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Massip C, Feletti L, Chagneau CV, Dumont Y, Maurin E, Muggeo A, Pichon M, Pompilio M, Buchler F, Halimi D, Dubois D. Evaluation of several routine methods for fosfomycin and mecillinam susceptibility testing of Enterobacterales urine isolates. J Antimicrob Chemother 2024; 79:2645-2652. [PMID: 39158189 PMCID: PMC11441990 DOI: 10.1093/jac/dkae271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 07/18/2024] [Indexed: 08/20/2024] Open
Abstract
OBJECTIVES Performance evaluation of routine laboratory methods to determine the susceptibility of Enterobacterales urinary isolates to fosfomycin (oral administration) and mecillinam. METHODS We collected 347 Enterobacterales isolates from monomicrobial midstream urine samples from women with significant bacteriuria and leukocyturia. Mostly non-Escherichia coli isolates (i.e. Klebsiella spp., Citrobacter koseri, Enterobacter cloacae complex and Proteus mirabilis) were included (n = 298). Performance of VITEK®2, ETEST®, and disc diffusion to determine fosfomycin and mecillinam susceptibility was evaluated following International Organization for Standardization (ISO) 20776-2:2021 (or 20776-2:2007 for disc diffusion) in comparison with the agar dilution reference method. RESULTS For fosfomycin testing, VITEK®2 and ETEST® were close to reaching ISO requirements (essential agreement ≥ 90%; bias ±30%) for C. koseri, E. coli and P. mirabilis. Categorical agreement (CA) and major error rates were acceptable for disc diffusion. Fosfomycin displayed lower activity against E. cloacae complex and Klebsiella spp., with MIC50 (minimum inhibitory concentration required to inhibit the growth of 50% of tested isolates) equal to the E. coli EUCAST breakpoint (8 mg/L). For these species, the three alternative techniques overestimated MICs and resistance, and did not meet performance criteria. For mecillinam testing of Enterobacterales isolates, apart from P. mirabilis, ETEST® nearly fulfilled ISO requirements, and CA rates were acceptable for disc diffusion. ISO criteria were reached for C. koseri and E. coli testing with VITEK®2, apart from too high rates of very major errors. For P. mirabilis, performances were unacceptable, whatever the routine method used. CONCLUSIONS Commercially available tests may serve as alternatives to agar dilution to assess fosfomycin (oral) and mecillinam susceptibility of Enterobacterales urinary isolates, with important interspecies variabilities. Additional studies comprising more fosfomycin- and mecillinam-resistant isolates are needed to strengthen our conclusions.
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Affiliation(s)
- C Massip
- Laboratoire de Bactériologie-Hygiène, CHU de Toulouse, Université de Toulouse Paul Sabatier, Toulouse, France
| | - L Feletti
- Laboratoire de Bactériologie-Hygiène, CHU de Toulouse, Université de Toulouse Paul Sabatier, Toulouse, France
| | - C V Chagneau
- Laboratoire de Bactériologie-Hygiène, CHU de Toulouse, Université de Toulouse Paul Sabatier, Toulouse, France
- Digestive Health Research Institute (IRSD), National Institute of Health and Medical Research (INSERM), Université de Toulouse Paul Sabatier, National Research Institute for Agriculture, Food and the Environment (INRAE), National Veterinary School of Toulouse (ENVT), Toulouse, France
| | - Y Dumont
- Laboratoire de Bactériologie, CHU de Montpellier, Montpellier, France
| | - E Maurin
- Laboratoire de Bactériologie Clinique, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - A Muggeo
- Université de Reims Champagne-Ardenne, INSERM, CHU de Reims, Laboratoire de Bactériologie-Virologie-Hygiène Hospitalière-Parasitologie-Mycologie, P3Cell, U 1250, Reims, France
| | - M Pichon
- Département des Agents Infectieux, CHU de Poitiers, Laboratoire de Bactériologie, Poitiers, France
- Université de Poitiers, INSERM U1070 Pharmacology of Antimicrobial Agents and Antibiotic Resistance, Poitiers, France
| | - M Pompilio
- Microbiology R&D, bioMérieux SA, La Balme les Grottes, France
| | - F Buchler
- Microbiology R&D, bioMérieux SA, La Balme les Grottes, France
| | - D Halimi
- Microbiology R&D, bioMérieux SA, La Balme les Grottes, France
| | - D Dubois
- Laboratoire de Bactériologie-Hygiène, CHU de Toulouse, Université de Toulouse Paul Sabatier, Toulouse, France
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Zhang LL, Liu Y, Huang QY, Zhang HW, Xie LJ, Chen J, Ding L, Zhou C, Sun LN, Wang YQ. Safety, pharmacokinetics, and food-effect of pivmecillinam after single- and multiple-dose in healthy Chinese subjects: a phase I study. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:7639-7647. [PMID: 38691150 DOI: 10.1007/s00210-024-03118-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 04/24/2024] [Indexed: 05/03/2024]
Abstract
Urinary tract infection (UTI) is one of the most prevalent bacterial infectious diseases worldwide. However, the resistance of urinary pathogens to other UTI antibiotics such as trimethoprim and trimethoprim/sulphamethoxazole increased. Pivmecillinam is a prodrug of mecillinam, which is effective for the treatment of urinary tract infections. The purpose of this study was to assess the safety, and pharmacokinetics of pivmecillinam and mecillinam after single- and multiple-dose oral administration of pivmecillinam tablets in healthy Chinese subjects. The study also investigated the profile of urinary excretion of mecillinam, as well as the effect of food and gender on the pharmacokinetics of pivmecillinam and mecillinam. This study was a single-center, open-label phase I study carried out in three groups. In total, 34 subjects were included in the study: group 1-food effect study with pivmecillinam 200 mg (n = 12); group 2-single- and multiple-dose study with pivmecillinam 400 mg (n = 12); group 3-single dose study with pivmecillinam 600 mg (n = 10). The plasma and urine concentrations of pivmecillinam and mecillinam were measured, and their pharmacokinetics were calculated. Treatment-emergent adverse events were evaluated and recorded in safety assessments for three groups. No severe adverse events were found in this study. After a single dose of pivmecillinam was taken orally, the maximum plasma concentration (Cmax) and the area under the concentration-time curve (AUC) of pivmecillinam increased in a dose-proportional manner, nor did mecillinam. Food had significant effects on Cmax and AUC0-t of pivmecillinam and Cmax of mecillinam. The mean cumulative percentage of urine excretion of mecillinam at 0 to 24 h ranged from 35.5 to 44.0%. Urinary cumulative excretion is relative to the drug dose, but the diet and multiple-dose administration did not affect the urinary cumulative excretion rate. The safety and pharmacokinetics of pivmecillinam and mecillinam after single- (200/400/600 mg) or multiple-dose (400 mg) administration were demonstrated in healthy Chinese subjects. Food affected the pharmacokinetics of pivmecillinam and mecillinam.
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Affiliation(s)
- Lu-Lu Zhang
- School of Pharmacy, Nanjing Medical University, Nanjing, 211166, China
| | - Yi Liu
- Research Division of Clinical Pharmacology, First Affiliated Hospital, Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Qiong-Ye Huang
- Research Division of Clinical Pharmacology, First Affiliated Hospital, Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Hong-Wen Zhang
- Research Division of Clinical Pharmacology, First Affiliated Hospital, Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Li-Jun Xie
- Research Division of Clinical Pharmacology, First Affiliated Hospital, Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Juan Chen
- Research Division of Clinical Pharmacology, First Affiliated Hospital, Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Li Ding
- Department of Pharmaceutical Analytical, China Pharmaceutical University, Nanjing, 210009, China
| | - Chen Zhou
- Research Division of Clinical Pharmacology, First Affiliated Hospital, Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Lu-Ning Sun
- School of Pharmacy, Nanjing Medical University, Nanjing, 211166, China.
- Research Division of Clinical Pharmacology, First Affiliated Hospital, Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China.
| | - Yong-Qing Wang
- School of Pharmacy, Nanjing Medical University, Nanjing, 211166, China.
- Research Division of Clinical Pharmacology, First Affiliated Hospital, Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China.
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Hawser S, Morrissey I, Kothari N, Monti F, Henriksen AS. Activity of mecillinam against USA urinary tract clinical isolates from 2017 to 2020 including isolates resistant to comparator antibiotics. J Glob Antimicrob Resist 2024; 39:137-143. [PMID: 39278462 DOI: 10.1016/j.jgar.2024.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 08/07/2024] [Accepted: 08/31/2024] [Indexed: 09/18/2024] Open
Abstract
OBJECTIVES To support the clinical development of mecillinam and pivmecillinam in the United States for the treatment of complicated and uncomplicated urinary tract infections (UTIs), this study investigated the activity of mecillinam compared with other antibiotics against Enterobacterales isolates from patients with UTIs in the United States during 2017 to 2020. Mecillinam is a first-in-class amidinopenicillin antibiotic, being the only β-lactam to exert its antibacterial activity through exclusive binding to penicillin-binding protein 2. Pivmecillinam is the oral prodrug of mecillinam and is recommended as a first-line therapy by the Infectious Disease Society of America guidelines for uncomplicated UTIs and is approved for the treatment of uncomplicated UTIs in Europe, Canada, and the United States. METHODS A total of 3303 isolates were collected and antimicrobial susceptibility determined according to Clinical Laboratory and Standards Institute (CLSI) guidelines. RESULTS Susceptibility was highest for fosfomycin (97.1% susceptible) and mecillinam (94.9% susceptible). Against extended-spectrum beta-lactamase (ESBL)-positive bacteria susceptibilities were highest for mecillinam (98.2% susceptible) and fosfomycin (97.3% susceptible) and against ESBL-positive K. pneumoniae only mecillinam and fosfomycin had > 80% susceptibility. Resistance to comparator antibiotics was highest for trimethoprim-sulfamethoxazole (27.1%), followed by ciprofloxacin (19.3%), ceftriaxone (19.2%), and nitrofurantoin (12.1%). Multi-drug-resistant isolates were most susceptible to mecillinam and fosfomycin. CONCLUSION The data further support the clinical development and clinical utility of mecillinam. © 2024 The Author(s). Published by Elsevier Ltd on behalf of International Society for Antimicrobial Chemotherapy.
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Affiliation(s)
| | - Ian Morrissey
- Antimicrobial Focus Ltd., Sawbridgeworth, Hertfordshire, UK
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Lodise TP, Kaye KS, Santerre Henriksen A, Kahlmeter G. Review of the In Vitro Microbiological Activity of Mecillinam Against Common Uropathogens in Uncomplicated Urinary Tract Infection: Focus on Resistant Pathogens. Open Forum Infect Dis 2024; 11:ofae296. [PMID: 38868308 PMCID: PMC11167674 DOI: 10.1093/ofid/ofae296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/22/2024] [Indexed: 06/14/2024] Open
Abstract
Antimicrobial resistance in uropathogens commonly causing urinary tract infections (UTIs) is a growing problem internationally. Pivmecillinam, the oral prodrug of mecillinam, has been used for over 40 years, primarily in Northern Europe and Canada. It is recommended in several countries as a first-line agent for the treatment of uncomplicated UTIs (uUTIs) and is now approved in the United States. We performed a structured literature search to review the available evidence on susceptibility of common uUTI-causing uropathogens to mecillinam. Among 38 studies included in this literature review, susceptibility rates for Escherichia coli to mecillinam-including resistant phenotypes such as extended-spectrum β-lactamase-producing E. coli-exceed 90% in most studies. High rates of susceptibility were also reported among many other uropathogens including Klebsiella spp., Enterobacter spp., and Citrobacter spp. In the current prescribing climate within the United States, pivmecillinam represents a viable first-line treatment option for patients with uUTI.
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Affiliation(s)
- Thomas P Lodise
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, New York, USA
| | - Keith S Kaye
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | | | - Gunnar Kahlmeter
- Department of Clinical Microbiology, Central Hospital, Växjö, Sweden
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Nakitanda AO, Odsbu I, Pasternak B, Karlsson P, Pazzagli L. Antibiotic use during pregnancy in Sweden: A nationwide utilization study covering 2007-2019. Acta Obstet Gynecol Scand 2024; 103:531-539. [PMID: 38108616 PMCID: PMC10867394 DOI: 10.1111/aogs.14741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 11/08/2023] [Accepted: 11/16/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION Antibiotics are often prescribed during pregnancy. Assessing the current state of prenatal antibiotic use is therefore imperative for optimizing prescribing and identifying emerging research priorities. The study aimed to describe recent trends and patterns in antibiotic use during pregnancy among women who gave birth in Sweden, including user characteristics. MATERIAL AND METHODS Population-based descriptive study using linked nationwide registers. All pregnancies delivered in Sweden from 2007 to 2019 were included. Prevalence of use was defined as the percentage of pregnancies during which at least one prescription forantibiotics was filled. Temporal trends in the prevalence of antibiotic use by calendar year, trimester and weeks of gestation were assessed from time series graphs. RESULTS Prescriptions for systemic antibiotics were filled in 20.7% of 1 434 431 pregnancies overall, decreasing from 24.7% in 2007 to 18.0% in 2019. Phenoxymethylpenicillin (8.5%), pivmecillinam (6.5%), nitrofurantoin (4.7%), amoxicillin (1.6%) and cefadroxil (1.5%) use were the most prevalent. Their use decreased over the 13-year period, except for pivmecillinam, which increased from 4.0% to 7.4%. Prevalence of use was highest in the second trimester (9.5%), with weekly trends peaking at 13 and 34 weeks of gestation. Compared with non-users, antibiotic users more often belonged to the youngest and oldest age strata, carried multipleton pregnancies, had delivered before, had attained a lower education level and smoked in early pregnancy. A higher body mass index, asthma, chronic renal disease and diabetes mellitus were more prevalent among antibiotic users than among non-users. CONCLUSIONS Although outpatient antibiotic use during pregnancy in Sweden has been declining, one in five pregnancies was exposed to systemic antibiotics.
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Affiliation(s)
- Aya Olivia Nakitanda
- Center for Pharmacoepidemiology, Department of Medicine SolnaKarolinska InstitutetStockholmSweden
| | - Ingvild Odsbu
- Center for Pharmacoepidemiology, Department of Medicine SolnaKarolinska InstitutetStockholmSweden
- Department of Chronic DiseasesNorwegian Institute of Public HealthOsloNorway
| | - Björn Pasternak
- Clinical Epidemiology Division, Department of Medicine SolnaKarolinska InstitutetStockholmSweden
- Department of Epidemiology ResearchStatens Serum InstitutCopenhagenDenmark
| | - Pär Karlsson
- Center for Pharmacoepidemiology, Department of Medicine SolnaKarolinska InstitutetStockholmSweden
| | - Laura Pazzagli
- Clinical Epidemiology Division, Department of Medicine SolnaKarolinska InstitutetStockholmSweden
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Deschner F, Risch T, Baier C, Schlüter D, Herrmann J, Müller R. Nitroxoline resistance is associated with significant fitness loss and diminishes in vivo virulence of Escherichia coli. Microbiol Spectr 2024; 12:e0307923. [PMID: 38063385 PMCID: PMC10782962 DOI: 10.1128/spectrum.03079-23] [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: 08/11/2023] [Accepted: 11/14/2023] [Indexed: 01/13/2024] Open
Abstract
IMPORTANCE Antimicrobial resistance (AMR) poses a global threat and requires the exploration of underestimated treatment options. Nitroxoline, an effective broad-spectrum antibiotic, does not suffer from high resistance rates in the clinics but surprisingly, it is not heavily used yet. Our findings provide compelling evidence that Nitroxoline resistance renders bacteria unable to cause an infection in vivo, thereby reinvigorating the potential of Nitroxoline in combating AMR.
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Affiliation(s)
- Felix Deschner
- Microbial Natural Products, Helmholtz Institute for Pharmaceutical Research Saarland (HIPS), Helmholtz Centre for Infection Research (HZI) and Department of Pharmacy Saarland University, Saarbrücken, Germany
- German Centre for Infection Research (DZIF), Braunschweig, Germany
| | - Timo Risch
- Microbial Natural Products, Helmholtz Institute for Pharmaceutical Research Saarland (HIPS), Helmholtz Centre for Infection Research (HZI) and Department of Pharmacy Saarland University, Saarbrücken, Germany
- German Centre for Infection Research (DZIF), Braunschweig, Germany
| | - Claas Baier
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School (MHH), Hannover, Germany
| | - Dirk Schlüter
- German Centre for Infection Research (DZIF), Braunschweig, Germany
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School (MHH), Hannover, Germany
| | - Jennifer Herrmann
- Microbial Natural Products, Helmholtz Institute for Pharmaceutical Research Saarland (HIPS), Helmholtz Centre for Infection Research (HZI) and Department of Pharmacy Saarland University, Saarbrücken, Germany
- German Centre for Infection Research (DZIF), Braunschweig, Germany
| | - Rolf Müller
- Microbial Natural Products, Helmholtz Institute for Pharmaceutical Research Saarland (HIPS), Helmholtz Centre for Infection Research (HZI) and Department of Pharmacy Saarland University, Saarbrücken, Germany
- German Centre for Infection Research (DZIF), Braunschweig, Germany
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Frimodt-Møller N, Bjerrum L. Treating urinary tract infections in the era of antibiotic resistance. Expert Rev Anti Infect Ther 2023; 21:1301-1308. [PMID: 37922147 DOI: 10.1080/14787210.2023.2279104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 10/31/2023] [Indexed: 11/05/2023]
Abstract
INTRODUCTION Urinary tract infections (UTIs) are associated with 25-40% of antibiotics consumed in primary care and are, therefore, driving antibiotic resistance. The worldwide increase in antibiotic resistance especially in Escherichia coli has complicated the treatment choices for UTIs and absence of effective oral antibiotics may lead to increasing need for more effective treatments. AREAS COVERED In this review we focus on the importance of the correct diagnosis of UTI as based on proof of urinary pathogens in the urine and discuss diagnostic measures including microscopy, dipstick, and culture. Antibiotic treatment can often await diagnostic measures with pain relief such as ibuprofen. The risk of an uncomplicated UTI leading to pyelonephritis is low (1-2%) and presence of bacteria in the bladder leaves some time for the immune system to react. Three antibiotics are recommended as based on their activity, and low propensity to select for resistance, i.e. nitrofurantoin, fosfomycin, and pivmecillinam, and in general, 3-5 days of treatment will suffice. EXPERT OPINION Understanding the usual benign course of uUTIs can help reduce antibiotic treatment in many cases, e.g. starting treatment by pain relief and awaiting the course of infection without antibiotics. Better rapid tests in primary care are urgently needed to enforce such policies.
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Affiliation(s)
| | - Lars Bjerrum
- Research Unit and Section of General Practice, Dept of Public Health, University of Copenhagen, Copenhagen, Denmark
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Sader HS, Carvalhaes CG, Huband MD, Mendes RE, Castanheira M. Antimicrobial activity of ceftibuten-avibactam against a global collection of Enterobacterales from patients with urinary tract infections (2021). Eur J Clin Microbiol Infect Dis 2023; 42:453-459. [PMID: 36810724 PMCID: PMC9998307 DOI: 10.1007/s10096-023-04562-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/03/2023] [Indexed: 02/24/2023]
Abstract
We evaluated the in vitro activity of ceftibuten-avibactam against Enterobacterales causing urinary tract infection (UTI). A total of 3216 isolates (1/patient) were consecutively collected from patients with UTI in 72 hospitals from 25 countries in 2021 then susceptibility tested by CLSI broth microdilution. Ceftibuten-susceptible breakpoints currently published by EUCAST (≤ 1 mg/L) and CLSI (≤ 8 mg/L) were applied to ceftibuten-avibactam for comparison. The most active agents were ceftibuten-avibactam (98.4%/99.6% inhibited at ≤ 1/ ≤ 8 mg/L), ceftazidime-avibactam (99.6% susceptible [S]), amikacin (99.1%S), and meropenem (98.2%S). Ceftibuten-avibactam (MIC50/90, 0.03/0.06 mg/L) was fourfold more potent than ceftazidime-avibactam (MIC50/90, 0.12/0.25 mg/L) based on MIC50/90 values. The most active oral agents were ceftibuten (89.3%S; 79.5% inhibited at ≤ 1 mg/L), levofloxacin (75.4%S), and trimethoprim-sulfamethoxazole (TMP-SMX; 73.4%S). Ceftibuten-avibactam inhibited 97.6% of isolates with an extended-spectrum β-lactamase phenotype, 92.1% of multidrug-resistant isolates, and 73.7% of carbapenem-resistant Enterobacterales (CRE) at ≤ 1 mg/L. The second most active oral agent against CRE was TMP-SMX (24.6%S). Ceftazidime-avibactam was active against 77.2% of CRE isolates. In conclusion, ceftibuten-avibactam was highly active against a large collection of contemporary Enterobacterales isolated from patients with UTI and exhibited a similar spectrum to ceftazidime-avibactam. Ceftibuten-avibactam may represent a valuable option for oral treatment of UTI caused by multidrug-resistant Enterobacterales.
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Affiliation(s)
- Helio S Sader
- JMI Laboratories, 345 Beaver Kreek Centre, Suite A, North Liberty, IA, 52317, USA.
| | - Cecilia G Carvalhaes
- JMI Laboratories, 345 Beaver Kreek Centre, Suite A, North Liberty, IA, 52317, USA
| | - Michael D Huband
- JMI Laboratories, 345 Beaver Kreek Centre, Suite A, North Liberty, IA, 52317, USA
| | - Rodrigo E Mendes
- JMI Laboratories, 345 Beaver Kreek Centre, Suite A, North Liberty, IA, 52317, USA
| | - Mariana Castanheira
- JMI Laboratories, 345 Beaver Kreek Centre, Suite A, North Liberty, IA, 52317, USA
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