Changing patterns of plasmid-mediated drug resistance during tetracycline therapy

Tetracycline use in the community may promote decreased susceptibility to quinolones in Escherichia coli isolates

We previously found that the hospital use of tetracyclines is associated with quinolone resistance in hospital isolates of Enterobacteriaceae. Tetracyclines are heavily used in the community. Our aim was to assess whether their use in the community favors quinolone resistance in community isolates of Escherichia coli. Monthly data of community antibiotics use and E. coli quinolone resistance in a 1.3 million inhabitant French area were obtained from 2009 to 2014, and were analyzed with autoregressive integrated moving average (ARIMA) models. Quinolone use decreased from 10.1% of the total antibiotic use in 2009 to 9.3% in 2014 (trend, - 0.016; p-value < 0.0001), while tetracycline use increased from 16.5% in 2009 to 17.1% in 2014 (trend, 0.016; p < 0.0001). The mean (95% confidence interval) monthly proportions of isolates that were non-susceptible to nalidixic acid and ciprofloxacin were 14.8% (14.2%-15.5%) and 9.5% (8.8%-10.1%), respectively, with no significant temporal trend. After adjusting on quinolone use, tetracycline use in the preceding month was significantly associated with nalidixic acid non-susceptibility (estimate [SD], 0.01 [0.007]; p-value, 0.04), but not with ciprofloxacin non-susceptibility (estimate [SD], 0.01 [0.009]; p-value, 0.23). Tetracycline use in the community may promote quinolone non-susceptibility in E. coli. Decreasing both tetracycline and quinolone use may be necessary to fight against the worldwide growth of quinolone resistance.

High consumption of tetracyclines for acne treatment among young Danish adults

BACKGROUND

Tetracyclines are used as acne treatment in adolescents worldwide. A large increase in the consumption of antimicrobial agents in Danish primary health care was recently linked to high levels of tetracycline use in adolescents.

METHODS

Here we closely examine how demographic factors influenced tetracycline use from 2005 to 2014 using consumption data from primary health care expressed as defined daily doses (DDDs) per 1000 inhabitants per day (DID) and number of persons treated per 1000 inhabitants.

RESULTS

From 2005 to 2013, tetracycline consumption increased by 54% followed by a decrease of 14% in 2014. Increases were especially pronounced in persons aged 15-39 years where nearly 9000 additional persons were treated with tetracyclines.

CONCLUSIONS

This study shows a long-lasting high consumption of tetracyclines in young Danes with a notable recent decrease breaking the otherwise worrying trend. To obtain a further decrease, focus on public awareness and suitable acne treatment guidelines are highly important.

The association between demographic factors and increased antibiotic consumption in Denmark 2001 to 2010

From 2001 to 2010, the consumption of antibiotics in Denmark increased by 32%. The objective of this study was to investigate the potential demographic factors associated with this increase. Defined daily doses (DDD) per 1000 inhabitant-days for the leading antibiotic groups and substances in primary health care in 2001 and 2010 were adjusted for population size and compared between and within age groups and genders. An increased antibiotic consumption was observed for all age groups between 2001 and 2010. Particular age-specific increases in the consumption of tetracyclines, extended-spectrum penicillins, and amoxicillin/clavulanic acid were observed. The generally increased consumption of antibacterial agents in the Danish population during the past decade was driven by people older than 65 y and, to a lesser extent, those aged 20-39 y. Evidence suggests that this increase may reflect general practitioners prescribing more antibiotics per visit and in larger doses.

Antimicrobial resistance and antimicrobial resistance genes in marine bacteria from salmon aquaculture and non-aquaculture sites

Antimicrobial resistance (AR) detected by disc diffusion and antimicrobial resistance genes detected by DNA hybridization and polymerase chain reaction with amplicon sequencing were studied in 124 marine bacterial isolates from a Chilean salmon aquaculture site and 76 from a site without aquaculture 8 km distant. Resistance to one or more antimicrobials was present in 81% of the isolates regardless of site. Resistance to tetracycline was most commonly encoded by tetA and tetG; to trimethoprim, by dfrA1, dfrA5 and dfrA12; to sulfamethizole, by sul1 and sul2; to amoxicillin, by blaTEM ; and to streptomycin, by strA-strB. Integron integrase intl1 was detected in 14 sul1-positive isolates, associated with aad9 gene cassettes in two from the aquaculture site. intl2 Integrase was only detected in three dfrA1-positive isolates from the aquaculture site and was not associated with gene cassettes in any. Of nine isolates tested for conjugation, two from the aquaculture site transferred AR determinants to Escherichia coli. High levels of AR in marine sediments from aquaculture and non-aquaculture sites suggest that dispersion of the large amounts of antimicrobials used in Chilean salmon aquaculture has created selective pressure in areas of the marine environment far removed from the initial site of use of these agents.

Ecological impact of doxycycline at low dose on normal oropharyngeal and intestinal microflora

This study included 34 healthy volunteers (16 male and 18 female) aged 19-37 years, of whom 17 received doxycycline 40 mg capsules orally once daily (o.d.) and 17 received placebo 40 mg capsules orally o.d. for 16 weeks. Plasma, saliva and faecal samples were collected before drug administration and at 4, 8, 16 and 20 weeks. Plasma samples were assayed for doxycycline concentrations, and saliva and faecal samples were investigated for doxycycline concentrations and microbiological analyses. Plasma concentrations of doxycycline in the doxycycline group were as follows: baseline visit (2 h), 0.20-0.61 mg/L; 4-week visit, 0.30-1.04 mg/L; 8-week visit, 0.43-1.49 mg/L; 16-week visit, 0.32-1.12 mg/L; and 20-week visit 0 mg/L. No doxycycline was detected in plasma in the placebo group. No doxycycline concentrations in the saliva samples were found in the doxycycline or placebo groups at the five visits. Faecal concentrations of doxycycline in the doxycycline group were as follows: baseline visit, 0 mg/kg; 4-week visit, 0-3.71 mg/kg; 8-week visit, 0-1.85 mg/kg; 16-week visit, 0-4.10 mg/kg; and 20-week visit, 0 mg/kg. No doxycycline faecal concentrations were detected in the placebo group. Minor effects on the aerobic and anaerobic oropharyngeal microflora were observed both in the doxycycline and placebo groups. There were minor changes in the number of enterococci and Escherichia coli in the doxycycline and placebo groups. The anaerobic intestinal microflora in the doxycycline and placebo groups was not changed, and no Clostridium difficile strains were isolated.

Risk factors for antibiotic-resistant Escherichia coli carriage in young children in Peru: community-based cross-sectional prevalence study

Few studies have examined the influence of individual-, household-, and community-scale risk factors on carriage of resistant commensal bacteria. We determined children's medical, agricultural, and environmental exposures by household, pharmacy, and health facility surveys and Escherichia coli cultures of children, mothers' hands, household animals, and market chickens in Peru. Among 522 children with a positive stool culture, by log-binomial regression, using "any antibiotic" and 1-14 (versus 0) sulfa doses in the past 3 months increased children's risk, respectively, for ampicillin- and sulfamethoxazole-resistant E. coli carriage (P = 0.01-0.02). Each household member taking "any antibiotic" increased children's risk for sulfamethoxazole- and multidrug-resistant E. coli carriage (P < 0.0001). Residence in a zone where a larger proportion of households served home-raised chicken (as contrasted with intensively antibiotic-raised market chicken) protected against carrying E. coli resistant to all drugs (P = 0.0004-0.04). Environmental contamination with drug-resistant bacteria appeared to significantly contribute to children's carriage of antibiotic-resistant E. coli.

Antibiotic resistance characteristics of environmental bacteria from an oxytetracycline production wastewater treatment plant and the receiving river

We characterized the bacterial populations in surface water receiving effluent from an oxytetracycline (OTC) production plant. Additional sampling sites included the receiving river water 5 km upstream and 20 km downstream from the discharge point. High levels of OTC were found in the wastewater (WW), and the antibiotic was still detectable in river water downstream (RWD), with undetectable levels in river water upstream (RWU). A total of 341 bacterial strains were isolated using nonselective media, with the majority being identified as Gammaproteobacteria. The MICs were determined for 10 antibiotics representing seven different classes of antibiotics, and the corresponding values were significantly higher for the WW and RWD isolates than for the RWU isolates. Almost all bacteria (97%) from the WW and RWD samples demonstrated multidrug-resistant (MDR) phenotypes, while in RWU samples, these were less frequent (28%). The WW and RWD isolates were analyzed for the presence of 23 tetracycline (tet) resistance genes. The majority of isolates (94.2% and 95.4% in WW and RWD, respectively) harbored the corresponding genes, with tet(A) being the most common (67.0%), followed by tet(W), tet(C), tet(J), tet(L), tet(D), tet(Y), and tet(K) (in the range between 21.0% and 40.6%). Class I integrons were detected in the majority of WW and RWD isolates (97.4% and 86.2%, respectively) but were not associated with the tet genes. We hypothesize that the strong selective pressure imposed by a high concentration of OTC contributes to the wide dissemination of tetracycline resistance genes and other antibiotic resistance genes, possibly through mobile genetic elements.

The role of tetracyclines in rosacea

There is a great deal of evidence to support the use of tetracycline and doxycycline in the treatment of papulopustular rosacea. Nevertheless, these agents have shared and unique adverse effects and relative contraindications. Recently, subantimicrobial-dose doxycycline was demonstrated to be an effective treatment for rosacea, due to its inherent anti-inflammatory properties. Furthermore, subantimicrobial-dose doxycycline has a more preferable tolerability profile and a lower occurrence of bacterial resistance than traditional-dose doxycycline. To further elucidate the role of tetracycline agents in rosacea, clinical trials that compare these agents with each other as well as with other effective rosacea treatments are called for. Adherence studies comparing oral tetracycline treatment with topical metronidazole treatment may also enhance clinical decision making.

Antibacterial resistance worldwide: causes, challenges and responses

The optimism of the early period of antimicrobial discovery has been tempered by the emergence of bacterial strains with resistance to these therapeutics. Today, clinically important bacteria are characterized not only by single drug resistance but also by multiple antibiotic resistance--the legacy of past decades of antimicrobial use and misuse. Drug resistance presents an ever-increasing global public health threat that involves all major microbial pathogens and antimicrobial drugs.

Use of Macrolides and Tetracyclines for Chronic Inflammatory Diseases

OBJECTIVE:

To review the efficacy of macrolides and tetracyclines in several chronic inflammatory conditions.

DATA SOURCES:

Searches of MEDLINE (1966–March 2004) and an extensive bibliography search were undertaken. Key terms included acne, blepharitis, cardiovascular disease, cystic fibrosis, periodontitis, rosacea, and rheumatoid arthritis.

STUDY SELECTION AND DATA EXTRACTION:

Data were obtained primarily from randomized placebo-controlled trials upon which key recommendations are based.

DATA SYNTHESIS:

Antibiotics are often prescribed for months or even years for treatment of chronic inflammatory conditions such as acne, blepharitis, cardiovascular disease, cystic fibrosis, periodontitis, rosacea, and rheumatoid arthritis. Randomized controlled trials have shown that azithromycin is useful in the management of cystic fibrosis and the tetracyclines are beneficial in the management of rheumatoid arthritis, acne, blepharitis, and periodontitis. Several large, randomized controlled trials have failed to show any benefit of macrolides in the secondary prevention of cardiovascular disease. No randomized placebo-controlled clinical trials have been performed to assess the efficacy of macrolides or tetracyclines in patients with rosacea.

CONCLUSIONS:

The use of tetracyclines and macrolides for rosacea is based primarily on anecdotal reports or open-label trials. Limited clinical trials support the use of tetracyclines or macrolides in acne, blepharitis, periodontitis, rheumatoid arthritis, and cystic fibrosis. Trials to date do not support the use of antibiotics for secondary prevention of cardiovascular disease.

The effects of antimicrobial acrylic strips on the subgingival microflora in chronic periodontitis

This study investigated the effects of root planing and/or the placement of acrylic strips containing chlorhexidine, metronidazole or tetracycline on the composition and antimicrobial susceptibility of the subgingival flora in chronic periodontitis. 101 periodontal pockets from 73 patients were entered into 6 treatment groups which were, chlorhexidine, metronidazole or tetracycline strips, root planing, root planing followed by metronidazole strips and a control, no treatment group. Total anaerobic counts and anaerobe/aerobe ratios were estimated from samples taken before treatment and 1, 2, 4, 8 and 12 weeks after treatment. In addition, a more detailed analysis of the effects of the treatments on the subgingival flora was carried out on 12 pockets in 12 patients. Tetracycline strips, metronidazole strips and root planing and metronidazole strips were more effective than chlorhexidine strips in causing reductions in total anaerobic count and anaerobe/aerobe ratio. However, the changes in microbial parameters rebounded to approach baseline levels 4 weeks after treatment. Chlorhexidine caused no detectable changes in the composition of the subgingival microflora, while metronidazole had a variable effect. Tetracycline appeared to effect major shifts in the composition of the microflora of treated pockets but caused a marked selection of tetracycline-resistant organisms.

Antibiotic availability and use: consequences to man and his environment

Antibiotics are the cornerstone of therapy for infectious diseases affecting people living worldwide. The ability of these agents to cure infections, with little if any harm to the host, has helped to propagate their designation as "miracle drugs". This idea has continued throughout the past four decades and into the present one. To a large extent, this concept has led to the inappropriate use of these agents. The consequence of this misuse affects not only the individuals taking antibiotics, but indirectly others who may subsequently need antibiotics, but find that the infecting pathogen is resistant. This phenomenon results from the strong selective environmental effect of these drugs for resistant bacteria. Resistant pathogens have emerged and spread worldwide. In response to this global health problem, the Alliance for the Prudent Use of Antibiotics was established. This international network of concerned prescribers and users aims to improve antibiotic use and eliminate inappropriate use worldwide. Prudent use of antibiotics will not only curtail health care costs and the potential side effects to the individual taking these drugs, but also diminish the wide ecologic effects leading to selection of antibiotic resistant forms of common disease-causing agents.

A simplified laboratory procedure to select an appropriate antibiotic for treatment of refractory periodontitis

THE FEASIBILITY OF USING A simplified laboratory procedure to select an appropriate antibiotic for treatment of refractory periodontitis was investigated. Six different antibiotics were added to commercially available CDC-agar plates. Plaque samples from periodontal pockets were inoculated onto the plates. The percentage kill was determined by comparing colony counts on the antibiotic-containing medium with those on the control plates. The three most effective antibiotics were ranked by visual inspection as well as by colony count. It was determined that visual inspection may be used to determine an effective antibiotic.

The resistance to anti-microbial agents of bacteria isolated from pathological conditions of birds in Victoria, 1978 to 1983

The resistance to anti-microbial agents of bacteria isolated from pathological conditions of birds in Victoria, 1978 to 1983, was determined for isolates of Escherichia coli, Salmonella species, Staphylococcus aureus, Pasteurella multocida, P. anatipestifer, Yersinia pseudotuberculosis and Haemophilus paragallinarum. The isolates of E. coli had a high prevalence of resistance to tetracycline and sulphonamides, and a lower prevalence of resistance to furazolidone and sulphamethoxazole-trimethoprim. The isolates of Salmonella spp commonly had resistance to tetracycline, sulphonamides, furazolidone and sulphamethoxazole-trimethoprim. Almost half the isolates of S. aureus showed resistance to lincomysin and many showed resistance to penicillin. Resistance to tetracycline was found in isolates of P. multocida, P. anatepestifer and Y. pseudotuberculosis. Some isolates of H. paragallinarum showed resistance to sulphonamides, streptomycin and sulphamethoxazole-trimethoprim.

Interventions for the control of diarrhoeal diseases among young children: chemoprophylaxis

A number of situations place young children at increased risk of diarrhoea. Among these, the best documented in developing countries is contact with a diarrhoea case in a family or household. The most common application of chemoprophylaxis in developing countries is to prevent cholera or shigellosis among household contacts of known cases. There is little evidence that chemoprophylaxis is effective in reducing diarrhoea morbidity and mortality, except perhaps in travellers. Theoretical calculations in this paper (based on optimistic assumptions) suggest that chemoprophylaxis of household contacts of known cholera cases in Bangladesh might reduce overall diarrhoea incidence rates in children under 5 years of age by 0.02-0.06% and diarrhoea mortality rates by 0.4-1.2%. Chemoprophylaxis of household contacts of known shigellosis cases might reduce overall diarrhoea incidence rates by 0.15-0.35% and diarrhoea mortality rates by 0.3-0.7% in the same age group. The correct identification of index cases of cholera and shigellosis, followed by the rapid distribution of drugs to their household contacts, requires skills and resources that are scarce in the developing countries. Chemoprophylaxis can contribute to the widespread emergence and dissemination of antimicrobial resistance. The available evidence suggests that chemoprophylaxis is not feasible in many settings and that, even if successfully implemented, it is not a cost-effective intervention for national diarrhoeal diseases control programmes.

Plasmid-mediated beta-lactam resistance of Escherichia coli isolated from travellers' diarrhoea in the Far East

The transfer of drug resistance and beta-lactamase activity of 28 E. coli from travellers' diarrhoea were examined. Plasmid-mediated beta-lactam resistance was found in 18 and at least 3 different types of beta-lactamases were demonstrated.

Emergence of high-level trimethoprim resistance in fecal Escherichia coli during oral administration of trimethoprim or trimethoprim--sulfamethoxazole

The effect of daily administration of trimethoprim (TMP), trimethoprim--sulfamethoxazole (TMP--SMX), or placebo on aerobically grown fecal gram-negative bacteria was monitored in 136 students from the United States during a two-week diarrhea-prevention study in Mexico. Unlike patients in other studies with these agents, who had urinary-tract infection or granulocytopenia, most persons in this study had no change in total fecal Enterobacteriaceae and had high-level TMP and SMX resistance in virtually all these strains. Escherichia coli was the predominant TMP-resistant organism isolated; 96 per cent of 165 TMP-resistant Esch. coli isolates were resistant to at least four antimicrobial agents, and 25 per cent were resistant to seven. TMP resistance was transferable in 40 ot 100 strains tested. Despite the lack of TMP resistance in other studies of prophylaxis, our results clearly demonstrate the remarkable capacity for emergence and dissemination of resistance to this agent.

Resistance to tetracycline, erythromycin, and clindamycin in the Bacteroides fragilis group: inducible versus constitutive tetracycline resistance

The transferability of plasmid-mediated tetracycline, erythromycin, and clindamycin resistance was studied in 63 clinical isolates of the Bacteroides fragilis group. Of 48 strains which were tetracycline resistant (Tcr), the regulation of both the expression of Tcr and its transferability was shown to be under inducible control by tetracycline. In 29 of the strains, Tcr was transferable; in the majority of these (26 strains), transferability was inducible (Trai) and it was constitutive (Trac) in only 3 strains. All four possible phenotypes were found (Tci Trai, Tci Trac, Tcc Trai, and Tcc Trac), which indicates independent control of both Tcr expression and its transferability. Resistance to erythromycin and clindamycin was cotransferred with Tcr in 14 of the 48 Tcr strains and transferred independently of Tcr in only 1 strain.

Subgingival microflora of periodontal patients on tetracycline therapy

Samples of subgingival plaque were collected from periodontal patients receiving two different tetracycline treatment regimens following conventional periodontal therapy. Four patients had received an oral dose of 1000 mg/day for 2 weeks and nine had received 1000 mg/day for 1 week followed by 250 mg/day for extended time periods. The latter regimen is similar so that commonly prescribed for the chronic skin disease, acne vulgaris. Taxonomic characterization of plaque isolates indicated that the predominant organisms cultured from both treatment groups were species of Streptococcus and the branching, filamentous Gram-positive rods, Actinomyces and Rothia. A much greater microbial complexity was observed among the flora isolated from patients taking 250 mg/day. The latter group harbored many of the fastidious Gram-negative organisms presently implicated in the etiology of periodontal disease. All bacterial strains isolated were tested for resistance to tetracycline by replica-plating cultures on an agar medium containing two-fold dilutions of the antibiotic. Streptococcus, Veillonella and Neisseria were the bacterial genera found to be consistently resistant to tetracycline, with minimum inhibitory concentrations as high as 128 micrograms/ml. Among the Actinomyces, selection for antibiotic resistance was common only within a single species, A. odontolyticus. However, A viscosus strains isolated at 54% of the subgingival flora from one patient did demonstrate an intermediate resistance level, growing on concentrations up to 8 micrograms/ml. Tetracycline resistance was shown by a variety of Gram-negative rods isolated from the low dosage group. Although a minimum number of patients were studied, extensive microbial analyses of the predominating subgingival bacteria indicated that the goal of tetracycline therapy was achieved during the 2-week therapy period at 1000 mg/day.

Isolation and characterization of multiply antibiotic-resistant Clostridum perfringens strains from porcine feces

Multiply antibiotic-resistant strains of Clostridium perfringens were isolated from porcine feces. Strains that were resistant to tetracycline, erythromycin, clindamycin, and lincomycin were isolated, but no penicillin- or chloramphenicol-resistant strains were obtained. Typical minimal inhibitory concentrations for resistant strains were 16 to 64 mug of tetracycline per ml, 64 to >128 mug of erythromycin per ml, >/=128 mug of lincomycin per ml, and 16 to 128 mug of clindamycin per ml. Resistance to erythromycin was always associated with resistance to lincomycin and clindamycin. Minimal inhibitory concentrations were determined for 258 strains from six farms that used antibiotics in their feeds and 240 strains from five farms that did not use antibiotics. The results show that 77.9 and 22.7% of the strains from the former farms were resistant to tetracycline and erythromycin-clindamycin-lincomycin, respectively. The comparable data from the latter farms were 25.0 and 0.8%, respectively. Agarose gel electrophoresis failed to reveal a plasmid band that was common to the resistant strains but absent in the susceptible strains. Attempts to transfer tetracycline, erythromycin, and clindamycin resistance from one strain, CW459, were not successful. Antibiotic-susceptible mutants were not isolated from this strain, despite the use of a variety of curing agents.