LETTER TO THE EDITOR

In Vitro Interaction between Cefixime and Amoxicillin-Clavulanate

against Extended-Spectrum-Beta-Lactamase-Producing Escherichia coli
Causing Urinary Tract Infection

W e read with interest the article by Campbell et al. (4)

suggesting that the combination of clavulanate and oral
expanded-spectrum cephalosporins (OESCs) could be an in-
teresting therapeutic option for urinary tract infection (UTI)
due to Escherichia coli producing extended-spectrum beta-lacta-
mase (ESBL), for which no or few oral antibiotic compounds are
available (4). However, among the OESCs tested in that study,
ation of synergy, one AC strip is placed on an agar plate for 1 h
and then removed and a second cefixime strip is placed on top
of the gradient of the first agent (1, 3, 12). The MIC of the
combination was interpreted as the value at which the inhibi-
tion zone intersected the scale on the Etest strip. (Fig. 1). Syn-
ergy was evaluated by calculating the fractional inhibitory con-
centration index (1).

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cefdinir and cefpodoxime may not be the best options. Indeed,
among the OESCs, cefixime has the lowest MICs and the best
pharmacokinetic/pharmacodynamic parameters for E. coli (9,
11). Even if the serum concentrations of all OESCs are low (Cmax,
1.5 to 4.5 ␮g/ml), the serum concentrations of free cefixime are
estimated to be greater than the E. coli MIC90 for more than 50%
of the time (11). Furthermore, two randomized trials of oral
cefixime versus sequential intravenous-oral antibiotic treatment
for acute pyelonephritis in children supported the use of this com-
pound for febrile UTI (2, 10). Here we tested in vitro the combi-
nation of cefixime and amoxicillin-clavulanate (AC) to assess
whether this combination could be useful for UTI due to ESBL-
producing E. coli.
The isolates tested in this study were 64 previously charac-
terized E. coli strains harboring ESBL obtained from 2009 to
2011. Antimicrobial susceptibility was determined by the disk
diffusion method and interpreted according to the guidelines
of the Clinical and Laboratory Standards Institute (5). Isolates
were screened for ESBL production by the double-disk synergy
test with an extended-spectrum cephalosporin (cefotaxime,
ceftazidime) and AC (7). Multiplex PCR was used to charac-
terize ␤-lactamase genes, including blaCTX-M, blaSHV, blaTEM,
and blaOXA-1, by previously described methods and primers
and then sequencing (6). The MICs of cefixime and AC were
determined by the Etest method (AB bioMérieux, Solna, Swe-
den). The Etest has also been used to evaluate the activity of the
antimicrobial combination of cefixime and AC: for the evalu-
Table 1 presents the distribution of MIC50s and MIC90s of
cefixime and AC and their combination according to ESBL,
TEM-1, and OXA-1 genes. Among the 64 ESBL-producing E.
coli isolates, 85% carried CTX-M genes and 15% carried
TEM-52 or SHV-12 ESBL genes. With the combination, syn-
ergy was obtained for 60 out of 64 strains, additivity was ob-
tained for 2 strains, and indifference was obtained for 2 strains.
Results did not differ when cefixime was placed first and AC
second.
Based on the European Committee on Antibiotic Suscepti-
bility Testing breakpoint of 1 ␮g/␮l, 93% of the ESBL-produc-
ing E. coli strains were resistant to cefixime alone (8). In con-
trast, the combination was active against more than 90% of
these strains. The MIC50 of the combination was 0.25 ␮g/ml,
which was comparable to the MIC50 for non-ESBL-producing
E. coli (11).
Our study shows that AC can protect the activity of cefixime in
vitro and the in vitro Etest can easily detect the synergy of these
agents, which is practical for routine use in clinical laboratories. A
simple approach would be to determine the MIC of the combina-
Published ahead of print 25 April 2012
Address correspondence to Edouard Bingen, edouard.bingen@rdb.aphp.fr.
Copyright © 2012, American Society for Microbiology. All Rights Reserved.
doi:10.1128/JCM.00526-12

TABLE 1 Activities of cefixime and AC alone and together versus ESBL-producing E. coli according to ␤-lactamase gene contenta
Cefixime AC Cefixime–AC
No. of
ESBL group isolates MIC50 MIC90 Range MIC50 MIC90 Range MIC50 MIC90 Range
Overall 64 6 ⬎64 0.50–⬎64 4 8 1.5–24 0.25 0.75 0.09–24
CTX-M-1 10 4 ⬎64 1–⬎64 4 8 3–24 0.25 0.38 0.09–16
CTX-M-1, TEM-1 9 3 8 1.5–32 6 6 4–6 0.38 0.5 0.19–0.75
CTX-M-3 1 64 6 25
CTX-M-14 11 4 8 0.50–12 4 6 2–⬎64 0.25 0.25 0.09–4
CTX-M-14, TEM-1 5 2 6 0.50–8 4 6 4–6 0.19 0.25 0.09–0.50
CTX-M-15 6 ⬎64 ⬎64 4–⬎64 6 12 3–12 0.38 0.5 0.25–0.50
CTX-M-15, TEM-1 2 8–⬎64 2–6 0.09–0.50
CTX-M-15, OXA-1 5 ⬎64 ⬎64 ⬎64 8 12 6–24 0.5 2 0.38–24
CTX-M-27, TEM-1 2 24–⬎64 4–6 0.25–0.50
CTX-M-32 2 32–⬎64 4–24 0.50–2
CTX-M-57 1 ⬎64 3 0.25
TEM-52 5 1 4 0.50–⬎64 2 4 1.5–24 0.09 0.19 0.09–12
SHV-12 5 6 12 4–16 3 4 2–4 0.19 0.25 0.19–0.38
a
Values are in micrograms per milliliter. When the number of isolates is ⬍5, only the range is given.

2540 jcm.asm.org Journal of Clinical Microbiology p. 2540 –2541 July 2012 Volume 50 Number 7
 Letter to the Editor

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