Comparison of 3 Etest® methods and time-kill assay for determination of antimicrobial synergy against carbapenemase-producing Klebsiella species

Targeted 'knock out' therapy with a combination antimicrobial regimen restores treatment options in the management of extensively drug-resistant carbapenemase-producing organisms

Introduction. Cefiderocol (FDC) and the combination of ceftazidime-avibactam and aztreonam (CZA+ATM) are emerging therapeutic options to combat carbapenemase-producing organisms (CPOs) that exhibit resistance due to multiple β-lactamases.Hypothesis/Gap Statement. Molecular diagnostics and specialized antimicrobial susceptibility testing (AST) are infrequently available in most clinical laboratories, and outputs from reference laboratories are not always timely. Practical methods must be explored to provide meaningful advice to treat infections due to CPOs in real time.Aim. To evaluate the in vitro efficacy of FDC and CZA+ATM against CPOs and to compare colistin (CST) MICs obtained locally with those from the reference laboratory.Methodology. CPOs isolated from 2017 to 2023 inclusive were retrieved. AST for FDC was performed using disc diffusion, CZA and ATM individually by E-tests and the E-test superposition method for the combination CZA+ATM. CST AST was performed locally using the VITEK2 system, and MICs were compared with those attained from the reference laboratory where manual broth microdilution is performed.Results. Fifty-eight CPOs were analysed. OXA-48 was the most frequently detected carbapenemase (37.9%, n=22). Co-existing β-lactamases of Ambler classes A and C were present for 79.3% of CPOs (n=46). Twenty-nine isolates (50%) were found to be susceptible to FDC. Fifty-seven isolates (98.3%) were susceptible to CST according to the VITEK2, compared to 44 of 47 tested isolates (93.6%) by the reference broth microdilution. Essential agreement was found to be 78.7%, and categorical agreement was 91.5% with one major error and three very major errors (VMEs) reported. CZA+ATM was tested against 26 CPOs, all of which harboured metallo-β-lactamases. Synergy was detected for all except one isolate where additivity was noted. Of the 32 isolates where combination therapy was not assessed, 29 (90.6%) possessed serine-β-lactamases and were susceptible to CZA monotherapy, whilst three (9.4%) possessed an isolated metallo-β-lactamase and were susceptible to ATM monotherapy.Conclusions. FDC appears to perform favourably against CPOs harbouring serine-β-lactamases, but not metallo-β-lactamases. The VITEK2 may provide presumptive categorical information for CST susceptibility, but MICs must be confirmed by broth microdilution as VMEs can lead to treatment failures. Moreover, our study confirms potent in vitro activity of CZA+ATM against CPOs expressing multiple β-lactamases.

Evaluation of in vitro activity of ceftaroline, ceftobiprole and their combination with trimethoprim/sulfamethoxazole against MRSA isolates: a two center study

There is an increasing need for new synergistic antimicrobial combinations against multidrug-resistant bacteria. Our objective was to evaluate the activity of ceftaroline, ceftobiprole and their combination with trimethoprim/sulfamethoxazole against methicillin-resistant Staphylococcus aureus (MRSA) isolates recovered at two centers in Turkey. Activities of ceftaroline and ceftobiprole were tested against 100 MRSA isolates using gradient diffusion method. Activities of ceftaroline and ceftobiprole in combination with trimethoprim/sulfamethoxazole against 20 selected isolates (including all isolates that were non-susceptible to ceftaroline or ceftobiprole, and randomly selected isolates) were investigated using MIC:MIC ratio method. Antimicrobial interactions were interpreted using the fractional inhibitory concentration (FIC) index. The MIC50/MIC90 values for ceftaroline and ceftobiprole were 0.75/1 and 1/1.5 mg/L, respectively. Ceftaroline and ceftobiprole susceptibility rates among 100 MRSA isolates were 94% and 96%, respectively. Ceftaroline, ceftobiprole and trimethoprim/sulfamethoxazole MICs of isolates were not increased when ceftaroline or ceftobiprole was combined with trimethoprim/sulfamethoxazole. Ceftobiprole- trimethoprim/sulfamethoxazole combination demonstrated additivity against 35%, whereas ceftaroline- trimethoprim/sulfamethoxazole combination demonstrated additivity against 10% of 20 MRSA isolates. The remaining interactions for MRSA isolates were indifference. Three (75%) of four ceftobiprole-resistant isolates became susceptible to ceftobiprole after adding trimethoprim/sulfamethoxazole. None of the ceftaroline non-susceptible isolates became susceptible to ceftaroline after adding trimethoprim/sulfamethoxazole. Ceftobiprole- trimethoprim/sulfamethoxazole combination may be a better treatment option than ceftaroline- trimethoprim/sulfamethoxazole combination for MRSA infections. Clinical studies are needed to confirm the results of our in vitro study.

Tracing the origin of NDM-1-producing and extensively drug-resistant Pseudomonas aeruginosa ST357 in the Netherlands

BACKGROUND

In the hospital environment, carbapenemase-producing Pseudomonas aeruginosa (CPPA) may lead to fatal patient infections. However, the transmission routes of CPPA often remain unknown. Therefore, this case study aimed to trace the origin of CPPA ST357, which caused a hospital-acquired pneumonia in a repatriated critically ill patient suffering from Guillain-Barré Syndrome in 2023.

METHODS

Antimicrobial susceptibility of the CPPA isolate for 30 single and combination therapies was determined by disk-diffusion, Etest or broth microdilution. Whole-genome sequencing was performed for three case CPPA isolates (one patient and two sinks) and four distinct CPPA ST357 patient isolates received in the Dutch CPPA surveillance program. Furthermore, 193 international P. aeruginosa ST357 assemblies were collected via three genome repositories and analyzed using whole-genome multi-locus sequence typing in combination with antimicrobial resistance gene (ARG) characterization.

RESULTS

A Dutch patient who carried NDM-1-producing CPPA was transferred from Kenya to the Netherlands, with subsequent dissemination of CPPA isolates to the local sinks within a month after admission. The CPPA case isolates presented an extensively drug-resistant phenotype, with susceptibility only for colistin and cefiderocol-fosfomycin. Phylogenetic analysis showed considerable variation in allelic distances (mean = 150, max = 527 alleles) among the ST357 isolates from Asia (n = 92), Europe (n = 58), Africa (n = 21), America (n = 16), Oceania (n = 2) and unregistered regions (n = 4). However, the case isolates (n = 3) and additional Dutch patient surveillance program isolates (n = 2) were located in a sub-clade of isolates from Kenya (n = 17; varying 15-49 alleles), the United States (n = 7; 21-115 alleles) and other countries (n = 6; 14-121 alleles). This was consistent with previous hospitalization in Kenya of 2/3 Dutch patients. Additionally, over half of the isolates (20/35) in this sub-clade presented an identical resistome with 9/17 Kenyan, 5/5 Dutch, 4/7 United States and 2/6 other countries, which were characterized by the blaNDM-1, aph(3')-VI, ARR-3 and cmlA1 ARGs.

CONCLUSION

This study presents an extensively-drug resistant subclone of NDM-producing P. aeruginosa ST357 with a unique resistome which was introduced to the Netherlands via repatriation of critically ill patients from Kenya. Therefore, the monitoring of repatriated patients for CPPA in conjunction with vigilance for the risk of environmental contamination is advisable to detect and prevent further dissemination.

Synergistic Effect and Time-Kill Evaluation of Eugenol Combined with Cefotaxime Against Staphylococcus aureus

Eugenol, a clove-derived aromatic compound has shown antibacterial activity against many species, including Staphylococcus aureus. Epidemiology studies from the past two decades reported an increased number of healthcare-associated and skin tissue infections due to S. aureus antimicrobial resistance (AMR) including several cases of resistance to β-lactam antibiotics, such as cefotaxime. We aimed to investigate whether eugenol can cause lethality of S. aureus including the strain resistant to methicillin and the wild strain isolated from a hospital patient. Moreover, we asked whether eugenol could enhance the therapeutic effect of cefotaxime, one of the most prescribed 3rd generation cephalosporin β-lactam antibiotics, of which S. aureus resistance to this antibiotic has emerged. The minimum inhibitory concentration (MIC) of each substance was determined using the standard broth microdilution test following the combination experiment performed using checkerboard dilution. The type of interactions, including synergistic and additivity, was determined using isobologram analysis, and the dose reduction index (DRI) was calculated. The time-kill kinetic assay was performed to evaluate the dynamic bactericidal activity of eugenol alone and in combination with cefotaxime. We showed that eugenol alone is bactericidal against S. aureus ATCC 33591 and the clinical isolate. Eugenol combined with cefotaxime resulted synergistic effect against S. aureus ATCC 33591, ATCC 29213, and ATCC 25923. Eugenol may be capable to improve the therapeutic effect of cefotaxime against methicillin-resistant S. aureus (MRSA).

Ceftazidime-Avibactam plus Aztreonam for the Treatment of Infections by VIM-Type-Producing Gram-Negative Bacteria

This is a retrospective single-center study of 24 patients who received ceftazidime-avibactam plus aztreonam (CZA/ATM) for the treatment of VIM-type-producing Gram-negative bacillus (GNB) infections. The bacteria isolated were Enterobacterales in 22 patients and Pseudomonas aeruginosa in 2. Sixteen out of 19 isolates showed synergistic activity. Two patients presented clinical failure at day 14, and the 30-day mortality was 17% (4/24). CZA/ATM could be considered an alternative therapy for VIM-type-producing GNB infections.

Antimicrobial Synergy Testing: Comparing the Tobramycin and Ceftazidime Gradient Diffusion Methodology Used in Assessing Synergy in Cystic Fibrosis-Derived Multidrug-Resistant Pseudomonas aeruginosa

The need for synergy testing is driven by the necessity to extend the antimicrobial spectrum, reducing drug dosage/toxicity and the development of resistance. Despite the abundance of synergy testing methods, there is the absence of a gold standard and a lack of synergy correlation among methods. The most popular method (checkerboard) is labor-intensive and is not practical for clinical use. Most clinical laboratories use several gradient synergy methods which are quicker/easier to use. This study sought to evaluate three gradient synergy methods (direct overlay, cross, MIC:MIC ratio) with the checkerboard, and compare two interpretative criteria (the fractional inhibitory concentration index (FICI) and susceptibility breakpoint index (SBPI)) regarding these methods. We tested 70 multidrug-resistant Pseudomonas aeruginosa, using a tobramycin and ceftazidime combination. The agreement between the checkerboard and gradient methods was 60 to 77% for FICI, while agreements for SBPI that ranged between 67 and 82.86% were statistically significant (p ≤ 0.001). High kappa agreements were observed using SBPI (Ƙ > 0.356) compared to FICI (Ƙ < 0.291) criteria, and the MIC:MIC method demonstrated the highest, albeit moderate, intraclass correlation coefficient (ICC = 0.542) estimate. Isolate resistance profiles suggest method-dependent synergism for isolates, with ceftazidime susceptibility after increased exposure. The results show that when interpretative criteria are considered, gradient diffusion (especially MIC:MIC) is a valuable and practical method that can inform the treatment of cystic fibrosis patients who are chronically infected with P. aeruginosa.

Infective Endocarditis Due to Corynebacterium Species: Clinical Features and Antibiotic Resistance

Background

Corynebacterium species are often dismissed as contaminants in blood cultures, but they can also cause infective endocarditis (IE), which is a severe condition. Antibiotic resistance of corynebacteria is increasing making treatment challenging. Reports on IE caused by Corynebacterium species are scarce and more knowledge is needed.

Methods

Cases of IE caused by Corynebacterium species were identified through the Swedish Registry of Infective Endocarditis. Isolates were collected for species redetermination by matrix-assisted laser desorption ionization-time of flight and for antibiotic susceptibility testing using Etests.

Results

Thirty episodes of IE due to Corynebacterium species were identified between 2008 and 2017. The median age of patients was 71 years (interquartile range, 60–76) and 77% were male. Corynebacterium striatum (n = 11) was the most common IE causing pathogen followed by Corynebacterium jeikeium (n = 5). Surgery was performed in 50% and in-hospital mortality rate was 13%. Patients with IE caused by Corynebacterium species were significantly more likely to have prosthetic valve endocarditis (70%), compared with patients with IE due to Staphylococcus aureus or non-beta-hemolytic streptococci (14% and 26%, respectively) (P < .0001). Vancomycin was active towards all Corynebacterium isolates, whereas resistance towards penicillin G was common.

Conclusions

Corynebacterium species cause IE, where prosthetic valves are mainly affected and surgery is often performed. Corynebacterium striatum is an important causative agent of IE within the genus. Antibiotic resistance of corynebacteria is relatively common but resistance towards vancomycin could not be detected in vitro.

Evaluation of the in vitro interaction of fosfomycin and meropenem against metallo-β-lactamase-producing Pseudomonas aeruginosa using Etest and time-kill assay

Pseudomonas aeruginosa is a nosocomial pathogen containing various resistance mechanisms. Among them, metallo-β-lactamase (MBL)-producing Pseudomonas are difficult to treat. Fosfomycin is an older antibiotic that has recently seen increased usage due to its activity against a broad spectrum of multidrug-resistant organisms. Our aim was to evaluate the combination of fosfomycin and meropenem against 20 MBL-producing P. aeruginosa (100% meropenem-resistant and 20% fosfomycin-resistant) using both an Etest minimal inhibitory concentration (MIC): MIC method and time-kill assay. MICs for fosfomycin and meropenem were determined by Etest and by broth microdilution method for the latter. The combination demonstrated synergy by Etest in 3/20 (15%) isolates and 5/20 (25%) isolates by time-kill assay. Results from the Etest method and time-kill assay were in agreement for 14/20 (70%) of isolates. No antagonism was found. Comparing both methods, Etest MIC: MIC method may be useful to rapidly evaluate other antimicrobial combinations.

Prevalence of Klebsiella pneumoniae carbapenemase - and New Delhi metallo-beta-lactamase-positive K. pneumoniae in Sergipe, Brazil, and combination therapy as a potential treatment option

INTRODUCTION

Carbapenem-resistant Klebsiella pneumoniae infection lacks treatment options and is associated with prolonged hospital stays and high mortality rates. The production of carbapenemases is one of the most important factors responsible for this multi-resistance phenomenon.

METHODS

In the present study, we analyzed the presence of genes encoding carbapenemases in K. pneumoniae isolates circulating in one of the public hospitals in the city of Aracaju, Sergipe, Brazil. We also determined the best combination of drugs that display in vitro antimicrobial synergy. First, 147 carbapenem-resistant K. pneumoniae isolates were validated for the presence of blaKPC, bla GES, bla NDM, bla SPM, bla IMP, bla VIM, and bla OXA-48 genes using multiplex polymerase chain reaction. Thereafter, using two isolates (97 and 102), the role of double and triple combinational drug therapy as a treatment option was analyzed.

RESULTS

Seventy-four (50.3%) isolates were positive for bla NDM, eight (5.4%) for bla KPC, and one (1.2%) for both bla NDM and bla KPC. In the synergy tests, double combinations were better than triple combinations. Polymyxin B and amikacin for isolate 97 and polymyxin B coupled with meropenem for isolate 102 showed the best response.

CONCLUSIONS

Clinicians in normal practice use multiple drugs to treat infections caused by multi-resistant microorganism; however, in most cases, the benefit of the combinations is unknown. In vitro synergistic tests, such as those described herein, are important as they might help select an appropriate multi-drug antibiotic therapy and a correct dosage, ultimately reducing toxicities and the development of antibiotic resistance.

Comparison of methods for the detection of in vitro synergy in multidrug-resistant gram-negative bacteria

BACKGROUND

The use of combined antibiotic therapy has become an option for infections caused by multidrug-resistant (MDR) bacteria. The time-kill (TK) assay is considered the gold standard method for the evaluation of in vitro synergy, but it is a time-consuming and expensive method. The purpose of this study was to evaluate two methods for testing in vitro antimicrobial combinations: the disk diffusion method through disk approximation (DA) and the agar gradient diffusion method via the MIC:MIC ratio. The TK assay was included as the gold standard. MDR Gram-negative clinical isolates (n = 62; 28 Pseudomonas aeruginosa, 20 Acinetobacter baumannii, and 14 Serratia marcescens) were submitted to TK, DA, and MIC:MIC ratio synergy methods.

RESULTS

Overall, the agreement between the DA and TK assays ranged from 20 to 93%. The isolates of A. baumannii showed variable results of synergism according to TK, and the calculated agreement was statistically significant in this species against fosfomycin with meropenem including colistin-resistant isolates. The MIC:MIC ratiometric agreed from 35 to 71% with TK assays. The kappa test showed good agreement for the combination of colistin with amikacin (K = 0.58; P = 0.04) among the colistin-resistant A. baumannii isolates.

CONCLUSIONS

The DA and MIC:MIC ratiometric methods are easier to perform and might be a more viable tool for clinical microbiology laboratories.

In vitro synergy with fosfomycin plus doxycyclin against linezolid and vancomycin-resistant Enterococcus faecium

OBJECTIVE

Linezolid and vancomycin-resistant Enterococcus faecium (LRVREF) is globally emerging as a urinary nosocomial pathogen. A decrease in the amount of successful treatment options has created a necessity for the development of novel antimicrobial therapies. Combination therapy may provide an effective alternative for treatment. Fosfomycin and doxycyclin are currently used individually for the treatment of urinary tract infections. Fosfomycin has recently seen increased use because of its persistent activity against a large spectrum of multidrug-resistant organisms. The purpose of this study was to investigate the interaction of fosfomycin plus doxycyclin against LRVREF isolates.

METHODS

MICs for fosfomycin and doxycyclin were determined for 24 unique clinical LRVREF isolates (4%, fosfomycin-susceptible; 92%, doxycyclin-susceptible). In vitro synergy testing with the combination of fosfomycin and doxycyclin was performed using an Etest method and time-kill assay.

RESULTS

The combination of fosfomycin and doxycyclin demonstrated synergy with the Etest method in 11/24 (46%) isolates and in 10/24 (42%) isolates by the time-kill assay. Results from the Etest method and time-kill assay were in agreement for 7/24 (29.2%) of isolates. No antagonism was found.

CONCLUSIONS

The combination of fosfomycin and doxycyclin should be evaluated further with additional LRVREF isolates. In vivo studies should also be performed before use in clinical situations.

In vitro activity of ceftaroline in combination with other antimicrobials active against Staphylococcus spp

INTRODUCTION

We evaluated the in vitro activity of the combination of ceftaroline with daptomycin, linezolid and vancomycin against methicillin-resistant Staphylococcus aureus and coagulase-negative Staphylococcus (CNS).

MATERIAL AND METHODS

We analysed 70 staphylococcal strains (31 S. aureus and 39 CNS) with the Etest using the MIC:MIC ratio method and calculation of fractional inhibitory concentration indexes.

RESULTS

The combination of ceftaroline with daptomycin showed an additive effect (53.2%) and synergy (6.6%) against methicillin-susceptible S. aureus, and an additive effect (81.2%) against methicillin-resistant S. aureus (MRSA). This combination also showed an additive effect against 33% of linezolid-susceptible CNS and was not synergistic against linezolid-resistant CNS. The combination of ceftaroline with vancomycin was synergistic (87%) and ceftaroline with linezolid was additive (37%) against MRSA.

CONCLUSIONS

The combinations of ceftaroline with daptomycin, vancomycin or linezolid showed additive and/or synergistic effects against methicillin-resistant Staphylococcus.

Candida glabrata complex from patients with healthcare-associated infections in Mansoura University Hospitals, Egypt: distribution, antifungal susceptibility and effect of fluconazole and polymyxin B combination

Introduction

Candida glabrata complex is composed of three cryptic species, Candida glabrata sensu stricto, C. bracarensis and C. nivariensis. Its reduced susceptibility to fluconazole is responsible for treatment failure of its infections. Combination therapy is recommended to treat these resistant strains. This study assessed the distribution of C. glabrata complex collected from patients in Mansoura University Hospitals and their antifungal susceptibility, with evaluation of fluconazole and polymyxin B combination against them.

Methods

C. glabrata complex was collected from patients with healthcare-associated infections. The isolates were identified biochemically then the species were detected using multiplex PCR. The susceptibility of isolates to antifungals and polymyxin B was tested by the microdilution assay. The effect of fluconazole and polymyxin B combination was assessed by checkerboard microdilution and time kill assays.

Results

This study included 45 isolates of Candida glabrata complex. The common isolate was Candida glabrata sensu stricto (38 isolates). There were 4 isolates of C. bracarensis and three isolates of C. nivariensis. All isolates were susceptible to amphotericin B, and 17.8% were susceptible to itraconazole. Regarding fluconazole, 48.9% of isolates were susceptible dose-dependent and 51.1% were resistant. Synergistic effect of the combination was observed in 68.9% of isolates by the checkerboard method and in 66.7% of isolates using the time kill assay.

Conclusions

Candida glabrata sensu stricto is the main member of the complex. Combination of fluconazole and polymyxin B can be considered a treatment option for fluconazole resistant C. glabrata complex infections. In vivo studies are needed to validate these results.

When One Drug Is Not Enough: Context, Methodology, and Future Prospects in Antibacterial Synergy Testing

Antibacterial combinations have long been used to accomplish a variety of therapeutic goals, including prevention of resistance and enhanced antimicrobial activity. In vitro synergy testing methods, including the checkerboard array, the time-kill study, diffusion assays, and pharmacokinetic/pharmacodynamic models, are used commonly in the research setting, but are not routinely performed in the clinical microbiology laboratory because of test complexity and uncertainty about their predictive value for patient outcomes. Optimized synergy testing techniques and better data on the relationship between in vitro results and clinical outcomes are needed to guide the rational use of antimicrobial combinations in the multidrug resistance era.

Evaluation of in vitro methods for testing tigecycline combinations against carbapenemase-producing Klebsiella pneumoniae isolates

OBJECTIVES

Treatment of infections caused by carbapenemase-producing Klebsiella pneumoniae (CPKP) frequently involves combination therapy with various antimicrobial agents in the hope of achieving synergistic effects. Routine laboratory antimicrobial synergy testing is a service that is currently unavailable owing to the laborious nature of the reference time-kill assay (TKA) as well as the widely used chequerboard method. In this study, we explored whether easier methods, based on the Etest technique, might offer a suitable alternative.

METHODS

In vitro interactions of tigecycline combination with colistin, gentamicin, fosfomycin or meropenem against 26 CPKP isolates were evaluated employing the TKA, chequerboard method and three Etest methodologies (the MIC/MIC ratio, the cross formation and the agar/Etest method). Rates of consequent synergy and concordance of the studied methods were determined.

RESULTS

All antimicrobial combinations demonstrated some degree of synergy against the CPKP isolates tested. No antagonism was observed for any of the combinations. All methods showed poor synergy concordance with the TKA, producing non-significant kappa (κ) results. Etest methods (MIC/MIC ratio and agar/Etest) exhibited fair agreement (κ=0.29 and 0.38, respectively) with the chequerboard method.

CONCLUSION

There is a poor correlation between synergy testing methods of tigecycline combinations, which may be associated with their different endpoints. To elucidate method comparability and reliability, their correlation with clinical outcomes appears important.

Activity of Ceftazidime-Avibactam Alone and in Combination with Ertapenem, Fosfomycin, and Tigecycline Against Carbapenemase-Producing Klebsiella pneumoniae

The aim of this study was to investigate the synergy between ceftazidime-avibactam, ertapenem, fosfomycin, and tigecycline against carbapenemase-producing Klebsiella pneumoniae using the E test MIC:MIC (minimum inhibitory concentration) ratio synergy method. The results were interpreted using fractional inhibitory concentration index (FICI) to describe the effects of antimicrobial combinations in vitro. To assess the clinical significance of each antibiotic combination, the susceptible breakpoint index (SBPI) was calculated for each combination, and within each strain. The FICI method revealed that the most synergistic combinations against carbapenemase-producing K. pneumoniae were ceftazidime-avibactam with ertapenem and ceftazidime-avibactam with fosfomycin. This effect was demonstrated in 47% (9/19) of all tested clinical K. pneumoniae isolates. Considering the effects of all drug combinations in K. pneumoniae harboring bla_KPC, bla_NDM, and bla_OXA-48 genes, we observed that the combination of ceftazidime-avibactam with fosfomycin was the most synergistic in New Delhi metallo-β-lactamase (NDM)-producing K. pneumoniae, and the combination of ceftazidime-avibactam with ertapenem was the most synergistic in K. pneumoniae carbapenemase (KPC)-producing K. pneumoniae. In addition, all tested combinations were synergistic against oxacillinase (OXA)-48-producing K. pneumoniae, except the combination of ceftazidime-avibactam with tigecycline. The SBPI index showed that ceftazidime-avibactam in combination with fosfomycin reduced the MIC to less than the susceptibility breakpoint among all tested carbapenemase-producing K. pneumoniae. Moreover, the combinations of ceftazidime-avibactam with ertapenem, and ceftazidime-avibactam with tigecycline were able to reduce the MIC to less than the susceptibility breakpoint in all KPC- and OXA-48-producing K. pneumoniae.

Optimizing Antibiotic Administration for Pneumonia

Pneumonia, including community-acquired bacterial pneumonia, hospital-acquired bacterial pneumonia, and ventilator-acquired bacterial pneumonia, carries unacceptably high morbidity and mortality. Despite advances in antimicrobial therapy, emergence of multidrug resistance and high rates of treatment failure have made optimization of antibiotic efficacy a priority. This review focuses on pharmacokinetic and pharmacodynamic approaches to antibacterial optimization within the lung environment and in the setting of critical illness. Strategies for including these approaches in drug development programs as well as clinical practice are described and reviewed.

In vitro investigation of synergy among fosfomycin and parenteral antimicrobials against carbapenemase-producing Enterobacteriaceae

Intravenous fosfomycin is undergoing clinical development in the United States for treatment of complicated urinary tract infections (cUTIs) and may be prescribed as a component of dual antibiotic regimens against carbapenemase-producing Enterobacteriaceae (CPE). Fosfomycin, aztreonam, cefepime, ceftazidime, ceftazidime/avibactam, ceftolozane/tazobactam, meropenem, piperacillin/tazobactam, and tobramycin minimum inhibitory concentrations (MICs) were determined by gradient diffusion strip (GDS) against CPE isolates (N = 49). The GDS cross method was used to assess antibiotic interactions between fosfomycin and the aforementioned parenteral antibiotics. The resultant fractional inhibitory concentration index was used to classify interactions. Fosfomycin-containing combinations were evaluated only if nonsusceptible to the second agent. The fosfomycin MIC₅₀ was ≥1024 mg/L by GDS. Synergy or additivity was detected in 80 (22%) fosfomycin-containing combinations. Antagonism was not observed. Ceftolozane/tazobactam most frequently displayed synergy [8 (16.3%) isolates]. When CPE are isolated, clinical laboratories should consider performing GDS synergy tests to identify favorable antibiotic interactions.

Prevalence of in vitro synergistic antibiotic interaction between fosfomycin and nonsusceptible antimicrobials in carbapenem-resistant Pseudomonas aeruginosa

PURPOSE

We assessed the synergistic potential of fosfomycin and parenteral antibiotics among carbapenem-resistant Pseudomonas aeruginosa (CRP).

METHODOLOGY

Minimum inhibitory concentrations (MICs) were determined by broth microdilution for all antibiotics except fosfomycin, for which the gradient diffusion strip (GDS) method was used. The GDS cross method was performed to assess interactions between fosfomycin and: aztreonam, cefepime, ceftazidime, ceftazidime/avibactam, ceftolozane/tazobactam, meropenem, piperacillin/tazobactam and tobramycin. Only organisms that were nonsusceptible to the second drug were assessed.

RESULTS

Among 153 clinical isolates, the fosfomycin MIC50/90 was 48/≥1024 mg l^-1 . Synergy was detected in 131/604 (21.7 %) fosfomycin-antibiotic combinations among 76 (49.7 %) isolates. Ceftazidime (42/81, 51.9%) and ceftolozane/tazobactam (7/14, 50.0%) displayed synergy most frequently. Meropenem susceptibility was restored in 21 (13.7 %) isolates. Antagonism was not observed.

CONCLUSION

Fosfomycin synergy was commonly observed in vitro among CRP. These data may guide the selection of combination antibiotic therapy. The susceptibility to other antibiotics was restored in combination with fosfomycin, warranting further in vivo evaluation.

Colistin monotherapy versus colistin/rifampicin combination therapy in pneumonia caused by colistin-resistant Acinetobacter baumannii: A randomised controlled trial

OBJECTIVES

The aim of this study was to confirm the synergistic effect of colistin/rifampicin combination therapy compared with colistin monotherapy in pneumonia caused by colistin-resistant Acinetobacter baumannii (CoRAB). The utility of the Etest was also assessed.

METHODS

Nine subjects with pneumonia caused by CoRAB were enrolled from 20 July 2016 to 21 June 2018. Subjects were randomised to colistin/rifampicin combination therapy or colistin monotherapy. After exclusion of one patient who dropped out, the microbiological response (MR) and clinical response (CR) on Day 14 and mortality on Day 30 were assessed. Etest was conducted using CoRAB isolated at study enrolment.

RESULTS

The MR rate in the colistin/rifampicin combination group (100.0%) was better than that in the colistin group (40.0%), however the difference was not statistically significant (P=0.196). The CR rate was not significantly different between the two groups. The MR (100.0%) and CR (100.0%) rates in subjects with 'partial synergy' as shown by Etest were higher than those (25.0% and 50.0%, respectively) in subjects with 'indifferent' results (i.e. no synergistic effect), however the difference was not statistically significant (P=0.143 and 0.429, respectively). Mortality occurred in two subjects with 'indifferent' results by Etest.

CONCLUSIONS

Colistin/rifampicin combination therapy may have potential to achieve MR in pneumonia caused by CoRAB; however, achieving CR with this treatment is doubtful. 'Partial synergy' of colistin and rifampicin, as shown by Etest, may be a good prognostic factor [ClinicalTrial.gov ID: NCT03622918].

Infective endocarditis due to Streptococcus dysgalactiae: clinical presentation and microbiological features

Knowledge of infective endocarditis (IE) caused by Streptococcus dysgalactiae (SD) is limited. This study aimed to identify the clinical and microbiological features of SD-caused IE and to investigate any possible synergy between penicillin and gentamicin on SD isolates. Cases of IE 2008-2016 due to SD reported to the Swedish Registry of Infective Endocarditis (SRIE) were identified. Isolates were emm typed and synergy between antibiotics was determined in time-kill experiments. Medical records were reviewed and SD-cases were compared to cases of IE due to other pathogens reported to the SRIE. Fifty cases of SD-caused IE were confirmed. emm types stC74a, stG62647, and stG643 were most commonly encountered. The patients had a median age of 74 years (range 38-93) and were significantly older compared to patients with Staphylococcus aureus-caused IE, (65 years (p = 0.003)). The median time to diagnosis from symptom onset was 1 day for patients with SD-caused IE which was less compared to patients with IE due to the other pathogens (2-15 days). Embolization was seen in 46% and the in-hospital mortality was 8%. Etest-based methods did not indicate any synergy between penicillin and gentamicin whereas synergy was noted for four out of nine isolates applying time-kill assays. This is the largest study of SD-caused IE, a condition with an acute onset predominantly affecting elderly people. Synergy between penicillin and gentamicin against some SD isolates was distinguished but the potential benefit of this must be weighed against the risk of aminoglycoside side effects.

An update on technical, interpretative and clinical relevance of antimicrobial synergy testing methodologies

Testing for antimicrobial interactions has gained popularity in the last decade due to the increasing prevalence of drug-resistant organisms and limited options for the treatment of these infections. In vitro combination testing provides information, on which two or more antimicrobials can be combined for a good clinical outcome. Amongst the various in vitro methods of drug interactions, time-kill assay (TKA), checkerboard (CB) assay and E-test-based methods are most commonly used. Comparative performance of these methods reveals the TKA as the most promising method to detect synergistic combinations followed by CB assay and E-test. Various combinations of antimicrobials have been tested to demonstrate synergistic activity. Promising results were obtained for the combinations of meropenem plus colistin and rifampicin plus colistin against Acinetobacter baumannii, colistin plus carbapenem and carbapenem plus fluoroquinolones against Pseudomonas aeruginosa and colistin/polymyxin B plus rifampicin/meropenem against Klebsiella pneumoniae. Antagonism was detected in only few instances. The presence of synergy or antagonism with a combination seems to correlate with minimum inhibitory concentration of the agent and molecular mechanism involved in the resistance. Further studies need to be conducted to assess the utility of in vitro testing to predict clinical outcome and direct therapy for drug-resistant organisms.

Assessing the in vitro activity of ceftazidime/avibactam and aztreonam among carbapenemase-producing Enterobacteriaceae: Defining the zone of hope

Ceftazidime/avibactam plus aztreonam (CZA+ATM) is an emerging option to combat carbapenemase-producing Enterobacteriaceae (CPE) expressing resistance via multiple β-lactamases within Ambler classes A, B, C, and D. The benefit of this combination is apparent when the pathogen-specific resistance genotype is characterized. However, rapid molecular diagnostic systems may be unavailable to allow this precision medicine-based approach. Using synergy tests with antibiotic gradient diffusion strips (GDSs), we aimed to prove that the defined phenotypic profile of CPE is reliably predicted by the genotype to confirm the utility of this method as a phenotypic profiling tool for use in the clinical setting. Synergy assessments for CPE (n=10) that co-produce serine- and metallo-β-lactamases were performed by crossing CZA and ATM antibiotic GDSs (Liofilchem^® and Etest^®). The minimum inhibitory concentration (MIC):MIC ratio method was also conducted for five CPE. All CPE were resistant to CZA and ATM when tested alone. Using classical fractional inhibitory concentration definitions, synergy (9/10) and additivity (1/10) was detected by at least one method for all isolates. As predicted by cross-coverage of genotypically defined serine- and metallo-β-lactamases, for all isolates CZA+ATM produced a phenotypic profile distinguished by sizeable zones of inhibited growth which we term the 'zone of hope'. In conclusion, simple procedures utilizing antibiotic GDSs were concordant with the known genotypic profile of the CPE selected for study. This approach appears to be a valuable tool for guiding therapy in the absence of molecular diagnostic systems. Furthermore, this study confirms potent in vitro activity of CZA+ATM against CPE expressing multiple β-lactamases.

Effectiveness of a Double-Carbapenem Regimen in a KPC-Producing Klebsiella pneumoniae Infection in an Immunocompromised Patient

The progressive increase of infections produced by extensively drug-resistant carbapenemase-producing Klebsiella pneumoniae (XDR-CPKP) represents an important threat to public health. Unfortunately, optimal therapeutic options are scarce. Retrospective studies have recommended combined therapy with more than one antibiotic and, more recently, a double-carbapenem regimen has been reported to be an effective alternative therapy. Here, we describe an episode of sepsis in an immunocompromised patient after allogeneic hematopoietic stem cell transplantation, caused by an XDR-CPKP. Several in vitro synergy tests revealed a synergistic effect combining ertapenem and meropenem, which were used as combination therapy achieving clinical and microbiological success.

Ceftaroline Plus Ampicillin Against Gram-Positive Organisms: Results from E-Test Synergy Assays

In an era of increasing drug resistance and limited numbers of antimicrobials in the drug production pipeline, healthcare-associated infections represent a growing public health threat. When therapeutic options are limited, clinicians often resort to using antimicrobial combinations that produce a synergistic effect on the target pathogen. Novel antibiotics are therefore welcome in the daily practice of medicine. For example, ceftaroline is a broad-spectrum cephalosporin active against a variety of bacteria, including methicillin-resistant Staphylococcus aureus, but with limited activity against enterococci, particularly Enterococcus faecium. In this study, we tested the efficacy of ceftaroline against clinical isolates of gram-positive bacteria (S. aureus, Enterococcus faecalis, and E. faecium) by the broth microdilution and E-test assays, and then evaluated the synergistic effect of ceftaroline and ampicillin using the E-test method. The time-kill assay was used to confirm the data on selected strains. This drug combination has been recently shown to be effective against E. faecalis and could offer the advantage of cost-effectiveness (compared to other synergistic associations) as well as good tolerability. The E-test was chosen because of its relative simplicity of use that makes it suitable for routine clinical laboratories as a quick tool to guide clinicians when confronted with difficult-to-treat infections that may require an empirical approach. Our results indicate the presence of a synergistic effect of ceftaroline and ampicillin on most of the strains used, especially E. faecium and E. faecalis. The fact that two of those Enterococcus strains were vancomycin resistant suggests that the possible use of this combination for combating the spread of vancomycin-resistant enterococci should be explored.

In vitro antimicrobial synergy of colistin with rifampicin and carbapenems against colistin-resistant Acinetobacter baumannii clinical isolates

Increased use of colistin in a clinical setting had resulted in the emergence of colistin-resistant (CoR) Acinetobacter baumannii. Combination therapy has been studied as a new approach to treat infections caused by A. baumannii. Here, we investigated the in vitro antimicrobial synergistic activities of several antimicrobial agent combinations against CoR A. baumannii. A total of 41 non-duplicate clinical isolates of CoR A. baumannii from a tertiary care hospital in Korea were prospectively collected from April 2012 to December 2014. As a control group, 41 carbapenem-resistant but colistin-susceptible (CoS) A. baumannii strains were also evaluated. Minimum inhibitory concentrations (MICs) of antimicrobial agents were determined by Etest in triplicate, and in vitro synergy tests were performed by the Etest MIC:MIC ratio method. Synergistic activity was determined as the sum of each antimicrobial agent's fractional inhibitory concentration evaluated (ΣFIC): synergy, ≤0.5; indifference, >0.5-4; and antagonism, >4. Synergistic activities were more frequently observed in the CoR group than the CoS group for combinations of colistin-rifampicin (80.5% vs. 14.6%, P< 0.0001), colistin-meropenem (85.4% vs. 4.9%, P< 0.0001), and colistin-imipenem (46.3% vs. 2.4%, P< 0.0001). Combination with rifampicin or meropenem lowered colistin MICs against CoR A. baumannii clinical isolates to the susceptible range (≤ 2 μg/mL) more frequently (61.0%, 25/41, both) than combination with imipenem (29.3%, 12/41). Clinical trials are needed to prove the in vivo efficacy of those antimicrobial combinations that exhibited significant in vitro antimicrobial synergistic effects against CoR A. baumannii.

Clinical and microbiological features of infective endocarditis caused by aerococci

PURPOSE

To define the clinical presentation of aerococcal infective endocarditis (IE) and the prevalence of synergy between penicillin and gentamicin on aerococcal isolates.

METHODS

Cases of aerococcal IE between 2002 and 2014 were identified in the Swedish Registry of Infective Endocarditis (SRIE). MALDI-TOF MS was used to confirm species determination. The medical records were analysed and compared to cases reported to the SRIE caused by other pathogens.

RESULTS

Sixteen cases of aerococcal IE, fourteen with Aerococcus urinae and two with Aerococcus sanguinicola, were confirmed. Etest-based methods and time-kill experiments suggested synergy between penicillin and gentamicin towards seven of fifteen isolates. The patients with aerococcal IE were significantly older than those with streptococci or Staphylococcus aureus IE. Most of the patients had underlying urinary tract diseases or symptoms suggesting a urinary tract focus of the infection. Seven patients with aerococcal IE presented with severe sepsis but ICU treatment was needed only in one patient and there was no fatality. Valve exchange surgery was needed in four patients and embolization was seen in three patients.

CONCLUSIONS

This report is the largest on aerococcal IE and suggests that the prognosis is relatively favourable despite the fact that the patients are old and have significant comorbidities.

Meropenem/colistin synergy testing for multidrug-resistant Acinetobacter baumannii strains by a two-dimensional gradient technique applicable in routine microbiology

OBJECTIVES

Precise assessment of potential therapeutic synergy, antagonism or indifference between antimicrobial agents currently depends on time-consuming and hard-to-standardize in vitro chequerboard titration methods. We here present a method based on a novel two-dimensional antibiotic gradient technique named Xact™.

METHODS

We used a test comprising a combination of perpendicular gradients of meropenem and colistin in a single quadrant. We compared test outcomes with those obtained with classical chequerboard microbroth dilution testing in a study involving 27 unique strains of multidrug-resistant Acinetobacter baumannii from diverse origins.

RESULTS

We were able to demonstrate 92% concordance between the new technology and classical chequerboard titration using the A. baumannii collection. Two strains could not be analysed by Xact™ due to their out-of-range MIC of meropenem (>128 mg/L).

CONCLUSIONS

The new test was shown to be diagnostically useful, easy to implement and less labour intensive than the classical method.

Time-kill assay and Etest evaluation for synergy with polymyxin B and fluconazole against Candida glabrata

Fluconazole-resistant Candida glabrata is an emerging pathogen that causes fungemia. Polymyxin B, a last-resort antibiotic used to treat multidrug-resistant Gram-negative bacterial infections, has been found to possess in vitro fungicidal activity and showed synergy with fluconazole against a single strain of C. glabrata. Since both agents may be used simultaneously in intensive care unit (ICU) patients, this study was performed to test for possible synergy of this combination against 35 C. glabrata blood isolates, using 2 methods: a time-kill assay and an experimental MIC-MIC Etest method. Thirty-five genetically unique C. glabrata bloodstream isolates were collected from 2009 to 2011, identified using an API 20C system, and genotyped by repetitive sequence-based PCR (rep-PCR). MICs were determined by Etest and broth microdilution methods. Synergy testing was performed using a modified bacterial Etest synergy method and time-kill assay, with final results read at 24 h. The Etest method showed synergy against 19/35 (54%) isolates; the time-kill assay showed synergy against 21/35 (60%) isolates. Isolates not showing drug synergy had an indifferent status. Concordance between methods was 60%. In vitro synergy of polymyxin B and fluconazole against the majority of C. glabrata isolates was demonstrated by both methods. The bacterial Etest synergy method adapted well when used with C. glabrata. Etest was easier to perform than time-kill assay and may be found to be an acceptable alternative to time-kill assay with antifungals.