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2016 EUROPE – NORDIC – U.S. SYMPOSIUM
Antibacterial Resistance:
Overview of the Threat
Fernando Baquero
Department of Microbiology
Ramón y Cajal University Hospital
IRYCIS, CIBERESP
Madrid, Spain
New Frontiers in Antibacterial Resistance Research
2016 EUROPE – NORDIC – U.S. SYMPOSIUM
Antibacterial Resistance:
Overview of the Threat
Fernando Baquero
Department of Microbiology
Ramón y Cajal University Hospital
IRYCIS, CIBERESP
Madrid, Spain
New Frontiers in Antibacterial Resistance Research
Fear, the EMOTION induced
by the perception of threat
A Symposium on Fear
Wendy Lesser (Berkeley, CA)
The Culture of Fear in the XXI Century
In our world, a world of wonders…….
Current fears take the form of the Alexis de Tocqueville paradox:
“plus tout va bien, plus on a peur”, or
“the more better things occur, the more fear we have”
Charlie Hass
Fear of Antibiotic Resistance
Frank Furedi argues that perceptions of risk,….. controversies over health, the environment and technology have little to do with science or empirical evidence. Rather, they are shaped by cultural assumptions about human vulnerability.
KIDULTHOOD
Examining fears in Antibiotic Resistance
Problems:
• Fear, a cultural construct, tends to fix as proved the worse expectations
• False identity between that we are scared of and that is really dangerous
• Continuous fear without solutions discredit scientific efforts
• Fear might suggest “we are at the mercy of the nature”
• Fear might be sustained and exploited by interested parties
Advantages:
• Fear facilitates analysis and adaptive responses (Ebola, AIDS,…)
• Fear stimulates motivation and creativity: emotion and knowledge
• Fear improves social and organizational cooperation (this meeting)
• Fear rise our awareness not to stop scientific and social progress
Fear in antibiotic resistance is converted in fear to antibiotics
Threat ratings
Exist or will certainly happen
We are confident will actually happen
Can happen and is likely to happen
Can happen but is not likely to happen
Will not happen
Threat 1: “Back to the pre-antibiotic era”
A “classic” among over-exaggerations!
• History never comes back again, never back to 1916. The social and medical resources in 2016 cannot be compared with those of 1916.
• Infectious diseases start declining before the discovery of antimicrobial agents: progress of hygiene-ecology and social welfare
• Many severe infectious diseases can be cured in our days without antibiotics, because of the advances of Medicine. (Guerrant RL et al., Cholera, diarrhea, and oral rehydration therapy: triumph and indictment, CID, 2003)
Severe illness, Death
Etiological therapy but therapy of the cascade of pathogenic events
Threat 1: “Back to the pre-antibiotic era”
A “classic” among over-exaggerations!
• History never comes back again
• Infectious diseases start declining before the discovery of antimicrobial agents: progress of hygiene-ecology and social welfare
• Many severe infectious diseases can be cured in our days without antibiotics, because of the advances of Medicine. (Guerrant RL et al., Cholera, diarrhea, and oral rehydration therapy: triumph and indictment, CID, 2003)
Severe illness, Death
Intensive Care Procedures
Threat 2: Many deaths as a direct result of antibiotic resistance
Need of better studies estimating the magnitude of the burden of antibiotic resistance in relation with mortality
Mantra figures: “At least…”
• 25,000 deaths/year because Ab-R in Europe (EMA-EUROPA, 2012)
• 23,000 deaths/year (CDC Ab-Resistance Threats in the US, 2013)
Very rare (difficult to achieve) case-control studies
• 18 deaths per million/year: 2% of death by coronary artery disease (940)
• 9,000 deaths/year in Europe?Kanerva et al. Antimicrobial Resistance and Infection Control 2012, 1:33
Who is dying from antibiotic resistance?
Threat 2: Many deaths as a direct result of antibiotic resistance
The population at risk of dying because antibiotic resistance
• Immuno-depressed patients
• Elderly (>75)
• Admission to the ICU
• APACHE II score at ICU admission
• Large spectrum antibiotics
• Special treatments
• Rhinogastric tube in place
High Risk of Death
Bu
rden
of
Dis
ease
Perfect Health
Population at
risk of dying
because Ab-R
Ab-RAb-S
• Nutritional immuno-deficiency
• Poor medical care, shortage ICUs
• Resistance to cheap available agents
Developing countries:
Threat 3: Antibiotic-R increases the number of severe infections
Antibiotic-selection of antibiotic-
resistant microorganisms, and
elimination of local competitors
results in a increase of the total
number of resistant organisms.
Increase in the probability of
translocation-invasion by resistant
organisms (bacteremia)
The probability of bacteremia
(translocation-invasion) by
frequent commensal pathogens
(as E. coli, Enterococcus) is
proportional to their total
population size.
Inside the host
probability of
translocation,
invasion
Microbiota
Susceptible microbiota
Susceptible
microbiota
Resistant
microbiota
probability of
translocation,
invasion
overgrowth
red
ucti
on
div
ers
ity
• The incidence of nosocomial bacteremia due to highly-resistant microorganisms increased8.7 times as fast as non-resistant ones (1996-2005)
• Moreover, the increase in resistance does not replace infections with susceptible pathogens, but adds to the total burden of bacteremia
• Hospitalized patients have become progressively more severely ill over the last 10 years. (Ammerlaan HSM, Bonten MJM et al., JAC 63:1064–1070, 2009)
Tedim ASP et al., AEM 2015
Enterococcus faeciumE. coli phylogroup B2
Irene Rodriguez ECCMID 2014
Bacteremia
RYC Hospital (1996-2012)
Threat 3:
Antibiotic-R increases the number of severe infections
resistant
Microbiota
• But it remains unclear if in many severe infections there is a worse outcome when caused by antibiotic resistant microorganisms.
Possible reasons:
• Bias: Bacteremia patients presenting with severe symptoms are probably more likely to have antibiotics administered prior to blood culture draw compared with less ill patients. Only those caused by resistant organisms are able to grow in cultures.
(Stig Lønberg Nielsen, PhD Thesis 2015, Dan Med J 62: B5128)
• Lesser virulence of antibiotic-R bacterial variants:
1- Multi-resistant clones are frequently derived from commensal (less pathogenic) lineages
2- Fitness costs of antibiotic resistance (Jon Tyrell, PhD Thesis 2014, Cardiff University)
In neonatal sepsis caused by blaNDM-1-positive Enterobacteriaceae, mortality was lower (13.3%) than cases caused by blaNDM-1-negative (22.2%)
(Datta et al., PLoS One. 9:e112101, 2014)
Threat 3:
Antibiotic-R increases the number of severe infections
• In detailed case-control studies in Greece, overall mortality in ICU patients with carbapenem-resistant K. pneumoniae was not different from the mortality of the control group with carbapenem-susceptible strains (same APACHE II score)
Expectation:
The mortality rates of antibiotic resistant infections should be
higher that in the case of infections by susceptible organisms
Carbapenem-R
K. pneumoniae
IT IS NOT NECESSARILY THE CASE
Antibiotic resistance increases the number of severe
infections (as bacteremia), and hence overall mortality
* Possible role of selective decontamination, SDD, SOD (Plantinga, Bonten, Crit. Care 2015)
• The adverse association between MRSA and all-cause mortality or infection-related mortality, were not
statistically significant after adjustment for important prognostic factors including age,
comorbidities, severity of acute illness, metastatic infections, and long-term care facility resident status
Falagas ME et al., JAC. 60:1124, 2007; Vardakas KZ et al., J. Infect 70:592. 2015; Yaw LK et al., LID 14:967, 2014
Threat 3:
Antibiotic-R increases the number of severe infections
Threat 4:
The invasion by resistant strains of normal microbiota
Treated
patient
Non-treated
Fitness R-bacteria
Treated and favoring condition
for R colonization
(as elderly)
Large R-colonization of non-treated
Age and cases E. coli bacteremia RYC Hospital Non-treated
• Normal microbiota might become
antibiotic resistant microbiota
• More risk for more patients
Threat 5:Antibiotic-R altering the human-microbiota interactions
Human-microbiota common evolutionary history
Bacteroidetes
Clostridium
C-I
Clostridium
C- XIVa
Proteobacteria
(Enterobacteriaceae)
• Most of the significant antibiotic-resistance genes are located in minority
bacterial populations organisms
• When minority bacterial populations reach majority, there is an ecological
disturbance that might be deleterious for the system –unpredictable
clinical consequences under global overuse of antibiotics
• Consequences of acquisition of resistance by members of majorities?
M. Rajilic´-Stojanovic et al.
EM. 2012
Reads/kb (normalized per gene size)
Resistance genes in minority populations revealed in metagenomic capture
platforms, less detectable in conventional metagenomics, addressing majorities
(V. Fernandez-Lanza, Baquero, Coque, ICETAR 2015)
Conventional metagenomics
Resistance genes capture platform
• Increase in total local number of resistant strains means increase the absolute amount of resistance genes, and mobile genetic elements
gene
integron
transposon
plasmid, ICE
Antibiotic resistance
might increase the
density of tools involved
in microbial genetic
interactions,
with
unpredictable
consequences
Threat 6Antibiotic resistance accelerates microbial evolution
Transmission of R genes (red) is probably
favored by homology of the incoming R
clone with resident ones (yellow)
Selection of incoming clone +
selection of the resident homologous clones
The risk of propagation of R genes increases with the homology between incoming R clones and
susceptible “kin” resident clones
Threat 7
High-speed “global dissemination” of R-clones
A “chain-reaction-like” spread of resistance in kin clonal populations?
Example of global dissemination: Petty NK et al., Proc Natl Acad Sci U S A. 2014, 111(15):5694-9 (E. coli ST131)
Kin clones already in place acquire resistance: INVASION OR CONVERSION?
Threat 8:Antibiotic release and antibiotic resistance altering the environmental life-sustaining microbiosphere
• Possible ecological functional disturbances by the antibiotics in the environment include nitrogen transformation, methanogenesis and sulfate reduction
• For instance, Cyanobacteria, largely susceptible to antimicrobial agents, as such type of organisms accounts for more than 70% of the total phytoplankton mass, and are responsible for more than a third of the total free O2 production, or CO2 fixation.
(Baquero F et al., Curr. Op. Biotechnol. 2008; 19:260–265; Dias E, et al. Frontiers in Microbiology 2015)
• Naturally-antibiotic resistant organisms might substitute under extended antibiotic pollution criticalsusceptible organisms of huge ecological interest. Alternatively, acquisition of antibiotic resistance might alter fitness or critical functional traits.
• Antibiotic disturbance of interbacterial signaling (semiotic space) with microecological consequences
Two final remarks:
“Fighting, defeating antibiotic resistance” A naïve statement.
Leslie Orgel’s Second Rule:
"Evolution is cleverer than you are.“
• We have 1012 E. coli cells in the intestine of a single human host, with about 200,000 mutations per gene and day.
• A gram of soil may contain between 5,000 and 40,000 speciesof microbes
• “Modular engineering of resistance”:
Transposases are the most common and abundant genes in nature.
Unlimited offer of bacterial genetic variation and
engineering in an unlimited number of niches
The Tool and the Goal• Don’t Confuse a Tool with a Goal!
• Our medical goal is NOT to fight antibiotic resistance, but morbidity and MORTALITY of BACTERIAL INFECTIOUS DISEASES.
Resistance
Antibiotic
hammer
The toolkit for controlling infections
The Tool and the Goal
• Don’t Confuse a Tool with a Goal!
• Our medical goal is NOT to fight antibiotic resistance, but morbidity and MORTALITY of BACTERIAL INFECTIOUS DISEASES.
Resistance
Antibiotic
hammer
The toolkit for controlling infections
Awl
Ministry of Social Affairs
and Health, Finland
• Teresa Coque, Val Fernández-Lanza, Ana-Sofía Tedim-Pedrosa, Rafael Cantón,…….. in our Department*
• Marc Bonten (Utrech), ICETAR presentation 2015, Rob Willems and Willem van Schaik (Utrech), coordination EvoTAR FP7
• Tim Walsh and Jon Tyrell (Cardiff) , discussions around Jon PhD Thesis.
• Bruce Levin (Emory)
• … and many others….
Acknowledgements
Integrated Knowledge Map
Decre
ase i
n β
-m
ino
rity
Antibiotic exposure increases
resistant minority populations
able to produce bacteremia
Threat 3:
Antibiotic-R increases the number of severe infections