Review

Cephalosporins currently in early

clinical trials for the treatment of
bacterial infections
1. Introduction
Timothy E Long† & Justin T Williams
2. Background †
Marshall University, School of Pharmacy, Department Pharmaceutical Science & Research,
3. Conclusion Huntington, USA
4. Expert opinion
Introduction: Healthcare-associated infections caused by multi-drug resistant
bacteria remain a major cause of worldwide mortality. With the recent
Expert Opin. Investig. Drugs Downloaded from informahealthcare.com by University of Maastricht on 06/24/14

approval of agents such as hetero-resistant cocci (i.e., ceftaroline, ceftobi-

prole, telavancin) for the treatment of Gram-positive infections by and drugs
like fidaxomicin for treating Clostridium difficile, present-day research on
antibacterials has largely shifted to developing interventions for diseases
caused by Gram-negative bacilli. Cephalosporins have gained significant
interest as antipseudomonals to be used in hospitals for treating device- and
procedure-associated infections. With extended-spectrum activity against
many enterobacterial pathogens, the introduction of new antipseudomonal
cephalosporin-based treatments will mark a significant advancement in the
management of hospital-borne diseases.
Areas covered: The following review examines the present-day status of
For personal use only.

investigational cephalosporins currently in preclinical, Phase I and Phase II

stage development. The article focuses specifically on treatments used for
healthcare-associated infections due to Gram-negative bacteria.
Expert opinion: There is an urgent need for new antimicrobials to treat
nosocomial infections due to multi-drug resistant Gram-negative bacteria.
The impending approvals of antipseudomonal cephalosporins co-formulated
with a b-lactamase inhibitor will allow clinicians to treat more hetero-resistant
infections with cephalosporins, while avoiding the use of more toxic agents
such as colistin. The growing interest in developing new b-lactamase inhibitor
combinatorial treatments with approved b-lactam antibiotics is anticipated to
decrease the number of novel cephalosporins entering clinical trials this
decade.

Keywords: antibacterial, ceftolozane, cephalosporin, Enterobacteriaceae, MRSA, Pseudomonas,

b-lactam

Expert Opin. Investig. Drugs [Early Online]

1. Introduction

Since their mid-twentieth century discovery, the cephalosporins have become one
of the most valued and frequently prescribed family of antibacterial therapies. The
majority of cephalosporins in clinical use today are obtained by semi-synthesis
from the deacylated product of microbial-derived cephalosporin C, that is, 7-
aminocephalosporanic acid (7-ACA). Over the years, continuous refinement of
the 7-ACA ring substituents has increased the utility of cephalosporins in treating
infectious diseases, particularly those caused by healthcare-associated pathogens.
The most recent group of cephalosporins to be approved were developed for
community-acquired pneumonia and acute bacteria skin and soft tissue infections.
The ‘anti-MRSA’ cephalosporins consisting of ceftaroline (CPT) [1] and ceftobi-
prole (CFB) [2] are noted for their bactericidal activity against MRSA and

10.1517/13543784.2014.930127 © 2014 Informa UK, Ltd. ISSN 1354-3784, e-ISSN 1744-7658 1

All rights reserved: reproduction in whole or in part not permitted
 T. E. Long & J. T. Williams
Article highlights.
. Cephalosporins remain one of the most frequently
prescribed antibacterials for both mild-to-serious
community- and healthcare-associated infections.
. Although cephalosporins are stable to Gram-positive
bacterial b-lactamases, they have variable stability to
degradation by b-lactamases in Gram-negative bacteria.
. With the recent approvals of ceftaroline, ceftobiprole
and other non-b-lactam antibacterials to treat
Gram-positive infections, a larger number of
cephalosporin-based therapies are in development today
for infections due to b-lactamase-producing
Gram-negative bacteria.
Expert Opin. Investig. Drugs Downloaded from informahealthcare.com by University of Maastricht on 06/24/14
. Among the popular strategies employed today to
develop new cephalosporins for Gram-negative bacterial
infections are to install siderophore-mimicking
substituents and co-formulating a cephalosporin with a
b-lactamase inhibitor.
. At the start of 2014, ceftolozane-tazobactam was the
only new investigational cephalosporin in clinical trials
and is expected to be approved before the end of
the year.
. With a large emphasis now on developing combination
treatments with b-lactamase inhibitors, it is anticipated
that new investigational b-lactam antibacterials will be
stalled in preclinical development.
For personal use only.
This box summarizes key points contained in the article.
penicillin-resistant Streptococcus pneumoniae (PRSP). Although
they were the first b-lactam antibacterials approved for
MRSA, the activity spectrum of CPT and CFB extends to
many species of Gram-negative bacilli, most notably Escheri-
chia coli and Klebsiella pneumoniae [3]. The susceptibility of
these organisms to the anti-MRSA cephalosporins, however,
is largely defined by the b-lactamases secreted by the bacteria.
Hospital isolates are often found to encode one or more b-
lactamase types that degrade cephalosporins in addition to
other b-lactam antibiotics including penicillins and monobac-
tams. Current cephalosporin research is centered largely on
7-ACA-derived analogs that are non-susceptible to cephalo-
sporinases (e.g., AmpC) and can transverse the outer mem-
brane of Gram-negative bacteria [4]. Over the past decade,
there have been significant advancements in developing the
group of cephems commonly dubbed ‘antipseudomonal’
cephalosporins to treat hetero-resistant infections due to
Enterobacteriaceae and non-fermenting Gram-negative bacilli
(e.g., Pseudomonas aeruginosa).
2. Background
2.1 Historical perspective on cephalosporin resistance
Development of the first cephalosporins during the 1950s was
stimulated by a critical need for oral b-lactam antibiotics that
were impervious to degradation by penicillinases. Shortly after
the first cephems were introduced in the 1960s, mutant
penicillinases that hydrolyzed cephalosporins begun to appear
2 Expert Opin. Investig. Drugs (2014) 23(10)
in healthcare-associated isolates of Gram-negative bacteria. In
the 1970s, scientists found that chemical modification of the
C-7 side chain with bulky oxyimino-aminothiazolyl substitu-
ents could hinder b-lactamase binding and led to the develop-
ment of the extended-spectrum cephalosporins. Excessive use
of these agents in the 1980s accelerated the arrival strains
harboring plasmid-encoded extended-spectrum b-lactamases
(ESBLs) [5] that degraded both oxyimino-substituted cephalo-
sporins and monobactams. By this time, additional cephalo-
sporin resistance factors had emerged including low-affinity
penicillin-binding proteins (PBPs) [6], metallo-b-lactamases
(MBLs) [7], efflux pumps [8] and repressed expression of porin
channels [9]. Research in the 1990s on cephalosporins to treat
pneumonia resulted in the approval of cefepime (FEP) and
later CPT whose unique zwiterionic properties enabled
them to be clinically useful against multi-drug resistant
(MDR) species with the exception of Gram-negative pro-
ducers of ESBLs, MBLs and/or AmpC b-lactamases (Table 1)
[10].
Ambler class A and C cephalosporinases are encoded by a
wide range of clinically relevant Gram-negative bacilli includ-
ing P. aeruginosa. Many Enterobacteriaceae secrete group 2b
b-lactamases that have undergone site-specific mutations,
which enables them to degrade extend-spectrum cephalospor-
ins, monobactams and to a lesser extent, penicillins [11,12].
Included in the group 2be ESBLs are TEM-type, SHV-type
and CTX-M b-lactamases, each of which can be disabled by
clavulanate (CLA) and tazobactam (TAZ) (Table 1). Another
family of class A b-lactamases with the capacity to degrade
all b-lactam antibiotics in clinical use including oxyimino-
cephalosporins is KPC [13]. The plasmid-encoded carbapene-
mases are produced by a diversity of enteric pathogens and
most exhibit weak affinity for approved b-lactamase inhibitors
(i.e., CLA, TAZ, sulbactam [SUL]). Efforts to identify inhib-
itors of KPC as well as AmpC b-lactamases (e.g., CMY) led
to the discovery of avibactam (AVI), (Figure 3A) a novel
bridged g-lactam currently in various stages of clinical trial
evaluation in fixed-dose combinations with an oxyimino-b-
lactam [14,15]. Of equal importance, AVI is able to inhibit
specific subclusters of OXA class D b-lactamases, most nota-
bly OXA-48 carbapenemase produced by virulent strains of
K. pneumoniae [16].
2.2Investigational cephalosporins for Gram-positive
infections
With the latest approvals of CPT and CFB in North America
and the European Union, the arrival of cephalosporins to treat
healthcare-associated infections caused by Gram-positive pro-
ducers of low-affinity PBP2a/PBP2x was finally realized.
Consequently, present-day research efforts on b-lactam anti-
bacterials are largely directed towards agents against hetero-
resistant Gram-negative bacilli and in turn have slowed or
stalled the development of new treatments to combat
Gram-positive bacteria. Cephems to treat diseases caused by
 Cephalosporins currently in early clinical trials for the treatment of bacterial infections

Table 1. Characteristics of clinically important b-lactamases [5,7,10-13,16,68-70].

Ambler classification Group Example(s) Substrate(s) Inhibitor(s) Representative producer(s)

Class A 2a PC1 PEN CLA, TAZ Bacillus spp., E. faecium,

(Ser b-lactamase) Staphylococcus spp.
2b SHV-1 PEN, CEP CLA, TAZ, AVI E. coli, K. pneumoniae
TEM-1,-2 PEN, CEP CLA, TAZ, AVI Enterobacteriaceae (e.g., E. coli,
P. mirabilis)
2be TEM-3,-10 PEN, eCEP, MON CLA, TAZ, AVI Enterobacteriaceae (e.g., E.coli,
K. pneumoniae)
CTX-M-15 PEN, eCEP, MON CLA, TAZ, AVI E. coli, Klebsiella spp., Salmonella spp.
PER-1 PEN, eCEP, MON CLA, TAZ, AVI A. baumannii, P. aeruginosa,
Salmonella spp.
Expert Opin. Investig. Drugs Downloaded from informahealthcare.com by University of Maastricht on 06/24/14

SHV-2 PEN, eCEP, MON CLA, TAZ, AVI E. coli, Klebsiella spp.
VEB-1 PEN, eCEP, MON CLA, TAZ, AVI A. baumannii, Enterobacteriaceae
(e.g., E. coli)
2br TEM-30,-31 PEN, CEP -- Enterobacteriaceae (e.g., E. coli,
Klebsiella spp.)
2ber SHV-10 PEN, eCEP -- E. cloacae, E. coli, Klebsiella spp.
TEM-50 eCEP, MON -- E. coli
2f KPC-2,-3 PEN, eCEP, MON, CLA*, AVI Acinetobacter spp., Enterobacteriaceae,
CBP Pseudomonas spp.
Class B 3a IMP-1 PEN, eCEP, CBP -- Enterobacteriaceae, Pseudomonas spp.,
(metallo-b-lactamase) S. maltophilia
NDM-1 PEN, eCEP, CBP -- Acinetobacter spp., E. coli,
K. pneumoniae, V. cholerae
VIM-2 PEN, eCEP, CBP -- K. pneumoniae, P. aeruginosa
Class C 1 ACC-1,-4 PEN, eCEP, MON TAZ*, AVI E. coli, H. alvei, K. pneumoniae
For personal use only.

(AmpC Ser b-lactamase) CMY-2,-10 PEN, eCEP, MON TAZ*, AVI Enterobacteriaceae(e.g. Salmonella spp.,
S. sonnei), P. aeruginosa
FOX-1 PEN, eCEP, MON AVI Aeromonas spp., K. pneumoniae,
P. aeruginosa
LAT-1 PEN, eCEP, MON AVI C. freundii, E. coli, K. pneumoniae
1e CMY-37 PEN, eCEP, MON AVI C. freundii, E. cloacae, P. aeruginosa
Class D 2d OXA-1,-10 PEN CLA*, TAZ*, Acinetobacter spp., Enterobacteriaceae,
(Ser b-lactamase) AVI* P. aeruginosa
2de OXA-11,-15 PEN, eCEP CLA*, TAZ* P. aeruginosa
2df OXA-23,-48 PEN, CBP AVI* A. baumannii, E. coli, Enterobacter spp.,
K. pneumoniae

*Variable.
AVI: Avibactam; CBP: Carbapenems; CEP: Early cephalosporins; CLA: Clavulanate; eCEP: Early and extended-spectrum cephalosporins; MON: Monobactams
PEN: Penicillins; TAZ: Tazobactam.

Gram-positive cocci, however, continue to be evaluated such
as the anti-staphylococcal carbacephems by Achaogen, Inc.
(San Francisco, USA). In development as the first oral
anti-MRSA cephems, the compounds lack the sulfur atom
in the dihydrothiazine ring of classical cephalosporins that
contributes to gastric acid instability. In their 2010 US patent
application [17], a continuation of PCT/US2008/081150,
Achaogen disclosed the preparation of 49 examples of the car-
bacephems (e.g., 1, Figure 1A) and their anti-MRSA activity.
Carbacephem 1 demonstrated the greatest potency against
a 5-member MRSA panel that included strains exhibiting
hetero-resistance to ciprofloxacin, erythromycin, clindamycin
and gentamicin (MIC 1.0 -- 8.0 µg/ml). Against USA300 and
USA400, the CA-MRSA clones exhibited equal or greater
in vitro susceptibility (MIC £ 1.0 µg/ml) to compound 1
versus CFB. The efficacy of carbacephem 1 against MRSA
(ATCC 33591) was further assessed in vivo using an infected
thigh mouse model [17]. Animals were treated by subcutane-
ous injection with up to 240 mg/kg/day using vancomycin
(VAN) for comparison. At 60 mg/kg/day, cephem 1 exhibited
a 1 log kill, which was deemed more effective than VAN
dosed at 110 mg/kg/day. Pharmacokinetic analysis revealed
that the compound possessed a long plasma circulation time
(Tin = 1.8 h) and large volume of distribution (Vss = 1.08 l/
kg). These data supported the findings of the in vivo efficacy
study that the cephem was able to eradicate the bacteria by
achieving high concentrations at the infection site in the
neutropenic model.
Similar to Achaogen’s efforts to develop unconventional
cephems, scientists at Guangzhou Baiyunshan Pharm. Co.
(Guangdong, China) have examined cephalosporins whose
C-7 oxyimino-side chain is replaced with a thiourea acetamide
group [18]. Work leading up to their 2008-10 US patent appli-
cations found that the thiourea substituent confers enhanced

Expert Opin. Investig. Drugs (2014) 23(10) 3

 T. E. Long & J. T. Williams

A. N OH B.
S H
H2N N H N H
N H N S
S N N NH O
O N S N O
N NH2 O
O S
CO2H N
CO2H N O
S H

1 BYS02
Achaogen, Inc. Guangzhou Baiyunshan Pharmaceuticals Co., Ltd.
(US 2010/0267685 A1) (US 7700581 B2)

OH
NH2

C.
Expert Opin. Investig. Drugs Downloaded from informahealthcare.com by University of Maastricht on 06/24/14

O
N O OH
N HO O
H2N H H
N S HO
S O O
O O O Cl
Cl N N
O HO Cl OH
CO2 O H O H
O N N N
N NH H
2 H
H O O O N
HHN O
O N
NH2
N OCH3 OH
N H N ( )4 O OH
H2N HO
N H
S
S compd MRSA
O
Cl N N MIC90(μg/mL) EDC90(mg/kg)
O
For personal use only.

CO2 VAN 3 9
2 < 0.1 < 0.1
3 3 < 0.1 < 0.2
Theravance, Inc.
(US 8557978 B2, 7067481 B2)

D. N OR1 N OH
H2N N H H2N N H
H N H
N S N S
S S S N
O R2 O
N N N
O S O
Me
CO2H CO2H

4 R1 = H, R2 = N 6
5 R1 = C(CH3)2CO2H, R2 = NMe

Shandong xuanzhu pharmaceutical technology Co., Ltd.

(CN101245079 B, CN101759710 A)
cmpda0 MIC90(μg/ml)
MSSE MSSA MRSA E. coli K. pneumoniae P. aeruginosa
CAZ 32 16 128 8 2 32
VAN − 1 4 − − −
4 − 0.125 1 2 0.5 2
5 − 0.5 2 0.5 0.25 0.5
6 0.125 0.032 − 0.032 0.032 1
a
ceftazidime/CAZ, vancomycin/VAN

Figure 1. Cephalosporins in development for the treatment of Gram-positive infections [17-22].

4 Expert Opin. Investig. Drugs (2014) 23(10)

 Cephalosporins currently in early clinical trials for the treatment of bacterial infections
antibacterial effects against Gram-positive species; however, the
nuclear analogs of 7-ACA were susceptible to b-lactamase deg-
radation and demonstrated low pharmacokinetic half-life (t½).
Conversion of the C-3 acetoxy- group to heterocycle-
substituted sulfide resolved the problems with enzyme stability,
while retaining activity against Gram-positive cocci including
Staphylococcus aureus (MIC 0.2 -- 4 µg/ml) and S. pneumoniae
(MIC 0.125 -- 0.5 µg/ml) [18]. A lead compound in their
work, BYS02 (Figure 1B), was evaluated in vivo for acute toxic-
ity (LD50 650 -- 700 mg/kg) and plasma concentrations (t½
2.19 ± 0.04) [18]. In final analysis, these data corroborated the
structure--activity relationships that chemical modification of
Expert Opin. Investig. Drugs Downloaded from informahealthcare.com by University of Maastricht on 06/24/14
the C-3 group affects both the antimicrobial properties and
metabolic stability of the cephalosporins.
Another company similarly taking an unconventional
approach to cephalosporin development is Theravance, Inc.
Since 2005, the San Francisco-based company has submitted
multiple US patent applications on cross-linked cephalospo-
rin-VAN compounds with enhanced potency against methicil-
lin-resistant staphylococcus epidermidis compared to VAN
alone [19,20]. The conjugates are prepared from VAN hydrochlo-
ride utilizing the C-40 carboxylate as the attachment site for the
cephalosporins. The two inhibitors of cell wall synthesis are
bound via a linker between the carboxylate and either the oxime
For personal use only.
of the C-7 oxyimino- group or the C-3 pyridinium side chain of
the cephalosporin. Of the examples cited in the patents, com-
pounds 2 and 3 (Figure 1C) proved to be among the most potent.
Against an 87-member panel of MRSA (n = 53) and coagulase-
negative Staphylococcus spp. (n = 34) including methicillin resis-
tant Staphylococcus aureus, conjugate 3 demonstrated a MIC90
of < 0.1 µg/ml compared to 3 -- 4 µg/ml for VAN [19]. In a time-
kill assay, compounds 2 and 3 both displayed bactericidal activ-
ity (> 99% kill) against MRSA at £ 0.1 µg/ml in 4 h, which was
significantly greater than the 4 µg/ml in 24 h for VAN [19,20].
Each inhibitor was also found to be more effective against
MRSA in a neutropenic mouse thigh infection model with an
ED50 of < 0.1 mg/kg compared to 9 mg/kg for VAN [19,20].
Lastly, anti-staphylococcal compounds with structures sim-
ilar to FEP have been in development at Xuanzhu Pharmaceu-
tical Technology Co. (Jinan, China). Each of the reported
S-azetidin-3-yl analogs (e.g., 4, 5, Figure 1D) exhibited greater
to equipotent activity (MIC90 1 -- 4 µg/ml) against a 263-
strain MRSA panel [21]. Those with a C-3 quaternary amine
(e.g., 5, 6, Figure 1D) further displayed extended-spectrum
activity against ESBL-producing E. coli and K. pneumoniae
in the sub-µg/ml MIC range [22]. Moreover, the analogs
were evaluated against ceftazidime (CAZ)-resistant PRSP
and P. aeruginosa but, displayed only weak-to-moderate activ-
ity (MIC90 4 -- 32 µg/ml) with the exception of compound 6.
2.3Investigational cephalosporins for Gram-negative
infections
A major focus of present-day b-lactam antibacterial research
is on cephalosporins that can be used to treat healthcare-
Expert Opin. Investig. Drugs (2014) 23(10)
associated infections due to the Gram-negative ‘ESKAPE’
pathogens K. pneumoniae, Acinetobacter baumannii, P. aerugi-
nosa and Enterobacter spp [23]. Anti-pseudomonal cephems are
among the most desired due to the high incidence of life-
threatening infections (e.g., ventilator-associated pneumonia)
caused by opportunistic P. aeruginosa [24]. Hospital isolates of
the aerobic pathogen will usually harbor genes to encode multi-
ple ESBLs (e.g., PER-1, KPC-2) and efflux pumps to defend
against b-lactam antibacterials. Moreover, the overexpression
of AmpC enzymes further protects MDR pseudomonal strains
from the bactericidal effects of the extended-spectrum cephalo-
sporins and cephamycins in clinical use today [25].
In recent years, several strategies have been identified to
improve the efficacy of cephalosporins against Pseudomonas
and other hetero-resistant bacilli. These include the installa-
tion C-3 blocking groups to prevent degradation by AmpC
enzymes (e.g., ceftolozane) and combining approved therapies
(e.g., CPT, CAZ) with an ESBL inhibitor (e.g., TAZ, AVI)
[14]. Another approach that researchers have evaluated since
the 1980s is to install an iron-binding group (e.g., catechol)
to facilitate cephalosporin uptake into the periplasmic space.
Many virulent bacterial species secrete small metal-scavenging
molecules called siderophores that bind exogenous Fe3+ for
transport into the cytoplasm and use in biosynthetic pro-
cesses [26]. In Gram-negative bacteria, an energy-transducing
complex located in the outer membrane regulates Fe3+-sidero-
phore entry into the periplasm upon receptor binding. The
TonB-mediated transport process is postulated to be less rigid
than the porin channels that cephalosporins utilize to access
the periplasmic PBPs. As Fe3+-acquisition is vital to the
survival of many Gram-negative pathogens, the ‘Trojan-horse’
strategy of using siderophore-mimicking antibiotics to
enhance cellular uptake has been long sought after as a means
to develop new antibacterial agents [27].
Cephalosporins that exploit the siderophore-transport pro-
cess are currently in preclinical-stage development at Shionogi
& Co. (Osaka-shi, Japan). The company’s design strategy
focuses on compounds with a catechol group that is fused
with or linked to a spacer containing a quaternary ammonium
ion bound via a methylene at the C-3 position. In the linker-
bound analogs (e.g., 7, Figure 2A), a chlorine atom is affixed
ortho to the catechol hydroxyl group to prevent O-methyltrans-
ferase inactivation of the chelating functionality [28]. In
their patent applications, Shinongi & Co. disclosed over
100 cephalosporins that were found to be exceptional growth
inhibitors in screens against MBL-producing P. aeruginosa
(MIC 0.125 -- 0.5 µg/ml) and Stenotrophomonas maltophilia
(MIC 0.25 -- 4 µg/ml), ESBL-producing K. pneumoniae
(0.031 -- 0.25 µg/ml) and A. baumannii (MIC 0.125 --
0.5 µg/ml) [29]. In a separate series of catechol-containing
analogs, the C-4 carboxyl ion was replaced with a tetrazole
bioisostere (e.g., 8 -- 10, Figure 2A) and found to be equally active
to their predecessors [30]. The compounds exhibited extended-
spectrum activity against P. aeruginosa, A. baumannii, and a
broad range of Enterobacteriaceae including CTX-M-9
5
 T. E. Long & J. T. Williams

A. CO2Na
O Cl
N O OH 7 R1 = CO2
H2N N H HN
N H
S 8 R1 =
S N OH
O N N
N N N N
O
R1

CO2Na O Cl
9 R1 = OH
N O
H2N N H
N H N
S OH
S N
Expert Opin. Investig. Drugs Downloaded from informahealthcare.com by University of Maastricht on 06/24/14

O
N R1
O OH
10 R1 =
N N N OH
N N

Shionogi & Co., Ltd.

(WO2012147773 A1, W02010050468 A1)

MIC (μg/ml)
Organism Strain Enzyme 7 8 9 10
E. coli ATCC BAA199 SHV-3 2 0.5 0.25 ≤ 0.031
K. pneumoniae ATCC BAA1705 KPC-2 0.125 ≤ 0.031 ≤ 0.031 ≤ 0.031
For personal use only.

A. baumannii SR27323 OXA-23,-56 1 0.5 0.5 0.125

P. aeruginosa SR27060 IMP-1 4 2 0.25 0.25
SR24837 PER-1 > 32 2 0.125 ≤ 0.031

B. R1 R2
CO2H

N O
H2N N H
N H
S N NH2
S N O
O
N N OH
O NH
H
CO2 N
N
O OH
11 R1 = Me, R2 = H
12 R1 = Me, R2 = Me

Legochem Biosciences, Inc.

(US 20130178455 A1)

compda MIC (mg/ml) ED50 t½

P. aeruginosa K. pneumoniae A. baumannii E. coli E. cloacae
(mg/kg) (h)
(n = 5) (n = 6) (n = 3) (n = 2) (n = 1)
CAZ 1 – 64 1 – 64 4 – 64 < 0.5 – 8 32 640 -
11 0.5 – 1 0.5 – 32 4 – 64 0.125 – 0.5 1 10 0.62
12 0.5 – 4V < 0.0625 – 32 8 – 128 < 0.025 – 0.5 32 - 0.87
a
ceftazidime/CAZ

Figure 2. Siderophore-mimicking cephalosporins development for Gram-negative infections [29-31].

6 Expert Opin. Investig. Drugs (2014) 23(10)

 Cephalosporins currently in early clinical trials for the treatment of bacterial infections
producing E. cloacae (e.g., 10 MIC £ 0.031 µg/ml). Most note-
worthy was their sub-µg/ml MIC performance against IMP and
OXA strains of P. aeruginosa and A. baumannii, respectively, as
epitomized by compound 10. Although the company’s current
patents do not present in vivo or toxicity data, the high potency
and b-lactamase stability of the cephem analogs with the
tetrazole isostere may represent a promising new scaffold to
develop siderophore-mimicking b-lactams as therapies for
MDR infections.
The siderophore-driven strategy is similarly being
employed by cephalosporin researchers at LegoChem
Biosciences (Daejeon, South Korea). The compounds in
Expert Opin. Investig. Drugs Downloaded from informahealthcare.com by University of Maastricht on 06/24/14
development contain an O-methyltransferase stable pyrido-
nate chelating ligand attached via quaternary ammonium
ion-containing spacer to the C-3 position. At the C-7 loca-
tion, the analogs are bound with the oxyimino-side chain of
an approved extended-spectrum cephalosporin. The test
results confirmed that the analogs were effective antagonists
of Gram-negative bacilli with the exception of A. baumannii
(Figure 2B) [31]. Lead compounds 11 and 12 underwent further
evaluation using a whole-body pseudomonal-infected mouse
[31]. In a comparison study with CAZ, compound 12 was
found to be twice as potent (ED50 1.25 mg/kg) in the
CAZ-sensitive P. aeruginosa infected model. Likewise,
For personal use only.
cephem 11 was concluded to be more effective than doripe-
nem and CAZ at ED50 10, 28 and 640 mg/kg, respectively,
in a CAZ-resistant P. aeruginosa infected model.
As mentioned, a major focus of present-day cephalosporin
research is on decreasing susceptibility to degradation by
ESBL and AmpC b-lactamases. A strategy that has successfully
advanced new treatments to clinical trials is combining
approved cephalosporins (e.g. CPT, CAZ) with AVI (AstraZe-
neca, London, UK), a novel inhibitor of Ambler class A, C and
D b-lactamases (Table 1). An example of the effects AVI has on
improving cephalosporin performance against b-lactamase-pro-
ducing bacilli is illustrated with the antipseudomonal agent
ceftazidime (CAZ) (Figure 3A). In a 2014 report, 624 healthcare
isolates of ESBL-producing E. coli and K. pneumoniae that
tested CAZ-resistant (MIC90s ‡ 32 µg/ml) were found to be
CAZ-susceptible when combined with AVI (MIC90s
£ 0.5 µg/ml) [32]. Likewise, CAZ potency was restored by AVI
against KPC, SHV, CMY-2-like and CTX-M-15-like produc-
ing Enterobacteriaceae with reductions in MIC90s from
> 32 to £ 2 µg/ml [33]. The synergistic activity of CAZ and
AVI was, however, less pronounced against clinical isolates of
P. aeruginosa and Acinetobacter spp., which usually harbor addi-
tional resistance factors to reduce periplasmic drug concentra-
tions (e.g., efflux pumps). Although a moderate increase in
CAZ susceptibility was observed for the Pseudomonas iso-
lates [32,34], the combination with AVI had negligible effects
on Acinetobacter [32].
Another cephalosporin-b-lactamase combination that has
advanced to clinical trials is ceftolozane-TAZ. Ceftolozane
(TOL) (i.e., CXA-101; Cubist Pharmaceuticals, Lexington,
USA) (Figure 3B) is a current drug candidate for the treatment
Expert Opin. Investig. Drugs (2014) 23(10)
of urinary tract, intra-abdominal and pulmonary infections
due to healthcare-associated Gram-negative bacilli [35]. The
most noteworthy application of TOL is as an antipseudomo-
nal agent for CAZ-resistant strains that overexpress AmpC b-
lactamases, produce efflux pumps and/or exhibit repressed
porin levels. The chemical structure of TOL is similar to
CAZ with the major exception of the large C-3 ureido-
pyrazole substituent. Researchers propose that the bulky side
chain hinders TOL entry into the binding pocket of AmpC
b-lactamases in P. aeruginosa, protecting the cephem from
degradation [36]. Moreover, the basic attribute of the
C-3 side chain is thought to increase outer membrane pene-
tration of TOL, whereas the ureido group was found to
improve the safety profile over CAZ as a weaker convulsion-
inducing agent [37].
Future use of TOL in the treatment of hospital-borne
infections will require co-administration with a b-lactamase-
inhibitor (i.e., TAZ) due to the susceptibility of the
oxyimino-cephem to ESBLs. The TOL-TAZ (i.e., CXA-201)
combination exhibits potent antibacterial activity against
many ESBL-producing E. coli [38-40], Klebsiella spp. [38-40],
P. aeruginosa [39,41,42] and Bacteriodes spp. (Figure 3B) [42]. Con-
versely, strains that produce MBLs or other carbapenemases
(e.g., KPC, IPM) are nonsusceptible due to the vulnerability
of TOL to degradation by these inhibitor-resistant enzymes [42].
Other resistance mechanisms that can also reduce subcellular
drug bioavailability (i.e., efflux pumps, porin loss) have been
found to have minimal effects on TOL activity. In a suscepti-
bility study on isogenic sets of P. aeruginosa with overexpressed
Mex-Opr efflux pump systems and/or decreased OprD porin
expression, TOL displayed equipotent activities (MIC
0.5 µg/ml) against the parent strains [41]. Comparable results
were observed in ESBL-producing E. coli and K. pneumoniae
with overexpressed AcrAB-TolC efflux pumps and reduced
Omp C, F or K porin levels [43].
Further preclinical studies on TOL were conducted in
animal infection models to assess therapeutic efficacy with and
without TAZ. In a murine sepsis model, the TOL/TAZ combi-
nation (ED50 25.5, 25.9 mg/kg) exhibited greater potency than
TOL alone (ED50 123.3, 192.3 mg/kg) and CAZ (ED50 25.6,
263.3 mg/kg) against two strains of ESBL-producing E. coli [44].
Likewise, in a mouse model infected intraperitoneally with
CTX-M-producing K. pneumoniae, the TOL/TAZ combina-
tion (ED50 44.9 mg/kg) was more efficacious than TOL alone
(ED50 183.3 mg/kg) and CAZ (ED50 > 300 mg/kg) [45]. Neu-
tropenic mouse infection models with P. aeruginosa were fur-
ther used to evaluate TOL as an antipseudomonal treatment
for pulmonary, urinary tract and burn wound infections. In
each respective model, TOL was more efficacious in reducing
the infections to ~3.4, 4.5 and 4.3 log10 CFUs/tissue than
CAZ at approximately 4.9, 5.6 and 7.6 log10 CFUs/tissue after
2 -- 3 days of treatment [35,41]. These findings as well as the favor-
able pharmacokinetic, pharmacodynamic and safety profile
were instrumental in advancing TOL/CAZ to human trials in
the US and Europe.
7
 T. E. Long & J. T. Williams

A. CO2H
N O O
H2N N H
N H H2N
S
S N
O H
N N N
O O OSO3Na
CO2

Ceftazidime Avibactam sodium

AstraZeneca PLC

Organism phenotypea CAZa CAZa + AVIb

(no. strains) MIC50 MIC90 MIC50 MIC90
Enterobacteriaceae var. (8640) 0.12 8 0.12 0.25
SHV (83) > 32 > 32 0.12 0.25
Expert Opin. Investig. Drugs Downloaded from informahealthcare.com by University of Maastricht on 06/24/14

CTX-M-15-like (288) 16 > 32 0.12 0.5

KPC (118) > 32 > 32 0.5 2
CMY-2-like (54) 16 > 32 0.12 0.5
E. coli var. (2767) 0.12 2 0.06 0.12
ESBL (328) 16 32 0.12 0.5
AmpC (94) 16 64 0.12 0.5
K. pneumoniae var. (1846) 0.12 32 0.12 0.5
ESBL (296) > 32 > 32 0.5 1
CTX-M- 15 (12) 8 64 0.06 0.25
OXA 256 > 512 0.25 0.5
MER-res. (115) > 32 > 32 0.5 2
E. cloacae var. (951) 0.25 > 32 0.12 0.5
CAZ-res. (200) >8 >8 0.5 1
P. aeruginosa var. (1967) 2 32 2 4
CAZ-res. (330) 32 > 32 4 16
MER-res. (354) 16 > 32 4 16
For personal use only.

Acinetobacter spp. var. (321) 32 > 32 16 > 32

a
variable/var., meropenem/MER, ceftazidime/CAZ, avibactam/AVI
b
fixed avibactam concentration m of 4 g/ml

B. CO2H
HN
N O NH2
N O N
H2N H NH HO O
N H
S S N N
S N
O NH2
N N N N H
O O
CO2H Me HSO4 CO2Na

Ceftolozane Tazobactam sodium

Cubist Pharmaceuticals, Inc.

organism phenotype
a TOLa TOLa+ TAZ b CAZ a
MIC50 MIC90 MIC50 MIC90 MIC50 MIC90
A. baumannii − − − 0.5 2 8 16
B. fragalis − > 32 > 32 1 4 − −
E. coli ESBL 64 > 64 0.5 4 > 16 > 16
K. pneumoniae ESBL > 32 > 64 0.5 64 32 −
KPC > 32 > 32 > 16 > 16 > 64 > 64
P. aeruginosa TZP-res. 2 4 2 4 32 128
CAZ-res. 2 16 4 16 32 256
MEM-res. 1 8 1 8 8 > 32
TOB-res. 2 64 2 64 32 128
MDR 2 16 1 2 64 256
P. mirabilis ESBL 8 > 32 1 8 ≤4 > 64
S. aureus − 32 32 32 64 8 32
S. pneumoniae − ≤ 0.12 4 ≤ 0.12 8 0.25 8
apiperacillin-tazobactam/TZP, ceftazidime/CAZ, meropenem/MEM, tobramycin/TOB,
ceftolozane/TOL
b
fixed tazobactam/TAZ concentration of 4 mg/ml

Figure 3. Susceptibility data for ceftazidime-avibactam [32-34] and ceftolozane-tazobactam [38-43] against b-lactamase-
producing Gram-negative bacilli.

8 Expert Opin. Investig. Drugs (2014) 23(10)

 Cephalosporins currently in early clinical trials for the treatment of bacterial infections
2.4 Investigational cephalosporins in Phase 1 and
2 clinical trials
As of April 2014, the only novel cephalosporin-based
treatments undergoing clinical trial evaluation were TOL-
TAZ, CAZ-AVI and CPT-AVI. To date, multiple studies
using TOL both as monotherapy and as a 2:1 fixed dose co-
formulation with TAZ have been completed. Phase I trials
have indicated that, like most other b-lactams, TOL is
eliminated primarily via urinary excretion [46,47]. The pharma-
cokinetics of TOL were studied as single doses from 250 to
2000 mg and as a 10-day therapy using doses of 500 mg every
8 h (q8h), 1000 mg q8h and 1500 mg every 12 h. First-order
Expert Opin. Investig. Drugs Downloaded from informahealthcare.com by University of Maastricht on 06/24/14
elimination was observed in studied single and repeated dose
ranges. The mean plasma t½ ranged from 2.3 h (range
1.9 -- 2.6 h) for subjects with normal renal function to
43.2 h (range 32.8 -- 56.9 h) for subjects on hemodialysis
(HD). The mean steady state volume of distribution was
13.1 -- 17.6 l for patients with normal renal function to
54.6 l (range 38.8 -- 77.9 l) for patients on HD [47]. Plasma
protein binding was 20% for TOL and 30% for TAZ [35]
with minimal accumulation and changes in AUC with
repeated doses when compared to single doses. The Phase I
studies further found that the addition of TAZ does not alter
For personal use only.
the pharmacokinetics of TOL, nor does TOL alter the phar-
macokinetics of TAZ [47]. The lack of interaction can be
explained due to different methods of elimination; TAZ is
eliminated primarily through renal tubular secretion. First-
order elimination of TOL-TAZ was demonstrated at doses
of 1000/500 mg q8h and 2000/1000 mg q8h. Of note, dos-
ing adjustments may be necessary in clinical settings for
patients with a creatinine clearance < 50 -- 60 ml/min
[35,46,47]. The extraction ratio of TOL and TAZ (calculated
as 100*(CA-CV)/CA where CA and CV were pre- and post-
dialyzer paired drug concentrations at the arterial and venous
sites, respectively) is 46% (±16) for TOL and 53% (±22)
for TAZ. The total effective removal (calculated as AUCoff-
HD -- AUCon-HD)/AUCon-HD) of TOL and TAZ were
66 and 56%, respectively [47].
Adverse reactions to TOL-TAZ during the clinical trials
have thus far been mild and infrequent across the studied
dose ranges. During the Phase I studies, no dose-limiting
toxicities or serious adverse events were observed and the
most commonly reported adverse reactions were infusion-
site-related events. Nausea, vomiting, flushing, menstrual
cramps, paresthesia, hypoesthesia, headaches and leg cramps
were adverse reactions reported more than once during tri-
als [35,46,47]. In all instances, the adverse reactions did not
appear to be dose dependent.
Following successful patient safety studies, Phase II clinical
trials evaluated the use of TOL in the treatment of complicated
urinary tract infections (cUTIs) (NCT00921024) [48] and
TOL-TAZ plus metronidazole (MET) in the treatment of
complicated intra-abdominal infections (cIAIs) (NCT01147
640) [49]. The former trial compared TOL 1000 mg intravenous
Expert Opin. Investig. Drugs (2014) 23(10)
(i.v.) q8h for 7 -- 10 days versus CAZ 1000 mg i.v. q8h for
7 -- 10 days. The primary outcome measure was microbiological
response at the test-to-cure (TOC) visit in microbiological
modified-intention-to-treat (mMITT) and microbiologically
evaluable (ME) populations. Secondary outcome measures
were the safety and pharmacokinetics of TOL and clinical
response at the TOC visit. The results of the trial showed no
statistical difference between TOL and CAZ in the primary or
secondary outcome measures. The latter trial compared TOL-
TAZ 1500 mg/750 mg plus MET 500 mg i.v. q8h for
7 --14 days versus MER 1000 mg i.v. q8h for 7 -- 14 days.
The primary outcome measure was clinical response at TOC
visit in mMITT and ME populations. Secondary outcome
measures were safety of TOL-TAZ plus MET, pharmacokinet-
ics of TOL-TAZ and microbiological response at the TOC visit
in the ME population. The results showed no statistical differ-
ence between the study drug regimen and MER in the primary
or secondary outcome measures. As of April 2014, TOL-TAZ
had advanced to and completed Phase III trials evaluating the
use of TOL-TAZ in the treatment of cUTIs (NCT01345955,
NCT01345929) and cIAIs (NCT01445665, NCT01445
678). Moreover, a Phase III trial for ventilator-associated pneu-
monia (NCT02070757) is currently recruiting patients follow-
ing termination of a previously approved study (NCT01853
982) in November 2013.
After TOL-TAZ, the only remaining cephalosporins in
clinical trials are CAZ and CPT co-formulated with AVI.
These two drug combinations may offer similar yet distinct
options to treat hospital-acquired infections. CAZ-AVI pro-
vides coverage for infections caused by P. aeruginosa, while
CPT-AVI provides coverage for infections caused by MRSA
and ESBL-producing Enterobacteriaceae [50]. There is no sta-
tistically significant alteration to the pharmacokinetic profile
of CAZ [51,52] or CPT [53] with the addition of AVI. The
safety and tolerability of both CAZ-AVI and CPT-AVI
appear to be similar to CAZ and CPT, respectively. Further-
more, AVI does not appear to affect QT/QTc intervals at
supratherapeutic levels [54].
3. Conclusion
Cephalosporins continue to be among the most highly inves-
tigated antibiotics due to their extend-spectrum coverage, low
toxicity and favorable pharmacokinetic properties. Research
that has led to the discovery of optimal C-3 and C-7 substitu-
ents to increase b-lactamase stability, PBP2a/2x binding and/
or outer membrane permeability, has allowed the cephalospo-
rin family to flourish during the last three decades. Most
recently, new strategies to overcome the mechanisms of resis-
tance in Enterobacteriaceae and Pseudomonas are expected to
result in new cephalosporin-based treatment approvals over
the next few years. The most advanced in development is
TOL-TAZ, which Cubist Pharmaceutical anticipates will sub-
mit approval applications to the FDA and EMA in 2014 for
indications of cUTI and cIAI [55]. Moreover, the company
9
 T. E. Long & J. T. Williams
has been granted approval in the US to conduct Phase III tri-
als on TOL-TAZ as an intervention for ventilated nosocomial
pneumonia in comparison with MER [56].
The second most advanced cephalosporin-based therapy in
development is CAZ-AVI. Although CAZ is an approved
extended-spectrum cephalosporin, it is degraded by many
Ambler class A and C b-lactamases that AVI effectively dis-
ables. As of April 2014, AstraZeneca was recruiting partici-
pants for Phase III trials to assess CAZ-AVI as a treatment
for cUTI [57,58], cIAI [58,59] and hospital-acquired pneumonia
(HAP) [60]. Similarly, AVI combinations with other approved
b-lactam antibiotics have undergone human trials including
Expert Opin. Investig. Drugs Downloaded from informahealthcare.com by University of Maastricht on 06/24/14
the anti-MRSA cephalosporin CPT as a cUTI intervention,
which completed Phase II trials in March 2012 [61]. The
untapped potential of AVI as a broad-spectrum b-lactamase
inhibitor may additionally fast track other combination ther-
apies with existing cephalosporins for infection types in which
CAZ and CPT are not indicated treatments.
After TOL-TAZ and CAZ-AVI, no other novel cephalospo-
rin therapies appear to be as advance in clinical development.
Those that have the potential for further development due to
their low toxicity and therapeutic efficacy in animal models
include carbacephem 1 and the siderophore-mimicking
cephem 11. Others that exhibit potent activity against MDR
For personal use only.
bacteria; however, in vivo testing has either not been performed
or disclosed include catechol-containing compounds 8 -- 10. In
the case of the siderophore-conjugated b-lactam antibacterials,
stability towards O-methyltransferase inactivation and effec-
tiveness against strains with suppressed porin channels are
factors that have likely stalled advancement to clinical trials.
It may also be possible that these and other cephalosporins
identified in the review are on hold in preclinical development
until the clinical trials of TOL-TAZ and CAZ-AVI have been
completed. The successful implementation of using cephalo-
sporin-b-lactamase inhibitor treatments may further prompt
pharmaceutical companies to focus their b-lactam antimicro-
bial research programs on developing other combination
therapies involving an approved cephalosporin, carbapenem
or monobactam (i.e., aztreonam).
4. Expert opinion
Device- and procedure-associated infections (e.g., ventilator-
associated pneumonia, catheter-related urinary tract infec-
tions and postoperative intra-abdominal infections) due to
MDR bacteria remain a major cause of worldwide mortality
and morbidity. In a recent multi-centre (n = 2039) survey
conducted in the US on healthcare-associated infections,
nearly 20% of the 81,139 isolates displayed the MDR phe-
notype: MRSA (8.5%); VAN-resistant Enterococcus (3%);
extended-spectrum cephalosporin-resistant Klebsiella spp.
(2%), E. coli (2%) and Enterobacter spp. (2%); and
carbapenem-resistant P. aeruginosa (2%) [62]. In a separate
2012--2013 survey of healthcare facilities (n = 66) across
15 countries, 78% reported encountering MDR Gram-
10 Expert Opin. Investig. Drugs (2014) 23(10)
negative bacteria displaying resistance towards all antimicro-
bials except colistin (52% Enterobacteriaceae, 59% Pseudo-
monas, 62% Acinetobacter) [63]. With the critical need for
new interventions to treat diseases by MDR Gram-positive
cocci recently met with CPT, CFB and telavancin, the anti-
bacterial research community has largely shifted their efforts
to the development of agents for MDR Gram-negative
bacilli. As a consequence, the need for new cephalosporins
as treatments for Gram-positive infections has diminished
and may have stalled the advancement of the compounds
in Figure 1 into clinical trials.
The future implementation of b-lactamase inhibitor com-
bination therapies will enable clinicians to treat more MDR
Gram-negative infections with cephalosporins, while poten-
tially avoiding more toxic agents such as gentamicin and colis-
tin. This could be of critical importance in hospitals with
immunocompromised patients (e.g., cancer, organ transplant)
already in a weakened state prior to the infection onset. As the
combination therapies become available, the treatment of
hetero-resistant infections (e.g., HAP) should be guided by
the susceptibility data and local epidemiology. Guidelines
may need to be developed to assist clinicians in their decision
between treatment options which in the future is expected
to include carbapenem-b-lactamase inhibitor combinations
(e.g., imipenem/MK7665) [64]. With pharmaceutical compa-
nies largely focused on developing therapies involving
approved cephalosporins, carbapenems and monobactams [65]
that are co-formulated with a b-lactamase inhibitor, advance-
ment of novel b-lactams antibacterials to clinical trials in the
coming years will continue to be stalled. The authors predict
that TOL may be one of few novel cephalosporins to be
approved during this decade due to climbing trend of devel-
oping combination therapies containing an approved b-
lactam antibacterial.
Current and future clinical studies on TOL and AVI com-
bination therapies will help fulfill the ‘10  ’20 Initiative’ of
the Infectious Diseases Society of America that ‘supports the
development of 10 new systemic antibacterial drugs through
the discovery of new drug classes as well as exploring possible
new drugs from existing classes of antibiotics’ [66]. Additional
candidates currently in advanced (Phase II or III) clinical trials
and expected to be approved by the 2020 Initiative deadline
include the b-lactamase inhibitor MK-7655 (co-formulated
with imipenem), the aminoglycoside plazomicin, the fluoro-
cycline eravacycline, the oxazolidinone tedizolid and the
peptide defense protein mimetic (a novel antibacterial class)
brilacidin [67]. It should be noted that while most of the
advance developmental stage antibacterials target resistant
pathogens, none of the candidates have effective, reliable cov-
erage against MDR Acinetobacter spp. It remains to be seen if
the cephems (e.g., 7) currently in preclinical development
with increased activity against Acinetobacter spp. will progress
to clinical trials.
With combination therapy becoming the preeminent
strategy to develop new cephalosporin-based therapies,
 Cephalosporins currently in early clinical trials for the treatment of bacterial infections

researchers are faced with the ongoing challenge to identify MDR infections by MBL-producing bacteria escalates, clini-
novel compounds that inactivate b-lactamases not covered by cians will continue to resort to last-line defenses (e.g., colistin)
CLA, SUL and TAZ. Several non-b-lactam classes of inhibi- until such inhibitors proved to be effective in combination
tors (e.g., boronic acids) have been discovered over the past therapies with b-lactam antibiotics.
35 years, however, few have been evaluated for safety and effi-
cacy in clinical trials. If approved, AVI will be the first non-b-
lactam inhibitor of cephalosporin-binding b-lactamases that Acknowledgment
are not effectively inhibited by CLA, SUL or TAZ (e.g.,
TE Long wishes to give special thanks to Professor Karen
AmpC, KPC). It is expected that the antibiotic research com-
Bush for her helpful discussion on b-lactamases.
munity will have greater interest in developing broad-spectrum
inhibitors of serine- and MBLs over the next decade. If those
efforts are unsuccessful, future cephalosporin therapies may Declaration of interest
Expert Opin. Investig. Drugs Downloaded from informahealthcare.com by University of Maastricht on 06/24/14

involve a combination of b-lactamase inhibitors due to the

potential ability of Gram-negative pathogens to encode
multiple Ambler class enzymes. A significant impediment for
medicinal chemists will be to device potent and druggable
antagonists of MBLs, which will likely become increasingly
observed in clinical isolates of P. aeruginosa, Acinetobacter and
Enterobacteriaceae. As the incidence of healthcare-associated
The authors acknowledge the Marshall School of Pharmacy
for support of the authors’ research. The authors have no
other relevant affiliations or financial involvement with any
organization or entity with a financial interest in or financial
conflict with the subject matter or materials discussed in the
manuscript apart from those disclosed.

Bibliography
Papers of special note have been highlighted as 8. Nikaido H, Pagès JM. Broad-specificity Available from: http://clinicaltrials.gov/
either of interest () or of considerable interest efflux pumps and their role in multidrug show/NCT01281462
() to readers. resistance of Gram-negative bacteria. 16. Aktas Z, Kayacan C, Oncul O. In vitro
FEMS Microbiol Rev 2012;36(2):340-63
For personal use only.

1. Lodise TP, Low DE. Ceftaroline fosamil activity of avibactam (NXL104) in

in the treatment of community-acquired
bacterial pneumonia and acute bacterial
skin and skin structure infections. Drugs
2012;72(11):1473-93
2. Barbour A, Schmidt S, Rand KH,
Derendorf H. Ceftobiprole: a novel
cephalosporin with activity against
Gram-positive and Gram-negative
pathogens, including methicillin-resistant
Staphylococcus aureus (MRSA). Int J
Antimicrob Agents 2009;34(1):1-7
3. Page MG. Anti-MRSA beta-lactams in
development. Curr Opin Pharmacol
2006;6(5):480-5
4. Theuretzbacher U. Resistance drives
antibacterial drug development.
Curr Opin Pharmacol 2011;11(5):433-8
9. Fernández L, Hancock RE. Adaptive and
mutational resistance: role of porins and
efflux pumps in drug resistance.
Clin Microbiol Rev 2012;25(4):661-81
10. Jacoby GA, Munoz-Price LS. The new
beta-lactamases. N Engl J Med
2005;352(4):380-91
11. Bush K, Jacoby GA. Updated functional
classification of beta-lactamases.
Antimicrob Agents Chemother
2010;54(3):969-76
12. Jacoby GA. AmpC beta-lactamases.
Clin Microbiol Rev 2009;22(1):161-82
13. Patel G1, Bonomo RA. ‘Stormy waters
ahead’: global emergence of
carbapenemases. Front Microbiol
2013;14(4):48
combination with beta-lactams against
gram-negative bacteria, including OXA-
48 beta-lactamase-producing Klebsiella
pneumoniae. Int J Antimicrob Agents
2012;39(1):86-9
17. Wagman AS, Moser HE. Carbacephem
beta-lactam antibiotics.
US20100267686 A1; 2010
18. Chen M, Zhu S. Cephalosporin
compounds comprising a C3 thio-methyl
moiety substituted with. N-containing
heterocyclic group, and a C7 thiourea
acetamido group, their preparations and
uses thereof. US20080182836 A1; 2008
19. Long DD. Cross-linked glycopeptide-
cephalosporin antibiotics.
US20120214967 A1; 2012

5. Falagas ME, Karageorgopoulos DE. 14. Lagacé-Wiens P, Walkty A, 20. Fatheree PR, Linsell MS, Marquess D,
Extended-spectrum Karlowsky JA. Ceftazidime-avibactam: et al. Cross-linked Glycopeptide-
beta-lactamase-producing organisms. an evidence-based review of its cephalosporin antibiotics.
J Hosp Infect 2009;73(4):345-54 pharmacology and potential use in the US20110224130 A1; 2011

6. Zapun A, Contreras-Martel C, Vernet T.
Penicillin-binding proteins and beta-
lactam resistance. FEMS Microbiol Rev
2008;32(2):361-85
7. Wang JF, Chou KC. Metallo-beta-
lactamases: structural features, antibiotic
recognition, inhibition, and inhibitor
design. Curr Top Med Chem
2013;13(10):1242-53
treatment of Gram-negative bacterial
infections. Core Evid 2014;9:13-25
. A comprehensive review of the
preclinical research and clinical trials
on ceftazidime-avibactam.
15. Comparative study of coadministered
ceftaroline fosamil and NXL104 vs.
intravenous doripenem in adult subjects
with complicated urinary tract infections.
21. Huang Z. Cephalosporin antibiotic
derivant. CN 101245079 B; 2010
22. Huang Z. Cephalosporin derivatives
containing substitutional nitrogen
heterocycle. CN101759710 B; 2010
23. Pendleton JN, Gorman SP, Gilmore BF.
Clinical relevance of the ESKAPE
pathogens. Expert Rev Anti Infect Ther
2013;11(3):297-308

Expert Opin. Investig. Drugs (2014) 23(10) 11

 T. E. Long & J. T. Williams
24. Driscoll JA, Brody SL, Kollef MH. The
epidemiology, pathogenesis and
treatment of Pseudomonas aeruginosa
infections. Drugs 2007;67(3):351-68
25. Strateva T, Yordanov D. Pseudomonas
aeruginosa - a phenomenon of bacterial
resistance. J Med Microbiol
2009;58(Pt 9):1133-48
26. Miethke M, Marahiel MA.
Siderophore-based iron acquisition and
pathogen control. Microbiol Mol
Biol Rev 2007;71(3):413-51
27. M€ollmann U, Heinisch L,
Expert Opin. Investig. Drugs Downloaded from informahealthcare.com by University of Maastricht on 06/24/14
Bauernfeind A, et al. Siderophores as
drug delivery agents: application of the
"Trojan Horse" strategy. Biometals
2009;22(4):615-24
28. Ohi N, Aoki B, Kuroki T, et al. T.
Semisynthetic beta-lactam antibiotics. III.
Effect on antibacterial activity and
COMT-susceptibility of chlorine-
introduction into the catechol nucleus of
6-[(R)-2-[3-(3,4-dihydroxybenzoyl)-3-(3-
hydroxypropyl)-1-ureido]-2-
phenylacetamido]penicillanic acid.
J Antibiot (Tokyo) 1987;40(1):22-8
For personal use only.
29. Nishitani Y, Yamawaki K, Yakeoka Y,
et al. Cephalosporins having catechol
group. W02010050468 A1; 2010
30. Nishitani Y, Aoki T, Sato J, et al. Novel
cephem compound having catechol or
pseudo-catechol structure.
WO2012147773 A1; 2012
31. Cho YL, Yun JY, Chae SE, et al. Novel
cephalosporin derivatives and
pharmaceutical compositions thereof.
US20130178455 A1; 2013
32. Sader HS, Castanheira M, Flamm RK,
et al. Antimicrobial activity of
ceftazidime-avibactam against Gram-
negative organisms collected from U.S.
medical centers in 2012.
Antimicrob Agents Chemother
2014;58(3):1684-92
.. MIC data for ceftazidime-avibactam
against 10,928 Gram-negative isolates
collected from 73 US hospitals.
33. Castanheira M, Farrell SE, Krause KM,
et al. Contemporary diversity of beta-
lactamases among Enterobacteriaceae in
the nine U.S. census regions and
ceftazidime-avibactam activity tested
against isolates producing the most
prevalent beta-lactamase groups.
Antimicrob Agents Chemother
2014;58(2):833-8
12
34. Mushtaq S, Warner M, Livermore DM.
In vitro activity of ceftazidime
+NXL104 against Pseudomonas
aeruginosa and other non-fermenters.
J Antimicrob Chemother
2010;65(11):2376-81
35. Zhanel GG, Chung P, Adam H, et al.
Ceftolozane/tazobactam: a novel
cephalosporin/beta-lactamase inhibitor
combination with activity against
multidrug-resistant gram-negative bacilli.
Drugs 2014;74:31-51
. A comprehensive review of the
preclinical research and clinical trials
on ceftolozane-tazobactam.
36. Murano K, Yamanaka T, Toda A, et al.
Structural requirements for the stability
of novel cephalosporins to AmpC beta-
lactamase based on 3D-structure.
Bioorg Med Chem 2008;16(5):2261-75
37. Toda A, Ohki H, Yamanaka T, et al.
Synthesis and SAR of novel parenteral
anti-pseudomonal cephalosporins:
discovery of FR264205. Bioorg Med
Chem Lett 2008;18(17):4849-52
38. Craig WA, Andes DR. In vivo activities
of ceftolozane, a new cephalosporin, with
and without tazobactam against
Pseudomonas aeruginosa and
Enterobacteriaceae, including strains with
extended-spectrum beta-lactamases, in the
thighs of neutropenic mice.
Antimicrob Agents Chemother
2013;57(4):1577-82
39. Farrell DJ, Flamm RK, Sader HS,
Jones RN. Antimicrobial activity of
ceftolozane-tazobactam tested against
Enterobacteriaceae and Pseudomonas
aeruginosa with various resistance
patterns isolated in U.S. Hospitals (2011-
2012). Antimicrob Agents Chemother
2013;57(12):6305-10
40. Livermore DM, Mushtaq S, Ge Y.
Chequerboard titration of cephalosporin
CXA-101 (FR264205) and tazobactam
versus beta-lactamase-producing
Enterobacteriaceae.
J Antimicrob Chemother
2010;65(9):1972-4
41. Takeda S, Nakai T, Wakai Y, et al. In
vitro and in vivo activities of a new
cephalosporin, FR264205, against
Pseudomonas aeruginosa.
Antimicrob Agents Chemother
2007;51(3):826-30
42. Sader H, Rhomberg P, Farrell DJ,
Jones RN. Antimicrobial activity of
CXA-101, a novel cephalosporin tested
Expert Opin. Investig. Drugs (2014) 23(10)
in combination with tazobactam against
Enterobacteriaceae, Pseudomonas
aeruginosa, and Bacteroides fragilis
strains having various resistance
phenotypes.
Antimicrob Agents Chemother
2011;55(5):2390-4
43. VanScoy B, Mendes RE, McCauley J,
et al. Pharmacological basis of beta-
lactamase inhibitor therapeutics:
tazobactam in combination with
ceftolozane.
Antimicrob Agents Chemother
2013;57(12):5924-30
44. Jacqueline C, Dessard C, Roquilly A,
et al. 50% effective dose (ED50)
determination of CXA-101 (CXA) alone
or in combination with tazobactam
(TAZ) for treating experimental
peritonitis in mice due to extended-
spectrum beta-lactamase (ESBL)-
producing Escherichia coli (EC) strains:
comparison with ceftazidime (CAZ) and
piperacillin/tazobactam (TZP) [abstract
F1-2000]. ICAAC Annual Meeting; San
Francisco, CA, USA; 2009
45. Jacqueline C, Dessard C, Batard E, et al.
ED50 determination of CXA-101 alone
and in combination with tazobactam
(TAZ) for treating experimental
peritonitis in mice due to ESBL-
producing Klebsiella pneumoniae (KP)
strains: comparison with ceftazidime
(CAZ) and piperacillin/tazobactam
(TZP) [abstract B-708]. ICAAC Annual
Meeting; Boston, MA, USA; 2010
46. Miller B, Herberget E, Benziger D, et al.
Pharmacokinetics and safety of
intravenous ceftolozane-tazobactam in
health adult subjects following single and
multiple ascending doses.
Antimicrob Agents Chemother
2012;56(6):3086-91
47. Wooley M, Miller B, Krishna G, et al.
Impact of renal function on the
pharmacokinetics and safety of
ceftolozane/tazobactam.
Antimicrob Agents Chemother
2014;58(4):2249-55
48. Umeh O, Cebrik D, Friedland I.
A double-blind, randomized,
phase 2 study to compare the safety and
efficacy of intravenous CXA-101 (CXA)
and intravenous ceftazidime (CTZ) in
complicated urinary tract infection
(cUTI) [astract L1-361A]. ICAAC
Annual Meeting; Boston, MA, USA;
2010
 Cephalosporins currently in early clinical trials for the treatment of bacterial infections
49. Lucasti Umek O, Cebrik D, Friedland I.
A multicenter, double-blind, randomized,
phase 2 study to assess safety and efficacy
of ceftolozane/tazobactam (TOL/TAZ)
plus metronidazole (MTZ) compared to
meropenem (MER) in adult patients
with complicated intra-abdominal
infectious (cIAI) [abstract K-1709].
ICAAC Annual Meeting; Denver, CO,
USA; 2013
50. Boucher H, Talbot G, Benjamin D Jr,
et al. 10 x ’20 Progress -- development of
new drugs active against gram-negative
Expert Opin. Investig. Drugs Downloaded from informahealthcare.com by University of Maastricht on 06/24/14
bacilli: an update from the Infectious
Diseases Society of America.
Clin Infect Dis 2013;56(12):1682-94
51. Lagacé O, Walkty A, Karlowsky J.
Ceftazidime-avibactam: an evidence-based
review of its pharmacology and potential
use in the treatment of Gram-negative
bacterial infections. Core Evid
2014;9:13-25
52. Edeki T, Armstrong J, Li J.
Pharmacokinetics of avibactam (AVI)
and ceftazidime (CAZ) following separate
or combined administration in healthy
For personal use only.
volunteers [Abstract A-1019]. ICAAC
Annual Meeting; Denver, CO, USA;
2013
53. Riccobene T, Su S, Rank D. Single- and
multiple-dose study to determine the
safety, tolerability, and pharmacokinetics
of ceftaroline fosamil in combination
with avibactam healthy subjects.
Antimicrob Agents Chemother
2013;57(3):1496-504
54. Das S, Armstrong J, Mathews D, et al.
Randomized, placebo-controlled study to
assess the impact on QT/QTc interval of
supratherapeutic doses of ceftazidime-
avibactam or ceftaroline
fosamil-avibactam. J Clin Pharmacol
2014;54(3):331-40
55. Cubist Pharmaceutical. Available from:
www.cubist.com/products/cxa_201
56. ClinicalTrials.gov. Safety and efficacy
study of ceftolozane/tazobactam to treat
ventilated nosocomial pneumonia
(ASPECT-NP). Available from: http://
clinicaltrials.gov/ct2/show/NCT02070757
57. ClinicalTrials.gov. Ceftazidime-avibactam
compared with doripenem followed by
oral therapy for hospitalized adults with
complicated UTIs (urinary tract
infections). Available from: www.
clinicaltrials.gov/ct2/show/NCT01595438
58. ClinicalTrials.gov. Ceftazidime-avibactam
for the treatment of infections due to
ceftazidime resistant pathogens. Available
from: www.clinicaltrials.gov/ct2/show/
NCT01644643
59. ClinicalTrials.gov. A study comparing
ceftazidime-avibactam+metronidazole
versus meropenem in adults with
complicated intra-abdominal infections.
Available from: www.clinicaltrials.gov/
ct2/show/NCT01500239
60. ClinicalTrials.gov. A study comparing
ceftazidime-avibactam versus meropenem
in hospitalized adults With nosocomial
pneumonia. Available from: www.
clinicaltrials.gov/ct2/show/NCT01808092
61. ClinicalTrials.gov. Comparative study of
coadministered ceftaroline Fosamil and
NXL104 vs. intravenous doripenem in
adult subjects with complicated urinary
tract infections. Available from: www.
clinicaltrials.gov/ct2/show/NCT01281462
62. Sievert DM, Ricks P, Edwards JR, et al.
Antimicrobial-resistant pathogens
associated with healthcare-associated
infections: summary of data reported to
the National Healthcare Safety Network
at the Centers for Disease Control and
Prevention, 2009-2010. Infect Control
Hosp Epidemiol 2013;34(1):1-14
63. Drees M, Pineles L, Harris AD,
Morgan DJ. Variation in definitions and
isolation procedures for multidrug-
resistant Gram-negative bacteria: a survey
of the society for healthcare epidemiology
of America research network.
Infect Control Hosp Epidemiol
2014;35(4):362-6
64. ClinicalTrials.gov. Study of the safety,
tolerability, and efficacy of MK-
7655 + imipenem/cilastatin versus
imipenem/cilastatin alone to treat
complicated intra-abdominal infection
[cIAI] (MK-7655-004 AM2). Available
from: https://clinicaltrials.gov/ct2/show/
NCT01506271
65. ClinicalTrials.gov. To investigate the
safety and tolerability of aztreonam-
Expert Opin. Investig. Drugs (2014) 23(10)
avibactam (ATM-AVI). Available from:
https://clinicaltrials.gov/ct2/show/
NCT01689207
66. Gilbert D, Guidis R, Boucher H, et al.
The 10 x ’20 initiative: pursuing a global
commitment to develop 10 new
antibacterial drugs by 2020.
Clin Infect Dis 2010;50:1081-3
67. Pucci MJ, Bush K. Investigational
antimicrobial agents of 2013.
Clin Microbiol Rev 2013;26(4):792-821
68. Bonnefoy A, Dupuis-Hamelin C,
Steier V, et al. In vitro activity of
AVE1220A, an innovative broad-
spectrum non-beta-lactam beta-lactamase
inhibitor. J Antimicrob Chemother
2004;54(2):410-17
69. Lagacé-Wiens PR, Tailor F, Simner P,
et al. Activity of NXL104 in
combination with beta-lactams against
genetically characterized Escherichia coli
and Klebsiella pneumoniae isolates
producing class A extended-spectrum
beta-lactamases and class C
beta-lactamases.
Antimicrob Agents Chemother
2011;55(5):2434-7
70. Livermore DM, Mushtaq S, Warner M,
et al. Activities of NXL103 combinations
with ceftazidime and aztreonam against
carbapenemase-producing
Enterobacteriaceae.
Antimicrob Agents Chemother
2011;55(1):390-4
Affiliation
Timothy E Long†1 & Justin T Williams2,3
†
Author for correspondence
1
Marshall University, School of Pharmacy,
Department Pharmaceutical Science & Research,
Huntington, WV 25755, USA
Tel: +1 304 696 7393;
Fax: +1 304 696 7309;
E-mail: longt@marshall.edu
2
Marshall University, School of Pharmacy,
Department of Pharmacy Practice,
Administration & Research, Huntington,
WV 25755, USA
3
Clinical Pharmacy Specialist, Internal Medicine,
St. Mary’s Medical Center, Huntington,
WV 25702, USA
13