title: Unexpected challenges in treating multidrug-resistant Gram-negative bacteria: resistance to ceftazidime-avibactam in archived isolates of Pseudomonas aeruginosa.
abstract: Pseudomonas aeruginosa is a notoriously difficult-to-treat pathogen that is a common cause of severe nosocomial infections. Investigating a collection of β-lactam-resistant P. aeruginosa clinical isolates from a decade ago, we uncovered resistance to ceftazidime-avibactam, a novel β-lactam/β-lactamase inhibitor combination. The isolates were systematically analyzed through a variety of genetic, biochemical, genomic, and microbiological methods to understand how resistance manifests to a unique drug combination that is not yet clinically released. We discovered that avibactam was able to inactivate different AmpC β-lactamase enzymes and that blaPDC regulatory elements and penicillin-binding protein differences did not contribute in a major way to resistance. By using carefully selected combinations of antimicrobial agents, we deduced that the greatest barrier to ceftazidime-avibactam is membrane permeability and drug efflux. To overcome the constellation of resistance determinants, we show that a combination of antimicrobial agents (ceftazidime/avibactam/fosfomycin) targeting multiple cell wall synthetic pathways can restore susceptibility. In P. aeruginosa, efflux, as a general mechanism of resistance, may pose the greatest challenge to future antibiotic development. Our unexpected findings create concern that even the development of antimicrobial agents targeted for the treatment of multidrug-resistant bacteria may encounter clinically important resistance. Antibiotic therapy in the future must consider these factors.
authors.affiliation: Department of Molecular Biology and Microbiology, Case Western Reserve University, Cleveland, Ohio, USA Research Service, Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio, USA.
authors.forename: Marisa L
authors.initials: ML
authors.lastname: Winkler
authors.affiliation: Research Service, Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio, USA Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA.
authors.forename: Krisztina M
authors.initials: KM
authors.lastname: Papp-Wallace
authors.affiliation: Research Service, Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio, USA Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA.
authors.forename: Andrea M
authors.initials: AM
authors.lastname: Hujer
authors.affiliation: Research Service, Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio, USA.
authors.forename: T Nicholas
authors.initials: TN
authors.lastname: Domitrovic
authors.affiliation: Research Service, Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio, USA Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA.
authors.forename: Kristine M
authors.initials: KM
authors.lastname: Hujer
authors.affiliation: Research Service, Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio, USA.
authors.forename: Kelly N
authors.initials: KN
authors.lastname: Hurless
authors.affiliation: Department of Clinical Pathology, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
authors.forename: Marion
authors.initials: M
authors.lastname: Tuohy
authors.affiliation: Department of Clinical Pathology, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
authors.forename: Geraldine
authors.initials: G
authors.lastname: Hall
authors.affiliation: Department of Molecular Biology and Microbiology, Case Western Reserve University, Cleveland, Ohio, USA Research Service, Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio, USA Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA Department of Pharmacology, Case Western Reserve University, Cleveland, Ohio, USA robert.bonomo@va.gov.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Bonomo
mesh_terms: D000900:Anti-Bacterial Agents / Q000494:pharmacology*; D053961:Azabicyclo Compounds / Q000494:pharmacology*; D002442:Ceftazidime / Q000494:pharmacology*; D005578:Fosfomycin / Q000494:pharmacology; D006090:Gram-Negative Bacteria; D006801:Humans; D008826:Microbial Sensitivity Tests; D011550:Pseudomonas aeruginosa / Q000187:drug effects*
chemical_list: D000900:Anti-Bacterial Agents; D053961:Azabicyclo Compounds; D005578:Fosfomycin; C543519:avibactam; D002442:Ceftazidime