Ceftobiprole: a new beta-lactam antibiotic.

The increasing threat of antimicrobial resistance in general, and that of methicillin-resistant Staphylococcus aureus (MRSA) in particular, is raising significant medical, economical and public health challenges worldwide, both within hospitals and throughout the community. These considerations, along with the extensive time and costs associated with the development and approval of new therapeutic agents, represent some of the major reasons why understanding the advantages and limitations of new antibiotics, ensuring their judicious use and maximising their active shelf life should become global priorities. On March 18, 2008, the Food and Drug Administration issued an approvable letter for ceftobiprole, a broad-spectrum beta-lactam antibiotic active against MRSA and other clinically relevant Gram-positive and Gram-negative pathogens. Ceftobiprole is currently available only for parenteral administration, and besides its remarkable antimicrobial spectrum, this antibiotic possesses additional desirable characteristics, such as low propensity to select for resistance, efficacy in animal models of disease and good safety profile. Furthermore, in recently completed clinical trials, ceftobiprole demonstrated non-inferiority to comparator compounds such as vancomycin, and emerged as a promising clinical option of monotherapy for the treatment of complicated skin and skin structure infections and community-acquired pneumonia. Here, we discuss some of the most important clinically relevant findings on ceftobiprole obtained from in vitro studies, animal models of disease and recently completed phase III clinical trials.

Angiotensin-converting enzyme: induction by hypertension-induced vessel distension.

Vascular angiotensin-converting enzyme (ACE) activity is increased in a variety of disorders representing both early and late stages of atherosclerosis. The factors governing the induction of vascular ACE are poorly understood. We hypothesized that vascular ACE activity might be increased by hypertension-induced vessel distension. Hypertension was induced in rats by suprarenal coarctation of the aorta. Analyses were performed 5 days and 4 weeks post-operation. ACE activity and ACE mRNA level were increased in thoracic aortae from coarctation hypertensive rats that had been exposed to elevated blood pressure, whereas they remained at normal level in abdominal aortae from those rats that had been exposed to normal blood pressure. The degree of aortic ACE induction correlated well with the degree of the trans-stenotic blood pressure gradient. An increase in ACE transcript level was also observed in carotid arteries from coarctation hypertensive rats that had been exposed to elevated blood pressure. In contrast, ACE activity and ACE mRNA expression were not altered in tissues that did not contain any large arteries from coarctation hypertensive rats, although these tissues had been exposed to elevated blood pressure. These results demonstrate an induction of ACE in large arteries that had been exposed to elevated blood pressure, and they imply that the induction of vascular ACE is due to hypertension-induced vessel distension.

Enhanced angiotensin-converting enzyme activity and impaired endothelium-dependent vasodilation in aortae from hypertensive rats: evidence for a causal link.

Endothelial vasomotor function is impaired in a variety of disorders representing both early and late stages of atherosclerosis. There is experimental evidence for enhanced vascular angiotensin-converting enzyme (ACE) activity in these disorders. We explored whether enhanced vascular ACE activity accounts for endothelial dysfunction in experimental hypertension. Hypertension was induced in rats by coarctation of the aorta. At 2 weeks post-operation, the animals were randomly divided into groups receiving the ACE inhibitor quinapril (2.0 mg.kg(-1).day(-1)), the angiotensin type-1 receptor antagonist losartan (3.0 mg.kg(-1).day(-1)), the B(2) kinin receptor antagonist icatibant (0.4 mg.kg(-1).day(-1)), quinapril plus icatibant, losartan plus icatibant, or no drug. Analyses were performed 4 weeks post-operation. None of the drug treatments had any significant effect on blood pressure. ACE activity was nearly doubled in aortae from untreated hypertensive rats as compared with sham-operated rats. Quinapril reduced ACE activity in aortae from hypertensive rats by 75%, losartan caused a 40% decrease, and icatibant had no effect. Endothelium-dependent, nitric oxide-mediated vasodilator responses studied in vitro were impaired by 40% in aortae from untreated hypertensive rats as compared with sham-operated rats. Both quinapril and losartan restored endothelial vasomotor function in aortae from hypertensive rats. Co-applied icatibant negated the effects of quinapril, but not those of losartan. The level of endothelial NO synthase (eNOS) mRNA determined by competitive RNA PCR was decreased by half in aortae from untreated hypertensive rats as compared with sham-operated rats. Quinapril induced an increase in the eNOS mRNA level of 350% in aortae from hypertensive rats, which was negated by co-applied icatibant. Losartan restored eNOS mRNA expression in aortae from hypertensive rats to normal levels, and this effect was not modified by co-applied icatibant. These findings suggest that enhanced vascular ACE activity accounts for endothelial vasomotor dysfunction by impairing the bioavailability of endothelium-derived NO. Both enhanced formation of angiotensin II and enhanced metabolism of bradykinin might account for a vascular deficiency of bioactive NO.

Estradiol induces the calcium-dependent translocation of endothelial nitric oxide synthase.

Although estrogen is known to stimulate nitric oxide synthesis in vascular endothelium, the molecular mechanisms responsible for this effect remain to be elucidated. Using quantitative immunofluorescence imaging approaches, we have investigated the effect of estradiol on the subcellular targeting of endothelial nitric oxide synthase (eNOS) in bovine aortic endothelial cells. In unstimulated endothelial cells, eNOS is predominantly localized at the cell membrane. Within 5 min after the addition of estradiol, most of the eNOS translocates from the membrane to intracellular sites close to the nucleus. On more prolonged exposure to estradiol, most of the eNOS returns to the membrane. This effect of estradiol is evident at a concentration of 1 pM, and a maximal estradiol effect is seen at a concentration of 1 nM. Neither progesterone nor testosterone has any effect on eNOS distribution. After estradiol addition, a transient rise in intracellular Ca2+ concentration precedes eNOS translocation. Both the Ca2+-mobilizing and eNOS-translocating effects of estradiol are completely blocked by the estrogen receptor antagonist ICI 182,780, and the intracellular Ca2+ chelator 1,2-bis-(o-aminophenoxy)ethane-N,N,N',N'-tetraacetic acid (BAPTA) prevents estradiol-induced eNOS translocation. Use of the nitric oxide-specific dye diaminofluorescein shows that estradiol treatment increases nitric oxide generation by endothelial cells; this response is blocked by ICI 182,780 and by the eNOS inhibitor Nomega-nitro-L-arginine. These results show that estradiol induces subcellular translocation of eNOS by a rapid, Ca2+-dependent, receptor-mediated mechanism, and they suggest a nongenomic role for estrogen in the modulation of NO-dependent vascular tone.

Receptor-regulated translocation of endothelial nitric-oxide synthase.

The endothelial nitric-oxide synthase (eNOS) is activated by transient increases in intracellular Ca2+ elicited by stimulation of diverse receptors, including bradykinin B2 receptors on endothelial cells. eNOS and B2 receptors are targeted to specialized signal-transducing domains in the plasma membrane termed plasmalemmal caveolae. Targeting to caveolae facilitates eNOS activation following receptor stimulation, but in resting cells, eNOS is tonically inhibited by its interactions with caveolin, the scaffolding protein in caveolae. We used a quantitative approach exploiting immunofluorescence microscopy to investigate regulation of the subcellular distribution of eNOS in endothelial cells by bradykinin and Ca2+. In resting cells, most of the eNOS is localized at the cell membrane. However, within 5 min following addition of bradykinin, nearly all the eNOS translocates to structures in the cell cytosol; following more protracted incubations with bradykinin, most of the cytosolic enzyme subsequently translocates back to the cell membrane. The bradykinin-induced internalization of eNOS is completely abrogated by the intracellular Ca2+ chelator BAPTA; conversely, Ca2+-mobilizing drugs and agonists promote eNOS translocation. These results establish that eNOS targeting to the membrane is labile and is subject to receptor-regulated Ca2+-dependent reversible translocation, providing another point for regulation of NO-dependent signaling in the vascular endothelium.

The antiatherogenic potential of blocking the renin-angiotensin system.

Angiotensin converting enzyme (ACE) inhibitors have proved effective in preventing or ameliorating clinical manifestations of atherosclerosis, such as myocardial infarction (MI) and heart failure. Experimental evidence demonstrates their anti-atherogenic potential; ACE inhibitors do not only suppress the formation of proatherogenic angiotensin II (AII), but also enhance the formation and release of anti-atherogenic nitric oxide (NO) at local tissue sites; both mechanisms are implicated in the suppression of neointima formation in the balloon-injured vessel wall. A similar anti-atherogenic potential is provided by the blockade of the renin-angiotensin system (RAS) at the level of the angiotensin type-1 (AT1) receptor. AT1 receptor antagonists do not only block the proatherogenic actions of AII, but also induce an enhanced formation and release of anti-atherogenic NO at local tissue sites. AT1 receptor antagonists may therefore prove as effective as ACE inhibitors in patients with manifest atherosclerosis.

Increased expression of endothelial constitutive nitric oxide synthase in rat aorta during pregnancy.

The mechanisms underlying enhanced vascular reactivity in pregnancy are not yet defined. In this study we have investigated the potential role of endothelium-derived vasodilator nitric oxide (EDNO). EDNO-mediated dilatory responses in vitro were markedly increased in aorta of pregnant as compared with nonpregnant rats. This increase in EDNO-releasability was accompanied by a two-fold increase in mRNA of endothelial constitutive nitric oxide synthase (NOS-III). Chronically substituted estrogen, but neither progesterone nor testosterone induced an upregulation of NOS-III mRNA in aorta of gonadectomized rats which amounted to about half that induced in aorta of pregnant rats. Thus, increased EDNO-releasability and increased NOS-III mRNA contribute to enhanced vascular reactivity in pregnancy.

The endothelium and the renin-angiotensin system.

An enhanced risk for myocardial infarction has been observed in humans with sustained activation of the local and/or systemic renin-angiotensin system, such as a high renin-sodium profile or a heritably enhanced expression of angiotensin converting enzyme. Chronic renin-angiotensin system blockade by angiotensin converting enzyme inhibition reduces the rate of myocardial reinfarction in patients with moderate heart failure. Preliminary experimental evidence suggests that these clinical observations may be partially explained by a proatherogenic effect of an activated renin-angiotensin system, which can downregulate the expression of the endothelial nitric oxide synthase III. Nitric oxide exerts many potentially antiatherogenic effects on endothelium, platelets and low density lipoproteins and indirectly on monocytes and leukocytes Hypertension-induced chronic distension of elastic arteries upregulates the local renin-angiotensin system in these arteries and thereby downregulates nitric oxide synthase. Enhanced local synthesis of the trophic factor angiotensin-II and reduced releasability of the antitrophic factor nitric oxide appear to cooperate in the trophic adaptation of the distended vessel wall to the enhanced load, but with the disadvantage of enhanced susceptibility for atheroma development due to reduced availability of nitric oxide. Chronic blockade of the renin-angiotensin system by angiotensin converting enzyme inhibitors or by angiotensin receptor type-1 antagonists normalizes a reduced endothelial nitric oxide availability in several models, partially by a bradykinin-dependent mechanism. This endothelial protection proved to attenuate the progression of atherosclerosis in experimental models. The antiatherogenic potential of renin-angiotensin system blockade in humans is presently under study.

Vascular renin-angiotensin-system, endothelial function and atherosclerosis?

Clinical observations demonstrate an enhanced risk for myocardial infarction in patients with sustained activation of the local and/or systemic renin-angiotensin system, such as a high renin-sodium profile or a heritably enhanced expression of angiotensin converting enzyme. Chronic renin-angiotensin system blockade by angiotensin converting enzyme inhibition in patients with moderate heart failure reduces the rate of myocardial infarction and reinfarction. Preliminary experimental evidence suggests that these clinical observations may be partially explained by a proatherogenic effect of an activated renin-angiotensin system, which can downregulate the endothelial releasability of nitric oxide. Nitric oxide exerts many potentially antiatherogenic effects on endothelium, platelets and low density lipoproteins and indirectly on monocytes and leukocytes. Hypertension-induced chronic distension of elastic arteries upregulates the local renin-angiotensin system in these arteries and thereby downregulates nitric oxide releasability. Enhanced local synthesis of the trophic factor angiotensin-II and reduced releasability of the antitrophic factor nitric oxide appear to cooperate in the trophic adaptation of the distended vessel wall to the enhanced load, but with the disadvantage of enhanced susceptibility for atheroma development due to reduced releasability of nitric oxide. Chronic blockade of the renin angiotensin system by angiotensin converting enzyme inhibitors or by angiotensin receptor type-1 antagonists normalizes a reduced endothelial releasability of nitric oxide in several models, partially by a bradykinin-dependent mechanism. This endothelial protection proved to attenuate the progression of atherosclerosis in experimental models. The antiatherogenic potential of renin angiotensin system blockade in humans is presently under study.

Peptides in coronary circulation: basis for therapeutic strategies.

Promising approaches towards new therapeutic strategies in coronary heart disease might emerge from an improved pathophysiological understanding of the role of certain peptides, which require a localizing event for their accumulation or expression in the coronary vasculature. Temporal myocardial ischaemia or hypoperfusion with reperfusion are such localizing acute events, which induce endothelial dysfunction and subsequent tissue damage in the affected myocardium. Peptides involved in these pathological processes are elements of the complement system, cell adhesion molecules on endothelial cells and on leukocytes, endothelial proteins affecting the coagulation cascade, and enzymes contributing to endothelial production of cytokines or superoxide anion. Protection against postischaemic reperfusion damage of the endothelium by antagonists or antibodies can be shown in experiments, and this endothelial protection appears crucial for reducing myocardial cell damage.