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Kaur JN, Klem JF, Liu Y, Boissonneault KR, Holden PN, Kreiswirth B, Chen L, Smith NM, Tsuji BT. Maximally precise combinations to overcome metallo-β-lactamase-producing Klebsiella pneumoniae. Antimicrob Agents Chemother 2024:e0077024. [PMID: 39287402 DOI: 10.1128/aac.00770-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 08/27/2024] [Indexed: 09/19/2024] Open
Abstract
Gram-negatives harboring metallo-β-lactamases (MBLs) and extended-spectrum β-lactamases (ESBLs) pose a substantial risk to the public health landscape. In ongoing efforts to combat these "superbugs," we explored the clinical combination of aztreonam and ceftazidime/avibactam together with varying dosages of polymyxin B and imipenem against Klebsiella pneumoniae (Kp CDC Nevada) in a 9-day hollow fiber infection model (HFIM). As previously reported by our group, although the base of aztreonam and ceftazidime/avibactam alone leads to 3.34 log10 fold reductions within 72 hours, addition of polymyxin B or imipenem to the base regimen caused maximal killing of 7.55 log10 and 7.4 log10 fold reduction, respectively, by the 72-hour time point. Although low-dose polymyxin B and imipenem enhanced the bactericidal activity as an adjuvant to aztreonam +ceftazidime/avibactam, regrowth to ~9 log10CFU/mL by 216 hours rendered these combinations ineffective. When aztreonam +ceftazidime/avibactam was supplemented with high-dose polymyxin B and or low-dose polymyxin B + imipenem, it resulted in effective long-term clearance of the bacterial population. Time lapse microscopy profiled the emergence of long filamentous cells in response to PBP3 binding due to aztreonam and ceftazidime. The emergence of spheroplasts via imipenem and damage to the outer membrane via polymyxin B was visualized as a mechanism of persister killing. Despite intrinsic mgrB and blaNDM-1 resistance, polymyxin B and β-lactam combinations represent a promising strategy. Future studies using an integrated molecularly precise pharmacodynamic approach are warranted to unravel the mechanistic details to propose optimal antibiotic combinations to combat untreatable, pan-drug-resistant Gram-negatives.
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Affiliation(s)
- Jan Naseer Kaur
- Center for Infectious Diseases Next Generation Therapeutics, University at Buffalo, Buffalo, New York, USA
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Jack F Klem
- Center for Infectious Diseases Next Generation Therapeutics, University at Buffalo, Buffalo, New York, USA
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Yang Liu
- Center for Infectious Diseases Next Generation Therapeutics, University at Buffalo, Buffalo, New York, USA
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | | | - Patricia N Holden
- Center for Infectious Diseases Next Generation Therapeutics, University at Buffalo, Buffalo, New York, USA
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Barry Kreiswirth
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Liang Chen
- Center for Infectious Diseases Next Generation Therapeutics, University at Buffalo, Buffalo, New York, USA
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Nicholas M Smith
- Center for Infectious Diseases Next Generation Therapeutics, University at Buffalo, Buffalo, New York, USA
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Brian T Tsuji
- Center for Infectious Diseases Next Generation Therapeutics, University at Buffalo, Buffalo, New York, USA
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
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Bulman ZP, Cao L, Curry BN, Biagi M, Vivo A, Suda KJ, Evans CT. Ceftazidime/avibactam alone or in combination with an aminoglycoside for treatment of carbapenem-resistant Enterobacterales infections: a retrospective cohort study. Int J Antimicrob Agents 2024:107321. [PMID: 39242050 DOI: 10.1016/j.ijantimicag.2024.107321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 08/21/2024] [Accepted: 08/29/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND Ceftazidime/avibactam is one of the preferred treatment options for carbapenem-resistant Enterobacterales (CRE). However, the benefit of combining ceftazidime/avibactam with another antibiotic remains unclear. OBJECTIVES To identify variables associated with treatment failure during the use of ceftazidime/avibactam for CRE infections and assess the effect of combining an aminoglycoside with ceftazidime/avibactam. METHODS This was a retrospective cohort study of patients with a positive CRE culture treated with ceftazidime/avibactam between 2015 and 2021 in 134 Veterans Affairs (VA) facilities. The primary outcome was 30-day mortality and the secondary outcome was in-hospital mortality. A subanalysis in patients who received an aminoglycoside was also performed. RESULTS A total of 303 patients were included. The overall 30-day and in-hospital mortality rates were 12.5% and 24.1%, respectively. Age (aOR 1.052, 95% CI 1.013-1.093), presence in the ICU (aOR 2.704, 95% CI 1.071-6.830), and receipt of an aminoglycoside prior to initiation of ceftazidime/avibactam (aOR 4.512, 95% CI 1.797-11.327) were independently associated with 30-day mortality. In the subgroup of patients that received an aminoglycoside (n=77), their use in combination with ceftazidime/avibactam had a 30-day mortality aOR of 0.321 (95% CI, 0.089-1.155). CONCLUSIONS In veterans treated with ceftazidime/avibactam for CRE infections, increased age, receipt of an empiric aminoglycoside, and presence in the ICU at the time of index culture were associated with higher 30-day mortality. Among patients who received an aminoglycoside, their use in combination with ceftazidime/avibactam trended toward protectiveness of 30-day mortality, suggesting a potential role for this combination to treat CRE infections in patients who are more severely ill.
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Affiliation(s)
- Zackery P Bulman
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL.
| | - Lishan Cao
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr VA Hospital, Hines, IL
| | - Brooke N Curry
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL
| | - Mark Biagi
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL
| | - Amanda Vivo
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr VA Hospital, Hines, IL
| | - Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, U.S. Department of Veterans Affairs, Pittsburgh, PA; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Charlesnika T Evans
- Center for Healthcare Studies and Department of Preventive Medicine Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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Smith NM, Boissonneault KR, Holden PN, Kaur JN, Klem JF, Cha R, Sutton MD, Tsuji BT. PBP-3 directed therapy in VIM-producing Pseudomonas aeruginosa creates bacterial transformers, persisters in disguise. Int J Antimicrob Agents 2024; 64:107260. [PMID: 38945177 DOI: 10.1016/j.ijantimicag.2024.107260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 05/03/2024] [Accepted: 06/16/2024] [Indexed: 07/02/2024]
Abstract
OBJECTIVES The proliferation of metallo-β-lactamase (MBL)-producing Pseudomonas aeruginosa represents a significant public health threat. P. aeruginosa undergoes significant phenotypic changes that drastically impair antibiotic efficacy. The objectives of this study were (1) to quantify the time-course of killing of VIM-2-producing P. aeruginosa in response to aztreonam-based therapies (including avibactam for coverage of AmpC), and (2) to document the capacity of P. aeruginosa to undergo morphological transformations that facilitate persistence. METHODS A well-characterised, clinical VIM-2-producing P. aeruginosa was studied in the hollow fibre infection model (HFIM) over 9 days (7 days of active antibiotic therapy, 2 days of treatment withdrawal) at a 107.5 CFU/mL starting inoculum. HFIM treatment arms included: growth control, aztreonam, ceftazidime/avibactam, aztreonam/ceftazidime/avibactam, polymyxin B, and aztreonam/ceftazidime/avibactam/polymyxin B. In addition, real-time imaging studies were conducted under static conditions to determine the time course of the reversion of persister cells. RESULTS There was a pronounced discrepancy between OD620 and bacterial counts obtained from plating methods (hereafter referred to as 'OD-count discrepancy'). For aztreonam monotherapy, observed counts were 0 CFU/mL by 120 h. Despite this, there was a significant OD-count discrepancy compared with the pre-treatment 0 h. Between therapy withdrawal at 168 h and 216 h, all arms with suppressed counts had regrown to the system-carrying capacity. Real-time imaging of the P. aeruginosa filaments after drug removal showed rapid reversion from a long, filamentous phenotype to many individual rods within 2 h. CONCLUSION Managing MBL-producing P. aeruginosa requires a multifaceted approach, focused on maximising killing and minimising proliferation of resistant and persistent subpopulations, which will involve eliminating drug-induced phenotypic transformers.
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Affiliation(s)
- Nicholas M Smith
- Division of Clinical and Translational Therapeutics, Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA.
| | - Katie Rose Boissonneault
- Division of Clinical and Translational Therapeutics, Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Patricia N Holden
- Division of Clinical and Translational Therapeutics, Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Jan Naseer Kaur
- Division of Clinical and Translational Therapeutics, Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Jack F Klem
- Division of Clinical and Translational Therapeutics, Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Raymond Cha
- Division of Clinical and Translational Therapeutics, Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Mark D Sutton
- Department of Biochemistry, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Brian T Tsuji
- Division of Clinical and Translational Therapeutics, Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA.
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Smith NM, Kaur H, Kaur R, Minoza T, Kent M, Barekat A, Lenhard JR. Influence of β-lactam pharmacodynamics on the systems microbiology of gram-positive and gram-negative polymicrobial communities. Front Pharmacol 2024; 15:1339858. [PMID: 38895629 PMCID: PMC11183306 DOI: 10.3389/fphar.2024.1339858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 05/06/2024] [Indexed: 06/21/2024] Open
Abstract
Objectives We sought to evaluate the pharmacodynamics of β-lactam antibacterials against polymicrobial communities of clinically relevant gram-positive and gram-negative pathogens. Methods Two Enterococcus faecalis isolates, two Staphylococcus aureus isolates, and three Escherichia coli isolates with varying β-lactamase production were evaluated in static time-killing experiments. Each gram-positive isolate was exposed to a concentration array of ampicillin (E. faecalis) or cefazolin (S. aureus) alone and during co-culture with an E. coli isolate that was β-lactamase-deficient, produced TEM-1, or produced KPC-3/TEM-1B. The results of the time-killing experiments were summarized using an integrated pharmacokinetic/pharmacodynamics analysis as well as mathematical modelling to fully characterize the antibacterial pharmacodynamics. Results In the integrated analysis, the maximum killing of ampicillin (Emax) against both E. faecalis isolates was ≥ 4.11 during monoculture experiments or co-culture with β-lactamase-deficient E. coli, whereas the Emax was reduced to ≤ 1.54 during co-culture with β-lactamase-producing E. coli. In comparison to monoculture experiments, culturing S. aureus with KPC-producing E. coli resulted in reductions of the cefazolin Emax from 3.25 and 3.71 down to 2.02 and 2.98, respectively. Two mathematical models were created to describe the interactions between E. coli and either E. faecalis or S. aureus. When in co-culture with E. coli, S. aureus experienced a reduction in its cefazolin Kmax by 24.8% (23.1%RSE). Similarly, β-lactamase-producing E. coli preferentially protected the ampicillin-resistant E. faecalis subpopulation, reducing Kmax,r by 90.1% (14%RSE). Discussion β-lactamase-producing E. coli were capable of protecting S. aureus and E. faecalis from exposure to β-lactam antibacterials.
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Affiliation(s)
- Nicholas M. Smith
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, United States
| | - Harpreet Kaur
- California Northstate University College of Pharmacy, Elk Grove, CA, United States
| | - Ravneet Kaur
- California Northstate University College of Pharmacy, Elk Grove, CA, United States
| | - Trisha Minoza
- California Northstate University College of Pharmacy, Elk Grove, CA, United States
| | - Michael Kent
- California Northstate University College of Pharmacy, Elk Grove, CA, United States
| | - Ayeh Barekat
- California Northstate University College of Pharmacy, Elk Grove, CA, United States
| | - Justin R. Lenhard
- California Northstate University College of Pharmacy, Elk Grove, CA, United States
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Petraitis V, Petraitiene R, Kavaliauskas P, Naing E, Garcia A, Zigmantaite V, Grigaleviciute R, Kucinskas A, Pockevicius A, Stakauskas R, Walsh TJ. Development of rabbit models of ventilator-associated bacterial pneumonia produced by carbapenem-resistant Pseudomonas aeruginosa. Antimicrob Agents Chemother 2024:e0020524. [PMID: 38687014 DOI: 10.1128/aac.00205-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 04/03/2024] [Indexed: 05/02/2024] Open
Abstract
Ventilator-associated bacterial pneumonia (VABP) is among the most intractable of carbapenem-resistant Gram-negative bacterial infections. New antimicrobial agents are critically needed for the treatment of VABP. However, current conventionally used animal model systems are inadequate to meet this challenge. We, therefore, developed rabbit models of VABP caused by carbapenem-resistant Pseudomonas aeruginosa. Persistently neutropenic New Zealand White rabbits were used throughout the study. The early-phase intubated model (0-24 h) received mechanical ventilation, while the late-phase intubated model (72-96 h) was ambulatory. The following outcome parameters were studied: survival, residual tissue bacterial burden (CFU/g), residual BAL bacterial burden (CFU/mL), lung weights, pulmonary lesion score, histology, O2 saturation, radiographic imaging, and histology. Each anesthetized rabbit received a predetermined endotracheal bacterial inoculum, and ventilators were set to FiO2 = 40% and PEEP = 8 mmHg. Within the first 12 h post-inoculation, mean bacterial burdens in lung tissue and BAL fluid, respectively, were established at approximately 107 CFU/g and 106 CFU/mL, persisted through 24 h in the early-phase model and increased in the late-phase model to approximately 108 CFU/g and 107 CFU/mL. Mean max SpO2 was ≥98 mmHg, and mean nadir SpO2 was ≥68 mmHg. Serial thoracic radiographs demonstrated progressive multilobar pneumonic infiltrates. Lung histology revealed progressive focal bronchopneumonia, coagulative necrosis, intra-alveolar hemorrhage, alveolar epithelial cell necrosis, and bacterial microcolonies. The new rabbit model of VABP produced by carbapenem-resistant Pseudomonas aeruginosa recapitulates the pathophysiological, microbiological, diagnostic imaging, and histological patterns of human disease by which to assess critically needed new antimicrobial agents against this lethal infection.
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Affiliation(s)
- Vidmantas Petraitis
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine of Cornell University, New York, New York, USA
- The Biological Research Center, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Ruta Petraitiene
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine of Cornell University, New York, New York, USA
| | - Povilas Kavaliauskas
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine of Cornell University, New York, New York, USA
- The Biological Research Center, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Ethan Naing
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine of Cornell University, New York, New York, USA
| | - Andrew Garcia
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine of Cornell University, New York, New York, USA
| | - Vilma Zigmantaite
- The Biological Research Center, Lithuanian University of Health Sciences, Kaunas, Lithuania
- Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Ramune Grigaleviciute
- The Biological Research Center, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Audrius Kucinskas
- The Biological Research Center, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Alius Pockevicius
- Department of Veterinary Pathobiology, Veterinary Academy, Pathology Center, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Rimantas Stakauskas
- The Biological Research Center, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Thomas J Walsh
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine of Cornell University, New York, New York, USA
- Center for Innovative Therapeutics and Diagnostics, Richmond, Virginia, USA
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6
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Smith NM, Nguyen TD, Lodise TP, Chen L, Kaur JN, Klem JF, Boissonneault KR, Holden PN, Roach DR, Tsuji BT. Machine Learning-Led Optimization of Combination Therapy: Confronting the Public Health Threat of Extensively Drug Resistant Gram-Negative Bacteria. Clin Pharmacol Ther 2024; 115:896-905. [PMID: 38062797 DOI: 10.1002/cpt.3134] [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: 09/22/2023] [Accepted: 11/28/2023] [Indexed: 12/22/2023]
Abstract
Developing optimized regimens for combination antibiotic therapy is challenging and often performed empirically over many clinical studies. Novel implementation of a hybrid machine-learning pharmacokinetic/pharmacodynamic/toxicodynamic (ML-PK/PD/TD) approach optimizes combination therapy using human PK/TD data along with in vitro PD data. This study utilized human population PK (PopPK) of aztreonam, ceftazidime/avibactam, and polymyxin B along with in vitro PDs from the Hollow Fiber Infection Model (HFIM) to derive optimal multi-drug regimens de novo through implementation of a genetic algorithm (GA). The mechanism-based PD model was constructed based on 7-day HFIM experiments across 4 clinical, extensively drug resistant Klebsiella pneumoniae isolates. GA-led optimization was performed using 13 different fitness functions to compare the effects of different efficacy (60%, 70%, 80%, or 90% of simulated subjects achieving bacterial counts of 102 CFU/mL) and toxicity (66% of simulated subjects having a target polymyxin B area under the concentration-time curve [AUC] of 100 mg·h/L and aztreonam AUC of 1,332 mg·h/L) on the optimized regimen. All regimens, except those most heavily weighted for toxicity prevention, were able to achieve the target efficacy threshold (102 CFU/mL). Overall, GA-based regimen optimization using preclinical data from animal-sparing in vitro studies and human PopPK produced clinically relevant dosage regimens similar to those developed empirically over many years for all three antibiotics. Taken together, these data provide significant insight into new therapeutic approaches incorporating ML to regimen design and treatment of resistant bacterial infections.
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Affiliation(s)
- Nicholas M Smith
- School of Pharmacy & Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Thomas D Nguyen
- School of Pharmacy & Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Thomas P Lodise
- Albany College of Pharmacy and Health Sciences, Troy, New York, USA
| | - Liang Chen
- Center for Discovery and Innovation, Hackensack-Meridian Health, Nutley, New Jersey, USA
| | - Jan Naseer Kaur
- School of Pharmacy & Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - John F Klem
- School of Pharmacy & Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | | | - Patricia N Holden
- School of Pharmacy & Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | | | - Brian T Tsuji
- School of Pharmacy & Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
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7
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Kaur JN, Singh N, Smith NM, Klem JF, Cha R, Lang Y, Chen L, Kreiswirth B, Holden PN, Bulitta JB, Tsuji BT. Next generation antibiotic combinations to combat pan-drug resistant Klebsiella pneumoniae. Sci Rep 2024; 14:3148. [PMID: 38326428 PMCID: PMC10850076 DOI: 10.1038/s41598-024-53130-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 01/29/2024] [Indexed: 02/09/2024] Open
Abstract
Antimicrobial resistance has emerged as one of the leading public health threats of the twenty-first century. Gram-negative pathogens have been a major contributor to the declining efficacy of antibiotics through both acquired resistance and tolerance. In this study, a pan-drug resistant (PDR), NDM-1 and CTX-M-15 co-producing isolate of K. pneumoniae, CDC Nevada, (Kp Nevada) was exposed to the clinical combination of aztreonam + ceftazidime/avibactam (ATM/CAZ/AVI) to overcome metallo-β-lactamases. Unexpectedly, the β-lactam combination resulted in long filamentous cell formation induced by PBP3 inhibition over 168 h in the hollow fiber infection model experiments with eventual reversion of the total population upon drug removal. However, the addition of imipenem to the two drug β-lactam combination was highly synergistic with suppression of all drug resistant subpopulations over 5 days. Scanning electron microscopy and fluorescence microscopy for all imipenem combinations in time kill studies suggested a role for imipenem in suppression of long filamentous persisters, via the formation of metabolically active spheroplasts. To complement the imaging studies, salient transcriptomic changes were quantified using RT-PCR and novel cassette assay evaluated β-lactam permeability. This showed significant upregulation of both spheroplast protein Y (SPY), a periplasmic chaperone protein that has been shown to be related to spheroplast formation, and penicillin binding proteins (PBP1, PBP2, PBP3) for all combinations involving imipenem. However, with aztreonam alone, pbp1, pbp3 and spy remained unchanged while pbp2 levels were downregulated by > 25%. Imipenem displayed 207-fold higher permeability as compared with aztreonam (mean permeability coefficient of 17,200 nm/s). Although the clinical combination of aztreonam/avibactam and ceftazidime has been proposed as an important treatment of MBL Gram-negatives, we report the first occurrence of long filamentous persister formation. To our knowledge, this is the first study that defines novel β-lactam combinations involving imipenem via maximal suppression of filamentous persisters to combat PDR CDC Nevada K. pneumoniae.
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Affiliation(s)
- Jan Naseer Kaur
- Center for Infectious Diseases Next Generation Therapeutics, University at Buffalo, Buffalo, NY, USA.
- Division of Clinical and Translational Therapeutics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA.
| | - Navaldeep Singh
- Center for Infectious Diseases Next Generation Therapeutics, University at Buffalo, Buffalo, NY, USA
- Division of Clinical and Translational Therapeutics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Nicholas M Smith
- Center for Infectious Diseases Next Generation Therapeutics, University at Buffalo, Buffalo, NY, USA
- Division of Clinical and Translational Therapeutics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Jack F Klem
- Center for Infectious Diseases Next Generation Therapeutics, University at Buffalo, Buffalo, NY, USA
- Division of Clinical and Translational Therapeutics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Raymond Cha
- Center for Infectious Diseases Next Generation Therapeutics, University at Buffalo, Buffalo, NY, USA
- Division of Clinical and Translational Therapeutics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Yinzhi Lang
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Liang Chen
- Center for Discovery and Innovation, Hackensack Meridian Health, Edison, NJ, USA
| | - Barry Kreiswirth
- Center for Discovery and Innovation, Hackensack Meridian Health, Edison, NJ, USA
| | - Patricia N Holden
- Center for Infectious Diseases Next Generation Therapeutics, University at Buffalo, Buffalo, NY, USA
- Division of Clinical and Translational Therapeutics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Jürgen B Bulitta
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Brian T Tsuji
- Center for Infectious Diseases Next Generation Therapeutics, University at Buffalo, Buffalo, NY, USA.
- Division of Clinical and Translational Therapeutics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA.
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8
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Smith NM, Nguyen TD, Chin WH, Sanborn JT, de Souza H, Ho BM, Luong T, Roach DR. A mechanism-based pathway toward administering highly active N-phage cocktails. Front Microbiol 2023; 14:1292618. [PMID: 38045026 PMCID: PMC10690594 DOI: 10.3389/fmicb.2023.1292618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 10/24/2023] [Indexed: 12/05/2023] Open
Abstract
Bacteriophage (phage) therapy is being explored as a possible response to the antimicrobial resistance public health emergency. Administering a mixture of different phage types as a cocktail is one proposed strategy for therapeutic applications, but the optimal method for formulating phage cocktails remains a major challenge. Each phage strain has complex pharmacokinetic/pharmacodynamic (PK/PD) properties which depend on the nano-scale size, target-mediated, self-dosing nature of each phage strain, and rapid selection of resistant subpopulations. The objective of this study was to explore the pharmacodynamics (PD) of three unique and clinically relevant anti-Pseudomonas phages after simulation of dynamic dosing strategies. The Hollow Fiber Infection Model (HFIM) is an in vitro system that mimics in vivo pharmacokinetics (PK) with high fidelity, providing an opportunity to quantify phage and bacteria concentration profiles over clinical time scales with rich sampling. Exogenous monotherapy-bolus (producing max concentrations of Cmax = 7 log10 PFU/mL) regimens of phages LUZ19, PYO2, and E215 produced Pseudomonas aeruginosa nadirs of 0, 2.14, or 2.99 log10 CFU/mL after 6 h of treatment, respectively. Exogenous combination therapy bolus regimens (LUZ19 + PYO2 or LUZ19 + E215) resulted in bacterial reduction to <2 log10 CFU/mL. In contrast, monotherapy as a continuous infusion (producing a steady-state concentration of Css,avg = 2 log10PFU/mL) was less effective at reducing bacterial densities. Specifically, PYO2 failed to reduce bacterial density. Next, a mechanism-based mathematical model was developed to describe phage pharmacodynamics, phage-phage competition, and phage-dependent adaptive phage resistance. Monte Carlo simulations supported bolus dose regimens, predicting lower bacterial counts with bolus dosing as compared to prolonged phage infusions. Together, in vitro and in silico evaluation of the time course of phage pharmacodynamics will better guide optimal patterns of administration of individual phages as a cocktail.
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Affiliation(s)
- Nicholas M. Smith
- Division of Clinical and Translational Therapeutics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, NY, United States
| | - Thomas D. Nguyen
- Division of Clinical and Translational Therapeutics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, NY, United States
| | - Wai Hoe Chin
- Department of Biology, San Diego State University, San Diego, CA, United States
| | - Jacob T. Sanborn
- Division of Clinical and Translational Therapeutics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, NY, United States
| | - Harriet de Souza
- Division of Clinical and Translational Therapeutics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, NY, United States
| | - Brian M. Ho
- Division of Clinical and Translational Therapeutics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, NY, United States
| | - Tiffany Luong
- Department of Biology, San Diego State University, San Diego, CA, United States
| | - Dwayne R. Roach
- Department of Biology, San Diego State University, San Diego, CA, United States
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Karvouniaris M, Almyroudi MP, Abdul-Aziz MH, Blot S, Paramythiotou E, Tsigou E, Koulenti D. Novel Antimicrobial Agents for Gram-Negative Pathogens. Antibiotics (Basel) 2023; 12:761. [PMID: 37107124 PMCID: PMC10135111 DOI: 10.3390/antibiotics12040761] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/08/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023] Open
Abstract
Gram-negative bacterial resistance to antimicrobials has had an exponential increase at a global level during the last decades and represent an everyday challenge, especially for the hospital practice of our era. Concerted efforts from the researchers and the industry have recently provided several novel promising antimicrobials, resilient to various bacterial resistance mechanisms. There are new antimicrobials that became commercially available during the last five years, namely, cefiderocol, imipenem-cilastatin-relebactam, eravacycline, omadacycline, and plazomicin. Furthermore, other agents are in advanced development, having reached phase 3 clinical trials, namely, aztreonam-avibactam, cefepime-enmetazobactam, cefepime-taniborbactam, cefepime-zidebactam, sulopenem, tebipenem, and benapenem. In this present review, we critically discuss the characteristics of the above-mentioned antimicrobials, their pharmacokinetic/pharmacodynamic properties and the current clinical data.
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Affiliation(s)
- Marios Karvouniaris
- Intensive Care Unit, AHEPA University Hospital, 546 36 Thessaloniki, Greece;
| | | | - Mohd Hafiz Abdul-Aziz
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QL 4029, Australia; (M.H.A.-A.); (S.B.)
| | - Stijn Blot
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QL 4029, Australia; (M.H.A.-A.); (S.B.)
- Department of Internal Medicine and Pediatrics, Ghent University, 9000 Ghent, Belgium
| | | | - Evdoxia Tsigou
- Intensive Care Department, ‘Aghioi Anargyroi’ Hospital of Kifissia, 145 64 Athens, Greece;
| | - Despoina Koulenti
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QL 4029, Australia; (M.H.A.-A.); (S.B.)
- Second Critical Care Department, Attikon University Hospital, 124 62 Athens, Greece;
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