Antimicrobial Agents and Chemotherapy

Linezolid is a key component of the bedaquiline, pretomanid, linezolid (BPaL) regimen for rifampin-resistant tuberculosis, but dose- and duration-dependent mitochondrial toxicity frequently limits its use. TBD09 (formerly MK-7762) is a novel oxazolidinone developed to maintain antitubercular potency comparable to linezolid while reducing related adverse events. We evaluated the contribution of TBD09 to the bactericidal and sterilizing activities of BPa-based regimens in a murine tuberculosis model. BALB/c mice were aerosol-infected with Mycobacterium tuberculosis H37Rv and treated starting 2 weeks post-infection. In Experiment 1, dose-ranging bactericidal activity of TBD09 (50, 100, 200 mg/kg) was assessed alone and in combination with BPa, with comparison to linezolid and sutezolid. In Experiment 2, the sterilizing activity of TBD09 (200 mg/kg) in combination with BPa and BPa plus moxifloxacin (M) was assessed by evaluating relapse after treatment durations of 4-22 weeks. TBD09 monotherapy was bacteriostatic, similar to linezolid over the first 4 weeks of treatment. The addition of TBD09 to BPa significantly enhanced bactericidal activity comparable to the addition of linezolid. In relapse assessments, BPa+TBD09 resulted in significantly fewer relapses compared to BPa alone after 14 weeks of treatment, and BPaM+TBD09 resulted in significantly fewer relapses compared to BPaM after 10 weeks. Model-based analysis estimated the treatment duration to 95% cure for BPa+TBD09 at 2.7 weeks, compared to 3.2 weeks for BPaL, although the time to 50% cure was similar. These results demonstrate that TBD09 provides bactericidal and sterilizing activity similar to linezolid in combination with BPa(M), supporting further clinical development of TBD09 for tuberculosis.

Rationale: Tuberculosis preventive therapy (TPT) is essential for global tuberculosis control, yet estimated coverage remains well below global targets. Current World Health Organization (WHO)-recommended regimens require 1-9 months of treatment and are associated with suboptimal completion rates. Long-acting injectable (LAI) formulations offer the potential to improve TPT uptake and completion, with ideal products providing "one-and-done" options via a single administration. Sorfequiline, a second-generation diarylquinoline with superior potency over bedaquiline and lower QT prolongation risk, is a promising candidate for LAI TPT.

Treatment shortening in tuberculosis therapy is needed, but testing all novel antibiotic combinations is unfeasible. Especially the tuberculosis relapsing mouse model is time- and resource demanding. Therefore, our objective is to develop a computational model predictive of long-term relapse prevention in mice based on short-term biomarkers, increasing the number of regimens that can be tested and prioritize regimens for further development. The innovative ribosomal RNA synthesis (RS) ratio is utilized to characterize drug effect on Mycobacterium tuberculosis health and activity, together with colony forming units (CFU) in murine lungs. Nine datasets of 58 unique regimens with 843 short-term biomarker and 2,239 long-term relapse observations were leveraged for model development in 3 iterations with external validations. The final model included therapeutic predictors, such as CFU and RS ratio change from baseline, and corrected for experimental conditions, to enable unbiased ranking of regimens between experiments. Model performance was optimal without model structure change despite fully separate model development at each iteration. Final external validation had an area under the receiver operator curve of 0.90. Challenging the model by assessing removal of either biomarker showed that performance of CFU only was similar to CFU and RS ratio once the sterilizing contribution of individual drugs to the regimens was accounted for. New drugs without this contribution quantified could benefit from RS ratio determination to predict relapse. Our predictive model can successfully differentiate between 2-, 3-, and 4-month regimens in the relapsing mouse model based on 4-week data only, supporting acceleration of treatment-shortening regimen development. One Sentence SummaryOur predictive model ranks new drug regimens by tuberculosis relapse prevention based on 28-day CFU and RS ratio, or on CFU only for known drugs.

Imipenem-relebactam (Imi/Rel) is a {beta}-lactam/{beta}-lactamase inhibitor combination used for the treatment of multidrug-resistant Pseudomonas aeruginosa infections. We previously reported that treatment-emergent resistance to Imi/Rel is associated with mutations in the AmpC beta-lactamase and/or the MexAB-OprM and MexEF-OprN efflux operons. However, the impact of these mutations on bacterial gene expression has not been explored extensively, particularly among P. aeruginosa from patients treated with Imi/Rel. To determine the effect of treatment-emergent Imi/Rel resistance on P. aeruginosa global transcription, we performed RNA sequencing on paired P. aeruginosa clinical isolates from six patients collected before and after Imi/Rel treatment. Transcriptional responses varied substantially, with no conserved changes in gene expression identified across all six patients. Three isolate pairs showed significant upregulation of previously characterized Imi/Rel resistance-associated genes in the treatment-emergent resistant isolate, while two resistant isolates displayed significant downregulation of ampC. Comparisons of the top 10 differentially regulated genes in the resistant isolate from each patient revealed only one gene that was shared between all six patients. Pathway enrichment analysis using Clusters of Orthologous Genes (COG) categories suggested that Imi/Rel exposure impacts transcription of genes involved in translation and metabolism, but these changes are highly variable between patients and isolates. Overall, we find that the transcriptional response of clinical P. aeruginosa to Imi/Rel exposure appears to be highly diverse and likely dependent on the genetic background of the infecting P. aeruginosa strain.

OXA-48-like {beta}-lactamases, such as OXA-163, OXA-181, OXA-405, OXA-505, among others, are class D carbapenem-hydrolyzing enzymes increasingly reported worldwide, yet some variants remain poorly characterized at the phenotypic levels. Here, we report OXA-439, a variant of OXA-163, in a producing uropathogenic Escherichia coli (UPEC) in Uruguay, recovered from a catheter-associated urinary tract infection with discordant routine susceptibility results. The specific contribution of OXA-439, bla-OXA-48, bla-OXA-163, and bla-OXA-439 were cloned into pET24a vector and expressed in Escherichia coli BL21(DE3), and their activity was evaluated by MIC microdilution against a panel of penicillins, ESCs, carbapenems, and {beta}-lactam/{beta}-lactamase inhibitor combinations. OXA-439 exhibited a substrate profile highly similar to OXA-163 conferring resistance to piperacillin and third-generation cephalosporins while remaining susceptible to carbapenems but with globally reduced MIC values and a complete loss of activity toward amoxicillin and clavulanate. These data suggest that the Y123H substitution, located near the catalytic Ser70/Lys73 region, subtly perturbs the active-site environment and decreases penicillinase efficiency.

Murine efficacy models inform advancement of preclinical tuberculosis treatment regimens to human clinical testing. A recent human Phase 2 trial was terminated early because investigational regimens (4-months of PaBQU or DBQU) did not meet the treatment shortening criteria outlined in the Target Regimen Profile ([≤] 3 months). We queried whether a factor leading to this early termination may have been lesional liability, meaning slow or diminished onset of effect in the caseum of complex lung lesions. We conducted a translational study, comparing the easy-to-treat BALB/c mouse, lacking complex lesions, to the hard-to-treat C3HeB/FeJ mouse that develops complex human-like lesions. We evaluated traditional and novel pharmacodynamic markers (colony forming units and RS ratio), relapse outcomes and ex vivo caseum pharmacokinetics. PaBQU and DBQU were slower to elicit bactericidal activity, RS ratio activity and prevent relapse in the C3HeB/FeJ mouse than the BALB/c mouse. A reference regimen (BPaMZ) had less lesional liability than PaBQU and DBQU. Fewer drugs in PaBQU were projected to achieve target attainment in caseum compared to BPaMZ, particularly early in treatment due to slow accumulation of bedaquiline in caseum. Here, we demonstrated application of a multi-modality pharmacokinetic-pharmacodynamic analysis that compared regimen activity in the hard-to-treat C3HeB/FeJ and easy-to-treat BALB/c mouse models, identifying lesional liability of PaBQU and DBQU. Systematic interrogation of additional diverse regimens is needed to determine the value of preclinical lesional liability as a means of predicting clinical treatment shortening activity.

Azoles remain the most common antifungal therapy worldwide. However, Nakaseomyces glabratus (previously named Candida glabrata) has a high intrinsic tolerance against azole drugs. The organism can also accrue additional chromosomal mutations to elevate its resistant level during treatment. These genetic alterations often result in overexpression of the ABC transmembrane transporter Cdr1, which has been shown to directly transport drugs out of the fungal cells. Another resistant mechanism is the upregulation of the ergosterol biosynthesis pathway, which is the direct target of azoles. Although the mechanisms of azole resistance in N. glabratus are well defined, knowledge of their regulation remains limited. Here, we show that the protein kinase Fpk1 is required for optimal azole response in vitro and in an in vivo mouse infection model. Loss of Fpk1 gene or its kinase function significantly enhances azole sensitivity in both azole-susceptible and -resistant clinical isolates. Fpk1 function is required for optimal expression of Cdr1 upon azole challenge. It also influences the intracellular trafficking of ergosterol, without affecting its biosynthesis. Together, our data demonstrates the important role of Fpk1 function in the N. glabratus azole response and characterizes it as a new regulator of the efflux pump and ergosterol biosynthesis pathways. IMPORTANCEAntifungal treatment against life-threatening bloodstream Candida infection remains limited to azoles, echinocandins, and polyenes. Among them, azoles are the most prescribed therapy worldwide. However, the pathogenic yeast Nakaseomyces glabrataus has a high level of resistance against azoles (> 10%) (1). This often complicates treatment and increases mortality and morbidity rates. Therefore, understanding the mechanism of azole resistance would reinforce the treatment strategy and bolster future therapy development. Here, we identify the protein kinase Fpk1 as an important regulator of the drug efflux plump and ergosterol biosynthesis pathways. Disruption of the Fpk1 function significantly enhances the azole efficacy in vitro and in a mouse model of Candida systemic infection. Protein kinases are druggable targets, and our data presents Fpk1 as a viable candidate for future antifungal development.

Background: Polymorphisms in the N-acetyltransferase 2 (NAT2) gene explain much of the interindividual variation in isoniazid (INH) metabolism and determine risk of toxicities. However, there is limited evidence to guide INH dose adjustment according to the NAT2 acetylator profile in weekly rifapentine-INH tuberculosis preventive therapy (TPT). Methods: In a prospective, multicenter, within-subject PK trial (NCT05413551), adults initiating 3HP in Brazil were assigned genotype-guided INH doses (slow: 5 mg/kg <=300 mg; intermediate: 15 mg/kg <=900 mg; rapid: 25 mg/kg <=1,500 mg) alongside a standard 900 mg flat dose on an alternate occasion. AUC0-24 and C24 were estimated from serial blood samples; a two-compartment Michaelis-Menten population PK model characterized NAT2 effects on clearance. Results: Among 228 participants, 47.4% (108/228) were intermediate, 43.4% (99/228) slow, and 9.2% (21/228) rapid acetylators. Genotype-guided dosing reduced AUC0-24 variability approximately two-fold versus standard dosing (CV 58.8% vs 76.8%) and increased exposure uniformity (median AUC0-24 27.2 [IQR 18.8-41.3] vs 43.2 [27.3-71.0] mg h/L). Among slow acetylators, C24 >0.15 ug/mL decreased from 27/42 (64%) with standard dosing to 1/42 (2%) with genotype-guided dosing (P<0.0001). In 104 participants with intensive PK sampling, rapid acetylators receiving guided doses had AUC0-24 similar to standard-dose intermediate acetylators (42.8 vs 39.5 mg h/L; P=.63). Monte Carlo simulations supported doses of 600, 900, and 1,200 mg for slow, intermediate, and rapid acetylators, respectively. Conclusions: NAT2-guided isoniazid dosing reduced variation in drug levels, averting very low and high AUC and C24. These findings inform genotype-stratified dosing of INH for TPT, which might reduce toxicities and improve outcomes.

Quinolone antibiotics such as ciprofloxacin inhibit DNA gyrase, leading to DNA double-strand breaks that result in rapid bacterial killing and induction of the mutagenic SOS DNA repair response. By contrast, the ciprofloxacin analogue IMP-1700 inhibits ciprofloxacin-induced SOS, suggesting a novel mechanism of action. Here, we provide evidence that IMP-1700 targets the quinolone binding domain of DNA gyrase but triggers a significantly higher frequency of division septa in S. aureus compared with other DNA gyrase targeting antibiotics, including ciprofloxacin. In keeping with this finding, the lipopeptide antibiotic daptomycin, which targets the division septum, bound more strongly to IMP-1700-treated cells relative to S. aureus exposed to other DNA gyrase inhibitors, leading to increased bacterial killing. This finding extended to a panel of paired daptomycin susceptible and resistant clinical isolates. We conclude that the ciprofloxacin analogue IMP-1700 has distinct effects on the cell envelope of S. aureus, despite appearing to share the same target as the parent drug, which result in the resensitisation of daptomycin resistant bacteria to the lipopeptide antibiotic.

Background. Optimal antibiotic dosing regimens depend on the pharmacokinetic/pharmacodynamic (PK/PD) index that best predicts antibacterial efficacy. PK/PD targets are traditionally determined using murine infection models based on a limited number of bacterial isolates. Objective. This study aimed to investigate whether animal experiments could be replaced by in vitro time-kill experiments performed on a large collection of clinical isolates and analyzed using a modelling approach accounting for inter-strain variability. The proposed framework was evaluated using meropenem against Pseudomonas aeruginosa. Materials and Methods. In vitro time-kill experiments were performed on 66 clinical isolates of P. aeruginosa. A population pharmacodynamic model was developed from experimental data. A murine pharmacokinetic model was reproduced from literature and combined with the pharmacodynamic model to simulate in vivo bacterial burden over time. The relationships between simulated bacterial counts at 24 h and the three main PK/PD indices (fCmax/MIC, fAUC/MIC and %fT>MIC) were characterized using nonlinear mixed-effects Imax models. Results. The PK/PD index showing the strongest correlation with meropenem efficacy at 24 h was %fT>MIC (R2 = 0.989), compared with fAUC/MIC (R2 = 0.373) and fCmax/MIC (R2 = 0.284). These findings are consistent with previous studies using murine thigh infection models. The %fT>MIC target required to achieve a 2-log CFU reduction was estimated at 44%, with substantial inter-strain variability (10th and 90th percentiles: 27% and 71%, respectively). Conclusions. Using meropenem against P. aeruginosa as a proof of concept, we demonstrate that in vitro time-kill experiments combined with pharmacometric modelling can identify the same PK/PD efficacy targets as animal infection models. Moreover, performing experiments on a large panel of clinical isolates enables the quantification of inter-strain variability in PK/PD targets, providing information that may improve their translation to clinical dosing optimization.

Purpose: Vancomycin-resistant Gram-positive organisms represent a potential therapeutic challenge in endophthalmitis. To evaluate alternative treatment options, the FDA-approved oxazolidinones linezolid (LZD) and tedizolid (TZD) were tested against a collection of Gram-positive bacterial endophthalmitis isolates. Methods: Minimum inhibitory concentrations (MICs) were determined using epsilometers (Etest strips) for coagulase negative staphylococci (CoNS, n=20), Staphylococcus aureus (n=18), Bacillus species (n=10), Enterococcus species (n=5), and Streptococcus pneumoniae (n=1). Available CLSI and EUCAST breakpoints were applied to determine susceptibility. Results: TZD exhibited a >5-fold reduction in median MIC compared with LZD across all organisms tested (p<0.0001). MIC90 values for CoNS were 2.0 /ml for LZD and 0.25 /ml for TZD. For S. aureus, MIC90 values were 1.5 /ml (LZD) and 0.19 /ml (TZD). For Bacillus spp., MIC90 values were 1.0 /ml (LZD) and 0.25 /ml (TZD). Among Enterococcus species, the MIC range was 0.5-4.0 /ml (LZD) and 0.064-0.75 /ml (TDZ). The single S. pneumoniae strain had a MIC of 0.5 for LZD and 0.064 for TZD. All isolates were susceptible to TZD. One Enterococcus isolate was non-susceptible to LZD; the remaining isolates were susceptible. Conclusions: LZD and TZD demonstrated in vitro activity against Gram-positive bacterial endophthalmitis isolates, with TZD displaying consistently lower MICs than LZD. These findings suggest that oxazolidinones may represent potential alternatives when vancomycin cannot be used, including infections caused by vancomycin-resistant Gram-positive organisms. Given their excellent oral bioavailability, favorable safety profile, and reported anti-virulence effects in certain pathogens, further evaluation of oxazolidinones for the treatment of intraocular infections is warranted.

Nitrofurantoin is commonly prescribed as a first-line treatment for urinary tract infections (UTIs) and is effective against most uropathogens; however, resistance among Klebsiella spp. remains high. In this study, we investigated synergistic drug combinations--defined as pairs of drugs whose combined effect exceeds that of each agent alone--to enhance treatment efficacy against drug-resistant Klebsiella pneumoniae. A high-throughput drug screen identified six and two small molecules that exhibited >50% synergistic activity in tested strains in combination with nitrofurantoin and ciprofloxacin, respectively. We further validated the top three candidates using nitrofurantoin-susceptible and resistant clinical isolates. Notably, the combination of nitrofurantoin and dequalinium demonstrated strong synergistic activity, observed in 68% of susceptible Escherichia coli strains and 94% of resistant Klebsiella pneumoniae strains tested. Combined inhibition of the citric acid cycle by nitrofurantoin and F1-ATPase by dequalinium resulted in a significant reduction in ATP levels compared to either treatment alone. Importantly, decreased ATP levels did not increase persister cell formation, and dequalinium alone reduced persister cell populations more effectively than nitrofurantoin. However, nitrofurantoin is processed into a poorly understood reactive intermediate whose specific metabolic targets have not been fully elucidated. Using metabolomic analyses, we identified aconitase and isocitrate dehydrogenase--key enzymes in the citric acid cycle--as altered in response to nitrofurantoin. Together, these findings demonstrate that dual targeting of bacterial metabolism by nitrofurantoin and dequalinium represents a promising therapeutic strategy for treating drug-resistant Klebsiella spp. in UTIs.

Nontuberculous mycobacterial (NTM) infections are a scourge that affect growing patient populations due to the rise of risk factors associated with these opportunistic pathogens. Cure rates are unacceptably low despite intensive multidrug and multi-year therapy. The issue of poor drug exposure relative to inferior potency of repurposed antibiotics against NTM pathogens is broadly recognized as a major factor underlying dismal success rates. Yet, a quantitative and systematic evaluation of probabilities of pharmacokinetic-pharmacodynamic (PK-PD) target attainment (PTA) is lacking. Here, we leveraged published population PK models and minimum inhibitory concentration distributions across large patient populations to generate PTAs for standard of care antibiotics used in the treatment of NTM infections. PTAs of tuberculosis drugs were included in our analysis as a baseline since tuberculosis cure rates are excellent compared to NTM diseases. We found that PK-PD target attainment for NTM was low overall and that PTAs were generally consistent with reported clinical outcomes. Specifically, drugs for which genetic resistance is associated with worse outcome showed favorable PTAs, consistent with their contribution to cure. These include macrolides for M. abscessus and the M. avium complex (MAC), and rifampicin for M. kansasii. Bedaquiline emerged as a promising option against M. abscessus and MAC, and clofazimine against the latter, consistent with recent clinical reports. Omadacycline PTAs predict improved efficacy compared to tigecycline for patients with M. abscessus and suggest clinical utility for MAC. As is common practice for antibacterials, PTA considerations could inform NTM treatment guidelines and help select drug combinations in future trials.

ObjectiveTo investigate the combined effects of multiple drugs and provide more therapeutic options for invasive fungal infections, this study evaluated the in vitro susceptibility of Aspergillus spp., Candida auris, Cryptococcus neoformans, and Exophiala dermatitidis to pibrentasvir (PIB) in combination with itraconazole (ITR), voriconazole (VOR), posaconazole (POS), or fluconazole (FLU). MethodsAccording to the M27-A3 and M38-A2 guidelines established by the Clinical and Laboratory Standards Institute (CLSI), the in vitro antifungal activities of PIB combined with ITR, VOR, POS, or FLU against 78 clinical isolates, including Aspergillus spp., E. dermatitidis, C. auris, and C. neoformans, were determined. The minimum inhibitory concentrations (MICs) and fractional inhibitory concentration indices (FICIs) were calculated to evaluate the synergistic effects. ResultsPIB alone exhibited no antifungal activity. Significant synergistic effects were observed when PIB was combined with azole antifungal agents. The PIB-POS combination showed synergistic effects against Aspergillus spp. (27/41, 65.90%), C. auris (9/10, 90.00%), C. neoformans (2/9, 22.20%), and E. dermatitidis (11/18, 61.11%). The PIB-ITR combination also showed synergistic effects against Aspergillus spp. (18/41, 43.9%), C. auris (9/10, 90.0%), C. neoformans (2/9, 22.2%), and E. dermatitidis (10/18, 55.5%). Synergistic effects were less frequently observed with the PIB-VOR or PIB-FLU combinations, and no antagonistic effects were observed. ConclusionThis study demonstrates that PIB acts as an azole sensitizer, with the strongest synergistic effects observed when combined with POS or ITR, providing a new research direction for combination therapy against invasive fungal infections.

Klebsiella aerogenes, a member of the Enterobacteriaceae, is a causative agent of healthcare-associated infections, and outbreaks caused by drug-resistant K. aerogenes have been reported worldwide. The range of antimicrobial agents available for treating infections caused by carbapenem-resistant K. aerogenes is limited. While in vivo animal experiments using clinical K. aerogenes isolates to evaluate antimicrobial therapy could facilitate selection of the most effective treatment, conducting infection experiments involving large numbers of mammals such as mice is challenging due to ethical concerns related to animal welfare. Silkworms are invertebrates increasingly used as experimental models for infectious disease research to evaluate antimicrobial efficacy. In this study, we aimed to establish a silkworm infection model using a clinical K. aerogenes isolate to evaluate its utility for determining effective antimicrobial doses. K. aerogenes strains were isolated from a patient at a Japanese hospital, and a silkworm infection model was established using the clinical isolate. The non-metallo-beta-lactamase-producing strain K. aerogenes TUM25562, isolated from a patient with a complicated urinary tract infection, was susceptible to meropenem (MEPM) and gentamicin (GM) in vitro. During treatment, additional isolates with increased resistance to MEPM and subsequently to both MEPM and GM emerged. K. aerogenes TUM25562 caused dose-dependent mortality in silkworms. Treatment with clinically equivalent weight-based doses of MEPM or GM did not cure the infected silkworms. The median effective (ED50) doses of MEPM and GM were therefore investigated using the silkworm infection model. Administration of higher doses corresponding to four times the ED50 significantly prolonged the survival of infected silkworms. These results suggest that a silkworm infection model using clinical K. aerogenes isolates may provide a practical approach for evaluating antimicrobial efficacy and determining effective antimicrobial doses.

Background: Pseudomonas aeruginosa is a ubiquitous opportunistic bacterial pathogen associated with nosocomial infections and is a leading cause of infection in persons with cystic fibrosis (pwCF). The front-line treatment for multidrug-resistant P. aeruginosa infections is ceftolozane-tazobactam (C/T). While previous research has characterized clinical P. aeruginosa isolates that evolved resistance to C/T, the collateral effect of evolved resistance on susceptibility to bacteriophages has not been explored. Methods: We collected paired P. aeruginosa clinical isolates from 10 pwCF and 18 non-pwCF who developed treatment-emergent C/T resistance. We compared genetic relatedness, acute and chronic virulence phenotypes, and antibiotic and phage susceptibilities between each pair of susceptible baseline and treatment-emergent C/T-resistant isolates. Results: Treatment-emergent C/T-resistant isolates were genetically closely related to baseline isolates in all patients. Virulence phenotypes did not differ between pre- and post-C/T exposure isolates, but isolates from pwCF demonstrated differences in protease production, twitching motility, and amino acid auxotrophy compared to isolates from non-pwCF. Treatment-emergent C/T resistance was associated with increased resistance to ceftazidime and ceftazidime/avibactam, but no other trends in antibiotic or phage susceptibility were detected. Conclusions: Treatment-emergent resistance to C/T does not cause predictable alterations in phage susceptibility across genotypically and phenotypically diverse multidrug-resistant P. aeruginosa clinical isolates.

Cutaneotrichosporon dermatis (formerly Trichosporon dermatis) is a basidiomycetous yeast-like fungus known to cause summer-type hypersensitivity pneumonitis, although its virulence in humans remains poorly understood. We performed morphological and molecular identification of an isolate from the sputum and blood cultures of an immunocompromised patient, together with pathogenicity assessment using a Galleria mellonella model, biofilm formation/eradication assays, antifungal susceptibility testing, drug combination effects, and the post-antifungal effect (PAFE), compared with Trichosporon asahii. The isolate was identified as C. dermatis by ITS/IGS1 sequencing, supported by phylogenetic analysis. Growth of C. dermatis increased more at 37 than at 25. In the Galleria mellonella assay, C. dermatis, T. asahii, and Candida albicans each showed dose-dependent pathogenicity at sufficiently high inocula, although Rhizopus oryzae was the most potent pathogen on a per-CFU basis. C. dermatis formed biofilms that were more completely inhibited by terbinafine (TRB) and amphotericin B (AmB) than azole agents, which showed only partial inhibitory activity even at high concentrations. Susceptibility testing showed relatively strong susceptibility to AmB and azole agents. In the TRB and azole combination assay, the fractional inhibitory concentration index (FICI) was below 0.5, indicating synergy. Isavuconazole (ISC) showed a markedly stronger PAFE than the other azole agents tested. These findings indicate that although azoles show only partial efficacy against its biofilm, C. dermatis can still cause invasive infection, and that azole monotherapy or TRB and azole combination therapy, aided by the potent PAFE of ISC, may represent effective treatment options.

Pharmacodynamic curves describe how changes in drug concentration affect pathogen growth. They are essential for designing treatments that promote pathogen eradication and minimize the evolution of antibiotic resistance. The classical function for modelling pharmacodynamics is a phenomenological, S-shaped curve with stable growth and death rates separated by a single drop. In this study, we characterized the pharmacodynamic curve of the {beta}-lactam antibiotic cefotaxime (CTX) acting against Escherichia coli. We found that the relationship between CTX concentration and net growth rate diverged from classical model predictions, instead yielding a two-step curve defined by distinct phases of growth, population maintenance, and killing. We hypothesized that the intermediate phase arose from antibiotic tolerance conferred by bacterial filaments. Microscopic assessment of treated cells indeed showed a difference in degree of filamentation with concentration. We further sought to explain this with a semi-mechanistic pharmacodynamic function, modelling the binding of CTX to its cellular targets, penicillin binding proteins (PBP) 1 and 3. By incorporating the preferential concentration-dependent binding of CTX to PBP3 and then PBP1, yielding filaments or lysed cells respectively, we replicated the two-step curve in silico. We also assessed the pharmacodynamics of CTX against mutants conferring resistance; these displayed further altered curves, in line with their fitness costs. Altogether, our results show that CTX has a two-step pharmacodynamic curve against E. coli arising from multiple targets separated in their affinity for the antibiotic. We present a model offering a mechanistically grounded framework for capturing such dynamics. These pharmacodynamic curves deserve careful consideration when defining optimal dosing.

BackgroundAztreonam-avibactam (AZA) is a recently approved agent active against metallo-{beta}-lactamase-producing Enterobacterales. However, independent evaluations of commercially available antimicrobial susceptibility testing (AST) products remain limited. MethodsWe evaluated 56 carbapenem-resistant Enterobacterales isolates using four newly available AZA AST products, including two gradient diffusion (bioMerieux Etest; Liofilchem MIC Test Strip) and two disk diffusion (Hardy, Liofilchem) tests across three Mueller-Hinton agar manufacturers at two independent clinical laboratories. A diverse isolate collection enriched for nonsusceptible and breakpoint-adjacent MICs was used to rigorously assess categorical agreement. Broth microdilution (BMD) was used as the reference method. Essential agreement (EA), categorical agreement (CA), error rates, and reproducibility were analyzed. ResultsAll four commercial AST products demonstrated acceptable analytical performance compared with reference BMD. Gradient diffusion demonstrated high EA (bioMerieux 94.3%, Liofilchem 90.5%), whereas CA ranged from 83.3% to 89.0% across all four products. Minor errors accounted for all categorical discrepancies, and occurred almost exclusively among breakpoint-adjacent isolates. Media-related variability was modest, and quality control performance was generally high, with strong within-site precision and consistent performance across laboratories. ConclusionsThis study provides the first comprehensive head-to-head comparison of commercial AZA susceptibility testing products and supports their implementation in clinical microbiology laboratories.

The human opportunistic pathogen Pseudomonas aeruginosa produces copious quantities of the secondary metabolite pyocyanin (PYO). PYO has recently been shown to interact with the aryl hydrocarbon receptor (AhR), a transcription factor controlling expression of a number of genes, including the cytochrome P450 CYP1A family involved in fluoroquinolone antibiotic clearance. In this study, we investigated whether Pseudomonas aeruginosa could influence the metabolism of ciprofloxacin through human CYP1A2 induction. Primary human hepatocytes were exposed to 1-100 M PYO, with high concentrations resulting in apparent cytotoxicity. Treatment with 5 {micro}M PYO led to a 6.2-fold change in CYP1A2 mRNA and a 3.6-fold increase in oxociprofloxacin metabolite formation. Our results suggest that sub-toxic concentrations of PYO induce CYP1A2 expression and increase ciprofloxacin metabolism, which could lead to sub-efficacious antibiotic concentrations and further drive resistance. This finding directs us to a novel mechanism by which Pseudomonas aeruginosa may escape antimicrobial therapy by hijacking host xenobiotic metabolism pathways. GRAPHICAL ABSTRACT O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=110 SRC="FIGDIR/small/740721v1_ufig1.gif" ALT="Figure 1"> View larger version (25K): org.highwire.dtl.DTLVardef@1b350forg.highwire.dtl.DTLVardef@388eb7org.highwire.dtl.DTLVardef@121bc9aorg.highwire.dtl.DTLVardef@1e53060_HPS_FORMAT_FIGEXP M_FIG C_FIG