B. Wiedemann

Bacterial resistance to antibiotics :

international epidemiology and new resistance

mechanisms

E.coli and Ampicillin (PEG)

0102030405060

% resistant strains

40 50 60 75 78 81 83 86 89 90 96 98 1 4

year

S.aureus (PEG)S.aureus (PEG)

0

10

20

30

% r

esis

tan

t st

rain

s

75 78 81 83 86 90 96 98 1 4

TET

Year

MIC-Distribution: MIC-Distribution: Ampicillin - Ampicillin - E.coliE.coli

Breakpoint and % sensitive Breakpoint and % sensitive strains strains

USA <16 65,3%

MIC [mg/l]

No

80

200

400

600

800

1000

1200

0,125 0,25 0,5 1 2 4 8 16 32 64

NL <4 43,6%

D <2 8,2%

S < 1 2%

E.coli (PEG)E.coli (PEG)

0

10

20

30

40

50

60

% r

esis

tant

str

ains

75 78 81 83 86 89 90 96 98 1 4

TOBCIP

SXTAMP

TET

Year

Resistance to Amoxicillin:Resistance to Amoxicillin: E.coli (GENARS) E.coli (GENARS)

0

20

40

60

% der Stämme

20

02

20

03

20

04

20

05

SR

Zeit

0

10

20

30

40

50

60

70

80

FI

IS DK

SI

EE

HR

GR

NL

AT

LU

MT

HU

FR

CZ

BE

DE

IT UK

PL

PT

SK

ES

IL IE BG

CY

RO

Ampicillin-Resistance E. coli (EARSS)

Resistance to Ciprofloxacin: E.coli

(GENARS)

9,3 11 11,3 12,8 13,8 15,7 14,7 16,5

0

20

40

60

80

100

% of strains20

02

2003

2004

2005

RS

year

Resistance to Meropenem: P.aeruginosa

0 1,87,4

2,8 3,3

22

02468

10121416182022

% der Stämme

PEG

S.aureus (PEG)S.aureus (PEG)

0

20

40

60

80

% r

esis

tan

t st

rain

s

75 78 81 83 86 90 96 98 1 4

CIPOXA

TOBTET

PEN

Year

Resistance to Oxacillin: S.aureus (GENARS)

0

20

40

60

80

100

% der Stämme

20

02

20

03

20

04

20

05

R

S

Zeit

MRSA incidence in Europe 2005 (EARSS)

0

10

20

30

40

50

60

70

NL

. SE

DK

EE

FI

SI

CZ

IT AT

SK

HU

LU

DE

NO

ES

FR

RO

BG

BE

IS HR

IE GR

UK

PL

LV

CY

PT

1,5

2,3

5,3

3,8

78,9

84,2

29,3

94,7

5,3

6,8

18,0

3,0

1,5

82,7

45,1

94,7

0,0

0,0

3,0

0,0

0,0

85,0

0 10 20 30 40 50 60 70 80 90 100

Linezolid

Vancomycin

Fusidinsäure

Rifampicin

Fosfomycin

Cotrimoxazol

Doxycyclin

Clindamycin

Erythromycin

Gentamicin

Ciprofloxacin

% resistente Stämme

2001 (n=133)2004 (n=133)

Crossresistance of MRSA

MRSA mit Oxacillin-MHK 8 mg/l

Molekular-biologischer Typ

Resistenzmuster

Vorkommen (%)

1994(n=121)

1996(n=140)

1998(n=337

2000(n=567)

2002(n=747)

2004(n=430)

Norddt.EMRSA (ST247)

PEN,OXA,GEN,ERY,CLI,TET,SXT,RIF,CIP

22,0 17,0 13,0 1,3 0,4 0,1

Süddt.EMRSA (ST228)

PEN,OXA,ERY,CLI,CIP (GEN),(TET*)

16,0 34,0 29,0 36,8 15,2 11,8

Hannover.EMRSA (ST254)

PEN,OXA,GEN,ERY,CLI,SXT,CIP

32,0 16,0 15,0 3,5 0,7 0,3

Rhein-HessenEMRSA (ST5)

PEN,OXA,ERY,CLI,CMP,CIP

5,0 1,0 - - 23,3 26,5

WienerEMRSA

PEN,OXA,GEN,ERY, CLI,SXT,CIP,TET,(FUS)

4,0 1,0 1,0 0,1 0,2 0,04

BerlinerEMRSA (ST45)

PEN,OXA,CIP,(GEN,ERY,CLI,SXT)

22,0 22,0 26,0 26,7 18,2 10,2

BarnimEMRSA (ST22)

PEN,OXA,ERY,CLI,CIP - - 9,0 19,8 28,0 35,3

Epidemic MRSA in Germany (RKI)

Witte (2005) Epidemiol Bull, Nr. 41: 376-80*Rückgang nach 1994

Resistance to Erythromycin: S.aureus

(GENARS)

19,4 18,5 21 21,5 21,8 23,7 23,5 25,1

0

20

40

60

80

100

% der Stämme

20

02

20

03

20

04

20

05

RS

Zeit

The Alexander Project 2000: S. pneumoniae, penicillin non-susceptible

Brazil 13.4% 3.0%

Mexico36% 17.5%

USA10.7% 22.7%

South Africa36.3% 15.4%

Saudi Arabia 31.2% 24.7%

Hong Kong3.6% 71.4%

Japan20.2% 30.9%

Singapore12.2% 32.6%

Russia3.1% 0.0%

Penicillin-intermediate (MIC 0.12 – 1 µg/mL)Penicillin-resistant (MIC 2 µg/mL)

The Alexander Project 2000:S. pneumoniae, penicillin non-susceptible

UK 3.0% 4.5%

Belgium 3.6% 4.8%

France 20.7% 40.0%

Germany 5.8% 0.8%

Czech Rep 5.3% 2.1%

Poland 2.6% 5.2%

Switzerland 7.8% 9.7%

Italy2.9% 3.9%

Portugal 6.7% 16.7% Greece

9.6% 8.8%

Slovak Rep 13.1% 19.0%

Spain 15.8% 20.8%

Penicillin-intermediate (MIC 0.12 – 1 µg/mL)Penicillin-resistant (MIC 2 µg/mL)

The Alexander Project 2000:S. pneumoniae, macrolide resistance

UK 11.9%

Belgium 21.7%

France 58.6%

Germany 8.3%

Czech Rep 0.0%

Poland 10.6%

Switzerland 9.7%

Italy31.4%

Portugal16.7% Greece

23.3%

Slovak Rep 19.0%

Spain 28.7% Resistance defined as erythromycin MIC > 1 mg/L

The Alexander Project 2000:S. pneumoniae, chloramphenicol resistance

UK 4.5%

Belgium 8.4%

France 15.9%

Germany 1.7%

Czech Rep 9.6%

Poland 11.3%

Switzerland 1.0%

Italy15.7%

Portugal6.7% Greece

12.2%

Slovak Rep 21.4%

Spain 24.8% Resistance defined as chloramphenicol MIC > 8 mg/L

The Alexander Project 2000:S. pneumoniae, co-trimoxazole resistance

UK 14.9%

Belgium 22.9%

France 44.8%

Germany 27.4%

Czech Rep 16.0%

Poland 39.7%

Switzerland 23.3%

Italy35.3%

Portugal30.0% Greece

24.2%

Slovak Rep 34.5%

Spain 40.6% Resistance defined as co-trimoxazole MIC > 1 mg/L

The Alexander Project 2000:

H. influenzae, β-lactamase production

Brazil9.1%

Mexico22.3%

USA25.9%

South Africa6.3%

Saudi Arabia 17.6%

Hong Kong17.6%

Japan10.7%

Singapore29.2%

Russia5.5%

Europe11.1%

Development of Makrolide Resistance

Resistance to Erythromycin MIC 1µg/ml

France

0

10

20

30

40

50

60

70

92 93 94 95 96 97 98 99

Spain

Italy

UKUSA

year

Mak

rolid

Res

ista

nce

(%

)

00

Streptococcus pneumoniae

The Alexander Project

Developement of Penicillin Resistance

France

0

10

20

30

40

50

60

70

92 93 94 95 96 97 98 99

Spain

USA

UK

Italy

year

Pen

icili

n R

esis

tan

ce (

%)

00

Streptococcus pneumoniae

Drug Mechanism

PEN PBP1A, PBP2B, PBP2X

ERY Mef (E)62.2%

Erm (B)22.5%

Mef (E) Erm (B)8.5%

SXT DHFR Ile 100 Leu

2,9% of isolates S.pneumoniae MDR in

Canada

Zhanel et al, Int J Antimicrob Agents 28 (2006) 465

Enzyme Substrate Host Gene localisation

Acetyltransferases

AACaminoglycosidesfluoroquinolones

gram-negative and gram-positive bacteria plasmid, transposon,chromosome

Vat streptogramin Astaphylococci,enterococci

plasmid

CAT chloramphenicol gram-negative and gram-positive bacteria plasmid, chromosome, transposon

Adenyltransferases

ANT aminoglycosides gram-negative and gram-positive bacteria plasmid, transposon

Lnu lincomycin staphylococci, E. faecium plasmid

Arr rifampicin gram-negative bacteria plasmid

Phosphotransferases

APH aminoglycosides gram-negative and gram-positive bacteria plasmid, transposon

Mph macrolides E. coli, S. aureus plasmid

Glutathionetransferase

Fo fosfomycin gram-negative and gram-positive bacteria plasmid

Antibiotic modifying enzymes

Molec. class

chromosomal mutations can lead to high-level production

plasmid- or transposon-mediated generally produced at high levels

A 

SHV-1 in K. pneumoniae, and in K. oxytoca BlaZ Staph.; TEM, SHV, VEB, PER and CTX-M penicillinases and ESBLs (-lactamases with activity against third generation cephalosporins and aztreonam) KPC, IMI/NMC and SME carbapenemases

B 

L1 of S. maltophilia; enzyme of Aeromonas spp.; CcrA enzyme found in 1–3% in B. fragilis. enzymes are carbapenemases

IMP, VIM and SPM type carbapenemases 

C AmpC enzymes of E. coli, Shigella spp., Enterobacter spp., C. freundii, M. morganii, Providencia spp. and Serratia spp. cephalosporinases with wide spectrum of activity

CMY, LAT, BIL, MOX, ACC, FOX and DHA types. All genes are ampC genes

D OXA enzymes of Acinetobacter spp. and some Aeromonas spp. Some OXA enzymes are carbapenemases

most OXA types are chromosomal

Classification of ß-lactamases

System Substrates Species Gene Location

ABC      

MsrA 14-,15- membered macrolides, streptogramin type B Staph. plasmid

Vga, Vga(B) streptogramin type A S. aureus plasmid

SMR      

Smr(QacC) quarternary ammonium compounds S. aureus plasmid

MFS      

NorA fluoroquinolones S. aureus chromosome

TetK tetracycline S. aureus plasmid

QacA quarternary ammonium compounds S. aureus plasmid

TetA tetracycline E. coli plasmid

MefA 14-,15- membered macrolides S. pyogenes chromosome

MefE 14-,15- membered macrolidesS. pneumoniae

chromosome

RND      

AcrAB-TolCtetracycline, fluoroquinolones, chloramphenicol, β-lactams except imipenem, novobiocin, erythromycin, fusidic acid, rifampicin

E. coli chromosome

MexAB-OprM

tetracycline, fluoroquinolones, chloramphenicol, β-lactams except imipenem, novobiocin, erythromycin, fusidic acid, rifampicin, trimethoprim, sulfamethoxazol

P. aeruginosa

chromosome

Examples of frequent bacterial efflux systems

Multiresistance: K. pneumoniaeMultiresistance: K. pneumoniae

Patients No. % n

ICU 70 8,8 793

In patients 57 3,5 1647

Out patients 1 0,3 396

total 128 4,5 2836

Antibiogramme

AmpAmpClav

AmpSul

Mezlo Pip Cezo Ctx Gent CipPipTaz

Fox Cetri CazImiMero

Tobra Ami

R R R R R R R R R R R R R S R S

According to MIC

Intermediate

Resistance with plasmid uptake coding forCMY ß-Laktamse

Klebsiella pneumoniae Klebsiella pneumoniae Hospital infectionHospital infection

Chirurgie Intensiv

Anästhesie Intensiv

Kardiochirurgie Intensiv

2002 2003 2004J F M A M J J A S O N D J F M A M J J A S O N D J F M A

AI-17

AI-18

AI-19

AI-21

AI-13

AI-14

AI-15

AI-16

AI-06

AI-10

AI-01

AI-02

AI-04

AI-05

CI-02

CI-03

CI-06

CI-09

AI-22

AI-23

CI-27

CI-28

CI-29

CI-30

CI-23

CI-24

CI-25

CI-26

CI-17

CI-18

CI-21

CI-22,

CI-30

CI-31

CI-32

CI-33

CI-34

CI-35

CI-36

CI-37

KI-08

KI-09

AI CI KI Normalstation

Patients mit K.pneumoniaePatients mit K.pneumoniae

Antibiotic sensitivity K.pneumoniae

AMP AMC PIT FOX CTX CTC MER CIP DOX CLM TOB AMI SXT

>128 >128 >128 128 >32 1 0,5 128 8 >128 16 8 >128

AMP AMC PIT FOX CTX CTC MER CIP DOX CLM TOB AMI SXT

>128 >128 >128 128 >32 >32 8 64 2 >128 4 2 >128

Outbreak 2002

outbreak 2004

Resistance determinants of K.pneumonia outbreak

AB-group 2002 2004

Pen/Ceph SHV1u12 TEM1a u b SHV1 TEM1a CTX-M 2

Cefoxitin Omp35 Omp35 u.36

Monobact SHV-12 CTX-M 2

Carbapen Omp35 u.36

Aminoglyc. AAC,APH,ANT,Str (8) AAC,ANT (2)

Fluoroquinol 2x gyrA, parC 2x gyrA, parC

Tetracycline Efflux Efflux

Chloramph. Cat 1 Cat 1

Antifolate Sul II, DfrV Sul I

Incidence of Fluoroquinolone-Resistance: E. coli(EARSS)

0

5

10

15

20

25

30

DK

NO

EE

SE

FI

RO

HR

NL

FR

SI

GR

SK

BE

UK

IE LU

AT

HU

PL

CZ

IL DE

ES

IT BG

CY

PT

MT

Chinolon consumption in Europe

Correlation of penicillin consumption and PEN

resistance

0

5

10

15

20

25

0 5 10 15 20 25 30 35 40

% resistance

DD

D/1

000

Bronzwear et al Emerging Infect Dis 8 2002

Inverse correlation of quinolone consumption and

CIP-resistance

0

0,5

1

1,5

2

2,5

3

3,5

4

0 5 10 15 20 25 30 35

% non susceptible

DD

D/1

000/d

ay

C. Gracia-Ray, J.a. Martin-Herrereo and F. Baquero CMI 12,Suppl 3 (2006)

Inverse correlation of quinolone consumption and

CIP-resistance

0

0,5

1

1,5

2

2,5

3

3,5

4

0 5 10 15 20 25 30 35

% non susceptible

DD

D/1

000/d

ay

C. Gracia-Ray, J.a. Martin-Herrereo and F. Baquero CMI 12,Suppl 3 (2006)

Exposure ExpansionSelektion

Sensitive Population Resistant clone Outbreak , epidemicInfek

tion con

trol

An

tibiotic con

trol

Model of resistance emergence

http://www.swab.nl

Types of resistance developement

individual resistance development

(Patient specific strain)E.coli QR,S.epidermidis QR

regional resistance development (Hospital strain)

Acinetobacter, Stenotrophomonas, S.aureus

global resistance development (global strain)

N.gonorrhöae, S.pneumoniae, H. influencae

hypothesis for the evolution of antibiotic

resistance

mutation

????

integration

integration

chromosomal gene

optimised chromosomal gene

gene in gene casette

gene casette in integron

integron in transposon

hypothesis for the evolution of antibiotic

resistance 2integron in transposon

transposition

transposon in a plasmid

transposition

??deletion??

transposon in chromosom

Deletion of transposon genes to optimise genestructure

Development of antibiotic resistance

uptake intobacterial cytoplasm

spread into the environment

rekombination

development Integrons

gene pool for antibiotic resistance

multi resistance

developmentof transposons

development of plasmids

summary 1summary 1

The knowledge of the epidemiology of resistant and sensitive pathogens

is needed forCalculated Antibiotic treatment of

the single patientImplementation of hygenic

measuresInfection controlStrategy for reduction of resistant

pathogens

Data depend on Region

Ward

Patientpopulation

Microbiological methos

source of data

Tendency in general: rising resistance

Multidrug resistance becomes a growing problem

summary 2summary 2

spread in the environment

survival in specific ecosystem

selektion pressure

mutation or aquisition of resistance plasmids

appropriate gene komplex

resistance developement

Necessary steps to manage the situation

With todays knowledge and scientific potential it should be possible

to identify resistance when it evolves in bacteria in their natural biotop

to kill these organissms before evolution comes to the point of no return

To avoid their spread

However, this needs resources, that we do not get

Testing for ESBLsTesting for ESBLs

Screening: Ceftazidime >=2 or Cefotaxime >=2 or Cefpodoxime >=8

ESBL confirmation: Rate Cefpodoxim/Cefpodoxim-Clavulansäure >=8

AMPC: RateCefpodoxim/Cefpodoxim-Clavulansäure <=1

ESBL: E.coli 2004ESBL: E.coli 2004

n %

total 1944 100

screening 84 4,3

CPP

CPC

1 21 1,0

2 – 4 20 1,0

8 33 1,7

11 strains could not be classified

ESBL: Klebsiella ESBL: Klebsiella pneumoniae 2004pneumoniae 2004

n %

Total 382 100

screening 40 10,2

CPP

CPC

1 7 1,8

2 – 4 6 2,0

8 27 7,1

4 strains could not be classified