Global challenge of antibiotic-resistant Mycoplasma genitalium. by author. Sabine Pereyre

Transcription

1 Global challenge of antibiotic-resistant Mycoplasma genitalium Sabine Pereyre USC EA 3671 Mycoplasmal and chlamydial infections in humans INRA - University of Bordeaux -Bordeaux University Hospital National French Reference Center for bacterial IST ECCMID, April 24 th 2018

2 Travel grants from Diagenode, Belgium SpeeDx, Australia Hologic, USA Disclosures My laboratory has received remuneration for contract work from biomérieux, France Meridian Bioscience, Europe Diagenode, Belgium SpeeDx, Australia Hologic, USA 2

3 M. genitalium STI agent responsible for Non gonococcal urethritis, proctitis Cervicitis, PID, preterm birth, spontaneous abortion Carriage frequently asymptomatic Prevalence Community-based population 1 3% STI center population (high risk sexual behaviour) 4 38% Diagnostic only NAAT tests No serology no culture antimicrobial susceptibility testing hardly achievable 3

4 M. genitalium and antibiotics Intrinsic resistance to ATB targeting the cell wall (-lactams, fosfomycin, glycopeptides) and rifampicin (mutation in rpob gene) In vitro active antibiotics Macrolides and related antibiotics (MLSK) Fluoroquinolones Tetracyclines 4

5 Relative potency in vitro MIC ranges (µg/ml) BUT, low eradication rate M. genitalium and tetracyclines Antibiotics M. genitalium M. hominis Ureaplasma spp. Tetracyclines** Doxycycline Minocycline MLS group Erythromycin > Microbiological cure of doxycycline : between 30 and 40 % Roxithromycin <0.01 > Not a first-line treatment Clarithromycin > Azithromycin > Pereyre, Antimicrob. Josamycin Chemother. Vaccines, 3rd edition, ; Jensen Antimicrob Agnets Chemother 2014; Jensen J Eur Acad Dermatol Venereol. 5

6 Low MICs M. genitalium and MLSK Antibiotics M. genitalium M. hominis Ureaplasma spp. MLSK group Erythromycin > Roxithromycin <0.01 > Clarithromycin > Azithromycin > Josamycin Clindamycin Pristinamycin Quinupristin/ Dalfopristin Telithromycin Solithromycin Pereyre, Antimicrob. Chemother. Vaccines, 3rd edition,

7 Acquired resistance to macrolides Point mutations in domain V of 23S rrna - Single operon encoding 16S and 23S rrna - A2058G/C/T, A2059G/C/T, A2062G/T (E. coli numbering) high level resistance 23S rrna 2062 Peptidyl transferase loop Domain V

8 All M. genitalium-positive test should be followed up with an assay capable of detecting macrolide resistanceassociated mutations 8

9 Detection of macrolide resistance-associated mutations Amplification and sequencing of 23S rrna Time-consuming, not adapted to routine Published in-house methods FRET real-time PCR (Touati et al. J. Clin. Microbiol. 2014) HRM (High Resolution Melting curve analysis) (Twin et al. PloS One 2012) PCR and pyrosequencing (Salado-Rasmussen et al. Clin. Infect. Dis. 2014) Taqman PCR using forward primers complementary to 23S mutations (Wold et al. J. Eur. Acas. Dermatol. Venereol. 2015), only if Ct<32. Taqman PCR using 3 probes and subsequent endpoint fluorescence analysis (Kristiansen et al. J. Clin. Microbiol. 2016) Single probe PCR and melting curve analysis (Gossé et al. J. Clin. Microbiol. 2016) Commercial kits ResistancePlus TM MG kit (SpeeDx, Australia) : multiplex real-time PCR (Le Roy, J. Clin. Microbiol. 2017) S-DiaMGRes kit (Diagenode, Belgium) : multiplex real-time PCR Others expected Detection of Mg and 5 mutations 9

10 No data <10% 10%-20% 20%-40% 40-60% >60% Prevalence of macrolide resistance in M. genitalium 58% 48% 100%(26/26) 35% 56-61% 18% 41% 57% 4.6-6,7% 29% 43-63% Anagrius, PloS one 2013; Tagg, J. Clin. Microbiol. 2013; Pond, Clin. Inf. Dis. 2014; Salado-Rasmussen, Clin. Inf. Dis, 2014; Kikuchi, J. Antimicrob. Chemother. 2014; Hay, Sex. Transm. Dis. 2015; Gushin, BMC Infect. Dis. 2015; Nijhuis, J. Antimicrob. Chemother. 2015; Gesink, Can. Fam. Physician, 2016; Getman, J. Clin. Microbiol. 2016; Gossé, J. Clin. Microbiol. 2016; Shipitsina, Plos One, 2017; Basu, J. Clin. Microbiol. 2017; Tabrizi, J. Clin. Microbiol. 2017; Barbera, Sex. Transm. Dis. 2017; Dumke, Diagn Microbiol infect Dis, 2016; Coorevits, J. Glob. Antimicrob. Resist. 2017; Anderson, J. Clin. Microbiol. 2017; Unemo, Clin. Microbiol. Infect % 9,8% 10 83% in MSM 72-77%

11 Pooled microbial cure rate (%) Treatment studies : azithromycin (AZM) 1g Meta-analysis on the efficacy of AZM 1g for Mg treatment (Lau et al Clin. Infect. Dis. 2015) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 83.5% 67% Before 2009 Since 2009 Selection of resistant mutants during AZM 1g treatment AZM 1g single dose is no more the 1 st line treatment Therapeutic failure if patient infected with a mutated strain The efficacy of azithromycin 1 g has decreased Björnelius Sex Transm Infect 2008; Manhart Clin Infect Dis 2013; Mena Clin Infect Dis 2009; Schwebke CID 2011, Sena J Infect Dis 2012; Stamm Sex Transm Infect 2007; Lau Clin Infect Dis 2015; Horner Clin Infect Dis 2015; Jensen BMC Infect Dis 2015

12 IMPORTANT MESSAGE : Rapid increasing prevalence of macrolide resistance most likely due to widespread use of azithromycin 1g single dose Uncomplicated M. genitalium infection: - In the absence of macrolide resistance-associated mutations Azithromycin 500 mg (day 1), then 250 mg (days 2-5) 85% effective Associated with lower risk of inducing AZM R (conflicting evidence) Patients failing azithromycin 1g single dose cannot be treated successfully with extended 1.5 g AZM 12 Anagrius PLoS One 2013, Bjornelius Sex Transm Infect 2008, Falk J Antimicrob Chemother 2015, Gundevia STI 2015, Read, Clin Inf Dis 2017; Horner Sex Trans Ingfect 2018; Jernberg Sex Transm Infect 2008, Jensen Clin Infect 2009

13 Uncomplicated M. genitalium infection: - Macrolide-resistant M. genitalium infection - Second line treatment for persistent M. genitalium infection Moxifloxacin 400 mg/d - 7 to 10 days Complicated M. genitalium infection (PID, epididymitis) Moxifloxacin: 400 mg - 14 days 13

14 M. genitalium and fluoroquinolones Only moxifloxacin and sitafloxacin have low MICs Antibiotics M. genitalium M. hominis Ureaplasma spp. Fluoroquinolones Ciprofloxacin Ofloxacin Levofloxacin Moxifloxacin Sitafloxacin (Japan) Deguchi, J Infect Chemother 2014; Pereyre, Antimicrob. Chemother. Vaccines, 3rd edition,

15 Fluoroquinolone resistance in M. genitalium Mutations in the bacterial target genes of fluoroquinolones - Most frequent mutations in parc (Topoisomerase IV) Primarily Ser83 and Asp87 - Rare mutations in gyra (DNA gyrase) Many mutations have not been evaluated by in vitro MIC determination Molecular detection only: amplification and sequencing of target genes

16 Prevalence of fluoroquinolone resistance-associated mutations 16 No data <10% 10%-20% 20%-40% 40-60% >60% 20% 13.6% 4.5% 10.2% 4.1% 10% 6% 8% 6.2% 31-47% 12-19% 23% Bissessor Clin Infect Dis 2015; Deguchi, Clin Infect Dis 2016; Dumke, DMID 2016; Kikuchi J Antimicrob Chemother 2014; Le Roy Emerg Infect Dis 2016; Pond Clin Infect Dis 2014; Shipitsina PLoS one 2017; Couldwell Int J STD and AIDS 2013; Gesink Can family Physian 2016; Tagg J Clin Microbiol 2013; Murray Emerg Infec Dis 2017; Barbera Sex Transm infect 2017; Anderson, J Clin Microbiol 2017, Unemo, Clin Microbiol Infect 2017.

17 Pooled microbial cure rate (%) M. genitalium fluoroquinolone treatment studies Meta-analysis on the efficacy of moxifloxacin for M. genitalium treatment 17 studies, 252 patients % 89 % Before 2010 Since 2010 Yi et al Int J STD AIDS 2017

18 Prevalence Japan : 17-30% Australia : % Denmark : 4.2% Dual class resistance Mainly due to successive treatment failures of macrolides then fluoroquinolones Enormous clinical implications No other highly effective antibiotics available What can we use as third line therapy? Murray Emerg Infect Dis 2017, Kikuchi J Antimicrobiol Chemother 2014; Le Roy Emerg Infect Dis 2016; Degushi Clin Infect Dis 2016; Kikuchi J Antimicrobiol Chemother

19 Third-line treatment for persistent MG infection after AZM and MXF Doxycycline 100 mg x2 daily for 14 days Pristinamycin 1 g x4 daily for 10 days

20 Pristinamycin MICs AZM-resistant strains have higher MIC 90 (0.5 mg/l) than AZM-susceptible strains (MIC 90 =0.125 mg/l) but MICs close to the breakpoint : 1 mg/l (French society for microbiology, not dedicated to mycoplasmas) Maximum dose of 1g 4 times/day for 10 days was retained Evaluation in patients after azithromycin failure ( , Australia) 114 persons : infection cured in 75% Option during pregnancy and in other situations where fluoroquinolones have failed or are contraindicated Not registered in many countries Renaudin et al. Antimicrob Agents Chemother. 1992; Bissessor et al. Clin Infect Dis 2015; Read et al. Emerg Inf Dis

21 Evaluating old antimicrobials Minocycline Therapeutic options MICs around four-fold lower than that of doxycycline Success of extended regimen 100 mg X2 for 14 days on 2 patients Spectinomycin (aminoglycoside-related AB) 1 clinical success after doxycycline, azithromycin and pristinamycin failure : 2g IM daily for 7 days IM administration painful, limited availability, optimal dosage not established, monotherapy is not recommended Degushi J Infect Chemother 2017; Falk J Antimicrobiol Chemother

22 New antimicrobials Sitafloxacin (fluoroquinolone) New therapeutic options Susceptible MICs in some moxifloxacin-resistant strains Registered in Japan only Solithromycin (fluoroketolide) In development for CA-pneumonia but potential hepatotoxicity (no FDA approval) Cross resistance in strains harboring the A2058G mutation Gepotidacin (topoisomerase II inhibitor that inhibits DNA replication. Mechanism and target different from FQ) MIC 90 =0.032 (4-fold<MOX) Ito J Infect Chemother 2012; Hamasuna Antimicrob Agents Chemother 2009; Degushi J Infect Chemother 2015; Jensen Antimicrob Agents Chemother 2014; Waites, STI and VIH world congress, Rio,

23 New antimicrobials New therapeutic options Zoliflodacin (spiropyrimidinetrione) Arrests the cleaved gyrase complex -> inhibit DNA biosynthesis (accumulation of doublestrand cleavages) Mode of action different from fluoroquinolone. No cross resistance Potent on 12/13 AZM-R and Moxi-R strains (MICs 1 mg/l) Promising candidate. Active against both N. gonorrhoeae and C. trachomatis Waites, Antimicrob agents Chemother. 2015; Gouveia, J. Antimicrob. Chemother

24 New antimicrobials New therapeutic options Lefamulin (semi-synthetic pleuromutilin) Inhibition of protein synthesis (binding to the peptidyltransferase center of the 50S ribosomal subunit). Phase 3 trials for treatment of community-acquired pneumonia Active against macrolide- and moxifloxacin-resistant Mg MIC 90 =0.063 mg/l (vs azithromycin >8 mg/l) Promising candidate. Active against C. trachomatis and susceptible and resistant N. gonorrhoeae Clinical trials are urgently needed Bradshaw et al. J Inf Dis 2017; Paukner et al. Antimicrob Agents Chemother

25 Sequential treatment New therapeutic strategy 1. Doxycycline 100 mg twice daily, 7 days Mean fall bacterial load : 2.9 log Test for macrolide resistance If macrolide-susceptible Mg : azithromycin 2.5 g 5 days If macrolide-resistant Mg : sitafloxacin 100 mg twice daily, 7 days Microbiologic cure Macrolide susceptible : 95.7% Macrolide resistant : 92.2 % Read et al, STI and HIV world congress, Rio, July 2017; Horner, Sex Transm Infect Syndromic treatment with doxycycline to reduce Mg load Targeted therapy based on the resistance profile Sex. Transm. Infect. 2018

26 Conclusion Threat of untreatable M. genitalium High prevalence of macrolide resistance worldwide Alarming increasing fluoroquinolone and dual resistance Rare other registered active antibiotics Superbug? New XDR bacteria? Need to detect Mg and macrolide resistance at the same time Need for new antimicrobial compounds and trials Lefamulin? Zoliflodacin? Need for trials of combinations of registered drugs 26

27 Bordeaux, France and its surroundings 27

28 28

29 Risk factors for treatment failure Organism load High organism loads are more likely to develop treatment failure and post-treatment resistance Walker Clin Infect Dis 2013; Guschin BMC Infect Dis 2015; Read Clin Infect Dis 2017 Rectal infection Macrolide resistance is more common in rectal infections Walker Clin Infect Dis % macrolide-r in male rectal infection in an STI clinic in Australia (Tabrizi J Clin Microbiol 2017) 80% macrolide-r in male rectal infection in HIV+ male in the USA (Dionne-Odom, Clin Infect Dis 2017) 29