Gram negative cephalosporium and carbapenem resistance robert bonomo md

62
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 41 st Annual Symposium “Global Movement of Infectious Pathogens and Improved Laboratory Detection” Eastern PA Branch-American Society for Microbiology November 17, 2011 Thomas Jefferson University, Philadelphia

TAGS:

description

Eastern PA Branch-ASM, 41st Annual Symposium, Nov 17, 2011

Transcript of Gram negative cephalosporium and carbapenem resistance robert bonomo md

Page 1: 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

Page 2: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 3: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 4: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 5: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 6: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 7: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 8: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 9: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 10: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 11: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 12: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 13: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 14: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 15: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 16: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 17: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 18: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 19: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 20: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 21: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 22: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 23: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 24: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 25: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 26: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 27: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 28: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 29: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 30: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 31: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 32: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 33: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 34: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 35: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 36: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 37: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 38: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 39: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 40: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 41: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 42: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 43: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 44: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 45: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 46: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 47: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 48: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 49: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 50: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 51: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 52: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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

Page 53: Gram negative cephalosporium and carbapenem resistance robert bonomo md

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


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