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At concentrations higher than those typically achieved\n                      <jats:italic toggle=\"yes\">in vivo<\/jats:italic>\n                      , it also has broad-spectrum direct antibacterial activity against\n                      <jats:italic toggle=\"yes\">Enterobacterales<\/jats:italic>\n                      strains, including metallo-\u03b2-lactamase-producing isolates, mediated by inhibition of penicillin-binding protein 2 (PBP2). This activity has some mechanistic similarities to that of more potent novel DBOs (zidebactam and nacubactam) in late clinical development. We found that resistance to AVI emerged readily, with a mutation frequency of 2 \u00d7 10\n                      <jats:sup>\u22126<\/jats:sup>\n                      to 8 \u00d7 10\n                      <jats:sup>\u22125<\/jats:sup>\n                      . Whole-genome sequencing of resistant isolates revealed a heterogeneous mutational target that permitted bacterial survival and replication despite PBP2 inhibition, in line with prior studies of PBP2-targeting drugs. While such mutations are believed to act by upregulating the bacterial stringent response, we found a similarly high mutation frequency in bacteria deficient in components of the stringent response, although we observed a different set of mutations in these strains. Although avibactam-resistant strains had increased lag time, suggesting a fitness cost that might render them less problematic in clinical infections, there was no statistically significant difference in growth rates between susceptible and resistant strains. The finding of rapid emergence of resistance to avibactam as the result of a large and complex mutational target adds to our understanding of resistance to PBP2-targeting drugs and has potential implications for novel DBOs with potent direct antibacterial activity, which are being developed with the goal of expanding cell wall-active treatment options for multidrug-resistant gram-negative infections.\n                    <\/jats:p>\n                    <jats:sec>\n                      <jats:title>IMPORTANCE<\/jats:title>\n                      <jats:p>Avibactam (AVI) is the first in a class of novel \u03b2-lactamase inhibitor antibiotics called diazabicyclooctanes (DBOs). In addition to its ability to inhibit bacterial \u03b2-lactamase enzymes that can destroy \u03b2-lactam antibiotics, we found that AVI had direct antibacterial activity, at concentrations higher than those used clinically, against even highly multidrug-resistant bacteria. This activity is the result of inhibition of the bacterial enzyme penicillin-binding protein 2 (PBP2). Resistance to other drugs that inhibit PBP2 occurs through mutations that involve upregulation of the bacterial \u201cstringent response\u201d to stress. We found that bacteria developed resistance to AVI at a high rate, as a result of mutations in stringent response genes. We also found that bacteria with impairments in the stringent response could still develop resistance to AVI through different mutations. Our findings indicate the importance of studying how resistance will emerge to newer, more potent DBOs in development and early clinical use.<\/jats:p>\n                    <\/jats:sec>\n                  <\/jats:sec>","DOI":"10.1128\/spectrum.03241-24","type":"journal-article","created":{"date-parts":[[2025,6,12]],"date-time":"2025-06-12T08:27:18Z","timestamp":1749716838000},"update-policy":"https:\/\/doi.org\/10.1128\/asmj-crossmark-policy-page","source":"Crossref","is-referenced-by-count":2,"title":["Rapid emergence of resistance to broad-spectrum direct antimicrobial activity of avibactam"],"prefix":"10.1128","volume":"13","author":[{"given":"Michelle","family":"N\u00e4geli","sequence":"first","affiliation":[{"name":"Department of Pathology, Beth Israel Deaconess Medical Center","place":["Boston, USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shade","family":"Rodriguez","sequence":"additional","affiliation":[{"name":"Department of Pathology, Beth Israel Deaconess Medical Center","place":["Boston, USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aimee","family":"Iradukunda","sequence":"additional","affiliation":[{"name":"Department of Pathology, Beth Israel Deaconess Medical Center","place":["Boston, USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3800-0714","authenticated-orcid":true,"given":"Abigail L.","family":"Manson","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/05a0ya142","id-type":"ROR","asserted-by":"publisher"}],"name":"Infectious Disease and Microbiome Program, Broad Institute of MIT and Harvard","place":["Cambridge, USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7857-9145","authenticated-orcid":true,"given":"Ashlee M.","family":"Earl","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/05a0ya142","id-type":"ROR","asserted-by":"publisher"}],"name":"Infectious Disease and Microbiome Program, Broad Institute of MIT and Harvard","place":["Cambridge, USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1284-0643","authenticated-orcid":true,"given":"Thea","family":"Brennan-Krohn","sequence":"additional","affiliation":[{"name":"Department of Pathology, Beth Israel Deaconess Medical Center","place":["Boston, USA"]},{"id":[{"id":"https:\/\/ror.org\/00dvg7y05","id-type":"ROR","asserted-by":"publisher"}],"name":"Division of Infectious Diseases, Boston Children\u2019s Hospital","place":["Boston, USA"]},{"name":"Harvard Medical School","place":["Boston, USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"235","reference":[{"key":"e_1_3_4_2_2","doi-asserted-by":"publisher","DOI":"10.1101\/cshperspect.a025247"},{"key":"e_1_3_4_3_2","doi-asserted-by":"publisher","DOI":"10.3201\/eid1710.110655"},{"key":"e_1_3_4_4_2","doi-asserted-by":"publisher","DOI":"10.1128\/CMR.00037-09"},{"key":"e_1_3_4_5_2","doi-asserted-by":"publisher","DOI":"10.1073\/pnas.1205073109"},{"key":"e_1_3_4_6_2","doi-asserted-by":"publisher","DOI":"10.1007\/s40265-013-0013-7"},{"key":"e_1_3_4_7_2","doi-asserted-by":"publisher","DOI":"10.1128\/AAC.02102-15"},{"key":"e_1_3_4_8_2","doi-asserted-by":"publisher","DOI":"10.1111\/j.1574-6976.2008.00105.x"},{"key":"e_1_3_4_9_2","doi-asserted-by":"publisher","DOI":"10.1093\/jac\/dky522"},{"key":"e_1_3_4_10_2","doi-asserted-by":"publisher","DOI":"10.1039\/c9ob02605c"},{"key":"e_1_3_4_11_2","doi-asserted-by":"publisher","DOI":"10.1055\/a-0748-5548"},{"key":"e_1_3_4_12_2","doi-asserted-by":"publisher","DOI":"10.1093\/jac\/dkw593"},{"key":"e_1_3_4_13_2","unstructured":"Study of Cefepime-zidebactam (FEP-ZID) in Complicated Urinary Tract Infection (cUTI) or Acute Pyelonephritis (AP). 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