Todar's Online Textbook of Bacteriology

Bacterial resistance to Antibiotics

© 2002 Kenneth Todar University of Wisconsin Department of Bacteriology

Definition of an antibiotic

Antibiotics are substances produced by microorganisms that kill or inhibit other

microorganisms. Antibiotics are products of the earth, more specifically of soil; they are
byproducts of cellular metabolism; antibiotics are "all natural".

History of antibiotics and antibiotic chemotherapy

The first antibiotic, penicillin, was discovered in 1929 by Sir Alexander Fleming who
observed inhibition of staphylococci on an agar plate contaminated by a Penicillium
mold. World War II (and the inevitable bacterial infections that occurred in war-related
wounds) was an important impetus to study the chemotherapeutic value of penicillin.
Penicillin became generally available for treatment of bacterial infections, especially
those caused by staphylococci and streptococci, about 1946. Initially, the antibiotic was
effective against all sorts of infections caused by these two Gram-positive bacteria. It is
important to note that a significant fraction of all human infections are caused by these
two bacteria (i.e., strep throat, pneumonia, septicemia, skin infections, wound
infections, scarlet fever, toxic shock syndrome). Penicillin had unbelievable ability to
kill these bacterial pathogens without harming the host that harbored them. This brings
to light the fundamental principle of antimicrobial chemotherapy that may be relevant in
this symposium, i.e., selective toxicity: Antibiotics used in the treatment of disease
must be effective against the pathogenic microorganism and not the host; the host
(patient taking the antibiotic) must essentially be resistant to the action of the drug.

Resistance to penicillin in some strains of staphylococci was recognized almost

immediately after introduction of the drug. (Resistance to penicillin today occurs in as
many as 80% of all strains of Staphylococcus aureus). Surprisingly, Streptococcus
pyogenes (Group A strep) have never fully developed resistance to penicillin and it
remains a reasonable choice antibiotic for many types of streptococcal infections.
Interestingly, penicillin has never been effective against most Gram-negative pathogens
(e.g. Salmonella, Shigella, Bordetella pertussis, Yersinia pestis, Pseudomonas) with the
notable exception of Neisseria gonorrhoeae. Gram-negative bacteria are inherently
resistant to penicillin because their vulnerable cell wall is protected by an outer
membrane that prevents permeation of the penicillin molecule.

The period of the late 1940s and early 1950s saw the discovery and introduction of
streptomycin, chloramphenicol, and tetracycline, and the age of antibiotic chemotherapy
came into full being. These antibiotics were effective against the full array of bacterial
pathogens including Gram-positive and Gram-negative bacteria, intracellular parasites,
and the tuberculosis bacillus. However, by 1953, during a Shigella outbreak in Japan, a
strain of the dysentery bacillus was isolated which was multiple drug resistant,
exhibiting resistance to chloramphenicol, tetracycline, streptomycin, and the
sulfanilamides. There was also evidence mounting that bacteria could pass genes for
multiple drug resistance between strains and even between species. It was also apparent
that Mycobacterium tuberculosis was capable of rapid development of resistance to
streptomycin which had become a mainstay in tuberculosis therapy.

Microorganisms that produce antibiotics

Penicillium and Cephalosporium: produce Beta-lactam antibiotics: penicillin,

cephalosporin, and their relatives.

Actinomycetes, mainly Streptomyces species: produce tetracyclines, aminoglycosides

(streptomycin and its relatives), macrolides (erythromycin and its relatives),
chloramphenicol, ivermectin, rifamycins, and most other clinically-useful antibiotics
that are not beta-lactams.

Bacillus species, such as B. polymyxa and Bacillus subtilis produce polypeptide

antibiotics (e.g. polymyxin and bacitracin), and B. cereus produces zwittermicin.

These organisms all have in common that they live in a soil habitat and they form some
sort of a spore or resting structure. It is not known why these microorganisms produce
antibiotics but it may rest in the obvious : affording them some nutritional advantage in
their habitat by antagonizing the competition; or the subtle: acting as some sort of
hormone or signal molecule associated with sporulation or dormancy or germination.
Antibiotics are secondary metabolites of microorganisms and they are produced at the
same time that the cells begin sporulation processes. Antibiotics tend to be rather large,
complicated, organic molecules and may require as many as 30 separate enzymatic
steps to synthesize. The maintenance of a substantial component of the bacterial
genome devoted solely to the synthesis of an antibiotic leads one to the conclusion that
the process (or molecule) is important, if not essential, to the survival of these
organisms in their natural habitat.

Most of the microorganisms that produce antibiotics are resistant to the action of their
own antibiotic, although the organisms are affected by other antibiotics, and their
antibiotic may be effective against closely-related strains. Generally speaking, how or
why bacteria are resistant to their own antibiotics is also unknown, but it may be worth
pondering or studying if we are to understand the cellular and molecular basis of
resistance.

The basis of microbial resistance to antibiotics

Inherent (Natural) Resistance. Bacteria may be inherently resistant to an antibiotic.

For example, a streptomycete has some gene that is responsible for resistance to its own
antibiotic; or a Gram-negative bacterium has an outer membrane that establishes a
permeability barrier against the antibiotic; or an organism lacks a transport system for
the antibiotic; or it lacks the target or reaction that is hit by the antibiotic.
Acquired Resistance. Bacteria can develop resistance to antibiotics, e.g. bacterial
populations previously-sensitive to antibiotics become resistant. This type of resistance
results from changes in the bacterial genome. Acquired resistance is driven by two
genetic processes in bacteria: (1) mutation and selection (sometimes referred to as
vertical evolution); (2) exchange of genes between strains and species (sometimes
called horizontal evolution).

Vertical evolution is strictly a matter of Darwinian evolution driven by principles of

natural selection: a spontaneous mutation in the bacterial chromosome imparts
resistance to a member of the bacterial population. In the selective environment of the
antibiotic, the wild type (non mutants) are killed and the resistant mutant is allowed to
grow and flourish. The mutation rate for most bacterial genes is approximately 10-8.
This means that if a bacterial population doubles from 108 cells to 2 x 108 cells, there is
likely to be a mutant present for any given gene. Since bacteria grow to reach
population densities far in excess of 109 cells, such a mutant could develop from a
single generation during 15 minutes of growth.

Horizontal evolution is the acquisition of genes for resistance from another organism.
For example, a streptomycete has a gene for resistance to streptomycin (its own
antibiotic), but somehow that gene escapes and gets into E. coli or Shigella. Or, more
likely, Some bacterium develops genetic resistance through the process of mutation and
selection and then donates these genes to some other bacterium through one of several
processes for genetic exchange that exist in bacteria.

Bacteria are able to exchange genes in nature by three processes: conjugation,

transduction and transformation. Conjugation involves cell-to-cell contact as DNA
crosses a sex pilus from donor to recipient. During transduction, a virus transfers the
genes between mating bacteria. In transformation, DNA is acquired directly from the
environment, having been released from another cell. Genetic recombination can follow
the transfer of DNA from one cell to another leading to the emergence of a new
genotype (recombinant). It is common for DNA to be transferred as plasmids between
mating bacteria. Since bacteria usually develop their genes for drug resistance on
plasmids (called resistance transfer factors, or RTFs), they are able to spread drug
resistance to other strains and species during genetic exchange processes.

The combined effects of fast growth rates, high concentrations of cells, genetic
processes of mutation and selection, and the ability to exchange genes, account for the
extraordinary rates of adaptation and evolution that can be observed in the bacteria. For
these reasons bacterial adaptation (resistance) to the antibiotic environment seems to
take place very rapidly in evolutionary time: bacteria evolve fast!

The medical problem of bacterial drug resistance

Obviously, if a bacterial pathogen is able to develop or acquire resistance to an

antibiotic, then that substance becomes useless in the treatment of infectious disease
caused by that pathogen (unless the resistance can somehow be overcome with
secondary measures). So as pathogens develop resistance, we must find new (different)
antibiotics to fill the place of the old ones in treatment regimes. Hence, natural
penicillins have become useless against staphylococci and must be replaced by other
antibiotics; tetracycline, having been so widely used and misused for decades, has
become worthless for many of the infections that once designated it as a "wonder drug".

Not only is there a problem in finding new antibiotics to fight old diseases (because
resistant strains of bacteria have emerged), there is a parallel problem to find new
antibiotics to fight new diseases. In the past two decades, many "new" bacterial diseases
have been discovered (Legionnaire's disease, gastric ulcers, Lyme disease, toxic shock
syndrome, "skin-eating" streptococci). We are only now able to examine patterns of
susceptibility and resistance to antibiotics among new pathogens that cause these
diseases. Broad patterns of resistance exist in these pathogens, and it seems likely that
we will soon need new antibiotics to replace the handful that are effective now against
these bacteria, especially as resistance begins to emerge among them in the selective
environment antibiotic chemotherapy.

Conclusions

It is said that the discovery and use of antibiotics and immunization procedures against
infectious disease are two developments in the field of microbiology that have
contributed about twenty years to the average life span of humans in developed
countries where these practices are employed. While the greater part of this span in time
is probably due to vaccination, most of us are either still alive or have family members
who are still alive because an antibiotic conquered an infectious disease that otherwise
would have killed the individual. If we want to retain this medical luxury in our society
we must be vigilant and proactive: we must fully understand how and why antimicrobial
agents work, and why they don't work, and realize that we must maintain a stride ahead
of microbial pathogens that can only be contained by antibiotic chemotherapy.