Aztreonam

Aztreonam, sold under the brand name Azactam among others, is an antibiotic used primarily to treat infections caused by gram-negative bacteria such as Pseudomonas aeruginosa.[1][2] This may include bone infections, endometritis, intra abdominal infections, pneumonia, urinary tract infections, and sepsis.[1] It is given by intravenous or intramuscular injection or by inhalation.[1]

Aztreonam
Clinical data
Trade namesAzactam, Cayston, others
AHFS/Drugs.comMonograph
License data
Pregnancy
category
  • AU: B1
Routes of
administration		Intravenous, intramuscular, inhalation
ATC code
Legal status
Legal status
Pharmacokinetic data
Bioavailability100% (IM) 0.1% (by mouth in rats) Unknown (by mouth in humans)
Protein binding56%
MetabolismLiver (minor %)
Elimination half-life1.7 hours
ExcretionKidney
Identifiers
  • 2-{[(1Z)-1-(2-Amino-1,3-thiazol-4-yl)-2-{[(2S,3S)-2-methyl-4-oxo-1-sulfoazetidin-3-yl]amino}-2-oxoethylidene]amino}oxy-2-methylpropanoic acid
CAS Number
PubChem CID
DrugBank
ChemSpider
UNII
KEGG
ChEBI
ChEMBL
CompTox Dashboard (EPA)
ECHA InfoCard100.071.652
Chemical and physical data
FormulaC13H17N5O8S2
Molar mass435.43 g·mol−1
3D model (JSmol)
Melting point227 °C (441 °F) (dec.)
  • O=S(=O)(O)N2C(=O)[C@@H](NC(=O)C(=N\OC(C(=O)O)(C)C)/c1nc(sc1)N)[C@@H]2C
  • InChI=1S/C13H17N5O8S2/c1-5-7(10(20)18(5)28(23,24)25)16-9(19)8(6-4-27-12(14)15-6)17-26-13(2,3)11(21)22/h4-5,7H,1-3H3,(H2,14,15)(H,16,19)(H,21,22)(H,23,24,25)/b17-8-/t5-,7-/m0/s1 checkY
  • Key:WZPBZJONDBGPKJ-VEHQQRBSSA-N checkY
  (verify)

Common side effects when given by injection include pain at the site of injection, vomiting, and rash.[1] Common side effects when inhaled include wheezing, cough, and vomiting.[1] Serious side effects include Clostridium difficile infection and allergic reactions including anaphylaxis.[1] Those who are allergic to other β-lactam have a low rate of allergy to aztreonam.[1] Use in pregnancy appears to be safe.[1] It is in the monobactam family of medications.[1] Aztreonam inhibits cell wall synthesis by blocking peptidoglycan crosslinking to cause bacterial death.[1]

Aztreonam was approved for medical use in the United States in 1986.[1] It was removed from the World Health Organization's List of Essential Medicines in 2019.[3][4] It is available as a generic medication.[1] It is a manufactured version of a chemical from the bacterium Chromobacterium violaceum.[5]

Medical uses

Nebulized forms of aztreonam are used to treat infections that are complications of cystic fibrosis and are approved for such use in Europe and the US; they are also used off-label for non-CF bronchiectasis, ventilator-associated pneumonia, chronic obstructive pulmonary disease, mycobacterial disease, and to treat infections in people who have received lung transplants.[6]

Aztreonam has strong activity against susceptible gram-negative bacteria, including Pseudomonas aeruginosa. It is resistant to some beta-lactamases, but is inactivated by extended-spectrum beta-lactamases.

It has no useful activity against gram-positive bacteria or anaerobes. It is known to be effective against a wide range of bacteria including Citrobacter, Enterobacter, E. coli, Haemophilus, Klebsiella, Proteus, and Serratia species.[7] The following represents minimum inhibitory concentration (MIC) susceptibility data for a few medically significant microorganisms.[8]

  • Staphylococcus aureus 8 - >128 μg/ml
  • Staphylococcus epidermidis 8 - 32 μg/ml
  • Streptococcus pyogenes 8 - ≥128 μg/ml

Synergism between aztreonam and arbekacin or tobramycin against P. aeruginosa has been suggested.[9]

Spectrum of activity

Acinetobacter anitratus, Escherichia coli, Pseudomonas aeruginosa, and Proteus mirabilis are generally susceptible to aztreonam, while some staphylococci, Staphylococcus aureus, Staphylococcus haemolyticus and Xanthomonas maltophilia are resistant to it. Furthermore, Aeromonas hydrophila, Citrobacter koseri (Citrobacter diversus), Pantoea agglomerans (Enterobacter agglomerans), Haemophilus spp. and Streptococcus pyogenes have developed resistance to aztreonam to varying degrees.[10]

Aztreonam can be safely used in patients with a penicillin or cephalosporin allergy (except for patients with a ceftazidime allergy as ceftazidime and aztreonam share a similar side chain).[11] It is also frequently used as an alternative to aminoglycosides because is not ototoxic or nephrotoxic.[12]

Aztreonam use has been recently reconsidered for human infections sustained by metallo-beta-lactamase (MBL)-producing Gram-negative bacteria. In these circumstances aztreonam is combined with avibactam (ceftazidime/avibactam). The combination of aztreonam and avibactam are in phase 3 clinical trails. [13] [14] The combination of aztreonam and avibactam has demonstrated to be active against 80% of MBL isolates reaching a clinical infection resolution in 80% of MBL-infected patients.[15]

Administration

Aztreonam is poorly absorbed when given orally, so it must be administered as an intravenous or intramuscular injection (trade name Azactam), or inhaled (trade name Cayston) using an ultrasonic nebulizer. In the United States, the Food and Drug Administration (FDA) approved the inhalation form on 22 February 2010, for the suppression of P. aeruginosa infections in patients with cystic fibrosis.[16] It received conditional approval for administration in Canada and the European Union in September 2009,[16] and has been fully approved in Australia.[17]

Side effects

Reported side effects include injection site reactions, rash, and rarely toxic epidermal necrolysis. Gastrointestinal side effects generally include diarrhea and nausea and vomiting. There may be drug-induced eosinophilia. Because of the unfused beta-lactam ring there is somewhat lower cross-reactivity between aztreonam and many other beta-lactam antibiotics, and it may be safe to administer aztreonam to many patients with hypersensitivity (allergies) to penicillins and nearly all cephalosporins.[18] There is a much lower risk of cross-sensitivity between aztreonam and other beta-lactam antibiotics than within other beta-lactam antibiotics. However, there is a higher chance of cross-sensitivity if a person is specifically allergic to ceftazidime, a cephalosporin. Aztreonam exhibits cross-sensitivity with ceftazidime due to a similar side chain.[19]

Mechanism of action

Aztreonam is similar in action to penicillin. It inhibits synthesis of the bacterial cell wall, by blocking peptidoglycan crosslinking. It has a very high affinity for penicillin-binding protein-3 and mild affinity for penicillin-binding protein-1a. Aztreonam binds the penicillin-binding proteins of Gram-positive and anaerobic bacteria very poorly and is largely ineffective against them.[18] Aztreonam is bactericidal, but less so than some of the cephalosporins.

References
  1. "Aztreonam". The American Society of Health-System Pharmacists. Retrieved 8 December 2017.
  2. British national formulary : BNF 69 (69 ed.). British Medical Association. 2015. p. 381. ISBN 9780857111562.
  3. World Health Organization (2019). Executive summary: the selection and use of essential medicines 2019: report of the 22nd WHO Expert Committee on the selection and use of essential medicines. Geneva: World Health Organization. hdl:10665/325773. WHO/MVP/EMP/IAU/2019.05. License: CC BY-NC-SA 3.0 IGO.
  4. World Health Organization (2019). The selection and use of essential medicines: report of the WHO Expert Committee on Selection and Use of Essential Medicines, 2019 (including the 21st WHO Model List of Essential Medicines and the 7th WHO Model List of Essential Medicines for Children). Geneva: World Health Organization. hdl:10665/330668. ISBN 9789241210300. ISSN 0512-3054. WHO technical report series;1021.
  5. Yaffe SJ, Aranda JV (2010). Neonatal and Pediatric Pharmacology: Therapeutic Principles in Practice. Lippincott Williams & Wilkins. p. 438. ISBN 9780781795388.
  6. Quon BS, Goss CH, Ramsey BW (March 2014). "Inhaled antibiotics for lower airway infections". Annals of the American Thoracic Society. 11 (3): 425–34. doi:10.1513/annalsats.201311-395fr. PMC 4028738. PMID 24673698.
  7. Mosby's Drug Consult 2006 (16th ed.). Mosby, Inc. 2006.
  8. "Aztreonam Susceptibility and Minimum Inhibitory Concentration (MIC) Data" (PDF). toku-e.com. 3 February 2020.
  9. Kobayashi Y, Uchida H, Kawakami Y (December 1992). "Synergy with aztreonam and arbekacin or tobramycin against Pseudomonas aeruginosa isolated from blood". The Journal of Antimicrobial Chemotherapy. 30 (6): 871–2. doi:10.1093/jac/30.6.871. PMID 1289363.
  10. "Aztreonam spectrum of bacterial susceptibility and Resistance" (PDF). Retrieved 15 May 2012.
  11. James CW, Gurk-Turner C (January 2001). "Cross-reactivity of beta-lactam antibiotics". Proceedings. 14 (1): 106–107. doi:10.1080/08998280.2001.11927741. PMC 1291320. PMID 16369597.
  12. Johnson DH, Cunha BA (1995). "Aztreonam". Medical Clinics of North America. 79 (4): 733–743. doi:10.1016/S0025-7125(16)30036-0. PMID 7791420.
  13. Pfizer (8 February 2023). "A PHASE 3 PROSPECTIVE, RANDOMIZED, MULTICENTER, OPEN-LABEL, CENTRAL ASSESSOR-BLINDED, PARALLEL GROUP, COMPARATIVE STUDY TO DETERMINE THE EFFICACY, SAFETY AND TOLERABILITY OF AZTREONAM-AVIBACTAM (ATM-AVI) ±METRONIDAZOLE (MTZ) VERSUS MEROPENEM±COLISTIN (MER±COL) FOR THE TREATMENT OF SERIOUS INFECTIONS DUE TO GRAM NEGATIVE BACTERIA, INCLUDING METALLO-Β-LACTAMASE (MBL) - PRODUCING MULTIDRUG RESISTANT PATHOGENS, FOR WHICH THERE ARE LIMITED OR NO TREATMENT OPTIONS". Innovative Medicines Initiative (IMI) COMBACTE-CARE (EU), Biomedical Advanced Research and Development Authority. {{cite journal}}: Cite journal requires |journal= (help)
  14. Pfizer (28 February 2023). "A PROSPECTIVE, RANDOMIZED,OPEN-LABEL, COMPARATIVE STUDY TO ASSESS THE EFFICACY, SAFETY AND TOLERABILITY OF AZTREONAM- AVIBACTAM (ATM-AVI) AND BEST AVAILABLE THERAPY FOR THE TREATMENT OF SERIOUS INFECTIONS DUE TO MULTI-DRUG RESISTANT GRAM- NEGATIVE BACTERIA PRODUCING METALLO -Β-LACTAMASE (MBL)". Allergan. {{cite journal}}: Cite journal requires |journal= (help)
  15. Mauri C, Maraolo AE, Di Bella S, Luzzaro F, Principe L (August 2021). "The Revival of Aztreonam in Combination with Avibactam against Metallo-β-Lactamase-Producing Gram-Negatives: A Systematic Review of In Vitro Studies and Clinical Cases". Antibiotics. 10 (8): 1012. doi:10.3390/antibiotics10081012. PMC 8388901. PMID 34439062.
  16. Catherine L (22 February 2010). "Gilead's Inhaled Antibiotic for Lungs Wins Approval". BusinessWeek. Archived from the original on 2 March 2010. Retrieved 5 March 2010.
  17. "FDA approves Gilead cystic fibrosis drug Cayston". BusinessWeek. 23 February 2010. Archived from the original on 1 March 2010. Retrieved 5 March 2010.
  18. AHFS Drug Information 2006 (2006 ed.). American Society of Health-System Pharmacists. 2006.
  19. Terico AT, Gallagher JC (December 2014). "Beta-lactam hypersensitivity and cross-reactivity". Journal of Pharmacy Practice. 27 (6): 530–544. doi:10.1177/0897190014546109. PMID 25124380. S2CID 19275020.
  • "Aztreonam". Drug Information Portal. U.S. National Library of Medicine.
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