WO2009151346A1

WO2009151346A1 - A method for determining bacterial antibiotic resistance or bacterial susceptibility, a diagnostic kit for the detection of the antibiotic resistance and use of such diagnostic kit

Info

Publication number: WO2009151346A1
Application number: PCT/PL2009/000066
Authority: WO
Inventors: Marek Ciesielski
Original assignee: Marek Ciesielski
Priority date: 2008-06-11
Filing date: 2009-06-10
Publication date: 2009-12-17
Also published as: GB2460882A; GB0812469D0; PL385415A1

Abstract

The subjects of invention are method for determining bacterial antibiotic resistance or bacterial susceptibility, a diagnostic kit for the detection of the antibiotic resistance and use of such diagnostic kit. Mote precisely a new, fast and efficient method for determining the antibiotic resistance of bacteria, screen test for antibiotic-resistant bacteria and test for the efficiency of the antimicrobial treatment, diagnostic set and use to the measurement of the drug detection or their metabolites are described. A new method for detection of bacterial antibiotic resistance, diagnostic set based on the lateral flow test or lateral immunochromatographic assays to detect drug resistance of the contagious factor and use of detection of the drug and/or products of its/theirs degradations are disclosed.

Description

A method for determining bacterial antibiotic resistance or bacterial susceptibility, a diagnostic kit for the detection of the antibiotic resistance and use of such diagnostic kit

Bacterial drug resistance may be detected in different ways. These methods can be divided into techniques used in cell/bacterial culture, e.g. disk diffusion method, colorimetric methods and non-culture techniques among them the most important are genetic techniques, e.g. PCR which enables the detection of DNA/RNA responsible for coding enzyme or based on bio-sensors. Other used methods are techniques based on the immunological techniques, based on the detection of presence special proteins or beta-lactamase enzyme, e.g. immunoblot reaction, slide agglutination test, latex agglutination etc. The lateral flow test or lateral immunochromatographic assays are commonly used diagnostic methods used to detect different compounds in body fluids such as serum or urine, or in the supernatant from the tissue culture or different homogenates. The existing penicillin detection test, e.g. Penicillin Rapid Inspection Test from Nankai biotech company is used to detect the food products penicillin spoilage, but not for the detection of the antibiotic resistance, neither screening tests for antibiotic- resistant bacteria, nor for tests for the efficiency of the antimicrobial treatment. Furthermore they are able to detect only a few antibiotics.

Authors of the article "Detection of Antimicrobial Activity in Urine for Epidemiologic Studies of Antibiotic Use" Yung-Ching Liu, Wen-Kuei Huang, Tsai-Shu Huang and Calvin M. Kunin published in the J Formos Med Assoc 1996 Jun;95(6):464- 8, described that presence of antibacterial agents in the urine may cause an unreliable results of bacterial culture in the urine. The authors propose a new test to evaluate these unreliable results by developing bacterial culture Bacillus stearothermophilus.

Wu JJ et al. described that in view of the high rate of occurrence of antimicrobial agents in urine specimens and the lack of information provided by most physicians to laboratories, a screening method (the culture of Bacillus stearothermophilus with urine sample as the indicator method) to detect the presence (or absence) of antimicrobials in urine specimens may be a useful tool [Wu JJ, Chien ML, Lee N, Chou SF, Wang HM, Tsai WC, Microbiologic assay for detection of antimicrobial agents in urine, J. Formos Med Assoc. 1996 Jun;95(6):464-8].

Patent application No. 2007231923 (pub. 2007-10-04) describes sampling and testing device for the detection of specific molds, allergens, viruses, bacteria, fungi, and other protein containing substances. Embodiments of the device include a sampling member slideably engaged with a base that contains a lateral flow strip adapted to detect specific analytes of interest. The sampling member defines a solvent reservoir that stores an elution solvent in a fluid-tight manner before the device is used to sample and test environmental surfaces. During slideable withdrawal of the sampling member from the base, the elution solvent stored in the reservoir is automatically released to a wick assembly of the sampling member. The wick assembly includes a wick adapted to receive, distribute, and retain the elution solvent. After a user samples an environmental surface for an analyte of interest with the elution solvent wetted wick, the sampling member is returned to the base where the wick contacts the lateral flow strip contained in the base. The wick transfers at least a portion of analyte and the elution solvent to the lateral flow strip for the calorimetric detection of specific allergens, viruses, bacteria, and other protein containing substances in the sample. The colorimetric results of the test are displayed through a window in the base. Another patent application US2007212715 (publ. 2007-09-13) describes a bacteria detection device, bacteria detection method and bacteria detection kit enabling rapid and accurate determination of bacteria present in a test sample, and particularly spore-forming, aerobic bacteria, with a simple procedure. The bacteria detection device according to the present invention is a microarray type of device in which an oligonucleotide, which is based on a nucleotide sequence specific to a genus or species to which a target spore-forming, aerobic bacteria belongs, is immobilized on a substrate. Spore-forming, aerobic bacteria present in a test sample can be easily, rapidly and accurately detected and identified based on the presence or absence of successful hybridization between a probe prepared from the test sample and the oligonucleotide immobilized on the substrate.

Patent application 2006078951 (publ. 2006-04-13) describes monoclonal antibody binding specifically to the p60 protein of Listeria monocytogenes, a hybridoma cell producing the monoclonal antibody, a test kit comprising the monoclonal antibody, and a method for detecting Listeria monocytogenes using the monoclonal antibody. The inventive monoclonal selectively recognizes only Listeria monocytogenes, so that the use of such an antibody allows for rapid determination of the food contamination with these bacteria pathogenic to humans.

Patent application 2005272113 (publ. 2005-12-08) describes a reagent for the detection of an extracellular enzymatically active protein produced by a beta-hemolytic streptococcus bacteria found in a host biological fluid includes a proteinaceous substrate or a cholesterol-containing membrane substrate for the extracellular protein. The substrate is nonspecific within the groups of beta-hemolytic streptococcus bacterium and is in contact with an inert solid matrix. Upon reaction between the streptococcus enzymatically activate protein and the substrate, a color change discernable by an unaided human eye results. Extracellular streptococcus protein found in saliva represents a less invasive source of biological fluid for the determination as to whether a host suffers acute pharyngitis.

Patent application WO03107007 (publ. 2003-12-24) describes rapid a test method for detecting at least one antigen by means of optical and/or chemical detection, using specific interactions. The inventive method is a universal rapid test method, which enables bacteria and viruses to be simultaneously and quantitatively determined.

Patent description PL 195495 (publ. 1999-12-29) discloses a process for determination of the presence and/or amount of antibiotics containing beta-lactam ring present in a biological fluid and especially in milk. The process complexes the antibiotic in the biological fluid with a known amount of recognition agent and then places the mixture of the biological fluid and recognition agent in contact with an antibiotic a support. A determination is made of the amount of the antibiotic present in the biological fluid. As recognition factor is used BIaR receptor or the BIaR-CTD receptor.

Patent description No. 6 485 982 describes "including determination of the presence of metabolites of drugs or toxins. The assay process and the cell are engineered specifically to detect the presence of a preselected individual ligand present in a body or other fluids." Apart from the described above techniques which are used in medical (or veterinary) diagnostics, disks diffusion methods and genetic detection of different antibiotic resistance plasmids, evaluation antibiotic resistance are useful, but expensive and time-consuming. They also require highly qualified staff. According to these disadvantages, there is still a need to develop an antibiotic resistance test and method that could guarantee sensitivity, reliability and should be achieved in a fast, easy, and cheap manner.

The main aim of this invention is to deliver a method, which could confirm the lack of antibiotic or its presence in concentration, lower than therapeutic concentration, based on the immunoenzymatic detection of medications or the lack of their presence. The applicant has just discovered a novel process for detecting antibiotic resistance, screen test for antibiotic resistance and efficient method of controlling the efficiency of antibiotic treatment by evaluation of presence of antibiotics in a biological fluid, which allows these objectives to be achieved in a noteworthy manner.

The invention discloses a process of detection of antibiotic resistance or a screen test for antibiotic resistance and efficient method of controlling the efficiency of antibiotic treatment, which is characterised that antibiotic resistance is detected by the lack of given antibiotic in the body fluids, because the antibiotic resistant bacteria destroy/degrade the antibiotic (to the inactive compounds). The presence (or absence) of an antibiotic is detected by the lateral flow test or lateral immunochromatographic assays.

The subject of invention is a method for determining bacterial antibiotic resistance or bacterial susceptibility, characterised in that, the drug resistance is detected by detection of the given antibiotic in the urine or other body fluids with the diagnostic set based on the lateral flow test or lateral immunochromatographic assays.

Preferably, said antibiotic resistance is detected when concentration of a given antibiotic or its active metabolites is lower or equal than therapeutic concentration. Preferably, said antibiotic susceptibility is detected when concentration of a given antibiotic or its active metabolites is higher or equal to therapeutic concentration.

Preferably, said method concerns human and/or animal organisms.

Preferably, said method could be used as screening method of healthy organisms, which could be asymptomatic carriers of antibiotic resistant bacteria. The next subject of invention is a diagnostic kit based on the lateral flow test or lateral immunochromatographic assays for the detection of the antibiotic resistance of the infective factor characterised in that said kit is a diagnostic assay contains a set of antibodies, preferably monoclonal antibodies, for detection of antibiotic resistance by detection of the presence of lack of the given antibiotic wherein said antibiotics are betalactams in biological fluids, especially in urine.

Preferably, said set is useful for screening healthy organisms or monitoring treatment efficiency.

The next subject of invention is an use of a diagnostic kit for detection of drug presence and/or its active metabolites by detection of its concentration in comparison to the therapeutic concentration in the body fluids with the lateral flow test or lateral immunochromatographic assays in screening and treatment of patients during antibiotic therapy to the antibiotic resistance detection in screening of the antibiotic resistance of the given antibiotic.

Preferably, antibiotic resistance is stated when concentration of a drug or/and its active metabolites is lower or equal than its therapeutic concentration.

Preferably, antibiotic susceptibility is, stated when concentration of a drug or/and its active metabolites are higher or equal to its therapeutic concentration.

Preferably, said use concerns human and/or animal organisms.

Preferably, it concerns screening of healthy organisms, which could be asymptomatic carriers of antibiotic resistant bacteria.

Figure 1 illustrates, for better understanding, the test for detection of antibiotic resistance (or screen test for antibiotic resistance and efficient method of controlling the efficiency of antibiotic treatment), wherein: 1 - input window, 2 - result window, 3 - test window, 4 - printed, 5 - urine or other body fluids, 6 - mobile Ab#l , 7 - bound Ab#2, 8 - bound Ab#3.

Below are some examples of the usage of the above defined invention.

Example Test - diagnostic set - is based on the lateral flow test or lateral immunochromatographic assays for detection of the drug resistance of infective factors, which is characterised, that drug resistance (e.g. antibiotic resistance) of the infective factor/s (e.g. bacteria which cause infection) comprise diagnostic set containing set of antibodies (e.g. monoclonal antibodies) to the antibiotic resistance detection by detection presence or absence of administered drug, and especially beta-lactam antibiotics (list below) in the biological fluids and especially in the urine. The above test may be used as a screen test for antibiotic resistance and efficient method of controlling the efficiency of antibiotic treatment as well. As an example: patient may be resistant to given beta-lactam antibiotic (e.g. amoxicillin), but it is still administered (with other antibacterial drugs), when the infectious factor is eliminated from the organism the amoxicillin might be detected in the urine again.

As examples of antibiotics which can be detected by means of the processes according to the present invention, mention may be made of the following antibiotics: Ampicillin, Pivampicillin, Carbenicillin, Amoxicillin, Carindacillin, Bacampicillin, Epicillin, Pivmecillinam, Azlocillin, Mezlocillin, Mecillinam, Piperacillin, Ticarcillin, Metampicillin, Talampicillin, Sulbenicillin, Temocillin, Hetacillin, Benzylpenicillin, Phenoxymethylpenicillin, Propicillin, Azidocillin, Pheneticillin, Penamecillin, Clometocillin, Benzathine benzylpenicillin, Procaine benzylpenicillin, Benzathine phenoxymethylpenicillin, Dicloxacillin, Cloxacillin, Methicillin, Oxacillin, Flucloxacillin, Sultamicillin, Cefalexin, Cefaloridine, Cefalotin, Cefazolin, Cefadroxil, Cefazedone, Cefatrizine, Cefapirin, Cefradine, Cefacetrile, Cefroxadine, Ceftezole, Cefoxitin, Cefuroxime, Cefamandole, Cefaclor, Cefotetan, Cefonicide, Cefotiam, Loracarbef, Cefmetazole, Cefprozil, Ceforanide, Cefotaxime, Ceftazidime, Cefsulodin, Ceftriaxone, Cefmenoxime, Latamoxef, Ceftizoxime, Cefixime, Cefodizime, Cefetamet, Cefpiramide, Cefoperazone, Cefpodoxime, Ceftibuten, Cefdinir, Cefditoren, Ceftriaxone, Cefoperazone, Cefepime, Cefpirome, Aztreonam, Meropenems, Ertapenem, Imipenem. The processes according to the invention allow the detection of antibiotics containing beta-lactam ring (or other antibiotics) in biological fluids such as urine, milk, blood, serum, saliva, pus and other wound discharges, or culture media (e.g. supernatant).

Below presented results confirms that the lateral flow test or lateral immunochromatographic assays is a useful alternative for so far used test like disk diffusion methods (and others), ESR or CRP.

Table 1

Comparison of the antibiotic resistance with the disk diffusion method to the lateral flow test (lateral immunochromatographic assays). The results of the lateral flow test are more correlated with patients' clinical condition.

The results about antibiotic resistance are obtained much more faster with lateral flow test (lateral immunochromatographic assays) than standard methods what is vitally important in case of serious infections (e.g. sepsis) or in case of patients with decreased immunological barrier (e.g. small children, elderly peoples, in case of AIDS, neoplastic diseases etc.)

Table 2

Comparison of the time required to detect the antibiotic resistance with the disk diffusion method to the lateral flow test (lateral immunochromatographic assays).

As mentioned above the great advantage of the lateral flow test is the fast result obtained. It depends on the way of administration of the drug.

Table 3

Comparison of the time required to detect the antibiotic resistance with the lateral flow test (lateral immunochromatographic assays) in dependence of the way of administration of the drug.

The lateral flow test (lateral immunochromatographic assays) is a very sensitive method of detection of medication present in urine comparing to HPLC (high performance liquid chromatography). Table 4

Comparison of the lateral flow test (lateral immunochromatographic assays) to HPLC (high performance liquid chromatography) for all the beta-lactam antibiotics. The lateral flow test (lateral immunochromatographic assays) specificity and sensitivity is 99.99%. Presented is monitoring efficiency of elimination of beta-lactams producing bacteria, when they are absent the penicillins started to be present in urine.

Bacteria MRSA (Methicillin-resisitant Staphylococcus aureus) are resistant to all known beta-lactams antibiotics, and in 90% there is a cross-resistance with macrolides and fluorochinolones. This can mean resistance to such macrolides as: erythromycin, spiramycin, roxythromycin, clarithromycin, azythromycin, telithromycin, and such fluorochinolones as ofloxacyllin, ciprofloxacillin, pefloxacyllin, norfloxacillin, levofloxacillin, moxyfloxacillin. So the proposed test is also useful in detection (with 90% probability) resistance to these antibiotics.

Resistance to aminoglicosides is caused by synthesis of the enzyme, which modifies the drug, which is localised on the transposon Tn-4001. So proposed test is also useful to detect resistance to aminoglicosides antibiotics (streptomycin, tobramycin, gentamycin, neomycine, amikacine, netelmycine etc.).

Proposed diagnostic test may be also very useful in the veterinary and other biological sciences. It may let to discover new mechanisms of drug resistance e.g. presence of endogenic enzymes of drug degradation. The lateral flow test (lateral immunochromatographic assays) is cheap, sensitive, efficient, easy to operate device, which (thanks to above mentioned features) may be a useful tool to achieve further progress in medicine, veterinary and other biological sciences.

The greatest advantage of the proposed lateral flow test (lateral immunochromatographic assays) is the immediate response for the most important question (from the point of view patient and his/her doctor): is the used treatment effective or not? The threshold sensitivity depends on the local epidemiological date and the type of an antibiotic and is compared between 1-999 micrograms/ml. Below this border (1-999 micrograms/ml) the result is recognised as negative, i.e. the antibiotic level is below this antibiotic concentration it means that the bacteria (responsible for infection or co- infection) are resistant to administered antibiotic.

Test's sensitivity and specificity

In case of negative test result, i.e. lack of antibiotic in urine - or other body fluids, correlation with the patient's clinical condition is above 99%.

But the positive result (i.e. detection of antibiotic in urine) means that the penicillinase (or similar enzyme which degrade the antibiotic) is not produced, but do not exclude antibiotic resistance on the other way, such as:

- decreased affinity for penicillin- binding proteins (e.g. for cefuroxime);

- impermeability or lack of cell wall;

- mechanism of efflux pumps. Above mechanisms are very rare and do not decrease the usefulness of proposed test.

Test description (fig. 1)

Test consists of a box with three windows: the first one - administration of a urine (or other body fluids), the second one - a result window, and the third one - a control window. Inside the container, there is a wick from a material (e.g. paper) which is easy to moisten by the biological fluids. On the "wick" there are: a) mobile primary antibody Ab#l (e.g. monoclonal antibody) - recognition agent against given antibiotic (or its active metabolite); b) secondary antibody Ab#2 (e.g. monoclonal antibody) which connects to the other epitop of the given antibiotic. The secondary antibody is coupled with to a labelling agent. This labelling agent can be of diverse nature. The labelling agent can be of particular type such as metallic colloidal particles (platinum, gold, silver, etc.), colloidal particles of selenium, carbon, sulphur or tellurium, or alternatively colloidal particles of coloured synthetic latexes. The labelling agent can also be a fluorescent substance, the labelling agent can also be enzymatic

(e.g. a peroxidase, a phosphatase etc.) with any other substrate which could produce coloured products; c) another antibody Ab#3 (e.g. monoclonal antibody) against antibody 1 anti-Ab#l There are printed two minuses on the wick.

General description of the test:

Positive result (when patient's infectious factor does not produce beta-lactamases or other enzymes which inactivate given antibiotic): L A few drops of urine (or other body fluid) are placed in the application window.

2. The fluid fraction along with its dissolved components including given antibiotic moves along with the liquid front.

3. When the fluid reaches the unbound Ab#l, which is in great excess, the given antibiotic begins reacting with Ab#l, but the complexes and the excess unreacted Ab#l flow along with the current.

4. When this reaches the line where Ab#2 is immobilised to the paper, another portion of the given antibiotic is "displayed" by Ab#l and binds with Ab#2. When this happens, the distorted Ab#2 triggers an enzyme (or other substance) to start making an insoluble dye, which upon accumulating causes the vertical bar on the "plus sign" to become visible.

5. The fluid front continues moving along and eventually crosses the "control window," where the excess Ab#l starts reacting with Ab#3 (also known as: anti- Ab#l), and that triggers the formation of a dye that completes the vertical portion of that plus sign. The control window shows plus to indicate that the antibodies in the paper (or the other spongy substance) were alright and working. This is to ensure the patient that the device had not become overheated (or damaged in any other way) during transit. If it had, patient would have two minuses - the second one telling the patient to take the device back because it could be a false negative.

6. Thus patient who received a proper antibiotic treatment ends up with two pluses.

Negative result (when patient's infectious factor produces beta-lactamases or other enzymes which inactivate given antibiotic):

1. The urine (or other body fluid) is applied.

2. When the fluid meets Ab#l, there is no given antibiotic to react with it. Only Ab#l floats along with the current. 3. In the "result" window, there is no "displayed" antibiotic to react with Ab#2, and no colour reaction occurs. Only the printed minus continues to be shown. 4. Finally, in the control window, the Ab#l is bound to Ab#3 and the "plus" is revealed, showing that the antibodies were effective, and that the fluid had flowed that far - far enough.

5. The test result is "minus-plus." It is also possible to detect antibiotic resistance by analysis of patient's body fluids. When antibiotic's concentration is higher or equals to the minimal inhibitory concentration in the body fluids, the bacteria is susceptible to the given antibiotic. In case when antibiotic's concentration is lower than the minimal inhibitory concentration in the body fluids the infectious factor is resistant to the given antibiotic. It could be done by redox reaction with iron chloride. The beta-lactam antibiotics are detected by hydrolysis of present antibiotic in the urine to the hydroxam acids (e.g. hydroxylamin) and FeCl₃ is added. In case of presence of beta-lactams (lack of antibiotic resistance) the violet colour appears. The antibiotic presence (detection of antibiotic resistance or susceptibility) may be detected (by evaluation of the antibiotic concentration) also with the usage of such devices as HPLC, gas chromatography and many other analytical devices which enables such analysis.

The process according to the invention allow the detection of antibiotics resistance in biological fluids such as urine, saliva, milk, blood, serum saliva, culture media, pus, wound discharge etc. The examples which follow illustrate various aspects and methods for implementing the present invention, without, however limiting its scope.

Example 1

Antibiotic resistance detection of in case of amoxicillin treatment

Amoxicillin is a beta-lactam antibiotic, which is active against Gram-positive and Gram-negative organisms but is inactivated by penicillinases, including those produced by Staphylococcus aureus and by common Gram-negative bacilli such as Escherichia coli. Amoxicillin is recommended as "first - line" antibiotic in most infections.

A patient, four days after natural delivery and breast-feeding, was complaining of infection of unknown origin with high temperature (39°C) etc. Doctor prescribed amoxicillin Ig twice daily and recommended proposed test (as a control the microbiological swab from lochia was taken). Patient took a urine sample and did test about 6 hours after first dose of the antibiotic. Six hours after first dose of the antibiotic, the test's result was positive (an antibiotic was present in the urine), the therapy was continued.

After three days (when patient felt much better) the microbiological result was known - Staphylococcus epidermidis, amoxicillin susceptible, the microbiological culture result confirmed the lateral flow test.

Example 2

Antibiotic resistance detection of in case of phenoxymethylpenicillin (Penicillin V) treatment

Given example antibiotic resistant detection during usual phenoxymethylpenicillin (Penicillin V) treatment in case of bacterial infection of the throat.

Phenoxymethylpenicillin (Penicillin V) is an oral beta-lactam antibiotic. Its antibacterial spectrum compares Streptococcus spp. and Staphylococcus spp. (which do not produce penicillinases). Phenoxymethylpenicillin (Penicillin V) is recommended as "first - line" antibiotic in most throat infections. Two patients, A and B complained of a usual bacterial throat infection. They were admitted by their General Practitioner who prescribed them a standardise of 500 mg four times a day. The General Practitioner recommended also an antibiotic resistance lateral flow test to be done 6 hours after first dose of an antibiotic. He took also a standard bacteriological swab. Patient A did a test and the result was positive (it showed that antibiotic is in the urine in concentration higher than therapeutic ones) so the treatment was continued. Patient B did a test as well and the result was negative (it showed that antibiotic is in the urine in concentration lower than therapeutic or was absent). The treatment was changed into amoxicillin with clavulanic acid (in standard doses). Six hours after administration of the antibiotics another test was carried out, which showed susceptibility on the given treatment.

Four days later both patients were checked by their doctor who found improvement in their health status. The doctor recommended continuation of the treatment. The results of the bacterial culture and antibiotic resistance (disk diffusion method) confirmed the fitness for purpose. Patient A was infected with Streptococcus pyogenes phenoxymethylpenicillin - susceptible and patient B was infected with Streptococcus pyogenes as well, phenoxymethylpenicillin -resistant. After several days both patient recovered, but in case of patient B the antibiotic resistance lateral flow test helped to find the proper antibiotic, and save the time to find the proper treatment.

Example 3

Antibiotic resistance detection of in case of cefalexin treatment Given example antibiotic resistant detection during usual cefalexin treatment in case of lower urinary tract bacterial infection. Cefalexin is a "first generation" of cefalosporins - broad-spectrum antibiotics that are used in the treatment septicaemia, pneumonia, meningitis, urinary tract infections etc. The pharmacology of the cefalosporins is similar to that of the penicillins, excretion being principal renal. Pregnant patient (30-gestation week) complains of symptoms of lower urinary tract bacterial infection. After examination doctor prescribed cefalexin 250 mg four times a day, bacterial culture (with antibiotic resistance) from a urine sample and (in addition) antibiotic resistance lateral flow test 6 hours after the first dose of the antibiotic. The patient was informed that in case of a negative result (when the antibiotic would not be present in urine) she had to contact her doctor again to have her antibiotic changed. Inappropriate treatment of urinary tract infections may lead to the pregnancy complications.

The result was positive, patient continued therapy, during the next visit the result of bacterial culture and disk diffusion method confirmed the result of antibiotic resistance lateral flow test, S. saprophytics cefalexin susceptible was the infectious factor.

Example 4

Antibiotic resistance detection of in case of cefuroxime treatment

Given example antibiotic resistant detection during cefuroxime treatment in case of septicaemia. Cefuroxime is a "second generation " cephalosporin that is less susceptible than the earlier cephalosporins to inactivation by beta-lactamases (except extended spectrum beta-lactamases). It is, therefore, active against certain bacteria, which are resistant to the other drugs, and has greater activity against certain bacteria. Sepsis is a serious medical condition characterised by a whole-body inflammatory state caused by infection. Sepsis is broadly defined as the presence of various pus-forming and other pathogenic organisms, or their toxins, in the blood or tissues. Sepsis is common and also more dangerous in elderly, immunocompromised, and critically ill patients. It occurs in l%-2% of all hospitalisations and accounts for as much as 25% of intensive care unit (ICU) bed utilization. It is a major cause of death in intensive care units world-wide, with mortality rates that range from 20% for sepsis to 40% for severe sepsis to >60% for septic shock. The therapy of sepsis rests on antibiotics and support of basic life functions. A problem in the adequate management of septic patients has been the delay in administering therapy after sepsis has been recognised. Published studies have demonstrated that for every hour delay in the administration of appropriate antibiotic therapy there is an associated 7% rise in mortality.

It is worth to mention that in neonates, sepsis is difficult to diagnose clinically. They may be relatively asymptomatic until hemodynamic and respiratory collapse is imminent, so if there is even a remote suspicion of sepsis, they are frequently treated with antibiotics empirically until cultures are sufficiently proven to be negative. In addition to fluid resuscitation and supportive care, a common antibiotic regimen in infants with suspected sepsis is a beta-lactam antibiotic (usually ampicillin) in combination with an aminoglycoside (usually gentamicin) or a third-generation cephalosporin (usually cefotaxime — ceftriaxone is generally avoided in neonates due to the theoretical risk of causing biliary stasis.) The organisms which are targeted are species that predominate in the female genitourinary tract and to which neonates are especially vulnerable to, specifically Group B Streptococcus, Escherichia coli, and Listeria monocytogenes (This is the main rationale for using ampicillin versus other beta-lactams.) Of course, neonates are also vulnerable to other common pathogens that can cause meningitis and bacteremia such as Streptococcus pneumoniae and Neisseria meningitidis. Although uncommon, if anaerobic species are suspected (such as in cases where necrotizing enterocolitis or intestinal perforation is a concern), clindamycin is often added. Diagnosis

The identification of the causative pathogen in sepsis can provide useful information to the doctor. In the past, this has been accomplished by growing bacterial cultures. However, this is a slow process as it takes a few days to grow up the cultures and correctly identify the pathogens. New molecular diagnostic tests (e.g. Roche's SeptiFast and SIRS Labs' Vyoo) are now available that uses genetic material from the pathogen to quickly (within hours) provide results. However, current practice has been to skip these tests altogether and directly prescribe broad-spectrum antibiotics to the patient. The proposed test has a greater advantage over so far proposed tests. An 8 year old child was admitted to hospital with sepsis. The sample of blood was taken for bacteriological test (culture and antibiotic resistance). The hospital does not have a molecular laboratory. The standard antibiotic treatment with IV cefuroxime was introduced. After 70 min since antibiotic administration it was possible to obtain the first urine sample (in case of emergency when urine is not accessible it is possible to use blood serum or even saliva). The result was "probably positive", and because of the direct life threatening the test was repeated after 3 and 6 hrs of the first administration of an antibiotic, to confirm the result and monitor the efficiency of treatment as well. The above case is an example that results obtained in proposed tests are faster than all tests used so far, is simpler and cheaper.

The above test enables to detect antibiotic resistance even in case of an unknown mechanism.

Example 5 Co -infection Patient was treated with standard dose of penicillin because of gonorrhoea infection. The treatment was ineffective. The bacteriological swab was taken to evaluate its antibiotic resistance, the infectious factor was identified as Neisseria gonorrhoea penicillin (highly) susceptible. The conducted antibiotic resistance immunoenzymatic test was negative. Further investigation showed that patient was co-infected with Staphylococcus aureus which produced beta-lactamases which deactivated the given penicillins. This phenomenon also protected Neisseria gonorrhoea against penicillin. After other one course of an antibiotic, the patient recovered.

Example 6

Treatment monitoring/supervision A very important feature of the proposed antibiotic resistance diagnostic set based on the lateral flow test or lateral immunochromatographic assays is using it as a test for the efficiency of antibacterial treatment. It can be described by below example.

A patient who suffered from bacterial infection (infectious factor was penicillin resistant) apart from the other antibiotics, received a standard dose of amoxicillin 250 mg three times a day to monitor a treatment efficiency. When the given amoxicillin was detectable in the urine - it meant that infectious factor was eliminated from the organism. The results of treatment with different antibiotics are showed in table 5. Table 6 shows (as comparison) tests CRP (C-reactive protein) and ESR (Erythrocyte Sedimentation Rate) used for monitoring the treatment efficiency.

Very important feature of the proposed antibiotic resistance diagnostic set, based on the lateral flow test or lateral immunochromatographic assays, which is used as a test for the efficiency of antibacterial treatment, is that the results are not on dependnt on the patient health condition. Sometimes patient's laboratory results (e.g. CRP or ESR) are fine, but patient is critically ill. His/her results are fine because the patient's liver is so damaged that is not able to produce all these compounds. The above test is an independent test which results directly correlated with treatment efficiency.

Table 5. Screening of the efficiency treatment (amoxicillin 250 mg three times a day) during treatment below given antibiotics:

Table 6. Comparison (collected data) of time of recovery to normal values of antibiotic resistance diagnostic test vs. CRP and ESR in case of successful bacterial treatment with antibiotics.

Example 7 Screening examination

Screening examination is aimed to detect asymptomatic carries of potentially pathogenic microorganisms, which produce penicillinase. The screening is extremely important in case of persons who are exposed on occupational injuries (e.g. firemen) - in case of broken bones the wound could be settled by pathogenic microorganisms, which could be very difficult to eradicate. The screening has an importance for patients who have artificial implants (e.g. artificial heart valves, etc.) because there is a risk of serious complications in case of colonisation by pathogenic organisms. The screening is very useful for patients who have to take the antibiotics as prevention against infection (e.g. in case of cystic fibrosis, after splenectomy, after tick bit - to prevent Lyme disease etc.), in such case early detection of beta-lactamase producing bacteria helps to change ineffective antibiotic prevention.

A simple test is proposed as screening test: patient takes a standard dose of 250 mg of amoxicillin and after 6 hrs a few drops of urine is put on the lateral flow test (or lateral immunochromatographic assays). In case of positive results (when the antibiotic is detected in urine) there is a proof of proper treatment, in case of negative result (when antibiotic is not detectable) the further examination should be done to find a source of potential infection. Example 8

Antibiotic resistance detection of in case of cow's mastitis treatment.

Mastitis is the inflammation of the mammary gland. Mastitis is the most common and the most expensive disease of the cows. This disease and resulting infection can significantly reduce the amount and quality milk production. Mastitis is most commonly found in dairy herds. It is now recognised as a growing problem in beef herds, too. This is a growing problem in beef herds, and can result in weaning weights being reduced by 7% to 12.5%. The cost of one case of mastitis is about 370€. Different types of mastitis could concern from 30-80 % of the herd. Two types of mastitis (infectious and non-infectious) can occur. The vast majority (99%) of the cases is infectious. About 80-90% of all infections are caused by 3 types of bacteria: streptococci {Streptococcus agalactiae, Streptococcus dysgalactiae i Streptococcus uteris), staphylococci (e.g. Staphylococcus aureus and others,), and E. coli. Antibiotics are the main group of medications which are use in the treatment and prevention of mastitis. The efficiency of treatment is constanty decreasing (even new antibiotic generations are enter into treatment). The most important reason is that bacteria acquire resistance to widely used antibiotics. The veterinary guidelines recommend the bacterial culture with susceptibility (disk diffusion method) before treatment. Otherwise the treatment could be ineffective and a farmer would lose money because of long treatment and decreased milk production. The broad usage of the proposed new method detection of bacterial antibiotic resistance, diagnostic set based on the lateral flow test or lateral immunochromatographic assays to detect drug resistance of the contagious factor and application of detection of the drug and/or products of its/theirs degradations would bring a great efficiency in the treatment of mastitis. What could be illustrated by an example below:

Diagnosed mastitis was commenced with standard cloxacillin suspension, which was administered to an udder (500mg/10g). The drug was administered after udders' were disinfected with careful milking of the infected udder. During the next milking the milk sample was taken, the presence of antibiotic was detected what means the infectious factor is susceptible on administered antibiotic, and the therapy may be continued during the next three days in 24hrs intervals (to prevent recurrence of the disease). In case of negative result the antibiotic would have to be changed. The usage of the new lateral flow test or lateral immunochromatographic assays to detect antibiotic resistance let to decreasing the cost, the given result is faster and lead to the short the pain of the animal.

The main difference among produced lateral flow tests (lateral immunochromatographic assays, quick tests, etc) for animals so far, is that all these test were used as test for detection the pollution of food (and other materials) with antibiotic. The proposed test (and method of detection antibiotic resistance) is developed, as device, which helps to detect if administered antibiotic, is efficient in given therapy. Another differences are different concentration, which these tests detect.

Claims

Patent claims

1. A method for determining bacterial antibiotic resistance or bacterial susceptibility, characterised in that, the drug resistance is detected by detection of the given antibiotic in the urine or other body fluids with the diagnostic set based on the lateral flow test or lateral immunochromatographic assays.

2. A method according to claim 1 characterised in that said antibiotic resistance is detected when concentration of a given antibiotic or its active metabolites is lower or equal than therapeutic concentration.

3. A method according to claim 1 characterised in that said antibiotic susceptibility is detected when concentration of a given antibiotic or its active metabolites is higher or equal to therapeutic concentration.

4. A method according to claim 1 characterised in that said method concerns human and/or animal organisms.

5. A method according to claim 1 characterised in that said method could be used as screening method of healthy organisms, which could be asymptomatic carriers of antibiotic resistant bacteria.

6. A diagnostic kit based on the lateral flow test or lateral immunochromatographic assays for the detection of the antibiotic resistance of the infective factor characterised in that said kit is a diagnostic assay contains a set of antibodies, preferably monoclonal antibodies, for detection of antibiotic resistance by detection of the presence of lack of the given antibiotic wherein said antibiotics are betalactams in biological fluids, especially in urine.

7. A diagnostic set according to claim 6 characterised in that said set is useful for screening healthy organisms or monitoring treatment efficiency.

8. Use of a diagnostic kit for detection of drug presence and/or its active metabolites by detection of its concentration in comparison to the therapeutic concentration in the body fluids with the lateral flow test or lateral immunochromatographic assays in screening and treatment of patients during antibiotic therapy to the antibiotic resistance detection in screening of the antibiotic resistance of the given antibiotic.

9. Use according to claim 8, in which antibiotic resistance is stated when concentration of a drug or/and its active metabolites is lower or equal than its therapeutic concentration.

10. Use according to claim 8, in which antibiotic susceptibility is, stated when concentration of a drug or/and its active metabolites are higher or equal to its therapeutic concentration.

11. Use according to claim 6, wherein said use concerns human and/or animal organisms.

12. Use according to claim 6, which concerns screening of healthy organisms, which could be asymptomatic carriers of antibiotic resistant bacteria.