- Molecular FormulaC13H17N5O8S2
- Average mass435.433 Da
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. This may include bone infections, endometritis, intra abdominal infections, pneumonia, urinary tract infections, and sepsis. It is given by intravenous or intramuscular injection or by inhalation.
Common side effects when given by injection include pain at the site of injection, vomiting, and rash. Common side effects when inhaled include wheezing, cough, and vomiting. Serious side effects include Clostridium difficile infection and allergic reactions including anaphylaxis. Those who are allergic to other β-lactam have a low rate of allergy to aztreonam. Use in pregnancy appears to be safe. It is in the monobactam family of medications. Aztreonam inhibits cell wall synthesis by blocking peptidoglycan crosslinking to cause bacterial death.
Aztreonam was approved for medical use in the United States in 1986. It was removed from the World Health Organization’s List of Essential Medicines in 2019. It is available as a generic medication. It is a manufactured version of a chemical from the bacterium Chromobacterium violaceum.
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.
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. The following represents minimum inhibitory concentration (MIC) susceptibility data for a few medically significant microorganisms.
- 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.
ACS Medicinal Chemistry Letters, 11(2), 162-165; 2020
Neal G. Anderson, Carl F. Anderson, “Delta form of aztreonam and preparation thereof.” U.S. Patent US4826973, issued January, 1983.
wherein R is acyl. The process comprises acylating azetidin with 2-(2-amino-4-thiazolyl)-2-(Z)-(alkoxyimino) acetic acid in the presence of 1-hydroxy-benzotriazole and dicyclohexylcarbodiimide.
is a 4, 5, 6 or 7 membered heterocyclic ring having at least one nitrogen atom in the ring or such a group fused to a phenyl or substituted phenyl ring, to form a compound of formula (I):
in which Het is an optionally amino-substituted, 5- or 6-membered, aromatic heterocycle containing 1 or 2 nitrogen atoms and optionally also an oxygen or sulphur atom, R1 may be lower alkoxycarbonyl-lower alkyl and R2 may be lower alkyl. The process entails acylating a compound of formula (II):
in which Het is as above and R10 has any of the values of R1. U.S. Pat. No. 4,652,651 discloses that where R10 is a lower alkoxycarbonyl-lower alkyl group, for example the t-butoxycarbonylmethyl group, this can be converted, if desired, into the corresponding carboxylower alkyl group by treatment with a strong acid such as trifluoroacetic acid (optionally in the presence of anisole), hydrochloric acid or p-toluenesulphonic acid at a low temperature such as −10° C. to room temperature.
SUMMARY OF THE INVENTION
- Aztreonam: 99.22%
- Aztreonam t-butyl ester: 0.44%
HPLC Impurity Profile of Sample from Reaction Mixture:
- Aztreonam: 82.20%
- Aztreonam t-butyl ester: 0.43%
- Aztreonam, open-chained: 7.22%
- Other main degradation product (RRT=0.56): 5.24%
- Aztreonam: 99.65%
- Aztreonam t-butyl ester: 0.21%
HPLC Impurity Profile of Sample from Reaction Mixture:
- Aztreonam: 89.43%
- Aztreonam t-butyl ester: 0.26%
- Aztreonam, open-chained: 4.70%
- Other main degradation product (RRT=0.56): 1.47%
This mixture was sterilized for 15 minutes at 121°C at 15 lbs/inch2 steam pressure prior to use. The fermentation flasks were incubated at 25°C for 40 to 45 hours on a of rotary shaker. A 250 liter batch of Agrobacterium radiobacter A.T.C.C. No. 31700 is fermented in a 100 gallon steel vessel with a media and operating conditions described below. Culture of Agrobacterium radiobacter grown out on agar slants, pH 7.3 consisted of yeast extract (1 g), beef extract (1 g), NZ amine A (2 g), glucose (10 g), agar (15 g) in 1000 ml distilled water. Loopful of surface growth from agar slant was used as the source of incolumn. Medium of oatmeal (20 g), tomato paste (20 g) tapped water to 1000 ml, pH 7, was sterilized for 15 min at 121°C at 15 lbs/inch2 steam pressure prior to use. 100 ml of the medium, containing incolumn is incubated at 25°C for about 24 hours on a rotary shaker. It was added to a mixture of yeast extract (5 g), glucose (10 g) in 1 L distilled water and incubated for about 42 hours at 25°C in 100 gallon stainless steel fermentation vessel.
During incubation, the broth is agitated at 155 r.p.m. and aerated at rate of 10.0 cubic feet per minute. An antifoam agent (Ucon LB625, Union Carbide) was added as needed. The fermentation beer was adjusted to pH 4 with aqueous HCl and calls separated by centrifugation. The supernatante (200 L) was extracted with 40 L of 0.05 m cetyldimethylbenzyl ammonium chloride in dichloromethane and extract concentrated in vacuo to 5.5 L. The concentrate was then extracted with solution of 177 g of sodium thiocyanate in 2 L of water, adjusting the mixture of pH 4.35 with phosphoric acid. The aqueous extract was concentrated in vacuo to 465 ml and added to 1840 ml of methanol. Solids are filtrated yielded 194 g of crude solid product. It was dissolved and chromatographed on a 5×106.5 cm column of Sephadex G-10 three times and after concentrating in vacuo gave 3.5 g of crude antibiotic M53 (azetreonam) which was chromatographed at first on QAE Sephadex A- 25 (liner gradient, prepared from 2.5 L of water and 2.5 L of 0.25 M sodium nitrate). Then the residue (fractions 26-75) gave M53 (natrium salt) after evaporation. It was triturated with methanol and the souble fraction, 0.40 g was chromatographed on a 2.5×20 cm column of Diaion HP20AG, eluting at 2 ml per minute with water and collecting 20 ml fractions. Fractions 26-75 gave 51.9 mg of antibiotic M53 (sodium salt).
Aztreonam, (Z)-2[[[(2-amino-4-thiazolyl)[[(2S,3S)-2-methyl-4-oxo-1-sulfo-3-azetidinyl]cabamoyl]methylen]amino]oxy]-2-methylpropionoic acid (188.8.131.52), is synthesized from tert-butyloxycarbonylthreonine, which is reacted with O-benzylhydroxylamine in the presence of dicyclohexylcarbodimide and 1-hydroxybenzotriazole, to form the benzyl hydroxamide derivative (184.108.40.206). This product undergoes a reaction with triphenylphosphine and ethyl azodicarboxylate, which results in the cyclodehydration of the product to (3S-trans)-N-benzyloxy-3-tert-butyloxycarbonylamino-4-methyl-azetidinone (220.127.116.11). Debenzylating this by hydrogen reduction using a palladium on carbon catalyst forms (3S-trans)-N-hydroxy-3-tertbutyloxycarbonyl-amino-4-methyl-azetidinone (18.104.22.168). The hydroxyl group in this compound is removed by reducing it with titanium trichloride, which forms azetidinone (22.214.171.124). Removing the tert-butyloxycarbonyl protection using trifluoroacetic acid and subsequent acylation of the resulting product with the benzyl chloroformate gives (3S-trans)-benzyloxycarbonylamino-4-methylazetidinone (126.96.36.199). Sulfonating this product with a mixture of sulfur trioxide and dimethylformamide gives the corresponding N-sulfonic acid. Turning the resulting Nsulfonic acid into a potassium salt by reacting it with potassium hydrophosphate, followed by replacing the potassium cation with a tetrabutylammonium cation by reacting it with tetrabutylammonium sulfate gives the product (188.8.131.52). Reducing this with hydrogen using a palladium on carbon catalyst gives 3-amino-4-methyl-monobactamic acid (184.108.40.206). Acylating this with (Z) 2-amino-α-[[2-(diphenylmethoxy)-1,1-dimethyl-2-oxoethoxy]imino] 4-thiazoleacetic acid in the presence of dicyclohexylcarbodiimide and 1-hydroxy-benzotriazole gives the diphenylmethyl ester of the desired aztreonam (220.127.116.11), which is hydrolyzed to aztreonam (18.104.22.168) using trifluoroacetic acid.
It is believed that the methyl group at position 4 increases the stability of the beta-lactam ring with respect to most beta-lactamases, and at the same time it does not induce formation of beta-lactamase as cephalosporins and imipenems do.
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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.
Aztreonam is often used in people who are penicillin allergic or who cannot tolerate aminoglycosides.[medical citation needed]
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. It received conditional approval for administration in Canada and the European Union in September 2009, and has been fully approved in Australia.
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. 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.
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. Aztreonam is bactericidal, but less so than some of the cephalosporins.[medical citation needed]
- ^ Jump up to:a b c d e f g h i j k l “Aztreonam”. The American Society of Health-System Pharmacists. Retrieved 8 December 2017.
- ^ British national formulary : BNF 69 (69 ed.). British Medical Association. 2015. p. 381. ISBN 9780857111562.
- ^ 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.
- ^ 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.
- ^ Yaffe SJ, Aranda JV (2010). Neonatal and Pediatric Pharmacology: Therapeutic Principles in Practice. Lippincott Williams & Wilkins. p. 438. ISBN 9780781795388.
- ^ 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.
- ^ Mosby’s Drug Consult 2006 (16th ed.). Mosby, Inc. 2006.
- ^ “Aztreonam Susceptibility and Minimum Inhibitory Concentration (MIC) Data” (PDF). toku-e.com. 3 February 2020.
- ^ 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.
- ^ “Aztreonam spectrum of bacterial susceptibility and Resistance” (PDF). Retrieved 15 May 2012.
- ^ Jump up to:a b Larkin C (22 February 2010). “Gilead’s Inhaled Antibiotic for Lungs Wins Approval”. BusinessWeek. Archived from the original on 2 March 2010. Retrieved 5 March 2010.
- ^ “FDA approves Gilead cystic fibrosis drug Cayston”. BusinessWeek. 23 February 2010. Retrieved 5 March 2010.
- ^ Jump up to:a b AHFS Drug Information 2006 (2006 ed.). American Society of Health-System Pharmacists. 2006.
- ^ Terico, AT; Gallagher, JC (December 2014). “Beta-lactam hypersensitivity and cross-reactivity”. Journal of Pharmacy Practice. 27 (6): 530–44. doi:10.1177/0897190014546109. PMID 25124380. S2CID 19275020.
- “Aztreonam”. Drug Information Portal. U.S. National Library of Medicine.
|Trade names||Azactam, Cayston, others|
|Intravenous, intramuscular, inhalation|
|Bioavailability||100% (IM) 0.1% (by mouth in rats) Unknown (by mouth in humans)|
|Metabolism||Liver (minor %)|
|Elimination half-life||1.7 hours|
|CompTox Dashboard (EPA)|
|Chemical and physical data|
|Molar mass||435.43 g·mol−1|
|3D model (JSmol)|
|Melting point||227 °C (441 °F) (dec.)|
Publication numberPriority datePublication dateAssigneeTitle
////////////////Aztreonam, SQ 26776, antibacterial, lactam, monobactam, UA2451400, азтреонам , أزتريونام , 氨曲南 ,