Progressive Development of Cefiderocol Resistance in Escherichia coli during Therapy is Associated with an Increase in blaNDM-5Copy Number and Gene Expression

Patricia J. Simner*, Heba H. Mostafa, Yehudit Bergman, Michael Ante, Tsigereda Tekle, Ayomikun Adebayo, Stephan Beisken, Kathryn Dzintars, Pranita D. Tamma

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

41 Scopus citations


Background: As cefiderocol is increasingly being prescribed in clinical practice, it is critical that we understand key mechanisms contributing to acquired resistance to this agent. Methods: We describe a patient with acute lymphoblastic leukemia and a New Delhi metallo-ß-lactamase (NDM)-5-producing Escherichia coli intra-Abdominal infection in whom resistance to cefiderocol evolved approximately 2 weeks after the start of treatment. Through whole-genome sequencing (WGS), messenger RNA expression studies, and ethylenediaminetetraacetic acid inhibition analysis, we investigated the role of increased NDM-5 production and genetic mutations contributing to the development of cefiderocol resistance, using 5 sequential clinical E. coli isolates obtained from the patient. Results: In all 5 isolates, blaNDM-5 genes were identified. The minimum inhibitory concentrations for cefiderocol were 2, 4, and >32 μg/mL for isolates 1-2, 3, and 4-5, respectively. WGS showed that isolates 1-3 contained a single copy of the blaNDM-5 gene, whereas isolates 4 and 5 had 5 and 10 copies of the blaNDM-5 gene, respectively, on an IncFIA/FIB/IncFII plasmid. These findings were correlated with those of blaNDM-5 messenger RNA expression analysis, in which isolates 4 and 5 expressed blaNDM-5 1.7-and 2.8-fold, respectively, compared to, isolate 1. Synergy testing with the combination of ceftazidime-Avibactam and aztreonam demonstrated expansion of the zone of inhibition between the disks for all isolates. The patient was successfully treated with this combination and remained infection free 1 year later. Conclusions: The findings in our patient suggest that increased copy numbers of blaNDM genes through translocation events are used by Enterobacterales to evade cefiderocol-mediated cell death. The frequency of increased blaNDM-5 expression in contributing to cefiderocol resistance needs investigation.

Original languageAmerican English
Pages (from-to)47-54
Number of pages8
JournalClinical Infectious Diseases
Issue number1
StatePublished - 1 Jul 2022
Externally publishedYes

Bibliographical note

Publisher Copyright:
© 2021 The Author(s). Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail:


  • Escherichia coli
  • NDM
  • antimicrobial resistance
  • cefiderocol


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