In vitro activity of the orally bioavailable ceftibuten/VNRX-7145 (VNRX-5236 etzadroxil) combination against a challenge set of Enterobacterales pathogens carrying molecularly characterized ß-lactamase genes.

OBJECTIVES: This study assessed the activity of ceftibuten, ceftibuten combined with the active form (VNRX-5236) of the ß-lactamase inhibitor VNRX-7145 and comparators against a challenge set of Gram-negative pathogens. METHODS: Two hundred and five Enterobacterales carrying plasmid AmpC (53 isolates), ESBL (50), KPC (50), OXA-48-like (49) or OXA-48-like with KPC (3) encoding genes were selected. Susceptibility was determined by broth microdilution. VNRX-5236 and avibactam were tested at a fixed concentration of 4 mg/L. RESULTS: Ceftibuten/VNRX-5236 (MIC50/90 0.12/1 mg/L) MIC values were 256-fold lower than those of ceftibuten (MIC50/90 32/256 mg/L) for all Enterobacterales and 2- to 4-fold lower than those of ceftazidime/avibactam (MIC50/90 0.5/2 mg/L). For isolates producing a plasmid-encoded AmpC, VNRX-5236 decreased ceftibuten MIC (MIC50/90 0.12/1 mg/L) by at least 512-fold compared with ceftibuten (MIC50/90 128/>256 mg/L). Ceftibuten/VNRX-5236 (MIC50/90 0.06/0.12 mg/L) and meropenem (MIC50/90 ≤0.03/0.06 mg/L; 100% susceptible) showed comparable activities against ESBL isolates and these agents had MIC90 values 4- to 8-fold lower than that of ceftazidime/avibactam (MIC50/90 0.25/0.5 mg/L; 100% susceptible). Ceftibuten/VNRX-5236 (MIC50/90 0.12/0.5 mg/L) had the lowest MIC for KPC producers, followed by ceftazidime/avibactam (MIC50/90 2/4 mg/L; 98.0% susceptible). The same MIC90 values were obtained for ceftibuten/VNRX-5236 (MIC50/90 0.25/1 mg/L) and ceftazidime/avibactam (MIC50/90 1/1 mg/L; 100.0% susceptible) for isolates carrying blaOXA-48-like. VNRX-5236 decreased the ceftibuten MIC at least 16-fold for three isolates carrying blaOXA-48-like and blaKPC. CONCLUSIONS: VNRX-5236 rescued the in vitro activity of ceftibuten against Enterobacterales carrying common serine ß-lactamases, including ESBL, AmpC and the KPC and OXA-48-like carbapenemases. Ceftibuten/VNRX-5236 may have potential as an oral treatment for infections caused by resistant Enterobacterales, while sparing carbapenems.

Development of Broth Microdilution MIC and Disk Diffusion Antimicrobial Susceptibility Test Quality Control Ranges for the Combination of Cefepime and the Novel ß-Lactamase Inhibitor Enmetazobactam.

Third-generation cephalosporin resistance among Enterobacteriaceae, mediated by the spread of extended-spectrum ß-lactamases (ESBLs), is a very serious medical concern with limited therapeutic options. Enmetazobactam (formerly AAI101) is a novel penicillanic sulfone ß-lactamase inhibitor active against a wide range of ESBLs. The combination of enmetazobactam and cefepime has entered phase 3 development in patients with complicated urinary tract infections. Using the Clinical and Laboratory Standards Institute (CLSI) M23 tier 2 study design, broth microdilution MIC and disk diffusion quality control (QC) ranges were determined for cefepime-enmetazobactam. Enmetazobactam was tested at a fixed concentration of 8 µg/ml in the MIC assay, and a cefepime-enmetazobactam disk mass of 30/20 µg was used in the disk diffusion assay. Escherichia coli ATCC 25922, E. coli ATCC 35218, E. coli NCTC 13353, Klebsiella pneumoniae ATCC 700603, and Pseudomonas aeruginosa ATCC 27853 were chosen as reference strains. The CTX-M-15-producing E. coli NCTC 13353 isolate is recommended for routine testing to control for inhibition of ESBL activity by enmetazobactam. Broth microdilution MIC QC ranges spanned 3 to 4 doubling dilutions and contained 99.6% to 100.0% of obtained MIC values for the five reference strains. Disk diffusion yielded inhibition zone diameter QC ranges that spanned 7 mm and encompassed 97.1% to 100.0% of the obtained values. Quality control ranges were approved by the CLSI in 2017 (broth microdilution MIC) and 2019 (disk diffusion). The established QC ranges will ensure that appropriate assay performance criteria are attained using CLSI reference methodology when determining the susceptibility of clinical isolates to cefepime-enmetazobactam.

Activity of fosfomycin when tested against US contemporary bacterial isolates.

Fosfomycin and comparators were susceptibility tested against over 2200 contemporary clinical isolates from US medical centers. Fosfomycin was active against Enterobacterales (MIC50/90, 4/16 µg/mL), including multidrug-resistant isolates. Potent activity was exhibited against gram-positive organisms, including Staphylococcus aureus (MIC50/90, 4/8 µg/mL). Fosfomycin may provide a promising alternative option for treatment of infections where resistant bacteria may occur.

Performance of BD Max StaphSR for Screening of Methicillin-Resistant Staphylococcus aureus Isolates among a Contemporary and Diverse Collection from 146 Institutions Located in Nine U.S. Census Regions: Prevalence of mecA Dropout Mutants.

This study determined the performance of BD Max StaphSR and the rate of methicillin-resistant Staphylococcus aureus (MRSA) with an unrecognized staphylococcal cassette chromosome mec (SCCmec) right-extremity junction (MREJ) region among 907 methicillin-resistant S. aureus (MRSA) and 900 methicillin-susceptible S. aureus (MSSA) isolates. The rate of mecA/mecC dropout mutants was also evaluated. Only three MRSA isolates (99.7% sensitivity; 904/907) were classified as MSSA by the BD Max StaphSR assay, due to negative results for MREJ. Eight MSSA isolates (99.1% sensitivity; 892/900) were assigned as MRSA. However, six of these MSSA isolates had the mecA gene confirmed by PCR and sequencing (99.8% sensitivity; 898/900). Overall, 7.1% (64/900) of MSSA isolates showed results compatible with a mecA dropout genotype.

PATIENT ENGAGEMENT AND MEANINGFUL USE: ASSESSING THE IMPACT OF THE EHR INCENTIVE PROGRAM ON CULTURAL COMPETENCE IN HEALTHCARE.

This paper examines the importance and increasing need for health care practitioners to develop cultural competence in an effort to engage patients in their care to minimize the health disparities that are found in predominately ethnic minority populations. Although Meaningful Use requires data collection related to race and ethnicity, there is no evidence to support that the data is being used to engage patients in a culturally competent way. Lessons learned from the field of education regarding strategies used to develop cultural competence in the teaching profession can be applied in the health care field. This paper argues that cultural competence and patient engagement are clearly linked.

More potency assay results for generic non-USA lots of piperacillin/tazobactam and initial reports for generic meropenem compounds marketed in the USA.

An ongoing program of international generic antimicrobial potency assays for piperacillin/tazobactam has been summarized here through December 2010, and the initial results for meropenem generic lots from the United States are also presented. Fifteen additional piperacillin/tazobactam generic lots revealed an average of -10% activity (range, +3 to -23%) compared to the branded product (Zosyn®; Wyeth-Pfizer), a finding consistent with prior reports (46 lots) of -16%. In contrast, meropenem branded and generic products had equivalent assay results (5 generic lots from 2 manufacturers [Hospira and Sandoz]). In conclusion, potencies for generic lots of parenteral broad-spectrum ß-lactams can vary widely when directly compared to branded products, requiring documentation by chemical, in vitro activity (potency assays as measured here), and purity testing before considering their addition to a hospital formulary.

Comparative potencies of contemporary generic vancomycin lot: in vitro assay results from nine products and a reference reagent-grade sample.

Numerous studies of generic vancomycin (GV) lots have emerged since the 1980s, casting some doubt on product quality. Publications question the in vivo activity, even when concurrent in vitro and chemical assays meet regulatory guidelines. This study assessed contemporary GV lots by an in vitro assay capable of measuring small variations from target-benchmark (BM) activity. Nine GV lots (Hospira [6 lots; 0.5- or 1.0-g vials], Akorn [1 lot; 1.0-g vial], APP [2 lots; 1.0-g vials]) were obtained from local United States distributors. A reagent-grade lot (Sigma lot 080M1341V) was tested as BM component due to the inability to purchase branded product vials in the USA. All lots of GV did not vary significantly from the analytical control when testing the 3 Staphylococcus aureus (wild-type 4B25, ATCC 25923, and 29213) and Enterococcus faecalis (ATCC 29212) strains. These MIC end points were read at 18 h of incubation, and Hospira lots averaged +3.5% potency (range, -3% to +8%), and Akorn and APP at 0% variance, e.g., acceptable performance. In conclusion, with a validated, precise multi-organism assay, current GV lots marketed in the USA showed minimal activity variations from a selected BM control lot. Generic antimicrobial products, in general, should be regularly monitored for potency, chemical purity, and in vivo activity before routine use in medical centers.

Fusidic acid resistance rates and prevalence of resistance mechanisms among Staphylococcus spp. isolated in North America and Australia, 2007-2008.

Among 4,167 Staphylococcus aureus and 790 coagulase-negative Staphylococcus (CoNS; not S. saprophyticus) isolates collected consecutively from North American and Australian hospitals, only 87 (1.7% overall) isolates displayed a fusidic acid (FA; also known as CEM-102) MIC of > or = 2 microg/ml (FA resistance). These strains were further evaluated with a multiplex PCR to amplify the acquired resistance genes fusB, fusC, and fusD. Mutations in fusA and fusE were evaluated in all isolates showing an absence of acquired resistance genes and/or showing FA MIC values of > or = 64 microg/ml. S. aureus resistance rates were very low in the United States (0.3%) and were higher in Canada and Australia (7.0% for both countries). Among CoNS isolates, FA resistance rates were significantly more elevated than that for S. aureus (7.2 to 20.0%; the highest rates were in Canada). All 52 (41 CoNS) FA-resistant isolates from the United States showed FA MIC results of < or = 64 microg/ml, and 7 of 11 S. aureus isolates carried fusC. CoNS strains from the United States carried fusB or fusC. In Canada, fusB and fusC occurrences were similar among S. aureus and CoNS isolates, and modestly elevated FA MIC values were observed (all MIC results were < or = 32 microg/ml). Isolates from Australia showed MIC values ranging from 2 to 32 microg/ml, and S. aureus isolates were predominantly fusC positive. fusA mutations were detected in only three S. aureus isolates, conferring FA MIC values of 2 to 8 microg/ml. Target mutations have been considered the primary FA resistance mechanism among Staphylococcus spp.; however, acquired resistance genes appear to have a dominant role in resistance against this older antimicrobial agent. In summary, this study shows that acquired genes are highly prevalent among FA-resistant strains (>90%) in three nations with distinct or absence (United States) of fusidic acid clinical use.

Occurrence and molecular characterization of fusidic acid resistance mechanisms among Staphylococcus spp. from European countries (2008).

OBJECTIVES: To determine fusidic acid resistance rates (MICs of > or = 2 mg/L) and the prevalence of fusidic acid resistance mechanisms among Staphylococcus spp. collected from European countries (2008). METHODS: Staphylococcal isolates (3134) collected from Europe were tested by CLSI broth microdilution. Isolates displaying a fusidic acid MIC of > or = 2 mg/L (non-susceptible; European Committee on Antimicrobial Susceptibility Testing breakpoint) were tested for fusB, fusC and fusD. The fusidic acid target sites fusA and fusE were then sequenced, and a method for the detection of the fusA mutation L461K was developed. Selected isolates were typed by PFGE. RESULTS: Fusidic acid resistance rates were higher among coagulase-negative staphylococci (CoNS) compared with Staphylococcus aureus. Acquired fusidic acid resistance genes were detected in 64.9% of the samples; fusB and fusC were detected among 10.1% and 16.9% of the fusidic acid-resistant S. aureus and among 26.5% and 11.3% of the CoNS, respectively. Ireland and Greece showed the highest S. aureus fusidic acid resistance levels, with low rates of acquired fusidic acid resistance genes. Isolates from these countries displayed MIC values of > or = 512 mg/L, the presence of the elongation factor G L461K alteration and clonal occurrences. Low S. aureus fusidic acid resistance rates (1%-3%) were observed in Germany, Israel, Italy, Poland, Spain and Sweden. Isolates with MIC values < or = 64 mg/L showed a great diversity of acquired fusidic acid resistance mechanisms. Acquired fusidic acid resistance genes were detected in the majority of fusidic acid-resistant isolates from Belgium, France, Switzerland, Sweden, Italy and the UK (72.2%-92.9%), and were slightly less frequent in Germany, Spain and Israel (61.3%-66.7%). CONCLUSIONS: This contemporary study showed that acquired fusidic acid resistance genes were prevalent among fusidic acid-non-susceptible European staphylococcal isolates.

Expanded studies of piperacillin/tazobactam formulations: variations among branded product lots and assessment of 46 generic lots.

The experience with analyzing the potency of piperacillin/tazobactam generic formulations by a precise multiorganism in vitro assay was expanded to 46 lots (29 manufacturers, 17 countries). Across all generic lots, the range of activity compared with a reference branded lot (RLOT; Zosyn; Wyeth Pharmaceuticals, Philadelphia, PA) was +10% to -42% (average, -16%). Eight lots of Zosyn were also tested with a range of +7 to -19 (average, only -6%), and the reproducibility (13 replicates) of the RLOT assay was confirmed (+/-3%). This ongoing quality assurance project demonstrated wide activity variations in piperacillin/tazobactam generic lots with a consistent trend toward subpotent performance (-16%) compared with the branded product. Generic substitutions within hospital formularies should consider parameters of in vitro activity, in addition to applied chemical analyses and measures of bioavailability to avoid potential adverse clinical consequences.

Daptomycin antimicrobial activity tested against methicillin-resistant staphylococci and vancomycin-resistant enterococci isolated in European medical centers (2005).

BACKGROUND: Daptomycin is a cyclic lipopeptide with potent activity and broad spectrum against Gram-positive bacteria currently used for the treatment of complicated skin and skin structure infections and bacteremia, including right sided endocarditis. We evaluated the in vitro activity of this compound and selected comparator agents tested against clinical strains of staphylococci and enterococci collected in European medical centers in 2005. METHODS: A total of 4,640 strains from 23 medical centers located in 10 European countries, Turkey and Israel (SENTRY Program platform) were tested for susceptibility by reference broth microdilution methods according to Clinical and Laboratory Standards Institute guidelines and interpretative criteria. Mueller-Hinton broth was supplemented to 50 mg/L Ca++ for testing daptomycin. Results for oxacillin (methicillin)-resistant staphylococci and vancomycin-resistant enterococci were analyzed separately. RESULTS: Oxacillin resistance rates among Staphylococcus aureus varied from 2.1% in Sweden to 42.5% in the United Kingdom (UK) and 54.7% in Ireland (29.1% overall), while vancomycin resistance rates varied from 0.0% in France, Sweden and Switzerland to 66.7% in the UK and 71.4% in Ireland among Enterococcus faecium (17.9% overall). All S. aureus strains were inhibited at daptomycin MIC of 1 mg/L (MIC50/90, 0.25/0.5 mg/L; 100.0% susceptible) and only one coagulase-negative staphylococci strain (0.1%) showed an elevated (>1 mg/L) daptomycin MIC value (4 mg/L). Among E. faecalis (MIC50/90, 0.5/1 mg/L; 100% susceptible) the highest daptomycin MIC value was 2 mg/L; while among E. faecium (MIC50/90, 2/4 mg/L; 100% susceptible) the highest MIC result was 4 mg/L. CONCLUSION: Daptomycin showed excellent in vitro activity against staphylococci and enterococci collected in European medical centers in 2005 and resistance to oxacillin, vancomycin or quinupristin/dalfopristin did not compromise its activity overall against these pathogens. Based on these results and those of previous publications, daptomycin appears to be an excellent therapeutic option for serious infections caused by oxacillin-resistant staphylococci and vancomycin-resistant enterococci in Europe.

Antimicrobial activity of a novel peptide deformylase inhibitor, LBM415, tested against respiratory tract and cutaneous infection pathogens: a global surveillance report (2003-2004).

OBJECTIVES: To evaluate the spectrum of activity and potency of LBM415, the first of the peptide deformylase inhibitor (PDFI) class to be developed for treatment of community-acquired respiratory tract infections and uncomplicated skin and soft tissue infections (uSSTI), against a large, contemporary international collection of targeted pathogens collected during 2003-2004. METHODS: A total of 21,636 isolates were tested by reference broth microdilution methods as part of a longitudinal international antimicrobial resistance surveillance study. Characteristics of the organism collection included resistance to oxacillin among 35.0% of Staphylococcus aureus and 76.0% of coagulase-negative staphylococci (CoNS); resistance to penicillin (MIC > or = 2 mg/L) among 18.0% of Streptococcus pneumoniae; vancomycin resistance among 20.0% of Enterococcus spp. and ampicillin resistance among 22.0% of Haemophilus influenzae. RESULTS: LBM415 displayed potent activity against staphylococci, streptococci, Enterococcus faecium and Moraxella catarrhalis, with > or = 99.0% of strains being inhibited at < or = 4 mg/L; 97.0% of Enterococcus faecalis isolates and 92.0% of H. influenzae isolates were also inhibited at this concentration. Seventy-seven percent of Burkholderia cepacia and 82.0% of Stenotrophomonas maltophilia were inhibited at < or = 8 mg/L. No differences in LBM415 activity against S. aureus, CoNS, S. pneumoniae, Enterococcus spp. and H. influenzae were detected for subsets susceptible or resistant to antimicrobials such as oxacillin, penicillin, ampicillin, macrolides, vancomycin and fluoroquinolones. While regional differences were apparent with some comparator agents, sensitivity to LBM415 did not vary significantly among strains from the various geographic areas sampled. One isolate of S. aureus displayed high-level resistance to LBM415 owing to multiple sequence changes in resistance phenotype genes (defB and fmt), despite the absence of the compound in clinical practice. This isolate remained susceptible to all other antimicrobials tested except for penicillin. CONCLUSIONS: With few differences detected among strains from various geographic regions, the first PDFI class agent to enter clinical development has consistently demonstrated a broad spectrum of activity against commonly isolated pathogens associated with uncomplicated respiratory and cutaneous infections. These compounds represent a significant therapeutic advance owing to their novel mechanism of action and antibacterial spectrum, including activity against resistant organisms, should pharmacokinetic and pharmacodynamic parameters support their continued development. Given the detection of a pre-existing PDFI-resistant isolate of S. aureus as demonstrated here, surveillance for resistance among the PDFI-targeted pathogens following introduction of this class of agent into clinical usage will be an important component of future studies.