Y seeresreaserca ‘open Aesets:Fullepen ees o ts andtnousand of cher pape at | rn gress com, Perspectives in Medicinal Chemistry Antibiotics and Bacterial Resistance in the 21st Century Richard J. Fair! and Yitzhak Tor? “Dsearmen er Blasi yt, tax Pancklnei of Colne an neta, arin, Geemy “Onparment of hemi and cvemany, errata nen San ge tank P88 secon Srchnmand athe wang eal ane cen ning sa oem Th pene hee Ingin the pra new socal agens ae ey dered Te tigs ef bbe ans uo prety emerging te ‘hen a epi on mete eben ney app manele of one Hira perce cha [KEYWORDS snbinc eioc eanc mechani deg resin none abt ges “The Rise of Antibiotic Resbtance Abii resistance ft facts 30% — All deaths that were bacterial infstion slated in preantbitie Ameria? 4 $20/ 1.6€billion ~ Escos healthcare cont of resistant inkection inthe US/EU™ © 8/25 cilia ~ Exces bnpitl days cated by eesietant ifections inthe US/ EU" 1+ 30% — Antimicrobial component of pharmaceutical bud- gets inthe US" +1696 Anuibioi alone of al deuge in development by major pharmaceutical empanis” ‘Multinational pharmaceutical sompanies with ati- bor division!" + St.Lbilion Cost oFunnecessrly prescribed atibiotie te US" +4996 — Proportion of US hospital tha have adapted stewardship plies” ‘+ 24.6million~ Pounds of sntbiotics used won-therapen- tically on anima in the US pe yarin early 2000 + 300,000 - Pounds of streptomycin Qa) and oxyetricy- cline (40) sprayed on produce inthe JS in 1996" ‘Bete ceitnce to antbiorca ha ben a recognized wale almost since the dawn of the antic er, but only ‘within the pst twenty years has the emergence of dangerous, ‘estan stun occured with a diturhg regula. This ‘ecalting evolution of resistance coped with a diminished ‘ntbiote piping ha Ted some to sin that a post antbonc ‘rai eminent! Given thatthe three min eabses of death in precanttioric Ameria were tuberculosis, preumonia and sattoietestinal infections, which combined accounted for 5096 ofall deaths, thsi frightening prospect? Though we ‘ae il far fom that ecnaro Becoming ery, the tend in PERSPECTWESINMEDIENAL CHEMISTRY OMS | 28Fair and Tor & ‘the sntbitis fil has decidedly been negative for sometime tow. The annual impact of resistant infections i estimated to be $20 billion in excess health care cots and 8 million ‘addiconal hospital days inthe United States (US) and over 1L6€ billion and 2.5 millon additional hospital days inthe European Union (EU) Antimirobile curently account for ‘over 30% of hoepital pharmacy budgets ia the US* Diminished Pharmaceutical Investment [A flagging interest in antibiotics bythe pharmaceutical ‘yisone factor thathas contributed to an increased oosrrence ‘of and to teat bacterial infections In 2004 fr example only 1.66 frog in clinical development by the word's 15 largest dug companies were antibiotics. This reduced ourpur of tnt- ‘lots ha several causex? Antibiotics regimens are typically administered for very limited durations making them far less ‘profitable than drugs used to treat chronic ailments, Furth newly approved droge for most other ailments are immed ely prescribed, wheres new antibiotics are typically held in ‘eserve nd only peescrbed for infections that mor extablished antibiotics ca teat. This policy helps delay the emergence of esitant strains, but it also Limits inital investment eeturn. ‘A market saturated with genetic competitor and the inevi= table grown of bucterial cesistance exaerbtes this prof di pasty ax compared to other drugs in the lng er. Regulatory hurdles have leo muted the inerest of msjor pharmaceutical companies, The tolerance of adverse side eects thas recently been decreased for many dug clases, including antibiotic. Approval quirements during clinical tals have ‘scala in moat cies from demonstration of nonineronty to superiority, and a times a lac of clea tral guidlines for antbitis, in particulag, have stifled development.® Phare _macetical companies are presented with a paradox whercin federal agencies ise cll fr antibiotic development while ‘concomitantly other Rederal agencies enact policies Limiting ‘the appeal ofthat very development. “These fictors have made investment in antibiotics deve lopment too high risk, and with the cost at an estimated 1.7billion per drug, with to litle potential reward for many lange pharmaceutical companies" A metic called net pres ‘ent value (NPV) has ben developed for pharmaceutical com- anes to detemine the best avenues of investment ata given time, NPV isa sk-adjsted measure ofthe projected fore revenues ofa drug discounting inital development investment nother projected fature expenses, A characteristic NPV for {an injectable antibiotic maybe around 100, which somewhat [unattractive compared to fpical cancer drug around 300, ‘ora neuroscience drug around 720? Since 1998 Asta Zeneca, ClasoSmithKline, Merk, Johnson 8 Johnson, and Pfzee/Wyeth have been the only _ajor pharmaceutical companies to develop an antibiotic pat phase I linia rials.” Sano Aventis, Ei Lilly Bristol-Myers Squibb, GlaxoSmithKline, Proctor and Gamble, Roche and ‘Wyeth have all greatly curtailed, eliminated, or spun off thee antibiotic RED divisions Tn fist, a8 oF 2013 there are only our multinational pharmaceutical companies with antibiotics Aivisins let." No government agency has ever suseeflly Aiscovered and developed an antibiotic and there have besn ‘indications that any will contribute the resurces necessary for such an endeavor anstme in the near futures Aa con sequence much of what is currency being dane in antibiotic ‘development in the western worlds sone in sal tical companies, Biotech entities, and academic institution. ‘A number oflage pharmaceutical companies fll playa central tol in antibiotic developmen in Japan, however ‘Policies have recently been enacted and incentives offered in an effot to reverse thie exodus from antibiotic R&D. Agencies including the Word Health Organization (WHO), the European Center for Diseate Prevention and Control (ECDC) the Inferious Diseases Society of America (IDSA, and even the US Congress have gotten invabed. 59 Iq the 11th congress the Generating Antibiotic Incentives Now (GAIN) Act and the Swategies to Addeess Antimicrobial Resistance (STAAR) Act were introduced.” In 2011 the US. goverment gave $94 millon in government funding for the evelopment of the structurally novel antbioei candidate, Anacor’s GSK-052 (hough t’scliniclerialswere subsequently ‘halted in 2012) and also $67 allio foe Teataphase's TP-434 (crvaqyline 4), 4 next generation Buoroeyeline currently in phare TI] trials” Even the FDA has recently publically acknowledged that ther is an antibiotic crisis 8” ‘Chronic Clinical Over-prescription and Public Misconceptions “The other factor fueling antibiotic resistance ie the evolution and dissemination of resistance factors within bacterial popu lations. heze ae a plethora of mesns by which humans have inadvertently accelerated the evolution of bacterial resistance, “The ver prescription of antibiotics by dctor fr symptoms ‘that in many cies may not be caueed by bacteria has histori= cally been one sich problematic policy. In rcent years steps dnave been eke to limit antibiotic over prescription, however. I surveys of doctor’ vis ia 1995 compared to 2005, the percentage that emled in antibiotic prseiptions decreed universally for symptoms including ear infections, cold, ‘bronchitis, soe Uvoats, and sims. Despite these postive ‘wends the Center fr Disease Control and Prevention (CDC) cently estimated cha approximately 50% of antibiotics are ‘sill prestbedl unnecessarily in the US at a yeasly cont of $1.1 billion ‘Antibiotic stewardship programs are becoming, more commonplace in hospital settings and have been cored in ‘nay cases to significant reductions i some tains of reat Iacteria” Despite these success only 48% of US howitale Ihave adopted stowardcip police to date and numbers are questimably even Jower in the majority of developing ‘ountres Varied methodologies in measuring antibiotic son ‘sumption in US hospitals hasbeen an undermining factor even 26 | PeRsPEcTives IN MEDICINAL CHEMISTRY 20148z ‘where tewandship policies are enacted though." Along with ‘overall reductions to antibiotic wage, eyling usage between ntbiotc canes, using combination therapies and avoiding ‘ue of broad spectrum and last resort antibiotics wheneves pos ible, have alo een implemented ax strategies to avid the ‘votionacy presse that acoersts resets ‘Oily long oF imprope: treatment regimens may also in some caves exert unnecetary evlutionary presute on bacteria" This can lead to acquired drog resistance in which 4 uinoiy cesstant bacterial phenotype can find themselves Jina les competitine, and theefore mone advantageous e= ronment ara phenotypically sensitive majority ie killed off ‘Ouxputine antbioic use hasbeen directly tie to macrolide resistance in Serpe pyoens and penicillin resistance in Siriptsouspreumonian.* More restive plisies regard ing outpatient regimes have eauled inthe decline of certain ‘sistant flats in both Finland France" [Alaceof public knowledge sbost antibiotics ha als led to ther overuse. Jn a 2009 European survey, of those who hnad taken antibiotics within the last year, 20% claimed to have taken them for influenza vical malady, and only 3686 of those surveyed answered correctly that antibiotics do aot All viruses" This particular vatiety of misoe is expecially problematic in counties where antibiotics can be obtained without prescriptions. Busoze has inetiuted an Antbitie ‘Auvareness Day annually on November 18th in an effort to ‘aise public knowledge.” Misuse by the Food Industry “The use of antibiotics in aninal fed stocks has also exacer- brated the pread of eistance. Especially egregious is thei wie for non-crative reasons suck a5 prophylaxis, metaphylas, and growth peomotion whic by one etimate accounted for 25-56 of all antibiotic conssmption in the early 2000 (ther assessments within the US during the rame time pesiod estimated agrcultunl use to be much greater at 24.6 alin pounds of antibiie being given to animal foe ‘on-therapeutic purposes, 2 lion pounds being wed ther ‘peuteally on asians, and 5 millon pounds beng used in Ihumans per year” Antbii we for growth promotion has been anne in the European Union (EU) since 2003 and finally n 2012 the FDA anaed the use of antibiotics in ve stock without a veterinary prsription.» There ase tll may ‘countries where this practice emans unegilate, however "These is tong evidence thatthe use Auocoquinalone ia {od animal sled othe emergence of fsroquinolonerei- tant Eel” Salmonall, and. Campyloacer™ The emer gence of vancomein estat Eiervast (VRE) in Europe ‘ted to the use of the gyeopepide avoparcin in food Animals.” Avopaccin was baaned ia the EU in 1997, which sesulted ina zeduction ia VRE ther," but many members of stitial antibiotic lasses are sil used or veterinary purposes Ti survey by the European Medicines Agency there wis actually increas in veterinary sales of faornquinatone and Anibioves and bacterial resistance fourth generation cephalosporins from 2005 to 2009: The fod industry’ use of antibiotics has aot been strc imited to livestock ether, In the US, in 1995 fr example, 300,000 pounds of the aninoghcosde streptomycin (24), and axytet Incyline wee spayed prophylacialy on apples and pears? Waste rinof contuining resistant bacters or antbiotice from lange comporste farms of agro-ndustil plants i also concern This serves aa mobile means of exponuce to ant otis andthe terrestrial locale provide an ideal envionment {a dissemination of resistance elements fom pathogen bas- ‘erin an potentially from sil bacteria ax well? Homan Independent Resistance “Though there is undoubeedy a sgnieant haman contrib tion tothe evolution of bacterial resistance, thee is alo resi ‘tance chat has occured in narure abseet human interference.” Resistance to fis in claws antibiotics such ax penkillin G (4) and streptomycin (24), discovered during the golden age of sails, were observed shortly after thee initial ol tion. Though this isnot always the eas, this phenomenon in eypical when examining the antibnc arsenal axa whole? ‘With the advent of cloning and sequencing i was powible to ‘uace Polactamass toa lage number of homologous, but d= tinct genes that were transferred vercally and horizontally ‘throughout many microbial communis, diredy beeween, bacteria and indirectly mediated hy the many bacteriophages that infec them. Resistance genes can associate in elsters and be transfered togsther as well This kind of genetic 4 week hospital stay! ‘+ 1.3million —Woridwie deaths caused by TB peryeae™ 4 $483,000— Average cost of NDRTB rrermene!" 130% —Tncreae in cartapenem resistant A. baumaan steans fom 1995-2008” + 30% - Quinolone resistance rate for Entracer™ {+ 700,000 A: gonnircaeinfctions i the US pes yea* #15.5%=HAL incidence rate in develpingcountris™ “There are many species of dangers grar-poitive ad gram-negative hacen A sampling of seme of the not po lematc pathogens and their mort alarming wisances are reviewed (Table 1). In the 1990 resistant gram postive bacteria rmatealized at « major trea with methicillin (MRSA) and ‘ancomycin (VRSA) resistant Staph aureas, VRE, pir ™ [B-tactam sesstnce in MRSA is pial due toexpresion of ‘the mad gene which encodes the low ainity penis bind ing protein (PBP 23):* ‘The gycopepides,wancompein (52) and rekoplanin (58) ace common testments for MRSA, however, resistance hat ‘ve developed towards them a wll. Vaneomin intermedi ae 5. aureus (VISA), which is aso usally insensitive ote planin (5), evolved a ess permeable cell wal tha taps these otic VISA ws fist isolted in 1996 Japan, bat has ‘nce been encountered globally? VRSA was fist reported {in 2002 ani fa es common Ie caused primarily by an azquied resistance fm the VRE ven gee, which alter the {erminal sequence of cell wall precursors, raking them poor substrates for vancomycin ($2) and teicoplanin (58) VISA find VRSA stuns are not tity opportunistic, making the ‘even more dangerous © Resistant Enterococci Tncluding VRE Resistant Ener ace primarily comprised of ewo species E. fais and. fam, both of which ae gram-positive, facultative anaerobic, opportusiaie pathogens. Entered! ave particulityeavizonmentally toler withthe ability to Withstand & wide ange of temperatures and pHs, aswell as thigh at conceneaion.® They ae also capable of cloning wide range of aes including the gut aki, and inasinae surfaces. Both have high eels of resistance rates (30-50%) agains the aminoglycosides gentamicin (28) and strepomy cin @4” £. facia s usually inherently resistant to lactam antbioccs als, making it paticuley dificult o teat when it develops vancomycin resistance, which it much more com ‘monly does than E faa” Te steepogramin combination, _quinupestin (69) dalfopistin (70) isan effective teatment {oc E.focinm, buts nective aginst Eisai Some VRE isolates express eaeronccalsurice protein, which allows fr the production of thicker more dg renin ills, Like VRSA, these trite make VRE common in Inealhcae-anocisted infections (HAL) and particlayin the oloniation ofinwelling medial device.” Vancomycin tse ‘ancein fact ncommon nthe US atin 2002, bower, ‘thi esitance ea les common in the BU. Though VRE it known to prodoe several reitance genes, the mos commen {oem of vancomycin resistance, as with VRSA, is ndz£ ‘Table 1. erg ctr rest Faculstve anaes acta pyeazentaes + Facute enaeobe ‘Hactans yooeptdesominglecndes ‘Seepteesceupreumenge + [Aerceerantanaeiode late. mscaices,qunoones ‘ction tee + Obit maeobe Jaca, uincores Imyeobactonum wowedosis + ‘aod Rares, urvlones,ainogycondes Escherichia coh Facuve anaerobe bata, uncles, ennoahcoses Peevdomones egioee Factiva enaerobe llsatesescept ptrnying Aenstnscer 5 Facute anaeobe ‘ilaeos Kieboe prewroniee 5 Facts anarobe lactams, guicones sninogheoedes Enisebecer : Faculte anaes ‘Hata qunlones Nicene gnoroese os ‘Hats cules ttacjelnes mac Streptacccas puenmoniae, §. preamaniae ix x gram postive, aerotaerant, anaerobic, opportunistic pathogen Iie ‘he lading cause of bacterial paeumonia, butt can also cause otitis moda, sinusitis, and meningitis among other patholo- sles Ichas a polysaccharide capsule chat makes it naturally resistant to phagocyte. I also produces hydrogen peroxide to ul ther bacteria." Approximately 4096 f trains ate ao lo ger susceptible to pencil, and is peniilia resistance often ‘onelates with resitances to macrolides, slfamies, oldet retrgyclines and eaiy generation cephalosporins.” Even absent Pelactam sesstance, macrolide resistances caused by pregulated efx encoded by mef or erm genes i increasing nS. pneumoniae.” Resistance to the third-generation for quinolone, levooracin (60), as also been observed recently.” ‘Though resistance ie a prevalent as in some other gram positive pathogens, the pathologies associated with S.prew- ‘moniae infection make the prospect of inceeased resistance ‘worth parculaeconsidertion. Catridinm dificil. C. df yasm-poiive, obi atcanarobi, spore forming opportunistic pathogen. Spores ace highly environmentally tolerant and are resistant vo hea, changes in pH, alcohol based hand sanitize, and many traditional clesning products that don't contain leach.” . dificil ca be community sequied, bu has particularly high ite of acquisition in hospital. Patients hospitalized for ‘over four wocks have an approximately 809% chance of son~ ttacting C dffie® I is probably best known for causing sntbioieaesciated diashea, This pathology results when C. dil is contacted and anciboves that ici resistant to kill ll other bacteria in the gestrointstnal tract. This subsequently cases C. dice overgrowths as they spread to inhabit these now vacant niches. Ie produces an entero- toxin (toxin A) and a cytotoxin (tin B) which play» role nthe resultant symptoms and can lad to colitis a6 well ac threatening complications" Prophylactic cephalosporin ‘ue in sngeries has been linked to this condition and their ‘ie fortis purpose is nw restricted in certain a popslatons! In 2005 a hypersinlentsrin of faorguinalone resistant C. dfs emerged and quickly apresd across North America. As serious C. dif infections rately emerge ‘without the se of antibiotics, eliminating unnecessary usage Decones especially important with the advent of eeitant strains ofthis pathogen. ANew Wave of Resistant Gram Negative Infections “These gram-poriive threats ae stil widespread and destrac- tive, accounting fr the majority of bacteri-elated death in ‘the United State by a significant margin (Fig. 2)¢In recent eats, however, resistance rates have stabilized or decreed {or many of them, including MRSA and VRE, according to the European Antiocrobial Resistance Suvsllance Network (BARS-Net). Unfortunate, within the past te yeas, as santbioxic development has focused on these threats drog Tesistant tuberculosis and a wave of now gram-negative ‘tens just as perilous as their gramm-posive counterparts Ihave evolved. At least one analysis as suggested that the resistant gram-negtives may not be even more costly then gram-positive, MRSA included." Also, ina European survey 2 compilation of some of the most commen gram-negative infctions were found t slightly aurmumber common gram positive infections In some ways the new resistant gam- negative pathogens are even more worrying, a their more Aiicol to penetrate outer membranes and higher prevalence ‘of efflux pumps make them naturally resistant to many atibi- ‘otes Cashapenem resistant gram negative stins, partial Ennrehaseracue (CRE), ae becoming increasingly common place. The main gram-negative threats are molt (MDR) snd pan- (PDR) drug resistant Eerie el, Peudemonas scrapie, Acmeobacter, Kila pneumoniae, Enerebacter, tnd most recently Nezeragonorhoe Mycobacterium rubeculsis (MDR-TB and XDR-TB). Mycobacterium tbercatads ea highly exbic, pathogenic bac terium that isthe main cause of tuberelors (TB). Thogh it doesnt rypially gram stsin because of a high iid content PEREPECTIVES IN MEDICINAL CHEMIsTAY 2186 | 28