MICROBIAL DRUG RESISTANCE

Volume 25, Number 6, 2019

ª Mary Ann Liebert, Inc.
DOI: 10.1089/mdr.2018.0319

Multidrug-Resistant Bacteria
and Alternative Methods to Control Them:
An Overview

Roberto Vivas,1 Ana Andréa Teixeira Barbosa,1 Silvio Santana Dolabela,1 and Sona Jain1,2

Antibiotic resistance is one of the greatest challenges in the health system nowadays, representing a serious
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problem for public health. Initially, antibiotic-resistant strains were restricted to the hospital environment, but
now they can be found everywhere. Globalization, excessive use of antibiotics in animal husbandry and
aquaculture, use of multiple broad-spectrum agents, and lack of good antimicrobial stewardship can be listed as
the factors most responsible for the spread of antibiotic resistance. The increase in the prevalence of antibiotic-
resistant pathogens implies having fewer antimicrobial agents to treat infections. The estimate is that by 2050,
there will be no effective antibiotic available, if no new drug is developed or discovered. This raises the need to
search for alternative methods of controlling antibiotic-resistant pathogens. Considering this problem, the
objective of this review is to outline the most frequent antibiotic-resistant bacteria and describe the advanta-
geous and limitations of alternative methods that have been proposed to control them.

Keywords: MRSA, VRE, antibiotic resistance, alternative therapies, bacteriocins, phage therapy

Introduction The increase in the prevalence of antibiotic-resistant

O ne of the greatest challenges in the health system
nowadays is the rise of pathogenic species resistant to
antibiotics. Infections caused by multidrug-resistant (MDR)
bacteria are increasingly common and represent a serious
problem for public health. Initially, these species were re-
stricted to the hospital environment, but now they can be
found everywhere. Among the gram-positive species, Sta-
phylococcus aureus, Enterococcus faecium, Enterococcus
faecalis, and Streptococcus pneumoniae are the most frequent
problem.1 Among the gram-negative strains, Escherichia coli,
Klebsiella pneumoniae, Pseudomonas aeruginosa, and Aci-
netobacter baumannii have been most common.2,3
Antimicrobial resistance in these strains is genetically
determined and most commonly mediated by the acquisition
of extra-chromosomal genetic elements via horizontal gene
transfer.4 Low permeability of the outer membrane in gram-
negative bacteria, efflux pumps, production of degrading
enzymes, and modification of targets are examples of
mechanisms used by bacteria to resist the toxicity of anti-
biotics. Globalization, excessive use of antibiotics in animal
husbandry and aquaculture, use of multiple broad-spectrum
agents, and lack of good antimicrobial stewardship can be
listed as the factors most responsible for the spread of an-
tibiotic resistance species.2
pathogens implies having fewer antimicrobial agents to treat
infections caused by these bacteria.5 The estimate is that by
2050, there will be no effective antibiotic available to treat
infections if no new drug is developed or discovered.6 This
raises the need to search for alternative methods of con-
trolling antibiotic-resistant pathogens, and there are in fact
many research groups around the world actively looking for
new solutions. The objective of this review is to list the most
frequent antibiotic-resistant bacteria and describe alternative
methods that have been proposed to control them.
Common Antibiotic-Resistant Bacterial Species
Health care-associated infections raise morbidity and
mortality rates worldwide. The increase in mortality is di-
rectly related to antimicrobial resistance which makes
antibiotic therapy more restrictive, thus also making it dif-
ficult to treat infections caused by multiresistant microor-
ganisms. At the beginning of the 21st century, infections
with carbapenem-resistant gram-negative bacilli, mainly
Enterobacteria, became a big public health problem.7 MDR
gram-negative bacteria including A. baumannii, Pseudomonas
aerugionosa, extended-spectrum beta-lactamase (ESBL)-
producing Enterobacteria, and carbapenem-resistant En-
terobacteria (CRE) are considered the main causative agents

1
Programa de Pós-Graduação em Biologia Parasitária, Universidade Federal de Sergipe, São Cristóvão, Sergipe, Brasil.
2
Programa de Pós-Graduação em Biotecnologia Industrial, Universidade Tiradentes, Aracaju, Sergipe, Brasil.

890
 ANTIBIOTIC RESISTANCE AND ALTERNATIVE METHODS 891

of nosocomial infections.8 Methicillin-resistant S. aureus as evidenced by current scenarios, methicillin-resistant

(MRSA) and vancomycin-resistant Enterococcus (VRE)
have been reported recently to be the most common bacterial
pathogens, and besides, hospitals have also been isolated
from foods of animal origins, water, and animals (Tables 1
and 2). MDR P. aeruginosa, Carbapenem-resistant En-
terobacteriaceae, and A. baumannii have been mainly asso-
ciated with clinical samples, but some strains have also been
isolated from foods, animals, and water (Tables 3–5).
All these strains have been associated with lethal infec-
tions, and in this section, their main characteristics will be
addressed.
Methicillin-resistant S. aureus
S. aureus is a gram-positive ubiquitous strain known to
produce several virulence factors that facilitate disease
causation and help rapidly develop antimicrobial resistance
against antimicrobial agents used for its control, a feature
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strains arose quickly.4
Since its emergence in 1961, MRSA has spread world-
wide, and infections caused by this microorganism are re-
garded as one of three major infectious diseases threatening
human health. This bacterium apart from causing infections
in cutaneous lesions can result in severe cases of pneumo-
nia, meningitis, endocarditis, septicemia, and even systemic
infections, with risk of death.10 Compared to infections
caused by S. aureus strains sensitive to methicillin, those
caused by MRSA usually have more severe clinical mani-
festations and are the most difficult to treat, as methicillin
resistance indirectly affects other virulence factors and en-
hances the pathogenesis of the bacterium.11
According to the data published by the Center for Disease
Control and Prevention (CDC) of the United States, more
than 80,000 illnesses and 11,000 deaths in the hospital set-
ting were caused by MRSA during 2011.12 The European
Centre for Disease Prevention and Control also published in

that increases the importance of this microorganism as a
pathogen.9 Initially, infections caused by S. aureus were
easily controlled by penicillin. However, S. aureus acquired
a plasmid-encoded beta-lactamase that conferred resistance
to penicillin already in the 1940s, shortly after its intro-
duction for clinical use. To solve this problem, a new,
semisynthetic, narrow spectrum, beta-lactamase-resistant
antibiotic named methicillin was developed and introduced
to combat penicillin-resistant strains in 1959. Unfortunately,
2013 that S. aureus is among the most frequently isolated
pathogen from health care-associated infections. Togneri
et al.10 made a retrospective review for 12 years (2002–
2013) of infections caused by S. aureus in adult patients
(AP) and in pediatric patients (PP) visiting the Hospital
Interzonal General of Treble Evita de Lanús in Argentina
and concluded that methicillin resistance increased from
28% to 78% in AP and stayed around 50% in PP. Chmie-
larczyk et al.13 isolated MRSA strains from patients in 12

Table 1. Methicillin-Resistant Staphylococcus aureus Isolated from Different Sources

and Countries in the World
Frequencya
Source Type Period/year (%) Country Refs.
149
Children and adult patients with skin and soft-tissue CA-MRSA 2009/2011 2.6 China
infections
150
Emergency departments CA-MRSA 2006/2007 2.4 USA
51
Hospital patients CA-MRSA 2011/2012 — Malaysia
HA-MRSA
152
Nasal swabs HA-MRSA — 15.1 Oman
Cell phone swabs HA-MRSA 9.0
153
Pork processing plant LA-MRSA 2010/2011 24.8 Canada
154
Hospital patients HA-MRSA 2010 — Brazil
CA-MRSA
155
Railway stations CA-MRSA 2013/2014 1.58 China
13
Infections from hospitalized patients HA-MRSA 2013 15.1 Poland
CA-MRSA
156
Chicken meat — 2013 6.0 Egypt
157
Milk — — 34 Pakistan
158
Zoo animals LA-MRSA 2013/2016 — United
Kingdom
159
Dairy sheep — 2012 0.7 Italy
160
Pus and blood samples from hospitalized patients HA-MRSA 2009/2012 — Zambia
161
Nasal secretion of healthy children CA-MRSA 2012 15.7 Brazil
162
Nasal secretion of healthy carrier individuals — 2010/2011 1.3 Spain
163
Raw meat products — 2012 1.2 USA
164
Pigs — 2016 99 Portugal
165
Blood samples at a Japanese University Hospital HA-MRSA 2012/2015 — Japan
CA-MRSA
a
AmongStaphylococcus aureus strains.
—, Not reported; MRSA, methicillin-resistant S. aureus; CA-MRSA, community-associated MRSA; LA-MRSA, livestock-associated
MRSA.
 892 VIVAS ET AL.

Table 2. Vancomicin-Resistant Enterococcus Isolated from Different Sources

and Countries in the World
Source Period/year Frequencya (%) Country Refs.
166
Wild animals 2014–2015 — Spain
167
Sewage — — Israel
168
Meat preprarations — 23.8 Spain
169
Wastewater effluent and surface water used for 2014 — Netherlands
drinking water production
170
Poultry infections 2011–2014 — Poland
171
Rectal cultures from inpatients 2012–2013 16.3 Taiwan
172
Reclaimed water used for spray irrigation 2009–2010 0.1–42.6 USA
173
Clinical samples 2009–2010 7.9 India
174
Clinical samples 2010–2012 — Brazil
175
Clinical samples of urine, blood, wound swabs and 2014 7 Ethiopia
other body fluids
176
Laundry facility that processes clinical linens 2015 53% in the dirty area and 8% in USA
the clean area.
177
Clinical samples 2015 — Iran
178
Patient with bacteraemia — — Greece
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a
Among Enterococcus strains.

different hospitals in southern Poland and the prevalence of
MRSA was higher in patients aged 80 years and more.
These results are just a few examples that show how com-
mon and persistent MRSA strains are worldwide.
Initially, MRSA was restricted to hospital environment
(HA-MRSA: health care-associated MRSA), but rapidly,
since the 1990s, this microorganism has also been found
associated with community settings (community associated
MRSA [CA-MRSA]) and has been isolated from the most
diverse sources worldwide (Table 1). Apart from HA-MRSA
and CA-MRSA, livestock-associated MRSA (LA-MRSA)
have been isolated from several animals such as cattle, pork,
chicken, and horse, among others and associated with zoo-
notic pneumonia, endocarditis, and necrotizing fasciitis since
1975.10,14 The fact that MRSA has been frequently isolated
from livestock animals has been worrying, as it has revealed
an expanded reservoir of MRSA.15 Consequently, MRSA has
also been isolated from animal based food products, including
meat and milk products, such as cheese,16 making it also an
important food-borne microorganism.17
The first case of LA-MRSA from a human source was
described in 2005, and van Loo et al.18 observed that LA-
MRSA strains in human population were responsible for
>20% of all MRSA in the Netherlands. Since then, trans-
mission of MRSA from animals to humans and vice-versa
has been constantly described.19 These findings show that
some S. aureus strains might not be strongly host species-
specific, and LA-MRSA can cause infection in humans.20 It
is believed that some LA-MRSA lineages have derived from
human strains following genetic adaptation.
Molecular and microbiological studies have demonstrated
that HA-MRSA and CA-MRSA strains have distinct genetic

Table 3. Carbapenem-Resistant Enterobacteriaceae Isolated from Different Sources

and Countries in the World
Source Strains Period/year Country Refs.
179
Clinical samples Klebsiella oxytoca 2013–2014 Iran
180
Clinical samples from outpatients Escherichia coli 2013 Italy
Klebsiella pneumoniae
Proteus mirabilis
181
Clinical samples E. coli 2010–2014 China
K. pneumoniae
182
Clinical samples from inpatients K. pneumoniae 2014–2015 Vietnam
183
28 hospitals from Brazil E. coli Brazil
K. pneumoniae
Enterobacter spp.
184
Post-acute-care hospitals K. pneumoniae 2008–2013 Israel
185
Clinical samples K. pneumoniae 2010–2014 Poland
186
Bloodstream isolates at medical centers K. pneumoniae Enterobacter spp. 2013 USA
E. coli
187
Clinical samples from inpatients K. pneumoniae 2007–2014 England
188
Dairy cows E. coli China
189
Beef, pork, and chicken samples E. coli 2013–2014 United Kingdom
190
River water E. coli Algeria
K. pneumoniae
 ANTIBIOTIC RESISTANCE AND ALTERNATIVE METHODS 893

Table 4. Carbapenem-Resistant Acinetobacter baumannii Isolated from Different Sources

and Countries in the World
Source Period/year Frequencya (%) Country Refs.
191
Dairy cattle 2014 0.3 USA
192
Clinical samples 2008–2014 — French Guiana
193
Clinical samples from hospitalized patients 2015–2016 — Iran
194
Health institutions 2008–2013 — Brazil
195
Hospitals 2008–2010 — Colombia
196
Clinical samples 2012–2014 74 Vietnam
197
Inpatient units of a tertiary hospital 2014–2015 97.7 Nepal
198
Clinical samples 2012–2013 45 China
199
Companion animals 2002–2013 — Germany
200
Meat samples 2013–2014 — Portugal
201
Lettuce and fruit 2013–2014 — Portugal
a
Among A. baumannii strains.

and phenotypic profiles.21,22 HA-MRSA is considered an Vancomycin (VAM) and daptomycin (DAP) are often the
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opportunistic pathogen and CA-MRSA is capable of causing
infections in healthy people. Since its inception, CA-MRSA
has become the most significant pathogen in several parts of
the world and its prevalence has surpassed the cases ac-
quired in hospital.10 Moreover, CA-MRSA is also infiltrat-
ing health care settings and infecting patients in many
regions worldwide. There is little evidence of the spread of
HA-MRSA outside the hospital setting23 although a HA-
MRSA variant strain causing infections in the community
has been reported.24
As is well established by several authors, methicillin re-
sistance in S. aureus is mediated by a penicillin-binding
protein (PBP2A) encoded by the mecA gene, that is carried
on a mobile genetic element designated staphylococcal
cassette chromosome mec (SCCmec). Moreover, methicillin
resistance determinants are different among HA-MRSA and
CA-MRSA. HA-MRSA strains present a relatively large
mobile genetic element known as SCCmec types I, II, or III,
which confers resistance to many classes of non-beta-lactam
antibiotics. In CA-MRSA, a smaller element, including
SCCmec IV and V, confers resistance, and these strains are
susceptible to many non-beta-lactam antibiotics.21 In addi-
tion, a large numbers of CA-MRSA strains produce the
Panton Valentine Leukocidin, potent virulence factor that
has greater cytotoxic activity against polymorphonuclear
cells.25
antibiotics of last resort for many S. aureus infections.26
However, MRSA strains have shown a MDR phenotype,
and the most worrying problem is the appearance of strains
exhibiting resistance or reduced susceptibility to these an-
tibiotics. Three classes of vancomycin-resistant S. aureus
that differ in vancomycin susceptibilities have emerged:
vancomycin-intermediate S. aureus (VISA), heterogeneous
VISA (hVISA), and high-level vancomycin-resistant S. au-
reus (VRSA).27
VRSA species arose due to the acquisition of the vanA
gene from vancomycin-resistant enterococci and have been
reported in the United States,28 Iran,29 and India.30 The
isolation of VISA and hVISA seems to be a serious emerg-
ing problem as they show high spreading potential. After the
first reports of VISA and hVISA from Japan,31 it did not
take long for this resistance phenotype to be recognized
around the world.27 The in vivo development of VISA
and hVISA has led to treatment failures and prolonged
hospitalization.32
DAP is bactericidal against MRSA and VISA strains and
was used to treat skin/soft-tissue infections caused by
MRSA in 2003 in the United States.33 Syrogiannopoulos
et al.34 showed that DAP alone or in combination with other
antimicrobial agents was efficacious to control MRSA in-
fections in children. However, studies are showing that
clinical S. aureus strains have developed DAP resistance

Table 5. Multidrug-Resistant Pseudomonas aeruginosa Isolated from Different Sources

and Countries in the World
Source Period/year Frequencya (%) Country Refs.
202
Burn patients 2013–2014 38 Iran
203
Clinical samples 2011–2013 — France
204
Wastewater collections from a hospital 2012 — Brazil
205
Clincal samples 2011 21.3 Iraq
206
Hospital environment 2015 84.5 Ethiopia
207
Burn patients 2014–2015 48.38 Algeria
208
Cystic fibrosis — — Spain
209
Clinical samples from immunocompetent patients 2007–2013 34 Spain
210
Clinical samples 2014–2016 — India
211
Urine samples 2004–2015 — Hungary
212
Clinical samples — — Pakistan
a
Among P. aeruginosa strains.
 894 VIVAS ET AL.

during DAP treatment.35 These findings raise the need to a drug of choice for the treatment of infections caused by
research for alternative methods for the control of MRSA. ESBL producing enterobacteriaceae for years, which is also
one of the main factors responsible for the emergence of
Vancomycin-resistant Enterococcus CREs through selective pressure.44
Among the Enterobacteriacea, K. pneumoniae is the most
Enterococci are indigenous flora of the gastrointestinal
common bacterium exhibiting carbapenem resistance fol-
tracts of animals and humans, and the species E. faecium
lowed by Enterobacter species. Others such as E. coli have
and E. faecalis have heightened interest because of their
been reported less frequently. CREs have emerged in recent
ability to cause serious infections and their intrinsic resis-
decades, but have become one of the major concerns of
tance to antimicrobials, including Vancomycin.36 VRE
hospital infection control services. High prevalence of in-
faecium (VREfm) has disseminated rapidly in hospitals in
fections by these bacteria is present in several countries on
many parts of the world since 2012. In contrast, vancomycin
all continents, leading to an important restriction in treat-
resistance has been reported considerably less frequently in
ment options.45 It is considered endemic in the north-eastern
E. faecalis globally.37
United States (mainly in the state of New York), Puerto
VRE was first isolated in Europe in 1986 from clinical
Rico, Colombia, Greece, Italy, Israel, China, and Brazil, and
samples. One year later, the first VRE isolates were
is also an important cause of nosocomial infections in these
identified in the United States. In Europe, the cases were
countries.46
related to community infections, transmitted by animal-
Early reports of CREs were related to overexpression of
based food products to humans, and associated with the
ampC, and ESBL associated with loss or modifications of
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use of Avorpacina (an antimicrobial of the group of gly-

porins. However, later they were confirmed to produce a new
copeptides) as a growth promoter in livestock. In the
type of enzymes (carbapenemases) with the capacity to inac-
United States, the predominance of VRE was observed in
tivate any type of beta-lactam, including the carbapenems.47
hospital setting which spread rapidly in the 1990s, prob-
The first carbapenemase was identified more than 20
ably due to the use of vancomycin. A similar situation
years ago in 1982, in Enterobacter cloacae, at a hospital in
occurred in Europe, where the spread of hospital-related
London, England.48 Subsequently, Serratia marcescens en-
VRE occurred a decade later in the 2000.38 VRE has been
zymes (SME) were described in S. marcescens.49 In 1995, in
an emerging problem in some Brazilian hospitals since the
Japan, blaIMP-1 gene was described in a plasmid in Ser-
1990s. The first report of a VRE infection in Brazil oc-
ratia. In 2001, in the United States, first blaKPC-1 gene was
curred in 1996 in Curitiba. Since 1997, the occurrence of
identified in K. Pneumonia.50 Since then, the number of new
outbreaks has been documented in hospitals from other
carbapenemases have increased and proliferated around the
Brazilian cities as well.39
world, generating one of the major therapeutic and epide-
VRE was described as ‘‘serious’’ (the second highest
miological concerns.51
threat level among organisms causing severe human infec-
According to the classification proposed by Ambler, the
tions) by CDC. Among hospitalized patients, over 20,000
betalactamases are divided into four groups (A–D) with
experience an infection due to VRE each year and it is
respect to their functional and molecular properties. Groups
estimated that 1,300 deaths occur directly due to these re-
A, C, and D are serine enzymes, whereas group B are me-
sistant infections in the United States.12 VRE is a common
talloenzymes. Carbapenemases belong mainly to three ma-
cause of nosocomial infections and has also associated with
jor groups of betalactamases A, B, and D, with differences
urinary tract infections, hospital-acquired bloodstream in-
not only in their genetic and biochemical properties but also
fections, endocarditis, abdominal and pelvic abscesses, and
in their clinical characteristics due to difference in their
chronic periodontitis.40
antimicrobial resistance and epidemiological features.52
Resistance to vancomycin is determined by one of nine
Carbapenemases represent the most versatile enzymes in
resistance determinants (vanA, B, C, D, E, G, L, M, and N),
the beta-lactamase family. The group of carbapenemases
but the vanA and vanB genotypes predominate worldwide.
class A includes members of families SME, IMI (Imipene-
These genetic determinants could be carried in the mobile
mase), NMC (Non Metalobetalactamase), GES (extended
genetic element, such as Tn1546, mostly located on con-
spectrum Guyana betalactamase), and K. pneumoniae Car-
jugative plasmids (variants of the vanA and vanB-type) or
bapenemase (KPC). Of these, KPCs are the most predomi-
located on the chromosome (vanC).41 The first case of VRE
nant, found mainly on plasmids in K. Pneumonia.47,49 Since
transmitting the vanA gene to MRSA (VRSA) was reported
its initial recognition, KPC has been also detected in many
in the United States in 2002, increasing the threat of in-
other strains, including Klebsiella oxytoca, Enterobacter
creased colonization and infections by VRE.42
spp., E. coli, Salmonella spp., Serratia spp., Citrobacter
Linezolid is the first-line drug for treatment of VRE in-
freundii, Proteus mirabilis, A. baumannii, P. aeruginosa,
fections, but the first reports of Linezolide-resistant VRE
and Pseudomonas putida.49
have appeared, reducing treatment options.38 Some authors
Class D carbapenemases, known as oxacillinases (OXA),
have also suggested daptomycin as an effective agent in the
consist of OXA derivatives, a family detected in A. bau-
treatment of VRE infections.43
mannii, but already also described in enterobacteria. These
beta-lactamases exhibit activity against carbapenems but do
Carbapenem-resistant enterobacteria
not degrade cephalosporins.47
The emergence of CRE is one of the major public health The metalobetalactamases belong to the families IMP,
problems in the world. Carbapenems are important for the VIM, SPM, GIM, and SIM and were detected mainly in
empirical treatment of critically ill patients at the risk of P. aeruginosa. One of the major threats among this carba-
multiresistant bacterial infection.44 They have been used as penemase group is New Delhi Metalobetalactamase (NDM),
 ANTIBIOTIC RESISTANCE AND ALTERNATIVE METHODS 895

which was discovered in 2008 in Sweden in K. pneumoniae
from an Indian patient. NDM has been found to exhibit a
rapid distribution in hospitalized patients throughout the
world in other enterobacterias as well.53
CREs are spread across several countries and have
emerged as a major threat to hospitalized patients. In the
case of infections caused by K. pneumoniae-producing
carbapenemases, the mortality rate may be as high as 75%,
but the associated factors such as age, comorbidities, func-
tional status, and underlying disease may influence this
rate.54
Carbapenem-resistant A. baumannii
The genus Acinetobacter consists of gram-negative, aer-
obic cocobacillus that are ubiquitous, immobile, non-
fermenting, catalase positive, and oxidase negative. The A.
calcoaceticus-A. baumannii complex is responsible for most
of the community or hospital-acquired infections.55
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lactam antibiotics. Betalactamases are the most impor-
tant cause of bacterial resistance, mainly in gram-negative
bacilli.61
Resistance to carbapenems may occur by combining
different mechanisms such as change in the affinity to PBPs
and efflux pumps. However, the main forms of resistance
to carbapenems are the expression of carbapenemases of
group B and D of Ambler, metallo-b-lactamases, and OXA,
respectively.61
Multidrug-resistant Pseudomonas
P. aeruginosa is a nonfermenting gram-negative bacillus,
widely distributed in nature and in hospital environment.
Responsible for nosocomial infections, it is one of the most
important opportunistic pathogen causing bloodstream in-
fection, urinary tract infection, and ventilator-associated
pneumonia, especially in critically ill patients receiving in-
tensive care.62 Moreover, it is also highly resistant to many

currently used drugs making it a major public health con-

The different species of Acinetobacter present in diverse
cern.63
natural habitats can be isolated from the soil, water, vege-
P. aeruginosa is intrinsically resistant to several antimi-
tables, and animal and human hosts. They are part of the
crobials and has great versatility to acquire new genes that
commensal flora of human skin and mucous membranes. A.
confer resistance to many other drugs. The antibiotic resis-
baumannii can survive in a variety of settings in the hospital
tance of this bacterium is mainly due to the low cell wall
environment: in dialysis machines, mechanical ventilation
permeability of this microorganism, which restricts the up-
systems, water sources, skin and mucous membranes of
take of antibiotics, associated with wide resistance mecha-
health professionals and patients, medicinal preparations,
nisms, such as efflux pumps and enzymes, which modify or
and disinfectants.56
degrade antibiotics and drug targets.64
For a long time Acinetobacter was considered an oppor-
Carbapenems are usually part of the first line of
tunistic agent with low pathogenicity. However, the pres-
therapeutic choice for treatment of Multdrug-resistant
ence of several virulence factors that allow its survival in the
Pseudomonas (MDR) P. aeruginosa infections. Resistance
hospital environment and enhance its capacity to cause
to carbapenems occurs mainly due to the impermeability
disease have resulted in it being one of the main causes of
to the drug, loss of porin, and action of efflux pumps, but
nosocomial infections in many countries.57 Recently, the
the production carbapenemases is the most important
World Health Organization announced this microorganism
mechanism.65
as the first priority pathogen, for which research and de-
The main carbapenemases expressed by P. aeruginosa are
velopment for new antibiotics are urgently needed.58
from class B of Ambler, called metallo-ß-lactamases (IMP,
A. baumannii is increasingly implicated for causing
VIM, SPM, GIM, NDM, and SIM families). These enzymes
health-associated infections, which confer a high risk of
confer resistance to carbapenems and are encoded in plas-
morbidity and mortality to patients. This bacterium can also
mids and integrons of class 1, which are responsible for their
be highly resistant to antimicrobials, especially those iso-
rapid global spread by horizontal transfer.66
lated from the patients in the intensive care units. Infections
P. aeruginosa resistant to carbapenems (PARC) has be-
caused by MDR A. baumannii strains may worsen patient
come one of the major problems for hospitals. Outbreaks of
outcomes due to inadequate initial therapy, limited treat-
infection caused by PARC have been reported by several
ment options, and high toxicity of available therapies. Risk
countries, including Brazil.66 The emergence of antimicro-
factors for infection and colonization by MDR A. baumannii
bial resistance is directly related to an increase in the pa-
include prolonged hospitalization especially in intensive
tient’s hospital stay, increased hospitalization costs, and an
care unit, mechanical ventilation, central venous catheteri-
increase in the mortality rate. In PARC infections, mortality
zation, urinary catheterization, previous antimicrobial ex-
may reach 53.6%.67
posure, increased disease severity, and exposure to surgical
and invasive procedures.59 In the United States, A. bau-
Alternative Methods Proposed for the Control
mannii is responsible for 12,000 cases of health-associated
of Multiresistant Pathogens: Advantages
infections annually, of which 7,200 are multiresistant
and Limitations
causing 500 deaths per year.60
This microorganism has progressively accumulated re- With the emergence of MDR pathogens, alternative
sistance to penicillins, cephalosporins, quinolones, and methods for their control have been studied by several re-
aminoglycosides. Consequently, carbapenems have become search groups. Among these, the use of bacteriocins, es-
the therapy of choice for serious infections. The mecha- sential oils (EOs), antibodies, and phage therapy have been
nisms of resistance of A. baumannii can be intrinsic or ac- reported as promising by several authors. In addition, re-
quired and are mediated by several factors, such as loss of search has also been focused on the use of quorum-sensing
membrane permeability and, more significantly, the pro- inhibitors (QSI) and nanotherapy (Fig. 1). Bacteriocins have
duction of betalactamases, enzymes that degrade beta- been proposed since the 1960s, and antibodies and
 896
FIG. 1. Published articles to date on the
use of alternative methods in the control of
multidrug-resistant pathogens. Source:
PubMed.
bacteriophages have been present since 1970’s. EOs have
been studied and proposed to control MDR pathogens since
1990, and more recently (since the year 2000), quorum
sensing inhibitors and nanotherapy have also gained status
as a promising method for the control of these resistant
strains. A brief review about these alternative methods will
be made in the next subsections addressing their importance
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and limitations.
Bacteriocins
Bacteriocins are antimicrobial peptides ribosomally syn-
thesized by almost all bacterial species and have a varied
mechanism of action and spectrum of activity. A good re-
view on bacteriocin structure, classification, and general
characteristics can be found in Snyder and Worobo.68 The
most studied bacteriocins with known industrial applications
are those produced by lactic acid bacteria, mainly due to
their generally recognized as safe (GRAS) status. Since their
discovery, these bacteriocins have been extensively studied
for their application in food industry and, more recently,
their therapeutic potential has been reported by several au-
thors. Bacteriocins have been proposed as potential anti-
cancer69 and anticarcinogenic agent70 and also suggested for
the treatment of skin infections71 and many other diseases.72
Besides, some authors suggest that bacteriocins may be-
come a potential candidate for replacing antibiotics to treat
MDR pathogens in the future.73 Okuda et al.74 tested the
effect of three different bacteriocins against MRSA biofilms
and showed that the bacteriocins formed stable pores on the
membrane of target cells and were effective to prevent or
cure biofilm-associated infections. Duracin 61A was found
to be effective against Clostridium difficile, VRE, and
MRSA, showing synergistic effect when used in combina-
tion with reuterin or vancomycin. The authors concluded
that durancin 61A alone or in combination with other bac-
teriocins or antibiotics may provide a possible therapeutic
option for the treatment of infections by these pathogens.75
Shokri et al.76 showed the potential use of a bacteriocin
produced by an E. faecium strain against VRE. Phumi-
santiphong et al.77 isolated and characterized a novel bac-
teriocin produced by a strain of Enterococcus faecalis that
showed high antibacterial activity against VRE and MDRE
(MDR enterococci). The lantibiotic NAI-107 also showed
bactericidal activity against MRSA and VRE in animal
models.78 Lacticin 3,147 and nisin were tested against
MRSA and VRE strains and also showed potent activity.79
Wang et al.80 tested the efficacy of sublancin for the pre-
vention of MRSA-related intraperitoneal infection in mice
and verified that the antimicrobial activity involved the de-
VIVAS ET AL.
struction of the bacterial cell wall and considerably reduced
the mortality and weight loss of MRSA-challenged mice.
Many properties of bacteriocins, such as high stability,
low toxicity, and both broad and narrow spectra of activity,
make them good alternative to antibiotics.81 In addition,
some bacteriocins, such as lantibiotics, have a dual mech-
anism of action not shared by other therapeutic compounds
in use, which reduces the probability of selecting resistant
strains.82 Unlike most antibiotics, which are secondary
metabolites, bacteriocins are ribosomally synthesized,
which allows bioengineering to improve its efficiency.
Bacteriocins are also sensitive to proteases in the human
stomach, not posing any risk of toxicity to the humans or to
gut flora.73
Among the lantibiotics, nisin is the most studied bacte-
riocin that has a GRAS status and has been approved by
Food and Drug Administration (FDA) as food additive since
1988.83 In the last decades, nisin has also been proposed for
therapeutic usage.84 Studies have shown that nisin can
prevent the growth of drug-resistant bacterial strains, such as
MRSA, S. pneumoniae, Enterococci, and C. difficile. It is
well known that bacteriocins have antimicrobial activities
mainly against gram-positive strains. However, many stud-
ies have demonstrated that nisin in combination with other
antibiotics can also be effective against gram-negative
pathogens.85
As described above, bacteriocins have the potential to
control antibiotic-resistant pathogens and are among the best
alternative methods proposed for this purpose. However,
certain points need to be carefully studied before their
clinical use: the first being the bacteriocin resistance in vitro.
Resistance to bacteriocin in vitro has been mostly associated
with physiological adaptation, unlike antibiotic resistance
that is related to genetic modification.86 Considering that
bacteriocins have not yet been used on the same scale as
antibiotics, an existing bacteriocin-resistant population does
not exist. Thus, before the therapeutic use of bacteriocins, it
would be interesting to develop strategies to avoid in the
future the current problem with resistance to traditional
antibiotics. The best way to use bacteriocins therapeutically
could be in combination with traditional antibiotics.
The second challenge involves development of a better
way to administer bacteriocin therapeutically, since en-
zymes present in the gastrointestinal tract inactivate them.
Topical, intranasal or intravenous use may be an alternative.
Some preliminary studies87 showed that nisin administered
intranasally inhibited the growth of S. aureus in the respi-
ratory tract of immunocompromised rats. Heunis et al.71
also demonstrated that nisin-containing nanofiber in wound
dressings has the potential to treat S. aureus skin infections.
 ANTIBIOTIC RESISTANCE AND ALTERNATIVE METHODS
Nanoparticles (NPs) could also be used as delivery system
for bacteriocins.88
Essential oils
Another alternative tool that has been frequently dis-
cussed by several authors as a solution to control MDR
pathogens are EOs extracted from medicinal plants.89 EOs
are defined as volatile, natural, and fragrant liquids that can
be extracted from different parts of the plants especially
leaves and flowers, and are produced by plants to protect
themselves from diverse pathogenic microbes. Due to their
antimicrobial activities, EOs have been extensively studied
to be used for the treatment of a wide range of microbial
infections.90 EOs have shown antimicrobial activity against
MRSA,91 MDR strains of K. oxytoca,92 b-lactamases and
carbapenemases producing E. Coli,90 erythromycin-resistant
Group A streptococci,93 and MDR-A. baumannii89 among
others.
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EOs have shown potential as inhibitory agents for use in
MRSA biofilm-related infections.94 Lahmar et al.95 showed
that three different EOs were effective in reducing the re-
sistance of MRSA to amoxicillin, tetracycline, piperacillin,
ofloxacin, and oxacillin, and resistance of A. baumannii to
amoxicillin and to ofloxacin in interactive manner. They
also showed synergism with the antibiotics ofloxacin and
novobiocin against the ESBL producing E. coli. In another
study, the bactericidal activity of herbal volatile oil extract
was tested against MDR A. baumannii and exhibited potent
antibacterial activity with minimal bactericidal concentra-
tion (MBC) values around 0.5.89 EOs and nonvolatile
compounds derived from chamaecyparis obtusa also showed
antimicrobial activity against MRSA and VRE strains.96
Cinnamon bark oil was reported to have antimicrobial ac-
tivity against clinical isolates of MDR P. aeruginosa with
minimum inhibitory concentration (MIC) of 0.0562–
0.225% v/v and MBC of 0.1125–1.8% v/v. Synergistic ef-
fect was also observed when used in combination with co-
listin. The authors proposed that this oil could be used as an
alternative for the treatment of infections caused by MDR
P. aeruginosa.63
Many other studies are showing the beneficial effects of
EOs when two or more EOs are mixed together or when
used in combination with commercial antibiotics.91 When
blended with antimicrobial agents, the constituents of EOs
can unlock the cell membrane channels, thus opening the
passage of antimicrobial agents to reach their internal target
sites.97 This is a great strategy to avoid selection of resistant
strains in the future.
Low water-solubility and high vapor pressure are some
characteristics that limit the utilization of EOs in commer-
cial applications.98 Consequently, EOs are difficult to be
used in aqueous-based products, and they have a tendency to
volatilize over time, thereby reducing their antimicrobial
activity. An effective means of overcoming some of these
limitations could be the utilization of EOs vapors, currently
being studied for decontaminating environment and wound
dressings.99 Moreover, to improve water dispersion and
protect EOs from degradation, nanosized formulations
emerge as a viable solution.100
Ghaderi et al.101 produced nanoemulsion-based delivery
systems containing EOs that were effective against gram-
897
positive and gram-negative strains related to upper respira-
tory tract infections. Cardamom oil loaded chitosan nano-
particles also showed excellent antimicrobial potential
against ESBL and MRSA. Rai et al.97 also suggest that the
use of EOs in combination with NPs may exert synergistic
antimicrobial activity, leading to the development of novel
approach for treatments of MDR pathogens. Besides, EOs
could also be incorporated into topical creams and nasal
sprays to treat skin wounds and upper respiratory tract in-
fections, respectively.102
Bacterial strains showing resistance to EOs are not de-
scribed yet. Moreover, Turchi et al.103 showed that the ex-
posure of S. aureus strains to a subinhibitory concentration
of EOs displayed an increased sensitivity in more than 95%
of the cases. These results suggest that resistance to EO’s
could be difficult to arise. At the same time, EOs have not
been used on the same scale as antibiotics, so an existing
EO-resistant population does not exist. Therefore, to avoid
emergence of resistant strains, similar to bacteriocins, the
best way to use EOs in the control of MDR pathogens could
be in combination with another antimicrobial agents, such as
commercial antibiotics, bacteriocins, or phage therapy.
Phage therapies
Phage, also known as bacteriophage, is a virus that infects
bacteria. Their therapeutic potential in medicine to control
MDR pathogens is due to their specificity and potency in
inducing lethal effects in the host bacterium by cell lysis.22
Bacteriophage therapy was first utilized in the 1930’s, but
the discovery of antibiotics, a more comfortable way to
control infectious diseases, led to a rapid decline in the in-
terests and investments within this field of research. Al-
though phage therapy was given the GRAS status by the
FDA in 2006, it is still not approved for use in humans. The
key regulatory barriers continue to prevent its approval by
the US FDA and by the European Medicines Agency.104
The worldwide rise of MDR pathogens and the decrease
in research and development of new antibiotics have stim-
ulated interest in phage therapy and several studies have
shown its efficacy against antibiotic-resistant pathogens.105
Phage therapy has been shown to be effective against ty-
phoid fever and S. aureus bacteremia106 and also against
MRSA strains.107 Rasool et al.107 showed that the phages
exhibit lytic activity against MRSA both in vivo and in vitro
experiments in another report, Jennes et al.108 described that
phage therapy was effective in the treatment of colistin-
only-sensitive P. aeruginosa septicemia in a patient with
acute kidney injury. Cheng et al.104 showed a high effi-
ciency of a broad host range lytic phage against E. faecalis
strains, including vancomycin-resistant strains. Chadha
et al.109 showed the potential of liposome entrapped phage
cocktail for treating K. pneumoniae-mediated infections.
Gelman et al.110 tested a combination of bacteriophages and
antibiotics against VRE Enterococcus faecalis in a mouse
model and concluded that this combination imparts an ad-
ditional beneficial effect on the treatment success, as a
single injection of the bacteriophage cocktail was sufficient
to completely reverse the 100% mortality trend caused by
VRE.
The use of phage therapy has been proposed via intra-
venous106 and oral routes,111 as liposome-entrapped phage
 898
cocktail,109 and for vaccine development.112 Some advan-
tages of using phage therapy instead of antibiotic include
lower developmental costs; 100% bactericidal nature; high
specificity thus also preventing secondary infections; and the
requirement of only a single dose or phage multiplication at
the infection site compared to antibiotics that require several
doses. In addition, phage therapy can be used in combination
with traditional antibiotics, or a combination of diverse
phages as a cocktail to increase its antibacterial spectrum.113
The use of whole phage to treat infection could have
some disadvantages, as the genetic material in temperate
phage could increase the virulence of certain species of
bacteria through transduction of virulence genes. An ex-
ample is the acquisition of the gene encoding the Panton
Valentine Leucocidin toxin, causing ‘‘scalded skin syn-
drome,’’114 common in CA-MRSA strains that increase their
pathogenicity. In this way, instead of the whole phage, some
studies have proposed the use of bacteriophage-encoded en-
dolysins that destroy the bacterial cell wall, resulting in cell
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death through lysis.105 Some advantages of using endolysins
as pointed by Fischetti et al.115 include their ability to retain
specificity without affecting commensal flora, rapid bacterial
lysis, genetically nontransducible nature, and lesser proba-
bility of acquiring resistance due to the essential bacterial
binding sites. These endolysins have demonstrated antibac-
terial activity against gram-positive and gram-negative strains
and also against MDR pathogens such as MRSA.116
Quorum-sensing inhibitors
QSI are another alternative method to control MDR path-
ogens proposed in the last years. Quorum sensing (QS) is an
intercellular bacterial communication used to coordinate
group behaviours in a cell density-dependent manner. At high
concentrations, pathogens can switch their transcription pro-
files to an invasive phenotype, including genes related to
antibiotic tolerance and virulence determinants, and cause
disease.117 In this way, QS systems constitute important an-
tivirulence targets, as they often regulate the expression of
several virulence genes simultaneously.118 QSI act by in-
hibiting cell-to-cell communications and, consequently, dis-
ease evolution, enabling the host immune system to prevent
bacterial colonization and/or to clear an established infection.
This antimicrobial control relies on reducing the burden of
virulence rather than killing the bacteria.119
Hansen et al.120 tested the use of lactam hybrid analogs of
solonamide B and autoinducing peptides to inhibit the Agr
QS system, which is a major inducer of virulence in CA-
MRSA. The authors concluded that this and closely related
compounds were 20- to 40-fold more potent in AgrC inhi-
bition than the starting hit compound. Baldry et al.121 also
showed that solonamide B and analogs alter immune re-
sponses to S. aureus, but do not exhibit adverse effects on
immune cell functions. However, the authors also stated that
application of compounds inducing an Agr-negative state
may have adverse interactions with host factors in favour of
host colonization. RNAIII-inhibiting peptide was also ap-
pointed by Simonetti et al.122 as useful for the control of
MRSA in infected wounds by inhibiting QS systems.
Hraiech et al.123 have shown that a lactonase isolated
from Sulfolobus solfataricus efficiently inhibited QS in
P. aeruginosa, reducing the mortality in rats from 75% to
VIVAS ET AL.
20% based on early treatment. QS system from this bacte-
rium was also inhibited by bioactive molecules extracted
from leaves of Kalanchoe blossfeldiana.124 D’Angelo
et al.125 tested FDA-approved drugs as antivirulence agents
targeting the pqs QS system of P. aeruginosa and found that
clofoctol (approved for clinical treatment of pulmonary in-
fections caused by gram-positive bacteria) has considerable
clinical potential as an antivirulence agent for the treatment
of P. aeruginosa lung infections. Anti-QS system against
P. aeruginosa was also observed in a study with EOs derived
from Ferula (Ferula asafoetida L.) and Dorema (Dorema
aucheri Bioss.), exhibiting anti-QS activity at 25 mg/mL of
concentration.126
In the last 20 years, various QSI from plants, animals, and
microorganisms have been characterized and animal and
plant infection models have demonstrated their antibacterial
efficacy against QS pathogens.119 QSI could thus serve as a
good alternative to treat infections caused by MDR pathogens.
However, its application in clinical medicine still requires
more research. According to Baldry et al.121 application of QSI
might have adverse interactions with host factors in favour of
host colonization.
Antibodies
The use of antibodies has also been proposed as a prom-
ising strategy for the containment of MDR bacterial strains,
as they can enhance phagocytosis or activation of comple-
ment proteins. To maximize antibody action, some authors
have proposed the use of more than one isotype, generally a
mix of Immunoglobulin M (IgM), Immunoglobulin G (IgG),
and Immunoglobulin A (IgA).127,128 A polyclonal prepara-
tion enriched with IgM immunoglobulins commercially
available is Pentaglobin (Biotest AG, Dreieich, Germany),
which contains 76% IgG, 12% IgA, and 12% IgM (IgGAM).
To date, there are at least three other licensed monoclonal
antibodies products against infectious targets: Palivizu-
mab,129 Raxibacumab,130 and Panobacumab.131
Several studies have shown the effectiveness of this al-
ternative treatment, which is also one of the most studied
methods (Fig. 1). Lu et al.132 tested Panobacumab, a fully
human monoclonal antibody of the IgM/k isotype directed
against the lipopolysaccharide (LPS) O-polysaccharide moi-
ety of P. aeruginosa, which enhances the phagocytosis of
this pathogen. The authors concluded that this therapy is
safe and is associated with high clinical cure and survival
rates in patients developing nosocomial P. aeruginosa infec-
tion. Rossmann et al.128 demonstrated that IgGAM induces
in vitro killing of MDR clinical isolates of K. pneumoniae
through enhancement of phagocytosis. Results obtained by
Giamarellos-Bourboulis et al.127 also showed that IgGAM
was effective as an adjunct to antimicrobial treatment for the
management of septic shock caused by MDR gram-negative
bacteria. Diago-Navarro et al.133 observed that anticapsular
antibodies promoted extracellular processes killing, comple-
ment deposition, deployment of neutrophil extracellular traps,
and opsonophagocytosis of carbapenem-resistant Klebsiella
pneumonia. The author concluded that the tested antibodies
could ultimately treat or protect patients infected or at risk of
infection by this MDR bacterium.
Antibody conjugates with antimicrobial agents have also
been shown to be effective to control MDR strains by
 ANTIBIOTIC RESISTANCE AND ALTERNATIVE METHODS
several other authors. Lehar et al.134 verified that an anti-
body–antibiotic conjugate eliminates intracellular S. aur-
eus01, and this conjugate was superior to vancomycin for
treatment of bacteraemia. Antibody-directed photodynamic
therapy was very effective in killing different MRSA strains,
in all growth phases and may be a good candidate for a
novel treatment of MRSA infections.135
As stated by Szijártó et al.,136 passive immunization was a
standard treatment option in the preantibiotic era, and as we
move toward a possible postantibiotic era, it may be prudent
to reconsider the merits of this therapy. The actual advances
in the research and biopharmaceutical manufacturing capa-
cities enable the development of highly purified humanized
antibodies against a range of pathogenic microorganisms.
Moreover, MAbs are directed against nonhuman targets and
in general have an excellent safety record. Similar to other
alternative methods, antibodies can complement antibiotic
therapy. A challenge of this therapy is to find molecular de-
terminants of the pathogens that are accessible on the cell
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surface.136
Nanotherapeutics
Besides the methods described above, some authors have
also proposed the use of nanotechnology in the control of
MDR strains. Some of the NPs proposed are silver NPs,137
Gold NPs,138 Photoexcited Quantum dots,139 anf Core–shell
Magnetic Nanoparticle (MNP)140 among others. As stated
by Singh et al.141 ‘‘Nanomaterials possess unique proper-
ties, and multiple bactericidal mechanisms render them
more effective than conventional drugs.’’ In addition, Zaidi
et al.88 also affirm that NPs have potential to overcome the
problem of antibiotic resistance in the present days and ‘‘to
revolutionize the diagnosis and treatment of bacterial in-
fections.’’
The use of NPs can enhance the antimicrobial activity of
available drugs by functioning as drug delivery systems that
can be targeted precisely.88 NPs material could be metallic
or organic and has been found to synergize the killing effect
of antibiotics142 and could also have the same effect in
combination with other antimicrobial agents, such as bac-
teriocins and EOs.100,105 Generally, the antimicrobial ac-
tivity of NP involves a triple mechanism of action: oxidative
stress, metal ion release, and nonoxidative stress,143 together
with the effect of any other antimicrobial that can be com-
bined with NPs. This multiple mechanism of action makes it
more difficult to acquire resistance. Moreover, NPs enhance
drug solubility, concurrent delivery of multiple drugs, and
prolonged systemic circulation.144
Yuan et al.137 used silver NPs to control drug-resistant
strains of S. aureus and P. aeruginosa and showed that it
induced cell death of these strains. Niemirowicz et al.139
anslyzed the synergistic effects of core–shell MNPs when
used in combination wth cathelicidin LL-37 (a human an-
tibacterial peptide), synthetic ceragenins (CSA-13 and CSA-
131), and classical antibiotics (vancomycin and colistin),
against MRSA. The authors concluded that MNPs po-
tentialize the effect of these antimicrobial agents and can be
considered as a method of delaying and overcoming bac-
terial drug resistance. Pei et al.145 developed a polymeric
particle formulation for encapsulation and intracellular de-
livery of vancomycin to MRSA-infected macrophages and
899
showed that this NP enhanced bacterial activity of the an-
tibiotic against MSRA. For in vivo application, the stability
of this formulation remains to be improved.145 Combination
of metal oxide NPs with ciprofloxacin, erythromycin,
methicillin, and vancomycin was reported to effectively
reduce the MICs of these antibiotics against VRE.146 Khan
et al.147 tested the photo inactivation of MDR strains of
E. coli and K. pneumoniae by monomeric methylene blue
conjugated gold NPs and obtained 97% killing of MDR
bacteria. They put forward the possibility of this NP-based
photodynamic therapy as a potential therapeutic approach
against MDR infections. Similarly in another report, tri-
methyl chitosan-capped silver NPs were shown to have high
antibacterial activity with a MIC of £12.25 mg/mL against
clinically isolated MDR A. Baumannii.148 NPs thus seem to
be a good alternative with high potential to solve the
emerging bacterial MDR.
Concluding Remarks
Antibiotic resistance is one of the greatest health prob-
lems we will have to face in the coming years. Considering
that little advancement has been made in the discovery of
novel antibiotics especially those effective against drug-
resistant strains, use of alternative methods could be the best
way to resolve this problem. As discussed in this review,
there are several promising alternatives to circumvent this
problem. It is up to the competent authorities to accelerate
and encourage further research and release appropriate fi-
nancial support for the successful implementation of these
methods. The alternative methods listed in this review
probably will be successfully used in combination with the
antibiotics available and not completely replace antibiotics
as treatment agents.
Acknowledgments
The authors thank the Conselho de Desenvolvimento
Cientıfico e Tecnologico (CNPq), Brasılia, Brazil, the
Fundação de Apoio a Pesquisa a InovaçãoTecnologica do
Estado de Sergipe (FAPITEC), Sergipe, Brazil, for provid-
ing fellowships and financial support, which support the
research with bacteriocins, essential oils, and antibiotic-
resistant pathogens in our laboratory.
This research did not receive any specific grant from
funding agencies in the public, commercial, or nonprofit
sectors.
Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Ana Andréa Teixeira Barbosa, DSc
Programa de Pós-Graduação em Biologia Parasitária
Universidade Federal de Sergipe
Cidade Univ. Prof. José Aloı́sio de Campos
Av. Marechal Rondon, s/n, Jd. Rosa Elze
São Cristóvão CEP 49100-000
Sergipe
Brasil
E-mail: ana.barbosaufs@yahoo.com.br