Introduction to Antibacterial Therapy Clinically Relevant Microbiology and Antibiotic Use Edward L....
Transcript of Introduction to Antibacterial Therapy Clinically Relevant Microbiology and Antibiotic Use Edward L....
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Introduction to Antibacterial Introduction to Antibacterial TherapyTherapy
Clinically Relevant Microbiology and Antibiotic Use
Edward L. Goodman, MD
July 22, 2010
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OutlineOutline
Basic Clinical BacteriologyAntibiotics
– Categories– Pharmacology – Mechanisms of Resistance
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Goodman’s Scheme for the Major Goodman’s Scheme for the Major Classes of Bacterial PathogensClasses of Bacterial Pathogens
Gram Positive CocciGram Negative RodsFastidious Gram Negative OrganismsAnaerobes
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Gram Positive CocciGram Positive Cocci
Gram stain: clusters Catalase pos = Staph Coag pos = S aureus Coag neg = variety of
species
Chains and pairs Catalase neg =
streptococci Classify by hemolysis Type by specific CHO
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Staphylococcus aureusStaphylococcus aureus
>95% produce penicillinase (beta lactamase) = penicillin resistant
At PHD ~60% of SA are hetero (methicillin) resistant = MRSA (less than national average)
Glycopeptide (vancomycin) intermediate (GISA) – MIC 8-16– Eight nationwide
First VRSA reported July 5, 2002 MMWR– Seven isolates reported (5/7 from Michigan)– MICs 32 - >128– No evidence of spread w/in families or hospital
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S. aureus
Penicillin
[1950s]
Penicillin-resistant
S. aureus
Evolution of Drug Evolution of Drug Resistance in Resistance in S. aureusS. aureus
Methicillin
[1970s]
Methicillin-resistant S. aureus (MRSA)
Vancomycin-resistant
enterococci (VRE)
Vancomycin
[1990s]
[1997]
Vancomycin
intermediate-resistantS. aureus (VISA)
[ 2002 ]Vancomycin-
resistantS. aureus
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MSSA vs. MRSA MSSA vs. MRSA Surgical Site InfectionsSurgical Site Infections
(1994 - 2000)(1994 - 2000)Controls(n=193)
MSSA SSI(n=165)
MRSA SSI(n=121)
Death, no. (%) 4(2.1) 11(6.7) 25(20.7)
LOS aftersurg., median
5 14 23
Hosp. charges,median $
29,455 52,791 92,363
CID. 2003;36: 592-598.
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Coagulase Negative StaphCoagulase Negative Staph
Many species – S. epidermidis most common
Mostly methicillin resistant (65-85%)Often contaminants or colonizers – use
specific criteria to distinguish– Major cause of overuse of vancomycin
S. lugdunensis is rarely a contaminant– Causes destructive endocarditis
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Clin Infect Dis 1999;29:239-244
Nosocomial Bloodstream Nosocomial Bloodstream IsolatesIsolates
SCOPE ProjectSCOPE Project
Other Other (11%)(11%)
Coagulase-Coagulase-negative negative
staphylococci staphylococci (32%)(32%)
Enterococci Enterococci (11%)(11%)
All gram-All gram-negative negative (21%)(21%)
Candida Candida (8%)(8%)
Viridans Viridans streptococci streptococci
(1%)(1%)
Staphylococci Staphylococci aureusaureus (16%) (16%)
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StreptococciStreptococci
Beta hemolysis: Group A,B,C etc.Invasive – mimic staph in virulenceS. pyogenes (Group A)
– Pharyngitis,– Soft tissue
Invasive TSS
– Non suppurative sequellae: ARF, AGN
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Other Beta hemolytic Other Beta hemolytic
S. agalactiae (Group B)– Peripartum/Neonatal– Diabetic foot– Bacteremia/endocarditis/metastatic foci
Group C/G Streptococcus– large colony variants: similar clinical illness as GAS
plus bacteremia, endocarditis, septic arthritis– Small colony variants = Strept milleri
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Viridans groupViridans group
Anginosus sp.Bovis sp.: Group DMutans sp.Salivarius sp.Mitis sp.
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Streptococcus anginosusStreptococcus anginosus GroupGroup
Formerly ‘Streptococcus milleri’ or ‘Streptococcus intermedius’.
S. intermedius; S. constellatus; S. anginosusOral cavity, nasopharynx, GI and
genitourinary tract.
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S. anginosusS. anginosus Group Group
Propensity for invasive pyogenic infections ie. abscesses.
Grow well in acidic environmentpolysaccharide capsule resists phagocytosisproduce hydrolytic enzymes: hyaluronidase,
deoxyribonucleotidase, chondroitin sulfatase, sialidase
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S. anginosusS. anginosus Group Group
Oral and maxillofacial infectionsBrain, epidural and subdural abscessesintraabdominal abscessesempyema and lung abscessesbacteremias usually secondary to an
underlying focus of infection. Look for the Abscess!
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EnterococciEnterococci
Formerly considered Group D Streptococci now a separate genus
Bacteremia/Endocarditis Bacteriuria Part of mixed abdominal/pelvic infections Intrinsically resistant to cephalosporins No bactericidal single agent (except ?Dapto) Role in mixed flora intra-abdominal infection
trivial- therapy for 2° peritonitis need not cover
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Gram Negative RodsGram Negative Rods
Fermentors Oxidase negative Facultative anaerobes Enteric flora Numerous genera
– Escherischia– Enterobacter– Serratia, etc
UTI, IAI, LRTI, 2°B
Non-fermentors Pure aerobes Pseudomonas (oxidase
+) and Acinetobacter (oxidase -)– Nosocomial LRTI,
bacteremia, UTI– Opportunistic– Inherently resistant
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Fastidious Gram Negatives Fastidious Gram Negatives
Neisseria, Hemophilus, Moraxella, HACEK Require CO2 for growth
Culture for Neisseria must be plated at bedside – Chocolate agar with CO2
– Ligase chain reaction (like PCR) has reduced number of GU cultures for N. gonorrhea
Can’t do MIC without culture Increasing resistance to FQ not detected w/o culture
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AnaerobesAnaerobes
Gram negative rods– Bacteroides (gut/gu flora)– Fusobacteria (oral and gut)– Prevotella (mostly oral)
Gram positive rods– Clostridia (gut)– Proprionobacteria (skin)
Gram positive cocci– Peptostreptococci and peptococci (oral, gut, gu)
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Anaerobic Gram Negative Anaerobic Gram Negative RodsRods
FastidiousProduce beta lactamaseEndogenous floraWhen to consider
– Part of mixed infections– Confer foul odor– Heterogeneous morphology– Gram stain shows GNR but routine cults negative
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Antibiotic ClassificationAntibiotic Classificationaccording to Goodmanaccording to Goodman
Narrow Spectrum– Active against only one of the four classes of
bacteriaBroad Spectrum
– Active against more than one of the classesBoutique
– Highly specialized use– Restricted to ID physicians
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Narrow SpectrumNarrow Spectrum
Active mostly against only one of the classes of bacteria– gram positive: glycopeptides, linezolid,
daptomycin, telavancin– aerobic gram negative: aminoglycosides,
aztreonam– anaerobes: metronidazole
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Narrow SpectrumNarrow SpectrumGPC GNR Fastid Anaer
Vanc ++++ ----- ----- only clostridia
Linezolid ++++ ----- ----- Only gram pos
Dapto/Telavancin
++++ ----- ----- -----
AG ----- ++++ ++ -----
Aztreon ----- +++ + -----
Metro ----- ----- ----- ++++
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Broad SpectrumBroad Spectrum
Active against more than one class GPC (incl many MRSA) and anaerobes:
clindamycin GPC (not MRSA*) and GNR: cephalosporins,
penicillins, sulfonamides, TMP/Sulfa (*include MRSA), FQ
GPC (not MRSA*), GNR and anaerobes: ureidopenicillins + BLI, carbapenems, tigecycline (*MRSA), tetracyclines (*MRSA), moxiflox
GPC and fastidious: macrolides
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Penicillins/CarbapenemsPenicillins/Carbapenems
Strep OSSA GNR Fastid Anaer
Pen ++++ -- +/-- -- +/--
Amp/ amox
++++ -- + +/-- +/--
Ticar ++ -- ++ +/-- +
Ureid +++ -- +++ +++ ++
U+BLI +++ ++++ ++++ +++ ++++
Carba ++++ ++++ ++++ ++++ ++++
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CephalosporinsCephalosporins
GPC non -MRSA
GNR FASTID ANAER
Ceph 1 ++++ + -- --
Ceph 2 ++ ++ + --
cefoxitincefotetan
++ ++ + +++
Ceph 3 +++ +++ +++ --
Ceph 4 +++ ++++ +++ --
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PharmacodynamicsPharmacodynamics
MIC=lowest concentration to inhibit growth MBC=the lowest concentration to killPeak=highest serum level after a dose AUC=area under the concentration time
curvePAE=persistent suppression of growth
following exposure to antimicrobial
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Pharmocodynamics: Dosing Pharmocodynamics: Dosing for Efficacyfor Efficacy
Blo
od L
evel
Time
Peak
MIC
Trough
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Parameters of antibacterial Parameters of antibacterial efficacyefficacy
Time above MIC (non concentration killing) - beta lactams, macrolides, clindamycin, glycopeptides
24 hour AUC/MIC - aminoglycosides, fluoroquinolones, azalides, tetracyclines, glycopeptides, quinupristin/dalfopristin
Peak/MIC (concentration dependent killing) - aminoglycosides, fluoroquinolones, daptomycin
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Time over MICTime over MIC
For beta lactams, should exceed MIC for at least 50% of dose interval
Higher doses may allow adequate time over MIC For most beta lactams, optimal time over MIC can
be achieved by continuous infusion (except unstable drugs such as imipenem, ampicillin)
For Vancomycin, evolving consensus that troughs should be >15 for most serious MRSA infections, especially pneumonia and bacteremia– If MRSA MIC is 1.5 - 2, should avoid vancomycin in
favor of daptomycin, linezolid or tigecycline
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Higher Serum/tissue levels are Higher Serum/tissue levels are
associated with faster killingassociated with faster killing Aminoglycosides
– Peak/MIC ratio of >10-12 optimal – Achieved by “Once Daily Dosing”– PAE helps
Fluoroquinolones – 10-12 ratio achieved for enteric GNR
PAE helps– not achieved for Pseudomonas – Not always achieved for Streptococcus pneumoniae
Daptomycin– Dose on actual body weight
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AUC/MIC = AUICAUC/MIC = AUIC
For Streptococcus pneumoniae, FQ should have AUIC >= 30
For gram negative rods where Peak/MIC ratio of 10-12 not possible, then AUIC should >= 125.
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Folic acid synthesis
ß-lactams & Glycopeptides (Vancomycin)
50 50 5030 30 30
DNA
mRNA
Ribosomes
PABA
DHFA
THFA
Cell wall synthesis
DNA gyrase
Quinolones
Protein synthesis inhibition
Protein synthesis inhibitionTetracyclines
Protein synthesis mistranslation
Macrolides & Lincomycins
Cohen. Science 1992; 257:1064
DNA-directed RNA polymerase
Rifampin
Aminoglycosides
Sulfonamides
Trimethoprim
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Pathways of Common Pathways of Common Resistance MechanismsResistance Mechanisms
Impede access of drug to target– Beta lactamases: multiple classes– Aminoglycoside altering enzymes– Chloramphenicol altering enzymes– Altered porin channels – carbapenems– Efflux pumps - macrolides
Alterations in target– Altered binding proteins: MRSA, DRSP– Methylation of ribosomes: macrolides– Bypass metabolic pathways: TMP/Sulfa– Alteration in gyrases
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Some Background onSome Background on EnterobacteriaceaeEnterobacteriaceae
β-lactam antibiotics (derivatives of penicillin) have long been the mainstay of treating infections caused by Enterobacteriaceae.
However, resistance to β-lactams emerged several years ago and has continued to rise.– Extended spectrum β-lactamase producing
Enterobacteriaceae (ESBLs)– Plasmid-mediated AmpC-type enzymes
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Extended Spectrum Beta Extended Spectrum Beta Lactamases (ESBL)Lactamases (ESBL)
Hyper production derived from TEM beta lactamases
Predominantly in Klebsiella and E coliConfer resistance to penicillins,
cephalosporins, monobactams – Plasmids also confers R to FQ/AG– Indications for carbapenems*
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Amp C Beta LactamasesAmp C Beta Lactamases Chromosomal cephalosporinases active against
– 1st - 3rd generation cephalosporins, penicillins even with BLI Constituent or Inducible Reside in periplasmic space
– Not easily detected when in low numbers SPICE organisms possess Amp C
– Serratia– Pseudomonas– Indole + Proteii– Citrobacter– Enterobacter
Indication for carbapenems* (imipenem, meropenem, ertapenem, doripenem)
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The Last Line of DefenseThe Last Line of Defense
Fortunately, our most potent β-lactam class, carbapenems, remained effective against almost all Enterobacteriaceae.
Doripenem, Ertapenem, Imipenem, Meropenem
Unfortunately, “Antimicrobial resistance follows antimicrobial use as surely as night follows day”
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KKlebsiella lebsiella PPneumoniae neumoniae CCarbapenemasearbapenemase
KPC is a class A -lactamase– Confers resistance to all -lactams including extended-spectrum
cephalosporins and carbapenems
Occurs in Enterobacteriaceae– Most commonly in Klebsiella pneumoniae– Also reported in: K. oxytoca, Citrobacter freundii, Enterobacter
spp., Escherichia coli, Salmonella spp., Serratia spp.,
Also reported in Pseudomonas aeruginosa (South America)
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Susceptibility Profile of KPC-Producing Susceptibility Profile of KPC-Producing K. pneumoniaeK. pneumoniae
Antimicrobial Interpretation Antimicrobial Interpretation
Amikacin I Chloramphenicol R
Amox/clav R Ciprofloxacin R
Ampicillin R Ertapenem R
Aztreonam R Gentamicin R
Cefazolin R Imipenem R
Cefpodoxime R Meropenem R
Cefotaxime R Pipercillin/Tazo R
Cetotetan R Tobramycin R
Cefoxitin R Trimeth/Sulfa R
Ceftazidime R Polymyxin B MIC >4μg/ml
Ceftriaxone R Colistin MIC >4μg/ml
Cefepime R Tigecycline S
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Carbapenem resistance in Carbapenem resistance in K. pneumoniaeK. pneumoniae
NHSN Jan 2006- Sept 2007NHSN Jan 2006- Sept 2007
CLABSI CAUTI VAP Pooled
Carbapenem resistant
K. pneumoniae11% 9% 4% 8%
Hidron, A et al Infect Control Hospital Epidemiol. 2008;29:996
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Geographical Distribution of
KPC-Producers
Frequent Occurrence
Sporadic Isolate(s)
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Antibiotic Use and ResistanceAntibiotic Use and Resistance
Strong epidemiological evidence that antibiotic use in humans and animals associated with increasing resistance
Subtherapeutic dosing encourages resistant mutants to emerge; conversely, rapid bactericidal activity discourages
Hospital antibiotic control programs have been demonstrated to reduce resistance
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Historic overview on treatment of Historic overview on treatment of infectionsinfections
2000 BC: Eat this root1000 AD: Say this prayer1800’s: Take this potion1940’s: Take penicillin, it is a miracle drug1980’s – 2000’s: Take this new antibiotic, it
is a bigger miracle!?2011: Eat this root!
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Antibiotic ArmageddonAntibiotic Armageddon
“There is only a thin red line of ID practitioners who have dedicated
themselves to rational therapy and control of hospital infections”
Kunin CID 1997;25:240
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Thanks toThanks to
Shahbaz Hasan, MD for allowing me to use slides from his 6/6/07 Clinical Grand Rounds on Streptococci
Eliane S Haron, MD for allowing me to use the “Eat this root” slide
Jean B. Patel, PhD and CDR Arjun Srinivasan, MD, Division of Healthcare Quality Promotion at CDC for Kpc slides