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Forgotten Antibiotics: an Inventory in Europe, the United States, Canada, and Australia

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Forgotten Antibiotics: an Inventory in Europe, the United States, Canada, and Australia REVIEWS OF ANTI-INFECTIVE AGENTS MAJOR ARTICLE Louis D. Saravolatz, Section Editor Forgotten Antibiotics: An Inventory in Europe, the United States, Canada, and Australia Ce´line Pulcini,1 Karen Bush,2 William A. Craig,3 Niels Frimodt-Møller,4 M. Lindsay Grayson,5 Johan W. Mouton,6 John Turnidge,7 Stephan Harbarth,8 Inge C. Gyssens,9,10 and the ESCMID Study Group for Antibiotic Policies 1Centre Hospitalier Universitaire de Nice, Service d'Infectiologie and Universite´ de Nice Sophia-Antipolis, Faculte´ de Me´decine, France; 2Biology Department, Indiana University, Bloomington; 3University of Wisconsin, School of Medicine and Public Health, Madison; 4Department of 5 Clinical Microbiology, Hvidovre Hospital, Copenhagen, Denmark; Infectious Diseases Department, Austin Health and Department of Medicine, Downloaded from University of Melbourne, Victoria, Australia; 6Department of Medical Microbiology, Radboud University Nijmegen Medical Centre and Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, the Netherlands; 7SA Pathology, The University of Adelaide, SA, Australia; 8Geneva University Hospitals and Medical School, Switzerland; 9Department of Medicine, Radboud University Nijmegen Medical Centre and Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, the Netherlands; and 10Hasselt University, Diepenbeek, Belgium http://cid.oxfordjournals.org/ In view of the alarming spread of antimicrobial resistance in the absence of new antibiotics, this study aimed at assessing the availability of potentially useful older antibiotics. A survey was performed in 38 countries among experts including hospital pharmacists, microbiologists, and infectious disease specialists in Europe, the United States, Canada, and Australia. An international expert panel selected systemic antibacterial drugs for their potential to treat infections caused by resistant bacteria or their unique value for specific criteria. Twenty-two of the 33 selected antibiotics were available in fewer than 20 of 38 countries. Economic motives were the major cause for discontinuation of marketing of these antibiotics. Fourteen of 33 antibiotics are at University of Wisconsin-Madison on October 31, 2013 potentially active against either resistant Gram-positive or Gram-negative bacteria. Urgent measures are then needed to ensure better availability of these antibiotics on a global scale. In the European Union, at least 25 000 persons are es- development of new antimicrobial drugs [1, 3–5]. Few timated to die each year from an infection caused by new antibiotics are in the drug development pipeline; in multidrug-resistant bacteria [1]. In the United States, just particular, recent analyses have shown that few anti- one organism, methicillin-resistant Staphylococcus aureus biotics in development have documented in vitro activity (MRSA), kills more Americans every year (approxi- against antibiotic-resistant Gram-negative bacteria [1, 3]. mately 19 000) than emphysema, human immunodefi- Furthermore, the arsenal of available antimicrobial drugs ciency virus/AIDS, Parkinson’s disease, and homicide is becoming smaller because older drugs are disappearing combined [2]. There is a gap between the current from the market or are temporarily unavailable. The worldwide spread of multiresistant bacteria and the ESCMID (European Society of Clinical Microbiology and Infectious Diseases) Study Group for Antibiotic Policies (ESGAP) performed a review in 2006 which Received 25 July 2011; accepted 13 October 2011. Presented in part: poster presentation at the European Congress of Clinical showed that shortages of narrow-spectrum antibacterial Microbiology and Infectious Diseases and oral presentations at the Journe´es drugs forced clinicians to use broad-spectrum drugs, Nationales d'Infectiologie (French Infectious Diseases Society meeting) and Interscience Conference on Antimicrobial Agents and Chemotherapy in 2011. adversely influencing the policies of prudent use [6, 7]. Correspondence: Ce´line Pulcini, MD, PhD, Centre Hospitalier Universitaire de The reasons for shortages and market withdrawals of Nice, Service d'Infectiologie, Hoˆpital l'Archet 1, 151 Route Saint Antoine de older antibiotics are incompletely understood. However, Ginestie`re, BP 3079, 06202 Nice Cedex 3, France ([email protected]). Clinical Infectious Diseases 2012;54(2):268–74 the lack of profit for drugs in limited market areas (small Ó The Author 2011. Published by Oxford University Press on behalf of the Infectious countries) and increasing regulatory requirements and Diseases Society of America. All rights reserved. For Permissions, please e-mail: [email protected]. bureaucracy appear to play a role. Several older, poten- DOI: 10.1093/cid/cir838 tially useful, sometimes ‘‘forgotten’’ antibiotics are not 268 d CID 2012:54 (15 January) d REVIEWS OF ANTI-INFECTIVE AGENTS available in many countries, either never having been in- for multiple resistance to antibiotics: MRSA; vancomycin- troduced or having now been withdrawn [8–10]. In view of intermediate S. aureus (VISA) and vancomycin-resistant S. aureus; the alarming development of resistance in the absence of new vancomycin-resistant enterococci (VRE; eg, Enterococcus faecium); antibiotics, it seemed opportune to collect reliable information on penicillin-resistant Streptococcus pneumoniae; third-generation the availability of currently useful older antibiotics. This study cephalosporin–resistant Enterobacteriaceae (eg, Escherichia coli, had 3 objectives: (1) to select systemic antibiotics (Anatomical Klebsiella pneumoniae); carbapenem-resistant Enterobacteriaceae Therapeutic Chemical [ATC] code J01) with (potential) activity (eg, K. pneumoniae); and carbapenem-resistant nonfermentative on resistant microorganisms and/or having a unique value Gram-negative bacteria (eg, Pseudomonas aeruginosa). for specific criteria and that had at any time been marketed in The selected agents were assessed for their antibacterial ac- Europe, the United States, Canada, and Australia; (2) to assess tivity against the selected bacteria based on actual data available the evidence base of efficacy of these antibiotics in infections in the reference textbook [12] and/or the literature. In the caused by current antibiotic-resistant bacteria, or their unique absence of available in vitro data, the expert panel also took value; and (3) to make an inventory of these selected antibiotics’ into account reasonable assumptions of the activity of some availability in Europe, the United States, Canada, and Australia. agents based on the properties of similar agents (ie, of the same class or with a common mechanism of action) to construct MATERIALS AND METHODS a ‘‘best-case scenario.’’ In vitro activity of each agent against the selected bacteria was Selection of Potentially Useful Antibiotics assigned based on the following approaches: We reviewed the list of all systemic antibacterials (ATC code J01, http://www.whocc.no/atc_ddd_publications/guidelines/)[11] d Actual data on in vitro activity were reviewed whenever that have been approved for human use by the US Food and Drug available. If actual data on in vitro activity were not Administration (FDA) and/or the European Medicines Agency reported for an agent against any of the selected (EMA) and/or in the following countries: Europe (35 countries, pathogens, assumptions were made regarding likely Supplementary Table 1), Canada, and Australia. Exclusion criteria activity based on the properties of the antibiotic class or included (1) antibiotics currently marketed in all countries of of the mechanism of action involved. interest; (2) antituberculous, antifungal, antiparasitic, and antivi- d The assessment of in vitro activity disregarded any known ral drugs; and (3) topical- or inhaled-only antibacterials. Newly potential for cross-resistance and coresistance. approved drugs, such as telavancin, ceftaroline, and fidaxomicin, d Although in vitro activity alone cannot predict in vivo were beyond the scope of our review. efficacy, it was decided not to take into account any Six experts (2 from Europe, 2 from the United States, and available pharmacokinetic data or pharmacokinetics/ 2 from Australia) with clinical/microbiological expertise in pharmacodynamics (PK/PD) analyses when scoring the the field were chosen as assessors. Five of them were authors antibacterial activity of agents because the amount of of a leading reference textbook on antimicrobial drugs [12]. data available was very variable. However, if there was All authors selected the antibiotics for their potential value already information available on nonclinical or clinical against current resistant bacteria and/or for their unique efficacy, these data were factored into the assessment. value for specific criteria, based on the textbook (Kucers’) d The assignment of in vitro activity, which took into [12] and their own experience. account available data together with assumptions based on class properties or mechanisms of action as well as the Assessment of the Potential of These Antibiotics Against route of administration, took the most optimistic view of Currently Resistant Bacteria and of Their Unique Value what the agent might be able to achieve and represents PubMed was searched for literature relevant to the selected a best-case scenario. antibiotics, published until October 2010 inclusive. Based on this literature review and the expert panel advice, the potential The unique value of each of these antibiotics,
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