In a hollow-fiber model, we mimicked the drug exposures achieved in the lungs of humans treated with standard amikacin, clarithromycin, and cefoxitin combination therapy for Mycobacterium abscessus infection. At optimal dosing, a kill rate of ؊0.09 (95% confidence interval, ؊0.04 to 0.03) log 10 CFU per ml/day was achieved over the first 14 days, after which there was regrowth due to acquired drug resistance. Thus, the standard regimen quickly failed. A new regimen is needed.
Clinicians treat Mycobacterium abscessus pulmonary disease with a combination of amikacin, clarithromycin, and cefoxitin for 1 to 2 months, followed by an oral maintenance regimen, usually with a fluoroquinolone, based on the recommendations of experts (1). However, the use of this approach "cures" only 50% even with adjunctive surgery, most of whom relapse or die (2). We have developed a hollow-fiber model of M. abscessus (HFS-M. abscessus) and evaluated the effect of monotherapy of amikacin and moxifloxacin in the system. Each drug failed dramatically, and acquired drug resistance (ADR) developed (3, 4). Since these drugs are given as combination therapy in patients, they could still work in combination. Here, we evaluated the performance of the standard combination regimen of amikacin, cefoxitin, and clarithromycin in the HFS-M. abscessus to determine potential synergy, and even more importantly, whether the combination therapy could prevent ADR.Antibiotics were purchased from the Baylor University Medical Center Pharmacy (Dallas, TX) and from Sigma-Aldrich (St. Louis, MO). Antibiotics were dissolved in water-methanol (clarithromycin), sterile filtered, and diluted to the desired concentrations in Middlebrook 7H9 broth (here broth; Remel, Lenexa, KS). Stock solutions of M. abscessus ATCC 19977 (ATCC, Manassas, VA) were grown to logarithmic-growth phase in the broth. MICs were measured using broth microdilution (5). The amikacin, cefoxitin, and clarithromycin MICs were 32, 16, and 8 mg/liter, respectively.The peripheral compartments of six HFS-M. abscessus systems were inoculated with 20 ml of 6.0 log 10 CFU/ml M. abscessus, as previously described (3). Three systems were immediately treated with a combination of amikacin, cefoxitin, and clarithromycin, while three replicate systems were nontreated controls. Amikacin, cefoxitin, and clarithromycin were administered via syringe pumps for 28 days, as in patients. We mimicked free-drug area under the concentration-time curve from 0 to 24 h (fAUC 0 -24 ), peak concentration (fC max ), and time to maximum concentration achieved in the lungs of humans treated with amikacin and clarithromycin administered once daily, at 1,000 mg, and cefoxitin administered at 2 g four times a day (6, 7). Different half-lives in each HFS-M. abscessus system were achieved, as described by us in the past (8). Antibiotic concentrations achieved in all the systems were validated by sampling from the central compartment of each system at seven time points over 24 h postdose, after which concentrations were assayed in ...