1
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Hoover RK, Krsak M, Molina KC, Shah K, Redell M. Kimyrsa, An Oritavancin-Containing Product: Clinical Study and Review of Properties. Open Forum Infect Dis 2022; 9:ofac090. [PMID: 35392455 PMCID: PMC8982769 DOI: 10.1093/ofid/ofac090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/25/2022] [Indexed: 11/25/2022] Open
Abstract
Background There is a need for improved antibiotic formulations for the treatment of acute bacterial skin and soft structure infection (ABSSSI), especially with the rise of antimicrobial resistance among Gram-positive bacteria. A new formulation of oritavancin was developed to reduce intravenous infusion volume (from 1000 mL to 250 mL), shorten infusion time (from 3 hours to 1 hour), and provide pharmacies with flexibility in oritavancin preparation (from 5% dextrose in sterile water to either normal saline or 5% dextrose in sterile water) compared with the current formulation. Methods A total of 102 adult patients with a diagnosis of ABSSSI suspected or confirmed to be caused by a Gram-positive pathogen were randomized 1:1 to receive either the new formulation of oritavancin or the current formulation. After a single 1200-mg intravenous infusion of oritavancin, the relative area-under-the-curve exposure of the new formulation and current formulation groups were compared. Safety and tolerability of the new formulation were assessed for treatment-emergent adverse events, serious adverse events, and changes to laboratory parameters. Results The area under the curve for 0 hour to 72 hours postdose was very similar in the new formulation group compared with the current formulation group. No differences in treatment-emergent adverse events were observed between the current and new formulation groups, and all treatment-emergent adverse events were consistent with the known safety profile of the current formulation. Conclusions The new formulation of oritavancin with reduced volume and duration of intravenous infusion demonstrates a safety profile and pharmacokinetics similar to that of the original formulation.
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Affiliation(s)
| | - Martin Krsak
- Assistant Professor of Medicine, University of Colorado School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kyle C Molina
- University of Colorado Hospital, Assistant Clinical Professor, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Kairav Shah
- Metro Infectious Disease Consultants, Stockbridge, GA, USA
| | - Mark Redell
- Medical Affairs, Melinta Therapeutics, Morristown, NJ, USA
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2
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Effects of L. plantarum HY7715 on the Gut Microbial Community and Riboflavin Production in a Three-Stage Semi-Continuous Simulated Gut System. Microorganisms 2021; 9:microorganisms9122478. [PMID: 34946080 PMCID: PMC8704370 DOI: 10.3390/microorganisms9122478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/23/2021] [Accepted: 11/26/2021] [Indexed: 12/26/2022] Open
Abstract
Probiotics should be well established in the gut, passing through the digestive tract with a high degree of viability, and produce metabolites that improve the gut environment by interacting with the gut microbiome. Our previous study revealed that the Lactiplantibacillus plantarum HY7715 strain shows good bile acid resistance and a riboflavin production capacity. To confirm the interaction between HY7715 and gut microbiome, we performed a metabolite and microbiome study using a simulated gut system (SGS) that mimics the intestinal environment. Changes in the microbiome were confirmed and compared with L. plantarum NCDO1752 as the control. After 14 days, the HY7715 treatment group showed a relatively high butyrate content compared to the control group, which showed increased acetate and propionate concentrations. Moreover, the riboflavin content was higher in the HY7715 treatment group, whereas the NCDO1752 treatment group produced only small amounts of riboflavin during the treatment period and showed a tendency to decrease during the washout stage; however, the HY7715 group produced riboflavin continuously in the ascending colon during the washout period. A correlation analysis of the genus that increased as the content of riboflavin increased revealed butyrate-producing microorganisms, such as Blautia and Flavonifractor. In conclusion, treatment with L. plantarum HY7715 induced the production and maintenance of riboflavin and the enrichment of the intestinal microbiome
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Roberts AK, Harris HC, Smith M, Giles J, Polak O, Buckley AM, Clark E, Ewin D, Moura IB, Spitall W, Shone CC, Wilcox M, Chilton C, Donev R. A Novel, Orally Delivered Antibody Therapy and Its Potential to Prevent Clostridioides difficile Infection in Pre-clinical Models. Front Microbiol 2020; 11:578903. [PMID: 33072047 PMCID: PMC7537341 DOI: 10.3389/fmicb.2020.578903] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/31/2020] [Indexed: 12/12/2022] Open
Abstract
Clostridioides difficile infection (CDI) is a toxin-mediated infection in the gut and a major burden on healthcare facilities worldwide. We rationalized that it would be beneficial to design an antibody therapy that is delivered to, and is active at the site of toxin production, rather than neutralizing the circulating and luminal toxins after significant damage of the layers of the intestines has occurred. Here we describe a highly potent therapeutic, OraCAb, with high antibody titers and a formulation that protects the antibodies from digestion/inactivation in the gastrointestinal tract. The potential of OraCAb to prevent CDI in an in vivo hamster model and an in vitro human colon model was assessed. In the hamster model we optimized the ratio of the antibodies against each of the toxins produced by C. difficile (Toxins A and B). The concentration of immunoglobulins that is effective in a hamster model of CDI was determined. A highly significant difference in animal survival for those given an optimized OraCAb formulation versus an untreated control group was observed. This is the first study testing the effect of oral antibodies for treatment of CDI in an in vitro gut model seeded with a human fecal inoculum. Treatment with OraCAb successfully neutralized toxin production and did not interfere with the colonic microbiota in this model. Also, treatment with a combination of vancomycin and OraCAb prevented simulated CDI recurrence, unlike vancomycin therapy alone. These data demonstrate the efficacy of OraCAb formulation for the treatment of CDI in pre-clinical models.
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Affiliation(s)
- April K Roberts
- Toxins Group, National Infection Service, Public Health England, Porton Down, United Kingdom
| | - Hannah C Harris
- Leeds Institute of Medical Research, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
| | - Michael Smith
- Toxins Group, National Infection Service, Public Health England, Porton Down, United Kingdom
| | - Joanna Giles
- MicroPharm Ltd., Newcastle Emlyn, United Kingdom
| | | | - Anthony M Buckley
- Leeds Institute of Medical Research, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
| | - Emma Clark
- Leeds Institute of Medical Research, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
| | - Duncan Ewin
- Leeds Institute of Medical Research, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
| | - Ines B Moura
- Leeds Institute of Medical Research, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
| | - William Spitall
- Leeds Institute of Medical Research, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
| | - Clifford C Shone
- Toxins Group, National Infection Service, Public Health England, Porton Down, United Kingdom
| | - Mark Wilcox
- Leeds Institute of Medical Research, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom.,Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds, United Kingdom
| | - Caroline Chilton
- Leeds Institute of Medical Research, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
| | - Rossen Donev
- MicroPharm Ltd., Newcastle Emlyn, United Kingdom
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4
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Moura IB, Normington C, Ewin D, Clark E, Wilcox MH, Buckley AM, Chilton CH. Method comparison for the direct enumeration of bacterial species using a chemostat model of the human colon. BMC Microbiol 2020; 20:2. [PMID: 31898476 PMCID: PMC6941270 DOI: 10.1186/s12866-019-1669-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 12/01/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Clostridioides difficile infection (CDI) has a high recurrent infection rate. Faecal microbiota transplantation (FMT) has been used successfully to treat recurrent CDI, but much remains unknown about the human gut microbiota response to replacement therapies. In this study, antibiotic-mediated dysbiosis of gut microbiota and bacterial growth dynamics were investigated by two quantitative methods: real-time quantitative PCR (qPCR) and direct culture enumeration, in triple-stage chemostat models of the human colon. Three in vitro models were exposed to clindamycin to induce simulated CDI. All models were treated with vancomycin, and two received an FMT. Populations of total bacteria, Bacteroides spp., Lactobacillus spp., Enterococcus spp., Bifidobacterium spp., C. difficile, and Enterobacteriaceae were monitored using both methods. Total clostridia were monitored by selective culture. Using qPCR analysis, we additionally monitored populations of Prevotella spp., Clostridium coccoides group, and Clostridium leptum group. RESULTS Both methods showed an exacerbation of disruption of the colonic microbiota following vancomycin (and earlier clindamycin) exposure, and a quicker recovery (within 4 days) of the bacterial populations in the models that received the FMT. C. difficile proliferation, consistent with CDI, was also observed by both qPCR and culture. Pearson correlation coefficient showed an association between results varying from 98% for Bacteroides spp., to 62% for Enterobacteriaceae. CONCLUSIONS Generally, a good correlation was observed between qPCR and bacterial culture. Overall, the molecular assays offer results in real-time, important for treatment efficacy, and allow the monitoring of additional microbiota groups. However, individual quantification of some genera (e.g. clostridia) might not be possible without selective culture.
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Affiliation(s)
- Ines B Moura
- Leeds Institute of Medical Research, Faculty of Medicine and Health, University of Leeds, Leeds, UK.
| | - Charmaine Normington
- Leeds Institute of Medical Research, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Duncan Ewin
- Leeds Institute of Medical Research, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Emma Clark
- Leeds Institute of Medical Research, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Mark H Wilcox
- Leeds Institute of Medical Research, Faculty of Medicine and Health, University of Leeds, Leeds, UK.,Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Anthony M Buckley
- Leeds Institute of Medical Research, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Caroline H Chilton
- Leeds Institute of Medical Research, Faculty of Medicine and Health, University of Leeds, Leeds, UK
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5
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Gil F, Calderón IL, Fuentes JA, Paredes-Sabja D. Clostridioides (Clostridium) difficile infection: current and alternative therapeutic strategies. Future Microbiol 2018; 13:469-482. [PMID: 29464969 DOI: 10.2217/fmb-2017-0203] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Clostridioides difficile (C. difficile) has become a pathogen of worldwide importance considering that epidemic strains are disseminated in hospitals of several countries, where community-acquired infections act as a constant source of new C. difficile strains into hospitals. Despite the advances in the treatment of infections, more effective therapies against C. difficile are needed but, at the same time, these therapies should be less harmful to the resident gastrointestinal microbiota. The purpose of this review is to present a description of issues associated to C. difficile infection, a summary of current therapies and those in developmental stage, and a discussion of potential combinations that may lead to an increased efficacy of C. difficile infection treatment.
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Affiliation(s)
- Fernando Gil
- Microbiota-Host Interactions & Clostridia Research Group, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andres Bello, Santiago, 8370035, Chile
| | - Iván L Calderón
- Laboratorio de Genética y Patogénesis Bacteriana, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andres Bello, Santiago, 8370035, Chile
| | - Juan A Fuentes
- Laboratorio de Genética y Patogénesis Bacteriana, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andres Bello, Santiago, 8370035, Chile
| | - Daniel Paredes-Sabja
- Microbiota-Host Interactions & Clostridia Research Group, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andres Bello, Santiago, 8370035, Chile
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6
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Fehér C, Soriano A, Mensa J. A Review of Experimental and Off-Label Therapies for Clostridium difficile Infection. Infect Dis Ther 2017; 6:1-35. [PMID: 27910000 PMCID: PMC5336415 DOI: 10.1007/s40121-016-0140-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Indexed: 12/16/2022] Open
Abstract
In spite of increased awareness and the efforts taken to optimize Clostridium difficile infection (CDI) management, with the limited number of currently available antibiotics for C. difficile the halt of this increasing epidemic remains out of reach. There are, however, close to 80 alternative treatment methods with controversial anti-clostridial efficacy or in experimental phase today. Indeed, some of these therapies are expected to become acknowledged members of the recommended anti-CDI arsenal within the next few years. None of these alternative treatment methods can respond in itself to all the major challenges of CDI management, which are primary prophylaxis in the susceptible population, clinical cure of severe cases, prevention of recurrences, and forestallment of asymptomatic C. difficile carriage and in-hospital spread. Yet, the greater the variety of treatment choices on hand, the better combination strategies can be developed to reach these goals in the future. The aim of this article is to provide a comprehensive summary of these experimental and currently off-label therapeutic options.
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Affiliation(s)
- Csaba Fehér
- Department of Infectious Diseases, Hospital Clínic of Barcelona, Barcelona, Spain.
| | - Alex Soriano
- Department of Infectious Diseases, Hospital Clínic of Barcelona, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
| | - Josep Mensa
- Department of Infectious Diseases, Hospital Clínic of Barcelona, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
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7
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Chilton CH, Crowther GS, Ashwin H, Longshaw CM, Wilcox MH. Association of Fidaxomicin with C. difficile Spores: Effects of Persistence on Subsequent Spore Recovery, Outgrowth and Toxin Production. PLoS One 2016; 11:e0161200. [PMID: 27556739 PMCID: PMC4996525 DOI: 10.1371/journal.pone.0161200] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 08/01/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND We have previously shown that fidaxomicin instillation prevents spore recovery in an in-vitro gut model, whereas vancomycin does not. The reasons for this are unclear. Here, we have investigated persistence of fidaxomicin and vancomycin on C. difficile spores, and examined post-antibiotic exposure spore recovery, outgrowth and toxin production. METHODS Prevalent UK C. difficile ribotypes (n = 10) were incubated with 200mg/L fidaxomicin, vancomycin or a non-antimicrobial containing control for 1 h in faecal filtrate or Phosphate Buffered Saline. Spores were washed three times with faecal filtrate or phosphate buffered saline, and residual spore-associated antimicrobial activity was determined by bioassay. For three ribotypes (027, 078, 015), antimicrobial-exposed, faecal filtrate-washed spores and controls were inoculated into broth. Viable vegetative and spore counts were enumerated on CCEYL agar. Percentage phase bright spores, phase dark spores and vegetative cells were enumerated by phase contrast microscopy at 0, 3, 6, 24 and 48 h post-inoculation. Toxin levels (24 and 48h) were determined by cell cytotoxicity assay. RESULTS Fidaxomicin, but not vancomycin persisted on spores of all ribotypes following washing in saline (mean = 10.1mg/L; range = 4.0-14mg/L) and faecal filtrate (mean = 17.4mg/L; 8.4-22.1mg/L). Outgrowth and proliferation rates of vancomycin-exposed spores were similar to controls, whereas fidaxomicin-exposed spores showed no vegetative cell growth after 24 and 48 h. At 48h, toxin levels averaged 3.7 and 3.3 relative units (RU) in control and vancomycin-exposed samples, respectively, but were undetectable in fidaxomicin-exposed samples. CONCLUSION Fidaxomicin persists on C. difficile spores, whereas vancomycin does not. This persistence prevents subsequent growth and toxin production in vitro. This may have implications on spore viability, thereby impacting CDI recurrence and transmission rates.
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Affiliation(s)
- Caroline H. Chilton
- Leeds Institute for Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom
- * E-mail:
| | - Grace S. Crowther
- Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, United Kingdom
| | - Helen Ashwin
- Leeds Institute for Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom
| | | | - Mark H. Wilcox
- Leeds Institute for Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, The General Infirmary, Old Medical School, Leeds, United Kingdom
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8
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Shah NJ. Reversing resistance: The next generation antibacterials. Indian J Pharmacol 2016; 47:248-55. [PMID: 26069360 PMCID: PMC4450548 DOI: 10.4103/0253-7613.157109] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 05/19/2014] [Accepted: 04/12/2015] [Indexed: 12/11/2022] Open
Abstract
Irrational antibiotic usage has led to vast spread resistance to available antibiotics, but we refuse to slide back to “preantibiotic era.” The threat is serious with the “Enterococcus, Staphylococcous, Klebsiella, Acinetobacter, Pseudomonas and Enterobacter” organisms causing nosocomial infections that are difficult to treat because of the production of extended spectrum β-lactamases, carbapenamases and metallo-β-lactamases. Facing us is a situation where soon multidrug resistance would have spread across the globe with no antibiotics to withstand it. The infectious disease society of America and Food and Drug Administration have taken initiatives like the 10 × ‘20 where they plan to develop 10 new antibiotics by the year 2020. Existing classes of antibiotics against resistant bacteria include the carbapenems, oxazolidinones, glycopeptides, monobactams, streptogramins and daptomycin. Newer drugs in existing classes of antibiotics such as cephalosporins, aminoglycosides, tetracyclines, glycopeptides and β-lactamase inhibitors continue to get synthesized. The situation demands newer targets against bacterial machinery. Some of them include the peptidoglycantransferase, outer membrane protein of Pseudomonas, tRNA synthase, fatty acid synthase and mycobacterial ATP synthase. To curb the irrational and excessive usage of presently available antibiotics should be a priority if they are still to be kept in usage for the future.
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Affiliation(s)
- Neel Jayesh Shah
- Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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9
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Crowther GS, Chilton CH, Longshaw C, Todhunter SL, Ewin D, Vernon J, Karas A, Wilcox MH. Efficacy of vancomycin extended-dosing regimens for treatment of simulatedClostridium difficileinfection within anin vitrohuman gut model. J Antimicrob Chemother 2016; 71:986-91. [DOI: 10.1093/jac/dkv453] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 11/25/2015] [Indexed: 01/04/2023] Open
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10
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Van Bambeke F. Lipoglycopeptide Antibacterial Agents in Gram-Positive Infections: A Comparative Review. Drugs 2015; 75:2073-95. [DOI: 10.1007/s40265-015-0505-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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11
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Jarrad A, Karoli T, Blaskovich MAT, Lyras D, Cooper MA. Clostridium difficile drug pipeline: challenges in discovery and development of new agents. J Med Chem 2015; 58:5164-85. [PMID: 25760275 PMCID: PMC4500462 DOI: 10.1021/jm5016846] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Indexed: 12/17/2022]
Abstract
In the past decade Clostridium difficile has become a bacterial pathogen of global significance. Epidemic strains have spread throughout hospitals, while community acquired infections and other sources ensure a constant inoculation of spores into hospitals. In response to the increasing medical burden, a new C. difficile antibiotic, fidaxomicin, was approved in 2011 for the treatment of C. difficile-associated diarrhea. Rudimentary fecal transplants are also being trialed as effective treatments. Despite these advances, therapies that are more effective against C. difficile spores and less damaging to the resident gastrointestinal microbiome and that reduce recurrent disease are still desperately needed. However, bringing a new treatment for C. difficile infection to market involves particular challenges. This review covers the current drug discovery pipeline, including both small molecule and biologic therapies, and highlights the challenges associated with in vitro and in vivo models of C. difficile infection for drug screening and lead optimization.
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Affiliation(s)
- Angie
M. Jarrad
- The
Institute for Molecular Bioscience, University
of Queensland, St. Lucia, Queensland 4072, Australia
| | - Tomislav Karoli
- The
Institute for Molecular Bioscience, University
of Queensland, St. Lucia, Queensland 4072, Australia
| | - Mark A. T. Blaskovich
- The
Institute for Molecular Bioscience, University
of Queensland, St. Lucia, Queensland 4072, Australia
| | - Dena Lyras
- School
of Biomedical Sciences, Monash University, Clayton, Victoria 3800, Australia
| | - Matthew A. Cooper
- The
Institute for Molecular Bioscience, University
of Queensland, St. Lucia, Queensland 4072, Australia
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Abstract
Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy & Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are sent in print and are also available on-line. Monographs can be customized to meet the needs of a facility. A drug class review is now published monthly with The Formulary Monograph Service. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service, call The Formulary at 800-322-4349. The December 2014 monograph topics are olodaterol, peginterferon beta-1a, testosterone nasal gel, ferric citrate corredination complex, and safinamide. The Safety MUE is on olodaterol.
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Affiliation(s)
- Dennis J Cada
- Founder and Contributing Editor, The Formulary , Washington State University , Spokane, Washington
| | - Danial E Baker
- Director, Drug Information Center, and Professor of Pharmacy Practice, College of Pharmacy , Washington State University Spokane, PO Box 1495, Spokane, Washington 99210-1495 . The authors indicate no relationships that could be perceived as a conflict of interest
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13
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Abstract
Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy & Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are sent in print and are also available on-line. Monographs can be customized to meet the needs of a facility. A drug class review is now published monthly with The Formulary Monograph Service. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service, call The Formulary at 800-322-4349. The December 2014 monograph topics are olodaterol, peginterferon beta-1a, testosterone nasal gel, ferric citrate corredination complex, and safinamide. The Safety MUE is on olodaterol.
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Affiliation(s)
- Dennis J Cada
- Founder and Contributing Editor, The Formulary , Washington State University , Spokane, Washington
| | - Danial E Baker
- Director, Drug Information Center, and Professor of Pharmacy Practice, College of Pharmacy , Washington State University Spokane, PO Box 1495, Spokane, Washington 99210-1495 . The authors indicate no relationships that could be perceived as a conflict of interest
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14
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Chilton CH, Crowther GS, Todhunter SL, Nicholson S, Freeman J, Chesnel L, Wilcox MH. Efficacy of surotomycin in an in vitro gut model of Clostridium difficile infection. J Antimicrob Chemother 2014; 69:2426-33. [PMID: 24816211 DOI: 10.1093/jac/dku141] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES We investigated the efficacy of the cyclic lipopeptide surotomycin in treating clindamycin-induced Clostridium difficile infection (CDI) using an in vitro gut model. METHODS Two three-stage chemostat gut models were inoculated with human faeces, spiked with C. difficile spores (∼10(7) cfu/mL, PCR ribotype 027 or 001). Clindamycin (33.9 mg/L, four times daily for 7 days) was dosed to induce CDI. Following high-level toxin production, surotomycin (250 mg/L, twice daily for 7 days) was instilled. Microflora populations, C. difficile vegetative cells and spores, cytotoxin titres and antimicrobial levels (LC-MS/MS and bioassay) were determined. The emergence of C. difficile and enterococci with reduced susceptibility to surotomycin was monitored on breakpoint agar (4 × MIC). RESULTS Counts of viable C. difficile were reduced to near the limit of detection on Days 1 and 3 of surotomycin instillation, and cytotoxin was undetectable on Days 3 and 4 of surotomycin instillation in the 027 and 001 models, respectively. Recurrence of vegetative growth and toxin production occurred 11 days (001 model) and 15 days (027 model) after surotomycin instillation had ceased, and remained for the duration of the experiment. Surotomycin instillation decreased populations of bifidobacteria, clostridia, enterococci and lactobacilli, but was sparing of Bacteroides fragilis group populations. All enumerated organisms had recovered to steady-state levels by 3 weeks post-surotomycin instillation. No evidence of the emergence of reduced susceptibility to surotomycin was observed. CONCLUSIONS Surotomycin successfully reduced C. difficile vegetative cell counts and toxin levels in the gut model and was sparing of B. fragilis group populations. There was no evidence of decreased susceptibility to surotomycin during exposure or post-exposure.
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Affiliation(s)
- C H Chilton
- Leeds Institute for Molecular Medicine, University of Leeds, Leeds, UK
| | - G S Crowther
- Leeds Institute for Molecular Medicine, University of Leeds, Leeds, UK
| | - S L Todhunter
- Leeds Institute for Molecular Medicine, University of Leeds, Leeds, UK
| | - S Nicholson
- Leeds Institute for Molecular Medicine, University of Leeds, Leeds, UK
| | - J Freeman
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, The General Infirmary, Old Medical School, Leeds, UK
| | - L Chesnel
- Cubist Pharmaceuticals, 65 Hayden Avenue, Lexington, MA 02421, USA
| | - M H Wilcox
- Leeds Institute for Molecular Medicine, University of Leeds, Leeds, UK Department of Microbiology, Leeds Teaching Hospitals NHS Trust, The General Infirmary, Old Medical School, Leeds, UK
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15
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Crowther GS, Chilton CH, Todhunter SL, Nicholson S, Freeman J, Baines SD, Wilcox MH. Comparison of planktonic and biofilm-associated communities of Clostridium difficile and indigenous gut microbiota in a triple-stage chemostat gut model. J Antimicrob Chemother 2014; 69:2137-47. [PMID: 24788662 DOI: 10.1093/jac/dku116] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Biofilms are characteristic of some chronic or recurrent infections and this mode of growth tends to reduce treatment efficacy. Clostridium difficile infection (CDI) is associated with a high rate of recurrent symptomatic disease. The presence and behaviour of C. difficile within intestinal biofilms remains largely unexplored, but may factor in recurrent infection. METHODS A triple-stage chemostat gut model designed to facilitate the formation of intestinal biofilm was inoculated with a pooled human faecal emulsion. Bacterial populations were allowed to equilibrate before simulated CDI was induced by clindamycin (33.9 mg/L, four times daily, 7 days) and subsequently treated with vancomycin (125 mg/L, four times daily, 7 days). Indigenous gut microbiota, C. difficile total viable counts, spores, cytotoxin and antimicrobial activity in planktonic and biofilm communities were monitored during the 10 week experimental period. RESULTS Vancomycin successfully treated the initial episode of simulated CDI, but ∼18 days after therapy cessation, recurrent infection occurred. Germination, proliferation and toxin production were evident within planktonic communities in both initial and recurrent CDI. In contrast, sessile C. difficile remained in dormant spore form for the duration of the experiment. The effects of and recovery from clindamycin and vancomycin exposure for sessile populations was delayed compared with responses for planktonic bacteria. CONCLUSIONS Intestinal biofilms provide a potential reservoir for C. difficile spore persistence, possibly facilitating their dispersal into the gut lumen after therapeutic intervention, leading to recurrent infection. Therapeutic options for CDI could have increased efficacy if they are more effective against sessile C. difficile.
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Affiliation(s)
- Grace S Crowther
- Leeds Institute of Biomedical and Clinical Sciences, Faculty of Medicine and Health, University of Leeds, Leeds LS2 9JT, UK
| | - Caroline H Chilton
- Leeds Institute of Biomedical and Clinical Sciences, Faculty of Medicine and Health, University of Leeds, Leeds LS2 9JT, UK
| | - Sharie L Todhunter
- Leeds Institute of Biomedical and Clinical Sciences, Faculty of Medicine and Health, University of Leeds, Leeds LS2 9JT, UK
| | - Scott Nicholson
- Leeds Institute of Biomedical and Clinical Sciences, Faculty of Medicine and Health, University of Leeds, Leeds LS2 9JT, UK
| | - Jane Freeman
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, The General Infirmary, Leeds LS1 3EX, UK
| | - Simon D Baines
- School of Life and Medical Sciences, Department of Human and Environmental Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK
| | - Mark H Wilcox
- Leeds Institute of Biomedical and Clinical Sciences, Faculty of Medicine and Health, University of Leeds, Leeds LS2 9JT, UK Department of Microbiology, Leeds Teaching Hospitals NHS Trust, The General Infirmary, Leeds LS1 3EX, UK
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Crowther GS, Chilton CH, Todhunter SL, Nicholson S, Freeman J, Baines SD, Wilcox MH. Development and validation of a chemostat gut model to study both planktonic and biofilm modes of growth of Clostridium difficile and human microbiota. PLoS One 2014; 9:e88396. [PMID: 24516647 PMCID: PMC3916432 DOI: 10.1371/journal.pone.0088396] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 01/05/2014] [Indexed: 12/18/2022] Open
Abstract
The human gastrointestinal tract harbours a complex microbial community which exist in planktonic and sessile form. The degree to which composition and function of faecal and mucosal microbiota differ remains unclear. We describe the development and characterisation of an in vitro human gut model, which can be used to facilitate the formation and longitudinal analysis of mature mixed species biofilms. This enables the investigation of the role of biofilms in Clostridium difficile infection (CDI). A well established and validated human gut model of simulated CDI was adapted to incorporate glass rods that create a solid-gaseous-liquid interface for biofilm formation. The continuous chemostat model was inoculated with a pooled human faecal emulsion and controlled to mimic colonic conditions in vivo. Planktonic and sessile bacterial populations were enumerated for up to 46 days. Biofilm consistently formed macroscopic structures on all glass rods over extended periods of time, providing a framework to sample and analyse biofilm structures independently. Whilst variation in biofilm biomass is evident between rods, populations of sessile bacterial groups (log10 cfu/g of biofilm) remain relatively consistent between rods at each sampling point. All bacterial groups enumerated within the planktonic communities were also present within biofilm structures. The planktonic mode of growth of C. difficile and gut microbiota closely reflected observations within the original gut model. However, distinct differences were observed in the behaviour of sessile and planktonic C. difficile populations, with C. difficile spores preferentially persisting within biofilm structures. The redesigned biofilm chemostat model has been validated for reproducible and consistent formation of mixed species intestinal biofilms. This model can be utilised for the analysis of sessile mixed species communities longitudinally, potentially providing information of the role of biofilms in CDI.
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Affiliation(s)
- Grace S. Crowther
- Leeds Institute of Biomedical and Clinical Sciences, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
| | - Caroline H. Chilton
- Leeds Institute of Biomedical and Clinical Sciences, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
| | - Sharie L. Todhunter
- Leeds Institute of Biomedical and Clinical Sciences, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
| | - Scott Nicholson
- School of Science, University of West Scotland, Hamilton, United Kingdom
| | - Jane Freeman
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Simon D. Baines
- School of Life and Medical Sciences, Department of Human and Environmental Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | - Mark H. Wilcox
- Leeds Institute of Biomedical and Clinical Sciences, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
- * E-mail:
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Tsutsumi LS, Owusu YB, Hurdle JG, Sun D. Progress in the discovery of treatments for C. difficile infection: A clinical and medicinal chemistry review. Curr Top Med Chem 2014; 14:152-75. [PMID: 24236721 PMCID: PMC3921470 DOI: 10.2174/1568026613666131113154753] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 09/06/2013] [Accepted: 09/15/2013] [Indexed: 02/07/2023]
Abstract
Clostridium difficile is an anaerobic, Gram-positive pathogen that causes C. difficile infection, which results in significant morbidity and mortality. The incidence of C. difficile infection in developed countries has become increasingly high due to the emergence of newer epidemic strains, a growing elderly population, extensive use of broad spectrum antibiotics, and limited therapies for this diarrheal disease. Because treatment options currently available for C. difficile infection have some drawbacks, including cost, promotion of resistance, and selectivity problems, new agents are urgently needed to address these challenges. This review article focuses on two parts: the first part summarizes current clinical treatment strategies and agents under clinical development for C. difficile infection; the second part reviews newly reported anti-difficile agents that have been evaluated or reevaluated in the last five years and are in the early stages of drug discovery and development. Antibiotics are divided into natural product inspired and synthetic small molecule compounds that may have the potential to be more efficacious than currently approved treatments. This includes potency, selectivity, reduced cytotoxicity, and novel modes of action to prevent resistance.
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Affiliation(s)
| | | | | | - Dianqing Sun
- Department of Pharmaceutical Sciences, The Daniel K. Inouye College of Pharmacy, University of Hawai'i at Hilo, 34 Rainbow Drive, Hilo, HI 96720, USA.
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Beran V, Chmelar D, Vobejdova J, Konigova A, Nemec J, Tvrdik J. Sensitivity to antibiotics of Clostridium difficile toxigenic nosocomial strains. Folia Microbiol (Praha) 2013; 59:209-15. [PMID: 24114414 DOI: 10.1007/s12223-013-0283-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 09/25/2013] [Indexed: 01/05/2023]
Abstract
Clostridium difficile is the etiological agent of diarrhoea and colitis, especially in elderly patients. The incidence of these diseases has increased during the last 10 years. Emergence of so-called hypervirulent strains is considered as one of the main factors responsible for the more severe disease and changed profile of sensitivity to antimicrobial agents. The aim of this work was to determine the sensitivity profile of toxigenic strains of C. difficile in the Czech Republic in 2011-2012 to selected antibiotics. The antibiotics clindamycin, metronidazole, vancomycin and amoxicillin with clavulanic acid were used for this purpose. Isolates cultured on Brazier's C. difficile selective agar were analysed for the presence of toxin genes using Xpert detection system. Xpert analysis revealed that 33 strains carried the genes for toxins tcdB, cdt and tcdCΔ117, thus showing characteristics typical for the hypervirulent ribotype 027/PFGE type NAP1/REA type B1. The remaining 29 strains carried only the gene for toxin B (tcdB) and not cdt and tcdCΔ117. Our results indicate the higher susceptibility of C. difficile hypertoxigenic strains to three out of four tested antibiotics (except vancomycin) than it is for the other toxigenic strains. We found that only 10.34% of other toxigenic strains were resistant to clindamycin, and no resistance was found in all other cases. All the isolates were sensitive to amoxicillin/clavulanic acid in vitro. However, its use is not recommended for therapy of infections caused by C. difficile.
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Affiliation(s)
- Vladimir Beran
- Czech Anaerobic Bacteria Reference Laboratory, Institute of Microbiology and Immunology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00, Ostrava, Czech Republic,
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Tran MCN, Claros MC, Goldstein EJC. Therapy of Clostridium difficile infection: perspectives on a changing paradigm. Expert Opin Pharmacother 2013; 14:2375-86. [PMID: 24053182 DOI: 10.1517/14656566.2013.838218] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Clostridium difficile disease (CDI) have increased in frequency and severity over the past decade and are a leading cause of hospital acquired infections, contributing to increased hospital length of stay and costs, as well as associated increased mortality, especially amongst the elderly. Standard therapy has been associated with 20 - 30% relapse rates. Consequently, new CDI therapeutic approaches have emerged. AREAS COVERED The role of metronidazole, vancomycin, fidaxomicin, rifaximin, nitizoxanide, tigecycline, fusidic acid, LFF-571, cardazolid, SMT 19969, CamSA and surotomycin were reviewed. EXPERT OPINION New IDSA/SHEA guidelines are expected within the next year and may impact selection of primary therapy for CDI. Until then, metronidazole will likely remain as first line therapy because of low cost and despite its inferiority compared to vancomycin. Vancomycin will likely see increasing use, especially as generics become available. Fidaxomicin will emerge as an important therapy for relapse patients and perhaps as initial therapy for patients at greatest risk for relapse, with concomitant antibiotics, multiple comorbidities and renal insufficiency, advanced age and hypoalbuminemia. Biotherapeutics such as fecal microbiota transplantation and non-toxogenic C. difficile prevention will emerge as the preferred therapy in multiple relapse patients and the development of an oral formulation will occur within five years.
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Affiliation(s)
- Mai-Chi N Tran
- St. Johns' Health Center, Department of Pharmacy , Santa Monica, CA 90404 , USA
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Chilton CH, Crowther GS, Freeman J, Todhunter SL, Nicholson S, Longshaw CM, Wilcox MH. Successful treatment of simulated Clostridium difficile infection in a human gut model by fidaxomicin first line and after vancomycin or metronidazole failure. J Antimicrob Chemother 2013; 69:451-62. [DOI: 10.1093/jac/dkt347] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Chilton CH, Freeman J, Baines SD, Crowther GS, Nicholson S, Wilcox MH. Evaluation of the effect of oritavancin on Clostridium difficile spore germination, outgrowth and recovery. J Antimicrob Chemother 2013; 68:2078-82. [DOI: 10.1093/jac/dkt160] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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Zucca M, Scutera S, Savoia D. Novel avenues forClostridium difficileinfection drug discovery. Expert Opin Drug Discov 2013; 8:459-77. [DOI: 10.1517/17460441.2013.770466] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Mario Zucca
- University of Torino, at S. Luigi Gonzaga Hospital, Department of Clinical and Biological Sciences, Regione Gonzole 10, Orbassano (To) 10043, Italy ;
| | - Sara Scutera
- University of Torino, Department of Public Health and Paediatric Sciences, V. Santena 9, Torino 10126, Italy
| | - Dianella Savoia
- University of Torino, at S. Luigi Gonzaga Hospital, Department of Clinical and Biological Sciences, Regione Gonzole 10, Orbassano (To) 10043, Italy ;
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Wu X, Cherian PT, Lee RE, Hurdle JG. The membrane as a target for controlling hypervirulent Clostridium difficile infections. J Antimicrob Chemother 2012; 68:806-15. [PMID: 23264511 DOI: 10.1093/jac/dks493] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES The stationary phase of Clostridium difficile, which is primarily responsible for diarrhoeal symptoms, is refractory to antibiotic killing. We investigated whether disrupting the functions of the clostridial membrane is an approach to control C. difficile infections by promptly removing growing and non-growing cells. METHODS The bactericidal activities of various membrane-active agents were determined against C. difficile logarithmic-phase and stationary-phase cultures and compared with known antibiotics. Their effects on the synthesis of ATP, toxins A/B and sporulation were also determined. The effect of rodent caecal contents on anti-difficile activities was examined using two reutericyclin lead compounds, clofazimine, daptomycin and other comparator antibiotics. RESULTS Most membrane-active agents and partially daptomycin showed concentration-dependent killing of both logarithmic-phase and stationary-phase cultures. The exposure of cells to compounds at their MBC resulted in a rapid loss of viability with concomitant reductions in cellular ATP, toxins A/B and spore numbers. With the exception of nisin, these effects were not due to membrane pore formation. Interestingly, the activity of the proton ionophore nigericin significantly increased as the growth of C. difficile decreased, suggesting the importance of the proton gradient to the survival of non-growing cells. The activities of the lipophilic antimicrobials reutericyclins and clofazimine were reduced by caecal contents. CONCLUSIONS These findings indicate that C. difficile is uniquely susceptible to killing by molecules affecting its membrane function and bioenergetics, indicating that the clostridial membrane is a novel antimicrobial target for agents to alleviate the burden of C. difficile infections.
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Affiliation(s)
- Xiaoqian Wu
- Department of Biology, University of Texas at Arlington, Arlington, TX 76019, USA
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