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Beta Lactamase Inhibitors

Authors

Niloufar R. Khanna1; Valerie Gerriets2.

Affiliations
1 California Northstate University
2 California Northstate University College of Medicine

Last Update: November 17, 2020.

Indications
Beta-lactam antimicrobials are used to treat a variety of bacterial infections and are among the most prescribed drugs
in the US.[1] Beta-lactamase inhibitors are drugs that are co-administered with beta-lactam antimicrobials to prevent
antimicrobial resistance by inhibiting serine beta-lactamases, which are enzymes that inactivate the beta-lactam ring,
which is a common chemical structure to all beta-lactam antimicrobials. Therefore, beta-lactamase inhibitors are
primarily indicated for infections by gram-negative bacteria, as they produce this enzyme.[2]

The most common bacteria treated by beta-lactamase inhibitors are the Enterobacteriaceae (Citrobacter, Escherichia
coli, Klebsiella pneumoniae, Morganella, Proteus vulgaris, Salmonella, Shigella), Haemophilus influenzae,
Mycobacterium tuberculosis, Neisseria gonorrhoeae, and Pseudomonas aeruginosa.[3] Additionally, the gram-
positive bacteria Staphylococcus aureus also contains the beta-lactamase enzyme. However, beta-lactamase inhibitors
are less commonly used for the treatment of staph due to the presence of an alternate antimicrobial resistance
mechanism, namely the presence of a penicillin-binding protein, which is ubiquitous among gram-positive bacteria.
[3] Several bacteria have developed extended-spectrum beta-lactamase enzymes (ESBLs), conferring additional
resistance against cephalosporin antimicrobials. Enterobacteriaceae and Pseudomonas aeruginosa are notable ESBL-
producing bacteria. Research has demonstrated that beta-lactamase inhibitors can effectively treat ESBL-producing
organisms, thereby improving our ability to fight these virulent bacteria.[1]

Avibactam is used in combination with ceftazidime (a cephalosporin) to treat urinary tract infections, intra-abdominal
infections, pyelonephritis, and hospital-acquired pneumonia caused by gram-negative bacteria, including ESBL-
producing bacteria.[4] Clavulanic acid (clavulanate) is administered with the penicillin antimicrobial amoxicillin and
with penicillin-resistant ticarcillin.[5][6] Amoxicillin/clavulanic acid treats respiratory tract infections, otitis media,
sinusitis, skin infections, and urinary tract infections, while ticarcillin/clavulanate is used to treat lower respiratory,
bone, gynecologic, joint, skin, urinary tract, and abdominal infections.[5][6] Relebactam is used in combination with
imipenem and cilastatin. It is used to treat pyelonephritis, urinary tract infections, and intra-abdominal infections.
[7] Sulbactam is used in combination with ampicillin and is used to treat skin, intrabdominal, and gynecologic
infections.[8] Tazobactam is used in combination with piperacillin to treat community-acquired pneumonia, intra-
abdominal infections, skin and skin structure infections, and female pelvic infections.[9] Vaborbactam is used in
combination with meropenem to treat urinary tract infections and pyelonephritis.[10] Tebipenem is a carbapenem
antimicrobial used to treat Mycobacterium tuberculosis that inhibits its beta-lactamase enzyme and is the only orally
available beta-lactamase inhibitor.[11] However, it does not yet have approval in the United States and is only
marketed in Japan. Beta-lactamase inhibitors are essential to improving the efficacy of beta-lactam antimicrobial
treatment and preventing antimicrobial resistance, which poses a serious public health risk. New research is
continuously underway to expand the number and effectiveness of beta-lactamase inhibitors.

Mechanism of Action
Beta-lactamase inhibitors work by one of two primary mechanisms. They may become substrates that bind the beta-
lactamase enzyme with high affinity but form sterically unfavorable interactions, such as the acyl-enzyme. They may
also become “suicide inhibitors,” which permanently inactivate the enzyme through secondary chemical reactions in
the active site. Avibactam and relebactam work by the former mechanism, while sulbactam, tazobactam, and
clavulanic acid work by the latter mechanism.[12] Beta-lactamase inhibitors are generally renally excreted and do not
undergo significant hepatic or GI first-pass metabolism. Their metabolism and pharmacokinetic properties are
influenced by their co-administration with beta-lactam antimicrobials as well as by the length of infusion, as most are
delivered intravenously.

Avibactam has a half-life of approximately 2 hours, and administration is in combination with ceftazidime in a 1:4
combination. It is cleared renally with dose adjustment for patients with renal disease. The ceftazidime MIC is 8 mg/L
at 4 mg/L avibactam concentrations. A dosing regimen of 2/0.5g ceftazidime/avibactam is used every 8 hours with a 2
hour infusion period for patients with normal kidney function.[13]

Clavulanic acid has a half-life of approximately 47 minutes with and without amoxicillin, with 37% unchanged
excretion in the urine alone and 57% with amoxicillin after the first 6 hours of administration. Current dosage
formulations of amoxicillin/clavulanic acid use a 4 to 1 concentration ratio.[14]

The pharmacokinetics of relebactam have been studied both alone and in combination with imipenem/cilastatin.
Clearance is significantly affected by renal function as assessed by creatinine clearance. Metabolism of relebactam is
not significantly affected by body weight or health status. A MIC of less than or equal to 4 micrograms/milliliter is
achievable for patient groups by modifying the dosing regimens, with an optimal dose of 250 mg.[15]

Sulbactam has a half-life of one hour and a volume of distribution of 12 liters. Seventy-five percent of the dose is
excreted unchanged in the urine. The pharmacokinetics of sulbactam are not significantly impacted by the co-
administration of sulbactam with beta-lactam antimicrobials.[16] Sulbactam is approximately 38% bound to plasma
proteins. Sulbactam has demonstrated greater efficacy with prolonged infusion strategies.[17]

The pharmacological properties of tazobactam have been studied both alone and in combination with piperacillin. The
mean concentrations of tazobactam in plasma at 4 hrs are 1.2 micrograms per milliliter with piperacillin and 0.6
micrograms per milliliter alone. The clearance of tazobactam alone is 203.5 ml/min, while that with piperacillin is
134.2 ml/min. There appears to be no significant difference in the volume of distribution, elimination half-life, the
volume of distribution, or AUC from 0 to infinity hours between tazobactam alone and tazobactam with piperacillin.
The total renal clearance is 73 micrograms/milliliter, the half-life is 1 hr, and the AUC from 0 to infinity is 237
micrograms*hours/ml. The maximum concentrations of tazobactam is 6.4 micrograms/ml alone and 11.3
micrograms/ml with piperacillin. Tazobactam is excreted renally, both alone and with piperacillin. The mean 24-hour
urinary excretion of tazobactam is 63.7% alone and 56.8% with piperacillin.[18]

Vaborbactam concentration has been shown to increase in a dose-dependent manner, suggesting first-order kinetics,
and does not accumulate with multiple doses. The terminal half-life of vaborbactam is 2.25 hours. Both the volume of
distribution and the plasma clearance is independent of dose. With a 2000 mg dose, the plasma clearance is 7.95
liters/hour, the AUC from 0 h to infinity is 835 mg*h/liter, and the Vss is 18.6 liters. Vaborbactam undergoes renal
excretion, and urinary recovery was 80% or greater over 48 h across all dose groups.[19] Vaborbactam does not
undergo hepatic first-pass metabolism.[20]

Tebipenem shows a dose-proportional plasma concentration, with a maximum concentration reached within 1.5 hours.
Between 55 and 60% of the drug is recovered in the urine. The half-life ranges from 0.8 to 1.1 hours. Renal clearance
is not affected by food.[21]

Administration
The administration of many beta-lactamase inhibitor medications is via intravenous infusion over several hours. Each
drug has different dosage scheduling options, allowing care providers to tailor a patient’s medication regime
according to his or her unique needs. Given the potential for nephrotoxicity, dosage adjustment is a recommendation
for patients with renal disease. Ceftazidime-avibactam administration is intravenous.[4] Sulbactam-ampicillin
administration may be parenteral or oral.[22] Tazobactam-piperacillin administration is parenteral.[22] Clavulanic
acid-amoxicillin administration is either parenteral or oral.[22] Clavulanic acid and ticarcillin administration is via the
parenteral route.[22] Relebactam-imipenem-cilastatin administration is intravenous via intravenous infusion, as is
vaborbactam-meropenem.[7] Tebipenem is administered orally.[23] Poor medication adherence is noted among
pediatric populations, particularly for dosing regimens greater than twice per day.[22] This factor merits consideration
when designing a treatment regimen for pediatric patients. It is also vital to regularly counsel patients and their
caregivers regarding the importance of patient adherence.

Adverse Effects
Adverse reactions associated with beta-lactamase inhibitors include gastrointestinal side effects, such as diarrhea,
nausea, and constipation; nervous system effects such as headaches, insomnia, and seizures; hematological effects
such as impaired platelet function; allergic reactions including anaphylaxis; pain at the injection site; and
dermatologic side effects including Stevens-Johnson syndrome, toxic epidermal necrolysis, and drug-induced
eosinophilia and systemic symptoms. Gastrointestinal side effects can be less severe if the patient takes the
medication with food and/or water. Beta-lactamase inhibitor use is also associated with Candida albicans and
Clostridioides (Clostridium) difficile infections.[24][25][26] It is important for clinicians to monitor patients for
adverse effects routinely and discontinue therapy immediately if severe side effects occur.

Contraindications
The use of beta-lactamase inhibitors is contraindicated in patients with a known anaphylactic reaction to penicillins,
due to the potential for cross-reactivity with other beta-lactam antimicrobials and beta-lactamase inhibitors. Patients
should be allergy tested to determine the presence of allergy as well as the type of allergic reaction prior to
administration of beta-lactamase inhibitor therapy.[27] Beta-lactamase inhibitor therapy is also contraindicated in
patients who have had previous adverse reactions to beta-lactamase inhibitors, such as neurotoxicity, hepatotoxicity,
or renal toxicity. Beta-lactamase inhibitors are not contraindicated in pregnancy, although some teratogenic effects
have occurred, and dose adjustments may be necessary for pregnant patients.[28]

Monitoring
Beta-lactamase inhibitory therapy has shown correlations with kidney, liver, gastrointestinal, hematologic, and
nervous system adverse effects.[12] Although most antimicrobial therapy is short term, and bloodwork to assess
kidney and/or liver function is generally not required for healthy individuals, several at-risk patient populations
require additional monitoring. Given that beta-lactamase inhibitors undergo renal elimination, patients with chronic
kidney disease must undergo routine screening and dose adjustment to prevent renal toxicity and acute kidney injury.
[29] Furthermore, bacterial antimicrobials may be associated with gastrointestinal side effects as well as an increased
risk of Clostridioides (Clostridium) difficile infection due to the death of protective gut microflora. Beta-lactam
antimicrobial/beta-lactamase inhibitor combination therapies are no exception to this rule. Therefore, patients with
pre-existing gastrointestinal issues, such as inflammatory bowel disease, as well as patients who are
immunocompromised, such as those with HIV/AIDS, should receive additional monitoring for these gastrointestinal
side effects.[30] Individuals who are prone to recurrent infections, and therefore require chronic antimicrobial use,
such as those with immunodeficiency syndromes, or cystic fibrosis, need to be monitored extra carefully for any signs
of organ toxicity. Data has shown that for cystic fibrosis, in particular, piperacillin-tazobactam usage is associated
with an increased risk of acute kidney injury.[31] Drug-drug interactions may occur with patients who are taking other
medications that are renally excreted, so it is important to monitor patients on additional medications as well. Beta-
lactamase inhibitors do have hematological side effects, including thrombocytopenia, so it is important to monitor the
platelet function of patients who are taking anticoagulants, such as heparin or warfarin.[26]

Toxicity
Many causes of organ toxicity due to beta-lactamase inhibitor therapy are directly related to the toxic effects of the
beta-lactam antimicrobial with which they are co-administered. Allergic reactions can lead to bronchoconstriction,
urticaria, intravascular hemolysis, and immune-mediated hemolytic anemia. Neurotoxicity, nephrotoxicity,
genotoxicity, and urogenital organ toxicity have also been noted.[32] Though beta-lactamase inhibitor therapy is
generally considered to be safe, the wide array of toxic effects associated with the use of these drugs underscores the
importance of routine monitoring of patients taking beta-lactam antimicrobial/beta-lactamase inhibitor combinations.
The treatment for toxicity associated with beta-lactamase inhibitor therapy is the cessation of drug use.

Enhancing Healthcare Team Outcomes

Beta-lactamase inhibitors are medications that are used ubiquitously in modern medicine due to their ability to combat
bacterial antimicrobial resistance mechanisms. Antimicrobial resistance poses an enormous global public health
challenge.[33] Therefore, careful monitoring and prescribing of patients taking Beta-lactamase inhibitors in
combination with beta-lactam antimicrobials are of paramount importance. Interprofessional health teams of doctors,
nurses, pharmacists, and other healthcare professionals must work together to determine the necessity of treatment, as
well as to counsel patients regarding the proper administration of this class of medications. Patients must complete
their entire course of medication and must not share this medication with others. By working together, members of an
interprofessional healthcare team can strive to prevent adverse outcomes for the patient and antimicrobial resistance in
the community.

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