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Koenig C, Kuti JL. Evolving resistance landscape in gram-negative pathogens: An update on β-lactam and β-lactam-inhibitor treatment combinations for carbapenem-resistant organisms. Pharmacotherapy 2024; 44:658-674. [PMID: 38949413 DOI: 10.1002/phar.2950] [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: 04/05/2024] [Revised: 05/24/2024] [Accepted: 05/25/2024] [Indexed: 07/02/2024]
Abstract
Antibiotic resistance has become a global threat as it is continuously growing due to the evolution of β-lactamases diminishing the activity of classic β-lactam (BL) antibiotics. Recent antibiotic discovery and development efforts have led to the availability of β-lactamase inhibitors (BLIs) with activity against extended-spectrum β-lactamases as well as Klebsiella pneumoniae carbapenemase (KPC)-producing carbapenem-resistant organisms (CRO). Nevertheless, there is still a lack of drugs that target metallo-β-lactamases (MBL), which hydrolyze carbapenems efficiently, and oxacillinases (OXA) often present in carbapenem-resistant Acinetobacter baumannii. This review aims to provide a snapshot of microbiology, pharmacology, and clinical data for currently available BL/BLI treatment options as well as agents in late stage development for CRO harboring various β-lactamases including MBL and OXA-enzymes.
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Affiliation(s)
- Christina Koenig
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
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2
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Murray TS, Stanley G, Koff JL. Novel Approaches to Multidrug-Resistant Infections in Cystic Fibrosis. Infect Dis Clin North Am 2024; 38:149-162. [PMID: 38280761 DOI: 10.1016/j.idc.2023.12.002] [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] [Indexed: 01/29/2024]
Abstract
Patients with cystic fibrosis (CF) often develop respiratory tract infections with pathogenic multidrug-resistant organisms (MDROs) such as methicillin-resistant Staphylococcus aureus, and a variety of gram-negative organisms that include Pseudomonas aeruginosa, Burkholderia sp., Stenotrophomonas maltophilia, Achromobacter xylosoxidans, and nontuberculous mycobacteria (NTM). Despite the introduction of new therapies to address underlying cystic fibrosis transmembrane conductance regulator (CFTR) dysfunction, MDRO infections remain a problem and novel antimicrobial interventions are still needed. Therapeutic approaches include improving the efficacy of existing drugs by adjusting the dose based on differences in CF patient pharmacokinetics/pharmacodynamics, the development of inhaled formulations to reduce systemic adverse events, and the use of newer beta-lactam/beta-lactamase combinations. Alternative innovative therapeutic approaches include the use of gallium and bacteriophages to treat MDRO pulmonary infections including those with extreme antibiotic resistance. However, additional clinical trials are required to determine the optimal dosing and efficacy of these different strategies and to identify patients with CF most likely to benefit from these new treatment options.
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Affiliation(s)
- Thomas S Murray
- Department of Pediatrics, Section Infectious Diseases and Global Health, Yale University School of Medicine, PO Box 208064, 333 Cedar Street, New Haven, CT 06520-8064, USA.
| | - Gail Stanley
- Department of Internal Medicine, Section Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, PO Box 208057, 300 Cedar Street TAC-441 South, New Haven, CT 06520-8057, USA; Adult Cystic Fibrosis Program; Yale University Center for Phage Biology & Therapy.
| | - Jonathan L Koff
- Adult Cystic Fibrosis Program; Yale University Center for Phage Biology & Therapy; Department of Internal Medicine, Section Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, PO Box 208057, 300 Cedar Street TAC-455A South, New Haven, CT 06520-8057, USA.
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3
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Hogan AM, Rahman ASMZ, Motnenko A, Natarajan A, Maydaniuk DT, León B, Batun Z, Palacios A, Bosch A, Cardona ST. Profiling cell envelope-antibiotic interactions reveals vulnerabilities to β-lactams in a multidrug-resistant bacterium. Nat Commun 2023; 14:4815. [PMID: 37558695 PMCID: PMC10412643 DOI: 10.1038/s41467-023-40494-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 07/28/2023] [Indexed: 08/11/2023] Open
Abstract
The cell envelope of Gram-negative bacteria belonging to the Burkholderia cepacia complex (Bcc) presents unique restrictions to antibiotic penetration. As a consequence, Bcc species are notorious for causing recalcitrant multidrug-resistant infections in immunocompromised individuals. Here, we present the results of a genome-wide screen for cell envelope-associated resistance and susceptibility determinants in a Burkholderia cenocepacia clinical isolate. For this purpose, we construct a high-density, randomly-barcoded transposon mutant library and expose it to 19 cell envelope-targeting antibiotics. By quantifying relative mutant fitness with BarSeq, followed by validation with CRISPR-interference, we profile over a hundred functional associations and identify mediators of antibiotic susceptibility in the Bcc cell envelope. We reveal connections between β-lactam susceptibility, peptidoglycan synthesis, and blockages in undecaprenyl phosphate metabolism. The synergy of the β-lactam/β-lactamase inhibitor combination ceftazidime/avibactam is primarily mediated by inhibition of the PenB carbapenemase. In comparison with ceftazidime, avibactam more strongly potentiates the activity of aztreonam and meropenem in a panel of Bcc clinical isolates. Finally, we characterize in Bcc the iron and receptor-dependent activity of the siderophore-cephalosporin antibiotic, cefiderocol. Our work has implications for antibiotic target prioritization, and for using additional combinations of β-lactam/β-lactamase inhibitors that can extend the utility of current antibacterial therapies.
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Affiliation(s)
- Andrew M Hogan
- Department of Microbiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Anna Motnenko
- Department of Microbiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Aakash Natarajan
- Department of Microbiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Dustin T Maydaniuk
- Department of Microbiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Beltina León
- CINDEFI, CONICET-CCT La Plata, Facultad de Ciencias Exactas, Universidad Nacional de La Plata, La Plata, Buenos Aires, Argentina
| | - Zayra Batun
- Department of Microbiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Armando Palacios
- Department of Microbiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alejandra Bosch
- CINDEFI, CONICET-CCT La Plata, Facultad de Ciencias Exactas, Universidad Nacional de La Plata, La Plata, Buenos Aires, Argentina
| | - Silvia T Cardona
- Department of Microbiology, University of Manitoba, Winnipeg, Manitoba, Canada.
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada.
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Haidar G, Chan BK, Cho ST, Kramer KH, Nordstrom HR, Wallace NR, Stellfox ME, Holland M, Kline EG, Kozar JM, Kilaru SD, Pilewski JM, LiPuma JJ, Cooper VS, Shields RK, Van Tyne D. Phage therapy in a lung transplant recipient with cystic fibrosis infected with multidrug-resistant Burkholderia multivorans. Transpl Infect Dis 2023; 25:e14041. [PMID: 36864824 PMCID: PMC10085838 DOI: 10.1111/tid.14041] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 02/06/2023] [Accepted: 02/09/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND There is increased interest in bacteriophage (phage) therapy to treat infections caused by antibiotic-resistant bacteria. A lung transplant recipient with cystic fibrosis and Burkholderia multivorans infection was treated with inhaled phage therapy for 7 days before she died. METHODS Phages were given via nebulization through the mechanical ventilation circuit. Remnant respiratory specimens and serum were collected. We quantified phage and bacterial deoxyribonucleic acid (DNA) using quantitative polymerase chain reaction, and tested phage neutralization in the presence of patient serum. We performed whole genome sequencing and antibiotic and phage susceptibility testing on 15 B. multivorans isolates. Finally, we extracted lipopolysaccharide (LPS) from two isolates and visualized their LPS using gel electrophoresis. RESULTS Phage therapy was temporally followed by a temporary improvement in leukocytosis and hemodynamics, followed by worsening leukocytosis on day 5, deterioration on day 7, and death on day 8. We detected phage DNA in respiratory samples after 6 days of nebulized phage therapy. Bacterial DNA in respiratory samples decreased over time, and no serum neutralization was detected. Isolates collected between 2001 and 2020 were closely related but differed in their antibiotic and phage susceptibility profiles. Early isolates were not susceptible to the phage used for therapy, while later isolates, including two isolates collected during phage therapy, were susceptible. Susceptibility to the phage used for therapy was correlated with differences in O-antigen profiles of an early versus a late isolate. CONCLUSIONS This case of clinical failure of nebulized phage therapy highlights the limitations, unknowns, and challenges of phage therapy for resistant infections.
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Affiliation(s)
- Ghady Haidar
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Benjamin K. Chan
- Department of Ecology and Evolutionary Biology, and Yale Center for Phage Biology and Therapy, Yale University, New Haven, CT 06520, USA
| | - Shu-Ting Cho
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Kailey Hughes Kramer
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Hayley R. Nordstrom
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Nathan R. Wallace
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Madison E. Stellfox
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Mische Holland
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Ellen G. Kline
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Jennifer M. Kozar
- Investigational Drug Service, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Silpa D. Kilaru
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Joseph M. Pilewski
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - John J. LiPuma
- Department of Pediatrics, University of Michigan School of Medicine, Ann Arbor, MI 48109, USA
| | - Vaughn S. Cooper
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
- Center for Evolutionary Biology and Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Ryan K. Shields
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Daria Van Tyne
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
- Center for Evolutionary Biology and Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
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5
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Murray TS, Stanley G, Koff JL. Novel Approaches to Multidrug-Resistant Infections in Cystic Fibrosis. Clin Chest Med 2022; 43:667-676. [PMID: 36344073 DOI: 10.1016/j.ccm.2022.06.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Patients with cystic fibrosis (CF) often develop respiratory tract infections with pathogenic multidrug-resistant organisms (MDROs) such as methicillin-resistant Staphylococcus aureus, and a variety of gram-negative organisms that include Pseudomonas aeruginosa, Burkholderia sp., Stenotrophomonas maltophilia, Achromobacter xylosoxidans, and nontuberculous mycobacteria (NTM). Despite the introduction of new therapies to address underlying cystic fibrosis transmembrane conductance regulator (CFTR) dysfunction, MDRO infections remain a problem and novel antimicrobial interventions are still needed. Therapeutic approaches include improving the efficacy of existing drugs by adjusting the dose based on differences in CF patient pharmacokinetics/pharmacodynamics, the development of inhaled formulations to reduce systemic adverse events, and the use of newer beta-lactam/beta-lactamase combinations. Alternative innovative therapeutic approaches include the use of gallium and bacteriophages to treat MDRO pulmonary infections including those with extreme antibiotic resistance. However, additional clinical trials are required to determine the optimal dosing and efficacy of these different strategies and to identify patients with CF most likely to benefit from these new treatment options.
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Affiliation(s)
- Thomas S Murray
- Department of Pediatrics, Section Infectious Diseases and Global Health, Yale University School of Medicine, PO Box 208064, 333 Cedar Street, New Haven, CT 06520-8064, USA.
| | - Gail Stanley
- Department of Internal Medicine, Section Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, PO Box 208057, 300 Cedar Street TAC-441 South, New Haven, CT 06520-8057, USA; Adult Cystic Fibrosis Program; Yale University Center for Phage Biology & Therapy.
| | - Jonathan L Koff
- Adult Cystic Fibrosis Program; Yale University Center for Phage Biology & Therapy; Department of Internal Medicine, Section Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, PO Box 208057, 300 Cedar Street TAC-455A South, New Haven, CT 06520-8057, USA.
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Dumlu R, Uyar NY, Ayaş M, Aksoy N, Öztürk N, Kocagöz AS. Investigation of ceftazidime-avibactam susceptibility in clinical isolates of gram-negative bacteria. Turk J Med Sci 2022; 52:1839-1844. [PMID: 36945980 PMCID: PMC10390182 DOI: 10.55730/1300-0144.5530] [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: 03/06/2022] [Accepted: 10/09/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Our study investigated the susceptibility rate of ceftazidime-avibactam and the risk factors associated with its resistance by analyzing gram-negative bacteria isolated from various patient samples. METHODS Between March and November 2020, 1119 gram-negative bacteria strains were isolated from patient samples in Acıbadem Healthcare Group hospitals; ceftazidime-avibactam susceptibility results were evaluated using a 10/4µg (Oxoid, UK) disc and evaluated according to Eucast 2020 recommendations. Patient and isolate characteristics that could be risk factors were retrospectively investigated and statistically analyzed using SPSS 25.0. RESULTS Male patients made up 52% (n = 581) of the study's total patient population, and they averaged 55.5 ± 24.9 years old. Of 1119 gram-negative strains culture and antibiogram, 1023 (91.4%) were sensitive to ceftazidime-avibactam. An increased risk of resistance was observed with female gender (OR = 2.29; CI 95% [1.45-3.61]; p < 0.05), Pseudomonas aeruginosa (OR = 1.67, CI 95% [1.03-2.7]; p < 0.05), the presence of multidrug-resistance (MDR) (OR = 4.07, CI 95% [2.47-6.7]; p < 0.05) pandrug-resistance (PDR) (OR = 12, (CI) 95% [9.9-14.7] ]; p < 0.05) and admission to intensive care unit (ICU) (OR = 1.89, CI 95% [1.22-2.93]; p < 0.05). DISCUSSION The resistance rate of ceftazidime-avibactam was found to be 8.6%, and it was thought that resistant strains produced metallo-ß-lactamase (MBL) type carbapenemase. Risk factors were female gender, Pseudomonas aeruginosa, MDR, PDR, and admission to ICU. Therefore, studying the ceftazidime-avibactam susceptibility test together with gram-negative bacteria identification, especially in groups at risk for resistance, is one of the important factors that can positively affect the success of treatment.
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Affiliation(s)
- Rıdvan Dumlu
- Department of Infectious Diseases and Clinical Microbiology, Prof. Dr. Cemil Taşçıoğlu City Hospital, İstanbul, Turkey
| | - Neval Yurttutan Uyar
- Department of Medical Microbiology, Faculty of Medicine, Acıbadem Mehmet Ali Aydınlar University, İstanbul, Turkey
| | - Meltem Ayaş
- Department of Medical Biotechnology, Graduate School of Health Sciences, Acıbadem Mehmet Ali Aydınlar University, İstanbul, Turkey
| | - Nilay Aksoy
- Department of Clinical Pharmacy, Faculty of Pharmacy, Altınbaş University, İstanbul, Turkey
| | - Nur Öztürk
- Department of Clinical Pharmacy, Graduate School of Health Sciences, İstanbul Medipol University, İstanbul, Turkey
| | - Ayşe Sesin Kocagöz
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Acıbadem Mehmet Ali Aydınlar University, İstanbul, Turkey
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7
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Ceftazidime/Avibactam in Ventilator-Associated Pneumonia Due to Difficult-to-Treat Non-Fermenter Gram-Negative Bacteria in COVID-19 Patients: A Case Series and Review of the Literature. Antibiotics (Basel) 2022; 11:antibiotics11081007. [PMID: 35892396 PMCID: PMC9330655 DOI: 10.3390/antibiotics11081007] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/22/2022] [Accepted: 07/22/2022] [Indexed: 02/06/2023] Open
Abstract
Ventilator-associated pneumonia (VAP) in critically ill patients with COVID-19 represents a very huge global threat due to a higher incidence rate compared to non-COVID-19 patients and almost 50% of the 30-day mortality rate. Pseudomonas aeruginosa was the first pathogen involved but uncommon non-fermenter gram-negative organisms such as Burkholderia cepacea and Stenotrophomonas maltophilia have emerged as other potential etiological causes. Against carbapenem-resistant gram-negative microorganisms, Ceftazidime/avibactam (CZA) is considered a first-line option, even more so in case of a ceftolozane/tazobactam resistance or shortage. The aim of this report was to describe our experience with CZA in a case series of COVID-19 patients hospitalized in the ICU with VAP due to difficult-to-treat (DTT) P. aeruginosa, Burkholderia cepacea, and Stenotrophomonas maltophilia and to compare it with data published in the literature. A total of 23 patients were treated from February 2020 to March 2022: 19/23 (82%) VAPs were caused by Pseudomonas spp. (16/19 DTT), 2 by Burkholderia cepacea, and 6 by Stenotrophomonas maltophilia; 12/23 (52.1%) were polymicrobial. Septic shock was diagnosed in 65.2% of the patients and VAP occurred after a median of 29 days from ICU admission. CZA was prescribed as a combination regimen in 86% of the cases, with either fosfomycin or inhaled amikacin or cotrimoxazole. Microbiological eradication was achieved in 52.3% of the cases and the 30-day overall mortality rate was 14/23 (60.8%). Despite the high mortality of critically ill COVID-19 patients, CZA, especially in combination therapy, could represent a valid treatment option for VAP due to DTT non-fermenter gram-negative bacteria, including uncommon pathogens such as Burkholderia cepacea and Stenotrophomonas maltophilia.
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8
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Prevalence of antibiotic resistance of Pseudomonas aeruginosa in cystic fibrosis infection: A systematic review and meta-analysis. Microb Pathog 2022; 165:105461. [DOI: 10.1016/j.micpath.2022.105461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 12/16/2022]
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9
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Soriano A, Carmeli Y, Omrani AS, Moore LSP, Tawadrous M, Irani P. Ceftazidime-Avibactam for the Treatment of Serious Gram-Negative Infections with Limited Treatment Options: A Systematic Literature Review. Infect Dis Ther 2021; 10:1989-2034. [PMID: 34379310 PMCID: PMC8355581 DOI: 10.1007/s40121-021-00507-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 07/16/2021] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION A systematic literature review was undertaken to evaluate real-world use of ceftazidime-avibactam for infections due to aerobic Gram-negative organisms in adults with limited treatment options. METHODS Literature searches retrieved peer-reviewed publications and abstracts from major international infectious disease congresses from January 2015 to February 2021. Results were screened using pre-defined criteria to limit the dataset to relevant publications (notable exclusions were paediatric data and outcomes data for bacteria intrinsically resistant to ceftazidime-avibactam). Data for included publications were subjected to qualitative synthesis. RESULTS Seventy-three relevant publications (62 peer-reviewed articles; 10 abstracts) comprising 1926 patients treated with ceftazidime-avibactam (either alone or combined with other antimicrobials) and 1114 comparator/control patients were identified. All patients were hospitalised for serious illness and most had multiple comorbidities. The most common infections were pneumonia, bacteraemia, and skin/soft tissue, urinary tract, or abdominal infections; smaller numbers of patients with meningitis, febrile neutropenia, osteomyelitis, and cystic fibrosis were also included. Carbapenem-resistant or carbapenemase-producing Enterobacterales (CRE; n = 1718) and carbapenem-resistant, multidrug-resistant (MDR), and extensively drug-resistant Pseudomonas aeruginosa (n = 150) were the most common pathogens. Most publications reported positive outcomes for ceftazidime-avibactam treatment (clinical success rates ranged from 45 to 100% and reported 30-day mortality from 0 to 63%), which were statistically superior versus comparators in some studies. ceftazidime-avibactam resistance emergence occurred infrequently and mostly in Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae strains. CONCLUSION This review provides qualitative evidence of successful use of ceftazidime-avibactam for the treatment of hospitalised patients with CRE and MDR P. aeruginosa infections with limited treatment options.
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Affiliation(s)
- Alex Soriano
- Division of Infectious Diseases, Hospital Clínic de Barcelona, Carrer de Villarroel 170, 08036, Barcelona, Spain.
- Institut D'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
| | - Yehuda Carmeli
- Division of Epidemiology, The National Center for Antibiotic Resistance and Infection Control, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ali S Omrani
- Division of Infectious Diseases, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
- Communicable Diseases Center, Hamad Medical Corporation, Doha, Qatar
| | - Luke S P Moore
- Chelsea & Westminster NHS Foundation Trust, London, UK
- Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
| | | | - Paurus Irani
- Global Medical Affairs, Anti-infectives, Pfizer, Tadworth, Surrey, UK
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10
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Daikos GL, da Cunha CA, Rossolini GM, Stone GG, Baillon-Plot N, Tawadrous M, Irani P. Review of Ceftazidime-Avibactam for the Treatment of Infections Caused by Pseudomonas aeruginosa. Antibiotics (Basel) 2021; 10:antibiotics10091126. [PMID: 34572708 PMCID: PMC8467554 DOI: 10.3390/antibiotics10091126] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/15/2021] [Accepted: 09/16/2021] [Indexed: 12/12/2022] Open
Abstract
Pseudomonas aeruginosa is an opportunistic Gram-negative pathogen that causes a range of serious infections that are often challenging to treat, as this pathogen can express multiple resistance mechanisms, including multidrug-resistant (MDR) and extensively drug-resistant (XDR) phenotypes. Ceftazidime–avibactam is a combination antimicrobial agent comprising ceftazidime, a third-generation semisynthetic cephalosporin, and avibactam, a novel non-β-lactam β-lactamase inhibitor. This review explores the potential role of ceftazidime–avibactam for the treatment of P. aeruginosa infections. Ceftazidime–avibactam has good in vitro activity against P. aeruginosa relative to comparator β-lactam agents and fluoroquinolones, comparable to amikacin and ceftolozane–tazobactam. In Phase 3 clinical trials, ceftazidime–avibactam has generally demonstrated similar clinical and microbiological outcomes to comparators in patients with complicated intra-abdominal infections, complicated urinary tract infections or hospital-acquired/ventilator-associated pneumonia caused by P. aeruginosa. Although real-world data are limited, favourable outcomes with ceftazidime–avibactam treatment have been reported in some patients with MDR and XDR P. aeruginosa infections. Thus, ceftazidime–avibactam may have a potentially important role in the management of serious and complicated P. aeruginosa infections, including those caused by MDR and XDR strains.
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Affiliation(s)
- George L. Daikos
- Department of Medicine, National and Kapodistrian University of Athens, 115-27 Athens, Greece
- Correspondence: ; Tel.: +30-210-804-9218
| | | | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, I-50134 Florence, Italy;
- Clinical Microbiology and Virology Unit, Careggi University Hospital, I-50134 Florence, Italy
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11
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Activity of imipenem-relebactam against multi-drug and extensively-drug resistant Burkholderia cepacia complex and Burkholderia gladioli. Antimicrob Agents Chemother 2021; 65:e0133221. [PMID: 34370574 DOI: 10.1128/aac.01332-21] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The Burkholderia cepacia complex (Bcc) and Burkholderia gladioli are opportunistic pathogens that most commonly infect persons with cystic fibrosis or compromised immune systems. Members of the Burkholderia genus are intrinsically multidrug resistant (MDR), possessing both a PenA carbapenemase and an AmpC β-lactamase, which renders treatment of infection due to these species problematic. Here, we tested the β-lactam-β-lactamase inhibitor combination, imipenem-relebactam, against a panel of MDR Bcc and B. gladioli. The addition of relebactam to imipenem dramatically lowered the MICs for Bcc and B. gladioli with only 16% of isolates testing susceptible to imipenem vs. 71.3% being susceptible to the imipenem-relebactam combination. While ceftazidime-avibactam remained the most potent combination drug against this panel of Bcc and B. gladioli, imipenem-relebactam was active against 71.4% of the ceftazidime-avibactam-resistant isolates. Relebactam demonstrated potent inactivation of the Burkholderia multivorans PenA1 with a Ki app value of 3.2 μM. Timed mass spectrometry revealed that PenA1 formed a very stable adduct with relebactam, without any detectable desulfation up to 24 hours. Based on our results, imipenem-relebactam may represent an alternative salvage therapy for Bcc and B. gladioli infection, especially in cases where the isolates are resistant to ceftazidime-avibactam.
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12
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Epps QJ, Epps KL, Zobell JT. Optimization of anti-pseudomonal antibiotics for cystic fibrosis pulmonary exacerbations: II. Cephalosporins and penicillins latest update. Pediatr Pulmonol 2021; 56:1784-1788. [PMID: 33524241 DOI: 10.1002/ppul.25282] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/11/2021] [Accepted: 01/15/2021] [Indexed: 12/28/2022]
Affiliation(s)
- Quovadis J Epps
- College of Pharmacy and Pharmaceutical Sciences, Florida Agricultural and Mechanical University, Jacksonville, Florida, USA
| | - Kevin L Epps
- Department of Pharmacy, The Mayo Clinic, Jacksonville, Florida, USA
| | - Jeffery T Zobell
- Department of Pharmacy, Intermountain Primary Children's Hospital, Salt Lake City, Utah, USA.,Primary Children's Cystic Fibrosis Center, Salt Lake City, Utah, USA
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13
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Strich JR, Ricotta E, Warner S, Lai YL, Demirkale CY, Hohmann SF, Rhee C, Klompas M, Palmore T, Powers JH, Dekker JP, Adjemian J, Matsouaka R, Woods CW, Danner RL, Kadri SS. Pharmacoepidemiology of Ceftazidime-Avibactam Use: A Retrospective Cohort Analysis of 210 US Hospitals. Clin Infect Dis 2021; 72:611-621. [PMID: 32107536 PMCID: PMC7884805 DOI: 10.1093/cid/ciaa061] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 01/17/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Ceftazidime-avibactam has in vitro activity against some carbapenem-resistant gram-negative infections (GNIs), and therefore may be a useful alternative to more toxic antibiotics such as colistin. Understanding ceftazidime-avibactam uptake and usage patterns would inform hospital formularies, stewardship, and antibiotic development. METHODS A retrospective cohort study assessed inpatient encounters in the Vizient database. Ceftazidime-avibactam and colistin administrations were categorized into presumed empiric (3 consecutive days of therapy or less with qualifying exclusions) versus targeted therapy (≥4 consecutive days of therapy) for presumed carbapenem-resistant GNIs. Quarterly percentage change (QPC) using modified Poisson regression and relative change in frequency of targeted ceftazidime-avibactam to colistin encounters was calculated. Factors associated with preferentially receiving targeted ceftazidime-avibactam versus colistin were identified using generalized estimating equations. RESULTS Between 2015 quarter (q) 1 and 2017q4, ceftazidime-avibactam was administered 21 215 times across 1901 encounters. Inpatient prescriptions for ceftazidime-avibactam increased from 0.44/10 000 hospitalizations in 2015q1 to 7.7/10 000 in 2017q4 (QPC, +11%; 95% CI, 10-13%; P < .01), while conversely colistin prescriptions decreased quarterly by 5% (95% CI, 4-6%; P < .01). Ceftazidime-avibactam therapy was categorized as empiric 25% of the time, targeted 65% of the time, and indeterminate 10% of the time. Patients with chronic kidney disease were twice as likely to receive targeted ceftazidime-avibactam versus colistin (RR, 2.02; 95% CI, 1.82-2.25), whereas those on dialysis were less likely to receive ceftazidime-avibactam than colistin (RR, 0.71; 95% CI, .61-.83). CONCLUSIONS Since approval in 2015, ceftazidime-avibactam use has grown for presumed carbapenem-resistant GNIs, while colistin has correspondingly declined. Renal function drove the choice between ceftazidime-avibactam and colistin as targeted therapy.
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Affiliation(s)
- Jeffrey R Strich
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
- US Public Health Service Commissioned Corps, Rockville, Maryland, USA
| | - Emily Ricotta
- Epidemiology Unit, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Sarah Warner
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Yi Ling Lai
- Epidemiology Unit, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Cumhur Y Demirkale
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | | | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - Tara Palmore
- Hospital Epidemiology Service, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - John H Powers
- Clinical Research Directorate/Clinical Monitoring Research Program, Leidos Biomedical Research, Inc, National Cancer Institute Campus at Frederick, Frederick, Maryland, USA
| | - John P Dekker
- Department of Laboratory Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Jennifer Adjemian
- US Public Health Service Commissioned Corps, Rockville, Maryland, USA
- Epidemiology Unit, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Roland Matsouaka
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
- Program of Comparative Effectiveness Methodology, Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | | | - Robert L Danner
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Sameer S Kadri
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
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14
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Lasko MJ, Huse HK, Nicolau DP, Kuti JL. Contemporary analysis of ETEST for antibiotic susceptibility and minimum inhibitory concentration agreement against Pseudomonas aeruginosa from patients with cystic fibrosis. Ann Clin Microbiol Antimicrob 2021; 20:9. [PMID: 33468149 PMCID: PMC7816365 DOI: 10.1186/s12941-021-00415-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/06/2021] [Indexed: 02/07/2023] Open
Abstract
Objectives Cystic fibrosis (CF) acute pulmonary exacerbations are often caused by Pseudomonas aeruginosa, including multi-drug resistant strains. Optimal antibiotic therapy is required to return lung function and should be guided by in vitro susceptibility results. There are sparse data describing ETEST performance for CF isolates using contemporary isolates, methods and interpretation, as well as novel antibiotics, such as ceftazidime–avibactam and ceftolozane–tazobactam. Methods Pseudomonas aeruginosa (n = 105) isolated during pulmonary exacerbation from patients with CF were acquired from 3 US hospitals. Minimum inhibitory concentrations (MICs) were assessed by reference broth microdilution (BMD) and ETEST for aztreonam, cefepime, ceftazidime, ceftazidime–avibactam, ceftolozane–tazobactam, ciprofloxacin, levofloxacin, meropenem, piperacillin–tazobactam, and tobramycin. Broth microdilution was conducted in concordance with the Clinical and Laboratory Standards Institute M100. ETEST methodology reflected package insert recommendations. Performance of ETEST strips was evaluated using the Food and Drug Administration (FDA) and Susceptibility Testing Manufacturers Association (STMA) guidance. Results Of the 105 P. aeruginosa included, 46% had a mucoid phenotype. ETEST MICs typically read 0–1 dilution higher than BMD for all drugs. Categorical agreement and essential agreement ranged from 64 to 93% and 63 to 86%, respectively. The majority of observed errors were minor. A single very major error occurred with ceftazidime (4.2%). For ceftazidime–vibactam, 2 very major errors were observed and both were within essential agreement. Major errors occurred for aztreonam (3.3%), cefepime (9.4%), ceftazidime–avibactam (5.3%, adjusted 2.1%), ceftolozane–tazobactam (1%), meropenem (3.3%), piperacillin–tazobactam (2.9%), and tobramycin (1.5%). Conclusions ETEST methods performed conservatively for most antibiotics against this challenging collection of P. aeruginosa from patients with CF.
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Affiliation(s)
- Maxwell J Lasko
- Center for Anti-Infective Research and Development, Hartford Hospital, 80 Seymour Street, Hartford, 06102, CT, USA
| | - Holly K Huse
- Department of Clinical Microbiology, Huntington Hospital, Pasadena, CA, USA.,Department of Clinical Microbiology, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, 80 Seymour Street, Hartford, 06102, CT, USA.,Division of Infectious Diseases, Hartford Hospital, Hartford, CT, USA
| | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, 80 Seymour Street, Hartford, 06102, CT, USA.
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15
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Yahav D, Giske CG, Grāmatniece A, Abodakpi H, Tam VH, Leibovici L. New β-Lactam-β-Lactamase Inhibitor Combinations. Clin Microbiol Rev 2020; 34:e00115-20. [PMID: 33177185 PMCID: PMC7667665 DOI: 10.1128/cmr.00115-20] [Citation(s) in RCA: 251] [Impact Index Per Article: 62.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The limited armamentarium against drug-resistant Gram-negative bacilli has led to the development of several novel β-lactam-β-lactamase inhibitor combinations (BLBLIs). In this review, we summarize their spectrum of in vitro activities, mechanisms of resistance, and pharmacokinetic-pharmacodynamic (PK-PD) characteristics. A summary of available clinical data is provided per drug. Four approved BLBLIs are discussed in detail. All are options for treating multidrug-resistant (MDR) Enterobacterales and Pseudomonas aeruginosa Ceftazidime-avibactam is a potential drug for treating Enterobacterales producing extended-spectrum β-lactamase (ESBL), Klebsiella pneumoniae carbapenemase (KPC), AmpC, and some class D β-lactamases (OXA-48) in addition to carbapenem-resistant Pseudomonas aeruginosa Ceftolozane-tazobactam is a treatment option mainly for carbapenem-resistant P. aeruginosa (non-carbapenemase producing), with some activity against ESBL-producing Enterobacterales Meropenem-vaborbactam has emerged as treatment option for Enterobacterales producing ESBL, KPC, or AmpC, with similar activity as meropenem against P. aeruginosa Imipenem-relebactam has documented activity against Enterobacterales producing ESBL, KPC, and AmpC, with the combination having some additional activity against P. aeruginosa relative to imipenem. None of these drugs present in vitro activity against Enterobacterales or P. aeruginosa producing metallo-β-lactamase (MBL) or against carbapenemase-producing Acinetobacter baumannii Clinical data regarding the use of these drugs to treat MDR bacteria are limited and rely mostly on nonrandomized studies. An overview on eight BLBLIs in development is also provided. These drugs provide various levels of in vitro coverage of carbapenem-resistant Enterobacterales, with several drugs presenting in vitro activity against MBLs (cefepime-zidebactam, aztreonam-avibactam, meropenem-nacubactam, and cefepime-taniborbactam). Among these drugs, some also present in vitro activity against carbapenem-resistant P. aeruginosa (cefepime-zidebactam and cefepime-taniborbactam) and A. baumannii (cefepime-zidebactam and sulbactam-durlobactam).
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Affiliation(s)
- Dafna Yahav
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel
| | - Christian G Giske
- Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Alise Grāmatniece
- Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
- Pauls Stradins University Hospital, University of Latvia, Riga, Latvia
| | - Henrietta Abodakpi
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Vincent H Tam
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Leonard Leibovici
- Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel
- Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
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16
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Nolan PJ, Jain R, Cohen L, Finklea JD, Smith TT. In vitro activity of ceftolozane-tazobactam and ceftazidime-avibactam against Pseudomonas aeruginosa isolated from patients with cystic fibrosis. Diagn Microbiol Infect Dis 2020; 99:115204. [PMID: 33152675 DOI: 10.1016/j.diagmicrobio.2020.115204] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/26/2020] [Accepted: 09/02/2020] [Indexed: 11/26/2022]
Abstract
Pseudomonas aeruginosa is a commonly isolated pathogen in adults with cystic fibrosis (CF). Antimicrobial resistance is an escalating problem due to chronic colonization and frequent antimicrobial exposure. Ceftolozane-tazobactam (C/T) and ceftazidime-avibactam (CZA) exhibit promising activity against antimicrobial resistant organisms, including P. aeruginosa. A retrospective review was conducted comparing the in vitro activities of C/T and CZA against 42 P. aeruginosa isolates from the respiratory tract of 32 adults with CF. The first isolate per patient per year that underwent susceptibility testing for C/T, CZA, and colistin was included. C/T was more susceptible than CZA (60% versus 43%). Thirty-eight (90%) isolates were considered highly drug resistant and demonstrated higher C/T susceptibilities compared to CZA (55% versus 45%). These results suggest using C/T while awaiting susceptibilities when standard antipseudomonal agents cannot be used.
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Affiliation(s)
- Patrick J Nolan
- Department of Pediatrics, Division of Internal Medicine and Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Raksha Jain
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Leah Cohen
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - James D Finklea
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tiffeny T Smith
- Department of Pharmacy, University of Texas Southwestern Medical Center, Dallas, TX, USA
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17
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Nwankwo L, Butt Z, Schelenz S. Experience of Ceftazidime/avibactam in a UK tertiary cardiopulmonary specialist center. Expert Rev Anti Infect Ther 2020; 19:101-108. [PMID: 32799594 DOI: 10.1080/14787210.2020.1810568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Antimicrobial resistance is a major threat to public health. New drugs such as Ceftazidime/avibactam have been developed for the treatment of Multi-Drug resistant (MDR) pathogens. Susceptibility can be variable and inappropriate use can add a financial strain on the National Health Service (NHS). There is a pressing need to ensure these new and invaluable antimicrobials are preserved and used effectively. METHODS We undertook a retrospective observational study to assess the use of Ceftazidime/avibactam and evaluated prescribing against applied standards. RESULTS Between August 2017 and January 2019, 28 patients received 31 courses of Ceftazidime/avibactam. Prescribing according to the approved indications was observed for 68% of prescriptions (p < 0.0001). Duration of therapy was often prolonged but improved with Antimicrobial stewardship interventions. We observed 56% susceptibility (15/27 isolates) of MDR organisms (Pseudomonas, Klebsiella, Burkholderia, Enterobacter aerogenes, Achromobacter). We also report first in vivo experience to treat pulmonary disease caused by Non-tuberculous mycobacteria (NTM). Ceftazidime/avibactam was well tolerated, with no evidence of development of resistance at 6-months follow-up. CONCLUSIONS Our study showed that Antimicrobial stewardship interventions led to a more appropriate use of Ceftazidime/avibactam (as measured by duration of therapy), preserving it as a treatment option for MDR infections.
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Affiliation(s)
- Lisa Nwankwo
- Pharmacy Department, Royal Brompton and Harefield Hospital Foundation NHS Trust , London, UK
| | - Zahraa Butt
- Pharmacy Department, Royal Brompton and Harefield Hospital Foundation NHS Trust , London, UK
| | - Silke Schelenz
- Department of Microbiology, Kings College Hospital , London, UK
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18
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Hu YY, Cao JM, Yang Q, Chen S, Lv HY, Zhou HW, Wu Z, Zhang R. Risk Factors for Carbapenem-Resistant Pseudomonas aeruginosa, Zhejiang Province, China. Emerg Infect Dis 2020; 25:1861-1867. [PMID: 31538558 PMCID: PMC6759267 DOI: 10.3201/eid2510.181699] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Carbapenem-resistant Pseudomonas aeruginosa (CRPA) is a public health concern worldwide, but comprehensive analysis of risk factors for CRPA remains limited in China. We conducted a retrospective observational study of carbapenem resistance in 71,880 P. aeruginosa isolates collected in Zhejiang Province during 2015–2017. We analyzed risk factors for CRPA, including the type of clinical specimen; the year, season, and region in which it was collected; patient information, including age, whether they were an outpatient or inpatient, and whether inpatients were in the intensive care unit or general ward; and the level of hospital submitting isolates. We found CRPA was more prevalent among isolates from patients >60 years of age and in inpatients, especially in intensive care units. In addition, specimen types and seasons in which they were collected were associated with higher rates of CRPA. Our findings can help hospitals reduce the spread of P. aeruginosa and optimize antimicrobial drug use.
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