Comparison of in vitro activities of tigecycline, doxycycline, and tetracycline against the spirochete borrelia burgdorferi
Ticks and Tick-borne Diseases 1 (2010) 30–34
Comparison of in vitro activities of tigecycline, doxycycline, and tetracyclineagainst the spirochete Borrelia burgdorferi
Louis Ates a, c, Christa Hanssen-H ¨ubner a, Douglas E. Norris b, Dania Richter d,Peter Kraiczy a, Klaus-Peter Hunfeld c,Ã
a Institute of Medical Microbiology and Infection Control, University Hospital of Frankfurt, Frankfurt/Main, Germanyb The Harry W. Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Marylandc Institute of Laboratory Medicine, Northwest Medical Centre, Academic Teaching Hospital, Medical Faculty, University of Frankfurt, Steinbacher Hohl 2–26,D-60488 Frankfurt/Main, Germanyd Abt. Parasitologie, Institut f¨ur Pathologie, Charite´ Universit¨atsmedizin Berlin, Malteserstrasse 74–100, 12249 Berlin, Germany
Tigecycline is a new glycylcycline that has recently been revealed to be very effective in vitro against a
variety of Gram-negative and Gram-positive bacteria including multi-drug resistant microorganisms.
Using a standardized microdilution susceptibility testing method, we determined the minimal
inhibitory concentrations (MICs) and the minimal bactericidal concentrations (MBCs) of tigecycline,
in parallel with doxycycline, tetracycline, and other antibiotic agents relevant for Lyme borreliosis
treatment such as ceftriaxone and cefotaxime. The activity of all agents against 16 different Borrelia
isolates belonging to all borrelial genospecies known to be pathogenic for humans was investigated and
analyzed under standardized conditions.
90s was tigecycline ( r 0.016 mg/L) 4 ceftriaxone (0.03 mg/L) 4
cefotaxime (r0.125 mg/L) 4 doxycycline (0.25 mg/L) 4 tetracycline (0.25 mg/L). The rank order of
MBC90s was tigecycline (0.5 mg/L) 4 ceftriaxone (2 mg/L) 4 tetracycline (16 mg/L) 4 doxycycline(16 mg/L) 4 cefotaxime (4 16 mg/L). High in vitro activity of the new glycylcycline against Borrelia wasfurther substantiated by time-kill experiments performed with B. afzelii isolate EB1. Parallel testing oftigecycline and ceftriaxone demonstrated a bacteriostatic effect for 0.016 mg/L of tigecycline and for0.03 mg/L for ceftriaxone after 72 h of incubation. Moreover, tigecycline was bactericidal at aconcentration of 0.25 mg/L showing a 4 3 log10 unit reduction of the initial inoculum, whereas forceftriaxone a concentration of 2 mg/L was needed.
& 2009 Elsevier GmbH. All rights reserved.
neurological disorders and late manifestations including acroderma-titis chronica atrophicans or chronic arthritis (
Lyme borreliosis is a vector-borne disease that is transmitted by
ixodid ticks and is caused by the spirochete Borrelia burgdorferi sensu
Lyme borreliosis is frequently treated by orally administered
lato (s.l.) complex. The 5 genospecies that are currently considered
doxycycline or intravenous ceftriaxone, which appear to be equally
to be human pathogens are B. burgdorferi sensu stricto (s.s.), B. afzelii,
B. garinii, and B. spielmanii, and the proposed but not yet validated
). Other often administered antibiotics are penicillin, amoxicillin,
novel species B. bavariensis ). In Europe, the
cefuroxime, cefotaxime, and tetracycline. Although these drugs have
incidence of Lyme borreliosis is estimated to range from 3.9 to 168/
been reported to be clinically effective in the majority of cases under
controlled study conditions, treatment failures have been repeatedly
manifest itself progressively as a multisystem disorder exhibiting a
large variety of clinical symptoms ). Early on in the
course of the infection, a bull’s-eye rash called erythema migrans
Tigecycline, a glycylcycline and structural analog of minocycline
is the most common disease manifestation appearing in 80–90%
is a relatively new antibiotic agent that has been found to be
of the patients. If left untreated, however, the infection may cause
effective against many Gram-positive and Gram-negative bacteriaincluding multi-drug resistant pathogens such as ESBL-producingenterobacteriaceae,
(MRSA), vancomycin-resistant enterococci (VRE), and multi-drug
Corresponding author. Tel.: + 49 69 7601 3252; fax: + 49 69 7601 3907.
1877-959X/$ - see front matter & 2009 Elsevier GmbH. All rights reserved.
L. Ates et al. / Ticks and Tick-borne Diseases 1 (2010) 30–34
Tigecycline is a primarily bacteriostatic agent that binds to
B. valaisiana and 2 B. lusitaniae isolates were tested. The clinical,
the bacterial 30S subunit of the bacterial ribosome ().
geographic, and phenotypic characteristics of 12 of the tested
Recently, tigecycline was also found to be effective in vitro against
several strains of B. burgdorferi s.l. (However, the
number of isolates tested in this study was small and so far
). In the present study, we also tested B. lusitaniae isolate
tigecycline has not been tested in parallel with other tetracyclines
MT0407 M3 (tick isolate, Portugal), B. lusitaniae isolate IP10907
against borreliae under well-controlled conditions. In this study, we
N1 (tick isolate, Germany), B. valaisiana isolate ZWU3 0507 N3
used a well-evaluated and standardized methodology to investigate
(tick isolate, Germany), and B. valaisiana isolate Bv9 (tick isolate,
the in vitro activity and bactericidal properties of tigecycline against
Germany). Genospecies were identiﬁed by restriction fragment
16 isolates of the B. burgdorferi s.l. complex in comparison to a series
length polymorphism patterns after digestion with endonuclease
of compounds relevant for the treatment of Lyme borreliosis in the
MluI and by application of plasmid analysis as described
clinical setting, including doxycycline, tetracycline, ceftriaxone, and
sequencing a 600-nucleotide fragment of the gene encoding the16SrRNA and comparing it to the same fragment of variousgenospecies type strains
The susceptibility of a total of 16 isolates belonging to 5 human
MIC values were obtained by applying our previously
pathogenic species of the B. burgdorferi s.l. complex as well as 2
Table 1Individual antibiotic susceptibilities of 16 B. burgdorferi s.l. isolates to tigecycline, doxycycline, tetracycline, ceftriaxone, and cefotaxime (MICs and MBCs in milligram per liter).
E. coli (ATCC 25922)Median MIC in BSK medium
a Antimicrobial susceptibility was determined on 3 different days, and MIC and MBC values for each isolate were reported as the median of 3 experiments.
b The test ranges (in mg/L) were as follows: tigecycline: 0.016–2; doxycycline: 0.016–32; tetracycline: 0.125–16; ceftriaxone: 0.004–8; cefotaxime: 0.125–16.
c To investigate signiﬁcant antibiotic–medium interaction, MICs for S. aureus (ATCC 29213) and E. coli (ATCC 25922) were determined on 3 different days, referring to
the CLSI method except for the use of BSK and preincubation of the antibiotic–medium test preparation for 48 h before testing. Results were reported as themedian of all 3 experiments.
L. Ates et al. / Ticks and Tick-borne Diseases 1 (2010) 30–34
were provided in lyophilized form on 96-well microtiter plates inserially diluted concentrations. The plates were supplied and
To detect possible variations in the antibiotic susceptibility
quality controlled by the manufacturer (Merlin GmbH, Bornheim-
pattern of the different borrelial genospecies, all MIC and MBC
Hersel, Germany). An inoculum (200 ml) of 5 Â 106 borreliae/well,
values were analyzed for intragenospecies-speciﬁc differences
in the log phase of growth, was incubated in Barbour-Stoenner-
applying the Kruskal-Wallis test. Calculations were performed
with the statistical program BIAS, version 8.3.8 (Epsilon Verlag,
with phenol red for 72 h at 33 1C. The absorbance of the test
medium was measured at 0, 24, 48, and 72 h using a spectro-photometer (PowerWave 200, Bio-Tec Instruments, USA), andgrowth curves were calculated by utilizing a software-assisted
method (MicroWin 3.0, Mikrotek Germany). Growth of samplesand controls was determined for each well based on the decrease
of absorbance after 72 h (Et72) in comparison to the initialabsorbance values (Et0). A sample was judged to exhibit growth
When comparing antibiotic activities of the different sub-
if the decrease from Et0 to Et72 accounted for more than 10%
stances against the tested isolates, the rank order of in vitro
activity against all tested borrelial genospecies considering the
isolate failed to grow in the presence of antibiotics was
median MICs of the individual substances for all tested isolates
interpreted as the colorimetric MIC ). Every
in milligram per liter was as follows: tigecycline (MIC90:
substance was tested in triplicate on different days, but all
substances were tested in parallel to each other, together with a
(MIC90: r0.125 mg/L), doxycycline (MIC90: 0.25 mg/L), tetracy-
control without antibiotic substance and a control without
cline (MIC90: 0.25 mg/L) ). The most active antibiotic
borreliae. The reported MIC is the median of all 3 independent
agent was tigecycline exhibiting an MIC of r0.016 mg/L in every
tested isolate. Doxycycline and tetracycline had identical median
As an additional quality control measure and to exclude
MIC values, but since the average sensitivity for doxycycline in the
signiﬁcant antibiotic–medium interactions, the method was also
tested isolates was lower, doxycycline was considered the more
applied using Escherichia coli ATCC 25922 and Staphylococcus
active substance. Antibiotic susceptibilities between the 7 tested
aureus ATCC 29213 in triplicate experiments following the CLSI
genospecies did not differ signiﬁcantly (Kruskal-Wallis test,
(formerly NCCLS) standard protocols except for preincubation of
po0.05). In addition, no signiﬁcant MIC deviations attributable
the used antibiotic–BSK preparation for 48 h before testing (
to interactions of the tested antimicrobial agents with compo-
nents of the BSK medium were detected in our quality controlexperiments with the reference organisms S. aureus ATCC 29213and E. coli ATCC 25922 for any of the antibiotics used ().
Conventional MBC values of doxycycline, tetracycline,
ceftriaxone, and cefotaxime were determined for at least one
The MBC (deﬁned as 100% killing) value of each isolate was
isolate of each genospecies by obtaining aliquots of 18 ml from
obtained after a 72-h exposure to the antibiotic substances
each well without growth after 72 h and transferring these
followed by an additional 3-week incubation of subcultures.
samples into vials containing 1332 ml of fresh BSK medium
When taking the median MBCs of all tested isolates in milligram
per liter into account, the rank order of MBC90s in the tested
low MIC values measured for tigecycline, an aliquot of 1.8 ml
isolates was: tigecycline (0.5 mg/L), ceftriaxone (2 mg/L), tetra-
was transferred into 1348 ml of BSK (dilution factor 1:750) for
cycline (16 mg/L), doxycycline (16 mg/L), cefotaxime ( Z16 mg/L)
this agent. Subcultures were then incubated at 33 1C for another
3 weeks. After slight agitation of the medium, 10 microscopicalﬁelds were examined for the presence or absence of viable
spirochetes using dark-ﬁeld microscopy (Carl Zeiss MicroIma-ging, G ¨ottingen, Germany).
The acitivity of tigecycline and ceftriaxone against the B. afzelii
isolate EB1 was further examined by time-kill experiments.
Tigecycline inhibited growth of the initial inoculum for 72 h at a
concentration of 0.016 mg/L, whereas ceftriaxone required con-centrations of 0.03 mg/L (). Tigecycline achieved a 43 log10-
Time-kill experiments were performed by culturing B. afzelii
unit reduction of the initial inoculum after 24 h at a concentration
isolate EB1 in the presence of 0.016, 0.03, 0.25, and 2 mg/L
of 0.25 mg/L, whereas in ceftriaxone a concentration of 2 mg/L
tigecycline or ceftriaxone as described in the MIC experiments.
The time-kill curve was constructed by counting the number ofviable spirochetes under a dark-ﬁeld microscope using a KOVAcounting chamber (Hycor Biomedical inc., Garden grove, CA) after
0, 24, 48, 72, and 96 h. Experiments were performed in duplicateand the data are depicted as the average of 2 experiments as
Doxycycline, and occasionally other tetracyclines, are fre-
described recently The concentration of the
antibiotic agent that inhibited growth of the inoculum for 72 h
was deﬁned as the MIC. The concentration that achieved a
effective in the majority of clinical cases (
4 3 log10 reduction of the inoculum after 72 h was deﬁned as the
early Lyme borreliosis occur in 5–10% of all patients including
L. Ates et al. / Ticks and Tick-borne Diseases 1 (2010) 30–34
the in vitro activity of tigecycline was tested in well-controlled
assays and compared to other clinically relevant antibiotics.
In our present study, tigecycline clearly had a low MIC90
( r0.016 mg/L) for all tested isolates. In fact, tigecycline was moreactive than doxycycline (MIC90: 0.25 mg/L) and appeared even
more active in vitro than ceftriaxone (MIC90: 0.03 mg/L) for all
isolates tested. Furthermore, tigecycline was the most borreliaci-dal compound of all tested substances resulting in an MBC90 of
0.5 mg/L for the tested isolates. Taking all MBC90 values into
account, tigecycline was 4 times more effective in vitro than the
second most active antibiotic, ceftriaxone (MBC90: 2 mg/L), and upto 32 times more effective than doxycycline (range of MBCs:
8–16 mg/L). Our observation of a high in vitro activity oftigecycline was further conﬁrmed by time-kill experiments usingthe B. afzelii isolate EB1. Tigecycline inhibited the growth of the
initial inoculum at 0.016 mg/L and reduced the inoculum by4 3 log
10 at 0.25 mg/L after 72 h of incubation, thereby corre-
sponding to the low MIC90 and MBC90 values as determined by
our microdilution susceptibility experiments. As depicted in, the in vitro susceptibility values of the other tested
tetracyclines and cephalosporins were found to be in goodaccordance with values published in the recent literature(). Moreover, our quality control experi-
ments clearly conﬁrmed that in vitro test results were notsigniﬁcantly hampered by possible interactions of the antibiotic
Interestingly, tigecycline was shown to be more effective than
related classical tetracyclines in many Gram-positive and Gram-
negative bacteria including multi-drug resistant pathogens withRND-efﬂux pumps Such RND-type efﬂux pumps are
prevalent in a wide variety of other Gram-negative bacteriae, such as
E. coli and Acinetobacter baumanii, where they appear to decrease thesusceptibility of these organisms to a large number of antibiotic
agents including tetracyclines (. Interestingly, such
a mechanism of antibiotic resistance has recently been described
also for B. burgdorferi demonstrating the efﬂux of antibiotics fromthe spirochete by use of a resistance nodulation-cell division (RND)
type efﬂux pump called BesABC ). A knockout ofBesC in a genetically modiﬁed B. burgdorferi s.s. strain was
Fig. 1. Time-kill curves of B. afzelii isolate EB1 cultured with different concentra-
demonstrated to result in an increased susceptibility to multiple
tions of tigecycline (A), or ceftriaxone Concentrations forceftriaxone were chosen as half the MIC (0.016 mg/L), the MIC (0.03 mg/L), 8
classes of antibiotics used in the therapy of Lyme borreliosis. For
times the MIC (0.25 mg/L), and the MBC (2 mg/L) as deﬁned by the microdilution
tetracycline, an 8-fold decrease of the MIC90 (0.31 mg/L in the wild-
test method Concentrations for tigecycline were 0.016 mg/L correspond-
type strain vs. 0.04 mg/L in the BesC knockout strain) and a 15-fold
ing to the MIC (growth inhibition of the initial inoculum), and 0.25 mg/L
decrease of the MBC (2.5 mg/L in the wild-type strain vs. 0.16 mg/L
corresponding to the MBC (>3 log10 reduction of the initial inoculum after 72 h).
Two experiments were performed in parallel. Depicted is the mean of the 2
in the BesC knockout strain) was observed using our standardized
susceptibility-testing assay One of theproposed reasons for the increased activity of tigecycline againstborrelia compared to classical tetracyclines as observed in our study
may be the fact that tigecycline is obviously more resistant to efﬂux
as mediated by RND-type efﬂux systems than are the classical
). The clinical success rate in patients with early or late
neuroborreliosis that were treated with doxycycline or ceftriax-
consideration the results of our study, the susceptibility testing of
borrelial mutants with altered tetracycline resistance against
Doxycycline seems to be as effective as ceftriaxone in
tigecycline would be a very interesting future approach of antibiotic
European patients affected by neuroborreliosis (
research in borrelia. Furthermore, tigecycline has a much larger
However, treatment failures may be more likely in later
volume of distribution Vd compared to the classical tetracyclines
stages of Lyme borreliosis than in the early phase characterized by
() (>10 L/kg vs. 0.14–1.6 L/kg) which is, however,
erythema migrans or neuroborreliosis ).
similar to the Vd of ceftriaxone ). These
In recent years, new substances for the treatment of bacterial
considerations and its high in vitro activity against Borrelia clearly
infections have become available. In our present study, we
warrant further clinical studies on tigecyline in the treatment of
performed in vitro susceptibility testing experiments with tigecy-
disseminated late manifestations of Lyme borreliosis, i.e. arthritis or
cline, a new tetracycline and a structural analog of minocycline.
acrodermatitis chronica atrophicans.
Tigecycline was recently reported to be effective in vitro against
In summary, we have further conﬁrmed that tigecycline is very
B. burgdorferi However, data on its in vitro
effective in vitro against a wide variety of B. burgdorferi s.l.
effectiveness against a wider range of Borrelia isolates under
isolates. In fact, it actually appears more effective in vitro than
standardized test conditions are missing. Here, for the ﬁrst time,
other agents that are frequently used for the treatment of Lyme
L. Ates et al. / Ticks and Tick-borne Diseases 1 (2010) 30–34
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LEY DE INSTITUCIONES DE ASISTENCIA PRIVADA DEL ESTADO DE MICHOACÁN DE ULTIMA REFORMA PUBLICADA EN EL PERIODICO OFICIAL: 23 DE AGOSTO DE 2007, SEGUNDA. SECCION. TOMO CXLII, NUM. 11 Ley publicada en el Periódico Oficial, el día miércoles 9 de junio de 2004. LÁZARO CÁRDENAS BATEL , Gobernador Constitucional del Estado Libre y Soberano de Michoacán de Ocampo, a todos sus habitantes hace
Aliskiren (Tekturna®) DESCRIPTION WHAT THE PATIENT NEEDS TO KNOW Aliskiren is a recently-approved, first-in-class Adverse effects associated with aliskiren are for the antihypertensive agent. It is approved for the most part mild. Excessive reductions in blood treatment of hypertension as monotherapy or in pressure have occasionally been reported, as has combination with o