Reduced sensitivity to beta-lactam antibiotics arising during ceftazidime treatment of Pseudomonas aeruginosa infections

Risk of emergence of Pseudomonas aeruginosa resistance to β-lactam antibiotics in intensive care units

OBJECTIVE

The emergence of Pseudomonas aeruginosa resistance to antimicrobial drugs is frequent in intensive care units and may be correlated with the use of some specific drugs. The purpose of our study was to identify a relationship between the use of various beta-lactam antibiotics and the emergence of resistance and to characterize the mechanism of resistance involved.

DESIGN

We conducted an open prospective study over a 3-yr period by including all patients in whom P. aeruginosa had been isolated from one or more specimens: bronchial aspiration, blood cultures, catheters, and urinary cultures.

SETTING

General intensive care unit.

PATIENTS

One hundred and thirty-two intensive care unit patients.

INTERVENTIONS

The antibiotics studied were amoxiclav, piperacillin-tazobactam, cefotaxime, ceftazidime, cefepim, and imipenem. The mechanisms of resistance studied were production of penicillinase or cephalosporinase, nonenzymatic mechanisms, and loss of porin OprD2. Analysis was performed using Cox proportional-hazard regression with time-dependant variables.

MEASUREMENTS AND MAIN RESULTS

Forty-two strains became resistant, 30 to one antibiotic, nine to two, and three to three, leading to the study of 57 resistant strains. Imipenem (hazard ratio 7.8; 95% confidence interval, 3.4-18.1), piperacillin-tazobactam (hazard ratio 3.9; 95% confidence interval, 1.3-11.9), and cefotaxim (hazard ratio 9.3; 95% confidence interval, 2.9-30.2) were strongly linked to the emergence of resistance. The use of imipenem (p<.0001) was associated with the loss of porin OprD2. Thirty-six strains from nine patients, assayed by pulsed-field gel electrophoresis, showed that for any one patient, all the strains were genetically related.

CONCLUSIONS

Our results show that there is a high risk of the emergence of drug resistance during treatment with cefotaxime, imipenem, and piperacillin-tazobactam. This has to be taken into account in the therapeutic choice and in the patient's surveillance.

In-vitro activities of various antibiotics, alone and in combination with amikacin against Pseudomonas aeruginosa

The in-vitro activities of various antibiotics, either alone or in combination with amikacin were assessed using clinical isolates of Pseudomonas aeruginosa. The minimum inhibitory concentrations (MIC) of these antibiotics were determined by microbroth dilution method against 50 clinical strains. The MIC values showed that 96, 94, and 74% of the isolates were susceptible or moderately susceptible to amikacin, meropenem and ceftazidime, respectively. The in vitro activities of ceftazidime and meropenem in combination with amikacin were determined by microbroth chequerboard technique and results were interpreted using the fractional inhibitory concentration (FIC) index. With a FIC index of < or =0.5 as borderline, synergistic interactions were more frequent with ceftazidime (70.8%) than with meropenem (40%). No antagonism was observed.

A nontoxic Pseudomonas exotoxin A induces active immunity and passive protective antibody against Pseudomonas exotoxin A intoxication

Pseudomonas exotoxin A (PE) is one of the most potent cytotoxic agents produced by Pseudomonas aeruginosa. In this study, we examined the possibility of using PE with a deletion of 38 carboxyl-terminal amino acid residues, designated PE(Delta576-613), for active immunization against PE-mediated disease. We first examined the toxic effects of PE and PE(Delta576-613) on 5- and 9-week-old ICR mice. The results show that the subcutaneous administration of PE(Delta576-613) at a dose of 250 microg was still nontoxic to 5- and 9-week-old ICR mice, while native PE was lethal at a dose of 0.5 and 1 microg, respectively. PE(Delta576-613) was then used to immunize ICR mice. The minimum dose of PE(Delta576-613) that could effectively induce anti-PE antibodies in 5- and 9-week-old ICR mice was found to be 250 ng. However, immunization with 250 ng PE(Delta576-613) failed to protect the immunized mice from a lethal dose of PE. The effective immunization dose of PE(Delta576-613) that could protect mice against a 2 microg PE challenge was found to be 15 microg. In addition, sera obtained from PE(Delta576-613)-immunized ICR mice were able to neutralize PE intoxication and effectively protect mice from PE. Thus, PE(Delta576-613) may be used as an alternative route to new PE vaccine development.

Frequency and mechanism of resistance to antibacterial action of ZM 240401, (6S)-6-fluoro-shikimic acid

Spontaneous resistance to (6S)-6-fluoro-shikimic acid arose in Escherichia coli and other enterobacteria at high frequencies, between 10(-5) and 10(-4). Two resistant variants of E. coli were tested for their susceptibilities to the diastereomeric compound, (6R)-6-fluoro-shikimate, and both of them had become resistant to this compound as well. (6S)-6-Fluoro-shikimate-resistant variants of E. coli generally failed to transport [14C]shikimate. In E. coli K-12, (6S)-6-fluoro-shikimate resistance cotransduced with his at the same frequency as shiA, a gene locus that governs shikimate transport phenotypes. We propose that the loss of susceptibility to (6S)-6-fluoro-shikimic acid in spontaneous resistant variants is due to the loss of activity of the transport system by which it enters the bacterial cytoplasm.

Mechanism of imipenem resistance acquired by three Pseudomonas aeruginosa strains during imipenem therapy

Imipenem sensitive pretherapy isolates (MICs 1-2 mg/l) and the corresponding resistant posttherapy isolates (MICs 16 mg/l) of Pseudomonas aeruginosa from three patients undergoing imipenem treatment were analyzed to establish the resistance mechanism. The identity of pyocin types, serotypes, DNA restriction endonuclease profiles and plasmid profiles strongly suggested isogenicity of pre- and posttherapy isolates. The imipenem resistant posttherapy isolates showed cross-resistance only to another carbapenem, meropenem. There were neither qualitative nor quantitative differences between pre- and posttherapy isolates in beta-lactamase production. Affinity of the penicillin-binding proteins 1A, 1B, 2, 3, 4,4' and 5 for [14C]imipenem was the same in pre- and posttherapy isolates. One-dimensional and two-dimensional gel electrophoresis of outer membrane protein preparations showed diminished expression of an outer membrane protein of about 46.5 and 47.5 kilodaltons, respectively, in the posttherapy isolates. This protein had an apparent isoelectric point of about pH 5.2 in two-dimensional gel electrophoresis. Growth in proteose peptone no. 2 broth did not reduce expression of this outer membrane protein, which spoke against its identity with the outer membrane protein D1. The permeability of the outer membrane for imipenem was reduced in the posttherapy isolates, since addition of 0.5 or 0.25 of the MIC of the permeabilizing agent ethylene-diaminetetraacetate reduced the MICs of imipenem for all isolates from each patient to the same (susceptible) level. The diminished expression of one of the outer membrane proteins might be the reason for this reduced permeability.

Isolation and characterization of a human monoclonal antibody that recognizes epitopes shared by Pseudomonas aeruginosa immunotype 1, 3, 4, and 6 lipopolysaccharides

A hybridoma line secreting a human monoclonal antibody (HMAb) capable of recognizing Fisher immunotype (IT) 1, 3, 4, and 6 lipopolysaccharide (LPS) in vitro was isolated. Peripheral blood lymphocytes (PBL) were obtained from volunteers immunized with an experimental Pseudomonas aeruginosa O polysaccharide-toxin A vaccine. PBL-expressing surface antibodies able to bind to P. aeruginosa LPS were isolated by adsorption onto LPS-coated plastic wells. Such PBL were transformed with Epstein-Barr virus. Lymphoblastoid cell lines secreting anti-P. aeruginosa LPS antibodies were identified by an enzyme-linked immunosorbent assay and fused to the F3B6 heteromyeloma line. A hybridoma line producing a HMAb (2-8AH79) able to bind IT-1, IT-3, IT-4, and IT-6 LPS was identified by an enzyme-linked immunosorbent assay. This HMAb was found to bind to the O-polysaccharide regions of IT-1, IT-3, IT-4, and IT-6 LPS, as determined by immunoblotting. By using an immunofluorescence microscopy assay, the cell surfaces of IT-3 and IT-4 bacteria were strongly stained by HMAb 2-8AH79, whereas those of IT-1 and IT-6 bacteria were weakly stained. This HMAb was found to promote the uptake and killing of IT-3 and IT-4 bacteria, but not IT-1 or IT-6 organisms, by human polymorphonuclear leukocytes. Similarly, the passive transfer of HMAb 2-8AH79 to mice afforded significant protection only against a challenge with IT-3 and IT-4 bacteria.

Intravenous/oral ciprofloxacin therapy versus intravenous ceftazidime therapy for selected bacterial infections

The efficacy and toxicity of sequential intravenous and oral ciprofloxacin therapy was compared with intravenously administered ceftazidime in a prospective, randomized, controlled, non-blinded trial. Thirty-two patients (16 patients receiving ciprofloxacin and 16 patients receiving ceftazidime) with 38 infections caused by susceptible Pseudomonas aeruginosa, enteric gram-negative rods, Salmonella group B, Serratia marcescens, Pseudomonas cepacia, and Xanthomonas maltophilia at various sites were evaluable for determination of efficacy. Length of therapy varied from seven to 25 days. Concomitant antimicrobials included intravenously administered beta-lactams for gram-positive organisms, intravenous/oral metronidazole and clindamycin for anaerobes, and intravenous/local amphotericin B for Candida albicans. Intravenous administration of 200 mg ciprofloxacin every 12 hours to 11 patients produced peak serum levels between 1.15 and 3.12 micrograms/ml; trough levels ranged between 0.08 and 0.86 micrograms/ml. Overall response rates were similar for patients receiving ciprofloxacin and ceftazidime. Emergence of resistance was similar in both groups--one Enterobacter cloacae and two P. aeruginosa became resistant after ciprofloxacin therapy and two P. aeruginosa became resistant after ceftazidime therapy. The frequency of superinfection with a variety of organisms was also similar in both groups. Adverse events related to ciprofloxacin included transient pruritus at the infusion site and generalized rash leading to drug discontinuation (one patient each), and with ceftazidime adverse effects included pain at the site of infusion and the development of allergic interstitial nephritis (one patient each). Overall, intravenous/oral ciprofloxin therapy appears to be as safe and effective as intravenous ceftazidime therapy in the treatment of a variety of infections due to susceptible aerobic gram-negative organisms.

Activity of cefepime against ceftazidime- and cefotaxime-resistant gram-negative bacteria and its relationship to beta-lactamase levels

One hundred clinical isolates resistant to ceftazidime and/or cefotaxime were examined for susceptibility to cefepime. The most frequently encountered ceftazidime-cefotaxime-resistant strains belonged to the genera Enterobacter, Pseudomonas, and Citrobacter. Among these strains, 92% were resistant to cefoperazone, 91% were resistant to cefotaxime, 84% were resistant to ceftazidime, and 6% were resistant to cefepime. Of the members of the family Enterobacteriaceae, 57% were resistant to ceftriaxone. The six strains resistant to cefepime were all Pseudomonas aeruginosa and were resistant to both cefotaxime and ceftazidime. Cefepime-resistant P. aeruginosa strains had exceptionally high levels of beta-lactamase activity, higher than the levels found in strains resistant to ceftazidime but susceptible to cefepime. The beta-lactamases from the cefepime-resistant strains were type I (Richmond-Sykes), were constitutively produced, and did not have increased affinity or hydrolytic activity for cefepime. Thus, cefepime was active against most gram-negative bacteria which have developed resistance to the broad-spectrum cephalosporins, and resistance to cefepime in P. aeruginosa appears to be associated with higher beta-lactamase levels than in cefepime-susceptible strains.

Permeability to cefsulodin of the outer membrane of Pseudomonas aeruginosa and discrimination between beta-lactamase-mediated trapping and hydrolysis as mechanisms of resistance

A pair of strains of Pseudomonas aeruginosa (3-Pre: cefsulodin-sensitive, inducible beta-lactamase; and 3-Post: cefsulodin-resistant, elevated beta-lactamase, derived from 3-Pre by subculture in the presence of cefsulodin) were taken as representative of the class of bacteria resistant to third-generation cephalosporins due to elevated synthesis of the normally inducible, chromosomally encoded beta-lactamase. These two strains were used to differentiate between 'trapping' and 'hydrolytic' mechanisms of cefsulodin resistance by (a) measuring the outer-membrane permeabilities to cefsulodin, (b) measuring the kinetics of cefsulodin hydrolysis and the stoichiometry of cefsulodin trapping by the periplasmic beta-lactamase, and (c) comparing the predictions of the trapping and hydrolysis hypotheses with the minimum inhibitory concentrations (MIC) of cefsulodin. The MIC of cefsulodin for strains 3-Pre and 3-Post were 2.35 microM (1.25 micrograms ml-1) and 37.6 microM (20.0 micrograms ml-1) respectively. The permeability parameter for cefsulodin of the outer membrane of the resistant strain was 0.0034 cm3 min-1 mg dry mass-1, so the flux of cefsulodin across its outer membrane at the MIC was calculated to be 0.120 nmol min-1 mg dry mass-1. Hydrolysis of cefsulodin by the beta-lactamase in the periplasm occurred at a rate of 0.118 nmol min-1 mg dry mass-1 which can thus account for resistance by matching the above rate of inflow. Trapping by the beta-lactamase, even with a 1:1 stoichiometry, would require the enzyme to be synthesized at 5.0 micrograms protein min-1 mg dry mass-1 or about 40% of the dry mass/generation. We conclude that hydrolysis, but not trapping, adequately explains the resistance to cefsulodin in P. aeruginosa 3-Post. A similar calculation for latamoxef resistance, using data taken from the literature, led to the same conclusion.

The efficacy results and safety profile of imipenem/cilastatin from the clinical research trials

Imipenem/cilastatin is highly effective for infections in many body sites against a broad range of gram-positive and gram-negative aerobic and anaerobic bacteria. During therapy, development of resistance is uncommon except in the case of Pseudomonas aeruginosa in which the incidence appears similar to that for other beta-lactam antibiotics. There appears to be a very low probability of cross-resistance. The clinical and laboratory adverse reactions are similar in type to those for other beta-lactam antibiotics. The frequency of colonization and superinfection during treatment with imipenem/cilastatin has been comparable to other antibiotics in comparative trials and to literature reports for other antibiotics for noncomparative trials.

Bactericidal interactions of a beta-lactam and beta-lactamase inhibitors in experimental Pseudomonas aeruginosa endocarditis caused by a constitutive overproducer of type Id beta-lactamase

We investigated the in vitro and in vivo effects of a combination of a beta-lactam (ceftazidime) and a beta-lactamase inhibitor (dicloxacillin) to synergistically kill a ceftazidime-resistant variant, Pseudomonas aeruginosa PA-48, which overproduces type Id cephalosporinase constitutively. In vitro, dicloxacillin plus ceftazidime exerted bactericidal synergy at approximately 10(5) CFU/ml of inoculum (but not at approximately 10(7)-CFU inoculum), whereas other beta-lactamase inhibitors (sulbactam, clavulanic acid) showed no enhanced killing of PA-48 when combined with ceftazidime at clinically achievable levels for each agent. Dicloxacillin was a potent competitive inhibitor of the extracted Id cephalosporinase from strain PA-48 in short-term comixture studies (less than 10 min [Ki = 2 nM]); in contrast, longer-term comixture studies (90 min) indicated that dicloxacillin functions as a competitive substrate for the enzyme. Growth of PA-48 cells in the presence of dicloxacillin (12.5 to 100 micrograms/ml) had no significant effect on the production rates or functional activity of the Id enzyme. In experimental aortic valve endocarditis due to the ceftazidime-resistant variant (PA-48), rabbits received either no therapy, ceftazidime (25 mg/kg intramuscularly, every 4 h), or ceftazidime plus dicloxacillin (200 mg/kg intramuscularly, every 4 h). The combination regimen reduced mean bacterial densities of PA-48 within cardiac vegetations significantly below those in the other groups at both days 3 and 6 of treatment (P less than 0.005). However, mean vegetation bacterial densities remained greater than 6 log10 CFU/g in the combined treatment group. This modest in vivo synergistic effect (as compared to striking in vitro synergy at approximately 10(5)-CFU inoculum) most likely reflects the high densities of PA-48 achieved in vivo within cardiac vegetations (greater than 8 log10 CFU/g).

Selection and properties of Pseudomonas aeruginosa variants resistant to beta-lactam antibiotics

The relation between basal and inducible beta-lactamase production and resistance to beta-lactam compounds was studied in five clinical Pseudomonas aeruginosa isolates and their corresponding resistant variants selected in the presence of either piperacillin, ceftazidime or aztreonam. In all wild-type strains enzyme levels were barely detectable in the uninduced state and most beta-lactams, including sulbactam and clavulanic acid, exhibited poor induction potency. Imipenem proved to be the most potent inducer in both these strains and their resistant variants. In the variants selected by either piperacillin or ceftazidime enzyme production amounted to 1.28 units/mg protein of the cell-free supernatants following the addition of beta-lactams as inducers. Additionally, these variants exhibited the phenomenon of "non-specific" induction, i.e. the increase of enzyme production by either a complex nutrient medium or by addition of vitamins. Enzyme production in the aztreonam-resistant variants was identical to that in the wild-type strains with a single exception, where the entire derepression of beta-lactamase production in one of the variants took place. Derepression of the chromosomally mediated enzyme affects the susceptibility to ureidopenicillins more than that to carboxy-penicillins and cephalosporins, whereas the beta-lactamase-independent resistance results in increased resistance to all beta-lactams with the single exception of imipenem.

Vaccine potential of Pseudomonas aeruginosa O-polysaccharide-toxin A conjugates

Serologically reactive O-polysaccharide from nine serotypes of Pseudomonas aeruginosa were covalently linked to toxin A via reductive amination, with adipic acid dihydrazide serving as a spacer molecule. The conjugates were composed of toxin A/O-polysaccharide ratios ranging from 1.17:1 to 3:1. All possessed an average Mr of greater than 10(6), were devoid of ADP ribosyltransferase activity associated with toxin A, and were nontoxic for mice and guinea pigs. The conjugates were stable from toxic reversion when stored at 37 degrees C for 28 days. The conjugation condition used preserved a substantial proportion of critical epitopes on the toxin A molecule as shown by the ability of toxin A-neutralizing monoclonal antibodies to react with the various conjugates. All nine conjugates were capable of evoking an antitoxin A and an antilipopolysaccharide immunoglobulin G (IgG) response in mice and rabbits. Rabbit antitoxin A IgG was capable of neutralizing the cytotoxic effect of toxin A, whereas mice immunized with any of the conjugates were protected against toxin A intoxication. Rabbit anti-conjugate IgG, when passively transferred to mice, was highly effective at preventing fatal P. aeruginosa burn wound sepsis.

Outbreak of cephalosporin resistant Enterobacter cloacae infection in a neonatal intensive care unit

Enterobacter cloacae resistant to third generation cephalosporins emerged rapidly during an outbreak of serious infections due to this organism in a neonatal intensive care unit where ampicillin and gentamicin were used as first line antibiotic treatment. Organisms resistant to cephalosporins were isolated from 12 infants, six of whom developed systemic infection. Two infants died. Isolates of E. cloacae from four of five infants treated with cefotaxime showed a loss of sensitivity to this antibiotic during treatment, but in the three infants who survived sensitive organisms were again isolated after treatment had stopped. Stopping treatment with the cephalosporins, closure of the unit to new admissions, and strict cohorting of colonised infants resulted in a prompt end to the outbreak. This outbreak suggests that the routine use of third generation cephalosporins for suspected sepsis may be inappropriate in the presence of a large reservoir of organisms with the potential for rapidly developing resistance. Routine bacteriological surveillance, however, might permit their use on a rotational basis.

Role of beta-lactamase in in vivo development of ceftazidime resistance in experimental Pseudomonas aeruginosa endocarditis

Two ceftazidime-resistant variants of Pseudomonas aeruginosa (PA-48, PA-60), obtained from cardiac vegetations of rabbits with endocarditis receiving ceftazidime therapy, were studied for mechanisms of resistance. Both resistant variants were stably derepressed for the type Id beta-lactamase, which was ceftazidime inducible in the parental strain (PA-96) used to initially infect the rabbits. There was no evidence of ceftazidime bioinactivation by the resistant strains, and their outer membrane permeabilities were comparable to those of the parental strain. No alterations were observed in patterns of outer membrane proteins or membrane lipopolysaccharides in the resistant variants as compared with the parental strain. Penicillin-binding protein patterns of the resistant variants revealed the absence of penicillin-binding protein 4 in both, with acquisition of a new protein of higher apparent molecular weight in PA-60. Calculation of the rate of appearance of ceftazidime in the periplasm at sub-MICs suggested that slow enzymatic hydrolysis of the beta-lactam, rather than nonhydrolytic trapping, was the major explanation for the induced resistance in vivo in strains PA-48 and PA-60.

Mechanisms of resistance to cephalosporin antibiotics

Cephalosporins, like other beta-lactams, bind to the bacterial penicillin-binding proteins (PBPs). These correspond to the D-ala-D-ala trans-, carboxy- and endo-peptidases responsible for catalysing the cross-linking of newly formed peptidoglycan. Resistance arises when the PBPs-and particularly the transpeptidases-are modified, or when they are protected by beta-lactamases or 'permeability barriers'. Target-mediated cephalosporin resistance can involve either reduced affinity of an existing PBP component, or the acquisition of a supplementary beta-lactam-insensitive PBP. beta-lactamases are produced widely by bacteria and may be determined by chromosomal or plasmid DNA. The chromosomal beta-lactamases are species-specific, but can be classified into a few broad groups. The plasmid-mediated enzymes cross interspecific and intergeneric boundaries. The level of beta-lactamase-mediated resistance relates to the amount of enzyme produced with or without induction; to the location of the enzyme (extracellular for Gram-positive organisms and periplasmic in Gram-negative ones); and to the kinetics of the enzyme's activity. In Gram-positive organisms the PBPs are located on the outer aspect of the cytoplasmic membrane and so shielding by permeability barriers is minimal. In Gram-negative cells, however, the PBPs are protected by the outer membrane, which most beta-lactams cross by diffusion through aqueous pores composed of 'porin' proteins. In enterobacteria, a clear correlation exists between porin quantity and cephalosporin resistance, suggesting that the outer membrane is the sole barrier to drug entry. Such relationships are less clear for Pseudomonas aeruginosa, where the cell may contain additional barriers between the outer membrane and the PBPs. Although elevated cephalosporin resistance often is attributed to a single factor (PBP-modification, beta-lactamase action or impermeability) an organism's response to a drug often reflects the interplay of several factors. Mathematical models can be proposed to describe this interplay.

Differences in drug susceptibility between isolates of Pseudomonas cepacia recovered from patients with cystic fibrosis and other sources and its relationship to beta-lactamase focusing pattern

Pseudomonas cepacia, a significant pulmonary pathogen among children with cystic fibrosis (CF), often possesses an inducible beta-lactamase. The beta-lactamase isoelectric focusing pattern and beta-lactam susceptibility of CF and non-CF isolates of P. cepacia were compared. Against all of the test strains, ceftazidime and piperacillin were more effective than aztreonam. More CF isolates were resistant to 8 micrograms/ml of ceftazidime than non-CF isolates. Isoelectric focusing of cefoxitin-induced, cell-free preparations of the CF isolates produced significantly more bands than comparable preparations of non-CF isolates. Organisms producing a beta-lactamase band that focused in the pH range of 8.5 to 8.7 were significantly more resistant to 8 micrograms/ml of ceftazidime than other isolates. The increased resistance of CF isolates of P. cepacia to ceftazidime may be the result of the production of a specific bacterial beta-lactamase.

Evidence for multiple forms of type I chromosomal beta-lactamase in Pseudomonas aeruginosa

The multiple stages of derepression of the type I chromosomal beta-lactamase in Pseudomonas aeruginosa were examined. Mutants partially and fully derepressed for beta-lactamase were selected from a wild-type clinical isolate. An analysis of the beta-lactamase produced by these mutants and the induced wild type revealed significant differences in the products of derepression at each stage. Beta-lactamase produced by the fully derepressed mutant showed a lower affinity (Km, 0.113 mM) for cephalothin than that produced by the partially derepressed mutant (Km, 0.049 mM). However, due to a very large Vmax, the former possessed a much greater hydrolytic efficiency. Differences in substrate profile were also noted. Only beta-lactamase from the fully derepressed mutant hydrolyzed cefamandole, cefoperazone, and cefonicid. The partially derepressed mutant possessed a single beta-lactamase band with a pI of 8.4. The fully derepressed mutant possessed this band and an additional major band with a pI of 7.5. Induction of the wild type with cefoxitin produced both bands. The changes in physiologic parameters of the enzymes produced in the different stages of derepression suggest a complex system for beta-lactamase expression in P. aeruginosa. This may involve at least two distinct structural regions, each of which is under control of the same repressor.

Emergence of resistance in gram-negative bacteria: a risk of broad-spectrum beta-lactam use

A number of new beta-lactam antibiotics have been developed to overcome bacterial resistance to older agents. Such resistance usually is caused by plasmid-mediated, constituently produced beta-lactamases. Second- and third-generation cephalosporins, ureidopenicillins, acylamino penicillins, and monobactams generally are resistant to hydrolysis by these enzymes. However, inducible beta-lactamases may confer resistance to these antibiotics. This induction may occur spontaneously or in response to cefoxitin or other beta-lactam agents. The mechanisms by which inducible enzymes produce this resistance are reviewed and implications for the prophylactic and therapeutic use of newer beta-lactams are considered.

Pseudomonas aeruginosa immunotype 5 polysaccharide-toxin A conjugate vaccine

Polysaccharide (PS) derived from Pseudomonas aeruginosa immunotype 5 lipopolysaccharide was covalently coupled to toxin A by reductive amination with adipic acid dihydrazide as a spacer molecule. The resulting PS-toxin A conjugate was composed of 27.5% PS and 72.5% toxin A. The conjugate was composed of heterogeneous high-molecular-weight species, all of which possessed an Mr greater than 670,000. The conjugate was nontoxic for mice and nonpyrogenic at a dose of 50 micrograms/kg of body weight when intravenously administered to rabbits. Immunization of rabbits with the conjugate evoked both an antilipopolysaccharide immunoglobulin G (IgG) and an anti-toxin A IgG response. Anticonjugate IgG was capable of neutralizing the cytotoxic effect of toxin A. Immunization of mice with the conjugate increased the mean lethal dose from 4.5 X 10(1) P. aeruginosa for control mice to 9.6 X 10(5) P. aeruginosa for vaccinated mice. Similarly, immunization raised the mean lethal dose for toxin A from 0.2 to 4.67 micrograms per mouse.

Ceftazidime in the treatment of serious Pseudomonas aeruginosa sepsis

28 patients with serious Pseudomonas aeruginosa sepsis were enrolled into a prospective open study using ceftazidime (CAZ). 10 patients had rapidly fatal underlying pathology, including 5 neutropenic (neutrophils less than 1.0 X 10(9)/l) patients with malignancy. 9 patients including all those with neutropenia also received concomitant therapy with other active antipseudomonal antibiotics (mainly aminoglycosides). All isolates were initially sensitive to CAZ. A favourable response was seen in 18/27 (67%) evaluable cases. Genitourinary infection and osteomyelitis responded well with 100% and 83% favourable responses respectively. Soft tissue and respiratory tract infection responded less well. Results with biliary sepsis were disappointing (all 3 failed therapy). Of the 9 patients failing treatment 5 responded to alternative antibiotics (usually combination therapy of ureidopenicillin plus aminoglycoside). 2 died primarily from underlying pathology and 2 as a direct result of Ps. aeruginosa sepsis. Toxicity was minimal. In the few cases observed other agents and underlying pathology possibly contributed. The most disturbing feature of the study was the emergence of multiple beta-lactam resistance in organisms whilst treated with CAZ. 5 cases occurred, 4 in the infected strain and 1 in a superinfecting strain, occurring in 4 patients within 10 days of starting therapy. 2 cases occurred in patients receiving concomitant aminoglycosides.

In vitro activity of ceftazidime in combination with other antibiotics

189 bacterial strains were investigated for their in vitro sensitivity against ceftazidime (alone and in combination with another antibiotic). Moreover, the possibility to prevent development of secondary bacterial resistance as observed in subcultures at subinhibitory antibiotic concentrations, was studied using specific antibiotic combinations. Of 115 staphylococcal strains (91 strains of Staphylococcus aureus, 24 strains of Staphylococcus epidermidis), 2% were sensitive, 82% were moderately sensitive and 16% were resistant to ceftazidime. On combining ceftazidime with vancomycin, synergism was found in 61% of the strains, and secondary resistance to ceftazidime could be prevented with this combination. The combination of ceftazidime and clindamycin showed synergism in 26% and an additive effect in 48% of the strains. Secondary resistance to ceftazidime did not develop with this combination in subcultures at subinhibitory concentrations in which loss of activity was only minimal with clindamycin alone. Rifampicin and fusidic acid were highly active against staphylococci. In combination with ceftazidime, only weak synergism or additive effects were seen in most strains; no antagonism could be observed. In subcultures at subinhibitory concentrations, secondary resistance to rifampicin and fusidic acid developed rapidly and could be partially prevented by adding ceftazidime. Of 60 Pseudomonas aeruginosa strains, 84% were sensitive, 13% were moderately sensitive and 2% were resistant to ceftazidime. Synergism was most frequently observed when ceftazidime was combined with tobramycin. Using this combination, secondary resistance of Pseudomonas strains to ceftazidime did not develop. When ceftazidime was combined with piperacillin, synergism was observed in most strains, but the development of secondary resistance in vitro was not prevented.(ABSTRACT TRUNCATED AT 250 WORDS)

Antimicrobial combinations in the therapy of infections due to gram-negative bacilli

Antimicrobial combinations are used most frequently to provide broad-spectrum coverage; however, they are also frequently employed to enhance antimicrobial activity (synergism). Although there is extensive in vitro documentation of synergism for many antibiotic combinations, a clear advantage for these combinations has been difficult to demonstrate in clinical studies. Several types of combinations have been useful in clinical medicine and frequently result in synergism. These include combinations of a cell wall-active agent with an aminoglycosidic aminocyclitol, combinations of a beta-lactamase inhibitor with a beta-lactam, and combinations of agents that inhibit sequential steps in a metabolic pathway. Given its spectrum of activity, aztreonam will often be used with clindamycin or a beta-lactam antibiotic. Combinations of beta-lactams may be synergistic via several mechanisms. However, these combinations also exhibit significant potential for antagonism when used against gram-negative bacilli and, therefore, require careful evaluation prior to clinical use.

Recognition and clinical significance of mechanisms of bacterial resistance to beta-lactams

Resistance to beta-lactams may be difficult to recognize. This is due to the difficulty in detecting these resistances, when the routine tests performed in diagnostic laboratories are interpreted in the usual manner. Since failure to recognize this type of resistance may have serious consequences for the patient, it is essential that it be detected when present. For the detection of methicillin resistance of Staphylococcus aureus a standardized method using either a medium containing 5% NaCl or a low incubation temperature is advocated. Methicillin resistance of S. epidermidis can only be recognized reliably by means of a quantitative test and incubation for 42-48 h. Resistance of Haemophilus influenzae to ampicillin may be intrinsic or it may be caused by a TEM beta-lactamase; a beta-lactamase test should be used to detect the latter type of resistance. Inducible cephalosporinase may be responsible for the rapid development of resistance of some bacterial species to cefamandole, even during therapy. If a stable beta-lactamase production is attained by mutation, resistance to other beta-lactams will usually be present as well. Routine induction tests should be performed for all isolates of species of Enterobacter, Serratia, Citrobacter and Proteus, indole-positive. The same type of 'hidden' resistance may be present in Pseudomonas aeruginosa, with regard to cefotaxime and other third-generation cephalosporins. Beta-lactamase-positive Neisseria gonorrhoeae can easily be recognized by a beta-lactamase test. In addition, the results of diffusion tests allow one to distinguish between beta-lactamase-positive and beta-lactamase-negative strains. Recognition of those strains of N. gonorrhoeae having a decreased susceptibility to penicillin is only possible when well-standardized quantitative tests are used.