Lack of correlation between beta-lactamase production and susceptibility to cefamandole or cefoxitin among spontaneous mutants of Enterobacteriaceae

Whole-cell modeling of E. coli colonies enables quantification of single-cell heterogeneity in antibiotic responses

Antibiotic resistance poses mounting risks to human health, as current antibiotics are losing efficacy against increasingly resistant pathogenic bacteria. Of particular concern is the emergence of multidrug-resistant strains, which has been rapid among Gram-negative bacteria such as Escherichia coli. A large body of work has established that antibiotic resistance mechanisms depend on phenotypic heterogeneity, which may be mediated by stochastic expression of antibiotic resistance genes. The link between such molecular-level expression and the population levels that result is complex and multi-scale. Therefore, to better understand antibiotic resistance, what is needed are new mechanistic models that reflect single-cell phenotypic dynamics together with population-level heterogeneity, as an integrated whole. In this work, we sought to bridge single-cell and population-scale modeling by building upon our previous experience in "whole-cell" modeling, an approach which integrates mathematical and mechanistic descriptions of biological processes to recapitulate the experimentally observed behaviors of entire cells. To extend whole-cell modeling to the "whole-colony" scale, we embedded multiple instances of a whole-cell E. coli model within a model of a dynamic spatial environment, allowing us to run large, parallelized simulations on the cloud that contained all the molecular detail of the previous whole-cell model and many interactive effects of a colony growing in a shared environment. The resulting simulations were used to explore the response of E. coli to two antibiotics with different mechanisms of action, tetracycline and ampicillin, enabling us to identify sub-generationally-expressed genes, such as the beta-lactamase ampC, which contributed greatly to dramatic cellular differences in steady-state periplasmic ampicillin and was a significant factor in determining cell survival.

Antibiotic combinations that exploit heteroresistance to multiple drugs effectively control infection

Antibiotic-resistant bacteria are a significant threat to human health, with one estimate suggesting they will cause 10 million worldwide deaths per year by 2050, surpassing deaths due to cancer1. Because new antibiotic development can take a decade or longer, it is imperative to effectively use currently available drugs. Antibiotic combination therapy offers promise for treating highly resistant bacterial infections, but the factors governing the sporadic efficacy of such regimens have remained unclear. Dogma suggests that antibiotics ineffective as monotherapy can be effective in combination2. Here, using carbapenem-resistant Enterobacteriaceae (CRE) clinical isolates, we reveal the underlying basis for the majority of effective combinations to be heteroresistance. Heteroresistance is a poorly understood mechanism of resistance reported for different classes of antibiotics3-6 in which only a subset of cells are phenotypically resistant7. Within an isolate, the subpopulations resistant to different antibiotics were distinct, and over 88% of CRE isolates exhibited heteroresistance to multiple antibiotics ('multiple heteroresistance'). Combinations targeting multiple heteroresistance were efficacious, whereas those targeting homogenous resistance were ineffective. Two pan-resistant Klebsiella isolates were eradicated by combinations targeting multiple heteroresistance, highlighting a rational strategy to identify effective combinations that employs existing antibiotics and could be clinically implemented immediately.

Antimicrobial heteroresistance: an emerging field in need of clarity

"Heteroresistance" describes a phenomenon where subpopulations of seemingly isogenic bacteria exhibit a range of susceptibilities to a particular antibiotic. Unfortunately, a lack of standard methods to determine heteroresistance has led to inappropriate use of this term. Heteroresistance has been recognized since at least 1947 and occurs in Gram-positive and Gram-negative bacteria. Its clinical relevance may be considerable, since more resistant subpopulations may be selected during antimicrobial therapy. However, the use of nonstandard methods to define heteroresistance, which are costly and involve considerable labor and resources, precludes evaluating the clinical magnitude and severity of this phenomenon. We review the available literature on antibiotic heteroresistance and propose recommendations for definitions and determination criteria for heteroresistant bacteria. This will help in assessing the global clinical impact of heteroresistance and developing uniform guidelines for improved therapeutic outcomes.

Lack of relevance of kinetic parameters for exocellular DD-peptidases to cephalosporin MICs

MICs of a set of cephalosporins against a variety of gram-positive and gram-negative pathogens showed no strong correlations with the rate at which these inhibitors acylate or are deacylated by beta-lactam-sensitive DD-peptidases excreted by Streptomyces sp. strain R61 and Actinomadura sp. strain R39.

Transfer of the chromosomal bla gene from Enterobacter cloacae to Escherichia coli by RP4::mini-Mu

The resistance gene for beta-lactamase-stable cephalosporins from Enterobacter cloacae was transferred to Escherichia coli by the aid of RP4::mini-Mu. The R-prime plasmids generated carried 60 to 80 kilobases (kb) of E. cloacae DNA and coded for the chromosomal E. cloacae beta-lactamase. The gene was fully expressed in the recipient. Restriction endonuclease EcoRI fragments of the R-prime plasmid pBP100 were cloned into the vector pBP328, yielding the plasmid pBP102 with a size of 14 kb. A restriction map of this plasmid was constructed. By digesting pBP102 into seven PstI fragments, ligating the fragments, and looking for the smallest plasmid generated, pBP103 was isolated. It consisted of three PstI fragments, two of them (together 4.2 kb) necessary for resistance. During the experiment (performed in a recA+ background) the largest PstI fragment had undergone a substitution of a 0.3-kb segment of pBP102 by a 0.7-kb segment in pBP103 (as deduced by heteroduplex analysis). The bla gene of resistant E. cloacae strains was dominant over the gene of susceptible organisms.

Mutational enzymatic resistance of Enterobacter species to beta-lactam antibiotics

Mutants with enhanced beta-lactam resistance were selected from strains of Enterobacter cloacae and E. aerogenes by using three antibiotics. High-level beta-lactamase-producing mutants had similar degrees of increased resistance, enzyme substrate profiles, and isoelectric (pI) values irrespective of the selective agent. Reverse mutants from a resistant E. cloacae mutant regained the susceptibility pattern originally exhibited by the wild type, or were of enhanced susceptibility, and no longer expressed increased beta-lactamase production. beta-Lactamases of the mutants were similar in pI values to the wild-type enzyme. The increased resistance of the mutants therefore appeared to be accounted for by increased beta-lactamase production.

Ro 13-9904, a long-acting broad-spectrum cephalosporin: in vitro and in vivo studies

Ro 13-9904, a new parenteral cephalosporin, was found to have high in vitro activity against Enterobacteriaceae and other gram-negative bacteria, including various isolates resistant to cefuroxime, cefamandole, cefoxitin, and cefazolin. It showed promising activity against Pseudomonas aeruginosa. Although inhibitory against Staphylococcus aureus at concentrations readily achievable in plasma, it was less potent against this pathogen than cefamandole, cefazolin, or cefuroxime. Isolates of Streptococcus faecalis were uniformly resistant to all the cephalosporins tested. Ro 13-9904 was more active than cefotaxime against Proteus mirabilis, Neisseria gonorrhoeae, Neisseria meningitidis, and Haemophilus influenzae, but less active against S. aureus. Ro 13-9904 was stable to various types of beta-lactamases. Its therapeutic efficacy against experimental septicemias in mice was equal to or slightly superior to that of cefotaxime and SCE-1365 when the antibiotics were administered in repeated subcutaneous doses after bacterial challenge. Cefoperazone, and particularly cefamandole nafate, cefazolin, and mezlocillin were less effective. Although structurally related to cefotaxime and SCE-1365, Ro 13-9904 was found to differ from them in one important respect, namely, in having a long duration of action; this was observed with single-dose treatment given before bacterial challenge. Its broad spectrum of activity coupled with favorable pharmacokinetic properties make Ro 13-9904 a promising compound for clinical studies.

Role of a cefoxitin-inducible beta-lactamase in a case of breakthrough bacteremia

Development of resistance during therapy with cefamandole contributes to treatment failure. A simple cefoxitin disk test was recently described which detects a cefamandole-active inducible beta-lactamase not otherwise detectable with cefamandole as the inducer. A case of breakthrough Enterobacter bacteremia due to selection of a resistant subpopulation is reported in an immunocompromised patient. The use of this simple disk test in selected clinical cases is advocated.

In vitro studies of moxalactam (LY127935), a new beta-lactam antibiotic with significant activity against gram-negative bacteria

Moxalactam (LY127935) is a new beta-lactam antibiotic which is chemically related to the cephalosporins. The agent is highly active against the Enterobacteriaceae, with most organisms sensitive to 0.1 mcg/ml or less. It is also active at low concentration against gentamicin-resistant strains of Providencia and Serratia. Minimal inhibitory concentrations of moxalactam for Pseudomonas aeruginosa are approximately four-fold lower than those of carbenicillin for the same isolates. It is highly active against Hemophilus influenzae, including ampicillin-resistant strains, with all strains tested sensitive to 0.1 mcg/ml or less. The majority of strains of Neisseria gonorrheae and Neisseria meningitidis are sensitive to 0.1 mcg/ml or less. Moxalactam is more active against Bacteroides fragilis than cefoxitin. However, activity of moxalactam against gram-positive cocci was uniformly less than cephalothin and other cephalosporins tested. Little effect of inoculum size was observed with moxalactam except for particular strains of gram-negative bacilli. The drug was found to be 40-43% bound to human serum proteins.

Comparison of activity and beta-lactamase stability of cefotaxime with those of six other cephalosporins

A study of the susceptibility to cefotaxime and six other cephalosporins in 213 nonselected strains of nine different bacterial species clearly showed that cefotaxime was the most active against aerobic gram-negative bacilli. The same pattern emerged with 84 cephalothin-resistant strains of five enterobacterial species, but the mean minimal inhibitory concentration values for all cephalosporins were about twofold higher in this group of strains. Cephalothin was the most active antibiotic against Staphylococcus aureus. The inoculus effect of 10 cephalothin-resistant strains was relatively small, but it was most marked for cefamandole, as compared with that of three other new cephalosporins, including cefotaxime. The susceptibility of these cephalosporins to beta-lactamases from 12 beta-lactamase-producing enterobacterial strains was determined. Half of these were slightly active against cefotaxime and had similar activity against cefuroxime. Cefoxitin was not degraded at all, and cefamandole was the most susceptible. No correlation between beta-lactamase susceptibility and minimal inhibitory concentration values of different cephalosporins was found. Cefotaxime combined high intrinsic antibiotic activity with marked resistance to beta-lactamase inactivation.

In vitro response of Enterobacter to ampicillin

Three strains of Enterobacter were studied for their response to ampicillin. They exhibited a basic level of resistance that depended on the medium used and high-level mutational resistance at a frequency of 10(-5) to 10(-7). Two classes of mutants were selected, one of which showed markedly enhanced antibiotic inactivation as indicated by a biological assay and the other of which resembled the wild type in this regard. Both mutants showed cross-resistance to other beta-lactam antibiotics. The results explained discrepancies between traditional broth dilution minimum inhibitory concentration tests and early read automated procedures.

Antibacterial activity of a new parenteral cephalosporin--HR 756: comparison with cefamandole and ceforanide

HR 756, a new parenteral cephalosporin that is beta-lactamase resistant, was tested against 271 bacterial isolates. Both agar and broth dilution testing were employed, using two media and two inoculum sizes of bacteria. Antibacterial activity of the drug was compared to that of cefamandole (CFM) and ceforanide (CFN). In agar, HR 756 was more active than CFM and CFN against all bacteria tested except isolates of Staphylococcus aureus, which were better inhibited by CFM. HR 756 exhibited some antipseudomonas activity in agar, although a marked inoculum effect was apparent. A comparison of median minimum inhibitory and bactericidal concentrations in broth showed again that HR 756 was the most active of these three drugs. HR 756 demonstrated enhanced antibacterial activity compared to CFM and CFN against bacteria sensitive to all three drugs as well as against more resistant isolates of Serratia marcescens, Enterobacter species, and indole-positive Proteus. As with other cephalosporins, results for most bacteria were affected by inoculum size, medium, and type of dilution test employed in in vitro studies.