Gram negative cephalosporium and carbapenem resistance robert bonomo md
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Transcript of Gram negative cephalosporium and carbapenem resistance robert bonomo md
New global challenges of Gram
negative cephalosporin and
carbapenem resistance Robert A Bonomo MD
Chief Medical Service
Director VISN 10 GRECC
Louis Stokes Cleveland VAMC
Vice Chairman Department of Medicine
University Hospitals Case Medical Center
Professor Case Western Reserve University School of Medicine
Presented at the 41st Annual Symposium
ldquoGlobal Movement of Infectious Pathogens and Improved Laboratory Detectionrdquo
Eastern PA Branch-American Society for Microbiology
November 17 2011
Thomas Jefferson University Philadelphia
Disclosures
bull Support from VA and NIH
bull Steris Foundation
bull Pfizer
bull Excitement rather than give formulas
Objectives
bull Overview of the problem of ATBR in
Gram negative bacteria
ndash A baumannii Pseudomonas aeruginosa
and Klebsiella pneumoniae
bull Summarize the rapidly expanding
landscape of resistance determinants
bull Use this knowledge to devise effective
treatment strategies
Part I
MDR and PDR Ab
The clinical challenge of
A baumannii
bull Multi-Drug Resistant (MDR) A baumannii are
among the most ldquoproblematic pathogensrdquo
encountered by clinicians
Why Ab factshellip
bull Most common (and emerging) drug
resistant pathogen in the US and world
bull 50-70 of Ab clinical isolates are now
eXtensively Drug Resistant (XDR ie
resistant to all antibiotics except
colistin or tigecycline) reflecting a gt15-
fold increase since 2000
bull ldquoPan Drugrdquo Resistant strains of Ab
resistant to tige + coli increasing
Perez et al AAC 2007 Talbot and others 2006 CID Talbot ERAIT 2009 Boucher CID 2009
Does resistance matter Yes
bull BSI by XDR Ab cause gt50-60 mortality
bull In a recent study 13796 patients in 1265
ICUs from 75 countries Ab was one of
only two of 19 microorganisms strongly
linked (plt001) to increased mortality by
multivariate analysis
bull Odds ratio for death-153
bull Resistance + virulence factors LPS
Fe siderophores PLD OMPs biofilm
McGowan ICHE 2019 Hoffman et al ICHE 2010 McGowan AJM 2006 Paterson CID 2006 Perez AAC 2007
Vincent JAMA 2009 Gordon JAC 2009
Survey of ldquoResistance genesrdquo in A baumannii
bla AMEs QRDR RND
Efflux pumps
OMPs Tet
ADC aacC1 gyrA AdeABC HMP-AB tetA
OXA aacC2 parC AdeM OmpA tetB
IMP aacC3 AdeIJK 33-36 kDa tetM
VIM GIM
SIM SPM
NDM
aacA4 AdeS
CraS
AdeDE
2529 kDa
CarO
tetX
PER aphA1 Res Is
OprD
(43kDA)
PBPs
TEM aphA6 AbaR 1-10 OmpW
SHV aadA1 Col R
pmrAB
44 47kDa 22 integrons
CTX-M rmt OMVs
Fournier et al PLoS Genet 2006 Jan2(1)e7 Epub 2006 Jan 13
ldquoThe Resistance Islandrdquo
86 Kb 88 orfs 82
orfs from another
source and 45
resistance genes
AbaR1-10
Threat 1 Carbapenem R
bull OXAs and MBLs
bull Naturally occurring and acquired
bull OXAs- Types and Groups
ndash Narrow spectrum
ndash Carbapenem hydrolyzing (CHDLs)
ndash ES type
bull Carbapenemases (Acinetobacter)
ndash Are not ES do not have both properties
ndash Imipenemgt meropenem
Poirel et al AAC 2010
ENTER NDM-1
Thanks Dr Perez
Threat 2 ColistinR
bull Polymyxins (E and B) are cationic polypeptide atbs
bull Colistin SO4 for PO and Colistimethate Na+ (sodium colistin methanesulphonate colistin sulfomethate sodium) for IV
bull Colistin displaces Ca+2 and Mg+2 from PO4-3 groups of membrane lipids Insertion of polymyxins disrupts the OM and LPS is released anti-endotoxin activity rapidly bactericidal
bull Urban et al reported a case of polymyxin BR A baumannii
Falgas et al CID 2005 Urban 2001 AAC Li et al AAC 2006
Li et al Int Journal of Antimicrobial Agents 2005
ColistinR bull ColR due to modifications of LPS
pmr (AdamshellipBonomo AAC US) vs lpxA-C and -D (Li and Nation Australia) Parks lab in S Korea found the same locus as we did
bull Heteroresistance (subpopulations of genetically identical subclones that are more R than the parent ) by Li et al implications for rx
bull ldquoColistin dependencerdquo 77 yo diabetic male with FI and bacteremia ldquoincreasingly luxuriant growthrdquo
Moffatt AAC 2010
Li et al AAC 2006
Hawley et al AAC
2007
Adams et al AAC 2009
Lower expression
of metabolic
proteins
and OmpA
JID 2011
Part II
MDR P aerugoinosa
The resistance challenge of the ages
Pa facts
bull Colonization rates by Pa are high in the
hospital (50) immunity and burn
bull Seriously ill patients in ICUs
bull Aggregate NNISS and EU data
ndash 20 to 30 of nosocomial pneumonias
ndash 10 to 20 of urinary tract infections
ndash 3 to 10 of bloodstream infections
Mechanisms of resistance
in Pa
Pa and ATBR
bull szlig-lactamases-all classes represented ndash Cephalosporinases
ndash class A ESBLs (PER)
ndash OXA ESBLs (OXA-10 -14)
ndash Carbapenemases (KPC and GES) MbLs
bull Loss of permeability (porins and efflux)
bull Quinolones and aminoglycosides ndash Active antimicrobial efflux
ndash Alterations in DNA gyrase
ndash Aminoglycoside-modifying enzymes
Antimicrobial resistance
bull Efflux pumps
ndash MFSmdashmajor facilitator superfamily
ndash ABCmdashATP-binding cassette family
ndash RNDmdashresistance nodulation division
ndash SMRmdashsmall multidrug resistance
ndash MATEmdashmultidrug and toxic compound
extrusion
RND and MFS extrude antibiotics and work by proton motive force In
GNRs RND works with MFP (periplasmic membrane fusion protein)
and OEP (outer membrane efflux protein) to get thru both membranes
The mysteries of the biofilm
Trends in Microbiology Jan 2001 9(1) 34-39
Part III
MDR K pneumoniae
ldquoKiller Klebsrdquo
Why should we be afraid of
Klebsiella pneumoniae KPCs
KPC K pneumoniae
AMIKACIN R
AMPICILLIN R
CEFAZOLIN R
CEFTAZIDIME R
CIPROFLOXACIN R
TRIMETHSULFA R
IMIMERO-PENEM 4 ugml rarr (gt 64)
GENTAMICIN S
AMPICILLINSUL R
CEFOTETAN R
CEFEPIME R
PIPTAZO R
Clinical impact of KPC
carbapenemases
bull ldquoThe dependability on ldquolast linerdquo antibiotics is shatteredrdquo
bull The emergence of KPC carbapenemase producing Gram-negatives is a major threat to the clinician ndash K pneumoniae Acinetobacter E
coli Enterobacter Serratia Pseudomonashellip the list grows
Patel and Bonomo 2011 Current Opinion
Clinical issues with KPC
bull ATB control Cephalosporin and b-
Lactam-b-Lactamase Inhibitor restriction
policies special populations Imipenem
restriction
bull How best to implement IC Carrot or
stick
bull Detection ESBL identification
Inoculum effect
bull Colistin-as empiric Rx combined
with aminoglycosides (gent) rifampin
Status of the KPC global
epidemic bull Two phenotypes MIClt 8 and MICgt 32
bull ST258gt ST384 ST388 othershellip
bull Plasmids from ST258 and other starins
has been transferred to E coli in
patients (Kreiswirth lab)
bull Colistin resistant ST258
bull Novel testing methods (ChromAgar
Boronates PCRESI-MS Microarray
methodsCheckpoints
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Disclosures
bull Support from VA and NIH
bull Steris Foundation
bull Pfizer
bull Excitement rather than give formulas
Objectives
bull Overview of the problem of ATBR in
Gram negative bacteria
ndash A baumannii Pseudomonas aeruginosa
and Klebsiella pneumoniae
bull Summarize the rapidly expanding
landscape of resistance determinants
bull Use this knowledge to devise effective
treatment strategies
Part I
MDR and PDR Ab
The clinical challenge of
A baumannii
bull Multi-Drug Resistant (MDR) A baumannii are
among the most ldquoproblematic pathogensrdquo
encountered by clinicians
Why Ab factshellip
bull Most common (and emerging) drug
resistant pathogen in the US and world
bull 50-70 of Ab clinical isolates are now
eXtensively Drug Resistant (XDR ie
resistant to all antibiotics except
colistin or tigecycline) reflecting a gt15-
fold increase since 2000
bull ldquoPan Drugrdquo Resistant strains of Ab
resistant to tige + coli increasing
Perez et al AAC 2007 Talbot and others 2006 CID Talbot ERAIT 2009 Boucher CID 2009
Does resistance matter Yes
bull BSI by XDR Ab cause gt50-60 mortality
bull In a recent study 13796 patients in 1265
ICUs from 75 countries Ab was one of
only two of 19 microorganisms strongly
linked (plt001) to increased mortality by
multivariate analysis
bull Odds ratio for death-153
bull Resistance + virulence factors LPS
Fe siderophores PLD OMPs biofilm
McGowan ICHE 2019 Hoffman et al ICHE 2010 McGowan AJM 2006 Paterson CID 2006 Perez AAC 2007
Vincent JAMA 2009 Gordon JAC 2009
Survey of ldquoResistance genesrdquo in A baumannii
bla AMEs QRDR RND
Efflux pumps
OMPs Tet
ADC aacC1 gyrA AdeABC HMP-AB tetA
OXA aacC2 parC AdeM OmpA tetB
IMP aacC3 AdeIJK 33-36 kDa tetM
VIM GIM
SIM SPM
NDM
aacA4 AdeS
CraS
AdeDE
2529 kDa
CarO
tetX
PER aphA1 Res Is
OprD
(43kDA)
PBPs
TEM aphA6 AbaR 1-10 OmpW
SHV aadA1 Col R
pmrAB
44 47kDa 22 integrons
CTX-M rmt OMVs
Fournier et al PLoS Genet 2006 Jan2(1)e7 Epub 2006 Jan 13
ldquoThe Resistance Islandrdquo
86 Kb 88 orfs 82
orfs from another
source and 45
resistance genes
AbaR1-10
Threat 1 Carbapenem R
bull OXAs and MBLs
bull Naturally occurring and acquired
bull OXAs- Types and Groups
ndash Narrow spectrum
ndash Carbapenem hydrolyzing (CHDLs)
ndash ES type
bull Carbapenemases (Acinetobacter)
ndash Are not ES do not have both properties
ndash Imipenemgt meropenem
Poirel et al AAC 2010
ENTER NDM-1
Thanks Dr Perez
Threat 2 ColistinR
bull Polymyxins (E and B) are cationic polypeptide atbs
bull Colistin SO4 for PO and Colistimethate Na+ (sodium colistin methanesulphonate colistin sulfomethate sodium) for IV
bull Colistin displaces Ca+2 and Mg+2 from PO4-3 groups of membrane lipids Insertion of polymyxins disrupts the OM and LPS is released anti-endotoxin activity rapidly bactericidal
bull Urban et al reported a case of polymyxin BR A baumannii
Falgas et al CID 2005 Urban 2001 AAC Li et al AAC 2006
Li et al Int Journal of Antimicrobial Agents 2005
ColistinR bull ColR due to modifications of LPS
pmr (AdamshellipBonomo AAC US) vs lpxA-C and -D (Li and Nation Australia) Parks lab in S Korea found the same locus as we did
bull Heteroresistance (subpopulations of genetically identical subclones that are more R than the parent ) by Li et al implications for rx
bull ldquoColistin dependencerdquo 77 yo diabetic male with FI and bacteremia ldquoincreasingly luxuriant growthrdquo
Moffatt AAC 2010
Li et al AAC 2006
Hawley et al AAC
2007
Adams et al AAC 2009
Lower expression
of metabolic
proteins
and OmpA
JID 2011
Part II
MDR P aerugoinosa
The resistance challenge of the ages
Pa facts
bull Colonization rates by Pa are high in the
hospital (50) immunity and burn
bull Seriously ill patients in ICUs
bull Aggregate NNISS and EU data
ndash 20 to 30 of nosocomial pneumonias
ndash 10 to 20 of urinary tract infections
ndash 3 to 10 of bloodstream infections
Mechanisms of resistance
in Pa
Pa and ATBR
bull szlig-lactamases-all classes represented ndash Cephalosporinases
ndash class A ESBLs (PER)
ndash OXA ESBLs (OXA-10 -14)
ndash Carbapenemases (KPC and GES) MbLs
bull Loss of permeability (porins and efflux)
bull Quinolones and aminoglycosides ndash Active antimicrobial efflux
ndash Alterations in DNA gyrase
ndash Aminoglycoside-modifying enzymes
Antimicrobial resistance
bull Efflux pumps
ndash MFSmdashmajor facilitator superfamily
ndash ABCmdashATP-binding cassette family
ndash RNDmdashresistance nodulation division
ndash SMRmdashsmall multidrug resistance
ndash MATEmdashmultidrug and toxic compound
extrusion
RND and MFS extrude antibiotics and work by proton motive force In
GNRs RND works with MFP (periplasmic membrane fusion protein)
and OEP (outer membrane efflux protein) to get thru both membranes
The mysteries of the biofilm
Trends in Microbiology Jan 2001 9(1) 34-39
Part III
MDR K pneumoniae
ldquoKiller Klebsrdquo
Why should we be afraid of
Klebsiella pneumoniae KPCs
KPC K pneumoniae
AMIKACIN R
AMPICILLIN R
CEFAZOLIN R
CEFTAZIDIME R
CIPROFLOXACIN R
TRIMETHSULFA R
IMIMERO-PENEM 4 ugml rarr (gt 64)
GENTAMICIN S
AMPICILLINSUL R
CEFOTETAN R
CEFEPIME R
PIPTAZO R
Clinical impact of KPC
carbapenemases
bull ldquoThe dependability on ldquolast linerdquo antibiotics is shatteredrdquo
bull The emergence of KPC carbapenemase producing Gram-negatives is a major threat to the clinician ndash K pneumoniae Acinetobacter E
coli Enterobacter Serratia Pseudomonashellip the list grows
Patel and Bonomo 2011 Current Opinion
Clinical issues with KPC
bull ATB control Cephalosporin and b-
Lactam-b-Lactamase Inhibitor restriction
policies special populations Imipenem
restriction
bull How best to implement IC Carrot or
stick
bull Detection ESBL identification
Inoculum effect
bull Colistin-as empiric Rx combined
with aminoglycosides (gent) rifampin
Status of the KPC global
epidemic bull Two phenotypes MIClt 8 and MICgt 32
bull ST258gt ST384 ST388 othershellip
bull Plasmids from ST258 and other starins
has been transferred to E coli in
patients (Kreiswirth lab)
bull Colistin resistant ST258
bull Novel testing methods (ChromAgar
Boronates PCRESI-MS Microarray
methodsCheckpoints
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Objectives
bull Overview of the problem of ATBR in
Gram negative bacteria
ndash A baumannii Pseudomonas aeruginosa
and Klebsiella pneumoniae
bull Summarize the rapidly expanding
landscape of resistance determinants
bull Use this knowledge to devise effective
treatment strategies
Part I
MDR and PDR Ab
The clinical challenge of
A baumannii
bull Multi-Drug Resistant (MDR) A baumannii are
among the most ldquoproblematic pathogensrdquo
encountered by clinicians
Why Ab factshellip
bull Most common (and emerging) drug
resistant pathogen in the US and world
bull 50-70 of Ab clinical isolates are now
eXtensively Drug Resistant (XDR ie
resistant to all antibiotics except
colistin or tigecycline) reflecting a gt15-
fold increase since 2000
bull ldquoPan Drugrdquo Resistant strains of Ab
resistant to tige + coli increasing
Perez et al AAC 2007 Talbot and others 2006 CID Talbot ERAIT 2009 Boucher CID 2009
Does resistance matter Yes
bull BSI by XDR Ab cause gt50-60 mortality
bull In a recent study 13796 patients in 1265
ICUs from 75 countries Ab was one of
only two of 19 microorganisms strongly
linked (plt001) to increased mortality by
multivariate analysis
bull Odds ratio for death-153
bull Resistance + virulence factors LPS
Fe siderophores PLD OMPs biofilm
McGowan ICHE 2019 Hoffman et al ICHE 2010 McGowan AJM 2006 Paterson CID 2006 Perez AAC 2007
Vincent JAMA 2009 Gordon JAC 2009
Survey of ldquoResistance genesrdquo in A baumannii
bla AMEs QRDR RND
Efflux pumps
OMPs Tet
ADC aacC1 gyrA AdeABC HMP-AB tetA
OXA aacC2 parC AdeM OmpA tetB
IMP aacC3 AdeIJK 33-36 kDa tetM
VIM GIM
SIM SPM
NDM
aacA4 AdeS
CraS
AdeDE
2529 kDa
CarO
tetX
PER aphA1 Res Is
OprD
(43kDA)
PBPs
TEM aphA6 AbaR 1-10 OmpW
SHV aadA1 Col R
pmrAB
44 47kDa 22 integrons
CTX-M rmt OMVs
Fournier et al PLoS Genet 2006 Jan2(1)e7 Epub 2006 Jan 13
ldquoThe Resistance Islandrdquo
86 Kb 88 orfs 82
orfs from another
source and 45
resistance genes
AbaR1-10
Threat 1 Carbapenem R
bull OXAs and MBLs
bull Naturally occurring and acquired
bull OXAs- Types and Groups
ndash Narrow spectrum
ndash Carbapenem hydrolyzing (CHDLs)
ndash ES type
bull Carbapenemases (Acinetobacter)
ndash Are not ES do not have both properties
ndash Imipenemgt meropenem
Poirel et al AAC 2010
ENTER NDM-1
Thanks Dr Perez
Threat 2 ColistinR
bull Polymyxins (E and B) are cationic polypeptide atbs
bull Colistin SO4 for PO and Colistimethate Na+ (sodium colistin methanesulphonate colistin sulfomethate sodium) for IV
bull Colistin displaces Ca+2 and Mg+2 from PO4-3 groups of membrane lipids Insertion of polymyxins disrupts the OM and LPS is released anti-endotoxin activity rapidly bactericidal
bull Urban et al reported a case of polymyxin BR A baumannii
Falgas et al CID 2005 Urban 2001 AAC Li et al AAC 2006
Li et al Int Journal of Antimicrobial Agents 2005
ColistinR bull ColR due to modifications of LPS
pmr (AdamshellipBonomo AAC US) vs lpxA-C and -D (Li and Nation Australia) Parks lab in S Korea found the same locus as we did
bull Heteroresistance (subpopulations of genetically identical subclones that are more R than the parent ) by Li et al implications for rx
bull ldquoColistin dependencerdquo 77 yo diabetic male with FI and bacteremia ldquoincreasingly luxuriant growthrdquo
Moffatt AAC 2010
Li et al AAC 2006
Hawley et al AAC
2007
Adams et al AAC 2009
Lower expression
of metabolic
proteins
and OmpA
JID 2011
Part II
MDR P aerugoinosa
The resistance challenge of the ages
Pa facts
bull Colonization rates by Pa are high in the
hospital (50) immunity and burn
bull Seriously ill patients in ICUs
bull Aggregate NNISS and EU data
ndash 20 to 30 of nosocomial pneumonias
ndash 10 to 20 of urinary tract infections
ndash 3 to 10 of bloodstream infections
Mechanisms of resistance
in Pa
Pa and ATBR
bull szlig-lactamases-all classes represented ndash Cephalosporinases
ndash class A ESBLs (PER)
ndash OXA ESBLs (OXA-10 -14)
ndash Carbapenemases (KPC and GES) MbLs
bull Loss of permeability (porins and efflux)
bull Quinolones and aminoglycosides ndash Active antimicrobial efflux
ndash Alterations in DNA gyrase
ndash Aminoglycoside-modifying enzymes
Antimicrobial resistance
bull Efflux pumps
ndash MFSmdashmajor facilitator superfamily
ndash ABCmdashATP-binding cassette family
ndash RNDmdashresistance nodulation division
ndash SMRmdashsmall multidrug resistance
ndash MATEmdashmultidrug and toxic compound
extrusion
RND and MFS extrude antibiotics and work by proton motive force In
GNRs RND works with MFP (periplasmic membrane fusion protein)
and OEP (outer membrane efflux protein) to get thru both membranes
The mysteries of the biofilm
Trends in Microbiology Jan 2001 9(1) 34-39
Part III
MDR K pneumoniae
ldquoKiller Klebsrdquo
Why should we be afraid of
Klebsiella pneumoniae KPCs
KPC K pneumoniae
AMIKACIN R
AMPICILLIN R
CEFAZOLIN R
CEFTAZIDIME R
CIPROFLOXACIN R
TRIMETHSULFA R
IMIMERO-PENEM 4 ugml rarr (gt 64)
GENTAMICIN S
AMPICILLINSUL R
CEFOTETAN R
CEFEPIME R
PIPTAZO R
Clinical impact of KPC
carbapenemases
bull ldquoThe dependability on ldquolast linerdquo antibiotics is shatteredrdquo
bull The emergence of KPC carbapenemase producing Gram-negatives is a major threat to the clinician ndash K pneumoniae Acinetobacter E
coli Enterobacter Serratia Pseudomonashellip the list grows
Patel and Bonomo 2011 Current Opinion
Clinical issues with KPC
bull ATB control Cephalosporin and b-
Lactam-b-Lactamase Inhibitor restriction
policies special populations Imipenem
restriction
bull How best to implement IC Carrot or
stick
bull Detection ESBL identification
Inoculum effect
bull Colistin-as empiric Rx combined
with aminoglycosides (gent) rifampin
Status of the KPC global
epidemic bull Two phenotypes MIClt 8 and MICgt 32
bull ST258gt ST384 ST388 othershellip
bull Plasmids from ST258 and other starins
has been transferred to E coli in
patients (Kreiswirth lab)
bull Colistin resistant ST258
bull Novel testing methods (ChromAgar
Boronates PCRESI-MS Microarray
methodsCheckpoints
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Part I
MDR and PDR Ab
The clinical challenge of
A baumannii
bull Multi-Drug Resistant (MDR) A baumannii are
among the most ldquoproblematic pathogensrdquo
encountered by clinicians
Why Ab factshellip
bull Most common (and emerging) drug
resistant pathogen in the US and world
bull 50-70 of Ab clinical isolates are now
eXtensively Drug Resistant (XDR ie
resistant to all antibiotics except
colistin or tigecycline) reflecting a gt15-
fold increase since 2000
bull ldquoPan Drugrdquo Resistant strains of Ab
resistant to tige + coli increasing
Perez et al AAC 2007 Talbot and others 2006 CID Talbot ERAIT 2009 Boucher CID 2009
Does resistance matter Yes
bull BSI by XDR Ab cause gt50-60 mortality
bull In a recent study 13796 patients in 1265
ICUs from 75 countries Ab was one of
only two of 19 microorganisms strongly
linked (plt001) to increased mortality by
multivariate analysis
bull Odds ratio for death-153
bull Resistance + virulence factors LPS
Fe siderophores PLD OMPs biofilm
McGowan ICHE 2019 Hoffman et al ICHE 2010 McGowan AJM 2006 Paterson CID 2006 Perez AAC 2007
Vincent JAMA 2009 Gordon JAC 2009
Survey of ldquoResistance genesrdquo in A baumannii
bla AMEs QRDR RND
Efflux pumps
OMPs Tet
ADC aacC1 gyrA AdeABC HMP-AB tetA
OXA aacC2 parC AdeM OmpA tetB
IMP aacC3 AdeIJK 33-36 kDa tetM
VIM GIM
SIM SPM
NDM
aacA4 AdeS
CraS
AdeDE
2529 kDa
CarO
tetX
PER aphA1 Res Is
OprD
(43kDA)
PBPs
TEM aphA6 AbaR 1-10 OmpW
SHV aadA1 Col R
pmrAB
44 47kDa 22 integrons
CTX-M rmt OMVs
Fournier et al PLoS Genet 2006 Jan2(1)e7 Epub 2006 Jan 13
ldquoThe Resistance Islandrdquo
86 Kb 88 orfs 82
orfs from another
source and 45
resistance genes
AbaR1-10
Threat 1 Carbapenem R
bull OXAs and MBLs
bull Naturally occurring and acquired
bull OXAs- Types and Groups
ndash Narrow spectrum
ndash Carbapenem hydrolyzing (CHDLs)
ndash ES type
bull Carbapenemases (Acinetobacter)
ndash Are not ES do not have both properties
ndash Imipenemgt meropenem
Poirel et al AAC 2010
ENTER NDM-1
Thanks Dr Perez
Threat 2 ColistinR
bull Polymyxins (E and B) are cationic polypeptide atbs
bull Colistin SO4 for PO and Colistimethate Na+ (sodium colistin methanesulphonate colistin sulfomethate sodium) for IV
bull Colistin displaces Ca+2 and Mg+2 from PO4-3 groups of membrane lipids Insertion of polymyxins disrupts the OM and LPS is released anti-endotoxin activity rapidly bactericidal
bull Urban et al reported a case of polymyxin BR A baumannii
Falgas et al CID 2005 Urban 2001 AAC Li et al AAC 2006
Li et al Int Journal of Antimicrobial Agents 2005
ColistinR bull ColR due to modifications of LPS
pmr (AdamshellipBonomo AAC US) vs lpxA-C and -D (Li and Nation Australia) Parks lab in S Korea found the same locus as we did
bull Heteroresistance (subpopulations of genetically identical subclones that are more R than the parent ) by Li et al implications for rx
bull ldquoColistin dependencerdquo 77 yo diabetic male with FI and bacteremia ldquoincreasingly luxuriant growthrdquo
Moffatt AAC 2010
Li et al AAC 2006
Hawley et al AAC
2007
Adams et al AAC 2009
Lower expression
of metabolic
proteins
and OmpA
JID 2011
Part II
MDR P aerugoinosa
The resistance challenge of the ages
Pa facts
bull Colonization rates by Pa are high in the
hospital (50) immunity and burn
bull Seriously ill patients in ICUs
bull Aggregate NNISS and EU data
ndash 20 to 30 of nosocomial pneumonias
ndash 10 to 20 of urinary tract infections
ndash 3 to 10 of bloodstream infections
Mechanisms of resistance
in Pa
Pa and ATBR
bull szlig-lactamases-all classes represented ndash Cephalosporinases
ndash class A ESBLs (PER)
ndash OXA ESBLs (OXA-10 -14)
ndash Carbapenemases (KPC and GES) MbLs
bull Loss of permeability (porins and efflux)
bull Quinolones and aminoglycosides ndash Active antimicrobial efflux
ndash Alterations in DNA gyrase
ndash Aminoglycoside-modifying enzymes
Antimicrobial resistance
bull Efflux pumps
ndash MFSmdashmajor facilitator superfamily
ndash ABCmdashATP-binding cassette family
ndash RNDmdashresistance nodulation division
ndash SMRmdashsmall multidrug resistance
ndash MATEmdashmultidrug and toxic compound
extrusion
RND and MFS extrude antibiotics and work by proton motive force In
GNRs RND works with MFP (periplasmic membrane fusion protein)
and OEP (outer membrane efflux protein) to get thru both membranes
The mysteries of the biofilm
Trends in Microbiology Jan 2001 9(1) 34-39
Part III
MDR K pneumoniae
ldquoKiller Klebsrdquo
Why should we be afraid of
Klebsiella pneumoniae KPCs
KPC K pneumoniae
AMIKACIN R
AMPICILLIN R
CEFAZOLIN R
CEFTAZIDIME R
CIPROFLOXACIN R
TRIMETHSULFA R
IMIMERO-PENEM 4 ugml rarr (gt 64)
GENTAMICIN S
AMPICILLINSUL R
CEFOTETAN R
CEFEPIME R
PIPTAZO R
Clinical impact of KPC
carbapenemases
bull ldquoThe dependability on ldquolast linerdquo antibiotics is shatteredrdquo
bull The emergence of KPC carbapenemase producing Gram-negatives is a major threat to the clinician ndash K pneumoniae Acinetobacter E
coli Enterobacter Serratia Pseudomonashellip the list grows
Patel and Bonomo 2011 Current Opinion
Clinical issues with KPC
bull ATB control Cephalosporin and b-
Lactam-b-Lactamase Inhibitor restriction
policies special populations Imipenem
restriction
bull How best to implement IC Carrot or
stick
bull Detection ESBL identification
Inoculum effect
bull Colistin-as empiric Rx combined
with aminoglycosides (gent) rifampin
Status of the KPC global
epidemic bull Two phenotypes MIClt 8 and MICgt 32
bull ST258gt ST384 ST388 othershellip
bull Plasmids from ST258 and other starins
has been transferred to E coli in
patients (Kreiswirth lab)
bull Colistin resistant ST258
bull Novel testing methods (ChromAgar
Boronates PCRESI-MS Microarray
methodsCheckpoints
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
The clinical challenge of
A baumannii
bull Multi-Drug Resistant (MDR) A baumannii are
among the most ldquoproblematic pathogensrdquo
encountered by clinicians
Why Ab factshellip
bull Most common (and emerging) drug
resistant pathogen in the US and world
bull 50-70 of Ab clinical isolates are now
eXtensively Drug Resistant (XDR ie
resistant to all antibiotics except
colistin or tigecycline) reflecting a gt15-
fold increase since 2000
bull ldquoPan Drugrdquo Resistant strains of Ab
resistant to tige + coli increasing
Perez et al AAC 2007 Talbot and others 2006 CID Talbot ERAIT 2009 Boucher CID 2009
Does resistance matter Yes
bull BSI by XDR Ab cause gt50-60 mortality
bull In a recent study 13796 patients in 1265
ICUs from 75 countries Ab was one of
only two of 19 microorganisms strongly
linked (plt001) to increased mortality by
multivariate analysis
bull Odds ratio for death-153
bull Resistance + virulence factors LPS
Fe siderophores PLD OMPs biofilm
McGowan ICHE 2019 Hoffman et al ICHE 2010 McGowan AJM 2006 Paterson CID 2006 Perez AAC 2007
Vincent JAMA 2009 Gordon JAC 2009
Survey of ldquoResistance genesrdquo in A baumannii
bla AMEs QRDR RND
Efflux pumps
OMPs Tet
ADC aacC1 gyrA AdeABC HMP-AB tetA
OXA aacC2 parC AdeM OmpA tetB
IMP aacC3 AdeIJK 33-36 kDa tetM
VIM GIM
SIM SPM
NDM
aacA4 AdeS
CraS
AdeDE
2529 kDa
CarO
tetX
PER aphA1 Res Is
OprD
(43kDA)
PBPs
TEM aphA6 AbaR 1-10 OmpW
SHV aadA1 Col R
pmrAB
44 47kDa 22 integrons
CTX-M rmt OMVs
Fournier et al PLoS Genet 2006 Jan2(1)e7 Epub 2006 Jan 13
ldquoThe Resistance Islandrdquo
86 Kb 88 orfs 82
orfs from another
source and 45
resistance genes
AbaR1-10
Threat 1 Carbapenem R
bull OXAs and MBLs
bull Naturally occurring and acquired
bull OXAs- Types and Groups
ndash Narrow spectrum
ndash Carbapenem hydrolyzing (CHDLs)
ndash ES type
bull Carbapenemases (Acinetobacter)
ndash Are not ES do not have both properties
ndash Imipenemgt meropenem
Poirel et al AAC 2010
ENTER NDM-1
Thanks Dr Perez
Threat 2 ColistinR
bull Polymyxins (E and B) are cationic polypeptide atbs
bull Colistin SO4 for PO and Colistimethate Na+ (sodium colistin methanesulphonate colistin sulfomethate sodium) for IV
bull Colistin displaces Ca+2 and Mg+2 from PO4-3 groups of membrane lipids Insertion of polymyxins disrupts the OM and LPS is released anti-endotoxin activity rapidly bactericidal
bull Urban et al reported a case of polymyxin BR A baumannii
Falgas et al CID 2005 Urban 2001 AAC Li et al AAC 2006
Li et al Int Journal of Antimicrobial Agents 2005
ColistinR bull ColR due to modifications of LPS
pmr (AdamshellipBonomo AAC US) vs lpxA-C and -D (Li and Nation Australia) Parks lab in S Korea found the same locus as we did
bull Heteroresistance (subpopulations of genetically identical subclones that are more R than the parent ) by Li et al implications for rx
bull ldquoColistin dependencerdquo 77 yo diabetic male with FI and bacteremia ldquoincreasingly luxuriant growthrdquo
Moffatt AAC 2010
Li et al AAC 2006
Hawley et al AAC
2007
Adams et al AAC 2009
Lower expression
of metabolic
proteins
and OmpA
JID 2011
Part II
MDR P aerugoinosa
The resistance challenge of the ages
Pa facts
bull Colonization rates by Pa are high in the
hospital (50) immunity and burn
bull Seriously ill patients in ICUs
bull Aggregate NNISS and EU data
ndash 20 to 30 of nosocomial pneumonias
ndash 10 to 20 of urinary tract infections
ndash 3 to 10 of bloodstream infections
Mechanisms of resistance
in Pa
Pa and ATBR
bull szlig-lactamases-all classes represented ndash Cephalosporinases
ndash class A ESBLs (PER)
ndash OXA ESBLs (OXA-10 -14)
ndash Carbapenemases (KPC and GES) MbLs
bull Loss of permeability (porins and efflux)
bull Quinolones and aminoglycosides ndash Active antimicrobial efflux
ndash Alterations in DNA gyrase
ndash Aminoglycoside-modifying enzymes
Antimicrobial resistance
bull Efflux pumps
ndash MFSmdashmajor facilitator superfamily
ndash ABCmdashATP-binding cassette family
ndash RNDmdashresistance nodulation division
ndash SMRmdashsmall multidrug resistance
ndash MATEmdashmultidrug and toxic compound
extrusion
RND and MFS extrude antibiotics and work by proton motive force In
GNRs RND works with MFP (periplasmic membrane fusion protein)
and OEP (outer membrane efflux protein) to get thru both membranes
The mysteries of the biofilm
Trends in Microbiology Jan 2001 9(1) 34-39
Part III
MDR K pneumoniae
ldquoKiller Klebsrdquo
Why should we be afraid of
Klebsiella pneumoniae KPCs
KPC K pneumoniae
AMIKACIN R
AMPICILLIN R
CEFAZOLIN R
CEFTAZIDIME R
CIPROFLOXACIN R
TRIMETHSULFA R
IMIMERO-PENEM 4 ugml rarr (gt 64)
GENTAMICIN S
AMPICILLINSUL R
CEFOTETAN R
CEFEPIME R
PIPTAZO R
Clinical impact of KPC
carbapenemases
bull ldquoThe dependability on ldquolast linerdquo antibiotics is shatteredrdquo
bull The emergence of KPC carbapenemase producing Gram-negatives is a major threat to the clinician ndash K pneumoniae Acinetobacter E
coli Enterobacter Serratia Pseudomonashellip the list grows
Patel and Bonomo 2011 Current Opinion
Clinical issues with KPC
bull ATB control Cephalosporin and b-
Lactam-b-Lactamase Inhibitor restriction
policies special populations Imipenem
restriction
bull How best to implement IC Carrot or
stick
bull Detection ESBL identification
Inoculum effect
bull Colistin-as empiric Rx combined
with aminoglycosides (gent) rifampin
Status of the KPC global
epidemic bull Two phenotypes MIClt 8 and MICgt 32
bull ST258gt ST384 ST388 othershellip
bull Plasmids from ST258 and other starins
has been transferred to E coli in
patients (Kreiswirth lab)
bull Colistin resistant ST258
bull Novel testing methods (ChromAgar
Boronates PCRESI-MS Microarray
methodsCheckpoints
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Why Ab factshellip
bull Most common (and emerging) drug
resistant pathogen in the US and world
bull 50-70 of Ab clinical isolates are now
eXtensively Drug Resistant (XDR ie
resistant to all antibiotics except
colistin or tigecycline) reflecting a gt15-
fold increase since 2000
bull ldquoPan Drugrdquo Resistant strains of Ab
resistant to tige + coli increasing
Perez et al AAC 2007 Talbot and others 2006 CID Talbot ERAIT 2009 Boucher CID 2009
Does resistance matter Yes
bull BSI by XDR Ab cause gt50-60 mortality
bull In a recent study 13796 patients in 1265
ICUs from 75 countries Ab was one of
only two of 19 microorganisms strongly
linked (plt001) to increased mortality by
multivariate analysis
bull Odds ratio for death-153
bull Resistance + virulence factors LPS
Fe siderophores PLD OMPs biofilm
McGowan ICHE 2019 Hoffman et al ICHE 2010 McGowan AJM 2006 Paterson CID 2006 Perez AAC 2007
Vincent JAMA 2009 Gordon JAC 2009
Survey of ldquoResistance genesrdquo in A baumannii
bla AMEs QRDR RND
Efflux pumps
OMPs Tet
ADC aacC1 gyrA AdeABC HMP-AB tetA
OXA aacC2 parC AdeM OmpA tetB
IMP aacC3 AdeIJK 33-36 kDa tetM
VIM GIM
SIM SPM
NDM
aacA4 AdeS
CraS
AdeDE
2529 kDa
CarO
tetX
PER aphA1 Res Is
OprD
(43kDA)
PBPs
TEM aphA6 AbaR 1-10 OmpW
SHV aadA1 Col R
pmrAB
44 47kDa 22 integrons
CTX-M rmt OMVs
Fournier et al PLoS Genet 2006 Jan2(1)e7 Epub 2006 Jan 13
ldquoThe Resistance Islandrdquo
86 Kb 88 orfs 82
orfs from another
source and 45
resistance genes
AbaR1-10
Threat 1 Carbapenem R
bull OXAs and MBLs
bull Naturally occurring and acquired
bull OXAs- Types and Groups
ndash Narrow spectrum
ndash Carbapenem hydrolyzing (CHDLs)
ndash ES type
bull Carbapenemases (Acinetobacter)
ndash Are not ES do not have both properties
ndash Imipenemgt meropenem
Poirel et al AAC 2010
ENTER NDM-1
Thanks Dr Perez
Threat 2 ColistinR
bull Polymyxins (E and B) are cationic polypeptide atbs
bull Colistin SO4 for PO and Colistimethate Na+ (sodium colistin methanesulphonate colistin sulfomethate sodium) for IV
bull Colistin displaces Ca+2 and Mg+2 from PO4-3 groups of membrane lipids Insertion of polymyxins disrupts the OM and LPS is released anti-endotoxin activity rapidly bactericidal
bull Urban et al reported a case of polymyxin BR A baumannii
Falgas et al CID 2005 Urban 2001 AAC Li et al AAC 2006
Li et al Int Journal of Antimicrobial Agents 2005
ColistinR bull ColR due to modifications of LPS
pmr (AdamshellipBonomo AAC US) vs lpxA-C and -D (Li and Nation Australia) Parks lab in S Korea found the same locus as we did
bull Heteroresistance (subpopulations of genetically identical subclones that are more R than the parent ) by Li et al implications for rx
bull ldquoColistin dependencerdquo 77 yo diabetic male with FI and bacteremia ldquoincreasingly luxuriant growthrdquo
Moffatt AAC 2010
Li et al AAC 2006
Hawley et al AAC
2007
Adams et al AAC 2009
Lower expression
of metabolic
proteins
and OmpA
JID 2011
Part II
MDR P aerugoinosa
The resistance challenge of the ages
Pa facts
bull Colonization rates by Pa are high in the
hospital (50) immunity and burn
bull Seriously ill patients in ICUs
bull Aggregate NNISS and EU data
ndash 20 to 30 of nosocomial pneumonias
ndash 10 to 20 of urinary tract infections
ndash 3 to 10 of bloodstream infections
Mechanisms of resistance
in Pa
Pa and ATBR
bull szlig-lactamases-all classes represented ndash Cephalosporinases
ndash class A ESBLs (PER)
ndash OXA ESBLs (OXA-10 -14)
ndash Carbapenemases (KPC and GES) MbLs
bull Loss of permeability (porins and efflux)
bull Quinolones and aminoglycosides ndash Active antimicrobial efflux
ndash Alterations in DNA gyrase
ndash Aminoglycoside-modifying enzymes
Antimicrobial resistance
bull Efflux pumps
ndash MFSmdashmajor facilitator superfamily
ndash ABCmdashATP-binding cassette family
ndash RNDmdashresistance nodulation division
ndash SMRmdashsmall multidrug resistance
ndash MATEmdashmultidrug and toxic compound
extrusion
RND and MFS extrude antibiotics and work by proton motive force In
GNRs RND works with MFP (periplasmic membrane fusion protein)
and OEP (outer membrane efflux protein) to get thru both membranes
The mysteries of the biofilm
Trends in Microbiology Jan 2001 9(1) 34-39
Part III
MDR K pneumoniae
ldquoKiller Klebsrdquo
Why should we be afraid of
Klebsiella pneumoniae KPCs
KPC K pneumoniae
AMIKACIN R
AMPICILLIN R
CEFAZOLIN R
CEFTAZIDIME R
CIPROFLOXACIN R
TRIMETHSULFA R
IMIMERO-PENEM 4 ugml rarr (gt 64)
GENTAMICIN S
AMPICILLINSUL R
CEFOTETAN R
CEFEPIME R
PIPTAZO R
Clinical impact of KPC
carbapenemases
bull ldquoThe dependability on ldquolast linerdquo antibiotics is shatteredrdquo
bull The emergence of KPC carbapenemase producing Gram-negatives is a major threat to the clinician ndash K pneumoniae Acinetobacter E
coli Enterobacter Serratia Pseudomonashellip the list grows
Patel and Bonomo 2011 Current Opinion
Clinical issues with KPC
bull ATB control Cephalosporin and b-
Lactam-b-Lactamase Inhibitor restriction
policies special populations Imipenem
restriction
bull How best to implement IC Carrot or
stick
bull Detection ESBL identification
Inoculum effect
bull Colistin-as empiric Rx combined
with aminoglycosides (gent) rifampin
Status of the KPC global
epidemic bull Two phenotypes MIClt 8 and MICgt 32
bull ST258gt ST384 ST388 othershellip
bull Plasmids from ST258 and other starins
has been transferred to E coli in
patients (Kreiswirth lab)
bull Colistin resistant ST258
bull Novel testing methods (ChromAgar
Boronates PCRESI-MS Microarray
methodsCheckpoints
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Does resistance matter Yes
bull BSI by XDR Ab cause gt50-60 mortality
bull In a recent study 13796 patients in 1265
ICUs from 75 countries Ab was one of
only two of 19 microorganisms strongly
linked (plt001) to increased mortality by
multivariate analysis
bull Odds ratio for death-153
bull Resistance + virulence factors LPS
Fe siderophores PLD OMPs biofilm
McGowan ICHE 2019 Hoffman et al ICHE 2010 McGowan AJM 2006 Paterson CID 2006 Perez AAC 2007
Vincent JAMA 2009 Gordon JAC 2009
Survey of ldquoResistance genesrdquo in A baumannii
bla AMEs QRDR RND
Efflux pumps
OMPs Tet
ADC aacC1 gyrA AdeABC HMP-AB tetA
OXA aacC2 parC AdeM OmpA tetB
IMP aacC3 AdeIJK 33-36 kDa tetM
VIM GIM
SIM SPM
NDM
aacA4 AdeS
CraS
AdeDE
2529 kDa
CarO
tetX
PER aphA1 Res Is
OprD
(43kDA)
PBPs
TEM aphA6 AbaR 1-10 OmpW
SHV aadA1 Col R
pmrAB
44 47kDa 22 integrons
CTX-M rmt OMVs
Fournier et al PLoS Genet 2006 Jan2(1)e7 Epub 2006 Jan 13
ldquoThe Resistance Islandrdquo
86 Kb 88 orfs 82
orfs from another
source and 45
resistance genes
AbaR1-10
Threat 1 Carbapenem R
bull OXAs and MBLs
bull Naturally occurring and acquired
bull OXAs- Types and Groups
ndash Narrow spectrum
ndash Carbapenem hydrolyzing (CHDLs)
ndash ES type
bull Carbapenemases (Acinetobacter)
ndash Are not ES do not have both properties
ndash Imipenemgt meropenem
Poirel et al AAC 2010
ENTER NDM-1
Thanks Dr Perez
Threat 2 ColistinR
bull Polymyxins (E and B) are cationic polypeptide atbs
bull Colistin SO4 for PO and Colistimethate Na+ (sodium colistin methanesulphonate colistin sulfomethate sodium) for IV
bull Colistin displaces Ca+2 and Mg+2 from PO4-3 groups of membrane lipids Insertion of polymyxins disrupts the OM and LPS is released anti-endotoxin activity rapidly bactericidal
bull Urban et al reported a case of polymyxin BR A baumannii
Falgas et al CID 2005 Urban 2001 AAC Li et al AAC 2006
Li et al Int Journal of Antimicrobial Agents 2005
ColistinR bull ColR due to modifications of LPS
pmr (AdamshellipBonomo AAC US) vs lpxA-C and -D (Li and Nation Australia) Parks lab in S Korea found the same locus as we did
bull Heteroresistance (subpopulations of genetically identical subclones that are more R than the parent ) by Li et al implications for rx
bull ldquoColistin dependencerdquo 77 yo diabetic male with FI and bacteremia ldquoincreasingly luxuriant growthrdquo
Moffatt AAC 2010
Li et al AAC 2006
Hawley et al AAC
2007
Adams et al AAC 2009
Lower expression
of metabolic
proteins
and OmpA
JID 2011
Part II
MDR P aerugoinosa
The resistance challenge of the ages
Pa facts
bull Colonization rates by Pa are high in the
hospital (50) immunity and burn
bull Seriously ill patients in ICUs
bull Aggregate NNISS and EU data
ndash 20 to 30 of nosocomial pneumonias
ndash 10 to 20 of urinary tract infections
ndash 3 to 10 of bloodstream infections
Mechanisms of resistance
in Pa
Pa and ATBR
bull szlig-lactamases-all classes represented ndash Cephalosporinases
ndash class A ESBLs (PER)
ndash OXA ESBLs (OXA-10 -14)
ndash Carbapenemases (KPC and GES) MbLs
bull Loss of permeability (porins and efflux)
bull Quinolones and aminoglycosides ndash Active antimicrobial efflux
ndash Alterations in DNA gyrase
ndash Aminoglycoside-modifying enzymes
Antimicrobial resistance
bull Efflux pumps
ndash MFSmdashmajor facilitator superfamily
ndash ABCmdashATP-binding cassette family
ndash RNDmdashresistance nodulation division
ndash SMRmdashsmall multidrug resistance
ndash MATEmdashmultidrug and toxic compound
extrusion
RND and MFS extrude antibiotics and work by proton motive force In
GNRs RND works with MFP (periplasmic membrane fusion protein)
and OEP (outer membrane efflux protein) to get thru both membranes
The mysteries of the biofilm
Trends in Microbiology Jan 2001 9(1) 34-39
Part III
MDR K pneumoniae
ldquoKiller Klebsrdquo
Why should we be afraid of
Klebsiella pneumoniae KPCs
KPC K pneumoniae
AMIKACIN R
AMPICILLIN R
CEFAZOLIN R
CEFTAZIDIME R
CIPROFLOXACIN R
TRIMETHSULFA R
IMIMERO-PENEM 4 ugml rarr (gt 64)
GENTAMICIN S
AMPICILLINSUL R
CEFOTETAN R
CEFEPIME R
PIPTAZO R
Clinical impact of KPC
carbapenemases
bull ldquoThe dependability on ldquolast linerdquo antibiotics is shatteredrdquo
bull The emergence of KPC carbapenemase producing Gram-negatives is a major threat to the clinician ndash K pneumoniae Acinetobacter E
coli Enterobacter Serratia Pseudomonashellip the list grows
Patel and Bonomo 2011 Current Opinion
Clinical issues with KPC
bull ATB control Cephalosporin and b-
Lactam-b-Lactamase Inhibitor restriction
policies special populations Imipenem
restriction
bull How best to implement IC Carrot or
stick
bull Detection ESBL identification
Inoculum effect
bull Colistin-as empiric Rx combined
with aminoglycosides (gent) rifampin
Status of the KPC global
epidemic bull Two phenotypes MIClt 8 and MICgt 32
bull ST258gt ST384 ST388 othershellip
bull Plasmids from ST258 and other starins
has been transferred to E coli in
patients (Kreiswirth lab)
bull Colistin resistant ST258
bull Novel testing methods (ChromAgar
Boronates PCRESI-MS Microarray
methodsCheckpoints
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Survey of ldquoResistance genesrdquo in A baumannii
bla AMEs QRDR RND
Efflux pumps
OMPs Tet
ADC aacC1 gyrA AdeABC HMP-AB tetA
OXA aacC2 parC AdeM OmpA tetB
IMP aacC3 AdeIJK 33-36 kDa tetM
VIM GIM
SIM SPM
NDM
aacA4 AdeS
CraS
AdeDE
2529 kDa
CarO
tetX
PER aphA1 Res Is
OprD
(43kDA)
PBPs
TEM aphA6 AbaR 1-10 OmpW
SHV aadA1 Col R
pmrAB
44 47kDa 22 integrons
CTX-M rmt OMVs
Fournier et al PLoS Genet 2006 Jan2(1)e7 Epub 2006 Jan 13
ldquoThe Resistance Islandrdquo
86 Kb 88 orfs 82
orfs from another
source and 45
resistance genes
AbaR1-10
Threat 1 Carbapenem R
bull OXAs and MBLs
bull Naturally occurring and acquired
bull OXAs- Types and Groups
ndash Narrow spectrum
ndash Carbapenem hydrolyzing (CHDLs)
ndash ES type
bull Carbapenemases (Acinetobacter)
ndash Are not ES do not have both properties
ndash Imipenemgt meropenem
Poirel et al AAC 2010
ENTER NDM-1
Thanks Dr Perez
Threat 2 ColistinR
bull Polymyxins (E and B) are cationic polypeptide atbs
bull Colistin SO4 for PO and Colistimethate Na+ (sodium colistin methanesulphonate colistin sulfomethate sodium) for IV
bull Colistin displaces Ca+2 and Mg+2 from PO4-3 groups of membrane lipids Insertion of polymyxins disrupts the OM and LPS is released anti-endotoxin activity rapidly bactericidal
bull Urban et al reported a case of polymyxin BR A baumannii
Falgas et al CID 2005 Urban 2001 AAC Li et al AAC 2006
Li et al Int Journal of Antimicrobial Agents 2005
ColistinR bull ColR due to modifications of LPS
pmr (AdamshellipBonomo AAC US) vs lpxA-C and -D (Li and Nation Australia) Parks lab in S Korea found the same locus as we did
bull Heteroresistance (subpopulations of genetically identical subclones that are more R than the parent ) by Li et al implications for rx
bull ldquoColistin dependencerdquo 77 yo diabetic male with FI and bacteremia ldquoincreasingly luxuriant growthrdquo
Moffatt AAC 2010
Li et al AAC 2006
Hawley et al AAC
2007
Adams et al AAC 2009
Lower expression
of metabolic
proteins
and OmpA
JID 2011
Part II
MDR P aerugoinosa
The resistance challenge of the ages
Pa facts
bull Colonization rates by Pa are high in the
hospital (50) immunity and burn
bull Seriously ill patients in ICUs
bull Aggregate NNISS and EU data
ndash 20 to 30 of nosocomial pneumonias
ndash 10 to 20 of urinary tract infections
ndash 3 to 10 of bloodstream infections
Mechanisms of resistance
in Pa
Pa and ATBR
bull szlig-lactamases-all classes represented ndash Cephalosporinases
ndash class A ESBLs (PER)
ndash OXA ESBLs (OXA-10 -14)
ndash Carbapenemases (KPC and GES) MbLs
bull Loss of permeability (porins and efflux)
bull Quinolones and aminoglycosides ndash Active antimicrobial efflux
ndash Alterations in DNA gyrase
ndash Aminoglycoside-modifying enzymes
Antimicrobial resistance
bull Efflux pumps
ndash MFSmdashmajor facilitator superfamily
ndash ABCmdashATP-binding cassette family
ndash RNDmdashresistance nodulation division
ndash SMRmdashsmall multidrug resistance
ndash MATEmdashmultidrug and toxic compound
extrusion
RND and MFS extrude antibiotics and work by proton motive force In
GNRs RND works with MFP (periplasmic membrane fusion protein)
and OEP (outer membrane efflux protein) to get thru both membranes
The mysteries of the biofilm
Trends in Microbiology Jan 2001 9(1) 34-39
Part III
MDR K pneumoniae
ldquoKiller Klebsrdquo
Why should we be afraid of
Klebsiella pneumoniae KPCs
KPC K pneumoniae
AMIKACIN R
AMPICILLIN R
CEFAZOLIN R
CEFTAZIDIME R
CIPROFLOXACIN R
TRIMETHSULFA R
IMIMERO-PENEM 4 ugml rarr (gt 64)
GENTAMICIN S
AMPICILLINSUL R
CEFOTETAN R
CEFEPIME R
PIPTAZO R
Clinical impact of KPC
carbapenemases
bull ldquoThe dependability on ldquolast linerdquo antibiotics is shatteredrdquo
bull The emergence of KPC carbapenemase producing Gram-negatives is a major threat to the clinician ndash K pneumoniae Acinetobacter E
coli Enterobacter Serratia Pseudomonashellip the list grows
Patel and Bonomo 2011 Current Opinion
Clinical issues with KPC
bull ATB control Cephalosporin and b-
Lactam-b-Lactamase Inhibitor restriction
policies special populations Imipenem
restriction
bull How best to implement IC Carrot or
stick
bull Detection ESBL identification
Inoculum effect
bull Colistin-as empiric Rx combined
with aminoglycosides (gent) rifampin
Status of the KPC global
epidemic bull Two phenotypes MIClt 8 and MICgt 32
bull ST258gt ST384 ST388 othershellip
bull Plasmids from ST258 and other starins
has been transferred to E coli in
patients (Kreiswirth lab)
bull Colistin resistant ST258
bull Novel testing methods (ChromAgar
Boronates PCRESI-MS Microarray
methodsCheckpoints
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Fournier et al PLoS Genet 2006 Jan2(1)e7 Epub 2006 Jan 13
ldquoThe Resistance Islandrdquo
86 Kb 88 orfs 82
orfs from another
source and 45
resistance genes
AbaR1-10
Threat 1 Carbapenem R
bull OXAs and MBLs
bull Naturally occurring and acquired
bull OXAs- Types and Groups
ndash Narrow spectrum
ndash Carbapenem hydrolyzing (CHDLs)
ndash ES type
bull Carbapenemases (Acinetobacter)
ndash Are not ES do not have both properties
ndash Imipenemgt meropenem
Poirel et al AAC 2010
ENTER NDM-1
Thanks Dr Perez
Threat 2 ColistinR
bull Polymyxins (E and B) are cationic polypeptide atbs
bull Colistin SO4 for PO and Colistimethate Na+ (sodium colistin methanesulphonate colistin sulfomethate sodium) for IV
bull Colistin displaces Ca+2 and Mg+2 from PO4-3 groups of membrane lipids Insertion of polymyxins disrupts the OM and LPS is released anti-endotoxin activity rapidly bactericidal
bull Urban et al reported a case of polymyxin BR A baumannii
Falgas et al CID 2005 Urban 2001 AAC Li et al AAC 2006
Li et al Int Journal of Antimicrobial Agents 2005
ColistinR bull ColR due to modifications of LPS
pmr (AdamshellipBonomo AAC US) vs lpxA-C and -D (Li and Nation Australia) Parks lab in S Korea found the same locus as we did
bull Heteroresistance (subpopulations of genetically identical subclones that are more R than the parent ) by Li et al implications for rx
bull ldquoColistin dependencerdquo 77 yo diabetic male with FI and bacteremia ldquoincreasingly luxuriant growthrdquo
Moffatt AAC 2010
Li et al AAC 2006
Hawley et al AAC
2007
Adams et al AAC 2009
Lower expression
of metabolic
proteins
and OmpA
JID 2011
Part II
MDR P aerugoinosa
The resistance challenge of the ages
Pa facts
bull Colonization rates by Pa are high in the
hospital (50) immunity and burn
bull Seriously ill patients in ICUs
bull Aggregate NNISS and EU data
ndash 20 to 30 of nosocomial pneumonias
ndash 10 to 20 of urinary tract infections
ndash 3 to 10 of bloodstream infections
Mechanisms of resistance
in Pa
Pa and ATBR
bull szlig-lactamases-all classes represented ndash Cephalosporinases
ndash class A ESBLs (PER)
ndash OXA ESBLs (OXA-10 -14)
ndash Carbapenemases (KPC and GES) MbLs
bull Loss of permeability (porins and efflux)
bull Quinolones and aminoglycosides ndash Active antimicrobial efflux
ndash Alterations in DNA gyrase
ndash Aminoglycoside-modifying enzymes
Antimicrobial resistance
bull Efflux pumps
ndash MFSmdashmajor facilitator superfamily
ndash ABCmdashATP-binding cassette family
ndash RNDmdashresistance nodulation division
ndash SMRmdashsmall multidrug resistance
ndash MATEmdashmultidrug and toxic compound
extrusion
RND and MFS extrude antibiotics and work by proton motive force In
GNRs RND works with MFP (periplasmic membrane fusion protein)
and OEP (outer membrane efflux protein) to get thru both membranes
The mysteries of the biofilm
Trends in Microbiology Jan 2001 9(1) 34-39
Part III
MDR K pneumoniae
ldquoKiller Klebsrdquo
Why should we be afraid of
Klebsiella pneumoniae KPCs
KPC K pneumoniae
AMIKACIN R
AMPICILLIN R
CEFAZOLIN R
CEFTAZIDIME R
CIPROFLOXACIN R
TRIMETHSULFA R
IMIMERO-PENEM 4 ugml rarr (gt 64)
GENTAMICIN S
AMPICILLINSUL R
CEFOTETAN R
CEFEPIME R
PIPTAZO R
Clinical impact of KPC
carbapenemases
bull ldquoThe dependability on ldquolast linerdquo antibiotics is shatteredrdquo
bull The emergence of KPC carbapenemase producing Gram-negatives is a major threat to the clinician ndash K pneumoniae Acinetobacter E
coli Enterobacter Serratia Pseudomonashellip the list grows
Patel and Bonomo 2011 Current Opinion
Clinical issues with KPC
bull ATB control Cephalosporin and b-
Lactam-b-Lactamase Inhibitor restriction
policies special populations Imipenem
restriction
bull How best to implement IC Carrot or
stick
bull Detection ESBL identification
Inoculum effect
bull Colistin-as empiric Rx combined
with aminoglycosides (gent) rifampin
Status of the KPC global
epidemic bull Two phenotypes MIClt 8 and MICgt 32
bull ST258gt ST384 ST388 othershellip
bull Plasmids from ST258 and other starins
has been transferred to E coli in
patients (Kreiswirth lab)
bull Colistin resistant ST258
bull Novel testing methods (ChromAgar
Boronates PCRESI-MS Microarray
methodsCheckpoints
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Threat 1 Carbapenem R
bull OXAs and MBLs
bull Naturally occurring and acquired
bull OXAs- Types and Groups
ndash Narrow spectrum
ndash Carbapenem hydrolyzing (CHDLs)
ndash ES type
bull Carbapenemases (Acinetobacter)
ndash Are not ES do not have both properties
ndash Imipenemgt meropenem
Poirel et al AAC 2010
ENTER NDM-1
Thanks Dr Perez
Threat 2 ColistinR
bull Polymyxins (E and B) are cationic polypeptide atbs
bull Colistin SO4 for PO and Colistimethate Na+ (sodium colistin methanesulphonate colistin sulfomethate sodium) for IV
bull Colistin displaces Ca+2 and Mg+2 from PO4-3 groups of membrane lipids Insertion of polymyxins disrupts the OM and LPS is released anti-endotoxin activity rapidly bactericidal
bull Urban et al reported a case of polymyxin BR A baumannii
Falgas et al CID 2005 Urban 2001 AAC Li et al AAC 2006
Li et al Int Journal of Antimicrobial Agents 2005
ColistinR bull ColR due to modifications of LPS
pmr (AdamshellipBonomo AAC US) vs lpxA-C and -D (Li and Nation Australia) Parks lab in S Korea found the same locus as we did
bull Heteroresistance (subpopulations of genetically identical subclones that are more R than the parent ) by Li et al implications for rx
bull ldquoColistin dependencerdquo 77 yo diabetic male with FI and bacteremia ldquoincreasingly luxuriant growthrdquo
Moffatt AAC 2010
Li et al AAC 2006
Hawley et al AAC
2007
Adams et al AAC 2009
Lower expression
of metabolic
proteins
and OmpA
JID 2011
Part II
MDR P aerugoinosa
The resistance challenge of the ages
Pa facts
bull Colonization rates by Pa are high in the
hospital (50) immunity and burn
bull Seriously ill patients in ICUs
bull Aggregate NNISS and EU data
ndash 20 to 30 of nosocomial pneumonias
ndash 10 to 20 of urinary tract infections
ndash 3 to 10 of bloodstream infections
Mechanisms of resistance
in Pa
Pa and ATBR
bull szlig-lactamases-all classes represented ndash Cephalosporinases
ndash class A ESBLs (PER)
ndash OXA ESBLs (OXA-10 -14)
ndash Carbapenemases (KPC and GES) MbLs
bull Loss of permeability (porins and efflux)
bull Quinolones and aminoglycosides ndash Active antimicrobial efflux
ndash Alterations in DNA gyrase
ndash Aminoglycoside-modifying enzymes
Antimicrobial resistance
bull Efflux pumps
ndash MFSmdashmajor facilitator superfamily
ndash ABCmdashATP-binding cassette family
ndash RNDmdashresistance nodulation division
ndash SMRmdashsmall multidrug resistance
ndash MATEmdashmultidrug and toxic compound
extrusion
RND and MFS extrude antibiotics and work by proton motive force In
GNRs RND works with MFP (periplasmic membrane fusion protein)
and OEP (outer membrane efflux protein) to get thru both membranes
The mysteries of the biofilm
Trends in Microbiology Jan 2001 9(1) 34-39
Part III
MDR K pneumoniae
ldquoKiller Klebsrdquo
Why should we be afraid of
Klebsiella pneumoniae KPCs
KPC K pneumoniae
AMIKACIN R
AMPICILLIN R
CEFAZOLIN R
CEFTAZIDIME R
CIPROFLOXACIN R
TRIMETHSULFA R
IMIMERO-PENEM 4 ugml rarr (gt 64)
GENTAMICIN S
AMPICILLINSUL R
CEFOTETAN R
CEFEPIME R
PIPTAZO R
Clinical impact of KPC
carbapenemases
bull ldquoThe dependability on ldquolast linerdquo antibiotics is shatteredrdquo
bull The emergence of KPC carbapenemase producing Gram-negatives is a major threat to the clinician ndash K pneumoniae Acinetobacter E
coli Enterobacter Serratia Pseudomonashellip the list grows
Patel and Bonomo 2011 Current Opinion
Clinical issues with KPC
bull ATB control Cephalosporin and b-
Lactam-b-Lactamase Inhibitor restriction
policies special populations Imipenem
restriction
bull How best to implement IC Carrot or
stick
bull Detection ESBL identification
Inoculum effect
bull Colistin-as empiric Rx combined
with aminoglycosides (gent) rifampin
Status of the KPC global
epidemic bull Two phenotypes MIClt 8 and MICgt 32
bull ST258gt ST384 ST388 othershellip
bull Plasmids from ST258 and other starins
has been transferred to E coli in
patients (Kreiswirth lab)
bull Colistin resistant ST258
bull Novel testing methods (ChromAgar
Boronates PCRESI-MS Microarray
methodsCheckpoints
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
ENTER NDM-1
Thanks Dr Perez
Threat 2 ColistinR
bull Polymyxins (E and B) are cationic polypeptide atbs
bull Colistin SO4 for PO and Colistimethate Na+ (sodium colistin methanesulphonate colistin sulfomethate sodium) for IV
bull Colistin displaces Ca+2 and Mg+2 from PO4-3 groups of membrane lipids Insertion of polymyxins disrupts the OM and LPS is released anti-endotoxin activity rapidly bactericidal
bull Urban et al reported a case of polymyxin BR A baumannii
Falgas et al CID 2005 Urban 2001 AAC Li et al AAC 2006
Li et al Int Journal of Antimicrobial Agents 2005
ColistinR bull ColR due to modifications of LPS
pmr (AdamshellipBonomo AAC US) vs lpxA-C and -D (Li and Nation Australia) Parks lab in S Korea found the same locus as we did
bull Heteroresistance (subpopulations of genetically identical subclones that are more R than the parent ) by Li et al implications for rx
bull ldquoColistin dependencerdquo 77 yo diabetic male with FI and bacteremia ldquoincreasingly luxuriant growthrdquo
Moffatt AAC 2010
Li et al AAC 2006
Hawley et al AAC
2007
Adams et al AAC 2009
Lower expression
of metabolic
proteins
and OmpA
JID 2011
Part II
MDR P aerugoinosa
The resistance challenge of the ages
Pa facts
bull Colonization rates by Pa are high in the
hospital (50) immunity and burn
bull Seriously ill patients in ICUs
bull Aggregate NNISS and EU data
ndash 20 to 30 of nosocomial pneumonias
ndash 10 to 20 of urinary tract infections
ndash 3 to 10 of bloodstream infections
Mechanisms of resistance
in Pa
Pa and ATBR
bull szlig-lactamases-all classes represented ndash Cephalosporinases
ndash class A ESBLs (PER)
ndash OXA ESBLs (OXA-10 -14)
ndash Carbapenemases (KPC and GES) MbLs
bull Loss of permeability (porins and efflux)
bull Quinolones and aminoglycosides ndash Active antimicrobial efflux
ndash Alterations in DNA gyrase
ndash Aminoglycoside-modifying enzymes
Antimicrobial resistance
bull Efflux pumps
ndash MFSmdashmajor facilitator superfamily
ndash ABCmdashATP-binding cassette family
ndash RNDmdashresistance nodulation division
ndash SMRmdashsmall multidrug resistance
ndash MATEmdashmultidrug and toxic compound
extrusion
RND and MFS extrude antibiotics and work by proton motive force In
GNRs RND works with MFP (periplasmic membrane fusion protein)
and OEP (outer membrane efflux protein) to get thru both membranes
The mysteries of the biofilm
Trends in Microbiology Jan 2001 9(1) 34-39
Part III
MDR K pneumoniae
ldquoKiller Klebsrdquo
Why should we be afraid of
Klebsiella pneumoniae KPCs
KPC K pneumoniae
AMIKACIN R
AMPICILLIN R
CEFAZOLIN R
CEFTAZIDIME R
CIPROFLOXACIN R
TRIMETHSULFA R
IMIMERO-PENEM 4 ugml rarr (gt 64)
GENTAMICIN S
AMPICILLINSUL R
CEFOTETAN R
CEFEPIME R
PIPTAZO R
Clinical impact of KPC
carbapenemases
bull ldquoThe dependability on ldquolast linerdquo antibiotics is shatteredrdquo
bull The emergence of KPC carbapenemase producing Gram-negatives is a major threat to the clinician ndash K pneumoniae Acinetobacter E
coli Enterobacter Serratia Pseudomonashellip the list grows
Patel and Bonomo 2011 Current Opinion
Clinical issues with KPC
bull ATB control Cephalosporin and b-
Lactam-b-Lactamase Inhibitor restriction
policies special populations Imipenem
restriction
bull How best to implement IC Carrot or
stick
bull Detection ESBL identification
Inoculum effect
bull Colistin-as empiric Rx combined
with aminoglycosides (gent) rifampin
Status of the KPC global
epidemic bull Two phenotypes MIClt 8 and MICgt 32
bull ST258gt ST384 ST388 othershellip
bull Plasmids from ST258 and other starins
has been transferred to E coli in
patients (Kreiswirth lab)
bull Colistin resistant ST258
bull Novel testing methods (ChromAgar
Boronates PCRESI-MS Microarray
methodsCheckpoints
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Threat 2 ColistinR
bull Polymyxins (E and B) are cationic polypeptide atbs
bull Colistin SO4 for PO and Colistimethate Na+ (sodium colistin methanesulphonate colistin sulfomethate sodium) for IV
bull Colistin displaces Ca+2 and Mg+2 from PO4-3 groups of membrane lipids Insertion of polymyxins disrupts the OM and LPS is released anti-endotoxin activity rapidly bactericidal
bull Urban et al reported a case of polymyxin BR A baumannii
Falgas et al CID 2005 Urban 2001 AAC Li et al AAC 2006
Li et al Int Journal of Antimicrobial Agents 2005
ColistinR bull ColR due to modifications of LPS
pmr (AdamshellipBonomo AAC US) vs lpxA-C and -D (Li and Nation Australia) Parks lab in S Korea found the same locus as we did
bull Heteroresistance (subpopulations of genetically identical subclones that are more R than the parent ) by Li et al implications for rx
bull ldquoColistin dependencerdquo 77 yo diabetic male with FI and bacteremia ldquoincreasingly luxuriant growthrdquo
Moffatt AAC 2010
Li et al AAC 2006
Hawley et al AAC
2007
Adams et al AAC 2009
Lower expression
of metabolic
proteins
and OmpA
JID 2011
Part II
MDR P aerugoinosa
The resistance challenge of the ages
Pa facts
bull Colonization rates by Pa are high in the
hospital (50) immunity and burn
bull Seriously ill patients in ICUs
bull Aggregate NNISS and EU data
ndash 20 to 30 of nosocomial pneumonias
ndash 10 to 20 of urinary tract infections
ndash 3 to 10 of bloodstream infections
Mechanisms of resistance
in Pa
Pa and ATBR
bull szlig-lactamases-all classes represented ndash Cephalosporinases
ndash class A ESBLs (PER)
ndash OXA ESBLs (OXA-10 -14)
ndash Carbapenemases (KPC and GES) MbLs
bull Loss of permeability (porins and efflux)
bull Quinolones and aminoglycosides ndash Active antimicrobial efflux
ndash Alterations in DNA gyrase
ndash Aminoglycoside-modifying enzymes
Antimicrobial resistance
bull Efflux pumps
ndash MFSmdashmajor facilitator superfamily
ndash ABCmdashATP-binding cassette family
ndash RNDmdashresistance nodulation division
ndash SMRmdashsmall multidrug resistance
ndash MATEmdashmultidrug and toxic compound
extrusion
RND and MFS extrude antibiotics and work by proton motive force In
GNRs RND works with MFP (periplasmic membrane fusion protein)
and OEP (outer membrane efflux protein) to get thru both membranes
The mysteries of the biofilm
Trends in Microbiology Jan 2001 9(1) 34-39
Part III
MDR K pneumoniae
ldquoKiller Klebsrdquo
Why should we be afraid of
Klebsiella pneumoniae KPCs
KPC K pneumoniae
AMIKACIN R
AMPICILLIN R
CEFAZOLIN R
CEFTAZIDIME R
CIPROFLOXACIN R
TRIMETHSULFA R
IMIMERO-PENEM 4 ugml rarr (gt 64)
GENTAMICIN S
AMPICILLINSUL R
CEFOTETAN R
CEFEPIME R
PIPTAZO R
Clinical impact of KPC
carbapenemases
bull ldquoThe dependability on ldquolast linerdquo antibiotics is shatteredrdquo
bull The emergence of KPC carbapenemase producing Gram-negatives is a major threat to the clinician ndash K pneumoniae Acinetobacter E
coli Enterobacter Serratia Pseudomonashellip the list grows
Patel and Bonomo 2011 Current Opinion
Clinical issues with KPC
bull ATB control Cephalosporin and b-
Lactam-b-Lactamase Inhibitor restriction
policies special populations Imipenem
restriction
bull How best to implement IC Carrot or
stick
bull Detection ESBL identification
Inoculum effect
bull Colistin-as empiric Rx combined
with aminoglycosides (gent) rifampin
Status of the KPC global
epidemic bull Two phenotypes MIClt 8 and MICgt 32
bull ST258gt ST384 ST388 othershellip
bull Plasmids from ST258 and other starins
has been transferred to E coli in
patients (Kreiswirth lab)
bull Colistin resistant ST258
bull Novel testing methods (ChromAgar
Boronates PCRESI-MS Microarray
methodsCheckpoints
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
ColistinR bull ColR due to modifications of LPS
pmr (AdamshellipBonomo AAC US) vs lpxA-C and -D (Li and Nation Australia) Parks lab in S Korea found the same locus as we did
bull Heteroresistance (subpopulations of genetically identical subclones that are more R than the parent ) by Li et al implications for rx
bull ldquoColistin dependencerdquo 77 yo diabetic male with FI and bacteremia ldquoincreasingly luxuriant growthrdquo
Moffatt AAC 2010
Li et al AAC 2006
Hawley et al AAC
2007
Adams et al AAC 2009
Lower expression
of metabolic
proteins
and OmpA
JID 2011
Part II
MDR P aerugoinosa
The resistance challenge of the ages
Pa facts
bull Colonization rates by Pa are high in the
hospital (50) immunity and burn
bull Seriously ill patients in ICUs
bull Aggregate NNISS and EU data
ndash 20 to 30 of nosocomial pneumonias
ndash 10 to 20 of urinary tract infections
ndash 3 to 10 of bloodstream infections
Mechanisms of resistance
in Pa
Pa and ATBR
bull szlig-lactamases-all classes represented ndash Cephalosporinases
ndash class A ESBLs (PER)
ndash OXA ESBLs (OXA-10 -14)
ndash Carbapenemases (KPC and GES) MbLs
bull Loss of permeability (porins and efflux)
bull Quinolones and aminoglycosides ndash Active antimicrobial efflux
ndash Alterations in DNA gyrase
ndash Aminoglycoside-modifying enzymes
Antimicrobial resistance
bull Efflux pumps
ndash MFSmdashmajor facilitator superfamily
ndash ABCmdashATP-binding cassette family
ndash RNDmdashresistance nodulation division
ndash SMRmdashsmall multidrug resistance
ndash MATEmdashmultidrug and toxic compound
extrusion
RND and MFS extrude antibiotics and work by proton motive force In
GNRs RND works with MFP (periplasmic membrane fusion protein)
and OEP (outer membrane efflux protein) to get thru both membranes
The mysteries of the biofilm
Trends in Microbiology Jan 2001 9(1) 34-39
Part III
MDR K pneumoniae
ldquoKiller Klebsrdquo
Why should we be afraid of
Klebsiella pneumoniae KPCs
KPC K pneumoniae
AMIKACIN R
AMPICILLIN R
CEFAZOLIN R
CEFTAZIDIME R
CIPROFLOXACIN R
TRIMETHSULFA R
IMIMERO-PENEM 4 ugml rarr (gt 64)
GENTAMICIN S
AMPICILLINSUL R
CEFOTETAN R
CEFEPIME R
PIPTAZO R
Clinical impact of KPC
carbapenemases
bull ldquoThe dependability on ldquolast linerdquo antibiotics is shatteredrdquo
bull The emergence of KPC carbapenemase producing Gram-negatives is a major threat to the clinician ndash K pneumoniae Acinetobacter E
coli Enterobacter Serratia Pseudomonashellip the list grows
Patel and Bonomo 2011 Current Opinion
Clinical issues with KPC
bull ATB control Cephalosporin and b-
Lactam-b-Lactamase Inhibitor restriction
policies special populations Imipenem
restriction
bull How best to implement IC Carrot or
stick
bull Detection ESBL identification
Inoculum effect
bull Colistin-as empiric Rx combined
with aminoglycosides (gent) rifampin
Status of the KPC global
epidemic bull Two phenotypes MIClt 8 and MICgt 32
bull ST258gt ST384 ST388 othershellip
bull Plasmids from ST258 and other starins
has been transferred to E coli in
patients (Kreiswirth lab)
bull Colistin resistant ST258
bull Novel testing methods (ChromAgar
Boronates PCRESI-MS Microarray
methodsCheckpoints
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Lower expression
of metabolic
proteins
and OmpA
JID 2011
Part II
MDR P aerugoinosa
The resistance challenge of the ages
Pa facts
bull Colonization rates by Pa are high in the
hospital (50) immunity and burn
bull Seriously ill patients in ICUs
bull Aggregate NNISS and EU data
ndash 20 to 30 of nosocomial pneumonias
ndash 10 to 20 of urinary tract infections
ndash 3 to 10 of bloodstream infections
Mechanisms of resistance
in Pa
Pa and ATBR
bull szlig-lactamases-all classes represented ndash Cephalosporinases
ndash class A ESBLs (PER)
ndash OXA ESBLs (OXA-10 -14)
ndash Carbapenemases (KPC and GES) MbLs
bull Loss of permeability (porins and efflux)
bull Quinolones and aminoglycosides ndash Active antimicrobial efflux
ndash Alterations in DNA gyrase
ndash Aminoglycoside-modifying enzymes
Antimicrobial resistance
bull Efflux pumps
ndash MFSmdashmajor facilitator superfamily
ndash ABCmdashATP-binding cassette family
ndash RNDmdashresistance nodulation division
ndash SMRmdashsmall multidrug resistance
ndash MATEmdashmultidrug and toxic compound
extrusion
RND and MFS extrude antibiotics and work by proton motive force In
GNRs RND works with MFP (periplasmic membrane fusion protein)
and OEP (outer membrane efflux protein) to get thru both membranes
The mysteries of the biofilm
Trends in Microbiology Jan 2001 9(1) 34-39
Part III
MDR K pneumoniae
ldquoKiller Klebsrdquo
Why should we be afraid of
Klebsiella pneumoniae KPCs
KPC K pneumoniae
AMIKACIN R
AMPICILLIN R
CEFAZOLIN R
CEFTAZIDIME R
CIPROFLOXACIN R
TRIMETHSULFA R
IMIMERO-PENEM 4 ugml rarr (gt 64)
GENTAMICIN S
AMPICILLINSUL R
CEFOTETAN R
CEFEPIME R
PIPTAZO R
Clinical impact of KPC
carbapenemases
bull ldquoThe dependability on ldquolast linerdquo antibiotics is shatteredrdquo
bull The emergence of KPC carbapenemase producing Gram-negatives is a major threat to the clinician ndash K pneumoniae Acinetobacter E
coli Enterobacter Serratia Pseudomonashellip the list grows
Patel and Bonomo 2011 Current Opinion
Clinical issues with KPC
bull ATB control Cephalosporin and b-
Lactam-b-Lactamase Inhibitor restriction
policies special populations Imipenem
restriction
bull How best to implement IC Carrot or
stick
bull Detection ESBL identification
Inoculum effect
bull Colistin-as empiric Rx combined
with aminoglycosides (gent) rifampin
Status of the KPC global
epidemic bull Two phenotypes MIClt 8 and MICgt 32
bull ST258gt ST384 ST388 othershellip
bull Plasmids from ST258 and other starins
has been transferred to E coli in
patients (Kreiswirth lab)
bull Colistin resistant ST258
bull Novel testing methods (ChromAgar
Boronates PCRESI-MS Microarray
methodsCheckpoints
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Part II
MDR P aerugoinosa
The resistance challenge of the ages
Pa facts
bull Colonization rates by Pa are high in the
hospital (50) immunity and burn
bull Seriously ill patients in ICUs
bull Aggregate NNISS and EU data
ndash 20 to 30 of nosocomial pneumonias
ndash 10 to 20 of urinary tract infections
ndash 3 to 10 of bloodstream infections
Mechanisms of resistance
in Pa
Pa and ATBR
bull szlig-lactamases-all classes represented ndash Cephalosporinases
ndash class A ESBLs (PER)
ndash OXA ESBLs (OXA-10 -14)
ndash Carbapenemases (KPC and GES) MbLs
bull Loss of permeability (porins and efflux)
bull Quinolones and aminoglycosides ndash Active antimicrobial efflux
ndash Alterations in DNA gyrase
ndash Aminoglycoside-modifying enzymes
Antimicrobial resistance
bull Efflux pumps
ndash MFSmdashmajor facilitator superfamily
ndash ABCmdashATP-binding cassette family
ndash RNDmdashresistance nodulation division
ndash SMRmdashsmall multidrug resistance
ndash MATEmdashmultidrug and toxic compound
extrusion
RND and MFS extrude antibiotics and work by proton motive force In
GNRs RND works with MFP (periplasmic membrane fusion protein)
and OEP (outer membrane efflux protein) to get thru both membranes
The mysteries of the biofilm
Trends in Microbiology Jan 2001 9(1) 34-39
Part III
MDR K pneumoniae
ldquoKiller Klebsrdquo
Why should we be afraid of
Klebsiella pneumoniae KPCs
KPC K pneumoniae
AMIKACIN R
AMPICILLIN R
CEFAZOLIN R
CEFTAZIDIME R
CIPROFLOXACIN R
TRIMETHSULFA R
IMIMERO-PENEM 4 ugml rarr (gt 64)
GENTAMICIN S
AMPICILLINSUL R
CEFOTETAN R
CEFEPIME R
PIPTAZO R
Clinical impact of KPC
carbapenemases
bull ldquoThe dependability on ldquolast linerdquo antibiotics is shatteredrdquo
bull The emergence of KPC carbapenemase producing Gram-negatives is a major threat to the clinician ndash K pneumoniae Acinetobacter E
coli Enterobacter Serratia Pseudomonashellip the list grows
Patel and Bonomo 2011 Current Opinion
Clinical issues with KPC
bull ATB control Cephalosporin and b-
Lactam-b-Lactamase Inhibitor restriction
policies special populations Imipenem
restriction
bull How best to implement IC Carrot or
stick
bull Detection ESBL identification
Inoculum effect
bull Colistin-as empiric Rx combined
with aminoglycosides (gent) rifampin
Status of the KPC global
epidemic bull Two phenotypes MIClt 8 and MICgt 32
bull ST258gt ST384 ST388 othershellip
bull Plasmids from ST258 and other starins
has been transferred to E coli in
patients (Kreiswirth lab)
bull Colistin resistant ST258
bull Novel testing methods (ChromAgar
Boronates PCRESI-MS Microarray
methodsCheckpoints
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Pa facts
bull Colonization rates by Pa are high in the
hospital (50) immunity and burn
bull Seriously ill patients in ICUs
bull Aggregate NNISS and EU data
ndash 20 to 30 of nosocomial pneumonias
ndash 10 to 20 of urinary tract infections
ndash 3 to 10 of bloodstream infections
Mechanisms of resistance
in Pa
Pa and ATBR
bull szlig-lactamases-all classes represented ndash Cephalosporinases
ndash class A ESBLs (PER)
ndash OXA ESBLs (OXA-10 -14)
ndash Carbapenemases (KPC and GES) MbLs
bull Loss of permeability (porins and efflux)
bull Quinolones and aminoglycosides ndash Active antimicrobial efflux
ndash Alterations in DNA gyrase
ndash Aminoglycoside-modifying enzymes
Antimicrobial resistance
bull Efflux pumps
ndash MFSmdashmajor facilitator superfamily
ndash ABCmdashATP-binding cassette family
ndash RNDmdashresistance nodulation division
ndash SMRmdashsmall multidrug resistance
ndash MATEmdashmultidrug and toxic compound
extrusion
RND and MFS extrude antibiotics and work by proton motive force In
GNRs RND works with MFP (periplasmic membrane fusion protein)
and OEP (outer membrane efflux protein) to get thru both membranes
The mysteries of the biofilm
Trends in Microbiology Jan 2001 9(1) 34-39
Part III
MDR K pneumoniae
ldquoKiller Klebsrdquo
Why should we be afraid of
Klebsiella pneumoniae KPCs
KPC K pneumoniae
AMIKACIN R
AMPICILLIN R
CEFAZOLIN R
CEFTAZIDIME R
CIPROFLOXACIN R
TRIMETHSULFA R
IMIMERO-PENEM 4 ugml rarr (gt 64)
GENTAMICIN S
AMPICILLINSUL R
CEFOTETAN R
CEFEPIME R
PIPTAZO R
Clinical impact of KPC
carbapenemases
bull ldquoThe dependability on ldquolast linerdquo antibiotics is shatteredrdquo
bull The emergence of KPC carbapenemase producing Gram-negatives is a major threat to the clinician ndash K pneumoniae Acinetobacter E
coli Enterobacter Serratia Pseudomonashellip the list grows
Patel and Bonomo 2011 Current Opinion
Clinical issues with KPC
bull ATB control Cephalosporin and b-
Lactam-b-Lactamase Inhibitor restriction
policies special populations Imipenem
restriction
bull How best to implement IC Carrot or
stick
bull Detection ESBL identification
Inoculum effect
bull Colistin-as empiric Rx combined
with aminoglycosides (gent) rifampin
Status of the KPC global
epidemic bull Two phenotypes MIClt 8 and MICgt 32
bull ST258gt ST384 ST388 othershellip
bull Plasmids from ST258 and other starins
has been transferred to E coli in
patients (Kreiswirth lab)
bull Colistin resistant ST258
bull Novel testing methods (ChromAgar
Boronates PCRESI-MS Microarray
methodsCheckpoints
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Mechanisms of resistance
in Pa
Pa and ATBR
bull szlig-lactamases-all classes represented ndash Cephalosporinases
ndash class A ESBLs (PER)
ndash OXA ESBLs (OXA-10 -14)
ndash Carbapenemases (KPC and GES) MbLs
bull Loss of permeability (porins and efflux)
bull Quinolones and aminoglycosides ndash Active antimicrobial efflux
ndash Alterations in DNA gyrase
ndash Aminoglycoside-modifying enzymes
Antimicrobial resistance
bull Efflux pumps
ndash MFSmdashmajor facilitator superfamily
ndash ABCmdashATP-binding cassette family
ndash RNDmdashresistance nodulation division
ndash SMRmdashsmall multidrug resistance
ndash MATEmdashmultidrug and toxic compound
extrusion
RND and MFS extrude antibiotics and work by proton motive force In
GNRs RND works with MFP (periplasmic membrane fusion protein)
and OEP (outer membrane efflux protein) to get thru both membranes
The mysteries of the biofilm
Trends in Microbiology Jan 2001 9(1) 34-39
Part III
MDR K pneumoniae
ldquoKiller Klebsrdquo
Why should we be afraid of
Klebsiella pneumoniae KPCs
KPC K pneumoniae
AMIKACIN R
AMPICILLIN R
CEFAZOLIN R
CEFTAZIDIME R
CIPROFLOXACIN R
TRIMETHSULFA R
IMIMERO-PENEM 4 ugml rarr (gt 64)
GENTAMICIN S
AMPICILLINSUL R
CEFOTETAN R
CEFEPIME R
PIPTAZO R
Clinical impact of KPC
carbapenemases
bull ldquoThe dependability on ldquolast linerdquo antibiotics is shatteredrdquo
bull The emergence of KPC carbapenemase producing Gram-negatives is a major threat to the clinician ndash K pneumoniae Acinetobacter E
coli Enterobacter Serratia Pseudomonashellip the list grows
Patel and Bonomo 2011 Current Opinion
Clinical issues with KPC
bull ATB control Cephalosporin and b-
Lactam-b-Lactamase Inhibitor restriction
policies special populations Imipenem
restriction
bull How best to implement IC Carrot or
stick
bull Detection ESBL identification
Inoculum effect
bull Colistin-as empiric Rx combined
with aminoglycosides (gent) rifampin
Status of the KPC global
epidemic bull Two phenotypes MIClt 8 and MICgt 32
bull ST258gt ST384 ST388 othershellip
bull Plasmids from ST258 and other starins
has been transferred to E coli in
patients (Kreiswirth lab)
bull Colistin resistant ST258
bull Novel testing methods (ChromAgar
Boronates PCRESI-MS Microarray
methodsCheckpoints
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Pa and ATBR
bull szlig-lactamases-all classes represented ndash Cephalosporinases
ndash class A ESBLs (PER)
ndash OXA ESBLs (OXA-10 -14)
ndash Carbapenemases (KPC and GES) MbLs
bull Loss of permeability (porins and efflux)
bull Quinolones and aminoglycosides ndash Active antimicrobial efflux
ndash Alterations in DNA gyrase
ndash Aminoglycoside-modifying enzymes
Antimicrobial resistance
bull Efflux pumps
ndash MFSmdashmajor facilitator superfamily
ndash ABCmdashATP-binding cassette family
ndash RNDmdashresistance nodulation division
ndash SMRmdashsmall multidrug resistance
ndash MATEmdashmultidrug and toxic compound
extrusion
RND and MFS extrude antibiotics and work by proton motive force In
GNRs RND works with MFP (periplasmic membrane fusion protein)
and OEP (outer membrane efflux protein) to get thru both membranes
The mysteries of the biofilm
Trends in Microbiology Jan 2001 9(1) 34-39
Part III
MDR K pneumoniae
ldquoKiller Klebsrdquo
Why should we be afraid of
Klebsiella pneumoniae KPCs
KPC K pneumoniae
AMIKACIN R
AMPICILLIN R
CEFAZOLIN R
CEFTAZIDIME R
CIPROFLOXACIN R
TRIMETHSULFA R
IMIMERO-PENEM 4 ugml rarr (gt 64)
GENTAMICIN S
AMPICILLINSUL R
CEFOTETAN R
CEFEPIME R
PIPTAZO R
Clinical impact of KPC
carbapenemases
bull ldquoThe dependability on ldquolast linerdquo antibiotics is shatteredrdquo
bull The emergence of KPC carbapenemase producing Gram-negatives is a major threat to the clinician ndash K pneumoniae Acinetobacter E
coli Enterobacter Serratia Pseudomonashellip the list grows
Patel and Bonomo 2011 Current Opinion
Clinical issues with KPC
bull ATB control Cephalosporin and b-
Lactam-b-Lactamase Inhibitor restriction
policies special populations Imipenem
restriction
bull How best to implement IC Carrot or
stick
bull Detection ESBL identification
Inoculum effect
bull Colistin-as empiric Rx combined
with aminoglycosides (gent) rifampin
Status of the KPC global
epidemic bull Two phenotypes MIClt 8 and MICgt 32
bull ST258gt ST384 ST388 othershellip
bull Plasmids from ST258 and other starins
has been transferred to E coli in
patients (Kreiswirth lab)
bull Colistin resistant ST258
bull Novel testing methods (ChromAgar
Boronates PCRESI-MS Microarray
methodsCheckpoints
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Antimicrobial resistance
bull Efflux pumps
ndash MFSmdashmajor facilitator superfamily
ndash ABCmdashATP-binding cassette family
ndash RNDmdashresistance nodulation division
ndash SMRmdashsmall multidrug resistance
ndash MATEmdashmultidrug and toxic compound
extrusion
RND and MFS extrude antibiotics and work by proton motive force In
GNRs RND works with MFP (periplasmic membrane fusion protein)
and OEP (outer membrane efflux protein) to get thru both membranes
The mysteries of the biofilm
Trends in Microbiology Jan 2001 9(1) 34-39
Part III
MDR K pneumoniae
ldquoKiller Klebsrdquo
Why should we be afraid of
Klebsiella pneumoniae KPCs
KPC K pneumoniae
AMIKACIN R
AMPICILLIN R
CEFAZOLIN R
CEFTAZIDIME R
CIPROFLOXACIN R
TRIMETHSULFA R
IMIMERO-PENEM 4 ugml rarr (gt 64)
GENTAMICIN S
AMPICILLINSUL R
CEFOTETAN R
CEFEPIME R
PIPTAZO R
Clinical impact of KPC
carbapenemases
bull ldquoThe dependability on ldquolast linerdquo antibiotics is shatteredrdquo
bull The emergence of KPC carbapenemase producing Gram-negatives is a major threat to the clinician ndash K pneumoniae Acinetobacter E
coli Enterobacter Serratia Pseudomonashellip the list grows
Patel and Bonomo 2011 Current Opinion
Clinical issues with KPC
bull ATB control Cephalosporin and b-
Lactam-b-Lactamase Inhibitor restriction
policies special populations Imipenem
restriction
bull How best to implement IC Carrot or
stick
bull Detection ESBL identification
Inoculum effect
bull Colistin-as empiric Rx combined
with aminoglycosides (gent) rifampin
Status of the KPC global
epidemic bull Two phenotypes MIClt 8 and MICgt 32
bull ST258gt ST384 ST388 othershellip
bull Plasmids from ST258 and other starins
has been transferred to E coli in
patients (Kreiswirth lab)
bull Colistin resistant ST258
bull Novel testing methods (ChromAgar
Boronates PCRESI-MS Microarray
methodsCheckpoints
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
The mysteries of the biofilm
Trends in Microbiology Jan 2001 9(1) 34-39
Part III
MDR K pneumoniae
ldquoKiller Klebsrdquo
Why should we be afraid of
Klebsiella pneumoniae KPCs
KPC K pneumoniae
AMIKACIN R
AMPICILLIN R
CEFAZOLIN R
CEFTAZIDIME R
CIPROFLOXACIN R
TRIMETHSULFA R
IMIMERO-PENEM 4 ugml rarr (gt 64)
GENTAMICIN S
AMPICILLINSUL R
CEFOTETAN R
CEFEPIME R
PIPTAZO R
Clinical impact of KPC
carbapenemases
bull ldquoThe dependability on ldquolast linerdquo antibiotics is shatteredrdquo
bull The emergence of KPC carbapenemase producing Gram-negatives is a major threat to the clinician ndash K pneumoniae Acinetobacter E
coli Enterobacter Serratia Pseudomonashellip the list grows
Patel and Bonomo 2011 Current Opinion
Clinical issues with KPC
bull ATB control Cephalosporin and b-
Lactam-b-Lactamase Inhibitor restriction
policies special populations Imipenem
restriction
bull How best to implement IC Carrot or
stick
bull Detection ESBL identification
Inoculum effect
bull Colistin-as empiric Rx combined
with aminoglycosides (gent) rifampin
Status of the KPC global
epidemic bull Two phenotypes MIClt 8 and MICgt 32
bull ST258gt ST384 ST388 othershellip
bull Plasmids from ST258 and other starins
has been transferred to E coli in
patients (Kreiswirth lab)
bull Colistin resistant ST258
bull Novel testing methods (ChromAgar
Boronates PCRESI-MS Microarray
methodsCheckpoints
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Part III
MDR K pneumoniae
ldquoKiller Klebsrdquo
Why should we be afraid of
Klebsiella pneumoniae KPCs
KPC K pneumoniae
AMIKACIN R
AMPICILLIN R
CEFAZOLIN R
CEFTAZIDIME R
CIPROFLOXACIN R
TRIMETHSULFA R
IMIMERO-PENEM 4 ugml rarr (gt 64)
GENTAMICIN S
AMPICILLINSUL R
CEFOTETAN R
CEFEPIME R
PIPTAZO R
Clinical impact of KPC
carbapenemases
bull ldquoThe dependability on ldquolast linerdquo antibiotics is shatteredrdquo
bull The emergence of KPC carbapenemase producing Gram-negatives is a major threat to the clinician ndash K pneumoniae Acinetobacter E
coli Enterobacter Serratia Pseudomonashellip the list grows
Patel and Bonomo 2011 Current Opinion
Clinical issues with KPC
bull ATB control Cephalosporin and b-
Lactam-b-Lactamase Inhibitor restriction
policies special populations Imipenem
restriction
bull How best to implement IC Carrot or
stick
bull Detection ESBL identification
Inoculum effect
bull Colistin-as empiric Rx combined
with aminoglycosides (gent) rifampin
Status of the KPC global
epidemic bull Two phenotypes MIClt 8 and MICgt 32
bull ST258gt ST384 ST388 othershellip
bull Plasmids from ST258 and other starins
has been transferred to E coli in
patients (Kreiswirth lab)
bull Colistin resistant ST258
bull Novel testing methods (ChromAgar
Boronates PCRESI-MS Microarray
methodsCheckpoints
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Why should we be afraid of
Klebsiella pneumoniae KPCs
KPC K pneumoniae
AMIKACIN R
AMPICILLIN R
CEFAZOLIN R
CEFTAZIDIME R
CIPROFLOXACIN R
TRIMETHSULFA R
IMIMERO-PENEM 4 ugml rarr (gt 64)
GENTAMICIN S
AMPICILLINSUL R
CEFOTETAN R
CEFEPIME R
PIPTAZO R
Clinical impact of KPC
carbapenemases
bull ldquoThe dependability on ldquolast linerdquo antibiotics is shatteredrdquo
bull The emergence of KPC carbapenemase producing Gram-negatives is a major threat to the clinician ndash K pneumoniae Acinetobacter E
coli Enterobacter Serratia Pseudomonashellip the list grows
Patel and Bonomo 2011 Current Opinion
Clinical issues with KPC
bull ATB control Cephalosporin and b-
Lactam-b-Lactamase Inhibitor restriction
policies special populations Imipenem
restriction
bull How best to implement IC Carrot or
stick
bull Detection ESBL identification
Inoculum effect
bull Colistin-as empiric Rx combined
with aminoglycosides (gent) rifampin
Status of the KPC global
epidemic bull Two phenotypes MIClt 8 and MICgt 32
bull ST258gt ST384 ST388 othershellip
bull Plasmids from ST258 and other starins
has been transferred to E coli in
patients (Kreiswirth lab)
bull Colistin resistant ST258
bull Novel testing methods (ChromAgar
Boronates PCRESI-MS Microarray
methodsCheckpoints
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
KPC K pneumoniae
AMIKACIN R
AMPICILLIN R
CEFAZOLIN R
CEFTAZIDIME R
CIPROFLOXACIN R
TRIMETHSULFA R
IMIMERO-PENEM 4 ugml rarr (gt 64)
GENTAMICIN S
AMPICILLINSUL R
CEFOTETAN R
CEFEPIME R
PIPTAZO R
Clinical impact of KPC
carbapenemases
bull ldquoThe dependability on ldquolast linerdquo antibiotics is shatteredrdquo
bull The emergence of KPC carbapenemase producing Gram-negatives is a major threat to the clinician ndash K pneumoniae Acinetobacter E
coli Enterobacter Serratia Pseudomonashellip the list grows
Patel and Bonomo 2011 Current Opinion
Clinical issues with KPC
bull ATB control Cephalosporin and b-
Lactam-b-Lactamase Inhibitor restriction
policies special populations Imipenem
restriction
bull How best to implement IC Carrot or
stick
bull Detection ESBL identification
Inoculum effect
bull Colistin-as empiric Rx combined
with aminoglycosides (gent) rifampin
Status of the KPC global
epidemic bull Two phenotypes MIClt 8 and MICgt 32
bull ST258gt ST384 ST388 othershellip
bull Plasmids from ST258 and other starins
has been transferred to E coli in
patients (Kreiswirth lab)
bull Colistin resistant ST258
bull Novel testing methods (ChromAgar
Boronates PCRESI-MS Microarray
methodsCheckpoints
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Clinical impact of KPC
carbapenemases
bull ldquoThe dependability on ldquolast linerdquo antibiotics is shatteredrdquo
bull The emergence of KPC carbapenemase producing Gram-negatives is a major threat to the clinician ndash K pneumoniae Acinetobacter E
coli Enterobacter Serratia Pseudomonashellip the list grows
Patel and Bonomo 2011 Current Opinion
Clinical issues with KPC
bull ATB control Cephalosporin and b-
Lactam-b-Lactamase Inhibitor restriction
policies special populations Imipenem
restriction
bull How best to implement IC Carrot or
stick
bull Detection ESBL identification
Inoculum effect
bull Colistin-as empiric Rx combined
with aminoglycosides (gent) rifampin
Status of the KPC global
epidemic bull Two phenotypes MIClt 8 and MICgt 32
bull ST258gt ST384 ST388 othershellip
bull Plasmids from ST258 and other starins
has been transferred to E coli in
patients (Kreiswirth lab)
bull Colistin resistant ST258
bull Novel testing methods (ChromAgar
Boronates PCRESI-MS Microarray
methodsCheckpoints
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Clinical issues with KPC
bull ATB control Cephalosporin and b-
Lactam-b-Lactamase Inhibitor restriction
policies special populations Imipenem
restriction
bull How best to implement IC Carrot or
stick
bull Detection ESBL identification
Inoculum effect
bull Colistin-as empiric Rx combined
with aminoglycosides (gent) rifampin
Status of the KPC global
epidemic bull Two phenotypes MIClt 8 and MICgt 32
bull ST258gt ST384 ST388 othershellip
bull Plasmids from ST258 and other starins
has been transferred to E coli in
patients (Kreiswirth lab)
bull Colistin resistant ST258
bull Novel testing methods (ChromAgar
Boronates PCRESI-MS Microarray
methodsCheckpoints
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Status of the KPC global
epidemic bull Two phenotypes MIClt 8 and MICgt 32
bull ST258gt ST384 ST388 othershellip
bull Plasmids from ST258 and other starins
has been transferred to E coli in
patients (Kreiswirth lab)
bull Colistin resistant ST258
bull Novel testing methods (ChromAgar
Boronates PCRESI-MS Microarray
methodsCheckpoints
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Enterobacteriaceae (K pneumoniae) Outbreaks
Mainly KPC-2 and KPC-3 (KPC-2 to KPC-
11) Poirel L et al
Thanks Dr Endimiani
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Hammerum AM et al IJAA 2010 Naas T et al AAC 2005
ldquoImportExportrdquo of patients carrying
blaKPC
Cuzon G et al
Dr Endimiani
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Genetic environment of blaKPC (Tn4401) Structure of Tn4401 and insertion sites
Possible genesis of Tn4401
bull Different isoform suggests that this
region is polymorphic
Tn4401 is at the origin of acquisition and
dissemination of blaKPC
Isoform B
Isoform A
Paeruginosa
Thanks
Dr Endimiani
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Western Blot
Relative copy number
with real-time PCR
(versus rpoB gene) Molecular characterization of
OmpK35 and OmpK36 genes
c Frameshift
(stop codon after aa 88)
Common in ST258
No deletion (isoform B)
68-bp deletion
100-bp deletion (isoform A)
255-bp deletion
Thanks
Dr Endimiani
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
The ldquoKPC Tsunamirdquo
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Worst case scenario
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Is there increased mortality
The mortality in the IRE group was 33 compared to
9 among controls
Being an IRE case was significantly associated with
increased mortality (P 0043)
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
The tip of the iceberghellip
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Clonal typing
gyrA parC
mecA PVL TSST
mupA nucA
The near future
The exciting future
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Options for treatment
ldquoThe basis for a new
research
agenda in Infectious
Diseasesrdquo
Can I approach this based upon a knowledge of genetics
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Therapy for MDR Ab et al
Colistin
Tigecycline
Minocycline
Rifampin
(Teicoplanin Vancomycin Are you crazy)
Do we have enough patients
studied properly Animal
models may have
(significant) limitations
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Colistin is King
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
ldquoAfter an exhaustive review of much the
available evidencehelliprdquo
Perez et al AAC 2007
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
CID 2010
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Not enough data Antagonistic
Synergy Sometimes
Meta-analysis (Falagas IJAA)--no statistical
difference in cure rates when colistimethate sodium
alone was compared with the combinations with
meropenem piperacillintazobactam or
ampicillinsulbactam
Colistin + rif
Colistin + minocycline
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
The colistin ldquobottom linerdquo bull ldquoEfficacy raterdquo of 57-76 in IV form
ldquomicrobiological eradicationrdquo of 67-909Renal tox 0-37
bull Nebulized colistin (CF studies + others) effective FDA warning impact of shift to more resistant strains use with IV
bull 32 cases ldquomicrobiological eradicationrdquo in the CNS with IThIVe colistin (safe e 1) (25 mgkg 10-20 mg ITh)
bull Colistin was independently associated with higher mortality vs treatment with sulbactam in patients with A b infections
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Colistin dosing
bull Administration of a loading dose (300
mg)
bull Colistin exposure during the first 12 h
ldquomay be beneficial providing enough
net killing such that the immune system
may be able to eradicate any remaining
colistin- resistant cellsrdquo
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Tigecycline 1Rapid resistance
can emerge
2Cases of breakthrough bacteremia reported
3 Adequacy of blood levels
Pachon and Vila Curr Opin
Investig Drugs 2009
Feb10(2)150-6
Giamarellou amp Poulakou Drugs
2009
Michalopoulos A Falagas ME
Expert Opin Pharmacother
2010 Apr11(5)779-88
Patients Improvement
25 84
18 50
17 824
29 30
75 70
34 68
45 78-90
Major concernshellipreal
bacteremic patients treated with tige failed to
clear their bacteremia 10-fold more commonly
than patients treated with comparator drugs
Gordon JAC 2009 Gardiner CID
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
My recommendations
bull Susceptible strains
1 AS 3 q6 higher doses
2 Imipenem meropenem is worrisome
dori Cephalosporins are tricky
3 Colistin loading dose 5 mgkg not to
exceed 300 mg then (45 mgkgday) and
split it tid (15 mgkg q8)
4 Colistin and rifampin tigecycline or
minocycline doripenem)
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Colistin and vanco
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
E-129
GSK2251052hellipComparative In Vitro
Activity Against Pseudomonas
aeruginosa from a Global Population
Bouchillon et al
Drug MIC range MIC50 MIC90 Susceptible
GSK2251052 006 ndash 64 2 4 NA
Imipenem le05 - gt16 2 16 729
Meropenem le012 - gt16 05 16 793
Cefepime le05 - gt32 4 32 753
Piptazob le05 - gt128 8 gt128 813
Amikacin le05 - gt64 4 16 902
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Combination therapy for
PSDA
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
If NDM-1 Treatment options
Aztreonam + NXL
BAL30072 meropenem
and
Tige
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
E-722
Activity of the Novel Sulfactam BAL30072
Alone and in Combination with
Meropenem Against Diverse Gram-
negative Isolates Carrying NDM-1 β-
lactamase Gene T R Walsh et al
Organism (N) Ceftazidime Meropenem Aztreonam BAL
30072
BAL30072
Meropenem
A baumannii (23) gt256 256 16 4 1
P aeruginosa (2) 256 32 16 05 lt0125
S maltophilia (1) 256 64 64 4 1
Escherichia coli (3) 256 32 64 32 1
K pneumoniae (2) 256 128 64 32 2
C freundii (3) 128 128 64 8 2
Dihydropyridone siderophore monocyclic sulfactam
Thanks to Dr F Perez
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
68 blaKPC-possessing K pneumoniae including
23 tigecycline- andor colistin-nonsusceptible strains
By agar dilution 93 of the overall
KpKPC were susceptible (MIC5090 of 1664 gml respectively)
Notably 5 out of 6 extremely drug-resistant (tigecycline
and colistin nonsusceptible) KpKPC were susceptible
to fosfomycin Compared to agar dilution disk diffusion
was more accurate than Etest
KPC Rx
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Summary
bull Extraordinary challenge against cunning
pathogens
bull Basic understanding of molecular biology is
needed (the complexities of resistance
genes will only increase)
bull Research is needed in therapeutics and
infection control
bull CALL TO ARMS Coordinate scientific and
clinical trials to answer these important
questions
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham
Acknowledgments
bull NIH VA Merit Review
bull Drs Alan Evangelista and Linda Miller
bull Dr Barry Kreiswirth
bull Chris Bethel Steve Marshall Magda Taracila
Kristine Hujer and Andrea Hujer
bull Drs Krisz Papp-Wallace Marisa Winkler
Federico Perez Curtis Donskey Dror
Marcham