Bacterial pathogens such as Staphylococcus aureus and Staphylococcus epidermidis can survive in different types of cells including professional phagocytes, causing intracellular infections. Antibiotic treatment of intracellular infections is often unsuccessful due to the low efficacy of most antibiotics inside cells. Therefore, novel techniques which can improve intracellular activity of antibiotics are urgently needed. We aimed to use photochemical internalization (PCI) to enhance cytosolic release of antibiotics from endocytic vesicles after internalization. Our results show that PCI indeed caused cytosolic release of gentamicin and significantly increased its efficacy against S. epidermidis in vitro in mouse macrophages. Upon illumination for 15 min, the killing of intracellular S. epidermidis in RAW 264.7 cells by 10 or 30 μg/ml gentamicin was increased to 1 or 3 CFU log, respectively, owing to the use of PCI, whereas no killing by gentamicin only without PCI was observed. Moreover, survival of S. aureus-infected zebrafish embryos was significantly improved by treatment with PCI-gentamicin. PCI improved the therapeutic efficacy of gentamicin at a dose of 0.1 ng per embryo to a level similar to that of a dose of 0.4 ng per embryo, indicating that PCI can lower the antibiotic dose required for treating (intracellular) staphylococcal infection. Thus, the present study shows that PCI is a promising novel approach to enhance the intracellular efficacy of antibiotics via cytosolic release, allowing them to reach intracellular bacteria. This will expand their therapeutic window and will increase the numbers of antibiotics which can be used for treatment of intracellular infections.

The emergence of clinical enterococcal isolates that are resistant to both ampicillin and vancomycin is a cause of great concern, as therapeutic alternatives for the treatment of infections caused by such organisms are becoming limited. Aquatic environments could play a role in the dissemination of antibiotic resistant enterococci. This study investigated the presence of ampicillin and vancomycin resistant enterococci in the treated effluent of six wastewater treatment plants (WWTPs) and in surface water used as a source for drinking water production in the Netherlands. Membrane filtration in combination with selective media with ampicillin or vancomycin was applied to determine the presence of ampicillin resistant Enterococcus (ARE) and vancomycin resistant Enterococcus (VRE) species. Ampicillin resistant E. faecium (minimal inhibitory concentration (MIC) >16 µg/ml; n=1033) was observed in all studied WWTP effluents. In surface water used for drinking water production (intake locations), no ARE or VRE were observed. At both types of location, intrinsic vancomycin resistant Pediococcus spp., Leuconostoc spp. and Lactobacillus spp. were isolated with the vancomycin medium. The ampicillin resistant E. faecium (AREfm) isolates (n=113) did not contain the vanA or vanB gene, but MIC testing for vancomycin showed intermediate vancomycin resistance (2 to 8 µg ml -1 ) to occur in these AREfm strains. This study documents the discharge of ampicillin resistant E. faecium strains with intermediate vancomycin resistance by the WWTPs into the surface water, but no presence of these strains downstream at intake locations for drinking water production.