Mechanisms of resistance to ceftolozane tazobactam Antonio Oliver Servicio de Microbiología, Hospital Son Espases.

Transcription

1 Mechanisms of resistance to ceftolozane tazobactam Antonio Oliver Servicio de Microbiología, Hospital Son Espases. Palma de Mallorca SPAIN ECCMID Madrid, April 22 nd

2 Disclosures: Awarded research grants and received speaker fees from MSD and Pfizer

3 Outline Overview of ceftolozane/tazobactam structure and spectrum Ceftolozane/tazobactam and ESBL-producing Enterobacteriaceae P. aeruginosa mutation-driven and horizontally-acquired resistance Stability of ceftolozane/tazobactam against P. aeruginosa resistance mechanisms and activity against clinical isolates Dynamics and mechanisms of in vitro ceftolozane/tazobactam resistance development esistance development during treatment of MD P. aeruginosa infections Other potential resistance mechanisms beyond β-lactamases Activity and resistance among P. aeruginosa cystic fibrosis isolates Concluding remarks

4 Ceftazidime Ceftolozane/tazobactam Ceftolozane Tazobactam Enhanced antipseudomonal activity and stability against PA resistance mechanisms Protection against (some) class A β-lactamases

5 Ceftolozane/tazobactam and ESBLs Van Duin and Bonomo CID 2016

6 P. aeruginosa multidrug resistance (MD) in Europe

7 P. aeruginosa intrinsic resistance (Inducible AmpC, intrinsic efflux, low permeability) ATM PIP IPM GEN FEP PIP/TZ CAZ TOB CIP ME AMC CTX Ampicillin Ticarcillin Piperacillin Piper/Tazo Amox/clav Cefoxitin Cefotaxime Ceftazidime Cefepime Aztreonam Imipenem Meropenem MIC > > > ,5-2 0,5-2 SXT NAL AMP AMK P. aeruginosa Interpr S S S S S I S S

8 Mutation-driven resistance in P. aeruginosa Antibiotic inactivation AmpC overexpression: Penicillins (piperacillin/tazo), cephalosporins (ceftazidime, cefepime) and monobactams (aztreonam) educed antibiotic concentration at target Efflux pumps overexpression: multiple antibiotics Inactivation or repression of OprD porin: carbapenems Target modificaton Topoisomerases II and IV (QD): fluoroquinolones. LPS Modifications driven by mutation in PmrAB, PhoPQ, ParS two-component regulators: polymixins (colistin)

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10 P. aeruginosa mutational resistance P. aeruginosa ampd - (AmpC overexpression) ATM PIP IPM GEN FEP PIP/TZ CAZ TOB CIP ME AMC CTX SXT NAL AMP AMK Ampicillin Ticarcillin Piperacillin Piper/Tazo Amox/clav Cefoxitin Cefotaxime Ceftazidime Cefepime Aztreonam Imipenem Meropenem MIC > > > >256 >256 >256 >256 8->256 4->256 8-> Frequent phenotype (20-30%) Interpr S S

11 P. aeruginosa mutational resistance (OprD inactivation) ATM PIP IPM GEN FEP PIP/TZ CAZ TOB CIP ME AMC CTX SXT NAL AMP AMK Ampicillin Ticarcillin Piperacillin Piper/Tazo Amox/clav Cefoxitin Cefotaxime Ceftazidime Cefepime Aztreonam Imipenem Meropenem MIC > > > Interpr S S S S S I I P. aeruginosa oprd - Frequent phenotype (20-30%)

12 Transferable resistance in P. aeruginosa Transferable -lactamases in P. aeruginosa Penicillinases: PSE-1 (CAB), narrow spectrum OXAs, etc.. ESBLs: PE, extended spectrum OXAs, VEB, BEL,GES (some with carbapenemase activity) Carbapenemases Class B carbapenemases (MBL) VIM, IMP, SPM, NDM, GIM, SIM, AIM, DIM - Located in transferable elements (integron-transposon-plasmid) together with aminog determinants (MD elements) - Enviromental reservoirs (such as P. putida) EDTA - Linked to wide-spread international MD (high-risk) clones (particularmente ST235)

13 P. aeruginosa transferable resistance Class B carbapenemases/mbl (IMP, VIM, etc..) ATM PIP IPM GEN FEP PIP/TZ CAZ TOB CIP ME AMC CTX P. aeruginosa VIM-2 Ampicilina Ticarcilina Piperacilina Piper/Tazo Amox/clav Cefoxitina Cefotaxina Ceftazidima Cefepime Aztreonam Imipenem Meropenem MIC > > > >256 >256 >256 >256 8->256 4->256 SXT NAL AMP AMK > >256 Interpr I Prevalence globally low, but wide geographical variation

14 P. aeruginosa population structure Fig. 1. Population snapshot of P. aeruginosa Oliver et al 2015 Drug resist. updat. Nonclonal epidemic population structure (A limited number of widespread clones are selected from a background of a large number of rare and unrelated genotypes that are recombining at high frequency)

15 P. aeruginosa nosocomial high-risk clones Fig 3. Worldwide distribution of P. aeruginosa ST235, ST111, and ST175 high-risk clones Oliver et al 2015 Drug resist. updat.

16 Acquired -lactamases in ST235 P. aeruginosa Oliver et al 2015 Drug resist. updat.

17 Genetic markers of resistance in XD/MD epidemic highrisk clones through whole genome sequencing ST175 Mec. Gene Mutation Phenotype AmpC amp G154 CAZ, FEP, PTZ, ATM OprD- oprd Q142X IMP, ME MexXY mexz G195E GEN, TOB, AMK, FEP, CIP QD gyra T83I & D87N CIP parc S87W CIP GlpT- glpt T211P FOS Transferable resistance Integron aadb GEN, TOB Detected in 7/10 Spanish hospitals The same mutational resistance profile Cabot et al AAC 2012 detected among French MD/XD ST175 isolates Cabot et al AAC 2016

18 1a 1b Ceftolozane

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22 Activity of ceftolozane/tazobactam against P. aeruginosa clinical strains Van Duin and Bonomo CID 2016

23 2015 multicentre study on XD P. aeruginosa infections 150 clinically-significant XD P. aeruginosa isolates recovered from 9 Spanish hospitals (6 different regions) studied, as part of a clinical trial (Colimero) ST175 was detected in all partipating hospitals Del Barrio-Tofiño E et al AAC 2017

24 WGS esistome ST235 ST244 ST multicentre study on XD P. aeruginosa infections IntI1 VIM-1 VIM-2 VIM-20 VIM-47 GES-1 GES-5 GES-19 OXA-2 OXA-10 OXA-46 Aac(6')-33 AacA4 AadA1 AadA13 AadA6 AadB AacC1 gyra T83I gyra D87N gyrb E468D parc S87L parc S87W pare V520A amp amp G154 dacb ampd 504C F533L mex nalc nald mexz mexz G195D mexs mext nfxb OprD- W138X Q142X W277X ST ID * ST ST ST CC ST ST ST ST ST NEW ST NEW ST NEW Acquired resistance determinants blavim blages blaoxa AMEs QD AmpC regulators PBP3 Efflux pumps regulators OprD

25 2015 multicentre study on XD P. aeruginosa infections Antibiotic XD isolates (n=150) %S MIC 50 MIC 90 Ceftolozane/tz >64 Ceftazidime >64 Cefepime >64 Aztreonam Piperacillin/tz Imipenem >64 Meropenem >64 Ciprofloxacin 1.3 >16 >16 Tobramicin >32 Amikacin Colistin Del Barrio-Tofiño E et al AAC 2017

26 2015 multicentre study on XD P. aeruginosa infections EUCAST breakpoint TOL/tz 4 mg/l S=68.7% TOL/tz MICs distribution EUCAST breakpoint CAZ, CAZ-AVI, FEP 8 mg/l S=79.3% Del Barrio-Tofiño E et al AAC 2017 Carbapenemase producing isolates

27 P. aeruginosa in vitro resistance development to ceftolozane/tz and comparators 2014 High level ceftolozane resistance occurred only for the hypermutable (muts) strain and involved multiple mutations Particularly relevant, overexpression (dacb and/or amp) and structural modification of AmpC (F147L, Q157, G183D, E247K, or V356I)

28 P. aeruginosa in vitro resistance development to ceftolozane/tz and comparators Mutants resistant to ceftazidime, meropenem or ciprofloxacin remained susceptible to ceftolozane/tz Ceftolozane/tz resistant mutants showed increased susceptibility to piperacillin/tz and imipenem Cabot et al AAC 2014 Emergence of ceftolozane/tz resistance during therapy of MD P. aeruginosa infections: 3/21 (14%) patients treated in Pittsburgh Med Center (Haidar CID 2017). 8/58 (14%) patients treated in H. Son Espases (Fraile-ibot PA JAC 2018) Same mechanism previously detected in vitro (AmpC overexpression + AmpC structural modifications)

29 Patient Isolation MLST MIC (mg/l) β-lactam resistance genotype date TIC PIP/ CAZ FEP TOL/ CAZ/ ATM IMP ME TOB AMK CIP TZ TZ AVI 1 18/07/16 ST179 > OXA /07/16 ST179 > > OXA-14, OprD W417X /11/2016 ST >16 OprD Q142X, Amp G154 14/12/16 ST >32 > >16 OprD Q142X, Amp G154, AmpC E247K 3 16/12/16 ST >16 OprD Q142X, Amp G154 07/01/16 ST >64 32 > >16 OprD Q142X, Amp G154, AmpC T96I 4 03/02/17 ST >16 OprD Q142X, Amp G154 20/02/17 ST > >16 OprD Q142X, Amp G154, AmpC T96I 5 27/03/17 ST >16 OprD Q142X, Amp G /04/17 ST >16 OprD Q142X, Amp G154, AmpC DelG229-E247 28/03/2017 ST >32 64 >16 19/04/2017 ST > > OXA-2, OprD 1bpIns OXA-2, OprD 1 bpins, AmpC F147L 7 20/07/2017 ST179 > OXA-10, OprD W6X 8 Mechanisms leading to in vivo resistance development to ceftolozane/tz 03/09/2017 ST179 > > > > OXA-14, mex 4bpIns, mexz 15bpDel, OprD W6X, ftsi (PBP3) F533L 21/08/2017 ST >16 OprD Q142X, Amp G154 04/09/2017 ST >64 16 > >16 Fraile-ibot PA et al JAC 2018, Díaz-Cañestro et al (unpublished) OprD Q142X, Amp G154, AmpC E247G

30 Mechanisms leading to in vivo resistance development to ceftolozane/tz Figure 1. epresentation of the AmpC β- lactamase (A) and detail of the Active Site surrounding area (B) from Pseudomonas aeruginosa Fraile-ibot PA et al JAC 2018

31 P. aeruginosa ST175 high-risk clone GEN PIP IPM FOS TOB PIP/TZ FEP CTX AMK ME AMC ATM LEV CIP CAZ CXM Ampicilina Ticarcilina Piperacilina Piper/tazo Amox/clav Cefoxitina Cefotaxina Ceftazidima Cefepime Aztreonam Imipenem Meropenem Ceftol/tazo Cefta/avi MIC >64 > >64 >64 > > Interpr I I S S

32 P. aeruginosa ST175 high-risk clone after ceftolozane/tazobactam treatment (ampc mutant) GEN PIP IPM FOS TOB PIP/TZ FEP CTX AMK ME AMC ATM LEV CIP CAZ CXM Ampicilina Ticarcilina Piperacilina Piper/tazo Amox/clav Cefoxitina Cefotaxina Ceftazidima Cefepime Aztreonam Imipenem Meropenem Ceftol/tazo Cefta/avi MIC >64 > >64 >64 >64 > Interpr S S I S S

33 Mechanisms leading to in vivo resistance development to ceftolozane/tz

34 Cephalosporin resistance Development mechanisms of CAZ esistance beyond β-lactamases Stepwise CAZ resistance development Cabot et al ECCMID 2018 MICx PAO1 PAO C PAO G DAY Strain Mutations Median MICs (mg/l)* CAZ CAZ/ AVI PAO1 dacb+ ampd or mpl (AmpC hyperexpression) > PAOΔC/ PAOΔG Large chrom. Deletions +/- PBP3 (Y503/504) +/- mex, nalc or nalb (MexAB hyperexpression) +/- mexb *Parent strains MICs: CAZ 1, CAZ/AVI 1, TOL/Tz 0.5 mg/l TOL/ Tz

35 KB specific Chromosomal deletions: Brown pigment (hmga) Increased β-lactam resistance (galu) Increased colistin susceptibility (galu) Increased aminoglycoside susceptibility (mexxy) Cabot et al ECCMID 2018

36 CMI 2010

37 2017

38 2017 Isolate ID MLST CAZ FEP ATM PIP/TZ TOL/TZ AmpC H AmpC AmpD PBP4 PBP3 MexAB H Mex NalD MexXY H MexZ FQSE * 274 0,38 1 0,094 0,38 0, Nt 290 Δ11 FQSE ,75 2 0,25 4 0,38 - P215L - + S9P FQSE ,75 3 0,125 0,75 0, IS FQSE ,75 6 0, A144V FQSE * G216S - + A194P FQSE A144V FQC , FQSE * , A194P AUS FQC AUS FQC Nt 459 Δ13 - FQSE * A194P FQSE * ,38 2 1, A194P FQSE * ,25 0,75 1, A194P FQSE , , IS FQSE ,38 4 1, A144V FQSE ,5 2 1, A144V FQSE ,75 8 1, A194P AUS ,5 + S315G - + Q164* FQSE Nt 396 Δ2 + IS FQSE , P215L - + S9P AUS601* 1043 >256 >256 > V239A 504C - + Q164* AUS G216S - + Q164* AUS690* , H133P + Nt 529 Δ1 AUS >256 >256 >256 > Q372P - + PAMB > >256 > P41L - - FQSE IS AUS034* 274 >256 >256 >256 > W350 P527T, G63S - 85H + Nt 334 Δ13

39 Concluding remarks Ceftolozane/tazobactam resistance TOL/Tz shows high activity against ESBL-producing E. coli, but considerably lower against ESBL-producing K. pneumoniae TOL/Tz is active against P. aeruginosa strains producing classical mutationdriven resistance mechanisms. Prevalence of TOL/Tz resistance among clinical strains is low, but variable, depending on the prevalence of acquired ESBLs and carbapenemases Emergence of TOL/Tz resistance may occur during the treatment of MD/XD P. aeruginosa infections in 10-15% of the cases, and it is mainly caused by structural mutations in intrinsic (AmpC) or acquired (OXAs) β-lactamases Development of TOL/Tz resistance tipically shows CAZ/AVI cross-resistance, but increased susceptibility to carbapenems and penicillins is frequently seen Other potential low-level TOL/Tz resistance mutations include specific large chromosomal deletions and PBP3 mutations. Active surveillance of TOL/Tz resistance mechanisms is needed

40 Acknowledgements Microbioloy Department and esearch Unit, H. Son Espases G. Cabot X. Mulet E. del Barrio MD. Macià A. Mena C. Juan I. Sánchez L. Zamorano C. López G. Torrens E. ojo J. L. Pérez L. Martínez. H. eina Sofía, Córdoba Carmen Peña. H. Alcoy Fernando Chaves. H. 12 Oct. Madrid. Cantón. H. amón y Cajal, Madrid J. Blázquez, CNB, Madrid JP Horcajada, H. del Mar, Barcelona