In vitro synergy and postantibiotic effect of colistin combinations with meropenem and vancomycin against Enterobacteriaceae with multiple carbapenem resistance mechanisms

Systematic review and meta-analysis of in vitro efficacy of antibiotic combination therapy against carbapenem-resistant Gram-negative bacilli

The superiority of combination therapy for carbapenem-resistant Gram-negative bacilli (CR-GNB) infections remains controversial. In vitro models may predict the efficacy of antibiotic regimens against CR-GNB. A systematic review and meta-analysis was performed including pharmacokinetic/pharmacodynamic (PK/PD) and time-kill (TK) studies examining the in vitro efficacy of antibiotic combinations against CR-GNB [PROSPERO registration no. CRD42019128104]. The primary outcome was in vitro synergy based on the effect size (ES): high, ES ≥ 0.75, moderate, 0.35 < ES < 0.75; low, ES ≤ 0.35; and absent, ES = 0). A network meta-analysis assessed the bactericidal effect and re-growth rate (secondary outcomes). An adapted version of the ToxRTool was used for risk-of-bias assessment. Over 180 combination regimens from 136 studies were included. The most frequently analysed classes were polymyxins and carbapenems. Limited data were available for ceftazidime/avibactam, ceftolozane/tazobactam and imipenem/relebactam. High or moderate synergism was shown for polymyxin/rifampicin against Acinetobacter baumannii [ES = 0.91, 95% confidence interval (CI) 0.44-1.00], polymyxin/fosfomycin against Klebsiella pneumoniae (ES = 1.00, 95% CI 0.66-1.00) and imipenem/amikacin against Pseudomonas aeruginosa (ES = 1.00, 95% CI 0.21-1.00). Compared with monotherapy, increased bactericidal activity and lower re-growth rates were reported for colistin/fosfomycin and polymyxin/rifampicin in K. pneumoniae and for imipenem/amikacin or imipenem/tobramycin against P. aeruginosa. High quality was documented for 65% and 53% of PK/PD and TK studies, respectively. Well-designed in vitro studies should be encouraged to guide the selection of combination therapies in clinical trials and to improve the armamentarium against carbapenem-resistant bacteria.

Divergence and Convergence of Cerebral Ischemia Pathways Profile Deciphers Differential Pure Additive and Synergistic Mechanisms

Aim

The variable mechanisms on additive and synergistic effects of jasminoidin (JA)-Baicalin (BA) combination and JA-ursodeoxycholic acid (UA) combination in treating cerebral ischemia are not completely understood. In this study, we explored the differential pure mechanisms of additive and synergistic effects based on pathway analysis that excluded ineffective interference.

Methods

The MCAO mice were divided into eight groups: sham, vehicle, BA, JA, UA, Concha Margaritifera (CM), BA-JA combination (BJ), and JA-UA combination (JU). The additive and synergistic effects of combination groups were identified by cerebral infarct volume calculation. The differentially expressed genes based on a microarray chip containing 16,463 oligoclones were uploaded to GeneGo MetaCore software for pathway analyses and function catalogue. The comparison of specific pathways and functions crosstalk between different groups were analyzed to reveal the underlying additive and synergistic pharmacological variations.

Results

Additive BJ and synergistic JU were more effective than monotherapies of BA, JA, and UA, while CM was ineffective. Compared with monotherapies, 43 pathways and six functions were found uniquely in BJ group, with 33 pathways and three functions in JU group. We found six overlapping pathways and six overlapping functions between BJ and JU groups, which mainly involved central nervous system development. Thirty-seven specific pathways and 10 functions were activated by additive BJ, which were mainly related to cell adhesion and G-protein signaling; and 27 specific pathways and three functions of synergistic JU were associated with regulation of metabolism, DNA damage, and translation. The overlapping and distinct pathways and functions may contribute to different additive and synergistic effects.

Conclusion

The divergence pathways of pure additive effect of BJ were mainly related to cell adhesion and G-protein signaling, while the pure synergistic mechanism of JU depended on metabolism, translation and DNA damage. Such a systematic analysis of pathways may provide an important paradigm to reveal the pharmacological mechanisms underlying drug combinations.

XDR-Klebsiella pneumoniae isolates harboring blaOXA-48: In vitro and in vivo evaluation using a murine thigh-infection model

Blood stream infection with extensively drug-resistant-carbapenamase producing Klebsiella (K.) pneumoniae usually represents a major threat with medical challenges among hospitalized cancer patients with poor functional status and underlying diseases. Accordingly, the aim of the study was to evaluate the efficacy of different antibiotics either alone or in combinations against extensively drug-resistant-OXA-48 producing K. pneumoniae clinical isolates that were previously recovered from febrile neutropenic pediatric cancer patients. The antimicrobial activity of amikacin, gentamicin, colistin, ertapenem, imipenem, meropenem and tigecycline was assessed by broth microdilution method. The results revealed that all the tested OXA-48 producing K. pneumoniae isolates exhibited extensively drug-resistant phenotype and all of them were susceptible to tigecycline. Checkerboard method was used to determine the fraction inhibitory concentration index, to further classify the effect of antibiotic combination as synergistic, additive, indifferent, or antagonistic effect. The results revealed that in vitro dual carbapenem combination of ertapenem with meropenem had shown synergistic effect against all of the tested isolates. Additionally, synergistic effect of meropenem with colistin was detected among three of four isolates tested. Herein we investigated the in vivo activity of colistin, meropenem alone and in combination in a rat thigh infection model. The results showed that addition of meropenem to colistin was not effective at reduction of bacterial count as compared to colistin alone at 24 h post treatment. Accordingly, we can conclude that in vitro antibiotic combinations of dual carbapenems (ertapenem plus meropenem) and meropenem plus colistin showed synergism in 100% and 75% of the tested isolates, respectively. Colistin alone had significantly reduced bacterial count while its combination with meropenem was not superior to monotherapy in murine thigh infection model.

Impact statement

The present study aimed to evaluate the effectiveness of various antibiotics both in vitro and in vivo using murine animal model either alone or in combination against various strains of extensively drug-resistant (XDR) Klebsiella pneumoniae, life-threatening pathogens of relevant medical importance isolated from febrile neutropenic pediatric cancer patients. This work also emphasizes how to select the appropriate antibiotics options and help the physicians to choice the appropriate antibiotic for the treatment of such superbugs (extensively drug-resistant (XDR) Klebsiella pneumoniae). The results showed that in vitro dual carbapenem combination of ertapenem with meropenem had shown synergistic effect against all of the tested XDR isolates. Antibiotic combinations of dual carbapenems and meropenem plus colistin showed synergism in 100% and 75% of the testes isolates, respectively. Results of the in vivo evaluation, colistin alone had significantly reduced bacterial count while its combination with meropenem was not superior to monotherapy.

Characterization of the anti-Staphylococcus aureus fraction from Penthorum chinense Pursh stems

Background

Methicillin-resistant Staphylococcus aureus (MRSA) causes serious infections in hospitals. Penthorum chinense Pursh (PCP), employed by the Miao ethnic minority in China, presents antibacterial activities. In this study, the anti-Staphylococcus aureus activities in the pinocembrin-7-O residue-rich fraction from PCP (PGF) were evaluated and characterized.

Methods

The PGF was prepared with 70% ethanol reflux extraction followed by fractional extraction and column chromatography. Pinocembrin-7-O residue components were identified with electrospray ionization mass spectrometry (ESI-MS). Anti-S. aureus activities of the fraction and the main components were evaluated in vitro with serially diluted microbroth assays. Cytotoxicity was evaluated with 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) chromogenic assays using the NCTC 1469 cell line.

Results

This study indicated that the PGF and three components (S1, S2, and S3) presented anti-S. aureus activities, including against clinically isolated MRSA strains. The molecular masses of S1, S2, and S3 were identical to those of pinocembrin-7-O-[4″,6″-hexahydroxydiphenoyl (HHDP)]-β-D-glucose, pinocembrin-7-O-[3″-O-galloyl-4″,6″-(s)-HHDP]-β-D-glucose, and Thonningianin A, respectively. The PGF, S1, S2, and S3 all presented an identical minimum inhibitory concentration (MIC) against S. aureus ATCC 25923 and ATCC 43300, which was 62.5 μg/mL. The minimum bactericidal concentrations (MBCs) of the PGF and S3 against ATCC 25923 were 125 and 250 μg/mL, and the MBCs of the PGF, S2, and S3 against ATCC 43300 were 250, 500, and 250 μg/mL, respectively. A time-kill assay consistently indicated that none of the bacterial clones of ATCC 25923 and ATCC 43300 could survive under 2× and 4× MIC PGF treatment for 24 h, respectively. In contrast, 10⁴ CFU (colony-forming units) of ATCC 25923 and ATCC 43300 were killed by 8× and 4× MIC S3 within 24 h, respectively. Additionally, 1×, 2×, and 4× MIC the PGF presented similar postantibiotic effects (PAEs) on the strain ATCC 25923. However, the PAE of the PGF on the strain ATCC 43300 was concentration dependent (1× < 2× < 4× MIC). Finally, the PGF (200 μg/mL) and S3 (60 μg/mL) showed no cytotoxicity against human hepatoma cells.

Conclusions

The PGF and S3 from PCP present potential for the treatment of S. aureus and MRSA infections. The components S1 and S2 present inhibition activities against S. aureus.