Fosfomycin

Fosfomycin, sold under the brand name BERNY among others, is an antibiotic primarily used to treat bladder infections.[1] It is not recommended for kidney infections.[1] Occasionally it is used for prostate infections.[1] It is generally taken by mouth.[1]

Not to be confused with Fosmidomycin.
Fosfomycin
Clinical data
Trade namesMonuril, Monurol, others
Other namesPhosphomycin, phosphonomycin, fosfomycin tromethamine
AHFS/Drugs.comMonograph
MedlinePlusa697008
Routes of
administration		By mouth
ATC code
Legal status
Legal status
Pharmacokinetic data
Bioavailability30–37% (by mouth, fosfomycin tromethamine); varies with food intake
Protein bindingNil
MetabolismNil
Elimination half-life5.7 hours (mean)
ExcretionKidney and fecal, unchanged
Identifiers
CAS Number
PubChem CID
DrugBank
ChemSpider
UNII
KEGG
ChEBI
ChEMBL
CompTox Dashboard (EPA)
ECHA InfoCard100.041.315
Chemical and physical data
FormulaC3H7O4P
Molar mass138.059 g·mol−1
3D model (JSmol)
Melting point94 °C (201 °F)
  (verify)

Common side effects include diarrhea, nausea, headache, and vaginal yeast infections.[1] Severe side effects may include anaphylaxis and Clostridium difficile-associated diarrhea.[1] While use during pregnancy has not been found to be harmful, such use is not recommended.[2] A single dose when breastfeeding appears safe.[2] Fosfomycin works by interfering with the production of the bacterial cell wall.[1]

Fosfomycin was discovered in 1969 and approved for medical use in the United States in 1996.[1][3] It is on the World Health Organization's List of Essential Medicines.[4] The World Health Organization classifies fosfomycin as critically important for human medicine.[5] It is available as a generic medication.[6] It was originally produced by certain types of Streptomyces, although it is now made chemically.[3]

Medical uses

Fosfomycin is used to treat bladder infections, where it is usually given as a single dose by mouth.[7]

It is not recommended for children and those over 75 years old.[8]

Additional uses have been proposed.[9] The global problem of advancing antimicrobial resistance has led to a renewed interest in its use more recently.[10]

Bacterial sensitivity

The fosfomycin molecule has an epoxide or oxirane ring, which is highly strained and thus very reactive.

Fosfomycin has broad antibacterial activity against both Gram-positive and Gram-negative pathogens, with useful activity against E. faecalis, E. coli, and various Gram-negatives such as Citrobacter and Proteus. Given a greater activity in a low-pH milieu, and predominant excretion in active form into the urine, fosfomycin has found use for the prophylaxis and treatment of UTIs caused by these uropathogens. Of note, activity against S. saprophyticus, Klebsiella, and Enterobacter is variable and should be confirmed by minimum inhibitory concentration testing. Activity against extended-spectrum β-lactamase-producing pathogens, notably ESBL-producing E. coli, is good to excellent, because the drug is not affected by cross-resistance issues. Existing clinical data support use in uncomplicated UTIs, caused by susceptible organisms. However, susceptibility break-points of 64 mg/l should not be applied for systemic infections.

Resistance

Development of bacterial resistance under therapy is a frequent occurrence and makes fosfomycin unsuitable for sustained therapy of severe infections. Mutations that inactivate the nonessential glycerophosphate transporter render bacteria resistant to fosfomycin.[11][12][13]

Prescribing fosfomycin together with at least another active drug reduces the risk of developing bacterial resistance. Fosfomycin acts synergistically with many other antibiotics, including cephalosporins, carbapenems, daptomycin and aminoglycosides. [14]

Enzymes conferring resistance to fosfomycin have also been identified and are encoded both chromosomally and on plasmids.[15]

Three related fosfomycin resistance enzymes (named FosA, FosB, and FosX) are members of the glyoxalase superfamily. These enzymes function by nucleophilic attack on carbon 1 of fosfomycin, which opens the epoxide ring and renders the drug ineffective.

The enzymes differ by the identity of the nucleophile used in the reaction: glutathione for FosA, bacillithiol for FosB,[16][17] and water for FosX.[15]

In general, FosA and FosX enzymes are produced by Gram-negative bacteria, whereas FosB is produced by Gram-positive bacteria.[15]

FosC uses ATP and adds a phosphate group to fosfomycin, thus altering its properties and making the drug ineffective.[18]

Side effects

The drug is well tolerated and has a low incidence of harmful side effects.[7]

Mechanism of action

Despite its name (ending in -omycin) Fosfomycin is not a macrolide. Fosfomycin is bactericidal and inhibits bacterial cell wall biogenesis by inactivating the enzyme UDP-N-acetylglucosamine-3-enolpyruvyltransferase, also known as MurA.[19] This enzyme catalyzes the committed step in peptidoglycan biosynthesis, namely the ligation of phosphoenolpyruvate (PEP) to the 3'-hydroxyl group of UDP-N-acetylglucosamine. This pyruvate moiety provides the linker that bridges the glycan and peptide portion of peptidoglycan. Fosfomycin is a PEP analog that inhibits MurA by alkylating an active site cysteine residue (Cys 115 in the Escherichia coli enzyme).[20][21]

Fosfomycin enters the bacterial cell through the glycerophosphate transporter.[22]

History

Fosfomycin (originally known as phosphonomycin) was discovered in a joint effort of Merck and Co. and Spain's Compañía Española de Penicilina y Antibióticos (CEPA). It was first isolated by screening broth cultures of Streptomyces fradiae isolated from soil samples for the ability to cause formation of spheroplasts by growing bacteria. The discovery was described in a series of papers published in 1969.[23] CEPA began producing fosfomycin on an industrial scale in 1971 at its Aranjuez facility.[24]

Manufacture

The complete fosfomycin biosynthetic gene cluster from Streptomyces fradiae has been cloned and sequenced and the heterologous production of fosfomycin in S. lividans has been achieved by Ryan Woodyer of the Huimin Zhao and Wilfred van der Donk research groups.[25]

References
  1. "Fosfomycin Tromethamine Monograph for Professionals". Drugs.com. Retrieved 29 October 2019.
  2. "Fosfomycin (Monurol) Use During Pregnancy". Drugs.com. Retrieved 29 October 2019.
  3. Finch, Roger G.; Greenwood, David; Whitley, Richard J.; Norrby, S. Ragnar (2010). Antibiotic and Chemotherapy E-Book. Elsevier Health Sciences. p. 259. ISBN 9780702047657.
  4. World Health Organization (2019). World Health Organization model list of essential medicines: 21st list 2019. Geneva: World Health Organization. hdl:10665/325771. WHO/MVP/EMP/IAU/2019.06. License: CC BY-NC-SA 3.0 IGO.
  5. World Health Organization (2019). Critically important antimicrobials for human medicine (6th revision ed.). Geneva: World Health Organization. hdl:10665/312266. ISBN 9789241515528.
  6. British national formulary : BNF 76 (76 ed.). Pharmaceutical Press. 2018. pp. 560–561. ISBN 9780857113382.
  7. Patel SS, Balfour JA, Bryson HM (April 1997). "Fosfomycin tromethamine. A review of its antibacterial activity, pharmacokinetic properties and therapeutic efficacy as a single-dose oral treatment for acute uncomplicated lower urinary tract infections". Drugs. 53 (4): 637–56. doi:10.2165/00003495-199753040-00007. PMID 9098664. S2CID 46972404.
  8. "MONURIL SACHETS 3G". Retrieved May 26, 2014.
  9. Falagas ME, Giannopoulou KP, Kokolakis GN, Rafailidis PI (April 2008). "Fosfomycin: use beyond urinary tract and gastrointestinal infections". Clinical Infectious Diseases. 46 (7): 1069–77. doi:10.1086/527442. PMID 18444827.
  10. Falagas ME, Grammatikos AP, Michalopoulos A (October 2008). "Potential of old-generation antibiotics to address current need for new antibiotics". Expert Review of Anti-Infective Therapy. 6 (5): 593–600. doi:10.1586/14787210.6.5.593. PMID 18847400. S2CID 13158593.
  11. Navas J, León J, Arroyo M, García Lobo JM (October 1990). "Nucleotide sequence and intracellular location of the product of the fosfomycin resistance gene from transposon Tn2921". Antimicrobial Agents and Chemotherapy. 34 (10): 2016–8. doi:10.1128/AAC.34.10.2016. PMC 171982. PMID 1963292.
  12. Kahan FM, Kahan JS, Cassidy PJ, Kropp H (May 1974). "The mechanism of action of fosfomycin (phosphonomycin)". Annals of the New York Academy of Sciences. 235 (1): 364–86. Bibcode:1974NYASA.235..364K. doi:10.1111/j.1749-6632.1974.tb43277.x. PMID 4605290.
  13. Castañeda-García A, Blázquez J, Rodríguez-Rojas A (April 2013). "Molecular Mechanisms and Clinical Impact of Acquired and Intrinsic Fosfomycin Resistance". Antibiotics. 2 (2): 217–36. doi:10.3390/antibiotics2020217. PMC 4790336. PMID 27029300.
  14. Antonello RM, Principe L, Maraolo AE, Viaggi V, Pol R, Fabbiani M, et al. (August 2020). "Fosfomycin as Partner Drug for Systemic Infection Management. A Systematic Review of Its Synergistic Properties from In Vitro and In Vivo Studies". Antibiotics. 9 (8): 500. doi:10.3390/antibiotics9080500. PMC 7460049. PMID 32785114.
  15. Rigsby RE, Fillgrove KL, Beihoffer LA, Armstrong RN (2005). "Fosfomycin resistance proteins: a nexus of glutathione transferases and epoxide hydrolases in a metalloenzyme superfamily". Gluthione Transferases and Gamma-Glutamyl Transpeptidases. Methods in Enzymology. 401. pp. 367–379. doi:10.1016/S0076-6879(05)01023-2. ISBN 9780121828066. PMID 16399398.
  16. Sharma SV, Jothivasan VK, Newton GL, Upton H, Wakabayashi JI, Kane MG, et al. (July 2011). "Chemical and Chemoenzymatic syntheses of bacillithiol: a unique low-molecular-weight thiol amongst low G + C Gram-positive bacteria". Angewandte Chemie. 50 (31): 7101–4. doi:10.1002/anie.201100196. PMID 21751306.
  17. Roberts AA, Sharma SV, Strankman AW, Duran SR, Rawat M, Hamilton CJ (April 2013). "Mechanistic studies of FosB: a divalent-metal-dependent bacillithiol-S-transferase that mediates fosfomycin resistance in Staphylococcus aureus". The Biochemical Journal. 451 (1): 69–79. doi:10.1042/BJ20121541. PMC 3960972. PMID 23256780.
  18. García P, Arca P, Evaristo Suárez J (July 1995). "Product of fosC, a gene from Pseudomonas syringae, mediates fosfomycin resistance by using ATP as cosubstrate". Antimicrobial Agents and Chemotherapy. 39 (7): 1569–73. doi:10.1128/aac.39.7.1569. PMC 162783. PMID 7492106.
  19. Brown ED, Vivas EI, Walsh CT, Kolter R (July 1995). "MurA (MurZ), the enzyme that catalyzes the first committed step in peptidoglycan biosynthesis, is essential in Escherichia coli". Journal of Bacteriology. 177 (14): 4194–7. doi:10.1128/jb.177.14.4194-4197.1995. PMC 177162. PMID 7608103.
  20. Zhu JY, Yang Y, Han H, Betzi S, Olesen SH, Marsilio F, Schönbrunn E (April 2012). "Functional consequence of covalent reaction of phosphoenolpyruvate with UDP-N-acetylglucosamine 1-carboxyvinyltransferase (MurA)". The Journal of Biological Chemistry. 287 (16): 12657–67. doi:10.1074/jbc.M112.342725. PMC 3339971. PMID 22378791.
  21. Krekel F, Samland AK, Macheroux P, Amrhein N, Evans JN (October 2000). "Determination of the pKa value of C115 in MurA (UDP-N-acetylglucosamine enolpyruvyltransferase) from Enterobacter cloacae". Biochemistry. 39 (41): 12671–7. doi:10.1021/bi001310x. PMID 11027147.
  22. Santoro A, Cappello AR, Madeo M, Martello E, Iacopetta D, Dolce V (December 2011). "Interaction of fosfomycin with the glycerol 3-phosphate transporter of Escherichia coli". Biochimica et Biophysica Acta (BBA) - General Subjects. 1810 (12): 1323–9. doi:10.1016/j.bbagen.2011.07.006. PMID 21791237.
  23. Silver LL (2011). "Chapter 2, Rational approaches to antibiotic discovery: pre-genomic directed and phenotypic screening". In Dougherty T, Pucci MJ (eds.). Antibiotic Discovery and Development. Springer. p. 46. doi:10.1007/978-1-4614-1400-1_2. ISBN 978-1-4614-1400-1.
  24. Encros About us: Our history. Archived 2011-09-14 at the Wayback Machine
  25. Woodyer RD, Shao Z, Thomas PM, Kelleher NL, Blodgett JA, Metcalf WW, et al. (November 2006). "Heterologous production of fosfomycin and identification of the minimal biosynthetic gene cluster". Chemistry & Biology. 13 (11): 1171–82. doi:10.1016/j.chembiol.2006.09.007. PMID 17113999.
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