Effectiveness of Antibiotic Combination Treatments to Control Heteroresistant Salmonella Typhimurium

This study was designed to assess the interactions between antibiotics in combination treatments of Salmonella enterica serovar Typhimurium in association with the development of antibiotic heteroresistance. Salmonella Typhimurium ATCC 19585 (ST^WT), ciprofloxacin (CIP)-induced S. Typhimurium ATCC 19585 (ST^CIP), and clinically isolated antibiotic-resistant S. Typhimurium CCARM 8009 (ST^CLI) treated with antibiotic alone (cephalothin [CEP], CIP, ceftriaxone [CEF], and tobramycin [TOB]) and combination antibiotics (CEP-CIP and CEF-TOB) were used to compare the antibiotic susceptibility, resistance fitness, and cross-resistance. The susceptibilities of ST^WT, ST^CIP, and ST^CLI to CEP were not significant differences between CEP and CEP-CIP treatments, whereas those of ST^WT, ST^CIP, and ST^CLI to TOB were significant differences between TOB and CEF-TOB treatments. The interactions between CEP and CIP in the combination treatment showed mutually synergistic activities against ST^WT and ST^CLI. For the CEF-TOB combination treatments, TOB helped enhance the antibiotic activity of CEF against ST^WT, showing directional synergistic effect. The CEF-TOB combination treatment increased bactericidal activity against ST^WT, ST^CIP, and ST^CLI without causing injured cells. The combination antibiotic treatments (CEP-CIP and CEF-TOB) increased the fitness cost (relative fitness = 0.7) and decreased the cross-resistance of ST^WT, ST^CIP, and ST^CLI when exposed to different classes of antibiotics. This study provides new insight for designing combination antibiotic regimens that can synergistically enhance the antimicrobial activity against antibiotic-resistant Salmonella and inhibit the emergence of cross-resistance to different classes of antibiotics.