Gour, N. | Search bioRxiv

bioRxiv2019

Ranking of Major Classes of Antibiotics for Activity against Stationary Phase Pseudomonas aeruginosa and Identification of Clinafloxacin + Cefuroxime + Gentamicin Drug Combination that Eradicates Persistent P. aeruginosa Infection in a Murine Cystic Fibrosis Model

Pseudomonas aeruginosa can cause serious persistent infections such as ventilator-associated pneumonia, sepsis, biofilm-related infections as in cystic fibrosis (CF) patients. Although CF lung infections can be treated with antibiotics, full clearance is difficult due to P. aeruginosa persistence. While antibiotic activity against growing P. aeruginosa is well documented, their activity against the non-growing persisters enriched in stationary phase cultures has not been well studied. Here, we systematically evaluated and ranked the six major classes of antibiotics, cell wall and cell membrane inhibitors, protein synthesis inhibitors, DNA synthesis inhibitors, RNA synthesis inhibitors, sulfa drugs, and nitrofurantoin, for their activity against both growing and persister forms of P. aeruginosa using colony forming count (CFU) and SYBR Green I/Propidium Iodide (PI) viability assay. Among the six major classes of antibiotics, cell wall and cell membrane inhibitors (Cefuroxime and Colistin), DNA synthesis inhibitors (Clinafloxacin) and sulfa drugs (Sulfamethoxazole) had good activity against stationary phase cells. In contrast, protein synthesis inhibitors (Gentamicin), RNA synthesis inhibitor (Rifampicin) and Nitrofurantoin had relatively poor activity against the stationary phase P. aeruginosa but relatively high activity against log phase P. aeruginosa. Clinafloxacin is the only single drug that could completely kill all (109 CFU) stationary phase cells in a 4 day drug exposure. The Cefuroxime + Gentamicin+ Clinafloxacin combination could kill all biofilm bacteria in 2 days whereas the clinically used drug combination Cefuroxime + Gentamicin + Colistin only partially killed the biofilm bacteria with 103 CFU remaining. In a murine persistent CF lung infection model, only Cefuroxime + Gentamicin+ Clinafloxacin cleared all bacteria in the infected lungs, whereas Clinafloxacin alone, or Cefuroxime + Clinafloxacin, or the current recommended drug combination Cefuroxime + Gentamicin, all failed to completely clear the bacterial load in the lungs. The complete sterilization of the bacterial load is a property of Clinafloxacin combination, as Cefuroxime + Gentamicin+ Levofloxacin combination was unable to clear the bacterial load in the lungs. Our findings demonstrate the importance of persister drug clinafloxacin, offer new therapeutic approaches for more effective treatment of persistent P. aeruginosa infections, and may have implications for treating other persistent infections.

microbiology↗

bioRxiv2019

A Drug Combination Approach Targeting Both Growing Bacteria and Dormant Persisters Eradicate Persistent Staphylococcus aureus Biofilm Infection

Staphylococcus aureus can cause a variety of infections, many of which involve biofilm infections. Inside biofilms, growing and non-growing bacteria such as persisters co-exist, making it challenging to completely eradicate a persistent and recurrent infection with current treatments. Despite the clinical relevance, most of the current antibiotic treatments mainly kill the growing bacteria and have poor activity against non-growing persister bacteria and thus have limited effect on treating persistent infections including biofilm infections. We previously proposed a Yin-Yang model using a drug combination approach targeting both growing bacteria and persister bacteria for more effective clearance of persistent infections. Here, as a proof of principle, we showed that combining drugs that have high activity against growing forms, such as vancomycin or meropenem, with drugs that have robust anti-persister activity, such as clinafloxacin and oritavancin, could completely eradicate S. aureus biofilm bacteria in vitro. In contrast, single or two drugs including the current treatment for persistent S. aureus infection doxycycline plus rifampin failed to kill all biofilm bacteria in vitro. We then developed a chronic persistent skin infection mouse model with biofilm-seeded bacterial inocula demonstrating that biofilm bacteria caused more severe and persistent skin lesions than log phase S. aureus bacteria. More importantly, we found that the drug combination which eradicated biofilm bacteria in vitro is more efficacious than current treatments and completely eradicated S. aureus biofilm infection in mice. The complete eradication of biofilm bacteria is attributed to the unique high anti-persister activity of clinafloxacin, which could not be replaced by other fluoroquinolones such as moxifloxacin, levofloxacin or ciprofloxacin. Our study is the first to demonstrate that the combination of meropenem, daptomycin, plus clinafloxacin completely cleared the persistent infection, healed the lesions, and had less inflammation, while mice treated with doxycycline plus rifampin, the current clinically recommended treatment for chronic tissue infection, failed to do so. We also compared our persister drug combination with other approaches for treating persistent infections including gentamicin+fructose and ADEP4+rifampin in the S. aureus biofilm infection mouse model. Neither gentamicin+fructose nor ADEP4+rifampin could eradicate or cure the persistent biofilm infection in mice. In contrast, our drug combination regimen with persister drug clinafloxacin plus meropenem and daptomycin completely eradicated and cured the persistent biofilm infection in 7 days. An unexpected observation is that ADEP4 treatment group developed worsened skin lesions and caused more extensive pathology than the untreated control mice. Our study demonstrates an important treatment principle for persistent infections by targeting both growing and non-growing heterogeneous bacterial populations utilizing persister drugs for more effective eradication of persistent and biofilm infections. Our findings may have implications for improved treatment of many other persistent infections in general.

microbiology↗