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Zheng M, Li FH, Liu J, Li WJ, Yin RX, Cai DT, Andrey DO, Zheng SL, Gales AC, Zhang WJ, Sun J, Liao XP, Yu Y. Synergistic effects of ceftazidime/avibactam combined with meropenem in a murine model of infection with KPC-producing Klebsiella pneumoniae. J Antimicrob Chemother 2024; 79:1069-1080. [PMID: 38526879 DOI: 10.1093/jac/dkae074] [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: 09/11/2023] [Accepted: 02/27/2024] [Indexed: 03/27/2024] Open
Abstract
OBJECTIVES The emergence and expansion of carbapenem-resistant Klebsiella pneumoniae infections is a concern due to the lack of 'first-line' antibiotic treatment options. The ceftazidime/avibactam is an important clinical treatment for carbapenem-resistant K. pneumoniae infections but there is an increasing number of cases of treatment failure and drug resistance. Therefore, a potential solution is combination therapies that result in synergistic activity against K. pneumoniae carbapenemase: producing K. pneumoniae (KPC-Kp) isolates and preventing the emergence of KPC mutants resistant to ceftazidime/avibactam are needed in lieu of novel antibiotics. METHODS To evaluate their synergistic activity, antibiotic combinations were tested against 26 KPC-Kp strains. Antibiotic resistance profiles, molecular characteristics and virulence genes were investigated by susceptibility testing and whole-genome sequencing. Antibiotic synergy was evaluated by in vitro chequerboard experiments, time-killing curves and dose-response assays. The mouse thigh model was used to confirm antibiotic combination activities in vivo. Additionally, antibiotic combinations were evaluated for their ability to prevent the emergence of ceftazidime/avibactam resistant mutations of blaKPC. RESULTS The combination of ceftazidime/avibactam plus meropenem showed remarkable synergistic activity against 26 strains and restored susceptibility to both the partnering antibiotics. The significant therapeutic effect of ceftazidime/avibactam combined with meropenem was also confirmed in the mouse model and bacterial loads in the thigh muscle of the combination groups were significantly reduced. Furthermore, ceftazidime/avibactam plus meropenem showed significant activity in preventing the occurrence of resistance mutations. CONCLUSIONS Our results indicated that the combination of ceftazidime/avibactam plus meropenem offers viable therapeutic alternatives in treating serious infections due to KPC-Kp.
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Affiliation(s)
- Mei Zheng
- State Key Laboratory for Animal Disease Control and Prevention, South China Agricultural University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
- Guangdong Laboratory for Lingnan Modern Agriculture, National Risk Assessment Laboratory for Antimicrobial Resistance of Animal Original Bacteria, College of Veterinary Medicine, South China Agricultural University, Guangzhou, China
| | - Fu-Hao Li
- State Key Laboratory for Animal Disease Control and Prevention, South China Agricultural University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
- Guangdong Laboratory for Lingnan Modern Agriculture, National Risk Assessment Laboratory for Antimicrobial Resistance of Animal Original Bacteria, College of Veterinary Medicine, South China Agricultural University, Guangzhou, China
| | - Juan Liu
- State Key Laboratory for Animal Disease Control and Prevention, South China Agricultural University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
- Guangdong Laboratory for Lingnan Modern Agriculture, National Risk Assessment Laboratory for Antimicrobial Resistance of Animal Original Bacteria, College of Veterinary Medicine, South China Agricultural University, Guangzhou, China
| | - Wen-Jie Li
- State Key Laboratory for Animal Disease Control and Prevention, South China Agricultural University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
- Guangdong Laboratory for Lingnan Modern Agriculture, National Risk Assessment Laboratory for Antimicrobial Resistance of Animal Original Bacteria, College of Veterinary Medicine, South China Agricultural University, Guangzhou, China
| | - Ruo-Xi Yin
- State Key Laboratory for Animal Disease Control and Prevention, South China Agricultural University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
- Guangdong Laboratory for Lingnan Modern Agriculture, National Risk Assessment Laboratory for Antimicrobial Resistance of Animal Original Bacteria, College of Veterinary Medicine, South China Agricultural University, Guangzhou, China
| | - Da-Tong Cai
- State Key Laboratory for Animal Disease Control and Prevention, South China Agricultural University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
| | - Diego O Andrey
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, 1211, Switzerland
| | - Si-Lin Zheng
- State Key Laboratory for Animal Disease Control and Prevention, South China Agricultural University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
| | - Ana C Gales
- Infectious Diseases Division, Federal University of Sao Paulo-UNIFESP, Escola Paulista de Medicina, São Paulo, Brazil
| | - Wan-Jiang Zhang
- State Key Laboratory of Veterinary Biotechnology, Harbin Veterinary Research Institute, Chinese Academy of Agricultural Sciences, Harbin, China
| | - Jian Sun
- State Key Laboratory for Animal Disease Control and Prevention, South China Agricultural University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
- Guangdong Laboratory for Lingnan Modern Agriculture, National Risk Assessment Laboratory for Antimicrobial Resistance of Animal Original Bacteria, College of Veterinary Medicine, South China Agricultural University, Guangzhou, China
| | - Xiao-Ping Liao
- State Key Laboratory for Animal Disease Control and Prevention, South China Agricultural University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
- Guangdong Laboratory for Lingnan Modern Agriculture, National Risk Assessment Laboratory for Antimicrobial Resistance of Animal Original Bacteria, College of Veterinary Medicine, South China Agricultural University, Guangzhou, China
| | - Yang Yu
- State Key Laboratory for Animal Disease Control and Prevention, South China Agricultural University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
- Guangdong Laboratory for Lingnan Modern Agriculture, National Risk Assessment Laboratory for Antimicrobial Resistance of Animal Original Bacteria, College of Veterinary Medicine, South China Agricultural University, Guangzhou, China
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Strukova EN, Golikova MV, Dovzhenko SA, Kobrin MB, Zinner SH. Pharmacodynamics of Doripenem Alone and in Combination with Relebactam in an In Vitro Hollow-Fiber Dynamic Model: Emergence of Resistance of Carbapenemase-Producing Klebsiella pneumoniae and the Inoculum Effect. Antibiotics (Basel) 2023; 12:1705. [PMID: 38136739 PMCID: PMC10741200 DOI: 10.3390/antibiotics12121705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/01/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
The emergence of bacteria resistant to beta-lactam/beta-lactamase inhibitor combinations is insufficiently studied, wherein the role of the inoculum effect (IE) in decreased efficacy is unclear. To address these issues, 5-day treatments with doripenem and doripenem/relebactam combination at different ratios of the agents were simulated in a hollow-fiber dynamic model against carbapenemase-producing K. pneumoniae at standard and high inocula. Minimal inhibitory concentrations (MICs) of doripenem alone and in the presence of relebactam at two inocula were determined. Combination MICs were tested using traditional (fixed relebactam concentration) and pharmacokinetic-based approach (fixed doripenem-to-relebactam concentration ratio equal to the therapeutic 24-h area under the concentration-time curve (AUC) ratio). In all experiments, resistant subpopulations were noted, but combined simulations reduced their numbers. With doripenem, the IE was apparent for both K. pneumoniae isolates in combined treatments for one strain. The pharmacokinetic-based approach to combination MIC estimation compared to traditional showed stronger correlation between DOSE/MIC and emergence of resistance. These results support (1) the constraint of relebactam combined with doripenem against the emergence of resistance and IE; (2) the applicability of a pharmacokinetic-based approach to estimate carbapenem MICs in the presence of an inhibitor to predict the IE and to describe the patterns of resistance occurrence.
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Affiliation(s)
- Elena N. Strukova
- Department of Pharmacokinetics & Pharmacodynamics, Gause Institute of New Antibiotics, 11 Bolshaya Pirogovskaya Street, 119021 Moscow, Russia; (E.N.S.); (S.A.D.); (M.B.K.)
| | - Maria V. Golikova
- Department of Pharmacokinetics & Pharmacodynamics, Gause Institute of New Antibiotics, 11 Bolshaya Pirogovskaya Street, 119021 Moscow, Russia; (E.N.S.); (S.A.D.); (M.B.K.)
| | - Svetlana A. Dovzhenko
- Department of Pharmacokinetics & Pharmacodynamics, Gause Institute of New Antibiotics, 11 Bolshaya Pirogovskaya Street, 119021 Moscow, Russia; (E.N.S.); (S.A.D.); (M.B.K.)
| | - Mikhail B. Kobrin
- Department of Pharmacokinetics & Pharmacodynamics, Gause Institute of New Antibiotics, 11 Bolshaya Pirogovskaya Street, 119021 Moscow, Russia; (E.N.S.); (S.A.D.); (M.B.K.)
| | - Stephen H. Zinner
- Harvard Medical School, Department of Medicine, Mount Auburn Hospital, 330 Mount Auburn St., Cambridge, MA 02138, USA;
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Cartagena AJ, Taylor KL, Smith JT, Manson AL, Pierce VM, Earl AM, Bhattacharyya RP. The carbapenem inoculum effect provides insight into the molecular mechanisms underlying carbapenem resistance in Enterobacterales. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.05.23.541813. [PMID: 37292717 PMCID: PMC10245868 DOI: 10.1101/2023.05.23.541813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Carbapenem-resistant Enterobacterales (CRE) are important pathogens that can develop resistance via multiple molecular mechanisms, including hydrolysis or reduced antibiotic influx. Identifying these mechanisms can improve pathogen surveillance, infection control, and patient care. We investigated how resistance mechanisms influence the carbapenem inoculum effect (IE), a phenomenon where inoculum size affects antimicrobial susceptibility testing (AST). We demonstrated that seven different carbapenemases impart a meropenem IE in Escherichia coli. Across 110 clinical CRE isolates, the carbapenem IE strictly depended on resistance mechanism: all carbapenemase-producing CRE (CP-CRE) exhibited a strong IE, whereas porin-deficient CRE displayed none. Concerningly, 50% and 24% of CP-CRE isolates changed susceptibility classification to meropenem and ertapenem, respectively, across the allowable inoculum range in clinical guidelines. The meropenem IE, and the ratio of ertapenem to meropenem minimal inhibitory concentration (MIC) at standard inoculum, reliably identified CP-CRE. Understanding how resistance mechanisms affect AST could improve diagnosis and guide therapies for CRE infections.
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Affiliation(s)
| | - Kyra L. Taylor
- Infectious Disease and Microbiome Program, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Joshua T. Smith
- Infectious Disease and Microbiome Program, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Abigail L. Manson
- Infectious Disease and Microbiome Program, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Virginia M. Pierce
- Microbiology Laboratory, Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Pathology and Clinical Laboratories, University of Michigan, Ann Arbor, MI 48109, USA
| | - Ashlee M. Earl
- Infectious Disease and Microbiome Program, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Roby P. Bhattacharyya
- Infectious Disease and Microbiome Program, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
- Infectious Diseases Division, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
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Stefanos SS, Sakaan S, Samarin M, Gelfand MS, Cleveland KO, Gant J, Kermeen S, Hobbs DA, Hobbs ALV. Assessing clinical cure of empirical piperacillin/tazobactam for ESBL urinary tract infections (ACCEPT-UTI). JAC Antimicrob Resist 2023; 5:dlad055. [PMID: 37180353 PMCID: PMC10174203 DOI: 10.1093/jacamr/dlad055] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 04/19/2023] [Indexed: 05/16/2023] Open
Abstract
Background Data are limited regarding use of piperacillin/tazobactam for ESBL urinary tract infections (UTIs). The objective of this study was to compare clinical outcomes of patients treated empirically with piperacillin/tazobactam versus carbapenems for ESBL UTIs. Methods This retrospective, observational, propensity score-matched study evaluated adults with an ESBL on urine culture. Patients who had UTI symptoms or leukocytosis, and who received a carbapenem or piperacillin/tazobactam empirically for at least 48 h were included. The primary outcome was clinical success within 48 h, defined as resolution of temperature (36-38°C), resolution of symptoms or leukocytosis (WBC <12 × 103/μL) in the absence of documented symptoms, and the absence of readmission for an ESBL UTI within 6 months. Secondary outcomes included time to clinical resolution, hospital length of stay, and in-hospital and 30 day all-cause mortality. Results Overall, 223 patients were included in the full cohort and 200 patients in the matched cohort (piperacillin/tazobactam = 100, carbapenem = 100). Baseline characteristics were similar between the groups. There was no difference in the primary outcome of clinical success between the carbapenem and piperacillin/tazobactam groups (58% versus 56%, respectively; P = 0.76). Additionally, there was no difference in median (IQR) time to clinical resolution [38.9 h (21.5, 50.9 h) versus 40.3 h (27.4, 57.5 h); P = 0.37], in-hospital all-cause mortality (3% versus 3%; P = 1.00), or 30 day all-cause mortality (4% versus 2%; P = 0.68) between the carbapenem and piperacillin/tazobactam groups, respectively. Conclusions There was no significant difference in clinical success for patients treated empirically with piperacillin/tazobactam compared with carbapenems for ESBL UTIs.
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Affiliation(s)
| | - Sami Sakaan
- Department of Pharmacy, Methodist University Hospital, 1265 Union Avenue, Memphis, TN 38104, USA
| | - Michael Samarin
- Department of Pharmacy, Methodist University Hospital, 1265 Union Avenue, Memphis, TN 38104, USA
| | - Michael S Gelfand
- Infectious Diseases, Methodist University Hospital, 1265 Union Avenue, Memphis, TN 38104, USA
- Division of Infectious Diseases, University of Tennessee Health Science Center, 875 Monroe Avenue, Memphis, TN 38163, USA
| | - Kerry O Cleveland
- Infectious Diseases, Methodist University Hospital, 1265 Union Avenue, Memphis, TN 38104, USA
- Division of Infectious Diseases, University of Tennessee Health Science Center, 875 Monroe Avenue, Memphis, TN 38163, USA
| | - Jessie Gant
- College of Pharmacy, University of Tennessee Health Science Center, 881 Madison Ave., Memphis, TN 38163, USA
| | - Sydney Kermeen
- College of Pharmacy, University of Tennessee Health Science Center, 881 Madison Ave., Memphis, TN 38163, USA
| | - Diana A Hobbs
- Department of Radiology, Washington University School of Medicine, 4525 Scott Ave., St Louis, MO 63110, USA
| | - Athena L V Hobbs
- Cardinal Health Innovative Delivery Solutions, 7000 Cardinal Place, Dublin, OH 43017, USA
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5
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Golikova MV, Strukova EN, Alieva KN, Ageevets VA, Avdeeva AA, Sulian OS, Zinner SH. Meropenem MICs at Standard and High Inocula and Mutant Prevention Concentration Inter-Relations: Comparative Study with Non-Carbapenemase-Producing and OXA-48-, KPC- and NDM-Producing Klebsiella pneumoniae. Antibiotics (Basel) 2023; 12:antibiotics12050872. [PMID: 37237775 DOI: 10.3390/antibiotics12050872] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/05/2023] [Accepted: 05/07/2023] [Indexed: 05/28/2023] Open
Abstract
The minimal inhibitory concentration (MIC) is conventionally used to define in vitro levels of susceptibility or resistance of a specific bacterial strain to an antibiotic and to predict its clinical efficacy. Along with MIC, other measures of bacteria resistance exist: the MIC determined at high bacterial inocula (MICHI) that allow the estimation of the occurrence of inoculum effect (IE) and the mutant prevention concentration, MPC. Together, MIC, MICHI and MPC represent the bacterial "resistance profile". In this paper, we provide a comprehensive analysis of such profiles of K. pneumoniae strains that differ by meropenem susceptibility, ability to produce carbapenemases and specific carbapenemase types. In addition, we have analyzed inter-relations between the MIC, MICHI and MPC for each tested K. pneumoniae strain. Low IE probability was detected with carbapenemase-non-producing K. pneumoniae, and high IE probability was detected with those that were carbapenemase-producing. MICs did not correlate with the MPCs; significant correlation was observed between the MICHIs and the MPCs, indicating that these bacteria/antibiotic characteristics display similar resistance properties of a given bacterial strain. To determine the possible resistance-related risk due to a given K. pneumoniae strain, we propose determining the MICHI. This can more or less predict the MPC value of the particular strain.
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Affiliation(s)
- Maria V Golikova
- Department of Pharmacokinetics & Pharmacodynamics, Gause Institute of New Antibiotics, 11 Bolshaya Pirogovskaya Street, 119021 Moscow, Russia
| | - Elena N Strukova
- Department of Pharmacokinetics & Pharmacodynamics, Gause Institute of New Antibiotics, 11 Bolshaya Pirogovskaya Street, 119021 Moscow, Russia
| | - Kamilla N Alieva
- Department of Pharmacokinetics & Pharmacodynamics, Gause Institute of New Antibiotics, 11 Bolshaya Pirogovskaya Street, 119021 Moscow, Russia
| | - Vladimir A Ageevets
- Pediatric Research and Clinical Center for Infectious Diseases, 9 Prof. Popov Street, 197022 St. Petersburg, Russia
| | - Alisa A Avdeeva
- Pediatric Research and Clinical Center for Infectious Diseases, 9 Prof. Popov Street, 197022 St. Petersburg, Russia
| | - Ofeliia S Sulian
- Pediatric Research and Clinical Center for Infectious Diseases, 9 Prof. Popov Street, 197022 St. Petersburg, Russia
| | - Stephen H Zinner
- Department of Medicine, Harvard Medical School, Mount Auburn Hospital, 330 Mount Auburn St., Cambridge, MA 02138, USA
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Fodah RA, Scott JB, Warawa JM. Direct monitoring of meropenem therapeutic efficacy against Klebsiella pneumoniae respiratory infection by bioluminescence imaging. J Med Microbiol 2023; 72. [PMID: 37252851 DOI: 10.1099/jmm.0.001686] [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: 06/01/2023] Open
Abstract
Introduction. Klebsiella pneumoniae is a major threat to public health worldwide. It is the causative agent for multiple disease presentations including urinary tract infection, septicemia, liver abscess, wound infection and respiratory tract infection. K. pneumoniae causes community- and hospital-acquired pneumonia, which is a devastating disease associated with high mortality rates.Hypothesis. There is a growing concern about the emergence of multidrug-resistant K. pneumoniae strains complicating the treatment with the current available therapeutics; therefore, there is an urgent need for the development of new antimicrobial agents.Aim. K. pneumoniae causes an acute respiratory disease in mice and in the current work we investigated the capability to perform non-invasive monitoring of bioluminescent Klebsiella to monitor therapeutic efficacy.Methodology. We engineered a bioluminescence reporter strain of K. pneumoniae to monitor the impact of antibiotics in a murine respiratory disease model.Results. We demonstrate that bioluminescence correlates with bacterial numbers in host tissues allowing for a non-invasive enumeration of bacterial replication in vivo. Light production is directly linked to bacterial viability, and this novel bioluminescent K. pneumoniae strain enabled monitoring of the efficacy of meropenem therapy in arresting bacterial proliferation in the lung.Conclusion. The use of non-invasive bioluminescent imaging improves preclinical animal model testing to detect study outcome earlier and with higher sensitivity.
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Affiliation(s)
- Ramy A Fodah
- Department of Microbiology and Immunology, University of Louisville, Louisville, USA
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Present address: King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Jacob B Scott
- Dental School, University of Louisville, Louisville, Kentucky, USA
| | - Jonathan M Warawa
- Department of Microbiology and Immunology, University of Louisville, Louisville, USA
- Center for Predictive Medicine, University of Louisville, Louisville, USA
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Reynolds D, Burnham JP, Vazquez Guillamet C, McCabe M, Yuenger V, Betthauser K, Micek ST, Kollef MH. The threat of multidrug-resistant/extensively drug-resistant Gram-negative respiratory infections: another pandemic. Eur Respir Rev 2022; 31:31/166/220068. [PMID: 36261159 DOI: 10.1183/16000617.0068-2022] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 06/09/2022] [Indexed: 12/22/2022] Open
Abstract
Antibiotic resistance is recognised as a global threat to human health by national healthcare agencies, governments and medical societies, as well as the World Health Organization. Increasing resistance to available antimicrobial agents is of concern for bacterial, fungal, viral and parasitic pathogens. One of the greatest concerns is the continuing escalation of antimicrobial resistance among Gram-negative bacteria resulting in the endemic presence of multidrug-resistant (MDR) and extremely drug-resistant (XDR) pathogens. This concern is heightened by the identification of such MDR/XDR Gram-negative bacteria in water and food sources, as colonisers of the intestine and other locations in both hospitalised patients and individuals in the community, and as agents of all types of infections. Pneumonia and other types of respiratory infections are among the most common infections caused by MDR/XDR Gram-negative bacteria and are associated with high rates of mortality. Future concerns are already heightened due to emergence of resistance to all existing antimicrobial agents developed in the past decade to treat MDR/XDR Gram-negative bacteria and a scarcity of novel agents in the developmental pipeline. This clinical scenario increases the likelihood of a future pandemic caused by MDR/XDR Gram-negative bacteria.
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Affiliation(s)
- Daniel Reynolds
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Jason P Burnham
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Mikaela McCabe
- Dept of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, MO, USA
| | - Valerie Yuenger
- Dept of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, MO, USA
| | - Kevin Betthauser
- Dept of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, MO, USA
| | - Scott T Micek
- Dept of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, MO, USA
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
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Evaluation of Piperacillin-Tazobactam ETEST for the Detection of OXA-1 Resistance Mechanism among Escherichia coli and Klebsiella pneumoniae. J Clin Microbiol 2022; 60:e0143022. [PMID: 36416539 PMCID: PMC9769679 DOI: 10.1128/jcm.01430-22] [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: 11/24/2022] Open
Abstract
Globally, piperacillin-tazobactam resistance among Escherichia coli and Klebsiella pneumoniae is driven by OXA-1 beta-lactamases. Expression of blaOXA-1 yields piperacillin-tazobactam MICs of 8 to 16 μg/mL, which straddle the susceptible/susceptible-dose dependent breakpoint set by the Clinical and Laboratory Standards Institute in 2022. Variability of the reference broth microdilution method (BMD) was evaluated by manufacturing BMD panels using 2 brands of piperacillin, 2 brands of tazobactam and 2 brands of cation-adjusted Mueller-Hinton broth. In addition, ETEST, which harbors an intermediate dilution of 12 μg/mL was evaluated for the ability to differentiate isolates with and without blaOXA-1. A collection of 200 E. coli and K. pneumoniae, of which 82 harbored a blaOXA-1 gene, were tested. BMD variability was on average 1.3-fold, within the accepted 2-fold variability of MICs. However, categorical agreement (CA) between BMD reads was 74.0% for all isolates and 63.4% for those with a blaOXA-1 gene and 81.3% for those without blaOXA-1 detected (P = 0.004, Pearson's Chi Square). ETEST overall CA with the BMD mode was 68.0% and essential agreement (EA) was 80.5%. For isolates with blaOXA-1, CA was 50.0% and EA was 69.5%, versus 80.5% and 88.1%, respectively, for isolates without blaOXA-1 (P < 0.0001 for both comparisons). All ETEST errors were major errors (false resistance) compared to BMD mode. However, the negative predictive value of the ETEST for the presence of blaOXA-1 was 94.1%, compared to only 74.2% negative predictive value for BMD. Clinicians and microbiologists should be aware of the challenges associated with testing piperacillin-tazobactam in regions where blaOXA-1 is prevalent.
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Burillo A, Bouza E. Controversies over the management of infections caused by Amp-C- and ESBL-producing Enterobacterales : what questions remain for future studies? Curr Opin Infect Dis 2022; 35:575-582. [PMID: 35942862 DOI: 10.1097/qco.0000000000000863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE OF REVIEW The continuous rise in infections caused by third-generation cephalosporin-resistant Enterobacterales (e.g. extended-spectrum beta-lactamase- or AmpC-producing Enterobacterales ) is a major health concern. Carbapenems are regarded as the antibiotics of choice for the treatment of these infections. However, their indiscriminant use is not without consequences, and has contributed to the emergence of carbapenem-resistant Enterobacterales .In this review, we discuss the available evidence supporting the use of other betalactams, nonbetalactams and the new betalactams/beta-lactamase inhibitors (BLA/BLI) to treat these infections. We also analyze unresolved issues in this field. RECENT FINDINGS Piperacillin tazobactam (PTZ) was classically recommended as a carbapenem-sparing agent. However, data have emerged against its use and it is now a controversial recommendation. IDSA, European and British guidelines reject the empirical use of PTZ for these pathogens, reserving its use for rare clinical situations.Other issues that continue to generate debate are the use of extended infusion (3 h) PTZ, the use of older antibiotics, a shortened course of carbapenems and reserving the new BLA/BLI for these infections. SUMMARY New treatment strategies should be based on clinical evidence, local epidemiology and the microbiological activity of these drugs.
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Affiliation(s)
- Almudena Burillo
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón.,Medicine Department, School of Medicine, Universidad Complutense de Madrid.,Instituto de Investigación Sanitaria Gregorio Marañón
| | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón.,Medicine Department, School of Medicine, Universidad Complutense de Madrid.,Instituto de Investigación Sanitaria Gregorio Marañón.,CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
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10
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Hetzler L, Kollef MH, Yuenger V, Micek ST, Betthauser KD. New antimicrobial treatment options for severe Gram-negative infections. Curr Opin Crit Care 2022; 28:522-533. [PMID: 35942725 DOI: 10.1097/mcc.0000000000000968] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review will provide rationale for the development of new antibiotics to treat severe or multidrug-resistant (MDR) Gram-negative infections. It will also provide an overview of recently approved and pipeline antibiotics for severe/MDR Gram-negative infections. RECENT FINDINGS MDR Gram-negative infections are recognized as critical threats by global and national organizations and carry a significant morbidity and mortality risk. Increasing antibiotic resistance amongst Gram-negative bacteria, including carbapenem-resistant Acinetobacter baumannii , extended-spectrum β-lactamase-producing Enterobacterales, carbapenem-resistant Enterobacterales and Pseudomonas aeruginosa , with difficult-to-treat-resistance has made both empiric and definitive treatment of these infections increasingly problematic. In recent years, several antibiotics have been approved for treatment of MDR Gram-negative infections and ongoing clinical trials are poised to provide additional options to clinicians' armamentarium. These agents include various β-lactam/β-lactamase inhibitor combinations, eravacycline, plazomicin and cefiderocol. SUMMARY Severe/MDR Gram-negative infections continue to be important infections due to their impact on patient outcomes, especially in critically ill and immunocompromised hosts. The availability of new antibiotics offers an opportunity to improve empiric and definitive treatment of these infections.
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Affiliation(s)
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine
| | | | - Scott T Micek
- Department of Pharmacy Practice, Barnes-Jewish Hospital
- Department of Pharmacy Practice
- Center for Health Outcomes Research and Education, University of Health Sciences and Pharmacy, St. Louis, Missouri, USA
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Arrazuria R, Kerscher B, Huber KE, Hoover JL, Lundberg CV, Hansen JU, Sordello S, Renard S, Aranzana-Climent V, Hughes D, Gribbon P, Friberg LE, Bekeredjian-Ding I. Variability of murine bacterial pneumonia models used to evaluate antimicrobial agents. Front Microbiol 2022; 13:988728. [PMID: 36160241 PMCID: PMC9493352 DOI: 10.3389/fmicb.2022.988728] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/15/2022] [Indexed: 11/20/2022] Open
Abstract
Antimicrobial resistance has become one of the greatest threats to human health, and new antibacterial treatments are urgently needed. As a tool to develop novel therapies, animal models are essential to bridge the gap between preclinical and clinical research. However, despite common usage of in vivo models that mimic clinical infection, translational challenges remain high. Standardization of in vivo models is deemed necessary to improve the robustness and reproducibility of preclinical studies and thus translational research. The European Innovative Medicines Initiative (IMI)-funded “Collaboration for prevention and treatment of MDR bacterial infections” (COMBINE) consortium, aims to develop a standardized, quality-controlled murine pneumonia model for preclinical efficacy testing of novel anti-infective candidates and to improve tools for the translation of preclinical data to the clinic. In this review of murine pneumonia model data published in the last 10 years, we present our findings of considerable variability in the protocols employed for testing the efficacy of antimicrobial compounds using this in vivo model. Based on specific inclusion criteria, fifty-three studies focusing on antimicrobial assessment against Pseudomonas aeruginosa, Klebsiella pneumoniae and Acinetobacter baumannii were reviewed in detail. The data revealed marked differences in the experimental design of the murine pneumonia models employed in the literature. Notably, several differences were observed in variables that are expected to impact the obtained results, such as the immune status of the animals, the age, infection route and sample processing, highlighting the necessity of a standardized model.
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Affiliation(s)
- Rakel Arrazuria
- Division of Microbiology, Paul-Ehrlich-Institut, Langen, Germany
| | | | - Karen E. Huber
- Division of Microbiology, Paul-Ehrlich-Institut, Langen, Germany
| | - Jennifer L. Hoover
- Infectious Diseases Research Unit, GlaxoSmithKline Pharmaceuticals, Collegeville, PA, United States
| | | | - Jon Ulf Hansen
- Department of Bacteria, Parasites & Fungi, Statens Serum Institut, Copenhagen, Denmark
| | | | | | | | - Diarmaid Hughes
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | - Philip Gribbon
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Discovery Research ScreeningPort, Hamburg, Germany
| | | | - Isabelle Bekeredjian-Ding
- Division of Microbiology, Paul-Ehrlich-Institut, Langen, Germany
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Bonn, Germany
- *Correspondence: Isabelle Bekeredjian-Ding,
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12
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Rando E, Giovannenze F, Murri R, Sacco E. A review of recent advances in the treatment of adults with complicated urinary tract infection. Expert Rev Clin Pharmacol 2022; 15:1053-1066. [PMID: 36062485 DOI: 10.1080/17512433.2022.2121703] [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: 11/04/2022]
Abstract
INTRODUCTION Complicated urinary tract infections (cUTIs) entail diverse clinical conditions that could be managed differently and not necessarily with premature empiric therapy. Since multidrug-resistant organisms (MDROs) are widely spreading worldwide, the possibility of encountering these resistant bacteria is inevitably part of the daily life of physicians who manage cUTIs. AREAS COVERED The advances in the management of cUTIs are explored, illustrating: 1) a proposed therapeutical approach to cUTIs within the antimicrobial stewardship context; 2) evidence regarding novel antibiotics targeting MDROs. Evidence research has been performed through MEDLINE/PubMed using appropriate keywords and terms regarding cUTIs published before June 2022. EXPERT OPINION Novel antimicrobial drugs are available in the clinicians' armamentarium. Selecting the optimal therapy for suitable patients may be challenging given the multifaceted group of cUTIs. Carbapenems use is widely increasing, the role of old β-lactam/β-lactamase inhibitors is constantly revised, and novel drugs lack real-life studies. Understanding the different ranges of the complexity of patients affected by cUTIs may help select the most suitable antibiotic for every single case. More multicentric observational studies targeting cUTIs are needed to elucidate the appropriate drug based on patient characteristics and presentations, providing stronger recommendations for cases encountered in everyday clinical practice.
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Affiliation(s)
- Emanuele Rando
- Dipartimento di Sicurezza e Bioetica - Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesca Giovannenze
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Rita Murri
- Dipartimento di Sicurezza e Bioetica - Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, Rome, Italy.,Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Emilio Sacco
- Urology Dept., Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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13
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Comparison of the Treatment Outcome of Piperacillin-Tazobactam versus Carbapenems for Patients with Bacteremia Caused by Extended-Spectrum β-Lactamase-Producing Escherichia coli in Areas with Low Frequency of Coproduction of OXA-1: a Preliminary Analysis. Microbiol Spectr 2022; 10:e0220622. [PMID: 35916524 PMCID: PMC9430612 DOI: 10.1128/spectrum.02206-22] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Although piperacillin-tazobactam (TZP) was shown to be less effective than carbapenems in treating bacteremia due to extended-spectrum β-lactamase-producing (ESBL)-producing organisms in a randomized controlled trial, the fact that many of the causative organisms co-produced inhibitor-resistant OXA-1 along with ESBLs may have influenced the results. In this study, we compared the therapeutic effectiveness of TZP and carbapenem in treating ESBL-producing Escherichia coli bacteremia in areas with low frequency of OXA-1 co-production. Forty patients, 14 in the TZP treatment group and 26 in the carbapenem treatment group, were included in the analysis. There were no significant differences in patient background between the two groups. Urinary tract infection or cholangitis was the source of bacteremia in 26 patients (65%), and the Pitt bacteremia score was zero or one in 35 patients (87.5%). Only four (11.4%) of the 35 causative isolates available for microbiological analysis harbored blaOXA-1, and only three (8.6%) were non-susceptible to TZP. Seventeen (48.6%) isolates carried blaCTX-M-27, none of which carried other β-lactamase genes. No significant difference in the frequency of treatment failure on day 14 of bacteremia was documented between the TZP and carbapenem treatment groups in both the crude analysis and the inverse probability of treatment weighting-adjusted analysis. This study demonstrates that TZP may be a treatment option for non-severe cases of ESBL-producing E. coli bacteremia in areas with low frequency of OXA-1 co-production. IMPORTANCE Although carbapenems are considered the drug of choice for severe infections caused by extended-spectrum β-lactamase-producing (ESBL)-producing organisms, other therapeutic options are being explored to avoid increasing the selective pressure for carbapenem-resistant organisms. In this study, it was suggested that piperacillin-tazobactam may be as effective as carbapenems for the treatment of mild bacteremia caused by ESBL-producing Escherichia coli in areas where OXA-1 co-production by ESBL-producing E. coli is rare. The genetic background of each regional epidemic clone differs even among multidrug-resistant bacteria classified under the same name (e.g., ESBL-producing organisms), resulting in possible differences in the efficacy of therapeutic agents. Exploration of treatment options for multidrug-resistant organisms according to local epidemiology is worthwhile from the perspective of antimicrobial stewardship.
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14
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Klebsiella pneumoniae Susceptibility to Carbapenem/Relebactam Combinations: Influence of Inoculum Density and Carbapenem-to-Inhibitor Concentration Ratio. Biomedicines 2022; 10:biomedicines10061454. [PMID: 35740475 PMCID: PMC9221057 DOI: 10.3390/biomedicines10061454] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 06/17/2022] [Accepted: 06/17/2022] [Indexed: 11/26/2022] Open
Abstract
The inoculum effect (IE) is a well-known phenomenon with beta-lactams. At the same time, the IE has not been extensively studied with carbapenem/carbapenemase inhibitor combinations. The antibiotic-to-inhibitor concentration ratio used in susceptibility testing can influence the in vitro activity of the combination. To explore the role of these factors, imipenem/relebactam and doripenem/relebactam MICs were estimated against six Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae strains at standard inocula (SI) and high inocula (HI) by two methods: with a fixed relebactam concentration and with a fixed, pharmacokinetic-based carbapenem-to-relebactam concentration ratio. The combination MICs at HI, compared to SI, increased with most of the tested strains. However, the IE occurred with only two K. pneumoniae strains regardless of the MIC testing method. The relationship between the MICs at SI and the respective inoculum-induced MIC changes was observed when the MICs were estimated at pharmacokinetic-based carbapenem-to-relebactam concentration ratios. Thus, (1) IE was observed with both carbapenem/relebactam combinations regardless of the MIC testing method; however, IE was not observed frequently among tested K. pneumoniae strains. (2) At HI, carbapenem/relebactam combination MICs increased to levels associated with carbapenem resistance. (3) Combination MICs determined at pharmacokinetic-based carbapenem-to-inhibitor concentration ratios predict susceptibility elevations at HI in KPC-producing K. pneumoniae.
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15
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Salazar-Vizcaya L, Atkinson A, Kronenberg A, Plüss-Suard C, Kouyos RD, Kachalov V, Troillet N, Marschall J, Sommerstein R. The impact of public health interventions on the future prevalence of ESBL-producing Klebsiella pneumoniae: a population based mathematical modelling study. BMC Infect Dis 2022; 22:487. [PMID: 35606726 PMCID: PMC9125893 DOI: 10.1186/s12879-022-07441-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 05/03/2022] [Indexed: 11/22/2022] Open
Abstract
Background Future prevalence of colonization with extended-spectrum betalactamase (ESBL-) producing K. pneumoniae in humans and the potential of public health interventions against the spread of these resistant bacteria remain uncertain. Methods Based on antimicrobial consumption and susceptibility data recorded during > 13 years in a Swiss region, we developed a mathematical model to assess the comparative effect of different interventions on the prevalence of colonization. Results Simulated prevalence stabilized in the near future when rates of antimicrobial consumption and in-hospital transmission were assumed to remain stable (2025 prevalence: 6.8% (95CI%:5.4–8.8%) in hospitals, 3.5% (2.5–5.0%) in the community versus 6.1% (5.0–7.5%) and 3.2% (2.3–4.2%) in 2019, respectively). When overall antimicrobial consumption was set to decrease by 50%, 2025 prevalence declined by 75% in hospitals and by 64% in the community. A 50% decline in in-hospital transmission rate led to a reduction in 2025 prevalence of 31% in hospitals and no reduction in the community. The best model fit estimated that 49% (6–100%) of observed colonizations could be attributable to sources other than human-to-human transmission within the geographical setting. Conclusions Projections suggests that overall antimicrobial consumption will be, by far, the most powerful driver of prevalence and that a large fraction of colonizations could be attributed to non-local transmissions. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07441-z.
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Affiliation(s)
- Luisa Salazar-Vizcaya
- Department of Infectious Diseases, Bern University Hospital, Inselspital, University of Bern, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland.
| | - Andrew Atkinson
- Department of Infectious Diseases, Bern University Hospital, Inselspital, University of Bern, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Andreas Kronenberg
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | | | - Roger D Kouyos
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland.,Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Viacheslav Kachalov
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland.,Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Nicolas Troillet
- Service of Infectious Diseases, Central Institute, Valais Hospitals, Sion, Switzerland
| | - Jonas Marschall
- Department of Infectious Diseases, Bern University Hospital, Inselspital, University of Bern, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Rami Sommerstein
- Department of Infectious Diseases, Bern University Hospital, Inselspital, University of Bern, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland.
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16
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Mizrahi A, Chat L, Danjean M, Mory C, Nguyen Van JC, de Ponfilly GP, Caméléna F, Le Monnier A, Bercot B, Birgy A, Jacquier H, Pilmis B. Inoculum effect of Enterobacterales co-expressing OXA-48 and CTX-M on the susceptibility to ceftazidime/avibactam and meropenem. Eur J Clin Microbiol Infect Dis 2022; 41:853-858. [PMID: 35322329 DOI: 10.1007/s10096-022-04430-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 03/09/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The treatment of infections caused by OXA-48/CTX-M-coproducing Enterobacterales may be based on new beta-lactam/beta-lactamase inhibitors, such as ceftazidime/avibactam (CZA), or on high dose of meropenem (MER). However, bacterial density at the infection site may vary widely, and the inoculum effect of such antimicrobial strategies has never been specifically investigated. To determine if CZA or MER susceptibilities are impacted by high inocula of Enterobacterales co-expressing both enzymes: OXA-48 like and CTX-M. METHODS Determination of an inoculum effect was performed with a standard inoculum of 108 CFU/mL (0.5 McFarland) as recommended by EUCAST guidelines and compared to a twofold increase as well as a tenfold increase (1 McFarland and 5 McFarland respectively). RESULTS Thirty-nine isolates of ceftazidime-resistant Enterobacterales were included of which 27 (70%) co-expressed OXA-48 + CTX-M-15, 6 (15%) OXA-48 + CTX-M-14, and 6 (15%) OXA-181 + CTX-M-15. The susceptibility to the CZA combination was preserved whatever the inoculum used. Regarding MER, 24 (61.5%) of the isolates were susceptible to MER with the standard inoculum, 19 (48.7%) with a twofold increase, and only 15 (38.5%) with a tenfold increase. CONCLUSION We showed that in vitro inoculum effect was observed with meropenem but not with CZA for OXA-48- combined with CTX-M-producing Enterobacterales.
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Affiliation(s)
- A Mizrahi
- Service de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, 185 rue Raymond Losserand, 75014, Paris, France.
- UMR 1319, Institut Micalis, Université Paris-Saclay, INRAeChâtenay Malabry, AgroParisTech, France.
| | - L Chat
- Service de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, 185 rue Raymond Losserand, 75014, Paris, France
| | - M Danjean
- Service de Microbiologie Clinique, Hôpital Universitaire Robert Debré, Paris, France
| | - C Mory
- Plateforme de Dosages Des Anti-Infectieux, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - J C Nguyen Van
- Service de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, 185 rue Raymond Losserand, 75014, Paris, France
| | - G Péan de Ponfilly
- Service de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, 185 rue Raymond Losserand, 75014, Paris, France
- UMR 1319, Institut Micalis, Université Paris-Saclay, INRAeChâtenay Malabry, AgroParisTech, France
| | - F Caméléna
- Service de Bactériologie, AP-HP Groupe Hospitalier Saint-Louis-Lariboisière-Fernand-Widal Site Saint Louis, Paris, France
- UMR1137, IAME, Université de Paris, INSERM, Paris, France
| | - A Le Monnier
- Service de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, 185 rue Raymond Losserand, 75014, Paris, France
- UMR 1319, Institut Micalis, Université Paris-Saclay, INRAeChâtenay Malabry, AgroParisTech, France
| | - B Bercot
- Service de Bactériologie, AP-HP Groupe Hospitalier Saint-Louis-Lariboisière-Fernand-Widal Site Saint Louis, Paris, France
- UMR1137, IAME, Université de Paris, INSERM, Paris, France
| | - A Birgy
- Service de Microbiologie Clinique, Hôpital Universitaire Robert Debré, Paris, France
- UMR1137, IAME, Université de Paris, INSERM, Paris, France
| | - H Jacquier
- Service de Bactériologie, AP-HP Groupe Hospitalier Saint-Louis-Lariboisière-Fernand-Widal Site Saint Louis, Paris, France
- UMR1137, IAME, Université de Paris, INSERM, Paris, France
| | - B Pilmis
- UMR1137, IAME, Université de Paris, INSERM, Paris, France
- Équipe Mobile de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France
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17
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Chauzy A, Akrong G, Aranzana-Climent V, Moreau J, Prouvensier L, Mirfendereski H, Buyck JM, Couet W, Marchand S. PKPD Modeling of the Inoculum Effect of Acinetobacter baumannii on Polymyxin B in vivo. Front Pharmacol 2022; 13:842921. [PMID: 35370719 PMCID: PMC8966651 DOI: 10.3389/fphar.2022.842921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 02/28/2022] [Indexed: 11/20/2022] Open
Abstract
The reduction in antimicrobial activity at high bacterial counts is a microbiological phenomenon known as the inoculum effect (IE). In a previous in vitro study, a significant IE was observed for polymyxin B (PMB) against a clinical isolate of Acinetobacter baumannii, and well described by a new pharmacokinetic-pharmacodynamic model. Few in vivo studies have investigated the impact of inoculum size on survival or antibiotic efficacy. Therefore, our objective was to confirm the influence of inoculum size of this A. baumannii clinical isolate on PMB in vivo effect over time. Pharmacokinetics and pharmacodynamics of PMB after a single subcutaneous administration (1, 15 and 40 mg/kg) were studied in a neutropenic murine thigh infection model. The impact of A. baumannii inoculum size (105, 106 and 107 CFU/thigh) on PMB efficacy was also evaluated. In vivo PMB PK was well described by a two-compartment model including saturable absorption from the subcutaneous injection site and linear elimination. The previous in vitro PD model was modified to adequately describe the decrease of PMB efficacy with increased inoculum size in infected mice. The IE was modeled as a decrease of 32% in the in vivo PMB bactericidal effect when the starting inoculum increases from 105 to 107 CFU/thigh. Although not as important as previously characterized in vitro an IE was confirmed in vivo.
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Affiliation(s)
- Alexia Chauzy
- INSERM U1070, Poitiers, France.,UFR Médecine-Pharmacie, Université de Poitiers, Poitiers, France
| | - Grace Akrong
- INSERM U1070, Poitiers, France.,UFR Médecine-Pharmacie, Université de Poitiers, Poitiers, France
| | - Vincent Aranzana-Climent
- INSERM U1070, Poitiers, France.,UFR Médecine-Pharmacie, Université de Poitiers, Poitiers, France
| | - Jérémy Moreau
- INSERM U1070, Poitiers, France.,UFR Médecine-Pharmacie, Université de Poitiers, Poitiers, France
| | - Laure Prouvensier
- INSERM U1070, Poitiers, France.,Département de Toxicologie et de Pharmacocinétique, CHU de Poitiers, Poitiers, France
| | - Hélène Mirfendereski
- INSERM U1070, Poitiers, France.,Département de Toxicologie et de Pharmacocinétique, CHU de Poitiers, Poitiers, France
| | - Julien M Buyck
- INSERM U1070, Poitiers, France.,UFR Médecine-Pharmacie, Université de Poitiers, Poitiers, France
| | - William Couet
- INSERM U1070, Poitiers, France.,UFR Médecine-Pharmacie, Université de Poitiers, Poitiers, France.,Département de Toxicologie et de Pharmacocinétique, CHU de Poitiers, Poitiers, France
| | - Sandrine Marchand
- INSERM U1070, Poitiers, France.,UFR Médecine-Pharmacie, Université de Poitiers, Poitiers, France.,Département de Toxicologie et de Pharmacocinétique, CHU de Poitiers, Poitiers, France
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18
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Hoo GSR, Cai Y, Quek YC, Teo JQ, Choudhury S, Koh TH, Lim TP, Marimuthu K, Ng OT, Kwa AL. Predictors and Outcomes of Healthcare-Associated Infections Caused by Carbapenem-Nonsusceptible Enterobacterales: A Parallel Matched Case-Control Study. Front Cell Infect Microbiol 2022; 12:719421. [PMID: 35281438 PMCID: PMC8907832 DOI: 10.3389/fcimb.2022.719421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives The increasing incidence of carbapenem-nonsusceptible Enterobacterales as major pathogens in healthcare associated infections (HAIs) is of paramount concern. To implement effective prevention strategies against carbapenem-nonsusceptible Enterobacterales (CnSE) HAIs, it is crucial to identify modifiable factors associated with these infections. We identified risk factors for CnSE-HAIs, and compared clinical outcomes of CnSE-HAI and carbapenem-sensitive Enterobacterales (CSE)-HAI patients. Methods We conducted a multi-centre parallel matched case-control study in two 1700-bedded Singapore acute-care hospitals from 2014–2016. Patients with CnSE-HAIs and CSE-HAIs were compared to a common control group without HAIs (1:1:3 ratio), matched by time-at-risk and patient ward. Carbapenem nonsusceptible was defined as non-susceptibility to either meropenem or imipenem. Presence of healthcare associated infections were defined by the criteria provided by the European Centre for Disease Prevention and Control. Outcomes of CnSE-HAI and CSE-HAI patients were compared using multivariable logistic and cox regression; the models were adjusted for infection and treatment characteristics. Results Eighty CnSE-HAI and 80 CSE-HAI patients were matched to 240 patients without HAIs. All CRE-HAIs patients had prior antibiotic exposure, with 44 (55.0%) with prior carbapenem exposure. The most common CnSE-HAIs were intra-abdominal infections (28.8%) and pneumonia (23.8%). The most common CnSE species was Klebsiella spp. (63.8%). In the risk factor analysis, presence of drainage devices [adjusted odds ratio (aOR), 2.19; 95% CI, 1.29 – 3.70] and prior carbapenem exposure (aOR,17.09; 95% CI, 3.06 – 95.43) independently predicted CnSE-HAIs. In the crude outcomes analysis, CnSE-HAI patients had higher all-cause in-hospital mortality and longer time to discharge compared to CSE-HAI patients. After adjusting for differences in receipt of antibiotics with reported susceptibility to the Enterobacterales, there was no significant difference in all-cause in-hospital mortality between the two groups (aOR, 1.76; 95% CI, 0.86–3.58). Time to discharge remained significantly longer in patients with CnSE-HAI (adjusted hazard ratio, 0.71; 95% CI, 0.51 – 0.98) after adjusting for disease severity, receipt of antibiotics with reported susceptibility and receipt of appropriate source control. Conclusion Appropriate management of deep-seated Enterobacterales infections and reducing exposure to carbapenems may reduce risk of CnSE-HAIs in Singapore. Efforts to improve antimicrobial therapy in CnSE-HAI patients may improve patient outcomes.
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Affiliation(s)
- Grace S. R. Hoo
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Yiying Cai
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
- Department of Pharmacy, National University of Singapore, Singapore, Singapore
- Programme in Health Services & Systems Research, Duke-National University of Singapore (NUS) Medical School, Singapore, Singapore
| | - Yan Ching Quek
- Department of Pharmacy, National University of Singapore, Singapore, Singapore
| | - Jocelyn Q. Teo
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Saugata Choudhury
- Department of Laboratory Medicine, Tan Tock Seng Hospital, Singapore, Singapore
- Dorevitch Pathology, Melbourne, VIC, Australia
| | - Tse Hsien Koh
- Department of Microbiology, Singapore General Hospital, Singapore, Singapore
- Singhealth Duke-National University of Singapore (NUS) Pathology Academic Clinical Programme, Singapore, Singapore
| | - Tze Peng Lim
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
- Singhealth Duke-National University of Singapore (NUS) Pathology Academic Clinical Programme, Singapore, Singapore
- Singhealth Duke-National University of Singapore (NUS) Medicine Academic Clinical Programme, Singapore, Singapore
| | - Kalisvar Marimuthu
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Hospital-Acquired Infection (HAI) Surveillance Unit, National Centre for Infectious Diseases, Singapore, Singapore
- Department of Infectious Diseases, National Centre for Infectious Diseases, Singapore, Singapore
| | - Oon Tek Ng
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore
- Department of Infectious Diseases, National Centre for Infectious Diseases, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Andrea L. Kwa
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
- Singhealth Duke-National University of Singapore (NUS) Medicine Academic Clinical Programme, Singapore, Singapore
- Emerging Infectious Diseases, Duke-National University of Singapore, Singapore, Singapore
- *Correspondence: Andrea L. Kwa,
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19
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Maseda E, de la Rica AS. Controversies in the management of ESBL-producing Enterabacterales. Clinical Implications. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2022; 35 Suppl 3:41-45. [PMID: 36285857 PMCID: PMC9717462 DOI: 10.37201/req/s03.10.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Extended-spectrum β-lactamases (ESBL)-producing organisms currently represent a major health problem. Although recently published guidelines still consider carbapenems as the treatment of choice for ESBL-producing infections, it is necessary to find non-carbapenem β-lactams as alternatives to reduce the effects associated with their overutilization. In this review we focus on these alternatives to carbepenem use. It is possible that piperacillin-tazobactam may be an alternative in clinical settings with "low inoculum" infections like urinary tract infections. Newer β-lactam-β-lactamase inhibitors (BLBLIs) are potential options too. The current available data support the efficacy of both ceftazidime-avibactam and ceftolozane-tazobactam against susceptible ESBL-producing Enterobacterales (ESBL-E). We are waiting for the results of MERINO-3 study to confirm whether ceftolozane-tazobactam is a good option versus meropenem for treating bloodstream infections caused by ESBL- or AmpC-producing Enterobacterales.
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Affiliation(s)
- Emilio Maseda
- Hospital La Paz. Hospital Quirón Torrejón. Madrid, Spain,Correspondence: Emilio Maseda Hospital La Paz. Madrid, Spain E-mail:
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Bae M, Kim T, Park JH, Bae S, Sung H, Kim MN, Jung J, Kim MJ, Kim SH, Lee SO, Choi SH, Kim YS, Chong YP. In Vitro Activities of Ceftazidime-Avibactam and Aztreonam-Avibactam at Different Inoculum Sizes of Extended-Spectrum β-Lactam-Resistant Enterobacterales Blood Isolates. Antibiotics (Basel) 2021; 10:antibiotics10121492. [PMID: 34943704 PMCID: PMC8698305 DOI: 10.3390/antibiotics10121492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 11/28/2021] [Accepted: 12/02/2021] [Indexed: 11/16/2022] Open
Abstract
β-lactam–avibactam combinations have been proposed as carbapenem-sparing therapies, but little data exist on their in vitro activities in infections with high bacterial inocula. We investigated the in vitro efficacies and the inoculum effects of ceftazidime–avibactam and aztreonam–avibactam against extended-spectrum β-lactam-resistant Enterobacterales blood isolates. A total of 228 non-repetitive extended-spectrum β-lactam-resistant Escherichia coli and Klebsiella pneumoniae blood isolates were prospectively collected in a tertiary center. In vitro susceptibilities to ceftazidime, aztreonam, meropenem, ceftazidime–avibactam, and aztreonam–avibactam were evaluated by broth microdilution method using standard and high inocula. An inoculum effect was defined as an eightfold or greater increase in MIC when tested with the high inoculum. Of the 228 isolates, 99% were susceptible to ceftazidime–avibactam and 99% had low aztreonam–avibactam MICs (≤8 mg/L). Ceftazidime–avibactam and aztreonam–avibactam exhibited good in vitro activities; MIC50/MIC90 values were 0.5/2 mg/L, 0.125/0.5 mg/L, and ≤0.03/0.25 mg/L, respectively, and aztreonam–avibactam was more active than ceftazidime–avibactam. The frequencies of the inoculum effect with ceftazidime–avibactam and aztreonam–avibactam were lower than with meropenem (14% vs. 38%, p < 0.001 and 30% vs. 38%, p = 0.03, respectively). The β-lactam-avibactam combinations could be useful as carbapenem-sparing strategies, and aztreonam–avibactam has the better in vitro activity but is more subject to the inoculum effect than ceftazidime–avibactam.
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Affiliation(s)
- Moonsuk Bae
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (M.B.); (J.H.P.); (S.B.); (J.J.); (M.J.K.); (S.-H.K.); (S.-O.L.); (S.-H.C.); (Y.S.K.)
- Division of Infectious Diseases, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan 50612, Korea
| | - Taeeun Kim
- Division of Infectious Diseases, Department of Medicine, Nowon Eulji University Hospital, Seoul 01830, Korea;
| | - Joung Ha Park
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (M.B.); (J.H.P.); (S.B.); (J.J.); (M.J.K.); (S.-H.K.); (S.-O.L.); (S.-H.C.); (Y.S.K.)
| | - Seongman Bae
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (M.B.); (J.H.P.); (S.B.); (J.J.); (M.J.K.); (S.-H.K.); (S.-O.L.); (S.-H.C.); (Y.S.K.)
| | - Heungsup Sung
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (H.S.); (M.-N.K.)
| | - Mi-Na Kim
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (H.S.); (M.-N.K.)
| | - Jiwon Jung
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (M.B.); (J.H.P.); (S.B.); (J.J.); (M.J.K.); (S.-H.K.); (S.-O.L.); (S.-H.C.); (Y.S.K.)
| | - Min Jae Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (M.B.); (J.H.P.); (S.B.); (J.J.); (M.J.K.); (S.-H.K.); (S.-O.L.); (S.-H.C.); (Y.S.K.)
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (M.B.); (J.H.P.); (S.B.); (J.J.); (M.J.K.); (S.-H.K.); (S.-O.L.); (S.-H.C.); (Y.S.K.)
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (M.B.); (J.H.P.); (S.B.); (J.J.); (M.J.K.); (S.-H.K.); (S.-O.L.); (S.-H.C.); (Y.S.K.)
| | - Sang-Ho Choi
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (M.B.); (J.H.P.); (S.B.); (J.J.); (M.J.K.); (S.-H.K.); (S.-O.L.); (S.-H.C.); (Y.S.K.)
| | - Yang Soo Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (M.B.); (J.H.P.); (S.B.); (J.J.); (M.J.K.); (S.-H.K.); (S.-O.L.); (S.-H.C.); (Y.S.K.)
| | - Yong Pil Chong
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (M.B.); (J.H.P.); (S.B.); (J.J.); (M.J.K.); (S.-H.K.); (S.-O.L.); (S.-H.C.); (Y.S.K.)
- Correspondence: ; Tel.: +82-2-3010-3306; Fax: +82-2-3010-6907
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A new PKPD model to characterize the inoculum effect of Acinetobacter baumannii on polymyxin B in vitro. Antimicrob Agents Chemother 2021; 66:e0178921. [PMID: 34780268 DOI: 10.1128/aac.01789-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The inoculum effect (i.e., reduction in antimicrobial activity at large starting inoculum) is a phenomenon described for various pathogens. Since limited data exist regarding inoculum effect of Acinetobacter baumannii, we evaluated killing of A. baumannii by polymyxin B, a last-resort antibiotic, at several starting inocula and developed a PKPD model to capture this phenomenon. In vitro static time-kill experiments were performed using polymyxin B at concentrations ranging from 0.125 to 128 mg/L against a clinical A. baumannii isolate at four starting inocula from 105 to 108 CFU/mL. Samples were collected up to 30 h to quantify the viable bacterial burden and were simultaneously modeled in the NONMEM software program. The expression of polymyxin B resistance genes (lpxACD, pmrCAB and wzc), and genetic modifications were studied by RT-qPCR and DNA sequencing experiments, respectively. The PKPD model included a single homogeneous bacterial population with adaptive resistance. Polymyxin B effect was modelled as a sigmoidal Emax model and the inoculum effect as an increase of polymyxin B EC50 with increasing starting inoculum using a power function. Polymyxin B displayed a reduced activity as the starting inoculum increased: a 20-fold increase of polymyxin B EC50 was observed between the lowest and the highest inoculum. No effects of polymyxin B and inoculum size were observed on the studied genes. The proposed PKPD model successfully described and predicted the pronounced in vitro inoculum effect of A. baumannii on polymyxin B activity. These results should be further validated using other bacteria/antibiotic combinations and in vivo models.
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Luo H, Xiao Y, Hang Y, Chen Y, Zhu H, Fang X, Cao X, Zou S, Hu X, Xiong J, Zhong Q, Hu L. Comparison of therapy with β-lactam/β-lactamase inhibitor combinations or carbapenems for bacteraemia of nonurinary source caused by ESBL-producing Escherichia coli or Klebsiella pneumoniae. Ann Clin Microbiol Antimicrob 2021; 20:63. [PMID: 34488786 PMCID: PMC8422674 DOI: 10.1186/s12941-021-00471-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 08/31/2021] [Indexed: 11/23/2022] Open
Abstract
Background Extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae has become a public health concern. This study aimed to compare the clinical outcomes of patients with nonurinary source bacteraemia caused by ESBL-producing Escherichia coli (E. coli) or Klebsiella pneumoniae (ESBL-producing EK) receiving β-lactam/β-lactamase inhibitor combinations (BLICs) versus carbapenem treatment and assess the risk factors of mortality with these two drugs. Methods We conducted a retrospective single-centre study of adult hospitalised patients with ESBL-producing EK bloodstream infection (BSI) from nonurinary source at our centre over a 4-year period. One hundred and eighty patients who received BLICs or carbapenems were included in the analysis. The outcome variables were 14-day treatment failure and 30-day mortality. For more reliable results, propensity score analysis was performed to compare the efficacy of the two drugs and analyse their risk factors for 30-day mortality. Results Out of 180 patients, 114 received BLICs, and 66 received carbapenem therapy. Compared to carbapenem-treated patients, those treated with BLICs were older and had higher age-adjusted Charlson comorbidity index, but they had shorter stay in the hospital. Additionally, their Pitt bacteraemia score, SOFA score, rate of leukaemia, and immune compromise were lower. After propensity score matching (PSM), the baseline characteristics of patients in the two treatment groups were balanced. BLICs were associated with a higher 14-day treatment failure rate (20.6%, 13/63) than carbapenems (16.3%, 7/43), although the difference was not significant in either univariate analysis (P = 0.429) or multivariate analysis (P = 0.122). And the 30-day mortality rate in BTG (11.1%, 7/63) and CTG (11.6%, 5/43) did not significantly differ (univariate analysis, P = 0.926; multivariate analysis, P = 0.420). In the multivariate analysis, after PSM, leukaemia was the only independent predictor of mortality in both BTG and CTG. Conclusions Our study showed that BLICs had higher 14-day treatment failure rate compared with carbapenems, although there were no statistically significant differences because of the small number of patients, therefore, further evaluation of the efficacy of BLICs is needed.
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Affiliation(s)
- Hong Luo
- Department of Jiangxi Provincial Key Laboratory of Medicine, Clinical Laboratory of the Second Affiliated Hospital of Nanchang University, Mingde Road No. 1, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Yanping Xiao
- Department of Jiangxi Provincial Key Laboratory of Medicine, Clinical Laboratory of the Second Affiliated Hospital of Nanchang University, Mingde Road No. 1, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Yaping Hang
- Department of Jiangxi Provincial Key Laboratory of Medicine, Clinical Laboratory of the Second Affiliated Hospital of Nanchang University, Mingde Road No. 1, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Yanhui Chen
- Department of Jiangxi Provincial Key Laboratory of Medicine, Clinical Laboratory of the Second Affiliated Hospital of Nanchang University, Mingde Road No. 1, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Hongying Zhu
- Department of Jiangxi Provincial Key Laboratory of Medicine, Clinical Laboratory of the Second Affiliated Hospital of Nanchang University, Mingde Road No. 1, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Xueyao Fang
- Department of Jiangxi Provincial Key Laboratory of Medicine, Clinical Laboratory of the Second Affiliated Hospital of Nanchang University, Mingde Road No. 1, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Xingwei Cao
- Department of Jiangxi Provincial Key Laboratory of Medicine, Clinical Laboratory of the Second Affiliated Hospital of Nanchang University, Mingde Road No. 1, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Shan Zou
- Department of Jiangxi Provincial Key Laboratory of Medicine, Clinical Laboratory of the Second Affiliated Hospital of Nanchang University, Mingde Road No. 1, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Xiaoyan Hu
- Department of Jiangxi Provincial Key Laboratory of Medicine, Clinical Laboratory of the Second Affiliated Hospital of Nanchang University, Mingde Road No. 1, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Jianqiu Xiong
- Department of Nursing, The Second Affiliated Hospital of Nanchang University, Mingde Road No. 1, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Qiaoshi Zhong
- Department of Jiangxi Provincial Key Laboratory of Medicine, Clinical Laboratory of the Second Affiliated Hospital of Nanchang University, Mingde Road No. 1, Nanchang, 330006, Jiangxi, People's Republic of China.
| | - Longhua Hu
- Department of Jiangxi Provincial Key Laboratory of Medicine, Clinical Laboratory of the Second Affiliated Hospital of Nanchang University, Mingde Road No. 1, Nanchang, 330006, Jiangxi, People's Republic of China.
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Non-carbapenem β-lactam/β-lactamase inhibitors versus carbapenems for urinary tract infections caused by extended-spectrum β-lactamase-producing Enterobacteriaceae: a systematic review. Int J Antimicrob Agents 2021; 58:106410. [PMID: 34339776 DOI: 10.1016/j.ijantimicag.2021.106410] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/26/2021] [Accepted: 07/23/2021] [Indexed: 01/11/2023]
Abstract
This systematic review was conducted to compare the efficacy of non-carbapenem β-lactam/β-lactamase inhibitors (BLBLIs) versus carbapenems for the treatment of urinary tract infections (UTIs) caused by extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE). A comprehensive search of the Cochrane Library, PubMed and Embase was conducted from January 1979 to December 2020. Clinical success, microbiological success, clinical and microbiological success, and mortality were assessed as efficacy outcomes. Heterogeneity was assessed using the I2 statistic, and a fixed-effects or random-effects model was applied for estimation of the risk ratio (RR). A total of 1612 patients from three randomised clinical trials (RCTs) and seven cohort studies were included in the meta-analysis. There was no statistically significant difference between BLBLIs and carbapenems in clinical success (RR = 0.99; P = 0.71), clinical and microbiological success (RR = 0.97; P = 0.46) and mortality (RR = 0.63; P = 0.22). A slightly higher rate of microbiological success was observed in BLBLI group (RR = 1.06; P = 0.01), which was mainly attributed to the efficacy of ceftazidime/avibactam based on a single RCT. BLBLIs were not inferior to carbapenems, with higher microbiological success, indicating an effective alternative non-carbapenem option for the treatment of UTIs caused by ESBL-PE. More high-quality and large-scale RCTs are required to further validate these findings. [Trial registration: PROSPERO ID: CRD42021233706].
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24
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Variability of Beta-Lactam Broth Microdilution for Pseudomonas aeruginosa. Antimicrob Agents Chemother 2021; 65:e0064021. [PMID: 34310211 DOI: 10.1128/aac.00640-21] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Antimicrobial susceptibility testing for Pseudomonas aeruginosa is critical to determine suitable treatment options. Commercial susceptibility tests are typically calibrated against the reference method, broth microdilution (BMD). Imprecision of minimum inhibitory concentrations (MICs) obtained by BMD for the same isolate on repeat testing is known to exist. Factors that impact the extent of variability include concentration of the inoculum, operator effects, contents of the media, inherent strain properties, and the testing process or materials. We evaluated the variability of BMD for anti-pseudomonal beta-lactams (aztreonam, cefepime, ceftazidime, meropenem, piperacillin-tazobactam, ceftazidime-avibactam, ceftolozane-tazobactam) tested against a collection of P. aeruginosa isolates. Multiple replicate BMD tests were performed and MICs were compared to assess reproducibility, including the impact of the inoculum and operator. Overall, essential agreement (EA) was ≥ 90% for all beta-lactams tested. Absolute agreement (AA) was as low as 70% for some beta-lactams. Variability from the inoculum and operators impacted the reproducibility of MICs. Piperacillin-tazobactam exhibited the highest degree of variability with 74% AA and 94%% EA. The implications of MIC variability are extensive as the MIC is essential for multiple facets of microbiology, such as the development of new compounds and susceptibility tests, dose optimization and pharmacokinetic/pharmacodynamic (PK/PD) targets for individual patients.
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25
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Tam VH, Abodakpi H, Wang W, Ledesma KR, Merlau PR, Chan K, Altman R, Tran TT, Nikolaou M, Sofjan AK. Optimizing pharmacokinetics/pharmacodynamics of β-lactam/β-lactamase inhibitor combinations against high inocula of ESBL-producing bacteria. J Antimicrob Chemother 2021; 76:179-183. [PMID: 33035321 DOI: 10.1093/jac/dkaa412] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/07/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Reduced in vitro β-lactam activity against a dense bacterial population is well recognized. It is commonly attributed to the presence of β-lactamase(s) and it is unknown whether the inoculum effect could be diminished by a β-lactamase inhibitor. We evaluated different β-lactam/β-lactamase inhibitor combinations in suppressing a high inoculum of ESBL-producing bacteria. METHODS Three clinical isolates expressing representative ESBLs (CTX-M-15 and SHV-12) were examined. The impact of escalating β-lactamase inhibitor (tazobactam or avibactam) concentrations on β-lactam (piperacillin or ceftazidime) MIC reduction was characterized by an inhibitory sigmoid Emax model. The effect of various dosing regimens of β-lactam/β-lactamase inhibitor combinations was predicted using %T>MICi and selected exposures were experimentally validated in a hollow-fibre infection model over 120 h. The threshold exposure to suppress bacterial regrowth was identified using recursive partitioning. RESULTS A concentration-dependent reduction in β-lactam MIC was observed (r2 ≥0.93). Regrowth could be suppressed in all six experiments using %T>MICi ≥73.6%, but only one out of six experiments below the threshold (P = 0.015). The exposures to suppress regrowth might be attained using the clinical dose of avibactam, but a much higher dose than the standard dose would be needed for tazobactam. CONCLUSIONS A dense population of ESBL-producing bacteria could be suppressed by an optimized dosing regimen of selected β-lactam/β-lactamase inhibitor combinations. The reversibility of enzyme inhibition could play an important role in diminishing the inoculum effect. In vivo investigations to validate these findings are warranted.
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Affiliation(s)
- Vincent H Tam
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA.,Department of Pharmacological and Pharmaceutical Sciences, University of Houston College of Pharmacy, Houston, TX, USA.,Department of Chemical and Biomolecular Engineering, University of Houston Cullen College of Engineering, Houston, TX, USA
| | - Henrietta Abodakpi
- Department of Pharmacological and Pharmaceutical Sciences, University of Houston College of Pharmacy, Houston, TX, USA
| | - Weiqun Wang
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
| | - Kimberly R Ledesma
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
| | - Paul R Merlau
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
| | - Katrina Chan
- Department of Pharmacological and Pharmaceutical Sciences, University of Houston College of Pharmacy, Houston, TX, USA
| | - Rachel Altman
- Department of Chemical and Biomolecular Engineering, University of Houston Cullen College of Engineering, Houston, TX, USA
| | - Truc T Tran
- Center for Antimicrobial Resistance and Microbial Genomics, University of Texas McGovern Medical School, Houston, TX, USA.,Division of Infectious Diseases, University of Texas McGovern Medical School, Houston, TX, USA
| | - Michael Nikolaou
- Department of Chemical and Biomolecular Engineering, University of Houston Cullen College of Engineering, Houston, TX, USA
| | - Amelia K Sofjan
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
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In Vitro Activities and Inoculum Effects of Ceftazidime-Avibactam and Aztreonam-Avibactam against Carbapenem-Resistant Enterobacterales Isolates from South Korea. Antibiotics (Basel) 2020; 9:antibiotics9120912. [PMID: 33334045 PMCID: PMC7765481 DOI: 10.3390/antibiotics9120912] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/12/2020] [Accepted: 12/14/2020] [Indexed: 12/13/2022] Open
Abstract
Ceftazidime-avibactam (CAZ-AVI) and aztreonam-avibactam (AZT-AVI) are novel antibiotic combinations active against multidrug-resistant Gram-negative pathogens. This study aimed to evaluate their in vitro activities and inoculum effects in carbapenem-resistant Enterobacterales (CRE), including carbapenemase-producing (CP)-CRE and non-CP-CRE. A total of 81 independent clinical isolates of carbapenem-resistant Escherichia coli and Klebsiella pneumoniae were collected. CAZ-AVI and AZT-AVI minimal inhibitory concentrations (MICs) were evaluated by broth microdilution using standard and high inocula. The inoculum effect was defined as an ≥8-fold increase in MIC with high inoculum. Phenotypic determination of β-lactam resistance mechanism and PCR for carbapenemase genes were performed. Of the 81 CRE isolates, 35 (43%) were CP-CRE. Overall, 73% of the isolates were susceptible to CAZ-AVI, and 95% had low AZT-AVI MICs (≤8 µg/mL). The MIC50/MIC90s of CAZ-AVI and AZT-AVI were 4/≥512 µg/mL and 0.5/4 µg/mL, respectively. CAZ-AVI was more active against non-CP-CRE than against CP-CRE (susceptibility 80% vs. 63%, p = 0.08; MIC50/MIC90, 2/16 μg/mL vs. 4/≥512 μg/mL), whereas AZT-AVI was more active against CP-CRE (MIC50/MIC90, 0.25/1 μg/mL vs. 0.5/8 μg/mL). All four isolates with high AZT-AVI MIC (≥16 μg/mL) were resistant to CAZ-AVI, but only 18% (4/22) of CAZ-AVI-resistant isolates had high AZT-AVI MIC. The rates of the inoculum effect for CAZ-AVI and AZT-AVI were 18% and 47%, respectively (p < 0.001). Interestingly, the frequency of the AZT-AVI inoculum effect was higher in K. pneumoniae than E. coli (64% vs. 8%, p < 0.001). AZT-AVI is more active against CRE than CAZ-AVI, even in CP-CRE and CAZ-AVI-resistant isolates. The presence of a substantial inoculum effect may contribute to clinical failure in high-inoculum infections treated with AZT-AVI.
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Raza A, Ngieng SC, Sime FB, Cabot PJ, Roberts JA, Popat A, Kumeria T, Falconer JR. Oral meropenem for superbugs: challenges and opportunities. Drug Discov Today 2020; 26:551-560. [PMID: 33197621 DOI: 10.1016/j.drudis.2020.11.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/10/2020] [Accepted: 11/05/2020] [Indexed: 12/18/2022]
Abstract
An increase in the number of multidrug-resistant microbial strains is the biggest threat to global health and is projected to cause >10 million deaths by 2055. The carbapenem family of antibacterial drugs are an important class of last-resort treatment of infections caused by drug-resistant bacteria and are only available as an injectable formulation. Given their instability within the gut and poor permeability across the gut wall, oral carbapenem formulations show poor bioavailability. Meropenem (MER), a carbapenem antibiotic, has broad-spectrum antibacterial activity, but suffers from the above-mentioned issues. In this review, we discuss strategies for improving the oral bioavailability of MER, such as inhibiting tubular secretion, prodrug formulations, and use of nanomedicine. We also highlight challenges and emerging approaches for the development of oral MER.
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Affiliation(s)
- Aun Raza
- School of Pharmacy, The University of Queensland, Woolloongabba, QLD 4102, Australia; Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, QLD 4102, Australia
| | - Shih Chen Ngieng
- School of Pharmacy, The University of Queensland, Woolloongabba, QLD 4102, Australia
| | - Fekade Bruck Sime
- School of Pharmacy, The University of Queensland, Woolloongabba, QLD 4102, Australia; Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, QLD 4102, Australia
| | - Peter J Cabot
- School of Pharmacy, The University of Queensland, Woolloongabba, QLD 4102, Australia
| | - Jason A Roberts
- School of Pharmacy, The University of Queensland, Woolloongabba, QLD 4102, Australia; Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, QLD 4102, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD 4102, Australia; Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, QLD 4102, Australia
| | - Amirali Popat
- School of Pharmacy, The University of Queensland, Woolloongabba, QLD 4102, Australia; Mater Research Institute, The University of Queensland, Translational Research Institute, Woolloongabba, QLD 4102, Australia.
| | - Tushar Kumeria
- School of Pharmacy, The University of Queensland, Woolloongabba, QLD 4102, Australia; School of Materials Science and Engineering, The University of New South Wales, Sydney, NSW 2052, Australia.
| | - James R Falconer
- School of Pharmacy, The University of Queensland, Woolloongabba, QLD 4102, Australia.
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Yoshida M, Tashiro M, Nishi K, Mishima M, Kawano K, Takazono T, Saijo T, Yamamoto K, Imamura Y, Miyazaki T, Kudo T, Yanagihara K, Mukae H, Izumikawa K. Detection of invasive pulmonary aspergillosis in mice using lung perfusion single-photon emission computed tomography with [99mTc]MAA. Med Mycol 2020; 58:965-972. [PMID: 31943043 DOI: 10.1093/mmy/myz131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 11/25/2019] [Accepted: 12/19/2019] [Indexed: 11/13/2022] Open
Abstract
There is an urgent need for development of better diagnostic strategies to improve outcomes in patients with invasive pulmonary aspergillosis (IPA). We hypothesized that lung perfusion single-photon emission computed tomography (SPECT) may be more sensitive and specific than computed tomography (CT) of the chest for detection of IPA because it is an angioinvasive pulmonary infection with characteristics that are different from those of bacterial pneumonia. We used SPECT with injection of technetium-99m-labeled macroaggregated albumin ([99mTc]MAA) to measure pulmonary perfusion in noninfected mice, mice with IPA, and mice with bacterial pneumonia. Histopathologic analysis was performed to evaluate the correlation between the perfusion defect and mould invasion. We also attempted to quantitatively evaluate the SPECT images to identify differences in decreased perfusion levels in affected areas in the mouse lung. Histopathologic analysis in the IPA mouse model showed a clear match between areas with a perfusion defect and the presence of mold, indicating that the location of the perfusion defect on a SPECT image reflects angioinvasion of the mould in the lungs. Some of these perfusion defects could be seen before appearance of the infiltrate of CT images. Quantitative analysis confirmed that perfusion in the affected areas was significantly decreased in the IPA model but not in the bacterial pneumonia model (P < .0001). This imaging method may be preferable to the alternative methods presently used to identify the presence of mold in a patient's lungs.
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Affiliation(s)
- Masataka Yoshida
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masato Tashiro
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Nagasaki University Infection Control and Education Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Kodai Nishi
- Department of Radioisotope Medicine, Atomic Bomb Disease Institute, Nagasaki University, Nagasaki, Japan
| | - Maki Mishima
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kei Kawano
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Nagasaki University Infection Control and Education Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Takahiro Takazono
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tomomi Saijo
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
- Nagasaki University Infection Control and Education Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Kazuko Yamamoto
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
- Nagasaki University Infection Control and Education Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Yoshifumi Imamura
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Taiga Miyazaki
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Takashi Kudo
- Department of Radioisotope Medicine, Atomic Bomb Disease Institute, Nagasaki University, Nagasaki, Japan
| | - Katsunori Yanagihara
- Department of Laboratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Koichi Izumikawa
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Nagasaki University Infection Control and Education Center, Nagasaki University Hospital, Nagasaki, Japan
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Zhang L, Zhang Y, Zhao G, Yang H, Wang X, Yu R, Liu H, Li S. Preparation of Poly(MTZ) n -(DMAEMA) m Micelles and Study on Their Antibacterial Property. ACS OMEGA 2020; 5:23053-23061. [PMID: 32954155 PMCID: PMC7495777 DOI: 10.1021/acsomega.0c02774] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 08/14/2020] [Indexed: 06/11/2023]
Abstract
Bacterial infections are the most common type of clinical infection. The abuse of clinical antibiotics has led to the frequent appearance of drug-resistant strains and even some super bacteria. In this study, we synthesized Poly(MTZ) n -(DMAEMA) m polymer micelles with cations on the surface. The synthesis of this novel polymer comes in two steps. First, Poly(MTZ) n was synthesized with metronidazole (MTZ) referred as the macromolecular chain transfer agent and v-501 as the initiator for initiating the polymerization of 4-cyanopentanoic acid dithiobenzoate. Then, novel polymer micelles were synthesized with Poly(MTZ) n referred as the macromolecular chain transfer agent and v-501 as the initiator for initiating the polymerization of the monomer 2-(dimethylamino) ethyl methacrylate, which could adsorb to the negatively charged bacterial surface via electrostatic interaction and enhance bactericidal activity. Scanning electron microscopy showed that the micelles could be accurately targeted to the surface of bacteria, and the zone of inhibition assay confirmed that the micelles could enhance the sensitivity of bacteria to drugs. Hence, Poly(MTZ) n -(DMAEMA) m polymer micelles will have potential use for the clinical treatment of anaerobic infections in the future.
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Affiliation(s)
- Long Zhang
- Insititute of Nervous
System Diseases, Xuzhou Medical University, Xuzhou 221002, P. R. China
| | - Yongkang Zhang
- Insititute of Nervous
System Diseases, Xuzhou Medical University, Xuzhou 221002, P. R. China
| | - Gang Zhao
- Insititute of Nervous
System Diseases, Xuzhou Medical University, Xuzhou 221002, P. R. China
| | - Han Yang
- Insititute of Nervous
System Diseases, Xuzhou Medical University, Xuzhou 221002, P. R. China
| | - Xiaoqian Wang
- Insititute of Nervous
System Diseases, Xuzhou Medical University, Xuzhou 221002, P. R. China
| | - Rutong Yu
- Insititute of Nervous
System Diseases, Xuzhou Medical University, Xuzhou 221002, P. R. China
- Department of Neurosurgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou 221002, P. R. China
| | - Hongmei Liu
- Insititute of Nervous
System Diseases, Xuzhou Medical University, Xuzhou 221002, P. R. China
- Department of Neurosurgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou 221002, P. R. China
| | - Shanshan Li
- Department of Forensic Medicine, Xuzhou Medical University, Xuzhou, Jiangsu 221002, China
- Jiangsu Medical
Engineering Research Center of Gene Detection, Xuzhou Medical University, Xuzhou, Jiangsu 221002, China
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Ota K, Kaku N, Yanagihara K. Efficacy of meropenem and amikacin combination therapy against carbapenemase-producing Klebsiella pneumoniae mouse model of pneumonia. J Infect Chemother 2020; 26:1237-1243. [PMID: 32868198 DOI: 10.1016/j.jiac.2020.07.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/27/2020] [Accepted: 07/08/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND The emergence and spread of carbapenem-resistant Enterobacteriaceae (CRE) is a global health problem due to its high mortality and limited treatment options. Combination antimicrobial therapy is reported to be effective against CRE in vitro; however, its efficacy in vivo has not been thoroughly evaluated. Thus, this study assessed the efficacy of combination therapy of meropenem (MEPM) and amikacin (AMK) in a carbapenem-resistant Klebsiella pneumoniae (CR-Kp) mouse model of pneumonia. MATERIALS AND METHODS Agar-based bacterial suspension of CR-Kp clinical isolates was inoculated into the trachea of BALB/c mice. Treatment was initiated 6 h post infection, with 100 mg/kg MEPM every 6 h, 100 mg/kg AMK every 12 h, or in combination; survival was evaluated for 7 days. The number of viable bacteria in the lungs, lung histopathology, and neutrophil counts in broncho-alveolar lavage fluid (BALF) were evaluated 42 h after infection. RESULTS All mice in the untreated control group died in 48 h, while all the mice in treatment groups survived past 7 days following infection. The bacterial count in the lungs (log10 CFU/mL, mean ± SEM) in the combination group (2.00 ± 0.00) decreased significantly compared to that in control (10.19 ± 0.11, p < 0.0001), MEPM (6.38 ± 0.17, p < 0.0001), and AMK (6.17 ± 0.16, p < 0.0001) groups. BALF neutrophil count reduced only in the combination therapy group. Combination therapy prevented the progression of lung inflammation, including alveolar neutrophil infiltration and hemorrhage. CONCLUSIONS This study demonstrates in vivo efficacy of MEPM and AMK combination therapy against CR-Kp pneumonia.
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Affiliation(s)
- Kenji Ota
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan; Department of Laboratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Norihito Kaku
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan; Department of Laboratory Medicine, Nagasaki University Hospital, Nagasaki, Japan.
| | - Katsunori Yanagihara
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan; Department of Laboratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
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Abstract
The phenomenon of attenuated antibacterial activity at inocula above those utilized for susceptibility testing is referred to as the inoculum effect. Although the inoculum effect has been reported for several decades, it is currently debatable whether the inoculum effect is clinically significant. The aim of the present review was to consolidate currently available evidence to summarize which β-lactam drug classes demonstrate an inoculum effect against specific bacterial pathogens. Review of the literature showed that the majority of studies that evaluated the inoculum effect of β-lactams were in vitro investigations of Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, Haemophilus influenzae and Staphylococcus aureus. Across all five pathogens, cephalosporins consistently displayed observable inoculum effects in vitro, whereas carbapenems were less susceptible to an inoculum effect. A handful of animal studies were available that validated that the in vitro inoculum effect translates into attenuated pharmacodynamics of β-lactams in vivo. Only a few clinical investigations were available and suggested that an in vitro inoculum effect of cefazolin against MSSA may correspond to an increased likeliness of adverse clinical outcomes in patients receiving cefazolin for bacteraemia. The presence of β-lactamase enzymes was the primary mechanism responsible for an inoculum effect, but the observation of an inoculum effect in multiple pathogens lacking β-lactamase enzymes indicates that there are likely multiple mechanisms that may result in an inoculum effect. Further clinical studies are needed to better define whether interventions made in the clinic in response to organisms displaying an in vitro inoculum effect will optimize clinical outcomes.
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Affiliation(s)
- Justin R Lenhard
- California Northstate University College of Pharmacy, Elk Grove, CA, USA
| | - Zackery P Bulman
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
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32
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Huang Z, Mao C, Wei Y, Gu X, Cai Q, Shen X, Ding H. Analysis of the mutant selection window and killing of Mycoplasma hyopneumoniae for doxycycline, tylosin, danofloxacin, tiamulin, and valnemulin. PLoS One 2020; 15:e0220350. [PMID: 32544163 PMCID: PMC7297357 DOI: 10.1371/journal.pone.0220350] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 05/14/2020] [Indexed: 11/20/2022] Open
Abstract
Mycoplasma hyopneumoniae is the major pathogenic microorganism causing enzootic pneumonia in pigs. With increasing resistance of M. hyopneumoniae to conventional antibiotics, treatment is becoming complicated. Herein, we investigated the mutant selection window (MSW) of doxycycline, tylosin, danofloxacin, tiamulin, and valnemulin for treating the M. hyopneumoniae type strain (ATCC 25934) to determine the likelihood of promoting resistance with continued use of these antibiotics. Minimum inhibitory concentration (MIC) values against M. hyopneumoniae were determined for each antimicrobial agent based on microdilution broth and agar dilution methods (bacterial numbers ranged from 105 colony-forming units (CFU)/mL to 109 CFU/mL). The minimal concentration inhibiting colony formation by 99% (MIC99) and the mutant prevention concentration (MPC) were determined by the agar dilution method with three inoculum sizes. Antimicrobial killing was determined based on MIC99 and MPC values for all five agents. MIC values ranged from 0.001 to 0.25 μg/mL based on the microdilution broth method, and from 0.008 to 1.0 μg/mL based on the agar dilution method. MPC values ranged from 0.0016 to 10.24 μg/mL. MPC/MIC99 values were ordered tylosin > doxycycline > danofloxacin > tiamulin > valnemulin. MPC achieved better bactericidal action than MIC99. Based on pharmacodynamic analyses, danofloxacin, tylosin, and doxycycline are more likely to select resistant mutants than tiamulin and valnemulin.
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Affiliation(s)
- Zilong Huang
- Guangdong Key Laboratory for Veterinary Drug Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
| | - Chunxiao Mao
- Guangdong Key Laboratory for Veterinary Drug Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
| | - Yanzhe Wei
- Guangdong Key Laboratory for Veterinary Drug Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
| | - Xiaoyan Gu
- Guangdong Key Laboratory for Veterinary Drug Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
| | - Qinren Cai
- Technical Center for Inspection and Quarantine, Zhuhai Entry-Exit Inspection and Quarantine Bureau, Zhuhai, China
| | - Xiangguang Shen
- Guangdong Key Laboratory for Veterinary Drug Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
| | - Huanzhong Ding
- Guangdong Key Laboratory for Veterinary Drug Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
- * E-mail:
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Exploring the microbiota of upper respiratory tract during the development of pneumonia in a mouse model. PLoS One 2019; 14:e0222589. [PMID: 31560693 PMCID: PMC6764665 DOI: 10.1371/journal.pone.0222589] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 09/02/2019] [Indexed: 12/31/2022] Open
Abstract
The alteration of the microbial community in the upper respiratory tract (URT) can contribute to the colonization and invasion of respiratory pathogens. However, there are no studies regarding whether the characteristics of the URT microbiota can be affected by infections in lower respiratory tract (LRT). To elucidate the microbial profiles of the URT during pneumonia, the oral, nasal, and lung microbiota was evaluated at the early phase in a murine pneumonia model by direct intratracheal inoculation of Klebsiella pneumoniae. The meta 16S rRNA sequencing of bronchoalveolar lavage fluid after K. pneumoniae inoculation presented alterations in the beta diversity of the microbes, but not in the alpha diversity. At this point, a significant increase in microbial alpha diversity was observed in the oral cavity, but not in the nasal cavity. The significant increase was observed in the family Carnobacteriaceae and family Enterococcaceae. These results suggest that characterizing the microbial community of the respiratory tract may not just involve a simple downstream relationship from the URT to the LRT. The health status of the LRT may influence the oral microbiota. Thus, evaluation of the oral microbiota may contribute towards monitoring lung health; the oral microbiota may act as a diagnostic marker of pneumonia.
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Lopez Quezada L, Li K, McDonald SL, Nguyen Q, Perkowski AJ, Pharr CW, Gold B, Roberts J, McAulay K, Saito K, Somersan Karakaya S, Javidnia PE, Porras de Francisco E, Amieva MM, Dı́az SP, Mendoza Losana A, Zimmerman M, Liang HPH, Zhang J, Dartois V, Sans S, Lagrange S, Goullieux L, Roubert C, Nathan C, Aubé J. Dual-Pharmacophore Pyrithione-Containing Cephalosporins Kill Both Replicating and Nonreplicating Mycobacterium tuberculosis. ACS Infect Dis 2019; 5:1433-1445. [PMID: 31184461 DOI: 10.1021/acsinfecdis.9b00112] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The historical view of β-lactams as ineffective antimycobacterials has given way to growing interest in the activity of this class against Mycobacterium tuberculosis (Mtb) in the presence of a β-lactamase inhibitor. However, most antimycobacterial β-lactams kill Mtb only or best when the bacilli are replicating. Here, a screen of 1904 β-lactams led to the identification of cephalosporins substituted with a pyrithione moiety at C3' that are active against Mtb under both replicating and nonreplicating conditions, neither activity requiring a β-lactamase inhibitor. Studies showed that activity against nonreplicating Mtb required the in situ release of the pyrithione, independent of the known class A β-lactamase, BlaC. In contrast, replicating Mtb could be killed both by released pyrithione and by the parent β-lactam. Thus, the antimycobacterial activity of pyrithione-containing cephalosporins arises from two mechanisms that kill mycobacteria in different metabolic states.
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Affiliation(s)
- Landys Lopez Quezada
- Department of Microbiology and Immunology, Weill Cornell Medicine, 1300 York Avenue, New York, New York 10065, United States
| | - Kelin Li
- Division of Chemical Biology and Medicinal Chemistry, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 125 Mason Farm Road, Chapel Hill, North Carolina 27599, United States
| | - Stacey L. McDonald
- Division of Chemical Biology and Medicinal Chemistry, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 125 Mason Farm Road, Chapel Hill, North Carolina 27599, United States
| | - Quyen Nguyen
- Division of Chemical Biology and Medicinal Chemistry, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 125 Mason Farm Road, Chapel Hill, North Carolina 27599, United States
| | - Andrew J. Perkowski
- Division of Chemical Biology and Medicinal Chemistry, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 125 Mason Farm Road, Chapel Hill, North Carolina 27599, United States
| | - Cameron W. Pharr
- Division of Chemical Biology and Medicinal Chemistry, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 125 Mason Farm Road, Chapel Hill, North Carolina 27599, United States
| | - Ben Gold
- Department of Microbiology and Immunology, Weill Cornell Medicine, 1300 York Avenue, New York, New York 10065, United States
| | - Julia Roberts
- Department of Microbiology and Immunology, Weill Cornell Medicine, 1300 York Avenue, New York, New York 10065, United States
| | - Kathrine McAulay
- Center for Global Health, Weill Cornell Medicine, 402 East 67th Street, New York, New York 10065, United States
- Les Centres GHESKIO, 33, Boulevard Harry Truman, Port-au-Prince, Haiti
| | - Kohta Saito
- Department of Medicine, Weill Cornell Medical College, New York, New York 10065, United States
| | - Selin Somersan Karakaya
- Department of Medicine, Weill Cornell Medical College, New York, New York 10065, United States
| | - Prisca Elis Javidnia
- Department of Medicine, Weill Cornell Medical College, New York, New York 10065, United States
| | - Esther Porras de Francisco
- Diseases of the Developing World (DDW), Tres Cantos Medicine Development Campus, GlaxoSmithKline, Severo Ochoa 2, Tres Cantos, Madrid 28760, Spain
| | - Manuel Marin Amieva
- Diseases of the Developing World (DDW), Tres Cantos Medicine Development Campus, GlaxoSmithKline, Severo Ochoa 2, Tres Cantos, Madrid 28760, Spain
| | - Sara Palomo Dı́az
- Diseases of the Developing World (DDW), Tres Cantos Medicine Development Campus, GlaxoSmithKline, Severo Ochoa 2, Tres Cantos, Madrid 28760, Spain
| | - Alfonso Mendoza Losana
- Diseases of the Developing World (DDW), Tres Cantos Medicine Development Campus, GlaxoSmithKline, Severo Ochoa 2, Tres Cantos, Madrid 28760, Spain
| | - Matthew Zimmerman
- Public Health Research Institute, New Jersey Medical School, Rutgers, the State University of New Jersey, 225 Warren Street, Newark, New Jersey 07013, United States
| | - Hsin-Pin Ho Liang
- Public Health Research Institute, New Jersey Medical School, Rutgers, the State University of New Jersey, 225 Warren Street, Newark, New Jersey 07013, United States
| | - Jun Zhang
- Department of Microbiology and Immunology, Weill Cornell Medicine, 1300 York Avenue, New York, New York 10065, United States
| | - Veronique Dartois
- Public Health Research Institute, New Jersey Medical School, Rutgers, the State University of New Jersey, 225 Warren Street, Newark, New Jersey 07013, United States
| | - Stéphanie Sans
- Evotec ID (Lyon), SAS, 1541, Avenue Marcel Merieux, Marcy l’Etoile 69280, France
| | - Sophie Lagrange
- Evotec ID (Lyon), SAS, 1541, Avenue Marcel Merieux, Marcy l’Etoile 69280, France
| | - Laurent Goullieux
- Evotec ID (Lyon), SAS, 1541, Avenue Marcel Merieux, Marcy l’Etoile 69280, France
| | - Christine Roubert
- Evotec ID (Lyon), SAS, 1541, Avenue Marcel Merieux, Marcy l’Etoile 69280, France
| | - Carl Nathan
- Department of Microbiology and Immunology, Weill Cornell Medicine, 1300 York Avenue, New York, New York 10065, United States
| | - Jeffrey Aubé
- Division of Chemical Biology and Medicinal Chemistry, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 125 Mason Farm Road, Chapel Hill, North Carolina 27599, United States
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Current options for the treatment of infections due to extended-spectrum beta-lactamase-producing Enterobacteriaceae in different groups of patients. Clin Microbiol Infect 2019; 25:932-942. [PMID: 30986558 DOI: 10.1016/j.cmi.2019.03.030] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 03/27/2019] [Accepted: 03/31/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND Extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) are a frequent cause of invasive infections worldwide. Carbapenems are nowadays the most used drugs to treat these infections. However, due to the increasing rates of resistance to these antimicrobials, carbapenem-sparing alternatives are being investigated. OBJECTIVES AND SOURCES The aim of this narrative literature review is to summarize the published information on the currently available antibiotics for the treatment of ESBL-E infections, providing specific information on three subgroups of patients: Group 1, patients with severe infections or infections from high-risk sources or in severely immunocompromised patients; Group 2, patients with non-severe infections from intermediate-risk source; and Group 3, patients with non-severe urinary tract infection. CONTENT AND IMPLICATIONS For patients in Group 1, the current data would support the use of carbapenems. For milder infections, however, particularly urinary tract infections, other non-carbapenem antibiotics can be considered in selected cases, including beta-lactam/beta-lactam inhibitor combinations, cephamycins, temocillin and aminoglycosides. While specific studies should be performed in these situations, individualized decisions may be taken in order to avoid overuse of carbapenems.
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Heng ST, Chen SL, Wong JGX, Lye DC, Ng TM. No association between resistance mutations, empiric antibiotic, and mortality in ceftriaxone-resistant Escherichia coli and Klebsiella pneumoniae bacteremia. Sci Rep 2018; 8:12785. [PMID: 30143706 PMCID: PMC6109088 DOI: 10.1038/s41598-018-31081-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 08/06/2018] [Indexed: 12/20/2022] Open
Abstract
The objective of this study was to correlate resistance mutations of extended spectrum beta-lactamases (ESBL) and AmpC beta-lactamases and virulence factors (VF) with 30-day mortality in patients treated with either piperacillin-tazobactam or carbapenems. A post-hoc analysis on 123 patients with ceftriaxone-resistant Escherichia coli and Klebsiella pneumoniae bacteremia treated empirically with piperacillin-tazobactam and carbapenems was performed. Beta-lactamase resistance mutations and VF were identified by whole genome sequencing (WGS). The primary endpoint was 30-day mortality. Multivariate analyses were performed using logistic regression. WGS showed diverse multilocus sequence types (MLST) in 43 K. pneumoniae strains, while ST131 predominated in E. coli strains (57/80). CTX-M was most commonly detected (76/80 [95%] of E. coli; 39/43 [91%] of K pneumoniae.), followed by OXA (53/80 [66%] of E. coli; 34/43 [79%] of K. pneumoniae). A significant correlation was found between the number of genes encoding third-generation cephalosporin-resistant beta-lactamases and 30-day mortality (p = 0.045). The positive association was not significant after controlling for empiric carbapenem, Pitt score 3 and K. pneumoniae (OR 2.43, P = 0.073). None of the VF was associated with 30-day mortality. No association was found between 30-day mortality and any ESBL and AmpC beta-lactamases or VF when piperacillin-tazobactam or carbapenems were given. No significant association between 30-day mortality and active empiric therapy was found.
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Affiliation(s)
- Shi Thong Heng
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Swaine L Chen
- GERMS and Infectious Diseases Group, Genome Institute of Singapore, Singapore, Singapore.
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
| | - Joshua G X Wong
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore
| | - David C Lye
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Tat Ming Ng
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
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The Inoculum Effect in the Era of Multidrug Resistance: Minor Differences in Inoculum Have Dramatic Effect on MIC Determination. Antimicrob Agents Chemother 2018; 62:AAC.00433-18. [PMID: 29784837 DOI: 10.1128/aac.00433-18] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 05/16/2018] [Indexed: 01/03/2023] Open
Abstract
The observed MIC may depend on the number of bacteria initially inoculated into the assay. This phenomenon is termed the inoculum effect (IE) and is often most pronounced for β-lactams in strains expressing β-lactamase enzymes. The Clinical and Laboratory Standards Institute (CLSI)-recommended inoculum is 5 × 105 CFU ml-1 with an acceptable range of 2 × 105 to 8 × 105 CFU ml-1 IE testing is typically performed using an inoculum 100-fold greater than the CLSI-recommended inoculum. Therefore, it remains unknown whether the IE influences MICs during testing performed according to CLSI guidelines. Here, we utilized inkjet printing technology to test the IE on cefepime, meropenem, and ceftazidime-avibactam. First, we determined that the inkjet dispense volume correlated well with the number of bacteria delivered to microwells in 2-fold (R2 = 0.99) or 1.1-fold (R2 = 0.98) serial dilutions. We then quantified the IE by dispensing orthogonal titrations of bacterial cells and antibiotics. For cefepime-resistant and susceptible dose-dependent strains, a 2-fold increase in inoculum resulted in a 1.6 log2-fold increase in MIC. For carbapenemase-producing strains, each 2-fold reduction in inoculum resulted in a 1.26 log2-fold reduction in meropenem MIC. At the lower end of the CLSI-allowable inoculum range, minor error rates of 34.8% were observed for meropenem when testing a resistant-strain set. Ceftazidime-avibactam was not subject to an appreciable IE. Our results suggest that IE is sufficiently pronounced for meropenem and cefepime in multidrug-resistant Gram-negative pathogens to affect categorical interpretations during standard laboratory testing.
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38
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Point-Counterpoint: Piperacillin-Tazobactam Should Be Used To Treat Infections with Extended-Spectrum-Beta-Lactamase-Positive Organisms. J Clin Microbiol 2018; 56:JCM.01917-17. [PMID: 29237787 DOI: 10.1128/jcm.01917-17] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTIONBeta-lactam/beta-lactamase inhibitor combination antimicrobials (BLBLIs) are among the most controversial classes of antibiotic agents available for the treatment of infections caused by extended-spectrum-beta-lactamase (ESBL)-producing Gram-negative bacteria (ESBL-GNR). Piperacillin-tazobactam (PTZ) is one of the most frequently utilized antibiotic agents for empirical Gram-negative bacterial coverage and remains active against a large proportion of ESBL-GNR strains. Furthermore, good antimicrobial stewardship practices encourage the use of carbapenem-sparing treatment regimens for infections due to ESBL-GNR. As rapid diagnostics are increasingly used in the clinical microbiology laboratory and have the capability of detecting CTX-M type or other ESBL resistance mechanisms, this issue continues to be pertinent. Some data imply reduced efficacy of PTZ against ESBLs. Several factors may affect a clinician's choice to use BLBLIs, including the isolate's MIC, the site and severity of infection, and the type of resistance mechanism. These factors are explored in this review of the pros and cons of BLBLI treatment of invasive infections due to ESBL-producing bacteria, as well as how laboratories should report results for BLBLIs for these organisms as they relate to antimicrobial stewardship. In this Point-Counterpoint, Audrey Schuetz provides the pro point of view and Sergio Reyes and Pranita Tamma provide the con, counterpoint view.
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Treatment of Infections Caused by Extended-Spectrum-Beta-Lactamase-, AmpC-, and Carbapenemase-Producing Enterobacteriaceae. Clin Microbiol Rev 2018; 31:31/2/e00079-17. [PMID: 29444952 DOI: 10.1128/cmr.00079-17] [Citation(s) in RCA: 421] [Impact Index Per Article: 70.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Therapy of invasive infections due to multidrug-resistant Enterobacteriaceae (MDR-E) is challenging, and some of the few active drugs are not available in many countries. For extended-spectrum β-lactamase and AmpC producers, carbapenems are the drugs of choice, but alternatives are needed because the rate of carbapenem resistance is rising. Potential active drugs include classic and newer β-lactam-β-lactamase inhibitor combinations, cephamycins, temocillin, aminoglycosides, tigecycline, fosfomycin, and, rarely, fluoroquinolones or trimethoprim-sulfamethoxazole. These drugs might be considered in some specific situations. AmpC producers are resistant to cephamycins, but cefepime is an option. In the case of carbapenemase-producing Enterobacteriaceae (CPE), only some "second-line" drugs, such as polymyxins, tigecycline, aminoglycosides, and fosfomycin, may be active; double carbapenems can also be considered in specific situations. Combination therapy is associated with better outcomes for high-risk patients, such as those in septic shock or with pneumonia. Ceftazidime-avibactam was recently approved and is active against KPC and OXA-48 producers; the available experience is scarce but promising, although development of resistance is a concern. New drugs active against some CPE isolates are in different stages of development, including meropenem-vaborbactam, imipenem-relebactam, plazomicin, cefiderocol, eravacycline, and aztreonam-avibactam. Overall, therapy of MDR-E infection must be individualized according to the susceptibility profile, type, and severity of infection and the features of the patient.
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Satlin MJ, Walsh TJ. Multidrug-resistant Enterobacteriaceae, Pseudomonas aeruginosa, and vancomycin-resistant Enterococcus: Three major threats to hematopoietic stem cell transplant recipients. Transpl Infect Dis 2017; 19. [PMID: 28815897 DOI: 10.1111/tid.12762] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 04/04/2017] [Accepted: 06/01/2017] [Indexed: 12/13/2022]
Abstract
Hematopoietic stem cell transplant (HSCT) recipients are uniquely threatened by the emergence of multidrug-resistant (MDR) bacteria because these patients rely on immediate active antimicrobial therapy to combat bacterial infections. This review describes the epidemiology and treatment considerations for three challenging MDR bacterial pathogens in HSCT recipients: MDR Enterobacteriaceae, including extended-spectrum β-lactamase (ESBL)-producing and carbapenem-resistant Enterobacteriaceae (CRE), Pseudomonas aeruginosa, and vancomycin-resistant Enterococcus (VRE). These bacteria are common causes of infection in this population and bacteremias caused by these organisms are associated with high mortality rates. Carbapenems remain the treatments of choice for serious infections due to ESBL-producing Enterobacteriaceae in HSCT recipients. Administration of β-lactam agents as an extended infusion is associated with improved outcomes in patients with severe infections caused by P. aeruginosa. Older agents used for the treatment of CRE and MDR P. aeruginosa infections, such as polymyxins and aminoglycosides, have major limitations. Newer agents, such as ceftazidime-avibactam and ceftolozane-tazobactam have great potential for the treatment of Klebsiella pneumoniae carbapemenase-producing CRE and MDR P. aeruginosa, respectively, but more pre-clinical and clinical data are needed to better evaluate their efficacy. Daptomycin dosages ≥8 mg/kg/day are recommended to treat VRE infections in this population, particularly in the setting of increasing daptomycin resistance. Strategies to prevent these infections include strict adherence to recommended infection control practices and multidisciplinary antimicrobial stewardship. Last, gastrointestinal screening to guide empirical therapy and the use of polymerase chain reaction-based rapid diagnostics may decrease the time to administration of appropriate therapy for these infections, thereby leading to improved outcomes.
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Affiliation(s)
- Michael J Satlin
- Transplantation-Oncology Infectious Diseases Program, Division of Infectious Diseases, Weill Cornell Medicine, New York, NY, USA.,Weill Cornell Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Thomas J Walsh
- Transplantation-Oncology Infectious Diseases Program, Division of Infectious Diseases, Weill Cornell Medicine, New York, NY, USA.,Weill Cornell Medical Center, New York-Presbyterian Hospital, New York, NY, USA.,Department of Pediatrics and Microbiology & Immunology, Weill Cornell Medicine, New York, NY, USA
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The impact of inoculum size on the activity of cefoperazone-sulbactam against multidrug resistant organisms. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2017; 51:207-213. [PMID: 29037802 DOI: 10.1016/j.jmii.2017.08.026] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 08/27/2017] [Accepted: 08/31/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVES This study aims to assess the in vitro activity of cefoperazone alone and different cefoperazone-sulbactam ratios against different inoculum sizes of multidrug resistant organisms. METHODS Minimum inhibitory concentrations (MICs) of cefoperazone, cefoperazone-sulbactam at fixed ratio of 1:1 and 2:1 against a normal inoculum size of 5 × 105 CFU/ml and a high inoculum size of 5 × 107 CFU/ml were measured. RESULTS Each 33 isolates of extended-spectrum β-lactamases (ESBL)-producing Escherichia coli, ESBL-producing Klebsiella pneumoniae, carbapenem-resistant E. coli, and carbapenem-resistant Pseudomonas aeruginosa and a total of 122 isolates of carbapenem-resistant Acinetobacter baumannii were collected. After the addition of sulbactam at a 1:1 ratio, most MIC50 and MIC90 values decreased. Cefoperazone-sulbactam at a 1:1 ratio had a higher susceptibility rate against ESBL-producing E. coli, carbapenem-resistant E. coli, and carbapenem-resistant A. baumannii than cefoperazone-sulbactam at a 2:1 ratio (all P < 0.05). For ESBL-producing E. coli, the susceptibility rate of cefoperazone-sulbactam at ratios of (1:1) and (2:1) decreased from 97.0 to 87.9% and 90.9 to 60.6%, for normal to high inoculum, respectively. For ESBL-producing K. pneumoniae, both susceptibility rate of cefoperazone-sulbactam at ratios of (1:1) and (2:1) decreased from 75.8%, and 63.6% at normal inoculum to 51.5% and 42.4% at high inoculum. CONCLUSIONS Cefoperazone-sulbactam at a 1:1 ratio has greater in vitro activity against most multidrug resistant organisms than cefoperazone-sulbactam at a 2:1 ratio. Such combinations were not influenced by the inoculum size of ESBL-producing E. coli and K. pneumoniae and could be a therapeutic option for treating severe infections.
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Use of β-Lactam/β-Lactamase Inhibitors for Extended-Spectrum-β-Lactamase Infections: Defining the Right Patient Population. Antimicrob Agents Chemother 2017; 61:AAC.01094-17. [PMID: 28584153 DOI: 10.1128/aac.01094-17] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In a multicenter, multinational observational study that included neutropenic patients with bloodstream infections by extended-spectrum-β-lactamase-producing species, Gudiol et al. (Antimicrob. Agents Chemother. 61:e00164-17, 2017, https://doi.org/10.1128/AAC.00164-17) demonstrated that β-lactam/β-lactamase inhibitors are effective treatment options. A review of this work, however, reminds us that some lingering questions remain for specific high-risk subgroups.
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Efficacy and Pharmacokinetics of the Combination of OP0595 and Cefepime in a Mouse Model of Pneumonia Caused by Extended-Spectrum-Beta-Lactamase-Producing Klebsiella pneumoniae. Antimicrob Agents Chemother 2017; 61:AAC.00828-17. [PMID: 28507106 DOI: 10.1128/aac.00828-17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 05/06/2017] [Indexed: 11/20/2022] Open
Abstract
OP0595 (RG6080) is a novel diazabicyclooctane that inhibits class A and C serine beta-lactamases. Although the combination of OP0595 and cefepime (FEP) showed good in vitro activity against extended-spectrum-beta-lactamase (ESBL)-producing pathogens, the effect of the combination therapy against severe infections, such as pneumonia or bacteremia, remains unknown in vivo In this study, we investigated the efficacy and pharmacokinetics of the combination therapy of OP0595 and FEP in a mouse model of pneumonia caused by Klebsiella pneumoniae harboring SHV- and CTX-M-9-type ESBLs. The infected BALB/c mice were intraperitoneally administered saline (control), 100 mg/kg of body weight of FEP, 20 mg/kg of OP0595, or both FEP and OP0595, twice a day. The MIC of FEP against the bacteria was 8 mg/liter and markedly improved to 0.06 mg/liter with the addition of 0.5 mg/ml of OP0595. In the survival study, the combination of FEP and OP0595 significantly improved the survival rate compared with that reported with either OP0595 or FEP alone (P < 0.001). The number of bacteria in the lungs and blood significantly decreased in the combination therapy group compared to that reported for the monotherapy groups (P < 0.001). In addition, the in vivo effect depended on the dose of FEP. However, pharmacokinetic analysis revealed that the percentage of time above MIC remained constant when increasing the dose of FEP in combination with 20 mg/kg of OP0595. The results of our study demonstrated the in vivo effectiveness of the combination of OP0595 and FEP.
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Rachow T, Schlüter V, Bremer-Streck S, Lindig U, Scholl S, Schlattmann P, Kiehntopf M, Hochhaus A, von Lilienfeld-Toal M. Measurement of piperacillin plasma concentrations in cancer patients with suspected infection. Infection 2017; 45:629-636. [DOI: 10.1007/s15010-017-1026-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 05/11/2017] [Indexed: 12/21/2022]
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Muhammed M, Flokas ME, Detsis M, Alevizakos M, Mylonakis E. Comparison Between Carbapenems and β-Lactam/β-Lactamase Inhibitors in the Treatment for Bloodstream Infections Caused by Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae: A Systematic Review and Meta-Analysis. Open Forum Infect Dis 2017; 4:ofx099. [PMID: 28702469 PMCID: PMC5499850 DOI: 10.1093/ofid/ofx099] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 05/10/2017] [Indexed: 11/13/2022] Open
Abstract
Background Carbapenems are widely used for the management of bloodstream infections (BSIs) caused by extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE). However, the wide use of carbapenems has been associated with carbapenem-resistant Enterobacteriaceae development. Methods We searched the PubMed and Scopus databases (last search date was on June 1, 2016) looking for studies that reported mortality in adult patients with ESBL-PE BSIs that were treated with carbapenems or β-lactam/β-lactamase inhibitors (BL/BLIs). Results Fourteen studies reported mortality data in adult patients with ESBL-PE BSI that were treated with carbapenems or BL/BLIs. Among them, 13 studies reported extractable data on empiric therapy, with no statistically significant difference in mortality of patients with ESBL-PE BSI that were treated empirically with carbapenems (22.1%; 121 of 547), compared with those that received empiric BL/BLIs (20.5%; 109 of 531; relative risk [RR], 1.05; 95% confidence interval [CI], 0.83–1.37; I2 = 20.7%; P = .241). In addition, 7 studies reported data on definitive therapy. In total, 767 patients (79.3%) received carbapenems and 199 patients (20.6%) received BL/BLIs as definitive therapy, and there was again no statistically significant difference (RR, 0.62; 95% CI, 0.25–1.52; I2 = 84.6%; P < .001). Regarding specific pathogens, the use of empiric BL/BLIs in patients with BSI due to ESBL-Escherichia coli was not associated with a statistically significant difference in mortality (RR, 1.014; 95% CI, 0.491–2.095; I2 = 62.5%; P = .046), compared with the use of empiric carbapenems. Conclusions These data do not support the wide use of carbapenems as empiric therapy, and BL/BLIs might be effective agents for initial/empiric therapy for patients with BSI caused by likely ESBL-PE, and especially ESBL-E coli.
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Affiliation(s)
- Maged Muhammed
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence
| | - Myrto Eleni Flokas
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence
| | - Marios Detsis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence
| | - Michail Alevizakos
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence
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Recent updates of carbapenem antibiotics. Eur J Med Chem 2017; 131:185-195. [PMID: 28324783 DOI: 10.1016/j.ejmech.2017.03.022] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/01/2017] [Accepted: 03/14/2017] [Indexed: 11/23/2022]
Abstract
Carbapenems are among the most commonly used and the most efficient antibiotics since they are relatively resistant to hydrolysis by most β-lactamases, they target penicillin-binding proteins, and generally have broad-spectrum antibacterial effect. In this review, we described the initial discovery and development of carbapenems, chemical characteristics, in vitro/in vivo activities, resistance studies, and clinical investigations for traditional carbapenem antibiotics in the market; imipenem-cilastatin, meropenem, ertapenem, doripenem, biapenem, panipenem/betamipron in addition to newer carbapenems such as razupenem, tebipenem, tomopenem, and sanfetrinem. We focused on the literature published from 2010 to 2016.
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Guet-Revillet H, Tomini E, Emirian A, Join-Lambert O, Lécuyer H, Zahar JR, Jullien V. Piperacillin/tazobactam as an alternative antibiotic therapy to carbapenems in the treatment of urinary tract infections due to extended-spectrum β-lactamase-producing Enterobacteriaceae: an in silico pharmacokinetic study. Int J Antimicrob Agents 2017; 49:62-66. [DOI: 10.1016/j.ijantimicag.2016.09.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 09/09/2016] [Accepted: 09/19/2016] [Indexed: 11/29/2022]
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Efficacy of High-Dose Meropenem (Six Grams per Day) in Treatment of Experimental Murine Pneumonia Induced by Meropenem-Resistant Pseudomonas aeruginosa. Antimicrob Agents Chemother 2016; 61:AAC.02056-16. [PMID: 27799201 DOI: 10.1128/aac.02056-16] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 10/22/2016] [Indexed: 02/06/2023] Open
Abstract
High-dose meropenem (MEPM; 6 g/day) has been approved as a treatment for purulent meningitis; however, little is known regarding its in vivo efficacy in refractory lower respiratory tract infections. The purpose of this study was to evaluate the efficacy of MEPM at 6 g/day in a murine model of severe pneumonia caused by MEPM-resistant Pseudomonas aeruginosa Experimental pneumonia induced by MEPM-resistant P. aeruginosa was treated with normal-dose MEPM (150 mg/kg of body weight, simulating a 3-g/day regimen in humans) or high-dose MEPM (500 mg/kg, simulating a 6-g/day regimen in humans). Mice treated with high-dose MEPM showed significantly restored survival relative to that of untreated mice and tended to show a survival rate higher than that of mice treated with normal-dose MEPM. The viable bacterial counts (of two clinical isolates) in the lungs decreased significantly in mice treated with high-dose MEPM from those for untreated mice (P < 0.001) or mice treated with normal-dose MEPM (P, <0.01 and <0.05). The number of inflammatory cells in the bronchoalveolar lavage fluid (BALF) was also significantly lower in mice treated with high-dose MEPM than in untreated mice. The free MEPM concentration in the epithelial lining fluid (ELF) exceeded 16 μg/ml for 85 min in mice treated with high-dose MEPM, but not for mice treated with normal-dose MEPM. Our results demonstrate that high-dose MEPM (6 g/day) might provide better protection against pneumonia caused by MEPM-resistant strains of P. aeruginosa than the dose normally administered (less than 3 g/day).
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Arizpe A, Reveles KR, Patel SD, Aitken SL. Updates in the Management of Cephalosporin-Resistant Gram-Negative Bacteria. Curr Infect Dis Rep 2016; 18:39. [PMID: 27743202 DOI: 10.1007/s11908-016-0552-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Resistance to cephalosporins is now common among Gram-negative bacterial infections, including those caused by the Enterobacteriaceae and Pseudomonas aeruginosa, posing a major threat to public health. As resistance to the traditional drugs of choice for these infections, carbapenems, has also become increasingly common, interest in cefepime and piperacillin-tazobactam as carbapenem-sparing alternatives has increased. Additionally, the availability of the novel β-lactam-β-lactamase inhibitor combinations ceftolozane-tazobactam and ceftazidime-avibactam has added to the antimicrobial armamentarium available to treat these multidrug-resistant infections. Here, we review the recent literature on the use of carbapenem-sparing alternatives and highlight the potential utility of novel antimicrobials.
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Affiliation(s)
- Andre Arizpe
- College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Kelly R Reveles
- College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education and Research Center, The University of Texas, Health Science Center at San Antonio, San Antonio, TX, USA
| | - Shrina D Patel
- Division of Pharmacy, The University of Texas, MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 0090, Houston, TX, 77030, USA
| | - Samuel L Aitken
- Division of Pharmacy, The University of Texas, MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 0090, Houston, TX, 77030, USA.
- Center for Antimicrobial Resistance and Microbial Genomics, UTHealth McGovern School of Medicine, Houston, TX, USA.
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Effect of Meropenem Concentration on the Detection of Low Numbers of Carbapenem-Resistant Enterobacteriaceae. Antimicrob Agents Chemother 2015; 60:712-3. [PMID: 26552977 DOI: 10.1128/aac.01904-15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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