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Khan M, Ma K, Wan I, Willcox MD. Ciprofloxacin resistance and tolerance of Pseudomonas aeruginosa ocular isolates. Cont Lens Anterior Eye 2023; 46:101819. [PMID: 36732125 DOI: 10.1016/j.clae.2023.101819] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 12/18/2022] [Accepted: 01/27/2023] [Indexed: 02/04/2023]
Abstract
PURPOSE Tolerance to antibiotics may occur due to changes in bacterial growth patterns and can be a precursor to development of resistance. However, there is a lack of information on the ability of ocular bacteria isolates to develop tolerance. This paper explores the tolerance to 8 different antibiotics of 61 microbial keratitis isolates of Pseudomonas aeruginosa from Australia and India using the MBC/MIC ratio, with tolerance defined by a ratio ≥ 32, and tolerance to ciprofloxacin by an agar diffusion assay. METHODS Antibiotics used were ciprofloxacin, levofloxacin, gentamicin, tobramycin, piperacillin, imipenem, ceftazidime and polymyxin B. Isolates were sourced from microbial keratitis infections in Australia and India. Minimum bactericidal and minimum inhibitory concentration (MBC and MIC) were obtained using broth microdilution and compared to breakpoints from the Clinical Laboratory Standards Institute (CLSI) and European Committee on Antimicrobial Susceptibility Testing (EUCAST) to determine bacterial susceptibility. Tolerance was assessed as MBC/MIC ≥ 32. An alternative method for tolerance detection (TD) was assessed with 13P. aeruginosa sensitive isolates by agar disk diffusion assay of ciprofloxacin followed by application of glucose to the agar and observation of re-growth of colonies. RESULTS Thirty-three isolates were resistant to imipenem, 20 to ciprofloxacin, 14 to tobramycin and piperacillin, 12 to levofloxacin and ceftazidime, 8 to gentamicin, and 5 to polymyxin B. The percentage of strains resistant to levofloxacin (7 vs 30 %; p = 0.023), gentamicin (0 vs 24 %; p = 0.005) and tobramycin (4 vs 33 %; p = 0.004) was significantly greater in isolates from India.On average, strains from India exhibited notably greater MIC and MBC values compared to strains obtained from Australia. Out of 61 isolates, none displayed an MBC/MIC ratio ≥ 32. However, three sensitive isolates had low tolerance, nine had medium tolerance and one had high tolerance to ciprofloxacin with the TDtest. CONCLUSIONS This study used two methods to determine whether P. aeruginosa strains could show tolerance to antibiotics. Using the MBC/MIC criteria no strain was considered tolerant to any of the eight antibiotics used. When 13 strains were tested for tolerance against ciprofloxacin, the most commonly used monotherapy for keratitis, one had high tolerance and nine had medium tolerance. This demonstrates the capacity of P. aeruginosa to develop tolerance which may result in therapeutic failures if inappropriate dosing regimens are used to treat keratitis.
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Affiliation(s)
- Mahjabeen Khan
- School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales 2052, Australia.
| | - Karen Ma
- School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales 2052, Australia
| | - Ingrid Wan
- School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales 2052, Australia
| | - Mark Dp Willcox
- School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales 2052, Australia
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Dörr T. Understanding tolerance to cell wall-active antibiotics. Ann N Y Acad Sci 2021; 1496:35-58. [PMID: 33274447 PMCID: PMC8359209 DOI: 10.1111/nyas.14541] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/02/2020] [Accepted: 11/04/2020] [Indexed: 12/19/2022]
Abstract
Antibiotic tolerance-the ability of bacteria to survive for an extended time in the presence of bactericidal antibiotics-is an understudied contributor to antibiotic treatment failure. Herein, I review the manifestations, mechanisms, and clinical relevance of tolerance to cell wall-active (CWA) antibiotics, one of the most important groups of antibiotics at the forefront of clinical use. I discuss definitions of tolerance and assays for tolerance detection, comprehensively discuss the mechanism of action of β-lactams and other CWA antibiotics, and then provide an overview of how cells mitigate the potentially lethal effects of CWA antibiotic-induced cell damage to become tolerant. Lastly, I discuss evidence for a role of CWA antibiotic tolerance in clinical antibiotic treatment failure.
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Affiliation(s)
- Tobias Dörr
- Weill Institute for Cell and Molecular Biology, Department of Microbiology, and Cornell Institute of Host–Pathogen Interactions and DiseaseCornell UniversityIthacaNew York
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3
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Liu Y, Yang K, Zhang H, Jia Y, Wang Z. Combating Antibiotic Tolerance Through Activating Bacterial Metabolism. Front Microbiol 2020; 11:577564. [PMID: 33193198 PMCID: PMC7642520 DOI: 10.3389/fmicb.2020.577564] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/25/2020] [Indexed: 12/18/2022] Open
Abstract
The emergence of antibiotic tolerance enables genetically susceptible bacteria to withstand the killing by clinically relevant antibiotics. As is reported, an increasing body of evidence sheds light on the critical and underappreciated role of antibiotic tolerance in the disease burden of bacterial infections. Considering this tense situation, new therapeutic strategies are urgently required for combating antibiotic tolerance. Herein, we provide an insightful illustration to distinguish between antibiotic resistance and tolerance, and highlight its clinical significance and complexities of drug-tolerant bacteria. Then, we discuss the close relationship between antibiotic tolerance and bacterial metabolism. As such, a bacterial metabolism-based approach was proposed to counter antibiotic tolerance. These exogenous metabolites including amino acids, tricarboxylic acid cycle (TCA cycle) metabolites, and nucleotides effectively activate bacterial metabolism and convert the tolerant cells to sensitive cells, and eventually restore antibiotic efficacy. A better understanding of molecular mechanisms of antibiotic tolerance particularly in vivo would substantially drive the development of novel strategies targeting bacterial metabolism.
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Affiliation(s)
- Yuan Liu
- College of Veterinary Medicine, Yangzhou University, Yangzhou, China.,Institute of Comparative Medicine, Yangzhou University, Yangzhou, China.,Jiangsu Co-innovation Center for Prevention and Control of Important Animal Infectious Diseases and Zoonoses, Yangzhou University, Yangzhou, China.,Joint International Research Laboratory of Agriculture and Agri-Product Safety, The Ministry of Education of China, Yangzhou University, Yangzhou, China
| | - Kangni Yang
- College of Veterinary Medicine, Yangzhou University, Yangzhou, China
| | - Haijie Zhang
- College of Veterinary Medicine, Yangzhou University, Yangzhou, China
| | - Yuqian Jia
- College of Veterinary Medicine, Yangzhou University, Yangzhou, China
| | - Zhiqiang Wang
- College of Veterinary Medicine, Yangzhou University, Yangzhou, China.,Jiangsu Co-innovation Center for Prevention and Control of Important Animal Infectious Diseases and Zoonoses, Yangzhou University, Yangzhou, China.,Joint International Research Laboratory of Agriculture and Agri-Product Safety, The Ministry of Education of China, Yangzhou University, Yangzhou, China
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Kuehl R, Morata L, Meylan S, Mensa J, Soriano A. When antibiotics fail: a clinical and microbiological perspective on antibiotic tolerance and persistence of Staphylococcus aureus. J Antimicrob Chemother 2020; 75:1071-1086. [PMID: 32016348 DOI: 10.1093/jac/dkz559] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Staphylococcus aureus is a major human pathogen causing a vast array of infections with significant mortality. Its versatile physiology enables it to adapt to various environments. Specific physiological changes are thought to underlie the frequent failure of antimicrobial therapy despite susceptibility in standard microbiological assays. Bacteria capable of surviving high antibiotic concentrations despite having a genetically susceptible background are described as 'antibiotic tolerant'. In this review, we put current knowledge on environmental triggers and molecular mechanisms of increased antibiotic survival of S. aureus into its clinical context. We discuss animal and clinical evidence of its significance and outline strategies to overcome infections with antibiotic-tolerant S. aureus.
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Affiliation(s)
- Richard Kuehl
- Service of Infectious Diseases, Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, Barcelona, Spain
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Laura Morata
- Service of Infectious Diseases, Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Sylvain Meylan
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
- Division de Maladies Infectieuses, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Josep Mensa
- Service of Infectious Diseases, Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Alex Soriano
- Service of Infectious Diseases, Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, Barcelona, Spain
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Abstract
Antibiotic tolerance and persistence are often associated with treatment failure and relapse, yet are poorly characterized. In distinction from resistance, which is measured using the minimum inhibitory concentration metric, tolerance and persistence values are not currently evaluated in the clinical setting, and so are overlooked when a course of treatment is prescribed. In this article, we introduce a metric and an automated experimental framework for measuring tolerance and persistence. The tolerance metric is the minimum duration for killing 99% of the population, MDK99, which can be evaluated by a statistical analysis of measurements performed manually or using a robotic system. We demonstrate the technique on strains of Escherichia coli with various tolerance levels. We hope that this, to our knowledge, new approach will be used, along with the existing minimum inhibitory concentration, as a standard for the in vitro characterization of sensitivity to antimicrobials. Quantification of tolerance and persistence may provide vital information in healthcare, and aid research in the field.
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Britt NS, Patel N, Shireman TI, El Atrouni WI, Horvat RT, Steed ME. Relationship between vancomycin tolerance and clinical outcomes in Staphylococcus aureus bacteraemia. J Antimicrob Chemother 2016; 72:535-542. [PMID: 27999028 DOI: 10.1093/jac/dkw453] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 09/18/2016] [Accepted: 09/23/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Previous data have demonstrated the clinical importance of vancomycin MIC values in Staphylococcus aureus bacteraemia (SAB); however, the impact of vancomycin tolerance (VT) is unknown. OBJECTIVES To compare the frequency of clinical failure between patients with VT and non-VT isolates in SAB. METHODS This was a retrospective cohort study of patients with SAB, excluding treatment <48 h or polymicrobial bacteraemia. The primary outcome was clinical failure (composite of 30 day mortality, non-resolving signs and symptoms, and 60 day recurrence). Vancomycin MIC and MBC were determined by broth microdilution. The association between VT (MBC/MIC ≥32) and clinical failure was evaluated by multivariable Poisson regression. RESULTS Of the 225 patients, 26.7% had VT isolates. VT was associated with clinical failure (48.0% overall) in unadjusted analysis [68.3% (n = 41/60) versus 40.6% (n = 67/165); P < 0.001] and this relationship persisted in multivariable analysis (adjusted risk ratio, 1.74; 95% CI, 1.36-2.24; P < 0.001). The association between VT and clinical failure was also consistent within strata of methicillin susceptibility [methicillin susceptible (n = 125, risk ratio, 1.67; 95% CI, 1.20-2.32; P = 0.002); methicillin resistant (n = 100, risk ratio, 1.69; 95% CI, 1.14-2.51; P = 0.010)]. Among methicillin-susceptible SAB cases treated with β-lactam therapy, VT remained associated with clinical failure (risk ratio, 1.77; 95% CI, 1.19-2.61; P = 0.004). CONCLUSIONS VT was associated with clinical failure in SAB, irrespective of methicillin susceptibility or definitive treatment. VT may decrease the effectiveness of cell-wall-active therapy or be a surrogate marker of some other pathogen-specific factor associated with poor outcomes. Future research should evaluate if bactericidal non-cell-wall-active agents improve outcomes in VT SAB.
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Affiliation(s)
- Nicholas S Britt
- Department of Pharmacy Practice, University of Kansas School of Pharmacy, 2010 Becker Drive, Lawrence, KS, USA.,Department of Preventive Medicine and Public Health, University of Kansas School of Medicine, 3901 Rainbow Boulevard, Kansas City, KS, USA
| | - Nimish Patel
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, 106 New Scotland Avenue, Albany, NY, USA
| | - Theresa I Shireman
- Department of Preventive Medicine and Public Health, University of Kansas School of Medicine, 3901 Rainbow Boulevard, Kansas City, KS, USA
| | - Wissam I El Atrouni
- Department of Medicine, Division of Infectious Diseases, University of Kansas School of Medicine, 3901 Rainbow Boulevard, Kansas City, KS, USA
| | - Rebecca T Horvat
- Department of Pathology and Laboratory Medicine, University of Kansas School of Medicine, 3901 Rainbow Boulevard, Kansas City, KS, USA
| | - Molly E Steed
- Department of Pharmacy Practice, University of Kansas School of Pharmacy, 2010 Becker Drive, Lawrence, KS, USA
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Distinguishing between resistance, tolerance and persistence to antibiotic treatment. Nat Rev Microbiol 2016; 14:320-30. [DOI: 10.1038/nrmicro.2016.34] [Citation(s) in RCA: 816] [Impact Index Per Article: 102.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Lodise TP, Drusano GL, Lazariu V, El-Fawal N, Evans A, Graffunder E, Stellrecht K, Mendes RE, Jones RN, Cosler L, McNutt LA. Quantifying the matrix of relationships between reduced vancomycin susceptibility phenotypes and outcomes among patients with MRSA bloodstream infections treated with vancomycin . J Antimicrob Chemother 2014; 69:2547-55. [PMID: 24840624 DOI: 10.1093/jac/dku135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES Several phenotypic characteristics of Staphylococcus aureus have been identified as aetiological factors responsible for adverse outcomes among patients receiving vancomycin. However, characterization of the outcomes associated with these reduced vancomycin susceptibility phenotypes (rVSPs) remains largely incomplete and it is unknown if these features contribute to deleterious treatment outcomes alone or in concert. This study described the interrelationship between rVSPs and assessed their individual and combined effects on outcomes among patients who received vancomycin for a methicillin-resistant S. aureus (MRSA) bloodstream infection. METHODS An observational study of adult, hospitalized patients with MRSA bloodstream infections who were treated with vancomycin between January 2005 and June 2009 was performed. The rVSPs evaluated included the following: (i) Etest MIC; (ii) broth microdilution MIC; (iii) MBC : MIC ratio; and (iv) heteroresistance to vancomycin by the Etest macromethod. Failure was defined as any of the following: (i) 30 day mortality; (ii) bacteraemia ≥ 7 days on therapy; or (iii) recurrence of MRSA bacteraemia within 60 days of therapy discontinuation. RESULTS During the study period, 184 cases met the study criteria and 41.3% met the failure criteria. There was a clear linear exposure-response relationship between the number of these phenotypic markers and outcomes. As the number of phenotypes escalated, the incidence of overall failure increased incrementally by 10%-18%. CONCLUSIONS The data suggest that rVSPs contribute to deleterious treatment outcomes in concert.
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Affiliation(s)
- T P Lodise
- Albany College of Pharmacy and Health Sciences, 106 New Scotland Avenue, Albany, NY, USA
| | - G L Drusano
- Institute for Therapeutic Innovation, College of Medicine, University of Florida, 6550 Sanger Road, Lake Nona, FL, USA
| | - V Lazariu
- University at Albany, State University of New York, Albany, 5 University Place, A217, Rensselaer, NY, USA
| | - N El-Fawal
- Albany College of Pharmacy and Health Sciences, 106 New Scotland Avenue, Albany, NY, USA
| | - A Evans
- Albany Medical Center Hospital, Department of Pathology and Laboratory Medicine, 43 New Scotland Avenue, Albany, NY, USA
| | - E Graffunder
- Albany Medical Center Hospital, Department of Epidemiology, 43 New Scotland Avenue, Albany, NY, USA
| | - K Stellrecht
- Albany Medical Center Hospital, Department of Pathology and Laboratory Medicine, 43 New Scotland Avenue, Albany, NY, USA
| | - R E Mendes
- JMI Laboratories, 345 Beaver Kreek Ctr, Ste A, North Liberty, IA, USA
| | - R N Jones
- JMI Laboratories, 345 Beaver Kreek Ctr, Ste A, North Liberty, IA, USA
| | - L Cosler
- Institute for Therapeutic Innovation, College of Medicine, University of Florida, 6550 Sanger Road, Lake Nona, FL, USA
| | - L A McNutt
- University at Albany, State University of New York, Albany, 5 University Place, A217, Rensselaer, NY, USA
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Comparative in vitro activities of daptomycin, vancomycin, teicoplanin and linezolid against resistant Gram-positive bacterial isolates from two large centres in western India. Int J Antimicrob Agents 2012; 40:567-9. [PMID: 22947124 DOI: 10.1016/j.ijantimicag.2012.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Revised: 07/15/2012] [Accepted: 07/17/2012] [Indexed: 11/22/2022]
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10
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Chang HJ, Hsu PC, Yang CC, Siu LK, Kuo AJ, Chia JH, Wu TL, Huang CT, Lee MH. Influence of teicoplanin MICs on treatment outcomes among patients with teicoplanin-treated methicillin-resistant Staphylococcus aureus bacteraemia: a hospital-based retrospective study. J Antimicrob Chemother 2011; 67:736-41. [PMID: 22169187 DOI: 10.1093/jac/dkr531] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES Higher vancomycin MIC values (≥1.5 mg/L via Etest) may be associated with vancomycin treatment failure among patients with serious methicillin-resistant Staphylococcus aureus (MRSA) infections. As there were limited similar data for teicoplanin, this retrospective cohort study intended to determine the predictive value of teicoplanin MICs for treatment failure among patients with MRSA bacteraemia. PATIENTS AND METHODS All patients with at least one blood culture positive for MRSA admitted to the hospital between January 2010 and January 2011 were reviewed. Patients with an age ≥18 years and receipt of teicoplanin therapy throughout the course or receipt of <72 h of vancomycin therapy and then teicoplanin for >3 days were enrolled. Teicoplanin Etest(®) MICs and treatment outcomes for MRSA bacteraemia were reviewed to identify the breakpoint of teicoplanin MICs influencing treatment outcomes. RESULTS Of the 101 patients enrolled, 56 had a lower teicoplanin MIC (≤1.5 mg/L) for MRSA and 45 had a higher MIC (>1.5 mg/L) for MRSA. A lower teicoplanin MIC was associated with a favourable outcome [37 (66.1%) versus 13 (28.9%); P<0.001] and a lower rate of bloodstream infection-related mortality [15 (26.8%) versus 22 (48.9%); P=0.022]. Patients with chronic obstructive pulmonary disease, bacteraemic pneumonia or higher Pittsburgh bacteraemia score had an unfavourable outcome (P=0.028, 0.022 and <0.001, respectively). Multivariate analysis showed that teicoplanin MIC >1.5 mg/L, higher Pittsburgh bacteraemia score and bacteraemic pneumonia were independent risk factors for unfavourable outcome. CONCLUSIONS A higher teicoplanin MIC value (>1.5 mg/L) may predict an unfavourable outcome and higher mortality rate among teicoplanin-treated MRSA bacteraemic patients.
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Affiliation(s)
- Hong-Jyun Chang
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
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