The prospect of post-antibiotic era:

waiting or do something about it?

Perspectiva erei post-antibiotice:

asteptam sau ne implicam?

Dorina Timofte
Institute of Veterinary Science
University of Liverpool
 Lecture outline
• The issue of antimicrobial resistance (AMR)

• AMR in humans…particularly Romania

• Pets as reservoirs of AMR

• What can WE do?

• Lets keep antibiotics working

 The issue of:
Antimicrobial resistance (AMR)
• A major challenge for the medical, veterinary and
agricultural industries
• Urgent need to understand AMR spread and
molecular mechanisms involved
The Global Challenge of Antimicrobial Resistance
The Jim O’Neill Review
In the past two decades we
have witnessed:
• The spread of extensively drug
resistant (XDR) Mycobacterium
tuberculosis;
• The spread of MRSA (methicillin-
resistant Staphylococcus aureus) in the
community;
• Emergence of vancomycin-resistant
enterococci (VRE)

The rise of plasmid-mediated

 ESBL-producing
Enterobacteriaceae
 Carbapenemase-producing
bacteria
 Colistin resistance
 From Beta-lactamase to Extended-
spectrum β-Lactamases
(ESBLs) and to Carbapenemases
The rise of:
• Extended-spectrum beta-lactamases (ESBLs)
– mutants of enzymes (Beta-lactamases) that previously
could only inactivate penicillins but now have gained
activity against many cephalosporins;
– Confer resistance to most beta-lactam antibiotics but NOT
carbapenems. Thus….
– Carbapenems are first line agents for treating infections
caused by ESBL-producing organisms
• The emergence of carbapenemases
such as KPC and NDM-1
 Carbapenemasele- De ce sa ne
ingrijoreze?

• Enzime care distrug antibioticele β-lactamice,

inclusiv carbapenemele
• Sunt amplasate pe elemente genetice mobile
(plasmide, integroni)
• Genele care le codifica sunt frecvent asociate cu alte
gene de rezistenta: PDR Pan-Drug-Resistance
• Extrem de dificil de tratat
• Asociate cu o rata crescuta de morbiditate si
mortalitate la pacientii infectati cu aceste organisme
 Mecanismul rezistentei la carbapeneme

Most Common
Classification Enzyme
Bacteria
Class A KPC, SME, Enterobacteriaceae
IMI, NMC, (rare reports in P. aeruginosa)
GES

Class B IMP, VIM, P. aeruginosa

(metallo-b- GIM, SPM, Enterobacteriaceae
lactamse) NDM Acinetobacter spp.
Class D OXA Acinetobacter spp.

“The BIG FIVE”

 Spectrul de rezistenta al uni izolate de
K. pneumoniae-producatoare de KPC

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 >4mg/ml
Ceftriaxone R Colistin MIC >4mg/ml
Cefepime R Tigecycline S

R = Resistance/NOT effective S= Sensitive/Effective

 AMR in Romania

Antimicrobial resistance in
Human hospitals in Romania

• SGM Grant May 2014: Implementing detection of carbapenemase

producing Enterobacteriaceae (CPE) and non-fermentative bacteria in
Romanian hospitals

• Pilot study: Implementation of carbapenemases

screening in three hospitals
• Main goal: raise awareness and provide the evidence
base demonstrating the necessity of a national
surveillance system
 Implementation of CPO faecal screening:
Romanian pilot study
• Three hospitals were selected from two areas
• Faecal screening for CPOs was implemented for in-
patients for 6 months;
• Clinical isolates were also included
• Patients with positive clinical isolates were included for
faecal screening
• Overall, 820 clinical, faecal and environmental samples
were analyzed

Romania
 Molecular testing: Liverpool University
PCR screening and sequencing for:
• extended spectrum beta-lactamases (ESBL)
including blaCTX-M, SHV, TEM, OXA
• carbapenem-resistance genes (blaNDM, blaKPC,,
blaGES, blaIMP, blaVIM, blaSPM)
• Carbapenem hydrolysing class D beta-
lactamases (CHDL) corresponding to OXA-23,
OXA-24/40, OXA-58 and OXA-148 groups
 What we found:
25

20
OXA 24

15 OXA 23
VIM-2
OXA-48
10
NDM1

0
H1 H3

81% of CNS from H1 and 73% from H3 –

produced carbapenemases

• Carbapenem non-susceptible (CNS) Gram-negative organisms:

5.11% (H1), 11.4% (H2) and 20.3% (H3)
Revealing a myriad of carbapenemase producing Gram-
negative bacteria

Morganella morganii OXA-48

VIM-2
Escherichia coli
VEB-1a
Klebsiella pneumoniae OXA 23
Pseudomonas… OXA 24/72
SHV/1/11/12
Acinetobacter… CTX-M-15
0 5 10 15 20 25
NDM-1
Hospital H1 OXA-48
LEN-25
Klebsiella CTX-M-15
pneumoniae
SHV-11
Serratia marcescens

0 10 20 30 40

Hospital H3
 Rezistenta la colistin mediata de
mcr-1 in Romania
Izolate clinice umane:
- 145 tulpini de Enterobacteriaceae (75% cu
rezistenta la colistin)- isolate clinice provenite
din Iasi, Cluj, Tg. Mures si Timisoara;

- Nr de tulpini positive pentru mcr-1: 0

Tulpini de E. coli izolate de la

pui (3 abatoare din Moldova):

- Tulpini positive 12/92 (13%) tulpini pozitive

Antimicrobial resistance in animal
reservoirs..
…with focus on companion animals
 Why do we need to worry about AMR in pets?

• Shared environment
• Close contact between owner and pets
• The number of companion animals has increased in the
last 50 years (…in the EU/UK)
– UK numbers (2017) - 8M cats, 8M dogs, 0.8M horses

• Certain people may be at risk (immunocompromised,

young children, elderly)
 Common antimicrobial resistance
issues for man and pets

Quiz time! 
• MRSA ?
• MRSP ?
• ESBL ?
• MDR ??....
• Pseudomonas spp, Enterococcus spp,
Acinetobacter baumannii
 Common antimicrobial resistance
issues for man and pets
• Methicillin-Resistant Staphylcoccus aureus (MRSA) and
other methicillin-resistant staphylococci (MRSP)
• Extended Spectrum beta-lactamase producing
Escherichia coli (ESBL) E. coli and other
Enterobacteriaceae
• Multi-Drug Resistant (MDR) Pseudomonas spp,
Enterococcus spp, Acinetobacter baumannii

 Both human and pets - risk of

colonisation/infection
 Transmission can occur both ways
 MRSA: sharing & public health risks
• MRSA is associated with infections in both humans and
animals
• Less than 1% of healthy humans carry MRSA
• Can be higher (7-8%) in healthcare workers
• Higher in vet staff: 7-13% of vets and nurses are colonised
with MRSA
• Increasing evidence that MRSA can be transmitted in both
directions (zoonotic and reverse zoonotic)
Methicillin-resistant Staphylococcus
pseudintermedius (MRSP)

• S. pseudintermedius is more commonly associated

with animals than man
• Thought to be involved in 95% of all canine
pyoderma cases
• Carriage in people is uncommon and transient
• UK prevalence of MRSP in dogs seems to be very
low
• However, it is highly resistant to antimicrobials
Schmidt et al (2014), BMC Veterinary Research, 10:17
 Carbapenems are not authorized for use in EU or UK
companion animals
 However, the concurrent presence of blaCMY-42 and other
antimicrobial resistance genes could lead to co-selection
of carbapenemase genes in this population.
 WHO-CIAs
ce sunt?
Critically Important Antibiotics (CIAs)
• The WHO maintains a list of CIAs (Critically Important
Antibiotics) for human health
• as many of the same antibiotics are used in both
humans and animals this list must be taken into
consideration when choosing and using antibiotics
in animals
Of particular note Fluoroquinolones and 3rd and 4th generation
Cephalosporins are given the very highest priority on the CIA list.

This means that these antibiotics should never be used

empirically and use should always be supported by culture
and sensitivity data indicating no suitable alternatives.
 HP-CIAs
Highly Protected Critically Important
Antimicrobials
 Resurse:
British Small Animal Association:
https://www.bsava.com/

Scotland’s Healthy Animals website:

https://www.scotlandshealthyanimals.scot/build-your-guidance/
What can WE do about AMR?
 Drivers of antibiotic resistance

• Antibiotic use
– 50% of the antibiotics used in hospitals are
unnecessary1
– Require better use of the available tests and the
development of new tests

• Transmission of resistant pathogens

– Good general infection control practices
– More targeted interventions
1Centersfor Disease Control and Prevention (2014). Overview and evidence to support
stewardship: http://www.cdc.gov/getsmart/healthcare/evidence.html
 Lord O’Neill:

“state-of-the-art rapid
diagnostics could be a
game-changer”

Antimicrobial Resistance: Tackling a crisis for the health and

wealth of nations. The Review on Antimicrobial Resistance
Chairedby Jim O’Neill December 2014, http://amr-review.org/
 Let`s keep antibiotics working !
“ I find it incredible that doctors must still prescribe
antibiotics based only on their immediate
assessment of a patient’s symptoms, just like they
used to when antibiotics first entered common use
in the 1950s”
 BSAVA Resources: Culture and
susceptibility testing
“Culture and sensitivity test results considerably
assist the choice of which antimicrobial to use.

Culture is not required in every case, but when

prolonged courses of antimicrobials are likely to be
needed (e.g. pyoderma, otitis externa and deep or
surgical would infections) or when there is
uncertainty about the presence or sensitivity of a
bacterial infection then culture and sensitivity
testing will improve the animal’s treatment”.

https://www.bsava.com/Resources/Veterinary-resources/Medicines-
Guide/Antibacterials
 BSAVA Resources: Likely pathogenic
organisms
“The veterinary surgeon may have a good idea of the likely organism(s)
involved in a particular condition.
Some organisms have stable and predictable resistance patterns
enabling rational antibacterial selection from empirical research and
experience…”

• Predictable susceptibility profiles:

– Pasteurella spp
– Streptococcus spp
– Truperella pyogenes

• Organisms with unpredictable susceptibility profiles:

Staphylococcus spp
E. coli (and all other Enterobacteriaceae)
Pseudomonas spp
 Can we afford to take this approach?

Chief Medical Officer, Professor Dame Sally Davies

• “…we could routinely see deaths from minor
surgery within 20 years if new antibiotics are
not discovered…”
http://bsac.org.uk/antimicrobial-resistance-poses-catastrophic-threat-says-chief-medical-officer/
 My pitch:

Increased USE of Culture and Susceptibility

Testing can preserve the efficacy of currently
available antibiotics
 Antimicrobial stewardship
and C&S answers

1. Is there a bacterial infection?

2. What is the most appropriate antibiotic?

This can often be a narrow spectrum AB

3. C&S provides the MIC (minimum inhibitory

concentration) thereby allowing optimisation of:
- dosing interval (T>MIC)
- the optimal dose (Cmax:MIC)
 Should we follow the Scandinavian
countries example?

There, prescription of FQs, 3rd and 4th

gen cephalosporins is possible based
only on C&S which demonstrates that
there is no susceptibility to first line
antimicrobials
Diagnostics: the power of knowing when
to prescribe antimicrobials

Culture & susceptibility (C&S)

sau

CULTURA si ANTIBIOGRAMA

The standard methods have not

changed for 50 years!
 Diagnostics: the power of knowing when to prescribe
antimicrobials

A. Pure cultures: RESULTS

24h 24h ID +AST REPORTED
testing @ 48h
ID + AST

B. Mixed cultures:
24h
24h 24h RESULTS
ID +AST REPORTED
@ 72h
ID + AST

Purification step
 What can we do now?
Introducing MALDI-TOF MALDI-TOF MS and Microorganisms
Identification
Bacterial, fungal, mycoplasma
Identification -in 20sec-20 min!!

Detection of antibiotic resistance

Direct detection of drug-modifying
enzymes, including beta-lactamases and
aminoglycoside- modifying enzymes
 first-line discrimination of MRSA isolates

ID

Allows informed empiric antibiotic selection 24-

48h earlier than with biochemical identification
 Common rapid Diagnostics

Point-of-Care Testing
Example:
SNAP Feline Triple Test- Detect three underdiagnosed
diseases
- FIV (Sen. 100%/Spec. 99.2%)
- FeLV (Sen. 100%/Spec. 98.6%), and
- Feline heartworm [Dirofilaria immitis, (Sen. 89.3%/Spec.
99.5%)] in just 10 minutes.

Shift to commercial platforms that perform

real-time amplification and detection assays f
or numerous pathogens
 Rapid molecular Diagnostics
Single-step, cartridge-based molecular test devices
target pathogens pertinent to clinical syndromes:
 respiratory tract infections
 CNS infections
 gastroenteritis

Canine diarrhoea
•Campylobacter spp. Includes C. jejuni.
C. lari, C. coli
•Clostridium perfringens alpha-toxin Bovine Respiratory Panel
•Clostridium perfringens enterotoxin cpe •Bovine Herpes Virus 1
•Salmonella spp. Including S. enterica •Parainfluenza Virus 3 (two types)
and S.bongori •Bovine Respiratory Syncytial Virus
•Canine Distemper Virus •Bovine Corona Virus
•Parvovirus •Mycoplasma bovis
•Canine Coronavirus
•Mycoplasma general
•Giardia lamblia
•Cryptosporidium (parvum and hominis) •Histophilum somni
•Neospora caninum •Pasteurella multocida
•Toxoplasma gondii •Mannheima hemaelytica
 What can we do now?

Provide minimum inhibitory concentration

(MIC) results

“Time-dependent" killing ABs work best with

continual exposure to drug concentrations
above the MIC
 Increasing frequency of administration will
increase efficacy (increasing the dose will
not)

“Concentration-dependent" killing:
 increasing dose (and not the dosing interval)
enhances efficacy.
 Recommendations
ECDC country visit to Romania to discuss
• Designate AMR as a national public health threat
encompassing all regions.
• Focus on writing a National Action Plan for AMR with a
’One Health’ approach and include the specific needs
related to diagnosis, surveillance, prevention and control of
multidrug-resistant organisms (MDROs).
• Determine costs of activities at both national and regional
level so that appropriate budgets can be made available.
• Continue the national public awareness campaign on the
prudent use of antibiotics.
• Ongoing surveillance of AMR in companion animals is
important for both animal and human health
 Also, to conclude…C & S
(sau antibiograma )
 Is critical for informed antibiotic selection

 It does NOT have to take 3-5 days anymore…

 Pathogen identification can be provided in less than

24h from sample submission (MALDI-TOF ID)

USE C&S TO COMBAT UNNECESSARY ANTIBIOTIC USE

 Thank you!

http://antibioticguardian.com/