MICROBIAL DRUG RESISTANCE Volume 20, Number 5, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/mdr.2013.0181
Activity of Ceftaroline-Avibactam Tested Against Contemporary Enterobacteriaceae Isolates Carrying b-Lactamases Prevalent in the United States Mariana Castanheira,1 Gregory Williams,2 Ronald N. Jones,1 and Helio S. Sader1
Contemporary (2012) b-lactamase-producing isolates (n = 493) from U.S. hospitals were tested against ceftaroline-avibactam. Klebsiella spp., Escherichia coli and Proteus mirabilis isolates displaying the Clinical and Laboratory Standards Institute (CLSI) screening criteria for extended spectrum b-lactamase (ESBL) production were evaluated. Isolates carried genes encoding CTX-M (n = 316, CTX-M-14-like and -15-like), KPC (n = 45), CMY-2-like (n = 54), or SHV enzyme with ESBL activity (n = 78). Ceftaroline-avibactam inhibited 98.2% of the isolates at £ 0.5 mg/mL, and all strains were inhibited by £ 2 mg/mL of this novel b-lactamase-inhibitor combination. These results confirm that ceftaroline-avibactam could be a useful therapeutic option for Enterobacteriaceae isolates producing b-lactamases that are prevalent in the United States.
enes encoding b-lactamases are usually carried on plasmids or genetic structures that harbor additional genes defining resistance to other antimicrobial classes and conferring the isolates as multidrug-resistant (MDR) phenotypes.11 Very few antimicrobial treatment options that are clinically available seem to provide an adequate coverage for these b-lactamase-producing isolates, especially for those strains producing KPC or metallo-b-lactamases. Isolates producing these carbapenemases are resistant to most or all clinically available b-lactam agents, including the carbapenems, as well as to fluoroquinolones and aminoglycosides and, in some instances, to colistin and tigecycline.1,10 b-Lactam/b-lactamase inhibitor combinations have been used in clinical practice for several decades; however, older inhibitors, such as tazobactam, sulbactam, and clavulanate, are not very active against isolates producing various contemporary b-lactamases.6 Avibactam is a novel non-blactam serine-b-lactamase inhibitor against Ambler structural classes A and C and some class D enzymes.2 When combined with a cephalosporin, avibactam has been able to reduce the minimum inhibitory concentration (MIC) values against b-lactamase-producing isolates including those carrying blaKPC, from the resistant category to susceptible MIC ranges in the vast majority of tested isolates.7 Ceftaroline, like other oxyimino cephalosporins, has limited activity against isolates producing broad-spectrum b-lactamases, but activity can be restored when combined with avibactam.
G
1 2
In this study, we evaluated the activity of ceftarolineavibactam tested against 493 Enterobacteriaceae contemporary isolates collected in U.S. hospitals during 2012 that produced very prevalent broad-spectrum b-lactamases. A total of 287 Escherichia coli, 167 Klebsiella pneumoniae, 27 Proteus mirabilis, and 12 Klebsiella oxytoca clinical isolates that displayed the Clinical and Laboratory Standards Institute (CLSI) criteria for extended spectrum blactamase (ESBL) production (MIC > 1 mg/mL for ceftazidime and/or ceftriaxone and/or aztreonam) were selected. Isolates were collected in 68 hospitals located in 35 U.S. states during 2012. Detection of b-lactamase-encoding genes was performed using Check-MDR CT101 kit (CheckPoints, Wageningen, Netherlands). Isolates produced KPC (n = 45), CTX-M (n = 316; 251 CTX-M-15-like and 65 CTX-M-14-like), SHV displaying ESBL activity (SHVESBL; n = 78), or CMY-2-like (n = 54) with or without one or more narrow-spectrum b-lactamases that included SHV and TEM enzymes. Isolates were susceptibility tested against ceftaroline with or without avibactam at a fixed concentration of 4 mg/mL and comparator agents using reference broth microdilution method as described by the CLSI.4 Quality control (QC) was performed using E. coli ATCC 25922 and Pseudomonas aeruginosa ATCC 27853. All QC results were within specified ranges as published in CLSI document M100-S23.5 The activity of ceftaroline was remarkably improved when this cephalosporin was combined with avibactam
JMI Laboratories, North Liberty, Iowa. Cerexa, Inc., Oakland, California.
436
437
£ 0.015 0.06
0.12
0.25
0.5
20 (64.8) – 1 (6.7) –
13 (27.8) – 1 (4.4) – – – 83 (35.5) 132 (81.5) – – 8 (8.4) 35 (29.3) – –
21 (46.2) –
10 (19.2) –
68 (26.9) 134 (69.3) – –
3 (96.3) –
– –
6 (99.4) 2 (0.8)
1
1 (98.1) –
– – 1 (0.3) 42 (96.2) 5 (97.9) 5 (99.7) – – 1 (0.6) 51 (59.9) 39 (83.2) 20 (95.2) – – 1 (0.3)
0 1 2 5 0
(0.3) (100.0) (1.8) (98.2) (0.3)
5 (93.3) –
1 (100.0) –
8 (100.0) – 2 (2.6) 2 (5.1)
7 (100.0) –
3 (13.3) 16 (48.9) 15 (82.2) – – –
14 (90.7) –
19 (70.5) 15 (89.7) – –
70 (91.5) 20 (97.8) – –
92 (23.7) 176 (59.4) 106 (80.9) 54 (91.9) 31 (98.2) – – – – 2 (0.4)
0.03
ESBL, extended-spectrum b-lactamase; MIC, minimum inhibitory concentration.
All isolates (493) Ceftaroline-avibactam 25 (5.1) Ceftaroline – CTX-M producers (316) Ceftaroline-avibactam 17 (5.4) Ceftaroline – SHV-ESBL producers (78) Ceftaroline-avibactam 5 (6.4) Ceftaroline – CMY producers (54) Ceftaroline-avibactam 2 (3.7) Ceftaroline – KPC producers (45) Ceftaroline-avibactam 1 (2.2) Ceftaroline – Escherichia coli (287) Ceftaroline-avibactam – Ceftaroline 19 (6.6) Klebsiella pneumoniae (167) – Ceftaroline-avibactam 6 (3.6) Ceftaroline –
Organism group (no. tested)/ antimicrobial agent
4
0 (0.3) – 6 (5.4) 3 (100.0) 0 (0.3)
3 (100.0) –
– –
– 7 (14.1)
– –
5 (2.1) – 6 (9.0) – 5 (2.1)
– –
– 1 (1.9)
– 11 (28.2)
– 1 (0.3)
3 (100.0) – 7 (2.2) 13 (4.9)
2
No. of isolates at MIC in mg/mL (cumulative %)
– 1 (0.9)
> 32
– –
– 9 (83.3)
– 9 (57.7)
– 5 (2.5)
– 45 (100.0)
– 9 (100.0)
– 33 (100.0)
– 308 (100.0)
11 (5.9) 20 (12.9) 10 (16.4) 240 (100.0) – – – – 3 (10.8) 7 (15.0) 7 (19.2) 135 (100.0) – – – – 11 (5.9) 20 (12.9) 10 (16.4) 240 (100.0)
– –
– – 11 (22.2) 24 (66.7) – –
32
– – – 36 (15.2) 23 (19.9) 395 (100.0)
16
– – 3 (32.1) 11 (46.2)
– 1 (0.6)
– 15 (7.9)
8
Table 1. MIC Frequency Distribution of the b-Lactamase-Producing Enterobacteriaceae Tested Against Ceftaroline-Avibactam and Ceftaroline Alone
438
CASTANHEIRA ET AL.
Table 2. Activity of Ceftaroline-Avibactam and Comparator Antimicrobial Agents When Tested Against 493 Enterobacteriaceae Isolates Carrying KPC, CTX-M, SHV, or CMY b-Lactamases Isolate group (no. tested)/ antimicrobial agent All isolates (493) Ceftaroline-avibactam Ceftaroline Ceftriaxone Imipenem Piperacillin/tazobactam Amikacin Tobramycin Ciprofloxacin Tetracycline CTX-M producers (316) Ceftaroline-avibactam Ceftaroline Ceftriaxone Imipenem Piperacillin/tazobactam Amikacin Tobramycin Ciprofloxacin Tetracycline SHV-ESBL producers (78) Ceftaroline-avibactam Ceftaroline Ceftriaxone Imipenem Piperacillin/tazobactam Amikacin Tobramycin Ciprofloxacin Tetracycline CMY producers (54) Ceftaroline-avibactam Ceftaroline Ceftriaxone Imipenem Piperacillin/tazobactam Amikacin Tobramycin Ciprofloxacin Tetracycline KPC producers (45) Ceftaroline-avibactam Ceftaroline Ceftriaxone Imipenem Piperacillin/tazobactam Amikacin Tobramycin Ciprofloxacin Tetracycline E. coli (287) Ceftaroline-avibactam Ceftaroline Ceftriaxone Imipenem Piperacillin/tazobactam Amikacin Tobramycin Ciprofloxacin Tetracycline
MIC (mg/mL)
CLSI a
EUCAST a
MIC50
MIC90
Range
%S/%I/%R
%S/%I/%R
0.06 > 32 >8 £ 0.12 8 4 16 >4 > 32
0.25 > 32 >8 2 > 64 16 > 16 >4 > 32
£ 0.015 to 2 0.5 to > 32 0.12 to > 8 £ 0.12 to > 8 £ 0.5 to > 64 0.5 to > 32 £ 0.12 to > 16 £ 0.03 to > 4 0.5 to > 32
-/-/0.4/0.4/99.2 1.8/2.9/95.3 87.6/3.3/9.1 65.3/10.0/24.7 91.0/7.4/1.6 37.7/9.4/52.9 22.1/2.6/75.3 37.1/3.5/59.4
-/-/0.4/0.0/99.6 1.8/2.9/95.3 90.9/4.2/4.9 52.9/12.4/34.7 79.8/11.2/9.0 34.1/3.6/62.3 18.3/3.8/77.9 -/-/-
0.06 > 32 >8 £ 0.12 8 4 16 >4 > 32
0.12 > 32 >8 0.25 > 64 16 > 16 >4 > 32
£ 0.015 to 0.5 4 to > 32 8 to > 8 £ 0.12 to 4 £ 0.5 to > 64 0.5 to > 32 £ 0.12 to > 16 £ 0.03 to > 4 0.5 to > 32
-/-/0.0/0.0/100.0 0.0/0.0/100.0 97.2/2.5/0.3 75.9/13.3/10.8 95.9/2.5/1.6 34.5/7.9/57.6 11.4/2.2/86.4 29.4/0.3/70.3
-/-/0.0/0.0/100.0 0.0/0.0/100.0 99.7/0.3/0.0 60.8/15.1/24.1 84.4/11.5/4.1 32.0/2.5/65.5 9.2/2.2/88.6 -/-/-
0.12 32 >8 £ 0.12 32 2 8 >4 4
0.5 > 32 >8 0.5 > 64 32 > 16 >4 > 32
£ 0.015 to 0.5 0.5 to > 32 0.12 to > 8 £ 0.12 to 1 1 to > 64 0.5 to > 32 0.25 to > 16 £ 0.03 to > 4 0.5 to > 32
-/-/2.6/2.5/94.9 10.3/7.6/82.1 100.0/0.0/0.0 48.7/3.9/47.4 83.3/14.1/2.6 35.9/19.2/44.9 38.5/3.8/57.7 56.4/7.7/35.9
-/-/2.6/0.0/97.4 10.3/7.6/82.1 100.0/0.0/0.0 38.5/10.2/51.3 69.2/14.1/16.7 28.2/7.7/64.1 29.5/9.0/61.5 -/-/-
0.06 16 >8 0.25 4 2 1 £ 0.03 > 32
0.12 > 32 >8 2 > 64 4 8 >4 > 32
£ 0.015 to 1 4 to > 32 0.5 to > 8 £ 0.12 to 4 £ 0.5 to > 64 1 to 32 0.25 to > 16 £ 0.03 to > 4 0.5 to > 32
-/-/0.0/0.0/100.0 1.9/14.8/83.3 85.2/11.1/3.7 81.5/7.4/11.1 98.1/1.9/0.0 83.3/7.4/9.3 68.5/1.9/29.6 33.3/1.9/64.8
-/-/0.0/0.0/100.0 1.9/14.8/83.3 96.3/3.7/0.0 72.2/9.3/18.5 98.1/0.0/1.9 77.8/5.5/16.7 64.8/3.7/31.5 -/-/-
0.5 > 32 >8 >8 > 64 16 16 >4 4
1 > 32 >8 >8 > 64 32 > 16 >4 16
£ 0.015 to 2 > 32 8 to > 8 1 to > 8 > 64 1 to > 32 0.5 to > 16 £ 0.03 to > 4 1 to > 32
-/-/0.0/0.0/100.0 0.0/0.0/100.0 2.2/4.5/93.3 0.0/0.0/100.0 62.2/35.6/2.2 8.9/4.4/86.7 13.3/4.5/82.2 62.2/20.0/17.8
-/-/0.0/0.0/100.0 0.0/0.0/100.0 6.7/40.0/53.3 0.0/0.0/100.0 44.4/17.8/37.8 6.7/2.2/91.1 6.7/6.6/86.7 -/-/-
> 32 0.06 >8 £ 0.12 4 16 >4 > 32 > 32
> 32 0.12 >8 0.25 16 > 16 >4 > 32 > 32
0.5 to > 32 £ 0.015 to 1 0.5 to > 8 £ 0.12 to 8 1 to > 32 0.25 to > 16 £ 0.03 to > 4 0.5 to > 32 0.5 to > 32
0.3/0.0/99.7 -/-/0.3/0.4/99.3 99.3/0.4/0.3 96.1/2.8/1.1 43.9/5.6/50.5 19.5/0.4/80.1 33.8/0.3/65.9 0.3/0.0/99.7
0.3/0.0/99.7 -/-/0.3/0.4/99.3 99.7/0.3/0.0 83.9/12.2/3.9 41.1/2.8/56.1 17.1/2.4/80.5 -/-/0.3/0.0/99.7 (continued)
CEFTAROLINE-AVIBACTAM VS. b-LACTAMASE PRODUCERS
439
Table 2. (Continued) CLSI a
EUCAST a
Range
%S/%I/%R
%S/%I/%R
0.5 to > 32 £ 0.015 to 2 0.12 to > 8 £ 0.12 to > 8 0.5 to > 32 £ 0.12 to > 16 £ 0.03 to > 4 1 to > 32 0.5 to > 32
0.6/1.2/98.2 -/-/4.2/2.4/93.4 76.6/0.0/23.4 81.4/16.2/2.4 22.2/13.7/64.1 22.8/5.3/71.9 46.7/8.4/44.9 0.6/1.2/98.2
0.6/0.0/99.4 -/-/4.2/2.4/93.4 76.6/9.0/14.4 69.5/11.9/18.6 18.6/3.6/77.8 19.2/3.6/77.2 -/-/0.6/0.0/99.4
MIC (mg/mL)
Isolate group (no. tested)/ antimicrobial agent
MIC50
MIC90
K. pneumoniae (167) Ceftaroline-avibactam Ceftaroline Ceftriaxone Imipenem Piperacillin/tazobactam Amikacin Tobramycin Ciprofloxacin Tetracycline
> 32 0.12 >8 £ 0.12 4 16 >4 8 > 32
> 32 0.5 >8 >8 32 > 16 >4 > 32 > 32
a
Criteria as published by the CLSI5 and EUCAST.8 –, criteria not available; CLSI, Clinical and Laboratory Standards Institute.
(Table 1). Overall, 98.2% of the isolates were inhibited by ceftaroline-avibactam at £ 0.5 mg/mL, whereas 0.4% of the isolates were inhibited by ceftaroline alone at the same concentration. Only nine isolates had ceftarolineavibactam MIC results > 0.5 mg/mL, including one CMY2-producing isolate (MIC = 1 mg/mL) and eight KPC producers displaying MIC values at 1 and 2 mg/mL. Amikacin, imipenem, and piperacillin/tazobactam were the only comparator agents displaying activity against all b-lactamase-producing isolates (n = 493) and these compounds inhibited 91.0%, 87.6%, and 65.3% of the isolates, respectively, at the CLSI susceptibility breakpoint (Table 2). Other comparator agents tested, including ceftriaxone, ciprofloxacin, tobramycin, tetracycline, and ceftaroline, alone had limited activity ( £ 37.7% susceptible) against this collection of isolates. All isolates producing CTX-M and SHV-ESBL variants were inhibited by ceftaroline-avibactam at £ 0.5 mg/mL. Ceftaroline-avibactam (MIC50/90 = 0.06/0.12 mg/mL) was very potent against isolates producing CTX-M enzymes and was slightly more active when compared with imipenem (MIC50/90 £ 0.12/0.25 mg/mL; Table 2). Amikacin (MIC50/ 90 = 4/16 mg/mL) was the only other comparator agent that displayed high activity against CTX-M-producing isolates and inhibited 95.9% of the isolates using the currently CLSI breakpoint criteria. Against isolates that produced an SHV-ESBL enzyme, ceftaroline-avibactam (MIC50/90 = 0.12/0.5 mg/mL; Table 2) had similar activity to that of imipenem (MIC50/90 £ 0.12/ 0.5 mg/mL). Imipenem and amikacin were the only compounds that inhibited > 80% of these isolates at the current CLSI breakpoints (100.0% and 83.3% susceptible, respectively). Isolates producing CMY-2-like transferable cephalosporinase were more susceptible to several of the comparator agents tested. The activity of ceftaroline-avibactam (MIC50/ 90 = 0.06/0.12 mg/mL) was notably elevated when compared with other agents tested (Table 2). Imipenem (MIC50/ 90 = 0.25/2 mg/mL) inhibited 85.2% of the isolates using the CLSI breakpoints, and the aminoglycosides, amikacin, and tobramycin, respectively, inhibited 98.1% and 83.3% of the CMY-producing isolates according to the CLSI breakpoint criteria. These isolates were also more susceptible to piperacillin/tazobactam (81.5% susceptible) and ciprofloxacin
(68.5% susceptible), when compared with other enzymeproducing groups tested (Table 2). KPC producers were highly resistant to most antimicrobial agents tested (Table 2); however, ceftaroline-avibactam was very active against these isolates (MIC50/90 = 0.5/1 mg/mL) and inhibited all strains at £ 2 mg/mL. Amikacin and tetracycline were the agents that displayed greatest coverage and inhibited 62.2% of the isolates at current CLSI breakpoints. E. coli and K. pneumoniae isolates were analyzed and ceftaroline-avibactam displayed MIC50/90 against those species of 0.06/0.12 and 0.12/0.5 mg/mL, respectively (Tables 1 and 2). Imipenem and amikacin were the most active agents tested against these bacterial species and inhibited 99.3% and 96.1% of the E. coli isolates at current CLSI breakpoints and 76.6% and 81.4% of the K. pneumoniae, respectively (Table 2). In a recent report, we demonstrated that CTX-M-15 and -14, KPC, CMY, and SHV enzymes with extended spectrum were very prevalent b-lactamases among Enterobacteriaceae isolates collected from U.S. hospitals.3 In several instances, these isolates were MDR, and the only clinically available antimicrobial agents with acceptable coverage were amikacin and tigecycline, both associated with some recognized toxicity.3 Ceftaroline-avibactam was recently demonstrated to offer safety and tolerability when administered in single and multiple intravenous doses or various infusion schemes.9 These characteristics along with the remarkable activity against troublesome b-lactamase-producing isolates make this combination very attractive as a possible therapeutic option. The combination of ceftaroline-avibactam has demonstrated activity against worldwide collections of isolates carrying one or more b-lactamases of Ambler classes A, C, and D.2 In the present study, we expand this knowledge to include very recent strains from U.S. hospitals producing the most common b-lactamases detected in this country. We show that this cephalosporin/b-lactamase inhibitor combination has potent activity against these contemporary Enterobacteriaceae isolates, including organisms producing KPC enzymes that are usually MDR and have become disseminated in numerous U.S. medical centers.
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Acknowledgments
The authors wish to express their appreciation to the JMI staff members for scientific and technical assistance in performing this study, in special to S.E. Farrell who performed the b-lactamase screening. This study was supported by Forest Laboratories, Inc., and JMI Laboratories received compensation fees for services in relation to preparing the article. Forest Laboratories, Inc., was involved in the study design and decision to present these results. Forest Laboratories, Inc., had no involvement in the collection, analysis, or interpretation of data. Scientific Therapeutics Information, Inc., provided editorial coordination, which was funded by Forest Research Institute, Inc. Disclosure Statement
JMI Laboratories, Inc., has received research and educational grants in 2011–2013 from Aires, American Proficiency Institute (API), Anacor, Astellas, AstraZeneca, Bayer, bioMerieux, Cempra, Cerexa, Contrafect, Cubist, Dipexium, Furiex, GlaxoSmithKline, Johnson & Johnson ( J&J), LegoChem Biosciences, Inc., Meiji Seika Kaisha, Merck, Nabriva, Novartis, Pfizer, PPD Therapeutics, Premier Research Group, Rempex, Rib-X Pharmaceuticals, Seachaid, Shionogi, The Medicines Co., Theravance, and ThermoFisher Scientific. Some JMI employees are advisors/ consultants for Astellas, Cubist, Pfizer, Cempra, CerexaForest, J&J, and Theravance. In regards to speakers bureaus and stock options, there are none to declare.
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5.
6. 7.
8.
9.
10.
References
1. Bogdanovich, T., J.M., Adams-Haduch, G.B., Tian, M.H., Nguyen, E.J., Kwak, C.A., Muto, and Y., Doi. 2011. Colistin-resistant, Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae belonging to the international epidemic clone ST258. Clin. Infect. Dis. 53:373–376. 2. Castanheira, M., H.S., Sader, D.J., Farrell, R.E., Mendes, and R.N., Jones. 2012. Activity of ceftaroline-avibactam tested against gram-negative organism populations, including strains expressing one or more beta-lactamases and methicillin-resistant Staphylococcus aureus carrying various SCCmec types. Antimicrob. Agents Chemother. 56:4779–4785. 3. Castanheira, M., S.E., Farrell, L.M., Deshpande, R.E., Mendes, and R.N., Jones. 2013. Prevalence of b-lactamase
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encoding genes among Enterobacteriaceae bacteremia isolates collected in 26 USA hospitals: Report from the SENTRY Antimicrobial Surveillance Program (2010). Antimicrob. Agents Chemother. 57:3012–3020. [CLSI] Clinical and Laboratory Standards Institute. 2012. M07-A9. Methods for dilution antimicrobial susceptibility tests for bacteria that grow aerobically; approved standard: ninth edition. Wayne, PA: Clinical and Laboratory Standards Institute. [CLSI] Clinical and Laboratory Standards Institute. 2013. M100-S23. Performance standards for antimicrobial susceptibility testing: 23rd informational supplement. Wayne, PA: Clinical and Laboratory Standards Institute. Drawz, S.M., and R.A., Bonomo. 2010. Three decades of beta-lactamase inhibitors. Clin. Microbiol. Rev. 23:160–201. Endimiani, A., Y., Choudhary, and R.A., Bonomo. 2009. In vitro activity of NXL104 in combination with b-lactams against Klebsiella pneumoniae isolates producing KPC carbapenemases. Antimicrob. Agents Chemother. 53:3599– 3601. EUCAST. 2013. Breakpoint tables for interpretation of MICs and zone diameters. Version 3.0, January 2013. Available at www.eucast.org/clinical_breakpoints/. (Accessed January 2, 2013). Riccobene, T.A., S.F., Su, and D., Rank. 2013. Singleand multiple-dose study to determine the safety, tolerability, and pharmacokinetics of ceftaroline fosamil in combination with avibactam in healthy subjects. Antimicrob. Agents Chemother. 57:1496–1504. Spanu, T., G., De Angelis, M., Cipriani, B., Pedruzzi, T., D’Inzeo, M.A., Cataldo, G., Sganga, and E., Tacconelli. 2012. In vivo emergence of tigecycline resistance in multidrug-resistant Klebsiella pneumoniae and Escherichia coli. Antimicrob. Agents Chemother. 56: 4516–4518. Woodford, N., J.F., Turton, and D.M., Livermore. 2011. Multiresistant Gram-negative bacteria: the role of high-risk clones in the dissemination of antibiotic resistance. FEMS Microbiol. Rev. 35:736–755.
Address correspondence to: Mariana Castanheira, PhD JMI Laboratories 345 Beaver Kreek Centre, Suite A North Liberty, IA 52317 E-mail: [email protected]
Activity of Ceftaroline-Avibactam Tested Against Contemporary Enterobacteriaceae Isolates Carrying b-Lactamases Prevalent in the United States Mariana Castanheira,1 Gregory Williams,2 Ronald N. Jones,1 and Helio S. Sader1
Contemporary (2012) b-lactamase-producing isolates (n = 493) from U.S. hospitals were tested against ceftaroline-avibactam. Klebsiella spp., Escherichia coli and Proteus mirabilis isolates displaying the Clinical and Laboratory Standards Institute (CLSI) screening criteria for extended spectrum b-lactamase (ESBL) production were evaluated. Isolates carried genes encoding CTX-M (n = 316, CTX-M-14-like and -15-like), KPC (n = 45), CMY-2-like (n = 54), or SHV enzyme with ESBL activity (n = 78). Ceftaroline-avibactam inhibited 98.2% of the isolates at £ 0.5 mg/mL, and all strains were inhibited by £ 2 mg/mL of this novel b-lactamase-inhibitor combination. These results confirm that ceftaroline-avibactam could be a useful therapeutic option for Enterobacteriaceae isolates producing b-lactamases that are prevalent in the United States.
enes encoding b-lactamases are usually carried on plasmids or genetic structures that harbor additional genes defining resistance to other antimicrobial classes and conferring the isolates as multidrug-resistant (MDR) phenotypes.11 Very few antimicrobial treatment options that are clinically available seem to provide an adequate coverage for these b-lactamase-producing isolates, especially for those strains producing KPC or metallo-b-lactamases. Isolates producing these carbapenemases are resistant to most or all clinically available b-lactam agents, including the carbapenems, as well as to fluoroquinolones and aminoglycosides and, in some instances, to colistin and tigecycline.1,10 b-Lactam/b-lactamase inhibitor combinations have been used in clinical practice for several decades; however, older inhibitors, such as tazobactam, sulbactam, and clavulanate, are not very active against isolates producing various contemporary b-lactamases.6 Avibactam is a novel non-blactam serine-b-lactamase inhibitor against Ambler structural classes A and C and some class D enzymes.2 When combined with a cephalosporin, avibactam has been able to reduce the minimum inhibitory concentration (MIC) values against b-lactamase-producing isolates including those carrying blaKPC, from the resistant category to susceptible MIC ranges in the vast majority of tested isolates.7 Ceftaroline, like other oxyimino cephalosporins, has limited activity against isolates producing broad-spectrum b-lactamases, but activity can be restored when combined with avibactam.
G
1 2
In this study, we evaluated the activity of ceftarolineavibactam tested against 493 Enterobacteriaceae contemporary isolates collected in U.S. hospitals during 2012 that produced very prevalent broad-spectrum b-lactamases. A total of 287 Escherichia coli, 167 Klebsiella pneumoniae, 27 Proteus mirabilis, and 12 Klebsiella oxytoca clinical isolates that displayed the Clinical and Laboratory Standards Institute (CLSI) criteria for extended spectrum blactamase (ESBL) production (MIC > 1 mg/mL for ceftazidime and/or ceftriaxone and/or aztreonam) were selected. Isolates were collected in 68 hospitals located in 35 U.S. states during 2012. Detection of b-lactamase-encoding genes was performed using Check-MDR CT101 kit (CheckPoints, Wageningen, Netherlands). Isolates produced KPC (n = 45), CTX-M (n = 316; 251 CTX-M-15-like and 65 CTX-M-14-like), SHV displaying ESBL activity (SHVESBL; n = 78), or CMY-2-like (n = 54) with or without one or more narrow-spectrum b-lactamases that included SHV and TEM enzymes. Isolates were susceptibility tested against ceftaroline with or without avibactam at a fixed concentration of 4 mg/mL and comparator agents using reference broth microdilution method as described by the CLSI.4 Quality control (QC) was performed using E. coli ATCC 25922 and Pseudomonas aeruginosa ATCC 27853. All QC results were within specified ranges as published in CLSI document M100-S23.5 The activity of ceftaroline was remarkably improved when this cephalosporin was combined with avibactam
JMI Laboratories, North Liberty, Iowa. Cerexa, Inc., Oakland, California.
436
437
£ 0.015 0.06
0.12
0.25
0.5
20 (64.8) – 1 (6.7) –
13 (27.8) – 1 (4.4) – – – 83 (35.5) 132 (81.5) – – 8 (8.4) 35 (29.3) – –
21 (46.2) –
10 (19.2) –
68 (26.9) 134 (69.3) – –
3 (96.3) –
– –
6 (99.4) 2 (0.8)
1
1 (98.1) –
– – 1 (0.3) 42 (96.2) 5 (97.9) 5 (99.7) – – 1 (0.6) 51 (59.9) 39 (83.2) 20 (95.2) – – 1 (0.3)
0 1 2 5 0
(0.3) (100.0) (1.8) (98.2) (0.3)
5 (93.3) –
1 (100.0) –
8 (100.0) – 2 (2.6) 2 (5.1)
7 (100.0) –
3 (13.3) 16 (48.9) 15 (82.2) – – –
14 (90.7) –
19 (70.5) 15 (89.7) – –
70 (91.5) 20 (97.8) – –
92 (23.7) 176 (59.4) 106 (80.9) 54 (91.9) 31 (98.2) – – – – 2 (0.4)
0.03
ESBL, extended-spectrum b-lactamase; MIC, minimum inhibitory concentration.
All isolates (493) Ceftaroline-avibactam 25 (5.1) Ceftaroline – CTX-M producers (316) Ceftaroline-avibactam 17 (5.4) Ceftaroline – SHV-ESBL producers (78) Ceftaroline-avibactam 5 (6.4) Ceftaroline – CMY producers (54) Ceftaroline-avibactam 2 (3.7) Ceftaroline – KPC producers (45) Ceftaroline-avibactam 1 (2.2) Ceftaroline – Escherichia coli (287) Ceftaroline-avibactam – Ceftaroline 19 (6.6) Klebsiella pneumoniae (167) – Ceftaroline-avibactam 6 (3.6) Ceftaroline –
Organism group (no. tested)/ antimicrobial agent
4
0 (0.3) – 6 (5.4) 3 (100.0) 0 (0.3)
3 (100.0) –
– –
– 7 (14.1)
– –
5 (2.1) – 6 (9.0) – 5 (2.1)
– –
– 1 (1.9)
– 11 (28.2)
– 1 (0.3)
3 (100.0) – 7 (2.2) 13 (4.9)
2
No. of isolates at MIC in mg/mL (cumulative %)
– 1 (0.9)
> 32
– –
– 9 (83.3)
– 9 (57.7)
– 5 (2.5)
– 45 (100.0)
– 9 (100.0)
– 33 (100.0)
– 308 (100.0)
11 (5.9) 20 (12.9) 10 (16.4) 240 (100.0) – – – – 3 (10.8) 7 (15.0) 7 (19.2) 135 (100.0) – – – – 11 (5.9) 20 (12.9) 10 (16.4) 240 (100.0)
– –
– – 11 (22.2) 24 (66.7) – –
32
– – – 36 (15.2) 23 (19.9) 395 (100.0)
16
– – 3 (32.1) 11 (46.2)
– 1 (0.6)
– 15 (7.9)
8
Table 1. MIC Frequency Distribution of the b-Lactamase-Producing Enterobacteriaceae Tested Against Ceftaroline-Avibactam and Ceftaroline Alone
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CASTANHEIRA ET AL.
Table 2. Activity of Ceftaroline-Avibactam and Comparator Antimicrobial Agents When Tested Against 493 Enterobacteriaceae Isolates Carrying KPC, CTX-M, SHV, or CMY b-Lactamases Isolate group (no. tested)/ antimicrobial agent All isolates (493) Ceftaroline-avibactam Ceftaroline Ceftriaxone Imipenem Piperacillin/tazobactam Amikacin Tobramycin Ciprofloxacin Tetracycline CTX-M producers (316) Ceftaroline-avibactam Ceftaroline Ceftriaxone Imipenem Piperacillin/tazobactam Amikacin Tobramycin Ciprofloxacin Tetracycline SHV-ESBL producers (78) Ceftaroline-avibactam Ceftaroline Ceftriaxone Imipenem Piperacillin/tazobactam Amikacin Tobramycin Ciprofloxacin Tetracycline CMY producers (54) Ceftaroline-avibactam Ceftaroline Ceftriaxone Imipenem Piperacillin/tazobactam Amikacin Tobramycin Ciprofloxacin Tetracycline KPC producers (45) Ceftaroline-avibactam Ceftaroline Ceftriaxone Imipenem Piperacillin/tazobactam Amikacin Tobramycin Ciprofloxacin Tetracycline E. coli (287) Ceftaroline-avibactam Ceftaroline Ceftriaxone Imipenem Piperacillin/tazobactam Amikacin Tobramycin Ciprofloxacin Tetracycline
MIC (mg/mL)
CLSI a
EUCAST a
MIC50
MIC90
Range
%S/%I/%R
%S/%I/%R
0.06 > 32 >8 £ 0.12 8 4 16 >4 > 32
0.25 > 32 >8 2 > 64 16 > 16 >4 > 32
£ 0.015 to 2 0.5 to > 32 0.12 to > 8 £ 0.12 to > 8 £ 0.5 to > 64 0.5 to > 32 £ 0.12 to > 16 £ 0.03 to > 4 0.5 to > 32
-/-/0.4/0.4/99.2 1.8/2.9/95.3 87.6/3.3/9.1 65.3/10.0/24.7 91.0/7.4/1.6 37.7/9.4/52.9 22.1/2.6/75.3 37.1/3.5/59.4
-/-/0.4/0.0/99.6 1.8/2.9/95.3 90.9/4.2/4.9 52.9/12.4/34.7 79.8/11.2/9.0 34.1/3.6/62.3 18.3/3.8/77.9 -/-/-
0.06 > 32 >8 £ 0.12 8 4 16 >4 > 32
0.12 > 32 >8 0.25 > 64 16 > 16 >4 > 32
£ 0.015 to 0.5 4 to > 32 8 to > 8 £ 0.12 to 4 £ 0.5 to > 64 0.5 to > 32 £ 0.12 to > 16 £ 0.03 to > 4 0.5 to > 32
-/-/0.0/0.0/100.0 0.0/0.0/100.0 97.2/2.5/0.3 75.9/13.3/10.8 95.9/2.5/1.6 34.5/7.9/57.6 11.4/2.2/86.4 29.4/0.3/70.3
-/-/0.0/0.0/100.0 0.0/0.0/100.0 99.7/0.3/0.0 60.8/15.1/24.1 84.4/11.5/4.1 32.0/2.5/65.5 9.2/2.2/88.6 -/-/-
0.12 32 >8 £ 0.12 32 2 8 >4 4
0.5 > 32 >8 0.5 > 64 32 > 16 >4 > 32
£ 0.015 to 0.5 0.5 to > 32 0.12 to > 8 £ 0.12 to 1 1 to > 64 0.5 to > 32 0.25 to > 16 £ 0.03 to > 4 0.5 to > 32
-/-/2.6/2.5/94.9 10.3/7.6/82.1 100.0/0.0/0.0 48.7/3.9/47.4 83.3/14.1/2.6 35.9/19.2/44.9 38.5/3.8/57.7 56.4/7.7/35.9
-/-/2.6/0.0/97.4 10.3/7.6/82.1 100.0/0.0/0.0 38.5/10.2/51.3 69.2/14.1/16.7 28.2/7.7/64.1 29.5/9.0/61.5 -/-/-
0.06 16 >8 0.25 4 2 1 £ 0.03 > 32
0.12 > 32 >8 2 > 64 4 8 >4 > 32
£ 0.015 to 1 4 to > 32 0.5 to > 8 £ 0.12 to 4 £ 0.5 to > 64 1 to 32 0.25 to > 16 £ 0.03 to > 4 0.5 to > 32
-/-/0.0/0.0/100.0 1.9/14.8/83.3 85.2/11.1/3.7 81.5/7.4/11.1 98.1/1.9/0.0 83.3/7.4/9.3 68.5/1.9/29.6 33.3/1.9/64.8
-/-/0.0/0.0/100.0 1.9/14.8/83.3 96.3/3.7/0.0 72.2/9.3/18.5 98.1/0.0/1.9 77.8/5.5/16.7 64.8/3.7/31.5 -/-/-
0.5 > 32 >8 >8 > 64 16 16 >4 4
1 > 32 >8 >8 > 64 32 > 16 >4 16
£ 0.015 to 2 > 32 8 to > 8 1 to > 8 > 64 1 to > 32 0.5 to > 16 £ 0.03 to > 4 1 to > 32
-/-/0.0/0.0/100.0 0.0/0.0/100.0 2.2/4.5/93.3 0.0/0.0/100.0 62.2/35.6/2.2 8.9/4.4/86.7 13.3/4.5/82.2 62.2/20.0/17.8
-/-/0.0/0.0/100.0 0.0/0.0/100.0 6.7/40.0/53.3 0.0/0.0/100.0 44.4/17.8/37.8 6.7/2.2/91.1 6.7/6.6/86.7 -/-/-
> 32 0.06 >8 £ 0.12 4 16 >4 > 32 > 32
> 32 0.12 >8 0.25 16 > 16 >4 > 32 > 32
0.5 to > 32 £ 0.015 to 1 0.5 to > 8 £ 0.12 to 8 1 to > 32 0.25 to > 16 £ 0.03 to > 4 0.5 to > 32 0.5 to > 32
0.3/0.0/99.7 -/-/0.3/0.4/99.3 99.3/0.4/0.3 96.1/2.8/1.1 43.9/5.6/50.5 19.5/0.4/80.1 33.8/0.3/65.9 0.3/0.0/99.7
0.3/0.0/99.7 -/-/0.3/0.4/99.3 99.7/0.3/0.0 83.9/12.2/3.9 41.1/2.8/56.1 17.1/2.4/80.5 -/-/0.3/0.0/99.7 (continued)
CEFTAROLINE-AVIBACTAM VS. b-LACTAMASE PRODUCERS
439
Table 2. (Continued) CLSI a
EUCAST a
Range
%S/%I/%R
%S/%I/%R
0.5 to > 32 £ 0.015 to 2 0.12 to > 8 £ 0.12 to > 8 0.5 to > 32 £ 0.12 to > 16 £ 0.03 to > 4 1 to > 32 0.5 to > 32
0.6/1.2/98.2 -/-/4.2/2.4/93.4 76.6/0.0/23.4 81.4/16.2/2.4 22.2/13.7/64.1 22.8/5.3/71.9 46.7/8.4/44.9 0.6/1.2/98.2
0.6/0.0/99.4 -/-/4.2/2.4/93.4 76.6/9.0/14.4 69.5/11.9/18.6 18.6/3.6/77.8 19.2/3.6/77.2 -/-/0.6/0.0/99.4
MIC (mg/mL)
Isolate group (no. tested)/ antimicrobial agent
MIC50
MIC90
K. pneumoniae (167) Ceftaroline-avibactam Ceftaroline Ceftriaxone Imipenem Piperacillin/tazobactam Amikacin Tobramycin Ciprofloxacin Tetracycline
> 32 0.12 >8 £ 0.12 4 16 >4 8 > 32
> 32 0.5 >8 >8 32 > 16 >4 > 32 > 32
a
Criteria as published by the CLSI5 and EUCAST.8 –, criteria not available; CLSI, Clinical and Laboratory Standards Institute.
(Table 1). Overall, 98.2% of the isolates were inhibited by ceftaroline-avibactam at £ 0.5 mg/mL, whereas 0.4% of the isolates were inhibited by ceftaroline alone at the same concentration. Only nine isolates had ceftarolineavibactam MIC results > 0.5 mg/mL, including one CMY2-producing isolate (MIC = 1 mg/mL) and eight KPC producers displaying MIC values at 1 and 2 mg/mL. Amikacin, imipenem, and piperacillin/tazobactam were the only comparator agents displaying activity against all b-lactamase-producing isolates (n = 493) and these compounds inhibited 91.0%, 87.6%, and 65.3% of the isolates, respectively, at the CLSI susceptibility breakpoint (Table 2). Other comparator agents tested, including ceftriaxone, ciprofloxacin, tobramycin, tetracycline, and ceftaroline, alone had limited activity ( £ 37.7% susceptible) against this collection of isolates. All isolates producing CTX-M and SHV-ESBL variants were inhibited by ceftaroline-avibactam at £ 0.5 mg/mL. Ceftaroline-avibactam (MIC50/90 = 0.06/0.12 mg/mL) was very potent against isolates producing CTX-M enzymes and was slightly more active when compared with imipenem (MIC50/90 £ 0.12/0.25 mg/mL; Table 2). Amikacin (MIC50/ 90 = 4/16 mg/mL) was the only other comparator agent that displayed high activity against CTX-M-producing isolates and inhibited 95.9% of the isolates using the currently CLSI breakpoint criteria. Against isolates that produced an SHV-ESBL enzyme, ceftaroline-avibactam (MIC50/90 = 0.12/0.5 mg/mL; Table 2) had similar activity to that of imipenem (MIC50/90 £ 0.12/ 0.5 mg/mL). Imipenem and amikacin were the only compounds that inhibited > 80% of these isolates at the current CLSI breakpoints (100.0% and 83.3% susceptible, respectively). Isolates producing CMY-2-like transferable cephalosporinase were more susceptible to several of the comparator agents tested. The activity of ceftaroline-avibactam (MIC50/ 90 = 0.06/0.12 mg/mL) was notably elevated when compared with other agents tested (Table 2). Imipenem (MIC50/ 90 = 0.25/2 mg/mL) inhibited 85.2% of the isolates using the CLSI breakpoints, and the aminoglycosides, amikacin, and tobramycin, respectively, inhibited 98.1% and 83.3% of the CMY-producing isolates according to the CLSI breakpoint criteria. These isolates were also more susceptible to piperacillin/tazobactam (81.5% susceptible) and ciprofloxacin
(68.5% susceptible), when compared with other enzymeproducing groups tested (Table 2). KPC producers were highly resistant to most antimicrobial agents tested (Table 2); however, ceftaroline-avibactam was very active against these isolates (MIC50/90 = 0.5/1 mg/mL) and inhibited all strains at £ 2 mg/mL. Amikacin and tetracycline were the agents that displayed greatest coverage and inhibited 62.2% of the isolates at current CLSI breakpoints. E. coli and K. pneumoniae isolates were analyzed and ceftaroline-avibactam displayed MIC50/90 against those species of 0.06/0.12 and 0.12/0.5 mg/mL, respectively (Tables 1 and 2). Imipenem and amikacin were the most active agents tested against these bacterial species and inhibited 99.3% and 96.1% of the E. coli isolates at current CLSI breakpoints and 76.6% and 81.4% of the K. pneumoniae, respectively (Table 2). In a recent report, we demonstrated that CTX-M-15 and -14, KPC, CMY, and SHV enzymes with extended spectrum were very prevalent b-lactamases among Enterobacteriaceae isolates collected from U.S. hospitals.3 In several instances, these isolates were MDR, and the only clinically available antimicrobial agents with acceptable coverage were amikacin and tigecycline, both associated with some recognized toxicity.3 Ceftaroline-avibactam was recently demonstrated to offer safety and tolerability when administered in single and multiple intravenous doses or various infusion schemes.9 These characteristics along with the remarkable activity against troublesome b-lactamase-producing isolates make this combination very attractive as a possible therapeutic option. The combination of ceftaroline-avibactam has demonstrated activity against worldwide collections of isolates carrying one or more b-lactamases of Ambler classes A, C, and D.2 In the present study, we expand this knowledge to include very recent strains from U.S. hospitals producing the most common b-lactamases detected in this country. We show that this cephalosporin/b-lactamase inhibitor combination has potent activity against these contemporary Enterobacteriaceae isolates, including organisms producing KPC enzymes that are usually MDR and have become disseminated in numerous U.S. medical centers.
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Acknowledgments
The authors wish to express their appreciation to the JMI staff members for scientific and technical assistance in performing this study, in special to S.E. Farrell who performed the b-lactamase screening. This study was supported by Forest Laboratories, Inc., and JMI Laboratories received compensation fees for services in relation to preparing the article. Forest Laboratories, Inc., was involved in the study design and decision to present these results. Forest Laboratories, Inc., had no involvement in the collection, analysis, or interpretation of data. Scientific Therapeutics Information, Inc., provided editorial coordination, which was funded by Forest Research Institute, Inc. Disclosure Statement
JMI Laboratories, Inc., has received research and educational grants in 2011–2013 from Aires, American Proficiency Institute (API), Anacor, Astellas, AstraZeneca, Bayer, bioMerieux, Cempra, Cerexa, Contrafect, Cubist, Dipexium, Furiex, GlaxoSmithKline, Johnson & Johnson ( J&J), LegoChem Biosciences, Inc., Meiji Seika Kaisha, Merck, Nabriva, Novartis, Pfizer, PPD Therapeutics, Premier Research Group, Rempex, Rib-X Pharmaceuticals, Seachaid, Shionogi, The Medicines Co., Theravance, and ThermoFisher Scientific. Some JMI employees are advisors/ consultants for Astellas, Cubist, Pfizer, Cempra, CerexaForest, J&J, and Theravance. In regards to speakers bureaus and stock options, there are none to declare.
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5.
6. 7.
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Address correspondence to: Mariana Castanheira, PhD JMI Laboratories 345 Beaver Kreek Centre, Suite A North Liberty, IA 52317 E-mail: [email protected]
