The antimicrobial armamentarium: evaluating current and future treatment options

A systematic scoping review of faropenem and other oral penems: treatment of Enterobacterales infections, development of resistance and cross-resistance to carbapenems

Background

Antimicrobial resistance is an urgent global healthcare concern. Beyond carbapenems as broad-spectrum, often 'last resort' antibiotics, oral penem antibiotics currently are approved only in Japan and India, used for the treatment of indications including urinary tract infections (UTIs). Exploring oral penem use to better understand the impact of antibiotic resistance on public health would help inform the management of infectious diseases, including UTIs.

Scoping Review Methodology

This scoping review investigated the impact of faropenem and other oral penems on Enterobacterales infection treatment and evaluated evidence for faropenem resistance and cross-resistance to carbapenems. PubMed, Embase, J-STAGE and CiNii were searched for relevant English- or Japanese-language articles published between 1 January 1996 and 6 August 2021.

Key Findings

From 705 unique publications, 29 eligible articles were included (16 in vitro studies; 10 clinical trials; 2 in vitro and in vivo studies; and 1 retrospective medical chart review). Limited evidence described faropenem to treat infectious disease; only four randomized clinical trials were identified. Faropenem dosing regimens varied broadly within and between indications. One study indicated potential dependence of penem efficacy on underlying antibiotic resistance mechanisms, while several studies reported UTI persistence or recurrence after faropenem treatment. In vitro MIC data suggested some potential bacterial resistance to faropenem, while limited clinical data showed resistance emergence after faropenem treatment. Preliminary in vitro evidence suggested faropenem resistance might foster cross-resistance to carbapenems. Overall, very limited clinical evidence describes faropenem for treating infectious diseases. Preclinical and clinical research investment and dedicated community surveillance monitoring is crucial for understanding faropenem treatment patterns, resistance and potential cross-resistance to carbapenems.

Clinical Pharmacokinetics and Pharmacodynamics of Imipenem-Cilastatin/Relebactam Combination Therapy

On 16 July, 2019, the US Food and Drug Administration approved imipenem-cilastatin/relebactam (Recarbrio™) for the treatment of adults with complicated urinary tract infections and complicated intra-abdominal infections. This decision was based on substantial clinical and pre-clinical data, including rigorous pharmacokinetic and pharmacodynamic work, and is an important step forward in the management of these debilitating conditions. This article provides an overview of the body of research associated with imipenem-cilastatin/relebactam, beginning with an examination of the fundamental underpinnings of the pharmacokinetic/pharmacodynamic index. This is followed by the pharmacokinetic/pharmacodynamic work that led to the approval of this novel drug combination, including data derived from checkerboard and hollow fiber infection studies, as well as large, multi-center, phase III clinical trials known as RESTORE-IMI 1 and RESTORE-IMI 2. The article also explores how this important new antibiotic may be used to treat other infections in the years to come, including hospital-acquired bacterial pneumonia and ventilator-associated pneumonia attributed to imipenem-non-susceptible pathogens and certain atypical mycobacterial infections.

Synthesis of new chrysin derivatives with substantial antibiofilm activity

Multidrug resistance mechanism of microorganisms towards conventional antimicrobials nowadays faces a common health problem. So, searching and development of new antibacterials are in the frontier areas of biochemistry. Functionalizations of various natural products or synthesis of compounds through molecular modeling followed by virtual screening are the ways to obtain potential leads. Chrysin is one of the plant secondary metabolites and is ubiquitously present in majority of plants. It has multi-dimensional potentiality however, with a very low bioavailability causing a very low efficacy. Very few chrysin derivatives possessing antimicrobial activity with a low anti-biofilm efficacy have been found in the literature. Thus, it has been attempted to synthesize a series of new chrysin derivatives (CDs). In this study, twenty-two new derivatives have been synthesized via its 7-OH modulation and antibiofilm activity was evaluated against a model bacterium viz. Escherichia coli MTCC 40 (Gram negative). Eleven CDs coded as 2a, 2b, 2c, 2e, 2f, 2g, 2h, 2i, 3j, 3k and 3l have been found more potent compared to chrysin (precursor of CDs) against planktonic form of E. coli. Biofilm inhibition studies indicated a noteworthy results for 2a (93.57%), 2b (92.14%), 2f (92.14%) and 3l (93.57%) compared to chrysin (33.57%). E. coli motility was also highly restricted by 2a, 2b, 2f and 3l than chrysin at their sub-inhibitory concentrations. Solubility studies indicated an extended-release of 2a, 2b, 2f and 3l in physiological systems. Relatively higher bioavailability of 2a, 2b, 2f and 3l than chrysin was revealed from the dissolution experiments and was further validated through in silico ADME-based SAR analysis. Hence, this study is more interesting in regard to antibacterial potentiality of chrysin derivatives against Escherichia coli MTCC 40 (Gram negative). Thus, this article might be useful for further design and development of new leads in the context of biofilm-associated bacterial infections.

D-amino acid substitution enhances the stability of antimicrobial peptide polybia-CP

With the increasing emergence of resistant microbes toward conventional antimicrobial agents, there is an urgent need for the development of antimicrobial agents with novel action mode. Antimicrobial peptides (AMPs) are believed to be one kind of ideal alternatives. However, AMPs can be easily degraded by protease, which limited their therapeutic use. In the present study, D-amino acid substitution strategy was employed to enhance the stability of polybia-CP. We investigated the stability of peptides against the degradation of trypsin and chymotrypsin by determining the antimicrobial activity or determining the HPLC profile of peptides after incubation with proteases. Our results showed that both the all D-amino acid derivative (D-CP) and partial D-lysine substitution derivative (D-lys-CP) have an improved stability against trypsin and chymotrypsin. Although D-CP takes left-hand α-helical conformation and D-lys-CP loses some α-helical content, both of the D-amino acid-substituted derivatives maintain their parental peptides' membrane active action mode. In addition, D-lys-CP showed a slight weaker antimicrobial activity than polybia-CP, but the hemolytic activity decreased greatly. These results suggest that D-CP and D-lys-CP can offer strategy to improve the property of AMPs and may be leading compounds for the development of novel antimicrobial agents.

Eugenol exhibits anti-virulence properties by competitively binding to quorum sensing receptors

The primary objective of this study was to ascertain the anti-biofilm and anti-virulence properties of sub-minimum inhibitory concentration (MIC) levels of eugenol against the standard strain PAO1 and two multi-drug resistant P. aeruginosa clinical isolates utilizing quorum sensing inhibition (QSI). Eugenol at 400 μM significantly reduced biofilm formation on urinary catheters and the virulence factors (VF) including extracellular polysaccharides, rhamnolipid, elastase, protease, pyocyanin, and pyoverdine (p < 0.001). Further, eugenol exhibited a marked effect on the production of QS signals (AIs) (p < 0.001) without affecting their chemical integrity. In silico docking studies demonstrated a stable molecular binding between eugenol and QS receptor(s) in comparison with respective AIs. Investigation on reporter strains confirmed the competitive binding of eugenol to a QS receptor (LasR) as the possible QSI mechanism leading to significant repression of QS associated genes besides the VF genes (p < 0.001). This study provides insights, for the first time, into the mechanism of the anti-virulence properties of eugenol.

3-Amino-4-aminoximidofurazan derivatives: small molecules possessing antimicrobial and antibiofilm activity against Staphylococcus aureus and Pseudomonas aeruginosa

AIM

The therapeutic treatment of microbial infections involving biofilm becomes quite challenging because of its increasing antibiotic resistance capacities. Towards this direction, in the present study we have evaluated the antibiofilm property of synthesized 3-amino-4-aminoximidofurazan compounds having polyamine skeleton. These derivatives were synthesized by incorporating furazan and biguanide moieties.

METHODS AND RESULTS

Different 3-amino-4-aminoximidofurazan derivatives (PI1-4) were synthesized via protic acid catalysis and subsequently characterized by (1) H NMR and (13) C NMR spectra, recorded at 400 and 100 MHz respectively. We have tested the antimicrobial and antibiofilm activities of these synthetic derivatives (PI1-4) against both Staphylococcus aureus and Pseudomonas aeruginosa. The compounds so tested were also compared with standard antibiotics namely Tobramycin (Ps. aeruginosa) and Azithromycin (Staph. aureus) which were used as a positive control in all experimental sets. All these compounds (PI1-4) exhibited moderate to significant antimicrobial activities against both micro-organisms wherein compound PI3 showed maximum activity. Biofilm inhibition of both micro-organisms was then evaluated by crystal violet and safranin staining, estimation of biofilm total protein and microscopy methods using sub-MIC dose of these compounds. Results showed that all compounds executed anti biofilm activity against both Staph. aureus and Ps. aeruginosa wherein compound PI3 exhibited maximum activity. In relation with microbial biofilm inhibition, we have observed reduction in bacterial motility, proteolytic activity and secreted exo-polysaccharide (EPS) from both Staph. aureus and Ps. aeruginosa when they were grown in presence of these compounds. While addressing the issue of toxicity on host, we have observed that these molecules exhibited minimum level of R.B.C degradation.

CONCLUSION

These findings establish the antibacterial and anti biofilm properties of 3-amino-4-aminoximidofurazan derivatives (PI1-4).

SIGNIFICANCE AND IMPACT OF THE STUDY

Therefore, our current findings demonstrate that 3-amino-4-aminoximidofurazan derivatives (PI1-4) may hold promise to be effective biofilm and microbial inhibitors that may be clinically significant.

Treatment options for multidrug-resistant bacteria

As a consequence of antibiotic overuse and misuse, nosocomial infections caused by multidrug-resistant bacteria represent a physician's nightmare throughout the world. No newer antimicrobials active against Pseudomonas aeruginosa, the main multidrug-resistant nosocomial pathogen, are available or under investigation. The only exceptions are linezolid, some newer glycopeptides (dalbavancin, oritavancin and telavancin) and daptomycin (a lipopeptide), which are active against methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) strains, as well as tigecycline, a potent in vitro glycylcycline against MRSA, VRE, Acinetobacter baumannii and entended-spectrum beta-lactamase (ESBL)+ Enterobacteriaceae. Colistin, an antibiotic of the 1950s has been rediscovered by intensive care unit physicians for use against ESBL+ Enterobacteriaceae, as well as against multidrug-resistant P. aeruginosa and A. baumannii isolates. Although success rates with colistin range between 50 and 73%, almost all studies are retrospective. Immunostimulation efforts against S. aureus are still under development. As antibiotic research and development stagnate, rational policies for prescribing existing antibiotics plus strict infection control are the current mainstay efforts for preventing and combating multidrug-resistant bacterial infections.

Zingerone inhibit biofilm formation and improve antibiofilm efficacy of ciprofloxacin against Pseudomonas aeruginosa PAO1

Multidrug resistant opportunistic pathogen Pseudomonas aeruginosa produces surface-associated communities called biofilms, which protect pathogen by forming a complex permeability barrier for antibiotics and immune cells. Biofilm formation contributes to persistent and chronic infections caused by P.aeruginosa. Extensive use of antibiotics to treat biofilm associated infections has culminated in the emergence of multiple drug-resistant strains. Hence novel strategies are urgently required to address this issue. Since phytochemicals are valuable source of antibacterial agents, these can be explored for antibiofilm activity. Therefore, the present study was planned to evaluate the inhibition of biofilm formation in presence of zingerone alone and its ability to increase the susceptibility of the pathogen to ciprofloxacin. Scanning electron microscopy of catheter surface showed thinner biofilm of P.aeruginosa in presence of zingerone. Evaluation of motility phenotypes indicated significant reduction (p < 0.05) in swimming, swarming and twitching motility. Further, biofilm was inhibited and eradicated in presence of zingerone alone and in combination with ciprofloxacin. Highly significant inhibition (p < 0.001) was observed when phytochemical and antibiotic were used as adjunct therapy. These findings prove zingerone as potential phytotherapeutic agent which in future can be employed to formulate preventive strategies against biofilm associated infections caused by P.aeruginosa.

Newer antibacterial drugs for a new century

IMPORTANCE OF THE FIELD

Antibacterial drug discovery and development has slowed considerably in recent years, with novel classes discovered decades ago and regulatory approvals tougher to get. Traditional approaches and the newer genomic mining approaches have not yielded novel classes of antibacterial compounds. Instead, improved analogues of existing classes of antibacterial drugs have been developed by improving potency, minimizing resistance and alleviating toxicity.

AREAS COVERED IN THIS REVIEW

This article is a comprehensive review of newer classes of antibacterial drugs introduced or approved after year 2000.

WHAT THE READER WILL GAIN

It describes their mechanisms of action/resistance, improved analogues, spectrum of activity and clinical trials. It also discusses new compounds in development with novel mechanisms of action, as well as novel unexploited bacterial targets and strategies that may pave the way for combating drug resistance and emerging pathogens in the twenty-first century.

TAKE HOME MESSAGE

The outlook of antibacterial drug discovery, though challenging, may not be insurmountable in the years ahead, with legislation on incentives and funding introduced for developing an antimicrobial discovery program and efforts to conserve antibacterial drug use.

Activity of Chitosans in combination with antibiotics in Pseudomonas aeruginosa

Chitosan and its derivative water soluble Chitosan oligosaccharide are used in a variety of applications in pharmaceutical preparations. In this study, 2 wild (ATCC 15729 and PAO1) and 2 mutant strains (PT121 and PT149) of P. aeruginosa are investigated for drug-drug interactions in vitro. 10 antimicrobial agents (antibiotics) are combined with different degree of deacetylated Chitosans and Chitosan oligosaccharide. All the chitosans show synergistic activity with sulfamethoxazole, a sulfonamide antimicrobial agent. It is interesting to observe that the MIC value for the MexEF-OprN overexpressing mutant strain of P. aeruginosa is 5 fold higher than the other strains under investigation suggesting a possible role of this efflux pump in Sulfamethoxazole efflux. The findings suggest on the use of chitosans as enhancing agent in combination with antibiotics in pharmaceutical preparations.

In vivo pharmacodynamic profiling of doripenem against Pseudomonas aeruginosa by simulating human exposures

Doripenem is a new broad-spectrum carbapenem with activity against a range of gram-negative pathogens, including nonfermenting bacteria such as Pseudomonas aeruginosa. The objective of this study was to evaluate simulated human exposures to doripenem using a neutropenic murine thigh infection model against 24 clinical P. aeruginosa isolates with a wide range of MICs. Dosing regimens in mice were designed to approximate the free time above MIC (fT>MIC) observed with 500 mg doripenem every 8 h given as either a 1-h or 4-h intravenous infusion in humans. Maximal antibacterial killing was associated with doripenem exposures of > or =40% fT>MIC; bacteriostatic effects were noted at approximately 20% fT>MIC. The simulated 1-h infusion provided bactericidal effects for isolates with MICs of < or =2 microg/ml, while variable killing was noted for isolates with MICs of 4 to 8 microg/ml and regrowth for isolates with an MIC of 16 microg/ml. The 4-h infusion regimen displayed similar killing for isolates with MICs of < or =2 microg/ml and enhanced activity for two of the four isolates with an MIC of 4 microg/ml. Given that the 4-h regimen yields negligible fT>MIC for MICs of > or =8 microg/ml, regrowth was generally observed. Simulated doses of 500 mg doripenem every 8 h infused over 1 h demonstrated antibacterial killing for P. aeruginosa isolates with MICs of 0.125 to 8 microg/ml. Exposures of > or =40% fT>MIC resulted in the most pronounced bactericidal effects, while killing was variable for 20 to 30% fT>MIC. Infusing doses over 4 h enhanced efficacy against selected pseudomonal isolates with an MIC of 4 microg/ml.

Update on the treatment of diabetic foot infections

This article brings the practicing clinician up to date on the current concepts regarding the medical treatment of diabetic foot infections. Topics include a review of the Infectious Diseases Society of America Practice Guidelines for the Diagnosis and Treatment of Diabetic Foot Infections and a discussion of newer antibiotics such as linezolid, ertapenem, moxifloxacin, dalbavancin, tigecycline, ceftobiprole and iclaprim.

Antibacterial Activity of Allicin Alone and in Combination with β-Lactams against Staphylococcus spp. and Pseudomonas aeruginosa

Allicin is one of the most effective compounds isolated from garlic showing antibacterial activity. Determination of MIC alone or in combination with cefazolin/oxacillin against Staphylococcus spp. or with cefoperazone against Pseudomonas aeruginosa showed that allicin alone did not have good antibacterial activity (MIC90>512 microg/ml) but it facilitated antibacterial activity of all three beta-lactams tested at subinhibitory concentrations. In the presence of 1/8 to 1/2 the MIC of allicin, the MIC90 values of cefazolin, oxicillin, and cefoperazone were reduced by 4 approximately 128, 32 approximately 64, and 8 approximately 16 fold, respectively. Thus, allicin-beta-lactam combinations offer promise of clinical utility especially if synergism is demonstrated by in vivo experimental studies.

Telavancin: a novel lipoglycopeptide for serious Gram-positive infections

Telavancin, a once-daily dosing lipoglycopeptide derived from vancomycin, has a broad-spectrum microbiologic activity against gram-positive bacteria, including vancomycin-resistant staphylococci. Telavancin displays a dual mode of action and a rapid bactericidal killing. The in vitro activity of telavancin is superior to vancomycin and comparable with, or greater than, linezolid, daptomycin and other novel lipoglycopeptides. Telavancin is effective against gram-positive pathogens in animal models of soft tissue infections and deep-seated infections including endocarditis, pneumonia and bacteremia. Clinical experience with telavancin in Phase II and III studies for complicated skin and skin structure infections have demonstrated similar efficacy and tolerability compared with standard anti-staphylococcal beta-lactams and vancomycin. Telavancin is in Phase III studies for nosocomial pneumonia. Telavancin seems to be promising as a novel agent for empiric therapy or as an alternative agent in serious infections caused by clinically important resistant gram-positive pathogens such as methicillin-resistant Staphylococcus aureus, vancomycin intermediate-susceptible S. aureus, vancomycin-resistant S. aureus and vancomycin-resistant enterococci.

Oritavancin – an investigational glycopeptide antibiotic

Antibiotics save countless lives each year; however, increasing rates of drug-resistant bacteria have limited antibiotic selection. Currently, there are few available options for treating resistant Gram-positive organisms. Oritavancin, a novel glycopeptide antibiotic with bactericidal activity, has been developed and recently completed the first round of Phase III clinical trials for the treatment of complicated skin and skin structure infections. Investigations into oritavancin's efficacy will be explored in catheter-related bacteraemia and nosocomial pneumonia. Oritavancin demonstrates similar activity to vancomycin but possesses extended activity against vancomycin-resistant Staphylococcus and Enterococcus. The pharmacokinetics and pharmacodynamics of oritavancin appear to be favourable and once-daily dosing is likely. The incidence of multi-drug resistant bacteria is increasing and explorations into additional treatment options are essential. Further development of oritavancin is necessary to determine clinical efficacy.

Mode of action of the new antibiotic for Gram-positive pathogens daptomycin: comparison with cationic antimicrobial peptides and lipopeptides

With the steady rise in the number of antibiotic-resistant Gram-positive pathogens, it has become increasingly important to find new antibacterial agents which are highly active and have novel and diversified mechanisms of action. Two classes will be discussed here: the cationic antimicrobial peptides, which are amphiphilic in nature, targeting membranes and increasing their permeability; and lipopeptides, which consist of linear or cyclic peptides with an N-terminus that is acylated with a fatty acid side chain. One member of the cyclic lipopeptide family, the anionic molecule daptomycin, has been extensively studied and is the major focus of this review. Models will be presented on its mode of action and comparisons will be made to the known modes of action of cationic antimicrobial peptides and other lipopeptides.