The global increase in antibiotic resistance levels in bacteria is a growing concern to our society and highlights the need for alternative strategies to combat bacterial infections. Bacterial viruses (phages) are the natural predators of bacteria and are as diverse as their hosts, but our understanding of them is limited. The current levels of knowledge regarding the role that phage play in the control of bacterial populations are poor, despite the use of phage therapy as a clinical therapy in Eastern Europe. The aim of this doctoral thesis is to increase knowledge of the diversity and characteristics of bacterial viruses and to assess their potential as therapeutic agents towards multi-resistant bacteria. Paper I is the product of de novo sequencing of newly isolated phages that infect and kill multi-resistant Klebsiella pneumoniae. Based on similarities in gene arrangement, lysis cassette type and conserved RNA polymerase, the creation of a new phage genus within Autographivirinae is proposed. Paper II describes the genomic and proteomic analysis of a phage of the rare C3 morphotype, a Podoviridae phage with an elongated head that uses multi-resistant Escherichia coli as its host. Paper III describes the study of a pre-made phage cocktail against 125 clinical K. pneumoniae isolates. The phage cocktail inhibited the growth of 99 (79 %) of the bacterial isolates tested. This study also demonstrates the need for common methodologies in the scientific community to determine how to assess phages that infect multiple serotypes to avoid false positive results. Paper IV studies the effects of phage predation on bacterial virulence: phages were first allowed to prey on a clinical K. pneumoniae isolate, followed by the isolation of phage-resistant bacteria. The phage resistant bacteria were then assessed for their growth rate, biofilm production in vitro. The virulence of the phage resistant bacteria was then assessed in Galleria mellonella. In the single phage treatments, two out of four phages showed an increased virulence in the in G. mellonella, which was also linked to an increased growth rate of the phage resistant bacteria. In multi-phage treatments however, three out of five phage cocktails decreased the bacterial virulence in G. mellonella compared to an untreated control. / <p>At the time of the doctoral defense, the following papers were unpublished and had a status as follows: Paper 3: Manuscript. Paper 4: Manuscript.</p>

The extensive medical and agricultural use and misuse of antibiotics during the last 70 years has caused an enrichment of resistant pathogenic bacteria that now severely threatens our capacity to efficiently treat bacterial infections. While is has been known for a long time that high concentrations of antibiotics can select for resistant mutants, less is known about the lower limit at which antibiotics can be selective and enrich for resistant bacteria. In this thesis we investigated the role of low concentrations of antibiotics and heavy metals in the enrichment and evolution of antibiotic resistance. Selection was studied using Escherichia coli and Salmonella enterica serovar Typhimurium LT2 with different resistance mutations, different chromosomal resistance genes as well as large conjugative multidrug resistance plasmids. Using very sensitive competition experiments, we showed that antibiotic and heavy metal levels more than several hundred-fold below the minimal inhibitory concentration of susceptible bacteria can enrich for resistant bacteria. Additionally, we demonstrated that subinhibitory levels of antibiotics can select for de novo resistant mutants, and that these conditions can select for a new spectrum of low-cost resistance mutations. The combinatorial effects of antibiotics and heavy metals can cause an enrichment of a multidrug resistance plasmid, even if the concentration of each compound individually is not high enough to cause selection. These results indicate that environments contaminated with low levels of antibiotics and heavy metals such as, for example, sewage water or soil fertilized with sludge or manure, could provide a setting for selection, enrichment and transfer of antibiotic resistance genes. This selection could be a critical step in the transfer of resistance genes from environmental bacteria to human pathogens.

Les infections nosocomiales à bactéries multi-résistantes sont en constante augmentation en réanimation. Elles ont des conséquences individuelles et collectives majeures. La mortalité en réanimation et les prolongations des durées de séjour sont les deux principales conséquences individuelles connues à ce jour. Plusieurs facteurs confondants rendent l'interprétation des études difficiles, dont l'état sous jacent du patient, la virulence de la bactérie et l'adéquation thérapeutique. Mesurer la part de chacun de ces facteurs et préciser leur responsabilité respective est indispensable pour mobiliser les différents acteurs et améliorer le pronostic des patients en réanimation. Dans cette thèse nous avons souhaité approcher la réponse quant aux conséquences individuelles. A partir d'une base de données incluant des patients de réanimation, nous avons utilisé les méthodes statistiques les plus récentes et avons tenté de prendre en compte les différents facteurs confondants , pour répondre à trois questions précises que sont : la mortalité liée à une espèce bactérienne donnée, les facteurs associés à la mortalité des patients présentant un sepsis sévère ou choc septique en réanimation et les conséquences liées à l'isolement des patients infectés ou colonisés avec une bactérie multi-résistante. Nous montrons que (1) par l'intermédiaire d'une prolongation de la durée de séjour en réanimation, l'infection à Clostridium difficile augmente la pression de colonisation, sans pour autant avoir d'impact direct sur le décès. (2) que le pronostic des sepsis sévères et des chocs septiques dépend de l'adéquation de l'antibiothérapie et que les bactéries résistantes sont plus souvent traitées de manière inadéquate. (3) que l'isolement contact est associé non seulement à une augmentation attendue du risque de pneumonie nosocomiale a germe multi-résistants mais aussi à une augmentation du risque d'erreurs thérapeutiques et d'événements indésirables non infectieux. Cet impact délétère suggéré par des études en dehors de la réanimation doit être pris en compte lors de la mise en place des précautions contact en réanimation. / Nosocomial infections with multidrug-resistant bacteria are increasing in ICU. They have major individual and collective consequences. Mortality in the ICU and prolongation of length of stay are the two main individual consequences known to date. Several confounding factors make it difficult to interpret studies, including the patient's underlying condition, the virulence of bacteria and the adequacy of therapy. It is essential to measure the share of each of these factors and to clarify their respective responsibilities to mobilize the different actors and improve the prognosis of patients in intensive care. In this thesis, and drawing upon a database including ICU patients, we used the latest statistical methods and tried to take into account the various confounding factors to evaluate the individual consequences of multidrug-resistant bacteria in ICU. We sought to address three specific questions: mortality linked to specific bacterial species, factors associated with mortality in patients with severe sepsis or septic shock in intensive care unit, and the consequences of the isolation of patients infected or colonized with multidrug-resistant bacteria. We demonstrated that (1) because they are associated with a longer stay in intensive care unit, Clostridium difficile infections increase the pressure of colonization although they have no direct consequence on mortality; (2) the prognosis of sever sepsis or septic shock depends on the adequacy of the antibiotic therapy and that resistant bacteria are often inadequately treated; and (3) that isolation is not only associated with an expected increase in the risk of nosocomial pneumonia with multi-drug resistant pathogens strains but also with an increase in non-infectious adverse events.

The long history of co-existence of bacteria and their protozoan predators in aquatic environments has led to evolution of protozoa resistant bacteria (PRB). Many of these bacteria are also pathogenic to humans. However, the ecological drivers determining the occurrence of different types of PRB in aquatic environments, and the eco-evolutionary link between bacterial adaptation and the resulting implications for mammalian hosts are poorly known. This thesis examines the impact of nutrients and predation on PRB, as well as the ecological and evolutionary connection between their life in aquatic environments and mammalian hosts. In the first study seven bacterial isolates from the Baltic Sea were investigated for their plasticity of adaptation to predation. The response to predation showed large variation where some bacteria rapidly developed a degree of grazing resistance when exposed to predators. The rapid adaptation observed may result in bacterial communities being resilient or resistant to predation, and thus rapid adaptation may be a structuring force in the food web. With the aim to elucidate the link between occurrence of PRB and environmental conditions, a field study and a laboratory experiment were performed. In both studies three PRB genera were found: Mycobacterium, Pseudomonas and Rickettsia. PRB were found both in oligotrophic and eutrophic waters, indicating that waters of all nutrient states can harbor pathogenic bacteria. However, the ecological strategy of the PRB varied depending on environmental nutrient level and disturbance. Using an advanced bioinformatic analysis, it was shown that ecotypes within the same PRB genus can be linked to specific environmental conditions or the presence of specific protozoa, cyanobacteria or phytoplankton taxa. These environmental conditions or specific plankton taxa could potentially act as indicators for occurrence of PRB. Finally, using four mutants (with specific protein deletions) of the pathogenic and predation resistant Francisella tularensis ssp. holarctica, I found evidence of an eco-evolutionary connection between the bacterium´s life in aquatic and mammalian hosts (aquatic amoeba Acanthamoeba castellanii and a murine macrophage).  To a large extent F. t. holarctica use similar mechanisms to persist predation by protozoa and to resist degradation by mammal macrophages. To summarize I found a link between predation resistant bacteria in aquatic environments and bacteria that are pathogenic to mammals. Further, I showed that different environmental conditions rapidly selects for PRB with either intracellular or extracellular lifestyles. This thesis provides insights regarding environmental conditions and biomarkers that can be used for assessment of aquatic environments at risk for spreading pathogenic bacteria. / <p>Medfinansiärer var även: Swedish Ministry of Defence (A4040, A4042, A404215, A404217), Swedish Minestry of Foreign Affairs (A4952), Swedish Civil Contingencies Agency (B4055)</p>

京都大学 / 0048 / 新制・課程博士 / 博士(工学) / 甲第22762号 / 工博第4761号 / 新制||工||1745(附属図書館) / 京都大学大学院工学研究科都市環境工学専攻 / (主査)教授 田中 宏明, 教授 米田 稔, 准教授 松田 知成 / 学位規則第4条第1項該当 / Doctor of Philosophy (Engineering) / Kyoto University / DFAM

Multi-resistant bacteria are a growing problem worldwide. In relation to the bacteria spreading, the proportion of patients with multi-resistant bacteria also increase. In nursing, the encounter is described as a central part and works to ensure that the patient can express their feelings. How the meeting takes place has a great impact on whether the patient experiences suffering or not. A professional approach and knowledge regarding patients experience of the encounter as well as communication, forms a basis for the nurse to be able to meet the patient's unique needs in the encounter. The aim of this study is to describe how patients with multi-resistant bacteria experience the encounter with healthcare. This is a literature study is based on analysis of qualitative studies. The ten articles that make up the work have been analysed using a fivestep model. This resulted in two main themes and five sub-themes, which describe the experience of the meeting. The results describe how the staff's hygiene routines, attitudes and knowledge affect how patients experience the encounter. It also highlights the impact of the isolation in which patients are cared for and the stigmatization that was experienced during the encounter. In summary, it showed that patients with multi-resistant bacteria are at risk of experiencing an encounter that is stigmatizing. Patients experienced feelings such as guilt and shame due to the healthcare staff´s routines and attitudes in the meeting.

Bakgrund: Multiresistenta bakterier är ett globalt växande samhällsproblem och ett utav de största folkhälsoproblemen. Förekomsten av multiresistenta bakterier ökar genom användning av antibiotika, framförallt bred-spektrumantibiotika. Multiresistenta bakterier leder till ökad sjuklighet och dödlighet, längre vårdtider och spridning sker både i samhället samt på sjukhus. MRSA, ESBL, VRE och MDR-TB är de multiresistenta bakterier som litteraturstudien fokuserar på. Syfte: Syftet var att belysa sjuksköterskans erfarenheter av att vårda patienter med multiresistenta bakterier. Metod: En allmän litteraturstudie med kvalitativ metod och induktiv ansats utfördes. Åtta vetenskapliga artiklar granskades och analyserades tills kategorier identifierades. Resultat: Analysen resulterade i att fem kategorier identifierades: sjuksköterskans rädslor, otillräcklig kunskap, sjuksköterskans ansvar, organisatoriska brister och utmaningar med patienter i isolering. Sjuksköterskorna beskrev att det förekom hinder i vårdandet av patienter med multiresistenta bakterier såsom bristande kunskap och ledarskap, rädsla för att smittas och smitta andra, avsaknad av riktlinjer samt isolering av patienter. Konklusion: Sjuksköterskor behöver mer kunskap och goda förutsättningar för att kunna ge patienter med multiresistenta bakterier optimal vård. / Background: Multidrug-resistant bacteria are a globally growing problem in society and one of the largest public health problems. The occurrence of multidrug-resistant bacteria increases through the use of antibiotics, especially broad-spectrum antibiotics. Multidrug-resistant bacteria leads to increased morbidity and mortality as well as longer treatments, and the bacteria are spread in both society and in hospitals. The literature study focuses on the multidrug-resistant bacteria MRSA, ESBL, VRE and MDR-TB. Aim: The aim was to illustrate the nurse''s experiences of caring for patients with multidrug-resistant bacteria. Method: A general literature study with a qualitative method and an inductive approach was carried out. Eight scientific articles were reviewed and analyzed until categories were identified. Results: The analysis resulted in five categories being identified: the nurse''s fears, insufficient knowledge, the nurse''s responsibilities, organizational deficiencies and challenges with patients in isolation. The nurses'' described obstacles in the care of patients with multiresistant bacteria such as lack of knowledge and leadership, fear of being infected and infecting others, lack of guidelines and isolation of patients. Conclusion: Nurses need more knowledge and good conditions to be able to give patients with multidrug-resistant bacteria optimal care.

The recent upsurge of multidrug resistant bacteria (MDRB) among global communities has become one of the most serious challenges facing health professionals and the human population worldwide. Cationic ultrashort antimicrobial peptides (USAMPs) are a promising group of molecules that meet the required criteria of novel antimicrobial drug development. UP-5, a novel penta-peptide, displayed significant antimicrobial activities against various standard and clinical isolates of MDRB. UP-5 displayed MICs values within the range of (10–15 M) and (55–65 M) against Gram-positive and Gram-negative bacteria, respectively. Furthermore, UP-5 displayed antibiofilm activity with minimum biofilm eradication concentration (MBEC) value as equal to twofold higher than MIC value. At the same inhibitory concentrations, UP-5 exhibited very low or negligible toxicity toward human erythrocytes and mammalian cells. Combining UP-5 with conventional antibiotics led to a synergistic or additive mode of action that resulted in the reduction of the MIC values for some of the antibiotics by 99.7% along a significant drop in MIC values of the peptide. The stability profile of UP-5 was evaluated in full mouse plasma and serum with results indicating a more stable pattern in plasma. The present study indicates that USAMPs are promising antimicrobial agents that can avoid the negative characteristics of conventional antimicrobial peptides. Additionally, USAMPs exhibit good to moderate activity against MDRB, negligible toxicity, and synergistic outcomes in combination with conventional antimicrobial agents.

Outputs of human-derived chemicals and constituents to the environment, and shifts in these outputs, can result in unintended consequences to human and ecological health. One such shift is the advent of the modern antibiotic era, in which mass production and outputs of antibiotics, which are mostly naturally-derived microbial defense compounds and include a few synthetic antimicrobials, has profound implications for contributing to the spread of antibiotic resistance. Antibiotic resistance arises from mutations and/or sharing of antibiotic resistance genes (ARGs) among bacteria via horizontal gene transfer, with carriage of ARGs by pathogenic bacteria of particular concern to human health. While most attention to stopping the spread of antibiotic resistance has been devoted to the clinic, it is critical to consider the environmental origin, ecology and pathways by which antibiotic resistance spreads in order to develop comprehensive strategies to combat antibiotic resistance. In particular, wastewater treatment plants (WWTPs) represent a potentially key critical control point given that they receive antibiotic resistant bacteria (ARB) and ARGs from the population, which are then routed to activated sludge biological treatment, consisting of high density, highly active microbial populations. The research projects described in this dissertation aimed to explore the occurrence of ARGs in WWTPs, particularly WWTPs in developing countries representing the extremes of what is expected to be encountered in terms of potential to spread antibiotic resistance, and to improve and apply novel technologies for monitoring key markers of antibiotic resistance in WWTPs and affected environments. The pathogen Staphylococcus aureus and a corresponding ARG (methicillin resistance mecA gene) were chosen as model biocontaminants of concern due to their environmental and public health relevance. The results reported in Chapters 3-5 advance the knowledge of bio(nano)sensing techniques and highlight areas of promise and challenge. The results reported in Chapter 2 provided insight into the baseline levels of ARGs expected in a highly impacted WWTP in India, thereby highlighting the magnitude and global scale of the problem of antibiotic resistance as well as the need for innovative solutions. / Ph. D.

Cattle are commonly treated with antibiotics that may survive digestion and promote antibiotic resistance when manure or composted manure is used as a soil amendment for crop production. This study was conducted to determine the effects of antibiotic administration and soil amendment practices on microbial diversity and antibiotic resistance of bacteria recovered from the surfaces of lettuce and radishes grown using recommended application rates. Vegetables were planted in field plots amended with raw manure from antibiotic-treated dairy cows, composted-manure from cows with different histories of antibiotic administration, or a chemical fertilizer control (12 plots, n=3). Culture-based methods, 16SrDNA amplicon sequencing, qPCR and shot-gun metagenomics were utilized to profile bacteria and characterize the different gene markers for antibiotic resistance. Culture-based methodologies revealed that lettuce grown in soils amended with BSAs had significantly larger clindamycin resistant populations compared to control conditions. Growth in BSAs was associated with significant changes to the bacterial community composition of radish and lettuce. Total sul1 copies were 160X more abundant on lettuce grown in manure and total tet(W) copies were 30X more abundant on radishes grown in manure. Analysis of shotgun metagenomic data revealed that lettuce grown in manure-amended soils possessed resistance genes for three additional antibiotic classes compared to other treatments. This study demonstrates that raw, antibiotic-exposed manure may alter microbiota and the antibiotic resistance genes present on vegetables. Proper composting of BSAs as recommended by the U.S. Department of Agriculture and Environmental Protection Agency is recommended to mitigate the spread of resistance to vegetable surfaces. / MSLFS / Antibiotics are drugs responsible for killing infectious diseases in both humans and animals. In cows, antibiotics are frequently used when they get infections in their udders. These drugs can be excreted through manure and urine and end up in the environment. Manure or composted manure is often applied as a soil amendment for crop production. The presence of antibiotics in soil may promote antibiotic resistance, meaning bacteria that carry antibiotic resistance genes (ARGs) are capable of surviving exposure to drugs that would normally kill them. Such bacteria may eventually pass their ARGs to pathogens, which then could no longer be treated effectively by antibiotics when there is an infection. Thus, there is concern that overuse of antibiotics in agriculture can contribute to reduced effectiveness of antibiotics and the growing global antibiotic resistance health crisis. This study sought to determine if prior antibiotic administration affected the antibiotic resistance of bacteria found on the surfaces of vegetables grown in soil amended with manure or compost from dairy cows. Lettuce and radishes were grown in the field in plots amended with raw manure from antibiotic-treated dairy cows, compost from cows with different histories of antibiotic administration, or a chemical fertilizer control. Mature vegetables were harvested and used to enumerate antibiotic-resistant bacterial colonies. Additionally, the 16S rRNA gene, which is a ubiquitous gene found in all bacteria, was sequenced to identify the kinds of microbes that colonized the radish and lettuce surfaces when grown under the different conditions. DNA was extracted from the bacteria collected from the vegetable surfaces to and different methods were used to identify the kinds of ARGs present and to which kinds of antibiotics they encode resistance. The results of the study indicated that raw, antibiotic-exposed manure may increase the bacteria found on vegetables in addition to their ARGs. Proper composting of manure, as recommended by the U.S. Department of Agriculture (USDA) and the Environmental Protection Agency (EPA), is recommended to mitigate resistance and control microbial populations on fresh vegetables.