Synergy between conventional antibiotics and anti-biofilm peptides in a murine, sub-cutaneous abscess model caused by recalcitrant ESKAPE pathogens

Abstract

With the antibiotic development pipeline running dry, many fear that we might soon run out of treatment options. High-density infections are particularly difficult to treat due to their adaptive multidrug-resistance and currently there are no therapies that adequately address this important issue. Here, a large-scale in vivo study was performed to enhance the activity of antibiotics to treat high-density infections caused by multidrug-resistant Gram-positive and Gram-negative bacteria. It was shown that synthetic peptides can be used in conjunction with the antibiotics ciprofloxacin, meropenem, erythromycin, gentamicin, and vancomycin to improve the treatment outcome of murine cutaneous abscesses caused by clinical hard-to-treat pathogens including all ESKAPE ( E nterococcus faecium, S taphylococcus aureus, K lebsiella pneumoniae, A cinetobacter baumannii, P seudomonas aeruginosa, E nterobacter cloacae) pathogens and Escherichia coli. Promisingly, combination treatment often showed synergistic effects that significantly reduced abscess sizes and/or improved clearance of bacterial isolates from the infection site, regardless of the antibiotic mode of action. In vitro data suggest that the mechanisms of peptide action in vivo include enhancement of antibiotic penetration and potential disruption of the stringent stress response.

Author summary

There has been enormous publicity about the inexorable rise of resistance and the dearth of new therapies. However less attention has been placed on adaptively multidrug-resistant high density bacterial infections for which antibiotics are highly used but no effective therapies currently exist. Here we have provided new hope for this previously intractable class of infections as typified by abscess infections that are responsible for 3.2 million annual emergency room visits in the US alone. We show how to enhance the activity of antibiotics to treat multidrug-resistant Gram-positive and Gram-negative bacteria, using peptides that target the bacterial stress response, persister-based resistance and the outer membrane permeability barrier. In particular we have employed a new bacterial subcutaneous abscess mouse model to demonstrate that: (a) 7 of the society’s most recalcitrant pathogens formed cutaneous abscesses and even when antibiotics were directly delivered into abscess tissues, they showed poor efficacy; (b) By combining antibiotics with the local administration of anti-biofilm peptides that target cellular (stringent) stress responses, we could pharmacologically treat the infection and reduce the severity of cutaneous abscesses; (c) This synergy was due to increased outer membrane permeability as well as the disruption of the conserved stringent stress response that controls virulence and antibiotic resistance, particularly due to so-called persisters. These peptides have therefore the potential to broaden our limited antibiotic arsenal for a group of extremely difficult to treat infections.