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Vol. 28. Issue 6.
(November - December 2024)
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Vol. 28. Issue 6.
(November - December 2024)
Original Article
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Comparative in vitro activity of Delafloxacin and other antimicrobials against isolates from patients with acute bacterial skin, skin-structure infection and osteomyelitis
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Ághata Cardoso da Silva Ribeiroa,1,
Corresponding author
aghata.cardoso@unifesp.br

Corresponding author.
, Fernanda Fernandes Santosa,1, Tiago Barcelos Valiattia, Michael Henrique Lenzia, Ingrid Nayara Marcelino Santosa, Raíssa Fidelis Baêta Nevesa, Ikechukwu Benjamin Mosesa,b, Jaqueline Pilon de Menesesc, Renata Gebara de Grande Di Sessac, Mauro José Sallesa, Ana Cristina Galesa
a Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicinan (EPM), Departamento de Medicina Interna, Divisão de Doenças Infecciosas, Laboratório Alerta, São Paulo, SP, Brazil
b Ebonyi State University, Faculty of Science, Department of Applied Microbiology, Abakaliki, Nigeria
c Eurofarma, Brazil
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Tables (4)
Table 1. Antimicrobial agents tested for the different species analyzed in this study and criteria applied for categorizing the antimicrobial susceptibility profile.
Table 2. Primers for gyrA and parC sequencing.
Table 3. Activity of delafloxacin and comparators against ABSSSI isolates from Brazilian samples.
Table 4. Delafloxacin and quinolone comparators MIC frequency distributions for the most frequent ABSSSI isolates.
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Abstract

The aim of this study was to compare the in vitro activity of delafloxacin with other fluoroquinolones against bacterial pathogens recovered from inpatients with osteomyelitis, Acute Bacterial Skin and Skin-Structure Infections (ABSSSI). In total, 100 bacterial isolates (58 % Gram-negative and 42 % Gram-positive) recovered from inpatients between January and April 2021, were reidentified at species level by MALDI-TOF MS. Antimicrobial susceptibility testing was conducted using the broth microdilution method and the detection of biofilm formation was assessed through the microtiter plate assay. The screening for mecA was carried out by PCR, while mutations in the Quinolone Resistance Determining Regions (QRDR), specifically gyrA and parC, were analyzed using PCR followed by Sanger sequencing. Results showed that delafloxacin exhibited greater in vitro potency (at least 64-times) than the other tested fluoroquinolones (levofloxacin and ciprofloxacin) when evaluating Staphylococcus aureus (MIC50 ≤0.008 mg/L) and coagulase-negative Staphylococcus (MIC50 0.06 mg/L). Furthermore, delafloxacin (MIC50 0.25 mg/L) was at least 4 times more potent than other tested fluoroquinolones (MIC50 1 mg/L) against P. aeruginosa. No difference in delafloxacin activity (MIC50 0.03 mg/L) was observed against Enterobacter cloacae when compared with ciprofloxacin (MIC50 0.03 mg/L). Despite presenting low activity against K. pneumoniae isolates (22.2 %), delafloxacin exhibited twice the activity compared to both levofloxacin and ciprofloxacin. Delafloxacin also exhibited a strong activity (71.4 %‒85.7 %.) against biofilm producing bacterial pathogens tested in this study. Interestingly, 82.14 % of the staphylococci tested in this study harbored mecA gene. In addition, the gyrA and parC genes in fluoroquinolone-resistant Gram-negative isolates displayed different mutations (substitutions and deletions). Herein, we showed that delafloxacin was the most active fluoroquinolone against staphylococci (including MRSA) and P. aeruginosa when compared to other fluoroquinolones such as ciprofloxacin and levofloxacin.

Keywords:
Acute bacterial skin
Skin-structure infection
Osteomyelitis
Delafloxacin
Antimicrobial-resistant bacteria
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Introduction

Antimicrobial resistance is one of the main threats to human health. In the last years, the rates of Multidrug-Resistant (MDR) bacteria have increased; thus, limiting treatment options which have encouraged the development of new antimicrobials.1,2 In this sense, recently, a new fluoroquinolone, delafloxacin, was developed and approved by Food and Drug Administration (FDA) and European Medicines Agency (EMA) to treat Acute Bacterial Skin and Skin-Structure Infections (ABSSSI),2 and lately it has also been approved in the USA for the treatment of community-acquired pneumonia3 and, more recently, in Brazil launched in 2022 also for treatment of ABSSSI.

Delafloxacin presents an anionic nature which provides improved activity in the infection site. During the infectious process, the environment tends to become acidic (excess of free protons), and unlike other fluoroquinolones, delafloxacin undergoes protonation within this environment, turning into a neutral molecule that can easily enter the bacterial cell. Once inside the bacteria (neutral pH), delafloxacin deprotonates and initiates its mechanism of action.4,5 Delafloxacin is a bactericide broad-spectrum anionic fluoroquinolone that targets both bacterial DNA gyrase and topoisomerase IV, enzymes of Gram-positive and Gram-negative bacteria.5–8

Regarding its use in clinical practice, delafloxacin has the advantage of being administered Intravenously (IV) (300 mg) and orally (450 mg) every 12 h. The Oral Administration (OR) shows a comparable bioavailability with IV, allowing the transition of therapy from IV to OR, and thus facilitating patient discharge.9,10 However, in Brazil, only the IV presentation is available.11

Recent studies have shown the efficacy of delafloxacin against both Methicillin-Susceptible Staphylococcus aureus (MSSA) and Methicillin-Resistant (MRSA), achieving up to 97.5 % of MRSA susceptibility. Moreover, it was observed that delafloxacin showed good activity against Pseudomonas aeruginosa.12-14

The present study aimed to evaluate the activity of delafloxacin in comparison to other antimicrobial agents against isolates recovered from patients diagnosed with ABSSSI or osteomyelitis in a tertiary hospital from the city of São Paulo, Brazil.

Material and methodsBacterial isolates

A total of 100 isolates recovered from patients diagnosed with ABSSSI or osteomyelitis were collected between January and April 2021. The isolates identification at species level was performed by Matrix Assisted Laser Desorption Ionization ‒ Time of Flight Mass Spectrometry (MALDI-TOF MS) using the Microflex spectrometer LT (Bruker Daltonics, Massachusetts, USA). The data obtained was analyzed by Biotyper version 3.1 software (Bruker Daltonics, Massachusetts, USA). Scores ≥ 2.0 to 2.99 were considered trustful for species-level identification, while scores ≥ 1.7 to 1.99 were considered sufficient for genus-level identification.15

Antimicrobial susceptibility testing

The antimicrobial susceptibility profile of the isolates was determined by broth microdilution method.16 The antimicrobials tested for each species were those recommended (Table 1). Quality control and the interpretation of results were performed according to BrCAST/EUCAST guidelines, with results following within the expected ranges. Since the FDA provides a broad range of delafloxacin MIC (Minimum Inhibitory Concentration) for different species, these FDA breakpoints were used to categorize the MICs of delafloxacin. Also, we used the delafloxacin breakpoints for S. haemolyticus to categorize other CoNS (Coagulase-Negative Staphylococci). The quality control strains used in this study were Escherichia coli ATCC 25922, Pseudomonas aeruginosa ATCC 27853, and Staphylococcus aureus ATCC 29213.16

Table 1.

Antimicrobial agents tested for the different species analyzed in this study and criteria applied for categorizing the antimicrobial susceptibility profile.

Antimicrobial agent  MicroorganismCriteria 
  Staphylococcus spp.  E. faecalis  Enterobacterales  Pseudomonas spp and other GNB   
Delafloxacin  Xa 
Ciprofloxacin  Xb 
Levofloxacin  Xb 
Tetracycline        Xb 
Linezolid      Xb 
Teicoplanin        Xb 
Vancomycin      Xb 
Oxacillin        Xb 
Cefepime      Xb 
Ceftazidime      Xb 
Imipenem      Xb 
Meropenem      Xb 
Ertapenem        Xb 
Amikacin      Xb 
Gentamicin      Xb 
Polymyxin B      Xb 

Xa, FDA criteria.

Xb, BRCAST criteria.

Biofilm formation assay

The detection of biofilm formation was performed by microtiter plate assay, using crystal violet on a polystyrene abiotic surface. The results were interpreted as previously reported.17 First, the isolates were cultured in Tryptone Soy Broth (TSB) overnight, and then 5 µL of these cultures were inoculated in a 96-well-plate containing 195 µL of TSB in each well. The plate was incubated for 24 h at 37 °C. After the incubation, TSB was removed and the wells were washed three times with Phosphate Buffered Saline (PBS), fixed with formaldehyde 3 %, and stained with crystal violet 1 %. The dye was solubilized in ethanol 95 % and the Optical Density (OD) was read in a spectrophotometer with a wavelength of 570 nm. This assay was performed in triplicate.

Detection of mutations in gyrA and parC in Gram-negative bacteria (GNB)

The delafloxacin-resistant GNB were selected to search for mutations in Quinolone Resistance Determining Regions (QRDR). The gyrA and parC genes were sequenced by Sanger method using specific primers (Table 2) for the selected isolates. Briefly, the amplicons were obtained by PCR and the DNA from PCR products were purified using the extraction kit Gel QIAquick (Qiagen, Courtaboeuf, France) according to manufacturer's instructions. The DNA quantification was performed in the NanoVue spectrophotometer (GE Healthcare, Canada) with a wavelength of 260 nm. For the sequencing, we used the Big Dye terminator Cycle Sequencing Kit (Applied Biosystems, Foster City, USA) and the run was performed in the ABI 3500 genetic Analyzer (Applied Biosystems, Perkin Elmer, USA) sequencer.

Table 2.

Primers for gyrA and parC sequencing.

Primer  Sequence (5′−3′)  Target  Amplicon (bp)  Reference 
gyrA-F  CGACCTTGCGAGAGAAAT       
    gyrA  626  Martins et al., 2015 
gyrA-R  GTT CCATCAGCCCTTCAA       
         
parC-F  AGCGCCTTGCGTACATGA AT  parC  938  Martins et al., 2015 
parC-R  GTGGTAGCGAAGAGGTGG TT       

The sequences obtained were analyzed in the Lasergene software (DNASTAR, Madison, USA) and the mutations analysis were performed using BioEdit® and SnapGene® software.

For evaluation of gyrA and parC mutations, we used different isolates’ sequences deposited in NCBI as controls: E. coli (NC_000913.3), Klebsiella pneumoniae (KN046818.1), Pseudomonas aeruginosa (NC_002516.2), Enterobacter spp. (NZ_MKEQ01000001.1), and Morganella morganii (NZ_JACOMH010000006.1).

Detection of mecA gene

The mecA gene was searched in all Staphylococcus spp. isolates (n = 36) by PCR, using specific primers (mecA147-F: 5′-GTGAAGATATACCAAGTGATT-3′; mecA147-R: 5′-ATGCGCTATAGATTGAAAGGAT-3′) . The PCR conditions were as follows: 94 °C for 5 min, 30 cycles at 94 °C for 1 min, 55 °C for 1 min, 72 °C for 2 min, and the final extension at 72 °C for 10 min. 18

ResultsIsolates characterization

Between January and April 2021, we collected 100 isolates recovered from 77 in patients diagnosed with ABSSI or osteomyelitis. Among the isolates, 58 % were GNB and 42 % were Gram-positive cocci.

The Enterobacterales corresponded to 63.8 % of the GNB with higher frequency of Klebsiella pneumoniae, followed by the non-fermenting GNB (36.2 %) with higher frequency of Pseudomonas aeruginosa. Among the Gram-positive bacteria, the most common genus was Staphylococcus spp. (n = 36/42), from which 50 % were identified as S. aureus and the other 50 % as belonging to the coagulase-negative group, represented by S. epidermidis (n = 10), S. capitis (n = 4), S. hominis (n = 2), S. haemolyticus (n = 1), and S. warnerii (n = 1).

Overall, the most frequent pathogenic species obtained were Staphylococcus aureus (n = 18), followed by Pseudomonas aeruginosa (n = 14), Klebsiella pneumoniae (n = 9), and Enterobacter cloacae (n = 7) (Fig. 1). The microorganisms were isolated mostly from skin injuries (n = 58) and bone tissue (n = 13) from 77 patients. From these, 59 presented monomicrobial infections and 18 polymicrobial infections (two [n = 15] and three [n = 3] pathogens). The isolates were recovered from patients often hospitalized in the emergency room and surgery center.

Fig. 1.

Species distribution of biofilm producers.

(0.24MB).
Antimicrobial susceptibility testing

In general, we observed a delafloxacin MIC ranging from ≤ 0.008 to > 4 mg/L, and the delafloxacin susceptibility rate was an average of 72.7 %.

S. aureus presented a susceptibility rate of 83.4 % to delafloxacin, with MIC50/90 of ≤ 0.008 and 2 mg/L, respectively. For the other comparators, the susceptibilities ranged from 27.8 % for tetracycline to 100 % for vancomycin and teicoplanin. According to the oxacillin susceptibility profile, nine S. aureus were classified as Methicillin-Resistant (MRSA) and nine were classified as Methicillin-Susceptible (MSSA). All the MSSA (100 %) were susceptible to delafloxacin (MIC50 ≤ 0.008 mg/L) and presented lower susceptibility rates for levofloxacin (11.1 % MIC50 0.5 mg/L), ciprofloxacin (77.8 % ‘susceptible, increasing the exposure’; MIC50 1 mg/L), and tetracycline (11.1 %; MIC50 2 mg/L). For the MRSA, the delafloxacin susceptibility rate was 66.7 % (MIC50 ≤ 0.008 mg/L), which was higher than the susceptibility obtained for the fluoroquinolone comparators [levofloxacin and ciprofloxacin (66.7 % ‘susceptible, increasing the exposure’; MIC50 0.5/1 mg/L)].

Among the CoNS, the susceptibility rate of delafloxacin was 83.3 % (MIC50/90 0.06/1 mg/L). This was higher than that for levofloxacin (44.4 % ‘susceptible, increasing the exposure’; MIC50/90 4/ > 4 mg/L) and ciprofloxacin (38.9 % ‘susceptible, increasing the exposure’; MIC50/90 4/ > 4 mg/L). The susceptibility for the other antimicrobials ranged from 33.3 % for tetracycline to 100 % for vancomycin and teicoplanin.

P. aeruginosa presented a delafloxacin susceptibility rate of 71.4 % (MIC50/90 0.25/1 mg/L). For the other fluoroquinolones, the susceptibility rates were 50 % of ‘susceptible, increasing the exposure’ (MIC50/90 0.5/ > 4 mg/L) for levofloxacin and 42.9 % ‘susceptible, increasing the exposure’ (MIC50/90 1/ > 4 mg/L) for ciprofloxacin. All P. aeruginosa isolates presented susceptibility to polymyxin B and resistance to carbapenems greater than 40 %.

Delafloxacin susceptibility rate against K. pneumoniae was 30 % (MIC50/90 1/ > 4 mg/L). For the other fluoroquinolone comparators, the susceptibility rates were 20 % for levofloxacin (MIC50/90 2/ > 4 mg/L) and 10 % for ciprofloxacin (MIC50/90 4/ > 4 mg/L). The lowest susceptibility rate obtained was for ciprofloxacin and the highest were for amikacin and polymyxin B (60 %).

For E. cloacae, the delafloxacin susceptibility rate was 85.7 % (MIC50 0.03 mg/L) which was the same value obtained for ciprofloxacin (MIC50 0.03 mg/L), and both were lower than that obtained for levofloxacin (100 %; MIC50 0.12 mg/L). In general, for E. cloacae, the susceptibility rates were higher than 70 %, except for ceftazidime (42.9 %) and cefepime (57.1 %).

For the other Enterobacterales (Citrobacter freundii = 2; Morganella morgannii = 3; E. coli = 4; Serratia marcescens = 4; and Proteus spp.= 6), the MIC50 was 0.25 mg/L and the MIC90 was 4 mg/L. Moreover, for the other species encountered (one isolate per species), the MIC for Achromobacter spp. was 0.12 mg/L; for Acinetobacter baumannii, 0.25 mg/L; for A. nosocomialis, A. ursingii, and Aeromonas spp., the MIC was ≤0.008 mg/L each. The overall susceptibility rates and the MIC50/90 for the antimicrobial agents are shown in Table 3. The MIC frequency distributions for delafloxacin and fluoroquinolone comparators are presented in Table 4 for the most frequent species.

Table 3.

Activity of delafloxacin and comparators against ABSSSI isolates from Brazilian samples.

Microorganism/Antimicrobial agent  MIC (mg/L)     
  MIC50  MIC90  MIC range  %S  %I  %R 
Staphylococcus aureus (n=18)             
Delafloxacine  ≤ 0.008  ≤ 0.008 ‒ 2  83.4  ‒  16.6 
Levofloxacin  0.5  > 4  0.12 ‒ > 4  5.6  66.7  27.8 
Ciprofloxacin  > 4  ≤ 0.008 ‒ > 4  ‒  72.2  27.8 
Oxacillinb  > 16  ≤ 0.5 ‒ > 16  50  ‒  50 
Vancomycin  1 ‒ 2  100  ‒  ‒ 
Teicoplanin  ≤ 0.25  0.25  ≤ 0.25 – 0.5  100  ‒  ‒ 
Linezolid  1 ‒ 4  100 %  ‒  ‒ 
Tetracycline  > 8  0.5 ‒ > 8  27.8  38.9  33.3 
MSSA (n=9)             
Delafloxacine  ≤ 0.008  a  ≤ 0.008‒4  100  ‒  ‒ 
Levofloxacin  0.5  a  0.12 ‒ > 4  11.1  66.7  22.1 
Ciprofloxacin  a  ≤ 0.008 ‒ > 4  ‒  77.8  22.2 
Oxacillinb  ≤ 0.5  a  ≤ 0.5 ‒ 2  100  ‒  ‒ 
Vancomycin  a  ≤ 0.25 ‒ 2  100  ‒  ‒ 
Teicoplanin  ≤ 0.25  a  ≤ 0.25 ‒ 0.25  100  ‒  ‒ 
Linezolid  a  0.5 ‒ 4  100  ‒  ‒ 
Tetracycline  a  0.5 ‒ > 8  11.1  55.6  33.3 
MRSA (n=9)             
Delafloxacine  ≤ 0.008  a  ≤ 0.008 ‒ 2  66.7  ‒  33.3 
Levofloxacin  0.5  a  0.5 ‒ > 4  ‒  66.7  33.3 
Ciprofloxacin  a  0.5 ‒ > 4  ‒  66.7  33.3 
Oxacillinb  > 16  a  4 ‒ > 16  ‒  ‒  100 
Vancomycin  a  1 ‒ 2  100  ‒  ‒ 
Teicoplanin  0.25  a  ≤ 0.25 ‒ 0.25  100  ‒  ‒ 
Linezolid  a  1 ‒ 2  100  ‒  ‒ 
Tetracycline  a  1 ‒ > 8  44.5  22.2  33.3 
CoNS (n=18)*             
Delafloxacinc  0.06  ≤ 0.008 ‒ 4  83.3  5.6  11.1 
Levofloxacin  > 4  0.25 ‒ > 4  ‒  44.4  55.6 
Ciprofloxacin  > 4  0.12 ‒ > 4  ‒  38.9  61.1 
Oxacillinb  16  > 16  ≤ 0.5 ‒ > 16  ‒  ‒  100 
Vancomycin  1 ‒ 4  100  ‒  ‒ 
Teicoplanin  ≤ 0.25 ‒ 2  100  ‒  ‒ 
Linezolid  0.5  0.25 ‒ 4  100  ‒  ‒ 
Tetracycline  1 ‒ > 8  33.3  5.6  61.1 
Klebsiella spp. (n=10)             
Delafloxacine  > 4  ≤ 0008 ‒ > 4  30  ‒  70 
Levofloxacin  > 4  ≤ 0.008 ‒ > 4  20  10  70 
Ciprofloxacin  > 4  ≤ 0.008 ‒ > 4  10  10  80 
Cefepime  64  > 64  ≤ 0.12 ‒ > 64  33.3  ‒  77.7 
Ceftazidime  64  > 64  0.25 ‒ > 64  40  ‒  60 
Imipenem  64  0.25 ‒ 64  50  ‒  50 
Meropenem  32  ≤ 0.12 ‒ > 64  40  10  50 
Ertapenem  0.5  > 64  ≤ 0.12 ‒ > 64  20  ‒  80 
Amikacin  > 64  1 ‒ > 64  60  ‒  40 
Gentamicin  32  > 64  0.25 ‒ > 64  20  ‒  80 
Polymyxin B  ≤ 0,25  32  ≤ 0.25 ‒ 64  60  ‒  40 
Klebsiella pneumoniaed(n=9)             
Delafloxacine  a  0.06 ‒ > 4  22.2  ‒  77.8 
Levofloxacin  a  0.25 ‒ > 4  11.1  11.1  77.8 
Ciprofloxacin  > 4  a  0.5 ‒ > 4  ‒  11.1  88.9 
Cefepime  > 64  a  ≤ 0.12 ‒ > 64  33.3  ‒  77.7 
Ceftazidime  64  a  0.25 ‒ > 64  33.3  ‒  77.7 
Imipenem  32  a  0.25 ‒ 64  44.5  ‒  55.5 
Meropenem  32  a  ≤ 0.12 ‒ > 64  33.3  11.1  55.5 
Ertapenem  64  a  ≤ 0.12 ‒ > 64  11.1  ‒  88.9 
Amikacin  a  1 ‒ > 64  55.5  ‒  44.4 
Gentamicin  32  a  0.25 ‒ > 64  11.1  ‒  88.9 
Polymyxin B  0.25  a  ≤ 0.25 ‒ 64  55.5  ‒  44.4 
Enterobacter cloacae (n=7)             
Delafloxacine  0.03  a  ≤ 0.008 ‒ 1  85.7  ‒  14.3 
Levofloxacin  0.12  a  0.03 ‒ 0.25  100  ‒  ‒ 
Ciprofloxacin  0.03  a  ≤ 0.008 ‒ 0.5  85.7  14.3  ‒ 
Cefepime  a  ≤ 0.12 ‒ > 64  57.1  14.3  28.6 
Ceftazidime  a  0.5 ‒ > 64  42.9  14.3  42.9 
Imipenem  a  0.25 ‒ 4  71.4  28.6  ‒ 
Meropenem  ≤ 0.12  a  ≤ 0.12 ‒ 4  71.4  28.6  ‒ 
Ertapenem  ≤ 0.12  a  ≤ 0.12 ‒ 32  71.4  ‒  28.6 
Amikacin  a  0.25 ‒ > 64  85.7  ‒  14.3 
Gentamicin  0.25  a  ≤ 0.12 ‒ 64  71.4  ‒  28.6 
Polymyxin B  ≤ 0.25  a  ≤ 0.25 ‒ > 128  71.4  ‒  28.6 
Pseudomonas spp.f(n=16)             
Delafloxacine  0.25  0.016 ‒ > 4  81.3  12.5  6.2 
Levofloxacin  0.5  > 4  0.03 ‒ > 4  ‒  50  50 
Ciprofloxacin  > 4  0.016 ‒ > 4  ‒  37.5  62.5 
Cefepime  > 64  ≤ 0.12 ‒ > 64  ‒  50  50 
Ceftazidime  32  0.25 ‒ 64  ‒  87.5  12.5 
Imipenem  16  0.25 ‒ 16  ‒  43.8  56.2 
Meropenem  32  0.25 ‒ 64  43.8  18.7  37.5 
Amikacin  > 64  0.5 ‒ > 64  68.7  ‒  31.3 
Gentamicing  > 64  ≤ 0.12 ‒ > 64  –  ‒  ‒ 
Polymyxin B  0.5  ≤ 0.25 ‒ 8  93.7  ‒  6.3 
Pseudomonas aeruginosa (n=14)             
Delafloxacine  0.25  0.016 ‒ > 4  78.7  14.2  7.1 
Levofloxacin  0.5  > 4  0.03 ‒ > 4  ‒  50  50 
Ciprofloxacin  > 4  0.016 ‒ > 4  ‒  42.9  57.1 
Cefepime  16  > 64  1 ‒ > 64  ‒  42.9  57.1 
Ceftazidime  32  0.25 ‒ 64  ‒  85.7  14.3 
Imipenem  16  1 ‒ 16  ‒  50  50 
Meropenem  32  0.25 ‒ 64  42.9  14.3  42.9 
Amikacin  > 64  2 ‒ > 64  64.3  ‒  35.7 
Gentamicin  > 64  1 ‒ > 64  g  g  g 
Polymyxin B  0.5  ≤ 0.25 ‒ 1  100  ‒  ‒ 

All CoNS were resistant to oxacillin.

a

It was not possible to calculate the MIC90 because the isolates number was lower than 10.

b

Categorization performed according to BRCAST/EUCAST (2021): S. aureus isolates presenting MIC > 2 mg/L for oxacillin were categorized as resistant to methicillin.

c

All CoNS were classified for delafloxacin according to the breakpoint for S. haemolyticus, preconized by the FDA (2020).

d

Klebsiella spp, Klebsiella oxytoca (1) and Klebsiella pneumoniae (9).

e

AST categorization for delafloxacin according to the breakpoints preconized by the FDA (2020). For the comparators the BRCAST/EUCAST (2021) breakpoint were used.

f

Pseudomonas spp. Pseudomonas aeruginosa (14), Pseudomonas putida (1) and 1 Pseudomonas stutzeri (1).

g

There is no breakpoint established by BRCAST/EUCAST (2021).

Table 4.

Delafloxacin and quinolone comparators MIC frequency distributions for the most frequent ABSSSI isolates.

  N° (cumulative %) of isolates inhibited at MIC (mg/L) of:
Microorganism or Microorganism group/ Antimicrobial agent  ≤ 0.008  0.016  0.03  0.06  0.12  0.25  0.5  ≥ 4  n (R%) 
S. aureus (n=18)
Delafloxacina  11 (61.1 %)  1 (66.7 %)  1 (72.2 %)  1 (77.8 %)  1 (83.3 %)  2 (94.4)  1 (100 %)  3 (16.6) 
Levofloxacin  1 (5.6 %)  12 (72.2 %)  5 (100 %)  5 (27.8) 
Ciprofloxacin  1 (5.6 %)  3 (22.2 %)  9 (72.2 %)  5 (100 %)  5 (27.8) 
Staphylococcus Coagulase Negative (n=18)
Delafloxacina  6 (33.3 %)  1 (38.9 %)  1 (44.5 %)  2 (55.7 %)  2 (66.9 %)  3 (83.7 %)  1 (89.3 %)  1 (94.9 %)  1 (100 %)  2 (11.1) 
Levofloxacin  2 (11.1 %)  6 (44.4 %)  10 (100 %)  10 (55.6) 
Ciprofloxacin  1 (5.6 %)  5 (33.3 %)  1 (38.9 %)  11 (100 %)  11 (61.1) 
Enterobacter cloacae (n=7)
Delafloxacinb  2 (28.6 %)  1 (42.9 %)  2 (7.,4 %)  1 (85.7 %)  1 (100 %)  1 (14.3) 
Levofloxacin      2 (28.6 %)  1 (42.9 %)  3 (85.7 %)  1 (100 %) 
Ciprofloxacin  3 (42.9 %)  1 (57.1 %)  2 (85.7 %)  1 (100 %) 
Pseudomonas spp. (n=16)
Delafloxacinb    1 (6.3 %)  3 (25.0 %)  2 (37.5 %)  1 (43.8 %)  5 (75.0 %)  1 (81.3 %)  2 93.8 %)  1 (100 %)  1 (6.2) 
Levofloxacin  1 (6.3 %)  1 (12.5 %)  4 (37.5 %)  2 (50.0 %)  4 (75.0 %)  4 (100 %)  8 (50.0) 
Ciprofloxacin  2 (12.5 %)  3 (31.3 %)  1 (37.5 %)  2 (50.0 %)  2 (62.5 %)  6 (100 %)  10 (62.5) 
Klebsiella spp. (n=10)
Delafloxacinb  1 (10.0 %)  1 (20.0 %)  1 (30.0 %)  3 (60.0 %)  2 (80.0 %)  2 (100 %)  7 (70.0) 
Levofloxacin  1 (10.0 %)  1 (20.0 %)  1 (30.0 %)  2 (50.0 %)  5 (100 %)  7 (70.0) 
Ciprofloxacin  1 (10.0 %)  1 (20.0 %)  8 (100 %)  8 (80.0) 

Shaded cells indicate the breakpoints for each antimicrobial agent according to BRCAST/EUCAST (2021) or FDA (2020).

a

All CoNS were classified for delafloxacin according to the breakpoint for S. haemolyticus, preconized by the FDA (2020).

b

Delafloxacin breakpoints used are from FDA (2020) and for the other quinolone comparators breakpoints are from BRCAST/EUCAST (2021).

Biofilm formation assay

Among the 100 isolates, 25 % were categorized as non-adherent, and 75 % were categorized as biofilm producers, with 47 % being classified as weakly adherent, 14 % as moderately adherent, and 14 % as strongly adherent.

The most common species of biofilm producers were P. aeruginosa, S. aureus, and S. epidermidis. The moderately and strongly adherent isolates were mostly P. aeruginosa (n = 3 and n = 4) and S. aureus (n = 3 and n = 4) (Fig. 1).

Moreover, we observed a good activity of delafloxacin against different biofilm-producing isolates (S. aureus, Enterococcus faecalis, P. aeruginosa, E. cloacae, Proteus spp., and CoNS). Among the biofilm-producers, those strongly and moderately adherent (28/75) presented a MIC range of ≤ 0.008 mg/L to > 4 mg/L, and the majority (23/28) presented MIC ≤ 0.25 mg/L. The strongly adherent isolates presented a delafloxacin susceptibility rate of 71.4 % and the moderately adherent 85.7 %.

Detection of mutations in QRDR of Gram-negative bacteria

Among 58 GNBs, 17 were resistant to delafloxacin. From these, 13 presented mutations in parC and 14 presented mutations in gyrA. In ParC protein, the predominant amino acid alteration was observed in position 80, where a serine was replaced by an Isoleucine (S80I) in E. coli and K. pneumoniae species. Also, we observed D79Y, A81P, and N105I mutations in K. pneumoniae, a deletion at position 21 and a substitution at position 87 (S87L) in P. aeruginosa. In GyrA protein, amino acid changes were more frequent at position 83. In E. coli, we detected S83L; in P. aeruginosa, T83I; and in K. pneumoniae, S83I and S83F. Moreover, we observed changes at position 87 (E. coli, D87N; and K. pneumoniae, D87A) and a deletion at position 163 in P. aeruginosa.

mecA gene detection in Staphylococcus spp

Among the 36 Staphylococcus spp. isolates (18 S. aureus and 18 CoNS), the mecA gene was detected in 77.7 % (n = 28/36). For S. aureus, 61.1 % (n = 11/18) were mecA-positive while 94.4 % (n = 17/18) were mecA positive for CoNS.

We could observe that among the 11 mecA-positive S. aureus, nine presented a resistance phenotype to oxacillin (MIC > 2 mg/L). Also, among the 18 oxacillin-resistant CoNS (MIC > 0.25 mg/L), 17 were mecA-positive.

Discussion

The new fluoroquinolone, delafloxacin, was approved for ABSSSI treatment and is active against Gram-negative and Gram-positive pathogens, including S. aureus (MSSA and MRSA), CoNS (S. haemolyticus and S. lugdunensis), Streptococcus spp., Enterococcus faecalis, E. coli, E. cloacae, K. pneumoniae and P. aeruginosa.13,19 Also, the FDA has approved its use for the treatment of community-acquired pneumonia.3 There are some publications showing good outcomes of delafloxacin use in clinical practice.20-22 Delafloxacin was successfully employed for treatment of eight patients with complicated ABSSSI admitted to Brazilian public teaching and reference hospital in infectious diseases from October 2022 to April 2023. Delafloxacin showed to be safe and effective for treating complicated ABSSSI including those caused by MRSA in people living with HIV/AIDS.23

In the present study, we observed that delafloxacin presented an excellent activity against S. aureus (MIC50 ≤ 0.008 mg/L) and CoNS (MIC50 0.06 mg/L) isolates, being at least 64 times more potent than both levofloxacin and ciprofloxacin (S. aureus; MIC50 0.5 mg/L; and CoNS; MIC50 4 mg/L). Overall, for Staphylococcus spp., delafloxacin was more active than the other fluoroquinolones comparators (Table 4). McCurdy and collaborators also obtained high rates of delafloxacin activity against levofloxacin-resistant S. aureus, with 95.0 % susceptibility to delafloxacin.24 Another study conducted in Europe showed that 92.4 % S. aureus were susceptible to delafloxacin (MIC50/90 ≤ 0.004/0.25), being more active than levofloxacin and moxifloxacin.13 Gerges and colleagues found delafloxacin susceptibilities of 40 % against MRSA, 80 % against MSSA, 50 % against methicillin-resistant-resistant CoNS and 95 % against methicillin-susceptible CoNS in pathogens recovered from oncologic patients.12 In a Brazilian study, Barth and collaborators accessed a rate of 100 % of susceptibility to delafloxacin in S. aureus isolated from ABSSSI.25 Moreover, Nicola and colleagues found delafloxacin susceptibilities of 97.5 % against MRSA, 97.7 % against MSSA, 93.5 % against CoNS in pathogens recovered from osteoarticular and skin infections.14

Delafloxacin (MIC50 0.25 mg/L) was at least four times more potent than ciprofloxacin (MIC50 1 mg/L) against P. aeruginosa, with an inhibition rate of 71.4 %. We also observed that these isolates presented resistance rates to carbapenems ≥ 50 %. Millar and collaborators observed that 50 % of ciprofloxacin-resistant or ciprofloxacin-‘susceptible increasing the exposure’ P. aeruginosa isolated from cystic fibrosis infection were susceptible to delafloxacin.26 Recently, a study conducted in the USA showed a delafloxacin susceptibility rate of 40 % in P. aeruginosa, with a rate of 75 % in P. aeruginosa non-MDR.13 Although all the P. aeruginosa isolates in this study were susceptible (100 %) to polymyxin, it is important to highlight that this drug presents high toxicity.27 Recently, another study conducted in the USA with isolates from ABSSSI, between 2017 and 2022, showed an overall susceptibility to delafloxacin of 70.3 %, with an increase of 8.8 % in the susceptibility rate.28

For E. cloacae, delafloxacin activity (MIC50 0.03 mg/L) was equal to ciprofloxacin (MIC50 0.03 mg/L) as well as the susceptibility rate (85.7 %). Similar results were obtained by Gerges and colleagues who observed a susceptibility rate of 85 % for these antimicrobials.12

Furthermore, in this study, delafloxacin presented a low activity against K. pneumoniae (22.2 %), as well as levofloxacin (11.1 %) and ciprofloxacin (11.1 %, ‘susceptible, increasing the exposure’). This could be explained by the high frequency of MDR-K. pneumoniae in the involved hospital, especially to aminoglycosides, carbapenems and polymyxin B29 as noted in Table 3. Another study showed 70 % of susceptibility to delafloxacin in K. pneumoniae, but these isolates were classified as non-ESBL and were susceptible to carbapenem.12

Moreover, we observed a good activity of delafloxacin against different biofilm-producing isolates. Interestingly, among these isolates, the majority (23/28) presented delafloxacin MIC ≤ 0.25 mg/L and the strongly adherent isolates presented a delafloxacin susceptibility rate of 71.4 % and the moderately adherent, 85.7 %. As it is already known, fluoroquinolones display good efficacy in treating osteomyelitis, due to their action on biofilm.30,31 Although clinical studies on the use of delafloxacin for osteomyelitis are scarce,32 recently a study of case was reported and a sacral osteomyelitis caused by P. aeruginosa that was not resolved after using polymyxin followed by ceftazidime/avibactam, was then extinguished after endovenous administration of delafloxacin.33 Previous studies had shown a potent activity of delafloxacin against biofilms from S. aureus, thus presenting an antimicrobial penetration from 0.6 % to 52 % on biofilm.34,35 In the present study, we did not test the activity of delafloxacin against biofilm, but against biofilm-producing isolates, hypothesizing that the antimicrobial could act against these isolates even before their biofilm formation.

Furthermore, mutations in gyrA and parC genes are recognized to be the main mechanism of resistance which confer a high-level resistance to fluoroquinolones. These mutations can confer amino acid alterations in these proteins, reflecting fluoroquinolone resistance.36 In the present study, we found amino acid changes in GyrA from E. coli, P. aeruginosa, and K. pneumoniae. Mostly, the amino acid in position 83 was replaced in all these three species. Also, the D87N/A change was detected in E. coli and K. pneumoniae; and in P. aeruginosa, a deletion at position 163 was observed. The most common mutations in gyrA related to fluoroquinolones resistance are associated with positions 83 and 87.37,38 However, to the best of our knowledge, this is the first time that the deletion in position 163 of GyrA in P. aeruginosa is reported as possibly to be related to fluoroquinolone resistance.

Furthermore, for parC gene, we observed amino acid changes mostly in position 80 in E. coli and K. pneumoniae, 87 in P. aeruginosa, 79 and 81 in K. pneumoniae. Also, a deletion in position 27 in P. aeruginosa was observed. The S80I substitution is already recognized to be related to fluoroquinolone resistance, as well as S87L in P. aeruginosa.39,40 However, to date, the mutations (D79 and A81P) in K. pneumoniae and deletion at position 27 in P. aeruginosa have not been reported to be possibly associated with fluoroquinolone resistance.

Finally, we could observe that delafloxacin presented a good activity against the Staphylococcus spp. resistant to oxacillin, with delafloxacin-susceptible MRSA rate of 66.7 % and delafloxacin-susceptible CoNS rate of 83.3 %. We also observed that 82.1 % of the Staphylococcus spp. harboring mecA gene were susceptible to delafloxacin. The study conducted by Saravolatz and collaborators assessed oxacillin susceptibility based on SCCmec typing for MRSA and showed that delafloxacin demonstrated activity against 94 % of SCCmec IVa USA300 isolates.41 On the other hand, our study is the first to present delafloxacin activity against isolates harboring the mecA gene.

However, our study shows limitations. The principal limitation of our work is the low number of isolates analyzed based on species. As we had a wide variety of species, the selected 100 isolates were distributed among them, thereby reflecting a low number by species. It is also important to highlight that we tested delafloxacin activity against biofilm producing isolates and not against the produced biofilm. Further studies are however needed to evaluate the activity of this drug on biofilm.

Conclusions

In the present study, we conducted a comparative analysis of delafloxacin's in vitro activity with other antimicrobials against various bacterial isolates obtained from patients diagnosed with ABSSSI or osteomyelitis. Among the fluoroquinolones, delafloxacin exhibited superior activity against the isolates, demonstrating up to 64 times greater potency than levofloxacin and ciprofloxacin. Furthermore, our findings revealed that delafloxacin displayed notable efficacy against MRSA, MSSA, CoNS and P. aeruginosa strains isolated in Brazil.

The gyrA and parC genes sequencing results revealed that there are different amino acid substitutions and deletions which might be related to fluoroquinolone resistance, thus highlighting the need for more studies to evaluate the impact of these mutations.

Interestingly, we observed a good activity of delafloxacin against biofilm-producing isolates, presuming that this antimicrobial could act against bacteria even before the formation of biofilm.

Acknowledgements

We acknowledge Streling, A.P. for all the help dispensed in the beginning of the project and Eurofarma Laboratórios S.A. for funding this research.

References
[1]
R. Giurazza, M.C. Mazza, R. Andini, P. Sansone, M.C. Pace, E Durante-Mangoni.
Emerging treatment options for multi-drug-resistant bacterial infections.
Life (Basel), 1 (2021), pp. 519
[2]
A. Rusu, A.C. Munteanu, E.M. Arbănași, V. Uivarosi.
Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile?.
Pharmaceutics, 15 (2013), pp. 804
[3]
Food and Drug Administration (FDA). Baxtela approval. 2019. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/208610s000,208611s000lbl.pdf.
[4]
F. Van Bambeke.
Delafloxacin, a non-zwitterionic fluoroquinolone in Phase III of clinical development: evaluation of its pharmacology, pharmacokinetics, pharmacodynamics and clinical efficacy.
Future Microbiol, 10 (2015), pp. 1111-1123
[5]
B. Kocsis, D. Gulyás, Szabó D. Delafloxacin.
Finafloxacin, and zabofloxacin: novel fluoroquinolones in the antibiotic pipeline.
Antibiotics (Basel), 10 (2021), pp. 1506
[6]
A.M. Nilius, L.L. Shen, D. Hensey-Rudloff, L.S. Almer, J.M. Beyer, Balli, et al.
In vitro antibacterial potency and spectrum of ABT-492, a new fluoroquinolone.
Antimicrob Agents Chemother, 47 (2003), pp. 3260-3269
[7]
S.J. Harnett, A.P. Fraise, J.M. Andrews, G. Jevons, N.P. Brenwald, R. Wise.
Comparative study of the in vitro activity of a new fluoroquinolone, ABT-492.
J Antimicrob Chemother, 53 (2004), pp. 783-792
[8]
M.A. Pfaller, H.S. Sader, P.R. Rhomberg, R.K. Flamm.
In Vitro activity of delafloxacin against contemporary bacterial pathogens from the United States and Europe, 2014.
Antimicrob Agents Chemother, 61 (2017), pp. e02609-e02616
[9]
A. Markham.
Delafloxacin: first global approval.
Drugs, 77 (2017), pp. 1481-1486
[10]
J. Shiu, G. Ting, T.K. Kiang.
Clinical pharmacokinetics and pharmacodynamics of delafloxacin.
Eur J Drug Metab Pharmacokinet, 44 (2019), pp. 305-317
[11]
Delabaxi: delafloxacino meglumine [medicine leaflet].
Dra. Ivanete A. Dias Assi, EUROFARMA, (2020),
[12]
B. Gerges, K. Rolston, S.A. Shelburne, J. Rosenblatt, R. Prince, I. Raad.
The in vitro activity of delafloxacin and comparator agents against bacterial pathogens isolated from patients with cancer.
JAC Antimicrob Resist, 5 (2023),
[13]
D. Shortridge, M.A. Pfaller, J.M. Streit, R.K. Flamm.
Update on the activity of delafloxacin against acute bacterial skin and skin-structure infection isolates from European hospitals (2014-2019).
J Glob Antimicrob Resist, 23 (2020), pp. 278-283
[14]
F. Nicola, N. Azula, G. Santoni, J. Smayevsky.
Actividad in vitro de delafloxacina frente a microorganismos aislados de infecciones osteoarticulares y de piel y partes blandas en Buenos Aires, Argentina [In vitro activity of delafloxacin against bacterial isolates from osteoarticular and skin infections in Buenos Aires, Argentina].
Rev Argent Microbiol, 54 (2022), pp. 114-119
[15]
L.C. Fehlberg, L.H. Andrade, D.M. Assis, R.H. Pereira, A.C. Gales, E.A. Marques.
Performance of MALDI-ToF MS for species identification of Burkholderia cepacia complex clinical isolates.
Diagn Microbiol Infect Dis, 77 (2013), pp. 126-128
[16]
BrCAST. Tabela-Pontos-de-Corte-Clinicos-BrCAST.
(2021),
[17]
S. Stepanovic, D. Vukovic, I. Dakic, B. Savic, M. Svabic-Vlahovic.
A modified microtiter-plate test for quantification of staphylococcal biofilm formation.
J Microbiol Methods, 40 (2000), pp. 175-179
[18]
K. Zhang, J.A. McClure, S. Elsayed, T. Louie, J.M Conly.
Novel multiplex PCR assay for characterization and concomitant subtyping of staphylococcal cassette chromosome mec types I to V in methicillin-resistant Staphylococcus aureus.
J Clin Microbiol, 43 (2005), pp. 5026-5033
[19]
Melinta Therapeutics. Baxdela (delafloxacin) prescribing information. Melinta Therapeutics. 2019.
[20]
J.P. Hornak, D. Reynoso.
Early clinical experience with delafloxacin: a case series.
Am J Med Sci, 363 (2022), pp. 359-363
[21]
C. Bouchand, D. Navas, S. Corvec, S. Pattier, J.C. Roussel, T. Lepoivre, et al.
Postoperative linezolid-resistant methicillin-resistant Staphylococcus epidermidis mediastinitis in a heart transplant patient: first case of therapeutic success with delafloxacin.
J Glob Antimicrob Resist, 32 (2023), pp. 72-73
[22]
M. Vidwans, A. Mitria, H. Kandil.
P41 Use of delafloxacin in osteomyelitis: a case report.
JAC Antimicrob Resist, 5 (2023),
[23]
R.K.L. Ito, C.T. Panico, R.D.F. Feijo, Y.C. Lian, A.S. Ibanes, S. Scota, et al.
Delafloxacino para o tratamento de infecções complicadas de pele e partes moles.
Braz J Infect Dis, 27 (2023),
[24]
S. McCurdy, L. Lawrence, M. Quintas, L. Woosley, R. Flamm, C. Tseng, et al.
In Vitro activity of delafloxacin and microbiological response against fluoroquinolone-susceptible and nonsusceptible staphylococcus aureus isolates from two phase 3 studies of acute bacterial skin and skin structure infections.
Antimicrob Agents Chemother, 61 (2017),
[25]
P.O. Barth, C.M. Wilhelm, R.M. Carrassai, A.L. Barth.
Avaliação Da atividade in vitro de delafloxacino frente a staphylococcus aureus de pacientes internados em hospital terciário no sul do Brasil.
Braz J Infect Dis, 27 (2023),
[26]
B.C. Millar, J. McCaughan, J.C. Rendall, J.E. Moore.
Delafloxacin ‒ a novel fluoroquinolone for the treatment of ciprofloxacin-resistant Pseudomonas aeruginosa in patients with cystic fibrosis.
Clin Resp J, 15 (2021), pp. 116-120
[27]
M.E. Falagas, S.K. Kasiakou.
Toxicity of polymyxins: a systematic review of the evidence from old and recent studies.
Crit Care (London, England), 10 (2006), pp. R27
[28]
M.D. Huband, D. Shortridge, C.G. Carvalhaes, L. Duncan, M. Castanheira.
Delafloxacin and Comparator Fluoroquinolones In Vitro Resistance Trends in Isolates from Skin and Skin Structure Infections in the USA (2017–2022).
IDWeek, (2023),
[29]
D.O. Andrey, P. Pereira Dantas, W.B.S. Martins, F. Marques De Carvalho, L.G.P. Almeida, K. Sands, et al.
An emerging clone, klebsiella pneumoniae carbapenemase 2-producing K. pneumoniae sequence type 16, associated with high mortality rates in a CC258-endemic setting.
Clin Infect Dis, 71 (2020), pp. e141-e150
[30]
R.P. Mangalore, J. Kwong, M.L Grayson.
Delafloxacin.
Kucers’ The Use of Antibiotics, pp. 2132-2138
[31]
F.F. Tuon, P.H. Suss, J.P. Telles, L.R. Dantas, N.H. Borges, V.S.T. Ribeiro.
Antimicrobial treatment of staphylococcus aureus biofilms.
Antibiotics (Basel), 12 (2023), pp. 87
[32]
A. Bloem, H.I. Bax, E. Yusuf, N.J. Verkaik.
New-generation antibiotics for treatment of gram-positive infections: a review with focus on endocarditis and osteomyelitis.
J Clin Med, 10 (2021), pp. 1743
[33]
B.B.S. Fernandes, O. Lupi, M.S. Conceição, M.G. Santos.
Osteomielite sacral- infecção de difícil tratamento.
Braz J Infect Dis, 27 (2023),
[34]
J. Bauer, W. Siala, P.M. Tulkens, F. Van Bambeke.
A combined pharmacodynamic quantitative and qualitative model reveals the potent activity of daptomycin and delafloxacin against Staphylococcus aureus biofilms.
Antimicrob Agents Chemother, 57 (2013), pp. 2726-2737
[35]
W. Siala, M.P. Mingeot-Leclercq, P.M. Tulkens, M. Hallin, O. Denis, F. Van Bambeke.
Comparison of the antibiotic activities of daptomycin, vancomycin, and the investigational fluoroquinolone delafloxacin against biofilms from staphylococcus aureus clinical isolates.
Antimicrob Agents Chemother, 58 (2014), pp. 6385-6397
[36]
D.C. Hooper, G.A. Jacoby.
Mechanisms of drug resistance: quinolone resistance.
Ann N Y Acad Sci, 1354 (2015), pp. 12-31
[37]
S. Kiyaga, C. Kyany'a, A.W. Muraya, H.J. Smith, E.G. Mills, C. Kibet, et al.
Genetic diversity, distribution, and genomic characterization of antibiotic resistance and virulence of clinical pseudomonas aeruginosa strains in Kenya.
Front Microbiol, 13 (2022),
[38]
L.A. Minarini, A.L. Darini.
Mutations in the quinolone resistance-determining regions of gyrA and parC in Enterobacteriaceae isolates from Brazil.
Braz J Microbiol, 43 (2012), pp. 1309-1314
[39]
P. Komp Lindgren, A. Karlsson, D Hughes.
Mutation rate and evolution of fluoroquinolone resistance in Escherichia coli isolates from patients with urinary tract infections.
Antimicrob Agents Chemother, 47 (2003), pp. 3222-3232
[40]
R. Nouri, M. Ahangarzadeh Rezaee, A. Hasani, M. Aghazadeh, M Asgharzadeh.
The role of gyrA and parC mutations in fluoroquinolones-resistant Pseudomonas aeruginosa isolates from Iran.
Braz J Microbio, 47 (2016), pp. 925-930
[41]
L.D. Saravolatz, G.E. Stein.
Delafloxacin: a New Anti-methicillin-resistant Staphylococcus aureus Fluoroquinolone.
Clin Infect Dis, 68 (2019), pp. 1058-1062

These authors contributed equally to the manuscript.

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