Cephalosporins development

A woman who came into contact with several cephalosporins developed contact dermatitis lesions on the eyelids as well as pruritus and dryness of the nasal and oral mucosal membranes. Patch testing revealed positive reactions to cephalothin, cefamandole, and cefazolin (Conde-Salazar et al. 1986). Cephradine has also been described as a cause of occupational dermatitis in the pharmaceutical industry by Rudzki et al. (1989). Although cross-sensitivity with penicillins is possible (Martindale 1993), this was not reported in these cases. 

Fig. 5.13 Structures of some of the more frequently used first-, second-, third-, fourth-, and fifth-generation (G) drugs out of the large number of cephalosporins developed as potential antibacterials... 

The development of new antibiotics to combat resistance, and to provide easier oral administration and improved pharmacokinetics has been successful through synthetic modifications. This approach has been particularly rewarding in the area of P-lactams. The commercial importance of the P-lactams is evident from Table 3 which gives the market share of antibacterials. Fully 62% of the 1989 world antibacterial market belonged to the cephalosporin and penicillin P-lactams (20). 

Historically, the development of penems is contemporary with that of the naturally occurring carbapenems and the direction of penem research has clearly been influenced by the stmctures of the closely related natural products. The origins of the two groups of compounds is, however, quite different. Unlike carbapenems, no penems have been found in nature. When first described (84,85) they were viewed as hybrid molecules combining stmctural features of penicillins and cephalosporins. 

AH cephalosporins found in nature (Tables 1 and 2) have the D-a-aminoadipic acid 7-acyl side chain (21). AH of these compounds can be classified as having rather low specific activity. A substantial amount of the early work in the cephalosporin area was unsuccessfiiHy directed toward replacing the aminoadipic acid side chain or modifying it appropriately by fermentation or enzymatic processes (6,22). A milestone ia the development of cephalosporins occurred in 1960 with the discovery of a practical chemical process to remove the side chain to afford 7-ACA (1) (1). Several related processes were subsequendy developed (22,23). The ready avaHabHity of 7-ACA opened the way to thousands of new semisynthetic cephalosporins. The cephalosporin stmcture offers more opportunities for chemical modification than does that of penicillins There are two side chains that especiaHy lend themselves to chemical manipulation the 7-acylamino and 3-acetoxymethyl substituents. 

The stmctures of selected cephalosporins on the U.S. market, or in the final stages of development, are shown in Tables 4—8 (see also 78, 87). For every cephalosporin which has made it to the marketplace, HteraHy thousands of analogues were synthesized in order to estabUsh the stmcture-activity profile and allow selection of a clinical candidate. In addition to these compounds, there is a tremendous number of cephalosporin compounds currendy at various stages of development. A more extensive listing of the newer cephalosporins under preclinical or clinical evaluation may be found in a number of reviews (79,88). 

Superior penicillin producing cultures ate capable of producing in excess of 30 mg/mL of penicillin G (154). Cephalosporin producing strains, however, generally grow poorly and cephalosporin C production is not as efficient as is that of penicillin. Factors such as strain maintenance, strain improvement, fermentation development, inoculum preparation, and fermentation equipment requkements ate discussed in the hterature (3,154). 

Although immediate reactions of anaphylaxis, bronchospasm, and urticaria have been reported, most commonly patients exhibiting an adverse reaction develop a maculopapular rash, usually after several days of therapy. They may also develop fever and eosinophilia (80,219). Cefoperazone (34) and ceftriaxone (39), having greater biUary excretion than other cephalosporins, are associated with an increased risk of diarrhea, which may be caused by selection of cytotoxin producing stains of Clostridium difficile (219). 

Early attempts to produce cephalosporin analogs by varying the 7-acylamino substituent were frustrated because, in contrast to previous experience with penicillins, a good method for producing the necessary 7-amino compound (33a) could not be found. This problem was finally solved when it was discovered that diazotization of the a-aminoadipyl residue produces an iminolactone (33b) which can be hydrolyzed to the free amine in good yield. Subsequently an improved procedure was developed which involves silylation of the carboxyl groups followed by reaction with phosphorus pentachloride to yield iminochloride (33c)... 

Scientists at Merck developed a cephalosporin synthesis based on the addition of azidoacetyl chloride to 1,3-thiazines (56). Although this gives the incorrect 7a -epimer (57), it could be equilibrated to a mixture of 7-amino epimers (see Section 5.10.3.3) from which the desired 7/3-isomer could be separated and further elaborated to cephalosporins (B-82MI51001). 

At Smith Kline French a general approach to cephalosporin and penicillin nuclear analogs was developed that utilizes a monocyclic /3-lactam (59) with the correct cis stereochemistry as a key intermediate. This is prepared by reaction of the mixed anhydride of azidoacetic acid and trifluoroacetic acid with imine (58) followed by oxidative removal of the dimethoxybenzyl group. This product could be further elaborated to intermediate (60) which, on reaction with a -bromoketones, provides isocephalosporins (61). These nuclear analogs displayed antibacterial properties similar to cephalosporins (b-79MI51000). 

In spite of the considerable progress in developing methods for total synthesis, this route to cephalosporins cannot compete with fermentation or penicillin rearrangement (see Sections 5.10.4.1 and 2) for the industrial production of cephalosporin antibiotics. While total synthesis does provide access to nuclear analogs not readily obtainable from fermentation products, none of the totally synthetic materials have displayed sufficient advantages to Warrant their development as new drug products (b-81MI51000). 

TiCl4, CH2CI2, —10° to 0°, 54-91% yield. These conditions were developed for use with cephalosporin t-butyl esters." ... 

The total syntheses of penicillin and cephalosporin represent elegant tours de force that demonstrated once again the power of synthetic organic chemistry. These syntheses, however, had little effect on the course of drug development in the respective fields, since they failed to provide access to analogs that could not be prepared by modification of either the side chains or, as in the case of more recent work, modification of 6-APA and 7-ACA themselves. In order to have an impact on drug development, a total synthesis must provide means for preparing... 

Very recently total syntheses have been developed for the cephalosporins that allow replacement of the sulfur in the six-membered ring by oxygen and carbon. 

There are very few totally synthetic antibiotics presently on the market. One of these is the 1-oxacephem, moxalactam (96). One may speculate that the enhanced potency of moxa-1actam stems in part from the substitution of the smaller oxygen atom for the sulfur normally present in the six-membered ring of cephalosporins thereby enhancing the reactivity of the adjoining four-membered ring. It is also partly a measure of the present stage of development of chemical synthesis and of the relative economics of production of 7-aminocephalosporanic acid that such an involved synthesis apparently is economically competitive. 

After a strain improvement and development programme similar to, but more complicated than that of penicillin, the D-a-aminoadipyl side chain containing cephalosporin C was obtained by large scale fermentation. However, cephalosporin C could not be isolated as easily as penicillin G or V. Due to its amphoteric nature it is soluble at any pH in the fermentation broth. Several costly isolation procedures involving ion-exchange chromatography have been developed, as a result of which cephalosporin C is much more expensive than penicillin G. 

It was almost immediately recognised that the deacylated product, 7-aminocephalosporanic add (7-ACA, Figure 6.16), would be of similar importance as was 6-APA in the development of new penidllins. However, 7-ACA, the cephalosporin equivalent of 6-APA, could not be found in fermentations of Cephalosporin acremonium. In Figure 6.15 we have shown that penicillin acylase hydrolyses the acyl residue from natural cephalosporins. Up to a point this is true. These acylases will, however, only work with a limited range of acyl residues. It now seems that nature does not provide for acylases or transacylases that have the capacity to remove or change the D-a-aminoadipyl side chain of cephalosporin C efficiently in a single step. Widespread search for such an enzyme still remains unsuccessful. 

Side-chains of the various cephalosporins, including those most recently developed, are presented in Fig. 5.4 and a summary of the properties of these antibiotics in Table 5.2. 

Recent developments by academic and industrial geneticists may well prove to have transformed this situation. Tremendous progress has been made since the mid-1980s both in the isolation and manipulation ofthe biosynthetic genes in this pathway and in the related routes to the cephalosporins (via the cephalosporin C-producing... 

Rearrangements involving sulfoxides have played an important role in the development of the chemistry of sulfoxides. It is therefore not surprising that all major literature surveys on sulfoxides " , or their sulfenate precursors , also include a discussion of this subject. However, while excellent and detailed coverage exists for certain rearrangements of general mechanistic and synthetic interest, such as, for example, the Pummerer " or the related penicillin sulfoxide-cephalosporin " rearrangement, the treatment of all... 

To prevent development of resistance and promote synergy, inhaled tobramycin or colistin is usually added to an oral fluoroquinolone for P. aeruginosa coverage.1,3 Methicillin-sensitive S. aureus (MSSA) may be treated with oral amoxiciUin-clavulanic acid, dicloxacillin, first- or second-generation cephalosporins, trimethoprim-sulfamethoxazole, or clindamycin, depending on sensitivity. Likewise, methiciUin-resistant S. aureus (MRSA) may be treated with oral trimethoprim-sulfamethoxazole, clindamycin, minocycline, or linezolid. H. influenzae often produces... 

Isolated seizures that are not epilepsy can be caused by stroke, central nervous system trauma, central nervous system infections, metabolic disturbances (e.g., hyponatremia and hypoglycemia), and hypoxia. If these underlying causes of seizures are not corrected, they may lead to the development of recurrent seizures I or epilepsy. Medications can also cause seizures. Some drugs that are commonly associated with seizures include tramadol, bupropion, theophylline, some antidepressants, some antipsy-chotics, amphetamines, cocaine, imipenem, lithium, excessive doses of penicillins or cephalosporins, and sympathomimetics or stimulants. 

Development of resistance to P -lactam antibiotics, including penicillins and cephalosporins, has significantly impacted the management of bacterial meningitis. Approximately 17% of United States pneumococcal CSF isolates are resistant to penicillin, and 3.5% of CSF isolates are resistant to cephalosporins.26 The Clinical and Laboratory Standards Institute (CLSI) has set a lower ceftriaxone susceptibility breakpoint for pneumococcal CSF isolates (1 mg/L) than for isolates from non-CNS sites (2 mg/L). Increasing pneumococcal resistance to penicillin G... 

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