Use of a Heavy Inoculum in the In Vitro Evaluation of the Anti-Staphylococcal Activity of 19 Cephalosporins

The in vitro activity of 19 cephalosporins against 105 clinical isolates of Staphylococcus aureus and S. epidermidis was determined by using a heavy inoculum, i.e., 10(8) to 10(9) organisms per ml, to maximally challenge the antibiotics. The anti-staphylococcal activities of cephaloridine and 87/312 were consistently decreased by the use of a heavy inoculum when compared with the activity obtained with two less-concentrated inocula. The activity of most of the other compounds was also decreased with the use of a heavy inoculum, but this was observed only with selected isolates. Cephapirin, cephalothin, and cefazaflur were the most active drugs against the methicillin-susceptible isolates. Cephaloridine, cefamandole, cefazaflur, and 87/312 had substantial activity against methicillin-resistant staphylococci even with heavy inocula. With the exception of cefaclor against S. aureus, the orally absorbed cephalosporins were generally one-half to one-sixteenth as active as the parenterally administered cephalosporins. The median minimal inhibitory concentrations of five of the 12 parenteral cephalosporins were lower with the methicillin-susceptible S. aureus than with the methicillin-susceptible S. epidermidis strains.     

Effect of Assay Medium on the Antibacterial Activity of Certain Penicillins and Cephalosporins

It is well known that the composition of the assay medium greatly affects the antimicrobial activity of aminoglycoside antibiotics. A similar response has now been observed with certain penicillins and cephalosporins. In the case of these compounds, this effect is apparently governed by the chemical nature of the penicillin 6- and cephalosporin 7-side chains. In comparison with their activity in Nutrient Broth, the activity of some of the beta-lactam antibiotics that have a weakly basic or basic group in their side chain was reduced as much as 40-fold in one or more of the following media: Mueller-Hinton, Trypticase soy, antibiotic assay, and heart infusion broths. In contrast, the assay medium had no effect on the activity of those compounds possessing an acidic or a nonionizable function in their side chain. The extent to which medium influences the antibacterial activity was also dependent upon the assay method and the organism, the effect being more pronounced in broth dilution than in agar dilution tests and occurring more frequently with gram-negative than with gram-positive organisms.     

Inhibition of Peptidoglycan Cross-Linking in Growing Cells of Escherichia coli by Penicillins and Cephalosporins, and Its Prevention by R Factor-Mediated Beta-Lactamase

The degree of peptidoglycan cross-linking has been studied in growing cells of a Dap⁻ Lys⁻ auxotroph of Escherichia coli K-12 by following the incorporation of [³H]diaminopimelic acid into the lysozyme digestion products of crude, isolated peptidoglycan. The percentage of inhibition of cross-linking increases with increasing concentrations of penicillin G, cephaloridine, and cefuroxime. When the R factor R1drd 19 was introduced into the strain by conjugation, it was found that the type IIIa, β-lactamase specified by the plasmid was able to protect the cross-linking target against inhibition by penicillin G but not against cephaloridine, even though the β-lactamase hydrolyzes this substrate 50% faster than penicillin G. Cefuroxime, which is completely resistant to hydrolysis by the type IIIa β-lactamase, inhibited the peptidoglycan cross-linking target in both the R⁺ and R⁻ variants of the assay strain. A mutant plasmid, R1drd19amp2, which specified no type IIIa β-lactamase synthesis, could not provide protection of the cross-linking target against penicillin G. The significance of these results, in relation to the ability of the antibiotics to pass the permeability barrier of the bacterial envelope, is discussed.     

In Vitro Activity and Beta-Lactamase Stability of BL-S786 Compared with Those of Other Cephalosporins

In vitro activity of BL-S786, a new parenterally semisynthetic cephalosporin, was investigated against 570 bacterial isolates. BL-S786 inhibited most Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, and Salmonella. It inhibited some Enterobacter and indole-positive Proteus, but it was less active against these later species than was cefamandole, cefuroxime, or cefoxitin. It was not active against Serratia marcescens, Pseudomonas aeruginosa, or Bacteroides fragilis. BL-S786 was the least active new cephalosporin tested against staphylococci and was less active than cephalothin against streptococcal species. The activity of BL-S786 was not altered by the type of assay medium nor by 50% serum. The size of the test inoculum altered the minimal inhibitory and bactericidal concentrations for inhibition of some organisms, particularly those with Richmond type I β-lactamases. BL-S786 was not hydrolyzed by the R-factor-mediated, Richmond type III β-lactamase, but it was hydrolyzed by type I β-lactamases.     

Susceptibility of Respiratory Tract Anaerobes to Orally Administered Penicillins and Cephalosporins

Anaerobic bacteria recovered from airway-related infections were tested by agar dilution against selected penicillins and cephalosporins available for oral administration. Against 136 isolates, penicillins G and V showed comparable activity, particularly when pharmacological differences were considered. Although many isolates were exquisitely susceptible to the penicillins, only 55% of the Bacteroides species and 72% of all isolates were inhibited at 0.5 μg of penicillin G per ml. Results for penicillin V at 1 μg/ml were similar (59 and 73%). The two cephalosporins were more active at achievable levels, inhibiting 94 to 95% of Bacteroides and 95 to 96% of all isolates at 8 μg/ml. These levels represent approximately 50% of the reported peak serum levels after oral administration of 625 mg of the penicillins and 500 mg of the cephalosporins. Dicloxacillin and nafcillin were tested against 50 isolates. The two were comparably active on a weight basis; dicloxacillin was more active when pharmacological differences were considered, but did not match the other penicillins or the cephalosporins.     

Peptidoglycan Transpeptidase Inhibition in Pseudomonas aeruginosa and Escherichia coli by Penicillins and Cephalosporins

Peptidoglycan transpeptidase activity has been studied in cells of Escherichia coli 146 and Pseudomonas aeruginosa 56 made permeable to exogenous, nucleotide-sugar peptidoglycan precursors by ether treatment. Transpeptidase activity was inhibited, in both organisms, by a range of penicillins and cephalosporins, the Pseudomonas enzyme being more sensitive to inhibition in each case. Conversely, growth of E. coli 146 was more susceptible to these antibiotics than growth of P. aeruginosa 56. Furthermore, similar transpeptidase inhibition values were ob-obtained for the four penicillins examined against the Pseudomonas enzyme, although only two of these (carbenicillin and pirbenicillin) inhibited the growth of this organism. We therefore conclude that the high resistance of P. aeruginosa 56 to growth inhibition by most beta-lactam antibiotics cannot be due to an insensitive peptidoglycan transpeptidase.     

Indirect Method for Assessing the Penetration of Beta-Lactamase-Nonsusceptible Penicillins and Cephalosporins in Escherichia coli Strains

Escherichia coli UB1005 and two mutants of this strain (DC2 and DC3) have been used to assess indirectly the relative ability of various β-lactam antibiotics to penetrate the outer layers of E. coli. Benzylpenicillin, ampicillin, methicillin, cloxacillin, cephaloridine, cephalothin, and cephalexin have been examined. The results confirm those obtained with other methods and show that, among the compounds studied here, cephalosporins seem to penetrate more readily than penicillins.     

Effect of Protein Binding on the Activity of Penicillins in Combination with Gentamicin Against Enterococci

To assess the effect of protein binding by human serum on the synergistic interaction of penicillins with gentamicin, time-kill curves were determined for four penicillins alone and in combination with gentamicin against 10 blood isolates of enterococci. Killing curves demonstrated synergism with penicillin G plus gentamicin against all 10 strains in either broth or 50% human serum. In broth the combinations of nafcillin plus gentamicin and oxacillin plus gentamicin were synergistic against 10 of 10 strains and 4 of 10 strains, respectively. However, in serum, nafcillin plus gentamicin was synergistically bactericidal against only two strains and oxacillin plus gentamicin against none. Methicillin plus gentamicin was synergistic against none of the enterococci in either medium. Thus, the semisynthetic, penicillinase-resistant penicillins are unlikely to be effective in the therapy of patients with enterococcal endocarditis.     

In Vitro Activity of Penicillins Against Anaerobes

The in vitro susceptibility of 162 anaerobic isolates from clinical material were tested to pencillin G, BL-P1654, and carbenicillin. Penicillin G and BL-P1654 showed good activity against Bacteroides fragilis, but only 60% of strains were susceptible to carbenicillin at achievable blood levels (128 μg/ml).     

Cefaclor: In Vitro Spectrum of Activity and Beta-Lactamase Stability

The in vitro activity of cefaclor against 556 clinical isolates of gram-positive and gram-negative bacteria was compared with that of other cephalosporins. Cefaclor had activity similar to that of cephalexin against gram-positive bacteria. It showed greater activity against Haemophilus strains than did cephalexin and inhibited β-lactamase-producing Haemophilus isolates. Cefaclor was more active than cephalexin or cephalothin against Escherichia coli, Salmonella, and Shigella isolates but did not act against Serratia, Acinetobacter, indole-positive Proteus, or Bacteroides isolates. Cefaclor was resistant to type III (TEM) β-lactamases but was destroyed by type I β-lactamases and, to a lesser degree, by type IV and type V β-lactamases.     

Beta-Lactamase Activity in Strains of Bacteroides melaninogenicus and Bacteroides oralis

beta-Lactamase from strains of Bacteroides melaninogenicus and Bacteroides oralis hydrolyzed penicillin more rapidly than ampicillin or carbenicillin. Cephalothin and a chromogenic cephalosporin (87/312) were also hydrolyzed by the enzyme. Activity was found only in beta-lactam-resistant strains, but there was considerable variation in activity among strains having the same minimal inhibitory concentrations of antibiotic. beta-Lactamase activity was cell bound and appeared to be tightly associated with the cell envelope since detergents were required to elute this activity.     

Effect of Semisynthetic Penicillins on the Limulus Lysate Test

Semisynthetic penicillins in concentrations greater than 1.0% (wt/vol) were found to inhibit the limulus lysate assay for endotoxin.     

Relation of Beta-Lactamase Activity to Antimicrobial Susceptibility in Serratia marcescens

One-hundred clinical isolates of Serratia marcescens were tested for susceptibility to cephalothin, carbenicillin, ticarcillin, ampicillin, and cefoxitin. The majority of the 100 isolates (≥70%) were susceptible to carbenicillin, ticarcillin, and cefoxitin; less than one-half were susceptible to ampicillin; none were susceptible to cephalothin. Ten isolates from the 100 organisms tested were selectively assayed for their β-lactamase activity. Enzyme activity was measured using either iodometric or spectrophotometric methods, and the microbiological assay technique. It was concluded that β-lactamase production was not the sole determinant in β-lactam antibiotic resistance. Resistance without demonstrable β-lactamase was evident in strains for cephalothin, ampicillin, and cefoxitin. In addition, one strain which was susceptible to all antibiotics except cephalothin, elaborated considerable β-lactamase activity.     

Cefatrizine Activity Compared with That of Other Cephalosporins

Cefatrizine, a new orally administered cephalosporin, was tested against 400 clinical isolates. Cefatrizine had excellent activity against gram-positive cocci, inhibiting all except enterococci at minimal inhibitory concentrations below 1 mug/ml. Cefatrizine inhibited the majority of Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, and Salmonella at concentrations below 12.5 mug/ml. Although cefatrizine was not hydrolyzed by many beta-lactamases, it did not inhibit a number of strains of Enterobacter, Serratia, or indole-positive Proteus. Cefatrizine was more active than cephalothin or cephalexin against E. coli, Klebsiella, Enterobacter, Citrobacter, Salmonella, and Shigella. Its overall activity was less than that of cefoxitin against strains resistant to cephalothin, but its activity against cephalothin-susceptible strains was equivalent to that of cefamandole.     

Mathematical Modeling To Characterize the Inoculum Effect

Killing by beta-lactams is well known to be reduced against a dense bacterial population, commonly known as the inoculum effect. However, the underlying mechanism of this phenomenon is not well understood. We proposed a semimechanistic mathematical model to account for the reduced in vitro killing observed. Time-kill studies were performed with 4 baseline inocula (ranging from approximately 1 × 10⁵ to 1 × 10⁸ CFU/ml) of Escherichia coli ATCC 25922 (MIC, 2 mg/liter). Constant but escalating piperacillin concentrations used ranged from 0.25× to 256× MIC. Serial samples were taken over 24 h to quantify viable bacterial burden, and all the killing profiles were mathematically modeled. The inoculum effect was attributed to a reduction of effective drug concentration available for bacterial killing, which was expressed as a function of the baseline inoculum. Biomasses associated with different inocula were examined using a colorimetric method. Despite identical drug-pathogen combinations, the baseline inoculum had a significant impact on bacterial killing. Our proposed mathematical model was unbiased and reasonable in capturing all 28 killing profiles collectively (r² = 0.88). Biomass was found to be significantly more after 24 h with a baseline inoculum of 1 × 10⁸ CFU/ml, compared to one where the initial inoculum was 1 × 10⁵ CFU/ml (P = 0.002). Our results corroborated previous observations that in vitro killing by piperacillin was significantly reduced against a dense bacterial inoculum. This phenomenon can be reasonably captured by our proposed mathematical model, and it may improve prediction of bacterial response to various drug exposures in future investigations.Escherichia coli is part of the human gastrointestinal flora and a common pathogen implicated in intra-abdominal infections such as perforated appendicitis and peritonitis. Beta-lactams are often the empirical drug of choice for the management of severe intra-abdominal infections, in view of their spectrum of activity and safety profile. In intra-abdominal infections, a heavy bacterial burden is commonly encountered and the clinical utility of the beta-lactams may be limited by the inoculum effect. This phenomenon is believed to be due to the physiologic state of the bacterial cells, or preferential expression of different penicillin-binding proteins, rendering the bacteria less susceptible to beta-lactams (17). Biofilm production and quorum sensing may also be involved.We and others have previously developed mathematical models to capture the dynamic relationship between a heterogeneous microbial population and constant drug concentrations (10, 13, 15, 16, 21, 24). Our models were further refined to predict the microbial response to multiple antimicrobial agent dosing regimens (fluctuating drug concentration over time) efficiently (14, 22). Such a modeling approach could be used as a decision-support tool for dosing regimen design, and it may be used at different stages of drug development. It is often observed that killing could be more pronounced against a lower bacterial burden than with a higher bacterial burden (1, 3, 18). Capturing this phenomenon in a mathematical model would require a killing function dependent on bacterial burden. However, one common assumption in most modeling approaches is that the killing function is independent of the bacterial burden (4, 11, 19). This modeling assumption is often restrictive and is useful only when there is not a very significant change in bacterial susceptibility to antimicrobials, as the bacterial burden changes. In other cases, it may be misleading in making accurate predictions about the bacterial behaviors. For example, an experiment with a higher bacterial burden may suggest a dosing exposure requirement to suppress regrowth, but this may overestimate the requirement to suppress regrowth at lower bacterial burdens. In order to capture the overall picture satisfactorily, we need a more robust model the conclusions of which can be extended over a wide range of bacterial burdens.Therefore, the objective of this study was to extend our mathematical modeling approach proposed previously, to further account for the reduced in vitro killing observed. For illustrative purposes, a standard wild-type E. coli strain with various baseline inocula was used in this investigation.     

Comparative In Vitro Activity of Five Cephalosporins Against Lactobacilli

Of five parenteral cephalosporins tested against 43 lactobacilli, cephaloridine, cefazolin, and cefamandole were the most active inhibitory and bactericidal agents. Timed-kill analysis revealed a slow bactericidal effect, with significant declines in mean minimal bactericidal concentration values at 48 h versus 24 h.     

Activity of Cefamandole and Other Cephalosporins Against Aerobic and Anaerobic Bacteria

The activity of cefamandole was comparable to that of cephalothin, cefazolin, and cephaloridine against Staphylococcus aureus, Streptococcus pyogenes, and Diplococcus pneumoniae. In contrast, cefamandole was considerably more active than cephalothin, cefazolin, or cephaloridine against gram-negative facultative bacilli, including Haemophilus influenzae, the most striking disparities being noted with indole-positive Proteus and Enterobacter. Bacteroides fragilis was more susceptible to cefoxitin than to cefamandole or cefazolin (median minimal inhibitory concentration, approximately 8, 32, and 32 μg/ml, respectively); cephalothin exhibited still less activity against this species. The majority of other anaerobes were inhibited by relatively low concentrations of all four cephalosporins. The results indicate a potentially valuable role for cefamandole against facultative gram-negative bacilli, including H. influenzae, but no exceptional activity against anaerobes.     

Activity of Three Aminoglycosides and Two Penicillins Against Four Species of Gram-Negative Bacilli

Three aminoglycoside antibiotics and two penicillins were compared for their in vitro activity against 60 isolates of Serratia, Pseudomonas, Proteus mirabilis, and indole-positive Proteus sp. Testing was done by the agar dilution method using Mueller-Hinton broth solidified with 1.5% agar. The activity of amikacin, aminodeoxybutirosin, and gentamicin against Proteus and Pseudomonas, as related to their peak blood levels, showed no significant differences. Amikacin was the most active against Serratia marcescens. Results using Mueller-Hinton media in broth dilution tests correlated with the agar dilution method except for Pseudomonas aeruginosa. The minimal inhibitory concentration for aminoglycosides in agar was considerably greater than the minimal inhibitory concentration in Mueller-Hinton broth, and the disparity was related to the higher divalent cation concentration of agar. BL-P1654 and carbenicillin were similar except that carbenicillin was much more active against indole-positive Proteus sp. Additionally, the ratio of bactericidal to bacteriostatic concentrations of BL-P1654 was considerably greater than for carbenicillin.     

Antimicrobial Activity of Cefmenoxime Compared with Those of Other Cephalosporins

The antimicrobial activity of cefmenoxime was compared with those of cefamandole, cefoperazone, cefotaxime, cephalothin, and moxalactam. In general, the activity of cefmenoxime was equivalent to those of the other cephalosporins. Cefmenoxime appears to be a potent antimicrobial agent against most gram-negative microorganisms other than Pseudomonas aeruginosa and Acinetobacter spp.     

Comparative In Vitro Activity of Newer Cephalosporins Against Anaerobic Bacteria

The in vitro susceptibilities of 408 recent clinical isolates of anaerobic bacteria against cefaclor, cephalexin, cephalothin, cefazolin, cefamandole, and cefoxitin were compared by an agar dilution technique. Against gram-positive bacteria, especially peptococci, peptostreptococci, and propionibacteria, cephalexin and cefaclor were significantly less active than cephalothin (P < 0.05). Cephalexin was also less active than cephalothin against clostridia and lactobacillus (P < 0.05). Against gram-negative bacteria, major differences were observed primarily with Bacteroides fragilis, against which cephalexin, cefazolin and cefoxitin were all significantly more active than cephalothin (P < 0.001). At concentrations of 16 μg per ml, however, all cephalosporins showed high in vitro activity, except against Lactobacillus species and B. fragilis. Cephalothin, cefazolin and cefamandole were considerably more active against the former, whereas cefoxitin was distinctly more active against the latter.