University of Rhode Island DigitalCommons@URI Pharmacy Practice Faculty Publications Pharmacy Practice 2016 Ampicillin in Combination with Ceftaroline, Cefepime, or Ceftriaxone Demonstrates Equivalent Activities in a High- Inoculum Enterococcus faecalis Infection Model Megan K. Luther University of Rhode Island Louis B. Rice Kerry L. LaPlante University of Rhode Island, [email protected] Follow this and additional works at: https://digitalcommons.uri.edu/php_facpubs Terms of Use All rights reserved under copyright. Citation/Publisher Attribution Luther MK, Rice LB, LaPlante KL. 2016. Ampicillin in combination with ceftaroline, cefepime, or ceftriaxone demonstrates equivalent activities in a highinoculum Enterococcus faecalis infection model. Antimicrob Agents Chemother 60:3178 –3182. doi: 10.1128/AAC.03126-15. Available at: http://dx.doi.org/10.1128/AAC.03126-15 This Article is brought to you for free and open access by the Pharmacy Practice at DigitalCommons@URI. It has been accepted for inclusion in Pharmacy Practice Faculty Publications by an authorized administrator of DigitalCommons@URI. For more information, please contact [email protected]. crossmark Ampicillin in Combination with Ceftaroline, Cefepime, or Ceftriaxone Demonstrates Equivalent Activities in a High-Inoculum Enterococcus faecalis Infection Model Megan K. Luther,a,b Louis B. Rice,c,d Kerry L. LaPlantea,b,c Department of Pharmacy Practice, University of Rhode Island, Kingston, Rhode Island, USAa; Rhode Island Infectious Diseases (RIID) Research Program, Veterans Affairs Medical Center, Providence, Rhode Island, USAb; Warren Alpert Medical School, Brown University, Providence, Rhode Island, USAc; Rhode Island Hospital, Providence, Rhode Island, USAd Ampicillin-ceftriaxone combination therapy has become a predominant treatment for serious Enterococcus faecalis infections, Downloaded from such as endocarditis. Unfortunately, ceftriaxone use is associated with future vancomycin-resistant enterococcus colonization. We evaluated E. faecalis in an in vitro pharmacodynamic model against simulated human concentration-time profiles of ampi- cillin plus ceftaroline, cefepime, ceftriaxone, or gentamicin. Ampicillin-cefepime and ampicillin-ceftaroline demonstrated activi- ties similar to those of ampicillin-ceftriaxone against E. faecalis. nterococcus faecalis is one of the most common causes of infec- (ϳ108 CFU/ml) over 24 h (15, 16). A 250-ml working-volume Etive endocarditis in hospitalized and/or immunocompro- glass model with inflow and outflow ports controlled by peristaltic mised patients. The combination regimen of ampicillin plus pumps was used to achieve desired antibiotic concentrations and http://aac.asm.org/ ceftriaxone has averted high-level aminoglycoside resistance half-lives. The regimens simulated free serum concentrations of (HLAR) and improved the safety profile in E. faecalis endocarditis human doses, including2gofampicillin every 4 h (maximum ␮ treatment over the traditional regimen of ampicillin plus genta- concentration in serum [Cmax], 150 g/ml; protein binding, 20%; micin (1–4). Accordingly, ampicillin and ceftriaxone were re- ␮ half-life, 1 h), 2 g of ceftriaxone every 12 h (Cmax, 257 g/ml; cently added as an option to treat both HLAR and non-HLAR E. protein binding, 90%; half-life, 6 h), 2 g of cefepime every 12 h faecalis endocarditis, according to national guidelines (5). While ␮ (Cmax, 163.9 g/ml; protein binding, 20%; half-life, 2 h), 600 mg this regimen has increased safety for patients with serious E. faeca- ␮ of ceftaroline every 12 h (Cmax, 21.3 g/ml; protein binding, 20%; lis infections, it may create long-term collateral damage, as ceftri- half-life, 2.66 h), and 6 mg/kg of body weight of gentamicin every axone carries an increased risk of vancomycin-resistant Enterococ- ␮ on February 5, 2019 by guest 24h(Cmax,24 g/ml; protein binding, 0%; half-life, 2 h) (17–22). cus (VRE) gastrointestinal colonization (6, 7). This increase in For combination regimens, the rate was set for the drug with the VRE colonization is likely due to ceftriaxone’s high biliary excre- shorter half-life; the drug with the longer half-life was supple- tion and is associated with increased risk for VRE bacteremia (6– mented. The following regimens were tested: ampicillin alone, 9). Cefepime and ceftaroline are cephalosporins with different ceftriaxone alone, cefepime alone, ampicillin plus ceftriaxone, spectra of activity, distinct structures, and less biliary excretion; ampicillin plus cefepime, ampicillin plus ceftaroline, ampicillin therefore, they should carry less risk of VRE colonization (6, 10). plus gentamicin, and no antibiotic (growth control). We therefore evaluated the activities of these dual ␤-lactam com- All model experiments were performed at least in duplicate to binations that have less potential for VRE colonization in a high- ensure reproducibility. Samples were removed from each model inoculum in vitro pharmacodynamic (IVPD) infection model (6, 10, 11). at 0, 4, 8, and 24 h. Once removed, samples were serially diluted, (A portion of the results were presented as a poster at the 54th plated on TSA, and incubated at 37°C for 24 h before colony count Interscience Conference on Antimicrobial Agents and Chemo- enumeration. The limit of detection for this method is 2.0 log10 therapy [ICAAC], 8 September 2014, Washington, DC.) CFU/ml. Antimicrobial carryover was minimized by serial dilu- We evaluated two previously described strains of E. faecalis: tion (1:10 to 1:10,000) of plated samples in conjunction with vac- one ampicillin-susceptible and gentamicin-susceptible strain uum filtration, if needed, as previously described (23). (OG1X), and a ␤-lactamase-producing although still ampicillin- The MICs of the antimicrobial agents were determined by Etest susceptible and HLAR gentamicin-resistant strain (HH22) (12, methodology (Table 1). All samples were incubated at 37°C in 13). Mueller-Hinton broth (MHB; Becton Dickinson, Sparks, MD, USA), adjusted to 25 mg/liter calcium and 12.5 mg/liter mag- nesium, was used for in vitro pharmacodynamic models (14). Col- Received 30 December 2015 Returned for modification 8 February 2016 ony counts were determined using tryptic soy agar (TSA; Difco, Accepted 20 February 2016 Becton Dickinson). Ampicillin (App Pharmaceuticals, Schaum- Accepted manuscript posted online 29 February 2016 Citation Luther MK, Rice LB, LaPlante KL. 2016. Ampicillin in combination with berg, IL), ceftriaxone (Hospira, Lake Forest, IL), cefepime (Sagent ceftaroline, cefepime, or ceftriaxone demonstrates equivalent activities in a high- Pharmaceuticals, Schaumberg, IL), ceftaroline research powder inoculum Enterococcus faecalis infection model. Antimicrob Agents Chemother (Forest Laboratories, New York, NY), and gentamicin (Sigma- 60:3178–3182. doi:10.1128/AAC.03126-15. Aldrich, St. Louis, MO) were evaluated. Address correspondence to Kerry L. LaPlante, [email protected]. A previously described IVPD model was used to evaluate sev- Copyright © 2016, American Society for Microbiology. All Rights Reserved. eral antibiotic regimens against enterococci at a high inoculum 3178 aac.asm.org Antimicrobial Agents and Chemotherapy May 2016 Volume 60 Number 5 Dual ␤-Lactams against Enterococci TABLE 1 MICs by Etest against two strains of E. faecalis CI], 0.46 to 4.52; P ϭ 0.01, and 3.62; 95% CI, 1.59 to 5.65; P ϭ MIC (mg/liter) (CLSI susceptibility)a 0.001). Ampicillin-ceftriaxone did not significantly increase activ- ity over that of ampicillin alone but was also not significantly OG1X, aminoglycoside HH22, high-level different from the other cephalosporin combinations. Against this Drug susceptible aminoglycoside resistant HLAR isolate, there was regrowth at 24 h with all monotherapy Ampicillin 0.19 (S) 2 (S) regimens and ampicillin-gentamicin. Despite regrowth, no in- Ͼ Ͼ Ceftriaxone 256* 256* creases in MIC were seen with any combination or ampicillin Cefepime 3* 16* monotherapy. There was no regrowth with ampicillin-cefepime Ceftaroline 0.047* 0.5* Gentamicin 12 (S) Ͼ500 (R) or ampicillin-ceftaroline. Enterococcal ␤-lactamase production has a negligible effect on a S, susceptible per CLSI guidelines; R, resistant per CLSI guidelines. *, no CLSI breakpoints for cephalosporins against enterococci. ampicillin MIC at standard testing inocula but raises the MIC when tested at high inocula (27). The significant differences we observed in the activities of ampicillin alone against the two strains in this study are consistent with these prior studies of Downloaded from ambient air for 24 h. Etests were also used to assess changes in MIC HH22. Our results are encouraging in that the reduced efficacy of at 24 h to detect resistance. ampicillin against the ␤-lactamase-producing strain was over- Changes in log10 CFU/ml were plotted to demonstrate reduc- come by the addition of cefepime or ceftaroline. Our study is tion by each regimen over 24 h. Bactericidal activity (99.9% kill) limited by the use of two strains and the 24-h duration. Additional Ն was defined as a 3-log10 CFU/ml reduction and bacteriostatic research will be required before the efficacy of cefepime and cef- Ͻ activity as a 3-log10 CFU/ml change in colony count from the taroline against E. faecalis endocarditis in the clinical setting can be initial inoculum. determined. Changes in bacterial growth (log10 CFU/ml) at 24 h were Overall, ampicillin-cephalosporin combinations demonstrated compared by analysis of variance with Tukey’s post hoc test. A P the greatest activity against both