Problems and Mechanisms of Antimicrobial Resistance

Antimicrobial resistance among enteric pathogens

Diarrhea is a major cause of morbidity and mortality in infants and children worldwide. Use of antimicrobial therapy in children with bacterial diarrhea involves consideration of advantages and limitations of use of appropriate agents in the general population and in specific hosts. Antimicrobial agents for bacterial diarrhea should be prescribed with an appreciation of limitations including antimicrobial resistance. Studies from many countries have reported resistance to Campylobacter jejuni, Campylobacter coli, Shigella species, Salmonella species, and shiga toxin producing Escherichia coli. In many geographic areas of the world including the United States, resistance patterns have demonstrated a consistent increase over the course of time, with resistance occurring to several classes of antimicrobial agents. Resistance patterns are influenced by geographic location, year isolates were obtained, classes of antimicrobial agents, pressure exerted by antimicrobial use, and source of the isolate. Because antimicrobial resistance among enteric pathogens is a common finding, has increased over time, and varies by geographic location, constant monitoring of susceptibility patterns is necessary for selection of appropriate antimicrobial agents for therapy when indicated.

Natural antimicrobial agent (reuterin) produced by lactobacillus reuteri for sanitization of biological tissues inoculated with pseudomonas aeruginosa

The study was done to evaluate the efficacy of using reuterin produced by Lactobacillus reuteri to sanitize biological tissues. The microorganism tested in the study was Pseudomonas aeruginosa, a common cause of nosocomial biomaterial-related infections. The inhibitory effect of reuterin on P. aeruginosa for an inoculated tissue was investigated at different conditions of concentration, temperature, and pH. Additionally, the cellular compatibility of the reuterin-sanitized tissue was evaluated. Glutaraldehyde was employed as a control. It was noted that the minimum inhibitory concentration (MIC, 33.0 +/- 2.9 ppm) and minimum bactericidal concentration (MBC, 50.0 +/- 0.0 ppm) values of reuterin for P. aeruginosa were significantly lower than their glutaraldehyde counterparts (MIC, 130.0 +/- 8.2 ppm and MBC, 180.0 +/- 18.3 ppm). This indicated that reuterin was more efficient than glutaraldehyde as an antimicrobial agent. The addition of reuterin on the inoculated tissue led to a reduced viability of P. aeruginosa. The reduction in the P. aeruginosa culture was more pronounced with increasing the concentration of reuterin (0-100 ppm). At increasing temperature (25-45 degrees C), there was an increasing effect of reuterin on its sanitization activity. However, it should be pointed out that the growth of P. aeruginosa in the nutrient broth was also significantly affected by temperature. The sanitization activity of reuterin was more evident with increasing the pH level (pH 6.5-8.5). The cytotoxicity of reuterin was significantly lower than that of glutaraldehyde. Additionally, the cellular compatibility of the reuterin-sanitized tissue was superior to its glutaraldehyde-sanitized counterpart.

Evaluation of use of a new chromogenic agar in detection of urinary tract pathogens

CHROMagar Orientation, a new chromogenic medium, was evaluated for the detection and differentiation of gram-positive and gram-negative pathogenic microorganisms in 900 urine samples from hospitalized patients. Performance characteristics of the medium were evaluated in comparison to those of 5% sheep blood and MacConkey agars by direct inoculation of the urine samples on the three media. Four gram-negative and two gram-positive strains as well as one yeast control strain from the American Type Culture Collection were used to ensure quality control. CHROMagar Orientation succeeded in detecting all the urine pathogens that were detected by the reference media, including gram-negative bacilli, staphylococci, streptococci, and yeasts. Colony color and morphology on CHROMagar Orientation accurately differentiated Escherichia coli, Proteus mirabilis, Proteus vulgaris, Pseudomonas aeruginosa, and Acinetobacter spp. Owing to the similarity in the pigmentation produced by Klebsiella, Enterobacter, and Citrobacter isolates, the medium failed to distinguish among them; however, these isolates were easily recognized as coliforms because of their metallic blue coloration. Staphylococci were clearly perceptible: S. aureus and S. epidermidis grow in regular-size colonies that range from opaque white to yellowish, and S. saprophyticus produces opaque pink colonies. All streptococcus strains, including those from groups B and C, were detected. They grow as undifferentiated flat dry diffused colonies, and additional tests were required for identification. Enterococci were easily discriminated by their strong turquoise pigmentation and their typical growth on the agar's surface. Yeast grow in typical creamy wet convex colonies. The accuracy of antibiotic susceptibility determinations according to standard methods was also tested by picking isolates directly from CHROMagar Orientation. The results showed excellent correlation with those obtained with microorganisms picked from reference media. Owing to the ease in differentiating mixed flora on CHROMagar Orientation, antimicrobic susceptibility tests were performed directly from primary isolates in all cases without the need for subcultures.

Comparative in vitro evaluation of piperacillin/tazobactam in a tertiary care hospital

Bacterial resistance is usually a serious problem in tertiary care hospitals. The aim of this in vitro study was to evaluate the beta-lactamase inhibitor combination piperacillin/tazobactam in a hospital environment with high bacterial resistance rates and compare it with other beta-lactam agents. Three hundred and sixty-two isolates from various clinical materials were studied during the period March-August 1996. Material for culture was collected from patients of all the wards of our hospital, with the majority being from the Intensive Care Unit (45%). Pathogenic Gram-positive and Gram-negative bacteria with high resistance rates and beta-lactamase production were studied (staphylococci, enterococci, Enterobacteriaceae, Pseudomonas). Significant bacterial resistance rates were identified for ceftazidime (50% for Klebsiellae, 60% for Enterobacter spp, 60% for Proteus spp, 33% for Pseudomonas spp, 75% for Acinetobacter spp) and ciprofloxacin (33% for both Klebsiellae and Enterobacter spp, 67% for Pseudomonas spp, 50% Acinetobacter spp). Fifty percent of Enterococcus isolates were resistance to ciprofloxacin but all of them were susceptible to piperacillin/tazobactam, amoxicillin/clavulanate and imipenem. The antibacterial activity of piperacillin/tazobactam (susceptibility rates 83 to 100% for Enterobacteriaceae, 83% for Pseudomonas spp and 75% for Acinetobacter spp) was higher than that of ceftazidime, piperacillin and ciprofloxacin. Imipenem, being mostly a reserve product, showed higher activity against Acinetobacter, Klebsiella and Enterobacter species.

Douglas-fir root-associated microorganisms with inhibitory activity towards fungal plant pathogens and human bacterial pathogens

A microbial culture collection composed of 1820 bacterial strains, including 298 actinomycete strains, was established from the roots of Douglas-fir (Pseudotsuga menziesii (Mirb.) Franco) seedlings harvested from conifer nurseries and forest sites. Two hundred and thirty-four strains inhibited the growth of Fusarium, Cylindrocarpon, and (or) Pythium spp. in in vitro assays. A significantly greater proportion of bacterial strains from actinomycete genera exhibited antifungal properties compared with bacterial strains from nonactinomycete genera. Eighty-nine percent of identified inhibitory strains were Streptomyces, Streptoverticillium, Bacillus, Pseudomonas, or Burkholderia species. The actinomycete species were isolated almost exclusively from forest seedlings. Recovery of inhibitory strains representing 29 microbial species was enhanced using a variety of methods to isolate microorganisms from the roots of seedlings from nursery and forest sites. Bacterial strains (including actinomycete strains) with antifungal activity were tested for in vitro growth inhibition of six clinical human bacterial pathogens (Enterococcus faecalis, Staphylococcus aureus, Klebsiella pneumoniae, Escherichia coli, Proteus mirabilis, and Pseudomonas aeruginosa). Forty-eight percent of the tested strains inhibited one or more human pathogens, Inhibitory activity towards fungal and bacterial pathogens was strain specific, not species specific, and many inhibitory strains exhibited broad-spectrum activity. Strains with antifungal activity against several conifer root pathogens were also more likely to inhibit multiple species of clinical bacterial pathogens.

A randomized, double-blind study comparing cefixime and trimethoprim-sulfamethoxazole in the treatment of childhood shigellosis

We compared the clinical and bacteriologic response of 5-day treatment with cefixime, 8 mg/kg per day, with the response to trimethoprim-sulfamethoxazole (TMP-SMX), 10-50 mg/kg per day, the currently recommended therapy. Of the assessable children with acute, culture-proven shigellosis, 38 received cefixime and 39 received TMP-SMX. Pretreatment data on the two study groups were similar. In the first group, all isolates were susceptible to cefixime; in the TMP-SMX group, 32 isolates were resistant and 7 were susceptible to TMP-SMX. Clinical response (day 5) showed cure, improvement, and failure in 89%, 8%, and 3%, respectively, of the cefixime group, and in 25%, 44%, and 31%, respectively, of the TMP-SMX-resistant group (p < 0.001). Bacteriologic cure (day 3) occurred in 78% and 23% of the cefixime and TMP-SMX-resistant groups, respectively (p < 0.001). Clinical or bacteriologic relapse (day 12) was infrequent in both groups. The response to treatment of the cefixime and the TMP-SMX-susceptible groups was similar. No significant side effects were noted. We conclude that cefixime is superior to TMP-SMX in the treatment of suspected shigellosis in areas with a high rate of resistance to TMP-SMX.

Antibiotic resistance of urinary pathogens isolated from patients attending The Toronto Hospital between 1986 and 1990

A study was carried out on 1523 urinary isolates obtained at The Toronto Hospital, Canada's largest tertiary care establishment, over three 1-month periods in 1986, 1987 and 1990. Escherichia coli was the most frequently isolated organism, with Enterococcus spp. the second most common isolate in 1986 and 1987, and Streptococcus spp. in 1990. Pseudomonas aeruginosa isolates were found to be resistant to many of the antimicrobial agents tested. Resistance patterns were found to commonly prescribed ampicillin, co-trimoxazole and, to some extent, the new fluoroquinolones, ciprofloxacin and norfloxacin. These results are relevant to the treatment and management of urinary tract infections in patients attending a tertiary care hospital.

Therapy for acute infectious diarrhea in children

This article reviews current recommendations of therapy with antidiarrheal compounds and antimicrobial agents for acute infectious diarrhea in children. In most infants and children with acute infectious diarrhea, treatment with antidiarrheal compounds is not indicated. Many of these compounds interfere with identification of enteropathogens in stool specimens, and the antimotility class has an overdose potential. Antimicrobial therapy is given to reduce symptoms and to prevent the spread of infection by decreasing fecal shedding of organisms. Although effective therapy is not available for patients with enteric viruses, Cryptosporidium, and Microsporidium, therapy is useful for children with amebiasis, antimicrobial-associated colitis, cholera, giardiasis, various forms of Escherichia coli diarrhea and Salmonella disease, isosporiasis, shigellosis, and strongyloidiasis. For several other conditions, antimicrobial therapy is of questionable benefit (infection with Campylobacter jejuni or Yersinia enterocolitica, intestinal salmonellosis and enterohemorrhagic E. coli infection). Compounds such as the fluoroquinolones, which are effective in the treatment of acute infectious diarrhea in adults, are not approved for use in children because of potential side effects. Many bacterial, viral, and parasitic organisms cause acute infectious diarrhea; appropriate antimicrobial therapy requires the accurate, rapid identification of the offending enteropathogen. In children with an underlying illness such as acquired immunodeficiency syndrome, manifestations may be prolonged, severe, and recurrent despite appropriate therapy.