b Amdinocillin (mecillinam) is a -lactam antibiotic that is used mainly for the treatment of uncomplicated urinary tract infections. The objectives of this study were to identify mutations that confer amdinocillin resistance on laboratory-isolated mutants and clinical isolates of Escherichia coli and to determine why amdinocillin resistance remains rare clinically even though resistance is easily selected in the laboratory. Under laboratory selection, frequencies of mutation to amdinocillin resistance varied from 8 ؋ 10 ؊8 to 2 ؋ 10 ؊5 per cell, depending on the concentration of amdinocillin used during selection. Several genes have been demonstrated to give amdinocillin resistance, but here eight novel genes previously unknown to be involved in amdinocillin resistance were identified. These genes encode functions involved in the respiratory chain, the ribosome, cysteine biosynthesis, tRNA synthesis, and pyrophosphate metabolism. The clinical isolates exhibited significantly greater fitness than the laboratory-isolated mutants and a different mutation spectrum. The cysB gene was mutated (inactivated) in all of the clinical isolates, in contrast to the laboratory-isolated mutants, where mainly other types of more costly mutations were found. Our results suggest that the frequency of mutation to amdinocillin resistance is high because of the large mutational target (at least 38 genes). However, the majority of these resistant mutants have a low growth rate, reducing the probability that they are stably maintained in the bladder. Inactivation of the cysB gene and a resulting loss of cysteine biosynthesis are the major mechanism of amdinocillin resistance in clinical isolates of E. coli.
Because of the rapid increase in antibiotic resistance, several first-line antibiotics have been rendered less suitable for empirical treatment. For example, in Sweden, the increasing resistance to trimethoprim has led to a shift in the empirical therapy of uncomplicated urinary tract infections (UTIs), with nitrofurantoin and pivmecillinam now being suggested as first-line therapy (1). It is also recommended as a first-line UTI treatment by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases (2). Amdinocillin (Amd; also known as mecillinam) is an extended-spectrum penicillin derivative, a 6-amidinopenicillanic acid developed in the 1970s (3, 4). It has been widely used in the Scandinavian countries for UTI treatment since the early 1980s (5, 6). A large proportion of the drug is excreted unchanged in the urine (1, 7), leading to high concentrations in urine and a limited effect on the commensal flora (1,8,9). Amd binds to and inhibits the transpeptidase activity of penicillin-binding protein 2 (PBP2) (10-13). PBP2 is responsible for the elongation of rod-shaped cells, and cells treated with Amd become enlarged, nondividing spheres that ultimately lyse (11,14).Resistance development has remained low in countries where it is used (15-17). This finding is seemingly a paradox, ...