COLLATERAL DAMAGE IN GRAM NEGATIVE BACTERIA Djoko Widodo Division of Tropical Medicine and Infectious Diseases Department of Internal Medicine Faculty of Medicine University of Indonesia / Cipto Mangunkusumo National Referral Hospital

ollateral damage is a term used to refer to ecological adverse effects of antibiotic therapy; namely, the selection of drug-resistant organisms and the unwanted development of colonization or

infection with multidrug-resistant (MDR) organisms. The risk of such damage can be assessed for different antibiotic classes by a variety of epidemiologic studies. Resistance to cephalosporins in Enterobacteriaceae is a critical problem in the Asia Pacific Region. Resistance is driven by usage of the 3rd generation cephalosporins. The presence of an ESBL-producing organism in an infection can lead to increased morbidity and mortality. The threat of the presence of an ESBL-producing organism in an infection may accelerate the early usage of a carbapenem. The emergence of the CTX-M enzyme makes the treatment of infections arising in the community a problem

ain risk factor associated with acquisition of multi-drug resistant A. baumannii (AbMR) strain was imipenem monotherapy . AbMR strain caused septic shock in 16.6% of cases. It is also associated

with high rate of morbidity and mortality. High mortality rate and long hospital stay attributable to infection and/or colonization with AbMR. Administration of imipenem and sulbactam combination, colistin, or aminoglycoside eradicated strain in 30% of cases. Hypotension or septic shock around time of isolation of bacterial strain a significant prognostic factor.

ephalosporin use has been linked to subsequent infection with vancomycin-resistant enterococci (VRE), extended-spectrum β-lactamase–producing Klebsiella pneumoniae, β -lactam–resistant

Acinetobacter species, and Clostridium difficile. The use of third-generation cephalosporins associated with emergence of methicillin-resistant Staphylococcus aureus (MRSA), VRE, MDR Klebsiella, Enterobacter, and MDR Acinetobacter. Quinolone use has been linked to infection with MRSA and with increasing quinolone resistance in gram-negative bacilli, such as Pseudomonas aeruginosa. Use of fluoroquinolones associated with emergence of MRSA, MDR Klebsiella, and MDR Pseudomonas and Acinetobacter.

se of carbapenems associated with emergence of MDR Klebsiella, Pseudomonas and Acinetobacter. Increased carbapenem use may accelerate emergence of pan-resistant isolates. Neither 3rd

generation cephalosporins nor quinolones appear suitable for sustained use in hospitals as “workhorse” antibiotic therapy. The use of 3rd generation cephalosporins and fluoroquinolones is associated with the increased incidence of CDAD. The need for antibiotic stewardship is indisputable. The need for new agents to treat nosocomial infections is critical. Imperative that substitution of either broad-spectrum agents or combination therapy for the third-generation cephalosporins, fluoroquinolones, and carbapenems be considered.

Keywords : “collateral damage”, drug-resistant, antibiotic, gram-negative bacteria

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