Penicillinase Plasmid Research Articles

BlaI and blaR1 regulate beta-lactamase and PBP 2a production in methicillin-resistant Staphylococcus aureus

For Staphylococcus aureus, it is hypothesized that two genes located upstream of the beta-lactamase gene, blaZ, are required for the inducible expression of beta-lactamase. blaR1 is predicted to encode a signal-transducing membrane protein, and blaI is predicted to encode a repressor protein. These same two genes may also regulate the production of penicillin-binding protein 2a (PBP 2a), a protein essential for expression of methicillin resistance. To confirm that these two genes encode products that can control both beta-lactamase and PBP 2a production, blaI, blaR1, and blaZ with a 150-nucleotide deletion at the 3' end were subcloned from a 30-kb staphylococcal beta-lactamase plasmid and three beta-lactamase-negative strains of methicillin-resistant S. aureus were transformed with the recombinant plasmid containing that insert. The production of PBP 2a and a nonfunctional beta-lactamase was detected by fluorography and by immunoblots with polyclonal antisera directed against each of the proteins. Whereas the parent strains did not produce beta-lactamase and constitutively produced PBP 2a, PBP 2a and a truncated beta-lactamase were now inducible in the transformants. Therefore, two plasmid-derived genes regulate the production of both PBP 2a and beta-lactamase.

Effect of ampicillin versus cefuroxime on the emergence of β-lactam resistance in faecal Enterobacter cloacae isolates from neonates

Enterobacter cloacae strains dominated the aerobic faecal flora of 8.3% of 953 infants discharged from 32 Swedish neonatal intensive care units and the susceptibility of these strains to seven beta-lactam antibiotics was determined. Isolates from infants treated with cefuroxime showed slightly increased MICs only to ampicillin, cephalexin and cephalothin as compared to isolates from untreated infants matched for ward and time of sampling (P = 0.02). In contrast, E. cloacae isolates from ampicillin treated infants showed markedly elevated MICs of all agents tested including piperacillin, cefuroxime, cefotaxime and ceftazidime as compared to those from control neonates (P values between 0.001 for ampicillin and 0.017 for cefotaxime). Thus, E. cloacae with cefotaxime MICs as high as 512 mg/L were isolated only after ampicillin therapy. The resistant strains were negative in a colony DNA hybridization assay using gene probes for the plasmid beta-lactamases TEM-1, OXA-1 and SHV-1. The resistant strains also showed only one beta-lactamase band when crude cell sonicates were analysed by isoelectric focusing, and were not found in other infants in the same ward. The results indicate that the selection of chromosomal E. cloacae mutants, presumably with stably derepressed beta-lactamase production, in the faecal flora of neonates is rare during treatment with cefuroxime and more common during ampicillin therapy.

Activity of meropenem against imipenem-resistant bacteria and selection in vitro of carbapenem-resistant Enterobacteriaceae.

The activity of meropenem against 106 imipenem-resistant (MIC > or = 8 mg/l) clinical isolates, and the frequency of resistance to meropenem and imipenem among 24 Enterobacteriaceae was determined. Both agents selected colonies on agar but 20-80% were susceptible after one subculture and 72% of the mutants reverted to susceptibility 1 to 6 months after selection. All isolates and stable mutants were inhibited by > 1 mg/l meropenem, although the MIC of imipenem was 4-16 mg/l. Three of six Xanthomonas maltophilia isolates were susceptible to meropenem (MICs 2-4 mg/l). Pseudomonas aeruginosa lacking outer membrane protein D2 were resistant to meropenem, although isolates with substantially reduced expression of this protein were susceptible. None of the imipenem-resistant gram-positive bacteria were susceptible to meropenem. There was no clear correlation between altered outer membrane protein expression and decreased susceptibility to carbapenems, and there was no apparent involvement of plasmid or chromosomal beta-lactamase.

Correlation between in vitro antimicrobial susceptibilities and beta-lactamase plasmid contents of isolates of Haemophilus ducreyi from the United States

We determined the susceptibilities of 94 strains of Haemophilus ducreyi isolated in various municipalities in the United States between 1982 and 1989 to the following antimicrobial agents: amoxicillin-clavulanic acid, ceftriaxone, erythromycin, azithromycin, ciprofloxacin, ofloxacin, trimethoprim, and spectinomycin. Ceftriaxone (MIC, less than or equal to 0.008 micrograms/ml), azithromycin (MIC, less than or equal to 0.125 micrograms/ml), erythromycin (MIC, less than or equal to 0.125 micrograms/ml), ciprofloxacin (MIC, less than or equal to 0.25 micrograms/ml), and ofloxacin (MIC, less than or equal to 0.25 micrograms/ml) were highly active against all isolates. Amoxicillin-clavulanic acid (MICs, 0.25 to 8.0 micrograms/ml), trimethoprim (MICs, 0.06 to 16.0 micrograms/ml), and spectinomycin (MICs, 2.0 to greater than or equal to 32.0 micrograms/ml) were less active against these isolates. Isolates possessing the 5.7-MDa beta-lactamase plasmid were less susceptible to erythromycin, trimethoprim, and spectinomycin than were isolates possessing the 3.2-MDa beta-lactamase plasmid. The susceptibilities of plasmidless isolates to erythromycin, trimethoprim, and spectinomycin were distributed bimodally; the median MIC for the more susceptible plasmidless isolates corresponded to that for isolates with the 3.2-MDa plasmid, and the median MIC for the less susceptible plasmidless isolates corresponded to that for isolates with the 5.7-MDa plasmid. Thus, plasmid profiles may be valuable markers for geographical variations in antimicrobial susceptibilities of H. ducreyi strains that may indicate the relative efficacy of regimens for the treatment of chancroid. Of the regimens recommended by the U.S. Public Health Service for the treatment of chancroid, our results support the use of erythromycin, ceftriaxone, and ciprofloxacin, and perhaps ofloxacin, but suggest that amoxicillin-clavulanic acid and sulfamethoxazole-trimethoprim should be used with caution.

Identification of a ROB-1 beta-lactamase in Haemophilus ducreyi.

A collection of 100 clinical isolates of Haemophilus ducreyi from Thailand were all found to harbor a 5.4-kb plasmid, designated pTH126, which was shown to contain the bla ROB-1 gene. Restriction enzyme analysis and DNA-DNA hybridization studies confirmed that pTH126 was similar to the ROB-1 beta-lactamase plasmid pVM105 from Actinobacillus pleuropneumoniae. In approximately one-half of the isolates, pTH126 was found together with pHD131, which mediates TEM-1 beta-lactamase production.

Correlation between regulation of mecA transcription and expression of methicillin resistance in staphylococci.

Total RNA was used to study the effect of penicillinase plasmid pI524 and of mecR, the regulatory region located on the methicillin resistance determinant (mec), on the expression of mecA, the gene coding for the low-affinity penicillin-binding protein PBP2', in methicillin-resistant staphylococci. In the present report, we show that the regulation of methicillin resistance occurs primarily at the level of mecA transcription and that in the presence of intact plasmid pI524 or mecR, the gene undergoes negative control. The relative amount of mecA mRNA present during exponential growth in uninduced cultures matches the type of mecA regulation and decreases in the following order: constitutive greater than pI524 greater than mecR-dependent mecA expression. Induction of mecA by methicillin is faster in pI524- than in mecR-controlled strains. The overall mRNA half-life is similar for all strains analyzed. Our results indicate that methicillin resistance under mecR control in certain staphylococcal strains could escape detection by the standard disk diffusion test and broth microdilution test because of the very slow derepression of the mecA gene. This finding is of importance for the clinical detection of this type of methicillin resistance.

Distribution of the 3.05-Mdal “Toronto” β-Lactamase Plasmid Among Penicillinase-Producing Isolates of Neisseria gonorrhoeae in the Far East

One hundred and fifty-two beta-lactamase-producing Neisseria gonorrhoeae isolates from Japan (n = 25; 1983, 1985, 1986), Taiwan (n = 14; 1983, 1984), and the Republics of Singapore (n = 58; 1986, 1987) and the Philippines (n = 55; 1989) isolated from 1983 through 1989 were characterized by auxotype, serovar, and plasmid content to determine the distribution and diversity of penicillinase-producing N. gonorrhoeae (PPNG) strains possessing the 3.05-Mdal "Toronto" beta-lactamase plasmid. PPNG isolates possessing a 3.05-Mdal beta-lactamase plasmid were isolated in Japan (1/25: 4%), Taiwan (4/14: 29%), and the Republic of the Philippines (3/55: 5%); no PPNG isolates with the 3.05-Mdal plasmid were isolated in the Republic of Singapore. All isolates possessing the 3.05-Mdal plasmid also possessed a 24.5-Mdal conjugative plasmid and belonged to the auxotype/serovar class, Proto/IB-1. Studies with five isolates possessing the 3.05-Mdal plasmid, and representing isolates from each country in which they were found, confirmed that the beta-lactamase plasmid in these strains could not be transferred to another gonococcal isolate by conjugation. PPNG isolates possessing the "Toronto" plasmid are widespread in the Far East; spread of these isolates may, however, be limited to the physical spread of a single strain.

Borderline susceptibility to antistaphylococcal penicillins is not conferred exclusively by the hyperproduction of beta-lactamase

Staphylococcus aureus strains bearing the 17.2-kb beta-lactamase plasmid pBW15 and belonging to phage group 94/96 exhibit borderline susceptibility to the antistaphylococcal penicillins. Borderline susceptibility within phage group 94/96 is thought to be mediated by the hyperproduction of type A staphylococcal beta-lactamase. Evaluation of 84 non-94/96 phage type S. aureus strains that also produced the type A enzyme identified 7 additional hyperproducing strains. However, none of these isolates contained pBW15, and only one met the criteria for borderline susceptibility. To determine the role of pBW15 and the 94/96 phage type in the expression of borderline susceptibility, pBW15 was transformed in two plasmid-free, penicillin-susceptible strains, one of which belonged to phage group 94/96. Penicillin MICs for both transformants and quantitative beta-lactamase activity were comparable to those for the parent pBW15-containing strain. A fourfold difference in the oxacillin MICs for the 94/96 and non-94/96 phage type transformants (1.0 and 0.25 microgram/ml, respectively) was identified, and only the 94/96 phage type transformant met the criteria for borderline susceptibility. Chromosomal DNA from borderline-susceptible phage group 94/96 strains did not hybridize with a probe for mecA, and the beta-lactam binding affinity of PBPs 1, 2, 3, and 4 from a penicillin-susceptible 94/96 phage type strain and a non-94/96 phage type strain were comparable. Although hyperproduction of the type A beta-lactamase appears to be necessary for the expression of borderline susceptibility within certain phage group 94/96 strains, beta-lactamase production of a comparable magnitude by a group of S. aureus strains belonging to other phage types does not confer borderline susceptibility. These data suggest that borderline susceptibility is not solely due to the hyperproduction of beta-lactamase.

In vitro activity of cefcanel versus other oral cephalosporins

Cefcanel is a new orally absorbed cephalosporin. Its activity was compared with that of cefuroxime, cefaclor, cephalexin, and cefixime against gram-positive and negative aerobic and anaerobic bacteria. Cefcanel had excellent activity against methicillin-susceptible Staphylococcus aureus and Staphylococcus epidermidis, MIC90 1 micrograms/ml, superior to the other oral cephalosporins. However, methicillin-resistant staphylococci were resistant, MIC greater than or equal to 16 micrograms/ml. Streptococcus pyogenes and Streptococcus pneumoniae were inhibited by 0.015-1 micrograms/ml, concentrations comparable to other cephalosporins. Clostridium spp. were inhibited by 0.25 micrograms/ml, 8- to 128-fold lower concentrations than were found for other agents, but the MICs were greater than 64 micrograms/ml for Bacteroides spp. The MIC90 for Moraxella catarrhalis was 1 micrograms/ml, similar to cefuroxime but 16-fold greater than the MICs of cefixime. Escherichia coli and Klebsiella pneumonia which were high beta-lactamase producers were resistant, MICs greater than 64 micrograms/ml, and 50% of Enterobacter cloacae and Citrobacter freundii were resistant. Cefcanel was hydrolyzed by TEM-1, TEM-3 and Moraxella Bro-1 beta-lactamases. Escherichia coli containing TEM-1, 2, 3, 5, 7, and 9 had cefcanel MICs of greater than or equal to 16 micrograms/ml. Although cefcanel inhibited gram-positive species as well as or at lower concentrations than other cephalosporins, it lacked activity against gram-negative species that produced common plasmid beta-lactamase although it inhibited Haemophilus influenzae carrying TEM-1.

Haemophilus Parainfluenzae Causing Sexually Transmitted Urethritis

A multiple antibiotic resistance, beta-lactamase-producing strain of Haemophilus parainfluenzae was isolated from a patient with sexually transmitted urethritis that was contracted in Northwest Africa. The strain was found to harbor a small (3.2 megadaltons) plasmid encoding for beta-lactamase production, which was successfully mobilized to Escherichia coli in triparental mating experiments by means of a broad host-range Inc-W conjugative plasmid. Since H. parainfluenzae is believed to be a source and reservoir for the spread of beta-lactamase plasmids to other bacterial species, such a plasmid mobilization may suggest a new possible means for resistance plasmid dissemination.

-Lactam Resistance Mechanisms of Methicillin-Resistant Staphylococcus aureus

In vitro and in vivo activity of amoxicillin and penicillin G alone or combined with a penicillinase inhibitor (clavulanate) were tested against five isogenic pairs of methicillin-resistant Staphylococcus aureus (MRSA) producing or not producing penicillinase. Loss of the penicillinase plasmid caused an eight times or greater reduction in the MICs of amoxicillin and penicillin G (from greater than or equal to 64 to 8 micrograms/ml), but not of the penicillinase-resistant drugs methicillin and cloxacillin (greater than or equal to 64 micrograms/ml). This difference in antibacterial effectiveness correlated with a more than 10 times greater penicillin-binding protein 2a affinity of amoxicillin and penicillin G than of methicillin and a greater than or equal to 90% successful amoxicillin treatment of experimental endocarditis due to penicillinase-negative MRSA compared with cloxacillin, which was totally ineffective (P less than .001). Amoxicillin was also effective against penicillinase-producing parent MRSA, provided it was combined with clavulanate. Penicillinase-sensitive beta-lactam antibiotics plus penicillinase inhibitors might offer a rational alternative treatment for MRSA infections.

In vitro activity and beta-lactamase stability of GR69153, a new long-acting cephalosporin

GR69153, a new parenteral cephalosporin, inhibited 90% of Escherichia coli, Klebsiella oxytoca, Proteus mirabilis, Citrobacter diversus, shigellae, and salmonellae at less than 0.25 micrograms/ml (MIC90). It had activity comparable to those of ceftazidime, cefpirome, cefepime, and E-1040. Against cephalosporinase-producing Enterobacter cloacae, Citrobacter freundii, and Serratia marcescens, MICs ranged from 0.12 to greater than 32 micrograms/ml, and cefpirome and cefepime were the most active agents against these species. Pseudomonas aeruginosa was highly susceptible to GR69153, and for this organism the MIC90 was less than or equal to 2 micrograms/ml, which was similar to the E-1040 MIC90, but most Pseudomonas cepacia and Xanthomonas maltophilia isolates were resistant. GR69153 inhibited Haemophilus influenzae and Moraxella branhamella at less than or equal to 0.5 micrograms/ml. For Staphylococcus aureus GR69153 MICs were similar to those of ceftazidime and E-1040. Enterococci and listeriae were resistant to GR69153, but Streptococcus pyogenes and Streptococcus pneumoniae were inhibited by 0.5 micrograms/ml. The activity of GR69153 was not affected by serum. GR69153 was not inactivated by the beta-lactamases of Staphylococcus aureus, TEM-1, TEM-2, SHV-1, and BRO-1, but it was hydrolyzed by TEM-3, TEM-9, and morganellae. GR69153 had overall activity comparable to those of commercially available parenteral cephalosporins or those found in clinical investigations. It is more active against bacteroides than most available aminothiazolyl parenteral cephalosporins are. GR69153 is hydrolyzed by the new plasmid beta-lactamases, and thus, its primary value may be related to its pharmacological properties.

Acquisition of β-lactamase and TetM-containing Conjugative Plasmids by Phenotypically Different Strains of Neisseria gonorrhoeae

beta-lactamase plasmids confer high-level penicillin resistance on strains of Neisseria gonorrhoeae and may be mobilized between strains by conjugative plasmids. The authors examined 32 isolates belonging to 23 auxotype/serovar (A/S) classes to determine the frequency with which they acquired the 4.4-, 3.2-, and 3.05-megadalton (Mdal) beta-lactamase plasmids, respectively. The 3.05-Mdal beta-lactamase plasmid was not acquired by any isolate. Each of 22 isolates possessing only the 2.6-Mdal plasmid or both the 2.6- and 24.5-Mdal plasmids acquired the 4.4- and 3.2-Mdal plasmids at similar frequencies, and 12 (55%) acquired the 4.4- or 3.2-Mdal plasmids at a frequency of greater than or equal to 10(-3) per input recipient; all transconjugants acquired the 24.5-Mdal conjugative plasmid. Among ten isolates that lacked the 2.6-Mdal plasmid (plasmidless), seven isolates that included five PAU/IB-2, -16 isolates acquired neither the 4.4- nor 3.2-Mdal plasmid; three non-PAU isolates acquired both the 4.4- and 3.2-Mdal plasmids (10(-2)-10(-5) per input recipient). All plasmidless isolates acquired the 25.2-Mdal TetM containing plasmid with frequencies ranging from 10(-1) to 10(-8) per input recipient. These data suggest that gonococcal strains possessing the 2.6-Mdal plasmid readily acquire the 4.4- and 3.2-Mdal beta-lactamase plasmids in vitro, whereas acquisition of these plasmids by strains lacking the 2.6-Mdal plasmid is strain dependent.

Role of penicillinase plasmids in the stability of the mecA gene in methicillin-resistant Staphylococcus aureus

The stability of methicillin resistance (Mcr) in three independent clinical isolates, MR108, MR6, and MR61, of methicillin-resistant Staphylococcus aureus (MRSA) was studied. The Mcr phenotype was stably maintained in the progeny of all three MRSA clones carrying penicillinase plasmids. However, when the clones were tested after elimination of the plasmids, methicillin-susceptible (Mcs) subclones appeared at various frequencies. Seven Mcs subclones were classified into two groups based on their stabilities. Five Mcs subclones, which were derived from homogeneous strains MR108 and MR61, were stably susceptible. They lost penicillin-binding protein 2' production, and moreover, the mecA gene was deleted in four of five subclones. Two subclones were derived from heterogeneous strain MR6. They were very unstable, and more than half of their progeny were Mcr revertants. However, the remainder were stably Mcs and had lost penicillin-binding protein 2' and the mecA gene. We propose that penicillinase plasmids, which are present in most MRSA strains, play an important role in the stability and phenotypic expression of the mecA gene.

Transfer of beta-lactamase plasmids by conjugation in Neisseria gonorrhoeae.

Conjugation experiments in vitro have been used in an attempt to explain certain epidemiological phenomena seen amongst penicillinase producing Neisseria gonorrhoeae (PPNG) isolated at St Mary's Hospital, London. These include changes in plasmid profiles, a lack of beta-lactamase encoding plasmids in PAOU-requiring strains and a difference in the serological classification of strains of PPNG and non-PPNG isolated from the same clinic. It was shown that acquisition of the conjugative plasmid by beta-lactamase producing transconjugants does vary, but is not related to the auxotype/serovar (A/S) class of, or type of beta-lactamase plasmid carried by the donor. It was not possible to transfer either the 3.2MDa or 4.4MDa plasmids to PAOU-requiring strains of N gonorrhoeae. The conjugation frequency from a single donor to different recipients was shown to be variable, but was not influenced by the serovar of the recipients. It was shown that the transfer and acceptance of beta-lactamase encoding plasmids is variable but it was not possible to identify the factors responsible.

Molecular epidemiology and novel combinations of auxotype, serovar, and plasmid content in tetracycline-resistant Neisseria gonorrhoeae isolated in Canada

Between October 1987 and June 1989, 84 isolates of Neisseria gonorrhoeae carrying the TetM resistance determinant (TRNG) were received at the Laboratory Centre for Disease Control, Ottawa, from six Canadian provinces and were characterized into classes based on auxotype, serovar and plasmid content. One-fifth (17/84) of the TRNG were also penicillinase producing (PPNG). The PPNG-TRNG isolates comprised six classes based on auxotype, serovar, and plasmid content. Most (16/17) PPNG-TRNG carried 3.2-MDa beta-lactamase plasmids and the 25.2-MDa TetM-containing plasmid. We report, for the first time, the association of a 4.5-MDa beta-lactamase plasmid with the 25.2-MDa plasmid in a clinical TRNG isolate. Non-PPNG TRNG isolates comprised 11 classes based on auxotype, serovar, and plasmid content, including two previously unreported auxotype-serovar classes, P/IB-26 and P/IB-20.

Perspectives of beta-lactamases inhibitors in therapy of infections caused by Escherichia coli or Klebsiella with plasmidic resistance to third generation cephalosporins

New plasmidic beta-lactamases inactivating so far stable cephalosporins, aztreonam and cephamycins restrict the use of these antibiotics in therapy of infections, e.g., by Escherichia coli and Klebsiella. Thus, combinations of beta-lactamase inhibitors and beta-lactam antibiotics were investigated in vitro with regard to their therapeutic perspectives. Minimal inhibitory concentrations and the kinetics of killing in a pharmacodynamic model were determined. Extended broad spectrum beta-lactamases (EBS-beta-lactamases) representative both for the TEM- and SHV-type were included. None of the available fixed combinations of penicillins and beta-lactamase inhibitors appears useful for therapy of infections caused by producers of EBS-beta-lactamases. In contrast, combinations of piperacillin and tazobactam or sulbactam plus cephalosporins (cefoperazone, cefotaxime, ceftazidime) or aztreonam are highly active (both by their MICs and bactericidal activity) against TEM-type EBS-beta-lactamases, but less promising for the SHV-type EBS-beta-lactamases, and plasmidic cephamycinase. Of the beta-lactams available, the monobactam carumonam and the carbapenems (imipenem, meropenem) remain safe in infections caused by E. coli and Klebsiella EBSBase producers.

Genetic and molecular analyses of the gene encoding staphylococcal enterotoxin D

The gene (entD) encoding staphylococcal enterotoxin D (SED) has been located on a 27.6-kilobase penicillinase plasmid designated pIB485. This plasmid was present in all SED-producing strains tested. The entD gene was cloned on a 2.0-kilobase DNA fragment and was expressed in Escherichia coli. Sequence analysis of this fragment revealed an open reading frame that encoded a 258-amino-acid protein that possessed a 30-amino-acid signal peptide. The 228-amino-acid mature polypeptide had a molecular weight of 26,360 and contained a high degree of sequence similarity to the other staphylococcal enterotoxins. S1 nuclease mapping showed that transcription of entD was initiated 266 nucleotides upstream from the translation start codon. The entD gene was also shown to be activated by the staphylococcal regulatory element known as agr.

Antibacterial activity and beta-lactamase stability of MDL 19,592, an oral cephalosporin

We compared the in vitro activity and beta-lactamase stability of MDL 19,592, an orally absorbed cephalosporin, with that of cephalexin and cefaclor. It inhabited Staphylococcus aureus at less than or equal to 4 micrograms/ml, Streptococcus pyogenes at 0.25 microgram/ml, sero groups B, C and G streptococci at 1 microgram/ml, and Streptococcus pneumoniae at 2 micrograms/ml. It was slightly more active than cefaclor and cephalexin. MDL 19,592 did not significantly inhibit Enterobacteriaceae, enterococci, Listeria monocytogenes, Pseudomonas aeruginosa, and Acinetobacter spp. strains (MIC greater than or equal to 32 micrograms/ml). MDL 19,592 was not hydrolyzed by the plasmid beta-lactamases TEM-1 and SHV-1 of Klebsiella but was hydrolyzed by the TEM-3, Staphylococcus aureus beta-lactamase, and the chromosomal-mediated Enterobacter cloacae P99 enzymes.

Overview of mechanisms of bacterial resistance

Many antimicrobial agents have been either found in nature or synthesized in the past 45 years. Antibacterial agents inhibit cell-wall formation, disrupt cytoplasmic membrane function, prevent DNA synthesis, interfere with protein synthesis, and halt folate synthesis. Resistance to antibiotics is a result of three major mechanisms: prevention of the antibacterial agent from reaching its receptor site, production of altered targets, and destruction or modification of the agents. Bacterial resistance has occurred due to chromosomal changes or the presence of plasmids and transposons. Resistance to beta-lactams is the result of beta-lactamases and the production of altered penicillin-binding proteins as well as altered cell-wall permeability. Important examples of these resistance forms occur in staphylococci and pneumococci which have altered penicillin-binding proteins. A new form of target change has been the production of proteins in enterococci that inhibit the activity of glycopeptides. Beta-lactamases are present in both Gram-positive and Gram-negative species; recently, new plasmid beta-lactamases have been isolated that destroy iminomethoxy and iminocarboxy cephalosporins. Resistance to aminoglycosides is due to enzymes that acetylate, adenylate, or phosphorylate aminoglycosides that inhibit binding to ribosomes and thus cause the poor uptake of drug. Tetracycline resistance is due to plasmids which cause efflux of the agent from the cytoplasm. Macrolide and lincinoid resistance is the result of an altered 23S ribosomal component of the 50S ribosomes. Sulfonamide and trimethoprim resistance is due to production of altered synthetase and reductase enzymes essential in the synthesis of folate. Resistance to new fluoroquinolones is due both to altered DNA gyrase and to cell-wall changes that prevent entry of the compound. Although resistance has been a major problem, the production of molecularly modified compounds and beta-lactamase inhibitors and the development of newer drugs have provided agents for treating highly resistant bacteria.