Properties of an R plasmid in Pseudomonas aeruginosa producing amikacin (BB-K8), butirosin, kanamycin, tobramycin, and sisomicin resistance

Amikacin: Uses, Resistance, and Prospects for Inhibition

Aminoglycosides are a group of antibiotics used since the 1940s to primarily treat a broad spectrum of bacterial infections. The primary resistance mechanism against these antibiotics is enzymatic modification by aminoglycoside-modifying enzymes that are divided into acetyl-transferases, phosphotransferases, and nucleotidyltransferases. To overcome this problem, new semisynthetic aminoglycosides were developed in the 70s. The most widely used semisynthetic aminoglycoside is amikacin, which is refractory to most aminoglycoside modifying enzymes. Amikacin was synthesized by acylation with the l-(-)-γ-amino-α-hydroxybutyryl side chain at the C-1 amino group of the deoxystreptamine moiety of kanamycin A. The main amikacin resistance mechanism found in the clinics is acetylation by the aminoglycoside 6'-N-acetyltransferase type Ib [AAC(6')-Ib], an enzyme coded for by a gene found in integrons, transposons, plasmids, and chromosomes of Gram-negative bacteria. Numerous efforts are focused on finding strategies to neutralize the action of AAC(6')-Ib and extend the useful life of amikacin. Small molecules as well as complexes ionophore-Zn⁺² or Cu⁺² were found to inhibit the acetylation reaction and induced phenotypic conversion to susceptibility in bacteria harboring the aac(6')-Ib gene. A new semisynthetic aminoglycoside, plazomicin, is in advance stage of development and will contribute to renewed interest in this kind of antibiotics.

Nosocomial outbreak of carbapenem-resistant Pseudomonas aeruginosa with a new bla(IMP) allele, bla(IMP-7)

Pseudomonas aeruginosa isolates from an outbreak in Canada were highly resistant to carbapenems and ceftazidime but not piperacillin. They produced a novel integron-associated metallo-beta-lactamase, designated IMP-7, with 91% identity to IMP-1. bla(IMP-7) was not detected with standard bla(IMP)-specific primers, owing to mismatches in the forward primer.

Appearance of amikacin and tobramycin resistance due to 4'-aminoglycoside nucleotidyltransferase [ANT(4')-II] in gram-negative pathogens

Following the use of amikacin as the principal aminoglycoside at a Denver hospital, amikacin resistance appeared first in Pseudomonas aeruginosa and then in Escherichia coli, Klebsiella pneumoniae, and other enteric organisms from debilitated and compromised patients who had spent time in intensive care units and who had been treated with multiple antibiotics, usually including amikacin. In a P. aeruginosa isolate, resistance to amikacin and tobramycin was transferable by the IncP-2 plasmid pMG77, while in E. coli and K. pneumoniae resistance was carried by the transmissible plasmids pMG220, pMG221, and pMG222 belonging to the IncM group. Isolates and transconjugants produced an enzyme with adenyltransferase activity with substrates having a 4'-hydroxyl group, such as amikacin, kanamycin, neomycin, Sch 21768, isepamicin (Sch 21420), or tobramycin, but not with aminoglycosides lacking this target, such as dibekacin, netilmicin, sisomicin, or gentamicin C components. Genes encoding the 4'-aminoglycoside nucleotidyltransferase [ANT(4')] activity were cloned from pMG77, pMG221, and pMG222. A DNA probe prepared from the ANT(4') found in P. aeruginosa hybridized with the ANT(4') determinant found in E. coli. A probe for the ANT(4') from Staphylococcal spp., which differs in its modification of substrates, like dibekacin, that have a 4"- but not a 4'-hydroxyl group, failed to hybridize with the gram-negative ANT(4') determinant, which consequently has been termed ANT(4')-II.

Transposon-mediated amikacin resistance in Klebsiella pneumoniae

A multiresistant Klebsiella pneumoniae strain isolated from neonates in Mendoza, Argentina, harbored a 48-kilobase-pair (kbp) plasmid, pMET1, with genetic determinants for resistance to amikacin and also ampicillin, kanamycin, streptomycin, and tobramycin. This plasmid was compared with pJHCMW1, a previously isolated 11-kbp plasmid carrying transposon Tn1331, which encodes resistance to amikacin, as well as ampicillin, kanamycin, streptomycin, and tobramycin, and which was originally present in a K. pneumoniae strain that caused an outbreak in a hospital in Buenos Aires, Argentina. The comparison demonstrated that the replication regions of the two plasmids are unrelated. However, in pMET1 an 11-kbp transposition element, Tn1331.2, was identified; it was closely related to Tn1331, with the difference that a 3-kbp BamHI DNA fragment carrying the aminoglycoside resistance genes was duplicated in tandem.

Cloning and sequencing of a gene encoding an aminoglycoside 6'-N-acetyltransferase from an R factor of Citrobacter diversus

The aacA1 gene, which encodes a 6'-N-acetyltransferase [AAC(6')-I] mediating resistance to kanamycin, tobramycin, and amikacin, was cloned from the Citrobacter diversus R plasmid pBWH100 into the Escherichia coli vector pBR322. The complete nucleotide sequence of the gene and flanking regions was determined. A protein of approximately 21 kilodaltons was identified when the chimeric plasmid encoding the aacA1 gene was introduced into E. coli maxicells. This value is consistent with the size predicted for a protein translated from the open reading frame of the gene.

Tn1331, a novel multiresistance transposon encoding resistance to amikacin and ampicillin in Klebsiella pneumoniae

A 7.5-kilobase-pair multiresistance transposon, Tn1331, harboring amikacin resistance was identified as part of Klebsiella pneumoniae plasmid pJHCMW1. Restriction mapping, hybridization, and transposition complementation experiments demonstrated that Tn1331 belongs to the Tn3 family. Its structure is similar to that of Tn3 with the insertion of a DNA fragment encoding resistance to amikacin, kanamycin, and tobramycin.

Molecular cloning of amikacin resistance determinants from a Klebsiella pneumoniae plasmid

A multiresistant Klebsiella pneumoniae strain, JHCK1, harbored several plasmids. One of these, plasmid pJHCMW1, carried determinants for resistance to amikacin in addition to kanamycin, tobramycin, and ampicillin. The amikacin resistance determinant(s) was cloned and studied by restriction mapping, insertion, and deletion analysis. The amikacin resistance gene(s) was localized in a 1.5-kilobase DNA fragment. This pJHCMW1 DNA region was responsible for not only the resistance to amikacin but also the resistance to kanamycin and tobramycin. The cloned DNA fragment specified both an acetyltransferase activity and a low level of phosphotransferase activity. The two activities were absent from mutants that did not confer resistance to amikacin, kanamycin, and tobramycin.

Review of epidemic aminoglycoside resistance worldwide

Epidemic aminoglycoside resistance may be caused by the spread of a species with distinctive chromosomal genes (e.g., Pseudomonas aeruginosa), or it may be due to the dissemination of plasmids or transposons between genera. Although strains of P. aeruginosa resistant to aminoglycosides because of impermeability may cause nosocomial outbreaks, most of the acute increases in aminoglycoside resistance are due to the spread of inactivating enzymes by plasmids. The index species for intergeneric outbreaks is usually Klebsiella pneumoniae carrying the ANT(2") or AAC(3) gene; however, the distribution of resistance varies greatly by location and species. The AAC(6')-I gene is most common in Serratia marcescens and in East Asian isolates of other species, whereas the AAC(3) gene is common in Chile. In the United States, the ANT(2") and AAC(3) genes are particularly common among Enterobacteriaceae, except for Proteus and Providencia, which often carry the AAC(2') gene. The most common patterns of epidemic resistance lead to the inactivation of gentamicin and, less frequently, tobramycin, but only rarely affect amikacin.

Isolation of a DNA fragment containing replication functions from IncP2 megaplasmid pMG2

Replication functions with IncP2 specificity were identified on a 3-kilobase DNA fragment isolated from the 400-kilobase Pseudomonas megaplasmid pMG2.

Properties of IncP-2 plasmids of Pseudomonas spp

Thirty IncP-2 R plasmids from isolates of Pseudomonas spp. of diverse geographical origins were examined for the production of resistance properties. All the plasmids determined resistance to tellurite and all inhibited the propagation of certain DNA phages, although several patterns of phage inhibition were detected. Of the 30 plasmids, 29 determined resistance to streptomycin, 28 determined resistance to mercuric ion, and 24 determined resistance to sulfonamide. Resistance to other antibiotics, to compounds of arsenic, boron, or chromium, and to UV irradiation was less common. The degradative plasmid CAM also belonged to this group. When CAM was introduced into recipients carrying an IncP-2 R plasmid, recombinant plasmids were often formed in which antibiotic resistance and the ability to grow on camphor were transferred together to further recipients or were lost together in a strain in which IncP-2 plasmids were unstable. Such hybrid plasmid formation was rec dependent. CAM and other IncP-2 plasmids that determine UV light resistance demonstrated UV-enhanced, nonpolarized transfer of the Pseudomonas aeruginosa chromosome. By agarose gel electrophoresis, all IncP-2 R plasmids and CAM were ca. 300 X 10(6) in molecular weight.

A chromosomally located transposon in Pseudomonas aeruginosa

A new transposon, Tn2521, coding for carbenicillin, streptomycin, spectinomycin, and sulfanilamide resistance, has been identified in Pseudomonas aeruginosa. The transposon occurs naturally in the chromosome of clinical strains of P. aeruginosa isolated in geographically separated hospitals. This has been demonstrated by its transductional linkage to the pur-136 marker and also by Southern hybridization. Tn2521 is 6.8 kilobases, can transpose from the chromosome to both IncP-1 and IncP-2 plasmid genomes, and has a pattern of restriction endonuclease sites unlike that of any previously described transposon. The carbenicillin resistance carried by Tn2521 is due to the PSE-4 type of beta-lactamase.

Plasmid-determined tobramycin and gentamicin resistance in strains of Pseudomonas aeruginosa from two Sydney hospitals

Strains of Pseudomonas aeruginosa resistant to gentamicin, tobramycin, streptomycin, and sulphonamide have been isolated from patients at two Sydney hospitals. The multiple resistance of all these strains was due to a transmissible plasmid. The significance of the identification of this plasmid, in this variety of strains and at two hospitals, for the treatment of Ps. aeruginosa infections is discussed.

Characteristics of gentamicin resistance in nosocomial infections

Characteristics of gentamicin resistance were studied in gram-negative bacilli from 50 consecutive patients with nosocomial infection, during a time when gentamicin resistance had recently become prevalent at Medical University Hospital. Burns, decubitus ulcers, and cystic fibrosis were common precipitating factors for acquisition of gentamicin-resistant organisms. Pseudomonas aeruginosa accounted for 76% and Enterobacteriaceae for 24% of isolates. There was high prevalence of cross-resistance to amikacin (61%) and tobramycin (58%). Of the P aeruginosa strains 36% possessed plasmids which were rapidly detected by agarose gel electrophoresis. None of the isolates transferred gentamicin resistance. Representative isolates failed to elaborate aminoglycoside-modifying enzymes or to take up labelled amikacin. Multiple immunotypes of P aeruginosa were identified. These data suggest that a nonplasmid mediated resistance mechanism such as impermeability was responsible for the emergence of gentamicin resistance.

[Investigations on the aminoglycoside inactivating enzyme AAC-(6') IV (author's transl)]

In Serratia marcescens and Pseudomonas aeruginosa from clinical specimen acetyltransferase AAC-(6') IV leads to varying phaenotypically expressed resistance to aminoglycoside antibiotics. The substrate profile and the rate of inactivation of the enzymes investigated are almost identical with each other and with the enzyme of P. aeruginosa GN 315. The enzymes cannot be associated with R factors by the standard methods for conjugation, transformation, density gradient centrifugation and agarose gel electrophoresis.

Isolation of large bacterial plasmids and characterization of the P2 incompatibility group plasmids pMG1 and pMG5

Large plasmids from Agrobacterium tumefaciens, Salmonella typhimurium, Escherichia coli, Pseudomonas putida, and Pseudomonas aeruginosa were routinely and consistently isolated using a procedure which does not require ultracentrifugation but includes steps designed to separate large-plasmid DNA from the bacterial folded chromosome. It also selectively removes fragments of broken chromosome. A variety of large plasmids was readily visualized with agarose gel electorphoresis, including five between 70 and 85 megadaltons (Mdal) in size, six between 90 and 143 Mdal, one that was larger than 200 Mdal, and one that was larger than 300 Mdal. This isolation procedure allowed initial estimation of the molecular sizes of the two IncP2 plasmids, pMG1 and pMG5, which were 312 and 280 Mdal, respectively. A standard curve for size determination by gel electrophoresis including plasmids between 23 and 143 Mdal in size did not extrapolate linearly for plasmids of the 300-Mdal size range. Unique response of different plasmids to the isolation procedure included sensitivity of IncP1 plasmids to high pH and the co-isolation of a 20-Mdal "cryptic" plasmid in conjunction.

Aminoglycoside cross-resistance patterns of gentamicin-resistant bacteria

Ten strains each of Escherichia coli, Staphylococcus aureus, and Pseudomonas aeruginosa were habituated to gentamicin by serial passage in antibiotic containing medium. Complete cross-resistance to streptomycin, neomycin, kanamycin, and tobramycin in a linear proportional fashion was demonstrated at all stages of habituation. Most strains of Staph. aureus and Ps. aeruginosa showed a greater increase in resistance to gentamicin than to the other three aminoglycosides. E. coli required more transfers to reach the same degree of resistance than did the other two species. Reversion to greater susceptibility to gentamicin took place after serial passage on antibiotic-free media. 'Wild' gentamicin-resistant strains showed no such proportionality of resistance to kanamycin, neomycin, or streptomycin. But many of these strains showed a proportional increase in resistance to tobramycin.

Cross infection in a surgical ward caused by Pseudomonas aeruginosa with transferable resistance to gentamicin and tobramycin

An outbreak of gentamicin- and tobramycin-resistant Pseudomonas aeruginosa infection occurred in a surgical ward over a three-month period. Resistant Ps. aeruginosa strains with the same serological, phage, and pyocin type were cultured from the urine of six patients. Identical organisms were found on urine bottles, bedpans, and the hands of attendant staff. Inadequate disinfection played a major role in cross-infection. Isolates of the epidemic strain from each of the patients and of an unrelated but similarly resistant Ps. aeruginosa from one of them could transfer resistance to a recipient strain of Ps. aeruginosa. Resistance to gentamicin, kanamycin, tobramycin, sulphonamides, and mercuric chloride was determined by R factors belonging to Pseudomonas incompatibility group P-3. Aminoglycoside resistance was due to acetylation.

Amikacin therapy of patients with multiply antibiotic-resistant Serratia marcescens infections: development of increasing resistance during therapy

Over a recent 22 month period, 222 patients in two adjacent hospitals became infected with a multiply antibiotic-resistant strain of Serratia marcescens; 13 were bacteremic. Nineteen patients with clinically significant infections received amikacin. Nine of 11 patients with urinary tract infections were cured. In contrast, only one of eight patients with pneumonia or other deep tissue infections was cured and four died. These eight patients were severely ill; many had infections with multiple microorganisms. In four of five patients in whom the infection failed to clear promptly. Serratia strains became increasingly resistant to amikacin during therapy and these strains contributed to the death of two of these patients. Amikacin proved useful in treating patients with infections due to gentamicin-resistant S. marcescens organisms, especially urinary tract infections. However, the capacity of some strains of S. marcescens to develop resistance to amikacin may limit the usefulness of this antibiotic in the treatment of deep tissue infections which involve this microorganism.

Mechanisms of resistance to aminoglycosides

Bacterial resistance to aminoglycoside antibiotics occurs by a variety of mechanisms. In clinical situations the most common mechanism is plasmid-determined modification of the drug that leads to a block of transport of the antibiotic into the cell. Amikacin, a semisynthetic aminoglycoside, is effective against a number of resistant strains because it has fewer sites of modification.

Superinfection inhibition by prophage B3 of some R plasmids in Pseudomonas aeruginosa

The prophage of the phage B3 ofP. aeruginosaexhibits superinfection inhibition towards certain R plasmids such as R18-1 or R18-3 as shown by a severe depression (c. 10−6) in the conjugal transfer of these plasmids into B3 lysogens. The transfer of other R plasmids into such lysogens and the transfer of R18-1 or R18-3 into bacteria lysogenic for unrelated phages was unimpaired. R18-1 or R18-3 was non-transducible into B3 lysogens although transducible into non-lysogens. The interaction appeared to be reciprocally expressed since B3 lysogenization of bacteria R+for R18-1 or R18-3 was also reduced. Consistent with the failure of co-existence of the prophage and the plasmids was the observation that when the transconjugants from the cross R18-1 donor ×B3 lysogenic recipients were tested, transfer-deficient plasmid derivatives were encountered (about 40%). Other transconjugants were cured of prophage, or carried mutant B3 prophage with lytic, lysogenization or superinfection inhibition functions impaired.

Recombination between plasmids of incompatibility groups P-1 and P-2

R plasmids of incompatibility group P-2 are readily transmissible between Pseudomonas strains, but not to Escherichia coli or other enterobacteria, whereas those of group P-1 have a broad host range. Pseudomonas aeruginosa donor strains carrying both a P-1 plasmid (RP1, RP4, or R751) and a P-2 plasmid (pMG1, pMG2, pMG5, or RPL11) were mated with E. coli K-12, and selection was imposed for resistance markers on the P-2 plasmids. Transconjugants were obtained at a low frequency, in which P-2 markers were expressed and were serially transmissible in E. coli together with P-1 markers. These plasmids had P-1 incompatibility properties, conferred susceptibility to phages active on P-1 carrying strains, and behaved on sucrose gradient centrifugation as unimolecular species of higher molecular weights than the P-1 parent. Recombinant plasmid formation was independent of a functional Rec gene in both donor and recipient and, with R751, had a preferred site leading to loss of trimethoprim resistance. Interaction between insertion sequences may be involved. Thus, plasmids of group P-2 can recombine with R factors of another group quite separate in compatibility properties, host range, and pilus type. Formation of such recombinants provides one pathway by which the genetic diversity of plasmids may have evolved.

Resistance plasmids of Pseudomonas aeruginosa: change from conjugative to nonconjugative in a hospital population

Properties of a population of carbenicillin- and gentamicin-resistant, tobramycin-susceptible Pseudomonas aeruginosa at Veteran's Administration Hospital, Cincinnati, Ohio, have been followed during a 16-month period. As originally described, the strains were isolated from patients with urinary tract colonizations and were predominantly Parke-Davis immunotype 7. For the majority of these organisms, antibiotic resistance was correlated with the presence of a self-conjugative plasmid of incompatibility group P-2. The source and relative incidence of multiply resistant isolates have remained constant during the current study, but the immunotype has shifted form type 7 to type 2. Concomitantly, the population has lost the property of conjugative transfer of resistance, and resistant strains are now compatible with P-2 plasmids. A group P-2 R plasmid, pMG5, will mobilize resistance markers, demonstrating that the multiple resistance of the nonconjugative strains is mediated by R plasmids. Additionally, gentamicin resistance due to either conjugative or nonconjugative plasmids is correlated with the presence of similar gentamicin acetyltransferase activity. pMG5-mobilized plasmids are shown to be incompatible with pMG5. pMG5 is also shown to mobilize resistance markers from nontransferring antibiotic-resistant strains representing populations from Parkland Memorial Hospital, Dallas, Texas, and Cleveland Clinic Foundation, Cleveland, Ohio.

Gentamicin-resistant Pseudomonas aeruginosa and Serratia marcescens in a general hospital

From Aug. 1, 1974, to July 31, 1975, inclusive, 19-1% of Pseudomonas aeruginosa and 50-0% of Serratia marcescens isolates from a general hospital were gentamicin resistant as determined by standardised disc testing; 80% of 118 different clinical isolates showed minimum inhibitory concentrations larger than or equal to 16 mug/ml of gentamicin in agar-dilution testing. All gentamicin-resistant S. marcescens and 79% of Ps. aeruginosa isolates were susceptible to amikacin, while tobramycin and sisomicin were shown to have little advantage over gentamicin. A wide variety of immunotypes was found for Ps. aeruginosa, but only two predominant types were found for S. marcescens. Most isolates originated from the urinary tract, but nine which came from urine or wounds were also isolated from blood. Resistant strains seemed to be as virulent as sensitive strains. A common source was not found. Clinical improvement was noted in 13 of 17 patients treated with amikacin. The high frequency of gentamicin resistance is a continuing problem in this hospital and soon may be in others.

Infection caused by Proteus mirabilis strains with transferrable gentamicin-resistance factors

During a period of 10 weeks, four patients in one hospital became infected with gentamicin-resistant Proteus mirabilis. In two of them septicaemia associated with indwelling catheters developed, one had urinary tract and wound infections, and in the fourth patient the organism was isolated from a superficial wound. The P. mirabilis strains showed multiple drug resistance. Strains form the first three patients were apparently identical and were sensitive to tobramycin. Their gentamicin resistance was not transferable to Escherichia coli K12, but could be transferred to another strain of P. mirablilis (PM13-3). The fourth strain was resistant to tobramycin; its gentamicin/tobramycin resistance was transferable to E. coli K12.