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Zhang S, Liao X, Ding T, Ahn J. Role of β-Lactamase Inhibitors as Potentiators in Antimicrobial Chemotherapy Targeting Gram-Negative Bacteria. Antibiotics (Basel) 2024; 13:260. [PMID: 38534695 DOI: 10.3390/antibiotics13030260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 03/13/2024] [Accepted: 03/14/2024] [Indexed: 03/28/2024] Open
Abstract
Since the discovery of penicillin, β-lactam antibiotics have commonly been used to treat bacterial infections. Unfortunately, at the same time, pathogens can develop resistance to β-lactam antibiotics such as penicillins, cephalosporins, monobactams, and carbapenems by producing β-lactamases. Therefore, a combination of β-lactam antibiotics with β-lactamase inhibitors has been a promising approach to controlling β-lactam-resistant bacteria. The discovery of novel β-lactamase inhibitors (BLIs) is essential for effectively treating antibiotic-resistant bacterial infections. Therefore, this review discusses the development of innovative inhibitors meant to enhance the activity of β-lactam antibiotics. Specifically, this review describes the classification and characteristics of different classes of β-lactamases and the synergistic mechanisms of β-lactams and BLIs. In addition, we introduce potential sources of compounds for use as novel BLIs. This provides insights into overcoming current challenges in β-lactamase-producing bacteria and designing effective treatment options in combination with BLIs.
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Affiliation(s)
- Song Zhang
- Department of Biomedical Science, Kangwon National University, Chuncheon 24341, Republic of Korea
| | - Xinyu Liao
- Future Food Laboratory, Innovation Center of Yangtze River Delta, Zhejiang University, Jiaxing 314100, China
| | - Tian Ding
- Future Food Laboratory, Innovation Center of Yangtze River Delta, Zhejiang University, Jiaxing 314100, China
- Department of Food Science and Nutrition, Zhejiang University, Hangzhou 310058, China
| | - Juhee Ahn
- Department of Biomedical Science, Kangwon National University, Chuncheon 24341, Republic of Korea
- Future Food Laboratory, Innovation Center of Yangtze River Delta, Zhejiang University, Jiaxing 314100, China
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Abstract
Imipenem (IMI)/cilastatin/relebactam (REL) (I/R) is a novel β-lactam/β-lactamase inhibitor combination with expanded microbiologic activity against carbapenem-resistant non-Morganellaceae Enterobacterales (CR-NME) and difficult-to-treat (DTR) Pseudomonas aeruginosa. Relebactam, a bicyclic diazabicyclooctane, has no direct antimicrobial activity but provides reliable inhibition of many Ambler class A and class C enzymes. It is currently approved for the treatment of adult patients with hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia (HABP/VABP) and those with complicated urinary tract infections (cUTIs) and complicated intra-abdominal infections (cIAIs) when limited or no alternative treatments are available. Given the number of recently approved β-lactams with expanded activity against highly resistant Gram-negative pathogens, this review summarizes the published literature on I/R, with a focus on its similar and distinguishing characteristics relative to those of other recently approved agents. Overall, available data support its use for the treatment of patients with HABP/VABP, cUTI, and cIAI due to CR-NME and DTR P. aeruginosa. Data indicate that I/R retains some activity against CR-NME and DTR P. aeruginosa isolates that are resistant to the newer β-lactams and vice versa, suggesting that susceptibility testing be performed for all the newer agents to determine optimal treatment options for patients with CR-NME and DTR P. aeruginosa infections. Further comparative PK/PD and clinical studies are warranted to determine the optimal role of I/R, alone and in combination, for the treatment of patients with highly resistant Gram-negative infections. Until further data are available, I/R is a potential treatment for patients with CR-NME and DTR P. aeruginosa infections when the benefits outweigh the risks.
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Principe L, Lupia T, Andriani L, Campanile F, Carcione D, Corcione S, De Rosa FG, Luzzati R, Stroffolini G, Steyde M, Decorti G, Di Bella S. Microbiological, Clinical, and PK/PD Features of the New Anti-Gram-Negative Antibiotics: β-Lactam/β-Lactamase Inhibitors in Combination and Cefiderocol—An All-Inclusive Guide for Clinicians. Pharmaceuticals (Basel) 2022; 15:ph15040463. [PMID: 35455461 PMCID: PMC9028825 DOI: 10.3390/ph15040463] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 04/07/2022] [Accepted: 04/07/2022] [Indexed: 01/27/2023] Open
Abstract
Bacterial resistance mechanisms are continuously and rapidly evolving. This is particularly true for Gram-negative bacteria. Over the last decade, the strategy to develop new β-lactam/β-lactamase inhibitors (BLs/BLIs) combinations has paid off and results from phase 3 and real-world studies are becoming available for several compounds. Cefiderocol warrants a separate discussion for its peculiar mechanism of action. Considering the complexity of summarizing and integrating the emerging literature data of clinical outcomes, microbiological mechanisms, and pharmacokinetic/pharmacodynamic properties of the new BL/BLI and cefiderocol, we aimed to provide an overview of data on the following compounds: aztreonam/avibactam, cefepime/enmetazobactam, cefepime/taniborbactam, cefepime/zidebactam, cefiderocol, ceftaroline/avibactam, ceftolozane/tazobactam, ceftazidime/avibactam, imipenem/relebactam, meropenem/nacubactam and meropenem/vaborbactam. Each compound is described in a dedicated section by experts in infectious diseases, microbiology, and pharmacology, with tables providing at-a-glance information.
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Affiliation(s)
- Luigi Principe
- Clinical Pathology and Microbiology Unit, “San Giovanni di Dio” Hospital, I-88900 Crotone, Italy;
| | - Tommaso Lupia
- Unit of Infectious Diseases, Cardinal Massaia Hospital, I-14100 Asti, Italy; (T.L.); (F.G.D.R.)
| | - Lilia Andriani
- Clinical Pathology and Microbiology Unit, Hospital of Sondrio, I-23100 Sondrio, Italy;
| | - Floriana Campanile
- Department of Biomedical and Biotechnological Sciences, Section of Microbiology, University of Catania, I-95123 Catania, Italy;
| | - Davide Carcione
- Laboratory of Microbiology and Virology, IRCCS San Raffaele Scientific Institute, I-20132 Milan, Italy;
| | - Silvia Corcione
- Infectious diseases Unit, Department of Medical Sciences, University of Torino, I-10124 Torino, Italy; (S.C.); (G.S.)
| | - Francesco Giuseppe De Rosa
- Unit of Infectious Diseases, Cardinal Massaia Hospital, I-14100 Asti, Italy; (T.L.); (F.G.D.R.)
- Infectious diseases Unit, Department of Medical Sciences, University of Torino, I-10124 Torino, Italy; (S.C.); (G.S.)
| | - Roberto Luzzati
- Clinical Department of Medical, Surgical and Health Sciences, University of Trieste, I-34149 Trieste, Italy; (R.L.); (M.S.); (S.D.B.)
| | - Giacomo Stroffolini
- Infectious diseases Unit, Department of Medical Sciences, University of Torino, I-10124 Torino, Italy; (S.C.); (G.S.)
| | - Marina Steyde
- Clinical Department of Medical, Surgical and Health Sciences, University of Trieste, I-34149 Trieste, Italy; (R.L.); (M.S.); (S.D.B.)
| | - Giuliana Decorti
- Clinical Department of Medical, Surgical and Health Sciences, University of Trieste, I-34149 Trieste, Italy; (R.L.); (M.S.); (S.D.B.)
- Institute for Maternal and Child Health–IRCCS Burlo Garofolo, I-34137 Trieste, Italy
- Correspondence: ; Tel.: +39 40-378-5362
| | - Stefano Di Bella
- Clinical Department of Medical, Surgical and Health Sciences, University of Trieste, I-34149 Trieste, Italy; (R.L.); (M.S.); (S.D.B.)
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Li W, Jiao Z, Liu Y, Yao J, Li G, Dong J. Role of organic anion transporter 3 in the renal excretion of biapenem and potential drug-drug interactions. Eur J Pharm Sci 2021; 162:105814. [PMID: 33753216 DOI: 10.1016/j.ejps.2021.105814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 02/28/2021] [Accepted: 03/16/2021] [Indexed: 12/16/2022]
Abstract
Biapenem is a carbapenem antibiotic. It is excreted predominantly through the kidney as unchanged forms. However, the molecular mechanism of renal excretion of biapenem and potential drug-drug interactions (DDIs) were still unknown. In the present study, the role of organic anion transporters (OAT) 1/3 and organic cation transporters (OCT) 2 in the renal excretion of biapenem, and the potential DDIs between biapenem and six clinical commonly prescribed antibiotics and antiviral drugs that acted as substrates or inhibitors of OAT3 were evaluated in vitro. Further, the effect of probenecid on the pharmacokinetics of biapenem was explored in the rats. We observed that biapenem could not inhibit the transport activities of OAT1 or OCT2, while mildly inhibited OAT3 (IC50 >500 μM). Among the tested antibiotics and antiviral drugs, the relatively high DDI index values (maximal unbound plasma concentration over IC50, Imax,u/IC50) were found for piperacillin, linezolid and benzylpenicillin, which were 2.84, 1.7 and 0.62, respectively. Although probenecid had the highest DDI index (27.1) in vitro, no significant impact of it on the pharmacokinetics of biapenem was observed in the rats. Our results indicated that biapenem was primarily eliminated by the glomerular filtration, while OAT3-mediated renal tubular secretion was a minor route. Biapenem is not a clinically relevant substrate or inhibitor because of its low affinity to OAT3. According to current results, it would be safe to use biapenem with other antibiotics and antiviral drugs that acted as substrates or inhibitors of OAT3.
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Affiliation(s)
- Wenyan Li
- Department of Pharmacy, Shanghai Pudong New Area Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, 241 West Huaihai Road, Shanghai 200030, PR China
| | - Yanhui Liu
- Department of Pharmacy, Shanghai Pudong New Area Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Jiacheng Yao
- Department of Pharmacy, Shanghai Pudong New Area Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Guodong Li
- Research Institute for Liver Diseases (Shanghai) Co., Ltd., Building 5, No. 200 Niudun Road, Zhangjiang High-tech Park, Pudong, Shanghai 201203, PR China
| | - Jing Dong
- Department of Pharmacy, Shanghai Pudong New Area Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China.
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Gatti M, Pea F. Pharmacokinetic/pharmacodynamic target attainment in critically ill renal patients on antimicrobial usage: focus on novel beta-lactams and beta lactams/beta-lactamase inhibitors. Expert Rev Clin Pharmacol 2021; 14:583-599. [PMID: 33687300 DOI: 10.1080/17512433.2021.1901574] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Several novel beta-lactams (BLs) and/or beta lactams/beta-lactamase inhibitors (BL/BLIs) have been recently developed for the management of multidrug-resistant bacterial infections. Data concerning dose optimization in critically ill patients with altered renal function are scanty. AREAS COVERED This article provides a critical reappraisal of pharmacokinetic and clinical issues emerged with novel BLs and/or BL/BLIs in renal critically ill patients. Clinical and pharmacokinetic studies published in English until December 2020 were searched on the PubMed-MEDLINE database. EXPERT OPINION Several issues emerged with the use of novel BLs and/or BL/BLIs in critically ill renal patients. Suboptimal clinical response rate with ceftazidime-avibactam and ceftolozane-tazobactam was reported in phase II-III trials in patients with moderate kidney injury; data on patients undergoing renal replacement therapy are limited to some case reports; dose adjustment in augmented renal clearance is provided only for cefiderocol. Implementation of altered dosing strategies (prolonged infusion and/or higher dosage) coupled with adaptive real-time therapeutic drug monitoring could represent the most effective approach in warranting optimal pharmacokinetic/pharmacodynamic targets with novel BLs and/or BL/BLIs in challenging scenarios, thus minimizing the risk of clinical failure and/or of resistance selection.
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Affiliation(s)
- Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy.,SSD Clinical Pharmacology, University Hospital IRCCS Policlinico Sant'Orsola, Bologna, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy.,SSD Clinical Pharmacology, University Hospital IRCCS Policlinico Sant'Orsola, Bologna, Italy
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Motsch J, Young K, Brown ML, Butterton JR, Paschke A. Reply to Sfeir. Clin Infect Dis 2021; 72:1485-1486. [PMID: 32634242 DOI: 10.1093/cid/ciaa881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Johann Motsch
- Universitätsklinikum Heidelberg, Heidelberg, Germany
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Abstract
Imipenem/cilastatin/relebactam (Recarbrio™) is an intravenously administered combination of the carbapenem imipenem, the renal dehydropeptidase-I inhibitor cilastatin, and the novel β-lactamase inhibitor relebactam. Relebactam is a potent inhibitor of class A and class C β-lactamases, conferring imipenem activity against many imipenem-nonsusceptible strains. Imipenem/cilastatin/relebactam is approved in the USA and EU for the treatment of hospital-acquired bacterial pneumonia (HABP) and ventilator-associated bacterial pneumonia (VABP) in adults and other gram-negative infections, including complicated urinary tract infections (cUTIs) [including pyelonephritis] and complicated intra-abdominal infections (cIAIs), in adults with limited or no alternative treatment options. In pivotal phase II and III trials, imipenem/cilastatin/relebactam was noninferior to piperacillin/tazobactam in patients with HABP/VABP and to imipenem/cilastatin in patients with cUTIs and cIAIs. It was also effective in imipenem-nonsusceptible infections. Imipenem/cilastatin/relebactam was generally well tolerated, with a safety profile consistent with that of imipenem/cilastatin. Available evidence indicates that imipenem/cilastatin/relebactam is an effective and generally well tolerated option for gram-negative infections in adults, including critically ill and/or high-risk patients, and a potential therapy for infections caused by carbapenem-resistant pathogens.
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Affiliation(s)
- Young-A Heo
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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Bhagunde P, Colon-Gonzalez F, Liu Y, Wu J, Xu SS, Garrett G, Jumes P, Lasseter K, Marbury T, Rizk ML, Lala M, Rhee EG, Butterton JR, Boundy K. Impact of renal impairment and human organic anion transporter inhibition on pharmacokinetics, safety and tolerability of relebactam combined with imipenem and cilastatin. Br J Clin Pharmacol 2020; 86:944-957. [PMID: 31856304 DOI: 10.1111/bcp.14204] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 11/06/2019] [Accepted: 11/17/2019] [Indexed: 01/22/2023] Open
Abstract
AIMS Two phase 1, open-label studies were conducted to investigate the effect of renal impairment (RI) and organic anion transporter (OAT) inhibition on pharmacokinetics (PK) and safety of relebactam (REL) plus imipenem/cilastatin (IMI). METHODS Study PN005 evaluated the PK of REL (125 mg) plus IMI (250 mg) in participants with RI vs healthy controls. Study PN019 evaluated the PK of REL (250 mg) and imipenem (500 mg; dosed as IMI) with/without probenecid (1 g; OAT inhibitor) in healthy adults. RESULTS Geometric mean ratios (RI/healthy matched controls) of area under the concentration-time curve from time 0 to infinity (AUC0-∞ ; 90% confidence interval) for REL, imipenem and cilastatin increased as RI increased from mild (1.6 [1.1, 2.4], 1.4 [1.1, 1.8] and 1.6 [1.0, 2.5], respectively) to severe (4.9 [3.4, 7.0], 2.5 [1.9, 3.3] and 5.6 [3.6, 8.6], respectively). For all 3 analytes, plasma and renal clearance decreased and corresponding plasma apparent terminal half-life increased with increasing RI. Geometric mean ratios ([probenecid+IMI/REL]/[IMI/REL]) of plasma exposure for REL and imipenem were 1.24 (1.19, 1.28) and 1.16 (1.13, 1.20), respectively. The dose fraction excreted (fe) in the urine decreased progressively from mild to severe RI. Probenecid reduced renal clearance of REL and imipenem by 25 and 31%, respectively. Compared with IMI/REL, coadministration of IMI/REL with probenecid yielded lower fe for REL and imipenem. In both studies, treatment was well tolerated; there were no serious adverse events or discontinuations due to adverse events. CONCLUSION RI increased plasma exposure and similarly decreased clearance of REL, imipenem and cilastatin; IMI/REL dose adjustment (fixed-ratio) will be required for patients with RI. Probenecid had no clinically meaningful impact on the PK of REL or imipenem.
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Affiliation(s)
| | | | - Yang Liu
- Merck & Co., Inc., Kenilworth, NJ, USA
| | - Jin Wu
- Merck & Co., Inc., Kenilworth, NJ, USA
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