Annals of Medicine, 2014; Early Online: 1–18 © 2014 Informa UK, Ltd. ISSN 0785-3890 print/ISSN 1365-2060 online DOI: 10.3109/07853890.2014.935470 REVIEW ARTICLE Renaissance of antibiotics against difficult infections: Focus on oritavancin and new ketolides and quinolones Françoise Van Bambeke Pharmacologie cellulaire et moléculaire, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium Lipoglycopeptide, ketolide, and quinolone antibiotics are currently Key messages in clinical development, with specific advantages over available molecules within their respective classes. The lipoglycopeptide • New antibiotics in the classes of lipoglycopeptides, ketolides, oritavancin is bactericidal against MRSA, vancomycin-resistant and quinolones are in the late stages of clinical development, enterococci, and multiresistant Streptococcus pneumoniae, and mainly for the treatment of acute bacterial infections of skin proved effective and safe for the treatment of acute bacterial and skin structures and/or of the respiratory tract. skin and skin structure infection (ABSSSI) upon administration • These molecules mainly address the problem of resistance of a single 1200 mg dose (two completed phase III trials). The in Gram-positive bacteria; their dose has been rationally ketolide solithromycin (two phase III studies recruiting for established based on pharmacokinetic/pharmacodynamic community-acquired pneumonia) shows a profile of activity concepts in order to optimize the chance of therapeutic similar to that of telithromycin, but in vitro data suggest a lower success while at the same time avoiding the risk of selection risk of hepatotoxicity, visual disturbance, and aggravation of of resistance. myasthenia gravis due to reduced affinity for nicotinic receptors. • They all presented a satisfactory safety profile in clinical trials, Among quinolones, finafloxacin and delafloxacin share the which should be further documented upon administration unique property of an improved activity in acidic environments to larger patient populations. For personal use only. (found in many infection sites). Finafloxacin (phase II completed; activity profile similar to that of ciprofloxacin) is evaluated for complicated urinary tract and Helicobacter pylori infections. The other quinolones (directed towards Gram-positive or the ‘Innovative Medicine Initiative’ (http://www.imi.europa. pathogens) show improved activity on MRSA and multiresistant eu/) from the European Union. At this stage, a series of mole- S. pneumoniae compared to current molecules. They are in cules are in the late stages of clinical development (2,3), many of clinical evaluation for ABSSSI (avarofloxacin (phase II completed), them being essentially new molecules in existing classes, which nemonoxacin and delafloxacin (ongoing phase III)), respiratory display, however, better properties in terms of intrinsic activity, tract infections (zabofloxacin and nemonoxacin (ongoing reduced susceptibility to resistance mechanisms, and improved phase III)), or gonorrhea (delafloxacin). pharmacokinetic or safety profiles. This paper will focus on Key words: Avarofloxacin, delafloxacin, EDP-322, finafloxacin, those families that count molecules in phase III of clinical de- oritavancin, nemonoxacin, solithromycin, zabofloxacin velopment, namely lipoglycopeptides (oritavancin), ketolides (solithromycin), and quinolones (nemonoxacin; delafloxacin). It will explain the prevailing rationale in the development of these antibiotics and examine their current pharmacological Ann Med Downloaded from informahealthcare.com by Centre de Biostatistique et Documentation Medicale on 07/24/14 Since the beginning of this century, only 14 new antibiotics have been approved for use in human medicine (Table I). Still- profile based on available clinical data. unmet needs include mainly the so-called ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneu- moniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Lipoglycopeptides: focus on oritavancin Enterobacter spp.), which remain difficult to treat because they Lipoglycopeptides are a subclass within the glycopeptide anti- have accumulated resistance mechanisms to most of the antibi- biotics, which all possess a lipophilic tail attached to the amino otics available so far. Global initiatives have been raised to try sugar substituting the cyclic heptapeptide core. Teicoplanin, stimulating research and investment in the field of antibiotic introduced in the clinics in Europe in 1988, is a natural represen- development, like the ‘10 x ‘20 Initiative’ (1) from the Infectious tative of this subclass. More recently, semi-synthetic derivatives Disease Society of America (http://www.idsociety.org/10x20/) were produced, among which telavancin has been on the market Correspondence: Françoise Van Bambeke, Pharmacologie cellulaire et moléculaire, Louvain Drug Research Institute, Université catholique de Louvain, Avenue Mounier 73, B1.73.05, 1200 Brussels, Belgium. E-mail: [email protected] (Received 27 April 2014; accepted 11 June 2014) 2 F. Van Bambeke Table I. Antibiotics approved by the FDA and the EMA since 2000. Date of approval Molecule Antibiotic class FDA EMA Linezolid oxazolidinone April 2000 (decentralized procedure; ∼ 2001) cefditoren pivoxil b-lactam August 2001 (available in specific countries) Ertapenem b-lactam November 2001 April 2004 Gemifloxacin fluoroquinolone April 2003 Not available Daptomycin lipopeptide September 2003 January 2006 Telithromycin ketolide April 2004 July 2007 Tigecycline glycylcycline 2005 April 2006 Retapamulin pleuromutilin April 2007 May 2007 Doripenem b-lactam October 2007 July 2008 Telavancin lipoglycopeptide September 2009 September 2009 Ceftaroline b-lactam November 2010 August 2012 Fidaxomicin fluoroquinolone May 2011 December 2011 Dalbavancin lipoglycopeptide May 2014 Not yet approved Tedizolid oxazolidinone June 2014 Not yet approved since 2009, dalbavancin has been approved by the FDA in May resistance is associated with higher risk of therapeutic failure 2014, and oritavancin is in the late phase of development. (13). The prevalence of these strains is controversial because of The rationale for the development of these drugs was to cope the difficulty to detect them correctly. with vancomycin resistance, which spread in enterococci mainly In this context, early work from Eli Lilly demonstrated that in the USA at the end of the 1980s. chloroeremomycin, which differs from vancomycin by the ste- Vancomycin’s mode of action consists in an inhibition of reochemistry of the sugar substituting the ring 4 amino-acid the late stages of peptidoglycan synthesis (4, and references and by the presence of an additional L-4-epi-vancosamine, cited herein). The cyclic heptapeptide core of the molecule displayed enhanced activity, including against vancomycin- establishes non-covalent interactions with the D-alanyl-D- resistant strains, possibly due to dimerization facilitating a alanine termini of the pentapeptide moiety of lipid II. The co-operative binding to the target (14). In parallel, deriva- resulting steric hindrance around these termini prevents the tives of vancomycin substituted by an alkyl side chain on their access of enzymes that are needed for cross-linking peptido- vancosamine sugar showed also enhanced activity on resis- glycan precursors via transglycosylation and transpeptidation tant strains (15). Combining these two features, oritavancin reactions. As a result, vancomycin is slowly bactericidal, with (initially LY333328; Eli Lilly, Indianapolis, IN, USA) was first a spectrum of activity limited to Gram-positive bacteria, be- described in 1996 (16) as the chlorobiphenylmethyl side chain cause its large size prevents it from crossing the outer mem- analog of chloroeremomycin (Figure 1). As compared to van- brane of Gram-negative bacteria. Two resistance mechanisms comycin, this antibiotic shows higher intrinsic activity (lower For personal use only. have emerged over the years (4, and references cited herein). MICs) (Table II) against susceptible Gram-positive organisms, The first one, mainly found in enterococci, consists in the -ac as well as against staphylococci displaying the VISA phenotype quisition of genes allowing for the synthesis of alternative cell or even against VRE (vancomycin-resisitant enterococci) or wall precursors ending in D-alanyl-D-lactate or in D-alanyl- VRSA (vancomycin-resistant S. aureus) (17,18). This can be D-serine, which show a reduced affinity for vancomycin. At explained by a dual mode of action (see for review 19), which the present time, the prevalence of this resistance mechanism combines an inhibition of transpeptidase and transglycosylase in enterococci collected from infection sites culminates in the activity with an alteration of membrane integrity (20) caused USA, reaching 14% (E. faecalis) to 88% (E. faecium) (5) versus by the anchoring of the lipophilic side chain in the bilayer (21). about 10% in Europe but with huge variations among coun- Importantly also, this novel mode of action confers to orita- tries (6), 15% in Latin America (7), 2% (E. faecalis) to 18% (E. vancin a rapid and intense bactericidal character, as well as a faecium) in Canada (8), and, quite surprisingly, low levels of maintained activity on slow-growing bacteria or on biofilms resistance ( 5%) in Asia (9). Worryingly, a few cases of gene (22). Among the other remarkable features of this molecule, transfer to multidrug-resistant MRSA (methicillin-resistant