1. Antimicrobial Agents and Impact of Antimicrobial Resistance Wen-Chien Ko Division of Infectious Disease National Cheng Kung University Hospital

2. Middle-Age Male No specific underlying disease Occupation: professional soldier Local symptom over knee area Clinical Diagnosis: SSTI Day 0 Pus culture: MRSA

3. Day 7

4. Case: Present Illness 81 year-old women presented with pneumonia due to multidrug resistance A. baumannii with respiratory s/p tracheostomy, and was referred for salvage antimicrobial therapy VRE urinary tract colonization Past History: –parkinsonism –vascular dementia –bed ridden with grade II bed sore –diabetes mellitus with anti-hypoglycemic agents

5. Physical Examination Consciousness: alert, E4VTM4 Vital sign –TPR: 37.8/110/23 –BP: 112/70 mmHg No pale face and conjunctive; no icteric sclera No jugular vein engorgement Breathing sound: bilateral coarse crackle Heart: regular heart beats without heart murmur Abdomen: soft; liver/spleen: impalpable Extremities: no pitting edema, free moveable

6. Laboratory Study CBC/DC 採檢 :96/04/18 全血 8221K94683 -------- ------------- ------------- WBC 11.6 xK/cmm 3.2-9.2 | RBC 4.23 xM/cmm 3.73-4.93 Hb 10.6 g/dl 11.6-14.8 | Hct 39.7 % 33.8-43.4 MCV 93.8 fl 82.7-95.5 | MCH 32.3 pg 28.2-33 MCHC 34.4 g/dl 33.2-35.2 | RDW H 15.2 % 11.6-13.6 Pl 161 xK/cmm 151-366 | Blast - % Pro - % | Myelo - % Meta - % | Band - % Seg H 77.7 % 43-64 | Eos 2.6 % 0-6 Baso 0.8 % 0-1 | Mono 7.4 % 3-9 Lymph L 21.5 % 27-47 | Aty-lym - % NRBC - /100WBCS | Remarks -

7. Laboratory Study Biochemistry Test and Arterial Blood Gas Analysis 採檢 :96/04/18 血漿 8261A88052 -------- ------------- ------------- -------- ------------- --------- CREA 0.4 mg/dL 0.6-1.2 | AST H 86 U/L 0-39 BUN 13 mg/dL 7-21 | NA L 122 mmol/L 135-148 K 3.6 mmol/L 3.5-5 | ALT 37 U/L 0-54 CRP H 141 mg/L 0-8 | GLU.P.C. 125 mg/dL 80-140 OSMO 260 mOsm/kg 280-295 採檢 :96/04/18 T-Mask (4 l/min) -------- ------------- ------------- PH 7.41 7.35-7.45 | PCO2 41 mmHg 35-45 PO2 71 mmHg 75-100 | HCO3- 26.6 mmol/L 21-28 TCO2 27.8 mmol/L | BEb 2.4 mmol/L BEecf 1.8 mmol/L | SBC 26.7 mmol/L %sO2c 94.2 % |

8. X-Ray and Microbiological Report 檢查 :96/04/18 AEROBIC CULTURE REPORT 菌 名 1.Acinetobacter baumannii S:Susceptible R:Resistant I:Intermediate M:Moderate 1 Ampi/sulbactam R Piperacillin R Pip/Tazobactam R Gentamicin R Ciprofloxacin R Imipenem R Ceftazidime R Tica/clavulnic R Co-Trimoxazole R Meropenem R Cefepime R Cefpirome R 960418

9. Microbiological Study 檢查 :96/04/18 全血 --------------------------------------------------------------- BLOOD CULTURE REPORT No aerobic and No anaerobic pathogens were isolated after 5 days incubation 檢查 :96/04/18 全血 --------------------------------------------------------------- BLOOD CULTURE REPORT No aerobic and No anaerobic pathogens were isolated after 5 days incubation 檢查日： 960424 第 1 次報告 ------------------------------------------------------- LEGIONELLA ANTIGEN REPORT Legionella antigen (urine): Negative

10. AEROBIC CULTURE REPORT 檢查 :96/04/18 菌 名 1. Acinetobacter baumannii S:Susceptible R:Resistant I:Intermediate (MIC 單位 : μg/ml ) Ampicillin/sulbactum R >32 Impenem R >32 Cefepime R >32 Colistin S <2 Tigecycline S 2

11. X-ray Serial Following

12. tigecycline imipenem colistin inhalation vancomycin Candidemia with profound septic shock Neutropenic fever MRSA, MDRAb pneumonia; CoNS bacteremia B. cepacia bacteremia

13. Final Diagnosis Candidemia Septic shock, complicated with multiple organs failure Pneumonia with respiratory failure s/p tracheostomy/ MDRAb and MRSA Parkinsonism Diabetes mellitus Related adrenal insufficiency AAD

14. Alexander Fleming 1881-1955

15. August 14, 1944 Life

16. The Ideal Drug 1.Selective toxicity: against target pathogen but not against host –LD 50 (high) vs. MIC and/or MBC (low) 2.Bactericidal vs. bacteriostatic 3.Favorable pharmacokinetics: reach target site in body with effective concentration 4.Spectrum of activity: broad vs. narrow 5.Lack of “side effects” –Therapeutic index: effective to toxic dose ratio 6.Little resistance development

17. Antibiotic Agents Approved, 1993-2004

18. ERA OF ANTIMICROBIALS 1930s Sulfonamides 1940s Penicillin G; Streptomycin 1950s Erythromycin; Tetracyclines Early 1960s Methicillin; Ampicillin Late 1960s Cephalosporins; Aminoglycosides 1970s More penicillins & Cephalosporins 1980s Newer  -lactams; Quinolones 1990s-present Newer macrolides, quinolones, Drugs for resistant organisms: linezolid, daptomycin, tigecycline

19. Development of New Antibiotics

20. Antibiotic Mechanisms of Action Transcription Translation Alteration of Cell Membrane Polymyxins Bacitracin Neomycin

21. Teichoic acid From: Goodman and Gilman, 9th ed.

22. Stages of Peptidoglycan Synthesis & Inhibitors

23. Cycloserine: Analog of alanine Cytoplasm sugar aminoacid X X X X Bacitracin Cell membrane Batoprenol P P Vancomycin Cell wall

24. Teichoic acid From: Goodman and Gilman, 9th ed. Crosslinks

27. Antimicrobials acting on protein synthesis Binding to 30s Subunit –aminoglycosides (bacteriocidal) streptomycin, gentamicin, amikacin –tetracyclines Binding to the 50s subunit –chloramphenicol –fusidic acid –macrolides (erythromycin, clarithromycin, azithromycin)

28. Inhibitors of Folic Acid Synthesis p-aminobenzoic acid + Pteridine Dihydropteroic acid Dihydrofolic acid Tetrahydrofolic acid Pteridine synthetase Dihydrofolate synthetase Dihydrofolate reductase Thymidine Purines Methionine TrimethoprimSulfonamides

29. Antimicrobials acting on nucleic acid synthesis Inhibitors of Precursor Synthesis –sulphonamides & trimethoprim are synthetic, bacteriostatic agents used in combination in co-trimoxazole –Sulphonamides inhibit early stages of folate synthesis dapsone, an anti-leprosy drug, acts this way too –Trimethoprim inhibits final enzyme in pathway, dihydrofolate synthetase. pyramethamine, an anti-toxoplasma and anti-PCP drug acts this way too

30. ALTERATION OF CELL MEMBRANES  Polymyxins and colistin destroys membranes active against gram-negative bacilli serious side effects used mostly for skin & eye infections

31. Antimicrobials acting on cell membrane polymyxins act like detergents and disrupt Gram-negative outer membrane –Not used parenterally because of toxicity to mammalian cell membrane amphotericin binds to sterol-containing membranes of fungi fluconazole and itraconazole interfere with biosynthesis of sterol in fungi

32. Antimicrobials acting on nucleic acid synthesis Inhibitors of DNA replication –Quinolones (e.g ciprofloxacin) inhibit DNA-gyrase –Orally active, broad spectrum Damage to DNA –Metronidazole (anti-anaerobes), nitrofurantoin (UTI) Inhibitors of Transcription –rifampicin (key anti-TB drug) inhibits bacterial RNA polymerase –flucytosine is incorporated into yeast mRNA

33. Agents for Infections Due to Gram-Positive Bacteria Staph. epidermidis MRSA Staph. aureusStreptococci (Group A and Group B) GNR RGNRPseudomonas aeruginosa Penicillin G Penicillin V Methicillin, Oxacillin, Nafcillin, Cloxacillin Dicloxacillin, Cloxacillin Vancomycin Dalfopristin/Quinopristin, Linezolid, Daptomycin Linezolid I.V. P.O.

34. Broad- and Extended-Spectrum Penicillins Staph. epidermidis MRSA Staph. aureusStreptococci (Group A and Group B) GNR RGNRPseudomonas aeruginosa Ampicillin Amoxicillin Carbenicillin, Mezlocillin, Piperacillin, Ticarcillin Ticarcillin + Clavulanic Acid = Timentin ®, Piperacillin + Tazobactam = Zosyn ® Ampicillin + Sulbactam = Unasyn ® Amoxicillin + Clavulanic Acid = Augmentin ®

35. Cephalosporins First Generation Second Generation Third Generation Fourth Generation * Oral Agent Cefadroxil * Cefaclor *CefdinirCefepime Cefazolin Cefamandole Cefoperaxone Cefpirome Cefelixin * Cefonicid Cefotaxime Cephalothin CeforanideCeftazidime Cephaprin CefotetanCeftibuten Cephradine * Cefoxitin Ceftizoxime Cefuroxime moxalactam Ceftriaxone

36. Cephalosporins Staph. epidermidis MRSA Staph. aureusStreptococci (Group A and Group B) GNR RGNRPseudomonas aeruginosa Cefazolin Cephalexin, Cefadroxil Cefepime, Cefpirome Cefuroxime, Cefoxitin Cefaclor, Loracarbef, Ceftibuten Cefprozil, Cefuroxime axetil, Cefpodoxime, Cefdinir Ceftriaxone, Cefotaxime Cefixime Ceftazidime 1 st Generation 2 nd Generation 3 rd Generation 4 th Generation

37. Macrolides, Azalides and Ketolides Staph. epidermidis MRSA Staph. aureus Streptococci (Group A and Group B) GNRRGNRPseudomonas aeruginosa Erythromycin Azithromycin Clarithromycin, Azithromycin, Telithromycin x Erythromycin

38. Broad Spectrum Antibiotics Staph. epidermidis MRSA Staph. aureusStreptococci (Group A and Group B) GNR RGNRPseudomonas aeruginosa Ciprofloxacin, Levofloxacin, Moxifloxacin, Gatifloxacin Ciprofloxacin, Levofloxacin, Moxifloxacin, Gatifloxicin Tetracycline, Doxycycline, Minocycline Tetracycline, Doxycycline, Minocycline, Tigecycline Gentamicin, Tobramycin, Netilmicin, Amikacin Imipenem, Meropenem, Ertapenem Trimethoprim/Sulfamethoxazole

39. Clinical use of antibiotics Gillespie SH & Bamford KB. 2003. Medical microbiology & infection at a glance.

40. MRSA PDRAB CRAB PRSP VRE VISA VRSA ESBL AmpC PDRPA CRPA PISP parC gyrA mecA pbp Fungi ? PDRSM LRSA

42. 台灣院內感染監視資訊系統（ TNIS ）

44. *** Emerging Nosocomial Pathogens *** Species SAMSAM PIPPIP TZPTZP GNGN ANAN CIPCIP IPMIPM CAZCAZ TIMTIM SXTSXT MEMMEM FEPFEP Acinetobacter baumanniiRRRRRRRRRRRR Escherichia coliRRRRRRRRRR Chryseobacterium spp.RRRRRRRRRRRR Pseudomonas putidaRRRRRRRRRRRR Pseudomonas spp.RRRRRRRRRRRR Stenotrophomonas maltophiliaRRRRRRRRRRRR SAM= ampicillin-sulbactam; PIP= piperacillin; TZP= piperacillin-tazobactam; GN= gentamicin AN= amikacin; CIP= ciprofloxacin; IPM= imipenem; CAZ= ceftazidime; TIM= ticarcillin- clavuanate; SXT= trimethoprim-sulfamethoxazole; MEM= meropenem; FEP= cefepime

45. Isolate number of pan-resistant Gram-negative bacilli in NCKUH 2001200220032004Total Acinetobacter baumannii 83131842 Pseudomonas putida 10438 Chryseobacterium spp. 22116 Pseudomonas aeruginosa 31104 Stenotrophomonas maltophilia 00314 Pseudomonas spp. 10023 Escherichia coli 00011

46. Impact of Antimicrobial-Resistant Bacteria Increased risk of death Prolonged hospitalization Treatment with more toxic/expensive antibiotics Limited antimicrobial therapy for certain resistant pathogens Excess costs: $100 million-30 billion dollars annually

47. Clinical outcome in relation to whether empirical therapy was judged appropriate or not Int J Antimicrob Agents 29 Suppl. 3 (2007) 1–7

48. Outcome of infections with antibiotic-resistant bacteria MRSA: 2X mortality c/t MSSA VRE: 2X mortality c/t VSE Multidrug-resistant gram-negative bacteria: up to 5X mortality compared to susceptible strains

49. Outcomes and Adjusted Analysis for Patients With Bacteremia Caused by Multidrug-Resistant (MDR) Acinetobacter baumannii (Case Group) or Non-MDR A. baumannii (Control Group) Infect Control Hosp Epidemiol 2007; 28:713-719

51. Mechanisms of Antibiotic Resistance Enzymatic inhibition Altered target site/enzyme Over-production of target enzyme Bypass inhibited steps Membrane impermeability Active pumping out of drug in use

52. Altered permeability –Altered influx Gram negative bacteria

53. Altered permeability –Altered efflux tetracycline

54. Inactivation –beta-lactamase –Chloramphenicol acetyl transferase

55. Altered target site –Penicillin binding proteins (penicillins) –RNA polymerase (rifampin) –30S ribosome (streptomycin)

57. Thanks for Your Attention !

58. Review of Initiation of Protein Synthesis 30S 1 3 2 GTP 123 Initiation Factors mRNA 3 1 2 GTP 30S Initiation Complex f-met-tRNA Spectinomycin Aminoglycosides 1 2 GDP + Pi 50S 70S Initiation Complex AP

59. Review of Elongation of Protein Synthesis GTP AP Tu GTP Tu GDP Ts Tu + GDP Ts Pi PA Tetracycline AP Erythromycin Fusidic Acid Chloramphenicol G GTP G GDP + Pi G GDP AP + GTP