L élargissement des indica1ons des macrolides au long cours doit- il faire craindre l émergence de Mycoplasma pneumoniae résistant aux macrolides?

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1 L élargissement des indica1ons des macrolides au long cours doit- il faire craindre l émergence de Mycoplasma pneumoniae résistant aux macrolides? écile Bébéar H de Bordeaux, France niversité de Bordeaux, INR, France entre National de Référence des IST bactériennes

2 onflit d intérêt Pas de conflit d intérêt en rapport avec ce3e présenta4on dans les 5 dernières années 2

3 haracteris1cs of mycoplasmas Smallest free- living eubacteria (500 to 2200 kbp) Lack of cell wall («Mollis cu/s» or Mollicutes) 17 human species: respiratory or urogenital tract 5 pathogenic species: - M. pneumoniae - M. genitalium - M. hominis -. urealy/cum -. parvum respiratory tract infec1ons (RTI) urogenital tract infec1ons 3

4 Mycoplasma pneumoniae infections hildren +++ and young adults RTI +++ typical pneumonia (20%) 2 nd cause of P after S. pneumoniae Tracheo-bronchitis (80%) sthma? M. pneumoniae with respiratory epithelial cells Extrarespiratory diseases utaneous Skin rash, exanthema, Stevens Johnson syndrome Neurologic Meningoencephalitis, peripheral neuropathy, uillain Barré syndrome 4

5 M. pneumoniae epidemiology Endemic with surges Every 4 to 7 years, lasting 18 months Short-course immunity (antigenic variations of the P1 adhesin) increase in the incidence of Mp infections worldwide Eurosurveillance, Novembre 2010 halker Euro Surv

6 Diagnosis of M. pneumoniae infections Direct diagnosis - Rarely culture, fastidious - Nucleic acid amplification tests (NTs) +++ more sensitive than serology at the early stage of infection New «gold standard» Serological diagnosis ++ - Specific antibodies, ELIS++ (variable performances) - Widely used but retrospective diagnosis - 2 serums collected 2 weeks apart - No PO but qualitative serological tests in ambulatory care (single IgM or IgM/) 6

7 Diagnosis of M. pneumoniae infections Molecular techniques definitively more sensitive than culture and serology in the early phase of infection. Still a great emphasis on serology despite limited value in diagnosis of acute infections. Serology is useful in epidemiological studies. Most cases detected by a combination of IgM antibody detection and PR. 7

8 M. pneumoniae and antibiotics Intrinsic resistance to TB targeting the cell wall (β-lactams +++) ctive antibiotics - Macrolides and related: macrolides, lincosamides, streptogramin combinations, ketolides (MLSK) - Fluoroquinolones - Tetracyclines! Macrolides and related antibiotics = 1 st line treatment for M. pneumoniae infections 8

9 n1bio1c suscep1bility tes1ng in M. pneumoniae Not in rou1ne (fas1dious growth) No commercialized kit or test LSI recommenda1ons M43-31(19), phenotypic techniques No agar diffusion Molecular techniques to detect macrolide resistance directly from specimens 9

10 MIs of MLSK against M. pneumoniae dapted from Bébéar et al., Future Microbiol

11 cquired resistance of human mycoplasmas enetic support - hromosomal mutations ++ (lack of DN repair systems -> high mutation rates) - Transposons + - No extrachromosal element Biochemical mechanisms - Target modification or protection Efflux + (in vitro) - No enzymatic inactivation 11

12 Mechanisms of macrolide resistance in bacteria MLSK Inactivating enzymes ctive efflux Ribosomal 50S s/u Methylation (2058, erm gene) Mutations in 23S rrn or in ribosomal proteins L4 and L22 12

13 cquired antimicrobial resistance in M. pneumoniae ntimicrobial Resistance lass In In Mechanism vitro vivo MLSK Yes Yes 23S rrn mutations at positions 2611, 2058, 2059, and 2062 Mutations, insertions or deletions in L4 and L22 ribosomal proteins (in vitro only) Tetracycline Yes No 16S rrn mutations at position 968 and 1193 (in vitro only) MI range for Resistant Isolates (µg/ml) 64 - >256 (erythromycin) Fluoroquinolones Yes No Mutations in gyr, gyrb, par or pare genes of QRDRs c (levofloxacin) 13

14 Macrolide resistance in M. pneumoniae Mutations in 23S rrn (1 copy in M. pneumoniae)... 5' 3' //T / S rrn domain V 14 Predominance of 2058

15 Emergence of macrolide resistance during macrolide treatment Boy 11 yo Hyper IgE syndrome Mp(+) pneumonia Josamycin Tt Failure iprofloxacin Recovering Wt M. pneumoniae MLV type I M. pneumoniae with 2059 MLV type I Position 2059 Hantz et al., J lin Microbiol,

16 Molecular diagnostic of macrolide resistance in M. pneumoniae Real-time (RT)-PR (FRET) with melting curve analysis mutated strains : lower Tm directly from clinical specimens used routinely in our diagnostic lab M129 FH WT 58 Other molecular methods: HRM RT-PR, Sanger sequencing, pyrosequencing Peuchant et al., J ntimicrob hemother, 2009 Bébéar et al., Future Microbiol,

17 Molecular typing to explore macrolide resistance? P1 adhesin gene and MLV typing No correlation between subtypes and antimicrobial resistance in most studies worlwide Polyclonal origin of macrolide resistance -> emergence of resistance de novo during tt The Spread of Mycoplasma pneumoniae Is Polyclonal in Both an Endemic Setting in France and in an Epidemic Setting in Israel Pereyre et al PLoS One,

18 onsequences of macrolide resistance in M. pneumoniae clinical isolates Need for macrolide resistance detection? Depends on macrolide resistance rates If rate >10% : molecular detection on all Mp-positive specimens ü Non-macrolide treatment promptly started if macrolide-resistant genotype identified If rate <10% : molecular detection in case of treatment failure Pereyre et al. Frontiers Microbiol

19 Evolution of macrolide resistance in M. pneumoniae in Japan Year % macrolide resistance Reference st clinical isolate described to 17% pediatric isolates Okazaki et al. Microbiol. Immunol Matsuoka ntimicrob. gents hemother. 2004; Morozumi ntimicrob. gents hemother % Morozumi et al. ntimicrob. gents hemother (national surv) 2120 children with RTI 73% Kawai et al., ntimicrob. gents hemother % Tanaka et al., Emerg. Infect. Dis and % and 59.3% Tanaka et al., Emerg. Infect. Dis % Tanaka et al., Emerg. Infect. Dis Most frequent substitutions : 2058 (95.8%) and 2058T (3.1%), 2059 (0.6%), 2611 (0.2%%), 2611T (0.1%) è Resistance high during but gradually decreased throughout Japan during

20 Evolution of macrolide resistance in M. pneumoniae in Bordeaux, France % macrolide resistance Reference Before % Peuchant et al. J. ntimicrob. hemother % Peuchant et al. J. ntimicrob. hemother % Pereyre et al. PLoS One % Pereyre et al. lin. Microbiol. Infect % Personal data % Personal data % Personal data (a few M. pneumoniae(+) samples) Most frequent substitutions : 2058 (54%) and 2059 (23%), 2611 (15%), 2062 (8%) " Resistance remains below 10% in France 20

21 Macrolide resistance in M. pneumoniae worldwide % 8-13% 2% 9% 3-4% 7-8% 26% 22-30% 47-63% % 44-90% 3.3% Data collated from the literature between High macrolide resistance rates certainly associated with antibiotic selective pressure because of extensive macrolide use < 5% 5-10% 10-50% >50% dapted from Pereyre et al. Frontiers Microbiol

22 Epidemiology of macrolide resistance in M. pneumoniae! Increase in resistance: result of antibiotic selective pressure in patients during a period of extensive macrolide use in countries (whatever the macrolide prescribed) 22

23 linical implications of macrolide resistance in M. pneumoniae linical implications ZM - Therapeutic failures, children and adults, out and in patients - # febrile days, persistent cough - Therapeutic change for FQ or T : Minocycline (MIN) and tosufloxacin (TFX) approved for treating macrolide-resistant Mp infections in children (aged 8 yo for T) in Japan (Japanese Societies of Pediatric ID and Pulmonology, 2011) MIN was more effective than TFX in achieving defervescence and in decreasing numbers of Mp copies after 3 days Okada et al., lin Infect Dis 2012; Kawai et al., ntimicrob hemother, 2013 TFX L MIN Kawai et al,

24 Treatment regimens for M. pneumoniae RTI Macrolides : 1st line treatment - zithromycin 5 days, clarithromycin 7-14 days - Erythromycin days Tetracyclines (not before 8 yo) - Tetracycline, doxycycline, minocycline days Fluoroquinolones (not before 18 yo) - Levofloxacin, 5 days - Moxifloxacin, 7-14 days Macrolide-R strains - Japan: minocycline or tosufloxacin, 7-14 days - Streptogramin combination (pristinamycin)? New ketolides? 24

25 onclusion Mp macrolide resistance, a matter of concern! In sia - Resistance rates extremely high, - onsider using an alternative to macrolides as initial treatment of Mp infection In Europe and S - Resistance still much less common, - Macrolides still be considered the first-line treatment, but with consideration for change to another drug class if unsatisfactory clinical response Waites et al. lin Microbiol Rev

26 onclusion What measures might be taken to prevent an increase in the prevalence of resistance to macrolides in M. pneumoniae? RT-PR and pyrosequencing assays for the rapid detection of macrolide-r mutants directly from clinical specimens: To adjust TB treatment To control and prevent macrolide-r outbreaks by decreasing the numbers of pharyngeal Mp and the dissemination of the infection. Macrolides used carefully especially for patients with mild symptoms Randomized trails to establish clinical guidelines for treatment of macrolide-r strains of M. pneumoniae Vaccine? No identified project Bébéar et al., lin Infect Dis 2012 Blyth and erber JPIDS

27 cknowledgments S E 3671 Sabine Pereyre Olivia Peuchant Sébastien Dégrange rabella Touati lain harron Hélène Renaudin Nadège Henin Marie ardette R. Nir-Paz (Israel) R. Dumke (ermany) V. halker (K) K. B. Waites (S) L. Xiao (S) Kitasato niversity, Japan M. Morozumi K. bukata Kawasaki Med. Sch, Japan T. Oishi