# Antibacterial activity of enmetazobactam against Acinetobacter spp.: a molecular dissection of mechanism of action and resistance determinants

## TL;DR

This study explores how enmetazobactam fights Acinetobacter bacteria, especially drug-resistant strains, and how resistance develops.

## Contribution

The study provides a detailed molecular analysis of enmetazobactam's activity and resistance mechanisms in Acinetobacter spp., including multidrug-resistant strains.

## Key findings

- Enmetazobactam shows high intrinsic activity against Acinetobacter spp., with reduced MICs for carbapenem-susceptible isolates.
- Enmetazobactam's antimicrobial activity is driven by selective binding to PBP2 and PBP3.
- OXA-23 inactivates enmetazobactam, highlighting the role of CHDLs in resistance.

## Abstract

The persistence of multidrug-resistant Acinetobacter baumannii remains a clinical challenge. Cefepime/enmetazobactam is a novel combination with demonstrated activity against extended-spectrum β-lactamase-producing Enterobacterales, but its activity against Acinetobacter has not yet been thoroughly explored. We aimed to assess its activity against Acinetobacter spp., including multidrug-resistant strains producing carbapenem-hydrolyzing class D β-lactamases (CHDLs). We analyzed 208 clinical isolates of Acinetobacter spp., including 67 carbapenem-resistant Acinetobacter baumannii (CRAB). Antibiotic susceptibility testing was conducted with cefepime, sulbactam, and imipenem, alone and in combination with enmetazobactam; the latter was also tested individually. Additionally, MICs of enmetazobactam/durlobactam and sulbactam/durlobactam were determined for CRAB and CHDL-producing A. baumannii ATCC 17978 transformants. PBP binding assays (IC₅₀), molecular docking, simulation studies with the enmetazobactam/OXA-23 adduct, hydrolysis kinetics (kcat, Km), and OXA-23 inhibition assays (IC₅₀, koff, t₁/₂) were performed to elucidate the mechanism of enmetazobactam and detect reduced susceptibility. Enmetazobactam showed high intrinsic activity against Acinetobacter spp., displaying reduced MICs against carbapenem-susceptible isolates. MIC50/90 of the enmetazobactam/durlobactam combination was 2/2 mg/L for CHDL-producing A. baumannii. Enmetazobactam exhibited bactericidal activity comparable to sulbactam. Binding assays revealed that the antimicrobial activity is driven by selective affinity for PBP2 (IC₅₀ 3.6 mg/L) and PBP3 (IC₅₀ 4.2 mg/L). OXA-23 readily inactivated enmetazobactam, confirming the major role of CHDLs in resistance to enmetazobactam, via substrate-assisted de-acylation. This study evidences the potent antimicrobial activity of enmetazobactam against A. baumannii via inhibition of PBP2 and PBP3. Its combination with new OXA-type inhibitors (e.g., durlobactam) represents a potential therapeutic alternative for multidrug-resistant A. baumannii.