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Eggers O, Renschler FA, Michalek LA, Wackler N, Walter E, Smollich F, Klein K, Sonnabend MS, Egle V, Angelov A, Engesser C, Borisova M, Mayer C, Schütz M, Bohn E. YgfB increases β-lactam resistance in Pseudomonas aeruginosa by counteracting AlpA-mediated ampDh3 expression. Commun Biol 2023; 6:254. [PMID: 36894667 PMCID: PMC9998450 DOI: 10.1038/s42003-023-04609-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 02/17/2023] [Indexed: 03/11/2023] Open
Abstract
YgfB-mediated β-lactam resistance was recently identified in multi drug resistant Pseudomonas aeruginosa. We show that YgfB upregulates expression of the β-lactamase AmpC by repressing the function of the regulator of the programmed cell death pathway AlpA. In response to DNA damage, the antiterminator AlpA induces expression of the alpBCDE autolysis genes and of the peptidoglycan amidase AmpDh3. YgfB interacts with AlpA and represses the ampDh3 expression. Thus, YgfB indirectly prevents AmpDh3 from reducing the levels of cell wall-derived 1,6-anhydro-N-acetylmuramyl-peptides, required to induce the transcriptional activator AmpR in promoting the ampC expression and β-lactam resistance. Ciprofloxacin-mediated DNA damage induces AlpA-dependent production of AmpDh3 as previously shown, which should reduce β-lactam resistance. YgfB, however, counteracts the β-lactam enhancing activity of ciprofloxacin by repressing ampDh3 expression and lowering the benefits of this drug combination. Altogether, YgfB represents an additional player in the complex regulatory network of AmpC regulation.
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Affiliation(s)
- Ole Eggers
- Institute for Medical Microbiology and Hygiene, Interfaculty Institute of Microbiology and Infection Medicine (IMIT), Eberhard Karls University Tübingen, Tübingen, Germany
| | - Fabian A Renschler
- Institute for Medical Microbiology and Hygiene, Interfaculty Institute of Microbiology and Infection Medicine (IMIT), Eberhard Karls University Tübingen, Tübingen, Germany
- German Centre for Infection Research (DZIF), Partner Site Tübingen, Tübingen, Germany
| | - Lydia Anita Michalek
- Institute for Medical Microbiology and Hygiene, Interfaculty Institute of Microbiology and Infection Medicine (IMIT), Eberhard Karls University Tübingen, Tübingen, Germany
| | - Noelle Wackler
- Institute for Medical Microbiology and Hygiene, Interfaculty Institute of Microbiology and Infection Medicine (IMIT), Eberhard Karls University Tübingen, Tübingen, Germany
| | - Elias Walter
- Institute for Medical Microbiology and Hygiene, Interfaculty Institute of Microbiology and Infection Medicine (IMIT), Eberhard Karls University Tübingen, Tübingen, Germany
| | - Fabian Smollich
- Institute for Medical Microbiology and Hygiene, Interfaculty Institute of Microbiology and Infection Medicine (IMIT), Eberhard Karls University Tübingen, Tübingen, Germany
| | - Kristina Klein
- Institute for Medical Microbiology and Hygiene, Interfaculty Institute of Microbiology and Infection Medicine (IMIT), Eberhard Karls University Tübingen, Tübingen, Germany
| | - Michael S Sonnabend
- Institute for Medical Microbiology and Hygiene, Interfaculty Institute of Microbiology and Infection Medicine (IMIT), Eberhard Karls University Tübingen, Tübingen, Germany
- NGS Competence Center Tübingen (NCCT), Institute for Medical Microbiology and Hygiene, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Valentin Egle
- Institute for Medical Microbiology and Hygiene, Interfaculty Institute of Microbiology and Infection Medicine (IMIT), Eberhard Karls University Tübingen, Tübingen, Germany
- Cluster of Excellence "Controlling Microbes to Fight Infections", University of Tübingen, Tübingen, Germany
| | - Angel Angelov
- NGS Competence Center Tübingen (NCCT), Institute for Medical Microbiology and Hygiene, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Christina Engesser
- NGS Competence Center Tübingen (NCCT), Institute for Medical Microbiology and Hygiene, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Marina Borisova
- Cluster of Excellence "Controlling Microbes to Fight Infections", University of Tübingen, Tübingen, Germany
- Department of Biology, Organismic Interactions/Glycobiology, Interfaculty Institute of Microbiology and Infection Medicine (IMIT), Eberhard Karls University Tübingen, Tübingen, Germany
| | - Christoph Mayer
- Cluster of Excellence "Controlling Microbes to Fight Infections", University of Tübingen, Tübingen, Germany
- Department of Biology, Organismic Interactions/Glycobiology, Interfaculty Institute of Microbiology and Infection Medicine (IMIT), Eberhard Karls University Tübingen, Tübingen, Germany
| | - Monika Schütz
- Institute for Medical Microbiology and Hygiene, Interfaculty Institute of Microbiology and Infection Medicine (IMIT), Eberhard Karls University Tübingen, Tübingen, Germany
- German Centre for Infection Research (DZIF), Partner Site Tübingen, Tübingen, Germany
| | - Erwin Bohn
- Institute for Medical Microbiology and Hygiene, Interfaculty Institute of Microbiology and Infection Medicine (IMIT), Eberhard Karls University Tübingen, Tübingen, Germany.
- German Centre for Infection Research (DZIF), Partner Site Tübingen, Tübingen, Germany.
- Cluster of Excellence "Controlling Microbes to Fight Infections", University of Tübingen, Tübingen, Germany.
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Use of the Hollow-Fiber Infection Model to Measure the Effect of Combination Therapy of Septic Shock Exposures of Meropenem and Ciprofloxacin against Intermediate and Resistant Pseudomonas aeruginosa Clinical Isolates. Antimicrob Agents Chemother 2022; 66:e0214021. [PMID: 35389238 DOI: 10.1128/aac.02140-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Meropenem-ciprofloxacin combination therapy was compared to the respective monotherapy in a Hollow-Fiber Infection Model against two Pseudomonas aeruginosa isolates. Following initial kill of ∼ 5-logs by each monotherapy, rapid regrowth occurred within 24 h, reaching 108 - 1010 CFU/mL at 120 h. In contrast, combination therapy achieved > 5-log kill within 6 h and suppressed bacterial regrowth throughout. The results suggest that meropenem-ciprofloxacin combination may provide significantly enhanced bacterial killing and resistance suppression against P. aeruginosa.
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Malawong S, Thammawithan S, Sirithongsuk P, Daduang S, Klaynongsruang S, Wong PT, Patramanon R. Silver Nanoparticles Enhance Antimicrobial Efficacy of Antibiotics and Restore That Efficacy against the Melioidosis Pathogen. Antibiotics (Basel) 2021; 10:839. [PMID: 34356761 PMCID: PMC8300767 DOI: 10.3390/antibiotics10070839] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/02/2021] [Accepted: 07/07/2021] [Indexed: 11/17/2022] Open
Abstract
Melioidosis is an infectious disease caused by Gram-negative bacillus bacteria Burkholderia pseudomallei. Due to the emerging resistance of B. pseudomallei to antibiotics including ceftazidime (CAZ), the development of novel antibiotics and alternative modes of treatment has become an urgent issue. Here, we demonstrated an ability to synergistically increase the efficiency of antibiotics through their combination with silver nanoparticles (AgNPs). Combinations of four conventional antibiotics including CAZ, imipenem (IMI), meropenem (MER), and gentamicin sulfate (GENT) with starch-stabilized AgNPs were tested for their antibacterial effects against three isolates of B. pseudomallei. The combination of each antibiotic with AgNPs featured fractional inhibitory concentration (FIC) index values and fractional bactericidal concentration (FBC) index values ranging from 0.312 to 0.75 µg/mL and 0.252 to 0.625 µg/mL, respectively, against the three isolates of B. pseudomallei. The study clearly showed that most of the combinatorial treatments exhibited synergistic antimicrobial effects against all three isolates of B. pseudomallei. The highest enhancing effect was observed for GENT with AgNPs. These results confirmed the combination of each antibiotic with AgNPs restored their bactericidal potency in the bacterial strains that had previously been shown to be resistant to the antibiotics. In addition, morphological changes examined by SEM confirmed that the bacterial cells were severely damaged by combinations at the FBC level. Although bacteria produce fibers to protect themselves, ultimately the bacteria were killed by the antibiotic-AgNPs combinations. Overall, these results suggest the study of antibiotic-AgNPs combinations as an alternative design strategy for potential therapeutics to more effectively combat the melioidosis pathogen.
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Affiliation(s)
- Sathit Malawong
- Department of Biochemistry, Faculty of Science, Khon Kaen University, Khon Kaen 40002, Thailand; (S.M.); (S.T.); (P.S.); (S.K.)
- Protein and Proteomics Research Center for Commercial and Industrial Purposes (ProCCI), Faculty of Science, Khon Kaen University, Khon Kaen 40002, Thailand;
| | - Saengrawee Thammawithan
- Department of Biochemistry, Faculty of Science, Khon Kaen University, Khon Kaen 40002, Thailand; (S.M.); (S.T.); (P.S.); (S.K.)
| | - Pawinee Sirithongsuk
- Department of Biochemistry, Faculty of Science, Khon Kaen University, Khon Kaen 40002, Thailand; (S.M.); (S.T.); (P.S.); (S.K.)
| | - Sakda Daduang
- Protein and Proteomics Research Center for Commercial and Industrial Purposes (ProCCI), Faculty of Science, Khon Kaen University, Khon Kaen 40002, Thailand;
- Division of Pharmacognosy and Toxicology, Faculty of Pharmaceutical Sciences, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Sompong Klaynongsruang
- Department of Biochemistry, Faculty of Science, Khon Kaen University, Khon Kaen 40002, Thailand; (S.M.); (S.T.); (P.S.); (S.K.)
- Protein and Proteomics Research Center for Commercial and Industrial Purposes (ProCCI), Faculty of Science, Khon Kaen University, Khon Kaen 40002, Thailand;
| | - Pamela T. Wong
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48109, USA;
- Michigan Nanotechnology Institute for Medicine and Biological Sciences, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Rina Patramanon
- Department of Biochemistry, Faculty of Science, Khon Kaen University, Khon Kaen 40002, Thailand; (S.M.); (S.T.); (P.S.); (S.K.)
- Protein and Proteomics Research Center for Commercial and Industrial Purposes (ProCCI), Faculty of Science, Khon Kaen University, Khon Kaen 40002, Thailand;
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Scudeller L, Righi E, Chiamenti M, Bragantini D, Menchinelli G, Cattaneo P, Giske CG, Lodise T, Sanguinetti M, Piddock LJV, Franceschi F, Ellis S, Carrara E, Savoldi A, Tacconelli E. Systematic review and meta-analysis of in vitro efficacy of antibiotic combination therapy against carbapenem-resistant Gram-negative bacilli. Int J Antimicrob Agents 2021; 57:106344. [PMID: 33857539 DOI: 10.1016/j.ijantimicag.2021.106344] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/26/2021] [Accepted: 04/03/2021] [Indexed: 01/23/2023]
Abstract
The superiority of combination therapy for carbapenem-resistant Gram-negative bacilli (CR-GNB) infections remains controversial. In vitro models may predict the efficacy of antibiotic regimens against CR-GNB. A systematic review and meta-analysis was performed including pharmacokinetic/pharmacodynamic (PK/PD) and time-kill (TK) studies examining the in vitro efficacy of antibiotic combinations against CR-GNB [PROSPERO registration no. CRD42019128104]. The primary outcome was in vitro synergy based on the effect size (ES): high, ES ≥ 0.75, moderate, 0.35 < ES < 0.75; low, ES ≤ 0.35; and absent, ES = 0). A network meta-analysis assessed the bactericidal effect and re-growth rate (secondary outcomes). An adapted version of the ToxRTool was used for risk-of-bias assessment. Over 180 combination regimens from 136 studies were included. The most frequently analysed classes were polymyxins and carbapenems. Limited data were available for ceftazidime/avibactam, ceftolozane/tazobactam and imipenem/relebactam. High or moderate synergism was shown for polymyxin/rifampicin against Acinetobacter baumannii [ES = 0.91, 95% confidence interval (CI) 0.44-1.00], polymyxin/fosfomycin against Klebsiella pneumoniae (ES = 1.00, 95% CI 0.66-1.00) and imipenem/amikacin against Pseudomonas aeruginosa (ES = 1.00, 95% CI 0.21-1.00). Compared with monotherapy, increased bactericidal activity and lower re-growth rates were reported for colistin/fosfomycin and polymyxin/rifampicin in K. pneumoniae and for imipenem/amikacin or imipenem/tobramycin against P. aeruginosa. High quality was documented for 65% and 53% of PK/PD and TK studies, respectively. Well-designed in vitro studies should be encouraged to guide the selection of combination therapies in clinical trials and to improve the armamentarium against carbapenem-resistant bacteria.
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Affiliation(s)
- Luigia Scudeller
- Clinical Epidemiology and Biostatistics, IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano Foundation, Milan, Italy
| | - Elda Righi
- Division of Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, P.Le L.A. Scuro 10, 37134 Verona, Italy
| | - Margherita Chiamenti
- Division of Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, P.Le L.A. Scuro 10, 37134 Verona, Italy
| | - Damiano Bragantini
- Division of Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, P.Le L.A. Scuro 10, 37134 Verona, Italy
| | - Giulia Menchinelli
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy; Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Paolo Cattaneo
- Division of Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, P.Le L.A. Scuro 10, 37134 Verona, Italy
| | - Christian G Giske
- Clinical Microbiology, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Thomas Lodise
- Albany College of Pharmacy and Health Sciences, Albany, New York, USA
| | - Maurizio Sanguinetti
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy; Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Laura J V Piddock
- Global Antibiotic Research & Development Partnership (GARDP), 15 Chemin Louis-Dunant, Geneva, Switzerland
| | - François Franceschi
- Global Antibiotic Research & Development Partnership (GARDP), 15 Chemin Louis-Dunant, Geneva, Switzerland
| | - Sally Ellis
- Global Antibiotic Research & Development Partnership (GARDP), 15 Chemin Louis-Dunant, Geneva, Switzerland
| | - Elena Carrara
- Division of Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, P.Le L.A. Scuro 10, 37134 Verona, Italy
| | - Alessia Savoldi
- Division of Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, P.Le L.A. Scuro 10, 37134 Verona, Italy
| | - Evelina Tacconelli
- Division of Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, P.Le L.A. Scuro 10, 37134 Verona, Italy; Division of Infectious Diseases, Department of Internal Medicine I, German Center for Infection Research, University of Tübingen, Otfried Müller Straße 12, 72074 Tübingen, Germany; German Centre for Infection Research (DZIF), Clinical Research Unit for Healthcare Associated Infections, Tübingen, Germany.
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Clinically Relevant Epithelial Lining Fluid Concentrations of Meropenem with Ciprofloxacin Provide Synergistic Killing and Resistance Suppression of Hypermutable Pseudomonas aeruginosa in a Dynamic Biofilm Model. Antimicrob Agents Chemother 2020; 64:AAC.00469-20. [PMID: 32366710 DOI: 10.1128/aac.00469-20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 04/20/2020] [Indexed: 01/18/2023] Open
Abstract
Treatment of exacerbations of chronic Pseudomonas aeruginosa infections in patients with cystic fibrosis (CF) is highly challenging due to hypermutability, biofilm formation, and an increased risk of resistance emergence. We evaluated the impact of ciprofloxacin and meropenem as monotherapy and in combination in the dynamic in vitro CDC biofilm reactor (CBR). Two hypermutable P. aeruginosa strains, PAOΔmutS (MIC of ciprofloxacin [MICciprofloxacin], 0.25 mg/liter; MICmeropenem, 2 mg/liter) and CW44 (MICciprofloxacin, 0.5 mg/liter; MICmeropenem, 4 mg/liter), were investigated for 120 h. Concentration-time profiles achievable in epithelial lining fluid (ELF) following FDA-approved doses were simulated in the CBR. Treatments were ciprofloxacin at 0.4 g every 8 h as 1-h infusions (80% ELF penetration), meropenem at 6 g/day as a continuous infusion (CI) (30% and 60% ELF penetration), and their combinations. Counts of total and less-susceptible planktonic and biofilm bacteria and MICs were determined. Antibiotic concentrations were quantified by an ultrahigh-performance liquid chromatography photodiode array (UHPLC-PDA) assay. For both strains, all monotherapies failed, with substantial regrowth and resistance of planktonic (≥8 log10 CFU/ml) and biofilm (>8 log10 CFU/cm2) bacteria at 120 h (MICciprofloxacin, up to 8 mg/liter; MICmeropenem, up to 64 mg/liter). Both combination treatments demonstrated synergistic bacterial killing of planktonic and biofilm bacteria of both strains from ∼48 h onwards and suppressed regrowth to ≤4 log10 CFU/ml and ≤6 log10 CFU/cm2 at 120 h. Overall, both combination treatments suppressed the amplification of resistance of planktonic bacteria for both strains and of biofilm bacteria for CW44. The combination with meropenem at 60% ELF penetration also suppressed the amplification of resistance of biofilm bacteria for PAOΔmutS Thus, combination treatment demonstrated synergistic bacterial killing and resistance suppression against difficult-to-treat hypermutable P. aeruginosa strains.
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Gai XY, Bo SN, Shen N, Zhou QT, Yin AY, Lu W. Pharmacokinetic-pharmacodynamic analysis of ciprofloxacin in elderly Chinese patients with lower respiratory tract infections caused by Gram-negative bacteria. Chin Med J (Engl) 2019; 132:638-646. [PMID: 30855292 PMCID: PMC6416024 DOI: 10.1097/cm9.0000000000000136] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: Ciprofloxacin is usually used in the treatment of lower respiratory tract infections (LRTIs). Recent studies abroad have shown ciprofloxacin is inadequately dosed and might lead to worse outcomes. The aim of this study was to perform pharmacokinetic and pharmacodynamic analyses of ciprofloxacin in elderly Chinese patients with severe LRTIs caused by Gram-negative bacteria. Methods: From September 2012 to June 2014, as many as 33 patients were empirically administered beta-lactam and ciprofloxacin combination therapy. Patients were infused with 200 or 400 mg of ciprofloxacin every 12 h, which was determined empirically by the attending physician based on the severity of the LRTI and the patient's renal condition. Ciprofloxacin serum concentrations were determined by high-performance liquid chromatography. Bacterial culture was performed from sputum samples and/or endotracheal aspirates, and the minimum inhibitory concentrations (MICs) of ciprofloxacin were determined. The ratios of the area under the serum concentration-time curve to the MIC (AUC/MIC) and of the maximum serum concentration of the drug to the MIC (Cmax/MIC) were calculated. The baseline data and pharmacokinetic parameters were compared between clinical success group and clinical failure group, bacteriologic success group and bacteriologic failure group. Results: Among the 33 patients enrolled in the study, 17 were infected with Pseudomonas aeruginosa, 14 were infected with Acinetobacter baumannii, and two were infected with Klebsiella pneumoniae. The mean age of the patients was 76.9 ± 6.7 years. Thirty-one patients (93.4%) did not reach the target AUC/MIC value of >125, and 29 patients (87.9%) did not reach the target Cmax/MIC value of >8. The AUC/MIC and Cmax/MIC ratios in the clinical success group were significantly higher than those in the clinical failure group (61.1 [31.7–214.9] vs. 10.4 [3.8–66.1], Z = −4.157; 9.6 [4.2–17.8] vs. 1.3 [0.4–4.7], Z = −4.018; both P < 0.001). The AUC/MIC and Cmax/MIC ratios in the patients for whom the pathogens were eradicated were significantly higher than those in the patients without the pathogens eradicated (75.3 [31.7–214.9] vs. 10.5 [3.8–66.1], Z = −3.938; 11.4 [4.2–17.8] vs. 1.4 [0.4–5.4], Z = −3.793; P < 0.001 for both). Receiver operating characteristic curve analysis showed that the AUC/MIC and Cmax/MIC values were closely associated with clinical and bacteriologic efficacies (P < 0.001 in both). Conclusions: Ciprofloxacin is inadequately dosed against Gram-negative bacteria, especially for those with relatively high MIC values. Consequently, the target values, AUC/MIC > 125 and Cmax/MIC > 8, cannot be reached.
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Affiliation(s)
- Xiao-Yan Gai
- Department of Pulmonary and Critical Care Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Shi-Ning Bo
- Intensive Care Unit, Peking University Third Hospital, Beijing 100191, China
| | - Ning Shen
- Department of Pulmonary and Critical Care Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Qing-Tao Zhou
- Department of Pulmonary and Critical Care Medicine, Peking University Third Hospital, Beijing 100191, China
| | - An-Yue Yin
- School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Wei Lu
- School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
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Meropenem Combined with Ciprofloxacin Combats Hypermutable Pseudomonas aeruginosa from Respiratory Infections of Cystic Fibrosis Patients. Antimicrob Agents Chemother 2018; 62:AAC.01150-18. [PMID: 30104278 DOI: 10.1128/aac.01150-18] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 08/08/2018] [Indexed: 12/11/2022] Open
Abstract
Hypermutable Pseudomonas aeruginosa organisms are prevalent in chronic respiratory infections and have been associated with reduced lung function in cystic fibrosis (CF); these isolates can become resistant to all antibiotics in monotherapy. This study aimed to evaluate the time course of bacterial killing and resistance of meropenem and ciprofloxacin in combination against hypermutable and nonhypermutable P. aeruginosa Static concentration time-kill experiments over 72 h assessed meropenem and ciprofloxacin in mono- and combination therapies against PAO1 (nonhypermutable), PAOΔmutS (hypermutable), and hypermutable isolates CW8, CW35, and CW44 obtained from CF patients with chronic respiratory infections. Meropenem (1 or 2 g every 8 h [q8h] as 3-h infusions and 3 g/day as a continuous infusion) and ciprofloxacin (400 mg q8h as 1-h infusions) in monotherapies and combinations were further evaluated in an 8-day hollow-fiber infection model study (HFIM) against CW44. Concentration-time profiles in lung epithelial lining fluid reflecting the pharmacokinetics in CF patients were simulated and counts of total and resistant bacteria determined. All data were analyzed by mechanism-based modeling (MBM). In the HFIM, all monotherapies resulted in rapid regrowth with resistance at 48 h. The maximum daily doses of 6 g meropenem (T>MIC of 80% to 88%) and 1.2 g ciprofloxacin (area under the concentration-time curve over 24 h in the steady state divided by the MIC [AUC/MIC], 176), both given intermittently, in monotherapy failed to suppress regrowth and resulted in substantial emergence of resistance (≥7.6 log10 CFU/ml resistant populations). The combination of these regimens achieved synergistic killing and suppressed resistance. MBM with subpopulation and mechanistic synergy yielded unbiased and precise curve fits. Thus, the combination of 6 g/day meropenem plus ciprofloxacin holds promise for future clinical evaluation against infections by susceptible hypermutable P. aeruginosa.
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Structural changes and differentially expressed genes in Pseudomonas aeruginosa exposed to meropenem-ciprofloxacin combination. Antimicrob Agents Chemother 2014; 58:3957-67. [PMID: 24798291 DOI: 10.1128/aac.02584-13] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The effect of a meropenem-ciprofloxacin combination (MCC) on the susceptibility of multidrug-resistant (MDR) Pseudomonas aeruginosa (MRPA) clinical isolates was determined using checkerboard and time-kill curve techniques. Structural changes and differential gene expression that resulted from the synergistic action of the MCC against one of the P. aeruginosa isolates (1071-MRPA]) were evaluated using electron microscopy and representational difference analysis (RDA), respectively. The differentially expressed, SOS response-associated, and resistance-associated genes in 1071-MRPA exposed to meropenem, ciprofloxacin, and the MCC were monitored by quantitative PCR. The MCC was synergistic against 25% and 40.6% of MDR P. aeruginosa isolates as shown by the checkerboard and time-kill curves, respectively. The morphological and structural changes that resulted from the synergistic action of the MCC against 1071-MRPA were a summation of the effects observed with each antimicrobial alone. One exception included outer membrane vesicles, which were seen in a greater amount upon ciprofloxacin exposure but were significantly inhibited upon MCC exposure. Cell wall- and DNA repair-associated genes were differentially expressed in 1071-MRPA exposed to meropenem, ciprofloxacin, and the MCC. However, some of the RDA-detected, resistance-associated, and SOS response-associated genes were expressed at significantly lower levels in 1071-MRPA exposed to the MCC. The MCC may be an alternative for the treatment of MDR P. aeruginosa. The effect of this antimicrobial combination may be not only the result of a summation of the effects of meropenem and ciprofloxacin but also a result of differential action that likely inhibits protective mechanisms in the bacteria.
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Santos DAFD, Nascimento MMP, Vitali LH, Martinez R. In vitro activity of antimicrobial combinations against multidrug-resistant Pseudomonas aeruginosa. Rev Soc Bras Med Trop 2014; 46:299-303. [PMID: 23856877 DOI: 10.1590/0037-8682-0012-2013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 05/15/2013] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Pseudomonas aeruginosa isolates related to nosocomial infections are often resistant to multiple antibacterial agents. In this study, antimicrobial combinations were evaluated to detect in vitro synergy against clinical isolates of P. aeruginosa. METHODS Four clinical P. aeruginosa isolates were selected at random among other isolates from inpatients treated at the public University hospital in Ribeirão Preto, SP, Brazil. Two isolates were susceptible to imipenem (IPM-S) and several other antimicrobials, while the other two isolates were imipenem and multidrug resistant (IPM-R). The checkerboard method was used to assess the interactions between antimicrobials. RESULTS Combinations of imipenem or other anti-Pseudomonas drugs with complementary antibiotics, such as aminoglycosides, fosfomycin and rifampin, reached synergy rates of 20.8%, 50%, 62.5% and 50% for the two IPM-S and two IPM-R Pseudomonas isolates, respectively. Imipenem, piperacillin-tazobactam and ceftazidime yielded a greater synergy rate than cefepime or ciprofloxacin. Synergist combinations were more commonly observed when the complementary drug was tobramycin (65%) or fosfomycin (57%). CONCLUSIONS Some antibacterial combinations led to significant reductions of the minimum inhibitory concentrations of both drugs, suggesting that they could be clinically applied to control infections caused by multidrug-resistant P. aeruginosa.
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Florescu DF, Grant W, Botha JF, Fey P, Kalil AC. Should multivisceral transplantation be considered in patients colonized with multidrug-resistant Pseudomonas aeruginosa? Microb Drug Resist 2011; 18:74-8. [PMID: 22107253 DOI: 10.1089/mdr.2011.0099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This report describes two subsequent liver-small bowel-pancreas-kidney (multivisceral) transplantations in a child colonized with multidrug-resistant Pseudomonas aeruginosa. We discuss the dilemma concerning the transplantation of patients colonized with multidrug-resistant Pseudomonas spp., its potential consequences, and the peri and postoperative management of these patients.
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Affiliation(s)
- Diana F Florescu
- Transplant Infectious Diseases Program, Infectious Diseases Division, University of Nebraska Medical Center, Omaha, Nebraska NE 68198-5400, USA.
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Jayaraman P, Sakharkar MK, Lim CS, Tang TH, Sakharkar KR. Activity and interactions of antibiotic and phytochemical combinations against Pseudomonas aeruginosa in vitro. Int J Biol Sci 2010; 6:556-68. [PMID: 20941374 PMCID: PMC2952406 DOI: 10.7150/ijbs.6.556] [Citation(s) in RCA: 119] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2010] [Accepted: 09/16/2010] [Indexed: 11/15/2022] Open
Abstract
In this study the in vitro activities of seven antibiotics (ciprofloxacin, ceftazidime, tetracycline, trimethoprim, sulfamethoxazole, polymyxin B and piperacillin) and six phytochemicals (protocatechuic acid, gallic acid, ellagic acid, rutin, berberine and myricetin) against five P. aeruginosa isolates, alone and in combination are evaluated. All the phytochemicals under investigation demonstrate potential inhibitory activity against P. aeruginosa. The combinations of sulfamethoxazole plus protocatechuic acid, sulfamethoxazole plus ellagic acid, sulfamethoxazole plus gallic acid and tetracycline plus gallic acid show synergistic mode of interaction. However, the combinations of sulfamethoxazole plus myricetin shows synergism for three strains (PA01, DB5218 and DR3062). The synergistic combinations are further evaluated for their bactericidal activity against P. aeruginosa ATCC strain using time-kill method. Sub-inhibitory dose responses of antibiotics and phytochemicals individually and in combination are presented along with their interaction network to suggest on the mechanism of action and potential targets for the phytochemicals under investigation. The identified synergistic combinations can be of potent therapeutic value against P. aeruginosa infections. These findings have potential implications in delaying the development of resistance as the antibacterial effect is achieved with lower concentrations of both drugs (antibiotics and phytochemicals).
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Affiliation(s)
- Premkumar Jayaraman
- Biomedical Engineering Research Centre, Nanyang Technological University, Singapore
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Combination Antimicrobial Treatment Versus Monotherapy: The Contribution of Meta-analyses. Infect Dis Clin North Am 2009; 23:277-93. [DOI: 10.1016/j.idc.2009.01.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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