CARBAPENEMS

BY

OLUDE YINKA FLORENCE

HSLT/20/0023

A SEMINAR WRITE-UP SUBMITTED TO

DEPARTMENT OF SCIENCE LABORATORY TECHNOLOGY

D.S ADEGBENRO ICT POLYTECHNIC, ERUKU-ITORI, EWEKORO, OGUN STATE

IN PARTIAL FULFILMENT OF THE AWARD OF HIGHER NATIONAL DIPLOMA IN

SCIENCE LABORATORY TECHNOLOGY

(MICROBIOLOGY OPTION)

MARCH, 2022

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 CERTIFICATION

This is to certify that this seminar report was written by OLUDE YINKA FLORENCE with

Matriculation Number HSLT/20/0023 of the department of Science Laboratory Technology

(Microbiology Option), D.S Adegbenro ICT Polytechnic, Itori-Ewekoro.

Mrs. Olugbenga O.M

(Supervisor) Signature & Date

Mr. ADELOYE, M.O.

(HOD, SLT) Signature & Date

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 ACKNOWLEDGEMENTS

First of all, I am indebted to the GOD Almighty for giving me an opportunity to excel in my efforts

to complete this seminar on time.

I appreciate my Supervisor, Mrs. Olugbenga O.M for all her efforts in guiding me through the art of

writing this seminar report. I also acknowledge the H.O.D, Mr Adeloye for His sacrifices in ensuring

the we become the best. Thank you, Sir. I appreciate all the lecturers of the department for impacting

me throughout my programme.

Special thanks to my parents, I am really proud of them for their unrelented effort, guidance and

counseling.

Thank you all.

OLUDE YINKA FLORENCE

HSLT/20/0023

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 TABLE OF CONTENTS

Title page i

Certification ii

Acknowledgement iii

Table of content iv

CHAPTER ONE

1.1 Introduction 1

CHAPTER TWO

2.1 Beta lactams 3

2.1.1 Mechanism of Resistance 4

2.1.2 Mechanism of Action 9

2.2 History of Carbepenems 9

2.3 Structure of Carbapenem 12

2.4 Types of Carbapenems  12

2.5 Classification of Carbapenemases 15

2.6 Carbapenems: Chemistry and Biology 16

2.7 Microbiological activity 16

2.8 Pharmacology and clinical use. 17

2.9 Safety and tolerability 18

2.10 Structure-function: considerations among carbapenemases 18

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CHAPTER THREE

3.1 Mechanism of Action 23

3.2 Applications of Carbapenem 23

3.3 Mechanisms of Resistance against Carbapenems 24

3.4 Carbapenems Medication 26

3.5 Restrictions and warnings 27

3.6 Common Carbapenems side effects 28

CHAPTER FOUR

4.1 Conclusion 31

References 34-42

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 CHAPTER ONE

1.0 Introduction

Carbapenems play a critically important role in our antibiotic armamentarium. Of the many hundreds

of different lactams, carbapenems possess the broadest spectrum of activity and greatest potency

against Gram-positive and Gram-negative bacteria. As a result, they are often used as “last-line

agents” or “antibiotics of last resort” when patients with infections become gravely ill or are suspected

of harboring resistant bacteria (Bradley et al, 1999). Unfortunately, the recent emergence of

multidrug-resistant (MDR) pathogens seriously threatens this class of lifesaving drugs (Queenan and

Bush, 2007). Several recent studies clearly show that resistance to carbapenems is increasing

throughout the world (Chouchani et al, 2011). Despite this menacing trend, our understanding of how

to best use these agents is undergoing a renaissance, especially concerning their role with regard to

lactamase inhibition. In this context, we view the number, type, and diversity of carbapenems as

compelling reasons to explore these compounds for new insights into drug development.

Beta-lactams are by far the most used antibiotics worldwide and include the penicillins,

cephalosporins, monobactams and carbapenems. They all share a common beta-lactam ring and act

similarly by binding to and inactivating the penicillin-binding proteins (PBPs), which are responsible

for the formation of the bacterial cell wall.

Carbapenems, among the beta-lactams, are the most effective against Gram-positive and

Gramnegative bacteria presenting a broad spectrum of antibacterial activity. Their unique molecular

structure is due to the presence of a carbapenem together with the beta-lactam ring. This combination

confers exceptional stability against most beta-lactamases (enzymes that inactivate betalactams)

including ampicillin and carbenicillin (AmpC) and the extended spectrum beta-lactamases (ESBLs).

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As they are highly effective against many bacterial species and less vulnerable to most beta-lactam

resistance determinants, carbapenems are considered to be the most reliable last-resort treatment for

bacterial infections. Furthermore, presenting fewer adverse effects, they are safer to use than other

last-line drugs such as the polymyxins. For these reasons, the emergence and rapid spread through all

continents of carbapenem resistance, mainly among Gram-negative bacteria, constitutes a global

public-healthcare problem of major importance.

Carbapenems are the important drugs in our antibiotic armamentarium. Of the various beta-lactams,

carbapenems exhibit the broadest spectrum of activity and greatest potency against Gram-positive and

Gramnegative bacteria (Abbanat et al, 2008).

They are often regarded as “lastline agents” or “antibiotics of last resort” in treatment of serious

infections (Akama et al, 2004). However, emergence of carbapenem resistant pathogens such as

carbapenem resistant Enterobacteriaceae (CRE), Acinetobacter baumannii and Pseudomonas

aeruginosa in infections such as hospital acquired infections has not only seriously threatened this

class of lifesaving drugs but also have posed a significant threat to public health (Albers-Schonberg et

al, 1976.). These resistant pathogens are difficult to treat and are associated with high mortality (Cole,

1980).

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 CHAPTER TWO

2.1. Beta lactams

Beta-lactam antibiotics are one of the most commonly prescribed drug classes with numerous clinical

indications. Their advent starting from the 30s of the twentieth century drastically changed the fight

against bacterial infectious diseases. Nowadays, it has been calculated that the annual expenditure for

these antibiotics amounts to approximately $15 billion USD, and it makes up 65% of the total

antibiotics market (Thakuria et al, 2013). Their use, however, clashes with the worrying phenomenon

of antimicrobial resistance remains, which represents a global health issue.

From a biochemical point of view, these drugs have a common feature, which is the 3-carbon and 1-

nitrogen ring (beta-lactam ring) that is highly reactive. This class includes:

 Penicillins. These antibiotics (most of which end in the suffix -cillin) contain a nucleus of 6-

animopenicillanic acid (lactam plus thiazolidine) ring and other ringside chains. The group

includes natural penicillins, beta-lactamase-resistant agents, aminopenicillins,

carboxypenicillins, and ureidopenicillins.

 Cephalosporins. They contain a 7-aminocephalosporanic acid nucleus and side-chain

containing 3, 6-dihydro-2 H-1,3- thiazane rings. Cephalosporins are traditionally divided into

five classes or generations, although acceptance of this terminology is not universal. 

 Carbapenems. Their defining structure is a carbapenem coupled to a beta-lactam ring that

confers protection against most beta-lactamases, although resistance to these compounds is a

significant issue and occurs mainly among gram-negative pathogens (e.g., Klebsiella

pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii), which produce

different classes of beta-lactamases termed as carbapenemase. 

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  Monobactams. The beta-lactam ring stands alone and not fused to another ring.

 Beta-lactamase inhibitors. They work primarily by inactivating serine beta-lactamases, which

are enzymes that hydrolyze and inactivate the beta-lactam ring (especially in gram-negative

bacteria). These agents include the first-generation beta-lactamase inhibitors (clavulanic acid,

sulbactam, and tazobactam) and the newer avibactam and vaborbactam that are active against

carbapenemase such as Klebsiella pneumoniae carbapenemase (KPC).

2.1.1 Mechanism of Resistance

Resistance to beta-lactams is an alarming and growing phenomenon and, in turn, a public health

challenge. It concerns, above all, Streptococcus pneumoniae and individual gram-negative bacilli such

as Pseudomonas aeruginosa. With emerging resistance for antibiotics, it makes sense to look into

mechanisms of resistance as it can help decide which drugs to prescribe in different scenarios and

ways to overcome the same. Although bacterial resistance to beta-lactams mostly expresses through

the production of beta-lactamases, other mechanisms are involved. Following are the mechanisms of

resistance (Ibrahim et al, 2019):

 Inactivation by the production of beta-lactamases 

 Decreased penetration to the target site (e.g., the resistance of Pseudomonas aeruginosa 

 Alteration of target site PBPs (e.g., penicillin resistance in pneumococci)

 Efflux from the periplasmic space through specific pumping mechanisms

Indications for Beta-Lactam Antibiotics

The indications for using the beta-lactam antibiotics are many and vary according to the subclass

considered (Probst-Kepper and Geginat, 2018)

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Penicillins

Natural penicillins [penicillin G (IV), penicillin V (PO)] are used to treat selected gram-positive and

gram-negative infections:

 Penicillin susceptible Streptococcus pneumonia and meningitis

 Streptococcal pharyngitis

 Endocarditis

 Skin and soft tissue infections

 Neisseria meningitides infections

 Syphilis

Beta-lactamase-resistant Agents

These agents [oxacillin (IV), nafcillin (IV), dicloxacillin (PO)] are active against gram-positive

organisms. Despite the occurrence of widespread resistance among staphylococci, they remain

antibiotics of choice in managing methicillin-susceptible staphylococci (MSSA):

 Skin and soft tissue infections (MSSA)

 Serious infections due to MSSA

Aminopenicillins

These antibiotics have activity against gram-positive and gram-negative bacteria (e.g.,

many Enterobacteriaceae) anaerobic organisms. They are commonly used together with beta-

lactamase inhibitors.

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Amoxicillin (PO), ampicillin (PO/IV):

 Upper respiratory tract infections (sinusitis, pharyngitis, otitis media)

 Enterococcus faecalis infections

 Listeria infections

 Aminopenicillins/beta-lactamase inhibitors: amoxicillin/clavulanate (PO), ampicillin-

sulbactam (IV)

 Upper respiratory tract infections (sinusitis, otitis media)

 Intra-abdominal infections

Ureidopenicillins

Piperacillin (ureidopenicillin) has activity against aminopenicillin-resistant gram-negative bacilli

(Pseudomonas aeruginosa). They are commonly combined with beta-lactamase inhibitors.

Cephalosporins

First-generation cephalosporins

Cefazolin(IV), cephalexin (PO), cefadroxil (PO)

 Skin and soft tissue infections serious infections due to MSSA 

 Perioperative surgical prophylaxis

Second-generation cephalosporins

Cefuroxime (IV/PO), cefoxitin (IV), cefotetan (IV), cefaclor (PO) cefprozil (PO)

 Upper respiratory tract infections (sinusitis, otitis media)

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  Cefoxitin, cefotetan-gynecologic infections,

 perioperative surgical prophylaxis

Third-generation cephalosporins

Cefotaxime (IV), ceftriaxone (IV), cefpodoxime (PO), cefixime (PO), cefdinir (PO), cefditoren (PO),

ceftibuten (PO)

 Community-acquired pneumonia, meningitis

 Urinary tract infections

 Streptococcal endocarditis

 Gonorrhea

 Severe Lyme disease.

Anti-pseudomonal Cephalosporins

Ceftazidime (IV), ceftazidime/avibactam (IV), cefepime (IV) [Fourth-

generation], ceftolozone/tazobactam (IV) [also been described as "fifth-generation"]

 Nosocomial infections-pneumonia

 Meningitis

 Complicated Intra-Abdominal Infections (cIAI) [ceftazolone plus beta-lactamase inhibitor]

 Complicated Urinary Tract Infections (cUTI) [ceftazolone plus beta-lactamase inhibitor]

Anti-Methicillin-resistant Staphylococcus aureus (MRSA) cephalosporins

Ceftaroline (IV), ceftobiprole (IV) [Also been described as "fifth-generation"] 

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  Community-acquired pneumonia

 Hospital-acquired pneumonia (excluding ventilator-acquired pneumonia)

 Skin and soft tissue infection

Carbapenems

Imipenem/cilastatin (IV), meropenem (IV), doripenem (IV)

 Nosocomial infections-pneumonia, intra-abdominal infections, urinary tract infections

 Meningitis (especially meropenem)      

Ertapenem (IV)

 Community-acquired infections

 Nosocomial infections.

Monobactams

Aztreonam (IV). It is effective only against aerobic gram-negative organisms but shows no activity

against gram-positive bacteria or anaerobes.

 Nosocomial infections, e.g., pneumonia

 Urinary tract infections    

Because the emergence of antimicrobial resistance has become a progressively great concern, new

beta-lactam and beta-lactamase inhibitor combinations (ceftolozane/tazobactam,

ceftazidime/avibactam, meropenem/vaborbactam, imipenem/cilastatin/relebactam,

aztreonam/avibactam), siderophore-conjugated cephalosporins (cefiderocol), and siderophore-

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conjugated monobactams have been developed and represent options for the management of

complicated infections, especially in the intensive care unit (Leone et al, 2019).

2.1.2 Mechanism of Action

Peptidoglycan or murein is a vital constituent of the bacterial cell wall that provides mechanical

stability to it. It is an extremely conserved constituent of both the gram-positive and gram-negative

envelopes. Nevertheless, peptidoglycan is a thick structure in gram-positive bacteria (≥10 layers),

while it is thin (one or two layers) in gram-negative ones. Concerning its structure, peptidoglycan is

composed of glycan chains made of N-acetylglucosamine and N-acetylmuramic acid disaccharide

subunits; the N-acetylmuramic part is linked to highly conserved pentapeptide or tetrapeptide stems (l-

alanine–d-isoglutamine–l-lysine–d-alanine–[d-alanine].

The beta-lactam antibiotics inhibit the last step in peptidoglycan synthesis by acylating the

transpeptidase involved in cross-linking peptides to form peptidoglycan. The targets for the actions of

beta-lactam antibiotics are known as penicillin-binding proteins (PBPs). This binding, in turn,

interrupts the terminal transpeptidation process and induces loss of viability and lysis, also through

autolytic processes within the bacterial cell (Eckburg, 2019)

2.2 History of Carbepenems

In the late 1960s, as bacterial-lactamases emerged and threatened the use of penicillin, the

search for-lactamase inhibitors began in earnest (Cole,1980). By 1976, the First-B-lactamase

inhibitors were discovered; these olivanic acids were natural products produced by the Gram-positive

bacterium Streptomyces clavuligerus. Olivanic acids possess a “carbapenem backbone” (a carbon at

the 1position, substituents at C-2, a C-6 ethoxy, andsp2-hybridizedC-3) and act as broad-spectrum-

lactams (Brown et al, 1976). Due to chemical instability and poor penetration into the bacterial cell,

the olivanic acids were not further pursued (Reading and Farmer. 1984). Shortly thereafter, two
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superior-lactamase inhibitors were discovered: (i) clavulanic acid (compound 2) from S. clavuligerus,

the first clinically available-lactamase inhibitor (Brown et al, 1976), and (ii)thienamycin (compound 3)

from Streptomyces cattleya (Albers-Schonberg et al, 1976). Thienamycin was the first “carbapenem”

and would eventually serve as the parent or model compound for all carbapenems. A series of other

carbapenems were also identified (Cassidy et al, 1981); however, the discovery of thienamycin was

paramount. The term “carbapenem” is defined as the 4:5 fused ring lactam of penicillins with a

double bond between C-2 and C-3 but with the substitution of carbon for sulfur at C-1. The

hydroxyethyl side chain of thienamycin is a radical departure from the structure of conventional

penicillins and cephalo-sporins, all of which have an acylamino substituent on the B-lactam ring; the

stereochemistry of this hydroxyethyl side chain is a key attribute of carbapenems and is important

foractivity (Kahan et al, 1979). Remarkably, thienamycin demonstrated potent broad-spectrum

antibacterial and-lactamase inhibitory activity (Kropp et al, 1976). This notable discovery was first

reported at the 16th Inter science Conference on Antimicrobial Agents and Chemotherapy (ICAAC)

meeting in 1976 (Kropp et al, 1976). Although thienamycin is a “natural product” and the biosynthetic

pathway was determined, yields from the purification process were low. With time, the synthetic prep-

aration of thienamycin assumed greater importance, especially as a key derivative, imipenem

(compound 4), was discovered.

Like other B-lactams, thienamycin bound to penicillin binding proteins (PBPs) (Kotsakis et al, 2010).

With time, enthusiasm for this com pound grew rapidly, since thienamycin displayed inhibitory

microbiological activity against Gram-negative bacteria, including isolates of Pseudomonas

aeruginosa, as well as anaerobes, like Bacteroides fragilis, and Gram-positive bacteria, such as

methicillin- or oxacillin-susceptible Staphylococcus aureus and streptococci (Fainstein et al, 1982).

Unfortunately, thienamycin was found to be unstable in aqueous solution, sensitive to mild base

hydrolysis (above pH8.0), and highly reactive to nucleophiles, such as hydroxyl-amine, cysteine, and
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even thienamycin’s own primary amine. The chemical instability of thienamycin stimulated the search

for analogous derivatives with increased stability. Due to the continued evolution of cephalosporin-

resistant Gram-negative and Gram-positive pathogens, compounds derived from thienamycin were

anticipated to have even greater value with time. The first developed was the N-formimidoyl

derivative, imipenem (Kang et al, 2003). Imipenem and a closely related carbapenem, panipenem

(compound 5), identified later, were more-stable derivatives of thienamycin and less sensitive to

base hydrolysis in solution. In 1985, imipenem (originally called MK0787) became the first

carbapenem available for the treatment of complex microbial infections. Imipenem, like its parent,

thienamycin, demonstrated high affinity for PBPs and stability against B-lactamases (Hashizume et al,

1984). However, both imipenem and panipenem were susceptible to deactivation by dehydropepti-

dase I (DHP-I), found in the human renal brush border (Graham et al, 1987). Therefore, co-

administration with an inhibitor, cilas-tatin (compound 6) or betamipron (compound 7), was necessary

(Norrby et al, 1983). Along the journey to the discovery of more stable carbapenems with a broader

spectrum, the other currently available compounds, meropenem, biapenem, ertapenem and doripenem

(compounds 8 to 11), were developed, and several novel carbapenems were also identified

(Hashihayata et al, 2001). A major advance in this “synthetic journey” was the addition of a methyl

group to the1-position. This modification was found to be protective against DHP-I hydrolysis.

Several carbapenems were identified with this modification in the subsequent 2 decades; many were

similar to the currently available carbapenems, having a 1—methyl and a pyrrolidine ring at C-2.

These novel carbapenems included antipseudomonal carbapenems, anti-methicillin-resistant

Staphylococcus aureus (MRSA) carbapenems (i.e., cationic and dithiocarbamate carbapenems), orally

available carbapenems, trinem carbapenems, a dual quinolo-nyl-carbapenem, and others.

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2.2 Structure of Carbapenem

Structurally, carbapenems are similar to the penicillins (penams), but the sulfur atom in position 1 of

the structure of penicillin has been replaced with a carbon atom.1 Thus, their bicyclic core consists of

a beta-lactam ring fused to a pyrroline ring (Figure 1). Combination of these two rings confers

exceptional stability against most beta-lactamases (enzymes that inactivate beta-lactams) including

ampicillin and carbenicillin (Amp C) and the extended spectrum beta-lactamases (ESBLs) (Meletis,

2016)

Figure 1: Structure of carbapenem.

2.3 Types of carbapenems 

Group 1 carbapenem

Invanz (ertapenem) is known as a group 1 carbapenem. It is the only group 1 carbapenem and has

a broad spectrum of activity against pathogens, including:

 Enterobacteriaceae (Enterobacter)

 Escherichia coli (E. coli)

 Haemophilus

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  Moraxella

 Neisseria

 Klebsiella pneumoniae

 Staphylococcus aureus (methicillin-susceptible)

 Streptococcus pneumoniae (penicillin-susceptible or penicillin-resistant) 

 Streptococcus pyogenes

 Viridans group streptococci

 Bacteroides

 Clostridium difficile

 Eubacterium

 Fusobacterium

 Peptostreptococcus

Invanz has limited activity against certain Gram-negative bacilli such as Pseudomonas aeruginosa (P.

aeruginosa). This medication is more suitable for community-acquired infections, meaning an

infection acquired in the community, outside of a healthcare or hospital setting. 

Group 2 carbapenems 

Carbapenems that contain imipenem (Primaxin and Recarbrio) or meropenem (Merrem and

Vabomere) are known as group 2 carbapenems. They also have a broad spectrum of

activity against pathogens, including:

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 Acinetobacter

 Enterobacteriaceae

 Escherichia coli (E. coli)

 Haemophilus

 Klebsiella pneumoniae

 Moraxella

 Neisseria

 Pseudomonas aeruginosa

 Listeria

 Staphylococcus aureus (methicillin-susceptible)

 Streptococcus pneumoniae (penicillin-susceptible and penicillin-resistant)

 Streptococcus pyogenes

 Viridans group streptococci

 Bacteroides

 Clostridium difficile

 Eubacterium

 Fusobacterium

 Peptostreptococcus

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  Propionibacterium

Group 2 carbapenems have better coverage of Gram-negative bacteria. They are especially useful in

treating nosocomial infections, which are infections acquired in a healthcare or hospital setting. 

2.4 Classification of carbapenemases

Carbapenemases are the β-lactamases with the widest spectrum of activity in general. In addition to

carbapenems, carbapenemases also hydrolyze most other members of the β-lactam family with a few

exceptions. On the basis of their molecular structure, carbapenemases are classified into Ambler’s

class A, B, or D enzymes (Basker, 1982). The plasmid-borne, class A Klebsiella pneumoniae

carbapenemases (KPCs) are currently the most prevalent and widely distributed carbapenemases

(Balke et al, 2006). Detection of KPC-producing organisms in microbiology laboratories is not always

straightforward because some isolates display minimum inhibitory concentrations (MICs) against

imipenem or meropenem that remain in the susceptible range. In vitro studies have suggested that

ertapenem is the most sensitive carbapenem substrate for detection of KPC production (Bassetti et al,

2009). Other clinically important carbapenemases include the class B metallo-β-lactamases (MBLs;

e.g., NDMs, IMPs, VIMs) and the class D OXA-type carbapenemases (e.g., OXA-23 in A. baumannii

and OXA-48 in K. pneumoniae). The latter group is unique in that they hydrolyze penicillins and

carbapenems but not cephalosporins. These carbapenemase genes are borne on plasmids, which can

facilitate their intra- and interspecies dissemination. Besides carbapenemase production, these

organisms may exhibit additional carbapenem resistance mechanisms, such as augmentation of efflux

pumps and porin loss that can further elevate carbapenem MICs (Bebrone, 2007).

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2.5 Carbapenems: Chemistry and Biology

Chemistry. From the studies conducted on the early carbapenems, the carbon atom at the C-1 position

was found to play a major role in the potency and spectrum of carbapenems and in their stability

against B-lactamases. We have also since learned that a strategically positioned hydroxyethyl R2 side

chain aids in resistance to hydrolysis by B-lactamases (Moellering et al., 1989). In addition,

carbapenems with an R configuration at C-8 are also very potent (Fig. 2E). The trans configuration of

the B-lactam ring at C-5 and C-6 results in stability against B-lactamases (Basker et al, 1981). Like

thienamycin, the clinically available carbapenems are R at C-8 and trans about the C-5OC-6 bond.

Carbapenems with a pyrrolidine moiety (panipenem, meropenem, ertapenem, and doripenem) among

various cyclic amines as a side chain have a broader antimicrobial spectrum.

Synthesis. As mentioned above, several chemical approaches were developed for the synthesis of

carbapenems since fermentation was not an efficient method for production (Cama and Christensen,

1978). Natural products (L-Cys, L-Val, L-- amino adipic acid, and S-adenosyl-Met) were often used as

starting material for production of carbapenems, and the synthetic approach was largely influenced by

the desired stereochemistry of the final compound. In addition, once a carbapenem is developed which

has an R configuration at C-8, is trans about the C-5OC-6 bond, and has a methyl at C-1 and a

hydroxyethyl at C-6, most modifications are at the R1 side chain (at position C-2). Thus, carbapenems

are unique compared to other B-lactams, which tend differ in both R1 and R2 side chains. The reader

is referred to R. B. Woodward’s classical discourse on this matter (Cartwright and Waley, 1983).

2.6 Microbiological activity

Carbapenems demonstrate an overall broader antimicrobial spectrum in vitro than the available

penicillins, cephalosporins, and B-lactam/B-lactamase inhibitor combinations (Bassetti et al, 2009). In

general, imipenem, panipenem, and doripenem are potent antibiotics against Gram-positive bacteria

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(Bassetti et al, 2009). Meropenem, biapenem, ertapenem, and doripenem are slightly more effective

against Gram-negative organisms (Cottagnoud et al, 2003). Important considerations here are the

following: (i) ertapenem has a more limited spectrum, because it is not as active as imipenem or

meropenem against P. aeruginosa; (ii) meropenem is not as potent as imipenem or doripenem against

Acinetobacter baumannii; (iii) doripenem has lower MICs than do imipenem and meropenem versus

P. aeruginosa and A. baumannii. In addition, doripenem is the carbapenem least susceptible to

hydrolysis by carbapenemases; hydrolysis of doripenem is 2- to 150-fold slower than that of

imipenem; (iv) a unique application of meropenem is that when combined with clavulanic acid, it is

potent at killing MDR Mycobacterium tuberculosis, a bacterium that typically is not susceptible to -

lactams due to a chromosomally expressed -lactamase. This ability to inhibit or kill M. tuberculosis is

likely to be a property of other carbapenems as research in this area grows. Carbapenems can also be

combined with other antimicrobials to treat serious infections. Combination therapy is a subject of

intense interest, since the emergence of MDR pathogens often requires us to treat patients with more

than one antibiotic (Balke et al, 2006). A list of the antibiotic combinations which have been tested in

vitro against common MDR organisms and their effects is presented. Some combinations demonstrate

positive effects, such as extending the spectrum or working additively or synergistically. Adverse

effects include increased resistance to one of the drugs used in the combination, as well as a lack of

synergy or additivity and strain dependence. A full debate on the benefits and drawbacks of

combination therapy with carbapenems is beyond the scope of this review.

2.7 Pharmacology and clinical use.

Several detailed reviews of the pharmacology of clinically available carbapenems exist (Kaloyanides,

1994). Briefly, all clinically available carbapenems have low oral bioavailability and thus do not cross

gastrointestinal membranes readily and must be administered intravenously; imipenem-cilastatin and

ertapenem can also be delivered intramuscularly (Goa and Noble, 2003). As with other -lactams, all of

17
these carbapenems are eliminated predominately by renal excretion. Carbapenems exhibit unique

pharmacological properties and are typically used to treat complicated bacterial infections. A

carbapenem is often combined with an antibiotic that targets Gram-positive bacteria when used for the

empirical treatment of patients with serious nosocomial infections of unidentified origin.

2.8 Safety and tolerability

Nephrotoxicity, neurotoxicity, and immune modulation have been reported with the use of

carbapenems, and thus predisposing factors should be considered when administering any carbapenem

(Cunha et al, 2008). In addition, the use of carbapenems can alter the intestinal microflora and select

for carbapenem-resistant isolates (Lee et al, 2004).

2.9 Structure-function: considerations among carbapenemases.

Several class A carbapenemase B-lactamases (i.e., KPC-2, SME-1, and NmcA) have been crystallized

(Ke et al., 2007). These enzymes possess a distinctive set of active-site residues that are suspected to

be involved in the hydrolysis of carbapenems. We will review here their important features.

A unique attribute of class A carbapenemases (i.e., KPC, SME, and NmcA) is the presence of a

disulfide bond between Cys69 and Cys238 (Ambler numbering system) (Ambler et al, 1991); this

bond changes the overall shape of the active site by altering the distance between active-site residues.

The distance between Ser70 and Thr237 is less, the length of the active site is decreased as indicated

by the distance between Glu166 and Thr237, and the space between Asn132 and Asn170 is increased

in comparison to SHV-1 and TEM-1. In addition, several active-site residues have different amino

acids in comparison to SHV-1 and TEM-1 (e.g., Thr/Ser237, His/Trp105, Arg220, and Glu276). These

significant structural changes decrease the steric hindrance caused by the C-6 hydroxyethyl side chain

of carbapenems, which is a key determinant in inhibition of noncarbapenemase class A B-lactamases

and allows class A carbapenemases to hydrolyze imipenem with kcat values (turnover rates) from 10 to
18
1,000 s1. Mutagenesis studies of the SME-1 and KPC-2 B-lactamases have revealed several sites that

may be necessary for carbapenem resistance (Majiduddin et al, 2005). However, the finding of a single

residue responsible for carbapenem resistance remains elusive.

GES-2 is unique to the class A carbapenemase family because a single amino acid substitution

(Gly170Asn) changes GES-1, which is an extended-spectrum B-lactamase (ESBL), into a

carbapenemase. GES-2 has a very low kcat for imipenem of ~0.01 s1. The Gly170Asn substitution is

found in the loop of GES-2. Molecular modeling studies with imipenem and the in silico-generated

GES-2 suggest that the shape of the active site accommodates the hydroxyethyl moiety Louie, A., et

al. 2010). In addition, Asn170 interacts with the predicted hydrolytic water molecule. Another

mutation at Gly170 to Ser (mimicking GES-5) results in increased carbapenemase activity in

comparison to that of GES-2; GES-5 exhibits a kcat for imipenem of 0.5 s1 (Lee et al, 2004). Initial

molecular modeling studies suggest that imipenem is bound in a similar manner in GES-5 and GES-1,

not explaining the increase in kcat (Lepelletier et al, 2010). Examining the microscopic rate constants

for imipenem with GES-1, -2, and -5 reveals that the rate-limiting step for GES-1 and GES-2 is

acylation (Lee et al, 2004). The rate of acylation for imipenem is enhanced by 5,000-fold for GES-5

and is no longer rate limiting. Deacylation is also enhanced in GES-5 but becomes the rate-limiting

step in imipenem hydrolysis. Further molecular modeling studies with GES B-lactamases have

disclosed the importance of the movement of Trp105 to the interior of the active site, which may alter

the acylation rates (Lee et al, 2005).

Class B B-lactamases require one or two Zn 2+ cations for activity and are subdivided into three groups,

B1, B2, and B3, based on sequence alignments and structural analysis (Livermore et al, 2011). All

three groups hydrolyze carbapenems (kcat for imipenem of 2 to 1,000 s1), but B-lactamases in group

B2 are strictly carbapenemases. B1 and B3 enzymes typically exhibit maximum activity when bound

19
by two Zn2+ ions. Conversely, B2 B-lactamases function as mono- Zn2+ enzymes, and binding of

another Zn2+ decreases activity.

The CphA B-lactamase is a strict carbapenemase of subclass B2. CphA has been crystallized with one

Zn2+ ion, two Zn2+ ions, and a biapenem intermediate trapped in the active site (Lepelletier et al, 2010).

Previously, the second inhibitory Zn2+ binding site was postulated to be remote from the active site

(Fonseca et al, 2011). However, the dizinc crystal structure of CphA reveals that this Zn 2+ sits in the

second Zn2+ binding site, similar to the case with subclass B1 and B3 metallo-- lactamases (Force, E.,

et al. 2009). Quantum mechanics and molecular mechanics have been used to dissect the mechanism

of carbapenem turnover by CphA. A mechanism is presented in Fig. 5A and is predicted to occur in a

single step. In this mechanism, His118 is the general base that coordinates a water molecule with

Asp120; this water serves as the nucleophile for B-lactam bond cleavage. Asp120, Cys221, and

His263 coordinate Zn2+ along with a water molecule, which also hydrogen bonds to the carboxylate of

carbapenems. This second water molecule donates a proton to B-lactam nitrogen to complete the

hydrolysis event. Zn2+ anchors the critical deacylation water molecule and stabilizes the complex.

In contrast, with subclass B1 and B3 di- Zn 2+ metallo-B- lactamases, one Zn2+ atom decreases the pKa

of the water molecule to generate a hydroxyl nucleophile for the attack of the B-lactam, while the

other Zn2+ stabilizes the tetrahedral intermediate. A recent study reveals a common catalytic feature of

mono- Zn2+ and di-Zn2+ metallo-B-lactamases using GOB-18, a member of the B3 metallo--

lactamases. This enzyme is fully active with only one Zn2+ bound. Studies to date indicate that only

one Zn2+ is essential for GOB-18 and its role is to anchor the substrate and stabilize the anionic

intermediate and not for nucleophile activation (Fig. 5C). A critical feature of the mono- Zn 2+

mechanism in GOB-18 is the positioning of the Zn2+ atom in the active site.

20
Class C -lactamases are not generally classified as carbapenemases. Most enzymes in this class have

weak activity toward carbapenems (kcat 4 s1) if any activity at all (Hirakata et al, 2009). So when an

AmpC enzyme is found in a strain with other resistance mechanisms, resistance toward carbapenems

may be enhanced. Curiously, rare class C enzymes that can confer resistance to imipenem are

described (Kim et al, 2006). The preeminent candidate enzyme with this altered substrate profile is

CMY-10 (Kim et al, 2006). Here, a three-amino-acid deletion in the R2 loop (near residue 303)

significantly widens part of the active site, which accommodates the R2 side chains of carbapenems.

The same deletion in P99 results in an enzyme with a similar phenotype. Consequently, the opening of

the R2 loop of the active site by the deletion of some residues in the R2 loop can be considered an

operative molecular strategy of class C B-lactamases to extend their substrate spectrum.

Hydrolysis of B-lactams by class D B-lactamases differs from that of class A and C enzymes. OXA

enzymes are a very heterogeneous population of B-lactamases that have evolved through multiple

mechanisms; their kcats for imipenem are 5 s 1. The structures of two OXA B-lactamases reveal two

different enzyme architectures; in addition, the two enzymes have different substrate specificities for

carbapenems.

The crystal structures of two deacylation-deficient variants (Lys84Asp and Val130Asp) of the

carbapenemase OXA-24/40 in complex with doripenem were recently determined (Kang et al, 1999).

The goal of this work was to investigate if the tautomeric state of the pyrroline ring contributes to the

different carbapenem hydrolysis rates of OXA-1 and OXA-24/40. In these structures, doripenem’s

conformation in the active site differs significantly from that in the OXA-1/doripenem complex. In the

doripenem structures of OXA-24/40, the hydroxyl side chain of the hydroxyethyl group is directed

away from the general base carboxy-Lys84 (different numbering from that of OXA-1).

21
22
 CHAPTER THREE

3.1 Mechanism of Action

Carbapenem antibiotics work by attaching to penicillin-binding proteins (PBPs) and preventing

bacteria from forming a cell wall. Preventing cell wall synthesis makes the bacteria die.

Because carbapenem antibiotics are similar in structure to penicillin antibiotics, people who are

allergic to penicillin antibiotics may be allergic to carbapenems (Bradley et al, 1999). 

As a class of B-lactams, carbapenems are not easily diffusible through the bacterial cell wall

(Martinez-Martinez, 2008). Generally speaking, carbapenems enter Gram-negative bacteria through

outer membrane proteins (OMPs), also known as porins. After transversing the periplasmic space,

carbapenems “permanently” acylate the PBPs (Hashizume et al, 194). PBPs are enzymes (i.e.,

transglycolases, transpeptidases, and carboxypeptidases) that catalyze the formation of peptidoglycan

in the cell wall of bacteria. Current insights into this process suggest that the glycan backbone forms a

right-handed helix with a periodicity of three per turn of the helix (Kropp, 1976). Carbapenems act as

mechanism-based inhibitors of the peptidase domain of PBPs and can inhibit peptide cross linking as

well as other peptidase reactions. A key factor of the efficacy of carbapenems is their ability to bind to

multiple different PBPs (Hikida et al, 1999). Since cell wall formation is a dynamic “three-

dimensional process” with formation and autolysis occurring at the same time, when PBPs are

inhibited, autolysis continues. Eventually the peptidoglycan weakens, and the cell bursts due to

osmotic pressure.

3.2 Applications of Carbapenems

Carbapenems can be used for various Gram-positive and Gram-negative aerobic (aerobes) and

anaerobic bacteria (anaerobes). Refer to each monograph for specific indications. General indications

for carbapenems include:
23
  Complicated intra-abdominal infections 

 Complicated skin and skin structure infections 

 Bone and joint infections

 Endocarditis 

 Community-acquired pneumonia 

 Lower respiratory tract infections

 Complicated urinary tract infections, including pyelonephritis

 Acute pelvic infections/gynecologic infections

 Bacterial meningitis

 Bacterial septicemia

 Hospital-acquired bacterial pneumonia 

 Ventilator-associated bacterial pneumonia 

 Prevention of surgical site infection after elective colorectal surgery

3.3 Mechanisms of Resistance against Carbapenems

Many non-fermenting Gram-negative bacteria (e.g., Pseudomonas spp., Acinetobacter spp., and

Stenotrophomonas spp.), as well as the Enterobacteriaceae (e.g., Klebsiella spp., Escherichia coli, and

Enterobacter spp.) and Gram-positive bacteria (e.g., Staphylococcus spp., Streptococcus spp.,

Enterococcus spp., and Nocardia spp.), are or are becoming resistant to most clinically available

carbapenems. This distressing pattern poses a major public health threat.

24
Mechanisms of resistance to carbapenems include production of b-lactamases, efflux pumps, and

mutations that alter the expression and/or function of porins and PBPs (Fig. 4). Combinations of these

mechanisms can cause high levels of resistance to carbapenems in certain bacterial species, such as

Klebsiella pneumoniae, P. aeruginosa, and A. baumannii (Limansky et al, 2004).

A distinction exists between resistance to carbapenems in Gram-positive cocci and Gram-negative

rods. In Gram-positive cocci, carbapenem resistance is typically the result of substitutions in amino

acid sequences of PBPs or acquisition/production of a new carbapenem-resistant PBP (Katayama et

al., 2004). Expression of -lactamases and efflux pumps, as well as porin loss and alterations in PBP,

are all associated with carbapenem resistance in Gram-negative rods (Nordmann et al, 2011). The

mechanism that has been investigated in the most detail is the production of B-lactamases, and thus it

is discussed in greater detail here than the other mechanisms of resistance.

B -Lactamases. B -Lactamases are a major antibiotic resistance mechanism employed by bacteria;

these periplasmic enzymes hydrolyze B-lactam antibiotics, preventing the drug from reaching the PBP

target. Presently, B-lactamases are classified into four distinct classes based on structural similarities

(classes A, B, C, and D) or four groups based on hydrolytic and inhibitor profiles (1 to 4) (Ambler et

al, 1991). Class B B-lactamases use Zn2+ to inactivate B -lactams, and all are carbapenemases. Class

A, C, and D B -lactamases use a serine as a nucleophile to hydrolyze the B -lactam bond.

Carbapenemases are specific B-lactamases with the ability to hydrolyze carbapenems. Production of

B-lactamases appears to be the most widespread cause of carbapenem resistance, since the

documentation of their distribution in different bacterial species is extensive (Fernandez-Cuenca et al,

2003). An increasing number of class A carbapenemases (e.g., KPC and GES enzymes), class B

metallo-B-lactamases (e.g., VIM, IMP, and NDM B-lactamases), and class D carbapenemases (e.g.,

OXA-23, 24/40, 48, 51, 55, 58, and 143) have recently emerged (Farra et al, 2004). In addition,

25
overproduction of class C B-lactamases, such as CMY-10 and PDC B-lactamases, which are not

robust carbapenemases, can lead to carbapenem resistance, especially when combined with other resis

tance mechanisms (e.g., porin loss).

3.4 Carbapenems Medication

Only the healthcare provider can determine if a carbapenem is safe and appropriate for use. Before

a carbapenem is ordered, the healthcare provider will review medical history and medical conditions,

and other medications the patient is taking to ensure that the carbapenem will be safe and appropriate

to use (Majiduddin et al, 2005). 

Men 

Men can take a carbapenem, provided they have a bacterial infection that is proven or strongly

suspected to be susceptible to a carbapenem and that the patient does not have any contraindications

for use. 

Women 

Women who are not pregnant or breastfeeding can take a carbapenem if they have a bacterial

infection that is proven or suspected to be susceptible to a carbapenem. The patient also must not have

any contraindications for the use of a carbapenem. 

Women who are pregnant or breastfeeding

Women who are pregnant or suspect they are pregnant, or breastfeeding, should consult

their healthcare provider before use of a carbapenem. With Invanz and meropenem, there is not

enough clinical trial data on pregnant women. In Primaxin animal studies, there were instances of

death in both the mother and fetus. Recarbrio animal studies showed harm to the fetus (abnormalities)

as well as loss of the fetus. Vabomere animal studies also concluded that there was harm to the fetus. 
26
Regarding breastfeeding, carbapenems are present or may be present in human milk, but the effects

are not known.  

Children 

Carbapenems may be used in children, except for Recarbrio and Vabomere. 

 Invanz and meropenem are indicated in children 3 months of age and older. 

 Primaxin may be used in children 3 months and older and is sometimes used in neonates.

However, Primaxin is not recommended for use in children with central nervous system (CNS)

infections because seizures may occur. Primaxin should not be used in children who weigh less

than 30 kg and have kidney problems. 

 Recarbrio and Vabomere have not been studied in children younger than 18 years old and are

not recommended for use in this age group. 

Seniors

In clinical studies, carbapenems had similar safety and efficacy in patients regardless of age, but the

prescribing information for carbapenems states that “greater sensitivity of some older individuals

cannot be ruled out.” Carbapenems are processed through the kidneys, so people with kidney problems

have a higher risk for toxic reactions to carbapenems. Since older adults are more likely to have

reduced kidney function, the healthcare provider may choose a lower dose and monitor kidney

function while the patient takes a carbapenem (Lee et al, 2004). 

3.5 Restrictions and warnings

 Patients who are hypersensitive or have had an anaphylactic reaction to a beta-lactam

antibiotic (such as Augmentin, amoxicillin, or cephalexin) should not take a carbapenem.

27
  Serious allergic reactions may occur. Patients who have symptoms of an allergic reaction, such

as hives, difficulty breathing, or facial swelling, should get medical help right away.

 Patients should be monitored for seizures and other central nervous system (CNS) effects such

as tremors. These events are more likely to occur in patients with a history of CNS disorders.

 Carbapenems interact with the anticonvulsants valproic acid and divalproex sodium, lowering

the absorption of the anticonvulsants. This could potentially increase the risk of seizures. The

combination of drugs is generally not recommended—another antimicrobial drug should be

used if possible.

 Antibiotic-associated diarrhea (Clostridioides difficile-associated diarrhea) may occur.

Symptoms may range from mild diarrhea to fatal colitis.

 Severe skin reactions have occurred with some carbapenems. These reactions include Stevens-

Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug reaction with eosinophilia

and systemic symptoms (DRESS), erythema multiforme (EM), and acute generalized

exanthematous pustulosis (AGEP).

 In some cases, patients with kidney problems have experienced low platelet levels

(thrombocytopenia).

3.6 Common carbapenems side effects

In general, the most common side effects associated with the use of carbapenems include:

 Stomach problems: nausea, vomiting, diarrhea or constipation, stomach pain

 Infusion site reaction

 Headache 

28
  Fever

 Swelling

 Insomnia 

 Shortness of breath 

 Rash/itching 

 Dizziness 

 Tingling 

 Altered mental status 

 Low blood pressure

 Vaginal inflammation

 Changes in lab values: liver function tests, hemoglobin, hematocrit, neutrophils

Less common, but severe side effects may occur. Serious side effects may include: 

 Pustules (acute generalized exanthematous pustulosis)

 Brain damage 

 Seizures 

 Hallucinations/delirium

 C. difficile-associated diarrhea

 High blood pressure

29
 Fast heart rate

 Superinfection (a second infection)

 Stevens-Johnson syndrome/toxic epidermal necrolysis

 Skin disorder with bullseye lesions (erythema multiforme)

 Low platelet counts

 Low granulocyte or neutrophil (types of white blood cell) counts

 Low red blood cells (anemia)

 Low white blood cell count (leukopenia)

 Liver toxicity 

 Kidney failure

30
 CHAPTER FOUR

4.1 Conclusion

The discovery of a þ-lactam (e.g., carbapenem) with PBP and þ-lactamase inhibitory properties was a

major breakthrough in infectious disease therapeutics. The carbapenems are often agents of “last

resort” for many com- plicated bacterial infections. As MDR pathogens continue to emerge, the

sustained study of the development of novel carbapenems is an essential undertaking.

From the early years, the carbapenems isolated from Streptomyces were found to be chemically

unstable and susceptible to hydrolysis by host enzymes (i.e., DHP-I). The region of the compound that

results in this instability was identified, leading to modification of the carbapenems as a class (e.g.,

decreasing the basicity of R1 and adding 1-þ-methyl). Additional work revealed the importance of the

R2 side and stereochemistry of carbapenems; these factors aid in resistance to hydrolysis by þ-

lactamases, as well as increasing the spectrum of activity.

Work with þ-lactamases and carbapenems revealed important features, which will directly aid in the

future optimization of carbapenems. The different classes of þ-lactamases are inhibited by

carbapenems due to similar overall principles. Tautomerization of the pyrroline double bond of

carbapenem is important for inhibition, since the A 1 isoform deacylates at a much lower rate (Di

Modugno et al, 1994). The steric hindrance created by the R 2 hydroxyethyl side chain plays a role in

inhibition by preventing the deacylating water molecule from getting activated, as well as altering the

reactivity of the general base (Bornet et al, 2003). Elimination of the hydroxyethyl group of

carbapenems, seen with class A and C þ-lactamases, is an intriguing preliminary observation, which

may facilitate the hydrolysis of the carbapenem (Bradford et al, 1997). The relative safety of these

compounds is a real advantage; the primary concern is selection of carbapenem resistant isolates,

which is also the reason to continue development.

31
Future prospects include understanding the role of resistance determinants (e.g., carbapenemases,

porins, PBPs, and efflux pumps), since overcoming resistance is essential in order to preserve

longevity. Therefore, the modification of carbapenems so that they are not inactivated by þ-lactamases

is an important goal. The biggest challenges are the metallo-þ-lactamases. However, some progress

has been made in identifying potential inhibitors (cephalosporin-derived reverse hydroxamates and

oximes, phthalic acid derivatives, mitoxantrone, 4-chloromercuribenzoic acid, sulfonyl-triazole

analogs, and NH-1,2,3-triazole-based compounds) (Ganta et al, 2009). Alternative inhibitors can

include carbapenems with different stereochemistries. Quantum and molecular mechanics may hold

the key to identifying a scaffold for competitive inhibitors of metallo-þ-lactamases.

Generating carbapenems with increased permeability through the bacterial outer membrane is another

avenue to explore, thus out-maneuvering the loss of porins. Several oral carbapenems with increased

permeability through the host gastrointestinal membrane have been developed; notably, sanfe-

trinemcilexetil also gets into phagocytes. Bypassing the con- tinued evolution of PBPs with new

carbapenems is attainable, as evidenced by the new anti-MRSA and antipseudomonal carbapenems.

Yet structures of clinically relevant PBPs with carbapenems are needed if we are to understand the

enhanced activity. Studies have shown that efflux pump inhibitors can restore the activity of

antibiotics (Hirakata et al, 2009). Designing carbapenems that bypass efflux is another option, since

efflux by bacteria needs to be studied in greater detail. The increasing number and type/diversity of

carbapenems should compel us to revisit these compounds for new leads in the face of expanding

resistance.

32
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