Synergistic Effect of Clinically Available Beta-Lactamase Inhibitors Combined with Cefiderocol against Carbapenemase-Producing Gram-Negative Organisms
by
, , , , ,
Gabriele Bianco
1,*
,
Paolo Gaibani
2,
Sara Comini
1,3,*,
Matteo Boattini
1,3,
Giuliana Banche
3,
Cristina Costa
1,3,
Rossana Cavallo
1,3 and
Patrice Nordmann
4,5,6,7 1
Microbiology and Virology Unit, University Hospital Città della Salute e della Scienza di Torino, 10126 Turin, Italy
2
Operative Unit of Microbiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
3
Department of Public Health and Paediatrics, University of Torino, 10124 Turin, Italy
4
Medical and Molecular Microbiology, Faculty of Science and Medicine, University of Fribourg, 1700 Fribourg, Switzerland
5
Swiss National Reference Center for Emerging Antibiotic Resistance (NARA), University of Fribourg, 1700 Fribourg, Switzerland
6
INSERM European Unit (IAME), University of Fribourg, 1700 Fribourg, Switzerland
7
Institute for Microbiology, University of Lausanne and University Hospital Centre, 1011 Lausanne, Switzerland
*
Authors to whom correspondence should be addressed.
Antibiotics 2022, 11(12), 1681; https://doi.org/10.3390/antibiotics11121681
Submission received: 2 November 2022
/
Revised: 10 November 2022
/
Accepted: 18 November 2022
/
Published: 22 November 2022
(This article belongs to the Special Issue Multi-Drug Resistant Gram-Negative Infections: Molecular Epidemiology, Microbiological Diagnosis and Antimicrobial Treatment)
Abstract
:The role of β-lactamases in reduced susceptibility or resistance to cefiderocol has been supported by recent reports. The purpose of this study was to investigate the in vitro impact of clinically available β-lactamase inhibitors on cefiderocol activity against characterized carbapenemase-producing Gram-negative isolates. A collection of 39 well-characterized Gram-negative isolates obtained from various clinical sources and countries were included. Cefiderocol antimicrobial susceptibility was evaluated via reference broth microdilution. The chequerboard microdilution method and time–kill assays were used to determine the synergy of tazobactam, avibactam, vaborbactam and relebactam in combination with cefiderocol. MICs of cefiderocol presented a 4- to 256-fold reduction against Klebsiella pneumoniae carbapenemase (KPC)-producing Gram-negative isolates (predominantly K. pneumoniae) when avibactam, vaborbactam and relebactam were combined individually. Notably, the KPC-inhibitors led to a 4- to 32-fold reduction in cefiderocol MICs in the four cefiderocol-resistant KPC-producing K. pneumoniae isolates, showing restoration of cefiderocol susceptibility (MIC ≤ 2 mg/L) in ten out of twelve cases. Tazobactam led to a 4- to 64-fold decrease in cefiderocol MICs only in K. pneumoniae strains harbouring blaKPC-41, blaKPC-31, blaKPC-53 and blaKPC-66. The synergistic effect of all serine-β-lactamase inhibitors on cefiderocol activity was also shown in OXA-48-like-producing Enterobacterales strains. Conversely, a combination of β-lactamases inhibitors with cefiderocol was not synergistic with all OXA-23-like-producing strains and most metallo-β-lactamases producers. In conclusion, the addition of clinically available serine β-lactamase inhibitors to cefiderocol might represent an important development in the formulation to increase its spectrum and therapeutic efficacy, and to limit in vivo resistance emergence.
1. Introduction
Cefiderocol is a novel siderophore cephalosporin with broad activity against Gram-negative bacteria. It is structurally similar to cefepime (pyrrolidium group on the C-3 side chain) and ceftazidime (carboxypropyl-oxymino group on the C-7 side chain), a characteristic that improves both stability against β-lactamases and transport across the bacterial outer membrane [1]. Furthermore, the chlorocatechol group on the end of the C-3 side chain confers siderophore activity and enhances hydrolytic stability against various β-lactamases, including carbapenemases. Further, binding to extracellular free ferric ions allows cefiderocol to be transported across the outer membrane via the iron transport system of Gram-negative organisms, overcoming resistance mechanisms such as efflux pumps upregulation and porin channel mutations [1].
Cefiderocol has been evaluated in large international surveillance studies, revealing promising activity against multidrug-resistant Gram-negative isolates [2,3,4,5,6,7,8]. In the SIDERO-WT surveillance program, the percentage of cefiderocol-resistant isolates was 0.4%, 0.6% and 0.7% in 2014–2015, 2015–2016 and 2016–2017, respectively [3,6,7]. Isolates with MIC > 4 mg/L were predominantly Acinetobacter baumannii (78.9%) and Enterobacterales (17.4%). The excellent in vitro activity of cefiderocol was also observed among isolates resistant to carbapenems. The SIDERO-CR study showed that 96.1% of isolates (1801/1873) were susceptible to cefiderocol, with most resistant isolates among A. baumannii (n = 38) and Enterobacterales (n = 31) [8].
Based on the mechanism of cefiderocol, mutations affecting the iron transporter systems are associated with clinical resistance. Mutations in piuD; pirR, pirA and piuA; and cirA have been identified in Pseudomonas aeruginosa, A. baumannii and Klebsiella pneumoniae clinical isolates, respectively [9]. However, the role of β-lactamases in reduced susceptibility or resistance to cefiderocol has been supported by several recent reports [9]. The SIDERO-CR study’s molecular investigation of resistant isolates with MIC > 4 mg/L identified the most common isolates as PER-producing A. baumannii and NDM-producing Enterobacterales [6,8]. Beta-lactamase inhibitors, including avibactam, clavulanic acid and dipicolinic acid, decreased cefiderocol MICs against Gram-negative isolates with a cefiderocol MIC of 8 mg/L, suggesting that serine β-lactamases and metallo β-lactamases may play a role in cefiderocol resistance [10].
In vivo emergence of cross-resistance to cefiderocol following treatment with ceftazidime/avibactam or ceftolozane/tazobactam has also been described [9]. Emergence of cross-resistance to ceftazidime/avibactam and cefiderocol in two Enterobacter hormaechei strains due to expression of the A292_L293del AmpC variant was described in two cefepime-treated patients [11]. In addition, Simner et al. reported ≥4-fold increases in cefiderocol MICs in P. aeruginosa isolates following ceftolozane/tazobactam treatment [12]. In vivo selection of Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae co-resistant to ceftazidime/avibactam and cefiderocol after ceftazidime/avibactam treatment was previously described [13], associated with the expression of KPC mutants. Combining cefiderocol with clinically available β-lactamase inhibitors could therefore be a way to enhance its activity and reduce the risk of in vivo emergence of resistant strains. In vitro and in vivo studies evaluating the activity of cefiderocol plus β-lactamase inhibitors are limited. The purpose of this study was to investigate the in vitro impact of four clinically available β-lactamase inhibitors on cefiderocol activity against diverse carbapenemase-producing Gram-negative isolates.
2. Results
2.1. Antimicrobial Susceptibility Testing and Chequerboard Assays
The MICs of tazobactam, vaborbactam and relebactam β-lactamase inhibitors for all 39 carbapenemase-producing strains were >64 mg/L, whereas the MICs of avibactam ranged from 16 mg/L to >64 mg/L, indicating that none of these molecules have intrinsic activity against those strains. Of the 39 strains, 30 were susceptible to cefiderocol (MICs range 0.03–2 mg/L). Nine strains were cefiderocol-resistant, of which four were KPC-producing K. pneumoniae (MICs range 4–16 mg/L), three were Enterobacterales NDM-producers (MICs range 4–8 mg/L), and two were A. baumannii NDM and OXA-23-like co-producers (MICs 8 mg/L and 16 mg/L, respectively) (Table 1).
As shown in Table 1, avibactam, vaborbactam and relebactam combined with cefiderocol had a synergistic effect on all KPC producers, regardless of other β-lactamases co-expressed. MICs of cefiderocol presented a 4- to 256-fold reduction when avibactam, vaborbactam and relebactam were combined individually.
The synergistic effect of tazobactam was only observed on KPC-41-producing K. pneumoniae (N435), KPC-50-producing K. pneumoniae (N859), KPC-53-producing K. pneumoniae (CAZ59BO), and KPC-66-producing K. pneumoniae (KPC_TO3). Among the 11 metallo-β-lactamase producers, β-lactamase inhibitors combined with cefiderocol had a very low synergistic effect rate; FICI values < 0.5 were observed for combinations including avibactam, tazobactam or relebactam on only three strains co-expressing metallo-β-lactamases (NDM or VIM) and various other β-lactamases belonging to Ambler classes A, C and D. No synergistic effect was observed for all OXA-carbapenemase producing A. baumannii strains, including those co-producers of NDM enzymes. Conversely, all β-lactamase inhibitors combined with cefiderocol showed a synergistic effect on all OXA-48-like-producing E. coli or K. pneumoniae.
2.2. Time–Kill Assays
Changes in bacterial load from 0 to 24 h for cefiderocol alone and in combination with β-lactamase inhibitors were tested against five representative carbapenemase-producing isolates (Figure 1). Time–kill curves (TKC) showed that cefiderocol alone at 1× MIC determined a decrease in viable counts of bacterial cells within 6–8 h, whereas regrowth occurred in all isolates tested. The TKC further displayed that avibactam, vaborbactam and relebactam, but not tazobactam, combined with cefiderocol had a synergistic effect on KPC_TO1 (blaKPC-3) and N859 (blaKPC-50). Likewise, TKC analysis confirmed the indifferent effect of all β-lactamase inhibitors on cefiderocol activity against NDM and OXA-23 producers (i.e., N1700 (blaNDM-1) and N1183 (blaOXA-23)). Lastly, tazobactam and avibactam, but neither vaborbactam nor relebactam, combined with cefiderocol were synergistic against OXA-48 producer K. pneumoniae N1081 (blaOXA-48).
Overall, time–kill experiments showed synergistic bactericidal effects of combinations involving avibactam and relebactam, for both combinations in K. pneumoniae N859 (blaKPC-50) and cefiderocol plus avibactam in K. pneumoniae N1091 (blaOXA-48). In these cases, bacterial cell viability in the cefiderocol/β-lactamase inhibitor combination continuously decreased within 24 h of incubation.
3. Discussion
Resistance to β-lactamases activity together with the “Trojan horse” entry strategy into bacterial cells represent the strengths of the recently approved siderophore-cephalosporin cefiderocol. Although surveillance studies have reported potent activity with low MIC90 and MIC50 values, even on MDR isolates, reports of cefiderocol resistance are steadily increasing [11,12,13,14,15,16]. The combination of several mechanisms, including mutations affecting function of siderophore receptors and expression of certain β-lactamases, seems to be the main cause of resistance to cefiderocol [9].
Herein, we evaluated the in vitro impact of four different clinical β-lactamase inhibitors on the activity of cefiderocol towards characterized carbapenemase-producing Gram-negative bacterial isolates. MICs of cefiderocol presented a 4- to 256-fold reduction against KPC-producing Gram-negative isolates (predominantly K. pneumoniae) when avibactam, vaborbactam and relebactam were combined individually. Three of the four cefiderocol-resistant isolates expressed KPC variants associated with ceftazidime/avibactam resistance (KPC-41, KPC-50 and KPC-31), highlighting the cross-resistance phenomenon recently reported in the literature [13,17]. Notably, the KPC-inhibitors led to a 4- to 32-fold reduction in cefiderocol MICs in the four cefiderocol-resistant KPC-producing K. pneumoniae isolates showing restoration of susceptibility to cefiderocol (MIC ≤ 2 mg/L) in ten out of twelve cases. These results support previously reported evidence of the role of combinations including cefiderocol and serine-β-lactamase inhibitors, such as avibactam and vaborbactam, against cefiderocol susceptible or resistant KPC-producing Enterobacterales [13]. Although all KPC-producing isolates co-expressed other β-lactamases, the impact of tazobactam on cefiderocol MIC was not significant, except on isolates expressing KPC variants conferring both ceftazidime/avibactam resistance and the ESBL phenotype. Indeed, tazobactam led to a 4- to 64-fold decrease in cefiderocol MICs in K. pneumoniae isolates harboring blaKPC-41, blaKPC-31, blaKPC-53 and blaKPC-66. [18,19]. The role of broad spectrum β-lactamases (e.g., SHV-type, CTX-M-type, PER-type and CMY-type) in cefiderocol activity has already been shown by experiments on isogenic mutants [20,21]. In accordance with this, we also observed the synergistic activity of cefiderocol plus all four β-lactamase inhibitors in K. pneumoniae ATCC 700603 isolate (blaSHV-18). The synergistic effect of all serine-β-lactamase inhibitors on cefiderocol activity was also shown in OXA-48-like-producing Enterobacterales isolates (N1067, N1091 and N1085) via chequerboard assays. Although tazobactam, vaborbactam and relebactam have no inhibitory effect on OXA-48-like carbapenemase [22], their addition caused a 4- to 8-fold decrease in cefiderocol MICs. However, synergistic effect was confirmed via time–kill assay only for the combination including tazobactam.
The combination of β-lactamase inhibitors with cefiderocol was not synergistic with all OXA-23-like-producing isolates and most metallo-β-lactamase producers. Synergistic effects were only observed with avibactam, tazobactam and relebactam on three strains expressing NDM-1 or VIM-2 metallo-β-lactamases together with various other β-lactamases of class A, C, or D. However, the combination of cefiderocol plus serine-β-lactamase inhibitors showed additive effects on most metallo-β-lactamase producers, emphasizing the contribution of multiple β-lactamases expression on the activity of cefiderocol in metallo-β-lactamase producers [23]. Kohira et al. observed a ≤2-fold cefiderocol MIC decrease with the addition of avibactam or dipicolinic acid (an in vitro inhibitor of metallo-β-lactamase) in NDM-1-producing K. pneumoniae isolates from a multi-national surveillance study (SIDERO-WT-2014) [18]. Interestingly, the addition of both avibactam and dipicolinic acid led to an 8- to 64-fold decrease in cefiderocol MIC. The same study showed the synergistic effect of avibactam plus cefiderocol against 28 cefiderocol-resistant (MICs ranging from 4 to >32 mg/L) A. baumannii isolates. However, most of the isolates were producers of PER-1, a broad-spectrum β-lactamase associated with significant hydrolytic activity on cefiderocol [20,24,25]. In contrast, herein, the VIM-producing P. aeruginosa strain N1215 carrying blaPER-1 showed a low MIC against cefiderocol (0.25 mg/L), and the combination of cefiderocol with β-lactamase inhibitors showed additive effects with tazobactam and avibactam, and synergistic effects only with relebactam. This might highlight the importance of the level of expression of β-lactamase genes in different bacterial species to cefiderocol resistance.
A further observation of our study is the lack of cefiderocol antibacterial activity in monotherapy at 1× MIC concentration in time–kill experiments. Cefiderocol acquired bactericidal activity only when combined with avibactam (in K. pneumoniae N859 (blaKPC-50) and K. pneumoniae N1091 (blaOXA-48)) and with relebactam (in K. pneumoniae N859 (blaKPC-50)). In agreement with our results, Ni et al. observed regrowth of A. baumannii after 6 h of treatment with 1× MIC cefiderocol monotherapy in time–kill assays, in isolates both susceptible and resistant to cefiderocol [26].
This represents the first in vitro evaluation of the impact of the four main clinically available β-lactamase inhibitors on cefiderocol activity against diverse carbapenemase-producing Gram-negative isolates. However, this study had some limitations. First, the number of isolates tested and β-lactamase variants included were limited. Second, characterization of mechanisms of resistance to cefiderocol other than β-lactamase production was not performed in detail for all isolates.
4. Materials and Methods
4.1. Bacterial Isolates
A collection of 39 well-characterized Gram-negative isolates obtained from various clinical sources and countries were included in this study (Table 1). Bacterial species included were K. pneumoniae (n = 19), A. baumannii (n = 7), E. coli (n = 6), P. aeruginosa (n = 5), Citrobacter freundii (n = 1) and Enterobacter cloacae (n = 1). All strains were carbapenemase-producers: Ambler class A (KPC-type (n = 18)), Ambler class B (NDM (n = 10), VIM-type (n = 2) and IMP-type (n = 1)), Ambler class D (OXA-23 (n = 5), OXA-48-like (n = 3), OXA-40 (n = 1) and OXA-58 (n = 1)). Reference strains E. coli ATCC 25922, K. pneumoniae ATCC 700603, K. pneumoniae ATCC BAA-2814 and P. aeruginosa ATCC 27853 were also included.
4.2. Cefiderocol Susceptibility Testing
Cefiderocol susceptibility was evaluated via reference broth microdilution using iron depleted Mueller–Hinton broth (ID-MHB) according to EUCAST guidelines [27]. Escherichia coli ATCC 25922 and P. aeruginosa ATCC 27853 were used as quality control strains for each experimental sitting, checking that quality control results were within the specified ranges. Susceptibility data were interpreted according to current EUCAST clinical breakpoints [28].
4.3. Chequerboard Assay
The chequerboard microdilution panel method determined the synergy of tazobactam, avibactam, vaborbactam and relebactam in combination with cefiderocol. Experiments were performed in triplicate using ID-MHB. Concentration of inhibitors was set at 4 mg/L and the final concentration of cefiderocol ranged from 0.007 to 16 mg/L. The fractional inhibitory concentration (FIC) was calculated as previously described [29]. Briefly, MIC of drug A or B in combination/MIC of drug A or B alone; the FIC index (FICI) was determined by summing the FICs of drugs A and B. According to the minimum FICI, the results of combination tests were interpreted as synergistic (FICI ≤ 0.5), additive (FICI > 0.5 and ≤1), indifferent (FICI > 1 and ≤4), and antagonistic (FICI > 4).
4.4. Time–Kill Assay
Five strains were selected for subsequent time–kill assays: two strains producing class A carbapenemase (KPC_T01 (blaKPC-3) and N859 (blaKPC-50)), one strain producing class B carbapenemase (N1700 (blaNDM-1)) and two strains producing class D carbapenemase (N1183 (blaOXA-23) and N1091 (blaOXA-48)). Time–kill assays were performed in duplicate by inoculating 2.5 × 105 cfu/mL of the test organism into 10 mL of ID-MHB. Cefiderocol and β-lactamase inhibitors were tested alone and in combination. Concentrations were tested at 1× MIC value for cefiderocol and at 4 mg/L for β-lactamase inhibitors. ID-MHB without any drug was set as positive control. Bacterial suspension was added to each experimental group and shaken at 37 °C at 200 rpm. The bacterial load (log10 cfu/mL) was determined at 2, 4, 8, 12 and 24 h by removing 100 µL of each suspension, serially diluting in sterile water and plating on Nutrient Agar ISO 21528 (Liofilchem®, Roseto degli Abruzzi, Italy). The lower limit of accurately quantifiable cfu using this method was 1 log10 of viable bacteria per mL. Synergy was defined as a reduction ≥2 log10 cfu/mL at 24 h for drugs in combination compared with the most active drug alone. No interaction was defined as a <2 log10 cfu/mL increase or decrease at 24 h for the drug combination in comparison with the most active antibiotic alone [30]. Bactericidal activity was defined as a >3 log10 cfu/mL reduction in the antibiotic combination treatment compared with the untreated control at the start of each assay from the original inocula, whereas bacteriostatic activity was defined as a <3 log10 cfu/mL decrease.
5. Conclusions
In conclusion, our results support the role of carbapenemases and other β-lactamases as sources of reduced susceptibility to cefiderocol, and consequently, the potential contribution of β-lactamase inhibitors for recovering its efficacy. The addition of clinically available serine β-lactamase inhibitors for cefiderocol might represent an important development in the formulation to increase its spectrum and therapeutic efficacy, and to limit in vivo emergence of resistance. Our results indicate that avibactam might be the best partner, as it had a broader spectrum of action and provided a bactericidal synergistic effect in combination with cefiderocol.
Author Contributions
Conceptualization, G.B. (Gabriele Bianco), P.G. and P.N.; methodology, G.B. (Gabriele Bianco) and S.C.; software, S.C.; validation, M.B. and G.B. (Gabriele Bianco); formal analysis, G.B. (Gabriele Bianco) and P.G.; investigation, G.B. (Gabriele Bianco) and S.C.; data curation, M.B. and C.C.; writing—original draft preparation, G.B. (Gabriele Bianco); writing—review and editing, P.G., S.C., M.B., G.B. (Giuliana Banche), C.C., R.C. and P.N.; supervision, R.C. and P.N. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Institutional Review Board Statement
Not applicable.
Informed Consent Statement
Not applicable.
Data Availability Statement
Not applicable.
Conflicts of Interest
The authors declare no conflict of interest.
References
- Sato, T.; Yamawaki, K. Cefiderocol: Discovery, Chemistry, and In vivo Profiles of a Novel Siderophore Cephalosporin. Clin. Infect. Dis. 2019, 69, S538–S543. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Jacobs, M.R.; Abdelhamed, A.M.; Good, C.E.; Rhoads, D.D.; Hujer, K.M.; Hujer, A.M.; Domitrovic, T.N.; Rudin, S.D.; Richter, S.S.; van Duin, D.; et al. ARGONAUT-I: Activity of Cefiderocol (S-649266), a Siderophore Cephalosporin, against Gram-Negative Bacteria, Including Carbapenem-Resistant Nonfermenters and Enterobacteriaceae with Defined Extended-Spectrum β-Lactamases and Carbapenemases. Antimicrob. Agents Chemother. 2018, 63, e01801-18. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Kazmierczak, K.M.; Tsuji, M.; Wise, M.G.; Hackel, M.; Yamano, Y.; Echols, R.; Sahm, D.F. In vitro activity of cefiderocol, a siderophore cephalosporin, against a recent collection of clinically relevant carbapenem-non-susceptible Gram-negative bacilli, including serine carbapenemase- and metallo-β-lactamase-producing isolates (SIDERO-WT-2014 Study). Int. J. Antimicrob. Agents 2019, 53, 177–184. [Google Scholar] [CrossRef] [PubMed]
- Dobias, J.; Dénervaud-Tendon, V.; Poirel, L.; Nordmann, P. Activity of the novel siderophore cephalosporin cefiderocol against multidrug-resistant Gram-negative pathogens. Eur. J. Clin. Microbiol. Infect. Dis. 2017, 36, 2319–2327. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Bianco, G.; Boattini, M.; Comini, S.; Iannaccone, M.; Casale, R.; Allizond, V.; Barbui, A.M.; Banche, G.; Cavallo, R.; Costa, C. Activity of ceftolozane-tazobactam, ceftazidime-avibactam, meropenem-vaborbactam, cefiderocol and comparators against Gram-negative organisms causing bloodstream infections in Northern Italy (2019–2021): Emergence of complex resistance phenotypes. J. Chemother. 2022, 34, 302–310. [Google Scholar] [CrossRef] [PubMed]
- Hackel, M.A.; Tsuji, M.; Yamano, Y.; Echols, R.; Karlowsky, J.A.; Sahm, D.F. In vitro Activity of the Siderophore Cephalosporin, Cefiderocol, against a Recent Collection of Clinically Relevant Gram-Negative Bacilli from North America and Europe, Including Carbapenem-Nonsusceptible Isolates (SIDERO-WT-2014 Study). Antimicrob. Agents Chemother. 2017, 61, e00093-17. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Karlowsky, J.A.; Hackel, M.A.; Tsuji, M.; Yamano, Y.; Echols, R.; Sahm, D.F. In vitro Activity of Cefiderocol, a Siderophore Cephalosporin, against Gram-Negative Bacilli Isolated by Clinical Laboratories in North America and Europe in 2015-2016: SIDERO-WT-2015. Int. J. Antimicrob. Agents 2019, 53, 456–466. [Google Scholar] [CrossRef]
- Hackel, M.A.; Tsuji, M.; Yamano, Y.; Echols, R.; Karlowsky, J.A.; Sahm, D.F. In vitro Activity of the Siderophore Cephalosporin, Cefiderocol, against Carbapenem-Nonsusceptible and Multidrug-Resistant Isolates of Gram-Negative Bacilli Collected Worldwide in 2014 to 2016. Antimicrob. Agents Chemother. 2018, 62, e01968-17. [Google Scholar] [CrossRef] [Green Version]
- Karakonstantis, S.; Rousaki, M.; Kritsotakis, E.I. Cefiderocol: Systematic Review of Mechanisms of Resistance, Heteroresistance and In vivo Emergence of Resistance. Antibiotics 2022, 11, 723. [Google Scholar] [CrossRef] [PubMed]
- Parsels, K.A.; Mastro, K.A.; Steele, J.M.; Thomas, S.J.; Kufel, W.D. Cefiderocol: A novel siderophore cephalosporin for multidrug-resistant Gram-negative bacterial infections. J. Antimicrob. Chemother. 2021, 76, 1379–1391. [Google Scholar] [CrossRef]
- Shields, R.K.; Iovleva, A.; Kline, E.G.; Kawai, A.; McElheny, C.L.; Doi, Y. Clinical Evolution of AmpC-Mediated Ceftazidime-Avibactam and Cefiderocol Resistance in Enterobacter cloacae Complex Following Exposure to Cefepime. Clin. Infect. Dis. 2020, 71, 2713–2716. [Google Scholar] [CrossRef] [PubMed]
- Simner, P.J.; Beisken, S.; Bergman, Y.; Posch, A.E.; Cosgrove, S.E.; Tamma, P.D. Cefiderocol Activity Against Clinical Pseudomonas aeruginosa Isolates Exhibiting Ceftolozane-Tazobactam Resistance. Open Forum Infect. Dis. 2021, 8, ofab311. [Google Scholar] [CrossRef]
- Bianco, G.; Boattini, M.; Comini, S.; Iannaccone, M.; Bondi, A.; Cavallo, R.; Costa, C. In vitro activity of cefiderocol against ceftazidime-avibactam susceptible and resistant KPC-producing Enterobacterales: Cross-resistance and synergistic effects. Eur. J. Clin. Microbiol. Infect. Dis. 2022, 41, 63–70. [Google Scholar] [CrossRef] [PubMed]
- Nordmann, P.; Shields, R.K.; Doi, Y.; Takemura, M.; Echols, R.; Matsunaga, Y.; Yamano, Y. Mechanisms of Reduced Susceptibility to Cefiderocol Among Isolates from the CREDIBLE-CR and APEKS-NP Clinical Trials. Microb. Drug Resist. 2022, 28, 398–407. [Google Scholar] [CrossRef] [PubMed]
- Smoke, S.M.; Brophy, A.; Reveron, S.; Iovleva, A.; Kline, E.G.; Marano, M.; Miller, L.P.; Shields, R.K. Evolution and transmission of cefiderocol-resistant Acinetobacter baumannii during an outbreak in the burn intensive care unit. Clin. Infect. Dis. 2022, ciac647. [Google Scholar] [CrossRef] [PubMed]
- Gaibani, P.; Amadesi, S.; Lazzarotto, T.; Ambretti, S. Genome characterization of a Klebsiella pneumoniae co-producing OXA-181 and KPC-121 resistant to ceftazidime/avibactam, meropenem/vaborbactam, imipenem/relebactam and cefiderocol isolated from a critically ill patient. J. Glob. Antimicrob. Resist. 2022, 30, 262–264. [Google Scholar] [CrossRef] [PubMed]
- Poirel, L.; Sadek, M.; Kusaksizoglu, A.; Nordmann, P. Co-resistance to ceftazidime-avibactam and cefiderocol in clinical isolates producing KPC variants. Eur. J. Clin. Microbiol. Infect. Dis. 2022, 41, 677–680. [Google Scholar] [CrossRef] [PubMed]
- Mueller, L.; Masseron, A.; Prod’Hom, G.; Galperine, T.; Greub, G.; Poirel, L.; Nordmann, P. Phenotypic, biochemical and genetic analysis of KPC-41, a KPC-3 variant conferring resistance to ceftazidime-avibactam and exhibiting reduced carbapenemase activity. Antimicrob. Agents Chemother. 2019, 63, e01111-19. [Google Scholar] [CrossRef] [Green Version]
- Carattoli, A.; Arcari, G.; Bibbolino, G.; Sacco, F.; Tomolillo, D.; Di Lella, F.M.; Trancassini, M.; Faino, L.; Venditti, M.; Antonelli, G.; et al. Evolutionary Trajectories toward Ceftazidime-Avibactam Resistance in Klebsiella pneumoniae Clinical Isolates. Antimicrob. Agents Chemother. 2021, 65, e0057421. [Google Scholar] [CrossRef]
- Poirel, L.; Ortiz de la Rosa, J.M.; Sadek, M.; Nordmann, P. Impact of Acquired Broad-Spectrum β-Lactamases on Susceptibility to Cefiderocol and Newly Developed β-Lactam/β-Lactamase Inhibitor Combinations in Escherichia coli and Pseudomonas aeruginosa. Antimicrob. Agents Chemother. 2022, 66, e00039-22. [Google Scholar] [CrossRef]
- Fröhlich, C.; Sørum, V.; Tokuriki, N.; Johnsen, P.J.; Samuelsen, Ø. Evolution of β-lactamase-mediated cefiderocol resistance. J. Antimicrob. Chemother. 2022, 77, 2429–2436. [Google Scholar] [CrossRef] [PubMed]
- Bonnin, R.A.; Bernabeu, S.; Emeraud, C.; Creton, E.; Vanparis, O.; Naas, T.; Jousset, A.B.; Dortet, L. Susceptibility of OXA-48-producing Enterobacterales to imipenem/relebactam, meropenem/vaborbactam and ceftazidime/avibactam. Int. J. Antimicrob. Agents 2022, 60, 106660. [Google Scholar] [CrossRef] [PubMed]
- Boattini, M.; Comini, S.; Bianco, G.; Iannaccone, M.; Casale, R.; Cavallo, R.; Costa, C. Activity of cefiderocol and synergy of novel β-lactam-β-lactamase inhibitor-based combinations against metallo-β-lactamase-producing gram-negative bacilli: Insights from a two-year study (2019–2020). J. Chemother. 2022, 1–7. [Google Scholar] [CrossRef] [PubMed]
- Kohira, N.; Hackel, M.A.; Ishioka, Y.; Kuroiwa, M.; Sahm, D.F.; Sato, T.; Maki, H.; Yamano, Y. Reduced susceptibility mechanism to cefiderocol, a siderophore cephalosporin, among clinical isolates from a global surveillance programme (SIDERO-WT-2014). J. Glob. Antimicrob. Resist. 2020, 22, 738–741. [Google Scholar] [CrossRef]
- Poirel, L.; Sadek, M.; Nordmann, P. Contribution of PER-Type and NDM-Type β-Lactamases to Cefiderocol Resistance in Acinetobacter baumannii. Antimicrob. Agents Chemother. 2021, 65, e00877-21. [Google Scholar] [CrossRef]
- Ni, W.; Wang, Y.; Ma, X.; He, Y.; Zhao, J.; Guan, J.; Li, Y.; Gao, Z. In vitro and in vivo efficacy of cefiderocol plus tigecycline, colistin, or meropenem against carbapenem-resistant Acinetobacter baumannii. Eur. J. Clin. Microbiol. Infect. Dis. 2022, 41, 1451–1457. [Google Scholar] [CrossRef]
- The European Committee on Antimicrobial Susceptibility Testing. Guidance Document on Broth Microdilution Testing of Cefiderocol. 2020. Available online: http://www.eucast.org (accessed on 31 October 2022).
- The European Committee on Antimicrobial Susceptibility Testing. Breakpoint Tables for Interpretation of MICs and Zone Diameters. Version 12.0. 2022. Available online: http://www.eucast.org (accessed on 31 October 2022).
- Doern, C.D. When does 2 plus 2 equal 5? A review of antimicrobial synergy testing. J. Clin. Microbiol. 2014, 52, 4124–4128. [Google Scholar] [CrossRef]
- Document M26-A; Methods for Determining Bactericidal Activity of Antimicrobial Agents: Approved Guideline. National Committee for Clinical Laboratory Standards (NCCLS): Wayne, PA, USA, 1999.
Figure 1.
Time–kill curves of cefiderocol alone and combined with tazobactam, avibactam, vaborbactam and relebactam against KPC_T01 carrying blaKPC-3 (A), N859 carrying blaKPC-50 (B), N1183 carrying blaOXA-23 (C), N1091 carrying blaOXA-48 (D) and N1700 carrying blaNDM-1 (E). Data are presented as arithmetic means. Differences ≤ 0.5 log10 at each time point were observed. Time–kill curves of β-lactamase inhibitors alone against the five isolates tested overlapped with the positive control (differences ≤ 0.5 log10 at each time point) and were not included in the graphs.
Figure 1.
Time–kill curves of cefiderocol alone and combined with tazobactam, avibactam, vaborbactam and relebactam against KPC_T01 carrying blaKPC-3 (A), N859 carrying blaKPC-50 (B), N1183 carrying blaOXA-23 (C), N1091 carrying blaOXA-48 (D) and N1700 carrying blaNDM-1 (E). Data are presented as arithmetic means. Differences ≤ 0.5 log10 at each time point were observed. Time–kill curves of β-lactamase inhibitors alone against the five isolates tested overlapped with the positive control (differences ≤ 0.5 log10 at each time point) and were not included in the graphs.
Table 1.
FICIs of tazobactam, avibactam, vaborbactam and relebactam in combination with cefiderocol against carbapenemase-producing Gram-negative strains.
Table 1.
FICIs of tazobactam, avibactam, vaborbactam and relebactam in combination with cefiderocol against carbapenemase-producing Gram-negative strains.
| Strain | Species | Sequence Typing | Carbapenemase Gene | Other β-Lactamases Genes | MIC (mg/L) | FICI and Interpretation | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| CFDC | CFDC+TAZ | CFDC+AVI | CFDC+VAB | CDFC+REL | CFDC+TAZ | CFDC+AVI | CFDC+VAB | CDFC+REL | |||||
| Ambler class A | |||||||||||||
| BO318KP [a] | K. pneumoniae | ST-512 | blaKPC-3 | blaTEM-1, blaSHV-11 | 4 | 2 | 1 | 1 | 1 | 0.56 | 0.25 | 0.31 | 0.31 |
| N1118 [b] | K. pneumoniae | - | blaKPC-2 | blaSHV-11 | 0.12 | 0.12 | ≤0.007 | 0.015 | 0.015 | 1.06 | 0.18 | 0.24 | 0.24 |
| N2350 [b] | K. pneumoniae | - | blaKPC-3 | blaSHV-11, blaOXA-9 | 2 | 2 | ≤0.007 | 0.25 | 0.125 | 1.06 | 0.25 | 0.37 | 0.31 |
| CAZ156BO [a] | K. pneumoniae | ST-101 | blaKPC-3 | blaSHV-156 | 1 | 0.5 | 0.125 | 0.06 | 0.125 | 0.56 | 0.19 | 0.12 | 0.19 |
| BAT16KP [a] | K. pneumoniae | ST-512 | blaKPC-3 | blaTEM-1, blaSHV-11 | 1 | 1 | 0.06 | 0.25 | 0.06 | 1.03 | 0.12 | 0.31 | 0.12 |
| BAT15KP [a] | K. pneumoniae | ST-512 | blaKPC-3 | blaTEM-1, blaSHV-11 | 1 | 1 | 0.12 | 0.25 | 0.12 | 1.06 | 0.18 | 0.31 | 0.18 |
| KPC_TO5 [c] | K. pneumoniae | ST-512 | blaKPC-3 | blaTEM-1A, blaOXA-9, blaSHV-11 | 0.5 | 0.25 | 0.015 | 0.12 | 0.015 | 0.56 | 0.09 | 0.3 | 0.09 |
| KPC_TO1 [c] | K. pneumoniae | ST-512 | blaKPC-3 | blaTEM-1A, blaOXA-9, blaSHV-11 | 0.12 | 0.06 | ≤0.007 | 0.015 | 0.015 | 0.56 | 0.12 | 0.19 | 0.19 |
| KPB07 [a] | K. pneumoniae | ST-1519 | blaKPC-3 | blaTEM-1, blaOXA-9, blaSHV-11 | 0.25 | 0.25 | 0.015 | 0.06 | 0.06 | 1.06 | 0.18 | 0.30 | 0.30 |
| KPB09 [a] | K. pneumoniae | ST-1519 | blaKPC-3 | blaTEM-1, blaOXA-9, blaSHV-11 | 0.125 | 0.125 | ≤0.007 | 0.015 | 0.015 | 1.06 | 0.18 | 0.18 | 0.18 |
| KPB013 [a] | K. pneumoniae | ST-1519 | blaKPC-3 | blaOXA-9, blaSHV-11 | 0.125 | 0.125 | ≤0.007 | 0.015 | ≤0.007 | 1.06 | 0.18 | 0.18 | 0.12 |
| KPB02 [a] | K. pneumoniae | ST-1519 | blaKPC-36 | blaTEM-1, blaOXA-9, blaSHV-11 | 0.25 | 0.25 | ≤0.007 | 0.06 | 0.06 | 1.06 | 0.28 | 0.30 | 0.30 |
| KPC_TO3 [c] | K. pneumoniae | ST-512 | blaKPC-66 | blaTEM-1A, blaOXA-9, blaSHV-11 | 0.5 | ≤0.007 | ≤0.007 | 0.015 | 0.015 | 0.26 | 0.08 | 0.09 | 0.09 |
| BOT-EMOKP [a] | K. pneumoniae | ST-1519 | blaKPC-31, blaKPC-3 | blaTEM-1, blaOXA-9, blaSHV-11 | 8 | 2 | 0.5 | 0.25 | 0.5 | 0.31 | 0.12 | 0.09 | 0.12 |
| N435 [b] | K. pneumoniae | - | blaKPC-41 | blaSHV-11, blaTEM-1 | 4 | 0.5 | 0.12 | 0.12 | 0.5 | 0.13 | 0.09 | 0.09 | 0.19 |
| N859 [b] | K. pneumoniae | ST-258 | blaKPC-50 | blaSHV-11 | 16 | 16 | 4 | 1 | 4 | 1.06 | 0.31 | 0.12 | 0.31 |
| CAZ59BO [a] | K. pneumoniae | ST-512 | blaKPC-53 | blaTEM-1, blaSHV-11 | 2 | 0.5 | 0.125 | 0.125 | 0.125 | 0.31 | 0.13 | 0.13 | 0.13 |
| R90 [b] | P. aeruginosa | - | blaKPC-2 | blaTEM-1 | 0.25 | 0.25 | 0.03 | 0.06 | 0.06 | 1.06 | 0.18 | 0.30 | 0.30 |
| Ambler class B | |||||||||||||
| N590 [b] | E. coli | ST-167 | blaNDM-5 | blaCMY-42 | 4 | 4 | 2 | 4 | 2 | 1.06 | 0.56 | 1.06 | 0.56 |
| N1700 [b] | E. coli | ST-69 | blaNDM-1 | blaCMY-4, blaCTX-M-15, blaOXA-10, blaTEM-1B | 2 | 0.5 | 0.06 | 1 | 1 | 0.31 | 0.28 | 0.56 | 0.56 |
| N2352 [b] | E. coli | - | blaNDM-5 | blaCTX-M-15, blaOXA-1, blaTEM-190 | 0.5 | 0.25 | 0.25 | 0.25 | 0.5 | 0.56 | 0.62 | 0.56 | 1.06 |
| R2752 [b] | E.coli | - | blaVIM-34 | blaTEM-1 | 0.06 | 0.03 | 0.03 | 0.06 | 0.03 | 0.56 | 0.75 | 1.06 | 0.56 |
| N1491 [b] | E. cloacae | ST-78 | blaNDM-1 | blaACT-24, blaCTX-M-15, blaTEM-1, blaOXA-1 | 4 | 4 | 2 | 4 | 4 | 1.06 | 0.62 | 1.06 | 1.06 |
| N1692 [b] | K. pneumoniae | ST-147 | blaNDM-1 | blaCTX-M-15, blaOXA-140, blaOXA-9, blaSHV-11, blaTEM-1A | 8 | 4 | 2 | 4 | 4 | 0.56 | 0.31 | 0.56 | 0.56 |
| N1697 [b] | C. freundi | - | blaNDM-1 | blaOXA-1, blaSHV-12 | 2 | 2 | 1 | 1 | 1 | 0.62 | 0.56 | 0.56 | 0.56 |
| N1215 [b] | P. aeruginosa | - | blaVIM-2 | blaOXA-486, blaPDC-3, blaPER-1, blaOXA-4 | 0.25 | 0.125 | 0.125 | 0.25 | 0.06 | 0.56 | 0.56 | 1.06 | 0.30 |
| N1539 [b] | P. aeruginosa | ST-235 | blaNDM-1 | blaPAO, blaOXA-50 | 0.06 | 0.06 | 0.06 | 0.06 | 0.06 | 1.06 | 1.06 | 1.06 | 1.06 |
| N1244 [b] | P. aeruginosa | ST-111 | blaIMP-18 | blaPDC-3, blaOXA-2, blaOXA-50 | 0.03 | 0.015 | 0.015 | 0.03 | 0.03 | 0.56 | 0.56 | 1.06 | 1.06 |
| N1744 [b] | P. aeruginosa | ST-2613 | blaNDM-1 | blaOXA-488, blaPAO-like | 1 | 1 | 0.5 | 0.5 | 0.5 | 1.06 | 0.56 | 0.56 | 0.56 |
| Ambler class B+D | |||||||||||||
| N1898 [b] | A. baumannii | ST-52 | blaNDM-9, blaOXA-58 | blaADC-158, blaOXA-98 | 16 | 8 | 16 | 8 | 16 | 0.56 | 1.06 | 0.56 | 1.06 |
| N2004 [b] | A. baumannii | - | blaNDM-1, blaOXA-23 | blaOXA-66, blaADC-30 | 8 | 8 | 8 | 8 | 8 | 1.06 | 1.06 | 1.06 | 1.06 |
| Ambler class D | |||||||||||||
| N1067 [b] | E. coli | ST-38 | blaOXA-181 | blaCTX-M-27 | 0.25 | 0.03 | 0.015 | 0.06 | 0.03 | 0.18 | 0.12 | 0.30 | 0.18 |
| N1085 [b] | E. coli | ST-38 | blaOXA-244 | blaCTX-M-27 | 0.12 | 0.015 | 0.03 | 0.03 | 0.015 | 0.19 | 0.37 | 0.31 | 0.19 |
| N1091 [b] | K. pneumoniae | ST-11 | blaOXA-48 | blaCTX-M-15, blaSHV-11 | 0.5 | 0.06 | 0.015 | 0.12 | 0.06 | 0.09 | 0.18 | 0.30 | 0.18 |
| N612 [b] | A. baumannii | ST-2 | blaOXA-23 | blaADC-25like, blaOXA-66 | 0.25 | 0.12 | 0.12 | 0.12 | 0.25 | 0.56 | 0.56 | 0.56 | 1.06 |
| N774 [b] | A. baumannii | ST-2 | blaOXA-40 | blaADC-25like, blaOXA-66 | 1 | 0.5 | 0.5 | 1 | 0.5 | 0.56 | 0.62 | 0.56 | 1.06 |
| N1183 [b] | A. baumannii | ST-2 | blaOXA-23 | blaADC-25-like, blaOXA-66 | 0.25 | 0.12 | 0.12 | 0.25 | 0.12 | 0.56 | 0.56 | 1.06 | 1.06 |
| ACBB0432 [a] | A. baumannii | ST-195 | blaOXA-23 | blaTEM-1 | 0.25 | 0.25 | 0.125 | 0.125 | 0.25 | 1.06 | 0.56 | 0.56 | 1.06 |
| BO415CRAB [a] | A. baumannii | ST-195 | blaOXA-23 | blaTEM-1 | 0.12 | 0.12 | 0.06 | 0.12 | 0.12 | 1.06 | 0.56 | 1.06 | 1.06 |
| Reference | |||||||||||||
| ATCC 25922 | E. coli | - | - | - | 0.06 | 0.06 | 0.06 | 0.06 | 0.06 | 1.06 | 1.25 | 1.06 | 1.06 |
| ATCC 700603 | K. pneumoniae | - | - | blaSHV-18 | 0.25 | 0.015 | 0.06 | 0.06 | 0.03 | 0.12 | 0.30 | 0.30 | 0.18 |
| ATCC BAA-2814 | K. pneumoniae | - | blaKPC | blaSHV-11, blaTEM-1 | 1 | 0.03 | 0.5 | 0.06 | 0.06 | 0.15 | 0.56 | 0.12 | 0.12 |
| ATCC 27853 | P. aeruginosa | - | - | - | 0.06 | 0.06 | 0.06 | 0.06 | 0.03 | 1.06 | 1.06 | 1.06 | 0.56 |
[a] Operative Unit of Microbiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; [b] National Reference Center for Emerging Antibiotic Resistance, Switzerland; and [c] Microbiology and Virology Unit, University Hospital Città della Salute e della Scienza di Torino, Italy. Grey shading indicates resistance. Underline and bold character indicate additive and synergistic effect, respectively. Abbreviations: CFDC, cefiderocol; TAZ, tazobactam; AVI, avibactam; VAB, vaborbactam; REL, relebactam; and FICI, Fractional inhibitory concentration index.
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. |
© 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
MDPI and ACS Style
Bianco, G.; Gaibani, P.; Comini, S.; Boattini, M.; Banche, G.; Costa, C.; Cavallo, R.; Nordmann, P. Synergistic Effect of Clinically Available Beta-Lactamase Inhibitors Combined with Cefiderocol against Carbapenemase-Producing Gram-Negative Organisms. Antibiotics 2022, 11, 1681. https://doi.org/10.3390/antibiotics11121681
AMA Style
Bianco G, Gaibani P, Comini S, Boattini M, Banche G, Costa C, Cavallo R, Nordmann P. Synergistic Effect of Clinically Available Beta-Lactamase Inhibitors Combined with Cefiderocol against Carbapenemase-Producing Gram-Negative Organisms. Antibiotics. 2022; 11(12):1681. https://doi.org/10.3390/antibiotics11121681
Chicago/Turabian StyleBianco, Gabriele, Paolo Gaibani, Sara Comini, Matteo Boattini, Giuliana Banche, Cristina Costa, Rossana Cavallo, and Patrice Nordmann. 2022. "Synergistic Effect of Clinically Available Beta-Lactamase Inhibitors Combined with Cefiderocol against Carbapenemase-Producing Gram-Negative Organisms" Antibiotics 11, no. 12: 1681. https://doi.org/10.3390/antibiotics11121681
Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.
