This document discusses the growing issue of antibiotic-resistant bacteria and extended spectrum beta lactamase (ESBL) genes. It notes that prostate biopsy patients and those who have recently taken antibiotics or traveled internationally are at higher risk of harboring drug-resistant gut bacteria. Travelers often return home with multi-drug resistant E. coli acquired abroad. Additionally, ESBL genes are commonly found in retail chicken meat and match those found in humans, suggesting food animals may serve as a reservoir for resistance genes. The global spread of antibiotic resistance poses challenges for clinical practice and patient outcomes.

1. Jason Gale
Editor-at-large – Global Health
Bloomberg News/Sydney
Tel. +61-2-9777-8660
E-mail: j.gale@bloomberg.net
Twitter: @jwgale

2. Transrectal ultrasound-guided
PROSTATE BIOPSIES
• Prostate needle biopsy
patients = sentinels for
ciprofloxacin-resistant (?MDR)
in gut commensals?
• Small BUT growing risk
Nam, Loeb, Williamson, Patel et al
• Travelers, health-care workers
(and their household members),
veterinarians, repeat Bx
patients, recent antibiotic-users
among those at highest risk
• New approaches to mitigating
risk needed
Source: Michael Liss, University of California, San Diego

3. Japan 0%
microbial
SOUVENIRS
• Travelers return with MDR gut commensals
• Cipro resistance 3.9% pre-travel 33% post-travel
• ESBL+ve 2% pre-travel 22% post-travel
North America 30%
China, Hong Kong,
Taiwan, Korea 69%
India/Nepal/
Sri Lanka 79%
Middle East/Africa 75%
South
America/
Mexico 60%
Europe 24%
Southeast Asia/Pacific 52%
Source: Kennedy et al, European Journal of Clinical Microbiology & Infectious Diseases, 2010

4. microbial
SEX

5. The Superbug, Biopsy, Sepsis
• Global problem
• Getting worse
• Challenging clinical practice
• Affecting outcomes

9. gut
Colonization
• E. coli strains are shared among
household members, including the
family dog
Johnson et al, Journal of Clinical Microbiology December 2008
• Multidrug-resistant E. coli may
colonize the GI tract for 1 year or
more
Nordmann et al, Journal of Antimicrobial Chemotherapy, 2011

11. Extended Spectrum Beta Lactamase
• Enzymes that open the beta-lactam ring, inactivating the
antibiotic
• Confer resistance to most beta-lactam antibiotics, including
penicillins, cephalosporins, and the monobactam aztreonam
• First plasmid-mediated beta lactamase in Gram-negative bacteria
was discovered in Greece in the 1960s
• Now worldwide
• CTX-M-15, probably from India
• CTX-M-14, probably from China
• First line options for UTIs are lost:
Trimethoprim • Trimethoprim/sulfamethoxazole • Gentamicin •
Ceftriaxone • Ticarcillin/clavulanate • Piperacillin/tazobactam •
Ciprofloxacin

12. Why?
• Nature of Gram-negative bacteria
• accumulate resistance mechanisms
• gut colonization
• combining with virulence mechanisms
• Antibiotic use
• in people
• in animals
• Global travel
• global trotting grandpas
• medical tourism

13. % Fluoroquinolone Resistance
in E. coli / K. pneumoniae Isolates*
• Greece – 24 / 71
• Bulgaria – 33 / 52
• Cyprus – 43 / 39
• Hungary – 37 / 43
• Italy – 39 / 39
• Czech Republic – 23 / 55
• Latvia – 14 / 52
• Poland – 26 / 33
• Portugal – 27 / 31
• Malta – 34 / 16
• Spain – 33 / 14
* Bacteraemias in (mostly) elderly and not necessarily reflective of gut carriage

16. resistance
RESERVOIRS? • ESBL genes in
80% of raw
chicken meat
sold at retail
• Predominant
ESBL genes in
chicken meat
and human
rectal swab
specimens were
identical
Source: Overdevest et al, Emerging
Infectious Diseases, July 2011

17. Jason Gale
Editor-at-large – Global Health
Bloomberg News/Sydney
Tel. +61-2-9777-8660
E-mail: j.gale@bloomberg.net
Twitter: @jwgale