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EDITORIAL

RESISTANCE TO ANTIBIOTIC AGENTS: PERSPECTIVE AND REALITY.


RESISTENCIA A LOS AGENTES ANTIBIÓTICOS: PERSPECTIVA Y REALIDAD.
DOI: 10.48018/rmv.v32.i1.e

Acosta España Jaime David 1,2


*

Este artículo está bajo una Microorganisms have infected humans since time immemorial and in
licencia de Creative Com-
mons de tipo Reconocimien- this context, we have lived through an endless war that has produced
to – No comercial – Sin obras increasingly complex adaptation and selection pressure. Although
derivadas 4.0 International.
antibiotics marked a new era beginning in 1928, it is interesting to mention
that traces of tetracycline were found in human bone samples from
1 Hospital Vozandes Quito – HVQ SA. Servicio de ancient Sudanese Nubia dating from 350–550 AD. C (1).
Microbiología. Quito – Ecuador.
2. Universidad de las Américas. Escuela de Medicina.
Quito - Ecuador Paul Erlich, by his staining methods, already deduced at the end of the
19th century and the beginning of the 20th century, that there may be
ORCID ID: a magic bullet that acts on microorganisms to eliminate them, without
Acosta España Jaime affecting other cell types. This molecule is currently known as an antibiotic
orcid.org/ orcid.org/0000-0001-5299-2732 or antimicrobial in relation to its natural or synthetic origin. Of this interest,
in 1910 the first molecule with studies in rabbits infected with syphilis to
*Corresponding author: Acosta España David demonstrate antimicrobial activity was described (2,3).
E-mail: jdacosta@hospitalvozandes.com
After this discovery, an antimicrobial revolution began with drugs
Article history from neosalvartan, penicillin, sulfonamidochrysoidine (prontosil)
Received: 08 – Mar – 2021 to complex molecules such as fifth-generation cephalosporins
Accepted: 02 – May – 2021 (ceftobiprole,ceftaroline,and ceftolozane) and even the association
Publish: 01 – Jun – 2021 with new beta-lactamase inhibitors that include ceftazidime/
avibactam,meropenem/vaborbactam,ceftolozane/tazobactam,
Conflict of interest: The author declares no imipenem- cilastatin- relebactam, among others (4–6).
conflict of interest.
So, it is essential to highlight that microorganisms have been exposed to
Financial disclosure: The authors has no financial various molecules: bactericides,bacteriostats, fungicides,antiprotozoa,
relationships relevant to this article to disclose. anthelmintics, antivirals, etc. And going back to the past again, as
mentioned in his book “... The Origin of Species ...” by Charles Darwin, in
Palabras clave: Resistencia, antimicrobianos, CO- which he referred that biological adaptation, is essential for the survival of
VID-19, perspectiva, actualidad, Ecuador
biological organism, microorganisms will continue to adapt and only the
best prepared for this adverse environment will be left (3).
Keywords: Resistance, antimicrobials, COVID-19,
perspective, present, Ecuador
Thus, microorganisms have developed various mechanisms to evade the
action of these antimicrobial substances since time immemorial, which
is currently known as antimicrobial resistance (AMR), among these, one
of the best known is bacterial resistance (7). In which natural resistance is
included: which is specific and intrinsic to microorganisms, for example
ampicillin in Klebsiella pneumoniae; and acquired resistance: which is
the one that microorganisms gain by various mechanisms, such as the
production of extended spectrum beta-lactamases (ESBL) from Klebsiella
pneumoniae by plasmids (8).

In our daily clinical practice, it is currently common to find cultures of


patients with resistant, multidrug resistant (MDR), extremely resistant (XDR)
or pandemic resistant (PDR) microorganisms. Which in certain cases
can result in a complicated work even for infectologists to find the best
therapeutic option. In fact, it has become a priority for the World Health
Organization (WHO), which has declared AMR as one of the 10 priority
Citation:
Acosta España J. RESISTANCE TO AN-
public health threats facing humanity, associated with higher mortality,
TIBIOTIC AGENTS: PERSPECTIVE AND increased health costs and therefore the government budget (9).
REALITY. Rev Med Vozandes. 2021; 32 (1):
…..- …….
Keys Words: SARS-Cov2, Pandemia, Aprendizajes

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Volumen 32, Número 1, 2021
RESISTANCE TO ANTIBIOTIC AGENTS: PERSPECTIVE AND REALITY. Acosta España J

WHO prioritized pathogens of importance for the (KPC, NDM, VIM, OXA) was observed and also with
surveillance and research of new antibiotics, for priority the presence of the mrc-1 gene. On the other hand,
one were considered: Acinetobacter baumannii Pseudomonas aeruginosa resistant to carbapenems
resistant to carbapenems, Pseudomonas aeruginosa through impermeability, efflux pumps, carbapenemases
resistant to carbapenems, Enterobacteriaceae resistant (VIM, IMP) and even ESBL producers. Finally,
to carbapenems and third generation cephalosporins. Staphylococcus aureus with 87% of isolates resistant to
Priority two describes: vancomycin-resistant Enterococcus penicillins, resistance to methicillin (MRSA) with a mean
faecium, methicillin-resistant Staphylococcus aureus (MRSA) for the years studied of 46% and even with production of
and vancomycin-intermediate (VISA), clarithromycin- methylases that confer resistance to macrolides (15).
resistant Helicobacter pylori, fluoroquinolone-resistant
Campylobacter sp, Salmonella spp. resistant to Unfortunately, at the time of writing this article, no updated
fluoroquinolone and Neisseria gonorrhoeae resistant to published data was found for this problem in relation
fluoroquinolones and third generation cephalosporins. to AMR in Ecuador. In any case, Ecuador in November
Finally, as priority 3: Streptococcus pneumoniae not 2019 launched the National Plan for the prevention
susceptible to penicillin, Haemophilus influenzae resistant to and control of antimicrobial resistance (AMR) 2019-
ampicillin and Shigella spp. resistant to fluoroquinolone (10). 2023 of Ecuador. In which a multisectoral intervention is
considered that includes the MSP, Ministry of Agriculture
These and other microorganisms are of special importance and Livestock, Ministry of the Environment, among others.
and it is advisable to know the biology, virulence factors, And this focuses on 4 objectives that range from improving
intrinsic or extrinsic resistance mechanisms, as well as the understanding of AMR, strengthening surveillance,
the most frequent infections related to them. Indeed, preventing and controlling HAIs, to strengthening the
the international bibliography asks to pay attention to rational use of drugs in human, animal and plant health (16).
the microorganisms ESKAPE, which is an acronym used
to refer to Enterobacter sp., Staphylococcus aureus, Finally, the picture was complex adverse projections,
Klebsiella pneumoniae, Acinetobacter baumannii, like those of the UN referred to the RAM 2050 will cause
Pseudomonas aeruginosa, and Enterococcus faecium. increased morbidity and mortality compared with
Since they lead the infections associated with health other diseases worldwide. But this reality is much closer
care worldwide due to their resistance mechanisms such due to the effects of the pandemic by “Coronavirus
as production of beta-lactamases, carbapenemases, Disease 2019” (COVID-19) produced by SARS-CoV-2,
efflux pumps, impermeability, etc. (11). where the indiscriminate use of antibiotics has
exceeded all expectations. The appearance of this
This appearance of AMR is multifactorial and has been new betacoranavirus at the end of 2019 led to the
related to the indiscriminate use of antibiotics by human use of antimicrobials such as azithromycin, ivermectin,
and veterinary health professionals, pharmacological nitazoxanide, etc. based on studies carried out in
waste in sewage with antibiotic residues, and untreated monkey kidney cell cultures or small populations (17–21).
water produced by health services, farms, among others.
It is important to analyze the veterinary use in food and In addition to the use of broad-spectrum antibiotics in
water of various types of antibiotics to enhance the patients hospitalized for their critical condition associated
growth of animals and prevent infections, which has with COVID-19, for example, Langford et al. report that
led several governments to prohibit the use of certain 71.8% of patients infected with SARS-CoV-2 received
antibiotics used in humans in the production of animals antibiotics (22). These interventions are generating selective
or to control their levels and promote rational use. And pressure on microorganisms and this can be evidenced
this holistic approach to fighting AMR is known as “ONE by the superinfection of MDR microorganisms in various
HEALTH” or one health (12–14). studies by E. Coli, K. pneumoniae, Pseudomonas
aeruginosa, etc (23–25). Another example is the Gonzalez-
In Ecuador, the reality is very similar to the world panorama Zorn study that shows the abuse of azithromycin in Spain,
and the surveillance faculty is carried out through the with an increase of 400% in March 2020 compared to
National Reference Center for Antimicrobial Resistance February of the same year (26).
(CRN-RAM), which receives mandatory surveillance
strains based on WHO recommendations. The Ministry of Although the limit between the clinical features of a
Public Health of Ecuador (MSP) in the document “Data coinfection or a bacterial superinfection in a COVID-19
Report On Antimicrobial Resistance In Ecuador 2014- patient is complex to define from the clinical point of
2018” that the microorganisms subject to surveillance view, the concern for possible infections with resistant
most frequently reported were in descending order: pathogens could lead to unnecessary empirical
Escherichia coli, Klebsiella pneumoniae, Staphylococcus prescription, inducing that only microorganisms more
aureus and Pseudomonas aeruginosa (15). resistant remain in the patients, hospital services in even
the environment. Which can lead to an antimicrobial
In the report document of the data analysis of resistance pathogen crisis sooner than expected.
antimicrobial resistance in Ecuador, it is described in Therefore, we must focus on multidisciplinary and
E. coli was observed resistant to carbapenems (KPC multidimensional actions for the prevention of infections,
and NDM type) and highlights the resistance to colistin rational use of antibiotics, adequate microbiological
through the micro-1 gene, among others. For Klebsiella diagnosis, antimicrobial analysis charts (Figure 1), strict
pneumoniae, the production of carbapenemase use of standard precautions, hand hygiene, etc.

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ESTUDIO DE COHORTE RETROSPECTIVA ARTÍCULO ORIGINAL

Figure 1 Example of antimicrobial analysis booklet from Hospital Vozandes Quito S.A.

Source: Hospital Vozandes Quito, Microbiology Laboratory.


Pathogen susceptibility analysis table, this tool can be used to establish an empirical therapy based on the usual hospital epidemiology. Resistant
microorganisms are shown in red and sensitive microorganisms are shown in green. This table does not replace the indication for culture in patients
who require it, since certain patients may present antimicrobial resistant microorganisms.

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