Multidrug-resistant (MDR) Acinetobacter baumannii have caused nosocomial infections worldwide. Nowadays, there are no effective regimens to treat MDR- A. baumannii. Therefore, this study’s objective was to find out an effective antimicrobial combination against MDR-A. baumannii. This project consisted of four parts. Part 1 was an in vitro antimicrobial susceptibility test of MDR-A. baumannii collected from Thailand. Minimum inhibitory concentrations (MICs) were performed according to the Clinical and Laboratory Standards Institute (CLSI) guidelines using a broth microdilution technique. This study found that colistin was the most active against MDR-A. baumannii (MIC50 0.5µg/mL, MIC90 1µg/mL). In addition, 77% of MBL -producing A. baumannii were reported using the MBL Etest strips. This prevalence was higher than previously reported. Part 2 was conducted to compare antimicrobial susceptibility profiles of pre- and post-colistin exposure A. baumannii isolates. After colistin exposure, A. baumannii isolates became resistant to colistin but more susceptible to cefepime, doxycycline, meropenem and rifampicin. These findings suggested the potential of a synergistic activity of colistin combinations. Part 3 was a time-kill study that compared activity of colistin alone and in combination against MDR-A. baumannii. Time-kill assays were performed using a standard inoculum. Colistin monotherapy was rapidly bactericidal against these isolates; however, regrowth occurred at 24 hrs. On the other hand, colistin in combination with cefepime, doxycycline, meropenem or rifampicin demonstrated synergy and maintained bactericidal activity over 24 hrs (100%). Part 4 was designed to optimize meropenem dosing regimens using a PK-PD model. Three MDR-A. baumannii with colistin MICs (0.5-1µg/mL) and meropenem MICs (32-128µg/mL) were tested. The antimicrobial regimens alone and in combination evaluated were: colistin 2.5mg/kg every 12 hrs, meropenem 3g and 6g continuously infused (CI) over 24 hrs. Colistin monotherapy was rapidly bactericidal but regrowth did occur. Both combinations express synergy (100%). Nevertheless, colistin and high dose meropenem (6g CI over 24 hrs) was bactericidal and prevented regrowth over 24 hrs. In conclusion, MBL-producing A. baumannii is more prevalent than previously thought and colistin combined with a high dose meropenem (6g/day) has good potential to overcome multidrug- and carbapenem-resistant A. baumannii. These findings should be further evaluated in animal models and clinical practices. / text

Un grupo de científicos de China ha encontrado un nuevo gen en las bacterias gram negativas, el MCR-1. Este gen ha sido responsable de otorgarle resistencia a estas bacterias patógenas ante la colistina, el antibacteriano que los médicos emplean como última arma para combatir ciertas infecciones multi-resistentes. Con este gen, las superbacterias serán potencialmente epidémicas y las enfermedades que se creían controladas, como la neumonía, la tuberculosis y las infecciones del tracto urinario, podrían ser nuevamente letales. / A group of Chinese scientists have found a new gene in gram negative bacteria, the MCR-1. This gene has given pathogenic bacteria resistance to colistin, which is the antibacterial that medical doctors use as last line of defense against multi-drug resistant infections. Superbacteria with MCR-1 will be potentially epidemic, and diseases that were believed to be controlled such as pneumonia, tuberculosis and urinary tract infections could be lethal again.

Understanding the cellular membrane interaction with membrane active biomolecules and antimicrobial agents provides an insight in their working mechanism. Here, we studied the effect of antimicrobial agents; a recently developed peptidomimetics E107-3 and colistin as well as the N-terminal helix H0, of Endophilin A1 on the lipid bilayer. It is important to discern the interaction mechanism of antimicrobial peptides with lipid membranes in battling multidrug resistant bacterial pathogens. We study the modification of structural and mechanical properties with a recently reported peptidomimetic on lipid bilayer. The compound referred to as E107-3 is synthesized based on the acylated reduced amide scaffold and has been shown to exhibit good antimicrobial potency. This compound increases lipid bilayer permeability as indicated by our vesicle leakage essay. Micropipette aspiration experiment shows that exposure of GUV to the compound causes the protrusion length Lp to spontaneously increase and then decrease, followed by GUV rupture. Solution atomic force microscopy (AFM) is used to visualize lipid bilayer structural modulation within a nanoscopic regime. This compound induces nanoscopic heterogeneous structures rather than pore like structures as produced by melittin. Finally, we use AFM-based force spectroscopy to study the impact of the compound on lipid bilayer’s mechanical properties. With the incremental addition of this compound, we found the bilayer puncture force decreases moderately and a 39% decrease of the bilayer area compressibility modulus KA. To explain our experimental data, we propose a membrane interaction model encompassing disruption of lipid chain packing and extraction of lipid molecules. The later action mode is supported by our observation of a double-bilayer structure in the presence of fusogenic calcium ions. Polyanionic Lipopolysaccharides LPS are important in regulating the permeability of outer membrane (OM) of gram-negative bacteria. To initiate the bactericidal activity of polymyxins, it is essential to impair the LPS-enriched OM. Here, we study the mechanism of membrane permeability caused by colistin (Polymyxin E) of LPS/phospholipid bilayers. Our vesicle leakage experiment showed that colistin binding enhanced bilayer permeability; the maximum increase in the bilayer permeability was positively correlated with the LPS fraction. Addition of magnesium ions abolished the effect of LPS in enhancing bilayer permeabilization. Solution atomic force microscopy (AFM) measurements on planar lipid bilayers shows the formation of nano- and macro clusters which protruded from the bilayer by ~2nm. Moreover, increasing the fraction of LPS or colistin enhances the formation of clusters but inhibits by magnesium ions addition. To explain our experimental data, we proposed a lipid-clustering model where colistin binds to LPS to form large-scale complexes segregated from zwitterionic phospholipids. The discontinuity (and thickness mismatch) at the edge of LPS-colistin clusters will create a passage that allows solutes to permeate through. The proposed model is consistent with all data obtained from our leakage and AFM experiments. Our results of LPS-dependent membrane restructuring provided useful insights into the mechanism that could be used by polymyxins in impairing the permeability barrier of the OM of Gram-negative bacteria. Also, we studied the effect of helix H0 of a membrane modification inducing protein endophilin, on planar bilayer. We obtained transmembrane defects on the bilayer when scanned.with AFM.

Multiresistens hos gramnegativa bakterier är ett stort problem i stora delar av världen. Avsaknaden av nya preparat har resulterat i återintroduktion av ett tidigare stoppat antibiotikum, kolistin, men dessvärre kantas resistensbestämningen av flertalet problem. Kolistin är en positivt laddad molekyl som binder till lipid A i yttermembranet, vilket destabiliseras och resulterar i celldöd. Flertalet resistensmekanismer mot kolistin finns beskrivna och majoriteten resulterar i förändrad lipid A-struktur, vilket leder till försämrad kolistininbindning. Syftet med examensarbetet var att utvärdera fyra potentiella screeningmetoder för att upptäcka kolistinresistens och jämföra resultaten mot buljongspädning som referensmetod. De fyra screeningmetoderna var buljongeluering och diskdiffusion samt de kommersiellt tillgängliga screeningtesterna Superpolymyxin och Rapid polymyxin NP. Totalt analyserades 57 helgenomsekvenserade Enterobacterales, varav 28 Escherichia coli och 29 Klebsiella pneumoniae, där aktuella resistensmekanismer var kända. Samtliga isolat analyserades en gång per metod och utöver detta analyserades även tre kontrollstammar. Vid buljongspädning erhölls värde för minsta inhiberande koncentration (MIC) kolistin, vilket användes för klassificering som känslig (MIC ≤ 2 mg/l) eller resistent (MIC > 2 mg/l). De fyra screeningtesterna var designade för att upptäcka resistenta isolat och innehöll 2–4 mg/l kolistin. Resultaten från screeningtesterna var kvalitativa och känslighetskategoriserade isolaten. Sensitivitet och specificitet beräknades för metoderna. Högst sensitivitet (100 %) noterades för Superpolymyxin och Rapid polymyxin NP, och lägst specificitet (76 %) för buljongeluering. Med hänsyn till resultat, prevalens, hållbarhets-, tids- och kostnadseffektivitet drogs slutsatsen att Rapid polymyxin NP är bästa alternativet som screeningmetod av utvärderade metoder. / Infections due to multidrug resistant Gram-negative bacteria are a major problem in large parts of the world. Due to lack of treatment options, a previously banned antibiotic, colistin, has been reintroduced. Unfortunately, susceptibility testing of colistin is problematic and currently the only recommended method is broth microdilution (BMD). Colistin is a positively charged molecule that binds to lipid A at the negatively charged outer cell membrane, which leads to cell disruption. Several mutations causing colistin resistance have been identified, most of them cause alterations of lipid A, resulting in impaired colistin outer cell membrane interaction. The aim of this study was to evaluate four potential screening methods for colistin resistance and compare the results with BMD (reference method). The four screening methods were broth disk elution, disk diffusion and the commercially available tests Superpolymyxin and Rapid polymyxin NP. A collection of 57 whole genome sequenced Enterobacterales consisting of 28 Escherichia coli and 29 Klebsiella pneumoniae were included in the study. Reference results were obtained by BMD, where the estimated minimum inhibitory concentration (MIC) values were used for classification of the isolates as sensitive (MIC ≤ 2 mg/l) or resistant (MIC > 2 mg/l). Sensitivity and specificity were calculated for the methods. The highest sensitivity (100 %) was noted for Superpolymyxin and Rapid polymyxin NP, and the lowest specificity (76 %) for broth disk elution. Considering the results, prevalence, durability, time and cost efficiency, it was concluded that Rapid polymyxin NP is the best alternative as a screening method of evaluated methods.

Antibiotic treatment failure might be due to bacterial resistance or suboptimal exposure at target site and there is a lack of knowledge on the interaction between antimicrobial pharmacodynamics (PD) and the immune response to bacterial infections. Therefore, it is crucial to develop tools to increase the understanding of drug disposition to better evaluate antibiotic candidates in drug development and to elucidate the role of the immune system in bacterial infections. Colistin is used as salvage therapy against multidrug resistant Gram-negative infections. In this work, a whole-body physiologically based pharmacokinetic model (WBPBPK) was developed to characterize the pharmacokinetics (PK) of colistin and its prodrug colistin methanesulfonate (CMS) in animal and human. The scalability of the model from animal to human was assessed with satisfactory predictive performance for CMS and demonstrating the need for a mechanistic understanding of colistin elimination. The WBPBPK model was applied to investigate the impact of pathophysiological changes commonly observed in critically ill patients on tissue distribution of colistin and to evaluate different dosing strategies. Model predicted concentrations in tissue were used in combination with a semi-mechanistic PKPD model to predict bacterial killing in tissue for two strains of Pseudomonas aeruginosa. Finally, a toxicokinetic (TK) model was constructed to describe the time course of E. coli endotoxin concentrations in plasma and the effect on pro-inflammatory cytokine release. The model adequately described the concentration-time profiles of endotoxin and its stimulation of IL-6 and TNF-α production using an indirect response model combined with a transit compartment chain with a tolerance component to endotoxemia. The WBPBPK model developed in this work increased the knowledge on colistin tissue exposure under various conditions and could be used in drug development process to assess antibiotic efficacy or to test new drug combinations. The model describing endotoxin TK and its effect on cytokines is a new tool to be further applied in longitudinal studies to explore the immune response cascade induced by bacterial infections. The methodology applied in this thesis contributes to the development of an integrated modeling framework including physiology, drug distribution, bacterial growth and killing as well as the immune response to infection.

Problems of emerging antibiotic resistance are becoming a serious threat worldwide, and at the same time, the interest to develop new antimicrobials has declined. There is consequently a need for efficient methods to develop new treatments that minimize the risk of resistance development and that are effective on infections caused by resistant strains. Based on in silico mathematical models, describing the time course of exposure (Pharmacokinetics, PK) and effect (Pharmacodynamics, PD) of a drug, information can be collected and the outcome of various exposures may be predicted. A general model structure, that characterizes the most important features of the system, has advantages as it can be used for different situations. The aim of this thesis was to develop Pharmacokinetic-Pharmacodynamic (PKPD) models describing the bacterial growth and killing after mono- and combination exposures to antibiotics and to explore the predictive ability of PKPD-models across preclinical experimental systems. Models were evaluated on data from other experimental settings, including prediction into animals. A PKPD model characterizing the growth and killing for a range of E. coli bacteria strains, with different MICs, as well as emergence of resistance, was developed.  The PKPD model was able to predict results from different experimental conditions including high start inoculum experiments, a range of laboratory and clinical strains as well as experiments where wild-type and mutant bacteria are competing at different drug concentrations. A PKPD model, developed based on in vitro data, was also illustrated to have the capability to replicate the data from an in vivo study. This thesis illustrates the potential of PKPD models to characterize in vitro data and their usage for predictions of different types of experiments. The thesis supports the use of PKPD models to facilitate development of new drugs and to improve the use of existing antibiotics.

La diffusion des bactéries multirésistantes aux antibiotiques associée à une diminution du nombre de nouveaux antibiotiques représente un véritable enjeu de santé publique. De nos jours, un vieil antibiotique, la colistine, connait un récent regain d’intérêt, constituant parfois la seule alternative thérapeutique. La colistine est, alors, qualifiée d’antibiotique de « dernier recours ». Cependant, il a été constaté l’apparition de souches résistantes à la colistine. L’objectif principal de ce travail de thèse a été d’étudier le(s) mécanisme(s) de résistance à la colistine chez K. pneumoniae. Afin de mener à bien notre projet, nous nous sommes intéressés à deux aspects de la problématique. Dans un premier temps, nous avons cherché à mieux comprendre ce mécanisme, en associant une étude génotypique à une étude phénotypique. Et dans un second temps, nous avons cherché des alternatives thérapeutiques, en évaluant différentes associations antibiotiques / The global spread of multidrug-resistant Gram-negative bacteria associated with a decrease in the number of new antibiotic therapies is a major public health issue. Colistin is often referred to as the "last-resort" antibiotic, used as the only therapeutic alternative for MDR Gram-negative bacteria infection, which explains the current renewal of interest in this antimicrobial agent. However, the appearance of colistin-resistant bacterial strains has been already observed. The main objective of this PhD work was to study the colistin resistance mechanism (s) in K. pneumoniae by looking at two aspects of the problem. Firstly, we sought to better understand this mechanism, associating a genotypic study with a phenotypic study. Next, we looked for therapeutic alternatives, by evaluating different antibiotic combinations

Notre travail de thèse a porté sur la recherche des bactéries multirésistantes zoonotiques dans les fèces des animaux du bassin méditerranéen, région pour laquelle peu de données sont disponibles. Cette thèse s’articule autour de quatre objectifs principaux ; (1) épidémiologie et prévalence des bactéries productrices de β-lactamases et de carbapénèmases chez les poulets d’Algérie, (2) étude et détection de la résistance plasmidique à la colistine chez les animaux d’Algérie, (3) recherche de vecteur et/ou réservoirs de bactéries zoonotiques résistantes à la colistine, (4) épidémiologie des bactéries résistantes à la colistine chez les humains en France, au Laos et au Liban. A travers ces investigations nous avons montré l’émergence et la dissémination du gène mcr-1 chez les animaux (poulets et caprins) dans plusieurs sites en Algérie. Nous avons également rapporté la détection de souches résistantes à la colistine dans des isolats humains en France et au Liban. Ces travaux ont participé à la description de l’épidémiologie du gène mcr-1 dans le monde chez les animaux et les humains et soulèvent la question du devenir de l’usage de la colistine chez l’homme et l’animal. Pour faire face à ces risques, nous pensons que des mesures de restriction d’usage des antibiotiques (y compris de la colistine) chez les animaux doivent s’appliquer, notamment en Algérie, pour limiter la propagation de ces gènes de résistance à l’homme. Il apparait donc nécessaire et urgent de mettre en place des enquêtes de surveillance de l’usage des antibiotiques chez les animaux notamment en Algérie pour éviter la propagation de souches résistantes chez l’homme. / This thesis is divided into 6 chapters with four objectives; (1) the epidemiology and prevalence of β-lactamases in chickens from Algeria, (2) contribution to the study and detection of plasmid resistance to colistin in animals from Algeria, (3) vectors/ reservoirs of zoonotic bacteria resistant to colistin, and (4) Epidemiology of bacteria resistant to colistin in humans in France, Laos and Lebanon.Throughout these investigations, we can conclude that there is an emergence and spread of mcr-1 in animals (chickens and goats) in several sites in Algeria. We also noted the detection of colistin-resistant bacteria in human isolates in France and in Lebanon. This indicates a spread of mcr-1 and colistin resistance genes worldwide in animals and humans and raises the question on the colistin usage in animals. To prevent this end, we believe that restrictions on the use of antibiotics (including colistin) should be applied, particularly in Algeria, to limit the spread of these resistance genes. Use control of colistin should be routinely performed in humans and animals through colistin resistance surveys in animals and humans.

Linhagens de Escherichia coli produtoras de β-lactamase de espectro estendido (ESβL) do tipo CTX-M são endêmicas no Brasil, sendo prevalentes em casos de infecções hospitalares e ambulatoriais. Atualmente, cepas produtoras de CTX-M têm sido recuperadas de ambientes urbanos, animais de companhia ou de produção e de alimentos de origem animal, inclusive afetando o agronegócio, o que aponta uma possível rota de disseminação em diferentes ecossistemas. Recentemente, nesta espécie, foi descoberto um novo gene, chamado de mcr-1, que confere resistência transferível à colistina, um dos últimos antibióticos eficazes para o tratamento de infecções causadas por bactérias produtoras de ESBL e carbapenemases. Deste modo, o presente estudo tem como objetivo elucidar os aspectos sobre a caracterização e a relação de plasmídeos que carregam genes do tipo blaCTX-M-8 e mcr- 1 em cepas de E. coli isoladas de seres humanos, animais, ambiente aquático e alimentos, no Brasil. Neste estudo são apresentados os resultados da análise plasmidial de 25 cepas de E. coli, das quais nove apresentaram o genótipo blaCTX-M-8/IncI1, 11 apresentaram o genótipo mcr-1/IncX4 e cinco apresentaram ambos os genótipos blaCTX-M-8/IncI1 e mcr-1/IncX4. Dos resultados, podemos observar que plasmídeos IncI1 (blaCTX-M-8) e IncX4 (mcr-1) estão circulando no Brasil desde o ano de 2009 entre diferentes clones (STs) de E. coli e em diferentes ambientes e hospedeiros. Os plasmídeos IncI1 foram conjugativos e pertencentes ao ST113, exceto o plasmídeo recuperado de um isolado humano, que foi pertencente ao ST131. Os plasmídeos IncI1 apresentaram sua arquitetura conservada, com a presença de genes de replicação, transferência e estabilidade. A partir do alinhamento, os plasmídeos IncI1 apresentaram 94-99% de similaridade genética entre eles. Dentre os plasmídeos IncX4, independente da fonte de isolamento, todos permaneceram com sua arquitetura altamente conservada. Entretanto, apenas dois plasmídeos (um encontrado em uma cepa de animal e outro encontrado em uma cepa de ambiente aquático) apresentaram uma IS1294, truncando o gene de mobilização. Na análise comparativa, todos os plasmídeos IncX4 apresentaram similaridade genética de 95-99,9% entre eles. No alinhamento de plasmídeos IncX4 brasileiros contra plasmídeos de outras regiões geográficas, foi observada similaridade genética > 99,9%, o que confirma a estabilidade e conservação desses plasmídeos. Neste estudo foram reportados dados inéditos da primeira identificação do gene mcr-1 em diferentes ecossistemas no Brasil, assim como a nova variante mcr-5.3. A análise filogenética dos plasmídeos IncI1 e IncX4, destacam que ambos compartilham uma arquitetura conservada, e a evolução é atribuída à aquisição de genes de resistência. Adicionalmente, um novo vetor de disseminação do gene mcr-1 no Brasil foi identificado - o plasmídeo IncHI2. Os resultados desse estudo demonstram o grave problema da resistência bacteriana dentro do conceito One-health e que, com o avanço de ferramentas moleculares, a identificação e a resolução desse problema poderá estar cada vez mais próxima de ser elucidada. / CTX-M-type extended-spectrum-β-lactamase (ESβL)-producing-Escherichia coli are endemic in Brazil and are prevalent in cases of nosocomial and ambulatory infections. Currently, CTXM-producing strains have been recovered from urban environments, companion/production animals and animal source foods, which indicates a possible route of dissemination in different ecosystems. Recently, in this species, a new gene, called mcr-1, has been discovered, conferring transferable resistance to colistin, one of the last effective antibiotics for the treatment of infections caused by ESBL- and carbapenemases -producing bacteria. Thus, the present study aims to elucidate unknown aspects of the pan-resistome and ancestral relationship of plasmids carrying blaCTX-M-8 and mcr-1 genes in strains of E. coli isolated from humans, animals, aquatic environment and food, in Brazil. In this study, we present results from the plasmidial analysis of 25 E. coli strains, from which nine presented the blaCTX-M-8/IncI1 genotype, 11 presented the mcr-1/IncX4, and five presented both blaCTX-M-8/IncI1 and mcr-1/IncX4 genotypes. Among these results, we can observe that IncI1 (blaCTX-M-8) and IncX4 (mcr-1) plasmids are circulating in Brazil since 2009, between different E. coli clones (STs) and different hosts and environments. IncI1 plasmids were conjugative and assigned to ST113, with exception of a plasmid recovered from a human isolate, which was assigned to ST131. IncI1 plasmids presented conserved architecture, with the presence of genes of replication, transference, and stability. From the alignment analysis, IncI1 plasmids presented 94-99% genetic similarity among them. Among the IncX4 plasmids, regardless the isolation source, their architecture remained highly conserved. However, only two plasmids (one detected in an animal\'s strain and another detected in an aquatic environment\'s strain) presented an IS1294, truncating the mobilization gene. In the comparative analysis, all IncX4 plasmids presented 95-99,9% genetic similarity among them. In the alignment of Brazilian IncX4 plasmids against plasmids from other geographic regions, >99.9% genetic similarity was observed, confirming the stability and conservation of these plasmids. In this study, unprecedented data from the first identification of the mcr-1 gene in different ecosystems in Brazil, as well as the new variant, mcr-5.3. Additionally, it was identified a new dissemination vector of the mcr-1 gene in Brazil - the IncHI2 plasmid. Phylogenetic analysis of IncI1and IncX4 plasmids highlight that both share a conserved backbone, and evolution is attributed to the acquisition of clinically relevant antimicrobial resistance genes. The results from this study demonstrate the serious problem of the bacterial resistance within the \"One-Health\" concept and that, with the advance of molecular tools, identification and resolution of this problem may be increasingly closer to being elucidate.

As multidrug resistance in Gram-negative bacilli increases, the old antibiotic colistin has rapidly gained attention as one of few last line treatment options in the form of colistin methanesulfonate (CMS), which is hydrolyzed to colistin both in vitro and in vivo. There is a dearth of knowledge on fundamental aspects of colistin, including pharmacokinetics and optimal dosing regimens. The aim of this thesis was to improve the basis for optimal colistin therapy. To be able to study colistin, an LC-MS/MS assay method was developed which is sensitive, specific and useful in both in vivo and in vitro studies. Using this method we detected a significant loss of colistin during standard laboratory procedures. This loss was characterized and quantified, the hypothesis being that the loss is mainly caused by adsorption to labware. The pharmacokinetics of colistin was studied in two populations of critically ill patients, one with normal renal function and one with renal replacement therapy. Plasma concentrations were assayed with the method above, and population modeling was employed to describe the data. The results include a previously unseen, long elimination half-life of colistin. The data from the population on renal replacement therapy was described without modeling, and showed that both CMS and colistin are cleared by hemodiafiltration. Combination therapy is an approach that is often used when treating patients infected with multidrug-resistant pathogens. The thesis discusses how the joint effect of antibiotics can be measured using colistin and meropenem as a model, and proposes a method for testing antibiotic combinations. Furthermore, a PKPD model was adapted to describe the pharmacodynamics of the combination. In conclusion, a specific and sensitive method for analysis of colistin was developed and the adsorption of colistin to materials was described. The assay method has been well accepted internationally. The pharmacokinetics of colistin and CMS was described in two important patient populations, partly with surprising results that have influenced dosages of colistin worldwide. The pharmacodynamics of combination therapy was investigated and quantified, and the methods applied could be further developed into clinically useful tools for selection of antibiotic combinations.