{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T18:17:49Z","timestamp":1791224269925,"version":"4.1.0"},"reference-count":46,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2025,6,13]],"date-time":"2025-06-13T00:00:00Z","timestamp":1749772800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Antibiotics"],"abstract":"<jats:p>Background: Urinary tract infections (UTIs) caused by the multidrug resistance (MDR) phenotype termed extended-spectrum beta lactamase (ESBL)-producing E. coli is a significant and growing global health concern. In response to the rising prevalence, the novel Beta Lactam-Beta Lactamase inhibitor (BL\/BLI) combinations have been introduced in recent years. While these agents have shown efficacy, their clinical utility is constrained by high cost, limited availability, and emerging resistance mechanisms. The rational of this study was to test the in vitro activity of a cost-effective alternative to currently available BL\u2013BLI combinations against ESBL-producing E. coli isolated from urinary tract infections (UTIs). Objective: This study investigates the in vitro antimicrobial activity of cefaclor (CFC), both as monotherapy and in combination with the \u03b2-lactamase inhibitors clavulanic acid (CA) and sulbactam (SUL), against 52 ESBL-producing E. coli isolates derived from urine cultures of patients diagnosed with UTIs. Methods: The susceptibility ranges were measured by disk diffusion and minimal inhibitory concentration (MIC) methods. In addition, the Time kill assay and disk approximation method were performed to measure the synergistic and bactericidal activity of the approached combination. Results: The MIC50 and MIC90 for CFC were improved from more than 128 \u00b5g\/mL to 8\/4 \u00b5g\/mL when CFC was combined with either CA or SUL. The triple combination format of CFC\/CA\/SUL showed MIC50 and MIC90 values at 8\/4\/4 \u00b5g\/mL and 64\/32\/32 \u00b5g\/mL, respectively. The recovered susceptibility percentages were 54%, 54%, and 58% for CFC\/CA, CFC\/SUL, and CFC\/CA\/SUL combinations, respectively. Disk approximation and time\u2013kill assay results revealed synergy and bactericidal effects when CFC combined with CA or SUL for isolates that showed susceptibility restorations of CFC when coupled with CA or SUL by the disk diffusion and MIC method. Conclusions: This study proposes a cost-effective combination that could mitigate resistance development and offer a sparing option to last resort treatment choices including carbapenems. However, testing efficacy in a clinical setting is crucial.<\/jats:p>","DOI":"10.3390\/antibiotics14060603","type":"journal-article","created":{"date-parts":[[2025,6,13]],"date-time":"2025-06-13T06:19:28Z","timestamp":1749795568000},"page":"603","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["In Vitro Activity of Cefaclor\/Beta-Lactamases Inhibitors (Clavulanic Acid and Sulbactam) Combination Against Extended-Spectrum Beta-Lactamase Producing Uropathogenic E. coli"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9742-4253","authenticated-orcid":false,"given":"Ali","family":"Atoom","sequence":"first","affiliation":[{"name":"Department of Medical Laboratory Sciences, Faculty of Allied Medical Sciences, Al-Ahliyya Amman University, Amman 19328, Jordan"},{"name":"Pharmacological and Diagnostic Research Center (PDRC), Al-Ahliyya Amman University, Amman 19328, Jordan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4156-9653","authenticated-orcid":false,"given":"Bayan","family":"Alzubi","sequence":"additional","affiliation":[{"name":"Department of Medical Laboratory Sciences, Faculty of Allied Medical Sciences, Al-Ahliyya Amman University, Amman 19328, Jordan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dana","family":"Barakat","sequence":"additional","affiliation":[{"name":"Department of Medical Laboratory Sciences, Faculty of Allied Medical Sciences, Al-Ahliyya Amman University, Amman 19328, Jordan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rana","family":"Abu-Gheyab","sequence":"additional","affiliation":[{"name":"Department of Medical Laboratory Sciences, Faculty of Allied Medical Sciences, Al-Ahliyya Amman University, Amman 19328, Jordan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dalia","family":"Ismail-Agha","sequence":"additional","affiliation":[{"name":"Department of Medical Laboratory Sciences, Faculty of Allied Medical Sciences, Al-Ahliyya Amman University, Amman 19328, Jordan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Awatef","family":"Al-Kaabneh","sequence":"additional","affiliation":[{"name":"Princess Iman Center for Research and Laboratory Sciences, Jordanian Royal Medical Services, Amman 11855, Jordan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-6657-3644","authenticated-orcid":false,"given":"Nawfal","family":"Numan","sequence":"additional","affiliation":[{"name":"College of Pharmacy, The University of Mashreq, Baghdad 10023, Iraq"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,6,13]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"15","DOI":"10.1038\/nature.2017.21550","article-title":"The drug-resistant bacteria that pose the greatest health threats","volume":"543","author":"Willyard","year":"2017","journal-title":"Nature"},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Maczynska, B., Frej-Madrzak, M., Sarowska, J., Woronowicz, K., Choroszy-Krol, I., and Jama-Kmiecik, A. (2023). Evolution of Antibiotic Resistance in Escherichia coli and Klebsiella pneumoniae Clinical Isolates in a Multi-Profile Hospital over 5 Years (2017\u20132021). J. Clin. Med., 12.","DOI":"10.3390\/jcm12062414"},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Alameri, M., Gharaibeh, L., Alsous, M., Yaghi, A., Tanash, A., Sa\u2019id, S., and Sartawi, H. (2025). Antibiotic Prescription Practice and Resistance Patterns of Bacterial Isolates from a Neonatal Intensive Care Unit: A Retrospective Study from Jordan. Antibiotics, 14.","DOI":"10.3390\/antibiotics14010105"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"dlab092","DOI":"10.1093\/jacamr\/dlab092","article-title":"Extended-spectrum beta-lactamases: An update on their characteristics, epidemiology and detection","volume":"3","author":"Castanheira","year":"2021","journal-title":"JAC-Antimicrob. Resist."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"383","DOI":"10.4103\/0976-9668.160014","article-title":"Phenotypic detection of extended spectrum beta-lactamase and Amp-C beta-lactamase producing clinical isolates in a Tertiary Care Hospital: A preliminary study","volume":"6","author":"Sageerabanoo","year":"2015","journal-title":"J. Nat. Sci. Biol. Med."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"e0033322","DOI":"10.1128\/aac.00333-22","article-title":"Consensus on beta-Lactamase Nomenclature","volume":"66","author":"Bradford","year":"2022","journal-title":"Antimicrob. Agents Chemother."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Tamma, P.D., Heil, E.L., Justo, J.A., Mathers, A.J., Satlin, M.J., and Bonomo, R.A. (2024). Infectious Diseases Society of America 2024 Guidance on the Treatment of Antimicrobial-Resistant Gram-Negative Infections. Clin. Infect. Dis., ciae403.","DOI":"10.1093\/cid\/ciae403"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"353","DOI":"10.2165\/00003495-200363040-00002","article-title":"Extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae: Considerations for diagnosis, prevention and drug treatment","volume":"63","author":"Rupp","year":"2003","journal-title":"Drugs"},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Carcione, D., Siracusa, C., Sulejmani, A., Leoni, V., and Intra, J. (2021). Old and New Beta-Lactamase Inhibitors: Molecular Structure, Mechanism of Action, and Clinical Use. Antibiotics, 10.","DOI":"10.3390\/antibiotics10080995"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"629","DOI":"10.1093\/jac\/dkm225","article-title":"Control of extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella pneumoniae in a children\u2019s hospital by changing antimicrobial agent usage policy","volume":"60","author":"Lee","year":"2007","journal-title":"J. Antimicrob. Chemother."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"125","DOI":"10.1016\/j.jhin.2019.09.011","article-title":"Role of antimicrobial restrictions in bacterial resistance control: A systematic literature review","volume":"104","author":"Chatzopoulou","year":"2020","journal-title":"J. Hosp. Infect."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"2540","DOI":"10.1128\/JCM.00526-12","article-title":"In vitro interaction between cefixime and amoxicillin-clavulanate against extended-spectrum-beta-lactamase-producing Escherichia coli causing urinary tract infection","volume":"50","author":"Bingen","year":"2012","journal-title":"J. Clin. Microbiol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1023","DOI":"10.1128\/JCM.06248-11","article-title":"Detection of favorable oral cephalosporin-clavulanate interactions by in vitro disk approximation susceptibility testing of extended-spectrum-Beta-lactamase-producing members of the enterobacteriaceae","volume":"50","author":"Campbell","year":"2012","journal-title":"J. Clin. Microbiol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1132","DOI":"10.1089\/mdr.2019.0065","article-title":"Effective Oral Combination Treatment for Extended-Spectrum Beta-Lactamase-Producing Escherichia coli","volume":"25","author":"Albalawi","year":"2019","journal-title":"Microb. Drug Resist."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"106858","DOI":"10.1016\/j.ijantimicag.2023.106858","article-title":"In-vitro activity of oral third-generation cephalosporins plus clavulanate against ESBL-producing Enterobacterales isolates from the MERINO trial","volume":"62","author":"Stewart","year":"2023","journal-title":"Int. J. Antimicrob. Agents"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"171","DOI":"10.1080\/00498254.2024.2333009","article-title":"Exploring the pharmacokinetics of second-generation cephalosporin, cefaclor: A systematic review in healthy and diseased populations","volume":"54","author":"Saleem","year":"2024","journal-title":"Xenobiotica"},{"key":"ref_17","first-page":"85","article-title":"Study on the efficacy of cefaclor for the treatment of asymptomatic bacteriuria and lower urinary tract infections in pregnant women with a history of hypersensitivity to penicillin","volume":"34","author":"Stamatiou","year":"2007","journal-title":"Clin. Exp. Obstet. Gynecol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"154","DOI":"10.1016\/S0149-2918(00)88477-5","article-title":"Cefaclor revisited","volume":"22","author":"Meyers","year":"2000","journal-title":"Clin. Ther."},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Koguchi, D., Murakami, Y., Ikeda, M., Dobashi, M., and Ishii, J. (2020). Cefaclor as a first-line treatment for acute uncomplicated cystitis: A retrospective single-center study. BMC Urol., 20.","DOI":"10.1186\/s12894-020-00605-6"},{"key":"ref_20","unstructured":"Wayne, P. (2023). Performance Standards for Antimicrobial Susceptibility Testing, Clinical and Laboratory Standards Institute (CLSI). [33rd ed.]. CLSI supplement M100."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"29","DOI":"10.1038\/s44259-024-00047-2","article-title":"Drug combinations targeting antibiotic resistance","volume":"2","author":"Bognar","year":"2024","journal-title":"Npj Antimicrob. Resist."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"269","DOI":"10.1038\/nrmicro3432","article-title":"Urinary tract infections: Epidemiology, mechanisms of infection and treatment options","volume":"13","author":"Walker","year":"2015","journal-title":"Nat. Rev. Microbiol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"899","DOI":"10.1016\/j.cmi.2015.05.022","article-title":"Contemporary resistance trends and mechanisms for the old antibiotics colistin, temocillin, fosfomycin, mecillinam and nitrofurantoin","volume":"21","author":"Giske","year":"2015","journal-title":"Clin. Microbiol. Infect."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"4228","DOI":"10.1128\/JCM.38.11.4228-4232.2000","article-title":"Detection of extended-spectrum beta-lactamases in klebsiellae with the Oxoid combination disk method","volume":"38","author":"Carter","year":"2000","journal-title":"J. Clin. Microbiol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"161","DOI":"10.1128\/CMR.00036-08","article-title":"AmpC beta-lactamases","volume":"22","author":"Jacoby","year":"2009","journal-title":"Clin. Microbiol. Rev."},{"key":"ref_26","first-page":"359","article-title":"Phenotypic & molecular characterization of AmpC beta-lactamases among Escherichia coli, Klebsiella spp. & Enterobacter spp. from five Indian Medical Centers","volume":"135","author":"Manoharan","year":"2012","journal-title":"Indian J. Med. Res."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"2924","DOI":"10.1128\/JCM.00091-11","article-title":"Detection of AmpC beta-lactamase in Escherichia coli: Comparison of three phenotypic confirmation assays and genetic analysis","volume":"49","author":"Polsfuss","year":"2011","journal-title":"J. Clin. Microbiol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"167","DOI":"10.1093\/cid\/cir790","article-title":"Beta-Lactam\/beta-lactam inhibitor combinations for the treatment of bacteremia due to extended-spectrum beta-lactamase-producing Escherichia coli: A post hoc analysis of prospective cohorts","volume":"54","author":"Navarro","year":"2012","journal-title":"Clin. Infect. Dis."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1319","DOI":"10.1093\/cid\/civ003","article-title":"Carbapenem therapy is associated with improved survival compared with piperacillin-tazobactam for patients with extended-spectrum beta-lactamase bacteremia","volume":"60","author":"Tamma","year":"2015","journal-title":"Clin. Infect. Dis."},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Ng, T.M., Khong, W.X., Harris, P.N., De, P.P., Chow, A., Tambyah, P.A., and Lye, D.C. (2016). Empiric Piperacillin-Tazobactam versus Carbapenems in the Treatment of Bacteraemia Due to Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae. PLoS ONE, 11.","DOI":"10.1371\/journal.pone.0153696"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"dlad041","DOI":"10.1093\/jacamr\/dlad041","article-title":"Association between piperacillin\/tazobactam MIC and survival among hospitalized patients with Enterobacterales infections: Retrospective cohort analysis of electronic health records from 161 US hospitals","volume":"5","author":"Strich","year":"2023","journal-title":"JAC-Antimicrob. Resist."},{"key":"ref_32","first-page":"425","article-title":"A comparative in vitro study of cephalosporin\/beta-lactamase inhibitor combinations against gram negative bacilli","volume":"57","author":"Susan","year":"2013","journal-title":"Indian J. Physiol. Pharmacol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"e00145-19","DOI":"10.1128\/AAC.00145-19","article-title":"In Vivo Pharmacodynamic Profile of Ceftibuten-Clavulanate Combination against Extended-Spectrum-beta-Lactamase-Producing Enterobacteriaceae in the Murine Thigh Infection Model","volume":"63","author":"Abdelraouf","year":"2019","journal-title":"Antimicrob. Agents Chemother."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"2384","DOI":"10.1093\/jac\/dkaa183","article-title":"Oral cephalosporin and beta-lactamase inhibitor combinations for ESBL-producing Enterobacteriaceae urinary tract infections","volume":"75","author":"Stewart","year":"2020","journal-title":"J. Antimicrob. Chemother."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"e00144-19","DOI":"10.1128\/AAC.00144-19","article-title":"In Vitro Pharmacodynamics of a Novel Ceftibuten-Clavulanate Combination Antibiotic against Enterobacteriaceae","volume":"63","author":"Grupper","year":"2019","journal-title":"Antimicrob. Agents Chemother."},{"key":"ref_36","first-page":"545","article-title":"In vitro study to compare sensitivity of amoxicillin+clavulanic acid and cefpodoxime+clavulanic acid among beta-lactamase positive clinical isolates of gram-positive and gram-negative pathogens","volume":"106","author":"Pal","year":"2008","journal-title":"J. Indian Med. Assoc."},{"key":"ref_37","first-page":"131","article-title":"In vitro evaluation of a new cefixime-clavulanic acid combination for gram-negative bacteria","volume":"40","author":"Rawat","year":"2009","journal-title":"Southeast Asian J. Trop. Med. Public Health"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1441","DOI":"10.2147\/IDR.S175257","article-title":"Appropriate composites of cefoperazone-sulbactam against multidrug-resistant organisms","volume":"11","author":"Lai","year":"2018","journal-title":"Infect. Drug Resist."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1016\/j.jmii.2017.08.026","article-title":"The impact of inoculum size on the activity of cefoperazone-sulbactam against multidrug resistant organisms","volume":"51","author":"Chang","year":"2018","journal-title":"J. Microbiol. Immunol. Infect."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1511","DOI":"10.2165\/00003495-200363140-00006","article-title":"Clinical role of beta-lactam\/beta-lactamase inhibitor combinations","volume":"63","author":"Lee","year":"2003","journal-title":"Drugs"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"160","DOI":"10.1128\/CMR.00037-09","article-title":"Three decades of beta-lactamase inhibitors","volume":"23","author":"Drawz","year":"2010","journal-title":"Clin. Microbiol. Rev."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"692","DOI":"10.1016\/j.jiac.2017.07.011","article-title":"Antimicrobial susceptibility of pathogens in acute uncomplicated cystitis cases in the urology department of a community hospital in Japan: Comparison with treatment outcome and hospital-wide antibiogram","volume":"23","author":"Etani","year":"2017","journal-title":"J. Infect. Chemother."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1987","DOI":"10.1016\/j.ophtha.2005.06.025","article-title":"An ophthalmologist\u2019s guide to understanding antibiotic susceptibility and minimum inhibitory concentration data","volume":"112","author":"Kowalski","year":"2005","journal-title":"Ophthalmology"},{"key":"ref_44","doi-asserted-by":"crossref","unstructured":"Gaudereto, J.J., Neto, L.V.P., Leite, G.C., Espinoza, E.P.S., Martins, R.C.R., Villas Boa Prado, G., Rossi, F., Guimaraes, T., Levin, A.S., and Costa, S.F. (2020). Comparison of methods for the detection of in vitro synergy in multidrug-resistant gram-negative bacteria. BMC Microbiol., 20.","DOI":"10.1186\/s12866-020-01756-0"},{"key":"ref_45","unstructured":"(1999). Methods for Determining Bactericidal Activity of Antimicrobial Agents: Approved Guideline. Standard No. CLSI M26-A."},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Katchanov, J., Asar, L., Klupp, E.M., Both, A., Rothe, C., Konig, C., Rohde, H., Kluge, S., and Maurer, F.P. (2018). Carbapenem-resistant Gram-negative pathogens in a German university medical center: Prevalence, clinical implications and the role of novel beta-lactam\/beta-lactamase inhibitor combinations. PLoS ONE, 13.","DOI":"10.1371\/journal.pone.0195757"}],"container-title":["Antibiotics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2079-6382\/14\/6\/603\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T17:51:25Z","timestamp":1760032285000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2079-6382\/14\/6\/603"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,6,13]]},"references-count":46,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2025,6]]}},"alternative-id":["antibiotics14060603"],"URL":"https:\/\/doi.org\/10.3390\/antibiotics14060603","relation":{},"ISSN":["2079-6382"],"issn-type":[{"value":"2079-6382","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,6,13]]}}}