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Hawkey PM, Warren RE, Livermore DM, McNulty CAM, Enoch DA, Otter JA, Wilson APR. Treatment of infections caused by multidrug-resistant Gram-negative bacteria: report of the British Society for Antimicrobial Chemotherapy/Healthcare Infection Society/British Infection Association Joint Working Party. J Antimicrob Chemother 2019. [PMID: 29514274 DOI: 10.1093/jac/dky027] [Citation(s) in RCA: 198] [Impact Index Per Article: 39.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The Working Party makes more than 100 tabulated recommendations in antimicrobial prescribing for the treatment of infections caused by multidrug-resistant (MDR) Gram-negative bacteria (GNB) and suggest further research, and algorithms for hospital and community antimicrobial usage in urinary infection. The international definition of MDR is complex, unsatisfactory and hinders the setting and monitoring of improvement programmes. We give a new definition of multiresistance. The background information on the mechanisms, global spread and UK prevalence of antibiotic prescribing and resistance has been systematically reviewed. The treatment options available in hospitals using intravenous antibiotics and in primary care using oral agents have been reviewed, ending with a consideration of antibiotic stewardship and recommendations. The guidance has been derived from current peer-reviewed publications and expert opinion with open consultation. Methods for systematic review were NICE compliant and in accordance with the SIGN 50 Handbook; critical appraisal was applied using AGREE II. Published guidelines were used as part of the evidence base and to support expert consensus. The guidance includes recommendations for stakeholders (including prescribers) and antibiotic-specific recommendations. The clinical efficacy of different agents is critically reviewed. We found there are very few good-quality comparative randomized clinical trials to support treatment regimens, particularly for licensed older agents. Susceptibility testing of MDR GNB causing infection to guide treatment needs critical enhancements. Meropenem- or imipenem-resistant Enterobacteriaceae should have their carbapenem MICs tested urgently, and any carbapenemase class should be identified: mandatory reporting of these isolates from all anatomical sites and specimens would improve risk assessments. Broth microdilution methods should be adopted for colistin susceptibility testing. Antimicrobial stewardship programmes should be instituted in all care settings, based on resistance rates and audit of compliance with guidelines, but should be augmented by improved surveillance of outcome in Gram-negative bacteraemia, and feedback to prescribers. Local and national surveillance of antibiotic use, resistance and outcomes should be supported and antibiotic prescribing guidelines should be informed by these data. The diagnosis and treatment of both presumptive and confirmed cases of infection by GNB should be improved. This guidance, with infection control to arrest increases in MDR, should be used to improve the outcome of infections with such strains. Anticipated users include medical, scientific, nursing, antimicrobial pharmacy and paramedical staff where they can be adapted for local use.
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Affiliation(s)
- Peter M Hawkey
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | | | | | - Cliodna A M McNulty
- Microbiology Department, Gloucestershire Royal Hospital, Great Western Road, Gloucester GL1 3NN, UK
| | - David A Enoch
- Public Health England, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - A Peter R Wilson
- Department of Microbiology and Virology, University College London Hospitals, London, UK
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Chalhoub H, Pletzer D, Weingart H, Braun Y, Tunney MM, Elborn JS, Rodriguez-Villalobos H, Plésiat P, Kahl BC, Denis O, Winterhalter M, Tulkens PM, Van Bambeke F. Mechanisms of intrinsic resistance and acquired susceptibility of Pseudomonas aeruginosa isolated from cystic fibrosis patients to temocillin, a revived antibiotic. Sci Rep 2017; 7:40208. [PMID: 28091521 PMCID: PMC5238406 DOI: 10.1038/srep40208] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 12/01/2016] [Indexed: 12/29/2022] Open
Abstract
The β-lactam antibiotic temocillin (6-α-methoxy-ticarcillin) shows stability to most extended spectrum β-lactamases, but is considered inactive against Pseudomonas aeruginosa. Mutations in the MexAB-OprM efflux system, naturally occurring in cystic fibrosis (CF) isolates, have been previously shown to reverse this intrinsic resistance. In the present study, we measured temocillin activity in a large collection (n = 333) of P. aeruginosa CF isolates. 29% of the isolates had MICs ≤ 16 mg/L (proposed clinical breakpoint for temocillin). Mutations were observed in mexA or mexB in isolates for which temocillin MIC was ≤512 mg/L (nucleotide insertions or deletions, premature termination, tandem repeat, nonstop, and missense mutations). A correlation was observed between temocillin MICs and efflux rate of N-phenyl-1-naphthylamine (MexAB-OprM fluorescent substrate) and extracellular exopolysaccharide abundance (contributing to a mucoid phenotype). OpdK or OpdF anion-specific porins expression decreased temocillin MIC by ~1 two-fold dilution only. Contrarily to the common assumption that temocillin is inactive on P. aeruginosa, we show here clinically-exploitable MICs on a non-negligible proportion of CF isolates, explained by a wide diversity of mutations in mexA and/or mexB. In a broader context, this work contributes to increase our understanding of MexAB-OprM functionality and help delineating how antibiotics interact with MexA and MexB.
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Affiliation(s)
- Hussein Chalhoub
- Pharmacologie cellulaire et moléculaire, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
| | - Daniel Pletzer
- Life Sciences, School of Engineering and Science, Jacobs University, Bremen, Germany
| | - Helge Weingart
- Life Sciences, School of Engineering and Science, Jacobs University, Bremen, Germany
| | - Yvonne Braun
- Life Sciences, School of Engineering and Science, Jacobs University, Bremen, Germany
| | - Michael M Tunney
- CF &Airways Microbiology Research Group, Queen's University Belfast, Belfast, UK
| | - J Stuart Elborn
- CF &Airways Microbiology Research Group, Queen's University Belfast, Belfast, UK
| | - Hector Rodriguez-Villalobos
- Laboratoire de microbiologie, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Patrick Plésiat
- Laboratoire de bactériologie, Hôpital Jean Minjoz, Besançon, France
| | | | - Olivier Denis
- Laboratoire de microbiologie, Hôpital Erasme, Université libre de Bruxelles, Brussels, Belgium
| | - Mathias Winterhalter
- Life Sciences, School of Engineering and Science, Jacobs University, Bremen, Germany
| | - Paul M Tulkens
- Pharmacologie cellulaire et moléculaire, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
| | - Françoise Van Bambeke
- Pharmacologie cellulaire et moléculaire, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
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Gautam V, Shafiq N, Singh M, Ray P, Singhal L, Jaiswal NP, Prasad A, Singh S, Agarwal A. Clinical and in vitro evidence for the antimicrobial therapy in Burkholderia cepacia complex infections. Expert Rev Anti Infect Ther 2015; 13:629-63. [PMID: 25772031 DOI: 10.1586/14787210.2015.1025056] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Treatment of infections caused by Burkholderia cepacia complex (Bcc) in cystic fibrosis (CF) patients poses a complex problem. Bcc is multidrug-resistant due to innate and acquired mechanisms of resistance. As CF patients receive multiple courses of antibiotics, susceptibility patterns of strains from CF patients may differ from those noted in strains from non-CF patients. Thus, there was a need for assessing in vitro and clinical data to guide antimicrobial therapy in these patients. A systematic search of literature, followed by extraction and analysis of available information from human and in vitro studies was done. The results of the analysis are used to address various aspects like use of antimicrobials for pulmonary and non-pulmonary infections, use of combination versus monotherapy, early eradication, duration of therapy, route of administration, management of biofilms, development of resistance during therapy, pharmacokinetics-pharmacodynamics correlations, therapy in post-transplant patients and newer drugs in Bcc-infected CF patients.
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Affiliation(s)
- Vikas Gautam
- Deparatment of Medical Microbiology, PGIMER, Chandigarh 160022, India
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Parkins MD, Rendall JC, Elborn JS. Incidence and Risk Factors for Pulmonary Exacerbation Treatment Failures in Patients With Cystic Fibrosis Chronically Infected With Pseudomonas aeruginosa. Chest 2012; 141:485-493. [DOI: 10.1378/chest.11-0917] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Bals R, Hubert D, Tümmler B. Antibiotic treatment of CF lung disease: from bench to bedside. J Cyst Fibros 2011; 10 Suppl 2:S146-51. [PMID: 21658633 DOI: 10.1016/s1569-1993(11)60019-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Chronic infection of the respiratory tract is a hallmark of cystic fibrosis (CF). Antibiotic treatment has been used as one of the mainstays of therapy and together with other treatment modalities has resulted in increased survival of CF patients. Increasing resistance of CF-specific pathogens to various classes of antibiotics explains the need for novel antibiotic strategies. This review focuses on the future development of new antibiotic therapies, including: (1) New targets, (2) novel antibiotic regimens in CF, (3) new antibiotics, and (4) other investigational therapies. In addition, we briefly summarize developments in the area of microbial diagnostics and discuss interactions between the complex pulmonary microflora.
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Affiliation(s)
- Robert Bals
- Klinik für Innere Medizin V, Pneumologie, Allergologie und Respiratorische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany.
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Van Acker H, Van Snick E, Nelis HJ, Coenye T. In vitro activity of temocillin against planktonic and sessile Burkholderia cepacia complex bacteria. J Cyst Fibros 2010; 9:450-4. [PMID: 20851061 DOI: 10.1016/j.jcf.2010.08.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Revised: 08/20/2010] [Accepted: 08/20/2010] [Indexed: 11/18/2022]
Abstract
Burkholderia cepacia complex (Bcc) bacteria are opportunistic respiratory pathogens which are particularly difficult to eradicate from the lungs of cystic fibrosis (CF) patients because of their innate resistance to antimicrobials and their capacity to form biofilms. The goal of the present study was to evaluate the bacteriostatic and bactericidal activities of temocillin against planktonic and sessile Bcc bacteria. 37 strains belonging to 17 Bcc species were tested. 75.7% of the strains were susceptible when grown planktonically (minimal inhibitory concentration <16 μg/ml). The minimal bactericidal concentrations were higher than 128 μg/ml for most strains. No remarkable differences in resistance between exponentially growing planktonic cells and 4 h old biofilms were observed: when grown in a biofilm, 59.5% of the strains were susceptible. After treating 24 h biofilms with a concentration of 10×MIC, only a minor reduction was seen in the number of sessile cells, indicating a limited bactericidal activity against biofilms. Our data indicate that temocillin has a good bacteriostatic in vitro activity against planktonic and 4 h old biofilms, but seems of limited use to eradicate 24 h old biofilms.
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Affiliation(s)
- Heleen Van Acker
- Laboratorium voor Farmaceutische Microbiologie, Universiteit Gent, Gent, Belgium
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Parkins MD, Elborn JS. Newer antibacterial agents and their potential role in cystic fibrosis pulmonary exacerbation management. J Antimicrob Chemother 2010; 65:1853-61. [DOI: 10.1093/jac/dkq245] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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