MRSA. Further investigations are warranted to determine the therapeutic potential of oritavancin against DNS MRSA.

Actinoplanes teichomyceticus ATCC 31121 as a cell factory for producing teicoplanin

BACKGROUND

Teicoplanin is a glycopeptide antibiotic used clinically in Europe and in Japan for the treatment of multi-resistant Gram-positive infections. It is produced by fermenting Actinoplanes teichomyceticus. The pharmaceutically active principle is teicoplanin A2, a complex of compounds designated T-A2-1-A2-5 differing in the length and branching of the fatty acid moiety linked to the glucosamine residue on the heptapeptide scaffold. According to European and Japanese Pharmacopoeia, components of the drug must be reproduced in fixed amounts to be authorized for clinical use.

RESULTS

We report our studies on optimizing the fermentation process to produce teicoplanin A2 in A. teichomyceticus ATCC 31121. Robustness of the process was assessed on scales from a miniaturized deep-well microtiter system to flasks and 3-L bioreactor fermenters. The production of individual factors T-A2-1-A2-5 was modulated by adding suitable precursors to the cultivation medium. Specific production of T-A2-1, characterized by a linear C10:1 acyl moiety, is enhanced by adding methyl linoleate, trilinoleate, and crude oils such as corn and cottonseed oils. Accumulation of T-A2-3, characterized by a linear C10:0 acyl chain, is stimulated by adding methyl oleate, trioleate, and oils such as olive and lard oils. Percentages of T-A2-2, T-A2-4, and, T-A2-5 bearing the iso-C10:0, anteiso-C11:0, and iso-C11:0 acyl moieties, respectively, are significantly increased by adding precursor amino acids L-valine, L-isoleucine, and L-leucine. Along with the stimulatory effect on specific complex components, fatty acid esters, oils, and amino acids (with the exception of L-valine) inhibit total antibiotic productivity overall. By adding industrial oils to medium containing L-valine the total production is comparable, giving unusual complex compositions.

CONCLUSIONS

Since the cost and the quality of teicoplanin production depend mainly on the fermentation process, we developed a robust and scalable fermentation process by using an industrial medium in which a complex composition can be modulated by the combined addition of suitable precursors. This work was performed in the wild-type strain ATCC 31121, which has a clear genetic background. This is important for starting a rational improvement program and also helps to better control teicoplanin production during process and strain development.

Actinoplanes teichomyceticus ATCC 31121 as a cell factory for producing teicoplanin

Background

Teicoplanin is a glycopeptide antibiotic used clinically in Europe and in Japan for the treatment of multi-resistant Gram-positive infections. It is produced by fermenting Actinoplanes teichomyceticus. The pharmaceutically active principle is teicoplanin A₂, a complex of compounds designated T-A_2-1-A_2-5 differing in the length and branching of the fatty acid moiety linked to the glucosamine residue on the heptapeptide scaffold. According to European and Japanese Pharmacopoeia, components of the drug must be reproduced in fixed amounts to be authorized for clinical use.

Results

We report our studies on optimizing the fermentation process to produce teicoplanin A₂ in A. teichomyceticus ATCC 31121. Robustness of the process was assessed on scales from a miniaturized deep-well microtiter system to flasks and 3-L bioreactor fermenters. The production of individual factors T-A_2-1-A_2-5 was modulated by adding suitable precursors to the cultivation medium. Specific production of T-A_2-1, characterized by a linear C10:1 acyl moiety, is enhanced by adding methyl linoleate, trilinoleate, and crude oils such as corn and cottonseed oils. Accumulation of T-A_2-3, characterized by a linear C10:0 acyl chain, is stimulated by adding methyl oleate, trioleate, and oils such as olive and lard oils. Percentages of T-A_2-2, T-A_2-4, and, T-A_2-5 bearing the iso-C10:0, anteiso-C11:0, and iso-C11:0 acyl moieties, respectively, are significantly increased by adding precursor amino acids L-valine, L-isoleucine, and L-leucine. Along with the stimulatory effect on specific complex components, fatty acid esters, oils, and amino acids (with the exception of L-valine) inhibit total antibiotic productivity overall. By adding industrial oils to medium containing L-valine the total production is comparable, giving unusual complex compositions.

Conclusions

Since the cost and the quality of teicoplanin production depend mainly on the fermentation process, we developed a robust and scalable fermentation process by using an industrial medium in which a complex composition can be modulated by the combined addition of suitable precursors. This work was performed in the wild-type strain ATCC 31121, which has a clear genetic background. This is important for starting a rational improvement program and also helps to better control teicoplanin production during process and strain development.

Construction of a conditional lethal Salmonella mutant via genetic recombination using the ara system and asd gene

In order to construct a conditional lethal Salmonella mutant, an arabinose-regulated recombinant genetic system was used. The Salmonella aspartate semialdehyde dehydrogenase (asd) gene was localized under the control of araC P(araBAD) in a plasmid to create the araC P(araBAD)::asd cassette. The cassette was cloned into a plasmid carrying a p15A replication origin to create the recombinant plasmid pMMP55. The growth of Salmonella MMP10 harboring pMMP55 was dependent on the presence of arabinose. In the presence of arabinose, the Asd deficiency due to chromosomal deletion of asd in the Salmonella host was complemented by the asd gene transcribed and translated under the P(araBAD) promoter and araBAD Shine-Dalgarno (SD) sequence in pMMP55. Growth inhibition of the strain was demonstrated by arabinose depletion in M9 minimal medium, indicating that the strain were unable to grow in an arabinose-limited environment. In addition, the analysis of a 50% lethal dose (LD50) using mice revealed that the strain MMP10 exhibited attenuation by approximately 100-fold relative to that of the unmodified strain. In conclusion, these data suggest that the araC P(araBAD)::asd system developed in this study can be used to construct conditional lethal Salmonella mutants for application as safe, live-attenuated Salmonella vaccines.

Tn916-like genetic elements: a diverse group of modular mobile elements conferring antibiotic resistance

Antibiotic-resistant Gram-positive bacteria are responsible for morbidity and mortality in healthcare environments. Enterococcus faecium, Enterococcus faecalis, Staphylococcus aureus and Streptococcus pneumoniae can all exhibit clinically relevant multidrug resistance phenotypes due to acquired resistance genes on mobile genetic elements. It is possible that clinically relevant multidrug-resistant Clostridium difficile strains will appear in the future, as the organism is adept at acquiring mobile genetic elements (plasmids and transposons). Conjugative transposons of the Tn916/Tn1545 family, which carry major antibiotic resistance determinants, are transmissible between these different bacteria by a conjugative mechanism during which the elements are excised by a staggered cut from donor cells, converted to a circular form, transferred by cell-cell contact and inserted into recipient cells by a site-specific recombinase. The ability of these conjugative transposons to acquire additional, clinically relevant antibiotic resistance genes importantly contributes to the emergence of multidrug resistance.

Multistep resistance development studies of ceftaroline in gram-positive and -negative bacteria

Ceftaroline, the active component of the prodrug ceftaroline fosamil, is a novel broad-spectrum cephalosporin with bactericidal activity against Gram-positive and -negative isolates. This study evaluated the potential for ceftaroline and comparator antibiotics to select for clones of Streptococcus pneumoniae, Streptococcus pyogenes, Haemophilus influenzae, Moraxella catarrhalis, Klebsiella pneumoniae, Staphylococcus aureus, and Enterococcus faecalis with elevated MICs. S. pneumoniae and S. pyogenes isolates in the present study were highly susceptible to ceftaroline (MIC range, 0.004 to 0.25 μg/ml). No streptococcal strains yielded ceftaroline clones with increased MICs (defined as an increase in MIC of >4-fold) after 50 daily passages. Ceftaroline MICs for H. influenzae and M. catarrhalis were 0.06 to 2 μg/ml for four strains and 8 μg/ml for a β-lactamase-positive, efflux-positive H. influenzae with a mutation in L22. One H. influenzae clone with an increased ceftaroline MIC (quinolone-resistant, β-lactamase-positive) was recovered after 20 days. The ceftaroline MIC for this isolate increased 16-fold, from 0.06 to 1 μg/ml. MICs for S. aureus ranged from 0.25 to 1 μg/ml. No S. aureus isolates tested with ceftaroline had clones with increased MIC (>4-fold) after 50 passages. Two E. faecalis isolates tested had ceftaroline MICs increased from 1 to 8 μg/ml after 38 days and from 4 to 32 μg/ml after 41 days, respectively. The parental ceftaroline MIC for the one K. pneumoniae extended-spectrum β-lactamase-negative isolate tested was 0.5 μg/ml and did not change after 50 daily passages.

Computational biology approaches for selecting host-pathogen drug targets

The proliferation of genomic platform data, ranging from silencing RNAs through mRNA and microRNA expression to proteomics, is providing new insights into the interplay between human and pathogen genes during infection: the so-called 'host-pathogen interactome'. Exploiting the interactome for novel human drug targets could provide new therapeutic avenues towards the treatment of infectious disease, which could ameliorate the growing clinical challenge of drug-resistant infections. Using the hepatitis C virus interactome as an example, here we suggest a computational biology framework for identifying and prioritizing potential human host targets against infectious diseases.