Medium compositions and culture conditions for the assay of fosfomycin susceptibility by Etest

The Etest (AB Biodisk, Solna, Sweden), a susceptibility testing method, was used for fosfomycin and was evaluated by comparison with the agar dilution method for 73 clinical isolates of Escherichia coli, including two resistant strains, and an optimal Etest method for fosfomycin was determined. Media and culture conditions greatly affected the minimum inhibitory concentrations (MICs) determined by the Etest for fosfomycin, as shown for the agar dilution methods. Our results showed that the most favorable conditions for the Etest for fosfomycin were with Mueller-Hinton agar (Becton-Dickinson Japan, Tokyo, Japan) under aerobic conditions. However, the MICs for the resistant strains were much higher than those determined by agar dilution methods, using Nutrient agar (Becton-Dickinson Japan) under anaerobic conditions. The addition of glucose-6-phosphate did not significantly affect the Etest results. Received: August 5, 1999 / Accepted: October 28, 1999     

Increased minimum inhibitory concentrations with anaerobiasis for tobramycin, gentamicin, and amikacin, compared to latamoxef, piperacillin, chloramphenicol, and clindamycin

Minimum inhibitory concentrations (MICs) were determined under both routine aerobic and anaerobic conditions for a total of 93 organisms representing nine genera. MICs for the aminoglycosides amikacin, gentamicin, and tobramycin were significantly increased under anaerobic conditions. Tobramycin was most sensitive to the loss of antimicrobial activity with anaerobiasis. MICs for staphylococci were increased by a higher factor than were MICs for gram-negative rods, but even within the latter group increases in MICs for Proteus species were greater than for Salmonella, Klebsiella and Escherichia coli. No change of anaerobic versus aerobic activity was seen for latamoxef, piperacillin, chloramphenicol, or clindamycin.     

Alteration of effectiveness of antibiotics by anaerobiosis.

In vitro antibiotic susceptibility tests of facultative organisms are routinely performed under aerobic conditions, despite the fact that many infections caused by these organisms occur in anaerobic areas, i.e., intra-abdominal absess. Experiments were performed aerobically and anaerobically to determine the susceptibility of E. coli, P. mirabilis, and K. pneumoniae to gentamicin, tobramycin, cephalothin, cefazolin, and cefamandole. Antibiotic sensitivities were determined by disc and agar dilution techniques in air and in anaerobic jars with CO2 absorbed. Tube dilution studies were performed in air and anaerobically and time-kill studies were done in aerobic and anaerobic broth. The amount of aminoglycoside required to inhibit bacterial growth was increased 4 to 20 times by anaerobiosis in 20 of 25 strains tested. Time-kill curves showed that bacterial killing by aminoglycosides was markedly impaired by anaerobiosis. Anaerobic conditions had no effect on the rate or extent of killing by cephalosporins. These data may have significance in determination of antibiotic susceptibility of facultative organisms under anaerobic tissue conditions. Antibiotic sensitivity testing done on these organisms in air may not reflect the actual state of antibiotic-bacterial interaction under conditions of the infection.     

Effect of Several Components of Anaerobic Incubation on Antibiotic Susceptibility Test Results

The factors influencing the in vitro activity of antibiotics during anaerobic incubation were studied by the disc method with a facultative organism, Escherichia coli. We observed the effects of incubation aerobically, anaerobically (Torbal jars), in a CO(2) incubator, and aerobically and anaerobically with all CO(2) removed. We also monitored pH changes during incubation and observed the effect of two different initial agar pH values (7.4 and 8.3). With aminoglycosides, zones were larger at pH 8.3 and, in each agar pH group, zones were decreased by incubation with increased CO(2) (anaerobically and CO(2) incubator). A fall in agar pH took place during the first 5 to 7 hr of incubation when increased CO(2) was present. Decreased aminoglycoside zones in the presence of increased CO(2) were due to fall in agar pH. Erythromycin showed the same zone size changes as the aminoglycosides. Chloramphenicol zones were somewhat smaller at the lower medium pH. Zones around tetracycline discs were largest after incubation anaerobically. Further aerobic (or CO(2)) incubation of plates after anaerobic incubation resulted in large "zones of relative inhibition" around the aminoglycoside discs. This suggests that these antibiotics had become more active after exposure to aerobic conditions. Our studies indicate that antibiotic susceptibility test results can be significantly altered by several components of anaerobic incubation including changes in agar pH and CO(2) concentration as well as anaerobiosis per se.     

Antimicrobial Activity of Fosfomycin-Tobramycin Combination against Pseudomonas aeruginosa Isolates Assessed by Time-Kill Assays and Mutant Prevention Concentrations

The antibacterial activity of fosfomycin-tobramycin combination was studied by time-kill assay in eight Pseudomonas aeruginosa clinical isolates belonging to the fosfomycin wild-type population (MIC = 64 μg/ml) but with different tobramycin susceptibilities (MIC range, 1 to 64 μg/ml). The mutant prevention concentration (MPC) and mutant selection window (MSW) were determined in five of these strains (tobramycin MIC range, 1 to 64 μg/ml) in aerobic and anaerobic conditions simulating environments that are present in biofilm-mediated infections. Fosfomycin-tobramycin was synergistic and bactericidal for the isolates with mutations in the mexZ repressor gene, with a tobramycin MIC of 4 μg/ml. This effect was not observed in strains displaying tobramycin MICs of 1 to 2 μg/ml due to the strong bactericidal effect of tobramycin alone. Fosfomycin presented higher MPC values (range, 2,048 to >2,048 μg/ml) in aerobic and anaerobic conditions than did tobramycin (range, 16 to 256 μg/ml). Interestingly, the association rendered narrow or even null MSWs in the two conditions. However, for isolates with high-level tobramycin resistance that harbored aminoglycoside nucleotidyltransferases, time-kill assays showed no synergy, with wide MSWs in the two environments. glpT gene mutations responsible for fosfomycin resistance in P. aeruginosa were determined in fosfomycin-susceptible wild-type strains and mutant derivatives recovered from MPC studies. All mutant derivatives had changes in the GlpT amino acid sequence, which resulted in a truncated permease responsible for fosfomycin resistance. These results suggest that fosfomycin-tobramycin can be an alternative for infections due to P. aeruginosa since it has demonstrated synergistic and bactericidal activity in susceptible isolates and those with low-level tobramycin resistance. It also prevents the emergence of resistant mutants in either aerobic or anaerobic environments.     

Effect of oxygen limitation on the in vitro activity of levofloxacin and other antibiotics administered by the aerosol route against Pseudomonas aeruginosa from cystic fibrosis patients

Studies have demonstrated that thickened mucous layers in the lungs of cystic fibrosis (CF) patients contain areas of low oxygen tension. These microaerophilic environments may reduce the activity of aerosol antibiotics used in the management of chronic infection in CF. The aim of this study was to compare the MICs of levofloxacin, tobramycin, amikacin, and aztreonam against Pseudomonas aeruginosa under reference and anaerobic conditions and evaluate the in vitro pharmacodynamics of levofloxacin under aerobic and hypoxic testing conditions. The MICs for 114 isolates of P. aeruginosa from CF patients were determined in cation-adjusted Mueller Hinton broth alone or supplemented with 1% potassium nitrate for anaerobic testing. Levofloxacin time–kill curves were performed under aerobic and hypoxic conditions using strains of P. aeruginosa with elevated efflux pump overexpression and/or target mutations. The MICs of nonmucoid or mucoid P. aeruginosa isolates to levofloxacin incubated under aerobic and anaerobic conditions were similar. In contrast, anaerobic incubation resulted in higher MICs for tobramycin, amikacin, and aztreonam among nonmucoid or mucoid isolates, with ≥4-fold increase in MICs for over 40% of the isolates. Time–kill curves performed in aerobic and hypoxic environments with levofloxacin concentrations attained in CF sputum demonstrated similar activity, approaching a maximum bactericidal effect within 10 min of exposure. Together, these results indicate that the activity of some antibiotics against P. aeruginosa is significantly reduced under conditions relevant to the CF lung environment. In contrast, levofloxacin maintains activity against P. aeruginosa under anaerobic or hypoxic conditions similar to those found in CF microaerophilic environments.     

In vitro and in vivo antibacterial activity of FR-31564, a phosphonic acid antimicrobial agent.

The in vitro and in vivo activity of FR-31564 [sodium hydrogen 3-(N-hydroxyformamido)propylphosphate] against gram-positive and -negative aerobic and anaerobic bacteria was investigated and compared with that of fosfomycin, cephalexin, carbenicillin, and trimethoprim-sulfamethoxazole. The in vitro activity of FR-31564 was markedly enhanced when combined with glucose 6-phosphate or fructose 6-phosphate, but not when combined with ribose phosphate, adenosine monophosphate, or glycerol phosphate. In vitro activity of FR-31564 also was enhanced by human or horse blood, but not by human serum. The type of medium had a great effect on the minimal inhibitory concentration, with the lowest minimal inhibitory concentrations achieved on nutrient agar, 8- to 16-fold less than with Mueller-Hinton, heart infusion, or Trypticase soy agars. FR-31564 was more active than fosfomycin, cephalexin, carbenicillin, or trimethoprimsulfamethoxazole against Escherichia coli, Klebsiella pneumoniae, Proteus vulgaris, Enterobacter cloacae, E. aerogenes, and Citrobacter. It was less active than fosfomycin against Serratia marcescens and Proteus mirabilis and did not inhibit gram-positive cocci or anaerobic species. FR-31564 inhibited a number of E. coli, K. pneumoniae, and some Pseudomonas aeruginosa strains resistant to the other agents. In the presence and absence of human blood FR-31564 showed bactericidal activity, and P. aeruginosa exposed to FR-31564 for 3 h showed a 6-h lag in regrowth. FR-31564 administered by the subcutaneous route was more active in protecting mice challenged with P. aeruginosa than was fosfomycin, carbenicillin, or cefoperazone. It was as active by the oral route in protecting mice challenged with E. coli as was fosfomycin, ampicillin, cephalexin, or trimethoprimsulfamethoxazole.     

Effect of different nitroheterocyclic compounds on aerobic, microaerophilic, and anaerobic bacteria.

The antibacterial activities of different nitroheterocyclic compounds were assessed by an agar dilution method against aerobic, microaerophilic, and anaerobic bacteria. Nitronaphthofurans inhibited the multiplication of aerobic bacteria at low concentrations (MIC for 50% of strains tested [MIC50], 1 mg/liter). Under anaerobic growth conditions the MICs were found to be even lower. The rough, DNA repair-deficient mutants of Salmonella typhimurium were more susceptible, whereas nitroreductase-deficient strains were resistant. Microaerophilic campylobacter isolates could be divided into two groups, one of which was as susceptible as aerobic bacteria (MIC50, 1 mg/liter) and the other of which was more highly susceptible (MIC50, 0.015 mg/liter). All anaerobic bacteria tested were susceptible to nitronaphthofurans (MIC50, 0.125 mg/liter). Nitrothiazole exerted antibacterial activities similar to those of the nitronaphthofurans. Metronidazole, a nitroimidazole derivative, and nitrofurans were definitely less active. Nitrobenzofurans showed relatively high MICs.     

Agar Shake Tube Technique for Simultaneous Determination of Aerobic and Anaerobic Susceptibility to Antibiotics

The broth dilution method of determining the minimum inhibitory concentration (MIC) of antibiotics has been adapted to an agar shake tube technique with semisolid media. This permits the simultaneous determination of the aerobic and anaerobic MICs for facultatively anaerobic bacteria such as staphylococci.     

Antimicrobial susceptibility testing of Bilophila wadsworthia by using triphenyltetrazolium chloride to facilitate endpoint determination.

Initial susceptibility studies of Bilophila wadsworthia indicated significant resistance to several beta-lactam antibiotics, including imipenem and cefoxitin. NO beta-lactamase production was detected. However, some B. wadsworthia strains may grow as a heavy "haze" at up to the highest concentration of an antibiotic on standard antimicrobial agent-containing plates, and it is often difficult to determine the point at which conventional growth stops and haze growth begins. We investigated the nature of the haze growth of B. wadsworthia by using triphenyltetrazolium chloride (TTC) as an indicator of viability during antimicrobial susceptibility testing, by determining viability counts on antimicrobial agent-containing plates at various times, and by microscopically inspecting stained preparations of the growth on the control plate and the haze area. TTC MICs were determined by applying a TTC solution over the growth on plates inside the anaerobic chamber or within 5 min after exposure to air (aerobic TTC MICs). The haze growth reduced TTC in the chamber but not under aerobic conditions, whereas TTC was reduced by the conventional growth in both atmospheres. The aerobic TTC MICs correlated with the viability counts. Separated proteins resolved by polyacrylamide gel electrophoresis and isoelectric focusing showed TTC-reactive bands only when stained under anaerobic conditions, further demonstrating the sensitivity of TTC reduction to aerobic conditions. Microscopic examination of the haze growth indicated spheroplast formation. A new antibiogram for B. wadsworthia has been established by use of aerobic TTC endpoints; we believe that the lower MICs obtained with the TTC method are likely the ones that are clinically relevant and should be used in tests of B. wadsworthia. Also, we found that when the organisms were grown on pyruvate-containing medium, 87% of 56 strains tested were Beta-lactamase positive.     

Fosfomycin tromethamine susceptibility of outpatient urine isolates of Escherichia coli and Enterococcus faecalis from ten North American medical centres by three methods.

One hundred percent of 1097 Escherichia coli and 97.5% of 157 Enterococcus faecalis isolates from outpatient urine specimens at ten North American medical centres were susceptible to fosfomycin tromethamine. The Etest MICs correlated well with those of agar dilution. Disc diffusion zone diameters correlated well with MICs and supported the previously proposed zone diameter breakpoints for fosfomycin.     

Effect of aerobic and anaerobic environments on antistaphylococcal activities of five fluoroquinolones.

A previously established in vitro pharmacodynamic system was used to evaluate the antistaphylococcal activities of five fluoroquinolones under both aerobic and anaerobic conditions. Staphylococcus aureus ATCC 29213 was exposed to a 5-micrograms/ml concentration of each of the following fluoroquinolones: ciprofloxacin, ofloxacin, temafloxacin, sparfloxacin, and clinafloxacin. Terminal elimination half-lives of 4, 6, 8, 8, and 13 h were simulated for the respective drugs. Each fluoroquinolone was bactericidal under both aerobic and anaerobic conditions. However, the bactericidal activity of each fluoroquinolone was delayed by anaerobiosis. This difference in fluoroquinolone activity under aerobic and anaerobic conditions could not be attributed to any particular parameter or physiochemical property but was most likely caused by a combination of factors (e.g., variations in hydrophobicity, intracellular pH, antibiotic concentration, and structure-activity relationships). Fluoroquinolone uptake studies were also performed to investigate the possibility of active, energy-dependent transport mechanisms in S. aureus ATCC 29213. Uptake studies indicated that active efflux does occur in S. aureus ATCC 29213.     

Broth-disk elution tests to predict the susceptibility of anaerobic bacteria to the ampicillin-sulbactam combination

The ampicillin-sulbactam Wilkins-Chalgren agar dilution MICs (2 ratios) were compared with the results of broth-disk elution (BDE) tests using various numbers of disks corresponding to elution breakpoints of less than or equal to 8:8 micrograms/ml, less than or equal to 16:8 micrograms/ml, and less than or equal to 16:16 micrograms/ml. This study showed that a 2:1 ratio MIC test and a 16:8 micrograms/ml BDE breakpoint were best for anaerobic organisms; a recommendation consistent with susceptibility testing criteria for rapidly growing aerobic species. The addition of four ampicillin disks (10 micrograms) and four ampicillin-sulbactam discs (10:10 micrograms) to 5 ml of thioglycolate broth was recommended. This test would achieve greater than 99% comparative accuracy to MICs determined with the reference National Committee for Clinical Laboratory Standards agar dilution method.     

International collaborative study on standardization of bacterial sensitivity to fosfomycin

An international collaborative study was undertaken involving 6 working groups to correlate the zone sizes obtained with 50 micrograms fosfomycin + 25 micrograms glucose-6-micrograms glucose-6-phosphate (G6P) and 50 micrograms fosfomycin + 50 micrograms G6P/disc with the MICs in the presence of 25 mg G6P/litre. The recommendations of the ICS for the MIC and disc diffusion methods were followed and Oxoid Mueller-Hinton agar was used. The regression lines obtained with the method of least squares show that the best correlation coefficient (r = 0.8227) corresponds to the disc with 50 micrograms fosfomycin + 50 micrograms G6P. Considering both the pharmacokinetics of fosfomycin after intravenous administration of 2 or 4 g and the distribution of sensitive bacterial populations, two breakpoints were established at MIC values of 16 and 64 mg/l corresponding to zone sizes and 18 and 22 mm, respectively.     

Lansoprazole, a novel benzimidazole proton pump inhibitor, and its related compounds have selective activity against Helicobacter pylori.

The activities of various types of antiulcer agents against Helicobacter pylori (formerly called Campylobacter pylori) strains were determined by an agar dilution method. Among the compounds tested, two benzimidazole proton pump inhibitors, lansoprazole (AG-1749) and omeprazole, were found to have significant activities against this organism. The activity of lansoprazole was comparable to that of bismuth citrate, with MICs ranging from 3.13 to 12.5 micrograms/ml, and fourfold more potent than that of omeprazole. A major metabolite and two acid-converted rearrangement products of lansoprazole also exhibited good activities comparable or superior to that of the parent compound. Exposure to lansoprazole of H. pylori growing in a liquid medium led to an extensive loss of viability without a reduction in culture turbidity and produced an aberrant bacterial morphology characterized by the irregular constriction of cells and the collapse of cell surface structures. The antibacterial activity of lansoprazole and its related compounds was selective against H. pylori; common aerobic and anaerobic bacteria and Campylobacter jejuni were not inhibited by 100 micrograms/ml.     

Metronidazole is bactericidal to dormant cells of Mycobacterium tuberculosis.

Very abrupt exposure to anaerobic conditions has a lethal effect on actively growing cultures of Mycobacterium tuberculosis. However, incubation under conditions in which oxygen is depleted gradually causes M. tuberculosis to shift down from active replication to dormancy. The dormant bacilli are resistant to the bactericidal effects of anaerobiosis and also exhibit partial or complete resistance to the bactericidal effects of isoniazid and rifampin. On the other hand, metronidazole, a drug specific for anaerobes, kills dormant tubercle bacilli under anaerobic conditions, but it has no effect on actively growing aerobic cultures. The lethal effect of metronidazole under anaerobic conditions is enhanced by rifampin. The possible implications of these findings on the phenomenon of latency in tuberculosis are discussed.     

Factors affecting the in vitro activity of cefoperazone against the Bacteroides fragilis group.

The in vitro activity of cefoperazone against 32 strains of bacteria of the Bacteroides fragilis group was determined on four media by using a variety of test parameters. Lower mean minimal inhibitory concentrations (MICs) were obtained on Mueller-Hinton blood agar and supplemented brain heart infusion agar than were obtained on brucella laked blood agar or Wilkins-Chalgren agar. Higher MICs were obtained with 6-h inocula than with 24-h inocula, and slightly higher MICs were obtained with tests read at 48 as compared with 24 h. Conducting tests in an anaerobic glove box had little effect. The greatest differences in mean MICs were seen with inoculum densities of 10(4) and 10(5) colony-forming units.     

Target site penetration of fosfomycin in critically ill patients

OBJECTIVE: The present study was undertaken to investigate the target site penetration properties of fosfomycin, an antibiotic particularly suitable for treatment of soft tissue infections (STIs) in critically ill patients. METHODS AND RESULTS: The study population included nine patients with sepsis. Penetration of fosfomycin into the interstitial space fluid of skeletal muscle was measured using the microdialysis technique, following a single intravenous administration of 8.0 g of fosfomycin to patients. The median (range) fosfomycin area under the concentration versus time profile for plasma and skeletal muscle were 673 (459-1108) and 477 (226-860) mg x h/L (P < 0.011), respectively. Interstitial maximum concentrations were lower than plasma values (P < 0.029). Median fosfomycin concentrations in the interstitium and plasma exceeded 70 mg/L throughout the observation period of 4 h and covered MICs for Streptococcus pyogenes, Staphylococcus aureus and Pseudomonas aeruginosa. Simulation of bacterial growth inhibition of S. pyogenes, based on tissue concentration data, confirmed the bactericidal properties of fosfomycin described in previous studies. CONCLUSION: Fosfomycin concentrations in muscle interstitium and plasma exceeded the MICs for a range of clinically relevant pathogens in critically ill patients. Thus, fosfomycin exhibits a tissue pharmacokinetic profile, which appears to offer an alternative to other broad-spectrum antibiotics in intensive care patients suffering from STI.     

Comparative activity of pradofloxacin against anaerobic bacteria isolated from dogs and cats

OBJECTIVES: To compare the intrinsic activity of pradofloxacin, a new fluoroquinolone developed for use in veterinary medicine, with other fluoroquinolones, against anaerobic bacteria isolated from dogs and cats. METHODS: One hundred and forty-one anaerobes were isolated from dogs and cats and comparative MICs of pradofloxacin, marbofloxacin, enrofloxacin, difloxacin and ibafloxacin were determined according to standardized agar dilution methodology. RESULTS: Pradofloxacin exerted the greatest antibacterial activity followed by marbofloxacin, enrofloxacin, difloxacin and ibafloxacin. Based on the distinctly lower MIC(50), MIC(90) and mode MIC values, pradofloxacin exhibited a higher in vitro activity than any of the comparator fluoroquinolones. CONCLUSIONS: Pradofloxacin, a novel third-generation fluoroquinolone, has broad-spectrum anti-anaerobe activity and offers utility as single-drug therapy for mixed aerobic/anaerobic infections.