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Veeraraghavan B, Bakthavatchalam YD, Manesh A, Lal B, Swaminathan S, Ansari A, Subbareddy K, Rangappa P, Choudhuri AH, Nagvekar V, Mehta Y, Appalaraju B, Baveja S, Baliga S, Shenoy S, Bhardwaj R, Kongre V, Dattatraya GS, Verma B, Mukherjee DN, Gupta S, Shanmugam P, Iravane J, Mishra SR, Barman P, Chopra S, Hariharan M, Surpam R, Pratap R, Turbadkar D, Taklikar S. India-discovered levonadifloxacin & alalevonadifloxacin: A review on susceptibility testing methods, CLSI quality control and breakpoints along with a brief account of their emerging therapeutic profile as a novel standard-of-care. Indian J Med Microbiol 2023; 41:71-80. [PMID: 36509611 DOI: 10.1016/j.ijmmb.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/04/2022] [Accepted: 11/11/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Levonadifloxacin (intravenous) and alalevonadifloxacin (oral prodrug) are novel antibiotics based on benzoquinolizine subclass of fluoroquinolone, licensed for clinical use in India in 2019. The active moiety, levonadifloxacin, is a broad-spectrum antibiotic with a high potency against methicillin-resistant Staphylococcus. aureus, multi-drug resistant pneumococci and anaerobes. OBJECTIVE This review, for the first time, critically analyses the antimicrobial susceptibility testing methods, Clinical Laboratory & Standards Institute (CLSI)-quality control of susceptibility testing and breakpoints of levonadifloxacin. Further, the genesis, discovery and developmental aspects as well as therapeutic profile of levonadifloxacin and alalevonadifloxacin are briefly described. CONTENTS In order to aid the scientific and clinician communities with a single comprehensive overview on all the key aspects of levonadifloxacin and alalevonadifloxacin, the present article covers the reference MIC and disk diffusion methods for levonadifloxacin susceptibility testing that were approved by CLSI and the reference ranges for quality control strains published in the CLSI M100 document. The breakpoints of levonadifloxacin were derived in concordance to US FDA, European Committee on Antibiotic Susceptibility Testing (EUCAST) and CLSI approaches. Further, the article provides a brief account of challenges encountered during the discovery stages of levonadifloxacin and alalevonadifloxacin, activity spectrum and safety benefits accruing from structural novelty-linked mechanism of action. Further, the review also covers in vitro and in vivo activities, registrational clinical studies and patient-friendly features of levonadifloxacin/alalevonadifloxacin. Cumulatively, levonadifloxacin has a potential to offer a long awaited new standard-of-care treatment for the resistant Gram-positive bacterial infections.
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Affiliation(s)
- Balaji Veeraraghavan
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamilnadu, India.
| | | | - Abi Manesh
- Department of Infectious Disease, Christian Medical College, Vellore, Tamil Nadu, India
| | - Binesh Lal
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamilnadu, India
| | | | - Abdul Ansari
- Critical Care Division, Nanavati Max Super Speciality Hospital, Mumbai, Maharashtra, India
| | - K Subbareddy
- Critical care, Apollo Hospitals, Hyderabad, India
| | | | - Anirban Hom Choudhuri
- Critical care, GB Pant Institute of Post Graduate Medical Education & Research, New Delhi, India
| | - Vasant Nagvekar
- Department of Physician/Internal Medicine, Infectious Diseases, Lilavati Hospital, Mumbai, Maharashtra, India
| | - Yatin Mehta
- Department of Medanta Institute of Critical Care and Anesthesiology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - Boppe Appalaraju
- Department of Microbiology, PSG Institute of Medical Sciences and Research, Peelamedu, Coimbatore, Tamil Nadu, India
| | - Sujata Baveja
- Department of Microbiology, Lokmanya Tilak Municipal General Hospital and Lokmanya Tilak Municipal Medical College, Sion, Mumbai, India
| | - Shrikala Baliga
- Department of Microbiology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Karnataka, India
| | - Suchitra Shenoy
- Department of Microbiology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Karnataka, India
| | - Renu Bhardwaj
- Department of Microbiology, Byramjee Jeejeebhoy Government Medical College and Sassoon Hospitals, Pune, Maharashtra, India
| | - Vaishali Kongre
- Department of Microbiology, Byramjee Jeejeebhoy Government Medical College and Sassoon Hospitals, Pune, Maharashtra, India
| | | | - Binita Verma
- Department of Microbiology, Shree Jagannath Hospital & Research Centre, Ranchi, Jharkhand, India
| | - D N Mukherjee
- Department of Microbiology, Woodlands Multispeciality Hospital Ltd, Kolkata, West Bengal, India
| | - Shalini Gupta
- Department of Microbiology, Somani Hospital, Jaipur, Rajasthan, India
| | - Priyadarshini Shanmugam
- Department of Microbiology, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Chennai, Tamil Nadu, India
| | - Jyoti Iravane
- Department of Microbiology, Government Medical College, Aurangabad, Maharashtra, India
| | - Sudhi Ranjan Mishra
- Department of Microbiology, Aditya Care Hospital, Bhubaneswar, Odisha, India
| | - Purabi Barman
- Department of Microbiology, BLK Super Speciality Hospital, New Delhi, India
| | - Shimpi Chopra
- Department of Microbiology, BLK Super Speciality Hospital, New Delhi, India
| | | | - Rajendra Surpam
- Department of Microbiology, Government Medical College and Hospital, Nagpur, Maharashtra, India
| | - Rana Pratap
- Department of Microbiology, Narayan Medical College and Hospital, Jamuhar, Bihar, India
| | - Dilip Turbadkar
- Department of Microbiology, Lokmanya Tilak Municipal General Hospital and Lokmanya Tilak Municipal Medical College, Sion, Mumbai, India
| | - Shripad Taklikar
- Department of Microbiology, Lokmanya Tilak Municipal General Hospital and Lokmanya Tilak Municipal Medical College, Sion, Mumbai, India
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Lautre C, Sharma S, Sahu JK. Chemistry, Biological Properties and Analytical Methods of Levonadifloxacin: A Review. Crit Rev Anal Chem 2020; 52:1069-1077. [PMID: 33307757 DOI: 10.1080/10408347.2020.1855412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Increased use of antibiotics globally has led to the threat of antibiotic resistance; this drove the urge of researchers toward discovering more potent and broad-spectrum antibiotics. Levonadifloxacin (LND) is the very first antibiotic developed by an Indian company Wockhardt. It is S (-) isomer of another broad-spectrum antibiotic Nadifloxacin which is used topically for skin, soft tissue bacterial infection. LND belongs to the benzo quinolizine category which is a subclass of fluoroquinolone, indicated for ABSSIS, CABP, and other infections including diabetic foot infection; formulated as l-arginine salt of levonadifloxacin (WCK177) for IV and l-alanine ester mesylate salt as alalevonadifloxacin (WCK2349) for oral administration. It generally shows dominant antibacterial activity against Gram-negative, and positive bacterial infections, particularly toward methicillin-resistant Staphylococcus aureus (MRSA) by dual inhibition of DNA gyrase and topoisomerase IV. Producing quality product that complies to regulatory requirements is a big concern for pharma industries. To this context, validated analytical methods for routine quality control are essential for quantification of LND as an API alone and together with pharmaceutical formulations. This review suggests therapeutic, pharmacological, and analytical aspects regarding the novel drug LND and particularly focuses on discussing various reported analytical methods present for analytical or bioanalytical estimation of the drug and suggest to develop a simple and validated method which also complies to green chemistry.
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Affiliation(s)
- Charul Lautre
- SVKM'S NMIMS School of Pharmacy and Technology Management, Shirpur, Maharashtra, India
| | - Sanjay Sharma
- SVKM'S NMIMS School of Pharmacy and Technology Management, Shirpur, Maharashtra, India
| | - Jagdish K Sahu
- SVKM'S NMIMS School of Pharmacy and Technology Management, Shirpur, Maharashtra, India
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Bakthavatchalam YD, Shankar A, Muniyasamy R, Peter JV, Marcus Z, Triplicane Dwarakanathan H, Gunasekaran K, Iyadurai R, Veeraraghavan B. Levonadifloxacin, a recently approved benzoquinolizine fluoroquinolone, exhibits potent in vitro activity against contemporary Staphylococcus aureus isolates and Bengal Bay clone isolates collected from a large Indian tertiary care hospital. J Antimicrob Chemother 2020; 75:2156-2159. [PMID: 32361727 DOI: 10.1093/jac/dkaa142] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 03/09/2020] [Accepted: 03/20/2020] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES Levonadifloxacin (WCK 771; IV) and its prodrug alalevonadifloxacin (WCK 2349; oral) are benzoquinolizine fluoroquinolones, recently approved in India for the treatment of acute bacterial skin and skin structure infections with concurrent bacteraemia and diabetic foot infections. Ahead of its market launch, the present study aimed to assess the in vitro activity of levonadifloxacin against contemporary Staphylococcus aureus isolates collected from a large tertiary care hospital in India. Additionally, levonadifloxacin activity was tested against hVISA and Bengal Bay clone MRSA isolates. METHODS Non-duplicate S. aureus (n = 793) isolates collected at Christian Medical College hospital, Vellore, India during 2013-19 were included in the study. MRSA isolates were identified using a cefoxitin disc diffusion assay. MICs of levonadifloxacin and comparator antibiotics were determined using the broth microdilution method. Mutations in QRDRs were identified for selected levofloxacin-non-susceptible isolates. MLST profiling was undertaken to detect the Bengal Bay clone. RESULTS Among the 793 isolates, 441 (55.6%) were MRSA and 626 (78.9%) were non-susceptible to levofloxacin. Levonadifloxacin showed MIC50 and MIC90 values of 0.25 and 0.5 mg/L, respectively, for all S. aureus, which included hVISA and Bengal Bay clone MRSA. The potency of levonadifloxacin was 16 times superior compared with levofloxacin. CONCLUSIONS The present study demonstrated potent activity of levonadifloxacin against contemporary S. aureus isolates, which included MRSA isolates, hVISA isolates, Bengal Bay clone isolates and a high proportion of quinolone-non-susceptible isolates. The potent activity of levonadifloxacin observed in this study supports its clinical use for the treatment of S. aureus infections.
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Affiliation(s)
| | - Abirami Shankar
- Department of Clinical Microbiology, Christian Medical College, Vellore 632004, India
| | - Rajeshwari Muniyasamy
- Department of Clinical Microbiology, Christian Medical College, Vellore 632004, India
| | - John Victor Peter
- Department of Critical Care Medicine, Christian Medical College, Vellore 632004, India
| | - Zervos Marcus
- Division of Infectious Disease, Henry Ford Health System, Detroit, MI 48202, USA
| | | | - Karthik Gunasekaran
- Department of Medicine, Unit V, Christian Medical College, Vellore 632004, India
| | - Ramya Iyadurai
- Department of Medicine, Unit V, Christian Medical College, Vellore 632004, India
| | - Balaji Veeraraghavan
- Department of Clinical Microbiology, Christian Medical College, Vellore 632004, India
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Baliga S, Mamtora DK, Gupta V, Shanmugam P, Biswas S, Mukherjee DN, Shenoy S. Assessment of antibacterial activity of levonadifloxacin against contemporary gram-positive clinical isolates collected from various Indian hospitals using disk-diffusion assay. Indian J Med Microbiol 2020; 38:307-312. [PMID: 33154240 DOI: 10.4103/ijmm.ijmm_20_307] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives Levonadifloxacin is a novel benzoquinolizine subclass of quinolone with broad-spectrum activities against problematic pathogens such as methicillin-resistant Staphylococcus aureus, quinolone-resistant S. aureus, vancomycin intermediate S. aureus, and vancomycin-resistant S. aureus. Levonadifloxacin and its oral prodrug, alalevonadifloxacin, have been recently approved in India for the treatment of acute bacterial skin and skin structure infections, including concurrent bacteraemia and diabetic foot infections. The aim of the study is to assess the activity of levonadifloxacin against Gram-positive clinical isolates collected from various Indian hospitals using the disc-diffusion method. Materials and Methods Nonduplicate isolates of S. aureus and other Gram-positive isolates collected from June 2019 to March 2020 were subjected to levonadifloxacin susceptibility testing (disk diffusion method) as per the Clinical and Laboratory Standards Institute guidelines (Year 2019). Levonadifloxacin 10 μg impregnated disks were used during the testing. Results A total of 664 diverse Gram-positive clinical isolates collected from six different hospitals in India were analyzed. Majority (65.5%) of the isolates were S. aureus. All the S. aureus and other Gram-positive isolates were found to be susceptible to levonadifloxacin as per the prespecified interpretive criteria identified based on population pharmacokinetic model and Monte Carlo simulation enabled probability of pharmacodynamic target attainment analysis. Conclusions The present study showed that levonadifloxacin was highly active against contemporary Gram-positive pathogens and furthermore demonstrated that levonadifloxacin susceptibilities can be reliably determined using the disc-diffusion method.
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Affiliation(s)
- Shrikala Baliga
- Department of Microbiology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Dhruv K Mamtora
- Department of Microbiology, S. L. Raheja (A Fortis Associate) Hospital, Mahim, Mumbai, Maharashtra, India
| | - Varsha Gupta
- Department of Microbiology, Government Medical College, Chandigarh, India
| | - Priyadarshini Shanmugam
- Department of Microbiology, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Chennai, Tamil Nadu, India
| | - Sanjay Biswas
- Department of Microbiology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - D N Mukherjee
- Department of Microbiology, Woodlands Multispeciality Hospital, Kolkata, West Bengal, India
| | - Suchitra Shenoy
- Department of Microbiology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Bhagwat SS, Nandanwar M, Kansagara A, Patel A, Takalkar S, Chavan R, Periasamy H, Yeole R, Deshpande PK, Bhavsar S, Bhatia A, Ahdal J, Jain R, Patel M. Levonadifloxacin, a Novel Broad-Spectrum Anti-MRSA Benzoquinolizine Quinolone Agent: Review of Current Evidence. Drug Des Devel Ther 2019; 13:4351-4365. [PMID: 31920285 PMCID: PMC6935279 DOI: 10.2147/dddt.s229882] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/17/2019] [Indexed: 12/29/2022] Open
Abstract
Levonadifloxacin and its prodrug alalevonadifloxacin are novel broad-spectrum anti-MRSA agents belonging to the benzoquinolizine subclass of quinolone, formulated for intravenous and oral administration, respectively. Various in vitro and in vivo studies have established their antimicrobial spectrum against clinically significant Gram-positive, Gram-negative, atypical, and anaerobic pathogens. The potent activity of levonadifloxacin against MRSA, quinolone-resistant Staphylococcus aureus, and hetero-vancomycin-intermediate strains is an outcome of its well-differentiated mechanism of action involving preferential targeting to DNA gyrase. Potent anti-staphylococcal activity of levonadifloxacin was also observed in clinically relevant experimental conditions such as acidic pH, the intracellular environment, and biofilms, suggesting that the drug is bestowed with enabling features for the treatment of difficult-to-treat MRSA infections. Levonadifloxacin also retains clinically relevant activity against resistant respiratory pathogens such as macrolide- and penicillin-resistant Streptococcus pneumoniae, Streptococcus pyogenes, Haemophilus influenzae, and Moraxella catarrhalis and, in conjunction with clinically established best-in-class human epithelial lung fluid concentration, has promising potential in the management of recalcitrant respiratory infections. Attractive features, such as resistance to NorA efflux, divergent mechanism of action in S. aureus, cidality against high-inoculum cultures, and low mutant prevention concentration, are likely to confer favorable resistance-suppression features to both agents. In vivo studies have shown promising efficacy in models of acute bacterial skin and skin structure infection, respiratory infections, pyelonephritis, and peritonitis at human-equivalent mouse doses. Both formulations were well tolerated in multiple phase I studies and overall showed a dose-dependent exposure. In particular, oral alalevonadifloxacin showed excellent bioavailability (~90%), almost mirroring the pharmacokinetic profile of intravenous levonadifloxacin, indicating the prodrug's seamless absorption and efficient cleavage to release the active parent drug. Hepatic impairment studies showed that clinical doses of levonadifloxacin/alalevonadifloxacin are not required to be adjusted for various degrees of hepatic impairment. With the successful completion of phase II and phase III studies for both levonadifloxacin and alalevonadifloxacin, they represent clinically attractive therapeutic options for the treatment of infections caused by multi-drug-resistant Gram-positive organisms. Herein, we review the current evidence on therapeutically appealing attributes of levonadifloxacin and alalevonadifloxacin, which are based on a range of non-clinical in vitro and in vivo investigations and clinical studies.
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Affiliation(s)
- Sachin S Bhagwat
- Department of Microbiology, Wockhardt Research Centre, Aurangabad, India
| | - Manohar Nandanwar
- Department of Toxicology, Wockhardt Research Centre, Aurangabad, India
| | - Atul Kansagara
- Department of Toxicology, Wockhardt Research Centre, Aurangabad, India
| | - Anusuya Patel
- Department of Safety Pharmacology, Wockhardt Research Centre, Aurangabad, India
| | - Swapna Takalkar
- Department of Microbiology, Wockhardt Research Centre, Aurangabad, India
| | - Rajesh Chavan
- Department of Drug Metabolism and Pharmacokinetics, Wockhardt Research Centre, Aurangabad, India
| | | | - Ravindra Yeole
- Department of Analytical Chemistry, Wockhardt Research Centre, Aurangabad, India
| | - Prasad K Deshpande
- Department of Medicinal Chemistry, Wockhardt Research Centre, Aurangabad, India
| | - Satish Bhavsar
- Department of Medicinal Chemistry, Wockhardt Research Centre, Aurangabad, India
| | - Ashima Bhatia
- Global Clinical Operations, Wockhardt Ltd, Mumbai, India
| | - Jaishid Ahdal
- Department of Medical Affairs, Wockhardt Ltd, Mumbai, India
| | - Rishi Jain
- Department of Medical Affairs, Wockhardt Ltd, Mumbai, India
| | - Mahesh Patel
- Drug Discovery Research, Wockhardt Research Centre, Aurangabad, India
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Bakthavatchalam YD, Rao SV, Isaac B, Manesh A, Nambi S, Swaminathan S, Nagvekar V, Nangia V, John PV, Veeraraghavan B. A comparative assessment of clinical, pharmacological and antimicrobial profile of novel anti-methicillin-resistant Staphylococcus aureus agent levonadifloxacin: Therapeutic role in nosocomial and community infections. Indian J Med Microbiol 2019; 37:478-487. [PMID: 32436868 DOI: 10.4103/ijmm.ijmm_20_34] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Staphylococcus aureus is of significant clinical concern in both community- and hospital-onset infections. The key to the success of S. aureus as a pathogen is its ability to swiftly develop antimicrobial resistance. Methicillin-resistant S. aureus (MRSA) is not only resistant to nearly all beta-lactams but also demonstrates resistance to several classes of antibiotics. A high prevalence of MRSA is seen across worldwide. For many decades, vancomycin remained as gold standard antibiotic for the treatment of MRSA infections. In the past decades, linezolid, daptomycin, ceftaroline and telavancin received regulatory approval for the treatment of infections caused by resistant Gram-positive pathogens. Although these drugs may offer some advantages over vancomycin, they also have significant limitations. These includes vancomycin's slow bactericidal activity, poor lung penetration and nephrotxicity;linezolid therapy induced myelosuppression and high cost of daptomycin greatly limits their clinical use. Moreover, daptomycin also gets inactivated by lung naturally occurring surfactants. Thus, currently available therapeutic options are unable to provide safe and efficacious treatment for those patients suffering from hospital-acquired pneumonia, bloodstream infections (BSIs), bone and joint infections and diabetic foot infections (DFI). An unmet need also exists for a safe and efficacious oral option for switch-over convenience and community treatment. Herein, the review is intended to describe the supporting role of anti-staphylococcal antibiotics used in the management of S. aureus infections with a special reference to levonadifloxacin. Levonadifloxacin and its prodrug alalevonadifloxacin are novel benzoquinolizine subclass of quinolone with broad-spectrum of anti-MRSA activity. It has been recently approved for the treatment of complicated skin and soft-tissue infection as well as concurrent bacteraemia and DFI in India.
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Affiliation(s)
| | - Shoma Vinay Rao
- Department of Critical Care Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - Barney Isaac
- Department of Pulmonary Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Abi Manesh
- Department of Internal Medicine and Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | - Senthur Nambi
- Department of Infectious Disease, Apollo Hospital, Chennai, Tamil Nadu, India
| | | | - Vasanth Nagvekar
- Department of Infectious disease, Lilavati Hospital, Mumbai, Maharashtra, India
| | - Vivek Nangia
- Department of Infectious Disease, Fortis Hospital, New Delhi, India
| | - Peter Victor John
- Critical Care Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Balaji Veeraraghavan
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
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