Carbapenems imipenem

L B. The patient has complicated urinary tract infection and nonsevere sepsis syndrome caused by P. aeruginosa. Effective antibiotics for Pseudomonas spp. include mezlocillin, piperacillin, piperacillin-tazobactam, ticarcillin, and ticarciUin-clavulanate. The carbapenems (imipenem and meropenem) and the monobactam (aztreonam) are also active against P. aeruginosa. Ampicillin-sulbactam and cefazolin are ineffective against P. 

Mechanism of Action A fixed-combination carbapenem. Imipenem penetrates the bacterial cell membrane and binds to penicillin-binding proteins, inhibiting cell wall synthesis. Cilastatin competitively inhibits the enzyme dehydropeptidase, preventing renal metabolism of imipenem. Therapeutic Effect Produces bacterial cell death. Pharmacokinetics Readily absorbed after IM administration. Protein binding 13%-21%. Widely distributed. Metabolized in the kidneys. Primarilyexcreted in urine. Removed by hemodialysis. Half-life 1 hr (increased in impaired renal function). 

Carbapenem Imipenem Wide action against gram-positive cocci, gram-negative rods, and some anaerobes. 

Carbapenems (imipenem more than meropenem) are believed to increase central nervons system excitation by inhibition of GABA binding to receptors. Combinations with other GABA inhibiting drngs snch as theophylline or qninolones have been reported to provoke seizures (45,46). 

Cephalosporin cefuroxime, ceftriaxone, cefotaxime. Carbapenem imipenem-cilastatin, meropenem. 

Third-generation cephalosporin ceftriaxone, cefotaxime, cefepime. Note that cephalosporins are not active against Listeria. Carbapenem imipenem-cilastatin, meropenem. 

FIGURE 120-1. Management of febrile episodes in neutropenic cancer patients. ANC = absolute neutrophil count carbapenem = imipenem-cilastatin, meropenem. (Adapted from Ref. 2.)... 

Chemistrjr Penicillins, cephalosporins, monolactams (aztreonam) and carbapenems (imipenem) all have a beta-lactam ring in the center. These drug becomes inactive if the ring is cleaved by p-lactamases (Fig. 7.11,7.12). 

Fig. 5.18 Structures of the monobactam aztreonam (a), oxazoUdine ring instead of the thiazolodine ring found in the carbapenems, imipenem (b) and meropenem (c), and peniciUins the clavam, clavulanic acid (d). Note that clavaras have an...

Extensive carbapenem and penem antibiotic research has been ongoing since thienamycin was discovered in 1978. However, only the imipenem-cilastatin combination has become a commercial product. Launched in 1985 in the United States as a broad-spectmm hospital product under the name Ptimaxin, this product had worldwide sales of some 300 million in 1988. Sales were predicted to rise to 345 million for the year ending 1989 (154). 

The first carbapenem released for clinical use was imipenem (5.46), a compound with relatively high resistance to microbial /3-lactamases. The addition of the (iminomethyl)amino side chain renders imipenem chemically more stable than thienamycin. But, like thienamycin, imipenem is also easily hydrolyzed by renal dehydropeptidase I, producing a mixture of /3-lactam ring-opened 1-pyrrolidine epimers at C(3) [161], The renal metabolism of imipenem can be minimized by co-administration of cilastatin (5.53), a competitive inhibitor of DHP-I [15 6] [162],... 

There are two additional important variations on the theme of p-lactam antibiotics. These are the carbapenems, of which imipenem (Primaxin) is the outstanding example, and the monobactams, of which aztreonam (Azactam) is the outstanding example (see figure 23.2). 

Carbapenems are representatives of another class of antibiotics that differ from penems in the absence of a sulfur atom in the penem ring. They include thienamicin (R = CH2CH2NH2), olivanic acid (R = CH=CHNH2>, and imipenem (R = CH2CH2NHC=NH). 

Mercaptopurine [6-MP] (Purinethol) [Antineoplastic/ Antimeta lite] Uses Acute leukemias, 2nd-line Rx of CML NHL, maint ALL in children, immunosuppressant w/ autoimmune Dzs (Crohn Dz) Action Antimetabolite, mimics hypoxanthine Dose Adults. 80-100 mg/mVd or 2.5-5 mg/kg/d maint 1.5-2.5 mg/kg/d Peds. Per protocol X w/ renal/hepatic insuff on empty stomach Caution [D, ] Contra Severe hepatic Dz, BM suppression, PRG Disp Tabs SE Mild hematotox, mucositis, stomatitis, D rash, fever, eosinophilia, jaundice. Hep Interactions T Effects W/ allopurinol T risk of BM suppression W/ trimethoprim-sulfamethoxazole X effects OF warfarin EMS May falsely T glucose OD May cause NA and liver necrosis symptomatic and supportive Meropenem (Merrem) [Antibiotic/Carbapenem] Uses lntra-abd Infxns, bacterial meningitis Action Carbapenem X cell wall synth, a [3-lactam Dose Adults. 1 to 2 g IV q8h Peds. >3 mo, <50 kg 10-40 mg/kg IV q 8h in renal insuff Caution [B, ] Contra [3-Lactam sensitivity Disp Inj 500 mg, 1 g SE Less Sz potential than imipenem D, thrombocytopenia Interactions T Effects W/ probenecid EMS Monitor for signs of electrolyte disturbances and... 

Meropenem (Merrem) is another carbapenem antibiotic with a broad spectrum of activity comparable to that of imipenem. A methyl group attached at the one-position on the five-member ring confers stability to dehydropeptidase 1. Consequently, meropenem does not require administration with cilastatin. When compared in human trials, imipenem-cilastatin and meropenem achieve similar clinical outcomes in patients with serious intraabdominal and soft tissue infections. Both imipenem-cilastatin and meropenem are used to treat infections caused by highly resistant Klebsiella pneumoniae producing ESBLs.The major cUnicaUy relevant distinction between imipenem-cilastatin and meropenem... 

Carbapenems (bactericidal, P-lactam-like activity) e.g., imipenem... 

The most common adverse effects of carbapenems—which tend to be more common with imipenem—are nausea, vomiting, diarrhea, skin rashes, and reactions at the infusion sites. Excessive levels of imipenem in patients with renal failure may lead to seizures. Meropenem, doripenem, and ertapenem are much less likely to cause seizures than imipenem. Patients allergic to penicillins may be allergic to carbapenems as well. 

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