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Lupia T, De Benedetto I, Stroffolini G, Di Bella S, Mornese Pinna S, Zerbato V, Rizzello B, Bosio R, Shbaklo N, Corcione S, De Rosa FG. Temocillin: Applications in Antimicrobial Stewardship as a Potential Carbapenem-Sparing Antibiotic. Antibiotics (Basel) 2022; 11:antibiotics11040493. [PMID: 35453244 PMCID: PMC9032032 DOI: 10.3390/antibiotics11040493] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/29/2022] [Accepted: 03/29/2022] [Indexed: 01/25/2023] Open
Abstract
Temocillin is an old antibiotic, but given its particular characteristics, it may be a suitable alternative to carbapenems for treating infections due to ESBL-producing Enterobacterales and uncomplicated UTI due to KPC-producers. In this narrative review, the main research question was to summarize current evidence on temocillin and its uses in infectious diseases. A search was run on PubMed using the terms (‘Temocillin’ [Mesh]) AND (‘Infection’ [Mesh]). Current knowledge regarding temocillin in urinary tract infection, blood-stream infections, pneumonia, intra-abdominal infections, central nervous system infections, skin and soft tissues infections, surgical sites infections and osteoarticular Infections were summarized. Temocillin retain a favourable profile on microbiota and risk of Clostridioides difficile infections and could be an option for treating outpatients. Temocillin may be a valuable tool to treat susceptible pathogens and for which a carbapenem could be spared. Other advantages in temocillin use are that it is well-tolerated; it is associated with a low rate of C. difficile infections; it is active against ESBL, AmpC, and KPC-producing Enterobacterales; and it can be used in the OPAT clinical setting.
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Affiliation(s)
- Tommaso Lupia
- Unit of Infectious Diseases, Cardinal Massaia, 14100 Asti, Italy;
- Correspondence:
| | - Ilaria De Benedetto
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10126 Turin, Italy; (I.D.B.); (G.S.); (S.M.P.); (B.R.); (R.B.); (N.S.); (S.C.)
| | - Giacomo Stroffolini
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10126 Turin, Italy; (I.D.B.); (G.S.); (S.M.P.); (B.R.); (R.B.); (N.S.); (S.C.)
| | - Stefano Di Bella
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy;
| | - Simone Mornese Pinna
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10126 Turin, Italy; (I.D.B.); (G.S.); (S.M.P.); (B.R.); (R.B.); (N.S.); (S.C.)
| | - Verena Zerbato
- Infectious Diseases Unit, Trieste University Hospital (ASUGI), 34125 Trieste, Italy;
| | - Barbara Rizzello
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10126 Turin, Italy; (I.D.B.); (G.S.); (S.M.P.); (B.R.); (R.B.); (N.S.); (S.C.)
| | - Roberta Bosio
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10126 Turin, Italy; (I.D.B.); (G.S.); (S.M.P.); (B.R.); (R.B.); (N.S.); (S.C.)
| | - Nour Shbaklo
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10126 Turin, Italy; (I.D.B.); (G.S.); (S.M.P.); (B.R.); (R.B.); (N.S.); (S.C.)
| | - Silvia Corcione
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10126 Turin, Italy; (I.D.B.); (G.S.); (S.M.P.); (B.R.); (R.B.); (N.S.); (S.C.)
- School of Medicine, Tufts University, Boston, MA 02111, USA
| | - Francesco Giuseppe De Rosa
- Unit of Infectious Diseases, Cardinal Massaia, 14100 Asti, Italy;
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10126 Turin, Italy; (I.D.B.); (G.S.); (S.M.P.); (B.R.); (R.B.); (N.S.); (S.C.)
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Miranda Bastos AC, Vandecasteele SJ, Spinewine A, Tulkens PM, Van Bambeke F. Temocillin dosing in haemodialysis patients based on population pharmacokinetics of total and unbound concentrations and Monte Carlo simulations. J Antimicrob Chemother 2019; 73:1630-1638. [PMID: 29579214 DOI: 10.1093/jac/dky078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 02/11/2018] [Indexed: 11/14/2022] Open
Abstract
Objectives To develop a population model describing temocillin pharmacokinetics (PK) in patients undergoing haemodialysis and investigate how pharmacokinetic/pharmacodynamic (PD) targets can be met with different dosage regimens. Patients and methods Sixteen patients received the currently licenced dosing of 1, 2 or 3 g of temocillin (total of 61 doses) corresponding to an inter-dialytic period of 20, 44 or 68 h, respectively, and a dialysis period of 4 h. A non-linear mixed-effects model was developed jointly for total and unbound temocillin serum concentrations. The performance of clinically feasible dosing regimens was evaluated using a 5000-subject Monte Carlo (MC) simulation for determining the highest MIC for which the PK/PD target of 40%ƒT>MIC would be reached in 90% of patients [probability of target attainment (PTA)]. This PK study was registered at ClinicalTrials.gov (NCT02285075). Results Temocillin unbound and total serum concentrations (429 samples) were used to fit an open two-compartment model with non-linear albumin binding and first-order elimination. In addition to total body clearance, dialysis clearance was modelled using the Michaels function. The currently licenced dosing achieved a 90% PTA for an MIC up to 8 mg/L. A new temocillin dosage regimen was designed that would achieve a 90% PTA for an MIC of 16 mg/L (MIC90 of target organisms) adjusted to patient weight and inter-dialytic period. Conclusions Currently licensed dosage regimen is suboptimal for MICs >8 mg/L (frequently found in clinical isolates). Model-based simulations allowed suggestion of a new dosage regimen with improved probability of microbiological success, applicability in routine clinical practice and more appropriate for empirical therapy.
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Affiliation(s)
- Ana C Miranda Bastos
- Pharmacologie cellulaire et moléculaire, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium.,Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
| | - Stefaan J Vandecasteele
- Department of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium
| | - Anne Spinewine
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
| | - Paul M Tulkens
- Pharmacologie cellulaire et moléculaire, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
| | - Françoise Van Bambeke
- Pharmacologie cellulaire et moléculaire, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
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Abstract
Temocillin, a 6-α-methoxy derivative of ticarcillin, is a forgotten antibiotic that has recently been rediscovered, and issues about clinical breakpoints and optimal therapeutic regimens are still ongoing. Temocillin spectrum is almost restricted to Enterobacteriaceae. The addition of the α-methoxy moiety on ticarcillin confers resistance to hydrolysis by Ambler classes A and C β-lactamases (extended spectrum β-lactamases, Klebsiella pneumoniae carbapenemase and AmpC hyperproduced enzymes). Temocillin is bactericidal, and the effect of inoculum size on its activity is relatively mild. The proportion of spontaneous resistant mutants in vitro to temocillin is low, as found in vivo. After intravenous infusion, temocillin showed a prolonged elimination half-life of approximately 5 h. The percentage of protein binding of temocillin is high (approximately 80%), and is concentration-dependent. Temocillin clearance is mainly renal, and urinary recovery is high, ranging from 72 to 82% after 24 h. Furthermore, the penetration of temocillin into bile and peritoneal fluid is high, but poor into cerebrospinal fluid. The cumulative percentage of a 24-h period during which the free drug concentration exceeds the minimum inhibitory concentration (fT > MIC) at steady-state pharmacokinetic conditions seems to be the best pharmacokinetic/pharmacodynamic (PK/PD) index correlating with temocillin efficacy. An fT > MIC of 40-50% is associated with antibacterial effect and survival in vivo. Monte Carlo simulations performed in critically ill patients showed that the 2 g every 12 h and 2 g every 8 h regimens provide a 95% probability of target attainment of 40% fT > MIC up to an MIC of 8 mg/L. In less severely ill patients or in specific foci of infection, such as urinary tract infection, a 4 g daily regimen should be adequate for strains with temocillin MIC up to 16 mg/L. Data regarding actual wild-type MIC distribution, clinical efficacy, PK profiling in volunteers or patients, and PD targets are scarce, and further studies are required to support appropriate dosing recommendations and determination of clinical breakpoints.
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Affiliation(s)
- Kevin Alexandre
- Infectious Diseases Department, Rouen University Hospital, GRAM (EA2656), Rouen, France
| | - Bruno Fantin
- Univ. Paris Diderot, IAME, UMR 1137, Sorbonne Paris Cité, 75018, Paris, France.
- Service de Médecine Interne, Hôpital Beaujon, AP-HP, 100 boulevard du Général Leclerc, 92110, Clichy, France.
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Resurrecting Old β-Lactams: Potent Inhibitory Activity of Temocillin against Multidrug-Resistant Burkholderia Species Isolates from the United States. Antimicrob Agents Chemother 2019; 63:AAC.02315-18. [PMID: 30718248 DOI: 10.1128/aac.02315-18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 01/26/2019] [Indexed: 12/17/2022] Open
Abstract
Burkholderia spp. are opportunistic human pathogens that infect persons with cystic fibrosis and the immunocompromised. Burkholderia spp. express class A and C β-lactamases, which are transcriptionally regulated by PenRA through linkage to cell wall metabolism and β-lactam exposure. The potency of temocillin, a 6-methoxy-β-lactam, was tested against a panel of multidrug-resistant (MDR) Burkholderia spp. In addition, the mechanistic basis of temocillin activity was assessed and compared to that of ticarcillin. Susceptibility testing with temocillin and ticarcillin was conducted, as was biochemical analysis of the PenA1 class A β-lactamase and AmpC1 class C β-lactamase. Molecular dynamics simulations (MDS) were performed using PenA1 with temocillin and ticarcillin. The majority (86.7%) of 150 MDR Burkholderia strains were susceptible to temocillin, while only 4% of the strains were susceptible to ticarcillin. Neither temocillin nor ticarcillin induced bla expression. Ticarcillin was hydrolyzed by PenA1 (k cat/Km = 1.7 ± 0.2 μM-1 s-1), while temocillin was slow to form a favorable complex (apparent Ki [Ki app] = ∼2 mM). Ticarcillin and temocillin were both potent inhibitors of AmpC1, with Ki app values of 4.9 ± 1.0 μM and 4.3 ± 0.4 μM, respectively. MDS of PenA revealed that ticarcillin is in an advantageous position for acylation and deacylation. Conversely, with temocillin, active-site residues K73 and S130 are rotated and the catalytic water molecule is displaced, thereby slowing acylation and allowing the 6-methoxy of temocillin to block deacylation. Temocillin is a β-lactam with potent activity against Burkholderia spp., as it does not induce bla expression and is poorly hydrolyzed by endogenous β-lactamases.
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