2. Introduction
Major defense of the Gram negative bacteria against the β-
lactam antibiotics
These antibiotics have a common four-atom ring known as a
beta-lactam.
Hydrolysis of the β-lactam ring & decarboxylation of the intermediate
The lactamase enzyme breaks the β-lactam ring
open, deactivating the molecule's antibacterial properties
Co-evolved with the β-lactam antibiotics since they came
into clinical use.
3. Earlier increased in microbes in which they were
uncommon (e.g. Staph. aureus) and then spread to
pathogens that had previously lacked them ( e.g. H.
influenzae and N. gonorrhea)
Introduction of the newer “resistant” β-lactam antibiotics
like cephamycins, oxyimino-cephalosporins,
carbepenems & monobactams 20 yrs back, resulted in
the emergence of a newer set of ESBLs, AmpC enzymes
and carbapenemases.
4. Classification of β-lactamases
Ambler Molecular Classification
AA similarity and 10 structure.
Classes A, C & D have serine residues at their active
site.
Class B are metallo-β-lactamases that require Zn & Ca
ions for their actions.
Classes A (TEM/SHV) & D (OXA) were plasmid
mediated.
Class B & C were chromosomal mediated.
5. Bush-Jacoby-Medieros Functional
Classification
Based on functional similarities i.e. substrate and
inhibitor profile.
4 main groups (1 to 4) and multiple subgroups.
More of immediate relevance to clinicians and
μbiologists because it considers β-lactamase
inhibitors and substrates that are clinically
relevant.
9. Class A β-lactamases
Broad and Expanded spectrum β-lactamases
Include TEM, SHV, CTX-M types commonly.
BES, GES/IBC family, PER, SFO, TLA & VEB are members
too.
Hydrolyze all classes of penicillins, Ist, IInd, IIIrd, IVth
gen. cephalosporins & monobactams.
Co-resistant to quinolones, aminoglycosides &
sulphamethoxazole.
10. Cephamycins and carbapenems are not
affected them, though the latter are the
most consistent in their action.
Inhibited by β-lactamase inhibitors
ESBL producing organisms may lose their
outer membrane proteins, not related to β-
lactamase production & become resistant
to cephamycins too.
11. TEM type β-lactamases
TEM-1, TEM-2 are broad spectrum against which
IIIrd, IVth gen. cephalosporins & monobactams were
active.
TEM-10, TEM-12 & TEM-26 are ESBLs, in majority
now, active against the above, though rarely
accompanied by resistance to inhibitors too.
Useful to follow the spread of individual resistance
genes.
12. SHV Type β-lactamases
SHV = sulphydryl variable
SHV-1 is a broad spectrum
β-lactamase similar to TEM-1.
Most commonly found in K.pneumoniae.
Are the most common clinically isolated in Europe and
USA.
13. Within 15 yrs, SHV-2 were found in every
inhabited continent, implying that selection
pressure from third-generation cephalosporins
in the first decade of their use was responsible.
SHV ESBLs have been detected in a wide range
of Enterobacteriaceae & outbreaks of SHV-
producing P. aeruginosa & Acinetobacter spp.
have now been reported.
SHV-5 and SHV-12 are among the most
common.
14. CTX-M ESBLs
Most common group of ESBLs not belonging to the
previous two were termed CTX-M to highlight their
greater activity against cefotaxime than cefepime or
ceftazidime.
Belying their name, they now hydrolyse ceftazidime
more than cefotaxime.
Mainly been found in strains of Salmonella enterica
serovar Typhimurium and E. coli.
15. Widespread findings of CTX-M-type ESBLs in
China and India, is speculated that CTX-M-type
ESBLs are now actually the most frequent ESBL
type worldwide.
Tazobactam exhibits an almost 10-fold greater
inhibitory activity than clavulanic acid against
CTX-M-type β-lactamases
CTX-M-15 are the most widespread in
India, Middle East, Europe and the USA.
16. Other Class A ESBLs
Uncommon, mostly in P. aeruginosa & at limited
areas.
VEB 1 & 2 in South East Asia.
Others are PER-1, GES-1 & 2, IBC-2, PES-1 and may
be found in Enterobacteriaceae too.
BES-1, IBC-1, SFO-1 & TLA-1 found only in
Enterobacteriaceae.
Include some carbapenemases as well.
17. Class B β-lactamases
Also called the Metallo β lactamases.
Are Zn dependant enzymes with a different
mechanism of action.
Exhibit resistance to
penicillins, cephalosporins, carbapenems and β
lactamase inhibitors.
Their hyrdolytic profile doesn’t include
Aztreonam.
Types include Plasmid-mediated IMP-type
carbapenemases, VIM and NDM-1 (New Delhi
metallo-β-lactamase)
18. NDM-1 (New Delhi metallo-β-
lactamase)
Originally described from New Delhi in 2009
widespread in Escherichia coli and Klebsiella
pneumoniae from India and Pakistan.
As of mid-2010, NDM-1 carrying bacteria have
been introduced to other countries (including
the United States and UK)
It’s the so called “super bug” spread due to
the large number of tourists travelling from
these countries.
19. Class C β-lactamase
Known as the serine cephalosporinases.
Mainly Amp C plasmid induced enzymes.
Substrates include the penicillins,
cephalosporins plus cephamycins and β
lactam – β lactamase inhibitor combinations.
Cefepime is poorly hydrlolysed by it.
They are mainly inhibited by cloxacillin,
oxacillin and aztreonam.
Responsible for the resistance emerging in
Enterobacter cloacae.
20. Class D serine oxacillinases
Initially found to hydrolyse oxacillin at a slow
rate.
Confer resistance to
penicillins, cephalosporins, extended
spectrum cephalosporins, carbapenems
and β lactamase inhibitors.
In vitro sodium chloride and chelating
agents like EDTA inhibit some carbapenem
hydrolysing oxacillinases.
21. Carbapenemases
Source of concern because they are active
against cephalosporins and carbapenems.
Include class A, B and D β lactamases.
Examples are
Plasmid mediated IMP type in enteric
Gram negative organisms, Pseudomonas and
Acinetobacter species.
VIM family of carbapenemases
KPC enzymes
OXA – type β lactamases
22. Factors influencing β
lactamase expression
Expanded spectrum activity may decrease
intrinsic hydrolytic activity like in TEM and SHV
which can be compensated for by increased
gene dosage or a promoter with increased
activity.
Active efflux mechanism as in Pseudomonas
allows selective enzymes with limited hydrolytic
activity to inactivate the drug.
Decreased expression of OMPs required like in K.
pneumoniae allow resistance to develop to
specific drugs.
23. Genetics of β lactamases
PLASMIDS: predominate in ESBLs and hospital
outbreaks if unifocal in origin like TEM but may
be multifocal too like in SHV and spread world
wide.
TRANSPOSONS: TEM – 1 and TEM – 2
CHROMOSOMES: Klebsiella strains producing
SHV – 1
INTEGRONS: Genes are incorporated into the
genome but have their origin elsewhere. So
the reservoir is large with ubiquitous spectrum.
Eg. CTX – M, Amp – C type
24. Risk factors Predisposing to infection by
β lactamase producing organisms
Diabetes mellitus
Previous antimicrobial exposure
(quinolones, third generation
cephalosporins, penicillin)
Previous hospital admissions
Older age
Male patients
Prolonged ICU and hospital stay.
Increased severity of illness
Use of a CVC/CAC, urinary catheter, ventilatory
assistance
Cephamycins : Cephalosporins with a 7α-methoxy side chain that blocks hydrolysis by Classes A n D β-lactamases.eg.Cefoxitin, cefotetan n cefmetazoleOxyimino-β-lactams : β-lactams with an oxyimino side chain designed to block the actions of β-lactamases. Eg. IIIrd gen. cephalosporins (cefotaxime, ceftriaxone, ceftazidime) and IVth gen. cephalosporins (cefepime, cefpodoxime)
Classes A n D were generally seen in E. coli and other Enterobacteriaceae while classes B n C were confined to a particular bacterial species.
Eg. Of β-lactamase inhibitors : Clavulanic acid,tazobactam & sulbactamNitrofurantoin is an alternative for uncomplicated UTIs by ESBL producing organisms
TEM were named after the patient Temoneira from whom the Ist clinical isolate was obtained.
Diff from class A in hydrolysing cephamycins and not being affected by beta lactamase inhibitors. Spreading plasmid mediated resistance to E. coli, Klebsiella and salmonella
Increased gene dosage through gene duplication or carriage on multicopy plasmids. Increased promoter activity through mutations and insertion sequence substitution. In Klebsiella the above mentioned is the mode of development of resistance to cefepime in TEM or SHV type ESBLs or imipenem resistance through Amp-C betalactamases.
