Antibacterial. Agents. Structure Activity Relationships. André Bryskier MD

Transcription

1 Antibacterial Agents Structure Activity Relationships André Bryskier MD 1 Lille - December 7 th 2004

2 Antibacterial Agents atural compounds Synthetic compounds Beta-lactams Aminoglycosides Macrolides Streptogramin Lincosamines Peptides Mupirocin Ansamycins Benzyl pyrimidines Sulphonamides Sulfones Furans 4-quinolones xazolidinones itroxoline Penem Fosfomycin Anti-TB

3 Antibiotic resistance 1941 Pre antibiotic era 2000 Antibiotic era 3

4 Research in anti-infectives infectives Research up miḏ- mid 80s Research after miḏ- mid 80s Enlarge the antibacterial spectrum Enhance the antibacterial activity (e.g. cefotaxime) vercome bacterial resistance Improve the pharmacokinetics (e.g. roxithromycin, clarithromycin, azithromycin) 4

5 Purification Semi synthetic e.g Penicillin G Erythromycin A Kanamycin ß-lactams Macrolides Aminoglycosides 5

6 Structure-Activity Activity-Relationships WHY Antibacterial activity in vitro and in vivo (?) Bacterial resistance Bactericidal activity Toxicity-tolerance ptimisation of chemical strcutures Improvement of physicochemical properties Pharmacodynamics Pharmacokinetics. 6

7 Antibacterial agents Future Screening Chemical atural products Existing compounds ew molecule entities ew targets Alterations chemical structures ptimization of existing non-antibacterials 7

8 Improvement of physicochemical properties Exemple : water- solubility (1) H H 3 C orfloxacin Pefloxacin (IV formulation) 8

9 Improvement of physicochemical properties Amino acid (2) Trovafloxacin Alatrovafloxacin (IV formulation) Amino acid (3) Ceftizoxime Prodrug H 2 S R H S Amino acid AS-924 9

10 Fluoroquinolones

11 Fluoroquinolones History of quinolones Pipemidic acid 7 7-piperazinyl moiety (partial cross-resistanceresistance With oxolonic acid) alidixic acid (1962) xolinic acid (quinoline) F 6 Fluoroquinolones Flumequine Piromedic acid 7 Pirrolidinyl moiety (+ ve activity) 11

12 Fluoroquinolones Definition R R 1 CH Synthetic antibacterial agents Pharmacophore : pyrridone-ß-carboxylic acid Auxopharmacophore : fused aromatic ring appended substituents 12

13 Fluoroquinolones CH ( ) 2 Ro Monocyclic derivative 13

14 Fluoroquinolones Structure - activity relationships Classification Microbiology Pharmacokinetics Adverse events 14

15 Fluoroquinolones Classifications Chemical classification Biological classification 15

16 Fluoroquinolones Group I Group II Group III Group IV Monocyclic derivatives Chemical classification Bicyclic derivatives Tricyclic derivatives Tetracyclic derivatives Ro Ro KB-5246 Group II B Group II A Group II C III A III B Pentacyclic ring Hexacyclic ring Heptacyclic ring on-fluorinated Fluorinated 16 T FD 501 FD 103 Tioxic xolinic acid Miloxacin E 272 DJ 6783 Droxacin III B1 floxacin Levofloxacin Flumequine Abufloxacin Rufloxacin S QA-241 D 9494 A MF 961 Marbofloxacin Verbafloxacin Pazufloxacin CP WQ 0835 KRQ III B2 Prulifloxacin

17 Fluoroquinolones Chemical classification (bicyclic derivatives) Group II Group II B Group II A -hexacyclic ring II A naphthyridine II A-2 Pyrido [2,3-b] pyrimidine II A-3 Quinoline o fluor alidixic acid 6-Fluor 7-piperazinyl 7-pyrrolidinyl ther Pipemidic acid Piromedic acid Enoxacin A AT 3295 AT 3765 Tosufloxacin A BMY BMY U-91939E PD (Cl 990) Gemifloxacin DC-756 BMY E-3499 Trovafloxacin Ecenofloxacin CP

18 Fluoroquinolones Chemical classification - Bicyclic derivatives Group II Group II B Group II A -six membered-ring II A-1 II A-2 II A-3 6-Fluor des (6) fluorinated 6-H 2 7-piperazinyl 7-pyrrolidinyl 7-pyrrylyl 7-azetidinyl Bicyclic ther 18 orfloxacin Pefloxacin Amifloxacin Difloxacin A Fleroxacin Sparfloxacin Lomefloxacin Temafloxacin CS 940 Grepafloxacin Gatifloxacin DW-116 SFQ-104 SFQ-105 AMQ-4 PD PD PD A PC Merafloxacin Clinafloxacin WQ 2128 A WQ 1197 SY 987 SY 1193 SY 1253 S Sitafloxacin Alumafloxacin Y-688 DC-756 Pirfloxacin (Irloxacin) E 3624 E Esteves series WQ 2724 WQ 2743 WQ 2756 WQ 2765 Moxifloxacin Bay y-3118 KRQ KRQ Y Binfloxacin Y Balofloxacin BAY y 3118 SY 987 S KRQ Y Acroxacin WI Piroxacin Garenoxacin DX-619 MF 5137

19 Fluoroquinolones Tricyclic derivatives R 1 R 2 F CH Flumequine H R 2 Methyl flumequine Abufloxacin R 1 Benzoquinazoline derivatives Verbufloxacin H 3 C 19

20 Fluoroquinolones Tricyclic derivatives R 1 R 2 F CH floxacin 4 -methyl piperazinyl R 2 R 1 Levofloxacin euquinoron CP methyl piperazinyl H 2 Pyridine 20

21 Fluoroquinolones F CH R 7 X 8 1 R 7-position Bicyclic Piperazinyl Pyrrolidinyl Azetidinyl Pyrryl Piperidinyl Pyridinyl Morpholine 21 Trovafloxacin Moxifloxacin Danafloxacin Garenoxacin Ciprofloxacin Lomefloxacin orfloxacin Fleroxacin floxacin Sparfloxacin Grepafloxacin Gatafloxacin Levofloxacin Clinafloxacin adifloxacin Sitafloxacin E 4695 E 4767 E 4633 Irloxacin Balofloxacin WI Y Y-25024

22 Fluoroquinolones R 5 R 6 CH R 7 X 8 R 1 Substituents at position 8 C-F C-ClCl C-Br CCHF 2 C-CH 3 CH 2 Sparfloxacin Lomefloxacin Fleroxacin KRQ Alumofloxacin Clinafloxacin Sitafloxacin WQ 2724 WQ 3034 WQ 2743 Enoxacin Tosufloxacin CI 990 Gemifloxacin Trovafloxacin Ecenofloxacin CS-940 Gatifloxacin Pazufloxacin Y-688 S Balofloxacin Moxifloxacin Garenoxacin DC-456 Y Ciprofloxacin Temafloxacin Pefloxacin orfloxacin Grepafloxacin 22

23 Fluoroquinolones R 6 CH R 7 X R 1 Substituents at -1 Ethyl (C 2 H 5 ) Fluoro ethyl (C 2 H 4 F) Cyclopropyl (c-c 3 H 5 ) Fluorophenyl (4'F-C 3 H 5 ) Difluorophenyl (2',4'-F-C 3 H 5 ) Methyl amino (H- ) t-butyl xetane Pefloxacin orfloxacin Enoxacin Lomefloxacin Fluorocyclopropyl Sitafloxacin DX-619 Fleroxacin 4'-F-pyridyl DW 116 Ciprofloxacin Grepafloxacin Y-688 S Alumofloxacin Gemifloxacin Moxifloxacin FD 501 FD 103 Ecenofloxacin CI 990 Balofloxacin CS 940 T-3811 KRQ Difloxacin 5'-amino 2',4'F pyridinium WQ 3034 WQ 2724 WQ 2743 Temafloxacin E-4868 Trovafloxacin Amifloxacin t-c 4 H WQ 175 WQ 1197 WQ

24 Fluoroquinolones R 5 Substituents at C-5 F CH H 2 R 7 X 8 R 1 Sparfloxacin WQ 0175 PD SY 987 FD 501 FD 103 KRQ Grepafloxacin BMY SY 1193 SY

25 Fluoroquinolones Prodrugs F CH R 7 R 1 R 1 R 7 R -aminoacid A difluorophenyl L-norval-norval H R PD Cyclopropyl L-alanyl H R H Alatrovafloxacin 2 4 difluorophenyl H R L-ala-L-ala 25 H

26 Fluoroquinolones Trovafloxacin enantiomers R In vitro activity In vivo activity Pharmacokinetics (animal) H H

27 Fluoroquinolones Enantiomers F CH H 3 C H In vitro activity Pharmacokinetics floxacin Less active o change Levofloxacin 2-4 x o change d-ofloxacin Inactive (MIC > 128 mg/l) o change 27

28 Fluoroquinolones Co drugs CH F C H 2 H 3 C F S H C C S Ro H H S FCE HC 28

29 Antibacterial activity

30 Fluoroquinolones Antibacterial activity Antibacterial activity R 5 Fixation sites uter membrane penetration DA gyrase mutagenesis F CH Antibacterial spectrum R 7 X 8 Anaerobes R 1 Global antibacterial activity 30

31 Fluoroquinolones Antibacterial activity F (6) R 5 (5) CH C-6 fluorine 7-substituent -1 substituent R 7 (7) X 8 (1) C-5 substituent (8) C-8 substituent R 1 31

32 Fluoroquinolones Antibacterial activity CH Minimal requirement. double bond in 2-3 must be reduced. free ketone in position 4. free carboxylic group in position has to be substituted R 1 32

33 Fluoroquinolones Antibacterial activity R 5 F C-6 fluorine enhances C 6 gyrase inhibition cell penetration. R 7 33

34 Fluoroquinolones Antibacterial activity R 5 (piperazinyl) F R Best moiety against Gram-negative bacteria C 7 H 2 R 7 X 8 (pyrrolidinyl) R Best moiety against Gram-positive cocci 34

35 Fluoroquinolones Antibacterial activity CH 1 1 R 1 Fluorocyclopropyl Cyclopropyl > 2 4 difluorophenyl > t-butyl > oxetane > butyl > ethyl F F C 2 H 5 35 Sitafloxacin DX-619 F Ciprofloxacin Temafloxacin BMY WQ 1107 orfloxacin

36 Fluoroquinolones Antibacterial activity R 5 F Additive activity against Gram-positive cocci C 5 H 2 > H > H e.g. : H 2... sparfloxacin... grepafloxacin R 7 X 8 36

37 Fluoroquinolones Antibacterial activity F Control anaerobe activity X 8 R 7 X 8 C-Cl = C-F = C- > CH > e.g. : C-Cl... clinafloxacin C-F... sparfloxacin 37

38 Fluoroquinolones Extend the antibacterial activity Gram-positive bacteria Anaerobes Targeted bacteria S. pneumoniae MRSA M. tuberculosis H. pylori 38

39 Fluoroquinolones Targeted indications mycobacteria Mycobacteria Structure- activity relationships have been extensively study Some fluoroquinolones are active in vitro and in clinical trials against M. tuberculosis M. leprae 1,8 naphthyridone are inactive. 39

40 Fluoroquinolones Targeted indications Mycobacteria F CH R 7 X R 1 R 1 X R 7 MIC (mg/l) M. fortuitum M. tuberculosis PD PD PD PD PD Ciprofloxacin Sparfloxacin Cyclopropyl Cyclopropyl tert butyl tert butyl Cyclopropyl Cyclopropyl Cyclopropyl C-Br C- C- CH 2 C-F 3'-methyl piperazinyl 4'-ethyl 3'-methyl piperazinyl 3', 5' dimethyl piperazinyl 3'-ethyl piperazinyl piperazinyl 3', 5' dimethyl piperazinyl

41 Fluoroquinolones Targeted indications H. pylori Two compounds atural compounds Y

42 Fluoroquinolones Targeted indications H. pylori In vitro activity - H. pylori MIC 50 (mg/l) F CH Y Levofloxacin 0.39 Sparfloxacin 0.20 Amoxicillin Clarithromycin In vivo (murine infection - H. pylori 1907) MIC (mg/l) Dose (mg/kg bid day 7) Clearance (%) Y Control Y Amoxicillin Clarithromycin From Sukurai et al, 1998

43 Piperazinyl derivatives Pyrrolidinyl derivatives Bicyclic derivatives X 3 R X 1 R 2 X 2 Temafloxacin Sparfloxacin Levofloxacin Gatifloxacin Grepafloxacin Tosufloxacin Clinafloxacin Trovafloxacin Moxifloxacin 43 S. pneumoniae

44 Respiratory Quinolones S. pneumoniae Ciprofloxacin orfloxacin Lomefloxacin Pefloxacin floxacin Enoxacin Fleroxacin Levofloxacin Moxifloxacin Gatifloxacin Sitafloxacin Gemifloxacin Garenofloxacin

45 Pharmacokinetics

46 Fluoroquinolones Pharmacokinetics F R 5 CH C-8 substituent C-7 substituent R 7 X 8 R 1 46

47 Fluoroquinolones Pharmacokinetics R 5 F CH R 7 X 8 R 1 C-8 substituent :oral absorption C-7 substituent :metabolism and oral absorption C-3 substituent :iron chelation 47

48 Fluoroquinolones Pharmacokinetics C 3 H Reduce oral absorption (interactions with antiacids, milk...) divalent cations : Ca ++, Fe ++, Zn ++ C 3 R 1 48

49 Metal cations,, antacids, anti-ulcers? Al 2+, Mg 2+, Ca 2+, Fe 2+ and other cations formchelate complexes with fluoroquinolones. Cation R 5 R H R 7 R 1? Reduce bioavailability of fluoroquinolones. 49

50 Fluoroquinolones Pharmacokinetics C 7 Improve oral absorption and water solubility eg. norfloxacin versus pefloxacin Site of metabolism for C-7 piperazinyl derivative. 50

51 Fluoroquinolones Pharmacokinetics R 5 F C 8 R 7 X 8 Substituent at C-8 may improved oral absorption C-F, C-Cl > C-, > CH 51

52 Fluoroquinolones Pharmacokinetics H or H 3 C C 7 metabolism Metabolism : 15-90% (nine metabolites) Metabolism : < 5% except grepafloxacin H 3 C H or H 52

53 Adverse events

54 Fluoroquinolones Adverse events Cutaneous rash Gastric pain Diarrhea Minor events Specific Adverse events Phototoxicity CS QTc prolongation Tendinopathies Hypoglycemia Hepatic injuries Urticaria 54

55 Fluoroquinolones Adverse events F R 5 CH C-7 substituent C-8 substituent -1 substituent R 7 X 8 R 1 55

56 Fluoroquinolones Adverse events R 5 R 7 F R 7 X 8 GABA binding (CS-tolerability) piperazine > pyrrole Theophylline interaction pyrrole > piperazine Genetic toxicity pyrrole > piperazine Solubility 56

57 Fluoroquinolones Adverse events R 5 X 8 F R 7 X 8 Phototoxicity C-F > C-Cl > > CH > C-, C-CF Genetic toxicity C-F > C-Cl > C- > > CH Water solubility 57

58 Fluoroquinolones Adverse events 1 1 CH Control theophylline cyclopropyl > ethyl > 2,4 -difluorophenyl > C 2 H 4 F Genetic toxicity cyclopropyl = t-butyl > difluorophenyl > ethyl R 1 58

59 Fluoroquinolones Adverse events Phototoxicity Solubility Genetic toxicity Theophylline CS C C C X

60 Fluoroquinolones Clastogenicity Concentration (mg/l) causing 50% cytotoxicity floxacin orfloxacin Temafloxacin Fleroxacin Ciprofloxacin Sparfloxacin Tosufloxacin Merafloxacin = 500 = 500 = 500 =

61 Fluoroquinolones Topoisomerase II activity ID 50 (mg/l) Compound floxacin Ciprofloxacin Levofloxacin Enoxacin Merafloxacin alidixic acid DA gyrase from E. coli KL topoisomerase II from thymus

62 Fluoroquinolones Affinity for GABA receptors R H IC 50 (M) > 10-3 F CH H 1.8 x 10-5 R H 3 C 1.0 x 10-3 H 3 C > 10-3 CH 2 H 5 C 2 C > 10-3 >

63 GABA receptors IC 50 (M) orfloxacin Enoxacin floxacin Ciprofloxacin Tosufloxacin Fleroxacin Sparfloxacin Levofloxacin Sitafloxacin BAY y 3118 Without SAID 1.4 x x x x x x x 10-4 > x 10-3 > biphenylacetate < x x x x x x x x x Affinity for the GABA receptor of fluoroquinolones Adapted from HRI

64 Fluoroquinolones Phototoxicity Substituents Phototoxicity C-F + C-ClCl R 7 Chemical structure 8 X R 1 C-H C-F C-CH 3-64 Adapted from Domagala

65 Fluoroquinolones Photosensibility Highest no effect phototoxic dosage (mg/kg) Ciprofloxacin > 300 Cl 990 > 300 floxacin > 300 Fleroxacin > 300 orfloxacin > 300 Clinafloxacin > 300 Tosufloxacin > 100 Sparfloxacin > 100 euroquino?? > 300 Lomefloxacin > 300 Temafloxacin 300 Cl Fleroxacin 172 Bay y Enrofloxacin 100 Murafloxacin

66 Phototoxicity? Method : ear swelling of mice after UV-A irradiation and quinolone administration X Dose (mg/kg) Inflammation F 8 X CH - 8-F -H /6 0/6 0/6 3/6 5/6 0/6 6/6 6/6 66 From Maratuni et al, 1993

67 Fluoroquinolones Photocarcino cino-genotoxicity Mice SKH-1 (hairless) hours / day of 25 J/cm 2 of UV-A A for 78 weeks 8-methoxy psoralen Lomefloxacin Fleroxacin floxacin Ciprofloxacin alidixic acid T 50 % (weeks) Carcinoma Tumors > 50 > 50 > (+)

68 Fluoroquinolones Mutagenicity F CH H 3 C R 1 R 2 ID 50 (mg/l) Compound R 1 R 2 MIC (µg/ml) DA gyrase topoisomerase II Levofloxacin H DR-3354 H floxacin D-9494 =CH DL-8165 H H

69 Fluoroquinolones Toxicity-tolerance tolerance : cardiotoxicity R 5 R 6 CH R 8 X 8 R 1 Bulky substituents at C- 5seem to be responsible for cardiotoxicity (e.g : sparfloxacin : C 5 = H 2 ) 69

70 Fluoroquinolones and QTc effect in humans Agent Route of administration QTc Prolongation (mean ± sd - msec) Sparfloxacin Grepafloxacin Gatifloxacin Gemifloxacin Levofloxacin P 10.3 ± 27.6 P 8 P 6 ± 26 IV 12.1 P / IV 2.9 ± 16.5 P 5 ± 25.6 P 4.6 ± wens, RC Jr. Pharmacotherapy ; 21 :

71 Theophylline (rat) R 7 % of inhibition of 1,3 DMU H 47 H < 1 2 H 3 C C 6 71

72 Conclusion

73 Fluoroquinolones Difficult to predict Increased difficulties in synthesis Tolerance Medical need ew concept vercome ciprofloxacin resistance (S. aureus, P. aeruginosa...) Targeted clinical indication : e.g... (Helicobacter pylori, mycobacteria) 73

74 Fluoroquinolones Expand the clinical indications Intra abdominal infections Lower respiratory tract intections Upper respiratory tract infections 74

75 Fluoroquinolones Future - ew avenues Development of new chemical structures Improvement in vitro activity correlated with clinical outcome Increased problems in the field of side effects. ew classifications of quinolones Extend the antibacterial activity Expand the clinical indications vercome ciprofloxacin- resistance. 75

76 Fluoroquinolones Garenoxacin H H CHF 2 H 3 C o 6-fluorine GAR TR CIP 7-dihydro isoindanyl S. pneumoniae Less activity on cartilage than other fluoroquinolones E. coli B. fragilis

77 77 ß-lactams

78 ß-lactam Classification H X R 1 Penems CH R 1 H R H R 1 H X R 2 monocyclic ß-lactams R 1 H X Penams CH R 2 78 Cephems CH

79 ß-lactam Penams Group I Group II Group III Group IV Group V Group VI Group VII xi imino penicillin Penicillin G Penicillin M 6-α-H-penicillin α carboxy penicillins Amidino penicillin xi imino penicillin BRL II A Ampicillin Amoxicillin Temocillin II B -acyl penicillins Carbenicillin Ticarcillin Sulbenicillin Mecillinam BRL Azlocillin Mezlocillin Piperacillin Apalcillin 79

80 Cephems

81 Cephalosporin C Discovered in 1953 (ewton & Abraham) Isolated from Cephalosporium acremonium (Brotzu, 1945) Chemical structure was elucidated in : 7- amino cephalosporinic acid (7-ACA) 81

82 Cephems Wave of parenteral cephems 7- ACA (1960) Cephalothin Cephaloridine (1964) 82

83 Cephems Classification Chemical classification (1) - Modification of the ring R 2 H X 1 X 1 R Cephalosporin xacephems S CH Carbacephems R 2 H X 1 X 1 R -iso-2 cephalosporin -iso-3 oxacephems S CH 83

84 Cephems Discovery of cephalosporin Mould from C. acremonium (1945) Cephalosporin C (1953) Hydrolysis 7- amino cephalosporinic acid (7- ACA) (1960) 84

85 Cephems Classification Chemical classification (2) - Modification substituents R H S R 1 H HCH S R 2 R 2 CH CH Cephamycins Cephabicins 85 R 1 H S CH Cephalosporins R R 1 Aryl CH 2 Aryl CH X Aryl CH X R

86 Cephems Microbiological classification Cephems could be divided according to their antibacterial spectrum in three groups limited spectrum : I and II Broad spectrum : III, IV and V arrow spectrum: VI and VII 86

87 Group I : Cephalothin, cephaloridine Active against penicillinase- producing S. aureus ther cephems from group I show marginal antibacterial activities Group I cephems show moderate anti Gram- negative activities. 87

88 Group I : Cephems Designed to overcome S. aureus resistant in penicillin G First cephalosporins to bear at C-3 an heterocycle moiety + Cephaloridine R CH Cefazolin S S Activity against Gram-negative bacilli (Enterobacteriaceae) and stability to ß-lactamase hydrolysis - equivalent to that of ampicillin. 88

89 Cephems Group II Designed to increase the antibacterial activity against Gram- negative bacilli (enterobacteriaceae). Increase stability to ß- lactamase hydrolysis. 89

90 Cephems - Group II R H H Cephalosporins R H Cephamycins 90

91 Group II-Cephems Limited spectrum cephems, stable to broad spectrum ß-lactamases Less active against S. aureus (penicillinase-producing strains) than group I compounds More active against Enterobacteriaceae than group I cephems. Cephem Cefuroxime was the first derivative with an oxime side-chain. C C H S R CH 91

92 Cephems - Group II In vitro activity MIC (mg/l) Cefuroxime Cefamandole Cefoxitin E. coli (TEM-1) K. pneumoniae (CEZ-R) S. marcescens 64.0 > H. influenzae S. aureus peni-r S. pneumoniae

93 Group III - cephems Cephems which belong to group III have two or more of the following characteristics. 2-amino-5-thiazolyl ring H 2 S. broad antibacterial spectrum. MIC 50 values = 1.0 mg/l for H. influenzae, eisseria spp, S. pneumoniae, S. pyogenes, Enterobacteriaceae (non producing class I ß-lactamases or ESBL). good stability to hydrolysis by plasmid mediated broad spectrum ß-lactamases. good antipseudomonal activity. 93

94 Group III - cephems Group III is the most important group All the molecules are chemically related to cefotaxime All have a 2-amino-5-thiazolyl ring. Alkoxy amino side chain at C-7 C C H 2 S R 94

95 Group III - cephems S R R R Ceftizoxime Cefotaxime -H - C C - a - Ceftriaxone H Cefodizime C 3 Side- chain Cefmenoxime S Cefuzonam S S S CH 2 CH 95

96 Cephems Group III - Five subgroups A to E Group III III A III B III C III D III E Cefotiam Cefoperazone Cefpimizole Cefpiramide Cefotaxime Ceftizoxime Cefodizime Ceftriaxone Ceftazidime Cefmenoxime Cefuzonam Moxalactam Flomoxef KT 3767 KT 3919 RU RU Ceftioxide CM

97 Cephems - Group III Chemical modifications C-7 7 oxime side-chain R ther H Standard Better anti Gram-positive activity 97

98 Cephems - Group III Chemical modifications C-7 : methoxyimino side-chain (cefuroxime) C C H C-3 : -methyl tetrazol thio moiety (cefamandole) Br H S CH 2 S CH 98

99 Cephems - Group III Chemical innovation C- 7moiety 2-amino 5-thiazolyl ring 5-amino 2-thiadiazolyl ring H 2 S H 2 S Improve antipneumococcal activity Decrease anti Enterobacteriaceae activity 99

100 Cephems - Group III Innovation Chemical structure 2-amino 5-thiazolyl ring H 2 S + xime side-chain R Discovery + R Antipseudomonas activity 100

101 Group III - cephems Evolution Strep 1 : toimprove the antibacterial activity extend the antibacterial spectrum Cefotaxime Strep 2 : to improve the pharmacokinetic profile Ceftriaxone Strep 3 : acquisition of new properties : immunorestoration Cefodizime 101

102 Group III - cephems Improve the antibacterial activity MIC (mg/l) S. pneumoniae E. coli Ampi-S E. coli Ampi-R K. pneumoniae cefazolin-s K. pneumoniae cefazolin-r Enterobacter spp C. freundii Indd + Proteus S. marcescens H. influenzae ß- H. influenzae ß+ Cefamandole > > Cefotaxime

103 Group III - cephems Long-acting cephem : ceftriaxone Elimination half-life life (min) (rats) H 3 C H 35 H 3 C 12 H 3 C 10 H 3 C

104 Cefodizime Structure-activity activity-relationships (pharmacokinetics) MIC (mg/l) T ½ (h) AUC (mg.h/l) CH S CH 2 CH S CH S CH S 3 CH Cefodizime Cefotaxime

105 Group III - cephems Cephalosporin BRM : cefodizime S C C H S S S Ca + Ca + 105

106 Cephems Group III - oxa-1-cephem R 1 R 2 C H Latamoxef R 1 CH CH - S Flomoxef F 2 CH S CH 2 -CH 2 -CH 2 H CH R S H 2 C S CH 2 -CH 2 -CH 2 H F 106

107 Cephems Group III - oxa-1-cephem Flomoxef is more active than latamoxef against Gram-positive cocci MIC 50 (mg/l) Latamoxef Flomoxef Cefotaxime S. aureus S. epidernidis S. pneumoniae = Latamoxef and flomoxef share tho same in vitro activity against Gram-negative bacilli Latamoxef is responsible of disuliram-like syndrome and hyprothrombinemia (-methyl substituent) and bleeding (α carboxylic group at C-7). 107

108 Cephems - Group IV These compounds have been designed overcome class I producing strains within Enterobacteriaceae. 108

109 Cephems Group IV - Definition Group III definition C- 3 quaternary ammonium moiety Activity against Enterobacteriaceae producing class 1- ß- lactamase. 109

110 Cephems Group IV - Antibacterial activity Enhance activity against Enterobacteriaceae producing class I ß- lactamase (Amp C) Mechanism of action Some compound retain good anti Gram- (cefpirome, cefozopran) positive activity Hydrolysis by ESBL. 110

111 Cephems Group IV - Classification C-3' quaternary ammonium cephems C-3 C-7 2-Amino-5-thiazolyl 5-Amino-2-thiadiazolyl D 9550 ICI ICI TC-39 TC-50 CP 6679 Ceftazidime Cefpirome Cefepime Cefquinone Cefoselis DQ-2556 CS-461 ME-1228 MT-520 MT-382 ME-1221 ME-1220 Cefclidin Cefozopran Cefluprenam FK 518 YM L L L

112 Cephems - Group VI C- 3quaternary ammonium cephem are zwitterionic compounds C C H H 2 S R + C - egative charge (S - or C - ) egative charge ( ) Dianionic cephems Ceftazidime Cefsulodin Zwitterionic cephems Cefpirome Cefepime Cefoselis Cefclidin Cefluprenam 112

113 Cephems - Group IV Mechanism of action Velocity through outer membrane Poor affinity + to ß-lactamase + Strong affinity to PBPS 113

114 Cephems Group IV - Weaknesses Hydrolysis by ESBL Variable activity against P. aeruginosa Short elimination half- life ( 2 hours). 114

115 Cephems Group V Designed to overcome resistance due to ESBL, producing strains Increase in vitro activity against P. aeruginosa 115

116 Cephems - Group V Chemical modification H H H R H Catechol moiety fixes on the oxime chain Pyrridone fixes on the oxime chain 116

117 Cephems Group V - Classification Cephems Catecholes Group V-1 Hydroxypyridones Group V-2 Group V-1A Group V-1B Group V-2A Group V-2B 117 C-3 C-7 C-3 C-7 Bo 1236 Bo 1341 Merck derivatives Ro Gr M E-0702 BRL 41897A RU LK Ro LB CP 6162 SPD 391 SPD 411 KP 736 MT 0703S

118 RU H 2 S H S + H H - Staphylococcus spp ß-lactamases Pharmacokinetics F H P. aeruginosa 118

119 Cephems - Group V Antibacterial activity. overcome ESBL. original additional mechanism of action : Fe 2+ chelation. Wearknesses. metabolism. tolerance (?). cost of production. 119

120 Cephems - Group VI Investigations. In vitro... MIC. Bactericidal activity. Affinity for PBP 2a. In vivo 120

121 Cephems - Group VI V A V B Anti pseudomonas Anti MRSA Cefsulodin RWJ RWJ BAL 9141 LY CP TAK

122 Cephems - Group VI Cefsulodin. Dianionic compound : derived from sulbenicillin Anti pseudomonal activity CH S 3 - C H S + C H 2 C - 122

123 Cephems group VI Cephems Group VI VI A VI B (antipseudomonal) (anti-mrsa) 123 Cefsulodin RWJ (MC ) TAK-599 (T-91825) Cefprozan derivatives S-3578 BMS Benzotiophene comp LY BAL-9141 CP-0467 SM PC TC-39 RWG CP 5068 ME 1209 (CP 6679) PGE PGE CB (BC 1175) RWJ LB Figure 57

124 Cephems - Group VI Cephems designed for an anti MRSA activity H H S + H 4 H 2 H 2 S CH S H 2 MC F H 2 H S X LY X 124 H 2 S - a +

125 Cephems - Group VI Antibacterial activity MIC (mg/l) IC 50 (mg/l) MRSA heterogenous MRSA homogenous PBP 2 LY Methicillin > afcillin

126 Cephems Pharmacokinetics classification (1) Apparent elimination half- life (three groups) Subdivision : elimination route 126

127 Cephems Pharmacokinetics classification Cephems T 1/2 (h) Group I < 1 h Group II 1 h - 3 h Group III 3 h - 8 h Urinary elimination Bile (> 20 %) Urinary elimination Bile (> 20 %) 127 Cephaloridine Cefacetrile Cephalothin Cephradine Cefotaxime Ceftizoxime Cefmenoxime Ceftazidime Cefuzonam Cefpirome Cefepime Cefclidin Cefozopran Flomoxef Latamoxef Cefluprenam Cefoperazone Cefodizime Cefotetan Ceftriaxone Cefpiramide

128 Cephems - Group II Improvement of antibacterial activity Fixed on numerous cephems within group II and III Side effect doe to the methyl group : disulfiram-like and hypothrombinemia removal of group R?????????????????????????????? 128

129 Cephems - Group VI Conclusion Powerfull successful research to meet medical needs S. aureus peni-r Gram-negative bacilli MRSA 129

130 Penems

131 Penem H H 3 C S H Synthetic compounds Antibacterial agents ß- lactams. CH 131

132 Penem Classification X Group I Group II Group III Penem Carbapenem xapenem 132 H 3 C H X CH R A Sch Sch B HR 664 C Ritipenem FCE FCE CGP CGP A D Faropenem TMA 3176 FCE Group II A Group II B Group II C Group II D CH 2 Imipenem L BMY Panipenem SY ß-methyl Meropenem Biapenem Lenapenem S 4661 CL CL CL B 2502 A DX-8739 Ertapenem Polycyclic GV S thers BMS Ro

133 Penem Classification H H 3 C X R CH R Group I A Group I B Group I C Group I D Group I E Thiopenem xypenem Alkylpenem Arylpenem Aminopenem SCH S4143 Sulopenem HR 654 Ritipenem FCE FCE CGP CGP A Furopenem FCE TMA

134 Penem Synthetic compounds ew compounds 134

135 Penem R SCH S4343 -S-C 2 H 5 -S-C 2 H 4 CH 2 S H 3 C H S Sulopenem Zeneca derivatives HR 664 S + - S H CH 2 R CGP Ritipenem -CH 2 -H 2 -CH 2 CH 2 CH FCE FCE CH 2 C -CH 2 Faropenem H TMA 3176 FCE CH + 135

136 Penem H Ester (R 2 ) Parent compound FCE FCE S R 1 SU A 0026 Fropenem CP C-C( ) 3 Sulopenem C-R 2 Ritipenem-acoxil -CH 2 C Ritipenem TMA-230 -CH 2 C TMA

137 Penem Structure-activity H Antibacterial activity H 3 C S H ß-lactamase stability CH 137

138 Penem Structure-activity Penem nucleus displays an antibacterial activity equal to that of ampicillin against ampi-s strains The stereochemistry of the 6-side-chain is compulsary C-2 side-chain retains the antibacterial activity. 138

139 Penem Hydrolysis by DHP-1 H H 3 C H H S H H HC H 3 C S CH DHP-1 M 1 (SU 9609) Hydrolytic site CH H Lung, kidney (dog, human) H 3 C H H S H HC 139 CH M 2 (SU 9608)

140 Penem Dioxolenone ester : metabolism C -C-C- diacetyl Gastro intestinal tract/liver CH-C- acetoine Liver 140 CH-CH- 2, 3 butenadiol

141 Penem André, je suis vraiment désolé... mais je ne vois rien du tout pour la figure page «Fro-penem 3» 141

142 Macrolides

143 Macrolides Three waves of macrolides 1st st Erythromycin A leandomycin Spiramycin bjectives S. aureus peni-r 2d 3d Roxithromycin Clarithromycin Azithromycin Dirithromycin Ketolides Atypical microorganisms Improvement of pharmacokinetics vercome resistance to erythromycin A Enhance activity against Gram-positive bacteria 143

144 Macrolides Second wave of molecules Target Increase absorption Good stability in acid conditions o enhancement of in vitro activity against common pathogens Increase in vitro activity against atypical pathogens. 144

145 Macrolide Erythromycin A leandomycin Spiramycin(s) Josamycin Midecamycin Tylosin Saccaropolyspora erythrea Streptomyces antibioticus Streptomyces ambofaciens Streptomyces narbonensis var. josamyceticus vova sp Streptomyces mycarofaciens Streptomyces fradiae

146 Macrolide Erythromycin A H 3 C 9 8 H H 3 C 11 H H 12 6 H 3 C H H 146

147 Macrolide H 3 C H H 6 [H + ] H 3 C H H [H + ] H 2 H 3 C Erythromycin A Hemicetal Didehydro-erythromycin A 147

148 Macrolide Concentrations (plasma) 2'-ester erythromycin A 2'-propionyl 2'-ethylsuccinyl 2'-acethyl 2'-butyryl 2'-valeryl 100 mg/l mg/l

149 Macrolide Erythromycin A Anhydroerythromycin A Cmax (mg/l) Tmax (h) T ½ (h) AUC 0-8 (mg.h/l) 0.9 ± ± ± ± ± ± ± ±

150 Macrolide Weak and link points of erythronolide A Weak point Linking point 1 H 3 C 9 8 H 6 R Linking point 2 H 12 H H 3 C H 3 C 150

151 Macrolide H H 3 C H 8 F H H 3 C 6 Flurithromycin H 3 C 12 H 3 C 11 X H 3 C 8 8 H H H H 3 C X = : Davercin X = : Carbamate Erythromycin A Clarithromycin 151 R other

152 Macrolide Semisynthetic derivatives of 9-erythromycin 9 A H 3 C R 9a azalide alkylation 9 Beckman rearrangement R roxithromycin 9 reduction H 2 intermediate synthesis derivative (9-oxime) 9 erythromycylamine weak point erythromycin A dirithromycin

153 Macrolide H 3 C (CH 2 ) 2 CH H H 3 C H H Dirithromycin H 3 C H 3 C H 3 C H H H Erythromycylamin Roxithromycin 153

154 Macrolide R 9 9a R 8a H H H 3 C H 3 C H 3 C H H H 3 C Erythromycin A 9a-azalide 8a-azalide H Azithromycin 154

155 Macrolide X R -10-methyl azalide X = H R = Lactam X = R = H 14-membered ring azalides 155

156 Macrolide H H 3 C [H + ] (translactonisation) H 3 C H H 3 C H 3 C Clarithromycin Pseudoclarithromycin 156

157 Macrolide H 3 C H 3 C H -Desosamine H -Desosamine [H + ] H H L-cladinose cleavage Azithromycin CP

158 Macrolide 2'-esters erythromycin A 5 2'-ester R Sale Acistrate C (CH 2 ) 16 CH Ethylsuccinate - Estolate Propionate CCH 2 CCH 2 C 12 H 25 S 3 H - 2' R RV-11 CCH 2 HS CH CH H 2 C CH D-desosamine 158

159 Ketolides

160 Ketolides Definition Semisynthetic derivatives of erythromycin A Lack of α- L- cladinose Highly stable in acidic environment vercome erythromycin A resistance (MLS B inducible, efflux) Unable to induce MLS B resistance. 160

161 ketolides Third wave of molecules Target Same pharmacokinetic profile Activity against erythromycin A resistant isolates. 161

162 ketolides Target Same pharmacokinetic profile of macrolides Activity against erythromycin A resistant isolates 162

163 Bacterial resistance to antibacterials β-lactams : penicillin G, amoxicillin, cephems ther antibacterials S. pneumoniae Fluoroquinolones 163 Co-trimoxazole Rifampicin Tetracycline Chloramphenicol Macrolides Lincosamides Streptogramins

164 Spread of bacterial resistance Gram-positive ther Gram-negative S. pneumoniae S. pyogenes Enterococcus spp S. aureus Coagulase negative staphylococci M. tuberculosis H. pylori Enterobacteriaceae P. aeruginosa 164

165 Ketolides In vitro activity of narbomycin 165

166 Ketolides atural ketolides C H 3 H H 3 C 6 H 3 C H 3 C Z Picromycin H arbomycin H 166

167 Ketolides atural derivatives Semi synthetic derivatives 167 Picromycin arbomycin 15-membered GW X 14-membered Telithromycin HMR 3004 Cethromycin HMR 3562 HMR 3787 HMR 3832 TE-802 TE-810 CP

168 Ketolides Telithromycin HMR 3004 HMR 3787 Aventis Pharma 3 -cladinose HMR 3832 HMR 3562 Cethromycin Abbott 3 Ketolide TE 802, TE 810 RWJ RWJ Taisho RW Johnson and pharmaceutical CP Pfizer 168

169 Ketolides They are composed of three specific chemical structures 3-keto function (lack of L-cladinose) Side-chain C 11 -C 12 Side chain C 6 169

170 KET FUCTI

171 Ketolides ew medicinal chemical entities Semisynthetic compounds obtained from erythromycin A Removal of the L- cladinose (neutral sugar), and oxidation of the 3- hydroxyl (H) yields to a 3- keto group (ketolide) cladinose H removal xidation 3- keto (= ketolide) 171

172 Ketolides 3-keto function 3-keto function imparts the following biological properties 3 Antibacterial activities against erm-containing-gram-positive cocci Absence of ability to induce MLSB resistance High stability in acidic environment. 172

173 Stability in acidic environment ph 1.0 at 37 C Telithromycin % of activity Azithromycin Clarithromycin Time (h) 173

174 Interaction with human motilin receptor Telithromycin Clarithromycin Erythromycin A IC 50 (µm) (inhibition of motilin binding) > 100µM (23 % inhibition at 100 µm) 100 µm (54 % inhibition at 100 µm) < 3 < 3 µm (60 % inhibition at 3 µm) 174

175 o inducer of MLS B resistance Ery/Ery TEL/Ery C/Ery Ery/Ery RU 69874/Ery C/Ery H 3 C H 3 C H 3 C C H C 3 H 3 C Telithromycin H H 3 C C H C 3 H H 3 C H RU

176 176 C11- C12 carbamate residue

177 Bacterial resistance to antibacterials β-lactams : penicillin G, amoxicillin, cephems ther antibacterials S. pneumoniae Fluoroquinolones 177 Co-trimoxazole Rifampicin Tetracycline Chloramphenicol Macrolides Lincosamides Streptogramins

178 Clarithromycin......carbamates analogues R A H A H A H R A A A CH 2 178

179 Spread of bacterial resistance Gram-positive ther Gram-negative S. pneumoniae S. pyogenes Enterococcus spp S. aureus Coagulase negative staphylococci M. tuberculosis H. pylori Enterobacteriaceae P. aeruginosa 179

180 C 11 -C 12 carbamate substituted side chain Ketolides In vitro activity Carbamate residue Pharmacokinetics Pharmacodynamics R Intracellular kinetics Efflux Mechanism of action Tolerance- toxicity. 180

181 Research in anti-infectives infectives Ketolides 3 ew chemical entities C 11 C 12 carbamate ketolide ptimisation R Substituted carbamate ketolide Innovation 181

182 pyridyll imidazolyl R butyl C telithromycin Carbamate ketolide 182

183 Ketolides C 11 - C 12 carbamate substituted side chain Quinoline ring Imidazolyl ring CH 3 H 3 C H C Pyridyl ring C H 3 HMR 3004 Telithromycin 183

184 Mode of action Significant of different mode of action A-2058 V A-2058 V 5S rra ERY 5S rra TEL A-752 cladinose o link with domain V II A-752 Link with domain II II Resistance to erythromycin A, azithromycin, roxithromycin, clarithromycin, Telithromycin retains activity against erythromycin A-resistant organisms 184

185 Ketolides C 11 - C 12 carbamate substituted side chain (1) Pharmacokinetics in mice Concentrations (mg/l) at Cmax (mg/l) Tmax (h) 0.25* Telithromycin HMR * sampling time (hours) Craig,

186 Ketolides C 11 - C 12 carbamate substituted side chain (2) Pharmacokinetics in mice Cmax (mg/l) Tmax (h) AUC 0-24h (mg.h/l) Telithromycin HMR Craig,

187 Ketolides C 11 -C 12 carbamate residue R Comparative human pharmacokinetics after a single oral dose 600 mg HMR 3004 HMR 3647 Cmax (mg/l) Tmax (h) AUC 0-8 (mg.h/l) C 24h (mg/l) t1/2 (h) 0.16 ± ± 0.11 D 2.25 ± 0.16 Cmax (mg/l) Tmax (h) AUC 0-8 (mg.h/l) C 24h (mg/l) t1/2 (h) 0.90 ± ± ± ±

188 Telithromycin Metabolites (1) CH 2 H C CH RU (-propyl carboxylic) H 3 C C H 3 C H C C - RU (-pyridine oxide) H 3 C Telithromycin H 3 C H RU (-monodemethyl desosamine) 188

189 Telithromycin Disposition Systemic circulation (blood stream) Intestinal secretion Bile Liver Kidney a Metabolism to : RU % RU % RU % RU % thers Urine (17.4 %) 11.8 % telithromycin 5.6 % metabolites Formation enzyme non CYP CYP3A CYP3A CYP3A/1A Absorption Gastrointestinal tract (Via bile) Feces (75.6 %) 20.2 % telithromycin 55.4 % metabolites Metabolites expressed as relative radioactivity in circulation (metabolite AUC / telithromycin AUC) 189

190 Structure activity relationships H 3 C 9 CH 3 Mode of action Reduced efflux C H C H 3 C 3 CH 3 Enhanced in vitro activity Intracellular accumulation Pharmacokinetics Tolerance H High stability in acidic ph vercoming MLSB on inducer of MLSB resistance C H 3 CH 3 190

191 Macrolide resistance 14-membered ring macrolide Phosphorylation H P H E. coli ocardia spp Glycosylation CH 2 H H 2' ( ) 2 H H H 1''' Streptomyces antibioticus Streptomyces Vendargensis ocardia spp 6 191

192 Macrolide resistance Ring hydrolysis by esterases H H 3 C H Hydrolysis esterases H 3 C 1 Erythromycin A H H Described in S. aureus - E. coli H 3 C 192

193 Macrolide resistance Erythromycin A binding site Transfert of methyl group in adenosyl methionine H 2 S-adenosyl-L-methionine H 3 C Erythromycin P H CH 2 Ribosome methylase Erne P H CH 2 o binding H H Adenine 2058 in 23 S rra erm gene Dimethylated A-2058 (A G) 193 Adapted from K. 'hara, 2000

194 Macrolides Mechanism of resistance H H 3 C H R 2 R 2 R 1 H H H H 3 C C 1 H CH H 3 C 3 R 1 Esterase C H 3 H H R 1 : α-l cladinose R 2 : D-desosamine 194