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Valzano F, La Bella G, Lopizzo T, Curci A, Lupo L, Morelli E, Mosca A, Marangi M, Melfitano R, Rollo T, De Nittis R, Arena F. Resistance to ceftazidime-avibactam and other new β-lactams in Pseudomonas aeruginosa clinical isolates: a multi-center surveillance study. Microbiol Spectr 2024; 12:e0426623. [PMID: 38934607 PMCID: PMC11302676 DOI: 10.1128/spectrum.04266-23] [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: 01/10/2024] [Accepted: 06/09/2024] [Indexed: 06/28/2024] Open
Abstract
New β-lactam-β-lactamase inhibitor combinations represent last-resort antibiotics to treat infections caused by multidrug-resistant Pseudomonas aeruginosa. Carbapenemase gene acquisition can limit their spectrum of activity, and reports of resistance toward these new molecules are increasing. In this multi-center study, we evaluated the prevalence of resistance to ceftazidime-avibactam (CZA) and comparators among P. aeruginosa clinical isolates from bloodstream infections, hospital-acquired or ventilator-associated pneumonia, and urinary tract infections, circulating in Southern Italy. We also investigated the clonality and content of relevant β-lactam resistance mechanisms of CZA-resistant (CZAR) isolates. A total of 120 P. aeruginosa isolates were collected. CZA was among the most active β-lactams, retaining susceptibility in the 81.7% of cases, preceded by cefiderocol (95.8%) and followed by ceftolozane-tazobactam (79.2%), meropenem-vaborbactam (76.1%), imipenem-relebactam (75%), and aztreonam (69.6%). Among non-β-lactams, colistin and amikacin were active against 100% and 85.8% of isolates respectively. In CZAR strains subjected to whole-genome sequencing (n = 18), resistance was mainly due to the expression of metallo-β-lactamases (66.6% VIM-type and 5.5% FIM-1), followed by PER-1 (16.6%) and GES-1 (5.5%) extended-spectrum β-lactamases, mostly carried by international high-risk clones (ST111 and ST235). Of note, two strains producing the PER-1 enzyme were resistant to all β-lactams, including cefiderocol. In conclusion, the CZA resistance rate among P. aeruginosa clinical isolates in Southern Italy remained low. CZAR isolates were mostly metallo-β-lactamases producers and belonging to ST111 and ST253 epidemic clones. It is important to implement robust surveillance systems to monitor emergence of new resistance mechanisms and to limit the spread of P. aeruginosa high-risk clones. IMPORTANCE Multidrug-resistant Pseudomonas aeruginosa infections are a growing threat due to the limited therapeutic options available. Ceftazidime-avibactam (CZA) is among the last-resort antibiotics for the treatment of difficult-to-treat P. aeruginosa infections, although resistance due to the acquisition of transferable β-lactamase genes is increasing. With this work, we report that CZA represents a highly active antipseudomonal β-lactam compound (after cefiderocol), and that metallo-β-lactamases (VIM-type) and extended-spectrum β-lactamases (GES and PER-type) production is the major factor underlying CZA resistance in isolates from Southern Italian hospitals. In addition, we reported that such resistance mechanisms were mainly carried by the international high-risk clones ST111 and ST235.
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Affiliation(s)
- Felice Valzano
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Gianfranco La Bella
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
- Istituto Zooprofilattico Sperimentale della Puglia e della Basilicata, Foggia, Italy
| | - Teresa Lopizzo
- Clinical Pathology and Microbiology Unit, AOR San Carlo, Potenza, Italy
| | - Anna Curci
- Clinical Pathology and Microbiology Unit, AOR San Carlo, Potenza, Italy
| | - Laura Lupo
- Clinical Pathology and Microbiology Unit, Vito Fazzi Hospital, Lecce, Italy
| | | | - Adriana Mosca
- Department of Interdisciplinary Medicine, Microbiology Section, University of Bari Aldo Moro, Bari, Italy
| | - Marianna Marangi
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | | | - Tiziana Rollo
- Microbiology and Virology Unit, AOU Policlinico Riuniti, Foggia, Italy
| | - Rosella De Nittis
- Microbiology and Virology Unit, AOU Policlinico Riuniti, Foggia, Italy
| | - Fabio Arena
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
- Microbiology and Virology Unit, AOU Policlinico Riuniti, Foggia, Italy
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Florence, Italy
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Fratoni AJ, Gethers ML, Nicolau DP, Kuti JL. Non-KPC Attributes of Newer β-lactam/β-lactamase Inhibitors, Part 1: Enterobacterales and Pseudomonas aeruginosa. Clin Infect Dis 2024; 79:33-42. [PMID: 38306487 DOI: 10.1093/cid/ciae048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 12/15/2023] [Accepted: 01/30/2024] [Indexed: 02/04/2024] Open
Abstract
Gram-negative antibiotic resistance continues to grow as a global problem due to the evolution and spread of β-lactamases. The early β-lactamase inhibitors (BLIs) are characterized by spectra limited to class A β-lactamases and ineffective against carbapenemases and most extended spectrum β-lactamases. In order to address this therapeutic need, newer BLIs were developed with the goal of treating carbapenemase producing, carbapenem resistant organisms (CRO), specifically targeting the Klebsiella pneumoniae carbapenemase (KPC). These BL/BLI combination drugs, avibactam/avibactam, meropenem/vaborbactam, and imipenem/relebactam, have proven to be indispensable tools in this effort. However, non-KPC mechanisms of resistance are rising in prevalence and increasingly challenging to treat. It is critical for clinicians to understand the unique spectra of these BL/BLIs with respect to non-KPC CRO. In Part 1of this 2-part series, we describe the non-KPC attributes of the newer BL/BLIs with a focus on utility against Enterobacterales and Pseudomonas aeruginosa.
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Affiliation(s)
- Andrew J Fratoni
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
| | - Matthew L Gethers
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
- Division of Infectious Diseases, Hartford Hospital, Hartford, Connecticut, USA
| | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
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Koenig C, Kuti JL. Evolving resistance landscape in gram-negative pathogens: An update on β-lactam and β-lactam-inhibitor treatment combinations for carbapenem-resistant organisms. Pharmacotherapy 2024. [PMID: 38949413 DOI: 10.1002/phar.2950] [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: 04/05/2024] [Revised: 05/24/2024] [Accepted: 05/25/2024] [Indexed: 07/02/2024]
Abstract
Antibiotic resistance has become a global threat as it is continuously growing due to the evolution of β-lactamases diminishing the activity of classic β-lactam (BL) antibiotics. Recent antibiotic discovery and development efforts have led to the availability of β-lactamase inhibitors (BLIs) with activity against extended-spectrum β-lactamases as well as Klebsiella pneumoniae carbapenemase (KPC)-producing carbapenem-resistant organisms (CRO). Nevertheless, there is still a lack of drugs that target metallo-β-lactamases (MBL), which hydrolyze carbapenems efficiently, and oxacillinases (OXA) often present in carbapenem-resistant Acinetobacter baumannii. This review aims to provide a snapshot of microbiology, pharmacology, and clinical data for currently available BL/BLI treatment options as well as agents in late stage development for CRO harboring various β-lactamases including MBL and OXA-enzymes.
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Affiliation(s)
- Christina Koenig
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
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Miller WR, Arias CA. ESKAPE pathogens: antimicrobial resistance, epidemiology, clinical impact and therapeutics. Nat Rev Microbiol 2024:10.1038/s41579-024-01054-w. [PMID: 38831030 DOI: 10.1038/s41579-024-01054-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 06/05/2024]
Abstract
The rise of antibiotic resistance and a dwindling antimicrobial pipeline have been recognized as emerging threats to public health. The ESKAPE pathogens - Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter spp. - were initially identified as critical multidrug-resistant bacteria for which effective therapies were rapidly needed. Now, entering the third decade of the twenty-first century, and despite the introduction of several new antibiotics and antibiotic adjuvants, such as novel β-lactamase inhibitors, these organisms continue to represent major therapeutic challenges. These bacteria share several key biological features, including adaptations for survival in the modern health-care setting, diverse methods for acquiring resistance determinants and the dissemination of successful high-risk clones around the world. With the advent of next-generation sequencing, novel tools to track and combat the spread of these organisms have rapidly evolved, as well as renewed interest in non-traditional antibiotic approaches. In this Review, we explore the current epidemiology and clinical impact of this important group of bacterial pathogens and discuss relevant mechanisms of resistance to recently introduced antibiotics that affect their use in clinical settings. Furthermore, we discuss emerging therapeutic strategies needed for effective patient care in the era of widespread antimicrobial resistance.
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Affiliation(s)
- William R Miller
- Department of Internal Medicine, Division of Infectious Diseases, Houston Methodist Hospital, Houston, TX, USA
- Center for Infectious Diseases, Houston Methodist Research Institute, Houston, TX, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Cesar A Arias
- Department of Internal Medicine, Division of Infectious Diseases, Houston Methodist Hospital, Houston, TX, USA.
- Center for Infectious Diseases, Houston Methodist Research Institute, Houston, TX, USA.
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
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Karlowsky JA, Lob SH, Siddiqui F, Polis T, Vallejo JL, Young K, Motyl MR, Sahm DF. Activity of ceftolozane/tazobactam and imipenem/relebactam against Gram-negative clinical isolates collected in Mexico-SMART 2017-2021. JAC Antimicrob Resist 2024; 6:dlae077. [PMID: 38799180 PMCID: PMC11126326 DOI: 10.1093/jacamr/dlae077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 05/02/2024] [Indexed: 05/29/2024] Open
Abstract
Objectives To investigate the activities of ceftolozane/tazobactam and imipenem/relebactam against Escherichia coli, Klebsiella pneumoniae and Pseudomonas aeruginosa isolated from hospitalized patients in Mexico in 2017-2021. Methods MICs were determined by CLSI broth microdilution and interpreted using CLSI M100 breakpoints. β-Lactamase genes were identified in ceftolozane/tazobactam-, imipenem/relebactam-, and/or imipenem-non-susceptible isolates. Results Ceftolozane/tazobactam and imipenem/relebactam inhibited 89% and 99% of E. coli isolates (n = 2337), and 87% and 94% of K. pneumoniae isolates (n = 1127). Sixty-four percent of E. coli and 47% of K. pneumoniae had an ESBL non-carbapenem-resistant Enterobacterales (ESBL non-CRE) phenotype. Eighty-six percent and 91% of ESBL non-CRE E. coli and K. pneumoniae were ceftolozane/tazobactam susceptible, and 99.9% and 99.8% were imipenem/relebactam susceptible. Ceftolozane/tazobactam was the most active agent studied against P. aeruginosa (n = 1068; 83% susceptible), 9-28 percentage points higher than carbapenems and comparator β-lactams excluding imipenem/relebactam (78% susceptible). Ceftolozane/tazobactam remained active against 35%-58%, and imipenem/relebactam against 32%-42%, of P. aeruginosa in meropenem-, piperacillin/tazobactam-, and cefepime-non-susceptible subsets. The majority of isolates of ceftolozane/tazobactam-non-susceptible E. coli carried an ESBL, whereas among ceftolozane/tazobactam-non-susceptible K. pneumoniae and P. aeruginosa, the majority carried carbapenemases. The most prevalent carbapenemase observed among E. coli (estimated at 0.7% of all isolates), K. pneumoniae (4.8%) and P. aeruginosa (10.0%) was an MBL. Almost all imipenem/relebactam-non-susceptible E. coli and K. pneumoniae carried MBL or OXA-48-like carbapenemases, whereas among imipenem/relebactam-non-susceptible P. aeruginosa, 56% carried MBL or GES carbapenemases. Conclusions Ceftolozane/tazobactam and imipenem/relebactam may provide treatment options for patients infected with β-lactam-non-susceptible Gram-negative bacilli, excluding isolates carrying an MBL- or OXA-48-like carbapenemase.
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Affiliation(s)
- James A Karlowsky
- IHMA, 2122 Palmer Drive, Schaumburg, IL 60173, USA
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, Room 543—745 Bannatyne Avenue, University of Manitoba, Winnipeg, MB R3E 0J9, Canada
| | | | - Fakhar Siddiqui
- Merck & Co., Inc., 126 East Lincoln Avenue, Rahway, NJ 07065, USA
| | - Thales Polis
- MSD Brasil, Av. Chucri Zaidan, 296—Vila Cordeiro, São Paulo 04583-110, Brazil
| | - Jose L Vallejo
- MSD Mexico, Av. San Jerónimo 369, Tizapán San Ángel, Tizapán, Álvaro Obregón, 01090 Mexico City, Mexico
| | - Katherine Young
- Merck & Co., Inc., 126 East Lincoln Avenue, Rahway, NJ 07065, USA
| | - Mary R Motyl
- Merck & Co., Inc., 126 East Lincoln Avenue, Rahway, NJ 07065, USA
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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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Oves M, Khan MS, Al-Shaeri M, Khan MS. Antifungal potential of multi-drug-resistant Pseudomonas aeruginosa: harnessing pyocyanin for candida growth inhibition. Front Cell Infect Microbiol 2024; 14:1375872. [PMID: 38846355 PMCID: PMC11155300 DOI: 10.3389/fcimb.2024.1375872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/11/2024] [Indexed: 06/09/2024] Open
Abstract
Introduction Pseudomonas aeruginosa is notorious for its multidrug resistance and its involvement in hospital-acquired infections. In this study, 20 bacterial strains isolated from soil samples near the Hindan River in Ghaziabad, India, were investigated for their biochemical and morphological characteristics, with a focus on identifying strains with exceptional drug resistance and pyocyanin production. Methods The isolated bacterial strains were subjected to biochemical and morphological analyses to characterize their properties, with a particular emphasis on exopolysaccharide production. Strain GZB16/CEES1, exhibiting remarkable drug resistance and pyocyanin production. Biochemical and molecular analyses, including sequencing of its 16S rRNA gene (accession number LN735036.1), plasmid-curing assays, and estimation of plasmid size, were conducted to elucidate its drug resistance mechanisms and further pyocynin based target the Candida albicans Strain GZB16/CEES1 demonstrated 100% resistance to various antibiotics used in the investigation, with plasmid-curing assays, suggesting plasmid-based resistance gene transmission. The plasmid in GZB16/CEES1 was estimated to be approximately 24 kb in size. The study focused on P. aeruginosa's pyocyanin production, revealing its association with anticandidal activity. The minimum inhibitory concentration (MIC) of the bacterial extract against Candida albicans was 50 μg/ml, with a slightly lower pyocyanin-based MIC of 38.5 μg/ml. Scanning electron microscopy illustrated direct interactions between P. aeruginosa strains and Candida albicans cells, leading to the destruction of the latter. Discussion These findings underscore the potential of P. aeruginosa in understanding microbial interactions and developing strategies to combat fungal infections. The study highlights the importance of investigating bacterial-fungal interactions and the role of pyocyanin in antimicrobial activity. Further research in this area could lead to the development of novel therapeutic approaches for combating multidrug-resistant infections.
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Affiliation(s)
- Mohammad Oves
- Center of Excellence in Environmental Studies, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohd Shahnawaz Khan
- Protein Research Chair, Department of Biochemistry, College of Science, King Saud University, Riyadh, Saudi Arabia
| | - Majed Al-Shaeri
- Department of Biological Science, Faculty of Science, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohammad Saghir Khan
- Department of Agricultural Microbiology, Faculty of Agricultural Science, Aligarh Muslim University, Aligarh, India
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Fimbres-García JO, Flores-Sauceda M, Othón-Díaz ED, García-Galaz A, Tapia-Rodriguez MR, Silva-Espinoza BA, Alvarez-Armenta A, Ayala-Zavala JF. Lippia graveolens Essential Oil to Enhance the Effect of Imipenem against Axenic and Co-Cultures of Pseudomonas aeruginosa and Acinetobacter baumannii. Antibiotics (Basel) 2024; 13:444. [PMID: 38786172 PMCID: PMC11117758 DOI: 10.3390/antibiotics13050444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 05/08/2024] [Accepted: 05/11/2024] [Indexed: 05/25/2024] Open
Abstract
This research focuses on assessing the synergistic effects of Mexican oregano (Lippia graveolens) essential oil or carvacrol when combined with the antibiotic imipenem, aiming to reduce the pathogenic viability and virulence of Acinetobacter baumannii and Pseudomonas aeruginosa. The study highlighted the synergistic effect of combining L. graveolens essential oil or carvacrol with imipenem, significantly reducing the required doses for inhibiting bacterial growth. The combination treatments drastically lowered the necessary imipenem doses, highlighting a potent enhancement in efficacy against A. baumannii and P. aeruginosa. For example, the minimum inhibitory concentrations (MIC) for the essential oil/imipenem combinations were notably low, at 0.03/0.000023 mg/mL for A. baumannii and 0.0073/0.000023 mg/mL for P. aeruginosa. Similarly, the combinations significantly inhibited biofilm formation at lower concentrations than when the components were used individually, demonstrating the strategic advantage of this approach in combating antibiotic resistance. For OXA-51, imipenem showed a relatively stable interaction during 30 ns of dynamic simulation of their interaction, indicating changes (<2 nm) in ligand positioning during this period. Carvacrol exhibited similar fluctuations to imipenem, suggesting its potential inhibition efficacy, while thymol showed significant variability, particularly at >10 ns, suggesting potential instability. With IMP-1, imipenem also displayed very stable interactions during 38 ns and demonstrated notable movement and positioning changes within the active site, indicating a more dynamic interaction. In contrast, carvacrol and thymol maintained their position within the active site only ~20 and ~15 ns, respectively. These results highlight the effectiveness of combining L. graveolens essential oil and carvacrol with imipenem in tackling the difficult-to-treat pathogens A. baumannii and P. aeruginosa.
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Affiliation(s)
- Jorge O. Fimbres-García
- Centro de Investigación en Alimentación y Desarrollo, A.C, Carretera Gustavo Enrique Astiazarán Rosas 46, Hermosillo 83304, Sonora, Mexico; (J.O.F.-G.); (A.G.-G.); (B.A.S.-E.)
| | - Marcela Flores-Sauceda
- Centro de Investigación en Alimentación y Desarrollo, A.C, Carretera Gustavo Enrique Astiazarán Rosas 46, Hermosillo 83304, Sonora, Mexico; (J.O.F.-G.); (A.G.-G.); (B.A.S.-E.)
| | - Elsa Daniela Othón-Díaz
- Centro de Investigación en Alimentación y Desarrollo, A.C, Carretera Gustavo Enrique Astiazarán Rosas 46, Hermosillo 83304, Sonora, Mexico; (J.O.F.-G.); (A.G.-G.); (B.A.S.-E.)
| | - Alfonso García-Galaz
- Centro de Investigación en Alimentación y Desarrollo, A.C, Carretera Gustavo Enrique Astiazarán Rosas 46, Hermosillo 83304, Sonora, Mexico; (J.O.F.-G.); (A.G.-G.); (B.A.S.-E.)
| | - Melvin R. Tapia-Rodriguez
- Departamento de Biotecnología y Ciencias Alimentarias, Instituto Tecnológico de Sonora, 5 de Febrero 818 Sur, Col. Centro, Ciudad Obregón 85000, Sonora, Mexico;
| | - Brenda A. Silva-Espinoza
- Centro de Investigación en Alimentación y Desarrollo, A.C, Carretera Gustavo Enrique Astiazarán Rosas 46, Hermosillo 83304, Sonora, Mexico; (J.O.F.-G.); (A.G.-G.); (B.A.S.-E.)
| | - Andres Alvarez-Armenta
- Departamento de Microbiología Molecular, Instituto de Biotecnología, Universidad Nacional Autónoma de México, Cuernavaca 62250, Morelos, Mexico;
| | - J. Fernando Ayala-Zavala
- Centro de Investigación en Alimentación y Desarrollo, A.C, Carretera Gustavo Enrique Astiazarán Rosas 46, Hermosillo 83304, Sonora, Mexico; (J.O.F.-G.); (A.G.-G.); (B.A.S.-E.)
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Monteagudo de Barros V, da Rocha BS, Rhoden J, Stein JF, Picoli SU, Rigotto C. Detection of metallo-beta-lactamase-producing genes blaSPM and blaNDM in Pseudomonas aeruginosa isolated from wastewater in Southern Brazil. JOURNAL OF WATER AND HEALTH 2024; 22:689-700. [PMID: 38678422 DOI: 10.2166/wh.2024.305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 03/01/2024] [Indexed: 04/30/2024]
Abstract
Pseudomonas aeruginosa is commonly associated with the ability to acquire antimicrobial resistance. The surveillance of resistance genes in various environmental matrices has gained prominence in recent years, being seen as a potential threat to public health. The objective of this study was to investigate genes encoding metallo-beta-lactamases (MBLs), which confer resistance to carbapenems, in wastewater. Fifteen isolates of P. aeruginosa were collected for five months from samples obtained from a municipal wastewater treatment plant in Rio Grande do Sul. These isolates were subjected to disk diffusion testing using 10 different antimicrobials. Phenotypic enzymatic tests for MBLs were conducted, and positive isolates underwent DNA extraction and gene detection using the polymerase chain reaction. The resistance rate to ceftazidime was 100%, cefepime 73.3%, piperacillin-tazobactam 66.67%, imipenem 53.30%, levofloxacin 46.67%, tobramycin 40%, and ciprofloxacin and amikacin 13.33%. Both meropenem and aztreonam resistances were rare accounting for 6.60% of the tested isolates. Among these isolates, 20% were classified as multidrug-resistant and were found to carry the blaNDM and blaSPM genes. The results suggest that evaluating resistance genes in bacteria from urban raw sewage can provide data that assist in surveillance, as this environment can stimulate increased bacterial resistance.
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Affiliation(s)
- Vinícius Monteagudo de Barros
- Molecular Microbiology Laboratory, Institute of Health Sciences, Feevale University, Red Building 2nd Floor, Room 205, RS 239, No. 2755, Vila Nova, Novo Hamburgo, RS 93352-000, Brazil E-mail:
| | - Bruna Seixas da Rocha
- Molecular Microbiology Laboratory, Institute of Health Sciences, Feevale University, Red Building 2nd Floor, Room 205, RS 239, No. 2755, Vila Nova, Novo Hamburgo, RS 93352-000, Brazil
| | - Jaqueline Rhoden
- Molecular Microbiology Laboratory, Institute of Health Sciences, Feevale University, Red Building 2nd Floor, Room 205, RS 239, No. 2755, Vila Nova, Novo Hamburgo, RS 93352-000, Brazil
| | - Janaína Franciele Stein
- Molecular Microbiology Laboratory, Institute of Health Sciences, Feevale University, Red Building 2nd Floor, Room 205, RS 239, No. 2755, Vila Nova, Novo Hamburgo, RS 93352-000, Brazil
| | - Simone Ulrich Picoli
- Integrated Health Specialties Center - CIES Feevale, Institute of Health Sciences, Feevale University, R. Rubem Berta, 200 - Vila Nova, Novo Hamburgo, RS 93525-080, Brazil
| | - Caroline Rigotto
- Molecular Microbiology Laboratory, Institute of Health Sciences, Feevale University, Red Building 2nd Floor, Room 205, RS 239, No. 2755, Vila Nova, Novo Hamburgo, RS 93352-000, Brazil
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Dong S, Zhao Z, Tang H, Li G, Pan J, Gu X, Jiang J, Xiao L, Scapin G, Hunter DN, Yang D, Huang Y, Bennett F, Yang SW, Mandal M, Tang H, Su J, Tudge C, deJesus RK, Ding FX, Lombardo M, Hicks JD, Fischmann T, Mirza A, Dayananth P, Painter RE, Villafania A, Garlisi CG, Zhang R, Mayhood TW, Si Q, Li N, Amin RP, Bhatt B, Chen F, Regan CP, Regan H, Lin X, Wu J, Leithead A, Pollack SR, Scott JD, Nargund RP, Therien AG, Black T, Young K, Pasternak A. Structure Guided Discovery of Novel Pan Metallo-β-Lactamase Inhibitors with Improved Gram-Negative Bacterial Cell Penetration. J Med Chem 2024; 67:3400-3418. [PMID: 38387069 DOI: 10.1021/acs.jmedchem.3c01614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
The use of β-lactam (BL) and β-lactamase inhibitor combination to overcome BL antibiotic resistance has been validated through clinically approved drug products. However, unmet medical needs still exist for the treatment of infections caused by Gram-negative (GN) bacteria expressing metallo-β-lactamases. Previously, we reported our effort to discover pan inhibitors of three main families in this class: IMP, VIM, and NDM. Herein, we describe our work to improve the GN coverage spectrum in combination with imipenem and relebactam. This was achieved through structure- and property-based optimization to tackle the GN cell penetration and efflux challenges. A significant discovery was made that inhibition of both VIM alleles, VIM-1 and VIM-2, is essential for broad GN coverage, especially against VIM-producing P. aeruginosa. In addition, pharmacokinetics and nonclinical safety profiles were investigated for select compounds. Key findings from this drug discovery campaign laid the foundation for further lead optimization toward identification of preclinical candidates.
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Affiliation(s)
- Shuzhi Dong
- Discovery Chemistry, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - Zhiqiang Zhao
- Discovery Chemistry, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - Haiqun Tang
- Discovery Chemistry, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - Guoqing Li
- Discovery Chemistry, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - Jianping Pan
- Discovery Chemistry, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - Xin Gu
- Discovery Chemistry, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - Jinlong Jiang
- Discovery Chemistry, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - Li Xiao
- Computational and Structural Chemistry, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - Giovanna Scapin
- Computational and Structural Chemistry, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - David N Hunter
- Discovery Chemistry, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - Dexi Yang
- Discovery Chemistry, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - Yuhua Huang
- Discovery Chemistry, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - Frank Bennett
- Discovery Chemistry, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - Shu-Wei Yang
- Discovery Chemistry, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - Mihirbaran Mandal
- Discovery Chemistry, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - Haifeng Tang
- Discovery Chemistry, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - Jing Su
- Discovery Chemistry, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - Clare Tudge
- Discovery Chemistry, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | | | - Fa-Xiang Ding
- Discovery Chemistry, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - Matthew Lombardo
- Discovery Chemistry, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - Jacqueline D Hicks
- Discovery Chemistry, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - Thierry Fischmann
- Computational and Structural Chemistry, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - Asra Mirza
- Antibacterial/Antifungal, Merck & Co., Inc., West Point, Pennsylvania 19486, United States
| | - Priya Dayananth
- Quantitative Biosciences, Merck & Co., Inc., West Point, Pennsylvania 19486, United States
| | - Ronald E Painter
- Quantitative Biosciences, Merck & Co., Inc., West Point, Pennsylvania 19486, United States
| | - Artjohn Villafania
- Quantitative Biosciences, Merck & Co., Inc., West Point, Pennsylvania 19486, United States
| | - Charles G Garlisi
- Quantitative Biosciences, Merck & Co., Inc., West Point, Pennsylvania 19486, United States
| | - Rumin Zhang
- Quantitative Biosciences, Merck & Co., Inc., West Point, Pennsylvania 19486, United States
| | - Todd W Mayhood
- Quantitative Biosciences, Merck & Co., Inc., West Point, Pennsylvania 19486, United States
| | - Qian Si
- Quantitative Biosciences, Merck & Co., Inc., West Point, Pennsylvania 19486, United States
| | - Nianyu Li
- Nonclinical Drug Safety, Merck & Co., Inc., West Point, Pennsylvania 19486, United States
| | - Rupesh P Amin
- Nonclinical Drug Safety, Merck & Co., Inc., West Point, Pennsylvania 19486, United States
| | - Bhavana Bhatt
- Nonclinical Drug Safety, Merck & Co., Inc., West Point, Pennsylvania 19486, United States
| | - Feifei Chen
- Nonclinical Drug Safety, Merck & Co., Inc., West Point, Pennsylvania 19486, United States
| | - Christopher P Regan
- Nonclinical Drug Safety, Merck & Co., Inc., West Point, Pennsylvania 19486, United States
| | - Hillary Regan
- Nonclinical Drug Safety, Merck & Co., Inc., West Point, Pennsylvania 19486, United States
| | - Xinjie Lin
- Pharmacokinetics Pharmacodynamics and Drug Metabolism, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - Jin Wu
- Pharmacokinetics Pharmacodynamics and Drug Metabolism, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - Andrew Leithead
- Discovery Pharmaceutical Sciences, Merck & Co., Inc., West Point, Pennsylvania 19486, United States
| | - Scott R Pollack
- Discovery Process Chemistry, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - Jack D Scott
- Discovery Chemistry, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - Ravi P Nargund
- Discovery Chemistry, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - Alex G Therien
- Exploratory Science Center, Merck & Co., Inc., Cambridge, Massachusetts 02139, United States
| | - Todd Black
- Antibacterial/Antifungal, Merck & Co., Inc., West Point, Pennsylvania 19486, United States
| | - Katherine Young
- Antibacterial/Antifungal, Merck & Co., Inc., West Point, Pennsylvania 19486, United States
| | - Alexander Pasternak
- Discovery Chemistry, Merck & Co., Inc., Rahway, New Jersey 07065, United States
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11
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Wise MG, Karlowsky JA, Chen WT, Siddiqui F, Young K, Motyl MR, Sahm DF. Susceptibility of gram-negative isolates collected in Taiwan to imipenem/relebactam and comparator agents - SMART 2018-2021. J Formos Med Assoc 2024; 123:400-407. [PMID: 37735013 DOI: 10.1016/j.jfma.2023.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 08/28/2023] [Accepted: 09/08/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Imipenem/relebactam (IMR) was approved for patient use in Taiwan in 2023. We evaluated the in vitro susceptibility of recent Gram-negative pathogens collected in Taiwan hospitals to IMR and comparators with a focus on carbapenem-resistant and KPC-carrying non-Morganellaceae Enterobacterales (NME), and carbapenem-resistant Pseudomonas aeruginosa (CRPA). METHODS From 2018 to 2021, eight hospitals in Taiwan each collected up to 250 consecutive, aerobic or facultative, Gram-negative pathogens per year from patients with bloodstream, intraabdominal, lower respiratory tract, and urinary tract infections. MICs were determined using Clinical Laboratory Standards Institute (CLSI) broth microdilution. Most isolates that were IMR-, imipenem-, or ceftolozane/tazobactam-nonsusceptible were screened for β-lactamase genes by PCR or whole-genome sequencing. RESULTS Ninety-eight percent of NME (n = 5063) and 94% of P. aeruginosa (n = 1518) isolates were IMR-susceptible. Percent susceptible values for non-carbapenem β-lactam comparators, including piperacillin/tazobactam, were 68-79% for NME isolates, while percent susceptible values for all β-lactam comparators, including meropenem, were 73-81% for P. aeruginosa. IMR retained activity against 93% of multidrug-resistant (MDR) NME and 70% of MDR P. aeruginosa. Sixty-five percent of carbapenem-resistant NME and 81% of KPC-positive NME (n = 80) were IMR-susceptible. IMR inhibited 70% of CRPA (n = 287). Fifty percent of IMR-nonsusceptible NME tested for β-lactamase carriage had an MBL or OXA-48-like enzyme, whereas most (95%) IMR-nonsusceptible P. aeruginosa examined did not carry acquired β-lactamase genes. CONCLUSION Based on our in vitro data, IMR may be a useful option for the treatment of hospitalized patients in Taiwan with infections caused by common Gram-negative pathogens, including carbapenem-resistant NME, KPC-positive NME, and CRPA.
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Affiliation(s)
| | - James A Karlowsky
- IHMA, Schaumburg, IL 60173, USA; Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB R3E 0J9, Canada
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12
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Delgado-Valverde M, Portillo-Calderón I, Alcalde-Rico M, Conejo MC, Hidalgo C, Del Toro Esperón C, Pascual Á. Activity of imipenem/relebactam and comparators against KPC-producing Klebsiella pneumoniae and imipenem-resistant Pseudomonas aeruginosa. Eur J Clin Microbiol Infect Dis 2024; 43:445-457. [PMID: 38157139 PMCID: PMC10917868 DOI: 10.1007/s10096-023-04735-1] [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: 05/23/2023] [Accepted: 12/05/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE Relebactam is a novel β-lactamase inhibitor, which, when combined with imipenem/cilastatin, is active against both class A and class C β-lactamases. To evaluate in vitro antimicrobial activity of imipenem/relebactam against a collection of recent clinical isolates of carbapenem-non-susceptible P. aeruginosa and K. pneumoniae ST258 and ST512 KPC producers belonging to different lineages from hospitals in Southern Spain. METHODS Six hundred and seventy-eight isolates were tested: 265 K. pneumoniae (230 ST512/KPC-3 and 35 ST258/KPC-3) and 413 carbapenem-non-susceptible P. aeruginosa. Imipenem, piperacillin/tazobactam, ceftazidime, cefepime, aztreonam, ceftolozane/tazobactam, meropenem, amikacin, ciprofloxacin, colistin, and ceftazidime/avibactam were used as comparators against P. aeruginosa. Against K. pneumoniae ceftazidime, cefepime, aztreonam, and ceftolozane/tazobactam were not tested, and tigecycline was studied instead. MICs were determined in duplicate by broth microdilution according to EUCAST guidelines. RESULTS Imipenem/relebactam displayed potent in vitro activity against both sequence types of KPC-3-producing K. pneumoniae. MIC50 and MIC90 values were 0.25 mg/L and 1 mg/L, respectively, with percent of susceptible isolates >97%. Only three K. pneumoniae ST512/KPC-3 isolates and one ST258/KPC-3 were resistant to imipenem/relebactam. Relebactam sensitized 98.5% of K. pneumoniae isolates resistant to imipenem. The activity of imipenem/relebactam against P. aeruginosa was moderate (susceptibility rate: 62.7%). Analysis of the acquired and mutational resistome of isolates with high levels of resistance to imipenem/relebactam has not shown a clear association between them. CONCLUSION Imipenem/relebactam showed excellent activity against K. pneumoniae KPC-3. The activity of imipenem/relebactam against imipenem-resistant P. aeruginosa was moderate.
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Affiliation(s)
- Mercedes Delgado-Valverde
- UGC Enfermedades Infecciosas y Microbiología Clínica, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen Macarena/CSIC/Universidad de Sevilla, Sevilla, Spain.
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Sevilla, Spain.
| | - Inés Portillo-Calderón
- UGC Enfermedades Infecciosas y Microbiología Clínica, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen Macarena/CSIC/Universidad de Sevilla, Sevilla, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Sevilla, Spain
| | - Manuel Alcalde-Rico
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Sevilla, Spain
- Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen Macarena, CSIC, Universidad de Sevilla, Sevilla, Spain
| | - M Carmen Conejo
- Departamento de Microbiología, Universidad de Sevilla, Sevilla, Spain
| | - Carmen Hidalgo
- UGC Enfermedades Infecciosas y Microbiología Clínica, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen Macarena/CSIC/Universidad de Sevilla, Sevilla, Spain
| | | | - Álvaro Pascual
- UGC Enfermedades Infecciosas y Microbiología Clínica, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen Macarena/CSIC/Universidad de Sevilla, Sevilla, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Sevilla, Spain
- Departamento de Microbiología, Universidad de Sevilla, Sevilla, Spain
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13
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Lombardi A, Alagna L, Palomba E, Viero G, Tonizzo A, Mangioni D, Bandera A. New Antibiotics Against Multidrug-Resistant Gram-Negative Bacteria in Liver Transplantation: Clinical Perspectives, Toxicity, and PK/PD Properties. Transpl Int 2024; 37:11692. [PMID: 38362283 PMCID: PMC10867129 DOI: 10.3389/ti.2024.11692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 01/19/2024] [Indexed: 02/17/2024]
Abstract
Antimicrobial resistance is a growing global health problem, and it is especially relevant among liver transplant recipients where infections, particularly when caused by microorganisms with a difficult-to-treat profile, are a significant cause of morbidity and mortality. We provide here a complete dissection of the antibiotics active against multidrug-resistant Gram-negative bacteria approved over the last years, focusing on their activity spectrum, toxicity profile and PK/PD properties, including therapeutic drug monitoring, in the setting of liver transplantation. Specifically, the following drugs are presented: ceftolozane/tazobactam, ceftazidime/avibactam, meropenem/vaborbactam, imipenem/relebactam, cefiderocol, and eravacycline. Overall, studies on the safety and optimal employment of these drugs in liver transplant recipients are limited and especially needed. Nevertheless, these pharmaceuticals have undeniably enhanced therapeutic options for infected liver transplant recipients.
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Affiliation(s)
- Andrea Lombardi
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
- Infectious Diseases Unit, IRCCS Ca’ Granda Ospedale Maggiore Policlinico Foundation, Milan, Italy
| | - Laura Alagna
- Infectious Diseases Unit, IRCCS Ca’ Granda Ospedale Maggiore Policlinico Foundation, Milan, Italy
| | - Emanuele Palomba
- Infectious Diseases Unit, IRCCS Ca’ Granda Ospedale Maggiore Policlinico Foundation, Milan, Italy
| | - Giulia Viero
- Infectious Diseases Unit, IRCCS Ca’ Granda Ospedale Maggiore Policlinico Foundation, Milan, Italy
| | - Anna Tonizzo
- Infectious Diseases Unit, IRCCS Ca’ Granda Ospedale Maggiore Policlinico Foundation, Milan, Italy
| | - Davide Mangioni
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
- Infectious Diseases Unit, IRCCS Ca’ Granda Ospedale Maggiore Policlinico Foundation, Milan, Italy
| | - Alessandra Bandera
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
- Infectious Diseases Unit, IRCCS Ca’ Granda Ospedale Maggiore Policlinico Foundation, Milan, Italy
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14
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Karlowsky JA, Lob SH, Bauer KA, Esterly J, Siddiqui F, Young K, Motyl MR, Sahm DF. Activity of ceftolozane/tazobactam, imipenem/relebactam and ceftazidime/avibactam against clinical Gram-negative isolates-SMART United States 2019-21. JAC Antimicrob Resist 2024; 6:dlad152. [PMID: 38222461 PMCID: PMC10786191 DOI: 10.1093/jacamr/dlad152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 12/13/2023] [Indexed: 01/16/2024] Open
Abstract
Background Ongoing national and international surveillance efforts are critical components of antimicrobial stewardship, resistance monitoring, and drug development programs. In this report, we summarize the results of ceftolozane/tazobactam, imipenem/relebactam, ceftazidime/avibactam and comparator agent testing against 10 509 Enterobacterales and 2524 Pseudomonas aeruginosa collected by USA clinical laboratories in 2019-21 as part of the SMART global surveillance programme. Methods MICs were determined by CLSI broth microdilution and interpreted using 2023 CLSI M100 breakpoints. Results Most Enterobacterales were ceftazidime/avibactam susceptible (>99%), meropenem susceptible (99%) and ceftolozane/tazobactam susceptible (94%). Non-Morganellaceae Enterobacterales were also highly susceptible to imipenem/relebactam (99%). Ceftolozane/tazobactam inhibited 94% of Escherichia coli and 89% of Klebsiella pneumoniae with ceftriaxone non-susceptible/non-carbapenem-resistant phenotypes. Against P. aeruginosa, ceftolozane/tazobactam (97% susceptible) was more active than ceftazidime/avibactam (95%) and imipenem/relebactam (91%). MDR and difficult-to-treat resistance (DTR) phenotypes were identified in 13% and 7% of P. aeruginosa isolates, respectively. Ceftolozane/tazobactam remained active against 78% of MDR P. aeruginosa (13% and 23% higher than ceftazidime/avibactam and imipenem/relebactam, respectively) and against 74% of DTR P. aeruginosa (24% and 37% higher than ceftazidime/avibactam and imipenem/relebactam, respectively). Length of hospital stay at the time of specimen collection, ward type and infection type resulted in percent susceptible value differences of >5% across isolate demographic strata for some antimicrobial agent/pathogen combinations. Conclusions We conclude that in the USA, in 2019-21, carbapenem (meropenem) resistance remained uncommon in Enterobacterales and ceftolozane/tazobactam was more active than both ceftazidime/avibactam and imipenem/relebactam against P. aeruginosa.
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Affiliation(s)
- James A Karlowsky
- IHMA, Schaumburg, IL 60173, USA
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB R3E 0J9, Canada
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15
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Mackow NA, van Duin D. Reviewing novel treatment options for carbapenem-resistant Enterobacterales. Expert Rev Anti Infect Ther 2024; 22:71-85. [PMID: 38183224 DOI: 10.1080/14787210.2024.2303028] [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: 08/02/2023] [Accepted: 01/04/2024] [Indexed: 01/07/2024]
Abstract
INTRODUCTION Carbapenem resistant Enterobacterales (CRE) are a major threat to global health and hospital-onset CRE infections have risen during the COVID-19 pandemic. Novel antimicrobials are now available for the treatment of CRE infections. There remains an urgent need for new antimicrobials for CRE, especially for those producing metallo-β-lactamases. AREAS COVERED This article discusses previously published research supporting currently available novel antimicrobials for the treatment of CRE infections. Newer compounds currently being evaluated in clinical trials are covered. A literature search was conducted in PubMed over all available dates for relevant published papers and conference abstracts with the search terms, 'CRE,' 'carbapenem-resistant Enterobacterales,' 'β-lactam-β-lactamase inhibitor,' 'KPC,' 'NDM,' 'metallo-β-lactamase,' 'ceftazidime-avibactam,' 'meropenem-vaborbactam,' 'imipenem-cilastatin-relebactam,' 'cefiderocol,' 'eravacycline,' 'plazomicin,' 'taniborbactam,' 'zidebactam,' and 'nacubactam.' EXPERT OPINION Novel antimicrobials for CRE infections have been developed, most notably the β-lactam-β-lactamase inhibitor combinations, though treatment options for infections with metallo-β-lactamase producing Enterobacterales remain few and have limitations. Development of antibiotics with activity against metallo-β-lactamase producing Enterobacterales is eagerly awaited, and there are promising new compounds in clinical trials. Finally, more clinical research is needed to optimize and individualize treatment approaches, which will help guide antimicrobial stewardship initiatives aimed at reducing the spread of CRE and development of further resistance.
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Affiliation(s)
- Natalie A Mackow
- Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - David van Duin
- Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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16
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Wang X, Xiong L, Wang Y, Yang K, Xiao T, Chi X, Chen T, Zhou Y, Lu P, Dilinuer D, Shen P, Chen Y, Xiao Y. Comparison of the inoculum effect of in vitro antibacterial activity of Imipenem/relebactam and Ceftazidime/avibactam against ESBL-, KPC- and AmpC-producing Escherichia coli and Klebsiella pneumoniae. Ann Clin Microbiol Antimicrob 2023; 22:107. [PMID: 38072972 PMCID: PMC10710711 DOI: 10.1186/s12941-023-00660-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 12/05/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVE To evaluate effect of inoculum size of extended-spectrum β-Lactamase (ESBL)-producing-, AmpC-producing-, and KPC-producing Escherichia coli and Klebsiella pneumoniae on the in vitro antibacterial effects of imipenem/relebactam (IMR) and ceftazidime/avibactam (CZA). METHODS We compared the impact of inoculum size on IMR and CZA of sixteen clinical isolates and three standard isolates through antimicrobial susceptibility tests, time-kill assays and in vitro PK/PD studies. RESULTS When inoculum size increased from 105 to 107 CFU/mL, an inoculum effect was observed for 26.3% (5/19) and 52.6% (10/19) of IMR and CZA, respectively; time-kill assays revealed that the concentration of CZA increased from ≥ 4 × MIC to 16 × MIC to reach 99.9% killing rate against K. pneumoniae ATCC-BAA 1705 (KPC-2-, OXA-9- and SHV-182-producing) and 60,700 (SHV-27- and DHA-1-producing). While for IMR, a concentration from 1 × MIC to 4 × MIC killed 99.9% of the four strains. When the inoculum size increased to 109 CFU/mL, neither IMR nor CZA showed a detectable antibacterial effect, even at a high concentration. An in vitro PK/PD study revealed a clear bactericidal effect when IMR administered as 1.25 g q6h when inoculum size increased. CONCLUSION An inoculum effect on CZA was observed more frequent than that on IMR. Among the β-lactamase-producing strains, the inoculum effect was most common for SHV-producing and KPC-producing strains.
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Affiliation(s)
- Xueting Wang
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Luying Xiong
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yuan Wang
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Kai Yang
- Fuwai Yunnan Cardiovascular Hospital, Kunming, China
| | - Tingting Xiao
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaohui Chi
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Tao Chen
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yanzi Zhou
- Department of Rheumatology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, China
| | - Ping Lu
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Dilimulati Dilinuer
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Pin Shen
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yunbo Chen
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yonghong Xiao
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.
- Jinan Microecological Biomedicine Shandong Laboratory, Jinan, China.
- Research Units of Infectious Disease and Microecology, Chinese Academy of Medical Sciences, Beijing, China.
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Russo C, Humphries R. Approaches to Testing Novel β-Lactam and β-Lactam Combination Agents in the Clinical Laboratory. Antibiotics (Basel) 2023; 12:1700. [PMID: 38136734 PMCID: PMC10740869 DOI: 10.3390/antibiotics12121700] [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: 10/31/2023] [Revised: 11/25/2023] [Accepted: 12/01/2023] [Indexed: 12/24/2023] Open
Abstract
The rapid emergence of multi-drug resistant Gram-negative pathogens has driven the introduction of novel β-lactam combination agents (BLCs) to the antibiotic market: ceftolozane-tazobactam, ceftazidime-avibactam, meropenem-vaborbactam, imipenem-relebactam, cefiderocol, and sulbactam-durlobactam. These agents are equipped with innovative mechanisms that confer broad Gram-negative activity, notably against certain challenging carbapenemases. While their introduction offers a beacon of hope, clinical microbiology laboratories must navigate the complexities of susceptibility testing for these agents due to their diverse activity profiles against specific β-lactamases and the possibility of acquired resistance mechanisms in some bacterial isolates. This review explores the complexities of these novel antimicrobial agents detailing the intricacies of their application, providing guidance on the nuances of susceptibility testing, interpretation, and result reporting in clinical microbiology laboratories.
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Affiliation(s)
| | - Romney Humphries
- Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232, USA;
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18
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Lee SY, Gill CM, Nicolau DP. Activity of novel β-lactam/β-lactamase inhibitor combinations against serine carbapenemase-producing carbapenem-resistant Pseudomonas aeruginosa. J Antimicrob Chemother 2023; 78:2795-2800. [PMID: 37840005 PMCID: PMC10689909 DOI: 10.1093/jac/dkad225] [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: 05/01/2023] [Accepted: 06/29/2023] [Indexed: 10/17/2023] Open
Abstract
BACKGROUND Antimicrobial resistance in Pseudomonas aeruginosa is complex and multifaceted. While the novel β-lactamase inhibitors (BLIs) avibactam, relebactam and vaborbactam inhibit serine-based β-lactamases, the comparative potency of the novel β-lactam (BL)/BLI combinations against serine carbapenemase-producing P. aeruginosa is unknown. OBJECTIVES To compare the in vitro activity of ceftazidime/avibactam, ceftazidime, imipenem/relebactam, imipenem, meropenem/vaborbactam and meropenem against serine β-lactamase-producing P. aeruginosa. METHODS Carbapenem-resistant P. aeruginosa were collated through the Enhancing Rational Antimicrobials against Carbapenem-resistant P. aeruginosa (ERACE-PA) Global Surveillance. Isolates positive for serine-based carbapenemases were assessed. MICs were determined by broth microdilution to each novel BL/BLI and BL alone. RESULTS GES was the most common carbapenemase identified (n = 59) followed by KPC (n = 8). Ceftazidime/avibactam had MIC50/MIC90 values of 4/8 mg/L and 91% of isolates were susceptible. Conversely, ceftazidime alone was active against only 3% of isolates. The MIC50/MIC90 of imipenem/relebactam were 16/>16 mg/L and 13% of all isolates were defined as susceptible. Of the KPC-producing isolates, 38% were susceptible to imipenem/relebactam, compared with 0% to imipenem. The meropenem/vaborbactam MIC50/MIC90 were >16/>16 mg/L, and 6% of isolates were susceptible, which was similar to meropenem alone (MIC50/90, >8/>8 mg/L; 3% susceptible) suggesting the addition of vaborbactam cannot overcome co-expressed, non-enzymatic resistance mechanisms. CONCLUSIONS Among the novel BL/BLIs, ceftazidime/avibactam displayed better in vitro activity and thus is a rational treatment option for serine carbapenemase-harbouring P. aeruginosa. While imipenem/relebactam displayed some activity, particularly against isolates with blaKPC, meropenem/vaborbactam exhibited poor activity, with MICs similar to meropenem alone.
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Affiliation(s)
- Su Young Lee
- School of Pharmacy, West Coast University, 590 N. Vermont Ave, Los Angeles, CA 90004, USA
| | - Christian M Gill
- Center for Anti-Infective Research & Development, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA
| | - David P Nicolau
- Center for Anti-Infective Research & Development, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA
- Division of Infectious Diseases, Hartford Hospital, Hartford, CT, USA
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Bradley JS, Makieieva N, Tøndel C, Roilides E, Kelly MS, Patel M, Vaddady P, Maniar A, Zhang Y, Paschke A, Chen LF. Pharmacokinetics, Safety, and Tolerability of Imipenem/Cilastatin/Relebactam in Children with Confirmed or Suspected Gram-Negative Bacterial Infections: A Phase 1b, Open-Label, Single-Dose Clinical Trial. J Clin Pharmacol 2023; 63:1387-1397. [PMID: 37562063 DOI: 10.1002/jcph.2334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/02/2023] [Indexed: 08/12/2023]
Abstract
Imipenem/cilastatin/relebactam is approved for the treatment of serious gram-negative bacterial infections in adults. This study assessed the pharmacokinetics (PK), safety, and tolerability of a single dose of imipenem/cilastatin/relebactam (with a fixed 2:1 ratio of imipenem/cilastatin to relebactam, and with a maximum dose of 15 mg/kg imipenem and 15 mg/kg cilastatin [≤500 mg imipenem and ≤500 mg cilastatin] and 7.5 mg/kg relebactam [≤250 mg relebactam]) in children with confirmed/suspected gram-negative bacterial infections receiving standard-of-care antibacterial therapy. In this phase 1, noncomparative study (ClinicalTrials.gov identifier, NCT03230916), PK parameters from 46 children were analyzed using both population modeling and noncompartmental analysis. The PK/pharmacodynamic (PD) target for imipenem was percent time of the dosing interval that unbound plasma concentration exceeded the minimum inhibitory concentration (%fT>MIC) of ≥30% (MIC = 2 mcg/mL). For relebactam, the PK/PD target was a free drug area under the plasma concentration-time curve (AUC) normalized to MIC (at 2 mcg/mL) of ≥8.0 (equivalent to an AUC from time zero extrapolated to infinity of ≥20.52 mcg·h/mL). Safety was assessed up to 14 days after drug infusion. For imipenem, the ranges for the geometric mean %fT>MIC and maximum concentration (Cmax ) across age cohorts were 56.5%-93.7% and 32.2-38.2 mcg/mL, respectively. For relebactam, the ranges of the geometric mean Cmax and AUC from 0 to 6 hours across age cohorts were 16.9-21.3 mcg/mL and 26.1-55.3 mcg·h/mL, respectively. In total, 8/46 (17%) children experienced ≥1 adverse events (AEs) and 2/46 (4%) children experienced nonserious AEs that were deemed drug related by the investigator. Imipenem and relebactam exceeded plasma PK/PD targets; single doses of imipenem/cilastatin/relebactam were well tolerated with no significant safety concerns identified. These results informed imipenem/cilastatin/relebactam dose selection for further pediatric clinical evaluation.
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Affiliation(s)
- John S Bradley
- Department of Pediatrics, University of California San Diego School of Medicine and Rady Children's Hospital of San Diego, San Diego, CA, USA
| | - Nataliia Makieieva
- Department of Pediatrics, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Camilla Tøndel
- Department of Clinical Science, University of Bergen, and Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Emmanuel Roilides
- Third Department of Pediatrics, Infectious Diseases Unit, School of Medicine, Aristotle University and Hippokration General Hospital, Thessaloniki, Greece
| | - Matthew S Kelly
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | | | - Pavan Vaddady
- Merck & Co. Inc, Rahway, NJ, USA
- Daiichi Sankyo, Inc., Basking Ridge, NJ, USA
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Ruiz VH, Fratoni A, Nicolau DP, Kuti JL. In vitro activity of imipenem/relebactam against Pseudomonas aeruginosa isolated from patients with cystic fibrosis. Antimicrob Agents Chemother 2023; 67:e0092023. [PMID: 37888987 PMCID: PMC10648857 DOI: 10.1128/aac.00920-23] [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: 07/11/2023] [Accepted: 09/20/2023] [Indexed: 10/28/2023] Open
Abstract
Pseudomonas aeruginosa is a common multidrug-resistant pathogen in patients with cystic fibrosis (CF). The in vitro activity of imipenem/relebactam and imipenem was compared with other antipseudomonal antibiotics against 105 isolates from patients with CF from three US hospitals. Imipenem/relebactam, imipenem, meropenem, ceftazidime/avibactam, and ceftolozane/tazobactam susceptibilities were 77%, 55%, 58%, 90%, and 92%, respectively. Relebactam potentiates imipenem against CF P. aeruginosa by fourfold leading imipenem/relebactam to retain susceptibility against most isolates in this cohort.
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Affiliation(s)
- Victor H. Ruiz
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
| | - Andrew Fratoni
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
| | - David P. Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
- Division of Infectious Diseases, Hartford Hospital, Hartford, Connecticut, USA
| | - Joseph L. Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
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21
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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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Montero MM, Horcajada JP. Multidrug-resistant Pseudomonas aeruginosa: A pathogen with challenging clinical management. ENFERMEDADES INFECCIOSAS Y MICROBIOLOGIA CLINICA (ENGLISH ED.) 2023; 41:451-453. [PMID: 37838452 DOI: 10.1016/j.eimce.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 05/22/2023] [Indexed: 10/16/2023]
Affiliation(s)
- Maria M Montero
- Infectious Diseases Service, Hospital del Mar, Barcelona, Spain; Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain; Department of Medicine and Life Sciences (MELIS), Universitat Pompeu Fabra Barcelona, Barcelona, Spain; CIBER of Infectious Diseases (CIBERINFEC CB21/13/00002), Institute of Health Carlos III, Madrid, Spain
| | - Juan P Horcajada
- Infectious Diseases Service, Hospital del Mar, Barcelona, Spain; Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain; Department of Medicine and Life Sciences (MELIS), Universitat Pompeu Fabra Barcelona, Barcelona, Spain; CIBER of Infectious Diseases (CIBERINFEC CB21/13/00002), Institute of Health Carlos III, Madrid, Spain.
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23
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Karlowsky JA, Lob SH, Chen WT, DeRyke CA, Siddiqui F, Young K, Motyl MR, Sahm DF. In vitro activity of imipenem/relebactam against non-Morganellaceae Enterobacterales and Pseudomonas aeruginosa in the Asia-Pacific region: SMART 2017-2020. Int J Antimicrob Agents 2023; 62:106900. [PMID: 37354921 DOI: 10.1016/j.ijantimicag.2023.106900] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 06/08/2023] [Accepted: 06/20/2023] [Indexed: 06/26/2023]
Abstract
OBJECTIVES To describe the in vitro activity of imipenem/relebactam (IMR) against non-Morganellaceae Enterobacterales (NME) and Pseudomonas aeruginosa, including piperacillin/tazobactam-nonsusceptible and meropenem-nonsusceptible isolates, infecting hospitalized patients in the Asia-Pacific region. METHODS From 2017 to 2020, 49 clinical laboratories in nine countries in the Asia-Pacific region participated in the SMART global surveillance program and contributed 26 783 NME and 6383 P. aeruginosa. Minimum inhibitory concentrations (MICs) were determined using CLSI broth microdilution and interpreted using CLSI M100 (2021) breakpoints. β-Lactamase genes were identified in selected isolate subsets (2017-2020) and oprD was sequenced in molecularly characterized P. aeruginosa collected in 2020. RESULTS Amikacin (97.9% susceptible), IMR (95.8%), meropenem (95.4%), and imipenem (92.6%) were the most active agents against NME. Among piperacillin/tazobactam-nonsusceptible NME (n=4070), 76.1% were IMR-susceptible (range by country, 97.5% [New Zealand] to 50.6% [Vietnam]); 22.4% of meropenem-nonsusceptible NME (n=1225) were IMR-susceptible (range by country, 68.8% [South Korea] to 7.6% [Thailand]). A total of 2.7% of NME carried a metallo-β-lactamase (MBL), 0.9% an OXA-48-like carbapenemase (MBL-negative), and 0.7% a KPC (MBL-negative). Amikacin (94.0% susceptible) and IMR (90.3%) were the most active agents against P. aeruginosa; 71.2% of isolates were imipenem-susceptible. Relebactam increased susceptibility to imipenem by 25.6% (from 40.5% to 66.1%) in piperacillin/tazobactam-nonsusceptible and by 44.8% (from 7.1% to 51.9%) in meropenem-nonsusceptible P. aeruginosa. Only 4.3% of P. aeruginosa were MBL-positive. A total of 70.3% (90/128) of IMR-nonsusceptible P. aeruginosa were oprD-deficient. CONCLUSION In 2017-2020, 96% of NME and 90% of P. aeruginosa from the Asia-Pacific region were IMR-susceptible. IMR percent susceptible rates were higher in countries with lower MBL carriage.
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Affiliation(s)
- James A Karlowsky
- IHMA, 2122 Palmer Drive, Schaumburg, IL, 60173, USA; Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Room 543-745 Bannatyne Avenue, Winnipeg, Manitoba, R3E 0J9, Canada
| | - Sibylle H Lob
- IHMA, 2122 Palmer Drive, Schaumburg, IL, 60173, USA.
| | - Wei-Ting Chen
- MSD, 12F, No. 106, Xin Yi Road, Sec 5, Taipei 11047, Taiwan
| | - C Andrew DeRyke
- Merck & Co., Inc., 126 East Lincoln Avenue, Rahway, NJ 07065, USA
| | - Fakhar Siddiqui
- Merck & Co., Inc., 126 East Lincoln Avenue, Rahway, NJ 07065, USA
| | - Katherine Young
- Merck & Co., Inc., 126 East Lincoln Avenue, Rahway, NJ 07065, USA
| | - Mary R Motyl
- Merck & Co., Inc., 126 East Lincoln Avenue, Rahway, NJ 07065, USA
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Karlowsky JA, Lob SH, Hawser SP, Kothari N, Siddiqui F, Alekseeva I, DeRyke CA, Young K, Motyl MR, Sahm DF. Activity of ceftolozane/tazobactam and imipenem/relebactam against clinical isolates of Enterobacterales and Pseudomonas aeruginosa collected in central and northern Europe (Belgium, Norway, Sweden, Switzerland)-SMART 2017-21. JAC Antimicrob Resist 2023; 5:dlad098. [PMID: 37577157 PMCID: PMC10416811 DOI: 10.1093/jacamr/dlad098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/02/2023] [Indexed: 08/15/2023] Open
Abstract
Objectives To evaluate the in vitro activities of ceftolozane/tazobactam and imipenem/relebactam against clinical isolates of Gram-negative bacilli collected in four central and northern European countries (Belgium, Norway, Sweden, Switzerland) during 2017-21. Methods Participating clinical laboratories each collected up to 250 consecutive Gram-negative isolates per year from patients with bloodstream, intraabdominal, lower respiratory tract or urinary tract infections. MICs were determined by CLSI broth microdilution and interpreted using 2022 EUCAST breakpoints. β-Lactamase genes were identified in select β-lactam-non-susceptible isolate subsets. Results Ninety-five percent of all Enterobacterales (n = 4158), 95% of ESBL-positive non-carbapenem-resistant Enterobacterales (non-CRE) phenotype Escherichia coli and 85% of ESBL-positive non-CRE phenotype Klebsiella pneumoniae were ceftolozane/tazobactam susceptible. By country, 88% (Belgium), 91% (Sweden, Switzerland) and 96% (Norway) of ESBL-positive non-CRE phenotype Enterobacterales were ceftolozane/tazobactam susceptible. Greater than ninety-nine percent of non-Morganellaceae Enterobacterales and all ESBL-positive non-CRE phenotype Enterobacterales were imipenem/relebactam susceptible. Ceftolozane/tazobactam (96%) and imipenem/relebactam (95%) inhibited most Pseudomonas aeruginosa (n = 823). Both agents retained activity against ≥75% of cefepime-resistant, ceftazidime-resistant and piperacillin/tazobactam-resistant isolates; 56% and 43% of meropenem-resistant isolates were ceftolozane/tazobactam susceptible and imipenem/relebactam susceptible, respectively. By country, 94% (Belgium), 95% (Sweden) and 100% (Norway, Switzerland) of P. aeruginosa were ceftolozane/tazobactam susceptible and 93% (Sweden) to 98% (Norway, Switzerland) were imipenem/relebactam susceptible. Carbapenemase gene carriage among Enterobacterales and P. aeruginosa isolates was generally low (<1%) or completely absent with one exception: an estimated 2.7% of P. aeruginosa isolates from Belgium carried an MBL. Conclusions Recent clinical isolates of Enterobacterales and P. aeruginosa collected in four central and northern European countries were highly susceptible (≥95%) to ceftolozane/tazobactam and imipenem/relebactam.
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Affiliation(s)
- James A Karlowsky
- IHMA, Schaumburg, IL 60173, USA
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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Venuti F, Romani L, De Luca M, Tripiciano C, Palma P, Chiriaco M, Finocchi A, Lancella L. Novel Beta Lactam Antibiotics for the Treatment of Multidrug-Resistant Gram-Negative Infections in Children: A Narrative Review. Microorganisms 2023; 11:1798. [PMID: 37512970 PMCID: PMC10385558 DOI: 10.3390/microorganisms11071798] [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: 05/30/2023] [Revised: 07/06/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023] Open
Abstract
Infections due to carbapenem-resistant Enterobacterales (CRE) are increasingly prevalent in children and are associated with poor clinical outcomes, especially in critically ill patients. Novel beta lactam antibiotics, including ceftolozane-tazobactam, ceftazidime-avibactam, meropenem-vaborbactam, imipenem-cilastatin-relebactam, and cefiderocol, have been released in recent years to face the emerging challenge of multidrug-resistant (MDR) Gram-negative bacteria. Nonetheless, several novel agents lack pediatric indications approved by the Food and Drug Administration (FDA) and the European Medicine Agency (EMA), leading to uncertain pediatric-specific treatment strategies and uncertain dosing regimens in the pediatric population. In this narrative review we have summarized the available clinical and pharmacological data, current limitations and future prospects of novel beta lactam antibiotics in the pediatric population.
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Affiliation(s)
- Francesco Venuti
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Amedeo di Savoia Hospital, 10149 Torino, Italy
| | - Lorenza Romani
- Infectious Disease Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Maia De Luca
- Infectious Disease Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Costanza Tripiciano
- Infectious Disease Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Paolo Palma
- Unit of Clinical Immunology and Vaccinology, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Maria Chiriaco
- Research Unit of Primary Immunodeficiencies, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Andrea Finocchi
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
- Research Unit of Primary Immunodeficiencies, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Laura Lancella
- Infectious Disease Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
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Hilbert DW, DeRyke CA, Motyl M, Hackel M, Young K. Relebactam restores susceptibility of resistant Pseudomonas aeruginosa and Enterobacterales and enhances imipenem activity against chromosomal AmpC-producing species: analysis of global SMART 2018-2020. BMC Microbiol 2023; 23:165. [PMID: 37312049 DOI: 10.1186/s12866-023-02864-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/18/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Carbapenem-resistant bacteria are an increasing problem in clinical practice; thus, it is important to identify β-lactamase inhibitors (e.g., relebactam) that can restore carbapenem susceptibility. We report analyses of relebactam enhancement of imipenem activity against both imipenem-nonsusceptible (NS) and imipenem-susceptible (S) Pseudomonas aeruginosa and Enterobacterales. Gram-negative bacterial isolates were collected for the ongoing Study for Monitoring Antimicrobial Resistance Trends global surveillance program. Clinical and Laboratory Standards Institute-defined broth microdilution minimum inhibitory concentrations (MIC) were used to determine the imipenem and imipenem/relebactam antibacterial susceptibilities of P. aeruginosa and Enterobacterales isolates. RESULTS Between 2018 and 2020, 36.2% of P. aeruginosa (N = 23,073) and 8.2% of Enterobacterales (N = 91,769) isolates were imipenem-NS. Relebactam restored imipenem susceptibility in 64.1% and 49.4% of imipenem-NS P. aeruginosa and Enterobacterales isolates, respectively. Restoration of susceptibility was largely observed among K. pneumoniae carbapenemase-producing Enterobacterales and carbapenemase-negative P. aeruginosa. Relebactam also caused a lowering of imipenem MIC among imipenem-S P. aeruginosa and Enterobacterales isolates from chromosomal Ambler class C β-lactamase (AmpC)-producing species. For both imipenem-NS and imipenem-S P. aeruginosa isolates, relebactam reduced the imipenem MIC mode from 16 μg/mL to 1 μg/mL and from 2 μg/mL to 0.5 μg/mL, respectively, compared with imipenem alone. CONCLUSIONS Relebactam restored imipenem susceptibility among nonsusceptible isolates of P. aeruginosa and Enterobacterales and enhanced imipenem susceptibility among susceptible isolates of P. aeruginosa and isolates from Enterobacterales species that can produce chromosomal AmpC. The reduced imipenem modal MIC values with relebactam may result in a higher probability of target attainment in patients.
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Affiliation(s)
| | | | | | - Meredith Hackel
- International Health Management Associates, Inc, Schaumburg, IL, USA
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Karlowsky JA, Lob SH, Estabrook MA, Siddiqui F, DeRyke CA, Young K, Motyl MR, Sahm DF. Susceptibility profile and β-lactamase content of global Pseudomonas aeruginosa isolates resistant to ceftolozane/tazobactam and/or imipenem/relebactam-SMART 2016-21. JAC Antimicrob Resist 2023; 5:dlad080. [PMID: 37388237 PMCID: PMC10306085 DOI: 10.1093/jacamr/dlad080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/01/2023] [Indexed: 07/01/2023] Open
Abstract
Objectives To determine susceptibility profiles and β-lactamase content for ceftolozane/tazobactam-resistant and imipenem/relebactam-resistant Pseudomonas aeruginosa isolates collected in eight global regions during 2016-21. Methods Broth microdilution MICs were interpreted using CLSI breakpoints. PCR to identify β-lactamase genes or WGS was performed on selected isolate subsets. Results Ceftolozane/tazobactam-resistant [from 0.6% (Australia/New Zealand) to 16.7% (Eastern Europe)] and imipenem/relebactam-resistant [from 1.3% (Australia/New Zealand) to 13.6% (Latin America)] P. aeruginosa varied by geographical region. Globally, 5.9% of isolates were both ceftolozane/tazobactam resistant and imipenem/relebactam resistant; 76% of these isolates carried MBLs. Most ceftolozane/tazobactam-resistant/imipenem/relebactam-susceptible isolates carried ESBLs (44%) or did not carry non-intrinsic (acquired) β-lactamases (49%); 95% of imipenem/relebactam-resistant/ceftolozane/tazobactam-susceptible isolates did not carry non-intrinsic β-lactamases. Isolates that carried indicators of strong PDC (Pseudomonas-derived cephalosporinase) up-regulation without a mutation known to expand the spectrum of PDC, or non-intrinsic β-lactamases, showed an 8-fold increase in ceftolozane/tazobactam modal MIC; however, this rarely (3%) resulted in ceftolozane/tazobactam resistance. Isolates with a PDC mutation and an indicator for PDC upregulation were ceftolozane/tazobactam non-susceptible (MIC, ≥ 8 mg/L). MICs ranged widely (1 to >32 mg/L) for isolates with a PDC mutation and no positively identified indicator for PDC up-regulation. Imipenem/relebactam-resistant/ceftolozane/tazobactam-susceptible isolates without non-intrinsic β-lactamases frequently (91%) harboured genetic lesions implying OprD loss of function; however, this finding alone did not account for this phenotype. Among imipenem-non-susceptible isolates without non-intrinsic β-lactamases, implied OprD loss only shifted the distribution of imipenem/relebactam MICs up by 1-2 doubling dilutions, resulting in ∼10% imipenem/relebactam-resistant isolates. Conclusions P. aeruginosa with ceftolozane/tazobactam-resistant/imipenem/relebactam-susceptible and imipenem/relebactam-resistant/ceftolozane/tazobactam-susceptible phenotypes were uncommon and harboured diverse resistance determinants.
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Martin-Loeches I, Shorr AF, Kollef MH, Du J, Losada MC, Paschke A, DeRyke CA, Wong M, Jensen EH, Chen LF. Participant- and Disease-Related Factors as Independent Predictors of Treatment Outcomes in the RESTORE-IMI 2 Clinical Trial: A Multivariable Regression Analysis. Open Forum Infect Dis 2023; 10:ofad225. [PMID: 37383243 PMCID: PMC10297016 DOI: 10.1093/ofid/ofad225] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 05/03/2023] [Indexed: 06/30/2023] Open
Abstract
Background In the RESTORE-IMI 2 trial, imipenem/cilastatin/relebactam (IMI/REL) was noninferior to piperacillin/tazobactam in treating hospital-acquired bacterial pneumonia/ventilator-associated bacterial pneumonia. This post hoc analysis was conducted to determine independent predictors of efficacy outcomes in the RESTORE-IMI 2 trial, to assist in treatment decision making. Methods A stepwise multivariable regression analysis was conducted to identify variables that were independently associated with day 28 all-cause mortality (ACM), favorable clinical response at early follow-up (EFU), and favorable microbiologic response at end of treatment (EOT). The analysis accounted for the number of baseline infecting pathogens and in vitro susceptibility to randomized treatment. Results Vasopressor use, renal impairment, bacteremia at baseline, and Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II scores ≥15 were associated with a greater risk of day 28 ACM. A favorable clinical response at EFU was associated with normal renal function, an APACHE II score <15, no vasopressor use, and no bacteremia at baseline. At EOT, a favorable microbiologic response was associated with IMI/REL treatment, normal renal function, no vasopressor use, nonventilated pneumonia at baseline, intensive care unit admission at randomization, monomicrobial infections at baseline, and absence of Acinetobacter calcoaceticus-baumannii complex at baseline. These factors remained significant after accounting for polymicrobial infection and in vitro susceptibility to assigned treatment. Conclusions This analysis, which accounted for baseline pathogen susceptibility, validated well-recognized patient- and disease-related factors as independent predictors of clinical outcomes. These results lend further support to the noninferiority of IMI/REL to piperacillin/tazobactam and suggests that pathogen eradication may be more likely with IMI/REL. Clinical Trials Registration NCT02493764.
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Affiliation(s)
- Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization, St James's University Hospital, Trinity Centre for Health Sciences, Dublin, Ireland
| | - Andrew F Shorr
- Section of Pulmonary, Critical Care, and Respiratory Services, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jiejun Du
- Merck & Co, Inc, Rahway, New Jersey, USA
| | | | | | - C Andrew DeRyke
- Correspondence: C. Andrew DeRyke, Pharm. D, Merck & Co, Inc, 351 N Sumneytown Pike, PO Box 1000 (UG1CD-70), North Wales, PA 19454, USA ()
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Karlowsky JA, Lob SH, Siddiqui F, Pavia J, DeRyke CA, Young K, Motyl MR, Sahm DF. In vitro activity of imipenem/relebactam against non-Morganellaceae Enterobacterales and Pseudomonas aeruginosa in Latin America: SMART 2018‒2020. Braz J Infect Dis 2023; 27:102775. [PMID: 37169345 DOI: 10.1016/j.bjid.2023.102775] [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: 10/17/2022] [Revised: 03/31/2023] [Accepted: 04/21/2023] [Indexed: 05/13/2023] Open
Abstract
Carbapenem-resistant Enterobacterales and Pseudomonas aeruginosa are being isolated from patient specimens with increasing frequency in Latin America and worldwide. The current study provides an initial description of the in vitro activity of Imipenem/Relebactam (IMR) against non-Morganellaceae Enterobacterales (NME) and P. aeruginosa infecting hospitalized patients in Latin America. From 2018 to 2020, 37 clinical laboratories in nine Latin American countries participated in the SMART global surveillance program and contributed 15,466 NME and 3408 P aeruginosa isolates. MICs for IMR and seven comparators were determined using CLSI broth microdilution and interpreted by CLSI M100 (2022) breakpoints. β-lactamase genes were identified in selected isolate subsets. IMR (96.9% susceptible), amikacin (95.9%), meropenem (90.7%), and imipenem (88.7%) were the most active agents against NME. Among piperacillin/tazobactam-nonsusceptible NME (n = 4124), 90.4% of isolates were IMR-susceptible (range by country, 97.2 [Chile] to 67.0% [Guatemala]) and among meropenem-nonsusceptible NME isolates (n = 1433), 74.0% were IMR-susceptible (94.1% [Puerto Rico] to 5.1% [Guatemala]). Overall, 6.3% of all collected NME isolates carried a KPC (metallo-β-lactamase [MBL]-negative), 1.8% an MBL, 0.4% an OXA-48-like carbapenemase (MBL-negative), and 0.1% a GES carbapenemase (MBL-negative). Amikacin (85.2% susceptible) and IMR (80.1%) were the most active agents against P. aeruginosa; only 56.5% of isolates were imipenem susceptible. Relebactam increased susceptibility to imipenem by 22.0% (from 23.9% to 45.9%) in piperacillin/tazobactam-nonsusceptible isolates (n = 1031) and by 35.5% (from 5.5% to 41.0%) in meropenem-nonsusceptible isolates (n = 1128). Overall, 7.6% of all collected P. aeruginosa isolates were MBL-positive and 0.7% carried a GES carbapenemase. In conclusion, in 2018‒2020, almost all NME (97%) and most P. aeruginosa (80%) isolates from Latin America were IMR-susceptible. Continued surveillance of the in vitro activities of IMR and comparator agents against Gram-negative pathogens, and monitoring for β-lactamase changes (in particular for increases in MBLs), is warranted.
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Affiliation(s)
- James A Karlowsky
- IHMA, Schaumburg, USA; University of Manitoba, Max Rady College of Medicine, Department of Medical Microbiology and Infectious Diseases, Winnipeg, Manitoba, Canada
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Olney KB, Thomas JK, Johnson WM. Review of novel β-lactams and β-lactam/β-lactamase inhibitor combinations with implications for pediatric use. Pharmacotherapy 2023. [PMID: 36825478 DOI: 10.1002/phar.2782] [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: 07/08/2022] [Revised: 01/18/2023] [Accepted: 01/21/2023] [Indexed: 02/25/2023]
Abstract
Antimicrobial resistance continues to surmount increasing concern globally, and treatment of difficult-to-treat (DTR) Pseudomonas aeruginosa, carbapenem-resistant (CR) Acinetobacter baumannii (CRAB), and CR Enterobacterales (CRE) remains a challenge for clinicians. Although previously rare, the incidence of multidrug-resistant (MDR) and CR infections in pediatric patients has increased drastically in the last decade and is associated with increased morbidity and mortality. To combat this issue, 14 novel antibiotics, including three β-lactam/novel β-lactamase inhibitor combinations (βL-βLIs) and two novel β-lactams (βLs), have received approval from the United States Food and Drug Administration since 2010. Improving clinician understanding of the utility of these novel therapies is imperative to improve judicious decision-making and prevent societal regression to a pre-penicillin era. In this review, we summarize the pharmacokinetic/pharmacodynamic (PK/PD) properties, clinical efficacy and safety data, dosing considerations, and subsequent role in therapy for ceftazidime-avibactam (CAZ-AVI), meropenem-vaborbactam (MER-VAB), imipenem-cilastatin-relebactam (IMI-REL), ceftolozane-tazobactam (TOL-TAZ), and cefiderocol in pediatric patients.
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Affiliation(s)
- Katie B Olney
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Jenni K Thomas
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Wes M Johnson
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
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Karlowsky JA, Lob SH, Siddiqui F, Akrich B, DeRyke CA, Young K, Motyl MR, Hawser SP, Sahm DF. In vitro activity of imipenem/relebactam against piperacillin/tazobactam-resistant and meropenem-resistant non- Morganellaceae Enterobacterales and Pseudomonas aeruginosa collected from patients with bloodstream, intra-abdominal and urinary tract infections in Western Europe: SMART 2018-2020. J Med Microbiol 2023; 72. [PMID: 36763081 DOI: 10.1099/jmm.0.001645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
Introduction. Piperacillin/tazobactam and carbapenems are important agents for the treatment of serious Gram-negative infections in hospitalized patients. Resistance to both agents is a significant concern in clinical isolates of Enterobacterales and Pseudomonas aeruginosa; new agents with improved activity are needed.Gap Statement. Publication of current, region-specific data describing the in vitro activity of newer agents such as imipenem/relebactam (IMR) against piperacillin/tazobactam-resistant and carbapenem-resistant Enterobacterales and P. aeruginosa are needed to support their clinical use.Aim. To describe the in vitro activity of IMR against non-Morganellaceae Enterobacterales (NME) and P. aeruginosa isolated from bloodstream, intra-abdominal and urinary tract infection samples by hospital laboratories in Western Europe with a focus on the activity of IMR against piperacillin/tazobactam-resistant and meropenem-resistant isolates.Methodology. From 2018 to 2020, 29 hospital laboratories in six countries in Western Europe participated in the SMART global surveillance programme and contributed 9487 NME and 1004 P. aeruginosa isolates. MICs were determined by CLSI broth microdilution testing and interpreted by EUCAST (2021) breakpoints. β-Lactamase genes were identified in selected isolate subsets (2018-2020) and oprD sequenced in molecularly characterized P. aeruginosa (2020).Results. IMR (99.4 % susceptible), amikacin (98.0 %), meropenem (97.7 %) and imipenem (97.6 %) were the most active agents against NME; 83.1 % of NME were piperacillin/tazobactam-susceptible. Relebactam increased imipenem susceptibility of NME from Italy by 8.3 %, from Portugal by 2.9 %, and from France, Germany, Spain and the UK by <1 %. In total, 96.4 % of piperacillin/tazobactam-resistant (n=1601) and 73.7 % of meropenem-resistant (n=152) NME were IMR-susceptible. Also, 0.4 % of NME were MBL-positive, 0.9 % OXA-48-like-positive (MBL-negative) and 1.5 % KPC-positive (MBL-negative). Amikacin (95.4 % susceptible) and IMR (94.1 %) were the most active agents against P. aeruginosa; 81.7 % of isolates were imipenem-susceptible and 79.6 % were piperacillin/tazobactam-susceptible. Relebactam increased susceptibility to imipenem by 12.5 % overall (range by country, 4.3-17.5 %); and by 30.7 % in piperacillin/tazobactam-resistant and 24.3 % in meropenem-resistant P. aeruginosa. In total, 1.6 % of P. aeruginosa isolates were MBL-positive. Seven of eight molecularly characterized IMR-resistant P. aeruginosa isolates from 2020 were oprD-deficient.Conclusion. IMR may be a potential treatment option for bloodstream, intra-abdominal and urinary tract infections caused by NME and P. aeruginosa in Western Europe, including infections caused by piperacillin/tazobactam-resistant and meropenem-resistant isolates.
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Affiliation(s)
- James A Karlowsky
- IHMA, Schaumburg, IL, 60173, USA.,Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, R3E 0J9, Canada
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Karlowsky JA, Lob SH, Akrich B, DeRyke CA, Siddiqui F, Young K, Motyl MR, Hawser SP, Sahm DF. In vitro activity of imipenem/relebactam against piperacillin/tazobactam-resistant and meropenem-resistant non-Morganellaceae Enterobacterales and Pseudomonas aeruginosa collected from patients with lower respiratory tract infections in Western Europe: SMART 2018-20. JAC Antimicrob Resist 2023; 5:dlad003. [PMID: 36694850 PMCID: PMC9856267 DOI: 10.1093/jacamr/dlad003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 01/05/2023] [Indexed: 01/21/2023] Open
Abstract
Objectives To describe the in vitro activity of imipenem/relebactam against non-Morganellaceae Enterobacterales (NME) and Pseudomonas aeruginosa recently isolated from lower respiratory tract infection samples by hospital laboratories in Western Europe. Methods From 2018 to 2020, 29 hospital laboratories in six countries in Western Europe participated in the SMART global surveillance programme and contributed 4414 NME and 1995 P. aeruginosa isolates. MICs were determined using the CLSI broth microdilution method and interpreted by EUCAST (2021) breakpoints. β-Lactamase genes were identified in selected isolate subsets (2018-20) and oprD sequenced in molecularly characterized P. aeruginosa (2020). Results Imipenem/relebactam (99.1% susceptible), amikacin (97.2%), meropenem (96.1%) and imipenem (95.9%) were the most active agents tested against NME; by country, relebactam increased imipenem susceptibility from <1% (France, Germany, UK) to 11.0% (Italy). A total of 96.0% of piperacillin/tazobactam-resistant (n = 990) and 81.1% of meropenem-resistant (n = 106) NME were imipenem/relebactam-susceptible. Only 0.5% of NME were MBL positive, 0.9% were OXA-48-like-positive (MBL negative) and 2.8% were KPC positive (MBL negative). Amikacin (91.5% susceptible) and imipenem/relebactam (91.4%) were the most active agents against P. aeruginosa; 72.3% of isolates were imipenem-susceptible. Relebactam increased susceptibility to imipenem by 34.4% (range by country, 39.1%-73.5%) in piperacillin/tazobactam-resistant and by 37.4% (3.1%-40.5%) in meropenem-resistant P. aeruginosa. Only 1.8% of P. aeruginosa isolates were MBL positive. Among molecularly characterized imipenem/relebactam-resistant P. aeruginosa isolates from 2020, 90.9% (30/33) were oprD deficient. Conclusions Imipenem/relebactam appears to be a potential treatment option for lower respiratory tract infections caused by piperacillin/tazobactam- and meropenem-resistant NME and P. aeruginosa in Western Europe.
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Affiliation(s)
- James A Karlowsky
- IHMA, 2122 Palmer Drive, Schaumburg, IL, 60173, USA,Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Room 543-745 Bannatyne Avenue, Winnipeg, Manitoba, R3E 0J9, Canada
| | | | | | - C Andrew DeRyke
- Merck & Co., Inc., 126 East Lincoln Avenue, Rahway, NJ, 07065, USA
| | - Fakhar Siddiqui
- Merck & Co., Inc., 126 East Lincoln Avenue, Rahway, NJ, 07065, USA
| | - Katherine Young
- Merck & Co., Inc., 126 East Lincoln Avenue, Rahway, NJ, 07065, USA
| | - Mary R Motyl
- Merck & Co., Inc., 126 East Lincoln Avenue, Rahway, NJ, 07065, USA
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Ito R, Kawamura M, Sato T, Fujimura S. Cefmetazole Resistance Mechanism for Escherichia Coli Including ESBL-Producing Strains. Infect Drug Resist 2022; 15:5867-5878. [PMID: 36237294 PMCID: PMC9553235 DOI: 10.2147/idr.s382142] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 09/20/2022] [Indexed: 12/19/2022] Open
Abstract
Purpose Cefmetazole (CMZ), a cephamycin antibiotic, is primarily used as a definitive therapy for Extended Spectrum β-Lactamase (ESBL)-producing Escherichia coli infections. However, the mechanism of CMZ resistance in E. coli is still unknown. To elucidate the resistance mechanism and to determine combined drugs for prevention of resistance acquisition. Methods Clinical isolates of 14 ESBL-producing E. coli and non-producing 12 isolates were used in in vitro testing of CMZ resistance acquisition. After 10-day of CMZ exposure (1st subculture), these strains were incubated in an antibacterial-free medium for 14-day. These strains were again exposed to CMZ for 10-day (2nd subculture) and confirmed for changes in MIC. For each strain detected after 1st subculture, each mRNA expression level of porin, chromosomal ampC, and drug-efflux pump was measured using real-time RT-PCR. Relebactam (REL) has the potency to recover antimicrobial activity against carbapenem-resistant Enterobacterales that has porin deficiency. REL was added to the CMZ dilution series, and MIC changes and those of porin were confirmed. Results Of these 26 strains, 15 strains (57.7%) acquired resistance after 1st subculture, but after passage culture on the antibacterial-free medium, 11 strains recovered susceptibility. These 11 strains showed resistance after 2nd subculture. The expression levels of ompF and ompC were significantly decreased in these strains (P<0.05). When REL was added, all strains suppressed resistance acquisition after 1st subculture. The mechanism was the activation of ompF. Conclusion Our results showed that the mRNA expression levels of genes encoding porin were decreased in the strains that acquired resistance due to CMZ exposure, and that ompF and ompC in particular were thought to be involved in the acquisition of resistance. The CMZ acquisition of resistance was also suppressed by the concomitant use of REL and actually suppressed the decrease in mRNA expression in ompF. It was confirmed that porin reactivated by REL.
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Affiliation(s)
- Ryota Ito
- Tohoku Medical and Pharmaceutical University, Division of Clinical Infectious Diseases & Chemotherapy, Sendai, Miyagi, Japan,Correspondence: Ryota Ito, Tohoku Medical and Pharmaceutical University, Division of Clinical Infectious Diseases & Chemotherapy, 4-4-1 Komatsushima, Aoba-ku, Sendai, Miyagi, 981-8558, Japan, Tel +81-22-727-0169, Fax +81-22-727-0176, Email
| | - Masato Kawamura
- Tohoku Medical and Pharmaceutical University, Division of Clinical Infectious Diseases & Chemotherapy, Sendai, Miyagi, Japan
| | - Takumi Sato
- Tohoku Medical and Pharmaceutical University, Division of Clinical Infectious Diseases & Chemotherapy, Sendai, Miyagi, Japan
| | - Shigeru Fujimura
- Tohoku Medical and Pharmaceutical University, Division of Clinical Infectious Diseases & Chemotherapy, Sendai, Miyagi, Japan
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Díaz Santos E, Mora Jiménez C, Del Río-Carbajo L, Vidal-Cortés P. Treatment of severe multi-drug resistant Pseudomonas aeruginosa infections. Med Intensiva 2022; 46:508-520. [PMID: 35840495 DOI: 10.1016/j.medine.2022.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/04/2022] [Accepted: 03/18/2022] [Indexed: 06/15/2023]
Abstract
Pseudomonas aeruginosa is the microorganism most frequently involved in the main ICU-acquired infections, with special importance in ventilator associated pneumonia. Its importance lies, in addition to its high incidence in critically ill patients, in the severity of the infections it causes and in the difficulty of its antimicrobial treatment, directly related to the high percentage of resistance to antibiotics classically considered first-line. New active antibiotics have recently been developed against Pseudomonas aeruginosa, even against multi-drug resistant strains. This review analyzes both the differential characteristics of Pseudomonas aeruginosa infections and the new therapeutic options, focusing on multi-drug resistant Pseudomonas aeruginosa.
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Affiliation(s)
- E Díaz Santos
- Medicina Intensiva, Consorci Corporació Sanitaria Parc Taulí, Sabadell, Barcelona, Spain; Departamento de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - C Mora Jiménez
- Medicina Intensiva, Consorci Corporació Sanitaria Parc Taulí, Sabadell, Barcelona, Spain
| | - L Del Río-Carbajo
- Medicina Intensiva, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | - P Vidal-Cortés
- Medicina Intensiva, Complexo Hospitalario Universitario de Ourense, Ourense, Spain.
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Canton R, Doi Y, Simner PJ. Treatment of carbapenem-resistant Pseudomonas aeruginosa infections: a case for cefiderocol. Expert Rev Anti Infect Ther 2022; 20:1077-1094. [PMID: 35502603 DOI: 10.1080/14787210.2022.2071701] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 04/26/2022] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Carbapenem-resistant (CR) Pseudomonas aeruginosa infections constitute a serious clinical threat globally. Patients are often critically ill and/or immunocompromised. Antibiotic options are limited and are currently centered on beta-lactam-beta-lactamase inhibitor (BL-BLI) combinations and the siderophore cephalosporin cefiderocol. AREAS COVERED This article reviews the mechanisms of P. aeruginosa resistance and their potential impact on the activity of current treatment options, along with evidence for the clinical efficacy of BL-BLI combinations in P. aeruginosa infections, some of which specifically target infections due to CR organisms. The preclinical and clinical evidence supporting cefiderocol as a treatment option for P. aeruginosa involving infections is also reviewed. EXPERT OPINION Cefiderocol is active against most known P. aeruginosa mechanisms mediating carbapenem resistance. It is stable against different serine- and metallo-beta-lactamases, and, due to its iron channel-dependent uptake mechanism, is not impacted by porin channel loss. Furthermore, the periplasmic level of cefiderocol is not affected by upregulated efflux pumps. The potential for on-treatment resistance development currently appears to be low, although more clinical data are required. Information from surveillance programs, real-world compassionate use, and clinical studies demonstrate that cefiderocol is an important treatment option for CR P. aeruginosa infections.
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Affiliation(s)
- Rafael Canton
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Yohei Doi
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Patricia J Simner
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Fratoni AJ, Mah JW, Nicolau DP, Kuti JL. Imipenem/cilastatin/relebactam pharmacokinetics in critically ill patients with augmented renal clearance. J Antimicrob Chemother 2022; 77:2992-2999. [PMID: 35906810 DOI: 10.1093/jac/dkac261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/12/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Imipenem and relebactam are predominantly excreted via glomerular filtration. Augmented renal clearance (ARC) is a common syndrome in critically-ill patients with sepsis, and sub-therapeutic antibiotic concentrations are of concern. Herein, we describe the pharmacokinetics of imipenem/relebactam in critically-ill patients with ARC. METHODS Infected patients in the ICU with ARC (CLCR ≥ 130 mL/min) received a single dose of imipenem/cilastatin/relebactam 1.25 g as a 30 min infusion. Blood samples were collected over 6 h for concentration determination. Protein binding was assessed by ultrafiltration. An 8 h urine creatinine collection confirmed ARC. Population pharmacokinetic models with and without covariates were fit using the non-parametric adaptive grid algorithm in Pmetrics. A 5000 patient Monte Carlo simulation assessed joint PTA using relebactam fAUC/MIC ≥8 and imipenem ≥40% fT>MIC. RESULTS Eight patients with ARC completed the study. A base population pharmacokinetic model with two-compartments fitted the data best. The mean ± SD parameters were: CL, 17.31 ± 5.76 L/h; Vc, 16.15 ± 7.75 L; k12, 1.62 ± 0.99 h-1; and k21, 3.53 ± 3.31 h-1 for imipenem, and 11.51 ± 4.79 L/h, 16.54 ± 7.43 L, 1.59 ± 1.12 h-1, and 2.83 ± 2.91 h-1 for relebactam. Imipenem/cilastatin/relebactam 1.25 g as a 30 min infusion every 6 h achieved 100% and 93% PTA at MICs of 1 and 2 mg/L, respectively. CONCLUSIONS Despite enhanced clearance of both imipenem and relebactam, the currently approved dosing regimen for normal renal function was predicted to achieve optimal exposure in critically-ill patients with ARC sufficient to treat most susceptible pathogens.
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Affiliation(s)
- Andrew J Fratoni
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT 06102, USA
| | - John W Mah
- Division of Surgical Critical Care, Hartford Hospital, Hartford, CT 06102, USA
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT 06102, USA
| | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT 06102, USA
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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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Imipenem/Relebactam Resistance in Clinical Isolates of Extensively Drug Resistant Pseudomonas aeruginosa: Inhibitor-Resistant β-Lactamases and Their Increasing Importance. Antimicrob Agents Chemother 2022; 66:e0179021. [PMID: 35435707 DOI: 10.1128/aac.01790-21] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Multidrug-resistant (MDR) Pseudomonas aeruginosa infections are a major clinical challenge. Many isolates are carbapenem resistant, which severely limits treatment options; thus, novel therapeutic combinations, such as imipenem-relebactam (IMI/REL), ceftazidime-avibactam (CAZ/AVI), ceftolozane-tazobactam (TOL/TAZO), and meropenem-vaborbactam (MEM/VAB) were developed. Here, we studied two extensively drug-resistant (XDR) P. aeruginosa isolates, collected in the United States and Mexico, that demonstrated resistance to IMI/REL. Whole-genome sequencing (WGS) showed that both isolates contained acquired GES β-lactamases, intrinsic PDC and OXA β-lactamases, and disruptions in the genes encoding the OprD porin, thereby inhibiting uptake of carbapenems. In one isolate (ST17), the entire C terminus of OprD deviated from the expected amino acid sequence after amino acid G388. In the other (ST309), the entire oprD gene was interrupted by an ISPa1328 insertion element after amino acid D43, rendering this porin nonfunctional. The poor inhibition by REL of the GES β-lactamases (GES-2, -19, and -20; apparent Ki of 19 ± 2 μM, 23 ± 2 μM, and 21 ± 2 μM, respectively) within the isolates also contributed to the observed IMI/REL-resistant phenotype. Modeling of REL binding to the active site of GES-20 suggested that the acylated REL is positioned in an unstable conformation as a result of a constrained Ω-loop.
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Antibiotic Therapy for Difficult-to-Treat Infections in Lung Transplant Recipients: A Practical Approach. Antibiotics (Basel) 2022; 11:antibiotics11050612. [PMID: 35625256 PMCID: PMC9137688 DOI: 10.3390/antibiotics11050612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/28/2022] [Accepted: 04/29/2022] [Indexed: 01/27/2023] Open
Abstract
Lung transplant recipients are at higher risk to develop infectious diseases due to multi-drug resistant pathogens, which often chronically colonize the respiratory tract before transplantation. The emergence of these difficult-to-treat infections is a therapeutic challenge, and it may represent a contraindication to lung transplantation. New antibiotic options are currently available, but data on their efficacy and safety in the transplant population are limited, and clinical evidence for choosing the most appropriate antibiotic therapy is often lacking. In this review, we provide a summary of the best evidence available in terms of choice of antibiotic and duration of therapy for MDR/XDR P. aeruginosa, Burkholderia cepacia complex, Mycobacterium abscessus complex and Nocardia spp. infections in lung transplant candidates and recipients.
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In Vitro Activity of Ceftolozane-Tazobactam, Imipenem-Relebactam, Ceftazidime-Avibactam, and Comparators against Pseudomonas aeruginosa Isolates Collected in United States Hospitals According to Results from the SMART Surveillance Program, 2018 to 2020. Antimicrob Agents Chemother 2022; 66:e0018922. [PMID: 35491836 DOI: 10.1128/aac.00189-22] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Ceftolozane-tazobactam (C/T), imipenem-relebactam (IMR), and ceftazidime-avibactam (CZA) were tested against 2,531 P. aeruginosa strains isolated from patients in the United States from 2018 to 2020 as part of the SMART (Study for Monitoring Antimicrobial Resistance Trends) surveillance program. MICs were determined by CLSI broth microdilution and interpreted using CLSI M100 (2021) breakpoints. Imipenem-, IMR-, or C/T-nonsusceptible isolates were screened for β-lactamase genes: 96.4% of all isolates and ≥70% of multidrug-resistant (MDR), pan-β-lactam-nonsusceptible, and difficult-to-treat resistance (DTR) isolates were C/T-susceptible; 52.2% of C/T-nonsusceptible isolates remained susceptible to IMR compared to 38.9% for CZA; and 1.7% of isolates tested were nonsusceptible to both C/T and IMR versus 2.2% of isolates with a C/T-nonsusceptible and CZA-resistant phenotype (a difference of 12 isolates). C/T and IMR modal MICs for pan-β-lactam-nonsusceptible isolates remained at or below their respective susceptible MIC breakpoints from 2018 to 2020, while the modal MIC for CZA increased 2-fold from 2018 to 2019 and exceeded the CZA-susceptible MIC breakpoint in both 2019 and 2020. Only six of 802 molecularly characterized isolates carried a metallo-β-lactamase, and two isolates carried a GES carbapenemase. Most P. aeruginosa isolates were C/T-susceptible, including many with MDR, pan-β-lactam-nonsusceptible, DTR, CZA-resistant, and IMR-nonsusceptible phenotypes. While C/T was the most active antipseudomonal agent, IMR demonstrated greater activity than CZA against isolates nonsusceptible to C/T.
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Tratamiento de las infecciones graves por Pseudomonas aeruginosa multirresistente. Med Intensiva 2022. [DOI: 10.1016/j.medin.2022.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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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: 31] [Impact Index Per Article: 15.5] [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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O'Donnell JN, Putra V, Belfiore GM, Maring BL, Young K, Lodise TP. In vitro activity of imipenem/relebactam plus aztreonam against metallo-β-lactamase producing, OprD-deficient Pseudomonas aeruginosa with varying levels of Pseudomonas-derived cephalosporinase production. Int J Antimicrob Agents 2022; 59:106595. [PMID: 35483625 DOI: 10.1016/j.ijantimicag.2022.106595] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 03/07/2022] [Accepted: 04/17/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Limited treatment options exist for metallo-β-lactamase (MBL)-producing Pseudomonas aeruginosa infections. Imipenem/relebactam plus aztreonam may be an option. METHODS Ten OprD(-) P. aeruginosa isolates (3 parent strains; 7 MBL-producers) were evaluated using checkerboard methodology and Fractional Inhibitory Concentration Index (FICI). Isolates exhibiting synergy in checkerboard studies (FICI ≤0.5) were evaluated using 24-hour static concentration time-kill. Bacteria in late log-phase growth were diluted to 1 × 106 cfu/mL and incubated at 37°C for 24 hours. Samples were drawn at 0, 2, 4, 6 and 24 hours. Physiologic fCmax, fCss,avg and fCmin of imipenem (26.7, 5.6, 0.5 mg/L), relebactam (13.1, 4, 0.8 mg/L) and aztreonam (62, 29, 8 mg/L) were used. Synergy in time-kill studies was defined as >2 log10 cfu/mL reduction compared to the most active individual agent. RESULTS Synergy was observed in five isolates in checkerboard studies, including three of seven MBL-producing isolates. Isolates which were OprD(-) and harboured inducible Pseudomonas-derived cephalosporinases (PDCs) did not show synergy as defined by FICI, however aztreonam MICs were significantly reduced with the combination. In time-kill studies, ATM alone was as active as combination regimens for MBL-producing isolates with deleted or inducible PDC production. For strains exhibiting constitutive PDC production, I/R plus ATM was synergistic at fCss,avg concentrations but exhibited similar activity to ATM at fCmin and fCmax concentrations. CONCLUSIONS Imipenem/relebactam plus aztreonam appears to exhibit synergy for some MBL-producing P. aeruginosa at physiologic concentrations. Further study of the effect of dynamic concentrations is needed to understand fully the utility of this combination.
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Affiliation(s)
- J Nicholas O'Donnell
- Assistant Professor of Pharmacy Practice, Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, NY, USA.
| | - Vibert Putra
- Graduate Research Assistant, Department of Basic and Clinical Sciences, Albany College of Pharmacy and Health Sciences, Albany, NY, USA
| | - Gina M Belfiore
- PharmD Candidate, Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, NY, USA
| | - Brittney L Maring
- Research Assistant, Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, NY, USA
| | - Katherine Young
- Senior Principal Scientist, Merck & Co., Inc., Kenilworth, NJ, USA
| | - Thomas P Lodise
- Professor of Pharmacy Practice, Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, NY, USA
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Abstract
Relebactam is a novel β-lactamase inhibitor of Ambler class A and C β-lactamases that has been developed in combination with imipenem/cilastatin for the treatment of carbapenem-resistant bacterial infections. In this study, we evaluated the in vitro antibacterial activity of imipenem/relebactam (IMR) against imipenem-nonsusceptible Enterobacterales and Pseudomonas aeruginosa isolates from Japan. Two sets of antibacterial susceptibility tests were conducted according to the susceptibility testing standard of the Clinical and Laboratory Standards Institute. In the first set, antibacterial susceptibility as measured by the MIC50/90 (MIC range) of IMR was assessed for the following 61 imipenem-nonsusceptible strains: 2 Enterobacter cloacae complex (not determined [0.25 μg/mL]), 33 Klebsiella aerogenes (0.5/1 μg/mL [0.5 to 1 μg/mL]), 2 Serratia marcescens (not determined [1 to 2 μg/mL]), and 24 P. aeruginosa (2/128 μg/mL [0.25 to >128 μg/mL]). In the second set, antibacterial susceptibility was assessed for the following 8 imipenem-nonsusceptible strains: 4 Escherichia coli, 1 E. cloacae complex and 3 Klebsiella pneumoniae. The MIC ranges of IMR for these strains were 0.25 to 0.5 μg/mL, 0.5 μg/mL, and 0.5 to 16 μg/mL, respectively. The antibacterial activity of IMR was similar to or lower than that of amikacin and comparable to or greater than those of other reference drugs. In conclusion, IMR has shown antibacterial activity against clinical isolates from Japan and, therefore, is expected to become a new therapeutic option for carbapenem-resistant infections in Japan. IMPORTANCE Carbapenem-resistant Enterobacterales and carbapenem-resistant Pseudomonas aeruginosa strains pose a global threat. Antibacterial activity of imipenem/relebactam (IMR) against clinical isolates of these bacteria from several global regions has been shown; however, as yet there are no reports on Japanese isolates. In this study, we evaluated the in vitro antibacterial activity of IMR against imipenem-nonsusceptible Enterobacterales and Pseudomonas aeruginosa isolates from Japan. The antibacterial activity of IMR against imipenem-nonsusceptible Enterobacterales was generally comparable to that of amikacin (AMK) and comparable to or higher than those of other reference drugs tested. The antibacterial activity of IMR against imipenem-nonsusceptible P. aeruginosa isolates was lower than that of AMK but comparable to or higher than those of other drugs. These results support the use of IMR as a new treatment option for infections due to Enterobacterales and P. aeruginosa strains that are resistant to existing β-lactams and other antibacterial agents.
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The Ins and Outs of Susceptibility Testing for New β-Lactam/β-Lactamase Inhibitor Combinations for Gram-Negative Organisms. J Clin Microbiol 2022; 60:e0080721. [PMID: 35387484 DOI: 10.1128/jcm.00807-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Ceftazidime-avibactam, meropenem-vaborbactam, and imipenem-relebactam are among the newest β-lactam/β-lactamase inhibitors (BL/BLIs) introduced to the North American antibiotic market. All have broad Gram-negative activity, including against certain carbapenemases. Despite this, susceptibility testing is warranted due to variable activity against certain β-lactamases (e.g., oxacillinases) and the presence of acquired resistance mechanisms in some isolates. Here, we discuss what we know about these new antimicrobial agents and how to navigate implementation of susceptibility testing and reporting of these agents in clinical laboratories.
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Kunz Coyne AJ, El Ghali A, Holger D, Rebold N, Rybak MJ. Therapeutic Strategies for Emerging Multidrug-Resistant Pseudomonas aeruginosa. Infect Dis Ther 2022; 11:661-682. [PMID: 35150435 PMCID: PMC8960490 DOI: 10.1007/s40121-022-00591-2] [Citation(s) in RCA: 73] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 01/10/2022] [Indexed: 12/18/2022] Open
Abstract
Multidrug-resistant (MDR) and extensively drug-resistant (XDR) Pseudomonas aeruginosa isolates are frequent causes of serious nosocomial infections that may compromise the selection of antimicrobial therapy. The goal of this review is to summarize recent epidemiologic, microbiologic, and clinical data pertinent to the therapeutic management of patients with infections caused by MDR/XDR-P. aeruginosa. Historically, conventional antipseudomonal β-lactam antibiotics have been used for the empiric treatment of MDR/XDR-P. aeruginosa. Owing to the remarkable capacity of P. aeruginosa to confer resistance via multiple mechanisms, these traditional therapies are often rendered ineffective. To increase the likelihood of administering empiric antipseudomonal therapy with in vitro activity, a second agent from a different antibiotic class is often administered concomitantly with a traditional antipseudomonal β-lactam. However, combination therapy may pose an increased risk of antibiotic toxicity and secondary infection, notably, Clostridioides difficile. Multiple novel agents that demonstrate in vitro activity against MDR-P. aeruginosa (e.g., β-lactam/β-lactamase inhibitor combinations and cefiderocol) have been recently granted US Food and Drug Administration (FDA) approval and are promising additions to the antipseudomonal armamentarium. Even so, comparative clinical data pertaining to these novel agents is sparse, and concerns surrounding the scarcity of antibiotics active against refractory MDR/XDR-P. aeruginosa necessitates continued assessment of alternative therapies. This is particularly important in patients with cystic fibrosis (CF) who may be chronically colonized and suffer from recurrent infections and disease exacerbations due in part to limited efficacious antipseudomonal agents. Bacteriophages represent a promising candidate for combatting recurrent and refractory infections with their ability to target specific host bacteria and circumvent traditional mechanisms of antibiotic resistance seen in MDR/XDR-P. aeruginosa. Future goals for the management of these infections include increased comparator clinical data of novel agents to determine in what scenario certain agents may be preferred over others. Until then, appropriate treatment of these infections requires a thorough evaluation of patient- and infection-specific factors to guide empiric and definitive therapeutic decisions.
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Affiliation(s)
- Ashlan J Kunz Coyne
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Avenue, Detroit, MI, 48201, USA
| | - Amer El Ghali
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Avenue, Detroit, MI, 48201, USA
| | - Dana Holger
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Avenue, Detroit, MI, 48201, USA
| | - Nicholas Rebold
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Avenue, Detroit, MI, 48201, USA
| | - Michael J Rybak
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Avenue, Detroit, MI, 48201, USA.
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Shields RK, Stellfox ME, Kline EG, Samanta P, Van Tyne D. Evolution of Imipenem-Relebactam Resistance Following Treatment of Multidrug-Resistant Pseudomonas aeruginosa Pneumonia. Clin Infect Dis 2022; 75:710-714. [PMID: 35136967 PMCID: PMC9890448 DOI: 10.1093/cid/ciac097] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Indexed: 02/04/2023] Open
Abstract
We report the emergence of imipenem-relebactam nonsusceptible Pseudomonas aeruginosa in 5 patients treated for nosocomial pneumonia for 10-28 days. Genome sequence analysis identified treatment-emergent mutations in MexAB-OprM and/or MexEF-OprN efflux operons that arose independently in each patient across distinct P. aeruginosa sequence types. Testing with efflux-inhibitor PAβN restored imipenem-relebactam susceptibility.
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Affiliation(s)
- Ryan K Shields
- Correspondence: R. K. Shields, Associate Professor of Medicine, University of Pittsburgh, 3601 Fifth Avenue, Falk Medical Building, Suite 5B, Pittsburgh, PA 15213 ()
| | - Madison E Stellfox
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ellen G Kline
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Palash Samanta
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA,Antibiotic Management Program, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Daria Van Tyne
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA,Center for Evolutionary Biology and Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Effectiveness of ceftazidime-avibactam for the treatment of infections due to Pseudomonas aeruginosa. Int J Antimicrob Agents 2022; 59:106517. [PMID: 34990760 DOI: 10.1016/j.ijantimicag.2021.106517] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 11/30/2021] [Accepted: 12/29/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Clinical experience with ceftazidime-avibactam (CAZ-AVI) for the treatment due to multidrug or extremely resistant (MDR/XDR) Pseudomonas aeruginosa is limited. METHODS We conducted a retrospective cohort study of patients with MDR/XDR P. aeruginosa infections treated with CAZ-AVI Primary outcome was clinical cure by day 14, evaluated by logistic regression adjusted for the propensity score to receive CAZ-AVI as combination therapy. 30-day all-cause mortality, 90-day recurrence, emerging CAZ-AVI resistance, and safety of therapy were secondary outcomes. RESULTS Sixty-one first episodes of MDR/XDR P. aeruginosa infection were included. The most common source was lower respiratory tract (34.4%), 14.8% episodes developed bloodstream infection and 50.8% sepsis at presentation. Ceftazidime-avibactam therapy was initiated at a median of 7.0 (interquartile range [IQR]: 3.5-12.0) days from symptoms onset. It was used as combined therapy in 29 (47.5%) episodes. Clinical cure rate by day 14 was 54.1% and predictors of response were days to source control (adjusted odds ratio [aOR]: 0.84; 95% confidence interval [CI]: 0.72-0.98; P-value = 0.024), days until the initiation of CAZ-AVI therapy (aOR: 0.65; 95% CI: 0.49-0.86; P-value = 0.003), age (aOR: 1.07; 95% CI: 0.99-1.15; P-value = 0.066) and CAZ-AVI combination therapy (aOR: 0.02; 95% CI: 0.01-0.38; P-value = 0.009). Rates of 30-day all-cause mortality and 90-day recurrence were 13.1% and 12.5%, respectively. Emergence of drug resistance to CAZ-AVI was not detected. Treatment-related adverse events occurred in 3 episodes (4.9%). CONCLUSIONS CAZ-AVI constitutes a valid alternative for the treatment of infections due to MDR/XDR P. aeruginosa.
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How to Manage Pseudomonas aeruginosa Infections. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1386:425-445. [DOI: 10.1007/978-3-031-08491-1_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Simner PJ, Cherian J, Suh GA, Bergman Y, Beisken S, Fackler J, Lee M, Hopkins RJ, Tamma PD. OUP accepted manuscript. JAC Antimicrob Resist 2022; 4:dlac046. [PMID: 35529052 PMCID: PMC9071546 DOI: 10.1093/jacamr/dlac046] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/04/2022] [Indexed: 11/21/2022] Open
Abstract
Background Pseudomonas aeruginosa has the ability to exhibit resistance to a broad range of antibiotics, highlighting the importance of identifying alternative or adjunctive treatment options, such as phages. Patients and methods We report the case of a 25-year-old male who experienced an accidental electrocution resulting in exposed calvarium in the left parieto-temporal region, complicated by a difficult-to-treat P. aeruginosa (DTR-P. aeruginosa) infection. Cefiderocol was the sole antibiotic with consistent activity against six bacterial isolates obtained from the infected region over a 38 day period. Results WGS analysis identified a blaGES-1 gene as well as the MDR efflux pumps MexD and MexX in all six of the patient’s ST235 DTR-P. aeruginosa isolates, when compared with the reference genome P. aeruginosa PA01 and a P. aeruginosa ST235 isolate from an unrelated patient. After debridement of infected scalp and bone, the patient received approximately 6 weeks of cefiderocol in conjunction with IV phage Pa14NPøPASA16. Some improvement was observed after the initiation of cefiderocol; however, sustained local site improvement and haemodynamic stability were not achieved until phage was administered. No medication-related toxicities were observed. The patient remains infection free more than 12 months after completion of therapy. Conclusions This report adds to the growing literature that phage therapy may be a safe and effective approach to augment antibiotic therapy for patients infected with drug-resistant pathogens. Furthermore, it highlights the importance of the GES β-lactamase family in contributing to inactivation of a broad range of β-lactam antibiotics in P. aeruginosa, including ceftolozane/tazobactam, ceftazidime/avibactam and imipenem/relebactam.
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Affiliation(s)
| | - Jerald Cherian
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Yehudit Bergman
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | - Martin Lee
- Adaptive Phage Therapeutics, Gaithersburg, MD, USA
| | | | - Pranita D. Tamma
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Corresponding author. E-mail: ; @SimnerLab; @Pranita_tamma
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