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Yu XH, Lv Z, Zhang CE, Gao Y, Li H, Ma XJ, Ma ZJ, Su JR, Huang LQ. Shengjiang Xiexin decoction mitigates murine Clostridium difficile infection through modulation of the gut microbiota and bile acid metabolism. JOURNAL OF ETHNOPHARMACOLOGY 2024; 320:117384. [PMID: 37925000 DOI: 10.1016/j.jep.2023.117384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 11/06/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE The overuse of antibiotics has resulted in Clostridium difficile infection (CDI) as a significant global public health concern. Studies have shown that imbalances in gut microbiota and metabolism play a vital role in the onset of CDI. Shengjiang Xiexin decoction (SJT), a traditional Chinese medicinal formula widely employed in the treatment of gastrointestinal ailments, demonstrates effectiveness in addressing murine CDI. However, the precise mechanistic role of SJT in CDI treatment remains uncertain, particularly regarding its impact on gut microbiota and intestinal metabolism. Thus, further investigation is imperative to shed light on these mechanisms. AIM OF THE STUDY This study aims to thoroughly investigate the therapeutic potential of SJT in the treatment of CDI, while also examining its impact on the intricate interplay between gut microbiota and bile acid metabolism. By employing a mouse model, we aspire to uncover novel insights that could pave the way for the development of more effective strategies in combating CDI. MATERIALS AND METHODS We developed a mouse model for CDI and assessed SJT's potential as a therapeutic agent through pharmacological analyses. Our study employed high-throughput sequencing of 16S rRNA to identify changes in gut microbiota composition and untargeted metabolomics analysis to evaluate SJT's intervention on intestinal metabolism. We also conducted targeted analysis of bile acid metabolism to examine the specific effects of SJT. Finally, the growth-inhibitory effect of SJT on C. difficile was confirmed through ex vivo cultivation of the pathogen using cecal contents, supporting its potential role in treating CDI by modulating gut microbiota and bile acid metabolism. RESULTS In pharmacological studies, SJT was found to effectively reduce the levels of A&B toxins and alleviate colonic inflammation in CDI mice. Mechanistically, SJT demonstrated a mild increase in the abundance and diversity of the gut microbiota. However, its most significant impact was observed in the substantial improvement of the structural composition of the gut microbiota. Specifically, SJT decreased the abundance of gut Polymorphs and Firmicutes while restoring the proportions of family Trichophyton and Bacteroides_S24-7 spp (P < 0.001). Moreover, SJT not only decreased the levels of primary bile acids but also elevated the levels of secondary bile acids. Notably, it enhanced the conversion of taurocholic acid (TCA) to deoxycholic acid (DCA), leading to a balanced bile acid metabolism. Finally, cecal contents of SJT-treated mice showed a significant reduction in the growth of C. difficile, underscoring the therapeutic potential of SJT via modulation of gut microbiota and bile acid metabolism. CONCLUSION SJT demonstrates remarkable efficacy in treating CDI in mice by not only effectively combating the infection but also restoring the intricate balance of gut microbiota and bile acid metabolism. Furthermore, promising indications suggest that SJT may have the potential to prevent CDI recurrence. These findings underscore the comprehensive therapeutic value of SJT in managing CDI. Moving forward, we plan to transition from the laboratory to clinical settings to conduct further studies, validating our conclusions on SJT's efficacy.
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Affiliation(s)
- Xiao-Hong Yu
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, 100050, Beijing, China
| | - Zhi Lv
- Clinical Laboratory Center, Beijing Friendship Hospital, Capital Medical University, 100050, Beijing, China
| | - Cong-En Zhang
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, 100050, Beijing, China
| | - Yan Gao
- Clinical Laboratory Center, Beijing Friendship Hospital, Capital Medical University, 100050, Beijing, China
| | - Hui Li
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China
| | - Xiao-Jing Ma
- Resource Center for Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China
| | - Zhi-Jie Ma
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, 100050, Beijing, China.
| | - Jian-Rong Su
- Clinical Laboratory Center, Beijing Friendship Hospital, Capital Medical University, 100050, Beijing, China.
| | - Lu-Qi Huang
- Resource Center for Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China.
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Walsh L, Lavelle A, O’Connor PM, Hill C, Ross RP. Comparison of fidaxomicin, thuricin CD, vancomycin and nisin highlights the narrow spectrum nature of thuricin CD. Gut Microbes 2024; 16:2342583. [PMID: 38722061 PMCID: PMC11085969 DOI: 10.1080/19490976.2024.2342583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 04/09/2024] [Indexed: 05/12/2024] Open
Abstract
Vancomycin and metronidazole are commonly used treatments for Clostridioides difficile infection (CDI). However, these antibiotics have been associated with high levels of relapse in patients. Fidaxomicin is a new treatment for CDI that is described as a narrow spectrum antibiotic that is minimally active on the commensal bacteria of the gut microbiome. The aim of this study was to compare the effect of fidaxomicin on the human gut microbiome with a number of narrow (thuricin CD) and broad spectrum (vancomycin and nisin) antimicrobials. The spectrum of activity of each antimicrobial was tested against 47 bacterial strains by well-diffusion assay. Minimum inhibitory concentrations (MICs) were calculated against a select number of these strains. Further, a pooled fecal slurry of 6 donors was prepared and incubated for 24 h with 100 µM of each antimicrobial in a mini-fermentation system together with a no-treatment control. Fidaxomicin, vancomycin, and nisin were active against most gram positive bacteria tested in vitro, although fidaxomicin and vancomycin produced larger zones of inhibition compared to nisin. In contrast, the antimicrobial activity of thuricin CD was specific to C. difficile and some Bacillus spp. The MICs showed similar results. Thuricin CD exhibited low MICs (<3.1 µg/mL) for C. difficile and Bacillus firmus, whereas fidaxomicin, vancomycin, and nisin demonstrated lower MICs for all other strains tested when compared to thuricin CD. The narrow spectrum of thuricin CD was also observed in the gut model system. We conclude that the spectrum of activity of fidaxomicin is comparable to that of the broad-spectrum antibiotic vancomycin in vitro and the broad spectrum bacteriocin nisin in a complex community.
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Affiliation(s)
- L. Walsh
- School of Microbiology, University College Cork, Cork, Ireland
- APC Microbiome Ireland, University College Cork, Cork, Ireland
| | - A. Lavelle
- School of Microbiology, University College Cork, Cork, Ireland
| | - PM O’Connor
- APC Microbiome Ireland, University College Cork, Cork, Ireland
- Teagasc Food Research Centre, Cork, Ireland
| | - C. Hill
- School of Microbiology, University College Cork, Cork, Ireland
- APC Microbiome Ireland, University College Cork, Cork, Ireland
| | - R. P. Ross
- School of Microbiology, University College Cork, Cork, Ireland
- APC Microbiome Ireland, University College Cork, Cork, Ireland
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3
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Fitzpatrick F, Brennan R, van Prehn J, Skally M, Brady M, Burns K, Rooney C, Wilcox MH. European Practice for CDI Treatment. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1435:57-84. [PMID: 38175471 DOI: 10.1007/978-3-031-42108-2_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Clostridioides difficile infection (CDI) remains a significant cause of morbidity and mortality worldwide. Historically, two antibiotics (metronidazole and vancomycin) and a recent third (fidaxomicin) have been used for CDI treatment; convincing data are now available showing that metronidazole is the least efficacious agent. The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) management guidance for CDI were updated in 2021. This guidance document outlines the treatment options for a variety of CDI clinical scenarios and for non-antimicrobial management (e.g., faecal microbiota transplantation, FMT). One of the main changes is that metronidazole is no longer recommended as first-line CDI treatment. Rather, fidaxomicin is preferred on the basis of reduced recurrence rates with vancomycin as an acceptable alternative. Recommended options for recurrent CDI now include bezlotoxumab as well as FMT.A 2017 survey of 20 European countries highlighted variation internationally in CDI management strategies. A variety of restrictions were in place in 65% countries prior to use of new anti-CDI treatments, including committee/infection specialist approval or economic review/restrictions. This survey was repeated in November 2022 to assess the current landscape of CDI management practices in Europe. Of 64 respondents from 17 countries, national CDI guidelines existed in 14 countries, and 11 have already/plan to incorporate the ESCMID 2021 CDI guidance, though implementation has not been surveyed in 6. Vancomycin is the most commonly used first-line agent for the treatment of CDI (n = 42, 66%), followed by fidaxomicin (n = 30, 47%). Six (9%) respondents use metronidazole as first-line agent for CDI treatment, whereas 22 (34%) only in selected low-risk patient groups. Fidaxomicin is more likely to be used in high-risk patient groups. Availability of anti-CDI therapy influenced prescribing in six respondents (9%). Approval pre-prescription was required before vancomycin (n = 3, 5%), fidaxomicin (n = 10, 6%), bezlotoxumab (n = 11, 17%) and FMT (n = 10, 6%). Implementation of CDI guidelines is rarely audited.Novel anti-CDI agents are being evaluated; it is not yet clear what will be the roles of these agents. The treatment of recurrent CDI is particularly troublesome, and several different live biotherapeutics are being developed, in addition to FMT.
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Affiliation(s)
- Fidelma Fitzpatrick
- Department of Clinical Microbiology, The Royal College of Surgeons in Ireland, Dublin, Ireland.
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland.
| | - Robert Brennan
- Department of Clinical Microbiology, The Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Joffrey van Prehn
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Mairead Skally
- Department of Clinical Microbiology, The Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
| | - Melissa Brady
- Health Protection Surveillance Centre (HPSC), Dublin, Ireland
| | - Karen Burns
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
| | - Christopher Rooney
- Microbiology, Leeds Teaching Hospitals, Leeds, UK
- University of Leeds, Leeds, UK
| | - Mark H Wilcox
- University of Leeds, Leeds, UK.
- Leeds Teaching Hospitals and Leeds Regional Public Health Laboratory, UK Health Security Agency (UKHSA), Leeds, UK.
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Kim D, Lee J, Shyaka C, Kwak JH, Pai H, Rho M, Ciufolini MA, Han M, Park JH, Kim YR, Jung S, Jang AR, Kim E, Lee JY, Lee H, Son YJ, Hwang HJ. Identification of Micrococcin P2-Derivatives as Antibiotic Candidates against Two Gram-Positive Pathogens. J Med Chem 2023; 66:14263-14277. [PMID: 37796116 DOI: 10.1021/acs.jmedchem.3c01309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
Thiopeptides exhibit potent antimicrobial activity against Gram-positive pathogens by inhibiting bacterial protein synthesis. Micrococcins are among the structurally simpler thiopeptides, but they have not been exploited in detail. This research involved a computational simulation of micrococcin P2 (MP2) docking in parallel with the structure-activity relationship (SAR) studied. The incorporation of particular nitrogen heterocycles in the side chain of MP2 enhances the antimicrobial activity. Micrococcin analogues 6c and 6d thus proved to be more effective against impetigo and C. difficile infection (CDI), respectively, as compared to current first-line treatments. Compound 6c also showed a shorter treatment period than that of a first-line treatment for impetigo. This may be attributed to its ability to downregulate pro-inflammatory cytokines. Compound 6d had no observed recurrence for C. difficile and exerted a minimal impact on the beneficial gut microbiome. Their pharmacokinetic properties and low toxicity profile make these compounds ideal candidates for the treatment of impetigo and CDI and validate their involvement in preclinical development.
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Affiliation(s)
- Dahyun Kim
- A&J Science Co., Ltd., 80 Chumbok Ro, Dong Gu, Daegu 41061, Republic of Korea
| | - Jusuk Lee
- A&J Science Co., Ltd., 80 Chumbok Ro, Dong Gu, Daegu 41061, Republic of Korea
| | - Clovis Shyaka
- A&J Science Co., Ltd., 80 Chumbok Ro, Dong Gu, Daegu 41061, Republic of Korea
| | - Jin-Hwan Kwak
- School of Life Science, Handong Global University, 558 Handong Ro, Heunghae-Eup, Buk-Gu, Pohang 37554, Republic of Korea
- Office of the President, Sunlin University, 30, 36 Chogok-gil, Heunghae-Eup, Buk-Gu, Pohang 37560, Republic of Korea
| | - Hyunjoo Pai
- Department of Internal Medicine, Hanyang University College of Medicine, 232 Wangsimri Ro, Seongdong-Gu, Seoul 04763, Republic of Korea
| | - Mina Rho
- Department of Computer Science, Hanyang University, 222 Wangsimri Ro, Seongdong-Gu, Seoul 04763, Republic of Korea
| | - Marco A Ciufolini
- Department of Chemistry, University of British Columbia, 2036 Main Mall, Vancouver, BC V6K 1Z1, Canada
| | - Minwoo Han
- New Drug Development Center, Daegu Gyeongbuk Medical Innovation Foundation, 80 Chumbok Ro, Dong Gu, Daegu 41061, Republic of Korea
| | - Jong-Hwan Park
- Laboratory Animal Medicine, College of Veterinary Medicine and Animal Medical Institute, Chonnam National University, 77 Yongbong-ro, Buk-Gu, Gwangju 61186, Republic of Korea
- Nodcure Inc., 77 Yongbong-ro, Buk-Gu, Gwangju 61186, Republic of Korea
| | - Young-Rok Kim
- School of Life Science, Handong Global University, 558 Handong Ro, Heunghae-Eup, Buk-Gu, Pohang 37554, Republic of Korea
| | - Sungji Jung
- School of Life Science, Handong Global University, 558 Handong Ro, Heunghae-Eup, Buk-Gu, Pohang 37554, Republic of Korea
| | - Ah-Ra Jang
- Nodcure Inc., 77 Yongbong-ro, Buk-Gu, Gwangju 61186, Republic of Korea
| | - Eunjung Kim
- School of Life Science, Handong Global University, 558 Handong Ro, Heunghae-Eup, Buk-Gu, Pohang 37554, Republic of Korea
| | - Jee-Young Lee
- New Drug Development Center, Daegu Gyeongbuk Medical Innovation Foundation, 80 Chumbok Ro, Dong Gu, Daegu 41061, Republic of Korea
| | - Hakyeong Lee
- A&J Science Co., Ltd., 80 Chumbok Ro, Dong Gu, Daegu 41061, Republic of Korea
| | - Young-Jin Son
- A&J Science Co., Ltd., 80 Chumbok Ro, Dong Gu, Daegu 41061, Republic of Korea
| | - Hee-Jong Hwang
- A&J Science Co., Ltd., 80 Chumbok Ro, Dong Gu, Daegu 41061, Republic of Korea
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5
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Collins DA, Riley TV. Ridinilazole: a novel, narrow-spectrum antimicrobial agent targeting Clostridium (Clostridioides) difficile. Lett Appl Microbiol 2022; 75:526-536. [PMID: 35119124 PMCID: PMC9541751 DOI: 10.1111/lam.13664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 01/12/2022] [Accepted: 01/31/2022] [Indexed: 11/26/2022]
Abstract
Clostridium (Clostridioides) difficile infection (CDI) remains an urgent threat to patients in health systems worldwide. Recurrent CDI occurs in up to 30% of cases due to sustained dysbiosis of the gut microbiota which normally protects against CDI. Associated costs of initial and recurrent episodes of CDI impose heavy financial burdens on health systems. Vancomycin and metronidazole have been the mainstay of therapy for CDI for many years; however, these agents continue to cause significant disruption to the gut microbiota and thus carry a high risk of recurrence for CDI patients. Treatment regimens are now turning towards novel narrow spectrum antimicrobial agents which target C. difficile while conserving the commensal gut microbiota, thus significantly reducing risk of recurrence. One such agent, fidaxomicin, has been in therapeutic use for several years and is now recommended as a first-line treatment for CDI, as it is superior to vancomycin in reducing risk of recurrence. Another narrow spectrum agent, ridnilazole, was recently developed and is undergoing evaluation of its potential clinical utility. This review aimed to summarize experimental reports of ridinilazole and assess its potential as a first-line agent for treatment of CDI. Reported results from in vitro assessments, and from hamster models of CDI, show potent activity against C. difficile, non-inferiority to vancomycin for clinical cure and non-susceptibility among most gut commensal bacteria. Phase I and II clinical trials have been completed with ridinilazole showing high tolerability and efficacy in treatment of CDI, and superiority over vancomycin in reducing recurrence of CDI within 30 days of treatment completion. Phase III trials are currently underway, the results of which may prove its potential to reduce recurrent CDI and lessen the heavy health and financial burden C. difficile imposes on patients and healthcare systems.
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Affiliation(s)
- Deirdre A Collins
- School of Medical and Health SciencesEdith Cowan UniversityJoondalupWesternAustralia
| | - Thomas V. Riley
- School of Medical and Health SciencesEdith Cowan UniversityJoondalupWesternAustralia
- Department of MicrobiologyPathWest Laboratory MedicineNedlandsWesternAustralia
- Medical, Molecular and Forensic SciencesMurdoch UniversityMurdochWestern AustraliaAustralia
- School of Biomedical SciencesThe University of Western AustraliaQueen Elizabeth II Medical CentreNedlandsWAAustralia
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6
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Buckley AM, Moura IB, Arai N, Spittal W, Clark E, Nishida Y, Harris HC, Bentley K, Davis G, Wang D, Mitra S, Higashiyama T, Wilcox MH. Trehalose-Induced Remodelling of the Human Microbiota Affects Clostridioides difficile Infection Outcome in an In Vitro Colonic Model: A Pilot Study. Front Cell Infect Microbiol 2021; 11:670935. [PMID: 34277467 PMCID: PMC8284250 DOI: 10.3389/fcimb.2021.670935] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 06/02/2021] [Indexed: 12/19/2022] Open
Abstract
Within the human intestinal tract, dietary, microbial- and host-derived compounds are used as signals by many pathogenic organisms, including Clostridioides difficile. Trehalose has been reported to enhance virulence of certain C. difficile ribotypes; however, such variants are widespread and not correlated with clinical outcomes for patients suffering from C. difficile infection (CDI). Here, we make preliminary observations on how trehalose supplementation affects the microbiota in an in vitro model and show that trehalose-induced changes can reduce the outgrowth of C. difficile, preventing simulated CDI. Three clinically reflective human gut models simulated the effects of sugar (trehalose or glucose) or saline ingestion on the microbiota. Models were instilled with sugar or saline and further exposed to C. difficile spores. The recovery of the microbiota following antibiotic treatment and CDI induction was monitored in each model. The human microbiota remodelled to utilise the bioavailable trehalose. Clindamycin induction caused simulated CDI in models supplemented with either glucose or saline; however, trehalose supplementation did not result in CDI, although limited spore germination did occur. The absence of CDI in trehalose model was associated with enhanced abundances of Finegoldia, Faecalibacterium and Oscillospira, and reduced abundances of Klebsiella and Clostridium spp., compared with the other models. Functional analysis of the microbiota in the trehalose model revealed differences in the metabolic pathways, such as amino acid metabolism, which could be attributed to prevention of CDI. Our data show that trehalose supplementation remodelled the microbiota, which prevented simulated CDI, potentially due to enhanced recovery of nutritionally competitive microbiota against C. difficile.
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Affiliation(s)
- Anthony M. Buckley
- Healthcare Associated Infection Research Group, Molecular Gastroenterology, Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
| | - Ines B. Moura
- Healthcare Associated Infection Research Group, Molecular Gastroenterology, Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
| | - Norie Arai
- R&D Division, Hayashibara Co. Ltd./NAGASE Group, Okayama, Japan
| | - William Spittal
- Healthcare Associated Infection Research Group, Molecular Gastroenterology, Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
| | - Emma Clark
- Healthcare Associated Infection Research Group, Molecular Gastroenterology, Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
| | | | - Hannah C. Harris
- Healthcare Associated Infection Research Group, Molecular Gastroenterology, Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
| | - Karen Bentley
- Healthcare Associated Infection Research Group, Molecular Gastroenterology, Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
| | - Georgina Davis
- Healthcare Associated Infection Research Group, Molecular Gastroenterology, Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
| | - Dapeng Wang
- LeedsOmics, University of Leeds, Leeds, United Kingdom
| | - Suparna Mitra
- Healthcare Associated Infection Research Group, Molecular Gastroenterology, Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
| | | | - Mark H. Wilcox
- Healthcare Associated Infection Research Group, Molecular Gastroenterology, Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
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7
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A Review of Clostridioides difficile Infection and Antibiotic-Associated Diarrhea. Gastroenterol Clin North Am 2021; 50:323-340. [PMID: 34024444 DOI: 10.1016/j.gtc.2021.02.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Antibiotic-associated diarrhea and Clostridioides difficile infection (CDI) occur frequently among adults. The pathophysiology of CDI is related to disruption of normal gut flora and risk factors include hospitalization, use of antibiotic therapy, and older age. Clinical manifestations can range from mild disease to toxic megacolon. Diagnosis is challenging and is based on a combination of clinical symptoms and diagnostic tests. Therapy includes cessation of antibiotics, or use of other agents depending on the severity of illness. Many novel agents for the treatment and prevention of CDI show promise and are under investigation.
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8
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Abstract
We examine 3 different approaches to protecting the gut microbiome: highly targeted antibiotics, antibiotic destruction, and antibiotic binding. Each approach shows promise to prevent the off-target effects of antibiotics on the gut microbiome.
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Affiliation(s)
- C M Rooney
- 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
| | - S Ahmed
- 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
| | - M H 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
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9
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Durham SH, Le P, Cassano AT. Navigating changes in Clostridioides difficile prevention and treatment. J Manag Care Spec Pharm 2020; 26:S3-S23. [PMID: 33533699 PMCID: PMC10408425 DOI: 10.18553/jmcp.2020.26.12-a.s3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Clostridioides difficile (C. difficile, previously known as Clostridium difficile) infections are a major health care concern. The Centers for Disease Control and Prevention (CDC) estimates that C. difficile causes almost half a million illnesses in the United States yearly, and approximately 1 in 5 patients with a C. difficile infection (CDI) will experience 1 or more recurrent infections. The incidence of infection has risen dramatically in recent years, and infection severity has increased due to the emergence of hypervirulent strains. There have been noteworthy advances in the development of CDI prevention and treatment, including a growth in the understanding of the role a patient's gut microbiome plays. The 2017 Infectious Diseases Society of America (IDSA) guidelines made a significant change in treatment recommendations for first time CDI episodes by recommending the use of oral vancomycin or fidaxomicin in place of metronidazole as a first-line treatment. The guidelines also included detailed recommendations on the use of fecal microbiota transplant (FMT) in those patients who experience 3 or more recurrent CDI episodes. A number of novel therapies for the treatment of CDI are in various stages of development. Treatments currently in phase 3 trials include the antibiotic ridinilazole, the microbiome products SER-109 and RBX2660, and a vaccine. All of these agents have shown promise in phase 1 and 2 trials. Additionally, several other antibiotic and microbiome candidates are currently in phase 1 or phase 2 trials. A qualitative review and evaluation of the literature on the cost-effectiveness of treatments for CDI in the U.S. setting was conducted, and the summary provided herein. Due to the higher cost of newer agents, cost-effectiveness evaluations will continue to be critical in clinical decision making for CDI. This paper reviews the updated CDI guidelines for prevention and treatment, the role of the microbiome in new and recurrent infections, pipeline medications, and comparative effectiveness research (CER) data on these treatments. DISCLOSURES: Durham and Le have nothing to disclose. Cassano reports consulting fees from Baxter Healthcare. Peer reviewers Drs. Ami Gopalan and Mark Rubin and Ms. Kathleen Jarvis have nothing to disclose. Planners Dr. Christine L. Cooper and Ms. Susan Yarbrough have nothing to disclose.
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Affiliation(s)
- Spencer H Durham
- BCPS, BCIDP, Auburn University Harrison School of Pharmacy, Auburn, AL
| | - Phuc Le
- Lerner College of Medicine, Case Western Reserve University and Center for Value-based Care Research, Cleveland Clinic, Cleveland, OH
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10
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Kullar R, Tran MCN, Goldstein EJC. Investigational Treatment Agents for Recurrent Clostridioides difficile Infection (rCDI). J Exp Pharmacol 2020; 12:371-384. [PMID: 33116952 PMCID: PMC7553590 DOI: 10.2147/jep.s242959] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/13/2020] [Indexed: 11/23/2022] Open
Abstract
Clostridioides difficile infection (CDI) is a major cause of nosocomial diarrhea that is deemed a global health threat. C. difficile strain BI/NAP1/027 has contributed to the increase in the mortality, severity of CDI outbreaks and recurrence rates (rCDI). Updated CDI treatment guidelines suggest vancomycin and fidaxomicin as initial first-line therapies that have initial clinical cure rates of over 80%. Unacceptably high recurrence rates of 15–30% in patients for the first episode and 40% for the second recurrent episode are reported. Alternative treatments for rCDI include fecal microbiota transplant and a human monoclonal antibody, bezlotoxumab, that can be used in patients with high risk of rCDI. Various emerging potential therapies with narrow spectrum of activity and little systemic absorption that are in development include 1) Ibezapolstat (formerly ACX-362E), MGB-BP-3, and DS-2969b-targeting bacterial DNA replication, 2) CRS3213 (REP3123)-inhibiting toxin production and spore formation, 3) ramizol and ramoplanin-affecting bacterial cell wall, 4) LFF-571-blocking protein synthesis, 5) Alanyl-L-Glutamine (alanylglutamine)-inhibiting damage caused by C. difficile by protecting intestinal mucosa, and 6) DNV3837 (MCB3681)-prodrug consisting of an oxazolidinone–quinolone combination that converts to the active form DNV3681 that has activity in vitro against C. difficile. This review article provides an overview of these developing drugs that can have potential role in the treatment of rCDI and in lowering recurrence rates.
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Affiliation(s)
| | - Mai-Chi N Tran
- Pharmacy Department, Keck Medical Center of USC, Los Angeles, CA, USA.,Clinica Juan Pablo Medical Group, Los Angeles, CA, USA
| | - Ellie J C Goldstein
- R.M. Alden Research Laboratory, Santa Monica, CA, USA.,David Geffen School of Medicine, Los Angeles, CA, USA
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11
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Ashammakhi N, Nasiri R, Barros NRD, Tebon P, Thakor J, Goudie M, Shamloo A, Martin MG, Khademhosseini A. Gut-on-a-chip: Current progress and future opportunities. Biomaterials 2020; 255:120196. [PMID: 32623181 PMCID: PMC7396314 DOI: 10.1016/j.biomaterials.2020.120196] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 04/11/2020] [Accepted: 06/09/2020] [Indexed: 12/21/2022]
Abstract
Organ-on-a-chip technology tries to mimic the complexity of native tissues in vitro. Important progress has recently been made in using this technology to study the gut with and without microbiota. These in vitro models can serve as an alternative to animal models for studying physiology, pathology, and pharmacology. While these models have greater physiological relevance than two-dimensional (2D) cell systems in vitro, endocrine and immunological functions in gut-on-a-chip models are still poorly represented. Furthermore, the construction of complex models, in which different cell types and structures interact, remains a challenge. Generally, gut-on-a-chip models have the potential to advance our understanding of the basic interactions found within the gut and lay the foundation for future applications in understanding pathophysiology, developing drugs, and personalizing medical treatments.
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Affiliation(s)
- Nureddin Ashammakhi
- Center for Minimally Invasive Therapeutics (C-MIT), University of California, Los Angeles, CA, USA; Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA; Department of Bioengineering, Samueli School of Engineering, University of California, Los Angeles, CA, USA.
| | - Rohollah Nasiri
- Center for Minimally Invasive Therapeutics (C-MIT), University of California, Los Angeles, CA, USA; Department of Bioengineering, Samueli School of Engineering, University of California, Los Angeles, CA, USA; Department of Mechanical Engineering, Sharif University of Technology, Tehran 11365-11155, Iran
| | - Natan Roberto de Barros
- Center for Minimally Invasive Therapeutics (C-MIT), University of California, Los Angeles, CA, USA; Department of Bioengineering, Samueli School of Engineering, University of California, Los Angeles, CA, USA.
| | - Peyton Tebon
- Center for Minimally Invasive Therapeutics (C-MIT), University of California, Los Angeles, CA, USA; Department of Bioengineering, Samueli School of Engineering, University of California, Los Angeles, CA, USA
| | - Jai Thakor
- Center for Minimally Invasive Therapeutics (C-MIT), University of California, Los Angeles, CA, USA; Department of Bioengineering, Samueli School of Engineering, University of California, Los Angeles, CA, USA
| | - Marcus Goudie
- Center for Minimally Invasive Therapeutics (C-MIT), University of California, Los Angeles, CA, USA; Department of Bioengineering, Samueli School of Engineering, University of California, Los Angeles, CA, USA
| | - Amir Shamloo
- Department of Mechanical Engineering, Sharif University of Technology, Tehran 11365-11155, Iran
| | - Martin G Martin
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Ali Khademhosseini
- Center for Minimally Invasive Therapeutics (C-MIT), University of California, Los Angeles, CA, USA; Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA; Department of Bioengineering, Samueli School of Engineering, University of California, Los Angeles, CA, USA; Department of Chemical and Biomolecular Engineering, Samueli School of Engineering, University of California, Los Angeles, CA, USA; Terasaki Institute for Biomedical Innovation, Los Angeles, CA, USA.
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12
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Antimicrobial Susceptibilities of Clostridium difficile Isolates from 12 Asia-Pacific Countries in 2014 and 2015. Antimicrob Agents Chemother 2020; 64:AAC.00296-20. [PMID: 32393487 DOI: 10.1128/aac.00296-20] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 05/02/2020] [Indexed: 01/05/2023] Open
Abstract
Clostridium (Clostridioides) difficile causes toxin-mediated diarrhea and pseudomembranous colitis, primarily among hospital inpatients. Outbreaks of C. difficile infection (CDI) have been caused by strains with acquired antimicrobial resistance, particularly fluoroquinolone resistance, including C. difficile ribotype (RT) 027 in North America and Europe and RT 017, the most common strain in Asia. Despite being the most common cause of hospital-acquired infection in high-income countries, and frequent misuse of antimicrobials in Asia, little is known about CDI in the Asia-Pacific region. We aimed to determine the antimicrobial susceptibility profiles of a collection of C. difficile isolates from the region. C. difficile isolates (n = 414) from a 2014 study of 13 Asia-Pacific countries were tested for susceptibility to moxifloxacin, amoxicillin-clavulanate, erythromycin, clindamycin, rifaximin, metronidazole, vancomycin, and fidaxomicin according to the Clinical and Laboratory Standards Institute's agar dilution method. All isolates were susceptible to metronidazole, vancomycin, amoxicillin-clavulanate, and fidaxomicin. Moxifloxacin resistance was detected in all countries except Australia, all RT 369 and QX 239 strains, and 92.7% of RT 018 and 70.6% of RT 017 strains. All C. difficile RT 012, 369, and QX 239 strains were also resistant to erythromycin and clindamycin. Rifaximin resistance was common in RT 017 strains only (63.2%) and was not detected in Australian, Japanese, or Singaporean isolates. In conclusion, antimicrobial susceptibility of C. difficile varied by strain type and by country. Multiresistance was common in emerging RTs 369 and QX 239 and the most common strain in Asia, RT 017. Ongoing surveillance is clearly warranted.
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Antibiotic Treatment Pipeline for Clostridioides difficile Infection (CDI): A Wide Array of Narrow-Spectrum Agents. Curr Infect Dis Rep 2020. [DOI: 10.1007/s11908-020-00730-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Carlson TJ, Endres BT, Bassères E, Gonzales-Luna AJ, Garey KW. Ridinilazole for the treatment of Clostridioides difficile infection. Expert Opin Investig Drugs 2019; 28:303-310. [PMID: 30767587 DOI: 10.1080/13543784.2019.1582640] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 02/11/2019] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Ridinilazole is a novel antibiotic being developed for the treatment of Clostridioides difficile infection (CDI). Ridinilazole has completed two phase II trials and phase III trials which are denoted Ri-CoDIFy 1 and 2, are planned (ClinicalTrials.gov identifiers: NCT03595553 and NCT03595566). Areas covered: This article covers the chemistry, mechanism of action, in vitro microbiology versus C. difficile and host microbiota, pre-clinical and clinical efficacy, pharmacokinetics, pharmacodynamics and safety and tolerability of ridinilazole. Expert opinion: Ridinilazole is a novel antibiotic with ideal properties for the treatment of CDI. Given the promising results from the phase II clinical trial, ridinilazole may have the capability to lower the risk for CDI recurrence thus improving sustained clinical response rates - a current unmet medical need. Assuming a positive phase III trial, ridinilazole will enter a market with heightened awareness on the importance of prevention of CDI. This along with further research into the economic consequences and decreased patient quality of life associated with recurrent CDI, should provide clinicians with further evidence for the need for therapy that limits CDI recurrence and improves sustained clinical cure.
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Affiliation(s)
- Travis J Carlson
- a Department of Pharmacy Practice and Translational Research , University of Houston College of Pharmacy , Houston , TX , USA
| | - Bradley T Endres
- a Department of Pharmacy Practice and Translational Research , University of Houston College of Pharmacy , Houston , TX , USA
| | - Eugénie Bassères
- a Department of Pharmacy Practice and Translational Research , University of Houston College of Pharmacy , Houston , TX , USA
| | - Anne J Gonzales-Luna
- a Department of Pharmacy Practice and Translational Research , University of Houston College of Pharmacy , Houston , TX , USA
| | - Kevin W Garey
- a Department of Pharmacy Practice and Translational Research , University of Houston College of Pharmacy , Houston , TX , USA
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Tran MCN, Kullar R, Goldstein EJC. Investigational drug therapies currently in early-stage clinical development for the treatment of clostridioides (clostridium) difficile infection. Expert Opin Investig Drugs 2019; 28:323-335. [DOI: 10.1080/13543784.2019.1581763] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Mai-Chi N. Tran
- Department of Pharmacy, Providence St. John’s Health Center, Santa Monica,
CA, USA
- Department of Pharmacy, Clinica Juan Pablo Medical Group, Los Angeles,
CA, USA
| | | | - Ellie J. C. Goldstein
- R M Alden Research Laboratory, Santa Monica,
CA, USA
- David Geffen School of Medicine, Los Angeles,
CA, USA
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Cho JC, Crotty MP, Pardo J. Ridinilazole: a novel antimicrobial for Clostridium difficile infection. Ann Gastroenterol 2018; 32:134-140. [PMID: 30837785 PMCID: PMC6394264 DOI: 10.20524/aog.2018.0336] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 11/07/2018] [Indexed: 12/12/2022] Open
Abstract
Clostridium difficile (C. difficile) infection remains a global healthcare threat worldwide and the limited options available for its treatment are of particular concern. Ridinilazole is one potential future agent, as it demonstrates rapid bactericidal activity against C. difficile. Current studies show that ridinilazole has a lower propensity for collateral damage to the gut microbiome and appears to diminish the production of C. difficile toxins. Results from phase II studies demonstrate that patients receiving ridinilazole had a higher sustained clinical response compared with patients receiving vancomycin (66.7% vs. 42.4%; P=0.0004). Adverse reactions were similar between ridinilazole and vancomycin (40% vs. 56%, respectively), with most being gastrointestinal-related. Nausea (20%) and abdominal pain (12%) were the most commonly reported adverse reactions associated with ridinilazole. Phase II study results are promising and future availability of phase III trial results will help further delineate the role and value of ridinilazole.
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Affiliation(s)
- Jonathan C Cho
- College of Pharmacy, The University of Texas at Tyler, Tyler, TX (Jonathan C. Cho), USA
| | - Matthew P Crotty
- Department of Pharmacy, Methodist Dallas Medical Center, Dallas, TX (Matthew P. Crotty), USA
| | - Joe Pardo
- Department of Pharmacy, North FL/South GA Veterans Health System, Gainesville, FL (Joe Pardo), USA
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Thorpe CM, Kane AV, Chang J, Tai A, Vickers RJ, Snydman DR. Enhanced preservation of the human intestinal microbiota by ridinilazole, a novel Clostridium difficile-targeting antibacterial, compared to vancomycin. PLoS One 2018; 13:e0199810. [PMID: 30071046 PMCID: PMC6071993 DOI: 10.1371/journal.pone.0199810] [Citation(s) in RCA: 42] [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: 01/09/2018] [Accepted: 05/09/2018] [Indexed: 12/21/2022] Open
Abstract
Ridinilazole, a novel targeted antibacterial being developed for the treatment of C. difficile infection (CDI) and prevention of recurrence, was shown in a recent Phase 2 study to be superior to vancomycin with regard to the primary efficacy measure, sustained clinical response (SCR), with the superiority being driven primarily by marked reductions in the rates of CDI recurrence within 30 days. Tolerability of ridinilazole was comparable to that of vancomycin. The current nested cohort study compared the effects of ridinilazole and vancomycin on fecal microbiota during and after treatment among participants in the Phase 2 study. Changes in the microbiota were assessed using qPCR and high-throughput sequencing on participants' stools collected at multiple time-points (baseline [Day 1], Day 5, end-of-treatment [EOT; Day 10], Day 25, end-of-study [EOS; Day 40], and at CDI recurrence). qPCR analyses showed profound losses of Bacteroides, C. coccoides, C. leptum, and Prevotella groups at EOT with vancomycin treatment, while ridinilazole-treated participants had a modest decrease in C. leptum group levels at EOT, with levels recovering by Day 25. Vancomycin-treated participants had a significant increase in the Enterobacteriaceae group, with this increase persisting beyond EOT. At EOT, alpha diversity decreased with both antibiotics, though to a significantly lesser extent with ridinilazole (p <0.0001). Beta diversity analysis showed a significantly larger weighted Unifrac distance from baseline-to-EOT with vancomycin. Taxonomically, ridinilazole had a markedly narrower impact, with modest reductions in relative abundance in Firmicutes taxa. Microbiota composition returned to baseline sooner with ridinilazole than with vancomycin. Vancomycin treatment resulted in microbiome-wide changes, with significant reductions in relative abundances of Firmicutes, Bacteroidetes, Actinobacteria, and a profound increase in abundance of Proteobacteria. These findings demonstrate that ridinilazole is significantly less disruptive to microbiota than vancomycin, which may contribute to the reduced CDI recurrence observed in the Phase 2 study.
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Affiliation(s)
- Cheleste M. Thorpe
- Tufts Medical Center, Boston, MA, United States of America
- Tufts University School of Medicine, Boston, MA, United States of America
| | - Anne V. Kane
- Tufts Medical Center, Boston, MA, United States of America
| | - Justin Chang
- Tufts University School of Medicine, Boston, MA, United States of America
| | - Albert Tai
- Tufts University School of Medicine, Boston, MA, United States of America
| | | | - David R. Snydman
- Tufts Medical Center, Boston, MA, United States of America
- Tufts University School of Medicine, Boston, MA, United States of America
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18
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Snydman DR, McDermott LA, Thorpe CM, Chang J, Wick J, Walk ST, Vickers RJ. Antimicrobial susceptibility and ribotypes of Clostridium difficile isolates from a Phase 2 clinical trial of ridinilazole (SMT19969) and vancomycin. J Antimicrob Chemother 2018; 73:2078-2084. [PMID: 29718329 PMCID: PMC6054158 DOI: 10.1093/jac/dky135] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 02/22/2018] [Accepted: 03/20/2018] [Indexed: 12/18/2022] Open
Abstract
Objectives We evaluated the antimicrobial susceptibility and ribotypes of Clostridium difficile isolates from participants in a Phase 2 study of ridinilazole, a novel targeted-spectrum agent for treatment of C. difficile infection. Methods Participants received ridinilazole (200 mg twice daily) or vancomycin (125 mg four times daily) for 10 days (ClinicalTrials.gov: NCT02092935). The MICs of ridinilazole and comparators for C. difficile isolates from stool samples were determined by agar dilution. Toxin gene profiling was performed by multiplex PCR and ribotype identification by capillary electrophoresis. Results Eighty-nine isolates were recovered from 88/100 participants (one participant had two strains at baseline). The median colony count (cfu/g stool) was 1.9 × 104 (range: 2.5 × 102-7.0 × 106). Twelve participants (three received ridinilazole and nine received vancomycin) experienced recurrence, confirmed by immunoassays for free toxin in stool samples. The ribotype of eight out of nine isolates obtained at recurrence matched those of the initial isolates. All isolates, including those obtained at recurrence, were susceptible to ridinilazole within the expected range [median (range) MIC: 0.12 (0.06-0.5) mg/L]. The median (range) vancomycin MIC was 1 (0.5-4.0) mg/L. At baseline, 13.6% and 13.3% of samples in the ridinilazole and vancomycin groups were positive for VRE, increasing to 23.7% and 29.7% by day 40, respectively. Common ribotypes included 014-20 (14 isolates), 027 (13), 106 (7), 002 (7), 078-126 (4), 001 (4), 087 (3) and 198 (3). Toxin gene profiling of nearly all baseline isolates (98.9%) revealed a binary toxin gene (cdtA/cdtB) prevalence of 35%. Conclusions Ridinilazole potently inhibited recovered C. difficile isolates. Recurrence was not associated with altered susceptibility.
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Affiliation(s)
- David R Snydman
- Division of Geographic Medicine and Infectious Diseases and Department of Medicine, Tufts Medical Center, Boston, MA, USA
- Tufts University School of Medicine, Boston, MA, USA
| | - Laura A McDermott
- Division of Geographic Medicine and Infectious Diseases and Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Cheleste M Thorpe
- Division of Geographic Medicine and Infectious Diseases and Department of Medicine, Tufts Medical Center, Boston, MA, USA
- Tufts University School of Medicine, Boston, MA, USA
| | - Justin Chang
- Division of Geographic Medicine and Infectious Diseases and Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Jenna Wick
- Division of Geographic Medicine and Infectious Diseases and Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Seth T Walk
- Department of Microbiology and Immunology, Montana State University, Bozeman, MT, USA
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Abstract
Clostridium difficile infection (CDI) represents one of the most serious nosocomial infections that have grown dramatically over the past decade. Vancomycin and metronidazole are currently used as a standard therapy for CDI. Metronidazole is recommended as a first-line therapy for mild-to-moderate infections and vancomycin is mainly used for severe and/or refractory cases. However, studies have demonstrated that there are quite high CDI relapse rates with both of these medications, which represents a challenge for clinicians. Over the last decade, a number of newer and novel therapeutic options have emerged as promising alternatives to these standard CDI therapies. The following review provides the updated summaries of these newer therapeutic agents and their status in the treatment of CDI.
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20
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Chilton C, Pickering D, Freeman J. Microbiologic factors affecting Clostridium difficile recurrence. Clin Microbiol Infect 2018; 24:476-482. [DOI: 10.1016/j.cmi.2017.11.017] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 11/22/2017] [Accepted: 11/24/2017] [Indexed: 12/17/2022]
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van Eijk E, Wittekoek B, Kuijper EJ, Smits WK. DNA replication proteins as potential targets for antimicrobials in drug-resistant bacterial pathogens. J Antimicrob Chemother 2018; 72:1275-1284. [PMID: 28073967 PMCID: PMC5400081 DOI: 10.1093/jac/dkw548] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
With the impending crisis of antimicrobial resistance, there is an urgent need to develop novel antimicrobials to combat difficult infections and MDR pathogenic microorganisms. DNA replication is essential for cell viability and is therefore an attractive target for antimicrobials. Although several antimicrobials targeting DNA replication proteins have been developed to date, gyrase/topoisomerase inhibitors are the only class widely used in the clinic. Given the numerous essential proteins in the bacterial replisome that may serve as a potential target for inhibitors and the relative paucity of suitable compounds, it is evident that antimicrobials targeting the replisome are underdeveloped so far. In this review, we report on the diversity of antimicrobial compounds targeting DNA replication and highlight some of the challenges in developing new drugs that target this process.
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Fitzpatrick F, Skally M, Brady M, Burns K, Rooney C, Wilcox MH. European Practice for CDI Treatment. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1050:117-135. [PMID: 29383667 DOI: 10.1007/978-3-319-72799-8_8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Clostridium difficile infection (CDI) remains a significant cause of morbidity and mortality worldwide. Historically, two antibiotics (metronidazole and vancomycin) and a recent third (fidaxomicin) have been used routinely for CDI treatment; convincing data are now available showing that metronidazole is the least efficacious agent. The European Society of Clinical Microbiology and Infectious Diseases CDI treatment guidelines outline the treatment options for a variety of CDI clinical scenarios, including use of the more traditional anti-CDI therapies (e.g., metronidazole, vancomycin), the role of newer anti-CDI agents (e.g., fidaxomicin), indications for surgical intervention and for non-antimicrobial management (e.g., faecal microbiota transplantation, FMT). A 2017 survey of 20 European countries found that while the majority (n = 14) have national CDI guidelines that provide a variety of recommendations for CDI treatment, only five have audited guideline implementation. A variety of restrictions are in place in 13 (65%) countries prior to use of new anti-CDI treatments, including committee/infection specialist approval or economic review/restrictions. Novel anti-CDI agents are being evaluated in Phase III trials; it is not yet clear what will be the roles of these agents. Prophylaxis is an optimum approach to reduce the impact of CDI especially in high-risk populations; monoclonal antibodies, antibiotic blocking approaches and multiple vaccines are currently in advanced clinical trials. The treatment of recurrent CDI is particularly troublesome, and several different live bio therapeutics are being developed, in addition to FMT.
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Affiliation(s)
- Fidelma Fitzpatrick
- Department of Clinical Microbiology, The Royal College of Surgeons in Ireland, Dublin, Ireland.
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland.
| | - Mairead Skally
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
| | - Melissa Brady
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
| | - Karen Burns
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
- Health Protection Surveillance Centre, Dublin, Ireland
| | - Christopher Rooney
- Microbiology, Leeds Teaching Hospitals and University of Leeds, Leeds, UK
| | - Mark H Wilcox
- Microbiology, Leeds Teaching Hospitals and University of Leeds, Leeds, UK.
- Leeds Teaching Hospitals and University of Leeds, Leeds, UK.
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Vickers RJ, Tillotson GS, Nathan R, Hazan S, Pullman J, Lucasti C, Deck K, Yacyshyn B, Maliakkal B, Pesant Y, Tejura B, Roblin D, Gerding DN, Wilcox MH. Efficacy and safety of ridinilazole compared with vancomycin for the treatment of Clostridium difficile infection: a phase 2, randomised, double-blind, active-controlled, non-inferiority study. THE LANCET. INFECTIOUS DISEASES 2017; 17:735-744. [PMID: 28461207 PMCID: PMC5483507 DOI: 10.1016/s1473-3099(17)30235-9] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 02/21/2017] [Accepted: 03/02/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Clostridium difficile infection is the most common health-care-associated infection in the USA. We assessed the safety and efficacy of ridinilazole versus vancomycin for treatment of C difficile infection. METHODS We did a phase 2, randomised, double-blind, active-controlled, non-inferiority study. Participants with signs and symptoms of C difficile infection and a positive diagnostic test result were recruited from 33 centres in the USA and Canada and randomly assigned (1:1) to receive oral ridinilazole (200 mg every 12 h) or oral vancomycin (125 mg every 6 h) for 10 days. The primary endpoint was achievement of a sustained clinical response, defined as clinical cure at the end of treatment and no recurrence within 30 days, which was used to establish non-inferiority (15% margin) of ridinilazole versus vancomycin. The primary efficacy analysis was done on a modified intention-to-treat population comprising all individuals with C difficile infection confirmed by the presence of free toxin in stool who were randomly assigned to receive one or more doses of the study drug. The study is registered with ClinicalTrials.gov, number NCT02092935. FINDINGS Between June 26, 2014, and August 31, 2015, 100 patients were recruited; 50 were randomly assigned to receive ridinilazole and 50 to vancomycin. 16 patients did not complete the study, and 11 discontinued treatment early. The primary efficacy analysis included 69 patients (n=36 in the ridinilazole group; n=33 in the vancomycin group). 24 of 36 (66·7%) patients in the ridinilazole group versus 14 of 33 (42·4%) of those in the vancomycin group had a sustained clinical response (treatment difference 21·1%, 90% CI 3·1-39·1, p=0·0004), establishing the non-inferiority of ridinilazole and also showing statistical superiority at the 10% level. Ridinilazole was well tolerated, with an adverse event profile similar to that of vancomycin: 82% (41 of 50) of participants reported adverse events in the ridinilazole group and 80% (40 of 50) in the vancomycin group. There were no adverse events related to ridinilazole that led to discontinuation. INTERPRETATION Ridinilazole is a targeted-spectrum antimicrobial that shows potential in treatment of initial C difficile infection and in providing sustained benefit through reduction in disease recurrence. Further clinical development is warranted. FUNDING Wellcome Trust and Summit Therapeutics.
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Affiliation(s)
| | | | | | | | | | | | - Kenneth Deck
- Alliance Research Centers, Laguna Hills, CA, USA
| | | | | | - Yves Pesant
- St-Jerome Medical Research, St-Jérôme, QC, Canada
| | | | | | - Dale N Gerding
- Edward Hines Jr Veterans Administration Hospital and Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
| | - Mark H Wilcox
- Microbiology, Leeds Teaching Hospitals and University of Leeds, Leeds, UK
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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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Bassères E, Endres BT, Dotson KM, Alam MJ, Garey KW. Novel antibiotics in development to treat Clostridium difficile infection. Curr Opin Gastroenterol 2017; 33:1-7. [PMID: 28134686 DOI: 10.1097/mog.0000000000000332] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Clostridium difficile infections (CDI) remain a challenge to treat clinically due primarily to limited number of antibiotics available and unacceptably high recurrence rates. Because of this, there has been significant demand for creating innovative therapeutics, which has resulted in the development of several novel antibiotics. RECENT FINDINGS This review updates seven different antibiotics that are currently in development to treat CDI including fidaxomicin, surotomycin, ridinilazole, ramoplanin, cadazolid, LFF571, and CRS3123. Available preclinical and clinical data are compared between these antibiotics. SUMMARY Many of these new antibiotics display almost ideal properties for antibiotics directed against CDI. Despite these properties, not all clinical development of these compounds has been successful. These studies have provided key insights into the pathogenesis of CDI and will continue to inform future drug development. Successful phase III clinical trials should result in several new and novel antibiotics to treat CDI.
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Abstract
PURPOSE OF REVIEW Clostridium difficile infection has attained high prominence given its prevalence and impacts on patients and healthcare institutions. Multiple new approaches to the prevention and treatment of C. difficile infection (CDI) are undergoing clinical trials. RECENT FINDINGS Bezlotoxumab is a monoclonal antibody against toxin B that has successfully completed phase III studies, demonstrating a significant reduction in recurrent CDI when given with standard of care antibiotics. Antibiotics under development include cadazolid and ridinilazole, whereas surotomycin has had disappointing phase III results. Multiple live biotherapeutics are being developed, including freeze thawed and encapsulated versions of faecal microbiota transplantation to improve the practicality of treating patients with recurrent CDI. Alternatives to faecal microbiota transplantation, that aim to improve safety, including a microbial suspension, RBX2660, and a complex spore formulation, SER-109, have progressed to phase II studies. A nontoxigenic C. difficile strain has also shown promise to prevent recurrent CDI. In addition, three C. difficile vaccines have progressed to phase II/III clinical trials. SUMMARY The diverse approaches to treating and preventing CDI offer substantial promise that new treatment options will soon emerge, particular ones that reduce the risk of recurrences.
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Affiliation(s)
- Jessica Martin
- aLeeds Teaching Hospitals NHS Trust/University of Leeds, Microbiology, Old Medical School, Leeds General Infirmary bLeeds Teaching Hospitals NHS Trust cUniversity of Leeds, Leeds dPublic Health England, UK
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Vickers RJ, Tillotson G, Goldstein EJC, Citron DM, Garey KW, Wilcox MH. Ridinilazole: a novel therapy for Clostridium difficile infection. Int J Antimicrob Agents 2016; 48:137-43. [PMID: 27283730 DOI: 10.1016/j.ijantimicag.2016.04.026] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 04/22/2016] [Accepted: 04/23/2016] [Indexed: 12/15/2022]
Abstract
Clostridium difficile infection (CDI) is the leading cause of infectious healthcare-associated diarrhoea. Recurrent CDI increases disease morbidity and mortality, posing a high burden to patients and a growing economic burden to the healthcare system. Thus, there exists a significant unmet and increasing medical need for new therapies for CDI. This review aims to provide a concise summary of CDI in general and a specific update on ridinilazole (formerly SMT19969), a novel antibacterial currently under development for the treatment of CDI. Owing to its highly targeted spectrum of activity and ability to spare the normal gut microbiota, ridinilazole provides significant advantages over metronidazole and vancomycin, the mainstay antibiotics for CDI. Ridinilazole is bactericidal against C. difficile and exhibits a prolonged post-antibiotic effect. Furthermore, treatment with ridinilazole results in decreased toxin production. A phase 1 trial demonstrated that oral ridinilazole is well tolerated and specifically targets clostridia whilst sparing other faecal bacteria. Phase 2 and 3 trials will hopefully further our understanding of the clinical utility of ridinilazole for the treatment of CDI.
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Affiliation(s)
- Richard J Vickers
- Summit Therapeutics plc, 85b Park Drive, Milton Park, Abingdon, Oxford OX14 4RY, UK.
| | | | - Ellie J C Goldstein
- R.M. Alden Research Laboratory, Culver City, CA, USA; David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Kevin W Garey
- University of Houston College of Pharmacy, Houston, TX, USA
| | - Mark H Wilcox
- Microbiology, Leeds Teaching Hospitals and University of Leeds, Old Medical School, Leeds General Infirmary, Leeds, UK
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Slayton ET, Hay AS, Babcock CK, Long TE. New antibiotics in clinical trials for Clostridium difficile. Expert Rev Anti Infect Ther 2016; 14:789-800. [PMID: 27410763 DOI: 10.1080/14787210.2016.1211931] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
INTRODUCTION There are limited number of approved therapies for C. difficile infections (CDIs) and new treatments are needed to decrease recurrence rates. Over the past 5 years, four novel antibiotics have been evaluated in clinical trials that offer distinct advantages over existing therapies for the treatment of CDI. AREAS COVERED This article reviews the preclinical and clinical studies of cadazolid, LFF571, ridinilazole, and surotomycin. The advantages that these antibiotics may have in the treatment of CDI is compared with current therapies metronidazole, vancomycin, and fidaxomicin. Expert commentary: The antibiotics examined have the potential to improve rates of CDI treatment without recurrence. We anticipate that one or more of these medications will be approved within five years.
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Affiliation(s)
- Eric T Slayton
- a Department of Pharmaceutical Science and Research, School of Pharmacy , Marshall University , Huntington , WV , USA
| | - Abigail S Hay
- b Department of Pharmacy Practice, Administration, and Research, School of Pharmacy , Marshall University , Huntington , WV , USA.,c Department of Pharmacy , St. Mary's Medical Center , Huntington , WV , USA
| | - Charles K Babcock
- b Department of Pharmacy Practice, Administration, and Research, School of Pharmacy , Marshall University , Huntington , WV , USA
| | - Timothy E Long
- a Department of Pharmaceutical Science and Research, School of Pharmacy , Marshall University , Huntington , WV , USA.,d Department of Biochemistry and Microbiology, Joan C. Edwards School of Medicine , Marshall University , Huntington , WV , USA
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Bassères E, Endres BT, Khaleduzzaman M, Miraftabi F, Alam MJ, Vickers RJ, Garey KW. Impact on toxin production and cell morphology in Clostridium difficile by ridinilazole (SMT19969), a novel treatment for C. difficile infection. J Antimicrob Chemother 2016; 71:1245-51. [PMID: 26895772 PMCID: PMC4830417 DOI: 10.1093/jac/dkv498] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 12/15/2015] [Accepted: 12/21/2015] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES Ridinilazole (SMT19969) is a narrow-spectrum, non-absorbable antimicrobial with activity against Clostridium difficile undergoing clinical trials. The purpose of this study was to assess the pharmacological activity of ridinilazole and assess the effects on cell morphology. METHODS Antibiotic killing curves were performed using the epidemic C. difficile ribotype 027 strain, R20291, using supra-MIC (4× and 40×) and sub-MIC (0.125×, 0.25× and 0.5×) concentrations of ridinilazole. Following exposure, C. difficile cells were collected for cfu counts, toxin A and B production, and morphological changes using scanning electron and fluorescence microscopy. Human intestinal cells (Caco-2) were co-incubated with ridinilazole-treated C. difficile growth medium to determine the effects on host inflammatory response (IL-8). RESULTS Treatment at supra-MIC concentrations (4× and 40× MIC) of ridinilazole resulted in a significant reduction in vegetative cells over 72 h (4 log difference, P < 0.01) compared with controls without inducing spore formation. These results correlated with a 75% decrease in toxin A production (P < 0.05) and a 96% decrease in toxin B production (P < 0.05). At sub-MIC levels (0.5× MIC), toxin A production was reduced by 91% (P < 0.01) and toxin B production was reduced by 100% (P < 0.001), which resulted in a 74% reduction in IL-8 release compared with controls (P < 0.05). Sub-MIC (0.5×)-treated cells formed filamentous structures ∼10-fold longer than control cells. Following fluorescence labelling, the cell septum was not forming in sub-MIC-treated cells, yet the DNA was dividing. CONCLUSIONS Ridinilazole had robust killing effects on C. difficile that significantly reduced toxin production and attenuated the inflammatory response. Ridinilazole also elicited significant cell division effects suggesting a potential mechanism of action.
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Affiliation(s)
- Eugénie Bassères
- University of Houston College of Pharmacy, 1441 Moursund Street, Houston, TX 77030, USA
| | - Bradley T Endres
- University of Houston College of Pharmacy, 1441 Moursund Street, Houston, TX 77030, USA
| | | | - Faranak Miraftabi
- University of Houston College of Pharmacy, 1441 Moursund Street, Houston, TX 77030, USA
| | - M Jahangir Alam
- University of Houston College of Pharmacy, 1441 Moursund Street, Houston, TX 77030, USA
| | - Richard J Vickers
- Summit Therapeutics, 85b Park Drive, Milton Park, Abingdon, Oxfordshire OX14 4RY, UK
| | - Kevin W Garey
- University of Houston College of Pharmacy, 1441 Moursund Street, Houston, TX 77030, USA
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Affiliation(s)
- Matthew C T Fyfe
- Topivert Limited, Imperial College Incubator, London, United Kingdom
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Auchtung JM, Robinson CD, Farrell K, Britton RA. MiniBioReactor Arrays (MBRAs) as a Tool for Studying C. difficile Physiology in the Presence of a Complex Community. Methods Mol Biol 2016; 1476:235-58. [PMID: 27507346 DOI: 10.1007/978-1-4939-6361-4_18] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The commensal microbiome plays an important role in the dynamics of Clostridium difficile infection. In this chapter, we describe minibioreactor arrays (MBRAs), an in vitro cultivation system that we developed that allows for C. difficile physiology to be assayed in the presence of complex fecal microbial communities. The small size of the bioreactors within the MBRAs allows for dozens of reactors to be run simultaneously and therefore several different variables can be tested with limited time and cost. When coupled with experiments in animal models of C. difficile infection, MBRAs can provide important insights into C. difficile physiology and pathogenesis.
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Affiliation(s)
- Jennifer M Auchtung
- Alkek Center for Metagenomics and Microbiome Research, Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, 77030, USA.
| | - Catherine D Robinson
- Alkek Center for Metagenomics and Microbiome Research, Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, 77030, USA.,Institute for Molecular Biology, University of Oregon, Eugene, OR, 97403, USA
| | - Kylie Farrell
- Alkek Center for Metagenomics and Microbiome Research, Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Robert A Britton
- Alkek Center for Metagenomics and Microbiome Research, Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, 77030, USA
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Baines SD, Wilcox MH. Antimicrobial Resistance and Reduced Susceptibility in Clostridium difficile: Potential Consequences for Induction, Treatment, and Recurrence of C. difficile Infection. Antibiotics (Basel) 2015; 4:267-98. [PMID: 27025625 PMCID: PMC4790285 DOI: 10.3390/antibiotics4030267] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 07/02/2015] [Accepted: 07/03/2015] [Indexed: 12/11/2022] Open
Abstract
Clostridium difficile infection (CDI) remains a substantial burden on healthcare systems and is likely to remain so given our reliance on antimicrobial therapies to treat bacterial infections, especially in an aging population in whom multiple co-morbidities are common. Antimicrobial agents are a key component in the aetiology of CDI, both in the establishment of the infection and also in its treatment. The purpose of this review is to summarise the role of antimicrobial agents in primary and recurrent CDI; assessing why certain antimicrobial classes may predispose to the induction of CDI according to a balance between antimicrobial activity against the gut microflora and C. difficile. Considering these aspects of CDI is important in both the prevention of the infection and in the development of new antimicrobial treatments.
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Affiliation(s)
- Simon D Baines
- Department of Biological and Environmental Sciences, School of Life and Medical 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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Vickers R, Robinson N, Best E, Echols R, Tillotson G, Wilcox M. A randomised phase 1 study to investigate safety, pharmacokinetics and impact on gut microbiota following single and multiple oral doses in healthy male subjects of SMT19969, a novel agent for Clostridium difficile infections. BMC Infect Dis 2015; 15:91. [PMID: 25880933 PMCID: PMC4349307 DOI: 10.1186/s12879-015-0759-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 01/15/2015] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Clostridium difficile infection (CDI) is a leading cause of diarrhoea in health care settings with symptoms ranging from mild and self-limiting to life threatening. SMT19969 is a novel, non-absorbable antibiotic currently under development for the treatment of CDI. Here we report the results from a Phase I study. METHODS A double-blind, randomized, placebo-controlled study assessing safety and tolerability of single and multiple oral doses of SMT19969 in healthy volunteers. Pharmacokinetic assessments included blood and faecal sampling. The effect of food on systemic exposure and analysis of the gut microbiota were also included. RESULTS Fifty-six healthy male subjects were enrolled. Following single oral doses of up to 2,000 mg in the fasted state, plasma concentrations of SMT19969 were generally below the lower limit of quantification. In the fed state levels ranged from 0.102 to 0.296 ng/mL after single dosing and after repeat dosing at Day 10 from 0.105 to 0.305 ng/mL. Following single and multiple oral doses of SMT19969, mean daily faecal concentrations increased with increasing dose level and were significantly above the typical MIC range for C. difficile (0.06-0.5 μg/mL). At 200 mg BID, mean (± SD) faecal concentrations of 1,466 (±547) μg/g and 1,364 (±446) μg/g were determined on days 5 and 10 of dosing respectively. No notable metabolites were detected in faeces. Overall, all doses of SMT19969 were well tolerated both as single oral doses or BID oral doses for 10 days. The majority (88%) of adverse events (AEs) were classified as gastrointestinal disorders and were mild in severity, resolving without treatment. The gut microbiota was analysed in the multiple dose groups with minimal changes observed in the bacterial groups analysed except for total clostridia which were reduced to below the limit of detection by day 4 of dosing. CONCLUSIONS Oral administration of SMT19969 was considered safe and well tolerated and was associated with negligible plasma concentrations after single and multiple doses. In addition, minimal disruption of normal gut microbiota was noted, confirming the highly selective spectrum of the compound. These results support the further clinical development of SMT19969 as an oral therapy for CDI. TRIAL REGISTRATION Current Controlled Trials. ISRCTN10858225 .
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Affiliation(s)
- Richard Vickers
- Summit PLC, 85b Park Drive, Milton Park, Abingdon, Oxford, OX14 4RY, UK.
| | - Neil Robinson
- Summit PLC, 85b Park Drive, Milton Park, Abingdon, Oxford, OX14 4RY, UK.
| | - Emma Best
- Microbiology, Leeds Teaching Hospitals & University of Leeds, Old Medical School, Leeds General Infirmary, Leeds, LS1 3EX, UK.
| | | | | | - Mark Wilcox
- Microbiology, Leeds Teaching Hospitals & University of Leeds, Old Medical School, Leeds General Infirmary, Leeds, LS1 3EX, UK.
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Corbett D, Wise A, Birchall S, Warn P, Baines SD, Crowther G, Freeman J, Chilton CH, Vernon J, Wilcox MH, Vickers RJ. In vitro susceptibility of Clostridium difficile to SMT19969 and comparators, as well as the killing kinetics and post-antibiotic effects of SMT19969 and comparators against C. difficile. J Antimicrob Chemother 2015; 70:1751-6. [PMID: 25652750 PMCID: PMC4498293 DOI: 10.1093/jac/dkv006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 12/17/2014] [Accepted: 12/31/2014] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES SMT19969 is a novel antimicrobial under clinical development for the treatment of Clostridium difficile infection (CDI). The objective was to determine the comparative susceptibility of 82 C. difficile clinical isolates (which included ribotype 027 isolates and isolates with reduced metronidazole susceptibility) to SMT19969, fidaxomicin, vancomycin and metronidazole and to determine the killing kinetics and post-antibiotic effects of SMT19969, fidaxomicin and vancomycin against C. difficile. METHODS MICs were determined by agar incorporation. Killing kinetics and post-antibiotic effects were determined against C. difficile BI1, 630 and 5325 (ribotypes 027, 012 and 078, respectively). RESULTS SMT19969 showed potent inhibition of C. difficile (MIC90=0.125 mg/L) and was markedly more active than either metronidazole (MIC90 = 8 mg/L) or vancomycin (MIC90 = 2 mg/L). There were no differences in susceptibility to SMT19969 between different ribotypes. Fidaxomicin was typically one doubling dilution more active than SMT19969 and both agents maintained activity against isolates with reduced susceptibility to metronidazole. In addition, SMT19969 was bactericidal against the C. difficile strains tested, with reductions in viable counts to below the limit of detection by 24 h post-inoculation. Vancomycin was bacteriostatic against all three strains. Fidaxomicin was bactericidal although reduced killing was observed at concentrations <20 × MIC against C. difficile BI1 (ribotype 027) compared with other strains tested. CONCLUSIONS These data demonstrate that SMT19969 is associated with potent and bactericidal activity against the strains tested and support further investigation of SMT19969 as potential therapy for CDI.
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Affiliation(s)
- D Corbett
- Evotec (UK), Williams House, Manchester Science Park, Lloyd Street North, Manchester M15 6SE, UK
| | - A Wise
- Evotec (UK), Williams House, Manchester Science Park, Lloyd Street North, Manchester M15 6SE, UK
| | - S Birchall
- Evotec (UK), Williams House, Manchester Science Park, Lloyd Street North, Manchester M15 6SE, UK
| | - P Warn
- Evotec (UK), Williams House, Manchester Science Park, Lloyd Street North, Manchester M15 6SE, UK
| | - S D Baines
- Department of Life and Medical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK
| | - G Crowther
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust and Healthcare Associated Infections Research Group, The University of Leeds, Old Medical School, Leeds LS1 3EX, UK
| | - J Freeman
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust and Healthcare Associated Infections Research Group, The University of Leeds, Old Medical School, Leeds LS1 3EX, UK
| | - C H Chilton
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust and Healthcare Associated Infections Research Group, The University of Leeds, Old Medical School, Leeds LS1 3EX, UK
| | - J Vernon
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust and Healthcare Associated Infections Research Group, The University of Leeds, Old Medical School, Leeds LS1 3EX, UK
| | - M H Wilcox
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust and Healthcare Associated Infections Research Group, The University of Leeds, Old Medical School, Leeds LS1 3EX, UK
| | - R J Vickers
- Summit plc, 85b Park Drive, Milton Park, Abingdon, Oxfordshire OX14 4RY, UK
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