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Antimicrobial Agents and Chemotherapy, December 2007, p. 4255-4260, Vol. 51, No. 12
0066-4804/07/$08.00+0 doi:10.1128/AAC.00824-07
Copyright © 2007, American Society for Microbiology. All Rights Reserved.
Bactericidal Action of Daptomycin against Stationary-Phase and Nondividing Staphylococcus aureus Cells
Carmela T. M. Mascio,*
Jeff D. Alder, and
Jared A. Silverman
Cubist Pharmaceuticals, Inc., Lexington, Massachusetts
Received 25 June 2007/
Returned for modification 27 July 2007/
Accepted 30 September 2007

ABSTRACT
Most antibiotics with bactericidal activity require that the
bacteria be actively dividing to produce rapid killing. However,
in many infections, such as endocarditis, prosthetic joint infections,
and infected embedded catheters, the bacteria divide slowly
or not at all. Daptomycin is a lipopeptide antibiotic with a
distinct mechanism of action that targets the cytoplasmic membrane
of gram-positive organisms, including
Staphylococcus aureus.
Daptomycin is rapidly bactericidal against exponentially growing
bacteria (a 3-log reduction in 60 min). The objectives of this
study were to determine if daptomycin is bactericidal against
nondividing
S. aureus and to quantify the extent of the bactericidal
activity. In high-inoculum methicillin-sensitive
S. aureus cultures
in stationary phase (10
10 CFU/ml), daptomycin displayed concentration-dependent
bactericidal activity, requiring 32 µg/ml to achieve a
3-log reduction. In a study comparing several antibiotics at
100 µg/ml, daptomycin demonstrated faster bactericidal
activity than nafcillin, ciprofloxacin, gentamicin, and vancomycin.
In experiments where bacterial cell growth was halted by the
metabolic inhibitor carbonyl cyanide
m-chlorophenylhydrazone
or erythromycin, daptomycin (10 µg/ml) achieved the bactericidal
end point (a 3-log reduction) within 2 h. In contrast, ciprofloxacin
(10 µg/ml) did not produce bactericidal activity. Daptomycin
(2 µg/ml) remained bactericidal against cold-arrested
S. aureus, which was protected from the actions of ciprofloxacin
and nafcillin. The data presented here suggest that, in contrast
to that of other classes of antibiotics, the bactericidal activity
of daptomycin does not require cell division or active metabolism,
most likely as a consequence of its direct action on the bacterial
membrane.

INTRODUCTION
Most in vitro studies examining the activity of antibiotics
have been performed on rapidly dividing planktonic bacterial
cultures supplemented with rich growth media. However, in infections,
bacteria seldom encounter optimal conditions that allow logarithmic
growth. Instead, long periods of limited or arrested growth
are normal (
20).
Staphylococcus aureus is known to modulate
gene expression to enhance endurance under less-than-optimal
growth conditions and survive periods in stationary phase (
27).
It is likely that stationary-phase or nondividing bacteria are
common in many persistent infections (e.g., endocarditis and
osteomyelitis) and in biofilm-associated infections (e.g., on
catheters, grafts, and foreign bodies) (
11,
16). Therefore,
antibiotics that are bactericidal under growth-arrested conditions
may be beneficial.
The mechanism of action of many bactericidal antibiotics requires ongoing cell activity and cell division for the drugs' killing activity. Such drugs therefore display limited activity against nondividing cultures (4, 14, 15, 17). For example, beta-lactams require ongoing bacterial cell wall synthesis (30), and the action of some quinolones requires ongoing RNA and protein synthesis for bactericidal activity, while others require ongoing cell division (15). Rifampin is one of the few antibiotics identified as retaining bactericidal activity against nongrowing bacterial cultures (32).
Daptomycin is a lipopeptide antibiotic that displays rapid bactericidal activity in vitro against gram-positive pathogens, including streptococci, methicillin-resistant S. aureus, and vancomycin-resistant enterococci (5, 13, 18, 31). Daptomycin works by disrupting membrane function and causing leakage of essential potassium ions, ultimately leading to loss of membrane potential and cell death (26). Studies of daptomycin using artificial membranes have shown that daptomycin can act directly on the lipid bilayer in the absence of any bacterial protein or other cell surface component. Direct interaction with the bilayer suggests that daptomycin could act independently of growth phase or cellular metabolic activity (23, 24, 26). Bactericidal activity, in the absence of cell proliferation, may be valuable against infections involving slow-growing or growth-arrested gram-positive organisms.
The potency of daptomycin in comparison with other antibiotics was determined against stationary-phase S. aureus cultures under growth arrest by nutrient depletion, chemical treatment, and cold temperature.
(Portions of this work were previously presented [45th Intersci. Conf. Antimicrob. Agents Chemother., abstr. E-1743, 2005].)

MATERIALS AND METHODS
Bacterial strain and culture conditions.
Methicillin-sensitive
S. aureus strain ATCC 29213 was used for
all of the studies presented here. Bacterial cultures were incubated
overnight at 37°C with shaking (200 rpm) in Mueller-Hinton
broth supplemented with 50-mg/liter free Ca
2+ (MHBc) and diluted
1:1,000 into fresh MHBc. To prepare exponential-phase cultures,
these diluted cultures were grown in MHBc for 2 h prior to experimentation.
To prepare stationary-phase cultures, diluted cultures were
grown for 17 to 20 h prior to testing.
Susceptibility testing.
MIC determinations were performed in MHBc following Clinical and Laboratory Standards Institute (formerly the National Committee for Clinical Laboratory Standards) guidelines for broth microdilution MIC assays, except that cultures were incubated at 37°C with shaking at 200 rpm.
Time-kill studies.
Bacterial suspension cultures in MHBc were treated with various concentrations of different antibiotics. Time-kill studies were performed at 37°C with shaking at 200 rpm, unless otherwise indicated. Culture aliquots (100 µl) were removed at the times shown in the figures, serially diluted in MHB or phosphate-buffered saline (pH 7.4 to 7.6), and then plated on tryptic soy agar fortified with 5% sheep blood and incubated overnight in a 35 to 37°C ambient-air incubator. Cell viability was assessed by enumerating the CFU per milliliter. The lower limit of detection for these studies was 103 CFU/ml, and bactericidal activity was defined as a
3-log reduction with antibiotic treatment compared with the untreated control at the start of each assay. Undiluted and 1:10-diluted samples were not titrated for the number of CFU per milliliter in order to reduce the effect of drug carryover and avoid misrepresentation of the effect of each compound during the course of the time-kill study.
Time-kill studies of exponential- and stationary-phase S. aureus.
Exponential-phase S. aureus cultures were prepared in MHBc as detailed and then treated with daptomycin at 2 µg/ml. Separately, high cell density stationary-phase cultures of S. aureus in MHBc were treated with various concentrations of daptomycin (0, 8, 16, 32, 64, and 128 µg/ml). On the basis of the data generated from the concentration range-finding study, the bactericidal actions of daptomycin and comparator antibiotics were evaluated. Stationary-phase cultures were separately treated with daptomycin, nafcillin, ciprofloxacin, gentamicin, or vancomycin at 100 µg/ml in MHBc. Cell density (the number of CFU per milliliter) was determined at the indicated time points.
Time-kill study of nutrient-depleted, growth-arrested S. aureus.
The bactericidal activity of daptomycin against exponentially growing, concentrated exponentially growing, stationary, and diluted stationary-phase S. aureus was determined in nutrient-depleted (or spent) MHBc medium (depMHBc). depMHBc was prepared by adding S. aureus to 400 ml of MHBc and incubating it at 37°C for 46.5 h. Afterward, the cultures were centrifuged (4,648 x g) for 10 min at 4°C to collect whole bacterial cells. The supernatant was removed and passed through a 0.45-µm-pore-size filter (Nalgene, Rochester, NY). The calcium concentration in the filtered supernatant was measured with the QuantiChrom Calcium Assay Kit (BioAssay Systems, Hayward, CA) and adjusted to 50 mg/liter.
Stationary-phase cells were prepared as detailed earlier and then centrifuged (6,588 x g) for 10 min at room temperature, washed with depMHBc, centrifuged again, and suspended to equal the initial volume in depMHBc. Exponentially growing, concentrated exponentially growing, stationary-phase, and diluted stationary-phase S. aureus cells were prepared in depMHBc by standardizing the optical density (OD600) to 3.75 for concentrated exponentially growing and stationary-phase cells and 0.1 for exponentially growing and diluted stationary-phase cells. Bacterial cultures were treated with daptomycin at 10 or 100 µg/ml and assayed at the indicated time points. During each assay, depMHBc sterility was confirmed by incubating a blank sample during the time-kill study.
Time-kill study of chemically growth-arrested S. aureus.
Exponentially growing cells were grown to an OD600 of approximately 0.3. Cultures were divided into three equal portions and left untreated (control) or treated with 10 µM carbonyl cyanide m-chlorophenylhydrazone (CCCP) or erythromycin at 2.5 µg/ml. Samples were incubated for 1 h at 37°C while shaking (200 rpm) to allow growth arrest. After the 1-h pretreatment, parallel experiments were performed to test the activity of daptomycin or ciprofloxacin at 10 µg/ml on growth-arrested cultures. Bacterial counts were assayed at various time points.
Time-kill study of S. aureus cultures growth arrested by cold temperature.
Exponentially growing S. aureus cells were chilled in an ice bath for 1 h while shaking (200 rpm) prior to treatment with a concentration of ciprofloxacin, daptomycin, or nafcillin equal to four times the MIC (2 µg/ml). Samples were incubated on ice (0°C) with shaking (200 rpm) during the time course experiment. After 24 h under these conditions, samples were returned to 37°C for 2 h. Numbers of CFU per milliliter were assayed at various time points.
Reagents.
Daptomycin was provided by Cubist Pharmaceuticals (Lexington, MA). Other antibiotics, including erythromycin, gentamicin, nafcillin, and vancomycin, were purchased from Sigma (St. Louis, MO), while ciprofloxacin was purchased from U.S. Biological (Swampscott, MA). CCCP and calcium chloride were obtained from Sigma (St. Louis, MO). Culture media, including blood agar plates and MHB, were obtained from bioMérieux (Lombard, IL) and Difco Becton Dickinson (Sparks, MD), respectively.

RESULTS
Susceptibility testing.
MIC determinations were performed in MHBc (
9). The MICs of the
antibiotics used in these studies, determined under growth conditions
that would support exponential growth as defined by the Clinical
and Laboratory Standards Institute, were as follows: ciprofloxacin,
0.5 µg/ml; daptomycin, 0.5 µg/ml; gentamicin, 0.25
µg/ml; nafcillin, 0.125 µg/ml; vancomycin, 0.5 µg/ml.
Bactericidal activity of daptomycin against exponentially growing S. aureus.
As a basis for comparison with experiments in growth-arrested cultures, the effects of daptomycin were evaluated in exponentially growing cultures of S. aureus. Daptomycin, at a concentration equal to four times the MIC, was added to cultures to determine the effects on cell viability compared with untreated control cells. At this concentration, daptomycin (2 µg/ml) exhibited rapid bactericidal activity in active cultures of S. aureus (as defined by a 3-log reduction in the number of CFU per milliliter) within 60 min (Fig. 1). Untreated bacterial cells divided rapidly, leading to a 20-fold cell density increase (from 5 x 107 to 1 x 109 CFU/ml) during the 120-min-long experiment (Fig. 1).
In order to determine whether daptomycin also had bactericidal
activity against stationary-phase organisms, bacteria were grown
for at least 17 h to create high inoculum density cultures (1
x 10
10 CFU/ml) and then subjected to increasing concentrations
of daptomycin in MHBc. In this experiment,
S. aureus cells appeared
to be in stationary phase because untreated cells did not proliferate,
as shown by the flat viability curve (Fig.
2). However, in cultures
treated with daptomycin, concentration-dependent cell killing
was measured. In comparison to exponentially growing
S. aureus,
stationary-phase cultures required higher concentrations of
daptomycin (32 µg/ml) to reach the bactericidal end point
after 24 h of treatment. This altered concentration response
to daptomycin may be due to an altered bacterial physiological
(growth) state, culture density, or both.
Bactericidal activities of daptomycin and comparator antibiotics against stationary-phase S. aureus.
The previous experiments demonstrated that higher concentrations
of daptomycin were required for bactericidal activity against
stationary-phase
S. aureus cells compared with exponentially
growing cells. Therefore, daptomycin at 100 µg/ml and
similarly high concentrations of comparator antibiotics were
examined for activity in high inoculum density stationary-phase
cultures in MHBc. Stationary-phase
S. aureus cultures were left
untreated or were treated separately with ciprofloxacin, daptomycin,
gentamicin, nafcillin, or vancomycin at 100 µg/ml. Under
these growth conditions, daptomycin and gentamicin retained
bactericidal activity against stationary-phase cultures (Fig.
3). Daptomycin treatment resulted in an immediate and progressive
reduction in viability, demonstrating a 3-log reduction in the
number of CFU per milliliter after 8 h. Gentamicin required
a longer time (24 h) to achieve a bactericidal effect; no change
in viability was seen for the first 4 h of exposure. In contrast,
under these conditions, ciprofloxacin, nafcillin, and vancomycin
did not achieve the bactericidal end point. At the 24-h time
point, cultures treated with these three drugs had cell densities
equal to those of untreated control cultures (Fig.
3).
Effects of S. aureus physiology on the bactericidal activity of daptomycin.
The previous experiment demonstrates that daptomycin retains
bactericidal activity against stationary-phase cultures but
that elevated levels of the antibiotic are required to achieve
the 3-log reduction end point. The requirement for higher drug
concentrations could be due to the well-documented inoculum
effect (
29) or to changes in cellular physiology in stationary-phase
cultures. To address this, exponential- and stationary-phase
bacterial cultures were prepared at high cell densities (5
x 10
9 CFU/ml) for treatment with a low (10 µg/ml) or high
(100 µg/ml) concentration of daptomycin. The lower daptomycin
concentration had a minimal effect on high inoculum density
stationary-phase
S. aureus over the 24-h experiment, while the
same concentration was bactericidal against high-density exponentially
growing cells over the same time period (Fig.
4A). The high
daptomycin concentration (100 µg/ml) had a very rapid
bactericidal effect on high-density exponentially growing cells
(a >3-log decrease in cell density in 1 h), but in stationary-phase
high-density cells, the same concentration was bactericidal
only after a prolonged treatment period (Fig.
4A).
To test if altered cell physiology mediates reduced daptomycin
susceptibility in stationary-phase
S. aureus, a culture dilution
experiment was performed. Stationary-phase cells were standardized
to an OD
600 of 3.75 and then diluted in depMHBc to an OD
600 of 0.1. Diluted cultures were treated with a low (10 µg/ml)
or high (100 µg/ml) concentration of daptomycin and compared
with concentrated stationary-phase cells. The lower daptomycin
concentration (10 µg/ml) had no bactericidal effect on
concentrated stationary-phase cells over 24 h; however, the
diluted cell cultures had some susceptibility (a >1-log decrease
in the number of CFU per milliliter) to the lower daptomycin
concentration (Fig.
4B). In contrast, the higher daptomycin
concentration (100 µg/ml) was bactericidal in both concentrated
and diluted
S. aureus cultures in stationary phase, although
the bactericidal effect was more pronounced in diluted cultures.
Taken together, these data suggest that under these experimental
conditions,
S. aureus cell physiology influences daptomycin
susceptibility more than inoculum density does.
Effects of daptomycin and ciprofloxacin on metabolically arrested S. aureus.
To determine the effect of artificial metabolic arrest on antibiotic susceptibility, exponentially growing cells were treated with a proton ionophore (CCCP) to abrogate cellular energy production or a protein synthesis inhibitor (erythromycin) prior to antibiotic treatment. Untreated control cultures grew almost 3 log units during the 4-h experiment (Fig. 5A and B), while treatment with CCCP or erythromycin stopped the proliferation of bacteria over 24 h (data not shown). Control cultures treated with daptomycin or ciprofloxacin at 10 µg/ml were effectively killed (Fig. 5A and B). Daptomycin also demonstrated a bactericidal effect against S. aureus in cultures growth arrested by both CCCP and erythromycin (Fig. 5A). However, CCCP- and erythromycin-mediated metabolic arrest protected S. aureus from the bactericidal action of ciprofloxacin (Fig. 5B).
Effects of daptomycin, ciprofloxacin, and nafcillin on S. aureus cultures growth arrested by cold temperature.
The effects of antibiotics on
S. aureus cultures growth arrested
by cold temperature were also examined. Exponentially growing
cultures were chilled in an ice bath prior to treatment with
ciprofloxacin, daptomycin, or nafcillin at 2 µg/ml. Time-kill
curves demonstrate that daptomycin remained bactericidal against
cold-arrested
S. aureus, while cold arrest protected the cells
against ciprofloxacin or nafcillin (Fig.
6). After 24 h on ice,
cultures were incubated at 37°C and each of the three antibiotics
was active and effectively demonstrated activity (Fig.
6).

DISCUSSION
Daptomycin is a cyclic lipopeptide antibacterial agent that
exhibits rapid, concentration-dependent in vitro bactericidal
activity against clinically significant strains of gram-positive
pathogens, including streptococci, methicillin-resistant
S. aureus, and vancomycin-resistant enterococci (
5,
13,
18,
31).
In the present study, the observed bactericidal activity against
stationary-phase
S. aureus ATCC 29213 is remarkable since most
other bactericidal agents interfere with cell division or processes
necessary for cell division and typically have little activity
against nondividing cells (
30).
The mechanism of action of daptomycin has not been fully elucidated, despite 20 years of study. Early efforts (3) suggested that the drug inhibited an early step in peptidoglycan synthesis, although no particular reaction was identified. Other authors (7) have suggested that daptomycin targets lipoteichoic acid biosynthesis. Subsequently, it has been shown that daptomycin becomes inserted into the bacterial plasma membrane in a calcium-dependent fashion, leading to membrane depolarization, release of intracellular potassium ions, and rapid cell death (1, 26). Since depolarization leads to a loss of transport and other metabolic activity, inhibition of lipoteichoic acid and peptidoglycan biosynthesis is a consequence of the primary mechanism (2, 22).
The ability of daptomycin to kill bacteria whose metabolism has been arrested by chemical treatment (dissipation of proton motive force by CCCP or inhibition of protein synthesis by erythromycin), cold, or nutrient depletion further supports the idea that inhibition of macromolecular synthesis is a secondary component of the bactericidal mechanism of action. Recent studies with artificial membranes (19, 26, 28) have suggested that daptomycin insertion causes positive-curvature strain of the membrane, which would ultimately result in cell leakage (28). Although this process has not been demonstrated to occur in vivo, it is consistent with the ability of daptomycin to kill growth-arrested bacteria.
In the present study, antibiotics with different mechanisms of action were selected as comparators. Ciprofloxacin blocks DNA replication, and nafcillin and vancomycin perturb cell wall synthesis, while gentamicin binds to the 30S ribosomal subunit, causing bacterial mRNA to be misread (30). As would be expected, ciprofloxacin, nafcillin, and vancomycin were not bactericidal against stationary-phase S. aureus cultures in all of the growth arrest models tested. Interestingly, gentamicin was bactericidal in stationary-phase cells at the 24-h time point. This may be a result of gentamicin's ability to disrupt the cell membrane as it is transported into the cell prior to acting on bacterial ribosomes (6).
It is well established that a high inoculum density can deter the effectiveness of many antibiotics (29). In the experiments presented here, inoculum effects were observed but appeared to have less of an impact on the effectiveness of daptomycin than did cell physiology or the growth state. The reason for this result is unknown. It is possible, however, that positive-curvature strain in the membrane is increased during bacterial cell division, resulting in more rapid bactericidal activity. In some S. aureus strains, the bactericidal activity of oleic acid has differential effects, depending on the phase of growth, that appear to coincide with changes in membrane fluidity (33).
A previous study by Lamp et al. had shown that in the presence of human sera, daptomycin was bactericidal in stationary-phase and exponentially growing isolates in vitro and exhibited statistically significantly faster killing rates than vancomycin against both methicillin-sensitive and methicillin-resistant strains (25). In each case, daptomycin and vancomycin were more effective against exponentially growing cultures than against stationary-phase cultures (25). In the present study, daptomycin had bactericidal activity against stationary-phase S. aureus at concentrations (
32 µg/ml) approximately 15 times that which is effective against exponentially growing cells (
2 µg/ml). High concentrations of daptomycin (minimum bactericidal concentration, 32 µg/ml) have shown bactericidal activity against adherent S. epidermidis (21) in an adherent-cell biofilm model. Interestingly, many of the genes characterized as assisting in bacterial survival in stationary phase, such as Clp homologues, are expressed by bacteria within biofilms (8); these similarities in physiology may translate into similarities in susceptibility.
In conclusion, the data suggest that the bactericidal activity of daptomycin in vitro does not require cell division or active metabolism, consistent with the proposed mechanism of disrupting membrane function. The activity of daptomycin, at high concentrations, against nongrowing cells might also indicate the alternative possibility that daptomycin possesses two mechanisms of action—one active against exponential-phase cultures at low concentrations (near the standard MIC) and one active against stationary-phase cells and observed only at high concentrations of the drug. We have no evidence that would support such a dual mechanism, but the possibility cannot be ruled out by the studies reported here.
The demonstration of daptomycin's bactericidal effect in stationary-phase bacteria may have implications for the additional in vivo use of this drug. Daptomycin was recently approved by the Food and Drug Administration for the treatment of S. aureus bacteremia and right-sided infective endocarditis (10, 12). The limitation of these daptomycin experiments is similar to that of many other in vitro studies; experimental conditions do not necessarily reflect those in human infections. However, these studies are valuable in gaining further understanding regarding the mechanism of its action. The present study suggests that further investigations of daptomycin in infection models involving stationary or slowly growing gram-positive bacteria would be of great interest.

ACKNOWLEDGMENTS
We thank the other members of the Discovery Microbiology group
(past and present) and the Drug Evaluation group of Cubist Pharmaceuticals,
Inc., for their support, scientific discussion, and assistance
with all aspects of this research.
We are all Cubist employees and own stock options.

FOOTNOTES
* Corresponding author. Mailing address: Cubist Pharmaceuticals, Inc., 65 Hayden Avenue, Lexington, MA 02421. Phone: (781) 860-8525. Fax: (781) 861-1164. E-mail:
carmela.mascio{at}cubist.com 
Published ahead of print on 8 October 2007. 

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Antimicrobial Agents and Chemotherapy, December 2007, p. 4255-4260, Vol. 51, No. 12
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