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The New Fifth-Generation Cephalosporins – a Balance Between Safety and Efficacy

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The New Fifth-Generation Cephalosporins – a Balance Between Safety and Efficacy REVIEWS Ref: Ro J Pharm Pract. 2020;13(3) DOI: 10.37897/RJPhP.2020.3.2 The new fifth-generation cephalosporins – a balance between safety and efficacy Aura Rusu1, Ioana-Andreea Lungu2 1 Pharmaceutical and Therapeutical Chemistry Department, Faculty of Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science and Technology, Targu Mures, Romania 2 Doctoral School of Medicine and Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science and Technology, Targu Mures, Romania Abstract Cephalosporins are beta-lactam antibiotics classified into five generations. The newest generation has three representa- tives: ceftaroline fosamile, the combination ceftolozane/tazobactam (cephalosporin/beta-lactamase inhibitor), and ceftobi- prole medocaril. These new cephalosporins are valuable anti-infective agents, with potent activity against multidrug-re- sistant bacteria, and with a positive balance between benefits and side effects. However, the fifth-generation cephalosporins should be judiciously used to prevent the occurrence of bacterial resistance phenomenon. Keywords: cephalosporins, ceftaroline, ceftolozane, ceftobiprole, MRSA, community-acquired pneumonia, complicated skin and soft tissue infections INTRODUCTION emerged as a result of increased only, in the situation where other Cephalosporins (CFs) are beta- bacterial resistance to classical antibacterial drugs were not lactam antibiotics with numerous antibiotics. Based on the efficient. representatives widely used in the antimicrobial activity, the CFs are therapy of infectious diseases. Like classified into five generations REPRESENTATIVES other beta-lactam antibiotics, CFs (Table 1) [1]. Representatives of the Ceftaroline fosamil inhibit the synthesis of the bacterial fifth-generation which are used in Ceftaroline fosamil (anatomical cell wall. The beta-lactam ring is therapy are comprised of: therapeutic chemical (ATC) code: essential in binding to the ceftaroline fosamil, ceftolozane/ J01DI02) is a relatively recent penicillin-binding proteins, crucial tazobactam, and ceftobiprole approved cephalosporin from the enzymes in the synthesis of the medocaril [1-3]. The clinical studies fifth-generation [1,4,5]. The U.S. bacterial cell wall. The high affinity conducted so far support the Food and Drug Administration of fifth-generation CFs for positive balance between benefits approved ceftaroline fosamil in penicillin-binding proteins leads to and side effects for these new CFs. 2010 and the European Medicine an efficient activity against clinically However, the fifth-generation CFs Agency, in 2011 (under trade name relevant pathogens. The new CFs should be judiciously used in Teflaro and Zinforo) [5-7]. (fourth and fifth generations) have difficult-to-treat bacterial infections Ceftaroline fosamil is active against Corresponding author: Aura Rusu E-mail: [email protected]\ https://FARMA.com.ro | PHARMACEUTICAL PRACTICE | 121 REVIEWS Gram-positive (G(+)) organisms, Safety of ceftaroline fosamil. including methicillin-resistant Ceftaroline fosamil is considered Staphylococcus aureus (MRSA) and effective in therapy, and well- Streptococcus pneumoniae, as well tolerated, with a good safety as common Gram-negative (G(-)) profile. However, ceftaroline organisms [6]. fosamil could be responsible for diarrhea, nausea, headache and Physical-chemical properties. pruritus as the most common side Ceftaroline is an oxyimino effects with similar rates compared compound based on the structure to other antibiotics [5,6,9-11]. of cefozopran (a fourth-generation Precautions for use and special representative) [6]. Ceftaroline warnings are for hypersensitivity fosamil is a prodrug that turns in reactions, Clostridium difficile- vivo into ceftaroline (the active associated diarrhea, superinfections metabolite). The name „fosamil” is with non-susceptible bacteria, and given by an extra phosphono group pre-existing seizure disorder. in the chemical structure Ceftaroline fosamil has a low comparative to ceftaroline. The potential for drug-drug interactions resulted compound has the [6,12]. Because the effects of the advantage that it is more water- compound in pregnancy and soluble [6]. The oxime group in the lactation or on fertility are C7 acyl moiety and a 1,3-thiazole unknown, it is advisable to avoid ring attached to the central nucleus the treatment in these situations (C3 position) facilitate the increased activity against MRSA (Table 2) [5]. More studies are needed in the [6,8]. The parenteral formulation future to assess the safety profile of (600 mg powder for concentrate for ceftaroline fosamil [9]. solution for infusion) contains an equivalent amount of ceftoraline Ceftolozane/tazobactam fosamil acetic acid solvate combination monohydrate [5]. Ceftolozane is a new fifth- generation CF, a derivative of Indications, dosing and ceftazidime (third generation). administration. Ceftaroline fosamil Because it is not resistant to has been approved for beta-lactamases, ceftolozane was administration to children combined with an inhibitor of (neonates, infants, children, beta-lactamases, respectively adolescents) for the same tazobactam. The obtained indications as for adults: combination provides great activity complicated skin and soft tissue against extended-spectrum beta- infections and community-acquired lactamase-producing pneumonia [5]. Ceftaroline fosamil Enterobacteriaceae, Pseudomonas is administrated intravenously (600 aeruginosa, and certain anaerobic mg every 12 hours over 1 hour in germs [2,13]. The combination of adults) during 5-14 days. Dosage ceftolozane with tazobactam (ATC adjustment is necessary for code: J01DI54) was approved in patients with moderate to severe 2014 by the FDA, and in 2015 by renal impairment [6]. Also, the EMA (under trade name ceftaroline fosamil is used off-label Zerbaxa). Recently, the FDA has in the treatment of bacteremia, approved Zerbaxa for the treatment endocarditis, osteoarticular of adults with hospital-acquired infections, hospital-acquired and ventilator-associated bacterial pneumonia, and meningitis [9]. pneumonia [14-16]. 122 | PHARMACEUTICAL PRACTICE | Vol. XIII, No. 3 (52), Year 2020 REVIEWS TABLE 1. Classification of the most used CFs by generation and route of administration (G(+) = Gram positive, G(-) = Gram negative) [1,2,17,22,24]. Generations/Administration First Second Third Fourth Fifth Cefalotine parenteral Cefamandol parenteral Cefotaxime parenteral Cefpirome parenteral Ceftaroline fosamil parenteral Ceftolozane/ parenteral Cefapirine parenteral Cefuroxime parenteral Ceftazidime parenteral Cefepime parenteral tazobactam Cefalexina oral Cefoxitin parenteral Ceftriaxone parenteral Ceftobiprol medocaril parenteral Cefadroxil oral Cefotetan parenteral Cefoperazone parenteral Cefatrizine oral Cefaclor oral Flomoxef parenteral Cefradine oral Cefprozil oral Cefixime oral Cefuroxime oral Ceftibuten oral axetil Antibacterial spectrum G(+) cocci All have less activity All have extended activity Cefepime is active Ceftaroline is a broad- (staphylococci spp. and against G(+) cocci against G(-) bacteria against Streptococcus spectrum antibiotic with great streptococci spp.) and increased activity (including those resistant pneumoniae, activity against MRSA, Listeria against G(-) bacilli to the first and second methicillin-resistant monocytogenes, Enterococcus All have minimal compared to the first- generation CFs or other Staphylococcus faecalis, and no activity against activity against G(-) generation. Cefuroxime beta-lactam antibiotics). aureus (MRSA), Pseudomonas aeruginosa. bacteria. has increased activity Ceftriaxone is useful and Pseudomonas against Haemophilus in the treatment of aeruginosa. In Ceftolozane/tazobactam influenza. Cefotetan meningitis (caused by addition to the has activity against resistant and cefoxitin have Haemophilus influenza, activity of the third G(-) pathogens (including Pseudomonas aeruginosa increased activity Neisseria meningitidis, generation, cefepime ), Enterobacteriaceae, against Bacteroides spp. or Streptococcus has activity against and pneumoniae) gonorrhea beta-lactamase- some anaerobic pathogens Bacteroides fragilis and disseminated Lyme producing G(-) bacilli. (e.g., ). disease. Ceftazidime Ceftobiprole is active against Streptococcus presents activity Cefepime is reserved MRSA and pneumoniae against Pseudomonas for severe systemic resistant to third- aeruginosa. infections produced generation CFs and penicillin, by multi-resistant and G(-) bacteria associated with organisms. hospital-acquired pneumonia and community-acquired pneumonia. Physical-chemical properties. The ceftolozane sulphate and Safety of ceftolozane/ chemical structure is based on the tazobactam sodium) [15]. tazobactame. Generally, therapy structure of ceftazidime (an with ceftolozane/tazobactam is well oxyimino-aminothiazolyl CF), Indications, dosing and tolerated. The reported common optimized to have activity on administration. Usually, the side effects such as nausea, Pseudomonas spp. The approved dose of ceftolozane/ vomiting, diarrhea, constipation, aminothiadiazole moiety (attached tazobactam is 1 g ceftolozane/0.5 g abdominal pain, hypotension, rash, to the side-chain from C7 position) tazobactam for the treatment of headache, dizziness, insomnia, confers increased activity against complicated intra-abdominal anxiety, hypokalemia, G(-) bacteria. Also, a pyrazole infections, urinary tract infections thrombocytosis, and Clostridioides difficile colitis were mild or moiety attached to the side-chain and
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