Macrocycle-Antibiotic Hybrids: A Path To Clinical Candidates

REVIEW
published: 30 April 2021

doi: 10.3389/fchem.2021.659845
Macrocycle-Antibiotic Hybrids: A Path

to Clinical Candidates
Abdrrahman Shemsu Surur and Dianqing Sun *
Department of Pharmaceutical Sciences, The Daniel K. Inouye College of Pharmacy, University of Hawai‘i at Hilo, Hilo, HI,
United States
The tale of abate in antibiotics continued defense mechanisms that chaperone the rise of
drug-defying superbugs—on the other hand, the astray in antibacterial drug discovery and
development. Our salvation lies in circumventing the genesis of resistance. Considering the
competitive advantages of antibacterial chemotherapeutic agents equipped with multiple
warheads against resistance, the development of hybrids has rejuvenated. The adoption of
antibiotic hybrid paradigm to macrocycles has advanced novel chemical entities to clinical
trials. The multi-targeted TD-1792, for instance, retained potent antibacterial activities
against multiple strains that are resistant to its constituent, vancomycin. Moreover, the
antibiotic conjugation of rifamycins has provided hybrid clinical candidates with desirable
efficacy and safety profiles. In 2020, the U.S. FDA has granted an orphan drug designation
to TNP-2092, a conjugate of rifamycin and fluoroquinolone, for the treatment of prosthetic
joint infections. DSTA4637S is a pioneer antibacterial agent under clinical development
and represents a novel class of bacterial therapy, that is, antibody–antibiotic conjugates.
DSTA4637S is effective against the notorious persistent S. aureus bacteremia, a revelation
Edited by:
Pavel Padnya,
of the abracadabra potential of antibiotic hybrid approaches.
Kazan Federal University, Russia
Keywords: antibiotic hybrid, macrocycle, macrocycle hybrid, TD-1792, TD-1607, TNP-2092, TNP-2198, DSTA4637S
Reviewed by:
Frank Schweizer,
University of Manitoba, Canada INTRODUCTION
Lihua Yuan,
Sichuan University, China Relentlessness in developing resistance is imperiling the competence of the antibacterial arsenal.
*Correspondence: A global health crisis is heightened by the emergence and prevalence of multidrug-resistant
Dianqing Sun bacteria pathogens, which are untreatable with commonly used antibiotics (Aslam et al., 2018).
dianqing@hawaii.edu According to the landmark 2019 Centers for Disease Control and Prevention (CDC) estimate,
there are over 2.8 million antibiotic-resistant infections every year in the United States, which
Specialty section: account for a death every 15 min (CDC, 2019). The once though magic bullets are no longer
This article was submitted to producing magical chemotherapeutic effects. The rising and compounding antimicrobial resistances
Supramolecular Chemistry, continue to mandate novel strategies in the antibacterial drug discovery and development
a section of the journal
process (Silver, 2011; Brown and Wright, 2016; Shang et al., 2020). The 2019 analysis of
Frontiers in Chemistry
antibacterial agents in clinical development by the World Health Organization (WHO) indicates
Received: 28 January 2021
the current clinical pipeline is insufficient to alleviate the threats posed by antimicrobial resistance
Accepted: 15 April 2021
(WHO, 2019a).
Published: 30 April 2021
Citation:
Surur AS and Sun D (2021)
Macrocycle-Antibiotic Hybrids: A Path ANTIBIOTIC COMBINATIONS VERSUS ANTIBIOTIC HYBRIDS
to Clinical Candidates.
Front. Chem. 9:659845. Single-target agents have dominated the current antibacterial collection, and bacteria seem capable of
doi: 10.3389/fchem.2021.659845 rendering all ineffective (East and Silver, 2013). Simultaneous use of drug molecules having different
Frontiers in Chemistry | www.frontiersin.org 1 April 2021 | Volume 9 | Article 659845

Surur and Sun Macrocycle-Antibiotic Hybrid
molecular targets, or polypharmacology, was then considered can be metabolized only by a specific strain, a very useful
more reliable to eliminate or at least slow the onset of strategy for the development of narrow-spectrum antibacterial
resistance (Gray and Wenzel, 2020). Accordingly, agents (Domalaon et al., 2018; Jubeh et al., 2020). In the
concomitant use of antibiotics is often practiced by belligerence of drug resistance, molecules composed of two
clinicians to prevent the development of resistance, broaden or more active structure motifs that are capable of acting at
the spectrum of activity, and/or optimize the dose of drugs. In their respective targets have been extensively explored (Shavit
combination therapy, an adjuvant which may be inactive on its et al., 2017). Selection of a matching partner in the antibiotic
own is used with an antibiotic—a strategy called hybrid strategy is crucial so that the resulting dual-acting
antibiotic–adjuvant approach (Liu et al., 2019). The hybrid will unlikely suffer from cross-resistance. An
adjuvant may enable entrance of the bona fide antibiotic by organism may develop resistance to a dual-acting hybrid if
improving the membrane permeability, inhibit enzymes it is not susceptible to the action of either drug (Parkes and
responsible for inactivation, or prevent the active efflux of Yule, 2016).
the antibiotic (Liu et al., 2019; Tyers and Wright, 2019). Over the past few decades, significant advances have been
Antibiotic–antibiotic combination approach, on the other made in medicinal chemistry and chemical biology of
hand, entails the use of dynamic dual antibiotics to achieve macrocyclic compounds (Yu and Sun, 2013; Yudin, 2015).
drug synergism or suppress the development of resistance, In contrast to large macromolecules and small synthetic
hypothesizing that bacteria will not survive the one-two punch molecules, macrocycles possess unique structural advantages
of the antibiotics (Tyers and Wright, 2019). This antibiotic and benefits from featuring both large molecules such as high
cocktail approach has prolonged the clinical utilities of some potency and impeccable selectivity, and small molecules such
antibiotics, albeit potential problems due to unfavorable as reasonable manufacturing costs, favorable PK, and the lack
pharmacokinetic (PK) interactions, and for several reasons, of immunogenicity (Peterson, 2017). The up-to-date
the boosted in vitro activity often does not translate well into in comprehensive review of antibacterial agents in clinical
vivo efficacy in animal models or clinical settings (Klahn and pipeline (Butler and Paterson, 2020) along with reviews
Bronstrup, 2017; Domalaon et al., 2018). In a scenario where regarding the 14- to 15-membered macrolide hybrids (Janas
the combined drugs lack PK complementarities, such as and Przybylski, 2019) and their potential as anti-infective and
dissimilar half-lives where a short-acting drug is excreted anti-inflammatory agents (Paljetak et al., 2017) indicates the
rapidly, or different tissue distributions where one antibiotic hybrid approach is trending in the development of
component is barely distributed, the other component will macrocyclic compounds. In this review, using terms such as
become vulnerable from the aspect of development of “drugs” and “bacterial infections,” clinical trials listed in
resistance (Domalaon et al., 2018). For example, multiple clinicaltrials.gov were searched meticulously. More than
resistance mechanisms have gradually limited the clinical 2,000 clinical trials matched our search criteria, and the
use of co-trimoxazole involving the dihydrofolate reductase search results were cross-checked with the 2019 global
(DHFR) inhibitor trimethoprim and the dihydropteroate observatory of the WHO for antibacterial products in
synthase (DHPS) inhibitor sulfamethoxazole, the esteemed clinical development (WHO, 2019b). Five novel macrocycle-
example of the antibiotic combination approach (Eliopoulos based antibiotic hybrids under clinical developments, that is,
and Huovinen, 2001). Pharmacokinetic disparities, such as TD-1792, TD-1607, TNP-2092, TNP-2198, and DSTA3647S,
dissimilar volume of distributions by the virtue of differences are highlighted and discussed.
in hydrophobic properties between trimethoprim and
sulfamethoxazole, might have contributed to the development of
resistance (Brown, 2014). In addition, drug combination or co- HYBRIDS OF VANCOMYCIN
formulation is also vulnerable to additive toxicities (Tamma et al.,
2012). The need for taking multiple drugs, especially if different Although about 6 decades have passed since vancomycin (VAN,
routes of administrations are involved, may also deflate patients’ 1, Figure 1) was initially approved by the U.S. Food and Drug
convenience (Fisher et al., 2020). Administration (FDA) in 1958 and introduced into clinical
An attractive alternative to the mix and match antibiotic practice, it is still commonly used for the treatment of many
combinations is to bridge two pharmacophores by a Gram-positive bacterial infections and often the last resort in
metabolically stable covalent bond to generate a modern treatment of drug-resistant infections (Okano et al.,
heteromeric synthetic construct, which behaves as a single 2017). However, a dark cloud lids over the use of 1, as
chemical entity pertaining to PK parameters, a strategy evidenced by widespread VAN-resistant Enterococci (VRE)
otherwise known as an antibiotic hybrid (Pokrovskaya and and VAN-resistant Staphylococcus aureus (VRSA) and the loss
Baasov, 2010; Klahn and Bronstrup, 2017). Diverse subjective of clinical efficacy against severe methicillin-resistant S. aureus
definitions are forged for antibiotic hybrids. Generally, the (MRSA) infections (Faron et al., 2016). Vancomycin has
antibiotic hybrid umbrella covers dual-acting antibiotic continued to be captured in the spotlight in antibacterial drug
hybrids, divalent or multivalent antibiotics, antibiotic development; its unique clinical successes, absence of cross-
conjugates, chimeric antibiotics, and antibiotic hybrid resistance with other antibacterial classes, a significant time
prodrugs (Wang et al., 2016; Domalaon et al., 2018). The span (30 years) between discovery and appearance of the first
latter involves a cleavable linker between synthons, which resistant strains in VRE, and advances in structural determinations

The lipid intermediate II (a membrane-anchored cell wall

precursor) and transpeptidase (the penicillin-binding protein), the
cellular targets of 1 and cephalosporins, respectively, are in close
proximity and catalyze sequential roles in the bacterial cell wall
biosynthesis. Consequently, their hybrid molecule might be able to
inhibit both targets simultaneously and therefore have superior
bactericidal properties (Long et al., 2008a). As mentioned above,
1 is equipped with at least three potential attachment sites (VV, VC,
and VR) (Long et al., 2008a; Blaskovich et al., 2018). Similarly, the C-
3 pyridinium (CP) moiety, the Z-oriented oxime (CO), and
thiazolylamino (CN) groups of the C-7 side chain of 2 are
suitable attachment sites in a cephalosporin nucleus (Figure 1,
Long et al., 2008a). All possible nine hybrid heteromers between
the above-mentioned attachment sites were synthesized via an
amide linker and exhibited excellent activity against a select panel
of Gram-positive bacteria pathogens, including MRSA and
vancomycin intermediate-resistant S. aureus (VISA) (Long et al.,
2008a). Cefilavancin was among the two most promising
heteromers, with an MIC90 value of 0.03 μg/ml against MRSA
isolates (Long et al., 2008a; Blais et al., 2012). Furthermore,
in vitro studies revealed that THRX-169797 (2), the
cephalosporin constituent of 3, was much less active than 3
against all S. aureus isolates tested (Blais et al., 2012). The
murine neutropenic thigh infection model of MRSA was
extended to 3. The ED50 of 0.19 mg/kg for 3 was 40 times more
effective than the ED50 of that for 1, with an ED50 of 8.1 mg/kg in
their assay (Long et al., 2008a). Consequently, 3 was selected and
advanced as a clinical candidate for further development.
Cefilavancin also showed very potent activity against the
FIGURE 1 | Suitable attachment positions in vancomycin (1) and THRX- heterogeneous VISA (hVISA), with minimum inhibitory
169797 (2).
concentration (MIC90) values of 0.03 μg/ml against 39 isolated
strains of hVISA, relative to 2 μg/ml for 1 (Blais et al., 2012). In
addition, 3 was the most active (MIC90 0.125 μg/ml) against various
or synthetic methods are among the reasons accounted (Blaskovich clinical isolates of VAN-intermediate staphylococcal species (VISS),
et al., 2018). Notably, three new structural analogs, that is, heterogeneous VISS (hVISS), and VRSA, compared to daptomycin,
® ®
telavancin (Vibativ ), dalbavancin (Dalvance ), and oritavancin quinupristin–dalfopristin, and linezolid (Leuthner et al., 2010). A
®
(Orbactiv ), were approved by the U.S. FDA in September 2009,
May 2014, and August 2014, respectively, for the treatments of
similar study identified the effect of plasma proteins on the
potency of 3 as low, and the MIC90 value remained the lowest
complicated skin and skin structure infections (cSSSIs) and acute compared to all comparators (Leuthner et al., 2010). Moreover, the
bacterial skin and skin structure infections (ABSSSIs) (Lexicomp, positive results from clinical trials have supported the continued
2021). Besides its historical clinical success and impact, 1 has also development of 3. In phase 1 studies, plasma concentrations after
been targeted in the antibiotic hybrid paradigm for two main intravenous (IV) administration of 2 mg/kg body weight were
reasons. First, the glycopeptide scaffold in 1 provides several continuously above the MIC value at which 100% MRSA isolates
substituents suitable for binding a partner—in particular, the free were inhibited (Blais et al., 2012). In phase 2 studies, the efficacy of 3
C-terminal carboxylic acid (VC), the primary amine in vancosamine was compared with that of 1 in the treatment of cSSSIs. The cure rate
sugar (VV), and the aryl group of the seventh amino acid (VR) at the end of the treatments with 1 and 3 was 90.7% and 91.7%,
(Figure 1, Long et al., 2008a; Long et al., 2008b; Blaskovich et al., respectively (Stryjewski et al., 2012). The incidence of the most
2018). Second, 1 increases the affinity to the target via cooperative common adverse effects was similar in both groups, except for
back-to-back dimerization. This opens a characteristic possibility to itching, which was more common in volunteers in the VAN arm
design potent conjugates where two vancomycin residues are (NCT00442832, 2006; Stryjewski et al., 2012). Currently, Theravance
dimerized or 1 is covalently linked to another partner such as 2 Biopharma and R-Pharm are conducting a phase 3 clinical
(Blaskovich et al., 2018). Although 1 has been dimerized or development of 3 in Russia (WHO, 2019a; Adis Insight, 2020).
conjugated with siderophores or fluorophores, only its antibiotic The hybridization of the nuclei in 3, but with a longer amide
hybrids have provided advanced candidates under clinical linker and different attachment positions, led to TD-1607 (4)
development, that is, cefilavancin (3, also known as TD-1792) (Figure 2, Fatheree et al., 2005). In 4, the aryl group closest to
and TD-1607 (4) in Figure 2 (Negash et al., 2019; the C-terminus of 1 (VR) is aminomethylated and linked to the
Theuretzbacher, 2020). pyridinyl substituent (CP) from the bicyclic lactam of cephalosporin

FIGURE 2 | Chemical structures of VAN hybrids, cefilavancin (3, TD-1792), and TD-1607 (4).
(Fatheree et al., 2005; Blaskovich et al., 2018). TD-1607 exerts its HYBRIDS OF RIFAMYCINS
antibacterial activity by inhibiting cell wall biosynthesis; in vitro
microbiological profiling showed a rapid and potent bactericidal Various clinical guidelines for the treatment of staphylococcal
effect against Gram-positive organisms (Sader et al., 2014). prosthetic joint infection (PJI), including the Infectious Diseases
Compound 4 proved to be the most effective against all Society of America (IDSA) guideline, recommend rifampin with a
comparators, including 1, with MIC values between 0.008 and fluoroquinolone companion (Osmon et al., 2013; Berbari et al.,
0.06 μg/ml against 1,026 MRSA isolates procured worldwide (Sader 2020). First, rifamycins are the drug of choice for persistent
et al., 2014; Liapikou et al., 2017). Single and multiple ascending dose bacterial infections such as PJI (Robertson et al., 2008).
phase 1 studies on the safety, tolerability, and PK of 4 were conducted Rifampin intervenes critical gene transcription process and
in healthy volunteers (NCT01791049, 2013; NCT01949103, 2013). prevents spread to deep-seated infection sites, crafting a
However, Theravance BioPharma has discontinued further clinical clinical success against slow-growing and nonreplicating
developments of 4 (Butler and Paterson, 2020). metabolic stages of bacteria (Robertson et al., 2008; Ma and
Lynch, 2016). Second, the formation of bacterial biofilms, a
Synthesis of Vancomycin Hybrids polysaccharide glycocalyx that provides a mechanical shield
Chemical syntheses of VAN conjugates 3 and 4 involved a series of from antibiotics and immune system of the host, over the
steps to construct the cephalosporin synthon attached to a linker and prosthesis is a central mechanism in the pathogenesis of PJI
an eventual coupling with vancomycin (Scheme 1). The synthesis of (Taha et al., 2018). According to various in vitro and/or in vivo
a cephalosporin and an amide anchor motif in 3 started by coupling animal model studies, rifampin diffuses well into biofilm and
N-Boc–protected bromopropylamine 5 with the hydroxylimino produces effective killing against biofilm-associated bacteria
moiety of a trityl-protected aminothiazolyl residue 6 (Long et al., (Sanchez et al., 2015). Third, a point mutation in the rpoB
2008a). Following ester hydrolysis of 7 and subsequent chlorination gene that encodes the β-subunit of RNA polymerase confers a
of the thiazolyl ring in 7 or 8 using N-chlorosuccinimide (NCS) high resistance to rifampin (Aubry-Damon et al., 1998; Silver,
yielded 9 or 10, respectively. Intermediates 9 and 10 were next 2011), and a companion drug may be needed to slow down the
coupled with 7-amino-3-chloromethyl-3-cephem-4-carboxylic development of resistance. In this context, in vivo and clinical
acid p-methoxybenzyl ester hydrochloride salt (ACLE). The 3- data indicated fluoroquinolones as the best concomitant drugs
chloro good leaving group in the ACLE moiety was replaced with with rifampin (Wells et al., 2018). However, the in vitro
pyridine or 4-(N-tert-butoxycarbonyl)aminomethyl pyridine to antagonism observed between rifampin and the
give 11 or 12, respectively (Fatheree et al., 2005; Long et al., fluoroquinolone class (Murillo et al., 2008) and the need to
2008a). The key cephalosporin intermediates 13 and 14 were take rifampin orally and fluoroquinolones intravenously
synthesized by global deprotection of their corresponding during the initial phase of the treatment regimen are major
precursors in TFA. Finally, VAN 1 was attached directly to 13 limitations for clinical use of this combination (Ma and
through amide bond formation to afford target compound 3 Lynch, 2016). Rifampin inhibits bacterial RNA synthesis which
(Fatheree et al., 2005; Long et al., 2008a). Unlike the direct may weaken the bactericidal effect of fluoroquinolones by
coupling in 3, target compound 4 was synthesized via impeding the supercoiling of DNA (Zimmerli and Sendi,
sequential bifunctional amide coupling of the cephalosporin CP 2019). To address these, a resolution by introducing a
synthon 14 and the VAN VR synthon via the di-HOAt ester of covalently linked hybrid of rifampin and a fluoroquinolone
adipic acid (Fatheree et al., 2005; Long et al., 2008a). pharmacophore was proposed. Furthermore, fluoroquinolones

SCHEME 1 | Synthesis of VAN hybrids 3 and 4 (Long et al., 2008a). (a) Cs2CO3, tetrabutylammonium iodide, DMF, rt, 2 h. (b) for 9: i. KOH, ethanol, 80°C, 30 min;
ii. NCS, CHCl3, rt, overnight; for 10: NCS, DMF, rt, overnight. (c) for 11: i. ACLE, THF, –45°C, 2,4,6-collidine, POCl3, 10 min; ii. NaI, acetone, N2, rt, 80 min, then pyridine,
150 min; for 12: i. ACLE, N-[3-dimethylaminopropyl]-N′-ethylcarbodiimide hydrochloride (EDCI), 2,4,6-collidine, DMF, rt, 2 h; ii. Acetone, NaI, N2, 4-(N-tert-
butoxycarbonyl)aminomethyl pyridine, rt, 2 h. (d) TFA, dichloromethane, anisole, rt, 2–3 h. (e) 1, benzotriazol-1-yl-oxytripyrrolidinophosphonium
hexafluorophosphate (PyBOP), HOAt, DIPEA, DMSO, DMF, rt, 30 min, then 2,4,6-collidine, 4 h. (f) di-HOAt adipic ester, DMF, ice bath, 2,4,6-collidine, 15 min, then the
VR synthon of 1, DMF, ice bath, 2,4,6-collidine, 20 min.
are one of the most widely used classes in the antibiotic hybrid carbonyl group at C-11 can be used as a conjugation site.
paradigm (Pham et al., 2019). A dual mechanism against Functionalization of the C-11 carbonyl to oxime led to a series
topoisomerase IV and DNA gyrase, which may compensate of novel 11-deoxy-11-hydroxyiminorifamycin derivatives, with
for any interference shadowed by steric hindrance from a better or equivalent activity against the RNA polymerase of S.
linker (Pokrovskaya and Baasov, 2010) or a second aureus (Li et al., 2007). Similarly, the C-25 position can be used
component with suitable attachment sites for bulky partners for attachment of a companion after replacement of the acetyl group
and stability under different synthetic conditions, are the with a carbamate. A series of C-25 carbamate rifamycins showed
arguments put forward for the fluoroquinolones (Fedorowicz improved antimycobacterial activity and absence of inactivation
and Sa˛czewski, 2018). through ribosylation of C-23 alcohol by ADP-ribosyl transferase of
As previously reported (Ma and Lynch, 2016), open spaces Mycobacterium smegmatis (Combrink et al., 2007).
and hence convenient positions for attachments to the C-3 and C- Various matching partners of rifamycins have been explored,
25 positions of rifampin were identified from a co-crystallized with rifamycin–quinolones being the most studied (Ma and Lynch,
structure of rifampin and RNA polymerase. This is further 2016). SARs from approximately 300 rifamycin–quinolone hybrids
illustrated in Figure 3 using a recently reported co-crystal revealed that the linker significantly influenced biological activity
structure (Molodtsov et al., 2017). Structure–activity relationships (Robertson et al., 2008; Klahn and Bronstrup, 2017). Partnering a
(SARs) from a series of spirorifamycins disclosed that a heterocycle rifamycin nucleus with a quinazolinone, a bioisostere of quinolone,
fused with both C-3 and adjacent C-4 of rifamycin can serve as an provided the activity-leading conjugate, called CBR-2092 or TNP-
attachment site for the second partner (Kim et al., 2007). The 2092 (15) (Figure 4, Ma and Lynch, 2016). Furthermore, the

system. In addition, the lack of efflux effectively traps 15 within

bacteria (Ma and Lynch, 2016). Almost half of fluoroquinolone-
resistant strains have enhanced expression of norA or mepA gene
(Robertson et al., 2008). 3) TNP-2092 appears to overcome the
antagonism between rifampin and ciprofloxacin (Murillo et al.,
2008); in a minimum biofilm bactericidal concentration (MBBC)
evaluation, ciprofloxacin plus rifampin exhibited MBBC levels higher
than the MBBC values of ciprofloxacin alone in 11 of 40 S. aureus and
in zero of 40 S. epidermidis isolates (Fisher et al., 2020). 4) TNP-2092
showed strong activity against pathogens resistant to its constituents.
The difference in MIC values of 15 between the wild-type (CB190)
and rifamycin-resistant S. aureus (CB370, rpoBH481Y) was smaller,
unlike 31,250 folds for rifampin. Compound 15 exhibited no activity
difference between CB190 and fluoroquinolone-resistant S. aureus
(CB814, gyrAS84L ParCS80F), while nearly 67-fold difference was
observed for ciprofloxacin (Robertson et al., 2008). Against
rifampin-resistant S. epidermidis strains, IDRL-10005 (rpoBD471E
FIGURE 3 | Most accessible positions for conjugation in the chemical rpoBI527Y) and IDRL-10692 (rpoBS486F), on the other hand, 15 had
structure of rifampin. The figure was generated from the crystal structure (Pdb MIC values of 0.06 and 0.125 μg/ml, respectively; in contrast, rifampin
5UAL) (Molodtsov et al., 2017) using PyMOL (Delano, 2002).
had high MIC values of ≥4 μg/ml, and ciprofloxacin had MIC values
of 8 and 1 μg/ml, respectively (Fisher et al., 2020). 5) Safety concerns
quinazolinone core possesses activity against the ParCS80F variant related to constituent elements such as hERG inhibition and induction
of topoisomerase IV, the activity that is not retained by of CYP3A4 isoenzyme were not observed in 15 (Ma and Lynch, 2016).
ciprofloxacin. This provides an explanation for the activity of 15 Rifaximin, a member of the rifamycin family and a nonsystemic
against bacterial isolates that are resistant to ciprofloxacin alone or in antibiotic, has been approved for the treatments of travelers’
combination with rifampin (Fisher et al., 2020). In 15, the C-3 of diarrhea, hepatic encephalopathy, and irritable bowel syndrome
rifamycin and the C-8 of quinazolinone pharmacophores are bound without constipation (Lexicomp, 2021). Its clinical benefits were
by a linker that resembles a covalently bound side chain of rifampin thought to be mediated through altered gastrointestinal (GI)
and ABT-719 (Ma and Lynch, 2016). The optimal linker in 15 also microbiota or dysbiosis (Chey et al., 2020). Antibacterial
clamps the binding of rifamycin and quinazolinone motifs to their evaluations of 15 against a representative panel of GI bacteria
respective binding sites (Ma and Lynch, 2016). revealed similarities with rifaximin (Yuan et al., 2020).
TNP-2092 was superior to rifampin plus ciprofloxacin in Interestingly, 15 was more active against Gram-negative bacteria
several facets, a credence to hybrid pharmaceuticals in the such as E. coli and A. baumannii, which were resistant to rifampin
antibacterial pipeline. 1) In S. aureus and coagulase-negative (Ma and Lynch, 2016). The low oral bioavailability of 15, 1.81% in
Staphylococci (coNS), the main causative agents and major rats and 0.315% in dogs, can offer additional benefits for local
elements of treatment failure in PJI, 15 has multi-targeted activities treatment of intestinal diseases (Yuan et al., 2020). The main
against RNA polymerase, DNA gyrase, and topoisomerase IV strategy for the treatment of hepatic encephalopathy, which is
(Robertson et al., 2008; Ma and Lynch, 2016). 2) TNP-2092 is not closely related to hyperammonemia, is to regulate urease-
a substrate for efflux pumps such as NorA or MepA and therefore producing bacteria located in the gut (Liu et al., 2018). Against a
retains activity against resistance mediated by mutations of the efflux panel of urease-producing strains, 15 was more active than rifampin
against Gram-negative bacteria such as Helicobacter pylori (H.
pylori) and Salmonella strains but lower activity against beneficial
commensals such as B. infantis and B. bifidum (Yuan et al., 2020).
TNP-2092 appears to be an attractive candidate for the treatment of
the urease-producing C. difficile. Compared to the standard
treatments of C. difficile infections (CDIs), vancomycin and
metronidazole, 15 showed superior activity against various
isolates of C. difficile (Yuan et al., 2020). In addition, following
7 days’ treatment with 15, the changes in the percentage of
intestinal microbiota were temporary and generally returned to
pretreatment levels. This explains the nonrecurrence of CDIs after
treatment with 15 (Yuan et al., 2020). The standard treatments
interfere with the intestinal microbiota and are the leading factors
for the recurrence of CDIs (Tsutsumi et al., 2014).
The phase 1 study of 15 on tissue distribution, PK, safety, and
tolerability in participants undergoing primary total hip
FIGURE 4 | Cores and linker in the structure of TNP-2092 (15).
replacement or knee arthroplasty is being planned, but

SCHEME 2 | Synthesis of rifamycin hybrid 15 (Ma and Lynch, 2016). (a) Ti(O-iPr)4, EtMgBr, Et2O/THF, −78°C, 20 min, then Et2O/BF3, rt, 2 h. (b) NaHCO3,
acetonitrile, reflux, 5 h. (c) i. LiOH, ethanol, 60°C, 1 h; ii. TFA, dichloromethane, 0°C to rt, 1 h. (d) i. NaOH, H2N–OSO3H, 0°C, 1 h; ii. 3-formyl rifamycin, MeOH/THF, rt,
30 min.
participants have not been recruited yet (NCT04294862, 2021).

Nevertheless, the phase 2 study of 15 for the treatment of ABSSSIs
was completed in September 2020 (NCT03964493, 2019).
TenNor Therapeutics presented “topline” phase 2 results of 15
for the treatment of ABSSSIs at the 2020 China Biomed
Innovation and Investment Conference (CBIIC) (TenNor,
2020b). In 2020, the FDA has granted an orphan drug status
for the IV use of 15 for the treatment of PJI (PR Newswire, 2020).
Synthesis of TNP-2092
A scheme suitable for kilogram quantity synthesis of 15 was
reported (Ma and Lynch, 2016). The scheme involved an initial
five-step synthesis of the linker intermediate 18, which was
subsequently coupled with the fluoroquinolone core 19 under
reflux in acetonitrile, to give 20. The fluoroquinolone-linker
motif 20 was further processed via hydrolysis of ethyl ester and
Boc deprotection to afford 21 using LiOH and TFA, respectively.
Eventually, following the conversion of the piperidine moiety in 21
to a hydrazine, 15 was produced by coupling the hydrazine variant
of 21 with 3-formyl rifamycin (Ma and Lynch, 2016; Scheme 2).
FIGURE 5 | Chemical structure of TNP-2198 (22).
Besides 15, TenNor Therapeutics is also developing a
conjugate of rifamycin and metronidazole (Figure 5), also
known as TNP-2198 (22). Metronidazole is used to treat nitroimidazole motif, was conjugated with rifamycin, an
infections caused by anaerobic bacteria and is the first-line established agent against biofilm-forming pathogens. The
treatment for bacterial vaginosis (BV) (Jones, 2019). However, resulting 22 showed strong synergistic property against GV (Ma
the effectiveness of metronidazole against Gardnerella vaginalis et al., 2020). The MIC value of 0.004 μg/ml of 22 against GV was
(GV), the leading cause of BV, is associated with 58% recurrence significantly lower than those of its constituents, with MICs of 4
(Bradshaw et al., 2012). The underlying factor for treatment and 0.5 μg/ml for metronidazole and rifampicin, respectively (Ma
failure is resistance by biofilms that form a protective shield to et al., 2020). In addition, the spectrum activity of 22 was not limited
reduce the penetration of metronidazole (Ma et al., 2020). to GV but also active against other pathogens that can cause BV
Leaving the essential nitroimidazole moiety intact, conjugates and other anaerobic bacteria. Apart from a few BV-causing
of metronidazole (Patel et al., 2021), via N1-alkyl or 2-methyl bacteria where equivalent activity was displayed, the MIC values
linker or both, with different structural nuclei such as of 22 were 100 to 1,000 folds lower than those of metronidazole
thiomorpholine-1,1-dioxide, have resulted in hybrids with (Ma et al., 2020). Very recently, TenNor Therapeutics initiated a
superior activity against metronidazole sensitive as well as phase 1b/2a clinical development of 22 for the treatment of H.
resistant H. pylori strains (Rossi and Ciofalo, 2020). pylori infection (TenNor, 2020a). Additional clinical development
Accordingly, the pharmacophore of metronidazole, a 5- status of 22 is listed in Table 1.

Frontiers in Chemistry | www.frontiersin.org
Surur and Sun

TABLE 1 | Overview and key parameters of clinical macrocycle–antibiotic hybrids.
Macrocycle Molecular miLogP tPSA Select Microorganism In vivo Half-life Company RoA Clinical
hybrid weight MIC90 ED50 (h) development
(Dalton) (µg/ml) (mg/kg) status
TD-1792a 1,984.28 −4.68 673.39 0.03 MRSA, hVISA 0.19 1.7 Theravance IV Phase 2 completed in 2007 NCT00442832,
biopharma/ (2006); phase 3 registered in Russia WHO
R-pharm (2019a)
TD-1607b 2,170.49 −4.98 751.81 0.008–0.06 MRSA 0.11 N/A Theravance IV Phase 1 completed in 2014 NCT01949103,
biopharma/ (2013); phase 1b completed in 2013
R-pharm NCT01791049, (2013)
TNP-2092c 1,205.39 5.85 282.18 0.015 MSSA, MRSA 1.4–3.8 0.4–4.1 TenNor IV Phase 1 for PJI (not yet recruiting)
therapeutics NCT04294862, (2021); phase 2 for ABSSSIs
completed NCT03964493, (2019)
PO Phase 2 ongoing in China
8
Topical Preclinical development

TNP-2198d 944.05 2.70 269.21 0.004 GV N/A N/A TenNor PO Phase 1b/2a ongoing in China
therapeutics
DSTA4637Se 149 kDa (DSTA4637A 4.30 230.67 0.004 µM MRSA (USA300) N/A 16.5–21.5 days Genentech, Inc./ IV Phase 1 completed in 2016 NCT02596399,
TAb); 927.06 (dmDNA31) (dmDNA31) (dmDNA31) Roche (2015)
(dmDNA31) Phase 1b completed in 2020 NCT03162250,
(2017)
MiLogP: the logP prediction developed at Molinspiration. tPSA: topological polar surface area. Both miLogP and tPSA values were calculated using Molinspiration cheminformatics (https://www.molinspiration.com/). RoA: route of
administration; N/A: not available.
a
MIC value (Blais et al., 2012); in vivo ED50 value (Long et al., 2008a); terminal half-life in mice (Hegde et al., 2012).
b
MIC value (Sader et al., 2014); in vivo ED50 value (Long et al., 2008a).
c
MIC value, in vivo ED50, and plasma half-life (Ma and Lynch, 2016); IV for medical device associated bacterial biofilm infections, PO for hepatic encephalopathy and irritable bowel symptom diarrhea, topical for superbugs and diabetic foot
infection (TenNor Therapeutics, 2021).
d
MIC value (Ma et al., 2020); PO for H. pylori and other anaerobic bacterial infections (TenNor Therapeutics, 2021).
e
MIC value (Lehar et al., 2015); mean half-life of DSTA4637S TAb from phase 1 clinical trial (Peck et al., 2019).
April 2021 | Volume 9 | Article 659845
Macrocycle-Antibiotic Hybrid
FIGURE 6 | Monoclonal antibody, linker, and the antibiotic of DSTA4637S (23).
Antibody–antibiotic conjugation (AAC), in addition to the

antibiotic-antibiotic hybrids mentioned above, is practiced for
the conjugation of rifamycins. The antibody–drug conjugate
(ADC) is mainly used in cancer immunotherapy, to selectively
deliver a cytotoxic warhead using a labeling antibody bound
via a linker (Beck et al., 2017). In 2015, the extension of ADC to
the treatment of bacterial infections caused by S. aureus was
first coined by Lehar et al. (2015). The infamous S. aureus is
able to survive the wrath of antibiotics by internalizing into
phagocytes (Fraunholz and Sinha, 2012). This intracellular
reservoir has enabled long-term colonization of a host and
promoted development of resistance, which explains the
recurrences associated with invasive S. aureus infections
(Lehar et al., 2015; Peyrusson et al., 2020). Despite available
appropriate treatments, S. aureus remains a leading cause of
death related to bacterial infections, with mortality rates of
around 20–30% (Yilmaz et al., 2016). A new strategy capable of
effectively eliminating the responsible intracellular foci of S.
aureus was needed. As such, a novel AAC platform,
THIOMAB ™antibody–antibiotic conjugate (TAC), was
utilized to target the intracellular S. aureus. DSTA4637S
(23) (Figure 6) is a novel conjugate of an antibiotic with an
anti–S. aureus antibody, which represents the first AAC in this FIGURE 7 | Simplified molecular structure of the WTA of common S.
aureus.
class under clinical development (Lehar et al., 2015;
Mariathasan and Tan, 2017; Poreba, 2020). Mechanistically,
the large-sized 23 cannot diffuse into mammalian cells. In
systemic circulation and tissues, the antibody directs the hydroxybenzoxazino rifamycin, dmDNA31 (rifalogue), are
binding of the conjugate to S. aureus, enabling the uptake linked by a protease cleavable valine–citrulline (vc) linker
of appended bacteria into phagocytes via opsonization (Cai (Lehar et al., 2015; Poreba, 2020). MSTA3852A was selected
et al., 2020). The linker is cleaved by cathepsins inside the from >40 anti–S. aureus antibodies that originated from the
phagolysosome to release the active antibiotic that can blood of patients recovering from different S. aureus infections.
eliminate the conjugate bound and other existing bacteria The highest level of binding by those antibodies was directed
(Lehar et al., 2015; Cai et al., 2020). against a major component in the cell wall of S. aureus, the wall-
In DSTA4637S, an artificially engineered monoclonal teichoic acids (WTAs) (Lehar et al., 2015; Deng et al., 2019).
antibody MSTA3852A against S. aureus from human In the majority of S. aureus lineages, WTA is composed of up
immunoglobulin (IgG1) and 4-dimethylaminopiperidino- to 40 repeating units of ribitol phosphate (RboP) that are

FIGURE 8 | Binding interactions between the β-WTA mimic and anti–S. aureus antibodies. (A) Stacking and ionic interactions between antibody 4462 and Rbo-5-P
(Pdb 6DWI). (B) Interactions between antibody 6078 and Rbo-5-P (Pdb 6DW2). (C) Arginine “tweezers” motif (Pdb 5D6C). Pictures (A)–(C) were generated from
reported Pdb files (Lehar et al., 2015; Fong et al., 2018) using PyMOL (Delano, 2002).
covalently linked to the N-acetylmuramic acid (MurNAc) residue phosphoribitol β-WTA, also revealed an arginine “tweezers”
of the peptidoglycan layer by a short polysaccharide anchor unit motif by Arg27d and 28 that dictated the β-anomer–specific
(Figure 7, Weidenmaier and Peschel, 2008; Fong et al., 2018). The recognition via triangulation of the ribitol phosphodiester
anchor unit is composed of glycerol-phosphate (GroP) units backbone in relation to the GlcNAc moiety (Figure 8C, Lehar
(1–3×), N-acetyl-D-mannosamine (ManNAc), and N-acetyl-D- et al., 2015).
glucosamine-1-phosphate (GlcNAc-1-P) (Winstel et al., 2014). Various features of rifalogue (dmDNA31) were considered in
RboP can be modified with α- or β-O-linked N-acetyl-D- the selection of the payload for anti–S. aureus antibody 4497.
glucosamine (α/β-O-GlcNAc) residues and D-alanine. Those dmDNA31 had an MIC value of 4 × 10–9 M against MRSA
modifications were reported to be essential for developing (USA300), with effective killing property against these well-
resistance to methicillin and cationic antimicrobial peptides recognized persister cells (Lehar et al., 2015). Persister cells are
(Brown et al., 2012). In MRSA strains, modifications with dormant, nonreplicating bacteria with a high level of tolerance to
β-1,4-GlcNAc and α-1,3-GlcNAc are catalyzed by antibiotics. Nondividing MRSA isolates inside macrophages were
glycotransferases TarS and TarM, respectively (Brown et al., effectively eliminated by dmDNA31 (Lehar et al., 2015).
2012; van Dalen et al., 2019). Recently, Gerlach et al. have Moreover, dmDNA31 conjugate was inactive against
identified an alternative glycotransferase for MRSA, TarP, extracellular bacteria, indicating the safety of the conjugate
which catalyzes the glycosylation of β-1,3-GlcNAc on WTA (Shopsin et al., 2016).
(Gerlach et al., 2018). This alternative glycan modification was V112C mutagenesis of the antibody MSTA3852A, in which
poorly immunogenic and sabotaged the recognition by host a valine in the light chain IgG1 is precisely replaced by a
antibodies (Gerlach et al., 2018). WTAs are promising reactive cysteine residue, enables site-specific conjugation with
antigens being pursued for the development of novel vaccines a drug–antibody ratio (DAR) of two vc-dmDNA31 per
against MRSA (van Dalen et al., 2019). antibody (Deng et al., 2019). Site-specific conjugation in
The majority of the host anti–S. aureus antibodies target β-1,4- ADC enables a direct and homogeneous conjugation of a
GlcNAc, followed by β-1,3-GlcNAc, and few antibodies are drug (Zhou, 2017). Stochastic or random conjugation, on
reactive to α-1,4-GlcNAc, albeit the underlying reason is not the other hand, often leads to heterogeneous products, with
fully understood (van Dalen et al., 2020). The binding pattern each subtype having different PK properties, efficacy, and
between antibodies and β-WTA was then characterized by co- safety profiles. In stochastic conjugates, there are also
crystallizing the Fab fragment of anti–β-WTA antibodies with a concerns about higher DAR, which are relatively more
minimal synthetic repeat of β-WTA, a β-glycosidic bonded unit active in vitro, less tolerated, and exhibit rapid elimination
between ribitol-1-phosphate (Rbo-1-P) or ribitol-5-phosphate than conjugates with lower DAR (Gauzy-Lazo et al., 2020).
(Rbo-5-P) and GlcNAc (Lehar et al., 2015; Fong et al., 2018).
Antibodies displayed a conserved mechanism to specifically
™
THIOMAB is one such site-specific conjugation technology
that led to 23 (Lehar et al., 2015; Wang-Lin and Balthasar,
recognize the β-anomer mimic, albeit different residues were 2018; Gauzy-Lazo et al., 2020). The linker in 23 will be cleaved
involved in different antibodies (Fong et al., 2018). In the co- within minutes following the entry of the opsonized S. aureus,
crystal structures of antibody 4462 or 6078, for example, the and when tested inside human macrophages, epithelial and
pyranose ring of GlcNAc of the mimic was stacked against the endothelial cells, AAC-opsonized MRSA isolates were killed in
amide chain of N95 or the indole side chain of W50, respectively all cases (Lehar et al., 2015). In an intravenous mice infection
(Figure 8, Fong et al., 2018). In antibody 4462, the C-5 phosphate model, the efficacy of 23 was superior than that of 1. The
of the WTA mimic formed ionic interactions with K94 efficacy of 1 declined when administered after 7–24 h of
(Figure 8A). Similarly, the interaction between the 5- infections, suggesting the failure of 1 due to the
phosphate and Y94 in antibody 6078 was indicated for internalization of MRSA into host cells (Lehar et al., 2015).
selectivity to β-linked GlcNAc (Figure 8B, Fong et al., 2018). After 24 h of infection, a single dose of TAC was effective and
Lehar et al., using a co-crystal structure of antibody 4497 with 1- superior to the twice-daily dose of 1 (Lehar et al., 2015).

The preclinical PK properties of TAC 23 were profiled in mice, gut and liver diseases (Ma and Lynch, 2016). In addition, given that
rats, and cynomolgus monkey (Zhou et al., 2016; Deng et al., the structure of the outer membrane (OM) in the cell wall of Gram-
2019). The PK profiling of TAC involved the analysis of three negative bacteria is well designed for intrinsic resistance to various
analytes: TAC total antibody (TAb) which includes fully antibacterial agents, the high molecular weight of antibiotic hybrids
conjugated (DAR 2), partially conjugated (DAR 1), and is also detrimental to their activity against Gram-negative
unconjugated antibodies (Zhou et al., 2016). The PK microorganisms. Moreover, the hydration sphere, created by
properties of typical monoclonal antibody-based therapeutics, hydrophilic carbohydrates, and the reduced fluidity caused by
that is, short distribution, slow clearance, and long half-life, were efficient packing of the lipid component restrict the passage of
demonstrated by DSTA4637A (the preclinical liquid formulation hydrophobic molecules across the OM (Domalaon et al., 2018).
of 23) in various in vivo animal studies (Zhou et al., 2016; Deng et al., What remains is a passage through unspecific, barrel-shaped protein
2019). In mice, the conjugation extended the half-life (∼3–4 h) of channels called porins. Nevertheless, only small molecules with a
unconjugated dmDNA31 to 4 days in ac-dmDNA31. A similar molecular weight of ≤600 g/mol are more favorable to pass the
clearance between 23 and the unconjugated antibody in mice molecular sieve imposed by the porins (Vergalli et al., 2020).
indicated the conjugation of dmDNA31 had relatively little effect Fortunately, some antibiotics with a molecular weight of >600 g/
on the clearance of the TAb (Zhou et al., 2016). Comparable PK mol, such as polymyxins, are able to pass through OM via various
properties of DSTA4637A TAb and MSTA3852A were also found in uptake mechanisms (e.g., self-promoted entry) (Moubareck, 2020).
rats and monkey (Deng et al., 2019). Three main reasons can explain Agents of this nature are capable of disturbing the electrostatic
the similar PK profiles between DSTA4637A and MSTA3852A. interactions between the divalent cations such as Mg2+ or Ca2+ and
First, conjugates with a DAR of 2–4 generally have slower clearance phosphate groups in the lipid, thereby creating a passage through
rates and longer half-lives than conjugates with a higher DAR (Deng (Deris et al., 2014). Further clarifications of the structural or
™
et al., 2019). Second, THIOMAB technology allows uniform
conjugation on the engineered cysteine without disrupting the
physicochemical criteria for self-promoted mechanism can extend
the antibacterial spectrum of macrocycle-antibiotic hybrids against
inter-disulfide bonds in the antibody (Sussman et al., 2018), and Gram-negative organisms (Domalaon et al., 2018).
therefore minimal PK changes after conjugation. Third, drug loading Pioneered by cefiderocol, a cephalosporin siderophore
and hydrophobicity are factors that cause significant changes in PK antibiotic approved by the U.S. FDA in November 2019
properties (Kamath and Iyer, 2016). The hydrophilic property of (Lexicomp, 2021), antibiotic–siderophore conjugates represent
dmDNA31 is expected to slow down clearance and extend the half- an attractive antibiotic hybrid class by conjugating iron-chelating
life of 23 (Deng et al., 2019). A minimal physiologically based PK microbial siderophores with an antibiotic to facilitate uptake and
model in mice indicated a low level of drug interactions between antibacterial efficacy (Schalk, 2018; Negash et al., 2019).
DSTA4637A and cytochrome P450 substrates. This model of PK Specifically, a macrocycle siderophore hybrid, involving the
disposition also indicated the liver and spleen, where phagocytes are conjugation of a macrocyclic antibiotic with a microbial
usually accumulated, may contain high concentrations of siderophore or a siderophore mimetic, may overcome the
dmDNA31 (Wang-Lin et al., 2018). penetration issue to pass through the OM of Gram-negative
Preclinical safety evaluations with high doses of 23, up to 250 bacteria. Siderophores benefit bacteria by dissolving and
and 500 mg/kg in monkeys and rats, respectively, were well importing iron (Ji et al., 2012). Conjugating with a
tolerated (Deng et al., 2019). In 2019, the results of the phase siderophore can facilitate the entry of the corresponding
1 investigations on the safety, PK, and immunogenicity in healthy hybrid through a ferri-siderophore uptake pathway that
volunteers were published, which showcased the favorable internalizes iron by an active transport mechanism, that is, a
profiles of 23 for human use (NCT02596399, 2015; Peck et al., Trojan horse mechanism (Schalk, 2018). Similarly, a self-
2019). No serious adverse effects were observed in the dose range promoted passage through means of polymyxins can be
between 5 and 150 mg/kg; no clinically significant changes in exploited to force the entry of macrocycle polymyxin
laboratory or vital signs or antibody responses induced by 23 conjugates (Negash et al., 2019). Conjugation with polymyxins
were observed (Peck et al., 2019). Therefore, further clinical can not only extend activity against Gram-negative bacteria but
development of 23 for S. aureus infections is expected also retain activity against resistance mechanism involving
following these favorable safety and PK profiles in human overexpression of efflux pumps as well (Negash et al., 2019).
volunteers (Peck et al., 2019). Various other hybrid chemical entities have also been reported,
including polymyxin B3-tobramycin hybrids with Pseudomonas
eruginosa–selective antibacterial activity and strong potentiation
LIMITATIONS AND WAYS FORWARD IN of rifampicin, minocycline, and vancomycin (Domalaon et al.,
MACROCYCLE-ANTIBIOTIC HYBRID 2017), azithromycin–benzoxaborole hybrid derivatives
(Tevyashova et al., 2019), as well as antitubercular rifampicin
APPROACH and clofazimine hybrid (Saravanan et al., 2021). Very recently,
The increase in molecular weight is a major limitation of the design and synthesis of vitamin B12–antibiotic conjugates led to
antibiotic hybrid approach. The resulting low oral bioavailability advanced candidates with >500-fold improved activity against
of such conjugates may impede oral dosage formulations for Gram-negative bacteria including E. coli, relative to ampicillin,
systemic applications (Gupta and Datta, 2019). However, this demonstrating that the vitamin B12 conjugate strategy is effective
opens the door to selectivity and efficacy for local treatments of for enabling cellular uptake and antibiotic delivery, thus

improving antibacterial efficacy (Zhao et al., 2020). Furthermore, most active hybrid displaying a 40-fold higher activity than
among numerous elegant examples by the Schweizer group VAN or nicin (Arnusch et al., 2008).
(Gorityala et al., 2016a; Gorityala et al., 2016b; Yang et al., Besides activity profiling, virtual tools depending on prior
2017; Domalaon et al., 2019), the use of antibiotic hybrids as knowledge or machine learning may enable prediction of
adjuvants such as nebramine-based hybrids (Yang et al., 2019) specificity, solubility, permeability, and general toxicity of
and lysine-tobramycin conjugates (Lyu et al., 2019) has hybrids (Mulligan, 2020; Zin et al., 2020). Prediction of
potentiated the activities of current existing antibiotics physical properties using molecular dynamics, a computer
including rifampicin and erythromycin, respectively. Similarly, simulation of the movement of a molecule surrounded by
rifamycin–tobramycin conjugate adjuvants were able to break water, may provide a more unbiased model than tools
intrinsic resistance of Pseudomonas aeruginosa to tetracyclines dependent on a database of a large number of compounds
and chloramphenicol (Idowu et al., 2019). with known properties (Mulligan, 2020). Efficient and reliable
Some key questions remain to be answered despite the computational tools for predicting physicochemical properties
progress and new advances of antibiotic hybrids to clinical such as permeability can be essential in the design of macrocyclic
development (Domalaon et al., 2018), highlighting the hybrids. Macrocycles and their antibiotic hybrids/conjugates are
potential to burgeon the antibacterial pipeline. Structure-based generally considered poor drug-like compounds and often violate
drug design, exemplified by X-ray co-crystal studies and desirable parameters for orally bioavailable drug molecules
molecular modeling, is among techniques capable of (Lipinski et al., 1997; Zin et al., 2020). Diverse functionalization
ameliorating the way forward of antibiotic hybrids. For strategies of macrocycles can modulate physicochemical properties
example, the co-crystal structure of rifampin with RNA by changing the rigidity, conformation, and basicity of the
polymerase has highlighted steric-free sites of attachments for macrocycle core and/or its side chain (Mallinson and Collins,
conjugates, vide supra (Ma and Lynch, 2016; Molodtsov et al., 2012). In addition, the decrease in degree of freedom by
2017). In addition, TenNor Therapeutics very recently presented macrocyclization may improve cell permeability of macrocycles
the outcome of their phase 2 clinical trial of TNP-2092 and (Dougherty et al., 2019). A recent study demonstrated modulation
disclosed the co-crystal structure of TNP-2092 bound with of scaffold rigidity to engineer favorable ADME properties in
bacterial RNA polymerase, along with its interaction with macrocyclic peptides (Furukawa et al., 2020). Finally, drug
DNA, at the 2020 CBIIC, which was held in Suzhou, China, design strategies, such as N-methylation or replacing NH with
in September 2020 (TenNor, 2020b). Computational strategies sulfur (or vice versa), were found to improve pharmacological
were also applied in the design of promising hybrids which are in activity, solubility, and/or permeability of macrocycles (Mallinson
the early stage of development. For example, in the design of and Collins, 2012; Liras and McClure, 2019; Stadelmann et al.,
macrocyclic peptide–peptoid hybrids, the crystal structure of the 2020; Buckton et al., 2021). Extending studies of this nature to
chemokine receptor CXCR4 was used as a template for the macrocyclic hybrids is expected to improve their oral
homology model of CXCR7 (Boehm et al., 2017). Besides bioavailability for systemic uses.
identifying residues important for activity, binding poses from
an induced fit docking also spotted spaces in the CXCR7 model
that are not occupied by the macrocycle peptide (Boehm et al., AUTHOR CONTRIBUTIONS
2017). Virtual tools also facilitated the design of VAN–nicin
conjugates, by predicting the optimal length of the linker and ASS and DS designed and prepared the manuscript, and critically
suitable attachment sites (Arnusch et al., 2008). Nicin is an reviewed and approved the submission of the final version of the
antimicrobial peptide that binds to lipid II and inhibits the manuscript.
transglycosylation step in the cell wall biosynthesis (Le et al.,
2017). Although each has different modes of action, lipid II is
targeted by both VAN and nicin. Predicting the optimal spacer FUNDING
and sites of connection was essential to place the constituting
elements to their respective binding sites in lipid II (Olsufyeva This work was supported in part by Leahi Fund to Treat and
and Tevyashova, 2017). Computationally guided design of Prevent Pulmonary Diseases of the Hawai’i Community
VAN–nicin hybrids led to promising derivatives, with the Foundation (19ADVC-95335).
Aslam, B., Wang, W., Arshad, M. I., Khurshid, M., Muzammil, S., Rasool, M. H.,
REFERENCES et al. (2018). Antibiotic Resistance: a Rundown of a Global Crisis. Infect. Drug
Resist. 11, 1645–1658. doi:10.2147/IDR.S173867
Adis Insight (2020). Cefilavancin - Theravance Biopharma. Springer Nature. Aubry-Damon, H., Soussy, C.-J., and Courvalin, P. (1998). Characterization of
Available: https://adisinsight.springer.com/drugs/800020586 (Accessed Mutations in the rpoB Gene that Confer Rifampin Resistance in Staphylococcus
January 11, 2021). aureus. Antimicrob. Agents Chemother. 42, 2590–2594. doi:10.1128/AAC.42.10.
Arnusch, C. J., Bonvin, A. M. J. J., Verel, A. M., Jansen, W. T. M., Liskamp, R. M. J., 2590
de Kruijff, B., et al. (2008). The Vancomycin−Nisin(1−12) Hybrid Restores Beck, A., Goetsch, L., Dumontet, C., and Corvaïa, N. (2017). Strategies and
Activity against Vancomycin Resistant Enterococci. Biochemistry 47, Challenges for the Next Generation of Antibody-Drug Conjugates. Nat. Rev.
12661–12663. doi:10.1021/bi801597b Drug Discov. 16, 315–337. doi:10.1038/nrd.2016.268

Berbari, E. F., Baddour, L. M., and Chen, A. F. (2020). “Prosthetic Joint Infection: Antibacterial Activity and Strong Potentiation of Rifampicin, Minocycline, and
Treatment,” in UpToDate. Editors D. Spelman and E. L. Baron (Waltham, MA: Vancomycin. ACS Infect. Dis. 3, 941–954. doi:10.1021/acsinfecdis.7b00145
Wolters Kluwer). https://www.uptodate.com/contents/prosthetic-joint- Dougherty, P. G., Sahni, A., and Pei, D. (2019). Understanding Cell Penetration of
infection-treatment (Accessed December 21, 2021). Cyclic Peptides. Chem. Rev. 119, 10241–10287. doi:10.1021/acs.chemrev.
Blais, J., Lewis, S. R., Krause, K. M., and Benton, B. M. (2012). Antistaphylococcal 9b00008
Activity of TD-1792, a Multivalent Glycopeptide-Cephalosporin Antibiotic. East, S. P., and Silver, L. L. (2013). Multitarget Ligands in Antibacterial Research:
Antimicrob. Agents Chemother. 56, 1584–1587. doi:10.1128/AAC.05532-11 Progress and Opportunities. Expert Opin. Drug Discov. 8, 143–156. doi:10.1517/
Blaskovich, M. A. T., Hansford, K. A., Butler, M. S., Jia, Z., Mark, A. E., and Cooper, 17460441.2013.743991
M. A. (2018). Developments in Glycopeptide Antibiotics. ACS Infect. Dis. 4, Eliopoulos, G. M., and Huovinen, P. (2001). Resistance to Trimethoprim-
715–735. doi:10.1021/acsinfecdis.7b00258 Sulfamethoxazole. Clin. Infect. Dis. 32, 1608–1614. doi:10.1086/320532
Boehm, M., Beaumont, K., Jones, R., Kalgutkar, A. S., Zhang, L., Atkinson, K., et al. Faron, M. L., Ledeboer, N. A., and Buchan, B. W. (2016). Resistance Mechanisms,
(2017). Discovery of Potent and Orally Bioavailable Macrocyclic Peptide- Epidemiology, and Approaches to Screening for Vancomycin-Resistant
Peptoid Hybrid CXCR7 Modulators. J. Med. Chem. 60, 9653–9663. doi:10. Enterococcus in the Health Care Setting. J. Clin. Microbiol. 54, 2436–2447.
1021/acs.jmedchem.7b01028 doi:10.1128/jcm.00211-16
Bradshaw, C. S., Vodstrcil, L. A., Hocking, J. S., Law, M., Pirotta, M., Garland, S. M., Fatheree, P. R., Linsell, M. S., Marquess, D. G., Trapp, S. G., Moran, E. J., and
et al. (2012). Recurrence of Bacterial Vaginosis Is Significantly Associated with Aggen, J. B. (2005). Cross-linked Glycopeptide-Cephalosporin Antibiotics.
Posttreatment Sexual Activities and Hormonal Contraceptive Use. Clin. Infect. International Patent Application WO 2005/005436 A2. January 20, 2005.
Dis. 56, 777–786. doi:10.1093/cid/cis1030 Fedorowicz, J., and Sa˛czewski, J. (2018). Modifications of Quinolones and
Brown, E. D., and Wright, G. D. (2016). Antibacterial Drug Discovery in the Fluoroquinolones: Hybrid Compounds and Dual-Action Molecules.
Resistance Era. Nature 529, 336–343. doi:10.1038/nature17042 Monatsh. Chem. 149, 1199–1245. doi:10.1007/s00706-018-2215-x
Brown, G. R. (2014). Cotrimoxazole - Optimal Dosing in the Critically Ill. Ann. Fisher, C. R., Schmidt-Malan, S. M., Ma, Z., Yuan, Y., He, S., and Patel, R. (2020). In
Intensive Care 4, 13. doi:10.1186/2110-5820-4-13 vitro activity of TNP-2092 against Periprosthetic Joint Infection-Associated
Brown, S., Xia, G., Luhachack, L. G., Campbell, J., Meredith, T. C., Chen, C., et al. Staphylococci. Diagn. Microbiol. Infect. Dis. 97, 115040. doi:10.1016/j.
(2012). Methicillin Resistance in Staphylococcus aureus Requires Glycosylated diagmicrobio.2020.115040
Wall Teichoic Acids. Proc. Natl. Acad. Sci. U S A. 109, 18909–18914. doi:10. Fong, R., Kajihara, K., Chen, M., Hotzel, I., Mariathasan, S., Hazenbos, W. L. W.,
1073/pnas.1209126109 et al. (2018). Structural Investigation of human S. aureus-Targeting Antibodies
Buckton, L. K., Rahimi, M. N., and McAlpine, S. R. (2021). Cyclic Peptides as Drugs that Bind Wall Teichoic Acid. MAbs 10, 1–13. doi:10.1080/19420862.2018.
for Intracellular Targets: The Next Frontier in Peptide Therapeutic 1501252
Development. Chem. Eur. J. 27, 1487–1513. doi:10.1002/chem.201905385 Fraunholz, M., and Sinha, B. (2012). Intracellular Staphylococcus aureus: Live-
Butler, M. S., and Paterson, D. L. (2020). Antibiotics in the Clinical Pipeline in in and let die. Front. Cell Infect. Microbiol. 2, 43. doi:10.3389/fcimb.2012.
October 2019. J. Antibiot. 73, 329–364. doi:10.1038/s41429-020-0291-8 00043
Cai, H., Yip, V., Lee, M. V., Wong, S., Saad, O., Ma, S., et al. (2020). Furukawa, A., Schwochert, J., Pye, C. R., Asano, D., Edmondson, Q. D., Turmon, A.
Characterization of Tissue Distribution, Catabolism, and Elimination of an C., et al. (2020). Drug-Like Properties in Macrocycles above MW 1000:
Anti-Staphylococcus aureus THIOMAB Antibody-Antibiotic Conjugate in Backbone Rigidity versus Side-Chain Lipophilicity. Angew. Chem. Int. Ed.
Rats. Drug Metab. Dispos. 48, 1161–1168. doi:10.1124/dmd.120.000092 Engl. 59, 21571–21577. doi:10.1002/anie.202004550
CDC (2019). Antibiotic Resistance Threats in the United States, 2019. Gauzy-Lazo, L., Sassoon, I., and Brun, M.-P. (2020). Advances in Antibody-Drug
Atlanta, GA: U.S. Department of Health and Human Services, Centers Conjugate Design: Current Clinical Landscape and Future Innovations. SLAS
for Disease Control and Prevention. Available: https://www.cdc.gov/ Discov. 25, 843–868. doi:10.1177/2472555220912955
drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf (Accessed Gerlach, D., Guo, Y., De Castro, C., Kim, S.-H., Schlatterer, K., Xu, F.-F., et al.
January 27, 2021). (2018). Methicillin-resistant Staphylococcus aureus Alters Cell Wall
Chey, W. D., Shah, E. D., and DuPont, H. L. (2020). Mechanism of Action and Glycosylation to Evade Immunity. Nature 563, 705–709. doi:10.1038/
Therapeutic Benefit of Rifaximin in Patients with Irritable Bowel Syndrome: a s41586-018-0730-x
Narrative Review. Ther. Adv. Gastroenterol. 13, 175628481989753–16. doi:10. Gorityala, B. K., Guchhait, G., Fernando, D. M., Deo, S., McKenna, S. A., Zhanel, G.
1177/1756284819897531 G., et al. (2016a). Adjuvants Based on Hybrid Antibiotics Overcome Resistance
Combrink, K. D., Denton, D. A., Harran, S., Ma, Z., Chapo, K., Yan, D., et al. in Pseudomonas aeruginosa and Enhance Fluoroquinolone Efficacy. Angew.
(2007). New C25 Carbamate Rifamycin Derivatives Are Resistant to Chem. Int. Ed. 55, 555–559. doi:10.1002/anie.201508330
Inactivation by ADP-Ribosyl Transferases. Bioorg. Med. Chem. Lett. 17, Gorityala, B. K., Guchhait, G., Goswami, S., Fernando, D. M., Kumar, A., Zhanel, G.
522–526. doi:10.1016/j.bmcl.2006.10.016 G., et al. (2016b). Hybrid Antibiotic Overcomes Resistance in P. aeruginosa by
Delano, W. L. (2002). The PyMOL Molecular Graphics System. San Carlos, CA, Enhancing Outer Membrane Penetration and Reducing Efflux. J. Med. Chem.
USA: Delano Scientific. 59, 8441–8455. doi:10.1021/acs.jmedchem.6b00867
Deng, R., Zhou, C., Li, D., Cai, H., Sukumaran, S., Carrasco-Triguero, M., et al. Gray, D. A., and Wenzel, M. (2020). Multitarget Approaches against
(2019). Preclinical and Translational Pharmacokinetics of a Novel THIOMAB Multiresistant Superbugs. ACS Infect. Dis. 6, 1346–1365. doi:10.1021/
Antibody-Antibiotic Conjugate against Staphylococcus aureus. mAbs 11, acsinfecdis.0c00001
1162–1174. doi:10.1080/19420862.2019.1627152 Gupta, V., and Datta, P. (2019). Next-generation Strategy for Treating Drug
Deris, Z. Z., Swarbrick, J. D., Roberts, K. D., Azad, M. A. K., Akter, J., Horne, A. S., Resistant Bacteria: Antibiotic Hybrids. Indian J. Med. Res. 149, 97–106.
et al. (2014). Probing the Penetration of Antimicrobial Polymyxin Lipopeptides doi:10.4103/ijmr.IJMR_755_18
into Gram-Negative Bacteria. Bioconjug. Chem. 25, 750–760. doi:10.1021/ Hegde, S. S., Okusanya, O. O., Skinner, R., Shaw, J.-P., Obedencio, G., Ambrose, P.
bc500094d G., et al. (2012). Pharmacodynamics of TD-1792, a Novel Glycopeptide-
Domalaon, R., Ammeter, D., Brizuela, M., Gorityala, B. K., Zhanel, G. G., and Cephalosporin Heterodimer Antibiotic Used against Gram-Positive Bacteria,
Schweizer, F. (2019). Repurposed Antimicrobial Combination Therapy: in a Neutropenic Murine Thigh Model. Antimicrob. Agents Chemother. 56,
Tobramycin-Ciprofloxacin Hybrid Augments Activity of the Anticancer 1578–1583. doi:10.1128/AAC.05382-11
Drug Mitomycin C against Multidrug-Resistant Gram-Negative Bacteria. Idowu, T., Arthur, G., Zhanel, G. G., and Schweizer, F. (2019). Heterodimeric
Front. Microbiol. 10, 1556. doi:10.3389/fmicb.2019.01556 Rifampicin-Tobramycin Conjugates Break Intrinsic Resistance of Pseudomonas
Domalaon, R., Idowu, T., Zhanel, G. G., and Schweizer, F. (2018). Antibiotic aeruginosa to Doxycycline and Chloramphenicol In Vitro and in a Galleria
Hybrids: the Next Generation of Agents and Adjuvants against Gram-Negative Mellonella In Vivo Model. Eur. J. Med. Chem. 174, 16–32. doi:10.1016/j.ejmech.
Pathogens?. Clin. Microbiol. Rev. 31, e00077-17. doi:10.1128/CMR.00077-17 2019.04.034
Domalaon, R., Yang, X., Lyu, Y., Zhanel, G. G., and Schweizer, F. (2017). Janas, A., and Przybylski, P. (2019). 14- and 15-Membered Lactone Macrolides and
Polymyxin B3-Tobramycin Hybrids with Pseudomonas Aeruginosa-Selective Their Analogues and Hybrids: Structure, Molecular Mechanism of Action and

Biological Activity. Eur. J. Med. Chem. 182, 111662. doi:10.1016/j.ejmech.2019. Ma, Z., Yuan, Y., Liu, Y., and Wang, X. (2020). New Use of Rifamycin-
111662 Nitroimidazole Conjugate Molecules. United States Patent Application US
Ji, C., Juárez-Hernández, R. E., and Miller, M. J. (2012). Exploiting Bacterial Iron 2020/0093807 A1. March 26, 2020.
Acquisition: Siderophore Conjugates. Future Med. Chem. 4, 297–313. doi:10. Mallinson, J., and Collins, I. (2012). Macrocycles in New Drug Discovery. Future
4155/fmc.11.191 Med. Chem. 4, 1409–1438. doi:10.4155/fmc.12.93
Jones, A. (2019). Bacterial Vaginosis: A Review of Treatment, Recurrence, and Mariathasan, S., and Tan, M.-W. (2017). Antibody-antibiotic Conjugates: a Novel
Disparities. J. Nurse Pract. 15, 420–423. doi:10.1016/j.nurpra.2019.03.010 Therapeutic Platform against Bacterial Infections. Trends Mol. Med. 23,
Jubeh, B., Breijyeh, Z., and Karaman, R. (2020). Antibacterial Prodrugs to 135–149. doi:10.1016/j.molmed.2016.12.008
Overcome Bacterial Resistance. Molecules 25, 1543. doi:10.3390/ Molodtsov, V., Scharf, N. T., Stefan, M. A., Garcia, G. A., and Murakami, K. S.
molecules25071543 (2017). Structural Basis for Rifamycin Resistance of Bacterial RNA Polymerase
Kamath, A. V., and Iyer, S. (2016). Challenges and Advances in the Assessment of by the Three Most Clinically Important RpoB Mutations Found in
the Disposition of Antibody-drug Conjugates. Biopharm. Drug Dispos. 37, Mycobacterium tuberculosis. Mol. Microbiol. 103, 1034–1045. doi:10.1111/
66–74. doi:10.1002/bdd.1957 mmi.13606
Kim, I. H., Combrink, K. D., Ma, Z., Chapo, K., Yan, D., Renick, P., et al. (2007). Moubareck, C. A. (2020). Polymyxins and Bacterial Membranes: A Review of
Synthesis and Antibacterial Evaluation of a Novel Series of Rifabutin-like Antibacterial Activity and Mechanisms of Resistance. Membranes 10, 181.
Spirorifamycins. Bioorg. Med. Chem. Lett. 17, 1181–1184. doi:10.1016/j. doi:10.3390/membranes10080181
bmcl.2006.12.026 Mulligan, V. K. (2020). The Emerging Role of Computational Design in Peptide
Klahn, P., and Brönstrup, M. (2017). Bifunctional Antimicrobial Conjugates Macrocycle Drug Discovery. Expert Opin. Drug Discov. 15, 833–852. doi:10.
and Hybrid Antimicrobials. Nat. Prod. Rep. 34, 832–885. doi:10.1039/ 1080/17460441.2020.1751117
c7np00006e Murillo, O., Pachón, M. E., Euba, G., Verdaguer, R., Tubau, F., Cabellos, C., et al.
Le, C. F., Fang, C. M., and Sekaran, S. D. (2017). Intracellular Targeting (2008). Antagonistic Effect of Rifampin on the Efficacy of High-Dose
Mechanisms by Antimicrobial Peptides. Antimicrob. Agents Chemother. 61, Levofloxacin in Staphylococcal Experimental Foreign-Body Infection.
e02340–02316. doi:10.1128/aac.02340-16 Antimicrob. Agents Chemother. 52, 3681–3686. doi:10.1128/AAC.00458-08
Lehar, S. M., Pillow, T., Xu, M., Staben, L., Kajihara, K. K., Vandlen, R., et al. (2015). NCT00442832 (2006). TD-1792 in Gram-Positive Complicated Skin and Skin
Novel Antibody-Antibiotic Conjugate Eliminates Intracellular S. aureus. Structure Infection. https://ClinicalTrials.gov/show/NCT00442832 (Accessed
Nature 527, 323–328. doi:10.1038/nature16057 November 25, 2020).
Leuthner, K. D., Vidaillac, C., Cheung, C. M., and Rybak, M. J. (2010). In vitro NCT01791049 (2013). TD-1607 SAD Study in Healthy Subjects. https://
activity of the New Multivalent Glycopeptide-Cephalosporin Antibiotic TD- clinicaltrials.gov/ct2/show/NCT01791049 (Accessed November 25, 2020).
1792 against Vancomycin-Nonsusceptible Staphylococcus Isolates. Antimicrob. NCT02596399 (2015). A Study to Investigate Safety, Tolerability and
Agents Chemother. 54, 3799–3803. doi:10.1128/aac.00452-10 Pharmacokinetics of DSTA4637S in Healhy Volunteers. Available: https://
Lexicomp (2021). Lexicomp® Online, Lexi-Drugs Online, Hudson. Ohio: clinicaltrials.gov/ct2/show/NCT02596399 (Accessed December 26, 2020).
UpToDate, Inc. (Accessed January 4, 2021). NCT03162250 (2017). Study to Investigate the Safety, Tolerability, and
Li, J., Ma, Z., Chapo, K., Yan, D., Lynch, A. S., and Ding, C. Z. (2007). Preparation Pharmacokinetics of DSTA4637S in Participants with Staphylococcus aureus
and In Vitro Anti-staphylococcal Activity of Novel 11-Deoxy-11- Bacteremia Receiving Standard-Of-Care Antibiotics. Available: https://
Hydroxyiminorifamycins. Bioorg. Med. Chem. Lett. 17, 5510–5513. doi:10. clinicaltrials.gov/ct2/show/NCT03162250 (Accessed December 28, 2020).
1016/j.bmcl.2007.08.048 NCT03964493 (2019). TNP-2092 to Treat Acute Bacterial Skin and Skin Structure
Liapikou, A., Cillóniz, C., and Torres, A. (2017). Investigational Drugs in Phase I Infection. Available: https://clinicaltrials.gov/ct2/show/NCT03964493 (Accessed
and Phase II Clinical Trials for the Treatment of Community-Acquired December 28, 2020).
Pneumonia. Expert Opin. Investig. Drugs 26, 1239–1248. doi:10.1080/ NCT04294862 (2021). Tissue Distribution, Pharmacokinetics, Safety, and
13543784.2017.1385761 Tolerability after a Single Dose of TNP-2092 in Participants Undergoing
Lipinski, C. A., Lombardo, F., Dominy, B. W., and Feeney, P. J. (1997). Primary Total Hip or Knee Arthroplasty. Available: https://clinicaltrials.gov/
Experimental and Computational Approaches to Estimate Solubility and ct2/show/NCT04294862 (Accessed January 11, 2021).
Permeability in Drug Discovery and Development Settings. Adv. Drug Deliv. NCT01791049 (2013). TD-1607 SAD Study in Healthy Subjects. Available at:
Rev. 23, 3–25. doi:10.1016/S0169-409X(96)00423-1 https://clinicaltrials.gov/ct2/show/NCT01791049 (Accessed November 25,
Liras, S., and McClure, K. F. (2019). Permeability of Cyclic Peptide Macrocycles 2020).
and Cyclotides and Their Potential as Therapeutics. ACS Med. Chem. Lett. 10, Negash, K. H., Norris, J. K. S., and Hodgkinson, J. T. (2019). Siderophore-antibiotic
1026–1032. doi:10.1021/acsmedchemlett.9b00149 Conjugate Design: New Drugs for Bad Bugs?. Molecules 24, 3314. doi:10.3390/
Liu, J., Lkhagva, E., Chung, H.-J., Kim, H.-J., and Hong, S.-T. (2018). The Pharmabiotic molecules24183314
Approach to Treat Hyperammonemia. Nutrients 10, 140. doi:10.3390/ Okano, A., Isley, N. A., and Boger, D. L. (2017). Total Syntheses of Vancomycin-
nu10020140 Related Glycopeptide Antibiotics and Key Analogues. Chem. Rev. 117,
Liu, Y., Li, R., Xiao, X., and Wang, Z. (2019). Antibiotic Adjuvants: an Alternative 11952–11993. doi:10.1021/acs.chemrev.6b00820
Approach to Overcome Multi-Drug Resistant Gram-Negative Bacteria. Crit. Olsufyeva, E. N., and Tevyashova, A. N. (2017). Synthesis, Properties, and
Rev. Microbiol. 45, 301–314. doi:10.1080/1040841X.2019.1599813 Mechanism of Action of New Generation of Polycyclic Glycopeptide
Long, D. D., Aggen, J. B., Chinn, J., Choi, S.-K., Christensen, B. G., Fatheree, P. R., Antibiotics. Curr. Top. Med. Chem. 17, 2166–2198. doi:10.2174/
et al. (2008a). Exploring the Positional Attachment of Glycopeptide/β-Lactam 1568026617666170130115957
Heterodimers. J. Antibiot. 61, 603–614. doi:10.1038/ja.2008.80 Osmon, D. R., Berbari, E. F., Berendt, A. R., Lew, D., Zimmerli, W., Steckelberg,
Long, D. D., Aggen, J. B., Christensen, B. G., Judice, J. K., Hegde, S. S., Kaniga, K., J. M., et al. (2013). Diagnosis and Management of Prosthetic Joint Infection:
et al. (2008b). A Multivalent Approach to Drug Discovery for Novel Antibiotics. Clinical Practice Guidelines by the Infectious Diseases Society of America. Clin.
J. Antibiot. 61, 595–602. doi:10.1038/ja.2008.79 Infect. Dis. 56, e1–e25. doi:10.1093/cid/cis803
Lyu, Y., Domalaon, R., Yang, X., and Schweizer, F. (2019). Amphiphilic Lysine Paljetak, H., Tomaskovic, L., Matijasic, M., Bukvic, M., Fajdetic, A., Verbanac, D.,
Conjugated to Tobramycin Synergizes Legacy Antibiotics against Wild-type et al. (2017). Macrolide Hybrid Compounds: Drug Discovery Opportunities in
and Multidrug-Resistant Pseudomonas aeruginosa. Pept. Sci. 111, e23091. Anti-infective and Anti-inflammatory Area. Curr. Top. Med. Chem. 17,
doi:10.1002/bip.23091 919–940. doi:10.2174/1568026616666160927160036
Ma, Z., and Lynch, A. S. (2016). Development of a Dual-Acting Antibacterial Agent Parkes, A. L., and Yule, I. A. (2016). Hybrid Antibiotics - Clinical Progress and
(TNP-2092) for the Treatment of Persistent Bacterial Infections. J. Med. Chem. Novel Designs. Expert Opin. Drug Discov. 11, 665–680. doi:10.1080/17460441.
59, 6645–6657. doi:10.1021/acs.jmedchem.6b00485 2016.1187597

Patel, O. P. S., Jesumoroti, O. J., Legoabe, L. J., and Beteck, R. M. (2021). Skin and Skin Structure Infections. Antimicrob. Agents Chemother. 56,
Metronidazole-conjugates: A Comprehensive Review of Recent Developments 5476–5483. doi:10.1128/AAC.00712-12
towards Synthesis and Medicinal Perspective. Eur. J. Med. Chem. 210, 112994. Sussman, D., Westendorf, L., Meyer, D. W., Leiske, C. I., Anderson, M., Okeley, N.
doi:10.1016/j.ejmech.2020.112994 M., et al. (2018). Engineered Cysteine Antibodies: an Improved Antibody-Drug
Peck, M., Rothenberg, M. E., Deng, R., Lewin-Koh, N., She, G., Kamath, A. V., et al. Conjugate Platform with a Novel Mechanism of Drug-Linker Stability. Protein
(2019). A Phase 1, Randomized, Single-Ascending-Dose Study to Investigate the Eng. Des. Sel. 31, 47–54. doi:10.1093/protein/gzx067
Safety, Tolerability, and Pharmacokinetics of DSTA4637S, an Anti-Staphylococcus Taha, M., Abdelbary, H., Ross, F. P., and Carli, A. V. (2018). New Innovations in
aureus THIOMAB Antibody-Antibiotic Conjugate, in Healthy Volunteers. the Treatment of PJI and Biofilms-Clinical and Preclinical Topics. Curr. Rev.
Antimicrob. Agents Chemother. 63, e02588–02518. doi:10.1128/AAC.02588-18 Musculoskelet. Med. 11, 380–388. doi:10.1007/s12178-018-9500-5
Peterson, M. L. (2017). The Evolution of Macrocycles in Drug Discovery: from Tamma, P. D., Cosgrove, S. E., and Maragakis, L. L. (2012). Combination Therapy
Technologies to Drugs. Available: https://www.americanpharmaceuticalreview. for Treatment of Infections with Gram-Negative Bacteria. Clin. Microbiol. Rev.
com/Featured-Articles/343609-The-Evolution-of-Macrocycles-in-Drug- 25, 450–470. doi:10.1128/cmr.05041-11
Discovery-From-Technologies-to-Drugs/(Accessed January 27, 2021). TenNor (2020a). TenNor Initiated TNP-2198 Phase 1b/IIa Clinical Trials.
Peyrusson, F., Varet, H., Nguyen, T. K., Legendre, R., Sismeiro, O., Coppée, J.-Y., Available: http://www.tennorx.com/en/h-nd-63.html (Accessed December
et al. (2020). Intracellular Staphylococcus aureus Persisters upon Antibiotic 25, 2020).
Exposure. Nat. Commun. 11, 2200. doi:10.1038/s41467-020-15966-7 TenNor (2020b). TenNor Presented Phase II Results of TNP-2092 at 2020 CBIIC.
Pham, T. D. M., Ziora, Z. M., and Blaskovich, M. A. T. (2019). Quinolone Available: http://www.tennorx.com/en/h-nd-61.html#fai_2_top (Accessed
Antibiotics. Med. Chem. Commun. 10, 1719–1739. doi:10.1039/c9md00120d December 25, 2020).
Pokrovskaya, V., and Baasov, T. (2010). Dual-acting Hybrid Antibiotics: a TenNor Therapeutics (2021). TenNor Therapeutics R&D Clinical Candidate
Promising Strategy to Combat Bacterial Resistance. Expert Opin. Drug Pipeline. Available: http://www.tennorx.com/en/ (Accessed January 27,
Discov. 5, 883–902. doi:10.1517/17460441.2010.508069 2021).
Poreba, M. (2020). Protease-activated Prodrugs: Strategies, Challenges, and Future Tevyashova, A. N., Korolev, A. M., Mirchink, E. P., Isakova, E. B., and Osterman, I.
Directions. FEBS J. 287, 1936–1969. doi:10.1111/febs.15227 A. (2019). Synthesis and Evaluation of Biological Activity of Benzoxaborole
PR Newswire (2020). TenNor Therapeutics Received FDA Orphan Drug Derivatives of Azithromycin. J. Antibiot. 72, 22–33. doi:10.1038/s41429-018-
Designation. Available: https://www.prnewswire.com/news-releases/tennor- 0107-2
therapeutics-received-fda-orphan-drug-designation-300989321.html Theuretzbacher, U. (2020). Dual-mechanism Antibiotics. Nat. Microbiol. 5,
(Accessed April 8, 2021). 984–985. doi:10.1038/s41564-020-0767-0
Robertson, G. T., Bonventre, E. J., Doyle, T. B., Du, Q., Duncan, L., Morris, T. Tsutsumi, L., Owusu, Y., Hurdle, J., and Sun, D. (2013). Progress in the Discovery of
W., et al. (2008). In vitro evaluation of CBR-2092, a Novel Rifamycin- Treatments for C. difficile Infection: A Clinical and Medicinal Chemistry Review.
Quinolone Hybrid Antibiotic: Studies of the Mode of Action in Curr. Top. Med. Chem. 14, 152–175. doi:10.2174/1568026613666131113154753
Staphylococcus aureus. Antimicrob. Agents Chemother. 52, 2313–2323. Tyers, M., and Wright, G. D. (2019). Drug Combinations: a Strategy to Extend the
doi:10.1128/AAC.01649-07 Life of Antibiotics in the 21st Century. Nat. Rev. Microbiol. 17, 141–155. doi:10.
Rossi, R., and Ciofalo, M. (2020). An Updated Review on the Synthesis and 1038/s41579-018-0141-x
Antibacterial Activity of Molecular Hybrids and Conjugates Bearing Imidazole van Dalen, R., Molendijk, M. M., Ali, S., van Kessel, K. P. M., Aerts, P., van Strijp,
Moiety. Molecules 25, 5133. doi:10.3390/molecules25215133 J. A. G., et al. (2019). Do Not Discard Staphylococcus aureus WTA as a Vaccine
Sader, H. S., Rhomberg, P. R., Farrell, D. J., Flamm, R. K., and Jones, R. N. (2014). Antigen. Nature 572, E1–E2. doi:10.1038/s41586-019-1416-8
“Antimicrobial Activity of TD-1607 Tested against Contemporary (2010-2012) van Dalen, R., Peschel, A., and van Sorge, N. M. (2020). Wall Teichoic Acid in
Methicillin-Resistant Staphylococcus aureus (MRSA) Strains,” in 54th Staphylococcus aureus Host Interaction. Trends Microbiol. 28, 985–998. doi:10.
Interscience Conference on Antimicrobial Agents and Chemotherapy 1016/j.tim.2020.05.017
(Washington DC: Abstract No: F-970). Vergalli, J., Bodrenko, I. V., Masi, M., Moynié, L., Acosta-Gutiérrez, S., Naismith,
Sanchez, C. J., Shiels, S. M., Tennent, D. J., Hardy, S. K., Murray, C. K., and Wenke, J. H., et al. (2020). Porins and Small-Molecule Translocation across the Outer
J. C. (2015). Rifamycin Derivatives Are Effective against Staphylococcal Membrane of Gram-Negative Bacteria. Nat. Rev. Microbiol. 18, 164–176.
Biofilms In Vitro and Elutable from PMMA. Clin. Orthop. Relat. Res. 473, doi:10.1038/s41579-019-0294-2
2874–2884. doi:10.1007/s11999-015-4300-3 Wang, K. K., Stone, L. K., Lieberman, T. D., Shavit, M., Baasov, T., and Kishony, R.
Saravanan, P., Dusthackeer, V. N. A., Rajmani, R. S., Mahizhaveni, B., Nirmal, C. R., (2016). A Hybrid Drug Limits Resistance by Evading the Action of the Multiple
Rajadas, S. E., et al. (2021). Discovery of a Highly Potent Novel Rifampicin Analog by Antibiotic Resistance Pathway. Mol. Biol. Evol. 33, 492–500. doi:10.1093/
Preparing a Hybrid of the Precursors of the Antibiotic Drugs Rifampicin and molbev/msv243
Clofazimine. Sci. Rep. 11, 1029. doi:10.1038/s41598-020-80439-2 Wang-Lin, S., and Balthasar, J. (2018). Pharmacokinetic and Pharmacodynamic
Schalk, I. J. (2018). Siderophore-antibiotic Conjugates: Exploiting Iron Uptake to Considerations for the Use of Monoclonal Antibodies in the Treatment of
Deliver Drugs into Bacteria. Clin. Microbiol. Infect. 24, 801–802. doi:10.1016/j. Bacterial Infections. Antibodies 7, 5. doi:10.3390/antib7010005
cmi.2018.03.037 Wang-Lin, S. X., Zhou, C., Kamath, A. V., Hong, K., Koppada, N., Saad, O. M., et al.
Shang, Z., Chan, S. Y., Song, Q., Li, P., and Huang, W. (2020). The Strategies of (2018). Minimal Physiologically-Based Pharmacokinetic Modeling of
Pathogen-Oriented Therapy on Circumventing Antimicrobial Resistance. DSTA4637A, A Novel THIOMAB Antibody Antibiotic Conjugate against
Research 2020, 1–32. doi:10.34133/2020/2016201 Staphylococcus aureus, in a Mouse Model. mAbs 10, 1–13. doi:10.1080/
Shavit, M., Pokrovskaya, V., Belakhov, V., and Baasov, T. (2017). Covalently Linked 19420862.2018.1494478
Kanamycin - Ciprofloxacin Hybrid Antibiotics as a Tool to Fight Bacterial Weidenmaier, C., and Peschel, A. (2008). Teichoic Acids and Related Cell-Wall
Resistance. Bioorg. Med. Chem. 25, 2917–2925. doi:10.1016/j.bmc.2017.02.068 Glycopolymers in Gram-Positive Physiology and Host Interactions. Nat. Rev.
Shopsin, B., Kaveri, S. V., and Bayry, J. (2016). Tackling Difficult Staphylococcus Microbiol. 6, 276–287. doi:10.1038/nrmicro1861
aureus Infections: Antibodies Show the Way. Cell Host Microbe 20, 555–557. Wells, C. M., Beenken, K. E., Smeltzer, M. S., Courtney, H. S., Jennings, J. A., and
doi:10.1016/j.chom.2016.10.018 Haggard, W. O. (2018). Ciprofloxacin and Rifampin Dual Antibiotic-Loaded
Silver, L. L. (2011). Challenges of Antibacterial Discovery. Clin. Microbiol. Rev. 24, Biopolymer Chitosan Sponge for Bacterial Inhibition. Mil. Med. 183, 433–444.
71–109. doi:10.1128/cmr.00030-10 doi:10.1093/milmed/usx150
Stadelmann, T., Subramanian, G., Menon, S., Townsend, C. E., Lokey, R. S., Ebert, WHO (2019a). 2019 Antibacterial Agents in Clinical Development: An Analysis of
M.-O., et al. (2020). Connecting the Conformational Behavior of Cyclic the Antibacterial Clinical Development Pipeline. Geneva, Switzerland: World
Octadepsipeptides with Their Ionophoric Property and Membrane Health Organization. Available: https://apps.who.int/iris/bitstream/handle/10665/
Permeability. Org. Biomol. Chem. 18, 7110–7126. doi:10.1039/d0ob01447h 330420/9789240000193-eng.pdf (Accessed January 27, 2021).
Stryjewski, M. E., Potgieter, P. D., Li, Y.-P., Barriere, S. L., Churukian, A., Kingsley, WHO (2019b). Antibacterial Products in Clinical Development for Priority
J., et al. (2012). TD-1792 versus Vancomycin for Treatment of Complicated Pathogens. Geneva, Switzerland: World Health Organization. Available:

https://www.who.int/research-observatory/monitoring/processes/antibacterial_ Zhao, S., Wang, Z.-P., Wen, X., Li, S., Wei, G., Guo, J., et al. (2020). Synthesis of Vitamin
products/en/ (Accessed January 11, 2021). B12-Antibiotic Conjugates with Greatly Improved Activity against Gram-Negative
Winstel, V., Xia, G., and Peschel, A. (2014). Pathways and Roles of Wall Teichoic Bacteria. Org. Lett. 22, 6632–6636. doi:10.1021/acs.orglett.0c02403
Acid Glycosylation in Staphylococcus aureus. Int. J. Med. Microbiol. 304, Zhou, C., Lehar, S., Gutierrez, J., Rosenberger, C. M., Ljumanovic, N., Dinoso, J.,
215–221. doi:10.1016/j.ijmm.2013.10.009 et al. (2016). Pharmacokinetics and Pharmacodynamics of DSTA4637A: A
Yang, X., Ammeter, D., Idowu, T., Domalaon, R., Brizuela, M., Okunnu, O., Novel THIOMAB Antibody Antibiotic Conjugate against Staphylococcus
et al. (2019). Amphiphilic Nebramine-Based Hybrids Rescue Legacy aureus in Mice. mAbs 8, 1612–1619. doi:10.1080/19420862.2016.1229722
Antibiotics from Intrinsic Resistance in Multidrug-Resistant Gram- Zhou, Q. (2017). Site-specific Antibody Conjugation for ADC and beyond.
Negative Bacilli. Eur. J. Med. Chem. 175, 187–200. doi:10.1016/j.ejmech. Biomedicines 5, 64. doi:10.3390/biomedicines5040064
2019.05.003 Zimmerli, W., and Sendi, P. (2019). Role of Rifampin against Staphylococcal
Yang, X., Goswami, S., Gorityala, B. K., Domalaon, R., Lyu, Y., Kumar, A., et al. Biofilm Infections In Vitro, in Animal Models, and in Orthopedic-Device-
(2017). A Tobramycin Vector Enhances Synergy and Efficacy of Efflux Pump Related Infections. Antimicrob. Agents Chemother. 63, e01746–18. doi:10.1128/
Inhibitors against Multidrug-Resistant Gram-Negative Bacteria. J. Med. Chem. AAC.01746-18
60, 3913–3932. doi:10.1021/acs.jmedchem.7b00156 Zin, P. P. K., Williams, G. J., and Ekins, S. (2020). Cheminformatics Analysis and
Yilmaz, M., Elaldi, N., Balkan, İ. İ., Arslan, F., Batırel, A. A., Bakıcı, M. Z., et al. Modeling with macrolactoneDB. Sci. Rep. 10, 6284. doi:10.1038/s41598-020-
(2016). Mortality Predictors of Staphylococcus aureus Bacteremia: a Prospective 63192-4
Multicenter Study. Ann. Clin. Microbiol. Antimicrob. 15, 7. doi:10.1186/s12941-
016-0122-8 Conflict of Interest: The authors declare that the research was conducted in the
Yu, X., and Sun, D. (2013). Macrocyclic Drugs and Synthetic Methodologies absence of any commercial or financial relationships that could be construed as a
toward Macrocycles. Molecules 18, 6230–6268. doi:10.3390/ potential conflict of interest.
molecules18066230
Yuan, Y., Wang, X., Xu, X., Liu, Y., Li, C., Yang, M., et al. (2020). Evaluation of a Copyright © 2021 Surur and Sun. This is an open-access article distributed under the
Dual-Acting Antibacterial Agent, TNP-2092, on Gut Microbiota and Potential terms of the Creative Commons Attribution License (CC BY). The use, distribution
Application in the Treatment of Gastrointestinal and Liver Disorders. ACS or reproduction in other forums is permitted, provided the original author(s) and the
Infect. Dis. 6, 820–831. doi:10.1021/acsinfecdis.9b00374 copyright owner(s) are credited and that the original publication in this journal is
Yudin, A. K. (2015). Macrocycles: Lessons from the Distant Past, Recent Developments, cited, in accordance with accepted academic practice. No use, distribution or
and Future Directions. Chem. Sci. 6, 30–49. doi:10.1039/c4sc03089c reproduction is permitted which does not comply with these terms.

Macrocycle-Antibiotic Hybrids: A Path To Clinical Candidates

Uploaded by

Copyright:

Available Formats

Macrocycle-Antibiotic Hybrids: A Path To Clinical Candidates

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Macrocycle-Antibiotic Hybrids: A Path To Clinical Candidates

Uploaded by

Copyright:

Available Formats

REVIEW

published: 30 April 2021

Macrocycle-Antibiotic Hybrids: A Path

Frontiers in Chemistry | www.frontiersin.org 1 April 2021 | Volume 9 | Article 659845

Frontiers in Chemistry | www.frontiersin.org 2 April 2021 | Volume 9 | Article 659845

The lipid intermediate II (a membrane-anchored cell wall

Frontiers in Chemistry | www.frontiersin.org 3 April 2021 | Volume 9 | Article 659845

Frontiers in Chemistry | www.frontiersin.org 4 April 2021 | Volume 9 | Article 659845

Frontiers in Chemistry | www.frontiersin.org 5 April 2021 | Volume 9 | Article 659845

system. In addition, the lack of efﬂux effectively traps 15 within

Frontiers in Chemistry | www.frontiersin.org 6 April 2021 | Volume 9 | Article 659845

participants have not been recruited yet (NCT04294862, 2021).

Frontiers in Chemistry | www.frontiersin.org 7 April 2021 | Volume 9 | Article 659845

Surur and Sun

Topical Preclinical development

FIGURE 6 | Monoclonal antibody, linker, and the antibiotic of DSTA4637S (23).

Antibody–antibiotic conjugation (AAC), in addition to the

Frontiers in Chemistry | www.frontiersin.org 9 April 2021 | Volume 9 | Article 659845

Frontiers in Chemistry | www.frontiersin.org 10 April 2021 | Volume 9 | Article 659845

Frontiers in Chemistry | www.frontiersin.org 11 April 2021 | Volume 9 | Article 659845

Frontiers in Chemistry | www.frontiersin.org 12 April 2021 | Volume 9 | Article 659845

Frontiers in Chemistry | www.frontiersin.org 13 April 2021 | Volume 9 | Article 659845

Frontiers in Chemistry | www.frontiersin.org 14 April 2021 | Volume 9 | Article 659845

Frontiers in Chemistry | www.frontiersin.org 15 April 2021 | Volume 9 | Article 659845

Frontiers in Chemistry | www.frontiersin.org 16 April 2021 | Volume 9 | Article 659845

You might also like

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.