Do antiseptics and disinfectants select for antibiotic resistance?
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Biomedical subjects
Publications and source records attributed to A D Russell.
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Antiseptics and disinfectants are extensively used in hospitals and other health care settings for a variety of topical and hard-surface applications. A wide variety of active chemical agents (biocides) are found in these products, many of which have been used for hundreds of years, including alcohols, phenols, iodine, and chlorine. Most of these active agents demonstrate broad-spectrum antimicrobial activity; however, little is known about the mode of action of these agents in comparison to antibiotics. This review considers what is known about the mode of action and spectrum of activity of antiseptics and disinfectants. The widespread use of these products has prompted some speculation on the development of microbial resistance, in particular whether antibiotic resistance is induced by antiseptics or disinfectants. Known mechanisms of microbial resistance (both intrinsic and acquired) to biocides are reviewed, with emphasis on the clinical implications of these reports.
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Stages in the encystment and excystment processes of Acanthamoeba castellanii have been studied. The kinetics of encystment involved measurements of the three phases (pre-encystment, cyst initiation and cyst wall synthesis). Excystment, starting from a mature cyst, involved pre-emergence, penetration outwards of the cyst wall and free trophozoite. The sensitivity to biocides of trophozoites in the exponential growth phase, pre-encystment trophozoites, mature cysts and pre-excystment cysts has been investigated. Some differences in relative sensitivity to a bisbiguanide (chlorhexidine) and a polymeric biguanide (polyhexamethylene biguanide) were observed, but mature cysts were always the most resistant cellular form.
Trophozoites and cysts of Acanthamoeba castellanii were exposed to chlorhexidine diacetate (CHA) and polyhexamethylene biguanide (PHMB); changes in cell ultrastructure and surface structure were examined by both transmission and scanning electron microscopy. PHMB caused a greater degree of structural and membrane damage; the cytoplasmic contents were severely depleted and there were clusters of densely stained precipitates on the cell surface. Concentrations of CHA greater than 100 microg ml(-1) produced shrinkage from the cyst wall. At high concentrations, PHMB induced a slight withdrawal of the cytoplasm from the wall and, unlike CHA, induced swelling of the cysts. These findings do not define the mechanisms of action of CHA and PHMB, but provide evidence that a major target site for both agents is the plasma membrane. However, additional intracellular damage undoubtedly contributes to the lethal effects. The greater resistance of cysts may be associated with reduced biguanide uptake.
The Malthus-AT system provided a satisfactory method for examining the effects of permeabilizing agents on the activity of sub-inhibitory concentrations of antibacterial agents against Pseudomonas aeruginosa G48. Under this system, disodium edetate potentiated the activity of chlorhexidine diacetate (CHA), cetylpyridinium chloride, para-chlorometaxylenol and triclosan. Nitrilotriacetic acid enhanced the activity of some of the antibacterials tested, whereas sodium polyphosphate markedly reduced the efficacy of CHA.
A simple Pseudomonas aeruginosa G48 biofilm on stainless steel discs provided a useful primary screen of potentiating effects of various permeabilizing agents on antibacterial agents. Experiments with Ps. aeruginosa suspensions could not be used to predict the effects of biocides and permeabilizers on biofilms. Although antibacterial activity against biofilms was less than demonstrated in suspension tests, potentiation by some permeabilizers was still observed.
The presence of divalent (Mg2+) ions greatly reduced the lysis of Pseudomonas aeruginosa strain G48 in a system at pH 7.8 or 9.0 consisting of ethylenediamine tetraacetic acid (EDTA), lysozyme and tris. Similar reductions in lysis occurred when EDTA was replaced by nitrilotriacetic acid, sodium citrate or sodium polyphosphate. The effect depended on the cation concentration. Mg2+ may replace cations removed from the outer membrane, or may effectively remove the permeabilizer from the system. The results suggest that the permeabilizing activity associated with these agents against this organism has a common basis in affecting the outer membrane.
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Plasmid-encoded bacterial resistance to antibiotics and to anions and cation (including important mercurial and silver compounds) has been widely studied. Plasmid-mediated resistance to organic cationic agents which are important biocides has been described for chlorhexidine and quaternary ammonium compounds (and also for the less important acridine, diamidines and ethidium bromide) in antibiotic-resistant Staphylococcus aureus and Staph. epidermidis strains. Plasmids may also encode reduced biocide susceptibility of Gram-negative bacteria, but intrinsic resistance is likely to be of greater significance. Antibiotic resistance and biocide resistance may be linked but this is not always found clinically.
Microbiologically it was demonstrated that amino acids, e.g. cysteine (CySH), and other compounds, e.g. sodium thioglycollate, containing thiol groups neutralized the activity of silver nitrate against Pseudomonas aeruginosa PAO1. Amino acids with disulphide bonds were inactive, with the exception of L-cystine dimethyl ester, as were all amino acids with no sulphur groups. Iodoacetamide reacted with CySH to produce a CyS-acetamide complex that was unable to quench the activity of Ag+. Chemical analyses using cyclic voltammetry demonstrated that high coordination numbers (3.1) were obtained with thiol-containing amino acids and low numbers (0.28-0.4) with other amino acids. Both microbiologically and chemically, the results imply that interaction of Ag+ with thiol groups plays an essential role in bacterial inactivation.
The lethal effects of various biocides, in particular two agents (chlorhexidine diacetate and polyhexamethylene biguanide) on cysts and trophozoites of Acanthamoeba castellanii have been measured by both plaque assay and flow cytometry (FCM). Minimum amoebicidal concentrations against trophozoites were generally the same by the two methods whereas minimum cysticidal concentrations were occasionally higher by FCM. Concentrations of biguanides required to produce an equal reduction in viability were also higher by FCM than by plaque assay.
A non-radioactive method was used to investigate the uptake by Acanthamoeba castellanii of chlorhexidine diacetate (CHA) and polyhexamethylene biguanide (PHMD). Based on the Giles et al. (1974) hypothesis, the uptake of CHA by trophozoites appeared to be of the L3 pattern whereas that of cysts was C2. Unlike CHA, trophozoites took up PHMB with an L2 pattern at low concentrations followed by a C-type pattern at higher concentrations, the uptake by cysts was found to be of the C2 pattern with a plateau effect at high concentrations. A diphasic leakage effect was found in trophozoites whereas a relatively low peak of maximal leakage occurred from cysts treated with high biocide concentrations. The amount of pentose release depended on the formulation ingredients. No correlation between pentose leakage and trophozoicidal or cysticidal activity was found.
Variable germination and outgrowth occurred when Bacillus subtilis NCTC 8236 spores were inoculated into nutrient broth prepared with distilled water. More reproducible findings were achieved when the medium was prepared with Elgastat water and the greatest reproducibility occurred with Elgastat water as vehicle combined with a rigorous acid-washing of all glassware. This combined procedure also produced optimum and reproducible results for the synchronous growth of two B. subtilis 168 strains in casein medium supplemented with appropriate amino acids, a technique of value in monitoring the development of resistance to antibacterial agents during sporulation. The levels of aluminium in distilled water were higher than those of other elements; however, the incorporation of aluminium sulphate into broth prepared with Elgastat water had no effect on germination, and outgrowth was reduced (but not eliminated) only at high concentrations of this salt.
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The mechanism of action of biocides against viruses has not been widely studied, although two main targets are viral proteins (capsids, enzymes) and the viral genome. This study was undertaken in order to investigate the efficacy of several disinfectants against the nucleic acid of the Pseudomonas aeruginosa PAO bacteriophage F116. Of all the biocides tested, only peracetic acid affected significantly the phage genome. However, it is not clear whether the nucleic acid was damaged inside the phage capsid or when released into the surrounding medium.