The primary pharmacology of ceftazidime/avibactam: microbiology from clinical studies, and development of resistance during treatment

Abstract As one of a series of thematically linked reviews of the primary pharmacology of the β-lactam/β-lactamase inhibitor combination, ceftazidime/avibactam, this article reviews the microbiological findings in drug-exposed patients. Earlier articles in the series focused on basic in vitro and in vivo translational biology (J Antimicrob Chemother 2022; 77: 2321–40 and 2341–52) and the development and mechanisms of resistance in vitro (J Antimicrob Chemother 2023: Epub ahead of print. doi: 10.1093/jac/dkac449). In clinical trials of ceftazidime/avibactam, combined favourable microbiological responses for evaluable patients infected at baseline by susceptible Enterobacterales or Pseudomonas aeruginosa were 86.1% (851/988). The corresponding percent favourable among patients infected by ceftazidime/avibactam-resistant pathogens was 58.8% (10/17), noting that the majority (15/17) of the resistant examples were P. aeruginosa. Microbiological response rates to comparator treatments in the same clinical trials ranged between 64% and 95%, depending on the type of infection and the analysis population. Uncontrolled case studies over a wide range of patients infected by antibiotic multiresistant Gram-negative bacteria have demonstrated that ceftazidime/avibactam can elicit microbiological clearance of ceftazidime/avibactam-susceptible strains. In case studies where a matched cohort of patients had been treated with antibacterial agents other than ceftazidime/avibactam, microbiological outcomes were comparable between treatments, mostly being observationally more favourable for ceftazidime/avibactam (recognizing that numbers were too small for definitive superiority assessments). Development of resistance to ceftazidime/avibactam during therapy is reviewed. The phenomenon has been reported multiple times, mostly in difficult-to-treat patients infected by KPC-producing Enterobacterales. Molecular mechanisms, when determined, have frequently been observed previously in vitro, such as the ‘Ω-loop’ D179Y (Asp179Tyr) substitution found in KPC variant enzymes. In human volunteers exposed to therapeutic levels of ceftazidime/avibactam, faecal numbers of Escherichia coli, other enterobacteria, lactobacilli, bifidobacteria, clostridia and Bacteroides spp. decreased. Clostridioides difficile was detected in the faeces, but this was of uncertain significance, because no unexposed controls were studied.