In Vitro Pharmacodynamics of a Novel Ceftibuten-Clavulanate Combination Antibiotic against Enterobacteriaceae.

A novel antibiotic combination of the oral cephalosporin ceftibuten (CTB) and the ß-lactamase inhibitor clavulanate (CLA) is currently in development for urinary tract infections, including those caused by extended-spectrum-ß-lactamase (ESBL)-producing organisms. This study aimed to identify the pharmacodynamic index and magnitude of this index for CLA, when combined with a fixed CTB exposure (∼59% free time above the CTB-CLA MIC) against ESBL-producing Escherichia coli and Klebsiella pneumoniae (CTB-CLA MICs of 0.25/0.125 to 1/0.5 µg/ml) using the in vitro chemostat model. Dose fractionation studies identified the time that free CLA concentrations remained above a threshold concentration (fT>threshold) to be the best pharmacodynamic index (R2 = 0.85) compared with the free area under the curve (AUC)/threshold ratio (R2 = 0.62) and free maximum concentration/threshold ratio (R2 = 0.37). For E. coli isolates, stasis and 1-log10 CFU reductions were achieved at 30.9 and 47.9% fT>CTB concentrations of the 2:1 CTB-CLA MIC (fT>MIC here), respectively. For K. pneumoniae isolates, stasis and 1-log10 CFU reductions were achieved at 51.9 and 92.0% fT>MIC, respectively. These data inform exposure requirements for CLA combined with CTB for optimizing pharmacodynamics against Enterobacteriaceae and should be useful in designing dosage regimens for this combination antibiotic.

Potential effect of selective pressure with different ß-lactam molecules on the emergence of reduced susceptibility to ß-lactams in group B Streptococci.

In this study, the selective potential of group B Streptococcus isolates with reduced penicillin susceptibility (PRGBS) in a neonate-hypervirulent sequence type (ST)17 lineage was investigated by in vitro exposure to ß-lactams. After 19 passages of stepwise penicillin exposure, PRGBS with a high penicillin minimum inhibitory concentration MIC (0.5 mg/L), greatly augmented ceftibuten MIC (>512 mg/L), and acquisition of G406D predicted to provide destabilizing effect (ΔΔG 0.099 kcal/mol) on PBP2X structure were identified. In early passages of stepwise cefotaxime exposure, PRGBS possessing G398E predicted to stabilize PBP2X (ΔΔG -0.038 kcal/mol) emerged with high MICs for cefotaxime (0.5 mg/L), ceftibuten (>512 mg/L) and penicillin (0.25 mg/L). Additionally, G398E + G329V + H438Y predicted to provide more stabilizing effect (ΔΔG -0.415 kcal/mol) were detected in mutants with higher MICs to cefotaxime (1 mg/L) and penicillin (0.5 mg/L). PRGBS mutants selected by penicillin and cefotaxime had a marked growth disadvantage compared with the parent strain. After two passages of stepwise ceftibuten exposure, the mutants exhibited increased MICs toward ceftibuten and acquisition of T555S predicted to provide stabilizing effect (ΔΔG -0.111 kcal/mol) in PBP 2X. In subsequent passages, gradual increases in ceftibuten MICs from 128 mg/L to 512 mg/L were found among selected mutants with accompanying stabilizing T555S+A354V (ΔΔG -0.257 kcal/mol) followed by stabilizing T555S + A354V + A536V (ΔΔG -0.322 kcal/mol), resulting in selection of a penicillin-susceptible group B Streptococcus lineage with reduced ceftibuten susceptibility (CTBr PSGBS). Notably, growth ability of CTBr PSGBS mutants was comparable to that of the parent strain. These findings may predict future failure of treatment for neonatal invasive infections caused by the neonate-hypervirulent PRGBS ST17 lineage.

Favourable effect of clavulanic acid on the minimum inhibitory concentrations of cefixime and ceftibuten in ESBL-producing Escherichia coli and Klebsiella pneumoniae.

OBJECTIVES: The use of cephalosporins combined with clavulanate for the treatment of ESBL-harbouring Enterobacteriaceae has been scarcely described. We aimed to describe the effect of different concentrations of clavulanate in the MIC of cefixime and ceftibuten of ESBL-producing Escherichia coli and Klebsiella pneumoniae. METHODS: ESBL-producing E. coli and K. pneumoniae isolates were studied. Fixed concentrations of cefixime and ceftibuten (ranges of 32-0.25 and 64-0.5 ng/ml, respectively) were used. Combinations of cefixime/clavulanate and ceftibuten/clavulanate in different ratios (1:0, 1:1, 2:1, 4:1, 8:1, 16:1, 32:1) were tested. MIC were determined by broth microdilution. RESULTS: A total of 6 ESBL-producing E. coli, 6 ESBL-producing K. pneumoniae and 2 control E. coli were tested. When different quantities of clavulanate were added to cefixime and ceftibuten, greater than two-fold decreases in the MIC were observed. When testing the 1:1 cefixime/clavulanate ratio, 10/12 isolates were susceptible. When the ratios 2:1, 4:1, 8:1 and 16:1 were tested, susceptibility was noted for 9/12, 8/12, 4/12 and 5/12 isolates, respectively. Only 2/12 K. pneumoniae isolates were susceptible when the ratio 32:1 was tested. When testing ceftibuten/clavulanate, all isolates remained susceptible across all experiments. CONCLUSIONS: Clavulanic acid has a favourable effect in reducing the MIC of cefixime and ceftibuten in isolates of ESBL-producing E. coli and K. pneumoniae. Combining clavulanate with ceftibuten or cefixime could be a useful treatment strategy.

Isolation of group B Streptococcus with reduced ß-lactam susceptibility from pregnant women.

ß-Lactam antibiotics are first-line agents for the treatment and prevention of group B Streptococcus (GBS) infections. We previously reported clinical GBS isolates with reduced ß-lactam susceptibility (GBS-RBS) and characterized them as harbouring amino acid substitutions in penicillin-binding proteins (PBPs). However, to our knowledge, GBS-RBS clinical isolates have never previously been isolated from pregnant women worldwide. We obtained 477 clinical GBS isolates from vaginal/rectal swabs of 4530 pregnant women in Japan. We determined the MICs of seven ß-lactams for all 477 clinical isolates. Five clinical isolates showed reduced ceftibuten susceptibility. For these isolates, we performed sequencing analysis of pbp genes. None of the 477 isolates were non-susceptible to penicillin G, ampicillin, and meropenem. For five isolates, the MICs of ceftibuten were relatively high (64-128 µg/ml). Each of these isolates possessed a single amino acid substitution in PBP2X, and some of the substitutions had been previously found in GBS with reduced penicillin susceptibility. This is the first report of the isolation of clinical GBS-RBS isolates harbouring amino acid substitutions in PBP2X that confer reduced ceftibuten susceptibility from pregnant women.