title: A novel combination approach of human polyclonal IVIG and antibiotics against multidrug-resistant Gram-positive bacteria.
abstract: BACKGROUND
  Gram-positive bacteria, especially methicillin-resistantStaphylococcus aureus(MRSA) and enterococci, have shown a remarkable ability to develop resistance to antimicrobial agents.
  
  
  OBJECTIVE
  We aimed to assess possible enhancement of the antimicrobial activity of vancomycin, amoxicillin, clarithromycin, and azithromycin by human polyclonal intravenous immunoglobulin G (IVIG) against 34 multidrug-resistant (MDR) bacterial isolates, including MRSA,Enterococcus faecium, andEnterococcus faecalis.
  
  
  METHODS
  Double combinations of the antibiotics with the IVIG were assessed by checkerboard assay, where the interaction was evaluated with respect to the minimum inhibitory concentration (MIC) of the antibiotics. The results of the checkerboard assay were verified in vitro using time-kill assay and in vivo using an invasive sepsis murine model.
  
  
  RESULTS
  The checkerboard assay showed that IVIG enhanced the antimicrobial activity of amoxicillin and clarithromycin against isolates from the three groups of bacteria, which were resistant to the same antibiotics when tested in the absence of IVIG. The efficacy of vancomycin against 15% of the tested isolates was enhanced when it was combined with the antibodies. Antagonism was demonstrated in 47% of theE. faecalisisolates when clarithromycin was combined with the IVIG. Synergism was proved in the time-kill assay when amoxicillin was combined with the antibodies; meanwhile, antagonism was not demonstrated in all tested combinations, even in combinations that showed such response in checkerboard assay.
  
  
  CONCLUSIONS
  The suggested approach is promising and could be helpful to enhance the antimicrobial activity of not only effective antibiotics but also antibiotics that have been proven to be ineffective against MDR bacteria. To our knowledge, this combinatorial approach against MDR bacteria, such as MRSA and enterococci, has not been investigated before.
authors.affiliation: Department of Microbiology, Immunology, and Biotechnology, Faculty of Pharmacy and Biotechnology, German University in Cairo, New Cairo City, Cairo, Egypt.
authors.forename: Mariam Madkour
authors.initials: MM
authors.lastname: Sallam
authors.affiliation: Department of Microbiology, Immunology, and Biotechnology, Faculty of Pharmacy and Biotechnology, German University in Cairo, New Cairo City, Cairo, Egypt.
authors.forename: Khaled
authors.initials: K
authors.lastname: Abou-Aisha
authors.affiliation: Department of Microbiology, Immunology, and Biotechnology, Faculty of Pharmacy and Biotechnology, German University in Cairo, New Cairo City, Cairo, Egypt.
authors.forename: Mohamed
authors.initials: M
authors.lastname: El-Azizi
keywords: Enterococcus faecalis; Enterococcus faecium; MRSA; amoxicillin; human polyclonal IVIG; multidrug resistance; nonconventional antimicrobials; vancomycin