The pharmacodynamics of avibactam in combination with ceftaroline or ceftazidime against β-lactamase-producing Enterobacteriaceae studied in an in vitro model of infection

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Objectives: Pharmacodynamics of β-lactamase inhibitors are an area of intense interest as new β-lactam/β-lactamase inhibitor combinations enter clinical development and clinical practice. Avibactam, a non-β-lactam β-lactamase inhibitor, has been combined with ceftaroline or ceftazidime but these two combinations have not been directly compared.

Methods: Using an in vitro pharmacokinetic model we simulated human drug concentration–time courses associated with ceftaroline 600 mg every 8 h and ceftazidime 2000 mg every 8 h. Avibactam was given by continuous infusion at a range of concentrations up to 10 mg/L and antibacterial effect assessed against a CTX-M-producing Escherichia coli, AmpC-hyperproducing Enterobacter cloacae and KPC-producing Klebsiella pneumoniae. Simulations were performed over 72 h.

Results: Avibactam, at a concentration of 1–2 mg/L, produced maximum bacterial clearance over 72 h for the E. coli and E. cloacae strains with both ceftaroline and ceftazidime. Avibactam (4 mg/L) was required for maximum reduction in bacterial load with the KPC-producing K. pneumoniae. A series of dose fractionation experiments were performed with avibactam against each of the three strains and AUC, Cmax or T > avibactam concentration of 1, 2 or 4 mg/L related to antibacterial effect as measured by change in bacterial count at 24 h. AUC or Cmax were best related to 24 h antibacterial effect for avibactam though there was no consistent pattern favouring one over the other.

Conclusions: As AUC is a much easier and more reliable pharmacokinetic measure than Cmax, it would be useful to explore how AUC-based indices for avibactam exposures could be used for translating the results of the present study into patients’ therapy.

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