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Shields RK, Yücel E, Turzhitsky V, Merchant S, Min JS, Watanabe AH. Real-world evaluation of imipenem/cilastatin/relebactam across US medical centres. J Glob Antimicrob Resist 2024; 37:190-194. [PMID: 38588973 DOI: 10.1016/j.jgar.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/25/2024] [Accepted: 03/05/2024] [Indexed: 04/10/2024] Open
Abstract
We assessed 160 patients who received imipenem/cilastatin/relebactam for ≥2 days. At treatment initiation, the median Charlson Comorbidity Index was 5, 45% were in the intensive care unit, and 19% required vasopressor support. The in-hospital mortality rate was 24%. These data advance our understanding of real-world indications and outcomes of imipenem/cilastatin/relebactam use.
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Affiliation(s)
- Ryan K Shields
- Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, PA
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Abniki R, Tashakor A, Masoudi M, Mansury D. Global Resistance of Imipenem/Relebactam against Gram-Negative Bacilli: Systematic Review and Meta-Analysis. CURRENT THERAPEUTIC RESEARCH 2023; 100:100723. [PMID: 38174096 PMCID: PMC10758719 DOI: 10.1016/j.curtheres.2023.100723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/18/2023] [Indexed: 01/05/2024]
Abstract
Background Relebactam, previously known as MK-7655, is currently being tested in combination with imipenem as a class A and class C β-lactamase inhibitor, including KPC from Klebsiella pneumoniae. Objective The objective of the current study was to evaluate the activity of imipenem/relebactam against gram-negative bacilli. Methods After applying exclusion and inclusion criteria, 72 articles with full texts that describe the prevalence of imipenem/relebactam resistance were chosen for the meta-analysis and systematic review. Articles published between January 2015 and February 2023 were surveyed. The systematic literature search was conducted in PubMed, Web of Science, Google Scholar, and Scopus. Results The pooled estimation of 282,621 sample isolates revealed that the prevalence rate of imipenem/relebactam resistance is roughly 14.6% (95% CI, 0.116%-0.182%). Conclusions The findings of this analysis show that imipenem/relebactam resistance is rare in the majority of developed countries. Given that relebactam has proven to restore the activity of imipenem against current clinical isolates, further research into imipenem/relebactam is necessary.
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Affiliation(s)
- Reza Abniki
- Student Research Committee, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amirhossein Tashakor
- Department of Microbiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Melika Masoudi
- Department of Microbiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Davood Mansury
- Department of Microbiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Corona A, De Santis V, Agarossi A, Prete A, Cattaneo D, Tomasini G, Bonetti G, Patroni A, Latronico N. Antibiotic Therapy Strategies for Treating Gram-Negative Severe Infections in the Critically Ill: A Narrative Review. Antibiotics (Basel) 2023; 12:1262. [PMID: 37627683 PMCID: PMC10451333 DOI: 10.3390/antibiotics12081262] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 07/04/2023] [Accepted: 07/26/2023] [Indexed: 08/27/2023] Open
Abstract
INTRODUCTION Not enough data exist to inform the optimal duration and type of antimicrobial therapy against GN infections in critically ill patients. METHODS Narrative review based on a literature search through PubMed and Cochrane using the following keywords: "multi-drug resistant (MDR)", "extensively drug resistant (XDR)", "pan-drug-resistant (PDR)", "difficult-to-treat (DTR) Gram-negative infection," "antibiotic duration therapy", "antibiotic combination therapy" "antibiotic monotherapy" "Gram-negative bacteremia", "Gram-negative pneumonia", and "Gram-negative intra-abdominal infection". RESULTS Current literature data suggest adopting longer (≥10-14 days) courses of synergistic combination therapy due to the high global prevalence of ESBL-producing (45-50%), MDR (35%), XDR (15-20%), PDR (5.9-6.2%), and carbapenemases (CP)/metallo-β-lactamases (MBL)-producing (12.5-20%) Gram-negative (GN) microorganisms (i.e., Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumanii). On the other hand, shorter courses (≤5-7 days) of monotherapy should be limited to treating infections caused by GN with higher (≥3 antibiotic classes) antibiotic susceptibility. A general approach should be based on (i) third or further generation cephalosporins ± quinolones/aminoglycosides in the case of MDR-GN; (ii) carbapenems ± fosfomycin/aminoglycosides for extended-spectrum β-lactamases (ESBLs); and (iii) the association of old drugs with new expanded-spectrum β-lactamase inhibitors for XDR, PDR, and CP microorganisms. Therapeutic drug monitoring (TDM) in combination with minimum inhibitory concentration (MIC), bactericidal vs. bacteriostatic antibiotics, and the presence of resistance risk predictors (linked to patient, antibiotic, and microorganism) should represent variables affecting the antimicrobial strategies for treating GN infections. CONCLUSIONS Despite the strategies of therapy described in the results, clinicians must remember that all treatment decisions are dynamic, requiring frequent reassessments depending on both the clinical and microbiological responses of the patient.
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Affiliation(s)
- Alberto Corona
- Accident, Emergency and ICU Department and Surgical Theatre, ASST Valcamonica, University of Brescia, 25043 Breno, Italy
| | | | - Andrea Agarossi
- Accident, Emergency and ICU Department, ASST Santi Paolo Carlo, 20142 Milan, Italy
| | - Anna Prete
- AUSL Romagna, Umberto I Hospital, 48022 Lugo, Italy
| | - Dario Cattaneo
- Unit of Clinical Pharmacology, ASST Fatebenefratelli Sacco University Hospital, Via GB Grassi 74, 20157 Milan, Italy
| | - Giacomina Tomasini
- Urgency and Emergency Surgery and Medicine Division ASST Valcamonica, 25123 Brescia, Italy
| | - Graziella Bonetti
- Clinical Pathology and Microbiology Laboratory, ASST Valcamonica, 25123 Brescia, Italy
| | - Andrea Patroni
- Medical Directorate, Infection Control Unit, ASST Valcamonica, 25123 Brescia, Italy
| | - Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy
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Abstract
Imipenem (IMI)/cilastatin/relebactam (REL) (I/R) is a novel β-lactam/β-lactamase inhibitor combination with expanded microbiologic activity against carbapenem-resistant non-Morganellaceae Enterobacterales (CR-NME) and difficult-to-treat (DTR) Pseudomonas aeruginosa. Relebactam, a bicyclic diazabicyclooctane, has no direct antimicrobial activity but provides reliable inhibition of many Ambler class A and class C enzymes. It is currently approved for the treatment of adult patients with hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia (HABP/VABP) and those with complicated urinary tract infections (cUTIs) and complicated intra-abdominal infections (cIAIs) when limited or no alternative treatments are available. Given the number of recently approved β-lactams with expanded activity against highly resistant Gram-negative pathogens, this review summarizes the published literature on I/R, with a focus on its similar and distinguishing characteristics relative to those of other recently approved agents. Overall, available data support its use for the treatment of patients with HABP/VABP, cUTI, and cIAI due to CR-NME and DTR P. aeruginosa. Data indicate that I/R retains some activity against CR-NME and DTR P. aeruginosa isolates that are resistant to the newer β-lactams and vice versa, suggesting that susceptibility testing be performed for all the newer agents to determine optimal treatment options for patients with CR-NME and DTR P. aeruginosa infections. Further comparative PK/PD and clinical studies are warranted to determine the optimal role of I/R, alone and in combination, for the treatment of patients with highly resistant Gram-negative infections. Until further data are available, I/R is a potential treatment for patients with CR-NME and DTR P. aeruginosa infections when the benefits outweigh the risks.
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Losito AR, Raffaelli F, Del Giacomo P, Tumbarello M. New Drugs for the Treatment of Pseudomonas aeruginosa Infections with Limited Treatment Options: A Narrative Review. Antibiotics (Basel) 2022; 11:antibiotics11050579. [PMID: 35625223 PMCID: PMC9137685 DOI: 10.3390/antibiotics11050579] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/22/2022] [Accepted: 04/24/2022] [Indexed: 12/13/2022] Open
Abstract
P. aeruginosa is still one of the most threatening pathogens responsible for serious hospital-acquired infections. It is intrinsically resistant to many antimicrobial agents and additional acquired resistance further complicates the management of such infections. High rates of combined antimicrobial resistance persist in many countries, especially in the eastern and south-eastern parts of Europe. The aim of this narrative review is to provide a comprehensive assessment of the epidemiology, latest data, and clinical evidence on the current and new available drugs active against P. aeruginosa isolates with limited treatment options. The latest evidence and recommendations supporting the use of ceftolozane-tazobactam and ceftazidime-avibactam, characterized by targeted clinical activity against a significant proportion of P. aeruginosa strains with limited treatment options, are described based on a review of the latest microbiological and clinical studies. Cefiderocol, with excellent in vitro activity against P. aeruginosa isolates, good stability to all β-lactamases and against porin and efflux pumps mutations, is also examined. New carbapenem combinations are explored, reviewing the latest experimental and initial clinical evidence. One section is devoted to a review of new anti-pseudomonal antibiotics in the pipeline, such as cefepime-taniborbactam and cefepime-zidebactam. Finally, other “old” antimicrobials, mainly fosfomycin, that can be used as combination strategies, are described.
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Affiliation(s)
- Angela Raffaella Losito
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (A.R.L.); (F.R.); (P.D.G.)
| | - Francesca Raffaelli
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (A.R.L.); (F.R.); (P.D.G.)
| | - Paola Del Giacomo
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (A.R.L.); (F.R.); (P.D.G.)
| | - Mario Tumbarello
- Dipartimento di Biotecnologie Mediche, Università degli Studi di Siena, 53100 Siena, Italy
- UOC Malattie Infettive e Tropicali, Azienda Ospedaliero Universitaria Senese, 53100 Siena, Italy
- Correspondence: or ; Tel.: +39-0577-586572
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Tamma PD, Aitken SL, Bonomo RA, Mathers AJ, van Duin D, Clancy CJ. Infectious Diseases Society of America 2022 Guidance on the Treatment of Extended-Spectrum β-lactamase Producing Enterobacterales (ESBL-E), Carbapenem-Resistant Enterobacterales (CRE), and Pseudomonas aeruginosa with Difficult-to-Treat Resistance (DTR-P. aeruginosa). Clin Infect Dis 2022; 75:187-212. [PMID: 35439291 PMCID: PMC9890506 DOI: 10.1093/cid/ciac268] [Citation(s) in RCA: 223] [Impact Index Per Article: 111.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/04/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The Infectious Diseases Society of America (IDSA) is committed to providing up-to-date guidance on the treatment of antimicrobial-resistant infections. The initial guidance document on infections caused by extended-spectrum β-lactamase producing Enterobacterales (ESBL-E), carbapenem-resistant Enterobacterales (CRE), and Pseudomonas aeruginosa with difficult-to-treat resistance (DTR-P. aeruginosa) was published on 17 September 2020. Over the past year, there have been a number of important publications furthering our understanding of the management of ESBL-E, CRE, and DTR-P. aeruginosa infections, prompting a rereview of the literature and this updated guidance document. METHODS A panel of 6 infectious diseases specialists with expertise in managing antimicrobial-resistant infections reviewed, updated, and expanded previously developed questions and recommendations about the treatment of ESBL-E, CRE, and DTR-P. aeruginosa infections. Because of differences in the epidemiology of resistance and availability of specific anti-infectives internationally, this document focuses on the treatment of infections in the United States. RESULTS Preferred and alternative treatment recommendations are provided with accompanying rationales, assuming the causative organism has been identified and antibiotic susceptibility results are known. Approaches to empiric treatment, duration of therapy, and other management considerations are also discussed briefly. Recommendations apply for both adult and pediatric populations. CONCLUSIONS The field of antimicrobial resistance is highly dynamic. Consultation with an infectious diseases specialist is recommended for the treatment of antimicrobial-resistant infections. This document is current as of 24 October 2021. The most current versions of IDSA documents, including dates of publication, are available at www.idsociety.org/practice-guideline/amr-guidance/.
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Affiliation(s)
- Pranita D Tamma
- Correspondence: P. D. Tamma, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA ()
| | - Samuel L Aitken
- Department of Pharmacy, University of Michigan Health, Ann Arbor, Michigan, USA
| | - Robert A Bonomo
- Medical Service and Center for Antimicrobial Resistance and Epidemiology, Louis Stokes Cleveland Veterans Affairs Medical Center, University Hospitals Cleveland Medical Center and Departments of Medicine, Pharmacology, Molecular Biology, and Microbiology, Case Western Reserve University, Cleveland, Ohio, USA
| | - Amy J Mathers
- Departments of Medicine and Pathology, University of Virginia, Charlottesville, Virginia, USA
| | - David van Duin
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Cornelius J Clancy
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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In vitro Activity of Imipenem-Relebactam Alone and in Combination with Fosfomycin against Carbapenem-Resistant Gram-negative Pathogens. Diagn Microbiol Infect Dis 2022; 103:115712. [DOI: 10.1016/j.diagmicrobio.2022.115712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 10/13/2021] [Accepted: 04/17/2022] [Indexed: 11/19/2022]
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Antimicrobial Treatment Options for Difficult-to-Treat Resistant Gram-Negative Bacteria Causing Cystitis, Pyelonephritis, and Prostatitis: A Narrative Review. Drugs 2022; 82:407-438. [PMID: 35286622 PMCID: PMC9057390 DOI: 10.1007/s40265-022-01676-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2022] [Indexed: 02/06/2023]
Abstract
Urinary tract infections, including cystitis, acute pyelonephritis, and prostatitis, are among the most common diagnoses prompting antibiotic prescribing. The rise in antimicrobial resistance over the past decades has led to the increasing challenge of urinary tract infections because of multidrug-resistant and "difficult-to-treat resistance" among Gram-negative bacteria. Recent advances in pharmacotherapy and medical microbiology are modernizing how these urinary tract infections are treated. Advances in pharmacotherapy have included not only the development and approval of novel antibiotics, such as ceftazidime/avibactam, meropenem/vaborbactam, imipenem/relebactam, ceftolozane/tazobactam, cefiderocol, plazomicin, and glycylcyclines, but also the re-examination of the potential role of legacy antibiotics, including older aminoglycosides and tetracyclines. Recent advances in medical microbiology allow phenotypic and molecular mechanism of resistance testing, and thus antibiotic prescribing can be tailored to the mechanism of resistance in the infecting pathogen. Here, we provide a narrative review on the clinical and pre-clinical studies of drugs that can be used for difficult-to-treat resistant Gram-negative bacteria, with a particular focus on data relevant to the urinary tract. We also offer a pragmatic framework for antibiotic selection when encountering urinary tract infections due to difficult-to-treat resistant Gram-negative bacteria based on the organism and its mechanism of resistance.
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Abstract
PURPOSE OF REVIEW To discuss the current literature on novel agents for the treatment of carbapenem-resistant nonfermenting Gram-negative bacteria (NF-GNB) infections. RECENT FINDINGS Some novel agents have recently become available that are expected to replace classical polymyxins as the first-line options for the treatment of carbapenem-resistant NF-GNB infections. SUMMARY In this narrative review, we provide a brief overview of the differential activity of various recently approved agents against NF-GNB most encountered in the daily clinical practice, as well as the results from phase-3 randomized clinical trials and large postapproval observational studies, with special focus on NF-GNB. Since resistance to novel agents has already been reported, the use of novel agents needs to be optimized, based on their differential activity (not only in terms of targeted bacteria, but also of resistance determinants), the local microbiological epidemiology, and the most updated pharmacokinetic/pharmacodynamic data. Large real-life experiences remain of crucial importance for further refining the optimal treatment of NF-GNB infections in the daily clinical practice.
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10
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Zhang H, Jia P, Zhu Y, Zhang G, Zhang J, Kang W, Duan S, Zhang W, Yang Q, Xu Y. Susceptibility to Imipenem/Relebactam of Pseudomonas aeruginosa and Acinetobacter baumannii Isolates from Chinese Intra-Abdominal, Respiratory and Urinary Tract Infections: SMART 2015 to 2018. Infect Drug Resist 2021; 14:3509-3518. [PMID: 34511942 PMCID: PMC8418378 DOI: 10.2147/idr.s325520] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/17/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose In recent years, less options are available for treating carbapenem-resistant Acinetobacter baumannii and carbapenem-resistant Pseudomonas aeruginosa. The present study investigates the susceptibility rates to imipenem/relebactam for the treatment of intra-abdominal infections (IAIs), respiratory tract infections (RTIs) and urinary tract infections (UTIs) caused by A. baumannii and P. aeruginosa in China. Patients and Methods A total of 1886 P. aeruginosa and 1889 A. baumannii isolates were collected in 21 centers (7 regions) as a part of the global SMART surveillance program between 2015 and 2018. Antimicrobial susceptibility testing was performed according to the Clinical and Laboratory Standards Institute (CLSI) recommendations using the broth microdilution methodology at Peking Union Medical College Hospital. Results For P. aeruginosa, overall susceptibility rates to imipenem/relebactam were 84.2% at a CLSI breakpoint of ≤2 mg/L compared to 55.7% for imipenem. Susceptibility rates of imipenem-non-susceptible P. aeruginosa to imipenem/relebactam were 64.4% and for multidrug-resistance (MDR) P. aeruginosa susceptibility rates were increased from 25.2% for imipenem to 65.8% for imipenem/relebactam. The susceptibilities of imipenem-non-susceptible and MDR P. aeruginosa strains were similarly restored by imipenem/relebactam in non-ICU and ICU wards. The rate of imipenem-non-susceptibilities A. baumannii isolates was 79.0%, whereas the MDR rate was 81.9%. Relebactam did not change the susceptibilities of imipenem-non susceptible or MDR A. baumannii isolates. Conclusion Imipenem/relebactam provides a therapy option to treat infections caused by MDR or imipenem-non-susceptible P. aeruginosa but not A. baumannii infections in China.
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Affiliation(s)
- Hui Zhang
- Department of Clinical Laboratory, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Peiyao Jia
- Department of Clinical Laboratory, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, People's Republic of China
| | - Ying Zhu
- Department of Clinical Laboratory, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, People's Republic of China
| | - Ge Zhang
- Department of Clinical Laboratory, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Jingjia Zhang
- Department of Clinical Laboratory, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Wei Kang
- Department of Clinical Laboratory, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Simeng Duan
- Department of Clinical Laboratory, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Weijuan Zhang
- MRL Global Medical Affairs, MSD China, Shanghai, People's Republic of China
| | - Qiwen Yang
- Department of Clinical Laboratory, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Yingchun Xu
- Department of Clinical Laboratory, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
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Imipenem-Relebactam Susceptibility and Genotypic Characteristics of Carbapenem-Resistant Enterobacterales (CRE) Identified during Population-Based Surveillance. Antimicrob Agents Chemother 2021; 65:e0228820. [PMID: 34370572 DOI: 10.1128/aac.02288-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Laboratories submit all carbapenem-resistant Enterobacter, Escherichia coli, and Klebsiella species to the Alameda County Public Health Department (ACPHD). ACPHD evaluated 75 isolates submitted during nine months for susceptibility to imipenem-relebactam (I-R) and identified β-lactamase genes using whole genome sequencing. Of 60 (80%) isolates susceptible to I-R, 8 (13%) had detectable carbapenemase genes, including four KPC, two NDM, and two OXA-48-like; we described the relationship between the presence of β-lactamase resistance genes and susceptibility to I-R.
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Le Run E, Atze H, Arthur M, Mainardi JL. Impact of relebactam-mediated inhibition of Mycobacterium abscessus BlaMab β-lactamase on the in vitro and intracellular efficacy of imipenem. J Antimicrob Chemother 2021; 75:379-383. [PMID: 31637424 DOI: 10.1093/jac/dkz433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 09/12/2019] [Accepted: 09/19/2019] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES Imipenem is one of the recommended β-lactams for the treatment of Mycobacterium abscessus pulmonary infections in spite of the production of BlaMab β-lactamase. Avibactam, a second-generation β-lactamase inhibitor, was previously shown to inactivate BlaMab, but its partner drug, ceftazidime, is devoid of any antibacterial activity against M. abscessus. Here, we investigate whether relebactam, a novel second-generation inhibitor developed in combination with imipenem, improves the activity of this carbapenem against M. abscessus. METHODS The impact of BlaMab inhibition by relebactam was evaluated by determining MICs, time-kill curves and M. abscessus intracellular proliferation in human macrophages. Kinetic parameters for the inhibition of BlaMab by relebactam were determined by spectrophotometry using nitrocefin as the substrate. The data were compared with those obtained with avibactam. RESULTS Combination of relebactam (4 mg/L) with β-lactams led to >128- and 2-fold decreases in the MICs of amoxicillin (from >4096 to 32 mg/L) and imipenem (from 8 to 4 mg/L). In vitro, M. abscessus was not killed by the imipenem/relebactam combination. In contrast, relebactam increased the intracellular activity of imipenem, leading to 88% killing. Relebactam and avibactam similarly potentiated the antibacterial activities of β-lactams although BlaMab was inactivated 150-fold less effectively by relebactam than by avibactam. CONCLUSIONS Inhibition of BlaMab by relebactam improves the efficacy of imipenem against M. abscessus in macrophages, indicating that the imipenem/relebactam combination should be clinically considered for the treatment of infections due to M. abscessus.
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Affiliation(s)
- Eva Le Run
- Centre de Recherche des Cordeliers, INSERM UMRS1138, Sorbonne Université, Université de Paris, F-75006, Paris, France
| | - Heiner Atze
- Centre de Recherche des Cordeliers, INSERM UMRS1138, Sorbonne Université, Université de Paris, F-75006, Paris, France
| | - Michel Arthur
- Centre de Recherche des Cordeliers, INSERM UMRS1138, Sorbonne Université, Université de Paris, F-75006, Paris, France
| | - Jean-Luc Mainardi
- Centre de Recherche des Cordeliers, INSERM UMRS1138, Sorbonne Université, Université de Paris, F-75006, Paris, France.,Assistance Publique-Hôpitaux de Paris, Centre-Université de Paris, Service de Microbiologie, Hôpital Européen Georges Pompidou, Paris, France
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Lob SH, Hackel MA, Young K, Motyl MR, Sahm DF. Activity of imipenem/relebactam and comparators against gram-negative pathogens from patients with bloodstream infections in the United States and Canada - SMART 2018-2019. Diagn Microbiol Infect Dis 2021; 100:115421. [PMID: 34082265 DOI: 10.1016/j.diagmicrobio.2021.115421] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/31/2021] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
Bloodstream infections (BSI) are often caused by drug-resistant pathogens, and novel antimicrobials are needed. We examined the activity of imipenem/relebactam against BSI pathogens from US and Canada: >99% of non-Morganellaceae Enterobacterales, including 100% of MDR isolates, and >94% of Pseudomonas aeruginosa were imipenem/relebactam-susceptible. Imipenem/relebactam could provide an important treatment option.
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Yahav D, Giske CG, Grāmatniece A, Abodakpi H, Tam VH, Leibovici L. New β-Lactam-β-Lactamase Inhibitor Combinations. Clin Microbiol Rev 2020; 34:e00115-20. [PMID: 33177185 PMCID: PMC7667665 DOI: 10.1128/cmr.00115-20] [Citation(s) in RCA: 258] [Impact Index Per Article: 64.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The limited armamentarium against drug-resistant Gram-negative bacilli has led to the development of several novel β-lactam-β-lactamase inhibitor combinations (BLBLIs). In this review, we summarize their spectrum of in vitro activities, mechanisms of resistance, and pharmacokinetic-pharmacodynamic (PK-PD) characteristics. A summary of available clinical data is provided per drug. Four approved BLBLIs are discussed in detail. All are options for treating multidrug-resistant (MDR) Enterobacterales and Pseudomonas aeruginosa Ceftazidime-avibactam is a potential drug for treating Enterobacterales producing extended-spectrum β-lactamase (ESBL), Klebsiella pneumoniae carbapenemase (KPC), AmpC, and some class D β-lactamases (OXA-48) in addition to carbapenem-resistant Pseudomonas aeruginosa Ceftolozane-tazobactam is a treatment option mainly for carbapenem-resistant P. aeruginosa (non-carbapenemase producing), with some activity against ESBL-producing Enterobacterales Meropenem-vaborbactam has emerged as treatment option for Enterobacterales producing ESBL, KPC, or AmpC, with similar activity as meropenem against P. aeruginosa Imipenem-relebactam has documented activity against Enterobacterales producing ESBL, KPC, and AmpC, with the combination having some additional activity against P. aeruginosa relative to imipenem. None of these drugs present in vitro activity against Enterobacterales or P. aeruginosa producing metallo-β-lactamase (MBL) or against carbapenemase-producing Acinetobacter baumannii Clinical data regarding the use of these drugs to treat MDR bacteria are limited and rely mostly on nonrandomized studies. An overview on eight BLBLIs in development is also provided. These drugs provide various levels of in vitro coverage of carbapenem-resistant Enterobacterales, with several drugs presenting in vitro activity against MBLs (cefepime-zidebactam, aztreonam-avibactam, meropenem-nacubactam, and cefepime-taniborbactam). Among these drugs, some also present in vitro activity against carbapenem-resistant P. aeruginosa (cefepime-zidebactam and cefepime-taniborbactam) and A. baumannii (cefepime-zidebactam and sulbactam-durlobactam).
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Affiliation(s)
- Dafna Yahav
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel
| | - Christian G Giske
- Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Alise Grāmatniece
- Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
- Pauls Stradins University Hospital, University of Latvia, Riga, Latvia
| | - Henrietta Abodakpi
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Vincent H Tam
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Leonard Leibovici
- Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel
- Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
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15
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Campanella TA, Gallagher JC. A Clinical Review and Critical Evaluation of Imipenem-Relebactam: Evidence to Date. Infect Drug Resist 2020; 13:4297-4308. [PMID: 33268997 PMCID: PMC7701153 DOI: 10.2147/idr.s224228] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 11/03/2020] [Indexed: 12/11/2022] Open
Abstract
Imipenem-relebactam (I-R) is a novel beta-lactam/beta-lactamase inhibitor combination given with cilastatin. It is indicated for the treatment of complicated urinary tract infections, complicated intra-abdominal infections, and hospital-acquired or ventilator-associated bacterial pneumonia. A literature search was completed to evaluate the evidence to date of I-R. I-R has in vitro activity against multidrug-resistant organisms including carbapenem-resistant Pseudomonas aeruginosa and extended-spectrum beta-lactamase and carbapenem-resistant Enterobacterales. It was granted FDA approval following the promising results of two phase II clinical trials in patients with complicated urinary tract infections and complicated intra-abdominal infections. The most common adverse drug events associated with I-R were nausea (6%), diarrhea (6%), and headache (4%). I-R is a new beta-lactam/beta-lactamase inhibitor combination that will be most likely used for patients with multidrug-resistant gram-negative infections in which there are limited or no available alternative treatment options.
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Affiliation(s)
- Toni A Campanella
- Department of Pharmacy, Jefferson Health Northeast, Philadelphia, PA, USA
| | - Jason C Gallagher
- Department of Pharmacy Practice, Temple University, Philadelphia, PA, USA
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16
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Unresolved issues in the identification and treatment of carbapenem-resistant Gram-negative organisms. Curr Opin Infect Dis 2020; 33:482-494. [PMID: 33009141 DOI: 10.1097/qco.0000000000000682] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Carbapenem-resistant organisms (CROs), including Pseudomonas aeruginosa, Acinetobacter baumannii and Enterobacterales, are a threat worldwide. This review will cover mechanisms of resistance within CROs and challenges with identification and treatment of these organisms while pointing out unresolved issues and ongoing challenges. RECENT FINDINGS The treatment of CROs has expanded through newer therapeutic options. Guided utilization through genotypic and phenotypic testing is necessary in order for these drugs to target the appropriate mechanisms of resistance and select optimal antibiotic therapy. SUMMARY Identification methods and treatment options need to be precisely understood in order to limit the spread and maximize outcomes of CRO infections.
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Shang Z, Chan SY, Song Q, Li P, Huang W. The Strategies of Pathogen-Oriented Therapy on Circumventing Antimicrobial Resistance. RESEARCH (WASHINGTON, D.C.) 2020; 2020:2016201. [PMID: 33083786 PMCID: PMC7539235 DOI: 10.34133/2020/2016201] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/02/2020] [Indexed: 12/23/2022]
Abstract
The emerging antimicrobial resistance (AMR) poses serious threats to the global public health. Conventional antibiotics have been eclipsed in combating with drug-resistant bacteria. Moreover, the developing and deploying of novel antimicrobial drugs have trudged, as few new antibiotics are being developed over time and even fewer of them can hit the market. Alternative therapeutic strategies to resolve the AMR crisis are urgently required. Pathogen-oriented therapy (POT) springs up as a promising approach in circumventing antibiotic resistance. The tactic underling POT is applying antibacterial compounds or materials directly to infected regions to treat specific bacteria species or strains with goals of improving the drug efficacy and reducing nontargeting and the development of drug resistance. This review exemplifies recent trends in the development of POTs for circumventing AMR, including the adoption of antibiotic-antibiotic conjugates, antimicrobial peptides, therapeutic monoclonal antibodies, nanotechnologies, CRISPR-Cas systems, and microbiota modulations. Employing these alternative approaches alone or in combination shows promising advantages for addressing the growing clinical embarrassment of antibiotics in fighting drug-resistant bacteria.
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Affiliation(s)
- Zifang Shang
- Frontiers Science Center for Flexible Electronics (FSCFE), Xi'an Institute of Flexible Electronics (IFE) & Xi'an Institute of Biomedical Materials and Engineering (IBME), Northwestern Polytechnical University (NPU), Xi'an 710072, China
| | - Siew Yin Chan
- Frontiers Science Center for Flexible Electronics (FSCFE), Xi'an Institute of Flexible Electronics (IFE) & Xi'an Institute of Biomedical Materials and Engineering (IBME), Northwestern Polytechnical University (NPU), Xi'an 710072, China
| | - Qing Song
- Frontiers Science Center for Flexible Electronics (FSCFE), Xi'an Institute of Flexible Electronics (IFE) & Xi'an Institute of Biomedical Materials and Engineering (IBME), Northwestern Polytechnical University (NPU), Xi'an 710072, China
- Key Laboratory for Organic Electronics and Information Displays (KLOEID) and Institute of Advanced Materials (IAM), Nanjing University of Posts and Telecommunications (NUPT), Nanjing 210023, China
| | - Peng Li
- Frontiers Science Center for Flexible Electronics (FSCFE), Xi'an Institute of Flexible Electronics (IFE) & Xi'an Institute of Biomedical Materials and Engineering (IBME), Northwestern Polytechnical University (NPU), Xi'an 710072, China
| | - Wei Huang
- Frontiers Science Center for Flexible Electronics (FSCFE), Xi'an Institute of Flexible Electronics (IFE) & Xi'an Institute of Biomedical Materials and Engineering (IBME), Northwestern Polytechnical University (NPU), Xi'an 710072, China
- Key Laboratory for Organic Electronics and Information Displays (KLOEID) and Institute of Advanced Materials (IAM), Nanjing University of Posts and Telecommunications (NUPT), Nanjing 210023, China
- Key Laboratory of Flexible Electronics (KLOFE) & Institute of Advanced Materials (IAM), Jiangsu National Synergetic Innovation Center for Advanced Materials (SICAM), Nanjing Tech University (NanjingTech), Nanjing 211816, China
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18
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Lob SH, Karlowsky JA, Young K, Motyl MR, Hawser S, Kothari ND, Gueny ME, Sahm DF. Activity of imipenem/relebactam against MDR Pseudomonas aeruginosa in Europe: SMART 2015-17. J Antimicrob Chemother 2020; 74:2284-2288. [PMID: 31086960 DOI: 10.1093/jac/dkz191] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/29/2019] [Accepted: 04/05/2019] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES Relebactam is a diazabicyclooctane non-β-lactam inhibitor of Ambler class A and C β-lactamases that is in clinical development in combination with imipenem/cilastatin. The current study evaluated the in vitro activity of imipenem/relebactam against 5447 isolates of Pseudomonas aeruginosa submitted to the SMART global surveillance programme in 2015-17 by 67 clinical laboratories in 22 European countries. METHODS MICs were determined using the CLSI broth microdilution reference method (Eleventh Edition: M07, 2018). Relebactam was tested at a fixed concentration of 4 mg/L in combination with doubling dilutions of imipenem. MICs were interpreted using EUCAST clinical breakpoints (version 8.1); imipenem breakpoints were applied to imipenem/relebactam. RESULTS Rates of susceptibility to imipenem and imipenem/relebactam (MIC ≤4 mg/L) were 69.4% and 92.4%, respectively, for all isolates of P. aeruginosa. Over one-third of all isolates (34.9%, 1902/5447) were MDR; lower respiratory tract isolates (38.3%, 1327/3461) were more frequently MDR than were intraabdominal (28.5%, 355/1245) or urinary tract (29.7%, 212/714) isolates. Of all MDR isolates, 78.2% were susceptible to imipenem/relebactam, a rate that was 50-77 percentage points higher than the rate of susceptibility to imipenem or any other β-lactam tested; rates of susceptibility to imipenem/relebactam were similar for MDR isolates from lower respiratory tract (77.8% susceptible), intraabdominal (80.3%) and urinary tract (76.4%) infections. Overall, relebactam restored imipenem susceptibility to 75.2% (1254/1668) of imipenem-non-susceptible isolates of P. aeruginosa and to 69.6% (947/1361) of imipenem-non-susceptible isolates with an MDR phenotype. CONCLUSIONS Relebactam restored in vitro susceptibility to imipenem for most imipenem-non-susceptible and MDR clinical isolates of P. aeruginosa from European patients.
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Affiliation(s)
- Sibylle H Lob
- International Health Management Associates (IHMA), Inc., Schaumburg, IL 60173, USA
| | - James A Karlowsky
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB R3E 0J9, Canada
| | | | | | | | | | | | - Daniel F Sahm
- International Health Management Associates (IHMA), Inc., Schaumburg, IL 60173, USA
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Moussa M, Abou Chakra M, Dellis A, Moussa Y, Papatsoris A. Pharmacotherapeutic advances for recurrent urinary tract infections in women. Expert Opin Pharmacother 2020; 21:2011-2026. [PMID: 32717156 DOI: 10.1080/14656566.2020.1795128] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Treatment of recurrent Urinary tract infections (UTIs) has become challenging because of the dramatic increase in the rates of recurrent infection andof multidrug-resistant (MDR) infections. AREAS COVERED The authors review recurrent UTIs(rUTI) management in women. EXPERT OPINION Continuous or post-coital prophylaxis with low-dose antimicrobials or intermittent self-treatment has all been demonstrated to be effective in managing rUTIs in women. Intravaginal estrogen therapy , shows potential toward preventing rUTI. Oral vaccine Uro-Vaxom seems to reduce the number of UTIs. There is evidence that other therapies (e.g. cranberry, Methenamine hippurate, oral D-mannose) may decrease the number of symptomatic UTIs. The treatment of CRE-UTIs is focused on a colistin backbone. Carbapenems are considered first-line agents for UTIs caused by ESBL, but their use is associated with increased MDR. The usage of non-carbapenem for the treatment of ESBL UTIs is necessary. Cefepime, Piperacillin-Tazobactam, Ceftolozane-Tazobactam, and Ceftazidime-Avibactam are justified options. Oral therapy with Pivmecillinam, Fosfomycin, and Nitrofurantoin can be used against uncomplicated UTIs due to ESBL infection.
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Affiliation(s)
- Mohamad Moussa
- Department of Urology, Al Zahraa Hospital, University Medical Center, Lebanese University , Beirut, Lebanon
| | - Mohamed Abou Chakra
- Department of Urology, Al Zahraa Hospital, University Medical Center, Lebanese University , Beirut, Lebanon
| | - Athanasios Dellis
- Department of Surgery, School of Medicine, Aretaieion Hospital, National and Kapodistrian University of Athens , Athens, Greece.,2nd Department of Urology, School of Medicine, Sismanoglio Hospital, National and Kapodistrian University of Athens , Athens, Greece
| | - Yasmin Moussa
- Clinic of Dermatology, Dr Brinkmann, Schult & Samini-Fard , Gladbeck, Germany
| | - Athanasios Papatsoris
- 2nd Department of Urology, School of Medicine, Sismanoglio Hospital, National and Kapodistrian University of Athens , Athens, Greece
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20
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Smith JR, Rybak JM, Claeys KC. Imipenem-Cilastatin-Relebactam: A Novel β-Lactam-β-Lactamase Inhibitor Combination for the Treatment of Multidrug-Resistant Gram-Negative Infections. Pharmacotherapy 2020; 40:343-356. [PMID: 32060929 DOI: 10.1002/phar.2378] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Imipenem-cilastatin-relebactam (IMI-REL) is a novel β-lactam-β-lactamase inhibitor combination recently approved for the treatment of complicated urinary tract infections (cUTIs) and complicated intraabdominal infections (cIAIs). Relebactam is a β-lactamase inhibitor with the ability to inhibit a broad spectrum of β-lactamases such as class A and class C β-lactamases, including carbapenemases. The addition of relebactam to imipenem restores imipenem activity against several imipenem-resistant bacteria, including Enterobacteriaceae and Pseudomonas aeruginosa. Clinical data demonstrate that IMI-REL is well tolerated and effective in the treatment of cUTIs and cIAIs due to imipenem-resistant bacteria. In a phase III trial comparing IMI-REL with imipenem plus colistin, favorable clinical response was achieved in 71% and 70% of patients, respectively. Available clinical and pharmacokinetic data support the approved dosage of a 30-minute infusion of imipenem 500 mg-cilastatin 500 mg-relebactam 250 mg every 6 hours, along with dosage adjustments based on renal function. In this review, we describe the chemistry, mechanism of action, spectrum of activity, pharmacokinetics and pharmacodynamics, and clinical efficacy, and safety and tolerability of this new agent. The approval of IMI-REL represents another important step in the ongoing fight against multidrug-resistant gram-negative pathogens.
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Affiliation(s)
- Jordan R Smith
- Department of Clinical Sciences, Fred Wilson School of Pharmacy, High Point University, High Point, North Carolina.,Cone Health, Greensboro, North Carolina
| | - Jeffrey M Rybak
- Department of Clinical Pharmacy and Translational Science, University of Tennessee College of Pharmacy, Memphis, Tennessee
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21
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Ma Y, Wang C, Li Y, Li J, Wan Q, Chen J, Tay FR, Niu L. Considerations and Caveats in Combating ESKAPE Pathogens against Nosocomial Infections. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2020; 7:1901872. [PMID: 31921562 PMCID: PMC6947519 DOI: 10.1002/advs.201901872] [Citation(s) in RCA: 149] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 10/04/2019] [Indexed: 05/19/2023]
Abstract
ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) are among the most common opportunistic pathogens in nosocomial infections. ESKAPE pathogens distinguish themselves from normal ones by developing a high level of antibiotic resistance that involves multiple mechanisms. Contemporary therapeutic strategies which are potential options in combating ESKAPE bacteria need further investigation. Herein, a broad overview of the antimicrobial research on ESKAPE pathogens over the past five years is provided with prospective clinical applications.
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Affiliation(s)
- Yu‐Xuan Ma
- State Key Laboratory of Military StomatologyNational Clinical Research Center for Oral DiseasesShaanxi Key Laboratory of StomatologyDepartment of ProsthodonticsSchool of StomatologyThe Fourth Military Medical University145 Changle West RoadXi'anShaanxi710032P. R. China
| | - Chen‐Yu Wang
- State Key Laboratory of Military StomatologyNational Clinical Research Center for Oral DiseasesShaanxi Key Laboratory of StomatologyDepartment of ProsthodonticsSchool of StomatologyThe Fourth Military Medical University145 Changle West RoadXi'anShaanxi710032P. R. China
| | - Yuan‐Yuan Li
- State Key Laboratory of Military StomatologyNational Clinical Research Center for Oral DiseasesShaanxi Key Laboratory of StomatologyDepartment of ProsthodonticsSchool of StomatologyThe Fourth Military Medical University145 Changle West RoadXi'anShaanxi710032P. R. China
| | - Jing Li
- State Key Laboratory of Military StomatologyNational Clinical Research Center for Oral DiseasesShaanxi Key Laboratory of StomatologyDepartment of ProsthodonticsSchool of StomatologyThe Fourth Military Medical University145 Changle West RoadXi'anShaanxi710032P. R. China
| | - Qian‐Qian Wan
- State Key Laboratory of Military StomatologyNational Clinical Research Center for Oral DiseasesShaanxi Key Laboratory of StomatologyDepartment of ProsthodonticsSchool of StomatologyThe Fourth Military Medical University145 Changle West RoadXi'anShaanxi710032P. R. China
| | - Ji‐Hua Chen
- State Key Laboratory of Military StomatologyNational Clinical Research Center for Oral DiseasesShaanxi Key Laboratory of StomatologyDepartment of ProsthodonticsSchool of StomatologyThe Fourth Military Medical University145 Changle West RoadXi'anShaanxi710032P. R. China
| | - Franklin R. Tay
- State Key Laboratory of Military StomatologyNational Clinical Research Center for Oral DiseasesShaanxi Key Laboratory of StomatologyDepartment of ProsthodonticsSchool of StomatologyThe Fourth Military Medical University145 Changle West RoadXi'anShaanxi710032P. R. China
- The Graduate SchoolAugusta University1430, John Wesley Gilbert DriveAugustaGA30912‐1129USA
| | - Li‐Na Niu
- State Key Laboratory of Military StomatologyNational Clinical Research Center for Oral DiseasesShaanxi Key Laboratory of StomatologyDepartment of ProsthodonticsSchool of StomatologyThe Fourth Military Medical University145 Changle West RoadXi'anShaanxi710032P. R. China
- The Graduate SchoolAugusta University1430, John Wesley Gilbert DriveAugustaGA30912‐1129USA
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22
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Papp-Wallace KM. The latest advances in β-lactam/β-lactamase inhibitor combinations for the treatment of Gram-negative bacterial infections. Expert Opin Pharmacother 2019; 20:2169-2184. [PMID: 31500471 PMCID: PMC6834881 DOI: 10.1080/14656566.2019.1660772] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 08/23/2019] [Indexed: 12/21/2022]
Abstract
Introduction: Antimicrobial resistance in Gram-negative pathogens is a significant threat to global health. β-Lactams (BL) are one of the safest and most-prescribed classes of antibiotics on the market today. The acquisition of β-lactamases, especially those which hydrolyze carbapenems, is eroding the efficacy of BLs for the treatment of serious infections. During the past decade, significant advances were made in the development of novel BL-β-lactamase inhibitor (BLI) combinations to target β-lactamase-mediated resistant Gram-negatives.Areas covered: The latest progress in 20 different approved, developing, and preclinical BL-BLI combinations to target serine β-lactamases produced by Gram-negatives are reviewed based on primary literature, conference abstracts (when available), and US clinical trial searches within the last 5 years. The majority of the compounds that are discussed are being evaluated as part of a BL-BLI combination.Expert opinion: The current trajectory in BLI development is promising; however, a significant challenge resides in the selection of an appropriate BL partner as well as the development of resistance linked to the BL partner. In addition, dosing regimens for these BL-BLI combinations need to be critically evaluated. A revolution in bacterial diagnostics is essential to aid clinicians in the appropriate selection of novel BL-BLI combinations for the treatment of serious infections.
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Affiliation(s)
- Krisztina M. Papp-Wallace
- Louis Stokes Cleveland Department of Veterans Affairs, Research Service, Cleveland, OH, USA
- Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
- Department of Biochemistry, Case Western Reserve University, Cleveland, OH, USA
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23
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Karlowsky JA, Lob SH, Kazmierczak KM, Young K, Motyl MR, Sahm DF. In vitro activity of imipenem/relebactam against Enterobacteriaceae and Pseudomonas aeruginosa isolated from intraabdominal and urinary tract infection samples: SMART Surveillance United States 2015-2017. J Glob Antimicrob Resist 2019; 21:223-228. [PMID: 31698105 DOI: 10.1016/j.jgar.2019.10.028] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 10/17/2019] [Accepted: 10/27/2019] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES Antimicrobial resistance, including multidrug-resistance (MDR), is increasing, especially among Gram-negative bacilli. New agents are needed to treat infections caused by these pathogens. This report assessed the activity of imipenem/relebactam against Gram-negative bacilli from intraabdominal infections (IAIs) and urinary tract infections (UTIs) submitted to the SMART (Study for Monitoring Antimicrobial Resistance Trends) global surveillance programme in the United States from 2015 to 2017. METHODS Broth microdilution MICs for imipenem/relebactam and comparators were determined by a central laboratory against isolates of non-Proteeae Enterobacteriaceae (NPE) and Pseudomonas aeruginosa (P. aeruginosa). Imipenem/relebactam MICs were interpreted using United States Food and Drug Administration (FDA) breakpoints. RESULTS 99.5% of NPE isolates collected from patients with IAIs (n=3633) and UTIs (n=3038) were susceptible to imipenem/relebactam, as were 77.9% of imipenem-nonsusceptible, 96.3% of Klebsiella pneumoniae carbapenemase (KPC)-positive, and 98.7% of MDR isolates from IAIs and UTIs combined. A total of 96.7% of IAI isolates (n=486) and 96.4% of UTI isolates (n=360) of P. aeruginosa were susceptible to imipenem/relebactam, as were 85.0% of imipenem-nonsusceptible and 87.3% of MDR isolates from IAIs and UTIs combined. Percent susceptibility to imipenem/relebactam for cefepime-, ceftazidime-, and piperacillin-tazobactam-nonsusceptible isolates was 98.3-98.8% for NPE and 87.3-90.0% for P. aeruginosa. CONCLUSIONS Imipenem/relebactam demonstrated potent in vitro activity against NPE and P. aeruginosa isolates from IAIs and UTIs, including against resistant subsets, and will provide important coverage for IAIs and UTIs caused by β-lactam-resistant, MDR, and KPC-positive Gram-negative bacilli.
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Affiliation(s)
- James A Karlowsky
- International Health Management Associates, Inc., Schaumburg, IL, USA; Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Sibylle H Lob
- International Health Management Associates, Inc., Schaumburg, IL, USA.
| | | | | | | | - Daniel F Sahm
- International Health Management Associates, Inc., Schaumburg, IL, USA
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24
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Horcajada JP, Montero M, Oliver A, Sorlí L, Luque S, Gómez-Zorrilla S, Benito N, Grau S. Epidemiology and Treatment of Multidrug-Resistant and Extensively Drug-Resistant Pseudomonas aeruginosa Infections. Clin Microbiol Rev 2019; 32:32/4/e00031-19. [PMID: 31462403 PMCID: PMC6730496 DOI: 10.1128/cmr.00031-19] [Citation(s) in RCA: 461] [Impact Index Per Article: 92.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
In recent years, the worldwide spread of the so-called high-risk clones of multidrug-resistant or extensively drug-resistant (MDR/XDR) Pseudomonas aeruginosa has become a public health threat. This article reviews their mechanisms of resistance, epidemiology, and clinical impact and current and upcoming therapeutic options. In vitro and in vivo treatment studies and pharmacokinetic and pharmacodynamic (PK/PD) models are discussed. Polymyxins are reviewed as an important therapeutic option, outlining dosage, pharmacokinetics and pharmacodynamics, and their clinical efficacy against MDR/XDR P. aeruginosa infections. Their narrow therapeutic window and potential for combination therapy are also discussed. Other "old" antimicrobials, such as certain β-lactams, aminoglycosides, and fosfomycin, are reviewed here. New antipseudomonals, as well as those in the pipeline, are also reviewed. Ceftolozane-tazobactam has clinical activity against a significant percentage of MDR/XDR P. aeruginosa strains, and its microbiological and clinical data, as well as recommendations for improving its use against these bacteria, are described, as are those for ceftazidime-avibactam, which has better activity against MDR/XDR P. aeruginosa, especially strains with certain specific mechanisms of resistance. A section is devoted to reviewing upcoming active drugs such as imipenem-relebactam, cefepime-zidebactam, cefiderocol, and murepavadin. Finally, other therapeutic strategies, such as use of vaccines, antibodies, bacteriocins, anti-quorum sensing, and bacteriophages, are described as future options.
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Affiliation(s)
- Juan P Horcajada
- Service of Infectious Diseases, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona, Barcelona, Spain
- Spanish Network for Research in Infectious Diseases (REIPI), Madrid, Spain
| | - Milagro Montero
- Service of Infectious Diseases, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona, Barcelona, Spain
- Spanish Network for Research in Infectious Diseases (REIPI), Madrid, Spain
| | - Antonio Oliver
- Service of Microbiology, Hospital Son Espases, Instituto de Investigación Sanitaria Illes Balears (IdISBa), Palma de Mallorca, Spain
| | - Luisa Sorlí
- Service of Infectious Diseases, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Pompeu Fabra, Barcelona, Spain
- Spanish Network for Research in Infectious Diseases (REIPI), Madrid, Spain
| | - Sònia Luque
- Service of Pharmacy, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Silvia Gómez-Zorrilla
- Service of Infectious Diseases, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Pompeu Fabra, Barcelona, Spain
- Spanish Network for Research in Infectious Diseases (REIPI), Madrid, Spain
| | - Natividad Benito
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Santiago Grau
- Service of Pharmacy, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona, Barcelona, Spain
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25
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Bhagunde P, Zhang Z, Racine F, Carr D, Wu J, Young K, Rizk ML. A translational pharmacokinetic/pharmacodynamic model to characterize bacterial kill in the presence of imipenem-relebactam. Int J Infect Dis 2019; 89:55-61. [PMID: 31479762 DOI: 10.1016/j.ijid.2019.08.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/22/2019] [Accepted: 08/25/2019] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVES Relebactam is a small molecule β-lactamase inhibitor under clinical investigation for use as a fixed-dose combination with imipenem/cilastatin. Here we present a translational pharmacokinetic/pharmacodynamic mathematical model to support optimal dose selection of relebactam. METHODS Data derived from in vitro checkerboard and hollow fiber infection studies of imipenem-resistant strains of Pseudomonas aeruginosa were incorporated into the model. The model integrates the effect of relebactam concentration on imipenem susceptibility in a semi-mechanistic manner using the checkerboard data and characterizes the bacterial time-kill profiles from the hollow fiber infection model data. RESULTS Simulations demonstrated that the ratio of the area under the concentration-time curve for free drug to the minimum inhibitory concentration (fAUC/MIC) was the pharmacokinetic driver for relebactam, with a target fAUC/MIC=7.5 associated with 2-log kill. At a clinical dose of 250mg relebactam, greater than 2-log reductions in bacterial load are projected for imipenem-resistant strains with an imipenem/relebactam MIC≤4μg/mL. CONCLUSIONS The study confirms that the pharmacokinetic/pharmacodynamic driver for relebactam is fAUC/MIC, that an fAUC/MIC ratio of 7.5 is associated with 2-log kill in vitro, and that a 250mg clinical dose of relebactam achieves this target value when delivered in combination with imipenem/cilastatin.
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Affiliation(s)
| | - Zufei Zhang
- Merck & Co., Inc., 2000 Galloping Hill Rd., Kenilworth, NJ, 07033, USA
| | - Fred Racine
- Merck & Co., Inc., 2000 Galloping Hill Rd., Kenilworth, NJ, 07033, USA
| | - Donna Carr
- Merck & Co., Inc., 2000 Galloping Hill Rd., Kenilworth, NJ, 07033, USA
| | - Jin Wu
- Merck & Co., Inc., 2000 Galloping Hill Rd., Kenilworth, NJ, 07033, USA
| | - Katherine Young
- Merck & Co., Inc., 2000 Galloping Hill Rd., Kenilworth, NJ, 07033, USA
| | - Matthew L Rizk
- Merck & Co., Inc., 2000 Galloping Hill Rd., Kenilworth, NJ, 07033, USA.
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26
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In Vitro Activity of Imipenem-Relebactam Alone or in Combination with Amikacin or Colistin against Pseudomonas aeruginosa. Antimicrob Agents Chemother 2019; 63:AAC.00997-19. [PMID: 31262769 DOI: 10.1128/aac.00997-19] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 06/27/2019] [Indexed: 12/16/2022] Open
Abstract
Relebactam is a novel class A/C β-lactamase inhibitor that restores imipenem in vitro activity against multidrug-resistant and carbapenem-nonsusceptible Pseudomonas aeruginosa Time-kill analyses were performed to evaluate the potential role of imipenem-relebactam in combination with amikacin or colistin against P. aeruginosa Ten clinical P. aeruginosa isolates (9 imipenem nonsusceptible) with imipenem-relebactam MICs ranging from 1/4 to 8/4 μg/ml were included. The isolates had varied susceptibilities to imipenem (1 to 32 μg/ml), amikacin (4 to 128 μg/ml), and colistin (0.5 to 1 μg/ml). Duplicate 24-h time-kill studies were conducted using the average steady-state concentrations (Cssavg) observed after the administration of imipenem-relebactam at 500 mg/250 mg every 6 hours (q6h) alone and in combination with the Cssavg of 25 mg/kg of body weight/day amikacin and 360 mg/day colistin in humans. Imipenem-relebactam alone resulted in 24-h bacterial densities of -2.93 ± 0.38, -1.67 ± 0.29, +0.38 ± 0.96, and +0.15 ± 0.65 log10 CFU/ml at imipenem-relebactam MICs of 1/4, 2/4, 4/4, and 8/4 μg/ml, respectively. No synergy was demonstrated against the single imipenem-susceptible isolate. Against the imipenem-nonsusceptible isolates (n = 9), imipenem-relebactam combined with amikacin resulted in synergy (-2.61 ± 1.50 log10 CFU/ml) against all amikacin-susceptible isolates and in two of three amikacin-intermediate (i.e., MIC, 32 μg/ml) isolates (-2.06 ± 0.19 log10 CFU/ml). Synergy with amikacin was not observed when the amikacin MIC was >32 μg/ml. Imipenem-relebactam combined with colistin demonstrated synergy in eight out of the nine imipenem-resistant isolates (-3.17 ± 1.00 log10 CFU/ml). Against these 10 P. aeruginosa isolates, imipenem-relebactam combined with either amikacin or colistin resulted in synergistic activity against the majority of strains. Further studies evaluating combination therapy with imipenem-relebactam are warranted.
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27
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Imipenem/relebactam activity compared to other antimicrobials against non-MBL-producing carbapenem-resistant Enterobacteriaceae from an academic medical center. Pathog Dis 2019; 77:5542198. [DOI: 10.1093/femspd/ftz040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 07/30/2019] [Indexed: 11/12/2022] Open
Abstract
ABSTRACT
Background
Carbapenem-resistant Enterobacteriaceae (CRE) cause significant mortality and are resistant to most antimicrobial agents. Imipenem/relebactam, a novel beta-lactam/beta-lactamase inhibitor combination, and 16 other antimicrobials were evaluated against non-metallo-beta-lactamase-producing carbapenem-resistant Enterobacteriaceae clinical isolates from a United States tertiary academic medical center.
Objectives
To evaluate imipenem/relebactam and other commonly utilised antimicrobial agents against carbapenem-resistant Enterobacteriaceae. Methods: Clinical isolates (n = 96) resistant to ertapenem or meropenem by BD Phoenix (Becton, Dickinson and Company, Franklin Lakes, NJ, USA) and negative for metallo-beta-lactamase-production by an EDTA (Sigma-Aldrich Corp., St. Louis, MO, USA)/phenylboronic acid (Sigma-Aldrich Corp., St. Louis, MO, USA) disk diffusion assay were identified and collected from January 2012 to January 2017. In vitro susceptibility by broth microdilution was performed according to CLSI guidelines using CLSI susceptibility breakpoints for 17 antimicrobials (Sigma-Aldrich Corp., St. Louis, MO, USA).
Results
CRE primarily produced Klebsiella pneumoniae carbapenemase (KPC) and consisted primarily of K. pneumoniae (55%) and Enterobacter spp. (25%), followed by Citrobacter spp. (10%), Escherichia coli (5%), and others (5%). CRE were most susceptible to imipenem/relebactam (100%), followed by amikacin (85%), tigecycline (82%), and polymyxin B/colistin (65%). The median reduction of imipenem minimum inhibitory concentrations (MICs) of non-MBL-producing CRE was 16-fold but ranged from 0.5 to >512-fold. The MIC50, MIC90 and MIC range of imipenem/relebactam was 0.5/4, 1/4 and 0.06/4–1/4 mg/L, respectively.
Conclusions
Imipenem/relebactam exhibits excellent activity against CRE that produce KPC.
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Carbapenem-Nonsusceptible Pseudomonas aeruginosa Isolates from Intensive Care Units in the United States: a Potential Role for New β-Lactam Combination Agents. J Clin Microbiol 2019; 57:JCM.00535-19. [PMID: 31118271 DOI: 10.1128/jcm.00535-19] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 05/20/2019] [Indexed: 01/09/2023] Open
Abstract
Pseudomonas aeruginosa, a frequent pathogen in the intensive care unit (ICU), has the propensity to develop antibiotic resistance. In particular, carbapenem-nonsusceptible (NS) P. aeruginosa poses tremendous challenges, and new antibiotics will be needed to treat this phenotype. Here we determine carbapenem nonsusceptibility rates for contemporary P. aeruginosa isolates from U.S. ICUs and in vitro activities of new β-lactam combination agents. Between July 2017 and June 2018, consecutive nonduplicate P. aeruginosa isolates from blood and respiratory tract sources were recovered from patients admitted to the ICUs of 36 geographically diverse U.S. hospitals. Antimicrobial susceptibility to the following antipseudomonal agents was tested: ceftazidime, imipenem, meropenem, ceftazidime-avibactam, and imipenem-relebactam (an investigational β-lactam/β-lactamase inhibitor). MICs and susceptibility rates were measured using Clinical and Laboratory Standards Institute reference broth microdilution methodology. Among the 538 consecutive ICU P. aeruginosa isolates collected, carbapenem nonsusceptibility was observed for 35% of the isolates and was more common among respiratory tract versus bloodstream specimens. Susceptibility rates, MIC50 values, and MIC90 values were as follows: ceftazidime-avibactam, 92.8%, 2 μg/ml, and 8 μg/ml; imipenem-relebactam, 91.5%, 0.25 μg/ml, and 2 μg/ml; ceftazidime, 77.1%, 4 μg/ml, and 64 μg/ml; meropenem, 72.7%, 1 μg/ml, and 16 μg/ml; imipenem, 67.1%, 2 μg/ml, and 16 μg/ml. Most (>75%) of the carbapenem-NS isolates were susceptible to ceftazidime-avibactam and imipenem-relebactam. In these U.S. hospital ICUs, carbapenem-NS P. aeruginosa isolates from respiratory sources were frequently observed. Novel β-lactam combination agents appear to retain active in vitro susceptibility profiles against these isolates and may play a role in the treatment of infections caused by carbapenem-NS P. aeruginosa strains.
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29
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Karlowsky JA, Lob SH, Young K, Motyl MR, Sahm DF. Activity of imipenem-relebactam against multidrug-resistant Pseudomonas aeruginosa from the United States - SMART 2015-2017. Diagn Microbiol Infect Dis 2019; 95:212-215. [PMID: 31174995 DOI: 10.1016/j.diagmicrobio.2019.05.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/01/2019] [Accepted: 05/01/2019] [Indexed: 12/30/2022]
Abstract
A total of 2732 isolates of Pseudomonas aeruginosa collected at 26 United States clinical laboratories in 2015-2017 were tested for susceptibility to imipenem-relebactam. Imipenem-relebactam MICs were interpreted using 2018 CLSI M100 imipenem breakpoints for P. aeruginosa. A total of 93.9% of P. aeruginosa isolates were susceptible to imipenem-relebactam. Among MDR isolates (n = 750), susceptibility to imipenem-relebactam was 79.7%, 46-73 percentage points higher than to other β-lactams tested. Relebactam restored imipenem susceptibility to 78.3% of imipenem-nonsusceptible isolates (n = 766) and to 69.6% of imipenem-nonsusceptible isolates with MDR phenotypes (n = 500).
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Affiliation(s)
- James A Karlowsky
- International Health Management Associates, Inc., Schaumburg, IL, 60173, USA; Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, R3E 0J9, Canada
| | - Sibylle H Lob
- International Health Management Associates, Inc., Schaumburg, IL, 60173, USA.
| | | | | | - Daniel F Sahm
- International Health Management Associates, Inc., Schaumburg, IL, 60173, USA
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El Hafi B, Rasheed SS, Abou Fayad AG, Araj GF, Matar GM. Evaluating the Efficacies of Carbapenem/β-Lactamase Inhibitors Against Carbapenem-Resistant Gram-Negative Bacteria in vitro and in vivo. Front Microbiol 2019; 10:933. [PMID: 31114565 PMCID: PMC6503214 DOI: 10.3389/fmicb.2019.00933] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 04/12/2019] [Indexed: 11/13/2022] Open
Abstract
Background Carbapenem-resistant Gram-negative bacteria are a major clinical concern as they cause virtually untreatable infections since carbapenems are among the last-resort antimicrobial agents. β-Lactamases implicated in carbapenem resistance include KPC, NDM, and OXA-type carbapenemases. Antimicrobial combination therapy is the current treatment approach against carbapenem resistance in order to limit the excessive use of colistin; however, its advantages over monotherapy remain debatable. An alternative treatment strategy would be the use of carbapenem/β-lactamase inhibitor (βLI) combinations. In this study, we assessed the in vitro and in vivo phenotypic and molecular efficacies of three βLIs when combined with different carbapenems against carbapenem-resistant Gram-negative clinical isolates. The chosen βLIs were (1) Avibactam, against OXA-type carbapenemases, (2) calcium-EDTA, against NDM-1, and (3) Relebactam, against KPC-2. Methods Six Acinetobacter baumannii clinical isolates were screened for bla OXA-23-like, bla OXA-24/40, bla OXA-51-like, bla OXA-58, and bla OXA-143-like, and eight Enterobacteriaceae clinical isolates were screened for bla OXA-48, bla NDM-1, and bla KPC-2. The minimal inhibitory concentrations of Imipenem (IPM), Ertapenem (ETP), and Meropenem (MEM) with corresponding βLIs for each isolate were determined. The efficacy of the most suitable in vitro treatment option against each of bla OXA-48, bla NDM-1, and bla KPC-2 was assessed via survival studies in a BALB/c murine infection model. Finally, RT-qPCR was performed to assess the molecular response of the genes of resistance to the carbapenem/βLI combinations used under both in vitro and in vivo settings. Results Combining MEM, IPM, and ETP with the corresponding βLIs restored the isolates' susceptibilities to those antimicrobial agents in 66.7%, 57.1%, and 30.8% of the samples, respectively. Survival studies in mice revealed 100% survival rates when MEM was combined with either Avibactam or Relebactam against bla OXA-48 and bla KPC-2, respectively. RT-qPCR demonstrated the consistent overexpression of bla OXA-48 upon treatment, without hindering Avibactam's activity, while bla NDM-1 and bla KPC-2 experienced variable expression levels upon treatment under in vitro and in vivo settings despite their effective phenotypic results. Conclusion New carbapenem/βLI combinations may be viable alternatives to antimicrobial combination therapy as they displayed high efficacy in vitro and in vivo. Meropenem/Avibactam and Meropenem/Relebactam should be tested on larger sample sizes with different carbapenemases before progressing further in its preclinical development.
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Affiliation(s)
- Bassam El Hafi
- Department of Experimental Pathology, Immunology and Microbiology, American University of Beirut, Beirut, Lebanon.,Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon
| | - Sari S Rasheed
- Department of Experimental Pathology, Immunology and Microbiology, American University of Beirut, Beirut, Lebanon.,Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon
| | - Antoine G Abou Fayad
- Department of Experimental Pathology, Immunology and Microbiology, American University of Beirut, Beirut, Lebanon.,Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon
| | - George F Araj
- Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon.,Department of Pathology and Laboratory Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ghassan M Matar
- Department of Experimental Pathology, Immunology and Microbiology, American University of Beirut, Beirut, Lebanon.,Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon
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31
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A Combination Antibiogram Evaluation for Pseudomonas aeruginosa in Respiratory and Blood Sources from Intensive Care Unit (ICU) and Non-ICU Settings in U.S. Hospitals. Antimicrob Agents Chemother 2019; 63:AAC.02564-18. [PMID: 30917987 PMCID: PMC6496158 DOI: 10.1128/aac.02564-18] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 01/21/2019] [Indexed: 12/23/2022] Open
Abstract
Pseudomonas aeruginosa is an important pathogen associated with significant morbidity and mortality. U.S. guidelines for the treatment of hospital-acquired and ventilator-associated pneumonia recommend the use of two antipseudomonal drugs for high-risk patients to ensure that ≥95% of patients receive active empirical therapy. We evaluated the utility of combination antibiograms in identifying optimal anti-P. aeruginosa drug regimens. We conducted a retrospective cross-sectional analysis of the antimicrobial susceptibility of all nonduplicate P. aeruginosa blood and respiratory isolates collected between 1 October 2016 and 30 September 2017 from 304 U.S. hospitals in the BD Insights Research Database. Combination antibiograms were used to determine in vitro rates of susceptibility to potential anti-P. aeruginosa combination regimens consisting of a backbone antibiotic (an extended-spectrum cephalosporin, carbapenem, or piperacillin-tazobactam) plus an aminoglycoside or fluoroquinolone. Single-agent susceptibility rates for the 11,701 nonduplicate P. aeruginosa isolates ranged from 72.7% for fluoroquinolones to 85.0% for piperacillin-tazobactam. Susceptibility rates were higher for blood isolates than for respiratory isolates (P < 0.05). Antibiotic combinations resulted in increased susceptibility rates but did not achieve the goal of 95% antibiotic coverage. Adding an aminoglycoside resulted in higher susceptibility rates than adding a fluoroquinolone; piperacillin-tazobactam plus an aminoglycoside resulted in the highest susceptibility rate (93.3%). Intensive care unit (ICU) isolates generally had lower susceptibility rates than non-ICU isolates. Commonly used antipseudomonal drugs, either alone or in combination, did not achieve 95% coverage against U.S. hospital P. aeruginosa isolates, suggesting that new drugs are needed to attain this goal. Local institutional use of combination antibiograms has the potential to optimize empirical therapy of infections caused by difficult-to-treat pathogens.
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32
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Heinz E, Ejaz H, Bartholdson Scott J, Wang N, Gujaran S, Pickard D, Wilksch J, Cao H, Haq IU, Dougan G, Strugnell RA. Resistance mechanisms and population structure of highly drug resistant Klebsiella in Pakistan during the introduction of the carbapenemase NDM-1. Sci Rep 2019; 9:2392. [PMID: 30787414 PMCID: PMC6382945 DOI: 10.1038/s41598-019-38943-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 01/11/2019] [Indexed: 11/25/2022] Open
Abstract
Klebsiella pneumoniae is a major threat to public health with the emergence of isolates resistant to most, if not all, useful antibiotics. We present an in-depth analysis of 178 extended-spectrum beta-lactamase (ESBL)-producing K. pneumoniae collected from patients resident in a region of Pakistan, during the period 2010-2012, when the now globally-distributed carbapenemase bla-NDM-1 was being acquired by Klebsiella. We observed two dominant lineages, but neither the overall resistance profile nor virulence-associated factors, explain their evolutionary success. Phenotypic analysis of resistance shows few differences between the acquisition of resistance genes and the phenotypic resistance profile, including beta-lactam antibiotics that were used to treat ESBL-positive strains. Resistance against these drugs could be explained by inhibitor-resistant beta-lactamase enzymes, carbapenemases or ampC type beta-lactamases, at least one of which was detected in most, but not all relevant strains analysed. Complete genomes for six selected strains are reported, these provide detailed insights into the mobile elements present in these isolates during the initial spread of NDM-1. The unexplained success of some lineages within this pool of highly resistant strains, and the discontinuity between phenotypic resistance and genotype at the macro level, indicate that intrinsic mechanisms contribute to competitive advantage and/or resistance.
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Affiliation(s)
- Eva Heinz
- Parasites and Microbes, Wellcome Trust Sanger Institute, Hinxton, CB10 1SA, UK.
| | - Hasan Ejaz
- Department of Clinical Laboratory Sciences, CAMS, Jouf University, Al-Jouf, Saudi Arabia
- Department of Microbiology and Immunology, The University of Melbourne, at Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
- Department of Microbiology, The Children's Hospital & The Institute of Child Health, Lahore, Pakistan
| | | | - Nancy Wang
- Department of Microbiology and Immunology, The University of Melbourne, at Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Shruti Gujaran
- Department of Microbiology and Immunology, The University of Melbourne, at Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Derek Pickard
- Parasites and Microbes, Wellcome Trust Sanger Institute, Hinxton, CB10 1SA, UK
| | - Jonathan Wilksch
- Department of Microbiology and Immunology, The University of Melbourne, at Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Hanwei Cao
- Department of Microbiology and Immunology, The University of Melbourne, at Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Ikram-Ul Haq
- Institute of Industrial Biotechnology, GC University, Lahore, Pakistan
| | - Gordon Dougan
- Parasites and Microbes, Wellcome Trust Sanger Institute, Hinxton, CB10 1SA, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Richard A Strugnell
- Department of Microbiology and Immunology, The University of Melbourne, at Peter Doherty Institute for Infection and Immunity, Melbourne, Australia.
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33
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Sheu CC, Chang YT, Lin SY, Chen YH, Hsueh PR. Infections Caused by Carbapenem-Resistant Enterobacteriaceae: An Update on Therapeutic Options. Front Microbiol 2019; 10:80. [PMID: 30761114 PMCID: PMC6363665 DOI: 10.3389/fmicb.2019.00080] [Citation(s) in RCA: 273] [Impact Index Per Article: 54.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 01/15/2019] [Indexed: 11/13/2022] Open
Abstract
Carbapenems are considered as last-resort antibiotics for the treatment of infections caused by multidrug-resistant Gram-negative bacteria. With the increasing use of carbapenems in clinical practice, the emergence of carbapenem-resistant pathogens now poses a great threat to human health. Currently, antibiotic options for the treatment of carbapenem-resistant Enterobacteriaceae (CRE) are very limited, with polymyxins, tigecycline, fosfomycin, and aminoglycosides as the mainstays of therapy. The need for new and effective anti-CRE therapies is urgent. Here, we describe the current understanding of issues related to CRE and review combination therapeutic strategies for CRE infections, including high-dose tigecycline, high-dose prolonged-infusion of carbapenem, and double carbapenem therapy. We also review the newly available antibiotics which have potential in the future treatment of CRE infections: ceftazidime/avibactam, which is active against KPC and OXA-48 producers; meropenem/vaborbactam, which is active against KPC producers; plazomicin, which is a next-generation aminoglycoside with in vitro activity against CRE; and eravacycline, which is a tetracycline class antibacterial with in vitro activity against CRE. Although direct evidence for CRE treatment is still lacking and the development of resistance is a concern, these new antibiotics provide additional therapeutic options for CRE infections. Finally, we review other potential anti-CRE antibiotics in development: imipenem/relebactam and cefiderocol. Currently, high-dose and combination strategies that may include the new β-lactam/β-lactamase inhibitors should be considered in severe CRE infections to maximize treatment success. In the future, when more treatment options are available, therapy for CRE infections should be individualized and based on molecular phenotypes of resistance, susceptibility profiles, disease severity, and patient characteristics. More high-quality studies are needed to guide effective treatment for infections caused by CRE.
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Affiliation(s)
- Chau-Chyun Sheu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,School of Medicine, Sepsis Research Institute, Graduate Institute of Medicine, Graduate Institute of Clinical Medicine, Center of Dengue Fever Control and Research, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ya-Ting Chang
- School of Medicine, Sepsis Research Institute, Graduate Institute of Medicine, Graduate Institute of Clinical Medicine, Center of Dengue Fever Control and Research, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Division of Infectious Disease, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Shang-Yi Lin
- School of Medicine, Sepsis Research Institute, Graduate Institute of Medicine, Graduate Institute of Clinical Medicine, Center of Dengue Fever Control and Research, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Division of Infectious Disease, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Yen-Hsu Chen
- School of Medicine, Sepsis Research Institute, Graduate Institute of Medicine, Graduate Institute of Clinical Medicine, Center of Dengue Fever Control and Research, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan.,Department of Biological Science and Technology, College of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan
| | - Po-Ren Hsueh
- Department of Laboratory Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
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