Modeling antibiotic treatment in hospitals: A systematic approach shows benefits of combination therapy over cycling, mixing, and mono-drug therapies

PLoS Comput Biol. 2017 Sep 15;13(9):e1005745. doi: 10.1371/journal.pcbi.1005745. eCollection 2017 Sep.

Abstract

Multiple treatment strategies are available for empiric antibiotic therapy in hospitals, but neither clinical studies nor theoretical investigations have yielded a clear picture when which strategy is optimal and why. Extending earlier work of others and us, we present a mathematical model capturing treatment strategies using two drugs, i.e the multi-drug therapies referred to as cycling, mixing, and combination therapy, as well as monotherapy with either drug. We randomly sample a large parameter space to determine the conditions determining success or failure of these strategies. We find that combination therapy tends to outperform the other treatment strategies. By using linear discriminant analysis and particle swarm optimization, we find that the most important parameters determining success or failure of combination therapy relative to the other treatment strategies are the de novo rate of emergence of double resistance in patients infected with sensitive bacteria and the fitness costs associated with double resistance. The rate at which double resistance is imported into the hospital via patients admitted from the outside community has little influence, as all treatment strategies are affected equally. The parameter sets for which combination therapy fails tend to fall into areas with low biological plausibility as they are characterised by very high rates of de novo emergence of resistance to both drugs compared to a single drug, and the cost of double resistance is considerably smaller than the sum of the costs of single resistance.

MeSH terms

  • Anti-Bacterial Agents* / administration & dosage
  • Anti-Bacterial Agents* / pharmacology
  • Anti-Bacterial Agents* / therapeutic use
  • Bacteria / drug effects
  • Bacteria / pathogenicity
  • Bacterial Infections / drug therapy
  • Bacterial Infections / microbiology
  • Computational Biology / methods*
  • Discriminant Analysis
  • Drug Resistance, Bacterial*
  • Drug Therapy, Combination*
  • Hospitals*
  • Humans
  • Models, Biological*

Substances

  • Anti-Bacterial Agents

Grants and funding

Swiss National Science Foundation (SNF: 155866) (http://www.snf.ch/en/Pages/default.aspx) and the European Research Council (ERC: PBDR 268540) (https://erc.europa.eu/) The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.