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LeBlanc A, Wuest WM. Siderophores: A Case Study in Translational Chemical Biology. Biochemistry 2024; 63:1877-1891. [PMID: 39041827 PMCID: PMC11308372 DOI: 10.1021/acs.biochem.4c00276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 07/09/2024] [Accepted: 07/10/2024] [Indexed: 07/24/2024]
Abstract
Siderophores are metal-binding secondary metabolites that assist in iron homeostasis and have been of interest to the scientific community for the last half century. Foundational siderophore research has enabled several translational applications including siderophore-antibiotic and siderophore-peptide conjugates, identification of new antimicrobial targets, advances in disease imaging, and novel therapeutics. This review aims to connect the basic science research (biosynthesis, cellular uptake, gene regulation, and effects on homeostasis) of well-known siderophores with the successive translational application that results. Intertwined throughout are connections to the career of Christopher T. Walsh, his impact on the field of chemical biology, and the legacy of his trainees who continue to innovate.
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Affiliation(s)
- Andrew
R. LeBlanc
- Department of Chemistry, Emory
University, Atlanta, Georgia 30322, United States
| | - William M. Wuest
- Department of Chemistry, Emory
University, Atlanta, Georgia 30322, United States
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2
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Hibbert T, Krpetic Z, Latimer J, Leighton H, McHugh R, Pottenger S, Wragg C, James CE. Antimicrobials: An update on new strategies to diversify treatment for bacterial infections. Adv Microb Physiol 2024; 84:135-241. [PMID: 38821632 DOI: 10.1016/bs.ampbs.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
Ninety-five years after Fleming's discovery of penicillin, a bounty of antibiotic compounds have been discovered, modified, or synthesised. Diversification of target sites, improved stability and altered activity spectra have enabled continued antibiotic efficacy, but overwhelming reliance and misuse has fuelled the global spread of antimicrobial resistance (AMR). An estimated 1.27 million deaths were attributable to antibiotic resistant bacteria in 2019, representing a major threat to modern medicine. Although antibiotics remain at the heart of strategies for treatment and control of bacterial diseases, the threat of AMR has reached catastrophic proportions urgently calling for fresh innovation. The last decade has been peppered with ground-breaking developments in genome sequencing, high throughput screening technologies and machine learning. These advances have opened new doors for bioprospecting for novel antimicrobials. They have also enabled more thorough exploration of complex and polymicrobial infections and interactions with the healthy microbiome. Using models of infection that more closely resemble the infection state in vivo, we are now beginning to measure the impacts of antimicrobial therapy on host/microbiota/pathogen interactions. However new approaches are needed for developing and standardising appropriate methods to measure efficacy of novel antimicrobial combinations in these contexts. A battery of promising new antimicrobials is now in various stages of development including co-administered inhibitors, phages, nanoparticles, immunotherapy, anti-biofilm and anti-virulence agents. These novel therapeutics need multidisciplinary collaboration and new ways of thinking to bring them into large scale clinical use.
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Affiliation(s)
- Tegan Hibbert
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences (IVES), University of Liverpool, Liverpool, UK
| | - Zeljka Krpetic
- School of Science, Engineering, and Environment, University of Salford, Salford, UK
| | - Joe Latimer
- School of Science, Engineering, and Environment, University of Salford, Salford, UK
| | - Hollie Leighton
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences (IVES), University of Liverpool, Liverpool, UK
| | - Rebecca McHugh
- School of Infection and Immunity, University of Glasgow, Glasgow, UK
| | - Sian Pottenger
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences (IVES), University of Liverpool, Liverpool, UK
| | - Charlotte Wragg
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences (IVES), University of Liverpool, Liverpool, UK
| | - Chloë E James
- School of Science, Engineering, and Environment, University of Salford, Salford, UK.
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3
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Rayner B, Verderosa AD, Ferro V, Blaskovich MAT. Siderophore conjugates to combat antibiotic-resistant bacteria. RSC Med Chem 2023; 14:800-822. [PMID: 37252105 PMCID: PMC10211321 DOI: 10.1039/d2md00465h] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 02/21/2023] [Indexed: 10/31/2023] Open
Abstract
Antimicrobial resistance (AMR) is a global threat to society due to the increasing emergence of multi-drug resistant bacteria that are not susceptible to our last line of defence antibiotics. Exacerbating this issue is a severe gap in antibiotic development, with no new clinically relevant classes of antibiotics developed in the last two decades. The combination of the rapidly increasing emergence of resistance and scarcity of new antibiotics in the clinical pipeline means there is an urgent need for new efficacious treatment strategies. One promising solution, known as the 'Trojan horse' approach, hijacks the iron transport system of bacteria to deliver antibiotics directly into cells - effectively tricking bacteria into killing themselves. This transport system uses natively produced siderophores, which are small molecules with a high affinity for iron. By linking antibiotics to siderophores, to make siderophore antibiotic conjugates, the activity of existing antibiotics can potentially be reinvigorated. The success of this strategy was recently exemplified with the clinical release of cefiderocol, a cephalosporin-siderophore conjugate with potent antibacterial activity against carbapenem-resistant and multi-drug resistant Gram-negative bacilli. This review discusses the recent advancements in siderophore antibiotic conjugates and the challenges associated with the design of these compounds that need to be overcome to deliver more efficacious therapeutics. Potential strategies have also been suggested for new generations of siderophore-antibiotics with enhanced activity.
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Affiliation(s)
- Beth Rayner
- Centre for Superbug Solutions, Institute for Molecular Bioscience, University of Queensland Brisbane Queensland Australia
- Australian Infectious Disease Research Centre, The University of Queensland Brisbane Queensland Australia
| | - Anthony D Verderosa
- Centre for Superbug Solutions, Institute for Molecular Bioscience, University of Queensland Brisbane Queensland Australia
- Australian Infectious Disease Research Centre, The University of Queensland Brisbane Queensland Australia
| | - Vito Ferro
- Australian Infectious Disease Research Centre, The University of Queensland Brisbane Queensland Australia
- School of Chemistry and Molecular Biosciences, The University of Queensland Australia
| | - Mark A T Blaskovich
- Centre for Superbug Solutions, Institute for Molecular Bioscience, University of Queensland Brisbane Queensland Australia
- Australian Infectious Disease Research Centre, The University of Queensland Brisbane Queensland Australia
- School of Chemistry and Molecular Biosciences, The University of Queensland Australia
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4
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Multidrug resistance crisis during COVID-19 pandemic: Role of anti-microbial peptides as next-generation therapeutics. Colloids Surf B Biointerfaces 2021; 211:112303. [PMID: 34952285 PMCID: PMC8685351 DOI: 10.1016/j.colsurfb.2021.112303] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 12/03/2021] [Accepted: 12/16/2021] [Indexed: 02/07/2023]
Abstract
The decreasing effectiveness of conventional drugs due to multidrug-resistance is a major challenge for the scientific community, necessitating development of novel antimicrobial agents. In the present era of coronavirus 2 (COVID-19) pandemic, patients are being widely exposed to antimicrobial drugs and hence the problem of multidrug-resistance shall be aggravated in the days to come. Consequently, revisiting the phenomena of multidrug resistance leading to formulation of effective antimicrobial agents is the need of the hour. As a result, this review sheds light on the looming crisis of multidrug resistance in wake of the COVID-19 pandemic. It highlights the problem, significance and approaches for tackling microbial resistance with special emphasis on anti-microbial peptides as next-generation therapeutics against multidrug resistance associated diseases. Antimicrobial peptides exhibit exceptional mechanism of action enabling rapid killing of microbes at low concentration, antibiofilm activity, immunomodulatory properties along with a low tendency for resistance development providing them an edge over conventional antibiotics. The review is unique as it discusses the mode of action, pharmacodynamic properties and application of antimicrobial peptides in areas ranging from therapeutics to agriculture.
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Abstract
Stenotrophomonas maltophilia is an opportunistic pathogen of significant concern to susceptible patient populations. This pathogen can cause nosocomial and community-acquired respiratory and bloodstream infections and various other infections in humans. Sources include water, plant rhizospheres, animals, and foods. Studies of the genetic heterogeneity of S. maltophilia strains have identified several new genogroups and suggested adaptation of this pathogen to its habitats. The mechanisms used by S. maltophilia during pathogenesis continue to be uncovered and explored. S. maltophilia virulence factors include use of motility, biofilm formation, iron acquisition mechanisms, outer membrane components, protein secretion systems, extracellular enzymes, and antimicrobial resistance mechanisms. S. maltophilia is intrinsically drug resistant to an array of different antibiotics and uses a broad arsenal to protect itself against antimicrobials. Surveillance studies have recorded increases in drug resistance for S. maltophilia, prompting new strategies to be developed against this opportunist. The interactions of this environmental bacterium with other microorganisms are being elucidated. S. maltophilia and its products have applications in biotechnology, including agriculture, biocontrol, and bioremediation.
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Docquier JD, Mangani S. An update on β-lactamase inhibitor discovery and development. Drug Resist Updat 2017; 36:13-29. [PMID: 29499835 DOI: 10.1016/j.drup.2017.11.002] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 11/01/2017] [Accepted: 11/03/2017] [Indexed: 11/27/2022]
Abstract
Antibiotic resistance, and the emergence of pan-resistant clinical isolates, seriously threatens our capability to treat bacterial diseases, including potentially deadly hospital-acquired infections. This growing issue certainly requires multiple adequate responses, including the improvement of both diagnosis methods and use of antibacterial agents, and obviously the development of novel antibacterial drugs, especially active against Gram-negative pathogens, which represent an urgent medical need. Considering the clinical relevance of both β-lactam antibiotics and β-lactamase-mediated resistance, the discovery and development of combinations including a β-lactamase inhibitor seems to be particularly attractive, despite being extremely challenging due to the enormous diversity, both structurally and mechanistically, of the potential β-lactamase targets. This review will cover the evolution of currently available β-lactamase inhibitors along with the most recent research leading to new β-lactamase inhibitors of potential clinical interest or already in the stage of clinical development.
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Affiliation(s)
- Jean-Denis Docquier
- Department of Medical Biotechnology, University of Siena, Viale Bracci 16, 53100 Siena, Italy.
| | - Stefano Mangani
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Via Aldo Moro 2, 53100 Siena, Italy.
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Abstract
In this issue of Cell Chemical Biology, Li et al. (2017) report on the biosynthesis of the monobactam sulfazecin by Pseudomonas acidophila and hypothesize a novel mechanism of β-lactam ring formation. As monobactam antibiotics are unaffected by some emerging resistance mechanisms (particularly metallo-β-lactamases), this discovery opens prospects to engineer β-lactam antibiotics against multi-drug resistant pathogens.
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Affiliation(s)
- Daniel Braga
- Junior Research Group Synthetic Microbiology, Friedrich Schiller University at the Leibniz Institute for Natural Product Research and Infection Biology - Hans Knöll Institute, Beutenbergstr.11a, 07745 Jena, Germany
| | - Gerald Lackner
- Junior Research Group Synthetic Microbiology, Friedrich Schiller University at the Leibniz Institute for Natural Product Research and Infection Biology - Hans Knöll Institute, Beutenbergstr.11a, 07745 Jena, Germany.
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8
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Decuyper L, Jukič M, Sosič I, Žula A, D'hooghe M, Gobec S. Antibacterial and β-Lactamase Inhibitory Activity of Monocyclic β-Lactams. Med Res Rev 2017; 38:426-503. [DOI: 10.1002/med.21443] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 01/16/2017] [Accepted: 02/08/2017] [Indexed: 01/06/2023]
Affiliation(s)
- Lena Decuyper
- SynBioC Research Group, Department of Sustainable Organic Chemistry and Technology, Faculty of Bioscience Engineering; Ghent University; Ghent Belgium
| | - Marko Jukič
- Faculty of Pharmacy; University of Ljubljana; Ljubljana Slovenia
| | - Izidor Sosič
- Faculty of Pharmacy; University of Ljubljana; Ljubljana Slovenia
| | - Aleš Žula
- Faculty of Pharmacy; University of Ljubljana; Ljubljana Slovenia
| | - Matthias D'hooghe
- SynBioC Research Group, Department of Sustainable Organic Chemistry and Technology, Faculty of Bioscience Engineering; Ghent University; Ghent Belgium
| | - Stanislav Gobec
- Faculty of Pharmacy; University of Ljubljana; Ljubljana Slovenia
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Abstract
Given the serious medical burden of β-lactamases, many approaches are being used identify candidate agents for β-lactamase inhibition. Here, we review two β-lactam-β-lactamase inhibitor (BL-BLI) combinations, ceftolozane-tazobactam and ceftazidime-avibactam that recently entered the clinic. In addition, we focus on BL-BLI combinations in preclinical development that have demonstrated activity in clinical isolates via susceptibility testing and/or in in vivo models of infection. We highlight only the BLIs that are able to reduce the Clinical Laboratory Standards Institute (CLSI) breakpoints for the BL partner into the susceptible range. Our analysis includes the primary literature, meeting abstracts, as well as the patent literature.
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Klahn P, Brönstrup M. Bifunctional antimicrobial conjugates and hybrid antimicrobials. Nat Prod Rep 2017; 34:832-885. [PMID: 28530279 DOI: 10.1039/c7np00006e] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Covering: up to the end of 2016Novel antimicrobial drugs are continuously needed to counteract bacterial resistance development. An innovative molecular design strategy for novel antibiotic drugs is based on the hybridization of an antibiotic with a second functional entity. Such conjugates can be grouped into two major categories. In the first category (antimicrobial hybrids), both functional elements of the hybrid exert antimicrobial activity. Due to the dual targeting, resistance development can be significantly impaired, the pharmacokinetic properties can be superior compared to combination therapies with the single antibiotics, and the antibacterial potency is often enhanced in a synergistic manner. In the second category (antimicrobial conjugates), one functional moiety controls the accumulation of the other part of the conjugate, e.g. by mediating an active transport into the bacterial cell or blocking the efflux. This approach is mostly applied to translocate compounds across the cell envelope of Gram-negative bacteria through membrane-embedded transporters (e.g. siderophore transporters) that provide nutrition and signalling compounds to the cell. Such 'Trojan Horse' approaches can expand the antibacterial activity of compounds against Gram-negative pathogens, or offer new options for natural products that could not be developed as standalone antibiotics, e.g. due to their toxicity.
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Affiliation(s)
- P Klahn
- Department for Chemical Biology, Helmholtz Centre for Infection Research, Inhoffenstraße 7, 38124 Braunschweig, Germany. and Institute for Organic Chemistry, Technische Universität Braunschweig, Hagenring 30, 38106 Braunschweig, Germany.
| | - M Brönstrup
- Department for Chemical Biology, Helmholtz Centre for Infection Research, Inhoffenstraße 7, 38124 Braunschweig, Germany.
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Magistro G, Marcon J, Schubert S, Gratzke C, Stief CG. [Pathogenesis of urinary tract infections : An update]. Urologe A 2017; 56:720-727. [PMID: 28455576 DOI: 10.1007/s00120-017-0391-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Urinary tract infections are among the most common bacterial infections worldwide. The management has become a public health concern of socioeconomic importance. Every second woman will experience at least one episode in her lifetime. Due to the emergence of multiresistant pathogens and the developmental void, treatment has become more challenging over the years. Deciphering the complex molecular interaction between host and pathogen is necessary to identify potent treatment targets for future approaches. The objective of this review is to present novel aspects on the pathogenesis of urinary tract infections and its relevance for clinical practice.
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Affiliation(s)
- G Magistro
- Urologische Klinik und Poliklinik der Universität München, Campus Großhadern, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland.
| | - J Marcon
- Urologische Klinik und Poliklinik der Universität München, Campus Großhadern, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland
| | - S Schubert
- Max von Pettenkofer-Institut für Hygiene und Medizinische Mikrobiologie, Ludwig-Maximilians-Universität München, München, Deutschland
| | - C Gratzke
- Urologische Klinik und Poliklinik der Universität München, Campus Großhadern, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland
| | - C G Stief
- Urologische Klinik und Poliklinik der Universität München, Campus Großhadern, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland
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12
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Skwarecki AS, Milewski S, Schielmann M, Milewska MJ. Antimicrobial molecular nanocarrier–drug conjugates. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2016; 12:2215-2240. [DOI: 10.1016/j.nano.2016.06.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 05/17/2016] [Accepted: 06/06/2016] [Indexed: 01/07/2023]
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Mukherjee P, Roy P. Genomic Potential of Stenotrophomonas maltophilia in Bioremediation with an Assessment of Its Multifaceted Role in Our Environment. Front Microbiol 2016; 7:967. [PMID: 27446008 PMCID: PMC4916776 DOI: 10.3389/fmicb.2016.00967] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 06/03/2016] [Indexed: 11/13/2022] Open
Abstract
The gram negative bacterium Stenotrophomonas is rapidly evolving as a nosocomial pathogen in immuno-compromised patients. Treatment of Stenotrophomonas maltophilia infections is problematic because of their increasing resistance to multiple antibiotics. This article aims to review the multi-disciplinary role of Stenotrophomonas in our environment with special focus on their metabolic and genetic potential in relation to bioremediation and phytoremediation. Current and emerging treatments and diagnosis for patients infected with S. maltophilia are discussed besides their capability of production of novel bioactive compounds. The plant growth promoting characteristics of this bacterium has been considered with special reference to secondary metabolite production. Nano-particle synthesis by Stenotrophomonas has also been reviewed in addition to their applications as effective biocontrol agents in plant and animal pathogenesis.
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Affiliation(s)
- Piyali Mukherjee
- Laboratory of Molecular Biology, Department of Biotechnology, Burdwan UniversityBurdwan, India
| | - Pranab Roy
- Department of Biotechnology, Haldia Institute of TechnologyHaldia, India
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Urinary Concentrations and Antibacterial Activity of BAL30072, a Novel Siderophore Monosulfactam, against Uropathogens after Intravenous Administration in Healthy Subjects. Antimicrob Agents Chemother 2016; 60:3309-15. [PMID: 26976871 DOI: 10.1128/aac.02425-15] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 03/07/2016] [Indexed: 01/29/2023] Open
Abstract
This annex study to a phase 1 study aimed to correlate urinary concentrations and bactericidal titers (UBTs) of BAL30072, a novel siderophore monosulfactam, in healthy subjects in order to evaluate which dosage of BAL30072 should be investigated in a clinical study on complicated urinary tract infection (UTI). Three cohorts of a total of 19 healthy male subjects were included in the add-on study and received the following BAL30072 dosages. The 1st cohort received 1 g once a day (q.d.) intravenously (i.v.) (1 h) on day 1 and 1 g thrice daily (t.i.d.) on day 2, the 2nd cohort received 2 g q.d. i.v. (1 h) on day 1 and 2 g t.i.d. on day 2, and the 3rd cohort received 1 g q.d. i.v. (4-h infusion) on day 8. Urine was collected up to 24 h after drug administration. UBTs were determined for seven Escherichia coli isolates (three wild type [WT], CTX-M-15, TEM-3, TEM-5, NDM-1), two Klebsiella pneumoniae isolates (WT, KPC), one Proteus mirabilis isolate (WT), and two Pseudomonas aeruginosa isolates (WT, VIM-1 plus AmpC). Urine drug concentrations were measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS). The median urinary excretions of BAL30072 ranged between 38% and 46% (3 cohorts). The median UBTs after i.v. administration of 1 or 2 g q.d. and after 1 or 2 g t.i.d. showed positive UBTs for 24 h after the lowest dosage (1 g q.d.) for 5 of 7 of the Enterobacteriaceae strains and after the higher dosage of 2 g administered i.v. t.i.d. for all strains tested. After i.v. infusion of 1 g over 4 h, positive UBTs were demonstrated for three E. coli strains for up to 12 h, for the K. pneumoniae (KPC) strain for up to 8 h, and for the P. aeruginosa (VIM-1 plus AmpC) strain for up to only 4 h. The minimal bactericidal concentrations (MBCs) of the E. coli (NDM-1) strain and the K. pneumoniae (WT) strain correlated well between broth and urine but did not correlate well for the two P. aeruginosa strains. BAL30072 exhibits positive UBTs for 24 h even after a dosage of 1 g administered i.v. q.d. for 5 of 7 Enterobacteriaceae strains and after 2 g administered i.v. t.i.d. for all strains except one P. aeruginosa strain (50% of the time). In general, the UBTs correlated well with the MICs of the Enterobacteriaceae but were lower for P. aeruginosa The clinical efficacy with a dosage regimen of BAL30072 of 2 g administered i.v. t.i.d. should be evaluated in the treatment of complicated UTI.
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Zhang SJ, Sun WW, Cao P, Dong XP, Liu JK, Wu B. Stereoselective Synthesis of Diazabicyclic β-Lactams through Intramolecular Amination of Unactivated C(sp3)–H Bonds of Carboxamides by Palladium Catalysis. J Org Chem 2016; 81:956-68. [PMID: 26745308 DOI: 10.1021/acs.joc.5b02532] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Shi-Jin Zhang
- Pharmacy
College, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
- State
Key Laboratory of Phytochemistry and Plant Resources in West China,
Kunming Institute of Botany, Chinese Academy of Sciences, Kunming 650201, China
| | - Wen-Wu Sun
- State
Key Laboratory of Phytochemistry and Plant Resources in West China,
Kunming Institute of Botany, Chinese Academy of Sciences, Kunming 650201, China
- University of Chinese Academy of Sciences, Beijing 100049, China
| | - Pei Cao
- State
Key Laboratory of Phytochemistry and Plant Resources in West China,
Kunming Institute of Botany, Chinese Academy of Sciences, Kunming 650201, China
| | - Xiao-Ping Dong
- Pharmacy
College, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Ji-Kai Liu
- School
of Pharmaceutical Sciences, South-Central University for Nationalities, Wuhan 430074, China
| | - Bin Wu
- State
Key Laboratory of Phytochemistry and Plant Resources in West China,
Kunming Institute of Botany, Chinese Academy of Sciences, Kunming 650201, China
- School
of Pharmaceutical Sciences, South-Central University for Nationalities, Wuhan 430074, China
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16
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Kinetics of the Interaction between BAL29880 and LK157 and the Class C β-Lactamase CHE-1. Antimicrob Agents Chemother 2016; 60:1747-50. [PMID: 26729500 DOI: 10.1128/aac.02062-15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 12/27/2015] [Indexed: 11/20/2022] Open
Abstract
The chromosome-encoded class C β-lactamase CHE-1 produced by Enterobacter cloacae exhibits a lower sensitivity to avibactam than the P99 enzyme from which it is derived by a 6-residue deletion in the H-10 helix. In the present study, we investigated the sensitivity of CHE-1 to two other β-lactamase inhibitors: LK-157 (or Lek 157), a tricyclic β-lactam, and BAL29880, a bridged monobactam. With both compounds, the second-order rate constants for inactivation were significantly lower for CHE-1, which can thus be considered an inactivator-resistant mutant of P99. However, the second-order rate constant for the inactivation by BAL29880 probably remains adequate for a rather rapid reaction with CHE-1 in the absence of protection by the substrate.
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17
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Chang YT, Lin CY, Chen YH, Hsueh PR. Update on infections caused by Stenotrophomonas maltophilia with particular attention to resistance mechanisms and therapeutic options. Front Microbiol 2015; 6:893. [PMID: 26388847 PMCID: PMC4557615 DOI: 10.3389/fmicb.2015.00893] [Citation(s) in RCA: 231] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 08/17/2015] [Indexed: 01/14/2023] Open
Abstract
Stenotrophomonas maltophilia is a Gram-negative, biofilm-forming bacterium. Although generally regarded as an organism of low virulence, S. maltophilia is an emerging multi-drug resistant opportunistic pathogen in hospital and community settings, especially among immunocompromised hosts. Risk factors associated with S. maltophilia infection include underlying malignancy, cystic fibrosis, corticosteroid or immunosuppressant therapy, the presence of an indwelling central venous catheter and exposure to broad spectrum antibiotics. In this review, we provide a synthesis of information on current global trends in S. maltophilia pathogenicity as well as updated information on the molecular mechanisms contributing to its resistance to an array of antimicrobial agents. The prevalence of S. maltophilia infection in the general population increased from 0.8-1.4% during 1997-2003 to 1.3-1.68% during 2007-2012. The most important molecular mechanisms contributing to its resistance to antibiotics include β-lactamase production, the expression of Qnr genes, and the presence of class 1 integrons and efflux pumps. Trimethoprim/sulfamethoxazole (TMP/SMX) is the antimicrobial drug of choice. Although a few studies have reported increased resistance to TMP/SMX, the majority of studies worldwide show that S. maltophilia continues to be highly susceptible. Drugs with historically good susceptibility results include ceftazidime, ticarcillin-clavulanate, and fluoroquinolones; however, a number of studies show an alarming trend in resistance to those agents. Tetracyclines such as tigecycline, minocycline, and doxycycline are also effective agents and consistently display good activity against S. maltophilia in various geographic regions and across different time periods. Combination therapies, novel agents, and aerosolized forms of antimicrobial drugs are currently being tested for their ability to treat infections caused by this multi-drug resistant organism.
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Affiliation(s)
- Ya-Ting Chang
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Municipal HsiaoKang Hospital Kaohsiung, Taiwan ; Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University Kaohsiung, Taiwan
| | - Chun-Yu Lin
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University Kaohsiung, Taiwan ; School of Medicine, Graduate Institute of Medicine, Sepsis Research Center, College of Medicine, Kaohsiung Medical University Kaohsiung, Taiwan
| | - Yen-Hsu Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University Kaohsiung, Taiwan ; School of Medicine, Graduate Institute of Medicine, Sepsis Research Center, College of Medicine, Kaohsiung Medical University Kaohsiung, Taiwan ; Department of Biological Science and Technology, College of Biological Science and Technology, National Chiao Tung University HsinChu, Taiwan
| | - Po-Ren Hsueh
- Departments of Laboratory Medicine and Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine Taipei, Taiwan
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Tommasi R, Brown DG, Walkup GK, Manchester JI, Miller AA. ESKAPEing the labyrinth of antibacterial discovery. Nat Rev Drug Discov 2015; 14:529-42. [DOI: 10.1038/nrd4572] [Citation(s) in RCA: 379] [Impact Index Per Article: 42.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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19
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Bassetti M, Ginocchio F, Mikulska M, Taramasso L, Giacobbe DR. Will new antimicrobials overcome resistance among Gram-negatives? Expert Rev Anti Infect Ther 2014; 9:909-22. [DOI: 10.1586/eri.11.107] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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20
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Watkins RR, Papp-Wallace KM, Drawz SM, Bonomo RA. Novel β-lactamase inhibitors: a therapeutic hope against the scourge of multidrug resistance. Front Microbiol 2013; 4:392. [PMID: 24399995 PMCID: PMC3871716 DOI: 10.3389/fmicb.2013.00392] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Accepted: 12/02/2013] [Indexed: 11/25/2022] Open
Abstract
The increasing incidence and prevalence of multi-drug resistance (MDR) among contemporary Gram-negative bacteria represents a significant threat to human health. Since their discovery, β-lactam antibiotics have been a major component of the armamentarium against these serious pathogens. Unfortunately, a wide range of β-lactamase enzymes have emerged that are capable of inactivating these powerful drugs. In the past 30 years, a major advancement in the battle against microbes has been the development of β-lactamase inhibitors, which restore the efficacy of β-lactam antibiotics (e.g., ampicillin/sulbactam, amoxicillin/clavulanate, ticarcillin/clavulanate, and piperacillin/tazobactam). Unfortunately, many newly discovered β-lactamases are not inactivated by currently available inhibitors. Is there hope? For the first time in many years, we can anticipate the development and introduction into clinical practice of novel inhibitors. Although these inhibitors may still not be effective for all β-lactamases, their introduction is still welcome. This review focuses on the novel β-lactamase inhibitors that are closest to being introduced in the clinic.
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Affiliation(s)
- Richard R Watkins
- Department of Internal Medicine, Northeast Ohio Medical University Rootstown, OH, USA ; Division of Infectious Diseases, Akron General Medical Center Akron, OH, USA
| | - Krisztina M Papp-Wallace
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center Cleveland, OH, USA ; Department of Medicine, Case Western Reserve University Cleveland, OH, USA
| | - Sarah M Drawz
- Department of Lab Medicine and Pathology, University of Minnesota Minneapolis, MN, USA
| | - Robert A Bonomo
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center Cleveland, OH, USA ; Department of Medicine, Case Western Reserve University Cleveland, OH, USA ; Pharmacology, Case Western Reserve University Cleveland, OH, USA ; Molecular Biology and Microbiology, Case Western Reserve University Cleveland, OH, USA
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Valade E, Davin-Regli A, Bolla JM, Pagès JM. Bacterial Membrane, a Key for Controlling Drug Influx and Efflux. Antibiotics (Basel) 2013. [DOI: 10.1002/9783527659685.ch9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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22
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Buynak JD. β-Lactamase inhibitors: a review of the patent literature (2010 – 2013). Expert Opin Ther Pat 2013; 23:1469-81. [DOI: 10.1517/13543776.2013.831071] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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23
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Castagnola E, Mikulska M, Barabino P, Lorenzi I, Haupt R, Viscoli C. Current research in empirical therapy for febrile neutropenia in cancer patients: what should be necessary and what is going on. Expert Opin Emerg Drugs 2013; 18:263-78. [DOI: 10.1517/14728214.2013.809419] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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24
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Olivares J, Bernardini A, Garcia-Leon G, Corona F, B Sanchez M, Martinez JL. The intrinsic resistome of bacterial pathogens. Front Microbiol 2013; 4:103. [PMID: 23641241 PMCID: PMC3639378 DOI: 10.3389/fmicb.2013.00103] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 04/11/2013] [Indexed: 11/13/2022] Open
Abstract
Intrinsically resistant bacteria have emerged as a relevant health problem in the last years. Those bacterial species, several of them with an environmental origin, present naturally low-level susceptibility to several drugs. It has been proposed that intrinsic resistance is mainly the consequence of the impermeability of cellular envelopes, the activity of multidrug efflux pumps or the lack of appropriate targets for a given family of drugs. However, recently published articles indicate that the characteristic phenotype of susceptibility to antibiotics of a given bacterial species depends on the concerted activity of several elements, what has been named as intrinsic resistome. These determinants comprise not just classical resistance genes. Other elements, several of them involved in basic bacterial metabolic processes, are of relevance for the intrinsic resistance of bacterial pathogens. In the present review we analyze recent publications on the intrinsic resistomes of Escherichia coli and Pseudomonas aeruginosa. We present as well information on the role that global regulators of bacterial metabolism, as Crc from P. aeruginosa, may have on modulating bacterial susceptibility to antibiotics. Finally, we discuss the possibility of searching inhibitors of the intrinsic resistome in the aim of improving the activity of drugs currently in use for clinical practice.
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Affiliation(s)
- Jorge Olivares
- Centro Nacional de Biotecnología, Consejo Superior de Investigaciones Científicas Madrid, Spain
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25
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Abstract
β-Lactam antibiotics are one of the most important antibiotic classes but are plagued by problems of resistance, and the development of new β-lactam antibiotics through side-chain modification of existing β-lactam classes is not keeping pace with resistance development. In this JOCSynopsis, we summarize small molecule strategies to overcome resistance to β-lactam antibiotics. These approaches include the development of β-lactamase inhibitors and compounds that interfere with the ability of the bacteria to sense an antibiotic threat and activate their resistance mechanisms.
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Affiliation(s)
- Roberta J Worthington
- Department of Chemistry, North Carolina State University, Raleigh, North Carolina 27695, United States
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26
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Abstract
There has been considerable effort expended in the investigation of the potential of siderophore conjugates of antibiotics to circumvent the permeability barrier imposed by the outer membrane of Gram-negative bacteria. There is also a small group of natural conjugates, the sideromycins. Among the synthetic analogues that have been investigated are conjugates of nucleosides, glycopeptides, macrolides, fluroquinolones, and, above all, β-lactams. Despite this effort, few compounds have progressed beyond experimental studies. One compound, the siderophore monosulfactam BAL30072, is in early clinical studies.
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27
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Patel G, Bonomo RA. "Stormy waters ahead": global emergence of carbapenemases. Front Microbiol 2013; 4:48. [PMID: 23504089 PMCID: PMC3596785 DOI: 10.3389/fmicb.2013.00048] [Citation(s) in RCA: 292] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 02/20/2013] [Indexed: 01/08/2023] Open
Abstract
Carbapenems, once considered the last line of defense against of serious infections with Enterobacteriaceae, are threatened with extinction. The increasing isolation of carbapenem-resistant Gram-negative pathogens is forcing practitioners to rely on uncertain alternatives. As little as 5 years ago, reports of carbapenem resistance in Enterobacteriaceae, common causes of both community and healthcare-associated infections, were sporadic and primarily limited to case reports, tertiary care centers, intensive care units, and outbreak settings. Carbapenem resistance mediated by β-lactamases, or carbapenemases, has become widespread and with the paucity of reliable antimicrobials available or in development, international focus has shifted to early detection and infection control. However, as reports of Klebsiella pneumoniae carbapenemases, New Delhi metallo-β-lactamase-1, and more recently OXA-48 (oxacillinase-48) become more common and with the conveniences of travel, the assumption that infections with highly resistant Gram-negative pathogens are limited to the infirmed and the heavily antibiotic and healthcare exposed are quickly being dispelled. Herein, we provide a status report describing the increasing challenges clinicians are facing and forecast the “stormy waters” ahead.
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Affiliation(s)
- Gopi Patel
- Department of Medicine, Mount Sinai School of Medicine New York, NY, USA
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28
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Hofer B, Dantier C, Gebhardt K, Desarbre E, Schmitt-Hoffmann A, Page MGP. Combined effects of the siderophore monosulfactam BAL30072 and carbapenems on multidrug-resistant Gram-negative bacilli. J Antimicrob Chemother 2013; 68:1120-9. [DOI: 10.1093/jac/dks527] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Worthington RJ, Melander C. Combination approaches to combat multidrug-resistant bacteria. Trends Biotechnol 2013; 31:177-84. [PMID: 23333434 DOI: 10.1016/j.tibtech.2012.12.006] [Citation(s) in RCA: 399] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 12/17/2012] [Accepted: 12/19/2012] [Indexed: 12/19/2022]
Abstract
The increasing prevalence of infections caused by multidrug-resistant bacteria is a global health problem that has been exacerbated by the dearth of novel classes of antibiotics entering the clinic over the past 40 years. Herein, we describe recent developments toward combination therapies for the treatment of multidrug-resistant bacterial infections. These efforts include antibiotic-antibiotic combinations, and the development of adjuvants that either directly target resistance mechanisms such as the inhibition of β-lactamase enzymes, or indirectly target resistance by interfering with bacterial signaling pathways such as two-component systems (TCSs). We also discuss screening of libraries of previously approved drugs to identify nonobvious antimicrobial adjuvants.
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Abstract
The "perpetual challenge of infectious diseases" is no better exemplified than by the phenomena of rapid emergence and spread of bacterial resistance. Although β-lactam antimicrobials have thus far been a mainstay of the therapeutic armamentarium for treatment of severe infections, their preeminent position has been challenged by an onslaught of resistance mechanisms in major nosocomial and community-acquired pathogens, including modification of penicillin-binding proteins, production of β-lactamases, overexpression of efflux pumps, and loss of porins. Given this formidable array of resistance mechanisms facing patients and their physicians, one can reasonably ask if there is hope for the future of β-lactams.
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31
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Mitton-Fry MJ, Arcari JT, Brown MF, Casavant JM, Finegan SM, Flanagan ME, Gao H, George DM, Gerstenberger BS, Han S, Hardink JR, Harris TM, Hoang T, Huband MD, Irvine R, Lall MS, Megan Lemmon M, Li C, Lin J, McCurdy SP, Mueller JP, Mullins L, Niosi M, Noe MC, Pattavina D, Penzien J, Plummer MS, Risley H, Schuff BP, Shanmugasundaram V, Starr JT, Sun J, Winton J, Young JA. Novel monobactams utilizing a siderophore uptake mechanism for the treatment of gram-negative infections. Bioorg Med Chem Lett 2012; 22:5989-94. [PMID: 22892121 DOI: 10.1016/j.bmcl.2012.07.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 06/27/2012] [Accepted: 07/02/2012] [Indexed: 11/16/2022]
Abstract
Novel siderophore-linked monobactams with in vitro and in vivo anti-microbial activity against MDR Gram-negative pathogens are described.
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Affiliation(s)
- Mark J Mitton-Fry
- Medicinal Chemistry, Pfizer Worldwide Research and Development, Eastern Point Road, Groton, CT 06340, USA
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32
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The antibiotic resistome: challenge and opportunity for therapeutic intervention. Future Med Chem 2012; 4:347-59. [PMID: 22393941 DOI: 10.4155/fmc.12.2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Despite the relevance of infectious disease as main causes of human morbidity and mortality, the development of new antibacterials is not among the highest priorities for pharmaceutical companies. Regulatory and economic issues, together with the lack of novel targets, might justify the reduced rate of discovery of new antimicrobials. With the increasing number of antibiotic resistant pathogens, the mechanisms of resistance appear as appealing alternatives for developing new drugs. Defining the elements that contribute to the characteristic phenotype of susceptibility to antibiotics of a given bacterial species, will serve to find those targets. Recent information on the elements forming part of bacterial intrinsic resistomes and on the inhibitors of resistance currently under development are presented. The possibility of developing new therapeutic procedures based on the administration, together with antibiotics of specific metabolic intermediates capable of increasing the susceptibility to antibiotics by altering bacterial physiology, are also discussed.
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Abstract
Stenotrophomonas maltophilia is an emerging multidrug-resistant global opportunistic pathogen. The increasing incidence of nosocomial and community-acquired S. maltophilia infections is of particular concern for immunocompromised individuals, as this bacterial pathogen is associated with a significant fatality/case ratio. S. maltophilia is an environmental bacterium found in aqueous habitats, including plant rhizospheres, animals, foods, and water sources. Infections of S. maltophilia can occur in a range of organs and tissues; the organism is commonly found in respiratory tract infections. This review summarizes the current literature and presents S. maltophilia as an organism with various molecular mechanisms used for colonization and infection. S. maltophilia can be recovered from polymicrobial infections, most notably from the respiratory tract of cystic fibrosis patients, as a cocolonizer with Pseudomonas aeruginosa. Recent evidence of cell-cell communication between these pathogens has implications for the development of novel pharmacological therapies. Animal models of S. maltophilia infection have provided useful information about the type of host immune response induced by this opportunistic pathogen. Current and emerging treatments for patients infected with S. maltophilia are discussed.
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Affiliation(s)
- Joanna S Brooke
- Department of Biological Sciences, DePaul University, Chicago, Illinois, USA.
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34
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Hooff GP, van Kampen JJA, Meesters RJW, van Belkum A, Goessens WHF, Luider TM. Characterization of β-lactamase enzyme activity in bacterial lysates using MALDI-mass spectrometry. J Proteome Res 2011; 11:79-84. [PMID: 22013912 DOI: 10.1021/pr200858r] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Plasmid-encoded β-lactamases are a major reason for antibiotic resistance in gram negative bacteria. These enzymes hydrolyze the β-lactam ring structure of certain β-lactam antibiotics, consequently leading to their inactivation. The clinical situation demands for specific first-line antibiotic therapy combined with a quick identification of bacterial strains and their antimicrobial susceptibility. Strategies for the identification of β-lactamase activity are often cumbersome and usually lack sensitivity and specificity. The current work demonstrates that matrix assisted laser desorption/ionization mass spectrometry (MALDI-MS) is an ideal tool for these analytical investigations. Herein, we describe a fast and specific assay to determine β-lactamase activity in bacterial lysates. The feasibility of the analytical read-out was demonstrated on a MALDI-triple quadrupole (QqQ) and a MALDI time-of-flight (TOF) instrument, and the results allow the comparison of both approaches. The assay specifically measures enzyme-mediated, time-dependent hydrolysis of the β-lactam ring structure of penicillin G and ampicillin and inhibition of hydrolysis by clavulanic acid for clavulanic acid susceptible β-lactamases. The assay is reproducible and builds the basis for future in-depth investigations of β-lactamase activity in various bacterial strains by mass spectrometry.
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Affiliation(s)
- Gero P Hooff
- Department of Neurology, Laboratory of Neuro-Oncology and Clinical and Cancer Proteomics, Erasmus University Medical Center (Erasmus MC), Rotterdam, The Netherlands.
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35
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Walsh TR, Toleman MA. The emergence of pan-resistant Gram-negative pathogens merits a rapid global political response. J Antimicrob Chemother 2011; 67:1-3. [PMID: 21994911 DOI: 10.1093/jac/dkr378] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Recent media coverage of New Delhi metallo-β-lactamase (NDM-1) put antibiotic resistance back on the political map if only for the wrong reasons, mainly the reaction to the naming of NDM-1 and the incorrect assumption that medical tourism was being deliberately targeted. However, work on NDM-1 has most certainly highlighted the rapid dissemination of new antibiotic resistance mechanisms via economic globalization. The example of NDM-1 has also magnified the desperate need for a publicly funded global antibiotic surveillance system rather than just national or regional systems. Furthermore, there is a pressing need to establish a global task force to enforce international transparency and accountability on antibiotic stewardship and the implementation of measures to curb antibiotic resistance. An international antibiotic stewardship index should be established that is related to each country's gross domestic product (GDP) and assesses how much of their GDP is committed to publically funded health initiatives aimed at controlling antibiotic resistance.
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Affiliation(s)
- Timothy R Walsh
- Section of Medical Microbiology, 6th Floor Main Building, IIB, School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4XN, UK.
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