Cephalosporins

Cephalosporins

 The cephalosporins had the useful property of activity against

penicillin-resistant cultures as a result of its stability to β-lactamases

 Cephalosporin C is not potent enough to be a useful antibiotic, but

removal, through chemical means, of the natural side chain produced
7-aminocephalosporanic acid (7-ACA), which, analogous to 6-APA,
could be fitted with unnatural side chains

 Many of the compounds produced in this way are remarkably useful

antibiotics. They differ in antimicrobial spectrum, β-lactamase stability,
absorption from the GI tract, metabolism, stability, and side effects

 Most cephalosporins have generic names beginning with cef- or ceph-

Mechanism of Action
Chemical preparation of 7-ACA and 7-ADCA.
 Chemical Properties
 The cephalosporins have their β-lactam ring annealed to a 6-
membered dihydrothiazine ring

 The cephalosporins are less strained and less reactive/potent. Much

of the reactivity loss is made up by possession of an olefinic linkage
at C-2,3 and a methyleneacetoxy group at C-3

 When the β-lactam ring is opened by hydrolysis, the acetoxy group

can be ejected, carrying away the developing negative charge. This
greatly reduces the energy required for the process.

 The facility with which the β-lactam bond is broken is modulated

both by the nature of the C-7 substituent as well as by the nature of
the C-3 substituent and its ability to serve as a leaving group.

 Considerable support for this hypothesis comes from the finding that
isomerization of the olefinic linkage to C-3,4 leads to great losses in
antibiotic activity
 Chemical Properties

 Most cephalosporins are comparatively unstable in aqueous

solutions, and the pharmacist often is directed to keep injectable
preparations frozen before use.

 Being carboxylic acids, they form water-soluble sodium salts,

whereas the free acids are comparatively water insoluble

 In many cases, when the free acids are supplied, the injectable
forms contain sodium bicarbonate to facilitate solution.
 Chemical Instabilities

 The principal chemical instability of the cephalosporins is associated

with β-lactam bond hydrolysis.

 Ejection of the C-3 substituent may, at certain times and with

specific cephalosporins, involve a discrete intermediate with the β-
lactam bond broken, but with the C-3 substituent not yet eliminated,
whereas other cephalosporins have nonejectable C-3 substituents.

 The methylthiotetrazole (MTT) group, found in a number of

cephalosporins, is capable of elimination. When this happens, this
moiety is believed to be responsible for clotting difficulties and acute
alcohol intolerance in certain patients.
 Clinically Relevant Chemical Instabilities

 The role of the C-7 side chain in all of these processes is clearly
important, but active participation of the amide moiety in a manner
analogous to the penicillins rarely is specifically invoked

 The same considerations that modulate the chemical stability of

cephalosporins are involved in dictating β-lactamase sensitivity,
potency, and allergenicity as well.
 Metabolism

 Cephalosporins that have an acetyl group in the side chain are

subject to enzymatic hydrolysis in the body. The result is molecules
with a hydroxymethyl moiety at C-3. A hydroxy moiety is a poor
leaving group, so this change is considerably deactivating with
respect to breakage of the β-lactam bond

 The particular geometry of this part of the molecule leads to facile

lactonization with the carboxyl group attached to C-2 which results in
inactivation of the drugs involved

 Lactonization masks docking functional group and so blocks affinity

of the inhibitor for the enzyme
 Structure-Activity Relationship

 The addition of an amino and a hydrogen to

the α and α′ position, respectively, results in
a basic compound that is protonated under
the acidic conditions of the stomach. The
ammonium ion improves the stability of the
β-lactam of the cephalosporin, leading to
orally active drugs.

 The 7β amino group is essential for

antimicrobial activity (X = H), whereas
replacement of the hydrogen at C-7 (X = H)
with an alkoxy (X = OR) results in
improvement of the antibacterial activity of
the cephalosporin

 Within specific cephalosporin derivatives, the

addition of a 7α methoxy also improves the
drugs stability toward β-lactamase
 SAR
 The derivatives where Y = S exhibit greater antibacterial activity than if Y =
O, but the reverse is true when stability toward β-lactamase is considered

 The 6α hydrogen is essential for biological activity

 Antibacterial activity is improved when Z is a 5-membered heterocycle

versus a 6-membered heterocycle.

 The following changes improved β-lactamase resistance:

1. The L-isomer of an α amino α′ hydrogen derivative of a cephalosporin
was 30- to 40-fold more stable than the D-isomer
2. The addition of a methoxyoxime to the α and α′ positions increased
stability nearly 100-fold,
3. The Z-oxime was as much as 20,000-fold more stable than the E-oxime

 These changes have been incorporated into a number of marketed and

experimental cephalosporins (Cefuroxime, Ceftizoxime, Ceftazidime, and
Cefixime)
 Mechanism of Action and Resistance
 The cephalosporins are believed to act in a manner analogous to
that of the penicillins by binding to the penicillin binding proteins,
followed by cell lysis

 Cephalosporins are bactericidal in clinical terms.

 Susceptible cephalosporins can be hydrolyzed by β-lactamases

before they reach the penicillin binding proteins. Resistance to β-
lactamase hydrolysis is conveyed by strategic steric bulk near the
side-chain amide linkage

 Recently, an increasing number of metallo-β-lactamases

(dependent on divalent metal ions, commonly zinc) have been
discovered .These are both chromosomally and plasmid derived and
are as yet confined to the G-ve rods. These enzymes attack some
penicillins, cephalosporins, and carbapenems

 Penetration barriers to the cephalosporins also are well known.

 Allergenicity

 Allergenicity is less commonly experienced and is less severe with

cephalosporins than with penicillins

 Cephalosporins frequently are administered to patients who have

had a mild or delayed penicillin reaction.

 Cross-allergenicity is comparatively common and cephalosporins

should be administered with caution for patients who have a history
of allergies

 Patients who have had a rapid and severe reaction to penicillins

should not be treated with cephalosporins.
 Nomenclature and Classification
 Most cephalosporins have generic names beginning with cef- or ceph-.
 The first-generation cephalosporins primarily are active in vitro against
Gram-positive cocci (penicillinase-positive and -negative Staphylococcus
aureus and S. epidermis), group A β-hemolytic streptococci (Streptococcus
pyogenes), group B streptococci (Streptococcus agalactiae), and
Streptococcus pneumoniae. They are not effective against MRSA.
They are not significantly active against Gram-negative bacteria, although
some strains of Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis,
and Shigella sp. may be sensitive.

 The second-generation cephalosporins generally retain the anti-Gram-

positive activity of the first-generation agents but include Haemophilus
influenzae as well and add to this better anti-Gram-negative activity so that
some strains of Acinetobacter, Citrobacter, Enterobacter, Escherichia coli,
Klebsiella, Neisseria, Proteus, Providencia, and Serratia also are sensitive.
Cefotetan, cefmetazole, and cefoxitin have some antianaerobic activity as
well.
 The third-generation cephalosporins are less active
against staphylococci than the first-generation agents
but are much more active against Gram-negative
bacteria than either the first- or the second-generation
drugs. They frequently are particularly useful against
nosocomial multidrug-resistant hospital-acquired strains.
One also adds Morganella sp. and Pseudomonas
aeruginosa to the list of species that often are sensitive.
Unfortunately, the third-generation agents tend to be
more expensive.
 The fourth-generation cephalosporins have an
antibacterial spectrum like the third-generation drugs but
add some enterobacteria that are resistant to the third-
generation cephalosporins. They also are more active
against some Gram-positive organisms.
First generation
 First-generation Cephalosporins

Cephapirin
 Cephapirin has a pyridylthiomethylene containing side chain at C-7
 It is comparatively resistant to staphylococcal β-lactamase,
although it is sensitive to many other β-lactamases
 Sensitive to host deacetylation in the liver, kidneys, and plasma,
which reduces potency by about half.
 It is not orally active and it is comparatively painful on IM injection

Cefazolin
 Cefazolin has the natural acetyl side chain at C-3 replaced by a
thio-linked thiadiazole ring. Although this group is an activating
leaving group, the moiety is not subject to the inactivating host
hydrolysis reaction that characterizes cephapirin
 At C-7, it possesses a tetrazoylmethylene unit
 It is comparatively unstable and should be protected from heat and
light.
 First-generation Cephalosporins

 Cephalexin
 Use of the ampicillin-type side chain conveys oral activity to
cephalexin. Whereas it no longer has an activating side chain at
C-3 and, as a consequence, is somewhat less potent
 It does not undergo metabolic deactivation and so maintains
potency
 It is rapidly and completely absorbed from the GI tract
 the use of the ampicillin side chain in the cephalosporins does
not result in a comparable shift in antimicrobial spectrum
 Cephalexin, like the other first-generation cephalosporins is
active against many Gram-positive aerobic cocci but is limited
against Gram-negative bacteria
 It is a widely used drug, particularly against Gram-negative
bacteria causing urinary tract infections, Gram-positive infections
of soft tissues, pharyngitis, and minor wounds.
 First-generation Cephalosporins

Cefadroxil
 Cefadroxil has an amoxicillin-like side chain at C-7 and is orally
active
 Cefadroxil has some immunostimulant properties mediated
through T-cell activation (assistance to patients in fighting
infections)
 The prolonged biological half-life of cefadroxil allows once-a-day
dosage.

Cephradine
 The aromatic ring in the ampicillin side chain has been partially
hydrogenated by a Birch reduction such that the resulting
molecule is still planar and π-electron excessive but has no
conjugated olefinic linkages
 It is comparatively acid stable (completely absorbed orally)
 Cephradine can be used both orally and IM so that parenteral
therapy can be started in an institutional setting and then the
patient can be sent home with the oral form
 Second
generation
 Second-Generation Cephalosporins
Cefamandole nafate
 Cefamandole nafate has a formylated D-mandelic amide moiety at
C7. The formate ester is cleaved rapidly in the host to release the
more active cefamandole. The esterification also apparently
overcomes the instability of cefamandole when it is stored in dry form

 This agent has increased activity against H. influenzae and some

Gram-negative bacilli as compared with the first-generation
cephalosporins

 Loss of the 5-thio-l-methyl-l-H-tetrazole moiety (MTT) from C-3 is

associated with prothrombin deficiency and bleeding problems as
well as with an Antabuse-like acute alcohol intolerance. This
grouping also enhances potency and prevents metabolism by
deacetylation

 Cefamandole is more active against G-ve bacteria. Mainly used for

lower respiratory tract, skin, bone and joint infections as well as
septicemia and UTI when the organisms are sensitive
 Second-Generation Cephalosporins
Cefuroxime
 Cefuroxime has a Z-oriented methoxyimino moiety as part of its C-
7 side chain (steric effect). This conveys considerable resistance to
attack by many β-lactamases, but not by all (the E-analogue is
attacked by β-lactamases)

 Resistance by P. aeruginosa is attributed to lack of penetration of

the drug rather than to enzymatic hydrolysis
 The carbamoyl moiety at C-3 is intermediate in metabolic stability
between the classic acetyl moieties and the thiotetrazoles.

 In the form of its axetil ester (1-[acetyloxy]ethyl ester) pro-drug,

cefuroxime axetil, a more lipophilic drug is produced that gives
satisfactory blood levels on oral administration. The ester bond is
cleaved metabolically, and the resulting intermediate form loses
acetaldehyde spontaneously to produce
cefuroxime itself.

 Cefuroxime axetil is stable for approximately 24 hrs

when it is dissolved in apple juice (Lyme disease)
 Second-Generation Cephalosporins
Cefoxitin
 Cefoxitin contains the same C-7 side chain as cephalothin and the
same C-3 side chain as cefuroxime

 The most novel chemical feature of cefoxitin is the possession of an

α-oriented methoxyl group in place of the normal H-atom at C-7.
This increased steric bulk conveys very significant stability against
β-lactamases.

 Cefoxitin has useful activity against gonorrhea and some anaerobic

infections as compared with its second-generation relatives. On the
negative side, cefoxitin has the capacity to induce certain broad-
spectrum β-lactamases.
 Second-Generation Cephalosporins
Cefotetan, cefaclor and loracarbef
Cefotetan
 Cefotetan has an unusual sulfur-containing C-7 side-chain amide.
Possession of two carboxyl groups leads to marketing it as a
disodium salt. The C-3 MTT side chain suggests caution in
monitoring prothrombin levels and bleeding times as well as in
ingesting alcohol when using this agent

Cefaclor
 Cefaclor differs from cephalexin primarily in the bio-isosteric
replacement of methyl by chlorine at C-3 and is quite acid stable,
allowing oral administration. It also is quite stable to metabolism.

Loracarbef
 The smaller methylene moiety (as compared to sulfur) would be
expected to make loracarbef more reactive/potent. It is more stable
chemically
 Third
generation
 Third-Generation Cephalosporins

Cefotaxime
 Cefotaxime, like cefuroxime, has a Z-methoxyimino moiety at C-7
that conveys significant β-lactamase resistance
 The oxime moiety of cefotaxime is connected to an aminothiazole
ring. It has a metabolically vulnerable acetoxy group attached to C-3
and loses approximately 90% of its activity when this is hydrolyzed.
 Cefotaxime should be protected from heat and light and may color
slightly without significant loss of potency

Ceftizoxime
 The whole C-3 side chain has been omitted to prevent deactivation
by hydrolysis

Ceftriaxone
 The C-3 side chain consists of a metabolically stable and activating
thiotriazinedione in place of the normal acetyl group. The C-3 side
chain is sufficiently acidic that at normal pH, it forms an enolic
sodium salt and so the commercial product is a disodium salt
 Fourth-Generation Cephalosporins
Cefepime
 Cefepime is a semisynthetic agent containing a Z-methoxyimine
moiety and an aminothiazolyl group at C-7, broadening its spectrum
and increasing its β-lactamase stability as well as increasing its
antistaphylococcal activity

 The quaternary N-methylpyrrolidine group at C-3 seems to help

penetration into Gram-negative bacteria

 The fourth-generation cephalosporins are characterized by

enhanced antistaphylococcal activity and broader anti-Gram-
negative activity than the third-generation group

 Cefepime is used IM and IV against UTI, skin and skin structure

infections, pneumonia, and intra-abdominal infections
 Other β–Lactam derivatives
Carbapenems
 Thienamycin, the first of the carbapenems, was isolated from
Streptomyces cattleya .Because of its extremely intense and broad-
spectrum antimicrobial activity as well as its ability to inactivate β-
lactamases, it combines in one molecule the functional features of
the best of the β-lactam antibiotics as well as the β-lactamase
inhibitors

 It differs structurally in several important respects from the penicillins

and cephalosporins. The sulfur atom in the five-membered ring has
been replaced by a methylene moiety at that position

 Carbon is roughly half the molecular size of sulfur. Consequently,

the carbapenem ring system is highly strained and very susceptible
to reactions cleaving the β-lactam bond

 The sulfur atom is now attached to C-3 as part of a functionalized

side chain.
 Carbapenems

 The endocyclic olefinic linkage also enhances the reactivity of the β-

lactam ring. Both make thienamycin unstable, which caused great
difficulties in the original isolation studies. The terminal amino group
in the side chain attached to C-3 is nucleophilic and attacks the β-
lactam bond of a nearby molecule through an intermolecular
reaction destroying activity

 Ultimately, this problem was overcome by changing the amino group

to a less nucleophilic N-formiminoyl moiety by a semisynthetic
process to produce imipenem

 At C-6, there is a 2-hydroxyethyl group attached with α-

stereochemistry. Thus, the absolute stereochemistry of the molecule
is 5R, 6S, 8S

 Thienamycin analogues bind differently to the PBP,

but result in very potent broad-spectrum activity
 Imipenem

 Imipenem penetrates very well through porins and is very stable,

even inhibitory, to many β-lactamases. Imipenem is not orally active

 When used to treat UTI, renal dehydropeptidase-1 hydrolyzes

imipenem through hydrolysis of the β-lactam and deactivates it

 An inhibitor for this enzyme, cilastatin, is coadministered with

imipenem to protect it. Inhibition of human dehydropeptidase does
not seem to have deleterious consequences to the patient, making
this combination highly efficacious against UTI.

 The combination of imipenem and cilastatin is broader in its

spectrum than any other antibiotic. This very potent combination is
especially useful for treatment of serious infections by aerobic G-ve
bacilli, anaerobes, and S. aureus
 Meropenem

 Meropenem is a synthetic carbapenem possessing a complex side

chain at C-3. It also has a chiral methyl group at C-4

 This methyl group conveys intrinsic resistance to hydrolysis by

dehydropeptidase-1. As a consequence, it can be administered as a
single agent for the treatment of severe bacterial infections.
 Monobactams Aztreonam

 Aztreonam is a totally synthetic parenteral antibiotic, the antimicrobial

spectrum of which is devoted almost exclusively to G-ve MO, and it is
capable of inactivating some β-lactamases

 Its molecular mode of action is closely similar to that of the penicillins,

cephalosporins, and carbapenems. Whereas the principal side chain
closely resembles that of ceftazidime, the sulfamic acid moiety
attached to the β-lactam ring was unprecedented

 Remembering the comparatively large size of sulfur atoms, this

assembly may sufficiently spatially resemble the corresponding C-2
carboxyl group of the precedent β-lactam antibiotics to confuse the
penicillin binding proteins
 Monobactams Aztreonam

 The strongly electron-withdrawing character of the sulfamic acid

group probably also makes the β-lactam bond more vulnerable to
hydrolysis

 In any case, the monobactams demonstrate that a fused ring is not

essential for antibiotic activity. The α-oriented methyl group at C-2 is
associated with the stability of aztreonam towards β-lactamases

 Aztreonam is given by injection and is primarily excreted in the urine

 The primary clinical use of aztreonam is against severe infections

caused by G-ve MO, especially those acquired in the hospital.
Mainly urinary tract, upper respiratory tract, bone, cartilage,
abdominal, and gynecologic infections, and septicemias.

 Cross-allergenicity with penicillins and cephalosporins has not been

reported