This chapter focuses on development of resistance to anticancer agents. In recent years there has been great progress made in identifying new mechanisms of resistance. From these studies, it has become clear that genomic instability and the tumor microenvironment strongly influence the development of resistance and play a major role in the evolution of resistance. A large number of scientific studies have focused on the identification and characterization of mechanisms of drug resistance using tissue culture-based models. In general, the mechanisms of microenvironment-related drug resistance can be subdivided into those that lead to reduced drug effect and those mechanisms that provide increased tolerance to damage. In a study with small cell lung cancer (SCLC) cells, extracellular matrix (ECM) proteins were found to protect the cells from chemotherapy induced apoptosis. While the focus on these highly resistant cell lines facilitated the elucidation of the mechanisms behind high level drug resistance, it is possible that the initial lines in which resistance was two-to-fourfold, relative to the original parent cell line, contained the secrets to understanding clinically relevant cancer drug resistance. Ultimately, the identification of the cellular factors that mediate this form of resistance may provide novel strategies for circumventing both intrinsic and acquired drug resistance. It was clear almost from the beginning that multidrug resistance in vitro and in vivo involved multiple mechanisms acting in concert to modulate chemo-sensitivity, although often this was not readily appreciated.

ABSTRACT Omadacycline is a novel first-in-class aminomethylcycline with potent activity against important skin and pneumonia pathogens, including community-acquired methicillin-resistant Staphylococcus aureus (MRSA), β-hemolytic streptococci, penicillin-resistant Streptococcus pneumoniae , Haemophilus influenzae , and Legionella . In this work, the mechanism of action for omadacycline was further elucidated using a variety of models. Functional assays demonstrated that omadacycline is active against strains expressing the two main forms of tetracycline resistance (efflux and ribosomal protection). Macromolecular synthesis experiments confirmed that the primary effect of omadacycline is on bacterial protein synthesis, inhibiting protein synthesis with a potency greater than that of tetracycline. Biophysical studies with isolated ribosomes confirmed that the binding site for omadacycline is similar to that for tetracycline. In addition, unlike tetracycline, omadacycline is active in vitro in the presence of the ribosomal protection protein Tet(O).

With increasing resistance to existing antimalarials, there is an urgent need to discover new drugs at affordable prices for countries in which malaria is endemic. One approach to the development of new antimalarial drugs is to improve upon existing antimalarial agents, such as the tetracyclines. Tetracyclines exhibit potent, albeit relatively slow, action against malaria parasites, and doxycycline is used for both treatment (with other agents) and prevention of malaria. We synthesized 18 novel 7-position modified tetracycline derivatives and screened them for activity against cultured malaria parasites. Compounds with potent in vitro activity and other favorable drug properties were further tested in a rodent malaria model. Ten compounds inhibited the development of cultured Plasmodium falciparum with a 50% inhibitory concentration (IC50) after 96 h of incubation of <30 nM, demonstrating activity markedly superior to that of doxycycline (IC50 at 96 h of 320 nM). Most compounds showed little mammalian cell cytotoxicity and no evidence of in vitro phototoxicity. In a murine Plasmodium berghei model, 13 compounds demonstrated improved activity relative to that of doxycycline. In summary, 7-position modified tetracyclines offer improved activity against malaria parasites compared to doxycycline. Optimized compounds may allow lower doses for treatment and chemoprophylaxis. If safety margins are adequate, dosing in children, the group at greatest risk for malaria in countries in which it is endemic, may be feasible.

ABSTRACT A randomized, investigator-blind, multicenter phase 2 trial involving patients with complicated skin and skin structure infections (cSSSI) compared the safety and efficacy of omadacycline, a broad-spectrum agent with activity against methicillin-resistant Staphylococcus aureus (MRSA), to those of linezolid (with or without aztreonam). Patients were randomized 1:1 to omadacycline (100 mg intravenously [i.v.] once a day [QD] with an option to transition to 200 mg orally QD) or linezolid (600 mg i.v. twice daily [BID] with an option to transition to 600 mg orally BID) at 11 U.S. sites. Patients suspected or documented to have infections caused by Gram-negative bacteria were given aztreonam (2 g i.v. every 12 h [q12h]) if randomized to linezolid or matching placebo infusions if randomized to omadacycline. Adverse events were reported in 46 (41.4%) omadacycline-treated and 55 (50.9%) linezolid-treated patients. Adverse events related to treatment were assessed by investigators in 24 (21.6%) omadacycline-treated and 33 (30.6%) linezolid-treated patients. The gastrointestinal tract was most commonly involved, with adverse events reported in 21 (18.9%) patients exposed to omadacycline and 20 (18.5%) exposed to linezolid. Rates of successful clinical response in the intent-to-treat (ITT) and clinical evaluable (CE) populations favored omadacycline (ITT, 88.3% versus 75.9%; 95% confidence interval [CI], 1.9 to 22.9; CE, 98.0% versus 93.2%; 95% CI, −1.7 to 11.3). For microbiologically evaluable (ME) patients with S. aureus infections, the clinical success rates were 97.2% (70/72) in omadacycline-treated and 92.7% (51/55) in linezolid-treated patients. This phase 2 experience supports conclusions that omadacycline is well tolerated in cSSSI patients and that this aminomethylcycline has potential to be an effective treatment for serious skin infections.

ExsA is a multiple adaptational response (MAR) transcription factor, regulating the expression of a virulence determinant, the type III secretion system (T3SS) in Pseudomonas aeruginosa. Non-cytotoxic, non-antibacterial N-hydroxybenzimidazoles were identified as effective inhibitors of ExsA-DNA binding, and their potential utility as anti-virulence agents for P. aeruginosa was demonstrated in a whole cell assay. Select N-hydroxybenzimidazole inhibitors were stable in an in vitro human liver microsomal assay.

There is at present no cure or effective therapy for spinal muscular atrophy (SMA), a neurodegenerative disease that is the leading genetic cause of infant mortality. SMA usually results from loss of the SMN1 (survival of motor neuron 1) gene, which leads to selective motor neuron degeneration. SMN2 is nearly identical to SMN1 but has a nucleotide replacement that causes exon 7 skipping, resulting in a truncated, unstable version of the SMA protein. SMN2 is present in all SMA patients, and correcting SMN2 splicing is a promising approach for SMA therapy. We identified a tetracycline-like compound, PTK-SMA1, which stimulates exon 7 splicing and increases SMN protein levels in vitro and in vivo in mice. Unlike previously identified molecules that stimulate SMN production via SMN2 promoter activation or undefined mechanisms, PTK-SMA1 is a unique therapeutic candidate in that it acts by directly stimulating splicing of exon 7. Synthetic small-molecule compounds such as PTK-SMA1 offer an alternative to antisense oligonucleotide therapies that are being developed as therapeutics for a number of disease-associated splicing defects.

The marC gene of Escherichia coli is divergently transcribed from the marRAB operon involved in resistance to multiple antibiotics (5, 8), oxidative stress agents (2), and organic solvents (3, 16). Previous data from our laboratory had suggested a role for marC in intrinsic multiple antibiotic resistance (4, 9, 16), and the gene has been so annotated in most databases. Because that earlier work had suggested that marC was regulated by the repressor MarR and induced by tetracycline, we sought the transcriptional start site for marC to see if the marC promoter might overlap the MarR binding sites within the marRAB promoter (5′ rapid amplification of cDNA end [RACE] system of Gibco/BRL Life Technologies, cells grown with 2 μg/ml tetracycline to increase the amount of mRNA). Transcription of marC started 30 nucleotides upstream from the putative ATG initiation codon of MarC (bp 1266 of Cohen et al. [4]). Therefore, the marC promoter does not contain the MarR binding sites. Moreover, Northern blot analysis of AG100 and its isogenic marR mutant AG112 (in which MarR is inactive [8, 12]) showed no differences in levels of marC mRNA between the two strains (data not shown), nor was expression of marC induced by salicylate, which inactivates the repressor MarR (1) (Fig. ​(Fig.1).1). We conclude that marC is not regulated by MarR. Since chloramphenicol does not bind to MarR (1), the apparent up-regulation by tetracycline and chloramphenicol (Fig. ​(Fig.1)1) (4) likely reflects stabilization of mRNA rather than true induction (11, 13, 14). FIG. 1. Northern blot analysis of marC from E. coli. RNA was isolated from mid-exponential-phase cells grown in LB broth at 30°C and treated for 1 h with the specified compounds. Separate cultures of E. coli AG100 following exposure to 5 mM salicylate ... We replaced the marC locus in E. coli AG100 with a kanamycin cassette as described previously (10) and looked for any increase in susceptibilities to antimicrobials. MICs were determined on LB agar by use of Etest strips (AB Biodisk, Solna, Sweden) with about three dozen different agents, including beta lactams, tetracyclines, fluoroquinolones, cephalosporins, imipenem, macrolides, aminoglycosides, chloramphenicol, fusidic acid, trimethoprim, and rifampin. Gradient plates (6) were used for oxidative stress agents (plumbagin, paraquat, phenylmethylsulfonate, dinitrophenol, and menadione) and for ethidium bromide. No differences in susceptibilities were seen for the marC::kan deletion mutant relative to the wild type. We then replaced the genes for the E. coli MarC paralogs YchE and YhgN in the marC::kan strain by use of spectinomycin and gentamicin cassettes, respectively, to create a triple knockout mutant, but again no differences in susceptibilities were seen. We also used three plasmid constructs designed to overexpress marC via the araBAD, T7, or native marC promoter. Plasmid pHA-1::marC (obtained from D. Daley) specifies membrane-bound MarC-PhoA regulated by Salmonella enterica serovar Typhimurium pBAD/AraC (7). We constructed pETmarC11 (T7 promoter/lac operator with lac repressor; specifying MarC-6H) and pACmarC1 (marC promoter starting 58 bp upstream of the transcriptional start site; specifying native MarC) by cloning PCR-amplified DNA into vectors pET21b (Novagen) and pACYC184, respectively. None of these three plasmids led to a change in susceptibility of cells to a variety of antibiotics and oxidative stress agents. We suggest that MarC no longer be classified as a multiple antibiotic resistance protein. However, we do not advise a name change until a function is found.