Development of Resistance mechanisms in Pseudomonas aeruginosa

Transcription

1 Development of Resistance mechanisms in Pseudomonas aeruginosa Luis Martínez Martínez ervice of Microbiology University Hospital Marqués de Valdecilla antander, pain 5th ECMID chool, antander June 2006

2 Antimicrobial agent Outer Memb. LP Phospholípids Porina Peripl. space Peptidoglycan ß-lactamase PBP Inner Memb. Phospholípids Cytoplasm Targets

3 Mechanisms of Resistance to ß-lactams

4 Natural Resistance AMP AMC CFZ CXM PIP CTX CAZ OXA FOX PTZ

5 Mechanisms of natural resistance to ß-lactams AmpC production Low permeability of outer membrane Expression of efflux pumps Altered PBPs?

6 AmpC: Basal production Cell Wall ampd ampr ampc PG Recycling AmpC: Low Level Hydrolysis

7 AmpC: Induction ß-lactam Cell Wall ampd ampr ampc PG Recycling [Partial hydrolysis] AmpC: High Level

8 AmpC: Derepression [ß-lactam] Cell Wall ampd ampr ampc PG Recycling AmpC: Very high level

9 AmpC: Resistance phenotypes INDUCIBLE PRODUCTION TIC PIP CAZ CPM CBPM /r PARTIAL DEREP. I I I /r TOTAL DEREP. I R R R /R

10 IPM CAZ CAZ FEP IPM FEP MPM PIP MPM PIP Deficiente en AmpC Inducible AmpC

11 AmpC Derepression IPM CAZ MPM FEP PIP Ticarcilina Piperacilina Piper/tazob Ceftazidima Cefepime Aztreonam Imipenem Meropenem CMI >64 >64 > Act. R R R R I R Interpr. R R R R I R

12 econdary ß-lactamases B-J-M Group PROPERTIE EXAMPLE 2a Pene/CLV () NP-1 2b BroadEsp/CLV () TEM 1/2 2be ExtEsp/CLV () PER-1; TEM-42 2c CARBse/CLV () PE-n, CARB-n 2d OXAse OXA-n, LCR-1 3 MetEnz/EDTA () IMP,VIM, PM,...

13 econdary ß-lactamases ANTIM. WILD TYPE PE1 TEM1 OXA3 OXA11 PER1 IMP1 TIC TIC-CLV PIP CAZ PIM ND AZT [4] IMP (var)

14 ß-lactamasa OXA-31 CAZ FEP ATM Ticarcillin Piperacilin Piper/tazob Ceftazidime Cefepime Aztreonam CMI Real I Interpr. I/R

15 Metallo-ß-lactamases IMP VIM PM GIM IM

16 VIM METALLO-β-LACTAMAE K cat /K m (M.s) VALUE VIM-1 VIM-2 IMP 1.3x x 10 6 MPM 2.6x x 10 6 Docquier et al. J-D, JAC 2003

17 VIM METALLO-β-LACTAMAE MIC VALUE IMP MPM P. aeruginosa (VIM-1) > >128 E. coli (VIM-1) 8 2 E. cloacae (VIM-2) 4 4 Miriagou V et al, AAC 2003; Jeong H et al, JAC 2003, Cornaglia G et al, CID 2000

18 MBL Production PIP IPM CAZ MPM FEP ATM Ticarcillin Piperacillin Piper/tazob Ceftazidime Cefepime Aztreonam Imipenem Meropenem CMI >64 >64 > >16 >16 Real Intepr. R R R R R R R R R R R R R R

19 MBL Detection Using Etest? IP: imipenem IPI: imipenem + EDTA

20 OprF P. aeruginosa

21 OmpA E. coli

22 OmpF E. coli

23

24 OprD EXPREION AND CARBAPENEM REITANCE IN P. aeruginosa MIC IMP OprD ++ OprD + OprD - <= >= Dib et al. EJCMID 1995

25 AmpC/OprD IN P. aeruginosa AmpC OprD IMP MPM CRB CAZ BAAL DEREPREED BAAL DEREPREED

26 OprD Loss PIP CAZ FEP ATM IPM MPM Ticarcillin Piperacillin Piper/tazob Ceftazidime Cefepime Aztreonam Imipenem Meropenem CMI <16 <16 < Real R Interpr. R I Inducible AmpC

27 OprD loss in clinical isolates of P. aeruginosa producing VIM-1 OprD VIM-1(+) Cornaglia et al, CID 2000

28 Loss of OprD porin in P. aeruginosa RNA expression of oprd I within oprd PCR amplification of oprd Walters et al, FEM ML 2004

29 ZINC DECREAE OprD LEVEL IN P. aeruginosa: REITANCE TO IMIPENEM 66.2 OprD OprD MH LUC Zn 2+ MH LUC Zn 2+ P. aeruginosa PAO1 P. aeruginosa PAO1 D- Conejo MC et al, AAC 2003

30 EFFLUX YTEM MAJOR FAMILIE 1. MF: Major Facilitator uperfamily 2. RND: Resistance Nodulation-Division 3. MR: mall Multidrug Resistance 4. ABC: ATP-Binding Cassette 5. MATE: Multidrug And Toxic Extrusion

31

32 mexa-mexb-oprm nalb mexr mexa mexb oprm mexe-mexf-oprn mext mexe mexf oprn Nakae, Microbiología EM, 1997 (Mod.)

33 EFFLUX PROTEIN Located in Cytoplasmic Membrane Multiprotein ystems (PUMP+MFP+OMF) Multiple variants in the same host Broad/Narrow substrate profile

34 OprM P. aeruginosa

35 MULTIDRUG EEFLUX PUMP IN P. aeruginosa PUMP MFP OMP GENE REG UBTRATE MexB MexA OprM mexamexboprm mexr Tet, Cl, FQ, β-l (MPM...), Rif, Nov, XT,... MexD MexC OprJ mexcmexdoprj mex Tet, Cl, FQ, β-l (Cephems), TMP MexF MexE OprN mexemexforpn mext Cl, TMP, FQ MexY MexX OprM mexxmexy mexz AmGlu, Tet, Ery

36 BAAL EXPREION OF EFFLUX YTEM Constitutively Expressed: MexAB-OprM, AcrAB-TolC, Inducible systems: MexXY-OprM, ilent in wild type strains: MexCD-OprJ, MexEF-OprN, INTRINIC REITANCE CONTRIBUTED BY CONTITUTIVE AND INDUCIBLE YTEM

37 EXPREION OF ACTIVE EFFLUX 1. BAAL EXPREION 2. OVEREXPREION Active efflux is present in both (clinically) susceptible and resistant organisms

38 CONTITUTIVE EXPREION OF EFFLUX PUMP() IN P. aeruginosa Antimicrobial Agent mexab-oprm mexab-oprm Nalidixic Acid Ciprofloxacin Tetracycline 64 1 Chloramphenicol Amoxicillin Piperacillin Carbenicillin Ceftazidime Cefepime Meropenem

39 EFFLUX PUMP ITEMA MUTACION IMP MPM PEN/CEF/IBL CF4G TET/CLO/TMP ERY FLQ MexAB/OprM nalb R R R R R R MexCD/OprJ nfxb-a R R R nfxb-b R R R R MexEF/OprN* nfxc R R / /R R R *OprD(-)

40 OprM/OprD IN P. aeruginosa OprM OprD IMP MPM CRB

41 mexe-mexf-oprn oprd mext mexe mexf oprn (-) (+) oprd czc czcr czcc czcb czca (-) (+) czccba Perron et al, JBC 2004 (Mod.)

42 ZINC AND REITANCE TO IMIPENEM. ROLE OF THE CzcCBA YTEM ublethal [Zn] induce resistance to Zn and to IMP Imipenem may also select for Zn-R Lethal [Zn] select stable mutants resistant to Zn and to IMP, because of mutation (V194L) in Czc Expression of mutated Czc causes increased expression of czcc and decreased expression of oprd.

43 Expression of OprN and OprD OprN OprM OprD PT75 PAO1 Köhler et al. Mol. Microbiol. 1997

44 MICs of Imipenem against P. aeruginosa hyperproducing MexCD-OprJ train OprD MexC IMP C MI MI-94C CD CD-921C Wolter et al, AAC 2005

45 Mechanisms of Resistance to other antimicrobials

46 Natural Resistance TET DOX CHL RIF XT

47 Resistance to Aminoglycosides Altered permeability Modifying enzymes Efflux pumps (MexXY-OprM)

48 Resistance to Aminoglycosides Interpretative reading: Difficult to perform >10 compounds to be tested) >80 different Mechanisms (but...5 of them represent 75% of cases)

49 Aminoglycosides GM TOB Nt AK Enzyme R AAC(3)-I R R ANT(2 )-I R R R AAC(6 )-II, AAC(3)-II,IV,V R R R AAC(6 )-I R APH(3 )-VI

50 Resistance to Aminoglycosides AK TOB GM GM TOB AK ANT(2 )-I AAC(6 )-II Combined mechanisms

51 Resistance to Fluoroquinolones: Wild-type phenotype NAL CIP LEV OFL NOR

52 Resistance to Fluoroquinolones Efflux pumps Target modification (Gyrase, Topo IV) Altered permeability: LP

53 Resistance to Fluoroquinolones CIP OFX Mex AB-OprM Ciprofloxacin Ofloxacin CMI 1 4 Real I Interpr. I I

54 EXPREION OF EFFLUX PUMP IN P. aeruginosa OprM OprJ OprN LVFX FEP CARB Lee A., J Bacteriol 2000

55 EFFECT OF PAN ON MIC OF LEVOFLOXACIN AGAINT P. aeruginosa train PAN MIC of Levofloxacin+[PAN] 0 mg/l 10 mg/l 20 mg/l WT >512 0,125 0,015 0,008 nalb > ,125 0,03 nfxb > ,125 0,03 nfxc > ,25 0,06 Mex(*) 32 0,015 0,015 0,008 Lomovskaya O et al, AAC 2001