A PERFECT STORM OF ANTIBIOTIC RESISTANCE
Section 6
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Antibiotic Resistance in Hospitals Revised 11/18/2011
It is puzzling that sewage and water experts who promote the use of reclaimed water and sewage sludge for irrigation
and fertilizer pretend ignorance about pathogenic antibiotic resistant E. coli and other members of the
Enterobacteriacea family (coliforms and fecal colifroms) that cause over 40% of hospital acquired infections. They claim
E. coli (the primary coliform and fecal coliform) does not generally cause disease even though it was one of the first
documented killers identified in hospitals.
In 1945, G. Johnson, et al., reported on the “ISOLATION OF TRICHOMONAS VAGINALIS WITH PENICILLIN.” They said,
“Exposure of Trichomonas vaginalis in vaginal discharge for 60 hours to 5,000-10,000 units of penicillin in 10.0 ml of a
medium containing cysteine (0.15 per cent.), peptone, liver infusion, maltose and human serum was adequate to
destroy the associated bacteria. Seven strains were isolated from seven women without a failure. This technic widens
the field of investigation by offering a means of obtaining additional strains of bacteria-free Trichomonas vaginalis for
comparative study. Efforts to isolate Trichomonas vaginalis by such laborious methods as washing, micropipetting and
migration have all failed to yield bacteria-free cultures at this and other laboratories. The adherence of bacteria to the
trichomonads, which appear to have sticky surfaces, and the relatively slow speed with which these protozoa swim are
probably in large measure responsible for failure. Further trials by these methods now seem unnecessary. In the cases
reported above the success of the penicillin method may be attributed to several factors. Resistance of Trichomonas
vaginalis to penicillin in the concentrations reported above, the absence from the specimens of vaginal discharge of
bacteria resistant to penicillin in these same concentrations, and the destruction of bacteria adherent to the sticky
surfaces of the trichomonads perhaps played a large part in assuring successful isolation of the protozoa.” http://www.
ncbi.nlm.nih.gov/pubmed/17777364
In 1949, C. Phillip Miller and Marjorie Bohnhoff, reported on the “Effect of streptomycin therapy on the bacterial flora of
the throat.” They said, “Specimens from the throats of patients receiving streptomycin were cultured onto streptomycin
media in order to detect the presence of streptomycin-resistant and streptomycin-dependent bacteria. Streptomycin-
resistant bacteria in large numbers were cultured from the throats of 98.4 per cent of sixty-one patients who were
receiving 1 to 4 Gm. of streptomycin per day. They began to appear during the first thirteen days of treatment in the
twenty-four patients who were followed from the beginning of streptomycin therapy. Results of a single survey of
another series of patients receiving small doses of streptomycin (0.5 to 0.75 Gm. per day) suggested that resistant flora
appeared more slowly. These streptomycin-resistant bacteria all belonged to species normally inhabiting the human
throat. Yeast-like forms (Monilia) were found in unusually high incidence. Streptomycin-dependent bacteria were found
in two-fifths of the patients receiving large doses of streptomycin, i.e., 1 Gm. or more per day. Streptomycin-resistant
bacteria in small numbers were recovered from only 4 per cent of 157 members of the hospital staff, student body and
clerical personnel and from 10 per cent of untreated patients. The highest incidence of positive cultures in the control
series, 21 per cent, occurred in the nursing and ward personnel. Strongly positive cultures were found in four nurses
who were caring for patients receiving streptomycin. Streptomycin-dependent micro-organisms were recovered from the
pharynx and large bowel of mice and rabbits after one week of treatment with large doses of streptomycin.” http://www.
sciencedirect.com/science/article/pii/0002934349902090
In 1949, P. N. Coleman and S. Taylor, Townleys Hospital at Bolton, Lancashire, reported on “COLIFORM INFECTION
OF THE URINARY TRACT.” They said, “This paper concerns the investigation of the types of coliform organisms
encountered in the urines of one hundred consecutive cases of pyuria admitted to Townleys Hospital, Bolton, during
1948. Recently Warner (1948), discussing urinary infection in paraplegic patients, has drawn attention to the frequency
with which Bact. Aerogenes was found. This organism was insensitive both to sulphanilamide and to penicillin, and
Warner considered that these drugs may be of only limited value in urinary infection. It was thought that it would be
interesting to discover if a similar high incidence of Bact. aerogenes would be found in other types of urinary infection
and to consider all the types of coliform organisms found from the point of view of chemotherapy. -- Of the eighteen
strains of Bact. aerogenes tested, six produced gas at 44°C. after 48 hours' incubation though not after 24 hours'. – It
was found that in group 1 Bact. coli was the predominant organism (49 strains compared with 12 of other organisms)
whereas in group 2 Bact. coli was relatively uncommon (7 strains compared with 56 of other organisms,). Its place was
taken in roughly equal proportions by P. vulgaris, P. morgani, and Bact. Aerogenes. – On the other hand, Warner found
that the 12 Bact. coli strains tested as well as the Bact. Aerogenes strains were insensitive to 50 mg./100 ml. of
sulphathiazole. – In cases of primary urinary infection Bact. coli was the predominant organism; in cases secondary to
urinary obstruction Bact. aerogenes, P. vulgaris, and P. morgani predominated. – Because of the high incidence of non-
sensitive strains found in cases of urinary infection secondary to obstruction, no benefit from treatment with
sulphonamnides or penicillin is likely.”
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1023247/pdf/jclinpath00007-0054.pdf
In 1954, Dr. R. Meyer, Jerusalem, reported on a “BONE ABSCESS CAUSED BY BACTERIUM COLI.” Meyer found an
abscess (pus pocket) in the knee of an 18 year old girl. There was no history of the girl being infected by E. coli. Meyer
found a pus sac in the knee joint. Pure E. coli cultures were grown from the pus. The E. coli was resistant to
streptomycin and pencillin. However, it was sensitive to cholomycetin. He noted the literature suggested that while
abscesses, conjunctivitis and invasion of body tissues had been observed, they were unusual.
http://web.jbjs.org.uk/cgi/reprint/36-B/3/436.pdf
In 1967, Susumu Mitsuhashi, et al., reported on “Drug Resistance of Enteric Bacteria IX. Distribution of R Factors in
Gram-negative Bacteria from Clinical Sources.” They said, “Many isolates belonging to the Enterobacteriaceae were
collected in 1965 from the inpatients at geographically scattered hospitals in Japan. Among 2,650 Shigella strains
examined, 58.4% were found to be drug-resistant; 95.0% of these resistant strains were multiply resistant. Among 434
resistant strains examined, 81% carried R factors that were transferable by cell-to-cell contact. Of 160 isolates of other
enteric bacteria, drug-resistant strains included 84.2% of the Escherichia coli, 93.0% of the Klebsiella, and 90.0% of the
Proteus cultures. Among these resistant strains, 70.3% of the E. coli, 66.7% of the Klebsiella, and 52.0% of the Proteus
were multiply resistant. Of these resistant strains, 84.0% of the E. coli, 88.0% of the Klebsiella, and 50.0% of the
Proteus strains carried R factors. These results indicate that R ors are widespread among gram-negative bacteria of
clinical significance.” http://jb.asm.org/cgi/content/abstract/93/4/1242
By 1969, Naomi Datta, Hammersmith Hospital in England, reported on “Drug Resistance and R Factors in the Bowel
Bacteria of London Patients before and after Admission to Hospital.” Datta said, “The content of drug-resistant coliform
bacteria in faecal specimens collected before admission from patients awaiting non-urgent surgery were compared with
specimens collected in hospital. Resistant strains of Escherichia coli were isolated from 52% of preadmission specimens
and were present in large numbers in 28%. Tetracycline, sulphonamide, and streptomycin resistance were commonest:
60% of resistant strains carried transmissible R factors and multiple resistance was commoner than single. No
characteristically resistant intestinal bacteria of any genera were found in hospital specimens as compared with those
from outside.” She said, “resistant bacteria which are harmless in the bowel may infect the urinary tract or cause other
parenteral infections.” Eighty-one different resistant E. coli strains as well as 30 strains of resistant Klebsiella species,
11 Proteus species, 4 Enterobacter, 7 Citrobacter, and 5 Pseudomonas aeruginosa.were found in the study. Moreover,
she said, “In hospital medicine there is no doubt of the importance of coliform infections of the urinary tract, of surgical
wounds, and of the blood stream and outside hospital E. coli in the urinary tract is one of the commonest causes of
infective illness.” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1983307/pdf/brmedj02032-0031.pdf
In 1976, T.D. Fontaine, 3rd, and A. W. Hoadley, reported in the study, “Transferable drug resistance associated with
coliforms isolated from hospital and domestic sewage” that “The incidence of antibiotic-resistant fecal coliforms in raw
and treated hospital and municipal wastes was investigated to determine whether such wastes may serve as reservoirs
for the spread of resistant bacteria and resistance transfer factors. Multiple resistance occurred in 87.8% of isolates
from hospital and 42.6% of isolates from municipal wastes. Antibiotic resistance was transferable to Escherichia coli and
Salmonella cholerae-suis recipient strains from 62.3% of resistant isolates from hospital and 90.9% of resistant isolates
from municipal wastes, and from 56.2% of all isolates from hospital and 45.9% of all isolates from municipal wastes.
Numbers of multiply-resistant fecal coliforms decreased during passage through a sewage treatment plant, but their
proportion did not change appreciably, although proportions exhibiting resistance to 3, 4, 5, 6, and 7 drugs decreased.
A study of transfer in sewage indicated that transfer of resistance from donors present in sewage to pathogenic
Salmonella strains can occur under appropriate conditions. The data suggest that both raw and treated wastes, and
especially those from hospitals, may serve as reservoirs for the spread of antibiotic-resistant bacteria and transferable
resistance in the environment.” http://www.ncbi.nlm.nih.gov/pubmed/789292
In the 1981 study “An R plasmid of broad host-range, coding for resistance to nine antimicrobial agents endemic in
Gram-negative nosocomial isolates” at the Hines VA hospital, S. Tantulavanich, et al., said, “These results show that a
particular R plasmid has established itself among the Enterobacteriaceae at Hines VA Hospital. This R plasmid appears
to be the predominant genetic element responsible for linked resistance to carbenicillin, gentamicin and to bramycin
among these hospital-associated bacteria.” Furthermore, “Of 3952 clinical isolates of Enterobacteriaceae, 246 exhibited
resistance to at least carbenicillin, gentamicin and tobramycin. All these isolates, representing eight genera, were
resistant to at least nine antimicrobial agents in common, including the three key antibiotics and streptomycin,
kanamycin, sisomycin, ampicillin, cephalothin and sulphonamide. The strains could be subdivided into seven groups
depending upon additional resistance traits and some were resistant to as many as 15 antibiotics. When mated with a
standard strain of Escherichia coli, 85% of 123 randomly selected donors transferred resistance to at least the nine
core antibiotics. Some donors occasionally transferred resistance to two additional antibiotics, neomycin and
tetracycline, while one Citrobacter freundi donor always transferred linked resistance to all 11 drugs.”
http://www.ncbi.nlm.nih.gov/pubmed/6273563
In 1982, Marylse Devaud, et al., University of Zurich, reported on “Transposon-Mediated Multiple Antibiotic Resistance
in Acinetobacter Strains,” an unusually resistant strain of Acinetobacter calcoaceticus subsp. Anitratus, that caused an
epidemic of respiratory tract infections in an intensive care unit. They said, “Only recently has this organism been found
to be a possible cause of nosocomial infections in compromised hosts. – We suggest that a plasmid resistant to multiple
antibiotics was transferred from the hospital flora into Acinetobacter sp. but could not be maintained stably in this host.
Instead, a multiply resistant DNA sequence was transposed and stably integrated into the Acinetobacter chromosome.
The occurrence of such multiply resistant transposons on conjugative plasmids contributes greatly to the genetic
variability of bacteria and may sometimes have serious epidemiological and therapeutic consequences.”
http://thewatchers.us/EPA/10/1982-antibio-transfer-hospital.pdf
In 1983, Gordon L. Archer and C. Glen Mayhall, Medical College of Virginia, Virginia Commonwealth University, reported
on the “Comparison of Epidemiological Markers Used in the Investigation of an Outbreak of Methicillin-Resistant
Staphylococcus aureus Infections.” They said, “The incidence of nosocomial [hospital] infections caused by methicillin-
resistant (MR) Staphylococcus aureus strains is increasing dramatically in hospitals in the United States. MR S. aureus
isolates have been shown to be fully virulent, causing staphylococcal endocarditis [inflammation heart lining and heart
valves] and septicemia [bacteria in the blood] at a frequency similar to that of methicillin-sensitive S. aureus isolates.
They said, “An outbreak of nosocomial infections was caused by a single strain of methicillin-resistant (MR)
Staphylococcus aureus. This strain was followed as it was transmitted from the index case to 17 patients, 3 hospital
personnel, and 12 items in the hospital environment – The epidemic strain was resistant to beta-lactam antibiotics,
gentamicin, erythromycin, clindamycin, and rifampin. Resistance to rifampin was the only unique marker in the
antibiogram which distinguished the epidemic strain from the indigenous strains – we found that plasmid pattern
analysis was a useful epidemiological tool for fingerprinting MR S. aureus strains. It has the following advantages. First,
the plasmid pattern is stable. We found that all 32 of the epidemic (rifampin-resistant) MR S. aureus isolates obtained
over 7 months had an identical pattern. Furthermore, the pattern remained stable for up to 1 year of storage at -70°C.”
http://thewatchers.us/EPA/10/1983-antibio-staph-hosp.pdf
In 1983, Shunro Kohbata, et al., Gifu University School of Medicine at Tsukasa-Machi, reported on “Lactose-
Fermenting, Multiple Drug-Resistant Salmonella typhi Strains Isolated from a Patient with Postoperative Typhoid Fever.”
They said, “Since 1959, frequent incidences of salmonellosis due to lactose-fermenting strains [coliforms] have been
reported from the United States, Brazil, Canada, and Japan (1, 9, 14, 24). In these cases, including two outbreaks in
Canada and Brazil, the isolates belonged to serogroups B, C1, C2, D, E1, or E4. – Among the lactose-fermenting
isolates, strain ST-2 was the only strain of naturally occurring Salmonella typhi hitherto reported in the literature.
Strain ST-2 was first reported by Baron et al. (4) in 1959 as a high frequency recombinant strain compatible with many
strains of Salmonella, Shigella, and Escherichia species. – Two lactose-fermenting Salmonella typhi strains were
isolated from bile and blood specimens of a typhoid fever patient who underwent a cholecystectomy due to
cholelithiasis. One lactose-fermenting S. typhi strain was also isolated from a pus specimen which was obtained at the
tip of the T-shaped tube withdrawn from the operative wound of the common bile duct of the patient. These three
lactose fermenting isolates: GIFU 11924 from bile, GIFU 11926 from pus, and GIFU 11927 from blood, were
phenotypically identical to the type strain (GIFU 11801 = ATCC 19430 = NCTC 8385) of S. typhi, except that the three
strains fermented lactose and failed to blacken the butt of Kligler iron agar or triple sugar iron agar medium. All three
lactose-fermenting strains were resistant to chloramphenicol, ampicillin, sulfomethoxazole, trimethoprim, gentamicin,
cephaloridine, and four other antimicrobial agents. The type strain was uniformly susceptible to these 10 drugs. The
strain GIFU 11925, a lactose-negative dissociant from strain GIFU 11926, was also susceptible to these drugs, with the
sole exception of chloramphenicol (minimal inhibitory concentration, 100,ug/ml).”
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC270931/pdf/jcm00135-0198.pdf
In 1995, R.R. Reinert, et al., Technical University of Aachen, reported on “Recurrent bacteremia due to Brevibacterium
casei in an immunocompromised patient.” They said, “A case of an immunocompromised patient who experienced two
episodes of septicemia caused by a coryneform bacterium is reported. Biochemical characteristics and analysis of
cellular fatty acids and of cell wall components showed two identical strains of Brevibacterium casei to be responsible for
these infections. The lack of easy-to-perform methods for identification may have led, in the past, to an underestimation
of the role of this bacterium, especially in immunocompromised patients.” http://www.ncbi.nlm.nih.gov/pubmed/8681984
In 1998, Piero Galieni and Catia Bigazzi, Università di Siena, reported on the “Recurrent Septicemia in an
Immunocompromised Patient Due to Probiotic Strains of Bacillus subtilis.” They said, “ Bacillus subtilis is a gram-
positive, aerobic, spore-forming soil bacterium ubiquitous in the environment. The beneficial effects of B. subtilis spores
on the balance of the intestinal microflora is the rationale for its general use as a probiotic preparation in the treatment
or prevention of intestinal disorders. B. subtilis spores are available in Italy as a pharmaceutical preparation for oral
use. Each dose contains a mixture of 109 spores of four distinct antibiotic-resistant derivatives of ATCC 9799
(Enterogermina; distributed by Sanofi Winthrop, Milan, Italy) (1, 4) per vial. The pathogenic potential of B. subtilis is
generally described as low or absent (2). Data on the general importance of infections due to B. subtilis are incomplete,
since it is a general practice of most microbiological laboratories to discard these strains or to report them as
contaminants. Also, in the cause-of-death statistics of the World Health Organization no data on B. subtilis infections are
present since, even if reported, they would be “invisible” at the international comparative level due to the coding used
for classification of death causes (2a). In the literature, only a few cases of infections due to B. subtilis are reported (3,
6–8, 10) and only one retrospective study describes the isolation of antibiotic-resistant strains of B. subtilis (6).”
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC124869/
In 1998, M.K. Glynn, et al., Centers for Disease Control and Prevention, reported on the “Emergence of multidrug-
resistant Salmonella enterica serotype typhimurium DT104 infections in the United States.” They said, “Strains of
salmonella that are resistant to antimicrobial agents have become a worldwide health problem. A distinct strain of
Salmonella enterica serotype typhimurium, known as definitive type 104 (DT104), is resistant to ampicillin,
chloramphenicol, streptomycin, sulfonamides, and tetracycline and has become a major cause of illness in humans and
animals in Europe, especially the United Kingdom. – we analyzed data collected by local and state health departments
and public health laboratories between 1979 and 1996 in national surveys of the antimicrobial-drug resistance of
salmonella. Selected typhimurium isolates with the five-drug pattern of resistance were phage typed. – The prevalence
of typhimurium isolates with the five-drug pattern of resistance increased from 0.6 percent in 1979-1980 to 34 percent
in 1996. In 1994-1995, such isolates were identified in samples from 36 of the 46 surveillance sites (78 percent). Thirty-
nine of 43 typhimurium isolates with the five-drug pattern of resistance identified in 1994-1995 and 1996 were phage
[virus] type DT104 or a closely related phage type. – Multidrug-resistant typhimurium DT104 has become a widespread
pathogen in the United States.” http://www.ncbi.nlm.nih.gov/pubmed/9571252
In 1998, Tessy A. Joseph, et al., Cook County Children's Hospital at Chicago, reported on the “Neonatal Early-Onset
Escherichia coli Disease – The Effect of Intrapartum Ampicillin.” They said, “Early-onset E coli infection was diagnosed
in 30 of 61498 live births. The overall infection rate (0.49 per 1000 live births) did not change significantly during the 2
time periods (0.37 per 1000 live births during period 1 vs 0.62 per 1000 live births during period 2, P=.21; 2 test);
however, there was an increase in the infection rate in neonates weighing between 1501 and 2500 g. Infected neonates
had a clinical syndrome that was indistinguishable from early-onset group B streptococcal infection; respiratory distress
was the single most frequent finding in 73% (22/30) infected neonates. An increase in the proportion of infections
caused by ampicillin-resistant E coli was observed during period 2 (12/18) compared with period 1 (3/12, P=.03; Fisher
exact test). During period 2, 61% (11/18) of mothers of infected neonates received intrapartum ampicillin compared with
17% (2/12; P=.02) during period 1. Overall, a higher proportion of neonates born to ampicillin-treated women had
ampicillin-resistant infection (12/13 vs 3/17; P<.001). Mothers of 10 of 15 neonates with ampicillin-resistant infection had
received more than 2 doses of intrapartum ampicillin. The difference between the prevalence of intrapartum fever in
mothers with sensitive organisms (40%, or 6/15) and resistant organisms (93%, or 14/15) was also significant (P=.003).
All 6 early-onset E coli– related deaths were due to ampicillin-resistant organisms; 4 of the 6 mothers received
intrapartum ampicillin. – We have shown a shift of early-onset E coli infection from a less fulminant disease caused by
ampicillin-sensitive organisms to a more fulminant disease caused by ampicillin-resistant organisms. Increased use of
maternal intrapartum ampicillin therapy may account for these changes. In the absence of evidence for group B
streptococcal disease, clinicians should consider the possibility of ampicillin-resistant E coli infection in critically ill
neonates born to women with a history of intrapartum fever and treatment with intrapartum ampicillin.”
http://archpedi.ama-assn.org/cgi/content/full/152/1/35
In 2000, G. Prats, et al., Hospital de la Santa Creu i Sant Pau, Universitat Autònoma at Barcelona, reported on
“Antibiotic resistance trends in enteropathogenic bacteria isolated in 1985-1987 and 1995-1998 in Barcelona.” They
said, “Trends in resistance to antimicrobial agents used for therapy have been evaluated with 3,797 enteropathogenic
bacteria, Campylobacter, Salmonella, Shigella, and Yersinia, between 1985-1987 and 1995-1998. The greater increase
in the rate of resistance was observed in Campylobacter jejuni for quinolones (from 1 to 82%) and tetracycline (from 23
to 72%) and in gastroenteric salmonellae for ampicillin (from 8 to 44%), chloramphenicol (from 1.7 to 26%), and
trimethoprim-sulfamethoxazole and nalidixic acid (from less than 0.5 to 11%). Multidrug resistance was detected in
several Salmonella serotypes. In the 1995-1998 period, 76% of Shigella strains were resistant to trimethoprim-
sulfamethoxazole, 43% were resistant to ampicillin, and 39% were resistant to chloramphenicol. Seventy-two percent of
Yersinia enterocolitica O3 strains were resistant to streptomycin, 45% were resistant to sulfonamides, 28% were
resistant to trimethoprim-sulfamethoxazole, and 20% were resistant to chloramphenicol..”
http://www.ncbi.nlm.nih.gov/pubmed/10770742
In 2002, David M. Livermore, Antibiotic Resistance Monitoring and Reference Laboratory, Central Public Health
Laboratory, Colindale, London, reported on the “Multiple Mechanisms of Antimicrobial Resistance in Pseudomonas
aeruginosa: Our Worst Nightmare?” He said, “Pseudomonas aeruginosa carries multiresistance plasmids less often
than does Klebsiella pneumoniae, develops mutational resistance to cephalosporins less readily than Enterobacter
species, and has less inherent resistance than Stenotrophomonas maltophilia. – A few isolates of P. aeruginosa are
resistant to all reliable antibiotics, and this problem seems likely to grow with the emergence of integrins that carry gene
cassettes encoding both carbapenemases and amikacin acetyltransferases. – The original emergence of multidrug
resistance in association with plasmids and integrins is less predictable than mutational resistance because it depends
on the random escape of genes to mobile DNA. However, once such resistance has emerged, either the host strain can
spread among patients or the resistance can disseminate among strains. – Many acquired β-lactamases and
aminoglycoside-modifying enzymes have been noted in P. aeruginosa. Some of these are widely prevalent among
isolates from southern Europe, Turkey, and Southeast Asia, although they are not widely prevalent in the United
Kingdom. – Permeability mutations are widely blamed for increased resistance to β-lactams and fluoroquinolones, but,
again, much of what was once attributed to impermeability is now understood to reflect up-regulated efflux. – In a
hospital in Thessaloniki, Greece, a serotype O:12 strain with a VIM β-lactamase and cross-resistance to aztreonam,
aminoglycosides, and ciprofloxacin persisted for 3 years, with µ211 isolates of this strain recovered. In South Korea,
VIM-2 producers are widespread in P. aeurginosa, with the enzyme being found in organisms at 9 of 29 hospitals
surveyed.”
http://cid.oxfordjournals.org/content/34/5/634.full
In 2002, Philip S. Stewart, Montana State University at Bozeman, reported on the “Mechanisms of antibiotic resistance in
bacterial biofilms.” He said, “Bacteria that attach to a surface and grow as a biofilm are protected from killing by
antibiotics. Reduced antibiotic susceptibility contributes to the persistence of biofilm infections such as those associated
with implanted devices. The protective mechanisms at work in biofilms appear to be distinct from those that are
responsible for conventional antibiotic resistance. In biofilms, poor antibiotic penetration, nutrient limitation and slow
growth, adaptive stress responses, and formation of persister cells are hypothesized to constitute a multi-layered
defense. The genetic and biochemical details of these biofilm defenses are only now beginning to emerge. Each gene
and gene product contributing to this resistance may be a target for the development of new chemotherapeutic agents.
Disabling biofilm resistance may enhance the ability of existing antibiotics to clear infections involving biofilms that are
refractory to current treatments.” http://www.sciencedirect.com/science/article/pii/S1438422104700909
In 2003, Thien-Fah Mah, et al., Dartmouth Medical School, Hanover, reported in “A genetic basis for Pseudomonas
aeruginosa biofilm antibiotic resistance” that, “Biofilms are surface-attached microbial communities with characteristic
architecture and phenotypic and biochemical properties distinct from their free-swimming, planktonic counterparts1.
One of the best-known of these biofilm-specific properties is the development of antibiotic resistance that can be up to
1,000-fold greater than planktonic cells2. We report a genetic determinant of this high-level resistance in the Gram-
negative opportunistic pathogen, Pseudomonas aeruginosa. We have identified a mutant of P. aeruginosa that, while
still capable of forming biofilms with the characteristic P. aeruginosa architecture, does not develop high-level biofilm-
specific resistance to three different classes of antibiotics. The locus identified in our screen, ndvB, is required for the
synthesis of periplasmic glucans. Our discovery that these periplasmic glucans interact physically with tobramycin
suggests that these glucose polymers may prevent antibiotics from reaching their sites of action by sequestering these
antimicrobial agents in the periplasm. Our results indicate that biofilms themselves are not simply a diffusion barrier to
these antibiotics, but rather that bacteria within these microbial communities employ distinct mechanisms to resist the
action of antimicrobial agents.” http://www.nature.com/nature/journal/v426/n6964/abs/nature02122.html
In 2003, James A. Karlowsky, et al., Focus Technologies and Clyde Thornsberry, Merck Research Laboratories,
reported on “Trends in Antimicrobial Susceptibilities among Enterobacteriaceae Isolated from Hospitalized Patients in
the United States from 1998 to 2001.” They said, “Longitudinal surveillance of Enterobacteriaceae [coliform &
thermotolerant fecal coliform] for antimicrobial susceptibility is important because species of this family are among the
most significant and prevalent human pathogens. – Members of the family Enterobacteriaceae are among the most
important bacterial human pathogens. They comprise approximately 80% of gram-negative bacteria and 50% of all
isolates identified in hospital laboratories in the United States. Escherichia coli, Klebsiella pneumoniae, Proteus
mirabilis, Enterobacter spp., and Serratia marcescens account for the majority of Enterobacteriaceae isolated from
clinical specimens. – Antimicrobial resistance is increasing in many species of Enterobacteriaceae as well as in other
gram-negative, gram-positive, and anaerobic bacteria. Current antimicrobial resistance issues for Enterobacteriaceae
include the emergence and proliferation of extended-spectrum ß-lactamases, ß-lactamase-inhibitor-resistant TEM
enzymes, stably derepressed and plasmid-encoded AmpC cephalosporinases, fluoroquinolone resistance, and the
dissemination of multidrug-resistant (MDR) strains.”
http://aac.asm.org/cgi/content/full/47/5/1672
Also, in 2003, Maria Sjölund, et al., University Hospital Uppsala, Swedish Institute for Infectious Disease Control and
New York University School of Medicine, reported on the “Long-Term Persistence of Resistant Enterococcus Species
after Antibiotics To Eradicate Helicobacter pylori.” They said, “Antibiotic treatment selects for resistance not only in the
pathogen to which it is directed but also in the indigenous microflora. – In treated patients, all enterococci isolated
immediately after treatment showed high-level clarithromycin resistance due to erm(B). In 3 patients, resistant
enterococci persisted for 1 to 3 years after treatment. No resistance developed among controls. – Conclusion: A
common H. pylori treatment selects for highly resistant enterococci that can persist for at least 3 years without further
selection.” http://www.annals.org/content/139/6/483.abstract
In 2004, Abigail A. Salyers, et al., University of Illinois at Urbana, reported on “Human intestinal bacteria as reservoirs for
antibiotic resistance genes.” They said, Human intestinal bacteria have many roles in human health, most of which are
beneficial or neutral for the host. In this review, we explore a more sinister side of intestinal bacteria; their role as
traffickers in antibiotic resistance genes. Evidence is accumulating to support the hypothesis that intestinal bacteria not
only exchange resistance genes among themselves but might also interact with bacteria that are passing through the
colon, causing these bacteria to acquire and transmit antibiotic resistance genes. http://thewatchers.
us/Antibioticresistants/NormalFlora-Resistant-transfer.pdf
In 2004, Edwin D. Charlebois, et al., Division of Infectious Diseases, San Francisco, reported on the “Origins of
Community Strains of Methicillin-Resistant Staphylococcus aureus.” They said, “To characterize methicillin-resistant
Staphylococcus aureus (MRSA) strains circulating in the community, we identified predictors of isolating community
MRSA and genotyped a sample of MRSA collected from a community-based, high-risk population. Computerized
databases of the Community Health Network of San Francisco and the Clinical Microbiology Laboratory were searched
electronically for the years 1992–1999 to identify community-onset infections caused by MRSA. Sequential analyses
were performed to identify predictors of MRSA strains. The majority (58%) of infections were caused by strains
traceable to the hospital or to long-term care facilities. Injection drug use was associated with infections that were not
associated with health care settings. Genotypes for 20 of 35 MRSA isolates recovered from injection drug users did not
match any of >600 genotypes of clinical isolates. In a nonoutbreak setting, the hospital was the main source of
community MRSA; however, the presence of genetically distinct and diverse MRSA strains indicates MRSA strains now
also originate from the community.” http://cid.oxfordjournals.org/content/39/1/47.full
In 2004, C. A. Fux, et al., Montana State University at Bozeman, reported on the “Detachment Characteristics and
Oxacillin Resistance of Staphyloccocus aureus Biofilm Emboli in an In Vitro Catheter Infection Model.” They said,
“Catheter-related bloodstream infections due to Staphylococcus aureus are of increasing clinical importance. The
pathophysiological steps leading to colonization and infection, however, are still incompletely defined. We observed
growth and detachment of S. aureus biofilms in an in vitro catheter-infection model by using time-lapse microscopy.
Biofilm emboli were characterized by their size and their susceptibility for oxacillin. Biofilm dispersal was found to be a
dynamic process in which clumps of a wide range of diameters detach. Large detached clumps were highly tolerant to
oxacillin compared with exponential-phase planktonic cultures. Interestingly, the degree of antibiotic tolerance in
stationary-phase planktonic cultures was equal to that in the large clumps. The mechanical disruption of large clumps
reduced the minimal bactericidal concentration (MBC) by more than 1,000 times. The MBC for whole biofilm effluent,
consisting of particles with an average number of 20 bacteria was 3.5 times higher than the MBC for planktonic cultures.
We conclude that the antibiotic resistance of detached biofilm particles depends on the embolus size and could be
attributed to nutrient-limited stationary-phase physiology of cells within the clumps. We hypothesize that the detachment
of multicellular clumps may explain the high rate of symptomatic metastatic infections seen with S. aureus.”
http://jb.asm.org/cgi/content/abstract/186/14/4486
In 2005, Maria Sjölund, et al., University Hospital at Uppsala, reported on the “Persistence of Resistant Staphylococcus
epidermidis after Single Course of Clarithromycin.” They said, “We examined how a common therapy that includes
clarithromycin affects normally colonizing Staphylococcus epidermidis. Samples from the nostrils of 5 patients receiving
therapy were collected before, immediately after, 1 year after, and 4 years after treatment. From each patient and
sample, S. epidermidis strains were isolated and analyzed for clarithromycin susceptibility and presence of the erm(C)
gene. We show that macrolide-resistant strains of S. epidermidis were selected during therapy and that the same
resistant strain may persist for 4 years, in the absence of further antimicrobial treatment.”
http://www.cdc.gov/ncidod/eid/vol11no09/pdfs/05-0124.pdf
In 2005, Carla Novais, et al., Universidade do Porto,Portugal, reported on the “Environmental Contamination with
Vancomycin-Resistant Enterococci from Hospital Sewage in Portugal.” They said, “Vancomycin-resistant enterococci
(VRE) were detected in samples of sewage obtained downstream of hospitals of the Porto area in Portugal, and in
samples from the Douro Estuary. Clonal analysis, Tn1546 typing, and presence of putative virulence traits indicate the
clinical origin of these isolates. This observation highlights the importance of hospital sewage in the VRE contamination
of the environment. – Enterococci have been traditionally considered as indicators of fecal contamination of drinking
and recreational waters, although they are usually recovered at high concentrations from natural environments lacking
exposure to heavy fecal contamination, such as rivers, seawater, and nonagricultural soils. Release of antibiotic-
resistant bacteria to the community is therefore of particular concern since they might proliferate in soil and surface
waters, persist and spread in different environments, and transfer antibiotic resistance genes among different species.
– Vancomycin-resistant enterococci (VRE) are one of the most worrisome pathogens in hospitals in the United States,
and they are starting to increase in European health institutions, Portugal being the area with the currently highest VRE
prevalence. – Our data suggest that both particular clones and mobile elements carrying antibiotic resistance or
virulence associated to the clinical setting might be continuously contaminating the community environment through
wastewater. Reducing the release of bacteria or genetic elements from the clinical setting to the community is becoming
a critical issue to avoid the buildup of environmental reservoirs of antibiotic resistance.” http://thewatchers.
us/Antibioticresistants/Enterococcus.pdf
In 2007, Z.A. Memish, et al., King Fahad National Guard Hospital at Riyadh, reported on the “Emergence and trends of
penicillin non-susceptible Streptococcus pneumoniae in Saudi Arabia and Kuwait - perspective and outstanding issues.”
They said, “For many years in the past Streptococcus pneumoniae was uniformly susceptible to penicillin until the
sudden and unexpected emergence of clinical infections caused by penicillin-resistant S. pneumoniae (PRSP) in 1967.
Within the following decade, reports of nosocomial and community outbreaks of infections due to PRSP became
widespread all over the world. Recent reports suggest that the incidence of resistance rates is rising in many countries
although there are geographical variations in the prevalence and patterns of resistance between countries. The
problem of antibiotic resistance is further compounded by the emergence of resistance to many beta-lactam antibiotics.
The first report of PRSP in Saudi Arabia was in 1991. Barely a year after, PRSP infection was reported in Kuwait in
1992. Since then, studies from various parts of these countries have recorded prevalence rates ranging from 6.2% in
Riyadh to 34% in Jeddah and 20% to 56% in neighboring Kuwait. These suggest considerable variation in the
prevalence of PRSP in different cities in the Saudi Kingdom and Kuwait. The mechanism of resistance is due to
chromosomally mediated alteration of penicillin-binding proteins (PBPs), which are target sites for beta-lactam
antibiotics. It would appear that the spread of PRSP strains in Saudi Arabia is driven by the selective pressure created
by excessive use and misuse of antimicrobial agents made possible by the easy availability of these agents, often
frequently obtainable over the counter. In Kuwait, irrational and misguided use of antibiotics may be the major driving
force favoring the spread of PRSP. The serotypes of strains encountered in Saudi Arabia and Kuwait are almost
identical, with serotypes 19, 6, 15, 14 and 23 being the most common; together they constitute about 70% of the
isolates circulating in these countries. In general, almost 90% of the serotypes included in the 23-polyvalent vaccine are
present in the general population. However, a much lower percentage of these serotypes is found in the conjugated
vaccines, which are more relevant to our communities. This paper reviews the emergence and the steady increase in
the prevalence of penicillin-resistant pneumococcal strains in Saudi Arabia and Kuwait during the last 10 years. It
discusses the trends, mechanisms of resistance and factors associated with the emergence, dissemination, and
colonization of resistant organisms and suggests options available to clinicians for management of infections due to
PRSP.” http://www.ncbi.nlm.nih.gov/pubmed/18073145
In 2008, Michaela Haas, et al., University of Ulm, reported on the “Detection of Resistance to Macrolides in
Thermotolerant Campylobacter Species by Fluorescence In Situ Hybridization,” They said, “Thermotolerant
Campylobacter spp. (C. jejuni, C. coli, C. lari, and C. upsaliensis) [while heat resistant, it is not a fecal coliform] are
leading causes of bacterial diarrhea. Even though most infections are self-limiting, antimicrobial therapy decreases the
duration and severity of symptoms and is mandatory in the case of severe illness. Because resistance to quinolones is
increasing, macrolides are currently the recommend first-line treatment. However, resistance to macrolides is an
emerging problem. In human isolates, the rate of resistance is about 5%, but rates vary considerably, reaching up to
80% in animal isolates of C. coli. http://jcm.asm.org/cgi/content/full/46/11/3842
In 2008, S.G. Jenkins, et al., Mount Sinai School of Medicine at New York, reported on the “Trends in antibacterial
resistance among Streptococcus pneumoniae isolated in the USA: update from PROTEKT US Years 1-4.” They said,
“The increasing prevalence of resistance to established antibiotics among key bacterial respiratory tract pathogens,
such as Streptococcus pneumoniae, is a major healthcare problem in the USA. The PROTEKT US study is a
longitudinal surveillance study designed to monitor the susceptibility of key respiratory tract pathogens in the USA to a
range of commonly used antimicrobials. Here, we assess the geographic and temporal trends in antibacterial resistance
of S. pneumoniae isolates from patients with community-acquired respiratory tract infections collected between Year 1
(2000-2001) and Year 4 (2003-2004) of PROTEKT US. – Over the first 4 years of PROTEKT US, penicillin and
erythromycin resistance among pneumococcal isolates has remained high. Although macrolide resistance rates have
stabilized, the prevalence of clonal isolates, with a combined erm(B) and mef(A) genotype together with high-level
macrolide and multidrug resistance, is increasing, and their spread may have serious health implications. Telithromycin
and levofloxacin both showed potent in vitro activity against S. pneumoniae isolates irrespective of macrolide resistance
genotype.” http://www.ncbi.nlm.nih.gov/pubmed/18190701
In 2008, Xuan Qin, et al., Children's Hospital and Regional Medical Center at Seattle, reported on the “Prevalence and
Mechanisms of Broad-Spectrum β-Lactam Resistance in Enterobacteriaceae: a Children's Hospital Experience.” They
said, “Resistant isolates of the Enterobacteriaceae have recently emerged as a problem in adults, both in hospital
settings and in community settings. The Enterobacteriaceae are also major pathogens in neonates, infants, and
children, although little is known about the broad-spectrum β-lactamase-producing strains in this specific age group.
The spread of β-lactam-resistant Enterobacteriaceae in children is of particular importance, since fluoroquinolones are
not approved for use in this age group and are not considered first-line agents for use in this age group. – The
objective of this study was to investigate the trends and patterns of resistance in β-lactamase-producing members of
the family Enterobacteriaceae in a children's hospital over a 9-year period (1999 to 2007). Clinically significant isolates
of the Enterobacteriaceae were screened for patterns of broad-spectrum resistance to β-lactams. The strains likely to
be resistant were subsequently confirmed by an inhibitor-based disc test. The plasmid-mediated resistance
determinants in these isolates were identified by PCR and by in vitro transformation, which successfully reproduced the
AmpC phenotype unrestricted by the species of the host organisms. Among 8,048 Enterobacteriaceae isolates
belonging to the four chromosomal ampC-negative or -nonfunctional genera, 86 (1.07%) isolates (56 Escherichia coli
isolates, 22 Klebsiella species isolates, 1 Proteus mirabilis isolate, and 7 Salmonella species isolates) exhibited broad-
spectrum β-lactam resistance patterns. These organisms collectively produced three classes of β-lactamases, including
class A extended-spectrum β-lactamases (n = 47), class C or AmpC β-lactamases (n = 36, including 4 isolates that
produced both class A and class C enzymes), and class A or B carbapenem-hydrolyzing β-lactamases (n = 3). The
proportion increased from 0.46% during the first 3 years to 1.84% during the last 3 years (relative risk [RR], 4.04; 95%
confidence interval [CI], 2.28 to 7.42; P < 0.001). The increase was mainly due to the emergence of a plasmid-mediated
blaCMY-2 β-lactamase, the incidence of which increased from 0.11% during the first 3 years to 0.96% during the last 3
years (RR, 9.11; 95% CI, 2.76 to 30.1; P = 0.001). Class A-type resistance increased slightly during the study period,
from 0.35% during the first 3 years to 0.85% during the last 3 years (RR, 2.42; 95% CI, 1.15 to 5.07; P = 0.02). A
Proteus mirabilis strain was documented to possess a novel blaDHA determinant. Of special concern, three
carbapenemase-producing isolates were identified between 2003 and 2006. The infections caused by resistant isolates
of the Enterobacteriaceae mainly affected hospitalized patients with underlying conditions; however, 19 (22%) episodes
were of community onset in otherwise well children. The rate of resistance to broad-spectrum β-lactams among isolates
of the Enterobacteriaceae is increasing in children in both hospital- and community-acquired settings, and the
resistance is driven largely by plasmid-mediated AmpC β-lactamases.” http://aac.asm.org/cgi/content/full/52/11/3909
In 2009, Burhan Arikan and Ashabil Ayan, Cukurova University & Kahramanmaras Sutcu Imam University, reported on
the “Resistance Variations of Third Generation of Cephalosporins in Some of the Enterobacteriaceae Members in
Hospital Sewage.” They said, “To estimate the resistance variation to 3rd generation Cephalosporin antibiotics, total
1457 strains of the Enterobacteriaceae family (Escherichia coli, Enterobacter aerogenes, Klebsiella pneumonia) were
isolated from hospital sewage water. – K. pneumonia showed the highest resistance to all three antibiotics compared to
the E. aerogenes and E. coli. – Total 655 bacterial samples were isolated on October, 2006- February, 2007. E. coli
was not the predominant strain (38.04%), compared to the E. aerogenes (33.69%) and K. pneumonia (27.02%) in the
first week of the October 2006-Fabruary 2007 period. Similar results were obtained in the second and the fifth weeks of
study. But in the third week, E. coli was the more predominant strain (69.14%) than E. aerogenes (15.95%) and K.
pneumonia (14.89%), while the lowest percentage of E. coli (9.77%) was obtained in the fourth week. Overall
percentage of the strains isolated in first period was 35.87% (E. coli), 37.09% (E. aerogenes) and 27.02% (K.
pneumonia). The water temperature was recorded as 12°C in first period and 32°C in the second period of the study. –
It was found that the rates of the antibiotic resistance in the all strains vary in periods. In the first period, almost half of
the E. coli strains had resistance to Ceftriaxone (CRO), Ceftizoxime (ZOX) and Cefotaxime (CTX), but the resistance
were rare in the fifth week (≤ 3%). – The existence of these resistance bacteria in sewage water, no mater where they
come from, is a real risk for acquiring such bacteria in the environment. – In conclusion, the results of this study
underline the importance of the water temperature for dissemination of the resistance factors between the
microorganism and such a screening of antibiotic resistance may be reflecting the consequence of the drug using
habits and would help to address the contribution spread of resistant bacteria to the
environment.” http://www.fspublishers.org/ijab/past-issues/IJABVOL_11_NO_1/20.pdf
In 2010, K. Chawla, et al., Kasturba Medical College at Manipal, “Reporting Emerging Resistance of Streptococcus
pneumoniae from India.” They said, “There are reports of emergence of resistant strains of S. pneumoniae showing
resistance to penicillin from all over the world, and now, resistance to multiple drugs (multidrug-resistant strains) has
been added to it. However, scanty reports are available so far from India, depicting such resistance. – A cross-sectional
study was conducted from June 2008 to December 2008, in our tertiary care center. Fifty pathogenic clinical isolates
were collected from patients suffering from lower respiratory tract infections. – Out of 50 isolates, 4% (95% Confidence
Interval - 1.4, 9.4) showed total resistance to penicillin, whereas, 10% (95% CI; 1.6, 18.3) showed intermediate
resistance. These penicillin-resistant pneumococci (4%) were also found to be multidrug-resistant (MDR) strains.
Maximum resistance was observed for cotrimoxazole and tetracycline (24% each with 95% CI; 12.2, 35.8) followed by
erythromycin and ciprofloxacin (14% each with 95%CI; 4.4, 23.6). – Increasing emergence of the resistant strains of S.
pneumoniae in the community set up requires continuous monitoring and a restricted use of antibiotics to keep a check
on its resistance pattern, for an effective treatment plan.” http://www.ncbi.nlm.nih.gov/pubmed/20300412
In 2010, J.S. JAGAI, et al., reported on the EPA Research Project “Trends and Seasonality in Antibiotic Resistance
Among Elderly Patients with Clostridium Difficile-Associated Disease.” They said, “In the US, over 300,000 cases of
Clostridium dijficile-associated disease (CDAD) occur annually in hospitals or long-term care facilities and incidence has
risen over the past two decades potentially due to increased antibiotic use. A primary risk factor for CDAD is previous
antibiotic exposure therefore, temporal patterns in CDAD hospitalizations may be driven by pathogens for which
antibiotics are prescribed. We evaluate differences in patterns between hospitalization rates of C. dijficile and
percentage of C. dijficile with antibiotic resistance (AR) by gender, geographic distribution, annual trends, and
seasonality. All 1,054,125 hospitalization records for the US elderly for C. difficile were abstracted from the Centers for
Medicare and Medicaid Services MedPAR database for a l-l-year period (1991-2004). In the population over 65,
hospitalization rates of CDAD increased from 13.71 per 10,000 in 1993 to 45.18 per 10,000 in 2004. Of all cases
19,654 (1.86%) exhibited co-morbid AR. The overall number of AR cases increased and the percentage of cases
demonstrated an increasing trend from 0.06% to 2.35% over the study period. As expected, the highest rate of
hospitalizations was observed in the 85+ years old individuals (48.2 per 10,000 population vs. 11.9 in 65-74 y.o., and
26.0 in 75-84 y.o.). Counts were organized into weekly time series and the highest rates of CDAD were observed in mid-
March (week 10) for all age groups. Cases of CDAD with AR did not show a clear seasonal pattern. These results
suggest that C. dijficile and antibiotic resistance is a significant and growing concern in the elderly population and is
associated with environmental characteristics that require further research.”
http://cfpub.epa.gov/si/si_public_record_report.cfm?dirEntryId=220116
In the 2011 CDC Research Article, "Global Distribution and Epidemiologic Associations of Escherichia coli Clonal Group
A, 1998–2007", James R. Johnson, et al., stated, "Escherichia coli clonal group A (CGA) was first reported in 2001 as
an emerging multidrug-resistant extraintestinalpathogen. Because CGA has considerable implications for public health,
we examined the trends of its global distribution, clinical associations, and temporal prevalence for the years 1998–
2007. We characterized 2,210 E. coli extraintestinal clinical isolates from 32 centers on 6 continents by CGA status for
comparison with trimethoprim/sulfamethoxazole (TMP/SMZ) phenotype, specimen type, inpatient/outpatient source, and
adult/child host; we adjusted for clustering by center. CGA prevalence varied greatly by center and continent, was
strongly associated with TMP/SMZ resistance but not with other epidemiologic variables, and exhibited no temporal
prevalence trend. Our fi ndings indicate that CGA is a prominent, primarily TMP/ SMZ-resistant extraintestinal pathogen
concentrated within the Western world, with considerable pathogenic versatility. The stable prevalence of CGA over
time suggests full emergence by the late 1990s, followed by variable endemicity worldwide as an antimicrobial drug–
resistant public health threat. CGA has been recognized primarily as a cause of community-acquired cystitis and
pyelonephritis in adult women mainly in the United States. http://wwwnc.cdc.gov/eid/article/17/11/pdfs/11-0488.pdf
The recommended disinfectants, depending on application, are chlorine, chloramines, ozone, chlorine dioxide, metals
and Ultraviolet light/radiation. While the vegetable type Enterobacteriacea coliforms are relatively easy to inactivate (not
destroy), other organisms are much more hardy. All may develop antibiotic resistance to some degree. Any treatment
system injures some bacteria leaving them viable but nonculturable as well as antibiotic resistant. It would seem the
experts forget bacteria have an autonomous repair system. They do know it takes longer than the 24 hours duration of
the tests to repair the damage.
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