IHMA, Inc. Longitudinal Global Analysis for ; A Report from the TEST Program 2004-2012 2122 Palmer Dr. Schaumburg, IL 60173 1 1 1 1 2 3 1294 S. Bouchillon , D. Biedenbach , M. Hackel , B. Johnson , S. Hawser , H. Leister-Tebbe Tel: +1.847.303.5003 1 International Health Management Associates, Schaumburg, IL, USA Fax: +1.847.303.5601 2 IHMA Europe, Sárl, Epalinges, Switzerland www.ihmainc.com 3Pfizer Inc., Collegeville, PA USA

Revised Abstract Materials & Methods Results Background:The Tigecycline Evaluation Surveillance Trial • Isolates were derived from blood, respiratory tract, wounds, Figure 1. Distribution of 110,615 global Enterobacteriaceae Table 2. Global antimicrobial % susceptible by year Table 5. Global E. aerogenes antimicrobial % susceptible by year (TEST) is a global longitudinal surveillance study that has and various other infection sources. Only one isolate per been monitoring the activity of a number of antimicrobial patient was accepted into the study. 110,615 Year 2004 2005 2006 2007 2008 2009 2010 2011 2012 P- Year 2004 2005 2006 2007 2008 2009 2010 2011 2012 P- Enterobacteriaceae were collected from 2,330 cumulative test Drug (n) (2086) (2273) (3065) (4077) (3872) (1927) (3670) (2954) (2726) value* Drug (n) (636) (610) (831) (1070) (905) (456) (916) (684) (696) value* agents against both gram-negative and gram-positive 6311 2374 Amikacin 97 97 94 94 92 92 95 94 94 <0.0001 organisms since 2004. This study reports the long term sites in 66 countries globally from 2004-2012. Isolates were 6804 6% 2% Amox-Clav 81 78 71 72 62 61 64 60 70 <0.0001 Amikacin 99 98 99 98 95 97 97 99 98 0.312 identified to the species level and tested at each site by the 6% Cefepime 93 90 85 84 78 77 80 73 78 <0.0001 Amox-Clav 4 4 4 3 3 4 4 5 4 0.338 analysis of these data for Enterobacteriaceae from 2004 participating laboratory. 11985 33940 Ceftriaxone 82 80 73 74 65 64 67 62 70 <0.0001 through 2012. Methods: A total of 110,615 Levofloxacin 88 86 80 81 74 72 75 70 76 <0.0001 Cefepime 95 95 97 95 91 95 96 96 95 0.840 • Organism collection, transport, confirmation of organism 11% 31% Klebsiella pneumoniae Enterobacteriaceae isolates from 2,330 cumulative sites and cloacae Meropenem -- -- 93 95 95 90 97 92 92 0.005 Ceftriaxone 72 69 75 72 56 63 59 66 66 < 0.0001 identification, , and development and management of a Minocycline 82 81 79 78 64 62 60 58 77 <0.0001 66 countries in Europe, North America, Asia, Latin America, Levofloxacin 90 87 90 88 83 89 85 88 91 0.416 centralized database were coordinated by Laboratories 22551 26650 Pip-Tazo 90 87 82 83 73 72 77 71 81 <0.0001 Enterobacter aerogenes Meropenem -- -- 99 98 95 96 97 98 98 0.757 Africa, Middle East, and South Pacific was evaluated. MIC International for Microbiology Studies (LIMS), a division of 20% 24% Tigecycline 94 96 95 96 96 95 96 96 94 0.898 Minocycline 89 88 88 86 74 75 71 76 90 < 0.0001 values were determined using common broth microdilution International Health Management Associates, Inc. located in * Cochran-Armitage Trend Test All Others* panels and interpretive criteria according to CLSI or FDA Schaumburg, IL, USA. Pip-Tazo 87 82 85 83 68 76 73 75 80 < 0.0001 Table 3. Global Enterobacter cloacae antimicrobial % susceptible by year guidelines. The Cochran-Armitage Trend Test was used to • MICs were determined by the Clinical and Laboratory Tigecycline 96 96 96 97 96 95 95 97 97 0.786 evaluate significance over time.* Results: % Susceptible is Standards Institute (CLSI) recommended broth microdilution Year 2004 2005 2006 2007 2008 2009 2010 2011 2012 P- * Cochran-Armitage Trend Test provided by year for each antimicrobial: testing method using supplied MicroScan (Siemens Medical Drug (n) (1705) (1814) (2553) (3460) (3285) (1551) (3323) (2532) (2328) value* Global Enterobacteriaceae * (558); Enterobacter agglomerans (367); Enterobacter asburiae (276); (244); Serratia liquefaciens (218); Solutions Diagnostics, West Sacramento, CA) or TREK Enterobacter sakazakii (128); Enterobacter, non-speciated (124); Enterobacter amnigenus (87); Serratia odorifera (76); Enterobacter gergoviae (49); Amikacin 99 98 97 97 96 95 97 97 98 0.003 % Susceptible by Year and Cumulative Years Klebsiella ozaenae (48); Serratia, non-speciated (46); Klebsiella, non-speciated (37); Serratia rubidaea (30); Klebsiella planticola (24); Klebsiella Amox-Clav 3 2 3 4 4 3 3 4 4 0.008 (TREK Diagnostic Systems, Cleveland, OH) panels [3]. All ornithinolytica (17); Enterobacter intermedium (13); Serratia plymuthica (9); Serratia fonticola (9); Enterobacter taylorae (7); Enterobacter 2004- P- liquifaciens (2); Serratia ficaria (2); (2); and Klebsiella rhinoscleromatis (1) Cefepime 95 93 90 93 89 90 90 91 90 < 0.0001 Year 2004 2005 2006 2007 2008 2009 2010 2011 2012 2012 value* antimicrobics were supplied by the panel manufacturers. Ceftriaxone 66 62 62 63 56 56 56 59 64 < 0.0001 Table 6. Global Klebsiella oxytoca antimicrobial % susceptible by year n's 8575 9276 12951 16789 15615 7617 15461 12112 12219 110615 • MIC interpretive criteria followed published CLSI and FDA Levofloxacin 92 87 87 87 84 85 85 85 89 0.001 Amikacin 99 98 97 97 95 95 97 97 97 97 <0.0001 Table 1. Global Escherichia coli antimicrobial % susceptible by year Meropenem -- -- 97 98 95 95 98 99 98 0.001 Year 2004 2005 2006 2007 2008 2009 2010 2011 2012 P- AmoxClav 48 48 45 45 40 40 41 41 45 43 <0.0001 guidelines where applicable [4, 5]. Minocycline 84 82 79 77 65 59 55 52 81 < 0.0001 Cefepime 95 93 91 90 86 87 87 86 88 89 <0.0001 Drug (n) (503) (491) (719) (969) (819) (432) (891) (684) (803) value* • Quality controls (QC) were performed on each day of testing Pip-Tazo 80 76 74 78 71 72 72 74 79 0.025 Ceftriaxone 81 79 75 75 68 68 68 69 73 72 <0.0001 Year 2004 2005 2006 2007 2008 2009 2010 2011 2012 P- Amikacin 99 99 99 98 98 99 99 99 99 0.777 using appropriate ATCC control strains, following CLSI and Tigecycline 94 94 94 96 96 94 95 95 95 < 0.0001 Levofloxacin 87 84 81 81 75 76 77 75 80 79 <0.0001 Drug (n) (2549) (2892) (4099) (5122) (4810) (2349) (4817) (3830) (3472) value* Amox-Clav 84 82 82 80 75 75 78 77 81 0.009 manufacturer guidelines. Results were included in the * Cochran-Armitage Trend Test Meropenem na na 97 97 97 95 98 97 97 97 0.0008 Amikacin 99 99 98 98 97 98 98 98 99 0.019 Cefepime 98 98 95 96 96 93 95 97 96 0.108 Minocycline 85 85 82 79 67 64 63 63 83 74 <0.0001 analysis only when corresponding QC results were within the Amox-Clav 74 74 68 67 61 61 63 64 70 <0.0001 Table 4. Global Serratia marcescens antimicrobial % susceptible by year Ceftriaxone 83 84 84 82 78 77 80 80 83 0.116 PipTazo 90 88 86 86 80 80 81 81 86 84 <0.0001 acceptable ranges [4]. Tigecycline 96 97 97 98 97 96 97 97 97 97 0.073 Cefepime 97 95 91 90 86 87 86 86 87 <0.0001 Levofloxacin 94 94 93 93 90 89 90 91 94 0.016 Year 2004 2005 2006 2007 2008 2009 2010 2011 2012 P- Ceftriaxone 90 89 83 83 75 76 73 75 77 <0.0001 Drug (n) (989) (1071) (1401) (1847) (1704) (810) (1702) (1269) (1192) value* Meropenem -- -- 100 98 99 99 98 99 99 0.975 Amikacin 99 96 96 96 95 94 97 96 98 0.434 Minocycline 93 93 91 88 84 79 82 84 93 < 0.0001 Conclusion: Tigecycline demonstrated no significant References Levofloxacin 77 75 70 68 61 63 62 63 66 <0.0001 Meropenem -- -- 99 99 99 99 99 100 100 <0.0001 Amox-Clav 2 2 3 4 4 4 3 5 3 0.001 Pip-Tazo 88 87 89 86 81 82 85 83 85 0.002 decrease in % susceptible (p=0.073) against all 1. Gyssens IC, 2008. All EU hands to the EU pumps: the Cefepime 97 95 96 96 93 94 94 94 97 0.05 Tigecycline 99 98 97 99 98 99 99 99 99 0.006 Minocycline 84 84 80 79 71 70 70 71 84 <0.0001 Ceftriaxone 83 79 78 81 78 76 78 79 83 0.789 Enterobacteriaceae since its initial pre-marketing values in Science Academies of Europe (EASAC) recommend strong * Cochran-Armitage Trend Test Pip-Tazo 96 95 93 93 88 87 88 89 93 <0.0001 Levofloxacin 96 94 92 93 92 89 92 91 95 0.104 2004. All other study drugs demonstrated significant support of research to tackle antibacterial resistance. Clin Tigecycline 99.96 100 99.95 99.96 99.9 100 99.92 99.87 99.88 0.027 Meropenem -- -- 97 97 97 96 98 98 97 0.115 decreases over the period of this study (p-values 0.0008 to Microbiol Infect; 14:889–891. Minocycline 89 91 88 80 60 48 52 54 83 < 0.0001 * Cochran-Armitage Trend Test <0.0001) although amikacin, meropenem, and tigecycline 2. Boucher HW, Talbot GH, Bradley JS et al. 2009. Bad bugs, Pip-Tazo 96 94 91 93 90 90 92 92 94 0.071 no drugs: no ESCAPE! An update from the Infectious Tigecycline 96 97 97 98 95 93 94 95 97 0.002 had equivalent in vitro activity in the last study year inhibiting * Cochran-Armitage Trend Test ≥97% of all Enterobacteriaceae at their respective Diseases Society of America. Clin Infect Dis; 48:1–12. breakpoints. 3. CLSI, 2012. Methods for Dilution Antimicrobial Susceptibility Tests for That Grow Aerobically; Approved Conclusions Standard—Ninth Edition, in Document M07-A9. Clinical and Introduction Laboratory Standards Institute (CLSI), Wayne, PA 19087- • This study evaluated >110,000 Enterobacteriaceae over a nine year period in 75 different countries for trends in antimicrobial activity. Only tigecycline demonstrated no Over the last decade special emphasis on combating the 1898 USA. significant reduction in in vitro activity (p=0.073) among nine comparators (p-values ranged between 0.008 to <0.0001) during the course of the study. problem of drug resistant gram-negative and gram-positive 4. CLSI, 2013. Performance Standards for Antimicrobial • The majority (55%) of the Enterobacteriaceae collected during this study consisted of two species, E. coli and K. pneumoniae. Amikacin, meropenem, and tigecycline were bacteria [1] and has noted the persistent increase in rates of Susceptibility Testing; Twenty-Third Informational resistance. Particular attention is paid to resistance rates of Supplement. CLSI Document M100-S23. Clinical and the most active agents against these two species, and although each of the three antimicrobial agents registered statistically significant changes against E. coli, none had gram-negative bacteria because of the link between resistance, Laboratory Standards Institute (CLSI), Wayne, PA 19087- susceptibility rates below 98%. A significant reduction in amikacin and meropenem activity was seen against K. pneumoniae with at least a 3% drop in susceptibility treatment failures, higher mortalities, and higher costs of 1898 USA. (p<0.0001 and 0.005, respectively) with no significant decrease in activity noted for tigecycline (p=0.898). prolonged hospital stays [2]. 5. Tygacil®, March 2009. FDA Product Information, Wyeth Pharmaceuticals Inc., Philadelphia, PA 19101, USA. • Variable results were seen against E. cloacae, S. marcescens, K. oxytoca, and E. aerogenes with amikacin, meropenem, and tigecycline retaining the highest activity against The Tigecycline Evaluation Surveillance Trial (TEST) is a global these four species. Cefepime, levofloxacin, and piperacillin-tazobactam also demonstrated in vitro activity >90% susceptible against S. marcescens. Cefepime and longitudinal surveillance study that has been monitoring the levofloxacin also retained significant activity against K. oxytoca and E. aerogenes. activity of a number of antimicrobial agents against both gram- Acknowledgements • Tigecycline’s retention of activity against a global community of Gram-negative Enterobacteriaceae over almost a decade of monitoring, suggests that tigecycline is a negative and Gram-positive organisms since 2004. This study We gratefully acknowledge the contributions of the investigators, laboratory reports the long term analysis of these data for personnel, and all members of the Tigecycline Evaluation Study Trials program reliable and potentially effective therapy option for these pathogens, especially those in which significant resistance continues to unfold. Enterobacteriaceae from 2004 through 2012. group. This study was sponsored by a grant from Pfizer, Inc.