NDM-1 Carbapenemase-Producing Enterobacteriaceae are Highly Susceptible to Ceragenins CSA-13, CSA-44, and CSA-131

Sylwia Joanna Chmielewska,1 Karol Skłodowski,1 Ewelina Piktel,1 Łukasz Suprewicz,1 Krzysztof Fiedoruk,1 Tamara Daniluk,1 Przemysław Wolak,2 Paul B Savage,3 Robert Bucki1 1Department of Medical Microbiology and Nanobiomedical Engineering, Medical University of Białystok, Białystok, Poland; 2The Faculty of Medicine and Health Sciences of the Jan Kochanowski University in Kielce, Kielce, Poland; 3Department of Chemistry and Biochemistry, Brigham Young University, Provo, UT, USACorrespondence: Robert BuckiDepartment of Medical Microbiology and Nanobiomedical Engineering, Medical University of Białystok, Mickiewicza 2C, Białystok 15-222, PolandTel +48 85 748 5493Fax +48 85 748 5416Email buckirobert@gmail.comBackground and Purpose: Treatment of infections caused by NDM-1 carbapenemase-producing Enterobacteriaceae (CPE) represents one of the major challenges of modern medicine. In order to address this issue, we tested ceragenins (CSAs – cationic steroid antimicrobials) as promising agents to eradicate various NDM-1-producing Gram-negative enteric rods.Materials and Methods: Susceptibility to CSA-13, CSA-44, and CSA-131 of four reference NDM-1 carbapenemase-producing strains, ie, Escherichia coli BAA-2471, Enterobacter cloacae BAA-2468, Klebsiella pneumoniae subsp. pneumoniae BAA-2472, and K. pneumoniae BAA-2473 was assessed by MIC/MBC testing of planktonic cells as well as biofilm formation/disruption assays. To define the mechanism of CSAs bactericidal activity, their ability to induce generation of reactive oxygen species (ROS), permeabilization of the inner and outer membranes, and their mechanical and adhesive properties upon CSA addition were examined. Additionally, hemolytic assays were performed to assess CSAs hemocompatibility.Results: All tested CSAs exert substantial bactericidal activity against NDM-1-producing bacteria. Moreover, CSAs significantly prevent biofilm formation as well as reduce the mass of developed biofilms. The mechanism of CSA action comprises both increased permeability of the outer and inner membrane, which is associated with an extensive ROS generation. Additionally, atomic force microscopy (AFM) analysis has shown morphological alterations in bacterial cells and the reduction of stiffness and adhesion properties. Importantly, CSAs are characterized by low hemolytic activity at concentrations that are bactericidal.Conclusion: Development of ceragenins should be viewed as one of the valid strategies to provide new treatment options against infections associated with CPE. The studies presented herein demonstrate that NDM-1-positive bacteria are more susceptible to ceragenins than to conventional antibiotics. In effect, CSA-13, CSA-44, and CSA-131 may be favorable for prevention and decrease of global burden of CPE.Keywords: antibiotic resistance, NDM-1, CSA-13, CSA-44, CSA-131, ceragenins, CPE