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Ya nye govoryu po russki
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Phenotype
modification
Microcolonies EPS production
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Source: World Health Organization /CDS
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CIM
Area under curve (AUC)
MIC
Pick MaxC
T
Pla
sma
con
cen
trat
ion
T1/2
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1940
1950
1960
1970
1980
Staphylococcus aureus resistance
N.gonorrhoeae resistance
First Inhibitors
Semisinthetic penicillins
H.Influenzae resistance
Clavulanic acid
Sulbactam (6-desaminopenicillin sulfona
Tazobactam
RESISTANCE TO BETALACTAMIC ANTIBIOTICS DUE TO BETALACTAMASES : CRONOLOGIC EVOLUTION AND SINTHESIS OF
INHIBITORS
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Ambler classification of ß-lactamases
ß-lactamases(based upon their amino acid sequences)
4 classes (A-B-C-D)
A- ß-lactamases IBL+ : penicillinases-BSBL-ESBL-KPC
B- metallo-ß-lactamases IBL- : carbapenemases (VIM-
IMP)
C- AmpC ß-lactamases (serine enzymes) IBL- : inductible
cephalosporinases, CMY
D- serine enzyme IBL+/-: oxacilinases (OXA)
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Schematic diagram of Ambler classification system
(Serine)
B-lactamase
Class B
(metallo)
Class A Class C Class D unnamed subclass B3
subclass B1 subclass B2
Sequence homology
Structural homology,
no sequence homology
No homology, hydrolyse by
different machanisms
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By the end of the 70´s, the first irreversible beta-lactamase
inhibitor (suicide) began to be clinically developed: the
clavulanic acid.
In parallel, there appeared the firsts reports on sulbactam,
another beta-lactamase suicidal inhibitor with pharmacodynamics
and clinical tolerance advantages over clavulanic acid.
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β-Lactamase inhibitors are most active against plasmid-encoded b-lactamases
The most common is TEM-1, so called for the initials of the original patient from whom the E coli β -lactamase containing isolate was derived.
There are also TEM-2; oxacillin-hydrolyzing enzymes OXA-1, -2, and -3; sulfhydro-inhibited enzymes SHV-1 and HMS; and PSE-1, -2, -3, and -4, originally thought to be enzymes found only in Pseudomonas but now found occasionally in E. coli.
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Sulbactam is a 6-desaminopenicillin sulfone
Sulbactam is a broader-spectrum b-lactamaseinhibitor than clavulanic acid
Sulbactam does not induce chromosomal β-lase, nor does it select for derepressed β-lase–producing bacteria
Sulbactam does not inhibit chromosomal β-lases
(Chromosomal β-lases of of Legionella and Bacteroides
are inhibited by β-lases inhibitors, as are some other
chromosomally mediated β-lases , such as the class IV
enzymes produced by Klebsiella)
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Sulbactam has pharmacokinetics in humans similar to those of amoxicillin
Sulbactam is excreted by the kidney and has a urinary recovery rate of 70 to 80% of a dose
It can be removed by hemodialysis
Concentrations of sulbactam in interstitial fluid and peritoneal secretions are comparable to levels in serum.
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Amoxicillin shows a better pharmacokinetics profile thanampicillin, allowing dosing at longer intervals and, inaddition, it has a high bactericidal activity againstS.pneumoniae
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Irreversible inhibitor of the majority of the most frequent βL in the clinical setting
Its higher stability in an aqueous solution
Possibility to be given by oral or parenteral (I.M. – I.V.) route
Good tissue penetration
It does not induce generation of bacterial β-lactamases
It exerts an own bactericidal activity against some species (N. gonorrhoeae and Acinetobacter)
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Mean plasma concentrations of amoxicillin and sulbactam
in 7 healthy volunteers, after the intake of one tablet
containing amoxicillin 250 mg and sulbactam 250 mg
Amoxicillin
Sulbactam
Hours
mcg/ml
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Amoxicillin and sulbactam plasma levels in Children with a
Single Dose (Ax 17 mg + Sb 17 mg) /kg1
Amoxicillin
Sulbactam
Am
oxic
illi
n an
d su
lbac
tam
m
g/L
T (h)
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Pharmacokinetics of Amoxicillin and Sulbactam in
pregnant and non pregnant women.
Amoxicillin Pregnancy
Amoxicillin non pregnancy
Sulbactam Pregnancy
Sulbactam non pregnancy
T (h)
Pla
smat
ic le
vels
mg/
L
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Since 1984……..
• In 1984 – in Argentina – our working group provided the first report (the first one at international level) on the combination of Amoxicillin – sulbactam
II Pan-American Congress of Infectology held in Buenos Aires
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Since 1984……..
TRIFAMOX IBL associates sulbactam withamoxicillin, thus recovering the originalactivity of amoxicillin and its greaterantimicrobial activity is evidenced againstmultiple microorganisms
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Since 1984……..
• Its most important medical use is for:
• URTI and LRTI: otitis, sinusitis, bronchitis, CAP
• Urinary tract and OBS-GYN infections
• Intra-abdominal infections
• In patients undergoing gyn surgery (prophylactic antibiotic)
• Skin and soft tissue infections.
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Bacterial Causes of Community Acquired
RTIs
Typical Atypical
• Streptococcus
pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis
• Staphlococcus aureus
(post influenza)
•Group A streptococcus
(Upper RTI)
Mycoplasma pneumoniae
• Chlamydophila
pneumoniae
• Chlamydophila psittaci
• Legionella pneumophila
• (Mycobacterium
tuberculosis)
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Causes of primary community acquired
pneumonia
Typical pathogens Atypical bacteria Viruses
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus
(Gran negative bacilli : e.g
Klebsiella pneumoniae)
Mycoplasma pneumoniae
Chlamydophila
pneumoniae
Legionella pneumophila
Coxiella sp
(M.tuberculosis)
Influenza A and
B
Parainfluenzae
Adenoviruses
RSV
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Comparative activity of AMX/SULB against other common antibiotics (RTIs)
ANTIMICROBIAL AGENTS
RESISTANT STRAINS %
n=55 n=44 n=19 n=52
S.pneumoniae H.influenzae S.pyogenes S.aureus
Amoxicillin (AMX) 9,1 12,3 0 96,9
AMX/sulbactam 7,3 0 0 46,9
Cefuroxime 7,3 0 0 56,3
Azithromycin 0 0 0 59,3
Clarithromycin 0 9,1 0 59,3
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First Argentinian clinical experiences
ACUTE OTITIS MEDIA, EFFICACY AND TOLERABILITY OF AMOXICILLIN-SULBACTAM COMBINATIONCLAVERO, Carlos A.Chief of OtorhinolaryngologyNational University of CórdobaLa Prensa Médica Argentina, 1990; (Ed. Esp.) 77: 20-23
Age (years)
Nº patients
0-56-910-1920-2930-3940-4950-58Total
3345942
30
TreatmentAdults:500/500<13 y:24mg/kg/day3/day; 5-12 d
Sulbactam administration (20 mg/kg) allowed to reach middle ear concentrations between 0.3 and 2.7 g/ml (serum concentrations 1.3 - 9 g/ml). (Reilly et al.)
Cure criterion in the study was exclusively clinical. Not any patient was submitted to tympanocentesis.
Adverse effectsDiarrhea was constated on 7 patients, being mild in 3, moderate in 3 and severe in 1 case
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THERAPEUTIC VALUE OF THE ASSOCIATION AMOXICILLIN-SULBACTAM ADMINISTERED EVERY 12 HOURS IN CHILDREN WITH ACUTE OTITIS MEDIA
MULTICENTRIC TRIAL
Aim : to assess the effectiveness and tolerability of amoxicillin + sulbactam (50/50 mg/kg/d total dose) administered orally twice daily, for the treatment of AOM in infants and children.
Coordinator: Prof. Enrique Mansilla. Head. Pediatric ORL Outpatient Service. Hospital de Clínicas. UBA. Buenos Aires.
Coordinator: Dr Andres Sibbald. Head. Department of Pediatrics. Hospital Británico. Buenos Aires
Rev Enf Infecciosas Ped 2000; 53:16-22
Treatment: amoxicillin + sulbactam 50/50 mg/kg/d, administering the total dose twice daily for 10 days
Results: 7 centers enrolled 231 patients; data from 222 of them were evaluated. In 41 cases miringocentesis was performed. The microorganisms more frequently isolated were: S. pneumoniae, H. influenzae, and M. catarrhalis.Otodynia decreased from 6.8 ± 0.11 to 2.3 ± 0.09 (p< 0.001) (days 1 and 10). There was also a dramatic improvement of clinical symptoms and otomicroscopic signs throughout the study.After a 10-day treatment period 100% of the patients had cure or improved.
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Common Causes of Pneumonia Listed
by Patient Age
Age Most Likely Organisms
Neonatal (0–1 month) Escherichia coli, Streptococcus
agalactiae (group B)
Infants (1–6 months) Chlamydia trachomatis, respiratory
syncytial virus
Children (6 months–5
years)
Respiratory syncytial virus,
parainfluenza viruses
Children (5–15 years) Mycoplasma pneumoniae, influenza
virus type A
Young adults (16–30
years)
Streptococcus pneumoniae ,M.
pneumoniae,
Older adults Streptococcus pneumoniae,
Haemophilus influenzae
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Treatment of LRTIsGuidelines????
0
2
4
6
8
1 0
1 2
1 4
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2007
Actualización de las recomendaciones ALAT sobre la neumonía adquirida en la comunidad. Grupo de trabajo de la Asociación Latinoamericana del Tórax (ALAT). Arch Bronconeumol 2004;40(8):364-74
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In vitro ATB activity against 7365 strains of S.pneumoniae-SENTRY*programm
USA Latinamérica Europa Asia Pacífico
n=4193 n=948 n=1478 n=746
ATB MIC 90 %R MIC 90 %R MIC 90 %R MIC 90 %R
Amoxicillin
Amoxi-sulb
Cafaclor
Cefuroxime
Cefotaxime
Clarithromycin
Azithromicin
2
2
>32
4
1
2
2
3.2
2.8
26.2
21.8
3.7
16.0
13.6
1
2
>32
4
1
0.5
0.5
0.51
0.4
21.7
15.8
1.8
9.8
8.6
1.7
2
>32
4
1
>32
>16
2
1.7
21.1
16.6
2.6
18.2
17.8
2
>32
8
1
>32
>16
0
0
35.7
29.1
3.7
38.7
36.7
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H.influenzae
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in vitro ATB activity against 7365 strains of
H.influenzae- SENTRY-programm
USA Latinamérica Europa Asia
Pacífico
n=4193 n=948 n=1478 n=746
ATB MIC 90 %R MIC 90 %R MIC 90 %R MIC 90 %R
Amoxicillin
Amoxi-sulb
Cefuroxime
Cefotaxime
Azithromycin
>8
2
2
0.03
2
31.5
0.3
0.6
0
0.5
>8
1
2
0.03
2
12.5
0
0
0
0.4
8
1
2
0.03
2
11.8
0.2
0
0
0.2
>8
1
4
0.03
1
16.2
0
0.4
0.03
0.2
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AMOXICILLIN-SULBACTAM COMBINATION IN THE TREATMENT OF
GYNECOLOGICAL BACTERIAL INFECTIONS (Prensa Med Arg; 1992; 79: 3-6.).
AMOXICILLIN + SULBACTAM: EFFICACY AND TOLERABILITY STUDY IN THE TREATMENT
OF BACTERIAL VAGINOSIS (VII PANAMERICAN CONGRESS OF
INFECTOLOGY. VI LATINAMERICAN CONGRESS OF PEDIATRIC INFECTOLOGY.
VI COLOMBIAN CONGRESS OF INFECTOLOGY. CARTAGENA DE LAS INDIAS –
COLOMBIA. 1995)
TREATMENT OF GONOCOCCAL URETHRITIS AND CERVICITIS WITH AMOXICILLIN-
SULBACTAM. (Prensa Med Arg, 1992; 79: 24-27)
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OBS/GYN Infections
Diagnosis Microorganisms
Susceptibility
Amoxicillin Amoxicillin /Sulbactam
Bartholin’s gland abscess Staphylococcus aureus S S
Bartholin’s gland abscess Staphylococcus aureus S S
Bartholin’s gland abscess Staphylococcus epidermidis S S
Ovarian tube abscess Peptostreptococcus sp -- --
Abdominal wall abscess Streptococcus viridans
Bacteroides spp
----
----
---
---
Abdominal wall abscess Escherichia coli R S
Mammary abscess Staphylococcus aureus R S
Necrotic infected myoma Staphylococcus aureus R S
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AMOXICILLIN PLUS SULBACTAM IN THE ENDOMETRITIS TREATMENT VI WORLD
CONFERENCE ON CLINICAL PHARMACOLOGY AND THERAPEUTICS. (A. Farinati, C. Ortega
Soler; P. Pucheta; M. Jugo; R. Guntin; G. Peñalba Buenos Aires, Argentina , 1996.)
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“IN VIVO” EFFICACY OF AMOXICILLIN – SULBACTAM ASSOCIATION IN URINARY
TRACT INFECTIONS (Prensa Med Arg, 1990; 77: 49-50 )
MANAGEMENT OF URINARY TRACT INFECTIONS WITH AMOXICILLIN SULBACTAM
(Prensa Med Arg, 1992; 79: 21-23)
EFFECTIVENESS OF AMOXICILLIN-SULBACTAM IN THE TREATMENT OF URINARY TRACT
INFECTIONS (XXVIII ARGENTINE CONGRESS OF PEDIATRICS( Buenos Aires , Argentina, 1988.)
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Amoxicillin sulbactam (Trifamox IBL) in UTI
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In vivo studies
Infection types N Efficacy (range)
Urinary Tract InfectionsObs/GynPediatric Upper Respiratory Tract InfectionsPediatric Lower Respiratory Tract InfectionsSTI (Non Disseminated N.gonorrhoeae)
19164 15397233
91 (83-99)94 (90-98)97 (94-100)100 (97-100)93,5 (90-97)
OthersCholecistytisSurgical p, CAP, PPB
364 90 (87-94)
H.L MuguerciaACTA MÉDICA 2000;9(1-2):96-100Cuba
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Clinical studies of the combination of sulbactam plus amoxicillin have revealed
no major renal, hematologic, hepatic, or central nervous system reactions
Sulbactam- amoxicillin has been used in the treatment of mixed bacterial infections such
as intra-abdominal infections, obstetric and gynecologic infections, and soft tissue and
bone infections.
It has been used to treat meningitis in infants and children and to treat epiglottitis and
selected other pediatric infections but third-generation cephalosporins would be preferred
in such infections.
Clinical experiences support the use in empirical treatment of upper and lower
respiratory tract infections
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