. 2023 Jun 28;26(7):107215.

doi: 10.1016/j.isci.2023.107215. eCollection 2023 Jul 21.

Ca-EDTA restores the activity of ceftazidime-avibactam or aztreonam against carbapenemase-producing Klebsiellapneumoniae infections

Dhammika Leshan Wannigama^{1

2

3

4

5

6}, Aye Mya Sithu Shein^{2

3}, Cameron Hurst⁷, Peter N Monk⁸, Parichart Hongsing^{9

10}, Phatthranit Phattharapornjaroen^{11

12}, William Graham Fox Ditcham⁴, Puey Ounjai¹³, Thammakorn Saethang¹⁴, Naphat Chantaravisoot^{15

16}, Pattama Wapeesittipan¹⁷, Sirirat Luk-In¹⁸, Sasipen Sae-Joo^{2

3}, Sumanee Nilgate^{2

3}, Ubolrat Rirerm^{2

3}, Chanikan Tanasatitchai^{2

3}, Naris Kueakulpattana^{2

3}, Matchima Laowansiri^{2

3}, Tingting Liao^{19

20}, Rosalyn Kupwiwat^{6

21}, Rojrit Rojanathanes²², Natharin Ngamwongsatit²³, Somkanya Tungsanga^{24

25}, Asada Leelahavanichkul^{2

26}, Naveen Kumar Devanga Ragupathi^{6

27

28}, Vishnu Nayak Badavath²⁹, S M Ali Hosseini Rad^{30

31}, Talerngsak Kanjanabuch^{24

32

33

34}, Nattiya Hirankarn^{2

31}, Robin James Storer³⁵, Longzhu Cui³⁶, Mohan Amarasiri³⁷, Hitoshi Ishikawa³⁸, Paul G Higgins^{39

40

41}, Stephen M Stick^{42

43

44}, Anthony Kicic^{42

43

44

45}, Tanittha Chatsuwan^{2

3}, Shuichi Abe^{5

6}

Affiliations

¹ Department of Infectious Diseases and Infection Control, Yamagata Prefectural Central Hospital, Yamagata, Japan.
² Department of Microbiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.
³ Center of Excellence in Antimicrobial Resistance and Stewardship Research, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
⁴ School of Medicine, Faculty of Health and Medical Sciences, The University of Western Australia, Nedlands, WA, Australia.
⁵ Biofilms and Antimicrobial Resistance Consortium of ODA Receiving Countries, The University of Sheffield, Sheffield, UK.
⁶ Pathogen Hunter's Research Team, Department of Infectious Diseases and Infection Control, Yamagata Prefectural Central Hospital, Yamagata, Japan.
⁷ Molly Wardaguga Research Centre, Charles Darwin University, Brisbane, QLD, Australia.
⁸ Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield Medical School, UK.
⁹ Mae Fah Luang University Hospital, Chiang Rai, Thailand.
¹⁰ School of Integrative Medicine, Mae Fah Luang University, Chiang Rai, Thailand.
¹¹ Department of Emergency Medicine, Center of Excellence, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
¹² Institute of Clinical Sciences, Department of Surgery, Sahlgrenska Academy, Gothenburg University, 40530 Gothenburg, Sweden.
¹³ Department of Biology, Faculty of Science, Mahidol University, Bangkok, Thailand.
¹⁴ Department of Computer Science, Faculty of Science, Kasetsart University, Bangkok, Thailand.
¹⁵ Center of Excellence in Systems Biology, Research Affairs, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
¹⁶ Department of Biochemistry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
¹⁷ Department of Clinical Science, University of Bergen, Bergen, Norway.
¹⁸ Department of Clinical Microbiology and Applied Technology, Faculty of Medical Technology, Mahidol University, Bangkok, Thailand.
¹⁹ Department of Physiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
²⁰ Center of Excellence for Microcirculation, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
²¹ Department of Dermatology. Faculty of Medicine Siriraj Hospital. Mahidol University, Bangkok, Thailand.
²² Center of Excellence in Materials and Bio-Interfaces, Faculty of Science, Chulalongkorn University, Bangkok, Thailand.
²³ Department of Clinical Sciences and Public Health, Faculty of Veterinary Science, Mahidol University, Nakhon Pathom, Thailand.
²⁴ Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
²⁵ Division of General Internal Medicine-Nephrology Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
²⁶ Translational Research in Inflammation and Immunology Research Unit (TRIRU), Department of Microbiology, Chulalongkorn University, Bangkok, Thailand.
²⁷ Department of Chemical and Biological Engineering, The University of Sheffield, Sheffield, UK.
²⁸ Department of Clinical Microbiology, Christian Medical College, Vellore, India.
²⁹ School of Pharmacy & Technology Management, SVKM's Narsee Monjee Institute of Management Studies (NMIMS), Hyderabad 509301, India.
³⁰ Department of Microbiology and Immunology, University of Otago, Dunedin, Otago 9010, New Zealand.
³¹ Center of Excellence in Immunology and Immune-Mediated Diseases, Chulalongkorn University, Bangkok 10330, Thailand.
³² Center of Excellence in Kidney Metabolic Disorders, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
³³ Dialysis Policy and Practice Program (DiP3), School of Global Health, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
³⁴ Peritoneal Dialysis Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.
³⁵ Office of Research Affairs, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
³⁶ Division of Bacteriology, School of Medicine, Jichi Medical University, Tochigi, Japan.
³⁷ Laboratory of Environmental Hygiene, Department of Health Science, School of Allied Health Sciences, Kitasato University, Kitasato, Sagamihara-Minami, Kanagawa 252-0373, Japan.
³⁸ Yamagata Prefectural University of Health Sciences, Kamiyanagi, Yamagata 990-2212, Japan.
³⁹ Institute for Medical Microbiology, Immunology and Hygiene, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
⁴⁰ German Centre for Infection Research, Partner site Bonn-Cologne, Cologne, Germany.
⁴¹ Center for Molecular Medicine Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50935 Cologne, Germany.
⁴² Telethon Kids Institute, University of Western Australia, Nedlands, WA 6009, Australia.
⁴³ Centre for Cell Therapy and Regenerative Medicine, Medical School, The University of Western Australia, Nedlands, WA 6009, Australia.
⁴⁴ Department of Respiratory and Sleep Medicine, Perth Children's Hospital, Nedlands, WA 6009, Australia.
⁴⁵ School of Public Health, Curtin University, Bentley, WA 6102, Australia.

PMID: 37496674
PMCID: PMC10366478
DOI: 10.1016/j.isci.2023.107215

Ca-EDTA restores the activity of ceftazidime-avibactam or aztreonam against carbapenemase-producing Klebsiellapneumoniae infections

Dhammika Leshan Wannigama et al. iScience. 2023.

. 2023 Jun 28;26(7):107215.

doi: 10.1016/j.isci.2023.107215. eCollection 2023 Jul 21.

Authors

Affiliations

¹ Department of Infectious Diseases and Infection Control, Yamagata Prefectural Central Hospital, Yamagata, Japan.
² Department of Microbiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.
³ Center of Excellence in Antimicrobial Resistance and Stewardship Research, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
⁴ School of Medicine, Faculty of Health and Medical Sciences, The University of Western Australia, Nedlands, WA, Australia.
⁵ Biofilms and Antimicrobial Resistance Consortium of ODA Receiving Countries, The University of Sheffield, Sheffield, UK.
⁶ Pathogen Hunter's Research Team, Department of Infectious Diseases and Infection Control, Yamagata Prefectural Central Hospital, Yamagata, Japan.
⁷ Molly Wardaguga Research Centre, Charles Darwin University, Brisbane, QLD, Australia.
⁸ Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield Medical School, UK.
⁹ Mae Fah Luang University Hospital, Chiang Rai, Thailand.
¹⁰ School of Integrative Medicine, Mae Fah Luang University, Chiang Rai, Thailand.
¹¹ Department of Emergency Medicine, Center of Excellence, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
¹² Institute of Clinical Sciences, Department of Surgery, Sahlgrenska Academy, Gothenburg University, 40530 Gothenburg, Sweden.
¹³ Department of Biology, Faculty of Science, Mahidol University, Bangkok, Thailand.
¹⁴ Department of Computer Science, Faculty of Science, Kasetsart University, Bangkok, Thailand.
¹⁵ Center of Excellence in Systems Biology, Research Affairs, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
¹⁶ Department of Biochemistry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
¹⁷ Department of Clinical Science, University of Bergen, Bergen, Norway.
¹⁸ Department of Clinical Microbiology and Applied Technology, Faculty of Medical Technology, Mahidol University, Bangkok, Thailand.
¹⁹ Department of Physiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
²⁰ Center of Excellence for Microcirculation, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
²¹ Department of Dermatology. Faculty of Medicine Siriraj Hospital. Mahidol University, Bangkok, Thailand.
²² Center of Excellence in Materials and Bio-Interfaces, Faculty of Science, Chulalongkorn University, Bangkok, Thailand.
²³ Department of Clinical Sciences and Public Health, Faculty of Veterinary Science, Mahidol University, Nakhon Pathom, Thailand.
²⁴ Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
²⁵ Division of General Internal Medicine-Nephrology Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
²⁶ Translational Research in Inflammation and Immunology Research Unit (TRIRU), Department of Microbiology, Chulalongkorn University, Bangkok, Thailand.
²⁷ Department of Chemical and Biological Engineering, The University of Sheffield, Sheffield, UK.
²⁸ Department of Clinical Microbiology, Christian Medical College, Vellore, India.
²⁹ School of Pharmacy & Technology Management, SVKM's Narsee Monjee Institute of Management Studies (NMIMS), Hyderabad 509301, India.
³⁰ Department of Microbiology and Immunology, University of Otago, Dunedin, Otago 9010, New Zealand.
³¹ Center of Excellence in Immunology and Immune-Mediated Diseases, Chulalongkorn University, Bangkok 10330, Thailand.
³² Center of Excellence in Kidney Metabolic Disorders, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
³³ Dialysis Policy and Practice Program (DiP3), School of Global Health, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
³⁴ Peritoneal Dialysis Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.
³⁵ Office of Research Affairs, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
³⁶ Division of Bacteriology, School of Medicine, Jichi Medical University, Tochigi, Japan.
³⁷ Laboratory of Environmental Hygiene, Department of Health Science, School of Allied Health Sciences, Kitasato University, Kitasato, Sagamihara-Minami, Kanagawa 252-0373, Japan.
³⁸ Yamagata Prefectural University of Health Sciences, Kamiyanagi, Yamagata 990-2212, Japan.
³⁹ Institute for Medical Microbiology, Immunology and Hygiene, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
⁴⁰ German Centre for Infection Research, Partner site Bonn-Cologne, Cologne, Germany.
⁴¹ Center for Molecular Medicine Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50935 Cologne, Germany.
⁴² Telethon Kids Institute, University of Western Australia, Nedlands, WA 6009, Australia.
⁴³ Centre for Cell Therapy and Regenerative Medicine, Medical School, The University of Western Australia, Nedlands, WA 6009, Australia.
⁴⁴ Department of Respiratory and Sleep Medicine, Perth Children's Hospital, Nedlands, WA 6009, Australia.
⁴⁵ School of Public Health, Curtin University, Bentley, WA 6102, Australia.

PMID: 37496674
PMCID: PMC10366478
DOI: 10.1016/j.isci.2023.107215

Abstract

Developing an effective therapy to overcome carbapenemase-positive Klebsiella pneumoniae (CPKp) is an important therapeutic challenge that must be addressed urgently. Here, we explored a Ca-EDTA combination with aztreonam or ceftazidime-avibactam in vitro and in vivo against diverse CPKp clinical isolates. The synergy testing of this study demonstrated that novel aztreonam-Ca-EDTA or ceftazidime-avibactam-Ca-EDTA combination was significantly effective in eliminating planktonic and mature biofilms in vitro, as well as eradicating CPKp infections in vivo. Both combinations revealed significant therapeutic efficacies in reducing bacterial load in internal organs and protecting treated mice from mortality. Conclusively, this is the first in vitro and in vivo study to demonstrate that novel aztreonam-Ca-EDTA or ceftazidime-avibactam-Ca-EDTA combinations provide favorable efficacy and safety for successful eradication of carbapenemase-producing Klebsiella pneumoniae planktonic and biofilm infections.

Keywords: Biological sciences; Health sciences; Immunology; Medical microbiology; Medical specialty; Medicine; Microbiology.

PubMed Disclaimer

Conflict of interest statement

The authors declare no competing interests.

Figures

**Figure 1**
Synergistic and Time-kill effect on carbapenemase-producing *K. pneumoniae* clinical isolates (n = 29) (A) Synergistic, and Time-kill data for (B) Ca-EDTA + ceftazidime/avibactam, (C) Ca-EDTA +aztreonam, (D) aztreonam + ceftazidime/avibactam. All experiments in (A) and (B) was performed as three biologically independent experiments, and the mean ± s.d. is shown. p values were determined using an unpaired, two-tailed Student’s t test.

**Figure 2**
Effects of Ca-EDTA, aztreonam and ceftazidime/avibactam and their combination *in vitro* (A) biofilm biovolume and (B) biofilm cell viability (%) of carbapenemase-producing *K. pneumoniae* clinical isolates (n = 29) at different time intervals. All experiments in a–b was performed as three biologically independent experiments, and the mean ± s.d. is shown. p values were determined using an unpaired, two-tailed Student’s t test.

**Figure 3**
Effects of Ca-EDTA, aztreonam and ceftazidime/avibactam and their combination on *catheter biofilm infections* Effects of PBS (control), aztreonam (16 μg/mL), ceftazidime/avibactam (1 μg/mL) (16 μg/mL), ceftazidime-avibactam + aztreonem (16/16 μg/mL), Ca-EDTA (24 mg/mL), aztreonam -Ca-EDTA (4/12 mg/mL) and ceftazidime/avibactam- Ca-EDTA (4 μg/mL + 12 mg/mL) on carbapenemase-producing *K. pneumoniae* clinical isolates (n = 7) catheter biofilm infection model *in vivo* (A) biovolume (B) Live/Dead cell ratio (C) bio-volume inhibition, and (D) survival of mice. Values were measured each of the 10 catheters and represented the as averages. All experiments in A–E were performed as three biologically independent experiments, and the mean ± s.d. is shown. p values were determined using an unpaired, two-tailed Student’s t test.

**Figure 4**
Confocal images of *in vivo* catheter biofilm Confocal imaging analysis (3D) z axis image stack visualizing (40x magnification) of (A) aztreonam (16 μg/mL), (B) ceftazidime/avibactam (1 μg/mL) (16 μg/mL), (C) ceftazidime-avibactam + aztreonem (16/16 μg/mL), (D) Ca-EDTA (24 mg/mL), (E) aztreonam -Ca-EDTA (4/12 mg/mL) and (F) ceftazidime/avibactam- Ca-EDTA (4 μg/mL + 12 mg/mL) on carbapenemase-producing *K. pneumoniae* clinical isolates (n = 7) catheter biofilm infection model *in vivo.* One catheter was selected from the 10 catheters after confocal scanning in each treatment group for visualization purposes and live bacteria were stained green and dead bacteria were stained red.

**Figure 5**
Effects of Ca-EDTA, aztreonam and ceftazidime/avibactam and their combination on *bacteremia* Effects of PBS (control), aztreonam (700 mg/kg), ceftazidime/avibactam (375 mg/kg), ceftazidime-avibactam + aztreonam (375 mg/kg + 700 mg/kg), Ca-EDTA (80 mg/kg/day), aztreonam -Ca-EDTA (700 mg/kg + 80 mg/kg/day) and ceftazidime/avibactam- Ca-EDTA (375 mg/kg + 80 mg/kg/day) on carbapenemase-producing *K. pneumoniae* clinical isolates (n = 7) mouse bacteremia infection model (A) illustration of a mouse model, (B) bacterial load in internal organs, (C) survival of mice. p values were determined using a two-sided Mann–Whitney U-test. All data were presented as means ± s.d.

**Figure 6**
Effects of Ca-EDTA, aztreonam and ceftazidime/avibactam and their combination on pneumonia Effects of PBS (control), aztreonam (700 mg/kg), ceftazidime/avibactam (375 mg/kg), ceftazidime-avibactam + aztreonam (375 mg/kg + 700 mg/kg), Ca-EDTA (80 mg/kg/day), aztreonam -Ca-EDTA (700 mg/kg + 80 mg/kg/day) and ceftazidime/avibactam- Ca-EDTA (375 mg/kg + 80 mg/kg/day) on carbapenemase-producing *K. pneumoniae* clinical isolates (n = 7) mouse lung infection model (A) illustration of a mouse model, (B) bacterial load in internal organs, (C) survival of mice. p values were determined using a two-sided Mann–Whitney U-test. All data were presented as means ± s.d.

**Figure 7**
Effects of Ca-EDTA, aztreonam and ceftazidime/avibactam and their combination on thigh infection Effects of PBS (control), aztreonam (700 mg/kg), ceftazidime/avibactam (375 mg/kg), ceftazidime-avibactam + Aztreonam (375 mg/kg + 700 mg/kg), Ca-EDTA (80 mg/kg/day), aztreonam -Ca-EDTA (700 mg/kg + 80 mg/kg/day) and ceftazidime/avibactam- Ca-EDTA (375 mg/kg + 80 mg/kg/day) on carbapenemase-producing *K. pneumoniae* clinical isolates (n = 7) mouse thigh infection model (A) illustration of a mouse model, (B) bacterial load in thigh, (C) serum creatinine of mice (D) relative expression of virulence genes. p values were determined using a two-sided Mann–Whitney U-test. All data were presented as means ± s.d.

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Ca-EDTA restores the activity of ceftazidime-avibactam or aztreonam against carbapenemase-producing Klebsiellapneumoniae infections

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Ca-EDTA restores the activity of ceftazidime-avibactam or aztreonam against carbapenemase-producing Klebsiellapneumoniae infections

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