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| Year : 2005 | Volume
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| Issue : 3 | Page : 120-129 |
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Antibacterial resistance: Current problems and possible solutions
Rashmi Sharma1, Chaman Lal Sharma2, Bhuvneshwar Kapoor1
1 Postgraduate Deptt. of Pharmacology and Therapeutics, Govt. Medical College, Jammu, India
2 Armed Medical Corps, Jammu, India
Correspondence Address:
Rashmi Sharma
216-A, Last Morh Gandhi Nagar Jammu, Tawi - 180 004, J&K
India
  | 8 |
DOI: 10.4103/0019-5359.15091 PMID: 15805685
Antimicrobial resistance is a natural biological phenomenon of response of microbes to the selective pressure of an antimicrobial drug. Resistance may be inherent, which explains the phenomenon of opportunistic infection or acquired. Concern about the resistance increased in the late 1990's and since then, many governmental and agency reports have been published regarding the agricultural use of antibacterials, advising less use of antibacterials, appropriate choice of antibacterials and regimens, prevention of cross-infection and development of new antibacterials. The emergence of multidrug resistant strains of Gram-negative bacteria (Pseudomonas, Klebsiella, Enterobacter, Acinetobacter, Salmonella species) and Gram-positve organisms (Staphylococcus, Enterococcus, Streptococcus species) is the more worrisome in the present therapeutic scenario. Multidrug - resistant tuberculosis is another serious public health problems. Resistance to some agents can be overcome by modifying the dosage regimens (e.g., using high-dose therapy) or inhibiting the resistance mechanism (e.g., beta-lactamase inhibitors), whereas other mechanisms of resistance can only be overcome by using an agent from a different class. It is urgently required to ban the sale of antibiotics without prescription, to use antibiotics more judiciously in hospitals by intensive teaching of the principles of the use of antibiotics and to establish better control measures for nosocomial infections. Thus, it is highly recommended that practicing physicians should become aware of the magnitude of existing problem of antibacterial resistance and help in fighting this deadly threat by rational prescribing.
Keywords: Rational drug use, Multidrug resistance, Newer antibiotics
How to cite this article:
Sharma R, Sharma CL, Kapoor B. Antibacterial resistance: Current problems and possible solutions. Indian J Med Sci 2005;59:120-9 |
Drug Resistance can be described as a state of insensitivity or of decreased sensitivity to drugs that ordinarily cause growth inhibition or cell death. This phenomenon has been recognized since the latter part of the 19th century in the micro-organisms and more recently in mammalian cells in vitro and in cancer cells in vivo. The discovery of antimicrobial agents by Paul Ehrlich was one of the most remarkable discoveries, that changed the face of medical practice.[1] However, the increased global flow of antimicrobials brought with it the threat of antimicrobial resistance. Concern about the resistance increased in the late 1990's since then, many governmental and agency reports have been published regarding the agricultural use of antibacterials, advising less use of antibacterials, appropriate choice of antibacterials and regimens, prevention of cross-infection and development of new antibacterials. As antimicrobials are frequently misused and overused in many developing countries, thus resistance to antimicrobials, has led to an increase in morbidity, mortality and cost of health care. To maintain the useful life of antimicrobial drugs in developing countries there is need to improve access to diagnostic laboratories, improved surveillance of the emergence of resistance, better regulation of the use of antibiotics, and better education of the public, doctors, and veterinarians in the appropriate use of the drugs.
| € Mechanisms of drug resistance | |  |
Resistance may be inherent, which explains the phenomenon of opportunistic infection or acquired.[2] Anaerobic bacteria, Enterococcus species are inherently resistant to aminoglycosides, Pseudomonas species to tetracycline and penicillins except ureidopenicillins, Gram-negative bacteria to glycopeptides and Gram-positive bacteria to aztreonams.[3] Acquired resistance can be developed by mutation or gene transfer. Gene transfer can occur through transformation, transduction and conjugation. Mutation may occur in the gene encoding target protein, transport protein, protein for drug activation or promoter or regulatory gene affecting expression of the target transport protein or an inactivating enzyme.[4] Production of beta-lactamases by the bacteria is the most important mechanism associated with beta-lactam antibiotic resistance. There are over 200 types of beta-lactamases.[2] Moreover, for many antibiotics including beta-lactam group, the primary means of transport across the outer memberane of enteric bacteria are a remarkable group of plasma proteins called as porins. Three major porins have been identified in E. coli, namely- (a) large porin channel outer membrane protein F(Omp F), (b) small channel porin Omp C and (c) Pho E (present in mutants and of no significance in antibiotic movement).[5] Factors like the charge on the molecule and hydrophobicity of the compound also play an important role in the transport of drug molecules. The negatively charged molecules like methicillin hang up in the negatively charged porin channel of Gram negative bacteria; where as beta-lactam antibiotics having long side chain (piperacillin, ceftazidime) can also cross the membrane poorly, except imipenem with compact structure.[5] The energy dependent efflux mechanism is a prime defense for bacteria against tetracycline, quinolones and macrolides.[5] P-glycoprotein transports a wide range of drugs like rifampin, sparfloxacin etc.[6]
Antibacterial Resistance in India
Antibacterial resistance is a natural biological phenomenon of response of bacteria to the selective pressure of an antibiotic. In recent years, emergence of macrolide-resistant S. pyogenes was reported in some areas of the world.[7],[8] Currently, the majority (80-90%) of Staphylococcus aureus strains in the community are beta-lactamase producers and thus are resistant to penicillin and ampicillin.[7],[9] However, these strains are susceptible to beta-lactamase resistant beta-lactam antibiotics such as nafcillin, methicillin or oxacillin. Recently more than 90% Staphylococcus aureus isolates from South Maharashtra have been found resistant to ampicillin, tobramycin, penicillin, erythromycin, kanamycin and gentamicin; whereas, only 39.1% strains are resistant to methicillin.[10] However, methicillin resistant Staphylococcus aureus (MRSA) strains are found sensitive to vancomycin.[10] In a retrospective study of bacterial isolates from cases of neonatal septicemia over a period of 5 years (July 1998 - June 2003) from Chandigarh, India, netilmicin and ciprofloxacin were the most effective drugs for S. aureus and Pseudomonas aeruginosa respectively.[11] Recently ciprofloxacin resistant S. aureus has also been reported from India, which necessitates the use of an alternate therapy for S aureus infection.[12] Acute respiratory tract infections cause 3.5 million deaths in children each year.[13] The most important pathogens associated with pneumonia are Haemophilus influenzae and Streptococcus pneumoniae. Many penicillin resistant pneumococci are also resistant to chloramphenicol, and cephalosporins such as cefuroxime and ceftriaxone, thus limiting treatment options.[13] Urinary tract infection (UTI) is one of the common infections diagnosed in outpatients as well as in hospitalized patients. In a study from Nagpur a large number of uropathogens are found to be extended spectrum beta lactamases producers and thus resistant to expanded spectrum cephalosporins like ceftazidime, cephotaxime which are used in the treatment of UTI.[14] In another study about 90% of E. coli causing UTI is found susceptible to nitrofurantoin, a relatively inexpensive and safe drug.[15] Enteropathogens have developed high level resistance to first line agents used for empiric treatment of diarrhoea. Typhoid fever continues to remain a health problem as the causative organism Salmonella More Details Typhi has developed resistance to many of the antibiotics used. In India 78.4% of Salmonella typhi isolates collected from infected patients between 1990 and 1991 demonstrated resistance to chloramphenicol, ampicillin and trimethoprim/sulfamethoxazole.[16] In 2000, 80% of strains from Ahmdabad were found resistant to chloramphenicol, ampicillin and trimethoprim/sulfamethoxazole, but sensitive to ciprofloxacin and ceftriaxone; whereas, 86.5% of the strains from Rourkela were found sensitive to chloramphenicol and 100% to ceftriaxone.[17] Salmonella enterica serotype typhi isolates (81%) from northern India were found resistant to chloramphenicol. However, all isolates (S. enterica serovar typhi and serovar paratyphi A) were susceptible to ciprofloxacin and ceftriaxone.[18] However, MDR(multi drug resistant) Salmonella enterica serotype typhimurium DT104 are usually resistant to five antibiotics including ampicillin, chloramphenicol, streptomycin, sulphona -mides, ciprofloxacin, trimethoprim/sulfamethoxazole and tetracycline.[19] Concurrently, a decline in the number of MDR isolates has been noted, with an increase in the number of isolates sensitive to all antibiotics except nalidixic acid, with reduced susceptibility to ciprofloxacin.[20] These changing pattern of resistance with S.typhi is again a matter of concern. In the United States patients found to have multidrug-resistant Salmonella typhi or nalidixic-acid-resistant Salmonella typhi (NARST) infections acquired their infections outside the USA, specially in the Indian subcontinent (Bangladesh, India and Pakistan). For children with multidrug-resistant Salmonella typhi, or NARST infections, therapeutic options may be more limited, because fluoroquinolones are not approved for use in children.[8] Although nalidixic acid is not a treatment for typhoid fever, this resistance may be clinically important, because of the decreased efficacy of ciprofloxacin in treating patients with NARST infections. Nalidixic acid strains of S.Typhi i.e., resistant to ciprofloxacin were first reported in Delhi in 1993.[17] Nalidixic acid susceptibility could be a useful screening test for the detection of decreased susceptibility of S. Typhi to ciprofloxacin. The clinicians should be advised to use ceftriaxone selectively in cases showing non-responsiveness to ciprofloxacin. Various multi-drug resistant (chloramphenicol, tetracycline, streptomycin, trimethoprim/sulfamethoxazole, furazolidone, tetracycline, and nalidixic) Shigella has also been reported.[7] A study from north India reported an overall resistance of 63.6, 58.1 and 16.3 per cent with Shigella to nalidixic acid, cotrimoxazole and furazolidone respectively.[21] V. cholerae isolated from northern India were generally found susceptible to tetracycline and other drugs except nalidixic acid (89.5% resistance) and cotrimoxazole (77.8% resistance).[21] However, tetracycline and related drug resistant strains of Vibrio cholerae have been identified in Africa and Asia.[7] Multidrug - resistant tuberculosis (MDRTb) is another serious public health problem. The median prevalence of MDRTb in new cases 1% and 9.3% in previously treated cases.[22] Even in presence of in-vitro sensitivity to an antimicrobial agent failure of therapy or relapse of infection(due to change in the host's immune system) with an organism can occur resulting in a state of clinical resistance.[4] Resistance to most of the commonly used antimicrobial agents indicates a need to replace these drugs with other agents and maintenance of surveillance to detect changing patterns of resistance, as well as, an urgent need for proper guidelines, dissemination of information to practitioners and supervision of antimicrobial usage in low income countries like India.
| € Possible solutions | | |
The emergence of multidrug resistant strains of Gram-negative bacteria (Pseudomonas, Klebsiella, Enterobacter, Acinetobacter, Salmonella species) and Gram-positve organisms (Staphylococcus, Enterococcus, Streptococcus species) is the more worrisome in the present therapeutic scenario. Methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci and multiresistant Gram-negative bacteria are spread primarily by direct or indirect person-to-person contact. The spread of penicillin-resistant pneumococci (PRP) and MDRTb is due to airborne transmission. Risk factors for the spread of PRP include overcrowding, tracheostomies and excessive use of penicillins for viral respiratory infections; where as for MDRTb they include poor compliance, convergence of immuno-suppressed patients, delayed diagnosis, delayed treatment, inadequate ventilation and isolation facilities. Nosocomial infection is an important factor in the spread of resistant bacteria. However, the possible solutions to fight against existing antimicrobial resistance threat are as follows:-
Rational use of Antimicrobials: Ideal antimicrobial use involves use of correct drug by the best route in right dose at optimum intervals for the appropriate period and after an accurate diagnosis.[23] The high prevalence of resistant bacteria seems to be related to irrational antimicrobial usage: 1) easy availability without prescription at drug stores, 2) injudicious use in hospitals, and 3) uncontrolled use in agriculture, animal husbandry, and fisheries. Many traditional practitioners are using allopathic drugs irrationally.[23] Moreover, it has been reported that dispensing medical practitioners (who earn by sale of medicines) prescribe more drugs than non-dispensing practitioners, thus further adding to irrational drug use.[23] In many developing countries the use of antimicrobial drugs for treating people and animals is unregulated; antibiotics can be purchased in pharmacies, general stores, and even market stalls. In the Rajbari district of Bangladesh, a survey of rural medical practitioners showed that each practitioner saw on an average 380 patients per month and prescribed antibiotics to 60% of these patients on the basis of symptoms alone.[13] Moreover, in some countries like India local production of many different antimicrobial drugs with poor quality and potency control, coupled with poor compliance of patients to costly antimicrobials further adds to the threat of antimicrobial resistance.[13] In a study from five districts of Tamilnadu state, India,: 285 general practitioners and specialists believed that antibiotics are overprescribed, especially broad-spectrum antibiotic and purulent discharge (65%), antibiotic-resistance concerns (48%), fever (40%), and patient satisfaction (29%) were proposed as the strong reasons to prescribe an antibiotic.[24] Factors like patient and time pressures, diagnostic and treatment uncertainties, poor patient compliance due to high cost and fear of antibiotic resistance are the key forces behind irrational prescription of antimicrobial combinations. Moreover, antimicrobials have been increasingly used to treat diseases in animals and plants. Antibiotics like glycopeptides and streptogramins are increasingly used as growth enhancers in subtherapeutic dose in animals further adding to the threat of antibacterial resistance.[25] The widespread use of antimicrobials in farming is also leading to emergence of resistant bacteria (Salmonella, Campylobacter) in animals, which in turn gets transmitted to humans from food of animal origin or through direct contact with farm animals.[25] It is urgently required to ban the sale of antibiotics without prescription, to use antibiotics more judiciously in hospitals by intensive teaching of the principles of the use of antibiotics, and to establish better control measures for nosocomial infections.[26] Regulation of antimicrobials for other than human use is also required. These issues require the collective action of governments, the pharmaceutical industry, health care providers and consumers.
Regulation of OTC(over the counter) drugs:- In developing countries like India, easy availability of a wide range of drugs coupled with inadequate health services result in increased proportions of drugs used as self medication compared to prescribed drugs thus resulting into impending health problems like irrational use of antimicrobials resulting into antimicrobial resistance, increased load of mortality and morbidity and economic loss.[27] The need for promoting appropriate use of drugs in health care system is not only because of the financial reasons with which policy makers and manager are usually most concerned, but also for health and medical care of patients and the community. There is need for authorities to make the existing laws regarding OTC drugs strong to ensure their rational sale and use of antimicrobials.
Preserve existing agents: In the prevailing situation of antimicrobial resistance, it is advisable to preserve the existing antimicrobials for future use and the new molecules should only be used if the old ones are ineffective. The emergence of reduced susceptibility to ciprofloxacin among Salmonella enterica serotype Typhi and serotype Paratyphi A leading to clinical failure of treatment poses a great therapeutic challenge.[28] However, Salmonella species, sensitive to chloramphenicol are increasingly emerging. It has been reported that a formulary switch to amikacin from gentamicin resulted into decline in resistance to the latter. Whereas, a shift from ceftazidime and imipenem from older cephalosporins resulted in the emergence of imipenem resistant Acinetobacter and Pseudomonas aeruginosa. [29] Recently data from Sir Ganga Ram Hospital, New Delhi also reported a correlation between Escherichia More Details coli resistance to third-generation cephalosporins and increased cephalosporin use, as well as resistance to co-amoxyclav and its use.[30]
Development of new drugs: New groups and newer compounds from the old groups of antimicrobial drugs are being developed to meet the challenge of antimicrobial resistance [Table - 1].[2],[31],[32],[33],[34],[35],[36],[37] However, rapid development of resistance to some of these newer agents has already been reported and this trend magnifies the importance of further need for effective antimicrobial agents. Several investigational agents, such as dalbavancin, oritavancin and tigecycline, are in advanced stages of development and are likely to proceed to licensing in the next few years. With their long half-lives, these agents have an advantage of less frequent dose administration with more rapid bactericidal activity and less likelihood for development of resistance. However, because of their proven activity against highly resistant organisms, these antibacterial agents should be reserved only for life-threatening situations and/or when resistant pathogens are suspected. Recent developments in the genomic mapping of many bacteria and advances in combinatorial chemistry promise to usher in a new era of antibiotic development.
Development of inhibitors of drug destroying molecules: Beta-lactamase inhibitors (clavulanic acid, sulbactam, tazobactam) resemble beta-lactam molecules, but have very weak antimicrobial activity. They are more active against Ambler class A beta-lactamases.[38] An effective countermeasure is to employ a combination product, consisting of both a beta-lactam antibiotic and a beta-lactamase inhibitor. Unfortunately, currently available inhibitors narrowly target only class A beta-lactamases.[39]
Future approaches under development: Various alternative strategies under development are plasmid containing engineered DNA to destroy genes of pathogens, antimicrobial peptides like protegrins, defensins, squalamines, histaninv, magainins etc, immunotherapy with cytokines [interleukin(IL)-2, IL-12, TNF(tumor necrosis factor), IFN(interferon)-r], recombinant colony stimulating factors etc, vaccine induced immunity, agents attacking quorum (Gram negative and Gram positive bacteria use quorum sensing communication circuits to regulate a diverse array of physiological activities like symbiosis, virulence, competence, conjugation, antibiotic production, motility, sporulation and biofilm formation) sensing in bacteria, bacteriophages, non-antibiotics (compounds having potential to modify cell wall permeability with broad spectrum antimicrobial activity) like. phenothiazines, anaesthetic agents, antihistamines, antihypertensives and diuretics and phototherapy by using differential phototoxicity of photosensitizers in bacterial and human cells and specific antibody linked photosensitizers.[2],[40],[41],[42],[43]
Antimicrobial resistance has snowballed to a serious public health concern with economic, social and political implications. The problem of changing resistance patterns will remain an ongoing threat for both developed and developing countries. Resistance to some agents can be overcome by modifying the dosage regimens (e.g., using high-dose therapy) or inhibiting the resistance mechanism (e.g., beta-lactamase inhibitors), whereas other mechanisms of resistance can only be overcome by using an agent from a different class. Understanding of the mechanisms of action of various agents can help clinicians to identify the agents that will increase the likelihood of achieving optimal outcomes. However, large number of commercial preparations, unethical drug promotions by pharmaceutical houses and irrational prescribing habits of clinicians are the important reasons for irrational prescription of drugs in clinical practice. Physician-industry interactions appears to affect prescribing and professional behavior which may result into negative outcomes like inability to identify wrong claims about medication, positive attitude toward pharmaceutical representatives, increasing prescription rate, prescribing fewer generic but more expensive, newer medications at no demonstrated advantage, antibiotic prescribing for viral conditions, prescribing of irrational antimicrobial combinations, antimicrobial prescribing for inadequate period etc. Thus, it is highly recommended that practicing physicians should become aware of the magnitude of existing problem of antimicrobial resistance and help in fighting this deadly threat by rational prescribing.
| € References | | |
| 1. | Wood JM, Morellering RC. Microbial resistance: Bacteria and more. Clin Inf Dis 2003;36:S2-3.  |
| 2. | Barker KF. Antibiotic resistance: a current perspective.Br J Clin Pharmacol 1999;48:109-24. [PUBMED] [FULLTEXT] |
| 3. | Bonfiglio G, Perilli M, Stafani S, Amicosante G, Nicoletti G. Prevalence of extended spectrum-lactameses among enterobacteriaceau: an Italian survey. Internat J Antimicrob Agents 2002;19:213-7. |
| 4. | Rang HP, Dale MM, Ritter JM, Moore PK. Basic Principles of chemotherapy. In: Pharmacology 5th edn. New York: Churchill Living Stone; 2004, p.620-34. |
| 5. | Koneman EW, Allen SD, Janda WM, Schrechenberger PC, Winn WC. Antimicrobial susceptibility testing. In: Color Atlas and Text book of diagnostic microbiology, 5th edn. London: Lippincott Williams and Wilkins; 1997, p.785-856. |
| 6. | Schwab M, Eichelbaum M, Fromm FF. Genetic polymorphisms of the human MDR1 drug transporter. Annu Rev Pharmacol Toxicol 2003;43:285-307. |
| 7. | Ang JY, Ezike E, Asmar BI. Antibacterial resistance. Indian J Pediatr 2004;71:229-39. [PUBMED] [FULLTEXT] |
| 8. | Fines M, Gueudin M, Ramon A, Lecllercq R. In vitro selection of resistance to clindamycin related to alterations in the attenuator of the erm (TR) gene of Streptococcus aureus UCN inducibly resistant erythromycin. J Antimicrobial Chemother 2001;48:411-6. |
| 9. | Paradisi F, Corti G, Messeri D. Antibiotic Therapy. Antistaphylococcal (MSSA, MRSA, MSSE, MRSE) antibiotics. Med Clin North Am 2001;85:1-17. [PUBMED] |
| 10. | Kandle SK, Ghatole MP, Takpere AY, Hittinhalli VB, Yemul VL. Bacteriophage typing and antibiotic sensitivity pattern of Staphylococcus aureus from clinical specimen in and around Solapur (South Maharashtra). J Commun Dis 2003;35:17-23. [PUBMED] |
| 11. | Agnihotri N, Kaistha N, Gupta V. Antimicrobial susceptibility of isolates from neonatal septicemia. Jpn J Infect Dis 2004;57:273-5. [PUBMED] [FULLTEXT] |
| 12. | Sharma V, Sharma S, Garg P, Rao GN. Clinical resistance of Staphylococcus keratitis to ciprofloxacin monotherapy. Indian J Ophthalmol 2004;52:287-92. |
| 13. | Hart CA, Kariuki S. Antimicrobial resistance in developing countries. BMJ 1998;317:647-50. [PUBMED] [FULLTEXT] |
| 14. | Tankhiwale SS, Jalgaonkar SV, Ahamad S, Hassani U. Evaluation of extended spectrum beta lactamase in urinary isolates. Indian J Med Res 2004;120:553-6. [PUBMED] [FULLTEXT] |
| 15. | Mathai E, Thomas RJ, Chandy S, Mathai M, Bergstrom S. Antimicrobials for the treatment of urinary tract infection in pregnancy: practices in southern India. Pharmacoepidemiol Drug Saf 2004;13:645-52. [PUBMED] [FULLTEXT] |
| 16. | Dunne EF, Fey PD, Kludt P. Emergence of domestically acquired ceftriaxone-resistant Salmonella infections associated with AmpC ?-lactamase. JAMA 2000;284:3151-6. |
| 17. | Kalra SP, Naithani N, Mehta SR, Swamy AJ. Current Trends in the management of Typhoid Fever. MJAFI 2003;59:130-5. |
| 18. | Safdar A, Kaur H, Elting L, Rolston KV. Antimicrobial susceptibility of 128 Salmonella enterica serovar typhi and paratyphi A isolates from northern India. Chemotherapy 2004;50:88-91. [PUBMED] [FULLTEXT] |
| 19. | Graham SM, Molyneux EM, Walsh AL. Nontyhoidal Salmonella infections of children in tropical Africa. Pediatr Infect Dis J 2000;19:1189-96. |
| 20. | Madhulika U, Harish BN, Parija SC. Current pattern in antimicrobial susceptibility of Salmonella Typhi isolates in Pondicherry. Indian J Med Res 2004;120:111-4. [PUBMED] [FULLTEXT] |
| 21. | Taneja N, Mohan B, Khurana S, Sharma M. Antimicrobial resistance in selected bacterial enteropathogens in north India. Indian J Med Res 2004;120:39-43. [PUBMED] [FULLTEXT] |
| 22. | Paramasivan CN. Status of drug resistance in Tuberculosis after the introduction of Rifampicin in India. J Indian Med Assoc 2003;101:154-6. [PUBMED] |
| 23. | Holloway K. Antimicrobial resistance: the facts. Essential Drug Monitor, WHO 2000;28&29:7-8. |
| 24. | Sivagnanam G, Thirumalaikolundusubramanian P, Mohanasundaram J, Raaj AA, Namasivayam K, Rajaram S. A survey on current attitude of practicing physicians upon usage of antimicrobial agents in southern part of India. Med Gen Med 2004;6:1. |
| 25. | Stohr K. Problems from antimicrobial use in farming. Essential Drug Monitor, WHO 2000;28&29:10 |
| 26. | Kim WJ, Park SC. Bacterial resistance to antimicrobial agents: an overview from Korea. Yonsei Med J 1998;39:488-94. |
| 27. | Sharma R, Verma U, Sharma CL, Kapoor B. Self medication among urban population of Jammu City. Ind J Pharmacol 2005:37:40-3. |
| 28. | Renuka K, Kapil A, Kabra SK, Wig N, Das BK, Prasad VV, et al. Reduced susceptibility to ciprofloxacin and gyra gene mutation in North Indian strains of Salmonella enterica serotype Typhi and serotype Paratyphi A. Microb Drug Resist 2004;10:146-53. |
| 29. | Livermore DM. Bacterial resistance: origins, Epidemiology and impact. Clin Inf Dis 2003;36:S11-23. |
| 30. | Wattal C, Joshi S, Sharma A, Oberoi JK, Prasad KJ. Prescription auditing and antimicrobial resistance at a tertiary care hospital in New Delhi, India. J Hosp Infect 2005;59:156-8. |
| 31. | Diekema DJ, Jones RN. Oxazolidinone antibiotics. Lancet 2001;358:1975-82. |
| 32. | Bennett PN, Brown MJ. Antibacterial Drugs. Clin Pharmacol, 9th edn. London: Churchill Living-stone; 2003, p.215-35.www.elsevier health.com. |
| 33. | Strahilevitz J, Rubinstein E. Novel agents for resistant Gram-positive infections-a review. Int J Infect Dis 2002;6:S38-46. |
| 34. | Raghavan M, Linden PK. Newer treatment options for skin and soft tissue infections. Drugs 2004;64:1621-42. |
| 35. | Aminimanizani A, Beringer P, Jellifer R. Comparative pharmacokinetics and pharmacodynamics of the newer fluoroquinolone antibacterials. Clin Pharmacokinetics 2001;40:109-87. |
| 36. | Stass H, Kubitza D, Schuhly U. Pharmacokinetics, safety and tolerability of moxifloxacin, a novel 8-methoxyfluoroquinolone after repeated oral administration. Clin Pharmacokinetics 2001;40:1-9. |
| 37. | Frame B, Koup J, Miller R, Lalonde R. Population pharmacokinetics of clinafloxacin in healthy volunteers and patients with infections. Clin Pharmacokinetics 2001;40:307-15. |
| 38. | 38.Chambers HF. Beta-lactam antibiotics and other inhibitors of cell wall synthesis. In: Katzung GB (editor). Basic and clinical pharmacology, 8th edn. New York: Lange Medical Books/Mc.Graw-Hill; 2004, p.734-53. |
| 39. | Buynak JD. The discovery and development of modified penicillin- and cephalosporin-derived beta-lactamase inhibitors. Curr Med Chem 2004;11:1951-64. |
| 40. | Drobniewski F. Multiple-drug -resistance tuberculosis. Balliere's Clin Infect Dis 1999;5:243-68. |
| 41. | Miller MB, Bassler BL. Quorum Sensing in bacteria. Annu Rev Microbiol 2001;55:165-99. |
| 42. | Summers WC. Bacteriophage therapy. Annu Rev Microbiol 2001;55:437-51. |
| 43. | Jacobs MR, Anon J, Appelbaum PC. Mechanisms of resistance among respiratory tract pathogens. Clin Lab Med 2004;24:419-53. |
Tables
[Table - 1]
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Functional genomics of enterococcus faecalis: Multiple novel genetic determinants for biofilm formation in the core genome |
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| Ballering, K.S., Kristich, C.J., Grindle, S.M., Oromendia, A., Beattie, D.T., Dunny, G.M. | | Journal of Bacteriology. 2009; 191(8): 2806-2814 | | [Pubmed] | | | 15 |
Epidemiology of hospital-treated Salmonella infection; Data from a national cohort over a ten-year period |
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| Gil Prieto, R., Alejandre, C.G., Meca, A.A., Barrera, V.H., de Miguel, A.G. | | Journal of Infection. 2009; 58(3): 175-181 | | [Pubmed] | | | 16 |
Treatment and prevention of ocular bacterial infections in Asia part II: The changing landscape of antibiotic treatment |
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| Espiritu, C.R.G. | | Asian Journal of Ophthalmology. 2008; 10(5-6): 388-394 | | [Pubmed] | | | 17 |
Broad-spectrum in vitro antibacterial activities of clay minerals against antibiotic-susceptible and antibiotic-resistant bacterial pathogens |
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| Haydel, S.E., Remenih, C.M., Williams, L.B. | | Journal of Antimicrobial Chemotherapy. 2008; 61(2): 353-361 | | [Pubmed] | | | 18 |
Cefoperazone-Sulbactam for Treatment of Intra-Abdominal Infections: Results from a Randomized, Parallel Group Study in India |
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| | | Surgical Infections. 2008; 9(3): 367 | | [VIEW] | | | 19 |
Incidence of ESβL producing Klebsiella pneumoniae among diabetic and non-diabetic patients from north-eastern part of Karnataka |
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| Gaddad, S.M., Muzaheed, Shivannavar, C.T. | | Research Journal of Biotechnology. 2008; 3(Spec Iss): 312-315 | | [Pubmed] | | | 20 |
Antimicrobial potential of Loligo duvauceli ink against the common clinical bacterial and yeast isolates |
|
| Girija, A.S.S., Hariprasad, G., Priyadharsini, J.V., Suba, K.P., Raghuraman, R., Gnanavendhan, S.G. | | Biomedicine. 2008; 28(3): 213-215 | | [Pubmed] | | | 21 |
Update on the antibacterial resistance crisis |
|
| Croft, A.C., DæAntoni, A.V., Terzulli, S.L. | | Medical Science Monitor. 2007; 13(6): RA103-RA118 | | [Pubmed] | | | 22 |
Prospectives of antimicrobial therapy in the near and far future | [Perspektivy antimikrobiální léčby v blízké a vzdálenější budoucnosti] |
|
| Kolář, M., Jedličková, A. | | Anesteziologie a Intenzivni Medicina. 2007; 18(2): 103-112 | | [Pubmed] | | | 23 |
The diversity of definitions of multidrug-resistant (MDR) and pandrug-resistant (PDR) Acinetobacter baumannii and Pseudomonas aeruginosa |
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| Falagas, M.E., Koletsi, P.K., Bliziotis, I.A. | | Journal of Medical Microbiology. 2006; 55(12): 1619-1629 | | [Pubmed] | | | 24 |
Comparative study of bacteriology in recurrent tonsillitis among children and adults |
|
| Loganathan, A., Arumainathan, U.D., Raman, R. | | Singapore Medical Journal. 2006; 47(4): 271-275 | | [Pubmed] | | | 25 |
The Need for New Antimicrobials for Intra-Abdominal Infections (IAI): Defining the Forthcoming Scenario |
|
| Jose M. Tellado | | Surgical Infections. 2006; 7(1): 1 | | [VIEW] | |
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