Development of resistance by Enterobacter cloacae during therapy of pulmonary infections in intensive care patients

Antibiotic definitive treatment in ventilator associated pneumonia caused by AmpC-producing Enterobacterales in critically ill patients: a prospective multicenter observational study

BACKGROUND

Ventilator associated pneumonia (VAP) due to wild-type AmpC-producing Enterobacterales (wtAE) is frequent in intensive care unit (ICU) patients. Despite a low level of evidence, definitive antimicrobial therapy (AMT) with third generation cephalosporins (3GCs) or piperacillin is discouraged.

METHODS

Observational prospective study including consecutive wtAE VAP patients in 20 French ICUs. The primary objective was to assess the association of the choice of definitive AMT, i.e. piperacillin ± tazobactam (PTZ), 3GCs or other molecule (4GCs, carbapenems, quinolones, cotrimoxazole; control group), with treatment success at day-7. Recurrence of infection was collected as a secondary outcome, and analyzed accounting for the competing risk of death.

RESULTS

From February 2021 to June 2022, 274 patients were included. Enterobacter cloacae was the most prevalent specie (31%). Seventy-eight patients (28%) had PTZ as definitive AMT while 44 (16%) had 3GCs and 152 (56%) were classified in the control group. Day-7 success rate was similar between the 3 groups (74% vs. 73% vs. 68% respectively, p = 0.814). Recurrence probability at day-28 was 31% (95% CI 21-42), 40% (95% CI 26-55) and 21% (95% CI 15-28) for PTZ, 3GCs and control groups (p = 0.020). In multivariable analysis, choice of definitive AMT was not associated with clinical success, but definitive AMT with 3GCs was associated with recurrence at day-28 [csHR(95%CI) 10.9 (1.92-61.91)].

CONCLUSION

Choice of definitive antimicrobial therapy was not associated with treatment success at day 7. However, recurrence of pneumonia at day-28 was higher in patients treated with third generation cephalosporins with no differences in mortality or mechanical ventilation duration.

Clinical outcome of wild-type AmpC-producing Enterobacterales infection in critically ill patients treated with β-lactams: a prospective multicenter study

Background

β-lactams are the main antibiotics used against wild-type AmpC-producing Enterobacterales (wtAE). However, they may fail or select AmpC-overproducing mutants. Our aim was to assess factors associated with clinical failure of β-lactams in the treatment of wtAE infection.

Methods

From September 2017 to December 2020, we prospectively included all consecutive patients treated by definitive β-lactams therapy for wtAE infection in four university ICUs. Clinical failure was defined as inadequate response to antimicrobial therapy leading to death or to the switch for a broader-spectrum antibiotic.

Results

177 patients were included and 29.4% progressed to clinical failure. E. cloacae was the most prevalent species (42.4%) and ventilator-associated pneumonia (VAP) was the most frequent wtAE infection (69.5%). Cefepime and cefotaxime were used as definitive antibiotic treatment in 42.9% and 27.7% of patients, respectively. Occurrence of AmpC-overproduction was documented in 5.6% of patients and was associated with clinical failure (p = 0.004). In multivariate analysis, VAP (p < 0.001, OR 11.58 [95% CI 3.11–43.02] and K. aerogenes (p = 0.030, OR 3.76 [95% CI 1.13–12.46]) were independently associated with clinical failure. Conversely, cefotaxime as definitive treatment was found inversely associated with the risk of clinical failure (p = 0.022, OR 0.25 [95% CI 0.08–0.82]). After inverse probability weighting, cefotaxime showed a 20% risk reduction of clinical failure (95% CI  5–35%, p = 0.007) whatever the location of infection, the SOFA score on the day of wtAE infection, or the bacterial species.

Conclusions

Clinical failure in the treatment of wtAE infections is associated with the infection site and the causal microorganism. Additionally, cefotaxime use is probably protective against clinical failure in wtAE infection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-01079-5.

Enterobacter cloacae: an "ICU bug" causing community acquired necrotizing meningo-encephalitis

Enterobacter cloacae is a gram negative bacillus that is ubiquitous as a contaminant and a pathogen in adult, paediatric, and neonatal ICUs. Its transmission is almost exclusively nosocomial with community acquired infection reported rarely. We report a case of community acquired, rapidly progressive E. cloacae meningo-encephalitis in a neonate. A three-week-old term infant presented from home, having been discharged from hospital within two days of delivery. She rapidly progressed to multi-organ dysfunction. Initial CT of her brain showed evidence of severe hypoxic changes and herniation of the frontal lobes through the anterior fontanelle. Care was withdrawn 72 hours after admission. Post mortem examination confirmed E.cloacae meningo-encephalitis as a cause of her death. The baby had not been in a critical care environment at any time before admission, making it highly likely to have been a community acquired infection. Transmission of the organism may have been vertical as maternal transmission with intestinal colonization of neonates with E. cloacae has previously been reported. This case confirms that infection with E. cloacae should be included in the differential diagnosis of any severely ill neonate presenting from the community, and antimicrobial therapy should be optimized accordingly.

beta-Lactamase induction and cell wall recycling in gram-negative bacteria

beta-Lactams with the ability to induce beta-lactamase in gram-negative bacteria bind to essential penicillin-binding proteins (PBPs) after entering the periplasmic space. This leads to inactivation of transpeptidase activities and thereby a decrease in the number of peptide cross-links, allowing further degradation of murein by soluble lytic transglycosylases. If all DD-carboxypeptidases (PBP 4, 5, 6a and 6b) are inhibited as well, the degradation product aD-pentapeptide (N-acetylglucosaminyl-1,6-anhydro-N-acetylmuramyl-L-alanyl-D-glutamyl-meso-diaminopimelic-acid-D-alanyl-D- alanine) accumulates, which is the case with inducing beta-lactams such as imipenem. These molecules in addition to tri- and tetrapeptides (N-acetylglucosaminyl-1,6-anhydro-N-acetylmuramyl-L-alanyl-D-glutamyl-meso-diaminopimelic-acid-[D-alanine]) which are the usual degradation products of peptidoglycan, are released into the cytoplasm and displace the UDP-pentapeptide (UDP-N-acetylmuramyl-L-alanyl-D-glutamyl-meso-diaminopimelic-acid-D-alanyl-D-alanine) from the DNA-binding protein AmpR, converting it into an activator of AmpC beta-lactamase expression.

Tigecycline: The answer to beta-lactam and fluoroquinolone resistance?

Patients with serious bacterial infections such as intra-abdominal infections and complicated skin and soft tissue infections are often treated empirically because a delay in appropriate initial antimicrobial therapy has been shown to significantly increase morbidity and mortality. Furthermore, pathogens that have developed resistance to mainstay therapeutic options are increasing in prevalence making these infections a challenge for physicians. Treatment guidelines for surgical and intra-abdominal infections recommend selection of an agent or a combination of agents with activity to cover both Gram-positive, Gram-negative organisms and anaerobes. Recommended agents include second-generation cephalosporins with anaerobic coverage, beta-lactam/beta-lactamase inhibitor agents, fluoroquinolone/metronidazole combinations and carbapenems. However, the effectiveness of these agents has come into question as once susceptible organisms are now showing signs of resistance to such antimicrobial therapies. Alternative agents specifically designed to overcome mechanisms of microbial resistance have been sought. The result of that search has been the development of a new class of antimicrobials termed glycylcyclines. The first of these novel antibacterials is tigecycline, with a broad spectrum of activity that includes coverage against vancomycin-resistant enterococci, methicillin-resistant S. aureus, and many species of multidrug-resistant Gram-negative bacteria. Tigecycline also has activity against most penicillin-susceptible and resistant Gram-positive organisms. Clinical trial experience with tigecycline has shown it to be at least as effective as current recommended regimens for the treatment of intra-abdominal infections and complicated skin and soft tissue infections. This new agent thus holds promise as an alternative to the beta-lactams and fluoroquinolones for the initial empiric treatment of serious bacterial infections.

Growth of cell-wall-deficient variants of Enterobacter cloacae facilitates beta-lactamase derepressed mutants

The degree to which cell-wall-deficient bacteria (CWDB) are involved in the generation of beta-lactamase derepressed mutants (DM) was measured using Enterobacter cloacae 3624. The frequency of DM in non-permissive isotonic ticarcillin medium was compared with their frequency in hypertonic ticarcillin medium that supports CWDB growth. DM were resistant to extended spectrum penicillins and cephalosporins and had a basal beta-lactamase activity of >300 units/mg protein. Anaerobic growth of CWDB increased the relative risk of DM 2 x 10(6)-fold. Aerobic incubation produced fewer CWDB colonies but the risk of DM was still increased 400-fold over non-permissive controls. These results define a new role for CWDB as intermediaries in the emergence of resistance.

Monotherapy versus combination therapy for bacterial infections

The authors discuss the latest findings regarding the use of one or more antimicrobial drugs for a variety of infections. They offer suggestions for treatment based on a host of considerations, including the synergy and antagonism of specific drugs, type of infection, potential toxicities, and cost.

Spectrum and transferability of beta-lactam resistance in hospital strains of Enterobacter isolated in Bratislava and Innsbruck

The transferability and expression of beta-lactam resistance were compared in multiresistant clinical isolates of Enterobacter spp. collected from different hospitals in Bratislava, Slovakia (n = 15) and Innsbruck, Austria (n = 19) during 1996-1997. The strains from Bratislava were resistant to ampicillin, cefoxitin, cefotaxime, ceftazidime and ceftriaxone. All strains from Innsbruck were resistant to ampicillin and cefoxitin; 17 were also resistant to ceftazidime and aztreonam but the majority remained susceptible to cefotaxime and ceftriaxone. All strains were susceptible to cefepime and imipenem. The majority of the tested strains transferred resistance determinants to E. coli recipient by conjugation. Production of beta-lactamase including ESBL was the major mechanism of beta-lactam resistance. Large plasmids of 77-88 and 91 kb were confirmed in clinical isolates from Bratislava and Innsbruck.

The signal molecule for beta-lactamase induction in Enterobacter cloacae is the anhydromuramyl-pentapeptide

Beta-lactamase induction in Enterobacter cloacae, which is linked to peptidoglycan recycling, was investigated by high-performance liquid chromatographic analysis of cell wall fragments in genetically defined cells of Escherichia coli. After treatment of cells with beta-lactams, we detected an increase in a D-tripeptide (disaccharide-tripeptide, N-acetylglucosaminyl-1,6-anhydro-N-acetylmuramyl-L-alanyl-D-glutamyl-mes o-diaminopimelic acid), aD-tetrapeptide (disaccharide-tetrapeptide, N-acetylglucosaminyl-1,6-anhydro-N-acetylmuramyl-L-alanyl-D-glutamyl-mes o-diaminopimelic acid-D-alanine), and aD-pentapeptide (disaccharide-pentapeptide, N-acetylglucosaminyl-1,6-anhydro-N-acetylmuramyl-L-alanyl-D-glutamyl-mes o-diaminopimelic acid-D-alanyl-D-alanine)levels in the periplasms of bacterial cells. Furthermore, only the accumulation of aD-pentapeptide correlates with the beta-lactamase-inducing capacity of the beta-lactam antibiotic. The transmembrane protein AmpG transports all three aD-peptides into the cytoplasm, where they are degraded into the corresponding monosaccharide peptides. In the absence of AmpD the constitutive overproduction of beta-lactamase is accompanied by an accumulation of aM-tripeptide (monosaccharide-tripeptide, anhydro-N-acetylmuramyl-L-alanyl-D-glutamyl-meso-diaminopimelic acid) and aM-pentapeptide (L1,6-anhydro-N-acetylmuramyl-L-alanyl-D-glutamyl-meso-diaminopimelic acid-D-alanyl-D-alanine), but not aM-tetrapeptide (anhydro-N-acetylmuramyl-L-alanyl-D-glutamyl-meso-diaminopimelic acid-D-alanine), in the cytoplasm. Only the amount of aM-pentapeptide is increased upon treatment with imipenem. These findings indicate that aD-pentapeptide is the main periplasmic muropeptide, which is converted into the cytoplasmic signal molecule for beta-lactamase induction, the aM-pentapeptide.

Cefotaxime. A reappraisal of its antibacterial activity and pharmacokinetic properties, and a review of its therapeutic efficacy when administered twice daily for the treatment of mild to moderate infections

Cefotaxime is well established as an effective and well tolerated antibacterial drug for 3 times daily parenteral treatment of a variety of moderate to severe infections in hospitalised patients. Its frequency of administration has recently been reassessed with a 12-hourly regimen. Comparative studies in hospitalised patients with nosocomial or community-acquired lower respiratory tract infections, demonstrate the similar clinical and bacteriological efficacy of twice daily cefotaxime 1 or 2 g and the same daily dose of ceftriaxone, usually administered once daily. Cefotaxime 2 g twice daily was also similar in efficacy to ceftriaxone 2 g once daily. Retrospective and post-marketing studies also reveal the similar efficacy of cefotaxime administered twice and 3 times daily, and pharmacoeconomic studies suggest that total direct costs of treatment with cefotaxime compared is similar to that with other third generation cephalosporins in currently used dosage regimens. When administered twice daily, cefotaxime is, thus, an effective antibacterial agent for the treatment of hospitalised patients outside the intensive care unit with a variety of mild to moderate non-CNS infections caused by susceptible organisms. When appropriately administered twice daily there is potential to lower the cost of antibacterial treatment without compromising efficacy.