In vitro efficacy of Imipenem-Relebactam and Cefepime-AAI101 against a global collection of ESBL-positive and carbapenemase-producing Enterobacteriaceae

Objectives: In vitro evaluation of the potential clinical efficacy of the novel β-lactam/β-lactamase-inhibitor combinations including imipenem-relebactam (IPM-REL) and cefepime-AAI101 (enmetazobactam) (FEP-AAI) against contemporary multidrug-resistant Enterobacteriaceae. Methods: Agar-based MIC screening against MDR-Enterobacteriaceae (n=264) was used to evaluate the in vitro efficacy of IPM-REL and FEP-AAI, to compare the results with established combinations, and to investigate alternative β-lactam partners for REL and AAI. The inhibition activities of REL, AAI and the comparators avibactam (AVI) and tazobactam, against isolated recombinant β-lactamases covering representatives from all four Ambler classes of β-lactamases were tested using a fluorescence-based assay. Results: Using recombinant proteins, all four inhibitors were highly active against the tested class A serine β-lactamases (SBLs); REL and AVI showed moderate activity against the Class C AmpC from P. aeruginosa and the Class D OXA-10/-48 SBLs, but outperformed tazobactam and AAI. All tested inhibitors lacked activity against Class B MBLs. In the presence of REL, IPM, but not AAI susceptibility increased against KPC-positive and OXA-48-positive isolates. Both aztreonam-AVI and ceftolozane-tazobactam were more efficacious than IPM-REL. In all the tested combinations, AAI was a more effective inhibitor of class A β-lactamases (ESBLs) than the established inhibitors. Conclusions: The results lead to the proposal of alternative combination therapies involving REL and AAI to potentiate the use of β-lactams against clinical Gram-negative isolates expressing a variety of β-lactamases. These results highlight the potential of novel combinations for combating strains not covered by existing therapies.