Diane M. Citron ECCMID 2013 R.M. Alden Research Lab In Vitro Activity of Ceftaroline (CPT) and Ceftaroline-Avibactam (CPA) Against 6133 Bristol Parkway, Ste 175 P1624 Culver City, CA 90230 Tel: 310.641.8340 Aerobic and Anaerobic Recovered From Diabetic Foot (DFI) Fax: 310.641.8840 www.rmaldenresearch.com Diane M. Citron and Ellie J.C. Goldstein R.M. Alden Research Lab, Culver City, California, USA

Abstract Introduction and Purpose Results Conclusion

Objectives: Diabetes mellitus (DM) affects ● The American Diabetes Association estimates Table 1. In Vitro Activity (µg/mL) of Ceftaroline, Ceftaroline-Avibactam, Table 2. In Vitro Activity (µg/mL) of Ceftaroline, Ceftaroline-Avibactam, ● Ceftaroline-avibactam showed substantially ● While ceftaroline alone has excellent in vitro more than 26 million Americans and an and Comparator Antimicrobial Agents Against Anaerobic Isolates and Comparator Antimicrobial Agents Against Aerobic Gram-Positive activity against most of the aerobic component that in the United States there are 25.8 million Recovered From Infected Diabetic Foot Wounds Isolates Recovered From Infected Diabetic Foot Wounds increased activity compared with ceftaroline additional 79 million are prediabetic. DFI are diabetics and that ~25% of diabetic patients Organism (no.) Organism (no.) alone against the β-lactamase-producing of found in moderate to severe Antimicrobial Agenta Range MIC MIC Antimicrobial Agent Range MIC MIC 50 90 50 90 DFIs, with the exception of P. aeruginosa, the most common infectious complication of develop foot ulcerations during their lifetime, Finegoldia magna (20) (51) Prevotella and Porphyromonas species, with over half of those ulcerations becoming Ceftaroline ≤0.015-0.5 0.25 0.5 Ceftaroline 0.06-025 0.125 0.25 the addition of avibactam results in a DM, and moderate to severe wounds are Ceftaroline-avibactam 0.06-0.25 0.125 0.25 and against Bacteroides fragilis and typically polymicrobial with aerobic (MRSA of infected Ceftaroline-avibactam ≤0.015-0.5 0.06 0.125 Ceftriaxone 1-4 2 4 Bacteroides caccae. While minimum inhibitory broader spectrum of activity that includes Ceftriaxone 0.06-8 8 8 0.125-4 0.5 4 the β-lactamase-producing Prevotella, increasing concern) and anaerobic ● Staphylococcus aureus is considered the main Clindamycin ≤0.03-64 0.25 2 Ertapenem 0.06-0.5 0.125 0.5 concentrations (MICs) for other B. fragilis group Levofloxacin 0.06-1 0.125 0.25 Ertapenem ≤0.015-1 0.06 0.25 Porphyromonas, and B. fragilis, making organisms. While CPT has excellent activity causative in early, uncomplicated Piperacillin-tazobactam 0.06-2 1 2 members were reduced, they were mostly in the Levofloxacin 0.25->32 16 >32 ceftaroline a promising agent for monotherapy against most gram-positives including MRSA diabetic foot infections (DFIs). In moderate to Methicillin-resistant S. aureus (29) 4- to 16-µg/mL range (Table 1) Piperacillin-tazobactam ≤0.03-2 0.125 0.25 Ceftaroline 0.25-1 0.5 0.5 against the wide spectrum of DFI isolates. severe infections, polymicrobial infections with 0.06-0.25 0.125 0.25 Ceftaroline-avibactam 0.25-1 0.5 0.5 and most enteric organisms, its activity Ceftriaxone 8->32 32 >32 ● Ceftaroline alone was active (MIC ≤2 µg/mL) b against β-lactamase producing anaerobes aerobic and anaerobic organisms are commonly Anaerobic, gram-positive cocci, other (25) Clindamycin 0.25->64 1 >64 against β-lactamase-producing strains of encountered, including those with methicillin- Ceftaroline ≤0.015-0.5 0.03 0.25 Ertapenem 0.5->32 2 16 and ESBLs is poor. CPA has shown enhanced Ceftaroline-avibactam ≤0.015-0.5 ≤0.015 0.5 Levofloxacin 0.125->32 8 >32 Piperacillin-tazobactam 4->64 16 64 sensitive (MSSA) and -resistant S. aureus Ceftriaxone 0.125-16 0.25 0.5 Staphylococcus species, other (20)a activity against such strains. 1-3 ● None of the comparator antimicrobials were (MRSA) Clindamycin ≤0.03->64 0.5 64 Ceftaroline ≤0.015-1 0.125 0.5 Ertapenem ≤0.015-1 0.06 0.5 Ceftaroline-avibactam ≤0.015-1 0.125 0.25 active against the entire spectrum of organisms Methods: MICs for 154 anaerobic and 316 Ceftriaxone 1->32 4 >32 ● Ceftaroline fosamil, the prodrug of ceftaroline, is Levofloxacin 0.5->32 4 >32 as single agents (Table 1) Clindamycin 0.06->64 0.125 0.5 References aerobic pathogens recovered from patients the first cephalosporin approved by the US Food Piperacillin-tazobactam ≤0.03-1 ≤0.03 0.5 Ertapenem 0.06->32 0.25 2 ● Ceftaroline and ceftaroline-avibactam showed with moderate to severe DFI during 2001 to and Drug Administration (FDA) for the treatment Metronidazole 0.125-2 0.5 2 Levofloxacin 0.06-16 0.25 16 1. Citron, D. M., E. J. Goldstein, C. V. Merriam, B. A. Non-sporeforming, gram-positive rods (10)c Piperacillin-tazobactam 0.06-64 1 8 excellent activity against anaerobic gram- Staphylococcus epidermidis (21) Lipsky, and M. A. Abramson. 2007. Bacteriology 2012, were tested and compared with MICs of acute bacterial skin and skin structure Ceftaroline ≤0.015-0.25 ≤0.015 0.125 Ceftaroline 0.03-0.5 0.25 0.25 positive species, including Finegoldia magna, a of moderate-to-severe diabetic foot infections and in obtained for ceftriaxone (CRO), clindamycin infections (including those caused by MRSA). Ceftaroline-avibactam ≤0.015-0.25 ≤0.015 0.125 Ceftaroline-avibactam 0.03-0.5 0.25 0.25 frequent diabetic foot pathogen (Table 1) vitro activity of antimicrobial agents. J Clin Microbiol. (CLI), ertapenem (ETP), levofloxacin (LEV), In addition, ceftaroline fosamil is also now Ceftriaxone ≤0.015-0.5 0.25 0.5 Ceftriaxone 0.5->32 16 32 Clindamycin ≤0.03->64 0.06 0.5 Clindamycin 0.125->64 0.25 >64 45(9):2819-2828. approved by the European Medicines Agency Ertapenem 0.06->32 2 >32 ● Against aerobic gram-positive strains, and piperacillin-tazobactam (PTZ). MIC Ertapenem 0.06-1 0.125 0.5 2. Levofloxacin 0.125->32 2 >32 ceftaroline demonstrated excellent activity that Castanheira, M., H. S. Sader, D. J. Farrell, R. E. testing of aerobes was done by broth for the treatment of complicated skin and soft- Levofloxacin 0.125-4 1 4 Piperacillin-tazobactam 0.125-32 2 4 Mendes, and R. N. Jones. 2012. Activity of ceftaroline- Piperacillin-tazobactam ≤0.03-4 0.25 1 agalactiae (20) was not enhanced by the addition of avibactam tissue infections Ceftaroline ≤0.015-0.03 ≤0.015 ≤0.015 avibactam tested against Gram-negative organism microdilution and by agar dilution for Metronidazole 0.25->32 32 >32 Ceftaroline-avibactam ≤0.015 ≤0.015 ≤0.015 (Table 2) populations, including strains expressing one or more d anaerobes, according to CLSI M7-A8 and ● Ceftaroline demonstrates excellent in vitro Clostridium species (17) Ceftriaxone 0.03-1 0.06 0.06 β-lactamases and methicillin-resistant Staphylococcus Ceftaroline ≤0.015-2 0.25 2 Clindamycin 0.06->64 0.06 >64 M11-A8 standards. activity against staphylococci and most enteric ● Among the enteric gram-negative rods, aureus carrying various staphylococcal cassette Ceftaroline-avibactam ≤0.015-2 0.06 1 Ertapenem ≤0.015-0.03 ≤0.015 0.03 organisms, however, its activity against Levofloxacin 0.25-1 0.5 1 ceftaroline alone showed excellent activity chromosome mec types. Antimicrob. Agents Chemother. Ceftriaxone 0.015-32 1 32 Piperacillin-tazobactam 0.125-0.25 0.125 0.25 Results: CPT and CPA MIC90 for all β-lactamase-producing anaerobic organisms is Clindamycin ≤0.03-64 0.5 32 Streptococcus anginosus (10) with an MIC90 of 0.5 µg/mL. The addition of 56(9):4779-4785. Staphylococcus species including methicillin- 3,4 Ertapenem ≤0.015-4 0.03 1 Ceftaroline ≤0.015-0.03 ≤0.015 ≤0.015 avibactam to ceftaroline reduced the MICs for poor Ceftaroline-avibactam ≤0.015 ≤0.015 ≤0.015 3. Lipsky, B. A., A. R. Berendt, P. B. Cornia, J. C. Pile, Levofloxacin 0.125-32 0.5 16 resistant isolates was 0.5 µg/mL, and for Ceftriaxone 0.06-0.25 0.125 0.25 most strains by 2- to 8-fold, and yielded an E. J. Peters, D. G. Armstrong, H. G. Deery, ● Avibactam (NXL-104) is a non-β-lactam Piperacillin-tazobactam ≤0.015-8 0.125 8 Clindamycin 0.06->64 0.06 >64 J. M. Embil, W. S. Joseph, A. W. Karchmer, E. faecalis and other enterococci was Metronidazole 0.06-4 0.25 2 Ertapenem 0.03-0.25 0.06 0.125 MIC90 of 0.125 µg/mL (Table 3). β-lactamase inhibitor, which alone shows little M. S. Pinzur, E. Senneville, and Infectious Diseases Bacteroides fragilis (19) Levofloxacin 0.125-0.5 0.5 0.5 1 µg/mL. The MIC90 for all comparator agents or no activity. In conjunction with ceftaroline, Piperacillin-tazobactam ≤0.03-0.125 0.06 0.125 Society of America. 2012. Executive summary: 2012. Ceftaroline 2->32 8 >32 Streptococcus dysgalactiae (10) Infectious Diseases Society of America clinical practice for staphylococci were >32 (CRO), >64 (CLI), AVI confers activity against many resistant Ceftaroline-avibactam 0.125-2 0.5 2 Ceftaroline ≤0.015 ≤0.015 ≤0.015 Table 3. In Vitro Activity (µg/mL) of Ceftaroline, Ceftaroline-Avibactam, and Comparator Antimicrobial Agents Against Aerobic Gram-Negative guideline for the diagnosis and treatment of diabetic foot 8 (ETP), 16 (LEV) and 32 (PTZ) µg/mL. anaerobic and aerobic gram-negative bacteria, Ceftriaxone 4->32 32 >32 Ceftaroline-avibactam ≤0.015 ≤0.015 ≤0.015 Ceftriaxone ≤0.015-0.03 0.03 0.03 Isolates Recovered From Infected Diabetic Foot Wounds Clindamycin 0.125->64 0.5 >64 infections. Clin Infect. Dis. 54(12):1679-1684. Clindamycin 0.06->64 0.125 0.125 CPT/CPA and all other drugs except CLI were including Class A (ESBL and KPC) and Class C Organism (no.) Ertapenem 0.125-4 0.25 2 Ertapenem ≤0.015 ≤0.015 ≤0.015 Antimicrobial Agent Range MIC MIC 4. Citron, D. M., K. L. Tyrrell, C. V. Merriam, and E. J. C. highly active against streptococci. CPT/CPA enzyme producers, but excluding Pseudomonas Levofloxacin 1->32 2 >32 Levofloxacin 0.25-8 0.25 0.5 50 90 2,5 a Goldstein. 2010. In vitro activity of ceftaroline against 623 aeruginosa. The combination of ceftaroline Piperacillin-tazobactam 0.25-2 0.5 2 Piperacillin-tazobactam ≤0.03-0.06 ≤0.03 0.06 Enterobacteriaceae (42) MIC90s for enteric gram-negative rods were group (15) diverse strains of anaerobic bacteria. Antimicrob. Agents Metronidazole 0.25-1 0.5 1 and avibactam is currently undergoing clinical Ceftaroline ≤0.015-0.5 ≤0.015 0.25 Ceftaroline ≤0.03->32 0.06 0.5 Chemother. 54:1627-1632. 0.5/0.125 µg/mL, respectively. CPA reduced Bacteroides fragilis group, other (16)e Ceftaroline-avibactam ≤0.015-0.5 ≤0.015 0.25 Ceftaroline-avibactam ≤0.015-0.5 0.03 0.125 the CPT MICs for 2 strains of resistant trials Ceftaroline 2->32 >32 >32 Ceftriaxone 0.03-4 0.06 2 5. Ehmann, D. E., H. Jahic, P. L. Ross, R. F. Gu, J. Hu, Clindamycin 0.06->64 0.06 32 Ceftaroline-avibactam 0.5-32 8 16 Ceftriaxone ≤0.015->32 0.06 0.5 Enterobacter spp and 1 of Morganella. CPT/ ● This study compared the activity of ceftaroline Ertapenem ≤0.015-2 0.03 1 G. Kern, G. K. Walkup, and S. L. Fisher. 2012. Ceftriaxone 8->32 >32 >32 with and without avibactam against the full Levofloxacin 0.5-16 1 1 Clindamycin 32->64 >64 >64 Avibactam is a covalent, reversible, non-β-lactam CPA showed excellent activity against Clindamycin ≤0.03->64 4 >64 Piperacillin-tazobactam ≤0.03-8 0.06 8 β-lactamase inhibitor. Proc. Natl. Acad. Sci. U. S. A. range of isolates encountered in moderate to Ertapenem 0.125-4 0.5 4 faecalis (20) Ertapenem ≤0.015->32 ≤0.015 0.125 anaerobic gram-positive cocci (GPAC) (MIC90, Ceftaroline 0.25-1 0.5 1 109(29):11663-11668. severe DFIs to that of other antimicrobial agents Levofloxacin 2->32 16 >32 Ceftaroline-avibactam 0.25-1 0.5 1 Levofloxacin ≤0.015-16 0.06 0.5 0.5 µg/mL). Sixty % of GPAC had LEV MIC Piperacillin-tazobactam 1-32 4 16 Ceftriaxone 8->32 32 >32 6. Clinical and Laboratory Standards Institute. 2012. commonly used to treat these infections. Piperacillin-tazobactam ≤0.03->64 1 4 >2 µg/ml. CPT/CPA MIC for was Metronidazole 0.06-1 0.25 1 Clindamycin 8->64 64 >64 Methods for dilution antimicrobial susceptibility tests 90 Ertapenem 4-8 4 8 Porphyromonas species (20)f Pseudomonas aeruginosa (10) for bacteria that grow aerobically; approved standard- 2/1 µg/mL and 32, 32, and 16 µg/mL for CRO, Levofloxacin 0.5-32 0.5 16 Ceftaroline ≤0.015-8 ≤0.015 0.5 Piperacillin-tazobactam 2-4 2 4 Ceftaroline 0.06->32 2 >32 ninth edition. Clinical and Laboratory Standards Institute b CLI and LEV, respectively. CPT/CPA MIC90s Methods Ceftaroline-avibactam ≤0.015-0.03 ≤0.015 ≤0.015 Enterococcus species (10) document M7-A9. CLSI, Wayne, Pa. Ceftaroline-avibactam ≤0.015-32 2 32 for Bacteroides fragilis were >32/2 µg/mL and Ceftriaxone ≤0.015-32 0.03 4 Ceftaroline 0.06-32 0.25 1 Ceftaroline-avibactam 0.06-32 0.25 1 7. Clinical and Laboratory Standards Institute. 2012. ● The following antimicrobial agents were Clindamycin ≤0.03->64 ≤0.03 >64 Ceftriaxone 2->32 16 >32 Ceftriaxone 0.06->32 4 >32 >32, >64, and >32 for CRO, CLI, and LEV, Ertapenem ≤0.015-0.03 ≤0.015 ≤0.015 Methods for antimicrobial susceptibility testing of studied: ceftaroline, ceftaroline-avibactam, Clindamycin 0.25->64 8 >64 Clindamycin 0.25->64 >64 >64 respectively. CPT/CPA MIC for the non- Levofloxacin 0.125-4 0.5 4 Ertapenem 2->32 4 16 anaerobic bacteria; approved standard-eighth edition. 90 Levofloxacin 1-32 1 32 piperacillin-tazobactam, ceftriaxone, ertapenem, Piperacillin-tazobactam ≤0.015 ≤0.015 ≤0.015 Ertapenem ≤0.015->32 2 >32 CLSI document M11-A8. CLSI, Wayne, Pa. fragilis Bacteroides spp was >32/16 µg/mL, Piperacillin-tazobactam 2->64 8 16 levofloxacin, clindamycin, and metronidazole. Metronidazole 0.06-0.5 0.06 0.25 c Other gram-positive cocci (11) Levofloxacin 0.06-16 0.5 16 8. Citron, D. M., K. L. Tyrrell, V. Merriam, and E. J. and >32, >64, >32 for CRO, CLI, and LEV, Prevotella species (27)g Ceftaroline ≤0.015-0.5 0.06 0.25 One hundred fifty-four (154) anaerobic and 316 Piperacillin-tazobactam ≤0.03->64 1 >64 Goldstein. 2011. In vitro activity of ceftazidime-NXL104 respectively. CPT/CPA MIC for Prevotella Ceftaroline ≤0.015->32 8 >32 Ceftaroline-avibactam ≤0.015-1 0.06 0.25 90 aerobic isolates were cultured from patients Ceftriaxone ≤0.015-8 2 4 b Ceftaroline-avibactam ≤0.015-1 0.25 1 Non-fermenting, gram-negative rods (10) against 396 strains of β-lactamase-producing anaerobes. spp were >32/1 µg/mL and >32, >64, 8 µg/mL Clindamycin 0.06->64 0.5 >64 Antimicrob. Agents Chemother. 55(7):3616-3620. residing in the United States with DFI Ceftriaxone 0.06->32 8 >32 Ertapenem ≤0.015-2 0.5 2 Ceftaroline 0.06->32 2 >32 for CRO, CLI and LEV respectively. Clindamycin ≤0.03->64 ≤0.03 >64 Levofloxacin 0.125-4 1 4 ● The susceptibility of aerobic organisms was Piperacillin-tazobactam ≤0.03-4 4 4 Ceftaroline-avibactam ≤0.015-32 2 32 Ertapenem ≤0.015-0.5 0.125 0.5 determined by the broth microdilution method Corynebacterium species (36)d Conclusion: CPT alone has excellent activity Levofloxacin 0.3-32 2 8 Ceftaroline 0.03->32 0.125 2 Ceftriaxone 0.06->32 4 >32 Ceftaroline-avibactam ≤0.015->32 0.06 2 according to procedures in the CLSI M07-A9 Piperacillin-tazobactam ≤0.03-1 ≤0.03 0.06 Clindamycin 0.25->64 >64 >64 against most of the aerobes found in Ceftriaxone 0.25->32 2 32 6 Metronidazole 0.125-4 0.5 2 Acknowledgements document . The susceptibility of anaerobic a 8 Clindamycin 0.25->64 >64 >64 Ertapenem ≤0.015->32 2 >32 moderate to severe DFI. The addition of Avibactam alone has been found to have little or no activity against anaerobes. This study was supported by Cerexa, Inc. (a wholly-owned subsidiary of organisms was determined by the agar dilution bAnaerococcus prevotii (1), A. tetradius (2), A. vaginalis (3), Parvimonas micra (4), Peptoniphilus Ertapenem 0.06->32 0.25 4 avibactam broadened the spectrum that asaccharolyticus (5), P. harei (6), anaerobius (4). Levofloxacin 0.06->32 0.5 32 Levofloxacin 0.06-16 0.5 16 Forest Laboratories, Inc., New York, NY, USA). method according to procedures in the CLSI cActinomyces meyeri (1), A. neuii ssp. anitratus (2), A. odontolyticus (1), A. turicensis (2), Piperacillin-tazobactam ≤0.03->64 4 >64 Cerexa, Inc., had no involvement in the design, collection, analysis, interpretation Propionibacterium acnes (2), Slackia exigua (2). aStaphylococcus lugdunensis (5), S. caprae (2), S. cohnii (2), S. haemolyticus (5), S. warneri (2), Piperacillin-tazobactam ≤0.03->64 1 >64 included the β-lactamase producing 7 5 d of data, or decision to present these results. M11-A8 document using an inoculum of 10 Clostridium aminovalericum (1), C. bolteae (1), C. cadaveris (3), C. hathewayi (2), C. innocuum (1), S. simulans (4). C. malenominatum (1), C. perfringens (6), C. sphenoides (1), C. subterminale (1). bEnterococcus gallinarum (2), E. casseliflavus (1), E. avium (2), E. faecium (5). aCitrobacter freundii (1), C. koseri (2), Enterobacter aerogenes (5), E. cloacae (5), Escherichia coli (7), Scientific Therapeutics Information, Inc., provided editorial coordination and Prevotella, B. fragilis and several enteric e c CFU/spot. Avibactam was tested at a constant Bacteroides caccae (2), B. ovatus (4), B. thetaiotaomicron (5), B. uniformis (3), B. vulgatus (2). Gemella morbillorum (5), Kocuria species (2), Aerococcus viridans (1), Vagococcus fluvialis (2), Klebsiella oxytoca (3), K. pneumoniae (3), Morganella morganii (3), Proteus mirabilis (3), P. vulgaris (3), production services, which were funded by Forest Research Institute, Inc. fPorphyromonas asaccharolytica (12), P. catoniae (1), P. endodontalis (1), P. levii (1), P. somerae (5). Rothia amarae (1). Providencia rettgeri (4), Serratia marcescens (3). strains. g d b concentration of 4 µg/mL. Prevotella bergensis (3), P. bivia (11), P. disiens (2), P. melaninogenica (4), P. nanciensis (1), P. oris (3), Corynebacterium amycolatum (11), C. urealyticum (1), C. striatum (10), C. xerosis (2), C. jeikeium (5), Acinetobacter baumannii (3), Alcaligenes faecalis (2), Chryseobacterium hominis (1), P. timonensis (2), P. veroralis (1). C. simulans (4), C. minutissimum (1), C. pseudotuberculosis (1), C. pseudodiphtheriticum (1). Myroides odoratus (1), Shewanella putrefaciens (1), Stenotrophomonas maltophilia (2).