Penicillins. A current review of their clinical pharmacology and therapeutic use

What Contributes to the Minimum Inhibitory Concentration? Beyond β-Lactamase Gene Detection in Klebsiella pneumoniae

BACKGROUND

Klebsiella pneumoniae is capable of resistance to β-lactam antibiotics through expression of β-lactamases (both chromosomal and plasmid-encoded) and downregulation of outer membrane porins. However, the extent to which these mechanisms interplay in a resistant phenotype is not well understood. The purpose of this study was to determine the extent to which β-lactamases and outer membrane porins affected β-lactam resistance.

METHODS

Minimum inhibitory concentrations (MICs) to β-lactams and inhibitor combinations were determined by agar dilution or Etest. Outer membrane porin production was evaluated by Western blot of outer membrane fractions. β-lactamase carriage was determined by whole genome sequencing and expression evaluated by real-time reverse-transcription polymerase chain reaction.

RESULTS

Plasmid-encoded β--lactamases were important for cefotaxime and ceftazidime resistance. Elevated expression of chromosomal SHV was important for ceftolozane-tazobactam resistance. Loss of outer membrane porins was predictive of meropenem resistance. Extended-spectrum β-lactamases and plasmid-encoded AmpCs (pAmpCs) in addition to porin loss were sufficient to confer resistance to the third-generation cephalosporins, piperacillin-tazobactam, ceftolozane-tazobactam, and meropenem. pAmpCs (CMY-2 and DHA) alone conferred resistance to piperacillin-tazobactam.

CONCLUSIONS

Detection of a resistance gene by whole genome sequencing was not sufficient to predict resistance to all antibiotics tested. Some β-lactam resistance was dependent on the expression of both plasmid-encoded and chromosomal β-lactamases and loss of porins.

The influence of pH and dissolved organic carbon on the ecotoxicity of ampicillin and clarithromycin

The impacts of water chemistry properties including pH and dissolved organic carbon (DOC) on the ecotoxicity of active pharmaceutical ingredients (APIs) are increasingly evident. These impacts are a result of alterations in API bioavailability: pH regulates the bioavailability of many ionizable APIs via chemical speciation, whereas DOC interacts with several APIs to inhibit the APIs from traversing the membrane system of organisms. In this study, we examined the influences of pH and DOC on the bioavailability of ampicillin (AMP) and clarithromycin (CLA) with the help of a bioavailability model. The effects on bioavailability were quantified by ecotoxicity observed in cyanobacteria growth inhibition tests with Microcystis aeruginosa PCC7806. The median effect concentration (96 h-EC50total) of AMP increased by 5-fold when pH raised from 7.4 to 9.0, suggesting the zwitterionic AMP+/- species being higher in bioavailability than the negatively charged AMP- species. CLA ecotoxicity showed no significant pH-dependency, suggesting CLA+ and CLA0 species to be equally bioavailable, albeit it correlated significantly with M. aeruginosa growth rate in negative controls. In addition, DOC demonstrated no significant effects on the ecotoxicity of AMP or CLA. Overall, together with earlier results on ciprofloxacin, our data show that bioavailability relations with pH and DOC are variable among different antibiotics. Factors other than chemical speciation alone could play a role in their bioavailability, such as their molecular size and polarity.

Molecular characterization of cefepime and aztreonam nonsusceptibility in Haemophilus influenzae

BACKGROUND

Cefepime and aztreonam are highly efficacious against H. influenzae, and resistant strains are rare. In this study, we isolated cefepime- and aztreonam-nonsusceptible H. influenzae strains and addressed the molecular basis of their resistance to cefepime and aztreonam.

METHODS

Two hundred and 28 specimens containing H. influenzae were screened, of which 32 isolates were enrolled and applied to antimicrobial susceptibility testing and whole-genome sequencing. Genetic variations that were detected in all nonsusceptible isolates with statistical significance by Fisher's exact tests were identified as cefepime or aztreonam nonsusceptibility related. Functional complementation assays were conducted to assess the in vitro effects of proteins with sequence substitutions on drug susceptibility.

RESULTS

Three H. influenzae isolates were nonsusceptible to cefepime, one of which was also nonsusceptible to aztreonam. Genes encoding TEM, SHV and CTX-M extended-spectrum β-lactamases were not detected in the cefepime- and aztreonam-nonsusceptible isolates. Five genetic variations in four genes and 10 genetic variations in five genes were associated with cefepime and aztreonam nonsusceptibility, respectively. Phylogenetic analyses revealed that changes in FtsI were correlated strongly with the MIC of cefepime and moderately with aztreonam. FtsI Thr532Ser-Tyr557His cosubstitution linked to cefepime nonsusceptibility and Asn305Lys-Ser385Asn-Glu416Asp cosubstitution to aztreonam nonsusceptibility. Functional complementation assays revealed that these cosubstitutions increased MICs of cefepime and aztreonam in susceptible H. influenzae isolates, respectively.

CONCLUSIONS

Genetic variations relevant to resistant phenotypes of cefepime and aztreonam nonsusceptibility in H. influenzae were identified. Moreover, the effects of FtsI cosubstitutions on increasing MICs of cefepime and aztreonam in H. influenzae were demonstrated.

The coordinated action of the enzymes in the L-lysine biosynthetic pathway and how to inhibit it for antibiotic targets

BACKGROUND

Antimicrobial resistance is a global health issue that requires immediate attention in terms of new antibiotics and new antibiotic targets. The l-lysine biosynthesis pathway (LBP) is a promising avenue for drug discovery as it is essential for bacterial growth and survival and is not required by human beings.

SCOPE OF REVIEW

The LBP involves a coordinated action of fourteen different enzymes distributed over four distinct sub-pathways. The enzymes involved in this pathway belong to different classes, such as aspartokinase, dehydrogenase, aminotransferase, epimerase, etc. This review provides a comprehensive account of the secondary and tertiary structure, conformational dynamics, active site architecture, mechanism of catalytic action, and inhibitors of all enzymes involved in LBP of different bacterial species.

MAJOR CONCLUSIONS

LBP offers a wide scope for novel antibiotic targets. The enzymology of a majority of the LBP enzymes is well understood, although these enzymes are less widely studied in the critical pathogens (according to the 2017 WHO report) that require immediate attention. In particular, the enzymes in the acetylase pathway, DapAT, DapDH, and Aspartokinase in critical pathogens have received little attention. High throughput screening for inhibitor design against the enzymes of lysine biosynthetic pathway is rather limited, both in number and in the extent of success.

GENERAL SIGNIFICANCE

This review can serve as a guide for the enzymology of LBP and help in identifying new drug targets and designing potential inhibitors.

Semisynthetic triterpenes led to the generation of selective antitrypanosomal lead compounds

Triterpenes α,β-amyrin are naturally occurring molecules that can serve as building blocks for synthesizing new chemical entities. This study synthesized acyl, carboxyesther, NSAID, and nitrogenous derivatives and evaluated their antimicrobial activity. A cyclodextrin complexation method was developed to improve the solubility of the derivatives. Of the 17 derivatives tested, five exhibited activity against Trypanosoma cruzi, T. brucei, Leishmania infantum, Candida albicans, Staphylococcus aureus, and Escherichia coli. The 9a/9b mixture showed weak activity against the parasites (IC₅₀ 24.45-40.32 μM). However, it showed no activity for the other microorganisms. Derivatives 14a/14b exhibited potent activity against T. cruzi (IC₅₀ 2.0 nM) in this tested concentration did not show activity to the other microorganisms and were not cytotoxic. Derivatives 15a/15b and 16a/16b demonstrated relevant activity against the parasites (IC₅₀ 2.24-5.44 μM), but were also cytotoxic. Derivatives 17a/17b showed low activity against the tested parasites (IC₅₀ 21.70-22.79 μM), but they were selective since they did not show activity against other microorganisms. In docking studies, in general, all derivatives showed complementarity with the CYP51 binding site of the trypanosomatid mainly by hydrophobic interactions; thus, it is not conclusive that the molecules act by inhibiting this enzyme. Our results showed that triterpenes derivatives with antitrypanosomal activity could be synthesized by an inexpensive and rapid method.

Obtention of biochar-Fe/Ce using Punica granatum with high adsorption of ampicillin capacity

This research presents the obtaining of a biochar (CB) from the use of pomegranate peel (Punica granatum) conditioned with iron and cerium nanoparticles (C-Fe/Ce), as well as its characterization by SEM (Scanning Electronic Microscopy), FTIR (Fourier Transform Infrared Spectrometry), TGA (Thermogravimetric analysis), EDS (Energy Dispersive Spectroscopy), XPS (X-Ray Photoelectron Spectroscopy) and evaluation of the adsorption capacity of ampicillin (AMP) in aqueous phase at 20, 30 and 40 °C. The maximum adsorption capacity for CB was 18.97 mg g-1 and for C-Fe/Ce, 27.61 mg g-1 at pH of 7, observing that with increasing temperature, the sorption capacity decreases in both materials, the experimental data was fitted to various mathematical models and the best fit was the pseudo-second order model for the kinetics, whilst for the adsorption isotherms the best fit was with the Langmuir model, indicating that the adsorption process is carried out in a monolayer on a homogeneous surface, through a chemisorption process. According to the thermodynamic parameters this process is carried out through an exothermic reaction. The results obtained indicate that both materials are suitable for the removal of AMP in the aqueous phase and that they can be reused up to 5 times.

Characteristics and Antibiotic Resistance of Haemophilus influenzae in Children with Lower Respiratory Tract Infection in Chengdu, China

Background: Haemophilus influenzae is an opportunistic pathogen of the human respiratory tract. Haemophilus influenzae can cause not only respiratory tract infection in children but also otitis media, epiglottitis and sinusitis. With the widespread use of antibiotics, the positive rate of β-lactamase in H. influenzae is increasing, and the rate of antimicrobial resistance is also increasing, which increases the difficulty of clinical treatment. Objectives: To study the infection characteristics of patients and the antibiotic resistance of H. influenzae in lower respiratory tract samples of children in Chengdu, so as to provide a reference for its clinical diagnosis and the rational use of antibiotics. Methods: Sputum samples of 15891 children aged 0-14 years with lower respiratory tract infection were collected. Haemophilus influenzae was cultured and identified, its drug susceptibility tested, and the results determined according to the guidelines of CLSI 2020. Results: A total of 15891 clinical isolate strains in sputum were detected for drug sensitivity from December 2018 to January 2020, of which 5488 were H. influenzae, accounting for 34.54% (5488/15891). The sex of children infected with H. influenzae was not skewed (P > 0.05). The detection rate of H. influenzae was the highest in children aged 7 - 11 months, and the lowest was in the age group ≤ 28 d. The detection rate was the highest in spring and the lowest in autumn. The positive rate of β-lactamase was 92.0%, the resistance rate to ampicillin was 92.0%, the sensitivity to amoxicillin/clavulanate was 70.2%, and the sensitivity to cefotaxime, ofloxacin, tetracycline, chloramphenicol, and rifampicin was more than 90.0%. Conclusions: Children aged 7 months to 14 years were generally susceptible to H. influenzae in spring, and the positive rate of β-lactamase was high. Doctors should refer to the infection characteristics and drug resistance of H. influenzae and choose antibiotics correctly to better control the infection.

Pharmacokinetic Drug-drug Interaction of Antibiotics Used in Sepsis Care in China

BACKGROUND

Many antibiotics have a high potential for interactions with drugs, as a perpetrator and/or victim, in critically ill patients, and particularly in sepsis patients.

METHODS

The aim of this review is to summarize the pharmacokinetic drug-drug interaction (DDI) of 45 antibiotics commonly used in sepsis care in China. Literature search was conducted to obtain human pharmacokinetics/ dispositions of the antibiotics, their interactions with drug-metabolizing enzymes or transporters, and their associated clinical drug interactions. Potential DDI is indicated by a DDI index ≥ 0.1 for inhibition or a treatedcell/ untreated-cell ratio of enzyme activity being ≥ 2 for induction.

RESULTS

The literature-mined information on human pharmacokinetics of the identified antibiotics and their potential drug interactions is summarized.

CONCLUSION

Antibiotic-perpetrated drug interactions, involving P450 enzyme inhibition, have been reported for four lipophilic antibacterials (ciprofloxacin, erythromycin, trimethoprim, and trimethoprim-sulfamethoxazole) and three antifungals (fluconazole, itraconazole, and voriconazole). In addition, seven hydrophilic antibacterials (ceftriaxone, cefamandole, piperacillin, penicillin G, amikacin, metronidazole, and linezolid) inhibit drug transporters in vitro. Despite no clinical PK drug interactions with the transporters, caution is advised in the use of these antibacterials. Eight hydrophilic antibiotics (all β-lactams; meropenem, cefotaxime, cefazolin, piperacillin, ticarcillin, penicillin G, ampicillin, and flucloxacillin), are potential victims of drug interactions due to transporter inhibition. Rifampin is reported to perpetrate drug interactions by inducing CYP3A or inhibiting OATP1B; it is also reported to be a victim of drug interactions, due to the dual inhibition of CYP3A4 and OATP1B by indinavir. In addition, three antifungals (caspofungin, itraconazole, and voriconazole) are reported to be victims of drug interactions because of P450 enzyme induction. Reports for other antibiotics acting as victims in drug interactions are scarce.

Synergistic and antagonistic drug interactions in the treatment of systemic fungal infections

Invasive fungal infections cause 1.6 million deaths annually, primarily in immunocompromised individuals. Mortality rates are as high as 90% due to limited treatments. The azole class antifungal, fluconazole, is widely available and has multi-species activity but only inhibits growth instead of killing fungal cells, necessitating long treatments. To improve treatment, we used our novel high-throughput method, the overlap² method (O2M) to identify drugs that interact with fluconazole, either increasing or decreasing efficacy. We identified 40 molecules that act synergistically (amplify activity) and 19 molecules that act antagonistically (decrease efficacy) when combined with fluconazole. We found that critical frontline beta-lactam antibiotics antagonize fluconazole activity. A promising fluconazole-synergizing anticholinergic drug, dicyclomine, increases fungal cell permeability and inhibits nutrient intake when combined with fluconazole. In vivo, this combination doubled the time-to-endpoint of mice with Cryptococcus neoformans meningitis. Thus, our ability to rapidly identify synergistic and antagonistic drug interactions can potentially alter the patient outcomes.

Individuals with weakened immune systems – such as recipients of organ transplants – can fall prey to illnesses caused by fungi that are harmless to most people. These infections are difficult to manage because few treatments exist to fight fungi, and many have severe side effects. Antifungal drugs usually slow the growth of fungi cells rather than kill them, which means that patients must remain under treatment for a long time, or even for life.

One way to boost efficiency and combat resistant infections is to combine antifungal treatments with drugs that work in complementary ways: the drugs strengthen each other’s actions, and together they can potentially kill the fungus rather than slow its progression. However, not all drug combinations are helpful. In fact, certain drugs may interact in ways that make treatment less effective. This is particularly concerning because people with weakened immune systems often take many types of medications.

Here, Wambaugh et al. harnessed a new high-throughput system to screen how 2,000 drugs (many of which already approved to treat other conditions) affected the efficiency of a common antifungal called fluconazole. This highlighted 19 drugs that made fluconazole less effective, some being antibiotics routinely used to treat patients with weakened immune systems.

On the other hand, 40 drugs boosted the efficiency of fluconazole, including dicyclomine, a compound currently used to treat inflammatory bowel syndrome. In fact, pairing dicyclomine and fluconazole more than doubled the survival rate of mice with severe fungal infections. The combined treatment could target many species of harmful fungi, even those that had become resistant to fluconazole alone.

The results by Wambaugh et al. point towards better treatments for individuals with serious fungal infections. Drugs already in circulation for other conditions could be used to boost the efficiency of fluconazole, while antibiotics that do not decrease the efficiency of this medication should be selected to treat at-risk patients.

Extensively drug-resistant Haemophilus influenzae - emergence, epidemiology, risk factors, and regimen

Background

Concern about Haemophilus influenzae infection has been increasing over recent decades. Given the emergence of H. influenzae with severe drug resistance, we assessed the prevalence of as well as risk factors and potential therapies for extensively drug-resistant (XDR) H. influenzae infection in Taiwan.

Results

In total, 2091 H. influenzae isolates with disk diffusion-based antibiotic susceptibility testing from 2007 to 2018 were enrolled. H. influenzae strains resistant to ampicillin, chloramphenicol, levofloxacin, and trimethoprim-sulfamethoxazole tended to be isolated from patient wards (≧41%), whereas those resistant to amoxicillin-clavulanate, cefotaxime, and cefuroxime were more likely to be isolated from intensive care units (approximately 50%). XDR H. influenzae was first identified in 2007, and its incidence did not significantly change thereafter. Overall prevalence of single, multiple, and extensively drug-resistant H. influenzae over 2007–2018 was 21.5% (n = 450), 26.6% (n = 557), and 2.5% (n = 52), respectively. A stepwise logistic regression analysis revealed that blood culture (odds ratio: 4.069, 95% confidence intervals: 1.339–12.365, P = 0.013) was an independent risk factor for XDR H. influenzae infection. No nosocomial transmission of XDR H. influenzae observed. Antibiotic susceptibility testing results demonstrated that cefotaxime was effective against 78.8% (n = 41) of the XDR strains.

Conclusions

The presence of XDR H. influenzae strains was identified in Taiwan, and cefotaxime was efficacious against most of these strains.

The cubane paradigm in bioactive molecule discovery: further scope, limitations and the cyclooctatetraene complement

The cubane phenyl ring bioisostere paradigm was further explored in an extensive study covering a wide range of pharmaceutical and agrochemical templates, which included antibiotics (cefaclor, penicillin G) and antihistamine (diphenhydramine), a smooth muscle relaxant (alverine), an anaesthetic (ketamine), an agrochemical instecticide (triflumuron), an antiparasitic (benznidazole) and an anticancer agent (tamibarotene). This investigation highlights the scope and limitations of incorporating cubane into bioactive molecule discovery, both in terms of synthetic compatibility and physical property matching. Cubane maintained bioisosterism in the case of the Chagas disease antiparasitic benznidazole, although it was less active in the case of the anticancer agent (tamibarotenne). Application of the cyclooctatetraene (COT) (bio)motif complement was found to optimize benznidazole relative to the benzene parent, and augmented anticancer activity relative to the cubane analogue in the case of tamibarotene. Like all bioisosteres, scaffolds and biomotifs, however, there are limitations (e.g. synthetic implementation), and these have been specifically highlighted herein using failed examples. A summary of all templates prepared to date by our group that were biologically evaluated strongly supports the concept that cubane is a valuable tool in bioactive molecule discovery and COT is a viable complement.

Pathogenic microbes contaminating mobile phones in hospital environment in Northeast India: incidence and antibiotic resistance

BACKGROUND

The present study attempts to identify and determine the pattern of drug susceptibility of the microorganisms present in mobile phones of health care workers (HCWs) and non-HCWs in a hospital environment. Mobile phones of 100 participants including both genders were randomly swabbed from nine different wards/units and the bacterial cultures were characterized using VITEK 2 system.

RESULTS

Forty-seven mobile phones were culture positive and a total of 57 isolates were obtained which consisted of 28 Gram-positive organisms and 29 Gram-negative organisms. The predominating organisms were Acinetobacter baumannii and Staphylococcus hominis. Among all the isolates from the mobile phones of HCW and non-HCWs, five isolates had ESBL and three isolates had colistin resistance. Incidentally, MRSA was not found on the mobile phones tested. The isolated organisms showed 100% susceptibility to linezolid, daptomycin, vancomycin, imipenem, meropenem, gentamicin, amikacin, ciprofloxacin and tigecycline, while high resistance was shown against benzylpenicillin (75.0%), cefuroxime and cefuroxime axetil (56.5%). Non-HCWs' mobile phones were more contaminated as compared to HCWs (P = 0.001) and irrespective of individuals' gender or toilet habits, both Gram-positive and Gram-negative organisms were present on the mobile phones.

CONCLUSION

This study reports for the first time that the mobile phones of non-health care workers harbour more bacterial diversity and are more prone to cause transmission of pathogens. This study can serve to educate the public on personal hand hygiene practices and on maintaining clean mobile phones through antiseptic measures.

Concise Review: Fat and Furious: Harnessing the Full Potential of Adipose-Derived Stromal Vascular Fraction

Due to their capacity to self-renew, proliferate and generate multi-lineage cells, adult-derived stem cells offer great potential for use in regenerative therapies to stop and/or reverse degenerative diseases such as diabetes, heart failure, Alzheimer's disease and others. However, these subsets of cells can be isolated from different niches, each with differing potential for therapeutic applications. The stromal vascular fraction (SVF), a stem cell enriched and adipose-derived cell population, has garnered interest as a therapeutic in regenerative medicine due to its ability to secrete paracrine factors that accelerate endogenous repair, ease of accessibility and lack of identified major adverse effects. Thus, one can easily understand the rush to employ adipose-derived SVF to treat human disease. Perhaps faster than any other cell preparation, SVF is making its way to clinics worldwide, while critical preclinical research needed to establish SVF safety, efficacy and optimal, standardized clinical procedures are underway. Here, we will provide an overview of the current knowledge driving this phenomenon, its regulatory issues and existing studies, and propose potential unmapped applications. Stem Cells Translational Medicine 2017;6:1096-1108.

Colonisation of antibiotic resistant bacteria in a cohort of HIV infected children in Ghana

Antibiotic use not only selects for resistance in pathogenic bacteria, but also in commensal flora of exposed individuals. Little is known epidemiologically about antibiotic resistance in relation to people with HIV infection in sub-Saharan Africa. This study investigated the carriage of antibiotic resistant bacteria among HIV infected children at a tertiary hospital in Ghana. One hundred and eighteen HIV positive children were recruited at the Korle-Bu Teaching Hospital in Ghana and nasopharyngeal specimens were collected from them. The specimens were cultured for bacteria, and the isolates were identified by standard microbiological methods. Antibiotic susceptibility tests were carried out on selected bacterial organisms by the Kirby Bauer method. Bacteria isolated from the study subjects included Moraxella catarrhalis (39.8%), coagulase negative staphylococci (33.1%), Streptococcus pneumoniae (30.5%), diptheroids (29.7%), viridian streptococci (27.1%), Staphylococcus aureus (22.0%), Citrobacter spp. (4.2%) and Neisseria meningitidis (0.9%). Prevalence of antibiotic resistance of S. pneumoniae ranged from 5.6% (ceftriaxone) to 58.3% (cotrimoxazole), M. catarrhalis ranged from 2.1% (gentamicin) to 80.6% (ampicillin), and S. aureus ranged from 7.7% (cefoxitin) to 100% (penicillin). The prevalence of multiple drug resistance was 16.7% for S. pneumoniae, 57.4% for M. catarrhalis and 84.6% for S. aureus. HIV infected children in the study area commonly carry multi-drug resistant isolates of several pathogenic bacteria such as S. aureus and S. pneumoniae. Infections arising in these patients that are caused by S. aureus and S. pneumoniae could be treated with ceftriaxone and cefoxitin respectively.

Magnetofluidic platform for multidimensional magnetic and optical barcoding of droplets

We present a concept of multidimensional magnetic and optical barcoding of droplets based on a magnetofluidic platform. The platform comprises multiple functional areas, such as an encoding area, an encoded droplet pool and a magnetic decoding area with integrated giant magnetoresistive (GMR) sensors. To prove this concept, penicillin functionalized with fluorescent dyes is coencapsulated with magnetic nanoparticles into droplets. While fluorescent dyes are used as conventional optical barcodes which are decoded with an optical decoding setup, an additional dimensionality of barcodes is created by using magnetic nanoparticles as magnetic barcodes for individual droplets and integrated micro-patterned GMR sensors as the corresponding magnetic decoding devices. The strategy of incorporating a magnetic encoding scheme provides a dynamic range of ~40 dB in addition to that of the optical method. When combined with magnetic barcodes, the encoding capacity can be increased by more than 1 order of magnitude compared with using only optical barcodes, that is, the magnetic platform provides more than 10 unique magnetic codes in addition to each optical barcode. Besides being a unique magnetic functional element for droplet microfluidics, the platform is capable of on-demand facile magnetic encoding and real-time decoding of droplets which paves the way for the development of novel non-optical encoding schemes for highly multiplexed droplet-based biological assays.

Cycloreversion of β-lactams via photoinduced electron transfer

With DABCO as an electron donor, photoinduced cycloreversion of β-lactams leads to olefins through 1,4-radical anions and 1,4-biradicals as intermediates.

Resistance to β-Lactams - The Permutations

The beta-lactam family of antimicrobials, in particular penicillins and cephalosporins, is the mainstay of treatment for community-acquired infections. However, the emergence of resistant isolates to these agents has raised concerns regarding the continued efficacy of existing therapies. Resistance to beta-lactams is most commonly expressed by the microbial production of beta-lactamases that hydrolyze the beta-lactam ring. Three further resistance mechanisms include conformational changes in penicillin-binding proteins (PBPs); permeability changes in the outer membrane; and active efflux of the antimicrobial. In addition to the pre-requisite efficacy and tolerability profiles, new beta-lactams should address these four resistance mechanisms. Overcoming resistance may be a serendipitous event or arrived at by design. A unique synthetic beta-lactam class, which demonstrates promise in terms of its activity against the range of bacteria responsible for community-acquired infections and its inherent stability to hydrolysis by beta-lactamases, is the penems. This discrete class of hybrid molecules combines properties from the penicillin (penam) and cephalosporin (cephem) beta-lactam classes. Faropenem is an example of a penem with a broad spectrum of activity designed to address these resistance issues.

Pleural infection-current diagnosis and management

Pleural infection is a common and increasing clinical problem in thoracic medicine, resulting in significant morbidity and mortality. In recent years there has been a marked increase in interests and publications relating to evolving interventions and management options for pleural infection and empyema. Recently published research data as well as guidelines have suggested better approaches of radiological assessment, updated management algorithms for pleural infection, intrapleural adjunct therapies and re-examined the roles of biomarkers, pleural drainage techniques, and the role of surgery. This review highlights some of the recent advances and recommendations relevant to clinical care of pleural infection.

Klebsiella pneumoniae carbapenemases in Enterobacteriaceae: history, evolution, and microbiology concerns

Since the discovery of penicillin 80 years ago, gram-negative bacteria have become proficient at evading the lethal activity of β-lactam antibiotics, principally through the production of β-lactamases. The rapid emergence of penicillinases in both gram-positive and gram-negative bacteria led to the development of cephalosporin β-lactam antibiotics, but production of plasmid-mediated extended-spectrum cephalosporinases (or extended-spectrum β-lactamases) and AmpC enzymes resulted in resistance to this drug class. Because carbapenems were the only β-lactam agents active against such extended-spectrum β-lactamase-producing strains, appropriate and inappropriate use soon resulted in Enterobacteriaceae resistance. As a result, two distinct types of carbapenemases-the metallo-β-lactamases and Klebsiella pneumoniae carbapenemases (KPCs)-were soon identified. The KPCs comprise 10 variants that differ from one another by one to three amino acid substitutions (KPC-2 to KPC-11). The KPC-producing Enterobacteriaceae are not only multidrug resistant but are also difficult to detect routinely in the clinical microbiology laboratory. Tigecycline, polymyxins (colistin and polymyxin B), and aminoglycosides are possible candidate therapies for infections caused by KPC-producing organisms, although well-conducted clinical trials are required to fully define their roles in patient management. The shortage of new antimicrobial agents on the immediate horizon suggests that enhanced adherence with infection prevention procedures and antimicrobial stewardship programs are needed to curb patient-to-patient transmission and to reduce the selection of multidrug-resistant bacteria.

EUCAST expert rules in antimicrobial susceptibility testing

EUCAST expert rules have been developed to assist clinical microbiologists and describe actions to be taken in response to specific antimicrobial susceptibility test results. They include recommendations on reporting, such as inferring susceptibility to other agents from results with one, suppression of results that may be inappropriate, and editing of results from susceptible to intermediate or resistant or from intermediate to resistant on the basis of an inferred resistance mechanism. They are based on current clinical and/or microbiological evidence. EUCAST expert rules also include intrinsic resistance phenotypes and exceptional resistance phenotypes, which have not yet been reported or are very rare. The applicability of EUCAST expert rules depends on the MIC breakpoints used to define the rules. Setting appropriate clinical breakpoints, based on treating patients and not on the detection of resistance mechanisms, may lead to modification of some expert rules in the future.

Antimicrobials in urogenital infections

Urinary tract infections (UTIs) and male genital infections are amongst the most prevalent infections. A prudent antibiotic policy therefore has a large impact on society. The clinical classification in uncomplicated cystitis, uncomplicated pyelonephritis, complicated UTI and genital infections is useful, also for the right choice of antibiotic treatment. In this regard pharmacokinetic and pharmacodynamic aspects have to be considered. Nowadays in uncomplicated cystitis antibiotics exclusively reserved for this indication are preferred, such as fosfomycin trometamol, nitrofurantoin and pivmecillinam, in order to reduce antibiotic pressure in this extremely frequent entity. In complicated UTI a broad bacterial spectrum has to be considered. Different antibiotic substances should be used for treatment, such as penicillins, with β-lactamase inhibitors, cephalosporins or carbapenems, fluoroquinolones, aminoglycosides or cotrimoxazole, if tested susceptible. For genital infections the pharmacokinetic properties of the antibiotics should especially be considered, such as in prostatitis, where mainly fluoroquinolones and macrolides show sufficient pharmacokinetic parameters for treatment of bacterial infections. Furthermore in genital infections fastidious organisms, such as Chlamydia or Mycoplasma spp. have to be considered with respect to their antimicrobial susceptibility.

Necrotizing soft tissue infection of the scalp after fronto-facial advancement by internal distraction in a 7-year old girl with Gorlin-Chaudhry-Moss syndrome--a case report

In 1960, Gorlin, Chaudhry and Moss described a syndrome consisting of craniofacial dysostosis in association with hypertrichosis, cardiac, genital, dental and ocular anomalies. Diagnosis is based on typical clinical findings and cannot be performed by molecular genetic analysis until now. There is little in the clinical literature concerning this rare craniofacial syndrome. For functional and psychosocial reasons, surgical correction of the complex craniofacial malformation in a 7-year old Hungarian girl with Gorlin-Chaudhry-Moss syndrome was performed by fronto-facial advancement using internal distraction devices. Postoperatively necrotizing soft tissue infection of the scalp developed leading to termination of the distraction process ahead of schedule and requiring aggressive surgical management. Typical physiological and clinical characteristics were observed both during the initial craniofacial correction as well as during the management of the infectious complication suggesting that the linking of different conditions (surgical trauma plus the selection of toxic microorganisms) has caused tissue destruction rather than the syndromal disorder or the surgical technique of distraction osteogenesis. Although skeletal improvement was achieved residual damage from the infectious complication must be considered as severe.

Ampicillin micronization by supercritical assisted atomization

The micronization technique called supercritical assisted atomization (SAA) was used to produce ampicillin microparticles with controlled particle size and particle size distribution suitable for aerosol drug delivery. The process is based on the solubilization of supercritical CO2 in a liquid solution. The ternary mixture is then sprayed through a nozzle and, as a consequence of enhanced atomization, solid microparticles are formed. Water and organic solvents were tested with ampicillin to determine the influence of the solvent on the process mechanism. SAA process parameters were studied by testing different supercritical/liquid solvent flow ratios, ampicillin concentrations in the liquid solution and nozzle diameters. The effect of these parameters on morphology, particle size and particle size distribution of microparticles was analysed. Ampicillin particles suitable for aerosol delivery in the size range 1–5 μm were obtained using buffered water. Moreover, by varying the solute concentration, ampicillin particles in a narrower range (1–3 μm) than that usually suggested for aerosol deliverable drugs were obtained. This is an example of particle size tailoring by SAA.

Rational antibiotic therapy and the position of ampicillin/sulbactam

In the current context of increasing antimicrobial resistance, it is important to use antibiotics rationally and to re-assess regularly the clinical usefulness of commonly used agents. This review focuses on the efficacy of the beta-lactam ampicillin co-administered with the beta-lactamase inhibitor sulbactam, either parenterally (ampicillin/sulbactam) or orally (sultamicillin), for the treatment of bacterial infections. Clinical findings from the past decade confirm the results of numerous older studies and together provide good evidence to support the continued use of ampicillin/sulbactam and sultamicillin in hospital- and community-acquired infections both in adults and children. This is also recognised in recent published national and international guidelines, many of which recommend ampicillin/sulbactam as first-line therapy for various respiratory and skin infections.

Anti-tumor activity of N-thiolated beta-lactam antibiotics

An ongoing strategy for cancer treatment is selective induction of apoptosis in cancer over normal cells. N-thiolated beta-lactams were found to induce DNA damage, growth arrest and apoptosis in cultured human cancer cells. However, whether these compounds have a similar effect in vivo has not been studied. We report here that treatment with the beta-lactam L-1 caused a significant inhibition of tumor growth in a breast cancer xenograft mouse model, associated with induction of DNA damage and apoptosis in vivo. These results suggest that the synthetic antibiotic N-thiolated beta-lactams hold great potential to be developed as novel anti-cancer drugs.

Piperacillin-tazobactam: a beta-lactam/beta-lactamase inhibitor combination

Piperacillin-tazobactam is a beta-lactam/beta-lactamase inhibitor combination with a broad spectrum of antibacterial activity that includes Gram-positive and -negative aerobic and anaerobic bacteria. Piperacillin-tazobactam retains its in vitro activity against broad-spectrum beta-lactamase-producing and some extended-spectrum beta-lactamase-producing Enterobacteriaceae, but not against isolates of Gram-negative bacilli harboring AmpC beta-lactamases. Piperacillin-tazobactam has recently been reformulated to include ethylenediaminetetraacetic acid and sodium citrate; this new formulation has been shown to be compatible in vitro with the two aminoglycosides, gentamicin and amikacin, allowing for simultaneous Y-site infusion, but not with tobramycin. Multicenter, randomized, double-blinded clinical trials have demonstrated piperacillin-tazobactam to be as clinically effective as relevant comparator antibiotics. Clinical trials have demonstrated piperacillin-tazobactam to be effective for the treatment of patients with intra-abdominal infections, skin and soft tissue infections, lower respiratory tract infections, complicated urinary tract infections, gynecological infections and more recently, febrile neutropenia. Piperacillin-tazobactam has an excellent safety and tolerability profile and continues to be a reliable option for the empiric treatment of moderate-to-severe infections in hospitalized patients.

Promethazine renders Escherichia coli susceptible to penicillin G: real-time measurement of bacterial susceptibility by fluoro-luminometry

Gram-negative bacteria are resistant to many hydrophobic antibiotics (such as penicillin G) owing to the highly hydrophilic saccharide part of lipopolysaccharide in the cell membrane, whilst most hydrophilic antibiotics (such as ampicillin) are more freely diffused into cells through aqueous porins. In this study, we investigated the possibility of altering the membrane permeability of Escherichia coli with tricyclic cationic compounds, such as the non-antibiotic drug promethazine. We also established the activity of these compounds as modifiers of antibiotic resistance in bacteria by a fluoro-luminometric approach. According to the results, promethazine has no bacteriostatic effect on E. coli at concentrations <64 microg/mL. However, promethazine at these concentrations in combination with penicillin G produced a significant synergistic activity against E. coli. Specifically, a constant promethazine concentration of 32 microg/mL in combination with penicillin G concentrations of 16-128 microg/mL suppressed the growth and viability of bacteria and converted penicillin G-resistant cells to being susceptible to this antibiotic with a minimum inhibitory concentration of 128 microg/mL. In contrast to penicillin G, the efficacy of ampicillin was apparently not increased in the presence of promethazine, suggesting that promethazine directly affects the membrane permeability of bacteria or alternatively inhibits the function of efflux pumps. In conclusion, we conclude that exposing E. coli cells to a given antibiotic in combination with promethazine can increase the susceptibility of bacteria; this effect is reliably assessed on a real-time basis using kinetic fluoro-luminometric measurements.

Carbonylation of heterocycles by homogeneous catalysts

This article summarizes the recent developments (particularly the uses of homogeneous organometallic catalysts) in ring-opening carbonylations, ring-opening carbonylative polymerizations and ring-expansion carbonylations of heterocycles such as epoxides, aziridines, lactones and oxazolines.

Asymptotics and bioavailability in a 17-compartment pharmacokinetic model with enterohepatic circulation and remetabolization

A 17-compartment linear pharmacokinetic model is designed, describing the complex process of enterohepatic circulation as a superposition of the net (remetabolizationfree) enterohepatic circulation, and remetabolization with subsequent intestinal absorption of the parent drug. Basically, the model is built by doubling the model describing the circulation of the parent drug in the body, so that the remetabolizable metabolite circulates in a model of the same structure as does the parent compound. The two submodels are cross-connected with arrows denoting the transition of the particular substance into the complementary part of the complex model. Asymptotic properties of the model are investigated, in particular, explicit formulas for its pharmacokinetic endpoints are given using the elements of its transition probability matrix. Conversely, taking account of the effect of bile cannulation, intravenous, intraportal and oral administration of the drug, as well as of the intravenous and intraportal administration of the remetabolizable metabolite, the transition probabilities of the system are determined in terms of certain measurable pharmacokinetic endpoints and the flow rates through the kidneys, liver and the cardiac output. Finally, the influence of the enterohepatic circulation and remetabolization process on bioavailability is examined. In particular, the inclusion-exclusion formula is derived, expressing its joint efficiency (defined as the relative increase of bioavailability) by means of the efficiencies of the net enterohepatic circulation and of the remetabolization process.

Antimicrobial therapy in Dermatology

The extensive and sometimes indiscriminate use of antibiotics sometimes without strict indications has led to increases in both bacterial resistance and sensitization of patients. Systemic antibiotics in skin infections are indicated when a severe local infection occurs which spreads into the surrounding tissue or when there are signs of systemic infection. There are special indications in patients with peripheral arterial occlusive disease,diabetes or immunosuppression. Topical use of antibiotics should be abandoned and replaced by antiseptics. The beta-lactam antibiotics are the antibiotics of first choice for many skin infections. They are usually effective, have a well-defined profile of adverse events and most are affordable. Penicillin G or V are the first line treatment for erysipelas. Infections with Staphylococcus aureus are usually treated with isoxazolyl penicillins or second generation cephalosporins. In mixed infections in patients with diabetes or peripheral arterial occlusive disease,the treatment of choice is metronidazole plus beta-lactam-/beta-lactamase inhibitor antibiotics, but quinolones or second generation cephalosporins can also be used, once again with metronidazole. The aim of this review is to define the indications for antibiotics in dermatology, to highlight their modes of action and adverse effects and to make suggestions for rational antibiotic therapy in cutaneous infections frequently encountered in the practice of dermatology.

Interaction of zwitterionic penicillins with the OmpF channel facilitates their translocation

To study translocation of beta-lactam antibiotics of different size and charge across the outer bacterial membrane, we combine an analysis of ion currents through single trimeric outer membrane protein F (OmpF) porins in planar lipid bilayers with molecular dynamics simulations. Because the size of penicillin molecules is close to the size of the narrowest part of the OmpF pore, penicillins occlude the pore during their translocation. Favorably interacting penicillins cause time-resolvable transient blockages of the small-ion current through the channel and thereby provide information about their dynamics within the pore. Analyzing these random fluctuations, we find that ampicillin and amoxicillin have a relatively high affinity for OmpF. In contrast, no or only a weak interaction is detected for carbenicillin, azlocillin, and piperacillin. Molecular dynamics simulations suggest a possible pathway of these drugs through the OmpF channel and rationalize our experimental findings. For zwitterionic ampicillin and amoxicillin, we identify a region of binding sites near the narrowest part of the channel pore. Interactions with these sites partially compensate for the entropic cost of drug confinement by the channel. Whereas azlocillin and piperacillin are clearly too big to pass through the channel constriction, dianionic carbenicillin does not find an efficient binding region in the constriction zone. Carbenicillin's favorable interactions are limited to the extracellular vestibule. These observations confirm our earlier suggestion that a set of high-affinity sites at the narrowest part of the OmpF channel improves a drug's ability to cross the membrane via the pore.

Gram-negative bacteria responsible for insoluble technetium formation and the fate of insoluble Tc in the water column above flooded paddy soil

We studied the characteristic gram-stain of Tc insolubilizing bacteria using various antibiotics, and the fate of insoluble Tc in a water column above flooded paddy soil to clarify Tc behavior in paddy fields. The formation of insoluble Tc in water column samples was inhibited by the addition of antibiotics, especially reagents against gram-negative bacteria. For a sample without antibiotics, insoluble Tc formation increased with time, and the maximum amount of insoluble Tc was observed on day 4 of incubation with (95m)Tc. In contrast, concentrations of ferrous ion decreased with time. These results suggested that gram-negative bacteria were mainly responsible for insoluble Tc formation, and that these bacteria were able to transform soluble Tc to insoluble forms under oxidizing conditions.

Synthesis and biological activity of novel antibacterial quinazolines

Novel quinazolines, having interesting antibacterial activity have been prepared, characterized and tested against a panel of susceptible and resistant Gram positive and Gram negative organisms.

Impact of tazobactam pharmacokinetics on the antimicrobial effect of piperacillin–tazobactam combinations

Pharmacokinetic-pharmacodynamic (PK-PD) modelling was used to study the impact of the pharmacokinetics of tazobactam on the antimicrobial effect of piperacillin-tazobactam combinations. An in vitro experiment using a novel dilution system was performed to compare the effects of two conditions of the combination therapy against Escherichia coli ATCC35218, a beta-lactamase producing bacterium. Both conditions simulated the same initial concentrations of piperacillin and tazobactam, but different elimination half-lives for tazobactam. The killing and regrowth kinetics of E. coli clearly indicated that there is a difference in the antimicrobial effects when there is a difference in the pharmacokinetics of tazobactam in the combination therapy. The results show that for equal piperacillin exposure, different tazobactam half-lives will have a significant effect on antimicrobial outcome.

Antibiotics and breast-feeding: a critical review of the literature

Continuous breast-feeding, an integral component of the postpartum period, is often threatened upon maternal initiation of antibiotics. The real risk of antibiotic use while breast-feeding must be carefully analysed with regard to all the variables that influence the extent of antibiotic distribution into breast milk, including breast milk composition, physicochemical properties of the antibiotic (molecular weight, lipid solubility, pH, protein binding), length of feeding, and maternal disposition. In addition, infant disposition, including ability to absorb, metabolize, eliminate, and tolerate any amounts of antibiotic, must also be considered prior to maternal administration of antibiotic. The milk to plasma (M/P) ratio is a frequently quoted parameter used to predict drug distribution into breast milk. However, its utility is questionable and often fraught with misinterpretation. An alternative approach when the amount of antibiotic concentration in breast milk is known (through clinical trials) is to calculate an estimated or expected infant drug exposure factoring in known/expected milk consumption, drug concentration and bioavailability. In this review, the following antibiotic classes and current literature regarding their distribution into breast milk are critically reviewed: beta-lactam antibiotics, fluoroquinolones, sulfonamides, macrolides, aminoglycosides, tetracyclines, nitrofurantoin, metronidazole, vancomycin, clindamycin and chloramphenicol. In the majority of instances, these antibiotics do not distribute into breast milk in sufficient concentrations to be of any clinical consequence in the breast-feeding infant.

Commonly used antibacterial and antifungal agents for hospitalised paediatric patients: implications for therapy with an emphasis on clinical pharmacokinetics

Due to normal growth and development, hospitalised paediatric patients with infection require unique consideration of immune function and drug disposition. Specifically, antibacterial and antifungal pharmacokinetics are influenced by volume of distribution, drug binding and elimination, which are a reflection of changing extracellular fluid volume, quantity and quality of plasma proteins, and renal and hepatic function. However, there is a paucity of data in paediatric patients addressing these issues and many empiric treatment practices are based on adult data. The penicillins and cephalosporins continue to be a mainstay of therapy because of their broad spectrum of activity, clinical efficacy and favourable tolerability profile. These antibacterials rapidly reach peak serum concentrations and readily diffuse into body tissues. Good penetration into the cerebrospinal fluid (CSF) has made the third-generation cephalosporins the agents of choice for the treatment of bacterial meningitis. These drugs are excreted primarily by the kidney. The carbapenems are broad-spectrum beta-lactam antibacterials which can potentially replace combination regimens. Vancomycin is a glycopeptide antibacterial with gram-positive activity useful for the treatment of resistant infections, or for those patients allergic to penicillins and cephalosporins. Volume of distribution is affected by age, gender, and bodyweight. It diffuses well across serous membranes and inflamed meninges. Vancomycin is excreted by the kidneys and is not removed by dialysis. The aminoglycosides continue to serve a useful role in the treatment of gram-negative, enterococcal and mycobacterial infections. Their volume of distribution approximates extracellular space. These drugs are also excreted renally and are removed by haemodialysis. Passage across the blood-brain barrier is poor, even in the face of meningeal inflammation. Low pH found in abscess conditions impairs function. Toxicity needs to be considered. Macrolide antibacterials are frequently used in the treatment of respiratory infections. Parenteral erythromycin can cause phlebitis, which limits its use. Parenteral azithromycin is better tolerated but paediatric pharmacokinetic data are lacking. Clindamycin is frequently used when anaerobic infections are suspected. Good oral absorption makes it a good choice for step-down therapy in intra-abdominal and skeletal infections. The use of quinolones in paediatrics has been restricted and most information available is in cystic fibrosis patients. High oral bioavailability is also important for step-down therapy. Amphotericin B has been the cornerstone of antifungal treatment in hospitalised patients. Its metabolism is poorly understood. The half-life increases with time and can be as long as 15 days after prolonged therapy. Oral absorption is poor. The azole antifungals are being used increasingly. Fluconazole is well tolerated, with high bioavailability and good penetration into the CSF. Itraconazole has greater activity against aspergillus, blastomycosis, histoplasmosis and sporotrichosis, although it's pharmacological and toxicity profiles are not as favourable.

Treatment of gram-positive infections: past, present, and future

The need for strategic planning for antimicrobial use has reached a critical point. The rise in resistant nosocomial and community gram-positive bacteria mandates appropriate antibiotic selection and dosing. The development of new compounds is not the answer, because many are based off existing structures to which bacteria have already developed resistance. New antimicrobial agents are falling to the resistant mechanisms developed by the bacteria, after only limited clinical exposure. Judicious use of antimicrobial agents and applying pharmacokinetic principles when dosing can help slow the rate of resistance.

Development and validation of limited-sampling strategies for predicting amoxicillin pharmacokinetic and pharmacodynamic parameters

Amoxicillin plasma concentrations (n = 1,152) obtained from 48 healthy subjects in two bioequivalence studies were used to develop limited-sampling strategy (LSS) models for estimating the area under the concentration-time curve (AUC), the maximum concentration of drug in plasma (C(max)), and the time interval of concentration above MIC susceptibility breakpoints in plasma (T>MIC). Each subject received 500-mg amoxicillin, as reference and test capsules or suspensions, and plasma concentrations were measured by a validated microbiological assay. Linear regression analysis and a "jack-knife" procedure revealed that three-point LSS models accurately estimated (R(2), 0.92; precision, <5.8%) the AUC from 0 h to infinity (AUC(0-infinity)) of amoxicillin for the four formulations tested. Validation tests indicated that a three-point LSS model (1, 2, and 5 h) developed for the reference capsule formulation predicts the following accurately (R(2), 0.94 to 0.99): (i) the individual AUC(0-infinity) for the test capsule formulation in the same subjects, (ii) the individual AUC(0-infinity) for both reference and test suspensions in 24 other subjects, and (iii) the average AUC(0-infinity) following single oral doses (250 to 1,000 mg) of various amoxicillin formulations in 11 previously published studies. A linear regression equation was derived, using the same sampling time points of the LSS model for the AUC(0-infinity), but using different coefficients and intercept, for estimating C(max). Bioequivalence assessments based on LSS-derived AUC(0-infinity)'s and C(max)'s provided results similar to those obtained using the original values for these parameters. Finally, two-point LSS models (R(2) = 0.86 to 0.95) were developed for T>MICs of 0.25 or 2.0 microg/ml, which are representative of microorganisms susceptible and resistant to amoxicillin.

Role of sultamicillin and ampicillin/sulbactam in the treatment of upper and lower bacterial respiratory tract infections

The emergence of beta-lactamase-mediated resistance to beta-lactam antibiotics among key respiratory tract pathogens has threatened the usefulness of the beta-lactam agents familiar to physicians as being clinically effective and well tolerated. This article reassesses the clinical usefulness of ampicillin when administered in combination with the beta-lactamase inhibitor sulbactam, either intravenously or orally (as the mutual prodrug sultamicillin), in the treatment of upper and lower respiratory tract infections. Numerous clinical studies and several meta-analyses indicate that ampicillin/sulbactam and sultamicillin are clinically effective and well tolerated in both adults and children, in agreement with published North American and European guidelines.