International Journal of Antimicrobial Agents 57 (2021) 106344

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International Journal of Antimicrobial Agents

journal homepage: www.elsevier.com/locate/ijantimicag

Review

Systematic review and meta-analysis of in vitro efficacy of antibiotic

combination therapy against carbapenem-resistant Gram-negative
bacilli
Luigia Scudeller a,1, Elda Righi b,1,∗, Margherita Chiamenti b, Damiano Bragantini b,
Giulia Menchinelli c,d, Paolo Cattaneo b, Christian G. Giske e, Thomas Lodise f,
Maurizio Sanguinetti c,d, Laura J.V. Piddock g, François Franceschi g, Sally Ellis g,
Elena Carrara b, Alessia Savoldi b, Evelina Tacconelli b,h,i,∗
a
Clinical Epidemiology and Biostatistics, IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano Foundation, Milan, Italy
b
Division of Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, P.Le L.A. Scuro 10, 37134 Verona, Italy
c
Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
d
Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
e
Clinical Microbiology, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
f
Albany College of Pharmacy and Health Sciences, Albany, New York, USA
g
Global Antibiotic Research & Development Partnership (GARDP), 15 Chemin Louis-Dunant, Geneva, Switzerland
h
Division of Infectious Diseases, Department of Internal Medicine I, German Center for Infection Research, University of Tübingen, Otfried Müller Straße 12,
72074 Tübingen, Germany
i
German Centre for Infection Research (DZIF), Clinical Research Unit for Healthcare Associated Infections, Tübingen, Germany

a r t i c l e i n f o a b s t r a c t

Article history: The superiority of combination therapy for carbapenem-resistant Gram-negative bacilli (CR-GNB) in-
Received 20 January 2021 fections remains controversial. In vitro models may predict the efficacy of antibiotic regimens
Accepted 3 April 2021
against CR-GNB. A systematic review and meta-analysis was performed including pharmacoki-
netic/pharmacodynamic (PK/PD) and time–kill (TK) studies examining the in vitro efficacy of antibi-
Editor: Dr Jim Gray otic combinations against CR-GNB [PROSPERO registration no. CRD42019128104]. The primary out-
come was in vitro synergy based on the effect size (ES): high, ES ≥ 0.75, moderate, 0.35 < ES <
Keywords:
0.75; low, ES ≤ 0.35; and absent, ES = 0). A network meta-analysis assessed the bactericidal ef-
In vitro synergy
Antibiotic combination fect and re-growth rate (secondary outcomes). An adapted version of the ToxRTool was used for
PK/PD risk-of-bias assessment. Over 180 combination regimens from 136 studies were included. The most
Time–kill frequently analysed classes were polymyxins and carbapenems. Limited data were available for cef-
Carbapenem-resistant bacteria tazidime/avibactam, ceftolozane/tazobactam and imipenem/relebactam. High or moderate synergism
was shown for polymyxin/rifampicin against Acinetobacter baumannii [ES = 0.91, 95% confidence in-
terval (CI) 0.44–1.00], polymyxin/fosfomycin against Klebsiella pneumoniae (ES = 1.00, 95% CI 0.66–
1.00) and imipenem/amikacin against Pseudomonas aeruginosa (ES = 1.00, 95% CI 0.21–1.00). Com-
pared with monotherapy, increased bactericidal activity and lower re-growth rates were reported
for colistin/fosfomycin and polymyxin/rifampicin in K. pneumoniae and for imipenem/amikacin or
imipenem/tobramycin against P. aeruginosa. High quality was documented for 65% and 53% of PK/PD and
TK studies, respectively. Well-designed in vitro studies should be encouraged to guide the selection of
combination therapies in clinical trials and to improve the armamentarium against carbapenem-resistant
bacteria.
© 2021 The Authors. Published by Elsevier Ltd.
This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)

1. Introduction
∗
Corresponding authors. Tel.: +39 045 812 8284.
The rapid emergence and dissemination of multidrug-resistant
E-mail address: [email protected] (E. Tacconelli).
1
These two authors contributed equally to this study. (MDR) Gram-negative bacilli (GNB) is recognised as a major public

https://doi.org/10.1016/j.ijantimicag.2021.106344
0924-8579/© 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
L. Scudeller, E. Righi, M. Chiamenti et al. International Journal of Antimicrobial Agents 57 (2021) 106344

health issue [1,2]. Treatment options against carbapenem-resistant 2018. All search strings were discussed with a qualified librarian.
(CR) GNB remain limited [3]. To direct research and development Details of the bibliographic search strategy are listed in the Sup-
of new antibiotics, in 2017 the World Health Organization (WHO) plementary methods. Bibliographies of reviews and original pub-
published a list of pathogens prioritising CR Acinetobacter bau- lications were hand-searched for further studies. To reduce publi-
mannii, CR Pseudomonas aeruginosa and CR Enterobacteriaceae [4]. cation bias, the Infectious Diseases Society of America (IDSA) and
Novel compounds displaying in vitro activity against CR-GNB have European Congress of Clinical Microbiology and Infectious Diseases
been mainly tested in clinical trials, often including carbapenem- (ECCMID) conference proceedings for the years 2016–2018 were
susceptible bacteria [3]. Other antibiotic classes (e.g. polymyxins, also reviewed.
carbapenems, aminoglycosides) have been used against CR-GNB
alone or in combination in observational studies [5,6]. The ra-
tionale for combining two or more antibiotics against CR-GNB is 2.2. Selection criteria
based on the possibility to achieve a higher rate of bacterial killing
and to reduce the development of resistance. Despite promising re- Reports including data of bacterial killing curves from PK/PD
sults highlighted by some studies, pooled data from meta-analyses and TK studies analysing combination therapies against CR-GNB
have not shown clear evidence to support the use of antibiotic were included. Any type of study except reviews, editorials and
combinations in the treatment of CR-GNB infections [5–8]. More- protocol papers was eligible for inclusion, and all antibiotic dosage
over, results from well-designed clinical trials including infections schedules and frequencies were considered. Standard inoculum
by MDR-GNB are lacking, limiting the evidence on the effectiveness sizes (4 × 105 CFU/mL or the nearest available value) were selected
of older compared with novel compounds. [14]. Gold-standard broth microdilution was considered as the sus-
The COHERENCE project (COmbination tHErapy to treat sepsis ceptibility testing method.
due to carbapenem-Resistant bacteria in adult and pediatric popu-
lations: EvideNCE and common practice) aimed to coherently and 2.3. Data extraction
comprehensively analyse data on the use of antibiotic combina-
tions for treating severe infections caused by CR-GNB. The project Two investigators (MC and DB) independently assessed each
was commissioned by the Global Antibiotic Research and Develop- potentially relevant study for eligibility. Disagreements were re-
ment Partnership (GARDP) and was intended to have a global per- solved by consultation with a third party (ER). If eligibility could
spective from real-world clinical practice assessment of published not be determined, the full article was retrieved.
evidence from in vitro and clinical studies. The present article re- A standardised data extraction method was used to record rel-
ports data deriving from the meta-analyses performed on in vitro evant features of each study in a database, including study char-
studies. acteristics (year of publication, country, type of in vitro combina-
In vitro assessments of bacterial killing and antibiotic synergism tion testing), bacterial characteristics (type of bacterial strain and
can be used to support the effectiveness of antibiotic combinations number of isolated tested, method of antimicrobial susceptibility
against MDR-GNB [9]. A recent meta-analysis including 26 clinical testing and carbapenemase identification) and antimicrobial ther-
cases from 11 reports showed that synergy-guided antibiotic com- apy (type and dose of antibiotic administration, treatment dura-
bination therapy against MDR-GNB (54% P. aeruginosa, 27% Enter- tion). Bacterial isolates were considered resistant to carbapenems
obacteriaceae and 19% A. baumannii) was significantly associated according to the local interpretive criteria. Unless otherwise speci-
with survival [odds ratio (OR) = 0.44, 95% confidence interval (CI) fied, resistance was determined according to European Committee
0.20–0.98] [10]. on Antimicrobial Susceptibility Testing (EUCAST) 2019 breakpoints
There are currently only two meta-analyses assessing the ef- [15]. Combination therapy was defined as the association of at least
fectiveness of antibiotic combinations against CR GNB, including two or more antibiotics used to treat CR-GNB.
in vitro studies up to March 2013 and July 2014, respectively Primary outcome assessed was in vitro synergy or antagonism
[11,12]. These reviews, however, restricted the search only to se- of combination therapy defined as a >2 log10 reduction or increase,
lected pathogens and to a limited number of antibiotic dosages and respectively, in CFU/mL for a combination compared with the most
combinations. active single agent on bacterial kill or inhibition. Secondary out-
The aim of this systematic review and meta-analysis was to comes included: (i) bactericidal rates, defined as a >3 log10 reduc-
evaluate the in vitro activity of all available antibiotic combinations tion in CFU/mL compared with pre-treatment counts; and (ii) re-
and dosages against CR (or carbapenemase-producing) strains of growth rates, defined as ≥2 log10 CFU/mL decrease of the initial
A. baumannii, P. aeruginosa and Enterobacteriaceae from time–kill colony count followed by an increase of ≥1 log10 CFU/mL at two
(TK) and pharmacokinetic/pharmacodynamic (PK/PD) studies. subsequent timepoints (12 h and 24 h). In TK analyses reporting
multiple carbapenem doses tested within the same study, only rel-
2. Methods evant carbapenem concentrations (e.g. at least twice the resistance
breakpoint for carbapenems) were included to limit heterogeneity.
This review is part of the broader COHERENCE study supported Studies testing single bacterial strains were excluded.
by GARDP, which also includes evidence on combination therapy
to treat CR-GNB infections from in vivo and human studies.
2.4. Quality assessment
2.1. Search strategy
An adapted version of the ToxRTool to assess in vitro studies
This study was conducted in accordance with the Pre- was generated to assess the risk of bias of the included studies
ferred Reporting Items for Systematic Reviews and Meta-Analyses [16]. Details of the quality assessment are reported in the Supple-
(PRISMA) guidelines [13]. This systematic review is registered mentary material. In summary, studies were assigned to four cate-
with the PROSPERO international prospective register of sys- gories according to their relevance and scored 0–18 points (reliable
tematic reviews (www.crd.york.ac.uk/PROSPERO/; registration no. without restrictions, 15–18 points; reliable with restrictions, 11–14
CRD42019128104). points, not reliable, <11 points; not assignable, if insufficient docu-
We searched PubMed, Scopus and Web of Science databases mentation to assess the study was provided). Studies with a score
for publications in any language from inception until 31 December of ≥11 points were classified as high quality.

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L. Scudeller, E. Righi, M. Chiamenti et al. International Journal of Antimicrobial Agents 57 (2021) 106344

2.5. Data analysis K. pneumoniae. However, the data were not sufficient to perform a
meta-analysis.
We calculated each outcome separately for bacterial species, an- A total of 182 different combination regimens were tested in TK
tibiotic treatment, dose and in vitro testing method. Synergy or an- studies: 172 (95%) and 10 (5%) were double and triple combination
tagonism, bactericidal rates and re-growth rates were counted as regimens, respectively. In PK/PD studies, 21 antibiotic agents be-
events (e.g. number of isolates showing the outcome) and the sam- longing to 12 classes were combined in 41 different treatments:
ple size was the number of isolates tested. In each study, pooled 37 (90%) and 4 (10%) were combinations of two or three antibi-
analysis of bacterial strains from the same species was performed. otics, respectively. Table 1 summarises the most common combi-
For primary outcomes, pooled proportions and 95% CI of syner- nation regimens tested in TK and PK/PD studies. The complete list
gistic or antagonist strains were calculated in random-effect mod- of antibiotic combinations and the type of outcome assessed for
els. Due to the large number of studies showing extreme magni- each pathogen is reported in Supplementary Table S2.
tude (0% and 100%) of synergy, bactericidal rates and re-growth High-quality assessment was shown by 73 studies (54%) and
rates, the pooled estimate was calculated after Freeman–Tukey was higher for PK/PD (65%) compared with TK (53%) studies.
double-arcsine transformation to stabilise the variances. CIs were
based on score procedures. When applicable, the I2 statistic was 3.2. Meta-analysis
used to test heterogeneity (low, 0–0.25; fair, 0.25–0.5; moder-
ate, 0.5–0.75; and high, >0.75). In case of high heterogeneity, the Synergy rates for combination treatments were assessed by
pooled effect was disregarded and not interpreted. Pooled synergy type of bacteria (e.g. A. baumannii, K. pneumoniae and P. aerugi-
or antagonism rate was defined based on the effect size (ES) as fol- nosa) and study type (TK or PK/PD). No antagonism was detected
lows: high, ES ≥ 0.75; moderate, 0.35 < ES < 0.75; low, ES ≤ 0.35; for any treatment among the assessed studies.
or absence of synergy, ES = 0. Positive trends were reported for
3.2.1. Acinetobacter baumannii
synergistic combination regimens showing no significant 95% CI.
Table 2 summarises the results for A. baumannii. Data from
While synergy and antagonism intrinsically compare a com-
TK studies showed high synergy rates for the following com-
bination therapy with its monotherapy, assessment of secondary
binations: meropenem and polymyxin B or colistin [ES = 0.82
outcomes may involve the comparison of multiple combinations
(95% CI 0.23–1.00) and ES = 0.87 (95% CI 0.48–1.00), respec-
with different monotherapies. For this reason, a network meta-
tively], colistin and tigecycline (ES = 0.89, 95% CI 0.61–1.00) and
analysis (NMA) was performed to assess bactericidal and re-growth
colistin and rifampicin (ES = 0.75, 95% CI 0.41–0.99). High syn-
rates [17]. Connected networks were identified for monotherapies
ergy rates were reported from single TK studies for combination
and the corresponding combinations for bactericidal rates (propor-
tion of strains showing bactericidal rates over the total number of of colistin and trimethoprim/sulfamethoxazole (ES = 1.00, 95% CI
0.51–1.00), polymyxin B and amikacin (ES = 1.00, 95% CI 0.34–
strains tested) and re-growth rates (proportion of strains showing
1.00) and imipenem and tigecycline (ES = 0.80, 95% CI 0.38–
re-growth over the total number of strains tested). When applica-
ble, inconsistency was reported. The surface under the cumulative 0.96). PK/PD studies showed high synergy rates for colistin and
rifampicin (ES = 0.91, 95% CI 0.44–1.00) and imipenem and to-
ranking (SUCRA) curve was used for ranking different treatments
bramycin (ES = 1.00, 95% CI 0.38–1.00) combinations.
[18]. Analyses were performed separately for PK/PD and TK stud-
ies. The results were clustered by study quality. Publication bias
3.2.2. Klebsiella pneumoniae
was not assessed. Stata Statistical Software: Release 16 (StataCorp
The results for K. pneumoniae are reported in Table 3. TK studies
LLC, College Station, TX, USA) was used for analysis.
showed high synergy rates for colistin and rifampicin (ES = 1.00,
95% CI 0.95–1.00) and for combination of polymyxin B and
2.6. Role of the funding source imipenem (ES = 1.00, 95% CI 0.67–1.00) or doripenem (ES = 1.00,
95% CI 0.51–1.00). High synergy rates were shown for car-
GARDP supported the entire project, and GARDP employees bapenem and aminoglycoside combination, specifically imipenem
contributed to study design, data interpretation and drafting the and amikacin (ES = 1.00, 95% CI 0.51–1.00) and meropenem and
report. All authors had full access to data and had final responsi- amikacin (ES = 1.00, 95% CI 0.51–1.00). In PK/PD studies, high syn-
bility to submit for publication. ergy rates were displayed by combination of ceftazidime/avibactam
and aztreonam (ES = 1.00, 95% CI 0.21–1.00) and polymyxin B and
3. Results fosfomycin (ES = 1.00, 95% CI 0.66–1.00).

3.2.3. Pseudomonas aeruginosa

Our search yielded 6849 articles, including 6559 from
Table 4 summarises the results for P. aeruginosa. TK
databases, 100 from conference proceedings and 190 from bibli-
studies showed moderate synergy rates for combination of
ographies of reviews and original publications. A total of 439 full-
ceftolozane/tazobactam and colistin (ES = 0.50, 95% CI 0.15–
texts were assessed and 136 studies (94 TK and 42 PK/PD) were
0.85), colistin and imipenem (ES = 0.67, 95% CI 0.08–1.00) and
included (Fig. 1) [19–154]. The main characteristics of all included
meropenem and amikacin (ES = 0.43, 95% CI 0.31–0.55). Similar
studies and their quality assessment are presented in Supplemen-
rates were shown for combination of colistin and meropenem
tary Tables S1a and S1b.
and combination of tobramycin and imipenem. High synergy
rates were shown for combination of imipenem and amikacin
3.1. Type of bacteria and antibiotic treatment (ES = 1.00, 95% CI 0.21–1.00), while moderate synergy was
reported for combination of colistin and doripenem in PK/PD
A total of 42 studies reported data on PK/PD (including 24 two- studies.
compartment and 18 one-compartment models) and 94 studies on
TK; 10 studies reported data on both methods. 3.3. Sensitivity analysis
A total of 56 studies (43 TK and 13 PK/PD) reported data on
A. baumannii, 54 (36 TK and 18 PK/PD) on Klebsiella pneumoniae Sensitivity analysis was performed on high-quality studies (de-
and 31 (23 TK and 8 PK/PD) on P. aeruginosa. We also retrieved fined as reliable, with or without restriction) showing ToxRTool
25 studies (6 PK/PD and 19 TK) on Enterobacteriaceae other than score ≥11.

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L. Scudeller, E. Righi, M. Chiamenti et al. International Journal of Antimicrobial Agents 57 (2021) 106344

Fig. 1. PRISMA flow diagram of included studies.

Table 1
Most commonly analysed antibiotic combinations for time–kill (TK) and pharmacoki-
netic/pharmacodynamic (PK/PD) studies

Bacterium/antibiotic combination TK study PK/PD study Total of studies

Acinetobacter baumannii

Polymyxins + carbapenems 42 7 49
Polymyxins + rifampicin 20 1 21
Carbapenems + rifampicin 14 0 14
Polymyxins + tigecycline 13 2 15
Carbapenems + sulbactam 13 3 16
Total 102 13 115

Klebsiella pneumoniae

Polymyxins + carbapenems 52 3 55
Double carbapenem 26 1 27
Polymyxins + rifampicin 17 1 18
Polymyxins + fosfomycin 6 5 11
Polymyxins + tigecycline 7 1 8
Total 108 11 119

Pseudomonas aeruginosa

Carbapenems + aminoglycosides 25 2 27
Carbapenems + fluoroquinolones 22 1 23
Fluoroquinolones + cephalosporins 18 0 18
Polymyxins + carbapenems 8 3 11
Fluoroquinolones + aminoglycosides 10 0 10
Total 83 6 89

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L. Scudeller, E. Righi, M. Chiamenti et al. International Journal of Antimicrobial Agents 57 (2021) 106344

Table 2
In vitro synergy of antibiotic combinations against Acinetobacter baumannii assessed by pharmacokinetic/pharmacodynamic (PK/PD) and time–kill (TK) studies

Antibiotic regimen Assay No. of strains No. of studies No. of tests ES 95% CI Synergy rate

Colistin + meropenem PK/PD 3 1 4 0.40 0.00–0.95 Positive trend

Colistin + rifampicin PK/PD 2 1 4 0.91 0.44–1.00 High
Colistin + tigecycline PK/PD 4 1 2 0.63 0.24–0.95 Moderate
Imipenem + tobramycin PK/PD 1 1 3 1.00 0.38–1.00 High
Meropenem + amikacin PK/PD 1 1 1 0.00 0.00–0.79 No synergy
Polymyxin B + tigecycline PK/PD 4 1 2 0.08 0.00–0.43 Positive trend
Colistin + ampicillin/sulbactam TK 2 1 1 0.00 0.00–0.66 No synergy
Colistin + ampicillin/sulbactam + rifampicin TK 2 1 1 0.50 0.09–0.91 Moderate
Colistin + doripenem TK 16 2 3 0.39 0.00–0.94 Positive trend
Colistin + imipenem TK 10 2 2 0.39 0.07–0.76 Moderate
Colistin + meropenem TK 24 3 4 0.87 0.48–1.00 High
Colistin + rifampicin TK 24 5 7 0.75 0.41–0.99 High
Colistin + sulbactam TK 18 1 1 0.56 0.34–0.75 Moderate
Colistin + tigecycline TK 6 1 2 0.89 0.61–1.00 High
Colistin + trimethoprim/sulfamethoxazole TK 4 1 1 1.00 0.51–1.00 High
Doripenem + amikacin TK 8 1 1 0.13 0.02–0.47 Low
Doripenem + sulbactam TK 18 1 1 0.28 0.12–0.51 Low
Imipenem + rifampicin TK 4 2 3 0.72 0.00–1.00 Positive trend
Imipenem + tigecycline TK 5 1 1 0.80 0.38–0.96 High
Meropenem + ampicillin/sulbactam TK 2 1 1 0.50 0.09–0.91 Moderate
Meropenem + aztreonam TK 5 1 1 0.00 0.00–0.43 No synergy
Polymyxin B + amikacin TK 2 1 1 1.00 0.34–1.00 High
Polymyxin B + ampicillin/sulbactam TK 2 1 1 0.00 0.00–0.66 No synergy
Polymyxin B + imipenem TK 2 1 1 0.50 0.09–0.91 Moderate
Polymyxin B + meropenem TK 4 2 2 0.82 0.23–1.00 High
Polymyxin B + meropenem + ampicillin/sulbactam TK 2 1 1 0.50 0.09–0.91 Moderate
Polymyxin B + meropenem + rifampicin TK 2 1 1 0.50 0.09–0.91 Moderate
Polymyxin B + rifampicin TK 33 2 2 0.53 0.32–0.73 Moderate
Polymyxin B + tigecycline TK 33 2 2 0.34 0.16–0.55 Low

ES, effect size; CI, confidence interval.

NOTE: Pooled synergy or antagonism rate was defined based on the ES as follows: high, ES ≥ 0.75; moderate, 0.35 < ES < 0.75; low, ES ≤ 0.35; and absence
of synergy, ES = 0. Positive trends were reported for synergistic combination regimens showing no significant 95% CI.

Table 3
In vitro synergy of antibiotic combinations against Klebsiella pneumoniae assessed by pharmacokinetic/pharmacodynamic (PK/PD) and time–kill
(TK) studies

Antibiotic regimen Assay No. of strains No. of studies No. of tests ES 95% CI Synergy rate

Ceftazidime/avibactam + amikacin PK/PD 3 1 1 0.33 0.06–0.79 Low

Ceftazidime/avibactam + aztreonam PK/PD 1 1 1 1.00 0.21–1.00 High
Colistin + doripenem PK/PD 1 1 4 0.50 0.00–1.00 Positive trend
Colistin + fosfomycin PK/PD 8 3 5 0.58 0.28–0.86 Moderate
Polymyxin B + fosfomycin PK/PD 4 2 4 1.00 0.66–1.00 High
Meropenem + tigecycline PK/PD 5 1 1 0.40 0.12–0.77 Moderate
Ceftazidime/avibactam + colistin TK 16 1 1 0.25 0.10–0.49 Low
Colistin + doripenem TK 62 5 6 0.50 0.28–0.71 Moderate
Colistin + ertapenem TK 9 1 2 0.38 0.10–0.70 Moderate
Colistin + fosfomycin TK 2 1 21 0.60 0.41–0.78 Moderate
Colistin + gentamicin TK 26 2 2 0.31 0.14–0.50 Low
Colistin + meropenem TK 9 2 2 0.12 0.00–0.46 No synergy
Colistin + meropenem + tigecycline TK 6 1 1 0.00 0.00–0.39 No synergy
Colistin + rifampicin TK 25 2 2 1.00 0.95–1.00 High
Colistin + tigecycline TK 10 2 3 0.42 0.00–0.98 Positive trend
Colistin + tobramycin TK 4 1 2 0.37 0.05–0.76 Moderate
Doripenem + ertapenem TK 12 1 1 0.00 0.00–0.24 No synergy
Doripenem + gentamicin TK 26 2 2 0.15 0.03–0.32 Low
Imipenem + amikacin TK 4 1 1 1.00 0.51–1.00 High
Meropenem + amikacin TK 4 1 1 1.00 0.51–1.00 High
Meropenem + ertapenem TK 21 1 1 0.43 0.24–0.63 Moderate
Meropenem + gentamicin TK 13 1 1 0.00 0.00–0.23 No synergy
Meropenem + tigecycline TK 13 1 1 0.00 0.00–0.23 No synergy
Meropenem + tigecycline + gentamicin TK 13 1 1 0.00 0.00–0.23 No synergy
Polymyxin B+ doripenem TK 1 1 4 1.00 0.51–1.00 High
Polymyxin B + imipenem TK 2 1 3 1.00 0.67–1.00 High
Polymyxin B + meropenem TK 25 6 50 0.45 0.36–0.53 Moderate

ES, effect size; CI, confidence interval.

NOTE: Pooled synergy or antagonism rate was defined based on the ES as follows: high, ES ≥ 0.75; moderate, 0.35 < ES < 0.75; low, ES ≤ 0.35;
and absence of synergy, ES = 0. Positive trends were reported for synergistic combination regimens showing no significant 95% CI.

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L. Scudeller, E. Righi, M. Chiamenti et al. International Journal of Antimicrobial Agents 57 (2021) 106344

Table 4
In vitro synergy of antibiotic combinations against Pseudomonas aeruginosa assessed by pharmacokinetic/pharmacodynamic (PK/PD) and
time–kill (TK) studies

Antibiotic regimen Assay No. of strains No. of studies No. of tests ES 95% CI Synergy rate

Ceftazidime/avibactam + amikacin PK/PD 3 1 1 0.33 0.06–0.79 Low

Colistin + doripenem PK/PD 3 2 6 0.57 0.03–1.00 Moderate
Imipenem + amikacin PK/PD 1 1 2 1.00 0.21–1.00 High
Ceftolozane/tazobactam + colistin TK 4 1 1 0.50 0.15–0.85 Moderate
Ceftolozane/tazobactam + aztreonam TK 4 1 1 0.00 0.00–0.49 No synergy
Ceftolozane/tazobactam + amikacin TK 4 1 1 0.00 0.00–0.49 No synergy
Colistin + imipenem TK 2 1 2 0.67 0.08–1.00 Moderate
Colistin + meropenem TK 7 1 4 0.43 0.16–0.75 Moderate
Imipenem + amikacin TK 87 4 7 0.35 0.23–0.47 Low
Imipenem + tobramycin TK 2 1 8 0.39 0.04–0.80 Moderate
Meropenem + amikacin TK 63 2 1 0.43 0.31–0.55 Moderate

ES, effect size; CI, confidence interval.

NOTE: Pooled synergy or antagonism rate was defined based on the ES as follows: high, ES ≥ 0.75; moderate, 0.35 < ES < 0.75; low, ES ≤
0.35; and absence of synergy, ES = 0. Positive trends were reported for synergistic combination regimens showing no significant 95% CI.

3.3.1. Acinetobacter baumannii 3.4.2. Klebsiella pneumoniae

Synergy was displayed with the combination of a polymyxin NMAs were performed to evaluate bactericidal rates in 9 and
plus a carbapenem in four high-quality TK studies assessing 30 combination regimens from PK/PD and TK studies, respectively.
polymyxin B/meropenem combination with or without rifampicin No significant heterogeneity was identified in pairwise comparison
[39], colistin/meropenem [61], colistin/imipenem [71] and col- for bactericidal rates.
istin/doripenem [96]. These results were not confirmed for com- Significantly higher bactericidal rates were shown by
bination of colistin and meropenem in one PK/PD study [47]. Syn- polymyxin-based combinations, specifically for polymyxin
ergy rates between 0.68 and 0.91 were confirmed for colistin and B/rifampicin (P < 0.05) and colistin/gentamicin (P < 0.05) com-
rifampicin combination both in PK/PK and TK studies [71,105,113], pared with a polymyxin used as monotherapy in TK studies.
while colistin and polymyxin B in combination with tigecycline Carbapenem-based combinations did not show significant dif-
showed conflicting results [36,54]. High synergy rates were con- ferences in bactericidal activity compared with monotherapy,
firmed for imipenem plus tobramycin and colistin plus trimetho- however a higher bactericidal trend was displayed by polymyxin B
prim/sulfamethoxazole [38,89]. plus imipenem (cumulative probability best 36.8%–SUCRA = 0.8),
colistin plus ertapenem (SUCRA = 0.9) and imipenem/relebactam
3.3.2. Klebsiella pneumoniae plus amikacin (SUCRA = 0.9). In PK/PD studies, colistin-based
Moderate and high synergy rates were displayed with the combinations did not present significant differences in bactericidal
combination of polymyxins and fosfomycin in one TK and activity compared with colistin alone. No evidence of significant
five PK/PD studies [21,27,28,32,40]. Polymyxin/rifampicin and inconsistency was found. In TK studies, significant difference
polymyxin/carbapenem combinations showed, respectively, high in re-growth rate (P < 0.05) was found between colistin plus
and moderate-high synergy rates in good-quality TK studies fosfomycin and monotherapies at 24 h, confirmed by a lower
[25,32,33,61,63,84–86,92,95,105,144,143,120]. re-growth trend at 12 h in PK/PD studies for both polymyxin B
and colistin plus fosfomycin (SUCRA = 0.8). Significant differences
3.3.3. Pseudomonas aeruginosa in re-growth rates (P < 0.05) at 24 h were found for polymyxin
Combination of colistin and doripenem was evaluated in two B plus meropenem compared with the combination of polymyxin
PK/PD studies [45,124]. Colistin combined with imipenem was as- B plus rifampicin and for ceftazidime/avibactam compared with
sessed in one good-quality TK study [124]. Synergy rates were colistin alone in TK studies.
above 0.50 for both combinations. Other combinations were evalu- In TK studies, re-growth rates were significantly lower (P <
ated in good-quality PK/PD studies confirming the previous results 0.05) at 24 h for colistin and fosfomycin compared with col-
[19,49]. istin and fosfomycin used as monotherapies, for polymyxin B and
meropenem compared with polymyxin B and rifampicin com-
3.4. Network meta-analysis bination and for ceftazidime/avibactam compared with colistin
monotherapy. Lower re-growth trend at 12 h was shown in PK/PD
The list of antibiotic combinations tested for bactericidal activ- studies for both polymyxin B and colistin plus fosfomycin (SU-
ity and re-growth in PK/PD and TK studies are reported in Supple- CRA = 0.8).
mentary Table S2.
3.4.3. Pseudomonas aeruginosa
3.4.1. Acinetobacter baumannii Bactericidal rates were analysed for three colistin-based and
Data were available to perform NMAs in 10 and 19 combi- three carbapenem-based combination regimens in PK/PD and TK
nation regimens from PK/PD and TK studies, respectively, includ- studies, respectively.
ing polymyxin-based and doripenem-based combinations. No over- TK studies showed that combination of meropenem and
all heterogeneity was identified in pairwise comparison. Signifi- amikacin or imipenem with either amikacin or tobramycin resulted
cant differences in bactericidal activity between combinations and in significantly higher bactericidal effect compared with monother-
monotherapies were not shown, although in PK/PD studies a pos- apy (P < 0.05). In PK/PD studies, colistin-based combination with
itive trend was displayed by combination of colistin and tigecy- doripenem, meropenem or ceftolozane/tazobactam resulted as ef-
cline (SUCRA = 0.8). No evidence of significant inconsistency was fective as colistin monotherapy in terms of bactericidal effect. An
found. No statistically significant differences in re-growth rates increased bactericidal trend was displayed by combination of col-
were found for antibiotic combinations tested against CR A. bau- istin and ceftolozane/tazobactam (SUCRA = 0.7). No evidence of
mannii. significant inconsistency was found.

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L. Scudeller, E. Righi, M. Chiamenti et al. International Journal of Antimicrobial Agents 57 (2021) 106344

Statistically significant differences (P < 0.05) in re-growth rates with polymyxin monotherapy in CR-GNB, including CR Enterobac-
were found for combination of imipenem and amikacin or to- teriaceae [161,162].
bramycin compared with monotherapies at 24 h in TK studies. A In our study, a polymyxin combined with rifampicin or fos-
lower re-growth trend at 24 h in PK/PD studies was shown for fomycin resulted in high or moderate synergy rates against CR
meropenem plus tobramycin compared with monotherapies (SU- K. pneumoniae. Association of colistin and fosfomycin, in partic-
CRA = 0.9). ular, showed increased bactericidal rates in PK/PD studies and
lower re-growth rate at 24 h compared with colistin or fosfomycin
4. Discussion monotherapy.
An increased bactericidal rate was also shown for col-
Only two meta-analyses reporting in vitro tests assessing antibi- istin/rifampicin combination compared with monotherapy. Com-
otic combinations against CR-GNB are currently available [11,12]. bination of a polymyxin with a carbapenem showed high or
Nevertheless, these studies were limited to single micro-organisms moderate synergy rates in good-quality TK studies. Furthermore,
and included only certain antibiotic combinations (e.g. polymyx- pooled data on bactericidal activity from TK studies showed that
ins plus carbapenems) with no standardisation in the selection of polymyxin B combined with meropenem was associated with
the antibiotic dosage used. To our knowledge, this is the first sys- higher killing rates compared with polymyxin B alone and signif-
tematic review and meta-analysis of in vitro studies analysing the icantly lower re-growth rates at 24 h compared with polymyxin
effect of over 180 combination therapies against three different CR- B with rifampicin. Scant data were available for novel compounds
GNB. that showed in vitro activity against CR K. pneumoniae, such
We selected in vitro methods that are based on killing curves, as ceftazidime/avibactam and imipenem/relebactam. Although cef-
specifically TK and PK/PD studies. Both methods present advan- tazidime/avibactam was tested in combination with various antibi-
tages in studying the effectiveness of combination therapies. The otics (e.g. polymyxin B, colistin, amikacin and aztreonam), the re-
TK assay is one of the most used, standardised and reproducible sults were retrieved mainly from single in vitro studies accounting
static methods for combination testing [119,155]. PK/PD models al- for a limited number of strains.
low the investigation of bacterial killing and re-growth simulat- Colistin, usually in association with meropenem, has been em-
ing human drug exposure and can be considered as an accurate ployed to treat MDR P. aeruginosa [163]. The use of aminoglyco-
and informative in vitro method for studying antibiotic combina- sides also represents a valid alternative in combination therapy,
tion regimens [156]. although the high risk of renal toxicity usually limits the com-
Our meta-analysis showed that colistin-based and carbapenem- bination of an aminoglycoside with colistin in clinical practice
based combinations were the most commonly assessed regimens [164]. Our review showed that the combination of imipenem with
for all bacteria tested. This result is in line with human studies amikacin resulted in a high synergy rate in one good-quality PK/PD
testing various combinations of old antibiotics with in vitro activ- study. The combination of a carbapenem with an aminoglycoside
ity against CR-GNB, often used in association with high-dose car- demonstrated advantages in terms of bactericidal effect and re-
bapenems [3]. growth rates compared with monotherapies. In terms of bacteri-
Few randomised controlled trials (RCTs) have investigated com- cidal effect, however, colistin used as monotherapy showed similar
bination treatments against CR A. baumannii. One RCT comparing results compared with other colistin-based combinations. Data on
colistin monotherapy with colistin and rifampicin in 210 critically recently approved antibiotics active against CR P. aeruginosa were
ill patients showed similar 30-day mortality rates (43.3% vs. 42.9%) limited. Synergy for combinations including ceftazidime/avibactam
but increased microbiological eradication among those receiving and ceftolozane/tazobactam were evaluated in single studies in-
combination therapy with rifampicin compared with monotherapy cluding PK/PD and both PK/PD and TK analyses, respectively.
(61% vs. 45%; P = 0.034) [157]. Similarly, a small RCT including While our systematic review highlighted promising re-
94 patients with CR A. baumannii infections assessed the combina- sults for selected in vitro antibiotic combinations (including
tion of colistin and fosfomycin compared with colistin monother- polymyxin/tigecycline and polymyxin/rifampicin against A. bau-
apy, showing increased microbiological eradication but similar clin- mannii, polymyxin/fosfomycin and polymyxin/rifampicin against K.
ical outcomes [158]. More recently, 406 patients with severe infec- pneumoniae, and combination of a carbapenem with an aminogly-
tions caused by CR-GNB (mainly A. baumannii) were treated with coside or colistin against P. aeruginosa), it also emphasises several
colistin combined with meropenem, showing similar clinical fail- drawbacks of the in vitro studies analysed. Specifically, for several
ure rates compared with colistin alone (73% vs. 79%) [159]. In our combinations, definitive conclusions could not be drawn due to the
study, polymyxin-based combinations with rifampicin or tigecy- limited number of reports available assessing in vitro synergism
cline resulted in high or moderate synergy against A. baumannii and because of the limited comparability between the available
both in PK/PD and TK studies, while combination with meropenem reports. Very few high-quality TK and PK/PD studies have been
showed high or moderate synergy rates in TK studies and was performed on antibiotic combinations including recently marketed
confirmed moderate in two good-quality PK/PD studies including antibiotics that are often used in clinical practice. Even for com-
polymyxin B. Increased bactericidal activity was displayed by com- binations where a meta-analysis was performed, a generalisable
bination of colistin with tigecycline or imipenem in NMA, although interpretation was hampered by a high study variability.
the differences between various combination treatments and col- Our study presents several limitations. First, the high variability
istin alone were not significant. Not enough data were available to in bacterial strains and resistance patterns both in TK and PK/PD
investigate treatments involving fosfomycin. Overall, no studies in- studies may limit the generalisability of our results. Second, as pre-
cluding antibiotics approved in the last 10 years were retrieved for viously highlighted by others, the use of different clinical break-
A. baumannii. points to interpret the susceptibility profiles represents an impor-
Various observational studies have analysed double or triple tant limitation for the analysis of efficacy of different antibiotic
combination regimens against CR K. pneumoniae, both including regimens [12]. Third, although re-growth rates were assessed at 12
old antibiotics (e.g. tigecycline, polymyxins, aminoglycosides, fos- h and 24 h, the emergence of resistance occurring after 24 h was
fomycin and high-dose carbapenems) and novel compounds (e.g. not analysed since not all studies included reported these data. Fi-
ceftazidime/avibactam) administered as monotherapy or as part nally, the overall quality of TK studies was low. For example, only
of combination treatments [3,5,6,160]. Furthermore, few RCTs are 39% of TK studies specified the number of repetitions of the exper-
currently ongoing comparing polymyxin/carbapenem combination iments.

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L. Scudeller, E. Righi, M. Chiamenti et al. International Journal of Antimicrobial Agents 57 (2021) 106344

Due to the propensity of CR-GNB to acquire resistance to multi- [7] Paul M, Carmeli Y, Durante-Mangoni E, et al. Combination therapy
ple antibiotics, support from in vitro studies is important to high- for carbapenem-resistant Gram-negative bacteria. J Antimicrob Chemother
2014;69:2305–9.
light potential synergies to test in human trials. A major advantage [8] Schmid A, Wolfensberger A, Nemeth J, Schreiber PW, Sax H, Kuster SP.
of in vitro studies, and in particular of PK/PD models, includes the Monotherapy versus combination therapy for multidrug-resistant Gram-neg-
possibility to tune the bacterial inoculum and to increase the study ative infections: systematic review and meta-analysis. Sci Rep 2019;9:15290.
[9] Sopirala MM, Mangino JE, Gebreyes WA, et al. Synergy testing by Etest, mi-
duration in order to explore effective antimicrobial regimens. The crodilution checkerboard, and time–kill methods for pan-drug-resistant Acine-
lack of verification by clinical data, however, remains the main lim- tobacter baumannii. Antimicrob Agents Chemother 2010;54:4678–83.
itation to interpret the significance of in vitro synergies. Further- [10] Vardakas KZ, Athanassaki F, Pitiriga V, Falagas ME. Clinical relevance of in
vitro synergistic activity of antibiotics for multidrug-resistant Gram-negative
more, a correct interpretation of in vitro results and limitations by
infections: a systematic review. J Glob Antimicrob Resist 2019;17:250–9.
clinicians is paramount. Results from in vitro data, however, can [11] Ni W, Shao X, Di X, Cui J, Wang R, Liu Y. In vitro synergy of polymyxins
inform on the potential use of existing methods to explore the ef- with other antibiotics for Acinetobacter baumannii: a systematic review and
meta-analysis. Int J Antimicrob Agents 2015;45:8–18.
ficacy of antibiotic combinations and can help the optimisation of
[12] Zusman O, Avni T, Leibovici L, et al. Systematic review and meta-analysis of in
synergy tests that may be of clinical interest also at individual- and vitro synergy of polymyxins and carbapenems. Antimicrob Agents Chemother
strain-specific levels. 2013;57:5104–11.
In conclusion, we analysed over 180 antibiotic combinations [13] Moher D, Shamseer L, Clarke M, et al. Preferred reporting items for system-
atic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev
against CR-GNB, most frequently involving the polymyxin and 2015;4:1.
carbapenem classes. Data on combination therapy including re- [14] Methods for determining bactericidal activity of antimicrobial agents; approved
cently approved antibiotics with activity against CR-GNB (e.g. cef- guideline. CLSI document M26-A. Wayne, PA: Clinical and Laboratory Stan-
dards Institute (CL SI)CL SI; 1999.
tazidime/avibactam and ceftolozane/tazobactam) were limited to [15] European Committee on Antimicrobial Susceptibility Testing (EUCAST).
single studies. Breakpoint tables for interpretation of MICs and zone diameters. Version
For A. baumannii, the most consistently reported synergism was 9.0, 2019. https://www.eucast.org/fileadmin/src/media/PDFs/EUCAST_files/
Breakpoint_tables/v_9.0_Breakpoint_Tables.pdf [accessed 13 April 2021].
shown by colistin/rifampicin combination both from PK/PK and TK [16] Schneider K, Schwarz M, Burkholder I, et al. ‘ToxRTool’, a new tool to assess
studies, while synergism between a polymyxin with either a car- the reliability of toxicological data. Toxicol Lett 2009;189:138–44.
bapenem or tigecycline was not always shown. The association [17] Shim S, Yoon B-H, Shin IS, Bae JM. Network meta-analysis: application and
practice using Stata. Epidemiol Health 2017;39:e2017047.
of colistin with rifampicin remains promising and has previously
[18] Mbuagbaw L, Rochwerg B, Jaeschke R, et al. Approaches to interpreting and
been demonstrated to increase the microbiological clearance of A. choosing the best treatments in network meta-analyses. Syst Rev 2017;6:79.
baumannii in two human RCTs, although no impact on mortality [19] Almarzoky Abuhussain SS, Kuti JL, Nicolau DP. Antibacterial activity of hu-
man simulated epithelial lining fluid concentrations of ceftazidime–avibac-
was reported [157,158]. Polymyxin/rifampicin synergism was also
tam alone or in combination with amikacin inhale (BAY41-6551) against car-
shown against K. pneumoniae, although the benefit of this com- bapenem-resistant Pseudomonas aeruginosa and Klebsiella pneumoniae. An-
bination has not been assessed in a RCT for this pathogen. Re- timicrob Agents Chemother 2018;62:e00113–18.
garding K. pneumoniae, fosfomycin represents a potential promis- [20] Albur MS, Noel A, Bowker K, MacGowan A. The combination of colistin and
fosfomycin is synergistic against NDM-1-producing Enterobacteriaceae in in
ing option to consider, showing not only synergism but also in- vitro pharmacokinetic/pharmacodynamic model experiments. Int J Antimi-
creased bactericidal activity in association with polymyxins. Finally, crob Agents 2015;46:560–7.
the association of an aminoglycoside with imipenem showed in- [21] Yu W, Zhou K, Guo L, et al. In vitro pharmacokinetics/pharmacodynamics
evaluation of fosfomycin combined with amikacin or colistin against
creased synergism (e.g. imipenem and amikacin) and bactericidal KPC2-producing Klebsiella pneumoniae. Front Cell Infect Microbiol 2017;7:246.
activity (e.g. imipenem/amikacin or imipenem/tobramycin) against [22] Smith N, Lakota EA, Lehnard J, et al. Translating polymyxin B (PolyB) and
P. aeruginosa. Although this combination is often used in clinical meropenem synergy against carbapenem-resistant Acinetobacter baumannii
(CRAB): moving toward a rational, combinatorial pharmacokinetic target 28th
practice as empirical therapy in bloodstream infections, limitations European Congress of Clinical Microbiology and Infectious Diseases (ECCMID)
are represented by aminoglycoside nephrotoxicity and their limited 21–24 April 2018; Madrid, Spain ESCMID; 2018.
lung penetration. [23] Bergen PJ, Tsuji BT, Bulitta JB, et al. Synergistic killing of multidrug-resis-
tant Pseudomonas aeruginosa at multiple inocula by colistin combined with
Our results encourage the use of high-quality in vitro studies to
doripenem in an in vitro pharmacokinetic/pharmacodynamic model. Antimi-
explore potentially promising combination regimens to be used in crob Agents Chemother 2011;55:5685–95.
clinical practice and to guide the selection of therapies in future [24] Bulik CC, Nicolau DP. Double-carbapenem therapy for carbapenemase-pro-
ducing Klebsiella pneumoniae. Antimicrob Agents Chemother 2011;55:3002–4.
RCTs in order to improve the armamentarium against CR-GNB.
[25] Bulman ZP, Chen L, Walsh TJ, et al. Polymyxin combinations combat Es-
Funding: This study was funded by the Global Antibiotic Re- cherichia coli harboring mcr-1 and blaNDM-5 : preparation for a postantibiotic
search and Development Partnership (GARDP). era. mBio 2017;8 e00540-17.
Competing interests: None declared. [26] Bulman ZP, Satlin MJ, Chen L, et al. New polymyxin B dosing strategies to
fortify old allies in the war against KPC-2-producing Klebsiella pneumoniae.
Ethical approval: Not required. Antimicrob Agents Chemother 2017;61:e02023–116.
[27] Zhao M, Bulman ZP, Lenhard JR, et al. Pharmacodynamics of colistin and
References fosfomycin: a ‘treasure trove’ combination combats KPC-producing Klebsiella
pneumoniae. J Antimicrob Chemother 2017;72:1985–90.
[1] Boucher HW, Talbot GH, Bradley JS, et al. Bad bugs, no drugs: no ESKAPE! [28] Bulman ZP, Zhao M, Satlin MJ, et al. Polymyxin B and fosfomycin thwart
An update from the Infectious Diseases Society of America. Clin Infect Dis KPC-producing Klebsiella pneumoniae in the hollow-fibre infection model. Int
2009;48:1–12. J Antimicrob Agents 2018;52:114–18.
[2] Cassini A, Hogberg LD, Plachouras D, et al. Attributable deaths and disabil- [29] Cai Y, Lim TP, Teo JQ, et al. Evaluating polymyxin B-based combinations
ity-adjusted life-years caused by infections with antibiotic-resistant bacteria against carbapenem-resistant Escherichia coli in time–kill studies and in a hol-
in the EU and the European Economic Area in 2015: a population-level mod- low-fiber infection model. Antimicrob Agents Chemother 2017;61:e01509–16.
elling analysis. Lancet Infect Dis 2019;19:56–66. [30] Cai Y, Lim TP, Teo J, et al. In vitro activity of polymyxin B in combination
[3] Peri AM, Doi Y, Potoski BA, Harris PNA, Paterson DL, Righi E. Antimicrobial with various antibiotics against extensively drug-resistant Enterobacter cloacae
treatment challenges in the era of carbapenem resistance. Diagn Microbiol with decreased susceptibility to polymyxin B. Antimicrob Agents Chemother
Infect Dis 2019;94:413–25. 2016;60:5238–46.
[4] Tacconelli E, Carrara E, Savoldi A, et al. Discovery, research, and development [31] Deris ZZ, Yu HH, Davis K, et al. The combination of colistin and doripenem is
of new antibiotics: the WHO priority list of antibiotic-resistant bacteria and synergistic against Klebsiella pneumoniae at multiple inocula and suppresses
tuberculosis. Lancet Infect Dis 2018;18:318–27. colistin resistance in an in vitro pharmacokinetic/pharmacodynamic model.
[5] Daikos GL, Tsaousi S, Tzouvelekis LS, et al. Carbapenemase-producing Kleb- Antimicrob Agents Chemother 2012;56:5103–12.
siella pneumoniae bloodstream infections: lowering mortality by antibiotic [32] Diep JK, Jacobs DM, Sharma R, et al. Polymyxin B in combination with ri-
combination schemes and the role of carbapenems. Antimicrob Agents fampin and meropenem against polymyxin B-resistant KPC-producing Kleb-
Chemother 2014;58:2322–8. siella pneumoniae. Antimicrob Agents Chemother 2017;61 e02121-16.
[6] Tumbarello M, Viale P, Viscoli C, et al. Predictors of mortality in bloodstream [33] Diep JK, Sharma R, Ellis-Grosse EJ, Abboud CS, Rao GG. Evaluation of ac-
infections caused by Klebsiella pneumoniae carbapenemase-producing K. pneu- tivity and emergence of resistance of polymyxin B and ZTI-01 (fosfomycin
moniae: importance of combination therapy. Clin Infect Dis 2012;55:943–50.

8
L. Scudeller, E. Righi, M. Chiamenti et al. International Journal of Antimicrobial Agents 57 (2021) 106344

for injection) against KPC-producing Klebsiella pneumoniae. Antimicrob Agents bination with meropenem against Acinetobacter baumannii. Infect Dis (Lond)
Chemother 2018;62:e01815–17. 2017;49:831–9.
[34] Gagetti P, Pasteran F, Martinez MP, et al. Modeling meropenem treatment, [57] Yadav RLC, Rogers K, Rees V, et al. Meropenem plus tobramycin combina-
alone and in combination with daptomycin, for KPC-producing Klebsiella tion dosage regimens against clinical hypermutable Pseudomonas aeruginosa
pneumoniae strains with unusually low carbapenem MICs. Antimicrob Agents at simulated epithelial lining fluid concentrations in the hollow-fibre infec-
Chemother 2016;60:5047–50. tion model 28th European Congress of Clinical Microbiology and Infectious
[35] Wiskirchen DE, Koomanachai P, Nicasio AM, Nicolau DP, Kuti JL. In vitro phar- Diseases (ECCMID) 21–24 April 2018; Madrid, Spain ESCMID; 2018.
macodynamics of simulated pulmonary exposures of tigecycline alone and in [58] Beganovic ML, Daffinee K, Laplante K. Activity of minocycline, polymyxin B,
combination against Klebsiella pneumoniae isolates producing a KPC carbapen- sulbactam and meropenem against multidrug resistant Acinetobacter bauman-
emase. Antimicrob Agents Chemother 2011;55:1420–7. nii in a 72-hour in vitro pharmacodynamic model. 28th European Congress
[36] Hagihara M, Housman ST, Nicolau DP, Kuti JL. In vitro pharmacodynam- of Clinical Microbiology and Infectious Diseases (ECCMID) 21–24 April 2018;
ics of polymyxin B and tigecycline alone and in combination against car- Madrid, Spain ESCMID; 2018.
bapenem-resistant Acinetobacter baumannii. Antimicrob Agents Chemother [59] Gomez-Junyent J, Benavent E, Sierra Y, et al. Efficacy of ceftolozane–tazobac-
2014;58:874–9. tam alone and in combination with colistin against extensively drug-resistant
[37] Housman ST, Hagihara M, Nicolau DP, Kuti JL. In vitro pharmacodynamics of Pseudomonas aeruginosa in an in vitro pharmacodynamic biofilm model 28th
human-simulated exposures of ampicillin/sulbactam, doripenem and tigecy- European Congress of Clinical Microbiology and Infectious Diseases (ECCMID)
cline alone and in combination against multidrug-resistant Acinetobacter bau- 21–24 April 2018; Madrid, Spain ESCMID; 2018.
mannii. J Antimicrob Chemother 2013;68:2296–304. [60] Lodise T, Smith NM, Holden P. Efficacy of ceftazidime–avibactam in combina-
[38] Landersdorfer CB, Yadav R, Rogers KE, et al. Combating carbapenem-resistant tion with aztreonam (COMBINE): solutions for metallo-β -lactamase produc-
Acinetobacter baumannii by an optimized imipenem-plus-tobramycin dosage ing-Enterobacteriaceae (MBL). Open Forum Infect Dis 2018;5(Suppl 1):S425.
regimen: prospective validation via hollow-fiber infection and mathematical [61] Bedenic B, Beader N, Godic-Torkar K, et al. Postantibiotic effect of colistin
modeling. Antimicrob Agents Chemother 2018;62 e02053-17. alone and combined with vancomycin or meropenem against Acinetobacter
[39] Lenhard JR, Bulitta JB, Connell TD, et al. High-intensity meropenem combina- spp. with well defined resistance mechanisms. J Chemother 2016;28:375–82.
tions with polymyxin B: new strategies to overcome carbapenem resistance [62] Huang D, Yu B, Diep JK, et al. In vitro assessment of combined
in Acinetobacter baumannii. J Antimicrob Chemother 2017;72:153–65. polymyxin B and minocycline therapy against Klebsiella pneumoniae car-
[40] Wang J, He JT, Bai Y, Wang R, Cai Y. Synergistic activity of colistin/fosfomycin bapenemase (KPC)-producing K. pneumoniae. Antimicrob Agents Chemother
combination against carbapenemase-producing Klebsiella pneumoniae in 2017;61:e0 0 073–117.
an in vitro pharmacokinetic/pharmacodynamic model. Biomed Res Int [63] Barth N, Ribeiro VB, Zavascki AP. In vitro activity of polymyxin B plus
2018;2018:5720417. imipenem, meropenem, or tigecycline against KPC-2-producing Enterobacteri-
[41] Lenhard JR, Smith NM, Bulman ZP, et al. High-dose ampicillin–sulbactam aceae with high MICs for these antimicrobials. Antimicrob Agents Chemother
combinations combat polymyxin-resistant Acinetobacter baumannii in a hol- 2015;59:3596–7.
low-fiber infection model. Antimicrob Agents Chemother 2017;61 e01268-16. [64] Wilhelm CM, Nunes LS, Martins AF, Barth AL. In vitro antimicrobial activity of
[42] Lenhard JR, Thamlikitkul V, Silveira FP, et al. Polymyxin-resistant, carbapen- imipenem plus amikacin or polymyxin B against carbapenem-resistant Pseu-
em-resistant Acinetobacter baumannii is eradicated by a triple combination of domonas aeruginosa isolates. Diagn Microbiol Infect Dis 2018;92:152–4.
agents that lack individual activity. J Antimicrob Chemother 2017;72:1415–20. [65] Lenhard JR, Gall JS, Bulitta JB, et al. Comparative pharmacodynamics of
[43] Lim TP, Cai Y, Hong Y, et al. In vitro pharmacodynamics of various antibi- four different carbapenems in combination with polymyxin B against
otics in combination against extensively drug-resistant Klebsiella pneumoniae. carbapenem-resistant Acinetobacter baumannii. Int J Antimicrob Agents
Antimicrob Agents Chemother 2015;59:2515–24. 2016;48:719–24.
[44] Louie A, Castanheira M, Liu W, et al. Pharmacodynamics of β -lactamase [66] Rahim NA, Cheah SE, Johnson MD, et al. Synergistic killing of NDM-producing
inhibition by NXL104 in combination with ceftaroline: examining organ- MDR Klebsiella pneumoniae by two ‘old’ antibiotics—polymyxin B and chlo-
isms with multiple types of β -lactamases. Antimicrob Agents Chemother ramphenicol. J Antimicrob Chemother 2015;70:2589–97.
2012;56:258–70. [67] Bedenic B, Car H, Slacanac D, et al. In vitro synergy and postantibiotic ef-
[45] Lora-Tamayo J, Murillo O, Bergen PJ, et al. Activity of colistin combined with fect of colistin combinations with meropenem and vancomycin against En-
doripenem at clinically relevant concentrations against multidrug-resistant terobacteriaceae with multiple carbapenem resistance mechanisms. J Infect
Pseudomonas aeruginosa in an in vitro dynamic biofilm model. J Antimicrob Chemother 2018;24:1016–19.
Chemother 2014;69:2434–42. [68] Berleur M, Guerin F, Massias L, et al. Activity of fosfomycin alone or combined
[46] Lee HJ, Bergen PJ, Bulitta JB, et al. Synergistic activity of colistin and ri- with temocillin in vitro and in a murine model of peritonitis due to KPC-3- or
fampin combination against multidrug-resistant Acinetobacter baumannii in OXA-48-producing Escherichia coli. J Antimicrob Chemother 2018;73:3074–80.
an in vitro pharmacokinetic/pharmacodynamic model. Antimicrob Agents [69] Bratu S, Tolaney P, Karumudi U, et al. Carbapenemase-producing Klebsiella
Chemother 2013;57:3738–45. pneumoniae in Brooklyn, NY: molecular epidemiology and in vitro activity of
[47] Liu X, Zhao M, Chen Y, et al. Synergistic killing by meropenem and colistin polymyxin B and other agents. J Antimicrob Chemother 2005;56:128–32.
combination of carbapenem-resistant Acinetobacter baumannii isolates from [70] Brennan-Krohn T, Pironti A, Kirby JE. Synergistic activity of colistin-containing
Chinese patients in an in vitro pharmacokinetic/pharmacodynamic model. Int combinations against colistin-resistant Enterobacteriaceae. Antimicrob Agents
J Antimicrob Agents 2016;48:559–63. Chemother 2018;62:e00873–918.
[48] Tsala M, Vourli S, Daikos G, et al. Combination therapy against multidrug re- [71] Tripodi MF, Durante-Mangoni E, Fortunato R, Utili R, Zarrilli R. Comparative
sistant carbapenemase producing Klebsiella pneumoniae in an in vitro phar- activities of colistin, rifampicin, imipenem and sulbactam/ampicillin alone
macokinetic–pharmacodynamic model. Arch Hell Med 2018;35:198–206. or in combination against epidemic multidrug-resistant Acinetobacter bau-
[49] McGrath BJ, Lamp KC, Rybak MJ. Pharmacodynamic effects of extended dos- mannii isolates producing OXA-58 carbapenemases. Int J Antimicrob Agents
ing intervals of imipenem alone and in combination with amikacin against 2007;30:537–40.
Pseudomonas aeruginosa in an in vitro model. Antimicrob Agents Chemother [72] Clancy CJ, Chen L, Hong JH, et al. Mutations of the ompK36 porin gene and
1993;37:1931–7. promoter impact responses of sequence type 258, KPC-2-producing Klebsiella
[50] MacGowan A, Tomaselli S, Noel A, Bowker K. The pharmacodynam- pneumoniae strains to doripenem and doripenem–colistin. Antimicrob Agents
ics of avibactam in combination with ceftaroline or ceftazidime against Chemother 2013;57:5258–65.
β -lactamase-producing Enterobacteriaceae studied in an in vitro model of in- [73] Bernabeu-Wittel M, Pichardo C, García-Curiel A, et al. Pharmacoki-
fection. J Antimicrob Chemother 2017;72:762–9. netic/pharmacodynamic assessment of the in-vivo efficacy of imipenem
[51] Lister PD, Wolter DJ, Wickman PA, Reisbig MD. Levofloxacin/imipenem pre- alone or in combination with amikacin for the treatment of experimen-
vents the emergence of high-level resistance among Pseudomonas aerugi- tal multiresistant Acinetobacter baumannii pneumonia. Clin Microbiol Infect
nosa strains already lacking susceptibility to one or both drugs. J Antimicrob 2005;11:319–25.
Chemother 20 06;57:999–10 03. [74] Zhou YF, Tao MT, Feng Y, et al. Increased activity of colistin in combination
[52] Gunderson BW, Ibrahim KH, Hovde LB, Fromm TL, Reed MD, Rotschafer JC. with amikacin against Escherichia coli co-producing NDM-5 and MCR-1. J An-
Synergistic activity of colistin and ceftazidime against multiantibiotic-resis- timicrob Chemother 2017;72:1723–30.
tant Pseudomonas aeruginosa in an in vitro pharmacodynamic model. Antimi- [75] Balabanian G, Rose M, Manning N, Landman D, Quale J. Effect of porins and
crob Agents Chemother 2003;47:905–9. blaKPC expression on activity of imipenem with relebactam in Klebsiella pneu-
[53] Singh R, Kim A, Tanudra MA, et al. Pharmacokinetics/pharmacodynamics of a moniae: can antibiotic combinations overcome resistance? Microb Drug Resist
β -lactam and β -lactamase inhibitor combination: a novel approach for aztre- 2018;24:877–81.
onam/avibactam. J Antimicrob Chemother 2015;70:2618–26. [76] Yadav R, Landersdorfer CB, Nation RL, Boyce JD, Bulitta JB. Novel approach to
[54] Cai X, Yang Z, Dai J, et al. Pharmacodynamics of tigecycline alone and in com- optimize synergistic carbapenem–aminoglycoside combinations against car-
bination with colistin against clinical isolates of multidrug-resistant Acineto- bapenem-resistant Acinetobacter baumannii. Antimicrob Agents Chemother
bacter baumannii in an in vitro pharmacodynamic model. Int J Antimicrob 2015;59:2286–98.
Agents 2017;49:609–16. [77] Giamarellos-Bourboulis EJ, Grecka P, Giamarellou H. In-vitro interactions of
[55] Cordoba J, Coronado-Alvarez NM, Parra D, Parra-Ruiz J. In vitro activities of DX-8739, a new carbapenem, meropenem and imipenem with amikacin
novel antimicrobial combinations against extensively drug-resistant Acineto- against multiresistant Pseudomonas aeruginosa. J Antimicrob Chemother
bacter baumannii. Antimicrob Agents Chemother 2015;59:7316–19. 1996;38:287–91.
[56] Ghazi IM, Grupper M, Nicolau DP. Antibacterial activity of human simulated [78] Giamarellos Bouroulis EJ, Grecka P, Giamarellou H. Comparative in vitro in-
epithelial lining fluid concentrations of amikacin inhale alone and in com- teractions of ceftazidime, meropenem, and imipenem with amikacin on mul-
tiresistant Pseudomonas aeruginosa. Diagn Microbiol Infect Dis 1997;29:81–6.

9
L. Scudeller, E. Righi, M. Chiamenti et al. International Journal of Antimicrobial Agents 57 (2021) 106344

[79] Song JY, Kee SY, Hwang IS, et al. In vitro activities of carbapenem/sulbactam [102] Laishram S, Anandan S, Devi BY, et al. Determination of synergy between sul-
combination, colistin, colistin/rifampicin combination and tigecycline against bactam, meropenem and colistin in carbapenem-resistant Klebsiella pneumo-
carbapenem-resistant Acinetobacter baumannii. J Antimicrob Chemother niae and Acinetobacter baumannii isolates and correlation with the molecular
2007;60:317–22. mechanism of resistance. J Chemother 2015;28:297–303.
[80] Singkham-In U, Chatsuwan T. In vitro activities of carbapenems in com- [103] Lim TP, Tan TY, Lee W, et al. In-vitro activity of polymyxin B, rifampicin, tige-
bination with amikacin, colistin, or fosfomycin against carbapenem-resis- cycline alone and in combination against carbapenem-resistant Acinetobacter
tant Acinetobacter baumannii clinical isolates. Diagn Microbiol Infect Dis baumannii in Singapore. PLoS One 2011;6:e18485.
2018;91:169–74. [104] Le J, McKee B, Srisupha-Olarn W, Burgess DS. In vitro activity of carbapen-
[81] Yadav R, Bulitta JB, Nation RL, Landersdorfer CB. Optimization of syner- ems alone and in combination with amikacin against KPC-producing Klebsiella
gistic combination regimens against carbapenem- and aminoglycoside-re- pneumoniae. J Clin Med Res 2011;3:106–10.
sistant clinical Pseudomonas aeruginosa isolates via mechanism-based phar- [105] Lee GC, Burgess DS. Polymyxins and doripenem combination against KPC-pro-
macokinetic/pharmacodynamic modeling. Antimicrob Agents Chemother ducing Klebsiella pneumoniae. J Clin Med Res 2013;5:97–100.
2017;61:e01011–16. [106] Teo J, Lim TP, Hsu LY, Tan TY, Sasikala S, Hon PY, et al. Extensively drug-re-
[82] Gomez-Garces JL, Gil-Romero Y, Sanz-Rodriguez N, Munoz-Paraiso C, Re- sistant Acinetobacter baumannii in a Thai hospital: a molecular epidemiologic
godon-Dominguez M. In vitro activity of fosfomycin, alone or in combination, analysis and identification of bactericidal polymyxin B-based combinations.
against clinical isolates of carbapenem resistant Pseudomonas aeruginosa [in Antimicrob Resist Infect Control 2015;4:2.
Spanish]. Enferm Infecc Microbiol Clin 2016;34:228–31. [107] Yoon J, Urban C, Terzian C, Mariano N, Rahal JJ. In vitro double and
[83] Shields RK, Nguyen MH, Hao B, Kline EG, Clancy CJ. Colistin does not potenti- triple synergistic activities of polymyxin B, imipenem, and rifampin against
ate ceftazidime–avibactam killing of carbapenem-resistant Enterobacteriaceae multidrug-resistant Acinetobacter baumannii. Antimicrob Agents Chemother
in vitro or suppress emergence of ceftazidime–avibactam resistance. Antimi- 2004;48:753–7.
crob Agents Chemother 2018;62:e01018. [108] Su J, Li D, Guo Q, Guo Y, Zheng Y, Xu X. In vitro bactericidal ac-
[84] Hong JH, Clancy CJ, Cheng S, et al. Characterization of porin expression in tivity of trimethoprim–sulfamethoxazole/colistin combination against car-
Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae identi- bapenem-resistant Klebsiella pneumoniae clinical isolates. Microb Drug Resist
fies isolates most susceptible to the combination of colistin and carbapenems. 2018;25:152–6.
Antimicrob Agents Chemother 2013;57:2147–53. [109] Yim H, Woo H, Song W, Park MJ, Kim HS, Lee KM, et al. Time–kill synergy
[85] Jernigan MG, Press EG, Nguyen MH, Clancy CJ, Shields RK. The combination tests of tigecycline combined with imipenem, amikacin, and ciprofloxacin
of doripenem and colistin is bactericidal and synergistic against colistin-re- against clinical isolates of multidrug-resistant Klebsiella pneumoniae and Es-
sistant, carbapenemase-producing Klebsiella pneumoniae. Antimicrob Agents cherichia coli. Ann Clin Lab Sci 2011;41:39–43.
Chemother 2012;56:3395–8. [110] Yang YS, Lee Y, Tseng KC, et al. In vivo and in vitro efficacy of minocy-
[86] Sharma R, Patel S, Abboud C, et al. Polymyxin B in combination cline-based combination therapy for minocycline-resistant Acinetobacter bau-
with meropenem against carbapenemase-producing Klebsiella pneumoniae: mannii. Antimicrob Agents Chemother 2016;60:4047–54.
pharmacodynamics and morphological changes. Int J Antimicrob Agents [111] Tascini C, Gemignani G, Ferranti S, et al. Microbiological activity and clinical
2017;49:224–32. efficacy of a colistin and rifampin combination in multidrug-resistant Pseu-
[87] Kanellakopoulou K, Sarafis P, Galani I, Giamarellou H, Giamarellos-Bour- domonas aeruginosa infections. J Chemother 2004;16:282–7.
boulis EJ. In vitro synergism of β -lactams with ciprofloxacin and moxifloxacin [112] Vidaillac C, Leonard SN, Sader HS, Jones RN, Rybak MJ. In vitro activ-
against genetically distinct multidrug-resistant isolates of Pseudomonas aerug- ity of ceftaroline alone and in combination against clinical isolates of re-
inosa. Int J Antimicrob Agents 2008;32:33–9. sistant Gram-negative pathogens, including β -lactamase-producing Enter-
[88] Rao GG, Ly NS, Diep J, et al. Combinatorial pharmacodynamics of polymyxin B obacteriaceae and Pseudomonas aeruginosa. Antimicrob Agents Chemother
and tigecycline against heteroresistant Acinetobacter baumannii. Int J Antimi- 2009;53:2360–6.
crob Agents 2016;48:331–6. [113] Pachon-Ibanez ME, Docobo-Perez F, Lopez-Rojas R, et al. Efficacy of rifampin
[89] Khalil MAF, Moawad SS, Hefzy EM. In vivo activity of co-trimoxazole com- and its combinations with imipenem, sulbactam, and colistin in experimental
bined with colistin against Acinetobacter baumannii producing OXA-23 in a models of infection caused by imipenem-resistant Acinetobacter baumannii.
Galleria mellonella model. J Med Microbiol 2019;68:52–9. Antimicrob Agents Chemother 2010;54:1165–72.
[90] Rao GG, Ly NS, Bulitta JB, et al. Polymyxin B in combination with doripenem [114] Leite GC, Oliveira MS, Perdigao-Neto LV, et al. Antimicrobial combinations
against heteroresistant Acinetobacter baumannii: pharmacodynamics of new against pan-resistant Acinetobacter baumannii isolates with different resis-
dosing strategies. J Antimicrob Chemother 2016;71:3148–56. tance mechanisms. PLoS One 2016;11:e0151270.
[91] Queenan AM, Davies TA, He W, Lynch AS. Assessment of the combina- [115] Pankuch GA, Lin G, Seifert H, Appelbaum PC. Activity of meropenem with
tion of doripenem plus a fluoroquinolone against non-susceptible Acineto- and without ciprofloxacin and colistin against Pseudomonas aeruginosa and
bacter baumannii isolates from nosocomial pneumonia patients. J Chemother Acinetobacter baumannii. Antimicrob Agents Chemother 2008;52:333–6.
2013;25:141–7. [116] Giamarellos-Bourboulis EJ, Sambatakou H, Galani I, Giamarellou H. In vitro in-
[92] Kulengowski B, Campion JJ, Feola DJ, Burgess DS. Effect of the meropenem teraction of colistin and rifampin on multidrug-resistant Pseudomonas aerug-
MIC on the killing activity of meropenem and polymyxin B in com- inosa. J Chemother 2003;15:235–8.
bination against KPC-producing Klebsiella pneumoniae. J Antibiot (Tokyo) [117] Ozbek B, Otuk G. In vitro activities of tigecycline alone and in combination
2017;70:974–8. with colistin sulfate or sulbactam against carbapenem-susceptible and -resis-
[93] Kulengowski B, Clark JA, Burgess DS. Staggering the administration of tant Acinetobacter baumannii strains isolated from intensive care units. Int J
polymyxin B and meropenem in time–kill against carbapenem-resistant En- Antimicrob Agents 2010;36:191–2.
terobacteriaceae exhibiting a wide range of meropenem MICs. Diagn Micro- [118] Pankuch GA, Seifert H, Appelbaum PC. Activity of doripenem with and with-
biol Infect Dis 2019;93:261–4. out levofloxacin, amikacin, and colistin against Pseudomonas aeruginosa and
[94] Poirel L, Kieffer N, Nordmann P. In vitro evaluation of dual carbapenem com- Acinetobacter baumannii. Diagn Microbiol Infect Dis 2010;67:191–7.
binations against carbapenemase-producing Enterobacteriaceae. J Antimicrob [119] Peck KR, Kim MJ, Choi JY, et al. In vitro time–kill studies of antimicro-
Chemother 2016;71:156–61. bial agents against blood isolates of imipenem-resistant Acinetobacter bau-
[95] Pachon-Ibanez ME, Labrador-Herrera G, Cebrero-Cangueiro T, et al. Efficacy mannii, including colistin- or tigecycline-resistant isolates. J Med Microbiol
of colistin and its combination with rifampin in vitro and in experimental 2012;61:353–60.
models of infection caused by carbapenemase-producing clinical isolates of [120] Mezzatesta ML, Caio C, Gona F, Zingali T, Salerno I, Stefani S. Colistin in-
Klebsiella pneumoniae. Front Microbiol 2018;9:912. creases the cidal activity of antibiotic combinations against multidrug-re-
[96] Principe L, Capone A, Mazzarelli A, et al. In vitro activity of doripenem in sistant Klebsiella pneumoniae: an in vitro model comparing multiple com-
combination with various antimicrobials against multidrug-resistant Acineto- bination bactericidal testing at one peak serum concentration and time–kill
bacter baumannii: possible options for the treatment of complicated infection. method. Microb Drug Resist 2016;22:360–3.
Microb Drug Resist 2013;19:407–14. [121] Principe L, D’Arezzo S, Capone A, Petrosillo N, Visca P. In vitro activity of
[97] Oleksiuk LM, Nguyen MH, Press EG, et al. In vitro responses of Acinetobacter tigecycline in combination with various antimicrobials against multidrug re-
baumannii to two- and three-drug combinations following exposure to col- sistant Acinetobacter baumannii. Ann Clin Microbiol Antimicrob 2009;8:18.
istin and doripenem. Antimicrob Agents Chemother 2014;58:1195–9. [122] Liang W, Liu XF, Huang J, Zhu DM, Li J, Zhang J. Activities of colistin-
[98] Ozbek B, Mataraci-Kara E, Er S, Ozdamar M, Yilmaz M. In vitro activi- and minocycline-based combinations against extensive drug resistant Acine-
ties of colistin, tigecycline and tobramycin, alone or in combination, against tobacter baumannii isolates from intensive care unit patients. BMC Infect Dis
carbapenem-resistant Enterobacteriaceae strains. J Glob Antimicrob Resist 2011;11:109.
2015;3:278–82. [123] Sader HS, Rhomberg PR, Jones RN. In vitro activity of β -lactam an-
[99] Kulengowski B, Rutter WC, Campion JJ, Lee GC, Feola DJ, Burgess DS. Effect of timicrobial agents in combination with aztreonam tested against
increasing meropenem MIC on the killing activity of meropenem in combi- metallo-β -lactamase-producing Pseudomonas aeruginosa and Acinetobac-
nation with amikacin or polymyxin B against MBL- and KPC-producing Enter- ter baumannii. J Chemother 2005;17:622–7.
obacter cloacae. Diagn Microbiol Infect Dis 2018;92:262–6. [124] Bergen PJ, Forrest A, Bulitta JB, Tsuji BT, Sidjabat HE, Paterson DL, et al. Clin-
[100] Lai CC, Chen CC, Huang HL, Chuang YC, Tang HJ. The role of doxycycline in the ically relevant plasma concentrations of colistin in combination with
therapy of multidrug-resistant E. coli—an in vitro study. Sci Rep 2016;6:31964. imipenem enhance pharmacodynamic activity against multidrug-resistant
[101] Montero A, Ariza J, Corbella X, Domenech A, Cabellos C, Ayats J, et al. An- Pseudomonas aeruginosa at multiple inocula. Antimicrob Agents Chemother
tibiotic combinations for serious infections caused by carbapenem-resis- 2011;55:5134–42.
tant Acinetobacter baumannii in a mouse pneumonia model. J Antimicrob [125] Sopirala MM, Mangino JE, Gebreyes WA, et al. Synergy testing by Etest, mi-
Chemother 2004;54:1085–91.

10
L. Scudeller, E. Righi, M. Chiamenti et al. International Journal of Antimicrobial Agents 57 (2021) 106344

crodilution checkerboard, and time–kill methods for pan-drug-resistant Acine- [146] Zhang W, Guo Y, Li J, et al. In vitro and in vivo bactericidal activity of cef-
tobacter baumannii. Antimicrob Agents Chemother 2010;54:4678–83. tazidime–avibactam against carbapenemase-producing Klebsiella pneumoniae.
[126] Cirioni O, Ghiselli R, Silvestri C, et al. Efficacy of tachyplesin III, colistin, and Antimicrob Resist Infect Control 2018;7:142.
imipenem against a multiresistant Pseudomonas aeruginosa strain. Antimicrob [147] Chopra S, Matsuyama K, Tran T, Madrid P. Systematic discovery of synergis-
Agents Chemother 20 07;51:20 05–10. tic novel antibiotic combinations targeting multidrug-resistant Acinetobacter
[127] Choi JY, Soo Park Y, Cho CH, et al. Synergic in-vitro activity of baumannii. Int J Antimicrob Agents 2012;40:377–9.
imipenem and sulbactam against Acinetobacter baumannii. Clin Microbiol In- [148] Drago L, De Vecchi E, Nicola L, Colombo A, Guerra A, Gismondo MR. Ac-
fect 2004;10:1098–101. tivity of levofloxacin and ciprofloxacin in combination with cefepime, cef-
[128] Visalli MA, Jacobs MR, Appelbaum PC. Determination of activities of lev- tazidime, imipenem, piperacillin–tazobactam and amikacin against different
ofloxacin, alone and combined with gentamicin, ceftazidime, cefpirome, and Pseudomonas aeruginosa phenotypes and Acinetobacter spp. Chemotherapy
meropenem, against 124 strains of Pseudomonas aeruginosa by checkerboard 2004;50:202–10.
and time–kill methodology. Antimicrob Agents Chemother 1998;42:953–5. [149] Mataraci-Kara E, Yilmaz M, Ozbek Çelik B. In vitro effectiveness of cefepime
[129] Yang H, Chen G, Hu L, Liu Y, et al. In vivo activity of daptomycin/colistin com- alone or in combination with sulbactam against OXA-48 positive carbapen-
bination therapy in a Galleria mellonella model of Acinetobacter baumannii in- em-resistant Klebsiella pneumoniae isolates. 28th European Congress of Clini-
fection. Int J Antimicrob Agents 2015;45:188–9. cal Microbiology and Infectious Diseases (ECCMID) 21–24 April 2018; Madrid,
[130] Sun Y, Wang L, Li J, et al. Synergistic efficacy of meropenem and rifampicin Spain ESCMID; 2018.
in a murine model of sepsis caused by multidrug-resistant Acinetobacter bau- [150] Montero M, Ochoa SD, Lopez Causape C, et al. In vitro synergistic effects
mannii. Eur J Pharmacol 2014;729:116–22. of colistin plus meropenem combination on extensively drug-resistant (XDR)
[131] Roussel-Delvallez M, Wallet F, Delpierre F, Courcol RJ. In vitro bactericidal ef- Pseudomonas aeruginosa high-risk clones 28th European Congress of Clini-
fect of a β -lactam + aminoglycoside combination against multiresistant Pseu- cal Microbiology and Infectious Diseases (ECCMID) 21–24 April 2018; Madrid,
domonas aeruginosa and Acinetobacter baumannii. J Chemother 1996;8:365–8. Spain ESCMID; 2018.
[132] Rao GG, Ly NS, Soon RL, Roman S, Kelchlin PA, Holden PN. Polymyxin B in [151] Borjan J, Meyer KA, Wenzler E. Synergistic activity of ceftazidime–avibac-
combination with doripenem against Acinetobacter baumannii demonstrates tam in combination with polymyxin B against carbapenem-resistant Klebsiella
high synergy and suppression of resistance. In: Proceedings of the 52nd Inter- pneumoniae. IDWeek 3–7 October 2018; San Francisco, CA; 2018.
science Conference on Antimicrobial Agents and Chemotherapy (ICAAC), 9–12 [152] Monogue M, Nicolau DP. In vitro antibacterial activity of
September 2012; San Francisco, CA. Washington, DC. ASM Press; 2012. ceftolozane/tazobactam (C/T) alone and in combination with other an-
[133] Moland ES, Craft DW, Hong SG, et al. In vitro activity of tigecycline timicrobial agents against multidrug-resistant (MDR) Pseudomonas aeruginosa
against multidrug-resistant Acinetobacter baumannii and selection of tigecy- (PSA). IDWeek 4–8 October 2017; San Diego, CA; 2017.
cline–amikacin synergy. Antimicrob Agents Chemother 2008;52:2940–2. [153] Netto B, Vieira BJ, Hermes DM, Ribeiro VB, Zavascki AP. In vitro activity of
[134] Mutlu Yilmaz E, Sunbul M, Aksoy A, Yilmaz H, Guney AK, Guvenc T. Ef- non-bactericidal concentrations of polymyxin B in combination with other
ficacy of tigecycline/colistin combination in a pneumonia model caused by antimicrobials against OXA-23-producing carbapenem-resistant Acinetobacter
extensively drug-resistant Acinetobacter baumannii. Int J Antimicrob Agents baumannii. Braz J Infect Dis 2013;17:502–4.
2012;40:332–6. [154] Nivedita S, Nguyen L, Ryback MJ, Kaye KS. Evaluation of meropenem (MEM)
[135] Burgess DS, Hall RG, Hardin TC. In vitro evaluation of the activity of two in combination with colistin (COL) against colistin resistant extensively drug
doses of levofloxacin alone and in combination with other agents against resistant (XRD) Gram negative bacteria. Open Forum Infect Dis 2018;5(Supp
Pseudomonas aeruginosa. Diagn Microbiol Infect Dis 2003;46:131–7. 1):S727.
[136] Safarika A, Galani I, Pistiki A, Giamarellos-Bourboulis EJ. Time–kill effect of [155] Tängdén T, Hickman RA, Forsberg P, Lagerbäck P, Giske CG, Cars O. Evaluation
levofloxacin on multidrug-resistant Pseudomonas aeruginosa and Acinetobacter of double- and triple-antibiotic combinations for VIM- and NDM-producing
baumannii: synergism with imipenem and colistin. Eur J Clin Microbiol Infect Klebsiella pneumoniae by in vitro time–kill experiments. Antimicrob Agents
Dis 2015;34:317–23. Chemother 2014;58:1757–62.
[137] Martin L, Pares AS, Plasencia V, et al. Colistin plus azithromycin as an al- [156] Rao GG, Li J, Garonzik SM, Nation RL, Forrest A. Assessment and modelling of
ternative treatment of infections caused by multidrug resistant Pseudomonas antibacterial combination regimens. Clin Microbiol Infect 2018;24:689–96.
aeruginosa 27th European Congress of Clinical Microbiology and Infectious [157] Durante-Mangoni E, Signoriello G, Andini R, et al. Colistin and rifampicin
Diseases (ECCMID) 22–25 April 2017; Vienna, Austria ESCMID; 2017. compared with colistin alone for the treatment of serious infections due to
[138] Bedenić B, Beader N, Francula-Zaninovic S, et al. In vitro synergy and postan- extensively drug-resistant Acinetobacter baumannii: a multicenter, randomized
tibiotic effect of colistin combined with meropenem against Enterobacte- clinical trial. Clin Infect Dis 2013;57:349–58.
riaceae with multiple carbapenem-resistance mechanisms 27th European [158] Sirijatuphat R, Thamlikitkul V. Colistin versus colistin plus fosfomycin for
Congress of Clinical Microbiology and Infectious Diseases (ECCMID) 22–25 treatment of carbapenem-resistant Acinetobacter baumannii infections: a pre-
April 2017; Vienna, Austria ESCMID; 2017. liminary study. Antimicrob Agents Chemother 2014;58:5598–601.
[139] Teo J, Lim TP, Tan SX, et al. Evaluation of polymyxin B (PB)-based and dual– [159] Paul M, Daikos GL, Durante-Mangoni E, et al. Colistin alone versus colistin
carbapenem combinations against carbapenem resistant Enterobacteriaceae plus meropenem for treatment of severe infections caused by carbapenem-re-
co-harbouring mcr-1 and KPC-2. In: 27th European Congress of Clinical Mi- sistant Gram-negative bacteria: an open-label, randomised controlled trial.
crobiology and Infectious Diseases (ECCMID); 2017. Lancet Infect Dis 2018;18:391–400.
[140] Pachon-Ibanez ME, Docobo-Perez F, Jimenez-Mejias ME, et al. Efficacy of ri- [160] Onorato L, Di Caprio G, Signoriello S, Coppola N. Efficacy of cef-
fampin, in monotherapy and in combinations, in an experimental murine tazidime/avibactam in monotherapy or combination therapy against car-
pneumonia model caused by panresistant Acinetobacter baumannii strains. Eur bapenem-resistant Gram-negative bacteria: a meta-analysis. Int J Antimicrob
J Clin Microbiol Infect Dis 2011;30:895–901. Agents 2019;54:735–40.
[141] Giamarellos-Bourboulis EJ, Kentepozidis N, Antonopoulou A, Plachouras D, [161] ClinicalTrials.gov. Polymyxin B monotherapy vs combination therapy in
Tsaganos T, Giamarellou H. Postantibiotic effect of antimicrobial combina- critically ill patients with multi-drug resistant pathogens. NCT03159078.
tions on multidrug-resistant Pseudomonas aeruginosa. Diagn Microbiol Infect https://clinicaltrials.gov/ct2/results?cond=&term=NCT03159078&cntry=
Dis 2005;51:113–17. &state=&city=&dist= [accessed 13 April 2021].
[142] Phee LM, Betts JW, Bharathan B, Wareham DW. Colistin and fusidic acid, [162] ClinicalTrials.gov. Trial for the treatment of extensively drug-resistant Gram-
a novel potent synergistic combination for treatment of multidrug-re- negative bacilli. NCT01597973. https://clinicaltrials.gov/ct2/results?cond=
sistant Acinetobacter baumannii infections. Antimicrob Agents Chemother &term=NCT01597973&cntry=&state=&city=&dist= [accessed 13 April 2021].
2015;59:4544–50. [163] Linden PK, Kusne S, Coley K, et al. Use of parenteral colistin for the treat-
[143] Del Bono V, Giacobbe DR, Marchese A, et al. Meropenem for treating KPC-pro- ment of serious infection due to antimicrobial-resistant Pseudomonas aerugi-
ducing Klebsiella pneumoniae bloodstream infections: should we get to the nosa. Clin Infect Dis 2003;37:154–60.
PK/PD root of the paradox? Virulence 2017;8:66–73. [164] Falagas ME, Rafailidis PI, Kasiakou SK, et al. Effectiveness and nephrotoxic-
[144] Clancy CJ, Hao B, Shields RK, et al. Doripenem, gentamicin, and colistin, alone ity of colistin monotherapy vs. colistin–meropenem combination therapy for
and in combinations, against gentamicin-susceptible, KPC-producing Kleb- multidrug-resistant Gram-negative bacterial infections. Clin Microbiol Infect
siella pneumoniae strains with various ompK36 genotypes. Antimicrob Agents 2006;12:1227–30.
Chemother 2014;58:3521–5.
[145] Liu B, Bai Y, Liu Y, et al. In vitro activity of tigecycline in combination with
cefoperazone–sulbactam against multidrug-resistant Acinetobacter baumannii.
J Chemother 2015;27:271–6.

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