Improving antibiotic targeting in vivo

Transcription

1 EXT GEERATI SUSCEPTIBILITY TESTIG: WHAT WRKS? Improving antibiotic targeting in vivo Françoise Van Bambeke, PharmD, PhD Pharmacologie cellulaire et moléculaire Louvain Drug Research Institute Université catholique de Louvain, Brussels, Belgium < 09/06/2017 ECSF antibiotic targeting 1

2 Where are bacteria (in CF)? (1/2) 2. in biofilms! 1. in mucus/sputum! sputum lung Hoiby et al, Future Microbiol. 2010; 5: D Angelo et al, Advanced Drug Delivery Reviews 2014; 75: /06/2017 ECSF antibiotic targeting 2

3 Where are bacteria (in CF)? (2/2) P. aeruginosa S. aureus B. cenocepacia 3. inside the cells! Goldberg & Pier, Trends Microbiol. 2000; 8: Jarry & Cheung, Infect Immun. 2006;74: Assani et al, PLoSone 2014; 9: e Cormet Boyaka et al, 2016; 09/06/2017 ECSF antibiotic targeting 3

4 How to improve targeting of these bacteria? Klinger-Strobel et al, Expert pin Drug Deliv. 2015; 12: /06/2017 ECSF antibiotic targeting 4

5 How to improve targeting of these bacteria? 09/06/2017 ECSF antibiotic targeting 5 1. Mucus penetration

6 Administration by inhalation: for which drugs? 09/06/2017 ECSF antibiotic targeting 6 airways deposition diffusion inhalation dissolution permeability absorption parenteral distribution Biopharmaceutics Classification System fluoroquinolones Class I high solubility high permeability Class II low solubility high permeability pulmonary conc. inhalation >> IV/P aminoglycosides polymyxins β-lactams Class III high solubility low permeability Class IV low solubility low permeability

7 Antibiotics by inhalation available today 09/06/2017 ECSF antibiotic targeting 7 Klinger-Strobel et al, Expert pin Drug Deliv. 2015; 12:

8 Antibiotics by inhalation: do they reach their target? Tobramycin powder for inhalation Globally similar PK but easier use for TIP (powder) than for TIS (solution) Miller et al, Mol. Pharmaceutics 2015; 12: Geller et al, Pediatr Pulmonol. 2007;42: /06/2017 ECSF antibiotic targeting 9

9 Delivery systems to increase drug concentrations D Angelo et al, Advanced Drug Delivery Reviews 2014; 75: /06/2017 ECSF antibiotic targeting 10

10 Antibiotics by inhalation: can we improve local concentrations? 09/06/2017 ECSF antibiotic targeting 11 Liposomal formulations

11 Antibiotics by inhalation: can we improve local concentrations? Liposomal formulations PK in rats at equivalent doses efficacy in rats at equivalent doses Higher concentration in lung and better efficacy for liposomal formulation Meers et al, JAC 2008; 61, /06/2017 ECSF antibiotic targeting 12

12 Approaches to enhance transport through CF sputum 09/06/2017 ECSF antibiotic targeting 13 Ibrahim et al, Expert pin. Drug Deliv. 2011; 8:451-66

13 Approaches to enhance transport through CF sputum anoparticles (AB + Dase) Higher penetration in mucus and better efficacy against strains non responding to free TB Deacon et al, J Control Release 2015; 198 : /06/2017 ECSF antibiotic targeting 14

14 How to improve targeting of these bacteria? 09/06/2017 ECSF antibiotic targeting Biofilm penetration

15 Antibiotic PK/PD parameters in biofilms catheter, bone, skin, cardiac valve, nutrients & oxygen pharmacokinetics diffusibility through the matrix bioavailability within the biofilm access to bacteria efflux out of bacteria pharmacodynamics bacterial responsiveness (metabolic activity of bacteria) antibiotic expression of activity (local environment [ 2, ph,..]) 09/06/2017 ECSF antibiotic targeting 16

16 Biofilm matrix: what is it made of? Rabin et al., Future Med. Chem. 2015; 7: /06/2017 ECSF antibiotic targeting 17

17 Antibiofilm strategies ~ antibiotic penetration Kostakioti et al. Cold Spring Harb Perspect Med 2013;3:a /06/2017 ECSF antibiotic targeting 18

18 Strategies to increase antibiotic penetration in biofilms Inhibiting matrix biosynthesis Enzymes involved in the synthesis of -acetylglycosamine polymers of biofilm matrix in S. aureus and P. aeruginosa share homology with 1,3-β-D-glucan synthase [Target for echinocandins in fungi] Siala et al., at. Commun. 2016; 7:13286; Kissoyan et al, Biofouling 2016; 32: /06/2017 ECSF antibiotic targeting 19

19 Strategies to increase antibiotic penetration in biofilms lo g 10 CFUs/catheter piece Inhibiting matrix biosynthesis S. aureus implanted catheter infection A A,B B C P. aeruginosa intraperitoneal infection Levofloxacin + micafungin control 2.5 CTRL CAS M XF M XF+CAS Levofloxacin Echinocandins are synergistic with fluoroquinolones in vivo Siala et al., at. Commun. 2016; 7:13286; Kissoyan et al, Biofouling 2016; 32: /06/2017 ECSF antibiotic targeting 20

20 Strategies to increase antibiotic penetration in biofilms Degrading preformed matrix by enzymes P. aeruginosa and tobramycin (512 mg/l) Enzymes degrading matrix constituents antibiotic activity in biofilms Alipour et al., JAC 2009; 64: /06/2017 ECSF antibiotic targeting 21

21 Antibiotic PK/PD parameters in biofilms -acetyl-cysteine (anti-oxidant + reducing disulfure bridges) Ciprofloxacin and Pseudomonas biofilms 8 CFU in biofilm AC 0 m g/m L AC 1 m g/m L AC 2.5 m g/m L C IP c o n c. ( X M IC ) AC increases CIP activity against biofilms in vitro Zhao & Liu BMC Microbiology 2010; 10:140 09/06/2017 ECSF antibiotic targeting 22

22 Antibiotic PK/PD parameters in biofilms -acetyl-cysteine (anti-oxidant + reducing disulfure bridges) But does it work in patients? 900 mg 3 x/day for 24 weeks Conrad et al., J. Cystic Fibrosis 2015; 14: /06/2017 ECSF antibiotic targeting 23

23 How to improve targeting of these bacteria? 09/06/2017 ECSF antibiotic targeting Intracellular targeting

24 PK/PD parameters against intracellular bacteria influx efflux metabolism binding accumulation and bioavailability cooperation with host defenses bacterial responsiveness physico-chemical conditions Carryn et al, Infect Dis Clin orth Am 2003; 17: /06/2017 ECSF antibiotic targeting 29

25 Antibiotic accumulation and subcellular distribution diffusion possible re-distribution confined in vacuoles endocytosis β-lactams; fast; ~ 1 x fluoroquinolones : fast CIP, LVX : 4-10 x MXF, GAR, GMF : x aminoglycosides: slow ; 2-4 x glycopeptides: slow VA ~ 8 x TLV ~ 50 x RI ~ x linezolid: ~ 1 x lincosamides: 1-4 x tetracyclines: 2-4 x rifampin : 2-10 x synercid: 30-50x? macrolides: fast ERY: 4-10 x CLR, RX, TEL: 10-50x AZM, SL: > 50 x some oxazolidinones: fast RDZ : 10 x mainly in vacuoles slow release diffusion/ segregation 09/06/2017 ECSF antibiotic targeting 30

26 Strategies to increase antibiotic cellular concentrations influx efflux metabolism binding accumulation and bioavailability cooperation with host defenses bacterial responsiveness physico-chemical conditions 09/06/2017 ECSF antibiotic targeting 31

27 Strategies to increase antibiotic cellular concentrations Influx and ph gradient + eutral/zwitterionic molecules are more diffusible - If extracellular ph : uptake of acidic molecules R C H S CH 3 CH 3 ph of airway surface in pigs uptake of basic molecules H 3 C H CH 3 CH 3 C H H F C H 3 C H 3 CH 2 C H H 3 C CH 3 (H3 C) 2 H H CH 3 H 2 CH 3 H 3 C Pezzulo et al, ature 2013; 487: H 3 C H 09/06/2017 ECSF antibiotic targeting 32

28 Strategies to increase antibiotic cellular concentrations β-lactams + - eutral/zwitterionic molecules are more diffusible Masking the charges to change diffusibility Ampicillin prodrug: accumulation and activity Intracellular L. monocytogenes Reload of the medium Chanteux et al., JAC 2003; 52: /06/2017 ECSF antibiotic targeting 33

29 Increasing accumulation by improving diffusibility fluoroquinolones + - eutral/zwitterionic molecules are more diffusible accumulation lower for most fluoroquinolones at acidic ph MXIFLXACI cellular accumulation (30 min; ratio to control values [ph 7.4]) ** ** moxifloxacin ph values ** * 09/06/2017 ECSF antibiotic targeting H 2 microspecies distribution cationic F CH 3 cationic H H 2 zwitterionic F CH 3 anionic zwitterionic anionic ph Lemaire et al. AAC 2011; 55:649-58; Van Bambeke, Future Microbiology 2015; 10: H F CH 3 34

30 Increasing accumulation by improving diffusibility fluoroquinolones + - eutral/zwitterionic molecules are more diffusible accumulation higher for acidic fluoroquinolones (delafloxacin/finafloxacin) DELAFLXACI cellular accumulation (30 min; ratio to control values [ph 7.4]) ** ** ** ** ** ** delafloxacin moxifloxacin ph values ** * 09/06/2017 ECSF antibiotic targeting H cationic microspecies distribution cationic neutral H neutral F Cl H 2 F anionic ph Lemaire et al. AAC 2011; 55:649-58; Van Bambeke, Future Microbiology 2015; 10: F Cl H H 2 F F H F H H anionic F Cl H 2 F F 35

31 Strategies to increase antibiotic cellular concentrations Inhibition of efflux Ciliated cells Basal cells Goblet cells Basal cells Macro phages P-gp MRP1 MRP2* BCRP* PEPT1-2 CT1 CT2 CT3 CT1 CT2 * Conflicting data Fluoroquinolones Macrolides β-lactams Rifampin Adapted from Bosquillon, J Pharm Sci, 2010; ; Van Bambeke et al, JAC 2003; 51: /06/2017 ECSF antibiotic targeting 37

32 Strategies to increase antibiotic cellular concentrations Inhibition of efflux P-gp Inhalation A B Parenteral B A 15 control 15 control Pgp-inhibitor Pgp-inhibitor Calu-3 cell Papp, 10-6 c m s Papp, 10-6 c m s C IP LVX MXF C IP LVX MXF fluoroquinolone fluoroquinolone Pgp activity modulates fluoroquinonolone concentrations to different extents Adapted from Brillault et al, AAC 2010; 54: /06/2017 ECSF antibiotic targeting 38

33 Strategies to increase antibiotic cellular concentrations Modulation of distribution: use of delivery systems gentamicin (GE) + surfactant (AT [bis(2-ethylhexyl) sulfosuccinate sodium salt]) 2 + poly(d,l-lactide-co-glycolide) (PLGA) µg/mg cell protein soluble fraction granules fraction nuclear fraction Cc/Ce = 1.3 Cc/Ce = 4.0 Cc/Ce = 12.0 GE GE-AT GE-AT 752H P S. aureus Delivery systems can help delivering antibiotics to different subcellular compartments L. monocytogenes Imbuluzqueta et al. Acta Biomater. 2011; 7: ; JAC 2012; 67: /06/2017 ECSF antibiotic targeting 39 lo g C F U fro m tim e 0 lo g C F U fro m tim e Control control 752H P 752H P GE G E * * * GE-AT G E-A T 752H P GE-AT G E-A T 752H P 24 h 12 h *

34 Take home messages Antibiotic access to bacteria is made difficult in CF lung by mucus/specific modes of life Enzymes and AC already used in the clinics but no direct demonstration of their adjuvant efficacy towards infections Many strategies evaluated in vitro still lacking in vivo and/or clinical evaluation A lot of work needed. 09/06/2017 ECSF antibiotic targeting 40

35 Acknowledgments Paul Tulkens Cristina Seral Wafi Siala Sandrine Lemaire Hugues Chanteux Jean-Michel Michot Edurne Imbuluzqueta Marie-Paule Mingeot-Leclercq 09/06/2017 ECSF antibiotic targeting 41