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Antimicrobial Agents and Chemotherapy, March 2001, p. 764-767, Vol. 45, No. 3
Department of Microbiology, University of
Texas Health Center, Tyler, Texas
Received 5 September 2000/Returned for modification 8 November
2000/Accepted 4 December 2000
Linezolid is an oxazolidinone available as an oral drug which has
activity against most gram-positive bacteria. However, few species of
the genus Mycobacterium have been studied. We tested 249 clinical isolates and 10 reference strains of rapidly growing mycobacteria for susceptibility to linezolid by broth microdilution. Clinical species included the Mycobacterium fortuitum group
(n = 74), M. abscessus (n = 98), M. chelonae (n = 50), M. mucogenicum (n = 10), and M. fortuitum third biovariant complex (10). The modal
MIC for M. mucogenicum was 1.0 µg/ml, and the MIC at
which 90% of the isolates tested are inhibited (MIC90) was
4 µg/ml; the modal MIC for the M. fortuitum group was 4 µg/ml, and the MIC90 was 16 µg/ml; the modal MIC for
the M. fortuitum third biovariant complex was 4 µg/ml,
and the MIC90 was 8 µg/ml; the modal MIC for M. chelonae was 8 µg/ml, and the MIC90 was 16 µg/ml;
and the modal MIC for M. abscessus was 32 µg/ml, and the
MIC90 was 64 µg/ml. Based on peak levels of linezolid in
serum of 15 to 20 µg/ml, we propose the following broth MIC
breakpoints for these species: susceptible, Treatment of infections due to
nontuberculous mycobacteria remains difficult, in part because they are
resistant to many of the first-line tuberculosis agents and in part
because so few other agents are available for therapy
(21). The oxazolidinones are one of several new classes of
agents active against gram-positive bacteria (4, 8, 11;
M. C. Birmingham, G. S. Zimmer, B. Hafkin, W. M. Todd,
T. Leach, D. H. Batts, S. M. Flavin, C. R. Rayner,
K. E. Welch, P. F. Smith, J. D. Root, N. E. Wilks,
and J. J. Schentag, Abstr. 39th Intersci. Conf. Antimicrob. Agents Chemother., abstr. 1098, 1999) which have the potential for activity against nontuberculous mycobacteria, including the rapidly growing mycobacteria (6; M. Wu, P. Aralor, K. Nash, L. E. Bermudez, C. B. Inderlied, and L. S. Young, Abstr. 38th
Intersci. Conf. Antimicrob. Agents Chemother., abstr. E-143, 1998;
L. E. Bermudez, Abstr. Int. Conf. Macrolides, Azalides,
Streptogramins, Ketolides and Oxazolidinone, abstr. 03.16, 2000).
We chose to study linezolid, which along with eperezolid is the first
of the oxazolidinones to reach clinical testing (4; M. C. Birmingham et al., 39th ICAAC) Linezolid offers special promise, as it is a twice-daily oral drug which is 100% bioavailable (Zyvox package insert, 2000 [Pharmacia & Upjohn, Inc.]; also see reference 8) and appears to be well tolerated
(8; N. E. Wilks, Abstr. 39th Intersci. Conf.
Antimicrob. Agents Chemother., abstr. 1763, 1999), important features
of therapeutic drugs to be used against nontuberculous mycobacteria
which cause chronic infections and require long-term therapy (often 6 months or longer) (21). The activities of linezolid
against a large number of clinical isolates of rapidly growing
mycobacteria, including the common disease-producing species
Mycobacterium fortuitum, M. chelonae, and M. abscessus (24), were studied.
(This work was presented in part as an abstract at the 100th General
Meeting of the American Society for Microbiology, Los Angeles, Calif.)
Organisms.
We tested 249 clinical isolates of rapidly
growing mycobacteria belonging to seven taxonomic groups which had been
submitted for susceptibility testing to the Mycobacteria/Nocardia
Laboratory at the University of Texas Health Center between 1998 and
2000. Organisms were identified to the species level by PCR restriction fragment length polymorphism analysis of the 439-bp (Telenti) segment
of the 65-kDa hsp gene (14, 17) or by pattern
of drug susceptibility to approximately 15 other drugs, including
aminoglycosides, beta-lactams, and quinolones (2). The
test species used and the number of clinical test isolates (in
parentheses) were as follows: M. fortuitum group without
separation into M. fortuitum, M. peregrinum, or M. fortuitum third biovariant complex (n = 74); M. fortuitum third biovariant complex (n = 10 [with five each being sorbitol positive and sorbitol
negative]); M. abscessus (n = 98); M. chelonae (n = 50); M. mucogenicum
(n=10); M. immunogenum (n=4) (see
reference 25; and M. smegmatis group
(n=3). Four reference strains obtained or submitted by our
laboratory to the American Type Culture Collection (Manassas, Va.) were
also tested. These included M. peregrinum ATCC 700686, M. fortuitum ATCC 6841T, M. chelonae
ATCC 35752T, and M. abscessus ATCC
19977T.
Susceptibility testing.
Susceptibility testing utilized
serial twofold broth microdilution in cation supplemented
Mueller-Hinton broth as previously described (2).
Susceptibilities to linezolid were read after incubation at 30°C in
room air for 3 days. The endpoint was complete (100%) inhibition of
visible growth.
Quality control.
Quality control was performed using
Staphylococcus aureus ATCC 29213. The acceptable range of
inhibition for this strain was 1 to 4 µg/ml (18 to 24 h of
incubation) (linezolid package insert, 2000 [Pharmacia & Upjohn,
Inc.]). M. peregrinum ATCC 700686 was also tested as a
rapid-grower control as recently recommended (26). Both
were used initially after preparation of the MIC panels and then weekly.
Susceptibility testing.
Susceptibility to linezolid was
determined for 249 clinical isolates of rapidly growing mycobacteria
belonging to seven taxonomic groups. In general, a unimodal
distribution of MICs was seen for the common species or groups, with
>90% of MICs within two dilutions of the mode. Of the common
pathogenic species, the drug was most active against isolates of
M. mucogenicum and the M. fortuitum group,
including both members of M. fortuitum third biovariant complex. Of the M. mucogenicum isolates, 6 of 10 (60%) were
inhibited by linezolid at concentrations of 1 µg/ml, and 100% were
inhibited by linezolid at 8 µg/ml. For M. fortuitum, 45 of
74 (61%) of the test isolates were inhibited by linezolid at
concentrations of 4 µg/ml or less, and 96% were inhibited by
linezolid at concentrations 16 µg/ml or less, with a mode of 4 µg/ml. For M. fortuitum third biovariant complex, all 10 isolates were within one dilution of the mode of 4 µg/ml (Tables
1 and
2).
0066-4804/01/$04.00+0 DOI: 10.1128/AAC.45.3.764-767.2001
Copyright © 2001, American Society for Microbiology. All rights reserved.
Activities of Linezolid against Rapidly
Growing Mycobacteria
ABSTRACT
Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
8 µg/ml; moderately
susceptible, 16 µg/ml; and resistant, 
32 µg/ml). These studies
demonstrate the excellent potential of linezolid for therapy of rapidly
growing mycobacteria.
INTRODUCTION
Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
MATERIALS AND METHODS
Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
RESULTS
Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
TABLE 1.
Susceptibility of 249 clinical isolates of seven species
or taxa of rapidly growing mycobacteria to linezolid as determined
by broth microdilution
TABLE 2.
Susceptibility of 249 isolates of rapidly growing
mycobacteria to linezolid as determined by broth microdilution
Quality control. The S. aureus control strain was within the expected MIC range. The strain of M. peregrinum ATCC 700686 recommended as an MIC control strain (26) was tested 54 times. The modal MIC was 4µg/ml (31 values), with 11 values at 2 µg/ml and 9 values at 8 µg/ml. A total of 51 of 54 (94%) values were within one dilution of the mode, and 100% were within two dilutions.
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DISCUSSION |
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Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
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The manufacturer of linezolid has proposed 8 µg/ml as the
resistance breakpoint of linezolid for Enterococcus spp.
(package insert for Zyvox, 2000 [Pharmacia & Upjohn Inc.]). For
Staphylococcus species the susceptibility breakpoint is 4
µg/ml, and for Streptococcus spp. it is 2 µg/ml. No
resistance breakpoints were given for these two groups because of the
absence of isolates for which the linezolid MICs were >4 µg/ml and
hence no experience with isolates such as these rapidly growing
mycobacteria which have higher MICs. Peak levels of the drug in serum
after oral doses of 600 mg twice a day (mean ± standard deviation
are 21.2 ± 5.8 µg/ml, with a half-life of 5.4 h (package insert
for Zyvox, 2000 [Pharmacia & Upjohn Inc.]), suggesting that 16 µg/ml might be an acceptable intermediate value for other organisms.
Pending clinical experience, we propose the following breakpoints for these mycobacterial species: susceptible, 8 µg/ml; intermediate, 16 µg/ml; and resistant, 32 µg/ml.
Drug treatment of rapidly growing mycobacteria has been severely
limited by the small number of available drugs with activity at
clinically achievable levels in tissue (blood), especially oral drugs
(15, 21, 24). For M. chelonae and M. abscessus, clarithromycin (and the other macrolides) is the only
oral agent active against all untreated strains (3, 15, 18, 19, 22). Acquired mutational resistance is a concern with
monotherapy with this drug, and several mutations have been described
which were associated with marked increases in macrolide MICs and
clinical treatment failure (16, 22). Linezolid offers
great promise as a macrolide companion drug for isolates of M. chelonae, as 94% of all isolates tested were inhibited by this
drug at concentrations of 16 µg/ml, with a mode of 8 µg/ml,
including strains with acquired clarithromycin resistance (data not shown).
The MICs were higher for M. abscessus than for M. chelonae, but 48% of these isolates were inhibited by linezolid at concentrations of 16 µg/ml. Chronic lung disease in the setting of bronchiectasis (nodular bronchiectasis in elderly women or young adolescents with cystic fibrosis) is one of the more common forms of clinical disease due to M. abscessus (5, 9, 10, 12, 24) and is currently incurable with drugs alone (5, 10, 12, 21). Despite these MICs, linezolid is one of the few drugs to offer promise for treatment of this disease.
The third common pathogenic rapidly growing mycobacterial species
(group) to be tested was the M. fortuitum group. This group includes M. fortuitum, M. peregrinum, M. fortuitum third
biovariant (sorbitol positive), and M. fortuitum third
biovariant (sorbitol negative) (23). These species and
taxa have very similar drug susceptibilities (15, 18, 20).
Most or all untreated strains are susceptible to the newer quinolones
and sulfamethoxazole (15, 18), although acquired
mutational resistance to the newer quinolones (18) limits
the use of this class of drugs as monotherapy. Some but not all
isolates of M. fortuitum are also susceptible to doxycycline and minocycline (42%) (15) and clarithromycin
(3). Isolates of M. peregrinum and M. fortuitum third biovariant sorbitol negative are all susceptible
to clarithromycin (MIC, 4 µg/ml) while all isolates of M. fortuitum third biovariant (sorbitol positive) are clarithromycin
resistant (MICs > 4 µg/ml) (3). For the M. fortuitum group, 61% of isolates were inhibited by 4 µg of linezolid per ml, and 86% were inhibited by 8 µg of linezolid per
ml. Thus, linezolid offers the promise of an additional oral drug which
could be used for all isolates of this species or group.
The MIC endpoint used in this study was 100% inhibition of visible
growth, an endpoint suggested by Pharmacia & Upjohn, Inc. Instructions
with the recently released linezolid E-test (AB Biodisk), however, are
to use an 80% growth inhibition endpoint rather than 100%. E-test MIC
data for clinical isolates in the present study were not available
because the 80% growth inhibition endpoint was not studied. A trailing
endpoint appeared to be minimal with these groups or species by broth
microdilution, as use of 80% inhibition compared to 100% inhibition
only decreased the MICs by an average of one dilution (data not shown).
Only clinical trials will determine if the suggested broth MIC
breakpoints for these mycobacteria (susceptible 8 µg/ml, moderately
susceptible = 16 µg/ml, resistance 32 µg/ml) is appropriate
or correct.
Acquired resistance to linezolid among gram-positive bacteria, primarily Enterococcus spp., has been described (P. Linden, D. Parkinson, A. W. Pasculle, M. Birmingham, G. Zurenko, B. Hafkin, and D. Batts, Abstr. 39th Intersci. Conf. Antimicrob. Agents Chemother., abstr. 1105, 1999; T. K. Chowdhry, S. H. Marshall, C. J. Donskey, R. A. Salata, and L. B. Rice, Abstr. 100th Meet. Am. Soc. Microbiol. abstr. A63, 2000; S. M. Swaney, D. Shinabarger, R. Schaadt, J. Bock, J. Slightom, and G. Zurenko, Abstr. 38th Intersci. Conf. Antimicrob. Agents Chemother., abstr. C-104, 1998). These cases have defined point mutations involving the rRNA gene. This is a point of concern with strains of M. chelonae and M. abscessus, which have only a single copy of the ribosomal operon (1, 7, 22) and for which single point mutations in the ribosomal gene following monotherapy would likely result in drug resistance. Resistance from such mutational changes in the ribosomes of these two species has been described with clarithromycin (A2058 or A2059 in the 16S rRNA gene) (16, 22) and amikacin (A1408 in the 23S r-RNA gene) (13). Previous studies have shown that mutational ribosomal resistance with the macrolides is a problem only in the setting of disseminated cutaneous disease or pulmonary disease, but not with localized wound infections. Thus, linezolid should be used in combination therapy whenever possible with treatment of M. chelonae and M. abscessus, in the setting of disseminated or pulmonary disease. There is less concern with isolates of the M. fortuitum group, as they have two copies of the ribosomal operon (1, 7) and heterologous resistance with amikacin is recessive.
A serious limitation on therapy of disease due to these organisms is the cost of the drug, which is approximately $45 for a single 600-mg tablet, with a daily dosing schedule of 600 mg twice daily. This likely will mean that only patients in desperate clinical straits or in whom other drugs have failed will receive treatment, which is a difficult situation in which to determine clinical efficacy. At present no phase four clinical trials or compassionate trials of treatment of mycobacterial disease with linezolid are planned or are under way in the United States, although the drug was available on a compassionate basis prior to approval by the Food and Drug Administration. Other oxazolidinones are in trial or under consideration (R. C. Gadwood, L. M. Thomasco, E. A. Weaver, G. E. Zurenko, and C. W. Ford, Abstr. 39th Intersci. Conf. Antimicrob. Agents Chemother., abstr. 571, 1999). Hopefully these will come with a lower price tag, which will allow greater investigation of this very promising drug for disease caused by rapidly growing mycobacteria.
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ACKNOWLEDGMENTS |
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We thank Joanne Woodring for her excellent clerical assistance.
This study was supported in part by a grant from Pharmacia and Upjohn, Inc.
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FOOTNOTES |
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* Corresponding author. Mailing address: The University of Texas Health Center, Department of Microbiology, 11937 U.S. Hwy. 271, Tyler, TX 75708. Phone: (903) 877-7680. Fax: (903) 877-7652. E-mail: Joanne.Woodring{at}uthct.edu.
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Antimicrobial Agents and Chemotherapy, March 2001, p. 764-767, Vol. 45, No. 3
0066-4804/01/$04.00+0 DOI: 10.1128/AAC.45.3.764-767.2001
Copyright © 2001, American Society for Microbiology. All rights reserved.
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(2002). Intrapulmonary Pharmacokinetics of Linezolid. Antimicrob. Agents Chemother.
46: 1475-1480
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