Antimicrobial Resistance and Antimicrobial Stewardship

#### **Chapter 8**

## Antimicrobial Resistance: A One Health Perspective in India

*Radhakrishnan Rahul, Narayanasamy Damodharan, Kakithakara Vajravelu Leela, Maheswary Datchanamoorthy and Anusha Gopinathan*

#### **Abstract**

One health is a collaborative, multi-sectoral, trans-disciplinary approach used to achieve optimal health and well-being outcomes that recognize the interconnections among people, animals, plants, and their shared environment. This approach is crucial because animals and people are colonized by the same bacteria species and treated with the same antibiotic classes; the technique is instrumental in fighting antibiotic resistance. The microorganism developed antibiotic-resistant genes, which were transferred to the animal and human population via the environment. Human activities speed up the organism to acquire resistance rapidly. The primary sources of antimicrobial resistance from the environment were improper sewage and hospital waste sanitation, effluents from antibiotic production units, animal husbandry waste, agricultural manure use, livestock, and aquatic sources. This study analyzed the various routes by which antimicrobial-resistant gene is transferred into humans and their pathway in India. The study concludes that implementing strict regulation and monitoring regarding the irrational use of antibiotics in animals, sewage disposal, waste disposal, and hospital infection control practices, and providing awareness to the public regarding antibiotic resistance can reduce the rate of developing antibiotic resistance to some extent along with implementing antibiotic stewardship programmes for veterinary medicine.

**Keywords:** antimicrobial resistance (AMR), antimicrobial stewardship (AMS), one health, environment, sources

#### **1. Introduction**

One health is a collaborative, multi-sectoral, trans-disciplinary approach working at local, regional, national, and global levels to achieve optimal health and well-being outcomes that recognize the interconnections among people, animals, plants, and their shared environment [1]. This approach is crucial because animals and people are colonized by the same bacteria species and treated with the same antibiotic classes; the technique is instrumental in fighting antibiotic resistance [2].

Antimicrobial resistance is defined as a microorganism's acquired or inherited capability to resist the effect of a particular antimicrobial and then continue its proliferation

#### **Figure 1.**

*Schematic diagram of antibiotic-resistant gene transfer from various sources to human.*

in the host. Superbugs are microorganisms that are capable of withstanding more than one antimicrobial. At the initial stage of antimicrobial discovery, primary sources were natural sources; therefore, the chances of developing antimicrobial resistance from natural sources are now at their peak. Every organism battles with antimicrobials for survival and existence, but human actions enhance this for an organism to acquire resistance. This has led to a global threat of antimicrobial resistance and treatment failures.

As per the World Health Organization (WHO), 07 lakh deaths are reported every year due to antimicrobial resistance resulting in treatment failure. Estimates show that 10 million deaths will be reported by 2050 due to antimicrobial-resistant infections. WHO further recognizes that antibiotic resistance bacteria (ARB) and resistant genes are the major contributors to environmental pollution, and they will be a significant threat to human and animal populations worldwide.

The prevalence and occurrence of antimicrobial resistance from environmental and natural sources is not studied extensively. The environmental factors also vary across locations based on the ethnicity, culture, belief, and practices of humans worldwide. As per the existing evidence, the primary sources of antimicrobial resistance from the environment were improper sewage and hospital waste disposal, effluents from antibiotic production units, animal husbandry waste, agricultural manure use, livestock, and aquatic sources (**Figure 1**). Due to globalization, these antibiotic-resistance genes spread rapidly from one region to another. Human migration and travel, importing and exporting goods primarily carry these resistant genes and organisms to different areas [3].

#### **2. Antibiotics in humans**

Various reports across the globe state that Asian countries are the most widespread consumers of antibiotics worldwide. More specifically, India (10.7 units per person)

#### *Antimicrobial Resistance: A One Health Perspective in India DOI: http://dx.doi.org/10.5772/intechopen.112201*

stands first, followed by China (7.5 units per person) in antibiotic consumption. As per the latest study, the BRICS countries (Brazil, Russia, India, China, and South Africa) observed a 76% increase in the consumption of antibiotics [4]. As per the antimicrobial resistance (AMR) surveillance data from India, the most common pathogen isolated was *Escherichia coli* (*E. coli*), followed by *Klebsiella species* (22%), *Staphylococcus aureus* (*S. aureus*) (18%), *Pseudomonas species*. (10%), *Enterococcus species* (9%) and *Acinetobacter species* (8%), *Salmonella Typhi* and *Para typhi* (0.5%) [5]. The frequently consumed antibiotics in India were cephalosporins (32%), penicillin (28%) and macrolides (14%), followed by tetracyclines (6%) [6]. As per the study by ICMR, more resistance was found in cephalosporins (60%) and fluoroquinolones (41.5%) [7].

#### **2.1 Antimicrobial resistance and human gut microbiome**

The bacteria, their genomes and the environmental circumstances of the human digestive tract are referred to as the 'human gut microbiome'. The use of highthroughput, low-cost sequencing tools has fuelled research into the gut microbiome in the recent decade to determine its composition, function, and role in health and illness [8]. The gut includes hundreds of bacterial species, collectively known as the microbiota, where Bacteroidetes and Firmicutes bacteria account for 90% of all species in healthy individuals' guts [9]. Less common bacteria such as phyla Actinobacteria, Proteobacteria and Fusobacteria can protect against diseases [10, 11]. The human host has a symbiotic or commensal connection with most intestinal microorganisms. However, some organisms belonging to Enterobacteriaceae, including *Escherichia coli* and *Klebsiella pneumonia*, and *Enterococcaceae*, particularly *Enterococcus faecalis* and *Enterococcus faecium*, are found in the gut microbiota. Intestinal carriage of these bacteria can predispose to urinary tract infections and more serious systemic infections in immunocompromised people [12–14]. Infections caused by antibiotic-resistant clones of *E. coli, Klebsiella pneumoniae* [15] and *E. faecium* [16] have increased globally in recent decades. Various studies have observed that multi-drug resistance diseases cause more morbidity and mortality in low- and middle-income countries in Asia, Africa and South America [17–19].

The essential methods by which bacteria might develop resistance to antibiotics are the prevention of antibiotics reaching toxic levels inside the cell, altering the antibiotic target, and modifying or degradation of the antibiotic itself [20]. These resistance mechanisms can occur due to chromosomal gene changes and the horizontal gene transfer (HGT) of antibiotic resistance genes (ARGs) from other strains of the same or different species. HGT aided significantly in the global distribution of ARGs. HGT can occur in any environment, especially when bacterial loads are high, such as in soil [21], wastewater treatment facilities [22, 23], and human and animal gut microbiomes [24–26]. Previous research has demonstrated that the gut has many antibiotic resistance determinants, known as 'gut resistome' [27, 28].

Oral ingestion of contaminated substances (food, trash, residual waste from occupational exposure or polluted surroundings) and inhalation of airborne ARB are two routes by which ARB and ARGs reach human gut ecosystems [29, 30]. The fate of ingested bacteria, including ARB, is determined by various factors such as preexisting microbiome structure, medication, host age and dietary environment. Under normal nutritional and physiological conditions, the diversity and abundance of the gut microbiome operate as a significant barrier to the integration of ingested bacteria, and most ingested bacteria only colonize the human body transiently. Antibiotic

treatment or intake of antibiotic residues, on the other hand, may significantly modify gut microbiota structure, facilitate ARB integration by reducing competition, and enhance ARG proliferation by removing competition.

Due to a favorable environment (e.g. high concentrations of ARG, stable temperature, physiochemical conditions, and nutrient availability), long-term colonization by ARB may also accelerate HGT in the human gut and contribute to the emergence of multi-drug resistance genes by pathogens such as methicillin-resistant *Staphylococcus aureus* (MRSA).

#### **2.2 Mechanism of horizontal gene transfer**

The transfer of genetic information between bacterial species is a dynamic and continuous process resulting in the constant evolution of the bacteria. It is known to impact the host significantly with delayed or immediate effects. Most frequently recognized mechanisms of HGT occur by transduction, transformation or conjugation. Naked DNA from the extracellular environment is taken up by bacteria and integrated into their genomes during transformation. Bacteria that are naturally transformable or competent are required for the transformation process. The genes involved in DNA uptake in several other species show this trait is more prevalent [31]. Over 80 bacterial species have been experimentally demonstrated to be naturally competent. The factors that cause naturally transformable bacteria to enter a capable condition are unknown; however, nutritional deprivation and the presence of competenceinducing peptides have been identified as triggers [32]. Due to this process, competent natural pathogens such as *Neisseria gonorrhoeae*, *Vibrio cholera* and *Streptococcus pneumoniae* have acquired antibiotic resistance [33].

Membrane vesicles (MVs) are 20–250 nm spherical objects produced mainly by Gram-negative bacteria when the outer membrane bulges away from the cell and is released by constriction [34]. The cargo is delivered when MVs fuse with their target cells. MVs are generated *in vitro* by commensal bacteria in the gut. MVs formed by gut bacteria can also include cytoplasmic components, including DNA, which are significant in the context of HGT [35]. Protrusion of the outer and inner membranes is thought to create DNA-containing MVs, which leads to the incorporation of cytoplasmic components into the vesicles. Similarly, vesicle-mediated transfer of DNA has also been reported for *E. coli* [36]. While MVs are produced in the gut and can potentially influence host immune responses [37], it is unclear whether they can contribute to HGT in the gut microbiome.

Transduction is the transfer of chromosomal and extrachromosomal DNA between bacteria *via* a viral intermediary known as a bacteriophage. Generalized, specialized, and lateral transductions are the three basic transduction methods. Antibiotic-resistant genes can mobilize any portion of a bacterial genome if favorable factors exist. When bacteriophages in the lytic cycle incorporate parts of the bacterial host's DNA during capsid production, this is known as generalized transduction. Regions immediately flanking a lysogenic phage's integration site are excised and packed into the capsid in specialized transduction [38]. Prophages initiate DNA replication while still integrated into the host, known as lateral transduction.

Before excision from the host genome, this mechanism makes numerous copies of DNA. After being excised, the DNA—which can be hundreds of kilobases long and comprise both phage and neighboring genes—is packaged into new phage particles and distributed to other bacterial strains [39]. The human gut has a diverse community of bacteriophages [40, 41], and ARG-carrying phages can be found in large

numbers in the gut and other settings [42]. Antibiotic therapy enhances the number of these ARG-carrying phages in the human stomach [43]. The quantitative contribution of phages to the horizontal transfer of ARGs is still unknown.

Mobile genetic elements like plasmids and integrative and conjugative elements (ICEs) are transmitted from one bacteria to another in the conjugation process [44]. Due to their large size and the common occurrence of one or more toxin-antitoxin modules that ensure that plasmids are kept inside their microbial hosts, conjugative plasmids are likely the most relevant for transmitting ARGs among conjugative elements [45].

A pilus carries DNA between bacteria close to one other during conjugation, a complicated, multi-stage, and contact-dependent process [46]. With its rich mucous coating and high density of bacterial cells, the gut provides an ideal habitat for conjugation. While colonizing the human gut, commensals and opportunistic infections have been found to transfer antibiotic resistance plasmids and ICEs [47, 48]. Notably, conjugative plasmids can supply the machinery that allows non-self-transmissible DNA to be mobilized, considerably enhancing the potential for resistance determinant HGT [49].

#### **3. Antibiotics use in animal husbandry**

In 1940, studies observed that the addition of antibiotics in cattle feed led to an enhancement in the weight gain and feed conversation ratio, which led to the irrational use of antibiotics in animals to enhance cattle growth. Over several years, this irrational use of antibiotics in cattle feed led to an increased prevalence of infectious diseases in animals due to the development of antibiotic resistance [50].

The cross-sectional study conducted in Haryana, with high milk consumption in the Indian subcontinent, showed the irrational use of antibiotics as growth enhancers and animal feed supplements. About 81% of the total participants in the study agreed that they were about to add antibiotics to improve the production of animal products. The survey indicates that 46% of the participants accepted that animal products transmitted resistant bacteria to humans. In animal husbandry, the diagnosis is critical for prescribing antibiotics [51].

The prevalence of multi-drug resistant, extended-spectrum beta-lactamases producing *Escherichia coli* from pig farms in Mizoram was studied by analyzing the fecal samples collected from organized and unorganized farms. From the analysis, they inferred that the majority of the *E. coli* were resistant to amoxicillin (81.7%), cefalexin (85.42%), co-trimoxazole (50.78%), sulfafurazole (69.38%), tetracycline (65.89%) and trimethoprim (TR) (51.94%). The results indicated the misuse and overuse of antibiotics in pig farms in India [52].

There are many possible routes for transmitting antibiotic-resistant bacteria from farm animals and their products, directly or indirectly, of which horizontal gene transfer plays a significant role [53, 54]. **Table 1** depicts various antibiotic-resistant gene observed in livestock. Shotgun metagenomics was used to analyze the characterization of the resistome, showing the presence of plasmid metagenomes in AMR genes. The most common resistance in cattle and animal products was to tetracycline, quinolone, and beta-lactams.

The behavior and destiny of ARB and ARGs discharged from animal husbandry to soil (e.g. by land application of manure and wastewater irrigation) and aquatic ecosystems have been studied extensively (e.g. through wastewater discharge and runoff).


#### **Table 1.**

*Antibiotic-resistant gene observed in livestock.*

Horizontal gene transfer (HGT) can transmit intracellular and free ARGs in surface and groundwater, soil and air [55–58] to indigenous bacteria [59, 60] through several paths. These ARBs may finally reach and colonize humans [21, 61], producing acute infections or long-term quiet colonization that can eventually evolve into an infection.

Bacteria-carrying ARGs are discharged into diverse receiving habitats from livestock farms *via* drainage, treated wastewater and solid waste. ARB and indigenous bacteria may undergo HGT. Humans can potentially become infected with ARB if exposed to it (e.g. water ingestion, food ingestion and inhalation). ARB might then replicate in the human body (particularly the gut) and cause endogenous or external infections.

#### **3.1 Antibiotic use in milk animals**

Raw milk is a product that is sold unprocessed. Therefore, the presence or grade of heat-treatment stages is left to the consumer's discretion. Furthermore, the

#### *Antimicrobial Resistance: A One Health Perspective in India DOI: http://dx.doi.org/10.5772/intechopen.112201*

consumption of non-heat-treated raw milk is now widely accepted as a trend in industrialized countries owing to its positive health effects.

The most identified antibiotics in milk animals, as per the National Dairy Research Institute (NDRI), were tetracycline, oxytetracycline, gentamicin, ampicillin, amoxicillin, cloxacillin, and penicillin due to their lower costs [62]. Studies show that farmers obtained antibiotics through various sources of consultancy. Only 50% of the small farmers consulted veterinary care for antibiotics, whereas 76.79% of medium and 87.50% of large farmers consulted the same. Other parakeet milk vendors have opted for over-the-counter medications [63]. A study conducted in 2021 at small-scale dairy farms in Assam and Haryana indicates that 53% of the small-scale farmers could not explain the term antibiotic, which stands out as an essential factor for the misuse of antibiotics in dairy farms. Residues of novobiocin, macrolides, and sulphonamides are found in the milk sample collected from the farmers [64].

The use of antibiotics and antibiotic residues in milk dates back to the 60s, indicating a swelling trend of antibiotic use in animal farms and animal products. The use of antibiotics in the milk industry may lead to antibiotic resistance and allergic reactions such as anaphylaxis and serum sickness. The antibiotic residues interact with DNA and RNA. Antibiotic residues may alter the chromosome, causing infertility due to mutation [65]. A study conducted by Modi et al. [66] studied the prevalence of *campylobacter* species in milk and milk products showing resistance against nalidixic acid, ciprofloxacin, and tetracycline. A study conducted in 2020 involved the detection of antibiotic-resistance genes in raw milk for human consumption. The traces of antibiotics in the milk clearly indicate giving antibiotics to the cattle, but there is no strict regulation to monitor and control the irrational use.

#### **3.2 Antibiotic use in poultry**

As per the reports, India was the fifth high consumer of antibiotics in animals as of 2010. However, this ratio will be doubled by 2030 [67]. Tetracycline, doxycycline, and ciprofloxacin were reported to be highly used in poultry and colistin as a growth promoter [68]. Several studies have shown traces of antibiotic residues in chicken meat intended for human consumption [69]. A survey conducted by Kaushik *et al.* in eastern India found that *E. coli* isolates showed high resistance to cefuroxime and penicillin in poultry [70].

Similarly, another study conducted in Mumbai reports a massive rise in tetracycline resistance among *Salmonella* species in poultry [71]. A recent study conducted in North India observed a high level of resistance genes against fluoroquinolones followed by tetracycline and beta-lactams [72]. Recent studies conducted in Kerala found that antibiotics were supplied along with feed, leading to antibiotic resistance [73]. Similarly, the study found *E. coli* resistance to beta-lactams and carbapenem in the poultry litter, and similar resistance has been observed and correlated with isolation from patients with UTI in that area.

Koirala *et al.* [74] conducted a cross-sectional study in 30 larger broiler poultry farms to understand the prevalence of antibiotic use and antibiotic resistance developed in poultry farms. The study found that 90% of the farms used antibiotics. Antibiotics were used for prophylaxis and therapeutic purposes. The standard categories of antibiotics used for prophylaxis are fluoroquinolone and aminoglycosides. For treatment, macrolides and polymyxin are used. In observation: 47% of them used tylosin and colistin. Neomycin and doxycycline were used in combination with antibiotic therapy. Gene mutation and enzyme production induced by chromosomes


**Table 2.**

*Antibiotic-resistant gene observed in poultry.*

within the bacteria chromosome exhibits intrinsic resistance. HGT is the reason for extrinsic or acquired resistance.

The use of antibiotics in the feed, exposure of the infected litter to the soil as manure, and consumption of meat by human can lead to the entry of resistant organisms into the human gut microbiota. **Table 2** depicts various antibiotic-resistant gene observed in poultry.

#### **4. Pollution from the antibiotic manufacturing industry**

India is the third largest country in pharmaceutical production in terms of volume, and India has 3000 manufacturing companies and 10,500 manufacturing units over the country. As per the Indian economic survey 2021, the domestic market will triple in the upcoming decade [75]. Regarding antibiotics, 80% were produced and exported globally by giant pharmaceutical manufacturers from India and China.

The studies have observed that industrial waste from these antibiotic production units has significant traces of antibiotic residues [76–78]. The flow of this antibiotic

residue to the environment will be from the bulk Active Pharmaceutical Ingredients (API) manufacturing unit and the sub-manufacturing unit. The habitats impacted by pharmaceutical industrial pollution were rich in ARGs and had the highest relative abundance of ARGs of all the ecosystems studied. The relative abundances of ARGs in wastewater/sludge were also compared to the relative abundances of ARGs in most other environmental habitats (sediment, water, soil and mine), all of which are presumably less impacted by human fecal waste.

The existing Good Manufacturing Practices regulation in India mainly focuses on drug safety, raising concerns over the environmental impact. The Central Pollution Control Board (CPCB) and its constituent units scrutinize industrial waste disposal, where strict control over antibiotic residuals should also be exerted [79]. The runaway of antibiotic residue from the manufacturing companies will contaminate the soil and water sources, further enhancing antibiotic resistance development through the food chain.

#### **5. Environmental sanitation**

Better sanitation facility is a basic need of human life. Over 2.0 billion people still need to catch up on common and basic sanitation facilities such as toilets or latrines. Of these, 673 million still defecate in the open, for example, in street gutters, behind bushes or into open bodies of water [80].

Even though India has improved drastically in providing better sanitation facilities, remote rural areas still need to be adequately equipped with sanitation facilities. The association between sanitation and the occurrence of antibiotic resistance is based on the two factors, such as the antibiotic resistance prevalence rate in the area and the concentration of resistant genes in the human gut.

Although on a lower scale, ARGs can also spread through receiving water and air habitats. ARG abundances in receiving surface water habitats are typically 100 times higher than those in upstream waters. When bacteria populate the intestinal mucosa of fishes, ARGs can be obtained by bacteria reaching receiving water bodies, where they can accumulate in sediments by sedimentation and adsorption. ARGs have been found in groundwater 250 meters downstream from treatment lagoons in swine farms [81]. ARGs are also identified in aerosols up to four orders of magnitude higher than at the source, downwind of animal husbandry operations [82].

The current practice of sewage waste treatment technologies like sludge will not extensively remove the wastewater's antibiotic residues and resistance genes. The sludge produced with antibiotic residues will freely flow to the soil and environment and, finally, can enter the food chain.

#### **6. Hospital infection control practices**

Several studies have reported the resistant gene reservoir in clinical settings [83–87] occurring due to HGT, but the rate and extent of this transfer mechanism are not elaborately studied. Hospital infection control practices are pivotal in preventing antibiotic resistance in humans. Irrational use of antibiotics and poor compliance with infection control practices among healthcare providers contribute to antibiotic resistance. The lacunae in knowledge among healthcare providers regarding the growing trend of antibiotic resistance and infection control practice guidelines of the hospitals lead to irrational or overuse of antibiotics in hospitals and more frequently among independent practitioners. These poor infection control practices contribute to the rapid transmission of superbugs like MRSA and vancomycin-resistant enterococci (VRE), and other multi-drug resistant Gram-negative bacterial infections among hospital patients [88–90].

The significant challenges in these areas were the gap between the implementation and practices of infection control guidelines. Lack of knowledge regarding hand hygiene to prevent the spread of hospital infections and lack of supervision, administration, and facilities lead to the decline in infection control practices.

#### **7. Conclusion**

There is an alarming increase in antimicrobial resistance, and there is insufficient evidence regarding the prevalence and occurrence of developing antimicrobial resistance from environmental and natural sources. The environmental factors may vary across different geographical locations based on the ethnicity, culture, belief and practices of human populations. Therefore, location-based studies should be conducted to correlate the burden of ever-increasing antibiotic resistance and its impact on therapeutic outcomes. The lack of proper implementation of laws and regulations regarding the disposal of biological waste and the use of antimicrobials in the animal and agriculture field is significant contributors to the development of antibiotic resistance.

#### **Acknowledgements**

The authors thank SRM College of Pharmacy, SRM Medical College Hospital and research centre, and SRM Institute of Science and Technology, India, for providing the necessary facility for this research.

#### **Conflict of interest**

The authors declare no conflict of interest.

*Antimicrobial Resistance: A One Health Perspective in India DOI: http://dx.doi.org/10.5772/intechopen.112201*

### **Author details**

Radhakrishnan Rahul1 , Narayanasamy Damodharan<sup>2</sup> , Kakithakara Vajravelu Leela3 , Maheswary Datchanamoorthy3 \* and Anusha Gopinathan3

1 Department of Pharmacy Practice, SRM College of Pharmacy, SRM Institute of Science and Technology, Kattankulathur, India

2 Department of Pharmaceutics, SRM College of Pharmacy, SRM Institute of Science and Technology, Kattankulathur, India

3 Department of Microbiology, SRM Medical College Hospital and Research Centre, SRM Institute of Science and Technology, Kattankulathur, India

\*Address all correspondence to: drmagidatchu@gmail.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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#### **Chapter 9**

## Antimicrobial Resistance in Environment and Antimicrobial Stewardship

*Sadia Khan*

#### **Abstract**

The spread of antimicrobial resistance (AMR) in the environment is an alarming issue for the world as the extensive use of antimicrobials in different sectors including healthcare facilities, food and pharmaceutical industries, agriculture, and animal farming has resulted in the enrichment of antibiotic-resistant bacteria (ARB) and antibiotic resistance genes (ARGs) in different environmental compartments such as surface water, wastewater, soil, and drinking water. Not only single-drug-resistant but multidrug-resistant (MDR) organisms are increasing at an alarming rate. Treatment technologies used in wastewater treatment plants (WWTP) are mostly focused on the removal of physical and chemical contaminants and less focused on the removal of biological contaminants like antimicrobial-resistant genes, which pose serious threats for both humans and the environment. Antimicrobial stewardship (AMS) programs have been started in different countries of the world to overcome the problem of antimicrobial resistance and minimize the impacts on the environment. This program is based on collective efforts from clinicians, technicians, physicians, scientists, leaders, and the public and their active participation in the possible eradication of antimicrobial resistance from the world.

**Keywords:** multidrug-resistant bacteria, wastewater treatment plant, chlorine, horizontal gene transfer, antimicrobial stewardship

#### **1. Introduction**

With the production of antibiotics in the twentieth century, the world is facing the dilemma of AMR, which decreases the efficiency of antimicrobial compounds for the treatment of infectious diseases. Antimicrobial resistance (AMR) has been recognized as a global threat and the endless emergence of multi-drug resistant strains of bacteria like New Delhi Metallo-β-lactamase-1 (NDM-1) containing *Enterobacteriaceae*, Multidrug-Resistant *Staphylococcus aureus* (MRSA), and Extensively Drug-Resistant Tuberculosis (X-DRTB) become a complicated challenge worldwide [1, 2]. The resistant organisms and their genes have been dispersed in different environments due to the widespread use of antimicrobials to avoid the onset of infections in humans and animals. The uncontrolled and unsafe use of antibiotics since the beginning resulted in the emergence of resistance in almost every environment including drinking

water, wastewater, soil, and even in pristine environments. Antibiotic resistance is so established in each environment that the analysis of bacteria for antibiotic resistance genes reveals the source of bacteria due to the use of different antibiotics for humans, livestock, and agriculture [3].

Antimicrobial resistance is not only developed in organisms when they are exposed to antimicrobial agents in the natural environment but also without any contact with antibiotics in the form of intrinsic resistance. Furthermore, not only the higher concentrations of antibiotics but also minimum inhibitory concentration (MIC) could enrich the antibiotic-resistant bacteria and their genes in the environment [4]. The high level of ARB and ARGs is due to anthropogenic activities and needs immediate attention as the use of antibiotics is continuously increasing, and the development of the next genera of antibiotics is limited.

#### **2. Wastewater and antimicrobial resistance**

Wastewater is one of the major sources of ARB and ARGs in the environment. The higher concentrations of antibiotics in wastewater cause the enrichment and propagation of resistance among other bacteria and also transfer resistance to another environment [5]. The discharge of untreated wastewater has resulted in the enrichment and prevalence of ARGs in the water environment and the wastewater treatment plants (WWTP) act as a major reservoir of ARB and ARGs as activated sludge and treated effluent contain ARB and ARGs in abundance [6]. Activated sludge faces a lot of stress and induces the AMR through the co-selection process in the wastewater environment [7].

Wastewater contains a variety of pollutants and diverse microbial communities and provides a favorable environment for the proliferation of ARGs among bacteria. The major sources of antimicrobial resistance are humans and animals. Discharges from clinical and industrial sources also contribute to the ARB and ARGs. These pollutants move with the water cycle and reach other water environments [5]. Natural water bodies now have higher concentrations of antimicrobial compounds in water and their sediments. Treatment technologies used in WWTP are not focused on the removal of ARB and ARGs, and they remain active in effluent. During wastewater treatment, primary, secondary, and tertiary treatments have been used to remove most of the pollutants, and disinfection is also applied at the last stages of the treatment. Biological treatments including aerobic and anaerobic bioreactors and constructed wetlands are used to remove resistant bacteria. The concentrations of commonly used antibiotics are much higher in wastewater and surface water indicating the possible transfer of these resistances to other environments as well as due to the use of polluted water or untreated or partially treated wastewater in agriculture and for plantation in many countries.

#### **3. Drinking water and antimicrobial resistance**

Physical, chemical, and biological environmental factors affect the occurrence and enrichment of ARB and ARGs in drinking water including the disinfectants such as chlorine and pipe materials of the distribution system [8]. Wastewater is considered a hotspot for the ARB and ARGs due to the presence of human excreta and chemicals that contribute to the emergence of resistance in the bacterial population, although drinking water can also harbor the same [9] despite having different physico-chemical and biological characteristics. Drinking water supply systems contain pathogens and resistant

#### *Antimicrobial Resistance in Environment and Antimicrobial Stewardship DOI: http://dx.doi.org/10.5772/intechopen.113224*

bacteria that can transfer genes to other populations. The water distribution system is considered a complex system, and it is difficult to inactivate and treat the resistant bacteria as complete information about the behavior of these bacteria is not well known. Disinfectants used for the treatment of pathogenic microorganisms can result in the proliferation of ARB and their genes in the water distribution system and drinking water.

Chlorine is a cheap and effective disinfectant for the elimination of harmful microorganisms, especially pathogens from drinking water [10]. It is used as residual disinfection, and it reacts with the organic matter in water and produces undesirable disinfectant by-products (DBPs). Several DBPs can be found in the treated drinking water at much higher concentrations; trihalomethane (THM), haloacetic acid HAA, dichloroacetic acid (DCAA), trichloroacetic acid (TCAA), dibromochloromethane (DBCM), trichloromethane (TCM), tribromomethane (TBM), bromodichloromethane (BDCM). Their concentration in drinking water depends on the chlorine dose, temperature, and pH of the water. They can cause several health effects; adverse birth outcome, growth reduction in infants, mutagenesis, bladder and colon cancer (carcinogenic), and neurotoxicity but the extent of adverse effects depends on the concentration of the DBP and the exposure duration, which in some cases exceeded up to 40 years [11, 12].

The response of antimicrobial compounds such as chlorine and monochloramine in the main distribution system and the premise plumbing system could be different: They disappear more quickly from the premise plumbing than the main system. As a reactive chemical and strong oxidizing agent, chlorine can react with plumbing materials such as copper [13, 14]. The concentration decreases and this sub-lethal concentration can cause the selection and enrichment of ARB. The minimum selective concentration of disinfectants exerts selective pressure on the resistant population to survive and proliferate in the distribution system thus enriching the ARB and ARGs [8].

Opportunistic pathogens are an emerging water-borne issue. They are not contaminants. They are a normal habitant of drinking water, but they can cause life-threatening human diseases with an economic loss of one billion dollars annually. Their common characteristics help them to proliferate in the drinking water distribution and plumbing systems. They are oligotrophic and can grow at low organic carbon. They are persistent in drinking water, have thermal tolerance, and can grow in amoebae and stagnant water [15].

Common sources of waterborne diseases from opportunistic pathogens are *Legionella pneumonia*, *Mycobacterium avium*, and *Pseudomonas aeruginosa* [16]. Besides them, other bacteria are also involved in these outbreaks such as *Methylobacterium*, *Acinetobacter*, and *Aeromonas*. *M. avium*, an opportunistic pathogen of household plumbing and causes pulmonary infections [17], is resistant to disinfectants, high temperatures, phagocytic amoebae, and tolerates low oxygen concentration [18]. These antimicrobial-resistant bacteria are posing a threat to the public.

A consistent habitant of the drinking water plumbing system is *Legionella pneumophila*, a waterborne pathogen and causative agent of the life-threatening lung disease "Legionnaires" [19, 20]. Drinking water species are more chlorine-resistant than laboratory-grown cultures because of their presence in amoebae and biofilms on pipes. In the United States, Legionella is the most prevalent pathogen of waterborne infection outbreaks. Another organism that is associated with tap water systems and causes pneumonia is *Pseudomonas aeruginosa* [21]. They are resistant to chlorine and antibiotics and can utilize nitrates, which helps them to survive in stagnant water, form biofilms [22, 23], and grow well in flowing water in pipes [24].

Opportunistic pathogens found in premise plumbing systems share some common features and have a selective advantage over other competitors. Their resistance to

disinfectants and phagocytosis, the ability of biofilm formation and regrowth, and tolerance of low oxygen concentrations allow their enrichment in drinking water distribution systems posing a health hazard for the population. Slow growth also facilitates their survival as they skip during disinfection, and their death rate is also diminished due to the growth rate. As normal inhabitants of drinking water, their concentration does not decrease when they move from the source as compared to contaminants [20, 25].

Bacteria added to the water from the environment cause water contamination. *Escherichia coli* and *Salmonella* species are well-known drinking water contaminants. There is no correlation between the presence of opportunistic pathogens and fecal indicator organisms in water. The advancement in treatment technologies resulted in a selective environment for opportunistic pathogen growth in drinking water distribution and plumbing systems, and state-of-the-art technologies are needed to overcome the problem in drinking water. The premise plumbing system is a complex and variable environment and difficult to control thus can easily cause an outbreak of a water-borne disease [20].

One recommended method to kill these pathogens is to increase the concentration of disinfectants, but it proves to be ineffective as resistance has been developed against the higher doses of the disinfectants. The same results were observed with disinfection substitution. Turbidity reduction can also reduce the number of these bacteria such as *Mycobacterium avium*. An increase in the temperature of the water could also result in the inhibition of the growth of some bacteria.

#### **4. Agriculture, soil, and animal farming**

In soil, antibiotics are absorbed on the organic residues and also undergo transformation and biodegradation thus increasing their persistence in the soil environment. Their strong binding with soil organic components resulted in stable residues that persist in the agro-environment for a longer period. They can make enzymatic changes in local microorganisms and alter their metabolic activities for different nutrient resources such as carbon. Additionally, they manipulate microbial biomass and relative abundances of different microbial species [26].

Landfilling sites that receive municipal solid waste as disposed material contain large amounts of pharmaceutical and personal care products; these are the key anthropogenic sources of antibiotics in soil [27]. The leachate from the landfilling sites serves as the hotspots for the dissemination and enrichment of ARB and ARGs. An important source of the development of ARB is the agroecosystem, which has a direct effect on human leaching from agricultural soil resulting in the contamination of surface water [28]. In agriculture, feces-contaminated manure is used, which can be a source of resistant development in soil bacteria as repeated exposure to sub-inhibitory concentrations of antibiotics provokes resistance in them [29].

Different factors might be involved in the overall occurrence of antimicrobial resistance in the agro-environment. The physicochemical properties of the antibiotic residues, soil characteristics, and climate factors such as rainfall, temperature, and humidity all could contribute to the persistence of antibiotic resistance in the soil environment [30]. Microbial colonization is very diversified in soil, which serves as a reservoir of resistance genes. A complete insight into the gene transfer mechanism is required to understand the mechanism [31]. Horizontal gene transfer (HGT) and co-selection are the two major methods of antimicrobial-resistant gene transfer in soil environments [32, 33]. Horizontal gene transfer is carried out by three methods in a

#### *Antimicrobial Resistance in Environment and Antimicrobial Stewardship DOI: http://dx.doi.org/10.5772/intechopen.113224*

bacterial cell, which are transduction, conjugation, and transformation. Transduction is the transfer of genetic material through a virus, conjugation is the direct transfer of genetic material from one bacterium to another, and in transformation bacteria directly take up foreign or exogenous genetic material from the environment without any direct contact with other bacteria (**Figure 1**).

#### **Figure 1.**

*Horizontal gene transfer in bacterial cells. a. transduction, b. conjugation, c. transformation.*

Antibiotics have been used extensively in different industries causing environmental contamination and the development of resistant organisms with human health impacts, such as increased use of antibiotics in animal farming could result in the selection of organisms with resistance to human-used antibiotics [29]. The European Union banned the use of growth-promoting antibiotics in the veterinary industry in 2006 [34]. Antibiotic use in animal husbandry has not only a higher potential for water pollution but also more ecotoxicological risks [29].

#### **5. Antibiotic stewardship**

To combat the complicated AMR, the widely used method is antimicrobial stewardship (AMS), which emphasizes minimized and controlled use of antibiotics in different fields and prevents the exposure of pathogens in the natural environment. Antibiotic stewardship is responsible and careful management of antibiotic use [35]. It is also mandatory to avoid the over-prescription of antibiotics by healthcare professionals as they are the major driving force for the misuse of antibiotics. Antibiotic stewardship programs educate them about the overuse of antibiotics and their impact on human beings in the natural environment. The incidences of overtreatment with multiple antibiotics must be minimized in healthcare [36] as this practice evolved AMR into harmless bacteria. Antibiotic stewardship programs also focus on the reduced cost of treatment and minimize the economic impact of AMR. A situational analysis is performed before starting AMR stewardship, and it consists of strengths, weaknesses, opportunities, and threats (SWOT) of any facility [37]. It identifies the possible barriers to the implementation of the AMS program and facilitators who can contribute to the process of AMS.

Broad-spectrum antibiotics are used in healthcare for the treatment of infectious diseases but to defeat the AMR, narrow-spectrum antibiotics becomes the choice along with the use of combinatorial drug therapy as no single antibiotic is found to be effective for the treatment of all infectious diseases [38]. Combination drug therapy has more efficiency than single antibiotics against bacterial infections as they are based on synergism and antagonism [39]. Contrary to this, narrowspectrum antimicrobials can put immense selective pressure on bacteria and can cause serious complications. Similarly, combinatorial drug therapy is expensive because two or more antibiotics are used in treatment although it is one of the most reliable and effective methods for the treatment of infectious diseases. This strategy is more effective for gram-negative bacteria than for gram-positive bacteria.

Several programs have been started by governments and agencies in developed countries for the eradication of AMR such as the National Antimicrobial Resistance Monitoring System for Enteric Bacteria (NARMS) by the Centers for Disease Control and Prevention (CDC) in the USA, which was established in 1996 and provides information about the emerging bacterial resistance. Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS) started in 2002 and collects information about the current trends in antimicrobial use and AMR in enteric bacteria to prolong the effectiveness of antimicrobial drugs in humans and livestock. The Danish Integrated Antimicrobial Resistance Monitoring and Research Programme (DANMAP) in Denmark, working since 1995, reviews the use of antibiotics in different sectors, the occurrence of antimicrobial resistance, the relationship between the use of antibiotics and the development of resistance, and the route of transmission to minimize the spread of AMR [1].

#### *Antimicrobial Resistance in Environment and Antimicrobial Stewardship DOI: http://dx.doi.org/10.5772/intechopen.113224*

Although the use of some antibiotics has decreased in the world, on the other hand, the use of other antibiotics has increased. This resulted in a decrease in resistance to one class of antibiotics but an increase in resistance to another class of antibiotics. There is no alternative drug for some antibiotics as pathogens have developed resistance against many broad-spectrum antibiotics. Many recently developed antimicrobial resistance genes have been identified such as Mobile Colistin Resistant Genes (MCR) for Colistin, which are isolated from multiple environmental sources including sea, rivers, and sewage wastewater [40].

Regular monitoring of the use of antibiotics in different sectors and their discharge into the natural environment must be effectively examined to prevent the spread of AMR in these environments. A hundred percent effectiveness of any program can be achieved by proper implementation of rules, regulations, public laws, and policies, especially those related to public health and the environment. Uninterrupted data inspection is needed for the use of antibiotics, development of resistance, resistant patterns of antibiotics, resistance to other drugs, and outbreak of bacterial diseases. National and international coordination with proper guidance for health organizations is necessary for antimicrobial stewardship as it becomes a challenge for developing countries that lack infrastructure and good governance. Developed countries ensure the antimicrobial stewardship implementation program to eradicate AMR.

Another issue facing the world regarding the eradication of AMR in the environment is the lack of discovery for advanced antibiotics as a drastic decline has been observed since 2000. The development of antibiotics is a time-consuming process that involves research, clinical trials, approvals, and production costs; hence pharmaceutical industries are not taking much interest in research and development for brand-new drugs. Bacteria have shown AMR against most of the antibiotics used in the world, and highly potent antibiotics are urgently needed to reduce the outbreaks of diseases [39]. Innovation is another factor for the development of effective antibiotics as most industries are using already well-established compounds. Only one or two potentially active compounds against gram-negative bacteria are expected in the next decade, although a lot of research is going on for this, but the success rate is low. Extensive investment should be made by the industries to solve the issue. Governments must declare it as a priority and provide the funding and human resources for AMR stewardship in their countries.

Increased use of antibiotics is prevalent not only in humans but also in animals for livestock management and food production, which resulted in the fixation of AMR in bacteria. These bacteria can transfer resistant genes from animal to human by direct or indirect contact. Direct contact involves the interaction with animals and their biological fluids such as blood, urine, milk, and saliva whereas indirect contact may involve the use of contaminated food such as dairy products, eggs, and meat. Thus, zoonotic animals are also a reservoir of AMR just like humans including adults, children, and infants. An important factor that contributes to the increased use of antibiotics is the over-the-counter availability of antibiotics in many countries. Co-selection of resistant genes is another important factor contributing to the spread of AMR in bacteria as it causes resistance to many antibiotics simultaneously, which belong to different classes of antibiotics [41].

Public awareness about any problem plays a vital role in the management and control of that problem. There is a lack of public awareness among people and even among practitioners and doctors who intentionally or forcefully over-prescribe antibiotics for treatment on the demands of pharmaceutical companies. Clinicians use higher doses of antibiotics than required and also prescribe them for a longer period than necessary [2]. Optimum use of antimicrobial compounds could also help to reduce the development of AMR. It is essential to start public awareness about AMR on a wider scale if we want to prevent it further. Similarly, public participation is a key factor in such stewardship programs as the active contribution of the general population makes the program successful.

Healthcare workers and policymakers must be encouraged to adapt best practices to combat AMR. Effective communication and training must be provided to the people working in the healthcare system so that they can educate others. Extensive research is needed to understand the mechanisms of development of AMR in the natural environment. Personal sanitation and hygiene should also be encouraged for infection prevention.

All forms of life from the smallest to largest organisms have defense mechanisms in the form of antimicrobial peptides, which have broad-spectrum activity against prokaryotic and eukaryotic microorganisms [39]. Due to their characteristics, they can be a useful alternative to currently used antibiotics [42]. An emerging method to control AMR is the use of bacteriophages (BP) for phage therapy [38, 43]. It uses natural or bioengineered phages for the lysis of disease-causing bacteria (**Figure 2**). It has many advantages over other methods such as lack of cross-resistance for other antibiotics, strain-specific, and effectiveness against a wide range of bacteria. They can be used individually or in combination with other antibiotics [43]. Small particles that are favorable to use against AMR are nanoparticles (NPs) as they are targetspecific and stabilize the drugs inside the body [38]. They can help in horizontal gene transfer, and their use can cause the emergence of resistance in other bacteria in the environment [44].

The bioactive phytochemicals in plants that belong to different chemical classes can also be used against AMR as they have bactericidal properties and can reverse AMR [45]. They have synergistic effects with other antibiotics and can serve as promising solutions for AMR. Biosurfactants have anti-adhesive properties. They inhibit bacterial colonization and have shown effectiveness against multidrugresistant *Bacillus subtilis*. Quorum sensing is a method of bacterial communication and is used for bacterial colonization; by inhibiting the quorum sensing with some

**Figure 2.**

*Phage therapy as an alternative to antibiotics for the treatment of bacterial infections.*

#### *Antimicrobial Resistance in Environment and Antimicrobial Stewardship DOI: http://dx.doi.org/10.5772/intechopen.113224*

inhibitors bacterial colonization can be restricted [46, 47]. The process is called Quorum quenching. Quorum quenching weakens the signals for bacterial colonization in the environment and decreases the pathogenicity of the microbes with the help of Quorum sensing inhibitors (**Figure 3**). Postbiotic compounds such as proteins, carbohydrates, lipids, vitamins, and organic acids can unambiguously manipulate microbial and host functions. This method is not globally accepted and needs further research.

Antimicrobial stewardship programs are based on three pillars, which include the strengthening of the health system by an integrated approach, patient safety, and infection prevention and control. It applies to human, animal, food, agriculture, and pharmaceutical sectors. Proper technology and data must be available to cope with AMR. State-of-the-art laboratories with advanced equipment and other facilities must be present for the on-time diagnosis and treatment of infectious diseases [38]. Furthermore, patients' records must be maintained who have been treated for multidrug-resistant infections or using antibiotics for a longer period [39]. AMR eradication from the natural environment is a slow and steady process and cannot be achieved overnight.

Leadership commitment plays a vital role in the success of any program and antibiotic stewardship also needs this commitment from leadership, healthcare workers, and physicians. Production and distribution records of antibiotics must be maintained by the government and healthcare facilities. Similarly, regulations and responsibilities should be documented to avoid the overuse of antibiotics in the healthcare system [39]. There must be accountability and proper distribution of responsibilities to achieve the target. A multidisciplinary team is needed, which may consist of physicians, microbiologists, nurses, lab technicians, pharmacists, and experts in infection management [42, 48] with a fast-track approach of rapid diagnosis, testing, and reporting of results [49].

AMR is a global concern and needs novel, innovative, and permanent solutions as the burden of the AMR economy is huge and needs to be solved immediately. Both developed and underdeveloped countries must work together to overcome the obstacles. The development of potent novel antimicrobial compounds and monitoring of antibiotic abuse are mandatory to win the fight against AMR [38, 42].

#### **Figure 3.**

*Quorum sensing inhibition mechanisms includes inhibition of synthesis of signal molecules (1), inhibition of transport of signal molecules (2), their degradation (3), and receptor inhibition of signal molecules through competitive inhibition.*

### **6. Conclusion**

As the antibiotic use increased in the world, the issue of their dispersion also increased in the environment resulting in the need for new and broad-spectrum antimicrobial compounds. The world has been trying to overcome the threat since the beginning of the development of resistance in bacteria against powerful antimicrobials, but the issue is not solved fully as it is present in almost all environments, and removal is not possible. The antimicrobial stewardship program has been designed keeping in mind the uncontrolled dispersion of resistance in the environmental compartments. Therapeutic strategies are highly anticipated with modern technology to eradicate multi-drug resistance from the environment and reduce the cost of treatment for the general public. Additionally, a comprehensive understanding of the advantages and disadvantages of the dispersion and enrichment of the ARB and ARGs in the environment and the use of modern and easily accessible technologies could broaden our horizon to get rid of the global threat permanently for all stakeholders.

### **Author details**

Sadia Khan

Department of Environmental Engineering, NED University of Engineering and Technology, Karachi, Pakistan

\*Address all correspondence to: sadiakhan@cloud.neduet.edu.pk

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Antimicrobial Resistance in Environment and Antimicrobial Stewardship DOI: http://dx.doi.org/10.5772/intechopen.113224*

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#### **Chapter 10**

## Antimicrobial Stewardship in the Management of Multidrug-Resistant Gram-Negative Bacteria Infections

*Temitope Oyedemi, Tolulope Fadeyi and Kolapo Fasina*

#### **Abstract**

Antimicrobial resistance constitutes a public health menace globally, affecting treatment outcomes in healthcare settings. This problem is exacerbated in Gram-negative bacteria including *Klebsiella pneumonia*, *Pseudomonas aeruginosa*, *Acinetobacter baumannii*, *E*. *coli, Salmonella* spp.*,* and others belonging to the Enterobacteriaceae family. These organisms have developed resistance mechanisms that render common antibiotics ineffective, making infections caused by these pathogens difficult to treat. Particularly, unregulated antibiotic use, selective pressure, and horizontal gene transfer are some of the contributors to their resistance to the available antibiotics. Effective antimicrobial stewardship plays a crucial role in managing these infections and preventing their further escalation through Antimicrobial Stewardship programs, de-escalation therapy, combination therapy, antibiotics dose optimization, and prophylactic antibiotic are used in those at high risk of infection. Education and training are vital for healthcare providers to enhance their knowledge of antimicrobial stewardship principles and implementation.

**Keywords:** antimicrobial resistance, Gram-negative bacteria, antibiotics, de-escalation therapy, antimicrobial stewardship

#### **1. Introduction**

#### **1.1 Background and significance**

Antimicrobial stewardship (AMS) is defined as "an organizational or healthcaresystem-wide approach for fostering and monitoring judicious use of antimicrobials to preserve their effectiveness" [1]. Multidrug-resistant Gram-negative bacterial infections have become a major global health concern due to the limited treatment options available and the high mortality rates associated with these infections [2]. Gram-negative bacteria, such as *Escherichia coli*, *Klebsiella pneumoniae*, *Acinetobacter baumannii*, and *Pseudomonas aeruginosa*, have developed resistance mechanisms that render common antibiotics ineffective, making infections caused by these pathogens difficult to treat [3]. Antimicrobial stewardship programs focus on improving the appropriate use of antimicrobial agents, to preserve their effectiveness and minimize the emergence and spread of resistance [4]. In the case of multidrug-resistant Gramnegative bacterial infections, effective antimicrobial stewardship plays a crucial role in managing these infections and preventing their further escalation [5].

The topic of antimicrobial stewardship in the management of multidrug-resistant Gram-negative bacterial infections holds significant importance due to several reasons:


*Antimicrobial Stewardship in the Management of Multidrug-Resistant Gram-Negative... DOI: http://dx.doi.org/10.5772/intechopen.112848*

interdisciplinary teamwork and communication, antimicrobial stewardship programs promote a holistic approach to patient care, ensuring that the right antibiotics are prescribed at the right time and in the right dosage [14].

#### **1.2 Multidrug-resistant Gram-negative bacteria (MDR-GNB)**

Multidrug-resistant Gram-negative bacteria (MDR-GNB) refer to the ability of these bacteria to exhibit resistance to multiple classes of antibiotics [15, 16]. Gram-negative bacteria are a group of bacteria that have a distinct cell wall structure and include common pathogens such as *Escherichia coli*, *Klebsiella pneumoniae*, *Acinetobacter baumannii*, and *Pseudomonas aeruginosa*. The term "multidrug" signifies resistance to multiple classes of antibiotics, which means that these bacteria are unaffected by several types of antimicrobial agents commonly used in clinical practice. This resistance can include resistance to β-lactams (such as penicillins and cephalosporins), fluoroquinolones, aminoglycosides, carbapenems, and other important antibiotic classes. Multidrug-resistant Gram-negative bacteria are of particular concern because they limit the treatment options available to healthcare professionals, leading to increased reliance on less effective or more toxic antibiotics [17]. MDR-GNB has acquired genetic mechanisms that enable them to evade the effects of different antibiotics, making them difficult to treat. These resistance mechanisms can include the production of enzymes that inactivate antibiotics, changes in the bacterial cell wall structure that prevent drug entry, and efflux pumps that actively remove antibiotics from within the bacterial cell [18, 19].

#### **1.3 Importance of antimicrobial stewardship in managing multidrug-resistant infections**

Antimicrobial stewardship plays a critical role in managing multidrug-resistant infections by addressing the challenges posed by antimicrobial resistance. The importance of antimicrobial stewardship in managing multidrug resistance infections can be summarized as follows:


#### **2. Challenges in managing multidrug-resistant Gram-negative bacterial infections**

Managing multidrug-resistant Gram-negative (MDR-GNB) bacterial infections poses several challenges, which include:

#### **2.1 Limited treatment options**

The challenge of limited treatment options in managing multidrug-resistant Gram-negative bacterial infections refers to the reduced effectiveness of available antibiotics against these infections. MDR-GNB has developed various mechanisms to evade the effects of commonly used antibiotics, making them resistant to multiple classes of drugs. MDR-GNB often exhibit resistance to multiple classes of antibiotics, limiting the available treatment options [26]. This scarcity of effective antibiotics can make it challenging to find appropriate therapies that can effectively target and eliminate the infection. Moreover, MDR-GNB are associated with higher morbidity and mortality rates compared to infections caused by susceptible strains [27]. Treatment failures, prolonged hospital stays, and increased risk of complications contribute to the poorer outcomes observed in patients with these infections.

#### **2.2 Rapid spread of resistance mechanism**

Gram-negative bacteria possess complex resistance mechanisms, including the production of enzymes that can degrade antibiotics, altered outer membrane permeability, and efflux pumps that actively remove antibiotics from within the bacterial cell [28, 29]. These complex resistance mechanisms make it difficult to combat multidrug-resistant infections and require the use of multiple strategies to overcome them. Several factors contribute to the complex and rapid spread of resistance mechanisms. These include genetic plasticity, which enables GNB to acquire resistance genes through various mechanisms [30]. These bacteria can acquire resistance genes through horizontal gene transfer, where genetic material is transferred between different bacteria, including those of the same or different species. This transfer can occur through plasmids, integrons, or transposons, facilitating the rapid spread of resistance mechanisms [31]. These elements can move between bacteria, allowing resistance genes to be transferred to new bacteria strains or species. Mobile genetic elements contribute to the horizontal transfer of resistance mechanisms and can rapidly disseminate resistance within a population or across different geographical locations. Likewise, the widespread use and misuse of antibiotics create a selective pressure that favors the survival and proliferation of multidrug-resistant bacteria [32]. Exposure to antibiotics provides a survival advantage to the bacteria carrying resistance mechanisms, allowing them to outcompete susceptible strains. The continuous exposure to suboptimal antibiotic concentrations or incomplete treatment courses can further drive the selection and expansion of resistant strains [33]. Healthcare settings and community transmission also contribute to the spread of MDR-GNB within healthcare facilities, where vulnerable patients with compromised immune systems and invasive medical procedures create opportunities for transmission. The complex network of healthcare-associated infections allows for the rapid dissemination of resistant strains. Additionally, these bacteria can also spread in community settings, where factors such as overcrowding, poor hygiene practices, and close contact contribute to their transmission [34].

#### **2.3 The need for effective infection prevention**

Effective infection prevention is crucial in managing multidrug-resistant Gramnegative bacterial infections due to high transmission rates [35]. MDR-GNB has the potential for rapid transmission within healthcare settings and the community [36]. These bacteria can survive on surfaces, medical equipment, and the hands of healthcare workers, facilitating their spread to susceptible individuals [37]. The challenge lies in preventing the transmission of these resistant bacteria to vulnerable patients and limiting the development of outbreaks. MDR-GNB can persist in the environment for extended periods, surviving on surfaces and in water sources. This persistence increases the risk of indirect transmission to patients and poses challenges for effective infection prevention. Rigorous cleaning and disinfection protocols, as well as appropriate water management strategies, are necessary to reduce the environmental reservoir of these resistant bacteria. The ability of MDR-GNB to colonize various sites in the human body, including the skin,

gastrointestinal tract, and respiratory tract is another factor [38]. Colonized individuals serve as a reservoir for transmission to others. Addressing the challenge of effective infection prevention requires a comprehensive approach that includes strict adherence to infection control measures, robust environmental cleaning and disinfection practices, surveillance of multidrug-resistant organisms, and appropriate use of antimicrobials. It also involves active collaboration between healthcare facilities, public health agencies, and the communities to raise awareness, implement preventive measures, and reduce the burden of multidrug-resistant Gam-negative bacterial infections.

#### **3. Antimicrobial stewardship strategies for managing multidrug resistance**

#### **3.1 Antimicrobial stewardship programs (ASPs)**

Antimicrobial Stewardship Programs (ASPs) are comprehensive strategies designed to optimize the use of antimicrobial agents in healthcare settings. They are crucial in managing multidrug-resistant infections. They help to preserve the effectiveness of existing antibiotics, reduce treatment failures, prevent the emergence of resistance, improve patient outcomes, and optimize healthcare resource utilization. Additionally, ASPs contribute to the global effort of combating antimicrobial resistance by promoting responsible antibiotic use and reducing the spread of multidrugresistant bacteria [7, 9, 11].

#### **3.2 De-escalation therapy**

De-escalation therapy is a strategy employed in the management of multidrug resistance that involves starting empiric broad-spectrum antibiotic treatment and subsequently narrowing down the antibiotic regimen based on clinical response and susceptibility testing. The goal of de-escalation is to optimize antimicrobial therapy by reducing the use of broad-spectrum antibiotics and minimizing the selection pressure for antibiotic resistance [39, 40]. De-escalation therapy begins with the administration of empiric broad-spectrum antibiotics that cover a wide range of potential pathogens, including multidrug-resistant bacteria. This initial approach ensures that appropriate antimicrobial therapy is promptly initiated, particularly in cases of severe infections where the causative organism may not be immediately identifiable. During de-escalation therapy, close monitoring of the patient's clinical response is essential. If the patient shows signs of improvement, such as decreased fever, resolution of symptoms, and improvement in laboratory markers, it indicates that the initial empiric therapy is effective [41]. Additionally, microbiological assessment, including culture and susceptibility testing, is crucial in identifying the causative pathogen and determining its susceptibility to antibiotics. Once the microbiological results become available, the antibiotic regimen is tailored to the specific pathogen and its susceptibility profile. De-escalation involves narrowing down the antibiotic coverage by selecting a more targeted and narrow-spectrum antibiotic or combination of antibiotics [42]. This approach helps minimize the unnecessary use of broad-spectrum antibiotics, which are associated with a higher risk of promoting antimicrobial resistance. De-escalation therapy takes into account the local resistance patterns and susceptibility data of pathogens commonly encountered in the healthcare facility or community. By considering local epidemiology, clinicians

*Antimicrobial Stewardship in the Management of Multidrug-Resistant Gram-Negative... DOI: http://dx.doi.org/10.5772/intechopen.112848*

can choose antibiotics that are effective against the prevalent multidrug-resistant bacteria while avoiding unnecessary use of broad-spectrum agents [43].

#### **3.3 Combination therapy**

Combination therapy, as a strategy for managing multidrug resistance, involves the simultaneous use of two or more antibiotics with different mechanisms of action to enhance treatment efficacy and overcome resistance mechanisms. Combination therapy aims to achieve synergistic effects, where the combined action of multiple antibiotics is greater than the sum of their individual effects [44]. By targeting different bacterial pathways or mechanisms, combination therapy can enhance bacterial killing, inhibit resistance mechanisms, and improve treatment outcomes. Combination therapy allows for broader coverage of potential pathogens, including those that may exhibit resistance to individual antibiotics. By combining antibiotics with different spectra of activity, the regimen can effectively target a wider range of bacteria, including multidrug-resistant strains. This broader coverage increases the likelihood of successful treatment, especially in infections where the causative organisms are unknown or resistant pathogens are prevalent. The use of combination therapy can help prevent the emergence of resistance [45]. Resistance mechanisms can be complex and multifaceted, requiring the coordinated action of multiple genetic changes in bacteria. By utilizing multiple antibiotics that target different pathways, the likelihood of bacteria developing simultaneous resistance to all components of the combination is reduced. This reduces the risk of treatment failure due to the emergence of resistance during therapy. Combination therapy can overcome existing resistance in multidrug-resistant bacteria. By utilizing antibiotics with different mechanisms of action, combination therapy can circumvent specific resistance mechanisms employed by bacteria. For example, if a bacterium possesses efflux pumps that can actively pump out a particular antibiotic, combining it with another antibiotic that is not a substrate for the efflux pump can help overcome this resistance mechanism and improve treatment efficacy [46].

#### **3.4 Dose optimization**

Dose optimization is a strategy employed in the management of multidrug resistance that focuses on achieving optimal drug concentrations at the site of infection to maximize treatment efficacy against resistant pathogens [47]. By adjusting the dosage of antibiotics, dose optimization aims to overcome resistance mechanisms, improve bacterial killing, and enhance treatment outcomes. Dose optimization takes into account the pharmacokinetics (PK) and pharmacodynamics (PD) of antibiotics [48]. PK refers to how the body processes a drug, including absorption, distribution, metabolism, and elimination. PD refers to the relationship between drug exposure and its effect on bacteria. Understanding the PK/PD properties of antibiotics is crucial in determining the optimal dosage regimen to achieve effective drug concentrations at the site of infection. The effectiveness of antibiotics against resistant pathogens is often related to achieving adequate drug exposure. By optimizing the dosage, the goal is to ensure that the antibiotic concentration at the site of infection exceeds the minimum inhibitory concentration (MIC) for the target pathogen. This exposure-response relationship is critical in achieving optimal bacterial killing and minimizing the risk of treatment failure [49]. Dose optimization should be employed alongside other comprehensive strategies and guided by PK/PD principles and individual patient factors to ensure the effective management of multidrug resistance.

#### **3.5 Prophylactic antibiotic use**

Prophylactic antibiotic use, as a strategy for managing multidrug resistance, involves the administration of antibiotics to prevent infections in individuals at high risk of developing infections [50]. While the primary aim of prophylaxis is to prevent infections, it can also play a role in managing multidrug resistance. Prophylactic antibiotics are typically administered to individuals who are at increased risk of developing infections, such as surgical patients, immunocompromised individuals, or patients with specific medical conditions [51]. By targeting those at high risk, prophylaxis aims to prevent infections that could potentially lead to multidrugresistant bacteria colonization or subsequent spread. The choice of antibiotics for prophylaxis is important to consider. Narrow-spectrum antibiotics with activity against the expected pathogens in the specific procedure or patient population are preferred. This approach helps minimize the disruption of the normal flora and reduces the selective pressure for multidrug resistance. Additionally, the selection of antibiotics should consider local resistance patterns and susceptibility data to ensure their effectiveness. The duration of prophylactic antibiotic use should be limited to the perioperative or high-risk period to avoid unnecessary prolonged exposure. Prolonged prophylactic use can lead to increased antibiotic consumption, potential adverse effects, and the development of resistance [52]. It is essential to adhere to recommended guidelines regarding the appropriate duration of prophylaxis for each indication. Prophylactic antibiotic use should be part of a comprehensive approach to infection prevention that includes other measures such as strict aseptic techniques, proper hand hygiene, adherence to infection control protocols, and vaccination. Combining prophylactic antibiotics with these multimodal strategies can further reduce the risk of infections and multidrug resistance. However, the risk of promoting antibiotic resistance should always be considered, and prophylactic antibiotic use should be tailored to individual patient needs while emphasizing the importance of antimicrobial stewardship.

#### **3.6 Guidelines on antibiotic prescription**

Guidelines on antibiotic prescription are an essential strategy for managing multidrug-resistant bacteria by promoting appropriate and judicious use of antibiotics. These guidelines provide evidence-based recommendations to healthcare providers regarding the selection, dosage, and duration of antibiotic therapy for specific infections [53]. Guidelines on antibiotic prescribing promote rational antibiotic use by guiding healthcare providers in choosing the most effective antibiotic therapy while minimizing the risk of resistance [11, 54]. They provide recommendations based on the local epidemiology of bacterial pathogens and their susceptibility patterns, considering factors such as resistance rates, healthcare-associated infections, and community-acquired infections. Guidelines take into account the specific characteristics of different infections and provide recommendations for tailored treatment [55]. By providing guidance on appropriate antibiotic selection, dosage, and duration, guidelines help ensure that patients receive optimal therapy, increasing the likelihood of successful treatment outcomes and minimizing the development of multidrug resistance. It also empowers healthcare providers with up-to-date information on the latest advancements in antimicrobial therapy and resistance patterns [56, 57].

#### **4. The roles of healthcare providers in antimicrobial stewardship**

#### **4.1 Multidisciplinary team approach**

The multidisciplinary team approach is a crucial aspect of antimicrobial stewardship, involving collaboration among various healthcare providers with different areas of expertise [58]. This team typically includes physicians, pharmacists, microbiologists, infection control practitioners, and other relevant healthcare professionals. The multidisciplinary team brings together professionals from different backgrounds, each with their unique knowledge and perspectives on antimicrobial use. Physicians provide clinical expertise; pharmacists contribute their knowledge of drug interactions and dosing; microbiologists offer insights into microbial identification and susceptibility, and infection control practitioners focus on preventing healthcareassociated infections. By working collaboratively, the team can develop comprehensive strategies to optimize antimicrobial use. Multidisciplinary teams play a crucial role in developing and implementing evidence-based guidelines and protocols for antimicrobial use. These guidelines provide standardized approaches to the diagnosis, treatment, and monitoring of infections, considering local epidemiology and antimicrobial resistance patterns. The team members contribute their expertise to ensure that guidelines are practical, feasible, and align with the best available evidence. The multidisciplinary team approach allows for continuous quality improvement in antimicrobial stewardship [59].

#### **4.2 Education and training**

Education and training are essential roles of healthcare providers in antimicrobial stewardship. Education plays a vital role in raising awareness about antimicrobial resistance and the importance of antimicrobial stewardship [60]. Healthcare providers need to understand the consequences of inappropriate antimicrobial use, including the development of resistance, increased healthcare costs, and adverse patient outcomes. Training programs provide healthcare professionals with updated information on antimicrobial resistance patterns, new treatment guidelines, and emerging resistance mechanisms. By staying informed, healthcare providers can make informed decisions and contribute to effective stewardship practices. Education and training initiatives emphasize the importance of patient education regarding antimicrobial use. Healthcare providers learn how to effectively communicate with patients, explaining when antibiotics are necessary and educating them about the risks of inappropriate antibiotic use. Patients are educated about the importance of completing the full course of antibiotics as prescribed, avoiding the sharing or saving of antibiotics, and understanding that antibiotics are not effective against viral infections. By engaging patients in these discussions, healthcare providers help reinforce responsible antibiotic use and promote patient adherence [61].

#### **4.3 Prescription and dispensing practices**

Prescription and dispensing practices are vital roles of healthcare providers in antimicrobial stewardship. By following appropriate prescribing and dispensing practices, healthcare providers contribute to the responsible use of antimicrobial agents [62]. Healthcare providers have a responsibility to prescribe antimicrobial

agents judiciously. By following evidence-based guidelines and considering factors such as the type and severity of the infection, local resistance patterns, and patientspecific factors (e.g., allergies and renal function), healthcare providers can select the most appropriate antibiotic therapy. This ensures that antibiotics are used only when necessary and minimizes the risk of antibiotic resistance. When prescribing antibiotics, healthcare providers should consider using narrow-spectrum antibiotics whenever possible. Narrow-spectrum antibiotics target specific bacteria, reducing the disruption of the body's normal flora and minimizing the selection pressure for resistance. Targeted therapy, based on culture and susceptibility results, helps ensure that the chosen antibiotic is effective against the identified pathogen [63]. This approach minimizes the unnecessary use of broad-spectrum antibiotics, which can contribute to the emergence of multidrug-resistant organisms.

#### **4.4 Use of clinical decision support systems**

The use of Clinical Decision Support Systems (CDSS) is an important role of healthcare providers in antimicrobial stewardship. CDSS refers to computer-based tools that provide healthcare professionals with clinical knowledge and patientspecific information to assist in decision-making [64]. CDSS can integrate evidencebased guidelines for antimicrobial use directly into the clinical workflow. This allows healthcare providers to access up-to-date recommendations at the point of care. The CDSS can provide guidance on appropriate antibiotic selection, dosing, and duration of therapy based on the specific infection and patient characteristics. By incorporating guidelines, CDSS helps ensure that healthcare providers have easy access to the most current and relevant information to support their prescribing decisions. CDSS can provide real-time alerts and reminders to healthcare providers when prescribing antimicrobials. These alerts can notify providers about potential drug interactions, allergies, duplicate therapies, or inappropriate antibiotic choices. By receiving these alerts, healthcare providers can review and reconsider their prescribing decisions, potentially leading to more appropriate antibiotic selection and improved patient outcomes [65]. CDSS can integrate with microbiology laboratory systems to provide real-time access to microbial identification and susceptibility results. This allows healthcare providers to make informed decisions regarding appropriate antibiotic therapy. CDSS can also incorporate local antimicrobial resistance data, providing information on prevalent resistance patterns and suggesting alternative antibiotics when necessary. By utilizing these integrated data sources, healthcare providers can make more targeted antibiotic choices and avoid unnecessary broad-spectrum use.

#### **5. Best practices in antimicrobial stewardship in multidrug-resistant Gram-negative bacterial infections**

#### **5.1 Surveillance and monitoring**

Surveillance and monitoring are crucial best practices in antimicrobial stewardship, particularly when addressing multidrug-resistant Gram-negative bacterial infections [66]. Surveillance and monitoring systems allow healthcare facilities to identify and track the emergence and spread of MDR-GNB. By routinely collecting and analyzing data on bacterial isolates and their antibiotic susceptibility patterns, healthcare providers can detect changes in resistance profiles and identify emerging

#### *Antimicrobial Stewardship in the Management of Multidrug-Resistant Gram-Negative... DOI: http://dx.doi.org/10.5772/intechopen.112848*

resistance mechanisms [67]. This early detection helps guide appropriate empiric antibiotic therapy and infection control measures. Surveillance data on MDR-GNB infections enable healthcare providers to make informed decisions regarding empiric antibiotic therapy. Knowing the local resistance patterns helps in selecting antibiotics that are likely to be effective against the prevalent pathogens. This targeted approach improves patient outcomes by reducing the risk of inadequate initial therapy and minimizing the unnecessary use of broad-spectrum antibiotics. Surveillance systems enable the monitoring of trends and changes in antimicrobial resistance patterns over time [68]. By tracking resistance data, healthcare providers can identify shifts in susceptibility profiles, new mechanisms of resistance, or the emergence of novel resistant strains. This information is crucial for guiding treatment decisions, developing local antimicrobial guidelines, and informing public health efforts to address antimicrobial resistance at a regional or national level [69].

Surveillance and monitoring systems enhance the ability to anticipate and respond to new threats posed by MDR-GNB by continuously monitoring resistance patterns, healthcare providers can detect the emergence of resistance to specific antibiotics or classes of antibiotics [70]. This information helps guide the development of alternative treatment strategies, such as novel antimicrobial agents or combination therapies, before resistance becomes widespread. Surveillance and monitoring efforts promote collaboration and data sharing among healthcare facilities, public health agencies, and research institutions. By sharing data on resistance patterns, outbreaks, and best practices, healthcare providers can learn from each other's experiences and adopt successful strategies in their own settings. Collaboration and data sharing also facilitate regional or national surveillance networks, enabling a broader understanding of the epidemiology of multidrug-resistant Gram-negative bacterial infections and supporting coordinated efforts to combat antimicrobial resistance [71].

#### **5.2 Guidelines for antibiotic use**

Guidelines for antibiotic use are essential best practices in antimicrobial stewardship, particularly in addressing multidrug-resistant Gram-negative bacterial infections. These guidelines provide evidence-based recommendations for healthcare providers to optimize antimicrobial therapy and combat the challenges posed by resistant bacteria [72]. Guidelines for antibiotic use provide evidence-based recommendations for the selection, dosing, and duration of antimicrobial therapy for multidrug-resistant Gram-negative bacterial infections. These guidelines are developed based on extensive research, clinical trials, and expert consensus. By following these recommendations, healthcare providers can make informed decisions about appropriate antibiotic therapy, considering factors such as the type of infection, local resistance patterns, and individual patient characteristics. Guidelines for antibiotic use emphasize the importance of targeted therapy for multidrug-resistant Gramnegative bacterial infections. Targeted therapy involves selecting antibiotics that are specifically effective against the identified pathogens, taking into account their susceptibility patterns. This approach helps minimize the unnecessary use of broadspectrum antibiotics, reducing the selective pressure for resistance and preserving the effectiveness of antibiotics. Guidelines may address the use of combination therapy for multidrug-resistant Gram-negative bacterial infections and provide recommendations on when combination therapy may be warranted and which specific combinations are supported by evidence. Guidelines for antibiotic use often include recommendations for implementing infection control measures to prevent the spread

of MDR-GNB [66]. These measures may include strategies such as contact precautions, hand hygiene, environmental cleaning, and patient cohort. By incorporating infection control guidelines into antibiotic use recommendations, healthcare providers can contribute to reducing the transmission of resistant bacteria and protecting vulnerable patients.

#### **5.3 Close collaboration between clinicians and microbiologists**

Close collaboration between clinicians and microbiologists is considered a best practice in antimicrobial stewardship, particularly in the management of multidrugresistant Gram-negative bacterial infections [73]. This collaboration facilitates effective communication, decision-making, and patient care. Microbiologists play a critical role in identifying the causative pathogens and their antimicrobial susceptibility patterns. Close collaboration between clinicians and microbiologists ensures that accurate and timely microbiological results are provided to guide appropriate antibiotic therapy. Rapid identification of MDR-GNB allows clinicians to initiate targeted therapy promptly, leading to better patient outcomes and reduced spread of resistant strains. In cases where microbiological results are not immediately available, clinicians rely on empirical antibiotic therapy. Collaboration between clinicians and microbiologists helps in selecting appropriate empiric therapy based on local resistance patterns and the knowledge of circulating MDR-GNB [65]. Microbiologists can provide valuable input regarding the likelihood of resistance to specific antibiotics, helping clinicians make informed decisions and avoid the unnecessary use of broad-spectrum agents. Close collaboration allows for effective feedback and quality improvement initiatives. Microbiologists can provide feedback to clinicians regarding the appropriateness of antibiotic prescribing based on microbiological data. This feedback helps clinicians understand the impact of their prescribing decisions on resistance patterns and guides them in optimizing antibiotic use. Regular meetings and discussions between clinicians and microbiologists enable the exchange of information and the identification of areas for improvement in antimicrobial stewardship practices.

#### **5.4 Benchmarking and quality improvement**

Benchmarking and quality improvement are crucial best practices in antimicrobial stewardship, particularly in the management of multidrug-resistant Gram-negative bacterial infections [74]. These practices involve measuring performance, comparing it against established benchmarks or standards, and implementing strategies to improve patient care and outcomes. Benchmarking in antimicrobial stewardship involves defining performance metrics to assess the appropriateness of antibiotic-prescribing practices. These metrics may include indicators such as antibiotic utilization rates, adherence to guidelines, rates of inappropriate prescribing, and outcomes of antimicrobial therapy. By establishing these metrics, healthcare facilities can measure their performance and identify areas that require improvement. Benchmarking allows healthcare facilities to compare their performance against established benchmarks or standards. These benchmarks may be developed based on national guidelines, expert consensus, or data from peer institutions. By comparing their performance, healthcare facilities can identify variations, gaps, or opportunities for improvement in antimicrobial-prescribing practices. Benchmarking facilitates the identification of variations in antimicrobial-prescribing practices among different healthcare

*Antimicrobial Stewardship in the Management of Multidrug-Resistant Gram-Negative... DOI: http://dx.doi.org/10.5772/intechopen.112848*

providers, departments, or units within a facility [75]. By analyzing these variations, healthcare facilities can identify the best practices and areas where improvement is needed. Understanding the factors contributing to variations in prescribing practices helps develop targeted interventions and share successful strategies across the organization. Benchmarking results guide the implementation of targeted interventions to improve antimicrobial prescribing practices. These interventions may include educational initiatives, clinical decision support systems, antibiotic stewardship rounds, audit and feedback, and guideline development or revision. By tailoring interventions to address specific areas of improvement identified through benchmarking, healthcare facilities can optimize antibiotic use, reduce inappropriate prescribing, and mitigate the development of resistance.

#### **6. Implications for practice**

Antimicrobial stewardship has significant implications for practice across healthcare settings. Implementing effective antimicrobial stewardship practices can improve patient outcomes, reduce healthcare costs, and contribute to the global efforts to combat antimicrobial resistance. Antimicrobial stewardship requires strong leadership and support from healthcare administrators and management. Establishing dedicated antimicrobial stewardship teams, providing necessary resources, and fostering a culture that prioritizes responsible antibiotic use are critical for successful implementation and sustainability of antimicrobial stewardship practices.

#### **7. Future directions for research**

The field of antimicrobial stewardship continues to evolve, and there are several directions for future research that can further enhance our understanding and implementation of effective stewardship practices. Here are some potential areas for future research:

#### **7.1 Outcome measures and impact assessment**

There is a need for standardized and validated outcome measures to assess the impact of antimicrobial stewardship interventions. Future research should focus on developing robust methods to evaluate the clinical, economic, and patient-centered outcomes associated with various stewardship strategies. This will help determine the most effective interventions and their impact on patient outcomes and antimicrobial resistance rates.

#### **7.2 Novel approaches and technologies**

Research can explore the development and implementation of innovative approaches and technologies in antimicrobial stewardship. This may include the use of artificial intelligence and machine learning algorithms to guide antibiotic prescription, the application of rapid diagnostic tests to facilitate targeted therapy, or the integration of electronic health records and clinical decision support systems to improve decision-making and optimize antimicrobial use.

#### **7.3 Antimicrobial stewardship in special populations**

Future research should focus on understanding the unique challenges and considerations for antimicrobial stewardship in special populations such as pediatrics, elderly patients, immunocompromised individuals, and those with specific comorbidities. Tailored stewardship strategies that address the specific needs and risks in these populations can optimize antibiotic use and improve patient outcomes.

#### **7.4 Antimicrobial stewardship in community settings**

While much of the existing research has focused on antimicrobial stewardship in hospitals and healthcare facilities, there is a need for more research on stewardship in community settings. Investigating the effectiveness of interventions, such as education campaigns, public awareness programs, and implementation of guidelines in primary care and outpatient settings, can help promote responsible antibiotic use and reduce the development of resistance.

#### **7.5 One Health approach**

Antimicrobial resistance is a complex issue that requires a One Health approach, considering the interplay between human, animal, and environmental factors. Future research can explore the impact of antimicrobial stewardship interventions in veterinary medicine, agricultural practices, and environmental reservoirs of resistance. Understanding the interconnected nature of antimicrobial resistance across different sectors can guide comprehensive and collaborative approaches to stewardship.

#### **7.6 Implementation science and strategies**

Research should focus on implementation science and strategies to enhance the adoption and sustainability of antimicrobial stewardship programs. Identifying barriers and facilitators to implementation, understanding the organizational and cultural factors that influence uptake, and developing effective implementation strategies tailored to different healthcare settings can optimize the success and impact of stewardship interventions.

#### **8. Conclusion**

Antimicrobial stewardship plays a crucial role in managing multidrug-resistant bacterial infections. De-escalation therapy, combination therapy, dose optimization, and prophylactic antibiotic use are key strategies. Guidelines on antibiotic prescribing, a multidisciplinary team approach, education and training, surveillance and monitoring, close collaboration between clinicians and microbiologists, and benchmarking and quality improvement all contribute to the uptake and performance evaluation of antimicrobial stewardship.

#### **Conflict of interest**

The authors declare that there is no conflict of interest.

*Antimicrobial Stewardship in the Management of Multidrug-Resistant Gram-Negative... DOI: http://dx.doi.org/10.5772/intechopen.112848*

#### **Author details**

Temitope Oyedemi1 \*, Tolulope Fadeyi<sup>2</sup> and Kolapo Fasina<sup>3</sup>

1 Department of Microbiology, Adeleke University, Ede, Osun State, Nigeria

2 Department of Pharmaceutical Microbiology, University of Ibadan, Ibadan, Oyo State, Nigeria

3 Biotechnology Division, Rubber Research Institute of Nigeria, Benin, Edo State, Nigeria

\*Address all correspondence to: topeoyedemi07@gmail.com

© 2024 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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#### **Chapter 11**

## Dispatching Biocompatible Polymers toward Antimicrobial Applications

*Ruogu Tang*

#### **Abstract**

Antimicrobial materials have become an essential part of various fields. In the past decades, various types of antimicrobial materials were developed and practically used. Based on the feedback from the clinical usage and market, the biocompatible materials have been very welcomed due to less side effects. This chapter provides a small and general review of biocompatible polymer materials and their applications in antimicrobial fields. This chapter could be divided into several parts: starting from the background introduction of microbial threats, the first section discusses the demands of biocompatible polymers for antimicrobial applications, then, the following sections would describe the basic knowledge of biocompatible polymers, including the definition, advantages, and typical examples, the next section reviewed and discussed some approaches to apply biocompatible polymers into antimicrobial applications.

**Keywords:** antimicrobial, biocompatibility, biocompatible polymer natural environment, functional modification, functional group

#### **1. Introduction**

Microbial invasions and infections have been accompanying human beings for thousands of years, and have caused countless causalities [1, 2]. The battle against microbial threats had already begun before people acquired the understanding of microorganisms [3]. During this long-lasting fighting, though the concept was not initially established, people had invented and developed antimicrobial materials, which contain contents that have the functions of preventing microbial invasion and/or sterilizing the microbes [4, 5]. Up to date, various types of antimicrobial materials have been developed and many of them have been successfully applied to real usages [6–9].

One major concern regarding the usage of antimicrobial materials is the side effects [10, 11]. For example, it was reported that some antimicrobial materials might cause damage to human bodies while killing the microbes [11]. Also, some antimicrobial materials, once abandoned or released, could lead to environmental and ecological issues [12]. Therefore, it has become a consensus that antimicrobial materials, no matter how potent they are, should be less collateral damaging. Under this demand, biocompatible polymers-based antimicrobial materials (i.e., biocompatible

antimicrobial polymers) have become more favorable among customers and markets, and this type of material has become a new area for research [12].

This chapter provides a mini-review of biocompatible antimicrobial polymers, including the description of typical polymer materials, their usage in antimicrobial fields, the current challenges, and future perspectives.

### **2. Understanding the biocompatible polymers**

#### **2.1 Definition of biocompatible polymers**

Admittedly, the terminology of biocompatible polymers is not well defined yet, and researchers prefer to create their own descriptions in the publications. However, so far, some consensuses regarding the definition of biocompatible polymers have been built and recognized among different researchers, which at least include the following:


#### **2.2 Advantages of biocompatible polymers**

It is easy to recognize that biocompatible polymers are attractive, but much more than the common opinions, biocompatible polymers have various advantages in different aspects. The following briefly describes some significant points:

Availability: unlike traditional polymers obtained from the synthesis of monomers, most biocompatible polymers (in the form of raw materials) could be obtained or extracted from natural products. For example, cellulose was rich in cotton, flax, and straw [14]; chitosan and chitin could be extracted in arthropod animals [15]; alginate could be obtained as a major product of brown algae [16]. The easy accessibility of biocompatible polymers reduces the costs, especially exempting the processing of monomer preparations and polymerizations.

#### *Dispatching Biocompatible Polymers toward Antimicrobial Applications DOI: http://dx.doi.org/10.5772/intechopen.114250*

Low hazard: as mentioned above, biocompatible polymers could leave fewer side effects; this was considered one of the most significant advantages. Within the antimicrobial application, the biocompatible polymers could be comfortably applied on humans without considering the toxicities or body exclusions, and there will be fewer concerns about byproducts during usage.

Biodegradability: for most traditional polymers, one critical shortage is collateral environmental pollution, as they are hard to decompose in the natural environment. However, many biocompatible polymers are biodegradable to microorganisms or medium, simplifying depolymerization's artificial processing after usage [17]. In addition, the degraded components are also generally biocompatible and could be further decomposed and absorbed by the microorganisms [17]. Therefore, the applications of biocompatible polymers could reduce environmental concerns.

#### **2.3 Representative examples of biocompatible polymers**

After years of development, certain biocompatible polymers have been commercially used, and more candidates are being investigated in the research labs. Among various products, they could be divided into natural and synthetic biocompatible polymers. This part listed some typical examples.

Cellulose: Cellulose is a linear polysaccharide that consists of 1,4-D-glucose units (**Figure 1**) [14]. It is one of the earliest used biocompatible polymers, even before people established the concept of polymer materials. Cellulose exists abundantly in nature and serves as a major component of the cell walls of plants and wood. As a natural product, cellulose is nontoxic, non-polluting, and fully biodegradable, making itself popular nowadays [18]. Within the antimicrobial applications, cellulose is more likely to be considered and used either as raw materials or substrate for further modification.

Chitin and chitosan: chitin and chitosan share a highly similar structure. Chitin is a linear polysaccharide that contains repeated N-acetyl-D-glucosamine units (**Figure 2**), and chitosan is a linear polysaccharide (**Figure 3**) composed of randomly distributed D-glucosamine (deacetylated unit) and N-acetyl-D-glucosamine (acetylated unit) [15]. Chitin and chitosan are also rich in nature, but unlike cellulose, chitin and chitosan are more likely to be found in arthropod animals such as crabs, shrimps, and some insects [15]. It is interesting to notice that chitin and some sorts of chitosan could be fully or partially digested by certain types of enzymes and decomposed into monosaccharides and ammonia [19]. The digestibility of chitosan and chitin has become a huge advantage for antimicrobial applications, as they have great potential for *in vivo* usage [19].

Alginic acid: alginic acid is a welcomed edible polysaccharide. Alginic acid has a copolymer structure of β-D-mannuronate block and α-L-guluronate block (**Figure 4**). In the natural environment, it often exists in the form of sodium salt (referred to as

**Figure 1.** *Structure of cellulose.*

**Figure 2.** *Structure of chitin.*

#### **Figure 3.**

*Structure of chitosan.*

#### **Figure 4.** *Structure of alginic acid.*

alginate) [16]. Thanks to its edibility, alginic acid is favorable in the food and drug industry and is becoming promising for antimicrobial applications.

Polyvinyl alcohol: polyvinyl alcohol (PVA) is a synthetic biocompatible polymer with the formula of [CH2CH(OH)]n. Though not invented as a biocompatible material, its biocompatibility was soon proved, and then, it started being investigated in biomedical engineering fields [20]. Unlike most polymers, PVA is water soluble, which could be fully carried forward in the case of antimicrobial application in aqueous conditions.

Of course, there are many more candidates than those listed above. To date, there is an increasing trend of research addressing biocompatible polymers [21], including obtaining novel materials, modifying current products, developing processing techniques, and exploring the markets.

#### **3. Practicing biocompatible polymers in antimicrobial applications**

#### **3.1 Approaches toward antimicrobial applications**

The intrinsic advantages of biocompatible polymers do not guarantee the feasibility of applications. Instead, the applications are largely associated with proper approaches. The following are some typical approaches developed for antimicrobial applications.

Direct processing: In terms of some biocompatible polymers, the raw materials could be extracted from natural products, and the raw materials could be directly manufactured to produce designed products without losing structure integrity, functionality, and biocompatibility. For example, chitosan with a high content of amino groups could be manufactured into thin films with antimicrobial functions due to the positively charged amino groups [22]. However, most biocompatible polymers in the form of raw materials do not have antimicrobial functions. Therefore, other approaches are needed.

Functional modification: For most biocompatible polymers, functional modification is the best approach to equip materials with antimicrobial abilities. A traditional and simple method is to physically blend polymers with antimicrobial moieties to obtain the antimicrobial mixtures, on which polymers could serve as the substrate materials to enhance the antimicrobial effects [23]. However, recent research has been more focused on the modifications of the polymer's own structures, as these kinds of materials are more chemically stable. Notably, many biocompatible polymers have functional groups on their backbones or side chains. These groups are chemically reactive and could be transferred into an antimicrobial moiety. For example, alginic acid and cyclodextrin could be oxidized, and the hydroxyl groups were transferred into aldehyde groups, which present some practical antimicrobial effects [24, 25]. Another method is to use crosslinkers, such as chitosan or other amino-containing polymers; the amino groups could be linked with crosslinkers containing aldehyde groups [26], acyl chloride [27], or other groups so the antimicrobial moieties could be covalently bound onto the polymers.

Transformation: It was found that materials in different forms would present different characteristics. This clue could be useful for biocompatible polymers. Many researches indicated that the raw polymers could be made into some "new" forms, such as nanoparticles [28], hydrogels [29], and colloids [30]. With a different size scale, shape, and morphology, the material might present antimicrobial functions or become a good candidate for antimicrobial modifications.

#### **3.2 Representative antimicrobial applications of biocompatible polymers**

A general recognition of biocompatible polymers for antimicrobial applications is the low and controllable side effects on targeted recipients while eliminating microorganisms. But when it comes to different specific fields, biocompatible polymers could present unique advantages in various ways; the following are some leading examples.

Medical and clinical usages: medical products made of biocompatible polymers have been top-rated in the market. Biocompatible polymer-based products, such as bandages, blood bags, and gauze, could be smoothly applied to humans. While eliminating and inhibiting microorganisms, the products could cause less toxic or

hazardous chemicals and leave less hurtful or uncomfortable sensing. There would be fewer concerns about the residues from the products after usage.

Food industry: traditional polymer materials have always been used in the food industry (such as food containers, food packages, and food processing instruments), but in recent years, biocompatible polymers have become more favored. One major advantage of biocompatible polymers is less generating and releasing poisons onto food, enhancing food safety [31]. In addition, biocompatible polymers with antimicrobial functions could protect the food from microbe-induced spoilage and improve the food quality [32].

Environment engineering: in this field, biocompatible polymers were adequately used to produce biocides while killing microorganisms; they would not cause pollution or collateral damage to the surrounding environment. In addition, biodegradable products could be processed by natural decomposers, leaving fewer problems in the after-usage stage [33].

#### **4. Conclusion**

As a novel class of polymeric materials, biocompatible polymers have various unique and irreplaceable advantages for antimicrobial applications. However, the basic information of biocompatible polymers was not well recognized yet. This chapter provided a brief summary about biocompatible polymers and usages in antimicrobial applications, including a comprehensible and understandable definition, a list of advantages and some typical examples. Based on these, the achieved and potential approaches for antimicrobial applications were discussed. This chapter could serve as a "getting started" brochure to introduce the concept of using biocompatible polymers for antimicrobial applications to the public.

#### **Conflict of interest**

The author declared no conflict of interest.

#### **Author details**

Ruogu Tang University of Massachusetts, Lowell, Massachusetts, USA

\*Address all correspondence to: ruogutang@gmail.com

© 2024 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Dispatching Biocompatible Polymers toward Antimicrobial Applications DOI: http://dx.doi.org/10.5772/intechopen.114250*

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#### **Chapter 12**

## Antimicrobial Resistance and Virulence of *Escherichia coli* in the Purview of Public Health Monitoring

*Pankti Dhumal, Srashti Bajpai, Nachiket Garge, Agrima Bhatt, Fatema Rampurwala, Nishat Sulaimani, Shikha Gaikwad, Utpal Roy, Manasi Mishra and Rehan Deshmukh*

#### **Abstract**

Antimicrobial resistance (AMR) has emerged as a major threat to human, animal, and environment health in the developed as well as the developing nations. The usage of antibiotics outside of the prescribed parameters in both the healthcare and livestock sectors is directly tied to this resistance event. Additionally, several *Escherichia coli* strains harbor the AMR genes, which can be transferred to humans leading to public health problems. Depending on the type of antibiotics used, *E. coli* has evolved to prowess several resistance mechanisms. Resistance genes that are horizontally transmissible also encode this resistance mechanism. Different resistance genes for each class of antibiotics are encoded by resistant *E. coli*. In conclusion, the current chapter ushers light on the molecular evolution of resistance and the regulatory genes contributing to the development of MDR in *E. coli.* Moreover, we have also discussed about the inappropriate practices of prescribing the antibiotics leading to intensifying the MDR in bacteria envisaging the implementation of rigorous guidelines for proper use of antibiotics in human beings.

**Keywords:** *E. coli*, antimicrobial resistance, genes, pathogenicity, virulence

#### **1. Introduction**

The primary concern that impacts public health in the twenty-first century is the resistance of pathogenic microorganisms to antibiotics [1]. This resistance is posing a more significant threat to public health worldwide [2]. Numerous classes of antibiotics can simultaneously render microorganisms resistant. The usage of antibiotics outside the prescribed parameters is linked to the emergence of antimicrobial resistance (AMR) [3]. The primary reasons fueling the egression of AMR in bacteria are its inappropriate use in agriculture, retail sectors like pharmacies, industries, and inefficacious prevention and control of infections in health care systems [4, 5].

The gastrointestinal tract of humans and animals is a reservoir of *Escherichia coli* which is a facultative anaerobe and usually, a harmless organism [6]. However, a few strains of *E. coli* have been known to cause infections in the gastrointestinal, urinary, and central nervous systems [7, 8]. Continuous exposure to antibiotics has shown to confer AMR in *E. coli* [9, 10]. Extended-spectrum β-lactamases (ESBLs) are plasmidmediated enzymes that hydrolyze β-lactam antibiotics, including penicillin, cephalosporin, and the monobactam aztreonam, resulting in multidrug-resistant (MDR) organisms. Bacteria exhibiting ESBLs have been linked with unsatisfactory treatment outcomes [11]. MDR *E. coli* produces ESBLs is an example of antibiotic resistance linked to the infections that can be fatal [12]. Such AMR strains of *E. coli* present in animals are significant in developing infections in humans [6, 13–19]. Studies showed that through the consumption of contaminated food and water, AMR strains of *E. coli* can be transmitted from the environment to humans [9]. Therefore, evaluating the widespread of such MDR *E. coli* in various habitats becomes very necessary for setting guidelines in animal and human health care domains [17–19].

To this end, we conducted a systematic review and meta-analysis to investigate the prevalence, molecular evolution and the regulatory genes contributing to AMR in *E. coli*. We have also discussed the factors contributing to the development of AMR and possible ways to tackle and mitigate multidrug resistant in *E. coli*.

#### **2. An overview of** *E. coli*

*E. coli* is a Gram-negative facultative anaerobe which belongs to *Enterobacteriaceae* family of the Gammaproteobacteria class [20]. It is commonly found as normal microflora in human and animal gut [21]. Sequence analysis of the *E. coli* genome was first reported in 1997. Since then, more than 4800 *E. coli* genomes have been sequenced [22, 23]. *E. coli* has been widely used to monitor AMR in livestock and food of animal origin. This is because *E. coli* can be found in the digestive tracts of warm-blooded animals [24]. Furthermore, various strains of *E. coli* are probable sources of the AMR gene, which can be transmitted to humans through various means [21, 25]. *E. coli* carried through feces or treatment of wastewater disposed of in waterways can pollute the environment [26]. The concentration of *E. coli* per gram of feces differs over the host species, usually reaching 107 –109 in humans and 104 –106 in domestic animals [27]. Shiga toxin-producing *E. coli* (STEC), entero-toxigenic *E. coli* (ETEC), enteropathogenic *E. coli* (EPEC), diffusely adherent *E. coli*, and entero-invasive *E. coli* are among the six intestinal pathotypes of *E. coli*. These bacteria are categorized according to their pathogenicity mechanisms and virulence traits [28–31]. *E. coli* is a major cause of enteric foodborne illness, bloodstream infections, intra-abdominal infections, and urinary tract infections (UTIs) in animals and humans [30, 31]. UTIs can also be caused by *Proteus* spp., *Staphylococcus saprophyticus*, *Klebsiella* spp., and other *Enterobacteriaceae* in addition to *E. coli*. However, *E. coli* is regarded as the most prevalent source of nosocomial and community-acquired UTI among bacteria that cause UTIs. Additionally, patients' history of UTI raises their risk of infection [22]. Antibiotics such as cotrimoxazole (trimethoprim/sulfamethoxazole), nitrofurantoin, ciprofloxacin, and ampicillin are used as therapeutic methods for treating UTIs [32, 33]. However, research on antibiotic resistance in *E. coli* isolates from the urinary tract have revealed a rise in resistance to several antibiotics, such as ampicillin and cotrimoxazole [32]. Bloodstream infections brought on by *E. coli* can result in morbidity, death, and other health issues [34]. These infections may raise hospital mortality rates and result in antibiotic resistance, which

*Antimicrobial Resistance and Virulence of* Escherichia coli *in the Purview of Public Health… DOI: http://dx.doi.org/10.5772/intechopen.108299*

lengthens hospital stays [35]. There have been reports of nosocomial bloodstream infections brought on by resistant bacteria, particularly in fragile and high-risk environments like critical care units and pediatric departments [36–38].

#### **3. Molecular evolution of AMR in** *E. coli*

AMR has been found to stem from human activities and indiscriminate or irrational uses of antibiotics. Various studies at genomic level pertaining to bacterial commensals and environmental bacteria revealed the presence of significant numbers of resistance determinants already embedded within their genomes not generated from any horizontal transmission and prior to the clinical introduction of antibiotics [39]. The molecular mechanism of emergence of antibiotic resistance and its spread, and persistence in bacterial population may be influenced by the interplay of several factors, such as (*a*) the mutation supply rate, (*b*) the level of resistance conferred by the resistance mechanism, (*c*) the fitness of the antibiotic-resistant mutant bacteria as a function of drug concentration, and (*d*) the strength of selective pressures [40]. Mutation supply rate is said to be determined by population sizes and mutation rates and horizontal gene transfer (HGT). Besides, in human hosts, the extent of genetic heterogeneity in a bacterial population is largely influenced by the mutation supply rate and the host-pathogen interaction [41]. The genetic perspective of AMR remains incomplete and impedes progress towards better patient outcomes and new therapeutics for resistant bacteria [42]. AMR surveillance drive indicated that drug-resistance to all the important antibiotics is in circulation among *E. coli* strains [43], including extended-spectrum β-lactams (ESBL), carbapenems, and more recently, plasmidmediated colistin resistance (mcr-1), particularly in food animals from Asian countries [44–46]. As inter- and intraspecies HGT and mobile genetic elements are factors for AMR [47], close genomic surveillance of AMR cargo within *E. coli* populations is need of the hour. The mobilization of cargo genes from a donor to a recipient site essentially provides a contribution to HGT [48]. Transposon7 (Tn7)-carrying cargo and as many as 50 Tn7-like transposons identified integrons with antibiotic resistance gene cassettes and heavy metal resistance genes [49].

Mutations are also responsible for the acquisition of amino acid substitutions leading to change of properties of protein structures to provide an altered function and a selective thriving advantage [50]. The newer introduction of more potent antibiotics into clinical settings could potentially trigger the evolution of antibiotic-ring hydrolyzing enzymes rendering powerful drug resistance. These enzymes achieve the ability towards drastically decimating the prowess of antibiotics by acquiring point mutations near or at their active sites that augment catalytic activity of β-lactamases [51]. Since enzymes are endowed with a limited capacity of taking fewer destabilizing mutations before unfolding or loosing activity, newer gain-of-function mutations at active sites often comes at the cost of stability of the enzymes [52, 53]. The alanine to valine (A77V) substitution is such a stabilizing (point) mutation that demonstrates the compensation for a loss in stability associated with substitutions that alter catalytic prowess. This compensation mechanism enables the enzymes to continuum of evolution, resulting in elevated resistance [54].

The unresolved teething problem here is to predict the probability of HGT leading to antibiotic resistance. In this regard, various related factors might play the roles in influencing the probability where particular gene would transfer into a relevant human pathogen have not been very well understood [55]. The global microbiome

might act as a potential source of resistance genes and genes for most classes of antibiotics have been found out in the human gut microbiome [ 56 ], and the soil microbiome [ 57 ].

 Quiet interestingly, it has been hypothesized that within the human microbiota, there has been frequent exchanges between bacteria of antibiotic resistance genes (ARGs), where the intestinal *E. coli* community acts as a melting pot for the HGT [ 58 , 59 ]. Antibiotic-sensitive bacterial populations developed drug-resistance either through HGTs or mutations and expression of resistance genes from other strains, either distantly or closely related ( **Figure 1** ). Detection of multiple mutational events can be selected in a step wisely to "train" resistance in a bacterium with successive mutations imparting additive effects [ 60 ]. As mentioned before, the human or animal gastrointestinal tract provides an ideal milieu where factors responsible for the upheaval of antibiotic resistance genes and spreading across resident bacterial populations are present [ 61 ]. The presence of high cell density is certainly one of the major factors. Additionally, spread of resistant infections is encouraged by selection followed by the innate ability for gene transfer through a variety of different mechanisms [ 62 ]. As bacterial cells get exposed to an anti-bacterial drug at sub minimum inhibitory concentrations (MIC), bacteria can thrive to gain resistance under selective pressure [ 63 ]. Recent work in this line demonstrated that there may be different resistance mechanisms induced by sub-inhibitory antibiotic exposure compared to lethal selection [ 64 ]. In *Salmonella enterica* , sub-inhibitory concentrations of streptomycin selected for high-level resistance through multiple-negligible-effect resistance

#### **Figure 1.**

 *E. coli virulence factors can be encoded by plasmids (e.g., heat-labile enterotoxin (LT) of ETEC and invasion factors of EIEC), several mobile genetic elements, including transposons (Tn) (e.g., heat stable enterotoxin (ST) of ETEC), pathogenicity islands (PAIs)- e.g., the locus of enterocyte effacement (LEE) of EPEC/EHEC and PAIs I and II of UPEC and bacteriophage (e.g., Shiga toxin of EHEC). Deletions, additions, and other genetic rearrangements may result in evolution of wild type to pathogenic E. coli strains responsible for causing dysentery (EIEC), diarrhea (EPEC, EAEC, EHEC, DAEC), urinary tract infections (UPEC) and hemolytic uremic syndrome (EHEC). UTI, urinary tract infection; HUS, hemolytic uremic syndrome. The figure was created using www.BioRender.com .* 

*Antimicrobial Resistance and Virulence of* Escherichia coli *in the Purview of Public Health… DOI: http://dx.doi.org/10.5772/intechopen.108299*

mutations, whereas lethal selection led to specific target mutations [65]. However, resistant mutants derived from sub-inhibitory fluoroquinolone exposure may not always induce causative changes in the target quinolone resistance determining region (QRDR) [65]. Experimental demonstrations also suggest that alterations in drug efflux systems are a major mechanism under pressure from sub-lethal ciprofloxacin exposure in case of *E. coli* [66]. Concentration-dependent responses are also mooted as anthropic drivers of resistance. These phenomena go beyond changes in resistance genes since different drug concentrations may alter the community behavior in response to drugs [67]. Reports are rife to indicate that for the manifestations of virulence and AMR, *E. coli* are armed with mobile genetic elements such as plasmids, genomic islands (PAIs and resistance islands [REIs]), or transposons [68]. The ability of mobile genetic elements is acquired at a higher rate [69] rendering *E. coli* ST131 an ideal subject to examine the co-evolution of AMR and virulence [70]. In such *E. coli* ST131 population, chromosomal mutations in quinolone-resistance determining regions (QRDR) of gyrA and parC, conferring high-level fluoroquinolone resistance were reported in the phylogenetic subclades, C1, and C2 [71, 72].

#### **4. Regulatory genes in MDR** *E. coli*

The emerging MDR of *E. coli* to several antibiotics is a significant problem leading to the development of pan resistant species and is the major bottleneck in the treatment of diseases. Development of resistance in bacterial pathogens is an adaptive trait and is acquired mainly either by HGT of mobile genetic elements carrying resistance or de novo mutations. *E. coli* strains producing ESBL enzymes like Cefotaximase-Munich (CTX-M) β-lactamases are emerging with higher frequency in hospital and healthcare-associated setups leading to community-onset urinary tract and bloodstream infections [73]. In many Gram-negative bacteria, chromosomal loci specifying global regulatory proteins that control MDR have been characterized in bacteria including *E. coli, Klebsiella pneumoniae,* and other *Enterobacteriaceae*, and *Neisseria gonorrhoeae*, *Bacillus subtilis,* and *S. aureus* [74]. In most instances, the regulatory proteins function as activators or repressors of transcription and contain either a single DNA-binding domain or two separate regions responsible for DNA binding and interacting with small-molecule substrates [75]. The potential genes responsible for encoding MDR in *E. coli* are listed in **Table 1**.

ESBLs hydrolyze and cause resistance to oxyimino-cephalosporins (e.g., cefotaxime, ceftazidime, ceftriaxone, cefuroxime and cefepime), monobactams (e.g., aztreonam), aminoglycosides and co-trimoxazole. ESBLs have evolved due to point mutations around the active site of β-lactamase [90]. Reports have described *ampC* genes present on the plasmid can be potentially transferred among *E. coli*, *Klebsiella* spp., and *Salmonella* spp. [76]. The ESBL/*ampC* genes are often surrounded by mobile genetic elements (e.g., transposons, IS elements or class 1 integrons), that mediate transmission, and involved in the expression of the genes IS*Ecp1* and IS*CR1* [77]. Gene encoding for CTX-M β-lactamases, *bla*CTX-M is encoded by narrow hostrange incompatibility type plasmids (i.e.IncFI, IncFII, IncHI2 and IncI) or the broad host-range incompatibility type plasmids (i.e. IncN, IncP-1-a, IncL/M and IncA/C) and is associated with highly efficient mobile genetic element IS*Ecp1* [78–80]. Insertion sequence IS*Ecp1* belongs to the chromosomes of the environmental bacteria called *Kluyvera spp*. [91]. Plasmids encoding for CTX-M-15 also carry additional antibiotic resistance genes—*bla*OXA-1, *bla*TEM-1, *tetA*, *aac(6*′*)-Ib-cr* and *aac(3)-II*, often


*Antimicrobial Resistance and Virulence of* Escherichia coli *in the Purview of Public Health… DOI: http://dx.doi.org/10.5772/intechopen.108299*


#### **Table 1.**

*List of genes encoding multiple drug resistance in E. coli.*

contained within class 1 integrons [79, 85]. ESBL-producing Enterobacteriaceae are now significantly emerging in the community. The prototype *cat* genes (*cat I*, *cat II*, *cat III*, *cat A*, *cat B*, etc.) encode for chloramphenicol acetyltransferases (CAT) which can inactivate chloramphenicol as well as thiamphenicol, azidamfenicol, and florfenicol [86]. CATs are detected in a wide variety of bacteria including *E. coli*. *cat I* was originally identified as part of transposon Tn9 in *E. coli* and has been detected in several resistance plasmids of Gram-negative bacteria [92]. Various groups of *cat* genes are often located on small multicopy plasmids also carrying streptomycin resistance or macrolide resistance gene [93]. Export of chloramphenicol and florfenicol out of the bacterial cell via specific membrane transporters or multidrug transporters is another mechanism of resistance shown by microorganisms. Genes encoding for such transporters/efflux proteins (E-1 to E-8) are found in several clinically relevant and environmental bacteria [94]. A number of genes [*pp-flo*, *cmlA*-like, *floSt*, *flo*, or *floR*] grouped in E-3 mediate combined resistance to chloramphenicol and florfenicol. These genes show high homology [96–100%] and their protein products also show 88–100% identity. Often these genes coding for CATs and specific transporters are located on conjugative plasmids, gene cassettes and associated with transposon elements. This facilitates their fast and efficient dissemination among bacteria of same or different species and genera.

Sulphonamide resistance genes *sul1* and *sul2* encoding for dihydropteroate synthase enzymes have been known since decades [83]. A third sulphonamide resistance gene, *sul3*, was identified from porcine *E. coli* [95]. *Mef* (B) gene encoding for macrolide-efflux pump which mediates resistance to macrolides was found located in the vicinity of *sul3* in porcine *E. coli* [84]. In previous reports, mef (A), a homolog of mef (B) was found to be present only in Gram positive bacteria being encoded on a transposable element. However, the emergence of new resistance genes is *E. coli* isolates reflects on the positive selection pressure for sulphonamide and macrolide resistance despite its restricted use is many countries.

In *E. coli*, the MarA is the protein that regulates the expression of many chromosomal genes (the Mar regulon), including those specifying an MDR efflux pump and other proteins (e.g., porins) that mediate antibiotic susceptibility [96]. In *E. coli*, over expression of this MarA leads to reduced expression of the OmpF porin [97] as well as increased expression of the multidrug efflux pump AcrAB [88], thereby conferring resistance to a large number of antimicrobial agents. Resistance-nodulation-division (RND) pumps in *E. coli*, TolC plays the roles of proton antiporters and confer resistance to many important antibiotics, tetracyclines, chloramphenicol, some β-lactams, vancomycin, and fluoroquinolones [98, 99].

The most common ESBL gene in *E. coli* isolates of human origin is *blaCTX-M-15* and ST-131 clone and are implicated in AMR dissemination [81]. The increase in carbapenems (CPE) is mainly associated with the extensive dissemination of acquired CPE. CPE encoding genes are usually located in mobile genetic elements (MGEs), implying in the emergence of MDR and XDR strains [100]. Extraintestinal pathogenic *E. coli* (ExPEC) bacteria are the group of pathogenic strains that have the uncanny ability to cause severe ailments, such as urinary tract infections (UTIs) and bacteremia [101]. The emergence of MDR in *E. coli* has already become a global concern, with particular emphasis on *E. coli* sequence type (ST) 131 reported in UTIs. *CTX*-*M* Drug resistance phenomenon is mediated by extended-spectrum β-lactamases (ESBLs), mainly of the CTX-M family, particularly CTX-M-15 and 14, and less frequently of the SHV and OXA families [102]. CTX-M-15 first detected in *E. coli* isolates from India has become one of the most widely spread CTX-M β-lactamase worldwide. Association of *bla*CTX-M-15 with the insertion element IS*Ecp1* plays an important role in its expression and mobilization [89]. From UTI patients, *E. coli* and *K. pneumoniae* with CTX-M type ESBLs were isolated. These enzymes are carried by *E. coli* with multidrug resistance phenotype [103]. MDR expressed by CTX-M-producing isolates from the community is often associated with the presence of multiple ESBLs genes, as well as aminoglycoside and quinolone resistance genes, thereby limiting the choice of effective antimicrobial drugs [104]. As mentioned earlier, that evolution in antibiotic resistance enzymes could rely on the acquisition of stabilizing mutations. A77V substitution is one such mutation that was detected in CTX-M extended-spectrum β-lactamases (ESBLs) from a good number of clinical isolates, pointing towards the significance of the β-lactamase evolution in antibiotic resistance in gram-negative bacteria [105].

Resistance to polypeptide antimicrobials like Colistin (CST) have also been reported in *E. coli* isolated from diseased pigs [106]. Most of such isolates also show resistance to sulfonamides, trimethoprim, tetracycline, ampicillin, or chloramphenicol. Acquired resistance to CST is known to be because of lipopolysaccharide (LPS) modifications—the addition of 2-aminoethanol, 4-amino-4-deoxy-L-arabinose (L-Ara4N) or phosphoethanolamine (PetN), or other strategies such as efflux pump and capsule formation. Mutations in chromosomal genes *mgrB*, *mgrR*, *etk* play a

*Antimicrobial Resistance and Virulence of* Escherichia coli *in the Purview of Public Health… DOI: http://dx.doi.org/10.5772/intechopen.108299*

role in resistance to CST in *E. coli* [ 87 ]. Resistance to colistin could also be due to mutations in chromosomal genes or it may be acquired. *Colistin-resistance in E. coli* is plasmid-mediated colistin resistance via the acquisition of the *MCR-1* gene that can propagate efficiently and imparts resistance to other bacteria [ 107 ]. *MCR-1* protein enables the addition of a phosphor-ethanolamine group to lipid A. This modification imparts a charge alteration on LPS, which in turn reduces the binding affinity of colistin towards LPS [ 82 ].

#### **5. AMR in** *E. coli* **: contributory factors and its mitigation**

MDR *E. coli* spreads over time and stop responding to the drugs which makes it difficult to control the infections caused by them. This increases the risk of spreading diseases, developing major illnesses, and their transmission from one person to other. Hence, uttermost attention is required to mitigate MDR as it plays a significant role in the accomplishment of the sustainable development goals (SDGs). There are numerous factors ( **Figure 2** ) which contribute to AMR in *E. coli* listed below.

#### **5.1 Overuse, misuse, and inappropriate prescribing of antibiotic or antimicrobials (AM)**

 It has been established that the main factors contributing to medication fatalities include taking antibiotics or AM specifically when not needed or ingesting it more than approved doses and concentrations. For example, any antibiotic used to treat a bacterial infection will kill susceptible bacteria; if appropriately targeted, the pathogenic microorganism will also be eradicated; nevertheless, the antibiotic will also

kill any sensitive microbiota in the patient along with the infecting bacteria [108]. If the anatomical region has robust bacteria, whether they come from the healthy microbiota or the pathogenic germs that are being treated, they will proliferate and finally take control. As a result, bacteria are evolving quickly in response to selective antibiotic pressure, which is a significant feature in the growth of multidrugresistant strains [108]. According to Balbina et al. [109], kanamycin, gentamicin, ciprofloxacin, fluoroquinolones, rifampicin, sulfisoxazole, cefoxitin, ampicillin, and fosfomycin are the most frequently prescribed antibiotics for treating *E. coli* related infections. However, ciprofloxacin is one of the drugs that are most likely to be prescribed incorrectly [109, 110]. Globally, the percentage of human antibiotic use was 65 percent between 2000 and 2015, however, if current trends are not changed, it is predicted that animal antibiotic use will increase by 11.5 percent by 2030, which will contribute to the emergence of additional MDR *E. coli* strains [111]. In the year 2021, Browne and his coworkers [112] reported that the global consumption rate of antibiotics was 14.3 well-defined daily doses (DDD) per thousand people per day in 2018 (40.2 [372–437] billion DDD), up 46% from 9.8 (92–105) DDD per 1000 per day in 2000 [112]. *E. coli* and other strains of the *Enterobacteriaceae* family are becoming gradually resistant to antibiotics due to an intensification in the appearance of membrane proteins that impel the drugs out of the cell, especially in topoisomerases, alterations in the target enzymes, and the presence of mobile genetic elements (plasmids, transposons, and integrons) that support in the lateral transmission of resistance genes in prokaryotes [113–115].

#### **5.2 Use of non-antibiotic antimicrobials (NAAM)**

Compared to antibiotics, a lot more non-antibiotic antimicrobial (NAAM) compounds are utilized as biocidal agents. As a result, the environment has significant residual levels of NAAM compounds in the soil, water, and air. One typical biocidal agent, triclosan (TCS), is utilized in more than 2000 different items, including hand washing liquids and toothpaste [116]. According to reports, triclosan causes *E. coli* to develop heritable multi-drug resistance [116]. 1.1 × 105 to 4.2 × 105 kg of TCS is released annually by wastewater treatment plants (WWTPs) in the US alone [117].

#### **5.3 Lack of sanitary facilities and clean water**

Water is a vital resource for all living things. All species, including humans, have microbes living inside and on them. According to Collignon et al. [118], environmental variable quantity such as advanced deficient technologies in waste management, availability of non-potable drinking water, overcrowded housing, and poor cleanliness may stimulate the growth and expansion of resistant bacteria globally. The unique capability of *E. coli* in colonization of the animal gut has given additional evolutionary benefit in acquiring resistance attributes from other bacteria in its environment [118]. Antibiotics are frequently used in livestock or food animals to combat and prevent diseases as well as to promote growth, which causes AMR to develop and raises the possibility of antibiotic-resistant bacterial colonization [118]. These bacteria may be spread while handling the animals, slaughtering them, or processing the meat. Additionally, fruits and vegetables can be infected with fecal material directly from the animals or through irrigation water that has been contaminated with animal or human waste [116, 118]. More than 1000 unique antibiotic-resistant genes have been identified in the human gut microbiota, and the transfer of these features between gut

*Antimicrobial Resistance and Virulence of* Escherichia coli *in the Purview of Public Health… DOI: http://dx.doi.org/10.5772/intechopen.108299*

commensals is prevalent, according to one study done by Hu et al. [119]. In underdeveloped regions of the world, antibiotic-resistant strains of *E. coli* are detected at the time of birth, at the highest rates in human feces. Studies in China [114] have stated that ESBL genes in *E. coli* are transmitted by conjugation that enters in food chain directly or indirectly which facilitates explaining why ESBL-producing *E. coli* are so prevalent in feces around the world.

#### **5.4 Insufficient infection prevention and control promote the spread of microbes**

Since many sick individuals congregate in hospitals and healthcare centers and antibiotic consumption is prevalent, resistant strains of bacteria are selected for and disseminated throughout these settings, making them important hotspots for most bugs [120]. Additionally, inadequate hygiene habits may make it easier for resistant microbes to transmit from patients or visitors to doctors, nurses, and other healthcare professionals through their hands or clothing [121]. Other risk factors include inadequate sanitation, inappropriate cleaning of the facilities, and dirty equipment. Few isolation rooms and crowded wards further encourage spread [120, 121]. Poor approaches towards reasonably priced medicines, vaccines, and diagnostics are the most defined factors for showing the resistance to antimicrobial treatment case of *E. coli*, which is understudied in many underdeveloped nations [122]. Patients face substantial health risks when doctors attempt to treat infections about which they are ignorant. Medical facilities should set up systems to guarantee the identification and management of a range of bacterial diseases without prescribing incorrect medications [122]. Over time, incorrect medicine prescriptions have led to several patients' deaths and even more severe health issues [120–122] With the right diagnosis and care, patients can reduce their risk of developing medication resistance-related issues. In addition, the ongoing development of strategies for the cultivation of bacteria using a variety of culture media and conditions a process known as culturomics is crucial for the identification of antibiotic resistance genes (ARGs) and the comprehension of the cellular mechanisms underlying the association between ARGs and resistance phenotypes in various bacteria [123]. One of the major issues with building a consolidated database is establishing a clear strategy and making it into a regular practice of environmental-quality monitoring [124].

#### **5.5 Lack of enforcement of legislation**

By 2050, it is predicted that antibiotic resistance will have killed more people than cancer today. According to Naghavi's analysis in the published report in the year 2022, there would be 12.7 million deaths caused by bacterial AMR in 2022, out of an expected 495 million deaths linked to bacterial AMR in 2019 [125]. Death by thirdgeneration cephalosporin-resistant *E. coli* was found to be the most prevalent [125]. Therefore, the lawmakers must keep an eye on how often antibiotics or other biocidal chemicals are used. The sum of all the efforts, including legislation, studies of community attitudes and knowledge regarding antibiotics, educational initiatives, and follow-up policies, will undoubtedly contribute not only to reducing antibiotic misuse in the short term but also to fostering appropriate knowledge among society members regarding the advantages of using antibiotics properly. These actions will be crucial to lowering patient demand for antibiotics and preventing detrimental effects on public health and the economy. Although the creation of stringent legislation like "Schedule H1" is crucial, it might only be one component of the solution. Delaying these reforms emphasizes the risky game we are playing with the health of people and animals, which might have terrible repercussions**.**

#### **5.6 The absence of new antibiotic discoveries**

It can be crucial in treating a variety of bacterial illnesses. Some bacterial strains are still evolving and developing medication resistance. Although few new antibiotics are being introduced to the market, they could be useful in attempting to close the gap.

#### **6. Conclusions and future horizons**

A persistent global concern in the field of medicine is microbial resistance to antibiotics. One among numerous bacteria is *E. coli*, which is frequently found in humans and animals. Finding novel antibiotic substitutes that are more potent in treating pathogenic infections, particularly the ones caused due to *E. coli* is required since there are less options for antibiotics that are sensitive to this bacterium. *E. coli* and other Gram-negative bacteria have evolved to develop different mechanism to encounter any antimicrobials. Moreover, different studies have showed higher prevalence of ESBL antibiotic resistance and MDR *E. coli* strains in animals than in humans. Besides, the stability and spread of colistin resistance in multiple reservoirs are an emerging public health threat worldwide. Dissemination of antibiotic resistance genes via transmissible plasmids, integrons and transposons to several environmental reservoirs like wastewater treatment plants (WWTPs), agriculture fields, animal manure, and hospital-associated setups is an emerging threat to environmental and public health safety. Our meta-analysis suggests that comprehensive surveilling of hospitalassociated diseases, careful monitoring of hospital waste management procedures, supervising antibiotic use in animals, tracking and evaluating antibiotics susceptibility trends, and the development of trustworthy antibiotic strategies may facilitate more corrective actions for the inhibition and control of *E. coli* infections in various parts of the world and practical guidelines can be put in place for proper prescription of antibiotics in humans to ensure better public health monitoring.

#### **Acknowledgements**

RD would like to thank Dr. Vishwanath Karad MIT-World Peace University for providing Students' Innovation Seed Fund to PD, SB, NG, AB, FR and NS. SG and MM are grateful to the institute for providing the facilities and infrastructure.

#### **Conflict of interest**

The authors declare no conflict of interest. All authors have contributed to the chapter and agreed for its publication.

*Antimicrobial Resistance and Virulence of* Escherichia coli *in the Purview of Public Health… DOI: http://dx.doi.org/10.5772/intechopen.108299*

#### **Author details**

Pankti Dhumal1 , Srashti Bajpai1 , Nachiket Garge1 , Agrima Bhatt1 , Fatema Rampurwala1 , Nishat Sulaimani1 , Shikha Gaikwad1 , Utpal Roy2 , Manasi Mishra1 and Rehan Deshmukh1 \*

1 Faculty of Science, School of Biology, Dr. Vishwanath Karad MIT World Peace University, Pune, India

2 Department of Biological Sciences, Birla Institute of Technology and Science-K.K. Birla Goa Campus, Goa, India

\*Address all correspondence to: rrehandeshmukh@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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#### **Chapter 13**

## Phylotypes and Pathotypes of Diarrheagenic *Escherichia coli* of Gastroenteritis

*Hadi Sajid Abdulabbas, Noor Al-Khafaji, Suhad Y. Abed, Hussein Al-Dahmoshi and Huda Najh Al-Baroody*

#### **Abstract**

*Escherichia coli* responsible for wide range of common bacterial infections, the frequent one is gastroenteritis. Bacterial gastroenteritis mainly attributed to diarrheagenic *E. coli* and accompanied by diarrhea and vomiting. Actually pathogenic *E. coli* can be classified according to the site of infection whether it be within intestine (called intestinal *pathogenic E. coli* InPEC) or cause infection outside intestine (called extraintestinal pathogenic *E. coli* ExPEC*)*. They are assigned to 4 main phylogenetic groups: InPEC include A and B1 while ExPEC have B2 and D groups. Seven Pathotypes have been assigned: Enteropathogenic *E. coli* (EPEC), enterotoxigenic *E. coli* (ETEC), enterohemorrhagic (Shiga-toxin producing *E. coli* (EHEC/STEC), enteroaggregative *E. coli* (EAEC), diffusely adherent *E. coli* (DAEC), enteroinvasive *E. coli* (EIEC) and adherent invasive *E. coli* (AIEC). The patho-phylotyping of diarrheagenic *E. coli* interaction along with antibiotic resistance and biofilm formation capacity may be valuable insight to know real threat of this pathogen and this is tried to be covered with this chapter. The results revealed that the among DEC, EPEC and ETEC were assigned in high rate to B1 followed by A, B2, D, E, C and F while EAEC show different assignment: D followed by B2, A, B1, C, E and F. The other DEC pathotypes showed different styles.

**Keywords:** Pathotypes, phylotypes, *E. coli*, antibiotic resistance, biofilm, InPEC, ExPEC

#### **1. Introduction**

*Escherichia coli* is commensal enterobacteial member emerging as opportunistic pathogen causing numerous of intestinal and extraintestinal infections. Concern Pathotypes of *E. coli*, they divided in to two main groups: Extraintestinal pathogenic *E. coli* (ExPEC) and intestinal pathogenic *E. coli* (InPEC). ExPEC cause range of infections for Human being outside intestine like meningitides as in neonatal meningitis *E. coli* (NMEC), urinary tract infection as in uropathogenic *E. coli* (UPEC) and sepsis-associated *E. coli* (SEPEC) [1–3]. InPEC includes 8 Pathotypes of diarrheagenic *E. coli* (DEC) including: enteropathogenic *E. coli* (EPEC), enterotoxigenic


#### **Table 1.**

*Genotypic profile for 6 phylogenetic groups and 5 clades of* E. coli.

*E. coli* (ETEC), enteroaggregative *E. coli* (EAEC), diffusely adherent *E. coli* (DAEC), enteroinvasive *E. coli* (EIEC), enterohemorrhagic *E. coli* (EHEC) (also known as Shiga-toxin-producing *E. coli* (STEC) or, verotoxin-producing *E. coli* (VTEC), necrotoxic *E. coli* (NTEC) and adherent-invasive *E. coli* (AIEC) [4–6]. Two systems named as Clermont triplex and quadruplex PCR were used to assign the *E. coli* isolates to seven phylogroups (A, B1, B2, C, D, E and F) and five clades (clade I, II, III, IV and V) according to presence/absence of six genes: chuA, yjaA, TspE4.C2, arpA, *arpAgpEh and trpA(*trpAgpC) as mentioned in **Table 1** [7–9].

#### **2. Diarrheagenic** *E. coli* **(DEC) phylotypes**

Diarrheagenic *E. coli* (DEC) is a term referring to 8 or 9 pathotypes of *E. coli* causing diarrhea in travelers. It accounting for up to 40% of infantile and children diarrhea worldwide [10] and responsible for most of diarrheal outbreaks globally [11]. All DEC Pathotypes categorized according to molecular contents of some virulence genes: *eae* and *bfpA* for EPEC [12]; *st1a*, *st1b* and *ltb1* for ETEC; *aggR* for EAEC; *stx1* and *stx2* for EHEC/STEC; *ipaH* for EIEC; *daaD* for DAEC [13]. Many studies revealed that, the most prevalent diarrheagenic *E. coli* were ETEC, EPEC, EAEC, AIEC, EHEC/STEC and DAEC [14–17]. Concern phylogroups of EPEC, the results gathered from 18 studies for 433 EPEC isolates revealed that: B1 compile (39.3%), A(23.3%), B2(18.2%), D(8.5%), (6.2%, 3.5% and 0.9%) for E, C and F phylogroups respectively (**Table 2**) [18–35]. ETEC phylogroups includes: B1(43.3%), A(28.2%), D(14%), B2(13.4%), C(0.6%), E(0.6%) and F(0.0%) (**Table 3**) [18, 23–25, 27, 28, 30, 31, 33, 35–37]. Concern EAEC phylogroups the results showed that, among 399 EAEC isolates they assigned for D(32.8%), B2(30.5%)A(19.2), B1(16.2%), C(0.8%), E(0.5%) and F(0.0%) (**Table 4**) [18, 24, 25, 27, 28, 30–32, 35, 37–40]. **Table 5** showed the phylogroups of EIEC, EHEC/STEC, AIEC and DAEC pathotypes. EIEC phylogroups were A, B1, E, D, B2 and C compile (37.6%, 21.2%, 17.7%, 12.9%, 8.2% and 2.4% respectively). EHEC/STEC phylogroups were C, B1, B2, A, E, D and Fcompile (21.5%, 20.1, 18.7%, 16.2%, 13.4%, 7.7% and 2.4% respectively). AIEC phylogroups were B2, D, A and B1 compile (51.3%, 25.2%, 18.3% and 5.2%


#### *Phylotypes and Pathotypes of Diarrheagenic* Escherichia coli *of Gastroenteritis DOI: http://dx.doi.org/10.5772/intechopen.109860*

#### **Table 2.**

*ExPEC and InPEC phylogroups of EPEC isolates.*


#### **Table 3.**

*ExPEC and InPEC phylogroups of ETEC isolates.*


#### **Table 4.**

*ExPEC and InPEC phylogroups of EAEC isolates.*


*Phylotypes and Pathotypes of Diarrheagenic* Escherichia coli *of Gastroenteritis DOI: http://dx.doi.org/10.5772/intechopen.109860*


**Table 5.**

*ExPEC and InPEC phylogroups of EIEC, EHEC/STEC AIEC and DAEC isolates.*

respectively) while DAEC phylogroups were A (5/11), B2(3/11) and B1(3/11) [18, 24–28, 33, 36, 37, 39–41, 43–47].

#### **3. Uropathogenic** *E. coli* **(UPEC) phylotypes**

Uropathogenic *E. coli* (UPEC) is the most common ExPEC causing UTI, one of the most frequent bacterial infections with significant morbidity worldwide, which


#### **Table 6.**

*Distribution of phylogenetic groups among UPEC isolates in Iraq.*

may convey a sets of virulence factors and belonging to diverse phylogenetic groups [48]. UPEC as ExPEC must be belong to either B2 or D phylogroups. The B2 include 2 phylosubgroups: B22 (*chuA+, yjaA+, TspE4.C2-, arpA-, arpAgpE-, TrpAgpC-*) and B23 (*chuA+, yjaA+, TspE4.C2+, arpA-, arpAgpE-, TrpAgpC-*) while D have 2 phylosubgroups: D1 (*chuA+, yjaA-, TspE4.C2-, arpA+, arpAgpE-, TrpAgpC-*) and D2 (*chuA+, yjaA-, TspE4.C2-, arpA+, arpAgpE-, TrpAgpC+*) [49, 50].

Many Iraqi studies studied the assignment of UPEC to phylogroups. Since 2017–2022 only 11 Iraqi studies with valuable no. of UPEC isolates analyze 1119 isolates and assigning them to 7 phylogroups and they are found that: 566(50.6%) for B2, 241(21.5%) for D, 208(18.6%) for A, 60(5.4%) for B1, 23(2.1%) for C, 11(1%) for E and 10(0.8%) for F (**Table 6**) [51–61]. Concern Iranian studies, 19 study were conducted including 2313 UPEC isolates assigned to phylogroups as follow: 1190(51.4%) for B2, 481(20.8%) for D, 399(17.3%) for A, 190(8.2%) for B1, 26(1.1%) for C, 23(1%) for E and 4(0.2%) for F (**Table 7**) [25, 62–79]. Ten studies from Egypt deal with 892 UPEC isolates stated that, B2 compile (38.1%), D (15.2%), A (23.2%), B1 (14.3%), C (3.4%), E (2.8%) and F (2.9%) as mentioned in **Table 8** [25, 42, 49, 54, 76, 80–84]. Nine Turkish studies showed that, among 901 isolated of UPEC, (39.3%) were B2,


#### **Table 7.**

*Distribution of phylogenetic groups among UPEC isolates in Iran.*


#### *Phylotypes and Pathotypes of Diarrheagenic* Escherichia coli *of Gastroenteritis DOI: http://dx.doi.org/10.5772/intechopen.109860*

#### **Table 8.**

*Distribution of phylogenetic groups among UPEC isolates in Egypt.*


#### **Table 9.**

*Distribution of phylogenetic groups among UPEC isolates in Turkey.*

(31.5%) for D, (2.4%) for A, (6.4%) for B1, (0.1%) for C, (2.1%) for E and (0.1%) for F phylogroups (**Table 9**) [85–93].

#### **4. Conclusion**

Data analysis of current study revealed that the among DEC, EPEC and ETEC were assigned in high rate to B1 followed by A, B2, D, E, C and F while EAEC show different assignment: D followed by B2, A, B1, C, E and F. The other DEC pathotypes showed different styles.

### **Conflict of interest**

There is no 'conflict of interest' for this work.

### **Author details**

Hadi Sajid Abdulabbas1 , Noor Al-Khafaji<sup>2</sup> , Suhad Y. Abed3 , Hussein Al-Dahmoshi2 \* and Huda Najh Al-Baroody4

1 Faculty of Dentistry, University of Al-Ameed, Karbala, Iraq

2 Biology Department, College of Science, University of Babylon, Hilla, Iraq

3 Department of Biology, College of Science, Mustansiriyah University, Baghdad, Iraq

4 Department of Microbiology, College of Medicine, University of Al-Ameed, Karbala, Iraq

\*Address all correspondence to: dr.dahmoshi83@gmail.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Phylotypes and Pathotypes of Diarrheagenic* Escherichia coli *of Gastroenteritis DOI: http://dx.doi.org/10.5772/intechopen.109860*

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### *Edited by Ghulam Mustafa*

Over the past many years, new and novel antibiotics have been developed against resistant bacterial species, but their increased clinical usage has led to reduced bacterial susceptibility and increased bacterial resistance to these novel agents. When a new antibiotic is developed, bacterial species initially show susceptibility to the agent, but with the passage of time, as the use of the antibiotic increases, the bacterial species acquire resistance against the drug or even the drug class. This book provides a comprehensive overview of antimicrobial stewardship programs and the obstacles to implementing and maintaining such programs. Antimicrobial stewardship is an important part of a multifaceted approach to preventing the emergence of antibiotic resistance in various microbial species. The book highlights the basic and initial steps necessary for initiating an antimicrobial stewardship program, as well as explores the different strategies of antimicrobial stewardship.

*Rosario Pignatello, Pharmaceutical Science Series Editor*

Published in London, UK © 2024 IntechOpen © LucaDAddezio / iStock

Antimicrobial Stewardship - New Insights

IntechOpen Series

Pharmaceutical Science, Volume 4

Antimicrobial Stewardship

New Insights

*Edited by Ghulam Mustafa*