In vitro Synergistic Activities of Fosfomycin in Combination with Other Antimicrobial Agents Against Carbapenem-Resistant Escherichia coli Harboring bla(NDM-1) on the IncN2 Plasmid and a Study of the Genomic Characteristics of These Pathogens

Purpose: The spread of New Delhi metallo-beta-lactamase (NDM) encoded by the bla(NDM) gene has been a global health crisis for many years. Most of bla(NDM)-harboring bacteria commonly carry various antimicrobial resistance (AMR) genes on their chromosomes or plasmids, leading to limited treatment options. Thus, we aimed to evaluate the synergistic effects of fosfomycin in combination with other antimicrobial agents against bla(NDM)-harboring carbapenem-resistant Escherichia coli (CREC) and to characterize the whole-genome and plasmid sequences of these pathogens. Methods: Thirty-eight CREC isolates were collected from patients in the Medicine Ward, Songklanagarind Hospital, Thailand. The activity of fosfomycin in combination with other antimicrobial agents against CREC isolates harboring bla(NDM) on the plasmid was evaluated using the checkerboard method. In this method, the serial dilutions of two antibiotics were mixed with the cultured CREC, the mixtures were incubated, and FICI was calculated to interpret the synergistic activity of the combination. The whole-genome and particular plasmids of these pathogens were sequenced using next-generation sequencing. Sequence analysis, especially on antimicrobial resistance (AMR) genes, mobile-genetic elements (MGEs), and virulence genes was performed using many bioinformatics tools. Results: Of the E. coli 38 isolates, only 3 isolates contained the bla(NDM-1) gene, which is located on the IncN2 plasmid. The combinations of fosfomycin with aminoglycosides, colistin, tigecycline, sitafloxacin, and ciprofloxacin were synergies against blabla(NDM-1)-harboring CREC isolates. Genomic analysis revealed that these isolates harbored many beta-lactam resistance genes and other AMR genes that may confer resistance to aminoglycoside, fluoroquinolone, rifampicin, trimethoprim, sulfonamide, tetracycline, and macrolide. Also, various MGEs, especially the blaNDM-1-bearing IncN2 plasmid, were present in these isolates. Conclusion: Our study demonstrated some synergistic effects of antimicrobial combination against CREC isolates harboring bla(NDM-1) on the IncN2 plasmid. Also, our data on the whole-genome and plasmid sequences might be beneficial in the control of the spread of bla(NDM-1)-harboring CREC isolates. The linkages between bla(NDM-1)-carrying plasmid, patient information, and time of collection will be elucidated to track the horizontal gene transfer in the future.