Antibacterial

Agents
Structure
Activity Relationships

André Bryskier MD

1 Lille - December 7 th 2004

 – Beta-lactams
– Aminoglycosides
– Macrolides
– Streptogramin
Natural compounds – Lincosamines
– Peptides
– Mupirocin
– Ansamycins

Antibacterial
Agents – Benzyl pyrimidines
– Sulphonamides
– Sulfones
– Furans
– 4-quinolones
Synthetic compounds – Oxazolidinones
– Nitroxoline
– Penem
– Fosfomycin
– Anti-TB
 Antibiotic resistance

Pre antibiotic
1941 era

Antibiotic
2000 era

3
 Research in anti-infectives

Research after mid

- 80s
Research up mid
- 80s

•Enlarge the antibacterial spectrum •Overcome bacterial resistance

• Enhance the antibacterial activity (e.g. cefotaxime)
• Improve the pharmacokinetics
(e.g. roxithromycin , clarithromycin, azithromycin)

4
 Purification e.g Penicillin G
Erythromycin A
Kanamycin

Semi synthetic

ß-lactams
Macrolides

Aminoglycosides

5
 Structure-Activity-Relationships

WHY

Antibacterial activity in vitro and in vivo (?)

Bacterial resistance
Bactericidal activity
Toxicity-tolerance
Optimisation of chemical strcutures
Improvement of physicochemical properties
Pharmacodynamics
Pharmacokinetics.
6
 Antibacterial agents

Screening " Chemical

Future
" Natural products

Existing New molecule

New targets
compounds entities

Optimization of existing
Alterations non-antibacterials
chemical structures

7
Improvement of physicochemical properties

Exemple : water- solubility

N N
(1)
N N
H H3C

Norfloxacin Pefloxacin (IV formulation)

8
Improvement of physicochemical properties

Amino acid

(2) Trovafloxacin Alatrovafloxacin (IV formulation)

Amino acid

(3) Ceftizoxime Prodrug

N N

H2 N N
S R H S

Amino acid ASN-924

9
Fluoroquinolones
 Fluoroquinolones
History of quinolones
Pipemidic acid
7

N 7-piperazinyl moiety (partial cross-

cross-resistance
With oxolonic acid)
acid )

F
Nalidixic acid Oxolinic acid 6
Fluoroquinolones
(1962) (quinoline)
Flumequine

7
Piromedic acid
N

Pirrolidinyl moiety (+ ve activity)

11
 Fluoroquinolones
Definition

COOH Synthetic antibacterial agents

Pharmacophore :
R pyrridone-ß-carboxylic acid

N Auxopharmacophore :
fused aromatic ring
appended substituents
R1

12
 Fluoroquinolones

COOH

(CH3)2N
N
Ro 13-5478

Monocyclic derivative

13
 Fluoroquinolones
Structure - activity relationships

Classification
Microbiology
Pharmacokinetics
Adverse events

14
 Fluoroquinolones
Classifications

Chemical classification
Biological classification

15
 Fluoroquinolones
Chemical classification
Group I Group II Group III Group IV
Monocyclic derivatives Bicyclic derivatives Tricyclic derivatives Tetracyclic derivatives

Ro-145478 Ro-149578
KB-5246
Group II B Group II A Group IIC III A III B

Pentacyclic ring Hexacyclic ring Heptacyclic ring Non-fluorinated Fluorinated

III B1 III B2
T - 14097 FD 501
FD 103
Tioxic Ofloxacin Prulifloxacin
Oxolinic acid Levofloxacin
Miloxacin Flumequine
EN 272 Abufloxacin
DJ 6783 Rufloxacin
Droxacin S-25932
QA-241
DN 9494
A-62824
MF 961
Marbofloxacin
Verbafloxacin
Pazufloxacin
CP 91121
WQ 0835
16 KRQ 10099
 Fluoroquinolones
Chemical classification (bicyclic derivatives )
Group II

Group IIB Group IIA -hexacyclic ring

IIA-1 IIA-2 IIA-3

1.8 naphthyridine Pyrido [2,3-b] pyrimidine Quinoline

No fluor 6-Fluor
Pipemidic acid
Nalidixic Piromedic acid
acid 7-piperazinyl 7-pyrrolidinyl Other
Enoxacin AT 3295 BMY 40062
A-57132 AT 3765 E-3499
Tosufloxacin Trovafloxacin
A-65485 Ecenofloxacin
BMY 43738 CP 99433
BMY 41802
U-91939E
PD 131112 (Cl 990)
Gemifloxacin
DC-756

17
 Fluoroquinolones
Chemical classification - Bicyclic derivatives
Group II

Group II B Group IIA -six membered-ring

IIA-1 IIA-2 IIA-3

6-Fluor des (6) fluorinated 6-NH2

7-piperazinyl 7-pyrrolidinyl 7-pyrrylyl 7-azetidinyl Bicyclic Other

Norfloxacin PD 117596 Pirfloxacin (Irloxacin) Esteves series Moxifloxacin Y-25024 Acroxacin MF 5137
Pefloxacin PD 117558 E 3624 WQ 2724 Bay y-3118 Binfloxacin WIN 35439
Amifloxacin PD 124816 E 3485 WQ 2743 KRQ 10196 Y-26611 Piroxacin
Difloxacin A 57132 . WQ 2756 KRQ 10099 Balofloxacin Garenoxacin
A – 56620 OPC 17080 . WQ 2765 BAY y 3118 DX-619
.
Fleroxacin Merafloxacin SYN 987
Sparfloxacin Clinafloxacin S-31076
Lomefloxacin WQ 2128 KRQ 10196
Temafloxacin A-80556 Y-34867
CS 940 WQ 1197
Grepafloxacin SYN 987
Gatifloxacin SYN 1193
DW-116 SYN 1253
NSFQ-104 S-32730
NSFQ-105 Sitafloxacin
AMQ-4 Alumafloxacin
Y-688
DC-756
18
 Fluoroquinolones
Tricyclic derivatives

O
R1 R2
F COOH
Flumequine CH3 H

Methyl flumequine CH3 CH3

R2 N
N
Abufloxacin CH3 N

R1

Verbufloxacin CH3
N

Benzoquinazoline derivatives H3CN

19
 Fluoroquinolones
Tricyclic derivatives

O
R1 R2
F COOH
Ofloxacin 4’-methyl piperazinyl

Levofloxacin 4’-methyl piperazinyl

R2 N
Neuquinoron H2N
O
R1 CP 92121 Pyridine

20
 Fluoroquinolones
O

F COOH

R7 X8 N1

R
7-position

Bicyclic Piperazinyl Pyrrolidinyl Azetidinyl Pyrryl Piperidinyl Pyridinyl Morpholine

Trovafloxacin Ciprofloxacin Clinafloxacin E 4695 Irloxacin Balofloxacin WIN 52773 Y-26611

Moxifloxacin Lomefloxacin Nadifloxacin E 4767 Y-25024
Danafloxacin Norfloxacin Sitafloxacin E 4633
Garenoxacin Fleroxacin
Ofloxacin
Sparfloxacin
Grepafloxacin
Gatafloxacin
Levofloxacin
21
 Fluoroquinolones

R5 O

R6 COOH

R7 X8 N

R1

Substituents at position 8

C-F CH3 C-Cl C-Br N COCHF 2 C-OCH3 CH2

Sparfloxacin Alumofloxacin Clinafloxacin WQ 2743 Enoxacin CS-940 Gatifloxacin Ciprofloxacin

Lomefloxacin Sitafloxacin Tosufloxacin Pazufloxacin Temafloxacin
Fleroxacin WQ 2724 CI 990 Y-688 Pefloxacin
KRQ 10196 WQ 3034 Gemifloxacin S-32730 Norfloxacin
Trovafloxacin Balofloxacin Grepafloxacin
Ecenofloxacin Moxifloxacin
Garenoxacin
DC-456
Y-34867

22
 Fluoroquinolones

R6 COOH

R7 X N

R1

Substituents at N-
N -1

Ethyl Fluoro ethyl Cyclopropyl Fluorophenyl Difluorophenyl Methyl amino t-butyl Oxetane
(C2 H5 ) (C2 H4F) (c-C3 H5 ) (4'F -C3H 5) (2',4'-F-C3H 5) (NH-CH3)

Pefloxacin Fleroxacin Ciprofloxacin Difloxacin Temafloxacin Amifloxacin t-C4 H6

40062 WQ 175
Norfloxacin Grepafloxacin E-4868
WQ 1197
Enoxacin Y-688 Trovafloxacin
WQ 1101
Lomefloxacin S-32730
Alumofloxacin
Fluorocyclopropyl 4'-F-pyridyl Gemifloxacin 5'-amino 2',4'F pyridinium
Moxifloxacin
Sitafloxacin DW 116 FD 501 WQ 3034
DX-619 FD 103 WQ 2724
Ecenofloxacin WQ 2743
CI 990
Balofloxacin
CS 940
T-3811
KRQ 10196

23
 Fluoroquinolones

R5 O Substituents at C-5

F COOH NH2 CH3 OCH3

Sparfloxacin Grepafloxacin SYN 1193
WQ 0175 BMY 43748 SYN 1253
PD 124816
R7 X8 N SYN 987
FD 501
FD 103
R1 KRQ 10196

24
 Fluoroquinolones
Prodrugs
O

F COOH

R7 N N

R1

R1 R7 R’-aminoacid

A 70826 2’4’ difluorophenyl N

L-norval-norval

HN R’

PD 131628 Cyclopropyl L-alanyl

HN R’

Alatrovafloxacin 2’4’ difluorophenyl L-ala-L-ala

HN R
H
25
 Fluoroquinolones
Trovafloxacin enantiomers

N N

In vitro activity In vivo activity Pharmacokinetics (animal)

+++ +++ +++

H2N

+++ + +
H2N

26
 Fluoroquinolones
Enantiomers
O

F COOH

N O
H3C H

In vitro activity Pharmacokinetics

CH3 Ofloxacin Less active No change

CH3 Levofloxacin 2-4 x No change
CH3 d-ofloxacin Inactive (MIC > 128 mg/l) No change

27
 Fluoroquinolones
Co drugs
COOH
O
NH2
O
F COO N O N

C S
S N C
N N H

N Ro 23-9484
N F OCH3
H3C

OH

NH

N FCE 26600
S
O
N
O

HOOC O O

28
Antibacterial activity
 Fluoroquinolones
Antibacterial activity

Antibacterial
activity
R5 O Fixation sites

Outer membrane penetration COOH

F
DNA gyrase mutagenesis

Antibacterial spectrum R7 X8 N

R1 Global antibacterial
activity
Anaerobes

30
 Fluoroquinolones
Antibacterial activity

R5 O
C-6 fluorine
(5)
F (6)
COOH
7-substituent
N-1 substituent

R7
(7)
X8 N C-5 substituent
(1)
(8)
C-8 substituent
R1

31
 Fluoroquinolones
Antibacterial activity

4
COOH Minimal requirement
3 . double bond in 2-3 must be reduced
. free ketone in position 4
2 . free carboxylic group in position 3
N1 . N-1 has to be substituted

R1

32
 Fluoroquinolones
Antibacterial activity

R5

F C-6 fluorine enhances

" gyrase inhibition
C6 " cell penetration.

R7

33
 Fluoroquinolones
Antibacterial activity

R5 N (piperazinyl)
N

F R
Best moiety against Gram-negative bacteria
C7
H2N
R7 X8
N (pyrrolidinyl)

Best moiety against Gram-positive cocci

34
 Fluoroquinolones
Antibacterial activity
O

COOH

N1 N1

R1

Fluorocyclopropyl Cyclopropyl > 2’4’ difluorophenyl > t-butyl > oxetane > butyl > ethyl

F C2H 5

Sitafloxacin Ciprofloxacin Temafloxacin BMY 10062 WQ 1107 Norfloxacin

35
DX-619
 Fluoroquinolones
Antibacterial activity

R5

F Additive activity against Gram-positive cocci

NH2 > OH > H
C5 e.g. : NH2 ... sparfloxacin
CH3 ... grepafloxacin
R7 X8

36
 Fluoroquinolones
Antibacterial activity

F Control anaerobe activity

X8 C-Cl = C-F = CO-CH3 > CH > N

e.g. : C-Cl ... clinafloxacin
X8
C-F ... sparfloxacin
R7

37
 Fluoroquinolones
Extend the antibacterial activity

Gram-positive Anaerobes Targeted

bacteria bacteria

S. pneumoniae M. tuberculosis
MRSA H. pylori

38
 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
 Fluoroquinolones
Targeted indications
O O

Mycobacteria F
COOH

R7 X N

R1

MIC (mg/l)
R1 X R7 M. fortuitum M. tuberculosis
PD 163753 Cyclopropyl C-Br 3'-methyl piperazinyl ≤ 0.03 0.76
PD 161144 Cyclopropyl C-OCH3 4'-ethyl ≤ 0.03 0.39
PD 163048 tert –butyl N 3'-methyl piperazinyl 0.03 0.78
PD 163049 tert –butyl N 3', 5' dimethyl piperazinyl 0.03 0.78
PD 161148 Cyclopropyl C-OCH3 3'-ethyl piperazinyl 0.03 0.10
Ciprofloxacin Cyclopropyl CH2 piperazinyl 0.06 0.25
Sparfloxacin Cyclopropyl C-F 3', 5' dimethyl piperazinyl 0.06 0.06

40
 Fluoroquinolones
Targeted indications H. pylori

Two compounds
Natural compounds
Y-34967

41
 Fluoroquinolones
Targeted indications H. pylori
In vitro activity - H. pylori
MIC50 (mg/l)

Y-34867 0.025
O
Levofloxacin 0.39
F COOH Sparfloxacin 0.20
Amoxicillin 0.012
N N Clarithromycin 0.025
O OCH3
In vivo (murine infection - H. pylori 1907)
CH3
N MIC Dose Clearance
CH3
(mg/l) (mg/kg bid day 7) (%)

Control - - 0
Y-34867
Y-34867 0.025 3 100
10 100
Amoxicillin 0.39 30 100
Clarithromycin 0.05 30 0
100 80

From Sukurai et al, 1998

42
 Piperazinyl derivatives Pyrrolidinyl derivatives Bicyclic derivatives

7 7
X3
N R1 N N
N
X1
R2
X2

Temafloxacin Tosufloxacin Trovafloxacin

Sparfloxacin Clinafloxacin Moxifloxacin
Levofloxacin
Gatifloxacin
Grepafloxacin

S. pneumoniae
43
 Respiratory Quinolones

S. pneumoniae

- +
Ciprofloxacin Levofloxacin
Norfloxacin Moxifloxacin
Lomefloxacin Gatifloxacin
Pefloxacin Sitafloxacin
Ofloxacin Gemifloxacin
Enoxacin Garenofloxacin
Fleroxacin
44
Pharmacokinetics
 Fluoroquinolones
Pharmacokinetics

R5 O
C-8 substituent
F COOH
C-7 substituent

R7 X8 N

R1

46
 Fluoroquinolones
Pharmacokinetics
R5 O

F COOH

R7 X8 N

R1

C-8 substituent :oral absorption

C-7 substituent :metabolism and oral absorption

C-3 substituent :iron chelation

47
 Fluoroquinolones
Pharmacokinetics

O O
Reduce oral absorption
O
OH
(interactions with antiacids, milk...)
C3 divalent cations : Ca++, Fe++, Zn++
N
C3
R1

48
 Metal cations, antacids, anti-ulcers

? Al2+, Mg2+, Ca2+, Fe2+ and other cations formchelate complexes

with fluoroquinolones .

Cation

R5 O O

R6
3 OH
4

R7 N

R1

? Reduce bioavailability of fluoroquinolones .

49
 Fluoroquinolones
Pharmacokinetics

Improve oral absorption and water solubility

eg. norfloxacin versus pefloxacin
C7

Site of metabolism for C-7 piperazinyl derivative.

50
 Fluoroquinolones
Pharmacokinetics

R5

C8
R7 X8

Substituent at C-8 may improved oral absorption

C-F, C-Cl > C-OCH3, > CH

51
 Fluoroquinolones
Pharmacokinetics

N N
or
HN N
H3C

Metabolism : 15-90% (nine metabolites)

C7 metabolism

Metabolism : < 5% except grepafloxacin

H3C
N N
or
HN HN

CH3 CH3

52
Adverse events
 Fluoroquinolones
Adverse events

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

54
 Fluoroquinolones
Adverse events

R5 O
C-7 substituent
F COOH
C-8 substituent
N-1 substituent

R7 X8 N

R1

55
 Fluoroquinolones
Adverse events

R5

F GABA binding (CNS-tolerability)

piperazine > pyrrole
R7 Theophylline interaction
pyrrole > piperazine
R7 X8
Genetic toxicity
pyrrole > piperazine
Solubility

56
 Fluoroquinolones
Adverse events

R5

F Phototoxicity
C-F > C-Cl > N > CH > C-OCH3, C-CF
X8 Genetic toxicity
C-F > C-Cl > C-OCH3 > N > CH
R7 X8
Water solubility

57
 Fluoroquinolones
Adverse events

COOH
Control theophylline
N1 cyclopropyl > ethyl > 2’,4’-difluorophenyl > C2H4F
Genetic toxicity
N1 cyclopropyl = t-butyl > 2.4’- difluorophenyl > ethyl

R1

58
 Fluoroquinolones
Adverse events

Phototoxicity Solubility Genetic toxicity Theophylline CNS

N-1 - - + + -
C-5 + - + - -
C-6 - - - - -
C-7 - ++ ++ + ++
X-8 ++ ++ ++ - -

59
 Fluoroquinolones
Clastogenicity

Concentration (mg/l) causing 50% cytotoxicity

Ofloxacin = 500
Norfloxacin = 500
Temafloxacin = 500
Fleroxacin = 500
Ciprofloxacin 330
Sparfloxacin 370
Tosufloxacin 120
Merafloxacin 190

60
 Fluoroquinolones
Topoisomerase II activity

ID50 (mg/l)
Compound DNA gyrase from E. coli KL-16 topoisomerase II from thymus
Ofloxacin 0.76 1870
Ciprofloxacin 0.13 155
Levofloxacin 0.78 280
Enoxacin 1.72 93
Merafloxacin 3.55 64
Nalidixic acid 23.00 325

61
 Fluoroquinolones
Affinity for GABA receptors

R IC50 (M)
O
H > 10-3
F COOH HN N 1.8 x 10-5

H3C N N 1.0 x 10-3

R N

O H3C N N > 10-3

CH2

H5C2 CO N N > 10-3

N > 10-3

62
 GABA receptors
IC50 (M)
Without NSAID 4-biphenylacetate
Norfloxacin 1.4 x 10-5 < 10-8
Enoxacin 1.4 x 10-4 1.1 x 10-7
Ofloxacin 1.0 x 10-3 8.3 x 10-7
Ciprofloxacin 7.6 x 10-5 3.0 x 10-8
Tosufloxacin 5.7 x 10-4 1.2 x 10-4
Fleroxacin 7.6 x 10-4 1.0 x 10-4
Sparfloxacin 9.1 x 10-4 5.2 x 10-5
Levofloxacin > 10-3 3.5 x 10-4
Sitafloxacin 1.0 x 10-3 3.6 x 10-4
BAY y 3118 > 10-3 2.2 x 10-4
63 Affinity for the GABA receptor of fluoroquinolones Adapted from HORI
 Fluoroquinolones
Phototoxicity

Substituents Phototoxicity
C-F +
C-Cl
8 N
R7 X N
C-H
Chemical structure
R1 C-F
C-OCH3 -

64 Adapted from Domagala

 Fluoroquinolones
Photosensibility

Highest no effect phototoxic dosage (mg/kg)

Ciprofloxacin > 300 Cl 990 > 300
Ofloxacin > 300 Fleroxacin > 300
Norfloxacin > 300 Clinafloxacin > 300
Tosufloxacin > 100 Sparfloxacin > 100
Neuroquino?? > 300 Lomefloxacin > 300
Temafloxacin 300 Cl 938 300
Fleroxacin 172 Bay y 3118 172
Enrofloxacin 100 Murafloxacin 100

65
 Phototoxicity

? Method :
ear swelling of mice after UV-A irradiation and quinolone administration

O
X Dose (mg/kg) N Inflammation
F COOH O-CH3 200 6 0/6
800 6 0/6
8
8-F 3.1 6 0/6
N X N 12.5 6 3/6
50 6 5/6
-H 8 50 6 0/6
CH3 200 6 6/6
800 6 6/6

66 From Maratuni et al, 1993

 Fluoroquinolones
Photocarcino-genotoxicity

Mice SKH-1 (hairless) - 1.5 hours / day of 25 J/cm2 of UV-A for 78 weeks

T50 % (weeks) Carcinoma Tumors

8-methoxy psoralen 4 ++
Lomefloxacin 16 +++
Fleroxacin 28 (+)
Ofloxacin > 50 -
Ciprofloxacin > 50 -
Nalidixic acid > 50 -

67
 Fluoroquinolones
Mutagenicity
O

F COOH

H3C N N N

O R1

R2
ID50 (mg/l)
Compound R1 R2 MIC (µg/ml) DNA gyrase topoisomerase II

Levofloxacin CH3 H 0.025 0.38 1380

DR-3354 H CH3 1.56 4.70 2550
Ofloxacin CH3 0.05 0.75 1870
DN-9494 =CH2 0.05 0.70 64
DL-8165 H H 0.10 3.10 178

68
 Fluoroquinolones
Toxicity-tolerance : cardiotoxicity

R5 O

R6 COOH

R8 X8 N

R1

Bulky substituents at C - 5seem to be responsible

for cardiotoxicity (e.g : sparfloxacin : C5 = NH2)

69
 Fluoroquinolones and QTc effect in humans

Agent Route of QTc Prolongation

administration (mean ± sd - msec)
Sparfloxacin PO 10.3 ± 27.6
Grepafloxacin PO 8
Gatifloxacin PO 6 ± 26
IV 12.1
Gemifloxacin PO / IV 2.9 ± 16.5
PO 5 ± 25.6
Levofloxacin PO 4.6 ± 2.3

70 Owens, RC Jr. Pharmacotherapy. 2001 ; 21 : 301 - 319.

 Theophylline (rat)

R7 % of inhibition of 1,3 DMU

N
HN 47

N
<1
O
N
HN 2

N
H3C CO N 6

71
Conclusion
 Fluoroquinolones

Difficult to predict
Increased difficulties in synthesis
Tolerance

Medical need
Overcome ciprofloxacin resistance
(S. aureus, P. aeruginosa....)

New concept
Targeted clinical indication : e.g ....
(Helicobacter pylori, mycobacteria)

73
 Fluoroquinolones
Expand the clinical indications

Intra abdominal
infections

Lower respiratory tract intections

Upper respiratory tract infections

74
 Fluoroquinolones
Future - New avenues

Development of new chemical structures

Improvement in vitro activity correlated with clinical outcome
Increased problems in the field of side effects.

New classifications of quinolones

Extend the antibacterial activity
Expand the clinical indications
Overcome ciprofloxacin - resistance.
75
 Fluoroquinolones
Garenoxacin
O O

OH

N
HN
OCHF 2

H3C

No 6-fluorine GAR TRO CIP

7-dihydro iso indanyl S. pneumoniae 0.03 0.12 1.0

E. coli 0.03 0.03 0.01
Less activity on cartilage B. fragilis 0.12 0.12 2.0
than other fluoroquinolones

76
 ß-lactams

77
 ß-lactam
Classification
OH

R1
Penems
N
O

COOH

H H H
R1 N R N R1 N
X

N N N
O R2 O O

COOH

monocyclic ß-lactams Penams

H
R1 N X

N
O R2

COOH
Cephems
78
 ß-lactam
Penams

Group I Group II Group III Group IV Group V Group VI Group VII Oxi imino
penicillin
Penicillin G Penicillin M 6-α-OH-penicillin α carboxy Amidino Oxi imino BRL 44154
penicillins penicillin penicillin

IIA Temocillin
Carbenicillin Mecillinam BRL 44154
IIB Ticarcillin
Ampicillin Sulbenicillin
Amoxicillin N-acyl penicillins

Azlocillin
Mezlocillin
Piperacillin
Apalcillin

79
Cephems
 Cephalosporin C

Discovered in 1953 (Newton & Abraham)

Isolated from Cephalosporium acremonium
(Brotzu, 1945)
Chemical structure was elucidated in 1959
1969 : -7 amino cephalosporinic acid (7-ACA)

81
 Cephems
Wave of parenteral cephems

-
7 ACA (1960)

Cephalothin
Cephaloridine
(1964)

82
 Cephems
Classification
Chemical classification (1) - Modification of the ring

H
R2 N X1 X1

Cephalosporin S
N
O R Oxacephems O
Carbacephems CH3
COOH
H
R2 N X1
X1
-iso-2 cephalosporin S
N
O R -iso-3 oxacephems O
CH3
COOH

83
 Cephems
Discovery of cephalosporin

Mould from C. acremonium (1945)

Cephalosporin C (1953)
Hydrolysis

- amino cephalosporinic acid (7

7 - ACA) (1960)

84
 Cephems
Classification
Chemical classification (2) - Modification substituents
H OCH3 H NHCHO
R N S R1 N S

N N
O R2 O R2

COOH COOH

Cephamycins Cephabicins

H
R1 N S
Aryl — CH2 —
R1 Aryl — CH —
N ¦
O R X
Aryl — CH
COOH ¦
Cephalosporins X—R
85
 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
Narrow spectrum : VI and VII

86
 Group I : Cephalothin, cephaloridine

Active against penicillinase

- producing S. aureus
Other cephems from group I show marginal
antibacterial activities
Group I cephems show moderate
anti Gram
- negative activities.

87
 Group I : Cephems

Designed to overcome S. aureus resistant in penicillin G

First cephalosporins to bear at C-3 an heterocycle moiety

N+ Cephaloridine

N R
N N
Cefazolin
COOH
S CH3
S

Activity against Gram-negative bacilli (Enterobacteriaceae)

and stability to ß-lactamase hydrolysis - equivalent to that of ampicillin.

88
 Cephems
Group II

Designed to increase the antibacterial activity

- negative bacilli (enterobacteriaceae).
against Gram

Increase stability to ß
- lactamase hydrolysis.

89
 Cephems - Group II

H
H
R N

Cephalosporins N
O

CH3
H
R N

Cephamycins N
O

90
 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 CO N S
H

N
O N
OCH3
O R

COOH

91
 Cephems - Group II
In vitro activity

MIC (mg/l)
Cefuroxime Cefamandole Cefoxitin

E. coli 1.0 1.0 4.0 (TEM-1)

K. pneumoniae 2.0 0.5 4.0 (CEZ-R)
S. marcescens 64.0 > 64.0 16.0
H. influenzae 0.5 1.0 2.0
S. aureus peni-R 1.0 1.0 1.0
S. pneumoniae 0.12 0.25 2.0

92
 Group III - cephems

Cephems which belong to group III have two or more of the following
characteristics
. 2-amino-5-thiazolyl ring
N

H2N
S

. broad antibacterial spectrum

. MIC50 values = 1.0 mg/l for H. influenzae, Neisseria 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
 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

N C CO

N
H2N
S O R

94
 Group III - cephems

S R R

Ceftizoxime -H
N
R Cefotaxime -CH3OCOCH3
OH
COO- Na- N
Ceftriaxone Cefodizime
CH2COOH
O S

C3 Side
- chain N N N
Cefuzonam
Cefmenoxime N N
S S
N S

CH3

95
 Cephems
Group III - Five subgroups A to E

Group III

IIIA IIIB IIIC IIID IIIE

Cefotiam Cefotaxime Moxalactam KT 3767 RU 45978

Cefoperazone Ceftizoxime Flomoxef KT 3919 RU 46069
Cefpimizole Cefodizime Ceftioxide
Cefpiramide Ceftriaxone CM 40874
Ceftazidime
Cefmenoxime
Cefuzonam

96
 Cephems - Group III
Chemical modifications
C-7 oxime side-chain

N
OR Other

— CH3 OH

Standard Better anti Gram-positive activity

97
 Cephems - Group III
Chemical modifications

C-7 : methoxyimino side-chain (cefuroxime)

H
C CO N

N
O OCH3 N
O

C-3 : N-methyl tetrazol thio moiety (cefamandole)

H
Br N S

N
O CH2 S N N

COOH N
N

CH3
98
 Cephems - Group III
Chemical innovation

- 7moiety
C

2-amino 5-thiazolyl ring 5-amino 2-thiadiazolyl ring

N N

N
H2N H2N
S S

• Improve antipneumococcal activity

• Decrease anti Enterobacteriaceae activity

99
 Cephems - Group III
Chemical structure

Innovation
2-amino 5-thiazolyl ring

+ Oxime side-chain
H2N
S O

N
O R

Discovery N+ R Antipseudomonas activity

100
 Group III - cephems
Evolution

Strep 1 : to improve 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
 Group III - cephems
Improve the antibacterial activity

MIC (mg/l)

Cefamandole Cefotaxime

S. pneumoniae 0.25 0.12

E. coli Ampi-S 1.00 0.03
E. coli Ampi-R 16.00 0.12
K. pneumoniae cefazolin-S 0.50 0.12
K. pneumoniae cefazolin-R > 128.00 0.12
Enterobacter spp 32.00 0.03
C. freundii 8.00 0.12
Indd + Proteus 8.00 0.12
S. marcescens > 64.00 0.12
H. influenzae ß- 1.00 0.03
H. influenzae ß+ 8.00 0.06

102
 Group III - cephems
Long-acting cephem : ceftriaxone

half - life (min) (rats)

Elimination half-

H3C N OH
N

35
O N O

H3C N OCH3
N

12
O N O

H3C N
N

10
O N O

H3C N O
N

10
O N O

103
 Cefodizime
Structure-activity-relationships (pharmacokinetics)

MIC (mg/l)
T ½ (h) AUC (mg.h/l)
N CH3 COOH

0.27 8.5
S

N CH2 CH3 COOH

0.31 1.8
S
CH3 COOH

N
0.52 15.2
CH3
S
CH3

N
1.28 40.7
CH3 COOH
S
Cefodizime

Cefotaxime 0.30 21.4

104
 Group III - cephems
Cephalosporin BRM : cefodizime

H CH3
N C CO N S
N
N
S OCH3 N S
O CH3COONa +
S

COONa +

105
 Cephems
Group III - oxa-1 -cephem

R1 R2

OCH3
R1 CO N
O
Latamoxef O CH -CH3
H COOH
N N

N S N Flomoxef F2 CH S CH2 -CH2-CH2OH

O N
NH2 OC
COOH R2
2355-S S CH2 -CH2-CH2OH
F

106
 Cephems
Group III - oxa-1 -cephem

Flomoxef is more active than latamoxef against Gram-positive cocci

MIC50 (mg/l)

Latamoxef Flomoxef Cefotaxime

S. aureus 6.25 0.39 1.56

S. epidernidis 25.00 1.56 1.56
S. pneumoniae 1.56 0.10 = 0.025

Latamoxef and flomoxef share tho same in vitro activity against

Gram-negative bacilli
Latamoxef is responsible of disuliram-like syndrome and hyprothrombinemia
(N-methyl substituent) and bleeding (α carboxylic group at C-7).

107
 Cephems - Group IV

These compounds have been designed

overcome class I producing strains within
Enterobacteriaceae.

108
 Cephems
Group IV - Definition

Group III definition

- 3’quaternary ammonium moiety
C
Activity against Enterobacteriaceae producing
class -1 ß- lactamase.

109
 Cephems
Group IV - Antibacterial activity

Enhance activity against Enterobacteriaceae

- lactamase (Amp C)
producing class I ß

Mechanism of action

Some compound retain good anti Gram

- positive activity
(cefpirome, cefozopran)

Hydrolysis by ESBL.

110
 Cephems
Group IV - Classification

C-3' quaternary ammonium cephems

C-3 C-7

2-Amino-5-thiazolyl 5-Amino-2-thiadiazolyl

Ceftazidime Cefclidin L-640876

Cefpirome Cefozopran L-642946
Cefepime Cefluprenam L-652813
Cefquinone FK 518
Cefoselis YM 40220
DQ-2556
DN 9550 CS-461
ICI 194008 ME-1228
ICI 193428 MT-520
TOC-39 MT-382
TOC-50 ME-1221
CP 6679 ME-1220

111
 Cephems - Group VI
- 3quaternary ammonium cephem
C
are zwitterionic compounds
H
N C CO N O

N
H2N
S R N N+
O

COO-

Negative charge Negative charge

(SO- or COO -) (OCH3)

Dianionic cephems Zwitterionic cephems

Ceftazidime Cefpirome
Cefsulodin Cefepime
Cefoselis
Cefclidin
Cefluprenam

112
 Cephems - Group IV
Mechanism of action

Velocity Poor affinity Strong

through outer + to ß-lactamase +
membrane affinity to PBPS

113
 Cephems
Group IV - Weaknesses

Hydrolysis by ESBL
Variable activity against P. aeruginosa
Short elimination half- life (≈ 2 hours).

114
 Cephems
Group V

Designed to overcome resistance due to ESBL,

producing strains
Increase in vitro activity against P. aeruginosa

115
 Cephems - Group V

Chemical modification

HO OH
N
OH

R
CH3 O
OH

Catechol moiety Pyrridone fixes

fixes on the oxime chain
on the oxime chain

116
 Cephems
Group V - Classification

Cephems

Catecholes Hydroxypyridones
Group V-1 Group V-2

Group V-1A Group V-1B Group V-2A Group V-2B

C-3 C-7 C-3 C-7

Bo 1236 Ro 091428 CP 6162 SPD 391
Bo 1341 Gr 69153 SPD 411
Merck derivatives M-14659 KP 736
E-0702 MT 0703S
BRL 41897A
RU 59863
LK 10517
Ro 44-3949
117
LB 10522
 RU 59863

N O

H2N
H
S N S

N
N N+
O O O

HO O O-
Staphylococcus spp
OH

ß-lactamases

F OH
P. aeruginosa
Pharmacokinetics

118
 Cephems - Group V

Antibacterial activity
. overcome ESBL
. original additional mechanism of action :
Fe2+ chelation.

Wearknesses
. metabolism
. tolerance (?)
. cost of production.

119
 Cephems - Group VI

Investigations
. In vitro .... MIC
. Bactericidal activity
. Affinity for PBP2a
. In vivo

120
 Cephems - Group VI

VA VB

Anti pseudomonas Anti MRSA

Cefsulodin RWJ
RWJ
BAL 9141
LY
CP
TAK-599

121
 Cephems - Group VI

Cefsulodin
. Dianionic compound : derived from sulbenicillin
Anti pseudomonal activity

CH CO N
S
H
SO3-
N N+ CO NH2
O

COO-

122
 Cephems group VI
Cephems Group VI

VIA VIB

(antipseudomonal) (anti-MRSA)

RWJ 54428 (MC 021079)

TAK-599 (T -91825)
Cefsulodin Cefprozan derivatives
S-3578
BMS-247243
Benzotiophene comp
LY-206 763
BAL-9141
CP-0467
SM-197436
OPC 20011
TOC-39
RWG 333 441
CP 5068
ME 1209 (CP 6679)
PGE 673410
PGE 9739390
CB 181963 (BC 1175)
RWJ 442831
123 Figure 57
LB 11058
 Cephems - Group VI
Cephems designed for an anti MRSA activity
OH
N+H4
N
H
N S
O NH2
N
O N
O S NH2
MC 02331
S
H2N COOH
O NH2
F

O
N
H
N S X
LY 274858 CH3
O
N O N
O X O
S N
H2N
O O-Na+
124
 Cephems - Group VI
Antibacterial activity

MIC (mg/l) IC50 (mg/l)

MRSA MRSA PBP 2’

heterogenous homogenous

LY 274858 1.0 1.9 3.5

Methicillin 256.0 > 52 456.0

Nafcillin 32.0 128 200.0

125
 Cephems
Pharmacokinetics classification (1)

Apparent elimination half- life (three groups)

Subdivision : elimination route

126
 Cephems
Pharmacokinetics classification
Cephems T 1/2 (h)

Group I Group II Group III

<1h 1h-3h 3h-8h

Urinary Bile Urinary Bile

elimination (> 20 %) elimination (> 20 %)
Cephaloridine Cefotaxime Cefoperazone Cefodizime Cefotetan
Cefacetrile Ceftizoxime Ceftriaxone
Cephalothin Cefmenoxime Cefpiramide
Cephradine Ceftazidime
Cefuzonam
Cefpirome
Cefepime
Cefclidin
Cefozopran
Flomoxef
Latamoxef
127 Cefluprenam
 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 CH3 group

N N

N N

CH3????? CH3?????

?????????? ??????????

128
 Cephems - Group VI
Conclusion

Powerfull successful research to meet medical needs

Ü S. aureus peni-R
Ü Gram-negative bacilli
Ü MRSA

129
Penems
 Penem

OH

S
Synthetic compounds
H3 C
H Antibacterial agents
N
O - lactams.
ß
COOH

131
 Penem
Classification
X
Group I Group II Group III

Penem Carbapenem Oxapenem

OH
A Sch 29482
Sch 34343
X
H3C B HR 664
R
N C Ritipenem Group IIA Group II B Group II C Group II D
O FCE 25199
CH2 1-ß-methyl Polycyclic Others
FCE 21420
COOH CGP 31608
CGP 39866 A Imipenem Meropenem GV 118819 BMS 181139
L 695256 Biapenem S 903012 Ro 403485
D Faropenem
BMY 25174 Lenapenem
TMA 3176
Panipenem S 4661
FCE 24362
SYN-513 CL 190294
CL 188624
CL 191121
B 2502 A
DX-8739
Ertapenem
132
 Penem
Classification
OH

X
H3C
R
N
O

COOH

Group IA Group IB Group IC Group ID Group IE

Thiopenem Oxypenem Alkylpenem Arylpenem Aminopenem

SCH 29182 HR 654 Ritipenem Furopenem

SCH 34143 FCE 25190 FCE 24362
Sulopenem FCE 21420 TMA 3176
CGP 31608
CGP 39068 A

133
 Penem

Synthetic compounds

New compounds

134
 Penem
R
SCH 29482 -S-C2H5
SCH 34343 -S-C2H4OCONH2
S

Sulopenem S+
-
OH O

S
Zeneca derivatives
NH

S
H3C HR 664 O CONH 2

R
CGP 31608 -CH2-NH2
N
O Ritipenem -CH2OCONH2
FCE 21420 -CH2OCOCH3
COOH
FCE 24964 -CH2OCH3

Faropenem
O
H

N
TMA 3176

CH N+
FCE 24362

135
 Penem

Ester (R 2) Parent compound

OH
CH3
FCE 25199 FCE 24964
S O O

R1 SUN A 0026 Fropenem

O
N

O CP 65207 -CO-C(CH3)3 Sulopenem

COO-R2
Ritipenem-acoxil -CH2OCOCH3 Ritipenem

TMA-230 -CH2OCOCH3 TMA-3176

136
 Penem
Structure-activity

OH
Antibacterial activity
S
H3C
H
N
O

COOH
ß-lactamase stability

137
 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
 Penem
Hydrolysis by DHP-1
OH

H H OH
H3C
S

HOOC N
OH

COOH
S
H3C DHP-1 M1 (SUN 9609)

N O Lung, kidney
O H (dog, human)
OH
COOH
H
OH
H3C
S
Hydrolytic site

HOOC N

COOH

M2 (SUN 9608)
139
 Penem
Dioxolenone ester : metabolism

COO

CH3-CO-CO-CH3
O O
diacetyl

O
Gastro intestinal tract/liver

CH3COH-CO-CH3
acetoine

Liver

CH3COH-COH-CH3
2, 3 butenadiol
140
 Penem

André, je suis vraiment désolé.......

mais je ne vois rien du tout pour la figure
page « Fro-penem 3 »

141
Macrolides
 Macrolides

Three waves of macrolides

Objectives

1st Erythromycin A
Oleandomycin • S. aureus peni-R
Spiramycin

2d Roxithromycin • Atypical microorganisms

Clarithromycin • Improvement of
Azithromycin pharmacokinetics
Dirithromycin

• Overcome resistance
3d Ketolides to erythromycin A
• Enhance activity against
Gram-positive bacteria
143
 Macrolides

Second wave of molecules

Target

Increase absorption
Good stability in acid conditions
No enhancement of in vitro activity against common
pathogens
Increase in vitro activity against atypical pathogens.
144
 Macrolide

Erythromycin A Saccaropolyspora erythrea 1952

Oleandomycin Streptomyces antibioticus 1954
Spiramycin(s) Streptomyces ambofaciens 1954
Josamycin Streptomyces narbonensis var. 1957
josamyceticus vova sp
Midecamycin Streptomyces mycarofaciens 1971
Tylosin Streptomyces fradiae 1961

145
 Macrolide
Erythromycin A
O

H3C CH3
9
8

11
HO OH
12
OH 6
CH3
H3C
H3C O
O
CH3

CH3
O
O O CH3

CH3 N CH3

OH O
OH
CH3
O CH3

CH3
146
 Macrolide

O OH
H H
H3C CH3 H3C CH3 H3C CH3
9 [H+] 9 [H+]
8 8
O
7
CH3 CH3 CH3
7
6 6
HO O H2O

Erythromycin A Hemicetal Didehydro-erythromycin A

147
 Macrolide

Concentrations (plasma)

2'-ester erythromycin A 100 mg/L 5 mg/L

2'-propionyl 69 247
2'-ethylsuccinyl 39 60
2'-acethyl 39 170
2'-butyryl 188 353
2'-valeryl 492 478

148
 Macrolide

Erythromycin A Anhydroerythromycin A

Cmax (mg/L) 0.9 ± 0.2 0.3 ± 0.1

Tmax (h) 2.6 ± 0.4 2±0
T ½ (h) 1.5 ± 0.1 3.3 ± 2.4
AUC0-8 (mg.h/L) 4.5 ± 1 4.1 ± 2.4

149
 Macrolide
Weak and link points of erythronolide A

Weak point CH3

Linking point 1
O 8
9 OH
H3C
CH3
6 R
O

Linking point 2 HO OH H3C

12

H3C

150
 Macrolide
O

F
H3C
8 CH3
HO
HO OH

6
H3C CH3

Flurithromycin

O O O

H3C H3C CH3 CH3

8
8
11 HO
O X HO OCH3
OH
11
12 12 6 6
H3C O H3C CH3

X = O : Davercin Erythromycin A Clarithromycin

X = N : Carbamate

R
other
151
 Macrolide
Semisynthetic derivatives of 9 -erythromycin A
OR
H3C N

N
9a
9
alkylation
azalide
O R

Beckman rearrangement N roxithromycin

9
reduction NH2

9
intermediate synthesis
derivative
(9-oxime)
erythromycylamine
O

weak point
9

erythromycin A dirithromycin
152
 Macrolide

O O CH3
N O
CH3
H3C CH3
H3C O(CH2 )2 O CH2
N
8
9
O HO OH
10
11
OH
H3C CH3
H3C O
Dirithromycin O
CH3
CH3
O O O
CH3
CH3 H3C
N CH3

H2N OH O
9
CH3 O
HO O CH3
10
11

CH3
Erythromycylamin

Roxithromycin

153
 Macrolide

CH3 H3C
H3C CH3
N
N
HO
R H3C CH3
O CH3
CH3 CH3 CH3 O
HO
R HO
N
O 8a HO
9
N
9a
H3C CH3

O O OCH3
CH3
Erythromycin A 9a-azalide 8a-azalide CH3 CH3
O
OH
O
CH3

Azithromycin

154
 Macrolide

CH3

X N-10-methyl azalide
X=H
R R = CH3
N
Lactam
X=O
R=H

14-membered ring azalides

155
 Macrolide

CH3 CH3

OCH3 OCH3
H3C H3C
HO CH3 [H+ ] (translactonisation) CH3
O
HO

H3C H3C

Clarithromycin Pseudoclarithromycin

156
 Macrolide

H3C H3C
N N

O-Desosamine O-Desosamine
HO HO

[H+ ]
O CH3
O OH

L-cladinose cleavage
OH
O

CH3
Azithromycin CP 66458

157
 Macrolide
2'-esters erythromycin A

OCH3

CH3
2'-ester R Sale
5

Acistrate COCH3 CH3(CH2)16COOH

O
Ethylsuccinate -
CH3
Estolate OCCH2CH3 C12H25OSO 3H
O
CH3 Propionate OCCH2CH3 -
N CH3 OCCH2CH3 HS—CH—COOH
RV-11
2'
¦
H2C—COOH
O R

D-desosamine

158
Ketolides
 Ketolides

Definition

Semisynthetic derivatives of erythromycin A

Lack of α
- L
- cladinose
Highly stable in acidic environment
Overcome erythromycin A resistance (MLSB inducible, efflux)
Unable to induce MLSB resistance.

160
 ketolides

Third
wave Target
of molecules

Same pharmacokinetic profile

Activity against erythromycin A resistant isolates.

161
 ketolides

Target

Same pharmacokinetic profile of macrolides

Activity against erythromycin A resistant isolates

162
 Bacterial resistance to antibacterials

β-lactams : penicillin G, amoxicillin, cephems

Other antibacterials S. pneumoniae Fluoroquinolones

Co-trimoxazole
Rifampicin
Macrolides
Tetracycline
Lincosamides
Chloramphenicol
Streptogramins
163
 Spread of bacterial resistance

Gram -positive Other Gram -negative

• S. pneumoniae • M. tuberculosis • Enterobacteriaceae

• S. pyogenes • P. aeruginosa
•H. pylori
• Enterococcus spp
• S. aureus
• Coagulase negative
staphylococci
164
 Ketolides

In vitro activity of narbomycin

165
 Ketolides

Natural ketolides

O O

CH3 C H3

HO CH3 CH 3
6 6
H 3C
H3C H 3C
O O

3 3
O O
O O
O O
O O
CH3 CH 3
N NZ

OH OH

Picromycin Narbomycin

166
 Ketolides

Natural derivatives Semi synthetic derivatives

Picromycin 14-membered
Narbomycin 15-membered
Telithromycin
HMR 3004
GW 581506X Cethromycin
HMR 3562
HMR 3787
HMR 3832
TE-802
TE-810
167 CP 654743
 Ketolides

Telithromycin
HMR 3004
HMR 3787 Aventis Pharma
3
HMR 3832
O-cladinose HMR 3562

Cethromycin Abbott

TE 802, TE 810 Taisho

Ketolide
3
•O RWJ 415 663 RW Johnson and pharmaceutical
RWJ 415 667

CP 654 743 Pfizer

168
 Ketolides

They are composed of three specific chemical structures

3-keto function (lack of L-cladinose)

Side-chain C11-C12
Side chain C6

169
 -
3 KETO FUNCTION

170
 Ketolides

New medicinal chemical entities

Semisynthetic compounds obtained from erythromycin A
Removal of the L- cladinose (neutral sugar), and oxidation
- hydroxyl (OH) yields to a -3 keto group (ketolide).
of the 3

3 3 3

O
cladinose OH
O (= ketolide)
- keto
3
removal Oxidation

171
 Ketolides

3-keto function

3-keto function imparts the following

biological properties

Antibacterial activities against erm-containing-Gram-positive cocci

Absence of ability to induce MLSB resistance
High stability in acidic environment.

172
 Stability in acidic environment

pH 1.0 at 37°C Telithromycin

100

80
% of activity

60

40

20 Azithromycin
Clarithromycin
0
0 1 2 3 4 5 6 Time (h)

173
 Interaction with human
motilin receptor

IC50 (µM) (inhibition of motilin binding )

Telithromycin > 100µM
(23 % inhibition at 100 µM)
Clarithromycin ≥ 100 µM
(54 % inhibition at 100 µM)
Erythromycin A < 3 µM
(60 % inhibition at 3 µM)

174
 No inducer of MLSB resistance
1.2 1.2

1.0 1.0

0.8 0.8

0.6 0.6

0.4 0.4

Ery/Ery 0.2 Ery/Ery

0.2
TEL/Ery RU 69874/Ery
0 0
C/Ery C/Ery
0 0.91 1.50 1.91 2.19 2.49 2.82 3.32 3.82 4.67 5.57 6.32 0 0.91 1.50 1.91 2.19 2.49 2.82 3.32 3.82 4.67 5.57 6.32

N N

O N O N

N H3C CH3 N
H3C CH3

C C
O O
N
O

CH3
CH 3
Telithromycin N
O CH3

CH3
H3C H3C
O
O
O H3C
O
O
O H3C
RU 69874
OH OH
CH3 CH3
O O
O O O
O CH3 CH3
CH3 N
H3C N
CH3 H3C
CH3 HO O CH3

175 OCH3
 C11
- C12 carbamate residue

176
 Bacterial resistance to antibacterials

β-lactams : penicillin G, amoxicillin, cephems

Other antibacterials S. pneumoniae Fluoroquinolones

Co-trimoxazole
Rifampicin
Macrolides
Tetracycline
Lincosamides
Chloramphenicol
Streptogramins
177
 Clarithromycin...
...carbamates analogues
R

A-61795 H

N
A-62514
H

O N
A-66173 H

N R
N
A-66005
O
N
A-64239

CH2
A-66321

178
 Spread of bacterial resistance

Gram -positive Other Gram -negative

• S. pneumoniae • M. tuberculosis • Enterobacteriaceae

• S. pyogenes • P. aeruginosa
•H. pylori
• Enterococcus spp
• S. aureus
• Coagulase negative
staphylococci
179
 Ketolides

C11-C12 carbamate substituted side chain

Carbamate residue
In vitro activity
Pharmacokinetics
O
Pharmacodynamics R
Intracellular kinetics N
11
O
12
Efflux O

Mechanism of action
Tolerance- toxicity.

180
 Research in anti-infectives

Ketolides 3 New chemical entities

O

N
11

C11 – C12 O 12
Optimisation
carbamate ketolide O

R
N
11
Substituted O Innovation
12
carbamate ketolide O

181
 pyridyll

imidazolyl
N
N
butyl
N

R C

N N
11 11
O
12
O
12
telithromycin
O O

Carbamate ketolide

182
 Ketolides
C11- C12 carbamate substituted side chain

Imidazolyl
Quinoline ring ring

O O N
N
CH HC CH3 N
3 3

HN C
O O
OCH3 O CH
N N 3
Pyridyl ring
CH3 CH
HC 3
3

O O

HMR 3004 Telithromycin

183
 Mode of action

Significant of different mode of action

A-2058 V A-2058 V

5S rRNA ERY 5S rRNA TEL

cladinose O

A-752 II A-752 II

No link with domain V Link with domain II

Resistance to erythromycin A, Telithromycin retains activity

azithromycin, against erythromycin A-resistant organisms
roxithromycin, clarithromycin,

184
 Ketolides
C11- C12 carbamate substituted side chain (1)

Pharmacokinetics in mice

Concentrations (mg/l) at

Cmax Tmax 0.25* 0.50 1.0 2.0 3.0 4.0

(mg/l) (h)

Telithromycin 4.67 0.50 3.97 4.67 3.52 1.60 1.70 0.90

HMR 3004 1.70 0.25 1.70 0.90 1.00 0.20 0.10 0.06
* sampling time (hours) Craig, 1996

185
 Ketolides
C11- C12 carbamate substituted side chain (2)

Pharmacokinetics in mice

Cmax (mg/l) Tmax (h) AUC0-24h (mg.h/l)

Telithromycin 4.67 0.50 17.92

HMR 3004 1.67 0.25 2.47
Craig, 1996

186
 Ketolides
R

N Comparative human
C11 -C12 carbamate O
11
pharmacokinetics after
12
residue O a single oral dose 600 mg

N
N
N

HMR 3004 HMR 3647

N

Cmax (mg/l) 0.16 ± 0.30 Cmax (mg/l) 0.90 ± 0.13

Tmax (h) 1.75 Tmax (h) 1.5
AUC 0-8 (mg.h/l) 0.59 ± 0.11 AUC 0-8 (mg.h/l) 4.09 ± 0.55
C24h (mg/l) ND C24h (mg/l) 0.01 ± 0.01
t1/2 (h) 2.25 ± 0.16 t1/2 (h) 11.0 ± 1.90

187
 Telithromycin Metabolites (1)

CH2 OH

N
N C
O
N
CH3 N COOH RU 78849 (N-propyl carboxylic)
O C OCH3
N C
N
H3C CH3 N
N
O O N O-
OH
O
C
RU 76584 (N-pyridine oxide)
CH3 N
H3C N O
H3C
O

CH3
Telithromycin H3C N

RU 72365 (N-monodemethyl desosamine)

188
 Telithromycin Disposition

Systemic circulation Urine (17.4 %)

Kidney
(blood stream) • 11.8 % telithromycin
• 5.6 % metabolites
Intestinal
secretion Metabolism to a : Formation enzyme
• RU 76363 12.6 % non CYP
• RU 72365 2.97 % CYP3A
Liver • RU 78849 2.22 % CYP3A
Bile • RU 76584 2.03 % CYP3A/1A
• Others

Absorption (Via bile)

Feces (75.6 %)
Gastrointestinal tract • 20.2 % telithromycin
• 55.4 % metabolites
Metabolites expressed as relative radioactivity in circulation (metabolite AUC / telithromycin AUC)

189
 Structure activity
relationships

O N

HC CH N
3 3
9
C
O 11
O CH
• Mode of action N
3
• Enhanced in vitro activity
12 C H3
• Reduced efflux H3C • Intracellular accumulation
O H3C • Pharmacokinetics
O
• Tolerance
CH3
3
O
O O
OH
CH3
O

CH
• High stability in acidic pH 3
H3C N
• Overcoming MLSB
• Non inducer of MLSB resistance CH3

190
 Macrolide resistance 14-membered ring
macrolide

Phosphorylation HO P OH E. coli
Nocardia spp
O

CH2 OH
Glycosylation
HO
O
Streptomyces antibioticus
1''' Streptomyces Vendargensis
CH3
HO O Nocardia spp
OH
O 2' N(CH 3)2 HO
CH3
6 O
O CH3

191
 Macrolide resistance Ring hydrolysis
by esterases

HO
11
H3C
12
13
HO

O
1
CH3
H3C
Hydrolysis esterases O
Erythromycin A

Described in S. aureus - E. coli

OH OH
H3C CH3

192
 Macrolide resistance

Erythromycin A
binding site
Transfert of methyl group in adenosyl methionine

H3C CH3
NH2 S-adenosyl-L-methionine N

N
N
N
N Erythromycin
O O
N N N N No binding
P O CH2 P O CH
H2
O O
HO Ribosome HO
methylase Erne
O OH O OH

Adenine 2058 erm gene Dimethylated A-2058

in 23 S rRNA (A ⇒ G)

193 Adapted from K. O'hara, 2000

 Macrolides
Mechanism of resistance

CH
3

O R2 R1
8
OH
H3C
CH3 OH
O R2 OH OH O O O
HO 9 6
5 15
H3C C O
14 13 12 11 10 9 7 5 3 2
4 1
CH 3
HO 3 H3C OH HO CH3
CH3 CH3 CH3 CH3
2
O R1 Esterase
O
1
CH3
H3C

R1 : α-L cladinose
R2 : D-desosamine

194