Emergence of ceftazidime/avibactam resistance in KPC-3-producing Klebsiella pneumoniae in vivo.

OBJECTIVES The β-lactam/β-lactamase inhibitor combination ceftazidime/avibactam is active against KPC-producing Enterobacterales. Herein, we present molecular and phenotypic characterization of ceftazidime/avibactam resistance in KPC-3-producing Klebsiella pneumoniae that emerged in vivo and in vitro. METHODS Sequence analysis of blaKPC-3 was performed from clinical and in vitro-generated ceftazidime/avibactam-resistant K. pneumoniae isolates. Time-kill kinetics and the Galleria mellonella infection model were applied to evaluate the activity of ceftazidime/avibactam and imipenem alone and in combination. RESULTS The ceftazidime/avibactam-resistant clinical K. pneumoniae isolate revealed the amino acid change D179Y in KPC-3. Sixteen novel mutational changes in KPC-3 among in vitro-selected ceftazidime/avibactam-resistant isolates were described. Time-kill kinetics showed the emergence of a resistant subpopulation under selection pressure with either imipenem or ceftazidime/avibactam. However, combined selection pressure with imipenem plus ceftazidime/avibactam prevented the development of resistance and resulted in bactericidal activity. Concordantly, the G. mellonella infection model revealed that monotherapy with ceftazidime/avibactam is prone to select for resistance in vivo and that combination therapy with imipenem results in significantly better survival. CONCLUSIONS Ceftazidime/avibactam is a valuable antibiotic against MDR and carbapenem-resistant Enterobacterales. Based on time-kill kinetics as well as an in vivo infection model we postulate a combination therapy of ceftazidime/avibactam and imipenem as a strategy to prevent the development of ceftazidime/avibactam resistance in KPC-producing Enterobacterales in vivo.

[1]  R. Humphries,et al.  Ceftazidime/avibactam resistance associated with L169P mutation in the omega loop of KPC-2 , 2019, The Journal of antimicrobial chemotherapy.

[2]  K. Kazmierczak,et al.  In Vitro Activity of Ceftazidime-Avibactam against Clinical Isolates of Enterobacteriaceae and Pseudomonas aeruginosa Collected in Latin American Countries: Results from the INFORM Global Surveillance Program, 2012 to 2015 , 2018, Antimicrobial Agents and Chemotherapy.

[3]  S. Antinori,et al.  Efficacy of Ceftazidime-Avibactam Salvage Therapy in Patients With Infections Caused by Klebsiella pneumoniae Carbapenemase–producing K. pneumoniae , 2018, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[4]  M. Castanheira,et al.  Analyses of a Ceftazidime-Avibactam-Resistant Citrobacter freundii Isolate Carrying blaKPC-2 Reveals a Heterogenous Population and Reversible Genotype , 2018, mSphere.

[5]  R. Bonomo,et al.  Defining the architecture of KPC-2 Carbapenemase: identifying allosteric networks to fight antibiotics resistance , 2018, Scientific Reports.

[6]  M. Castanheira,et al.  Frequency and antimicrobial susceptibility of Gram-negative bacteria isolated from patients with pneumonia hospitalized in ICUs of US medical centres (2015–17) , 2018, The Journal of antimicrobial chemotherapy.

[7]  S. Pongolini,et al.  In vivo evolution of resistant subpopulations of KPC-producing Klebsiella pneumoniae during ceftazidime/avibactam treatment , 2018, The Journal of antimicrobial chemotherapy.

[8]  K. Kazmierczak,et al.  In Vitro Activity of Ceftazidime-Avibactam against Clinical Isolates of Enterobacteriaceae and Pseudomonas aeruginosa Collected in Asia-Pacific Countries: Results from the INFORM Global Surveillance Program, 2012 to 2015 , 2018, Antimicrobial Agents and Chemotherapy.

[9]  M. Gönen,et al.  Impact of the ST101 clone on fatality among patients with colistin-resistant Klebsiella pneumoniae infection , 2018, The Journal of antimicrobial chemotherapy.

[10]  N. Woodford,et al.  Activity of ceftazidime/avibactam against problem Enterobacteriaceae and Pseudomonas aeruginosa in the UK, 2015–16 , 2018, The Journal of antimicrobial chemotherapy.

[11]  D. Landman,et al.  In vitro and in vivo activity of single and dual antimicrobial agents against KPC-producing Klebsiella pneumoniae , 2018, The Journal of antimicrobial chemotherapy.

[12]  Stephania Stump,et al.  Successive Emergence of Ceftazidime-Avibactam Resistance through Distinct Genomic Adaptations in blaKPC-2-Harboring Klebsiella pneumoniae Sequence Type 307 Isolates , 2017, Antimicrobial Agents and Chemotherapy.

[13]  M. Landini,et al.  In vitro interaction of ceftazidime-avibactam in combination with different antimicrobials against KPC-producing Klebsiella pneumoniae clinical isolates. , 2017, International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases.

[14]  Brad Spellberg,et al.  Klebsiella pneumoniae Carbapenemase-2 (KPC-2), Substitutions at Ambler Position Asp179, and Resistance to Ceftazidime-Avibactam: Unique Antibiotic-Resistant Phenotypes Emerge from β-Lactamase Protein Engineering , 2017, mBio.

[15]  A. Kasarskis,et al.  Resistance to Ceftazidime-Avibactam Is Due to Transposition of KPC in a Porin-Deficient Strain of Klebsiella pneumoniae with Increased Efflux Activity , 2017, Antimicrobial Agents and Chemotherapy.

[16]  B. Kreiswirth,et al.  Emergence of Ceftazidime-Avibactam Resistance and Restoration of Carbapenem Susceptibility in Klebsiella pneumoniae Carbapenemase-Producing K pneumoniae: A Case Report and Review of Literature , 2017, Open forum infectious diseases.

[17]  B. Kreiswirth,et al.  Ceftazidime-Avibactam Is Superior to Other Treatment Regimens against Carbapenem-Resistant Klebsiella pneumoniae Bacteremia , 2017, Antimicrobial Agents and Chemotherapy.

[18]  M. Arthur,et al.  Impaired Inhibition by Avibactam and Resistance to the Ceftazidime-Avibactam Combination Due to the D179Y Substitution in the KPC-2 β-Lactamase , 2017, Antimicrobial Agents and Chemotherapy.

[19]  B. Kreiswirth,et al.  In Vitro Selection of Meropenem Resistance among Ceftazidime-Avibactam-Resistant, Meropenem-Susceptible Klebsiella pneumoniae Isolates with Variant KPC-3 Carbapenemases , 2017, Antimicrobial Agents and Chemotherapy.

[20]  C. Clancy,et al.  Mutations in blaKPC-3 That Confer Ceftazidime-Avibactam Resistance Encode Novel KPC-3 Variants That Function as Extended-Spectrum β-Lactamases , 2017, Antimicrobial Agents and Chemotherapy.

[21]  B. Kreiswirth,et al.  Emergence of Ceftazidime-Avibactam Resistance Due to Plasmid-Borne blaKPC-3 Mutations during Treatment of Carbapenem-Resistant Klebsiella pneumoniae Infections , 2016, Antimicrobial Agents and Chemotherapy.

[22]  D. Paterson,et al.  Spotlight on ceftazidime/avibactam: a new option for MDR Gram-negative infections. , 2016, The Journal of antimicrobial chemotherapy.

[23]  R. Bonomo,et al.  Activity of ceftazidime/avibactam against isogenic strains of Escherichia coli containing KPC and SHV β-lactamases with single amino acid substitutions in the Ω-loop. , 2015, The Journal of antimicrobial chemotherapy.

[24]  N. Woodford,et al.  In Vitro Selection of Ceftazidime-Avibactam Resistance in Enterobacteriaceae with KPC-3 Carbapenemase , 2015, Antimicrobial Agents and Chemotherapy.

[25]  R. Bonomo,et al.  Variants of β-Lactamase KPC-2 That Are Resistant to Inhibition by Avibactam , 2015, Antimicrobial Agents and Chemotherapy.

[26]  B. Kreiswirth,et al.  Mutations of the ompK36 Porin Gene and Promoter Impact Responses of Sequence Type 258, KPC-2-Producing Klebsiella pneumoniae Strains to Doripenem and Doripenem-Colistin , 2013, Antimicrobial Agents and Chemotherapy.

[27]  G. Daikos,et al.  Carbapenemases in Klebsiella pneumoniae and Other Enterobacteriaceae: an Evolving Crisis of Global Dimensions , 2012, Clinical Microbiology Reviews.

[28]  R. Bonomo,et al.  Exploring the Role of a Conserved Class A Residue in the Ω-Loop of KPC-2 β-Lactamase , 2012, The Journal of Biological Chemistry.

[29]  R. Bonomo,et al.  Crystal structure of KPC-2: insights into carbapenemase activity in class A beta-lactamases. , 2007, Biochemistry.

[30]  P. Bradford,et al.  Emergence of carbapenem-resistant Klebsiella species possessing the class A carbapenem-hydrolyzing KPC-2 and inhibitor-resistant TEM-30 beta-lactamases in New York City. , 2004, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[31]  J M Ghuysen,et al.  A standard numbering scheme for the class A beta-lactamases. , 1991, The Biochemical journal.